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#1066
17.01.2007, 06:24
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The correct answer is D. This patient most likely has an accessory nipple (polythelia) and extraglandular breast tissue (polymastia), which are present in approximately 2% to 5% of the population. They usually occur along the "milk line," which is an embryologic line that extends from the axilla to the inguinal region. Normal breasts form along this line and other areas of breast tissue and accessory nipples can too. Patients often think that they are "moles" and generally are only concerned about the cosmetic appearance. They can be simply removed as an outpatient, and additional treatment is not usually necessary.
Coal tar ointment and ultraviolet light therapy is an old but useful treatment (choice A) is a true statement concerning psoriasis, not polythelia or polymastia. Psoriasis is characterized by erythematous plaques with silvery scales. It typically occurs on the elbows, knees, lower back, and scalp. Some studies have shown an association between polythelia, polymastia and kidney and urinary tract defects. However, this is only in about 8% of the cases. It is therefore incorrect to tell her that she has a 70% chance of having a kidney and/or urinary tract defect (choice B). Further kidney and urinary tract evaluation may be indicated. Accessory nipples (polythelia) and extraglandular breast tissue (polymastia) are not typically considered precancerous, therefore it is incorrect to tell her that the lesion needs to be removed immediately because it is precancerous (choice C). They are usually removed for cosmetic purposes. Accessory nipples (polythelia) and extraglandular breast tissue (polymastia) are not typically considered malignant and therefore it is incorrect to tell her that this needs to be removed immediately and that she will need radiation therapy (choice E). 
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#1067
17.01.2007, 06:26
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A 29-year-old man is admitted to the hospital with fever and cough. The symptoms began roughly 1-month prior and have been intermittent. He states that his cough is often productive of thick secretions and that, despite normal food intake, he has lost about 10 pounds in the past month. He is a volunteer at a local hospital and has received no special health care personnel vaccinations or screening tests. On examination, the patient appears somewhat thin, tired, and is coughing intermittently. His temperature is 38.0 C (100.4 F) and respirations are 16/min. He has patchy bilateral rhonchi over all lung fields. Prior to initiating therapy for this condition, the laboratory test required to confirm the suspected diagnosis is a
A. chest radiograph B. sputum acid-fast stain C. sputum culture D. sputum Gram stain E. tuberculin skin test
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#1068
17.01.2007, 07:52
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Туберкулез!
Собственно все варианты, кроме окраски по Граму, применяются при диагностике туберкулеза. Рентгенограмма ОГК важна, но картина может быть неспецифической, признаки, выявленные при рентгенографии, не являются 100% подтверждением туберкулезной этиологии процесса. tuberculin skin test – недостоверен, может быть как положительная, так и отрицательная реакция. C. sputum culture – очень важный подтверждающий признак! Но, вначале нужно рассмотреть под микроскопом кислотоустойчивые палочки, потом назначить лечение и дожидаться результатов посева. Выбираю: B. sputum acid-fast stain
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#1069
18.01.2007, 02:57
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The correct answer is B. The patient likely has tuberculosis. Virtually all M. tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter. The symptoms of tuberculosis are protean and nonspecific and can be classified as either systemic or organ-specific. Classic systemic symptoms include fever, night sweats, anorexia, weight loss, and weakness. However, since tuberculosis is associated with other illnesses that have similar symptoms, this lack of specificity can result in a delayed diagnosis or even a misdiagnosis. Organ-specific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and hemoptysis. The requirement for diagnosis is the presence of the organism that appears by acid-fast staining in a sputum sample.
In patients with primary tuberculosis, chest radiographs (choice A) often show infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy. These findings are non-specific and are not used for confirmation of the diagnosis. A sputum culture (choice C) is not useful in this case since the organism responsible for TB is fastidious and is difficult to culture, and certainly does not grow rapidly. The organism responsible for TB does not stain with traditional Gram stain dyes (choice D) and therefore requires special staining such as acid-fast in order to detect it. Although it is imperfect, the gold standard for diagnosing latent tuberculosis infection remains the intradermal injection (choice E) of purified protein derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux method). The test has no role in the diagnosis of active infection.
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#1070
19.01.2007, 17:46
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A 2-year-old boy is brought to the office for the first time by both his parents for a well-child visit. The family just moved to your city from a small town, where they were very dissatisfied with the medical care. They tell you that the boy has been "a little off since birth." He failed to ever develop a social smile, his face is expressionless, and he does not make eye contact. He often plays by himself in the corner, despite the parent's effort to make numerous play-dates with other children his age. They often find him twirling the buttons on his shirt for hours at a time. He appears to be a well-developed child, however he refuses to speak to you. The parents are not actually sure if he is able to speak. The most likely diagnosis is
A. attention-deficit hyperactivity disorder B. autistic disorder C. childhood-onset schizophrenia D. oppositional defiant disorder E. Tourette's disorder
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#1073
21.01.2007, 18:36
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The correct answer is B. This child most likely has autism, which is a pervasive developmental disorder that is characterized by the impairment of social interactions, impairment of communication, and repetitive, stereotyped behaviors. It is more common in boys and in a sibling of a child with autism. It is associated with mental retardation, seizures, and self-mutilation. The treatment includes structured classroom training with behavioral management techniques and haloperidol. Mood stabilizers may decrease the self-harming behaviors.
Attention-deficit hyperactivity disorder (ADHD) (choice A) is a childhood disorder characterized by impulsiveness, hyperactivity, easy distractibility, and inattention. Methylphenidate, a psychostimulant, is the pharmacotherapy of choice. Weight loss and insomnia are major side effects. The child in this case is not overactive or inattentive. Childhood-onset schizophrenia (choice C) may be diagnosed in a child that develops positive and negative psychotic symptoms between 5 years of age and adolescence or early adulthood. The children often have normal intelligence. Childhood-onset schizophrenia is often associated with a gradual lifelong decline in functioning and a poor response to medication. Treatment includes antipsychotic agents and structured classroom training with behavioral management techniques. It is unlikely that this 2-year-old child has this disorder. He appears to have impairment of social interactions and impairment of communication, not psychotic symptoms. Oppositional defiant disorder (choice D) is a pattern of behavior characterized by the unwillingness to comply with the rules of others and majorly difficult, disruptive behavior. It is generally regarded as a less severe form of conduct disorder. The child in this case does not fit this description. Tourette's disorder (choice E) is characterized by motor and vocal tics. Patients say that they try to control the behavior, but the urge is often too overwhelming. It is associated with obsessive-compulsive disorder. The child in this case does twirl his shirt buttons a lot, however this is not a tic, which is a sudden, recurrent, rapid behavior.
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#1074
21.01.2007, 18:37
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A 17-month-old boy is brought to the emergency department by his mother who states that the child fell while walking across the room 2 hours ago and has been irritable ever since. The child has been reportedly healthy up until now. On physical examination, the child is tearful and inconsolable, vital signs are stable, pupils are equal, round, and reactive to light. He moves all 4 extremities equally. A head CT is ordered which demonstrates bilateral subdural hematomas with acute blood on the right and subacute blood on the left. There is no midline shift or significant mass effect. There is also bifrontal atrophy and no skull fractures. The most appropriate management is to
A. admit him for observation B. arrange for immediate surgical decompression of the subdural hematomas, then discharge when patient is stable C. call the local police and have the mother taken into custody for suspected child abuse D. discharge the patient with follow up in neurosurgery clinic E. obtain immediate neurosurgical consultation for the subdural hematomas and call child protective services consultation for evaluation of child abuse
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#1075
21.01.2007, 18:43
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E. obtain immediate neurosurgical consultation for the subdural hematomas and call child protective services consultation for evaluation of child abuse
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#1076
21.01.2007, 19:33
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Цитата:
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#1077
22.01.2007, 00:00
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The correct answer is E. This is a fairly clear-cut case of non-accidental trauma. A child of this size falling down while walking cannot generate the type of force that is required to cause this degree of trauma. Anytime bilateral subdural hematomas, particularly of varying ages, are seen in a young child, abuse must be considered. The atrophy is another ancillary finding. Another useful radiologic test in the evaluation of non-accidental trauma is a bone survey to evaluate for fractures of varying ages, as well as typical fractures associated with child abuse such as fractures of the posterior ribs and corners of the metaphyses of the bones. Clearly a neurosurgical consultation for the acute subdural hematoma is also warranted.
Admitting him for observation (choice A) or simply discharging the patient (choice D) is not addressing the problems raised in this case. Surgical decompression of the hematoma (choice B) may be warranted depending on its size and the progression or resolution of the child's symptoms. However, this choice is definitely incorrect because no mention is made of addressing the issue of non-accidental trauma. The local police (choice C) may need to be involved at some point. However, a child protective service evaluation is usually the preferable first step.
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#1078
22.01.2007, 00:01
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A 41-year-old woman comes to your clinic because she injured her arm during a fall 2 days ago. She has had multiple visits to the clinic for various reasons, with a significant number of visits over the past two years for fractures and falls. The patient has consistently reported that her falls and fractures are related to her job as a cleaning woman at a local factory. Her most recent visit three weeks ago was for a bruised face requiring six sutures for a laceration over her forehead. The patient lives with her boyfriend of 15 years. He is unemployed and has been hospitalized for alcohol withdrawal seizures three times. The patient reports that she and her boyfriend argue fairly often but that he is often drunk and does not remember what he says or does. The patient has a 7th grade education and a 20-year smoking history. She has four children all from her current partner. She reports that her children also fall quite a bit and have been treated for fractures and bruises as well. When you inquire about her home life, the patient offers no response and tries to leave the clinic. The most accurate statement concerning screening for domestic violence is:
A. Do not interview the patient alone B. A few direct questions about abuse may be recommended in adult patients C. Routine screening is indicated only for high-risk patients D. Routine screening is not indicated E. Women are more likely to report domestic violence to a non-medical person
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#1080
22.01.2007, 13:08
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Цитата:
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Линейный вид
