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【交流】USMLE读书笔记（美国医学执照考试）---欢迎战友积极参与，加分从优

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这个帖子发布于13年零4天前，其中的信息可能已发生改变或有所发展。

USMLE对很多人来说很遥远也很陌生。鄙人在最初接触相关书籍时其实也并无心上大洋彼岸去考board，只是总觉得既然这么多过来人都说美国的医生地位多么高，USMLE多么难，那么想来他们的这项门户考试一定是函盖老美最权威的point了。
于是决心每日一题，好好研读下相关的核心参考材料。顺便加点个人体会。欢迎感兴趣的
战友前来讨论，批评，指正。

1．An 18-year-old woman presents with abdominal pain,fever,and leukocytosis.With the presumptive diagnosis of appendicitis,a right lower quadrant(McBurney) incision is made and the lesion pictured below is delivered.The process is 50 cm proximal to the ileocecal valve.This lesion
（图片上是一个蒂部狭窄扭转的憩室，和我们平时看到的基底宽大的美克尔憩室似有不同）
a. Can best be diagnosied by preoperative angiogram,which should be done whenever the diagnosis is suspected
b.Should routinely be removed when incidentally discovered during celiotomy
c..Is embryologically derived from a persistent vitelline duct
d.Often contains ectopic adrenal tissue
e.Is frequently associated with cutaneous flushing and episodic tachycardia

答案是c。
答案补充说明里介绍了相关的内容。比如术前无法与阑尾炎相鉴别，多数憩室存在胃（或胰腺组织）黏膜异位，ECT有重要诊断价值等等大家都知道的我就不说了，只想提出其中一点：如果在对其它疾病行剖腹探察术时，发现无症状的美克尔憩室，除非是可以扪及憩室内存在明显的异位组织（胃及胰腺）或是蒂部狭窄易梗阻或扭转的，一般不主张切除。
而黄家驷外科学第六版却写明：如果在对其它疾病行剖腹探察术时，发现无症状的美克尔憩室，应行切除，以绝后患。
看来还是存在争议哦。

2．Which of the following statement is true regarding the neck trauma?

a. All gunshot wounds in the middle zone of the neck should be surgically explored
b.Wounds that penetrate the platysma should be managed as an out patient basis
c.Gun shot wounds in the upper zone needs esophagogram,and bronchoscopy.
d.Expanding or large neck hematoma should have an angiography.
e.Any stab wound in the neck needs a surgical intervention.

答案是a

个人体会：颈部外伤严格来说算头颈外科—耳鼻喉科接诊，但实际上很多都推给普外了，
大家都应该有体会吧，呵呵。
对这个领域不大了解，完全是学习了。但是却很重要，因为虽然急诊不多，一来就都是
很可怕的。

相关介绍里主要介绍了颈部外伤的分区：
Zone 1(lower zone) 锁骨至环状软骨
Zone2(middle zone) 环状软骨至下颌三角
Zone3(upper zong) 下颌三角至颅底

The management protocols for neck trauma are as follows;

Zone 2: Trauma in this region can involve significant structures like major vasculature, laryngotracheal apparatus and pharyngoesophageal structures. In case of middle zone injuries that penetrate the platysma, mandatory exploration is safe, economical and time honored (Choice B ). (越早越好的意思？) All gun shot injury in middle zone of neck should be surgically explored (Choice A), however stab wound injury to middle zone in asymptomatic patient can be safely observed (Choice E).

Zone 1 and 3: selective management is done for injuries to zone 1 and 3, which include dividing the neck in three anatomic components (digestive, respiratory and cardiovascular) and identifying injuries to each of this component. Indications of surgery are:
1. Vascular indication: Persistent hemorrhage, pulsatile or expanding hematoma, coma and stroke.
2. Respiratory indication: subcutaneous emphysema, dysphonia, hemoptysis, palpable laryngeal injury, stridor, and tracheal tenderness.
3. Digestive indication: Dysphagia, crepitation and hematemesis.

Cervical spine should be assessed in all the patients with severe blunt trauma to neck.

Choice C: Gunshot wound in lower zone (zone 1) and not upper zone (zone 3) needs esophagogram and bronchoscopy.

Choice D: Expanding or large neck hematomas need surgical intervention.

Choice E: Stab wound in an asymptomatic patient can be safely observed especially in upper and middle zones.

Educational Objective:
In reference to neck trauma, neck can be divided into three zones and the treatment depends on the zone involved.

PS:应版主要求,我把07年的usmleworld外科部分附上(外科综合的模拟题)---因为太大,分1,2两个部分.

资料均来自"飘洋过海"版版主zzwhe的热情提供,同时向在英文方面提供无私帮助的nicolelee(英文很好的mm哦)战友致谢!!

1.rar(274.48k)

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2008-01-22 20:52 浏览 : 18823 回复 : 219

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lightningwing 编辑于 2014-07-23 04:11

• 大家见过从患者体内取出过哪些异物？

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Taquilar

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第二部分

2.rar(276.3k)

2008-01-22 21:45

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• 患者家属撕心裂肺的一跪让我深思许久，记录一下规培生涯里遇到的一些人、一些事

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Taquilar

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3. A 50-year-old man has been complaining of abdominal pain for several days.He states that the pain has been shifting through his abdomen and he doesn’t remember its location at its onset.He Vomited grayish material 2 hours ago.He hasn’t moved his bowels for 3 days and hasn’t passed flatus for 1day.His abdomen is distended,tender to palpation in all four quadrants,but is without guarding and rebound.Bowel sounds are absent.His vital signs are:HR:120/min;BP110/80mm of HG;RR:30/min;temperature:37.C(97.8F)

The laboratory results are

HB14.0
Hematocrit 40
WBC12.300 cmm
Blood glucose 5.1 mmol/L
BUN 6mmol/L
Amylase 20 U/L
PH 7.36
PO2 90
PCO2 28
HCO3 15

The patient is ambulatory and wants you to give him pain medication and let him go home.What is the most appropriate treatment for this patient?

a. Give laxative,but no analgesic
b.barium enema
c.Nasogastric tube,IV fluids and nothing per mouth
d.Laparotomy
e.Laparoscopy

选项是d.

这是普外科常见情况了，我觉得老美的思路很有意思，所以大体翻译后把全部说明帖出。

选项B和C适用于存在simple mechanical obstruction的情况。而simple mechanical obstruction常常导致患者出现代谢性碱中毒，该患者表现为代酸（代偿期），提示肠管缺血或坏死。同时患者还有休克早期（代偿期）表现，提示sepsis。由此分析他可能存在绞窄性肠梗阻继发腹膜炎，或者是由于空腔脏器穿孔引起腹膜炎，从而继发paralytic ileus(麻痹性肠梗阻)。这样一来，不管是上述的哪一种情况，都是（答案e）腹腔镜检查的禁忌。
值得强调的是，答案a中laxative（泻剂）是禁用于肠梗阻患者的。

Kaplan知识点:

Mechanical intestinal obstruction is typically caused by adhesions in those who have had a prior laparotomy There is colicky abdominal pain and protracted vomiting, progressive abdominal distention (if it is a low obstruction), and no passage of gas or feces. Early on,high-pitched bowel sounds coincide with the colicky pain (after a few days there is silence).
X-rays show distended loops of small bowel, with air-fluid levels. Treatment starts with NPO,NG suction, and IV fluids, hoping for spontaneous resolution, while watching for early signs of strangulation.
Strangulated obstruction (compromised blood supply) starts as described above, but eventually the patient develops fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full-blown peritonitis and sepsis. Emergenry surgery is required.

2008-01-23 21:06

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Taquilar 编辑于 2008-08-31 13:23

• 首张“新冠患者分子全景图”

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Taquilar

丁香园准中级站友

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所以唉,原来做小医生总被教授教导:有腹膜炎体征就是手术
探察的指征.
后来慢慢才发现其中复杂难以言说,关键还是大环境不行.

2008-01-23 22:24

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• 年轻女性，腹痛伴血肌酐升高

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