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Детский вариант пилюльки
Ув. педиатры!
На форуме терапевтов есть пилюлька от Нескучина. Предлагаю у нас на форуме ее детский вариант. Для начала вот такой вопрос: A 17-year-old woman comes to the office complaining of a 3-month history of "crampy" abdominal pain along with alternating episodes of constipation and diarrhea. She reports that the pain has been worse recently since starting a new job, which she describes as "high stress." Pain also seems worse with eating fatty meals. Her temperature is 37.0 C (98.6F), blood pressure is 120/72 mm Hg, pulse is 63/min, and respirations are 10/min. Physical examination reveals a soft, non-tender, non-distended abdomen with normal bowel sounds and without organomegally. Her rectal exam reveals normal tone. The correct diagnosis would be supported by finding A. a biopsy with transmural intestinal inflammation B. fistula formation within the abdomen C. a history of bloody diarrhea D. a normal colonoscopy E. positive H. pylori antibody titers |
Думаю, что это синдром раздраженной толстой кишки, т.е. D.
С другой стороны, не вполне понятна локализация болей. М.б. и гастрит или дуоденит, тогда E. Но вообще говоря, для гастрита характерна болезненность при пальпации. Нет, все-таки D. |
По-мoему тоже D.
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Тим, возможно. Но что-то мне кажется, что и на НЯК похоже. Так что - будь, что будет:) - вариант С
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Насчет НЯКа, меня остановил совершенно спокойный живот при пальпации, да и при ректальном обследовании все хорошо.
Немного смущает, правда, тот факт, что ей кажется, что похуже от жирной пищи (это ведь тест, а в тесте, как в сказке про Алису, все не просто так), но все равно физикально при НЯКе что-то должно находиться... |
Тим, тоже верно. Однако характер у меня дурной - самый "напрашивающийся" вариант отметаю сразу и ищу подвох))) Кроме того, что при пальпации живот спокойный и нормы при ректальном исследовании, все остальное при наличии диареи с кровью очень похоже на НЯК. Хотя вполне возможен и воспалительный процесс.
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Explanation:The correct answer is D. This patient has irritable bowel syndrome (IBS). This is the most common functional GI disorder. It is characterized by abdominal pain with alternating diarrhea and constipation. It is often related to stress or exercise. Diagnosis is made by history and thoughtful exclusion of other organic diseases. Colonoscopy, if performed, should be normal. Indication for colonoscopy would be to differentiate irritable bowel syndrome from inflammatory bowel disease.
Transmural inflammation (choice A) and fistula formation (choice B) is typical of Crohn disease. Crohn disease is characterized by inflammation of any part of the gastrointestinal tract (mouth to anus). Patients often have lesions, which are not continuous, described as skip lesions. The inflammation is transmural, which means that it involves all layers of the mucosal wall contrary to UC. Patients typically present with non-bloody diarrhea, weight loss, and abdominal pain. Bloody diarrhea (choice C) is a finding in ulcerative colitis (UC). UC is characterized by inflammation limited to the colon and rectum and is typically described as continuous (as opposed to "skip" lesions). Bloody diarrhea is the typical presenting symptom. H. pylori (choice E) may be a cause of abdominal pain and its eradication is recommended if it is discovered incidentally, but routine serology checks in the work-up of abdominal pain is of unproved benefit. |
4 вопроса про судороги.
Q1] The parents of a 2-year-old come in to discuss their child's febrile seizures. The child has experienced four seizures, each associated with fever (usually from an ear infection). Each seizure lasted less than 2 minutes and was generalized tonic-clonic. The child was usually post-ictal for about 60 minutes but then returned to his normal level of mental function. The parents are concerned about the long-term significance for these seizures, specifically about any permanent brain damage and retardation. They ask if their child should be on medication to prevent the seizures. Which one of the following should you tell them? A) Children with a history of febrile seizures usually go on to a more complicated seizure pattern as they age. B) Children with a history of febrile seizures typically perform less well on standardized school tests. C) Children with febrile seizures typically are growth retarded. D) Children with febrile seizures are at greater risk for premature death than the general public. E) Most children who experience febrile seizures develop normally. Q2] You receive a telephone call from a worried mother. She says her 8 month old son just had a seizure lasting for 2 minutes.The seizure has subsided.He is feeding well. His temp 103 RR: 34/min She asks you what needs to be done. You say: A] Take him immediately to the nearest ER B] This is nothing serious. Stay calm C] Give antipyretics to the child and monitor the temp. Q3] Mother in Q2 asks you what is the risk of her child developing a recurrent febrile seizure now. You say: A] There is no such risk in your child B] Risk is increased if his family member has a h/o febrile seizure C] He will definitely have an increased risk since he already had one febrile seizure Q4] Mother in Q2 also asks you, " Doctor. I am very worried. Does this episode of seizure increase my son's risk of developing future epilepsy?" You should say: A] Your child is definitely at increased risk of developing epilepsy B] Your son will be at an increased risk if father has history of febrile seizures. C] If another seizure occurs during this illness then he will be at increased risk D]He will not have increased risk of developing future epilepsy. |
1.E(вариант А - возможно, но не обязательно)
2.C 3.C 4.D или С |
E, C, C, D
Из фаренгейта пересчитывал вручную, какой ужас :eek: |
Из Фаренгейта не надо пересчитывать. Я никогда не пересчитываю.:)
E, C, C, D. |
Е,А,С,D.По поводу второго вопроса,конечно,можно дискутировать.Но ребенок до года с впервые возникшими судорогами все-таки должен быть госпитализирован.
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Цитата:
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Цитата:
...ах, да: ECCD |
Ну мы сейчас не об этом, все всё понимают.
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1 - E
2 - C 3 - B [ Remember having had one febrile seizure does not increase the risk of recurrence but family history does. ] 4 - C. If the pt has no risk factors you can say that he will not have increased risk. Apparently, the pt in Q does not have risk factors. But choice C says what if another seizure occurs during this same illness?....then he will be at increased risk. [ refer to risk factors in above notes ]. So this would be ur best response [ Save your skin ] Family h/o febrile seizure is not a risk factor for future |
Все-таки не очень понятно какое отношение имеет риск по эпилепсии к фебрильным судорогам,даже если они возникнут в течение той же болезни.(по поводу пункта 4).Или это мой английский так сильно хромает? :)
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Мара_док, не хромает, это, видимо, существует такая статистика. Наверное, она отражает склонность к формированию эпилептогенных очагов у тех детей, у которых повышена судорожная готовность. Простите, если что не так сказала - не специалист.
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Я в этом вопросе тоже не специалист.Просто нас учили,что существует эпилепсия,существует эпилептический синдром при разных состояниях,в том числе при высокой температуре.И одно к другому отношения не имеет.Но теперь я уже во всем сомневаюсь. :)
Может быть кто-нибудь из уважаемых невропатологов прокомментирует. |
Существуют эпилептиформные припадки, и не обязательно при повышении температуры, про эпилептический с-м не слышала.
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При атипичных фебрильных судорогах повышается риск возникновения гиппокампального склероза - одной из частых причин эпилепсии. См. [Ссылки могут видеть только зарегистрированные пользователи. ]
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Василий Юрьевич,спасибо за ссылку.Но в задачке нигде не сказано.что судороги атипичные,точнее на это нет никаких указаний,их ведь видела только мама ребенка.Правильно я поняла?Но они возникли при высокой температуре,быстро самостоятельно купировались...Но задача есть задача.В них всегда присутствует определенная условность.
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Повторные ФС относятся к сложным (простите за термин "атипичные"), прогностически менее благоприятным.
Упоминание о гиппокампальном склерозе я привел как наиболее распространенную гипотезу, это не единственное объяснение возможных механизмов эпилептогенеза, которое, к тому же, многими оспаривается. P.S. Я все это пишу, а сам то пропустил в вопросе условие о повторении судорог. Так что пойду я лучше на дежурство. :( |
Спасибо,Василий Юрьевич!
Но в условии то как раз и нет ничего про повторение судорог.А речь идет о том,что они еще только могут повториться и поэтому предлагается сказать,что вероятность эпилепсии будет выше.Подстраховаться.А вот подстраховаться с госпитализацией не предлагается. :) Спокойного вам дежурства! :) |
Цитата:
P.S. Неужели только у нас считается дурной приметой желать удачного дежурства? :( Буду теперь знать, кто мне сглазил. :mad: |
Простите великодушно!Больше не буду!
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A 2-month-old boy is brought to the office for a routine well-baby visit. The mother tells you that he is doing very well, that he drinks 5 oz of formula every 4 hours, stools twice a day, and sleeps 6 hours at a time. His temperature is 37.0 C (98.6 F). Physical examination is normal and he is growing along the 50th percentile for height and weight. After addressing all of the mothers questions and concerns, the most appropriate next step in management is to
A. administer the DTaP, haemophilus-hepatitis B, inactivated polio, and pneumococcal “conjugate” vaccines B. obtain a bagged urine specimen to check for reducing substances C. order a complete blood count to evaluate for anemia D. send the patient home with his mother for a return visit in 2 months E. send the patient home with his mother and schedule a return visit in 3 weeks |
Полез в календарь прививок и решил А, хотя перед А надо бы В и С.
А сколько правильных ответов? один или много? |
Цитата:
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Думаю, что А
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Добрый день!
Насколько я знаю,введение пневмококковой вакцины не рекомендуется до двух лет,поэтому скорее всего ответ - С. |
The correct answer is A. The 2-month visit is the visit of first vaccines. The initial vaccines are DTaP, Hib-Hep B, IPV, and pneumococcal vaccines.
A bagged urine specimen (choice B) is not routinely obtained. A complete blood count (choice C) is usually done at about the 9 month visit, not at 2 months. After the initial set of vaccines, the patient may be sent home with a follow up in 2 months. Without the vaccines, it is inappropriate management to send him home for a return visit in 2 months (choice D) or with a return visit in 3 weeks (choice E). |
A 3-year-old boy with fever
A 3-year-old boy is brought to the office because of a 2-day history of fever, nausea, weakness, and "yellow skin." He has always been a healthy child, rarely having more that a sore throat or ear infection. The family has not traveled recently and no other family members are sick. A couple of children in his childcare center are sick and a parent of one of the other children has similar symptoms. His temperature is 38.1 C (100.6 F). Physical examination shows icteric skin and conjunctiva but is otherwise unremarkable. Laboratory studies show:
IgM Anti-HAV Positive HbsAg Negative HCV-Ag Negative You should advise the mother that: A. Hepatitis vaccination that is routinely recommended for all children in the United States would have prevented this illness B. Her son can return to childcare 5 days after the onset of symptoms C. Household contacts should receive immune globulin within 2 weeks after last exposure D. It is likely that her child was sexually abused by his friend's father E. There is a 30% chance that her son will develop chronic hepatitis |
Цитата:
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Александр,спасибо за объяснение. :)
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Цитата:
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Я тоже за С
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А разве в США вакцинация против гепатита А не включена в календарь?
Я, вообще-то, скорее за А; во всяком случае, я против того, чтобы всем контактным вводить иммуноглобулин в такой ситуации. В новых СП, насколько я помню, предусмотрена вакцинация контактных. |
Ребенок уже болен(вероятно, он не был вакцинирован ранее). Поэтому вакцину Вы ему вводить не будете. Вариант А не подходит.
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А.
Там , как я понимаю , речь идет о том, что вакцинация могла предотвратить это заболевание . |
Цитата:
Если бы написано было "в мире", то этот пункт однозначно не годится, т.к. в международный календарь входит только вакцина против гепатита В. В США, как мне кажется, вакцинируют по календарю и от гепатита А. Так что вариант "А" вполне приемлем. |
The correct answer is C. This patient has an infection with the hepatitis A virus, which is usually transmitted by the fecal-oral route. Since young children tend to put many things in their mouths, including dirty fingers, it is not hard to imagine how they can contract this disease. It can also occur from contaminated food and water, international travel, and rarely through homosexual activity. The treatment is supportive. Household contacts should receive immune globulin within 2 weeks after last exposure.
The hepatitis vaccination that is routinely recommended for all children in the United States would have prevented this illness (choice A) is incorrect. The hepatitis B vaccine, not the hepatitis A vaccine, is routinely recommended for children in the U.S. Ну и, кроме всего прочего, он ведь уже заболел, так что уж теперь говорить, что могло бы быть ( не быть ), если бы... It is incorrect to advise her that her son can return to childcare 5 days after the onset of symptoms (choice B). Children can return to childcare 7 days after the onset of symptoms. While the hepatitis A virus may be transmitted through homosexual activity, you should not advise her that it is likely that her child was sexually abused by his friend's father (choice D). Close contact, not necessarily sexual contact, and fecal-oral transmission are the most likely sources of infection. Since you have absolutely no evidence that this child has been sexually abused, it is inappropriate to say this to the mother at this time. Since hepatitis A is not associated with chronic infection, it is incorrect to tell the mother that there is a 30% chance that her son will develop chronic hepatitis (choice E). P.S. В Израиле привика от гепатита А а в календаре прививок с 1998 г. ( Гепатит В с 1992 г.) |
Цитата:
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The mother of a 3-year-old patient of yours, calls the office after the child banged his head against the coffee table in their family room. The mother is absolutely frantic, saying that her son has been "screaming and crying" for the past 45 minutes and that she cannot calm him down. She tells you that he did not lose consciousness. You advise her to bring him into the office, even though you just finished seeing your last patient and were just planning on leaving for the evening. When they arrive, you notice that the boy's eyes appear very red from crying, but that he has calmed down. The mother is still very concerned. They have both been patients of yours for many years, and they have always been very healthy and compliant. You notice that there is a 0.5-cm edematous area on the back of his head. The skin is intact over the wound. The remainder of the physical examination, including a complete neurologic and funduscopic examination, is unremarkable. After calming the mother down, the most appropriate next step is to
A. advise them to go to the emergency department for observation B. obtain a skull radiograph C. order a CT scan of the head D. recommend regular monitoring and observation for any abnormalities, and if they arise, that they should go to the emergency department E. report the case to the child protective service agency |
D......
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В жизни - D, но Е здесь тоже наверное не просто так... :confused:
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Да уж, так и представляю фразу врача: "Успокойтесь, мамочка, сейчас направим report of the case to the child protective service agency, и все будет отлично!"
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Explanation:
The correct answer is D. This boy has a minor closed head injury with no loss of consciousness, which is one of the most common injuries in children. All children "bump" their heads at some point. It is important to do a physical examination, including a complete neurologic and funduscopic examination, and if this is normal, be able to recognize that further studies are generally not indicated. Regular monitoring and observation for any abnormalities can be done by a competent caregiver. If this occurred during the day, you may consider having them stay in your waiting room for a little while, but since you are leaving for the night and the mother has always been responsible and compliant, you can send them home for observation. It is inappropriate to advise them to go to the emergency department for observation (choice A). This child had a minor head injury with no loss of consciousness and he has a normal neurologic and funduscopic examination. It is very unlikely that he has an intracranial injury, and therefore, as long as you know that the mother is a competent caretaker, you should send them home after advising her to seek assistance if he begins to deteriorate. It is unnecessary to obtain a skull radiograph (choice B) at this time in this child with a minor closed head injury without a loss of consciousness. He does not have any signs of a skull fracture, which include battle signs (ecchymoses behind the ear), a palpable depression, or blood in the ear and therefore it is very unlikely that the radiograph will show a skull fracture. Also, even if he did have a skull fracture that does not necessarily mean that he has an intracranial injury. A CT scan (choice C) is not indicated at this time in this patient with a minor closed head injury, no loss of consciousness, and a normal neurologic and funduscopic examination. Studies have shown that the risk of intracranial injury is negligible in this situation, and that fewer than 1 in 5,000 patients with minor closed head injuries and no loss of consciousness have intracranial injuries that require medical or neurosurgical intervention. Since this case states that they are very healthy and compliant patients and the physical exam does not reveal any abnormalities besides this head wound that seems consistent with the story the mother told you, it is inappropriate to report the case to the child protective service agency (choice E). It is always important to be aware of signs of child abuse, such as many emergency room visits, many wounds in various stages of healing, implausible and inconsistent stories, and bringing the child in a while after the injury took place. This case does not seem to fit this description |
A 6-year-old boy is brought to the office by his parents who are concerned because he has been refusing to use his left arm for 1 day. The parents report that he has been in good health and has not suffered any recent falls or injuries to the arm that they are aware of. The father does recall one incident 2 days ago when he pulled upward on the boy's right arm to prevent him from tripping as they descended a flight of stairs. The boy is holding his right arm with the elbow flexed and the forearm pronated. He begins to cry when you attempt to examine the arm. The most appropriate next step is
A. closed reduction and cast immobilization B. a CT of the right arm C. measurement of compartment pressure of the forearm D. supination of the forearm with the elbow flexed E. a trial of compressive bandage on the right arm |
Вывих локтевого сустава.
A. closed reduction and cast immobilization |
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