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#289
31.07.2006, 20:20
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Цитата:
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#290
31.07.2006, 21:39
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The correct answer is E. This presentation is concerning for venous sinus thrombosis. MRV is the best noninvasive test to confirm this diagnosis. If the MRI/MRV is negative, then she should have a lumbar puncture to rule out idiopathic intracranial hypertension (pseudotumor cerebri).
Intravenous heparin (choice A) is the usual treatment for a venous sinus thrombosis, however, the diagnosis should be confirmed first if possible. Therefore, a brain MRI and MRV is the most appropriate next step in management. A neurosurgical consult (choice B) is not indicated in this case. Naratriptan (choice C) is used for the acute treatment of migraine headaches. This is atypical for a migraine, but she should be further evaluated before she is discharged and treated. Soft cervical collar and metaxalone (choice D) are used to treat headaches from cervical muscle spasms. There was no neck muscle spasms noted on exam, and she should be further evaluated before she is discharged.
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#291
31.07.2006, 21:42
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A 28-year-old woman comes to the office because of a 3-hour history of severe nausea, vomiting, abdominal cramps, and diarrhea. She ate lettuce with salad dressing, custard, and pastries and drank stream water at a family picnic at a local park 2 hours before the onset of the symptoms. She is unsure whether anyone got sick. She was "absolutely fine" before she went to the picnic. She does not take any medications. Her temperature is 36.7 C (98.0 F), blood pressure is 110/70 mm Hg, pulse is 65/min, and respirations are 14/min. Physical examination shows mild abdominal tenderness. A stool sample shows large numbers of Gram-positive cocci in clusters. At this time the most correct statement about her condition is:
A. An antibiotic is indicated to treat her infection B. Colonoscopy will show pseudomembranes and friable mucosa C. Contaminated stream water at the picnic caused these symptoms D. Her symptoms are due to an enterotoxin produced by the organism E. It is unlikely that the organism was transmitted from an individual with purulent lesions on the hands, nose, and face
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#293
31.07.2006, 22:45
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Вот здесь я почти на 100% уверен, что ответил правильно!
Диагноз: Стафилококковый гастроэнтерит, обусловленный энтеротоксином Staphylococcus aureus. Антибиотик не нужен. Колоноскопической картины псевдомембранозного колита не будет. Вода не виновата. Через руки передается другой стафилококк (methicillin-resistant Staphylococcus aureus ). Остается правильный ответ: D. Her symptoms are due to an enterotoxin produced by the organism
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#294
31.07.2006, 23:58
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Е. Короткий (2 часа) латентный период действительно свидетельствует о экзотоксине как причине заболевания, следовательно, показаний к назначению антибиотиков нет, несмотря на наличие кокков в материале;
Для псевдомембранозного колита отсутствуют указания на предшествовавшую а/б терапию, нехарактерно и острое начало, явная связь с пикником; Загрязнённая вода - не причина из-за краткости латентного периода для развития инфекции; Энтеротоксины, продуцируемые собственной кишечной флорой - нет видимой причины; Стафилококковый экзотоксин, который содержался в заварном креме, явился причиной заболевания, контаминация стафилококком от больного или носителя действительно маловероятна. Кстати, метициллин-резистентный стафилококк, если и передаётся контактным путём, то через руки хирурга, реаниматолога или акушера. У остальных вероятность носительства антибиотикоустойчивого патогенного микроба гораздо ниже.
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#295
01.08.2006, 05:46
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Причиной заболевания является не стафилококк, попавший в организм, а его энтеротоксин, накопившийся в заварном креме. most correct statement about her condition – причина состояния – токсин, и это важно в плане лечения, именно из-за этого антибиотик не поможет. По этому я думаю, что лучший ответ - D.
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#296
01.08.2006, 15:57
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The correct answer is D. This patient most likely has staphylococcal food poisoning, which typically presents with nausea, vomiting, abdominal cramps, and diarrhea within hours of consuming the contaminated food. The contaminated foods have usually come into contact with food handlers or contaminated preparation equipment. These food handlers are infected carriers who may have abscesses, boils, and purulent lesions on their bodies. The staphylococcal infection is usually due to an enterotoxin producing Staphylococcus aureus strain. Large amounts of S. aureus are found in the vomitus and the stool of infected patients. The treatment is supportive. Antimicrobials are not indicated.
Even though this patient most likely has staphylococcal food poisoning, an antibiotic is NOT indicated to treat her infection (choice A). This condition is usually self-limited. Colonoscopy will show pseudomembranes and friable mucosa (choice B) in pseudomembranous colitis, which is usually associated with Clostridium difficile infection. C. difficile typically occurs in patients taking antibiotics and usually presents with fever and large amounts of watery diarrhea. If this patient had giardiasis, contaminated stream water at the picnic would have caused these symptoms (choice C). However the incubation period for this patient's symptoms was hours and is therefore more consistent with staphylococcal food poisoning than with giardiasis. Giardiasis typically has an incubation period of days to weeks. It is unlikely that the organism was transmitted from an individual with purulent lesions on the hands, nose, and face (choice E) is incorrect. This patient most likely has staphylococcal food poisoning, which is often associated with food handlers that have abscesses, boils, and purulent lesions on their bodies.
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#297
01.08.2006, 16:00
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55-year-old woman is brought to the emergency department by her daughter because of left lower quadrant abdominal pain, anorexia, fever, and chills for the past 24 hours. Her temperature is 38.7 C (101.6 F), pulse is 110/min, and respirations are 18/min. She is awake and alert, although she appears uncomfortable. Examination shows hypoactive bowel sounds and a soft abdomen with mild voluntary guarding especially in the left lower quadrant. Digital rectal examination is significant for heme-positive stool. An electrocardiogram shows a sinus tachycardia at 110 beats per minute. There are no ST segment changes when compared with old electrocardiograms. A chest x-ray shows no acute disease. Abdominal x-ray demonstrates no air under the diaphragm and no ileus. A complete blood count, biochemical profile, cardiac enzymes, amylase, and lipase are drawn, but results are not yet available. The most appropriate initial management of this patient is to
A. admit for intravenous antibiotics, nil per os diet, and abdominal CT scan B. discharge to home on a clear liquid diet and PO antibiotics C. immediately refer to a gastroenterologist for colonoscopy D. prepare the patient for immediate surgical exploration E. send patient for urgent cardiac catheterization
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#299
01.08.2006, 17:42
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По клинике можно предполагать дивертикулит. Но настораживает - Digital rectal examination is significant for heme-positive stool. Нужно срочно установить место кровотечения.
Ответ - C. immediately refer to a gastroenterologist for colonoscopy
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Линейный вид
