Еще одна пилюлька Hескучина

[peebody]

для начала а) проверить отток

[yananshs]

The correct answer is C. All central line placements are associated with complications. The nature and incidence of those complications are site specific. For subclavian lines, the incidence of pneumothorax is between 1-3% and for this reason, all line placements must have a follow-up chest x-ray to document that none exists.

Aspiration of the central line injection port (choice A) should have been done prior to using the line to be certain that it was intravascular and to remove free air. Since the line was used in the operating room, there is no reason to perform this maneuver again.

Because the line was used successfully in the operating room does not mean that no diagnostic testing is required since the line was used without issue (choice B). This is because a pneumothorax does not exclude a normal intravascular placement of the line. The complication could have occurred (as it usually does) during the "seeker" phase of the line placement.

There is no need for an echocardiogram (choice D) unless there is a high suspicion that air was entrained during placement of the line. Such a suspicion usually presents because of an obvious air entrainment during the procedure, or because the patient is complaining of shortness of breath or is hypotensive secondary to air embolism.

An intravenous contrast study under fluoroscopy (choice E) is not required for routine central line placement but is often used during Port-a-cath placement to determine vessel patency after the procedure.

[yananshs]

A 32- year-old woman is brought to your emergency department following a suicide attempt. She tells you that she has ingested an entire bottle, approximately 250 tablets, of acetaminophen prior to calling the emergency medical technicians. On arrival, she is complaining of nausea and diaphoresis. Her medical history is significant for depression and multiple prior suicide attempts. She is not on any medications and denies allergies. She also denies ingestion of other substances. She is awake and communicative. Her temperature is 37 C (98.6 F), blood pressure is 120/67 mm Hg, pulse is 78/min, and respirations are 25/min. Physical and neurologic examinations are unremarkable. A tube is placed into the stomach and multiple pill fragments are obtained with aspiration. Based upon the available data, the most appropriate next intervention is
A. administration of acetyl cysteine
B. administration of amyl nitrite
C. administration of ethanol
D. administration of methanol
E. administration of pyridoxine

[Anna_Shvedova]

Я думаю, А

[dr.Ira]

А. N-acetylcysteine (NAC) is an effective antidote for acetaminophen-induced hepatotoxicity resulting from an acute overdose, especially if administered within 8-10 hours after ingestion.

[Rodionov]

Нашла чем травиться! У неё запасная печень в шкафу что ли лежит??

[Dr.]

А так, кроме А ничего не остается, поскольку все остальные антидоты к ядам, которые не относятся к таблеткам, которых можно выпить многих и от которых помирают не быстро (типа цианида ((амилнитрит), который, может, и есть в таблетках для ЦРУ, но тогда бы ее не довезли или метанола (этанол)) и т.д. Кстати, в Москве тоже бывают такие отравления, к нам как-то привозили, я даже на конференции умничал про ацц

[papadoctor]

Да это просто! Следующий случай, пор фавор!

[yananshs]

The correct answer is A. Acetyl cysteine is used as an antidote for acetaminophen toxicity and works by functioning as a glutathione substrate in the hepatic clearance of acetaminophen.

Amyl nitrite (choice B) can be used in the treatment of cyanide toxicity, but has no role in the management of acetaminophen toxicity. In cyanide toxicity, amyl nitrite acts like sodium nitrate in converting hemoglobin to methemoglobin, which will bind cyanide avidly and remove it from plasma.

Ethanol (choice C) is used in the treatment of methanol toxicity, but has no role in the treatment of acetaminophen toxicity. Infact, co-administration of ethanol in the setting of acetaminophen overdose can significantly exacerbate hepatic toxicity.

Methanol (choice D) is not used in the treatment of acetaminophen toxicity. Indeed, methanol is not used as an antidote for any toxic agent and is itself associated with significant toxicity from its conversion to formic acid.

Pyridoxine (choice E) is used as an antidote for isoniazid (INH) toxicity, but has no role in the management of acetaminophen toxicity.

[yananshs]

A 26-year-old Spanish-speaking woman presents to your clinic for a bruised left arm. The patient is a local woman who speaks no English and has recently moved to this area from overseas. She works at the local telephone company and has moved in with her fiancee. This is her fourth visit to the clinic for various bruises and injuries. On this visit she has a diffuse ecchymoses and purpura over her entire left arm and forearm in the shape of “hand prints.” She claims that she fell while walking down the stairs. On her previous visits, she has had similar bruises on her chest, abdomen, and back, all of which she attributed to various “falls”. She is otherwise healthy, denies tobacco or alcohol. She does report that he fiancee drinks ethanol to intoxication quite frequently and has recently lost his job. She is somewhat tearful when mentioning him. Her physical examination is remarkable for the left arm bruising as above, various bruises in her back and abdomen is various stages of healing, and a valgus deformity of her left leg. The remainder of her examination is unremarkable. The most appropriate course of action is to
A. ask the patient in simple, direct language if she has been hit by her fiancee
B. contact the police for intervention
C. no action is indicated as the patient has no active medical issues
D. no action is indicated as the patient will be offended and leave the clinic
E. question the patient in the presence of other health care workers in the clinic

[riltsov]

Domestic violence.
A. ask the patient in simple, direct language if she has been hit by her fiancee
Потом, возможно, нужно будет полицию подключить.

[yananshs]

The correct answer A.

Ask the patient in simple, direct language if she has been hit by her fiancee. Because of the high prevalence of domestic violence (DV) and the wide range of clinical settings in which it can be seen, routine screening must be a part of preventative care. A number of studies have demonstrated reasonable sensitivity for the Partner Violence Screen that consists of three simple and direct questions.
Contacting the police (choice B) is not appropriate given that it has not even been established that this patient suffers from DV and you should first try to address the issue with the patient.
There are a number of barriers to effective physician screening of DV; the belief that no action is indicated as the patient has no active medical issues (choice C) as well as that no action is indicated as the patient will be offended and leave the clinic (choice D) are among the more common reasons.
It is vital to make the patient feel safe and secure and to question them in private (choice E).

[yananshs]

A 32-year-old woman comes to the clinic with recurrent attacks of anxiety and fear of dying of a heart attack. The attacks are accompanied by shortness of breath, dizziness, tingling, sweating, and tightness in her chest. They started after she had almost fainted in the subway once, a couple of months ago. The attacks have increased in frequency now, and appear without an obvious precipitant. She has limited her activities to the house and tries to avoid driving far from home for fear of having another "heart attack". She insists on having every single test to find out what is happening to her because she had a bad attack the night before, and almost went to the hospital. Her prior medical history is significant only for 1 ectopic pregnancy 7 years ago. She does not smoke, drink alcohol, or use drugs. She is not taking any over the counter medication on a regular basis. She has never seen a psychiatrist, but reports having a fear of water after she had almost drowned as a child in the lake. Her physical examination is unremarkable. Before you can establish a diagnosis of panic disorder you should order
A. cardiac enzymes
B. echocardiogram
C. electroencephalogram
D. serum theophylline level
E. thyroid function tests

[riltsov]

Диагноз: Паническое расстройство.
Снять ЭКГ необходимо, прежде всего, для успокоения пациентки. Нормальная экг убедит пациентку в том, что её сердце в порядке!

ЭКГ также сможет, в какой-то мере, исключить аритмогенную природу заболевания.

C. electroencephalogram

[riltsov]

Ой... что-то я не доглядел... Видимо хотел увидеть ЭКГ в вариантах ответов! И увидел!

Все равно рассматриваю вариант С. для исключения эпилепсии, также актуален вариант Е. для исключения тиреотоксикоза.
Вариант B. подходит для успокоения пациентки! Я бы остановился на этом варианте. Но допустимо ли назначать ненужное исследование?
Я теряюсь в догадках! Буду думать!