hawaiii
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please explain reason for the option choosen??
1--A 56-year-old Native American man returns to the office to discuss results of studies obtained during a previous visit 8 weeks ago. The patient has a 19-year history of diabetes mellitus treated with sulfonylurea. He checks his serum glucose concentration approximately once daily. He does not smoke cigarettes and rarely drinks alcoholic beverages. He is 183 cm (6 ft) tall and weighs 76 kg (168 lb); BMI is 23 kg/m2. Vital signs during the previous visit were temperature 36.9°C (98.4°F), pulse 82/min, and blood pressure 130/85 mm Hg. Physical examination of the neck disclosed a right-sided carotid bruit. Examination of the extremities disclosed diminished pulses with associated hair loss over both legs. Hemoglobin A1c was 7.2%. Urine albumin-creatine ratio was 62 mg/g/24 h (N<30). Ankle-brachial index (ABI) was 0.89 on the left and 0.98 on the right; duplex carotid ultrasonography showed nonulcerated plaque with 70% stenosis in the right internal carotid artery. The patient was referred to an ophthalmologist, who diagnosed him with nonproliferative background diabetic retinopathy. Which of the following findings in this patient is of most concern?
A
) 70% stenosis of the right carotid artery
B
) Hemoglobin A1c of 7.2%
C
) Left ABI of 0.89
D
) Nonproliferative diabetic retinopathy
E
) Urine albumin-creatine ratio of 62 mg/g/24 h
2-- A 25-year-old woman returns to the office because of intermenstrual spotting since beginning oral contraceptive therapy 6 months ago. This is her first attempt at oral contraceptive therapy; she and her partner primarily used condoms for contraception in the past. Before this current therapy her menstrual periods had always been regular. Which of the following is the most appropriate management?
A
) Advise her to take two pills daily until the bleeding stops
B
) Discontinue the oral contraceptive therapy and have her resume use of condoms for birth control
C
) Reassure her that the bleeding problem will resolve in a few months
D
) Switch the current oral contraceptive pill to one containing a higher estrogen dose
E
) Switch to a progestin-only oral contraceptive pill
3-- A 23-year-old white nulligravid woman returns to the office for follow-up of a 2-year history of primary infertility. Menstrual periods occur at regular 28-day intervals. She has a history of chronic pelvic pain. Analysis of her husband's semen shows a sperm count of 40 million with 65% motility and normal morphology. Diagnostic laparoscopy with hydrotubation shows normal pelvic anatomy, with no evidence of endometriosis or pelvic adhesions. Both fallopian tubes spill methylene blue dye. The patient's basal body temperatures recorded during the past month are shown. Which of the following is the most likely cause of the patient's inability to conceive?
A
) Anovulation
B
) Male factor infertility
C
) Old pelvic inflammatory disease
D
) Polycystic ovary syndrome
E
) No cause can be identified at this time
4-- In the course of routine prenatal care at the health center, a 30-year-old Hispanic woman is found to have gestational diabetes. This is her first pregnancy and she is at 20 weeks' gestation. She should be counseled that adequate prenatal care, including regular determination of blood glucose concentrations and adherence to a controlled dietary regimen, may reduce the possibility of which of the following?
A
) The fetus developing macrosomia
B
) Her developing essential hypertension
C
) Her developing type 1 diabetes mellitus in the future
D
) Intrauterine growth restriction
E
) Premature delivery
5- 34-year-old man comes to the office with his wife and daughter because he has had some dusky lesions on his shoulder for the past 2 months. He says that two have become larger during the past week. He and his wife have recently adopted an 18-month-old girl from the Ukraine who has a similar rash. He is an environmental scientist and his work requires him to travel overseas and work outdoors. He is concerned about the possibility of skin cancer. Vital signs are normal. Physical examination shows a cluster of six discrete papular lesions on his left shoulder that are slightly tender. These lesions have a central depression containing some pus-like material. There is no axillary or cervical adenopathy. Which of the following is the most appropriate management for the patient?
A
) Acyclovir
B
) Scabicidal cream
C
) Topical corticosteroid cream
D
) Topical fluconazole
E
) Topical liquid nitrogen
6-A 10-year-old Asian-American boy is brought to the office for a sports physical examination. He has been healthy except for a few episodes of otitis media as an infant. He has had no shortness of breath, syncope or chest pain in the past. Growth has been normal. Vital signs are: temperature 36.6°C (97.8°F), pulse 80/min, respirations 16/min, and blood pressure 110/76 mm Hg. Cardiac examination discloses an early systolic click at the apex, a midsystolic ejection murmur at the right upper sternal border and a thrill in the suprasternal notch. The remainder of the physical examination is normal. The patient is referred to the cardiologist and the diagnosis of aortic stenosis is confirmed by echocardiogram. Close follow-up and graded exercise testing are recommended. The patient is at increased risk for which of the following?
A
) Atrial arrhythmias
B
) Complete heart block
C
) Coronary artery disease
D
) Pulmonary hypertension
E
) Sudden death
7-- A 12-year-old Haitian boy is brought to the health center for the first time by his mother and maternal grandmother. The mother states, "There was a voodoo curse placed on my family and now my son is having problems because of that." She reports that for the past 6 months he has been talking back to his teachers, has been suspended from school for skipping class, and has been defiant with all adults. He is failing two subjects in school and will need to attend summer classes. His medical history is significant for an allergy to sulfa drugs, a positive PPD skin test for which he was treated prophylactically at age 10 years, and encopresis that resolved. He currently takes no medications. The patient is 163 cm (5 ft 4 in) tall and weighs 49 kg (108 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 80/min, respirations 18/min and blood pressure 90/50 mm Hg. Which of the following is the most appropriate opening statement to the mother?
A
) "Do you think your son may be taking drugs?"
B
) "I suggest you consult a voodoo priest for help with this problem."
C
) "Tell me more about the voodoo and its effect on your son's behavior."
D
) "There is no such thing as voodoo."
E
) "Voodoo does not cause children to have bad behavior."
8-You are invited to a council meeting of Native-Americans to discuss a heptavalent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar7) for use in the community's children, many of whom are younger than age 12 months. All of the infants and children in the community are up-to-date on standard recommended vaccinations. The council spokesperson says, "We are skeptical about the safety of giving our sons and daughters yet another vaccine." Which of the following is the most compelling reason to recommend vaccination of all infants younger than 12 months of age?
A
) Administration of the vaccine will decrease the incidence of invasive pneumococcal disease among the children in the community
B
) Administration of the vaccine will decrease the likelihood of secondary pneumonia during respiratory syncytial virus (RSV) season
C
) Administration of the vaccine will significantly decrease the severity of acute otitis media and prevent hearing loss
D
) Native-American children make ineffective antibodies when the 23-valent pneumococcal vaccine alone is administered to them
E
) The peak incidence of pneumococcal disease occurs in children younger than 12 months of age
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| hawaiii
Forum Senior
Topics: 19
Posts: 103
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nobody
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| hero
Forum Guru
Topics: 42
Posts: 557
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is it nbme?
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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1E DM with renal =bad (imho, if it is a bad value :P i didnt check/dont know values)
2D ?
3 no picture ...either A or E (if that sperm analysis is good?)
4A (or E?)
5...call Dermato consult STAT, in the mean time rub some steroids on it... :P (dont know)
6A (or D or E) 
7C
8A or B...no idea.
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| sandra
Forum Guru
Topics: 201
Posts: 472
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1-a
2-c
3-?
4-a
5-b
6-e
7-c
8-a
please post the right answers if u've them
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| arlete
Forum Fanatic
Topics: 50
Posts: 3,569
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1 - A
2 - D
4 - A
5 - D
6 - E
7 - C
8 - A
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| hero
Forum Guru
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is it NBME?
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| usmletopper2
Forum Senior
Topics: 32
Posts: 140
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1 E,(Carotid artery stenosis with no symptoms no need to rx)
2.D(i'm not sure)
3.---no pic
4.A
5.A????--Molluscum contagiosum-pox virus
6.E???????sounds more of hocm rather than AS
7.C
8.A
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| mukho
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1E--in the given case as end organ damage, kidney should be most important
2C--intermenstural bleeding is common S/E; usually seen in first 3 cycles
3A--no pic but sounds like anovulation
4A--nothing else is prevented
5E--umbilicated lsions are molluscum contagiosum; treatment includes cryo with liq notrogen; topical antiviral like cidofovir (not acyclovir) are also used
6E--AS or HOCM or AS like pic because of HOCM, any case sudden death in chlid
7C--open ended cross culturally sensitive question
8A--recommended for <2 yrs children for preventing invasive diease
these are from UW i think
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| peter90036
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#2, true, but its been 6 months...
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| hawaiii
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Topics: 19
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[
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| mukho
Forum Elite
Topics: 6
Posts: 558
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peter u do have a point there so i searched a bit and found the following:
What is the best treatment for intermenstrual bleeding on the combined oral contraceptive pill (OCP)?
Reassurance is often the best approach to this common concern, as break through bleeding usually disappears by the third pill cycle. If breakthrough bleeding persists beyond three months the clinician should rule out infection or cervical disease and ensure correct use. If breakthrough bleeding still persists it might be worthwhile to try a combined OCP with another category of progestin or change to a 50ug estrogen combined OCP. Unfortunately, no good evidence supports any of the numerous published recommendations for the management of intermenstrual bleeding. A short course of exogenous estrogen such as conjugated estrogen, 1.25 mg conjugated estrogen or estradiol 1-2 mg can be administered when the bleeding is present no matter where a woman is in her cycle. A woman should continue to adhere to the schedule of pill taking. Doubling up or tripling up on the pill increases the risk of estrogen related side effects without altering the ratio of estrogen to progestin that may be responsible for the endometrial instability -and has not been shown to be effective. Given the gradual decline in bleeding over the first six months, changing formulations before six months of use is not generally warranted.
So yes, D after 6 mnths sounds more appropriate...but the more I read on the topic more confused I'm getting and as I am a pediatrician i decided to quit while still ahead!!
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| arlete
Forum Fanatic
Topics: 50
Posts: 3,569
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usmletopper2:
Assymptomatic patients with carotid stenosis greater or equal to 70% ARE treated with intervention (CEA, CAS) when perioperative risk is <3% and life expectancy is greater than 5 years, and medically in other situations (Aspirin and risk factors control). But I am not sure if it's A or E.
mukho:
The answer is D according to a recent lecture I attended. I think that's an NBME question.
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| mukho
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aah..thanks for that arlete...
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| Anand007
Forum Senior
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i also agree with arlete.. patients below 60years with 70% stenosis need intervention, even if asymptomatic
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| peter90036
Forum Elite
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is DM with renal disease perioperative risk <3% ...?
people can live a long time with unilateral carotid stenosis since the other side can compensate. sure there is some risk of emboli....
imma go look it up... i gotta go now...
Edited by peter90036 on 06/12/08 - 09:23 AM
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| mukho
Forum Elite
Topics: 6
Posts: 558
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finding of most concern should that which is pronounces gravest prognosis...from end organ damage point of view most concerning will be kidney...especially because u can intervene for carotid stenosis (transplantation, dialysis less permanent) it is less concerning...at least thats why i said kidney
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| Anand007
Forum Senior
Topics: 5
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i thought proteinuria isnt very bad in this case.. and adding ACE inhibitors would be sufficient to control it ..
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| hope4dabest
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For Q2-- ??? changing it to higher estro pill will make endometerium more stable and so more intermenstural bleed ???? can anyone explain why is it D ??
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| hope4dabest
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Posts: 438
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i mean will make endometerium more *unstable*...
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