Еще одна пилюлька Hескучина
 

An 83-year-old woman with a history of hypertension and osteoarthritis comes to the office because of abdominal pain with occasional nausea, constipation, muscle weakness, and fatigue over the last 4 months. She denies taking any over-the-counter medications or vitamins. She denies weight changes, change in stool diameter, melena, bright red blood per rectum, or shortness of breath. You notice in her chart that she had a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is normal except for mild kyphosis. Her rectal examination is heme negative.

Labs:
RBC 4.2 million per µL
Hemoglobin 7.9 mmol/L
WBC 6 000 per mm3
Platelet 300,000 per mm3

Albumin: 4 g/dl
Alkaline phosphatase: 60 IU/L
ALT (alanine transaminase): 20 IU/L
AST (aspartate aminotransferase): 16 IU/L
BUN (blood urea nitrogen): 10 mg/dl
Calcium - serum: 14 mg/dl
Serum chloride: 105 mmol/L
Creatinine: 1.4 mg/dl
Direct bilirubin: 0.1 mg/dl
Gamma-GT (gamma-glutamyl transpeptidase): 2 IU/L
Glucose: 100 mg/dl
LDH (lactate dehydrogenase): 110 IU/L
Phosphorus - serum: 3 mg/dl
Potassium : 4 mEq/L
Serum sodium: 140 mEq/L
Total bilirubin: 1.0 mg/dl
Total cholesterol: 250 mg/dl
Total protein: 7 g/dl
Uric acid: 5 mg/dl

The most appropriate next step is to
A. determine parathyroid hormone levels
B. determine serum vitamin D levels
C. determine thyroid stimulating hormone levels
D. order a CT scan of the neck
E. order a serum protein electrophoresis

вначале-А

Слишком простая была задачка. :)
Другая:
A 65-year-old man suffers a fall down his stairs at home and is admitted to the hospital for a fractured hip. The patient has no significant past medical history and takes only an aspirin daily. He is very active and plays golf and tennis 3 times per week. This morning, he slipped on the icy stairs and fell, breaking his right femur and acetabulum. He is brought to the operating room where the hip is repaired uneventfully. On postoperative day number 2, the patient develops acute shortness of breath and pleuritic chest pain on the right. His temperature is 37 C (98.6 F), blood pressure is 130/90 mm Hg, pulse is 110/min, and respirations are 22/min. Physical examination shows a tender, swollen left calf. The most appropriate therapy at this time is
A. embolectomy
B. intravenous heparin bolus plus continuous infusion
C. oral warfarin
D. subcutaneous heparin
E. thrombolysis

вначале Д

Не верно.

A. embolectomy

Опять мимо.

Я разрываюсь между тромболизисом и гепарином. Склоняюсь к тромболизису. Но прошу не судить строго - не специалист.

Хотелось бы кроме ответов - обоснования того или иного выбора. :)
Строго судить никого не будем. :)
Это задачки из USMLE 3, который сдают врачи всех специальностей чтобы получить лицензию. До Борда. Борд сдают после получения лицензии.

Merci, что не судите строго.
Я думаю, что вследствие травмы у гражданина развился тромбоз, связанный, возможно, с жировой эмболией (sorry (c) брукса). Таким образом, учитывая небольшое время от onset'а, надо вводить тромболитики. Тем более что клиника множественных тромбов налицо.

Я думаю, что он развил тромбоэмболию мелких ветвей, и ему надо делать тромболизис. Т.к. время от начала заболевания прошло достаточно мало (я не помню, разумеется, сколько максимом, но, судя по условию задачи, прошло, пока, не много времени), поэтому тромболизис может помочь.
Е.

A. embolectomy - нет, стабильная гемодинамика не требует инвазивной процедуры
B. intravenous heparin bolus plus continuous infusion - да
C. oral warfarin - нет, назначается после гепарина
D. subcutaneous heparin - нет, профилактическая доза
E. thrombolysis - нет, слишком высокий риск кровотечения после ортопедической операции

Да, но ведь гепарин не приведет к лизису уже существующих тромбов...

Гепарин блокирует формирование новых тромбов. За лизис существующих тромбов отвечает фибринолитическая система. Тромболитики показаны при массивной ТЭЛА вызывающей гемодинамическую нестабильность при отсутствии противопоказаний (недавние операции, инсульт, неконтролируемое давление и пр.). В описанном случае, больной только что перенес крупную операцию, его состояние в целом стабильное - показан гепарин (или низкомолекулярный гепарин) с последующим назначением варфарина на 3-6 месяцев.

Это так,но откуда такая уверенность что именно об этом идет речь в данном случае.
Из тех же тестов,о наиболее частом осложнении при переломе-операции больших трубчатых костей, речь может идти о жировой эмболии.

Да.., об этом я как-то не подумала...

Судя по предложенным вариантам ответов, речь идет не о жировой эмболии :) Все-таки ТЭЛА. Я тоже за болюс+инфузия гепарина, так как для тромболизиса - не та тяжесть, а п/к введение - это не лечение ТЭЛА, а профилактика.

Что меня радует, так это то, что я, хотя бы, угадала, что это ТЭЛА! :)

судя по клинике -болезненость в голени, в задаче имеется в виду не жировая эмболия,а тромбоз вен голени и тЭЛА, а вот почему низкомолекулярный гепарин не может быть назначен подкожно, и не как профилактическое средство, не понимаю

Целесообразно болюсное в/в введение , имеющее более стабильную фармакокинетику , в отличие от подкожного введения , при котором Смах в крови создается через 3-6 часов .

То, что подкожное введение - это не то, понятно. Я все-таки склонялся к тромболизису, но раз это увеличивает риск кровотечения...
В принципе, логично, да.

В подтверждение своих слов, что в данной ситуации возможно подкожное введение низкомолекулярного гепарина нашла метаанализ. Так как пациент не умер и имеет стабильную гемодинамику, то у него вероятнее всего субмассивная ТЭЛА. Соответствено все нижеследующее к нему применимо.

Low-molecular-weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism: a meta-analysis of randomized, controlled trials.
Quinlan DJ; McQuillan A; Eikelboom JW
Ann Intern Med 2004 Feb 3;140(3):175-83.


BACKGROUND: Low-molecular-weight heparin has greatly simplified the management of deep venous thrombosis. However, for patients who present with pulmonary embolism, the role of low-molecular-weight heparin is uncertain and unfractionated heparin remains widely used. PURPOSE: To compare the efficacy and safety of fixed-dose subcutaneous low-molecular-weight heparin with that of dose-adjusted intravenous unfractionated heparin to treat acute pulmonary embolism. DATA SOURCES: The MEDLINE, EMBASE, and Cochrane Library databases were searched up to 1 August 2003. Additional data sources were manual searches of abstract proceedings and personal contact with investigators and pharmaceutical companies. STUDY SELECTION: Randomized trials comparing fixed-dose subcutaneous low-molecular-weight heparin with dose-adjusted intravenous unfractionated heparin for the treatment of nonmassive symptomatic pulmonary embolism or asymptomatic pulmonary embolism in the context of symptomatic deep venous thrombosis. DATA EXTRACTION: Two reviewers independently selected studies and extracted data on study design; quality; and clinical outcomes, including symptomatic venous thromboembolism, death, and major and minor bleeding. Odds ratios for individual outcomes were calculated for each trial and were pooled by using the Mantel-Haenszel method. DATA SYNTHESIS: Fourteen trials involving 2110 patients with pulmonary embolism met the inclusion criteria. Separate outcome data for patients with pulmonary embolism were not available from 2 trials (159 patients), leaving 12 trials for meta-analysis. Compared with unfractionated heparin, low-molecular-weight heparin was associated with a non-statistically significant decrease in recurrent symptomatic venous thromboembolism at the end of treatment (1.4% vs. 2.4%; odds ratio, 0.63 [95% CI, 0.33 to 1.18]) and at 3 months (3.0% vs. 4.4%; odds ratio, 0.68 [CI, 0.42 to 1.09]). Similar estimates were obtained for patients who presented with symptomatic pulmonary embolism (1.7% vs. 2.3%; odds ratio, 0.72 [CI, 0.35 to 1.48]) or asymptomatic pulmonary embolism (1.2% vs. 3.2%; odds ratio, 0.53 [CI, 0.15 to 1.88]). For major bleeding complications, the odds ratio favoring low-molecular-weight heparin (1.3% vs. 2.1%; odds ratio, 0.67 [CI, 0.36 to 1.27]) was also not statistically significant. CONCLUSIONS: Fixed-dose low-molecular-weight heparin treatment appears to be as effective and safe as dose-adjusted intravenous unfractionated heparin for the initial treatment of nonmassive pulmonary emboli

Обьяснение авторов задачи:

The correct answer is B. This patient has almost certainly suffered a pulmonary embolism. All postoperative patients are at increased risk for this disorder, but orthopedic patients have a much-increased risk above that for venous thrombosis and embolism. For this reason, all of these patients are placed on aggressive prophylaxis measures postoperatively. Once present however, the best intervention to reduce 24-hour mortality is aggressive anticoagulation with intravenous unfractionated heparin at 80U/kg bolus and 18U/kg/hr infusion titrated to a PTT of 60-75.

Embolectomy (choice A) is reserved for patients with pulmonary emboli who have acute right heart failure as a result. These patients have elevated jugular venous pulsations, hypotension, and tachycardia. Even when present, embolectomy, or its less-invasive option, thrombolysis (choice E), have not been shown to be efficacious in terms of mortality prevention. Clearly thrombolysis is less invasive but does carry a substantial risk of bleeding (3-10%).

Starting oral warfarin (choice C) in the absence of heparin is not appropriate. The correct therapy involves a standard regimen of heparin overlapped with warfarin until an international normalized ratio (INR) of 2.0 to 3.0 is obtained on two consecutive days. This regimen is sufficient for the prevention of skin necrosis, which may occur during the initiation of warfarin therapy in patients with a deficiency of protein C.

Mini-dose or subcutaneous heparin (choice D) is used for prophylaxis, not treatment.

Видимо, в варианте D авторы не имели ввиду низкомолекулярный гепарин. :confused:

A 22-year-old college student comes to the emergency department with a severe right lower quadrant pain. She says that the pain started approximately 6 hours ago and has progressively worsened. She has no significant medical problems and her only medication is oral contraceptive pills. She is sexually active with 1 partner, her boyfriend. Her last menstrual period was 2 weeks ago. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 120/70 mm Hg, and pulse is 80/min. Abdominal examination is significant for focal tenderness in the right lower quadrant. Pelvic examination reveals exquisite tenderness in the right adnexa, a closed cervical os, and clear vaginal discharge. Laboratory studies show:

B-HCG negative
Leukocyte 7300/mm3
Hg 14g/dl

The most likely etiology of this patient's symptoms is
A. acute appendicitis
B. diverticulitis
C. ovarian torsion
D. a ruptured ectopic pregnancy
E. a tuboovarian abscess

Ну, раз не внематочная беременность, то А - острый аппендицит.
Хотя, лейкоциты как-то низковаты.

С.
-----

Ира, а как вы догадались? :)

А last menstrual period was 2 weeks ago и еще her only medication is oral contraceptive pills... (хотя я не та Ира).

...So?

Забыла привести обьяснение к первой задаче:

Explanation:

The correct answer is A. This patient has symptomatic hypercalcemia. The most likely etiology in this patient is hyperparathyroidism. This diagnosis is made by checking PTH levels. Since her calcium is elevated, a normal or high PTH level is inappropriate and therefore would help confirm the diagnosis.

Vitamin D (choice B) intoxication is typically secondary to patients taking large amounts of vitamin D (often for treatment of hypoparathyroidism). The treatment is to discontinue vitamin supplementation and recheck levels. This patient denied taking over-the-counter medications or vitamins.

Ordering a TSH (choice C) is never a bad idea in a patient with a variety of vague complaints since thyroid disease is very common and because it can explain these symptoms. In this patient, you would expect to find hypothyroidism based on her symptoms but an elevated serum calcium is more likely explained by hyperthyroidism secondary to increased bone turnover. Therefore, a PTH level would more likely lead to the correct diagnosis.

CT scanning of the neck (choice D) is very sensitive for parathyroid disease but it is not meant to be used as a screening test for hyperparathyroidism. Rather, the diagnosis is made by checking serum calcium and PTH levels.

Multiple myeloma is a common disease and can cause hypercalcemia as well. A serum protein electrophoresis (choice E) is helpful in making this diagnosis by demonstrating a monoclonal spike in the beta or gamma globulin region. Our patient lacks anemia, renal disease, or significant back pain which makes multiple myeloma less likely.

Частые болезни бывают часто, а редкие редко...

Нет, Ира, так просто теперь не отделаетесь. :)
Почему именно ovarian torsion?

Ну, ладно, расскажу :) .
1) Гормон беременности отрицателен, значит внематочная отпадает.
2) Аппендицит и дивертикулит не начинаются внезапно. Вначале боль при этих заболеваниях представляет из себя чувство дискомфорта, которое постепенно усиливается, превращаясь в боль + кровь не подходит.
3) Абсцесс даст другую формулу крови.
И есть еще один "секрет" при решении таких тестов. :) В них нет ни одного лишнего слова. Раз сказано о середине цикла, о гинекологическом осмотре, о точном времени начала болей, о гинекологическом анамнезе, значит сказано неспроста. :)
Оvarian torsion происходит именно в середине цикла (если происходит). Тоже самое касается и ovarian cyst.

Pelvic examination reveals exquisite tenderness in the right adnexa

Вот это + отсутствие лейкоцитоза и интенсивные (нарастающие по интенсивности) боли - говорит за С, наверное. Хотя задним умом мы все крепки, я размышляла над аппендицитом и ovarial torsion

P.S. - пока писала, тут все рассказали..

...но чаще, чем их диагностируют ;)

В задачках все обычно по прямой коррелирует ;) Это по жизни иногда на такую фигню попадешь... :( Например, как вот тут .

Как подтвердить диагноз? Что делать дальше?
Др.Ира - не подсказывайте :)

[Ссылки могут видеть только зарегистрированные пользователи. ] is the primary modality of imaging for patients with suspected ovarian torsion. Computed tomography may demonstrate an enlarged ovary and adnexal masses but is unable to evaluate the presence or absence of blood flow to the involved ovary. However, CT may be useful in ruling out other possible causes of lower abdominal pain in cases of diagnostic uncertainty. И т.д. по ссылке.

Не-е-е-т. :) Эти задачи составлены совсем по другому принципу. Это уже более высокий уровень. :)

Я помню в наших госэкзаменационных тестах был такой прикольный вопрос: в какой дозе при ГКМП назначают b-адреноблокаторы? Ответ: 240 мг. Имелся в виду пропранолол. При этом никто естественно этого не знал, потому что тесты учились по ответнику, совершенно официально изданному под грифом МЗ РФ (тогда еще). Там было много тупых вопросов и несколько явно неправильных ответов, но отвечать нужно было "как в ответнике". Впрочем, большинство вряд ли заметило эти ошибки. Ситуационные задачи я не могу вспоминать без слез, у нас всегда были бумажки типа:
"Женщина, 53 лет... — инфаркт миокарда,
мужчина, слесарь... — рак легкого. И т. д.".
Задач вроде той про ТЭЛА конечно не было, да еще с такими объяснениями, почему то правильно, а это нет. Тогда как сами эти объяснения на мой взгляд очень полезны.

Предсталяете, когда мы на кафедре СПбГМУ получили эти тесты, то всей кафедрой сели и проверили все, исправили ответы на правильные и только после этого запустили студентам...
Но тасовали ключи постоянно.

The correct answer is C. Ovarian torsion is the most likely cause of abdominal pain localized to the right adnexa in this patient. She has no significant medical problems and presents with an acute onset of right lower quadrant pain in the absence of fever or other laboratory signs of an infectious process. Ovarian torsion often occurs in the setting of other ovarian pathology such as a cyst or other lesions in the ovary that causes it to twist upon its vascular supply. Ovarian torsion is quickly diagnosed by ultrasonography of the pelvis with the demonstration of absence of flow to the ovary. This is an urgent diagnosis and surgery is required to restore blood flow.

Acute appendicitis (choice A) is not a likely cause of abdominal pain in this patient. Acute appendicitis is an infectious process that results from obstruction of the appendix (usually by a fecalith) and subsequent bacterial infection. It usually presents with right lower quadrant pain, fever, and leukocytosis. The presence of peritoneal signs such as rebound tenderness raises the suspicion for a ruptured appendix.

Diverticulitis (choice B) is not a likely cause of abdominal pain in this patient. Diverticulitis is an infectious process that typically affects older patients who have diverticulosis. This most often affects the sigmoid colon, although diverticulosis can occur anywhere in the colon. Signs and symptoms of diverticulitis include lower abdominal pain, fever, nausea, vomiting, and leukocytosis.

A ruptured ectopic pregnancy (choice D) is not a likely cause of abdominal pain in this patient. This diagnosis must be considered in any pregnant woman who presents with abdominal pain, vaginal bleeding, and symptoms of shock. It is a surgical emergency. This patient has a negative serum Beta-HCG, which rules out the possibility of an intrauterine or ectopic pregnancy.

A tuboovarian abscess (choice E) is not a likely cause of abdominal pain in this patient. A tuboovarian abscess is an advanced form of pelvic inflammatory disease most often caused by the spread of bacteria from the lower genital tract. The most common bacterial pathogens are anaerobic. Risk factors for pelvic inflammatory disease include those associated with an increased risk of contracting a sexually transmitted disease, early age of first sexual encounter, multiple sexual partners, history of sexually transmitted disease, and douching. In addition, women using IUDs are at increased risk for pelvic inflammatory disease and tuboovarian abscess. Symptoms of tuboovarian abscess include pelvic pain, fever, leukocytosis, and abnormal cervical or vaginal discharge in the setting of pelvic inflammatory disease.

A 56-year-old man comes to the emergency department with severe right flank pain for the past 5 days. He says that the pain started after he returned from a long hiking trip in the Grand Canyon, and despite taking some ibuprofen, it has not improved. Infact, he came to the hospital today because the pain has increased and he now has new onset of nausea and chills. He tells you that he had similar pain several years ago that was diagnosed as uric acid stones. He was treated conservatively and eventually passed all the stones spontaneously. His temperature is 38.1 C (100.6 F), blood pressure is 130/80 mm Hg, and pulse is 115/min. On examination, the patient is unable to lie still because of the pain and has significant right costovertebral tenderness radiating to his right testicle. Leukocyte count is 16,000/mm3 and his creatinine is 2.1 mg/dL. The most appropriate study after starting the patient on intravenous hydration and antibiotics is
A. a CT scan of the abdomen and pelvis
B. a DMSA renal scan
C. an intravenous pyelogram
D. a radiograph of the kidneys, ureters, and bladder
E. a renal ultrasound

E или А :confused:
С одной стороны US вполне достаточно для диагностики наличия камней, проблем со стороны почек и мочеточника (Dilatation of Collecting system, Hydronephrosis, например), с другой стороны - СТ живота дает больше возможностей (во всяком случае, мне всегда так казалось... :) ).
Нет, все-таки, если бы мне пришлось лечить такого больного, я бы, в первую очередь, сделала US.
Ответ Е.

Мне кажется E. Картина достаточно типичная, необходимо уточнить есть ли обструкция. Это вполне можно сделать с помощью УЗИ. Это будет заведомо дешевле, чем КТ.

Какие-нибудь еше мнения?

Начать с Е( исследование 1 шага), а дальнейшая тактика по результатам

Что покажет Е - предсказуемо.

Ну, я вот тут почитала в eMedicine...
In the setting of flank pain, fever, and pyuria, pyelonephritis can be diagnosed and treated without immediate imaging. Failure to respond to therapy within the usual 48 hours should prompt a renal ultrasound to look for infection associated with significant obstructive uropathy that may require placement of a percutaneous nephrostomy. Renal and ureteral calculi are imaged best with a noncontrast spiral CT scan.

А какой ответ правильный именно в этой задачке? :confused: :)

The correct answer is A. The patient's symptoms are consistent with an infected and obstructing ureteral stone, especially in light of his past stone history and probable dehydration from his hiking trip. Colicky flank pain radiating to the groin typically marks the presence of a midureteral obstruction. An obstruction in the presence of an infection is a medical emergency because of the very high possibility of septic shock, therefore a quick diagnosis is needed. The best imaging study for nephrolithiasis is a non-contrast CT scan which can visualize all types of stones and then accurately locate them. It can also tell us whether the patient has hydronephrosis, hence, disclosing whether the patient has an obstruction. Once the diagnosis is made, a urologist will most likely need to put in a ureteral stent to correct the obstruction.

A DMSA renal scan (choice B) is a radionucleotide study that evaluates renal function and does not give much information about a renal obstruction. It also takes 4-24 hours to obtain optimal images.

An IVP (choice C) is incorrect because of the patient's renal insufficiency at the time of presentation. The elevated creatinine is a contraindication to IV contrast. In any other cases of noninfected nephrolithiasis with a normal creatinine, an IVP would be appropriate.

A KUB (choice D) would not be able to demonstrate the presence of a renal obstruction. It can be helpful in verifying the presence of kidney stones. However, uric acid stones are radiolucent and would not be seen on a plain film.

A renal ultrasound (choice E) is incorrect because an ultrasound cannot visualize the presence of ureteral stones. It can tell us whether the patient has hydronephrosis, but nothing more.