Детский вариант пилюльки

[Dr. W.N.]

В жизни - D, но Е здесь тоже наверное не просто так...

[Tim Vetrov]

Да уж, так и представляю фразу врача: "Успокойтесь, мамочка, сейчас направим report of the case to the child protective service agency, и все будет отлично!"

[dr.Ira]

Explanation:

The correct answer is D. This boy has a minor closed head injury with no loss of consciousness, which is one of the most common injuries in children. All children "bump" their heads at some point. It is important to do a physical examination, including a complete neurologic and funduscopic examination, and if this is normal, be able to recognize that further studies are generally not indicated. Regular monitoring and observation for any abnormalities can be done by a competent caregiver. If this occurred during the day, you may consider having them stay in your waiting room for a little while, but since you are leaving for the night and the mother has always been responsible and compliant, you can send them home for observation.

It is inappropriate to advise them to go to the emergency department for observation (choice A). This child had a minor head injury with no loss of consciousness and he has a normal neurologic and funduscopic examination. It is very unlikely that he has an intracranial injury, and therefore, as long as you know that the mother is a competent caretaker, you should send them home after advising her to seek assistance if he begins to deteriorate.

It is unnecessary to obtain a skull radiograph (choice B) at this time in this child with a minor closed head injury without a loss of consciousness. He does not have any signs of a skull fracture, which include battle signs (ecchymoses behind the ear), a palpable depression, or blood in the ear and therefore it is very unlikely that the radiograph will show a skull fracture. Also, even if he did have a skull fracture that does not necessarily mean that he has an intracranial injury.

A CT scan (choice C) is not indicated at this time in this patient with a minor closed head injury, no loss of consciousness, and a normal neurologic and funduscopic examination. Studies have shown that the risk of intracranial injury is negligible in this situation, and that fewer than 1 in 5,000 patients with minor closed head injuries and no loss of consciousness have intracranial injuries that require medical or neurosurgical intervention.

Since this case states that they are very healthy and compliant patients and the physical exam does not reveal any abnormalities besides this head wound that seems consistent with the story the mother told you, it is inappropriate to report the case to the child protective service agency (choice E). It is always important to be aware of signs of child abuse, such as many emergency room visits, many wounds in various stages of healing, implausible and inconsistent stories, and bringing the child in a while after the injury took place. This case does not seem to fit this description

[dr.Ira]

A 6-year-old boy is brought to the office by his parents who are concerned because he has been refusing to use his left arm for 1 day. The parents report that he has been in good health and has not suffered any recent falls or injuries to the arm that they are aware of. The father does recall one incident 2 days ago when he pulled upward on the boy's right arm to prevent him from tripping as they descended a flight of stairs. The boy is holding his right arm with the elbow flexed and the forearm pronated. He begins to cry when you attempt to examine the arm. The most appropriate next step is
A. closed reduction and cast immobilization
B. a CT of the right arm
C. measurement of compartment pressure of the forearm
D. supination of the forearm with the elbow flexed
E. a trial of compressive bandage on the right arm

[riltsov]

Вывих локтевого сустава.
A. closed reduction and cast immobilization

[denis_doc]

A. наиболее вероятно.

[antibiotik]

Д. Иммобилизации не нужно, наоборот, нужно давать ребенку игрушку, чтобы оценить движения в конечности, и, следовательно эффективность манипуляции.
Дз: подвывих головки луча.

[Nancy]

А нельзя рентген сделать?)))
Можно попробовать пункт Е, а потом сделать снимок.

[dr.Ira]

Explanation:

The correct answer is D. This boy has the signs and symptoms of a very common injury in little children. "Nursemaid's elbow" or subluxation of the radial head, which occurs when there is longitudinal traction on the pronated extended elbow. This traction can cause the radial head to slip from beneath the annular ligament. Children will often refuse to move the arm following this injury. X-rays of the forearm and elbow are usually normal and treatment involves supination of the forearm with the elbow flexed. Recurrence is uncommon and no immobilization of the affected arm is necessary.

Closed reduction and cast immobilization (choice A) is necessary for fractures of the forearm, not for subluxation of the radial head. Fractures of the forearm are also very common in children, but usually have an antecedent history of fall or injury.

Obtaining a CT of the right arm (choice B) is not necessary for this patient. X-rays of the right arm can be done to rule out a fracture or hemarthrosis. A CT of the extremity is sometimes performed if the x-ray demonstrates a fracture. The history given by the boy's parents and the boy's presenting symptoms strongly suggest subluxation of the radial head. X-rays of the forearm and elbow are usually normal in this setting and are not necessary to make the diagnosis.

There is no reason to suspect compartment syndrome (choice C) in this child. Signs of compartment syndrome include severe pain in the limb especially with active or passive stretching of the ischemic muscle, cyanosis, and numbness. This syndrome is an uncommon complication of any traumatic injury to the extremities. Subluxation of the radial head is not associated with compartment syndrome.

A trial of a compressive bandage (choice E) is not necessary in this patient. Supination of the forearm should reduce the subluxation of the radial head. Compressive bandages or immobilization are not necessary after reduction of the subluxation.

А, кстати, что не совсем типично в условии в этой задачке?

[antibiotik]

Кстати да, совсем не посмотрел на возраст ребенка, 6 лет, обычно такая травма у детей в полтора-два года.

[dr.Ira]

Я нашла в сети вариант экзамена на Step.3 Два минуса: он на каком-то Acrobat'е, поэтому скопировать через copy-paste не получается. И второй минус - правильные ответы есть, но без объяснений.
Я на работе уже второй день эти задачки отгадываю (и не без удовольствия ).
Если хотите, могу по нескольку штук выкладывать и здесь.

[Dr.Nathalie]

Ира! Для того, чтобы скопипастить из акробата, нажми на кнопку TEXT в меню, тогда дурацкая "ладошка" исчезнет, и ты сможешь выделить и скопировать любой текст.

[dr.Ira]

Thanks! Завтра попробую.

[dr.Ira]

Наталья, тебе отдельное спасибо!
Выкладываю первые 10 вопросов. Дерзайте! (с)

1. A 21-year-old man comes to the clinic because he has become increasingly short of breath and has had a cough for the past week.
He appears dyspneic and has a temperature of 38.3EC (101.0EF). On physical examination he has bibasilar rales and generalized
lymphadenopathy (1 to 2 cm). Rectal examination shows multiple perianal contusions and a small amount of blood oozing from the
anal orifice. Chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate course of action is to order blood tests
and to do which of the following?
(A) Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
(B) Admit him to the hospital and begin administration of penicillin and gentamicin, intravenously
(C) Begin administration of erythromycin, orally, and see him again the next day
(D) Prescribe isoniazid and rifampin, orally
(E) Recommend aspirin, fluids and rest at home

2. A 17-year-old white girl returns to the health center for a family planning follow-up visit. She gave birth to a healthy baby girl 8
months ago and does not want to become pregnant again. She is monogamous with the father of her baby but worries that he is not
monogamous with her. They live together and are not married. She is taking an oral contraceptive and "sometimes" uses condoms.
She says that she has great trouble remembering to take her pills and wants to discuss other contraceptive options. In addressing this
issue, which of the following is the most appropriate next step?
(A) Advise her to continue taking an oral contraceptive because it is one of the most effective methods of birth control
(B) Advise her that an intrauterine device would be a good contraceptive choice for her
(C) Discuss implantable or injection long-term progestational contraceptive agents
(D) Discuss the option of tubal ligation
(E) Fit the patient with a diaphragm and instruct her on proper use

3. A 19-year-old African-American college student comes to the student health center because of marked fatigue. Temperature is
38.3°C (101.0°F). Physical examination shows striking pallor of skin, nail beds and conjunctivae. There are petechial hemorrhages
in the skin of his legs. A soft, blowing systolic murmur is present over the precordium. No other abnormalities are present. Which
of the following is the most appropriate study at this time?
(A) Complete blood count
(B) Determination of bleeding and clotting time
(C) Examination of bone marrow aspirate
(D) Hemoglobin electrophoresis
(E) Serological testing for infectious mononucleosis

4. A 12-year-old girl is referred to the clinic by the school nurse for evaluation of scoliosis. The girl's scoliosis was detected during a
routine screening examination at the school, and it appears to be mild (curve less than 10 degrees). She is athletic and is otherwise
in good health. During the physical examination, particular attention should be given to which of the following?
(A) Arm length
(B) Blood pressure
(C) Body weight
(D) Cardiac examination
(E) Stage of pubertal development

5. A 10-month-old infant is brought to the health center by his mother because of eight watery bowel movements during the past
24 hours. On physical examination the infant is lethargic and somnolent. The mucous membranes are dry and the skin turgor is
poor. The anterior fontanel is sunken. At his last visit 2 weeks ago, he weighed 10 kg (22 lb); today his weight is 9 kg (20 lb). His
temperature is 37.2EC (99.0EF), pulse is 170/min and blood pressure is 100/60 mm Hg. Which of the following is the most
appropriate next step in management of this infant?
(A) Begin intravenous hydration with isotonic saline solution
(B) Educate the mother on how to recognize dehydration and worsening clinical symptoms in her infant
(C) Obtain serum electrolyte concentrations and begin oral rehydration therapy
(D) Obtain a stool culture and begin amoxicillin therapy
(E) Tell the mother to stop breast-feeding and have her give the infant a soy-based formula

[dr.Ira]

43
A 45-year-old woman is brought to the health center by her husband because of nausea, confusion, chills, fever, flank pain and cloudy
urine. She has a history of insulin-dependent diabetes mellitus, poorly controlled hypertension and recurrent urinary tract infections. Her
vital signs are:
Temperature 40.0°C (104.0°F)
Pulse 120/min
Respirations 24/min
Blood pressure 110/70 mm Hg
Funduscopic examination shows diabetic retinopathy, which is unchanged from the previous examination. Neck is supple. Lungs are clear
to auscultation and percussion. Examination of the abdomen is normal. Marked pain is present at the right costovertebral angle. Several
hemorrhagic bullous lesions are noted on the extremities.
6. Without prompt and aggressive treatment, this patient is most likely to develop which of the following?
(A) Diabetic ketoacidosis
(B) Hyperosmolar coma
(C) Meningitis
(D) Pneumonia
(E) Septic shock

7. If this patient were to develop anuria, which of the following would be the most likely cause?
(A) Acute papillary necrosis
(B) Bladder outlet obstruction
(C) Neurogenic bladder
(D) Renal lithiasis
(E) Tumor encroachment on the ureters
END OF SET

8. A 23-year-old registered nurse comes to the employee health clinic because she says, "I'm too tired to work." She has had
increasing fatigue, malaise and anorexia during the past several days. Laboratory studies show:
Serum Blood
ALT 1160 U/L PT 13 sec
Bilirubin 1.8 mg/dL
HBsAg Positive
She is instructed to rest at home and return in 3 days if no new symptoms develop. Two days after the visit she calls to say that she
has now developed an urticarial rash and swelling of the joints of her fingers. At this time which of the following is the most correct
statement about her condition?
(A) The arthritis and rash are the result of an associated immune complex disorder
(B) The arthritis and rash are unrelated to her liver disease
(C) It is unlikely that her blood is infectious
(D) She has a 50% risk for developing chronic liver disease
(E) She should be given hepatitis B immune globulin

9. A 47-year-old Italian-American man comes to the office for the first time for routine medical care. He has been referred to you by
his psychiatrist who has informed you that the patient has paranoid personality disorder. The patient has no other medical problems
at this time. He is unmarried, lives alone and has no close friends, but he occasionally attends family gatherings. He functions well
working alone in a technical position in an engineering firm. Which of the following is the best way to structure the
physician-patient relationship with this patient?
(A) Avoid giving him excessive details about possible, but infrequent, side effects and complications in order to avoid
triggering his paranoia
(B) Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional,
but not overly friendly stance
(C) Go out of your way to be warm and friendly so that he can develop trust in you
(D) Have his psychiatrist, with whom he has been working for several years, take the lead in presenting medical treatment
options
(E) Try to communicate with his family or medical personnel when he is not present in order to overcome his withholding
information because of distrust

10. A 12-month-old boy is brought to the office by his mother for his routine health check-up. She informs you that she has just been
diagnosed with hypercholesterolemia. Her fasting serum total cholesterol concentration was 260 mg/dL and her LDL-cholesterol
concentration was 130 mg/dL (rec<129 mg/dL). She is unaware of a family history of coronary artery disease because she was
raised by her godmother when her parents died in their early 30s in a motor vehicle accident. A special diet has been recommended
for her; however, she is very concerned about the risk of hypercholesterolemia for her son. Which of the following is the most
appropriate management at this time?
(A) Ask her to reduce the child's fat intake and give him skim milk instead of whole milk
(B) Do nothing until the child is 2 years of age
(C) Have the child return for a fasting lipoprotein analysis
(D) Obtain a random serum total cholesterol concentration for the child today
(E) Refer the child to a lipid specialist