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#1
07.02.2007, 22:29
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Недавно вопрос о роли алкоголя в развитии head-and-neck cancer обсуждался в задачке от уважаемого коллеги AlexMD.
Ответ - C. head-and-neck cancer 
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#3
08.02.2007, 06:41
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Меня подвела моя невнимательность.... необратил внимание на то, что пациент принимает 5 дриньков в неделю, а не в день. При такой микроскопический дозе алкоголя, трудно говорить о каких-либо его негативных последствиях.
Остается ответ В.
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#4
08.02.2007, 18:12
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Цитата:
V takom vozraste pri ljubom rasklade- hot' pej kovshami- hot' v benzole kupajsja- risk raka budet nizhe riska IBS ... 
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#5
09.02.2007, 07:34
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The correct answer is B. Coronary artery disease is the most prevalent disease in this age group. Cancer is also prevalent in this age group with lung, prostate, and colon cancer being the most common. Keep in mind the difference between prevalence and incidence when answering this sort of question. Prevalence is the percent of a given population effected at any given time. Incidence is the number of new cases arising for a period of time.
Accidental trauma (choice A) is the leading cause of death in the under 30 age group. HIV (choice D) is prevalent in younger populations particularly in groups that have multiple sexual partners and use intravenous drugs. Head-and-neck cancer (choice C) is one of the most common causes of cancer-related death, but would be less common than coronary artery disease in this age group. Osteogenic sarcoma (choice E) occurs in the second to fifth decades of life in long tubular bones and would be relatively rare in this population. Suicide (choice F) is second only to accidental trauma as the cause of death in the under 30 age group.
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#6
09.02.2007, 07:35
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A 57-year old woman comes to the emergency department because of a "very high fever." She has diabetes mellitus and hemodialysis-dependent renal failure. She also has hypertension and is status-post total abdominal hysterectomy. She is frail appearing and diaphoretic. Her blood pressure is 170/90 mm Hg and temperature is 38.3 C (101.0 F). Her neck is supple without any specific meningismus. She has a Tesio catheter in her left subclavian vein. Her lungs are clear and she has no costovertebral angle tenderness. Her laboratory studies show a white blood cell count of 23,000/mm3 and a hematocrit of 31%. Her urinalysis is dipstick negative for white blood cells. The most appropriate next step in management is to
A. begin antibiotic therapy with gentamycin B. begin antibiotic therapy with vancomycin and gentamycin C. order urinalysis analysis and culture D. perform a lumbar puncture and send CSF for analysis and culture E. schedule emergent surgical removal of her Tesio catheter
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#7
09.02.2007, 09:26
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Варианты C. и D. отпадают, т.к. нет оснований делать посев мочи и пункцию, и нет времени ждать результатов этих обследований. Нужно что-то делать прямо сейчас.
Можно рассмотреть варианты A, B. и E. Вариант А отпал, назначение гентамицина неоправданно в такой ситуации. Вариант B. весьма привлекательный. У пациентки с диабетом и ХПН, находящейся на гемодиализе, высок риск внутрибольничной инфекции, в том числе обусловленной MRSA. Однако, где могут быть входные ворота инфекции? Tesio catheter! Выбираю ответ E. schedule emergent surgical removal of her Tesio catheter
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#9
09.02.2007, 13:01
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Цитата:
во всяком случае- так практичнее. ...не знаю только, кто писал этот тест- инфекционист или нефролог.
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#10
09.02.2007, 17:10
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The correct answer is B. Infection is the most common cause of death in patients with chronic renal failure. This is followed closely by cardiovascular events. The etiology of increased risk of infection is multifactorial and involves a complex interplay of decreased immune response and complement activation by dialysis membranes all coupled with long-term indwelling components such as catheters. When a dialysis patient presents with infection, the first step in their management is to initiate broad antibiotic coverage based upon the likely causative organisms. This patient has an indwelling catheter and therefore has an increased risk of infection with both coagulase-positive and coagulase-negative Gram-positive cocci. Given the large percentage (25% at most centers) of methicillin resistant Staphylococcus aureus (MRSA), vancomycin is usually initiated until sensitivity data is available. An aminoglycoside is usually added to cover for very common Gram-negative infections.
Begin antibiotic therapy with gentamicin (choice A) is inadequate since the majority of infections in patients such as these will not be covered by an aminoglycoside alone. Sending her urine for analysis and culture (choice C), although prudent, to perform this with a negative urine dipstick for WBCs, will not change your initial management and decision to cover the patient with broad spectrum antibiotics. Performing a lumbar puncture and sending a CSF for analysis and culture (choice D) implies meningitis as a cause for the fevers. Meningitis is a rare cause of fevers generally. And although dialysis patients are at mildly increased risk of meningeal infections, in the absence of localized signs and symptoms, the likelihood of meningitis is very low and therefore the risk of an LP is not warranted. Schedule emergent surgical removal of her Tesio catheter (choice E) is not an appropriate initial management step in a febrile patient. This may be indicated later in the course of care, but concern over removal before antibiotics have begun, is not appropriate.
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#11
10.02.2007, 10:42
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Цитата:
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#12
12.02.2007, 23:29
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The correct answer is E. True hyponatremia is always hypotonic. There are then three types of hyponatremia: hypovolemic, euvolemic, or hypervolemic. The therapy for the hyponatremia depends on both the urinary concentration of sodium as well as the volume status for each patient. Once the patient's total body volume status has been estimated, urinary sodium usually allows focusing of the differential diagnosis. For this patient, he clearly has total body volume overload. He has cirrhosis and portal hypertension. The standard therapy for these patients is salt restriction and management of volume status with diuretics. This patient, at the core of his therapy requires salt restriction.
Although some forms of hyponatremia respond to administering hypertonic saline (choice A), knowing the pathophysiology of this patient's hyponatremia, it can be clearly seen that this intervention will only aggravate this patient's condition. Giving the patient sodium chloride tablets (choice B) will clearly not be beneficial to this patient given the above explanations. Increasing the dose of furosemide (choice C) or the dose of spironolactone (choice D) will certainly serve to diurese the patient, but in the presence of a salt load, the kidneys will respond by avid retention of salt and water and thus aggravate the patient's condition.
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#13
12.02.2007, 23:31
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You are working in a busy emergency department on a very hot day in the summer. A 16-year old boy is brought in by 2 friends who state that they were outside hiking on a nearby mountain range all day. The friends report that the patient began to complain of nausea and "seeing bright lights," after which he became increasingly confused and disoriented. They were able to get him to a vehicle and bring him to the hospital, but during the 15-minute car ride he vomited and then lost consciousness briefly. They are not aware of any medical problems that the patient may have. Glancing at his chart, you see that his temperature was recorded as 39.5 C (103.1 F), blood pressure 110/68 mm Hg, pulse 122/min, and respirations 20/min. You walk over to examine him and note that he is sitting upright in the gurney talking rapidly and incoherently in a loud voice. He does not answer your questions. You quickly perform an initial examination and find that his skin is erythematous and warm to touch, but he does not appear to have a rash. Except for slightly dry mucous membranes and tachycardia, the examination is otherwise normal. During your examination, he seems to become somewhat calmer and is able to cooperate with a brief neurologic survey which is non-focal. While you are examining the patient, the nurse draws blood and you send it for the appropriate laboratory studies. The most important immediate next step in the management of this patient is to
A. administer acetaminophen B. begin empiric antibiotic therapy C. call the patient's parents to obtain his medical history D. initiate cooling measures E. perform lumbar puncture and blood cultures F. obtain urine for drug screen G. order a CT scan of the head
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