tommyk
05-14-2006, 12:45 PM
Hy 2214
Listen, today is Sunday. Did you all go to church? (Well, if you are Jewish, then I mean yesterday. There will be NO talk of religion on my side on this site, even though I am a devout Roman Catholic). Also, today is MOTHER’S DAY. Have you called all the mommies you KNOW? Please, hear me, a 60-year-old woman with a history of alcoholic cirrhosis is brought to the emergency department by her neighbor because of increasing lethargy. She has continued to abuse alcohol despite a history of multiple esophageal variceal bleeds and prior admissions for hepatic encephalopathy. She lost a son in a car accident 30 years ago, and still blames herself and cannot stop her drinking. You feel so saddened by her life story and wish to help. Her past medical history is also significant for duodenal ulcer, hypertension, and gout. On physical examination she is lethargic and easily falls asleep when not being stimulated. Her temperature is 37.1 C (98.7 F), blood pressure is 128/80 mm Hg (HINT: ON BOARDS, WHENEVER GIVEN A “NORMAL” LAB VALUE, USE IT TO ELIMINATE WRONG ANSWER CHOICES. LIKE IN THIS CASE, HER B.P. IS NORMAL. THAT REDUCES THE DIFFERENTIAL A LOT), pulse is 96/min, and respirations are 18/min. She has dry mucous membranes. A neurologic examination is nonfocal, but asterixis is present. Which of the following medications is most likely to be contributing to this patient's clinical condition?
1-Colchicine
2-Enalpralil
3-Furosemide
4-Beta Blocker
5-Calcium Channel blocker
6-Omeprazole
7-Famotidine
ans) #3. (Lasix) Patients with known portal hypertension have multiple risk factors for hepatic encephalopathy, including dehydration, infection, electrolyte abnormalities (hypokalemia and metabolic alkalosis), sedative administration, and gastrointestinal bleeding. Many of these patients are on diuretics, such as furosemide, to control ascites related to their liver disease and hypoalbuminemia. The resulting dehydration from excessive diuretic use may precipitate an episode or exacerbate underlying hepatic encephalopathy. The uricosuric agent colchicine is used for gout. It can cause gastrointestinal symptoms, marrow depression, and peripheral neuritis, but would not be expected to cause a change in mental status or precipitate hepatic encephalopathy. The ACE inhibitor enalapril is used to control hypertension. It can cause angioedema, anaphylaxis, hypotension, neutropenia, and fetalmorbidity. It very rarely, as an idiosyncratic reaction, will cause a (new) fulminant hepatic necrosis, but would not be expected to be a specific problem in a patient with underlying cirrhosis. In any event, the diuretic furosemide is a much more common cause of worsening hepatic encephalopathy.
The beta blocker metoprolol is used to control either systemic hypertension or portal hypertension. It can cause depression, but only rarely causes mental confusion and would not be expected to precipitate hepatic encephalopathy. The proton pump inhibitor omeprazole is used for peptic ulcer disease and is generally well tolerated. It would not be expected to cause a change in mental status or precipitate hepatic encephalopathy. And neither would Famotidine. Oh, when I mention these drugs, do you recall all the mech of action of each of them???
Listen, today is Sunday. Did you all go to church? (Well, if you are Jewish, then I mean yesterday. There will be NO talk of religion on my side on this site, even though I am a devout Roman Catholic). Also, today is MOTHER’S DAY. Have you called all the mommies you KNOW? Please, hear me, a 60-year-old woman with a history of alcoholic cirrhosis is brought to the emergency department by her neighbor because of increasing lethargy. She has continued to abuse alcohol despite a history of multiple esophageal variceal bleeds and prior admissions for hepatic encephalopathy. She lost a son in a car accident 30 years ago, and still blames herself and cannot stop her drinking. You feel so saddened by her life story and wish to help. Her past medical history is also significant for duodenal ulcer, hypertension, and gout. On physical examination she is lethargic and easily falls asleep when not being stimulated. Her temperature is 37.1 C (98.7 F), blood pressure is 128/80 mm Hg (HINT: ON BOARDS, WHENEVER GIVEN A “NORMAL” LAB VALUE, USE IT TO ELIMINATE WRONG ANSWER CHOICES. LIKE IN THIS CASE, HER B.P. IS NORMAL. THAT REDUCES THE DIFFERENTIAL A LOT), pulse is 96/min, and respirations are 18/min. She has dry mucous membranes. A neurologic examination is nonfocal, but asterixis is present. Which of the following medications is most likely to be contributing to this patient's clinical condition?
1-Colchicine
2-Enalpralil
3-Furosemide
4-Beta Blocker
5-Calcium Channel blocker
6-Omeprazole
7-Famotidine
ans) #3. (Lasix) Patients with known portal hypertension have multiple risk factors for hepatic encephalopathy, including dehydration, infection, electrolyte abnormalities (hypokalemia and metabolic alkalosis), sedative administration, and gastrointestinal bleeding. Many of these patients are on diuretics, such as furosemide, to control ascites related to their liver disease and hypoalbuminemia. The resulting dehydration from excessive diuretic use may precipitate an episode or exacerbate underlying hepatic encephalopathy. The uricosuric agent colchicine is used for gout. It can cause gastrointestinal symptoms, marrow depression, and peripheral neuritis, but would not be expected to cause a change in mental status or precipitate hepatic encephalopathy. The ACE inhibitor enalapril is used to control hypertension. It can cause angioedema, anaphylaxis, hypotension, neutropenia, and fetalmorbidity. It very rarely, as an idiosyncratic reaction, will cause a (new) fulminant hepatic necrosis, but would not be expected to be a specific problem in a patient with underlying cirrhosis. In any event, the diuretic furosemide is a much more common cause of worsening hepatic encephalopathy.
The beta blocker metoprolol is used to control either systemic hypertension or portal hypertension. It can cause depression, but only rarely causes mental confusion and would not be expected to precipitate hepatic encephalopathy. The proton pump inhibitor omeprazole is used for peptic ulcer disease and is generally well tolerated. It would not be expected to cause a change in mental status or precipitate hepatic encephalopathy. And neither would Famotidine. Oh, when I mention these drugs, do you recall all the mech of action of each of them???