zzpearl
Forum Senior
Topics: 51
Posts: 138
|
Guys, please give your input on these NBME Qs. I have add the discussion has been put online before, and some info. I found. But still can not reach the correct answer. Please help, my exam is in 4 days. Thanks<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
NBME 2
1. ???A 62-year-old man comes to the emergency department
because of
progressive shortness of breath for 3 days. He has
not had chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. He
completed chemotherapy for
small cell carcinoma of the lung 10 months ago. He
has a history of twice
nightly nocturia that has resolved over the past 3
days. He smoked two
packs of cigarettes daily for 30 years but quit 1 year
ago. His blood
pressure is 96/60 mm Hg, and pulse is 116/min. There
is jugular venous
distention to the angle of the jaw. The lungs are
clear to
auscultation. Cardiac examination shows distant heart
sounds, an S1 and S2, and no
gallops or rubs. The liver has a span of 12 cm and is
tender. There
is no pedal edema. Laboratory studies show:
Hemoglobin 10 g/dL
Serum
Na+ 135 mEq/L
Cl– 110 mEq/L
K+ 4.2 mEq/L
HCO3– 22 mEq/L
Urea nitrogen (BUN) 40 mg/dL
Creatinine 1.6 mg/dL
An ECG shows diminished amplitude of the QRS
complexes. An x-ray film
of the chest shows clear lung fields with an enlarged
cardiac
silhouette. Which of the following findings is most
likely to be accentuated?
A
) Cardiac output
B
) Fall in systolic arterial pressure with
inspiration (pulsus paradoxus)
C
) Left ventricular end-diastolic pressure
D
) Mitral regurgitation
E
) Ventricular septal wall motion
restrictive cardiomyopathy: infiltrative: neoplasia; impede ventricular filling and raising cardiac filling pressure from abnormal diastolic function. X-ray: mild cardiomegaly, pulmonary congestion, EKG: low voltage, conduction disturbances, Q waves.
Pericarditis / Pericardial effusion: EKG: diffuse ST segment elevation w/ upright T waves, chest pain
2. ??? A 27-year-old primigravid woman at 29 weeks' gestation
comes to the
emergency department because of a 24-hour history of
increasingly severe
right-sided abdominal pain and no appetite. She has
vomited twice over
the past 4 hours. She has not had vaginal bleeding.
Her temperature
is 38.2 C (100.8 F). Examination shows exquisite
tenderness of the
right lateral flank and the fundus. There are no
peritoneal signs. Bowel
sounds are absent. The fetal heart rate is 144/min.
Laboratory
studies show:
Hematocrit 37%
Leukocyte count 16,000/mm3
Serum
Total bilirubin 1.1 mg/dL
Amylase 32 U/L
Lactate dehydrogenase 110 U/L
Urine WBC 3–5/hpf
Which of the following is the most likely diagnosis?
A
) Abruptio placentae
B
) Appendicitis
C
) Cholelithiasis
D
) Colitis
E
) Pyelonephritis
Pyelonephritis causes paralytic ileus, nausea, vomiting and anorexia.
Being as Pyelo is an infection most often starting in the renal pelvis and collecting system, casts are not always found initially. Besides, the information given is an incomplete UA at best, and while you might have casts + WBCs, finding WBCs definately does not rule out pyelo, it only rules out glomerulonephritis which is exclusively casts due to the location of the disease.
You could argue for abruptio placenta (Class 1 with no bleeding) but the basis would be fundal pain exclusively as none of the other symptoms match. Also the fundal pain could be from the fact that it is a 30 week pregnancy and the uterus would be touching the inflammed kidney causing confusion of referred pain in an already unreliable area.
If you say Appy then you have to argue for a concurrent UTI which is an unlikely test question.
I think I would have to say most of the signs point toward pyelo.
Abswer is BBB appendicitis..dont be confused by flank pain..in pregnancy appendietis present as flank pain because of upward displacement of appendix by uterus
If two or more leukocytes per each high power field appear in non-contaminated urine, the specimen is probably abnormal
Pyelonephritis: Although it is conceivable that pyelonephritis may exist without WBC´s in the urine, this is very rare. Over 90% have WBC´s and/or WBC casts in their UA. So why do I think it is appendicitis? Well, for the first part this is a rather young woman in her third trimester, which means that the appendix has shifted from a lower-right-quadrant position to a higher, periumbilical or even upper-right-quadrant position. This could cause "right lateral flank pain". Additionally, it would explain why bowel sounds are absent (reactive inflammation) and also explain why the patient is anorexic and nauseous/vomiting, what happens frequently with appendicitis, even during pregnancy.
16000 wbc is normal in pregnancy. 5 WBC in urine is also normal. aswer is B UPTO 5 WBC is considered as normal,>10 is abnormal)+
3. ???33. A healthy 8-year-old girl is brought to the
physician in July
for a well-child examination. Her mother says that
her daughter is
spending the summer at a nearby lake. Over the past
month, she has had two
episodes of painful sunburn despite her mother's
efforts, including SPF
25 sunblock just before she goes swimming and urging
her to wear a hat
and long-sleeved garments. The child takes no
medications. She has
blond hair, blue eyes, and a fair complexion. The
mother seeks advice
about preventing further sun damage to her child's
skin. Which of the
following is the most appropriate recommendation?
A
) Prohibit swimming on cloudless days
B
) Apply the sunblock lotion 45 minutes before
swimming
C
) Change to a higher-level SPF lotion
D
) Apply Burrow's solution compresses after each
overexposure
E
) Daily use of antioxidant vitamin supplement
F
) Early treatment of any sun overexposure with
topical
corticosteroids
4. ??? A 15-year-old girl is brought to the physician 3
months after she
had a blood pressure of 150/95 mm Hg at a routine
examination prior to
participation in school sports. She is asymptomatic
and has no history
of serious illness. Twelve months ago, she was
diagnosed with a
urinary tract infection and treated with oral
trimethoprim-sulfamethoxazole.
She currently takes no medications. Subsequent blood
pressure
measurements on three separate occasions since the
last visit have been: 155/94
mm Hg, 145/90 mm Hg, and 150/92 mm Hg. She is at the
50th percentile
for height and 95th percentile for weight. Her blood
pressure today is
150/90 mm Hg confirmed by a second measurement, pulse
is 80/min, and
respirations are 12/min. Examination shows no other
abnormalities. Her
hematocrit is 40%. Urinalysis is within normal limits.
Cardiac and
renal ultrasonography shows no abnormalities. Which
of the following is
the most appropriate next step in management?
A
) Exercise and weight reduction program
B
) Measurement of urine catecholamine levels
C
) Measurement of urine corticosteroid levels
D
) Captopril therapy
E
) Hydrochlorothiazide therapy
Pt w/ diastolic pressure >90mmHg despite 3-6 mo trila of nonpharmacologiv Rx should be started on medications. Initial dilutices. HTN in very young <25, need to find 2nd cause, but Q stem doesnot give any clue to Pheochromocytoma ( episodic HTN w/ headaches, sweatings, palpitation, tachycardia. Cushing : physical menisfestation, . ?? it is classification 1 of HTN. Need treatment. Not OK with wt reduction. Mostly in child it is due to secondary. need to find out the cause b4 tx. So I go with B or C. Being obese and UTI incline to C?
5. ???35. A previously healthy 47-year-old nulliparous
woman is brought to
the emergency department by ambulance because of acute
low back pain
radiating to the right posterior leg for 2 hours. The
pain began when
she bent over at work to retrieve a file from the
lowest drawer of a
filing cabinet. She does not smoke cigarettes or
drink alcohol.
Examination shows right paraspinous muscle spasm and
pain in the lower back with
right straight-leg raising at 30 degrees. She says
that she plans to
file a claim for a work-related injury. Which of the
following findings
is the strongest risk factor for a prolonged episode
of pain in this
patient?
A
) Arrival for care in an ambulance
B
) Claim that pain is work-related
C
) Gender
D
) Nulliparity
E
) Positive straight-leg raising test
F
) Radiation of the pain into the posterior lower
extremity
B..well E, with analgesics and as little as two days rest, pts with prolapse even can go back to work and thus won't be a reason for prolonged pain..and F too.
STRAIGHT LEG RAISE TEST
The straight leg raise test is an easy test to perform to evaluate the patient for disk herniation. The patient is placed in the supine position and the leg is elevated by the clinician up to 70 degrees. A positive test reproduces radicular pain below the knee along the path of a nerve root in the 30- to 70-degree range of elevation. A positive test result can be further verified by lowering the leg 10 degrees from the point of radicular pain and dorsiflexing the foot. This should produce a similar radicular pain. Reproduction of the patient's back pain or pain in the hamstring is not a positive test.
A positive straight leg raise test is approximately 80% sensitive for disk herniation. Further, if there is radicular pain down the affected leg when the asymptomatic leg is raised (positive crossed straight leg raise), it is highly specific but not sensitive for disk herniation.
"To be sure if she malingering ,while she is sitting on the couch hanging her legs try to extend yhe affected leg if she is malingering there will be no pain.I don't think the issue here is whether she is malingering at the moment. And i wonder whether malingering can cause muscle spasm per se. The question here is which of the risk factors is the strongest for a prolonged episode of pain? Common sense would suggest that when people file legal action or work related injuries they tend to exaggerate their symptoms to make a greater impact on their case so therefore this would be a strong risk factor.
6. ???A 32-year-old woman comes to the physician because of
a 4-month history
of fatigue, cough, and shortness of breath with
exertion. She has had
two episodes of pneumonia and one episode of severe
sinusitis over the
past 2 years. She has never smoked. She takes no
medications.
Crackles are heard at the left lung base. An x-ray
film of the chest shows a
left lower lobe infiltrate and scarring of the right
base.
A
) Measurement of serum a1-antitrypsin level
B
) Methacholine challenge test
C
) Quantitative measurement of serum antibody levels Wegener's Granulomatosis???
D
) Sweat chloride test
E
) Ventilation-perfusion lung scans
Symptoms of alpha-1 antitrypsin deficiency include shortness of breath, wheezing, rhonchi, rales may be present and appear to be recurring respiratory infections (but isn't), or obstructive asthma that does not respond to treatment. Individuals with alpha-1 may develop emphysema during their thirties or forties, without a history of significant smoking (although smoking greatly increases the risk for emphysema). A1AD also causes impaired liver function in some patients and may lead to cirrhosis and liver failure (15%). It is the leading cause of liver transplantation in newborns.
7. ??? A 13-year-old girl is brought to the emergency department because of shortness of breath for 2 hours. The symptoms began after consuming chili, cornbread, and fruit salad with strawberries, kiwi, and bananas. She has a 1-year history of shortness of breath while playing soccer or baseball and uses a bronchodilator inhaler as needed while exercising. She is allergic to penicillin and pineapples. Her blood pressure is 80/60 mm Hg, pulse is 120/min and regular, and respirations are 20/min with use of accessory muscles. Examination of the lungs shows poor air entry bilaterally with diffuse expiratory wheezes. Which of the following is the most appropriate initial pharmacotherapy?
A) Inhaled bronchodilators
B) Inhaled cromolyn sodium
C) Inhaled ipratropium bromide
D) Intravenous corticosteroids
E) Subcutaneous epinephrine
If those vital keep on going this way, she is going to shock and die.
She has got hx of exercise induced asthma--->for which is already on prophlaxis for one yr
blood pressure is 80/60 mm Hg, pulse is 120/min and regular, and respirations are 20/min
The symptoms began after consuming chili, cornbread, and fruit salad with strawberries, kiwi, and bananas.
Hemodynamically UNSTABLE--->can be anaphylaxis-->specially with hx of multiple allergy to food and asthma hx---->E
i'll go with A.
sounds like an acute exacerbation of asthma, a person going into anaphylactic shock would most likely not make it to 2 hrs without the imm epinephrine.the important thing abt anaphylaxis is the urgency of treatment.it's touch and go. which is also why most pts with h/o allergies are advised to carry epipens with them at alltimes.
the question in addition gives us the contents of the fruit salad she had
also the previous h/o asthma, use of intercostals, expi wheeze decreased breath sounds point to a realy bad case of asthma.then it would be A , inhaled bronchodialtors and maybe systemic steroids later
my guess is the all that food was probably put in there as a distractor or maybe some food allergen triggered the asthma, as happens in people with extrinsic asthma
I think the key of this Q is this pte has INSPIRATORY problem ( poor air entry) that is more severe than just reversible obstructive disease- asthma.
Epinephrine is needed first
For asthma exacerbation, O2 , inhaled b2 agonist is 1st line, systemic steroid.
8. ???A 72-year-old man comes to the physician
because of generalized
weakness and night sweats for 6 months. During this
period he has had
a 5-kg (11-lb) weight loss. He has had polycythemia
vera for 12 years
treated with hydroxyurea and multiple phlebotomies.
Examination shows
cachexia. The liver is enlarged and nontender with a
span of 13 cm;
the spleen is enlarged. Hematocrit is 27%, leukocyte
count is 3200/mm3,
and platelet count is 150,000/mm3. A blood smear is
shown. Which of
the following is the most likely diagnosis?
A
) Acute myelogenous leukemia
B
) Cirrhosis of the liver
C
) Hodgkin's disease
D
) Miliary tuberculosis
E
) Myelofibrosis
In rare cases, polycythemia vera may lead to other blood diseases, including a progressive disorder in which bone marrow is replaced with scar tissue (myelofibrosis), a condition in which stem cells don't mature or function properly (myelodysplastic syndrome), or cancer of the blood and bone marrow (acute leukemia).
About 10 percent to 15 percent of people with myelofibrosis eventually develop acute myelogenous leukemia, a type of blood and bone marrow cancer that progresses rapidly. Myelofibrosis usually develops slowly. In its very early stages, many people don't experience any signs or symptoms. But as disruption of normal blood cell production increases, signs and symptoms may include:
Feeling tired, weak or short of breath, usually because of anemia
Pain or fullness below your ribs on the left side, due to enlarged spleen
Enlarged liver
Pale skin
Easy bruising
Easy bleeding
Excessive sweating during sleep (night sweats)
Fever
Frequent infections
Bone pain
AML may have are:
Tiredness or no energy
Shortness of breath during physical activity
Pale skin
Swollen gums
Slow healing of cuts
Pinhead-size red spots under the skin
Prolonged bleeding from minor cuts
Mild fever
Black-and-blue marks (bruises) with no clear cause
Aches in bones or knees, hips or shoulder.
10. ??? 31. A 62-year-old woman comes to the physician
because of severe
pain and swelling of her right knee for 1 day. She
has no history of
joint disease or trauma to the knee. She has
hypertension treated with
hydrochlorothiazide and type 2 diabetes mellitus
treated with glyburide.
She is sexually active only with her husband, and they
have sexual
intercourse one to two times each week. Her
temperature is 37 C (98.6 F),
blood pressure is 140/84 mm Hg, and pulse is 80/min.
Examination of
the right knee shows edema, erythema, and exquisite
tenderness to light
touch; there is an effusion. The remainder of the
examination shows no
abnormalities. Which of the following is the most
likely mechanism of
these findings?
A
) Immune complex deposition
B
) Inflammatory reaction to antisynovial antibodies Rheumatoid arthritis etiology unknown, T cell activation and infiltration, rare in HIV.
C
) Inflammatory reaction to monosodium urate
crystals
D
) Neisseria gonorrhoeae infection, sexual activity is the only risk factor, 50% are polyarticular, tenosynovitis is more common, effusion is less common, migratory polyarthralgia are common, skin manifestation.
E
) Streptococcus pneumoniae infection, nongonococcal, mcc is S . aureus, 60%, Strp 15%, Step Pneumococcus 5%. Monoarticular >85%, knee most common.
11. ???45. A 2-year-old girl has had fever and bloody
diarrhea for 10 days.
A stool culture obtained 7 days ago grew Salmonella
species sensitive
to amoxicillin. A blood culture was negative.
Despite beginning oral
amoxicillin therapy 4 days ago, her diarrhea has
persisted. Current
examination shows no other abnormalities except for a
temperature of 38.6 C
(101.5 F). Which of the following is the most likely
explanation for
the failure of amoxicillin to improve her symptoms?
A
) Amoxicillin does not alter the course of
Salmonella enteritidis
B
) Amoxicillin has caused pseudomembranous colitis
C
) Amoxicillin is absorbed at the level of the
jejunum, leaving no
drug to be delivered to the colon
D
) Oral amoxicillin is not absorbed into the
systemic circulation in
the presence of diarrhea
E
) Salmonella has expressed an inducible ß-lactamase
that inactivates
amoxicillin
Guys, the answer is probably A. There was a study done in the 1980's that looked at precisely the question whether or not ampicillins shorten Salmonelle gastroenteritis and the answer was: Noooo.
Ampicillin/amoxicillin/ceftriaxone helps in systemic S-infections.
I also read the information on Salmonelle resistant outbreaks in the community and their increase, but these Salmonella spp. primarily had a resistance gene at the outset of them infecting people, while the girl in this question has "Salmonella species sensitive to amoxicillin".
It's hard to believe a 4-day amoxicillin use would lead to pseudomembranous colitis. Clindamycin is the antibiotic classically associated with this disorder, but any antibiotic can cause the condition. Even though they are not particularly likely to cause pseudomembranous colitis, but, rather, due to their very frequent use, cephalosporin antibiotics account for a large percentage of cases.Recently, evidence has emerged to suggest that the use of ciprofloxacin (in addition to a primary causative antibiotic such as clindamycin) is associated with increased mortality in patients with pseudomembranous colitis.
|
| MAGY17
Forum Elite
Topics: 30
Posts: 234
|
1=E
2=B
3=B
4=B???????
5=B????
|
|
| |
| | |
