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#94
12.07.2006, 14:51
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The correct answer is A. Examining the hair microscopically with potassium hydroxide (KOH) is correct because this child has tinea capitis secondary to his mother's tinea corporis. Tinea capitis commonly presents as areas of alopecia with studded black dots representing infected hairs broken off at or below the surface of the scalp. Different species of fungus can cause either inflammatory or non-inflammatory lesions. Trichophyton mentagrophytes, the species responsible for both inflammatory tinea capitis and tinea corporis, can result in pain and regional lymphadenopathy. Most commonly, the mode of transmission is child to child in school age children. The fact that this child's mom has classic "ringworm" on her left shoulder, which is usually described as concentric erythematous plaque with central clearing and superficial scales points the differential diagnosis toward a fungal infection. Diagnosis of tinea capitis is usually confirmed with microscopic exam of the hair and looking for ectothrix or endothrix spores.
Inquiring about autoimmune disease (choice B) is incorrect because autoimmune processes are usually associated with alopecia areata, not tinea capitis. Alopecia areata is not usually associated with lymphadenopathy or "black dots" of broken hair. Punch biopsy of the scalp (choice C) is incorrect because if tinea capitis is suspected, the first step toward diagnosis includes KOH of hair and a fungal culture of the scalp. Wood's light exam of the scalp (choice D) is incorrect because only ectothrix species fluoresce with Wood's light but not endothrix types. Therefore, this is not the best diagnostic method to confirm tinea capitis Referral to psychiatry for trichotillomania (choice E) is incorrect, because this type of alopecia should not have associated lymphadenopathy. 
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#95
12.07.2006, 14:53
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A 14-year-old girl is brought to the office because of a 5-month history of "red lines" on her abdomen and breasts. She says that she has gained 14.1kg (31lbs.) in the past 6 months, and she has not gotten any taller. She used to play on the junior varsity basketball team, but she quit 6 1/2 months ago because "the other girls were mean." Now she comes home after school, watches television on the couch, and "snacks on whatever food is in the cabinet." Menarche was at age 11 and she has been menstruating at regular, 29-day intervals since age 12. She does not take any medications. Her blood pressure is 110/70 mm Hg. Physical examination shows breasts with projection of the areola and papilla forming a secondary mound, an obese abdomen, adult quantity and type of pubic hair, normal external genitalia, and reddish-purple striae on her breasts, abdomen, and outer thighs. She is most concerned about the "lines". At this time it is most appropriate to
A. order a low-dose dexamethasone suppression test (0.5 mg every 6 hours for 48 hours) B. order a plasma ACTH C. order a plasma cortisol at 8 a.m. after a 1mg dexamethasone at midnight D. order a 24-hour urine free cortisol E. reassure her that the striae are a relatively common issue in adolescence due to rapid body changes
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#98
13.07.2006, 16:21
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Explanation:
The correct answer is E. This patient has cutaneous striae ("stretch marks"), which are an extremely common occurrence in teenage girls, pregnant women, obese patients, and any other individuals with a rapid change in weight. They are most likely due to weakening and rupture of the preexisting collagen fibers in the dermis caused by the rapid stretching of the skin. Unfortunately, there are not any reasonable, effective treatments for this yet. After she is reassured about the "stretch marks," it is important to discuss increasing her exercise, decreasing her "snacking on whatever food is in the cabinet," and address the emotional issues that led her to quit the basketball team. All of the other choices are part of the work-up for Cushing syndrome. Cushing syndrome is characterized by increased weight, hypertension, hirsutism, amenorrhea, striae, personality changes, osteoporosis, ecchymoses, edema, weakness, fatigability, and a typical body habitus (buffalo hump, "moon facies", and truncal obesity). The work-up typically begins with a plasma cortisol at 8 a.m. after a 1mg dexamethasone at midnight (choice C) or a 24-hour urine free cortisol (choice D) and then a low-dose dexamethasone suppression test (0.5mg every 6 hours for 48 hours) (choice A). If there is no response to the low-dose dexamethasone suppression test, plasma ACTH (choice B) is measured. If this is high, the syndrome is most likely due to adrenal hyperplasia due to an ACTH-producing tumor. If ACTH is low, an adrenal adenoma is the most likely cause of the syndrome. If the patient is able to suppress her cortisol levels after a low-dose dexamethasone suppression test, the most likely cause of the syndrome is adrenal hyperplasia due to pituitary ACTH secretion. The patient in this case is obese and has striae, however she does not have any other symptoms consistent with Cushing syndrome. Her striae are most likely a result of her rapid weight gain due to a lack of exercise and an increase in the amount of "snacks".
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#99
13.07.2006, 16:22
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A 72-year-old man with non-Hodgkin's lymphoma, who is 10 days post chemotherapy, has persistent fevers. Of note, 3 days after his chemotherapy finished, he had a temperature of 38.5 C (101.3 F). He was started on ceftazadime and tobramycin. His fever resolved initially. However, now it is 7 days later and he again has similar temperature elevations. He has also developed some minimal hemoptysis. His blood pressure is 115/85 mm Hg, pulse 82/min, and respirations 20/min. Heart has a regular rhythm with no murmurs, lungs have some dry basilar crackles, abdomen is benign, and extremities have 1+ edema, but no erythema. Laboratory studies show a leukocyte count of 3,200mm3, hematocrit 28%, and platelets 18,000mm3. A chest x-ray shows development of some bilateral nodular densities. A CT scan of the lungs confirms multiple lung nodules, many of which have small hazy borders consistent with minimal perinodular hemorrhage. The most appropriate next step in management is to
A. add amphotericin B intravenous therapy to his current therapy B. change the chemotherapy regimen due to treatment failure C. continue the ceftazidime and tobramycin and give it time to work D. refer the patient to radiation oncology for emergent bilateral lung radiation E. send him for a transesophageal echocardiogram
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#101
14.07.2006, 19:23
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A 35-year-old woman comes to the office because of tremors, weakness, weight loss despite an increased appetite, frequent bowel movements, and "itchy legs." She does not drink alcohol or caffeine and she does not smoke cigarettes. She appears anxious and fidgety, and has a "frightened" look. Her blood pressure is 120/80 mm Hg and pulse is 88/min. Physical examination shows a proptosis with stare and lid lag. The thyroid gland is lobular and asymmetrically enlarged. There are waxy, infiltrated plaques over the dorsum of her legs and the affected area has a peau d'orange appearance. An ECG shows sinus tachycardia. Laboratory studies show:
TSH : undetectable Thyroxine : 20 ug/dl Treatment options are discussed, and she decides upon radioactive iodine. In discussing radioactive iodine therapy with the patient, you should inform her that A. continuous or repeated doses of radioiodine are usually necessary B. hepatitis, arthralgias, agranulocytosis, and a rash are common side effects of radioiodine therapy C. patients treated with radioiodine will often require replacement doses of thyroid hormone within 10 years D. radioiodine therapy is the treatment of choice if she is currently pregnant E. there is plenty of evidence that the dose of radioiodine that she will receive has leukemogenic effects
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#102
14.07.2006, 19:27
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Цитата:
A. add amphotericin B intravenous therapy to his current therapy Explanation: The correct answer is A. In any post chemotherapy patient who has persistent fever despite appropriate broad-spectrum antibiotic coverage, fungal and resistant Gram-positive organisms need to be considered. This patient also has a chest CT scan showing multiple bilateral lung nodules with surrounding hemorrhage which is classic for invasive aspergillosis. The most effective current therapy is with amphotericin B. Continuing the ceftazadime and tobramycin (choice C) alone would not address the current problem. The patient is presenting with an acute infectious process related to chemotherapy induced immune suppression. Although a lymphoma can involve the lung directly, it is not particularly common and does not fit this clinical scenario. This makes a treatment failure (choice B) incorrect. Bilateral lung irradiation is not something that is typically done in non-Hodgkin's lymphoma and certainly would not be an emergent procedure (choice D). A transesophageal echocardiogram (choice E) can be used to look at vegetations on heart valves seen in endocarditis. If the vegetations are on the tricuspid or pulmonary valves, they can give off septic emboli to the lungs. This too can cause multiple lung nodules. However, they are often cavitary and do not show the perinodular hemorrhage that is classic for invasive aspergillosis.
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#103
14.07.2006, 19:55
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С
Ну никак все остальное не подходит Про заместительные дозы все понятно, а почему именно 10 лет?
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#105
14.07.2006, 20:25
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A 34-year-old man comes to the office because of a 5-month history of a left-sided headache and jaw pain. The headache usually feels dull, achy and radiates to his ear. He says that it almost feels as if his "jaw is off-centered", and it often "clicks" when he eats or chews gums. There is a constant feeling of jaw stiffness, and it feels as if it is "sticking" when he tries to open his mouth. He denies any fever, shortness of breath, changes in weight or vision, or any other arthralgias, and states that he is otherwise in good health. His temperature is 37 C (98.6 F), blood pressure is 115/80 mm Hg, pulse is 65/min, and respirations are 12/min. Laboratory studies show:
Hg 16.5g/dl Hct 47% Leucocyte 6000/mm3 ESR 8mm/h The most appropriate next step to establish a diagnosis is to A. administer corticosteroids immediately B. auscultate the left carotid artery C. palpate the area just in front of the left tragus D. palpate the left posterior auricular region E. palpate the left temporal artery
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Линейный вид
