Saturday, November 24, 2007

Strategies to Avoid Medicare’s Big Hole - New York Times

Strategies to Avoid Medicare’s Big Hole - New York Times Technorati tags: ,

Medicare drug benefits have a gap from $2,510 to $5,726. This has lead many patients to try generic drugs before they reach the $2,510 limit. Companies such as Wal-Mart (WMT) are offering good discounts on generic drugs, and some companies are offering free generic drugs so their employees stay healthy.

Saturday, November 10, 2007

hyperpigmentation after pregnancy

Dizziness
A 29 year old female presents to your office after noticing increased skin pigmentation over the last four months in winter. She's also noticed dizzyness and a ten pound weight loss. She delivered her first baby four months ago. The delivery was complicated by excessive blood loss, and she lost consciousness for a brief period after the delivery. Review of systems is notable for decreased appetite, nausea and vomiting, and feeling thirsty. She has also been unable to breastfeed her baby since she is unable to form breast milk. Her blood pressure in the office is 100/70, while blood pressure from last year was 120/80. After ordering a basic metabolic panel, it's significant for a sodium of 130 and a potassium of 5.2.
What is the patient's most likely condition?
A) Conn's Syndrome
B) Pheochromocytoma
C) Addison's disease
D) Secondary adrenal insufficiency
E) Hashimoto's thyroiditis
What is the next immediate step?
A) IV Fluids
B) Hydrocortisone
C) CT Abdomen
D) Renal Ultrasound
E) Aspirin
What is the name of her pregnancy related condition?
A) Eclampsia
B) Preeclampsia
C) Sheehan's syndrome
D) Hemochromatosis
Answer: This recently pregnant patient with hyperpigmentation, syncope, and hypotension most likely has secondary adrenal insufficiency. Other supporting information include his hyponatremia and hyperkalemia. Addrenal insufficiency requires immediate action including IV fluids and hydrocortisone. She likely has Sheehan's syndrome from postpartum hemorrhage and hypotension. This is likely causing her inablility to breastfeed also. She should be interviewed further for endocrine abnormalities.

Sources:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

Dizziness

A 27 year old male presents to your office after having an episode of dizziness followed by a loss of consciousness. Over the last four months, he's noticed a ten pound weight loss. Although it's December, he has noticed increased skin pigmentation. Review of systems is notable for decreased appetite, nausea and vomiting, and feeling thirsty. His blood pressure in the office is 100/70, while his blood pressure from last year was 120/80. After ordering a basic metabolic panel, it's significant for a sodium of 128 and a potassium of 5.
What is the patient's most likely condition?
A) Conn's Syndrome
B) Pheochromocytoma
C) Addison's disease
D) Graves' disease
E) Hashimoto's thyroiditis
What is the next immediate step?
A) IV Fluids
B) Hydrocortisone
C) CT Abdomen
D) Renal Ultrasound
E) Aspirin

Answer: This patient with hyperpigmentation, syncope, and hypotension most likely has Addison's disease. Other supporting information include his hyponatremia and hyperkalemia. Addison's disease is a medical emergency which requires immediate action including IV fluids and hydrocortisone.

Sources:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

Tuesday, November 06, 2007

purulent nasal discharge

A 32 year old woman comes into the office with yellow nasal discharge for one week. She has also had a headache during this time. Physical exam shows tenderness over the frontal sinus and an inability to transilluminate the frontal sinuses. The maxillary sinuses are non-tender. CT of head shows opacification of the frontal sinus.
What pathogens can cause this condition?
A) Moraxella
B) Cocciodides
C) Respiratory Synctial Virus
D) S. pneumoniae
E) Haemophilus species
What is the first line of treatment?
A) Penicillin
B) Amoxicillin
C) Second generation Cephalosporin
D) Tetracylcine

Answer: This patient with nasal discharge and frontal sinus tenderness most likely has sinusitis. Common pathogens include Haemophilus species and S. pneumonia. Treatment can be begin with amoxicillin or second-generation cephalosporin.

Sources:1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.2.
Books for Medical Students

A tired farmer

A 62 year old farmer in New Mexico comes to the office with a 1 week history of malaise, fevers, cough, joint pain, and a headache. The patient denies smoking. A chest x-ray shows a 2 cm round nodule not present on prior x-rays.
What can cause this condition in this patient?
A) Histoplasmosis
B) Tuberculosis
C) Hamartoma
D) Lung cancer
E) Coccidiodes immitis
What is this condition called?
A) Death Valley Fever
B) San Joaquin Valley Fever
C) San Andreas chills
D) desert pneumonia
What can happen 1-2 weeks later?
A) diarrhea
B) vomitting
C) blurry vision
D) rash
E) erythema nodosum
F) erythema multiforme

Answer: This patient living in the southwest United States likely has an infection with Coccidiodes immitis. It is a flu like syndrome along with small nodules found on x-ray. The condition is called San Joaquin Valley Fever. Only 40% of those with the infection develop symptoms. 1-2 weeks later they can develop a rash, erythema nodosum, and erythema multiforme.

Sources:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
2. http://www.accessmedicine.com/content.aspx?aID=2763279
Books for Medical Students

Wheezing 1 year old

In December, a 1 year old baby girl is brought into the emergency room. The mother states the baby has been wheezing for 1 day intermittently. The baby is crying and when she pauses to take a breath you can hear wheezing bilaterally. Her temperature is 101.9 degrees Fahrenheit. What can cause wheezing in this 1 year old?
A) Foreign Object
B) Asthma
C) Respiratory Synctial Virus
D) Pneumonia
What is the standard for diagnosis?
A) Chest X-ray
B) Elisa of blood
C) Elisa of nasal washings
D) Culture of nasopharyngeal secretions
What is the treatment?
A) Humidification, hydration, and ventilatory support
B) Ribavirin
C) Corticosteroids
D) Bronchodilators
E) Palivizumab

Answer: Although asthma and a foreign object can cause wheezing, respiratory synctial virus must also be considered for wheezing in patients less than 2 years old. RSV occurs during the winter and can be accompanied by a fever. The standard for diagnosis is culture of nasopharyngeal secretions. Initial treatment is humidification, hydration, and ventilatory support. The other methods listed are advanced treatments.

Source:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
2. http://www.accessmedicine.com/content.aspx?aid=2549353
Books for Medical Students

young person with difficulty breathing

A 25 year old male comes into the office with progressive shortness of breath. He admits to a 3 year history of smoking cigarettes averaging less than 1/2 a pack per day. Physical exam shows a prolonged expiratory phase, end-expiratory wheezing, and decreased heart and breath sounds. What is a likely etiology of his current condition?
A) Pneumonia
B) Asthma
C) Asbestos
D) Alpha1 Trypsin Deficiency

Answer: This young 25 year old male appears to have emphysema. This usually develops after several years of smoking in older individuals. In this person with a short smoking history and physical findings consistent with emphysema, alpha1 Trypsin deficiency should be considered.

Source:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

COPD trouble breathing

A patient with COPD comes into the ER with altered mental status. An arterial blood gas is ordered and it shows CO2 of 54 and an O2 of 48. The pH was 7.25 while he was breathing room air. 2 liters oxygen is given by nasal canula yet the patient is not improving symptomatically, and his scalene muscles are contracting heavily. What is the next step?
A) Increase nasal canula to 4 L
B) Give albuterol nebulizers
C) Intubate
D) Give epinephrine

Answer:
This person has several indications for intubation including a CO2 > 50, O2 <50, pH <7.30 on room air, and lack of improvement with nasal canula. He is also starting to use his accesory muscles to breathe.

Source:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students