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+--- Thread: Discuss NBME Form 2 Block 4 - grazie (/showthread.php?tid=786891)
Discuss NBME Form 2 Block 4 - grazie - ArchivalUser - 08-27-2014
NBME FORM 2 BLOCK 4
Ok, let's continue with this self nominated job to review these questions, no ice buckets, no vagal maneuvers for me, I am not an stable SVT
I remember when I was preparing for CK, somebody out there made a review like this for nbmes and I was thanking him in my mind the whole time
I am sure my explanations are not as good but at least I get to review these high yield topics and just maybe I can help somebody out there with this little review Your answers and little notes are always appreciated
0 - ArchivalUser - 08-27-2014
Thank you for taking the time to post these questions and answers!
Your efforts are greatly appreciated!
Grazie!
0 - ArchivalUser - 08-27-2014
You are more than welcome
0 - ArchivalUser - 08-27-2014
1.
A 68-year-old Hispanic American man is brought to the emergency department by rescue squad after he experienced acute respiratory distress. On arrival he receives 100% oxygen and is awake but agitated. Vital signs are temperature 37.7°C (99.9°F), pulse 90/min, respirations 31/min, and blood pressure 180/100 mm Hg. Physical examination shows coarse crackles and inspiratory and expiratory wheezing over both lung fields. His cardiac examination is positive for a systolic ejection murmur, but there is no rub or gallop. He is unable to give any further history. Chest x-ray shows diffuse pulmonary edema greater on the right lung than on the left.
Arterial blood gas analysis is shown:
Po2 50 mm Hg
Pco2 55 mm Hg
pH 7.29
HCO3− 26 mEq/L
Which of the following is the most appropriate pharmacotherapy at this time?
A) Aminophylline
B) Digoxin
C) Dopamine
D) Furosemide
E) Morphine
2.
A 78-year-old man is brought to the emergency department by his son because of diffuse abdominal pain and left-sided abdominal swelling that awoke him from sleep 8 hours ago. The patient rates the pain as a 7 on a 10-point scale and says it has persisted despite the use of a heating pad. He has not passed flatus since his pain began. His last bowel movement was 2 days ago. Medical history is remarkable for prostate cancer treated with radical prostatectomy 2 years ago; there was no evidence of recurrence at his most recent follow-up visit with his primary care physician 6 months ago. He also has hypertension controlled with hydrochlorothiazide and he underwent appendectomy at age 10 years. He states that he is in "great shape" for his age. Vital signs are temperature 37.6°C (99.6°F), pulse 100/min and regular, respirations 16/min, and blood pressure 140/88 mm Hg. Abdominal examination discloses diffuse distention with moderate tenderness but no peritoneal signs. Rectal examination discloses moderate discomfort and no stool. Leukocyte count is 12,600/mm3. Serum urea nitrogen, creatinine, and electrolyte concentrations are within the reference ranges. Abdominal x-ray is shown. Which of the following is the most likely diagnosis?
A) Intestinal ileus
B) Megacolon
C) Ogilvie syndrome
D) Perforated intestine
E) Sigmoid volvulus
3.
A 36-year-old woman comes to the emergency department because of an 8-hour history of severe right lower quadrant pain with nausea. She tells you that she learned last week that she is pregnant. She says she was surprised by this news because she and her husband had not conceived during their 4 years of marriage despite not using contraception. Her last menstrual period was 8 weeks ago, although she has had spotting and mild lower abdominal discomfort for the past 3 days. Which of the following is the most appropriate diagnostic step?
A) Complete blood count with differential
B) Determination of serum progesterone concentration
C) Determination of urine quantitative β-hCG concentration
D) Diagnostic laparoscopy
E) Transvaginal ultrasonography
4.
A 4-day-old newborn is brought to the emergency department by his mother because he has had yellow-green discharge and swelling of his left upper and lower eyelids since awakening 6 hours ago. Two days ago, the mother noticed redness of the left eye, which has progressively worsened. The infant was born at home and did not receive medical care following his birth. His mother received no prenatal care. His length is 51 cm (20 in; 50th percentile) and weight is 2948 g (6 lb 8 oz; 10th percentile). Birth weight is unknown. Today, vital signs are temperature 37.6°C (99.6°F), pulse 145/min, and respirations 36/min. The left eyelids are moderately swollen and erythematous. There is copious yellow-green discharge at the lid margins. Examination of the left globe shows significant bulbar conjunctival injection with mild chemosis. A Gram stain of the discharge discloses intracellular gram-negative diplococci. The remainder of the examination discloses no abnormalities. Which of the following is the most appropriate treatment for the newborn's condition?
A) Intramuscular penicillin
B) Intravenous ceftriaxone
C) Oral erythromycin
D) Topical dexamethasone
E) Topical ofloxacin
5.
A 47-year-old man comes to the emergency department because of a 2-hour history of acute abdominal pain and a 2- to 3-day history of nausea and loss of appetite. He rates the abdominal pain as a 9 on a 10-point scale. He has not had vomiting, weight loss, or change in bowel habits. He also reports a 1-year history of epigastric pain that occasionally awakens him from sleep but is relieved by over-the-counter antacids, H2 antagonists, or milk. Medical history is otherwise unremarkable and he takes no routine medications. He appears apprehensive. Vital signs are temperature 38.3°C (99.1°F), pulse 105/min, respirations 15/min, and blood pressure 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Lungs are clear to auscultation and cardiac examination discloses no abnormalities. The abdomen is flat and rigid on palpation; bowel sounds are absent. X-ray of the chest and abdomen is shown.
http://i42.photobucket.com/albums/e338/Graziedoc/STEP%203%20PICS/nbme3F2B4q5_zpsfdd9c099.png
Which of the following is the most appropriate next step?
A) CT scan of the abdomen
B) Gastrografin swallow
C) Laparotomy
D) Ultrasonography of the abdomen
E) Upper gastrointestinal endoscopy
0 - ArchivalUser - 08-27-2014
1.
A 68-year-old Hispanic American man is brought to the emergency department by rescue squad after he experienced acute respiratory distress. On arrival he receives 100% oxygen and is awake but agitated. Vital signs are temperature 37.7°C (99.9°F), pulse 90/min, respirations 31/min, and blood pressure 180/100 mm Hg. Physical examination shows coarse crackles and inspiratory and expiratory wheezing over both lung fields. His cardiac examination is positive for a systolic ejection murmur, but there is no rub or gallop. He is unable to give any further history. Chest x-ray shows diffuse pulmonary edema greater on the right lung than on the left.
Arterial blood gas analysis is shown:
Po2 50 mm Hg
Pco2 55 mm Hg
pH 7.29
HCO3− 26 mEq/L
Which of the following is the most appropriate pharmacotherapy at this time?
A) Aminophylline
B) Digoxin
C) Dopamine
D) Furosemide
E) Morphine
Ans: D
(nbme cert)
Pulmonary Edema:
Oxygen, FUROSEMIDE, nitrates, and morphine are the mainstay of therapy for acute pulmonary edema. Although they are not associated with a concrete mortality benefit, they are the standard of care for pulmonary edema, which is the worst manifestation of CHF.
REMOVING VOLUME from the vascular system and, therefore, the lungs is more important than any form of diagnostic testing. Pulmonary edema is a clinical diagnosis. Shortness of breath, rales, S3, and orthopnea are more important in establishing the diagnosis than any single test.
CCS Tip: On CCS, move the clock forward no more than 15–30 minutes at a time for acutely unstable ICU or emergency department patients.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1558-1560).
0 - ArchivalUser - 08-27-2014
2.
A 78-year-old man is brought to the emergency department by his son because of diffuse abdominal pain and left-sided abdominal swelling that awoke him from sleep 8 hours ago. The patient rates the pain as a 7 on a 10-point scale and says it has persisted despite the use of a heating pad. He has not passed flatus since his pain began. His last bowel movement was 2 days ago. Medical history is remarkable for prostate cancer treated with radical prostatectomy 2 years ago; there was no evidence of recurrence at his most recent follow-up visit with his primary care physician 6 months ago. He also has hypertension controlled with hydrochlorothiazide and he underwent appendectomy at age 10 years. He states that he is in "great shape" for his age. Vital signs are temperature 37.6°C (99.6°F), pulse 100/min and regular, respirations 16/min, and blood pressure 140/88 mm Hg. Abdominal examination discloses diffuse distention with moderate tenderness but no peritoneal signs. Rectal examination discloses moderate discomfort and no stool. Leukocyte count is 12,600/mm3. Serum urea nitrogen, creatinine, and electrolyte concentrations are within the reference ranges. Abdominal x-ray is shown. Which of the following is the most likely diagnosis?
http://i42.photobucket.com/albums/e338/Graziedoc/STEP%203%20PICS/F2b4q2_zps3f3452c8.png
A) Intestinal ileus
B) Megacolon
C) Ogilvie syndrome
D) Perforated intestine
E) Sigmoid volvulus
0 - ArchivalUser - 08-27-2014
q2)
Ans: E
E) Sigmoid volvulus
(nbme cert)
SIGMOID VOLVULUS
Is a twisting of sigmoid colon around its mesenteric attachment. Volvulus of the colon can induce an acute intestinal obstruction. It is the mc form of volvulus of the GI tract, followed by cecal volvulus. The mean age of a sigmoid volvulus patient in the United States is 70 years old.
Sx: Look for older pt with crampy LLQ pain + abdominal distention + constipation
Dx: Abdominal X-Ray - will show "parrot's beak" appearance
Tx: Rigid Proctosigmoidoscopy, rectal tube is left in place to prevent recurrence
0 - ArchivalUser - 08-27-2014
3.
A 36-year-old woman comes to the emergency department because of an 8-hour history of severe right lower quadrant pain with nausea. She tells you that she learned last week that she is pregnant. She says she was surprised by this news because she and her husband had not conceived during their 4 years of marriage despite not using contraception. Her last menstrual period was 8 weeks ago, although she has had spotting and mild lower abdominal discomfort for the past 3 days. Which of the following is the most appropriate diagnostic step?
A) Complete blood count with differential
B) Determination of serum progesterone concentration
C) Determination of urine quantitative β-hCG concentration
D) Diagnostic laparoscopy
E) Transvaginal ultrasonography
Ans: E
(nbme cert)
So, there is some vaginal spotting, let's have an Ultrasound to see the products of conception. No doubts about this.
0 - ArchivalUser - 08-27-2014
4.
A 4-day-old newborn is brought to the emergency department by his mother because he has had yellow-green discharge and swelling of his left upper and lower eyelids since awakening 6 hours ago. Two days ago, the mother noticed redness of the left eye, which has progressively worsened. The infant was born at home and did not receive medical care following his birth. His mother received no prenatal care. His length is 51 cm (20 in; 50th percentile) and weight is 2948 g (6 lb 8 oz; 10th percentile). Birth weight is unknown. Today, vital signs are temperature 37.6°C (99.6°F), pulse 145/min, and respirations 36/min. The left eyelids are moderately swollen and erythematous. There is copious yellow-green discharge at the lid margins. Examination of the left globe shows significant bulbar conjunctival injection with mild chemosis. A Gram stain of the discharge discloses intracellular gram-negative diplococci. The remainder of the examination discloses no abnormalities. Which of the following is the most appropriate treatment for the newborn's condition?
A) Intramuscular penicillin
B) Intravenous ceftriaxone
C) Oral erythromycin
D) Topical dexamethasone
E) Topical ofloxacin
Ans: B
(nbme cert)
Gonococcal Conjunctivitis
Sx: Purulent eye discharge presents within 1st week of birth
Tx: Saline irrigation + IV or IM Ceftriaxone
Amninder S. Dhesi, MD. “Next Step in management” USMLE Step 3. (2nd Ed.)
0 - ArchivalUser - 08-27-2014
5.
A 47-year-old man comes to the emergency department because of a 2-hour history of acute abdominal pain and a 2- to 3-day history of nausea and loss of appetite. He rates the abdominal pain as a 9 on a 10-point scale. He has not had vomiting, weight loss, or change in bowel habits. He also reports a 1-year history of epigastric pain that occasionally awakens him from sleep but is relieved by over-the-counter antacids, H2 antagonists, or milk. Medical history is otherwise unremarkable and he takes no routine medications. He appears apprehensive. Vital signs are temperature 38.3°C (99.1°F), pulse 105/min, respirations 15/min, and blood pressure 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Lungs are clear to auscultation and cardiac examination discloses no abnormalities. The abdomen is flat and rigid on palpation; bowel sounds are absent. X-ray of the chest and abdomen is shown.
http://i42.photobucket.com/albums/e338/Graziedoc/STEP%203%20PICS/nbme3F2B4q5_...dd9c099.png
Which of the following is the most appropriate next step?
A) CT scan of the abdomen
B) Gastrografin swallow
C) Laparotomy
D) Ultrasonography of the abdomen
E) Upper gastrointestinal endoscopy
Ans 5) C
(nbme cert)
Intestinal Perforation, air under the diaphragm. This is an emergency, take him to OR.