11-21-2006, 06:37 AM
USMLE Forum
Step 1
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Matching & Residency
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* Step 2 CK * Archives *
* To all UW readers - let us help ourself ..
#123398
amith - 10/02/06 05:06
Guys we all know it would be very vital to revise UW and no matter we did it once or twice still we miss a subtle detail what may be a detail crucial for exam. This thread is only for UW.......we can post any info that you all think is important for differentiatiing 2 close d/d or important NSIMX...or be it InitialSIMX..........so that a day or two before exam we can just can all revise..................to remind you this is thread only for UW and info only from UW....and no discussions(any doubts can be postd in another title if yu may need.
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* cardio: nsimx in pt with cocaine induced ischemia
#499558
dolly123 - 10/11/06 11:40
benzodiazepine ( diazepam)
nitrates
aspirin
increases coronary perfusion, allays anxiety and pain, decreases chances of the emb formation
BETA BLOCKERS SHOULD NOT BE GIVEN
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* cardio: nsimx in pt with stable angina
#499501
dolly123 - 10/11/06 11:19
pt is already on adequate meds, and getsanginal episodes well controlled by SL nitroglycerine. nsimx in inv?
exercise stress testing
if this is c/i for any reason then do pharmacologic stress testing.
the purpose of stress testing is for risk stratification
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* cardio: nsimx in bradycardia due to sick sinus syn
#499446
dolly123 - 10/11/06 11:06
pt gets a single lead ventricular pacemaker
atropine / isoproterenol will always be one of the choices here but is not the right answer since it is temp mangement, and most pts are usually stable needing a more definitive treatment
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* cardio: abdominal dissection next diagnostic step
#497710
dolly123 - 10/10/06 12:51
c/f tearing pain radiating to back ie acute dissection
dx---> transesophageal echo (TEE)
----> also CT
if pt has chronic presentation and is hemodynamically stable
------> MRI
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* Re:To all UW readers - let us help ourself ..
#497673
amith - 10/10/06 12:40
Post natal jaundice : Criteria for extensive evaluation
* Jaundice 24-36hrs
* Dir.Bil >2mg/dl anytime
* Ser.Bil rate of inc at 5mg/dl/day
* Full term Ser.Bil >12mg/dl
* Preterm Ser.Bil>10-14mg/dl
Physiological Jaundice starts 2-3 d------>peaks 2-4 day---->normal 5-7day
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* cardio: nsimx in hyperthyroidism induced Afib
#497487
dolly123 - 10/10/06 11:14
PROPRANOLOL
digoxin is not a good choice because the rpid ventricular response in hyperthy induced afib is resistant to cardiac glycosides
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* CARDIO: cold leg nsimx and follow thru
#497473
dolly123 - 10/10/06 11:10
cold leg in post MI case is likely a thrombus from the LV ( Arterial embolus )
to localize: angiogram
to treat : embolectomy if proximal
endoarterial thrombolysis is distal
another important test to be done:ECHO
this is to localize site of embolus origin in ventricle
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* cardio: unstable angina
#497457
dolly123 - 10/10/06 11:05
tt is
heparin,
beta blocker,
nitroglycerin
aspirin
remember: THROMBOLYTIC THERAPY WITH tPA IS NOT INDICATED IN UNSTABLE ANGINA
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* Re:To all UW readers - let us help ourself ..
#497470
him_vadodaria - 10/10/06 11:09
cong .h. dis.
1)down ---ASD endocardial cusion type
2)turner---coarctation of aorta
--a. stenosis
---pul.ste( noonan syndrom)
3)marfan ---aortic and pulmonary artery dilatation
---M.R ,AR.
4)holt oram syndrom --familial asd
5)rubella --PDA (most comm)
--PUL.STE.
--VSD(Acco C.P.D.T. and GHAI)
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* Re:To all UW readers - let us help ourself ..
#497448
him_vadodaria - 10/10/06 10:59
hocm
c/o--most comm.-dyspnoea
--sudden death may be frist menifest
--systolic murmur (due to m.r.) -hallmark
---doubble and triple apex beat
diag
echo --best
rx
beta block.,ccb.
avoid
digitalis
diuretices
nitrates
beta agonist
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* Re:To all UW readers - let us help ourself ..
#497425
him_vadodaria - 10/10/06 10:51
ekg changes of the
1)hypokelamia
-st depression
-inverted t wawe
-prominant U wawe
-prolong p-r interval
2)hyperkelamia
early.........
peaked t wawe
increse t wawe amplitude
later
-prolong p-r interval and qrs duration
-loss of p wawe
-av conduction delay
-sine wawe pattern
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* cardio: nsimx in pulsatile abdominal mass
#497412
dolly123 - 10/10/06 10:46
dx is abdominal aortic aneurym
diagnostic test of choice-----> USG
CT is less sensitvei,MRI and is not cost effective
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* Re:To all UW readers - let us help ourself ..
#497409
him_vadodaria - 10/10/06 10:45
st segment changes
elevated with convexity upwards
-acute m.i
-priz. angina
-l.v. anuresum
with concavity upwards
-acute pericarditis
st segment depression
1)with oblique plane-angina pectoris
2)with mirror image mark-digitalis
3)with convexity upwards-strain pattren of ventricular hypertrophy
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* Re:To all UW readers - let us help ourself ..
#497395
him_vadodaria - 10/10/06 10:38
cause of s4 sound
-hocm
-hypertention
-a.s.
-acute m.r.
-is.heart.dis
absent s4
a. fib
ventriculaer aneurysum
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* Re:To all UW readers - let us help ourself ..
#497289
kr - 10/10/06 09:40
beta blocker overdose(poisoning) rx:1-cardiac monitoring,resp support.
2-if there is bradycardia or AVblock 1st give atropine..if that fails give isoprterenol.if both fail..next give GLUCAGONE.
3-if all drug therapy fails -temporary pacemaker.
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* cardio: more on SVT
#497082
dolly123 - 10/10/06 00:34
if patient is hemodyanmically UNSTABLE: try electrical cardioversion immediately
if hemodyanmically stable: do as above in previous post on SVT
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* cardio: nsimx in supraventricular tahcycardia
#497078
dolly123 - 10/10/06 00:31
first try------------------> carotid sinus massage to convert the rythm
if it does not work -----> give IV adnosine push
most imp : learn to recognise supraventricular tachy on ECG
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* CARDIO: HOCM screening
#497047
dolly123 - 10/10/06 00:20
in a young athlete if u want to screen for hypertrophic cardio myopathy what is the best measure?
ans: detailed persona, family history and exam
keyword: screen for hocm not diagnose.
in that case probably EKG and ECHO although they have high false + and are useful only in conjunction with the family/personal history
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* NSIMx in aortic regurgition
#496895
dolly123 - 10/09/06 22:57
c/f of AR are: high pitched blowing diastolic decrescendo murmur in 3rd ICS
The defintive tt is surgical replacement of the valve
The nsimx in
chronic AR --->digoxin, ACE I , Diuretics (DAD)
acute AR ---> sodium nitroprusside, dobutamine, dopamine
in both of above cases the meds tt is to stabilze the pt prior to surgery
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* Re:To all UW readers - let us help ourself ..
#496695
amith - 10/09/06 20:47
Given a case of seizure NSIMX
Pt with fit or h/o of fit some time ago --------------------------->O/E Look for any focal neuro deficits/consciousness------------>CBC/Electrolytes/EKG/CXR/Urine toxicology screen -------------------->lorazapam given empirically for fit----------------->CT without contrast/CT with contrast for SOL to rule out IC Hem or tumor(depending upon clinical clues)------------------------>Dilantin if seizure doesnt stop still(Mx along side invst cause)---------------->LP only if CT rules out raised ICT and/or febrile patient (with neck rigidity..clinical clues of meningitis)--------------------->EEG last after stabilizing acute seizures activity but gold standard for documentng epilepsy type. Mx further depends upon results and diagnosis
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* Re:To all UW readers - let us help ourself ..
#494234
amith - 10/08/06 06:38
Aspirin Toxicity in adults and children
adults - acute stage - respiratory alkalosis only
later stages - primary repiratory alkalosis with primary metabolic acidosis(not compensated)
children- acute stages - primary metabolic acidosis with compensatory respiratory alkalosis.........compensatn depends on the timing but usually is very quick in hrs...
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* Re:To all UW readers - let us help ourself ..
#494225
amith - 10/08/06 06:16
Pt with metabolic acidosis and non anionic gap acidosis(an example here is pt with diarheaa with DM nephropathy)
2 causes of NonAnionic Gap Met.Acidosis in our case:
*bicarbonate losses by gi loss in diarhhea
*defective Nh4+ synthesis in renal syn secondary to DM nephropathy
Nsimx ---->calculate urine anionic gap UAG by formula... urine (Na+K) - urine Cl
---->Nrm UAG IS FROM 0 TO (-50)------->If positive-(low c--->low nh4 excretn)-it can either type 1 RTA or type 4RTA---------->IF NEG >cl --->more NH4+ excreted--->renal causes rules out and so it is blammed on GI losses
Note: Bicarbonate gap is used in mixed acid base disorder
Osmolar gap is used in inc anionic gap metabolic acidosis
Urine Ph is used in differentiating types of RTA
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* Re:To all UW readers - let us help ourself ..
#493504
amith - 10/07/06 16:46
Acute pyelonephritis and recurrent...with bacteruria/pyuria/costovertebral tenderness or flank pain n the puzzle behind
SIMX - theme:
Acute febrile illness with costovertebral tenderness and findings of pyuria and bacteriuria on urinalysis suggest the diagnosis of acute pyelonephritis.------------------------------------------
-------->(Oral or parenteral antibiotics can be used to treat acute pyelonephritis depending upon the disease severity) When disease is severe or the patient cannot take the antibiotics orally, IV ampicillin plus gentamycin is an appropriate choice as an empiric therapy for acute uncomplicated pyelonephritis / Those patients who can take the drugs orally, who are compliant or who are not suffering from severe diseases can be started on oral ciprofloxacin as an empiric therapy.------------------------------------------------------------------------------------>When a patient with acute pyelonephritis does not respond to 72 hr treatment with appropriate antibiotics, urological imaging with CT scan or ultrasound must be performed to exclude obstruction, renal, perirenal abscess, or some other complication
In mild recurrent pyelo who on cipro already doesnt respond-----------> may also indicate the presence of obstruction, abscess, or other complications of acute pyelonephritis---->same workup
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* Re:To all UW readers - let us help ourself ..
#493165
amith - 10/07/06 13:06
Mx of calcium oxalate urolithiasis
Increase fluid intake (>3 L/dL) -------->Normal or increased calcium diet (recommended daily allowance is 1000 mg/dL)----->Dietary sodium restriction (<100 mEq/dL)--->
Oxalate restriction (i.e., dark roughage, chocolate, and vitamin C)--->Decrease dietary proteins (i.e., beef, fish, eggs, and poultry
Mx of recurrent hypercalciuric renal stones is increased fluid intake, sodium restriction, and a thiazide diuretic. Calcium restriction is not advised.
Mx of a first uncomplicated calcium stone is hydration and observation.
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* Re:To all UW readers - let us help ourself ..
#492895
amith - 10/07/06 09:12
Acute tubular necrosis
The hallmark finding of acute tubular necrosis is "muddy brown granular casts" consisting of renal tubular epithelial cells; The serum BUN and Cr ratio is less than 20:1. The other findings that support the diagnosis of acute tubular necrosis are:
Urine osmolality of 300-350 mOsm/L (but never <300)
Urine Na of >20 mEq/L
FEÂÂÂÂNa ÂÂ>1%
Casts can be classified as follows:
WBC casts ---------> Interstitial nephritis, pyelonephritis, etc.
RBC casts ---------> Indicative of glomerular disease or vasculitis.
Hyaline casts ------> asymptomatic individuals and pre-renal azotemia.
Fatty casts ---------> nephrotic syndrome.
Broad casts --------> chronic renal failure (CRF).
Waxy cast----------> chronic renal disease.
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* Re:To all UW readers - let us help ourself ..
#490901
ben - 10/06/06 13:19
Acute Pancreatitis
Def
Inflammation d/t autodigestion by proteolytic enzymes
Causes
1. Alcohol (MC in US) “ AST 2x > ALT
2. Gallstones
3. Drugs (Furosemide,Thiazides/IBD Azathioprine/Valproic Acid/Didanosine,
Pentimidine/Metro,Tetracylines)
4. ERCP
Clinically
- Midepigastric Pain Radiating to Back, Fever, Nausea/Vomt. Worse after Food
Dx:
1. Amylase , Lipase levels (Very High)-- Initial to establish acute Pancreatitis
2. US “To r/o Stones as cause
3. CT scan when pancreatitis is severe
- Development of complications: Necrosis, Pseudocysts, Abcess)
(w/ incr severity elevated WBC/Glucose/LDH/AST/ BUN/Hypoxia/↓ Ca
Rx:
In Acute Pancreatitis d/t any cause
- *Bed Rest, NPO, Ab™s, IV Fluids (Conservative Mx)
Once resolved and cause was Stones (seen by US)
- ERCP then later elective Cholecystectomy
Complications that can develop (best seen w/ CT scan)
- *Phlegmon-inflamed pancreas “(48hrs of onset) “ Conservative Mx
- Necrosis (Turner & Cullens sign)“ 2 wks from onset “ Surgical Debridment
- Pseudocyts (occurs 2- 4 wks after acute or chronic pancreatitis)
-> If less 5 cm & ASx = Observe
-> If less 5 cm Sx = Drain
-> If > 5cm & > 1mo there is danger of rupture = CT guided Surgical Removal
- Abscess “ 4-6 wks from onset = CT guided Aspiration
Chronic Pancreatitis
Def
Chronic inflammation of pancreas
Causes
1. Alcohol (70%)
2. Idiotpathic (30%)
3. In Children ---Think CF
Clinically
- Midepigastric Pain, Diarrhae-steatorrhea & Malabsorption,
Diabetes
Dx:
1. X ray = Shows Calcifications (not sensitive so do #2 initially if you susp cancer)
2. CT scan = If you suspect Pancreatic Cancer
(Old, rapid weight loss, dilated CBD)
Labs
- Low trypsin, nl or mild AST/ALT
Rx:
1. Replace Pancreatic Enzymes
2. Medium Chain Triglycerides in diet
3. Decr Fat intake
4. Supplements/Vitamins/Anagesics
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* Re:To all UW readers - let us help ourself ..
#490435
sc98 - 10/06/06 10:46
NSIM-Pleural effusion-
CXR,thn thoraco centesis,if malig cells + ->CT
if cytology non dx with lung mass thn bronchoscopy
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* neuro:nsimx in tonic clonic seizure
#490387
dolly123 - 10/06/06 10:34
pt with no hh/o seizures is seen having t-c seizures
there is disorientatin but no focal neuro s/s
all intial workuo done, incl met screenn, tox screen, glucose given etcetc
next step?
do CT without contrast to rule out intracrebral hge
2nd step: load pt on dilantin (phenytoin) to suppress further seizire activity
However best test to demonstrate epileptiform activity is EEG
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* Re:To all UW readers - let us help ourself ..
#490361
amith - 10/06/06 10:26
NSIMx - Virilisation symtoms ass with genital abnormalities in women
Phase 1) To start with suspect tumor in either adrenal or ovary-----measure testosterone n DHEAS--------->if inc test with nrm DHEA IT IS OVARIAN tumor-------->if inc DHEA with normal Testosterone, it is adrenal origin.
Phase 2) After localising to adrenal measure 17 alpha hydroxy prog for late onset CAH that would explain further the clitoromegaly along with virilisation
Note : LH N FSH r used in cases of PCOD
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* Re:To all UW readers - let us help ourself ..
#489525
amith - 10/05/06 20:58
NSIMx of Thyroid nodule -------> check clinically state---->if hyper/hypo symp+------------------>TSH,T3 N T4---->lab status comes out to be hyperthyroidism ---->do Radionucleotide scan----if hot nodule it shud be benign----/if cold ---->do FNAC(then mostly work up for malinancy)
If clinically euthyroid--------->TSH only-->LAB shows euthyroid----->FNAC to look for benign cond or malignancy.
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* Re:To all UW readers - let us help ourself ..
#489162
amith - 10/05/06 18:23
Primary hyperparathyroidism-
Mx is Surgery IN symptomatic/Medical Surveillance(in surgicaly unfit )
If asymptomatic --------Surgery if
a) ser.ca >1mg/dl of upper nrm limit of calcium + urinary ca exc >50mg/24hr
b) Urine ca>400mg/day
c)pregnancy
d)follow up is difficult
e) cortical bone densiy 2sd f) <50 years
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* Re:To all UW readers - let us help ourself ..
#488975
amith - 10/05/06 17:18
Mx of Hyponatremia from SIADH.
Mild (asymptomatic with sodium 120-130 meq/L) = Fluid restriction
Moderate (asymptomatic with sodium 110-120 meq/L) = Loop diuretic + normal saline
Severe (symptomatic) = hypertonic saline
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* neuro: acoustic neuroma
#488774
dolly123 - 10/05/06 15:51
in a yong pt with gradually dev tinnitus. decreased hearing, and cafe au lait spots think of NF type II
best test: MRI with gladolinium enhancement
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* Re:To all UW readers - let us help ourself ..
#488713
amith - 10/05/06 15:37
Addisons NSIMx
Cosynntropin test----->diagnosis of Addisons made -----------further if yu want to diff primary from secondary do Plasma ACTH level----------->if >50picograms it is primary----<50 is secondary
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* Neuro: diagnosis of alzheimers
#488677
dolly123 - 10/05/06 15:21
The only definitive way to diagnose Alzheimers is by post mortem brain autopsy!!!
Brain autopsy shows:
neurofibrillary tangles
neuronal loss
gliosis
hirano bodies
senile neuritic plaques
beta amyloid in the walls of the intracerebral arteries
other tests commonly done are:
CT = cortical atrophy,widenening of sulci etc..these are not definitve.
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* neuro: mgx of myasthenia gravis
#488525
dolly123 - 10/05/06 14:27
3 tt options:
1. anticholinesterase : pyridostigmine/neostigmine
2. immuno suppressive : azathiprine /prednisolone/cyclosporine
3. thymectomey
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* neuro: SHY DRAGGER SYNDROME
#488496
dolly123 - 10/05/06 14:17
how to diagnose: history suggestive of PD with h/o fall, dry mounth, dry skin and erectile dysfunction
the importance is that PD drugs dont work here and the treatment is :
volume xpansion, salt supplementation, alpha adrenergic agonists and tight garments in lower body
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* neuro: pseudotumor cerebri
#488480
dolly123 - 10/05/06 14:12
pt presentation:
young....obese.....female.....preseneof 6th nerve palsy sign: double vision etc
on exam: papilledema
on csf: n except increased opening prs >200
tt: weight reduction------->acetazolamide-------> optic nerve fenestration to prevent blindness
long term effect if not ttd: blindness!!
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* NEURO: cerebral hge vs cerebral infarction
#488472
dolly123 - 10/05/06 14:08
in a ct the hge is a HYPERdense area, wherea the infarction is a HYPOdense area
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* neuro: cerebellar hge
#488468
dolly123 - 10/05/06 14:07
pt presentation:
ataxia.......vomiting......occipital heaache....gaze paralysis...facial weakness
IMPORTANT TO REMEBER: THERE IS NO HEMIPARESIS
HEMIPARESIS IS SEEN ONLY IN CEREBRAL HGE
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* sorry guys
#488464
dolly123 - 10/05/06 14:04
the two d/d ones i posted were meant to look like tables but it got formatted when i posted it
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* neuro: d/d between tick borne and GBS
#488460
dolly123 - 10/05/06 14:02
progress fever sensation csf
Tick few hrs --- N N
GBS few weeks + decreassed/abN proteins high>100
also GBS has a preceding history in most cases, (GIT infection), tick borne does not
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* neuro: syringomyelia
#488442
dolly123 - 10/05/06 13:52
'cape' distribution of neurological defects
UL weakness and areflexia
dissociated anaesthesia( ie pain and temp gone with vib/position sense preserved)
etio: cord cavitation
most frequent site: lower cervical/upper thoracic spine
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* Neuro: diabetic neuropathy
#488430
dolly123 - 10/05/06 13:49
best test ot diagnose:
EMG and nerve conduction studies
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* neuro:d/d between absence and complex partial
#488424
dolly123 - 10/05/06 13:48
loss of conciousness automatism postictal stg EEGchange
Absence + (sec) + ---- +
Complex PArtial +(min) + + - ? (not sure)
EEG changes in the absence seizures can be increased or challenged by hypeerventilation
Absence seizures also have typical EEG changes (wave and spike ch)
Atypical absence seizures: last longer and have lower voltage EEG changes
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* neuro: tonic clonic seizure
#488409
dolly123 - 10/05/06 13:41
aura
stiffness
unconciousness
seizure
post ictal stage
tt: supportive if seizures are over, diazepam.
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* neuro: cauda equina syndrome
#488404
dolly123 - 10/05/06 13:37
pt presents with :
1. complete motor loss of LE b/l
2. complete sensory loss of L/E b/l
3. loss of rectal tone and perneal sensation
4. inability to pass urine
tt: emergency surgery for spinal cord decompression
if this is a repeat scenario in a pt think of spinal metastases...often seen in a prostate cancer old pt
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* neuro: tt protocol for status epilepticus
#488391
dolly123 - 10/05/06 13:30
ABC---> DIAZEPAM/LORAZEPAM---->PHENYTOIN---->PHENOBARB--->
MIDAZOLAM, AND INTUBATE
(every arrow implies failure of the previous tt, however ABC is a must in all seizing pts )
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* neuro: tt protocol for parkinsons
#488386
dolly123 - 10/05/06 13:27
if resting tremors and no /minimal functional impairment---> check pt's age
if < 70 give benztropine (anticholinergic)
if >70 give amantadine
if more bradykinesia nd functional imp
give, carbidopa and levodopa
if thereis response fluctuation in carbi/levo give Rapinerole or selegeline
best drug to decrease progress of disease is selegeline
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* Neuro: trigeminal neuralgia
#488375
dolly123 - 10/05/06 13:22
best drug for tt = carbamazepine
this has to be routinely followed up bec of risk of aplastic anemia
if there is b/l trig neuralgia in history think of multiple schlerosis
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* Re:To all UW readers - let us help ourself ..
#487887
sc98 - 10/05/06 10:38
nocturnal dysnea
-asthma
-gerd
-lv dysfn
-obs sleep apnea
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* Re:To all UW readers - let us help ourself ..
#487859
sc98 - 10/05/06 10:22
lets try to keep this thread alive
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* Re:To all UW readers - let us help ourself ..
#485328
amith - 10/04/06 10:59
NSIMX IN Diabetic ulcer UW
Grade 1) superficial ulcer 2) deep 3)- deep with cellulitis or abscess 4)- local gangrene
5-extensive gangrene
grade 1 n 2------->wound care+debridement
grade 3------------>short period of hosp/debridement/ulcer material culture/bone biopsy/iv antio bio
grade 4 and 5------->Urgent hospital with exploratn for amputation
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* Re:To all UW readers - let us help ourself ..
#484888
amith - 10/04/06 08:15
In acute respiratiry decompensation
A-a Gradient is the best predictor--->calculate it-using formula(PAO2 - Pao2) where PAO2 is 0.21(760-47) - PaCO2/0.8 this shud be (5 - 15 nrml)---->diffusion defects looked for by V/Q mismatch
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* Re:To all UW readers - let us help ourself ..
#484761
amith - 10/04/06 05:47
Community acquired Pneumonia trt
When clinial n CXR shows CAP with difficulty in isolating organisms....trt is empirical most of the time
A) first step decide on hosopitalisatn based on PSI pneumonia severity index.
----->if HIGH RISK AND IP----->BEST IS NEW GEN QUINOLONES(LEVO/GATIFLOXACIN)
B)if OP-AND LESS RISK--> AZITHRO OR DOXY
C) icu setup ---->RISK OF MRSA-->VANCOMYICN
D) Alcoholic/recent stroke/sedation for endoscopy.---->Clindamycin(High Yield)
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* surgery
#484441
airmax - 10/03/06 23:48
i had copy pasted this on my comp.... smne had posted it on the forum... don rmbr his/her name but thanks
dislocation.
1.Hip is shortened and internally rotated==post dislocation.
ap/lat xray
emergency reduction(risk of avasc necrosis
2.Hip is shortened and externally rotated====ant dislocation.
ap/lat xray
reduction.
3.Pt fell on shoulder. Arm adducted and Forearm externally rotated==*ant dislocation of the shoulder joint.
*x ray
*reduction.
4. Pt had a violent seizure. Arm adducted Forearm internally rotated==ap/lateral Xrays/axillary view
reduction..
look for axillary nerve injury in first(ant) and vascular injury in second.(post)
DO distal neurovascular testing in all fractures.
URETHRAL /bladder injuryINJURY.
Urethal injury: Triad: Blood in meatus, No void and Distended bladder.test,,retrograde urethrogram
- post: associated with blunt trauma. prostate is displaced up - high ridging prostate.
tx..suprapubic catheter now....2.surgery later.
- Ant: associated with pelvis fracture. also scrotal hematoma.more of straddle injury - in which the patient falls on the crossbar of a bike or the top of a fence .
tx...immediate surgery.
bladder injury
- Type 1: contusion
Type 2: Extraperotineal injury
EP - MC with pelvic # - generally bladder not full - more on base or lateral bladder injury
3: Intraperitoenal injury. when bladder is full - dome is stretched - dome injury
4: Both
Dx: Retrograde cystogram with postvoiding films! Don;t forget the postvoiding films!!!.
summary..
Anterior- blood at meatus + scrotal hematoma
Ix: retrograde urethrogram
Treament- immediate repair
Posterior- blood at meatus + scrotal hematoma+ high riding prostate
Ix: retrograde urethrogram
Treament- suprapubic cather, delayed repair after 6 months
For both folate cather can't pass
bladder injury====+/- blood at meatus.....foleys can be passed but blood in catheter as soon as foleys is passed+ suprapubic pain + and ass #of pelvis present
LACERATED WOUND MX
it is a lacerated wound - No Closing - just dressing - first let the inflammation subside, rule out infection - as the patient was able to walk - you can fix it later.
Leggs calv pertheis Mx
. less 5 - no Rx usually resolves spont
2. greater 5 or severe Sx- - casting and crutches
spindolysisthesis.
Spondylolisthesis is a condition that is seen when one spinal segment 'slips' away from another. Spondylolisthesis is most commonly seen with degenerative (aging) changes of the spine, but there may be other causes
superior saggital sinus thrombosis.
HEADACHE, fever, altered sensorium, paraplegia, seizures, hemiparesis and focal deficit.6th cranial N.effect..Lat rectal palsy
Dequrivein tenosynovitis,
SIGN...
tenderness localised to radial styloid
palpable thickening of tendon sheath leaading to limitation of movement
TESTS
pain aggravated by
1. adduction of thumb over palm
2. forcing ulnar deviation
3. radial deviation against resistance
TREAT
early stage....1. rest in slab
2. analgesics
3.ultrasonic radiation
4. local infiltration of hydrocortisone
chronic case.....slitting n excision of tendon sheath
Compartment syndrome
compartment synd is when the interstitial pressure is elevated in a closed osseofascial compartment resulting in microvascular compromise n thus may cause irreversible damage 2 the contents of the space.
causes....
decrease in compartment size...
closure of fascial defects,
tight dressing
increase in compartment....
bleedin,
vascular injury
increase cappilary permeability...
burns ,
trauma,
seizures,venous obstruction
muscle hypertrophy
infiltrated effusion
nephrotic synd
pathophysio.....
ext or int constrictions leads to increase in arterial spasm.....causes musle ischemia..... leads to increase in cappilary permeability.....causes increase in intramuscular oedema...thus increase in im pressure....further arterial compromise........leads to muscle necrosis....replaced by collagen......contractures
HALLMARKS....6 P'S
pain
pallor paraesthesia
paralysis
pulselessness
+ passive stretch test
treatment..
record ICP,
if + clinical findingsdo fasciotomy
if doubtful clinically but ICP more than 30 mm hg do fasciotomy
osteogenic sacroma/ewing sarcoma
OS
1.10-20
2.distal femur n proximal tibia
3. codsman triangle...periosteal elevation due to tumor
sunburst pattern...lytic lesion
4.excision n local irradiation
ES
1.<15
2.diaphesis..
3.onion skinning
4.chemo
**ewing..more aggressive with systemic symtoms
OS..metaphysis...ES=diaphysis.. os also associated with retinoblastoma..
hemoatofenous osteomylitis
ist test----XRay.
specific....bone scan
confirmatory/gold.....cultures
tx..oxa/cloxa/dicloxa..(cillin
SEPTIC HIP
1.child...staph
2.young...gonococcus
3.oleder...ataph
4.sicle cell...salmonella.
5.due to nail puncture....psedomonas.
for children .first arhtrocentesis then hospitalized and tx with antibiotics with 10--21 days .
herniated disc/quada equina
1.herniated=sensory deficit on level of spinal nerve compress
Cauda=saddle anesthesia, acute urinary retention,dec anal tone
2.spine XRAY
3.spinal MRI
4.herniated= anti inflamatory, if nrve root compression-laminectomy
cauda= emergency surgical decompresion.
herniated disk can lead to cauda equina if advanced, it is just like differentiating MI from LVF, MI can have many manifestations, LVF being a serious manifestation of MI though it might have many other causes also.
myocardial contusion/pulm contusion
guess for cardiac contusion is just the same as MI ... but the problem will be less compliant venrticular wall as compared to the less SV in MI .. so we will have less CO with high SVR with High PCWP with less SVO2
do ekg...enzymes...early onset of sx<24 hrs.
mi-->lv wall necrosis-->lv failure to contract-->decrease in stroke vol-->dec in cardiac output-->this dec perfusion to peripheries--->this causes increase in SVR---->inc in afterload
lvf also causes---->pooling of blood in lv----->backward failure---->inc blood in pulmn veins--->pulmn congestion--->pulmn edema-----> inc in pulmn htn---->inc pcwp---->inc jvd and rt heart
In Pul contusion does it affect Hemodynamics .. well it depends on the extent .. if affect a whole lung .. wich will also cos the lung to be edematous & stiff & permitting less blood to pass in Pul cap. which will caz the CO to go down , the PCWP down , the SVO2 down & the PVR increased ... this is my logic ..any correction is fraily welcome
(white out lung...pulm infiltrate...characerstic)..after 24 hrs)
tension pneumothorax
caused by any lthorax injury that acts as a one way valve and allowsair inside but no exit--->air enters lung but cannot exit--->incrsd pressure in intrapleural space----->compresses the affected lung, the heart and mediastinum to contralateral side---->collapsed lung causes hypoxia,,compression of thin walls of rt atrium causes dec venous return and becoz the heart is compressed it becomes kind of stiff ---> leading to pooling of blood backwards..in the venous sys----> this causes inc in JVP---->the decreased venous return and the non compliant compressed heart also cause decrsd CO---->leading to hypotension----> shock
CO poisioning
. What could you so on P/E (external signs)
--soot inside mouth, chery red color
2. Initial Tests / Confirmatory Test
--I=ABG /
--C=Bronchoscopy --determines extend
3. What lab do you need to determine extend of damage and need for support
--Via ABG (incr carboxyhb levels)--dteremines actual extend & need for resp support
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#483553
amith - 10/03/06 19:10
Parapneumonic effusion
In recurrent cases of effusion decision on placing tube thorocostomy---
------------>is pleural fluid ph <7.2
------------>Glucose<60mg/dl
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#483484
amith - 10/03/06 18:39
Post OP diagnosis usinmg time scale------if nothing works out then follow this!
Immediete post op or Day 1 -------> Atelectasis
Day 3 to 7----------------------------> Pneumonia
Day 5 to 7----------------------------> PE
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* NEURO: Hypertensive Stroke
#482938
dolly123 - 10/03/06 15:27
Most common cause of htn is stroke
Most common type of htn sroke is the lacunar stroke due to thrombotic thickening of the small vessels
4 common presentations:
1. Pure motor hemiparesis due to a u/l motor deficit inv the face/arm/ and to a lesser extent theleg. There is also mild dysarthria ( clumsiness)
But no sensory /visual/cortical dysfunction
Stroke in the posterior limb of the internal capsule
2. Pure sensory stroke: u/l sensory loss/numbness and paresthesias, hemisensory deficit involving the face/leg/armtrunk
This is due to a stroke in the ventroposterolateral (vpl) nucles of the thalamus
3. Ataxic-hemiparesis in arm, and to a greater extent in the leg, with same side arm-leg incordination.
Stroke in posterior limb of internal capsule
4. Dysarthria: clumsy hand syndrome: stroke at the basis pontis
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#481953
amith - 10/03/06 10:14
DVT --------MX IDEAS UW
Test of choice for suspected deep vein thrombosis (DVT) is compression ultrasonography.
Impedence plethysmography is the study of choice for recurrent DVT.
Venography ---------> gold standard n used only when the noninvasive testing is not possible or the results obtained by noninvasive testing are equivocal.
Only when the diagnosis of DVT is made by diagnostic testing,----------> anticoagulation therapy is started to prevent thrombus propagation and pulmonary embolism.
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* some quick facts regardin ards
#481885
airmax - 10/03/06 09:38
normal cardiac output
normal pulmonary capillary wedge pressure
increased pulmonary artery pressure
decreased PaO2 and normal or increased PaCo2
decreased pulmonary compliance
decreased alveolar-arterial PaO2
the last two are due to the pulmonary odema which is present due to increased permiablitiy
criteria for diagnosis of ARDS
1. pulm capillary wedge pressure < 18 mm of Hg
2. PaO2 to FiO2 ratio of <= 200 mm of Hg
3. Diffuse, B/L infiltrates on CXR
Rx - treat underlying disorder. If conditioning worsening then put him on IPPV or PEEP.
common complication in IPPV or PEEP - barotrauma (suspect when there is drop in O2 in patient on PPV)
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#481848
fjaan - 10/03/06 08:38
blastomycosis: blasts SKIN,LUNG AND BONE
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* Rx of MS
#481393
airmax - 10/02/06 21:51
drdepa00 - 09/12/06 17:52
Tx of MS
1-Relapsing Remitting ds--3 disease modifying agents--INF-B1a,INF-B1b and Glatiramer acetate (B=Beta)
2-Secondary progessive disease--INF-B1b and Mitoxantrone
(Mitoxantrone give only to pts with normal EF)
If pts with above two cant tolerate INF orglatiramer acetate then considerMethotrexate,cyclophosphamide,IV Immunoglobulin or azathioprine
If pt has MS + Pain/spasticity--Baclofen
If pt has Ms+ Fatigue--Amantadine or Fluoxetine
If pt has MS+ Urinary Incontinency--Oxybutynine
If pt has Ms+ Urinary Retention--Bethanecole
If pt has Erectile Dysfunction--Sildenafil acetate
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#481117
pinkee - 10/02/06 19:24
a decrease in MSAFP and estriol and increase in BhCG is typical of down's syndrome.
all of the above parameters are decreased in edward's syndrome.
condylomata acuminata also known as vulvar papillomatosis -- caused by HPV
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#480414
amith - 10/02/06 13:54
Few more to add ...to the above mentioned forgot to mention that this is only in hemodynamically compromised...or unstable....and not to mention even after embolectomy pt shud be warfinarised for a few months
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#480399
amith - 10/02/06 13:50
PE thrombolysis
Fibrinolysis is the best trt for acute PE clot lysis---(But if h/o trauma/surgery.Fibrinolysis in NOT INDICATED)----->embolectomy
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#480384
amith - 10/02/06 13:46
COPD/ASTHMA DIFFERENTIATION
A bronchodilator response test (administration of a beta2-agonist) measuring forced expiratory volume (FEV1) before and after ----------------> Significant improvement in FEV1
after bronchodilator administration
(15% or greater) indicates
reversibility of obstruction, and
this finding is more consistent with
asthma.....n not so in copd
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#480130
airmax - 10/02/06 12:46
prostatodynia
- pt hav irritative voiding symp. physical exam as well as urinalysis is normal. expressed prostatic secr hav normal WBC nd culture is negative for bacteria. Usually no past hist of UTI but voiding abn may be present in the past... hey if nybdy knws its Rx then pls post it
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#480118
airmax - 10/02/06 12:40
hey guys can we post such relevant information according to topic or subject .... it willl help keep things in order
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#480113
airmax - 10/02/06 12:39
criteria for hospitalization in PID
pregnancy , failure to respond to out patient treatment , suspected non compliance to Rx , nulligravida, severe illness (indlucding nausea, vomiting or high fever) , suspected tubo-ovarian or pelvic abscess , failure to rule out surgical emergencies..
Rx cefotetan or cefoxitin IV plus Doxcy PO
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* NEURO: multiple schlerosis
#479937
dolly123 - 10/02/06 11:55
best test to diagnose: MRI
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* NEURO: D/D OF ds based on neuroimaging
#479854
dolly123 - 10/02/06 11:27
Huntington's Chorea : atrophy of the caudate nucleus
Alzheimers ds: atrpohy of cerebral cortex
Wilson's ds : atrophy of lenticular disease
Pick's ds : atrophy of frontal /temporal lobes
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* NEURO: d/d between TIA and RIND
#479845
dolly123 - 10/02/06 11:21
TIA : reversible ischemic episode lasting <24hours
RIND (revrsible ischemicneurologic deficit) the local s/s resolve iin 24hrs to one week
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* NEURO: d/d between TIA and RIND
#479843
dolly123 - 10/02/06 11:20
TIA : reversible ischemic episode lasting <24hours
RIND (revrsible ischemicneurologic deficit) the local s/s resolve iin 24hrs to
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* d/d between SHY DRAGGER AND RILEY DAY SYND
#479818
dolly123 - 10/02/06 11:08
SHY DRAGGER:
older PD type pt
orthostatic hypotension
impotence
incontinence
RILEY - DAY SYNDROME
autosomal ds in askenzai jew CHILDREN
SEVERE orthostaic hypotension
gross dysfunction of the sutonomic nervous system
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* variant creutzfeldt jacob ds
#479813
dolly123 - 10/02/06 11:01
age of onset: 25-30
slower disease progression
sensory abnormality common
EEG abnormal but no high voltage complexes
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* CREUTZ FELDT JACOB DS : clincal features etc
#479810
dolly123 - 10/02/06 10:59
50-7- yrs of age
reapidly progressive dementia
myoclonus
CSF normal
HIGH voltage EEG complexes
NO SPECIFIC TT
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* tt of pesudotumor cerebri
#479741
dolly123 - 10/02/06 10:05
1. Weight reduction
2. Acetazolamide
3. Surgery: shunting or optic nerve fenestration
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* d/d of paralysis of infectious origin .. BOTULISM
#479732
dolly123 - 10/02/06 09:56
DESCENDING PARALYSIS !!
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* d/d of paralysis of infectious origin GBS
#479730
dolly123 - 10/02/06 09:55
ASCENDING P'lysis....... SLOW ASCENT in days to weeks
annormal csf
abnormal sensation
h/o FEVER +
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* d/d of paralysis of infectious origin TICK BORNE
#479728
dolly123 - 10/02/06 09:54
TICK BORNE
ASCENDING P'lysis....... FAST ASCENT in hrs to days
Normal CSF
NORMAL sensation
NO fever
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* best test for diabetic polyneuropathy
#479708
dolly123 - 10/02/06 09:43
Electromyography and conduction studies
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* cluster headache prophylaxis
#479706
dolly123 - 10/02/06 09:39
VERAPAMIL given asap after onset of ACUTE attack
(other options: propanolol,methysergide, indomathacin , lithium,
Lithium for prophylaxis of CHRONIC FORM OF CLUSTER HEADACHE
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* cluster headache acute
#479701
dolly123 - 10/02/06 09:33
best tt: 100% O2
best med: nasal or subcutaneous SUMATRIPTAN
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#479702
amith - 10/02/06 09:34
UW ARRYTHMIAS APPROACH
Anytime if the patient is hemodynamically unstable [ means BP is low or patient not responding to the verbal commands treatment of choice is electrical cardioversion.
2. If the patient is hemodynamically stable, then you have to think whether it is an acute process? or a chronic process?.
a. If it is an acute [ < 48 hrs] process
i. initial approach is usually rate control.
ii. Electrical or pharmacologic cardioversion may be necessary
1. if rate control cannot be achieved and
2. the patient is experiencing ongoing ischemia or
3. hemodynamic instability.
iii. 4-6 wks warfarin anticoagulation
b. If it is a chronic [ > 48 hrs] process
i. initial approach is usually rate control
ii. 4-6 wks warfarin anticoagulation
iii. Electrical or pharmacologic cardioversion
TREATMENT
Rate control by
1. I.V beta blockers like I.V metoprolol & I.V esmolol
2. I.V calcium channel blockers like I.V verapamil or I.V diltiazem
3. I.V digoxin
4. Quinidine---for SVT ( supraventricular tachycardias )
Cardioversion
1. electrical
2. chemical like I.V ibutilide
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* spinal cord compression
#479698
dolly123 - 10/02/06 09:29
Best treatment: URGENT surgical decompression as it affects prognosis
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#479700
amith - 10/02/06 09:32
ISOIMMUNISATION
fetus is at risk when
1.mother is ag -ve
2. father is ag +ve
3.atypical ag test is +ve
4.abs associated withhemolytic ds of newborn are +ve
5.>1:8ab titre fetus is at risk
is fetus anemic
what is to be done ?
1.Amniocentesis for af bil. Bil plotted on liley graph
2. PUBS
if fetal hematocrit is <25 anemic... nl is 40
is it the time to intervene? i.e is the anemia severe enough ?
on liley graph
zone1: no or mild anemia repeat amniocentesis
zone2: moderate repeat amniocentesis
zone3: high risk intervention required
intervention
if fetus<34wks --------------- intra uterine transfusion
if fetus>34wks --------------- deliver
Prevention
1. routinely to all rh-ve mothers at 28wks
2.within 72 hrs of cvs,amniocentesis,d&c to a rh-ve mother
3.within 72 hrs of delivery of rh+ve baby to a rh-ve mother
300micro gm of rhogam neutralises 15ml of fetal rbc i.e 30ml of fetal blood
TO REMEMBER
1.ABO incompatibility decreases risk of maternal isoimmunisation
2). Duffy ------------------>Dies
3) kell kills,lewis --------->lives
4.atypical abs test(att)------ INDIRECT COOMBS TEST
5.kleihauer-betke test----fetal cells in maternal blood both qualitative &quantitative
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* cataplexy
#479696
dolly123 - 10/02/06 09:28
the basic pathophysio underlying cataplexy is DISTURBED REM SLEEP REGULATION
Not a true syncope
d/d is through associated features:
no lossof conciousness
loss of muscular tone
assc with some emotion
coexistent with narcolepsy in 75% cases (daytime somnolece and hypnogogic hallucinations)
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#479693
amith - 10/02/06 09:25
Pulmonary embolism guys please dont get confused with this thread byfar this is the best discussion we ve had for PE MXN NSIMX----->I would take usmle20 and depa's conclusion as a review.....
www.usmleforum.com/forum/message.php?id=118928
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* with ref to benign essential tremor
#479691
dolly123 - 10/02/06 09:20
the drug PRIMIDONE mentioned before has S/e of acute intermmittent porphyria..to elaborate on its clinical presentation , the c/f of AIP will be
1.abdominal pain
2.psych
3.neurological abnormalities
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* SAH and hyponattremia
#479690
dolly123 - 10/02/06 09:16
In a case of subarachmoid hge, the associated electrolyte imbalance os hyponatremia
Thsi is cerebral salt wasting syndrome, due to SIADH and increased vasopressin secretion
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* status epilepticus
#479689
dolly123 - 10/02/06 09:13
if routine antiepileptic mx does not break seizure, INTUBATION is the tt of choice
workup is done after the control of seizure
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* Re:To all UW readers - let us help ourself ..
#479687
amith - 10/02/06 09:12
The previous post was from Ben/star earlier discussion based on UW thx n from my collections
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#479686
amith - 10/02/06 09:11
Ca/Ph/PTH --------------CONUNDRUMS
1. Osteoprorosis
--nl PTH/Ca & Ph-- Dec osteoclast--->dec resorption, Bone loss but mineraliztion is normal
2. Pagets
--Nl PTH/Ca & PhInc ALP--defect in skeletal meneralization/incr bone turnover-incr resop & formation(Inc osteoclast And Inc Osteoblast---> thick sclerotic bone.)
3. Osteomalacia
--Vit D ineffective (not deficient)/low Ca & Ph/high PTH/ nl 1,25 Vit levels (aka calcitrol)
--Defect in mineralization/looser zoenes - pseudofractures/Blurring of Spine on X ray
4. Type II Vit D dependent Rickets
--Mutation of Vit D receptor thus nl Vit D levels (calcitrol) other Values same as osteomalacia
--defcet in mineraliztion of bone and cartilage (growth plate)
5. X linked Hypophophatemic Rickets
--isolated decr Ph / everything else normal/may nl to low Calcitrol
6. Milk Alki Syndrome
--incr Ca/decr PTH, alkalosis & renal failure
7. Osteogenis Imperfecta Type I
--Defect in Collagen Type I
8. Primary Hyperparathyroidsm
--incr PTH & Ca / decr Ph
--MCC = parathyroid adenoma
9. Secondary Hyperparathyroidsm
--incr PTH/ low Ca & Ph
--exp . Vit D def and Renal failure (incr PTH & Ph and decr Ca--?)
10. Pseudohypoparathyroidism
--incr PTH and Ph and decr Ca
11. CRF-- dec ca,incr phosphorous,inc PTH
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#479683
hope00 - 10/02/06 09:10
cmplication of supracondyl # of humerus?
Volkman contraction
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#479680
hope00 - 10/02/06 09:06
indication to use asprin in kids
1.kawasaki disease
2.juvenil rhematoid arthritis
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#479678
hope00 - 10/02/06 09:00
pnemothorax---hypotension, Inc jvp and dec air entary in affected side
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#479675
hope00 - 10/02/06 08:57
pt with MVA in shock with normal chest and plevic Xray.abd exam little tenderness do abd US or DPL befor laparatomy.
but if abd exam with signs of peritpneal irritation eg rebound tendernss go for laparatomy immediately.
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#479672
upsups - 10/02/06 08:53
Benign Essential tremor..
DOC Propanolol or Primidone anti convulsant which can precipitate acute intermittent porphyria
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* tt of trigeminal neuralgia
#479670
dolly123 - 10/02/06 08:52
CARBAMAZEPINE is tt of choice
follow the CBC count due to the risk of the aplastic anemia with prolonged anemia
ailure of medical tt , other tt are:
surgical gangliolysis
suboccipital craniectomy for decompression of the trig nerve.
Carbamazepine is also used for tt of atypical bipolar depression
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#479669
hope00 - 10/02/06 08:49
cardiac temponad-Beck's triad--muffled heart sounds,hypotension,inc JVP
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#479668
amith - 10/02/06 08:48
Respiratory - Bronchiectasis
Steps in Mx
First localisatn of anatomical lesion ---High resoluion CT(Tram track app/ring shadows/peribronchial thickening/also to rule out obstructive lesions) ---->Sputum examinatn n AFB.
Please title the topic otherwise readers will not understand what u intend to say...thx
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#479667
nida - 10/02/06 08:48
* Patient with stable angina and hypertension, a beta-blocker is the DOC.
* Depressed CO combined with elevated PCWP, indicator of left ventricular failure.
* Statin-induced myopathy is due to reduced CoQ10 production.
* PTCA with stent placement has better outcomes than thyrombolytic therapy in patietns with acute ST elevation MI.
* I.V. adenosin is the DOC for paroxysmal SVT.
* Renal artery stenosis (RAS) is a common cause of resistant hypertension in patients with atherosclerosis. Continuous periumblical area murmur is the characteristic of RAS
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* D/D of intracerebral hge
#479666
dolly123 - 10/02/06 08:48
PUTAMEN hge : hemiparesis, hemisensory loss, homonymous hemianopsia, stupor , coma
CEREBELLARhge: ataxia, vomiting,occipital headache, gaze palsy, faical weakness. NO HEMIPARESIS..if left unttd then there is stupor or coma due to brainstem comprssion
PONTINE HGE
udden dramatic onset of severe headache, no focal neuro signs, no HTN risk and ususally due to saccularaneurysm and vascular malformation Report Abuse
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#479664
hope00 - 10/02/06 08:46
when you need home O2 therapy in COPD?
when Po2<55 or O2 sat <88%
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#479661
hope00 - 10/02/06 08:44
How diagnosis malabsorption?
24hrs stool for fat,if >7g it is malabsorption
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* other bugs in gbs
#479656
dolly123 - 10/02/06 08:37
HERPES VIRUS
MYCOPLASMA
HEMOPHILUS INFLUENZA
RECENT HIV
RECENT IMMUNIZATION
GBS also seen in pts with lymphoma, SLE and sarcoidosis
other bugs as distractors:
ecoli O157:H7 in HUS
salmonella, shigella, campy, yersinia, chlamydia in REACTIVE ARTHRITIS
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#479659
hope00 - 10/02/06 08:41
Which condtion need blood transfusion?
loss 1500cc of blood
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* INFECTIVE AGENT IN GB syndrome
#479653
dolly123 - 10/02/06 08:33
Guillain Barre syndrom e is preceded by an resp or GIT infection
frequent bug responsible/involved: CAMPYLOBACTER JEJUNI
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* PD features
#479650
dolly123 - 10/02/06 08:28
In addition to tremors, cogwheel rigidity, bradykinesia, retropulsion, also look for
1.subtle dementia,
2.depression and
3. MICROGRAPHIA
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* sudden painless loss of vision NSMx
#479648
dolly123 - 10/02/06 08:26
NSMx is duplex ultrasound of carotids is done with painless loss of vision lasting few seconds. amaurosis fugax.
the usg detects the presence of emboli at the carotid bifurcation
CT?MRI is indicated only if there is associated h/o of stroke or any focal neurological s/s
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* Drugs for resting and other tremors
#479643
dolly123 - 10/02/06 08:17
Propanolol : for benign essential tremors
Benztropine: anticholinergic improves resting tremor and rigidity, with minimal or no effect on bradykinesia
they are most useful in under 70s, with a disturbing element of resting tremor and minimal bradykinesia
They are also used in advanced disease in thosewhere tremors do not improve with l-dopa
they are discourage in the elderly due to their anticholinergic side effects
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#479614
amith - 10/02/06 05:12
Psych
Mania - - mania which may be ass with acute agiattion - -- immediete Simx----Haloperidol
Mania --- Abrubt onset of symptoms witout agiatation---- Valproate best
alaternatively Lithium(takes 4 to 10 days to act)
After Antiphyscotic trt -
Dytonia duration of occurence 4hr to 4 days
Parkinsons -- 4d to 4m
Tardive dyskinesia - 4m to 4yr
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#501877
amith - 10/12/06 10:06
Stable and unstable angina -Differentiation
Both conditions wud have more or less same presentation clinically....so what do u do
first..------------>start the treatment protocol of asa, ntg, o2 , morphine..........>..mesnwhile take an ekg............>if ur ekg shows st elev ..----->u got ur diagnosis.--------->mi-------------->tx wth thrombolysis etc
If ekg shows no ST elev ------->.then it cud be either unstable angina / NSTEMI/ cud also be an evolving mi which is slowly evolving so what do u do./.u send cardiac enzymes-------------->dont wait for results------->.mean while take serial ekgs------->and start tx------->for UA/NSTEMI(tx for both is Aspirin, NTG, betablockers, heparin, o2, morphine).---->a) if the serial ekg shows evolved MI wth st elev then add TPI------/------or b) on otherhand if cardiac enzymes r raised with ST elevation -->STEMI---->Rx Aspirin, NTG, betablockers, heparin, o2, morphine + STK/tPA/PTCA if in window period-----/--c) If cardiac enzymed raised with ST depression as seen previously----confirm diagnosis of NSTEMI -------d) If ST dep and T inv with no rise in cardiac enzymes---->confirm Unstable angina
Reference: for the above protocol
Diagnosis..... EKG.........................cardiac enzy................treatment
USA........normal/T inv/ST dep.......not raised......Aspirin, NTG, beta, heparin, o2, morphine
Nstemi....normal/T inv/ST dep........raised...........same as above
STEMI....ST elevation/new LBBB.....raised...... ...same + STK/tPA/PTCA if in window period
Courtesy: ajeet ,cg, airmax and ben
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* heme/onc: metastatic bone pain
#506637
dolly123 - 10/14/06 08:53
CA PRostate: nsimx
IV dexamethasone
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* * heme/onc: metastatic bone pain
#506640
dolly123 - 10/14/06 08:55
then MRI or CT myelogram to confirm site/diagnosis of the pain as due to anterior cord compression
then radiotherapy
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* Re:To all UW readers - let us help ourself ..
#506655
amith - 10/14/06 09:16
Time scale- Simple guesses
*Generalised Anxiety Disorder - too many things to worry - min 6mn duratn
*PTSD - Flashbacks and nightmares(important words) - >4 weeks
*Acute Stress Disorder - <4 weeks Similar symptoms as PTSD
*Adjustment disorder - diff it with major depression /some signs of depression but within 3 mnths to 6 months but def <6months Vs Major depressn which shud have a min of 6 months
*Brief psychotic disorder - psychotic symptoms <1 months
*Schizophrenia - have symptms for 6 months to establish diagnosis
*Schizophreniform - >1month but <6 month
*Schizoaffective - schizo+mood symptoms but schizo symptoms of delusion n hallucinatn should be present exclusively for 2 weeks in absence of mood symtoms
*Delusional disorder - Nonbizzare delusion at least for 1 month without functional impairment
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* heme/onc: metastatic bone pain
#506659
dolly123 - 10/14/06 09:24
CA prostate:
ina stage 4 pt with bone pain not responding to NSAID, start with short acting morphine to achieve control, once done switch to long acting opiates.
Fentanyl patches referred to in the Q take 8-12 hrs to start acting..not a good choice
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* heme/onc: basal cell CA ( > sun exposure)
#506662
dolly123 - 10/14/06 09:28
nsimx :
full thickness biopsy
after diagnosis:
excision with 1-2 mm of clear margins
then watch pt diligently over time for new sites of recurrence
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* Re:To all UW readers - let us help ourself ..
#507804
amith - 10/15/06 09:09
NSIMx of mild preeclampsia- -- - - - a) Pt at term and fetal lung maturity is fine ----->induce labour for delivery if no other risks
b) Pt is remote from term and fetal lung not matured----->wait until 34 weeks--->bed rest/salt restrictn and close obs to manage HT+dexamethasone ----->as soon as lung maturity is accomplished with dexa------->delivery to be carried out in anycase within 34 weeks
NSIMx of severe preeclampsia
Bed rest/salt rest/dexa and ANTI HT to everyone irrespective to stabilise the pt
a) if pt stabilised------->decison for delivery depends on gestation age....same as in mild preeclampsia with lil changes
1) if pt at term - deliver
2) pt is remote -->wait for lung maturity till 34 weeks.....but not later even if not matured
b) if pt does not respond to initial therapy and is not stabilisd irrespective of factor immediete deliver
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* hemeonc: ITP nsimx
#509520
dolly123 - 10/16/06 13:54
dx: thrombocytopeni with no cause
or thrombocytopenia with ab to IIc/IIIb or Ib/IX
tt: steroids for 2 wks
no response---> splenectomy
no reposnce---> anticancer drugs: cyclophosphamide/danazol
if bleeding crises / before surgery: IV Ig infusion and platelet tranfusion
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* heme onc: post orchiectomy prostatic met s pain
#509567
dolly123 - 10/16/06 14:01
nsimx: for areas of bony metastasis in post orchiectomy pt ?
Radiation therapy, since pt has already had surgical androgen ablatioin..if that were not the case we do that first with appropriate drugs
these are: flutamide and cyproterone acetate..
please confirm?
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* Re:To all UW readers - let us help ourself ..
#511213
hope00 - 10/17/06 10:10
--------
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* Re:To all UW readers - let us help ourself ..
#511218
amith - 10/17/06 10:12
ITP---dec plat all others normal
TTP---dec plat ,hemolytic anemia,nuerologic symptoms, inc ur/cr
HUS--same as TTP but high inc in ur/cr little neurologic sypmtoms
DIC---dec plat ,inc PT,inc PTT,inc bleeding time, inc FDP
CLL---sumdge cells ,thrombocytosis,splenomegaly,anemia
CML-----low LAP,phelidepha ch +
thx to hope
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* heme/onc: solid testicular tumor ...nsimx
#511434
dolly123 - 10/17/06 11:25
After the diagnosis of a solid testicular mass has been made, (a painless hard mass in testicle + suggestive ultrasound), the initial management is removal of the testis and its associated cord, orchiectomy.
Depending on the cell type of the cancer present other therapies, i.e. additional surgery, radiation therapy, or possibly chemotherapy may be indicated
REMEMBER!!!
FNAC, or transscrotal biopsy, is contraindicated because of the risk of spillage of cancer cells, which can potentially spread through lymphatics and blood vessels
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* Re:To all UW readers - let us help ourself ..
#511552
amith - 10/17/06 12:07
Asthma Mx Protocol
4 types
1) Mild Intermittent - symtoms<=twice a week/nocturnal symp occur <= twice a month
Rx Inh short acting beta 2 agonist/flares with inh steroids if needed ...Note:daily medicatn not needed
2) Mild persistent - symptoms >twice a week/noc sym occur >twice a month
Rx Low dose inh steroids/flares with short acting b2agonist...............long term control only req daily trt
3) Moderate persistent - daily symptoms +exacerbatn >=twice a week
Rx Low doseInhaled corticosteroids + long acting beta agonist or medium dose inhaled steroids
4) Severe persistent - High dose Inhaled steroids + long acting beta agonist/also leukotriene antagonist and systemic steroids if needed
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* Re:To all UW readers - let us help ourself ..
#511571
amith - 10/17/06 12:14
*Also add continuous symptoms with freq exacerbatn in severe persistent
*3 n 4 requires daily trt
*Exercise induced asthma best trt by inhaled b2agonist
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* Re:To all UW readers - let us help ourself ..
#521546
amith - 10/21/06 19:23
Tuboovarian abscess trt
Admit the pt------>Triple antibiotic regimen -----Gentamycin + Ampicillin +clindamycin --------------->if no response within 24 to 48 hrs --->drainage
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* Re:To all UW readers - let us help ourself ..
#522416
amith - 10/22/06 13:10
Burns - HY
1) Rules - second degree and third degree b urns are only counted for these formula n calculatns of fluid replacement
2) Rule of nine in adults
Head ----------9 peds - Head - 18
Left hand --- 9 both legs ---- 27
Right hand --- 9 all the rest same
Left leg ------ 18
Right leg ------18
trunk ----------36
3) Parkland Formula - Body weight x% of burns(only upto 50) x 4(4 - 6 in babies)+
(additionally 2000ml D5W to compensate as pt on NPO and NG tube in place)
This is the amount of RL to be given in first 24 hrs.
Given as : Half dose within first 8 hrs and second half within next 16hrs
4) Colloids not given in first day due to loss in edema fluid so given in 2nd day in 16hrs
5) Empirically for anyone coming with burns >20% BSA start with 1000ml/h initially in adults and 20ml/kg/hr in kids
6) Third degree burns differ in adults n children ------leathery gray in adults/deep bright red in children
7) Give TT prophylaxis/antibio silver sulphadiazine(mafenide acetate restricted use only in deep burns not anywhere else)
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* Re:To all UW readers - let us help ourself ..
#516254
amith - 10/19/06 06:49
Precocious puberty
Its divided into 2 groups and deals w/ normal developmental factors that shuld be seen at a certain age. If these devlop are seen to early its called precocious puberty.
Its includes
-Breast develpment-->nl develp at 9-10 years
-Pubic & Hair--> nl at 10-11
-Growth--> nl at 11-12
-Menarche-->nl at 12-13
Its divided into 2 groups
a. Incomplete
--Involves only one change on the list
--D/t transient elevations of FSH/LH or end organ damage
--Mx Conservative
b. Complete
--Involves all changes on the list
--Also has 2 types
--> GNRH dependent
--> GNRH indepdent
GNRH dependant
------->also called as true isosexual precocious puberty is secondary to activation by hypothalamic-pituitary axis - ex pituitary tumors.etc
GNRH independant
-------->also called as pseudoisosexual precocious puberty is secondary to end organ causes withouit activatn of the Hypotha pit axis - ex ovarian tumors, adrenal tumors, exogenous estrogen exposure,advanced hypothyroidism and Macune Albright syndrome
To differentiate this we do a test called GNRH stimulation test(most important test) - 100micrograms are administred as IV bolus -----> a gud reponse of LH release-->true isosexual puberty
However we do other nonspecific test to detect the underlying problem like MRI/Serial bone age/Visual testing so on....
1) Adrenarche n thelarche <6year