Еще одна пилюлька Hескучина

[riltsov]

D. order a plain radiograph of the forearm
Клиника перелома - надо делать рентген. carpal tunnel syndrome и weak left radial pulse увязать не могу.

[Anna_Shvedova]

ИМХО, С.
Боль, отек, деформация после травмы - перелом есть. Слабый пульс и выраженный отек - травма лучевой артерии? Вот ее и надо верифицировать в первую очередь, и перелом тоже на КТ должно быть видно. Хотя у нас, конечно, таких изысков нет, и сделали бы простой рентген.

[Rodionov]

Я за D. Начнем с дешевой рентгенографии.

[riltsov]

Если правильный ответ D., то какая связь с carpal tunnel syndrome и weak left radial pulse. Неужели последние приведены, чтобы запутать нас (red herring). А вот в этой связке carpal tunnel syndrome и weak left radial pulse и есть ключ к правильному ответу. Покопался в литературе... И я эту связь нашел. Compartment syndrome (CS) occurs when pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia. Очевидно, что есть перелом у пациентки но, прежде всего, нужно восстановить перфузию тканей и иннервацию ниже места сдавления.
Поэтому скорее ответ B. measure forearm compartment pressures.

[yananshs]

The correct answer is B. This patient is presenting with symptoms of forearm compartment syndrome. This is caused by hemorrhage or edema of a facial compartment causing diminished inflow and outflow of blood to muscles, nerves, and other structures in that anatomic compartment. Compartment syndrome is typically post-traumatic or iatrogenic from arterial lines or intravenous lines. In this case, the patient clinically has a fracture of the radius and ulna with likely hemorrhage in the forearm. A weak pulse is suggestive of an impending compartment syndrome. The clinical indicators of compartment syndrome are extremity pain, pulselessness, paraesthesia, and pallor indicating a “perishing” extremity. Time is critical, as tissue is actively infarcting. Needles must be inserted into the forearm compartments to assess for pressure increases. If the pressure is greater than 15 mm Hg (normal is near zero), an emergent fasciotomy and drainage is indicated. A surgery consult should also be sought.

Bilateral brachial blood pressures are used as a clinical test for aortic dissection (choice A). Definitive evaluation must be performed with a computed tomography (CT) scan or transesophageal echocardiography. Aortic dissection is common only in the setting of major thoracic trauma, not in cases of isolated extremity trauma. In this patient, blood pressure measurement of the left extremity will be technically difficult given severe forearm trauma.

Time is critical as tissue is actively infarcting. Needles must be inserted into the forearm compartments to assess for pressure increases. If the pressure is greater than 15 mm Hg (normal is near zero), an emergent fasciotomy and drainage is indicated. Obtaining a CTA of the forearm is a problem solving tool after a clinical diagnosis of vascular injury has been established to aid in planning the surgical repair of damaged vessels (choice C).

Time is critical as tissue is actively infarcting. Needles must be inserted into the forearm compartments to assess for pressure increases. If the pressure is greater than 15 mm Hg (normal is near zero), an emergent fasciotomy and drainage is indicated. A plain film of the forearm (choice D) is a necessary first step in evaluating for fracture, but this can be performed after compartment pressure measurements have been obtained.

Prescribing pain medication (choice E) will be necessary after a diagnosis has been made. A diagnosis needs to be made before beginning treatment.

[yananshs]

A 36-year-old man is admitted to the hospital for acute management of his schizophrenia. He is a homeless man that you often see hanging out around the neighborhood. He has had multiple hospitalizations over the past 5 years and they usually occur when he stops taking his medications. He usually believes that his dead cousin speaks directly to him through fire hydrants and that she tells him that he does not need to take any medication. Unfortunately, she is the only person that he listens to. You are called to see him because you have treated him many times in the past. When you get to the floor, the nurse tells you that you should be careful when you enter the room because orders for the medication have not been written yet. You hear howling as you are talking to the nurse and when you get to his room you see that he is kneeling at the window "howling at the moon." He becomes angry and violent when you try to enter his room. You go back to the nurse station and tell her to give him an injection of haloperidol and diazepam. In addition, at this time you should
A. begin psychosocial treatment with behavior skills training
B. give dantrolene to prevent neuroleptic malignant syndrome
C. prescribe benztropine to prevent parkinsonian-like symptoms
D. prescribe clozapine to treat his negative symptoms
E. schedule immediate electroconvulsive therapy

[papadoctor]

>>C<<

[riltsov]

Профиль не мой, но с шизофрениками приходиться общаться регулярно. Исходя из общих знаний, ответ найти, не могу, пришлось копаться в книгах, журналах.

behavior skills training – если на луну воет, не поможет.

Benztropine не нужен т.к. угрожающий лекарственный паркинсонизм не разовьется сразу.

Clozapine едва ли нужен в данной острой ситуации – вой на луну и общение с покойницей не являются негативными симптомами.

Electroconvulsive therapy – брутальный метод ... я бы не назначал.

В книжке «An Atlas of SCHIZOPHRENIA» нашел The most life-threatening side-effect of neuroleptic use is neuroleptic malignant syndrome. И прочитал, что может он быть от первой дозы нейролептиков.

Стало быть - B. give dantrolene to prevent neuroleptic malignant syndrome

P.S. Подобные задачки решать невероятно интересно!! Спасибо!! Пилюлька Hескучина будучи мощным ноотропом великолепно развивает головной мозг и его всяческие skills ;-)))

[Mikhail]

dantrolene не предотвращает острый нейролептический синдром (написано в епократесе). по этому - С. Хотя клозапин написано показан для рефрактерной шизы (но при этом рестриктед access in US...)

[yananshs]

The correct answer is C. In acute psychiatric emergencies, a neuroleptic agent (haloperidol) and a benzodiazepine (diazepam) are typically given to control the patient and aid in sedation. An anticholinergic agent, such as benztropine, should be added to prevent parkinsonian-like symptoms (rigidity and akinesia) that may occur in patients treated with high-potency antipsychotic agents (haloperidol).

In this acute situation, it is inappropriate to begin psychosocial treatment with behavior skills training (choice A). Psychosocial treatment, including behavior skills training, multi-family groups, vocational training, and workshops, is very important in the long-term management of schizophrenia. During the patient's hospitalization, after the patient is stabilized, the treatment plan should focus on practical issues, and set the stage for outpatient psychosocial issues.

Dantrolene is the treatment for neuroleptic malignant syndrome (choice B), which may be caused by high-potency antipsychotic agents (haloperidol). It is not routinely given to prevent this condition. NMS is associated with a high fever, autonomic instability, rigidity, behavioral changes, and laboratory abnormalities such as elevated white blood cell count, creatine kinase, and abnormal liver function tests.

Clozapine (choice D) is used as a second-line antipsychotic agent for patients who do not respond to the typical antipsychotic medications and have prominent negative symptoms (flat affect, poverty of speech, and asociality). It is not typically the first agent given in an acute psychiatric emergency. It is associated with agranulocytosis (1%) and requires weekly monitoring of the white blood cell count.

Electroconvulsive therapy (choice E) may be used in cases of non-responsive catatonia. It is not often used to treat an acute psychiatric emergency with a wild and out of control patient.

[yananshs]

A 34-year-old woman comes to the office for a follow-up examination after passing a kidney stone in the hospital last week. You were away on vacation and so your partner was involved in her in-patient treatment. The patient tells you that your partner did not tell her anything about her condition and always seemed "as if he was late for his golf tee-off time." Passing the stone was "more painful than the vaginal delivery of all 3 children combined" and so she wants to make sure that she never has one again. She has no chronic medical conditions, never had surgery, and takes no medications. Her father and brother both suffer from nephrolithiasis. You go over to the computer to check if the laboratory report on the composition of her kidney stone is complete. You see that the stone was composed of calcium and that she had a 24-hour urine collection done in the hospital that showed 295 mg of calcium and 15 mg of oxalate. Her serum calcium level is 8.5 mg/dL. The most appropriate course of action is to
A. prescribe allopurinol, orally
B. prescribe cholestyramine, orally, and a low-fat diet
C. prescribe hydrochlorothiazide, orally
D. recommend a high fluid intake, but no medications or supplements
E. recommend megadoses of vitamin C

[riltsov]

Hydrochlorothiazide уменьшает кальциурию и предотвращает нефролитиаз.
C. prescribe hydrochlorothiazide, orally

[filbi]

Д----, хотя отягощенная наследственность немного смущает, но все-таки Д

[Aladdyn]

D. Уровень кальциурии и оксалурии невысок, в дальнейшем при неэффективности можно - С. А вот Е - только при сильно выраженном мазохизме.

[yananshs]

The correct answer is C. This patient most likely has idiopathic hypercalcuria, which is characterized by calcium kidney stones, normocalcemia, and unexplained hypercalcuria. It is believed to be hereditary and is more common in men. Hydrochlorothiazide has been shown to decrease urinary calcium levels and therefore decrease the rate of calcium stone formation.

Allopurinol (choice A) is a xanthine oxidase inhibitor that is used in patients with kidney stones composed of uric acid. It decreases serum and urinary uric acid levels.

Cholestyramine (choice B), an oxalate binding resin, combined with a low-fat diet, is used in patients with intestinal hyperoxaluria for the prevention of calcium stones. These patients have a 24-hour urinary oxalate level greater than 50 mg. It occurs in patients with prior bowel surgery and chronic diseases of the gastrointestinal tract that lead to malabsorption and bacterial overgrowth.

It is inappropriate to recommend a high fluid intake, with no medications or supplements (choice D) to a patient with idiopathic hypercalcuria and kidney stones. Thiazides have been shown to reduce the rate of kidney stone formation in a patient with her condition.

Megadoses of vitamin C (choice E) are controversial and have been associated with the formation of kidney stones. Megadoses of vitamin C are not generally recommended for the prevention of calcium stones in patients with idiopathic hypercalcuria.