Hello everyone,
CK basically revolves around the questions asking us about the best initial test, most accurate test, appropriate next step and Best treatment. I would try to make as many post I can and I would hope that other people would contribute in this thread too.
I would start with the Aortic Dissection
Best next step if BP is given: Control BP (a) Beta Blocker (b) Nitroprusside
Best Initial test: Chest X-ray
Accurate test: Angiogram
Rx: Surgical correction
Note: TEE=Constrast CT=MRA. Between TEE and TTE, choose TEE
* Please correct me if I make any mistakes. Thanks.
MS: Best indicator of severity is A2 to OS Best initial test is TTE; more accurate is TEE and most accurate is Cathertization If asymptomatic= follow up If mild sym= medical ttt If failed medical ttt= Valvoplasty If unsuccessful Valvoplasty= valve replacement In pregnancy manage with Valvoplasty Indication of replacement: 1- Symptomatic pt with MR 2- Sever calcified MV 3- Failure of Valvoplasty 4- CHF with sever symptoms
MI: #Diagnostic tests: *Best initial test= ECG= elevation in 1 or > 1 mm in to consequent leads
#In posterior MI looks to ECG paper from up side down to see ST elevation *Most accurate method= Angiography *Confirmatory test= CK-MB is dx of choice,, Troponin is most specific *Stress test= done when etiology of chest pain is uncertain and EKG is not diagnostic and it limited by:
#If pt can't able to exercise= (1) Dobutamine + Echo OR (2) Dipyridamole or (adenosine= C/I in Reactive airway Dz coz provoke bronchospasm) + thallium or sestamib # If can't able to read ECG= (1) thallium or sestamib {decrease uptake} OR (2) Echo for detection of motion abnormalities *Treatment of ACS: # Treatment of stable A: *Best initial= NG + ASP * BB= start at any time # Treatment of ST elevation: * Best initial= O2 + morphine + NG + ASP(Clopidogrel if allergy to ASP)
* PCI Angioplasty within 90 min
* Immediate Thrombolytic (TPA)= within 2 hrs If Angioplasty delayed *Heparin= after thrombolytic or PCI *BB= start at any time and if not tolerate BB {in asthmatic pt} can use CCB (Verapamil or Diltiazem)
*Statin= if LDL> 100
*ACEI= if low EF
*CABG
# Treatment of ST depression or unstable A or posterior MI: · Best initial= O2 + NG + ASP · Next step= Heparin · BB= start at any time · Gp 2b/3a {Abciximab, tirofiban}=
# Rt side heart failure: · Best initial= I.V fluids + prepare pt for revascularization · If BP not maintain with I.V fluid add Dopamine
*Mortality benefit: #ASP #Angioplasty #BB= start at any time #tPA= mortality benefit within 2 hrs #Statin= if LDL> 100 #ACEI= if EF < 40%
Next Appropriate step: Loop Diuretic
Best Initial Test(s):1- ECG,2- X-ray,3- TTE
Rx- LMNO (Loop, Morphine, Nitrate, O2)
Preload Reducers like Dobutamine, amrinone and milrinone
(Digonxin not used since it takes weeks)
Afterload Reducers: Acute setting> Hydralazine, nitrates
chronic setting>ACEI/ARBS
Management of acute asthma: 1- Best initial management are O2 + Inhaled albuterol (SABA), if pt respond continue ttt and close observation 2- If no response add low dose inhaled corticosteroid (ICS) (beclomethasone) 3- If no response addsalmertrol or increase dose of ICS 4- If no response addmax dose of ICS 5- If no response addOmalizumab 6- If no response addoral corticosteroid (prednisone)
Interpretation of Arterial Blood Gases in Asthma and when to intubate the patient:
During an Asthma Attack at the start of an asthma attack the PaO2 falls(e.g. to 60mm Hg), the PaCO2 falls (e.g. to 30 mm Hg) and increase the pH (e.g. to 7.50).
Slowly but surely the PaO2 and the PaCO2 continue to fall and the pH continues to rise as the disease worsens. Eventually, a state is reached wherein the lungs are unable to blow off more carbon dioxide. At this point the PaCO2 starts to rise and the pH starts to fall, but the PaO2 continues to fall. As the asthma attack gets worse and worse the low PaCO2 and the high pH start to move back toward their normal values.
Eventually as the asthma attack becomes extreme, the PaCO2 rises above 40 mm Hg and may reach for example 50 mm Hg or more and the pH falls below 7.40 and may reach for example 7.30. The PaO2 continues to fall and may reach for example 20 mm Hg.At this point patient is candidate for Intubation.
Initial test- X-ray(increase in the AP diameter)
Accurate test- PFT ( Obstructive lung disease pattern)
Note: Bicarbonate to assess for disease progression
Rx- Short Acting Bronchodilators [B-agonist/ or Short acting Anticholinergic agents(eg Ipratropium)] for intermittent/mild symptoms
*Antibiotics if necessary: macrolides, Cephalosporin, Augmentin, Qunolones, Doxycycline, TMP/SMX
Criteria for O2 use:
pO2 less than or equal to 55 mmHg, 02 Saturation below 88%, Hct> 55, Evidence of Cor pulmonale
Contrictive Pericarditis>>> Signs of RHF, Kussmaul Sign, Knock
Best Initial Test: X-ray shows calcification n Fibrosis Accurate Test: CT or MRI *after* X-ray Treatment: Diuretics, Surgery
Pericarditis:
1-History and Physical Exam- Sharp pleuritic chest pain that improves leaning forward
2-TESTS:
(a) ECG in all cases- ST segment elevation in all leads, most specific is PR segment depression
(b) X-ray in all cases
(c) Echocardiography in All cases
3- Find the underlying cause(eg. TB, ANA etc), if suspected
Combination of above lead to the diagnosis of pericarditis.
Rx: NSAIDS, if fails use Steroids.
Improve mortality: 1- - O2 with titration of 90 % sat and the goal is to maintain pO2 of 60 mmHg 2- Smoking cessation slow progression 3- Influenza and Pneumococcal Vaccine Improve symptoms: 1- first line= ipratropium MDI + inhaler B agonist (metoprotrenol) 2- If pt have tachyarrhythmiause ipratropium as first line 3- If first line failedadd theophylline 4- Inhaled steroid= use for short term exacerbation but have no role in long term 5- LABA 6- Postural drainage
Criteria of intubation: 1- pO2 < 50 2- Alter mental status 3- Profound academia 4- Cardiac dysfunction Acute exacerbation of COPD:
defines as an acute increase in symptoms beyond normal day-to-day variation. This generally includes an acute increase in one or more of the following cardinal symptoms:
Cough increases in frequency and severity
Sputum production increases in volume and/or changes character
Dyspnea increases
Management:
1- Admission
2- If alter mental status or unstable HD= Intubation
3- O2 supplementation
4- Ipratropium
5- Systemic steroid I.V
6- Antibiotics despite normal X- ray
7- Don't stop theophylline if pt take it and not start it if pt not take it
8- Complete all investigation= CXR, ABG, O2 sat, ECG, CBC, theophylline level Best prognostic indicator of survival is FEV1
ok i like this topic, but since i just started studying i dont have anything to contribute so far
i will also do once i start things up.
I am typing this in here, so that i get frequent emails saying that this topic is still active and its good to keep reading it, atleast 1 day it might stick in my brain. lol
Hi friends
Could we discuss Cervical Neoplasia (Screening, workup, and management)? cuz this is most important and controversial topics in GYN so we should mastered it.
Release Date: March 2012 These recommendations apply to women who have a cervix, regardless of sexual history. These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval.
Grade: A Recommendation.
The USPSTF recommends against screening for cervical cancer in women younger than age 21 years.
Grade: D Recommendation.
The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors.
Grade: D Recommendation.
The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.
Grade: D Recommendation.
The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
Grade: D Recommendation.
The treatment of cervical cancer varies with the stage of the disease, as follows:
Stage 0: Carcinoma in situ (stage 0) is treated with local ablative or excisional measures such as cryosurgery, laser ablation, and loop excision; surgical removal is preferred
Stage IA1: The treatment of choice for stage IA1 disease is surgery; total hysterectomy, radical hysterectomy, and conization are accepted procedures
Stage IA2, IB, or IIA: Combined external beam radiation with brachytherapy and radical hysterectomy with bilateral pelvic lymphadenectomy for patients with stage IB or IIA disease; radical vaginal trachelectomy with pelvic lymph node dissection is appropriate for fertility preservation in women with stage IA2 disease and those with stage IB1 disease whose lesions are 2 cm or smaller
Stage IIB, III, or IVA: Cisplatin-based chemotherapy with radiation is the standard of care[8]
Stage IVB and recurrent cancer: Individualized therapy is used on a palliative basis; radiation therapy is used alone for control of bleeding and pain; systemic chemotherapy is used for disseminated disease[8]
Currently, the diagnosis can be confidently based on genetic testing for the C282Y mutation; thus, liver biopsy is no longer essential for diagnosis in many cases. However, liver biopsy may not only be useful to identify liver disease and to determine the presence or absence of cirrhosis, which directly affects prognosis, but it may also be helpful in patients with cirrhosis, which is the primary risk factor for hepatocellular carcinoma.
Thanks Novo
I see you are bold the best initial test of hemochromatosis (Transferrin saturation) inspite you know that in UW the initial evaluation is serum iron study. I think you are right but i would like to know your explanation.
Management of Cervical Dysplasia According to Histology:
CIN1: three options: a-Observation and follow-up:
reapeat Pap in 6 and 12 month or colposcopy and repeat Pap in 12 months or HPV DNA testing in 12 months. OR b-Ablative therapy:
cryotherapy,lazer,electrofulguration. OR c-Excisional procedure:
LEEP,cold-knife conization.
Management of cervical dysplasia/neoplasia in pregnancy:
CIN lesions during pragnany(=no breakage of basal membrane) .all CIN1,2&3 have same management in pregnancy): follow by Pap smear and colposcopy every 3 months during pregnancy.delivered vaginally if appropriate .at 6-8 weeks postpartum any persistent lesions treated.
Microinvasion: cone biopsy to ensure no frank invasion(NB:ECC not performed durig pregnancy)also follow ,vaginal delivery,reevaluate and treat 6-8 weeks postpartum.
Invasive cancer: 1)before 24 weeks of pregnancy,ignore pregnancy treat as in non pregnant as appropriate according to the stage. 2)after 24 weeks, conservative management till 32-33weeks(to allow fetal maturity) c section delivery and begin definitve treatment.
# Evaluate immediately any patient with new onset back pain and history of cancer, for possible spinal cord compression.
# As soon as you suspect spinal cord compression the best next step is to give dexametasone.
# MRI is the test of choice (whole spine )
# Radiation for lymphoma and MM.
# Surgery for most solid tumors.
Heartbeat,
MTB says its both Transferrin saturation and serum iron. And in the next line TIBC. I believe all of these are considered part of serum iron studies.
Please correct me If I'm wrong.
Transferrin saturation (ratio of serum iron and total iron-binding capacity, multiplied by 100) is part of the iron studies along with serum iron and transferrin. However, among all these iron studies Transferrin saturation is most specific since serum iron and transferrin can be raised in other conditions being acute phase reactants. It also detects hemochromatosis in earlier stages as compared to the others.
Transferrin saturation, abbreviated as TSAT and measured as a percentage, is a medical laboratory value. It is the ratio of serum iron and total iron-binding capacity, multiplied by 100. Of the transferrin that is available to bind iron, this value tells a clinician how much serum iron is actually bound. For instance, a value of 15% means that 15% of iron-binding sites of transferrin is being occupied by iron.
Stroke Best intial test:CT scan without contrast Most accurate test:MRI (only done if CT is negative)
Best initial therapy for ishemic stroke: Less than 3 hours of onset of symptoms:thrombolytics(tPA) which is associated with better outcome. More than 3 hours:Aspirin for secondary prevention.
If recurre while on aspirin or the patient already taking aspirin add dipryidamole or witch to clopidog.
Search for the source of embli and manage it: Echo:Valvular damage:surgery,thrombi:heparin and warfarin EKG:A fib:warfarin and rate control. Holter monitor:to look for Afib if EKG is negative. Carotid douplex:if more than 70% stenosis and patient has sypmtomatic cardiovascular disease:carotid endartrectomy.
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