Еще одна пилюлька Hескучина

[exomen]

Т.к. такое уже было и реагировало на такую схему, если речь идет о немедленном действии, то
В.
что бы раньше локализовать инфекцию пока не случилось гнойного расплавления барьеров и генерализации.
КТ практически сразу или одновременно, для оценки костей и перепонки, хотя по клинике там вроде все цело.
D. м.б. и еще лучше, но там надо wait for improvement, а это опасно, м.б. уже надо делать разрез.

[OrFun]

Немедленно , видимо надо назначить В . Но в плане обследования перед КТ все-таки хочется уточнить возбудителя - все- таки рецидивирующие отиты ... может там вообще отомикоз...Так что может и Е - send a culture of the ear. Заодно и определится с оптимальным выбором антибиотиков.

[Dtver]

Вот если бы send a culture of the ear, provide therapy with intravenous antibiotics и order a CT scan with contrast - вместе. А так просто глаза разбегаются

[yananshs]

The correct answer is C. This gentleman has signs and symptoms of otitis externa. His previous episodes were treated with antibiotic eardrops and oral antibiotics. Otitis externa due to Pseudomonas in a diabetic patient can lead to malignant otitis externa. Malignant otitis externa can invade the mastoid causing mastoiditis, and can result in complications like meningitis and abscess. In this patient, the otitis externa, treated by the patient himself with antibiotic eardrops, turned into malignant otitis externa. Mastoiditis may be present and cannot be ruled out from mastoid non-tenderness. If this invasive form of otitis externa is not diagnosed and appropriately treated with antibiotic therapy, there is a potential for meningitis. Hence, a CT scan with contrast should be performed to rule out any involvements of the mastoid. Once malignant otitis externa is diagnosed and the extent of it is defined by means of clinical examination, an otolaryngological examination and a CT scan with contrast, the patient should be admitted for intravenous antibiotic therapy.

The patient is already taking antibiotic eardrops (choice A). These eardrops are not enough to control and treat malignant otitis externa.

Administration of antibiotic eardrops and oral antibiotics against Pseudomonas, which is the most common organism for malignant otitis externa, is essential once the diagnosis is made (choice B). But most of the time, intravenous antibiotic therapy (choice D) is essential in malignant otitis externa rather than oral antibiotics. Culture of the ears, hydrogen peroxide irrigation, and acetic acid drops (choice E) are forms of the therapy in otitis externa. But these measures, by themselves, would not treat malignant otitis externa and a CT scan must be performed to rule out mastoid involvement.

[yananshs]

A 61-year-old man comes to the office complaining of joint stiffness and pain. He is otherwise healthy and enjoys an active lifestyle but reports that over the past few months his hands and knees have begun to ache as his day progresses and that they often become "tight" or "stiff". He has difficulty extending his legs completely and his hands, he finds, are less dextrous than a few years ago. His vital signs are normal. His knees show mild crepitus bilaterally with some tenderness to palpation of the left knee and his PIP joints of his fingers are mildly enlarged. A radiograph of his knees shows narrowing of the joint spaces bilaterally with subchondral sclerosis. At this time the most correct statement about this patient's condition is:
A. A fixed daily dose of nonsteroidal anti-inflammatory drugs is indicated
B. He requires knee replacement surgery for pain relief and increased mobility
C. MRI of the knees is indicated for a more detailed joint evaluation
D. Nonpharmacologic management and acetaminophen therapy should be initiated
E. These are normal age-related changes to his joints

[Rodionov]

D....

[Aladdyn]

A. Деформирующий артроз, по всей видимости. НПВС лучше.

[dr.Ira]

E. These are normal age-related changes to his joints

???

[riltsov]

Изменения на рентгене могут трактоваться как вариант возрастной нормы, если пациент asymptomatic. С учетом клиники это деформирующий остеоартроз. НПВС подходят, но парацетамол безопаснее. Лучше начать с D. Nonpharmacologic management and acetaminophen therapy should be initiated

[Dtver]

Согласен с предыдущими ораторами насчет Д.

[Tim Vetrov]

В ответе А меня смущает слово fixed. Я был бы склонен начать с диклофенака по необходимости (как с препарата лучшего по соотношению безопасность/эффективность), все-таки, парацетамол очень слабый.

Но раз таковы условия теста, то D.

[Rodionov]

Терапия ОА (только он уже не деформирующий ) по рекомендациям носит ступенчатый характер: немедикаментозное лечение - парацетамол - ибупрофен/диклофенак - (трамал) - протезирование. Тут как раз начальная стадия.

[yananshs]

The correct answer is D. This patient has osteoarthritis that is a degeneration of the cartilage and hypertrophy of bone at the articular margins. Radiographs often show the characteristic joint-space narrowing, subchondral sclerosis and cyst formation, and marginal osteophytes. There is however minimal correlation between the severity of the radiographic findings and the clinical symptoms or functional limitations. This patient has mild symptoms by his own description and therefore, will almost certainly benefit from medical management with acetaminophen and nonpharmacologic management with thermal modalities, strengthening exercises, well-cushioned soles of shoes, and possibly a cane.

A fixed daily dose of nonsteroidal anti-inflammatory drugs is NOT indicated (choice A) because of the adverse gastrointestinal effects of these agents. Acetaminophen should be recommended, and if this is not effective, NSAIDs can be used on an "as needed" basis.

In general, joint replacement (choice B) is reserved for those patients who have severe daily pain, functional limitation, and/or pain at rest refractory to medical therapy.

Unless a disease other than osteoarthritis is suspected, the patient does not require an MRI for additional evaluation of his joint space (choice C).

Based upon the symptoms of limitation of motion, pain, and stiffness, as well as the radiographic findings, this patient has more than simply age-related changes (choice E), he has accelerated loss of cartilage and loss of function.

[yananshs]

A 26-year-old African American woman walks into the emergency department where you are working. She is 37-weeks pregnant and is complaining of a severe headache for the past 24 hours. She also tells you that she has noticed that the vision in her right eye has been extremely blurry since she woke up this morning. She states that her pregnancy has been uneventful and that she receives prenatal care at the hospital clinic. The card she is carrying with her indicates that all prenatal tests were within normal limits. Three consecutive blood pressure readings 15 minutes apart are 156/102 mm Hg, 164/112 mm Hg, and 144/98 mm Hg. The nurse informs you that her bedside urine dipstick reveals 3+ proteinuria. On physical examination you find a mild systolic ejection murmur and 2+ pitting edema of her lower extremities. A sterile vaginal exam reveals a long and closed cervix. Tocodynomometer shows irregular uterine contractions every 8-10 minutes. The external fetal heart tracing is reassuring. The most appropriate next step in this patient's management is
A. an emergent ophthalmology consult
B. intravenous administration of magnesium sulfate and induction of labor
C. intravenous administration of magnesium sulfate and a shot of intramuscular terbutaline to quiet her uterine contractions
D. prolonged external fetal heart monitoring
E. ultrasound examination of the fetus to evaluate amniotic fluid index and fetal well being

[audovichenko]

Выходит, магнезию считают лучшим средством лечения преэклапсии не только в России?
По-моему, ответ С. Потому что если преэклампсия, несмотря на терапию, будет прогрессировать, вроде бы рекомендуют кесарить, так что самостоятельная активность матки в любом случае не нужна.