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#511
15.08.2006, 17:33
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A 61-year-old woman with chronic renal insufficiency due to long-standing diabetes mellitus comes to the office with a fever, cough, shaking chills, and fatigue. She has long-standing diabetes mellitus with her last hemoglobin A1C being 9.1%, BUN 51 mg/dL, and creatinine 2.1 mg/dL. A chest radiograph demonstrates a right lower lobe infiltrate. Oral antibiotics are prescribed for the patient. The most correct statement concerning a diabetic patient with an infectious process is:
A. Antimicrobial dosing must be adjusted due to decreased liver function B. Antimicrobial dosing must be adjusted due to decreased renal function C. Diabetics have the same epidemiology of pulmonary infections as non-diabetics D. It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics E. Oral antibiotics are not efficacious for treating pneumonia in diabetics 
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#513
15.08.2006, 22:04
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Я тоже за В, хотя мг/дл сбивают меня с толку.
И хочется такую женщину госпитализировать и полечить ее пневмонию в стационаре - может быть, это у меня неправильный подход к госпитализациям, обусловленный российскими реалиями?
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#514
15.08.2006, 22:42
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У нее умеренно выраженная почечная недостаточность. Стоит назначать антибиотики не требующие коррекции дозы (хотя это и не обязательно). Я бы назначил моксифлоксацин или азитромицин. Этиология пневмонии у диабетиков и не диабетиков вроде бы не отличается, но риск развития тяжелой пневмонии у диабетиков выше. Поэтому мой ответ - С.
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#515
15.08.2006, 23:58
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про статистику пневмоний у диабетиков и недиабетиков к сожалению ничего не знаю. про функцию печени вроде ничего не говорится. поэтому отвечу "В"
Dmitry Voskovets
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#516
16.08.2006, 03:58
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Голосую за "В" - calculated GFR (glomerular filtration rate) 25мл/мин, что соответствует тяжелой почечной недостаточности (можно начинать диализ при GFR меньше 15мл/мин). Препараты выбора при пневмонии у диабетиков - фторхинолоны с расширенным спектром действия в отношении S.pneumoniae (левофлоксацин, гатифлоксацин), их дозировка требует коррекции при ХПН. Моксифлоксацин - исключение, не требует коррекции дозы
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#517
16.08.2006, 18:47
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The correct answer is B. All drugs (substances in general) are eliminated from the body by means of either renal or hepatic clearance or both. This is one of the most important concepts known by physicians. Almost every patient that presents to inpatient medical services today has some impairment of one or both of these mechanisms. This must be kept in mind when prescribing any drug. In the case of this patient, renal antibiotic dosing schedules for variable renal function are available to every student and house officer and should be consulted regularly. This patient has a creatinine of 2.1 mg/dL, reflecting abnormal renal function.
Antimicrobial dosing must be adjusted due to decreased liver function (choice A), although true as a general rule, is not particularly relevant to diabetics since their disease has no impact on liver function. We have no specific evidence that this patient has impaired hepatic function. Diabetics have the same epidemiology of pulmonary infections as non-diabetics (choice C) is incorrect as diabetics are more likely to suffer from Staphylococcus aureus and fungal pneumonia. It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics (choice D) is incorrect. Although certain patient populations tend to have anatomical variation in the location of their pneumonia, the common relationship between all of them is that they suffer from some sort of aspiration. Examples include intubated patients on mechanical ventilation and alcoholics. Diabetics are not included in this group. Oral antibiotics are not efficacious for treating pneumonia in diabetics (choice E) is false. Oral antibiotic efficacy is determined by the causative organism and location of the infection. Some specific dysfunctions such as gastric achlorhydria or bowel obstruction may interfere with oral efficacy, but not simply the presence of diabetes. Being a diabetic may make one prone to more malignant infections. There is no data that initial treatment of community acquired pneumonia in diabetics should be any different when compared to non-diabetics.
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#518
16.08.2006, 18:48
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A 12-year-old girl is brought to the office by her mother with complaints of foul smelling discharge, and hearing loss in left ear for the past few days. The girl has no past medical history. She underwent an uneventful appendectomy at the age of 9, after which she was discharged from the hospital within 3 days. On examination, the girl is afebrile with normal vital signs. Head and neck examination did not reveal any abnormalities. Examination of the left ear shows purulent discharge in the external auditory canal. After clearing the external auditory canals, otoscopic examination shows a perforation in the pars flaccida. Apart from the perforation, small bits of amorphous white debris are also found in the left ear. Examination of the right ear is normal. Appropriate management of this patient's condition is
A. antibiotic eardrops, decongestants, and follow-up in 4 weeks B. mastoidectomy C. oral antibiotics and follow-up in 2 weeks D. reassurance and follow-up in 3 weeks E. tympanoplasty
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#524
16.08.2006, 23:59
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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.
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#525
17.08.2006, 00:14
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Q-tip.
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Линейный вид
