clinical mastery series medicine form 4
if any one of you have done the CMS Medicine form 4 ,would you please take some time to discuss answers to some of the questions i did wrong..
1.a 42 yr old woman comes to the physician for a follow up examination.She was diagnosed with hypertension 6 months ago,and hydrochlorothiazide therapy was begun.Eight weeks ago ,her blood pressure was 176/96 mm Hg,and Lisinopril was added to her regimen.She says she feels well.She has no other history of serious illness she occasionally takes Ibuprofen for muscle pain or headache.She walks for 30 minutes three times weekly.She is 170 cm,(5ft 7in)tall and weighs 66 kg(145 lb);BMI is 23 kg/m2.Her pulse is 76/min,and blood pressure is 160/98 mm Hg in the right upper extremity and 162/96 mm Hg in the left upper extremity while sitting and standing.Cardiopulmonary examination shows no abnormalities.There is no peripheral edema.Fsating laboratory studies show:
K+ 4 mEq/L
Cl- 105 mEq/L
urea nitrogen 16 mEq/L
creatinine 1 mg/dl
urine protein 1+
The patient asks how she can decrease her risk of renal failure.Which of the following is the most appropriate recommendation?
A) Protein restricted diet
B) 24 hour urine collection for measurement of protein concentration
C) Increasing the dose of lisinopril (i think this one )
D) Switching from hydrocholothiazide to furosemide (WRONG)
E) No further measures are indicated at this time
3.A 62 yr old man has a 2 day h/o gen weakness & inability to walk w/o assistance 7 days after admn to ICU for t/t of fever,cough and a left upper lobe consolidation.T/t with ceftriaxone and azithromycin initially improved his symptoms.He has not had fever for 2 days.He has type II DM current meds are ceftriaxone,heparin omeprazole & insulin glargine.A peripheral catheter is in place ,there is no central access.Vitals are WNL.Examn of skin shows no lesions.On pul exam rhonchi are herad in the left upper lobe.Lab studeis show :
Day 5 Day 7
Hemoglobin 10.8 g/dl 10 g/dl
Leukocyte count 11,500 12,000
platelets 330,000 90,000
which of the following is the most appropriate next step in m/t?
a) add epoetin alfa to the med regimen
b) discontinue ceftriaxone & begin physical therapy
c) switch from ceftriaxone to pip-taz
d)switch from heparin to direct thrombin inhibitor therapy (i think this)
e) switch from heparin to Low mol weight heparin (WRONG)
4 72 y o woman comes to phy because she is concerned about high bp.2 days ago her bp was 200/105 .she has a 20 yrs h/o htn well controlled with a thiazide diuretic.at her last visit 3 months ago her bp was 140/75.today her pr-80/m,rr-12/min & bp-210/114.fundoscopy shows a-v nicking.a right carotid bruit is heard.lab studies are wnl.following is the most likely cause of her findings?
c) coarctation of aorta
i)renal artery stenosis ( i think this one)
5 ) asymptomatic 24 y o man who is HIV+ve ,comes for follow-up.has been seen regularly since he was diagnosed 3 yrs ago & has been following all recommendations.currently takes no meds.exam shows no abnormalities.lab studies show:
hematocrit 42%,leukocyte count-4000/mm3,CD4-550/mm3,plasma HIV viral load-200 copies/ml
most appropriate recommendation ?
a)follow-up in 6 mo
b)2 drug art only
c)2 drug art & P.jiroveci prophylaxis
d)3 drug art
e)3 drug art & P.jiroveci prophylaxis
****recently there has been a new CDC-WHO guidiline to start ART as soon as pat is diagnosed of HIV irrespective of CD 4 count(START trial)i marked d but it was wrong,i know acc to previous guidelines answer may be a i.e follo up after 6 months.
more to follow..
C,D,I, and last one you answered right according to new guidelines .. but i guess what they are getting to here is not starting meds until CD is at 500 ?? and viral load is low, 100,000 is the number to lock out for i guess ..
This is what is mentioned in MTB3
When to start therapy?
· CD4 count < 500 without exception
· Symptomatic patients with any CD4 count or viral load
· Pregnant women: All of them, any stage of pregnancy, any CD4
· Needle-stick scenario, where patient is known to be HIV-positive
· Optional at any CD4 count, even > 500
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