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#196
24.07.2006, 20:42
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The correct answer is D. Sulfadiazine and pyrimethamine is proper treatment for T. gondii infection.
Intravenous acyclovir (choice A) is used to treat herpes encephalitis. Neurosurgical removal of the lesions (choice B) is not indicated. Oral fluconazole (choice C) is a treatment for fungal infections. Thiabendazole (choice E) is used to treat helminth infections. 
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#197
24.07.2006, 20:42
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A 74-year-old man with insulin-dependent diabetes mellitus and chronic renal failure comes to the emergency department because of nausea and vomiting for 24 hours. He denies any chest pain or abdominal pain. He underwent his routine hemodialysis yesterday without any complications. His temperature is 38.8 C (101.8 F), blood pressure is 120/70 mm Hg, and pulse is 110/min. Abdominal examination reveals guarding in the right upper quadrant with no tenderness or peritoneal signs. Laboratory studies show a leukocyte count of 24,000/mm3 and a serum bilirubin of 2.2 mg/dL. An ultrasound examination of the right upper quadrant reveals a gallbladder with sludge, but no stones. The most appropriate next step in the management of this patient is
A. a CT scan of the abdomen B. a colonoscopy C. intravenous antibiotics and continued observation D. a hepatobiliary scan E. an upper gastrointestinal endoscopy
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#199
24.07.2006, 21:41
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Начнём с очевидного-признаки инфекции налицо-возможный путь заражения есть-ответ C! Хотя D-тоже заманчиво
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#200
24.07.2006, 22:02
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Я тоже разрываюсь между C и D
 А ведь ответ-то правильный - один!!!
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#202
24.07.2006, 22:49
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Я за "сначала С, а потом D". I have never seen a 74-year-old man with insulin-dependent diabetes mellitus
 They die earlier here..
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#203
25.07.2006, 00:14
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The correct answer is A. Patients with diabetes mellitus and chronic renal failure and multiple organ failure can develop acalculous cholecystitis. Acalculous cholecystitis is characterized by the absence of gallstones and sometimes even biliary sludge. These patients may not present with classical signs of cholecystitis, because of associated diabetes mellitus and multiple organ failure. Ultrasound may fail to show evidence of gallstones or obvious signs of cholecystitis. A CT scan of the abdomen and pelvis will reveal a thickened gallbladder wall, pericholecystic fluid, gas within the gallbladder wall, and evidence of surrounding inflammation.
Colonoscopy (choice B) is not helpful in the work up of biliary symptoms. Intravenous antibiotics (choice C) are indicated to treat cholecystitis, but in the presence of gangrene or unresponsive cholecystitis, surgery is indicated. Continued observation may result in worsening of the symptoms and signs and the development of complications like systemic sepsis. Also, further evaluation is indicated at this time. A hepatobiliary nuclear scan (choice D) may not show complete evidence of the severity of the disease and may be misleading with false negative results in this particular patient. An upper gastrointestinal endoscopy (choice E) helps in the diagnosis of pathology in the stomach or duodenum, but won't be helpful in this patient.
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#204
25.07.2006, 00:16
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A 29-year-old woman who you have been treating for bipolar disorder comes to the office because of feelings of "sadness" over the past few months. She has been taking lithium carbonate for 3 years and has not had any "periods of sadness" or manic episodes requiring hospitalization since starting therapy. Before that time, she had been hospitalized 4 times for manic episodes. She feels "sluggish" and tired and has difficulty concentrating at the office. Her skin is dry and cool, but the remainder of the examination is unremarkable.
The most appropriate action at this time is to A. add St. John's wort B. add fluoxetine to her current therapy C. order TSH. D. discontinue lithium carbonate therapy E. lower the dose of lithium carbonate F. make no changes in therapy
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#205
25.07.2006, 00:32
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C....
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#209
25.07.2006, 15:01
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В. По-моему, у дамы инверсия фазы.
upd. Перечитала, решила пространнее высказаться. Меня конечно тоже подмывает написать С, но! 1)имеется установленный диагноз биполярного расстройства, а антидепрессивного лечения дама вроде бы не получает. Прием же лития может давать инверсию. 2) в данной ситуации, несмотря на то, что кожа у нее холодная и сухая, ничего особенного физикально не нашлось.
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#210
25.07.2006, 16:04
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У авторов задачи другое мнение. но, наверное, они терапевты, а не психиатры.
 The correct answer is C. This patient likely has hypothyroidism, which is a known side effect of lithium carbonate therapy. It occurs in approximately 5-9% of patients taking the drug and for this reason, routine testing of thyroid function is recommended at least every year during therapy. In addition to routine testing, hypothyroidism should be ruled out in any patient who experiences depressive symptoms during lithium therapy. Treatment with levothyroxine is indicated in patients on lithium therapy who develop symptoms of hypothyroidism. Some believe that treatment for asymptomatic thyroid dysfunction is also necessary. Since this patient has signs and symptoms including a sad mood, difficulty concentrating, "sluggishness", and cool, dry skin, TSH should be ordered. It is incorrect to add St John's wort (choice A) to her current therapy. St. John's wort is an herbal medication that many people believe is effective in the treatment of depression. It is not FDA approved. Adding fluoxetine (choice B) is the incorrect treatment for this patient's "sadness" without knowing her thyroid function, because she has signs and symptoms of hypothyroidism. It is inappropriate to discontinue lithium carbonate therapy (choice D). This patient needs the lithium for her bipolar disorder, especially because she required hospitalizations in the past. Lowering the dose of lithium carbonate (choice E) is not appropriate. This patient's bipolar disorder is being adequately treated with the dose that she is taking. Since thyroid dysfunction is a known side effect of this therapy it is important to watch for it and treat it, but lowering the dose in her case is not necessary. If this patient has hypothyroidism she should be treated with levothyroxine, therefore making no changes in her therapy (choice F) is incorrect.
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