В реальной жизни,я думаю,что начали бы с парентерального введения железа,а потом бы разбирались,если бы не было эффекта через день-два.Но все-таки подходы у нас и "на западе" отличаются.Скорее бы правильные ответы нам рассказали. :)

53. D
54. D
59. A

Ну.. во-первых я не претендую на истину в последней инстанции...
Если гематома нарастает - по идее если ее вскрыть - можно получить кровотечение.. А на ухе - остановка кровотечения может быть проблематичной.. неудобно там.. ИМХО

О.К. Едем дальше... :)

Items 62-63
A 4-day-old Greek-American neonate is brought to the office because of the development of yellow skin and a rash 1 day after
hospital discharge. She weighed 3400 g (7 lb 8 oz) at birth and is the product of a normal pregnancy. The mother is now gravida 2,
para 2 and she is blood type A, Rh positive. The neonate is blood type O, Rh positive with a negative direct Coombs test. She had
an Apgar score of 8 and 9 at 1 and 5 minutes respectively. The neonate was breast-feeding and was doing well at the time of
discharge. Yesterday, the mother says, the neonate developed about 20 small red spots over her face, trunk and extremities. Today
on physical examination there are many papules that have small vesicles with clear to slightly turbid fluid. Her skin color has
become yellow. The mother says that she continues to feed well. On physical examination the neonate weighs 3250 g (7 lb 2 oz).
There is scleral and skin icterus. No organomegaly or adenopathy is noted. Studies on the neonate show a serum total bilirubin
concentration of 8.7 mg/dL, and concentration of serum conjugated (direct) bilirubin is 0.7 mg/dL.

62. In addition to scheduling a follow-up visit in 1 week, which of the following is the most appropriate advice to give the
mother regarding the icterus?

(A) Ask her to avoid eating foods containing large quantities of carotene
(B) Begin administering small doses of phenobarbital to the neonate
(C) Discontinue breast-feeding until the jaundice has disappeared
(D) Recommend home phototherapy for the neonate
(E) Recommend no change in child care or feeding of the neonate


63. The appropriate steps are taken. You explain to the mother that the neonate's rash is probably erythema toxicum. Which of
the following is the most appropriate management?

(A) 0.5% hydrocortisone cream applied twice a day
(B) Daily wet-to-dry povidone-iodine (Betadine®) soaks with 1×1 gauze pads on each vesicle
(C) Polymyxin ointment applied twice a day
(D) Routine skin care with soap and water
(E) Scrubbing with entsufon cleanser each day firmly enough to unroof the vesicles


Items 64-65
A 10-year-old girl, who has been undergoing treatment for chronic juvenile rheumatoid arthritis for the past 3 years, is brought to
the office because of painful swelling of the right knee. She has had three episodes of painless swelling of her left knee and ankle,
which have subsided spontaneously with rest and aspirin therapy. She has used no medications between episodes. On physical
examination today there is pronounced redness and warmth around the right knee, and a large effusion is present. Attempts at
active and passive motion cause severe pain.

64. Which of the following is the most appropriate step at this time?

(A) Joint aspiration
(B) Serum antinuclear antibody titer
(C) Serum rheumatoid factor assay
(D) Technetium 99m scan
(E) X-ray films of the joint


65. Which of the following new symptoms or findings, if present, would best indicate the need for further diagnostic studies?
(A) Decreased viscosity of joint fluid
(B) Diffuse increase in technetium 99m uptake around the knee on bone scan
(C) Positive Gram stain of joint fluid
(D) Positive serum rheumatoid factor test
(E) Soft-tissue swelling seen on x-ray films

62-63

1.Думаю ,Е (для фототерапии уровень билирубина должен быть выше 350 мм/л , т.е 20 мг/дл , для пробного прекращения ГВ-12 мг/дл)
2. Д

62. E
63. D
64. A
65. C

Следующие три вопроса:

73. A 4-year-old boy is brought to the office because he has become unmanageable at his day-care center. At previous visits he
exhibited some behavior problems to which his mother did not set limits. He constantly interrupted situations, seeking his
mother's attention. She now reports that during the past few months his fighting, refusal to obey the day-care workers and
violations of "time out" have become much worse. He began to attend day-care at 6 weeks of age so that his mother could
return to work. His father works as a house painter and he is alcohol-dependent. The boy has a 6-month-old sister who also
attends the same day-care center. Records show his height and weight are at the 5th percentile, and his growth velocity is
normal. There were no complications during the pregnancy with this child and he has not had any significant medical
problems. His physical examination today is normal. Which of the following is the most likely cause for this child's
worsening behavior?

(A) Aggressiveness to compensate for a poor self-image caused by short stature
(B) Attention-deficit/hyperactivity disorder
(C) A reaction to his father's drinking
(D) Reduction in his mother's attention because of his new sibling
(E) A toxic reaction to organic fumes from his father's clothes and work materials


88. A 6-month-old Latino infant is brought to the office by his parents because of intermittent swelling in his right scrotum.
They say the swelling is more pronounced when he cries. The swelling has never been red or "stuck." A right inguinal
hernia is confirmed on physical examination. In discussing repair of the hernia with the parents, you should inform them
which of the following?

(A) Herniorrhaphy can be postponed until age 2 years because many hernias close spontaneously
(B) Herniorrhaphy can be postponed until age 12 years because oligospermia does not develop before age 12
(C) Herniorrhaphy should be scheduled at the earliest convenient time
(D) Herniorrhaphy should be scheduled as an emergency
(E) There is no need to repair a hernia in childhood unless incarceration occurs


92. An 8-month-old infant with trisomy 21 (Down syndrome) has a grade 2-3/6 systolic ejection murmur heard best at the left
sternal border, but it can be heard all over the precordium. S2 is split normally and is loud. She has had two episodes of
pneumonia in the past 2 months. Which of the following is the most appropriate next step?

(A) Do a PPD skin test
(B) Initiate an immunologic evaluation
(C) Order sweat chloride test
(D) Presume the murmur is functional and schedule follow-up visits
(E) Seek consultation with a cardiologist

1.D
2.A
3.E (интересно , а назначить эхо-кг без кардиолога можно ?)
Дааа , больше вопросов у меня , чем ответов ...но тем интересней узнать правильные.

1.B.Все-таки проблемы с поведением были и до появления сестры?
2.С.Пахово-мошоночные грыжи оперируют не дожидаясь 12 лет.
3.Е.

73. - D
88. - C
92. - E

У нас можно. Другое дело, что у нас ЭХО делают детям делают детские кардиологи. Поэтому, давая направление на ЭХО, я знаю, что ребенка будет смотреть кардиолог.

В 4 года такой диагноз не ставят. :)

Следующие три вопроса. :)

Items 112-113

An obese 10-year-old boy with diabetes mellitus is admitted to the hospital because of severe ketoacidosis and cardiovascular
collapse. Initial management consists of cardiac monitoring and intravenous administration of fluids, electrolytes and insulin.
Because of the difficulty in obtaining satisfactory peripheral venous access, the left femoral vein is catheterized percutaneously. Six
hours later, his mental status is improved, blood pressure is 120/70 mm Hg and serum glucose concentration is 250 mg/dL.
Physical examination at that time shows a cold left foot with diminished pulses compared with those of the right foot.


112. Which of the following is the most likely explanation for this patient's diminished pulses?
(A) Paradoxical embolus from the femoral vein
(B) Diabetic arteriopathy
(C) Inadvertent injury of the femoral artery
(D) Intense arteriolar constriction induced by hyperosmolality
(E) Thrombosis of the catheterized femoral vein

113. A deficit of which of the following electrolytes in this patient is most likely to cause death?
(A) Bicarbonate
(B) Calcium
(C) Chloride
(D) Potassium
(E) Sodium


123. A 15-year-old African-American girl comes to the emergency department because, she says, "something is sticking out of
my bottom since I had a bowel movement this morning." She denies previous episodes, although for more than 1 year she
has had occasional difficulty passing stools. She is not in pain at present, but she is afraid to move her bowels for fear that the
problem will get worse. In response to your questions, she tells you that she moved away from home more than a year ago
and her parents contribute nothing to her support. She has a 6-month-old child and lives with a 28-year-old female cousin.
She has never been married and does not work or attend school. She has no other symptoms. In order to follow the correct
procedure for treating a minor, which of the following is the most appropriate step prior to evaluating this patient's rectal
problem?

(A) Accept the girl's consent as sufficient
(B) Obtain a court order permitting evaluation
(C) Obtain the written consent of at least two licensed physicians
(D) Obtain written consent from at least one of her parents
(E) Obtain written consent from her 28-year-old cousin

112 - А (может быть, С - но тогда был бы напряженный отек?)
113 - D
114 - C (а то пока решения суда дождешься...)

112-Е (или все-таки А)???
113-Д(этот вариант напрашивается , но данный пациент в кетоацидозе , потому и А тоже нельзя сбрасывать со счетов...)
114-Д
Опять одни вопросы ... Скучать не приходится ;)