Items 27-29

An 18-year-old white high school student comes to the office in late August because of a stuffy nose for 1 week. He reminds you that he
has had severe hay fever in the fall for the past 10 years. Review of his chart shows that he has positive skin tests to ragweed, dust and dust
mites, and he is receiving maintenance immunotherapy with extracts of these antigens. He also takes over-the-counter antihistamines for
symptomatic relief. This regimen has not provided relief so far this season. Physical examination is normal, apart from clear rhinorrhea.
He is afebrile, and there is normal transillumination of the frontal and maxillary sinuses. In reviewing his medical records you note that
smears of his nasal mucus contained large numbers of eosinophils. There is no record of any extensive immunologic work-up. You tell
him that he now has either an early viral upper respiratory tract infection or the beginnings of his seasonal allergic rhinitis. You suggest
that he use a corticosteroid nasal spray plus his usual antihistamines as needed. The appropriate treatment is undertaken, but 4 days later
he returns because of a toothache and fever. On physical examination he has right facial fullness and pain below his eye when he leans
forward. There is tenderness in the region of the upper premolar and molar teeth on the right side. His temperature is 38.7EC (101.6EF),
orally. He has bloody, thick, green mucus coming from his right nostril. The remainder of his physical examination is normal. You suspect
maxillary sinusitis on the basis of the clinical findings.

27. Before beginning antibiotic treatment in this patient, it is necessary to first do which of the following?
(A) Confirm the diagnosis with CT films of the sinus
(B) Confirm the diagnosis with plain x-ray films of the sinus
(C) Confirm the diagnosis with transillumination of the sinus
(D) Request consultation with a dentist
(E) No additional steps are necessary

28. The appropriate steps are taken. In prescribing antibiotic therapy for this patient, it is most important to remember which of the
following?
(A) Antibiotics are ineffective unless there is a concomitant surgical drainage procedure
(B) He is likely to be allergic to penicillin
(C) He needs to take medication for more than 7 days
(D) Only bactericidal antibiotics are effective
(E) Ordinarily at least two antibiotics are given
He is treated and initially feels much better. However, soon thereafter he developed a headache, right ear pain and painful stiff neck; he
spikes a temperature to 39.3EC (102.7EF), orally. Extraocular movements are normal.

29. Which of the following is the most likely explanation for these new symptoms?
(A) Allergic reaction to the antibiotic(s)
(B) Associated meningeal inflammation or infection
(C) Development of cavernous sinus thrombosis
(D) Direct spread of infection from the maxillary to the mastoid sinus
(E) Obstruction of the orifice of the maxillary sinus with a mucous plug
END OF SET

1. (D) Request consultation with a dentist
2. (B) He is likely to be allergic to penicillin
3. (D) Direct spread of infection from the maxillary to the mastoid sinus

1.С
2.А
3.D

1.(D) Request consultation with a dentist
2.(A) Antibiotics are ineffective unless there is a concomitant surgical drainage procedure
3. C третьим сложнее.. Не могу в полной мере согласиться ни с одним из вариантов. Пусть будет (D) Direct spread of infection from the maxillary to the mastoid sinus

Правильные ответы

27. Е. В любом случае, нужно назначать антибиотикотерапию сроком не менее, чем на 7 дней . Поэтому, ничего из предложенного не нужно.

28. С.
29. В.

Почему вот только первый вопрос Е?

Потому что, независимо от того, будете Вы проводить все перечисленное или нет, в первую очередь, все-равно, надо назначать антибиотик. Вопрос же стоит, фaктически, нужно ли
(A) Confirm the diagnosis with CT films of the sinus
(B) Confirm the diagnosis with plain x-ray films of the sinus
(C) Confirm the diagnosis with transillumination of the sinus
(D) Request consultation with a dentist
(E) No additional steps are necessary
ПЕРЕД назначением антибиотика? - Нет, не нужно.

Нужно назначить антибиотик, а уж дальше - разбирайтесь, что привело к такой клинике.

ой.. я в них немного запуталась...
По поводу второго вопроса: мне кажется, все упирается в давний спор Яны с нашими ЛОР-врачами...
и вообще.. все равно остается ощущение, что я недопонимаю акценты или окраску :( вопроса, сформулированного на другом языке...

Трудности перевода тоже имеют место.Не всегда понятно ,что собственно от тебя хотят :( Все-таки у нас обычно смотрит ЛОР в такой ситуации и решает нужно ли хирургическое вмешательство.

Уважаемая dr.Ира !А можно еще задачек ?Очень интересно и полезно.Заранее спасибо. :)

49. A 14-year-old boy is brought to the walk-in clinic by his father late on Saturday afternoon because his left ear is swollen and
painful. The boy's ear has been black and blue since he injured it in a wrestling match 3 days ago. Symptoms have increased
significantly following a repeat injury 3 hours ago. On physical examination, his left ear is markedly swollen and tender to
palpation. Which of the following is the most appropriate next step?

(A) Reassure him and start aspirin therapy
(B) Reassure him and start codeine therapy
(C) Recommend that he apply cold packs to the ear for the next 12 hours
(D) Recommend that he apply hot packs to the ear for the next 12 hours
(E) Refer him to a surgeon for immediate drainage of the lesion

Items 50-51
A 6-week-old infant is brought to the health center by his mother because of projectile vomiting. You have not seen this infant before
and the mother says he has not been seen by a physician since birth. Weight at birth was 3550 g (7 lb 13 oz) and physical
examination was normal. Examination today is normal except for weight, now 4000 g (8 lb 13 oz), and slight dehydration.

50. Which of the following is the most appropriate management for this infant?
(A) Elevate the head of his crib to relieve gastroesophageal reflux
(B) Order supine and decubitus x-ray films of the abdomen
(C) Order ultrasonography of the pylorus
(D) Order an upper gastrointestinal barium study
(E) Place him on a clear pediatric electrolyte solution

51. The appropriate diagnostic test is done and is equivocal. Which of the following imaging modalities necessary to help
diagnose this infant's illness is most operator-dependent?
(A) CT scan
(B) Radionuclide gastric emptying time studies
(C) Routine x-ray films
(D) Ultrasonography
(E) Upper and lower gastrointestinal barium studies

49-Е
50-А.Скорее всего это рефлюкс,хотя надо исключать и пилоростеноз.
51-С

The appropriate diagnostic test is done and is equivocal. Which of the following imaging modalities necessary to help
diagnose this infant's illness is most operator-dependent?
Суть вопроса - какое из обследований наиболее зависит от врача ( техника ), выполняющего обследование. (operator-dependent).

Спасибо,за подсказку.Как-то не задумывалась в таком аспекте.Наверное все-таки УЗИ-D.

Гм.. по поводу 49 - там описан отек, но ухо "сине-черное" кажется? Если расценивать эту синеву как гематому - напряженные гематомы вскрывают - но ввиду свежей травмы, этого делать нельзя - С
прошу прощения.

(в дитях не сильна, но самый operator-dependent метод обследования ИМХО УЗИ)