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#481
10.08.2006, 21:48
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D. Well-established gynecologic benefits include a reduction in dysmenorrhea and menorrhagia, iron-deficiency anemia, ectopic pregnancy, and PID.
[Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] Не очень шикарный был вопрос. Sorry.  The correct answer is D. OCPs have many beneficial effects, and one is that they decrease the risk for PID. This is thought to be due to the effects that OCPs have on the endometrium and cervix leading to increased endocervical mucus that resists the spread of gonococcal infection from the cervix to the endometrium and then the fallopian tubes. OCPs have been associated with an increased risk of chlamydial infections and therefore, condoms SHOULD be used to prevent chlamydial infections (choice A). This increased risk may be associated with the fact that OCPs widen the ectocervix , increasing the area of mucus-secreting cells and making the individual more susceptible to chlamydial infections. It is incorrect to inform her that her menstrual periods will become longer and heavier (choice B) because OCPs are typically associated with shorter, less painful, and scanty menses. Smoking in women that are over the age of 35 is a relative contraindication to the use of OCPs. While smoking may increase the risk of complications in women under 35, it is not a contraindication to their use. You should advise her that it is best if she quits (in general and because of the OCPs), but it is not correct to inform her that she must stop smoking before you prescribe oral contraceptive pills (choice C). Oral contraceptive pills have been associated with a decreased risk for ovarian cancer, not an increased risk (choice E). 
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#482
10.08.2006, 21:55
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Да уже, вопрос из серии "тест всегда прав"...
Озадачены были все, мне кажется. Я так вообще на грани шока. Непонятно, какой конструктивный смысл обсуждать подобные вещи с пациенткой? Что, получая противозачаточные таблетки, она не рискует получить гонококковую инфекцию? Мне кажется, что презерватив в этом смысле намного надежнее. В общем, какая-то непонятная ерунда.
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#483
10.08.2006, 22:59
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A 79-year-old man with a history of colon cancer comes to the emergency department because of right lower extremity pain below the knee, which is worse with ambulation for the past 4 hours. He has never had a pain like this before and rates the pain as 9/10 in intensity below the knee. He denies shortness of breath. Physical examination is significant for absent dorsalis pedis and posterior tibial pulses in the right lower extremity. The right foot and leg is cold with 1+ edema on all aspects of the leg and foot. All other pulses are 3+. Electrocardiogram demonstrates occasional premature ventricular contractions at a rate of 79/min. An abdominal plain film is normal. The next step in the management of this patient is to
A. initiate heparin therapy, intravenously B. initiate heparin therapy, intravenously, and prepare him for a surgical embolectomy C. order an ultrasound of the left leg D. prepare him for a surgical embolectomy E. provide symptomatic treatment with oxycodone
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#485
10.08.2006, 23:28
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Цитата:
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#486
10.08.2006, 23:44
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Тоже думаю, что В. Все-таки, крупный сосуд перекрыт.
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#487
10.08.2006, 23:55
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Почему не D:
Patients presenting with acute limb ischemia secondary to thromboembolic arterial occlusion usually receive prompt anticoagulation with therapeutic dosages of UFH in order to prevent clot propagation and to obviate further embolism. The logic of this common clinical practice is not questioned, even though no formal studies have established unequivocally a beneficial role of any antithrombotic agent in patients with acute embolic occlusion. The expected adverse effect of perioperative anticoagulant therapy is an increased risk of wound complications, particularly hematomas. Из [Ссылки доступны только зарегистрированным пользователям ]
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#488
11.08.2006, 02:43
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Цитата:
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#489
11.08.2006, 03:25
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Уважаемый коллега,
Мне кажется что с тромболизисом не так все однозначно в данной ситуации, хотя бы согласно этому: EMBOLI IN NORMAL LIMB ARTERIES: The majority of patients should have high quality vascular imaging before any intervention. However, in some cases, the clinical diagnosis of arterial embolism in the leg may be suggested on the basis of the following criteria: (1) sudden onset of clinical symptoms, (2) presence of embolic source, (3) absence of preceding claudication, and (4) presence of normal pulses and Doppler systolic blood pressures in the unaffected limb. Patients fulfilling these criteria and presenting with an acutely ischemic (white) leg due to a proximal embolus require emergency thromboembolectomy. This is usually through surgical intervention, but thrombolysis and, if necessary, surgical reconstruction could also be employed. Из J Vasc Interv Radiol. 2003 Sep;14(9 Pt 2):S337-49. Thrombolysis in the management of lower limb peripheral arterial occlusion--a consensus document.
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#490
11.08.2006, 05:15
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Абсолютно разумное замечание! Но в госпитале с активной сосудистой программой HQ vascular study можно сделать 24х7 и у представленного больного я не вижу явного источника эмболизации.
Еще раз повторюсь, что это студентческий вопрос по базисному уровню знаний, и скорее всего от нас требуется начать гепарин по номограмме и позвать сосудистого хирурга, т.е. В
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#491
11.08.2006, 06:59
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Согласен, что задачка исключительно академическая, поэтому включены все консесуальные критерии, что бы без HQ vasc. imaging приступить к интервенции:
(1) right lower extremity pain below the knee, which is worse with ambulation for the past 4 hours (2) history of colon cancer (3) never had a pain like this before (4) All other pulses are 3+ Дабы только был один правильный вопрос - тромболизис исключен. Цитата:
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#492
11.08.2006, 13:49
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Цитата:
P.S. А, риск PID. Ну да, там же какой-то хитрый механизм уплотнения этой слизистой пробки что ли
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#493
11.08.2006, 14:45
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Цитата:
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#495
11.08.2006, 15:52
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Ответ, наверное, опять никому не понравится. Пора другие задачки искать.
The correct answer is B. This patient is likely having an acute arterial occlusion leading to a cold, pulseless foot. This patient is at risk for arterial insufficiency because of a history of malignancy. Treatment is emergent and consists of immediate heparin and surgical embolectomy. Heparin (choice A) will stop further clots from forming, but it will not dissolve the clot that is causing this limb-threatening circulatory compromise. This patient is likely having an acute arterial occlusion leading to a cold, pulseless foot. This patient is at risk for arterial insufficiency because of a history of malignancy. Treatment is emergent and consists of immediate heparin and surgical embolectomy. An ultrasound (choice C) should only be attempted in a non-emergent setting, such as if pulses were still present, but reduced or normal with complaints of pain. As surgical embolectomy (choice D) in this patient is not sufficient, heparin therapy must also be started to avoid further clot formations in this oncology patient. Symptomatic treatment alone (choice E) will likely lead to the loss of the threatened limb. This patient is likely having an acute arterial occlusion leading to a cold, pulseless foot. This patient is at risk for arterial insufficiency with her history of malignancy. Treatment is emergent and consists of immediate heparin and surgical embolectomy.
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