CK Sample questions

[aimskyhigh]

A 25-year-old man is brought to the emergency department after being discovered semiconscious and incoherent at home. On arrival, he is stuporous. His blood pressure is 105/70 mm Hg, pulse is 80/min, and respirations are 12/min. Examination shows cool, damp skin. The pupils are pinpoint and react sluggishly to light. Which of the following is the most likely substance taken?

(A) Alcohol (B) Barbiturates (C) Cocaine (D) Heroin (E) LSD


Depressants = Alcohol, Opiates(Heroin), Barbiturates, Benzos
Since pt is declining in respiration I chose Barbiturates. I don't get how the answer is D.

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[aimskyhigh]

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[LostinLift]

A 25-year-old man is brought to the emergency department after being discovered semiconscious and incoherent at home. On arrival, he is stuporous. His blood pressure is 105/70 mm Hg, pulse is 80/min, and respirations are 12/min. Examination shows cool, damp skin. The pupils are pinpoint and react sluggishly to light. Which of the following is the most likely substance taken?

(A) Alcohol (B) Barbiturates (C) Cocaine (D) Heroin (E) LSD


Depressants = Alcohol, Opiates(Heroin), Barbiturates, Benzos
Since pt is declining in respiration I chose Barbiturates. I don't get how the answer is D.

Where does it say he's declining in respiration? 12 is normal. Pinpoint pupils are a key sign of opiate use/toxicity. LSD/Cocaine withdrawal/after use can result in pinpoint pupils whereas acute intoxication causes dilation. Alcohol shouldn't cause pinpoint pupils. In general I don't think pupil changes are associated with barbituates either.

 

[Mscarn2014]

Tough question because theres so many depressants. Respiratory rate of 12 is low normal however, I believe that true resp. depression 2/2 barbs would be worse than that vs the other drugs. Pinpoint pupils and sluggish reaction I think is more the key phrase here. The others would have less so I believe.

 

[iBS1972]

From a purely exam-taking standpoint, I believe the answer would be Heroin. As Mscarn2014 has suggested, pinpoint pupils is the key phrase. Of the options listed, only opiates is classically associated with pin-point pupils, at least for USMLE. Lack of hypertension suggests against cocaine. Nothing in question suggest LSD (ie. hallucinations...).

It would be great if someone can comment on the association between pinpoint pupils and other substances, specifically alcohol and barbiturates in the real practice. As stated previously, on exams, alcohol and barbiturates are usually not associated with pinpoint pupils.

Wikitox discussion:
Large pupils suggest a toxin with anticholinergic effects (TCAs) or adrenergic drugs (cocaine, amphetamines). Adrenergic drugs do not usually lead to coma unless complicated by seizures or cerebrovascular events.

Fixed and dilated pupils may suggest a nontoxic effect such as raised intracranial pressure or brain death but drug effects on the brain stem should still be suspected. Drugs that can be the cause include baclofen, quinine or massive barbiturate or other sedative drug overdose (including carbamazepine).

Small pupils suggest opioids but neuroleptics, alcohol, benzodiazepines, isopropyl alcohol, lithium, and organophosphates may all lead to miosis - check response to naloxone.

 

[aimskyhigh]

Thank you for the great replies... For the question below I was between C, D, & E.

 

[aimskyhigh]

If it is mentioned on his card that he is an organ donor, shouldn't we start the process of organ donation since it has to be done within certain time? What else should we know about organ donation for USMLE?

 

[aimskyhigh]

I was between D and C. I think I came across another question before where ice water bath was indicated for such situations.

 

[aimskyhigh]

For this question, my dx was Cholelithiasis, I was thinking of HIDA scan of the biliary tract to be more precise. Ans is C.

 

[aimskyhigh]

This patient is a chronic smoker so I was thinking of buerger disease = vasculitis.

 

[iBS1972]

Thank you for the great replies... For the question below I was between C, D, & E.

View attachment 220390

I believe answer is decrease in cardiac output. From xray, you can see blacked out left lung, meaning patient has a pneumothorax. Furthermore, hypotension with tachycardia suggests that something is pressing on heart (tension pneumo, cardiac tamponade...). The pressure decreases cardiac output because the heart can't expand enough in diastole, so less blood is pumped out during systole.
I can see atelectasis as cause of collapsed lung, but it has to be huge; And atelectasis doesn't just happen usually. It occurs in setting of obstruction (ex. mucous).
Severe bronchospasm, no-- kid has tension pneumo (blacked out left lung, deviated trachea, hypotension with tachycardia.

 

[iBS1972]

If it is mentioned on his card that he is an organ donor, shouldn't we start the process of organ donation since it has to be done within certain time? What else should we know about organ donation for USMLE?
View attachment 220391

Yes, start organ procurement protocol immediately, as you've stated it is time-sensitive.

Basically: underage, kidney disease, HTN, DM, organ damage, HIV; I don't know why the kidney damage/HTN/DM are contraindications, perhaps others can comment. My guess is that they impair perfusion.

 

[iBS1972]

I was between D and C. I think I came across another question before where ice water bath was indicated for such situations.
View attachment 220392

You're right. Cold-shower/lower temp as fast as possible. Kid has heat-exhaustion.
Note difference between heat-exhaustion (<104F) and heat-stroke (<105F and due to heat exhaustion)
Per emedicine:
Heat Exhaustion Symptoms & Warning Signs Heat Stroke Symptoms & Warning Signs
Pale, cool, clammy skin Flushed vs. hot, dry skin
Profuse sweating vs. The person may no longer sweat due to dehydration.
Core body temperature usually is elevated to more than 100 F (37.7 C), but not above 104 F (40 C) vs. Core body temperature is 105 F (40.5 C) or more.
Dizziness or lightheadedness vs. Fainting, confusion, coma
no blood pressure changes vs. Blood pressure changes (may be high or low)
no hyperventilation vs. Hyperventilation (rapid breathing)

 

[iBS1972]

For this question, my dx was Cholelithiasis, I was thinking of HIDA scan of the biliary tract to be more precise. Ans is C.
View attachment 220393

US before HIDA, always. It is less invasive. Dx is correct. Know difference between cholelithiasis vs. cholecystitis.

 

[iBS1972]

This patient is a chronic smoker so I was thinking of buerger disease = vasculitis.
View attachment 220395

I'm not completely sure about this one. I was leaning more towards fem-pop stenosis because claudication sign is unilateral, with calf involvement. Buerger tends to affect the distal digits (fingers and toes), and since it's a systemic disease, I would think it would cause bilateral symptoms. Perhaps others can contribute.

 

[iBS1972]

Please post additional questions in Official Step2CK High Yield Concepts Thread

Thank you.

 

[aimskyhigh]

Yes, start organ procurement protocol immediately, as you've stated it is time-sensitive.

Basically: underage, kidney disease, HTN, DM, organ damage, HIV; I don't know why the kidney damage/HTN/DM are contraindications, perhaps others can comment. My guess is that they impair perfusion.

Thank you for the explanations. For this the answer was A, not D. They want "(A) Arrange for the regional organ procurement organization to address the issue with the patient's family" not "Initiate organ donation at this time".

 

[aimskyhigh]

You're right. Cold-shower/lower temp as fast as possible. Kid has heat-exhaustion.
Note difference between heat-exhaustion (<104F) and heat-stroke (<105F and due to heat exhaustion)
Per emedicine:
Heat Exhaustion Symptoms & Warning Signs Heat Stroke Symptoms & Warning Signs
Pale, cool, clammy skin Flushed vs. hot, dry skin
Profuse sweating vs. The person may no longer sweat due to dehydration.
Core body temperature usually is elevated to more than 100 F (37.7 C), but not above 104 F (40 C) vs. Core body temperature is 105 F (40.5 C) or more.
Dizziness or lightheadedness vs. Fainting, confusion, coma
no blood pressure changes vs. Blood pressure changes (may be high or low)
no hyperventilation vs. Hyperventilation (rapid breathing)

Ans to this question is C not D.

 

[aimskyhigh]

I'm not completely sure about this one. I was leaning more towards fem-pop stenosis because claudication sign is unilateral, with calf involvement. Buerger tends to affect the distal digits (fingers and toes), and since it's a systemic disease, I would think it would cause bilateral symptoms. Perhaps others can contribute.

Ans is B... Thank you for the explanation.