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#916
01.11.2006, 21:06
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The correct answer is C. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. The disease is characterized by a high fever for longer than 5 days, bilateral conjunctival injection, fissured lips, a "strawberry tongue", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gammaglobulin. An echocardiogram is necessary to evaluate cardiac involvement.
Corticosteroids (choice A) are not used to treat Kawasaki disease. They may be used to treat some of the symptoms in severe Henoch-Schonlein purpura (HSP), which is a vasculitis involving kidneys, gastrointestinal tract, skin, and joints. Individuals with HSP typically have a rash on the lower extremities and buttocks. Ibuprofen (choice B) is not the most appropriate therapy at this time. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. Oxacillin (choice D) is used to treat staphylococcal scalded skin syndrome (SSSS), not Kawasaki disease. SSSS is characterized by fever, malaise, periorbital edema, and a generalized, fine, erythematous rash. With gentle rubbing, the epidermal layer of the skin may exfoliate. It is usually preceded by an upper respiratory infection. Thrombocytosis is generally not present. Penicillin V (choice E) is the treatment for scarlet fever, not Kawasaki disease. Scarlet fever usually presents with an erythematous sandpaper-like rash with fever and a "strawberry" tongue. It is typically associated with streptococcal pharyngitis. Desquamation may occur. It is usually not associated with bilateral conjunctivitis, fissured lips, or thrombocytosis. 
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#917
01.11.2006, 21:06
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A 27-year-old HIV-positive man comes to the clinic for a periodic health maintenance examination. He contracted the disease 5 years ago from a former partner. He has been followed in the community health clinic since that time. He has no other medical history and takes only diazepam orally for anxiety. His last visit was 11 months ago. His temperature is 37.0 C (98.6 F), blood pressure is 140/85 mm Hg, pulse is 78/min, and respirations are 12/min. He has clear lung fields bilaterally, his skin is free of rashes or excoriations, and his abdomen is soft and nontender. Blood work drawn a few weeks ago reveals a CD4 count of 98 cells/mm3 and a hematocrit of 34% with an MCV of 95 fl. His last tuberculin skin test was 3 months ago and was read as 4mm and flat. In addition to initiating vitamin B12 and folate therapy for his patient, the most appropriate intervention at this time is
A. antibiotic prophylaxis for PCP pneumonia B. antibiotic prophylaxis for tuberculosis C. a skin test for tuberculosis D. treatment for active tuberculosis infection E. none is indicated based upon his CD4 count at this time
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#919
06.11.2006, 22:31
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When HIV infection is first recognized, the patient should receive a tuberculin skin test (TST) by administration of intermediate-strength (5-TU) purified protein derivative (PPD) by the Mantoux method (AI).
All HIV-infected persons who have a positive TST result (>5 mm of induration) should undergo chest radiography and clinical evaluation to rule out active TB. HIV-infected adults and adolescents, including pregnant women and those on HAART, should receive chemoprophylaxis against PCP if they have a CD4+ T lymphocyte count of <200/µL (AI) or a history of oropharyngeal candidiasis (AII). Persons who have a CD4+ T lymphocyte percentage of <14% or a history of an AIDS-defining illness, but do not otherwise qualify, should be considered for prophylaxis (BII). When monitoring CD4+ T lymphocyte counts for >3 months is not possible, initiating chemoprophylaxis at a CD4+ T lymphocyte count of >200, but <250 cells/µL, also should be considered (BII). [Ссылки доступны только зарегистрированным пользователям ] IMHO - A. antibiotic prophylaxis for PCP pneumonia
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#921
08.11.2006, 17:51
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Explanation:
The correct answer is A. Opportunistic infections occur in people with HIV and define many of the components of the clinical syndrome known as AIDS. They are caused by a wide variety of pathogens and all have the common etiology that the host is susceptible due to the immune destruction brought on by the HIV virus. Prognosis depends on the type of infection and often, even with appropriate therapy, morbidity and mortality is high. There are means to prevent or reduce the likelihood of developing these infections. For this patient, his CD4 count of less than 200 cells/mm3 indicates that he should begin antibiotic prophylaxis, usually with TMP/SMX, for PCP pneumonia. Starting antibiotic prophylaxis for tuberculosis (choice B) is not routine practice except in persons with a PPD-positive skin test, which this patient does not have. Since the patient was tested for tuberculosis within the last year, and there is no evidence that he is anergic, there is no indication to test him again at this time (choice C). The patient does not have active tuberculosis infection (choice D). Even if his PPD test were positive, active infection requires documentation of the organism in sputum by PCR or acid-fast staining. Any patient with a CD4 count of less than 200 cells/mm3 should be considered for prophylaxis therapy for at least PCP pneumonia and toxoplasmosis (choice E).
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#922
08.11.2006, 17:52
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A 67-year-old man comes to the office for a follow-up visit to review the findings from a colonoscopy that was performed 2 weeks earlier. A 0.9 cm tubular adenoma was removed from his sigmoid colon. No other lesions were visualized in the colon. He has no family history of colon cancer and is very concerned when you tell him that the polyp was adenomatous. All previous colonoscopies were normal. In explaining the findings to him, you should tell him that:
A. A chest x-ray should be performed to ensure that there are no abnormalities associated with the adenoma B. A colectomy should be performed to avoid the risk of developing colon cancer C. Colonoscopy will be required every 6 months to determine if any new polyps have formed D. His children should have screening colonoscopies beginning at age 25 E. Tubular adenomas such as his have a low risk of malignant potential
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#923
08.11.2006, 19:37
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E. Tubular adenomas such as his have a low risk of malignant potential Однозначно! Все остальные комментарии явно неуместны!!!
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#924
08.11.2006, 20:15
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Single tubular adenoma <1 cm, no other lesions, no family history of colon cancer. E, разумеется.
PS Ответ B, видимо, предусмотрен как exclusion criterion, после которого экзаменуемого лишают права приближаться к любому из госпиталей ближе чем на 3 км 
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#926
04.12.2006, 18:35
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The correct answer is E. Colonic polyps are very common in older patients, with approximately 40% of all patients at age 60 having at least 1 adenomatous polyp, (and 50% at age 70). Since there is a link between polyps and the development of malignancy, it is recommended that polyps be removed and evaluated. There are 3 types of adenomas≈tubular, tubulovillous, and villous. Tubular adenomas have a low risk for malignant foci (approximately 5% risk), tubulovillous have an intermediate risk (approximately 20%), and villous have a high risk (approximately 40%).
A chest x-ray should be performed to ensure that there are no abnormalities associated with the adenoma (choice A) is incorrect. Since the case does not say that the tubular adenoma found has any malignant foci, there will not be any associated changes found in the lung. A colectomy should be performed to avoid the risk of developing colon cancer (choice B) is inappropriate. This patient does not have a malignancy and therefore any additional treatment for this polyp is unnecessary. Prophylactic colectomies are typically recommended for patients with autosomal dominant polyposis syndrome because it is associated with an almost 100% risk of colon cancer by age 40. Patients with a history of colonic polyps need to be followed closely with a colonoscopy every 1-3 years, not every 6 months (choice C). Since about 40-50% of all patients in this age range will have at least 1 polyp, it is not that unusual that this 67-year-old patient has a polyp. His children should NOT have screening colonoscopies beginning at age 25 (choice D) because this is too young and the chance of them having polyps at that age is small. According to the United States Preventive Services Task Force, the recommended screening for colon cancer is an annual fecal occult blood test and/or a sigmoidoscopy every 3-5 years beginning at age 50.
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#927
04.12.2006, 18:35
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A 31-year-old man undergoes an uneventful standard "open" repair of the hernia using "mesh plug" technique. As planned, he is discharged home on the same day of surgery. At his first postoperative visit, he complains of numbness over the upper aspect of his right thigh and the right side of the scrotum. Physical examination reveals an incision that is clean and dry without any evidence of infection. The right hemi-scrotum is moderately edematous and minimally tender, both testicles are normal to palpation. Motor sensation of his right lower extremity is completely intact. Sensory examination reveals decreased sensation to touch over the medial aspect of the thigh just below the inguinal ligament as well as over the right side of the scrotum. He is given instructions to observe this complaint and follow up in 2 weeks. The injured nerve is most likely the
A. iliohypogastric B. ilioinguinal C. lateral femoral cutaneous D. obturator E. pudendal
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#929
04.12.2006, 20:14
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Obturator.
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Линейный вид
