HY USMLE Q #369 – Emergency / Internal medicine — Transcript

Full transcript

1. 0:00how's it going guys so slightly unusual
2. 0:01question this has shown up on a
3. 0:03student's real usmle so uh before we get
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12. 0:20start the question here 45 year old
13. 0:21woman she's brought in to the hospital
14. 0:23by police uh she was found sleeping in
15. 0:26the snow her breath smells of alcohol
16. 0:27she appears slightly
17. 0:29and confused
18. 0:30confusion in the study of alcohol we
19. 0:32could think of things like wernicke okay
20. 0:34b1 deficiency
21. 0:35temperature clearly hypothermic should
22. 0:37be 98.6 she's rewarmed in the emergency
23. 0:40department using heating blankets and
24. 0:42warm iv saline so a picture of her feet
25. 0:45is shown and you say what the okay
26. 0:48so
27. 0:49this is showing increased perfusion
28. 0:51hyperemia
29. 0:53secondary to rewarming okay not crazy
30. 0:55nothing dramatic
31. 0:57um so i'm just going to walk through the
32. 0:58answers here so
33. 1:00hyper chloremia hypochloremia the
34. 1:03chloride answers they're never going to
35. 1:05show up on usmla okay they're just here
36. 1:07as distractors nothing you need to know
37. 1:09about chloride it is the least important
38. 1:12variable for us simile apart from just
39. 1:14knowing its part of anion gap okay we
40. 1:17calculate uh mud piles type acid-base
41. 1:20disturbances it's part of calculations
42. 1:22but never actually a formal hypo or
43. 1:25hyper diagnosis that you need to know
44. 1:30hyperkalemia is the correct answer here
45. 1:32now
46. 1:33when we re-warm tissues
47. 1:36and we get hyperemia
48. 1:38we can get free radical damage due to
49. 1:41increased oxygen delivery okay this is
50. 1:44no different from reperfusion injury
51. 1:45when we have mi and we do percutaneous
52. 1:49coronary intervention okay and we can
53. 1:51get increased ckmb increase troponins
54. 1:54following stenting okay so reperfusion
55. 1:58injury due to oxygen radicals very
56. 1:59important uh patients can not so
57. 2:02the reperfusion injury here
58. 2:05this can actually cause rhabdomyolysis
59. 2:07especially in the setting of alcohol big
60. 2:09risk factor for rhabdo so not only will
61. 2:12the lysis of
62. 2:14muscle cells release potassium into the
63. 2:16blood causing increased
64. 2:18serum levels but also myoglobin is
65. 2:20nephrotoxic it can cause acute tubular
66. 2:22necrosis acute renal failure which will
67. 2:25also increase potassium levels so when
68. 2:28we re-warm tissues
69. 2:30in general but especially in alcoholics
70. 2:32we worry about things like rhabdo we
71. 2:34want to make sure we look at potassium
72. 2:37potassium can cause cardiac
73. 2:39abnormalities okay arrhythmia so we also
74. 2:41want to have the patient on an ecg
75. 2:43sodium in contrast hyper versus hypo can
76. 2:46cause cns dysfunction okay confusion
77. 2:49coma especially
78. 2:51uh just hypernatremia if we have um
79. 2:54[Music]
80. 2:55diabetes insipidus okay that's a high
81. 2:57yield cause in u.s similarly high serum
82. 2:59sodium in the setting of dilute urine uh
83. 3:02in contrast hyponatremia sidh and we
84. 3:05have concentrated urine all right uh
85. 3:07there's lots of discussion points
86. 3:09regarding electrolyte disturbances we
87. 3:10could make this an extended clip
88. 3:12hyper phosphatemia can be seen not only
89. 3:16in the setting of hypo
90. 3:18parathyroidism we can also see it in
91. 3:20secondary hyper parathyroidism due to
92. 3:24renal failure we can also see high
93. 3:26phosphate in the setting of tumor lysis
94. 3:29syndrome okay
95. 3:30hypophosphatemia is re-feeding syndrome
96. 3:33that's a weird one okay but especially
97. 3:34high yield on 2ck if a patient has not
98. 3:37been fed for a while does not have to
99. 3:39have low bmi okay if the patient has not
100. 3:41consumed any food in a while and then we
101. 3:42give a lot of food
102. 3:44very quickly uh we can we can get
103. 3:47trapping of glycolytic intermediates uh
104. 3:50by the liver okay so phosphate uh needed
105. 3:52for the formation of glycolytic
106. 3:54intermediates and we can get a transient
107. 3:56uh decrease in serum phosphate so
108. 3:58refeeding syndrome hypoglycemia high
109. 4:00yield
110. 4:02metabolic acidosis alkalosis i mean
111. 4:04obviously things to consider okay i mean
112. 4:06for sure we can get lactic acidosis due
113. 4:09to alcohol
114. 4:10so definitely considerations i mean we
115. 4:13have a challenging question here but we
116. 4:15clearly have
117. 4:16re-warming
118. 4:18in the setting of alcohol
119. 4:20potential rhabdo and we're going to have
120. 4:22to think about our potassium levels here
121. 4:25okay rhabdo is nephrotoxic cause acute
122. 4:27necrosis high potassium and release the
123. 4:29potassium to the blood to the lysis of
124. 4:31muscle cells as i said before and we're
125. 4:33going to have the patient on ecg
126. 4:35you know the deal i'm going to continue
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129. 4:39and i appreciate your time that's it