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#586
23.08.2006, 19:47
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Очередной ляп???
Очевидно, по моему, что глупо заниматься постановкой дополнительной вены в аппер экстримити, когда одна уже есть
Цитата:
ЗЫ: Я спокоен, я совершенно спокоен  
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#589
23.08.2006, 20:32
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You are notified that one of your patients, a 32-year-old woman, delivered a healthy baby girl 6 hours earlier. You happen to be in the hospital discharging another patient, so you go to the labor and delivery floor to see her. You have been treating her for dysthymia and for a couple of episodes of major depressive disorder over the years. She developed postpartum "blues" after her last child was born that resolved spontaneously after 5 days. You hear a woman screaming as you get off the elevator and head towards her room. As you get closer, you recognize the voice and realize that it is your patient. She is running around her room, tearing off the hospital gown, and yelling that, "they are coming to get her." When she sees that you are standing in the room, she begins to throw flower vases, the telephone, and the bedding at you. The nurses appear and tell you that she has been very disorganized and has had bizarre, grandiose delusions. She then goes back to the nurse's station. You notice the newborn in the corner of the room. The most appropriate next step is to
A. ask the nurse to get haloperidol from the medication closet B. call for an immediate psychiatry consultation C. encourage her to breastfeed and bond with her newborn D. remove the newborn from the room E. try to talk to her and calm her down
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#590
23.08.2006, 20:40
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D
Логика проста: маме, конечно, хочется помочь, но за newborn боязно.
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#591
23.08.2006, 22:43
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The correct answer is D. This woman is experiencing postpartum psychosis and may harm herself and/or her newborn. You must immediately remove the newborn from the room before the mother has a chance to harm her. Postpartum psychosis is a relatively uncommon disorder that may affect women with bipolar disorder, depression, and schizophrenia. It may also occur in women with no previous psychiatric history. The treatment includes the protection of the newborn, the administration of an antipsychotic medication, and observation. Both suicide and infanticide may occur with postpartum psychosis.
Haloperidol (choice A) is part of the acute treatment of postpartum psychosis. However the action that is most likely to have the most immediate effect is to remove the newborn from the room as fast as possible and then to administer medication to the mother. The antipsychotic agent will not have an immediate effect so it is first mandatory to protect the baby from the mother's rage. An immediate psychiatry consultation (choice B) may be necessary, but it is important to first protect the newborn by removing her from the mother's room. At this time it is completely inappropriate to encourage her to breastfeed and bond with her newborn (choice C). This woman most likely has postpartum psychosis and is out of control. You must remove the newborn from the room and then administer antipsychotic agents. She then needs close observation. Encouraging bonding at this time may only worsen her condition and endanger the life of the baby. After you remove the baby from the room and administer an antipsychotic agent, you can try to talk to her and calm her down (choice E). It will most likely be useless to do this before the medication, and you first need to remove the infant from this violent situation
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#592
23.08.2006, 22:44
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You are working in the emergency department seeing an 88-year-old woman with extensive history of coronary artery disease, status post a ventricular aneurysm repair and pacemaker placement who developed an acute onset of right-sided eye pain along with left-sided hemiparesis 2 hours earlier while watching TV with her husband. She is awake with normal language functions and has good insight into her medical condition. Her memory functions are normal. Pupils are symmetric with conjugate eye deviation to the right but can cross midline on volition. She does not blink to threat on the left and has a left-sided facial droop. There is severe left arm more than leg hemiplegia. She has decreased sensation in her left arm but otherwise appears to be intact in her leg and face. Her left toe is upgoing. Laboratory studies are normal and a CT scan of the head is negative for hemorrhage or acute infarction. The most appropriate next step in management is to
A. administer tissue plasminogen activator B. admit the patient and plan for a neurological consult in the morning C. get a brain MRI and MRA D. give an aspirin and admit for observation E. load her with intravenous phenytoin
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#594
24.08.2006, 04:36
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>>C<<. Sne is too old for tPA, I guess
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#597
24.08.2006, 13:33
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где-то на форуме была дискуссия по тромболизису. тут как раз в 3 часа укладывается. по поводу возраста, если не ошибаюсь, противопоказаний не было, а дефицит вроде как большой.
A. administer tissue plasminogen activator Dmitry Voskovets
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#598
24.08.2006, 18:11
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Формально -не учитывая возраст- ситуация идеальна для тромболизиса , А ,но 88 лет ! Хотя , конечно , в противопоказаниях возраст не указан .Но все- таки , наверное В.
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#599
24.08.2006, 18:15
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Тромболизис может быть выполнен, если объем инфаркта не превышает 1⁄3 объема полушария мозга (согласно Guidelines for the Early Management of Patients With Ischemic Stroke 2003). Возраст не противопоказание. Поскольку КТ negative for hemorrhage or acute infarction, необходимо выполнить MRI and MRA, что позволит определить объем инфаркта и окклюзированную артерию. После этого может быть рассмотрена возможность тромболизиса.
Поэтому я за C. get a brain MRI and MRA.
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Линейный вид
