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#49
10.07.2006, 18:13
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Ну, я вот тут почитала в eMedicine...
In the setting of flank pain, fever, and pyuria, pyelonephritis can be diagnosed and treated without immediate imaging. Failure to respond to therapy within the usual 48 hours should prompt a renal ultrasound to look for infection associated with significant obstructive uropathy that may require placement of a percutaneous nephrostomy. Renal and ureteral calculi are imaged best with a noncontrast spiral CT scan. А какой ответ правильный именно в этой задачке?   
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#50
10.07.2006, 18:18
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The correct answer is A. The patient's symptoms are consistent with an infected and obstructing ureteral stone, especially in light of his past stone history and probable dehydration from his hiking trip. Colicky flank pain radiating to the groin typically marks the presence of a midureteral obstruction. An obstruction in the presence of an infection is a medical emergency because of the very high possibility of septic shock, therefore a quick diagnosis is needed. The best imaging study for nephrolithiasis is a non-contrast CT scan which can visualize all types of stones and then accurately locate them. It can also tell us whether the patient has hydronephrosis, hence, disclosing whether the patient has an obstruction. Once the diagnosis is made, a urologist will most likely need to put in a ureteral stent to correct the obstruction.
A DMSA renal scan (choice B) is a radionucleotide study that evaluates renal function and does not give much information about a renal obstruction. It also takes 4-24 hours to obtain optimal images. An IVP (choice C) is incorrect because of the patient's renal insufficiency at the time of presentation. The elevated creatinine is a contraindication to IV contrast. In any other cases of noninfected nephrolithiasis with a normal creatinine, an IVP would be appropriate. A KUB (choice D) would not be able to demonstrate the presence of a renal obstruction. It can be helpful in verifying the presence of kidney stones. However, uric acid stones are radiolucent and would not be seen on a plain film. A renal ultrasound (choice E) is incorrect because an ultrasound cannot visualize the presence of ureteral stones. It can tell us whether the patient has hydronephrosis, but nothing more.
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#51
10.07.2006, 18:37
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A 16-year-old boy is brought to the emergency department by the paramedics, accompanied by his parents who called 911. The parents report that their son has been acting strangely off and on for the past couple of weeks. They say that he has been going to parties with his friends and comes home late. He often gets up and is irritable and at times makes inappropriate comments. When asked what he meant by the comments, he would just move on to another topic. In the past week he has been locking himself in his room, playing loud music, and talking loudly, even though there is no phone in his room. This morning he started talking about the great silver cross that can be found buried on the cemetery in the east side of town. He claimed that he was hearing God's voice telling him to fly like a bird through the window and get it. The parents grabbed him as he was reaching for the window. The patient has no prior psychiatric history. Medical history is significant for an appendectomy at the age of 11. The parents say that he was always a good student, and basically a good, somewhat introverted, child. The parents are confident that he is not on any drugs or prescription medication. The family history is negative for psychiatric disorders. The patient looks tired, sleepy, and unkempt. His blood pressure and pulse are slightly elevated, but other than that, his physical examination is unremarkable. He is cooperative with the examination, and oriented appropriately, but seems to be responding to internal stimuli and unable to carry on a meaningful conversation. The most appropriate first step in this patient's management is to
A. order a head CT B. place the patient in 4-point restraints C. prescribe an antipsychotic agent D. send urine for drug screen E. set up a psychology consult to do a Rorschach test
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#52
10.07.2006, 18:40
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Да, чего-то мне эта задачка не очень понравилась. УЗИ в качестве первого исследования, на мой взгляд вполне логично. См. и цитату от Dr. Ira. А что скажет доктор Живов?
Конечно, здесь еще стоит учесть затраты и не только финансовые. У нас в случае emergency лучше сделать УЗИ, поскольку КТ редко бывает в близкой и быстрой доступности.
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#53
10.07.2006, 18:42
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Цитата:
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#54
10.07.2006, 18:45
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D. send urine for drug screen
B. place the patient in 4-point restraints наверное излишне, но постоянное наблюдение необходимо, учитывая опасное поведение.
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#55
10.07.2006, 18:50
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У нас в госпитале ночью УЗИ сделать сложнее чем КТ. К тому же КТ занимает пару-тройку минут. УЗИ - дольше. КТ даст больше информации. Мне показалось, что очень разумно в данном случае обойтись без УЗИ. Хотя, наверное, задачка спорная.
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#57
10.07.2006, 18:53
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Цитата:
Цитата:
Цитата:
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#58
10.07.2006, 18:58
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Цитата:
Анамнез указывает на амфетаминовоый психоз. Для начала посылаем мочу на анализ, больного оставляем под наблюдением. Как осуществляется наблюдение, наверное, зависит от того, как это принято в конкретной клинике.
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#59
10.07.2006, 19:02
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Цитата:
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#60
10.07.2006, 19:12
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The correct answer is D. The first step in this patient's management would be to order a urine drug screen. Even though the parents seem to think he is not using drugs, his age, recent onset, and history of behavior in the past several weeks may indicate possible drug abuse. Therefore, substance induced psychotic disorder should be ruled out first.
Head CT (choice A) is a part of a workup for delirium. It also is a part of the workup for first break psychosis. There seems to be no indication that the patient is delirious and physical exam seems to be normal. If other laboratory vales are unremarkable, a head CT can be done once the patient is admitted to the unit. Putting the patient in 4-point restraints (choice B) is currently not indicated. The patient seems calm, cooperative, and not currently endangering himself or anyone else. However, given the history of commanding hallucinations, close observation of the patient should be in place. Prescribing an antipsychotic (choice C) before the patient has been medically cleared and a provisional psychiatric diagnosis established is not justified. It should be done only in emergency situations, such as when the patient is agitated and there is increased paranoia, hallucinatory behavior, etc. If it is done, it should be only as a temporary measure until the final disposition is made because of the possibility of side effects and the need to follow up on treatment results. This patient is being cooperative, and is not combative and so this is not immediately necessary, it can wait until a more thorough evaluation is performed, including a drug screen. A psychology consult to do a Rorschach test(choice E) is not necessary at this point. Rorschach is projective test that is used to test for psychotic material. Since this patient seems overtly psychotic and actively responds to internal stimuli, it would be difficult and fruitless to perform this test.
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Линейный вид
