Еще одна пилюлька Hескучина

[yananshs]

A 41-year-old-man comes to the clinic because of right facial weakness for the past 6 days. He denies any pain or changes in hearing. The patient visited the office last week because of an upper respiratory infection for which you advised symptomatic therapy. He has no significant past medical history and takes no medications. Vital signs are: temperature 37 C (98.6 F), blood pressure 90/70 mm Hg, pulse 90/min, and respirations 15/min. Oxygen saturation is 99% on room air. Physical examination reveals weakness of the right side of the face with a droop. The left side of the face is normal. The remainder of a complete neurologic examination and a mini-mental status examination are normal. The next step in the management of this patient is to
A. administer prednisolone intravenous pulse therapy
B. advise him to take aspirin
C. order a CT scan of the head
D. order an MRI of the brain
E. order a nerve conduction study
F. prescribe ampicillin
G. provide reassurance and close clinical follow up

[Anna_Shvedova]

E, а КТ потребуется, если вдруг на Е проводимость окажется нормальной..

[papadoctor]

А? Только почему в вену??

[Alevgen]

Действительно, похоже А...
...Steroid therapy has been recommended for Bell palsy to relieve edema in the nerve...
Только сразу пульс и в вену??? Странно, хотя я не невролог!

[yananshs]

Конечно странно. Никто не будет пульс и в вену.

[OrFun]

G.......
Глюкокортикоиды п.о. в ранние сроки . тут такого ответа нет

[yananshs]

The correct answer is G. This patient has Bell's palsy, an idiopathic inflammatory neuropathy of the facial nerve usually following a viral upper respiratory infection. Over 90% of patients recover without residual symptoms in 1 month. Oral prednisone with or without acyclovir is sometimes used to shorten the recovery period and possibly improve the outcome. However, this is based on a limited amount of studies.

Prednisolone therapy (choice A) is not indicated. High-potency intravenous steroids are not used in Bell's palsy as they have no proven benefit and many side effects. Low-potency oral steroids are used anecdotally, although they have no proven benefit.

Aspirin (choice B) has no direct role in the treatment of Bell's palsy.

A CT of the head (choice C) is not necessary in the evaluation of Bell's palsy. Focal facial nerve neuropathy following an upper respiratory infection is the classic presentation of Bell's palsy. The presence of other neurologic symptoms or signs would point to a primary neurologic process and would then warrant some type of neuroimaging.

An MRI of the brain (choice D) is not necessary in the evaluation of Bell's palsy. Focal facial nerve neuropathy following an upper respiratory infection is the classic presentation of Bell's palsy. The presence of other neurologic symptoms or signs would point to a primary neurologic process and would then warrant some type of neuroimaging.

Nerve conduction studies (choice E) are not necessary in the evaluation of Bell's palsy.

Ampicillin (choice F) is not indicated because a facial nerve neuropathy is not due to a bacterial infection. The patient should be managed conservatively for Bell's palsy.

[yananshs]

A 16-year-old girl is brought to the office by her mother for a periodic health maintenance examination. She has no complaints. She is preparing to go to Spain for 4 months as part of a foreign exchange program. She tells you that she earns As and Bs in school, participates on the tennis and badminton teams, and is the assistant editor of the school newspaper. Her mother joins in by saying that she is so proud that her daughter is president of Student Athletes Against Drugs. Before you begin the physical examination you want to ask her if she is sexually active and so you ask the mother to leave the room. She tells you that the daughter shares "everything" with her and so she can stay. At this time you should
A. ask the patient if she engages in sexual activity with girls, guys, or both
B. ask the patient if she has ever had sexual intercourse or if she has ever been sexually active
C. ask the patient if she wants her mother to stay in the room during the sexual history
D. tell the mother that the annual checkup of every adolescent includes a private interview
E. tell the mother that you doubt that her daughter shares "everything" and since it is important for your management to know "the whole truth," the interview should be done in private

[Max Melker]

По логике вещей-скорее С,так как девочка не является полностью совершеннолетней,и должна быть обследована в присутствии ответственного лица/опекуна.Сбор анамнеза-часть обследования.Другое дело,что девочка может пожелать интервью без матери,в таком случае необходимо письменное подтверждение.Правильно?

[Aladdyn]

D. Уточнять при матери, что речь пойдёт о половом анамнезе нет необходимости. Ребёнок 16 лет имеет такое же право на врачебную тайну, как и совершеннолетний. Фраза о порядке прохождения диспансеризации с включением в неё частной беседы - наиболее нейтральна.

[Rodionov]

В России будет С.
Ребенок ( ) старше 16 лет самостоятельно может принимать решения, касающиеся медицинских вмешательств, следовательно в присутствии матери необходимости нет. Если сопровождающий настаивает на присутствии во время беседы/осмотра, мы так и спрашиваем пациента: "Хотите ли вы, чтобы ваш сопровождающий находился в кабинете?"

[yananshs]

The correct answer is D. Since many adolescents are sexually active and many are uncomfortable discussing this in front of their parents, it is important to discuss the issues of confidentiality and privacy with the mother and daughter. The best way to make everyone feel comfortable when asking the mother to leave the room is by telling her that the annual checkup of every adolescent includes a private interview. This way, it does not seem like there is anything that makes you suspicious about her daughter's sexual activity.

When asking patient's about their sexual activity, you should be completely open and ask if the patient engages in sexual activity with girls, guys, or both (choice A). Asking her if she has ever had sexual intercourse or if she has ever been sexually active (choice B) is necessary for appropriate management. However, in this case, you should first tell the mother that the annual checkup of every adolescent includes a private interview.

Asking the patient if she wants her mother to stay in the room during the sexual history (choice C) is incorrect because it puts the patient in an uncomfortable situation. If she says yes out of fear or guilt, you may not get an accurate history, and if she says no, her mother will be angry or suspicious. It is best to make a general statement like "the annual checkup of every adolescent includes a private interview" and if the patient wants her mother to stay, she can speak up without being directly questioned.

It is completely inappropriate to tell the mother that you doubt that her daughter shares "everything" and since it is important for your management to know "the whole truth," the interview should be done in private (choice E) because this will only lead to an argument. A general statement like "the annual checkup of every adolescent includes a private interview" is much more appropriate.

[yananshs]

A 28-year-old woman with AIDS is admitted to the hospital because of confusion and difficulty walking. Her blood pressure of 130/80 mm Hg and pulse is 104/min. She is aphasic and has a moderate right hemiparesis. Her chart indicates that she has hepatitis C and recently suffered from Pneumocystis carinii pneumonia (PCP). A CT scan of the head shows several rim-enhancing lesions. Serologic studies demonstrate the presence of IgG antibodies to Toxoplasma gondii. Her CD4 lymphocyte count is 50/mm3. Appropriate treatment for this patient should include
A. intravenous acyclovir
B. neurosurgical removal of the lesions
C. oral fluconazole
D. sulfadiazine and pyrimethamine
E. thiabendazole

[Rodionov]

D....

[Max Melker]

D,так как синергичное действие этих препаратов позволяет рассчитывать на эффект от терапии.Остальное-не по теме.