Еще одна пилюлька Hескучина

[yananshs]

В обшем, не знаю, что делают чаше - индукцию или кесарево, но авторы задачи предпочитают индукцию. Tоколитики не одобряются.

The correct answer is B. This patient has preeclampsia; (hypertension that results as a consequence of pregnancy and regresses postpartum, proteinuria, and/or pathologic edema (i.e., facial/hand)). Preeclampsia may progress to eclampsia, which is a generalized seizure. Patients at term (37 weeks and on) who present with preeclampsia should be induced and given magnesium sulfate at the time of induction as a seizure prophylaxis.

In some cases patients who are preeclamptic experience visual changes secondary to retinal detachment. This patient is complaining of blurred vision, which may indicate that she needs an ophthalmologic evaluation (choice A). However, the top priority is delivery.

This patient is having irregular contractions. These are normal for any term patient and even if you were not going to induce her labor, you would not want to give her a tocolytic such as terbutaline (choice C).

Fetal evaluation is important in preeclamptic patients (choice D). In addition, many preeclamptic patients present with a decreased amniotic fluid index (oligohydramnios) secondary to placental insufficiency (choice E). However, delivery is again the top priority.

[yananshs]

A 32-year-old African American woman returns to the clinic for a follow-up visit. She was seen 2 weeks prior with complaints of dyspnea, dry cough, chest pain, and tightness of the chest. An electrocardiogram was within normal limits. A chest x-ray was performed a week later which showed bilateral hilar lymphadenopathy with pulmonary infiltrate. While in clinic now, she points out a rash on her nasal tip that has been present for a number of months. There is a 4 x 2 cm violaceous, indurated plaque involving the nasal tip extending to the bilateral ala. There are a few tiny button-like papules in the center of the plaque. In addition, there are waxy, translucent lesions with flat tops on the face, lids, around the orbits, and in the nasolabial folds. The most appropriate next step in evaluation is to
A. determine serum angiotensin-converting enzyme and serum calcium levels
B. determine serum CEA marker level
C. order a complete blood count
D. refer her for a bronchoscopy
E. send her for a lung biopsy

[Aladdyn]

В. Паранеопластический процесс при раке лёгких, вероятно. Хотя общего со склеродермией тоже много, кроме собственно лёгочных изменений.

[zoe_zoe]

Сыпь на лице появилась давно- больше похоже на склеродермию.

[papadoctor]

Ooops! The wrong answer to the previous question!

[filbi]

Диагноз, здесь на мой взгляд однозначный-саркоидоз. Ответ я думаю-А, так как Е конечно подтверждает диагноз, но нет смысла мучать пациентку, так как биопсия возможна и из кожных поражений.

[dr.Ira]

Раз

Сообщение от yananshs

A 32-year-old African American woman

а на рентгене

Сообщение от yananshs

A chest x-ray showed bilateral hilar lymphadenopathy

то это, разумеется, саркоидоз.
Что с ним делать дальше, я уже не помню. В жизни саркоидоз не видела ни разу.

[yananshs]

The correct answer is A. Determining serum angiotensin-converting enzyme (ACE) and serum calcium is the correct management for this patient with suspected sarcoidosis. Although a bronchoscopy (choice D) and a lung biopsy (choice E) will also help with diagnosis of sarcoidosis, serum ACE and calcium levels are less invasive tests to obtain for diagnosis. Sarcoidosis involves multisystems including lungs, eyes, peripheral lymph nodes, spleen, gastrointestinal tract, hearing, and musculoskeletal systems. Hypercalcemia may occur in any stage of sarcoidosis. Corticosteroids lower the raised calcium level to normal by inhibiting the peripheral action of 1,25(OH)2D3 and by metabolizing the compound to an inactive metabolite. The serum ACE level is also raised in 60% of patients. ACE activity is higher in patients with hilar adenopathy and pulmonary infiltration.

A complete blood count (choice C) is incorrect, because hemolytic anemia is rare in sarcoid and leukopenia alone is too non-specific for diagnosis of sarcoid.

Serum CEA level (choice B) is incorrect, because this is a non-specific tumor marker used to monitor for colon carcinoma recurrence, as well as some lung adenocarcinoma responses to chemotherapy.

[yananshs]

A 52-year old man with hypertension and severe hypercholesterolemia comes to the clinic because of a 2-day history of left posterior ankle pain. The pain began during a touch football game and has become progressively worse to the point where he is almost unable to walk. He has never had symptoms like this before. The patient has been prescribed simvastatin, but is noncompliant. He is a moderately obese male with a palpable lump in the posterior left calf with severe pain and erythema of the left posterior ankle. There is normal ability to invert and evert the foot, but the patient is unable to dorsiflex or plantarflex the foot. Physical examination is also significant for xanthelasma. Laboratory studies from 1 month earlier show a total cholesterol level of 250 mg/dL and a low density lipoprotein level of 220 mg/dL. The most appropriate management of this patient is to
A. advise him to begin a cardiac diet and return to the clinic in 1 week
B. advise him to rest and return to the clinic in 1 week
C. perform an ankle plain film to exclude xanthoma
D. schedule him for an urgent cardiology consult
E. schedule him for an urgent orthopedic consult

[riltsov]

Я допускаю что palpable lump in the posterior left calf это ксантома, которая была повреждена во время игры в футбол. Содержимое ксантомы распространилось вниз, чем обусловлены severe pain and erythema of the left posterior ankle. Перелома нет, рентген не нужен. У пациента гиперхолестеринемия (около 6,2 ммоль /л) и резко повышен low density lipoprotein. Я думаю, нужны диета, статины и временно покой. Я не вижу необходимости в срочной консультации ортопеда и кардиолога. Разрываюсь между ответами А и В. Диета нужна, но только со статинами. Одна диета вряд ли ускорит выздоровление при этих симптомах.
Из ответов выбираю:
B. advise him to rest and return to the clinic in 1 week

[yananshs]

Другие мнения?

[papadoctor]

Ну если ни БЭ, то тогда Си.Сделаем рентген, и на него посмотрим!

[yananshs]

No way!

[papadoctor]

MRI from the get go?

[dr.Ira]

Я бы отправила к ортопеду. Это может быть разрыв (надрыв) икроножной мышцы. Е.