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* nbme-em
  kennychan - 12/04/17 17:30
  A previously healthy 4-month-old girl is brought to the Emergency department because of a 2-day history of fever, vomiting, and loose stools. Her parents have been giving her water to keep her hydrated. She appears lethargic. Her temperature is 38.2 C (100.8 F), pulse is 188/min, respirations are 28/min, and blood pressure is 60/32 mm Hg. Examination shows a sunken anterior fontanel and dry mucous membranes. The lungs are clear to auscultation. No murmurs are heard. Abdominal examination shows distention and tenderness; bowel sounds are hyperactive throughout. Serum studies show:
Na+ 122 mEg/L
K+ 3 mEq/L
CL- 100 mEq/L
HCO3- 8 mEg/L
Urea nitrogen 26 mg/dL
Glucose 66 mg/dL
Creatinine 0.5 mg/dl

Which of the following is the most likely explanation for this patientís hypotnesion?
a) Decreased cardia preload
b) Decreased venous tone
c) Increased pulmonary vascular resistance
d) Increased stroke volume
e) Increased sympathetic tone
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* Re:nbme-em
  kennychan - 12/04/17 18:05
  A 13-year-old girl is brought to the emergency department 30 minutes after she fell of a sailboat into a freshwater later. A witness reported that she was under water for approximately about 2 minutes; when she was rescued, she was cyanotic and unresponsive. After initial mouth-to-mouth resuscitation, she began coughing and breathing again, an her color returned. On arrival in the emergency department, the patient is awake and alert. She has mild shortness of breath and a cough. Her temperature is 37 C, pulse is 108/min, respirations are 20/min, and blood pressure is 93/45 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Auscultation of the lungs discloses mild wheezes . There are no signs of external trauma. A CXR shows mild diffuse interstitial marking. Which of the following is the most appropriate next step in management?
a) Admission to the hospital for observation
b) Antibiotic therapy
c) Corticosteroid therapy
d) Diuretic therapy
e) Noninvasive positive-pressure ventilation

Please help!
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* Re:nbme-em
  kennychan - 12/04/17 21:27
  For second question, the patient likely has pulmonary edema due to fresh water. Probably, diuretic therapy can be used to reduce the edema. Please give your opinions. I will appreciate it.  
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* Re:nbme-em
  amrith277 - 12/04/17 22:37
  Q 1 answer could be decreased cardiac preload, she is in Metaolic acidosis and hypovolemic shock.

Q 2 could be corticosteroids. If its pulm edema B / L rhonchi would be mentioned
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* Re:nbme-em
  kennychan - 12/04/17 22:51
  For Q2, I did google that there is no role of corticosteroids or antibiotic for patient with near drowning.  
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* Re:nbme-em
  tchops - 12/05/17 11:03
  for Q2 it should be NPPV...wheezes ,CXR s/o ARDs  
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* Re:nbme-em
  kennychan - 12/16/17 13:07
  For Q2 NPPV is wrong answer, I think it is diuretic because of fresh water.  
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* Re:nbme-em
  cardio69 - 12/16/17 17:22
  You manage it with HYPER therapy.  
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* Re:nbme-em
  tchops - 12/17/17 09:10
  Kennychan pull out Kaplan lecture notes medicine..ch10 emergency medicine will get your ans  
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* Re:nbme-em
  morticia - 12/17/17 16:22
  Answer for q 2 is E  
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* Re:nbme-em
  kennychan - 12/19/17 19:26
  Q2 is from NBME-Emergency Medicine Form 1. I submitted the question with answer E. But it shows wrong answer on the feedback. You know it only shows wrong answers on your feedback on NBME.  
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