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#376
04.08.2006, 22:07
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The correct answer is C. This patient has established postherpetic neuralgia. She has all of the classical signs of neuropathic pain including, allodynia (nonpainful stimuli eliciting pain), primary hyperalgesia (pain increasing in intensity with stimulation), and secondary hyperalgesia (surrounding tissue having pain). This entity often follows the varicella zoster reactivation disease shingles and it follows the distribution of the original infection. The main risk factor for the neuralgia is increasing age. There is excellent clinical data showing dramatic pain relief from the use of tricyclic antidepressants. The mechanism of action is unknown.
The use of acyclovir (choice A) is indicated for the prevention of postherpetic neuralgia and hastening the resolution of the zoster infection. These anti-retroviral agents have no efficacy in pain control for established postherpetic pain. There is no benefit to the use of amantadine (choice B). This class of drugs has benefit in decreasing infectivity from influenza virus by inhibiting early stages of the infection process. There is some evidence that topical lidocaine cream (choice D) offers some pain relief from neuropathic pain, but compared to tricyclic therapy, the benefits are minimal. Narcotic drugs such as oxycodone (choice E) are actually very ineffective at controlling neuropathic pain. In fact, they have no recommended role in the management of this type of pain. Oxycodone, sustained release, is an oral sustained release formulation of morphine and is used for the treatment of chronic, nonneuropathic pain conditions. Sustained release formulation are not to be used for the management of acute pain. 
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#377
04.08.2006, 22:08
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A 10-year-old boy is brought to the emergency department by his parents after he sprayed himself while playing with an unmarked spray can. After several minutes, he began tearing and drooling according to his mother. By the time his father arrived, the boy had collapsed on the floor and was unresponsive. On examination, the boy appears comatose and is profusely diaphoretic. His heart rate is 48/min and his blood pressure is 80/40 mm Hg. The patient's respirations are slow and shallow, and his expiratory time is prolonged. Pupils are constricted and unresponsive. Lung auscultation reveals bilateral wheezes. Multiple fasciculations are observed in various muscle groups. Pulse oximetry measures an oxygen saturation of 70% on room air. An arterial blood gas shows:
A chest radiograph demonstrates clear lungs. The child is immediately intubated and ventilated on 100% supplemental oxygen. Intravenous saline infusion is started. The most appropriate next step is to A. administer atropine sulfate, intravenously B. administer corticosteroids, intravenously C. administer edrophonium, intravenously D. administer epinephrine, subcutaneously E. administer methylene blue, intravenously
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#378
04.08.2006, 22:12
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а? В смысле, я за А
 Картина ужасная, в токсикологии понимаю очень мало, но вспоминаются страшные вещи про V-gases.
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#381
04.08.2006, 23:12
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The correct answer is A. The child is exhibiting symptoms of excessive parasympathetic tone after exposure to an unknown substance. This is a classic case of severe organophosphate poisoning. Symptoms include lacrimation, salivation, blurred vision, urinary incontinence, diarrhea, and diaphoresis. Other more severe effects are bronchospasm, bradycardia, hypotension, respiratory paralysis, and mental status change. Organophosphates include many pesticides that irreversibly react with postsynaptic acetylcholinesterase molecules and inhibit their activity. Atropine is the drug of choice to treat the acute toxic effects of organophosphate poisoning by blocking muscarinic acetylcholine receptors. In addition, an antidote, pralidoxime, can reactivate acetylcholinesterases bound by organophosphates and should be administered along with atropine.
The bronchospasm and hypotension arises from increased cholinergic activity not from an inflammatory or anaphylactic response. Corticosteroids (choice B) are not useful in this situation. Edrophonium (choice C) is an inhibitor of acetylcholinesterase and has effects similar to organophosphates, so it would only worsen his symptoms. Epinephrine (choice D) may improve the bronchospasm, bradycardia, and hypotension, but it will counteract the other effects of organophosphate poisoning. Methylene blue (choice E) is the antidote for severe methemoglobinemia. It is not indicated in organophosphate poisoning.
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#382
04.08.2006, 23:12
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A 51-year-old man comes to the clinic for a pre-employment examination. He has diet-controlled diabetes mellitus for 25 years, hypertension, glaucoma, mild peripheral vascular disease, and osteoarthritis. His medications include lisinopril, atenolol, aspirin, and acetaminophen as needed for pain. His blood pressure is 160/80 mm Hg and pulse is 61/min. His examination is notable for a left carotid bruit, a 2/6 systolic ejection murmur heard best at the left sternal border, and clear lungs. His abdomen is soft with no masses but there is a previously appreciated abdominal bruit. He hands you a piece of paper that shows that his last BUN and creatinine were 65 mg/dL and 1.6 mg/dL respectively. His last HA1C value was 8.3%. The most accurate statement concerning this patient's condition is:
A. He has normal renal function B. He has poorly controlled diabetes and severe diabetic renal disease C. He has renal insufficiency D. He is not a candidate for a renal transplant E. He requires hemodialysis
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#383
05.08.2006, 03:04
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>>D<<
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#384
05.08.2006, 09:47
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Это трудный вопрос. Подходит С, пока что подходит D, и уж точно he has poorly controlled diabetes, давно пора задуматься о лечении помимо диеты!
С.
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#386
05.08.2006, 20:46
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Цитата:
Если не трудно, подскажите, что наводит на мысль: has poorly controlled diabetes? Вроде бы HA1C повышен совсем чуть-чуть, а больше я ничего не заметил. Или что-то пропустил  ?Спасибо Dmitry Voskovets.
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#388
06.08.2006, 07:45
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Цитата:
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#389
06.08.2006, 16:19
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Цитата:
А - не подходит, В - то, что диабет плохо контролируется - ясно, но шум над почечными (?) артериями + лизиноприл  , С - ХПН по одному анализу с креатинином 1,6 мг/дл все-таки не ставится (как же я ненавижу мг/дл). А вот то, что с СКФ около 48 он пока не кандитат для трансплантации - вполне логично.
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#390
06.08.2006, 21:04
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The correct answer is C. A BUN and creatinine as high as this patient's reflect a glomerular filtration rate that is below normal, therefore indicating renal insufficiency.
By definition this is renal insufficiency and not normal renal function (choice A). Although this patient has a HA1C level of 8.3% reflecting a mean blood glucose concentration of greater that 225 mg/dL and therefore poorly controlled diabetes, he does not have severe diabetic renal disease (choice B) based upon the fact that he has only mildly elevated renal indices. The evaluation of patient as a transplant candidate is a complex process involving medical, psychiatric, and social issues and since we have no information on most of these points, it is not possible to say that this patient is not a candidate for a renal transplant (choice D). There are five indications for hemodialysis: uremia, hyperkalemia, acidosis, volume, and uremic pericarditis. Since this patient has none of these he does not require hemodialysis (choice E).
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Линейный вид
