Discuss NBME Form 2 Block 5/5 - grazie

[ArchivalUser]

can not see ECG any way
28a ......stage2 hypertension,could we add 2nd drug??
29e
30c..??

[ArchivalUser]

30 C) Menstrual history

Amylophagia is a condition involving the compulsive consumption of excessive amounts of purified starch. It is a form of PICA and is often observed in pregnant women. In this condition patients feel a compulsion to consume refined starch such as cornstarch and continue to eat it for at least one month. It is also believed that it is a result of a nutritional deficiency.

The health risks associated with Amylophagia include hyperglycemia, malnutrition and anemia.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2522275/

[ArchivalUser]

q28 and 29
picture

http://i42.photobucket.com/albums/e338/G...2f39da.png

[ArchivalUser]

@grazie...ECG to me looks like showing LV hypertrophy. my answ are the same,let us hope other folks will help.

[ArchivalUser]

AA MALE+ SBP >160 AND TACHYCARDIA[ALMOST 100]
LVH IN EKG,
SHOULD WE ADD ONE MORE DRUG LOWER BP AND HR?

28=AAA?

[ArchivalUser]

30 = she is eating corn
niacin def?
pellagra-3D
EE?

[ArchivalUser]

@perception
yes, it is just confirming the info we had from the case


Left Ventricular Hypertrophy

A common cause of LVH is hypertensive heart disease, initially with concentric hypertrophy, increased left ventricular mass, impaired diastolic function, and normal systolic function.

As LVH progresses toward end-stage heart disease, systolic dysfunction develops and the left ventricle dilates. The left atrium will eventually dilate because of decreased left ventricular compliance and possibly mitral regurgitation. (A left atrial dimension greater than 4.5 cm indicates an increased risk of developing atrial fibrillation.) Frequently, the aortic root will dilate and there will be associated aortic valve sclerosis. There may also be mitral annular calcification.


Pfenninger and Fowler's Procedures for Primary Care , Third Edition
John L. Pfenninger, and Grant C. Fowler
CHAPTER 90, 585-597
© 2011

[ArchivalUser]

30.
A 35-year-old African American woman, gravida 2, para 2, comes to the office for an annual health maintenance examination. She has been generally healthy and takes no medications. Family history is remarkable for rheumatoid arthritis in her mother and hypertension in her father. She does not smoke cigarettes or drink alcoholic beverages. She is married and does not work outside the home. Further history is obtained, and the patient says, "I began eating corn starch about 4 years ago after the birth of my second child. I eat about half a box a day." Specific additional history should be obtained regarding which of the following?

A) Depressive symptoms
B) Headaches
C) Menstrual history
D) Polydipsia
E) Rashes

Ans) C ?

A clinical manifestation unique to iron deficiency is pica, which is an unusual craving for certain non-nutritional substances. Pica may manifest as a craving for Ice (Pagophagia) or, less commonly, for Clay (Geophagia) or Starch (Amylophagia); pagophagia is believed to be the most specific for iron deficiency.

[ArchivalUser]

31.
An 18-year-old competitive ice skater comes to the office with her mother because of a 23-kg (50-lb) weight loss during the past 12 months. She says she started following a low-carbohydrate, low-calorie diet 12 months ago but she stopped 4 weeks ago because she was losing too much weight. Now she reports lack of appetite and says she is unable to eat and her weight loss has continued. Medical history is unremarkable and she takes no medications. Menses are regular and typically last 3 to 5 days; her last menstrual period was 2 weeks ago. She does not smoke cigarettes, use illicit drugs, or drink alcoholic beverages. Family history is unremarkable. The patient is 168 cm (5 ft 6 in) tall and weighs 54 kg (120 lb); BMI is 19 kg/m2. She appears well. Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 18/min, and blood pressure 120/80 mm Hg. Physical examination discloses no abnormalities. Results of complete blood count, serum thyroid-stimulating hormone concentration, serum chemistry profile, and urinalysis are within the reference ranges. In addition to nutritional counseling and asking the patient to keep a dietary log, which of the following is the most appropriate management?

A) High-calorie liquid nutritional supplements
B) Megestrol acetate therapy
C) Regular weight checks at the office
D) Supportive psychotherapy
E) Reassurance only


32.
A 33-year-old postal worker comes to the office because of a 2-week history of low back pain radiating to the right leg. She says that the pain began suddenly when she lifted a large bag of mail while at work. Since that time, she has been on bed rest while on medical leave from work and her symptoms have not improved. At the time of the injury she was prescribed acetaminophen with codeine, but this has not relieved the pain. Vital signs are temperature 36.9°C (98.4°F), pulse 90/min, respirations 20/min, and blood pressure 130/80 mm Hg. The patient is thin and appears anxious. She wrings her hands and shifts in her chair. Lungs are clear to auscultation. Cardiac examination discloses normal heart sounds with no murmur. Abdomen is soft and is not tender. Back is not tender. Straight leg elevation causes pain in her right lower extremity above the knee. Which of the following is the most appropriate management?

A) Continued bed rest for 4 more weeks

B) Epidural steroid injection

C) Hydrotherapy

D) Ketorolac therapy

E) Oxycodone therapy


33.
A 32-year-old married white man comes to the office for an initial visit. During the interview, he says that he thinks he is very healthy except for one big problem. During the past year, he has had increasing difficulty going out in public. This is presenting great difficulty for him because he sells bonds and must spend much of his time entertaining customers, taking them out to dinner and socializing at cocktail parties. He has started to drink fairly heavily in order to be able to do his work. Without the alcohol, he says he barely can go out of the house. He admits to having one episode of extreme anxiety when he went out, during which time he felt as if he were going to die. This episode occurred only recently but his difficulty in going out has been a problem for a long while. Which of the following questions will provide the most insight into the cause of this patient's symptoms?

A) "Did you have any other symptoms during this episode?"

B) "Do you have a family history of alcoholism?"

C) "Does anyone else in your family have a similar problem?"

D) "What concerns you about going out in public?"

E) "What do you think about when you wake up at night?"



The following vignette applies to the next 2 items.

A 15-year-old high school sophomore is brought to the office by her parents because they realized that her recent 7-kg (15-lb) weight gain and frequent abdominal discomfort were the result of pregnancy. The girl admits that her last menstrual period occurred 7 months ago. Personal and family medical histories are unremarkable and the patient takes no medication. She is 168 cm (5 ft 6 in) tall and weighs 56 kg(124 lb). Vital signs are temperature 37.0°C (98.6°F), pulse 64/min, respirations 18/min, and blood pressure 100/50 mm Hg. Physical examination discloses a nonradiating grade 2/6 systolic ejection murmur over the left sternal border. Lungs are clear to auscultation. Fundal height is 28 cm. Pelvic examination discloses a closed and thick cervix. Prenatal laboratory studies are obtained and results are pending. You discuss her 28-week fundal height with her and explain that the estimated delivery date is approximately 12 weeks. The parents express concern that their daughter's lack of prenatal care might adversely affect the baby.

34.
Item 1 of 2
Which of the following is the most accurate statement concerning this patient?

A) The baby will likely be born with congenital iron deficiency anemia

B) The baby will most likely not be affected by lack of early prenatal care

C) The patient will probably develop preeclampsia

D) The patient will probably experience preterm labor and delivery

E) Since the patient has gained only 15 lb, the baby is probably growth-restricted



35.
Item 2 of 2
You counsel the patient and her parents about proper nutrition during pregnancy. Which of the following is the most appropriate monitoring approach regarding her nutrition at this time?

A) Assess her weight gain at each prenatal visit

B) Have a nutritionist make home visits twice weekly to ensure dietary compliance

C) Have the parents calculate daily caloric intake

D) Measure serum iron and total iron-binding capacity (TIBC)

E) Measure serum protein concentrations

End of Set


36.
A 52-year-old African American Internet executive comes to the office for a periodic health evaluation. She has been your patient for the past 10 years. Today she states that she is becoming more concerned about osteoporosis as she experiences menopause. She reminds you that her mother fractured her hip at age 72 years. The patient asks about an exercise plan to help increase bone density and decrease the health risks associated with osteoporosis. Medical history is significant for hypertension treated with hydrochlorothiazide and atenolol. She is married with two sons ages 19 and 12 years. She is 163 cm (5 ft 4 in) tall and weighs 59 kg (130 lb); BMI is 22 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 84/min, respirations 16/min, and blood pressure 130/74 mm Hg. With regard to exercise, which of the following is the most appropriate advice for this patient?

A) Begin a brisk walking program

B) Begin a daily swimming regime

C) Begin weekly yoga classes

D) Join a health club and attend a spinning/cycling class

E) No exercise will help

[ArchivalUser]

31
An 18-year-old competitive ice skater comes to the office with her mother because of a 23-kg (50-lb) weight loss during the past 12 months. She says she started following a low-carbohydrate, low-calorie diet 12 months ago but she stopped 4 weeks ago because she was losing too much weight. Now she reports lack of appetite and says she is unable to eat and her weight loss has continued. Medical history is unremarkable and she takes no medications. Menses are regular and typically last 3 to 5 days; her last menstrual period was 2 weeks ago. She does not smoke cigarettes, use illicit drugs, or drink alcoholic beverages. Family history is unremarkable. The patient is 168 cm (5 ft 6 in) tall and weighs 54 kg (120 lb); BMI is 19 kg/m2. She appears well. Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 18/min, and blood pressure 120/80 mm Hg. Physical examination discloses no abnormalities. Results of complete blood count, serum thyroid-stimulating hormone concentration, serum chemistry profile, and urinalysis are within the reference ranges. In addition to nutritional counseling and asking the patient to keep a dietary log, which of the following is the most appropriate management?
A) High-calorie liquid nutritional supplements
B) Megestrol acetate therapy
C) Regular weight checks at the office
D) Supportive psychotherapy
E) Reassurance only

Ans: C ?

Her BMI is in the lower limits but still in the healthy zone, so maybe the management can be a conservative therapy before prescribing meds like Megestrol. An anorexic will never accept she is too skinny and she never had amenorrhea so we can’t call this anorexia. Her weight needs to be monitored to see her progress.


Megestrol acetate is a progesterone derivative; it is also a powerful appetite stimulant which lead to weight gain, composed of both fat mass and fat-free mass. Megestrol acetate is well tolerated, with few and mild side-effects. If megestrol acetate therapy is started at the onset of anorexia, the use of more expensive, invasive and complicated techniques of nutritional support may be avoided.