#1
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Åùå îäíà ïèëþëüêà Håñêó÷èíà
An 83-year-old woman with a history of hypertension and osteoarthritis comes to the office because of abdominal pain with occasional nausea, constipation, muscle weakness, and fatigue over the last 4 months. She denies taking any over-the-counter medications or vitamins. She denies weight changes, change in stool diameter, melena, bright red blood per rectum, or shortness of breath. You notice in her chart that she had a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is normal except for mild kyphosis. Her rectal examination is heme negative.
Labs: RBC 4.2 million per µL Hemoglobin 7.9 mmol/L WBC 6 000 per mm3 Platelet 300,000 per mm3 Albumin: 4 g/dl Alkaline phosphatase: 60 IU/L ALT (alanine transaminase): 20 IU/L AST (aspartate aminotransferase): 16 IU/L BUN (blood urea nitrogen): 10 mg/dl Calcium - serum: 14 mg/dl Serum chloride: 105 mmol/L Creatinine: 1.4 mg/dl Direct bilirubin: 0.1 mg/dl Gamma-GT (gamma-glutamyl transpeptidase): 2 IU/L Glucose: 100 mg/dl LDH (lactate dehydrogenase): 110 IU/L Phosphorus - serum: 3 mg/dl Potassium : 4 mEq/L Serum sodium: 140 mEq/L Total bilirubin: 1.0 mg/dl Total cholesterol: 250 mg/dl Total protein: 7 g/dl Uric acid: 5 mg/dl The most appropriate next step is to A. determine parathyroid hormone levels B. determine serum vitamin D levels C. determine thyroid stimulating hormone levels D. order a CT scan of the neck E. order a serum protein electrophoresis |
#2
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âíà÷àëå-À
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#3
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Ñëèøêîì ïðîñòàÿ áûëà çàäà÷êà.
Äðóãàÿ: A 65-year-old man suffers a fall down his stairs at home and is admitted to the hospital for a fractured hip. The patient has no significant past medical history and takes only an aspirin daily. He is very active and plays golf and tennis 3 times per week. This morning, he slipped on the icy stairs and fell, breaking his right femur and acetabulum. He is brought to the operating room where the hip is repaired uneventfully. On postoperative day number 2, the patient develops acute shortness of breath and pleuritic chest pain on the right. His temperature is 37 C (98.6 F), blood pressure is 130/90 mm Hg, pulse is 110/min, and respirations are 22/min. Physical examination shows a tender, swollen left calf. The most appropriate therapy at this time is A. embolectomy B. intravenous heparin bolus plus continuous infusion C. oral warfarin D. subcutaneous heparin E. thrombolysis |
#4
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âíà÷àëå Ä
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#5
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Íå âåðíî.
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#6
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A. embolectomy
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doctor Ðolonsky israel Ñíèìêè ñìîòðþ òîëüêî â ïðÿìîì ïîêàçå.,áåç íåîáõîäèìîñòè ñêà÷èâàíèÿ. Ïðîñüáà ïîêàçûâàòü ñíèìêè â ïðàâèëüíîì ïîëîæåíèè. |
#7
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Îïÿòü ìèìî.
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#8
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ß ðàçðûâàþñü ìåæäó òðîìáîëèçèñîì è ãåïàðèíîì. Ñêëîíÿþñü ê òðîìáîëèçèñó. Íî ïðîøó íå ñóäèòü ñòðîãî - íå ñïåöèàëèñò.
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#9
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Õîòåëîñü áû êðîìå îòâåòîâ - îáîñíîâàíèÿ òîãî èëè èíîãî âûáîðà.
Ñòðîãî ñóäèòü íèêîãî íå áóäåì. Ýòî çàäà÷êè èç USMLE 3, êîòîðûé ñäàþò âðà÷è âñåõ ñïåöèàëüíîñòåé ÷òîáû ïîëó÷èòü ëèöåíçèþ. Äî Áîðäà. Áîðä ñäàþò ïîñëå ïîëó÷åíèÿ ëèöåíçèè. |
#10
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Merci, ÷òî íå ñóäèòå ñòðîãî.
ß äóìàþ, ÷òî âñëåäñòâèå òðàâìû ó ãðàæäàíèíà ðàçâèëñÿ òðîìáîç, ñâÿçàííûé, âîçìîæíî, ñ æèðîâîé ýìáîëèåé (sorry (c) áðóêñà). Òàêèì îáðàçîì, ó÷èòûâàÿ íåáîëüøîå âðåìÿ îò onset'à, íàäî ââîäèòü òðîìáîëèòèêè. Òåì áîëåå ÷òî êëèíèêà ìíîæåñòâåííûõ òðîìáîâ íàëèöî. |
#11
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ß äóìàþ, ÷òî îí ðàçâèë òðîìáîýìáîëèþ ìåëêèõ âåòâåé, è åìó íàäî äåëàòü òðîìáîëèçèñ. Ò.ê. âðåìÿ îò íà÷àëà çàáîëåâàíèÿ ïðîøëî äîñòàòî÷íî ìàëî (ÿ íå ïîìíþ, ðàçóìååòñÿ, ñêîëüêî ìàêñèìîì, íî, ñóäÿ ïî óñëîâèþ çàäà÷è, ïðîøëî, ïîêà, íå ìíîãî âðåìåíè), ïîýòîìó òðîìáîëèçèñ ìîæåò ïîìî÷ü.
Å. |
#12
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A. embolectomy - íåò, ñòàáèëüíàÿ ãåìîäèíàìèêà íå òðåáóåò èíâàçèâíîé ïðîöåäóðû
B. intravenous heparin bolus plus continuous infusion - äà C. oral warfarin - íåò, íàçíà÷àåòñÿ ïîñëå ãåïàðèíà D. subcutaneous heparin - íåò, ïðîôèëàêòè÷åñêàÿ äîçà E. thrombolysis - íåò, ñëèøêîì âûñîêèé ðèñê êðîâîòå÷åíèÿ ïîñëå îðòîïåäè÷åñêîé îïåðàöèè |
#13
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Äà, íî âåäü ãåïàðèí íå ïðèâåäåò ê ëèçèñó óæå ñóùåñòâóþùèõ òðîìáîâ...
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#14
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Ãåïàðèí áëîêèðóåò ôîðìèðîâàíèå íîâûõ òðîìáîâ. Çà ëèçèñ ñóùåñòâóþùèõ òðîìáîâ îòâå÷àåò ôèáðèíîëèòè÷åñêàÿ ñèñòåìà. Òðîìáîëèòèêè ïîêàçàíû ïðè ìàññèâíîé ÒÝËÀ âûçûâàþùåé ãåìîäèíàìè÷åñêóþ íåñòàáèëüíîñòü ïðè îòñóòñòâèè ïðîòèâîïîêàçàíèé (íåäàâíèå îïåðàöèè, èíñóëüò, íåêîíòðîëèðóåìîå äàâëåíèå è ïð.).  îïèñàííîì ñëó÷àå, áîëüíîé òîëüêî ÷òî ïåðåíåñ êðóïíóþ îïåðàöèþ, åãî ñîñòîÿíèå â öåëîì ñòàáèëüíîå - ïîêàçàí ãåïàðèí (èëè íèçêîìîëåêóëÿðíûé ãåïàðèí) ñ ïîñëåäóþùèì íàçíà÷åíèåì âàðôàðèíà íà 3-6 ìåñÿöåâ.
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#15
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Öèòàòà:
Èç òåõ æå òåñòîâ,î íàèáîëåå ÷àñòîì îñëîæíåíèè ïðè ïåðåëîìå-îïåðàöèè áîëüøèõ òðóá÷àòûõ êîñòåé, ðå÷ü ìîæåò èäòè î æèðîâîé ýìáîëèè.
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doctor Ðolonsky israel Ñíèìêè ñìîòðþ òîëüêî â ïðÿìîì ïîêàçå.,áåç íåîáõîäèìîñòè ñêà÷èâàíèÿ. Ïðîñüáà ïîêàçûâàòü ñíèìêè â ïðàâèëüíîì ïîëîæåíèè. |