Friday, May 28, 2010

Diphyllobothrium latum during Colonoscopy

A 46-year-old woman presented with a history of 3 days of pruritus in the anal area and 1 day of excretion of tapelike materials. During the year before presentation, she had reported intermittent colicky abdominal pain and loose stool, which had been attributed to irritable bowel syndrome. Laboratory evaluation was unremarkable, with no evidence of anemia. Colonoscopy revealed a long, moving tapeworm, Diphyllobothrium latum, located in the terminal ileum and extending to the sigmoid colon.

D. latum is a fish tapeworm that can infect humans after they consume infected undercooked or raw fish. The patient had a history of eating raw fish and recalled eating raw trout most recently 2 months before presentation. She was treated with a single dose of praziquantel. After administration, the abdominal pain resolved, but she continued to have intermittent loose stool.

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Choose the correct answer !!

A 59-year-old man presents to the emergency department (ED) complaining of new onset chest pain that radiates to his left arm. He has a historyof hypertension, hypercholesterolemia, and a 20-pack-year smoking history.
His ECG is remarkable for T-wave inversions in the lateral leads. Which of
the following is the most appropriate next step in management?

a.Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves
b.Place the patient on a cardiac monitor, administer oxygen, and give aspirin
c.Call the cardiac catherization lab for immediate percutaneous intervention (PCI)
d.Order a chest x-ray, administer aspirin, clopidogrel, and heparin
e.Start a b-blocker immediately

The answer :
1. The answer is b. The patient’s presentation is classic for an ACS. He has multiple risk factorswith T-wave abnormalities on his ECG. The most appropriate initial management includes placing the patient on a cardiac monitor to detect dysrhythmias, establish intravenous
access, provide supplemental oxygen, and administer aspirin.
If the patient is having active chest pain in the ED, sublingual nitroglycerin or morphine should be administered until the pain resolves. This decreases wall tension and myocardial oxygen demand. A common mnemonic used is that MONA (morphine, oxygen, nitroglycerin, aspirin) greets chest pain patients at the door.
(a) Although nitroglycerin is one of the early agents used in ACS, it is prudent to first rule out a right ventricular infarct, which if present, may lead to hypotension. (c)Percutaneous intervention (PCI) is warranted if the patient’s ECG showed ST-segment elevation. (d) The patient will require a chest x-ray and most likely receive clopidogrel and heparin; however this is done only after being on a monitor with oxygen and chewing an aspirin. (e) b-Blockers are usually added for tachycardia, hypertension, and persistent pain and only given once the patient is evaluated for contraindications. Relative contraindications to the use of b-blockers include asthma or chronic obstructive lung disease, CHF, and third-trimester pregnancy

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Head and Neck Lymph nodes Exam

Lymph Nodes: The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw. If the nodes are quite big, you may be able to see them bulging under the skin, particularly if the enlargement is asymmetric (i.e. it will be more obvious if one side is larger then the other). To palpate,use......

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