Еще одна пилюлька Hескучина

[yananshs]

The correct answer is B. This patient has Meniere's syndrome (endolymphatic hydrops). Meniere's syndrome is characterized but intermittent vertigo lasting about 1-8 hours with associated hearing loss, aural pressure, and tinnitus. Symptoms tend to wax and wane. It differs from benign positional vertigo in that the symptoms do not necessarily worsen with positional changes. In addition, positional vertigo doesn't have the same associated factors as Meniere's syndrome does. The treatment is a low salt diet and HCTZ. If the patient is resistant to medical therapy, surgery to decompress the endolymphatic sac can be a last resort.

Diazepam (choice A) is a useful treatment to ablate an acute episode of acute vertigo but is not a first line therapy for Meniere's syndrome.

Meclizine (choice C) is an antihistamine, which is useful in the management of less severe attacks of vertigo.

Scopolamine (choice D) is sometimes used in a transdermal preparation to be beneficial in the management of chronic vertigo. The anticholinergic side effects can limit its usefulness.

Physical therapy (choice E) is becoming more important in the management of vertigo. It is thought to help the enhance CNS ability to compensate for labyrinthine dysfunction. Recently, use of specific head maneuvers has been incorporated into the management of vertigo.

[yananshs]

A 51-year-old woman comes to the office because of a "lump" in her left axilla. She says that she noticed it 3 months ago in the shower and it has been slowly increasing in size. She has not seen a physician in ages because her mother died from ovarian cancer at age 42 and she is angry at "all physicians" because they did not find it before it was too late. She is generally very healthy, exercises regularly, eats a low-fat diet, does not smoke cigarettes, lives alone with her dog, and has not traveled recently. She is allergic to flowers and cats. She denies fever, night sweats, or fatigue. Physical examination shows a 2.0 cm fixed round lesion in her axilla. The remainder of the examination, including a clinical breast examination and pelvic examination, are normal. A complete blood count is unremarkable. The most appropriate next step is to
A. obtain cultures for Epstein-Barr virus and Cytomegalovirus
B. order a complete biochemical profile and chest x-ray
C. reassure her and have her return in 2 weeks for reexamination
D. schedule a mammography
E. send her to a surgeon for a lymph node biopsy

[riltsov]

Разрезать и посмотреть!!!
E. send her to a surgeon for a lymph node biopsy

[yananshs]

Wrong. Sorry.

[riltsov]

Lump выросла быстро и она fixed round lesion in her axilla + семейный анамнез = подозрение на злокачественную опухоль. Разрываюсь между D. schedule a mammography и
E. send her to a surgeon for a lymph node biopsy. Меняю свою позицию. Начать надо с маммографии так проще и быстрее. Подозрение на рак молочной железы.
Ответ D. schedule a mammography

[yananshs]

The correct answer is D. In general, a patient with axillary adenopathy, without fever, weight loss, fatigue, and night sweats should be evaluated for cellulitis, cat-scratch disease, sporotrichosis, and breast cancer. Since the first 3 disorders can basically be ruled out with a complete history and physical examination, a mammography is needed to evaluate for breast cancer.

Epstein-Barr virus and Cytomegalovirus (choice A) are typically associated with cervical adenopathy, not a single, fixed axillary lymph node.

A biochemical profile and chest x-ray (choice B) are not indicated at this time in this patient with a single fixed axillary lymph node, since she has a family history of cancer and has not been to a doctor in "ages" and is probably due for a mammogram.

Since this lymph node has been present for months, it is inappropriate to reassure her and have her return in 2 weeks for reexamination (choice C) because it is unlikely to decrease in size spontaneously by then. She requires evaluation at this time.

A lymph node biopsy (choice E) would be the appropriate step if this was a supraclavicular lymph node. However, the evaluation of an axillary lymph node in a woman typically includes a mammogram with a biopsy if a lesion is found. A lymph node biopsy should be performed after a breast lesion is ruled out.

[yananshs]

A previously healthy 31-year-old woman comes to your office complaining of 1-day history of a cough and a fever. She reports that she was celebrating a job promotion 3 days prior and drank quite a bit of alcohol at a local bar. She had 2 episodes of vomiting that evening. She takes no regular medications and has only been using acetaminophen for fever suppression. Her temperature is 38.2 C (100.8 F). Her lungs have decreased breath sounds in the left base and right upper lobe. She has a cough that is productive of foul-smelling sputum. The remainder of her examination is unremarkable. The most appropriate management is to
A. admit the patient to the hospital for clindamycin therapy
B. admit the patient to the hospital for penicillin therapy
C. admit the patient to the intensive care unit for levofloxacin therapy
D. begin outpatient cefuroxime therapy
E. begin outpatient erythromycin therapy

[riltsov]

Когда пациентка напилась и рвала она аспирировала микрофлору полости рта + возможно немного желудочного сока. Пневмония аспирационная. foul-smelling sputum – анаэробная микрофлора. Чем лечить не знаю - гадаю!
Ответ
A. admit the patient to the hospital for clindamycin therapy
Где-то читал, что убивает клиндамицин подобную флору.

[yananshs]

The correct answer is A. This is a patient who likely has pneumonia in the setting of likely aspiration. Since most pneumonia never have the etiologic agent identified, the treatment is empirical based upon patient locale at time of infection and presumed organisms based upon epidemiology. In this case, the presumed aspiration indicates that coverage for Gram-negative and anaerobic organisms is required. Clindamycin is a macrolide derivative that has activity against these agents. It is effective and is well-tolerated orally. Uncomplicated pneumonia such as community acquired or atypical infections rarely require hospitalization. For this patient with a likely anaerobic, purulent infection, a more monitored setting for therapy is required.

Penicillin (choice B) is an excellent choice for community acuquired pneumonia with the caveat that an increasing number of isolates of S. pneumonia are resistant. In some centers, this number is as high as 20%. However, penicillin has no activity against Gram-negative or anaerobic organisms.

Levofloxacin (choice C) is a fluoroquinolone that has broad activity against Gram-positive, Gram-negative, and some anaerobes. However, it does not have adequate coverage of anaerobic organisms to provide effective coverage for presumed aspiration. This patient has no objective findings that would warrant an ICU admission. Hemodynamic instability or respiratory distress requiring intubation would be classical reasons why patients with severe pneumonia may require an ICU stay.

Outpatient cefuroxime (choice D) is a second-generation cephalosporin that is standard outpatient therapy for community acquired pneumonia. It does not have the required broad Gram-negative (although it has some) coverage and it has no anaerobic coverage. This patient should however be hospitalized for observation during initial therapy.

Erythromycin (choice E) is a macrolide antibiotic that is also effective for both typical and atypical community acquired pneumonia but is only minimally useful in cases of aspiration pneumonia.

[yananshs]

A 20-year-old man with alpha-1 antitrypsin deficiency comes to the student health clinic for an initial visit when starting school. He tells you that he is here for a few years and would like to establish a relationship with the doctors in the clinic because of his chronic condition. He is currently asymptomatic. His vital signs and physical examination are normal. A chest x-ray reveals mildly increased lung volumes. Liver function tests are normal. Besides the routine counseling that you provide to all patients at the student health clinic, the most important preventive care issue for this specific patient is
A. avoidance of alcohol and tobacco
B. avoidance of accidental trauma
C. keeping vaccinations current
D. safe sex practices
E. seatbelt use while driving

[Rodionov]

Я бы сказал про курение, то тогда при чем тут алкоголь...
Тогда "С". Пусть вакцинируется

[yananshs]

Besides the routine counseling that you provide to all patients at the student health clinic, the most important preventive care issue for this specific patient

........

[Rodionov]

Это я понял.
В рекомендациях по ведению первым пунктом стоит табак (Make a concerted effort to inform patients about the serious consequences of smoking on AAT deficiency and provide them with one of the many aids to help them quit). Стало быть А. Но вроде про алкоголь нигде не говорится.
Вторым пунктом: Pneumonia and annual influenza vaccines will help prevent respiratory infections

А про секс и битие в машинах вроде бы и ни к чему. Хотя тоже не вредно. Особенно безопасный секс.. Генетическое ведь заболевание

[yananshs]

Не говорится про алкоголь?. Ну может авторы задачи попутали.
The correct answer is A. Patients with alpha-1 antitrypsin deficiency are prone to developing pulmonary emphysema and cirrhosis of the liver. Tobacco and alcohol use can greatly accelerate these processes. Given the prevalence of tobacco and alcohol in the college-age population, these are critical issues to discuss with this patient.

Trauma (choice B) is an important issue to discuss with all young patients, as it is the leading cause of death in this age group. It must be part of the routine counseling that you provide to all patients at the student health clinic. In this particular patient, however, the increased risk of alcohol and tobacco in the setting of alpha-1 antitrypsin deficiency must be discussed.

A majority of recommended vaccinations (choice C) have been administered at this time. Determination of vaccination history is a routine part of an exam. In this particular patient, as the question asks, the increased risk of alcohol and tobacco in the setting of alpha-1 antitrypsin deficiency must be discussed.

Safe sex practices (choice D) are particularly important in the college age patient. It must be part of the routine counseling that you provide to all patients at the student health clinic. In this particular patient, the increased risk of alcohol and tobacco in the setting of alpha-1 antitrypsin deficiency must be discussed, aside from the routine counseling.

Seatbelt use (choice E) is an important issue to discuss with all young patients, as motor vehicle accidents are the most common cause of death in this age group. This must be included in all counseling of patients in the student health clinic. In addition to routine counseling, due to his condition, the increased risk of alcohol and tobacco in the setting of alpha-1 antitrypsin deficiency must be discussed.

[yananshs]

A 63-year-old woman comes to the office because of a 3-week history of a "dull, achy" headache. She says that it started out as an intermittent headache that was exacerbated by bending down, lifting heavy objects, sneezing, defecating, and coughing, but lately it has become constant. She cannot associate the headaches with food or hunger, alcohol, weather or barometric pressure changes, sounds, or irregular sleep patterns. She is generally very healthy, but recalls having some nausea and vomiting a few weeks before the headaches started. She has never had headaches before. She does not take any medications, rarely drinks alcohol, and exercises regularly. Her temperature is 37.0 C (98.6 F), 130/80 mm Hg, pulse is 70/min, and respirations are 15/min. Physical examination is unremarkable. An erythrocyte sedimentation rate, complete blood count, and electrolytes are normal. A trial of oral prednisone, sublingual ergotamine, and oral sumatriptan is ineffective. The most appropriate next step is to
A. administer glucocorticoids, intravenously
B. administer sumatriptan, intramuscularly
C. give her oxygen inhalation therapy
D. obtain a temporal artery biopsy
E. order an MRI of the head
F. perform a lumbar puncture