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#152
17.12.2006, 12:12
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A 16-year-old boy is admitted to the hospital for pneumonia. The patient reports that over the past 3 days he has had an increasing cough, productive of thick, green sputum and pleuritic chest pain. He has a history of cystic fibrosis and has been hospitalized for pneumonia 9 times in the past 3 years. He has never been intubated, but has required prolonged hospital stays at times in order to manage his infections. His medications include pancreatic enzymes and acetylcysteine nebulizers. The most appropriate management of this patient is to
A. begin aggressive chest physiotherapy B. give him inhaled beta agonists C. enroll him in gene therapy trials D. evaluate him for lung transplantation E. obtain a sputum culture and await results for directed antibiotic therapy 
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#153
17.12.2006, 12:25
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cystic fibrosis - это муковисцидоз?Если это так
то я выбираю сначала в2-адреномиметики(ответ В)
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#156
17.12.2006, 13:34
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Цитата:
А насчет пересадки легкого.Не знаю,делают ли ее при муковисцидозе.Есть ли в этом смысл.Хотя я еще так и не уверена,что речь идет именно о нем. 
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#157
17.12.2006, 13:49
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Речь именно о муковисцидозе. А пересадки делают, по-моему(не уверена). 9 раз за 3 года госпитализация по поводу пневмоний - это достаточно много, чтобы думать о трансплантации.
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#159
17.12.2006, 17:38
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Ира,а можно еще подсказку?
aggressive chest physiotherapy - что под этим подразумевается?Массаж и постуральный дренаж?Если да,то возможно именно это надо проводить в первую очередь.
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#160
17.12.2006, 17:49
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The correct answer is A. Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.
Inhaled beta agonists (choice B) offer no benefit for these patients since they have no element of bronchoconstriction to their disease. All of the airway issues in these patients relates to the thick mucous plugs that they are unable to clear. Despite some of the early successes in gene therapy for CF, early enrollment in gene therapy trials (choice C) is still not considered a standard of care and does not replace in any way the most basic management principles of caring for patients with CF which is antibiotics and chest physical therapy. It is appropriate to begin evaluation for lung transplantation (choice D) at any time during the course of CF. However, such an evaluation does not in any way assist in managing the acute infection that the patient is currently suffering. Most patients with CF have defined pathogenic flora such as pseudomonas. For this reason, a sputum culture for directed antibiotic therapy (choice E) to direct therapy is not critical and antibiotic coverage can be initiated prior to any definitive culture data being returned.
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#161
17.12.2006, 17:50
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You are asked to see a baby in the newborn nursery. The baby is small for gestational age and has microcephaly. Physical examination shows hepatomegaly, a widened pulse pressure, a "machinery" heart murmur, and a purpuric skin rash. There is no red reflex in either eye. At this point, you are suspicious that the baby has a congenital infection caused by
A. Cytomegalovirus B. rubella virus C. Toxoplasma gondii D. Treponema pallidum E. varicella-zoster virus
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#162
17.12.2006, 18:17
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Скорее все же краснуха.
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#163
18.12.2006, 10:50
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The correct answer is B. This baby most likely has congenital rubella. Some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a "blueberry muffin" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect.
Congenital Cytomegalovirus (CMV) infection (choice A) is usually asymptomatic at birth (approximately 85% of the time). Clinical manifestation is found to be severe in approximately 5% of babies with congenital CMV. Manifestations include: intrauterine growth retardation, chorioretinitis, microcephaly, intracerebral calcifications, hepatosplenomegaly, jaundice, thrombocytopenia, neutropenia, purpura, and pneumonia. Although the baby in the question has many of the defects found in congenital CMV, congential heart defects and cataracts are not associated with CMV. Toxoplasma gondii(choice C) is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth will develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash. Treponema pallidum(choice D) is the organism responsible for syphilis infection. Congenital syphilis is characterized by nonimmune hydrops, prematurity, anemia, neutropenia, thrombocytopenia, pneumonia, and hepatomegaly. Late onset syphilis, which may present up to two years of age, is characterized by snuffles, rash, hepatosplenomegaly, condylomata lata, osteochondritis, cerebrospinal fluid pleocytosis, lymphadenopathy, and thrombocytopenia. Untreated infants may develop late manifestations involving the central nervous system, teeth, eyes, skin, ears, bones, and joints. Varicella-zoster infection (choice E) in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death.
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#164
25.01.2007, 08:34
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[Изображения доступны только зарегистрированным пользователям]
A 7-year-old girl is admitted to the hospital because of a 3-week history of fever, leukopenia, nausea, abdominal pain, and arm weakness. The patient had undergone a workup for infection at an outside facility prior to admission and was given a 5-day course of doxycycline to treat a fever of unknown cause. On this presentation, a peripheral blood smear is obtained and shows numerous leukoblasts. Subsequent bone marrow biopsy reveals acute lymphoblastic leukemia (ALL). Induction therapy, which includes dexamethasone, vincristine, pegylated (PEG)-asparaginase, and intrathecal methotrexate, is initiated. Nine days after therapy begins, the patient has 2 tender, slightly raised, and erythematous lesions on her right arm. Her WBC count is 1.81 X 10/L (1810/µL) cm2 with a platelet count of 39 X 109/L (39 X 10/µL). The next morning, the largest lesion, which measures 15 mm, has a 5-mm darkened center. The lesions progress, and, by the next day, measure 20 mm with a 10-mm central area with dark discoloration (see Image 1). Cefepime is administered for a suspected diagnosis of ecthyma gangrenosum, and fluconazole as prophylactic therapy is continued. Despite treatment with the antimicrobials, the lesion continues to grow and becomes increasingly tender to palpation, with progression to small surrounding satellite areas. The patient is taken to an operating room, where the lesions are widely resected and samples are obtained to be sent to pathology and microbiology for examination. In addition to the tissue undergoing standard Gram staining and aerobic and anaerobic culture, acid-fast staining, mycobacterial culture, fungal staining, and viral culture are also performed. Histopathology of the resected specimen reveals a 2.6 X 1.5 X 0.8-cm ellipse of skin that contains several lesions. The largest lesion is 1.0 X 1.3 cm and has a 1- to 2-mm rim of erythema around its dark center. About 4 mm from the largest lesion, a second lesion measures 3 X 2 mm and has surrounding erythema. The epidermis is laterally intact but centrally affected by ischemic necrosis (see Image 2). The dermis and subcutaneous tissues contain an extensive infiltrate of fungal hyphal elements involving the walls of the blood vessels, surrounding tissues, and focal perineural areas (see Image 3). Fungal elements are noted within 1 mm of each lateral resection margin (see Image 4). What was the diagnosis?
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Линейный вид
