Еще одна пилюлька Hескучина

[yananshs]

У авторов другой ответ. Не знаю, кто прав.
The correct answer is B. Acanthosis nigricans (AN) is characterized by hyperpigmentation and papillary hypertrophy, which are symmetrically distributed. Different types of AN have been described. The most common variety of AN is grayish, velvety thickening of the skin of the sides of the neck, axillae, and groin. It occurs in obesity, insulin-resistance, with or without endocrine disorders such as diabetes mellitus and hypothyroidism as well as Cushing's syndrome and Addison's disease. Therefore, an elevated hemoglobin A1C, which is associated with diabetes, is correlated with these findings.

High chorionic embryo antigen (choice A) is incorrect. One of the rare variants of AN is the malignant type which may either precede, accompany, or follow the onset of internal cancer. Most cases are associated with adenocarcinoma, especially of the gastrointestinal tract, lung and breast. Less often, the gallbladder, pancreas, esophagus, liver, prostate, kidney, colon, rectum, uterus, and ovaries are involved.

High testosterone level (choice C) is incorrect. Sex hormones has not been associated with AN.

High total cholesterol (choice D) and high triglyceride (choice E) are both incorrect. Although, these two findings are likely in an obese patient, they are not directly related to AN.

[Rodionov]

Хм, неужто гликогемоглобин глядеть дешевле, чем пальцем в глюкометр ткнуть?

[yananshs]

A 36-year-old man is brought to the emergency department because of shortness of breath and stridor. His shortness of breath has been progressive for the past few months but has worsened significantly in the past week. He was in a serious motor vehicle accident 14 months ago after which he was intubated and ventilated for nearly 3 months. His intensive care unit stay was complicated by ventilator-associated pneumonia. He was eventually weaned from the ventilator and extubated 7 months ago. Since that time, he has been convalescing well but his shortness of breath has become increasingly troublesome. In the last 2 or 3 days his wife has noticed the stridor. His temperature is 37.0 C (98.6F), blood pressure is 140/75 mm Hg, pulse is 72/min, and respirations are 24/min. His lungs are clear bilaterally, but inspiratory stridor is appreciated. A chest CT scan shows a tracheal stenosis of 7mm at the level of C6 vertebral body. The most appropriate management at this time is to
A. admit the patient for observation
B. give the patient bronchodilator therapy
C. initiate antiinflammatory therapy
D. intubate the patient immediately
E. obtain a thoracic surgical consult

[Rodionov]

Поскольку задачка для терапевтов, предположу что С (уменьшая воспаление, снимаем отек), но принципиально надо думать о реконструкции (Е).

[Anna_Shvedova]

Е. Не могу себе представить, как все остальное может помочь больному, а интубировать экстренно его не нужно.

[exomen]

D. у пациента относительно компенсирована дыхательная функция (ЧД-24), однако, учитывая динамику нарастания стеноза с появлением стридора ему показана интубация в условиях отделения ER, несмотря на то, что она может закончиться фатально при таком стенозе трахеи (7 мм на ур-не С6). В него войдет труба с внешним диаметром 7 мм (дай бог), при этом внутренний просвет будет 6 мм, без аппарата сам дышать не сможет. Ну и пусть, зато просвет трахеи будет защищен, и он сможнь дождаться консультации торацик серджен. В противном случае, через пару часов в него и трубу не смогут запихать, трахеостомия при таком уровне стеноза будет крайне трудна.
Евгений

[yananshs]

The correct answer is E. This patient has tracheal stenosis secondary to long-term intubation. This is a common complication of long-term intubation and is one of the main reasons that tracheostomy tubes are placed in patients that are in need of long-term mechanical ventilation. Stridor is caused by the inflow of air across a narrow obstruction in the airway. It signifies that some part of the trachea or main stem bronchi are quite narrow and portends an airway disaster if the disease process is allowed to progress. The CT scan demonstrates tracheal stenosis of moderate degree (3-8 mm is moderate) that will require surgical correction in the near term.

Simply admitting the patient for observation (choice A) fails to address management of a clearly abnormal airway. It is critical to act in cases such as this and triage the patient to the appropriate management as soon as possible.

The trachea is not responsive to bronchodilator therapy (choice B), only the distal bronchioles.

The inflammation and fibrosis that are responsible for the stenosis have already occurred and therefore, antiinflammatory therapy (choice C) will offer little benefit at this time.

There is no need to intubate the patient immediately (choice D). His ventilation and oxygenation are adequate and he does not appear to be in respiratory distress. His airway can in fact become much more narrow (1-2 mm) before any major respiratory distress is appreciated. In addition, since his stenosis is at the level of the cricoid cartilage (C6), an endotracheal tube will not be able to pass.

[Aladdyn]

Е. Противовоспалительная и бронхолитическая терапия не имеют смысла при постинтубационном стенозе трахеи. Показаний к интубации нет, да и технически интубация вероятно неосуществима, скорее постстеностическая трахеостомия. Наблюдение за пациентом с установленным диагнозом и явном отсутствии вожможности спонтанного разрешения клинической ситуации неоправдано.

[yananshs]

A 44-year-old man comes to the emergency department because of a 7-day history of fever and a 2-day history of red spots on his eyes. He also reports some lethargy and fatigue. His past medical history is otherwise unremarkable. He does state that when he was a teenager a physician once told him that he had a "heart valve problem" that would require him to take antibiotics on dental visits. His temperature is 38.0 C (99.4F), blood pressure is 140/75 mm Hg, pulse is 92/min, and respirations are 16/min. He has bilateral conjunctival hemorrhages and small indurations present on the dorsal surface of his hands. He has a 1/6 systolic ejection murmur heard best at the apex. The finding most likely to confirm the diagnosis is
A. echocardiograph showing mitral regurgitation
B. echocardiograph showing valvular mass
C. elevated erythrocyte sedimentation rate
D. positive V/Q scan
E. single positive blood culture

[Aladdyn]

Бактериальный эндокардит. Вероятно, В. Было бы верно и Е, но не однократное определение культуры, а хотя бы двукратное и из разных вен.

[exomen]

The correct answer is E. This patient has tracheal stenosis secondary to long-term intubation. This is a common complication of long-term intubation and is one of the main reasons that tracheostomy tubes are placed in patients that are in need of long-term mechanical ventilation. Stridor is caused by the inflow of air across a narrow obstruction in the airway. It signifies that some part of the trachea or main stem bronchi are quite narrow and portends an airway disaster if the disease process is allowed to progress. The CT scan demonstrates tracheal stenosis of moderate degree (3-8 mm is moderate) that will require surgical correction in the near term.

Я уверен, что врачи, наблюдающие этот тест отдают себе отчет в том, что тесты тестами, а жизнь весьма часто вносит свои коррективы. Ситуация, описанная в данном случае, часто встречается в клинике. Имейте в виду, что интубация пациента со стенозом 7 мм проще и успешнее, чем интубация пациента со стенозом 6 мм и менее. Прогрессия от 7 мм до 5-3 мм будет происходить гоораздо быстрее, чем от 10 мм до 7 мм. Проведение трахеостомии без интубации, под местной анестезией, чревато гораздо большими проблемами. В противном случае все плановые трахеостомии проводили бы под местными анестезиями.
При стенозе 7 мм можно завести трубку небольшого диаметра и наладить вспомогательную вентиляцию в режиме СРАР+PS. Все дело во времени - пока вы будете ждать консультацию торакального хирурга и подадите пациента в операционную он может успешно впасть в респираторный дисстрес. Если кто обладает провидческими способностями - то можно спокойно дожидаться консультации.
Евгений

[papadoctor]

Eugene! This serious matter should be discussed in Anesthesiology section, not here, where we are just having fun!

[yananshs]

Сообщение от exomen

Я уверен, что врачи, наблюдающие этот тест отдают себе отчет в том, что тесты тестами, а жизнь весьма часто вносит свои коррективы. ...Евгений

Евгений, не расстраивайтесь. Это всего лишь тесты для американских резидентов. Это USMLE3, а не борды. Любой узкий специалист может найти в них ляпы по своей специальности. Я тоже в них нашла "остеолитические очаги на сцинтиграфии скелета" и "внутривенное введение радиоактивного иода".

[papadoctor]

Повеселим коллег-анестезиологов.
Among physicians with history of substance abuse, which of the following is MOST likely to be a risk factor for relapse?
A- Abuse of fentanyl
B- Age greater than 40
C- Male sex
D- History of smoking

[Dr.]

Сообщение от yananshs

A 44-year-old man comes to the emergency department because of a 7-day history of fever and a 2-day history of red spots on his eyes.

Ого, да это же пятна Лукина

P.S.

B. echocardiograph showing valvular mass