Еще одна пилюлька Hескучина

[yananshs]

You are visited in your office by a 40-year-old woman who began experiencing nausea, vomiting, and numbness in left hand and foot 1 week ago. Today she began to feel "crescendo pain" in the right retroorbital area. She has had a headache for a few months that she describes as throbbing and positional, particularly when she bends forward. The headaches are especially intense in the morning and at times they have woke her up at night. On examination the only deficits she has are loss of double simultaneous tactile stimulation and a left lower facial droop when smiling. The most appropriate next step in management is to
A. administer intravenous prochlorperazine in your office
B. get her to the emergency department for neurologic evaluation as soon as possible
C. give her a prescription for zolmitriptan and send her home
D. make an appointment for her to see a neurologist next month
E. order an electroencephalogram to rule out seizures

[riltsov]

Очаговые неврологические симптомы требуют скорейшего неврологического обследования.
B. get her to the emergency department for neurologic evaluation as soon as possible

[vosk]

и правда очень похоже на нарушение. я за "В".

Dmitry Voskovets

[riltsov]

Головные боли мигренозные или связанные с синуситом. Трудно дифференцировать. Пирамидная недостаточность слева и центральная недостаточность левого лицевого нерва. Возможно мигренозный инсульт.
B. get her to the emergency department for neurologic evaluation as soon as possible

[yananshs]

The correct answer is B. The headache is typical of that caused by intracranial hypertension. Additionally, she has focal neurological symptoms and signs. This is particularly concerning for a brain tumor or hemorrhage. This should be evaluated as soon as possible. An appointment next month (choice D) is too late.

Intravenous prochlorperazine (choice A) is a good treatment for status migrainous, however this history is atypical for such a diagnosis and more serious problems should be ruled out first in the emergency department.

Zolmitriptan (choice C) is a treatment for migraines. This history is not typical for migraine and zolmitriptan is relatively contraindicated in patients with complex migraine.

This history is very atypical for seizures and an electroencephalogram (choice E) is not likely to provide useful information in this case.

[yananshs]

A 43-year-old has been coming to you for 5 years for the management of his HIV infection. Over the past few years he has had Pneumocystis carinii pneumonia, Kaposi's sarcoma, oral candidiasis, and "everything else under the sun." He has been with the same partner for 6 years, who is also HIV positive. They have both been on a variety of "cocktails" and have suffered through many adverse side effects. You notice that he looks healthier and ask him how he was able to bulk up so well. He replies, "I have finally found a cure for the nausea and lack of appetite- marijuana! My partner and I have been growing it in our yard and we smoke it a couple of times a day. We feel great!" His partner is also a patient of yours. The best response is:
A. "Are you aware that marijuana use has been associated with respiratory problems?"
B. "I am sorry, but I am going to have to call the police and turn you in."
C. "I can provide you with a medication that will also alleviate these symptoms, instead of using marijuana."
D. "I have read about other patients doing that. However, do you really think that using an illegal drug is a good idea?"
E. "That is against the law, and you must stop at once!"

[riltsov]

Я убежден, что это наиболее корректный ответ:
D. "I have read about other patients doing that. However, do you really think that using an illegal drug is a good idea?"

[riltsov]

Такой ответ (D.) расположит пациента к врачу, откроет возможность для диалога в результате, которого будет найдена возможность предложить другое medication that will also alleviate these symptoms. Другие варианты могут рассердить пациента. А вот какой будет ответ, с точки зрения юридической я не знаю. Насколько я знаю, врач в Америке должен сообщать в полицию о совершенном преступлении, по крайней мере, если речь идет о violence or child abuse.

[Anna_Shvedova]

Я тоже за Д.
Главное, чтобы другим не продавали. А для себя пусть сами решают, нам надо предупредить о рисках. Может быть, я слишком терпима к марихуане?

[Aminazinka]

Сообщение от yananshs

The correct answer is C. In acute psychiatric emergencies, a neuroleptic agent (haloperidol) and a benzodiazepine (diazepam) are typically given to control the patient and aid in sedation. An anticholinergic agent, such as benztropine, should be added to prevent parkinsonian-like symptoms (rigidity and akinesia) that may occur in patients treated with high-potency antipsychotic agents (haloperidol).

In this acute situation, it is inappropriate to begin psychosocial treatment with behavior skills training (choice A). Psychosocial treatment, including behavior skills training, multi-family groups, vocational training, and workshops, is very important in the long-term management of schizophrenia. During the patient's hospitalization, after the patient is stabilized, the treatment plan should focus on practical issues, and set the stage for outpatient psychosocial issues.

Dantrolene is the treatment for neuroleptic malignant syndrome (choice B), which may be caused by high-potency antipsychotic agents (haloperidol). It is not routinely given to prevent this condition. NMS is associated with a high fever, autonomic instability, rigidity, behavioral changes, and laboratory abnormalities such as elevated white blood cell count, creatine kinase, and abnormal liver function tests.

Clozapine (choice D) is used as a second-line antipsychotic agent for patients who do not respond to the typical antipsychotic medications and have prominent negative symptoms (flat affect, poverty of speech, and asociality). It is not typically the first agent given in an acute psychiatric emergency. It is associated with agranulocytosis (1%) and requires weekly monitoring of the white blood cell count.

Electroconvulsive therapy (choice E) may be used in cases of non-responsive catatonia. It is not often used to treat an acute psychiatric emergency with a wild and out of control patient.

Прошу прощения, что не вовремя, не хотела портить праздник непсихиатрам и прозевала .
Так вот. В наших странах (до распада СССР, в России до сих пор) препаратом первого ряда, который назначается вместе с галоперидолом в первый же день, является циклодол. Препарат, к сожалению, попал в разряд учетных, однако в острой психиатрии он есть всегда. И еще немножко насчет ECT (ЭСТ). Не только при кататонии. Но и при резистентной к терапии шизофрении (кстати, и депрессии) вообще. Абсолютно точно то, что в качестве скорой помощи не применяется никогда.

[yananshs]

The correct answer is C. As a general rule, when a patient tells you that they are using an illegal drug or a questionable alternative treatment, it is best to dissuade them by recommending a better alternative, rather than criticizing them. Simply put, don't argue with their practice, instead, suggest something better.

"Are you aware that marijuana use has been associated with respiratory problems?" (choice A) and "I have read about other patients doing that. However, do you really think that using an illegal drug is a good idea?" (choice D) are not the best responses because they are both a bit critical and argumentative. Ideally, you should try to dissuade patients from questionable practices, not by criticizing the practices, but by recommending better alternatives.

"I am sorry, but I am going to have to call the police and turn you in." (choice B) and "That is against the law, and you must stop at once!" (choice E) are not the best responses because while marijuana is illegal, it is not the physician's responsibility to enforce the law. The patient's comfort is most important and his/her interest comes first. Also, being combative will typically alienate the patient, which is not a good way to maintain a physician-patient relationship. If you are critical and combative your patients will be reluctant to tell you about their use of these practices (if they come back to you at all).

[yananshs]

A 66-year-old woman comes to the clinic complaining of severe pain across her chest and abdomen. You treated the patient for shingles 5 months ago and at that time she had a shingles band at the right T8 level. The current pain is in the same region where she had her shingles. She states that she cannot stand to have her clothes touch the area and that even shower water hurts. She has hypertension and glaucoma for which she takes beta blocker eye drops and lisinopril. At the level of her T8 dermatome on the right, she has marked allodynia, primary and secondary hyperalgesia. The area is exceptionally tender to palpation. The most appropriate therapy is at this time is
A. acyclovir
B. amantadine
C. amitriptyline
D. lidocaine cream
E. oxycodone, sustained release

[riltsov]

Постгерпетическая невралгия
D. lidocaine cream

[yananshs]

Ответ неверный.

[riltsov]

Acyclovir and amantadine применяются при лечении опоясывающего лишая, но не постгерпетической невралгии. Amitriptyline подходит, но он противопоказан при глаукоме. Остаются lidocaine и oxycodone. Лидокаин точно применяется при постгерпетической невралгии, и он одобрен FDA для применения по этому показанию.
По-видимому, в связи с marked allodynia, primary and secondary hyperalgesia правильным ответом будет E. oxycodone, sustained release.