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#256
27.07.2006, 21:52
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Е. По крайней мере, нас учили, что дерматомиозит (а клиника в данном случае приведена просто классическая) у пожилых весьма часто может являться ппаранеопластической реакцией.
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#258
27.07.2006, 23:26
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The correct answer is E. Searching for internal neoplasm is the best work up, because dermatomyositis in adults often appears as a paraneoplastic phenomenon. Progressive weakness is the major clinical manifestation. Difficulty in rising from low chairs, climbing stairs, or holding the arms above the head are common symptoms. The most specific skin manifestation is a maculopapular erythema on the bony prominences, such as the knuckles, elbows, and knees that appears in about 70% of cases. A blotchy erythema, especially on sun-exposed skin, occurs in about a third of patients. More chronic macular erythema and poikilodermatous lesions may also develop on the trunk and proximal parts of the limbs. A distinctive sign is an erythematous blush on the eyelids and around the eyes. It has a lavender shade and is called a heliotrope erythema. Patients over the age of 50 at onset, should be evaluated for the presence of a malignant tumor. Chest x-ray, gastrointestinal evaluation, and careful breast and genitourinary examinations are sufficient unless symptoms point elsewhere.
While antinuclear antibody (choice A) may be positive in dermatomyositis, it is not the best work up nor is it the most diagnostic test. Anti-Rho and anti-La (choice B) is incorrect, because these are the main markers for Sjogren's, subacute lupus erythematosus, and neonatal lupus, but not for dermatomyositis. A liver function test (choice C) is incorrect, because it is neither diagnostic for dermatomyositis nor the best work up. Checking rheumatoid factor levels(choice D) is incorrect, because dermatomyositis patients do not usually have an elevated rheumatoid factor level.
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#259
27.07.2006, 23:32
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A 51-year old woman with systemic lupus erythematosus comes to the clinic with right hip pain for the past 3 days. She has no history of trauma. The patient has been postmenopausal for the past 3 years. She takes naproxen, ibuprofen, and prednisone 100 mg a day. She has been taking these medications for the past 10 years. She tells you that she stopped taking estrogen secondary to occasional nausea. Her temperature is 37.4 C (99.4 F). Physical examination reveals a butterfly facial rash, multiple swollen joints of the hands and feet, and a systolic flow murmur. A plain radiograph of the hip is normal. A bone scan reveals decreased 99Tc MDP tracer uptake in the right femoral head. The patient should be advised to
A. avoid weightbearing and immediately stop prednisone B. avoid weightbearing and taper off prednisone C. begin an exercise program and calcium supplementation D. begin an exercise program and taper off prednisone E. begin an exercise program, calcium supplementation, and estrogen replacement therapy
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#261
28.07.2006, 00:37
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E. Хотя, просто гадаю на кофейной гуще.
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#262
28.07.2006, 07:45
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Мне, честно говоря, не нравится ни один из вариантов.
Во-первых, действительно смущает доза преднизолона. 100 мг для СКВ, как совершенно справедливо заметил коллега Aladdyn, непомерно много для волчанки, в таких случаях проводят пульс-терапию. Ну а во-вторых, профилактика и лечение кортикостероид-индуцированного остеопороза, неизбежно возникающего у женщины старше 50 лет, получающей системные стероиды, не ограничивается добавками кальция.
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#265
28.07.2006, 16:25
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Да, наверное, с дозой они погорячились. Но Е не подходит. На сцинтиграфии - аваскулярный некроз ( A bone scan reveals decreased 99Tc MDP tracer uptake in the right femoral head.) Физическая нагрузка вряд ли показана.
The correct answer is B. The history, physical exam, and bone scan results are consistent with systemic lupus erythematosus and avascular necrosis (AVN) of the right femoral head. This is a common complication of long-term steroid therapy. AVN may also be a result of pancreatitis, fat embolus, alcoholism, sickle cell anemia, air emboli, or idiopathic causes as in Legg-Calve-Perthes disease. Avoidance of activity, especially weightbearing is necessary to ensure that the femoral head does not collapse and fracture. Given a prednisone dose greater than 10mg QD, a slow taper should be initiated to allow the adrenal glands to resume normal cortisol production. A rapid taper of prednisone (choice A) could result in adrenal insufficiency. Symptoms of this iatrogenic condition include fatigue, tiredness, depression, and weight loss. More severe cases result in hypotension, irregular pulse, and nausea. Exercise involving the lower extremities (choice C) must be avoided as collapse and fracture of the femoral head may occur. AVN is not a symptom of osteoporosis, so standard osteoporosis treatments do not apply. Exercise involving the lower extremities (choice D) must be avoided as collapse and fracture of the femoral head may occur. Exercise involving the lower extremities (choice E) must be avoided as collapse and fracture of the femoral head may occur. AVN is not a symptom of osteoporosis, so standard osteoporosis treatments do not apply. Since this patient is postmenopausal, estrogen replacement therapy should be begun as a separate issue.
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#266
28.07.2006, 16:26
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A 29-year-old man comes to the office for advice on an "embarrassing issue". He tells you that he has always been very shy and worried about everything. He has been able to manage his career fairly well, even though he is tremendously anxious about his performance. However, he has always felt intimidated by women. He recently started dating a girl that he is very much in love with and he considers this his first serious relationship. They have had sexual intercourse on several occasions, but it seems that he always ejaculates prematurely. He has had this problem before with other women that have meant nothing to him, but he is very concerned now that this new woman will "not be able to tolerate it for much longer". He seems reasonably embarrassed and tearful while talking about it. He asks if you know of anything that can help him with this problem. At this time you should prescribe
A. estrogen B. fluoxetine C. methantheline bromide D. progesterone E. propranolol
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#269
29.07.2006, 06:55
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Зачем такие грустные вопросы задавать!
Если флуоксетин - это Прозак, то его назначать ИМХО низзя, поскольку препарат убъет либидо у нашего молодца.
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#270
29.07.2006, 15:08
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Fluoxetine удлиняет время полового акта (возможно за счет анестезирующего действия на половые органы) и убирает тревогу. Ответ B. Fluoxetine.
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Линейный вид
