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#407
07.08.2006, 16:07
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Наверное, пора опубликовать мнение авторов задачки.
The correct answer is E. This patient is an elderly female who presented with 2 days of atrial fibrillation and associated symptoms of lightheadedness and nausea. The etiology of the atrial fibrillation is stenosis of her mitral valve. Mitral stenosis with elevated left atrial pressures results in left atrial enlargement, a predisposing factor for the development of atrial fibrillation. Atrial fibrillation, in the context of mitral stenosis, may compromise proper left ventricular filling due to the lack of an atrial contraction. This can result in a decreased cardiac output with presenting symptoms of dizziness, lightheadedness, and even syncope. A rapid ventricular response to atrial fibrillation can decrease ventricular filling time as well, decreasing cardiac output. Rate control of atrial fibrillation can be accomplished by beta-blockers, Ca+2 channel blockers, or digoxin. Patients in atrial fibrillation for >48 hours are at risk for developing atrial thrombi that can embolize. Anticoagulation initially with heparin is required. Conversion of atrial fibrillation to sinus rhythm can be accomplished by either electrical or pharmacological methods. In either case, anticoagulation with warfarin is essential before elective cardioversion can proceed. In emergency cases, if the patient is unstable despite rate control, cardioversion can be done after assessment of the left atrium for mural thrombus by transesophageal echocardiogram. The presence of coronary artery disease is not a contraindication for cardioversion, and the suspicion of ischemic heart disease is low. A coronary angiogram (choice A) is not required. Again, the presence of underlying ischemia or coronary artery disease is not a contraindication for cardioversion. A stress test (choice B) is not required before elective cardioversion. A transesophageal echocardiogram (choice C) is used to assess the left atrium for mural thrombus before emergency cardioversion in unstable patients. This patient is stable and undergoing an elective procedure. The patient's heart rate appears to be well controlled with beta-blockers and she does not need digoxin therapy (choice D). 
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#409
07.08.2006, 16:12
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Цитата:
 
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#410
07.08.2006, 16:25
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Цитата:
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#411
07.08.2006, 16:26
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Цитата:
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#412
07.08.2006, 16:27
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A 19-year-old man who is in the hospital because of an asthma exacerbation, has a painful sore on his penis. He tells you that 4 days prior to admission, he had unprotected sexual intercourse with a new partner. Yesterday, he began developing "painful sores" over the distal aspect of his penis. He also complains of dysuria, but denies fevers, chills, meatal discharge, or any previously similar episodes. Three months ago he had an HIV test which was negative. He has bilateral inguinal adenopathy, which is firm and tender to palpation. There is no discharge elicited from the meatus. Dispersed on the penile shaft are multiple small tender vesicles on an erythematous base. Rectal examination shows normal sphincter tone with a firm, appropriately sized, non-tender prostate. Urine dipstick is negative for any sign of infection. You send off a culture from one of the lesions. The next best step in the management of this patient is to
A. give 1 intramuscular injection of benzathine penicillin G B. prescribe ceftriaxone 250 mg intramuscularly, a single dose C. prescribe oral acyclovir D. prescribe topical acyclovir E. prescribe azithromycin 1gm ; orally a single dose F. repeat the HIV test G. wait for culture results to return
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#413
07.08.2006, 16:27
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Цитата:
 Dmitry Voskovets
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#415
07.08.2006, 17:57
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It's a chancroid! E
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#418
07.08.2006, 20:35
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Цитата:
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#419
07.08.2006, 21:50
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Цитата:
Dmitry Voskovets
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#420
07.08.2006, 22:31
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The correct answer is C. This patient has a classic case of primary genital herpes. Typically, this presents as penile lesions of grouped vesicles on an erythematous base that do not follow a neural distribution. The lesions are tender to touch and the associated adenopathy is bilateral, mildly tender, non-fixed, and slightly firm. The primary episode is more severe, than recurrent attacks and the incubation period is 2-10 days. The herpes simplex virus is a double-stranded DNA virus capable of causing persistent and latent infections. Most genital herpes are caused by type 2 virus, however, up to 25% of genital herpes may be caused by type 1 virus. Partners of infected patients are at risk of transmission, even when the virus is asymptomatic. Acyclovir is the only drug that has shown efficacy in the treatment of the signs and symptoms of genital herpes, however, there is no known cure. The medication works by acting as an inhibitor of viral DNA polymerase and acts as a chain terminator. It treats the symptoms by decreasing the duration of viral shedding, the time of crusting of the lesions, and the time for healing of the lesions. Topical acyclovir (choice D) is much less effective than oral or IV therapy and is therefore discouraged.
Benzathine penicillin G(choice A) is used for the treatment of primary syphilis. Syphilis is caused by the spirochete Treponema pallidum and the primary disease presents as a painless, firm, indurated chancre. Adenopathy may be tender or non-tender and is typically firm and "rubbery". IM ceftriaxone (choice B) is used in the treatment of chancroid. The causative agent in this disease is Haemophilus ducreyi. The ulcer associated with chancroid is deep with an undermined border and a friable base that bleeds easily. The adenopathy in painful and with chronic infection may cause lymphatic obstruction. One gram of azithromycin (choice E) may also be utilized in the treatment of chancroid. Repeating the HIV test (choice F) in this patient with high-risk behavior is appropriate. However, it may be performed after treatment of his herpes is initiated. This test should not delay the necessary immediate intervention. The most sensitive technique for diagnosing herpes is to isolate the virus in a culture. However, results take 5 days and therapy should not be withheld if clinical suspicion for herpes is high (choice G).
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