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Old 07-11-2015
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Star NBME 4 discussion***********

HI
I'll put here some Questions from nbme 4...
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Quote:
Originally Posted by Pedro Rodrigo View Post
HI
I'll put here some Questions from nbme 4...
13 year old boy is brought to the physician because of a 3 month history of left knee pain that is exacerbated by vigorous exercise. He also has had occasional pain in his right knee. There is no history of trauma. He is at 50th percentile for height and weight. His temperature is 37C(98.6F). Examination shows mild swelling and tenderness of the left tibial tubrcle; range of motion is full

for each patient with knee pain; next step in management

A. Radionuclide bone scan
B. MRI of the affected knee
C. Antiobiotic therapy
D. NSAID therapy
E. Knee immobilization
F. Joint Aspiration
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Originally Posted by Pedro Rodrigo View Post
13 year old boy is brought to the physician because of a 3 month history of left knee pain that is exacerbated by vigorous exercise. He also has had occasional pain in his right knee. There is no history of trauma. He is at 50th percentile for height and weight. His temperature is 37C(98.6F). Examination shows mild swelling and tenderness of the left tibial tubrcle; range of motion is full

for each patient with knee pain; next step in management

A. Radionuclide bone scan
B. MRI of the affected knee
C. Antiobiotic therapy
D. NSAID therapy
E. Knee immobilization
F. Joint Aspiration
I selected Knee Immobilization, and was wrong.


Is the answer NSAIDs, as most posible???
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Post hi

another query:
form 4 section 1 q 17:

17. A 16-year-old boy is brought to the physician because of a 3-day history of right knee pain associated with redness and swelling. There is no history of trauma.he is at the
50th percentile for height and weight. His temperature is 38.6°C (101.5°F). Examination shows ery thema. swelling, and tenderness of the right knee ,and range of motion is limited.
select the most appropriate next step in management:

o A) Radionuclide bone scan
O B) MRI of the affected knee
O C) Antibiotic therapy
O D) Nonsteroidal anti-inflammatory drug therapy
o E) Knee immobilization
O F) Joint aspiration

See that have temperature, it's like septic arthritis
NSAIDs are wrong here

WHat is the answer? to Give antibiotics, or to make joint aspiration first???
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A 32-year-old woman comes for a follow-up examination 1 week after a Pap smear showed a high-grade squamous intraepithelial lesion. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) Repeat Pap smear

B ) Trichloroacetic acid therapy

C ) Colposcopic-directed biopsy

D ) Cone biopsy of the cervix

E ) Cryosurgery of the cervix
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Originally Posted by Pedro Rodrigo View Post
A 32-year-old woman comes for a follow-up examination 1 week after a Pap smear showed a high-grade squamous intraepithelial lesion. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) Repeat Pap smear

B ) Trichloroacetic acid therapy

C ) Colposcopic-directed biopsy

D ) Cone biopsy of the cervix

E ) Cryosurgery of the cervix
Answer is C colposcopic directed biopsy, as confirmatory , to see in deepth...
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37. A 47-year-old woman comes to the physician because of difficulty sleeping for 2 months. During this period, she has been awakening at 3 AM and remaining awake worrying about work, even though she is tired. She has unstable angina pectoris and required placement of one coronary artery stent 6 months ago and a second stent 4 months ago. Her chest pain started to recur 1 month ago. and she now has it almost daily. Evaluation shows no organic cause for her recurring chest pain. She works as an attorney for a large firm and reports that she has been given more responsibility during the past year. For the past month, she has not enjoyed her work as much as she previously did. She forces herself to goto work and has difficulty paying attention while she is there. She is a gourmet cook but no longer prepares meals because she does not enjoy the taste of the food. Physical examination shows no abnormalities. On mental status examination, she has a sad and worried mood and a reactive affect. She is alert and oriented to person, place, and time. She states that she frequently becomes despondent, especially when she thinks about her heart disease. Which of the following is the most likely diagnosis?
O A) Adjustment disorder wrong
O B) Dysthymic disorder do not feat here
O C) Generalized anxiety disorder should be more than 6 months
O D) Major depressive disorder**** don't see other symptoms characteristics
O E) Primary insomnia*****?????

Last edited by Pedro Rodrigo; 07-11-2015 at 01:32 PM.
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Originally Posted by Pedro Rodrigo View Post
37. A 47-year-old woman comes to the physician because of difficulty sleeping for 2 months. During this period, she has been awakening at 3 AM and remaining awake worrying about work, even though she is tired. She has unstable angina pectoris and required placement of one coronary artery stent 6 months ago and a second stent 4 months ago. Her chest pain started to recur 1 month ago. and she now has it almost daily. Evaluation shows no organic cause for her recurring chest pain. She works as an attorney for a large firm and reports that she has been given more responsibility during the past year. For the past month, she has not enjoyed her work as much as she previously did. She forces herself to goto work and has difficulty paying attention while she is there. She is a gourmet cook but no longer prepares meals because she does not enjoy the taste of the food. Physical examination shows no abnormalities. On mental status examination, she has a sad and worried mood and a reactive affect. She is alert and oriented to person, place, and time. She states that she frequently becomes despondent, especially when she thinks about her heart disease. Which of the following is the most likely diagnosis?
O A) Adjustment disorder wrong
O B) Dysthymic disorder do not feat here
O C) Generalized anxiety disorder should be more than 6 months
O D) Major depressive disorder**** don't see other symptoms characteristics
O E) Primary insomnia*****?????
Decreased sleep, anxiety, worry, do not cook more because do not see any interest and tasty food, so it's like Major depressive disorder...
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25 A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 2 years She also has had pain with sexual intercourse over the past 6 months She has been otherwise healthy Menarche was at the age of 13 years, and menses have occurred at regular 28-day intervals Her last menstrual period was 1 week ago Her temperature is 37C (986F). pulse is 80mm. respirations are 20/mm, and blood pressure is 120/80mm Hg Abdominal examination shows right lower quadrant tenderness Pelvic examination shows a 5-cm. tender. right adnexal mass Laboratory studies show
Hemoglobin 12 gdL
Leukocyte count 9000mm3
Segmented neutrophils 60%
Bands 5%
Lymphocytes 30%
Monocvtes 5%
Ervthrocyte sedimentation rate 15 rnnti
A urine pregnancy test is negative Urasonography shows a 5-cm nght adnexal mass containing low-level. homogeneous. internal echos A biopsy specimen of the mass is most likely to show which of the following?
O A) Atypical ovarian epithelial cels
o B) Enciometnal glands and stroma
O C) Luteinized granulosa cells
o 0) Myometrium
o E) Squamous cells. cartilage. and bone is wrong because mass is homogeneous******
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Originally Posted by Pedro Rodrigo View Post
25 A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 2 years She also has had pain with sexual intercourse over the past 6 months She has been otherwise healthy Menarche was at the age of 13 years, and menses have occurred at regular 28-day intervals Her last menstrual period was 1 week ago Her temperature is 37C (986F). pulse is 80mm. respirations are 20/mm, and blood pressure is 120/80mm Hg Abdominal examination shows right lower quadrant tenderness Pelvic examination shows a 5-cm. tender. right adnexal mass Laboratory studies show
Hemoglobin 12 gdL
Leukocyte count 9000mm3
Segmented neutrophils 60%
Bands 5%
Lymphocytes 30%
Monocvtes 5%
Ervthrocyte sedimentation rate 15 rnnti
A urine pregnancy test is negative Urasonography shows a 5-cm nght adnexal mass containing low-level. homogeneous. internal echos A biopsy specimen of the mass is most likely to show which of the following?
O A) Atypical ovarian epithelial cels
o B) Enciometnal glands and stroma
O C) Luteinized granulosa cells
o 0) Myometrium
o E) Squamous cells. cartilage. and bone is wrong because mass is homogeneous******
Answer looks to be B
Because have pain with intercouse, patients from that age most likely have Endometrioma that produce pain during intercourse instead of cancer...
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30. A 17.year-old boy is brought to the emergency department by his parents because they were informed by his school counselor that he wants to commit suicide. Last week, he
broke up with his girlfriend of 2 years, and today he learned that he did not get accepted to his university of choice. On questioning, he says that he is sad and admits that he
had spoken of suicide to a friend but states that he does not want to hurt himself because of religious beliefs “My family would be hurt, too." he states. He has no history of
medical or psychiatric illness and takes no medications He does not smoke cigarettes or drink alcohol Physical examination shows no abnormalities On mental status
examination, he is cooperative and makes good eye contact In addition to recommending outpatient therapy, which of the following is the most appropriate physician
recommendation to this patient's parents?
o A) “Don’t make him go to school until he feels better. He can’t concentrate in his present state of mind”
O B) "Let him rest and spend time alone. He needs space to think.”
o C) "Make sure he does not have access to guns”
o D) "Perhaps you should invite his ex-girlfriend over to cheer him up”
0 E) "Pray with him daily. Religion is an important protective factor”
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Quote:
Originally Posted by Pedro Rodrigo View Post
30. A 17.year-old boy is brought to the emergency department by his parents because they were informed by his school counselor that he wants to commit suicide. Last week, he
broke up with his girlfriend of 2 years, and today he learned that he did not get accepted to his university of choice. On questioning, he says that he is sad and admits that he
had spoken of suicide to a friend but states that he does not want to hurt himself because of religious beliefs “My family would be hurt, too." he states. He has no history of
medical or psychiatric illness and takes no medications He does not smoke cigarettes or drink alcohol Physical examination shows no abnormalities On mental status
examination, he is cooperative and makes good eye contact In addition to recommending outpatient therapy, which of the following is the most appropriate physician
recommendation to this patient's parents?
o A) “Don’t make him go to school until he feels better. He can’t concentrate in his present state of mind”
O B) "Let him rest and spend time alone. He needs space to think.”
o C) "Make sure he does not have access to guns”
o D) "Perhaps you should invite his ex-girlfriend over to cheer him up”
0 E) "Pray with him daily. Religion is an important protective factor”

This is the why from UpTodate: Outpatient therapy is usually the best option for lower risk individuals (eg, patients who are medically stable and are not imminently suicidal) [19,25]. Outpatient therapy requires the involvement of the family and their willingness to stay with the patient indefinitely [2,12,13]. All lethal means of suicide, particularly firearms and medications, should be made unavailable to the patient. The acute crises that precipitated the event must be addressed and attempts made to resolve them. The patient and parents should be warned about the dangerous disinhibiting effects of alcohol and other drugs [2]. Psychiatric follow-up must be secured within 48 hours and the patient and family members should be instructed to return to the emergency department if things are not going well

Medication, and guns or any subject that can serve as suicide to protect and take fairly from patient...
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A cohort study is conducted to assess the relationship between oral contraceptive use and risk of breast cancer. PArticipants are chosen from closed panel health maintainance organizaion(HMO) and include 530 women between 30 and 40 years of age with no gynaecologic disease. Each participant is asked to complete a questionnaire about her use of oral contraceptive. twenty years later 40% of the participants are enrolled in the same HMO . Of the 100 women who remained with the HMO and continued to use an OCP, 12 patients had histologically confirmed breast cancer compared to 4 patients among the women who did not use an OCP . Which of the following features of the study is most likely to affect its validity?
a. Differential follow up
b. Lead time Bias
c. Misclassification of exposure wroooooooooooong
d. Misclassification of outcome wrooooooooooong
e. Recall bias
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Quote:
Originally Posted by Pedro Rodrigo View Post
A cohort study is conducted to assess the relationship between oral contraceptive use and risk of breast cancer. PArticipants are chosen from closed panel health maintainance organizaion(HMO) and include 530 women between 30 and 40 years of age with no gynaecologic disease. Each participant is asked to complete a questionnaire about her use of oral contraceptive. twenty years later 40% of the participants are enrolled in the same HMO . Of the 100 women who remained with the HMO and continued to use an OCP, 12 patients had histologically confirmed breast cancer compared to 4 patients among the women who did not use an OCP . Which of the following features of the study is most likely to affect its validity?
a. Differential follow up
b. Lead time Bias
c. Misclassification of exposure wroooooooooooong
d. Misclassification of outcome wrooooooooooong
e. Recall bias
Answer is A. I got it right in online nbme. many reasons: out of 530 only 100 remained in the study. this "loss to follow up" creates huge selection bias problem. so differential followup here means that people of different exposures are followed differentially distorting the results.


http://sphweb.bumc.bu.edu/otlt/MPH-M...ias_print.html

Preventing Loss to Follow-up

LightBulb.jpg

The only way to prevent bias from loss to follow-up is to maintain high follow up rates (>80%). This can be achieved by:



Enrolling motivated subjects
Using subjects who are easy to track
Making questionnaires as easy to complete as possible
Maintaining the interest of participants and making them feel that the study is important
Providing incentives
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10. A previously healthy 57 yo man complains of impotence for 1 year. Examination shows a bronze- colored skin. His serum ferritin is 4050. The patient is at increased risk for the following complication?

A. Hepatocellular carcinoma
B. Interstitial lung disease
C. MI
D. Progressive pancytopenia
E. Renal Failure
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Quote:
Originally Posted by Pedro Rodrigo View Post
10. A previously healthy 57 yo man complains of impotence for 1 year. Examination shows a bronze- colored skin. His serum ferritin is 4050. The patient is at increased risk for the following complication?

A. Hepatocellular carcinoma
B. Interstitial lung disease wrong
C. MI
D. Progressive pancytopenia not
E. Renal Failure
not

I think answer is MI because in hemochromatosis, patients develop constrictive cardiomyopathy.
and Cirrhosis if not corelated Iron level with phlebotomy , but not mostly Hepatocellular carcinoma...
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7. A 27-year-old woman is brought to the physician because ot a 3day history of visual loss and aching discomfort in her right eye. Three years ago,she had vertigo,diplopia and an ataxic gait and was diagnosed with an inner ear infection Her symptoms resolved within 1 month without treatment. Examination shows markedly diminished visual acuity on the right: the peripheral visual fields are full to confrontation. Color vision is decreased in the right eye. The right eye does not react to light but has a normal consensual response. Fundoscopic examination shows no abnormalities. She has an ataxic gait. Babinski sign is present bilaterally. Which of the following is the most appropriate next step in diagnosis?
o A) Carotid ultrasonography
o B) Electromyography
o C) Visual evoked potentials
o D) CT scan of the head with contrast
o E) MRI of the brain with contrast
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7. A 27-year-old woman is brought to the physician because ot a 3day history of visual loss and aching discomfort in her right eye. Three years ago,she had vertigo,diplopia and an ataxic gait and was diagnosed with an inner ear infection Her symptoms resolved within 1 month without treatment. Examination shows markedly diminished visual acuity on the right: the peripheral visual fields are full to confrontation. Color vision is decreased in the right eye. The right eye does not react to light but has a normal consensual response. Fundoscopic examination shows no abnormalities. She has an ataxic gait. Babinski sign is present bilaterally. Which of the following is the most appropriate next step in diagnosis?
o A) Carotid ultrasonography
o B) Electromyography
o C) Visual evoked potentials
o D) CT scan of the head with contrast
o E) MRI of the brain with contrast
Ataxic gait plus symptoms of optic neuritis

MRI is most accurate test for Multiple sclerosis...
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10. A 13-year-old boy is brought to the physician because of a 2-week history of left hip pain with an associated limp. He has had no redness or swelling ofthe left leg or hip.
There is no history of trauma or musculoskeletal problems. He is at the 50th percentile for height and above the 95th percentile forweight. Sexual development is Tanner
stage 2. His temperature is 3?.5°C (99.5°F). pulse is 80/min. respirations are l2/min. and blood pressure is l20/75 mm Hg. He holds his left lower extremity in slight external
rotation and hip flexion at rest. Internal rotation and abduction ofthe left hip are decreased. Range of motion ofthe knees and ankles is full. and there is no swelling or
erythema ofthe knee and ankle joints. He walks with a limp and is unable to bear his full weight on the left. Which ofthe following is the most likely underlying cause of this
patient's condition'?
O A) Acute inflammatory reaction ofthe synovial lining ofthe hip joint
O B) Avascular necrosis of proximal femur
O C) Bacterial infection ofthe hip joint
O D) Disruption ofthe femoral head epiphyseal plate
O E) Inflammation ofthe ligaments ofthe hip joint
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Quote:
Originally Posted by Pedro Rodrigo View Post
10. A 13-year-old boy is brought to the physician because of a 2-week history of left hip pain with an associated limp. He has had no redness or swelling ofthe left leg or hip.
There is no history of trauma or musculoskeletal problems. He is at the 50th percentile for height and above the 95th percentile forweight. Sexual development is Tanner
stage 2. His temperature is 3?.5°C (99.5°F). pulse is 80/min. respirations are l2/min. and blood pressure is l20/75 mm Hg. He holds his left lower extremity in slight external
rotation and hip flexion at rest. Internal rotation and abduction ofthe left hip are decreased. Range of motion ofthe knees and ankles is full. and there is no swelling or
erythema ofthe knee and ankle joints. He walks with a limp and is unable to bear his full weight on the left. Which ofthe following is the most likely underlying cause of this
patient's condition'?
O A) Acute inflammatory reaction ofthe synovial lining ofthe hip joint
O B) Avascular necrosis of proximal femur
O C) Bacterial infection ofthe hip joint
O D) Disruption ofthe femoral head epiphyseal plate
O E) Inflammation ofthe ligaments ofthe hip joint

Adolescent with 95 percentile of weight, that signify is overweight, obese, externaly rotated foot,mostly going to answer D
DIsruption of the femoral head epiphyseal plate.
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46. A 67 year old man comes to the physician for a follow up examination. 3 years ago he underwent radical resection of a T3 N0 M0 epidermoid carcinoma of the floor of his mouth and supraomohyoid disection of his neck. He currently takes no medications. He smoked 3 packs of cigarettes daily for 40 years but stopped 3 years ago. Vital signs are within normal limits. Examination shows well healed surgical scars. There is no sign of local recurrence. An X-Ray of the chest shows a 3cm mass in the mediastinal upper lobe of the right lung. Which of the following is the most likely cause of these findings?
a. Bronchioalviolar carcinoma of the lung
b. Metastatic carcinoma
c. Obstructive pneumonia
d. Primary squamous cell carcinoma of the lung
e. Sarcoidosis
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Originally Posted by Pedro Rodrigo View Post
46. A 67 year old man comes to the physician for a follow up examination. 3 years ago he underwent radical resection of a T3 N0 M0 epidermoid carcinoma of the floor of his mouth and supraomohyoid disection of his neck. He currently takes no medications. He smoked 3 packs of cigarettes daily for 40 years but stopped 3 years ago. Vital signs are within normal limits. Examination shows well healed surgical scars. There is no sign of local recurrence. An X-Ray of the chest shows a 3cm mass in the mediastinal upper lobe of the right lung. Which of the following is the most likely cause of these findings?
a. Bronchioalviolar carcinoma of the lung
b. Metastatic carcinoma
c. Obstructive pneumonia
d. Primary squamous cell carcinoma of the lung
e. Sarcoidosis
Primary lung cancer because:
N0 M0 means that no involvement of nodules, and no metastasis
Also cancer that is detected now on X ray is in the middle lobe, that mean is centraly located.
Patient have a history of smoking, so Squamous cell carcinoma and small cell carcinoma are associated with SMOKING

Do NOT SMOKE GUYS ))
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22. A 37-year-old man comes to the physician because of a 1-week history of pain with swallowing. He received the diagnosis of AIDS 4 years ago. but he has not been able to
tolerate highly active antiretroviral therapy. He currently takes trimethoprim-sulfamethoxazole. Vital signs are within normal limits. Examination shows a few white plagues over
the pharynx. No other abnormalities are noted. Laboratory studies show a CD4+ T-lymphocyte count of 50.··'mm3 (Normal2500) and a plasma HIV viral load of 50.000
copies.··`mL. Which ofthe following is the most appropriate pharmacotherapy?
O A) Acyclovir
O B]Amphotericin B
O C) Ciprofloxacin
O D) Fluconazole**************
O E) Foscarnet


D for sure, White plaques from candida, best initial treatment si oral Fluconazole, if do not heal then do Endoscopy upper to visulize...
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A 3 month old infant has had tachypnea and tachycardia for 10 days; during this period he has been feeding poorly. A grade 3/6 systolic murmur and a grade 2/6, apical mid-diastolic murmur are heard. An x-ray of the chest shows cardiomegaly with increased pulmonary vascular markings. Echocardiography shows a large ventricular septal defect. Whch of the following is the most likely cause of these symptoms

A)Excessive Pulmonary blood flow
B) Mitral Valve obstruction
C) reduced left ventricular contractibility
D) Reduced right ventricular preload
E) Right Ventricular pressure overload
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Quote:
Originally Posted by Pedro Rodrigo View Post
A 3 month old infant has had tachypnea and tachycardia for 10 days; during this period he has been feeding poorly. A grade 3/6 systolic murmur and a grade 2/6, apical mid-diastolic murmur are heard. An x-ray of the chest shows cardiomegaly with increased pulmonary vascular markings. Echocardiography shows a large ventricular septal defect. Whch of the following is the most likely cause of these symptoms

A)Excessive Pulmonary blood flow
B) Mitral Valve obstruction
C) reduced left ventricular contractibility
D) Reduced right ventricular preload
E) Right Ventricular pressure overload
Hypertrophic right ventricle and a high pulmonary arteries tension

cardiomegaly + increase pulmonary vascular marking ,meaning there s pulmonary hypertension that gonna give u of course right ventricular hypertrophy + right side heart failure
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Planning

43 - A 77-year-old woman is brought to the emergency department by paramedics 1 hour after the sudden onset of right-sided weakness and difficulty speaking. Her son found her at home after he became concerned because he did not get his usual morning phone call. She has a history of hypertension and hypercholesterolemia treated with a β-adrenergic blocking agent and a lipid-lowering agent. Her pulse is 72/min, and blood pressure is 160/90 mm Hg. During examination, she is only able to give single-word answers with many paraphasic errors. She has good comprehension. Examination shows normal visual fields. There is weakness of the right side of the mouth. Muscle strength of the right upper extremity is 2/5. There is mild weakness of flexion of the right hip; muscle strength of the right lower extremity is otherwise normal. Sensation to pinprick is decreased over the right upper extremity. Deep tendon reflexes are more brisk on the right side than the left, and Babinski sign is present on the right. Which of the following arteries is most likely to be occluded?

A
) Basilar

B
) Left anterior cerebral

C
) Left internal carotid

D
) Left middle cerebral

E
) Left ophthalmic

F
) Left posterior cerebral

G
) Right anterior cerebral

H
) Right internal carotid

I
) Right middle cerebral

J
) Right ophthalmic

K
) Right posterior cerebral
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Quote:
Originally Posted by Pedro Rodrigo View Post
43 - A 77-year-old woman is brought to the emergency department by paramedics 1 hour after the sudden onset of right-sided weakness and difficulty speaking. Her son found her at home after he became concerned because he did not get his usual morning phone call. She has a history of hypertension and hypercholesterolemia treated with a β-adrenergic blocking agent and a lipid-lowering agent. Her pulse is 72/min, and blood pressure is 160/90 mm Hg. During examination, she is only able to give single-word answers with many paraphasic errors. She has good comprehension. Examination shows normal visual fields. There is weakness of the right side of the mouth. Muscle strength of the right upper extremity is 2/5. There is mild weakness of flexion of the right hip; muscle strength of the right lower extremity is otherwise normal. Sensation to pinprick is decreased over the right upper extremity. Deep tendon reflexes are more brisk on the right side than the left, and Babinski sign is present on the right. Which of the following arteries is most likely to be occluded?

A
) Basilar

B
) Left anterior cerebral

C
) Left internal carotid

D
) Left middle cerebral

E
) Left ophthalmic

F
) Left posterior cerebral

G
) Right anterior cerebral

H
) Right internal carotid

I
) Right middle cerebral wrong ((((

J
) Right ophthalmic

K
) Right posterior cerebral


Occlusion of the MCA presents with contralateral hemiplegia, hemisensory loss, and homonymous hemianopsia with eyes deviated toward the cortical lesion. Dominant hemisphere involvement results in aphasia. Nondominant hemisphere involvement results in preserved speech, comprehension with confusion, and apraxia with spatial and contructional deficits.

Kaplan IM page 357
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8. A 42-year old woman comes to the physician because of progressive shortness of breath during the past 6 months. She now has to r est three or four times when climbing one flight of stairs. Shew has smoked one pack of cigarettes daily for 26 years. She has a chronic nonproductive cough and has wheezing controlled with an albuterol inhaler two to three times weekly. During the past year, he BMI has increased from 45kg/sq.m to 52kg/sq.m. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 24/min and shallow, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is distended. There is 1+ edema of the ankles. Arterial blood gas analysis on room air shows:

pH 7.37
Pco2 48 mm Hg
Po2 62 mm Hg
o2 saturation 92%
Her FEV1 is 75% of predicted, and total lung capacity is 50% of predicted. Which of the following is the most likely diagnosis?

A) Chronic obstructive pulmonary disease
B) Congestive heart failure
C) Interstitial pneumonia
D) Recurrent pulmonary embolism
E) Restrictive lung disease
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Quote:
Originally Posted by Pedro Rodrigo View Post
8. A 42-year old woman comes to the physician because of progressive shortness of breath during the past 6 months. She now has to r est three or four times when climbing one flight of stairs. Shew has smoked one pack of cigarettes daily for 26 years. She has a chronic nonproductive cough and has wheezing controlled with an albuterol inhaler two to three times weekly. During the past year, he BMI has increased from 45kg/sq.m to 52kg/sq.m. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 24/min and shallow, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is distended. There is 1+ edema of the ankles. Arterial blood gas analysis on room air shows:

pH 7.37
Pco2 48 mm Hg
Po2 62 mm Hg
o2 saturation 92%
Her FEV1 is 75% of predicted, and total lung capacity is 50% of predicted. Which of the following is the most likely diagnosis?

A) Chronic obstructive pulmonary disease
B) Congestive heart failure
C) Interstitial pneumonia
D) Recurrent pulmonary embolism
E) Restrictive lung disease
E
Restricted because total lung capacity is decreased by half, which mean that is restrictive type of affection of lungs...
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Zipped Files

6. A 43-year-old man comes to the physician because of headache. blurred vision. and confusion for 2 days. He has not had weakness or numbness. difficulty walking.‘chest pain
or discomfort. diplopia. orvertigo. He has hypertension treated with propranolol but says that he does not take his medication regularly. His temperature is 3E5.4°C (9?.5°F).
pulse is ?4.··`min. respirations are l4.··`min. and blood pressure is l90.··`120 mm Hg. The neck is supple. Funduscopic examination shows enlargement ofthe optic discs with
indistinct borders. Blood vessels nearthe discs are indistinct. The lungs are clearto auscultation. There is an S4 with no murmur. Neurologic examination shows no
abnormalities. Which of the following is the most likely diagnosis?
O A) Cerebral infarction
O B) lylalignant hypertension
O C) Retinal detachment
O D) Subarachnoid hemorrhage
O E) Transient ischemic attack
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Quote:
Originally Posted by Pedro Rodrigo View Post
6. A 43-year-old man comes to the physician because of headache. blurred vision. and confusion for 2 days. He has not had weakness or numbness. difficulty walking.‘chest pain
or discomfort. diplopia. orvertigo. He has hypertension treated with propranolol but says that he does not take his medication regularly. His temperature is 3E5.4°C (9?.5°F).
pulse is ?4.··`min. respirations are l4.··`min. and blood pressure is l90.··`120 mm Hg. The neck is supple. Funduscopic examination shows enlargement ofthe optic discs with
indistinct borders. Blood vessels nearthe discs are indistinct. The lungs are clearto auscultation. There is an S4 with no murmur. Neurologic examination shows no
abnormalities. Which of the following is the most likely diagnosis?
O A) Cerebral infarction
O B) lylalignant hypertension
O C) Retinal detachment
O D) Subarachnoid hemorrhage
O E) Transient ischemic attack wrrrrrrrrrrrrrooooooooong
I think about malignang hypertension
Because first at all high BP , confusion
and blurred vision only...
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Personal Statement

1. 25 yo woman at 12 weeks gestation. She has schizoaffective disorder and had been taking Haloperidol sporadically until 2 months ago. She says she is impregnated by evil and demands an abortion to get rid of the "Devils Baby." PE shows a uterus consistent in size and mental status exam shows she is agitated. In addition to admitting her which of the following is most appropriate?

A. Defer the decision about abortion and observe the patient
B. Defer and begin valproic acid
C. Defer and resume haloperidol
D. Arrange for an abortion and begin valproic acid
E. Arrange for an abortion and resume haloperidol
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Correct Answer

Quote:
Originally Posted by Pedro Rodrigo View Post
1. 25 yo woman at 12 weeks gestation. She has schizoaffective disorder and had been taking Haloperidol sporadically until 2 months ago. She says she is impregnated by evil and demands an abortion to get rid of the "Devils Baby." PE shows a uterus consistent in size and mental status exam shows she is agitated. In addition to admitting her which of the following is most appropriate?

A. Defer the decision about abortion and observe the patient
B. Defer and begin valproic acid
C. Defer and resume haloperidol
D. Arrange for an abortion and begin valproic acid
E. Arrange for an abortion and resume haloperidol
When agreeing with the patient is not enough: a schizophrenic woman requests pregnancy termination.
Dudzinski DM1, Sullivan M.
Author information
Abstract
In this article, we discuss the ethical dilemma health care providers faced when Rebecca, a pregnant schizophrenic patient who lacked decision-making capacity, inconsistently requested elective pregnancy termination. When a patient's decision-making capacity is severely impaired, how does the physician balance obligations to protect the patient from harm (beneficence) while also respecting her reproductive preferences and decisions (respect for autonomy)? Rebecca suffers from polysubstance abuse and paranoid schizophrenia characterized by disorganized thought and speech, auditory hallucinations, and delusional ideas. She arrived 14+ weeks pregnant and unaccompanied at an obstetric clinic requesting an abortion. This is her second and final request. On all prior and subsequent occasions, she was either ambivalent or said she wanted to continue the pregnancy. After the consulting psychiatrist determined that she lacked decision-making capacity, steps were taken to address ethical and clinical issues. The steps included treating her schizophrenia to see if she could regain decision-making capacity; identifying a surrogate and using a shared decision-making model; and devising strategies to protect Rebecca and her fetus without resorting to excessive paternalism. Rebecca continued her pregnancy. Due to poor adherence to medical regimen and inadequate social support, Rebecca's schizophrenia was poorly controlled and she continued to use drugs during the pregnancy. She delivered a term baby who was soon removed from her custody. Despite some people's desire to protect Rebecca by complying with her request for abortion, we conclude that to do so would be ethically unjustified. To treat a decisionally impaired patient's requests for abortion as autonomous is disrespectful of the vulnerable patient because such paternalism fails to respect the patient's liberty and the surrogate's authority.
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37 yr old with 12 hours of vomiting, abd cramping and swelling. He has had constipation for 4 days. Diagnosed with Crohns 7 years ago. His symptoms of diarrhea and pain have been well controlled with mesalalmine for past 3 years. His t 96.8, pulse 98 regular, BP 110/70. Exam shows diffusely distended, tympanitic abdomen and visible peristalsis. High pitched bowel sounds are heart. Rectal exam shows no stool in rectal vault. Xray shows SBO. Which is the most likely cause?
-colon cancer
-ileocecal fistula
-small bowel adhesions
-small bowel fibrotic stricture
-small bowel intussusception
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Quote:
Originally Posted by Pedro Rodrigo View Post
37 yr old with 12 hours of vomiting, abd cramping and swelling. He has had constipation for 4 days. Diagnosed with Crohns 7 years ago. His symptoms of diarrhea and pain have been well controlled with mesalalmine for past 3 years. His t 96.8, pulse 98 regular, BP 110/70. Exam shows diffusely distended, tympanitic abdomen and visible peristalsis. High pitched bowel sounds are heart. Rectal exam shows no stool in rectal vault. Xray shows SBO. Which is the most likely cause?
-colon cancer
-ileocecal fistula
-small bowel adhesions
-small bowel fibrotic stricture
-small bowel intussusception
answer is Fibrotic stricture
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West Virginia

A previously healthy 10-month old boy is brought to the emergency department by his parents because he has vomited twice during the past 2 hours. During this period, he has had episodes of inconsolable crying and has passed one bloody stool. On arrival, he appears lethargic and is difficult to arouse. His temperature is 38C (100.4F), pulse is 110/min, respiration are 24/min, and blood pressure is 90/65 mm Hg. The abdomen is soft with no masses or organomegaly. Rectal examination shows bloody mucus in the rectal vault. Which of the following is the most appropriate next step in diagnosis?
A. Test of the stool for Clostridium difficile toxin
B. Contrast enema
C. Upper gastrointestinal series with small bowel follow-through
D. CT scan of the head
E. colonocsopy

Intussusception in childrens>>> Do Enema with or without contrast that is diagnostic and in most cases therapeutical...
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Shopping

A 17 year old girl comes to the physician because of fatigue, increased thirst, and increased urination over the past 2 weeks. She has had a 4.5 kg (10 lb) weight loss during this period despite an increased appetite. She has not had dysuria. At the onset of her symptoms, she had a mild upper respiratory tract infection that resolved without treatment. Her temperature is 36.8 deg C (98.2 deg F), pulse is 86/min, respirations are 14/min, and blood pressure is 100/50 mm Hg. Cranial nerves are intact. Muscle strength is 5/5, and deep tendon reflexes are symmetric. Serum studies show: Na+ is 132, Cl- is 96, K+ is 3.7, HCO3- is 26, and Creatinine is 1.2. Which of the following is the most likely location of the primary disease process?

A) Adrenal gland
B) Bone marrow
C) CNS
D) Kidney
E) Liver
F) Muscle
G) Pancreas
H) Parathyroid gland
I) Pituitary gland
J) Thyroid gland


Pancreas involvement because, persist symptoms like Polyuria, polydispia, and most important Incrreased appetite despite weight loss...
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Grenada

6. A 37year old woman comes to the physician because of increasingly severe pain and masses in both breasts over the past 3 months. She has a 12-year history of similar episodes that were not as severe. The masses vary in size with her menstrual cycles. She has used an oral contraceptive for 16years. Examination shows multinodular breasts; the largest mass is 1 x 2 cm. There is no axillary adenopathy. Which of the following is the most likely diagnosis?

A) Benign cyst
B) Breast abscess
C) Breast carcinoma
D) Breast engorgement
E) Ductal papilloma
F) Fibroadenoma
G) Fibrocystic changes of the breast
H) Mastitis
I) Oral contraceptive-induced breast changes



G
Young women with breast masses, pain and tenderness, that is intensified by mentruation, classic for Fibrocystic changes of the breast...
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a 35 year old woman is brought to the ED 20mins after sustaining a stab wound to the left side of the chest. alert, oriented. she has left sided chest pain and difficulty breathing. pulse is 100/min, RR30, bp:110/70. exam shows a 1cm stab wound in the 5th ICS at the midclavicular line. the left hemithorax is hyperresonant to percussion, and breath sounds are decreased. the neck veins are distended, and the treachea is deviated to the right. during exam, her palpable systolic bp decreases to 70, which of the following is the most likely diagnosis?
A. acute diaphragmatic hernia
B. flail chest
C. hemothroax
D. pericardial tamponade wronggggg
E. simple pneumothorax
F. Tension pneumothorax **************
G. Traumatic aortic transection

Definitely it is Tension pneumothorax :
1. Trauma, chest trauma
2. Pain
3.Hypersonant cavity that mean is entraped air there.
4. Unilateral
5. Tracheal deviation
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Info

A
) Allergic conjunctivitis

B
) Chemical conjunctivitis

C
) Chlamydial conjunctivitis

D
) Gonococcal conjunctivitis

E
) Mucocutaneous lymph node syndrome (Kawasaki disease)

F
) Viral conjunctivitis


9. A previously healthy 6-year-old girl is brought to the physician because of right eye tearing and irritation over the past 2 days. The eye does not itch. She appears well. Her temperature is 37.1C (98.8F), pulse is 82/min, respirations are 20/min, and blood pressure is 100/64 mm Hg. The right conjunctiva is erythematous with clear discharge and crusting. Examination of the left eye shows no abnormalities. There is slight nasal congestion and erythematous mucosa. No other abnormalities are noted.





Viral conjunctivitis



1. Clear tearing
2 Not bilateral but anyway
3. Previous nasal discharge like sinusitis
4. 90% of sinusitis are from viral origin
5.Normal vision( child do not expect any visual problems)
6. Child is subfebrile.
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37. A previously heaThy 6-year-old boy is brought to the physician because of bilateral eye itching and mild nasal congestion over the past 3 weeks He appears well His
temperature is 37 1°C (98 8°F). pulse is 80/mni, respirations are 22/min. and blood pressure is 102/64 mm Hg Examination shows bilateral conjunctival erythema and
tearing There is a cobblestone appearance of the tarsal conjunctivae bilaterally. The nasal mucosa is pale and boggv No other abnommalities are noted

o A) Allergic conjunctivitis ***********************
o B) Chemical conjunctivitis
o C) Chlamydial conjunctivitis
o D) Gonococcal conjunctivitis
O E) Mucocutaneous lymph node syndrome (Kawasaki disease)
O F) Viral conjunctivitis wrong




1.bilateral itchy eyes
2 More than 3 weeks, so viral origin goes away here
3.Nasal mucosa is boggy and pale, looks like polyps this description
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6.
A 47-year-old man has had marked shortness of breath during ambulation and at rest for 24 hours. He has no chest pain. He completed a required course of chemotherapy including doxorubicin for non-Hodgkin lymphoma 4 months ago. His resting pulse has increased from 80/min to 110/min during this period. Echocardiography shows a left ventricular ejection fraction of 40%. An ECG shows sinus tachycardia but is otherwise normal. Which of the following is the most likely explanation for these findings?

A
)
Congestive heart failure

B
)
Endocarditis

C
)
Pericarditis

D
)
Pneumonia

E
)
Pulmonary embolus


The key here is :
1 Chemotherapy with Doxorubicin
2. Doxorubicin causes dilated cardiomyopathy which will lead to congestive heart failure with presents symptoms like Dyspnea, cough, and edema
3. ECG show normaly, exept sinus tachycardia, no Electrical alternans which is present in Tamponade
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6. A 42-year-old woman comes to the physician because of decreased energy. apathy, and difficulty sleeping since being fired from her job 3 weeks ago Since then, she has
awakened at 4 AM daily and has been unable to fall back asleep She also has crying spells every morning During the past 6 months, she has had a 3.2-kg (7-Ib) weight loss
She has no history of serious illness and takes no medications Her father committed suicide at the age of 52 years The patient is 170 cm (5 ft 7 in) tall and weighs 69 kg (152
Ib): BMI is 24 kg/m2 Physical examination shows no abnormalities. On mental status examination, she is sad and teartul. Her speech is soft and goal directed. she says that
she has not thought about suicide and does not want to die. Laboratory findings, including a complete blood count, serum electrolyte concentrations, and serum
thyroid-stimulating hormone concentration, are within the reterence range which of the following is the most appropriate next step in management?
O A) Psychodynamic psychotherapy wrong
o B) Citalopram therapy ***********************
O C) Lithium carbonate therapy
O D) Zolpidem therapy
O E) Electroconvulsive therapy

1.Should be A. Based on UW, the treatment of choice for adjustment disorder is psychodynamic psychotherapy
2.Dx: major depressive disorder
3. Treatment of choice in depression is antidepressive like SSRIs
4.SSRIs: Fluoxetine
Paroxetine
Sertraline
CItalopram
Escitalopram
Fluvoxamine
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A previously healthy 18 year old primigravid African Ameircan woman at 18 weeks gestation is brought to the emergency department because of a 2-day history of fever and a 12-hour history of severe left-sided back pain. She has had no prenatal care. Her family history is unknown because she was adopted. Her temperature is 102.4 deg F, pulse is 110, blood pressure is 100/62. Exam shows left costovertebral angle tenderness. The uterus is consistent in size with an 18-week gestation.

Lab shows:
Hemoglobin 7.9
Hemoglobin Electrophoresis: Hb A1 14%, Hb A2 4%, Hb F 7%, Hb S 75%
MCV 90
Platelet count 159,000
Urine bacteria 3+, Urine WBC 3+

In addition to antibiotic therapy treatment, which of the following is the most appropriate pharmacotherapy?

A) EPO
B) Folic Acid *********************
C) Iron wrooooooooooooong
D) Vitamin B12
E) Vitamin C


http://patient.info/doctor/anaemia-in-pregnancy

Despite of all, in pregnancy Folic acid is essential...
Rapidly dividing cell of baby ,require a lot of Folic acid
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An 82-yo woman is brought to the emergency department 30 minutes after collapsing at a shopping center. Her pulse is 120/min, respiratioin is 12/min, and blood pressure is 90/60 mm Hg. She does not respond to painful stimuli. Thirty minutes later, her granddaughter comes to the hospital and shows the physcician an advance directive signed by the patient requesting no intubation or “artificial means to prolong life.” Which of the following is the most appropriate next step in management?


A. contact the hospital ethics committee
B. Contact the patient’s attorney regarding plans for extubation
C. continue mechanical ventilation and monitor closely in the coronary care unit
D. Obtain nuclear brain blood flow scan to determine brain death
E. Extubate the patient and provide supportive care only


A is wronggggg


Patient desire was do not intube,
Intubation was executed because of emergency
But now as wife told the desire of husband, we can extubate patient and provide only paliative or suportive care...
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72 year old man comes to the ER because he vomited blood three times during the past 12 hours. He has had dizziness during this period. He has 5 year history of arthritis treated with daily ibuprofen. Over past 4 weeks, he has increased his daily dose of ibuprofen because of worsening joint pain but is not sure how many pills he has been taking. He has been unable to take his daily walks because of the joint pain. He has not had chest pain. He had an uncomplicated myocardial infarction 10 years ago. He appears pale. His temperature is 37.5 deg C (99.5 deg F), pulse is 110, respirations 24, blood pressure 90/60. Examination shows dried blood near the mouth. The lungs are clear to auscultation. Heart sounds are normal. The stool is black, and test for occult blood is positive. His hematocrit is 22%, and platelet count is 215,000. Upper endoscopy shows hemorrhagic gastritis with no active site of bleeding. Thirty minutes after fluid resuscitation with crystalloid solution and transfusion of 4 units of crossmatched packed red blood cells, the patient has shortness of breath. Diffuse rhonchi about crackles are heard bilaterally. Which of the following is the most likely cause of the dyspnea?

A) ABO incompatibility
B) Acute respiratory distress syndrome Wrooooooooooong
C) Aspiration of gastric contents
D) Fluid overload
E) Pulmonary embolism

1.Diffuse rhonchi and cracles bilateraly
2.After fluid resuscitation appears symptoms: SOB
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A 57-year-old man comes to the physician for a routine health maintenance examination. He takes an angiotension-converting enzyme (ACE) inhibitor for hypertension and has been advised to lose weight. He works as a pharmacist. His temperature is 37.2 degrees C (99 degrees F), pulse is 92/min, respirations are 14/min, and blood pressure is 152/94 mm Hg. Examination shows no abnormalities. Serum thyroid studies show a thyroid-stimulating hormone concentration of 0.2 uU/mL, a thyroxine (T4) concentration of 18 ug/dL, and triiodothyronine (T3) concentration of 220 ng/dL. A radioactive thyroid scan shows decreased uptake and a small gland. Which of the following is the most likely cause of this patient's findings?

A) Acute suppurative thyroiditis
B) Chronic lymphocytic thyroiditis (Hashimoto disease) wroooooooooong
C) Drug-induced hypothyroidism
D) Euthyroid sick syndrome
E) Exogenous administration of thyroid hormone ***************
F) Grave disease
G) Multiple endocrine neoplasia, type 2
H) Subacute thyroiditis
I) Thyroid cancer



1. High T3 and T4
2 Low TSH
3 Desire to loss weight
4. One of the methods is to take thyroid hormones that will increase metabolism
5. no signs of inflammation or pain in the thyroid area
6. It's obvious sign that patient administer Thyroid hormones, which are exogenous...
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previously healthy 37yr man brought in ER immediately after being involved in a RTA.HE was the restrained driver.The vehicle was not equipped with airbags.At the scene,the steering was deformed and there was substantial damage to the rest of the vehicle.En route,his hemodynamic status and respirations were stable.On arrival,he is alert and oriented to person,place and time.He says he has severe ant chest pain.His vitalsulse 110bpm,RR 24/min,BP 90/60,JVP-distended,tenderness+ on sternum palpation.After IV admin of 2L of normal saline,his pulse decreases to 100 bpm,BP increases to 100/70.During the next 10 min,his BP decreases to 80/50.Whats the cuz of this BP decrease?

a.MI
b.Pericardial Tamponade ****************
c.Pulm Embolism
d.Ruptured Thoracic Aorta wroooooooooong
e.Tension pneumothorax

1.Vehicle accident trauma
2.Chest pain
3 Hypotension, tachycardia, tachypnea
4 *** distended Jugular venous vessels
5. Blood pressure corrected, decreased again, as we know pericardium may accomodate from 50 ml of blood to 2 Liter
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Old 07-15-2015
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Quote:
Originally Posted by Pedro Rodrigo View Post
13 year old boy is brought to the physician because of a 3 month history of left knee pain that is exacerbated by vigorous exercise. He also has had occasional pain in his right knee. There is no history of trauma. He is at 50th percentile for height and weight. His temperature is 37C(98.6F). Examination shows mild swelling and tenderness of the left tibial tubrcle; range of motion is full

for each patient with knee pain; next step in management

A. Radionuclide bone scan
B. MRI of the affected knee
C. Antiobiotic therapy
D. NSAID therapy
E. Knee immobilization
F. Joint Aspiration
no matter what first step is always aspiration if there are signs of effusion , so the other joint questions is aspirations. but here this is classic osgood shlatter disease however u spell it. so give NSAIDS is best. and rest.
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72 year old man comes to the ER because he vomited blood three times during the past 12 hours. He has had dizziness during this period. He has 5 year history of arthritis treated with daily ibuprofen. Over past 4 weeks, he has increased his daily dose of ibuprofen because of worsening joint pain but is not sure how many pills he has been taking. He has been unable to take his daily walks because of the joint pain. He has not had chest pain. He had an uncomplicated myocardial infarction 10 years ago. He appears pale. His temperature is 37.5 deg C (99.5 deg F), pulse is 110, respirations 24, blood pressure 90/60. Examination shows dried blood near the mouth. The lungs are clear to auscultation. Heart sounds are normal. The stool is black, and test for occult blood is positive. His hematocrit is 22%, and platelet count is 215,000. Upper endoscopy shows hemorrhagic gastritis with no active site of bleeding. Thirty minutes after fluid resuscitation with crystalloid solution and transfusion of 4 units of crossmatched packed red blood cells, the patient has shortness of breath. Diffuse rhonchi about crackles are heard bilaterally. Which of the following is the most likely cause of the dyspnea?

A) ABO incompatibility
B) Acute respiratory distress syndrome Wrooooooooooong
C) Aspiration of gastric contents
D) Fluid overload
E) Pulmonary embolism

1.Diffuse rhonchi and cracles bilateraly
2.After fluid resuscitation appears symptoms: SOB
also you can see how much fluid is being given, thats alot, esp for elderly, who cannot accomodate that much so fast.
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  #51  
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Originally Posted by alittlebitmore View Post
no matter what first step is always aspiration if there are signs of effusion , so the other joint questions is aspirations. but here this is classic osgood shlatter disease however u spell it. so give NSAIDS is best. and rest.
Thanks for contribution man...
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  #52  
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A 23 y primigravid woman at 10 weeks gestation comes to the physician for the prematal visit.
she follows veg diet and eats no meat or fish.
exam shows a uterus consistent insize with a 10 week gestation.
she intends to breast feed .
which of the foll most appropriate additional supplement vitamin for this patient during preg and lactation.
A).B12(cycanocobalamin)
B) C
D)E
E)K
Vit D is wrong
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  #53  
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Correct Answer

Quote:
Originally Posted by Pedro Rodrigo View Post
A 23 y primigravid woman at 10 weeks gestation comes to the physician for the prematal visit.
she follows veg diet and eats no meat or fish.
exam shows a uterus consistent insize with a 10 week gestation.
she intends to breast feed .
which of the foll most appropriate additional supplement vitamin for this patient during preg and lactation.
A).B12(cycanocobalamin)
B) C
D)E
E)K
Vit D is wrong
She is vegetarian, and i think it's a cyancobalamin deficiency
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A hospitalized 67 y/o woman has 24 hr history of nausea and abdominal distention. During this period, she vomited 3 times, continued to pass flatus, and has had one bowel movement. She underwent surgical repair of a suprarenal abdominal aortic aneurysm 6 days ago. Post-op, she tolerated clear liquid diet. Her temp is 100.6 deg F, pulse is 95/min and regular, and blood pressure is 120/80 mm Hg. The lungs are clear to auscultation. Heart sounds are normal. The abdomen is distended and tympanitic. There is epigastric tenderness with no guarding or rebound. The surgical incision is intact with inflammation. Labs show:

Hb 10.5 g/dL
Leukocyte count 11,000/mm3
Serum K+ is 4.0
Serum Ca is 9.2
AST 50
ALT 1000
LDH 80

A CT scan of abdomen shows thickened, indurated pancreas with loss of surrounding soft tissue planes. Which of the following is the next step in management?

A) IV Calcium therapy
B) IV Cephalosporin therapy Wrongggggg
C) IV Prednisone therapy
D) Enteral hyperalimentation
E) Nasogastric decompression **********

Patient has surgery, and now presents with symptoms for Pancreatitis, with vomiting, fever, nausea, and bloating

Nothing per oral, nasogastric decompression, bowel rest, and IV infusion will be the best approach..
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An 82-year-old widower comes to the physician because of a 1-month history of sudden forgetfulness. Previously, he had noticed mild memory impairment and had difficulty managing his checkbook; he has had to ask his daughter for help. He thinks that his deficits have become more severe during the past month and reports occasionally getting lost and having to ask for directions. He has hypertension treated with hydrochlorothiazide. He does not drink alcohol. He is 170 cm (5 ft 7 in) tall and weighs 83 kg (182 lb); BMI is 29 kg/m2. His pulse is 78/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Muscle strength in the left upper and lower extremities is 3/5. Babinski sign is present on the left. Neurologic examination shows no other focal findings. He is able to recall one of three objects after 5 minutes. Long-term memory is intact. His Mini-Mental State Examination score is 23/30. Which of the following is the most likely diagnosis?


Alzheimer type is wroooooooooooong answer....
a) Huntington disease
b) Lewy body dementia
c) Multi-infarct (vascular) dementia
d) Pick disease

Key word here is sudden forgetfullness, that cannot develop in Alzheimer, which is slow onset
Rapid onset mostly if from vascular disease, like hypertension, with ischemia
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  #56  
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34.
A 22-year-old nulligravid woman comes to the physician requesting contraceptive advice. She has been sexually active with a new male partner for the past 3 weeks, and they do not use contraception. She would like a prescription for an oral contraceptive. Her temperature is 37°C (98.6°F), pulse is 76/min, respirations are 18/min, and blood pressure is 110/65 mm Hg. Pelvic examination shows normal external genitalia. Speculum examination shows normal vaginal mucosa and a mucopurulent exudate at the cervical os. Bimanual examination shows a normal-sized uterus without tenderness and normal adnexa. Which of the following is the most likely cause of these findings?

A
)
Bacterial vaginosis wrrrrrrrrrrrooooooooooooooong

B
)
Candida albicans

C
)
Chlamydia trachomatis

D
)
Haemophilus ducreyi

E
)
Herpes simplex virus


Chlamydia trachomatis is the answer here, as Chlamydia is the most common cause of cervicitis, and mucopurulent discharge...
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A 47-y/o man comes to the emergency department 2 hrs after the onset of severe neck pain that began while he was lifting a heavy tool at his counstruction job. The pain is exacerbated when he turns his neck or coughs and now radiates over his right shoulder and arm. He has a 3 year history of intermittent neck pain that is relieved by ibuprofen use. He is in severe distress. When asked to turn his head he turns it slowly to avoid pain. Muscle strenght is 4/5 in the elbow flexor and wrist extensor muscles on the right. Deep tendon relfexs are decreased on the right biceps and brachioradialis muscles. Which of the following is the most likley cause of these findings?


A) Central cord lesion wronnnnnnnnng
B) compression of the lower brachial plexus wroooooooooong
C) compression of the musculocutaneous nerve wroooooooooooong
D) compression of the upper brachial plexus
E) herniated disc C5-6



Direct posterior ruptures, although infrequent, can produce progressive myelopathy, whereas the more common posterolateral herniations can cause acute cervical radiculopathy. The levels of most frequent involvement are C5-C6 (C6 root) usually right sided, and C6-C7 (C7 root), usually left sided. C6 root compression accounts for 20% of cases, whereas C7 root compression accounts for 70% of cervical disk herniation.5

The symptoms of an acute cervical disk prolapse include neck pain, headache, pain referred to the shoulder and along the medial scapular border, and dermatome pain and dysesthesia in the spinal root distribution to the shoulder and arm. Motor signs include fasciculations, atrophy and weakness in the dermatome distribution of the spinal root, loss of deep tendon reflexes, and, with cervical myelopathy, lower extremity hyperreflexia, Babinski sign, and rarely, loss of sphincter control. Cervical hyperextension and lateral flexion to the symptomatic side may replicate the symptoms (with or without gentle pressure on the headSpurling sign), as can a Valsalva maneuver, whereas manual cervical distraction in flexion alleviates them.
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42yr woman brought to ER 30min after her hubby found her uncoscious in her bed.She has a 6yr h/o SLE treated with Prednisone. Her hubby says she has been on a drinking binge for the past 7 days and has not been eating. 3 days ago,she had the onset of Rhinits,conjunctivitis,and a non-productive cough.She has a long standing h/o alcoholism. She moans in response to painful stimuli. Her temp 38.9'c[102'F],Pulse 110bpm,RR 22/min,Palpable SBP 80/min.Lung clear to asucultation and percussion.Abdomincal exam normal. Fluid resuscitation is begun.Which of the following is the most appropiate initial step in management?

a. serum ANA assay
b. Steroid Therapy **********************8
c. Cyclosporine Therapy
d. Ganciclovir Therapy wronggg
e.NSAID Therapy

Key here is that she is on steroids, and have missed for 7 days as mean, tablets from persistent vomiting, and now is in shock, so we schould treat schock, with IV fluids, and Steroids that she has missed
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36.
A 57-year-old woman is brought to the physician by her daughter who is concerned because her mother has become lost while driving home from the store several times during the past month. The patient states that she simply made a few wrong turns and that it is not really a problem. She worked as an accountant for 25 years but retired 3 years ago because the work was getting more difficult for her. She is neatly dressed. Her temperature is 36.9°C (98.4°F), pulse is 75/min, respirations are 10/min, and blood pressure is 137/75 mm Hg. Physical examination shows no abnormalities. On mental status examination, she has a bright affect. Her Mini-Mental State Examination score is 24/30. She recalls zero of three words after 5 minutes. She is oriented to person and place but is not sure of the month or year. Dysregulation of which of the following neurotransmitters is the most likely cause of this patient's symptoms?

A
)
Acetylcholine

B
)
γ-Aminobutyric acid

C
)
Cholecystokinin

D
)
Dopamine

E
)
Glutamate

F
)
Histamine

G
)
Serotonin wrongggggg

H
)
Somatostatin

Diagnosis mostly going to Alzheimer disease , so answer will be Ach...
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41 A previously healthy 7.year-old girl is brought to the physician because of a 2-week history of fever, intermittent rash, and joint pain and swelIing She had three similar
episodes dunng the past 2 years. She appears ill Her temperature is 394°C (1029°F), pulse is 108/mni, respirations are 20;min, and blood pressure is 100/70 mm Hg
Examination shows a generalized pink macular rash over the trunk and upper and lower extremities There are several warm, swollen interphalangeal joints, range of motion
is decreased This patient most likely has which of the following abnormalities in the synovium?
O A) Calcium deposits
O B) Gram-positive bacteria wrongggg
O C) Leukocvtes
O D) Malignant cells
0 E) Urate crystals


Looks to be CCCCCC, as calcium deposition is for Calcium pyrophosphate deposition disea, G+ bacteria like streptococcus can cause bone infection like osteomyelitis but not generalized pink macular rash
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A double blind study is conducted to assesss the effectivness of combination HRT on the incidence of cancer in the postmenopausal women. A total of16,408 postmenopausal women who have not undergone histerectomy are randomly assigned to recieve combination HRT or a placebo. After both groups are observed for 6 years the results show,
Number of cases in Hazard ratio for HRT group 95%CI
Cancer both groups vs placebo group
Ovarian 62 1.58 1.2-3.24
Endometrial 58 0.81 0.48-1.36
Cervical 13 0.8 0.5-1.2
The most accurate conclusion regarding the effect of HRT on incidence if ovarian Ca?

A HRT decrease the incidence of ovarian Ca
B HRT increase the incidence of ovarian Ca
C HRT has no effect on the incidence of ovarian Ca
D HRT has the protective effect against the ovarian Ca
E No conclusion can be made on data given wrong


Hazard ratio is more than 1,meaning there s increase risk of cancer.95 interval is good (more than 1)
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47 year old woman comes in 1 week after noticing lump in her left breast. last menstrual period was 3 weeks ago. 2 cm mobile mass in upper outer quad of left breast. LN not enlarged in axilla. mammography shows irregular borders with no calcification. next step?

1. observe and reaxmine in 1 month for changes wronggg
2. tamoxifen and reexamine in 1 month
3. fine needle biopsy of mass
4. radiation and chemo
5. mastectomy wronggg

It may be fibroadenoma, mostly for years 30-35, and the first step in management will be FNA
No calcification means that is not proven to be cancer...
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23. A 25-year-old woman comes to the physician because of a 1-month history of severe headaches. During this period, she has missed several days of work because ofthe pain. She has a 10-year history of intermittent headaches that are responsive to treatment with naproxen. She has major depressive disorder treated with fluoxetine. She
appears uncomfortable. She is 160 cm (5 ft 3 in) tall and weighs 50 kg (110 lb); BMI is 20 kg/m Funduscopic examination shows bilateral papilledema. The pupils are 5 mm and reactive to light. The remainder ofthe neurologic examination shows no abnormalities. An MRIofthe brain is shown. Which of the following is the most likely cause of these findings?



O A) Idiopathic intracranial hypertension wronggg
o B) Impaired resorption of cerebrospinal fluid (CSF)
O C) Infection ofthe CSF
O D) Obstruction ofthe ventricular system ***********************
O E) Overproduction of CSF wrong


D- its a tumor obstructing the flow of CSF from the 2 lateral ventricles into the 3rd ventricle, interventricular foramen of Monroe
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21.
A 27-year-old man comes to the emergency department because of a 12-hour history of vomiting and mild, intermittent, nonradiating abdominal pain. He has passed flatus, and his last bowel movement was today. He underwent exploratory laparotomy secondary to a gunshot wound 6 years ago. His temperature is 37°C (98.6°F), pulse is 102/min, and blood pressure is 120/75 mm Hg. The lungs are clear to auscultation. The abdomen is soft, distended, and nontender. There is no flank tenderness. Bowel sounds are hyperactive. Rectal examination shows no abnormalities; test of the stool for occult blood is negative. His leukocyte count is 6900/mm3. Urinalysis is within normal limits. X-rays of the abdomen show dilated loops of small bowel and air-fluid levels; there is gas in the ascending colon and rectum. Which of the following is the most appropriate next step in management?

A
)
Tap water enema

B
)
Lactulose therapy wronggg

C
)
Colonoscopic decompression

D
)
Nasogastric tube decompression *********

E
)
Exploratory laparotomy wrong


Air fluid levels post surgery means that patient have small bowel obstruction after surgery,
Again decompression with NGT is the best initial aproach to...
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29.
A 25-year-old woman comes to the physician because of shortness of breath, marked malaise, weakness, and fatigue for 4 hours. She felt well until 24 hours ago when she developed muscle soreness after an unusually strenuous physical workout; she took ibuprofen for the pain 1 hour before her symptoms began. She has a history of frequent migraines that have been prevented by taking metoprolol (twice daily) over the past month. Her blood pressure is 100/70 mm Hg. Examination shows facial flushing and mild periorbital edema. Multiple wheezes are heard throughout the lung fields. Avoidance of which of the following substances is most likely to prevent recurrence of a similar episode?

A
)
Acetaminophen

B
)
Aspirin ***************************************

C
)
Meperidine wronnnnnnnnnnng

D
)
Prednisone

E
)
Propoxyphene wroooooooooong


Aspirin sensitivity
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Georgia

6.
A 32-year-old man with AIDS comes to the emergency department because of a 1-week history of temperatures to 40°C (104°F) and cough productive of small amounts of clear sputum. Current medications include trimethoprim-sulfamethoxazole and three antiretroviral agents. His temperature is 39.7°C (103.5°F), pulse is 100/min, respirations are 20/min, and blood pressure is 126/60 mm Hg. There is no lymphadenopathy or edema. Moist crackles are heard over the right lung base. Cardiac examination shows no abnormalities. An x-ray of the chest shows an infiltrate in the right lower lobe. Which of the following is the most likely causal organism?

A
)
Aspergillus fumigatus wrong

B
)
Candida albicans

C
)
Pneumocystis jiroveci (formerly P. carinii) wrong

D
)
Rhodococcus equi

E
)
Streptococcus pneumoniae

Patient is already on TMP SMX, so prophylaxis against PCP is made
RIght lower lobe, like a lobar pneumonia
Most common cause of pneumonia si Pneumococcus pneumonia
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37 year old primigravid woman at 25 weeks gestation is brought to the emergency department by her husband because of confusion for 12 hours. She also has had progressive fever and intermittent nausea and vomiting over the past 2 weeks. She has not had any contractions but has noted decreased fetal movement. Her preg had been uncomplicated.
family h/o HTN, type1 DM, seizure disorder
Vitals - temp 101.9, pulse 168/min, BP 187/84
Examination - mildly enlarged thyroid.
lungs - clear
CVS - 3/6 systolic ejection murmur
Abd - Uterus 25 weeks gest; no tenderness
FHR - 182/min

Labs: Hb:9.9
platelet = 282,000
Na = 134
cl - 94
k - 2.9
Glucose - 102
Urea nitrogen - 62
TSH - 0.01
AST = 33
LDH - 112
Uric acid - 5.4

Dx?
1. Acute Tubular Necrosis
2. Chronic pyelonephritis
3. Coarctation of aorta
4. Eclampsia
5. Essential HTN
6. Gest trophoblastic disease
7. Malignant HTN
8. Preclampsia
9. Superimposed Preclampsia
10. Pheochromocytoma
11. Primary aldosteronism
12. SLE
12. Thyroid Storm

TSH is very low, fever, enlarged thyroid gland looks like Thyroid storm after infection...
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A 32 year old woman comes to the physician because of a 4 day history of fever. She has had swelling and redness of her left leg during this period. She has a history of chronic lymphedema in both legs. She is 5 ft 5 in tall and weighs 235 lbs. BMI is 39. Her temp is 101.3 deg F. The left lower extremity is diffusely red and edematous from just below the knee to the ankle with a sharp demarcation separating the erythematous area from the normal skin and knee. The erythematous area is painful and hyperesthetic to touch. The left femoral nodes are enlarged and painful. Which of the following is the most likely cause of this patient's illness?

A) Deep vein thrombosis
B) Escherichia coli infection
C) Group A streptococcus infection
D) Necrotizing fasciitis wrong
E) Superficial thrombophlebitis

SHarp demarcation of erythema is mostly for Erysipelas from Step pyogenes infection...
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6 month old boy is brought to the physicain for follow up exam bec of chronic constipation since age of 1 wk current tx is with rectal stiulation, glycering suppositories , prune juice produce 1 firm string like stool every 4 days he was breast fed until 2 wks of age then switched to cow's milk folmula his current diet also include cereals,fruits and pured vegetables.he doesnt have vomiting but occasionally spit up after meals . growth and development are normal. immunizations are up to date abd exam shows tenderness without tenderness. rectal exam shows no palpable stool in ampulla which of the following is the most appropriate next step in mangament


a.switch to lactose free formula
b.test of the stool for botulism toxin
c. stool culture
d.measure tsh Wroooooooooong
e.rectal manometry ********
f.upper gi series

Dx Hisprung disease, no palpable ampulla, we schould make differential diagnosis between Hisprung and functional constipation, only manometry can show us accurately what is wrong with this portion of bowel
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a 37 year-old man comes to physician because of a 6 weeks history of the rash shown. He has had three episodes of a similar rash over the past 5 years that had resolved with treatment. With sun exposure, the rash becomes lighter than his tanned skin. Exam shows no other abnormalities. Which of the following is the most appropriate pharmocotherapy?


a. oral cephalexin
b. oral prednisone
c. selenium sulfide shampoo **********************
d. topical mupirocin
e. topical triamcinolone
f. no pharmacotherapy indicated

Picture show Pityriasis versicolor
Info from UW

Pityriasis versicolor, aslo called Tinea versicolor or Pityrosporum orbiculare

Multicolor skin lesions from tan to pink, lesions more pale than surroungind skin.
Dx KOH prep and fungal culture 6 weeks take,
Tx Ketoconazole or selenium sulfide
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A 62-year-old man is brought to the emergency department 4 hours after the sudden onset of vomiting and severe abdominal pain. During the past year, he has had mild, intermittent epigastric pain, which is relieved with antacid use. He has no history of serious illness. He has smoked one and one-half packs of cigarettes daily for 35 years. He drinks one to two alcoholic beverages daily. He appears diaphoretic and is in acute distress. His temperature is 38.4°C (101.1°F), pulse is 100/min, respirations are 18/min, and blood pressure is 115/75 mm Hg. The abdomen is rigid and tympanitic to percussion over the liver. There is severe diffuse tenderness. Bowel sounds are absent. Which of the following is the most appropriate next step in diagnosis?

a) X-rays of the chest and abdomen *************
b) Barium enema
c) CT scan of the abdomen wrooooooong
d) Colonoscopy
e) Flexible esophagogastroduodenoscopy

History of gastric ulcers that respond to antiacids
SO it may be perforated ulcer, as patient have Fever, pain, diaphoresis and rigid abdomen
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A 47 year old man comes to the physician for a follow up exam after being diagnosed with stage 1 hypertension 5 months ago. A 3 month trial of diet modification and exercise failed to control his blood pressure and hydrochlorothiazide therapy was begun. Over the past month, he has felt fatigued. Examination shows no abnormalities. Which of the following is the most likely cause of the patient's symptoms?

A) Hyperglycemia
B) Hyperlipidemia
C) Hypocalcemia
D) Hypokalemia ************************
E) Hyponatremia wronggg
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4) A 32-yo woman comes to her doctor because of a 1-month history diarrhea, abdominal bloating, and loss of appetite resulting in an 8-lb weight loss. She reports 3 to 4 semi-liquid stools daily. She has no fever, abdominal pain or rectal bleeding. She returned from a scuba diving vacation from Mexico 6-weeks ago; her boyfriend who went with her did not have any symptoms. Abdominal and rectal exam show no abnormalities. Which of the following is the most likely cause?

A) E.coli O157:H7 wrongggg
B) Giardia lamblia *************************
C) Rotavirus wroooooong
D) Vibrio cholera
E) Yersinia enterocolitica


Non-bloody diarrhea, E coli is excluded
ROtavirus is mostly for children
Vibrio cholera, profuse watery diarrhea 15 stools per day


Important thing here is that Patient traveled to Mexico, so it's a Giardia Lamblia
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A 52-year-old woman comes to the physician because of an 8-month history of an intermittent nonproductive cough. She takes no medications. She has smoked one pack of cigarettes daily for 25 years. She has had three episodes of sinusitis over the past 18 months. Examination shows pale nasal mucosa and cobblestoning of the posterior pharynx. The lungs are clear to auscultation. There is no clubbing or cyanosis. Which of the following is the most likely cause of this patient's cough?

A) Allergic rhinitis
B) Bronchiectasis
C) Chronic bronchitis wrongggg
D) Hypersensitivity pneumonitis
E) Rhinitis medicamentosa wrongg

She do not take medications
No signs of pneumonia, just sinusitis
No signs of bronchitis, especialy chronic which should be more then 3 episodes per year with 2 month of symptoms at least every
Bronchiectasis may be after a lung infection chronic, cancer, or any destruction of the lung

Description in question is clear for Allergic rhinitis:
Pale mucosa, cobblestones

Presentation for Allergic rhinitis are :

Watery eyes, sneezing, itchy nose, and ithcy eyes
Inflamed, boggy nasal mucosa
Pale or violaceous turbinates
Nasal polyps
Cobblestones
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  #75  
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A 52-year-old man is brought to the emergency department by his brother because of fever and muscular rigidity for 24 hours. He has been taking chlorpromazine for 4 days for agitation and insomnia. He was well until 2 days ago when he began to sweat profusely and feel agitated. He went to bed and began to have visual hallucinations. On examination today, he is agitated, disheveled, and yelling. His temperature is 39.2C (102.5F), pulse is 120/min, respirations are 24/min, and blood pressure is 150/100 mm Hg. Physical examination shows clammy skin and rigid extremities. Deep tendon reflexes are 2+ bilaterally. Hoffmann and Babinski signs are absent. On mental status examination, he appears to be having visual hallucinations. He is not oriented to person, place, or time. In addition to hydration, which of the following is the most appropriate next step in management?

A) Add acyclovir to the regimen wrong

B) Add benztropine to the regimen wronnnnnnnnnng

C) Add ceftriaxone to the regimen

D) Administer intravenous physostigmine

E) Discontinue chlorpromazine *************

It's malignant hyperthermia from Antipsychotic medication

1. Stop medication ( Antipsychotic)
2. Add benzotripine
3. Or add dantrolene

So first thing is to exclude or stop medication that make posible these symptoms..
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  #76  
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A 4-year-old boy is brought to the physician because of scalp lesions that have been increasing in size during the past week. He went for a nature walk with his day-care class 10 days ago. Examination shows scattered papules with some scaly areas on the scalp; the surrounding hair is broken near the base with mild alopecia. Which of the following is most likely to have prevented this condition?

a) Avoidance of wooded areas
b) Avoidance of sharing hats *******
c) Use of insect repellent
d) Use of sunscreen wrong

So broken hair is present along the base of scalp , or in areas between hair and loss of hair, so avoid the heat, that can damage that part of hair...
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  #77  
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) 19 yr old with sudden onset confusion 36 hours after admission to hospital for motorcycle collision. Underwent cast immobilization of fracture of right medial malleolus and open reduction and internal fixation of fracture of left femur. Currently on morphine. Not oriented to person, place or time. T 102.4, p 110, respit 26, bp 100/50. O2 sat on RA 94%. Exam shows petechia over shoulders, chest and axillae. Lungs are clear. What explains findings?


-ARDS
-Fat embolism *************************
-pulm embolism wrong
-sepsis
-waterhouse-friderichsen syndrome

History of trauma, decreease BP, increased REspiration and HR
Especilly important things here are: fracture of long bones like femur and Pethechia petichia on the chest...
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38. An asymptomatic 57-yo woman comes to the physician for a routine health maintenance examination. She has smoked one pack of cigarettes daily for 40 years. She drinks wine occasionally at social events. She takes vitamin D daily. Examination shows no abnormalities. Laboratory studies show:
Hematocrit 42%
Serum
Ca++ 11 mg/dL
Phosphorus 2.8 mg/dL
Urea nitrogen 15 mg/dL
Creatinine 1 mg/dL
Alkaline phosphatase 50 U/L
Parathyroidhormone, intact 12 pg/ml (N=1-65)
An x-ray of the chest shows a 2-cm nodule in the right upper lobe of the lung. A CT scan shows the same nodule with no evidence of metastases. Which of the following is the most likely cause of this patient’s increased serum calcium concentration?


A. Bone metastasis
B. Decreased renal excretion of calcium
C. Excessive intake of vitamin D
D. Paraneoplastic syndrome **********
E. Primary hyperparathyroidism

Clear history of smoking and lung cancer ( 2cm nodule on the right upper lobe) which is peripheral, but also can be squamous cell carcinoma not obligation to be only central
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  #79  
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7. A hospitalized 20-year-old man has the sudden onset of confusion and hypotension 5 minutes after initiation of intravenous nafcillin and gentamicin for staphylococcal
endocarditis. He has a history of heroin use. His temperature is 38.7°C (101.7°F), pulse is 130/mni, respirations are 321mni, and blood pressure is 80/60 mm Hg. Examination
shows needle marks in both antecubital fossae and two wheals on the left buttock and thigh. Wheezing is heard bilaterally. S1 is normal. and S2 is decreased. A grade 1/6,
systolic ejection murmur is heard at the base of the heart, and a grade 216, blowing diastolic murmur is heard at the right sternal border. Laboratory studies show:
Hemoglobin 10.3 g/dL
Leukocyte count 18.6001mm3
Segmented neutrophils 71%
Bands 15%
Eosinophils 9%
Lymphocytes 5%
Pulmonary artery catheterization shows decreased cardiac output, pulmonary capillary wedge pressure, and systemic vascular resistance. An x-ray of the chest shows
cardiomegaly. An ECG shows sinus tachycardia of 140/mni, T-wave inversion in leads I, aVL, and vi through Ve, and ST-segment depression in leads V5 through V6. Which of
the following is the most likely cause of this patient's deteriorating condition?


o A) Anaphylaxis
O B) Aortic cusp rupture
O C) Coronary artery embolus
o D) Drug withdrawal
O E) Gastrointestinal hemorrhage

1.Eosinophilia 9%
2. Reaction of hypotension , increased HR and cardiac collapse coming after administration of DRUGS
3. Wheezing
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57 year DM pt came with unable 2 bend his foot since 4 hrs after awakening ..had 2 yr H/Ointermittent back ache..O/E there is numbness over right foot,cant dorsirt .ankle and toes..DTR-+2 bilat..SLR -VE



a.multple sclersis
2.peroneal neuropathy ****************
c.S1 radiculopathy wronggggg
d.sciatica
e.thrombosis lt MCA

Peroneal nerve compromise results in the clinical complaint of weakness of the ankle dorsiflexors and evertors

A peroneal nerve injury (also called foot drop or drop foot), is a peripheral nerve injury that affects a patient's ability to lift the foot at the ankle.
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44) A 67-year-old woman comes to the physician because of a 2-month history of an intermittent mild buRning sensation in her epigastrium. The sensation occurs after she walks
one block or climbs one flight of stairs and is occasionally associated with light-headedness and profuse sweating Her epigastric discomfort is relieved with rest and does
not respond to antacids Current medications include a daily muftivitamin and a calcium supplement She has smoked one pack of cigarettes daily for 40 years She drinks
one alcoholic beverage once or twice weekly. Her temperature is 37°C (986°F), pulse is 98/mnm, respirations are 1 5imin, and blood pressure is 150/90 mm Hg Examination
shows no other abnormalities. Resufts of laboratory studies, including cardiac enzyme activities, are within the reference range An ECG shows no abnommalities. Which of
the following is the most appropriate next step in diagnosis?
o A) Ambulatory ECG monitoring
o B) Abdominal ulrasonographys
0 C) Cardiac stress scintigraphy
o D) 24-Hour monitoring of esophageal pH
0 E) Esophaqogastroduodenoscopy

Diaphoresis, confusion, pain in the epigastri area>>>>>> like MI
ECG in myocardial infarction may now show anything, like not ST segment elevation MI non STEMI

patient have pain and will not go for treadmil or some exercise tests
So Dipyridamole Thallium or scintigraphy test that is used in patient who cannot tolerate stress can help in making right diagnosis..
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  #82  
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19 yr old female at 32 wks gestation with one month history of generalized rash that has not changes. No pruritis or fever. She has had no prenatal care. Macular rash of palms, chest, back, abdomen, extremities and soles. What is the causal organism???

Correct answer is Treponema palidum:
Generalized rash that involves also PALMS AND SOLES which is specific for Syphilis
No history of vaccination to know maybe missed Rubella vaccine
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  #83  
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31. A 62-year-old woman with hypertension comes to the physician for a follow-up examination. Her hypertension was well controlled until 1 year ago; during the past year, her blood pressure has ranged between 160/100 mm Hg and 180/120 mm Hg. Treatment with maximal doses of an ACE inhibitor, a diuretic, and a 6-adrenergic blocking agent for 10 months has not controlled her hypertension. She has a 2-year history of increasing leg pain with walking that improves with rest; she is otherwise asymptomatic. Her last menstrual period was 7 years ago. She smoked one to two packs of cigarettes dai ly for 40 years but quit 1 year ago. Her exercise capacity has improved during the past
year. She is 152 cm (5 ft) tall and weighs 48 kg (105 lb); BMI is 21 kg/m . Her pulse is 85/min and regular, and blood pressure is 160/100 mm Hg in the right arm, 175/105 mm Hg in the left arm, and 155/90 mm Hg in the right leg. Cardiac examination shows a nondisplaced point of maximal impulse: there is an S4 but no murmurs, heaves, or thrills. Abdominal examination shows no abnormalities. Pulses are 2+ in the upper extremities; the femoral and dorsalis pedis pulses are 1+ bilaterally. Serum studies show a potassium concentration of 4.5 mEq/L urea nitrogen concentration of 20 mg/dL. and creatinine concentration of 1.2 mg/dL Which of the following is the most likely cause of this patient's hypertension?

O A) Atherosclerotic renal artery stenosis ************
O B) Coarctation of the aorta wronnnnnnnnggg
O C) Fibromuscular hyperplasia of the renal artery
O D) Polycystic kidney disease
O E) Primary hyperaldosteronism

Not E because Potassium is normal
D no mentions about abdominal masses bilaterally usually
C fibromuscular hyperplasia is founded mostly on young patients
B in coarctation of aorta, BP in right arm should be much more that left and not inversly, also in lower extremities BP should be much more less then in upper extremities

Patient have history of smoking that predispose to atherosclerosis, and changes in BP, that do not respond to medication. Looks like Periferal artery disease as Ankle brachial index is marked here...
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  #84  
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7. A hospitalized 20-year-old man has the sudden onset of confusion and hypotension 5 minutes after initiation of intravenous nafcillin and gentamicin for staphylococcal
endocarditis. He has a history of heroin use. His temperature is 38.7°C (101.7°F), pulse is 130/mni, respirations are 321mni, and blood pressure is 80/60 mm Hg. Examination
shows needle marks in both antecubital fossae and two wheals on the left buttock and thigh. Wheezing is heard bilaterally. S1 is normal. and S2 is decreased. A grade 1/6,
systolic ejection murmur is heard at the base of the heart, and a grade 216, blowing diastolic murmur is heard at the right sternal border. Laboratory studies show:
Hemoglobin 10.3 g/dL
Leukocyte count 18.6001mm3
Segmented neutrophils 71%
Bands 15%
Eosinophils 9%
Lymphocytes 5%
Pulmonary artery catheterization shows decreased cardiac output, pulmonary capillary wedge pressure, and systemic vascular resistance. An x-ray of the chest shows
cardiomegaly. An ECG shows sinus tachycardia of 140/mni, T-wave inversion in leads I, aVL, and vi through Ve, and ST-segment depression in leads V5 through V6.

Which of
the following is the most likely cause of this patient's deteriorating condition?

A) Anaphylaxis
O B) Aortic cusp rupture wrooooooooongg
O C) Coronary artery embolus
o D) Drug withdrawal
O E) Gastrointestinal hemorrhage


A 5 minutes after administration of Nafcilin startet to appear symptoms...
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  #85  
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6 An 87-year-old woman with metastatic ovarian cancer has poorly controlled pain. Her cancer has been unresponsive to chemotherapy Current medications include long-acting
oral morphine, short-acting morphine as needed, and docusate Her family is having difficulty caring for her at home The patient's oldest daughter calls the physician to discuss
her mother’s care She says, “We want my mother to receive hospice care at home, but no one wants her to die at home. Can she still have hospice serices?” which of the
following is the most appropriate response?



o A) "No, but we can try to arrange for some other type of home service”

o B) "No lt is important that hospice patients die at home"

0 C) “No. The patient cannot be enrolled in the hospice program if the patient or family prefer that death not take place at home” wrooooooooong

o D) “Yes, but we would have to transfer her to a nursing home to enroll her in the hospice program.” WROOOOOOOOOOOONG

0 E) “Yes. Hospice can provide home-based care and attempt to transfer the patient to another site before death." ********************
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  #86  
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an 18 month old girl is brought to the physician because hse has not used her right arm since falling while running hand in hand with her older sister 2 hours ago. she holds her arm in pronation internally rotated. she cant supinate the arm or flex the forearm. there is no obvious point tenderness or swelling. which of the following is the best initial management?


a) rest ice and elevation fo the elbow wrong because no tenderness or swelling
b) supinate the forearm
c)use of swing and swathe
d) application of figure 8 strape
e) use post splint...
Nursemaid elbow

ANswer is to supinate the forearm gently
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One hour after a splenectomy for injuries sustained in a motor vehicle accident, a 42 year-old man has severe shortness of breath. His temp is normal, pulse is 133/min, respirations are 35/min, and blood pressure was 80/65. Breath sounds are absent on the left. Abdominal examination shows slight distension; bowel sounds are absent. Which of the following is the next best management?

A) CXR
B) Transfusion of typed blood wrong
C) IV Heparin therapy wro ng
D) Fiberoptic bronchoscopy wrongg
E) Endotracheal intubation wronggggg
F) Placement of vena cava filter wronggg
G) Needle thoracostomy. ****************************************

1. Abdominam distention is common after surger, because of drug use like opiods
2. patient have left hemithorax
3. Do docompresion like insert a needle
4, after you can do X-ray to reassure about changes
5.It's evidend hemothorax no need to confirm again when you see a urgency
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  #88  
Old 07-19-2015
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27 year old woman comes to ER with 12 hour history of severe shortness of breath. She has 15 year history of asthma treated with inhaled corticosteroids twice daily. One week ago, her son had a cough and nasal congestion. Two days ago, she developed the same symptoms and used her rescue bronchodilator several times yesterday and today without relief of symptoms. She was awake most of last night due to wheezing and respiratory distress. She does not smoke. On arrival, she is unable to speak in full sentences. She is using accessory muscles of respiration. Her pulse is 130, respirations are 36, and blood pressure is 120/75. Pulse oximetry on room air shows an oxygen saturation of 90%. Diffuse expiratory wheezes are heard. Cardiac exam shows no murmurs.

Arterial blood gas analysis of 50% oxygen by face mask shows:

pH 7.52, pCO2 30 mm Hg, pO2 78 mm Hg, HCO3 28 mEq/L

Twenty minutes after two nebulized bronchodilator treatments are administered, arterial blood gas analysis shows:

pH 7.40, pCO2 42 mm Hg, pO2 62 mm Hg, HCO3 28 mEq/L

Spirometry shows a peak expiratory flow rate of 150 L/min. Which of the following is the most appropriate next step in management?

A) Chest physical therapy Wrongggg
B) Benzodiazepine therapy
C) Magnesium Supplementation
D) Theophylline therapy
E) Intubation ****************************

Patient is unable to have a good respiratory cycles
150 ml of tidal volume is too low, also PO2 is low
Accesory muscle use mean inadequancy of patient respiratory acting
Confusion also pleading to intubate patient
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A 57 year old woman comes because of 6 month history of moderate periumbilical pain that occurs within 1 hour after eating. She has had 11 kg (25 lbs) weight loss as a result of eating less to avoid the pain. She has a 5 year history hypertension and claudication. Current medication include a diuretic, a B adrenerginc blocking agent, and antiplatelet agent. She is 165 cm (5 ft 5 in) tall and weight 50 kg (110 lbs). BMI is 18 kg/mt2. Her pulse is 75 per minute, and blood pressure is 145/90 mm Hg.
The abdomen is soft, nondistended, and nontender. There are no masses or organomegaly. Femoral pulses are palpable bilaterally, and popliteal and distal pulses are absent bilaterally. Test of the stool for occult blood is negative. Which of the following is the most appropiate next step in diagnosis?

A) HIDA scan
B) Colonoscopy
C) Upper gastrointestinal edoscopy
D) Arteriography ******************
E) Endoscopy retrograde cholangiopancreatography

Most accurate test for arteries study is Angiogram
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  #90  
Old 07-20-2015
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43.
A 2-year-old girl is brought to the physician because of shortness of breath for the past 2 hours. She has a 3-day history of runny nose, sneezing, and nasal congestion. She appears tired. Her temperature is 38.5°C (101.3°F), pulse is 130/min, and respirations are 48/min. Examination shows moderate dyspnea. There is audible stridor and moderate retractions with inspiration. The lungs are clear to auscultation. There is an occasional barking cough. Which of the following is the most likely causal organism?

A
)
Bordetella pertussis

B
)
Group A streptococcus

C
)
Haemophilus influenzae type b

D
)
Neisseria meningitidis

E
)
Parainfluenza virus


Important key is BARKING COUGH

Barking cough, croup , Parainfluenza virus

Also another presentation from MTB 2ck:
Croup presents with barking cough, coryza, and inspiratory stridor. The child will have more difficulty breathing when lying down and may show signs of hypoxia such as peripheral cyanosis and accesory muscle use. Chest X-ray will show the classic steeple sing, a narrowing of the air column in the trachea. However, x-ray is rarely done and is always the wrong answer to the most appropiate next step.
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Old 07-20-2015
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45.
A 52-year-old woman comes to the physician for a routine health maintenance examination. One year ago, she was started on daily hormone replacement therapy (estradiol and medroxyprogesterone) to treat severe vasomotor symptoms. But she has been taking the medroxyprogesterone intermittently because of severe depression and mood changes when taking it. Menses had stopped for the first 6 months on the original regimen, but since she changed her regimen, she has had vaginal spotting two to three times monthly. Which of the following is the most appropriate next step in management?

A
)
Discontinue medroxyprogesterone therapy only

B
)
Increase the dosage of estradiol

C
)
Add an antidepressant to the medication regimen

D
)
Endometrial ablation

E
)
Endometrial biopsy ******************************
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  #92  
Old 07-20-2015
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Q36
A 62-year-old man with alcoholism comes to the physician because of a nonhealing ulcer on his tongue for the past 6 months He has smoked two packs of cigarettes daily for 25 years Examination shows a 6-mm ulcer on his tongue There is no lymphadenopathy The lesion is removed surgically, and a pathology report describes pleomorphic cells with many mitotic figures infittrating deeply into the tongue muscle. Which of the following is the most likely diagnosis?

o A) Aphthous ulcer
o B) Leiomyosarcoma
o C) Lymphoma
o D) Oral candidiasis
0 E) Squamous cell carcinoma *****************

Alcoholic, with nonhealing ulcer of his toungue
No lymphadenopathy
Highly mitotic cells can be any, but squamous cells are dividing very fast, as is the external layer of mucosas
Tongue is composed by skeletal muscle not smooth which opposed to Dx like Leiomyosarcoma

For aphtous ulcer is characteristic only multiple ulcers, deep, without infiltration with cell, also can found on other mucosas, like vaginal
Also important here is that they mention, infiltrating cells are not origin from Muscle but infiltrate muscles, it's different absolutely...
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  #93  
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24. A 57-year-old woman is admitted to the hospital because of a 2-week history of progressive jaundice and a 5-kg (11-lb) weight loss. She has had dark urine and pale
stools during this period. She has no history of serious illness and takes no medications. Her temperature is 37.2C (99F), pulse is 80lmin, and blood pressure is
120/80 mm Hg. Examination shows severe jaundice. The gallbladder is palpated in the right upper quadrant of the abdomen. Urine dipstick is positive for bilirubin.
Abdominal ultrasonography shows a dilated gallbladder and dilated intrahepatic and extrahepatic biliary ducts; there are no calculi. Which of the following is the most
appropriate next step in diagnosis?


A) Endoscopic ultrasonography
B) CT scan of the abdomen
C) Fine-needle aspiration of the pancreas
D) Laparoscopic cholecystectomy
E) Surgical exploration of the common bile duct

Key points: Jaundice with empty gallbladder, distended, but no stones in.
Advanced age of patient, usualy appearing jaundice in that ages mean a pancreatic head cancer, which is well visualized by CT,, as good as gastrinoma or any other tumor
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  #94  
Old 07-20-2015
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43. A 16-year-old girl comes to the physician because of painful genital lesions for 2 days. Over the past 6 months, she has been sexually active with five male partners; she last had sexual intercourse 2 weeks ago. As far as she knows, her sexual partners have not had similar symptoms. Examination shows two 3 x3-mm ulcerated lesions on the anteri or vagi nal vault. She currently has a new boyfri end with whom she has not had sexual i ntercourse and would li ke to know the best way to prevent transmi ssi on of her infection. Which of the following is the most appropriate strategyto prevent transmission?



o A) Use of condoms when lesions are present
O B) Consistent condom use *********************
O C) Acyclovir therapy for the patient far 7 days
O D) Penicillin therapy for the patient for 3 weeks
O E) Prophylactic acyclovir t


Painful ulcers can be only Herpes virus, or Hemophylus ducrey
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26. An 87-year-old woman who is a resident of a skilled nursing care facility is brought to the physician by staff because of fever for 1 day. A urinary catheter was placed 2 weeks ago because of urinary incontinence. She has dementia, Alzheimer type, and is unable to communicate verbally. Her temperature is 37.8C (100F), pulse is 86/min, respirations are 14/min, and blood pressure is 120/74 mm Hg. Mucous membranes are moist and pink. Urinalysis shows:

Color
cloudy brown
pH
8.8
Blood
2+
Glucose
negative
Protein
2+
RBC
too numerous to count
WBC
2025/hpf
Nitrites
3+
Leukocyte esterase
3+
Bacteria
many

A Gram stain of urine shows gram-negative bacilli. Which of the following measures is most likely to have prevented this patient's current condition?

A
) Use of incontinence briefs instead of the catheter

B
) Changing the catheter daily wrooooooooonggg

C
) Cleaning the urethral orifice with povidone-iodine daily

D
) Flushing the catheter with an antibiotic solution daily

E
) Oral antibiotic prophylaxis

F
) Oral oxybutynin therapy


Can anyone helpt here, as changing the catheter daily is incorrect
???
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Arrow

Please help me with following questions?


24 yea old woman comes to the physician because of mouth sores Arthiritis and Nephrotic syndrome.
Dx?

Catheter complications prevention?

A 13 year old girl is brought to the physician because her mother is concerned that her daughter never had menstrual period



A previously healthy 57 year old woman is brought to the physician by her family 6 hours after the onset of progressive confusion.


A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 2 years She also has had pain with sexual intercourse over the past 6 months She has been otherwise healthy Menarche was at the age of 13 years, and menses have occurred at regular 28-day intervals Her last menstrual period was 1 week ago Her temperature is 37C (986F). pulse is 80mm. respirations are 20/mm, and blood pressure is 120/80mm Hg Abdominal examination shows right lower quadrant tenderness Pelvic examination shows a 5-cm. tender. right adnexal mass Laboratory studies show Hemoglobin 12 gdL Leukocyte count 9000mm3 Segmented neutrophils 60% Bands 5% Lymphocytes 30% Monocvtes 5% Ervthrocyte sedimentation rate 15 rnnti A urine pregnancy test is negative Urasonography shows a 5-cm nght adnexal mass containing low-level. homogeneous. internal echos A biopsy specimen of the mass is most likely to show which of the following? O A) Atypical ovarian epithelial cels o B) Enciometnal glands and stroma O C) Luteinized granulosa cells o 0) Myometrium o E) Squamous cells. cartilage. and bone


a 37 year-old man comes to physician because of a 6 weeks history of the rash shown. He has had three episodes of a similar rash over the past 5 years that had resolved with treatment. With sun exposure, the rash becomes lighter than his tanned skin. Exam shows no other abnormalities. Which of the following is the most appropriate pharmocotherapy? a. oral cephalexin b. oral prednisone c. selenium sulfide shampoo d. topical mupirocin e. topical triamcinolone f. no pharmacotherapy indicated

A 19-year-old woman at 32 weeks' gestation comes to the physician because of a 1-month history of a generalized rash that has not expanded or changed. She has not had pruritus or fever. She has had no prenatal care. Examination shows a macular rash involving the palms, chest, back, abdomen, extremities, and soles. Which of the following is the most likely causal organism? a) Bordetella pertussis b) Chlamydia trachomatis c) Cytomegalovirus d) Escherichia coli e) Group B streptococcus f) Herpes simplex virus g) Parvovirus h) Rubella virus i) Toxoplasma gondii j) Treponema pallidum k) Trichomonas vaginalis

A 22-year-old woman with asthma comes to the physician for a follow-up examination She feels well She has been treated for six acute episodes of wheezing and nonproductive cough dunng the past year her last episode was 1 month ago Her symptoms are exacerbated when she is outside during the spring and fall Current medications include an albuterol inhaler and ectnacea She has smoked one-half pack of cigarettes daily for 5 years and does not dnnk alcohol She is employed in a jewehy factcwy Her temperature is 372C (99F). pidse is 80mm. respirations are 12/mm, and blood pressure is 12080 mm Hg Examination and an x-ray of the chest show no abnognalibes In addition to counseling about smoking cessation, which of the following measures is most likely to reduce the frequency of asthma exacerbations? O A) Change in woik environment O B) Desensitization to ammnal dander O C) Fluticasone inhaler therapy o D) Heernophilus influenzae type b vaccine o E) Influenza vaccine o F) 23-Valent pneumococcal vaccine

A 52-year-old woman comes to the physician because of an 8-month history of an intermittent nonproductive cough. She takes no medications. She has smoked one pack of cigarettes daily for 25 years. She has had three episodes of sinusitis over the past 18 months. Examination shows pale nasal mucosa and cobblestoning of the posterior pharynx. The lungs are clear to auscultation. There is no clubbing or cyanosis. Which of the following is the most likely cause of this patient's cough? A) Allergic rhinitis B) Bronchiectasis C) Chronic bronchitis D) Hypersensitivity pneumonitis E) Rhinitis medicamentosa


A 15-year-old girl is brought to the physician because of a 1-week history of vaginal discharge and a 2-day history of sore throat and white spots in her mouth. She has had recurrent candidal infections of the skin and mucous membranes since childhood. She has a 2-year history of type 1 diabetes mellitus and a 1-year history of autoimmune thyroiditis. Medications include insulin and levothyroxine. Examination shows oral candidiasis. Pelvic examination shows a thick white vaginal discharge. Microscopic examination shows budding yeast. Which of the following is the most likely mechanism of her recurrent candidal infections? A ) Autoimmune destruction of the thymus B ) Blunting of the inflammatory response from complement deficiency C ) Deficiency in anticandidal antibodies D ) Impaired cell-mediated immunity E ) Inability of macrophage to present candidal antigen

A 42-year old woman comes to the physician because of progressive shortness of breath during the past 6 months. She now has to r est three or four times when climbing one flight of stairs. Shew has smoked one pack of cigarettes daily for 26 years. She has a chronic nonproductive cough and has wheezing controlled with an albuterol inhaler two to three times weekly. During the past year, he BMI has increased from 45kg/sq.m to 52kg/sq.m. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 24/min and shallow, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is distended. There is 1+ edema of the ankles. Arterial blood gas analysis on room air shows: pH 7.37 Pco2 48 mm Hg Po2 62 mm Hg o2 saturation 92% Her FEV1 is 75% of predicted, and total lung capacity is 50% of predicted. Which of the following is the most likely diagnosis? A) Chronic obstructive pulmonary disease B) Congestive heart failure C) Interstitial pneumonia D) Recurrent pulmonary embolism E) Restrictive lung disease


A 25-yo woman comes to the emergency department because of nausea, diarrhea, and anxiety for 2 days. She also has noticed dizziness and tingling sensations shooting down her forearms. Her sleep and appetite have been normal. She has a 3 year history of social phobia well controlled for the past year with paroxitine. She is attending an out-of-town conference and forgot to pack her medication; her last dose was 3 days ago. She does not drink alcohol or use illicit drugs. She is 163cm tall and weighs 89 kg. BMI is 30 kg/m2. Her temperature is 37C, pulse is 80/min, and blood pressure is 110/75 mm Hg. Physical examination shows no other abnormalities. Mental status examination shows an irritable mood with a full range of affect. Her speech is of normal rate and rhythm. There is no evidence of suicidal ideation or hallucination. She can recall three objects after 5 minutes. Long-term memory is intact. Serum studies show no traces of paroxitine. Which of the following is the most appropriate next step in management? A) Begin behavioral therapy B) Begin alprazolam therapy C) Begin bupropion therapy D) Begin clomipramine therapy E) Begin gabapentin therapy F) Resume paroxetine
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  #97  
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Originally Posted by Alice13 View Post
Please help me with following questions?


24 yea old woman comes to the physician because of mouth sores… Arthiritis and Nephrotic syndrome.
Dx?


SLE


Malar rash (rash on cheeks)
Discoid rash (red, scaly patches on skin that cause scarring)
Serositis
Oral ulcers (includes oral or nasopharyngeal ulcers)
Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion;
Photosensitivity (exposure to ultraviolet light causes rash, or other symptoms of SLE flareups)
Blood—hematologic disorder—hemolytic anemia (low red blood cell count), leukopenia (white blood cell count<4000/l), lymphopenia (<1500/l), or low platelet count (<100000/l) in the absence of offending drug; Hypocomplementemia is also seen, due to either consumption of C3 and C4 by immune complex-induced inflammation or to congenitally complement deficiency, which may predispose to SLE.
Renal disorder
Antinuclear antibody test positive
Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody, and/or false positive serological test for syphilis
Neurologic disorder: Seizures or psychosis

Catheter complications prevention?


hand washing with soap.



Read CDC guidelines.
http://www.cdc.gov/hicpac/pdf/guidel...lines-2011.pdf
quick summary - Catheter and site care *—*
Catheter and site care measures can minimize the incidence of catheter-related infections.
Hand washing with antiseptic-containing soap or alcohol-based gels or foams; the use of gloves does not obviate the need for hand hygiene.
Full barrier precautions during insertion of central venous catheters, including sterile gloves, long-sleeved surgical gown, a surgical mask, and a large sterile sheet drape.
2 percent chlorhexidine for skin disinfection. The antiseptic should air dry before catheter insertion.
Avoidance of the femoral insertion site.
Prompt removal of catheters when no longer indicated.
For intensive care unit patients, we suggest daily chlorhexidine bathing to reduce catheter-associated bloodstream infections.
gauze rather than transparent dressings with central venous catheters A gauze dressing is particularly preferred if the patient is diaphoretic or the site is bleeding or oozing.
Except for central venous catheters used for hemodialysis, we suggest NOT using topical antibiotic ointment or cream on the insertion site because of lack of proven benefit and the potential to promote antimicrobial resistance and fungal colonization
With respect to the care of CVC points of access (eg, needleless intravascular devices and injection ports), the Centers for Disease Control recommendations cited above should be followed . The evidence was strongest for cleaning the points of access before accessing the system (70 percent alcohol is preferred).
We recommend exchanging administration sets every 72 hours unless catheter-related infection is suspected and every 24 hours if lipid emulsions or blood or blood products are given since these fluids enhance microbial growth


A 13 year old girl is brought to the physician because her mother is concerned that her daughter never had menstrual period


Reexamination


Primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics. If by age 13 menses has not occurred and the onset of puberty, such as breast development, is absent, a workup for primary amenorrhea should start.


A previously healthy 57 year old woman is brought to the physician by her family 6 hours after the onset of progressive confusion. You meant productive cough , right?


If yes, then Dx is Emphysema.


if PFTs suggest obstructive pattern( FEV/FVC< 0.75)==> FEV1 response to bronchodilatator ==> if minimal ==> DLCO==> decreased DLCO - emphysema, normal DLCO - Chronic bronchitis


A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 2 years She also has had pain with sexual intercourse over the past 6 months She has been otherwise healthy Menarche was at the age of 13 years, and menses have occurred at regular 28-day intervals Her last menstrual period was 1 week ago Her temperature is 37C (986F). pulse is 80mm. respirations are 20/mm, and blood pressure is 120/80mm Hg Abdominal examination shows right lower quadrant tenderness Pelvic examination shows a 5-cm. tender. right adnexal mass Laboratory studies show Hemoglobin 12 gdL Leukocyte count 9000mm3 Segmented neutrophils 60% Bands 5% Lymphocytes 30% Monocvtes 5% Ervthrocyte sedimentation rate 15 rnnti A urine pregnancy test is negative Urasonography shows a 5-cm nght adnexal mass containing low-level. homogeneous. internal echos A biopsy specimen of the mass is most likely to show which of the following? O A) Atypical ovarian epithelial cels o B) Enciometnal glands and stroma O C) Luteinized
granulosa cells o 0) Myometrium o E) Squamous cells. cartilage. and bone



Endometriosis is defined as the presence of endometrial glands and stroma at one or more extrauterine sites. It is a common, benign, chronic, estrogen-dependent disorder.The most common sites of endometriosis, in decreasing order of frequency, are the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligament.Pain (chronic pelvic, deep dyspareunia, dysmenorrhea) is a common clinical manifestation of endometriosis. Endometriosis is also associated with infertility and a variety of nonspecific symptoms

a 37 year-old man comes to physician because of a 6 weeks history of the rash shown. He has had three episodes of a similar rash over the past 5 years that had resolved with treatment. With sun exposure, the rash becomes lighter than his tanned skin. Exam shows no other abnormalities. Which of the following is the most appropriate pharmocotherapy? a. oral cephalexin b. oral prednisone c. selenium sulfide shampoo d. topical mupirocin e. topical triamcinolone f. no pharmacotherapy indicated



Tinea versicolor is a common fungal skin infection. The disorder occurs worldwide, but is most prevalent in tropical climates. Adolescents and young adults are affected most frequently. Tinea versicolor is not contagious
Patients with tinea versicolor can exhibit hypopigmented, hyperpigmented, or erythematous macules and patches. The most common areas of involvement include the upper trunk and proximal upper extremities; facial and intertriginous areas are less frequently affected.
The potassium hydroxide preparation is a quick and effective way to diagnose tinea versicolor. A Wood's lamp examination will reveal yellow to yellow-green fluorescence in a minority of patients
Topical therapy is a safe and effective treatment for most patients with tinea versicolor. Topical antifungal medications containing selenium sulfide are often recommended. Ketoconazole (Nizoral ointment and shampoo) is another treatment.

A 19-year-old woman at 32 weeks' gestation comes to the physician because of a 1-month history of a generalized rash that has not expanded or changed. She has not had pruritus or fever. She has had no prenatal care. Examination shows a macular rash involving the palms, chest, back, abdomen, extremities, and soles. Which of the following is the most likely causal organism? a) Bordetella pertussis b) Chlamydia trachomatis c) Cytomegalovirus d) Escherichia coli e) Group B streptococcus f) Herpes simplex virus g) Parvovirus h) Rubella virus i) Toxoplasma gondii j) Treponema pallidum k) Trichomonas vaginalis


1 months history of non-pruritic papular rash Syphilis. The rash is classically a diffuse, symmetric macular or papular eruption involving the entire trunk and extremities ,including the palms and soles although localized lesions can also occur . Individual lesions are discrete red or reddish-brown and measure 0.5 to 2 cm in diameter .They are often scaly but may be smooth and rarely pustular. Pustular syphilis can take the form of small pustular syphilide, large pustular syphilide, flat pustular syphiloderm, and pustular-ulcerative syphilide (ie, malignant syphilis). Nodular lesions also may be seen. The involvement of the palms and soles is an important clue to the diagnosis of secondary syphilis.


A 22-year-old woman with asthma comes to the physician for a follow-up examination She feels well She has been treated for six acute episodes of wheezing and nonproductive cough dunng the past year her last episode was 1 month ago Her symptoms are exacerbated when she is outside during the spring and fall Current medications include an albuterol inhaler and ectnacea She has smoked one-half pack of cigarettes daily for 5 years and does not dnnk alcohol She is employed in a jewehy factcwy Her temperature is 372C (99F). pidse is 80mm. respirations are 12/mm, and blood pressure is 12080 mm Hg Examination and an x-ray of the chest show no abnognalibes In addition to counseling about smoking cessation, which of the following measures is most likely to reduce the frequency of asthma exacerbations? O A) Change in woik environment O B) Desensitization to ammnal dander O C) Fluticasone inhaler therapy o D) Heernophilus influenzae type b vaccine o E) Influenza vaccine o F) 23-Valent pneumococcal vaccine


Complications of influenza – Annual administration of influenza vaccine is recommended for patients with asthma because they are at risk for complications of infection. However, vaccination does not reduce the number or severity of asthma exacerbations during the influenza season, and providers should ensure that patients understand this distinction


A 52-year-old woman comes to the physician because of an 8-month history of an intermittent nonproductive cough. She takes no medications. She has smoked one pack of cigarettes daily for 25 years. She has had three episodes of sinusitis over the past 18 months. Examination shows pale nasal mucosa and cobblestoning of the posterior pharynx. The lungs are clear to auscultation. There is no clubbing or cyanosis. Which of the following is the most likely cause of this patient's cough? A) Allergic rhinitis B) Bronchiectasis C) Chronic bronchitis D) Hypersensitivity pneumonitis E) Rhinitis medicamentosa


Active allergic rhinitis:
Infraorbital edema and darkening due to subcutaneous venodilation.
Accentuated lines or folds below the lower lids (Dennie-Morgan lines), which suggests concomitant allergic conjunctivitis
A transverse nasal crease caused by repeated rubbing and pushing the tip of the nose up with the hand.
"Allergic facies," which are typically seen in children with early-onset allergic rhinitis, consist of a highly arched palate, open mouth due to mouth breathing, and dental malocclusion
The nasal mucosa of patients with active allergic rhinitis frequently has a pale bluish hue or pallor along with turbinate edema
Clear rhinorrhea may be visible anteriorly, or if the nasal passages are obstructed, rhinorrhea may be visible dripping down the posterior pharynx
Hyperplastic lymphoid tissue lining the posterior pharynx, which resembles cobblestones (a finding called “cobblestoning”)
Serous fluid may accumulate behind tympanic membranes in patients with significant nasal mucosal swelling and eustachian tube dysfunction


A 15-year-old girl is brought to the physician because of a 1-week history of vaginal discharge and a 2-day history of sore throat and white spots in her mouth. She has had recurrent candidal infections of the skin and mucous membranes since childhood. She has a 2-year history of type 1 diabetes mellitus and a 1-year history of autoimmune thyroiditis. Medications include insulin and levothyroxine. Examination shows oral candidiasis. Pelvic examination shows a thick white vaginal discharge. Microscopic examination shows budding yeast. Which of the following is the most likely mechanism of her recurrent candidal infections? A ) Autoimmune destruction of the thymus B ) Blunting of the inflammatory response from complement deficiency C ) Deficiency in anticandidal antibodies D ) Impaired cell-mediated immunity E ) Inability of macrophage to present candidal antigen


Chronic mucocutaneous candidiasis *—*Chronic mucocutaneous candidiasis is a rare syndrome that usually has its onset in childhood. Some patients have autosomal recessive polyglandular autoimmune syndrome type I, which is also referred to as the autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome.CMC is associated with a defect in cell-mediated immunity that may either be limited to*Candida*antigens or be part of a more general immune abnormality.*


A 42-year old woman comes to the physician because of progressive shortness of breath during the past 6 months. She now has to r est three or four times when climbing one flight of stairs. Shew has smoked one pack of cigarettes daily for 26 years. She has a chronic nonproductive cough and has wheezing controlled with an albuterol inhaler two to three times weekly. During the past year, he BMI has increased from 45kg/sq.m to 52kg/sq.m. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 24/min and shallow, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is distended. There is 1+ edema of the ankles. Arterial blood gas analysis on room air shows: pH 7.37 Pco2 48 mm Hg Po2 62 mm Hg o2 saturation 92% Her FEV1 is 75% of predicted, and total lung capacity is 50% of predicted. Which of the following is the most likely diagnosis? A) Chronic obstructive pulmonary disease B) Congestive heart failure C) Interstitial pneumonia D) Recurrent pulmonary embolism E) Restrictive lung disease


TLC is decreased => restrictive pattern. Check DLCO , if DLCO is nl think about chest wall disroders/NM disorders/pleural disease/morbid obesity; if DLCO is decreased ==> ILD, CHF.

A 25-yo woman comes to the emergency department because of nausea, diarrhea, and anxiety for 2 days. She also has noticed dizziness and tingling sensations shooting down her forearms. Her sleep and appetite have been normal. She has a 3 year history of social phobia well controlled for the past year with paroxitine. She is attending an out-of-town conference and forgot to pack her medication; her last dose was 3 days ago. She does not drink alcohol or use illicit drugs. She is 163cm tall and weighs 89 kg. BMI is 30 kg/m2. Her temperature is 37C, pulse is 80/min, and blood pressure is 110/75 mm Hg. Physical examination shows no other abnormalities. Mental status examination shows an irritable mood with a full range of affect. Her speech is of normal rate and rhythm. There is no evidence of suicidal ideation or hallucination. She can recall three objects after 5 minutes. Long-term memory is intact. Serum studies show no traces of paroxitine. Which of the following is the most appropriate next step in management? A) Begin behavioral therapy B) Begin alprazolam therapy C) Begin bupropion therapy D) Begin clomipramine therapy E) Begin gabapentin therapy F) Resume paroxetine


Antidepressant Discontinuation Syndrome
Typical symptoms of antidepressant discontinuation syndrome include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. These symptoms usually are mild, last one to two weeks, and are rapidly extinguished with reinstitution of antidepressant medication
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Last edited by Jisb11; 02-05-2016 at 03:48 AM. Reason: sds
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The above post was thanked by:
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  #98  
Old 02-09-2016
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Correct Answer

Thank you very much!
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  #99  
Old 07-16-2016
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Default why stricture not adhesion?

Quote:
Originally Posted by Pedro Rodrigo View Post
answer is Fibrotic stricture
why stricture not adhesion?
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