NBME1 qs 3, 4 thanks!

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NBME1 qs 3, 4 thanks!

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13 Posts

Perhaps
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Topics: 61
Posts: 162

08/13/06 - 12:50 PM

3
Three days after being hospitalized for treatment of a hip fracture sustained in a fall, a 62-year-old woman becomes acutely short of breath and coughs up a small amount of blood-tinged sputum. She appears anxious. Her blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 24/min. Examination shows no other abnormalities. Arterial blood gas analysis on 40% oxygen by face mask shows:

pH 7.40

PCO2 38 mm Hg

PO2 70 mm Hg

Ventilation-perfusion lung scans show multiple segmental areas of mismatch on the right. Which of the following is the most appropriate next step in management?

A) Pulmonary angiography

B) Dopamine therapy

C) Heparin therapy

D) Urokinase therapy

E) Intubation

4

A 57-year-old woman with breast cancer comes to the physician because of increasing neck pain over the past 3 days. She has fallen frequently because of muscle weakness. Vital signs are within normal limits. Examination shows hyperreflexia of all extremities. There is tenderness over the cervical spine. Serum calcium level is 11 mg/dL. X-ray films show metastases to the cervical spine. Which of the following is the most appropriate next step in management?

A) Application of a soft cervical collar

B) Physical therapy

C) Mithramycin therapy

D) Tamoxifen therapy

E) Spinal cord decompression and cervical stabilization

neurogirl
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08/14/06 - 07:00 PM

3-E

4-E

???

shumaila
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08/14/06 - 09:30 PM

these questions have already been discussed

Perhaps
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08/15/06 - 09:09 AM

Thanks for the input.

4 agree
3 still not sure if heparin should be given.

neurogirl
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08/15/06 - 10:04 AM

It's fat embols-heparin will not work

Perhaps
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08/15/06 - 01:02 PM

fat embolism should have some skin changes?
also 'Ventilation-perfusion lung scans show multiple segmental areas of mismatch on the right.' makes PE more likely...

neurogirl
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08/15/06 - 04:32 PM

Yes it's PE,but with fat embols from the broken hip

humbty
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08/16/06 - 10:25 AM

neurogirl wrote:
Yes it's PE,but with fat embols from the broken hip

Wouldnt be sure about that. Hip fracture + orthopedic surgery is a huge risk factor for DVT.

She has no other symptoms suggestive of fat embolism. Also I think fat embolism is more common in fractures of the diaphysis where more fat and bone marrow is than in the meta/epiphysis.

neurogirl
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08/16/06 - 04:11 PM

There are no other symptoms of hypercoagulable PE either.

There is just an association: broken bone-fat embolism;bed-ridden(usually after day 7)-PE with blood clot.

How do you know which part of bone is broken? There is not a word about that.It's just said "hip fracture".

I will not argue-it's just my point of view.

humbty
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Posts: 135

08/17/06 - 01:45 AM

#10

neurogirl wrote:
There are no other symptoms of hypercoagulable PE either.

There is just an association: broken bone-fat embolism;bed-ridden(usually after day 7)-PE with blood clot.

How do you know which part of bone is broken? There is not a word about that.It's just said "hip fracture".

I will not argue-it's just my point of view.

My understanding is that the hip is the head and neck of the femur not the diaphysis. BUt maybe I m wrong. English is not my mother tongue.

And the other question is also if heparin is useless in fat embolism, how can you be sure that it is fat embolism in this case? You can not in my opinion and so by dont giving heparin you could miss a normal PE.

I dont wanna argue, I just wanna discuss the question.

neurogirl
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08/17/06 - 10:17 AM

#11

The most common complication of a bone fracture is fat embolism.That's why I'm sure(almost smiling face

) that it's fat embols.

"Hip"-it's just bone without any specification,you cannot suppose specific place of fracture.

Anyway,intubation is always helpful in PE

I had a similar question on UW. Very tricky question.

humbty
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Posts: 135

08/17/06 - 11:43 AM

#12

neurogirl wrote:
The most common complication of a bone fracture is fat embolism.That's why I'm sure(almost) that it's fat embols.

"Hip"-it's just bone without any specification,you cannot suppose specific place of fracture.

Anyway,intubation is always helpful in PE

I had a similar question on UW. Very tricky question.

Hm do you have any data about the incidence of fat embolism? I didnt find any good data how common it really is. If you know something about that, would be great if you could post it.

At least according to emedicine hip fractures dont include femoral shaft fractures the hip is not the same as the femur bone. http://www.emedicine.com/emerg/topic198.htm

My understanding is that fat embolism is a complication of long bone fractures with slightly more insidious onset than PE (tachypnea, tachycardia andso on beginning 12-72h after the incident) possible skin manifestations and neurologic symptoms.

The patient has a sudden onset of symptoms with hemoptysis (For me thats pointing toward a sudden bigger embolus, not the small vessel occlusion caused by multiple fat embolisms) and has no other symptoms suggestive of fat embolism. In my opinion not even a long bone fracture.

So I think she may have fat embolism but absolutely not sure if its not a normal DVT PE and I wouldnt risk the potential harm of not treating her with heparin and killing her from subsequent PEs. And according to the time course I dont think its too early for a usual PE, today I had three UW questions with PE following orthopedic surgery 2-3days post-op.

But you re right this question is really tricky wink

by the way here is another discussion about the question:

http://www.prep4usmle.com/forum/thread/38674

humbty
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Topics: 24
Posts: 135

08/17/06 - 11:53 AM

#13

By the way the V/Q Scan is pretty specific for PE multiple SEGMENTAL mismatches is typical for PE. for fat embolism it would be normal scan or subsegmental mismatches.

So i would go for PE but still not sure if the normal PCO2 (Should be low in PE) isnt a reason to intubate but she doesnt seem unstable at the moment and needs in every case heparin so I took C.

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