j**W
发帖数: 89 | 1 Thanks a lot for the warmhearted help from this board, especially gomer.
An update: My Mom had a DDDR type pacemaker installed. She is on low dose of
metoprolol (25mg daily). As far as I understand, medicines for afib do not
eliminate afib except for slowing down overall heart beat. Is it right? It
is a miracle that her afib also goes away (from the telemetry exam) since
her procedure a week ago! Is it known that a pacemaker sometimes can help
improve afib?
I tried to read the pacemaker manual, |
|
t****o
发帖数: 342 | 2 下面讲治疗, 是emergency时候的处理：
1.Treatment of atrial fibrillation (AFib) associated with Wolff-Parkinson-White syndrome
# The basic treatment principle in Wolff-Parkinson-White AFib is to prolong the anterograde refractory period of the accessory pathway relative to the atrioventricular node (AVN). This slows the rate of impulse transmission through the accessory pathway and, thus, the ventricular rate. This is in direct contradistinction to the goal of treatment of non–Wolff-Parkinson-White AFib, whic |
|
f****o
发帖数: 2770 | 3 心率不齐是哪种心率啊？
如果是afib难道不用rhythm control和rate control了么？
如果是afib warfarin/pradaxa alone就够了啊？为什么要加aspirin?哪里有guideline
说afibers要warfarin+aspirin了？ |
|
m********4
发帖数: 607 | 4 Afib is one of major risk factors to cause stroke. It is common to see pts
with afib in both hospital and clinic. How to manage pts with afib w/o
stroke?
*Thank eastlake to contribute Anticoagulation question.
http://www.mitbbs.com/article_t/Medicalpractice/31165.html
I would recommend the following paper to read.
* A new landscape for stroke prevention in atrial fibrillation: focus on new
anticoagulants, antiarrhythmic drugs, and devices.
Stroke. 2011 Nov;42(11):3316-22. Epub 2011 Oct 13.
A... 阅读全帖 |
|
g***r
发帖数: 285 | 5
sinus
it?
quite a few patients with sick sinus syndrome, they have this alternating
brady-tachy arrhythmia, and the tachy arrhythmia is often afib, that causes
sinus node remodeling, and when the rhythm is changing from afib to sinus,
there will be a prolonged pause, during which period the patient may have
symptoms, such as passing out; then in that case radiofrequency ablation may
help avoid the pacer,
keep in mind if she is symptomatic from other conditions, such as high grade
av block, i do |
|
a*********d
发帖数: 2763 | 6 dig IV is the best one for afib if pt has BP issue. adenosin is best for
PSVT. if pt unstable due to a fib with RVR, sync cardioversion is the choice
, but when i was a resident, i rarely had chance do that unless you have
cardio guys with you.
the most common reason for acute a-fib, is fluid overload, uncontrolled HTN,
and MI. everytime you see a pt run a new diagnosed Afib, it should be a
reflex to check her cardiac enzymes.
did you give her NS 1L for bolus? if you wrote NS 1L, they would
auto |
|
a*********d
发帖数: 2763 | 7 PE is always high on the list of any patients with active malignancy,
heparin is a no brainer at those situations, esp if pt has DVT/PE in the
past, and her INR is subtherapeutic.
also very important, she should be on lovenox lifelong as long as her cancer
is not cured, instead of coumadin.
but I am not that sure her rapid onset of Afib in this case is caused by
another epside of PE because she did not present with related symptoms(breas
swelling is her chief complain) and her afib only happened |
|
l********y
发帖数: 2295 | 8 【 以下文字转载自 Pre_Resident_Club 俱乐部 】
发信人: lovelypony (pony), 信区: Pre_Resident_Club
标 题: Tips for IM interns
发信站: BBS 未名空间站 (Sun May 27 09:34:24 2012, 美东)
INTERNS: daily management (orders, consults, pages, calls); replete lytes
daily before rounds (check for renal failure first; if Cr up, run by
resident before ordering repletion); the groundwork to get stuff done and
care for patients
--> BEFORE ROUNDS: arrive by 6am (weekdays), get signout, review all labs
and test results, see all your patients... 阅读全帖 |
|
r*****1
发帖数: 805 | 9 My CCS protocol:
P.S.：多有重复，谨防遗漏，仅供参考。
Screening test: General—Lipid profile/ multi-vitamin; Elderly—DEXA scan&
Calcium& VitD/ Colonscopy or FOBT/ vaccination; F-- >18yo Pap smear; >50yo
Mammogram; reproductive age- folate; menopause- Lipid/DEXA/FOBT; M-- >50yo
PSA; sickle cell dz child-prophylaxis w penicillin till 5yo, CF-prophylaxis
w Abx
Prophylaxis: Pantoprazole, pneumatic compression stocking;
Acute abd w perforation: triple Abx- Gentamycin/ Ampicillin/
Metronidazole (口诀：阿扁举旗庆国庆)
E... 阅读全帖 |
|
z******8
发帖数: 844 | 10 ☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Thu May 15 00:13:42 2014, 美东) 提到:
Step3考场壮烈回来。第一天挺累人，最后一个block甚至做到有心无力状，看着题反应
不过来，导致来不及做完。非常没有信心能否通过。所以match之前先考Step3的童鞋，
需要考前调整生物钟，坚持锻炼，提高耐力。
MCQ没有资格说，CCS有一点小感受，拿出来分享下。大家请轻拍砖。
复习资料：
UW 52 online cases : 基础。最好复习早起找高手一起过一遍，尽快摸熟软件，进入
状态。第二遍找一位水平相近童鞋过一遍，不断总结protocol. 考前迅速做一遍，熟练
运用protocol.
UW 41 offline cases: 我当时和partner每个case仔细做一遍，虽然不像online有反馈
，但对练临床思维，补充protocol非常有帮助。最后考试与41 case有异曲同工之处，
遇到复杂case也不慌神。
CD 6 cases： 最后再熟悉下考试软件。与UW相近，但... 阅读全帖 |
|
Q*****3
发帖数: 218 | 11 ARDS 死亡率很高。你的病人有 sepsis,还合并afib估计是resp distress triger, 如
果没有afib history, 这样的心率loss the atrial kick, 血压更难搞。这样的病人,
我们这边都是用低的tidal volume 450-500ml, high peep, hyperventilation, rr 16
或者更快。他的pH 7.21, overventilation 可以帮助稍稍纠正一下acidosis.
不过,看你们的医生会不会激进一些,用到bivent. 这个病人基本要上肌松剂才行。我见
过活下来的病人, 是那种上了autoprone床加bivent的病人。 |
|
Q*****3
发帖数: 218 | 12 ARDS 死亡率很高。你的病人有 sepsis,还合并afib估计是resp distress triger, 如
果没有afib history, 这样的心率loss the atrial kick, 血压更难搞。这样的病人,
我们这边都是用低的tidal volume 450-500ml, high peep, hyperventilation, rr 16
或者更快。他的pH 7.21, overventilation 可以帮助稍稍纠正一下acidosis.
不过,看你们的医生会不会激进一些,用到bivent. 这个病人基本要上肌松剂才行。我见
过活下来的病人, 是那种上了autoprone床加bivent的病人。 |
|
w********y
发帖数: 35 | 13 Ok, if you are talking about clinical evidence, warfarin is never indicated
for MI or acute coronary syndrome. Again MI is caused by atherosclerosis plaque build up, different from the blood clot in DVT/PE. There are side by
side studies of warfarin and aspirin but it was for Afib, in which warfarin
at therapeutic range is truly superior to aspirin.
The newest chest guideline which was published in Feburary 17th
2012 has already recommend pradaxa over warfarin for stroke prevention in patient wi... 阅读全帖 |
|
f****o
发帖数: 2770 | 14 Afib guideline不是either aspirin or warfarin没有说一起用么。。。
afib stroke prophylaxis和post-stroke management不同的啊。。。 |
|
e******e
发帖数: 118 | 15 Pt with afib not on anticoagulation before came with TIA, chads 4, in terms
of A/C, do you start coumadin right away or birding lovenox first?
I know if it is just afib requiring A/C, we can just start coumadin; if it
is just TIA, no need for A/C. What about the above scenario?
Thank u for ur input. |
|
e******e
发帖数: 118 | 16 she has no afib.her coagu panel is nl. previous MRA was negative for vasular
deficit.
we consider to repeat MRA if pt can tolerate. I think she may also need some
work up to r/o vasculitis or hypercoagulabe state.
as for 2nd prevention of stroke, there is no data suggesting which is
superior among ASA, plavix vs aggrenox. In practice, physician alternatively
choose them. eg, if one fails on asa, physician may change it to plavix or
aggrenox.
coumadin,it is only indicated in pts with afib or intr... 阅读全帖 |
|
C**A
发帖数: 535 | 17 这样的话随便找个有afib 的就可以验证。
: 俺脚得是测到心率之后
: 模拟一个PQRST波形叠加上去
|
|
f******I
发帖数: 769 | 18
she could still have paroxysmal afib that 24 hrs holter failed to capture,
what is her ejection fraction? does she also have any significant valvular
disease, such as mitral valve? what are her atrial sizes? what medications
does she take? |
|
EO
发帖数: 57 | 19 上blood thiner, heparin, coumadin,TPA， 还要搞清atrium 怎麽会有血栓形成？最
主要的原因是房颤（Afib).
★ Sent from iPhone App: iReader Mitbbs Lite 7.20 |
|
|
l*****t
发帖数: 2851 | 21 初步确诊 atrial fibrillation， 医生说下午就做 ablation手术。
usmle提到
谁会一次afib就做ablation阿 something is missing
我们在的 hospital, 这个心脏科还是挺有名气的。
请问，我们是否应该等一等，多咨询一下？ |
|
s*********0
发帖数: 2045 | 22 速效救心丸是中药，没人知道成分是什么，要卖的话只有试试99这样的中国店，或者去
LA San Gabriel那片找中国店。
治Afib可以吃beta blocker，本身很便宜，但一定要看医生开药方和剂量。去yelp上找
找clinic，有便宜的带病人去看一下付cash就好了。 |
|
c******n
发帖数: 5697 | 23 你学什么的？跟他聊聊麻醉就是了， 问问他什么MAC最好, 他喜欢sevoflurane还是
desflurane，怎么辨别 afib和a flutter，用你的绝顶智慧把他彻底征服 |
|
|
u***e
发帖数: 611 | 25 因为是direct admission，根本没有任何lab，我order的stat lab那时居然还没来抽，
把我给急的。。。 running afib时BP还是差不多80/50，而且病人还是没有任何症状，
笑嘻嘻的看着我急的样子。
给amio? 我当时是想start cardizem drip，不知道哪种好？
adenosine用于a-fib? 而且在血压这么低的情况下，觉得不妥。 |
|
yf
发帖数: 272 | 26 Afib may be caused by fluid overload. Dig IV should be given.Stop the IV
fluid. |
|
u***e
发帖数: 611 | 27 不佩服风mm不行，又学了不少。
没有人想到PE吗？半夜里把attending叫起来后，她第一个反应是病人又来了一次PE。
病人在做CT前就被上了heparin drip，转到了ICU。PT INR回来后是1.2. SaO2很好，没
有chest pain, SOB.
至于fluid，a-fib八成是和这个有关，病人的确如风mm分析的以前的echo有右心扩大，
LV的EF是正常的，我和senior谈了他还是认为要bolus病人。肺没有crackle，CXR没有
congestion. 脚也不肿，不太像是fluid overload. 现在病人还在run着fluid..... 我
不知道well compensated的右心衰是不是需要fluid restriction.
BMP回来后钾只有2.1，低钾会导致afib吗，不太确定。
BUN 55,Creatinine 1.2, 看上去像dehydration. 这个肾功能你们会让病人去做
contrast CT吗？
下回分解。 |
|
u***e
发帖数: 611 | 28 最后更新一下最新进展，attending还是决定hydrate病人后送去CT，CT结果是。。。。
。。。。没有PE. 病人on heparin同时加了coumadin，明天我去问问她为什么不用
lovenox.
cardiologist给用了amiodarine drip, 病人不久就恢复了sinus rhythm. 病人血压还
是出奇的低，对fluid没有反应，一度降到70，很吓人，但病人却没什么不舒服的。他
们还是给上了dopamine.
afib的病人自然是查了TSH了，呵呵，是正常的，troponin也正常。
明天又要on call了，看看会不会收到有趣的病人再来和大伙讨论讨论。 |
|
d*******e
发帖数: 89 | 29 Thanks for answering.
I'm not clear with these concepts , either. I agree, per guideline, even
WPW, when you see regular narrow QRS
tachycardia, ---- give adenosine first if the patient is stable and at the
same time ,you need to be prepared
for defibrillation.
For WPW associated Afib --- avoid any drugs that may slow the AVN conduction
and choose procainamide .
I could understand LZ's indication of using b-blocker or similar drugs.
Thank again.
SVT |
|
t****o
发帖数: 342 | 30 Although many types of dysrhythmias can occur in a patient with Wolff-
Parkinson-White syndrome, the two most common are CMT and atrial fibrillation (AFib). CMT is the more common dysrhythmia of the two.
* A critically timed premature atrial beat that occurs during the
refractory period of the accessory pathway typically initiates CMT. The
impulse, therefore, travels solely down the AVN but returns retrograde
through the accessory pathway, resulting in CMT (orthodromic conduction).
* Thi |
|
o**i
发帖数: 1165 | 31 谢谢tele十分detailed intern工作生活的讲解，联想起自己久远的实习生活，现在反
而没有那时候的大胆。用手机听的讲座，没法提问，其实想听听关于intern和以后
resident期间的家庭生活，和家人一起住还是完全照顾不到家（其实看看她们的
schedule也知道了）：（
1. preparation for intern--
1.1) limited license: since PGY-1, can prepare for limited/full license,
which is required before PGY-4(fellowship begin), have prescription number.
some start it since prematch.
check state board of medicine, have meeting every month. Prepared in April.
Email documents to programm, ask medical school mail documents to progr... 阅读全帖 |
|
s*****1
发帖数: 273 | 32 Original Template. Specifically pay attention to the one liner. HPI is the
most important part intern need to work on.
one liner:
This is a 27 year old male presented with feet ulcer for 2 weeks, with no known history of Diabetes for unknown duration.
=============================
XXXX, y/o M, with past medical history of , presented with….for …...-----
written format.(short part--PMH too long for oral present)
XXXX, y/o M, presented with….for …, his PMH is...-----better oral format.
XXXX, y/o ... 阅读全帖 |
|
f*****y
发帖数: 464 | 33 在offline form里是block3 #47.
72 yo woman who is right-handed is brought to the ER by her husband 3 hours
after the sudden onset of difficulty speaking. She has a history of afib.
She is alert. Neuro exam shows weakness of lower 2/3 face on right. She
understands verbals commands such as "raise your right arm." Her speech is
not spontaneous and consists of brief phrases without intonation (prosody).
Damage to which of the following labeled structures in the drawing of the
brain is the most likely c... 阅读全帖 |
|
d****y
发帖数: 2180 | 34 ☆─────────────────────────────────────☆
firefly (飞萤扑火) 于 (Fri Jan 4 14:45:32 2013, 美东) 提到:
在offline form里是block3 #47.
72 yo woman who is right-handed is brought to the ER by her husband 3 hours
after the sudden onset of difficulty speaking. She has a history of afib.
She is alert. Neuro exam shows weakness of lower 2/3 face on right. She
understands verbals commands such as "raise your right arm." Her speech is
not spontaneous and consists of brief phrases without intonation (prosody).
Dam... 阅读全帖 |
|
e****0
发帖数: 678 | 35 • Exaggerated deep tendon reflexes can be seen in lock in syndrome.
• Non bleeding varices are managed with nonselective beta-
adrenergic antagonists, such as propranolol.
• Sclerotherapy, endoscopic band ligation, and surgery are
indicated after a patient has a first episode of variceal bleeding.
• TIPS is a last resort in variceal bleeding unresponsive to
medical and endoscopic intervention.
• Ischemic colitis
CT—thickening of eth bowel ... 阅读全帖 |
|
a********n
发帖数: 438 | 36 TELE分几种的,MED/TELE是一些CHF,AFIB之类的不需要手术的心脏病人. SUR/TELE
是收心脏手术的病人.工作的繁重程度和医院也有很大的关系,大医院收的病人手术复杂
,病人相对比较SICK,PROCEDURE也多.
不会看EKG也不是大问题,可以慢慢学. 至于CODE,做了几次后,就心里有数了,也不用担
心.
俺觉得你的3个OFFER都不错,祝好运.
HOUSTON
TELE |
|
l********8
发帖数: 491 | 37 暂时性的脑部血管堵塞: transient ischemic accident?
TIA is usually warning signs of stroke, and usually leave no neurological
deficit. the main thing to do is management of the risk factors, including
high cholesterol, high blood pressure, diabetes, any heart problems, etc.
looks like lovastatin, amlodipine are on board for cholesterol and BP.
aspirin is on board for anti-platelet. But choice of drug really depends on
patient history. does he has any kind of heart problem? such as Afib? Heart
failure?
OZA |
|
w********y
发帖数: 35 | 38 warfarin主要针对 clot formation （fibrin rich 的clot 以及静脉血栓）. 主要用
于prevention of stroke in patients with A-fib，or treatment VTE.
antiplatelets such as aspirin 用来防止 platelet rich thrombus formation. 所
以主要用于心脑血管病的防治。机理不一样，所以针对也有不同。
warfarin bleeding risk 远大于aspirin。特别是不能做到有效 routine therapeutic
monitoring 的情况下。
There are situations when a patient will need aspirin, plavix, and warfarin
(比如history of ischemic stroke due to afib, and recent MI with drug eluding stent placement)
There are new antithromboti... 阅读全帖 |
|
l******k
发帖数: 27533 | 39 是的，我回头看了下，那些对比试验确实是针对A.fib的
而且我也没有查新的chest
1月份我们还在讨论dabigatran的各种问题，没想到二月份chest就确定其地位，呵呵
MI这块我不说了，学了很久了，忘了不少，也没时间回头看
你们继续，我围观学习：）
indicated
atherosclerosis
plaque build up, different from the blood clot in DVT/PE. There are side
by
warfarin
in
patient with afib.
I
really don't know how easy INR routine monitoring is in China. At the
sometimes
it |
|
f****o
发帖数: 2770 | 40 aggrenox is not for stroke prevention in AFibers
pradaxa reduce the stroke number just a little bit compare to warfarin, but
way more expensive, no follow up, no reversal agent... |
|
r********r
发帖数: 352 | 41 you need to assess both stroke risk and bleeding risk.
I wouldn't recommend aspirin 325 for long term if she is on pradaxa or
warfarin.
agree with fiorio for using CHADS2 score to determine if long term
anticoagulant is necessary. Yes, since she had a TIA already, if Afib
persists, she definitely will need a anticoagulant.
What other medication is she taking?
If she goes back to China, I think warfarin will be a better choice, at
lease it is cheap, and easy to monitor, as long as you take the ef... 阅读全帖 |
|
r********r
发帖数: 352 | 42 were you following a stroke doctor or a family medicine or internal medicine
doctor?
Read this article, especially the bottom left paragraph in page 249
Stroke. 2011;42:227-276
aspirin and warfarin works differently, but they both carry bleeding risk.
When a patient with afib on warfarin and an antiplatelet agent and had a
recurrent stroke. There are many questions we need to ask. Is the INR in
rage? Is the blood pressure controlled, what is the LDL level? How old is
the patient? what is his/her... 阅读全帖 |
|
w******e
发帖数: 42 | 43 start 25 mg captopril TID (Monitoring: looking for signs of hypotension (
dizziness, weakness).
Why you want to challenge the patient?
metoprolol tartrate is NOT apporved for CHF.
You are right about it. But in reality, some cardiologists do not care...
Since she has CHF now, beta blocker wouldn't be good choice.
Please refer the COMET trial.
she might need an anticoagulant due to her CHADS2 score being high.
Usually you do not need anticoagulation if pt do not have Afib and HF.
Please refer War... 阅读全帖 |
|
r********r
发帖数: 352 | 44 I agree with ann2008 on this topic. Dig is not a first-line medication for
patient with heart failure. It doesn't have mortality benefit, has dangerous
side effects, and requires careful therapeutic monitoring. If the dig level
is above 0.8, it could produce worse outcome, and increase mortality. Not
that dig should bot be used in patient with heart failure. But I wouldn't
recommend it until all the standard therapy (BB/ACEI or ARB) are being
optimized. If a patient is already on target dose bb ... 阅读全帖 |
|
u*******s
发帖数: 688 | 45 几个follow up的问题：
1.你说你妈妈年轻时候血压偏低，请问她现在的血压多少?
2.你妈妈能感觉出明显的a-fib症状吗，比如明显感受到心跳不齐。如果afib症状明显
，心跳维持在110以下也是可以的。不需要太苛求。
3.你说她吃了metoprolol以后血压过低，请问她吃的是哪一种metoprolol,剂量多少，
怎么吃的，吃药以后血压多少？需要警惕的反应是systolic BP<80, heart rate<60。
医生应该调整药的剂量，不是直接就不吃。。
我说的时常监控的是心电图。sotalol在4%的病人中会产生qt prolongation and
torsade de pointe(ventricular tachycardia)，这个副作用是和血药浓度正相关，所
以要结合你妈妈的肾功能来考虑。
最后，你妈妈的药你也买不了啊，没有处方。 |
|
u*******s
发帖数: 688 | 46 warfarin用的比较久，医学界对它的Profile都了解的比较透彻。降低血块形成的可能
，有效降低中风的风险。当然这也意味着它的主要副作用是增加出血风险。此外，吃
warfarin的病人的饮食要很讲究（avoid leafy greens)，有一些药物之间的反应，病
人还要经常monitor inr比较麻烦。
你说你父亲已经使用warfarin2年多，inr在target内，也没有什么不适（有没有仔细
monitor bleeding signs?），应该来说是manage的比较好的病人。
Dabigatran/Apixaban/Rivaroxaban是近年来出的新药。Dabigatran是direct thrombin
inhibitor, 后两个是factor 10a inhibitor。这些药的主要特性就是不需要频繁
Monitor inr，也降低了出血风险（跟剂量有关），而且还对预防中风更有效（或者non
-inferior)。价格自然也贵。
你父亲医生想给他换apixaban，有一个trial叫ARISTOTLE,评价这个药和warfarin在
afib病人中预防中风的优... 阅读全帖 |
|
u***e
发帖数: 611 | 47 有起搏器了心率只有50不make sense, 那要起搏器干嘛，经常afib rvr 的病人装了起
搏器后就可以把beta blocker剂量大胆加上去，减少rvr的几率，心率不会低于起搏器
的频率一般是60 |
|
n*******c
发帖数: 501 | 48 I always start warfarin with bridging LWMH because warfarin can cause
transient hypercoagulable state, not because I want A/C to treat TIA.
I have seen one case who was on warfarin for afib but then stopped because
of dental procedure. warfarin was recommenced ?1-2 days after the procedure
with no LWMH cover and he ended up having a pontine infarct. Although I am
not 100% sure if warfarin is the culprit, I would use LWMH cover if it is
not contraindicated. The risk of stroke is small but real. |
|
e******e
发帖数: 118 | 49 Thank u for the explanation. What if for pt with chronic rate controlled
afib who is coumadin naive, do u bridge or no? I see a lot of doc start
coumadin directly w/o briding. |
|
R*******t
发帖数: 367 | 50 Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
artery plaque. |
|
