Еще одна пилюлька Hескучина

[Anna_Shvedova]

Присоединяюсь к этим замечательным мужчинам - F

[OrFun]

F .....

[yananshs]

The correct answer is F. This patient has a history and physical exam consistent with a history of alcoholism and hepatitis C. These are both risk factors for cirrhosis of the liver. Upper gastrointestinal bleeding in the form of bloody emesis should immediately bring the thought of variceal hemorrhage to mind. Endoscopy is necessary to evaluate for variceal hemorrhage or peptic ulcer disease.

This patient is at a high risk for cirrhosis (choice A) and already has physical exam findings of cirrhosis such as ascites and a caput medusa. Cirrhosis in itself is insidious, leading to liver failure, an immunocompromised state, and a higher risk for hepatocellular carcinoma. A consequence of cirrhosis is portal hypertension and esophageal varices. This is the most urgent issue that needs to be addressed.

Delirium tremens (choice B) may be life threatening if untreated, but this patient has no symptoms of alcohol withdrawal or seizures at this time.

Esophageal cancer (choice C) is in the differential for upper gastrointestinal bleeding, but in this patient with risk factors for cirrhosis, variceal bleeding is the first concern.

Gastric carcinoma (choice D) is in the differential for upper gastrointestinal bleeding, but in this patient with risk factors for cirrhosis, variceal bleeding is the first concern.

Portal vein thrombosis (choice E) may be associated with systemic or local infection such as cholangitis, adjacent suppurative lymphadenitis, pancreatitis, and a hepatic abscess. It is also seen in patients in hypercoagulable states. Portal vein thrombosis occurs in 10% of patients with cirrhosis and frequently accompanies hepatocellular carcinoma. Portal vein thrombosis is not symptomatic itself, but it can lead to complications such as esophageal varices. The urgent issue that needs to be addressed in this patient is the evaluation of the hematemesis.

[yananshs]

A 45-year-old disheveled man is brought to the emergency department by paramedics stating, “I can't see!” The paramedics tell you that he is a homeless man who was found this morning locked in an automotive garage when the manager of the garage went to open for business. They also state that he was found next to an empty bottle of window washing fluid and an empty 40oz beer can. The patient is alert, but uncooperative during questioning and keeps repeating “Doctor... I just can't see!” As you are examining him, he begins to retch, holds his abdomen and vomits twice. His temperature is 37 C (98.6 F), blood pressure is 150/92 mm Hg, pulse is 100/min, respirations are 24/min, and oxygen saturation is 97% on room air. His pupils are dilated at 5mm and are only sluggishly reactive. Funduscopic examination reveals hyperemia of both discs without papilledema; the cranial nerves are otherwise intact. The remainder of the physical examination is unremarkable except you notice that he is taking very deep and rapid breaths. The most appropriate first diagnostic step is to
A. administer intravenous ethanol and monitor for reversal of his visual deficit
B. observe him in the emergency department as this man is obviously intoxicated with alcohol and just needs to sleep it off
C. order arterial blood gas and serum electrolytes and osmolality
D. perform a CT scan of his head to rule out intracranial pathology
E. request an immediate ophthalmology consult

[papadoctor]

C....

[filbi]

C вначале, потом А

[Rodionov]

Lab Studies:

Serum electrolytes, blood urea nitrogen, creatinine, and glucose levels
For ethanol and methanol toxicity, look for increased serum osmolal gap accompanied by an increased serum anion gap and hypoglycemia.

Methanol increases the osmolal gap by 32 mOsm/L for every 100 mg/dL.

Methanol: A severe anion gap metabolic acidosis is the hallmark. Severity of acidosis is the best predictor of prognosis when clinical status also is considered.

Ответ C.

А потом будем вводить ему спи-и-ирт...

[yananshs]

The correct answer is C. This patient presents with the classic signs and symptoms of acute methanol toxicity. Methanol is commonly found in windshield washing fluid, solvents, and paint thinners. Methanol is converted by alcohol dehydrogenase into formaldehyde, which is then converted into formic acid, which produces an anion gap metabolic acidosis. The formic acid also affects the optic nerve function resulting in optic papillitis and retinal edema leading to blindness. An arterial blood gas would help you determine the pH and amount of acidemia, with an associated low bicarbonate level and likely low pCO2 level from respiratory compensation. The respiratory compensation for a metabolic acidosis would explain his rapid respiratory rate at 24/min. The serum electrolyte panel will help determine the anion gap using the formula (Anion Gap = Na-Cl-HCO3). The anion gap is normally less than 12. Methanol poisoning also produces an osmol gap which is the difference between the measured osmolality and calculated osmolarity.

The normal measured serum osmolality is 280-295mOsm (milliosmols). The calculated osmolarity can be determined using the formula [osmolarity = (2xNa)+(BUN/2.8)+(glucose/18)]. An osmol gap of greater than 10mOsm is abnormal and indicates that osmotically active substances are present in the blood (methanol, ethylene glycol, isopropyl alcohol).

Administration of IV Ethanol (choice A) may be necessary as a treatment for methanol toxicity, as well as possible dialysis. However, diagnostic studies need to be performed first to confirm the diagnosis.

Observation without intervention (choice B) is improper management as this patient warrants further investigation.

A CT scan of the head (choice D) is likely to be normal in this patient, and thus of minimal benefit in ascertaining a diagnosis.

An ophthalmology consultation (choice E) will help rule out other pathological causes of blindness, but should not be your first step in the management of this particular patient.

[yananshs]

A 6-month-old infant is brought to the office for a routine well-child check. The father says that everything is going well at home, and that she is eating, sleeping and "progressing developmentally, just like the other kids." She is up-to-date on her immunizations. Physical examination is unremarkable. The father tells you that they recently got a new family car with both driver and passenger side airbags. The infant seat that they have is a rear-facing infant seat. At this time you should
A. advise him to disconnect the passenger-side airbag and place the infant in the infant seat on the passenger side of the front seat
B. advise him to put the infant in the rear-facing infant seat on the passenger side of the front seat
C. inform him that the safest seating position for the infant in the car is the middle of the rear seat
D. recommend that the infant wear a helmet in the car to reduce the risk for a serious head injury
E. tell him that airbags, in conjunction with lap and shoulder belts, have not been shown to reduce motor vehicle crash-related morbidity and mortality

[yananshs]

Пападоктор,
Вам отвечать не нужно.

[papadoctor]

I won't, I promise. But how Russian-trained doctors would know the answer? I understand that logically they will figure out, but...

[yananshs]

Дерюжкина Марина Владимировна (Специальность: Медицина катастроф. Москва): "Иногда больше пользы, если ребенок вылетит через лобовое стекло... А Вы ни разу не видели как ребенок улетает с этим креслом куда подальше? или же впечатывается в переднее сидение? А я видела и не хочу, чтобы такое еще раз с кем-нибудь повторилось...ремень безопасности в несколько раз повышает риск травматизации..." etc, etc...
"Медицина катастроф" точно будет в затруднении.

[Alevgen]

Скорее C...
...Do not put an infant seat in a seat equipped with an air bag. Serious injuries or death may result if the air bag inflates... - как пишут на сайте Transport Canada: road safety. Плюс, там же, есть понятие "kid zone" на заднем сидении автомобиля...

[Anna_Shvedova]

Вроде бы С, но зачем рассказ про подушки?
Если не С, тогда А.

[Anna_Shvedova]

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