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استطلاع الرأي إلى أي مدى تعتبر أنّ الدراسة النظريّة للطبّ في كليتنا ستخدمك سريرياً في المستقبل؟ أعتبر أنّ الفائدة معدومة في ظل النظام التدريسيّ الحالي. 28% الفائدة كبيرة جداً، وهي أساس التميز العملي. 6% الأمر نسبي، يختلف من طالب لآخر، ومن مادة لأخرى. 67% عدد الأصوات: 240 أهلاً بك ! تفضل الإبحار |
 Persistent Nausea and Vomiting
Green Wave - الثلاثاء, 2008-07-15 00:46 |
الوصف الكامل Background: A 66 yo CF came to the ED with nausea and vomiting for two months. She had been admitted to an OSH a week ago for nausea and vomiting and an EGD was negative. She vomited on average two to three times per day - typically a couple of hours after eating a meal. The emesis was yellow and watery. Medications Fosamax, Novolog, Lantus, Furosemide, Digitek 0.25mg daily, Citalopram, Amiodarone, Diovan, Vytorin, Coumadin, Iron tablets, Aspirin الشكوى الرئيسية CC: القصة المرضية HPI: الأجهزة الأخرى ROS: السوابق المرضية الشخصية PMH: CHF, DM Type II, Atrial Fibrillation, Cardiomyopathy, Anemia, Osteoporosis, Osteoarthritis, Sleep apnea
السوابق المرضية العائلية FMH: الوضع الصحي والاجتماعي SH: الفحص السريري Clinical Exam: VSS
Chest: CTA (B) CVS: Clear S1S2 Abdomen: Soft, NT, ND, +BS Extremities: no c/c/e Neurologic: awake and alert, normal speech Psychiatric: normal affect, conversant, appropriate التشخيص التفريقي DD: الاستقصاءات Investigations: التدبير Managment: كتابة حرة وطرح موضوع النقاش!: What is the most likely diagnosis?
Anything else? What tests would you order? |
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Few things you have to clarify
Is there any abdominal pain
Is there any wieght loss
How about bowel movements
How long did she had diabetus for?
Any new medications or change in doses
Any heatburn or reflux sensations
Any moring headache
Does she bring up old undigested food
THe differential diagnosis of Nausea and vomiting is very wide (I think it is the most chanelling GI symptom) and careful detailed history is the key for diagnosis most of the time. I frequently see paople jumping to EGD (endoscopy ) to try to find the cause which is helpful on only 15% of the time.In 85% there is something that EGD is not going to help you with.
Is there any abdominal pain
Is there any wieght loss
How about bowel movements
How long did she had diabetus for?
Any new medications or change in doses
Any heatburn or reflux sensations
Any moring headache
Does she bring up old undigested food
no abdominal pain
no weight loss
bowl movements were auscultated ,nothing abnormal
diabetes was diagnosed and monitored since she was 50.
she also complains that she got bored of these huge amounts of drugs she should take .
no heart burn ,no reflux sensation ,neither morning headaches.
I really don't know,but do these medication cause such problem???
either a GI upset due one of these 100 drugs she's taking, or it may be gastroparesis.
i was about to ask a question but i think ABIM has answered it for me, why EGD? why not an ultrasound first !
dr.ABIM asked about the diabetes of the pt,maybe he was thinking about Diabetic gastroparesis,idon't no but anyways in more detailed examination the pt didn't reveal any other gastroenterologic symptoms ..
.........
let's think about sth else..
more investigations are available ..
why EGD? why not an ultrasound first !
i think that dr.ABIM is the best to answer u ..with all respect
.............
mbs ..waiting HOUSE effects
When you order a test you always ask yourself what are you looking for. SO you asked about US of the abdomen. What is the likelihood that US can show you a diagnosis that explains the vomting in the abscess of other GI symptoms (esp pain) ? If you can answewr this you will know why US is not a good test to order in this senario. But I see your point ablackside . Your thinking is based on doing less invasive testing before which is a good idea but the more important concept is to do the test that is more likely to yeild the diagnosis and not waste money .
i told her to calm down and be patient coz her nausea is about to be worked out ..
i think our doctors will come tonight and reorganize your remedies..so don,t worry ..
well,we will see...
after your suspect mbs about Digoxin intoxication ,we order the pt many tests :
CBC
CMP
Digoxin level
KUB, CXR
UA
EKG
i think that digo level and the EKG is enough ,but anyway we will check other things ,u know how chronic she is..
Later.........,
ECG showed a LBBB (not new, compared to previous EKGs) and first degree AVB, HR 64 bpm.
Laboratory results were unremarkable. Digoxin level was pending.
........
so you're right mbs ..
_______________________________________
what's the next step?
please doctors my pt's Digoxin level came back as 5.0 ng/mL. Repeated levels were 5.2 and 5.6 respectively.
The patient became bradycardic ...Pleeeeeease Do somethingggg...
first we have to stop givving her the digoxin
then we give her Digibind
and I don't thin that we have to trat her first degree avb
what do u mean bu Digibind??
if you mean " digoxin-specific Fab fragments ",we can give the pt what do u want .But if not,u should explain more Dr.
....................
Quizzes :
1. what the most important electrolyte we should monitor while giving the Digo.?
2.what are The indications for administration of digoxin-specific Fab fragments?
digoxin-specific Fab fragments "=digibind
1. what the most important electrolyte we should monitor while giving the Digo.?
2.what are The indications for administration of digoxin-specific Fab fragments?
(1) ingestion of massive quantities of digitalis (children 4 mg or 0.1 mg/kg, adults 10 mg),
(2) hyperkalemia (>5 mEq/L),
(3) digoxin-induced ventricular dysrhythmias or high-grade AV block,
(4) rapidly progressive signs and symptoms of toxicity, (5) cardiac arrest or cardiogenic shock in a patient with suspected digoxin toxicity, and
(6) postdistribution serum digoxin levels greater than 5 ng/mL.
by the way :
old people are at high risk of digoxin toxicity, so : use lower doses.
the reference : OHCM
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now at the end ,just because it came to my mind,i hope u answer me:
WPW+Digoxin
What does it reveal to u?
.............
WPW :Wolf Parkinson White