CCS doubt (case #51)

8/6/2014 2:37:26 PM
Hey all,

In the approach section to CCS case #51 (ATTN: SPOILER ALERT), it has been mentioned that metoprolol has to be discontinued in a patient with aortic dissection. I was under the impression that the initial management in patients with acute aortic dissection is with IV beta blockers (IV propranolol or labetalol) to decrease the stress on the aorta. Does anyone know why they suggested to D/C metoprolol?

Thanks in advance!


8/7/2014 5:56:05 PM
Glad you asked this question because it solidifies concepts.

you are right that BB decrease the share forces in Aortic Aneurysms and they are the correct management of chronic, asymptomatic and stable aneurysms.

However, the pt in the case is most likely experiencing a ruptured Aortic abdominal aneurysm, with unstable VS (hypotensive, tachycardic). I believe the metoprolol was D/C to prevent worsening hypotension.

ASA was also D/C.
edited by on 8/7/2014


8/13/2014 3:48:58 PM
Dr. Napa,

About CCS cases, did you notice that in acute pericarditits (post viral) the pt does not improve unless we give colchicine. I thought that the primary tx is NSAIDS such as Ibuprofen and if the pt doesn't get better we add steroids...in severe or recurrent cases we add colchicine. Is that right? or do we have to start colchicine prior to steroids?

Also in Hemophilia case:
Do we need to avoid sports (there is no option such as contact sports)?
Do we need to avoid Aspirin? I though aspirin increases bleeding time and is avoided in VW factor def. and has no effect on PTT? Do you think we should avoid that anyway?

Thank you for your suggestions!


8/13/2014 9:39:58 PM
Hey Napa,

Thank you for replying to my post! It finally makes sense!


8/15/2014 9:16:58 AM
PaPa61518864 wrote:
Dr. Napa,

About CCS cases, did you notice that in acute pericarditits (post viral) the pt does not improve unless we give colchicine. I thought that the primary tx is NSAIDS such as Ibuprofen and if the pt doesn't get better we add steroids...in severe or recurrent cases we add colchicine. Is that right? or do we have to start colchicine prior to steroids?

Also in Hemophilia case:
Do we need to avoid sports (there is no option such as contact sports)?
Do we need to avoid Aspirin? I though aspirin increases bleeding time and is avoided in VW factor def. and has no effect on PTT? Do you think we should avoid that anyway?

Thank you for your suggestions!



Hey PaPa,

I see you practicing those CCS cases with all your posts! So for Pericarditis case, i tried doing it several times too and you are absolutely right regarding all your questions. Basically i admitted him to unit because of fever, rx Ibuprofen and Colchicine (studies show Colchicine when added to NSAIDs decrease the recurrent risk of Pericarditis). I r/o tamponade with the Echo, didnt do pericardiocentesis. I D/C the pt home on the meds and monitored CBC and ESR. He became afebrile and ESR was going down and he was relieved, but i couldn't get the case to end? I followed the alogorhythm. what did you do?


8/15/2014 9:24:38 AM
PaPa61518864 wrote:
Dr. Napa,

About CCS cases, did you notice that in acute pericarditits (post viral) the pt does not improve unless we give colchicine. I thought that the primary tx is NSAIDS such as Ibuprofen and if the pt doesn't get better we add steroids...in severe or recurrent cases we add colchicine. Is that right? or do we have to start colchicine prior to steroids?

Also in Hemophilia case:
Do we need to avoid sports (there is no option such as contact sports)?
Do we need to avoid Aspirin? I though aspirin increases bleeding time and is avoided in VW factor def. and has no effect on PTT? Do you think we should avoid that anyway?

Thank you for your suggestions!


For Hemophilia Case, the scoring tab suggested " NO ASA, Counseling, consult genetics"
keep in mind, the Primum software is a tweak different from CCS. I practiced on the FRED's software and some of the orders weren't there, i can't remember which because i did the USMLE practice cases, but just use what is there. its possible you won't remember everything on test day, but fill the basics and life preserving tasks. don't kill your patient.


8/15/2014 12:06:22 PM
Dr. NaPa,

Thanks a lot for sharing your experience.

I admitted the patient and ruled out tamponade as you mentioned but kept the pt in hospital until he became afebrile which was day 5. Ordered daily CBC and ESR, and D/C him on day 6! Is it ok to keep him that long in the hospital?

Initially, I ordered Ibuprofen for a day and then added steroid since the pt did not improve but he was still not doing well until I added colchicine! Then he improved. I was not sure when to stop steroid. I stopped after the pt became afebrile!!

So, the protocol suggests starting them on Ibuprofen and Colchicine simultaneously and if the pt did not improve in 2 days add steroids? How long we should keep them on steroids?

Thank you again for your comments.
edited by on 8/15/2014


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