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#331
02.08.2006, 20:09
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Вероятно, причиной головных болей является повышенное внутричерепное давление, возможно, это идиопатическая внутричерепная гипертензия. Но скорее это вторичное состояние т.к. возраст не молодой. В начале я бы выполнил пункцию, чтобы определить состав ликвора и его давление.
F. perform a lumbar puncture 
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#333
02.08.2006, 20:39
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Да, конечно ... погорячился. Покопался в литературе... нашел соответствующую статью (про idiopathic intracranial hypertension), безусловно, в алгоритмах вначале МРТ потом пункция
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#334
03.08.2006, 10:14
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Ну конечно Е. Сначала исключить медленно прогрессирующий процесс (скорее опухоль - менингеому, чем повышение ВЧД - при этом был бы застой на гл.дне а здесь Physical examination is unremarkable.), а затем уж все остальное.
С относиться к кластерной головной боли, Д - к темпоральному эндартерииту.
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#335
03.08.2006, 15:40
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Вы такой умный, Михаил. На вас одобрялок не напастись.
 The correct answer is E. In any patient with a new headache that is associated with nausea and vomiting and exacerbated by exertion or positional changes, a brain tumor should be suspected. This is the typical presentation of a posterior fossa brain tumor. Weight loss, systemic symptoms, and an elevated erythrocyte sedimentation rate are not typically associated with a primary brain tumor. Papilledema, caused by increased intracranial pressure, is rarely found in patients over 55 years old with an intracranial mass. An MRI or CT scan of the head will establish the diagnosis. Administration of 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. The diagnosis of temporal arteritis is established with a temporal artery biopsy (choice D). The erythrocyte sedimentation rate is typically elevated in temporal arteritis Administration of sumatriptan, intramuscularly (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. An intermittent headache that becomes constant is not the typical pattern of a migraine. The sublingual ergotamine and oral sumatriptan that this patient was taking are typically effective in treating a migraine. Oxygen inhalation therapy (choice C) is the treatment for a cluster headache. 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. This patient's history is inconsistent with a cluster headache. A lumbar puncture (choice F) 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. An intracranial hemorrhage may present with a headache and nuchal rigidity, seizures, and confusion. A CT scan of the head usually establishes the diagnosis. The patient's history is inconsistent with meningitis and is more consistent with a brain tumor than an intracranial bleed. A lumbar puncture should not be performed in this patient or any patient with a suspected brain tumor because it may cause brain herniation.
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#336
03.08.2006, 15:41
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A 29-year-old truck driver is transferred to the general medical floor from the intensive care unit where he was being treated after sustaining multiple fractures from a motor vehicle accident. It is determined that the patient was under the influence of alcohol at the time of the accident. He has been in the intensive care unit for 20 days following open reduction and internal fixation of bilateral femur, tibia, and fibula fractures. The patient is otherwise doing well and has full use of his upper body. Legal proceedings will begin subsequent to discharge, and the patient states he is committed to ceasing alcohol consumption. Past medical history is significant for alcoholism. Medications include imipenem and morphine administered via patient-controlled analgesic pump. At this time, the patient is at greatest risk for
A. alcohol withdrawal B. deep venous thrombosis C. fat emboli to lungs D. narcotic addiction from the morphine E. suicide
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#340
03.08.2006, 18:06
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А я за В. Лежал в ПИТе, множественные переломы костей нижних конечностей, а его алкоголизм, возможно, еще и поспособствует тромбозу
 (это уже мои домыслы)
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#341
03.08.2006, 18:11
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Пациент находиться в состоянии безысходности: тяжелые переломы, алкогольная абстиненция, впереди суд. Риск суицида. Есть мотив. В руках способ - patient-controlled analgesic pump!
E. suicide
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#344
03.08.2006, 18:22
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The correct answer is B. This patient is profoundly immobile due to multiple fractures of both legs and he is at increased risk for developing a thrombus in the veins of his lower extremities. Deep venous thrombosis (DVT) prophylaxis with subcutaneous heparin should already have been started. DVT prophylaxis is necessary in all immobile patients, especially those who have sustained major orthopedic injury.
Alcohol withdrawal (choice A) usually occurs a few hours to 10 days after the last drink. Most typically, it occurs in the first 48 hours. Symptoms include acute psychosis with hallucinations, delusions, disorientation, agitation, and tremors. In this patient, alcohol withdrawal is very unlikely to start now, 20 days after the injury. A fat emboli (choice C) from bone fractures occurs in close temporal proximity to the fracture or to the surgery. The patient is now 10 days postoperative and 20 days after the initial injuries, making this unlikely. Narcotic addiction (choice D) from patient controlled analgesia is very rare and allows the patient to participate in his medical care. Care must always be taken to balance analgesia and addiction potential. Suicide (choice E) is unlikely given the hopeful outlook of this patient and lack of history of depression or suicidal tendencies.
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#345
03.08.2006, 18:23
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A 24-year-old woman with a history of carpal tunnel syndrome comes to the emergency department after a fall on her left forearm while ice skating. She has severe pain and left hand numbness. There is a weak left radial pulse at 85/min. The right radial pulse is normal at 86/min. There is severe left forearm edema, pain, and a deformity of the forearm suspicious for a fracture of the radius and ulna. There is weakness of the left hand and decreased sensation of the left hand to both touch and, to a lesser extent, pain. The right hand is normal. The most appropriate next step in management of this patient is to
A. measure bilateral brachial blood pressures B. measure forearm compartment pressures C. order a computed tomography angiogram (CTA) scan of the forearm D. order a plain radiograph of the forearm E. prescribe oral ibuprofen for pain relief
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Линейный вид
