CCS- Acute Cholecystitis
> plain abdominal X-ray
> abdominal USG
> abdominal CT
> oral cholecystogram
> MR cholangiography
> hepatobiliary scan with Tc-99m-IDA
> CBC with diff
> chem 7, serum lipase and amylase
> blood type and screen,BUN Glu, Creatinine,PT,PTT
> 1.NPO and IVF
> 2.Reduce fat in diet
> 3.pain control-morphine
> 4.decompression of the pressure in the abdomen by a
> tube placed in
> the stomach
> 5.antibiotics to eliminate the infection
> 6.emergency cholecystectomy if perforation,
> pancreatitis or CBD
> 7.Percutaneous transheptic cholecystostomy
CCS is a cost effective exam
1.PT,PTT without h/o bleeding in fammily not needed
2.MRI angiogram/Hepatobillary scan? Why?
3.Pain control maperidine not morphine
4.Where is surgery consult.
5.Pancretitis and CBD -How could could be percutanous transhepatic cholesistomy?=It is for pus in billiary tree
morphine cause spasm of sphincter
of oddi, so meperidine, pentazocine is desirable.
but i would order PT/PTT for preparing preop. order..
also oral cholecystogram is low cost, readily available, identification of GB anomalies, accurate identification of gallstones, but more time-consuming than GB ultrasound..
GB ultrasound - procedure of choic for detection of stones
radioisotope scan(HIDA,DIDA,ETC) is useful in diagnosis acalculous cholecystopathy, especially if given with CCK to assess GB emptying
iam not sure usefulness of CT, PTBD or PTCD in this case.
Which one of the following drug
can cause acute hepatic necrosis ?
classification of drug-induced
zonal necrosis: acetaminophen, carbon tetrachloride
nonspecific hepatitis: aspirin,oxacillin
viral hepatitis-like reactions; halothane, INH, phenytoin, diclofenac
-autoimmune hepatitislike: methyldopa, dantrolene
-viral hepatits lke;; INH,halothane
-large droplet: ethanol, corticosteroid
-small droplet: tetracycline, valproic acid
- adenoma: estrogen
-angiosarcoma: vinyl chloride, arsenic, thorium dioxide
here's the infou can decide..
Methyl dopa and INH --- chronic hepatitis.
Acetaminophen--- normally acetaminophen undergoes sulfation and glucuronidation for elimination. However, when capacity is exceeded conversion to toxic metabolite which binds to cell components.
-- centrilobular necrosis
· beware: alcoholic with P450 induction plus glutathione depletion leading to enhanced sensitivity to acetaminophen
severe halothane hepatitis usually develops after multiple exposures
· delay before exposure and hepatotoxicity
· liver biopsy: similar to viral hepatitis
· protein adducts formed in initial toxic reaction provide the hapten for the formation of antibodies which augments damage on re-exposure
A 54-year-old man who lost his job
approximately 5 months ago complains of profound difficulty sleeping at night.
He recently found a new job but has continued to experience difficulty
sleeping. He notes that he falls asleep more easily while watching television
early in the evening and feels sleepy outside the house. He is preoccupied with
his inability to sleep at night. General physical examination and routine
laboratory screening are unremarkable. He denies the use of alcohol, coffee,
and other drugs. What is the most appropriate approach?
A Administration of a benzodiazepine
B Administration of stimulants
C Administration of estrogen
D Administration of tricyclic antidepressants
E No therapy
The answer is A
Chronic or long-term insomnia, by definition, lasts for months or years and usually is reflective of a psychiatric or chronic medical condition, drug use (including caffeine or alcohol), or a primary sleep disorder. Psychophysiologic insomnia is characterized by preoccupation with the inability to sleep at night. The problem often is triggered by a stressful event but may persist for long periods because of the acquisition of poor sleep habits. Patients often are aroused by their own failed efforts to sleep. They more readily sleep at unusual times or places. This patient does not have narcolepsy, since excessive daytime sleep and cataplexy are not included in his syndrome. Narcolepsy may be treated with stimulants such as methylphenidate. Moreover, he has no findings suggestive of sleep apnea syndromes, which might benefit from the use of conjugated estrogens. Instead, rigorous attention to sleep hygiene, such as making sure the bedroom is used only for sleep and removing distracting stimuli at bedtime, is most appropriate. Benzodiazepine hypnotics may be helpful during the initiation of treatment by serving to allow behavioral therapy, which is probably the most specific way to treat this problem.
A 14-year-old boy residing with
his parents on a military base presents with a fever of 38.6°C (101.5°F) and
complains of lower back, knee, and wrist pain. The arthritis is not localized
to any one joint. He gives a history of a severe sore throat several weeks
earlier. Physical examination of the skin reveals pea-sized swellings over the
elbows and wrists. He also has two serpiginous, erythematous pink areas on the
anterior trunk, each about 5 cm in diameter. Laboratory investigation includes
negative blood cultures, negative throat culture, normal CBC, and an erythrocyte
sedimentation rate (ESR) of 100. An antistreptolysin-O (ASO) titer is elevated.
At this point, appropriate therapy would consist of
A supportive care alone
B parenteral penicillin
C parenteral penicillin and glucocorticoids
D parenteral penicillin and aspirin
E parenteral penicillin, aspirin, and diazepam
major manifestation( migratory polyarthritis, erythema marginatum)
minor manifestation( fever, arthralgia, elevated ESR)
elevated ASO titer
aspirin for sx. of arthritis
steroid only for heart failure and severe carditis
digitalis and furosemide only for CHF
diazepam or haloperidol only for chorea but controversial
Which of the following statements
about Paget's disease of bone is true?
a. It involves cancellous and cortical bone.
b. It frequently undergoes malignant transformation.
c. It is a contraindication to joint replacement surgery.
d. It is rarely asymptomatic.
e. It does not affect the bone marrow.
The highest prevalence of latex
allergy is found in individuals with which one of the following conditions?
b. Spina bifida
c. Allergic rhinitis
d. Peanut allergy
e. Prosthetic heart valves
Today it is known that latex
allergy occurs more frequently in individuals or groups who have high exposure
to NRL products. Healthcare workers, children with spina-bifida, other
individuals who have undergone multiple surgical or dental procedures, and
persons with atopy (atopic eczema, allergic rhinitis, hay fever, asthma) are
considered to be at increased risk.
Rates in children with spina bifida are alarmingly high, ranging from 34% to 67%. Rates in children with atopic dermatitis have generally varied between 2% and 4%, although one study in 1996 found that almost 21% of atopic children with hand dermatitis were sensitized to latex.
The prevalence of latex sensitization in the general population also varies. Studies show rates that range between 0.4% and 7.9%, with one recent study of 2,000 unselected blood donors revealing a sensitization rate greater than 5%.
A 27-year-old woman has a 2-year
history of systemic lupus erythematosus (SLE). She originally presented with
symmetrical arthritis and intermittent pleuritic chest pain.
At that time, laboratory data indicated the following: WBC count 3.5, Hb 11.6, platelet 165,000, P 85, L 10, M 5; creatinine 0.9; ANA 1/320 speckled pattern; ds DNA antibody negative, SS-A 60 (normal < 29); C3 60 (N 73–120), C4 12 (N 15–30), urinalysis negative.
She was treated with nonsteroidal antiinflammatory drugs and eventually with hydroxychloroquine for control of her arthritis. She now presents with a 1-month history of temperature of 99°F to 100°F, increased arthralgias, and anorexia. Examination shows BP 180/110, fundi benign, lungs clear, heart without gallops or murmurs, mild swelling and tenderness of her proximal interphalangeals (PIPs), and 1+ pretibial edema.
Laboratory studies show Hb 9.5, Hct 27, P 90, L 8, M 2; creatinine 2.2; ds DNA 150, C3 32, C4 <8; urinalysis 3+, protein 2+, blood 5 to 10 RBC/HPF. She undergoes renal biopsy that shows diffuse proliferative glomerulonephritis with mild interstitial fibrosis.
The most appropriate treatment regimen for this patient would be
a. Prednisone 60 mg/day for 1 month, then tapering doses
b. Prednisone 60 mg and monthly pulses of cyclophosphamide 0.75 g/m2
c. Intravenous methylprednisolone 1000 mg daily for 3 days, followed by prednisone 60 mg
d. Intravenous methylprednisolone 1000 mg daily for 3 days, followed by prednisone 60 mg daily and monthly pulses of cyclophosphamide 0.75 g/m2
diffuse proliferative GN and
a predominance of irreversible changes with little acute inflammation portrends a poor response to therapy and should modify the aggressiveness of immunosuppressive treatment.
patients with severe renal disease are treated initially with methylprednisolone 500mg IV q12hrs for 3days and then prednisone po 0.5-1mg/kg qd
prednisone should then be tapered over6-8 weeks to the lowest dosage
and then cytoxan 0.5-1g/m2 IV monthly for 6months
it has been shown to retard progressive scarring within the kidney, prevent loss of renal function, reduce the risk of ESRD.
Source)washington manual and primer on the rheumatic disease..
A 12-year-old is brought to the
emergency department 20 minutes after a near-drowning episode. He required only
minimal resuscitation at the swimming pool and is now alert, oriented, and in
What further action would you take?
a.Intubate the patient for bronchial suctioning
b.Admit for observation and monitoring
c.Discharge after he is observed for 30 minutes
d.Discharge if the physical examination is normal
Even near-drowning patients who require minimal resuscitation need advanced life support follow-up because a substantial number will have respiratory distress within 4 hours after the event. Intubation would be done only for its usual indications.
Even if there r no sings or symptoms after a near-drowning experience..the patient must be kept under observation for 24 hours due to the possibility of late development of ARDS.
A kid with clavicale
fracture,after proper management,
how long the patient could do regular physical activities ?
Ilio-Tibial Band Syndrome (ITBS)
Ilio-Tibial Band Syndrome (ITBS)
Lateral knee pain in runnersis often caused by Iliotibial Band Syndrome (ITBS). The ITB is a thick band of tissue which runs from the outside of the pelvis (over the hip) down the thigh and inserts just below the knee (on the outside). The symptoms range from a stinging sensation on the outside of the knee (most common), or along the entire length of the ITB, to swelling. The pain will worsen with activity when the foot strikes the ground and overpronates (where the foot 'spreads' to the floor), especially if you overstride or run downhill and may persist afterward. A single workout of excessive distance or increase in mileage can aggravate the condition.
Treating ITB should consist of the following:
Ice knee after activity
Alternate running direction on banked surface
Stretching the ITB.
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