General-Principles-Main一般性治療-1-10（英文）

GeneralPrinciplesMain.1-10Q1A57-year-oldwomancomestothephysicianforafollow-upvisitregardingherlowerbackpain.Sheoriginallypresentedlastmonthwithsignificantcontinuouslowerbackpainthatwasworseatnightandwouldawakenherfromsleep.Shetriedover-the-counteribuprofen,withnoreliefofhersymptoms.Whenherpainpersisted,thepatientwasscheduledformagneticresonanceimagingofherback.Thereportreturnedtodayandshowsfindingsconsistentwithmetastaticlesionsinherspine.Thesourceoftheprimaryneoplasmremainsundetermined.Thepatienthasnotyetbeentoldaboutthefindingsandiswaitinginaprivateroom.Whichofthefollowingisthemostappropriatenextstepininitiatingaconversationabouthercondition?A.Haveyouconsideredwhetheryouwanttoknowthetestresults,regardlessoftheoutcome?B.I'msorrytohavebadnewsaboutyourtestresults;itseemsthatcancerhasmetastasizedtoyourback.C.Itlookslikeyouhavecancerinyourback,andweshouldbeabletodosomethingaboutitwithradiationandchemotherapy.D.Thetestresultsarenotgood.Doyouwanttoknowthem?E.Whatdoyouthinkisgoingonwithyourback?A1

Correctanswer:EBreakingbadnewsisoneofthemostdifficultsituationsaphysicianwillencounter.Asensitiveyethonestapproachmustbeusedtomakethepatientfeelmorecomfortable.OnesuchapproachistheSPIKESmethod(Table),whichinvolvesaseriesof6sequentialsteps.Inthefirststep,settingthestage,itishelpfultoaskifthepatientwouldlikethecompanyoffamilyorfriendsbeforethediscussionbegins.Ifthepatientdoesnotknowthephysician,itisalsoappropriatetoexplainthephysician'sroleinsubsequentcare.Thenextstepistoassessthepatient'sperceptionofwhathashappenedandgetanideaofhis/hervocabularyandcomprehensionofmedicalfacts,itwouldbeappropriatetoaskthispatientaboutherbacktodeterminehowsheperceiveshercondition.Thephysicianshouldtheninvitethepatienttoreceiveadditionalinformationanddetermineifhe/shewishestoknowtheresults.Ifthepatientdeclinestoheartheresults,thisrequestshouldbehonored.ChoiceAwouldbeconsideredaninvitationforthepatientandwouldbeappropriateafterthequestioninChoiceE.Oncethediagnosishasbeenstated,thepatient'sfeelingsshouldbeexploredandsupportshouldbeprovided,itisalsoImportanttoletthepatientaskquestionsbutnotoverloadhim/herwithtoomuchinformation.Finally,Itisimperativetoclearlyoutlinethetreatmentplanandprognosis.Thisinformationmayneedtoberepeatedlater,aftertherealityofthesituationhasbeenabsorbed.(ChoiceB)Immediatelystatingthediagnosisisnotanappropriatewaytobeginthediscussionwiththepatientbecausehe/shewillhavedifficultyadaptingtothenews.Also,itisbettertousesimplervocabularyratherthanmedicalwordssuchas"metastasized."(ChoiceC)Itistooearlytostatethatthispatienthascancerinherbackandthenjumpstraighttotreatmentoptions.Thephysicianshouldpauseafterdeliveringthediagnosisandseehowthepatientreactsasthereisusuallysomedegreeofshockand/ordenial.(ChoiceD)Itisimportanttomakethepatientfeelateasebeforestatingthediagnosis.Beginningthediscussionwith“Thetestresultsarenotgood"isnotappropriate.Educationalobjective:Whenbreakingbadnews，aphysicianshouldfirstsetthestageandassessthepatient'scomprehensionbeforedeliveringthenewsinanempatheticyetcomprehensiblemanner.Q2A70-year-oldwomancomestothephysicianforaroutinepreventivevisit.Shehasnospecificcomplaintsandfeelswell.Thepatientisaretiredschoolteacher,livesalone,anddoesnotsmoke.Shedrinksalcoholoccasionally.Otherthananemergencyappendectomy40yearsago;shehasnosignificantpastmedicalhistory.Thepatienttakesnomedicationsandhasnopersonalorfamilyhistoryofcancerorheartdisease.Shehadanormalmammogram,Papsmear,andlipidpanelatherexamination2yearsago.Acolonoscopy7yearsagoshowednolesions.Whichofthefollowingstudiesismostappropriateatthisvisit?A.Chestx-rayB.ColonoscopyC.ElectrocardiogramD.LipidprofileE.MammographyF.PapsmearA2Correctanswer:ETheUSPreventiveServicesTaskForcerecommendsbiennial(every2years)screeningmammographyforwomenage50-74years.Routinemammographyisnotnecessarybeyondage75，althoughscreeningforthoseage75-85maybeindividualized.Otherrecommendedscreeningproceduresaresummarizedinthetable.(ChoiceA)Chestradiographyisnotrecommendedforlungcancerscreeninginasymptomaticindividualsasithaslowsensitivityandspecificityfordetectingearly-stagecancersthatareamenabietotreatment.Forpatientswithasignificantsmokinghistory,screeningwithlow-dosecomputedtomographyhasbeenadvocated,butprotocolsarenotwidelystandardized.(ChoiceB)Patientsshouldbeofferedscreeningforcoloncanceratage50-75witheitherannualfecaloccultbloodtestingorcolonoscopyevery10years.Morefrequentcolonoscopyisnotrecommendedasthebenefithasnotbeenproventooutweighthepotentialrisk.(ChoiceC)Althoughsomeexpertsadvisescreeninghigh-riskpatientsforasymptomaticcoronaryarterydiseasewithrestingelectrocardiography,thereisnoevidencetosupportitsroutineuseinpatientsataveragerisk.(ChoiceD)TheTaskForcerecommendsroutinecholesterolscreeninginmenataverageriskforcoronaryarterydiseasebeginningatage35andinwomenatincreasedriskbeginningatage45.Theidealagetodiscontinuescreeningisnotknown,buttheyieldlikelydecreasesinelderlypatientswithconsistentlynormallipidresults.A5-yearintervalismostcommonlyrecommended,andthereislikelylittlebenefitfrommorefrequenttestinginpatientswithnormalriskforcoronaryarterydiseaseandnormallipidsinthepast.(ChoiceF)TheincidenceofcervicalcancerintheUnitedStatespeaksbeforeage50anddeclinesthereafter.Papsmearscanthereforebediscontinuedatage65ifthepatienthashadadequatescreeninguntilthenwithnoevidenceofmalignantorpremaiignantfindings.Educationalobjective:Mammogramsshouldbeperformedevery2yearsstartingatage50inwomenataverageriskforbreastcancer.Routinemammographyisnotnecessarybeyondage75.Q3A29-year-oldwomancomestotheofficeinthefallforahealthmaintenanceexamination.Shehasbeenfeelingwellandhermedicalhistoryisunremarkable.Shereceivedherlastvaccinationsatage17.HerlastPapsmear,performedatage25,showednoabnormalities.Thepatientworksasanadministrativeassistantanddoesnotusealcohol,tobacco,orillicitdrugs.Shestartedanewsexualrelationship3monthsago.Thereisnofamilyhistoryofcancer.Whichofthefollowingscreeningtestsandvaccinationsarerecommendedforthispatient?Abbreviations:HPV-HumanpapillomavirusTdap-Tetanustoxoid,reduceddiphtheriatoxoid,andacellularpertussisTd-TetanusanddiphtheriatoxoidsA.HPVvaccine,influenzavaccine,andPapsmearB.HPVvaccine,influenzavaccine,Papsmear,andTdap/TdvaccineC.HPVvaccine,Papsmear,andTdap/TdvaccineD.influenzavaccine.Papsmear,andTdap/TdvaccineE.PapsmearandTdap/TdvaccineA3Correctanswer:DExplanation:TheUnitedStatesAdvisoryCommitteeonImmunizationPracticesrecommendsasingledoseofTdapvaccineatage11-18(preferablyage11-12).Tdapisalsorecommendedforthoseage>19whodidnotreceiveitearlier.SubsequentvaccinationwithTdshouldbecontinuedevery10yearsthereaftertomaintainimmunity.AdoseofTdapisalsorecommendedduringeachpregnancyregardlessofthenumberofyearssinceawoman'spriorTdorTdapvaccination.Currentguidelinesrecommendcervicalcancerscreeningwithcytology(Papsmear)every3yearsstartingatage21inwomenage21-29.Forwomenage30-65,screeningisrecommendedwitheithercontinuedPapsmearsevery3yearsorwithacombinationofPapsmearandhumanpapillomavirus(HPV)testingevery5years.Inimmunocompromisedpatients,Papscreeningisrecommendedannuallybeginningatage21,andpatientswithHIVshouldalsobescreenedtwiceinthefirstyearafterHIVdiagnosisandannuallythereafter.(ChoicesA,B,andC)HPVvaccinationisrecommendedforbothmaleandfemalepatientsatage11-12andmaybeconsideredasearlyasage9.Forpatientswhodidnotreceivetheinitialvaccineseries,itisrecommendedthroughage26forwomenandthroughage21formen.Itisnotcurrentlyrecommendedforolderpatients.(ChoiceE)Influenzavaccinationisrecommendedannuallyforailpatientsage>6monthsandshouldbegivenassoonasitisavailabl、einthefalLEducationalobjective:WomenshouldbescreenedforcervicalcancerwithaPapsmearevery3yearsatage21-65(orwithPapsmearandHPVtestingevery5yearsatage30-65).AsingledoseofTdap(tetanustoxoid;reduceddiphtheriatoxoid,andaceiiuiarpertussis)isrecommendedbeginningatage11,withId(tetanusanddiphtheriatoxoids)every10yearsthereafter.Q4A46-year-oldwomancomestotheclinicduetoleftSowerextremityswellingforthepast2years.ShehashadseveralepisodesofcellulitisInvolvingtheleftleg.Duringthemostrecentepisode6monthsago，sheunderwenttreatmentwithintravenousantibioticsthatwascomplicatedbyacatheter-relatedaxillaryveinthrombosisrequiring3monthsofanticoagulationtherapy.Hermedicalhistoryisalsosignificantfordiet-controlledtype2diabetesmetSitus.BMIis34kg/㎡,Physicalexaminationshowsfirmedemaoftheleftlowerextremity.Thereisnoerythemaorwarmth.Theexaminercannotlifttheskinfromthedorsumofthetoesontheleftfootbutisabletodosowiththetoesontherightfoot.Whichofthefollowingisthemostlikelycauseofthispatient'ssymptoms?A.AlbuminuriaB.DisruptionoflymphaticsC.IncreasedcentralvenouspressureD.SystemicsclerosisE.VenousvalveincompetenceA4Correctanswer:BThispatientmostlikelyhaschroniclymphedemaoftheleftleg.Lymphedemamostcommonlyresultsfromanacquireddisruptionofthelymphaticsystemthatieadstoaccumulationoflymphaticfluidintheinterstitium.CommoncausesIncludemalignancyandItstreatment(eg,radiation,lymphnodedissection),chronicinflammation(eg,recurrentcellulitis,connectivetissuedisease),andseverechronicvenousinsufficiency.Obesityisoftenastrongcontributingfactor.Chroniclymphedematypicallypresentswithpain,swelling,andheavinessinoneormoreextremities.Patientswithearlydiseaseusuallydemonstratesoftskinwithpittingedema.However,progressivedepositionofsubcutaneouscollagenandadiposetissueoccurs,leadingtolaterdevelopmentoffirm,thickenedskinandnonpittingedema.Inadvancedcases,theskinmaydevelopawartyappearance.Inabilitytolifttheskinonthedorsumofthesecondtoe(positiveStemmersign)ishighlyspecificforlymphedema.Thediagnosisisusuallybasedonclinicalpresentation:butimaging(eg,duplexultrasound)maybeusefulinsomecases.Treatmentischallengingandmayinvolveweightloss;limbelevation,compressionbandages,andphysiotherapy(eg，lymphaticdrainagebymassage).(ChoicesAandC)Severealbuminuria(eg.diabeticnephropathy)canleadtoperipheraledemaduetolowoncoticpressureoftheblood,andincreasedcentralvenouspressure(eg,heartfailure)canleadtolowerextremityedemaduetoelevatedhydrostaticpressureinthedeepveinsofthelegs.Lymphedema,evidencedbythickskinandapositiveStemmersign,isnottypicalIneithersetting.(ChoiceD)Systemicsclerosisoftenleadstoperipheraledemaduetoinflammatorydisruptionofbloodvesselwalls;lymphedemaduetoinflammatorydisruptionoflymphaticscanoccurbutislesscommon.Ifsystemicsclerosiswerepresentinthispatient,othersuggestivefeatures(eg,sclerodactyly,Raynaudphenomenon)wouldbeexpected.(ChoiceE)Venousvalveincompetenceisthemajorcauseoflowerextremityedemaduetochronicvenousinsufficiency.Whensevere,lymphedemamayoccurduetolymphaticobstruction.However,thispatient'sunilateralsymptomsandhistoryofrecurrentcellulitismakevenousvalveincompetenceanunlikelyunderlyingcause.Educationalobjective:Chroniclymphedemaismostcommonlycausedbyanacquireddisruptionofthelymphaticsystem(eg,chronicinflammation,malignancy)andtypicallypresentswithpainandswellinginoneormoreextremities.Patientsusuallyhavepittingedemathatlaterprogressestononpittingedemaaccompaniedbyfirm,thickenedskin.

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5A6-month-oldgirlisbroughttothephysicianforaroutinewell-childexamination.Shehasbeenbreastfeedingwellandrecentlystartedstage1solidfoods.Herbrotherhasaspeechdelayrequiringtherapy3timesaweek.Sheisatthe40thpercentiieforlength,50thpercentileforweight,and60thpercentileforheadcircumference.Onexamination,theInfantsitsmomentarilyonproppedhands.Shetransfersherbottlefromherlefttorighthand.Whenherfathercallshername,sheturnstohimandsmiies,revealingamandibularcentralincisor.Sheisunabletopulitoastand.Moroandgraspreflexesareabsent.Firmstrokingofthesolesofherfeetcausesthebigtoestoturnup.Whichofthefollowingisthemostappropriateassessmentofthischild'sdevelopment?A5Correctanswer:HAssessmentofdevelopmentalmilestonesisessentialateverywell-childexamination.Developmentaldelayscanbeanominoussignofaseriousmedicalcondition,suchasabraintumororotherneurologicproblem.Promptrecognitionisalsoimportantasearlyinterventionwithphysical,occupational,and/orpsychosocialtherapiesiscriticalinoptimizingskillacquisitionandoveralllong-termhealth.infantdevelopmentprogressesfromcephalictocaudal;fromproximaltodistal;andfromstimul、us-basedreflexestospecific,goal-orientedreactionsthatbecomeincreasinglyprecisewithage.Thisinfantdemonstratesappropriatemotorandcognitivedevelopmentalskillsfora6-month-old.Byage4months,primitivereflexes(eg,Moro,grasp)haveeitheralreadydisappeared,orarestartingtodisappearastheinfantInitiatespurposefulmovementoftheextremities.Thetongueprotrusionreflexalsoshoulddisappearbyage4months,allowingforcoordinationtoingestsolidfoodsatage4-6months.TheBabinskireflexistheonlyprimitivereflexthatmaypersistinhealthychildrenuptoage2yearsbutcandisappearasearlyasage12months.Educationalobjective:Ahealthy6-month-oldinfantshouldbeabletositmomentarilyonproppedhands,transferobjectsfromhandtohand,andrespondtoname.Strangeranxietyalsodevelopsatthisage.Q6A12-month-oidboyisbroughttothepediatricianforaroutineweil-chiidvisit.Hewasbornat39weeksgestation.Birthweightwas3.4kg(7pounds8ounces)andlengthwas50.8cm(20Inches).Hewasprimarilybreastfeduntillastweek:whenhewastransitionedtocow'smilk.Thechildcanfeedhimselfsmallpiecesoftablefoodwithhisthumbandfirstfingeranddrinksfromasippycup.Hisonlywordsare"mama”“dada，;""doggy，”and"teddy."Hisparentsareconcernedabouthisgrowthbecausesomechildrenathisdaycarecenterseemtaller.Thechildweighs10.5kg(23lb)andis76.2cm(30in)tall.Onexamination,hecanpuliuptostandandcantake3-4stepsindependently.Hecannotwalkbackwards.Hecomestohisparentswhencailedbynamebutdoesnotspeakduringtheexamination.Whichofthefollowingisthemostappropriateassessmentofthischild'sdevelopment?GrowthMotorLanguageA6Correctanswer:HEverywell-childvisitshouldincludeathoroughassessmentofgrowthanddevelopmentasdelayscansignifyaseriousmedicalproblem(eg,malabsorption;braintumor)thatmayrequirepromptdiagnosisandtreatment.Normalgrowthinvolvesperiodsofrapidincreaseinweightandlength("growthspurts"):especiallyduringthefirst6monthsoflife.Byage12months,achild'sweightshouldtripleandheightshouldincreaseby50%.Majordevelopmentalmilestonesofthefirstyearoflifeareshowninthetable.Other12-monthmilestonesincludefollowingaone-stepcommandaccompaniedbyagesture,imitatinganaction,andcooperatingwithdressingofclothes.Theseparentsshouldbereassuredthattheirsonisgrowinganddevelopingnormally.Thechildmaynotdemonstratefulllanguageabilitiesatthephysician'sofficeduetoshynessinanunfamiliarenvironment.Educationalobjective:Byage12months,achild'sweightshouldtripleandheightshouldincreaseby50%.Developmentalmilestonesincludewalkingindependently,usinga2-fingerpincergrasp,sayingafewwordsotherthan"mama"and"dada,"andimitatingtheactionsofothers.Q

7A4-year-oldboyisbroughttothephysicianforbedwetting.Toilet-trainingwasinitiatedatage2whenhelearnedthewords"pee"and"poop."Hehasasoftbowelmovementinthetoileteveryday.Howeverhisparentsarefrustratedandconcernedthattheboystillurinatesinhisbedatleast1nightaweekdespiteavoidingfluidintake2hourspriortobedtime.Hisoldersistersweretoilet-trainedduringthedayandnightbyage3.Hehasnomedicalproblemsandtakesnomedications.Physicalexaminationshowsawell-nourished，talkativeboy.Thereisnosacraldimpleorhairtuft.Testesaredescendedbilaterallyandtheurethralmeatusisatthetipofthegians.Hecanhoponeachfootforafewseconds.Heidentifiesthecolorsof"pee"and"poop"asyellowandbrown，respectively.Whatisthemostappropriatenextstepinmanagementofthispatient?A.AdvisegentlespankingofthebuttockstodiscouragebedwettingB.Orderabdominalx-rayC.OrderscrotalultrasoundD.OrderurinalysisE.PrescribeanenuresisalarmF.PrescribedesmopressinG.ReassuranceA7Correctanswer:GThispatientisadevelopmentallynormalchildwhohasnotyetachievedcompleteurinarycontinence.Mostchildrenarereadytobegintoilet-trainingatage>2withtheacquisitionofthefollowingskills:VoluntarilycontrolsphinctersWalkRemovepantsFollow2-stepcommandsCommunicatetheneedtourinateandstoolImitateactionsofotherpeople[eg，sitontoiiet)Prematureinitiationoftoilet-trainingcanprolongthedurationoftraining.Parentsshouldberemindednottorushthechildandthatbedwettingisnormalbeforeage5.Mostchildrenmasterdaytimecontinencewithinmonths，butnighttimecontinencecansometimestakeyearstoaccomplish.Also，boysgenerallycompletetoilet-traininglaterthangirls.Encouragementandpositivereinforcementshouldbeprovidedwhenthechilddemonstratesreadinessandsucceedsinstayingdry.(ChoiceA)Corporalpunishment(eg,spanking)significantlyincreasestheriskofaggression,depression,andinterpersonalconflictsthroughoutlife.Inaddition,punishmentcanleadtoanxietyandstresswithelimination,resultinginstoolwithholdingandsubsequentconstipation/encopresis.(ChoiceB)Chronicconstipationcanreducebladdercapacityandcontributetourinaryincontinence.Stoolburdencanbeassessedbyabdominalx-raybutisunnecessaryinthesettingofsoft,regularbowelmovements.(ChoiceC)Displacementoft:ieurethralmeatusisassociatedwithotherurologicanomalies(eg:cryptorchidism)andincontinenceproblems,butthischildhasanormalgenitourinaryexamination.(ChoicesD，E,andF)Theprevalenceofurinaryincontinencedecreasesto15%atage5,andurinalysisshouldbeperformedinchildrenage>5toscreenforurinarytractinfection,diabetesmellitus,anddiabetesinsipidus.Thesecomorbiditiesareunlikelyinanasymptomatictoddlerwhoisgraduallyachievingcompletecontinence.Theprevalencedecreaseswithincreasingageaschildrenachievecontrolattheirownpace.Someolderchildrenmaybenefitfromaccelerationofcontinencefromalarmordesmopressintherapy,butinterventionsareunwarrantedforchildrenage<5.Educationalobjective:Bedwettingisnormalbeforeage5.Masteryofnighttimecontinencecantakemonthstoyears,andboysgenerallyachievethismilestonelaterthangirls.Q8A3-year-oidgirlisbroughttotheemergencydepartmentwithlethargyandfever.Shehaddiarrheaforseveraldays，andherparentssaythat"shesuddenlytookaturnfortheworse".Thegirlhasrefusedliquidsforthepast12hoursandhasnoturinatedtoday.Shehasnoallergiesandtakesnomedications.Hertemperatureis39.7C(103.5F),bloodpressureis60/23mmHg，andpulseis145/min.Onexaminationsheislethargicandhaspoorskinturgor.Hercapillaryrefilltimeis5secondscentrally.Despitenumerousattempts，itisnotpossibletostartaperipheralintravenousline,andthechild'sconditioncontinuestodeteriorate.WhichofthefollowingisthebestnextstepInmanagementofthispatient?A.AttemptarteriallineplacementB.AttemptcentralvenouscatheterplacementC.AttemptintraosseouscannulationD.AttemptnasogastrictubeplacementE.AttemptperipheralintravenouslineplacementF.TransporttointensivecareunitforcentralvenouscatheterplacementA8Correctanswer:CExplanation: Thischild'spresentationisconcerningforhypovolemicorsepticshockandrequiresemergencyfluidresuscitation.Whenintravenousaccesscannotbeobtainedinemergencycases,intraosseous(IO)accessshouldbeattemptedimmediately.IOaccessrequireslessskillandpracticethancentrallineplacement,andclinicaltrialshavedemonstratedIOlinestobesaferandfasterthancentrallines.IOcathetersprovideacannulalargeenoughtodeliverfluidsandmedicationsrapidlyandtoobtainbloodsamplesforlaboratorytesting.ThemostcommonsiteforIOaccessistheproximaltibiaduetoitswide,flatsurfaceanddistancefromthesternumincasecardiopulmonaryresuscitationisperformedsimultaneously.However,anylargebonecanbeused.IOcatheterscanbeplacedmanuallyorwithadriver.ContraindicationstoIOplacementincludeinfection(eg,cellulitis)overlyingtheaccesssite,fractureorpreviousIOattemptsinthechosenextremity,orbonefragility(eg,osteogenesisimperfecta).(ChoiceA)Arteriallinesareusedforcontinuousbloodpressuremonitoringandtodrawlaboratorystudies.Theyarenotusedforfluidresuscitationandshouldbeplacedafterthepatienthasbeenresuscitatedastheproceduretakestimeandgreatskill.(ChoicesBandF)CentralcatheterstakelongertoplacethanIOlinesandrequireahigheramountofproceduralskillandpractice.Thischildneedsimmediateaccessforfluidresuscitation,andtransportingherwithinthehospitalwillcausedelays.Acentrallinecanbeplacedlaterifnecessarywhenthepatientisstable.(ChoiceD)Althoughnasogastricfluidsarepreferredformildtomoderatedehydrationassociatedwithgastrointestinaldisease,theyarenotrecommendedinshock,whenthesplanchniccirculationisconstricted.Atthispoint,absorptionofenteralfluidswillnotberapidenoughtocorrectthepatient'shypovolemia.(ChoiceE)Severalattemptsatperipheralintravenousinsertionhavealreadyfailed.Giventhatthechildisinuncompensatedshock,accessshouldbeescalatedto10placement.Educationalobjective:Intraosseouslinescanbeplacedrapidlywhenemergencyaccessisnecessaryandperipheralaccesscannotbeobtained,intraosseousaccesscanbeperformedwithlessrequiredskillandpracticethancentralvenousaccess.Q

9A5-day-oldgirlisbroughttothephysicianforherfirstcheckup.Shewasbomfulltermtoaprimigravidmotherbyuncomplicatedvaginaldelivery.Shewasdischargedfromthewell-babynursery3daysago.Sincethen:shehasbeenbreastfeedingexclusivelyevery1-3hoursfor15minutesperbreast.Shehashad5-6wetdiapersand3-4yellow:seedy"stoolsdaily.Birthweightwas3402g(7lb8oz).Currentweightis3260grams(7lb3oz).Onexamination,thegirlisawakeandalert.Theanteriorfontanelleisopen,soft,andflat.Hermucousmembranesaremoistandcapillaryrefillis<2seconds.Peelingofthehandsandfeetisseen,asisacrocyanosis.Herdiaperisshownbelow.Whichofthefollowingisthemostappropriatenextstepinmanagementofthispatient?A.ContinuecurrentfeedingregimenB.FortificationofbreastmilkwithpowderedformulaC.intravenousfluidsD.SerumelectrolytesE.SupplementationwithinfantformulainadditiontobreastfeedingF.SupplementationwithwaterinadditiontobreastfeedingG.UrinalysisA9Correctanswer:AThisfull-termnewbornhasanormalphysicalexamination.Dry，flaky,peelingskinofthehandsandfeetisexpectedastheskinadjuststothedryextrauterineenvironment.Theappearanceof"pinkstains"or"brickdust"inneonataldiapersrepresenturicacidcrystals.Uricacidexcretionisespeciallyhighatbirthanddecreasesuntiladolescencewhenadultlevelsareobserved.UricacidcrystalsarecommonlyseenduringthefirstweekasthemothersmilkIscomingin,orinlatermonthswiththemorningvoidaftertheinfantbeginstosleepthroughthenight.Althoughthispatient'sweightis~4%decreasedfrombirth,healthyneonatesnormallyloseupto7%oftheirbirthweightinthefirst5daysoflifeduetoexcretionofexcessfluidacquiredinuteroandduringlabor.Theweightlossismorepronouncedinexclusivelybreastfedinfantsasthemother'smilksupplygraduallyincreasestomeetinfantdemands.Frequentbreastfeedingshouldbeencouraged,andeducationaboutdehydrationshouldbeprovided.Signsofdehydrationincludedrymucousmembranes,asunkenfontanelle,anddecreasedurineoutput.Asageneralrule,thenumberofwetdiapersshouldequalageindaysforthefirstweekoflife.Forexample,a4-day-oldneonateshouldhave>4wetdiapersperday.Afterthefirstweek,infantsshouldhave>6wetdiapersperday.Birthweightshouldberegainedbyage10-14days.(ChoiceB)Breastmilkfortifiedwithpowderedinfantformulamaybeusedforinfantswithfailuretothriveorforpreterminfantsbutisnotrecommendedforphysiologicneonatalweightloss.(ChoiceC)Intravenousfluidsshouldbereservedfordehydratedinfantswhocannotingestadequateoralnutrition.Thisinfantappearswellhydrated,makingintravenousfluidsunnecessary.(ChoiceD)Serumelectrolytes，particularlyserumsodium,canbeusedasameasureofdehydration.Infantswholose>7%ofbirthwei