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#827
22.09.2006, 17:53
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The correct answer is D. This patient has developed a tension pneumothorax, which is an emergency that requires immediate intervention with a needle on the side of the pneumothorax. He presented with a spontaneous pneumothorax, that progressed to a tension pneumothorax, and decompression to relieve the increased intrathoracic pressure is the first step in management. Young, thin men are at an increased risk for developing a spontaneous pneumothorax, and the exact cause is unknown.
Blood gases (choice A) are not the most important next step in management of this case. He requires a needle into the left 2nd intercostal space, which is a life-saving intervention in a patient with a tension pneumothorax. Blood gases may be drawn later on, after the needle and then the chest tube are inserted. Endotracheal intubation (choice B) is the treatment for a flail chest, which presents with paradoxical chest wall motion, splinting, and crepitus of rib fragments. The patient in this case has a tension pneumothorax, not a flail chest. A chest tube (choice C) is inserted after the needle is placed into the left 2nd intercostal space. By the time all of the required chest tube equipment is put together, a patient with a tension pneumothorax may die. Therefore, a needle insertion is the quickest life-saving procedure for this patient. A chest x-ray (choice E) is not required to make the diagnosis of a tension pneumothorax. The diagnosis is clinical and a chest x-ray will only waste precious time. 
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#828
22.09.2006, 17:53
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An 18-year-old girl comes to the clinic because of a 3-day history of vaginal discharge. The discharge is malodorous and has a greenish-yellow color. She admits to sexual intercourse with a "random guy at a fraternity party" 5 days earlier. Physical examination shows a malodorous, purulent vaginal discharge. Complete physical and pelvic examinations are unremarkable. A Gram stain of the discharge shows Gram-negative diplococci within polymorphonuclear leukocytes. Culture on a chocolate agar confirms the diagnosis. The most appropriate next step is to
A. admit her to the hospital for intravenous therapy with cefotetan B. contact the board of health to report a case of gonorrhea C. contact the "random guy at a fraternity party" and provide treatment and counseling D. give her a single dose of ceftriaxone, intramuscularly and a single dose of azithromycin, orally E. prescribe metronidazole for this patient and her sexual partner
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#829
22.09.2006, 20:27
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Гонорея. The most appropriate next step для пациентки это:
D. give her a single dose of ceftriaxone, intramuscularly and a single dose of azithromycin, orally Сообщить куда следует, и разобраться с заразившим её парнем, можно позже.
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#830
25.09.2006, 16:33
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The correct answer is D. This patient has a gonococcal infection and should be treated with a single dose of ceftriaxone, intramuscularly and a single dose of azithromycin, orally. The ceftriaxone treats the gonococcal infection and the azithromycin is added for the presumptive treatment of Chlamydia trachomatis. This is because many patients have co-existing infections. After treating the patient, this case should be reported to the board of health because gonorrhea is a notifiable infectious disease. Sexual contacts should be treated and counseled.
It is unnecessary to admit her to the hospital for intravenous therapy with cefotetan (choice A). This is part of the treatment of pelvic inflammatory disease, which is a disease of the upper genital tract. Patients often have cervical motion tenderness, lower abdominal tenderness, and adnexal tenderness, fever, cervical discharge, and laboratory documentation of N. Gonorrhea and/or C. trachomatis. These patients are treated with a cephalosporin for gonorrhea and doxycycline for chlamydia. This patient seems to have an uncomplicated gonococcal infection that can be treated as an outpatient. Since gonorrhea is a notifiable disease, it is necessary to contact the board of health to report a case of gonorrhea (choice B) after treating the patient with the appropriate antibiotics. The "random guy at a fraternity party" should be contacted to provide treatment and counseling (choice C) after treating the patient with the appropriate antibiotics. It is incorrect to prescribe metronidazole for this patient and her sexual partner (choice E) because this is the treatment for Trichomonas vaginalis, not gonorrhea. Trichomonas vaginalis often presents with a frothy vaginal discharge. A wet mount shows motile flagellated organisms. Gram-negative diplococci within polymorphonuclear leukocytes are not found in this infection.
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#831
26.09.2006, 06:12
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A 24-year-old woman comes to the office complaining of 2 days of intermittent severe right lower quadrant pain. Initially, she was able to continue her work as a waitress, but now is afraid that another "bout of pain" will occur while she is at work. She feels a "heaviness" in her lower abdomen and has low-grade pain all the time. A few times a day the pain becomes severe in the right lower quadrant and then she may vomit. She has had no fever or chills, but has had a poor appetite secondary to the waves of nausea occurring when the pain became severe. She is otherwise healthy and has never been hospitalized or had surgery. She has never been sexually active and is not using any form of contraception. The patient also relates that she was evaluated in the emergency department last night, "although the pain became much better by the time I got to the hospital." She presents a piece of paper with laboratory values and urinary tests from her visit: hematocrit 39%, white blood cell count 11,400/mm3, platelet count 367,000/mm3, sodium 138 mEq/L, potassium 4.0 mEq/L, creatinine 1.0 mg/dL, SGOT 18 U/L, and SGPT 22 U/L. A urinalysis was negative for leukocyte esterase, nitrite, and red or white blood cells. A urine pregnancy test was negative. No diagnostic studies were performed in the emergency department. Her temperature is 37.5 C (99.5 F), blood pressure 130/70 mm Hg, pulse is 100/min, and respirations are 20/min. On physical examination, there is most likely to be
A. abdominal rebound tenderness and guarding B. an adnexal mass C. isolated tenderness at McBurney point D. normal pelvic exam E. vaginal bleeding
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#832
26.09.2006, 06:51
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Подозрение на аппендицит. При этом может быть болезненность в McBurney's point и abdominal rebound tenderness and guarding.
Следовательно, правильный ответ: D. normal pelvic exam
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#834
26.09.2006, 22:24
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A. abdominal rebound tenderness and guarding
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#837
26.09.2006, 22:37
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Цитата:
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#839
26.09.2006, 22:40
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>>B<<.
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#840
26.09.2006, 22:44
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Цитата:
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Линейный вид
