Еще одна пилюлька Hескучина

[riltsov]

C. Meniere's disease

[Dr. Vadim]

Болезнь Меньера Ответ С

В завуалированном виде описан симптом системного головокружения. Кроме того, высокочастотный звук/шум звон (ringing) в ушах, снижение слуха на одно ухо и нистагм.

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[Gilarov]

Я тоже думаю, Меньер.

[alex_md]

Хватит решать детские задачки, давайте попробуем на сербезные вопросы ответить из борда по медицине . Тут вроде как форум для терапевтов. Ок for the starters...

46 y/o woman with rheumatoid arthritis is evaluated in your office with complaints that a nodule that was present on her elbow has increased in size. She has also developed similar noduler on the Achilles tendons bilaterally. Currently she takes methotraxate in the dose of 17.5 mg per week and naproxen 500 mg 2 times per day. This regiment has aleviated her pain and now her morning stiffnes lasts only for 30 min versus 2 hours before the treatment began. On examination the nodules are hot warm to touch and her joint overall inmproved. No other abnornalities found. What do you do next?

a) Biopsy of the newly developed nodule
b) Reassurence
c) Skin test for TB
d) Measure serum uric acid
e) Discontinue methotrexate and start prednisone 40 mg per day

[alex_md]

A 36 y/o woman has just completed a 6 month course of anticoagulation treatment for pulmonary embolism. She comes to your office for advice regarding the discontinuation of anticoagulation. She has been using oral contaceptives for ten years when the embolism was diagnosed. She stopped right away. She has no family history of thrombosis. You advised her to stop the anticoagulation and go for blood tests. Two weeks after she was taken of the warfarin she was found to be heterozygouse for the protrombin G20210A mutation. What is your nest step?

a) Resume oral anticoagulation with terget 2-3
b) Resume anticoagulation with target 1.5-2.5
c) Aspirin 81 mg daily
d) Prescribe a combination of ASA and dipyridamole
e) No anticoagulation needed

[alex_md]

43 y/o male has aplastic anemia and did not respond to immunosupressive therapy. He remains transfusion dependent for the platelets and red cells. He has HLA identical brother who was cleared for potential allogenic stem cell transplant. They are both CMV negative. What would be prevemted by using irradiated blood products in this patient?

a) CMV disease
b) Alloimmunisation
c) Transfusion related GVHD
d) Febrile non-hemolytic transfusion reaction
e) Hemolytic transfusion reaction

[alex_md]

25 y/o woman comes to your office to initial visit. She is healthy but has a family history of cancer. Her mother had a lung cancer in the age of sixty and her father had a head and neck cancer. She wants to know what she can do to reduse the risks of these cancers. In addition to not smoking which of the following has being shown to reduce the risks of both of this cancers?

a) Avoidance of alcohol
b) Daily intake of antioxidant vitamins
c) Avoidance of exposure to benzene
d) Daily intake of betta-carotene
e) Anual physical examination

[riltsov]

Задачка №1. Я предполагаю, что эти узелки образовались в связи с гиперурикемией.
Следовательно, ответ: d) Measure serum uric acid. Хотя, это ответ слишком прост, чтобы быть правильным...

Задачка №2. protrombin G20210A mutation повышает риск тромбоза. Однако, пациентка молода, семейный анамнез не отягощен, гормональные контрацептивы, надеюсь, остались в прошлом. Достаточно ли 6-имесячного курса антикоагуляции? Сложная ситуация, но решение принимать надо. Разрываюсь между b) и e). Рискну ответить так:
e) No anticoagulation needed

Задачка №3. Ответ к этой задачке без Гугла найти невозможно. GVHD - graft-versus-host disease. Облучение крови инактивирует лимфоциты. Ответ : c) Transfusion related GVHD

Задачка №4. Ответ: e) Anual physical examination! Однозначно!

[Anton Verbine]

[quote=alex_md]
No 1
b) Reassurence
...typical place /setting for rheum. nodules. Prob. "accelerated " nodulosis. As far as I know- not a sign of progression, otherwise tolerates Mtx fairly well , fair control- no need to discontinue or change.

No 2
a) Resume oral anticoagulation with target 2-3
High-risk episode in inherent thrombophilia = minimum 12 mo of anticoagulatiom. Besides, seems to tolerate warfarin fairly good.

No 3
b) Alloimmunisation, my simple guess.
...nobody told that blood transfused is from that relative donor...

No 4
a) Avoidance of alcohol. Kinda weak association with lung Cr, but definite with head and neck. Rest- does not seem to reduce the risks.

[thorn]

N1. b) Reassurence... разгибательная поверхность...похоже на ревматоидные узелки
N2. e) однозначно 6 месяцев достаточно...есть provoked VTE event...при гетерозиготе PT G20210A достаточно
N3. с) Transfusion related GVHD... это типа "трансплантат-против-хозяина"?
N4. a) Avoidance of alcohol ...жаль девушку лишать такого удовольствия но и anual physical examination как-то не в кассу

[yananshs]

If annual physical examination includes PAP-smear, then #4 - e.
P.S. Sorry, I was completely wrong:

Сообщение от alex_md

the risks of both of THESE cancers

Тогда, конечно, алкоголь.

[alex_md]

1/ You are correct. On Mtx treatment we do sometimes see increase in the nodule size and and also new nodules can appear. This is not a reason to stop treatment.

2/ Heterozygouse factor II does NOT increase the risks of recurrent VTE. Six months is Ok. (The risk of recurrent venous thromboembolism among heterozygous carriers of the G20210A prothrombin gene mutation.
AU De Stefano V; Martinelli I; Mannucci PM; Paciaroni K; Rossi E; Chiusolo P; Casorelli I; Leone G SO Br J Haematol 2001 Jun;113(3):630-5.)

3/ Transfusion related Graft-Versus-Host disease can be prevented by irradiating the blood products. Normally transfusion related GVHD does NOT happen because the donor WBCs are killed by the hosts immune system. There are two reasons why this can occure. 1/ immunosupression 2/ partial or complete HLA match. This second reason is why all blood products (platelets, RBCs etc) should be irradiated. By the way there in NO treatment for transfusion related GVHD, mortality 90%.

4/ As you rightly pointed out thre is a connection between the alcohol and those cancers.

[Dtver]

У меня 25 % В активе первая задача за счет фразы у Харрисона: «In some patients, treatment with methotrexate can increase the number of nodules dramatically».

Решая вторую, опирался на следующее: «For patients with a first episode of PE who have documented deficiency of аntithrombin, deficiency of protein C or protein S, or the factor V Leiden or prothrombin 20210 gene mutation, homocysteinemia, or high factor VIII levels (90th percentile of normal), we recommend treatment for 6 to 12 months (Grade 1A).
We suggest indefinite therapy as for patients with idiopathic PE (Grade 2C)».
А также «We recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (range, 2.0 and 3.0) for all treatment durations (Grade 1A). We recommend against high-intensity VKA therapy (INR range, 3.1 to 4.0) [Grade 1A]. We recommend against low-intensity therapy (INR range, 1.5 to 1.9) compared to INR range of 2.0 to 3.0 (Grade 1A)».
Source: Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126;401-428.
И там не сказано, что «Heterozygouse factor II does NOT increase the risks of recurrent VTE»

Про третью позорно промолчу, а про четвертую… У того же Харрисона, равно как и в Manual of Clinical Oncology by Dennis A. Casciato, Barry B. Lowitz, 2000 сказано: «Alcohol and tobacco use are the most common risk factors for head and neck cancer in the United States». Странно, но ни там, ни там ничего не сказано про алкоголь и рак легких

Резюме: уважаемые Александр и Яна, продолжайте, пожалуйста

[alex_md]

Денис, это не самые простые вопросы. Что касается протромбина, то многие не обратили внимание на гетерозиготность.Ну, думаю, что все, кто хотел уже поучаствовал. Продолжим.

1
27 y/o man of Arab ancestry came to you office (in Bronx) complaining of one week history of fever rash and muscle pains. The patient remembers that the epizode began with headache and fatigue? followed within few hours with fever (102 (38.9)) and chills. The fever responded partially to Tylenol but persisted all week.
With the fever patient also developed a large red painfull area on the right thigh, that has now migrated to the right calf.
The patient had similar episode 6 months ago that lasted for two weeks. Within the last few years he was also treated for unexplained fever and pleuritis that responded to prednisone 20 mg per day. He was hospitalised once for unexplained fever and abdominal pain.
As a child he had intermittent knee swelling and was diagnosed with juvenile RA. Nobbody in the family has similar problems but he remembers that his mother had some problems with abdominal pain and redness of the eyes.
On exam his temp is 102. He has a VERY tender red macular rash on the right calf. No other abnormalities. Joints are normal.

Labs:
WBC 16000 (86% Neutr)
ESR 120
CK - 58
CRP 6.2
RF- 25

What is most lickely to establish the diagnosis
A. Therapeutic trial of colchicine for 2 months
B. MRI of the calf
C. Sequensing of exon 10 of MEFV for mutation in purine protein
D. Measure serum ferritin
E. Sequescing TNFRSF1A for mutation in TNF factor receptor

2.
Your friend 50 y/o surgeon has come to your office complaining of severe pain in the right inguinal area, lowere back and hands. The pain gets worse when he walks and gets very bad in the evening. On examination external rotation of the hip causes severe groin pain. The second, third and fourth MCP joints are swollen, tender and warm. X-Ray shows severe osteoarythritis of the right hip.
Which in the best test to confirm the diagnosis?
A. Rheumatoid factor
B. HLA-B27
C. Serum iron and TIBC
D. Fasting glucose
E. Serum uric acid

[alex_md]

3
54 y/o man has 4 months history of diarrhea and 5 kg weight loss. He reports a childhood history of diarrhea. Physical exam is normal. The blood tests show hypokalcemia, macrocytic anemia and prolonged PT. Bone DEXA shoes T score -3.5. Upper endoscopy with small bowel biopsy is done. The mucosa samples show severe villous atrophy and increased intraepithelial lymphocytes. The patient is placed on strict gluten-free diet but his symptoms did not improve and he lost another 4 kg in the next two months. What is the most likely reason for not responding to the diet.
A. Presence of chronic pancreatitis
B. Intestinal lymphoma
C. Intestinal carcinoma
D. Noncompliance
E. Ulcerative jejunitis