49-е
50-с (больше похоже на пилоростеноз)
51-d (Узи)

49 - E
50 - C
51 - D

53. A 2-year-old boy who has recently become one of your patients is brought to the clinic by his mother for a follow-up visit of a
chromosome analysis done 1 month ago. This child has minor dysmorphic features, and growth and developmental delay.
Chromosome analysis showed a small unbalanced chromosome translocation, with extra chromosomal material at the tip of
chromosome 3. The cytogenetics laboratory requested blood samples from both parents for follow-up studies. The parents are
divorced, and the mother has custody of the child. The relationship between the parents is hostile. The mother has been tested
and has normal chromosomes without evidence of translocation. At today's visit, she reacts angrily when the issue of
contacting the child's father for testing is raised. She states that he abandoned them, and that he has no interest in his child.
She refuses to cooperate in contacting the father, who could be a translocation carrier. You do not know the father, but an
office worker told you that he lives in a nearby town. The mother says that he is living with a new girlfriend. Which of the
following is the most appropriate next step?

(A) Attempt to identify the father's physician and work with that physician to obtain chromosome studies on the
father
(B) Contact the father by telephone and arrange for him to give a blood sample at a local hospital
(C) Document your attempts to work with the mother but proceed no further, since you have no physician-patient
relationship with the father
(D) Help the mother deal with her anger and educate her regarding the potential benefit to her son and others if the
father's chromosome studies are done
(E) Send the father a letter (expressing few details about the patient) and suggest that he contact your office for an
appointment and further discussion of his child


54. An 18-month-old white infant is brought to the clinic because of pallor and irritability. Her mother says the infant's diet
consists almost exclusively of whole milk, approximately 40 oz per day. On physical examination, the infant has a pulse of
160/min, respirations of 50/min, and normal heart sounds with a grade 2/6 systolic ejection murmur. Liver is palpable 3 cm
below the right costal margin. Laboratory studies show:
Blood
Hematocrit 13%
Hemoglobin 3 g/dL
Mean corpuscular volume 48 µm3
Platelet count 400,000/mm3
Reticulocyte count 0.8% (N=0.5-1.5% of red cells)
WBC 12,000/mm3
Following appropriate evaluation, which of the following is the most appropriate treatment?

(A) Administration of oral folate therapy
(B) Administration of parenteral iron therapy
(C) Administration of parenteral vitamin B12 (cyanocobalamin) therapy
(D) Transfusion with packed erythrocytes
(E) Transfusion with whole blood

59. A 3-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite,
sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where
there is demolition of old buildings. Examination of a peripheral blood smear is likely to show which of the following?

(A) Basophilic stippling of erythrocytes
(B) Degranulation of eosinophils
(C) Diminished numbers of platelets
(D) Howell-Jolly bodies
(E) Macrocytic erythrocytes

53.Снова вопрос этического характера:) Е, наверное
54.Такой низкий гематокрит...Вариант Е
59.А?

Почему?

WHOLE blood никто не переливает :)

Ааа:)
Ну тогда эритроцитарную массу.

59-А.Похоже на отравление свинцом.Ожидаем базофильную зернистость эритроцитов.

Перепроверила - правильный ответ Е. Объяснений там нет. Я тоже расценила это, как гематому, но я не знала, что ввиду свежей травмы, их нельзя вскрывать. А почему?

По поводу уха,там кажется травма три дня назад?

Там еще и повторная свежая травма 3 часа назад.

53-Е
54-анемия связана скорее всего с микрокровотечениями при молочном перекорме.Перевести oral folate therapy не получается.нужна коррекция препаратами железа.В тяжелых случаях переливание эритроцитарной массы.
59-А.
Пойду совершенствовать свой английский.

Меня все-таки очень смущает эта анемия...Либо для детей нормативы очень отличаются от "взрослых", либо ребенок на грани гибели... Гемоглобин - 3 г/дл, это 30 г/л, гематокрит вообще ни в какие ворота не лезет...

Да,Наиля,я согласна,наверное тут есть какой-то подвох.Но один раз наблюдала девочку подростка,которая все лето пила козье молоко и больше почти ничего не ела.Гемоглобин был 60 г\л.В стационаре,где она лежала никаких причин анемии так и не нашли.Лечили парентеральным введением железа.Может быть и талассемия,а про молоко сказано,чтобы нас запутать?

Мара, мне что-то уже кажется, что не усваивается железо. Тогда вариант с парентеральным введением подходит.