Extern Recall: 2010

Tuesday, June 15, 2010

Standard initial management in Heart failure

Supplemental Oxygen
Endotracheal intubation with mechanical ventilation is indicated if instability
Cardiac monitoring
pulse oximetry
12-lead electrocardiogram
Intravenous access
Frequent vital sign assessments.
Chest radiography
Complete blood cell count
Electrolytes
BNP level
Cardiac markers

Acute Pulmonary Edema

Intravenous diuretics, diuresis can begin 10 to 15 min after intravenous furosemide. If urine output is inadequate in 20 to 30 min, the diuretic dose is increased and repeated.
Furosemide Dose
   No prior use: 40 mg IVP
   If prior use: Double last 24-h usage (range, 80–180 mg)
   If no effect by 20–30 mins: re-double dose

Natriuretic Peptide Assay(BNP levels) in Heart Failure

These proteins are released by ventricular pressure or volume stimulus.
Age < 50 BNP level cut point = 450 pg/ml
Age 50-75 BNP level cut point = 900 pg/ml
Age >75 BNP level cut point = 1900 pg/ml

There are confounders to BNP as an HF test. BNP is increased in the elderly, women, those with cirrhosis or renal failure, possibly those on hormone replacement therapy, and probably those with pulmonary embolus and primary pulmonary hypertension.

Precipitating Heart failure

Hypertension
Endocrine
Anemia
Rheumatic heart disease
Toxin
Failure to take meds
Arrhythmia
Infection
Lung (pulmonary embolism)
Electrolytes
Diet (excess Na+)

Sunday, May 23, 2010

Inferior vena caval (IVC) filters in Deep vein thrombosis

DVT occurring in deep knee or thigh veins, known as proximal DVT, require hospitalization and anticoagulation because of increased risk of pulmonary embolus.

Most experts agree with placing an inferior vena caval (IVC) filters in patients with acute proximal DVT and an absolute contraindication to anticoagulation. If the contraindication to anticoagulation is temporary (eg, perisurgical patients), placement of a retrievable IVC filter should be considered so that the device can be removed once anticoagulation has been started and has been shown to be tolerated.

Complications of IVC filters include local thrombosis, tilting, migration, and inability to retrieve the device.

Child-Turcotte-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems for staging cirrhosis.

Child-Turcotte-Pugh
and Model for End-Stage Liver
Disease (MELD) scoring systems for staging cirrhosis.

	Child-Turcotte-Pugh scoring system
	Numerical Score
Parameter	1	2	3
Ascites	None	Slight	Moderate to severe
Encephalopathy	None	Slight to moderate	Moderate to severe
Bilirubin (mg/dL)	< 2.0	2–3	> 3.0
Albumin (g/dL)	> 3.5	2.8–3.5	< 2.8
Prothrombin time (seconds increased)	1–3	4–6	> 6.0
	Total numerical score and corresponding Child-Turcotte-Pugh class
	Score		Class
	5–6		A
	7–9		B
	10–15		C
MELD scoring system
MELD = 11.2 loge (INR) + 3.78 loge (bilirubin [mg/dL]) + 9.57 loge (creatinine [mg/dL]) + 6.43 (Range 6–40).

INR, international normalized ratio.

Prognosis

Factors determining survival include ability to stop alcohol intake and the Child-Turcotte-Pugh class
The Model for End-Stage Liver Disease (MELD) is used to determine priorities for liver transplantation

Wednesday, May 19, 2010

Ranson's Criteria

Table 33-4 Ranson's
Prognostic Signs of Pancreatitis

Criteria for acute pancreatitis not due to gallstones
At admission	During the initial 48 h
Age >55 y	Hematocrit fall >10 points
WBC >16,000/mm³	BUN elevation >5 mg/dL
Blood glucose >200 mg/dL	Serum calcium <8 mg/dL
Serum LDH >350 IU/L	Arterial PO₂ <60 mm Hg
Serum AST >250 U/dL	Base deficit >4 mEq/L
	Estimated fluid sequestration >6 L
Criteria for acute gallstone pancreatitis
At admission	During the initial 48 h
Age >70 y	Hematocrit fall >10 points
WBC >18,000/mm³	BUN elevation >2 mg/dL
Blood glucose >220 mg/dL	Serum calcium <8 mg/dL
Serum LDH >400 IU/L	Base deficit >5 mEq/L
Serum AST >250 U/dL	Estimated fluid sequestration >4 L

AST = aspartate
transaminase; BUN = blood urea nitrogen; LDH = lactate
dehydrogenase; PO₂ = partial pressure
of oxygen; WBC = white blood cell count.

Source: Data from Ranson JHC: Etiological and prognostic factors
in human acute pancreatitis: A review. Am J Gastroenterol 77:633,
1982. From Macmillan Publishers Ltd. Ranson JH, Rifkind KM, Roses
DF, et al: Prognostic signs and the role of operative management
in acute pancreatitis. Surg Gynecol Obstet 139:69,
1974.

MRCP (Magnetic resonance cholangiopancreatography )

Indication
Evaluation of intra- and extra-hepatic biliary and pancreatic duct dilatation, and the cause of obstruction.

Advantages

Noninvasive. No ionizing radiation. Imaging in all planes. Can image ducts beyond the point of obstruction.

Evaluates extra-luminal disease.

Disadvantages/Contraindications

Special instrumentation required for patients on life support.

Contraindications and risks: Contraindicated in patients with cardiac pacemakers, intraocular metallic foreign bodies, intracranial aneurysm clips, cochlear implants, and some artificial heart valves.

Preparation

Preferably NPO for 6 hours.

Endoscopic retrograde cholangiopancreatography (ERCP)

Indications

Demonstrates cause, location, and extent of extrahepatic biliary obstruction (eg, choledocholithiasis).

Can diagnose chronic pancreatitis.

Primary sclerosing cholangitis, AIDS-associated cholangitis, and cholangiocarcinomas.

Advantages

Avoids surgery.

Less invasive than percutaneous transhepatic cholangiography.

Offers therapeutic potential (sphincterotomy and extraction of common bile duct stone, balloon dilatation of strictures, placement of stents).

Finds gallstones in up to 14% of patients with symptoms but negative ultrasound.

Disadvantages/Contraindications

Requires endoscopy. May cause pancreatitis (1%), cholangitis (<1%), peritonitis, hemorrhage (if sphincterotomy performed), and death (rare).

Contraindications and risks: Relatively contraindicated in patients with concurrent or recent (<6 weeks) acute pancreatitis or suspected pancreatic pseudocyst. Contraindicated in pregnancy because of the potential harm of ionizing radiation to the fetus.

Preparation

NPO for 6 hours.

Sedation required.

Vital signs should be monitored by the nursing staff.

Not possible in patient who has undergone Roux-en-Y hepaticojejunostomy.

Wednesday, April 28, 2010

Treatment anaphylaxis

Epinephrine

Epinephrine 1:1000, 0.01 mg/kg to a maximum of 0.5 mg, should be injected intramuscularly, without delay. This dose may be repeated at intervals of 5–15 minutes as necessary for controlling symptoms and maintaining blood pressure.

Antihistamines

CPM an H₁-blocker, 0.1 mg/kg IV q 6 hr.

Ranitidine, an H₂-blocker, 1 mg/kg up to 50 mg intravenously

Cimetidine, an H2-blocker, 4 mg/kg IV q 8-12 hr

Fluids

Treatment of persistent hypotension despite epinephrine requires restoration of intravascular volume by fluid replacement, initially with a crystalloid solution, 20–30 mL/kg in the first hour.

Bronchodilators

Nebulized

₂-agonists Salbutamol(Ventolin) (5mg/1ml) dose 0.03-0.05 ml/kg/dose diluted in 2–3 mL saline

Corticosteroids

for prevent biphasic anaphylaxis. Intravenous methylprednisolone, 1 mg/kg, or hydrocortisone, 5 mg/kg, can be given every 6 hours.

Common Causes of Systemic Allergic and Pseudoallergic Reactions.

Causes of anaphylaxis

Drugs

Antibiotics

Anesthetic agents

Foods

Peanuts, tree nuts, shellfish, and others

Biologicals

Latex

Insulin

Allergen extracts

Antisera

Blood products

Enzymes

Monoclonal antibodies (eg omalizumab)

Insect venoms

Causes of anaphylactoid reactions

Radiocontrast media

Aspirin and other nonsteroidal anti-inflammatory drugs

Anesthetic agents

Anaphylaxis criteria

Anaphylaxis is highly likely when any one of the following three criteria are fulfilled:

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of the following:

a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)

b. Reduced blood pressure or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence)

2. Two of more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

a. Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula)

b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEFR, hypoxemia)

c. Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)

d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)

3. Reduced blood pressure after exposure to a known allergen for that patient (minutes to several hours)

a. Infants and children: low systolic blood pressure (age specific) or greater than 30% decrease in systolic pressure

b. Low systolic blood pressure in children, defined as less than 70 mm Hg in those aged from 1 month to 1 year, less than (70 mm Hg + [2 x age]) in those 1–10 years of age, and less than 90 mm Hg in those 11–17 years

Saturday, April 3, 2010

Corrected calcium in hypoalbumin

Corrected calcium = serum calcium + 0.08 (40 - serum albumin)

Normal range: 9-10.5 mg/dL

Treatment of hypomagnesium

Medication

Oral replacement is appropriate for mild symptoms, while IV replacement is indicated for severe clinical effects.

Dacryocystitis?

Question?

Dacryocystitis?

Metatarsus Adductus vs Congenital Clubfoot

Question?

Metatarsus Adductus vs Congenital Clubfoot ?

Differential Diagnosis from vaginal discharge

Differential Diagnosis of Vaginal Infections

Diagnostic Criteria	Normal	Bacterial Vaginosis	Vaginitis Trichomonas	Candida Vulvovaginitis
Vaginal pH	3.8 - 4.2	> 4.5	4.5	< 4.5 (usually)
Discharge	White,thin, flocculent	Thin, white (milky), gray	Yellow, green, frothy	White, curdy, "cottage cheese"
Amine odor "whiff" test	Absent	fishy	fishy	Absent
Microscopic	Lactobacilli, epithelial cells	Clue cells, adherent cocci, no WBC's	Trichomonads, WBC's >10/hpf	Budding yeast, hyphae, pseudohyphae

Wednesday, March 17, 2010

Trauma zone in Penetrating neck injuries?

Question?

Trauma zone in Penetrating neck injuries?

Classic description of amebic liver abscess content?

Question?

Classic description of amebic liver abscess contents?

What is the most common site of liver abscess?

Question?

What is the most common site of liver abscess?

Abnormal blood chemistry in severe vomiting is...?

Question?

Abnormal blood chemistry in severe vomiting is...?

this peripheral smear of ?

Question?

this peripheral smear of ?

Apgar score

Score of 0	Score of 1	Score of 2	Component of acronym
blue or pale all over	blue at extremities body pink	body and extremities pink	Appearance
0	<100	≥100	Pulse
no response	grimace	Sneeze, cough, pulls away	Grimace
none	Arms and legs flexed	Active Movement	Activity
absent	weak, irregular	strong, lusty cry	Respiration