Case 1

Question 1

difference between PT and PTT?

Answer 1

PTT measures intrinsic clotting pathway

• vit K deficiency
• liver disease
• diseminated intravascular coagulation
• factors deficiency (all except factor 7)

PT measures extrinsic clotting pathway

• liver disease
• VitK
• factors deficiency
• diseeminated intravascular coagulation

difference: PTT doesn’t measure factor 7

Question 2

APAP levels

Answer 2

plasma acetaminophen

found using modified rumack-matthew normogram- everything above/right of reference line is potential for hepatoxicity

need to know time since ingestion

Question 3

APAP levels w/o knowing time since injestion

Answer 3

if above 10 ug, give NAC Rx

Question 4

what is NAC? why is it given

Answer 4

it is a glucathione precursor

glucathione substitute

Question 5

how is acetominophen metabolized

Answer 5

1) it can be attached to a glucuromide
2) can be attached to sulfur
3) can go through C450 to NAPQ** (5%- normally)
* this is toxic and can be converted into another toxic metabolite

glucathione changes this to a non toxic metabolite

Question 6

how does alcohol enhance the toxicity of acetominophen? how does cimetidine?

Answer 6

alcohol increases the Cp450 pathway, increasing the amount of NAPQ that is generated, causing increased toxicity

cimetidine inhibits CP450 and thus can be protective

Question 7

what do increased AST, ALT, and direct bilirubin

Answer 7

hepatocellular death

Question 8

hepatic encephalopathy

Answer 8

increased blood ammonia levels d/t liver failure cause psychological disturbance

Question 9

conjugated v unconjugated v delta v direct v indirect bilirubin

Answer 9

unconjugated- no glucuronide attached

conjugated- attached to glucuronide

delta- attached to albumin

conjugation and delta require hepatocytes

direct- refers to conjugated + delta bilirubin

indirect- total- direct

Question 10

astericksis

Answer 10

try to dorsiflex hands, can’t hold them dorsiflexed

Question 11

why give someone with hepatic encephalopathy lactulose, frozen plasma, and vitamin K

Answer 11

lactulose- decrease ammonia by acidifying colon and preventing H from being absorbed

frozen plasma/vit K- return clotting factors

Question 12

how are the pts lack of bowel sounds, distended stomach, and fever related?

Answer 12

lack of bowel sounds means perstalsis has stopped

allows bacteria to grow- infection = fever

bacteria produce gas = distension

Question 13

what do CVP, RVP, and Pulmonary arterial pressures indicated

Answer 13

CVP- pressure in right atrium

RVP- pressure in pulmonary circulation

PAP- pressure in left atrium

Question 14

“left shit” in WBCs?

Answer 14

high number of immature leukocytes in blood d/t overwhelming need

Question 15

amylase

Answer 15

found in pancrease and salivary glands

breaks down complex sugars

along w/ lipase, it is used to detect pancreatitis

Question 16

what is DIC?

Answer 16

disseminated intravascular coagulation

clotting system is activated and causing inappropriate clotting in multiple places

results in consumption of all clotting factors, and pt bleeds

Question 17

why does this pts kidney stop working?

Answer 17

DIC blocks glomeruli

Question 18

what does the accelerated timeline indicate?

Answer 18

in theory, around 1-2 days after ingestion, pt should feel better

pt may have felt improvement and failed to come for treatment initially, and so our timeline might be off (he was further along in the progression of the disease than we originally thought)