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#1246
22.02.2007, 18:50
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Не видно пока показаний для повышения дозы преднизолона и сульфасалазина: течение болезни стабильное, признаков ухудшения нет.
Для колоноскопии тоже нет показаний (не планируется биопсия, да и год назад уже делали). Думаю, что правильный ответ - D. 
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#1247
22.02.2007, 19:03
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C. prophylactic colectomy
vs E. surveillance colonoscopy every year Taking into account, that it's not pan-colitis, and presuming, that colono is with the biopsies- I'd choose E Though, some experts, especially in pan-colitis with mayor changes- can recommend prophylactic colectomy for both UC and Chron's. After 15 yrs the risk of cancer is high, and it's often gets invasive early...
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#1248
22.02.2007, 19:30
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E. probably
surveillance barium enema every year - could be used as well, but it's not as sensitive as colonoscopy. As he feels well and we don't see any signs of complications there is no point in changing therapy
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#1249
23.02.2007, 18:00
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The correct answer is E. The most important recommendation for this patient is a surveillance colonoscopy every year in an effort to detect colon cancer early. Although the risk of colon cancer in Crohn's disease is much less than in ulcerative colitis, the risk increases significantly with involvement of the colon, and if the disease has been present for more than 10 years. This patient is at increased risk for colon cancer because he has had Crohn's disease for at least 15 years and has evidence of colon involvement. A colonoscopy is recommended because it is superior at detecting small lesions and biopsy of suspicious lesions can also be performed simultaneously.
An increase in prednisone dosage (choice A) is not indicated in this patient at this time. He reports feeling well and has only rare episodes of diarrhea. Medication adjustments should be made based on the patient's symptoms. An increase in sulfasalazine dosage (choice B) is not indicated in this patient at this time. He reports feeling well and has only rare episodes of diarrhea. Medication adjustments should be made based on the patient's symptoms. Prophylactic colectomy (choice C) is not indicated or recommended for this patient. Many patients with Crohn's disease who have extensive colitis undergo colectomy early in the course of disease to relieve persistent symptoms. This patient does not have severe symptoms nor does he have prior colonoscopy findings of dysplasia to warrant a colectomy. Prophylactic colectomy is often recommended for patients with ulcerative colitis with long standing colitis due to the increased risk of colon cancer. Surveillance barium enema (choice D) is not the best recommendation for this patient. He has had Crohn's disease for over 10 years and is at increased risk for developing colon cancer. A barium enema is not as sensitive or specific for the detection of early colon cancer. Colonoscopy is recommended because it is superior at detecting small lesions and biopsy of suspicious lesions can also be performed simultaneously.
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#1250
23.02.2007, 18:01
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A 32-year-old woman comes to the office "for a prescription of propranolol for stage fright." She tells you that she is professional singer and lately she has been experiencing "butterflies" and palpitations before performances. She has been so worried about having one of these symptoms that she is having trouble sleeping at night. She tells you that a friend of hers has a similar problem and propranolol has "cured her." She has been a patient of yours for the past 10 years and you remember that she has severe asthma, requiring many hospitalizations, the most recent being 2 weeks ago. Her asthma attacks have been increasingly more severe and have been occurring at an increased frequency. She tells you that she is in a rush and all she needs is the prescription. The most appropriate next step is to
A. administer a pulmonary function test B. explain that propranolol is not a good drug for her C. give her a referral to a psychiatrist D. order a chest x-ray E. prescribe propranolol for her to take before her performances
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#1251
23.02.2007, 18:18
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Безусловно, В - объяснить пациентке, почему пропранолол - не просто неподходящее, но и опасное лекарство для нее.
И возможно, обсудить направление к психотерапевту - уже потом.
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#1252
23.02.2007, 23:10
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Слишком очевидно. Ответ В.
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#1254
24.02.2007, 02:49
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The correct answer is B. This patient most likely has performance anxiety, which is a form of social phobia. The treatment usually involves beta-blockers before a performance to decrease the symptoms. However, a patient with severe asthma should avoid beta-blockers because they can cause bronchoconstriction and precipitate into an asthmatic attack.
A pulmonary function test (choice A) and a chest x-ray (choice D) are not indicated at this time. You already know that she has asthma that has required hospitalizations and the results of these tests are unlikely to change your management. A referral to a psychiatrist (choice C) may be helpful in treating her performance anxiety, but she is in your office for propranolol, so it is your responsibility to first try to explain to her that her asthma makes her a bad candidate for this treatment. You should not prescribe propranolol for her to take before her performances (choice E) because she has severe asthma, which makes beta-blockers a dangerous medication for her. Beta-blockers can cause airway obstruction, which may lead to worsening asthma.
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#1255
24.02.2007, 02:50
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A 62-year-old man comes to the emergency department after passing approximately 500 milliliters of bright red blood per rectum in the toilet 2 hours earlier. His past medical history is significant for very severe emphysema requiring two partial lobectomies. The bleeding episode was painless and stopped spontaneously. His blood pressure is 110/80 mm Hg, pulse is 70/min, and respirations are 16/min. Laboratory studies show:
White blood cell count 13,000/mm3 Hct 24% Platelet 180,000/mm3 An abdominal CT scan reveals multiple diverticula in the descending colon. He is admitted for observation overnight and 2 units of packed red blood cells are transfused. Around midnight, the patient has another episode of bleeding. At this time his heat rate is 120/min and his blood pressure is 88/54 mm Hg . A 99Tc-labeled red blood cell scan reveals active bleeding in the sigmoid colon and the bleeding source is subsequently determined by angiography. Given the patient's presentation, the best intervention option at this time is A. colonoscopy and sclerosis of the bleeding site B. intraarterial embolization C. intraarterial vasopressin infusion D. medical management and supportive care E. partial colectomy and temporary colostomy
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#1256
24.02.2007, 06:29
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May be B.
C - is an option too, but as someone knows exact source of bleeding embolization would be better (the rate of rebleeding after vasopressin injection is too high). A - colonoscopy is contraindicated in acute diverticulitis (13 000 WBC means acute inflammation...).
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#1257
24.02.2007, 11:28
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В остром кровотечении при колоноскопии, полагаю, ничего не видно.
B - Если такое возможно?! Дивертикулэктомию с временной колоностомой если не поможет -В-
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#1258
24.02.2007, 14:16
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Цитата:
I'd particularly like C in the case of brisk diverticular bleed- can be done faster
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#1259
25.02.2007, 03:50
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This is a good candidate for embolisation. And to make things even easier he is ALREADY in the IR lab. Clearly B. If not would be VERY surprised.
DDAVP may stop the bleed, but will NOT control it for a long time. Surgery is not a viable option  - (still depends on the surgeon and intensivist I guess). In our joint patient would be in OR (after 10-15 L of water and 4-6 units of blood hanging from every available site) by the morning and hope for the best .
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#1260
25.02.2007, 05:27
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Discending colon gotta come out! It's a 45 min procedure with min blood loss.Post op analgesia is of paramount importance in a COPder, but this is a colon case, not a ruptured AAA, so nobody is expecting decaliters of infusion therapy and depletion of blood bank reserves.
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