Еще одна пилюлька Hескучина

[filbi]

я тоже бы сделала вначале колоноскопию, но диагноз тут может быть и не дивертикулит, а например ишемический колит,хотя и не уверена,конечно. А срочно потому что, ЧСС 110, наверно не может быть полностью отнесено к лихорадке, а является отражением кровотечения или гиповолемии. С другой стороны если думать о дивертикулите, то А (КТ) достаточно информативна.

[Dr.]

Сообщение от yananshs

55-year-old woman is brought to the emergency department by her daughter because of left lower quadrant abdominal pain, anorexia, fever, and chills for the past 24 hours. Her temperature is 38.7 C (101.6 F), pulse is 110/min, and respirations are 18/min. She is awake and alert, although she appears uncomfortable. Examination shows hypoactive bowel sounds and a soft abdomen with mild voluntary guarding especially in the left lower quadrant. Digital rectal examination is significant for heme-positive stool. An electrocardiogram shows a sinus tachycardia at 110 beats per minute. There are no ST segment changes when compared with old electrocardiograms. A chest x-ray shows no acute disease. Abdominal x-ray demonstrates no air under the diaphragm and no ileus. A complete blood count, biochemical profile, cardiac enzymes, amylase, and lipase are drawn, but results are not yet available. The most appropriate initial management of this patient is to
A. admit for intravenous antibiotics, nil per os diet, and abdominal CT scan
B. discharge to home on a clear liquid diet and PO antibiotics
C. immediately refer to a gastroenterologist for colonoscopy
D. prepare the patient for immediate surgical exploration
E. send patient for urgent cardiac catheterization

С одной стороны, лихорадка и боли в левой половине живота - не исключены гинекологические дела вроде сальпингита, с другой стороны - похоже на дивертикулит. А кровь в стуле есть. Может быть, у нее брюшной тиф? . Разрываюсь между А и С. С предполагает какую-то срочность с вызовом консультанта, наверное за это можно получить по заднице в США. Пусть будет А.

[yananshs]

The correct answer is A. This patient most likely has diverticulitis, an inflamed herniation of the mucosa of the colon through the muscular layer of the bowel wall. The best way to diagnose diverticulitis is with an abdominal CT scan. The appropriate management of this patient is admission to the hospital. She should be kept NPO and given IV antibiotics.

Mild cases of diverticulitis may be treated as an outpatient with a clear liquid diet and PO antibiotics (choice B). However, this patient is too sick to be discharged and ought to be treated with IV antibiotics.

A colonoscopy (choice C) is useful to diagnose diverticulosis, but would not be used during an acute attack of diverticulitis because of risk of perforation.

Indications for urgent surgical intervention include abscess formation, severe disease, or confirmed perforation. This patient does not yet show signs of needing surgical intervention (choice D).

Abdominal pain is often the presenting sign of cardiac ischemia. However, this patient has few risk factors, no EKG changes, and does have abdominal exam findings. Therefore, cardiac catheterization (choice E) would not be indicated. You should, however, still continue to monitor her cardiac function and obtain cardiac enzymes.

[yananshs]

A 19-year-old boy comes to the office because of a cough for the past 2 weeks. It was initially a "dry, annoying cough," but it has recently changed to a "wet cough with yellowish-green sputum." He is a college freshman and is "pledging" a fraternity. He admits to many nights of "hard drinking." You notice that his front tooth is missing and he says that he lost it 2 weeks ago during a "hazing" event when the pledges were forced to "funnel" beer. Her temperature is 37.8 C (100.0 F), blood pressure is 110/80 mm Hg, and respirations are 20/min. Physical examination shows wheezes over the right lung base. It is otherwise unremarkable. The most appropriate next step is to
A. admit him to the hospital for immediate bronchoscopy
B. order a chest x-ray
C. order pulmonary function tests
D. order tomography of the right lower lobe
E. prescribe antibiotics and send him home

[Dr.]

Сообщение от yananshs

A 19-year-old boy comes to the office because of a cough for the past 2 weeks. It was initially a "dry, annoying cough," but it has recently changed to a "wet cough with yellowish-green sputum." He is a college freshman and is "pledging" a fraternity. He admits to many nights of "hard drinking." You notice that his front tooth is missing and he says that he lost it 2 weeks ago during a "hazing" event when the pledges were forced to "funnel" beer. Her temperature is 37.8 C (100.0 F), blood pressure is 110/80 mm Hg, and respirations are 20/min. Physical examination shows wheezes over the right lung base. It is otherwise unremarkable. The most appropriate next step is to
A. admit him to the hospital for immediate bronchoscopy
B. order a chest x-ray
C. order pulmonary function tests
D. order tomography of the right lower lobe
E. prescribe antibiotics and send him home

B. order a chest x-ray

А вообще мужик, hard drinking. over-eating and the casual sex! Вряд ли конечно он куски зуба-то аспирировал.

[yananshs]

The correct answer is B. This patient most likely has a foreign body aspiration (his tooth). A foreign body aspiration typically presents with a new cough, wheezing and the patient often has a history of heavy drinking, drug overdose, or trauma. This patient was "funneling" beer, which is when a large funnel and a tube are used to supply a large amount of beer into the recipient's mouth at a rapid speed. A chest x-ray is the initial study and may show a radiopaque object and postobstructive pneumonia or abscess. Management is by bronchoscopy combined with antibiotics.

Admitting him to the hospital for immediate bronchoscopy (choice A) is inappropriate because while it seems likely that he has a foreign body aspiration (his tooth), a chest x-ray should be ordered first. He should be evaluated for a radiopaque object and postobstructive pneumonia, abscess or another process that may be causing these symptoms.

Pulmonary function tests (choice C) are inappropriate at this time. This patient most likely has a foreign body aspiration, not asthma. The wheezing that is heard over the right lower lobe is most likely caused by obstruction of a bronchus.

Tomography of the right lower lobe (choice D) is not the next step in evaluating this patient who most likely has a foreign body aspiration. A chest x-ray should be ordered.

Since this patient most likely has a foreign body aspiration, it is inappropriate to prescribe antibiotics and send him home (choice E). He requires removal of the object and antibiotics. Sending him home with antibiotics may be appropriate if he is a healthy patient with a cough and a suspected mycoplasma pneumonia infection, however a chest x-ray is usually indicated in this situation too.

[yananshs]

A 77-year-old man with comes to the emergency department with left knee swelling and intense pain for 7 hours. He has a history of hypertension, treated with hydrochlorothiazide, alcohol abuse, and chronic renal insufficiency with a baseline creatinine of 3.4 mg/dL. His temperature is 37.3 C (99.2 F). Physical examination shows an erythematous, warm, tender knee. The remainder of the examination is unremarkable. You aspirate fluid from his knee and send it for evaluation. The results come back as "negatively birefringent crystals." The most appropriate management at this time is to administer
A. allopurinol
B. aspirin
C. colchicine
D. indomethacin
E. intraarticular steroids

[filbi]

я думаю, что в этой задаче заложен правильный ответ А, но в реальной практике я рентген бы сделала сначала

[Aladdyn]

Е. Подагра, по данным анамнеза и микроскопии синовиальной жидкости. Аллопуринол для лечения острого подагрического артрита не применяется. Аспирин менее эффективен, чем индометацин. Колхицин противопоказан из-за почечной недостаточности. Между индометацином и в/с ГКС выбрать труднее, но, учитывая поражение одного сустава и ранее обращение, а также большую безопасность у данного больного, склоняюсь к внутрисуставному введению гормона.

[papadoctor]

Не знаю, не знаю. По классике надо вводить колчицин на острый приступ подагры. Кретинин 3.4 у 77 летнего говорит от том, что почек просто не осталось.

[Dr.]

Сообщение от yananshs

A 77-year-old man with comes to the emergency department with left knee swelling and intense pain for 7 hours. He has a history of hypertension, treated with hydrochlorothiazide, alcohol abuse, and chronic renal insufficiency with a baseline creatinine of 3.4 mg/dL. His temperature is 37.3 C (99.2 F). Physical examination shows an erythematous, warm, tender knee. The remainder of the examination is unremarkable. You aspirate fluid from his knee and send it for evaluation. The results come back as "negatively birefringent crystals." The most appropriate management at this time is to administer
A. allopurinol
B. aspirin
C. colchicine
D. indomethacin
E. intraarticular steroids

D. indomethacin

В настоящее время - первая атака подагры, так что получите НПВС, отменим наконец-то гидрохлортиазид, раз этого раньше не сделали, с таким-то креатинином (как же я ненавижу мг/дл) . А там уже ясно будет. Аллопуринол, как мне кажется, потом, если он водочку пить, конечно, перестанет . Насчет колхицина...с могучим ХПН-ом не рискнул бы...

[exomen]

а также большую безопасность у данного больного, склоняюсь к внутрисуставному введению гормона.

НПВС - при нарушении функци почек проигрывает гормонам.
Е.

[yananshs]

The correct answer is E. Steroids, especially intraarticular steroids, are very effective when NSAIDs (which are the treatment of choice for gout) are contraindicated. In this patient, chronic renal insufficiency is a relative contraindication to NSAID use. Therefore, intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects.

Allopurinol (choice A) is a xanthine oxidase inhibitor, which is an effective therapy for hyperuricemia. Allopurinol has no role in the treatment of acute gout since it may cause the mobilization of tophi, thereby causing increased pain. It is useful to keep the uric acid level within normal limits and should be started after the acute attack has resolved to prevent recurrences. Do not forget to keep a patient's comorbidity in mind prior to prescribing treatments. This patient would likely benefit from decreasing his alcohol intake and changing his antihypertensive medication to one that will not increase uric acid levels.

Aspirin (choice B), especially low-dose aspirin, may increase uric acid levels by inhibiting renal excretion of uric acid. Aspirin is therefore not indicated in the treatment of gout.

Colchicine (choice C) is an effective treatment for gout but there are several side effects associated with its use. It is often associated with severe GI side effects. At high doses (especially IV therapy), bone marrow suppression can occur. Liver disease and kidney disease may increase colchicine levels and should be avoided in these patients if possible.

NSAIDs, such as indomethacin, (choice D) are the treatment of choice for most patients with gout. Typically, treatment begins with high dose NSAIDs, which are rapidly tapered. This patient has kidney disease and therefore should not be given high-dose NSAIDs.

[yananshs]

A 71-year-old man with mild hypertension and high cholesterol comes to the office complaining of 2 weeks of intermittent vertigo with each episode lasting about 2-4 hours. He also reports hearing a low frequency buzzing, which is constant but waxes and wanes in intensity. He tells you that over this time he has been having trouble hearing while in noisy areas such as in restaurants or temple gatherings. Physical examination is normal. Vertigo is not exacerbated by changes in head position. The most appropriate management of this patient is to
A. begin diazepam therapy
B. begin hydrochlorothiazide therapy
C. begin meclizine therapy
D. begin scopolamine therapy
E. recommend physical therapy

[Mikhail]

B. Диуретики можно применять в межприступный период. Вестибулосупрессанты (остальные ответы) - при приступе.
ЗЫ: Это симптомы б-ни Меньера.