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USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


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  #1  
Old 03-02-2016
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Default clinical mastery neurology nbme form 1

A 52 year-old woman comes to the physician because of constant severe burning pain over the right side of her ribs for 2 days. She says the pain keeps her awake at night and does not respond to acetaminophen or aspirin. During this period, she has had a mild rash over the painful area and intermittent low-grade fever. She has type 2 DM controlled w/ diet and hypertension controlled w/ a thiazide diuretic. Vital signs are w/in normal limits. Examination shows an 8 -cm area of painful erythema and vesicles from T4 to the right costal margin. Results of a complete blood count and serum electrolyte concentrations are w/in the reference range. Which of the following is the most appropriate pharmacotherapy?

a) oral acyclovir
b) oral amantadine
c) oral ganciclovir
d) IV acyclovir
e) IV foscarnet
f) IV ganciclovir

* put IV acyclovir it was wrong

An 82 year old woman w/ mild dementia, alzheimer type, is admitted to the hospital for treatment of pyelonephritis. She has been living at home under the care of her husband. She has been receiving IV antibiotics for 1 day. Her pulse if 90/min, respirations are 16/min, and blood pressure is 152/70 mmHg. Physical examination show right CVA tenderness. on mental status examination, she is alert and oriented to person and place but not to time. she is calm. Her husband is concerned b/c she becomes more confused and agitated when she is away from home, especially at night. Which of the following is most appropriate to prevent agitation in this patient during hospitalization?

A) Bright illumination of the room at all times
B) Decrease ambient noise and number of interruptions at night
C) hourly orientation by nurses to her situations
D) low-dose haloperidol
E) use of restraints as needed

* put A, it was wrong

A previously healthy 67-year-old man comes to the physician b/c of a 2-month history of back pain that awakens him at night. Physical examination, including rectal examination, shows no abnormalities. X-rays of the spine show multiple osteoblastic lesions; a biopsy specimen of the lesions shows well-differentiated adenocarcinoma. Which of the following is the most appropriate next step to establish the origin of cancer in this patient?

a) measurement of alpha-fetoprotein concentration
b) measurement of serum PSA concentration
c) urine immunoelectrophoresis
d) X-ray of the chest
e) colonscopy

* put C it was wrong
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  #2  
Old 03-02-2016
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A.
Reactivation of latent varicella-zoster virus (VZV) infection within the sensory ganglia results in herpes zoster, or "shingles." This syndrome is usually characterized by a painful, unilateral vesicular eruption in a dermatomal distribution.
The goals of antiviral therapy are to promote more rapid healing of skin lesions, to lessen the severity and duration of pain associated with acute neuritis, and to reduce the incidence or severity of chronic pain, referred to as postherpetic neuralgia.
Antiviral drugs with activity against VZV include acyclovir , famciclovir , and valacyclovir , all of which are well tolerated. Antiviral therapy leads to faster resolution of cutaneous lesions and acute neuritis compared with no therapeutic intervention. However, it is unclear if treatment of acute herpes zoster decreases the risk or the duration of post-herpetic neuralgia.
Oral valacyclovir (1000 mg three times daily) or famciclovir (500 mg three times daily) because of their lower dosing frequency, compared with acyclovir . All regimens should be given for seven days.


B. Will you be able to stay asleep/ be calm if your room would have been constantly illuminated?
Effective measures to prevent delirium include avoiding where possible, those factors known to cause or aggravate delirium, orientation protocols, environmental modification and nonpharmacologic sleep aids, early mobilization and minimizing use of physical restraints, and visual and hearing aids.
Prophylactic medications (cholinesterase inhibitors, antipsychotic agents) do NOT appear to be useful to prevent delirium.
Thiamine supplementation should be considered in all patients with delirium.
When the underlying acute illness responsible for delirium is identified, specific therapy is directed toward that condition as the most effective means of reversing the delirium.
Physical restraints should be used only as a last resort, if at all, as they frequently increase agitation and create additional problems, such as loss of mobility, pressure ulcers, aspiration, and prolonged delirium.
Frequent reassurance, touch, and verbal orientation from familiar persons lessen disruptive behaviors.



B. Adenocarcinoma + blastic mts in male pt = prostatic cancer.
Sclerotic or blastic bone metastases can arise from a number of different primary malignancies including

prostate carcinoma (most common)
breast carcinoma (may be mixed)
transitional cell carcinoma (TCC)
carcinoid
medulloblastoma
neuroblastoma
mucinous adenocarcinoma of the gastrointestinal tract - e.g. colon carcinoma
lymphoma


Lytic bone metastases are due to a variety of primary tumours, and are more common than sclerotic metastases (although many may occasionally have mixed lytic and sclerotic components). They include 1:

thyroid cancer
renal cell cancer
adrenal gland carcinoma and pheochromocytoma
uterine carcinoma
gastrointestinal carcinomas
Wilms tumour
Ewing sarcoma
melanoma
hepatocellular carcinoma
squamous cell carcinoma of the skin
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Old 03-02-2016
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Default re: prostate cancer

would you still consider prostate cancer given a normal DRE?
or would you do colonscopy given the patient's age and most colon cancer is adenocarcinoma?
PSA is also non specific
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Old 03-02-2016
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Quote:
Originally Posted by chiefcomplaint View Post
would you still consider prostate cancer given a normal DRE?
or would you do colonscopy given the patient's age and most colon cancer is adenocarcinoma?
PSA is also non specific
Patient's age is consistent with prostate cancer too. Also(and more importantly) as Jisb11 already explained prostate cancer gives blastic bone metastases whereas colon cancer doesn't. Also, a colon cancer that has metastasized is unlikely to be devoid of GI symptoms and present with just back pain, whereas prostate cancer does present in this manner. It produces urinary symptoms very late.

Histological type is not a good way to determine the site of primary tumor. Adenocarcinoma can arise in GI, breast, prostate, lung. We need to narrow down our differential by clinical clues, not broaden it.
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