Еще одна пилюлька Hескучина

[Anna_Shvedova]

B
But I have some doubts because his current medication is not adequate. If he has angina pectoris, he should take another medications (at least, not only nitrate).
So maybe A and review of diagnosis and administrations?

[yananshs]

The correct answer is B. Erectile dysfunction (ED) is a very common problem. The evaluation typically includes a detailed history and physical examination, serum testosterone and prolactin levels, and a medication review. This patient's evaluation is unremarkable. He is specifically asking for a prescription for sildenafil, but it is contraindicated in patients taking any medications that contain nitrates because the combination can lead to life-threatening hypotension, a heart attack, or stroke. This should be explained to him and other options should be considered. Sex therapy and/or a vacuum device (that draws blood into the penis) should be offered.

Since this patient is taking isosorbide mononitrate for angina, which can be a serious problem, he should not be advised to discontinue it (choice A). Also, this agent is not typically associated with ED. Some cardiovascular drugs that have been associated with ED are thiazides, spironolactone, calcium channel blocks, methyldopa, beta blockers, clonidine, and digoxin.

Since this patient takes a nitrate medication, it is incorrect to prescribe sildenafil citrate tablets for him to take an hour before sexual activity (choice C). Sildenafil is contraindicated in patients taking nitrates.

Since there are other less invasive options for this patient to try, it is inappropriate to recommend implantation of an inflatable prosthesis (choice D) at this time. Sex therapy and a vacuum device should be offered.

It is incorrect to tell him that his erectile dysfunction is psychogenic (choice E) because a full evaluation was not performed. Nocturnal penile tumescence testing, vascular testing, neurologic testing, and psychological testing can help determine the exact cause. All of these tests are not usually necessary because they may be expensive and invasive.

[yananshs]

A 42-year-old man with a history of alcoholism comes to the clinic because of a "swollen tongue." He feels as if his tongue is taking up more room in his mouth and it is sometimes mildly painful. He drinks a half a bottle of vodka per night and smokes a pack of cigarettes per day. He denies intravenous drug use and has never had a sexually transmitted disease. He laughs when you ask him about his sexual activity, stating that he "hasn't had sex in ages." Physical examination shows a slightly enlarged, smooth pale tongue with a loss of filiform papillae. The remainder of his examination is unremarkable. Laboratory studies show:

Hg :12 g/dl
Hct : 37 %
MCV ; 105 mm3


The most appropriate next step is to
A. advise him to decrease his alcohol consumption and perform no further studies
B. determine vitamin B12 level
C. perform a brush biopsy of the tongue for cytologic evaluation
D. prescribe fluconazole, orally
E. refer him to a surgeon for an incisional biopsy

[papadoctor]

If this is amyloidosis - E. But I forgot everything already.

[yananshs]

Сообщение от Anna_Shvedova

B
But I have some doubts because his current medication is not adequate. If he has angina pectoris, he should take another medications (at least, not only nitrate).
So maybe A and review of diagnosis and administrations?

Да, наверное, если бы в варианте А было бы написано не только отменить препарат, а и пересмотреть терапию.

[yananshs]

Сообщение от papadoctor

If this is amyloidosis - E. But I forgot everything already.

Да, давно вы, Виктор, не лечили алкоголиков.

[Tim Vetrov]

B

Я бы и B12, и другие витамины назначил (B1, B6).
И посоветовал бы прекратить пить.

[Psychiatr]

B....

[yananshs]

The correct answer is B. This patient has glossitis, which is most likely due to anemia. He is an alcoholic with a macrocytic anemia (decreased hemoglobin, hematocrit and an elevated MCV), and therefore, vitamin B12 levels should be determined. It is very likely that he has a vitamin B12 deficiency.

While it is always appropriate to advise him to decrease his alcohol consumption, you need to determine his vitamin B12 levels, so performing no further studies (choice A) is incorrect. If he is vitamin B12 deficient, vitamin replacement is indicated.

A brush biopsy of the tongue for cytologic evaluation (choice C) and an incisional biopsy (choice E) are usually performed to evaluate a lesion for malignancy. This patient has a generalized glossitis without a specific lesion.

Fluconazole (choice D) is prescribed for candidiasis, which typically presents with a white coating on the tongue. This patient's physical findings are inconsistent with this diagnosis.

[yananshs]

A 29-year-old attractive married woman has been calling your office several times in the past week. Her physician is out of town, and you, as his younger colleague, are covering in his absence. She has called twice at the end of office hours complaining of vague symptoms. She also appeared in the office without an appointment, insisting she needed a physical examination, because she has a new lump on her breast. You provided the examination in the presence of a female nurse as a chaperone and found nothing. A review of her previous medical records shows no significant medical problems. She appears again after several days at the office demanding to be seen, just after all of the office staff has left. She tells you that she has established trust in you and admires your patience to listen to people's problems. She shares that she had never experienced that with your colleague and questions if she could switch providers. The most appropriate intervention at this time is to
A. bring her into the office and call her husband letting him know about her need for understanding
B. point out that she is only attention-seeking and there is nothing wrong with her
C. reassure her calmly that she will be seen at the next appointment given during office hours
D. refuse to talk to her and tell her that you are going to call security to escort her out
E. see her since she has shown up, even though it is after normal office hours

[Tim Vetrov]

Все-таки E.
Хотя подмывает сделать B и даже D.

[papadoctor]

Молодая симпатичная женщина завсегда приятнее алкоголика с макроглоссией, хотя намного более опаснее. Я видел этот вопрос несколько раз в различных плоскостях и знаю нескольких врачей, чьи карьеры были очень подпорчены, поскольку они не совсем правильно себя вели в подобных ситуациях.

[Psychiatr]

B....
И потом мягонько, мягонько... направить к психиатру/психотерапевту.
Согласен с пападоктором, лучше алкоголик с макроглоссией...

[papadoctor]

Раз в году и палка стреляет!! А если там действительно опухоль? Даму нужно посмотреть, но посмотреть в урочные часы, т.к. неотложного в её состоянии нечего нет. С шепароном разумеется. Только потом делать выводы.

[yananshs]

The correct answer is C. Any patient is entitled to a thorough medical evaluation. However, they should be respectful of boundaries. Patients should be seen when others are present in the office to avoid potential conflicts and accusations, especially because these patients tend to be manipulative.

Staying alone with the seductive patient in the office (choice A) and calling her husband, are not appropriate interventions. They are not aimed at helping the patient, and may cause more damage to both parties.

Pointing out attention-seeking behavior (choice B) even though it may be true, is not an appropriate intervention. In order to change it, the patient needs to understand the origins of such needs.

Refusing to talk to her (choice D) is unacceptable and unethical. Even if this is only attention-seeking behavior, it indicates the presence of a certain pathology, and needs to be addressed appropriately. Security should be called though if the patient still adamantly refuses to leave after a calm and direct suggestion to schedule an appointment during office hours or go to the emergency room if there is anything urgent.

After hours consultations (choice E) are not appropriate. This patient crossed the boundaries several times and most probably will take advantage of such a situation. In a case of emergency, a referral to the emergency room should be made and the physicians there should be contacted.