Internal Medicine: NBME 1 and 2 thread

[Apoplexy__]

Post and answer questions about the NBME's for IM here. Be sure and paraphrase/reword any questions you ask to avoid copyright infringement.

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[Apoplexy__]

Thanks, both of you. I think your NBME 1 answers sound great. Maybe someone who got the NBME 2 Q's in question correct could stop in sometime in the future.

Not sure if you're allowed to post these questions. That being said, here is my help before this post gets deleted

I don't think there's any problem with posting them since I paraphrased all the Q's. Pretty sure I saw a thread where people who were posting copy-pastes of the Q's had their posts deleted and the mod told them to paraphrase at least.

 

[Vexare]

My thought process for the NBME 2 skin lesion question was the same -- definitely thought sporotrichosis as a knee-jerk for linear cutaneous lesions, but the face+neck threw me off. Vexare, any particular weed you're suspecting, or are you just thinking some sort of contact dermatitis based on the dermatopathological description?

To be honest I have no idea which weeds in particular could cause it, I just thought of contact dermatitis based on the description and guessed that weeds would be the most common culprit of those 3 answer choices dealing with "avoidance of contact."

 

[evilbooyaa]

Oh, OK. I wasn't aware you had paraphrased. I believe if you paraphrase it is OK.

Regarding NBME 2 - Yeah, I really don't know about that first one. I feel like contact dermatitis for #2 wouldn't sound so ugly though (bullae, vesicles, etc.) generally contact dermatitis is erythema maybe with macules/papules/maybe vesicles.

I just see linear and roses and knee jerk to that. If it's a trick question then it got me. Remember that supraclav nodes are in the neck and routinely drain axillary nodes (which drain the arm). The bit about the face I guess I don't know.

 

[Apoplexy__]

Are these from the Mastery Clinical Series from the NBME?

Yep, exactly.

 

[DermViser]

Yep, exactly.

I'm just surprised the questions are so small. Usually they're huge vignettes.

 

[Apoplexy__]

I'm just surprised the questions are so small. Usually they're huge vignettes.

Nah, they're bigger. I trimmed the fat and reworded (except for key phrasing) in order to post them here.

 

[mt10eers2016]

To be honest I have no idea which weeds in particular could cause it, I just thought of contact dermatitis based on the description and guessed that weeds would be the most common culprit of those 3 answer choices dealing with "avoidance of contact."

Poison Ivy or poison oak or poison sumac are likely what they are getting at.

 

[sjonies88]

Couple questions I wanted to ask!

-What's the typical BP difference in the arms needed for coarct? Is it as small of a difference as, say 180 and 185 systolic, or does it need to be much wider?

-middle aged male, 4 day progressive SOB and productive cough with yellow sputum. has COPD tx w ipratropium but this is not working anymore. heavy smoker in the past, quit 6 months ago. works in homeless shelter for 10 years. afebrile, tachycardic, tachypneic, 130/80, decreased breath sounds with rhonchi. pulse ox 90% room air, CXR shows hyperinflation of lungs.

I narrowed this down to TB, bronchitis or community acquired pneumonia. Chose TB because I felt like the shelter work fit better with that than bronchitis, and thought he would have a fever with CAP, but TB was wrong. thoughts?

-42 yo female with new poylcystic kidney disease and wants to know if her kids will get it. her parents and three kids do not have the disease and neither does the kids' father. risk of PKD in her kids is?
options were 50% because it is AD, 25% because it is controlled by several genes, 100% for each male since it is X linked, or no risk since patient represents a new mutation or no risk since it is not genetic
This confused me because I know PKD is AD but if it is AD, how do neither of her parents have it??

Thank you!

 

[sjonies88]

@kirbymiester - thank you for your input! The bronchitis/TB question was NBME form 2.

 

[Apoplexy__]

@kirbymiester - thank you for your input! The bronchitis/TB question was NBME form 2.

No prob. Yeah, I just checked and the answer is bronchitis.

 

[metukah]

did you guys find that there was any difference in terms of difficulty between form 1 and 2?
and any idea of how predictive they are?
thanks

 

[Apoplexy__]

[

did you guys find that there was any difference in terms of difficulty between form 1 and 2?
and any idea of how predictive they are?
thanks

I did significantly better on NBME 2 and personally found it easier. My NBMEs were 5 and 15 points off my real score. In general, I'm finding the NBMEs to be significantly less predictive of shelf performance than the NBMEs for Step 1.

 

[Vexare]

I did significantly better on NBME 2 and personally found it easier. My NBMEs were 5 and 15 points off my real score. In general, I'm finding the NBMEs to be significantly less predictive of shelf performance than the NBMEs for Step 1.

Just out of curiosity, under or overprediction?

I'd be interested to see what everyone else thinks of this as well. Just from reading people's NBME scores and eventual shelf score, it seems that 3rd year NBMEs consistently underpredict how well people do. Obviously this is a good thing, but at the same time there are so many variables that it's hard to make anything of it. For example, people that barely touch UWorld still seem to score high, while others read SUTM 3x, do UWorld and whatever other resource they can and barely make the mean. Sure, the same could be said for any shelf, but I can't help but think there's an underlying correlation between step 1 score and IM shelf exam score that skews things a little. Anybody have any thoughts on that?

 

[Apoplexy__]

Just out of curiosity, under or overprediction?

I'd be interested to see what everyone else thinks of this as well. Just from reading people's NBME scores and eventual shelf score, it seems that 3rd year NBMEs consistently underpredict how well people do. Obviously this is a good thing, but at the same time there are so many variables that it's hard to make anything of it. For example, people that barely touch UWorld still seem to score high, while others read SUTM 3x, do UWorld and whatever other resource they can and barely make the mean. Sure, the same could be said for any shelf, but I can't help but think there's an underlying correlation between step 1 score and IM shelf exam score that skews things a little. Anybody have any thoughts on that?

Overprediction, for me. I kinda slacked/croaked at the tail end of studying and on test day though, so maybe that was it.

I think the Step 1 score does skew things peoples' prep stories vs. score. I scored 80 on the shelf after a 261 on Step 1. I didn't get through 400 IM UWorld Q's, and pretty much used only UWorld to study. I suppose that makes my prep less than others'.

 

[chicagostudent]

Answers in quote!

Thanks!!!!!

I'm still confused about NBME 2 Q35. So what explains the absent bowel sound, coarse breath sounds on the lung exam, and the productive cough x3 months?

 

[Apoplexy__]

Thanks!!!!!

I'm still confused about NBME 2 Q35. So what explains the absent bowel sound, coarse breath sounds on the lung exam, and the productive cough x3 months?

No problem. The productive cough for 3 months is probably unrelated, since it's a chronic condition. Probably COPD/bronchitis from smoking. Coarse breath sounds may be from smoking as well, or if they were referring to coarse crackles, it may be a sign of developing pulmonary edema/ARDS (can be seen in pancreatitis).

I had no clue about the ileus, but I guess it can be a sign of disease severity of pancreatitis according to this article:
http://www.patient.co.uk/doctor/acute-pancreatitis-pro

 

[DryHopped]

Just out of curiosity, under or overprediction?

I'd be interested to see what everyone else thinks of this as well. Just from reading people's NBME scores and eventual shelf score, it seems that 3rd year NBMEs consistently underpredict how well people do. Obviously this is a good thing, but at the same time there are so many variables that it's hard to make anything of it. For example, people that barely touch UWorld still seem to score high, while others read SUTM 3x, do UWorld and whatever other resource they can and barely make the mean. Sure, the same could be said for any shelf, but I can't help but think there's an underlying correlation between step 1 score and IM shelf exam score that skews things a little. Anybody have any thoughts on that?

The NBMEs have been random for me. Peds overpredicted, IM underpredicted, psych underpredicted. I've gotten to the point where I just use them for extra practice questions and don't think much about what I score on them.

 

[Vexare]

please can someone help me with
Not sure when this question was made but JNC-8 guidelines relaxed the 130/80 goal for diabetics to 140/90. There are some trials that show benefit from lower pressures if no adverse side effects are encountered, but this question probably has no place on a current shelf exam given the new guidelines and degree of uncertainty.

 

[Apoplexy__]

Not sure when this question was made but JNC-8 guidelines relaxed the 130/80 goal for diabetics to 140/90. There are some trials that show benefit from lower pressures if no adverse side effects are encountered, but this question probably has no place on a current shelf exam given the new guidelines and degree of uncertainty.

Ah interesting. That being said, there's currently a UWorld question in the Step 2 bank just like this where a diabetic has >140/90 and they want you to apply the principle of high-priority HTN control in diabetics. So it might still be a valuable Q, even if a little out of date.

 

[Vexare]

Ah interesting. That being said, there's currently a UWorld question in the Step 2 bank just like this where a diabetic has >140/90 and they want you to apply the principle of high-priority HTN control in diabetics. So it might still be a valuable Q, even if a little out of date.

Agreed, the concept tested is quite important. Haven't done the UWorld question you're referencing yet but it seems UWorld took the uncertainty out of the equation and made it >140/90, which is how this topic should be tested. Hopefully current shelf exams keep their intentions as clear.

 

[Apoplexy__]

Agreed, the concept tested is quite important. Haven't done the UWorld question you're referencing yet but it seems UWorld took the uncertainty out of the equation and made it >140/90, which is how this topic should be tested. Hopefully current shelf exams keep their intentions as clear.

To revisit this question/beat the dead horse, I just did another UWorld question that made it clear that UWorld is on top of the JNC-8 guidelines. A summary of UWorld's info on this topic:
-Diabetics age 40-75 all should be placed on statins regardless of lipid panel (so the patient in this Q qualifies)
-HTN meds are indicated at BP > 140/90 or >130/80 in the setting of diabetic nephropathy

There are two possibilities as to why the NBME's question has statins as the wrong answer:
-By "diabetic complications", it meant nephropathy and not atherosclerosis/CAD; an ACEI would be most suitable for that
-It is testing knowledge of outdated guidelines and is wrong

Either way, it looks like we shouldn't get caught up on this NBME Q.

 

[bearboots]

Hey, is UW for CK IM Section enough to answer this series? Or would another question - book source help? I missed the benefit of using uptodate like some students did while in rotations and so I can't imagine using it now as a starting point to learn from.

 

[general admission]

.

 

[Apoplexy__]

@general admission

1. Yeah, acyclovir. She's got opportunistic zoster in the setting of chemo immunosuppression.
2. Yep, renal tubule. Eosinophils in urine = interstitial nephritis, which among the answer choices is the only one that is really interstitial.
3. You got it, give INH in a healthcare worker with PPD > 10 cm. (UWorld QID 4470 has a great table on this)
4. Blood on dipstick can either be blood or myoglobin (a little clinical pearl). In the setting of muscle swelling and weakness, with probable ARF (oliguria), this is rhabdomyolysis.
5. Answer is lactic acid. This is shock (probably hypovolemic), secondary to diverticulitis, probably. I say probably because the acute abdomen with point tenderness, shock, and a strong leukocytosis with left shift is indicative, but the presence of a mass on PE throws me off. Either way, they were testing on you knowing the correlation between shock and lactic acidosis.

 

[general admission]

@general admission

1. Yeah, acyclovir. She's got opportunistic zoster in the setting of chemo immunosuppression.
2. Yep, renal tubule. Eosinophils in urine = interstitial nephritis, which among the answer choices is the only one that is really interstitial.
3. You got it, give INH in a healthcare worker with PPD > 10 cm. (UWorld QID 4470 has a great table on this)
4. Blood on dipstick can either be blood or myoglobin (a little clinical pearl). In the setting of muscle swelling and weakness, with probable ARF (oliguria), this is rhabdomyolysis.
5. Answer is lactic acid. This is shock (probably hypovolemic), secondary to diverticulitis, probably. I say probably because the acute abdomen with point tenderness, shock, and a strong leukocytosis with left shift is indicative, but the presence of a mass on PE throws me off. Either way, they were testing on you knowing the correlation between shock and lactic acidosis.

@general admission

Now that's service. Thanks man! Yeah, pretty much could go to what I thought was the correct answer on all of em after seeing them the second time. Just gotta become captain hindsight on the real deal haha.

 

[J ROD]

Cipro is the right answer....not sure what they say. You need an FQ to pentrate that hard to get area.

Cipro or Levaquin for around 28 days.

 

[notbobtrustme]

how the heck do you treat hypercalcemia; everyone seems to have their own algorithm. Just took NBME 2 and the question regarding the woman with metastatic breast cancer and a calcium of 16 really threw me off.

I eventually went with furosemide but that was wrong. Is it saline or the bisphophonate?

 

[Apoplexy__]

how the heck do you treat hypercalcemia; everyone seems to have their own algorithm. Just took NBME 2 and the question regarding the woman with metastatic breast cancer and a calcium of 16 really threw me off.

I eventually went with furosemide but that was wrong. Is it saline or the bisphophonate?

It's saline, I got it right.

UWorld says saline + calcitonin for acute management (notably, this NBME question had you choose saline over calcitonin), then bisphosphonates long-term.

There was actually a UWorld question just like this one which states that bisphosphonates are first line in the setting of hypercalcemia due to malignancy (having you choose bisphosphonates over saline) but that wasn't the answer in this NBME question, even though bisphosphonates were an answer choice too. Maybe it's because the patient's already been on bisphosphonates for the past year, and still on them. Or, maybe we would all do well to take this as a sign to keep it simple and say hypercalcemia --> NaCl reflexively.

 

[lordman]

@kirbymiester Are you still ready to take some form 2 questions?

 

[lordman]

1 ) The 72 y/o F with dementia asking to sign out against medical advice...MMSE is 25....I picked "Allow the patient to sign out and document in her records that she should remain at the hospital" and it was wrong....Not sure what is the correct answer. Is it "Assess her decision making capacity"? or "Discharge and schedule a f/u after 2 days"?

2) The cause of anorexia..I picked hyperkalemia haphazardly (did not have time) and it was wrong...I did not really understand the case!

3) 37 y/o woman w heartburn unresponsive to anti-acids, diarrhea and painful digital edema....Has Raynaud's in her fingers too..Choices: Amyloidosis, scleroderma, SLE, Carcinoid, or ZE Syndrome...I picked the latter and it was wrong...What is the case here? Painful digital edema!!

4) The DM question. I know this have already been discussed here...But want to make sure about some facts here...No need for ACE-I/ARB antagnosits if there is no proteinuria? In other words, aside from the ideal BP that has been discussed above, which is more important, ACE-I or Anti-lipids?

5) The transudative pleural effusion (due to CHD), what to do find in the effusion? I picked the neutrophil count > 1000 and it was wrong! I thought it was an easy question since 3 choices were those of exudative effusion criteria and eryrthrocyte count > 15,000! Explain please!!

6) The two item set....One case of 15 y/o girl with 2 week chest pain under left breast...I picked reassurance and it was correct...but what is the case here? Muskuloskeletal?!
The second case was 32 y/o woman with 2 week chest pain worse at night, improves by sitting up or walking 10 minutes...Has mild tenderness in the right upper quadrant....What is the case here? The question asks for the next management step!

7) A case of obstructive lung disease...His brother had a lung transplant for COPD...asking about the mechanism of the disease...I thought it's COPD and picked "Destructive changes in bronchial wall elastic and muscular layer....it was wrong!!

8) RA with hx of methotrexate...CBCs shows leukopenia....I thought it's drug induced myelofibrosis...wrong...Is it CLL? Platelets are normal and lymphocytes are high...so probably CLL?

9) Pilonidal sinus....I always learned in surgery that you do wide excision and leave it to hear by 2 intention...Got it wrong! Is it surgical drainage?

10) That crazy Rash q...Is it avoidance of sunscreen?

11) SOB for 5 days...Had upper resp infection 2 weeks ago...on physical exam has JV distension, S3, pitting edema....Is it dilated cardiomyopathy from myocarditis? So Lasix?


@kirbymiester @Phloston @PeurtoRico @CaliAtenza @noxe Need your help guys! I really found form 1 a bit easier than 2.....Also, how to get the most benefit out of those forms if exam so close?

 

[lordman]

As for Q4....Just check UW4336.....simvastatin should be the correct answer...

 

[lordman]

As for Q6...OK...I think of GERD now...but there was no choice of PPI!

 

[notbobtrustme]

1 ) The 72 y/o F with dementia asking to sign out against medical advice...MMSE is 25....I picked "Allow the patient to sign out and document in her records that she should remain at the hospital" and it was wrong....Not sure what is the correct answer. Is it "Assess her decision making capacity"? or "Discharge and schedule a f/u after 2 days"?

signing out AMA is always the wrong answer. You shouldn't d/c people lacking competence, so you assess her competency state.

2) The cause of anorexia..I picked hyperkalemia haphazardly (did not have time) and it was wrong...I did not really understand the case!

need more details.

3) 37 y/o woman w heartburn unresponsive to anti-acids, diarrhea and painful digital edema....Has Raynaud's in her fingers too..Choices: Amyloidosis, scleroderma, SLE, Carcinoid, or ZE Syndrome...I picked the latter and it was wrong...What is the case here? Painful digital edema!!

scleroderma. There's fibrosis of the smooth muscle which leads to malignant GERD.

4) The DM question. I know this have already been discussed here...But want to make sure about some facts here...No need for ACE-I/ARB antagnosits if there is no proteinuria? In other words, aside from the ideal BP that has been discussed above, which is more important, ACE-I or Anti-lipids?

iirc, his BP was still high for diabetics. Might as well treat with an ACE and kill 2 birds with 1 stone.

5) The transudative pleural effusion (due to CHD), what to do find in the effusion? I picked the neutrophil count > 1000 and it was wrong! I thought it was an easy question since 3 choices were those of exudative effusion criteria and eryrthrocyte count > 15,000! Explain please!!

need more details

6) The two item set....One case of 15 y/o girl with 2 week chest pain under left breast...I picked reassurance and it was correct...but what is the case here? Muskuloskeletal?!
The second case was 32 y/o woman with 2 week chest pain worse at night, improves by sitting up or walking 10 minutes...Has mild tenderness in the right upper quadrant....What is the case here? The question asks for the next management step!

first sounds like either tender breasts due to puberty or costochronditis. She had like no risk factors for anything cardiac.

need more details on the second one, but sounds like GERD/hepatitis/gastritis.

7) A case of obstructive lung disease...His brother had a lung transplant for COPD...asking about the mechanism of the disease...I thought it's COPD and picked "Destructive changes in bronchial wall elastic and muscular layer....it was wrong!!

IIRC, this was testing anti-trypsin 1 deficiency. So decreased inhibitor of protease or increased intrinsic protease activity; something along those lines.

8) RA with hx of methotrexate...CBCs shows leukopenia....I thought it's drug induced myelofibrosis...wrong...Is it CLL? Platelets are normal and lymphocytes are high...so probably CLL?

need more details.

9) Pilonidal sinus....I always learned in surgery that you do wide excision and leave it to hear by 2 intention...Got it wrong! Is it surgical drainage?

10) That crazy Rash q...Is it avoidance of sunscreen?

11) SOB for 5 days...Had upper resp infection 2 weeks ago...on physical exam has JV distension, S3, pitting edema....Is it dilated cardiomyopathy from myocarditis? So Lasix?

need some more details on what's going on/what the question was/answer choices.

 

[Apoplexy__]

Answers in blue!

1 ) The 72 y/o F with dementia asking to sign out against medical advice...MMSE is 25....I picked "Allow the patient to sign out and document in her records that she should remain at the hospital" and it was wrong....Not sure what is the correct answer. Is it "Assess her decision making capacity"? or "Discharge and schedule a f/u after 2 days"?

Assess decision making capacity. Patients with neuropsychiatric illness that make medical decisions against their own health should be evaluated for decision making capacity.

2) The cause of anorexia..I picked hyperkalemia haphazardly (did not have time) and it was wrong...I did not really understand the case!

The 90 yr old with generalized pruritis right? The answer is in the lab values. BUN and Cr are way high, and her electrolytes are all being retained. Uremia is causing pruritis and anorexia. Answer is renal failure.

3) 37 y/o woman w heartburn unresponsive to anti-acids, diarrhea and painful digital edema....Has Raynaud's in her fingers too..Choices: Amyloidosis, scleroderma, SLE, Carcinoid, or ZE Syndrome...I picked the latter and it was wrong...What is the case here? Painful digital edema!!

Yeah, scleroderma, like notbobtrustme said.

4) The DM question. I know this have already been discussed here...But want to make sure about some facts here...No need for ACE-I/ARB antagnosits if there is no proteinuria? In other words, aside from the ideal BP that has been discussed above, which is more important, ACE-I or Anti-lipids?

Answer is actually enalapril here. But I'd basically ignore this question and just follow UWorld since this Q tests on old guidelines. Like you're saying, UWorld directly contradicts this Q in QID 4336. Don't worry, I got questions similar to this one on my real deal FM shelf and they were very straightforward.

5) The transudative pleural effusion (due to CHD), what to do find in the effusion? I picked the neutrophil count > 1000 and it was wrong! I thought it was an easy question since 3 choices were those of exudative effusion criteria and eryrthrocyte count > 15,000! Explain please!!

I didn't get this one right, but they're simultaneously testing Light's criteria and the qualities of normal pleural fluid. The answer is serum glucose = pleural fluid glucose. For your own knowledge, here are 3 normal characteristics of pleural fluid:
-RBC < 1000
-WBC < 1000
-Pleural glucose = serum glucose

And here are Light's criteria, any one of which indicate exudative effusion:
-Pleural albumin >50% of serum albumin
-Pleural LDH >60% of serum LDH
-Pleural LDH > 200

Also, a pleural fluid pH < 7.2 is indicative of empyema.

6) The two item set....One case of 15 y/o girl with 2 week chest pain under left breast...I picked reassurance and it was correct...but what is the case here? Muskuloskeletal?!
The second case was 32 y/o woman with 2 week chest pain worse at night, improves by sitting up or walking 10 minutes...Has mild tenderness in the right upper quadrant....What is the case here? The question asks for the next management step!

First is reassurance, second is H2-blockers.

Not too sure if they really wanted you to obtain an actual diagnosis on the first one. I think the idea is that it could be anything (e.g. MSK, period cramps, fibrocystic disease, etc.) and that given her profile, it's highly unconcerning. As for the second, it's GERD and H2-blockers are the only sensible treatment for her case (PPIs aren't an answer choice).

7) A case of obstructive lung disease...His brother had a lung transplant for COPD...asking about the mechanism of the disease...I thought it's COPD and picked "Destructive changes in bronchial wall elastic and muscular layer....it was wrong!!

What notbobtrustme said. This guy doesn't smoke, yet he has COPD. The answer is the one that refers to an abnormality of antiprotease.

8) RA with hx of methotrexate...CBCs shows leukopenia....I thought it's drug induced myelofibrosis...wrong...Is it CLL? Platelets are normal and lymphocytes are high...so probably CLL?

Felty syndrome: RA + neutropenia. Note that lymphocytes weren't actually high (just a relative increase), since the overall WBC count was low.

9) Pilonidal sinus....I always learned in surgery that you do wide excision and leave it to hear by 2 intention...Got it wrong! Is it surgical drainage?

Surgical drainage is the answer. I was fortunate enough to not know what you're referring to at the time of taking this test, so I just thought abscess --> drain. I suppose the logic is that you would drain the abscess first, then excise the pilonidal tract. I've never gone wrong by answering I+D for every abscess question, basically.

10) That crazy Rash q...Is it avoidance of sunscreen?

Sorry, still have no idea.

11) SOB for 5 days...Had upper resp infection 2 weeks ago...on physical exam has JV distension, S3, pitting edema....Is it dilated cardiomyopathy from myocarditis? So Lasix?

Yep. Furosemide is very often the answer anytime someone has symptomatic CHF and you're asked what to do next.

 

[lordman]

.

 

[Apoplexy__]

.

 

[lordman]

@kirbymiester Thanks a lot man! What is your advice on those mastery series? How to get the most benefit out of them if step 2 exam is so close?

 

[Apoplexy__]

@kirbymiester Thanks a lot man! What is your advice on those mastery series? How to get the most benefit out of them if step 2 exam is so close?

Sure! I'll PM you.

 

[PeurtoRico]

6) The two item set....One case of 15 y/o girl with 2 week chest pain under left breast...I picked reassurance and it was correct...but what is the case here? Muskuloskeletal?!
The second case was 32 y/o woman with 2 week chest pain worse at night, improves by sitting up or walking 10 minutes...Has mild tenderness in the right upper quadrant....What is the case here? The question asks for the next management step!

First is reassurance, second is H2-blockers.

___> for the second one, are you sure its H2 blockers? Because I thought I saw CXR somewhere since the patient has got MR, which would lead to left atrial enlargement, would compress on esophagus and cause GERD.

 

[Apoplexy__]

6) The two item set....One case of 15 y/o girl with 2 week chest pain under left breast...I picked reassurance and it was correct...but what is the case here? Muskuloskeletal?!
The second case was 32 y/o woman with 2 week chest pain worse at night, improves by sitting up or walking 10 minutes...Has mild tenderness in the right upper quadrant....What is the case here? The question asks for the next management step!

First is reassurance, second is H2-blockers.

___> for the second one, are you sure its H2 blockers? Because I thought I saw CXR somewhere since the patient has got MR, which would lead to left atrial enlargement, would compress on esophagus and cause GERD.

Yeah, I put H2-blockers and got it right. What CXR do you mean? The question didn't reference one. I was thrown off by the murmur too, but thought it could be MVP since it was low-grade. Just seemed like a distractor.

 

[PeurtoRico]

Chest X ray to see left atrial enlargement. But anyway! H2 blockers it is. Thanks.

 

[001100010010011]

Just wanted to add my 2 cents:


The woman gardening roses/picking weeds/wearing sunscreen and developing a rash was poison ivy. Avoid weeds.

 

[byaaaaaaah23]

Yeah, weeds is the correct answer to that question. So weird, who would randomly have poison ivy in their garden unless they lived in the middle of a forest I guess? Or maybe she gardens infrequently.

A few questions of my own:

1) The man with ashen gray skin, muffled heart sounds, and hypotension 6 hours after suffering an MI-- asking for the mechanism of hypotension. SUTM says that ventricular diastolic filling is impaired, so I picked decreased ventricular filling pressure but it was wrong. Other choices: 3rd degree AV block, decreased contractility (possibly the answer if he isn't in tamponade), decreased intravascular volume and pulmonary edema.

2) The man with hemochromatosis p/w AMS, HR 130, decreased bowel sounds, shifting dullness, peripheral edema. CT abdomen is wrong: other choices are echo, EGD, liver biopsy, LP, paracentesis.
- I guess an LP for AMS?

Any thoughts?

 

[mcloaf]

Yeah, weeds is the correct answer to that question. So weird, who would randomly have poison ivy in their garden unless they lived in the middle of a forest I guess? Or maybe she gardens infrequently.

A few questions of my own:

1) The man with ashen gray skin, muffled heart sounds, and hypotension 6 hours after suffering an MI-- asking for the mechanism of hypotension. SUTM says that ventricular diastolic filling is impaired, so I picked decreased ventricular filling pressure but it was wrong. Other choices: 3rd degree AV block, decreased contractility (possibly the answer if he isn't in tamponade), decreased intravascular volume and pulmonary edema.

2) The man with hemochromatosis p/w AMS, HR 130, decreased bowel sounds, shifting dullness, peripheral edema. CT abdomen is wrong: other choices are echo, EGD, liver biopsy, LP, paracentesis.
- I guess an LP for AMS?

Any thoughts?

1. he just had an MI and his myocardium is dead/dying, it's not going to have the same contractility as healthy, perfused myocardium. Time window for ventricular rupture causing tamponade is on the order of days.

2. the dude is cirrhotic and has ascites. Anybody with ascites and AMS has earned themselves a paracentesis to eval for SBP, I'd think.

 

[byaaaaaaah23]

1. he just had an MI and his myocardium is dead/dying, it's not going to have the same contractility as healthy, perfused myocardium. Time window for ventricular rupture causing tamponade is on the order of days.

2. the dude is cirrhotic and has ascites. Anybody with ascites and AMS has earned themselves a paracentesis to eval for SBP, I'd think.

Thanks! Great points. The number of times I've been burned by not knowing post-MI complications well is too damn high.

The other thing I was considering for #2 would be echo for acute HF caused by infiltrative cardiomyopathy given that he has hemochromatosis, but that probably wouldn't present as acutely?

 

[mcloaf]

Thanks! Great points. The number of times I've been burned by not knowing post-MI complications well is too damn high.

The other thing I was considering for #2 would be echo for acute HF caused by infiltrative cardiomyopathy given that he has hemochromatosis, but that probably wouldn't present as acutely?

Yeah cardiomyopathy is on the radar in someone with hemochromatosis, but I'm not sure how that would present as acute MS change. Further, you have to triage things in a logical order. SBP is highly morbid, simple to treat, and a diagnostic para is fast and effective.

 

[byaaaaaaah23]

Yeah cardiomyopathy is on the radar in someone with hemochromatosis, but I'm not sure how that would present as acute MS change. Further, you have to triage things in a logical order. SBP is highly morbid, simple to treat, and a diagnostic para is fast and effective.

Thanks!

Did you do form 1?

The 24M with ACL repair has an elevated indirect bilirubin and LDH with otherwise normal labs. G6PD deficiency was incorrect, was the answer Gilbert syndrome?
-Acute hepatitis
-A1AT defiicency
-biliary atresia
-cholangiocarcinoma
-choledocolithiasis
-gilbert
-G6PD
-liver abscess
-peptic ulcer disease

25F with 5 days of fatigue, nausea, jaundice and decreased appetite. Originally told she had a virus and sent home, presents 1 week later with mild hepatomegaly and elevated AST, ALT, LDH.
-Acute hepatitis
-A1AT defiicency
-biliary atresia
-cholangiocarcinoma
-choledocolithiasis
-gilbert
-G6PD
-liver abscess
-peptic ulcer disease

 

[CodeRedDew]

Thanks!

Did you do form 1?

The 24M with ACL repair has an elevated indirect bilirubin and LDH with otherwise normal labs. G6PD deficiency was incorrect, was the answer Gilbert syndrome?
-Acute hepatitis
-A1AT defiicency
-biliary atresia
-cholangiocarcinoma
-choledocolithiasis
-gilbert (yup, asymptomatic young pt with rise in indirect bili during time of stress = most likely gilbert)
-G6PD
-liver abscess
-peptic ulcer disease



25F with 5 days of fatigue, nausea, jaundice and decreased appetite. Originally told she had a virus and sent home, presents 1 week later with mild hepatomegaly and elevated AST, ALT, LDH.
-Acute hepatitis (she most likely has a bout of acute hepatitis A)
-A1AT defiicency
-biliary atresia
-cholangiocarcinoma
-choledocolithiasis
-gilbert
-G6PD
-liver abscess
-peptic ulcer disease

Answers in bold

 

[byaaaaaaah23]

Answers in bold

Thanks. For the first one, why does Gilbert have an elevated LDH? Thought that was only high in hemolysis.