d****y
发帖数: 2180 | 1 选A还是E？
Paracentesis 虽说是比较general 的抽液，在这题可以理解为心包抽液吗？
18. A 50-year-old woman has had progressive dyspnea over the past 2
weeks
and constant, sharp chest pain for 4 days. The pain is localized to the
center of the chest and is worse while supine. She underwent a right,
modified radical mastectomy and adjuvant chemotherapy for breast cancer
3
years ago. She has a history of hypothyroidism treated with thyroid
replacement therapy. She has smoked one pack of cigarettes daily for 30
years and drinks two ounces of alcohol daily. She is dyspneic and
diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70
mm Hg
with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations
are
28/min. Examination shows jugular venous distention to the angle of the
mandible. The liver span is 14 cm with 4 cm of shifting abdominal
dullness.
Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30
mm Hg
, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged
cardiac
silhouette with a globular configuration. An ECG shows sinus tachycardia
with nonspecific ST-segment changes diffusely. Which of the following is
the
most appropriate next step in management?
A ) Echocardiography
B ) CT scan of the abdomen
C ) Ventilation-perfusion lung scans
D ) Bronchoscopy
E ) Paracentesis |
H****y
发帖数: 156 | 2 A, best accurate diagnostic test
Paracentesis is a medical procedure involving needle drainage of fluid from
a body cavity,[1] most commonly the peritoneal cavity in the abdomen.
A related procedure is thoracocentesis, which is needle drainage of the
chest cavity. Pericardiocentesis involves taking fluid in the area of the
pericardium. |
s*********a
发帖数: 336 | 3 Yes, I think E is what I would choose. For a patient in distress, secure the
vital signs is possibly the best next step. Paracentesis could be a short
for pericardial paracentesis, just like "type and cross reaction" means "
blood type and patient-donor serum-red blood cell cross reaction" before
transfusion. Also, Echocardiography might not be able to provide more
information to the diagnosis of acute pericardial effusion. So, ABC first. |
d****y
发帖数: 2180 | 4 Good point. Thanks.
I think the diagnosis of Cardiac Tamponade can be made even without Echo in
this case. Cardiac Tamponade is a clinical diagnosis.
This patient is hemodynamically unstable, isn't it urgent to tap some water
out to relieve the pressure to heart before any diagnostic test?
Of caourse the term paracentesis is not a good one, if this option
change to pericardiocentesis, which one would you choose?
http://emedicine.medscape.com/article/152083-treatment
Removal of pericardial fluid is the definitive therapy for tamponade and can
be done by the following 3 methods.
Emergency subxiphoid percutaneous drainage: This is a life-saving bedside
procedure. The subxiphoid approach is extrapleural; hence, it is the safest
for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an
angle of 30-45° to the skin, near the left xiphocostal angle, aiming
towards the left shoulder. When performed emergently, this procedure is
associated with a reported mortality rate of approximately 4% and a
complication rate of 17%.
Echocardiographically guided pericardiocentesis (often performed in the
cardiac catheterization laboratory): This is usually performed from the left
intercostal space. First, mark the site of entry based on the area of
maximal fluid accumulation closest to the transducer. Then, measure the
distance from the skin to the pericardial space. The angle of the transducer
should be the trajectory of the needle during the procedure. Avoid the
inferior rib margin while advancing the needle to prevent neurovascular
injury. Leave a 16-gauge catheter in place for continuous drainage.
Percutaneous balloon pericardiotomy: This can be performed using an approach
similar to that for echo-guided pericardiocentesis, in which the balloon is
used to create a pericardial window.
Patients should receive treatment of the underlying cause t
from
【在 H****y 的大作中提到】
: A, best accurate diagnostic test
: Paracentesis is a medical procedure involving needle drainage of fluid from
: a body cavity,[1] most commonly the peritoneal cavity in the abdomen.
: A related procedure is thoracocentesis, which is needle drainage of the
: chest cavity. Pericardiocentesis involves taking fluid in the area of the
: pericardium.
|
S******9
发帖数: 2837 | 5 you are right.
if E is pericardiocentesis, then E is the best one
in
water
can
【在 d****y 的大作中提到】
: Good point. Thanks.
: I think the diagnosis of Cardiac Tamponade can be made even without Echo in
: this case. Cardiac Tamponade is a clinical diagnosis.
: This patient is hemodynamically unstable, isn't it urgent to tap some water
: out to relieve the pressure to heart before any diagnostic test?
: Of caourse the term paracentesis is not a good one, if this option
: change to pericardiocentesis, which one would you choose?
: http://emedicine.medscape.com/article/152083-treatment
: Removal of pericardial fluid is the definitive therapy for tamponade and can
: be done by the following 3 methods.
|
H****y
发帖数: 156 | 6 if pericardiocentesis, I definitely choose it. For the echo, there is
emergent bedside echo, which provide diagnosis and guidance of
pericardiocentesis at the same time. So I think it the first thing to do
right before pericardiocentesis. paracentesis is distracting option here.
it is just my opinion.
Actually, it is more important to learn from the Q above about the principle
of how to manage pt with cardial tamponade.
Nice to discuss with you here, which makes me look at it in-depth. |
l*******8
发帖数: 290 | 7 A.
I would choose E if it specifically states pericaidiocentesis. But it's not.
My personal impression is that NBME likes to give out tricks like this. You
know everything about the disease. But you could only narrow down to two
options. Either one seems like reasonable and could be the right answer. But
, paracentesis is not the perfect one. So here you go, A. |
D*********t
发帖数: 140 | 8 If echo is available, it's hard to imagine you do puncture without guiding. As you know, heart can beat and increase the risk of complications. Plus I never notice anywhere refer paracentesis to the same meaning of pericardiocentesis.
So, I would definitely go A. |
s*********a
发帖数: 336 | 9 This patient is an urgent one, she could stop breathing any time on the way
to the echo. Plus she is not in ED, it is not surprise if you do not have a
portable echo handy in the office. Blind pericardial parenthesis is doable,
just as the treatment for tension pneumothorax. It is a basic for an MD with
the advanced life support certificate which is almost an obligation. |
s*********a
发帖数: 336 | 10 Paracentesis is a medical procedure involving needle drainage of fluid from
a body cavity,most commonly the peritoneal cavity in the abdomen.
A related procedure is thoracocentesis, which is needle drainage of the
chest cavity. Pericardiocentesis involves taking fluid in the area of the
pericardium. |
|
|
D*********t
发帖数: 140 | 11 I read the question stem again and still didnt see the urgency of puncture
without any guiding. The patient is still not very bad.
Please also note that a bedside echo is generally available now. |
s*********a
发帖数: 336 | 12 Patient in distress:
she is dyspneic and diaphoretic. Her blood pressure is 90/70 mm Hg with a
pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min.
Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30
mm Hg, and PO2 of 70 mm Hg.
What do you think? Send her to ED? I assume the portal CARDIO echo is using
a different frequency with the regular abd? My PCP does not know how to
operate a cardio echo, how about yours? |
D*********t
发帖数: 140 | 13 @sunflowerla: lol Wish you a happy day. |
s*********a
发帖数: 336 | 14 Thank you, you too.
【在 D*********t 的大作中提到】
: @sunflowerla: lol Wish you a happy day.
|
d****y
发帖数: 2180 | 15 Emergency subxiphoid percutaneous drainage: This is a life-saving bedside
procedure. The subxiphoid approach is extrapleural; hence, it is the safest
for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an
angle of 30-45° to the skin, near the left xiphocostal angle, aiming
towards the left shoulder. When performed emergently, this procedure is
associated with a reported mortality rate of approximately 4% and a
complication rate of 17%.
You don't have time to do the Echo.
. As you know, heart can beat and increase the risk of complications. Plus I
never notice anywhere refer paracentesis to the same meaning of
pericardiocentesis.
【在 D*********t 的大作中提到】
: If echo is available, it's hard to imagine you do puncture without guiding. As you know, heart can beat and increase the risk of complications. Plus I never notice anywhere refer paracentesis to the same meaning of pericardiocentesis.
: So, I would definitely go A.
|
d****y
发帖数: 2180 | 16 有没有cardiologist 出来给讲解一下，这情况算不算急，要不要马上做心包穿刺抽液
，还是先做Echo在Echo下抽液？ |
s********p
发帖数: 1319 | 17 Daisy大大，Sorry，刚看到问题。
只要有明显的呼吸、循环功能障碍，就需要紧急心包穿刺，减压——救命是第一位的原
则：
第一：急性心包填塞，哪怕积液量很少，但来不及代偿，有明显的呼吸、循环功能障碍
，需要紧急心包穿刺，减压；
第二：你上面的这个病例，有4天的胸痛史，虽然在代偿，但患者的循环和呼吸功能已
经有大问题了。循环方面，脉压差已经只有20mmHg(90/70mmHg),就凭借这个，可以判断
患者有器官和微循环水平的灌注障碍了——需要紧急心包穿刺，减压——不管有无影像
支持！
我个人认为，答案A，只有定位、定量诊断，再好，没有治疗——有呼吸循环功能不好的病人，不用考虑！
X-Ray发现球形心，这个积液量已经不少了，所以，缓慢、谨慎的18G穿刺针进去，导致
心外膜挫裂伤的可能性很小——哪怕没有床旁Echo指导。
实践中，一说心包穿刺，大家默认的都是——如果有影像学支持的诊所或者医院，默认
的都是在影像学支持下进行——床旁Echo或者导管室X-Ray下进行。
实践中，再差的医院或者诊所，至少EKG是有的——而18G的钢针如果触及到心外膜，除心律失常外，还有其他明显的EKG表现的。实在没有其他影像学指导的话，EKG也是有用的！
实践中时这么操作的：
先，18G的钢针缓慢进去，有落空感、轻轻回抽见液体后，退注射器，然后从钢针里进
一根指引导丝——最前边是我们食指比成“9”字型那种指引导丝，很软，不会刺伤心
肌的。然后退钢针，沿指引导丝进个有开关的鞘管，再沿鞘管进根“猪尾”，就可以接
上空针缓慢抽除心包积液了。
——以上就是现代血管和心包的穿刺的基本过程，设计很聪明、科学，那根指引导丝或
叫指引钢丝在，鞘管是沿着它走，不会撕裂血管。它是整个现代心脏和血管介入治疗的
基础。
——我也再看CK。感觉CK的题，对处理顺序上要求非常严格。有循环和呼吸障碍，解除
威胁生命的危险，是No.1,也是正确答案。
另外一些例子就是心律失常的治疗。都知道对心律失常，任何电复律手段，是不能维持
较长时间的——病因未解除！但一旦患者血液动力学状况，或者生命体征不平稳，没有
任何含糊——电复律。不管是在美国还是在中国、也不管是CK还是在实践中，解除威胁
生命的情况，都是No.1的事。
你给的这个题，在解释中，有一点没有给我们解释清楚：判断循环功能的参数，除了收
缩压>=90mmHg外，还有个更重要的参数，就是脉压差——更主要的，是靠这个差值推动
血液循环的，比如：140/120mmHg这种血压，也是非常危险的血压！！
不敢在Medi回答问题了——那些刚Match上的、或者社区小医院的小医生，都洋气得不
得了了，“美国”了！。在他们看来，协和的、北医的，都是“土”医生，都是“江湖
郎中”，就他们“洋气”——我回答问题，他们,琐男、琐女们要吐我口水，要打我，好痛啊！
嘿！嘿！
新年好！！ |
S******9
发帖数: 2837 | 18 不好意思，我又要拍你了，呵呵，尽管我也在紧急没有echo的情况下穿过2次。
但是现在是做题目，一切要规范，要符合考试。
那个E答案是腹穿，所以是这个题目答案选A的原因。是几个答案中优选。
好的病人，不用考虑！
【在 s********p 的大作中提到】
: Daisy大大，Sorry，刚看到问题。
: 只要有明显的呼吸、循环功能障碍，就需要紧急心包穿刺，减压——救命是第一位的原
: 则：
: 第一：急性心包填塞，哪怕积液量很少，但来不及代偿，有明显的呼吸、循环功能障碍
: ，需要紧急心包穿刺，减压；
: 第二：你上面的这个病例，有4天的胸痛史，虽然在代偿，但患者的循环和呼吸功能已
: 经有大问题了。循环方面，脉压差已经只有20mmHg(90/70mmHg),就凭借这个，可以判断
: 患者有器官和微循环水平的灌注障碍了——需要紧急心包穿刺，减压——不管有无影像
: 支持！
: 我个人认为，答案A，只有定位、定量诊断，再好，没有治疗——有呼吸循环功能不好的病人，不用考虑！
|
s********p
发帖数: 1319 | 19 Paracentesis这个单词，我又查了：（放液）穿刺。
当然，如果Paracentesis只是指“腹腔穿刺”，就和这道题风马牛不相及。
我说的这个病人的处理，没有错啊。
【在 S******9 的大作中提到】
: 不好意思，我又要拍你了，呵呵，尽管我也在紧急没有echo的情况下穿过2次。
: 但是现在是做题目，一切要规范，要符合考试。
: 那个E答案是腹穿，所以是这个题目答案选A的原因。是几个答案中优选。
:
: 好的病人，不用考虑！
|
d****y
发帖数: 2180 | 20 Paracentesis is a medical procedure involving needle drainage of fluid from
a body cavity,most commonly the peritoneal cavity in the abdomen.
A related procedure is thoracocentesis, which is needle drainage of the
chest cavity. Pericardiocentesis involves taking fluid in the area of the
pericardium.
Paracentesis只是范指的抽取体腔积液， 并没有具体指那个体腔，当然抽腹腔的多，
但也可能是胸腔，心包腔的。
【在 S******9 的大作中提到】
: 不好意思，我又要拍你了，呵呵，尽管我也在紧急没有echo的情况下穿过2次。
: 但是现在是做题目，一切要规范，要符合考试。
: 那个E答案是腹穿，所以是这个题目答案选A的原因。是几个答案中优选。
:
: 好的病人，不用考虑！
|
|
|
d****y
发帖数: 2180 | 21 这道题看来就是挺有争议的。如果E选项是 pericardiocentesis, 可能大部分人都同意
选这个。不过这个 paracentesis， 到底是泛指抽取体腔积液呢，还是就指腹穿，看来
只有出题的人才知道了。
非常感谢大家的回复， 问题要多讨论才能理解得更透彻。 再次感谢！ |
d****y
发帖数: 2180 | 22 看看这本书，paracentesis 就是指的抽液， 可以是指从心包腔抽液，不一定特指腹穿。
Principles and Practice of Medicine a Textbook for Students and
Practitioners
By Prasad
http://books.google.com/books?id=FwjONWDm6HkC&pg=PA250&dq=Cardi |
s********p
发帖数: 1319 | 23 谢谢Daisy.
如果NBME没有给出正确的答案，各位大虾在Google里查一下：
Cardiac Tamponade Paracentesis
如果Paracentesis这个词可以用在心包填塞这个术语包含的内容中，答案就明确了。
穿。
【在 d****y 的大作中提到】
: 看看这本书，paracentesis 就是指的抽液， 可以是指从心包腔抽液，不一定特指腹穿。
: Principles and Practice of Medicine a Textbook for Students and
: Practitioners
: By Prasad
: http://books.google.com/books?id=FwjONWDm6HkC&pg=PA250&dq=Cardi
|
s********p
发帖数: 1319 | 24 我想：XDJM们再换个角度思考一下，问题的答案就更明确。
如果有另外一个考题：心包填塞的临床诊断究竟靠什么？——Beck's Triad,还是Echo?
!我们选什么？！
而且，还有X-Ray的结果摆在那里，这个患者的诊断，不需要Echo了吧？!而且，这个病
人，已经没有任何退路了。对这病人，Echo的作用只有一个，是用来引导穿刺，而不是
用来诊断的。
所以，在答案A和E之间，哪怕就是CK过于不过之间，毫无疑问，我就选E——因为那个
单词的意思，是穿刺放液，而不只限于腹腔穿刺。 |
d****y
发帖数: 2180 | 25 另外穿刺放液，也不等于不是超声介导下的穿刺。题目只是说穿刺抽液，至于什么方式
途径，并没有说。（呵呵，我前面也有点儿想偏了，老想到无超声盲穿了，其实题目里
并没有这个意思。）
这个病人的情况，已经等不及多做其他检查了，马上抽液减压，是救命的。
Echo?
【在 s********p 的大作中提到】
: 我想：XDJM们再换个角度思考一下，问题的答案就更明确。
: 如果有另外一个考题：心包填塞的临床诊断究竟靠什么？——Beck's Triad,还是Echo?
: !我们选什么？！
: 而且，还有X-Ray的结果摆在那里，这个患者的诊断，不需要Echo了吧？!而且，这个病
: 人，已经没有任何退路了。对这病人，Echo的作用只有一个，是用来引导穿刺，而不是
: 用来诊断的。
: 所以，在答案A和E之间，哪怕就是CK过于不过之间，毫无疑问，我就选E——因为那个
: 单词的意思，是穿刺放液，而不只限于腹腔穿刺。
|
