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Q18)
Ans: D
D) Dry, brittle, easily plucked hair
It seems like the main manifestations of Vitamin C deficits are expressed on skin appendages and not so strong on bleeding gums, oh boy!
SCURVY OR VITAMIN C DEFICIENCY
Manifests as Follicular Hyperkeratosis and perifollicular hemorrhage, ecchymoses, xerosis, leg edema, poor wound healing, and/or bent or coiled body hairs. Large purpuric plaques, especially on the extremities, may occur. Gingivitis with gum hemorrhage occurs only in dentulous patients and commonly occurs in the presence of poor oral hygiene and periodontal disease. Scurvy is mc in alcoholics, but may occur with Crohn's or Whipple's disease.
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed. Copyright © 2010 Saunders, An Imprint of Elsevier
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19.
A 65-year-old white man is in the intensive care unit because of end-stage cardiomyopathy. At the insistence of his wife, he was intubated yesterday in the emergency department because of severe hypoxia, coma, and pulmonary edema. Today his pulmonary and neurologic conditions are stabilized via a ventilator. You see him today while you are on rounds. He appears angry and motions you to the bedside. He writes, "I have a Living Will. Get me off this machine now. I'm ready to die. I'm tired of living hooked up to machines." The patient has been evaluated by a psychiatrist, who determined that he is competent to make decisions. You arrange a meeting with the patient and his wife, who is the patient's durable power of attorney. Which of the following is the most appropriate statement to the patient?
A) "I am legally bound to continue all support as long as you and your wife disagree."
B) "I cannot take you off the ventilator until you are medically ready."
C) "I will respect your wishes for palliative care only."
D) "Your Living Will only applies if you are comatose."
E) "Your wife as your proxy decision-maker may overrule your wishes."
Ans: C (Confirmed by NBME)
Rule No1
“Competent patients have the right to refuse medical treatment.”
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20.
A 67-year-old man with metastatic lung cancer is seen in the nursing care facility because of progressive headache, vomiting, and pain in the extremities and abdomen for the past 2 days. He has tumors that have metastasized to multiple sites in the liver, lungs, bones, and brain. The patient has been receiving hospice care for the past month. Medications include 4 mg intravenous dexamethasone four times daily, morphine 10 mg/hour by intravenous infusion, and 10 mg intravenous metoclopramide six times daily. Now he is drowsy and moaning, but he responds to voices, follows commands with all extremities, and communicates in brief sentences. He is not oriented to place and time. Vital signs are temperature 37.0°C (98.6°F), pulse 105/min and regular, respirations 10/min, and blood pressure 110/60 mm Hg. Auscultation of the chest discloses normal breath sounds with crackles in the lung bases. The liver is enlarged and extremely tender to palpation. The abdomen is soft, and bowel sounds are decreased. There is diffuse tenderness over the bones. Which of the following is the most appropriate change to the patient's medication regimen?
A) Begin intravenous cefuroxime therapy
B) Begin intravenous lorazepam therapy
C) Begin intravenous mannitol therapy
D) Increase the dexamethasone dosage
E) Increase the morphine infusion rate
Ans) E (confirmed by NBME)
A terminal patient with metastasized lung cancer, in morphine but still suffering pain. The only thing left is to keep the patient pain free.
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21.
An 18-year-old college student is admitted to the hospital for observation after sustaining a closed head injury in a fall from a second-story porch. According to paramedics, the patient was unconscious for several minutes after the fall. On arrival at the emergency department 9 hours ago, he was oriented to person but not to place or time. At that time, vital signs and physical examination, including funduscopic and neurologic examinations, were otherwise noncontributory. A CT scan of the head was normal. The patient's confusion improved during the next 8 hours. Now, he is alert and oriented. He says he remembers tripping on the stairs and falling after drinking beer and smoking marijuana with a group of older students. The patient was seen in the student health center 3 weeks ago because of difficulty sleeping. At that time, depression was diagnosed and fluoxetine therapy was initiated, in addition to recommending sessions at the campus counseling center. Which of the following is the most significant risk factor leading to this patient's injury?
A) History of depression
B) Patient's age
C) Use of alcohol (confirmed by nbme)
D) Use of fluoxetine
E) Use of marijuana
Ans) C (confirmed by nbme)
There is a significant difference in the pattern and severity of injury sustained during falls if the patient has consumed alcohol or not. Alcohol related falls are more often associated with severe craniofacial injury. The severity of both limb and head injury is greater and correlates directly with blood alcohol concentration.
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22.
A 62-year-old man with a history of chronic obstructive pulmonary disease is admitted to the hospital because of progressive shortness of breath and increasing cyanosis. Vital signs are temperature 39.2°C (102.5°F), pulse 110/min, respirations 32/min, and blood pressure 60/40 mm Hg. Physical examination discloses crackles in the right lung base with dullness to percussion and mottling of his skin. Pulmonary capillary wedge pressure is 10 mm Hg. Which of the following is the most likely pathophysiologic mechanism underlying the hypotension?
A) Decreased peripheral vascular resistance *** (by nbme)
B) Decreased right ventricular contraction
C) Increased cardiac output
D) Increased pulmonary vascular resistance
E) Increased renal loss of sodium
Ans) A
The pt is in Septic Shock.
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A 26-year-old woman is admitted to the hospital 1 hour following dilatation and curettage for an incomplete abortion at 12 weeks' gestation. Preoperative hematocrit was 35%. Estimated blood loss was 200 mL. The patient is now alert but complains of shortness of breath and abdominal pain. There has been minimal vaginal bleeding. Pulse is 140/min and blood pressure is 80/60 mm Hg. Lungs are clear on auscultation. Abdomen is distended with notable guarding and rebound. Which of the following is the most appropriate next step?
A) Blood transfusion
B) Exploratory laparotomy
C) Paracentesis
D) Repeat dilatation and curettage
E) Ultrasonography of the pelvis
Ans) B
This patient is experiencing an acute abdomen so exploratory laparotomy is indicated.
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24.
A 28-year-old primigravid woman, who is at 29 weeks' gestation, is admitted to the hospital because of a 2-day history of fever, shaking chills, and right lower flank pain. Her prenatal course has been complicated by pyelonephritis at 20 weeks' gestation. The patient has been taking suppressive nitrofurantoin therapy daily since that time. Medical history otherwise is unremarkable. She is 167.5 cm (5 ft 6 in) tall. She weighed 68 kg (150 lb) prior to her pregnancy; BMI was 24 kg/m2. She has had a 6-kg (13-lb) weight gain during her pregnancy. Vital signs on admission are temperature 39.3°C (102.7°F), pulse120/min, respirations 30/min, and blood pressure 125/74 mm Hg. Fundal height is 30 cm. Fetal heart rate is 150/min. Palpation discloses right costovertebral angle tenderness. Leukocyte count is 12,700/mm3. Results of urinalysis are shown:
Urine
Leukocyte esterase Positive
WBC 15/hpf
RBC 2/hpf
Intravenous administration of cefazolin is begun. After 36 hours, urine culture shows colonies of Escherichia coli that are highly sensitive to the antibiotic; however, the patient's condition does not improve during the next 72 hours. At this time, which of the following is the most appropriate management?
A) Add intravenous clindamycin
B) Continue the cefazolin therapy
C) Order intravenous pyelography
D) Order renal ultrasonography ***
Ans) D (confirmed by nbme)
If the right atb is not helping, we definitely need a picture of what’s happening in there.
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25.
A 44-year-old man is hospitalized for intravenous antibiotic treatment of subacute bacterial endocarditis. On the third hospital day he has abdominal cramps, weakness, and sweating. Vital signs are temperature 37.0°C (98.6°F), pulse 110/min, respirations 24/min, and blood pressure 140/90 mm Hg. On physical examination pupils are dilated, and the patient is diaphoretic and trembling. Which of the following is the most likely diagnosis?
A) Benzodiazepine withdrawal
B) Cocaine withdrawal
C) Drug allergy
D) Generalized anxiety disorder
E) Heroin withdrawal ***
Ans) E (by NBME)
Opioid withdrawal is a common occurrence in the adult emergency department and newborn nursery. Symptoms of nausea, vomiting, increased bowel sounds, abdominal cramps, and dehydration are characteristic. The ONSET, duration and severity of symptoms depend on the pharmacologic properties of the withdrawn opioid and on the pattern of its use.
Heroin withdrawal, for example, begins within 4 TO 24 HOURS after the last use and generally peaks at 36 TO 48 HOURS. In neonates, failure to thrive, poor suck reflex, and feeding difficulties are noted in about half of those withdrawing from heroin. Similarly, poor feeding is seen in infants and young children withdrawing from chronically administered opioid analgesia.
Clues to the diagnosis of opioid withdrawal include DILATED PUPILS, YAWNING, lacrimation, rhinorrhea, muscle CRAMPING, MYALGIAS, hyperactive bowel sounds, and piloerection.
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26.
A 55-year-old man is transferred to the coronary care unit from the emergency department after sustaining an acute myocardial infarction. Medical history is significant for essential hypertension, for which he takes thiazide diuretic medication. Vital signs are pulse 90/min, respirations greater than 30/min and regular, and systolic blood pressure 90 mm Hg. Upon arrival in the coronary care unit, his systolic blood pressure decreases to 70 mm Hg. He is given a bolus of crystalloid fluid, but he continues to be hypotensive. Physical examination shows distended neck veins. The patient's hypotension is refractory to maximal doses of dobutamine and dopamine. The most appropriate next step is to do which of the following?
A) Administer a bolus of lidocaine
B) Apply pneumatic antishock garments
C) Do emergency cardiac catheterization
D) Insert an intra-aortic balloon pump
E) Seek a Do Not Resuscitate order
27.
A 67-year-old man undergoes laparotomy and lysis of adhesions for a high-grade small-bowel obstruction. Postanesthesia extubation is unremarkable except for emesis of 100 mL of bilious fluid. On the first postoperative day vital signs are temperature 38.2°C (100.8°F), pulse 124/min, and respirations 34/min. Breathing is shallow and breath sounds are associated with wheezing and are diminished in both lung fields. Abdomen is mildly distended and tender. Which of the following is the most likely diagnosis?
A) Aspiration pneumonitis
B) Atelectasis
C) Postanesthesia respiratory insufficiency
D) Pulmonary edema
E) Pulmonary embolus
28.
A 73-year-old man is admitted to the hospital because of pancreatitis following a 2-day history of abdominal pain, nausea, and vomiting. On admission vital signs are temperature 37.8°C (100.0°F), pulse 90/min, respirations 16/min, and blood pressure 160/90 mm Hg. There is tenderness and voluntary guarding in the epigastrium with hypoactive bowel sounds. Physical examination is otherwise normal. Laboratory studies show a leukocyte count of 17,500/mm3 and a serum amylase concentration of 540 U/L. Orders are written that he is to be given nothing by mouth; intravenous fluids are administered and he is given meperidine intravenously for pain. Twenty-four hours after admission the patient becomes dyspneic. There are decreased breath sounds at the left lung base. Vital signs are temperature 39.4°C (103.0°F), pulse 120/min, and blood pressure 80/60 mm Hg. On physical examination there is splinting of the left hemithorax. Chest x-ray shows a left lower lobe infiltrate and bilateral small pleural effusions. Arterial blood gas analysis while breathing room air is shown:
Po2 78 mm Hg
Pco2 26 mm Hg
pH 7.45
Which of the following is the most likely cause for the patient's acute deterioration?
A) Infected pseudocyst
B) Massive atelectasis
C) Pancreatic fistula
D) Pneumonia
E) Sympathetic pleural effusion
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