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Discuss NBME Form 2 Block 4 - grazie
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08-27-2014, 09:19 PM
Q15)
Ans) E E) Septic arthritis nbme cert Fever, leukocytosis. Diabetic pt with Osteoarthritis and a recent fall that skinned both knees.
08-27-2014, 09:26 PM
16.
A 28-year-old woman is brought to the emergency department by ambulance because she has had three seizures during the past hour. Her husband told paramedics that the seizures began with jerking of the right arm and leg, followed by jerking of all four extremities. One week ago, she sustained a closed head injury when she slipped on an icy sidewalk. The injury was treated in the emergency department with ice packs and observation. She has a history of hypertension and type 2 diabetes mellitus. She has smoked two packs of cigarettes daily for the past 13 years. On arrival, the patient is comatose. Pulse oximetry on room air shows an oxygen saturation of 97%. Vital signs are temperature 37.0°C (98.6°F), pulse 68/min, respirations 20/min, and blood pressure 180/95 mm Hg. Physical examination shows needle tracks on both upper extremities. Both eyes deviate to the right. Cardiac examination shows a grade 3/6 holosystolic murmur at the cardiac apex. During deep pain stimulation the patient is able to move the left extremities better than the right extremities. Deep tendon reflexes in the right extremities are brisk. Babinski sign is present on the right. Serum glucose concentration is 210 mg/dL. CT scan of the head shows a large ring-enhancing lesion in the posterior portion of the left frontal lobe. Which of the following is the most significant risk factor for development of this patient's condition? A) Cigarette smoking B) Closed head injury C) Diabetes mellitus D) Heroin abuse E) Hypertension Ans) D NBME cert. Heroin-associated strokes are most often attributed to infectious complications such as endocarditis or ruptured mycotic aneurysm.
08-27-2014, 09:35 PM
17.
A 75-year-old woman of German descent is brought to the emergency department by her husband because of increasing confusion, constant headache, and nausea for the past 2 days. Five days ago she was evaluated in the emergency department following a head injury. A CT scan of the head showed a subdural hematoma. The patient was given oxycodone with acetaminophen and sent home to await liquefaction of the clot prior to surgical evacuation. On arrival at the emergency department today, the patient is oriented to person but not to place or date, and she repeatedly says, "I want to go home now." Her husband reports she has been drinking about 24 oz of liquid per day. Skin turgor appears normal. Vital signs are temperature 37.2°C (99.0°F), pulse 92/min, respirations 18/min, and blood pressure 95/60 mm Hg. On physical examination, there is no papilledema. Neurologic examination discloses no other abnormalities. Which of the following factors in this patient's history most strongly indicates the severity of her condition? A) Abnormal CT scan of the head B) Continuing headache C) Duration of nausea D) Increasing confusion E) Low blood pressure Ans: D D) Increasing confusion nbme cert Symptoms of subdural hematoma depend mostly on the rate of bleeding: ------------------------------------------------------------------------------------ * In head injuries with sudden, severe bleeding causing a subdural hematoma, a person may lose consciousness and enter coma immediately. * A person may appear normal for days after a head injury, but slowly become CONFUSED and then Unconscious several days later. This results from a slower rate of bleeding, causing a slowly enlarging Subdural hematoma. * In very slow-growing subdural hematomas, there may be no noticeable symptoms for more than two weeks after the bleeding starts.
08-27-2014, 10:04 PM
18.
A 26-year-old man is brought to the emergency department by ambulance 20 minutes after he was stabbed in the right chest by a man on the street during a domestic dispute. On arrival, he is angry and appears distraught. He reports mild shortness of breath and says he has no other symptoms or injuries. There is an odor of alcohol on his breath. Paramedics initiated oxygen therapy and intravenous 0.9% saline at the scene. The patient's medical history is unremarkable. He takes no medications and says he does not use illicit drugs. Vital signs are temperature 37.0°C (98.6°F), pulse 92/min, respirations 24/min, and blood pressure 122/80 mm Hg. Pulse oximetry on 4 L of oxygen via nasal cannula shows an oxygen saturation of 99%. Auscultation of the lungs discloses normal breath sounds bilaterally. There is no palpable crepitus or tenderness. Petroleum gauze dressing is in place covering a 2-cm laceration in the right 4th intercostal space at the mid-clavicular line. The remainder of the physical examination shows no abnormalities. Chest x-ray is shown. http://i42.photobucket.com/albums/e338/G...dbe950.png Which of the following is the most appropriate next step? A) Administer intravenous ciprofloxacin B) Contact social services C) Insert chest tube (wrong by nbme) D) Obtain CT scan of the chest (wrong by nbme) E) Suture the wound Ans: E? This pt is practically fine, he just had a fight but seems like he kicked some butt  I marked D but it was wrong. So, maybe E? Any comments?
08-27-2014, 10:16 PM
19.
A 29-year-old man is brought to the emergency department by ambulance 45 minutes after a motor vehicle collision in which he was the restrained driver. Paramedics applied a cervical collar, placed him on a backboard, and began therapy with intravenous fluids en route to the emergency department. On arrival the patient is alert and oriented and reports neck pain. Vital signs are temperature 36.7°C (98.0°F), pulse 90/min, respirations 22/min, and blood pressure 110/70 mm Hg. Pulse oximetry on 100% oxygen via non-rebreather mask shows an oxygen saturation of 100%. Physical examination discloses tenderness of the neck and anterior chest wall with ecchymoses over the chest. There is no abdominal tenderness. Portable chest x-ray shows a widened mediastinal contour of the chest. In addition to x-rays of the cervical spine, which of the following is the most appropriate next step in evaluating this patient? A) Abdominal ultrasonography B) CT angiography of the chest C) CT scan of the abdomen D) Thoracic aortography E) Transthoracic echocardiography Ans: B) CT angiography of the chest To study for Aortic compromise
08-27-2014, 10:19 PM
20.
A 30-year-old woman comes to the emergency department because of shortness of breath and numbness and tingling of her fingers. If arterial blood gas values were ordered, results would most likely show which of the following? Po2 Pco2 pH HCO3− (mm Hg) (mm Hg) (mEq/L) A) 70 60 7.25 27 B) 40 60 7.37 33 C) 90 40 7.40 24 D) 110 25 7.50 19 E) 40 60 7.51 27
08-27-2014, 10:22 PM
q20)
Ans: D? Respiratory alkalosis with metabolic compensation
08-27-2014, 11:04 PM
21.
A 75-year-old white man is brought to the emergency department by ambulance after having a seizure while playing golf. Oxygen by mask has been administered by the emergency medical technicians. On arrival he is mildly lethargic and has a diffuse headache. He has no history of previous neurologic problems and takes no medications. Vital signs are temperature 37.0°C (98.6°F), pulse 86/min and regular, respirations 15/min, and blood pressure 160/90 mm Hg. The physical examination is normal except for papilledema bilaterally. Which of the following is the most appropriate initial diagnostic study? A) Contrast enhanced CT scan of the head B) Doppler ultrasonography of the carotid arteries C) Echocardiography D) Electroencephalography E) X-rays of the skull 22. During a Little League game, a 10-year-old boy was hit on the head by a baseball. Despite being momentarily stunned, he remained conscious and continued playing. Three days later he started complaining of headache in the left temple, which progressively worsened during the next few days. His parents noticed that he was having difficulty using his right hand and started staggering while walking. He is brought to the emergency department where on admission he has a focal seizure involving the right arm. Which of the following is the most likely diagnosis? A) Acute subdural hematoma B) Cerebral concussion C) Intraventricular hemorrhage D) New-onset epilepsy E) Ruptured berry aneurysm 23. A 34-year-old man is brought to the emergency department 15 minutes after he sustained burns in a house fire. On arrival he is coughing up soot. Vital signs are temperature 38.0°C (100.4°F), pulse 130/min, respirations 16/min, and blood pressure 130/80 mm Hg. Physical examination shows third-degree burns over 30% of the body surface area of his torso and legs. His mustache and eyebrows are singed. His voice is hoarse. X-ray of the chest is normal. A helicopter will be available to transfer the patient to the regional burn center in 30 minutes with an estimated flight time of 45 minutes. The most appropriate respiratory intervention at this time would be initiation of 100% oxygen by which of the following? A) Air entrainment (Venturi) face mask B) Endotracheal tube C) Face mask with humidification D) Laryngeal mask airway E) Nasal cannula 24. A 78-year-old man is brought to the emergency department by his son because of a 2-month history of increasing forgetfulness, fatigue, and difficulty walking. The patient reports mild forgetfulness of names of friends and family members whom he has not seen in several years. He also notes memory loss of recent events. He says he is finding it difficult to drive because he often cannot remember how to get where he is going. The patient had been healthy prior to his recent symptoms and is independent in activities of daily living. Medical history is unremarkable and his only medication is a daily 81-mg aspirin. He does not smoke cigarettes, but he drinks two glasses of wine daily with dinner. Physical examination shows an atrophic, shiny tongue but is otherwise noncontributory. Neurologic examination shows decreased sensation to vibration of the lower extremities. Mental status examination discloses decreased short- and long-term memory. Mini-Mental State Examination score is 21/30. The patient has a broad, shuffling gait. Results of laboratory studies are shown: Serum Blood ALT 36 U/L Hematocrit 37% AST 40 U/L Hemoglobin 12.0 g/dL Bilirubin, total 1.6 mg/dL WBC 3900/mm3 Lactate dehydrogenase 600 U/L MCV 106 μm3 Platelet count 140,000/mm3 Peripheral blood smear is shown. http://i42.photobucket.com/albums/e338/G...fb6a06.png Which of the following is the most likely diagnosis? A) Alcoholic cirrhosis B) Chronic myelogenous leukemia C) Dementia, Alzheimer type D) Hypothyroidism E) Pernicious anemia 25. A 35-year-old man comes to the emergency department because of a 2-hour history of shortness of breath and left-sided chest pain that is aggravated by deep inspiration. He has no history of trauma, surgery, or illness requiring prolonged bed rest. On physical examination he is now pain-free but he has slight dyspnea. He also has mild tachycardia and slight tenderness to pressure over the left chest wall. Arterial blood gas analysis while breathing room air is shown: Po2 65 mm Hg Pco2 25 mm Hg pH 7.40 Chest x-ray discloses a blunted left costophrenic angle. ECG is normal. Ventilation-perfusion lung scan is reported as "intermediate probability for thromboembolic disease, disclosing a mismatch with one segment showing no perfusion." Doppler ultrasonography of the lower extremities shows deep venous thrombosis. At this time it is most appropriate to initiate therapy with which of the following? A) Heparin B) Indomethacin C) Streptokinase D) Theophylline E) Warfarin 26. A 68-year-old man is brought to the emergency department by ambulance 20 minutes after he collapsed while shoveling snow on his driveway. The patient's daughter witnessed the collapse and immediately began mouth-to-mouth resuscitation and cardiac compressions, but her father did not regain consciousness. Paramedics arrived 5 minutes later, but the patient was pulseless and apneic. He was intubated and cardiac compressions were continued. Paramedics were unable to start an intravenous line, but did administer atropine and epinephrine via endotracheal tube. Medical history provided by the daughter is remarkable for type 1 diabetes mellitus, hypertension, and a myocardial infarction 5 years ago. Daily medications include furosemide, insulin, metoprolol, and an 81-mg aspirin. During transport the cardiac monitor showed asystole. Fingerstick glucose concentration was 90 mg/dL. Intravenous access was established and 0.9% saline was initiated. On arrival the patient is intubated with ongoing cardiac compressions. Cardiac monitor is unchanged. Which of the following factors most strongly indicates a poor prognosis? A) Bystander cardiopulmonary resuscitation B) Cardiac monitor showing asystole C) History of type 1 diabetes mellitus D) Lack of prehospital intravenous medication administration E) Time elapsed before arrival of paramedics 26. A 68-year-old man is brought to the emergency department by ambulance 20 minutes after he collapsed while shoveling snow on his driveway. The patient's daughter witnessed the collapse and immediately began mouth-to-mouth resuscitation and cardiac compressions, but her father did not regain consciousness. Paramedics arrived 5 minutes later, but the patient was pulseless and apneic. He was intubated and cardiac compressions were continued. Paramedics were unable to start an intravenous line, but did administer atropine and epinephrine via endotracheal tube. Medical history provided by the daughter is remarkable for type 1 diabetes mellitus, hypertension, and a myocardial infarction 5 years ago. Daily medications include furosemide, insulin, metoprolol, and an 81-mg aspirin. During transport the cardiac monitor showed asystole. Fingerstick glucose concentration was 90 mg/dL. Intravenous access was established and 0.9% saline was initiated. On arrival the patient is intubated with ongoing cardiac compressions. Cardiac monitor is unchanged. Which of the following factors most strongly indicates a poor prognosis? A) Bystander cardiopulmonary resuscitation B) Cardiac monitor showing asystole C) History of type 1 diabetes mellitus D) Lack of prehospital intravenous medication administration E) Time elapsed before arrival of paramedics 27. A 55-year-old woman with diabetes mellitus is brought to the emergency department after she was found unconscious at home. Results of initial laboratory studies obtained on admission are shown: Serum Na+ 120 mEq/L K+ 5.5 mEq/L Cl− 85 mEq/L HCO3− 10 mEq/L Glucose 800 mg/dL After she has received an appropriate initial dose of insulin, which of the following parenteral fluids should be administered? A) 0.9% Saline B) 5% Albumin in 0.9% saline C) 5% Glucose in 0.9% saline D) 5% Glucose in water E) Hypertonic saline 28. A 70-year-old woman is brought to the emergency department by her family because of difficulty breathing at rest during the past 2 days. Her symptoms have progressively worsened since beginning 3 weeks ago when she had trouble catching her breath after walking two blocks. She says she feels like she is "being smothered" and has had to sleep upright in a chair in order to breathe during the night. She also reports a mildly productive cough and swelling of both legs. Medical history is remarkable for hypertension treated with hydrochlorothiazide. She has smoked one pack of cigarettes daily for the past 50 years but does not drink alcoholic beverages. Vital signs are temperature 37.0°C (98.6°F), pulse 110/min, respirations 25/min, and blood pressure 95/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Physical examination shows jugular venous distention, 7 cm at 45 degrees. Peripheral pulses are symmetrically diminished and there are soft carotid and femoral artery bruits. Palpation of the right breast discloses a large, hard mass on the outer upper quadrant with associated skin dimpling. There are firm lymph nodes in the right axilla. There is 2+ pitting edema bilaterally to the knees. Results of laboratory studies are shown: Serum Blood Urea nitrogen 23 mg/dL Hemoglobin 8.5 g/dL Creatinine 1.5 mg/dL WBC 11,200/mm3 Arterial blood gas analysis Po2 70 mm Hg Pco2 32 mm Hg pH 7.48 ECG shows low voltage in all leads and alternating amplitude of the P waves and QRS complexes. Chest x-ray shows two 3 x 3-cm densities in the right lung field. Which of the following is the most appropriate next step? A) Bronchoscopy B) Echocardiography C) Venous Doppler ultrasonography of the lower extremities D) Ventilation-perfusion lung scans E) Mammography 29. A 32-year-old man with schizophrenia is brought to the emergency department by his group home caregiver because of a 10-day history of dizziness, falls, and light-headedness. He also has had constipation, headache, blurred vision, and urinary hesitancy. He has not had hallucinations or delusions with this episode. He was discharged from the inpatient psychiatric unit 4 weeks ago after a 2-week admission for paranoia and hallucinations. Clozapine therapy was initiated during his hospital stay. A discharge summary is obtained and shows that his only side effects were constipation and sialorrhea. Serum clozapine concentration obtained immediately prior to discharge was within the reference range. In addition to clozapine, he also takes docusate. His medications are administered by the caregivers at the group home where he resides. Vital signs now are temperature 37.2°C (99.0°F); pulse 110/min supine and 125/min, standing; respirations 20/min; and blood pressure 140/85 mm Hg supine and 110/60 mm Hg standing. He is subjectively light-headed while standing. Physical examination discloses no abnormalities. Specific additional history should be obtained regarding increased consumption of which of the following? A) Alcohol B) Caffeine C) Cruciferous vegetables D) Grapefruit juice E) Tobacco F) Tomato juice 30. A 3-year-old girl is brought to the emergency department by her parents because she was stung on the right cheek by a bee 2 hours ago and has developed an itchy, blotchy rash on her trunk. The rash appeared 1 hour after the bee sting. The child has not had fever, nausea, difficulty breathing, or sore throat. Vital signs are temperature 37.2°C (98.9°F), pulse 122/min, respirations 18/min, and blood pressure 82/52 mm Hg. Examination of the right cheek discloses a small, raised papule in the area of the bee sting. Examination of the trunk shows a blotchy, raised, erythematous, urticarial-appearing eruption that is mildly excoriated. The eruption extends over her back. The remainder of the physical examination discloses no abnormalities. Which of the following factors would most significantly influence therapy for this patient? A) Development of dysphagia B) Erythema of the cheek C) Extension of urticaria D) Progression of eruption to the lower extremities E) Swelling of the hands and feet
08-28-2014, 06:46 AM
For q20
Can anybody help? I don't have the right answer from nbme 20 A 30-year-old woman comes to the emergency department because of shortness of breath and numbness and tingling of her fingers. If arterial blood gas values were ordered, results would most likely show which of the following? Po2 Pco2 pH HCO3− (mm Hg) (mm Hg) (mEq/L) A) 70 60 7.25 27 B) 40 60 7.37 33 C) 90 40 7.40 24 D) 110 25 7.50 19 E) 40 60 7.51 27 This is a case of Anxiety attack right? If the pt is anxious or panic, they often hyperventilate, there is also numbness and tingling in the tips of fingers on both hands and even a similar sensation around the mouth. Most of the time these symptoms are from anxiety causing hyperventilation. Ok, now... PO2 ----- PCO2 ------ pH ------ HCO3− PO2 PCO2 ph HCO3 Somebody?
08-28-2014, 07:03 AM
i think panic attack
hyperventilation= resp alkalosis and metabolic acidosis |
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