CCS- Acute Cholecystitis

CCS- Acute Cholecystitis

Investigations:
> 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
>
> Intervention:
> 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
> dilatation
> 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 ?
a. INH
b. Acetominophine
c. halothane
d. methydopa
e. erythromycin

B

classification of drug-induced liver disease
zonal necrosis: acetaminophen, carbon tetrachloride
nonspecific hepatitis: aspirin,oxacillin
viral hepatitis-like reactions; halothane, INH, phenytoin, diclofenac
chronic hepatitis
-autoimmune hepatitislike: methyldopa, dantrolene
-viral hepatits lke;; INH,halothane
cholestasis: estrogen
fatty liver
-large droplet: ethanol, corticosteroid
-small droplet: tetracycline, valproic acid
tumors
- 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

Halothane---
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 38.6C (101.5F) 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

D

he shows
pharyngitis hx.
major manifestation( migratory polyarthritis, erythema marginatum)
minor manifestation( fever, arthralgia, elevated ESR)
elevated ASO titer
so
penicillin and
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.

A

1. Paget's disease of bone (osteitis deformans) is a disorder of bone formation that affects both cortical and cancellous bone. Initially there is excessive bone resorption, producing radiolucent areas. Excessive bone formation occurs later in the course, producing thickening, deformity, and trabecular disorganization. Paget's disease is most often asymptomatic; when pain occurs, it is due to secondary osteoarthritis, nerve impingement, or fracture. Osteosarcoma occurs in fewer than 1% of cases. The majority of patients who undergo joint replacement surgery, usually of the hips or knees, obtain excellent results.

The highest prevalence of latex allergy is found in individuals with which one of the following conditions?

a. Asthma
b. Spina bifida
c. Allergic rhinitis
d. Peanut allergy
e. Prosthetic heart valves

B

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 73120), C4 12 (N 1530), 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 99F to 100F, 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

D

diffuse proliferative GN and interstitial fibrosis
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 no distress.

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

B

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 ?

2-4 weaks

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:
Decrease mileage
Ice knee after activity
Alternate running direction on banked surface
Stretching the ITB.