Helping myself to keep my eye on the ball - amaranta

[ArchivalUser]

Coffee is gone. Back is hurting. Time for lunch, I guess.

[ArchivalUser]

Time for a block of Qs.

[ArchivalUser]

Finished the block.

Dig into the fridge and only found a piece of fruit It's only Thursday...1 more day before the next grocery shopping trip.

Block review starting now.

[ArchivalUser]

Question review really takes time. Spent 1.5 hr on it...still got about 1/2 block to go over. People say spending 1 hr on reviewing of each block. They must have photographic memory. I had to take notes and review them or I will forget!

Uh, I think I will have to rewrite my schedule.

[ArchivalUser]

Ok. Tomorrow = tackle one of the 4 system: Endo, Neuro, Renal, Peds.

[ArchivalUser]

doc...writing letters like less than , more than rather than signs will help posting your post on the forum, i heard.

- reviewing a block in 1 hr is ispiring. GL

[ArchivalUser]

Thanks Validation! Your suggestion s very helpful. I will definitely keep that in mind when posting.

Today - neuro

The past hour - reviewing flash cards

[ArchivalUser]

Stroke
• 1st step = CT
• ischemic stroke
o within 3 hrs from onset  tPA (r/o C/I 1st – BP must be >185/110!!!)
o after 3 hr  ASA
o already on ASA  add dipyridamole or SWITCH to clopidogrel (heart can do duo therapy not delicate brain!)

stroke & BP more than 220 / 120  IV labetalol or nicardipine


post-stroke workup
ECHO -- surgery if valve damage – replacement
-- warfarin to INR of 2-3 if thrombi
ECG – AF + stroke  warfarin, debigatran (thrombin inh), rivaroxaban (Xa inh)
Holter (if ECG negative) @telemetry
Carotid Duplex U/S

CHADS2 score in AF-- risks and benefits of initiating antithrombotic therapy. ======= CHF, HTN, Age>75, DM, Stroke/TIA
The more recently developed CHA2DS2-VASc score takes into account other stroke risk factors and may be able to accurately identify which patients are at low enough stroke risk to forgo oral anticoagulation.

[ArchivalUser]

stroke management:
Any sudden onset neurological deficit 1st step do ct scan head (r/o hemorrhage)

If blood present conservative management for hemorrhagic stroke:

Anticonvulsants - To prevent seizure recurrence
Antihypertensive agents - To reduce BP and other risk factors of heart disease
Osmotic diuretics - To decrease intracranial pressure in the subarachnoid space
Intubation and hyperventilate if ICP increased and watch vitals and neuro check regularly ..
So for hemorrhagic stroke all conservative mx!!

If no blood in CT or CT negative for stroke but dense hemiplegia do MRI brain ( stroke seen in MRI within 24 hrs-- most accurate test for stroke)

So If ischemic stroke mx in the line of ischemic stroke has to be done
As follows:

If patient presents less than 3 hrs
Give tpa unless contraindicated.
If patient presents more than 3 hrs
Give aspirin..

If patient is already on aspirin add dipyridamole to prevent recurrent stroke or the patient may be switched to clopidogrel!!

(UW---stroke on aspirin therapy and patient with intracranial large artery atherosclerosis give Aspirin+clopidogrel)

Stroke with evidence of atrial fibrillation--- long term anticoagulation
Warfarin,dabigatran,rivaroxaban


Use heparin if patient has atrial fibrillation,basilar artery thrombosis or stroke in evolution

Do EKG: if chronic afib:: continue on warfarin

Do echo: if MS-- valvulotomy
Do carotid duplex to look for stenosis
If carotid stenosis more than 70 % -- do endarterectomy!!



Also contraindications for tpa::
1.hemorrhagic stroke or h/o intracranial hemorrhage
2.stroke or serious head trauma within 3 months
3.hemorrhage (GI/GU) within 21 days
4.major surgery within 14 days
5.arterial puncture within 7 days
6. Lumbar puncture within 7 days
7.MI in past 3 months
8.seizure at onset of stroke
9.systolic bp >185 mmhg or diastolic bp >110 mmhg
10. Platelet

[ArchivalUser]

add to post-stroke workup

Hypercoagulable state work up in 3 pt populations
(1) if pt