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#1007
29.12.2006, 17:28
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Pure guess: stool for O&P.
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#1008
29.12.2006, 19:24
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The correct answer is C. This patient most likely has acute giardiasis, which is a common infection that affects hikers and campers that drink water from streams. The symptoms include diarrhea or loose stools, bloating, flatus, abdominal pain, nausea, and vomiting. The diagnosis can be established by identifying cysts or trophozoites in the stool or duodenal fluid. The most appropriate next step in this case is to examine his stool for ova and parasites.
Asking him to bring in 5 stool samples over the next 5 days (choice A) is a bit ridiculous. This patient most likely has acute giardiasis. A stool sample sent for ova and parasites may establish the diagnosis and then he should be treated with metronidazole. It is recommended that at least 3 stool samples be examined to establish the diagnosis of giardiasis, but asking him to do this for 5 days will most likely lead to an unhappy and noncompliant patient. In this patient who most likely has acute giardiasis, obtaining a sample of duodenal fluid (choice B) is excessive and not cost effective. It may be helpful in establishing the diagnosis, but it should not necessarily be done in every case of acute giardiasis. It may be useful in patients that you suspect have chronic giardiasis that cannot be proven with less expensive and invasive studies. Since this patient most likely has giardiasis, a stool sample should be examined for ova and parasites. After this establishes the diagnosis, it is appropriate for you to prescribe a 5-day course of metronidazole (choice D). This patient most likely has acute giardiasis and therefore it is incorrect to reassure him that this condition is self-limited and that no treatment is indicated (choice E). Untreated giardiasis may lead to chronic infection. This patient most likely has giardiasis and requires treatment. Having him tell his friends to schedule an appointment (choice F) may be a good idea if they have the same condition, but it is not the next step in caring for this patient.
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#1009
29.12.2006, 19:25
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A 51-year-old woman with end-stage liver disease due to cryptogenic cirrhosis is being cared for by your medical team. She was recently admitted for increasing abdominal girth and confusion. She was diagnosed with cirrhosis and portal hypertension 3 years ago and has long-standing ascites and 2 previous admissions for hepatic encephalopathy. She has no allergies. Her current medications include oral lactulose, ofloxacin, spironolactone, and furosemide. Over the past few days, the team has been attempting to reduce her ascites by both repeated large-volume paracentesis and aggressive diuresis. The patient has been having four to five bowel movements daily while on lactulose. On reviewing the morning laboratory data, the following values are noted:
Day 1: Sodium 126 mEq/l, Potassium 3.2 mEq/l, BUN 20 mg/dl, Creatinine 1.1 mg/dl Day 2: Sodium 129 mEq/l, Potassium 3.5 mEq/l, BUN 29 mg/dl, Creatinine 1.4 mg/dl Day 3: Sodium 134 mEq/l, Potassium 4.2 mEq/l, BUN 33 mg/dl, Creatinine 1.7 mg/dl Day 4: Sodium 142 mEq/l, Potassium 4.8 mEq/l, BUN 41 mg/dl, Creatinine 2.1 mg/dl Day 5: Sodium 148 mEq/l, Potassium 5.2 mEq/l, BUN 55 mg/dl, Creatinine 2.9 mg/dl The most important management is to A. administer sodium polystyrene sulfonate, orally B. bolus 500cc of normal saline C. discontinue the furosemide D. discontinue the spironolactone E. obtain a 12 lead electrocardiogram
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#1010
29.12.2006, 19:44
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Цитата:
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#1013
29.12.2006, 20:09
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ЭКГ нужно снять обязательно! Собственно у меня было две конкурирующих догадки: спиронолактон отменить или ЭКГ снять. Выбрал все-таки отмену спиронолактона, т.к. калий не очень высок, пока только 5.2.
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#1014
29.12.2006, 20:37
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The correct answer is D. Aggressive diuresis and fluid management is the mainstay of therapy for ascites related to liver failure. In the case of this patient, the aggressive diuresis has caused progressive renal insufficiency. The potassium sparing diuretic spironolactone is only worsening the hyperkalemia and should be promptly discontinued until the patient's renal function returns to normal.
Administering sodium polystyrene sulfonate orally (choice A) would be indicated if a 12 lead EKG suggested evidence of hyperkalemia (QRS changes, T wave elevations). Kayexalate is a potassium binding resin used to lower serum potassium. Bolus 500cc of normal saline (choice B) may help with the worsening pre-renal failure, but will not reverse the problem in a definitive manner. Discontinuing the furosemide (choice C) is not the primary diuretic to address, since by keeping spironolactone, the potassium elevation will likely only worsen. Obtaining a 12 lead electrocardiogram (choice E) is not unwise but given that the potassium is not severely elevated, discontinuing the offending diuretic is the most important concept to grasp. Blindly checking an EKG for a marginally elevated potassium misses the point of a rising creatinine and potassium in the setting of aggressive diuresis.
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#1015
29.12.2006, 20:38
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A 48-year-old woman comes to the office because of a "mole". On examination, a single 0.4 cm benign-looking lesion is noticed on the forearm. No other similar lesions were noted. She asks you to remove the lesion today. After obtaining informed consent, you proceed to remove the lesion under local anesthesia. She collapses after the removal of the lesion. Her blood pressure is 76/0 mm Hg, pulse is 48/min, and respirations are 24/min. The most appropriate initial management is
A. administration of atropine, intravenously B. administration of epinephrine, intravenously C. administration of naloxone (Narcan) D. endotracheal intubation E. rapid administration of 1000 ml of normal saline solution
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#1018
29.12.2006, 22:20
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The correct answer is B. Anaphylactic reaction from local anesthetic causes sudden cardiovascular collapse, manifested by hypotension. While adhering to the ABC rule of resuscitation, this patient's airway is clear, and she is breathing without any support. Her blood pressure needs to be improved immediately by administering intravenous epinephrine, as prolonged hypoperfusion to the brain may result in complications.
This patient's heart rate is reasonable and therefore intravenous atropine (choice A) is not going to help in resuscitation. Also, increased heart rate might decrease diastolic ventricular filling, and may result in increased hypotension. Naloxone (choice C) is a specific antagonist for morphine, which was not administered in this patient. She received local anesthetics, not morphine. Endotracheal intubation (choice D) is not indicated in a patient who is breathing comfortably with a good respiratory rate and adequate tidal volume. Because of anaphylactic reaction, this patient's peripheral vascular system is vasodilated. Administering rapid infusion of 1000 ml. of intravenous fluid (choice E) is not going to raise the blood pressure unless the vasodilatation is reversed by intravenous epinephrine.
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#1019
29.12.2006, 22:20
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A 67-year-old woman comes to the office because of "ringing in her ears," a feeling of "spinning", and a progressive loss of hearing in her right ear over the past 5 months. She says that this all began "a while ago with a slight feeling of unsteadiness." She never went to the doctor because she thought she was "going crazy," but now her husband is getting worried because the television needs to be much louder and she constantly says "what?" when he speaks to her on her right side. She has no chronic medical conditions, does not take any medications, and does not drink alcohol. Examination shows nystagmus, but no other abnormalities. The most likely diagnosis is
A. benign positional vertigo B. benign recurrent vertigo C. Meniere's disease D. toxic labyrinthitis E. vestibular neuronitis
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#1020
30.12.2006, 02:04
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Acoustic neuroma.
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Линейный вид
