NSAID-GASTRITIS

Q.) In NSAID-associated ulceration true are-

a. Adverse effects from NSAIDs are rare
b. Prostaglandins (PGE2 and PGI2) increase gastric acid secretion
c. Eradication of Helicobacter pylori will reduce the risk of NSAID-induced bleeding
d. Ibuprofen is less likely to cause serious gastrointestinal side effects than diclofenac.

Ans: D.

Adverse effects from NSAIDs (non-steroidal anti-inflammatory drugs) are common, especially as they are often given for long periods of time to elderly patients. NSAIDs inhibit cyclooxygenase and decrease the production of prostaglandins, which are protective, via a decrease in gastric acid secretion. Although eradicating H. pylori may help reduce the overall risk of ulceration in those starting long-term NSAID treatment that have dyspepsia or a history of ulceration, it is unlikely to reduce the risk of NSAID-induced bleeding or ulceration in those already on NSAIDs. Ibuprofen is the NSAID associated with the lowest risk of bleeding.


Important : 

Inhibition of Gastric Secretion:

Although intestinal chyme slightly stimulates gastric secretion during the early intestinal phase of stomach secretion, it paradoxically inhibits gastric secretion at other times. This inhibition results from at least two influences. The presence of food in the small intestine initiates a reverse enterogastric reflex, transmitted through the myenteric nervous system and extrinsic sympathetic and vagus nerves, that inhibits stomach secretion. This reflex can be initiated by distending the small bowel, by the presence of acid in the upper intestine, by the presence of protein breakdown products, or by irritation of the mucosa. This is part of the complex mechanism discussed in Chapter 63 for slowing stomach emptying when the intestines are already filled. The presence of acid, fat, protein breakdown products, hyperosmotic or hypo-osmotic fluids, or any irritating factor in the upper small intestine causes release of several intestinal hormones. One of these is secretin, which is especially important for control of pancreatic secretion. However, secretin opposes stomach secretion. Three other hormones-gastric inhibitory peptide (glucose-dependent insulinotropic peptide), vasoactive intestinal polypeptide, and somatostatin-also have slight to moderate effects in inhibiting gastric secretion PGE2,PGI2 both inhibit acid secretion.  source: Guyton textbook of physiology

RESPIRATORY EMERGENCY

Q).  For confirming endotracheal tube placement following intubation of a patient in cardiac arrest, which ONE of the following methods is the most reliable?

A. Waveform capnography

B. Calorimetric end-tidal carbon dioxide (ETCO2)

C. Oesophageal detector device

D. Pulse oximetry

1. Answer: A

The detection of ETCO2 is widely accepted as the most reliable method for verifying tracheal intubation. However, the efficacy of this method can be hindered in situations where insufficient CO2 is exhaled because of reduced pulmonary blood flow, such as during cardiac arrest, which has led to the assumption that the oesophageal detector device (EDD) might be more accurate in cardiac arrest situations. However, conflicting results have been reported regarding the accuracy of EDD in emergency situations, and even less evidence is available for patients with cardiac arrest. Studies of colorimetric ETCO2 detectors, non-waveform ETCO2 capnometers and EDD showed that the accuracy of these devices is similar to the accuracy of clinical assessment for confirming the tracheal position of a tracheal tube in those experiencing cardiac arrest. Two studies of waveform capnography to verify endotracheal tube placement in those experiencing cardiac arrest after intubation demonstrated 100% sensitivity and specificity in identifying correct tracheal tube placement. These studies were reviewed by ILCOR in 2010, which has led to the recommendation that ETCO2 monitoring with waveform capnography is the most sensitive and specific way to confirm and continuously monitor the position of a tracheal tube in a patient in cardiac arrest and should supplement clinical assessment (visualisation of the tube through the cords and auscultation)

Q). Regarding the use of bilevel positive airway pressure (BiPAP) in acute hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD), adjustment of which ONE of the following parameters will most effectively reduce PCO2 levels?

A. Increase positive end-expiratory pressure (PEEP)

B. Increase inspiratory positive airway pressure (IPAP)

C. Increase PEEP and IPAP proportionally

D. Decrease the timed ventilations when in spontaneous/timed (S/T) mode

 Answer: B

Increasing the IPAP increases the pressure support (IPAP–EPAP) provided by the ventilator. Pressure support augments the tidal volume during a spontaneous breath and reduces the work of

breathing, resulting in increased alveolar ventilation, and therefore reduced CO2. Increasing the PEEP (also known as EPAP) alone will improve oxygenation due to alveolar recruitment and reduction of intrapulmonary shunting but not ventilation. Increasing PEEP and IPAP proportionally may improve oxygenation but not ventilation because the pressure support remains unchanged. During S/T mode, the timed ventilations are merely a back-up rate should spontaneous respirations cease and therefore do not influence gas exchange

Q). Regarding non-invasive ventilation (NIV) in acute cardiogenic pulmonary oedema, which ONE of the following is TRUE?

A. BiPAP has been shown to be superior to continuous positive airway pressure (CPAP)

B. PEEP should never be increased above 5 cm H2O

C. It has a proven short-term mortality benefit

D. It improves cardiac output

Answer: D

There is high-quality evidence that NIV decreases the need for intubation and induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy in patients with acute cardiogenic pulmonary oedema. However, there is conflicting evidence regarding the impact of NIV on mortality, with most studies suggesting that it has no effect on short-term mortality. The optimal mode of NIV (BiPAP versus CPAP) is yet to be established. NIV improves cardiogenic pulmonary oedema by establishing a positive intrathoracic pressure and reducing LV afterload. In patients with acute pulmonary oedema, the application of PEEP can improve haemodynamics by reducing preload and afterload, as positive pressure reduces venous return to the left ventricle. In patients with normal LV function, and hence those sensitive to changes in preload, a subsequent reduction in cardiac output may occur. However, in patients with impaired LV function, a reduction in preload actually improves cardiac function. The optimal PEEP remains to be resolved, although 10 cm H2O appears to be safe and effective in the majority of patients. The addition of a differential inspiratory pressure (BiPAP) appears to be as effective as CPAP but does not appear to provide an additional outcome benefit and some concerns have been raised that BiPAP may increase the rate of myocardial infarction.

Q).Regarding severe life-threatening asthma, which ONE of the following is the most appropriate indication for intubation?

A. PCO2 > 70 mmHg

B. pH < 7.35

C. SaO2 85%

D. Respiratory exhaustion

 Answer: D

The decision to intubate in acute severe asthma is a clinical decision and should not be based solely on blood gases. Markers of deterioration include rising PaCO2 levels, exhaustion, mental status depression, refractory hypoxaemia and haemodynamic instability. Many patients will present with hypercapnia or hypoxia and will rapidly improve with medical intervention and not require intubation.

LYMPHOMA

Q) An 18-year-old boy presents with cough, chest pain, and low-grade nightly fevers of severalweeks duration. He has a 4-year history of smoking two packs of cigarettes per day. Chest x-ray reveals a large mass in the mediastinumwith extension into the right upper chest. Which of the following is the most likely diagnosis?
(A) adenocarcinoma
(B) squamous cell carcinoma
(C) small cell carcinoma
(D) lymphoma
(E) metastatic Wilms tumo

Ans: D.

The differences between adults and children are frequently emphasized in medical training.

The differences between adults and adolescents should also be recognized. The differential diagnosis for many conditions, such as an intrathoracic mass seen in this case, is age dependent. While carcinoma of the lung is a leading cause of intrathoracic mass in adults, it is very rare in adolescents, even those who have a significant smoking history. That eliminates choices (A), (B), and (C). While it is true that Wilms tumor frequently metastasizes to the lung, this malignancy almost always presents in the first few years of age and would be unheard of in an 18-year-old. That leaves lymphoma as the only remaining choice and the most likely diagnosis. (D) is the correct answer. Other causes, such as tuberculosis, histoplasmosis, and sarcoid need to be considered but were not listed as choices

CAH

Q.) 3-week-old infant is admitted with vomiting of 5 days’ duration. Physical examination reveals a rapid heart rate, evidence of dehydration, and ambiguous genitalia. Serum electrolytes are Na+ 120 meq/L, K+ 7.5 meq/L, HCO3 − 12 meq/L, BUN 20 mg/dL. In addition to intravenous fluid replacement with normal saline, administration of which of the following would be most important?
(A) diuretics
(B) potassium exchange resin
(C) glucose and insulin
(D) antibiotics
(E) hydrocortisone

Ans:  (E) The child described probably has congenital adrenal hyperplasia (CAH), an inborn metabolic error of the adrenal cortex. The acidosis (HCO3 −12 meq/L) helps to rule out pyloric stenosis as the cause of the emesis, as most infants with pyloric stenosis have a metabolic alkalosis. The enzyme deficiency in CAH results in decreased production of cortisol and other adrenal cortical hormones and secondary hypertrophy of the adrenal gland. Accumulation of androgen-like precursors of cortisol during fetal development leads to masculinization of the female fetus and ambiguous genitalia, which is an important clue in this case. The low serumsodium and high serum potassium levels are classic findings in this condition, reflecting the lack of mineralocorticoids. In addition to the use of saline, administration of a mineralocorticoid such as cortisone or hydrocortisone is critical. The elevated serum potassium level usually responds rapidly to administration of saline and steroids, and specific therapy with exchange resins or glucose and insulin usually is unnecessary.

As did the preceding question, this question tests the examinee’s ability of recall rather

than recognition, a more difficult but clinically more relevant skill. Instead of providing a list of

diseases or syndromes as possible answers, it provides a list of additional features or findings, one of which is associated with the disorder in question. In this case, as in the preceding question, the feature to be selected is the appropriate therapy. The question tests more than the examinee’s ability to recite the treatment of hyperkalemia. It tests his or her ability to analyze the

clinical situation, make a correct diagnosis, set priorities, and tailor therapy to the specific

pathophysiology involved.