Еще одна пилюлька Hескучина

[riltsov]

Аспирационная пневмония, обусловленная анаэробами из полости рта.
(B) Pneumonia secondary to anaerobes

[Dr.]

Конечно В. Буду искать что-то жестокое. Ща...

[Dtver]

А что там с задачей от уважаемой Яны (которой, кстати, огромное спасибо за тему) за № 654?
По мне, так Д, но хотелось бы с комментариями

[yananshs]

Сообщение от Dtver

А что там с задачей за № 654?
По мне, так Д, но хотелось бы с комментариями

The correct answer is D. The patient is a young male involved in a motor vehicle accident with evidence of head trauma. On initial observation, the patient appeared to be stable and his coma score was within normal range. The major injury seemed to be his left leg fracture and possible laceration of his femoral artery. As he was to undergo angiography of the left leg, he had an abrupt change in his mental status. The elevated blood pressure, respiratory irregularities (Cheyne-Stokes breathing), and the bradycardia are evidence for increased intracranial pressure (Cushing triad). The fixation and dilation of the right pupil suggest possible uncal or brainstem herniation. The first step is to immediately intubate the patient for airway control as the patient's brainstem is at risk. Secondarily, intubation and hyperventilation can reduce cerebral blood flow and attenuate increasing intracranial pressure. The next step is to reduce intracranial pressure to prevent further herniation with administration of one bolus dose of mannitol. And lastly, a head CT is required to determine the type of trauma, such as a hemorrhage, and to distinguish if the case is operable or not.

The change in mental status and the vital signs are indicative of increased intracranial pressure, and it is imperative to reduce cerebral blood flow to limit the increase. Intubation and hyperventilation can cause a limited reduction in intracranial pressure. Mannitol must be administered next, to effectively decrease the pressure further before any other intervention to prevent additional herniation. This is the emergency treatment that must be done before he has the CT scan. Therefore, a CT scan of the head, intubation, mannitol administration (choice A) and intubation, CT scan of the head, mannitol administration (choice C) are the correct interventions in the wrong order.

CT scan of the head, phenytoin bolus, thiamine (choice B) is inappropriate because intubation is always the first step in this situation for airway control. This choice omits this step as well as mannitol administration.

Intubation, mannitol administration, MRI of the head (choice E) is inappropriate because this choice includes a head MRI instead of a CT scan. An MRI is a longer procedure, and for the initial evaluation and decision for surgery a non-contrast head CT scan is sufficient.

[yananshs]

A 60-year-old man with diabetes mellitus, hypertension, hyperlipidemia, and chronic renal insufficiency is admitted to the hospital because of lightheadedness. His medications include NPH insulin, amlodipine, and simvastatin. He is allergic to penicillin to which he gets an angioedema. His temperature is 37.1 C (98.8 F), blood pressure is 98/65 mm Hg, pulse is 87/min, and his respiratory rate is 22/min. On exam, he is ill appearing. His cardiac rhythm is regular and breath sounds are clear bilaterally. His abdominal exam is benign. A chest radiograph shows clear lungs. An electrocardiogram shows a sinus rhythm with peaked T waves. Laboratory studies show a serum sodium of 134 mEq/L, glucose of 98 mg/dL, and potassium of 6.2 mEq/L. The most appropriate intervention at this time is
A. administration of glucose, orally
B. administration of insulin and glucose, intravenously
C. administration of furosemide, orally
D. administration of ringers lactate, intravenously
E. administration of sodium chloride, intravenously

[papadoctor]

>>B<<

[Gilarov]

В, у него гиперкалиемия

[vosk]

гиперкалиемия по ЭКГ и крови. инсулин с глюкозой в самый раз. фуросемид наверно будет не так быстро, да и непонятно как там будет при ХПН
B. administration of insulin and glucose, intravenously
Dmitry Voskovets

[riltsov]

Уважаемая Яна Сергеевна. Выложите, пожалуйста, ответ на последнюю задачку про гиперкалиемию. Очень интересно почитать комментарии.

[yananshs]

OK
The correct answer is B. Hyperkalemia with electrocardiographic changes (peaked T waves) requires immediate medical treatment to prevent the onset of hyperkalemia-induced dysrhythmias. Administration of insulin intravenously causes serum potassium to move intracellularly, acutely reducing serum potassium. Glucose is co-administered to prevent insulin-induced hypoglycemia.

Oral glucose (choice A) is of no utility in the treatment of hyperglycemia. Even when insulin is used for the treatment of hyperkalemia, glucose should be co-administered intravenously.

Oral furosemide (choice C) is an appropriate choice for the long-term treatment of hyperkalemia, i.e., once the acute hyperkalemia has been treated. Interventions such as insulin and glucose simply cause the potassium to shift intracellularly. Its excretion can then be promoted by administration of diuretic agents such as furosemide.

Ringers lactate (choice D) should be avoided with hyperkalemic patients since it contains potassium as a constituent (4 mEq/L).

Sodium chloride (choice E) is not useful in the management of hyperkalemia

[yananshs]

A 72-year-old man is admitted to the hospital because of increasing left-sided ear pain, low-grade fever, and purulent ear discharge. He treated himself with antibiotic eardrops that he had at home and noticed some initial relief of symptoms, but for the past day the pain has been getting worse and the purulent discharge from the left ear is increasing. He also reports severe left-sided headaches early in the mornings. His medical history is significant for diabetes mellitus, which is well controlled with insulin. He reports that he has had previous left ear infections, which were treated with antibiotic eardrops and occasional oral antibiotics. His temperature is 38.1 C (100.6 F), blood pressure is 140/76 mm Hg, and pulse is 84/min. There are no palpable lymph nodes on the neck or in the supraclavicular region. There are no neurological deficits on his face. His right ear on otoscopic examination is found to be normal. The left ear is tender on manipulation and there is a purulent discharge coming from the external auditory meatus. On clearance of the discharge from the left external auditory meatus, the canal is noted to be swollen and the eardrum cannot be appreciated. There is no associated mastoid tenderness. The most appropriate management is to
A. begin therapy with antibiotic eardrops
B. begin therapy with antibiotic eardrops and oral antibiotics
C. order a CT scan with contrast
D. provide therapy with intravenous antibiotics and watch for improvement
E. send a culture of the ear, irrigate with hydrogen peroxide, and provide acetic acid drops

[Alexey D]

A и В наверняка не подходят, так как он уже закапывает капли. D звучит как-то подозрительно ("watch for improvement"). Может С, чтобы определиться?

[riltsov]

Сильная головная боль и особенности течения заболевания (ухудшение после первоначального улучшения) свидетельствуют о возможных осложнениях. Я бы начал с обследования головы.
C. order a CT scan with contrast

[Anna_Shvedova]

Я тоже за С. Тем более, что диабет у него.

[vosk]

судя по тому, что eardrops оказались малоэффективными, и учитывая клинику, ему требуется системное применение антибиотиков. почему бы их не начать перед выполнением СТ.
B. begin therapy with antibiotic eardrops and oral antibiotics
dmitry voskovets