Еще одна пилюлька Hескучина

[yananshs]

The correct answer is C. This patient is in respiratory distress and requires immediate intubation. His already severe underlying lung disease has been compounded with an acute pneumonia. His nonexistent pulmonary reserve has been exhausted. This is not an uncommon scenario for severe COPD patients. He has poor oxygenation, minimal air movement with inspiratory effort, and his carbon dioxide levels are certainly rising which will shortly result in narcosis and then death. All of these are signs and symptoms of imminent pulmonary collapse. The patient requires a controlled airway, mechanical ventilation, and aggressive pulmonary toilet with antibiotic therapy.

Delivery of nebulized beta agonist (choice A) or nebulized anticholinergics (choice B) is inappropriate. These agents require that a patient have some ability to move air during inspiration so that the nebulized drugs can be delivered to the distal airways. This patient has no such ability. In addition, the time course in which these agents act is not rapid enough to reverse the imminent collapse that this patient will suffer.

Wanting to give morphine sulfate intravenously (choice D) is reasonable, only after the intubation however. Morphine possesses excellent pulmonary vasodilatory properties which makes it a great drug for the relief of dyspnea. This is humanitarian in this case but giving it prior to securing the airway will depress this patient's respiratory rate, cause an acute carbon dioxide narcosis, deoxygenation, and cardiac arrest from hypoxia.

Use of continuous positive airway pressure (CPAP) (choice E) is often appropriate in patients such as this to allow stenting of the airways and facilitate gas exchange. In order to do this however, the patient first requires endotracheal intubation.

[yananshs]

A 28-year-old gravida 3, para 2 woman comes to the clinic for prenatal care at 11-weeks gestation. Her medical and surgical history are unremarkable, although she relates a social history significant for alcohol consumption. She drinks 1-2 glasses of wine with lunch and 3-4 glasses of wine with and after dinner on most nights. Given her history, her fetus is at greatest risk for
A. a bowel obstruction
B. a cardiac defect
C. cleft lip and palate
D. macrosomia
E. tall stature

[doctor Asya]

Я считаю : B . A cardiac defect.

[dr.Ira]

Из предложенного - В

[yananshs]

The correct answer is B. Any fetus exposed to alcohol, especially during the first trimester, is at risk for fetal alcohol syndrome (FAS). Cardiac malformations, especially ventricular septal defect (VSD), are noted with increased frequency among infants exposed to excessive levels of alcohol in utero. Additional characteristics of children with FAS may include CNS impairments such as microcephaly, mental retardation, and attention deficit disorders. For women with "moderate" alcohol intake, defined as 1-2 oz of absolute alcohol per day (i.e., 2-4 drinks per day), the risk of FAS is 10%. This woman consumes 4-6 drinks per day and thus places her fetus at risk for some component of FAS.

Bowel obstruction (choice A) is incorrect because it is not found in FAS. Bowel obstruction, which can occur with duodenal atresia, is found with increased frequency in a fetus with Down's syndrome, not FAS.

Cleft lip and palate (choice C) is incorrect. Facial dysmorphia found in FAS includes low-set ears, smooth philtrum, and short palpebral fissures.

Macrosomia (choice D) is incorrect. Growth restriction (not macrosomia or tall stature) is found either prenatally or postnatally in FAS.

Tall stature (choice E) is also incorrect. Children with FAS are small for gestational age and growth restricted.

[yananshs]

A 12-year-old boy is brought to the office because of a 2-week history of pain and swelling of his right leg. The pain is worse on the shin, just below the knee, and is exacerbated by running, jumping, and going up and down stairs. His mother states that he is a very active child; ⌠he is always on the go." He plays basketball with friends on the court in their backyard, and baseball on a neighborhood little league team. He recently started playing volleyball in gym class. Physical examination reveals a pubescent boy with point tenderness and swelling over the right tibial tubercle. The left leg is unremarkable. The most likely diagnosis is
A. "growing pains"
B. Legg-Calve-Perthes disease
C. Osgood-Schlatter disease
D. osteosarcoma
E. slipped capital femoral epiphysis

[Alon]

FLOOD INSIDE

[vosk]

C. Osgood-Schlatter disease
Dmitry Voskovets

[dr.Ira]

Да, скорее всего, С.

[yananshs]

The correct answer is C. This patient most likely has Osgood-Schlatter disease. The typical patient is a physically active pubescent boy who has pain and swelling over the tibial tuberosity. The pain is exacerbated by physical activity. It is caused by apophysitis, (inflammation of the tibial tuberosity), and cartilage detachment. Diagnosis is made by history and tibial tuberosity tenderness. Treatment is the reduction of physical activity.

"Growing pains", (choice A) are usually characterized by deep, severe, bilateral, diffuse pains that are worse at night. There is no associated limp.

Legg-Calve-Perthes disease (choice B), avascular necrosis of the femoral head, is characterized by hip and knee pain, a limp, and decreased range of motion. It usually affects boys between 4 to 8 years of age. Casting and surgery are treatment options.

Osteosarcoma (choice D), is the most common malignant bone tumor in kids. It occurs in the metaphyses of long bones, and presents with pain, swelling, and a palpable mass. X-rays show a lytic lesion with a "sunburst" pattern. Treatment is surgery.

Slipped Capital Femoral Epiphysis (choice E), is a disorder of overweight boys that is caused by a displacement of the femoral head from the femoral neck. There is knee or thigh pain, and a limp. Treatment is immediate surgical fixation.

[yananshs]

A 102-year-old man is brought to the clinic from his apartment by a neighbor because of a cough productive of green sputum. He has a past medical history of a stroke 10 years ago with residual left arm weakness. The patient is widowed and lives alone. He takes no medications. Vital signs are: temperature 38.8 C (101.8 F), blood pressure 100/50 mm Hg, pulse 110/min. On physical examination, the patient has rhonchi in the right lower lung field. A chest x-ray reveals an infiltrate in the right lower and middle lobes. The patient has a score of 30/30 on a mini mental status examination. The patient states that he has "lived a good life and now wants to go home". He refuses any intravenous medications and will only take pills. After discussing that the pneumonia could potentially be fatal without intravenous antibiotic treatment, the patient continues to ask to be sent home. The neighbor insists that the patient should be admitted to the hospital. The next step in the care of this patient is to
A. admit the patient to hospital care with intravenous antibiotics
B. admit the patient to hospital care without intravenous antibiotics
C. admit the patient to psychiatric ward with antibiotics
D. discharge the patient home with oral antibiotics
E. discuss the case with the hospital attorney
F. initiate antidepressant therapy and administer intravenous antibiotics

[Melnichenko]

Яна, у меня сохраняется дальтонизм?

[Annabella]

Я бы сделала вариант Д. Пусть очень пожилой, но разумный человек. Имеет право.
Хотя я конечно, могу быть неправа.

[Gilarov]

А я бы - В. Наблюдение все же...

[Annabella]

У нас, в России, может быть, и В (впрочем у нас в стационаре "таблеточный" антибиотик - большое удивление).
Но пациент хочет идти домой, он вменяемый, как можно задержать? Или обратиться к юристу больницы, как указано в Е?