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ONE OF THE GREATEST RECALL COLLECTIONS! PART IV LAST ONE! CCS included at the end!

March 13 2004 at 12:12 PM
vitger  (Login vitger)
from IP address 128.205.247.63

 
Q:
The pt developed hypothyroid, what should you do first?

Stop the Lithium
Start on Synthroid
Do both
Do none

A: DO NOT STOP LITHIUM!!!!, give synthroid. exact same question from NMSR for step III excelent book.
dude...u can continue tx with lithium and synthroid...bipolar is not a easy thing to manag
once a patient is stable...ONE should not change medications specially in bipolar disorder...
since he is responding to meds....and developed some s/e
best thing is to correct the s/e instead of starting a new medication and who knowz what kind of s/e he will get from other medication


Q:
Which of the following drugs is the least sedating and anticholinergic, which can be prescribed safely to elderly patients with depression?
a.fluoxetine
b.MAOI
c.Imipramine
d.Sertraline
e.Trazodone

A: ?

fluoxitine is least anticholenergic and sedating of all SSRI:s
most sedating and cholinergic is paxil
sertraline is in the middle
and prozac is least sedating
infact prozac is given to PERK up the pt because of its stimulating effects

Q:
which anti AIDS drug not cause seizure
1. fosticanr
2. ziduviidn
3, ???

A: AZT cause ZS


Q:
What is the initial ( empirical ) atbx choice for a pt with IV drug-induced endocarditis ?
1.nafcillin
2.penicillin
3.vancomycin

A: guy one: nafcillin
Guy two: vancomycin


Q: What is the initial ( empirical ) atbx choice for a 25 year-old pt with a typical s/s meningitis ?
1.nafcillin+ cefotaxime
2.amp. + cefotaxime
3.vancomycin
4.vancomycin + cefotaxime
5.cefotaxime

A: Texas, it's 4,vancomycin + cefotaxime, I comfirmed with infectious stuff in my hospital and he told me it's routine now to give vancomycin + cefotaxime.
welcome comment. This test is asked in real one !
vancomycin+ceftrixone is right ..i checked it with the albert einstein college of med , montefiore program website


Q:
What is the initial ( empirical ) atbx choice for a 1 year-old pt with a typical s/s meningitis ?
1.nafcillin+ cefotaxime
2.amp. + cefotaxime
3. amp. + cefotaxime + dexamethasone
4.vancomycin + cefotaxime
5.cefotaxime

A: it's 3, CMDT and wash. Manu.
The original Q should be one-month old boy, not one-yr.
what is the choice ?
only if not immunised to h influenzae, give dexa first then antithey will give you a hint of inadequate immunization,

there was no vaccination against h inflenza b(It was the mcc cause).It was routine then to give a shot od dexamethasone before antibiotics.But now we all know that h influenza is not the commones t cause of meningitis.But usemle is still fond of cases in which vaccination of hib is not given.Its primary purpose is to prevent deafn ess


Q:
which is the antibiotic which should not b given when phenytoin is given
cefalexin
imepenim
sulphas
tetracycline

A: imepenem lowers th seizure threshold
phenytoin was given for seizures


Q:
A pt has flu and was treated with Amantadine. Now the Q ask the drug is belonged to:
1.chemotherapy
2.antibiotics

A:
Amantadine February 18 2003, 1:24 PM
Amantadine is an anti-viral. Prophylaxis for influenza A. Mech. of Action: Interfere with virus ability to enter a cell. Also blocks uncoating of the virus particle when in the cell.Also can be used to tx symptomatic parkinsonism. It has some ability to potentiate dopaminergic response in the CNS.It is not an antibiotic!!! Must be a chemotheraputic agent.





Bacterial-related

Q:
Which one of the following statements is true regarding tuberculosis testing and evaluation?
a.The CDC recommends two-step screening of new employees of long-term care facilities using a booster dose of Mantoux followed by repeat testing in 1-2 weeks
b.BCG vaccine should be considered for TB prevention in HIV-positive patients
c.A positive Mantoux test is defined as erythema greater than 10 mm in diameter at 48-72 hours, or greater than 5 mm in patients who are HIV positive, who have recent documented TB contact, or who have radiologic evidence of old TB
d.Tuberculin testing should not be given on the same day as live virus vaccines
e.Patients who report a positive skin test many years ago but cannot recall any details should be retested and the induration measured and documented

A: You place a PPD skin test. If negative, you repeat the PPD after a week. This acts as a booster. If the second reading is positive, you take it to be positive.
This is to avoid missing a positive PPD in cases of waned immune response.

Q:
Most common STD in usa ?

A:
clamydia is a most common bacterial std.?
most common OVERALL STD is HPV( human papiloma virus) ome wich causes cervical cancer..

Q:
Most common parasitic STD in usa ?

A: You are right...Trichomonas....

Q:
A 72 year-old Iranian-born nursing home resident is brought to your clinic because of an abnormal tuberculin test. The patient has Alzheimer's disease, but is physically in good condition. When he was admitted to the nursing home one year ago his tuberculin test was negative at 4 mm. On this year's routine evaluation, his tuberculin test is 13 mm. What is the most likely cause for the positive PPD?

A Active tuberculosis
B Recent infection with Mycobacterium tuberculosis
C Recent infection with nontuberculous mycobacterium
D Inaccurate recording of PPD in the medical record
E. Recall of waned immunity (booster phenomenon)
i am confused with these ppd,please give a simple explanation.thanks.....

A: PPD is positive when,

5mm or greater in patients of immunosuppressed,HIV individuals or people in contact with a person with cavitatory TB
10mm for high risk people like health care workers
15mm for low risk individuals.
A PPD positive does not mean that you have TB.It means an infection or recall of waned immunity.

A recall of waned immunity would not be as high as 14 mmm...so probably this is a case of recent infection with M TB.
A NON M TB can be identified only after treatment with routine anti TB drugs does not work...then again it could be a case of resistant M TB.

e is the answer,
waned immunity-the second one > than 6 mm
do cxr if negative no treatment.
recent converter-
>35 yr, ppd must be>15 mm within 2 yrs.
do cxr if negative give 6 mon inh
this is what explain in the answer,but so confusiing.
correct it if i am wrong.

Q:
A 3-month-old child was exposed to an adult with active pulmonary tuberculosis. What is the recommended approach to this problem?
A. Administer a TST and reevaluate in 3 months.
B. Administer a TST, perform a CXR, and reevaluate in 3 months.
C. Administer a TST, perform a CXR, administer INH, and reevaluate in 3 months.
D. Reevaluate after 3 months.
E. None of the above.

do you do a tst test in a child.

A: Child Exposed to active TB
ans: C
the kid should be given INH prophylaxis even if CXR/PPD are negative. You have to reevaluate in 3 months with a skin test:
. if the test is negative :- to D/C INH
. if the test is positive :- to coninue INH for another 6 months (total 9 months )


Q:
a 22 y/o pregnant woman, 8 wks, with Trichomonis vaginal discharge, what is should be the treatment of choice?

A:
In 1st trim. focal Clotrimazole suppository
After 1st trim. a single 2-g dose of metronidazole

Ref. http://www.emedicine.com/ped/topic2291.htm


Q:
Childs picture with scabies...the choices were,
a.permerthrin ointment
b.oral ivermectin
it was a 2 month old child with extensive scabies.
I was not sure of the answer.

A: a.permerthrin ointment

Q:
what will you do for the family of the child who had scabies?
a.fumigate the house
b.apply permerthrin for all members
c.fumigate the matress
d.change the mattress

A: b.apply permerthrin for all members


Q:
PPD post in American mexican. Xray neg, given INH 6 month. nest step after 6 month
1. nothing
2. rpt xray
3. rpt ppd

A: I had this Q too, repeat PPD positive, do nothing
Now let's say the same pt comes back tomorrow and is symptomatic, then you go ahead and repeat an CHEST X-RAY.

Q:
in q below , rpt ppd is positive in 6 month, next step
1. do nothing
2. inh for 12 month
2. rpt ppd in 12 month and no inh
4. ??

A: The way this question is presented, we presume that the PPD he had before was negative and it makes sense to repeat it here. Now with the repeat PPD it is positive indicating that it is a case of Recent Skin Test Conversion and that is the reason you are justified in giving INH Prophylaxis.

make sure you monitor patient for peripheral neuropathy since long term inh, in that case give pyridoxine as prophylactic.

Need search for the answer to the 2 Qs above!!!


Q:
pt ate turkry, ( not rice )potato slad , now have vomiting in 1-2 hoyrs
1. stap
2. bacillus cerius
3. ??

A: STAPYL. aureus ...within 6 hours...most vomitting.....B .cereus occurs with reheated RICE


Q:
which syphilys is transferable
1. prinary
2. seondary
3. tertiary
4. primary and secondary

A: syphillis is transmitted by DIRECT mucocutaneous lesion... of BOTH primary and secondary lesion

another mode is vertical transmission (pregnancy)...intrestingly in this case...maximal risk is during 16-36 wks of pregnancy)
tertiary syphylis is not transmisible ( rarely i would say)
in other words...NO lesions no transmission
Ref:
www.emedicine.com/emerg/topic563.htm
only tertiary syphilis is non-transmissible.

Q:
TCA toxicity what do you give the Pt?

A: After initial gastric decontamination..

For cardiac toxicity - Alkalinization with sodium bicarbonate
For refractory ventricular arryhtmias - Lidocain or phenytion ( prcainamide, quinidine, disopyramide contraindicated )
Temporary pacing for complite heart block
For CNS complication - treat seizure with diazepam and phenytion,
Physostigmine reverses CNS depression but it has narrow margine of sefty, may cause seizure, its use generally not recommended.
For respiratory deprassion - Intubation and mechanical ventilation

rx is 1. check ABC
2. gastric lavage
3. charcoal (activated)
4. iv soda bicarb
5. check for cardiac arrhythmias
6. phenytoin for seizures

A,B,Cs stabilize vitals. Pt often presents with Anti-Ach symp.Decreased BP start IV fluid fluid . If this fails to increase BP, can use vasopressors Severity of toxicity correlates most closely with the EKG. ORS greater 100 mili/sec. increased seizure incidence. Greater 160 mili/sec greater Ventricular arrhythmias. R wave greater 3mm on aVR greater conduction disturbances.
Life threatening arrhythmia must be tx. immediately. EKG changes: increased QRS, VT, torssades de pointes, heart block, EMD
Control life threats.
Decomtaminate bowel to prevent further absorption with charcoal
Magnesium citrate can speed process by binding TCA
No real antidote. Sodium bicarb. helps block the TCA effect on heart and electrical conduction system. Must admit to ICU for monitored setting if mental status or EKG Ab NL.




Bacterial-related

Q1
prophylaxis for PCP in HIV positive child?
2 choices were
Pentamidine
Dapsone
dont recall the rest,no SMZ/TMP wasnt an option.

The recommended regimen is co-trimoxazole (trimethoprim 150 mg/m<^>2/day by mouth with sulphamethoxazole 750 mg/m<^>2/day by mouth in divided doses three times a week on consecutive days (e.g. Mon-Tue-Weds)). Alternative schedules include the same dosages given as a single daily dose three times a week on consecutive days; the same dosages given in two divided doses every day; and the same dosages given as two divided doses three times a week on alternating days (e.g. Mon-Weds-Fri). In the case of intolerance to co-trimoxazole, alternative regimens are: nebulised pentamidine 300 mg/month via the Respirgard II nebuliser (for children aged over 5 years); or dapsone (2 mg/kg/day by mouth); or atovaquone (30mg/kg once daily for children aged 1-3 months and over 24 months, and 45mg/kg for children aged 4-24 months.BASIC IDEA IS SMALL CHILDREN FIND DIFFICULT TO USE AEROSOLSO<5YR DAPSONE>5YR PENTA

Q2:
pregnant exposed to a lacy rashed boy:
1- it will not affect you.
2- you get mild disease.
3- you are vaccinated to this. no harm
4- your may loose your fetus

answer: Once the rash appears, the kid is no longer infectious. Therefore, do nothing.

The boy got fifth disease/erythema infectiosum, is characterised by fiery red " slapped cheek ", circumoral pallor and subsequent lacy, maculopapular rash.
In pregnency, fetal loss and hydrops fetalis have been reported.
The cause of this infection is parvo virus B19. The Pt is infective before to develope the rush(prodromal period). When the rush appear he`s not infecive.

Fetal and Neonatal Infection
Although human parvovirus B19 infections are not teratogenic, they can destroy erythroid precursors and cause fetal anemia, which may lead to subsequent heart failure, nonimmune hydrops and death.21 The rate of transplacental transmission is approximately 30 percent.22 When maternal infection occurs before 20 weeks of gestation, the rate of fetal loss is 9 percent. However, in one large series,23 the risk of fetal loss did not increase when maternal infection occurred after 20 weeks of gestation. Among infants who have survived infection with parvovirus, no abnormalities or late effects have been found after seven to 10 years of follow-up.23 After a household exposure to parvovirus, the risk of fetal death has been estimated as less than 2.5 percent; after a workplace exposure, the risk is less than 1.5 percent.2

Postexposure Management
Pregnant women who have been exposed to parvovirus should undergo serologic testing. IgG antibodies are usually detectable by the seventh day of illness, persist indefinitely and, in the absence of IgM antibodies, indicate immunity. IgM antibodies appear three days after onset of the illness and may persist for 30 to 60 days. If susceptibility or recent infection is indicated by serology, weekly ultrasound examinations should be performed for four to eight weeks after exposure (or two to six weeks after infection) to detect hydrops. Fetal transfusion may be considered for hydropic fetuses, although spontaneous resolution has occurred.

Q3
is ppd given in active tb when patient comes to u for a visit with complains of fever

Answer: used to screen in high risk pts not to diagnose in a pt with active tb

Q:
The most common prasite infection in N. America

A: Pinworm, or Enterobius vermicularis, is prevalent throughout the temperate zones of the world and is the most common helminthic infection in the US.

E vermicularis is a 2-13 mm, white, slender nematode that dwells in the caecum, appendix, and ascending colon of humans (see Picture 1). Infection is generally asymptomatic. Some individuals who are infected experience sharp, pricking pains or intense itching in the anal area, especially at night.

Pinworm infection is primarily a condition of children, and parents typically are infected by transmission through their children. Transmission is through direct contact with contaminated furniture, bedclothes, or doorknobs. The parasite also can be transmitted during sexual contact



Psychiatry

Q:
The mother of a newborn female who has bilateral cleft lip and palate refuses to nurse her and asks the nurses to feed her in the nursery rather than in her room.

Of the following, the MOST likely explanation for this response is

A. denial that the condition exists
B. fears over the baby's appearance
C. feelings of anger
D. feelings of guilt
E. mourning the loss of a normal child
Does anyone know ans to this?
with expl will help. Thankx

A: answer is Anger.........not denial...
patient is acting out....she is not denying that this kid is abnormal...she akowledges the fact that kid is abnormal and she is ANGRY about it...she doent want to see the kid because it makes her more ANGRY and upset..
worth to mention this....the stages of grief ....denial anger acceptance etc etc.... they do not occur in sequence...any stage can occur at any time during the grieving process..


Q:
If a patient has depression with psychotic features the treatment should be an tricyclic antidepressant plus an antipsychotic?
If a patient has mania with psychotic features the treatment is lithium carbonate plus an antipsychotic?

A: Tricyclics are not the Drug of first choice..these days SSRI plus Antipsychotic
No ref.

Q:
For a young woman, the most frequent cause of insomnia is depression or anxiety?

A:
should be anxiety


Q:
Chronic schizophrenic patient, on antipsychotic and antiparkinson therapy develops tardive dyskinesia. Next step in management:
a. continue anti-psychotic and increase dose of antiparkinson drug
b. decrease or stop antipsychotic
c. cont. antipsychotic and decrease antipark. drug
d. increase antipsychotic and stop antipark drug

A: b. decrease or stop antipsychotic.
start on clozapine
give lorazapin in acute case


Q:
The differential dx between adjustment disorder (depressive type) and depression ? What is the key point for ddx ?

A: adjusment symptoms are not as severe as depression...
adjustment is kind of related to stressful situation..immediately after a stress...
ADJUSTMENT DiSOREDER is a mild form of depression ..wich doesnt meet all the criteria of depression

IN depression u will see Hopelessness..guilt...loss on interest in daily activities..persistent depress mood ,sleep .appetite problems,,wt loss...ALL THESE SYMPTOMS are continous....like MOST of the days FOR 2 weeks..


Q: treatment for tourreet or tic
clonidine
haldol

A: Haldol is the treatment


Q &A:
antideprssion in cases with depression

mostly use ssri
elderly- zoloft
diabetic- avoid ssri and use wellbutrin
obsesity- wellbutrin
with hypertension- avoid venlafaxin
with seizres- avoid wellbutrin
with anxiety- use bezo intially
obessive compulsive- high dose paxil
alzimers - ssri
parkinsons- ssri or ?
pediatric behaviaral problem- ssri
sickle patients - avoid trazadone.
serazone-
remerone-
correct and add


Q:
sertraline and depression in seniorFebruary 17 2003 at 7:23 PM UPMC (no login)from IP address 136.142.56.164

do we all agree that the DOC for depression in senior citizen is sertraline (i.e., zoloft)? can someone come up with the reasoning or reference?

A:
No one uses TCA's even psychiatrist these days...SSRI are first line drugs..read below February 17 2003, 8:30 PM
FIRST clarify this concept...TCA (tricyclic antidepressants ) are not used as often as we think...reason Long list fo s/eSo the drug of choice is SSRIsecond point is...I DOUBT they gonna ask u wich SSRI (prozac/zoloft/paxil )because............. ther eis no consensus WHICH SSRI is superior then others...in general they say....paxil(paroxitine) is most anticholenergic and sedatingSertraline is some where in the middle (btw prozac and paxil)prozac is one of the oldest SSRI...and most often prescribed medicine.if they ask u which drug has least drug :drug interactions then Celexa is the best answerso in short..IN my opinion NO one knows WHICH SSRI is better... but this is for sure SSRI is the FIRST DOC in elderly.


CCS

CSS1----Breast Mass

Breast mass work up:
complete physical
1. Mammography and Ultrasound(to determine cystic or solid)
2. Fine needle aspiration if + then Biopsy
3. Determine the receptors status
4. CXR-LFT-CBC-Chem 7-Blood type/cross match-Pt/PTT/abdominal CT. EKG
Consult surgery why? Breast Lumpectomy
Consult oncology why ? evaluate for chem/hormon/radio therapy
5. Counselling: Pt
6. Counselling family: advance directive

Other guy add:
For initial staging, in addn to CXR
CT scan of brain with contrast/MRI
Bone scan, alkaline PO4ase
Liver USG

CCS2----overdose
50 yr women in er collapsed in work found with whisky no medication found,friend says taking something for sleep, not responding, breathing,vitals stable
please post the work up

(Everything is checked out with clerk)

Beno. and barbiturate has similar presentation.

Management :
Order:
Oxygen
PULSE OXYMETRY
endotracheal intubation( this pt's respiration is
ok, no need of mechanical ventilation, but you need intubation for gastric lavage in obtunded pt)
I/v acces
Ekg monitor.
catheter, foley
PE : Complete physical.
Order : IVF, NS
glucose, finger stick
naloxone + Dextran + Thiamine (bolus)
CBC
sma 12
urine txocology
BAL
ABG
CT, head
lFT
ua
blood level, aspirin/aceto ( not this case)
gastric lavage
charcoal, activeted (good in both, reapet
in 2-3 hrs)
sodium bicarbonate (good in both)
Interval H&P
result : In benzo,
flumazenil i/v
In barbi,
No specific antidote, continue...above RX
Move to ICU'
vitals q 1 hr
Intake & output
If pt. continue to detoreate consider
charcoal hemoperfusion.
cathertics >magnesium sulfate
counsel fmaily for advance directivs
If this( going to haven or hell) person come back to this world of illusion( regain full conscious)
consult psych> (scucide/depreesion)

counsel to stop alcohol.
********************************
NORTRIPTYLINE TOXICITY

depressed elderly pt in coma, respi dep.. widened qrs on ekg..tca overdose.

ensure ABC

ordered oxygen,
iv access and
gave triple combo (thiamine, dextrose 50% and naloxone-all are iv bolus one time dose)......
(Don't go first for physical exam in this case. Unconsciousness/unstable pt warrants urgent treatment).....
i then did brief physical of 3min......

start her on normal saline,

and do cbcd,
SMA12
ekg 12 lead,
cxr portable,
pulseox,
ekg monitoring,
ua,
urine drug scrren,
blood alcohol,
blood aspirin and
bl acetaminophen level,

Rx:

Gastric lavage. (which revealed pills fragments).......
Activated charcoal with intermittent gastric suctioning
Induce alkalinisation with NaHCo3 to maintain pH of 7.45 to7.55
If he is intubated hyperventilate to a PCo2 not< 25mmHg
If ECG normal and patient is asymptomatic, observe for 6 hrs in ER
otherwise admit into icu
After Admission ECG should be normal for 24hrs to discharge for psychiatric disposition
Suggestions welcome...........

CCS3-------Stroke management

HEMORRHAGIC STROKE:
Evaluate GCS (if <9 intubation is very likely)
(if >9 check ABC and manage accordingly)
CT scan (unless already done) W/O contrast; if atypical ICH site (subarachnoid or lobar blood i.e.) check for secondary causes (AVM, Aneurysm, clotting abnormalities); if typical site (basal ganglia, esp. putamen +++) very likely primary (=hypertensive ICH).
If pt. has intraventricular blood with or without hydrocephalus, call neurosurgeon; this situation is very ominous. NS can place intraventricular catheter for drain at bedside
BP control is OK (keep MAP < 130 mmHg but >70 mmHg) don't lower too much-> risk of poor cerebral perfusion.
Use either nicardipine or labetalol as they act slowly enough to prevent sudden BP pressure drops.
If pt has impending herniation (i.e. with cerebellar clot or large parenchymal clot) manage w. intubation, osmotics (mannitol +++) hyperventilation, place in ICU and call Neurosurgeons for (possible) evacuation.
Cerebellar clots are evacuated most of the times.
If pt. fairly OK place her/him in ICU anyway, since 50% of ICH enlarge within 24 hrs with subsequent pt deterioration.
STEROIDS HAVE NO PLACE AT ALL...

ICHEMIC STROKES
Evaluate neurological status and type of stroke according to the onset (TIA, RIND, COMPLETED?).
ABC as usual...
emergent CT (r/o SAH, ICH) possibly within 6hr.
If TIA, RIND or frank CVA are ascertained, it is most important the timing of onset as t-PA must be given (unless C/I) within 3 hrs of onset.
Exclusion criteria:
-ICH
-(significant) head trauma in the last 3 mo
-SBP > 190 or DBP > 110
-rapidly improving symptoms
-h/o GI or GU hemorrhage in the last 3 wks
-arterial puncture at non compressible site in the last 7 days
-pt on anticoagulants
-seizure at onset of CVA
-SAH (worst h/a of my life...more or less like step 3)
-major surgery during last 2 weeks
-another CVA in the last 3 mo.
-blood glucose >400 or < 50
....if pt cannot undergo thrombolysis....
place pt in ICU
routine blood lab (SMA 12, coag, U/A, EKG, CXR, ABG, cardiac profile, lipid profile)
O2 (2L NC) -- check ABG
EKG monitor (~ 5% EKG change and ~2% of MI following CVA)
Foley if unable to void or unconscious: check I/O
IVF NS or 1/2NS at 50cc/hr (avoid hyperhydration)
check glucose often (hyperglycemia may expand ischemic penumbra)
BP control (labetalol if no C/I)
ASA

At present there is NO clear indication for heparin tx for acute focal ischemia as it risks overweighs the benefits; the AHA says that until more studies are available, heparin remains a matter of preference of the treating physician...
I hope this helps...

CCS4----ITP

in the CCS-ITP case on USMLE CD
do we need to so a bone marrow biopsy?
or just do the nasal packing and steroids?

nasal pack
CBc
PT, PTT
Chem7
Peripheral smear, bone marrow
Prednisone
IV IG
if severe splenectomy---

Bone marrow biopsy is confirmatory , antiplatate antibody will be positive.. Plz reassure pt. before gining nasal packing.
then give prednision >>>>pt. gets better
In this case pt dose not need IVIG (in severe case) or splenectomy( in refractory case)
Repeat CBC to see platelate count is improving or not.
Counsel Parent.
Remove nasal pack and discharge in 2nd day

CCS5--- Panic Attack

What could be your approch to a young man with Palpitation who turns to have "Panic Attack".Please post your work up and other stuff.I appreciate your time and help.

PE
If in office complete.

INVESTIGATIONS
EKG
Thyroid function tests
SMA 7
CBC
Blood Glucose
Urine for VMA and Metanephrines if the pt has high blood pressure.

Treatment

Short acting benzo for acute attacks
Behaveioural modifications
SSRIs + Benzo for long term treatment.

Panic attack:
1. Alprazolam/lorazepam for urgent Rx
2. SSRI (sertraline) for maintenance

Suggestions additions welcome..........

Reassurence( clerk has it),
counsel pt.(just choose counsel pt. because it dose not have> counsel pt. about the disease),
advise reluxasion techneque.
Pt. with repeated attack can be sent for cognitve Psychotherapy.

why not a beta blocker as well for quick symptomatic relief
because, techycardia resolve as soon as they breath in bag and reluxe. also advise pt. for resiratory training.
B-blocker is not rutinely used in panic attack.
Though panic attack is one of the indication of non conventional use of B-blocker.

CCS6--- giardiasis

What is the 4th case in the USMLE CD?
Is it giardiasis?
so just treat with metronidiazole.
Do we need to give loperamide?
is there a way to coucel about safe drinking water etc?
suggestions welcome.....
Please respond....
thanks in advance..........

i/v fluids,you can try loperamide in the ward first day
whether you keep in in the ward or send home its 2-3 days before pt gets better.Loperamide is recommended in traveller's diarrhea,but this pt has it for a couple of weeks.once you have the results you can send him home with the proper treatment and f/u in a week.

CCS7--- ectopic

in the case of an unstable pt who is crashing do we do emergent laprotomy or laproscopy or sapingiostomy? whom do you consult? Surgery or OBGYN

Laparoscopic surgery is also preferable in ectopic pregnancy when the mass is larger than 4.0 cm. Laparotomy is needed only for catastrophic hemorrhage.
NEJM
Laparotomy if pt unstable and ovarian,ligamentous or abdominal preg
e-medicine

Do consult..eventhough you are managing the case Not conuslting expert- is the biggest blunder one can make in real ccs. Always consult expert at appropriate time and when needed. This is the additional point. They really want to make sure that you utilize this sense (as in real world). Now in real exam, consultation expert is not going to help you in managing case. They have std message that reads"You manage the case" i.e. ultimately you have to manage the case (soley by ourselves) but calling expert on time is additional plus point eventhough they are going be useless in solving the case........thanks. step 3 passer

CCS8---alcoholic---aspirin intake

35 yo woman, alcohol intoxication, took aspirin and got intra cerebral hemorrhage (confirmed by head CT scan)

can any one post a breif work up for this pt.......
How do we check the airway in CCS?
when airway is typed the clark has only airway, intubation.....

ABC, then whole PE
dispostion Depends on VS, severe to ICU
normally admit
neurological statue
gastric lavage within 1 hour of ingestion
activated charcoal
Blood EOTH, glucose, drug and substance screen
Chem 12, ABG, Urine Ph and plasma Ph
input and output
iv 50%GS after vit b1, sodium bicarbonte, potassium
hemodialysis and hemoperfusion
Counsult neurologist
couselling psychiatrist

PL correct this one.
I don't airway or intube in CCS

Koosti said: it’s not a good work up

CCS9----DUB

in the ccs for DUB when we select OCP it gives a whole list with different amt of progestrons and estrogens
Which one is to be selected?
NOTE: for emergent bleeding it is I/V con estrogens.......
Later when the pt is stable we have to switch to OCP....Then is the problem
Which one is to be selected?

high estrogen/med.progesterone

note ; If anybody comes with intermenstryal spotting
then > low estrogen/high progesterone

CCS Question: UGI Bleeding
1) do we need to give SBE prophylaxis even if there is no risk factors?
2) in the ccs is there a way to order pt not to take nsaids? (i saw no aspirin)
3) is there a way to order urea breath test?

SBE prophylaxis when there is risk factor.
No choice regurding aviod NSAID'
Only about aspirin
In aspirin list there is 'abstain from aspirin'
In aviod list "avoid oral aspirin"
In clerk cant order > breath urea test
have to order H-pylori antibody serum.

CCS collection------01/03/03

1- polycystic kidney disease: 50 y.o.w.m with PMH of HTN presented with mental problem (I dont remmber). I did UA, sma7 and then Echo which was diagnostic. hemodialysis..
2- angioderma: shellfish with edema in face and lips and SOB. epineph and o2...discharge.
3- pneumonia (60 y.o.w with right upper abdominal pain had URI three days ago): CXR and erythromycin only!!!!
4acute diverticulitis (50 y.o.AA.w. with left lower abdominal pain, no Occult blood), exam abdomen and rectum only!, showed mass, KUB: dilated loops. metro and cefotaxim and sendf home on diet.
5- chf with sob, R/O MI and supportive care and add HCTZ for his regimen which included aspirin and ACEI.
6-dmII (tricky). prostate problem in a 60 y.o.m presented with thirst and improved urinary problems.. glucose only...350.. workup diet and other junk staff and send home and F/U...The only thing happen in this case that he was still thirsty which i called him in and hydrate him..and then all massges were ok.
7- sickle cell anemia with chest pain. supportive ICU and hydroxyurea.
8- HTN, stage I: AA boy wants to be involved in football teem HTN repeat and repeat....then diet, smoke alcohol, drugs.... improves over 3 months...and happy!!!!
9- pid classic easy.

CCS10-Ectopic pregnancy
CCS-Ectopic pregnancy
a middle aged female with h/o 7 weeks amenorrhea,vaginal bleeding and abdominal pain.there will be past h/o PID
PE-genaral,cvs,rs abdo and pelvic or vaginal
Order sheet-
Stabilize the pt with Iv NS
CBC,BMP,b-HCG,bllod type and cross match
U/S abdominal and transvaginal
culdocentesis to R/O rupture
serum progesterone levels[>25 ng/ml assures intreauterine pregnancy,<5 are suspicious of abnormal pregnancy]
OBG consult[laparoscopy or laporotomy for ectopic pregnancy]
Procedures can be-
salpingostomy,segmental resection or salpingectomy depending upon the site of implantation and the size of the mass

Sometimes methotrexate can be tried for medical management if B-HCg titres are <6000 and the size is less than 3cm diameter.A single im dose is given after liver enzymes are found to be WNL.
Administer Rh immunoglobulin if the pt is rh negative.
And discharge with age appropriate advice and F/U appt in a week for b-hcg levels,test weekly until they return to normal[non-pregnant values]

Add-1 Also, if your pt. has a ruptured tubal ectopic, she's going to be in severe pain. So, give her demerol as soon as you have made your diagnosis. Otherwise, the nurse will keep popping up saying that pt. is in pain!

Add-2 why culdocentisis after T/V ultrasound?and Progesterone , they sound good but are they actually done in many centers?

CCS11----- turner syndrome

Pe will show the typical features
Order sheet_
CBC with differential
U/A,BMP-these will just be baseline
karyotye will confirm the diagnosis
EKG ECHO,CXR,XRAY OF HAND AND WRIST
consult cardiology for any cardiac anomalies,also consult OBg,ortho
REASSURANCE
If the age is before puberty[<8 YEARS],
prescribe growth hormone IM qd and anabolic steroids[oxandrolone]
If >12 years,estrogen+medroxyprogesterone
Counsel the family regarding genetics and advice social support groups

Add—1: would add if mosaicism on chromosomal analysis is present then higher risk of ovarian malignancy therefore oophorectomy is indicated in these girls.

there was 3 case of fatigue tirdness
1.wt gain and cold intolerance
2.easy brusing in 25 yrs
3.fobt positive,colono -ive, but endo esop varices with hyperplasia- do we need h.pylori testing and what is the drug you give in this case- h2 blocker or ppi or surgery

A:
1) the first case is Hypothyroidism so the routine testing
2)Do the cbc , coagualtion profile , reticulocyte count,Bleeding time , ANA, anti platelet ab testing,u/a.sma7,FOBT.
3)As you said this case apears to be with varices, therefore , you proceed with the LFT,cbc,sma12,endoscopy.You t/t with iv somatostatin, endoscopic banding if bleeding, and start b blocker
I do not think you need h pylori testing ,it is needed only in case of ulcers. And here you give ppi+metronidazole+amoxicillin
Hope that helps

discussion of the 3rd case
varices present do not mean they are cause of bleeding
so it is better to do H.Plori testing
and no treatement with octreatide needed-- that is for acute managment, in bleeding varices, you can see.


CCS--- multiple myleoma

most likely african american >40 years of age, c/o of bone pain,had Increase in calcium and x-ray show lytic bone lesion. so one thing that should be at the top of your differential is Muliple myleoma or hyperaparathyroidis, but lytic bone lesion is your big clues,

workup:
cbc,sma 7, calcium level,SPEP,urine for bence-jone, beta 2 microglobulin,Bone marrow bx.

Tx: chemo and prednisone, Melphalan,cane for walking, counsel.

ferrie said: no bone scan for MM, bone scan not sensitive for lytic lesions, its sensitive for blastic lesions only.


CCS---DocG---2/4/2003

1.53 y/o lady with pelvic pressure symptoms ,had hysterectomy but no oophorectomy,also has ascites.
Abdominal ultrasound showed a tumor...and my diagnosis was ovarian carcinoma

2.16 year old with high fever and rash....
tampon present!
I gave naficillin....patient felt better...
My diagnosis was staph toxic shock syndrome

3.Lady with vaginal discharge...
I did saline mount....etc..
it showed clue cells...i agve metronidazole,she felt better...
Bacterial vaginosis

4.64 year old man with cough,blood streaked sputum...
cxr....obstructive pneumonia
h/o smoking..
CT chest....clear cut mass..
Percutaneous biopsy-squamous cell carcinoma
sent for surgery consult

5.20 y/o man...massive trauma...had renal failure...
Acute tubular necrosis.All chemistrys demonstrated.

6.23 y/o with diarrhoea...
did upper GI series among other tests....showed ilietis..did colonoscopy with biopsy..showed granuloma...gave prednisolone and sulfasalazine..patient felt better......chrons

7.IV drug abuse...fever and chills
Infective endocarditis

8.Sickle cell crisis...in a 11 year old guy.came with hand pain.

9.60 y/o man with CHF with exacerbation....had to manage...
he improved with all anti CHF drugs


CCS----- Ovarian cancer

this is one of the cases posted by Doc G.
1.53 y/o lady with pelvic pressure symptoms ,had hysterectomy but no oophorectomy,also has ascites.
Abdominal ultrasound showed a tumor...and my diagnosis was ovarian carcinoma

clinical exam-

General exam,cvs,rs,abd,genital,heent.

inv-
cbc
esr
bmp
lfts
albumin
ascitic tap-disgnostic and therapeutic
usg-pelvis
cxr
ivp
abd -xray

after receing the USG report for ovarian cancer-
ca-125
obstetric consult
counsel patient

does one proceed to oopherectomy directly?and when should we suggest chemo and radiotherapy-as adjuncts

- What are ESR, IVP for ? I don¡¯t think they are necessary.
- LFT includes albumin
- DO NOT perform ascitic tap- will cause tumor spread
- after usg-pelvis, you need CT pelvis and abd.
- oopherectomy should be done .
welcome correction

no need for esr-agreed.
ivp-because ovarian cancer very often invaeds the ureters.
Thanks for your input


Q: what is the different between edta mobilisation and therapy, both are avilable in usmle ccs.case od lead poison

A: edta mobilization is for lead levels 25-55, it is a test, read below, measure urine lead after 8 hrs, if> 200, go for chelation


Q:
in the ccs cases we have

1.ovarian mass- laparoscopic biopsy ater ct and then surgery if malignant or dermoid??
2.renal mass- we do nehrctomy without biopsy and then chemo
3.lung mass need transbrnchial or brnchoscopy biopsy
before surgery
4.testicular- no biopsy
5.pancratic mass- need biopsy through ercp or trans
6.thyrod-fnac
please correct



CCS- Discuss aortic dissection

That is 5 th case of ccs

My management if u don`t agree please feel free to comment!

first take examination of heent chest heart
then order
morphine
ecg
ckmb,CXR portable
I/V labetolol

BP monitor

advance clock
CXR wide mediastinum

surgery consult
npo
chem 7
pt aptt
consent
advance clock

ICU, how u order 2 large bore IV lines? do u have to order seperately? IVaccess twice?? ....iv access x 2 in each arm???

guys I think u should order those investigation before the surgicl consult and never forgetthe bloodcrossmatching

CCS_narcotic overdose

does anyone know this, for the ccs on narcotic overdose, can you just order Urine toxicology or do you have to order each test separately, ie blood acetaminophen,blood aspirin, blood barbiturates so on and so forth. thank you

urine toxicology includes.....drug of abuse only...for eg.....coacine.amphetmaine,barbiturates,opioids(heroine) maybe some other drugs marijuana etc
for acetaminophen u have to order blood level of acetaminphen...
u dont fo aspirin levels normally...
for tricyclics u have to do Blood level of individual drugs...like imipramine,amytriptaline etc etc
digoxin u do blood levels.... not normally unless u have suspicion or u want to monitor the dosage
for MOOD stbilizer... valporic acid..lithium..carbamezapine U do blood level of individual medications
for LEAD u do blood level
for ALHOHOL u do blood alcohol level


these are the most common scenarios wher eu check levels

now in case of OVERDOSE PATIENT u would do this...

check ABC... vitals
cocktail tx.... glucose, thiamine, naloxone

urine toxicology
blood level of TCA
EKG to rule out arrythmias secondary to TCA

there is somewhere a case of Posioning in this forum..not sure exactly where is that posting but this is a START


CCS- new CCS, 17hrs baby down synd. vomit what do you do?

Think of Duodenal atresia......Read work-up
1/3rd pts. of duodenal atresia have Trisomy 21.Foll. is from emedicineLab Studies: Serum electrolytesOnce delivered, neonates must be resuscitated well and electrolyte disturbances must be corrected prior to repair of duodenal atresia. If duodenal atresia is diagnosed early, electrolyte and fluid balance should be normal. If the diagnosis is delayed at all, laboratory assessment of electrolyte and fluid status is imperative for an infant with duodenal atresia. As noted, prolonged vomiting can result in a hypokalemic/hypochloremic metabolic alkalosis with paradoxical aciduria. Obtain blood to measure serum electrolytes in order to confirm electrolyte status to prepare for adequate resuscitation.UrinalysisUrine specific gravity can serve as a reliable indicator of fluid status. Fluid status can also be adequately assessed by urine output, mucous membrane examination, and fontanelle character.Other laboratory studies are superfluous to diagnose and manage this defect.Imaging Studies: Prenatal ultrasonographyPerform prenatal ultrasonography during any pregnancy with associated polyhydramnios. Examination of a fetus with duodenal atresia may reveal a dilated fluid-filled stomach and duodenum in addition to other (eg, cardiac) abnormalities. However, absence of these findings does not rule out duodenal obstruction. Fetal vomiting may cause normal sonographic findings in the presence of a duodenal atresia. Mothers with amniotic fluid abnormalities should be monitored with repeat scans. Prenatal ultrasonography does not detect duodenal stenosis. Diagnosis prior to birth enables prenatal consultation with a pediatric surgeon and provides parents an opportunity to discuss plans for postnatal care and management.Erect and recumbent plain radiography of the abdomenWhen duodenal atresia is suspected, erect and recumbent plain radiography of the abdomen should be the first imaging study obtained. A characteristic finding of duodenal obstruction is the double bubble image of an air-filled stomach proximal to an air-filled first portion of the duodenum. Absence of gas in the remaining small and large bowel suggests atresia, whereas scattered amounts of gas distal to the obstruction suggests stenosis or malrotation/volvulus.Cardiac and/or renal ultrasonography: Ultrasonography of the heart and kidneys may be warranted to identify potentially life-threatening abnormalities prior to definitive repair of the duodenal obstruction.Upper gastrointestinal contrast evaluationUpper gastrointestinal contrast evaluation in the infant with duodenal atresias is unnecessary unless correction is going to be delayed. An upper gastrointestinal contrast study may be useful if surgery is delayed to detect the presence of malrotation with midgut volvulus or to confirm the presence of an intrinsic duodenal obstruction.Histologic Findings: Histologic examination is rarely performed or necessary because repair does not involve removal of the obstruction. TREATMENT Medical therapy: No medical therapies are available for duodenal atresia or stenosis; all treatment is surgical.Surgical therapy: Duodenal atresia and stenosis are treated surgically. In patients with duodenal obstruction, a duodenoduodenostomy is the most commonly performed procedure. Some advocate duodenojejunostomy, a procedure practiced by few because of its higher risk of long-term complications.Preoperative details: Little preoperative preparation is necessary if the diagnosis is secured within the first 24 hours. Place an OG tube and maintain on IV fluids all infants with a suspected duodenal obstruction. Prior to proceeding with operative repair, the surgeon should ensure that both fluid and electrolyte derangements are adequately corrected. The surgeon should also perform a thorough examination of the infant with special attention to cardiac and pulmonary function before starting duodenal repair.



CCS---IV drug user
IV drug abuse with fever & chills
cxr showed PCP,blood culture was positive for staph aureus.That was the only tough case she had itseems ,,rest of them were the usual ones
Oh, that's the first case I heard with 2 lesions. Work-up and mgt....... February 15 2003, 2:03 PM
Admit patient.Blood work-up: CBC, Blood C/S, Se electrolytes, Se glu, LFTs, BUN, Creat, ABGSerology: HIV, VDRL, HBsAgUrinalysis, If respiratory Symptoms/findings+PulseoxSputum: Routine, C/S and for PCP and AFBCXR.Tuberculin skin test.iF CVS EXAM murmur present: Do ECHOTREATMENT:On admission: You suspect IE due to staph in this IV drug abuser. Therefore start oxacillin IV bolus every 4 hrs. But cover for Gm neg also with Gentamycin.IV bolus 8hrly. Therapy can be modified later based on blood C/S. Treatment for 4wks.If patient has respr S/S and pulseox shows low O2 saturation, give him oxygen.After his Xray and sputum findings, you can make a diagnosis of PCP pneumonia.TMP/SMX IV bolus 6hrly. Orally after patient improves. Prednisone PO bid if PaO2 < 70 mmHgBoth above treatments for 21 daysIf patient is HIV positive, Do CD4countStart Antiretroviral therapy. 2 Nucleoside analogs+ 1 protease inhibitor. say ZDV+ddI+ritonavirPlasma HIV RNA load used to monitor therapy. Do at the beginning and 4 wks. after.Depending on CD4 counts, decide prophylaxis of opportunistic infections.-------------------------------------------------------Any additions are welcome!


CCS--- Alzheimers friend had Alzheimers as case. How do you order mini mental status exam the clerk does not have this order, any body know?

agree when u do neurological exam..it tells u MINI mental automatically..

I also checked, you cannot order mmse on ccs. so no need to order.

I have posted some work up below.

INVESTIGATIONS

CBC
Urinalysis (to exclude infection),
Thyroid hormones (TSH, T4, T3)
(urine drug screen)
ESR, if elevated then ANA (r/o lupus celebritis can casue confusion)
SMA 7
LFTs
Serum Vit B12
lumber puncture is must - especially to r/o cjd
Syphilis serology
urine check for heavy metals
ct scan head to r/o head injury, subdural hematoma(this is routinely ordered in dementia pt)
(HIV) status

Additions and suggestions welcome.....



Pharmacologic therapy of cancer pain


Q: what is the approach of pharmacologic treatment for cancer pain?

A: @ for mild pain, utilizes non-opioids and adjuvant drugs.
@ For increasing pain, an opioid is added.
@ For severe pain, more potent opioids are added.


Q: how do you track pain intensity, be reliable on repeated use in the same patient?

A:



Q: what is nonverbal pain manifestations?

A: * Autonomic changes such as hypertension, tachycardia, and diaphoresis.

Agitation or confusion in patients with organic brain disease.

Apathy, inactivity, or irritability in patients with cognitive impairment


Q: what is non-opioid pain killer?

A: @ NSAIDs and acetaminophen are routinely used in the treatment of cancer pain. In general, they should be used on an around-the-clock schedule before advancing to step two of the pain ladder

@ not tolerate a particular NSAID may do well on another, no improved efficacy of one NSAID over another



Q: what is the side effects of NSAID?

A: aspirin irreversibly inhibits platelet aggregation for the lifetime of the platelet (four to seven days); the inhibitory effect of other NSAIDs lasts about two days.

GI side effects, including dyspepsia and gastric ulceration.
misoprostol(PG, no in pregnancy), high doses of some H2 blockers, and a proton pump inhibitor to prevent
reversible renal insufficiency due to renal vasoconstriction, acute interstitial nephritis, and a predisposition to acute tubular necrosis in the patient with low renal perfusion

Other side effects of NSAIDS include hepatic toxicity, even at normally recommended doses; The elevations in liver enzymes are generally mild and reversible with discontinuation of the NSAID. Acetaminophen can produce a more severe form of hepatotoxicity, particularly in chronic alcoholics.

Q: how to use opioids
A: . The "weak" opioids (codeine, hydrocodone, oxycodone) are commonly prepared in combination with nonopioid analgesics (acetaminophen, aspirin, NSAIDs). The coanalgesic prevents unfettered dose escalation, necessitating a change to another opioid or preparation as pain increases.
The first preparation chosen typically has a short half-life and is taken as needed, since initial pain is often episodic and predictable. As pain becomes constant, a sustained-release preparation (available orally for morphine and oxycodone (OxyContin) and transdermally for fentanyl), methadone, or levorphanol is added on a regular dosing schedule.


Q: what about opioid in renal failure patient with chronic pain?
A: Meperidine (Demerol) is particularly dangerous, since its active metabolite, normeperidine, accumulates with renal dysfunction or prolonged use at high doses. Normeperidine has a long half-life and causes central nervous system (CNS) excitability.

Q: what is analgesic adjuvants?
A: @ antidepressants, anticonvulsants, and local anesthetics.
@ rarely adequate analgesics when used alone for cancer pain.
@ primarily used to relieve neuropathic pain and to provide an opioid-sparing effect, thereby lessening opioid-related side effects and possibly slowing the development of opioid tolerance. Neuropathic pain is often difficult to treat with opioids alone



Q: what is the side effects of tricyclic antidepressants
A: @ primarily anticholinergic, including sedation, constipation, urinary retention and overflow incontinence, tachycardia, dry mouth, blurred vision, dysphoria, and agitation.
@ Antihistaminergic effects include sedation and weight gain,
@ alpha-1 and alpha-2 adrenergic blockade contribute to orthostatic hypotension and tachycardia.
@ Most of these side effects are not life-threatening and diminish with time, except for dry mouth which tends to persist. However, they often prevent the continued use of tricyclics.

Q: what is the side effects of anticonvulsants?
A:



Q: opioids causes nausea and vomiting, how you manage it?
A: @ Opioids have three emetogenic mechanisms: a direct effect on the chemoreceptor trigger zone, an enhancing effect on vestibular sensitivity and a slowing effect on gastric emptying
@ If nausea follows meals or is accompanied by postprandial vomiting, metoclopramide is an appropriate choice.

@ If it occurs with movement, meclizine may be more effective.

@ In the absence of these associations, treat empirically with a phenothiazine, antihistamine, or serotonin antagonist


Q: opioids cause constipation, how do you manage it?

A: @ Opioid-induced constipation is so common that cathartic and stool softening medications should be routinely initiated with around-the-clock opioid orders.
@ adequate hydration, physical activity, and regular toileting are also helpful.
@ coadministration of docusate (100 mg PO BID) and senna (2 to 8 tablets QHS) for prophylaxis
@ After ruling out obstruction, treat uncontrolled constipation with an osmotic laxative, such as lactulose (10 to 20 gm), polyethylene glycol (17 gm), or magnesium citrate (200 mL).
@ if too nauseated to take oral cathartics, a bisacodyl suppository or sodium phosphate/biphosphate enema is used
@ Disimpaction may be facilitated with oral mineral oil, glycerine suppositories, or saline enemas.
@ Refractory constipation may respond to oral naloxone (1 to 12 mg), naloxone is only about 3 percent bioavailable, systemic opioid withdrawal and recrudescence of pain can be minimized with low doses.



Q: what is other side effects of opioids use?

A: @ Somnolence and mental clouding are common complaints
-------- Psychostimulants, such as caffeine, dextroamphetamine or methylphenidate may be added to offset the sedative effects of opioids,
-------- but these drugs can produce hallucinations, delirium or psychosis, decreased appetite, tremor, and tachycardia.

@ Respiratory depression occurs with sedation when opioids are given systemically, but tolerance to this effect occurs quickly
-------- If hypoventilation occur, it is best to withhold further opioids until the respiratory rate rises or pain returns
------- If respiratory depression or sedation is severe, need ventilatory support and a small dose of naloxone

@ Myoclonus and hyperalgesia seen at very high doses of opioids.
------- A change to another opioid and the addition of coanalgesics and adjuvants to reduce opioid dose

@ Pruritus due to histamine release is observed in 2 to 10 percent of patients receiving chronic opioids
--------- Antihistamines are commonly recommended



 
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tala
(no login)
67.173.157.162

Iunderst and that you r still under the process of posting right or

March 13 2004, 1:26 PM 

I have mislooked something ...CSS will appear soon I presume ..in the end.None of us on earth can reward you for this but God.

 
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vitger
(Login vitger)
128.205.249.77

No, this is the last one, with CCS at the end. If more people joined us, we would have a

March 13 2004, 2:50 PM 

lot more...

 
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tala
(no login)
67.173.157.162

Oh sorry I didnot scroll down this message while posting you that message

March 13 2004, 4:30 PM 

.

 
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