Еще одна пилюлька Hескучина

[riltsov]

А. Едва ли нужна буллэктомия после единственного пневмоторакса.
B. Кислородная подушка в полете не поможет.
C. Сменить профессию – это слишком жестко после одного пневмоторакса.

Я разрываюсь между ответами D. И E. Если пациент курит надо обязательно прекратить курение. Если не курит, через неделю можно летать.
Выбираю E. resume his duties after 1 week of rest !

[papadoctor]

АААААААА!! По роду проф. деятельности булэктомия с плевродезом показана после первого пневмоторакса.Курить бросать полезно, но в плановом порядке. Пилоты комmерческих авиалиний зарабатывают более 150 килозелени в год и менять свою работу из-за неправильных рекомендаций врачей не будут!

[Gilarov]

Думаю, что А... И пусть летает.

[yananshs]

The correct answer is A. A spontaneous pneumothorax can recur especially if associated with bulla. In patients with high risk due to the possibility of recurrence, a first episode of a pneumothorax deserves definitive treatment. Airline pilots and patients living away from hospital facilities are at risk for morbidity and mortality from recurrence of a pneumothorax when they are far from treatment facilities. Hence, this patient needs to be advised to undergo definitive treatment for resection of the bulla before resumption of duties.

Oxygen is helpful in treating a pneumothorax when it is of small percentage and asymptomatic. A sudden high percentage of a pneumothorax cannot be cured by oxygen (choice B).

A pneumothorax from a bulla can be treated and recurrence can be avoided by bullectomy and pleurodesis. Hence, changing careers is not essential (choice C).

Quitting smoking (choice D) has no association with avoiding the recurrence of a pneumothorax.

After appropriate treatment of pneumothorax, the recurrence risk is small and duties can be resumed as soon as possible. Taking rest has no association with avoiding recurrence of a pneumothorax (choice E).

[yananshs]

A 37-year-old man comes to the clinic because of bright red blood on the toilet paper with bowel movements. He can also feel "bumps" around his anus and wonders if they are hemorrhoidal masses. He tells you that he has had difficulty gaining weight in the past few years and admits to occasional heroin usage and multiple sexual partners. On examination, he appears emaciated with temporal wasting and lipodystrophy of the face. There are multiple moist, pink cauliflower-like 0.2 - 0.5 cm papules surrounding the anus. Digital rectal examination reveals guaiac-negative, brown stool. He consents to whatever you think is appropriate management. At this time you should
A. perform anoscopy
B. recommend increased fluid intake and a high fiber diet
C. refer him for resection of condylomata acuminata
D. refer him for resection of hemorrhoids
E. send studies for sexually transmitted diseases including HIV

[Rodionov]

Учитывая отсутствие острой ситуации, думаю, Е.

[Dr. Vadim]

Ну, у этого парня светлое будующее , но пока E.

[yananshs]

The correct answer is E. You should send studies for sexually transmitted diseases, is correct because his complex sexual history, temporal wasting, lipodystrophy of face, and genital warts (condylomata acuminata) all point toward high risk for HIV. Condylomata acuminata occur in men anywhere on the penis or about the anus. When perianal lesions occur, a prior history of receptive anal intercourse will usually predict whether intra-anal warts are present and will help to determine the need for anoscopy. Genital warts are sexually transmitted. A complete history should be taken and the patient should be screened for other sexually transmitted diseases as appropriate.

Anoscopy (choice A) is unnecessary at this time. The bright red blood on the toilet paper for this patient is most likely secondary to irritation of the friable genital warts.

Increased fluid intake and a high fiber diet (choice B) are appropriate for hemorrhoids, not HPV.

Referral for general surgery for resection of condylomata acuminata (choice C) is incorrect. This may be appropriate as follow-up care for this patient, but the most important first step is to work him up for HIV.

Referral to general surgery for resection of hemorrhoids (choice D) is incorrect because this patient has HPV, not hemorrhoids.

[yananshs]

A 14-year-old boy is brought to the office by his mother because of "bedwetting" episodes that have been occurring about twice a week for the past few months. The mother says that she noticed this "problem" when she washed his pajamas, and he "refused" to talk about it when she tried to bring it up. She is hoping that he will talk to you. You ask her to leave the room so you can have some privacy with her son. He starts the conversation by stating that "this is getting embarrassing" and he "doesn't understand what's going on." He says that he gets up and finds his pajamas "wet and sticky." He denies any dysuria or frequency during the day, and denies any problems at school or at home. He is on the basketball team, socializes with friends, and gets good grades. Physical examination is unremarkable and shows a pubic hair stage of Tanner IV and genital development Tanner stage III. The next best step is to
A. advise him to stop drinking water at 8 pm and urinate before bed
B. begin a 3-day treatment regimen with trimethoprim-sulfamethoxazole
C. obtain a urine sample for culture and sensitivity
D. order a renal ultrasound
E. reassure him that this is a completely normal part of puberty

[papadoctor]

The boy is growing!Good!

[yananshs]

Good.
The correct answer is E. This adolescent boy is most likely having nocturnal emissions ("wet dreams"), which are a normal part of puberty. A nocturnal emission is when the penis becomes erect during sleep and ejaculates. If the boy or his mother do not know about nocturnal emissions before they occur, they may think that he urinated. He should be reassured that this is normal. It is also important to discuss it with his mother so she does not make him feel uncomfortable about it in the future.

It is not necessary to advise him to stop drinking water at 8 pm and urinate before bed (choice A) because he is having a nocturnal emission, which is not related to urination.

It is inappropriate to begin a 3-day treatment regimen with trimethoprim-sulfamethoxazole (choice B) because this boy is most likely having nocturnal emissions, not a urinary tract infection. Nocturnal emissions are normal and do not require treatment.

It is not necessary to obtain a urine sample for culture and sensitivity (choice C) or a renal ultrasound (choice D) because this boy is most likely having nocturnal emissions, which are not related to urinary tract infections (UTI). He does not have the symptoms of a UTI, which include frequency, dysuria, and nocturia. The nighttime "wetness and stickiness" that he describes is most likely due to semen, not urine.

[yananshs]

A 34-year-old man is admitted to the intensive care unit after an exploratory laparotomy. The patient was in a high-speed motor vehicle accident a few hours prior and on arrival to the emergency department there was evidence of a severe liver laceration. The patient was brought emergently to the operating room. While under anesthesia, the patient had a left subclavian central line placed. The line was used for drug and blood product delivery during the surgical procedure with no apparent complications. The most important management when he arrives in the intensive care unit is to
A. aspirate of the central line injection port
B. do nothing since the line was used without issue
C. obtain a chest radiograph
D. order an echocardiogram
E. order an intravenous contrast study under fluoroscopy

[papadoctor]

I gonna be quiet for a little while.

[riltsov]

Пусть будет:
C. obtain a chest radiograph
Посмотреть положение central line, и исключить осложнения.

[yananshs]

Другие мнения?