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32.
A 22-year-old woman comes to the emergency department because of low back pain since lifting grocery bags at the supermarket 24 hours ago. She rates the pain as a 5 on a 10-point scale and says it radiates to her buttocks. The pain has made it difficult for her to rise from her bed and from a seated position. She reports no numbness or loss of bowel or bladder function. She has not had back pain in the past. Medical history is unremarkable and she takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 54 kg (120 lb); BMI is 21 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 16/min, and blood pressure 130/80 mm Hg. Examination of the back discloses diffuse tenderness in the lumbar and sacroiliac regions. Muscle strength and deep tendon reflexes are normal and sensation is intact. Range of motion testing of the back elicits pain. Straight-leg raising of both lower extremities elicits no pain or paresthesias. Which of the following imaging studies is most likely to confirm the diagnosis?

A) CT scan of the lumbar spine
B) Myelography of the lumbar spine
C) Triple-phase bone scan
D) X-ray of the lumbosacral spine
E) No imaging study is required

q32)

Ans: E
E) No imaging study is required
(nbme cert)


The Lasègue's sign is negative so we kind of rule out a herniated disk and this must be just a muscle strain. Patients with acute muscle strain in the low back often have histories of acute injury. PE may reveal tenderness or muscle spasms.

Tx:
NSAIDs, muscle relaxants, massage therapy, physical therapy, or even acupuncture often provide effective pain relief.

33.
A 22-year-old man is brought to the emergency department by his friends 1 hour after smoking crack cocaine. The friends say that he began acting agitated and complaining of chest pain shortly after he began smoking. They note that the patient has tried Ecstasy and marijuana in the past but that he had not tried cocaine until today. The patient has no known medical conditions. On admission the patient appears to be in moderate distress, is perspiring, is unable to sit still, and is verbally abusive to staff. Vital signs are temperature 37.2°C (99.0°F), pulse 100/min, respirations 24/min, and blood pressure 170/110 mm Hg. The patient appears agitated and anxious. ECG shows tachycardia. The most appropriate immediate step is to administer which of the following?
A) Diazepam
B) Haloperidol
C) Meperidine
D) Naloxone
E) Promethazine

q33)

Ans: A
A) Diazepam


Cocaine Intoxication

Treatment
* Supportive
* May control agitation with BENZODIAZEPINES
* Alpha Blockers (Phentolamine) or combina alpha/beta blockers (Labetalol) can be used to control HTN
* AVOID USING PURE BETA BLOCKERS, they can cause unopposed alpha-stimulatory effects

Some patients experience psychosis with hallucinations, paranoia; in this case antipsychotic medications are a useful treatment.

34.
A 3-year-old boy is brought to the emergency department by his mother because of a 24-hour history of fever, sore throat, and hoarseness. He has been generally healthy. He takes no medications and has not received any vaccinations. On arrival today, the child is drooling. Vital signs are temperature 38.5°C (101.3°F), pulse 120/min, respirations 30/min, and blood pressure 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Physical examination discloses mild inspiratory stridor and suprasternal retractions. Which of the following is the most appropriate diagnostic study at this time?

A) AP and lateral cervical x-rays
B) Chest x-ray
C) CT scan of the neck and chest
D) Flexible bronchoscopy
E) Nasotracheal suctioning for culture and sensitivity

q34)

Ans: A
A) AP and lateral cervical x-rays
(nbme cert)


This kid has not been vaccinated >( horrible mom!


Somebody gave me this mnemonic once

epigloTTitis T

Thumbprint T

inTubation T

======================

EPIGLOTTITIS

1. Cause: Mostly HIB; then Strep-spp; virus.
2. Age group: 3-7yr. Rapid onset (4-12h) of high fever, dysphagia, drooling, muffled voice , and Resp distress with a seated & neck extended position; not improved by Ep.
3. Do not examine the throat unless the anesthesia or tracheostomy is ready in case of laryngospasm.
4. Lateral X-film: Swollen epiglottis as “THUMBPRINT SIGN”.

Tx: A true emergency!
1) Keep patient calm, prepare for anesthesia, and then perform ENDOTRACHEAL INTUBATION or TRACHEOSTOMY.
2) IV 3rd-generation Cephalosporin (ceftriaxone).

Gong MD, Yale (2013-02-05). Yale-G's Refined Clinical Review for USMLE Step 2 & 3 (New Edition) (Kindle Locations 6943-6947). www.usmle-yaleg.com. Kindle Edition.

35.
An 18-month-old African American boy is brought to the emergency department by his mother, who is accompanied by her live-in boyfriend. The mother says, "My son has been fussy all day, but since late this afternoon all he wants to do is sleep. It is very hard to keep him awake." The boyfriend adds that the child "is clumsy and falls a lot." The child's height and weight are at the 20th percentile for age. Vital signs are temperature 37.0°C (98.6°F), pulse 70/min, respirations 18/min, and blood pressure 95/60 mm Hg. On physical examination the child is moderately lethargic and is difficult to arouse. Bruises are noted over the buttocks and lower back. Physical examination is otherwise unremarkable. Which of the following is the most appropriate diagnostic study at this time?

A) Bone scintigraphy
B) Complete blood count
C) CT scan of the head
D) X-rays of the lumbar spine
E) X-rays of the pelvis

q35)

Ans: C
C) CT scan of the head

Children at risk for abuse:

Younger than 1 year
Stepchildren
Premature children
Very active
"Defective" children


Medical Evaluation of Suspected Physical Abuse

1) Physical examination and documentation of all injuries, the history in child's own words, and photographs before any medical treatment.

2) Radiographs of any suspected skeletal injury.

3) Radiographic skeletal survey in all children less than 2 years suspected of abuse.

4) Head CT scan: Perform on all suspected abuse victims 2 year of age or younger.

5) Nuclear Medicine Bone Scan. Usually not necessary. Perform this if there are equivocal findings on the skeletal survey.

6) Brain MRI scan: Perform if the suspected or confirmed abuse is older (weeks to months or even years), to look for evidence of chronic blood collections (chronic subdural hematoma) and brain damage.

36.
A 74-year-old man with chronic obstructive pulmonary disease is brought to the emergency department by ambulance from an assisted living facility because of a 1-week history of increasingly severe shortness of breath. He also has had associated low-grade fever and worsening of his chronic productive cough. Medications include combined ipratropium bromide and albuterol and theophylline. The patient has smoked two packs of cigarettes daily for 45 years. Vital signs on admission are temperature 37.6°C (99.7°F), pulse 94/min and irregularly irregular, respirations 30/min, and blood pressure 108/67 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 83%. Auscultation of the chest discloses scattered expiratory rhonchi and prolonged expiratory phase. Heart sounds are distant and irregular; a grade 2/6 systolic flow murmur is present. Examination of the extremities shows 1+ pretibial pitting edema. Arterial blood gas analysis is shown:
Po2 46 mm Hg
Pco2 51 mm Hg
pH 7.31

ECG shows atrial fibrillation and no acute signs of ischemia and chest x-ray shows hyperinflation and apical bullae; findings on both studies are unchanged from previous study results. The patient is treated with 5 L/min of oxygen via nasal cannula, after which a repeat blood gas analysis shows the following:

Po2 56 mm Hg
Pco2 64 mm Hg
pH 7.25

Which of the following is the most appropriate treatment at this time?
A) Continued oxygen by nasal cannula
B) Intubation with volume-controlled ventilation
C) Noninvasive positive pressure ventilation
D) Oxygen by Venturi mask

Q36
I need help with this qs.
B is wrong