Is my whole life a lie? (CSSA form 7)

[SpecterGT260]

Seriously... I am working through the ones I missed and between myself, uptodate, and about a dozen prep books, and good ol fashioned google, I cannot come up with why most of these are wrong. I did pretty well on step1 and have been hitting at or above average on the random UWorld sets I do. Anyone else do this assessment and feel like they ask some pretty random crap with some pretty ridiculous stems? Also... I feel like several of their answers are just plain wrong...

You do get yourself a quick Doppler US when suspecting testicular torsion prior to calling the surgeon, right?

For suspected meningitis, LP > Head CT and LP should be first, right?

I'm sure I'll come across some others that I just cannot reconcile as I go through this...

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[SpecterGT260]

I thought there was jaundice, and enough pain to suspect pancreatitis, that was my rationale at least.


anyone comfortable with immuno deficiencies?
4 yo girl with cough and weight loss, no history of serious illness has negative epidermal skin testing for PPD, tetanus, candida, trichophyton, wbc 5100 gastric aspirates have TB in them.
antibody deficiency
complement deficiency
chemtaxis imparied
resp burst impaired
neutropenia
splenic dysfunction
t lymph dysfunction

There may have been jaundice. I dont remember the specifics of the case. I was just commenting on the utility of HIDA vs ERCP. HIDA is only useful with an equivocal US *in the setting* of a suggestive clinical picture. Witg ercp, you can look at several things but you can only really treat ampullary stones or main duct stones. So without some evidence of a distal stone you are really only exposing your patient to a significant risk of iatrogenic pancreatitis without any utility or benefit.

So I don't remember case specifics but this was the overall clinical reasoning I use.

 

[Bagheera]

I thought there was jaundice, and enough pain to suspect pancreatitis, that was my rationale at least.


anyone comfortable with immuno deficiencies?
4 yo girl with cough and weight loss, no history of serious illness has negative epidermal skin testing for PPD, tetanus, candida, trichophyton, wbc 5100 gastric aspirates have TB in them.
antibody deficiency
complement deficiency
chemtaxis imparied
resp burst impaired
neutropenia
splenic dysfunction
t lymph dysfunction

The answer seems to be T lymp dysfunction.

 

[123qwe]

42 yo F with 3 months of fatigue, palp, anxiety, 7# loss, heat intolerance. all signs point to graves, low TSH, elevated T4, scan shows diffuse uptake.

Is there any reason the treatment would not be oral I 131?

 

[res1cue]

HIDA can tell you if there is an obstruction. Some 40% of people have stones and are asymptomatic. IIRC you have to see the pericholic fluid or wall thickening to diagnose it. Ercp is only therapeutic if you have gallstone pancreatitis in which case you would see jaundice and more pancreatic pain (epigastric and whatnot)

post cholecystectomy syndrome is dx by ERCP. US first, which shows either dilated ducts (some kind of pathology) or normal ducts (functional pain - expectant management)

dilated ducts you go in w/ ERCP and its usually one of 2 things: SOD dysfunction (sphincterotomy) or retained stone (remove it)

HIDA tells you gallbladder EF, which you cant do if theres no gall bladder

 

[SpecterGT260]

post cholecystectomy syndrome is dx by ERCP. US first, which shows either dilated ducts (some kind of pathology) or normal ducts (functional pain - expectant management)

dilated ducts you go in w/ ERCP and its usually one of 2 things: SOD dysfunction (sphincterotomy) or retained stone (remove it)

HIDA tells you gallbladder EF, which you cant do if theres no gall bladder



candida = must be T cell dysfunction

Oh... Yeah... Good point

 

[res1cue]

Is this the only thread on CCSSA Form 7? I haven't found any others

I also got a much lower score than I was expecting. I'm glad I'm not alone!

I'm going over my wrong answers, and I'm not sure about a couple of them. Maybe you guys can help me out:

1) Acute gouty arthritis that doesn't respond to celecoxib. Next step in pharmacotherapy is indomethacin?
2) Woman who underwent laparoscopic cholecystectomy presents 7 days later with fever, jaundice and abdominal pain (I assume this is bile duct injury with biliary obstruction). Next step in diagnosis? Medscape mentions CT, HIDA & ERCP as valid options. Which one is preferred?
3) Formication (feeling of insects crawling under skin). Caused by amphetamines?
4) 43-year-old man with pneumonia & small Gram-negative bacilli in sputum. It wasn't Pseudomonas. The only other GNB in the list were E.coli & H.influenzae. Which one, and why?
5) 19-year-old with intermittent watery diarrhea + abdominal cramps & bloating. Most likely cause of diarrhea? Is it decreased bowel motility (IBS)?
6) Claustrophobic patient who has a panic attack during an MRI. "Wishes to resume and complete the test". Next step in management?
7) 20-year-old man with psychotic behavior for the past year + hyperreflexia + resting tremor. Diagnosed with hypothyroidism 6 months ago, now treated with levothyroxine. Normal TSH, normal tox screen. How do you interpret this one? I answered psychotic disorder due to a general medical condition and it was wrong.

Thanks!

1) NSAIDs first line for acute gout
3) yes cocaine and amphetamines
4) E. coli is a bacillus, H. Influenzae is a coccobacillus (can't remember that question specifically though)
5)cant remember that exactly, but i think it had constipation too. Diarrhea + constipation = IBS
6) Claustrophobia + you need MRI = give a dose of benzos just get them through it
7) cant remember sorry

 

[Bagheera]

42 yo F with 3 months of fatigue, palp, anxiety, 7# loss, heat intolerance. all signs point to graves, low TSH, elevated T4, scan shows diffuse uptake.

Is there any reason the treatment would not be oral I 131?

What are the answer choices? If a patient came with said symptoms you would want to stabilize them first. In the case the patient having palpitations due to graves disease, you probably would want to give Beta blockers. However I do not know the answer choices for this questions so I am just going off the top of my head. But for sure you would not start with Oral I31. If question stated what is the most definitive treatment, then that would be the answer however.

 

[Bagheera]

post cholecystectomy syndrome is dx by ERCP. US first, which shows either dilated ducts (some kind of pathology) or normal ducts (functional pain - expectant management)

dilated ducts you go in w/ ERCP and its usually one of 2 things: SOD dysfunction (sphincterotomy) or retained stone (remove it)

HIDA tells you gallbladder EF, which you cant do if theres no gall bladder



candida = must be T cell dysfunction

Where are you getting the patient has candida; it just stated the patient had a negative candida skin test? The patient has TB in gastric aspirates. Cell mediated immunity, or T cell immunity, is what is responsible for fighting off Tb. Also you see from the negative PPD test, which should be positive in the case of this patient TB status. But since patient does not have cell mediated immunity, PPD is negative.

 

[res1cue]

Whoops youre right! Read too fast. Will edit my post. Been a long day

 

[ketosisevangelist]

It's also used during a sobriety test

 

[ketosisevangelist]

On the side of the road usually.

 

[SMT86]

Thanks everyone!

I answered T cell dysfunction and got it right. I figured she has TB, but since she has an impaired Th1 response she can't form granulomas, and therefore her PPD is negative. I'm not entirely sure what the diagnosis is though.

 

[thekarmapolice172]

Anyone have any input on how predictive this form was for the real test? Took it today and got 240. Took #6 almost 2 weeks ago and got a 242... Scored 252 on step 1 and want to at least match my score....Test is 1 wk away. Was going to take UWSA this week and see how I do, just don't want to get blindsided by a low score. Any opinions on this one would be helpful, thanks in advance

 

[vokey588]

I'd like to hear others' opinions on this question:
57 yo F is 5 days post-op after splenectomy for ITP. "Dissection of the splenic hilum was difficult." She develops SOB, but is afebrile and normotensive. Breath sounds decreased on left lung base. Leuks are 15,600; plt 112,000; and serum amylase 90. What is the next step in mgmt?

a) CXR
b) Abd US
c) IV abx
d) IVIG
e) Systemic heparin tx
f) Pulmonary angiography

With a post-op pt with new SOB, I was expecting a CTA to be one of the answer choices, but the only PE workup test was pulmonary angiography (which is out of favor). One of the UWorld question explanations specifically says that if you have a high suspicion of PE then you start heparin before you get them to the CT scanner, so I chose E. Is the correct answer A? Are they getting at a post-op pneumonia (she's afebrile, though)?

 

[res1cue]

Decreased breath sounds unilateral, think pleural effusion

Surgery on left, near diaphragm, white count, possible abscess formation irritating diaphragm and pleura causing effusion

Cxr best to confirm, consider lateral views too to see fluid level


Pod 5, expect dvt but not pe which is usually around 7

 

[mastmastdonan]

Any ideas on these 3 I'd appreciate it:

1) 27 y/o m brought to ED 30 mins after MVA. Unconscious at scene, Glasgow 10. Temp 98, RR 36, HR 130, BP 90/60. Breath sounds dec on Right; crepitus to palpation over right hemithorax. X-ray shows right hemopneumothorax. FAST normal. X-ray shows unstable pelvic fracture. Right thoracostomy tube yields 300 mL of blood. Given 3L of crystalloid but still tachy/hypotensive. What's next step?

a) epinephrine
b) hetastarch
c) recombinant factor vii
d) FFP
e) packed RBC's

I picked A because I dunno still hypotensive. But I'm guessing he needs blood?

2) Study is proposed to assess effectiveness of a new HIV vaccine. Vaccine has been successfully tested on animals. Study will include members of a prison population. Those who participate will be considered for early parole. Prisoners will be randomly assigned to receive vaccine or placebo. Which is biggest concern?

a) coercion of a vulnerable population
b) conflict of interest
c) failure to use an appropriate placebo
d) inadequate informed consent
e) lack of generalizability

I picked E because it reminded me of a UWorld question lol. I'm sure this is simple for many of you but I suck at these questions.

3) 23 y/o man brought by his mom because his wife died in a MVA 1 week ago and he's been having auditory hallucinations. Mother reports he was unable to make decisions for his wife's funeral and has been confused and disorganized since (no ****). Normal PE, AAO x3. Sad affect, appears preoccupied and has difficulty concentrating. States that he hears his brother's voice saying everything will be ok, but mom says his brother lives in a different state. Diagnosis?

a) bereavement
b) brief psychotic disorder
c) PTSD
d) schizoaffective
e) schizophrenia

I picked A b/c I thought auditory hallucinations were part of bereavement?

 

[vokey588]

Just wanted to throw in my experience with NBME Form 7. Took it yesterday as my first practice test and was shocked to get a 500/237 because I was 89%tile on my random UWorld Q bank and did very well on my shelf exams. Took UWSA today and scored 690/254. I think a trend is developing wrt NBME 7...

 

[vokey588]

Any ideas on these 3 I'd appreciate it:

1) 27 y/o m brought to ED 30 mins after MVA. Unconscious at scene, Glasgow 10. Temp 98, RR 36, HR 130, BP 90/60. Breath sounds dec on Right; crepitus to palpation over right hemithorax. X-ray shows right hemopneumothorax. FAST normal. X-ray shows unstable pelvic fracture. Right thoracostomy tube yields 300 mL of blood. Given 3L of crystalloid but still tachy/hypotensive. What's next step?

a) epinephrine
b) hetastarch
c) recombinant factor vii
d) FFP
e) packed RBC's

I picked A because I dunno still hypotensive. But I'm guessing he needs blood?

2) Study is proposed to assess effectiveness of a new HIV vaccine. Vaccine has been successfully tested on animals. Study will include members of a prison population. Those who participate will be considered for early parole. Prisoners will be randomly assigned to receive vaccine or placebo. Which is biggest concern?

a) coercion of a vulnerable population
b) conflict of interest
c) failure to use an appropriate placebo
d) inadequate informed consent
e) lack of generalizability

I picked E because it reminded me of a UWorld question lol. I'm sure this is simple for many of you but I suck at these questions.

3) 23 y/o man brought by his mom because his wife died in a MVA 1 week ago and he's been having auditory hallucinations. Mother reports he was unable to make decisions for his wife's funeral and has been confused and disorganized since (no ****). Normal PE, AAO x3. Sad affect, appears preoccupied and has difficulty concentrating. States that he hears his brother's voice saying everything will be ok, but mom says his brother lives in a different state. Diagnosis?

a) bereavement
b) brief psychotic disorder
c) PTSD
d) schizoaffective
e) schizophrenia

I picked A b/c I thought auditory hallucinations were part of bereavement?

#1: I also was unsure about that question. The correct answer is pRBC iirc.
#2: The answer was (a). From a scientific ethics point of view, you cannot induce or entice research subjects to participate by a reward system. If subjects are paid, the amount can only be enough to compensate them for their time, and not a cent more. In that question you are enticing prisoners to participate by offering early parole to get inoculated with your vaccine.
#3: I thought it was bereavement as well, for the same reason you cited. I guess the correct answer is probably brief psychotic disorder. It could be related to the fact that in normal bereavement, the auditory hallucination is usually of the deceased's voice. In this question it is his brother's voice. Maybe that's the reasoning.

 

[Apoplexy__]

I picked A b/c I thought auditory hallucinations were part of bereavement?

#3: I thought it was bereavement as well, for the same reason you cited. I guess the correct answer is probably brief psychotic disorder. It could be related to the fact that in normal bereavement, the auditory hallucination is usually of the deceased's voice. In this question it is his brother's voice. Maybe that's the reasoning.

Delusions = normal bereavement (they realize it's not really there)
Hallucinations = psychosis (they genuinely perceive the sensory stimulus and believe it)

"Disorganized" in the Q stem is also your buzzword for psychosis. Timeframe narrows it to Brief Psychotic Disorder.

 

[thehundredthone]

I picked A because I dunno still hypotensive. But I'm guessing he needs blood?

I picked E because it reminded me of a UWorld question lol. I'm sure this is simple for many of you but I suck at these questions.

I picked A b/c I thought auditory hallucinations were part of bereavement?

1. Yes he needs blood first, the epinephrine is not going to be able to shunt blood to the vital organs if there isn't any in the vessels.

2. This is all about the incentive given. The rule is that you can neither coerce nor prevent any vulnerable group from participating in a study. So telling the prisoners that they'll get early parole by participating is arm twisting.

3. Like kirbymeister mentioned, the disorganisation and being out of touch with reality is key. Otherwise, anything in the first month outside of suicidality is usually bereavement.

 

[epicccfail]

Par for the course I guess. I got the above answer from Master the Boards and First Aid. Regardless, its absurd to have 2 right answers on a question. Oh well

So I was under the impression that it wasn't a torsion if I'm thinking of the same question. It sounded like a strangulated hernia. I believe there were details about decreased bowel sounds, n/v, testicle was normal on exam, etc.. but thats if I'm thinking of the same question

 

[epicccfail]

If someone goes to the ER at midnight bc they have sever flank pain with RLQ pain thats better with morphine, what would you think the dx is? The UA had some blood and WBCs. I thought it was stones and figured they needed imaging. What do you guys think?

 

[epicccfail]

1)back pain in young person, asthma hx w/ long term steroid use, cushing/hairy appearance, low back is tender w/ paramuscle spasm. dx?

2)Muscle weakness that starts in the leg and spreads to all other extremities, hard to swallow solids/liquids, atrophy of quads and deltoids, +babinski. I though this would be AML but what would we see on EMG?

3) young female wondering about risk for ovarian cancer, mother dx in 40s, not sexually active for 6 months and used condoms when active, BMI 21. What to recommend patient?

4) depression history patient, feels insects under skin, tx for scabies, later told it was herpies and given acyclovir, now seeing worms coming out from skin, what drug is he on NOT INCLUDING cocaine

5) n/v, diarrhea, abd pain, visual changes, dry mouth, paresthesias after eating meat, rice, canned food at party. also had uri a week ago, pupils sluggishly reactive, muscle strength and reflexes ok. dx?

6)exposed to toxic gas, miosis, copious oral secretions, rhinorrhea, muscular fasciculation. what is tx?

 

[epicccfail]

I'd like to hear others' opinions on this question:
57 yo F is 5 days post-op after splenectomy for ITP. "Dissection of the splenic hilum was difficult." She develops SOB, but is afebrile and normotensive. Breath sounds decreased on left lung base. Leuks are 15,600; plt 112,000; and serum amylase 90. What is the next step in mgmt?

a) CXR
b) Abd US
c) IV abx
d) IVIG
e) Systemic heparin tx
f) Pulmonary angiography

With a post-op pt with new SOB, I was expecting a CTA to be one of the answer choices, but the only PE workup test was pulmonary angiography (which is out of favor). One of the UWorld question explanations specifically says that if you have a high suspicion of PE then you start heparin before you get them to the CT scanner, so I chose E. Is the correct answer A? Are they getting at a post-op pneumonia (she's afebrile, though)?

I just thought post op atelectasis

 

[epicccfail]

more ?s

1) pregnant at 20 weeks epigastric pain radiates to back, vomited, next step is?

2) pregnant at 37 weeks, epigastric pain and headache, bp is high, urine protein is 3+, next step is?

3)question about the girl with the picture of rash provided at summer camp, sore throat, fever, nonprod cough, not arousable, bp is low, cool extrem, what is dx? TSS was wrong

4) Barium swallow of what looked like achalasia to me. esophageal eristalsis is up/down, lower esophageal sphincter tone is up/down. I thought they were both up

5) Guillen barre patient that seemed to have aspiration pneumonia. what could have prevented this? nasogastric suction was wrong. I think eleveation of the head of bed was answer. Can anyone confirm?

6) Old lady w/ ascites, hx of breast cancer, on tamoxifen, fluid wave on PE, pelvic mass at vaginal cul-de-sac. next step?

7) Can't move legs and urine incontinence after removing epidural catheter. Diagnosis? I think its epidural hematoma. Put herniated nucleus pulposis which was wrong

8) baby had head rotated to left w/ chin dev. to the right. mass on right side of neck. diagnosis?

9) Bunch of newborns exposed to chickenpox, how to prevent infection?

10)Newborn has clubfoot, no sensation in feet and bladder is full

 

[res1cue]

1)back pain in young person, asthma hx w/ long term steroid use, cushing/hairy appearance, low back is tender w/ paramuscle spasm. dx?

2)Muscle weakness that starts in the leg and spreads to all other extremities, hard to swallow solids/liquids, atrophy of quads and deltoids, +babinski. I though this would be AML but what would we see on EMG?

3) young female wondering about risk for ovarian cancer, mother dx in 40s, not sexually active for 6 months and used condoms when active, BMI 21. What to recommend patient?

4) depression history patient, feels insects under skin, tx for scabies, later told it was herpies and given acyclovir, now seeing worms coming out from skin, what drug is he on NOT INCLUDING cocaine

5) n/v, diarrhea, abd pain, visual changes, dry mouth, paresthesias after eating meat, rice, canned food at party. also had uri a week ago, pupils sluggishly reactive, muscle strength and reflexes ok. dx?

6)exposed to toxic gas, miosis, copious oral secretions, rhinorrhea, muscular fasciculation. what is tx?

1. Compression fx

3. OCP

4. meth

6. nerve gas, its cholinergic, so atropine/pralidoxime

more ?s

1) pregnant at 20 weeks epigastric pain radiates to back, vomited, next step is?

2) pregnant at 37 weeks, epigastric pain and headache, bp is high, urine protein is 3+, next step is?

3)question about the girl with the picture of rash provided at summer camp, sore throat, fever, nonprod cough, not arousable, bp is low, cool extrem, what is dx? TSS was wrong

4) Barium swallow of what looked like achalasia to me. esophageal eristalsis is up/down, lower esophageal sphincter tone is up/down. I thought they were both up

5) Guillen barre patient that seemed to have aspiration pneumonia. what could have prevented this? nasogastric suction was wrong. I think eleveation of the head of bed was answer. Can anyone confirm?

6) Old lady w/ ascites, hx of breast cancer, on tamoxifen, fluid wave on PE, pelvic mass at vaginal cul-de-sac. next step?

7) Can't move legs and urine incontinence after removing epidural catheter. Diagnosis? I think its epidural hematoma. Put herniated nucleus pulposis which was wrong

8) baby had head rotated to left w/ chin dev. to the right. mass on right side of neck. diagnosis?

9) Bunch of newborns exposed to chickenpox, how to prevent infection?

10)Newborn has clubfoot, no sensation in feet and bladder is full

1 and 2, do you know the options?

3. meningococcal meningitis

4. I think persistalsis is down, LES is up

5. elevate head of bed

6. Don't know the options, but usually ovarian CA workup starts with US/CA125

7. I think it is epidural hematoma too

8. torticollis

9.i don't think you have to do anything

 

[epicccfail]

1. Compression fx

3. OCP

4. meth

6. nerve gas, its cholinergic, so atropine/pralidoxime



1 and 2, do you know the options?

3. meningococcal meningitis

4. I think persistalsis is down, LES is up

5. elevate head of bed

6. Don't know the options, but usually ovarian CA workup starts with US/CA125

7. I think it is epidural hematoma too

8. torticollis

9.i don't think you have to do anything

Thanks for all your help! Looking back, a lot of it makes me face palm. Hope I avoid the silly mistakes in the real exam.

The options for 1 and 2 are the same. They are Culdocentesis, CT of abdomen, platelet count, measure amylase, paracentesis, IV pyelography, stool for occult blood, US of pelvis

For 6 (lady with ascites), the options were albumin, antibiotic, cisplatin/paclitaxel, ACE inhibitor, spironolactone, paracentesis (wrong), laparotomy

For 8, I thought it was torticollis too and the choice closest to it was "fibrosis of the sternomastoid muscle." I thought torticollis was spasm (vs fibrosis). So that threw me off. Other choices, abcess of lymph node, fracture of R clavicle, hemivertebra of cervical spine, tumor

 

[res1cue]

Thanks for all your help! Looking back, a lot of it makes me face palm. Hope I avoid the silly mistakes in the real exam.

The options for 1 and 2 are the same. They are Culdocentesis, CT of abdomen, platelet count, measure amylase, paracentesis, IV pyelography, stool for occult blood, US of pelvis

For 6 (lady with ascites), the options were albumin, antibiotic, cisplatin/paclitaxel, ACE inhibitor, spironolactone, paracentesis (wrong), laparotomy

For 8, I thought it was torticollis too and the choice closest to it was "fibrosis of the sternomastoid muscle." I thought torticollis was spasm (vs fibrosis). So that threw me off. Other choices, abcess of lymph node, fracture of R clavicle, hemivertebra of cervical spine, tumor

Yeah it is a frustrating nbme, I felt the same way

1) amylase
2) platelet count weirdly, I guessed that and got it right
6) exlap, ovarian cancer is surgically staged
8) actually I don't remember this completely, and it may be fx of clavicle, im not sure completely

 

[SLC]

If someone goes to the ER at midnight bc they have sever flank pain with RLQ pain thats better with morphine, what would you think the dx is? The UA had some blood and WBCs. I thought it was stones and figured they needed imaging. What do you guys think?

The logic is sound. Based on what you've written I'd wager you were correct.

 

[thehundredthone]

Yeah it is a frustrating nbme, I felt the same way

2) platelet count weirdly, I guessed that and got it right

She is pre-ecclamptic. You want to rule out HELLP syndrome, thus the platelet count.

8) actually I don't remember this completely, and it may be fx of clavicle, im not sure completely

Fibrosis of sternocleidomastoid. It's called a sternocleidomastoid tumor and is the most common cause of congenital muscular torticollis. It's also called fibromatosis colli.

If someone goes to the ER at midnight bc they have sever flank pain with RLQ pain thats better with morphine, what would you think the dx is? The UA had some blood and WBCs. I thought it was stones and figured they needed imaging. What do you guys think?

Sounds fine to me. If the pain had improved they had likely passed the stone and now just needed to be told to drink plenty of water.

 

[as90]

Hey did you guys get the question about the girl with the rash in block 4? next step in mgmt? amoxicillin or none?

 

[JoshSt]

Hey did you guys get the question about the girl with the rash in block 4? next step in mgmt? amoxicillin or none?

No tx

 

[as90]

thanks, I feel pretty pathetic for asking, but was this some type of viral thing? god I feel like I got so many wrong on this exam. I got a 210 on the UWSA a few weeks ago.

 

[MEN2C]

"exam shows bilateral nystagmus, constricted pupils, hypertonia..."

I think it was just a bad question

PCP causes constricted pupils, hypertonia and nystagmus.

If the question posted earlier is accurate, it can also cause the patient to experience blank stares and causes you to have a decreased pain sensation (as the link I posted says, the patient may present with agitation, or something else like slurred speech or blank staring spells, and they will have decreased pain sensation ).

I haven't taken the test, but I do not know another substance that would cause all of those findings. I don't think it was a bad question - just a difficult one. You would expect 10-15% of the questions to be difficult like that.

(The only reason I knew the answer was pure luck, since I had to do a presentation on PCP intoxication for psych rotation).

 

[tayberry]

thanks, I feel pretty pathetic for asking, but was this some type of viral thing? god I feel like I got so many wrong on this exam. I got a 210 on the UWSA a few weeks ago.

I think it's Parvo B-19 or at least one of those rashes that don't require treatment. I can't quite remember the stem now so I'll have to look at it again to be sure.

Anyways, I took this test and went down 20 points from my UWSA. I just reviewed my incorrects and I feel like this exam was just really nitpicky (urethral diverticulum vs. vesiculovaginal fistula??) and so you either did really well because you knew what they were nitpicky on, or you did poorly because you couldn't guess well/didn't know what some of the answer choices were. Not saying that this won't happen on the actual test, but we'll see how it goes. I have a hunch the actual score and the overall representation of questions will be more similar to UWSA.

 

[gasman654]

1)A previously healthy 42 yo woman w generalized weakness, lethargy and double vision for 2 wks. CXR shows upper anterior mediastinal mass. What is the most likely dx?

Lymphoma
Neurogenic tumor
Parathyroid tumor
Teratoma
Thymoma

2) 47 yo woman with fatigue for 1 wk. 10 yr hx of DM currently tx w short acting insulin before each meal and 12 U of intermeidate acting insulin at bed time. OVer the past week, her BG have been over 250 and have been greater than 350 on several occasions. Her previous BG had ranged from 90 to 110. Weight is 150 lb, BMI is 27. Her temp is 101.3, pulse is 90 while supine and 120 while standing. BP is 110/70 while supine and 90/40 while standing. The remained ofer the exam shows nothing. Her fingerstick BG concentration is 350. Urine dipstick is positve for glucose and negative for protein and ketones. UA shows 6-10 WBC/hpf and no RBCs or casts. Which of the following is the cause of her postural hypotension?

Adrenal insufficiency
Autonomic infufficiency Intravascular volume depletion
Renal salt wasting
Venous pooling

 

[thehundredthone]

1. Thymoma - You have Myasthenia like symptoms.

2. Volume depletion given her recent poor glycemic control. The water's gone out with all that glucose in her urine.

 

[balboah]

I got some more questions and would appreciate your input:

1. 4 y/o male, increasing fatigue since viral illness 3 wks ago, pale, bleeding gums, adenopathy and hepatomegaly, hb: 8 mg/dl, leukos: 3000, platelets: 30,000. next best step?
Answer choices: pRBCs, platelets, vit k, BM aspiration, LP

2. 25 y/o @ 27 wks, cervix 1-2cm dilated and 70% effaced, GBS culture positive, Next best step?
choices: oral amoxi, observe, c-section, IM betamethasone, cerclage

3. 67 y/o M, 3 vodka with dinner, wide based gait, what would have prevented current condition?
choices: alcohol abstinence or geen leafy vegetables; chose the latter, was thinking of B12 def, but they're probably going for atrophic gastritis and decreases IF production. what do you think?

4. 25 y/o with painful ulcers on penis + lymphadenopathy (with pic)
HSV, Chancroid, Granuloma ing, Lymphgran ven., Prim syph
Was thinking HSV, but the picture didn't really show vesicles. Chose Chancroid b/o the painful ulcers + lymphnodes, but that didn't seem to be it

5. the 27 y/o in labor with the graph in the question, variable decelerations? can anyone who took the test remember the correct answer for that?

6. 72 y/o F w/ mass in cul du sac (hx of breast cancer) - does this already warrant an exploratory laparotomy?

7. Another alcoholic with wide based gait, bilat rectus palsy, horizontal nystagmus. Which vitamine def? the gait threw me off and i chose B12, but was probably B1 b/o the nystagmus

8. M plumber with pruritic rash on back, moves around under houses during work. lab: 45% neutros, 15 eos, 30 lymphos, 10 monos, tracks on examination
Choices: Scabies, ascariasis, fire ant bites, hypereo syndr., cutaneous larva migrans

Thanks so much for your help with those questions.

 

[balboah]

What are the answer choices? If a patient came with said symptoms you would want to stabilize them first. In the case the patient having palpitations due to graves disease, you probably would want to give Beta blockers. However I do not know the answer choices for this questions so I am just going off the top of my head. But for sure you would not start with Oral I31. If question stated what is the most definitive treatment, then that would be the answer however.

They were asking for the most appropriate initial step in management; think PTU is the right answer

 

[GyroProtagonist]

I got some more questions and would appreciate your input:

1. 4 y/o male, increasing fatigue since viral illness 3 wks ago, pale, bleeding gums, adenopathy and hepatomegaly, hb: 8 mg/dl, leukos: 3000, platelets: 30,000. next best step?
Answer choices: pRBCs, platelets, vit k, BM aspiration, LP

2. 25 y/o @ 27 wks, cervix 1-2cm dilated and 70% effaced, GBS culture positive, Next best step?
choices: oral amoxi, observe, c-section, IM betamethasone, cerclage

3. 67 y/o M, 3 vodka with dinner, wide based gait, what would have prevented current condition?
choices: alcohol abstinence or geen leafy vegetables; chose the latter, was thinking of B12 def, but they're probably going for atrophic gastritis and decreases IF production. what do you think?

4. 25 y/o with painful ulcers on penis + lymphadenopathy (with pic)
HSV, Chancroid, Granuloma ing, Lymphgran ven., Prim syph
Was thinking HSV, but the picture didn't really show vesicles. Chose Chancroid b/o the painful ulcers + lymphnodes, but that didn't seem to be it

5. the 27 y/o in labor with the graph in the question, variable decelerations? can anyone who took the test remember the correct answer for that?

6. 72 y/o F w/ mass in cul du sac (hx of breast cancer) - does this already warrant an exploratory laparotomy?

7. Another alcoholic with wide based gait, bilat rectus palsy, horizontal nystagmus. Which vitamine def? the gait threw me off and i chose B12, but was probably B1 b/o the nystagmus

8. M plumber with pruritic rash on back, moves around under houses during work. lab: 45% neutros, 15 eos, 30 lymphos, 10 monos, tracks on examination
Choices: Scabies, ascariasis, fire ant bites, hypereo syndr., cutaneous larva migrans

Thanks so much for your help with those questions.

1. DDx is ALL vs. parvovirus - need BM biopsy to guide therapy. Vote no for pRBC and plt since he is not anemic and generally you can wait until plt are <20k in children before tranfusing plts.

2. IM betamethasone. Need IV PCN/amox for GBS coverage, lung immaturity will kill infant.

3. EtOH abstinence - I think they are going for EtOH-induced cerebellar dysfuction ("EtOH whacks the vermis").

4. HSV. Most common cause of painful lesions with LAD.

5. Hard to tell without the graph. Variables are steep/quick, late have nadir after peak of contraction and early have nadir at peak of contraction.

6. Go to laparotomy. MCC of ascites in older female is ovarian cancer, and laparatomy is required for staging.

7. Thiamine deficiency - the opthalmaplegia gives it away

8. Cutaneous larva migrans. Parasite in soil that causes serpiginous tracks on skin where it enters.

Good luck! If it's any comfort, NBME7 underpredicted me by ~15 points.

 

[balboah]

1. DDx is ALL vs. parvovirus - need BM biopsy to guide therapy. Vote no for pRBC and plt since he is not anemic and generally you can wait until plt are <20k in children before tranfusing plts.

2. IM betamethasone. Need IV PCN/amox for GBS coverage, lung immaturity will kill infant.

3. EtOH abstinence - I think they are going for EtOH-induced cerebellar dysfuction ("EtOH whacks the vermis").

4. HSV. Most common cause of painful lesions with LAD.

5. Hard to tell without the graph. Variables are steep/quick, late have nadir after peak of contraction and early have nadir at peak of contraction.

6. Go to laparotomy. MCC of ascites in older female is ovarian cancer, and laparatomy is required for staging.

7. Thiamine deficiency - the opthalmaplegia gives it away

8. Cutaneous larva migrans. Parasite in soil that causes serpiginous tracks on skin where it enters.

Good luck! If it's any comfort, NBME7 underpredicted me by ~15 points.

Oh man, thanks a lot! Reading through your answers I could only shake my head, wondering how I missed those questions. Especially the first one...

ad 2. She is is active labor, right? So would IM cortisone even help with lung maturity in that short period of time? Thought it need to be around 24 hrs

 

[thehundredthone]

IM betamethasone, and yes, even though ideally we would like 24 hours for the steroids to work, we take whatever little time we get. She may still take a long while to deliver, she's in the latent stage.

 

[ChessMaster3000]

"20-year-old man with psychotic behavior for the past year + hyperreflexia + resting tremor. Diagnosed with hypothyroidism 6 months ago, now treated with levothyroxine. Normal TSH, normal tox screen."

psychotic disorder due to medical condition vs schizophrenia---for that question, is it NOT due to medical condition because he had a normal TSH? I've been burned before by putting a primary psych diagnosis (ie, schizo) in a question where someone has another med condition even if that condition is controlled. So annoying!

 

[thehundredthone]

In that question, especially given the reflexes and tremor, it is due to a medical condition (or drug adverse effect). Schizophrenia does not have either of those symptoms.

 

[ChessMaster3000]

In that question, especially given the reflexes and tremor, it is due to a medical condition (or drug adverse effect). Schizophrenia does not have either of those symptoms.

That's what I answered, but I believe someone earlier on this thread noted that this response was incorrect.

 

[thehundredthone]

That's what I answered, but I believe someone earlier on this thread noted that this response was incorrect.

I just went back and read the actual question. The psychotic features have been present since before the hypothyroidism. Brain fart on my part, sorry. That's schizophrenia. I thought he presented with psychosis and the other symptoms all at once.

 

[2maitaisplease]

Just took 7. Definitely a lot of questions where you had to just go with your gut feeling. Have a few Qs hoping you can help with.

1. 27F p/w abd pain n/v, HA, vomiting x 5d. h/o CD, has been tapering of pred x2 weeks. meds: mesalamine and azathioprine. LMP was 7 weeks ago, inconsistent condom use. 101.2 fever, bp 90/50. abd distended, diffusely tender, tympanitic. bs decreased. pelvic exam wnl. hct 31%, wbc 15, amylase 300.
choices: pregnancy (wrong), pancreatitis, gastric outlet obstruction, gastroparesis, pid, sbo, viral gastroenteritis

2. 18F at 37w gestation in labor had most recent episode of herpes 6 weeks ago. currently asymptomatic and no lesions. next appropriate step:
choices: genital culture for herpes and tocolysis, IV acyclovir (wrong), amnioinfusion, amniotomy and vag deliv, c section

3. 75F h/o chf treated with dig and diuretics, 2 hrs s/p gastric ulcer repair p/w multifocal pvcs.
choices: decreased ca, decreased mg, decreased k, decreased na, increased ca, increased mg, increased k (wrong), increased na

4. 55F h/o br ca mets p/w confusion progressing to obtundation over 24h, barely arousable
choices: decreased ca, decreased mg, decreased k, decreased na (wrong), increased ca, increased mg, increased k, increased na

5. 63F p/w tightness and tenderness of left calf 3 days s/p orif for femoral fx. most appropriate study to confirm the dx?
choices: duplex, radioactive labeled fibrinogen study, angiography, impedance plethysmography (wrong), venography

6. 72M h/o schizoaffective disorder on risperdone p/w orientation to person but not place or time 4 weeks s/p 10d course of quinolone abx for UTI. has been drinking 10-15 glasses water to prevent another UTI. exam: dry oral mucosa, everything else wnl. labs sig for Na 122, BUN 16 Cr 1.1, urine Na 20, osm 200. what is the cause of his hyponatemia?
choices: adrenal insufficiency, adverse effect of quinolone, DI (wrong), psychogenic polydipsia, salt losing nephropathy, SIADH


7. 62M p/w intermittent painless rectal bleeding x3 weeks. 5cm ulcerated mass on anoscopy; bx shows adenoca. next step in mgmt?
choices: colonoscopy to the cecum, sigmoidoscopy (wrong), RT to the rectum, transanal tumor excision, surgical resection of rectum

8. 67M p/w aching in calves while walking x2 mos, pain relieved by rest. caused by narrowing of which vessels?
choices:Abd aorta, femoropopliteal arteries, iliac arteries, peroneal arteries, tibial and peroneal arteries (wrong)

9. 25F p/w tremulousness and fatigue x1 mo, tachycardic. thyroid nonenlarged, nontender. iodine update decreased. underlying cause?
choices: bacterial infxn, Ig antag of TSH receptor, Ig stimulation of thyroid (wrong), iodine exposure, neoplastic infiltration, surrepititiouns admin of thyroxine, viral infx

Thank you.

 

[Hikkup]

Just took 7. Definitely a lot of questions where you had to just go with your gut feeling. Have a few Qs hoping you can help with.

1. 27F p/w abd pain n/v, HA, vomiting x 5d. h/o CD, has been tapering of pred x2 weeks. meds: mesalamine and azathioprine. LMP was 7 weeks ago, inconsistent condom use. 101.2 fever, bp 90/50. abd distended, diffusely tender, tympanitic. bs decreased. pelvic exam wnl. hct 31%, wbc 15, amylase 300.
choices: pregnancy (wrong), pancreatitis, gastric outlet obstruction, gastroparesis, pid, sbo, viral gastroenteritis
also had a problem with this one. Not gastric outlet obstruction.

2. 18F at 37w gestation in labor had most recent episode of herpes 6 weeks ago. currently asymptomatic and no lesions. next appropriate step:
choices: genital culture for herpes and tocolysis, IV acyclovir (wrong), amnioinfusion, amniotomy and vag deliv, c section
Amiotomy and vaginal delivery

3. 75F h/o chf treated with dig and diuretics, 2 hrs s/p gastric ulcer repair p/w multifocal pvcs.
choices: decreased ca, decreased mg, decreased k, decreased na, increased ca, increased mg, increased k (wrong), increased na
also got this one wrong

4. 55F h/o br ca mets p/w confusion progressing to obtundation over 24h, barely arousable
choices: decreased ca, decreased mg, decreased k, decreased na (wrong), increased ca, increased mg, increased k, increased na
increased Ca2+.

5. 63F p/w tightness and tenderness of left calf 3 days s/p orif for femoral fx. most appropriate study to confirm the dx?
choices: duplex, radioactive labeled fibrinogen study, angiography, impedance plethysmography (wrong), venography
Duplex to workup DVT

6. 72M h/o schizoaffective disorder on risperdone p/w orientation to person but not place or time 4 weeks s/p 10d course of quinolone abx for UTI. has been drinking 10-15 glasses water to prevent another UTI. exam: dry oral mucosa, everything else wnl. labs sig for Na 122, BUN 16 Cr 1.1, urine Na 20, osm 200. what is the cause of his hyponatemia?
choices: adrenal insufficiency, adverse effect of quinolone, DI (wrong), psychogenic polydipsia, salt losing nephropathy, SIADH
also got this one wrong..

7. 62M p/w intermittent painless rectal bleeding x3 weeks. 5cm ulcerated mass on anoscopy; bx shows adenoca. next step in mgmt?
choices: colonoscopy to the cecum, sigmoidoscopy (wrong), RT to the rectum, transanal tumor excision, surgical resection of rectum
colonoscopy to the cecum

8. 67M p/w aching in calves while walking x2 mos, pain relieved by rest. caused by narrowing of which vessels?
choices:Abd aorta, femoropopliteal arteries, iliac arteries, peroneal arteries, tibial and peroneal arteries (wrong)
also got this one wrong.. not iliacs

9. 25F p/w tremulousness and fatigue x1 mo, tachycardic. thyroid nonenlarged, nontender. iodine update decreased. underlying cause?
choices: bacterial infxn, Ig antag of TSH receptor, Ig stimulation of thyroid (wrong), iodine exposure, neoplastic infiltration, surrepititiouns admin of thyroxine, viral infx
surreptitious administration of thyroxine
Thank you.

 

[Hikkup]

some extra questions if someone can help me out! it would be greatly appreciated!

1. 27y/o M unable to conceive after trying for the past 10mos. Wife's fertility stuff all cleared. Husband's exam shows ill-defined soft masses palpated b/l, high in the scrotum. What are they?
B/l direct inguinal hernias, b/l epidiymitis, b/l hydroceles, b/l varicoceles, previous sports related injury

2. 52y/o M with acute pain and swelling of his great R toe since undergoing appendectomy 10 days ago. Celecoxib hasn't worked. Pt afebrile. Exam shows toe swelling, erythema, and tenderness of the MTP joint. Most appropriate pharmacotherapy?
Acetaminophen, Allopurinol, Aspirin, Dexamethasone, Indomethacin

3. Homeless 66y/o M with 1wk of jaundice. 20lb weight loss over 1 year. Hx alcoholism. Exam: scleral icterus, palmar erythema, spider angiomata. Mg levels are 0.8. Serum studies are most likely to show?
Decreased calcitonin, decreased Ca, decreased tSH, Increased calcitonin, increased Ca, increased Mg, increased PTH, increased TSH, increased T3

4. 26y/o M with SOBx3wks and 2-3cm tender red painful bumps on anterior shin x 1wk. T 100.8, BP 140/85, pulse 80. CXR shows b/l hilar fullness. Serum studies?
Decreased calcitonin, decreased Ca, decreased tSH, Increased calcitonin, increased Ca, increased Mg, increased PTH, increased TSH, increased T3


5. 25y/o G2P1 F at 20wks with severe epigastric pain radiating to the back for 12hrs. Vomit x1. T 100.0. P 92bpm. BP 120/80. Fundus nontender. FHR 130bpm. Hct 42%, WBC 9000, Platelet 220000. Management?
Culdocentesis, CT abd, Platelet count measurement, amylase measurement, paracentesis, single shot IV pyelography, test stool for occult blood, US pelvis

6. 57y/o F with increasing L groin and anterior thigh pain x1yr. Active ROM of hip joint reproduces pain. 20degree hip flexion contracture. ESR 20. (xray) Most likely dx?
AS, OA, Osteonecrosis, psoas abscess, RA

7. 42y/o F with intermittent loss of small amounts of urine x3wks. Sx only happen after voiding. Otherwise asymptomatic. Exam: 3cm midline cystic tender mass in mid third of vagina. UA WNL. Post void residual = 50mL. Dx?
Interstitial cystitis, neurogenic bladder, stress incontinence, urethral diverticulum, urethral syndrome, UTI, vesicovaginal fistula

8. 25y/o primigravid F at 27wks with severe contractions q6h. Vaginal spotting noticed the last time she voided. Fetal monitoring shows adequate contractions, FHR of 130bpm with no decels. Cervix 1cm dilated, 10% effaced. Pt's afebrile, pulse 110bpm, RR 16, BP 110/80. Lungs CTA. Cervix progresses to be 1-2cm dilated, 70% effaced. Vaginal culture for GBS is +. Management?
Observation, oral amoxicillin, IM betamethasome, cervical cerclage, C-section

9. 72y/o M with decreased urine output 2days after admission for Rx of cholecystitis. Lab results showed G- bacteremia and DIC. Currently receiving cefoxitin and gentamicin. T101.3 P110bpm BP 90/64. Exam: RUQ tenderness. Cr increased from 1.5 to 3. UA findings will show? (changes in blood, protein, RBC, WBC, casts, other microscopic findings?)

10. 77y/o M with progressive forgetfulness x2yrs. "no longer himself". Vitals stable. Exam: liver palpable 3cm from R costal margin. 2+ nonpitting edema in LE. DTRs 1+, sensation intact. Gait is slow. Responds slowly to questions. MMSE 20/30. Serum studies Na of 131. K 3.8. Cr 1.2. Alk Phos 160. AST 80. Dx?
Huntington's, Hypothyroidism, Vascular dementia, Pernicious anemia, Syphilis

11. 82y/o M with CHF. Furosemide dose was increased 1mo ago. Other meds, just Lisinopril. PMH: CKD, baseline Cr bw 1.3-1.5, no protein in UA. Today, vitals stable. Trace edema in ankles. BUN up from 15 to 24. Cr up from 1.8 to 2.3. UA WNL. Explanation for bump in Cr?
Decreased Renal blood flow, glomerular inflammation, renal cortical necrosis, renal interstitial inflammation, renal tubular necrosis, rental tubular obstruction

12. 52y/o F with progressive DOE x2wks. PMH: breast cancer s/p mastectomy and chemo. Annual exams show no recurrence. Vitals stable. No JVD. Dullness to percussion over R lower lung. No peripheral edema. Cause of DOE?
Hypothyroidism, LV dysfunction, pericardial tamponade, pleural mets, RLL pneumonia

thanks again!

 

[ZGX]

some extra questions if someone can help me out! it would be greatly appreciated!

1. 27y/o M unable to conceive after trying for the past 10mos. Wife's fertility stuff all cleared. Husband's exam shows ill-defined soft masses palpated b/l, high in the scrotum. What are they?
B/l direct inguinal hernias, b/l epidiymitis, b/l hydroceles, b/l varicoceles, previous sports related injury

2. 52y/o M with acute pain and swelling of his great R toe since undergoing appendectomy 10 days ago. Celecoxib hasn't worked. Pt afebrile. Exam shows toe swelling, erythema, and tenderness of the MTP joint. Most appropriate pharmacotherapy?
Acetaminophen, Allopurinol, Aspirin, Dexamethasone, Indomethacin

3. Homeless 66y/o M with 1wk of jaundice. 20lb weight loss over 1 year. Hx alcoholism. Exam: scleral icterus, palmar erythema, spider angiomata. Mg levels are 0.8. Serum studies are most likely to show?
Decreased calcitonin, decreased Ca, decreased tSH, Increased calcitonin, increased Ca, increased Mg, increased PTH, increased TSH, increased T3

4. 26y/o M with SOBx3wks and 2-3cm tender red painful bumps on anterior shin x 1wk. T 100.8, BP 140/85, pulse 80. CXR shows b/l hilar fullness. Serum studies?
Decreased calcitonin, decreased Ca, decreased tSH, Increased calcitonin, increased Ca, increased Mg, increased PTH, increased TSH, increased T3


5. 25y/o G2P1 F at 20wks with severe epigastric pain radiating to the back for 12hrs. Vomit x1. T 100.0. P 92bpm. BP 120/80. Fundus nontender. FHR 130bpm. Hct 42%, WBC 9000, Platelet 220000. Management?
Culdocentesis, CT abd, Platelet count measurement, amylase measurement, paracentesis, single shot IV pyelography, test stool for occult blood, US pelvis

6. 57y/o F with increasing L groin and anterior thigh pain x1yr. Active ROM of hip joint reproduces pain. 20degree hip flexion contracture. ESR 20. (xray) Most likely dx?
AS, OA, Osteonecrosis, psoas abscess, RA

7. 42y/o F with intermittent loss of small amounts of urine x3wks. Sx only happen after voiding. Otherwise asymptomatic. Exam: 3cm midline cystic tender mass in mid third of vagina. UA WNL. Post void residual = 50mL. Dx?
Interstitial cystitis, neurogenic bladder, stress incontinence, urethral diverticulum, urethral syndrome, UTI, vesicovaginal fistula

8. 25y/o primigravid F at 27wks with severe contractions q6h. Vaginal spotting noticed the last time she voided. Fetal monitoring shows adequate contractions, FHR of 130bpm with no decels. Cervix 1cm dilated, 10% effaced. Pt's afebrile, pulse 110bpm, RR 16, BP 110/80. Lungs CTA. Cervix progresses to be 1-2cm dilated, 70% effaced. Vaginal culture for GBS is +. Management?
Observation, oral amoxicillin, IM betamethasome, cervical cerclage, C-section

9. 72y/o M with decreased urine output 2days after admission for Rx of cholecystitis. Lab results showed G- bacteremia and DIC. Currently receiving cefoxitin and gentamicin. T101.3 P110bpm BP 90/64. Exam: RUQ tenderness. Cr increased from 1.5 to 3. UA findings will show? (changes in blood, protein, RBC, WBC, casts, other microscopic findings?)
Sepsis
10. 77y/o M with progressive forgetfulness x2yrs. "no longer himself". Vitals stable. Exam: liver palpable 3cm from R costal margin. 2+ nonpitting edema in LE. DTRs 1+, sensation intact. Gait is slow. Responds slowly to questions. MMSE 20/30. Serum studies Na of 131. K 3.8. Cr 1.2. Alk Phos 160. AST 80. Dx?
Huntington's, Hypothyroidism (Weird question - Didn't know Hypothyroidism can cause MMSE20/30), Vascular dementia, Pernicious anemia, Syphilis

11. 82y/o M with CHF. Furosemide dose was increased 1mo ago. Other meds, just Lisinopril. PMH: CKD, baseline Cr bw 1.3-1.5, no protein in UA. Today, vitals stable. Trace edema in ankles. BUN up from 15 to 24. Cr up from 1.8 to 2.3. UA WNL. Explanation for bump in Cr?
Decreased Renal blood flow (uworld question), glomerular inflammation, renal cortical necrosis, renal interstitial inflammation, renal tubular necrosis, rental tubular obstruction

12. 52y/o F with progressive DOE x2wks. PMH: breast cancer s/p mastectomy and chemo. Annual exams show no recurrence. Vitals stable. No JVD. Dullness to percussion over R lower lung. No peripheral edema. Cause of DOE?
Hypothyroidism, LV dysfunction, pericardial tamponade, pleural mets, RLL pneumonia

thanks again!

I think those are the answers. Feel free to UpToDate them.
NBME 7 - Ambiguous Exam