Discuss NBME Form 2 Block 4 - grazie

[ArchivalUser]

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

[ArchivalUser]

q22
Ans: A
A) Acute subdural hematoma
(nbme cert)

Subdural Hematoma

SDHs are classified by the time to clinical presentation:

Acute SDHs are symptomatic within 24 hours after trauma. Patients with acute SDHs often have a decreased level of consciousness. Most patients with an SDH have a GCS (Glasgow) score less than 8. Approximately 12 to 38% of patients will have a lucid period at some point in their presentation. The overall mortality of patients who have an SDH and require surgical intervention is 40 to 60%.

A subacute SDH is symptomatic between 24 hours and 2 weeks after injury. It may appear hypodense or isodense on CT scans. Contrast increases detection of isodense lesions. Patients complain of a headache, altered mental status, or focal deficits. Most patients with subacute SDH require surgical evacuation of the lesion.

A chronic SDH becomes symptomatic 2 weeks or more after trauma. The signs and symptoms may be very subtle or nonspecific, but many patients demonstrate unilateral weakness or hemiparesis. Most report an altered level of consciousness, but some patients are unable to recall their head injury or describe only a minor injury.

Marx: Rosen's Emergency Medicine - Concepts and Clinical Practice, 8th ed.
Copyright © 2013 Saunders, An Imprint of Elsevier

[ArchivalUser]

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

[ArchivalUser]

Q23

Ans: B
B) Endotracheal tube
(nbme cert)

In this case we have CO poisoning, so 100% O2 will be mandatory; the pt is also coughing up soot, thus there is Respiratory burn.
We need to determine blood levels of Carboxyhemoglobin and give O2. We dx Respiratory Burn with a Bronchoscopy and if + we proceed to INTUBATE the patient and even use of Ventilator if is needed.

[ArchivalUser]

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

[ArchivalUser]

Q24

Ans: E
E) Pernicious anemia
(nbme cert)

This is Megaloblastic anemia (MCV 106) with neurologic problems, so Vitamin B12 deficiency is the problem, from the choices only E matched.

[ArchivalUser]

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

[ArchivalUser]

q25

Ans: A
A) Heparin
(nbme cert)

DVT
Treatment :
-------------
Heparin and oxygen: This is the standard of care in pulmonary embolism.
Warfarin: Should be used for at least 6 months after the use of heparin.
Venous interruption filter: This should be placed in all patients who have a contraindication to anticoagulation. Thrombolytics: These are used in patients who are hemodynamically unstable. Hemodynamic instability can be defined as hypotension.
Thrombolytics essentially replace embolectomy, which is rarely performed because of the high operative mortality.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 3036-3041).

[ArchivalUser]

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

[ArchivalUser]

I need help with this!