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#496
11.08.2006, 16:17
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A 29-year-old man comes to the office because of a recurrent rash that worsens in the summer season and recurs more frequently with humid weather. Usually the rash involves his upper back and occasion spreads to the shoulders and proximal arms. It is occasionally pruritic. Physical examination shows multiple hypopigmented oval macules and patches on his upper back. His hands and feet are not involved and all nails appear normal. You examine scrapings of the scale with potassium hydroxide under the microscope and find numerous short hyphae with multiple round spores in clumps. You should tell the patient that he has
A. tinea corporis and should be treated with oral terbinafine B. tinea corporis and should be treated with topical ketoconazole C. tinea corporis and should be treated with topical terbinafine D. tinea versicolor and should be treated with oral terbinafine E. tinea versicolor and should use ketoconazole shampoo 
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#498
12.08.2006, 17:33
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The correct answer is E. This patient has tinea versicolor and he should be treated with ketoconazole shampoo. Tinea versicolor, also known as pityriasis versicolor, usually presents on the upper trunk and extends onto the upper arms, finely scaling, guttate, or nummular patches appear, particularly on young adults who perspire freely. The individual patches are yellowish or brownish macules in pale skin or hypopigmented macules in dark skin, with delicate scaling. Mild itching and inflammation may be present. This common disease is most prevalent in the tropics, where there is high humidity, high temperatures and frequent exposure to sunlight. The fungus is easily demonstrated in scrapings of the scales. Microscopically, there are short, thick fungal hyphae and large numbers of variously sized spores. This combination is commonly referred to as "spaghetti and meatballs". Treatment is accomplished with topical imidazoles, oral ketoconazole, or itraconazole. Oral terbinafine (choice D) has been shown to be ineffective.
Tinea corporis (choices A, B, C) are all incorrect, because the lesions described on this young man are not consistent with tinea corporis. Typical tinea corporis lesions (also known as ring worm) are round, erythematous borders with central clearing and superficial scales. The borders tend to be elevated rather than flat.
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#499
12.08.2006, 17:36
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A 65-year-old woman is admitted to the hospital with severe ascites and fever. She has a 2-year history of portal hypertension secondary to hepatitis C-induced cirrhosis. The patient was placed on the liver transplant waiting list 3 months ago. Four months prior to admission she suffered an upper gastrointestinal bleed secondary to esophageal varices, which was subsequently banded via endoscopy. Two days ago, the patient developed abdominal pain, increasing abdominal girth, and fever. She was admitted to the hospital with the diagnosis of spontaneous bacterial peritonitis. The appropriate therapy is initiated and over the course of the next 4 days the patient appeared to be responding well. On the day of discharge you begin to plan her outpatient management and follow-up care. To prevent further disability from her current acute condition, you should prescribe
A. hydrochlorothiazide B. lactulose C. levofloxacin D. oral protein supplements E. propranolol
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#500
12.08.2006, 19:28
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Пациентке перенесшей спонтанный бактериальный перитонит и имеющей варикозные вены пищевода показана антибактериальная профилактика, но в левофлоксацине смущает его цена. Но всетаки левофлоксацин -C
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#501
12.08.2006, 20:15
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Цитата:
Поскольку current acute condition - спонтанный перитонит, а лактулоза - для лечения печеночной энцефалопатии, oral protein supplements - для прогрессирования печеночной энцефалопатии, пропранолол - для снижения риска кровотечения из варикозных вен, гипотиазид - мочегонное.
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#503
14.08.2006, 15:41
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The correct answer is C. The 1-year risk of recurrent infection in patients surviving spontaneous bacterial peritonitis (SBP) is as high at 70%. Prophylaxis has been tested in this group and shown to be efficacious. The rate of recurrence is less with therapy, although there is no survival benefit. The agents tested have mostly been fluoroquinolone antibiotics. Levofloxacin is now the preferred agent in that class.
Hydrochlorothiazide (choice A) is a diuretic useful in controlling ascites. It is, however, not a more important therapeutic intervention than SBP prophylaxis. Oral lactulose (choice B) is indicated when the patient begins to suffer from hepatic encephalopathy. Oral protein supplements (choice D) are never indicated despite the clear nutritional and total protein deficiency in these patients. The reasoning is that the metabolized nitrogen products cannot be effectively cleared and often precipitate episodes of hepatic encephalopathy. Propranolol (choice E) is a non-selective beta-blocker used to prevent variceal bleeding. This patient has no documented varices at this time and even if they were present, the efficacy of propranolol for preventing bleeds is questionable.
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#504
14.08.2006, 15:42
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A 19-year-old man is brought to the emergency department after being stabbed. Initial survey of the patient reveals a well-developed white man with a blood pressure of 100/60 mm Hg, heart rate of 100/min with no pulsus paradoxus. His airway is class I (Mallam-Patti classification) with some blood in the oropharynx. He has a 5-cm stab wound on his right chest just superior to the right nipple. He has multiple bruises and contusions across his thorax and abdomen. Heart sounds are distant but audible and there are no extra sounds. Breath sounds are clear on the left but diminished on the right. The abdomen is mildly tender in the left upper quadrant. The most appropriate study at this time is a/an
A. abdominal CT scan B. abdominal ultrasound C. aortic arteriogram D. chest radiograph E. echocardiogram
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#507
14.08.2006, 20:38
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D. Ослабление дыхания со стороны травмы + кровь в дыхательных путях с высокой вероятностью свидетельствуют о травматическом гемопневмотораксе. Приглушенность тонов сердца (ещё информативнее в данном случае были бы перкуторно определенные границы сердечной тупости) + нестабильность гемодинамики может свидетельствовать о напряжённом пневмотораксе со смещением сердца влево, который требует первоочередных ургентных мероприятий, либо о массивном гемотораксе.
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#508
14.08.2006, 21:31
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Цитата:
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#510
15.08.2006, 17:33
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The correct answer is D. This patient has multiple reasons to have chest/pulmonary trauma; his stab wound caused a pneumothorax, his bruises suggest rib fractures, flail chest or pulmonary contusion, and there is the possibility of a widened mediastinum. A chest x-ray is a low cost, very high yield imaging test in trauma cases.
An abdominal CT scan (choice A) or an abdominal ultrasound (choice B) may be indicated for this patient, but are not the first choices in imaging tests. The evaluation of the abdomen for bleeding or injury is a complex process and can be done by ultrasound, CT, diagnostic lavage, or exploratory laparotomy. These decisions are based on the patient's examination and location of injuries. An aortic arteriogram (choice C) is useful when there is a possibility of aortic dissection. It is not indicated at this time in this patient. Similar reasoning holds for an echocardiogram (choice E). This test may be indicated to assess for pericardial effusion or tamponade or so called "commotio-cordis" after blunt chest injury. It is however not a routine test ordered on trauma patients.
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