Еще одна пилюлька Hескучина

[yananshs]

The correct answer is B. Since he seems to be depressed and wants help with his condition, selective serotonin reuptake inhibitors like fluoxetine can improve his depressive symptoms and cause retarded ejaculation which would be appropriate in this case.

Estrogen (choice A) can cause lower libido in men and can be used for treatment of increased libido in demented patients with high testosterone levels. It is not indicated in this case.

Methantheline bromide (choice C) can cause impotence and is not indicated in the treatment of premature ejaculation.

Progesterone (choice D) can also lower libido and cause impotence and is not indicated for treatment of premature ejaculation.

Propranolol (choice E) can be used to reduce performance anxiety in low doses, but would lower the libido and possibly cause impotence, without affecting ejaculation.

[yananshs]

A 46-year-old woman with Wolff-Parkinson-White syndrome is admitted to the hospital because of a 24-hour history of abdominal pain. She reports that over the past 24 hours she had the acute onset of pain, which has gradually worsened. The pain is located in her right upper quadrant and radiates to the umbilicus. She takes no medications. She states how she "feels her heart race" often, but usually by holding her breath and baring down, it slows. A diagnosis of acute cholangitis is made and the patient is admitted to the intensive care unit. While there, the alarm sounds at the nurse's station where she is seen to be in a tachycardia with a heart rate of 250 /min. On arrival to the room, her pulse is regular at 240-260 /min and her blood pressure is nonpalpable. The patient is not responsive. A 12 lead electrocardiogram reveals a supraventricular tachycardia at 220/min. Chest compressions are begun. At this time you should
A. give intravenous amiodarone
B. give intravenous metoprolol
C. give intravenous verapamil
D. perform synchronized cardioversion
E. perform unsynchronized cardioversion

[Rodionov]

D. Какие уж там лекарства.

[Anna_Shvedova]

Однозначно - у больной все показания к немедленной кардиоверсии. А поскольку синхронизироваться на наджелудочковой тахикардии можно, то D.

[yananshs]

The correct answer is D. This patient has WPW, a congenital presence of an accessory conduction pathway between the ventricles and the atria. These patients are prone to reentrant tachyarrhythmias. For this patient, she is in a pulseless ventricular tachycardia/ventricular fibrillation pathway of the ACLS algorithm and should be managed in that manner. The sequence is airway, breathing, chest compressions, and synchronized cardioversion to avoid the R on T phenomenon and precipitate ventricular tachycardia or asystole.

Intravenous amiodarone (choice A) has been shown to be superior to lidocaine in the management of pulseless VT/VF after cardioversion or countershock and epinephrine. It has taken a class IIb indication (demonstrated benefit) in these scenarios. It is also used as an adjunct to electrical cardioversion of reentrant ventricular tachycardia.

Metopolol (choice B) is a beta-1 specific antagonist used for rate control in hemodynamically stable atrial and ventricular tachycardias. This patient is not hemodynamically stable.

Verapamil (choice C) should be avoided in patients with WPW. Verapamil, diltiazem, and digitalis (drugs that slow AV nodal conduction) can cause a paradoxical increase in ventricular rates by facilitating preferential conduction through the accessory pathway.

Unsynchronized cardioversion (choice E) is inappropriate because of the presence of an electrical QRS complex that can be synchronized with the defibrillator.

[yananshs]

A 22-year-old woman is brought to the emergency department following a motor vehicle accident. She was an unrestrained driver in a head-on collision. She was unresponsive on the scene and was intubated by the EMTs on the field. She has no known medical history or drug allergies. She is able to breath spontaneously and has a cervical collar in place. Her blood pressure is 120/60 mm Hg, pulse is 90/min, and respiratory rate is 32/min. Her oxygen saturation on 100% oxygen is 100%. She has multiple ecchymoses over her left chest and her trachea is midline. Breath sounds are diminished over the left side. The remainder of the examination is unremarkable. Based on the available information, the most appropriate next diagnostic step is to
A. obtain a CT scan of the abdomen
B. order a chest radiograph at maximal inspiration
C. order a chest radiograph at maximal expiration
D. order an echocardiogram
E. order a ventilation-perfusion scan

[Rodionov]

Левосторонний пневмоторакс? С.

[riltsov]

Ответ В. В связи с multiple ecchymoses думаю, что это гемоторакс и необходимо сделать chest radiograph at maximal inspiration, допускаю, что в такой позиции будет лучше контрастироваться кровь в плевральной полости.

[Aladdyn]

Изолированный гемоторакс без пневмоторакса при таком механизме травмы встречается реже. И кровь видна будет одинаково хорошо вне зависимости от фазы дыхания. А вот пневмоторакс надо смотреть на выдохе - лёгкое коллабирует в большей степени. Всё-таки, С.

[yananshs]

The correct answer is C. This patient's exam shows evidence of chest wall trauma and decreased breath sounds. There is concern for a pneumothorax. Often, small pneumothoraces can be difficult to see on routine chest radiography. A chest radiograph at maximal expiration, by collapsing the lungs to a small volume, will increase the opportunity to visualize a pneumothorax.

An abdominal computerized tomogram (choice A) is not indicated in this patient at this juncture given her benign abdominal exam.

A chest radiograph at maximal inspiration (choice B), by inflating the lungs to the maximum, will not assist in the diagnosis of a pneumothorax.

An echocardiogram (choice D) can be used to diagnose cardiac or aortic pathology in the setting of a motor vehicle accident as with this patient. However, given the available information including the hemodynamic data, there is no reason to suspect such pathology here.

A ventilation-perfusion scan (choice E) is used in the diagnosis of a pulmonary embolus. There is no evidence that this patient has this pathology.

[yananshs]

A 40-year-old man is rushed into your emergency department. He was the restrained passenger in a motor vehicle accident involved in a hit and run. Upon arrival, he is awake and communicating. He denies any loss of consciousness and his only complaint is right-sided abdominal pain. As the physician in charge of the case, you assign your team to assess the patient completely. He is evaluated by standard trauma protocol. His vital signs are stable, and his neck and spine are determined to be without injury. Upon examination of his abdomen, you elicit a moderate amount of tenderness in the right upper quadrant. There is associated guarding, but no rebound. There is no flank ecchymosis or clinical suspicion of rib fractures. No abnormalities are noted on genital examination and no extremity fractures are appreciated. His serum chemistries and complete blood count are within normal limits. However, urinalysis (from a spontaneously voided specimen) is significant for 35 RBC, 3 WBC, negative leukocyte esterase, and negative nitrates. You are concerned about his right upper quadrant pain and elect to perform a CT scan. A CT scan of the abdomen and pelvis reveals a subcapsular hematoma with a superficial laceration of the right renal cortex. There is no extravasation of intravenous contrast from the right kidney. No free air is seen and no other organs appear to have any damage. The most appropriate way to manage this patient's renal injury is to
A. admit the patient for serial abdominal exams and blood counts
B. obtain an intravenous pyelogram
C. order a retrograde urethrogram
D. perform angiography of the right kidney
E. place a Foley catheter and perform bladder irrigation
F. surgically explore and evacuate hematoma

[riltsov]

A. admit the patient for serial abdominal exams and blood counts
Я думаю, что такую гематому следует вести консервативно. Поверхностное повреждение коркового вещества и микрогематурия это показание только для наблюдения за пациентом.

[yananshs]

The correct answer is A. This patient has a grade II renal injury. The kidney is the most common organ injured in the urinary system, with most injuries occurring from automobile accidents or sporting mishaps. Kidneys with pathological conditions such as hydronephrosis or malignant tumors are more readily ruptured from mild trauma. Blunt trauma is the most common mechanism of renal injury, causing 80-85% of all renal trauma. Gunshot and knife wounds are responsible for most penetrating renal trauma.Renal trauma can be classified as minor, major, and vascular and are rated from a grade I up to grade V. For minor injuries, a renal contusion of the parenchyma is the most common lesion, and usually associated with a subcapsular hematoma. A superficial cortical laceration may also be noted. These injuries rarely require surgical exploration. Major renal trauma occurs when lacerations extend deeply into the corticomedullary and collecting system tissue. This results in extravasation of urine into the perirenal space. Many of these injuries can also be managed conservatively, however, it is not uncommon to perform surgical exploration of the most serious injuries from this category. Vascular injuries to the renal pedicle are rare. It may be caused by total avulsion of the artery and vein or thrombosis secondary to stretching of the main renal artery. Vascular injuries are difficult to diagnosis and frequently result in total kidney destruction.

Intravenous pyelogram, or IVP, (choice B) is performed to establish the presence or absence of both kidneys, to define renal outlines and cortical borders, and to outline the collecting systems and ureters. All of these goals are reached with the CT scan you ordered for this patient. Therefore, an IVP is not indicated at this time. Prior to a CT scan, it was the method of choice for initial radiological imaging of kidneys suspected of traumatic injury.

A retrograde urethrogram (choice C) is performed in patients suspected of having a urethral injury. These patients typically have blood at the meatus, a perineal hematoma, a high riding prostate, a pelvic fracture, or a mechanism of injury suspicious for urethral damage. This patient does not meet any of these criteria. He also voided spontaneously, which is frequently not the case with urethral injury. His microscopic hematuria is from his renal injury.

Angiography (choice D) can be used to define the major arterial and parenchymal injuries of the kidney. In patients who are actively bleeding, this exam will also allow for embolization of a lacerated blood vessel. In this patient with a minor renal injury and stable vital signs, it is not indicated at this initial stage.

This patient has voided spontaneously with grossly clear urine. His hematuria is microscopic. There is no evidence that he has any bladder injury or that he is suffering from clot retention within his bladder. Therefore, there is no need to place a catheter or to irrigate his bladder (choice E).

Surgical exploration (choice F) is not indicated in a patient who is hemodynamically stable, has no other organ injury, and does not appear to have any evidence of continued bleeding. Attempting to evacuate this small hematoma is not necessary as this minor injury will most definitely remain stable and resolve on its own. For this reason, admitting the patient for serial evaluations is the most appropriate step in management. If the patient's injury continues to progress, it will manifest itself clinically with dropping hematocrit, worsening abdominal pain, and hemodynamic instability.

[yananshs]

You are seeing a 34-year-old woman in the emergency department who is now 10 days post emergent C-section for preeclampsia at 29 weeks, and presents with a 3-day history of a headache. She describes it as "pain starting at the right temple and shooting through the head to the left temple". There is some associated photophobia and phonophobia. At its worst, the headache is a 10 of 10 on the pain scale, with 10 being the worst pain that she ever felt in her life. This is similar to a headache she was having a month ago during her pregnancy. There is no relief with acetaminophen. Prior to delivery she had numbness of her right cheek that was transient. Her blood pressure is 160/90 mm Hg. Examination shows bilateral papilledema. The most appropriate next step in management is to
A. begin intravenous heparin
B. call a neurosurgical consult
C. discharge the patient with a prescription for naratriptan
D. discharge the patient with a soft cervical collar and prescription for metaxalone
E. order a brain MRI and MRV

[riltsov]

Worst pain that she ever felt in her life – это означает, что головная боль имеет вторичный характер, это не мигрень. По характеру симптомов предполагаю субарахноидальное кровоизлияние.
Правильный ответ: E. order a brain MRI and MRV