Tutor profile: Jessica L.
A 46 year old male presents to the ED with complaints of right upper quadrant pain for 4 days time with associated nausea, vomiting, fever for 2 days time. Vitals show temperature 102F, BP 85/40, HR 125, RR 22, O2 95%. History was taken from his partner due to his inability to communicate intelligible words. He appears diaphoretic and is mumbling words that no one can understand. His partner says that his speech started like this a 30 mins ago and that is when the partner called 911. The patients sclera are yellow and he has positive Murphy sign. After starting IV fluids, starting 2L nasal cannula, and drawing labs you recheck his vitals. T: 102F, BP 90/50, HR 120, RR 20, O2 97%. You also order a RUQ ultrasound that shows a dilated common bile duct with a stone distal to dilation and a distended gallbladder with stones. There is pericholic fluid and edema as well as common bile duct thickening. What is the next best step in management? A. immediate cholecystectomy followed by ERCP B. Immediate ERCP followed by cholecystectomy C. Empiric antibiotics and observation D. Empiric antibiotics and Interventional radiology consult
This question begins by checking to see if you can identify the diagnosis based off the clinical presentation. This presentation represents Reynolds Pentad: RUQ pain, jaundice, fever, altered mental status and shock (hypotension and tachycardia). Once you have identified this you should recognize reynolds pentad for acute ascending cholangitis. Now the most common treatment for a mild case of ascending cholangitis would be immediate ERCP to remove the stone, decompress the gallbladder and give empiric antibiotics with possible cholecystectomy later in the treatment plan. However, this case is severe with shock and altered mental status. The best treatment plan for this situation would be to give empiric antibiotics and consult Interventional radiology for a cholecystostomy tube placement. This patient is VERY sick, to try and take them to the OR could possibly kill him. The placement of a tube into the gallbladder will alleviate the pressure and drain the infection. You will also give antibiotics and continue treating his shock with fluids, oxygen etc. Once he stabilizes, then the plan would be ERCP and cholecystectomy.
Subject: Biomedical Science
A student is studying estrogen's effects on endothelial cells. While researching this interaction, they discover that estrogen receptors are found to be intracellular. If estrogen receptors are intracellular, name one possibility in which estrogen can reach an intracellular receptor.
This question covers a few components. One: what does it mean to be intracellular- this refers to the receptor being inside of the cell thus behind the double phospholipid bilayer. Two: now you must remember the mechanisms in which a compound can enter a cell through this bilayer. Method 1: lipophilic/hydrophobic substances can pass through a lipid bilayer, because "like" attracts "like". This happens to be the method in which estrogen uses to enter the cell. Method 2: non polar. Uncharged molecules may pass through the bilayer as long as the size is small enough. Method 3: using a channel. These are the major ways in which substances can enter the cell through the phospholipid bilayer
Your friend comes up to you saying he is worried about his father because he is scheduled for an elective surgical procedure to correct his inguinal hernia. Since you are both first year medical students you vaguely remember hearing about hesselbach's triangle in anatomy class. What is the lateral border of hesselbach's triangle?
inferior epigastric vessels
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