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#571
22.08.2006, 22:30
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Я думаю, что С. Есть признаки воспаления, диабет декомпенсированный, так что, возможно, это именно инфекция.
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#573
22.08.2006, 23:09
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Ну, неспецифическая какая-нибудь. Не знаю, какая.
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#574
22.08.2006, 23:14
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The correct answer is C. This diabetic patient most likely has mucormycosis, which is a fungal infection that typically only affects individuals with a preexisting disease (diabetes). The clinical features are a fever, sinus pain, thin, bloody nasal discharge, double vision with a reduction of movement of his left eye, and red or necrotic nasal turbinates. The fungal invasion of the ophthalmic artery and globe may cause blindness and a direct invasion of the brain may lead to obtundation and coma. A CT scan, MRI, and biopsies are all helpful in establishing the diagnosis and in evaluating the extent of the disease. The treatment involves extensive surgical debridement and amphotericin B. Regulation of the blood glucose levels is an important part of treating the disease.
Since this patient most likely has mucormycosis, it is unlikely that a biopsy of his nasal turbinates will show invasive squamous cell carcinoma (choice A). Nasopharyngeal carcinoma is very rare in the United States, but when it does occur, it typically presents with eustachian tube and nasal obstruction. A middle ear effusion may be present. In this patient with poorly controlled diabetes, a high temperature, and the relatively sudden onset of these symptoms, mucormycosis is more likely than nasopharyngeal carcinoma. Insulin, intravenous fluids, and potassium replacement will improve his symptoms (choice B) is incorrect because this is the treatment for diabetic ketoacidosis, not mucormycosis. This patient needs surgical debridement and amphotericin B. The symptoms on the left side of his face are unrelated to his diabetes mellitus (choice D) is incorrect because his poorly controlled diabetes is the main risk factor for developing mucormycosis of the paranasal sinuses and nose. While tight control of his diabetes is important in treating mucormycosis along with debridement and amphotericin B, it alone will not reverse the symptoms on the left side of his face (choice E).
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#575
22.08.2006, 23:22
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A 21-year-old man is brought by ambulance to the emergency department after being involved in a high-speed collision on his motorcycle. The patient struck a retaining wall at over 100 miles per hour. At the scene, he was non-responsive. He was intubated, a peripheral intravenous was placed, and he was transported to the hospital. On arrival, the patient is non-responsive to command. His temperature is 37.0 C (98.6 F), blood pressure is 60/30 mm Hg, pulse is 140/min, and respirations are 10/min via mechanical ventilator. He has multiple ecchymoses on his abdomen and chest, with an open femur fracture on the right and a depressed skull fracture. His abdomen is distended and tense and a radiograph suggests massive blood in the abdomen from a venous tear. A femoral vein cut-down is performed by the surgical team and a femoral vein central line is placed. After rapid infusion of 6 liters of crystalloid and 4 units of packed red cells via the femoral line, the patient is noted to be in pulseless electrical activity. The most appropriate next step in the management of this patient is to
A. bring the patient emergently to the operating room B. continue rapid transfusion of blood products and crystalloid via the femoral line C. give epinephrine, intravenously D. place an upper extremity intravenous line and infuse volume and blood product E. perform DC cardioversion at 200 Joules
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#576
22.08.2006, 23:32
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Да, позор мне. Мало я знаю про инфекции у иммунокомпрометированных лиц...
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#577
22.08.2006, 23:38
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Поскольку внутривенно вводить адреналин при отсутствии циркуляции странно, наверное, E. Остановка сердца (гиперкалиемия, да?) - дефибрилляция...
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#578
22.08.2006, 23:41
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Цитата:
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#580
23.08.2006, 01:31
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Цитата:
Цитата:
Цитата:
Цитата:
Цитата:
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#581
23.08.2006, 01:47
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>>A<<
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#583
23.08.2006, 16:02
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Цитата:
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#584
23.08.2006, 16:05
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сложно что-либо добавить. То, что дырки нужно закрывать, это без вопросов. Но пока его довезут и разрежут, может все-таки введут в периферию симпатомиметик на фоне наружного массажа? Хотя может довезут раньше, чем введут. Все равно:
C. give epinephrine, intravenously Dmitry Voskovets PS: приятно, что все оживились 
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#585
23.08.2006, 18:48
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The correct answer is D. The utility of central lines are related to the nature of the injury or clinical condition of the patient. For example, internal jugular lines are useful when the shoulders or chest is going to be operated on. For this patient who likely has an inferior vena cava rupture, a precaval line does nothing except deliver blood product to his vena cava that promptly discharges it through a defect into the abdominal space. This patient is now in PEA because he has continued to lose volume through his defect. An upper extremity line should be placed (utilizes SVC) and volume should be delivered in that manner.
Attempting to bring the patient emergently to the operating room (choice A) could result in his death. Patients must be stabilized (the ABCs of resuscitation) before any additional interventions are taken. This patient is in an ACLS arrest and must be resuscitated prior to being discharged from the emergency department to the operating room. For the reasons discussed above, to continue rapid transfusion of blood products and crystalloid via the femoral line (choice B) would be ineffective at restoring this patient's pressure. Similarly, giving epinephrine intravenously (choice C) is not correct because this is only called for in pulseless VT or VF. DC cardioversion at 200 Joules (choice E) is incorrect because this patient is in PEA arrest. This ACLS algorithm calls for interventions that restore the circulatory tone. There is no evidence that this patient is in pulseless ventricular tachycardia or fibrillation, which does call for countershock.
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Линейный вид
