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#736
10.09.2006, 05:46
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Это болезнь Кавасаки.
B. Influenza vaccination is necessary if this patient requires long-term salicylate therapy. Это теоретически должно защитить от синдрома Рэя. 
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#737
11.09.2006, 05:16
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The correct answer is B. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gamma globulin. The disease is characterized by a high fever for longer than 5 days, bilateral conjunctival injection, fissured lips, a "strawberry tongue", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gamma globulin. An echocardiogram is necessary to evaluate cardiac involvement. The influenza vaccine is necessary if this patient requires long-term salicylate therapy because of the possible increased risk of Reye syndrome. Reye syndrome may develop in patients with influenza who receive salicylates.
Corticosteroids are necessary to decrease the risk of aneurysms within 10 days of the onset of fever (choice A) is incorrect. Initially, intravenous gamma globulin and aspirin are routinely used to decrease the risk of aneurysms in patients with Kawasaki disease. Some believe that steroids should be used later if therapy with intravenous gamma globulin and aspirin is unsuccessful. But steroids are not necessary to decrease the risk of aneurysms. MMR vaccination should be given within a month if this patient receives intravenous gamma globulin (choice C) is incorrect. MMR vaccination should be given 11 months after treatment with intravenous gamma globulin. It should not be given sooner because intravenous gamma globulin interferes with the serologic response to the measles vaccine. If there is a high risk that this child will be exposed to measles, which is unlikely in the United States, immunization should be given, and if at 11 months serologic testing indicates that the earlier immunization was unsuccessful, she should be re-immunized. It is incorrect to say that nasopharyngeal cultures will help to establish the diagnosis (choice D) because no single study can diagnose Kawasaki disease. The exact cause of this disease is unknown. There is a 40% risk of death associated with her disease (choice E) is incorrect. In the United States, the mortality rate due to Kawasaki disease is 0.05%. Death is usually due to a myocardial infarction or ruptured coronary aneurysm.
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#738
11.09.2006, 05:16
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A 32-year-old medical student is brought to the emergency department from the operating room after he "fainted". This was going to be his first time "scrubbing in" to a case on the first day of his surgery rotation. Another medical student who was "scrubbed in" to the case, tells you that the he was standing next to the student when "all of a sudden he collapsed." He is now on a stretcher and appears fine. He tells you that he is not sure what happened, all he remembers is that he was looking forward to seeing a liver transplant and then he "woke up" on a stretcher. He is brought into a room and all of his clothes are taken off, revealing erythematous plaques with a mica-like scale on his elbows, knees, and lower back. His blood pressure is 100/70 mm Hg, pulse is 60/min, and respirations are 15/min. His physical examination is otherwise unremarkable. The student says that this is the second day of their third year, and that the only other patient contact that they have had was during the first year when they went as a group to evaluate a patient in respiratory isolation. At this time the most correct statement about his condition is:
A. He should be admitted for 24-hour electrocardiographic monitoring B. He should have an electroencephalogram C. He should undergo tilt-table testing D. His symptoms are the result of bioactive mediators released when exposed to an antigen E. It is unlikely that the rash is related to his loss of consciousness
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#739
11.09.2006, 05:43
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Высыпания, обусловленные псориазом, не имеют отношения к обмороку в операционной.
E. It is unlikely that the rash is related to his loss of consciousness
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#741
11.09.2006, 15:26
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The correct answer is E. This patient most likely had an episode of neurocardiogenic syncope and also has psoriasis (the rash), and therefore it is unlikely that the rash is related to his loss of consciousness. Anxiety and stress from the first surgical experience probably caused this episode of neurocardiogenic (also called vasodepressor or vasovagal) syncope, which is the cause of the common "faint". It frequently occurs during periods of stress or fear and often occurs in medical students during new experiences. It is caused by peripheral venous pooling, decreased venous return, a decreased left ventricular volume, increased cardiac contractility, parasympathetic activation, inappropriate peripheral vasodilation, and bradycardia. The symptoms include hypotension, bradycardia, nausea, pallor, diaphoresis, and a sudden, transient loss of consciousness. Lying down and elevating the legs reverses the symptoms. An electrocardiogram may be performed to rule out an arrhythmia, however the history is consistent with vasovagal syncope.
24-hour electrocardiographic monitoring (choice A) is appropriate if a cardiac arrhythmia is suspected, however an electrocardiogram should be done first. However, this history is consistent with vasovagal syncope, and therefore does not require admission and monitoring. An electroencephalogram (choice B) may be appropriate if a seizure is suspected, however, this patient's history is consistent with vasovagal syncope, and therefore does not require an EEG. A tilt-table test (choice C) is used in patients with recurrent unexplained episodes of vasovagal syncope. This patient's anxiety and stress is a perfect explanation for this single episode and therefore does not require tilt testing at this time. It is unlikely that this patient symptoms are the result of bioactive mediators released when exposed to an antigen (choice D). This would be the case if he developed respiratory distress, urticaria, and angioedema within seconds to minutes of exposure to an antigen (the latex gloves). This would be the description for anaphylaxis and other manifestations including vascular collapse, gastrointestinal symptoms, and shock. The reaction involves IgE-dependent activation of mast cells, basophils and the release of mediators such as histamine, cytokines, and lipid mediators. The immediate treatment includes the ABCs (intubation, oxygen, and intravenous saline), epinephrine, a vasopressor agent such as dopamine, an antihistamine such as diphenhydramine, and glucocorticoids to alleviate later recurrence of symptoms. This patient does not have respiratory symptoms.
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#742
11.09.2006, 15:27
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You are called to meet with a patient's family on the oncology floor. The patient is a 60-year-old Caucasian man who is on the board of trustees of the hospital where you are employed. His family describes the patient as an extremely controlling and arrogant, yet emotionally vulnerable person. The results of a recent metastatic work up indicate that the patient has disseminated colon cancer and he has been told that the chances for 'cure' of his cancer are 1-5%. The patient's family requests that, even if the patient asks, he not be told of the results of his testing as it will only "depress him". On the patient's previous mental status examination, he is found to be fully oriented, meticulously groomed, and well related. His attitude is noted to be dismissive; he frequently asks why you are assessing him without a surgeon present and writes down your name for credentials verification. There is no evidence of any psychotic process, and the patient laughs when asked about depressive symptoms or suicidal ideation. During his hospital course, he has frequently asked that he be kept fully informed of all pertinent details of his medical testing. The most appropriate response to give to the patient's family regarding their request would be that you
A. are going to comply with the patient's wishes given his rights as a competent person with self determination of care B. feel that, given the patient's personality, chemotherapy should be initiated promptly with the family consenting in lieu of the patient C. recognize the personality traits described by the family in your interaction with the patient and will comply with their request D. will begin a titration of antidepressant medication for approximately 1 week prior to revealing the patient's prognosis to him E. will discharge the patient imminently given that nothing acute needs to be done and you will let the patient's family divulge whatever they feel is appropriate
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#743
11.09.2006, 15:59
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>>A<<
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#747
11.09.2006, 19:33
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The correct answer is A. The patient described does have personality traits that suggest a possible narcissistic personality disorder. He is extremely haughty during interaction with someone he feels does not have sufficient training to take care of a man of his importance, is described as arrogant by his family, and seems to make demands for special treatment while hospitalized. However, the patient clearly demonstrates an ability to participate in decisions pertaining to his health. He is not psychotic, nor gives any evidence of dementing illness or severe depression. Therefore, if his request is to know exact details about his diagnosis and prognosis, then that wish must be honored.
Telling them that you feel that, given the patient's personality, chemotherapy should be initiated promptly with the family consenting in lieu of the patient (choice B) is also incorrect due to the patient's competence and rights to decide appropriate treatment for himself. Telling them that you recognize the personality traits described by the family in your interaction with the patient and will comply with their request (choice C) is incorrect due to the fact that the patient is competent and should therefore be allowed to know his diagnosis, treatment options, and prognosis. Telling them that you will begin a titration of antidepressant medication for approximately 1 week prior to revealing the patient's prognosis to him (choice D) is incorrect for two primary reasons. The first is the patient's obvious competence. The second is that the patient does not appear to be clinically depressed, and even if he were, the patient has the right to decide whether he receives pharmacologic treatment for depression. Telling them that you will discharge the patient imminently given that nothing acute needs to be done and you will let the patient's family divulge whatever they feel is appropriate (choice E) is incorrect due to the fact that the patient is competent and has asked that his condition be explained to him in detail by a medical professional.
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#748
11.09.2006, 19:35
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You are in the emergency department evaluating a 78-year-old woman with atrial fibrillation who woke up today feeling slightly nauseated. This quickly passed and she ate breakfast and later in the day felt wobbly in her left leg, as if she could not hold herself up. Her calf in particular felt very ⌠sloppy and weak■. This weakness lasted for about 10 minutes and she immediately came to the hospital. About 2 1/2 weeks ago, while on vacation, she went to a hospital because of a severe pain in the back of her neck. She tells you that, "they did an MRI, which showed a blood clot." She was told to stop taking her warfarin and sent home with ibuprofen for the neck pain. Over the past few weeks she has had tingling in her left leg, which would come and go and last for about 4-5 hours at a time. She also has had times when she felt very disoriented and was unable to sign her name on checks. Physical examination at this time is normal, except for a slight left pronator drift. Cell counts, chemistries, and coagulation studies are normal. The most appropriate next step is to
A. immediately load her with intravenous phenytoin B. order a carotid ultrasound study C. order a CT scan of the head D. order an electroencephalogram E. tell her that everything looks good and send her home
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#749
11.09.2006, 19:37
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Цитата:
PS. Ooops!I didn't see that the answer is already posted.
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#750
11.09.2006, 19:43
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We have a patient with A.fib and coumadin was discontinued. Too simple.
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Линейный вид
