09-10-2014, 04:55 PM
Yes perception 
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Discuss NBME Form 3 Block 4 - grazie
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09-10-2014, 04:56 PM
I think its D as well!! no sure cause i had it wrong!! But EKg sounds the best
09-10-2014, 04:58 PM
25.
A mother and her six children are referred to the emergency department by the county health agency because they have been exposed to elemental mercury. The mother, a single parent, discovered a jar of mercury in her 12-year-old son's bedroom. Her son said he found the material about 1 month ago in an abandoned laboratory building in their neighborhood. He shares his room with his 9-year-old and 7-year-old brothers, who also have been playing with the mercury. Twin girls, age 6 years, and one other sister, age 4 years, sleep in another room and apparently have not been in contact with the substance. The mother is anxious and upset about the situation, but she reports no new physical symptoms or signs in her children. The children appear to be in good health. They are frightened and cling to their mother. Physical examinations of all seven patients are normal. The family is placed in temporary housing. In counseling the mother you would inform her that the most frequent early symptoms and signs of subacute or chronic mercury toxicity involve which of the following? A) Bone marrow B) Central nervous system C) Endocrine system D) Liver E) Respiratory system Ans: B B) Central nervous system nbme cert! Acute mercury intoxication among children can occur through unintentional exposure, and neurotoxicity is one of the main findings in acute exposures. ========================================== The chronic inhalation of mercury results in neuropsychiatric manifestations: Gingivostomatitis, and Tremor. The second syndrome is Erythism, a neuropsychiatric constellation of findings that includes fatigue, insomnia, memory impairment, nervousness, irritability, shyness, social withdrawal, loss of confidence, timidity, and depression. Chronic occupational exposure to inorganic mercury may cause subclinical psychomotor and neuromuscular abnormalities as well as long-term behavioral impairment. Neuropsychiatric abnormalities (inattention, memory, construction, and motor performance) appear to be dose related. Treatment A patient with mercury poisoning should immediately be removed from the contaminated environment. The treatment is primarily symptomatic and supportive. Chelation therapy is used to increase the excretion of mercury. SUCCIMER is the chelator of choice because it can be given orally and has been effective in reducing brain levels of methyl mercury. D-Penicillamine is less effective than succimer and has a higher adverse drug reaction rate. Dimercaprol is not recommended because of its potential to shift mercury from peripheral tissues into the brain. N-acetylcysteine has been proposed as a chelator of methyl mercury, and repeated oral administration may interrupt the enterohepatic recirculation of methyl mercury; however, use of the drug for this purpose has not undergone clinical trials and is not approved by the FDA.
09-10-2014, 04:58 PM
26.
A 67-year-old man is brought to the emergency department by ambulance because of two episodes of chest pressure and mild shortness of breath that occurred at rest. The first episode occurred 1½ hours ago and subsided spontaneously 20 minutes later; the second episode began 30 minutes ago and has persisted. He has not had nausea or diaphoresis. Paramedics placed an intravenous line and initiated 2 L/min oxygen via nasal cannula and aspirin therapy. On arrival in the emergency department the patient says his chest pain is slightly improved and now rates it as a 5 on a 10-point scale. Medical history is remarkable for type 2 diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Routine medications include glyburide, amlodipine, an ipratropium-albuterol inhaler, and 81-mg aspirin. The patient appears moderately obese. Vital signs are temperature 37.2°C (99.0°F), pulse 88/min, respirations 18/min, and blood pressure 165/95 mm Hg. Pulse oximetry on 2 L oxygen via nasal cannula shows an oxygen saturation of 98%. Physical examination discloses no jugular venous distention or bruits. Auscultation of the lungs discloses decreased breath sounds with mild, diffuse end-expiratory wheezes. Cardiac examination discloses a regular rate and rhythm with no audible murmurs, rubs, or gallops. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate immediate next step? A) Inhaled albuterol-ipratropium therapy B) Intravenous metoprolol therapy C) Intravenous nitroglycerin therapy D) 12-Lead ECG E) Portable chest x-ray
09-10-2014, 05:06 PM
q26)
Ans: D nbme cert. We need to rule out an MI first so a 12 lead EKG is appropriate at this time.
09-10-2014, 05:07 PM
27.
A 35-year-old man is brought to the emergency department by his wife 15 minutes after falling off of a ladder and striking his head on a concrete sidewalk. On arrival, he is awake but disoriented. His wife reports a 10-minute period of unconsciousness after the accident. She states her husband is otherwise healthy and takes only an 81-mg aspirin daily. Vital signs are temperature 36.8°C (98.2°F), pulse 74/min, respirations 18/min, and blood pressure 122/76 mm Hg. Pulse oximetry on 2 L oxygen via nasal cannula shows an oxygen saturation of 99%. Physical examination discloses a 4-cm laceration in the right occipital area. Bleeding is controlled but there is minimal venous oozing. No palpable fracture is identified. Examinations of the chest, abdomen, and extremities show no abnormalities. Pupils are equal and reactive. There is no cervical spine tenderness. The remainder of the neurologic examination discloses no abnormalities. An intravenous line administering 0.9% saline is inserted in the left antecubital fossa. CT scan of the head is shown. Which of the following is the most appropriate management? A) Dexamethasone therapy B) Lumbar puncture C) Mannitol therapy D) Surgical evacuation E) Observation 28. A 78-year-old Asian woman is brought to the emergency department by ambulance because of a 3-day history of confusion. The patient's husband reports that his wife can sleep only for a few minutes at a time, does not seem to know where she is, and forgets what she is told within a few minutes. He says that his wife thought she saw a dog in their home 1 day ago but they have no pets. The patient was discharged from the hospital 3 days ago following a 2-day hospitalization for treatment of pneumonia with amoxicillin. Prior to discharge, the patient was instructed to continue the amoxicillin for 7 days. She also was prescribed cimetidine therapy for heartburn, which developed 1 day prior to discharge. At discharge, the patient's mental status was normal. Now, on arrival at the emergency department, she is disoriented to place and time and paranoid about the nurse wanting to draw her blood for laboratory studies. Vital signs now are temperature 36.6°C (97.9°F), pulse 72/min, respirations 16/min, and blood pressure 135/85 mm Hg. Examination of the head shows no abnormalities. Lungs are clear to auscultation. Cardiac examination shows no abnormalities. There is no pain or tenderness on palpation of the abdomen. Neurologic examination is unremarkable. Cranial nerves are intact and there are no focal findings. Serum electrolyte concentrations and complete blood count are within the reference ranges. Which of the following is the most likely explanation for this patient's condition? A) Adverse reaction to amoxicillin B) Adverse reaction to cimetidine C) Brain tumor D) Recurrence of pneumonia E) Urinary tract infection 29. A 36-year-old truck driver is brought to the emergency department by ambulance after his truck was in a head-on collision with another truck. He was wearing a seat belt but there was no airbag. The steering wheel was broken. The paramedics immobilized the patient with a cervical collar and placed him on a long board at the scene. They state that the patient has remained hemodynamically stable. The patient says, "I have terrible chest pain." Vital signs on admission are pulse 110/min, respirations 20/min, and blood pressure 140/90 mm Hg. Physical examination shows an anxious, obese man with flat neck veins. The anterior chest has precordial ecchymosis and bilateral, equal breath sounds on auscultation. Abdomen is normal. ECG shows sinus tachycardia. Chest x-ray is shown. The patient most likely has which of the following? A) Aortic disruption B) Cardiac tamponade C) Esophageal rupture D) Tension pneumothorax E) Tracheobronchial rupture 30. A 6-year-old white girl is brought to the emergency department by her parents because of fever for the past 4 days and progressively increasing right knee pain. At first the patient had only a fever and some general malaise, but for the past 3 days there has been pain in the area of the right knee, which has gotten worse each day. The girl is now quite uncomfortable. She has had no significant medical problems, allergies, or hospitalizations. Vital signs are temperature 39.6°C (103.2°F), pulse 100/min, respirations 18/min, and blood pressure 102/54 mm Hg. Physical examination shows no abnormalities except for regular tachycardia and tenderness on the medial side of the right distal femur. Examination of the right knee joint demonstrates no fluid. The girl appears apprehensive and although she resists examination of her knee, a full range of motion is present. X-ray of the knee is normal. Urinalysis is normal. Results of complete blood count are shown: Blood Hemoglobin 11.2 g/dL WBC 22,200/mm3 Neutrophils, segmented 82% Neutrophils, band 4% Lymphocytes 14% Which of the following is the most likely causal organism? A) Haemophilus influenzae, type b B) Salmonella species C) Staphylococcus aureus D) Streptococcus pneumoniae E) Viridans streptococcus 31. A 17-year-old boy is brought to the emergency department by his parents because of pain radiating from his belly button to his right side for the past 12 hours. He privately tells you that he consumed a large amount of vodka and inhaled cocaine just prior to the onset of pain. He is not hungry. He is sexually active and was treated for chlamydia 6 months ago. Vital signs now are temperature 38.9°C (102.0°F), pulse 100/min and regular, respirations 18/min, and blood pressure 130/80 mm Hg. Examination of the abdomen shows tenderness at McBurney point, rebound, and Rovsing sign. Rectal examination shows tenderness in the right rectal wall. Prostate is normal. Laboratory studies show hemoglobin of 16 g/dL and leukocyte count of 24,000/mm3. Which of the following is the most appropriate next step? A) Air contrast lower gastrointestinal barium study B) CT scan of the abdomen and pelvis C) Emergent upper endoscopy D) Intravenous morphine and observation E) Surgical consultation 32. A 32-year-old woman comes to the emergency department because of a red right eye. She says a coworker noticed an abnormality with her right eye while they were having lunch today. The eye is not painful and there is no history of trauma. She does not wear contact lenses. She is otherwise healthy. Visual acuity and vital signs are noncontributory. A picture of the eye is shown. Which of the following is the most appropriate diagnostic study? A) Fluorescein staining B) Pupillary dilatation C) Schiotz tonometry D) Visual field assessment E) No diagnostic study is indicated 33. A 42-year-old woman is brought to the emergency department by her husband because of a 3-day history of fever, night sweats, and neck pain. Her husband says that today she seemed somewhat confused and lethargic. She was previously healthy. She takes no medications. She does not smoke cigarettes or drink alcoholic beverages. Vital signs are temperature 39.4°C (103.0°F), pulse 100/min, respirations 24/min, and blood pressure 108/64 mm Hg. The patient is lethargic but arousable to voice. She resists movement of her neck. Multiple cultures are obtained from blood and cerebrospinal fluid. Gram stain of cerebrospinal fluid appears as shown. At this time, which of the following is the most appropriate antibiotic therapy for this patient? A) Ampicillin B) Cephalexin C) Ciprofloxacin D) Penicillin E) Vancomycin 34. A 32-year-old woman, gravida 2, para 2, comes to the emergency department 1 month post partum because of abdominal pain, nausea, and vomiting that began 2 days ago after she ate a meal of fried chicken. She has had normal bowel movements with flatus. She has not been able to keep down fluids during this time. Pregnancy and delivery were uncomplicated. Vital signs are temperature 38.6°C (101.5°F), pulse 120/min, respirations 20/min, and blood pressure 100/60 mm Hg. Sclerae are anicteric. Abdominal examination shows right upper quadrant tenderness. Results of laboratory studies are shown: Serum Amylase 1012 U/L Bilirubin 2.6 mg/dL Lipase 982 U/L (N
09-10-2014, 05:13 PM
09-10-2014, 05:36 PM
27. D NBME CERT Epidural hematoma
28. A Wrong by NBME --- maybe its E delirium that is caused by uremia or infections?? 29. A NBME CERT 30. C NBME CERT 31. B wrong by NBME--- E i guess clinical studies is enough for appendix... whoops 32. E Corrected it :-) Simple stress hemorrhage 33. E NBME CERT 34.C Wrong by NBME--- I think its E do nothing  !! I DONT KNOW
09-10-2014, 06:50 PM
q27)
Ans: D) Surgical evacuation nbme cert. ::::::::::::::::::::::::::::::::::: Epidural Hematoma: Forms between Dura and Skull, caused by tear of the Middle Meningeal Art > Lens or “Lentiforme” shape on non-contrasted CT, usually with midline deviation (always acute) Sx: Initial LOC > Lucid interval > recurrent LOC Neurologic EMG, requires Surgical Decompression; otherwise rapid hematoma expansion causes increased ICP, brain herniation and death.
09-10-2014, 06:51 PM
q28)
Ans: B) Adverse reaction to cimetidine nbme cert. ::::::::::::::::::::::::::::::::::::::::::: H2 Antagonists side effects include: Dizziness, somnolence, slurred speech and delirium especially in elderly. Cimetidine is also a major inhibitor of P450 isoforms, drug interaxn via increase effects of Quinidine, Phenytoin, TCA and Warfarin. Cimetidine also decreases Androgens; Gynecomastia and decreased Libido are also adverse effects. |
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