Еще одна пилюлька Hескучина

[Dr. Vadim]

Если не ошибаюсь, подвздошно-паховый нерв является исключительно сенсорным (не содержит моторных волокон) и зона иннервации его как раз там, где имеются жалобы. Ответ B - n. ilioinguinalis

[ksn1968]

B. ilioinguinal

[yananshs]

Explanation:

The correct answer is B. Although it is now possible to perform inguinal hernia repairs laparoscopically, the traditional approach is through an incision over the inguinal canal. At the time of surgery, the inguinal canal is opened via sharp dissection through the external oblique aponeurosis, (the anterior wall of the inguinal canal). The ilioinguinal nerve is then encountered as it runs on the anterior aspect of the spermatic cord. If not properly identified at time of surgery, it is possible to transect the ilioinguinal nerve or to "trap" it during closure. If the ilioinguinal nerve is transected on "entrapped" in closure, the patient will complain of numbness over the nerve's distribution, (i.e. the upper medial aspect of the thigh and the anterior portion of the scrotum on the affected side).

The iliohypogastric nerve (choice A) is derived from L1 (as is the ilioinguinal nerve), and runs with the ilioinguinal nerve as they both pierce the transversus abdominis muscle near the anterior superior iliac spine, and then pass through the internal and external oblique muscles to supply the skin of the suprapubic and inguinal regions and the abdominal musculature. The iliohypogastric sends a lateral branch to the skin of the gluteal region and then continues on, to pass through the superficial inguinal ring.

The lateral femoral cutaneous nerve (choice C) originates from L2 and L3 and is a direct branch of the lumbar plexus. It enters the thigh deep to the lateral end of the inguinal ligament, near the anterior superior iliac spine and supplies the skin on the anterior and lateral aspects of the thigh.

The obturator nerve (choice D) is the nerve of the adductor muscles of the thigh. It arises from the lumbar plexus (L2, L3, L4), enters the pelvis minor, and then leaves the pelvis via the obturator foramen. The obturator nerve also sends a small cutaneous branch to the medial aspect of the mid thigh.

The pudendal nerve (choice E) arises from the sacral plexus (S2, S3, S4), and accompanies the internal pudendal artery and leaves the pelvis between the piriformis and coccygeus muscles. The nerve hooks around the sacrospinous ligament to enter the perineum through the lesser sciatic foramen to supply the muscles of the perineum, including the external anal sphincter and then ends as the dorsal nerve of the penis or clitoris. It also supplies some sensation to the external genitalia.

The iliohypogastric, lateral femoral cutaneous, obturator, and pudendal nerves are not encountered during traditional inguinal hernia repair.

[yananshs]

A 55-year-old man comes to the emergency department because of numerous pustules associated with fever, fatigue, and arthralgias over the past 2 days. He has a history of "eczema" and was seen by a dermatologist 10 days prior due to a "flare-up of his eczema." He was given tapering doses of oral corticosteroids, which he completed 3 days ago. On further questioning you learn that his father and brother both have severe psoriasis. His temperature is 38.8 C (101.8 F). He has dry oral mucosa and generalized erythema with hundreds of small, pinpoint pustules involving the entire skin surface, some coalescing into large pools of pustule pockets. There are multiple "oil drops" of pitting in the fingernail beds. At this time the most correct statement is that
A. the appropriate management would be to culture the pustules and admit the patient for intravenous antibiotic therapy
B. he has pustular psoriasis and the offending culprit is the systemic corticosteroids
C. he has scalded skin syndrome and oral antibiotic therapy is indicated.
D. he has toxic epidermal necrolysis and you need to start intravenous immunoglobulin treatment
E. this is a pustular drug eruption; the patient is allergic to prednisone

[ksn1968]

Симптом "маслянного пятна" помню ещё с института как один из патогномоничных симптомов псориаза. Семейный анамнез делают его наиболее вероятным диагнозом. Ухудшение на следующий день после окончания приема кортокостероидов, так что предполагать аллергическую, токсическую реакцию по моему не приходится Вероятнее всего B. he has pustular psoriasis and the offending culprit is the systemic corticosteroids

[yananshs]

The correct answer is B. Pustular psoriasis is characterized by acute onset of sheets of sterile pustules on a background of erythema. The pustules often become confluent, forming lakes of pus. The skin is painful and tender. The pustules are accompanied by fever, malaise, arthralgia, and diarrhea. Pustular psoriasis in known to be triggered by systemic corticosteroids as a rebound phenomenon in a person with known psoriasis. In this patient, his previously treated "eczema" may have been a misdiagnosed psoriatic plaque, given his strong family history of psoriasis. Treatment includes supportive care, intravenous hydration, and systemic cyclosporine.

To culture the pustules and admit for intravenous antibiotic (choice A) is incorrect because as mentioned above, pustular psoriasis is composed of sterile pustules and an antibiotic will not alleviate the flare.

Scalded skin syndrome (choice C) is incorrect because this is a disorder generally seen in adults with immunosuppression or renal impairment. Clinical manifestation includes malaise, fever, irritability, a generalized macular erythema, and a fine, stippled, sandpaper or nutmeg-like appearance that quickly progresses to a tender scarlatiniform phase over 1 to 2 days. From the intertriginous and periorificial areas and trunk, the erythema and tenderness spread over the entire body, usually sparing the hairy parts. This is followed by an exfoliative phase, heralded by exudation and crusting around the mouth and sometimes the orbits.

Toxic epidermal necrolysis (choice D) is incorrect because this is a disorder with widespread macular erythema and stomatitis with exfoliation of the skin. As the erythema becomes more universal, the skin begins to develop areas of separation between epidermis and dermis. The pathogenesis of toxic epidermal necrolysis involves a drug-induced necrosis of the basal cell layer of the epidermis, with the production of subepidermal separation rather than a superficial split as seen in scalded skin syndrome.

Pustular drug eruption (choice E) is incorrect because prednisone can cause acneiform eruption at follicles but does not usually cause pustules that coalesce into lakes. In addition, the strong family history of psoriasis in this patient should lead you to a diagnosis of pustular psoriasis.

[yananshs]

Nine days after delivering a healthy, full-term baby girl, a 36-year-old woman comes to the office because she "obviously is not meant to breast-feed" and she needs advice. She states that she has been doing everything the lactating nurse taught her to do, but the baby has lost weight during the first week. Her mother-in-law, who is staying at their apartment to "help-out," is constantly saying that she must not be producing any milk because, "who ever heard of a baby losing weight? All of my four children gained weight in the first week." She is so upset that she is thinking of calling the La Leche League to teach her the "right way to nurse." She is tearful and very frustrated. She wants to know what is "going on." The most appropriate response to this patient is
A. "Don't worry. Most breast-fed infants lose weight during the first week."
B. "Don't worry. You are most likely not producing milk, but we'll figure it out."
C. "It's okay, many women who want to breast feed find that they can't; infant formulas provide excellent nutrition."
D. "Supplementation with an infant formula is the best management at this time."
E. "Your mother-in-law is most likely correct. You are probably not producing any milk."

[dr.Ira]

Я пока подожду отвечать, хотя, я знаю правильный ответ. Пусть "взрослые" врачи помучаются.

[riltsov]

A. "Don't worry. Most breast-fed infants lose weight during the first week." !?

[Rodionov]

ИМХО тоже А. Злобная свекровь забыла, что мелким детям свойственно худеть...

[yananshs]

Ни в одной задаче нет "адекватных бабушек"(с).

[yananshs]

The correct answer is A. Newborns can lose up to 10% of their birth weight during the first week. This often causes concern, especially in breast-feeding mothers who feel that they are doing something wrong or not producing an adequate amount of milk. Reassurance and patient education are most important at this time. The patient should be told that feeding should be on demand and that the infant should be encouraged to empty both breasts at each feeding. She should be encouraged to continue breast-feeding and to be educated about its benefits. Human colostrum contains macrophages, viral antibodies, bacterial antibodies, and IgA antibodies, which can protect the newborn from enteric pathogens. Other benefits of breast-feeding include increased convenience, decreased cost, digestibility, and lack of allergic phenomena and constipation.

"Don't worry. You are most likely not producing milk, but we'll figure it out" (choice B) and "Your mother-in-law is most likely correct. You are probably not producing any milk"(choice E) are inappropriate responses on the part of the physician. Human colostrum is produced during the first few days postpartum and milk production typically occurs on the 3rd to 6th day postpartum. It is normal for a newborn to lose weight during the first week of life, and there is no reason to believe that this patient is not producing milk.

"It's okay, many women who want to breast feed find that they can't; infant formulas provide excellent nutrition" (choice C) is inappropriate because it is normal for a newborn to lose weight during the first week of life, and there is no reason to believe that this patient is not producing milk. This woman needs reassurance and education. However, if it were true that she was not producing an adequate amount of milk, infant formulas would provide good alternative. Infant formulas are often associated with an increase in constipation.

"Supplementation with an infant formula is the best management at this time" (choice D) is an inappropriate response because it does not seem that there is anything abnormal at this point. It is normal for a newborn to lose weight during the first week of life, and there is no reason to believe that this patient is not producing milk. The mother should be encouraged to continue breast-feeding, and if there comes a point when the infant is not gaining weight and she does not feel comfortable with her breast feeding technique, she can receive assistance from a nursing organization, such as La Leche League. Also, if she is exhausted but able to express milk, other people can assist with the feedings. If this does not work out, infant formula can be given following each breast-feeding.

[yananshs]

A 34-year-old airline pilot is admitted to the hospital with a first episode of a spontaneous pneumothorax. The pneumothorax resolved after 2 days of pleural decompression by a chest tube. A chest x-ray shows complete resolution of the pneumothorax, and a CT scan of the chest shows an apical bulla in the right lung. While discussing further management of his condition, it is appropriate to advise the patient to
A. avoid flying until after bullectomy
B. carry oxygen with him during the flight
C. change his career
D. quit smoking
E. resume his duties after 1 week of rest

[audovichenko]

В России - было бы С. В Америке - не знаю ... Может быть, А?

[Tim Vetrov]

Интересно, можно ли управлять самолетом, когда у тебя пневмоторакс?
Я думаю, что вряд ли это будет безопасно.
Думаю, что правильный ответ A.

D - это всегда хорошо, конечно, но при уже готовой булле вряд ли спасет.
______________________
Ну, С - это уж слишком...