Еще одна пилюлька Hескучина

[yananshs]

An 83-year-old woman with a history of hypertension and osteoarthritis comes to the office because of abdominal pain with occasional nausea, constipation, muscle weakness, and fatigue over the last 4 months. She denies taking any over-the-counter medications or vitamins. She denies weight changes, change in stool diameter, melena, bright red blood per rectum, or shortness of breath. You notice in her chart that she had a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is normal except for mild kyphosis. Her rectal examination is heme negative.

Labs:
RBC 4.2 million per µL
Hemoglobin 7.9 mmol/L
WBC 6 000 per mm3
Platelet 300,000 per mm3

Albumin: 4 g/dl
Alkaline phosphatase: 60 IU/L
ALT (alanine transaminase): 20 IU/L
AST (aspartate aminotransferase): 16 IU/L
BUN (blood urea nitrogen): 10 mg/dl
Calcium - serum: 14 mg/dl
Serum chloride: 105 mmol/L
Creatinine: 1.4 mg/dl
Direct bilirubin: 0.1 mg/dl
Gamma-GT (gamma-glutamyl transpeptidase): 2 IU/L
Glucose: 100 mg/dl
LDH (lactate dehydrogenase): 110 IU/L
Phosphorus - serum: 3 mg/dl
Potassium : 4 mEq/L
Serum sodium: 140 mEq/L
Total bilirubin: 1.0 mg/dl
Total cholesterol: 250 mg/dl
Total protein: 7 g/dl
Uric acid: 5 mg/dl

The most appropriate next step is to
A. determine parathyroid hormone levels
B. determine serum vitamin D levels
C. determine thyroid stimulating hormone levels
D. order a CT scan of the neck
E. order a serum protein electrophoresis

[filbi]

вначале-А

[yananshs]

Слишком простая была задачка.
Другая:
A 65-year-old man suffers a fall down his stairs at home and is admitted to the hospital for a fractured hip. The patient has no significant past medical history and takes only an aspirin daily. He is very active and plays golf and tennis 3 times per week. This morning, he slipped on the icy stairs and fell, breaking his right femur and acetabulum. He is brought to the operating room where the hip is repaired uneventfully. On postoperative day number 2, the patient develops acute shortness of breath and pleuritic chest pain on the right. His temperature is 37 C (98.6 F), blood pressure is 130/90 mm Hg, pulse is 110/min, and respirations are 22/min. Physical examination shows a tender, swollen left calf. The most appropriate therapy at this time is
A. embolectomy
B. intravenous heparin bolus plus continuous infusion
C. oral warfarin
D. subcutaneous heparin
E. thrombolysis

[filbi]

вначале Д

[yananshs]

Не верно.

[doctor101]

A. embolectomy

[Aladdyn]

Изолированный гемоторакс без пневмоторакса при таком механизме травмы встречается реже. И кровь видна будет одинаково хорошо вне зависимости от фазы дыхания. А вот пневмоторакс надо смотреть на выдохе - лёгкое коллабирует в большей степени. Всё-таки, С.

[yananshs]

The correct answer is C. This patient's exam shows evidence of chest wall trauma and decreased breath sounds. There is concern for a pneumothorax. Often, small pneumothoraces can be difficult to see on routine chest radiography. A chest radiograph at maximal expiration, by collapsing the lungs to a small volume, will increase the opportunity to visualize a pneumothorax.

An abdominal computerized tomogram (choice A) is not indicated in this patient at this juncture given her benign abdominal exam.

A chest radiograph at maximal inspiration (choice B), by inflating the lungs to the maximum, will not assist in the diagnosis of a pneumothorax.

An echocardiogram (choice D) can be used to diagnose cardiac or aortic pathology in the setting of a motor vehicle accident as with this patient. However, given the available information including the hemodynamic data, there is no reason to suspect such pathology here.

A ventilation-perfusion scan (choice E) is used in the diagnosis of a pulmonary embolus. There is no evidence that this patient has this pathology.

[yananshs]

A 40-year-old man is rushed into your emergency department. He was the restrained passenger in a motor vehicle accident involved in a hit and run. Upon arrival, he is awake and communicating. He denies any loss of consciousness and his only complaint is right-sided abdominal pain. As the physician in charge of the case, you assign your team to assess the patient completely. He is evaluated by standard trauma protocol. His vital signs are stable, and his neck and spine are determined to be without injury. Upon examination of his abdomen, you elicit a moderate amount of tenderness in the right upper quadrant. There is associated guarding, but no rebound. There is no flank ecchymosis or clinical suspicion of rib fractures. No abnormalities are noted on genital examination and no extremity fractures are appreciated. His serum chemistries and complete blood count are within normal limits. However, urinalysis (from a spontaneously voided specimen) is significant for 35 RBC, 3 WBC, negative leukocyte esterase, and negative nitrates. You are concerned about his right upper quadrant pain and elect to perform a CT scan. A CT scan of the abdomen and pelvis reveals a subcapsular hematoma with a superficial laceration of the right renal cortex. There is no extravasation of intravenous contrast from the right kidney. No free air is seen and no other organs appear to have any damage. The most appropriate way to manage this patient's renal injury is to
A. admit the patient for serial abdominal exams and blood counts
B. obtain an intravenous pyelogram
C. order a retrograde urethrogram
D. perform angiography of the right kidney
E. place a Foley catheter and perform bladder irrigation
F. surgically explore and evacuate hematoma

[riltsov]

A. admit the patient for serial abdominal exams and blood counts
Я думаю, что такую гематому следует вести консервативно. Поверхностное повреждение коркового вещества и микрогематурия это показание только для наблюдения за пациентом.

[yananshs]

The correct answer is A. This patient has a grade II renal injury. The kidney is the most common organ injured in the urinary system, with most injuries occurring from automobile accidents or sporting mishaps. Kidneys with pathological conditions such as hydronephrosis or malignant tumors are more readily ruptured from mild trauma. Blunt trauma is the most common mechanism of renal injury, causing 80-85% of all renal trauma. Gunshot and knife wounds are responsible for most penetrating renal trauma.Renal trauma can be classified as minor, major, and vascular and are rated from a grade I up to grade V. For minor injuries, a renal contusion of the parenchyma is the most common lesion, and usually associated with a subcapsular hematoma. A superficial cortical laceration may also be noted. These injuries rarely require surgical exploration. Major renal trauma occurs when lacerations extend deeply into the corticomedullary and collecting system tissue. This results in extravasation of urine into the perirenal space. Many of these injuries can also be managed conservatively, however, it is not uncommon to perform surgical exploration of the most serious injuries from this category. Vascular injuries to the renal pedicle are rare. It may be caused by total avulsion of the artery and vein or thrombosis secondary to stretching of the main renal artery. Vascular injuries are difficult to diagnosis and frequently result in total kidney destruction.

Intravenous pyelogram, or IVP, (choice B) is performed to establish the presence or absence of both kidneys, to define renal outlines and cortical borders, and to outline the collecting systems and ureters. All of these goals are reached with the CT scan you ordered for this patient. Therefore, an IVP is not indicated at this time. Prior to a CT scan, it was the method of choice for initial radiological imaging of kidneys suspected of traumatic injury.

A retrograde urethrogram (choice C) is performed in patients suspected of having a urethral injury. These patients typically have blood at the meatus, a perineal hematoma, a high riding prostate, a pelvic fracture, or a mechanism of injury suspicious for urethral damage. This patient does not meet any of these criteria. He also voided spontaneously, which is frequently not the case with urethral injury. His microscopic hematuria is from his renal injury.

Angiography (choice D) can be used to define the major arterial and parenchymal injuries of the kidney. In patients who are actively bleeding, this exam will also allow for embolization of a lacerated blood vessel. In this patient with a minor renal injury and stable vital signs, it is not indicated at this initial stage.

This patient has voided spontaneously with grossly clear urine. His hematuria is microscopic. There is no evidence that he has any bladder injury or that he is suffering from clot retention within his bladder. Therefore, there is no need to place a catheter or to irrigate his bladder (choice E).

Surgical exploration (choice F) is not indicated in a patient who is hemodynamically stable, has no other organ injury, and does not appear to have any evidence of continued bleeding. Attempting to evacuate this small hematoma is not necessary as this minor injury will most definitely remain stable and resolve on its own. For this reason, admitting the patient for serial evaluations is the most appropriate step in management. If the patient's injury continues to progress, it will manifest itself clinically with dropping hematocrit, worsening abdominal pain, and hemodynamic instability.

[Aladdyn]

Е. Противовоспалительная и бронхолитическая терапия не имеют смысла при постинтубационном стенозе трахеи. Показаний к интубации нет, да и технически интубация вероятно неосуществима, скорее постстеностическая трахеостомия. Наблюдение за пациентом с установленным диагнозом и явном отсутствии вожможности спонтанного разрешения клинической ситуации неоправдано.

[Aladdyn]

Перфоративный острый гнойный средний отит.

[yananshs]

Нет, тут немного сложнее.

[Aladdyn]

Да, отсутствие мало-мальской интоксикации и предшествовавших перфорации болей делает этот диагноз крайне маловероятным. Скорее, травматическая перфорация, обнаружены волокна ваты, видимо. Тогда А с возможным последующим Е, в зависимости от величины дефекта.