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#241
26.07.2006, 20:12
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A 41-year-old woman comes to the office because of a 40-pound weight gain in the past 6 months. She is very upset because she has always been thin and never had to watch her diet before. She has no change in appetite, no change in eating habits, and has no other symptoms. She takes no medications, does not drink alcohol, and smokes a pack of cigarettes a day for the past 10 years. She rollerblades with her daughter every evening and tries to eat a well-balanced, low-fat diet. She denies anxiety and any psychiatric problems. She tells you that her mother and sister have always been overweight and they always complain about their "apple-shaped" bodies. Her temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and respirations are 16/min. Physical examination shows an obese abdomen and thin lower extremities, but is otherwise unremarkable. The most appropriate next step is to
A. determine thyroid stimulating hormone levels B. order a biochemical profile C. order a dexamethasone suppression test D. refer her to a nutritionist E. schedule a CT scan of the abdomen 
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#244
27.07.2006, 05:45
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Да, я чувствую себя полным идиотом. С выглядит хорошо, но смушает отсутствие гипертонии. Давайте для начала биохимию. В.Промажу еще раз!
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#246
27.07.2006, 11:44
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Bingo! Конечно биохимия!
The correct answer is B. The initial work-up for weight gain is a detailed history, including medication and drug use and recent smoking cessation, and a biochemical profile. A biochemical profile may indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes will most likely lead to an elevated glucose, while Cushing is sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis, hyperglycemia, and hypercholesterolemia. An individual with an "apple-shaped" body typically has a large abdomen and chest and thin legs. A "pear-shaped" body typically refers to a thin torso with larger hips, buttocks, and legs. This is included in the vignette to show that the patient's "obese abdomen" is consistent with her family's body type and is not necessarily associated with Cushings or any other conditions. Determining thyroid stimulating hormone levels (choice A) is appropriate in the evaluation of weight gain if there is a negative drug history, no recent smoking cessation, and a normal biochemical profile. Since hypothyroidism is part of the differential diagnosis for weight gain, you should consider it early in the work-up, but a biochemical profile should be performed first. A dexamethasone suppression test (choice C) is part of the initial evaluation of Cushing syndrome. You should first order a biochemical profile to determine if this diagnosis is more likely than diabetes mellitus. Referring her to a nutritionist (choice D) is inappropriate at this time. The case says that the patient has had weight gain with no change in appetite or eating habits. She requires evaluation for a medical condition, such as Cushing syndrome, diabetes mellitus, thyroid disease, (even though this is usually associated with a poor appetite), and fluid overload. A CT scan of the abdomen (choice E) may be used to visualize an adrenal mass leading to Cushing syndrome and weight gain. It may be ordered after a biochemical profile, dexamethasone suppression test, and plasma cortisol. This study is not appropriate at this time.
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#247
27.07.2006, 11:49
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A 56-year-old man with coronary artery disease comes to the clinic for follow up of a prostate specific antigen test (PSA). He was seen 3 weeks ago and a screening PSA level was drawn. The test result came back at 9.4 ng/mL and the patient returns to discuss this result. His medications are atenolol, pravastatin, enalapril, and aspirin. He denies any symptoms of urinary retention, hesitancy, pain on urination, and post-void dribbling. The most appropriate next step in management is to
A. arrange for a prostate biopsy B. follow up with the patient in 6 months and obtain a second PSA level C. inform the patient that he has benign prostatic hypertrophy D. inform the patient that he has prostate cancer E. reassure him that he does not have prostate cancer
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#248
27.07.2006, 12:13
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При уровне ПСА от 4 до 10, у 20-30% мужчин выявляют рак простаты. Для постановки диагноза необходима биопсия (где мой черный пистолет, биопсийный
 ) и трансректальное УЗИ. Сл-но, А.
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#249
27.07.2006, 12:28
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Цитата:
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#250
27.07.2006, 12:29
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Good!
The correct answer is A. Men have between a 15-20% lifetime risk of developing prostate cancer. The PSA test was introduced in the late 1980s and quantifies a glycoprotein produced by the prostate that spills over into the blood. Although current guidelines differ by society, clinical practice and standard of care is to test high risk men over the age of 40 years for PSA levels. Any level greater than 4.0 ng/mL requires a prostate biopsy. The positive and negative predictive values of the test vary tremendously with patient population, but roughly 30% of patients with elevated PSA levels will have prostate cancer. Although some physicians follow marginal elevations in PSA levels for a few months (choice B), this patient has a nearly 3-fold increase above that required for further workup (4.0ng/mL). Just as the PSA test has poor sensitivity, its specificity (false positives) is also variable, ranging from 80-97%. For this reason, elevations may not indicate the presence of cancer, but perhaps are due to benign prostatic hypertrophy (choice C). However, until the biopsy is performed, a determination as to the cause of the PSA elevation is not possible (choice D). As stated above, roughly 30% of patients with elevated PSA levels will have prostate cancer (the probability of prostate cancer given an elevated PSA is 30%). Since the incidence of false-negative results is approximately 30-50% (sensitivity), there is no possible way to determine that this patient is cancer free unless biopsies are taken (choice E).
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#251
27.07.2006, 12:32
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A 51-year-old woman who is admitted to the hospital for a third cycle of chemotherapy for non-Hodgkin's lymphoma (NHL) reports gradual development of blurry vision. Her past medical history is significant for NHL, which is widely metastatic to the neck, chest, and abdomen. Vital signs are normal. Physical examination reveals mild bilateral papilledema. Extraocular movements are intact bilaterally. The pupils are equal, round, and normally reactive to light. Vision is 20/200 bilaterally. Review of an eye examination performed 6 months ago reveals that vision was 20/40 bilaterally. The sinuses and ears are normal on examination. A neurologic examination is normal. Laboratory studies show:
Leukocyte 3200/mm3 Hct 39% Platelet 200,000/mm3 An MRI of the orbits demonstrates edematous extraocular muscles without fatty replacement. An MRI of the brain is normal. There is mild optic nerve edema bilaterally. The most important immediate next step is A. intravenous antibiotics B. intravenous heparin C. intravenous steroids D. orbital decompression surgery E. standard NHL chemotherapy
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#253
27.07.2006, 14:39
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C. But just a guess.
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#254
27.07.2006, 21:34
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The correct answer is C. This patient has clinical and MRI evidence of non-Hodgkin's lymphoma (NHL) metastatic to the extraocular muscles. This is causing secondary compression of the optic nerve which manifests as blurry vision. Immediate intravenous steroid administration is critical to reduce inflammation and relieve optic nerve pressure.
Antibiotics (choice A) are not necessary as there are no clinical signs of infection. Sinusitis and/or orbital cellulitis are common causes of unilateral optic nerve compression. This patient has clinical and MRI evidence of non-Hodgkin's lymphoma (NHL) metastatic to the extraocular muscles. This is causing secondary compression of the optic nerve. Immediate intravenous steroid administration is critical to reduce inflammation and relieve optic nerve pressure. Anticoagulation with heparin (choice B) is not necessary since her symptoms are not related to a stroke. Orbital decompression surgery (choice D) has no role in the treatment of this patient. Metastatic non-Hodgkin's lymphoma (NHL) is the primary cause of extraorbital muscle enlargement and secondary optic nerve decompression. Chemotherapy (choice E) should continue on an urgent basis. Intravenous steroid therapy is the most important immediate treatment to reduce inflammation and relieve optic nerve pressure.
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#255
27.07.2006, 21:35
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A 67-year-old man comes to the clinic with a new rash on his upper eyelids that he says he has had for a few months. He also reports to have experienced increasing weakness of his lower extremities, especially when he tries to stand up from a sitting position. He has hypertension, which is well controlled with amlodipine, and hypercholesterolemia controlled with diet and exercise, that he's no longer able to perform. He denies any recent weight loss. Physical examination reveals a well-nourished male with normal chest and lung exam. A diffuse, ill-defined, violaceous plaque is apparent on each upper eyelid. The oral mucosa is within normal limits. Notable on extremities are firm, violaceous plaques overlying the proximal and distal interphalangeal joints on the dorsum surface. There is no involvement of the space between joints on his hands. The general appearance of his hands resembles a mechanic's hands. He also has a poikiodermatous patch (hypopigmentation, hyperpigmentation, telangiectatic, and atrophy) involving the V of the neck as well as the upper back. Brief neurologic examination reveals proximal lower extremity weakness. The most appropriate management of this patient is to
A. determine the antinuclear antibody level B. determine anti-Rho and anti-La levels C. order a liver function test D. order a rheumatoid factor level E. search for an internal neoplasm
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