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#1171
07.02.2007, 09:28
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A 64-year-old African American man comes to the clinic for a periodic health maintenance examination. He is currently asymptomatic, has no significant past medical history, and takes no medications. He is married with 2 children, works as an accountant, and does not smoke. He drinks 5 alcoholic drinks per week. This patient is most at risk for
A. accidental trauma B. coronary artery disease C. head-and-neck cancer D. Human Immunodeficiency Virus (HIV) E. osteogenic sarcoma F. suicide 
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#1172
07.02.2007, 18:11
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Вот это вопрос! Идеальный 64-летний афроамериканский бухгалтер. Я бы всё ж таки ответил В - по крайней мере возраст и пол как факторы риска ИБС никуда не денешь.
Ну еще есть вариант, что его трактор забодает на шумной Нью-Йоркской улице (А), но в Америке же все такие дисциплинированные!  А с крыши сарая прыгать - возраст не тот.
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#1173
07.02.2007, 18:36
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Думаю, скорее всего, B.
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#1175
07.02.2007, 22:29
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Недавно вопрос о роли алкоголя в развитии head-and-neck cancer обсуждался в задачке от уважаемого коллеги AlexMD.
Ответ - C. head-and-neck cancer
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#1177
08.02.2007, 06:41
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Меня подвела моя невнимательность.... необратил внимание на то, что пациент принимает 5 дриньков в неделю, а не в день. При такой микроскопический дозе алкоголя, трудно говорить о каких-либо его негативных последствиях.
Остается ответ В.
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#1178
08.02.2007, 18:12
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Цитата:
V takom vozraste pri ljubom rasklade- hot' pej kovshami- hot' v benzole kupajsja- risk raka budet nizhe riska IBS ... 
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#1179
09.02.2007, 07:34
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The correct answer is B. Coronary artery disease is the most prevalent disease in this age group. Cancer is also prevalent in this age group with lung, prostate, and colon cancer being the most common. Keep in mind the difference between prevalence and incidence when answering this sort of question. Prevalence is the percent of a given population effected at any given time. Incidence is the number of new cases arising for a period of time.
Accidental trauma (choice A) is the leading cause of death in the under 30 age group. HIV (choice D) is prevalent in younger populations particularly in groups that have multiple sexual partners and use intravenous drugs. Head-and-neck cancer (choice C) is one of the most common causes of cancer-related death, but would be less common than coronary artery disease in this age group. Osteogenic sarcoma (choice E) occurs in the second to fifth decades of life in long tubular bones and would be relatively rare in this population. Suicide (choice F) is second only to accidental trauma as the cause of death in the under 30 age group.
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#1180
09.02.2007, 07:35
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A 57-year old woman comes to the emergency department because of a "very high fever." She has diabetes mellitus and hemodialysis-dependent renal failure. She also has hypertension and is status-post total abdominal hysterectomy. She is frail appearing and diaphoretic. Her blood pressure is 170/90 mm Hg and temperature is 38.3 C (101.0 F). Her neck is supple without any specific meningismus. She has a Tesio catheter in her left subclavian vein. Her lungs are clear and she has no costovertebral angle tenderness. Her laboratory studies show a white blood cell count of 23,000/mm3 and a hematocrit of 31%. Her urinalysis is dipstick negative for white blood cells. The most appropriate next step in management is to
A. begin antibiotic therapy with gentamycin B. begin antibiotic therapy with vancomycin and gentamycin C. order urinalysis analysis and culture D. perform a lumbar puncture and send CSF for analysis and culture E. schedule emergent surgical removal of her Tesio catheter
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#1181
09.02.2007, 09:26
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Варианты C. и D. отпадают, т.к. нет оснований делать посев мочи и пункцию, и нет времени ждать результатов этих обследований. Нужно что-то делать прямо сейчас.
Можно рассмотреть варианты A, B. и E. Вариант А отпал, назначение гентамицина неоправданно в такой ситуации. Вариант B. весьма привлекательный. У пациентки с диабетом и ХПН, находящейся на гемодиализе, высок риск внутрибольничной инфекции, в том числе обусловленной MRSA. Однако, где могут быть входные ворота инфекции? Tesio catheter! Выбираю ответ E. schedule emergent surgical removal of her Tesio catheter
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#1183
09.02.2007, 13:01
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Цитата:
во всяком случае- так практичнее. ...не знаю только, кто писал этот тест- инфекционист или нефролог.
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#1184
09.02.2007, 17:10
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The correct answer is B. Infection is the most common cause of death in patients with chronic renal failure. This is followed closely by cardiovascular events. The etiology of increased risk of infection is multifactorial and involves a complex interplay of decreased immune response and complement activation by dialysis membranes all coupled with long-term indwelling components such as catheters. When a dialysis patient presents with infection, the first step in their management is to initiate broad antibiotic coverage based upon the likely causative organisms. This patient has an indwelling catheter and therefore has an increased risk of infection with both coagulase-positive and coagulase-negative Gram-positive cocci. Given the large percentage (25% at most centers) of methicillin resistant Staphylococcus aureus (MRSA), vancomycin is usually initiated until sensitivity data is available. An aminoglycoside is usually added to cover for very common Gram-negative infections.
Begin antibiotic therapy with gentamicin (choice A) is inadequate since the majority of infections in patients such as these will not be covered by an aminoglycoside alone. Sending her urine for analysis and culture (choice C), although prudent, to perform this with a negative urine dipstick for WBCs, will not change your initial management and decision to cover the patient with broad spectrum antibiotics. Performing a lumbar puncture and sending a CSF for analysis and culture (choice D) implies meningitis as a cause for the fevers. Meningitis is a rare cause of fevers generally. And although dialysis patients are at mildly increased risk of meningeal infections, in the absence of localized signs and symptoms, the likelihood of meningitis is very low and therefore the risk of an LP is not warranted. Schedule emergent surgical removal of her Tesio catheter (choice E) is not an appropriate initial management step in a febrile patient. This may be indicated later in the course of care, but concern over removal before antibiotics have begun, is not appropriate.
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#1185
09.02.2007, 17:11
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A 58-year-old alcoholic with hepatitis C cirrhosis is admitted to the hospital for management of his ascites. He has been managed as an outpatient with diuretics and oral lactulose, but over the past few weeks, he reports increasing abdominal girth, weight gain and lower extremity edema. He has been noncompliant with his low-sodium diet. His medications include furosemide, spironolactone, lactulose, ciprofloxacin, and thiamine. On physical examination, he appears grossly edematous and appropriately responsive. His lungs are clear and his heart is without extra sounds or murmurs. His abdomen is tense with a fluid wave and shifting dullness on percussion. He has numerous non-blanching telangiectasias on his torso and abdomen. His testes are small for his age and there is no asterixis. Admission laboratory studies show:
Sodium 121 mEq/L Potassium 4.3 mEq/L Bicarbonate 29 mEq/L BUN 38 mg/dL Creatinine 1.5 mg/dL Urinalysis shows some granular casts and a urinary sodium concentration of <10 mmol/L. The most appropriate therapy is to A. administer hypertonic saline B. administer sodium chloride tablets C. increase the dose of furosemide D. increase the dose of spironolactone E. salt restrict
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