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#782
13.09.2006, 16:12
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Цитата:
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#785
13.09.2006, 21:31
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Согласен с предыдущими ораторами - А.
Из предложенного - это единственное мероприятие по поиску симптоматической АГ, кою в 21 год и следует подозревать в первую очередь.
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#786
14.09.2006, 19:29
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The correct answer is A. This patient should be suspected of having renal artery stenosis, most likely secondary to fibromuscular dysplasia from the early age of onset of severe hypertension. In addition, the poor control of this patient's hypertension, even with three agents is suspicious for renovascular hypertension. About 5% of patients with hypertension have renovascular hypertension. The renal arteries need to be evaluated by duplex ultrasound of the renal arteries, conventional angiography, spiral computed tomography, or magnetic resonance angiography.
Given signs of left ventricular hypertrophy on electrocardiogram, echocardiography (choice B) is warranted. The next immediate step however, is an evaluation of the renal arteries. Triamterene (choice C) is a potassium-sparing diuretic often used in conjunction with hydrochlorothiazide. It is very unlikely that the three agents prescribed in high doses could not control the blood pressure of a patient with essential hypertension. Renovascular hypertension must be suspected. Repeat electrocardiograms (choice D) should be performed every year to evaluate for the development of end-organ damage in a chronic hypertensive. This patient has electrocardiographic evidence of left ventricular hypertrophy. However, it is best followed with echocardiography. Repeat ophthalmoscopy examinations (choice E) should be performed every year or so to evaluate for the development of end-organ damage in a chronic hypertensive.
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#787
14.09.2006, 19:31
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A 2-year-old boy is brought to the office for a follow-up visit after being diagnosed with an ear infection 2 weeks earlier. His mother says that he is still complaining of ear pain even though he finished the 10-day course of amoxicillin that your partner had prescribed. While reviewing his chart you notice that this mother does not believe in immunizations and despite encouragement and counseling, has kept her children unimmunized. His temperature is 38.1 C (100.6 F). Physical examination shows an erythematous and bulging right tympanic membrane, a loss of light reflex, and decreased motility of the tympanic membrane. The left ear is unremarkable. A culture of the right middle ear grows Gram-negative diplococci. At this time the most correct statement about his condition is:
A. Appropriate treatment is needed to prevent the development of rheumatic fever B. Bronchopulmonary infections and bacteremia are commonly seen in healthy adolescents and young adults with this infection C. The full routine recommended immunization series would most likely have prevented this infection D. The responsible bacteria is part of the normal flora of the upper respiratory tract E. The responsible bacteria rarely produces Б-lactamase that mediates resistance to penicillins
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#790
14.09.2006, 20:32
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"Меня терзают смутные сомнения" (С)
Разве гемофильная палочка - это диплококк? И потом, в столь раннем возрасте гемофильная палочка у меня скорее ассоциируется с тяжелым менингитом. Если высеваются грам-отрицательные диплококки - что это? Мне в голову приходят только менингококки... Не гонококки же, в самом деле. Тем не менее, я тоже выбираю С.
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#791
14.09.2006, 20:36
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Цитата:
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#792
14.09.2006, 20:54
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Поскольку лечение амоксициллином не помогло, с учетом особенности формулировки вопроса (At this time the most correct statement...), выбираю ответ:
E. The responsible bacteria rarely produces Б-lactamase that mediates resistance to penicillins
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#793
14.09.2006, 21:00
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Цитата:
Однако, что же это за бактерия? И потом, rarely ведь означает по сути, что чаще всего она НЕ вырабатывает бета-лактамазу и, следовательно, чаще всего чувствительна к амокси... В то время как в данном случае идет именно резистентность.
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#795
14.09.2006, 21:19
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Согласен, все правильно, это очень возможно (про них забыл, посыпаю голову пеплом).
Однако, эти возбудители именно нечувствительны к пенициллинам, и слово rarely тут как-то неуместно. А вакцин против них нет. Значит, D! Ага! Правильный ответ - D! Да здравствует Riltsov!
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