5 clinical mastery series medicine form questions

[vincentannie]

1. shortly after admission to hospital for an acute MI, 47yo man ECG shown. he continues to have chest pain, but vital stable. premature beats originate from ?
a) AV reentry pathway
b)atrium
c)bundle of his
d)sinus node
e)ventricles

can anyone instruct me how to paste the ekg image here? thanks

2. 52yo woman with breast cancer to ED 8 hours after 39.4C, shaking chills, generalized malaise. she has been chemo via indwelling central venous catheter for 2 mo; her last treatment was 3 wks ago. current meds: prochloperazine, lorazepam, sertaline. her bp 90/50. SaO2 99%. P/E shows no erythema surrounding catheter site. lung clear. 2/6 systolic murmur at upper left sternal border w/o radiation.
leukocyte count 3200, segmented neutrophils 70%, bands 10%, lymphocytes 12%, monocytes 8%.
urine RBC 2, WBC 2, bacteria occasional
in addition to ceftazidime, empiric antibiotic therapy for this pt should include ?
a) imipenem
b) levofloxacin
c) metronidazole
d)nafcillin
e) vancomycin (wrong)
f)no additional antibiotics

3. 52 yo obese woman to ED because of severe shortness of breath for 1 hour. healthy until 5 days ago, she had SOB with exertion. Upper respiratory tract infection 2 weeks ago. current meds: fluoxetine for depression.. 37C, 100/min, 142/88mmHg, jugular venous distention, bilateral crackels in posterior lung. 1+pitting edema of lower extremities. next step?
a)inhaled albuterol
b)IV captopril
c)iv digoxin
d)iv dobutamine (wrong)
e)iv furosemid
f)iv metoprolol
g)iv 0.9 saline

4. previously healthy 32 yo woman to ED because of intermittent burning chest pain in midsternum past 2 weeks. worse at night. relived after sitting upright. she has nausea but no SOB or palpitations. she smoke and take OCP. 37C, 80/min, 120/70mmHg, 2/6 holosystolic murmur at apex radiates to axilla. abdominal P/E mild tenderness in RUQ with no mass or organomegaly. bowel sounds normal. next step?
a) beta-blocker
b)ct chest
c) hepatobiliary scan
d)oral H2 blocker
e)oral NSAID
f)stress test
g)reassurance
h)sublingual nitroglycerin
i)ultrasonography of abdomen
j)upper endoscopy
k)upper GI series
l) ventilation perfusion lung scan
m) CXR

5. 57yo woman to ED 4 hours after onset of confusion and drowsiness. she has 2 day history of nausea and vomitting and generalized weakness. diagnosed with breast cancer metastatic to bone 1 year ago now receive pamidronate and tamoxifen. P/E sunken eyes and dry mucous. serum calcium 16. next step?
a) intramuscular calcitonin (wrong)
b)iv furosemide
c)iv mithramycin
d)iv pamidronate
e)iv 0.9% saline

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[CaliAtenza]

2. Its Imipenem. The woman is on chemo for her breast CA and has developed febrile neutropenia. Although, according to Uptodate, ANC has to be 500 or below, but Uworld still says 1500. In any case, we got to protect against Pseudomonas here. I've gotten questions like this both in the NBMEs and Uworld. If I recall, I may have gotten one in my real exam as well, but I can't remember now lol.
3. IV Furosemide.
4. No alarm symptoms here, and she's not older than 55, so we can try Oral H2 Blocker, which is answer choice d. She's probably having some GERD, possibly due to the smoking.
5. She has sunken eyes and dry mucous, which are signs of severe dehydration. Her confusion and drowsiness are also indicators to that diagnosis. Give her iv 0.9% saline.

 

[bearboots]

Hey CaliAtenza or, what are you using to study to help in answering or coming up with a better thought process in those questions?

 

[vincentannie]

2. Its Imipenem. The woman is on chemo for her breast CA and has developed febrile neutropenia. Although, according to Uptodate, ANC has to be 500 or below, but Uworld still says 1500. In any case, we got to protect against Pseudomonas here. I've gotten questions like this both in the NBMEs and Uworld. If I recall, I may have gotten one in my real exam as well, but I can't remember now lol.
3. IV Furosemide.
4. No alarm symptoms here, and she's not older than 55, so we can try Oral H2 Blocker, which is answer choice d. She's probably having some GERD, possibly due to the smoking.
5. She has sunken eyes and dry mucous, which are signs of severe dehydration. Her confusion and drowsiness are also indicators to that diagnosis. Give her iv 0.9% saline.

Thank you! but sorry for question #5, i forgot to put her BP 142/90..so since she's not hypotension, should we choose C instead? wiki says mithramycin can be used to treat malignancy-induced hypercalcemia, but its production discontinued in 2000...

 

[CaliAtenza]

Hey CaliAtenza or, what are you using to study to help in answering or coming up with a better thought process in those questions?

I already took my exam, but it's all Uworld pretty much. Uworld and UpToDate, like what Pholston talks about in his guide. I also used First Aid for CK.

 

[CaliAtenza]

Thank you! but sorry for question #5, i forgot to put her BP 142/90..so since she's not hypotension, should we choose C instead? wiki says mithramycin can be used to treat malignancy-induced hypercalcemia, but its production discontinued in 2000...

The point about mithramycin is important, but look at her symptoms though. She has sunken eyes and dry mucous membranes. Mithramycin wouldn't help for that. She's dehydrated, so she needs fluids. The fluids would help combat both the hypercalcemia and the dehydration symptoms. She's having a hypercalcemic crisis, due to the metastatic CA. First thing to do is extensive fluids and calcitonin.

Lets say you didn't pick up on the hypercalcemic crisis part, which at first I didn't. In any case, she is having severe dehydration symptoms, so she needs the fluid for sure.

 

[ShenMeYiSi]

2. Its Imipenem. The woman is on chemo for her breast CA and has developed febrile neutropenia. Although, according to Uptodate, ANC has to be 500 or below, but Uworld still says 1500. In any case, we got to protect against Pseudomonas here. I've gotten questions like this both in the NBMEs and Uworld. If I recall, I may have gotten one in my real exam as well, but I can't remember now lol.
3. IV Furosemide.
4. No alarm symptoms here, and she's not older than 55, so we can try Oral H2 Blocker, which is answer choice d. She's probably having some GERD, possibly due to the smoking.
5. She has sunken eyes and dry mucous, which are signs of severe dehydration. Her confusion and drowsiness are also indicators to that diagnosis. Give her iv 0.9% saline.

For #2, I think the answer is F-no extra abx needed - correct me if I'm wrong, but I think the point behind the question is that the pt has febrile neutropenia 2* to chemo, and you want to give her broad spectrum abx and cover pseudomonas, and ceftazidime does that, so she doesn't need any extra abx. i put imipenem and it was wrong, that's why I wanted to clarify as well.

 

[CaliAtenza]

For #2, I think the answer is F-no extra abx needed - correct me if I'm wrong, but I think the point behind the question is that the pt has febrile neutropenia 2* to chemo, and you want to give her broad spectrum abx and cover pseudomonas, and ceftazidime does that, so she doesn't need any extra abx. i put imipenem and it was wrong, that's why I wanted to clarify as well.

Ah damn, okay then I guess no abx would be the way to go then. Yeah ceftazadime would cover it. My thought process was right but I should have realized that ceftazadime would cover pseudomonas too. Sorry guys, my mistake! Man now I'm hoping I didn't do something like that on the real thing!

 

[vincentannie]

For #2, I think the answer is F-no extra abx needed - correct me if I'm wrong, but I think the point behind the question is that the pt has febrile neutropenia 2* to chemo, and you want to give her broad spectrum abx and cover pseudomonas, and ceftazidime does that, so she doesn't need any extra abx. i put imipenem and it was wrong, that's why I wanted to clarify as well.

agree with you. according to uptodate, in such case:
"Initiation of monotherapy with an antipseudomonal beta-lactam agent, such as cefepime,meropenem, imipenem-cilastatin, or piperacillin-tazobactam. Ceftazidime monotherapy has also been shown to be effective and continues to be used at some cancer centers"

 

[Distant]

3. 52 yo obese woman to ED because of severe shortness of breath for 1 hour. healthy until 5 days ago, she had SOB with exertion. Upper respiratory tract infection 2 weeks ago. current meds: fluoxetine for depression.. 37C, 100/min, 142/88mmHg, jugular venous distention, bilateral crackels in posterior lung. 1+pitting edema of lower extremities. next step?
a)inhaled albuterol
b)IV captopril
c)iv digoxin
d)iv dobutamine (wrong)
e)iv furosemid
f)iv metoprolol
g)iv 0.9 saline
This is a Case of Viral Carditis, where you need to give NSAIDs and Furosamide [E]

4. previously healthy 32 yo woman to ED because of intermittent burning chest pain in midsternum past 2 weeks. worse at night. relived after sitting upright. she has nausea but no SOB or palpitations. she smoke and take OCP. 37C, 80/min, 120/70mmHg, 2/6 holosystolic murmur at apex radiates to axilla. abdominal P/E mild tenderness in RUQ with no mass or organomegaly. bowel sounds normal. next step?
a) beta-blocker
b)ct chest
c) hepatobiliary scan
d)oral H2 blocker
e)oral NSAID
f)stress test
g)reassurance
h)sublingual nitroglycerin
i)ultrasonography of abdomen
j)upper endoscopy
k)upper GI series
l) ventilation perfusion lung scan
m) CXR
[M) CXR] Mitral Regurge > Left Atrial Enlargement > Compression of the Esophagus > Burning Chest pain... NEXT Step is a Chest X ray to see the LA Enlargement.

5. 57yo woman to ED 4 hours after onset of confusion and drowsiness. she has 2 day history of nausea and vomitting and generalized weakness. diagnosed with breast cancer metastatic to bone 1 year ago now receive pamidronate and tamoxifen. P/E sunken eyes and dry mucous. serum calcium 16. next step?
a) intramuscular calcitonin (wrong)
b)iv furosemide
c)iv mithramycin
d)iv pamidronate
e)iv 0.9% saline
Severe HyperCalcemia, needs Hydration immediatly [E].

 

[CaliAtenza]

Damn, number 4 is much more complicated than I thought. I totally didn't take into account the murmer... But yeah that makes sense though.

 

[MrGrrrMonster]

Just to be clear, the patient in number 2 doesn't meet criteria for neutropenia. Her ANC is greater than 1500, ( actually it's about 2500). Also, an ANC of less than 500 is considered severe neutropenia. Just symantics, but thought I would chime in. I am somewhat surprised that vancomycin wasn't correct, as with an indwelling catheter I would think you would want to cover staph and strep spp, and without knowing susceptibilities you would begin with vanc.

 

[CaliAtenza]

Just to be clear, the patient in number 2 doesn't meet criteria for neutropenia. Her ANC is greater than 1500, ( actually it's about 2500). Also, an ANC of less than 500 is considered severe neutropenia. Just symantics, but thought I would chime in. I am somewhat surprised that vancomycin wasn't correct, as with an indwelling catheter I would think you would want to cover staph and strep spp, and without knowing susceptibilities you would begin with vanc.

Are you sure about that? I calculated ANC as 960 or so.

 

[ShenMeYiSi]

for #4, I put oral H2 blocker because I thought the dx was GERD and it didn't appear on my list of wrong answers. I think it's simply GERD and they threw in the murmur to throw you off. The second question in that series is a little trickier:

15yoF with 2wk of intermittent fleeting pain under her R breast - no cough/nausea/SOB. FHx: uncle died of MI at age 38. Vitals are temp 97.4, HR: 96/min, and RR 25/min, lungs CTA. Cardiac exam shows normal s1/s2 with a midsystolic click. SaO2 on room air shows O2 sat of 98%. EKG is normal. (same answer choices)
My thoughts were that given this presentation and a positive FHx for something that looks like HOCM, do a CXR, but that was wrong. Any thoughts? Maybe it's just reassurance - because the pain is intermittent and fleeting and she is asx overall, but I worry about the midsystolic click and don't want to overlook that either - if Echo was one of the choices, I'd have chosen that.

 

[MrGrrrMonster]

Are you sure about that? I calculated ANC as 960 or so.

If her white count is 3200 with 70% neuts and 10% bands then 80% of 3200 is 2560. Also of note with that question: Since the patient is not neutropenic this looks more like endocarditis rather than sepsis secondary to a line infection. In this case, a penicillin may be appropriate, though I would still think you would start with vancomycin.

 

[MrGrrrMonster]

Cardiac exam shows normal s1/s2 with a midsystolic click

This is classical MVP. Reassurance is all that is necessary if the patient is relatively symptom free.

 

[CaliAtenza]

for #4, I put oral H2 blocker because I thought the dx was GERD and it didn't appear on my list of wrong answers. I think it's simply GERD and they threw in the murmur to throw you off. The second question in that series is a little trickier:

15yoF with 2wk of intermittent fleeting pain under her R breast - no cough/nausea/SOB. FHx: uncle died of MI at age 38. Vitals are temp 97.4, HR: 96/min, and RR 25/min, lungs CTA. Cardiac exam shows normal s1/s2 with a midsystolic click. SaO2 on room air shows O2 sat of 98%. EKG is normal. (same answer choices)
My thoughts were that given this presentation and a positive FHx for something that looks like HOCM, do a CXR, but that was wrong. Any thoughts? Maybe it's just reassurance - because the pain is intermittent and fleeting and she is asx overall, but I worry about the midsystolic click and don't want to overlook that either - if Echo was one of the choices, I'd have chosen that.

Okay so I was right on my initial thought on #4, that it was GERD. I recalled the protocols from Uworld when I was thinking about that question.

 

[PeurtoRico]

1 is e. Since the ECG was wide-complex, its originating from ventricles

1. shortly after admission to hospital for an acute MI, 47yo man ECG shown. he continues to have chest pain, but vital stable. premature beats originate from ?
a) AV reentry pathway
b)atrium
c)bundle of his
d)sinus node
e)ventricles

can anyone instruct me how to paste the ekg image here? thanks

2. 52yo woman with breast cancer to ED 8 hours after 39.4C, shaking chills, generalized malaise. she has been chemo via indwelling central venous catheter for 2 mo; her last treatment was 3 wks ago. current meds: prochloperazine, lorazepam, sertaline. her bp 90/50. SaO2 99%. P/E shows no erythema surrounding catheter site. lung clear. 2/6 systolic murmur at upper left sternal border w/o radiation.
leukocyte count 3200, segmented neutrophils 70%, bands 10%, lymphocytes 12%, monocytes 8%.
urine RBC 2, WBC 2, bacteria occasional
in addition to ceftazidime, empiric antibiotic therapy for this pt should include ?
a) imipenem
b) levofloxacin
c) metronidazole
d)nafcillin
e) vancomycin (wrong)
f)no additional antibiotics

3. 52 yo obese woman to ED because of severe shortness of breath for 1 hour. healthy until 5 days ago, she had SOB with exertion. Upper respiratory tract infection 2 weeks ago. current meds: fluoxetine for depression.. 37C, 100/min, 142/88mmHg, jugular venous distention, bilateral crackels in posterior lung. 1+pitting edema of lower extremities. next step?
a)inhaled albuterol
b)IV captopril
c)iv digoxin
d)iv dobutamine (wrong)
e)iv furosemid
f)iv metoprolol
g)iv 0.9 saline

4. previously healthy 32 yo woman to ED because of intermittent burning chest pain in midsternum past 2 weeks. worse at night. relived after sitting upright. she has nausea but no SOB or palpitations. she smoke and take OCP. 37C, 80/min, 120/70mmHg, 2/6 holosystolic murmur at apex radiates to axilla. abdominal P/E mild tenderness in RUQ with no mass or organomegaly. bowel sounds normal. next step?
a) beta-blocker
b)ct chest
c) hepatobiliary scan
d)oral H2 blocker
e)oral NSAID
f)stress test
g)reassurance
h)sublingual nitroglycerin
i)ultrasonography of abdomen
j)upper endoscopy
k)upper GI series
l) ventilation perfusion lung scan
m) CXR

5. 57yo woman to ED 4 hours after onset of confusion and drowsiness. she has 2 day history of nausea and vomitting and generalized weakness. diagnosed with breast cancer metastatic to bone 1 year ago now receive pamidronate and tamoxifen. P/E sunken eyes and dry mucous. serum calcium 16. next step?
a) intramuscular calcitonin (wrong)
b)iv furosemide
c)iv mithramycin
d)iv pamidronate
e)iv 0.9% saline

 

[zany_brainy]

1. shortly after admission to hospital for an acute MI, 47yo man ECG shown. he continues to have chest pain, but vital stable. premature beats originate from ?
a) AV reentry pathway
b)atrium
c)bundle of his
d)sinus node
e)ventricles

can anyone instruct me how to paste the ekg image here? thanks

2. 52yo woman with breast cancer to ED 8 hours after 39.4C, shaking chills, generalized malaise. she has been chemo via indwelling central venous catheter for 2 mo; her last treatment was 3 wks ago. current meds: prochloperazine, lorazepam, sertaline. her bp 90/50. SaO2 99%. P/E shows no erythema surrounding catheter site. lung clear. 2/6 systolic murmur at upper left sternal border w/o radiation.
leukocyte count 3200, segmented neutrophils 70%, bands 10%, lymphocytes 12%, monocytes 8%.
urine RBC 2, WBC 2, bacteria occasional
in addition to ceftazidime, empiric antibiotic therapy for this pt should include ?
a) imipenem
b) levofloxacin
c) metronidazole
d)nafcillin
e) vancomycin (wrong)
f)no additional antibiotics

3. 52 yo obese woman to ED because of severe shortness of breath for 1 hour. healthy until 5 days ago, she had SOB with exertion. Upper respiratory tract infection 2 weeks ago. current meds: fluoxetine for depression.. 37C, 100/min, 142/88mmHg, jugular venous distention, bilateral crackels in posterior lung. 1+pitting edema of lower extremities. next step?
a)inhaled albuterol
b)IV captopril
c)iv digoxin
d)iv dobutamine (wrong)
e)iv furosemid
f)iv metoprolol
g)iv 0.9 saline

4. previously healthy 32 yo woman to ED because of intermittent burning chest pain in midsternum past 2 weeks. worse at night. relived after sitting upright. she has nausea but no SOB or palpitations. she smoke and take OCP. 37C, 80/min, 120/70mmHg, 2/6 holosystolic murmur at apex radiates to axilla. abdominal P/E mild tenderness in RUQ with no mass or organomegaly. bowel sounds normal. next step?
a) beta-blocker
b)ct chest
c) hepatobiliary scan
d)oral H2 blocker
e)oral NSAID
f)stress test
g)reassurance
h)sublingual nitroglycerin
i)ultrasonography of abdomen
j)upper endoscopy
k)upper GI series
l) ventilation perfusion lung scan
m) CXR

5. 57yo woman to ED 4 hours after onset of confusion and drowsiness. she has 2 day history of nausea and vomitting and generalized weakness. diagnosed with breast cancer metastatic to bone 1 year ago now receive pamidronate and tamoxifen. P/E sunken eyes and dry mucous. serum calcium 16. next step?
a) intramuscular calcitonin (wrong)
b)iv furosemide
c)iv mithramycin
d)iv pamidronate
e)iv 0.9% saline

Wait, are you sure you got #2 wrong? I put vanco as my answer and I got it correct

 

[PeurtoRico]

I think I put in Vanc too and it was right.

 

[PeurtoRico]

On medicine form 2, there is a question on contact dermatitis, the correct answer to which is "avoidance of weeds." I have a hard time understanding why is that the correct answer. Since, rose thorns can cause contact dermatitis too!

 

[PeurtoRico]

Here is the question from form2:
A previously healthy 32 year old woman comes to the physician 1 day after a rash developed on her face, neck and hands. Prior to the symptom onset, she was weeding and fertilizing in the backyard. she used a sunscreen but not a hat or insect repellant. she reports receiving several scratches from rose bushes. examination shows bright red papules, vesicles and bullae, some in linear pattern on her forearm, neck and face. there are oozing vesicles over the wrists. what could prevent this rash?
a) avoidance of contact with fertilizers
b) avoidance of contact with weeds
c) avoidance of contact with rose thorns
d) avoidance of sunscreen
e) wearing insect repellant

 

[ShenMeYiSi]

Here is the question from form2:
A previously healthy 32 year old woman comes to the physician 1 day after a rash developed on her face, neck and hands. Prior to the symptom onset, she was weeding and fertilizing in the backyard. she used a sunscreen but not a hat or insect repellant. she reports receiving several scratches from rose bushes. examination shows bright red papules, vesicles and bullae, some in linear pattern on her forearm, neck and face. there are oozing vesicles over the wrists. what could prevent this rash?
a) avoidance of contact with fertilizers
b) avoidance of contact with weeds
c) avoidance of contact with rose thorns
d) avoidance of sunscreen
e) wearing insect repellant

i think the reason the answer is 'avoid weeds' here is because the pt has poison ivy. you may be leaning towards choosing to avoid rose thorns because you are suspicious of sporothrix shenckii? it's important to know that sporothrix infection spreads along dermal lymphatics and creates ulcerated lesions at sites that are distant from initial infection. vesicles, bullae and extention to neck and face point more towards poison ivy exposure because those are all areas that she might have scratched with her fingers after touching the poison ivy leaves. the answer is definitely B, but beyond that tiny explanation to rule out sporothrix, they don't specify what kind of weeds or how late the rash presented after exposure, so it doesn't give you much in the way of a time frame to diagnose that it's a delayed type hypersensitivity.

 

[PeurtoRico]

Thank you, that's really helpful!

 

[Dhenki]

Previously healthy 82 yo. man presents with a 2 mo. hx of decreased energy, 7 lb. weight loss due to loss of appetite, and is mildly emaciated. 5'7", 132 lbs. 98.6F, 68 bpm, 90/50 mmHg. Lungs are CTA and cardiac exam is normal.

Hemoglobin- 14
Leukocyte count- 7500 (Neutrophils = 56%, Eosinophils = 23%, Lymphocytes = 14%, and Monocytes = 7%).
Serum- Na = 128, K = 6, BUN = 30, and Cr = 1.6.

Next step?

A) ACTH stimulation test.
B) 3 serial stool tests for ova and parasites.
C) Blood culture.
D) HIV Ab test.
E) Renal US.
F) Bone Marrow Biopsy.

Any ideas?

 

[Dhenki]

Previously healthy 82 yo. man presents with a 2 mo. hx of decreased energy, 7 lb. weight loss due to loss of appetite, and is mildly emaciated. 5'7", 132 lbs. 98.6F, 68 bpm, 90/50 mmHg. Lungs are CTA and cardiac exam is normal.

Hemoglobin- 14
Leukocyte count- 7500 (Neutrophils = 56%, Eosinophils = 23%, Lymphocytes = 14%, and Monocytes = 7%).
Serum- Na = 128, K = 6, BUN = 30, and Cr = 1.6.

Next step?

A) ACTH stimulation test.
B) 3 serial stool tests for ova and parasites.
C) Blood culture.
D) HIV Ab test.
E) Renal US.
F) Bone Marrow Biopsy.

Any ideas?

Nevermind, it's hypoadrenalism. Answer is A.

 

[Dhenki]

82 yo. female presents with constant, increasing abdominal pain for 2 wks. Not related to eating. Associated with generalized pruritus, jaundice, and excoriations on bother UE. Pt. underwent cholecystectomy for gallstones at 58 yrs. old. She is 5'6", BMI is 28. 98.2F, 76 bpm, 142/82 mmHg. Mild epigastric tenderness with normal CBC.

Total bili = 11.9
ALP = 305
AST = 34, ALT = 42
Amylase = 56
Abdominal US shows dilation of common bile duct and pancreatic duct. Pancreas is poorly visualized b/c of overlying bowel gas.

Next step?

A) CT of abdomen.
B) MRCP.
C) Biliary Manometry.
D) Mesenteric Angiography.
E) Transhepatic Cholangiography.

I'd appreciate the help!!

 

[Dhenki]

82 yo. female presents with constant, increasing abdominal pain for 2 wks. Not related to eating. Associated with generalized pruritus, jaundice, and excoriations on bother UE. Pt. underwent cholecystectomy for gallstones at 58 yrs. old. She is 5'6", BMI is 28. 98.2F, 76 bpm, 142/82 mmHg. Mild epigastric tenderness with normal CBC.

Total bili = 11.9
ALP = 305
AST = 34, ALT = 42
Amylase = 56
Abdominal US shows dilation of common bile duct and pancreatic duct. Pancreas is poorly visualized b/c of overlying bowel gas.

Next step?

A) CT of abdomen.
B) MRCP.
C) Biliary Manometry.
D) Mesenteric Angiography.
E) Transhepatic Cholangiography.

I'd appreciate the help!!

She obviously has some sort of obstructive jaundice. I thought choledocholithiasis, so is choose B, but it was wrong.

Never mind, I'm pretty sure this is sphincter of Oddi dysfunction and the answer is C. I struggle with these biliary diseases.

 

[ShenMeYiSi]

She obviously has some sort of obstructive jaundice. I thought choledocholithiasis, so is choose B, but it was wrong.

I chose B first too and after getting it wrong, discussed it with a few people to come to this conclusion - you have to first r/o a mass at the head of the pancreas by doing a CT abdomen - this can cause obstructive jaundice also, but if you jump straight in and do an MRCP you won't be able to visualize that mass because you'll just be checking for obstructions along the biliary tract. She no longer has a gallbladder though, so the likelihood of any types of stones still in the tract is kind of low. With a CT abdomen you can first rule out pancreatic ca, and if that's negative you can proceed to MRCP.

 

[Dhenki]

I chose B first too and after getting it wrong, discussed it with a few people to come to this conclusion - you have to first r/o a mass at the head of the pancreas by doing a CT abdomen - this can cause obstructive jaundice also, but if you jump straight in and do an MRCP you won't be able to visualize that mass because you'll just be checking for obstructions along the biliary tract. She no longer has a gallbladder though, so the likelihood of any types of stones still in the tract is kind of low. With a CT abdomen you can first rule out pancreatic ca, and if that's negative you can proceed to MRCP.

Oh wow, so the answer is A? Would not have figured that out. Makes sense though to rule out pancreatic cancer. Thanks for the explanation!

 

[Dhenki]

Anyone remember the question about the 22 yo. with a closed head injury from a MVA? Initial head CT on admission was normal. 2 days later his urine output is 50mL/hr, Na = 120, and urine osmolarity = 340.

I know he has central DI secondary to trauma so I choose to do a 2nd CT scan, thinking there might be new changes but that was wrong. Now I'm thinking fluid restriction (aka water deprivation test).

A) Fluid restriction.
B) Head CT.
C) ADH.
D) 0.9% saline bolus.
E) 3% saline bolus.

 

[Dhenki]

62 yo. woman brought into the ED due to a 2 day hx of confusion. She has HTN and DM type 2. On ramipril and glipizide A&O to person but not place or time. 98.6F. Normal neuro exam.

Hct = 24%.
Leukocyte = 3400 (neutrophils = 65%, lymphocytes = 35%).
Serum- Ca = 13, Cr = 2, total protein = 9.5, and albumin = 4.5.

Next step?

A) CT of head.
B) Cefepime.
C) IV 0.9% saline.
D) LP.
E) Hemodialysis.

I think this is HHS and the answer is C but not sure.

 

[Dhenki]

52 yo. presents with increasingly severe right knee since she tripped and fell 1 wk. ago. Swelling developed but she was able to walk on it. But within the past 4 days, pain has worsened, unable to bear weight. 5 yr. hx of DM type 2 treated with metformin. Exam shows warmth and small effusion. Passive and active ROM restricted due to pain.
Leukocyte count = 10,000, ESR = 40
x-ray shows degenerative disease and osteopenia but no fracture.

Next step?

A) serum Rh factor.
B) triple- phase technetium 99m bone scam.
C) MRI of knee.
D) Aspiration of knee joint.
E) Bone biopsy.

 

[MrGrrrMonster]

No no no you're thinking of a lot of these all wrong. Let me help you some.

1. Old Woman with pruritus and painless jaundice: With obstructive (cholestatic) pattern on her LFT's you most definitely need an abdominal CT to rule out pancreatic cancer. She had a cholecystectomy, so no retained stones for her. Also, sphincter of Oddi pain is spastic, not insidious.

2. 22 yo with closed head injury has HYPOnatremia, not HYPERnatremia. With the history of head trauma you need to think of SIADH. Not DI (at least not in this setting). Water deprivation= confirmatory test for DI. Fluid restriction= treatment for SIADH, so these are different as well.

3. Lady with altered mental status and a SERUM CALCIUM of 13. Good thought on HHS with history of DM type 2, but this is not mentioned at all, and with a calcium that high, remember your stones, groans, moans, psychiatric overtones (or whatever). The answer is C (Normal saline), but not for HHS, instead for hypercalcemia.

4. Most definitely aspirate a warm and swollen joint in someone with restricted active (and especially passive) ROM with an effusion and a history of trauma to the area.

Hope this helps, wasn't trying to bring you down at all. This is a perfect example of why its important on programs like Uworld to look at even the ones you get right. Because you may get them right, but for the completely wrong reason. Good Luck!!

 

[Dhenki]

No no no you're thinking of a lot of these all wrong. Let me help you some.

1. Old Woman with pruritus and painless jaundice: With obstructive (cholestatic) pattern on her LFT's you most definitely need an abdominal CT to rule out pancreatic cancer. She had a cholecystectomy, so no retained stones for her. Also, sphincter of Oddi pain is spastic, not insidious.

2. 22 yo with closed head injury has HYPOnatremia, not HYPERnatremia. With the history of head trauma you need to think of SIADH. Not DI (at least not in this setting). Water deprivation= confirmatory test for DI. Fluid restriction= treatment for SIADH, so these are different as well.

3. Lady with altered mental status and a SERUM CALCIUM of 13. Good thought on HHS with history of DM type 2, but this is not mentioned at all, and with a calcium that high, remember your stones, groans, moans, psychiatric overtones (or whatever). The answer is C (Normal saline), but not for HHS, instead for hypercalcemia.

4. Most definitely aspirate a warm and swollen joint in someone with restricted active (and especially passive) ROM with an effusion and a history of trauma to the area.

Hope this helps, wasn't trying to bring you down at all. This is a perfect example of why its important on programs like Uworld to look at even the ones you get right. Because you may get them right, but for the completely wrong reason. Good Luck!!

Thank you!!! I really appreciate these explanations. Didn't realize I was getting concepts mixed up like that.

 

[ilovemed1]

Hi everyone, some Form 2 Questions... if someone could explain these answers that would be great!!

1) For 2 mo, a 27 year old woman has hip pain that is most severe with weight bearing. She takes ibuprofen occasionally for headaches and methylprednisolone for SLE. There is no other history of serious illness. She walks with a marked limp. Passive and active movement causes pain. An Xray is shown (see attachment). Which is the most likely diagnosis?
a) osteonecrosis (i think this is the answer..?)
b) reactive arthritis
c) rheumatoid arthritis
d) septic arthritis
e) stress fracture
f) transient osteoporosis

2) 27 year old man, HIV+. On antiretrovirals and double strength of TMP/SMX qd. Labs show CD4 of 110, a + toxoplasma antibody assay, and a + hep B surfance antibody assay. What is the most appropriate next step to assess this patients risk for illness related to opportunistic infx?
a) PPD
b) sputum cytology
c) Urine CMV assay
d) MAC stool culture
e) Chest XR (I was thinking about PCP even though he was on tmp/smx and his cd4 was <200)

3) Question about PKD.. newly diagnosed in a 42 year old..asks about if her 3 kids would inherit it. Her parents/siblings do not have the disorder or does the her husband. What is the risk?
a) 50% because its AD
b) 25% since it is controlled by many genes
c) 100% since it is X-linked
d) no risk since its a new mutation
e) no risk bc its not a genetic disorder

ok so... not sure why this question tripped me up so bad. I thought PKD can be AR/AD/acquired depending on the type...confused as to what the answer would be.

4) 48 year old man with upper abdominal pain, n/v X 2 days. Productive cough for 3 mo. Alcoholic and drinks a 12 pack daily. Smoked 2ppd X30 years/ Temp is 101, pulse 120, resp 16, bp 90/55. Coarse breath sounds are head on auscultation. CV exam is normal. Tenderness with voluntary guarding in the LUQ, - bowel sounds. +occult blood in stool. Calcium is 7.6, and serum albumin is 3.5... Diagnosis?
- addisons
- hyperPTH
- hypoalbumin
- hypomag
-hypoPTH
- lithium carbonate tox
- massive cell lysis
- metastatic malignancy
- milk alkali
- pancreatitis
- rhabdo
- sarcoid
- TB
-vit D def

 

[noxe]

Hi everyone, some Form 2 Questions... if someone could explain these answers that would be great!!

1) For 2 mo, a 27 year old woman has hip pain that is most severe with weight bearing. She takes ibuprofen occasionally for headaches and methylprednisolone for SLE. There is no other history of serious illness. She walks with a marked limp. Passive and active movement causes pain. An Xray is shown (see attachment). Which is the most likely diagnosis?
a) osteonecrosis (i think this is the answer..?)
b) reactive arthritis
c) rheumatoid arthritis
d) septic arthritis
e) stress fracture
f) transient osteoporosis



2) 27 year old man, HIV+. On antiretrovirals and double strength of TMP/SMX qd. Labs show CD4 of 110, a + toxoplasma antibody assay, and a + hep B surfance antibody assay. What is the most appropriate next step to assess this patients risk for illness related to opportunistic infx?
a) PPD
b) sputum cytology
c) Urine CMV assay
d) MAC stool culture
e) Chest XR (I was thinking about PCP even though he was on tmp/smx and his cd4 was <200)

3) Question about PKD.. newly diagnosed in a 42 year old..asks about if her 3 kids would inherit it. Her parents/siblings do not have the disorder or does the her husband. What is the risk?
a) 50% because its AD
b) 25% since it is controlled by many genes
c) 100% since it is X-linked
d) no risk since its a new mutation
e) no risk bc its not a genetic disorder

ok so... not sure why this question tripped me up so bad. I thought PKD can be AR/AD/acquired depending on the type...confused as to what the answer would be.

4) 48 year old man with upper abdominal pain, n/v X 2 days. Productive cough for 3 mo. Alcoholic and drinks a 12 pack daily. Smoked 2ppd X30 years/ Temp is 101, pulse 120, resp 16, bp 90/55. Coarse breath sounds are head on auscultation. CV exam is normal. Tenderness with voluntary guarding in the LUQ, - bowel sounds. +occult blood in stool. Calcium is 7.6, and serum albumin is 3.5... Diagnosis?
- addisons
- hyperPTH
- hypoalbumin
- hypomag
-hypoPTH
- lithium carbonate tox
- massive cell lysis
- metastatic malignancy
- milk alkali
- pancreatitis
- rhabdo
- sarcoid
- TB
-vit D def

1) Yes , it is A. Chronic steroid use and excessive alcohol causes avascular necorsis of bone (osteonecrosis)
2) I believe I picked D for this question and got it right. It's beyond me to explain this beside 'risk for illness related to opportunistic infx' which I thought MAC would be the case, though it came down to picking between CMV or MAC, and I went with MAC
3) It is A, adult polycystic kidney dz is autosomal dominant, hence it is 50% risk
4) This was a tough one, I guessed Pancreatitis, nothing else really made sense to me, and it was correct. If someone has an explanation for it, would be interested in this also.

 

[ilovemed1]

1) Yes , it is A. Chronic steroid use and excessive alcohol causes avascular necorsis of bone (osteonecrosis)
2) I believe I picked D for this question and got it right. It's beyond me to explain this beside 'risk for illness related to opportunistic infx' which I thought MAC would be the case, though it came down to picking between CMV or MAC, and I went with MAC
3) It is A, adult polycystic kidney dz is autosomal dominant, hence it is 50% risk
4) This was a tough one, I guessed Pancreatitis, nothing else really made sense to me, and it was correct. If someone has an explanation for it, would be interested in this also.

hey thanks....

so for the PKD question (i know).......... how did you get A? wouldn't her parents have the disease too? Or is it the whole variable penetrace thing.. ::insert brain fart::

 

[Newyorkgiants]

1) Yes , it is A. Chronic steroid use and excessive alcohol causes avascular necorsis of bone (osteonecrosis)
2) I believe I picked D for this question and got it right. It's beyond me to explain this beside 'risk for illness related to opportunistic infx' which I thought MAC would be the case, though it came down to picking between CMV or MAC, and I went with MAC
3) It is A, adult polycystic kidney dz is autosomal dominant, hence it is 50% risk
4) This was a tough one, I guessed Pancreatitis, nothing else really made sense to me, and it was correct. If someone has an explanation for it, would be interested in this also.

For number 2 the actual answer is A. MAC is an opportunistic infection when the cd4<50. There are no tests to really assess the risk for infection with CMV and MAC. The only answer choice that actually assess a risk would be a PPD. A positive ppd would indicate a Latent TB infection. With HIV and a low CD4 count there is a risk of transformation of the latent TB into an active infection. Testing for MAC and CMV won't assess the risk it will just diagnose you with an opportunistic infection. I took this test online and A was the correct answer.

 

[Elixir6]

For #2, I think the answer is F-no extra abx needed - correct me if I'm wrong, but I think the point behind the question is that the pt has febrile neutropenia 2* to chemo, and you want to give her broad spectrum abx and cover pseudomonas, and ceftazidime does that, so she doesn't need any extra abx. i put imipenem and it was wrong, that's why I wanted to clarify as well.

@CaliAtenza

I also put imipenem and was wrong. Plus ANA is >1500

Seems like a few people put vanc, and got it right. I understand now that they want coverage against MRSA sepsis and that's why they want vanc. I thought imipenem had that coverage but I'm wrong! Live and learn.

 

[doc0610]

for question 4, he is an alcoholic, so his low calcium level would be due to low magnesium levels? won't that make sense?

 

[doc0610]

No no no you're thinking of a lot of these all wrong. Let me help you some.

1. Old Woman with pruritus and painless jaundice: With obstructive (cholestatic) pattern on her LFT's you most definitely need an abdominal CT to rule out pancreatic cancer. She had a cholecystectomy, so no retained stones for her. Also, sphincter of Oddi pain is spastic, not insidious.

2. 22 yo with closed head injury has HYPOnatremia, not HYPERnatremia. With the history of head trauma you need to think of SIADH. Not DI (at least not in this setting). Water deprivation= confirmatory test for DI. Fluid restriction= treatment for SIADH, so these are different as well.

3. Lady with altered mental status and a SERUM CALCIUM of 13. Good thought on HHS with history of DM type 2, but this is not mentioned at all, and with a calcium that high, remember your stones, groans, moans, psychiatric overtones (or whatever). The answer is C (Normal saline), but not for HHS, instead for hypercalcemia.

4. Most definitely aspirate a warm and swollen joint in someone with restricted active (and especially passive) ROM with an effusion and a history of trauma to the area.

Hope this helps, wasn't trying to bring you down at all. This is a perfect example of why its important on programs like Uworld to look at even the ones you get right. Because you may get them right, but for the completely wrong reason. Good Luck!!

For the fourth one, her WBC's aren't that high for a septic joint, am I wrong? Also, since she had a fall and Rom is decreased, it could be a meniscal tear? Do an MRI maybe?

 

[MrGrrrMonster]

For the fourth one, her WBC's aren't that high for a septic joint, am I wrong? Also, since she had a fall and Rom is decreased, it could be a meniscal tear? Do an MRI maybe?

They aren't that high, but with a warm joint that has been passively getting worse over a week and an ESR of 40 with a restricted ROM... Tap it.

Also, the WBC is not her joint white count obviously. But she also has DM type 2, so she may have a mild degree of immunodeficiency as well and might not mount as robust of a response. It's easy, cheap, and therapeutic/diagnostic to tap a joint vs. an expensive MRI that if it shows fluid/ inflammation, you still need to tap it to do cultures, sensitivities, and treat.

 

[doctorbunny]

Help with a few more pretty please?

31. Healthy 72 yo woman in ED after being found on floor. Tripped and fell 2 days ago, couldn't get up. Alert, lethargic, pain in right hip. Pulse 140 regular
BP 88/54 mmHg
PE shows dry mucus membranes, dry axillary, R leg is shorter than L and held in external rotation.
Hb 17.5
Leuk's 14,500
Serum Na 155
Glucose 295
Xray shows fracture of femoral neck. Most appropriate next step?
A. IV 5% dextrose in water only
B. IV 5% dextrose in water + subQ insulin
C. IV dopamine
D. IV 0.45% saline *wrong
E. IV 0.9% saline
F. SubQ insulin only


34. 37 yo white woman w 2 days of painful pumps on her right index finger. 3 years ago same thing resolved without tx. No relevant PMH, no medications. Works as respiratory therapist. PE shows tender lesions. No other abnormalities. Which of the following is the most appropriate?
A. topical betamethasone
B. oral acyclovir
C. oral dicloxacillan *wrong
D. IV cefazolin
E. surgical incision + drainage

 

[dfib slim]

Help with a few more pretty please?

31. Healthy 72 yo woman in ED after being found on floor. Tripped and fell 2 days ago, couldn't get up. Alert, lethargic, pain in right hip. Pulse 140 regular
BP 88/54 mmHg
PE shows dry mucus membranes, dry axillary, R leg is shorter than L and held in external rotation.
Hb 17.5
Leuk's 14,500
Serum Na 155
Glucose 295
Xray shows fracture of femoral neck. Most appropriate next step?
A. IV 5% dextrose in water only
B. IV 5% dextrose in water + subQ insulin
C. IV dopamine
D. IV 0.45% saline *wrong
E. IV 0.9% saline
F. SubQ insulin only

NS first, not 1/2NS

34. 37 yo white woman w 2 days of painful pumps on her right index finger. 3 years ago same thing resolved without tx. No relevant PMH, no medications. Works as respiratory therapist. PE shows tender lesions. No other abnormalities. Which of the following is the most appropriate?
A. topical betamethasone
B. oral acyclovir
C. oral dicloxacillan *wrong
D. IV cefazolin
E. surgical incision + drainage

Sounds like herpetic whitlow

 

[Oxymoron]

Form 4.50 77 yof w/ 3 day hx n/v and abdominal cramps. No fever. Type II DM. PSH lap chole
HR 100 BP 110/70. Abdominal exam: mild distention, tenderness, w/o rebound/guarding. BS increased and high pitched. Labs show leukocytosis, Cr 1.2. AXR shows dilated loops of small bowel and air fluid levels w/o a clear transition zone or free air. Dx?
a. adhesions b. diabetic neuropathy c. inguinal hernia d. mesenteric ischemia (wrong) e. sigmoid volvulus.
What's the significance of no transition zone?

 

[medicoQA]

I chose B first too and after getting it wrong, discussed it with a few people to come to this conclusion - you have to first r/o a mass at the head of the pancreas by doing a CT abdomen - this can cause obstructive jaundice also, but if you jump straight in and do an MRCP you won't be able to visualize that mass because you'll just be checking for obstructions along the biliary tract. She no longer has a gallbladder though, so the likelihood of any types of stones still in the tract is kind of low. With a CT abdomen you can first rule out pancreatic ca, and if that's negative you can proceed to MRCP.

Yes i think you are right, what if this was a young pt ? Then MRCP would be first choice ?