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#721
08.09.2006, 21:20
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Я думаю, что здесь как-то задействованы кристаллы холестерина вышедшие из ксантомы во время игры в футбол. Если В. неправильный ответ, выбираю D. schedule him for an urgent cardiology consult, в связи с выраженной дислипидемией.
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#722
08.09.2006, 21:33
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Я тоже бы склонился к D, но по причине возможности эмболий.
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#723
09.09.2006, 00:25
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Цитата:
2 Тим. Как Кардиолог может предупредить развитие эмболий??
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#724
09.09.2006, 00:29
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Ну, стрептокиназу ввести...
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#725
09.09.2006, 07:06
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The correct answer is E. This patient has an acute rupture of the Achilles tendon (tendo calcaneus). The typical presentation is that of the occasional athlete presenting with pain after strenuous activity. There is limited ability to plantarflex the ankle. In this case, the tear was partial at first, but has become progressively a complete tear as manifest by the contraction of the gastrocnemius and soleus, forming the lump in the posterior calf. The tear typically occurs 2-3 cm above the calcaneus. Tears of the Achilles tendon are managed surgically except in patients who cannot undergo surgery. This case is complicated by the presence of severe hyperlipidemia with xanthelasma.
A cardiac diet (choice A) may be necessary for this patient, but the Achilles tendon rupture must be treated urgently. Initial management would focus on lipid levels and controlling hypertension. Medication compliance issues must also be addressed. The presence of xanthelasma indicates severe hyperlipidemia and warrants immediate, aggressive management of hyperlipidemia and hypertension, both of which are risk factors for coronary heart disease. Also, a return to the clinic in 1 week is unnecessary. Conservative management (choice B) is not appropriate for Achilles tendon ruptures in active patients. The presence of retraction of the calf muscles signifies a separation of the distal and proximal Achilles tendon which must be reduced surgically. An MRI would allow for differentiation of xanthoma secondary to hyperlipidemia and Achilles tendon tear. The history and exam is classic for Achilles tendon rupture in this patient however. Most clinicians would choose to operate based on these findings alone. In the setting of a suspected xanthoma complicating the picture of a simple Achilles tendon rupture, a magnetic resonance imaging (MRI) scan is indicated, not a plain film (choice C). Xanthomas are unusual fatty tumors occurring in patients with familial hypercholesterolemia, severe primary hypercholesterolemia, as in the patient, or idiopathically. Typically xanthomas are asymptomatic masses of connective tissues. An association with a tendon rupture is unusual. This patient would benefit from aggressive hypertension and lipid management, but there are no symptoms of coronary disease at this time to warrant immediate cardiology consultation. (choice D). Moreover, the Achilles tendon rupture must be addressed urgently.
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#726
09.09.2006, 07:09
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A 47-year-old man comes to the office for follow-up management of his ascites and cirrhosis. He has been your patient for 3 years. He has known hepatitis B and alcohol-induced cirrhosis. He takes furosemide and spironolactone daily. Six weeks ago he underwent an upper endoscopy that showed grade 3 esophageal varices. You are interested in offering him therapy to prevent a possible devastating upper gastrointestinal bleed. The most appropriate management to prevent bleeding is to
A. begin to take a beta-1 selective blocker B. begin to take a beta-2 selective blocker C. continue to take his current medications D. schedule endoscopic banding of the varices E. schedule a transjugular intrahepatic portosystemic shunt (TIPS) procedure
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#728
09.09.2006, 08:40
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А почему не D?
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#731
09.09.2006, 21:56
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если менее инвазивно, может быть можно было просто довавить бета-блокеров. А если хотим активнее, я бы выбрал E. schedule a transjugular intrahepatic portosystemic shunt (TIPS) procedure
Dmitry Voskovets
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#732
09.09.2006, 22:13
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Согласен с Voskом. Если уж совсем консервативно то бетта блокаторы, если инвазивно то TIPS. Смущает лишь выраженность варикоза при отсутствии данных о давности его развития. До момента обращения пациенту было достаточно лишь мочегонных. Предположим что варикоз уже давно, поэтому склоняюсь к рекомендации консервативного лечения.
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#733
09.09.2006, 22:16
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Все же скорее ответ Д. Е рассматривается как second-line, правильнее было бы начать первичную профилактику кровотечения с неселективных бета-блокеров, но их среди ответов нет:
Endoscopic screening for the presence of esophagogastric varices should be done in all patients after the diagnosis of cirrhosis. Screening should be repeated every 3 years in patients without varices and every 2 years in those with small varices. Endoscopic follow-up should then relate to the initial size of detected varices. In case of large varices, endoscopic follow-up is not necessary, and primary prophylaxis with a nonselective b-blocker (propranolol or nadolol) should be started. Endoscopic band ligation is useful in preventing variceal bleeding in patients with medium or large varices; however, its long-term benefit requires further research, and it is not currently proposed for use in primary prophylaxis unless the patient has contraindications to or side effects from nonselective b-blocker therapy. [Ссылки доступны только зарегистрированным пользователям ]
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#734
10.09.2006, 01:52
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The correct answer is D. The options for preventing an initial UGI bleed due to varices in patients are essentially nonselective beta blockade, endoscopic sclerotherapy or banding, and shunt surgery. A tremendous number of clinical trials on these options have been published. The current favored therapy is endoscopic banding of any visible varices and subsequent endoscopy to band any additional varices. The rate of initial bleeds is decreased by this intervention but none of the interventions have yet to show any survival advantage.
It is incorrect that the most effective prevention of a variceal bleed is a beta-1 selective blocker (choice A) or beta-2 selective blocker (choice B). As alluded to in the discussion above, these are not superior to banding, and in fact, beta blockade has not been clearly shown to even decrease risk of initial bleeding. Continuing to take his current medications (choice C) is not the most effective management to prevent bleeding. None of his current medications are effective for prophylaxis. He should still take them though. A TIPS procedure (choice E) is a form a shunting performed by interventional radiologists. TIPS involves placing a "shunt" via a transjugular approach into a deep branch of the hepatic vein coupled to a deep branch of the portal vein. They are designed to relieve portal hypertension and thus decrease the risk of bleeding. These procedures are used as a bridge to transplant in most centers, and are rarely used in primary bleed prevention as the shunts tend to thrombose and cause problems within one year of placement.
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#735
10.09.2006, 01:54
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You are notified that one of your patients, a 3 -year-old previously healthy girl, is admitted to the hospital because of 6-day history of fever, irritability, and erythema of the hands and feet. Her physical examination on admission showed a temperature of 39.7 C (103.4 F), bilateral conjunctival injection, an enlarged left-sided cervical lymph node (2.0 cm), fissured lips, a red tongue with red papillae, pharyngeal hyperemia, erythematous and edematous palms and soles, and a confluent, blanching erythematous rash on the trunk. The mother told the emergency department physician that she had been giving her daughter aspirin for the past week to reduce her fever. In the emergency department, intravenous fluids were started, the aspirin therapy was continued, and laboratory studies were ordered. These laboratory studies just returned and show an erythrocyte sedimentation rate of 28mm/h and a platelet count of 490,000/mm3. The patient is extremely uncomfortable and now shows desquamation of the fingers and toes. The mother is very concerned about her daughter's condition. At this time the most correct statement about her condition is:
A. Corticosteroids are necessary to decrease the risk of aneurysms within 10 days of the onset of fever B. Influenza vaccination is necessary if this patient requires long-term salicylate therapy C. MMR vaccination should be given within a month if this patient receives intravenous gamma globulin D. Nasopharyngeal cultures will help to establish the diagnosis E. There is a 40% risk of death associated with her disease
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