Еще одна пилюлька Hескучина

[Anna_Shvedova]

С. ВНЧ сустав слева не в порядке..

[OrFun]

С .....

[yananshs]

The correct answer is C. This patient most likely has a temporomandibular joint (TMJ) disorder, which is a very common disorder that can usually be detected by palpating the area just in front of the tragus. Joint clicking may be found when the patient opens and closes his mouth. Symptoms of TMJ include orofacial pain, a noisy joint, and restricted jaw function.

Corticosteroids (choice A) are necessary in cases of temporal arteritis, when the patient complains of visual changes. However, this patient is a young man who does not complain of a headache over the temporal artery or a change in vision. He is afebrile, has a normal hemoglobin, hematocrit, and erythrocyte sedimentation rate, and does not have any systemic symptoms. It is unlikely that he has temporal arteritis.

If a transient ischemic attack is suspected, auscultation of the left carotid artery (choice B), is appropriate to detect the presence of a carotid bruit. However, this young patient is describing the 3 main symptoms of TMJ which include orofacial pain, a noisy joint, and restricted jaw function. It is unlikely that he has carotid artery disease.

This patient most likely has a temporomandibular joint (TMJ) disorder, which is a very common disorder that can usually be detected by palpating the area just in front of the tragus, not the left posterior auricular region (choice D). Here is a practical explanation: put your finger in front of your ear, and open and close your mouth. You can feel the movement of your jaw. Now, put your finger behind your ear, in the posterior auricular region, and open and close your mouth. You cannot really feel your jaw move.

If temporal arteritis was suspected, particular attention should be given to the left temporal artery (choice E). However, this patient is a young man who does not complain of a headache over the temporal artery or a change in vision, is afebrile, has a normal hemoglobin, hematocrit, erythrocyte sedimentation rate, and does not have any systemic symptoms. Palpation of the temporal artery is appropriate during the examination to rule out temporal arteritis, but particular attention should be given to the area just in front of the left tragus, to detect TMJ.

[yananshs]

A 31-year-old man is admitted to the hospital after a motorcycle accident. He was fully alert and oriented upon arrival and a primary survey revealed a left pneumothorax and small hemothorax with multiple rib fractures bilaterally. Other than some abrasions and lacerations requiring sutures, the patient was otherwise unremarkable. Initial laboratory results and electrocardiograms were unremarkable. After a chest tube was placed, the patient had reinflation of his left lung as demonstrated by chest radiograph. He is now concerned about further complications. The complication that this patient is at greatest risk for is
A. aortic dissection
B. empyema
C. myocardial infarction
D. pneumonia
E. subarachnoid hemorrhage

[Tim Vetrov]

Учитывая гематоракс - B, эмпиема.

[yananshs]

Другие мнения?

[papadoctor]

pneumonia

[yananshs]

Еще какие мнения?

[filbi]

ну все-таки эмпиема

[yananshs]

Счет 2:2

[Artemij Okhotin]

Пневмония.

[papadoctor]

What do they want? R/o type B aortic dissection?

[yananshs]

I did not say you were wrong. Did I?

The correct answer is D. Rib fractures are exquisitely painful. The magnitude of the pain forces people to halt their inspiratory efforts after small tidal volumes and prohibits them from effectively coughing and clearing secretions. This pattern of rapid, shallow breathing with no coughing predisposes patients to profound atelectasis of the lungs and infection due to residual secretions. Therefore he is at greatest risk for developing pneumonia. Often, these patients will receive rib blocks or thoracic epidural catheters for pain management. Opiates are not very effective since they produce somnolence, often worsening the respiratory problems.

All major chest trauma carries the possibility of aortic dissection (choice A), which is why chest radiographs are obtained to rule out a widened mediastinum. Although the negative predictive value of such films is not 100%, the fact that this patient has no chest or back pain coupled with a normal chest radiograph makes him especially low risk for this complication.

An empyema (choice B) is an infection of the pleural space. Since this patient has had his hemothorax drained, his risk of subsequent infection is essentially the same as the general population. His chest tube confers only a minimal increased risk of empyema.

With major myocardial contusions from blunt chest trauma, both direct myocardial injury as well as coronary dissection can result in infarction (choice C). This patient has a normal EKG, no symptoms of chest pain, and no evidence of major blunt chest trauma in the form of a hematoma or bruise across the sternum. For these reasons, his risk of infarction is quite low.

The most common cause of subarachnoid hemorrhage (choice E) is trauma. The presentation of SAH however is often directly after the trauma, and it is most often head trauma as the precipitating event. It is very rare for a SAH to have a delayed manifestation of hours or days after the trauma was suffered.

[yananshs]

A 58-year-old man comes to the office because of difficulty with erections for the past few years. He says that he has a great relationship with his wife and is still very sexually aroused by her. He is occasionally able to initiate an erection, but he is unable to sustain it. The remainder of his medical, sexual, and psychological history is unremarkable. He takes isosorbide mononitrate for chest pain. His blood pressure is 130/90 mm Hg. Physical examination is unremarkable. Prolactin and testosterone levels are within normal limits. He asks for the "little blue pill" that is so often advertised on television commercials. At this time you should
A. advise him to discontinue the isosorbide mononitrate
B. explain that he cannot take sildenafil because of his current medication
C. prescribe sildenafil citrate tablets for him to take an hour before sexual activity
D. recommend implantation of an inflatable prosthesis
E. tell him that his erectile dysfunction is psychogenic

[Psychiatr]

B....