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Old 09-21-2012
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Arrow Gyrus Daily Questions; Internal Medicine #10

A 65-year-old man is brought to the emergency room by ambulance after his daughter found him to be incoherent earlier today. She last spoke with him yesterday, and at that time, he was complaining of 2 days of myalgias, headache, and fever. He had attributed it to an upper respiratory tract infection and did not seek evaluation from his primary care physician. Today, he did not answer when she called his home, and she found him lying in his bed smelling of urine. He was minimally arousable but appeared to be moving all of his extremities. His past medical history is significant for hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease. He was evaluated 2 weeks previously for a transient ischemic attack after an episode where he had numbness and weakness of his left arm and leg that resolved over 6 h without intervention. His current medications include aspirin, 81 mg daily, clopidogrel, 75 mg daily, atenolol, 100 mg daily, atorvastatin, 20 mg daily, and tiotropium, once daily. He is allergic to lisinopril, which caused angioedema. He is a former smoker and drinks alcohol rarely. On physical examination, he is obtunded and minimally arousable. He is febrile with a temperature of 38.9°C. His blood pressure is 159/96 mmHg, and heart rate is 98 beats/ min. He is breathing at a rate of 24 breaths/min with a room air oxygen saturation of 95%. He has minimal scleral icterus. The oropharynx reveals dry mucous membranes. His cardiovascular, pulmonary, and abdominal examinations are normal. There are no rashes. His neurologic examination is difficult to obtain. There are no cranial nerve findings. He resists movement of his extremities but has normal strength. Deep tendon reflexes are brisk, 3+ and equal. The laboratory values are as follows: hemoglobin 9.3 g/ dL, hematocrit 29.1%, white blood cell count 14,000/μL, and platelets 42,000/μL. The differential demonstrates 83% neutrophils, 2% band forms, 6% lymphocytes, and 9% monocytes. The sodium is 145 meq/L, potassium 3.8 meq/L, chloride 113 meq/L, bicarbonate 19 meq/L, blood urea nitrogen 68 mg/dL, and creatinine 3.4 mg/dL. The bilirubin is 2.4 mg/dL, and lactate dehydrogenase is 450 U/L. A peripheral blood smear shows diminished platelets and many schistocytes.What is the next most appropriate step in this patient’s care?


A. Discontinue clopidogrel.
B. Discontinue clopidogrel and initiate plasmapheresis.
C. Initiate therapy with intravenous immunoglobulin.
D. Obtain a head CT scan and initiate treatment with
factor VIIa, if subarachnoid hemorrhage is seen.
E. Perform a lumbar puncture and start broad-spectrum
antibiotic coverage with ceftazidime and vancomycin
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Old 09-21-2012
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This case ate my brain.. but this dude has TTP,secondary to clopidrogel, what you do is discontinue the offending drug and give plasmaphereis ASAP
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So whats the answer gyrus? looks like no one will try to answer this question :S or if they will they are taking too long
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Quote:
Originally Posted by cingulate.gyrus View Post
A 65-year-old man is brought to the emergency room by ambulance after his daughter found him to be incoherent earlier today. She last spoke with him yesterday, and at that time, he was complaining of 2 days of myalgias, headache, and fever. He had attributed it to an upper respiratory tract infection and did not seek evaluation from his primary care physician. Today, he did not answer when she called his home, and she found him lying in his bed smelling of urine. He was minimally arousable but appeared to be moving all of his extremities. His past medical history is significant for hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease. He was evaluated 2 weeks previously for a transient ischemic attack after an episode where he had numbness and weakness of his left arm and leg that resolved over 6 h without intervention. His current medications include aspirin, 81 mg daily, clopidogrel, 75 mg daily, atenolol, 100 mg daily, atorvastatin, 20 mg daily, and tiotropium, once daily. He is allergic to lisinopril, which caused angioedema. He is a former smoker and drinks alcohol rarely. On physical examination, he is obtunded and minimally arousable. He is febrile with a temperature of 38.9°C. His blood pressure is 159/96 mmHg, and heart rate is 98 beats/ min. He is breathing at a rate of 24 breaths/min with a room air oxygen saturation of 95%. He has minimal scleral icterus. The oropharynx reveals dry mucous membranes. His cardiovascular, pulmonary, and abdominal examinations are normal. There are no rashes. His neurologic examination is difficult to obtain. There are no cranial nerve findings. He resists movement of his extremities but has normal strength. Deep tendon reflexes are brisk, 3+ and equal. The laboratory values are as follows: hemoglobin 9.3 g/ dL, hematocrit 29.1%, white blood cell count 14,000/μL, and platelets 42,000/μL. The differential demonstrates 83% neutrophils, 2% band forms, 6% lymphocytes, and 9% monocytes. The sodium is 145 meq/L, potassium 3.8 meq/L, chloride 113 meq/L, bicarbonate 19 meq/L, blood urea nitrogen 68 mg/dL, and creatinine 3.4 mg/dL. The bilirubin is 2.4 mg/dL, and lactate dehydrogenase is 450 U/L. A peripheral blood smear shows diminished platelets and many schistocytes.What is the next most appropriate step in this patient’s care?


A. Discontinue clopidogrel.
B. Discontinue clopidogrel and initiate plasmapheresis.
C. Initiate therapy with intravenous immunoglobulin.
D. Obtain a head CT scan and initiate treatment with
factor VIIa, if subarachnoid hemorrhage is seen.
E. Perform a lumbar puncture and start broad-spectrum
antibiotic coverage with ceftazidime and vancomycin
The clinical pic of fever, CNS dysfuntion, and labs showing thrombocytopnea, abnormal renal functions, with schistocytes all suggestive of microangiopathy which's TTP, which can be due to clopidogrel
So the answer might be B
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Quote:
Originally Posted by cingulate.gyrus View Post
A 65-year-old man is brought to the emergency room by ambulance after his daughter found him to be incoherent earlier today. She last spoke with him yesterday, and at that time, he was complaining of 2 days of myalgias, headache, and fever. He had attributed it to an upper respiratory tract infection and did not seek evaluation from his primary care physician. Today, he did not answer when she called his home, and she found him lying in his bed smelling of urine. He was minimally arousable but appeared to be moving all of his extremities. His past medical history is significant for hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease. He was evaluated 2 weeks previously for a transient ischemic attack after an episode where he had numbness and weakness of his left arm and leg that resolved over 6 h without intervention. His current medications include aspirin, 81 mg daily, clopidogrel, 75 mg daily, atenolol, 100 mg daily, atorvastatin, 20 mg daily, and tiotropium, once daily. He is allergic to lisinopril, which caused angioedema. He is a former smoker and drinks alcohol rarely. On physical examination, he is obtunded and minimally arousable. He is febrile with a temperature of 38.9°C. His blood pressure is 159/96 mmHg, and heart rate is 98 beats/ min. He is breathing at a rate of 24 breaths/min with a room air oxygen saturation of 95%. He has minimal scleral icterus. The oropharynx reveals dry mucous membranes. His cardiovascular, pulmonary, and abdominal examinations are normal. There are no rashes. His neurologic examination is difficult to obtain. There are no cranial nerve findings. He resists movement of his extremities but has normal strength. Deep tendon reflexes are brisk, 3+ and equal. The laboratory values are as follows: hemoglobin 9.3 g/ dL, hematocrit 29.1%, white blood cell count 14,000/μL, and platelets 42,000/μL. The differential demonstrates 83% neutrophils, 2% band forms, 6% lymphocytes, and 9% monocytes. The sodium is 145 meq/L, potassium 3.8 meq/L, chloride 113 meq/L, bicarbonate 19 meq/L, blood urea nitrogen 68 mg/dL, and creatinine 3.4 mg/dL. The bilirubin is 2.4 mg/dL, and lactate dehydrogenase is 450 U/L. A peripheral blood smear shows diminished platelets and many schistocytes.What is the next most appropriate step in this patient’s care?
B. Discontinue clopidogrel and initiate plasmapheresis.
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Old 09-21-2012
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Thanks guys you all are correct..
Step 2 CK is ck is characterised by this type of lengthy questions...
I think We Have to do reading practice for time managment...

The answer is B.Discontinue clopidogrel and initiate plasmapheresis.


The patient has evidence of thrombotic thrombocytopenic purpura (TTP) from clopidogrel manifested as

altered mental status,
fever,
acute renal failure,
thrombocytopenia, and microangiopathic hemolytic anemia.


The peripheral blood smear show anisocytosis with schistocytes and platelet clumping consistent with this disease.

Clopidogrel is a thienopyridine antiplatelet agent that is known to be associated with life-threatening hematologic effects, including neutropenia,
TTP, and aplastic anemia. The true incidence of TTP associated with thienopyridine use is unknown, but it occurs with both clopidogrel and ticlopidine use. When compared to ticlopidine, TTP associated with clopidogrel use occurs earlier (often within 2 weeks) and tends to be less responsive to therapy with plasmapheresis.

In addition, individuals with TTP associated with clopidogrel generally have a higher platelet count and creatinine and their TTP is less likely to be associated with ADAMTS13 deficiency, a von Willebrand factor– cleaving protease implicated in the pathogenesis of idiopathic TTP.

The mortality of
TTP associated with thienopyridines is approximately 25–30%.


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