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#1186
09.02.2007, 21:56
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Из пациента много натрия выгнали. Поэтому варианты D. C. и E. исключены.
Остаются варианты A. и B. Выбираю вариант B., т.к. он предполагает возврат натрия в кровяное русло, где его не хватает. 
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#1187
10.02.2007, 10:12
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Цитата:
решительно возражаю против соли в любом виде- изотоническом, гипертоническом, сухом (однако ситуация по описанию нуждается в более решительных действиях, чем просто ограничить соль). В изотоническом р-ре 154 ммол/л на- если пациент не в шоке- показаний нет, это и риск быстрой коррекции, и- обязательное последуюшее усиление отёков.про гипертонический вообше речи нет, только если перед трансплантацией... хроническая гипоNа у цирротиков практически не приводит к неврологическим последствиям. Мелькала информация, что может усугубить сушествуюшую энцефалопатию, но до таких изысков тестам, думаю, далеко.
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#1188
10.02.2007, 10:42
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Цитата:
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#1189
12.02.2007, 23:29
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The correct answer is E. True hyponatremia is always hypotonic. There are then three types of hyponatremia: hypovolemic, euvolemic, or hypervolemic. The therapy for the hyponatremia depends on both the urinary concentration of sodium as well as the volume status for each patient. Once the patient's total body volume status has been estimated, urinary sodium usually allows focusing of the differential diagnosis. For this patient, he clearly has total body volume overload. He has cirrhosis and portal hypertension. The standard therapy for these patients is salt restriction and management of volume status with diuretics. This patient, at the core of his therapy requires salt restriction.
Although some forms of hyponatremia respond to administering hypertonic saline (choice A), knowing the pathophysiology of this patient's hyponatremia, it can be clearly seen that this intervention will only aggravate this patient's condition. Giving the patient sodium chloride tablets (choice B) will clearly not be beneficial to this patient given the above explanations. Increasing the dose of furosemide (choice C) or the dose of spironolactone (choice D) will certainly serve to diurese the patient, but in the presence of a salt load, the kidneys will respond by avid retention of salt and water and thus aggravate the patient's condition.
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#1190
12.02.2007, 23:31
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You are working in a busy emergency department on a very hot day in the summer. A 16-year old boy is brought in by 2 friends who state that they were outside hiking on a nearby mountain range all day. The friends report that the patient began to complain of nausea and "seeing bright lights," after which he became increasingly confused and disoriented. They were able to get him to a vehicle and bring him to the hospital, but during the 15-minute car ride he vomited and then lost consciousness briefly. They are not aware of any medical problems that the patient may have. Glancing at his chart, you see that his temperature was recorded as 39.5 C (103.1 F), blood pressure 110/68 mm Hg, pulse 122/min, and respirations 20/min. You walk over to examine him and note that he is sitting upright in the gurney talking rapidly and incoherently in a loud voice. He does not answer your questions. You quickly perform an initial examination and find that his skin is erythematous and warm to touch, but he does not appear to have a rash. Except for slightly dry mucous membranes and tachycardia, the examination is otherwise normal. During your examination, he seems to become somewhat calmer and is able to cooperate with a brief neurologic survey which is non-focal. While you are examining the patient, the nurse draws blood and you send it for the appropriate laboratory studies. The most important immediate next step in the management of this patient is to
A. administer acetaminophen B. begin empiric antibiotic therapy C. call the patient's parents to obtain his medical history D. initiate cooling measures E. perform lumbar puncture and blood cultures F. obtain urine for drug screen G. order a CT scan of the head
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#1191
13.02.2007, 00:05
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Думаю, что это "тепловой удар", D. Турист перегрелся.
Жаропонижающие не показаны, т.к. причина повышения температуры - не воспаление. Потому же не показаны антибиотики. Картины менингококцемии тоже нет - во-первых, нет сыпи, во-вторых, нет шока, в третьих, нет менингеальных, в четвертых - положительная динамика. Насчет КТ - нет очаговой симптоматики.
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#1192
15.02.2007, 17:05
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Цитата:
Я бы выбрал -F проверить кровь-мочу на наркотики (кокаин- "стимуляторы", конечно).Они описывают делирий- слишком серьёзный просто для т 39... Обильная регидратация представляется гораздо важнее "охлаждения" (температура "ядра" сравнительно невысока), но такого варианта ответа нет.
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#1193
15.02.2007, 17:56
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The correct answer is D. This patient is suffering from heatstroke, which is a true medical emergency. Loss of consciousness is the hallmark of heatstroke, along with elevated core body temperature. The cornerstone of management is rapid initiation of cooling measures, which should take precedence over any other diagnostic or management procedure. This can be accomplished by immersion in ice water or by placing cold, wet sheets around the patient and starting a fan. Other methods, such as cold IV fluids, gastric lavage with ice water, or use of cooling blankets are not recommended since they are ineffective at lowering core-body temperature rapidly enough. Heat exhaustion, which is characterized by nausea, dizziness, confusion, chills, and profuse sweating, usually precedes heatstroke.
Administering acetaminophen (choice A) is inappropriate for the treatment of heatstroke. Antipyretics are used to treat fever caused by an elevated hypothalamic set point from the release of pyrogens. In heatstroke, the set point is normal; fever results from the failure of the body's normal cooling mechanisms. Morbidity in heatstroke is directly related to the duration of hyperthermia. Therefore, although other causes of fever and/or altered mental status are important considerations, initiation of immediate cooling measures is critical. Therefore, although empiric antibiotic therapy (choice B), perform lumbar puncture and blood cultures (choice E), obtain urine for drug screen (choice F), and a CT of the head (choice G) may play a role in this case, they must be deferred. Calling the patient's parents (choice C), may be helpful to obtain a more complete history but is appropriate only after resuscitation has been performed and the patient is stabilized.
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#1194
15.02.2007, 17:58
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A 29-year-old man is admitted to the hospital for severe diarrhea. He presented to the hospital after 3 days of nearly 20 "very watery" bowel movements daily. He had just recently returned from a trip to the flooded areas of the Carolina coast. On examination, he appears listless but responsive. His vital signs are stable. His skin turgor is increased and he has prolonged capillary refill time. His heart and lung examinations are unremarkable. His serum sodium is 118 mmol/L and urine sodium is less than 10 mmol/L. His serum potassium is 2.9 mmol/L and bicarbonate is 12 mmol/L. The most appropriate therapy is
A. fluid restriction B. intravenous bicarbonate C. intravenous hypertonic saline D. intravenous hypotonic saline E. intravenous isotonic saline
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#1195
15.02.2007, 20:27
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У пациента выраженная гипонатриемия, связанная с потерей электролитов со стулом. Менее выраженная гипокалиемия и ацидоз (по-видимому, компенсированный) тоже присутствует. В данном случае наиболее актуально восстановление натрия, так что ответ - C.
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#1196
15.02.2007, 21:38
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...на местную холеру намекают?
 ...Хлорид сыворотки неизвесен, гап не подсчитать... Думаю, он в норме- т.к. нам намекнули, что перфузия пока в порядке ...Итого- причина ацидоза- потеря бикарбоната натрия со стулом. В жизни я бы развел 3 ампулы бикарбоната На на 1 л 5% глюкозы- и получил бы бикарбонат На в 150 мэкв , почти изоосмолярный.... Гипертонический На, кстати, в данной ситуации может привести к тетраплегии в результате центрального "мостового" миелинолиза...
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#1197
16.02.2007, 01:10
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Вообще, странно представить потерю натрия со стулом без потери хлора.
В принципе, можно компенсировать натрий и раствором гидрокарбоната, то тогда надо вводить где-то 400 мл в пересчете на 4% раствор. Немножко многовато соды (200 ммоль вместо 120), но ничего страшного. У меня другое сомнение: клинических признаков ацидоза мы не видим, зачем тогда сода? И потом, если мы будем вводить изотонический раствор, то как быть с отеком периферии? Все-таки, гипертоническая регидратация выведет лишнюю воду из периферических тканей. Если бы пациент был "сухой", да еще и с признаками ацидоза... но тут такого не представлено. Нет, я все-таки за С.
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#1198
16.02.2007, 01:13
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First I would replace the VOLUME, so the answer sould be E. The patient has methabolic normal anion gap acidosis. His kidneys are trying to work hard to hold on to free water without any respect to osmolality! By restoring volume we will supress his high ADH and nornalize his sodium. Giving bicarb now is not correct. First need to restore perfusion. If you give the bicarb it will drive his K+ into the cells and may cause severe hypokalemia. I personally do not give bolus bicarb for if Ph> 6.9 but his not that sick, right?
PS: Low or high sodium is NEVER about sodium. It is ALWAYS about free water. PPS: Hypertonic saline is givent in only ONE case in Medicine - Hyponatremic seizures. In all other cases it is considered malpactice. If you sodium increases by more then 10 in first 24 hours or so you will paralize the poor guy.
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