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Nonatal infections


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neonatal infections

Oral candidiasis; peaks at 14 days of life.
Clinically. White plaques on erythematous base over oral mucosa, tongue.
Treatment. Nystatin suspension 100,000 to 200,000 U PO QID for 7 days. Mycostatin cream to maternal areola and nipple if breast-fed infant.

Neonatal Bacterial Sepsis
General comments. Neonatal bacterial sepsis is associated with 10% to 40% mortality and significant morbidity, especially neurologic sequelae of meningitis. Infants <1 month old are immunologically deficient and are predisposed to serious infections.
Predisposing factors. Premature rupture of membranes (>24 hours), premature labor, maternal fever, UTI, foul lochia, chorioamnionitis, IV catheters (in infant), intrapartum asphyxia, and intrauterine monitoring (pressure catheter or scalp electrode).
Early infection (0 to 4 days of age). Group B streptococci and Escherichia coli 60% to 70% of infections. Also Listeria (rare in United States), Klebsiella, Enterococcus, Staphylococcus aureus (uncommon), Streptococcus pneumoniae, group A streptococci.
Late infection (>5 days of age). Staph. aureus, group B streptococci, E. coli, Klebsiella, Pseudomonas, Serratia, Staph. epidermidis, Haemophilus influenzae.
Signs and symptoms. Presentation may be subtle; thus any febrile neonate must have a septic work-up. Fever may be absent; so watch for symptoms below.
The presentation may include irritability, vomiting, poor feeding, poor temperature control, lethargy, apneic spells.
May progress to respiratory distress, poor perfusion, abdominal distension, jaundice, bleeding, petechiae, or seizures.
Bulging fontanel is a very late sign of neonatal meningitis, and Brudzinski's sign or Kernig's sign is rarely found.
Include LP for cell count, protein, glucose, and culture.
UA, CBC (remember neutropenia or thrombocytopenia are also suggestive of infection) and repeat in 5 hours, CXR and C-reactive protein.
Cultures of blood, urine, and any other site as indicated. Latex agglutination test for pneumococcus, E. coli, H. influenzae, group B streptococci, and meningococcus in blood, urine, and CSF is done even though the usefulness is questionable. Negative latex agglutination tests do not rule out infection, but positive results may help guide therapy.
Associated lab findings. Hypocalcemia, hypoglycemia, hyponatremia, and DIC.
Should be tailored to age of onset, clinical setting, and initial findings.
There should be NO DELAY in antibiotic therapy. Begin empiric therapy after cultures are obtained or before cultures if any delay is anticipated.
Empiric early (0 to 4 days old). Ampicillin 50 mg/kg/day (100 mg/kg/day in meningitis) divided 12 hours IV and gentamicin 5 mg/kg/day divided 12 hours IV.
Empiric late (>5 days old). Depends on cause (for example, methicillin-resistant Staph. aureus outbreak requires vancomycin) ampicillin 100 to 200 mg/kg/day divided Q8h plus (ceftriaxone 100 mg/kg/day IV Q12h or cefotaxime 150 mg/kg/day IV Q8h), or ampicillin-gentamicin as above usually adequate.
Repeat cultures in 24 to 48 hours. In meningitis, repeat LP every day until clear.
There are isolates of Streptococcus pneumoniae that are resistant to penicillin and cephalosporins. Depending on your institution, vancomycin plus rifampin should be added to the above regimens until sensitivities are known.
Other. Hemodynamic, respiratory, hematologic, metabolic, and nutritional support and surveillance are critical. Shock may require volume expansion (FFP preferred) or respiratory depression may require supplemental oxygen or artificial ventilation

**In a pregnant patient with chronic hypertension and no underlying renal disease, the best indicator of superimposed preeclampsia is

a. proteinuria (300 mg/24 hr)
b. hyperuricemia
c. exacerbation of hypertension, as evidenced by a 10-mm Hg increase in diastolic blood pressure
d. edema


In the absence of renal disease, the onset of proteinuria (at least 300 mg/24 hr) is the best indicator of superimposed preeclampsia in a patient with chronic hypertension.

**Which one of the following is true of a pregnant patient who has diabetes mellitus?

a. Adjustments in hypoglycemic medications are best made by following urine glucose readings
b. Oral hypoglycemic agents are useful during pregnancy in patients with mild diabetes mellitus
c. A precise knowledge of fetal age is important to a successful outcome for the fetus
d. Because the fetal pancreas helps control the diabetes, ketoacidosis is less likely during pregnancy


Ideally, the child of an overtly diabetic woman should be delivered close to term. Precise knowledge of fetal age (by menstrual history, accurate measurements of uterine height during the second trimester, and confirmation by sonography) is very important to a successful outcome for the fetus. In diabetic women the likelihood of severe metabolic acidosis is increased appreciably. Oral hypoglycemics should not be used during pregnancy. Pregnant diabetic women should be maintained in glucose homeostasis as close as possible to that of nondiabetic pregnant females. Home serum glucose monitoring has become the standard practice and is replacing urine glucose monitoring.

**Severe growth retardation is diagnosed in the fetus of a 19-year-old unmarried white female at 36 weeks gestation. The diagnosis is based on biparietal diameter and there is scant amniotic fluid.

Which one of the following is the most appropriate management?

a. Perform serial L/S ratios until greater than 3.0, followed by prompt delivery
b. Induce labor, with careful fetal monitoring
c. Perform an immediate cesarean section
d. Follow the mother weekly with serial ultrasounds
e. Follow the mother weekly with nonstress tests


Appropriate management of the preterm infant who is severely growth retarded depends on several factors. Generally those near term should be delivered promptly. By the time that growth retardation has become severe, the fetus is usually mature enough to survive if delivered promptly. However, the fetus must be monitored carefully during labor, with facilities for immediate cesarean section if there is deterioration, and the neonate must receive excellent neonatal care beginning immediately after delivery.

**Ultrasonography reveals placenta previa in a 41-year-old asymptomatic gravida 4 para 3 at 21 weeks gestation. Appropriate management would be

a. weekly speculum examinations under aseptic conditions beginning in her third trimester to assess the risk of bleeding
b. an MRI scan, with a repeat scan later in the pregnancy if indicated
c. repeat ultrasonography in her third trimester
d. cesarean delivery at 28 weeks gestation if her L/S ratio is favorable
e. reassurance that ultrasound diagnosis of placenta previa without evidence of bleeding is no cause for concern and can be disregarded


The incidence of placenta previa ranges from 6% to 45% in the second trimester, but more than 95% of these resolve by the third trimester. However, it remains a cause for concern and should be watched, not ignored, even if there is no bleeding. This patient should have repeat ultrasonography in her third trimester. An MRI is very helpful but need not be used except in a difficult diagnostic situation. Weekly speculum examinations would create a risk of hemorrhage. Delivery at 28 weeks would not be appropriate in a patient with no symptoms and without confirmation of the persistence of placenta previa.

**A 27-year-old nondiabetic multiparous woman at 39 weeks gestation has had a previously uncomplicated pregnancy. Fundal height and estimates of fetal size have been at the upper limits of normal for several weeks. Today the fundus measures 44 cm from the pubis and you estimate on palpation that the fetus is large. Clinical pelvimetry is normal.

Which one of the following treatment plans is supported by objective clinical evidence?

a. Perform external podalic version to breech position and deliver vaginally, in order to decrease the likelihood of shoulder dystocia
b. Place the mother on a 500-calorie/day diet in order to slow fetal weight gain
c. Perform a cesarean section based on the clinical estimate of above-normal fetal size
d. Order ultrasonography and perform a cesarean section if estimated fetal weight is 4000 g
e. Plan vaginal delivery, with personnel in the delivery room who are trained to assist with a difficult shoulder delivery should it occur


No study has demonstrated improvement in fetal outcome with cesarean delivery for estimated fetal weight above 4800 g, either estimated by fundal measurement and palpation or by ultrasonography, except in the case of diabetic women. Statistical estimates show greater increased morbidity and mortality for the mother than any achievable decrease in fetal morbidity and mortality. Therefore, vaginal delivery should generally be planned with delivery room personnel present to assist, should shoulder dystocia occur. An extremely low-calorie diet would be contraindicated and dangerous to both mother and fetus. External podalic version would be contraindicated and place the fetus at risk of a dangerous breech delivery.

**Following a prolonged labor and traumatic delivery, a 5015 gram (11 lb 1 oz) white male infant holds his right arm in an abducted and internally rotated position with extension at the elbow, pronation of the forearm, and flexion of the wrist. Although the grasp reflex is intact, the biceps and brachioradialis reflexes are absent.

The most likely diagnosis is a

a. rotator cuff tear
b. clavicle fracture
c. brachial plexus injury
d. cerebral injury
e. fractured humerus


The clinical picture in this infant is typical of brachial plexus injury. Most cases of brachial plexus injury follow a prolonged and difficult labor culminating in a traumatic delivery. Duchenne-Erb (upper arm) paralysis, resulting from injury of the fifth and sixth cervical roots, is by far the most common manifestation of this disorder. The infant with upper arm paralysis holds the affected arm in a characteristic position, reflecting involvement of the shoulder abductors and external rotators, forearm flexors and supinators, and wrist extensors. In addition, the Moro, biceps, and brachioradialis reflexes are absent. Roentgenographic studies of the shoulder should be made to exclude tearing of the joint capsule, fracture of the clavicle, and fracture, dislocation, or upper epiphyseal detachment of the humerus. Cerebral injury is usually evidenced by other signs of central nervous system damage. Typically, rotator cuff tears are not associated with neurologic findings.

**Which one of the following is an absolute contraindication to tocolytic treatment for preterm labor?

a. Urinary tract infection
b. Documented gestation less than 28 weeks
c. Chorioamnionitis
d. Uncontrolled diabetes mellitus
e. Any vaginal bleeding due to mild abruptio placentae


Before tocolytic treatment is instituted, absolute contraindications to tocolysis must be ruled out. These include chorioamnionitis, severe abruptio placentae, severe bleeding from any cause, severe pregnancy-induced hypertension, fetal death, fetal anomaly incompatible with life, and severe fetal growth retardation. Chorioamnionitis may precipitate preterm labor and is an absolute contraindication to tocolysis. It may be present in a febrile pregnant patient even with intact membranes. In this case amniocentesis may be required to rule out infection. There are also a number of relative contraindications. These include uncontrolled diabetes, hyperthyroidism, maternal cardiac disease, mild chronic hypertension, mild abruptio placentae, stable placenta previa, fetal distress, fetal anomaly, mild fetal growth retardation, and cervical dilatation greater than 5 cm. In patients with relative contraindications to tocolysis the risk of complications from prematurity must be weighed against the risk of tocolysis. Not all vaginal bleeding is due to a serious obstetric condition. Cervical effacement or dilatation may be the cause. Even if the source of bleeding is determined to be a placental abruption, if the bleeding is minor, the abruption is mild, and the fetus is not in distress, tocolysis is not absolutely contraindicated.
While diabetes mellitus may be adversely affected by beta-adrenergic tocolytic agents, it is not an absolute contraindication to tocolysis. Close glycemic monitoring is, of course, mandatory. Even a few weeks of effective tocolysis may significantly alter the perinatal outcome of gestations between 25 and 27 weeks. Gestational age less than 28 weeks is therefore not a contraindication to tocolysis. While a urinary tract infection may precipitate preterm labor, tocolysis is not contraindicated. The infection, of course, should be treated.

A middlaged man with chest discomfort on exercise.
Diagnosis: stable angina.
How would you manage this patient.

Please add your input to the following list:

stress test

calcium-channel blockers.

1st line lab- CBC, Chem7, Lipid profile, UA,FOBT
Counsell- smoking cessation(if any), reduce alcohol intake, exercise, refer to dietecian for formulation of diet etc.
Aspirin PO
Metoprolol PO
Nitroglycerin SL prn(prn choice not available)
Take 1 tab SL q5min- if pain not relieved, immediately attend ER
F/U after 7 days.

Evaluation of patients with angina.
ECG. During an episode of pain, the ECG may show ST-segment depression, T-wave inversions, or it may be normal. The absence of ECG changes during an episode of angina does not rule out cardiac ischemia because the circumflex and posterolateral distributions can be electrically silent. Increasing use is being made of echocardiography and thallium studies (see below) to evaluate patients with continuing symptoms in the absence of ECG changes. Coronary artery disease is suggested if there is evidence of an old MI.
Graded exercise stress test or treadmill (GXT). The predictive value of a positive test depends on the prevalence of disease in the population being tested. Specificity is high in particular groups of symptomatic individuals but is generally <50% in asymptomatic individuals. Compared with men, women (especially young women) have higher rates of false-positive GXT. An early positive GXT may be indicative of left main disease or three-vessel disease. Absolute contraindications to GXT include CHF, acute MI, active myocarditis, unstable angina, recent embolism, dissecting aneurysm, acute illness, thrombophlebitis, and moderate to severe aortic stenosis. Relative contraindications include severe hypertension, mild to moderate aortic stenosis, hypertrophic obstructive cardiomyopathy, frequent ectopy, and many other conditions that may increase the risk of a GXT.
Thallium dipyridamole scan, or thallium GXT. Thallium dipyridamole scans can be useful for patients who cannot tolerate the physical demands of the GXT (because of arthritis, COPD). During the test, thallium is taken up by viable, well-perfused myocardium. Areas of myocardial infarction are indicated by fixed perfusion defects with no uptake during rest or exercise. During the thallium-GXT, areas that are hypoperfused (that is, ischemic) demonstrate thallium uptake only during the postexercise 'resting' images. Adenosine, dipyridamole, and dobutamine may be used to augment the perfusion of normal myocardium and shunt blood flow away from areas of relative ischemia. These agents are used in patients who have a contraindication to exercise or are unlikely to attain target heart rates.
Echocardiography. The stress echocardiogram is a widely performed test used to assess patients for coronary disease. Baseline echocardiographic images are obtained at rest. These are used to evaluate left ventricular function, wall motion, and valve function. Images are then acquired during peak stress (that is, during a GXT or with dobutamine) and compared with those at rest. Regional wall-motion abnormalities with stress indicate areas of hypoperfusion or ischemia. Echocardiography is now used routinely to assess CAD in women because of their high false-positive rate on GXT. It is also gaining increased usage among patients with an abnormal baseline ECG (that is, LBBB), those receiving digoxin, and after CABG or PTCA. Transesophageal echocardiography is more sensitive at identifying abnormalities such as valvular vegetations or atrial and ventricular thrombi.
Coronary angiography. Used to identify foci of coronary disease. It is the evaluation of choice in patients with angina that is (1) poorly responsive to medication, or (2) unstable. It is also indicated in patients with test results consistent with a high risk for CAD.

Treatment of Angina
Medical. May use two- or three-drug combination to maximize benefit while minimizing side effects.
Aspirin. Daily aspirin (325 mg) unless contraindicated to inhibit platelet aggregation.
Beta-blockers (metoprolol, atenolol, nadolol, propranolol, and others). Decrease myocardial oxygen demand by decreasing heart rate, systolic blood pressure, and contractility. Because they prolong diastole, beta-blockers also increase O2 supply by increasing myocardial perfusion time. Some beta-blockers (those without intrinsic sympathomimetic activity [ISA] activity, especially lipophilic ones [see below]) prolong life when given for the first year after an MI. This benefit extends into subsequent years in those with a complicated course. Lipophilic beta-blockers (timolol, metoprolol, and propranolol) decrease the incidence of postinfarction ventricular fibrillation and sudden death in both men and women by increasing the electrical stability of myocardium. They are also useful in patients whose angina is regularly provoked by exercise though they may limit exercise tolerance. Start with a low dose and increase until symptoms are controlled or the resting heart rate is 50 to 60 beats/min. Side effects can include bradycardia, bronchospasm, fatigue, GI upset, symptoms of LV failure, and orthostatic hypotension. Impotence, depression, and Raynaud's phenomenon can occur. Do not discontinue beta-blockers abruptly, since rebound tachycardia can occur.
Calcium-channel blockers (verapamil, diltiazem, nifedipine, and others). These drugs act by blocking the influx of calcium through slow channels into vascular smooth muscle and myocardial cells. They promote peripheral arterial vasodilatation, which decreases oxygen demand by decreasing afterload. Calcium-channel blockers also decrease coronary vasospasm and improve collateral flow. Diastolic relaxation of the LV is enhanced, and coronary perfusion is increased with those agents that slow heart rate. Verapamil and diltiazem decrease conduction through the AV node and can be useful to abolish SVT or to slow the ventricular response in atrial fibrillation and atrial flutter. Heart block or asystole can develop in patients with AV node or sinus node disease. First-generation calcium-channel blockers have negative inotropic effects, which can lead to CHF in patients with impaired LV function. Other common side effects of calcium-channel blockers include headache, ankle swelling, GI upset, and constipation. Diltiazem and verapamil are relatively contraindicated after MI in those with CHF and should be avoided. Recent information suggests that nifedipine may increase mortality in some patients (probably as a result of reflex tachycardia).
Nitrates (nitropaste, nitropatches, isosorbide dinitrate, others). Effects include venous and arteriolar vasodilatation, which decreases oxygen demand. The resulting coronary artery vasodilatation increases coronary oxygen supply. Tolerance can develop but can be overcome by providing an 8-hour nitrate-free interval each day. Preparations include oral, transdermal patches, ointment, sublingual tablets, or spray. A common side effect is headache, which usually responds to aspirin or acetaminophen and tends to improve with continued use. Sublingual nitroglycerin tablets (0.4 mg PRN) or spray are used for acute episodes of angina and may be repeated at 5-minute intervals for up to 3 doses. Patients should be instructed to go to the emergency department if angina is not relieved after 3 doses of nitroglycerin.
ACE inhibitors, though not traditionally indicated for angina, may be useful in the patient whose symptoms are difficult to control. ACE inhibitors reduce afterload and directly dilate coronary arteries.
Coronary artery bypass grafting (CABG). Primary indication is angina refractory to medical therapy or lesions that are more amenable to surgery than to angioplasty. CABG has been shown to prolong survival in patients with left main disease (>50% luminal narrowing) and in three-vessel CAD with LV dysfunction (ejection fraction >50%). Surgery may prolong survival in three-vessel disease with normal LV function and in two-vessel disease with significant proximal stenosis of LAD (if not anatomically suited for PTCA).
Contraindications. Advanced age with pronounced debility, absence of ischemia, or ungraftable coronary arteries. Advanced age in and of itself is not a contraindication. In one sample of patients 80 years and older, coronary revascularization by either CABG or PTCA (see below) was associated with a high likelihood of attaining a good or excellent quality of life and of a patient being able to care for himself or herself subsequent to an MI.
PTCA (percutaneous transluminal coronary angioplasty). Can be useful for significant (<50% luminal narrowing) single-vessel CAD when lesions are amenable to the procedure. PTCA does not prevent MI or prolong life. Randomized clinical trails comparing medical therapy with PTCA in single-vessel disease have not shown any significant advantage to using PTCA. Several controlled clinical trials have shown that PTCA can be used as an alternative to CABG in two- and three-vessel CAD when lesions are amenable to PTCA. There was general agreement among these trials that the procedures provide equal improvement in angina. The PTCA groups generally have a higher frequency of antianginal use after 1 year and are more likely to require additional intervention (CABG or repeat PTCA) compared to patients who undergo CABG. PTCA is an acceptable alternative to repeat CABG if lesions are amenable to dilatation (single-vessel stenosis, or easily accessible two-vessel stenoses). Diabetics have a particularly poor long-term result with PTCA. Intracoronary stenting may be preferred in these patients.
Intracoronary stenting. Controlled clinical trials have demonstrated that intracoronary stenting reduces restenosis rates after PTCA from a range of 40% to 50% to a range of 15% to 25%. Recently developed stent deployment techniques using high-pressure balloon inflation and combinations of aspirin and ticlodipine have reduced the abrupt closure rate for stents to <1% and reduced hospital stays to 1 or 2 days.

**a pateint presented to the ER c/o sever headache following head trauma in a motor vehicle accident. he is also confused and mini mental exam confirmed that. His rt foot is showing some bruising and his ankle is swollen. His BP is 144/90 and his pulse is 78 and regular. you ordered cbc and chem 7 and the Na came back 117meq/l. suddenely he started developing siezures and biting his tongue. you immediately inserted an airway. What would you do next to correct his hypo Na?
B. 0.45 Na Cl
c. Glucose 5%
d. Hypertonic saline
e. Ringer lactate


Acute hyponatremia is less common than chronic hyponatremia and typically is seen in patients with a history of sudden free water loading (eg, patients with psychogenic polydipsia, infants fed tap water for 1-2 days, patients given hypotonic fluids in the postoperative period).
Acute evolution of hyponatremia leaves little opportunity for compensatory extrusion of CNS intracellular solutes.

The ultimate danger for these patients is brainstem herniation when Na levels fall below 120 mEq/L.

The therapeutic goal is to increase serum sodium rapidly by 4-6 mEq/L over the first 1-2 hours.

First, the source of free water must be identified and eliminated.

In patients with healthy renal function and mild to moderately severe symptoms, serum sodium may correct spontaneously without further intervention.

Patients with seizures, severe confusion, coma, or signs of brainstem herniation should receive hypertonic (3%) saline to rapidly correct serum sodium toward normal, but only enough to arrest the progression of symptoms.

An increase in serum sodium of 4-6 mEq/L is generally sufficient.

**A 28-year-old gravida 2 para 1 presents to the emergency department at 16 weeks gestation. She has noted the sudden onset of dyspnea, pleuritic chest pain, and mild hemoptysis. Both calves are mildly edematous and somewhat tender. A lung scan shows a high probability of pulmonary emboli.

Which one of the following would be appropriate management at this time?

a. Warfarin therapy only, with the prothrombin time maintained at 18 to 20 seconds (INR 2.0 to 3.0)
b. Aspirin, 81 mg/day throughout the pregnancy
c. Intravenous heparin for 5 to 10 days followed by warfarin anticoagulation
d. Intravenous heparin for 5 to 10 days followed by subcutaneous heparin for the duration of the pregnancy
e. Placement of an inferior venous umbrella filter


The risk of pulmonary embolism is five times higher in a pregnant woman than in a nonpregnant woman of similar age, and venous thromboembolism is a leading cause of illness and death during pregnancy. There has been a considerable change in management over the past two decades.
Because heparin does not cross the placenta, it is considered the safest anticoagulant to use during pregnancy. Initially, patients with venous thromboembolism during pregnancy should be managed with heparin given according to the recommendations for nonpregnant patients.
Warfarin should not be used throughout pregnancy. It is definitely teratogenic during the first trimester and extensive fetal abnormalities have been associated with exposure to warfarin in any trimester. Warfarin readily crosses the placenta and can result in a host of problems.
Women with venous thromboembolism during pregnancy should receive intravenous heparin for 5 to 10 days followed by subcutaneous heparin for the duration of the pregnancy. Warfarin therapy can be given after pregnancy, since it is not present in breast milk.
The indications for placement of inferior vena cava filters in pregnant patients are the same as in nonpregnant patients-any contraindication to anticoagulant therapy, heparin-induced thrombocytopenia, and recurrence of pulmonary embolism in patients receiving adequate anticoagulant therapy.
There are no data to support the use of treatment or prophylaxis of pulmonary embolism either during or after pregnancy.

**A 24-year-old white primigravida has developed several 1- to 2-mm erythematous papules on her abdomen in the third trimester. They are pruritic and tend to appear in her striae. Liver function tests and a CBC are normal.

Which one of the following is the most likely diagnosis?

a. Pruritus gravidarum
b. Spangler's papular dermatitis
c. Impetigo herpetiformis
d. Herpes gestationis
e. Pruritic urticarial papules and plaques (PUPP)


The findings in this patient are most consistent with PUPP. This condition is usually benign, is not associated with increased fetal morbidity, and resolves after delivery, and there is usually no recurrence in subsequent pregnancies. Herpes gestationis, impetigo herpetiformis, and Spangler's papular dermatitis have different presentations and may be associated with increased fetal morbidity. Pruritus gravidarum is characterized by pruritus without skin lesions.

My approach:

Intravenous access, Oxygen, morphine, nitroglycerin SL, if pain persists after 3 SL, assume MI and start IV nitroglycerin, and titrate dose upwards until pain relieved). Monitor vital signs (how often, not sure).

ECG (how often), chem7, CBC, UA, Chest X ray, lipid profile
Troponin T, I, CK-MB
Stress test to risk stratify

If stable, follow earlier discussion on stable angina
If unstable, then admit the patient, prepare for coronary angiography, and consider ballon angiography with or w/o a stent in the same session.

metoprolol, IV (if no contraindications)
low molecular heparin, IV
IIb/IIIa blockers: abciximab or tirofoban, or eptifibatide

treat any arrythmias and other complications

Admit if: new angina
accelerating angina
admit to a monitored bed.

If angiography single vessel: PTCA, triple or left main (esp. w/ LV dysfunction): CABG, double and some triple, either PTCA or CABG, if no major stenosis, medical therapy, but be wary of acute coronary syndrome still, consider stress test, if inconclusive still, consider additional stress echocardiogram, or stress myocardial perfusion scintigram. If none of these positive (inclucding ECG), investigate other organ systems.

Long term management:

Aggressive and extensive risk factor modification
Continue LMW heparin if recurrent and high risk for MI in whom revascularization not possible.
Beta-blockers: metaprolol
quit smoking,
lipid lowering therapy
ACE inhibitors

Please try to develop a better algorithm and change any sequence if you think anything I did was not in the right order.

**An 85-year-old white male nursing-home resident has a 18 days history of anorexia, malaise, and intermittent fever to 38.5 C (101.3 F). The fever has persisted despite empiric therapy with amoxicillin, followed by ciprofloxacin (Cipro). Her present weight is 49.5 kg , compared to 54.5 kg 3 weeks ago. Her mental status, characterized by a dementia pattern consistent with Alzheimer's disease, has not changed. A physical examination discloses no significant abnormalities. A CBC, urinalysis, erythrocyte sedimentation rate, and chest radiograph are also unremarkable.

Which one of the following is most likely to help make the diagnosis?

1.PPD skin testing
3.CT scan of the head
4.Serologic testing for syphilis
5.Liver biopsy

a biochemistry prof, with fatigue and Normal H&P, CVS,RS,Abdo, GEnital, REctal,HEENT normal, normal vitals.only thing was Calcium of, he had all normal lelvels of all possible calcium related endocrine parameters?
what the hell did he have?

2)40 yr , lady, with cough, dry in nature. previuosly treated for 3 days with Erythromycincomes again with same cough..and CXR shows mild hilar lnpathy with some reticular shadowing. WBC-8000, with 60 neutro, 30 lympho, 4 eosin, 6 macro.
Incidentally patient has vaginal yeast infection too
Any correlation between two

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