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Old 09-28-2012
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Arrow Gyrus Daily Questions; Internal Medicine #33

A 28-year-old male with HIV and a CD4 count of 4/µL is admitted to the hospital with several days of epigas-tric boring abdominal pain radiating to the back with asso-ciated nausea and bilious vomiting. He has a history of disseminated mycobacterial disease, cryptococcal pneumonia, and injection drug use. His current medica-tions include fluconazole, trimethoprim-sulfamethoxazole, clarithromycin, ethambutol, and rifabutin. On physical ex-amination he has normal vital signs, decreased bowel sounds, and tender epigastrium without rebound or guard-ing. Rectal exam is guaiac-negative. The remainder of the examination is normal. Amylase and lipase are elevated.
The patient is treated conservatively with intravenous fluids and bowel rest, with resolution of symptoms. Right upper quadrant ultrasound is normal, and calcium and triglycer-ides are normal. Which of the following changes to his medical regimen should be recommended on discharge?

A. Discontinue rifabutin.
B. Substitute azithromycin for clarithromycin.
C. Substitute dapsone for trimethoprim-sulfamethoxa-zole.
D. Substitute amphotericin for fluconazole.
E. Discontinue trimethoprim-sulfamethoxazole.
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just to keep an eye on this thread......would pick C
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no clue .....whats the answer ???
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mm its weird i dont know the purpose of the question, probably i would choose C
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The answer is C. Substitute dapsone for trimethoprim-sulfamethoxazole.


A diagnosis of pancreatitis is made in an appropriate clinical setting with abdominal pain radiating to the back and elevated amylase and lip-ase. Although there are many causes of acute pancreatitis, among the most common are medications, alcohol, and gallstones. This patient does not drink alcohol and right upper quadrant ultrasound does not show cholelithiasis, leaving medications as the likely etiology. Commonly associated drugs are sulfonamides, estrogens, 6-mercaptopurine, azathioprine, anti-HIV medications, and valproic acid. The patient was taking sulfa-methoxazole, which is a sulfonamide. He should be advised to discontinue this medica-tion, and different Pneumocystis carinii pneumonia prophylaxis should be prescribed.
Alternative regimens include dapsone, aerosolized pentamidine, and atovaquone. Dis-continuation of all Pneumocystis pneumonia prophylaxis with his degree of immune sup-pression is unadvisable.
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lol know i see, yes the patient has pancreatitis, god i can be so stupid sometimes.
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Quote:
Originally Posted by K06100 View Post
no clue .....whats the answer ???
If you don't have a clue about a drug side effect then choose trimethoprim-sulfamethoxazole since it can cause any thing know to man.

Hyperkalemia is an important one.

Quote:
Trimethoprim/sulfamethoxazole may have the following adverse reactions:[10]
Quote:
Originally Posted by K06100 View Post
Sir, when there is no clue about the answer, just remember God and pick one choice....Dont leave the question unattempted as u just did .
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Quote:
Originally Posted by Novobiocin View Post
If you don't have a clue about a drug side effect then choose trimethoprim-sulfamethoxazole since it can cause any thing know to man.
U caught me , Sir .......I was trying to guess but didn't find any sufficient clue to guess either.......
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Quote:
Originally Posted by K06100 View Post
U caught me , Sir .......I was trying to guess but didn't find any sufficient clue to guess either.......
There are two ways of doing this question:

1. The usual way:

Any epigastric pain radiating to back (associated with vomiting etc) is pancreatitis unless proven otherwise.
Now you have to look (know) the drugs causing it.

2. By exclusion:

A. Discontinue rifabutin.>>>>Unlikely since they have not provided any alternative to it to cover for disseminated mycobacterial disease.
B. Substitute azithromycin for clarithromycin.>>>> Highly unlikely since they are essentially the same class
C. Substitute dapsone for trimethoprim-sulfamethoxa-zole.
D. Substitute amphotericin for fluconazole. >>>Highly unlikely since Ampho has far more toxicity
E. Discontinue trimethoprim-sulfamethoxazole.>>>>Highly unlikely since it would amount to homocide and professional suicide

Basically you are left to decide between A & C and based on the reputation I would pick C.
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Quote:
Originally Posted by Novobiocin View Post
There are two ways of doing this question:

1. The usual way:

Any epigastric pain radiating to back (associated with vomiting etc) is pancreatitis unless proven otherwise.
Now you have to look (know) the drugs causing it.

2. By exclusion:

A. Discontinue rifabutin.>>>>Unlikely since they have not provided any alternative to it to cover for disseminated mycobacterial disease.
B. Substitute azithromycin for clarithromycin.>>>> Highly unlikely since they are essentially the same class
C. Substitute dapsone for trimethoprim-sulfamethoxa-zole.
D. Substitute amphotericin for fluconazole. >>>Highly unlikely since Ampho has far more toxicity
E. Discontinue trimethoprim-sulfamethoxazole.>>>>Highly unlikely since it would amount to homocide and professional suicide

Basically you are left to decide between A & C and based on the reputation I would pick C.
U r genius , sir........
Can u exchange ur brain with mine ????
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In USMLE as far as i have come across..In case of abdominal pain. The site of pain will give the diagnosis...






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I have put this question because Pancreatitis is a high yield topic in USMLE and Especially Drug induced pancratitis...For a discussion..

Thanks all for participating in it....

Gyrus Daily Questions; Internal Medicine #33-causes-pancreatitis.jpg
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Gastroenterology-, Internal-Medicine-, Step-2-Questions, Tables-

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