Most appropriate next step ?

[heartbeat]

Case 1 :

A 75-year-old white man complains to a physician of abdominal pain. His temperature is 37 C (9S.6 F), blood pressure is 110/65 mm Hg, pulse is 63/min, and respirations are 16/min. The abdomen is soft, with focal tenderness in the left lower quadrant. His erythrocyte count is 4.5 millionlmm3, leukocyte count is 9000/mm3 with 60% neutrophils and 5% bands, and platelet count is 250,000/mm3. Serum chemistries show:
Sodium 140 mEq/L
Potassium 5mEq/L
Chloride 102 mEq/L
Creatinine 1.1 mgldL
Urea nitrogen 12 mgldL
Which of the following is the most appropriate next
step in diagnosis?
(A) Barium enema
(B) Colonoscopy
(C) CT of abdomen
(D) Plain film of abdomen
(E) Trial therapy of a liquid diet

Case 2 :

One day after sustaining a laceration of the right hand at work, a 28-year-old man comes to the emergency department because of fever, chills, and painful swelling of the right arm. His temperature is 39.4 C (103 F),blood pressure is 110/65 mm Hg, pulse is 110/min, and respiration are 20/min. His right arm is swollen and extremely tender from the elbow up to the shoulder.
The skin shows a diffuse dusky erythema. Sensation to touch and pain is reduced in the forearm and hand. A blood sample is immediately taken for cultures. Which of the following is the most appropriate next step in management?
(A) Supportive measures until culture results areavailable
(B) Treatment with clindamycin
(C) Treatment with penicillin V
(D) Parenteral treatment with penicillin G
(E) Parenteral treatment with vancomycin
(F) Surgical exploration and debridement

Case 3 :

A 55-year-old woman with a history of rheumatoid arthritis since age 28 presents with new symptoms of recent onset. She complains of persistent fatigue and weight loss, diarrhea, and leg swelling. Furthermore,
she has had pain in her wrists with a tingling sensation at the tips of thumb and first two digits, which bothers her especially at night. Examination reveals waxy skin plaques about the axillary folds, macroglossia,
hepatosplenomegaly, pitting edema of the legs, and peripheral neuropathy. The stool guaiac test is positive. Serum chemistry studies show only mild hypoalbuminemia. Proteinuria in the nephrotic range is found on urinalysis, without hematuria. Which of the following is the most appropriate next step in diagnosis?
(A) Electrophoresis of serum proteins
(B) X-rays of vertebral column and skull
(C) Biopsy of skin, rectal mucosa, or abdominal fat
(D) Renal biopsy
(E) Endomyocardial biopsy

Case 4 :

A 58-year-old woman comes to the physician because of persistent joint aches affecting hands and hips in an asymmetric distribution. The pain is slow in onset and is aggravated by activity. She reports a brief (less than 30
minutes) phase of morning stiffness relieved by heat and movement. She denies fever or weight loss. On the contrary, she has gained approximately 5% of her baseline weight in the past 6 months. Her temperature is 37 C
(98.6 F), blood pressure is 130/80 mm Hg, pulse is 74/min, and respirations are 12/min. Examination reveals nodular thickening of the distal interphalangeal joints without redness. Mild limitation in joint motion is
appreciated bilaterally in hand joints and in the right hip joint. The patient's walking is characterized by a slightly shortened length of stride on the right side. Cardiac and respiratory examination reveals no abnormalities. At this
time, which of the following is the most appropriate next step in diagnosis?
(A) No further evaluation necessary
(B) Complete blood count and erythrocyte sedimentation rate
(C) Blood test for rheumatoid factor
(D) Blood test for antinuclear antibodies
(E) X-ray studies
(F) Bone densitometry
(G) Diagnostic arthrocentesis

[sonu.agarwall]

Ct scan
Surgical debridement
Skin fat pad biopsy
X ray studies

[sneha89]

Please let us know if these are from any NBME tests. Those of us who haven't taken the NBME yet would prefer not to see the questions.

Besides it is against the forum rules to post NBME questions.

Thanks.

[mayursn39]

What is the diagnosis in the first question ?

[K06100]

C
e
d
e

[zohaib]

A- Diverticulosis so i guess Colonscopy
B- answer B,just a guess
C- Amyloidosis A
D- osteoarthritis E

[sonu.agarwall]

I think amyloidosis we go for skin or fat pad biopsy..given in uw

[patelMD]

Originally Posted by zohaib

A- Diverticulosis so i guess Colonscopy
B- answer B,just a guess
C- Amyloidosis A
D- osteoarthritis E

Never do colonoscopy for diverticulosis due to risk of perforation. CT is better!

My answers:
C - Diverticulosis
E - Necrotizing Fascitis (w/ s+s of compartment symp, I didn't chose debridement beecause its not the same as fasciotomy)
C - IBD?
B - (Polymyositis?)

[mayursn39]

Originally Posted by patelMD

Never do colonoscopy for diverticulosis due to risk of perforation. CT is better!

This is for diverticulitis and not for diverticulosis
For diverticulosis colonoscopy is the best.

[heartbeat]

Originally Posted by mayursn39

What is the diagnosis in the first question ?

Case 1 :

The correct answer is E. The probable diagnosis is diverticulitis (pain + tenderness+ leukocytosis ) ,while Diverticulosis is asymptomatic most of the time or associated with mild abdominal pain (relieved after passing stool or gas) , Constipation and Abdominal bloating .
The relatively mild symptoms, normal vital signs, and normal laboratory values in this patient indicate that he is not very ill. This means that he can be treated at home with rest, a liquid diet, and oral antibiotics. In this setting, the response to the therapeutic trial itself serves as a confirmatory test , and as the patient start feeling better,it recommend that you slowly add low-fiber foods.
Seriously ill patients with diverticulitis are usually treated in the hospital and may require IV antibiotics .

Barium enema studies with air contrast and Colonoscopy (choice A & B) are dangerous in acute diverticulitis because increase risk of perforation , so can be performed if necessary at 2 weeks to confirm presence of diverticula .

CT of the abdomen (choice C) is used in severe cases and when the differential diagnosis includes pelvic abscess and appendicitis.

Plain film of the abdomen (choice D) is of limited utility in this setting but may show increased gas in the bowel if the diverticulitis has lowered intestinal motility.

[heartbeat]

Originally Posted by sonu.agarwall

X ray studies

You know i choice X-ray studies same as you did but the correct answer is A. In the presence of this classic symptomatology, the clinical judgment alone is sufficiently accurate. Thus, no further laboratory or radiologic investigations are needed to support a diagnosis of primary osteoarthritis in a patient with characteristic signs and symptoms. If there are atypical manifestations, further investigations may be indicated to rule out other conditions.

X-ray studies (choice E) are not necessary in the diagnostic assessment of typical osteoarthritis .

[heartbeat]

Originally Posted by patelMD

E - Necrotizing Fascitis (w/ s+s of compartment symp, I didn't chose debridement beecause its not the same as fasciotomy)
)

You are right the diagnosis in case 2 is Necrotizing Fasciitis ( sever infection begins locally at a site of trauma + painful swelling + extremely tenderness + diffuse dusky erythema + decrease Sensation + systemic signs and symptoms of toxemia ) but the correct answer is F because as soon as necrotizing fasciitis is suspected, surgical exploration and debridement is mandatory because it best initial step and also confirm the diagnosis .

[heartbeat]

Originally Posted by zohaib

C- Amyloidosis A

Electrophoresis of serum proteins (choice A) is useful in demonstrating monoclonal gammopathy, which is usually associated with Multiple myeloma (which is also cause of amyloidosis ), but this woman is known case of long-standing rheumatoid arthritis which is currently one of the most common causes of systemic amyloidosis. This may give rise to a complex clinical picture resulting from amyloid deposition in the skin, kidneys, tongue, gastrointestinal tract, or peripheral nerves, for example. Carpal tunnel syndrome, skin plaques in the axillary region, nephrotic syndrome, hepatosplenomegaly, and macroglossia, are among the most common manifestations. Chronic diarrhea with malabsorption and occult bleeding are frequent as well. Biopsies of the skin, rectal mucosa, abdominal fat pad, or gingiva are the most helpful to confirm the clinical diagnosis. So the correct answer is C .

Renal biopsy (choice D) and endomyocardial biopsy (choice E) may also be used to demonstrate amyloid deposition in the myocardium or kidney, but these should be used only when other, less invasive procedures have been ineffective.