Еще одна пилюлька Hескучина

[Dtver]

Как то "меня терзают смутные сомнения". По клинике, конечно, похоже на IBD. Но формально мы имеем дело с Acute Inflammatory Diarrhea, значит, выбираю С.

[riltsov]

Сообщение от Dtver

Как то "меня терзают смутные сомнения". По клинике, конечно, похоже на IBD. Но формально мы имеем дело с Acute Inflammatory Diarrhea, значит, выбираю С.

Кстати, сам изначально именно поэтому хотел остановиться на варианте С. Но результат посева будет нескоро, результат КТ станет очевидным сразу. Признаки IBD в анамнезе игнорировать не стоит. У этого пациента может быть осложнение IBD.
Я выбираю КТ.

[Dtver]

Уважаемый Александр Юрьевич, Вы путаете: в анамнезе у пациента "irritable bowel syndrome". В этой связи очень сильно не хватает информации о том, как ведут себя текущие боли по ночам, нарушен ли сон, но лихорадка все равно заставляет предположить что то более серьезное, чем IBS (СРК по нашему).

Подождем Яну с ответом

[yananshs]

The correct answer is E. Although this patient carries the diagnosis of irritable bowel syndrome, his presentation on this occasion has some elements that are concerning. In particular his fever and impressive abdominal examination coupled with his diarrhea and pain raise a high suspicion for an acute abdomen of some variety. This process may or may not be related to any existing abdominal pathology that this patient may have. He requires imaging of his abdomen to rule out an acute abdominal process such as abscess, pancreatitis, appendicitis, or even colitis.

Prescribing corticosteroids (choice A) or loperamide (choice B) and seeing the patient in two weeks presumes that this presentation has a similar etiology to his past presentations. Again, the impressive abdominal examination and fever makes the likelihood of this being related simply to irritable bowel syndrome very unlikely.

A stool Gram stain and culture (choice C) would be useful, but not more so than abdominal imaging.

Arranging for an immediate colonoscopy (choice D) is not correct for two reasons. First, the bowel preparation required for a good study doesn't make this test useful for acute situations. Secondly, the test limits visualization of possible etiologies to those that affect the large bowel.

[yananshs]

A 31-year-old man with insulin dependent diabetes mellitus is admitted to the hospital because of a severe diabetic crisis. His wife reports that over the past few days he has developed "the flu." During that time, his blood sugars had become much more difficult to manage despite diligent attention. She states that over the past 24 hours his sugars have been above 500 mg/dL despite insulin and diet control, that have always controlled the sugars in the past. The patient began to breathe very fast in the last 8 hours and he has become somewhat confused in the past 4 hours. His temperature is 38.0 C (99.6 F), blood pressure is 140/85 mm Hg, pulse is 88/min, and respirations are 24/min. His urine is 4+ for ketones and sugar. A fingerstick blood glucose reveals a blood sugar of 850 mg/dL. An arterial blood gas would most likely show:
A. PaCO2 14 mm Hg, pH 7.12, PaO2 60 mm Hg
B. PaCO2 14 mm Hg, pH 7.22, PaO2 90 mm Hg
C. PaCO2 14 mm Hg, pH 7.38, PaO22 90 mm Hg
D. PaCO22 35 mm Hg, pH 7.36, PaO2 90 mm Hg
E. PaCO2 68 mm Hg, pH 6.80, PaO2 60 mm Hg

[papadoctor]

"Что-то слышиться родное" (С). Где неделю назад подобному кадру проводили аппендектомию по поводу гангренозного аппендицита. До 850 сахер недотянул,- был менее 700, но не намного!

[riltsov]

К сожалению, по этой задачке аргументировано рассуждать не могу. Положусь на интуицию, выберу вариант с самым низким рН.
E. PaCO2 68 mm Hg, pH 6.80, PaO2 60 mm Hg

[Aladdyn]

B. PaCO2 14 mm Hg, pH 7.22, PaO2 90 mm Hg
Мне кажется, что не Е потому, что и ацидоз не предельный должен быть (такой скорее для отравления метанолом характерен), и компенсаторный респираторный алкалоз должен развиваться при наличии Куссмауля, и гипоксии быть не должно. Хотя я тоже, конечно, не эндокринолог, могу ошибаться.

[Anton Verbine]

Сообщение от Aladdyn

B. PaCO2 14 mm Hg, pH 7.22, PaO2 90 mm Hg
... и гипоксии быть не должно. .

V principe, logichno. Molodoj paren' s diabetom- tiabet 1-go tipa- ketoacidoz. Ishem metabolicheskij acidoz. Teper' ostalos' vybrat' iz dvuh- acidoz pomen'she- i bez gipoksii, ili- acidoz pobol'she, i s nekotoroj gipoksiej.
Ja by vybral pobol'she, i s gipoksiej- A., t.k, vo- pervyh, zdorovyj do jetogo chelovek- "sputalsja", a vo-vtoryh- s chego-to jeto dolzhno bylo nachat'sja- byli kakie-to simptomy so storony respir. sistemy- pochemu by ne pnevmonija?

[yananshs]

The correct answer is B. When looking at arterial blood gases, examine the pH to identify the acid-base disturbance and then determine whether the acid-base disturbance is respiratory (change in CO2) or metabolic. The relationship between PaCO2 and pH determines whether the condition is acute or chronic. Chronic conditions have a pH closer to 7.4 than would be predicted based upon PCO2 because of compensation. This patient has diabetic ketoacidosis. This condition occurs when some event "pushes" the patient over the edge and they are unable to regulate glucose balance. Typical events include infection or stress. For this man, his primary problem is a metabolic acidosis that will cause him to hyperventilate to compensate for. His oxygenation will be essentially normal since he has no pulmonary pathology: PaCO2 14 mm Hg, pH 7.22, and PaO2 90 mm Hg.

A PaCO2 of 14 mm Hg, pH of 7.12, and PaO2 of 60 mm Hg (choice A) reflects a profound metabolic acidosis with hypoxemia. This is not DKA but perhaps a condition such as sepsis or cyanide poisoning.

A PaCO2 of 14 mm Hg, pH 7.38, and PaO2 90mm Hg (choice C) represents a chronic acidosis. The pH is mildly acidic with a very low PaCO2. For this PaCO2, the patient should be alkalotic, but since he is not, it must have increased the pH from a very low level to near normal. This is the hallmark of a compensated metabolic acidosis. This can be seen with conditions such as Type I and II renal tubular acidosis.

A PaCO2 of 35 mmHg, pH 7.36, and PaO2 of 90 mm Hg (choice D) is a compensated metabolic acidosis. The PaCO2 is nearly normal which suggests the acidosis is mild. Such mild acidosis can occur with specific renal tubular disorders or with chronic diarrhea.

A PaCO2 of 68 mmHg, pH 6.80, and PaO2 of 60 mm Hg (choice E) represents a combined metabolic/respiratory acidosis. The patient has a severe acidosis (pH), the expected PaCO2 should be low to compensate. Instead, it is high. The patient also has hypoxemia. This is typical of severe respiratory failure. Hypoxia causes a metabolic acidosis and the pulmonary system cannot compensate.

[yananshs]

A 27-year-old man comes to the emergency department because of an "exquisitely painful" scrotum. He says that he was walking to lunch with friends when the pain hit him "like a thunderclap." He says that he has a steady girlfriend and that they have an "active sex life." He is "very healthy" and has never experienced pain like this before. He regularly checks himself "there" after that young comedian underwent testicular surgery on television. His temperature is 37 C (98.6 F), blood pressure is 130/85 mm Hg, pulse is 86/min, and respirations are 19/min. Physical examination shows severe scrotal tenderness that is not relieved when the scrotum is elevated. The right testes is high in the scrotum and riding in a horizontal position. The cord above the testes is not tender. A urinalysis shows:

Color straw/light Microscopic
Specific gravity 1.020 WBC 4/hpf
pH 5.8 Glucose absent
Protein absent Bacteria absent

The most appropriate next step is to
A. administer ciprofloxacin, intravenously
B. apply ice packs and observe in the emergency department
C. measure serum HCG and AFP
D. perform a trans-scrotal testicular biopsy
E. request a urology consultation, STAT

[riltsov]

Заворот яичка.
E. request a urology consultation, STAT

[vosk]

судя по описанию, похоже на testicular torsion. как же это у урологов по-русски называется? в общем, думаю надо их и вызвать, пусть там разворачивают как положено.

E. request a urology consultation, STAT

Dmitry Voskovets
PS: а что такое STAT?

[riltsov]

Сообщение от vosk

PS: а что такое STAT?

С помощью интернета нашел ответ на этот вопрос.
Statim = 'Immediately' in Latin. 'STAT' is a medical abbreviation implying urgent or rush

[yananshs]

The correct answer is E. This patient has the classic presentation of testicular torsion, which is a surgical emergency, and therefore requires an immediate urologic consultation. He requires surgical intervention to reverse the spermatic cord torsion and restore blood flow.

Antibiotics, such a ciprofloxacin (choice A) are necessary to treat epididymitis, which typically presents with scrotal pain, fever, pyuria, a tender cord, and a normal positioned testes. Elevation of the testes may somewhat relieve the pain. Ice packs, bed rest, antiinflammatory agents, and scrotal support are typically used in conjunction with the antibiotics.

Applying ice packs and observing him in the emergency department (choice B) is inappropriate management of testicular torsion, which requires immediate urologic consultation.

Measuring serum HCG and AFP (choice C) is part of the evaluation for testicular cancer, which typically presents as a painless mass. If tenderness is present, it is often dull and aching, rarely acute and "exquisitely painful."

Performing a trans-scrotal testicular biopsy (choice D) is not useful in testicular torsion, which is a surgical emergency, and therefore requires an immediate urologic consultation. A trans-scrotal testicular biopsy is usually avoided, even if a testicular malignancy is suspected, to prevent potential tumor contamination of the lymphatics.