|
#226
25.07.2006, 21:41
|
|||
|
|||
|
c-c-c
|
|
#228
26.07.2006, 08:49
|
|||
|
|||
|
C.
Acute postinfectious cerebellar ataxia is the most common CNS complication, with an incidence of 1 case per 4000 patients with varicella. Ataxia has sudden onset that usually occurs 2-3 weeks after the onset of varicella. The condition may persist for 2 months.
|
|
#229
26.07.2006, 11:09
|
||||
|
||||
|
The correct answer is C. The history given above is a classic presentation of acute post-infectious cerebellar ataxia. 25% of children with this disorder have a history of varicella infection within 1 month prior to the onset of the disorder and 5% of children have a previous history of varicella vaccination. The onset of acute cerebellar ataxia is usually explosive, often with the child awakening from sleep with maximal symptoms of ataxia and nystagmus. In any child with acute ataxia, it is important to obtain a drug screen and a careful history of any possible toxic exposures since poisoning and acute cerebellar ataxia account for most of the cases of acute ataxia in children. Resolution of the symptoms occurs in most children over a period of weeks to months.
Concomitant diarrhea (choice A) is not relevant to this presentation. Although there are forms of Guillain-Barre syndrome that have ataxia as a prominent component, this child does not have the other symptoms associated with these variants of GBS (ophthalmoplegia, depressed reflexes), and Campylobacter diarrhea usually precedes the onset of GBS. While an intracranial tumor is always of concern in a child with neurologic symptoms, the history above is atypical for tumors, which usually present more indolently. The history of a cousin with a brain tumor does not increase the likelihood that this child's symptoms are due to an intracranial mass (choice B). Pseudoataxia (choice D) is a syndrome of recurrent bouts of ataxia that are actually atypical seizures on EEG. The attacks are similar in timing to seizures and there may be a postictal state. They are not likely to persist over days as in this child. Recent streptococcal pharyngitis (choice E) is of importance in movement disorders associated with acute rheumatic fever, such as Sydenham chorea, but does not predispose to any known form of ataxia.
|
|
#230
26.07.2006, 11:10
|
||||
|
||||
|
A 24-year-old man comes to the office because of a 2-day history of "excruciating" pain during defecation. He states that the pain often lasts for a couple of hours after defecation and is accompanied by spasms of what he assumes is the anal sphincter. There is bright red blood on the toilet paper during wiping. There is sometimes blood, not associated with stool, on the toilet paper that he uses to "pat the pain away" for up to a half an hour after defecation. He says, "there is not a minute of the day that is pain-free." He has no other medical conditions, does not take any medication, and does not smoke cigarettes. He is sexually active with "many partners." His grandfather died from colon cancer at age 64. His father has "benign polyps" removed during colonoscopies every other year, starting at age 50. Physical examination shows an external skin tag protruding from the anal margin, an enlarged anal papilla, and a single 0.7-cm linear ulcer in the posterior commissure of the anal verge. The most appropriate next step is to
A. advise him to take stool softeners and sitz baths B. prescribe acyclovir therapy C. prescribe metronidazole therapy D. refer him for an internal sphincterotomy E. schedule a colonoscopy
|
|
#232
26.07.2006, 13:18
|
|||
|
|||
|
D??????Anal fissure.
|
|
#234
26.07.2006, 16:57
|
|||
|
|||
|
Речь идет об Anal fissure, скорее всего. Если бы речь шла о ребенке, я бы начала с А. А уж потом - все остальное, включая возможное хирургическое лечение.
|
|
#235
26.07.2006, 17:43
|
||||
|
||||
|
The correct answer is A. This patient has the classic symptoms of an acute anal fissure, which is a linear ulceration of the anoderm, often caused by hard stool, and is therefore initially treated with stool softeners and sitz baths. Increased dietary fiber is also recommended. It is often said that the pain of an anal fissure is disproportionate to the size of the lesion.
Acyclovir (choice B) is used to treat herpes infections, which are characterized by painful vesicles and pustules that ulcerate. A single linear ulcer is not the typical presentation. Metronidazole (choice C) is often prescribed for anorectal abscesses associated with Crohn's disease, which may be larger, purulent, and less "benign" looking. The pain of an abscess may be constant and not necessarily triggered by defecation, as it is in this case. This patient does not have any of the symptoms associated with Crohn's disease. Internal sphincterotomy (choice D) is often reserved for chronic anal fissures. It is not generally performed for an ulcer that has been present for 2 days. Conservative management is generally recommended. A colonoscopy (choice E) is not indicated in this 24-year-old man with the classic presentation of an anal fissure. Even though he has a family history of colon cancer, it is extremely unlikely that this is fissure is associated with cancer. A colonoscopy may be indicated at an earlier age than usually recommended (50 years) because of his family history, but certainly not at age 24. This decision is often made based on many factors in each individual case.
|
|
#236
26.07.2006, 17:46
|
||||
|
||||
|
A 57-year-old woman with coronary artery disease associated with hyperlipidemia comes to the clinic for a scheduled follow-up appointment. She saw you for the first time approximately 1 month ago to establish care. In the interim, she was started on hydrochlorothiazide for elevated blood pressure (confirmed on a repeat nurses visit) and on simvastatin for a fasting LDL of 190. She has a remote history of alcoholism, but denies any alcohol intake over the past 10 years. Today, she complains of mild, generalized weakness and states that her shoulders and thighs are "achy". She denies rhinorrhea, fevers, chills, nausea, vomiting, or diarrhea. While she does not complain of any dysuria, she states that her urine has been very dark for the past few days. She denies abdominal or flank pain. Laboratory studies show a mildly elevated white blood cell count, a normal hematocrit, and normal electrolytes. Her AST (or SGOT) is 415 and her ALT is 25. Bilirubin and alkaline phosphatase are within normal limits. The most appropriate next step in evaluation is to
A. determine creatinine kinase level B. obtain an erythrocyte sedimentation rate C. order a GGT level and a serum alcohol level D. send Hepatitis A, B, and C serologies E. send her for a right upper quadrant ultrasound
|
|
#237
26.07.2006, 17:54
|
||||
|
||||
|
А. Миоглобинурия вследствие рабдомиолиза (статин-индуцированного)?
|
|
#238
26.07.2006, 18:35
|
|||
|
|||
|
Цитата:
|
|
#240
26.07.2006, 20:11
|
||||
|
||||
|
The correct answer is A. AST is less specific for liver than ALT. AST is found in multiple organs and will be elevated with any muscle injury. In fact, before the advent of assays for the MB fraction or troponin, AST was used to assess for myocardial infarction. The patient was recently placed on simvastatin (an HMG Co-A reductase inhibitor). While these cholesterol-lowering drugs are generally benign, myositis is a complication that the prescribing physician must be aware of. The patient's presentation of fatigue and muscle aches fits the diagnosis of myositis. In addition, an elevated AST with an otherwise completely normal liver panel should heighten suspicion that the AST is not coming from the liver. The patient's dark urine is classic for myoglobinuria. The patient should be treated with intravenous fluids to maintain renal perfusion, therefore avoiding renal tubular injury from the myoglobin. Depending on the level of the creatinine kinase, alkalinizing the urine may also help protect the kidney from injury in this setting. There is no definitive treatment for the myositis itself. Typically, the myositis resolves after the offending agent (simvastatin in this case) is discontinued.
An erythrocyte sedimentation rate (choice B) is incorrect. While an erythrocyte sedimentation rate may be useful as a sensitive marker of inflammation, it is not specific for any disease process. As this case illustrates, recently prescribed medicines should always be considered at the top of your differential diagnosis as the etiology of a new disease process. The erythrocyte sedimentation rate would not help make the diagnosis, nor would the result change management. An elevated AST to ALT ratio may be suggestive of alcoholic liver injury. This is thought to be due to the fact that ethanol decreases ALT synthesis. In addition, ethanol is thought to cause mitochondrial damage in the liver, where AST lives. However, the ratio of AST to ALT in alcoholic hepatitis is more frequently closer to 2:1. The extremely high ratio in this case (again, with a normal ALT) points to an extrahepatic process. An elevated GGT can reflect alcoholic liver damage, but again, this is unlikely in the face of completely normal bilirubin and alkaline phosphatase. Therefore, ordering a GGT level and a serum alcohol level (choice C) is not correct. Hepatitis A, B, and C serologies (choice D) are incorrect because the viral hepatitides should not cause an isolated level in AST. A right upper quadrant ultrasound (choice E) is incorrect mainly for the same reasons as elucidated above. A right upper quadrant ultrasound is useful for evaluating suspected structural disease. Typically, structural disease of the liver is suspected when there are clues of hepatic obstruction. Elevated bilirubin and alkaline phosphatase are typically elevated in hepatic obstruction, and both are normal in this case.
|
Линейный вид
