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  #1  
Old 08-25-2014
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Default Help!! NBME 6

WOuld really appreciate if any one could help me out with these:

2 hours ago, a 24 year old man had sudden onset of pain in the right side of his chest that has become increasingly severe. He is feeling short of breath noe. His temp, BP, pulse are normal. An Xray is shown. Which of the following is the most appropriate next step of management?
bed rest and sedative therapy
antibiotic therapy
anticoagulant therapy
tube thoracotomy
immediate thoracotomy (wrong)

9. An 82-year-old woman is brought to the physician by her granddaughter because of a 6-week history of increasing forgetfulness. She is a retired schoolteacher and lives independently. Her granddaughter is concerned because on several occasions she has left the stove on when she went to bed. During conversations with her granddaughter, she has difficulty remembering past events and seems unconcerned about her memory lapses. The patient describes trouble sleeping through the night and has had a decreased appetite resulting in a 4.5-kg (10-lb) weight loss over the past month. She has a history of similar symptoms 2 and 5 years ago that were successfully treated with medication. She appears unkempt and has poor personal hygiene. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, and pulse is 80/min and regular. Mental status examination shows psychomotor retardation, a flat affect, impaired ability to recall past events, and trouble repeating three numbers in sequence. She is unable to recall the names of recent presidents. Her serum urea nitrogen (BUN) level is 25 mg/dL, and serum creatinine level is 1.7 mg/dL.

For each patient with cognitive impairment, select the most likely diagnosis.


A ) Acute stress disorder

B ) Dementia, Alzheimer's type

C ) Dissociative amnesia

D ) General paresis

E ) Head trauma

F ) Hepatolenticular degeneration (Wilson's disease)

G ) HIV encephalitis

H ) Huntington's disease

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

K ) Niacin deficiency

L ) Normal-pressure hydrocephalus

M ) Parkinson's disease

N ) Pick's disease

O ) Schizophrenia, catatonic type

P ) Normal aging




A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1 day. She is in the third week of second grade. Her temperature is 38.6 C (101.5 F). Examination shows an erythematous pharynx and slightly enlarged tonsils without exudate. There is no significant cervical lymphadenopathy. A rapid test for group A streptococcus is negative. Which of the following is the most appropriate next step in management?

A) Throat culture
B) Monospot test
C) Intramuscular penicillin therapy
D) Oral erythromycin therapy
E) Oral penicillin therapy


A 27-year-old woman comes to the physician because of a 2-year history of intermittent diarrhea and severe cramping abdominal pain. The stools are watery, occasionally foul-smelling, and nonbloody. She is currently pain-free and has not had diarrhea for 2 days. She also has intermittent constipation. She has not had fever or weight loss. She returned from a trip to Mexico 3 months ago. She had an appendectomy at the age of 12 years and a cesarean delivery 4 years ago. Examination shows no abnormalities. Which of the following is the most likely diagnosis?

A
) Bacterial gastroenteritis

B
) Crohn's disease

C
) Intermittent small-bowel obstruction

D
) Irritable bowel syndrome[IMG]file:///C:\Users\Lenovo\AppData\Local\Temp\msohtmlclip1\01 \clip_image002.gif[/IMG]

E
) Laxative abuse




46. A 47-year-old man is admitted to the hospital after threatening to harm a radio announcer he believed was broadcasting his thoughts. Over the past 20 years, he has had multiple psychiatric hospitalizations for threatening people who he believed were plotting against him, trying to control his mind, or causing him to hear voices by implanting devices in his head. Past symptoms improved with neuroleptic therapy; after discharge, he discontinued the medication and his symptoms worsened. Which of the following is the most appropriate pharmacotherapy to decrease this patient's risk for future hospitalization?

A
) Clozapine

B
) Fluphenazine hydrochloride

C
) Haloperidol decanoate

D
) Risperidone (id read on uworld that risperidone can be given as depot for non-compliant patients, so i marked that) its wrong

E
) Trifluoperazine hydrochloride

A 42 year old woman comes to the physician because of right sided abdominal cramps and nausea. During this perios she has noticed that her eyes are yellow. She has not had any other symptoms, no other h/o jaundice. 2 months ago, she underwent a lap cholecyctectomy for acute cholecyctitis; no intra-op cholangiography performed. No meds currently, Vitals stable, sclera icterus present. Cardio-pul exam normal. Abdo nondistended, mild RUQ tenderness. No peritoneal signs present. Bowel sounds normal. Serum studies:
Total bili 8 direct 5
ALP 650
AST 20
ALT 18
Abd USG shows dilated intrahepatic biliary ducts. Most appropriate next step?


CT scan abdo
HIDA scan
i.v Antibiotics
ERCP
Sx exploration of abdomen
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  #2  
Old 08-26-2014
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A 57-year-old woman comes to the physician because of a 6-month history of moderate penumbibcal pain that occurs within 1 hour after eating She has had an 11-kg (25-Ib) weight loss as a result ot eating less to avoid the pain She has a 5-year history of hypertension and claudication Current medications include a diuretic. a 3-adrenergic
blocking agent. and an antiplatelet agent She is 165 cm(5 ft 5 in) tall and weighs 50kg (110 Ib). BMI is 18 kgm2 Her pulse is 75min, and blood pressure is 145190mm Hg The abdomen is soft, nondistended, and nontender there are no masses or organomegaly Femoral pulses are palpable bilaterally, and popliteal arid distal pulses are absent bilateraly Test of the stool for occult blood is negative WlIch of the following is the most appropriate next step in diagnosis?
O A) HIDA scan
O B) Colonoscopy
O C) Upper gastrorntestinal endoscopy
o D) Arteriographv
o E) Endoscopic retrograde cholangiopancreatography
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  #3  
Old 08-26-2014
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9. An 82-year-old woman is brought to the physician by her granddaughter because of a 6-week history of increasing forgetfulness. She is a retired schoolteacher and lives independently. Her granddaughter is concerned because on several occasions she has left the stove on when she went to bed. During conversations with her granddaughter, she has difficulty remembering past events and seems unconcerned about her memory lapses. The patient describes trouble sleeping through the night and has had a decreased appetite resulting in a 4.5-kg (10-lb) weight loss over the past month. She has a history of similar symptoms 2 and 5 years ago that were successfully treated with medication. She appears unkempt and has poor personal hygiene. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, and pulse is 80/min and regular. Mental status examination shows psychomotor retardation, a flat affect, impaired ability to recall past events, and trouble repeating three numbers in sequence. She is unable to recall the names of recent presidents. Her serum urea nitrogen (BUN) level is 25 mg/dL, and serum creatinine level is 1.7 mg/dL.

For each patient with cognitive impairment, select the most likely diagnosis.


A ) Acute stress disorder

B ) Dementia, Alzheimer's type

C ) Dissociative amnesia

D ) General paresis

E ) Head trauma

F ) Hepatolenticular degeneration (Wilson's disease)

G ) HIV encephalitis

H ) Huntington's disease

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

K ) Niacin deficiency

L ) Normal-pressure hydrocephalus

M ) Parkinson's disease
N ) Pick's disease

O ) Schizophrenia, catatonic type

P ) Normal aging

Maj depressive disorder is what i think it is
A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1 day. She is in the third week of second grade. Her temperature is 38.6 C (101.5 F). Examination shows an erythematous pharynx and slightly enlarged tonsils without exudate. There is no significant cervical lymphadenopathy. A rapid test for group A streptococcus is negative. Which of the following is the most appropriate next step in management?

A) Throat culture
B) Monospot test
C) Intramuscular penicillin therapy
D) Oral erythromycin therapy
E) Oral penicillin therapy

A is the answer
A 27-year-old woman comes to the physician because of a 2-year history of intermittent diarrhea and severe cramping abdominal pain. The stools are watery, occasionally foul-smelling, and nonbloody. She is currently pain-free and has not had diarrhea for 2 days. She also has intermittent constipation. She has not had fever or weight loss. She returned from a trip to Mexico 3 months ago. She had an appendectomy at the age of 12 years and a cesarean delivery 4 years ago. Examination shows no abnormalities. Which of the following is the most likely diagnosis?

A
) Bacterial gastroenteritis

B
) Crohn's disease

C
) Intermittent small-bowel obstruction

D
) Irritable bowel syndrome[IMG]file:///C:\Users\Lenovo\AppData\Local\Temp\msohtmlclip1\01 \clip_image002.gif[/IMG]

E
) Laxative abuse

It's D irritable bowel syndrome

46. A 47-year-old man is admitted to the hospital after threatening to harm a radio announcer he believed was broadcasting his thoughts. Over the past 20 years, he has had multiple psychiatric hospitalizations for threatening people who he believed were plotting against him, trying to control his mind, or causing him to hear voices by implanting devices in his head. Past symptoms improved with neuroleptic therapy; after discharge, he discontinued the medication and his symptoms worsened. Which of the following is the most appropriate pharmacotherapy to decrease this patient's risk for future hospitalization?

A
) Clozapine

B
) Fluphenazine hydrochloride

C
) Haloperidol decanoate

D
) Risperidone (id read on uworld that risperidone can be given as depot for non-compliant patients, so i marked that) its wrong

E
) Trifluoperazine hydrochloride

Yes, all the 3 option of Risperisone, Haloperidol and fluphenazine. can be given I.V but there is a catch it said haloperidol deconate which is the most potent iv. the other 2 have different iv forms. which are not the same as the ones listed.

A 42 year old woman comes to the physician because of right sided abdominal cramps and nausea. During this perios she has noticed that her eyes are yellow. She has not had any other symptoms, no other h/o jaundice. 2 months ago, she underwent a lap cholecyctectomy for acute cholecyctitis; no intra-op cholangiography performed. No meds currently, Vitals stable, sclera icterus present. Cardio-pul exam normal. Abdo nondistended, mild RUQ tenderness. No peritoneal signs present. Bowel sounds normal. Serum studies:
Total bili 8 direct 5
ALP 650
AST 20
ALT 18
Abd USG shows dilated intrahepatic biliary ducts. Most appropriate next step?


ERCP for this one. I think.

A 57-year-old woman comes to the physician because of a 6-month history of moderate penumbibcal pain that occurs within 1 hour after eating She has had an 11-kg (25-Ib) weight loss as a result ot eating less to avoid the pain She has a 5-year history of hypertension and claudication Current medications include a diuretic. a 3-adrenergic
blocking agent. and an antiplatelet agent She is 165 cm(5 ft 5 in) tall and weighs 50kg (110 Ib). BMI is 18 kgm2 Her pulse is 75min, and blood pressure is 145190mm Hg The abdomen is soft, nondistended, and nontender there are no masses or organomegaly Femoral pulses are palpable bilaterally, and popliteal arid distal pulses are absent bilateraly Test of the stool for occult blood is negative WlIch of the following is the most appropriate next step in diagnosis?
O A) HIDA scan
O B) Colonoscopy
O C) Upper gastrorntestinal endoscopy
o D) Arteriographv
o E) Endoscopic retrograde cholangiopancreatography


D
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jili1409 (08-26-2014)
 
  #4  
Old 08-26-2014
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Thanks doc007, can you explain why the and to the first quest is major depression and not AD? And also arteriography for the last one. I can figure out how the periumbilical pain after eating and wt loss can be related to the aorta. Or is the femoral weak pulses just the more imp aspect of the question?
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  #5  
Old 08-27-2014
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Quote:
Originally Posted by jili1409 View Post
Thanks doc007, can you explain why the and to the first quest is major depression and not AD? And also arteriography for the last one. I can figure out how the periumbilical pain after eating and wt loss can be related to the aorta. Or is the femoral weak pulses just the more imp aspect of the question?
In regards to the MDD vs AD look at the following:
"She has a history of similar symptoms 2 and 5 years ago that were successfully treated with medication."
"6-week history of increasing forgetfulness. "
Remember Alzheimer takes a very long time to result in the classic symptoms. This patient however had MDD that was "successfully treated with medication". Alzheimer has never been successfully treated, except in Dawn Planet of the Apes.
This makes MDD more likely as the answer. Also look for SIG E CAPS. The question is very confusing and can mislead you to AD. Gotta read carefully.

As for the Arteriography question:
"moderate penumbibcal pain that occurs within 1 hour after eating"
"History of hypertension and claudication"
"popliteal arid distal pulses are absent bilaterally"

I am suspecting this is chronic mesenteric ischemia. She has all the risk factors for given her history and physical exam. Another question that must be read carefully.
__________________
"Be Water, my friend."
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