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#1276
13.03.2007, 19:01
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5- Which of the following factors, if present, predicts a worse long-term outcome for this patient?
a. Apolipoprotein E-4 genotype b. Apolipoprotein B level c. College education d. Right hemispheric injury e. Use of propofol treatment 
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#1277
14.03.2007, 07:45
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К сожалению, исходя из общих знаний и интуиции, ответить на этот вопрос не могу, поэтому вчера не ответил. Беглый поиск в Пабмед позволил сразу найти море информации по связи аполипопротена Е с прогнозом при ЧМТ.
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#1278
14.03.2007, 07:56
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5- The answer is a.
Genetic studies have recently shown that patients with the apolipoprotein E-4 genotype have an increased risk of developing AlzheimerЎЇs disease, posttraumatic encephalopathy associated with boxing, and worse outcome after traumatic brain injury. Other predictors of a poor outcome are increasing age, lower premorbid level of education, substance abuse history, diffuse axonal injury, subarachnoid hemorrhage, severity of the initial injury, and presence of other systemic injuries. Propofol has been shown in recent studies to improve outcome after injury.
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#1279
14.03.2007, 08:00
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A 19-year-old college student was seen in the emergency department 4 days ago for a painful lump on her buttocks. She does not remember what "diagnosis" the emergency department physician gave her, but she was instructed to apply warm compresses to the lump, keep the area covered with a dry gauze, and take an antibiotic (the name of which she does not remember). She now comes to you stating that the gauze is getting dirty with foul-smelling drainage. She is ruining her clothing and has become quite concerned. She denies any fevers, chills, weight loss, trauma to the area, or similar prior episodes. There is no contributory past medical, surgical, familial, or social history. Her temperature is 37.0 C (98.6 F). Her abdomen is soft, nontender, without organomegaly or palpable masses. There is no inguinal adenopathy. Pelvic examination reveals no vaginal discharge, cervical motion tenderness, or adnexal masses. There is a 2 cm mass between the superior area of her gluteal folds. The mass is red, warm, fluctuant, and very tender. You notice an area of drainage from the mass. Rectal examination shows good sphincter tone without masses, tenderness, or fluctuance. Stool is guaiac-negative. The most likely diagnosis is
A. an enterocutaneous fistula B. genital warts C. an infected Bartholin's cyst D. an infected pilonidal cyst E. metastatic rectal cancer
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#1280
14.03.2007, 08:53
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Однозначно - D. an infected pilonidal cyst!
Остальное просто исключено. Цитата:
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#1281
14.03.2007, 09:26
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Bravo!
Explanation: The correct answer is D. This woman is suffering from an infected pilonidal cyst. This cyst, sometimes called a pilonidal sinus, is caused by infection of the hair follicle in the sacrococcygeal area. It may present as an acute abscess at the sacrococcygeal area that may rupture spontaneously. The most common presentation is a painful and fluctuant mass. Initially only cellulites may be present. However, in the chronic stage, the diagnosis is confirmed by the presence of a sinus opening in the intergluteal fold, about 5 cm above the anus. Examination may reveal a pit or pits in the midline that represent infected hair follicles. Treatment of the acute infection includes incision and drainage of the sinus. All hair must be removed. Long-term treatment may require extensive excision of all midline pits or sinuses and removal of all hair and debris. An enterocutaneous fistula (choice A) is an abnormally draining sinus occurring between the colon and the skin. The foul smelling drainage from this woman's abscess is pus, not stool. Patients with enterocutaneous fistulas have compromised immune function and usually have undergone some form of bowel surgery. The fistula is usually on the anterior abdominal wall. Genital warts (choice B) may be painful depending on the etiology. They present on the labia, not the gluteus. An infected Bartholin's cyst (choice C) occurs when the Bartholin's gland has a duct (which drains into the distal aspect of the vagina), that becomes obstructed. This obstruction causes the mucoid secretion to collect and causes dilatation of the cyst. This collection may get infected. Therapy requires incision and drainage of the gland or possibly marsupialization of the gland. This patient is quite young to have rectal cancer (choice E), let alone metastatic rectal cancer. The combination of no masses on rectal exam, guaiac-negative stool, no family history, and the location of this mass makes this answer highly unlikely.
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#1282
14.03.2007, 09:29
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A 49-year-old woman comes to the office for a periodic health maintenance examination. She is in good health and has no complaints. However, she has a "very important question." She says that one of her best friends recently passed away from ovarian cancer, and she is very worried because the woman never experienced any symptoms and did not have a family history of the disease. She wants to know if you can review her history and tell her if there is anything that will affect her risk for developing the disease. You flip through her chart and notice that she had menarche at age 11 and is still menstruating. She and her husband were trying unsuccessfully to conceive for 7 years, she took oral contraceptive pills for 18 years, and she has always been about 60-70 pounds overweight. The most accurate statement concerning this patient's risk for developing ovarian cancer is that she
A. decreased her risk by taking oral contraceptive pills (OCPs) B. needs to have periodic pelvic sonograms because oral contraceptive pills put her at an increased risk C. needs to have periodic pelvic sonograms because she never had kids and is overweight, which increases her risk for developing the disease D. should consider having a hysterectomy and bilateral oophorectomy because there is a good chance that she will develop the disease due to the fact that she took OCPs, never had children, and is overweight E. should take hormonal replacement therapy when she reaches menopause to decrease her risk of developing the disease
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#1285
14.03.2007, 16:03
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The correct answer is A. Numerous studies demonstrate that the use of oral contraceptive pills (OCPs) decreases a woman's likelihood of developing ovarian cancer. One theory to explain the decreased ovarian cancer risk is that the OCPs provide hormones that inhibit the hormonal suppression by the pituitary, which then decreases the amount of gonadotropins that are produced and helps to suppress monthly ovarian germinal capsule disruptions caused by ovulation. Some other studies suggest that factors that increase the risk of developing ovarian cancer are nulliparity, the use of postmenopausal replacement therapy, and ovulation-inducing drugs. These findings are controversial.
Periodic pelvic sonograms (choice B and C) are not recommended to screen asymptomatic women for ovarian cancer. Also, OCPs have been shown to decrease a woman's risk for ovarian cancer. Nulliparity may be associated with an increased risk, and obesity is not typically associated with ovarian cancer. She should not consider having a hysterectomy and bilateral oophorectomy because there is a good chance that she will not develop the disease due to the fact that she took OCPs, never had children, and is overweight (choice D). A prophylactic hysterectomy and bilateral oophorectomy is not indicated in this woman with no family history of disease. OCPs have been shown to decrease a woman's risk for ovarian cancer. Nulliparity may be associated with an increased risk, and obesity is not typically associated with ovarian cancer. She should not take hormonal replacement therapy when she reaches menopause to decrease her risk of developing the disease (choice E) because hormonal replacement therapy does not decrease the risk.
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#1286
14.03.2007, 16:04
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You are called to see one of your patients, a 29-year-old woman, who was admitted to the hospital from your office 24 hours earlier because of a stiff neck and a temperature of 39.7 C (103.4 F). She is presumed to have meningitis, but the results of the cerebrospinal fluid analysis are still pending. A lumbar puncture was performed when she arrived at the hospital and intravenous antibiotics were started. She is now complaining of a dull, frontal headache that is worse when she is sitting upright and relieved by lying down. Her temperature is now 39.3 C (102.8 F), blood pressure is 110/70, pulse is 75/min, and respirations are 18/min. Physical examination shows nuchal rigidity and there is a palpable purpuric rash on her lower extremities and trunk. Funduscopic examination is unremarkable. The most appropriate next step is to
A. administer sumatriptan, intramuscularly B. advise her to remain in a horizontal position C. ask her if she has been drinking red wine D. order a CT scan of the brain to look for intracranial hemorrhage E. order an MRI of the brain to look for an intracranial mass
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#1288
14.03.2007, 20:10
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The correct answer is B. This patient most likely has a lumbar puncture headache, which often begins within 24 hours of the procedure. The headache is positional in nature, meaning that it is worse when she is sitting upright and relieved by lying down. It is believed to be due to a loss of cerebrospinal fluid during the lumbar puncture, causing decreases in the cushioning of the brain. Patients should be told to remain horizontal after the procedure to decrease the incidence of this complication. The treatment includes remaining in a horizontal position and possibly intravenous caffeine sodium benzoate. If this is not effective, an epidural blood patch should be performed.
Sumatriptan (choice A) is often used to treat an acute migraine headache which is characterized by a throbbing headache usually accompanied by nausea and vomiting. It is unlikely that this woman is having a migraine because of the positional nature of this headache, and the fact that she had a lumbar puncture performed 24 hours ago. This is consistent with a post-LP headache. Asking her if she has been drinking red wine (choice C) is inappropriate at this time. Red wine is often a trigger for a migraine headache. However, this patient's history is more consistent with a post-LP headache. It is unlikely that this patient has an intracranial hemorrhage, and therefore a CT scan of the brain (choice D) is unnecessary at this time. The positional nature of the headache is more consistent with a post-LP headache. An MRI of the brain to look for an intracranial mass (choice E) is also unnecessary at this time. Her funduscopic examination did not show papilledema, a sign of increased intracranial pressure, and the onset of the headache within 24 hours of the lumbar puncture and its positional nature makes it more consistent with a post-LP headache than with an intracranial mass.
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#1289
14.03.2007, 20:12
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A 28-year-old man comes to the emergency department because of moderate left shoulder pain that is worse with abduction of the shoulder. He plays baseball occasionally with friends and has noticed that the pain worsens when throwing the ball. He denies any history of trauma. Physical examination shows weakness of the shoulder, most pronounced with abduction. A shoulder x-ray reveals no fractures or dislocations. The most appropriate next step in management is to
A. advise patient that he should rest and ice the shoulder B. order an emergent CT scan of the shoulder C. order an emergent MRI of the shoulder D. order an outpatient MRI of the shoulder E. prescribe nonsteroidal antiinflammatory drugs
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