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#136
18.07.2006, 19:12
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A 40-year-old man comes to the office complaining of a 3-day history of midsternal chest pain, non-radiating that is worse with inspiration and relieved by sitting forward. He has no past medical history, is on no medications, does not smoke, and has no known drug allergies. He leads an active lifestyle, and had been running about 10 miles a week without problem until a week ago when he developed a “viral syndrome.” His temperature is 38.4 C (100 F), blood pressure is 130/70 mm Hg, pulse is 100/min and regular, and respiratory rate is 20/min. He has a high pitched, grating sound that can be auscultated throughout the cardiac cycle over his precordium. An electrocardiogram shows diffuse ST elevation, diffuse PR depression with PR elevation in lead aVR. The most likely diagnosis is
A. angina B. myocardial infarction C. pericarditis D. pneumonia E. pulmonary embolism 
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#139
18.07.2006, 22:12
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С, перикардит как в учебнике.
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#140
18.07.2006, 22:15
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The correct is answer is C. A chest pain that is pleuritic and improves with sitting up and leaning forward is a classic description of the chest pain associated with pericarditis, as is the precordial rub auscultated on physical exam. Diffuse ST elevations with diffuse PR depressions and PR elevation in lead aVR is also the classic description of the EKG findings associated with pericarditis.
Angina (choice A) or myocardial infarction (choice B) are less likely given that the patient has no risk for coronary artery disease (hypertension, hyperlipidemia, diabetes, tobacco). He also describes a very active lifestyle without symptoms, suggestive of no cardiac pathology prior to the onset of these symptoms. The ST changes on EKG, that alone would suggest ischemia, become more consistent with pericarditis since they are associated with PR segment changes that are classically associated with this particular disease process. Pneumonia (choice D) is unlikely since there is no history of cough or dyspnea, and there is no mention of findings on the chest exam consistent with such a process (e.g., findings suggesting a consolidative process such as decreased breath sounds, increased fremitus, and egophony over the affected area). Pulmonary embolism (choice E) is less likely, given that there are no apparent risk factors such as a history of hypercoagulability or poor activity. The EKG findings are also not consistent with a pulmonary embolism, where one would classically see an S wave in lead I, Q wave and T wave inversion in lead III, or ST-T wave changes in leads V1 through V4.
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#141
18.07.2006, 22:17
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A 43-year-old man with acquired immunodeficiency syndrome (AIDS) is in the hospital for pneumonia. On his second hospital day, he reports difficulty swallowing his meals. He says that for the last month he has had difficulty swallowing food and medications. He also occasionally feels a burning pain in his upper chest when swallowing. He denies abdominal pain, nausea, or vomiting. Vital signs are: 37.0 C (98.6 F), blood pressure 129/88 mm Hg, pulse 80/min. Examination of his mouth reveals pink oral mucosa and a normal tongue. He has no significant cervical lymphadenopathy. Abdominal examination is normal. The patient's last CD4 count was performed 5 months ago and at that time was 190/mm3. The most appropriate next step in the management of this patient is to
A. order esophagogastroduodenoscopy (EGD) B. order a Helicobacter pylori antibody test C. prescribe a trial of antacids and schedule a follow-up appointment D. prescribe oral acyclovir E. prescribe oral fluconazole
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#142
18.07.2006, 22:28
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A....., хотя есть рекомендации вначале на 3 суток назначить флуконазол, и только в отсутствии эффекта делать эндоскопию, то есть Е.
Отсутствие орофарингеального кандидоза делают диагноз кандидоза пищевода менее вероятным. Поэтому я бы начала бы с А+ биопсия.
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#145
20.07.2006, 17:21
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The correct answer is A. The symptoms of dysphagia and odynophagia in a patient with AIDS are highly suspicious for esophagitis. The causes of esophagitis in the setting of AIDS or other immunocompromised states include Candida albicans, cytomegalovirus (CMV), and herpes simplex virus (HSV). The most frequent cause is C. albicans, which accounts for 50-70% of all cases. Esophagogastroduodenoscopy (EGD) is the best way to diagnose the etiology of esophagitis by providing both direct visualization of the esophageal lesions and the ability to obtain biopsies. If the patient has oral thrush and symptoms of esophagitis, the most likely etiology is C. albicans and treatment with fluconazole can be initiated empirically. This patient, however, has normal oral mucosa and needs an EGD prior to treatment.
The Helicobacter pylori antibody test (choice B) is used to determine the etiology of gastric ulcers. This test is not indicated in this patient because he does not have symptoms of ulcer disease. The symptoms of dysphagia and odynophagia in a patient with AIDS are highly suspicious for a fungal or viral esophagitis. A trial of antacids (choice C) is inappropriate for this patient. The symptoms of dysphagia and odynophagia in a patient with AIDS are highly suspicious for fungal or viral esophagitis. Antacids are used primarily for gastroesophageal reflux disease and will not help in this case. A follow-up appointment is important, however, after the patient has an esophagogastroduodenoscopy (EGD) and is started on appropriate medications. Treatment with acyclovir (choice D) is premature at this time. There are multiple causes of esophagitis in patients with AIDS and an esophagogastroduodenoscopy (EGD) should be performed to evaluate the esophageal lesions as well as to obtain biopsies. If the esophagitis is caused by herpes simplex virus (HSV), acyclovir is the anti-viral medication of choice. Treatment with fluconazole (choice E) is premature at this time. There are multiple causes of esophagitis in patients with AIDS and esophagogastroduodenoscopy (EGD) should be performed to evaluate the esophageal lesions as well as to obtain biopsies. If the esophagitis is caused by Candida albicans, fluconazole is the anti-fungal medication of choice.
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#146
20.07.2006, 17:22
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A 45-year-old man who is admitted to the hospital for alcohol detoxification develops a bloody emesis on hospital day 3. Over the past hour there has been approximately 500 cc of bloody emesis. The patient has a history of alcoholism and hepatitis C. Vital signs are: temperature 37 C (98.6 F), blood pressure 100/80 mm Hg, pulse 122/min, and respirations 9/min. The patient is oriented and answers questions normally. Physical examination reveals a thin, jaundiced man in a mildly lethargic state. He has mild ascites, a caput medusa, and lower extremity edema. The most urgent clinical issue that should be addressed is
A. cirrhosis B. delirium tremens C. esophageal carcinoma D. gastric carcinoma E. portal vein thrombosis F. variceal hemorrhage
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