c****m
发帖数: 626 | 1 我也贡献一个：
MPJE（texas): 准备了一周吧， 95 分
2014 年有很多更新，用59页要注意updates。 个人推荐TPA 的law symposium， 上课
的老师直接给了我们一道考试题和答案～～
我还用了
Pass the Texas Pharmacy Law Exam: A Study Guide and Review for the Texas
MPJE
http://www.amazon.com/gp/product/0615655181/ref=oh_details_o04_
没有看书，直接做的练习题。
只有这本书有texas law 的练习题。
NAPLEX： 考完law 后有两周准备，其间由于technician 度假去了，被安排工作了50小
时。只考了100分。
只准备了常见的disease state. 用的RxPrep, 和quiz bank。 由于时间很紧，就只把
quiz bank的计算老老实实做完了。其它的章节就挑着看的。最后三天就完全没有看书
了，直接做quiz bank。
考试的时候出了一个小插曲吧。
刚开始考试，周围其他人考其它考试敲... 阅读全帖 |
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A*******s
发帖数: 9638 | 2 In her case, for the first stroke, no heparin, sure.
But for the second stroke, I have no other choices. She was not a TPA
candidate.
Again, risks over benefits.
The patient and family should always be informed prior to the initiation of
anticoagulation.
make |
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A*******s
发帖数: 9638 | 3 In her case, for the first stroke, no heparin, sure.
But for the second stroke, I have no other choices. She was not a TPA
candidate.
Again, risks over benefits.
The patient and family should always be informed prior to the initiation of
anticoagulation.
make |
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A*******s
发帖数: 9638 | 4 来自主题: Medicalpractice版 - a case If you don't take my advice, you will get killed in your residency. :)
My questions are:
1. Did you make the diagnosis on CXR or CT of the chest?
2. Did you give the TPA?
BTW, Do not use AAA for ascending aortic aneurysm. I know what you mean, but not the others. |
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f*****w
发帖数: 1451 | 5 来自主题: Medicalpractice版 - a case 病人的症状是上半身,所以可能是medial cerebral artery,不知道病人有无 speech
problem.除了肢体的症状,EMS应该还会做一些stroke assessment, 比如辛辛那提
stroke assess, 不能光凭上肢的感觉和运动异常就认为是stroke,还需要综合判断, 因
为关节肌肉神经损伤也可能导致上述症状,尤其是不伴有其他面部,语言等等症状的话.
当然,在做CT前,stroke team也会对病人做出评估.
如果确定是stroke,那么80% 的stroke是ischemic, CT supposed to be negative.
然后立刻进行tpa eligibility order........
小辈班门弄斧,请前辈指点.... |
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A*******s
发帖数: 9638 | 6 来自主题: Medicalpractice版 - a case 这个case的最重要一点是pain。 我开始想到了carotid dissection， 但应该引起对侧
的偏瘫。 一般stroke是没有pain的， 当然有些posterior fossa的stroke可能会引起
headache。
ascending aortic dissection可以引起ischemic neuropathy。 我想病人的症状是
brachial plexus ischemia。 如果没有gut给TPA， heparin是必须的。
What was your followup，宝宝？ |
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V*****G
发帖数: 337 | 7 Here is my understanding about treatment of stroke, please correct me if I
was wrong.
1. For ischemic stroke, tpa if within 3 hours , otherwise supportive only.
No routine heparin regardless of dissection or not. But if there is A-fib,
can use heparin.
2. For homerrhagic stroke, control bp. Prevent increased icp, surgery if
indicated. R/o bleeding disease, No heparin.
3. Carrotid dissection is contradiction of heparin.
4. For vasospasm, give amlodipine, no beta blocker. Do we need heparin in
t... 阅读全帖 |
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a**e
发帖数: 5094 | 8 这和我有什么关系，pay cut是radiology，又不是neurology。
但是我觉得这项政策does not make sense to me。不知道是哪个外行拍脑门想出来的
。CT和MRI是不同的指证。比如acute stroke病人来了，inital HCT r/o ICH prep for
tPA。没有ICH的话，做MRI。难道一开始HCT negative，就拖着不做MRI，等第二天嘛
？收住院又要多花多少钱？
grow up, |
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s**********t
发帖数: 217 | 9 I am talking about systemic thromyolytic treatment, like tPA. Not systemic
anticoagulation therapy, like heparin or LMWH. |
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A*******s
发帖数: 9638 | 10 That is correct.
If you understand the concept of penumbra, you will know the perfusion to
the area is so important in stroke management. Because of bleeding, he is
not a candidate for tPA. What affects cerebral perfusion? BP.
view. |
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M****a
发帖数: 577 | 11 再写几段，结束我internship的第一个月
第四周是从星期一开始的。刚过了一个golden weekend，所以这周有black weekend，
两天都得上工。加上第一个月到下周三才结束，下周四周五在新的service上工，我两
个星期都没得休息。
Intern已经做了3周了，熟练说不上，系统倒是熟悉一点了。每天主要还是floor work
。逐渐意识到，intern最需要学的是nursing，主要是很多流程，比如什么时候病人可
以不连monitor，谁可以把pacing wire拔出来，谁可以把Foley拔出来等等。以前上学
时也知道nursing很重要，但是每天要应付pimping+OR，加上护士也不是很上心教学生
东西 （因为学生不能写order，护士教了也是白教），所以nursing很多东西不会。现
在成天是floor work，OR基本不去了，pimping也少了，所以nursing就成了每天生活的
重点内容。
药物剂量也成了另一个重点。和很多人不同，我从来不用epocrates，原因是每个医院
formulary都不同，restriction也不同，确保药物安全最稳妥... 阅读全帖 |
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C*****D
发帖数: 1299 | 12 药商当神药. 有的医生说效果有限.二一添做五, 是不是有的有效,有的无效? |
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A*******s
发帖数: 9638 | 13 It really depends.
My view is: it works better when stroke is small and treatment is given
earlier. It is the only treatment available and FDA approved for early
stroke. |
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n*******c
发帖数: 501 | 14 不是碗，是小盆(友)，俺目前见过或经手的，1/3很好，1/3无效，还有1/3 dwi 啥也没
有，那个郁闷...只有一个HT的，不过本来也是个大中风，不用预后也不见得好。
用的好的其实跟药没啥关系，俺们都是把病人狠狠表扬一番:这病能治好都是您的功劳
，早早的来了，让俺们有机会把药用上... |
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b*****l
发帖数: 8603 | 15 Neuro~~
4. A 35 years old female with history of migraine and depression/anxiety
disorder suddenly developed slurred speech and left sided weakness involving
the face, arm and leg. She also complained about severe headache with
photophobia and nausea/vomiting. She was sent to ER by EMS within 2 hours
and had a negative CT of brain. A TPA treatment was given but her symptoms
of weakness remained same for at least 3 days. A followup MRI of brain was
negative on the next day. What is your diag... 阅读全帖 |
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d******a
发帖数: 99 | 16 cath lab or tPA (if no cath available)
. |
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A*******s
发帖数: 9638 | 17 By no means I intended to make any comments on the treatment by our fellow
chinese physicians. Instead, I just try to clarify some points on the
treatment of stroke in the US for our Externs.
1. TPA probably is not going to work for such a large stroke, what is the
alternative treatment?
2. What do you think about the craniotomy? |
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d**o
发帖数: 618 | 18 I'm not sure what are the points you try to clarify.
1. At this point there is no alternative that is proven better than tPA.
http://www.medscape.com/viewarticle/778998
2. You may say the pt is a little too old for hemicraniectomy, but it is not
excessive.
"Patients with malignant MCA territory infarction should be enrolled in
randomized controlled trials of decompressive hemicraniectomy if this option
is available. In the absence of clinical trial availability, and given the
dire prognosis asso... 阅读全帖 |
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m****g
发帖数: 118 | 19 谢谢答复！请问tPA 是什么呀？ MRA 是指 MRI 么？做 MRA 目的是？（病人有做CT） |
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d**o
发帖数: 618 | 20 sorry for the confusion, 那个回复只是跟Aplusplus讨论用的，跟您这个病例关系不
大，我已经删了
tPA就是alteplase. 做MRA(是一种MRI)并不是必须的标准程序. |
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A*******s
发帖数: 9638 | 21 先简单的说一下evidence的分类（详细的请自己google）：
CLASS I
Benefit >>> Risk， Procedure/treatment SHOULD be performed/administered
CLASS II
Benefit > Risk Additional studies with focused objectives needed
IT IS REASONABLE to perform procedure/administer treatment
CLASS III No Benefit/harm
怎样运用EBM，是医疗实践的艺术。
如果一个中老年病人突然大面积中风，用tPA无效，而perfusion CT显示有penumbra，
很多医生会选择endovascular intervention，这个intervention到目前为止顶多是
Class II。
尽管各种治疗手段，病人还是昏迷不醒，并出现脑疝的迹象，有医生会做craniectomy
，这个手术曾经很流行，但几个trials包括HAMLET证明手术与药物治疗没区别，所以现
在也挺... 阅读全帖 |
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N****a
发帖数: 100 | 22 版上好文越来越多，能从前辈学到不少知识。
我在神经内科轮转时，一个80岁黑人老太入急诊室时是stroke code，头部CT排除颅内
出血，由于距离她collapse短于三小时，一个非常出色的主治医生决定給TPA。后来在
病房类似stroke症状再发生。最后发现老太体位性SBP差巨大，根本不是什么stroke。
我印象很深。 |
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d**o
发帖数: 618 | 23 这种文章一看是欧洲医生搞出来的病人数大的吓人的trial，就要打个大问号了。目前
的潮流好象就是欧洲医生喜欢捣鼓一些大trial把美国有定论的一些经典trial给否定掉
，连tpa 3-hour都被他们给否了 (IST-3, 2012)，还有什么不可能？我对欧洲不熟，但
总觉得美国人做的trial还是挺认真的，不一定说病人数越大就越有说服力。观望几年
看看吧
Are you guys still using hypothermia for post cardiac arrest? |
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w*******y
发帖数: 60932 | 25 One of Travelzoo's current "Top 20" is Hotwire.com's current special on car
rental rates:
http://iway.org/9577791
at select locations nationwide. (you need a Travelzoo.com account (free)
to access the link). Rates are as much as 60% off.
The Hotwire link to the specials is Here:
http://iway.org/9577801
.
Travelzoo says that you must book by May 25, 2012.
It appears the special is from select airport locations.
Below are a list of locations & rates that came up. Upon clicking on the
Details... 阅读全帖 |
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