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Collection of Best Intial, Most Accurate Test, Best Next Step, Best Treatment!

42K views 80 replies 20 participants last post by  DigitalDoctor1 
#1 ·
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.
 
#2 ·
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
 
#4 · (Edited)
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%
 
#5 ·
Acute Pulmonary Edema

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
 
#7 ·
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 add salmertrol or increase dose of ICS
4- If no response add max dose of ICS
5- If no response add Omalizumab
6- If no response add oral corticosteroid (prednisone)
 
#9 ·
ASTHMA

Best Initial Test
: ABG(increased A-a Gradient) or PEF(Decreased)

Accurate test: PFT ( decreased FEV1/ FVC, Increased DLCO, Obstructive disease pattern)

Rx- ET for Mechanical Ventilation is used when patients PCo2 is very high
(rest of treatment in the previous post)

P.S:sorry: People come on Contribute. In the end, we can make a huge PDF file so that people would actually benefit from this.:toosad:
 
#10 ·
ASTHMA
Rx- ET for Mechanical Ventilation is used when patients PCo2 is very high
(rest of treatment in the previous post)
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.
 
#11 ·
COPD

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

Persistent symptoms/moderate- Tiotropium(long acting)+ Albuterol >>>> Tiotropium+salmeterol

Frequent Exacerbations/Severe--Tiotropium+Formoterol or salmeterol+Inhaled Corticosteroids

Respiratory Failure/V. Severe-- Supplemental O2, Lung Volume Reduction surgery, Lung transplant

*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
 
#12 ·
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.
 
#14 ·
COPD: I WILL ADD THESE CONCEPTS

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
 
#18 ·
MYASTHENIA GRAVIS

Best Initial: Acetylcholine Receptor Antibodies (NOT tensilon test)
Most Accurate: Electromyography

BEST INITIAL Tx: Pyridostigmine or Neostigmine

Tx if Pyridostigmine dont work (Chronic):
Steroids if pt above 60y ; Thymectomy if pt below 60y.

ACUTE MYASTHENIC CRISIS:

Best Initial Tx: Intravenous Immunoglobulins OR Plasmapheresis
 
#19 · (Edited)
Screening for Cervical Cancer

Current Recommendation

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.
Screening recommendations for specific patient age groups are as follows[4, 3] :

  • < 21 years - No screening recommended
  • 21-29 years - Cytology (Pap smear) alone every 3 years
  • 30-65 years - Human papillomavirus (HPV) and cytology cotesting every 5 years (preferred) or cytology alone every 3 years (acceptable)
  • > 65 years - No screening recommended if adequate prior screening has been negative and high risk is not present
Women who have had a total hysterectomy may stop undergoing cervical cancer screening. Exceptions are as follows:

  • Women who had a hysterectomy without removal of the cervix
  • Women who have had a CIN grade 2 or 3 lesion treated in the past 20 years
  • Women who have had cervical carcinoma at any time
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]
 
#21 ·
Hemochromatosis

Best Initial: Transferrin saturation

Most Accurate: Liver biopsy

Prognostic Indicator: Liver biopsy

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.
 
#24 · (Edited)
Hemochromatosis

Best Initial: Transferrin saturation
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.
 
#22 ·
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.

CIN2 & CIN3:NO observation:
a-Ablative therapy OR b-Excisional procedure.

*For biopsy confirmed,recurrent CIN2 & CIN3 Hysterectomy is acceptable.
 
#23 ·
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.
 
#27 ·
Back pain:

# 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.
 
#29 ·
That's correct.

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.
 
#30 ·
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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