General-Principles-Main一般性治疗-11-20

GeneralPrinciplesMain.11-20Q1Whileworkingon-siteatafactorydoingphysicalexaminationsforworkers，aphysicianissuddenlycalledtohelpaworkerwhoamputatedhisfinger.Whichofthefollowingisthemostappropriatenextstepinmanagementinthissituation?A.PlacetheamputatedfingerinaplasticbagwithwaterandbringitalongwiththepatienttotheemergencydepartmentB.Placetheamputatedfingerinaplasticbagwithalcohol;placethebagonabedoficeandbringitalongwiththepatienttotheemergencydepartmentC.Placetheamputatedfingerinsalinemoistenedgauzeinaplasticbag;placethebagonabedoficeandbringitalongwiththepatienttotheemergencydepartmentD.PlacetheamputatedfingerinantisepticsolutionandbringitalongwiththepatienttotheemergencydepartmentE.PlacetheamputatedfingeronabedoficeandbringitalongwiththepatienttotheemergencydepartmentA1Correctanswer:CExplanation:Allpatientssufferingtraumaticamputationsshouldbetreatedascandidatesforreimplantationwhileinthefield.Assuchtheiramputatedlimbordigitshouldbewrappedinsterilegauze，moistenedwithsterilesalineandplacedinaplasticbag.Thebagshouldbethenplacedoniceandtransportedwiththepatienttothenearestemergencydepartment.Theamputatedpartshouldnotbeallowedtofreeze.Packagingoftheamputatedpartinthismannerprolongstheviabilityofthepartforupto24hours.Youngerpatientssufferingsharpamputationswithnocrushinjuryoravulsionarethebestcandidatesforamputationreimplantation.(ChoiceA)Theamputatedpartshouldnotbeimmersedinwaterasthismaymakedigitalvesselrepairmoredifficult.(ChoicesBandD)Theamputatedpartshouldnotbeplacedinantisepticsolutionoralcoholaschemicalinjurymayoccur.Thepatientwillbeappropriatelytreatedwithantibioticsandtheamputatedpartirrigatedandcleansedbeforereimplantationisattempted.(ChoiceE)Theamputatedpartshouldnotbeplaceddirectlyonicebecausethiscouldresultinfrostbiteinjurytotheamputatedtissueandlossofviability.Educationalobjective:Incaseofamputationinjury,amputatedpartsshouldbewrappedinsaline-moistenedgauze,sealedinaplasticbag,placedoniceandbroughttotheemergencydepartmentwiththepatient.Q2A62-year-oldmancomestotheemergencydepartmentbecauseofsevereabdominalpain.Hestatesthathesuddenlyfeltweakdiaphoretic,andhadnoenergy.Heisasmokerandhashypertension.Hisbloodpressureoninitialexaminationwas110/70mmHg.Physicalexaminationshowsadiffuselytenderabdomen.DuringCTscanhebecomespaleanddrowsy.CTscanisshownbelow.Repeatexaminationshowsamanwithanxietyandabloodpressureof30/50mmHgandpulseof110/min.Whichofthefollowingisthemostappropriatenextstepinmanagement?A.ExploratoryabdominalsurgeryB.ObtainultrasoundC.CheckamylaseandlipaseD.LaparoscopyE.DrainfluidfromtheabdomenA2Correctanswer:AExplanation:Theabovepatientisadmittedwithhypotensionandabdominalpain.TheCTscanshowsarupturedaortawithbloodcollectionintheadventitiallayer.Thisisaclassicpresentationofarupturedabdominalaorticaneurysm.Anabdominalaorticaneurysmcanrupturefreelyintotheperitonealcavityorintotheretroperitoneum.Theserupturesareassociatedwithsignificantabdominalpainandhypotension.Patientswitharupturedaorticaneurysmrequireurgentsurgery.Ifthepatientisunstableandrupturehasbeendiagnosed,nofurtherevaluationisrequiredandthepatientistransferredstraighttotheoperatingroom.CTscanningIsonlydoneinstablepatients.InpatientsnotstableenoughtoundergoCTscan,thepresenceofananeurysmcanbeconfirmedatthebedsidebyultrasound.Surgicalrepairofarupturedaorticaneurysmcarriesaveryhighmorbidityandmortalityrate(ChoiceA).(ChoiceB)intheabovepatient,theCTscanshowsarupturedabdominalaorticaneurysm.Theroleofultrasoundinthepresenceofarupturedaorticaneurysmislimited.Ifapatienthashypotensionandthereisapossibilityofprobableabdominalaneurysm,confirmationoftheaneurysmcanbeobtainedbyultrasound.Allpatientswhoarehypotensiveandhaveapulsatilemassshouldbeevaluatedintheoperatingroom.Ultrasoundisportable,sensitive,andreadilyavailable.(ChoiceC)Amylaseandlipasearemarkersforacutepancreatitis.AdditionalsupportforthediagnosisincludesanelevatedWBC,mildazotemia,andhypocalcemia.CTscancanbeusedtoconfirmthediagnosisofpancreatitis.(ChoiceD)Laparoscopyisnotindicatedinthisacutecondition.(ChoiceE)TheaboveCTscanshowsnoevidenceofascites.Whenthereisexcessivefluidintheabdomen,itcanbedrainedbyapercutaneoustechnique.EducationalObjective:Apatient,whoishypotensivewithabdominalpainandhasaCTscanshowinganenlargedaorticsilhouette,hasadiagnosisofarupturedabdominalaorticaneurysm.Thispatientneedsimmediatesurgery.Q3A25-year-oldpreviouslyhealthymanisbroughttotheemergencydepartmentafterfallingfromatree.Hewasbuildingatreehousewhenhelosthisbalance,fellabout3m(10ft),andlandedonhisleftside.Thepatientdidnotloseconsciousnessbutstartedexperiencingleft-sidedchestandabdominalpain.Healsohasleftshoulderpain.Bloodpressureis113/71mmHgandpulseis116/min.Physicalexaminationshowsbruisingontheleftchestwall.Heartsoundsarenormalwithoutmurmur.Thepatientreportssharpleftchestpainwithdeepinspirationbuthasequalbreathsoundonbothsides.Thereistendernessoftheleftcostalmarginandleftupperquadrantoftheabdomenwithguarding.Bowelsoundsarenormal.Rangeofmotionoftheleftshoulderisnormal.Hishemoglobinis11.8g/dLandasingle-viewchestx-rayisnorma