Evaluation of the Chronic Cough

Evaluation of the Chronic Cough

Most common causes in order of frequency.
Postnasal drip/chronic sinusitis, asthma, including postviral reactive airways, GE reflux disease. Consider also medication (ACE inhibitors), CHF, pertussis, TB. Pertussis in adults may present only with chronic cough and may be present despite childhood immunization and represent 21% of those with chronic cough in one series (check acute and convalescent titers).

One Approach.
Treat with antihistamine or decongestant empirically. Consider course of antibiotics for sinusitis if appropriate.
If positive titer for pertussis, treat with erythromycin or other macrolide.
If this fails, do bronchoprovocation testing for asthma and treat patients with positive results with beta-agonists and prednisone (if fail, beta- agonists alone).
If cough continues or bronchoprovocation is negative, do CXR and sinus CT. Treat positives.
Evaluate negatives for GE reflux and give trial of H2-blocker.
If patient still coughing, consider bronchoscopy.
This approach leads to successful treatment in 96% (though there are recurrences).

A 58-year-old man seeks attention in the emergency department for weakness and melena, which he has had for 3 days. He says he has not had significant abdominal pain and had no prior gastrointestinal bleeding. On examination he is disheveled and unshaven, appears older than his stated age, and has a 20 mmHg orthostatic drop in blood pressure. Findings include bilateral temporal wasting, anicteric and pale conjunctivae, spider angiomas on his upper torso, muscle wasting, hepatosplenomegaly, and hyperactive bowel sounds without abdominal tenderness to palpation. Stool is melenic. Nasogastric aspiration reveals 'coffee-grounds' material, which quickly clears with lavage. Hematocrit is 30 percent, and mean corpuscular volume is 105 fL. Saline gastric lavage is initiated. The appropriate next step in the management of this man's illness would be to

A perform gastroscopy
B pass a Sengstaken-Blakemore tube and begin an intravenous infusion of vasopressin (Pitressin)
C order an upper gastrointestinal series
D order immediate visceral angiography
E insert a large-bore intravenous line and type and cross-match the man's blood

The answer is E
The presence of coffee-grounds material in a nasogastric aspirate from a person with melena indicates recent bleeding of the upper gastrointestinal tract. In a patient with obvious signs of cirrhosis, esophageal varices must be considered in the differential diagnosis of upper gastrointestinal bleeding; other possible diagnoses include peptic ulcer, gastroduodenitis, esophagitis, and a Mallory-Weiss tear. Before diagnostic procedures such as endoscopy and an upper gastrointestinal series are undertaken, the placement of a large-bore intravenous line and commencement of volume replacement therapy are mandatory to prevent hypotension. Moreover, blood should be typed and cross-matched in case of further bleeding. Diagnostic angiography is indicated only when brisk bleeding prevents diagnosis by endoscopy or barium study.

Which disease could be with high BP in low extremity
than BP in upper extremity?

what is the indication for
1.Intubation.
2.Cardiac catheter.
3.Foley catheter
4.Echocardiagraphy
5.Ejection fraction
6.PTCA
7.CABG
8.Blood transfusion

16yo girl need to do C-section, who will sign the consent form?

She can sign consent form.
Minors have the ethical and legal authority to make medical decisions for themselves when they have reached the legal age of majority or become 'emancipated.' Most states recognize an emancipated minor as a person who meets one of the following criteria:

self-supporting and not living at home
married
pregnant
a parent
in the military
In addition, most states allow treatment without parental consent for sexually transmitted diseases, pregnancy, and drug or alcohol abuse.

A 46-year-old Haitian man presents with shortness of breath. Chest x-ray reveals a right pleural effusion extending about halfway up the chest. The patient has no other known medical problems and is on no medicines. The rest of the general physical examination is unremarkable. Diagnostic thoracentesis reveals the following: lactate dehydrogenase 1.7 kat/L (100 U/L), glucose 6.4 mmol/L (150 mg/dL), and amylase 1.6 kat/L (90 U/L). Cell count reveals 1000 red cells per microliter and 1000 white cells per microliter (differential: 50 percent neutrophils, 25 percent lymphocytes, and 25 percent monocytes). A ventilation-perfusion lung scan is indeterminate on the right side because of the large effusion, but there are no ventilation-perfusion mismatches elsewhere. The next most appropriate step would be

A:pulmonary arteriogram
B:abdominal CT
C:chest CT
D:needle biopsy of pleura
E:administration of isoniazid with ethambutol

The answer is D
The initial step in the evaluation of a pleural effusion is the determination of the presence of either a transudative effusion, usually caused by congestive heart failure, cirrhosis, or nephrotic syndrome, or an exudative pleural effusion, which may be due to a host of causes. The working definition of an exudative effusion is one that meets any of the following criteria: (1) pleural fluid to serum protein concentration ratio greater than 0.5, (2) pleural fluid to serum lactic dehydrogenase (LDH) concentration ratio greater than 0.6, (3) pleural fluid LDH concentration greater than two-thirds of the upper limit of normal serum LDH. This patient's effusion is an exudate. Additional studies to be done include measurement of pleural glucose and cultures for bacterial mycobacteria and fungi. If the glucose is less than 60 mg/dL, malignancy, empyema, or rheumatoid pleuritis should be considered. Esophageal rupture, pancreatitis, and malignancy can cause an elevated pleural fluid amylase. If no diagnosis is apparent after the above studies, occult pulmonary embolism should be considered. If there is still no diagnosis based on these studies, it is then appropriate to perform a needle biopsy of the pleura with particular attention to histologic analysis for tuberculosis or cancer.

A 70-year-old man presents with a second episode of painless hematuria. Physical examination is negative for petechiae, purpura, and lymphadenopathy, but the spleen tip is palpable. Peripheral blood smear demonstrates a leukocyte count of 14,000 with no shift, hemoglobin of 14.5 g, and platelet count of 850,000. Partial thromboplastin time was mildly prolonged, with a normal prothrombin time. Cytoscopy demonstrates diffuse oozing from the bladder surface with no evidence of neoplasm.
Which of the following statements about this patient's condition is not true?

a. Elevated leukocyte alkaline phosphatase, serum B12, and unbound B12 binding capacity in the presence of a hypercellular bone marrow fulfill the diagnostic criteria.
b. Panmyelosis may evolve through a proliferative phase to a myeloid metaplasia phase to a leukemic phase, which is resistent to therapy.
c. Therapeutic options include phlebotomy, which may be associated with increased incidence of thrombotic events, chemotherapy with hydroxyurea, or radiophosphorus, which is contraindicated in elderly patients.
d. Bleeding may be related to platelet dysfunction or coagulation abnormalities, which may improve as the erythrocyte mass is lowered.
e. The patient's prior history of peptic ulcer disease and gout may be due to the myeloproliferative disorder.

A

i think this is a case of a myeloproliferative disorder. the option a, is diagnostic of leukemia, whereas the other options are indicative of the patient suffering from polycythemia although the pts hb in normal, but one has to note that his hb is normal despite of 2nd episode of painless hematuria. The pt does have thrombocytosis but it is not primary thrombocytosis since the spleen tip is palpable. i personally think he has relative polycythemia with essential thrombocytosis. As far as option he is concerned yes PUD and gout maybe indiactive of prior disorder since malignancies cause increase uric acid production and the pt maybe have prescribed aspirin for thrombocytosis giving rise to PUD. I am not sure if this makes sense to anyone but it was the only logical thing i could come up with.

sorry, i did check the Merck Manual on this one. As per them choice a does fulfill the diagnostic criteria, Also options b, d and e are also mentioned in the article however as far as treatment goes, they say that radioactive pohophorus is the treament of choice in elderly whereas the (c) options says radio. P is contraindicated in the elderly so i am confused as well. Please see the attachement from merck manual below if anyoone is interested.
Also, Mark from where did u get this Q?

Polycythemia Vera

Incidence and Pathophysiology

Polycythemia vera (PV) occurs in about
5/1,000,000 persons, more often in males
(about 1.4:1). The mean age at diagnosis is 60
yr (range, 15 to 90 yr; rarely in childhood); 5% of patients are < 40 yr at onset.

The bone marrow sometimes appears normal but usually is hypercellular; hyperplasia involves all
marrow elements and replaces marrow fat. There is increased production and turnover of RBCs,
neutrophils, and platelets. Increased megakaryocytes may be present in clumps. Marrow iron is
absent in > 90% of patients, even when phlebotomy has not been performed.

Studies of women with PV who are heterozygous at the X-chromosome-linked locus for G6PD
have shown that RBCs, neutrophils, and platelets have the same G6PD isoenzyme, supporting a
clonal origin of this disorder at a pluripotent stem cell level. The cause of this proliferation is
unknown.

Eventually, about 25% of patients have reduced RBC survival and fail to adequately increase
erythropoiesis; anemia and myelofibrosis develop. Extramedullary hemopoiesis occurs in the
spleen, liver, and other sites with the potential for blood cell formation.

Symptoms and Signs

Some patients are asymptomatic and are first identified on routine blood examination. Complaints
(weakness, headache, light-headedness, visual disturbances, fatigue, dyspnea) usually can be
attributed to expanded blood volume and hyperviscosity. A bleeding diathesis is common. Pruritus
often occurs, particularly after a hot bath. The face may be red and the retinal veins engorged.
Hepatomegaly is common, and > 75% of patients have splenomegaly (which may be massive,
extending to the pelvic brim); a friction rub may be heard if splenic infarction occurs. Patients may
present with peptic ulcer disease, thrombosis, Budd-Chiari syndrome, or bone pain.
Complications of hyperuricemia (eg, gout, renal calculi) tend to occur later in PV.

Eventually, erythroid activity in the marrow decreases. Immature WBCs and RBC precursors are
found in the peripheral blood, and marked anisocytosis and poikilocytosis, with microcytes,
elliptocytes, and teardrop-shaped cells develop. Neutrophils and platelets may be morphologically
abnormal, and their numbers may increase. The bone marrow shows increased reticulin, and
progressive splenomegaly caused by extramedullary hemopoiesis may be found. During this 'spent
phase,' anemia and thrombocytopenia may develop.

Abnormal platelet function often leads to problems with hemostasis. Because surgical procedures
may be hazardous, elective surgery should be postponed until the Hct is reduced to < 42% and
platelets to < 600,000/L.

Diagnosis

Polycythemia vera can be diagnosed when a patient has all three major criteria (i.e., increased red blood cell mass
[at least 36 mL per kg for men, at least 32 mL per kg for women]; normal arterial oxygen saturation [at least 92
percent]; and splenomegaly) or the first two major criteria plus any two of the minor criteria (i.e., platelet count of
more than 400 3 103 per L [400 3 109 per L]; leukocyte count of more than 12 3 103 per L [.01 3 109 per L];
alkaline phosphatase level of more than 100 U per L; a vitamin B12 level of more than 900 pg per mL [664 pmol per
L] or an unbound vitamin B12 binding capacity of more than 2,200 pg per mL [1,623 pmol per L]).












PV must be considered in men with Hct > 54% and women with Hct > 49%. Because PV is a
panmyelosis, its diagnosis is clear in patients with elevations of all three peripheral blood
components, splenomegaly, and no evidence of secondary erythrocytosis. Diagnostic guidelines
are listed in Table 130-2.

Because the Hct is a ratio of the number of circulating RBCs per unit volume of whole blood, an
elevated Hct may be caused by decreased plasma volume. Thus, a diagnosis of true erythrocytosis
is based on demonstrating an increased RBC mass. When measured with radioactive chromium
(51Cr)-labeled RBCs, RBC mass > 36 mL/kg in men (normal, 28.3 2.8 mL/kg) and > 32
mL/kg in women (normal, 25.4 2.6 mL/kg) is considered abnormal. In relative (spurious)
erythrocytosis (ie, stress polycythemia, Gaisbck's syndrome), the RBC mass is normal and the
elevated Hct is caused by a decreased plasma volume. Once erythrocytosis has been established,
its cause must be sought (see Table 130-3). Secondary erythrocytosis (see below) caused by
lung disease, smokers' polycythemia caused by elevated carboxyhemoglobin levels, and tumors
producing erythropoietic substances is more common. Table 130-4 lists laboratory tests for
differential diagnosis, and Fig. 130-1 lists suggested steps in the evaluation of erythrocytosis.

If the arterial Hb O2 concentration is < 92%, tissue hypoxia may underlie the erythrocytosis. The
leukocyte alkaline phosphatase (LAP) score is a histochemical stain for a neutrophil enzyme. The
LAP score is elevated in 75% of patients with PV but is usually normal in patients with other
causes of erythrocytosis. However, because fever, infection, or inflammation can elevate the LAP
score, the LAP score is helpful in establishing a diagnosis of PV only in the absence of these
stimuli. Urinalysis may detect microscopic hematuria, and renal ultrasonography or CT may reveal
a renal lesion causing secondary erythrocytosis. The P50 (the partial pressure of O2 at which Hb
becomes 50% saturated) measures the affinity of Hb for O2 and excludes a high-affinity Hb (a
familial abnormality) as the cause of erythrocytosis.

Patients with PV have low or undetectable serum erythropoietin levels; those with
hypoxia-induced erythrocytosis have elevated levels; and those with tumor-associated
erythrocytosis have normal or elevated levels. Bone marrow from patients with PV has the
capacity to form endogenous erythroid colonies in culture, thus, the addition of erythropoietin is
unnecessary. In contrast, in healthy patients or those with secondary erythrocytosis, the marrow
requires added erythropoietin for erythroid colony formation.

Other laboratory abnormalities may occur in PV: Hyperuricemia and hyperuricosuria occur in >=
30% of patients, qualitative abnormalities in platelet function may be present, and vitamin B12 and
B12-binding capacity are frequently elevated.

Prognosis

Without treatment, 50% of symptomatic patients die within 18 mo of diagnosis. (For information
about support for the patient and family, see Ch. 294.) With treatment, median survival is 7 to 15
yr. Thrombosis is the most common cause of death, followed by complications of myeloid
metaplasia, hemorrhage, and development of leukemia.

The incidence of transformation into an acute leukemia is greater in patients treated with
radioactive phosphate (32P) or alkylating agents than in those treated with phlebotomy alone. PV
that transforms into acute leukemia is more resistant to induction chemotherapy than de novo
leukemia.

Treatment

Because PV is the only form of erythrocytosis for which myelosuppressive therapy may be
indicated, accurate diagnosis is critical. Therapy must be individualized according to age, sex,
medical status, clinical manifestations, and hematologic findings.

Phlebotomy is integral to therapy and may be the only regimen needed. It is the treatment of
choice for women of childbearing age and patients < 40 yr because it is not mutagenic and it
eliminates symptoms of hypervolemia. Initially, 300 to 500 mL of blood should be removed every
other day until the Hct is < 45%. Phlebotomies should be performed more cautiously (ie, 200 to
300 mL twice/wk) in elderly patients and those with cardiac or cerebrovascular disease. Once the
Hct is normal, the patient should be seen monthly and phlebotomized if the Hct is > 45%.
Emergency surgery should be preceded by phlebotomy to reduce the RBC volume to normal. If
necessary, intravascular volume can be maintained with crystalloid or colloid solutions.

Myelosuppressive therapy may be indicated for patients with platelet counts > 1 106/L,
with discomfort from visceral enlargement, with thrombosis, and with symptoms caused by
hypermetabolism or uncontrolled pruritus and for elderly patients or those with cardiovascular
disease who do not tolerate phlebotomy well.

Radioactive phosphate (32P) has a success rate of 80 to 90%. Remissions may last 6 mo to
several years. It is well tolerated and requires fewer follow-up visits when the disease is
controlled. However, 32P is associated with an increased incidence of acute leukemic
transformation and thus requires careful patient selection (eg, best reserved for patients > 70 yr).
After a normal Hct (40 to 45%) is achieved with phlebotomy, 32P 2.7 mCi/m2 BSA is given IV
(total dose <= 5 mCi). This dose usually normalizes the platelet count and Hct within 4 to 8 wk.
32P can be repeated and the dose increased if control has not been achieved. If there is no
response after three injections during the first year of therapy, the patient should be managed with
phlebotomy or hydroxyurea.

Alkylating agents are leukemogenic and should be avoided. However, hydroxyurea, which
inhibits the enzyme ribonucleoside diphosphate reductase, has been used successfully in patients in
whom myelosuppressive therapy is indicated. Hydroxyurea has been used for this purpose for
many years; its long-term safety regarding leukemogenesis continues to be studied. Patients are
phlebotomized to a normal Hct (40 to 45%) and given hydroxyurea 10 to 15 mg/kg/day po. The
patient is monitored with a weekly CBC. When a steady state is achieved, the interval between
CBCs is lengthened to 2 wk and then 4 wk. If the WBC count falls to < 4000/L or the platelet
count to < 100,000/L, hydroxyurea is withheld and reinstituted at 50% of the dose when the
CBC normalizes. For poorly controlled patients who require frequent phlebotomies or who are
thrombocythemic (platelet counts > 600,000/L), the dosage can be increased by 5 mg/kg/day at
monthly intervals with frequent monitoring until control is achieved. Acute toxicity is minimal;
occasionally, patients develop a rash, GI symptoms, or fever.

Interferon- has been used for patients who cannot tolerate hydroxyurea or for whom the drug
does not control the peripheral blood count. The typical starting dose of interferon- is 3.0 106
U sc 3 times/wk. Cost, acute toxicities, and long-term safety are factors in its use.

Hyperuricemia can be managed with allopurinol 300 mg/day po. Pruritus may be managed with
antihistamines but is often difficult to control. After bathing, the skin should be dried gently.
Cholestyramine 4 g po tid, cyproheptadine 4 to 16 mg po qid, and cimetidine 300 mg po qid have
also been successful. Aspirin relieves symptoms of erythromelalgia (tender, inflamed toes).

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Select the best treatment for a 70-year-old woman presents with iron deficiency anemia and is found to have adenocarcinoma of the cecum. She undergoes resection, and pathology reveals two pericolic lymph nodes with metastases. Exploration of the liver is negative for metastases.

a. Chemotherapy in combination with radiation postoperatively
b. Adjuvant chemotherapy
c. Radiation therapy
d. Surgical resection with postoperative adjuvant chemotherapy
e. Hospice

A

Rectal cancer patients with one to four positive lymph nodes derive most benefit from combined radiotherapy and chemotherapy; when more than four positive lymph nodes are found in the resected specimen, combined modalities are less effective. The effective regimen studied is fluorouracil (5-FU) with or without folinic acid.(MERK MANUAL)

A 70-year-old former shipyard worker, who smokes one pack of cigarettes daily, notes progressive weight loss and debility over a period of 6 months. Over a period of 1 month, he develops right chest pain and a nonproductive cough. A chest x-ray reveals extensive pleural thickening, pleural effusion, and hilar adenopathy. A pleural biopsy confirms mesothelioma. Which of the following is a favorable prognostic factor in this patient?

a. Male sex
b. Extent of disease at diagnosis
c. Good performance status
d. Pain as presenting symptom
e. Age over 65
f. None of the above

f is CORRECT.
All of the clinical components noted exhibit very poor prognostic factors in the patient with mesothelioma, a particularly aggressive disease that remains unresponsive to many forms of aggressive therapy.

A 29 year old pregnant lady ingested alcohol and illicit drugs(cocaine) which are harmful to fetus. What should a physician do?

the physician should be careful in reporting this case because the pregnant women may not come back for prenatal care which is important for both the mother and the fetus. So advice is important

Can a physician provide sterile needles for IV drug abusers?

yes, it reduces the risk of acquiring hiv or hepatitis.
for this the patient should be referred to appropriate health facilities

A 16 year old homosexual boy wanted to change his sexual orientation. He was not successful. He needed help. He requested the physician not to tell his parents.

What is the next step in management

do not tell his parents
2.physician should help him avoid homosexual activities because patient has requested

A 16 y.o. boy was dx. with Osteosarcoma of the Right thigh. The surgeon recommended amputation. The boy refused amputation. He is doing very well otherwise. He is aware that death is certain without surgery.
What is the next step in management?

amputation should not be performed. competant adolescents(>15yrs) can give genuine conce

I read abt osteosarcoma.If lung involvement is not present than i will not agree with boys..but if
prognosis is poor as you indicated.than i will consider boys wishes
osteosarcoma is curable cancer..

Prognosis
From 70 percent to 90 percent of osteosarcomas in the limbs can be treated by limb-sparing surgery and chemotherapy - no amputation is needed. When osteosarcoma affects only one limb, the long-term survival is 60 percent to 75 percent; however, this percentage drops to 40 percent or less if cancer has also metastasized to the lungs.(National Cancer
Institute (NCI))