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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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Old 07-21-2016
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Default Help pls CMS Surgery Form 4

1. A 62*-year-*old man is brought to the emergency department because of a 12-*hour history of fever, fatigue, and severe pain in the toes of his left foot. He rates the pain as a 9 on a 10*point scale. He has not had abdominal pain. Six weeks ago, he was discharged from the hospital following antibiotic treatment for diverticulitis; at that time, he was prescribed a 14-*day course of intravenous piperacillin and tazobactam to be administered at home via percutaneous intravenous catheter. He has hypertension treated with atenolol. His temperature is 38.9C (102F), pulse is 120/min and regular, respirations are 22/min, and blood pressure is 100/60 mm Hg. There is an intravenous catheter in his medial right arm. A grade 2/6, decrescendo, diastolic murmur is heard best at the upper right sternal border. The abdomen is flat and nontender. There is no pedal edema. The second and third toes of the left foot are pale blue and tender. His leukocyte count is 17,000/mm3 (70% segmented neutrophils, 10% bands, and 20% lymphocytes). A blood culture is positive for Staphylococcus aureus. Echocardiography shows vegetations on the aortic valve. Which of the following is most likely to have prevented this complication?

A) Implantation of a port instead of a catheter for administration of piperacillin and tazobactam (WRONG)
B) Initiation of ampicillin and gentamicin therapy instead of piperacillin and tazobactam
C) Addition of fluconazole to the medication regimen for his diverticulitis
D) Removal of the percutaneous intravenous catheter after completion of piperacillin and tazobactam therapy
E) Administration of the pneumococcal polysaccharide vaccine, 23-*valent, at discharge
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2. Three weeks after undergoing arteriography through the right groin for evaluation of progressive left calf claudication, a 64*-year*-old man is noted to have a palpable thrill and a continuous machinery murmur at the arteriography site. Examination shows decreased pedal pulses on the right; pulses had been normal prior to the procedure. The arteriogram is shown (http://imgur.com/a/WekUl). Which of the following factors is most predictive of the development of heart failure in this patient?

A) Degree of edema in the lower extremity
B) Groin compression causing bradycardia
C) Presence of pallor with elevation and dependent rubor
D) Presence of a pseudoaneurysm
E) Size of the abnormality
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Quote:
Originally Posted by doc2530 View Post
1. A 62*-year-*old man is brought to the emergency department because of a 12-*hour history of fever, fatigue, and severe pain in the toes of his left foot. He rates the pain as a 9 on a 10*point scale. He has not had abdominal pain. Six weeks ago, he was discharged from the hospital following antibiotic treatment for diverticulitis; at that time, he was prescribed a 14-*day course of intravenous piperacillin and tazobactam to be administered at home via percutaneous intravenous catheter. He has hypertension treated with atenolol. His temperature is 38.9C (102F), pulse is 120/min and regular, respirations are 22/min, and blood pressure is 100/60 mm Hg. There is an intravenous catheter in his medial right arm. A grade 2/6, decrescendo, diastolic murmur is heard best at the upper right sternal border. The abdomen is flat and nontender. There is no pedal edema. The second and third toes of the left foot are pale blue and tender. His leukocyte count is 17,000/mm3 (70% segmented neutrophils, 10% bands, and 20% lymphocytes). A blood culture is positive for Staphylococcus aureus. Echocardiography shows vegetations on the aortic valve. Which of the following is most likely to have prevented this complication?

A) Implantation of a port instead of a catheter for administration of piperacillin and tazobactam (WRONG)
B) Initiation of ampicillin and gentamicin therapy instead of piperacillin and tazobactam
C) Addition of fluconazole to the medication regimen for his diverticulitis
D) Removal of the percutaneous intravenous catheter after completion of piperacillin and tazobactam therapy
E) Administration of the pneumococcal polysaccharide vaccine, 23-*valent, at discharge
D. IE with septic emboli
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Originally Posted by doc2530 View Post
2. Three weeks after undergoing arteriography through the right groin for evaluation of progressive left calf claudication, a 64*-year*-old man is noted to have a palpable thrill and a continuous machinery murmur at the arteriography site. Examination shows decreased pedal pulses on the right; pulses had been normal prior to the procedure. The arteriogram is shown (http://imgur.com/a/WekUl). Which of the following factors is most predictive of the development of heart failure in this patient?

A) Degree of edema in the lower extremity
B) Groin compression causing bradycardia
C) Presence of pallor with elevation and dependent rubor
D) Presence of a pseudoaneurysm
E) Size of the abnormality
E? A-V fistula. Larger fistulas would cause heart failure quicker
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3. A 25*-year-*old construction worker has had fever and a painful, swollen right hand for 2 days. His temperature is 39C (102.2F). The dorsum of the hand is swollen, erythematous, and tender; there is a small traumatic laceration on the dorsum of the hand with a beefy*red expanding margin and red streaks extending up the arm. The axillary lymph nodes are palpable and tender. Which of the following is the most likely pathogen?

A) Bacteroides fragilis
B) Clostridium difficile
C) Clostridium perfringens
D) Clostridium tetani
E) Enterobacter cloacae
F) Enterococcus faecalis
G) Escherichia coli
H) Staphylococcus epidermidis
I) Streptococcus pneumoniae
J) Streptococcus pyogenes (Group A)

4. A 42-*year-*old man who is HIV positive comes to the emergency department because of a 6*week history of moderate pain and intermittent bleeding from his rectum. He also has an enlarging mass in his rectum that he first noticed 6 months ago; he has not sought treatment for the pain until today. He has a 10*year history of perianal warts that were last treated 2 years ago with topical podophyllin. His medications are triple*drug antiretroviral therapy; he also takes ibuprofen for pain. Vital signs are within normal limits. There is no inguinal lymphadenopathy. Examination shows a 10-*cm, cauliflower-*like mass involving the entire perineum. A photograph of the mass is shown (http://imgur.com/a/iPF8F). Laboratory studies show:

Hemoglobin 14 g/dL
Leukocyte count 16,000/mm3
Segmented neutrophils 72%
Bands 8%
Eosinophils 4%
Basophils 4%
Lymphocytes 10%
Monocytes 2%
Platelet count 215,000/mm3
CD4+ T*lymphocyte count 300/mm3 (Normal≥500)
Serum
Na+ 142 mEq/L
K+ 4.3 mEq/L
Cl− 98 mEq/L
HCO3− 28 mEq/L
Urea nitrogen 26 mg/dL
Creatinine 0.9 mg/dL

Which of the following is the most appropriate next step in management?
A) Topical podophyllin therapy
B) Administration of the human papillomavirus vaccine
C) Biopsy of the mass
D) Chemotherapy
E) Radiation therapy
F) Local excision of the mass
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Originally Posted by doc2530 View Post
3. A 25*-year-*old construction worker has had fever and a painful, swollen right hand for 2 days. His temperature is 39C (102.2F). The dorsum of the hand is swollen, erythematous, and tender; there is a small traumatic laceration on the dorsum of the hand with a beefy*red expanding margin and red streaks extending up the arm. The axillary lymph nodes are palpable and tender. Which of the following is the most likely pathogen?

A) Bacteroides fragilis
B) Clostridium difficile
C) Clostridium perfringens
D) Clostridium tetani
E) Enterobacter cloacae
F) Enterococcus faecalis
G) Escherichia coli
H) Staphylococcus epidermidis
I) Streptococcus pneumoniae
J) Streptococcus pyogenes (Group A)

4. A 42-*year-*old man who is HIV positive comes to the emergency department because of a 6*week history of moderate pain and intermittent bleeding from his rectum. He also has an enlarging mass in his rectum that he first noticed 6 months ago; he has not sought treatment for the pain until today. He has a 10*year history of perianal warts that were last treated 2 years ago with topical podophyllin. His medications are triple*drug antiretroviral therapy; he also takes ibuprofen for pain. Vital signs are within normal limits. There is no inguinal lymphadenopathy. Examination shows a 10-*cm, cauliflower-*like mass involving the entire perineum. A photograph of the mass is shown (http://imgur.com/a/iPF8F). Laboratory studies show:

Hemoglobin 14 g/dL
Leukocyte count 16,000/mm3
Segmented neutrophils 72%
Bands 8%
Eosinophils 4%
Basophils 4%
Lymphocytes 10%
Monocytes 2%
Platelet count 215,000/mm3
CD4+ T*lymphocyte count 300/mm3 (Normal≥500)
Serum
Na+ 142 mEq/L
K+ 4.3 mEq/L
Cl− 98 mEq/L
HCO3− 28 mEq/L
Urea nitrogen 26 mg/dL
Creatinine 0.9 mg/dL

Which of the following is the most appropriate next step in management?
A) Topical podophyllin therapy
B) Administration of the human papillomavirus vaccine
C) Biopsy of the mass
D) Chemotherapy
E) Radiation therapy
F) Local excision of the mass
J. Lyphangitis from GAS

C or E? Nigro chemoradiation is the preferred Rx rather than surgery for SCC anus but not sure which among them is done first
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5. A 37*-year-*old woman comes to the physician because of a 3* month history of neck swelling and tightness in her throat. She has not had weakness, weight change, or heat or cold intolerance. Examination shows a diffusely enlarged and firm thyroid gland; there is no nodularity. Serum thyroid-*stimulating hormone, thyroxine (T4), and triiodothyronine (T3) concentrations are within normal limits. Serum studies show circulating antibodies against thyroid peroxidase and thyroglobulin. Which of the following is the most likely diagnosis?

A) Anaplastic thyroid carcinoma
B) Chronic lymphocytic thyroiditis (Hashimoto disease)
C) Graves disease
D) Papillary carcinoma of the thyroid gland (wrong)
E) Subacute thyroiditis

IF the answer is actually B, then how come the thyroid hormones are normal??
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Originally Posted by doc2530 View Post
5. A 37*-year-*old woman comes to the physician because of a 3* month history of neck swelling and tightness in her throat. She has not had weakness, weight change, or heat or cold intolerance. Examination shows a diffusely enlarged and firm thyroid gland; there is no nodularity. Serum thyroid-*stimulating hormone, thyroxine (T4), and triiodothyronine (T3) concentrations are within normal limits. Serum studies show circulating antibodies against thyroid peroxidase and thyroglobulin. Which of the following is the most likely diagnosis?

A) Anaplastic thyroid carcinoma
B) Chronic lymphocytic thyroiditis (Hashimoto disease)
C) Graves disease
D) Papillary carcinoma of the thyroid gland (wrong)
E) Subacute thyroiditis

IF the answer is actually B, then how come the thyroid hormones are normal??
Hashimoto's is initially associated with transient thyrotoxicosis ( due to damage of follicles from inflammation) followed by a euthyroid state and eventually in hypothyroidism (burnt out thyroid)
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6. A 65*-year*-old woman is brought to the emergency department 1 hour after she fell. She has right wrist pain. Her last visit to a physician was 10 years ago. Examination shows swelling and tenderness of the right wrist. An x*ray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. Her serum calcium concentration is 12.4 mg/dL, and serum creatinine concentration is 1.2 mg/dL. Which of the following serum concentrations is most likely to be decreased in this patient?

A) 1,25-*Dihydroxycholecalciferol
B) Magnesium
C) Parathyroid hormone
D) Phosphorus
E) Vitamin C
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Originally Posted by doc2530 View Post
6. A 65*-year*-old woman is brought to the emergency department 1 hour after she fell. She has right wrist pain. Her last visit to a physician was 10 years ago. Examination shows swelling and tenderness of the right wrist. An x*ray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. Her serum calcium concentration is 12.4 mg/dL, and serum creatinine concentration is 1.2 mg/dL. Which of the following serum concentrations is most likely to be decreased in this patient?

A) 1,25-*Dihydroxycholecalciferol
B) Magnesium
C) Parathyroid hormone
D) Phosphorus
E) Vitamin C
D. Looks like primary hyperparathyroidism (hypercalcemia, subperiosteal bone resorption, normal to midly elevated SCr). Elevated PTH causes phosphaturia
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7. A 67*-year-*old woman has required mechanical ventilation to maintain adequate tissue oxygenation since she sustained a severe head injury 2 weeks ago. Serial x-*rays of the chest during hospitalization show findings consistent with acute respiratory distress syndrome. Cultures of bronchial washings have grown numerous organisms for which she is receiving broad*-spectrum antibiotic therapy. A current x-*ray of the chest shows a cavitary lesion in the right upper lobe of the lung. Which of the following is the most likely diagnosis?

A) Aspergillosis
B) Atelectasis
C) Lung abscess
D) Pneumatocele
E) Tuberculosis
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8. An 87*-year-*old woman is brought to the emergency department from a skilled nursing care facility because of a change in mental status during the past 12 hours. She has severe dementia, Alzheimer type, and is unable to give a history. She is currently taking donepezil, atenolol, digoxin, lisinopril, sertraline, docusate, psyllium, and aspirin. On arrival, she is agitated and does not respond to verbal stimuli. Her temperature is 38C (100.4F), pulse is 92/min, respirations are 24/min, and blood pressure is 148/86 mm Hg. The lungs are clear to auscultation. The abdomen is distended. There is diffuse guarding with no rebound. Test of the stool for occult blood is negative. Her hematocrit is 34%, leukocyte count is 9500/mm3, and platelet count is 267,000/mm3. An x-*ray of the abdomen is shown (http://imgur.com/a/jb7aK). Which of the following is the most appropriate next step in management?

A) Serial measurement of cardiac enzyme activities
B) CT scan of the abdomen
C) Discontinuation of sertraline
D) Sigmoidoscopy-*guided placement of a rectal tube
E) Exploratory laparatomy (Wrong)
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Quote:
Originally Posted by doc2530 View Post
7. A 67*-year-*old woman has required mechanical ventilation to maintain adequate tissue oxygenation since she sustained a severe head injury 2 weeks ago. Serial x-*rays of the chest during hospitalization show findings consistent with acute respiratory distress syndrome. Cultures of bronchial washings have grown numerous organisms for which she is receiving broad*-spectrum antibiotic therapy. A current x-*ray of the chest shows a cavitary lesion in the right upper lobe of the lung. Which of the following is the most likely diagnosis?

A) Aspergillosis
B) Atelectasis
C) Lung abscess
D) Pneumatocele
E) Tuberculosis
C. Mechanical ventilation increases the risk of aspiration (right lobe) and lung abscess (polymicrobial infection)
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Originally Posted by saxo View Post
C. Mechanical ventilation increases the risk of aspiration (right lobe) and lung abscess (polymicrobial infection)
Thanks @Saxo, What about Answer D for 7? Wikipedia says a pneumatocele is a cavity in the lung parenchyma filled with air that may result from pulmonary trauma during mechanical ventilation.

8. A 37-*year-*old woman comes to the physician because of a 2-*day history of increasing shortness of breath and fatigue. At the age of 5 years, she underwent successful repair of a ventricular septal defect. She has no other history of serious illness and takes no medications. She does not smoke cigarettes. Her pulse is 110/min and irregularly irregular, respirations are 28/min, and blood pressure is 110/60 mm Hg. Examination shows perioral cyanosis. The lungs are clear to auscultation. On cardiac examination, a grade 4/6, soft holosystolic murmur is heard best at the left sternal border. There is 3+ pretibial edema. Which of the following is the most likely explanation for this patient's symptoms?

A) Decreased pulmonary artery flow
B) Decreased pulmonary vascular resistance
C) Decreased systemic vascular resistance
D) Increased pulmonary artery blood flow
E) Increased pulmonary vascular resistance
F) Increased systemic vascular resistance
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No idea about 8
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From what I know pnematocele can be due to excessive ventilation or secondary to necrotizing pneumonia from staph aureus but the polymicrobial cultures and involvement of right lobe point more to lung abscess secondary to aspiration
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E. Increased pulmonary vascular resistance. Hx of VSD with heart failure and cyanosis = eisenmenger syndrome
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Originally Posted by saxo View Post
From what I know pnematocele can be due to excessive ventilation or secondary to necrotizing pneumonia from staph aureus but the polymicrobial cultures and involvement of right lobe point more to lung abscess secondary to aspiration
@Saxo, thanks but her vitals show she is afebrile, and her white count is bordering normal, and the lesion is in the upper lobe. All these characteristics make it seem unlikely to be a lung abscess.
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Originally Posted by doc2530 View Post
@Saxo, thanks but her vitals show she is afebrile, and her white count is bordering normal, and the lesion is in the upper lobe. All these characteristics make it seem unlikely to be a lung abscess.
Sorry Saxo, I was looking at a different question!
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9. A 27-*year-*old woman, gravida 2, para 2, comes to the physician because of a 1-*week history of painful bowel movements. She has noticed bright red blood on the surface of her stool during this period. She reports she has had bowel movements twice weekly since delivery of her youngest child 2 years ago. She has no history of serious illness and takes no medications. Examination of the perineum shows an ulcer in the posterior midline of the anal canal with an adjacent edematous skin tag at the anal verge. Rectal examination cannot be performed because of pain and increased anal sphincter tone. In addition to treatment with stool softeners, which of the following is the most appropriate next step in management?

A) Sitz bath
B) Hydrocortisone enemas
C) Anal manometry
D) Placement of elastic bands (wrong)
E) Surgical drainage of the abscess
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10. A 67-*year-*old man is brought to the physician because of severe pain in the right foot for 6 hours. On examination, the right foot is pale and cool, and pedal pulses are not palpable. He can wiggle his toes. Examination of the left foot shows no abnormalities. There are bilateral femoral pulses and pulsatile masses in the popliteal fossae. Which of the following is the most appropriate next step in diagnosis?

A) Cardiolipin antibody assay
B) Measurement of transcutaneous oxygen tension in the feet
C) Measurement of serum antithrombin III concentration
D) Impedance plethysmography
E) Arteriography with runoff
F) Venography of the right lower extremity
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11. A previously healthy 25-*year-*old woman is brought to the emergency department 20 minutes after being struck by an automobile. On arrival, she has pelvic and left lower extremity pain. Her temperature is 36.8C (98.3F), pulse is 135/min, respirations are 26/min, and blood pressure is 90/48 mm Hg. Examination shows an unstable pelvis and an obvious deformity of the left thigh. X-*rays show fractures of the left iliac wing and left midshaft femur. Ten units of packed red blood cells are administered, and her blood pressure stabilizes. Nine days after operative repair of her fractures, she develops jaundice. Abdominal examination shows no abnormalities. Serum studies show:

Bilirubin, total 5 mg/dL
Direct 2.3 mg/dL
Alkaline phosphatase 150 U/L
γ*-Glutamyltransferase 35 U/L (N=550)


Which of the following is the most likely underlying cause of these findings?
A) Decreased excretion of bilirubin into the bile
B) Decreased hepatic conjugation of bilirubin
C) Decreased hepatic uptake of bilirubin
D) Obstruction of common bile duct
E) Overproduction of bilirubin
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12. A 42-*year*-old construction worker is brought to the emergency department 20 minutes after falling 30 feet from a scaffold. En route to the hospital, he received 1 L of lactated Ringer solution. On arrival, he is awake and alert and has severe abdominal and leg pain. He can move all extremities. His temperature is 37C (98.6F), pulse is 110/min, respirations are 16/min, and blood pressure is 120/70 mm Hg. Examination shows ecchymoses over the left forehead and lower abdomen. There is an obvious deformity of the left lower extremity. There is no neck tenderness. Cardiopulmonary examination shows no abnormalities. The lower abdomen is slightly distended and exquisitely tender. There is no blood at the urethral meatus. Rectal examination shows no abnormalities. Insertion of a urinary catheter yields 30 mL of grossly bloody fluid. An additional 1.5 L of lactated Ringer solution is administered, and the left lower extremity is placed in traction. Thirty minutes later, his pulse is 95/min, and blood pressure is 140/80 mm Hg. No additional urine has drained from the catheter. Which of the following is the most likely cause of this patient's anuria?

A) Acute tubular necrosis
B) Hypovolemia
C) Rupture of the bladder
D) Syndrome of inappropriate secretion of ADH (vasopressin)
E) Transection of the urethra
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13. An obese 72*-year*-old man is brought to the emergency department 15 minutes after he collapsed at home. His wife reports that he has had upper abdominal pain, nausea, and vomiting for the past 24 hours. He has hypertension and coronary artery disease. He is diaphoretic. His temperature is 36.5C (97.7F), pulse is 115/min and irregularly irregular, respirations are 22/min, and palpable systolic blood pressure is 80 mm Hg. There is no jugular venous distention. The lungs are clear to auscultation. No murmurs or gallops are heard. The abdomen is tender and rigid. Pulmonary artery catheterization shows:
Cardiac index 1.2 L/min/m2 (N=2.54.2)
Mean pulmonary arterial pressure 5 mm Hg (N=916)
Pulmonary capillary wedge pressure1 mm Hg (N=516)
Systemic vascular resistance 1929 dyns/cm5 (N=7701500)

Which of the following is the predominant type of shock in this patient?
A) Anaphylactic B) Cardiogenic C) Hypovolemic D) Neurogenic E) Septic
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14. A previously healthy 37-*year*-old woman comes to the physician because of a 2*-month history of intermittent, right upper abdominal pain that usually occurs after meals. She has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. She takes no medications. Her temperature is 37C (98.6F), pulse is 68/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Examination shows no jaundice or scleral icterus. Abdominal examination shows no abnormalities. Her leukocyte count is 5000/mm3. Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2*-cm hepatic mass in the right lobe. An abdominal CT scan shows the mass to be 4.2 3.5 cm with a central scar. Which of the following is the most appropriate next step in diagnosis?

A) Measurement of serum α-*fetoprotein concentration
B) Hepatitis B virus serology
C) Radionuclide liver scan (wrong)
D) MRI of the liver
E) Fine*-needle aspiration biopsy of the mass
F) No further testing is indicated
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Quote:
Originally Posted by doc2530 View Post
8. An 87*-year-*old woman is brought to the emergency department from a skilled nursing care facility because of a change in mental status during the past 12 hours. She has severe dementia, Alzheimer type, and is unable to give a history. She is currently taking donepezil, atenolol, digoxin, lisinopril, sertraline, docusate, psyllium, and aspirin. On arrival, she is agitated and does not respond to verbal stimuli. Her temperature is 38C (100.4F), pulse is 92/min, respirations are 24/min, and blood pressure is 148/86 mm Hg. The lungs are clear to auscultation. The abdomen is distended. There is diffuse guarding with no rebound. Test of the stool for occult blood is negative. Her hematocrit is 34%, leukocyte count is 9500/mm3, and platelet count is 267,000/mm3. An x-*ray of the abdomen is shown (http://imgur.com/a/jb7aK). Which of the following is the most appropriate next step in management?

A) Serial measurement of cardiac enzyme activities
B) CT scan of the abdomen
C) Discontinuation of sertraline
D) Sigmoidoscopy-*guided placement of a rectal tube
E) Exploratory laparatomy (Wrong)
It's D

Patient has a LBO .. Pt is stable and only has diffuse guarding with NO rebound so E is wrong.
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  #27  
Old 07-21-2016
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Originally Posted by doc2530 View Post
11. A previously healthy 25-*year-*old woman is brought to the emergency department 20 minutes after being struck by an automobile. On arrival, she has pelvic and left lower extremity pain. Her temperature is 36.8C (98.3F), pulse is 135/min, respirations are 26/min, and blood pressure is 90/48 mm Hg. Examination shows an unstable pelvis and an obvious deformity of the left thigh. X-*rays show fractures of the left iliac wing and left midshaft femur. Ten units of packed red blood cells are administered, and her blood pressure stabilizes. Nine days after operative repair of her fractures, she develops jaundice. Abdominal examination shows no abnormalities. Serum studies show:

Bilirubin, total 5 mg/dL
Direct 2.3 mg/dL
Alkaline phosphatase 150 U/L
γ*-Glutamyltransferase 35 U/L (N=550)


Which of the following is the most likely underlying cause of these findings?
A) Decreased excretion of bilirubin into the bile
B) Decreased hepatic conjugation of bilirubin
C) Decreased hepatic uptake of bilirubin
D) Obstruction of common bile duct
E) Overproduction of bilirubin
I think E ... TEN units of RBC , Thats a lot packed RBCs and i'm sure Most have a short half-life vs the fresh cells with 90 days .
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Originally Posted by doc2530 View Post
13. An obese 72*-year*-old man is brought to the emergency department 15 minutes after he collapsed at home. His wife reports that he has had upper abdominal pain, nausea, and vomiting for the past 24 hours. He has hypertension and coronary artery disease. He is diaphoretic. His temperature is 36.5C (97.7F), pulse is 115/min and irregularly irregular, respirations are 22/min, and palpable systolic blood pressure is 80 mm Hg. There is no jugular venous distention. The lungs are clear to auscultation. No murmurs or gallops are heard. The abdomen is tender and rigid. Pulmonary artery catheterization shows:
Cardiac index 1.2 L/min/m2 (N=2.54.2)
Mean pulmonary arterial pressure 5 mm Hg (N=916)
Pulmonary capillary wedge pressure1 mm Hg (N=516)
Systemic vascular resistance 1929 dyns/cm5 (N=7701500)

Which of the following is the predominant type of shock in this patient?
A) Anaphylactic B) Cardiogenic C) Hypovolemic D) Neurogenic E) Septic
C for this one
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  #29  
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Originally Posted by doc2530 View Post
14. A previously healthy 37-*year*-old woman comes to the physician because of a 2*-month history of intermittent, right upper abdominal pain that usually occurs after meals. She has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. She takes no medications. Her temperature is 37C (98.6F), pulse is 68/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Examination shows no jaundice or scleral icterus. Abdominal examination shows no abnormalities. Her leukocyte count is 5000/mm3. Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2*-cm hepatic mass in the right lobe. An abdominal CT scan shows the mass to be 4.2 3.5 cm with a central scar. Which of the following is the most appropriate next step in diagnosis?

A) Measurement of serum α-*fetoprotein concentration
B) Hepatitis B virus serology
C) Radionuclide liver scan (wrong)
D) MRI of the liver
E) Fine*-needle aspiration biopsy of the mass
F) No further testing is indicated
F .. Pretty sure it's a Focal nodular hyperplasia which is benign, with no malignant potential or risk of complication as in rupture or hemorrhage .

The gallbladder issue requires no further testing , only an elective surgery .
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Originally Posted by doc2530 View Post
12. A 42-*year*-old construction worker is brought to the emergency department 20 minutes after falling 30 feet from a scaffold. En route to the hospital, he received 1 L of lactated Ringer solution. On arrival, he is awake and alert and has severe abdominal and leg pain. He can move all extremities. His temperature is 37C (98.6F), pulse is 110/min, respirations are 16/min, and blood pressure is 120/70 mm Hg. Examination shows ecchymoses over the left forehead and lower abdomen. There is an obvious deformity of the left lower extremity. There is no neck tenderness. Cardiopulmonary examination shows no abnormalities. The lower abdomen is slightly distended and exquisitely tender. There is no blood at the urethral meatus. Rectal examination shows no abnormalities. Insertion of a urinary catheter yields 30 mL of grossly bloody fluid. An additional 1.5 L of lactated Ringer solution is administered, and the left lower extremity is placed in traction. Thirty minutes later, his pulse is 95/min, and blood pressure is 140/80 mm Hg. No additional urine has drained from the catheter. Which of the following is the most likely cause of this patient's anuria?

A) Acute tubular necrosis
B) Hypovolemia
C) Rupture of the bladder
D) Syndrome of inappropriate secretion of ADH (vasopressin)
E) Transection of the urethra
C..Bladder rupture ,
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  #31  
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Quote:
Originally Posted by compaq1 View Post
I think E ... TEN units of RBC , Thats a lot packed RBCs and i'm sure Most have a short half-life vs the fresh cells with 90 days .
But jaundice from hemolysis would be associated predominantly with indirect hyperbilirubinemia unlike the cholestatic jaundice with elevated direct bili in this case. I think its A, due to decreased hepatic excretion of bilirubin (trauma and the associated shock cause cholestasis, injury to biliary tree?)
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  #32  
Old 07-22-2016
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Originally Posted by saxo View Post
But jaundice from hemolysis would be associated predominantly with indirect hyperbilirubinemia unlike the cholestatic jaundice with elevated direct bili in this case. I think its A, due to decreased hepatic excretion of bilirubin (trauma and the associated shock cause cholestasis, injury to biliary tree?)
It's looks to be to be a Mixture of elevated Direct and indirect .. Also the Alk P and GGT is normal levels ruling out liver or billiary cause . i think it's hemolysis along with saturation of liver enzyme that are responsible for transporting the conjecated bilirubin out of the liver , leading to a back flow of already conjecated bilirubin back into the circulation
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  #33  
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http://njcc.nl/sites/default/files/NJCC_04%20Kors.pdf
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  #34  
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I agree with what your saying , i just don't see any other symptoms in this patient that are associated with a " Shock liver " .. I do plan on taking this form online this week .. So i will update later this week .
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Quote:
Originally Posted by doc2530 View Post
7. A 67*-year-*old woman has required mechanical ventilation to maintain adequate tissue oxygenation since she sustained a severe head injury 2 weeks ago. Serial x-*rays of the chest during hospitalization show findings consistent with acute respiratory distress syndrome. Cultures of bronchial washings have grown numerous organisms for which she is receiving broad*-spectrum antibiotic therapy. A current x-*ray of the chest shows a cavitary lesion in the right upper lobe of the lung. Which of the following is the most likely diagnosis?

A) Aspergillosis
B) Atelectasis
C) Lung abscess
D) Pneumatocele
E) Tuberculosis
C. Lung abcess
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  #36  
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Originally Posted by doc2530 View Post
10. A 67-*year-*old man is brought to the physician because of severe pain in the right foot for 6 hours. On examination, the right foot is pale and cool, and pedal pulses are not palpable. He can wiggle his toes. Examination of the left foot shows no abnormalities. There are bilateral femoral pulses and pulsatile masses in the popliteal fossae. Which of the following is the most appropriate next step in diagnosis?

A) Cardiolipin antibody assay
B) Measurement of transcutaneous oxygen tension in the feet
C) Measurement of serum antithrombin III concentration
D) Impedance plethysmography
E) Arteriography with runoff
F) Venography of the right lower extremity
E) Arteriography with runoff
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Default more questions need help

1. 57 year old woman admitted to hospital for an elective gastrectomy. During insertion of subclavian venous catheter via a left infraclavicular approach, suddenly begins squirming under the drapes and has shortness of breath. Her pulse is 100/min, respirations 24/min and blood pressure 100/70. exam shows jugular venous distention. Breath sounds are decreased on the left. What ist he most likely diagnosis?
Air embolism
Cardiac tamponade
Claustrophobia
Massive hemothorax
Tension pneumothorax

2. 18. A 25-year-old woman remians in the intensive care unit 5 days after undergoing pancreaticodudodenectomy for injuries sustained from a gunshot wound to the abdomen. A jejunostomy tube was placed distal to the anastomosis at the time of surgery. Current medications include morphine and cimetidine. She is 152 cm (5 ft) tall and weighs 100 kg (220 lb); bmi IS 43 kg/m. Examination shows a well-healing incision. Which of the following is the most appropriate next step in providing nutrition to this patient?
A) Enteral tube feedings
B) Intrvenous administration of 10% dextrose in water
C) Parental administration of lipid emulsion
D) Total parenteral nutrition
E) No nutrients should be given at this time

3. 21. A 32-year-old man comes to the physician for evaluation of infertility. Two months ago, he was found to have a low sperm count during an infertility workup. There is no family history of infertility. Examination shows no abnormalities except for dilated veins in the left scrotum. Which of the following is the most likely mechanism for this patient's infertility?
A) Decreased serum testosterone concentration
B) Idiopathic
C) Increased scrotal temperature
D) Increased serum corticosteroid concentration
E)Isolated luteinizing hormone deficiency

4. 24. A 63-year-old man has had dysphagia and chest pain during meals for 4 months. He has a 6-year history of gastroesophageal reflux. He has limited his intake to liquids for 3 weeks because he regurgitates solid foo.d Which of the following is the most likely cause of his symptoms?
A) Disordered neuromuscular transmission in the esophagus
B) Disordered neuromuscular transmission in the oropharynx
C) Failure of oropharyngeal propulsion
D) Paraesophageal hiatal hernia
E) Stricture of the distal esophagus

5. 33. A 52-year-old man comes to the physician for a follow-up examination. He has a 4-year history of hypertension and a 1-year history of hypokalemia. Current medications include labetalol, enalapril, and potassium chloride .His blood pressure is 154/90. The remiander of examination shows no abnormalities. His fasting serum aldosterone ratio is increased. A CT scan shows a 1-cm, left adrenal mass. Adrenal vein sampling before and after adminstration of ACTH shows bilateral hypersecretion of aldosterone. Which of the following is the most appropriate next step in management?
A) Candesartan therapy
B) Furosemide therapy
C) Spironolactone therapy
D) Bilateral adrenalectomy
E)Unilateral adrenalectomy

6. 36. A 67-year-old man comes to the physican because of a ulcer on the glans penis that has been increasing in size over the past 6 months. He is sexually active with multiple partners and rarely uses a condom. Examination shows an uncircumcised penis with bilateral, firm inguinal adenopathy and a painless ulcer on the glans. A serologic VDRL test is nonreactive. Which of the following is the most likely diagnosis?
A) Chancroid
B) Epididymitis
C) Gonococcal urethritis
D) Herpes
E) Inguinal hernia
F) Nongonococcal urethritis
G) Penile cancer
H) Scrotal abscess
E)Syphillis
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  #38  
Old 02-16-2017
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Quote:
Originally Posted by doc49855 View Post
1. 57 year old woman admitted to hospital for an elective gastrectomy. During insertion of subclavian venous catheter via a left infraclavicular approach, suddenly begins squirming under the drapes and has shortness of breath. Her pulse is 100/min, respirations 24/min and blood pressure 100/70. exam shows jugular venous distention. Breath sounds are decreased on the left. What ist he most likely diagnosis?
Air embolism
Cardiac tamponade
Claustrophobia
Massive hemothorax
Tension pneumothorax


2. 18. A 25-year-old woman remians in the intensive care unit 5 days after undergoing pancreaticodudodenectomy for injuries sustained from a gunshot wound to the abdomen. A jejunostomy tube was placed distal to the anastomosis at the time of surgery. Current medications include morphine and cimetidine. She is 152 cm (5 ft) tall and weighs 100 kg (220 lb); bmi IS 43 kg/m. Examination shows a well-healing incision. Which of the following is the most appropriate next step in providing nutrition to this patient?
A) Enteral tube feedings
B) Intrvenous administration of 10% dextrose in water
C) Parental administration of lipid emulsion
D) Total parenteral nutrition
E) No nutrients should be given at this time

A) Enteral tube feedings - always the best and this patient has a J tube to use

3. 21. A 32-year-old man comes to the physician for evaluation of infertility. Two months ago, he was found to have a low sperm count during an infertility workup. There is no family history of infertility. Examination shows no abnormalities except for dilated veins in the left scrotum. Which of the following is the most likely mechanism for this patient's infertility?
A) Decreased serum testosterone concentration
B) Idiopathic
C) Increased scrotal temperature
D) Increased serum corticosteroid concentration
E)Isolated luteinizing hormone deficiency

C) Increased scrotal temperature - varicocele causes an increase in temperature because the blood can not go back into the venous system, sperm don't like the heat leading to infertility

4. 24. A 63-year-old man has had dysphagia and chest pain during meals for 4 months. He has a 6-year history of gastroesophageal reflux. He has limited his intake to liquids for 3 weeks because he regurgitates solid foo.d Which of the following is the most likely cause of his symptoms?
A) Disordered neuromuscular transmission in the esophagus
B) Disordered neuromuscular transmission in the oropharynx
C) Failure of oropharyngeal propulsion
D) Paraesophageal hiatal hernia
E) Stricture of the distal esophagus
E) Stricture of the distal esophagus - long term GERD can lead to damage of the esophagus


6. 36. A 67-year-old man comes to the physican because of a ulcer on the glans penis that has been increasing in size over the past 6 months. He is sexually active with multiple partners and rarely uses a condom. Examination shows an uncircumcised penis with bilateral, firm inguinal adenopathy and a painless ulcer on the glans. A serologic VDRL test is nonreactive. Which of the following is the most likely diagnosis?
A) Chancroid
B) Epididymitis
C) Gonococcal urethritis
D) Herpes
E) Inguinal hernia
F) Nongonococcal urethritis
G) Penile cancer
H) Scrotal abscess
E)Syphillis

G) Penile cancer - VDRL negative, painless ulcer and inguinal adenopathy
1. Tension pneumothorax - JVD, SOB decreased breath sounds PTX
2. A) Enteral tube feedings - always the best and this patient has a J tube to use
3. C) Increased scrotal temperature - varicocele causes an increase in temperature because the blood can not go back into the venous system, sperm don't like the heat leading to infertility
4. E) Stricture of the distal esophagus - long term GERD can lead to damage of the esophagus
6. G) Penile cancer - VDRL negative, painless ulcer and inguinal adenopathy
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