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#1111
26.01.2007, 18:43
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A 57-year-old man comes to the emergency department because of a severe headache. The headache came on suddenly as he was leaving the light show at the planetarium. He also has right eye pain and nausea and he vomited twice during the car ride over to the hospital. He has no significant past medical history. He has had other headaches in the past, but has never experienced anything like this. His temperature is 36.7 C (98.0 F), blood pressure is 130/90 mm Hg, pulse is 75/min, and respirations are 18/min. Physical examination shows a tender red right eye with a partially dilated pupil, but is otherwise unremarkable. The most appropriate next step is to
A. administer glucocorticoids, intravenously B. administer sumatriptan, intramuscularly C. give him oxygen therapy, 100% for 15 minutes D. measure intraocular pressure E. order a CT scan of the head F. order an erythrocyte sedimentation rate G. perform a lumbar puncture 
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#1112
26.01.2007, 19:25
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Острый приступ глаукомы. Я предполагаю, что физиологический мидриаз в планетарии спровоцировал приступ глаукомы.
D. measure intraocular pressure
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#1115
28.01.2007, 18:05
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The correct answer is D. This patient with a headache and a red eye either has acute glaucoma or a cluster headache. The partially dilated pupil is more consistent with acute glaucoma. Acute glaucoma, which is caused by increased intraocular pressure, often presents with abdominal pain, nausea, vomiting, and a headache. It is an ophthalmologic emergency that may lead to blindness, so this diagnosis should be included in your differential when a patient presents with these other symptoms. The patient usually has eye pain, but it may be overshadowed by the other symptoms. The diagnosis is established by measuring intraocular pressure. You should call for an immediate ophthalmologic consultation and possibly administer acetazolamide, topical beta blockers, mannitol, and pilocarpine. A cluster headache is an episodic headache that typically presents with a few short headaches a day for a few weeks that is associated with periorbital pain, reddening of the eye, and lacrimation. A partially dilated pupil is not a common finding.
Administer glucocorticoids, intravenously (choice A) is the appropriate treatment to prevent blindness in a suspected case of temporal arteritis. Temporal arteritis typically presents with a unilateral headache, myalgias, jaw pain, fever, and weight loss. A tender, reddened temporal artery is often found. Visual changes may occur and blindness is a feared complication. This patient does not have any of the usual systemic symptoms associated with temporal arteritis. Also, the red eye with a dilated pupil is inconsistent with this diagnosis. The diagnosis of temporal arteritis is established with a temporal artery biopsy. The erythrocyte sedimentation rate (choice F) is typically elevated in temporal arteritis Sumatriptan (choice B) is the treatment for a migraine headache, which typically presents with a throbbing headache, nausea, vomiting, photophobia, and functional impairment. An aura consisting of hallucinations and scotomas sometimes occurs before the headache. A partially dilated pupil is inconsistent with a migraine. Oxygen therapy, 100% for 15 minutes (choice C), is the treatment for a cluster headache. Sumatriptan may also be given to shorten the attack. A CT scan of the head (choice E) is important if an intracranial hemorrhage is suspected. An intracranial hemorrhage may present with a headache and nuchal rigidity, seizures and confusion. A red, tender eye is not a typical finding. A lumbar puncture (choice G) should be performed in a suspected case of meningitis and possibly in a suspected intracranial hemorrhage, if the CT scan fails to show the bleed. Meningitis often presents with a headache, nuchal rigidity, and photophobia. Fever and a rash may be present. A tender, red eye with a partially dilated pupil is not typically found in meningitis or an intracranial hemorrhage.
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#1116
28.01.2007, 18:06
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A 47-year-old man comes in to see you for a full physical exam and complains of new blisters forming on his hands for the last few months. He is a construction worker and has been busy for the summer season. While working, he "pulled a muscle" and has been taking naproxen daily to relieve the pain for the past 2-3 months. He noted shortly after initiation of naproxen that new blisters developed on the back of his hands. He appears healthy and tanned. Cutaneous examination shows no sclerodermoid changes on his face or hands and no hypertrichosis on his face. There are numerous hyperpigmented scars mixed with 2-3 tense bullae overlying normal skin on the dorsum of his hands. Around the scars, there are numerous 1-2 mm white papules. He denies any history of hepatitis. Your next step should be to
A. ask about gluten sensitivity and diarrhea because this is most likely Dermatitis herpetiformis B. check antinuclear antibody level and look for dry eyes and mouth C. check antinuclear antibody level and renal panel to rule out lupus erythematosus D. search for an occult internal neoplasm E. stop naproxen and check urine porphyrin level and a viral hepatitis panel
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#1118
28.01.2007, 22:36
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Dermatitis herpetiformis (DH) is incorrect because it is a chronic, intensely pruritic, papulovesicular eruption associated with gluten-sensitive enteropathy. Lesions typically appear symmetrically on extensor surfaces, particularly on the shoulders, elbows, buttocks, sacrum, knees, and posterior hairline.
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#1120
29.01.2007, 06:59
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По-видимому, у пациента реакция фотосенсибилизации спровоцированная напроксеном. Почти при всех заболеваниях, подразумеваемых в вариантах ответов, возможны реакции фотосенсибилизации.
Цитата:
E. stop naproxen and check urine porphyrin level and a viral hepatitis panel Этот ответ хорош еще тем, что предполагает отмену провоцирующего фактора, чего нет в других вариантах.
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#1122
29.01.2007, 18:30
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The correct answer is E. Porphyria cutanea tarda (PCT) and pseudoporphyria (pseudo PCT) are two entities with similar if not identical presentation. When a patient presents with subepidermal (tense) bullae formation on sun exposed skin, PCT and drug-induced PCT (pseudoporphyria) should be the considered. PCT patients typically present with blistering in a sun exposed area, skin fragility, scarring with milia formation (presents as 1-2 mm white papules) and hypertrichosis. Other cutaneous changes include hyperpigmentation and sclerodermoid lesions. In sporadic PCT or acquired PCT, association with exposure to hepatitis B or C or HIV as well as alcohol intake, estrogen therapy, and dialysis treatment is increasingly recognized. Manifestation of PCT is related to deficiency of the activity of the enzyme uroporphyrinogen decarboxylase. Therefore, confirmation of PCT is by demonstration of the excess porphyrin by-products resulting from the enzyme defect: chiefly uroporphyrin and hepatocarboxylic porphyrins in urine and plasma or serum and isocoproporphyrin in feces. Pseudo PCT can mimic PCT except with normal levels of porphyrins in urine, plasma, and stool. The condition is precipitated by certain drugs including tetracycline, nalidixic acid, naproxen, furosemide, dapsone, and pyridoxine. Onset of bullae may occur 1 week after treatment has been initiated or may not occur for months. One important clue to pseudo PCT is that few patients have hypertrichosis, hyperpigmentation, or sclerodermoid changes as seen in PCT. When evaluating a patient with new onset of bullae, PCT should be ruled out even if an offending drug is obvious. Therefore, checking urine porphyrin levels and a hepatitis panel and taking a good history are as important as removing the offending drug and suggesting sun avoidance.
Dermatitis herpetiformis (DH) is incorrect because it is a chronic, intensely pruritic, papulovesicular eruption associated with gluten-sensitive enteropathy. Lesions typically appear symmetrically on extensor surfaces, particularly on the shoulders, elbows, buttocks, sacrum, knees, and posterior hairline. Avoidance of dietary gluten (choice A), a protein found in various grains such as wheat, rye, and oats, results in remission of the disorder. DH is also associated with frequent occurrence of other autoimmune diseases, including systemic lupus erythematosus (choice C) and Sjogren's syndrome with dry eyes and mouth (choice B). It is also associated with an increased risk for lymphoma and other malignancy (choice D).
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#1123
29.01.2007, 18:31
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A 2-day-old female infant in the neonatal unit has a distended abdomen and has not passed meconium since birth. The child was delivered vaginally at term, but her birth was induced with magnesium sulfate, because the mother was diagnosed with preeclampsia. The infant's vital signs are: temperature 38.1 C (100.6 F), blood pressure 70/40 mm Hg, pulse 130/min, and respirations 22/min. Physical examination is significant for a distended abdomen. An abdominal x-ray demonstrates a "bubbly" bowel gas pattern on the left side of the abdomen. The next step in the management of this patient is
A. bowel rest B. contrast enema C. intravenous fluids D. laparotomy E. an ultrasonography
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#1124
29.01.2007, 18:42
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Роль магнезии в данном случае мне трудно оценить.
Поскольку у ребенка признаки кишечной непроходимости, логично применить «контрастную клизму» и установить уровень обструкции. B. contrast enema
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Линейный вид
