a*******n
发帖数: 82 | 1 78 yo female was transferred for evaluation of torsades. The patient has one
year history of AF and has been taking amiodarone and coumadine. For the
past 5 months, she has been feeling severe nausea. She was admitted to xxx
Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
was stopped for suspicious GI bleeding. Levothyroxine was started.She was
also given 2 units of pRBC. EGD was done and found diffuse gastritis without
finding any active bleeding sites. MRI brain was unremarkable. She was
given antiemetics and her nausea didn't improve. From telemetry, her QTc was
prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
Then the patient was transferred to our hospital for further management.
This was basically what I got before I walked into the patient's room. What
will you do next? Or what do you want to know next? |
s*******1
发帖数: 428 | 2 check serum calcium levels, because she received 2 units of pRBC.
And I might start to give magnesium even before I get the lab results, then
give calcium. |
I****a
发帖数: 407 | 3 From hematological point of view, I would like a entire diff including RBC
indices and reticount before and after the blood transfusion.
From the cardiology point of view, I would like to have electrolytes
including Mg and an ECHO.
From endocrinology point of view, I would like a complete thyroid panel, FT3
, FT4 and TSH.
In addition, I also like information of her PMH/PSH, medication including
any OTC stuff, habits etc.
My hunch at this point is that everything is originated from her thyroid.
one
coumadin
without
was
.
【在 a*******n 的大作中提到】
: 78 yo female was transferred for evaluation of torsades. The patient has one
: year history of AF and has been taking amiodarone and coumadine. For the
: past 5 months, she has been feeling severe nausea. She was admitted to xxx
: Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
: Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
: was stopped for suspicious GI bleeding. Levothyroxine was started.She was
: also given 2 units of pRBC. EGD was done and found diffuse gastritis without
: finding any active bleeding sites. MRI brain was unremarkable. She was
: given antiemetics and her nausea didn't improve. From telemetry, her QTc was
: prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
|
V*****G
发帖数: 337 | 4 I will ask what was used for antiemetics (drug side effect for Torsades) and
check electrolyte.
Also would like to know any vomitting and diarrhea for electrolyte
perspective.
Amiodarone can cause torsades, and since it's half life is so long, and this is also one reasonable culprit.
one
coumadin
without
was
.
【在 a*******n 的大作中提到】
: 78 yo female was transferred for evaluation of torsades. The patient has one
: year history of AF and has been taking amiodarone and coumadine. For the
: past 5 months, she has been feeling severe nausea. She was admitted to xxx
: Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
: Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
: was stopped for suspicious GI bleeding. Levothyroxine was started.She was
: also given 2 units of pRBC. EGD was done and found diffuse gastritis without
: finding any active bleeding sites. MRI brain was unremarkable. She was
: given antiemetics and her nausea didn't improve. From telemetry, her QTc was
: prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
|
A*******s
发帖数: 9638 | 5 D/C Amiodarone as well as using antiemetic agents like zofran could increase
the chance of cardiac arrhythmia icluding Torsades.
http://virtue.ucdenver.edu/ArticleOfMonth/Prolongation%20of%20Q
Just curious why they did a MRI of brain? |
a*******n
发帖数: 82 | 6 They are all valuable points!
She was given Zofran, Phenergan and compazine in the other hospital.
MRI of brain was done for evaluation of severe nausea.
For her PMH/PSH, significant for iron-deficiency anemia, treated with iron
supplements in the past; HTN; DLP; h/o C. diff colitis 6 months ago; pAF
with RVR 8 months ago; yearly normal mammogram; normal colonoscopy 3 years
ago; chronic lymphedema from lower extremities; lung nodule with stable CT
followup. She was on dig, amiodarone, coumadin, simvastatin, lisinopril at
home. On transfer, she was on levothyroxine 75 mcg, lisinopril 5 mg,
simvastatin 40 mg. She is allergic to PCN. She is lifetime nonsmoker and
doesn't drink alcohol. No family history of thyroid disease, heart disease
or cancer.
Upon interviewing the patient, she complained of severe positional nausea
and some mild headache. Her oral intake has been poor from the nausea and no
weight change noticed recently. She felt her leg swelling got worse.
On exam, the patient is pale, weak and depressed without resp. distress. DMM
. Decreased breath sounds on bilateral bases. 2/6 systolic murmur throughout
. Abdomen benign. 2+ leg edema with pitting component.
Intial labs/studies: TSH 33 (2 weeks after the one in the other hospital),
Mag 1.5, K 3.6, BUN/Cr 34/1.8, Hgb 9.6.
EKG showed SB of 48 with QTc 568 msec. CXR mod right pleural effusion and
mild left pleural effusion. Wet read suggested congestive heart failure.
Echo showed mod TR with EF 63%, mild pul hypertension.
The patient was on Cardiology service primarily for torsades. Medicine was
consulted for other medical issues like hypothyroidism, acute renal injury,
pleural effusion and many others. Endo was on board and didn't think her
nausea and pleural effusion was from hypothyroidism. Cardiology said no
antiemetics concerning for QT elongation and fix her nausea so they can do
further studies like possible EP.
And what I should do next?
PS: The patient is still with me. |
a*******n
发帖数: 82 | 7 Mannual diff only significant for Monocyte percentage 25-30%. She had low
iron saturation, but elevated ferritin (this is after 2 units she got from
the other hospital). Normal hapto and slight elevated LDH. normal reti index
. Normal RBC folate and B12.
FT3
【在 I****a 的大作中提到】
: From hematological point of view, I would like a entire diff including RBC
: indices and reticount before and after the blood transfusion.
: From the cardiology point of view, I would like to have electrolytes
: including Mg and an ECHO.
: From endocrinology point of view, I would like a complete thyroid panel, FT3
: , FT4 and TSH.
: In addition, I also like information of her PMH/PSH, medication including
: any OTC stuff, habits etc.
: My hunch at this point is that everything is originated from her thyroid.
:
|
a*******n
发帖数: 82 | 8 Good thoughts! She didn't have any GI symptoms except nausea and poor oral
intake. No diarrhea or vomiting. No abd pain.
and
this is also one reasonable culprit.
【在 V*****G 的大作中提到】
: I will ask what was used for antiemetics (drug side effect for Torsades) and
: check electrolyte.
: Also would like to know any vomitting and diarrhea for electrolyte
: perspective.
: Amiodarone can cause torsades, and since it's half life is so long, and this is also one reasonable culprit.
:
: one
: coumadin
: without
: was
|
A*******s
发帖数: 9638 | 9 Her nausea seems to be from vestibulopathy. But I have no gut to put her on
antivert which is anticholinergic. Instead, I would use benzo for nausea
only, which also helps the anxiety.
Call me crazy but I think it is reasonable to put her back on amiodarone.
1. Amiodarone has nothing to do with her nausea.
2. Hypothyroidism can be corrected with synthroid.
3. Asymptomatic (cardiac wise)when on amiodarone.
4. A good agent for ventricular arrhythmia and A-fib.
Did her symptoms all start after D/C amiodarone? |
I****a
发帖数: 407 | 10 Interesting. I would like a UA, LFT including total protein and albumin. |
|
|
I****a
发帖数: 407 | 11 Forgot to ask what her vitals? |
a*******n
发帖数: 82 | 12 En, I gave her Ativan 0.5 mg once. Her nausea was unchanged.
Her vitals: afebril, HR 56, BP 105/68, RR 12, Sating 94% on 2 L NC.
Her UA showed >20 WBC, positive nitrites, positive LE and culture eventually
grew out E coli. LFT showed albumin 2.5, TP 4.6, otherwise unremarkable.
She had a million of things going on, however, I believed "nausea" is the
key. She didn't have any vertigo or dizziness or vision change, which made
CNS cause less likely. Gastritis? severe nausea without pain? Doesn't sound
like. But I checked H.pylori anyway. It was serum ab positive, stool antigen
negative. What else?
My first thought was lymphoma or leukemia, something malignant. So I scanned
her. Because of her renal injury, all the studies were done without
contrast. I ordered chest CT, MRI of brain (yes, A+, I just have to rule out
CNS process and I don't believe report).
Chest CT showed 5 small nodules, largest about 2 cm on RUL, LUL, RLL.
Because she was visiting from PA, we don't really have her medical records.
Her family mentioned she had lung nodules in the past, which had been stable
from CT scan every 6 months. MRI showed multiple round lucency on frontal
skull and submandibular bone.( What a bummer!)
Then UPEP and SPEP were ordered. I called Hem/Onc fellow. |
a*******n
发帖数: 82 | 13 Her fatigue and nausea has been going on for months. It was two week prior
when they found her severe hypothyroidism, amioderaone was stopped.
on
【在 A*******s 的大作中提到】
: Her nausea seems to be from vestibulopathy. But I have no gut to put her on
: antivert which is anticholinergic. Instead, I would use benzo for nausea
: only, which also helps the anxiety.
: Call me crazy but I think it is reasonable to put her back on amiodarone.
: 1. Amiodarone has nothing to do with her nausea.
: 2. Hypothyroidism can be corrected with synthroid.
: 3. Asymptomatic (cardiac wise)when on amiodarone.
: 4. A good agent for ventricular arrhythmia and A-fib.
: Did her symptoms all start after D/C amiodarone?
|
I****a
发帖数: 407 | 14 That is exactly my next guess for old female with anemia and renal failure.
She could have amyloid affecting her heart as well as autonomic nerve
contributing nausea. |
A*******s
发帖数: 9638 | 15 So you did a bone scan? |
I****a
发帖数: 407 | 16 Bone scan might not reveal the lytic bone lesions. Bone survey is the way to
go. What is the UPEP and SPEP result? |
A*******s
发帖数: 9638 | 17 hey， it takes 3-4 days for SPEP, but same day for a bone scan. So you have
to wait. lol
to
【在 I****a 的大作中提到】
: Bone scan might not reveal the lytic bone lesions. Bone survey is the way to
: go. What is the UPEP and SPEP result?
|
I****a
发帖数: 407 | 18 I guess it also depends where you practice. I remember it was always a big
hassle to collect patient's 24 hrs urine during my residency. Nurses
sometimes do not do their job. |
a*******n
发帖数: 82 | 19 Sorry for late followup(on vacation:)
The patient had lung nodule biopsy. It was diffuse large B-cell lymphoma.
PET scan revealed lesions in skull, lung, abdominal lymph nodes, pelvic and
hip joints. She received one cycle of RCVP as palliative chemo.
Before this dx, for her nausea, I had been giving her dexamethasone, which
worked magically for her nausea. My big name H/O attending said "You have
been treating her cancer and pretreating her from tumor lysis syndrome
before chemo" Yeah! |
A*******s
发帖数: 9638 | 20 I thought you were vaporized. Congratulations for the right treatment prior
to the diagnosis. And yes, you deserve another internship. lol.
It was a good search for the causes of anemia.
I have a question:
Why do you think she was so nauseated? It doesn't seem to me the lymphoma
invaded the gut although it is possible and GI should be able to catch it. |
|
|
A*******s
发帖数: 9638 | 21 先爬楼再评论， 这是对LZ的尊重。 LZ做resident应该没多少时间上网的。
你要真戒网就得把PC砸了， 我治疗成瘾很有一套： 舍不了孩子打不了狼。
不过我很欢迎您光临，这网有什么可戒的。 |
s********p
发帖数: 1319 | 22 我是差等生——Step 1、2都不考过多次啦！！
【在 A*******s 的大作中提到】
: 先爬楼再评论， 这是对LZ的尊重。 LZ做resident应该没多少时间上网的。
: 你要真戒网就得把PC砸了， 我治疗成瘾很有一套： 舍不了孩子打不了狼。
: 不过我很欢迎您光临，这网有什么可戒的。
|
A*******s
发帖数: 9638 | 23 我没问你step1，2什么的， 我们这儿不兴谈这个。
你现在的水平直接考step3得了， 临床医生要那么多基础知识有啥用？
开个玩笑， 不要当真。
不过你说得如果是真的， 不要灰心啦。 我有个朋友， 考了无数次， 考过就match上了。 原来国内的基础好， 可能跟你情况差不多。当然， 你要是在这里瞎说，就当我没说。
【在 s********p 的大作中提到】
: 我是差等生——Step 1、2都不考过多次啦！！
|
s********p
发帖数: 1319 | 24 赫本会瞎说话吗？！
——从2月份起开始准备到今天，而且是全职，但Step1、CS、CK、Step3一而再、再
而三推迟，现在脑袋里进了很多水，电路全乱、处处短路！！都不好意思再到网上去延期啦！！！ |
I****a
发帖数: 407 | 25 I might disagree. Giving steroid for suspected multiple myeloma/lymphoma may
sometimes jeopardize the yield of future definitive tissue diagnosis. She
has so much extra nodal disease burden so I won't be surprised if her GI
tract is also involved.
and
【在 a*******n 的大作中提到】
: Sorry for late followup(on vacation:)
: The patient had lung nodule biopsy. It was diffuse large B-cell lymphoma.
: PET scan revealed lesions in skull, lung, abdominal lymph nodes, pelvic and
: hip joints. She received one cycle of RCVP as palliative chemo.
: Before this dx, for her nausea, I had been giving her dexamethasone, which
: worked magically for her nausea. My big name H/O attending said "You have
: been treating her cancer and pretreating her from tumor lysis syndrome
: before chemo" Yeah!
|
a*******n
发帖数: 82 | 26 78 yo female was transferred for evaluation of torsades. The patient has one
year history of AF and has been taking amiodarone and coumadine. For the
past 5 months, she has been feeling severe nausea. She was admitted to xxx
Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
was stopped for suspicious GI bleeding. Levothyroxine was started.She was
also given 2 units of pRBC. EGD was done and found diffuse gastritis without
finding any active bleeding sites. MRI brain was unremarkable. She was
given antiemetics and her nausea didn't improve. From telemetry, her QTc was
prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
Then the patient was transferred to our hospital for further management.
This was basically what I got before I walked into the patient's room. What
will you do next? Or what do you want to know next? |
s*******1
发帖数: 428 | 27 check serum calcium levels, because she received 2 units of pRBC.
And I might start to give magnesium even before I get the lab results, then
give calcium. |
I****a
发帖数: 407 | 28 From hematological point of view, I would like a entire diff including RBC
indices and reticount before and after the blood transfusion.
From the cardiology point of view, I would like to have electrolytes
including Mg and an ECHO.
From endocrinology point of view, I would like a complete thyroid panel, FT3
, FT4 and TSH.
In addition, I also like information of her PMH/PSH, medication including
any OTC stuff, habits etc.
My hunch at this point is that everything is originated from her thyroid.
one
coumadin
without
was
.
【在 a*******n 的大作中提到】
: 78 yo female was transferred for evaluation of torsades. The patient has one
: year history of AF and has been taking amiodarone and coumadine. For the
: past 5 months, she has been feeling severe nausea. She was admitted to xxx
: Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
: Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
: was stopped for suspicious GI bleeding. Levothyroxine was started.She was
: also given 2 units of pRBC. EGD was done and found diffuse gastritis without
: finding any active bleeding sites. MRI brain was unremarkable. She was
: given antiemetics and her nausea didn't improve. From telemetry, her QTc was
: prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
|
V*****G
发帖数: 337 | 29 I will ask what was used for antiemetics (drug side effect for Torsades) and
check electrolyte.
Also would like to know any vomitting and diarrhea for electrolyte
perspective.
Amiodarone can cause torsades, and since it's half life is so long, and this is also one reasonable culprit.
one
coumadin
without
was
.
【在 a*******n 的大作中提到】
: 78 yo female was transferred for evaluation of torsades. The patient has one
: year history of AF and has been taking amiodarone and coumadine. For the
: past 5 months, she has been feeling severe nausea. She was admitted to xxx
: Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
: Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
: was stopped for suspicious GI bleeding. Levothyroxine was started.She was
: also given 2 units of pRBC. EGD was done and found diffuse gastritis without
: finding any active bleeding sites. MRI brain was unremarkable. She was
: given antiemetics and her nausea didn't improve. From telemetry, her QTc was
: prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
|
A*******s
发帖数: 9638 | 30 D/C Amiodarone as well as using antiemetic agents like zofran could increase
the chance of cardiac arrhythmia icluding Torsades.
http://virtue.ucdenver.edu/ArticleOfMonth/Prolongation%20of%20Q
Just curious why they did a MRI of brain? |
|
|
a*******n
发帖数: 82 | 31 They are all valuable points!
She was given Zofran, Phenergan and compazine in the other hospital.
MRI of brain was done for evaluation of severe nausea.
For her PMH/PSH, significant for iron-deficiency anemia, treated with iron
supplements in the past; HTN; DLP; h/o C. diff colitis 6 months ago; pAF
with RVR 8 months ago; yearly normal mammogram; normal colonoscopy 3 years
ago; chronic lymphedema from lower extremities; lung nodule with stable CT
followup. She was on dig, amiodarone, coumadin, simvastatin, lisinopril at
home. On transfer, she was on levothyroxine 75 mcg, lisinopril 5 mg,
simvastatin 40 mg. She is allergic to PCN. She is lifetime nonsmoker and
doesn't drink alcohol. No family history of thyroid disease, heart disease
or cancer.
Upon interviewing the patient, she complained of severe positional nausea
and some mild headache. Her oral intake has been poor from the nausea and no
weight change noticed recently. She felt her leg swelling got worse.
On exam, the patient is pale, weak and depressed without resp. distress. DMM
. Decreased breath sounds on bilateral bases. 2/6 systolic murmur throughout
. Abdomen benign. 2+ leg edema with pitting component.
Intial labs/studies: TSH 33 (2 weeks after the one in the other hospital),
Mag 1.5, K 3.6, BUN/Cr 34/1.8, Hgb 9.6.
EKG showed SB of 48 with QTc 568 msec. CXR mod right pleural effusion and
mild left pleural effusion. Wet read suggested congestive heart failure.
Echo showed mod TR with EF 63%, mild pul hypertension.
The patient was on Cardiology service primarily for torsades. Medicine was
consulted for other medical issues like hypothyroidism, acute renal injury,
pleural effusion and many others. Endo was on board and didn't think her
nausea and pleural effusion was from hypothyroidism. Cardiology said no
antiemetics concerning for QT elongation and fix her nausea so they can do
further studies like possible EP.
And what I should do next?
PS: The patient is still with me. |
a*******n
发帖数: 82 | 32 Mannual diff only significant for Monocyte percentage 25-30%. She had low
iron saturation, but elevated ferritin (this is after 2 units she got from
the other hospital). Normal hapto and slight elevated LDH. normal reti index
. Normal RBC folate and B12.
FT3
【在 I****a 的大作中提到】
: From hematological point of view, I would like a entire diff including RBC
: indices and reticount before and after the blood transfusion.
: From the cardiology point of view, I would like to have electrolytes
: including Mg and an ECHO.
: From endocrinology point of view, I would like a complete thyroid panel, FT3
: , FT4 and TSH.
: In addition, I also like information of her PMH/PSH, medication including
: any OTC stuff, habits etc.
: My hunch at this point is that everything is originated from her thyroid.
:
|
a*******n
发帖数: 82 | 33 Good thoughts! She didn't have any GI symptoms except nausea and poor oral
intake. No diarrhea or vomiting. No abd pain.
and
this is also one reasonable culprit.
【在 V*****G 的大作中提到】
: I will ask what was used for antiemetics (drug side effect for Torsades) and
: check electrolyte.
: Also would like to know any vomitting and diarrhea for electrolyte
: perspective.
: Amiodarone can cause torsades, and since it's half life is so long, and this is also one reasonable culprit.
:
: one
: coumadin
: without
: was
|
A*******s
发帖数: 9638 | 34 Her nausea seems to be from vestibulopathy. But I have no gut to put her on
antivert which is anticholinergic. Instead, I would use benzo for nausea
only, which also helps the anxiety.
Call me crazy but I think it is reasonable to put her back on amiodarone.
1. Amiodarone has nothing to do with her nausea.
2. Hypothyroidism can be corrected with synthroid.
3. Asymptomatic (cardiac wise)when on amiodarone.
4. A good agent for ventricular arrhythmia and A-fib.
Did her symptoms all start after D/C amiodarone? |
I****a
发帖数: 407 | 35 Interesting. I would like a UA, LFT including total protein and albumin. |
I****a
发帖数: 407 | 36 Forgot to ask what her vitals? |
a*******n
发帖数: 82 | 37 En, I gave her Ativan 0.5 mg once. Her nausea was unchanged.
Her vitals: afebril, HR 56, BP 105/68, RR 12, Sating 94% on 2 L NC.
Her UA showed >20 WBC, positive nitrites, positive LE and culture eventually
grew out E coli. LFT showed albumin 2.5, TP 4.6, otherwise unremarkable.
She had a million of things going on, however, I believed "nausea" is the
key. She didn't have any vertigo or dizziness or vision change, which made
CNS cause less likely. Gastritis? severe nausea without pain? Doesn't sound
like. But I checked H.pylori anyway. It was serum ab positive, stool antigen
negative. What else?
My first thought was lymphoma or leukemia, something malignant. So I scanned
her. Because of her renal injury, all the studies were done without
contrast. I ordered chest CT, MRI of brain (yes, A+, I just have to rule out
CNS process and I don't believe report).
Chest CT showed 5 small nodules, largest about 2 cm on RUL, LUL, RLL.
Because she was visiting from PA, we don't really have her medical records.
Her family mentioned she had lung nodules in the past, which had been stable
from CT scan every 6 months. MRI showed multiple round lucency on frontal
skull and submandibular bone.( What a bummer!)
Then UPEP and SPEP were ordered. I called Hem/Onc fellow. |
a*******n
发帖数: 82 | 38 Her fatigue and nausea has been going on for months. It was two week prior
when they found her severe hypothyroidism, amioderaone was stopped.
on
【在 A*******s 的大作中提到】
: Her nausea seems to be from vestibulopathy. But I have no gut to put her on
: antivert which is anticholinergic. Instead, I would use benzo for nausea
: only, which also helps the anxiety.
: Call me crazy but I think it is reasonable to put her back on amiodarone.
: 1. Amiodarone has nothing to do with her nausea.
: 2. Hypothyroidism can be corrected with synthroid.
: 3. Asymptomatic (cardiac wise)when on amiodarone.
: 4. A good agent for ventricular arrhythmia and A-fib.
: Did her symptoms all start after D/C amiodarone?
|
I****a
发帖数: 407 | 39 That is exactly my next guess for old female with anemia and renal failure.
She could have amyloid affecting her heart as well as autonomic nerve
contributing nausea. |
A*******s
发帖数: 9638 | 40 So you did a bone scan? |
|
|
I****a
发帖数: 407 | 41 Bone scan might not reveal the lytic bone lesions. Bone survey is the way to
go. What is the UPEP and SPEP result? |
A*******s
发帖数: 9638 | 42 hey， it takes 3-4 days for SPEP, but same day for a bone scan. So you have
to wait. lol
to
【在 I****a 的大作中提到】
: Bone scan might not reveal the lytic bone lesions. Bone survey is the way to
: go. What is the UPEP and SPEP result?
|
I****a
发帖数: 407 | 43 I guess it also depends where you practice. I remember it was always a big
hassle to collect patient's 24 hrs urine during my residency. Nurses
sometimes do not do their job. |
a*******n
发帖数: 82 | 44 Sorry for late followup(on vacation:)
The patient had lung nodule biopsy. It was diffuse large B-cell lymphoma.
PET scan revealed lesions in skull, lung, abdominal lymph nodes, pelvic and
hip joints. She received one cycle of RCVP as palliative chemo.
Before this dx, for her nausea, I had been giving her dexamethasone, which
worked magically for her nausea. My big name H/O attending said "You have
been treating her cancer and pretreating her from tumor lysis syndrome
before chemo" Yeah! |
A*******s
发帖数: 9638 | 45 I thought you were vaporized. Congratulations for the right treatment prior
to the diagnosis. And yes, you deserve another internship. lol.
It was a good search for the causes of anemia.
I have a question:
Why do you think she was so nauseated? It doesn't seem to me the lymphoma
invaded the gut although it is possible and GI should be able to catch it. |
A*******s
发帖数: 9638 | 46 先爬楼再评论， 这是对LZ的尊重。 LZ做resident应该没多少时间上网的。
你要真戒网就得把PC砸了， 我治疗成瘾很有一套： 舍不了孩子打不了狼。
不过我很欢迎您光临，这网有什么可戒的。
【在 s********p 的大作中提到】
: 赫本会瞎说话吗？！
: ——从2月份起开始准备到今天，而且是全职，但Step1、CS、CK、Step3一而再、再
: 而三推迟，现在脑袋里进了很多水，电路全乱、处处短路！！都不好意思再到网上去延期啦！！！
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s********p
发帖数: 1319 | 47 我是差等生——Step 1、2都不考过多次啦！！
【在 A*******s 的大作中提到】
: 先爬楼再评论， 这是对LZ的尊重。 LZ做resident应该没多少时间上网的。
: 你要真戒网就得把PC砸了， 我治疗成瘾很有一套： 舍不了孩子打不了狼。
: 不过我很欢迎您光临，这网有什么可戒的。
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A*******s
发帖数: 9638 | 48 我没问你step1，2什么的， 我们这儿不兴谈这个。
你现在的水平直接考step3得了， 临床医生要那么多基础知识有啥用？
开个玩笑， 不要当真。
不过你说得如果是真的， 不要灰心啦。 我有个朋友， 考了无数次， 考过就match上了。 原来国内的基础好， 可能跟你情况差不多。当然， 你要是在这里瞎说，就当我没说。
【在 s********p 的大作中提到】
: 我是差等生——Step 1、2都不考过多次啦！！
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s********p
发帖数: 1319 | 49 赫本会瞎说话吗？！
——从2月份起开始准备到今天，而且是全职，但Step1、CS、CK、Step3一而再、再
而三推迟，现在脑袋里进了很多水，电路全乱、处处短路！！都不好意思再到网上去延期啦！！！ |
I****a
发帖数: 407 | 50 I might disagree. Giving steroid for suspected multiple myeloma/lymphoma may
sometimes jeopardize the yield of future definitive tissue diagnosis. She
has so much extra nodal disease burden so I won't be surprised if her GI
tract is also involved.
and
【在 a*******n 的大作中提到】
: Sorry for late followup(on vacation:)
: The patient had lung nodule biopsy. It was diffuse large B-cell lymphoma.
: PET scan revealed lesions in skull, lung, abdominal lymph nodes, pelvic and
: hip joints. She received one cycle of RCVP as palliative chemo.
: Before this dx, for her nausea, I had been giving her dexamethasone, which
: worked magically for her nausea. My big name H/O attending said "You have
: been treating her cancer and pretreating her from tumor lysis syndrome
: before chemo" Yeah!
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D**i
发帖数: 325 | 51 óD2?
one
coumadin
without
was
.
【在 a*******n 的大作中提到】
: 78 yo female was transferred for evaluation of torsades. The patient has one
: year history of AF and has been taking amiodarone and coumadine. For the
: past 5 months, she has been feeling severe nausea. She was admitted to xxx
: Hospital for evaluation. There, her Hgb was 7.8 and TSH was over 40. Then
: Amiodarone was stopped for presumed toxicity to thyroid gland. And coumadin
: was stopped for suspicious GI bleeding. Levothyroxine was started.She was
: also given 2 units of pRBC. EGD was done and found diffuse gastritis without
: finding any active bleeding sites. MRI brain was unremarkable. She was
: given antiemetics and her nausea didn't improve. From telemetry, her QTc was
: prolonged to 650 msecs and two episodes of 23-beat torsades were recorded.
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