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#529
17.08.2006, 00:47
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Диагностика основывается на выявлении краевой перфорации барабанной перепонки, холестеатомных масс белого цвета и выделений с гнилостным запахом. При отоскопии нередко трудно осмотреть барабанную перепонку из-за резкого сужения наружного слухового прохода обтурирующим полипом или за счет провисания задневерхней стенки, что обусловлено распространением холестеатомы под надкостницу с отслойкой инфильтрированной кожи в костном, а иногда перепончато-хрящевом отделе наружного слухового прохода.
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#530
17.08.2006, 15:13
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The correct answer is B. The condition described in this girl is a cholesteatoma. A cholesteatoma occurs when the middle ear is lined with stratified squamous epithelium. The squamous epithelium desquamates in a closed space, which cannot be cleared and hence accumulates serving as a culture medium for the organisms. Cholesteatomas have the ability to destroy bone, including ossicles. Those arising in association with a perforation in the pars flaccida are called primary acquired cholesteatoma, while those arising in association with marginal perforations are called secondary acquired cholesteatoma. The presence of cholesteatoma greatly increases the probability of the development of serious complications, such as purulent labyrinthitis, facial paralysis, or intracranial suppurations like meningitis, brain abscess, subdural empyema, or epidural abscess. They are usually recognized by the small bits of amorphous white debris in the middle ear, and by the destruction of the bone of the external auditory canal superior to the perforation. A CT scan of the temporal bone is helpful in determining destruction of the bone. Cholesteatoma requires surgical treatment. The primary goal of the operation is to make the ear safe and the secondary goal is to maintain, or improve the hearing. The objective of the therapy is to remove the cholesteatoma or exteriorize it. A mastoidectomy, sparing the tympanic membrane, is the appropriate form of therapy for a cholesteatoma. In a radical mastoidectomy, the middle ear including the attic, the antrum, and the mastoid antrum are converted into one cavity that is in communication to the exterior, through the ear canal. The modified radical mastoidectomy spares the tympanic membrane remnants and ossicles to preserve the hearing.
Antibiotic eardrops and decongestants are not sufficient forms of therapy in treating a cholesteatoma (choice A). Delay in the treatment without a mastoidectomy, usually results in the progression of the disease. Oral antibiotics (choice C) are not a sufficient form of therapy in treating a cholesteatoma. Although after a mastoidectomy, this condition can be treated with antibiotics, initially surgical treatment is the option. Reassurance and follow-up in 3 weeks to see if the perforation closes spontaneously (choice D) is not optimal treatment. Cholesteatoma usually progresses, with the destruction of the bone and becomes a culture medium for the bacteria, unless a surgical debridement is carried out. Tympanoplasty (choice E) is not a safe option, as this will not treat the primary pathology in a cholesteatoma.
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#531
17.08.2006, 15:14
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A 15-year-old boy who has been HIV-positive since birth is admitted to the hospital because of severe lower back pain. He denies a history of trauma and “has no idea how this started". His temperature is 37 C (98.6 F), blood pressure is 140/70 mm Hg, pulse is 100/min, and respirations are 19/min. Physical examination shows point tenderness of L4 and L5 posteriorly. A neurologic examination is otherwise unremarkable and there is a normal gait. Laboratory studies show a leukocyte count of 15,000/mm3 . An MRI of the lumbar spine reveals inflammation of the L4 and L5 vertebral bodies and the L4-5 intervertebral disc. There is a focal fluid collection in the L4-5 disc space. There is no cord compromise or abscess. The next step, after initiating broad-spectrum antibiotic therapy is to
A. aspirate the L4-5 disc space under fluoroscopic guidance B. prepare him for an exploratory laminectomy and decompression C. order lower extremity nerve conduction studies D. send him for a non-contrast head CT E. send STAT blood cultures
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#535
17.08.2006, 22:32
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Цитата:
Именно для того чтобы установить этиологию заболевания нужно A. aspirate the L4-5 disc space under fluoroscopic guidance.
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#537
18.08.2006, 10:48
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Цитата:
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#539
18.08.2006, 20:33
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The correct answer is A. This patient has symptoms and imaging findings consistent with L4-5 discitis. Given the immunocompromised status of the patient, a wide variety of organisms are likely pathogens. In this case, hematogenous spread to the disc space is likely. It is essential to begin immediate broad-spectrum antibiotic therapy and obtain tissue in an attempt to isolate an organism. Systemic blood cultures will certainly be drawn, but they are low yield. Tissue must be obtained under imaging guidance to isolate an organism and narrow antibiotic coverage.
Exploratory laminectomy and decompression (choice B) would be necessary only in the setting of an abscess that compromises the spinal cord. A repeat MRI should be performed if symptoms of cord compression develop. Lower extremity nerve conduction studies (choice C) are used in the setting of suspected peripheral neuropathy. The physical exam is normal in this case, so there is no indication of spinal cord compression at this time. Non-contrast head CT (choice D) is necessary prior to lumbar puncture to exclude a cause of increased intracranial pressure that could lead to herniation during or after a lumbar puncture. A lumbar puncture is not necessary here given the lack of neurologic and MRI findings of cord compromise. Blood cultures (choice E) must be drawn, but they are unlikely to be positive given the lack of fever. Obtaining tissue for staining and culture, at the infected site, is paramount.
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#540
18.08.2006, 20:34
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A 63-year-old woman with type 2 diabetes comes to the office after 5 episodes of vaginal bleeding over the past 3 months. There is no discharge accompanying the bleeding. The patient has been postmenopausal for 12 years and has never experienced any bleeding since then. Her past medical history is significant for anxiety disorder, depression, hypertension, and gout. The patient refuses to give a sexual history. Her blood pressure is 140/90 mm Hg, pulse is 80/min, and her weight is 136 kg (300 lbs). You are concerned that her vaginal bleeding is caused by
A. cervical cancer B. endometrial cancer C. endometriosis D. ovarian cancer E. vaginal cancer F. vulvar cancer
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