|
#871
09.10.2006, 19:11
|
||||
|
||||
|
The most appropriate next step is E
"а вот с ее меноррагиями что делать" - D The correct answer is E. This patient has iron-deficiency anemia, a very common diagnosis in women of childbearing age. This is a type of microcytic anemia characterized by MCV <80 and a ferritin level less than 12 mcg/L. The loss of iron for both men and women is about 30gm per month. For menstruating women, it can be twice this. For this reason, iron deficiency is prevalent in this population. Oral iron tables are the therapy of choice. They are usually well tolerated and often remedy the problem within 12 weeks. Intravenous iron (choice A) is not routinely used in the management of iron-deficiency anemia. It does have some indications, for example in hospitalized patients unable to take oral medications or solids due maldigestion or malabsorption. Vitamin B12 (choice B) is used to treat macrocytic anemia (MCV >100). Folate (choice C) is used for macrocytic anemia as well and in pregnant women for the prevention of neural tube defects. Serum B12 and folate levels can be checked once the diagnosis of macrocytic anemia is made, but often, both are prescribed since persons deficient in one are often, for dietary reasons, deficient in the other. Changing her oral contraceptive formulation to estrogen only (choice D) may help her to remedy her excessive menses, but will do nothing to increase her iron stores and correct her anemia. Therapy in this case is first directed towards fixing the anemia. 
|
|
#872
09.10.2006, 19:12
|
||||
|
||||
|
A 35-year-old African American man presents to your office for a first time visit. He has no past medical history, and takes a multivitamin daily. He is active and runs approximately 3 miles per week. He has a 10-pack year history of smoking and has 1-2 beers per week. His temperature is 37 C (98.4 F), blood pressure is 110/60 mm/Hg, pulse is 65/min and regular, and respiratory rate is 15/min. On examination you note a II/VI systolic ejection murmur at the right upper sternal border that has no respiratory variation, increases in intensity upon going from supine to standing and Valsalva, and decreases in intensity with sustained handgrip. There is a prominent, nondisplaced point of maximal impulse. The remainder of his examination is unremarkable. The most likely diagnosis is
A. aortic stenosis B. idiopathic hypertrophic subaortic stenosis C. mitral regurgitation D. patent ductus arteriosus E. tricuspid regurgitation
|
|
#874
09.10.2006, 20:32
|
|||
|
|||
|
Цитата:
|
|
#875
11.10.2006, 21:59
|
|||
|
|||
|
Ага, как помниться из пропедевтики при вертикализации и маневре Вальсальвы усиливаются только шумы ПМК и обструктивной ГКМП. Для ПМК локализация не та, стало быть - ИГСС.
P.S. Уважаемая Яна, Вы не против если я буду использовать сии задачи для натаскивания клинических ординаторов?
|
|
#876
11.10.2006, 22:51
|
|||
|
|||
|
Цитата:
|
|
#877
12.10.2006, 17:32
|
||||
|
||||
|
Explanation:
The correct answer is B. This condition involves an aortic outflow obstruction that is dependent upon both preload and afterload. As preload is decreased (i.e., as with a Valsalva maneuver or moving from supine to erect) the ventricular chamber size is decreased, the degree of outflow obstruction is increased, and the intensity of the murmur is increased. As the afterload is increased (i.e., with handgrip) the end systolic chamber size is increased, the degree of outflow obstruction decreased, and the intensity of the murmur is decreased. The prominent point of maximum impulse suggests a left ventricle that has hypertrophied in response to the outflow obstruction. The identification of IHSS is important since those with this form of cardiomyopathy are at increased risk for sudden death. Aortic stenosis (choice A) is incorrect because this murmur increases with increasing preload. Mitral regurgitation (choice C) is incorrect because it is a holosystolic murmur that is heard best at the cardiac apex, and radiates to the axilla. The murmur of mitral regurgitation also increases with increasing afterload (e.g., increasing handgrip). Patent ductus arteriosus (choice D) is incorrect since it is a murmur that can be heard through both systole and diastole. Tricuspid regurgitation (choice E) is incorrect because it is a holosystolic murmur heard best over the lower sternal border and increases with inspiration and right sided flows are increased with negative intrathoracic pressures.
|
|
#878
12.10.2006, 17:34
|
||||
|
||||
|
A 79-year-old man is admitted to the medical ward 3 days status post subdural hematoma drainage, C3 cervical spine fracture, and fixation of multiple extremity fractures sustained in a motor vehicle accident. The patient is now awake and oriented to person, place, and time, but is a lower cervical spine incomplete quadriplegic. Physical examination reveals some minimal sensation in the legs, but no ability to move the extremities. There is a Foley catheter in place that is draining yellow colored urine. Doppler ultrasonography demonstrates a thrombus in the left popliteal vein. The most important next step in the management of this patient is
A. daily Doppler ultrasonography of the lower extremities B. inferior vena cava filter placement C. subcutaneous heparin D. tissue plasminogen activator thrombolysis E. warfarin F. weekly ventilation/perfusion scans for a pulmonary embolus
|
|
#879
12.10.2006, 17:44
|
|||
|
|||
|
..B..
|
|
#881
13.10.2006, 21:57
|
|||
|
|||
|
Похоже на B, хотя подколенная - все же не бедренная, про флотацию не сказано. Может надо сначала понаблюдать - пока тромб подрастет и начнет флотировать, т.е. А, а там уж без вопросов - В?
P.S. Уважаемая Яна, спасибо, сегодня ссылка сработала 
|
|
#882
13.10.2006, 22:28
|
|||
|
|||
|
Who is going to pay for A??
|
|
#883
14.10.2006, 21:59
|
|||
|
|||
|
Фильтр оплатиться страховкой, ежедневный Допплер - нет!
|
|
#885
15.10.2006, 10:09
|
|||
|
|||
|
Цитата:
Но с его "status post subdural hematoma drainage" этого делать не стоит. поэтому "В". Dmitry Voskovets
|
Линейный вид
