Solving NBME Form 1 - maritzasf

[ArchivalUser]

Answer Q-18:

E ) Reinsertion of a Foley catheter


POUR - Postoperative Urinary Retention is very common, particularly after surgery in the abdomen, pelvis, perineum or groin.

Tx: In-and-out Bladder Catheterization should be done at 6h Post-op if no spontaneous voiding has occurred. Indwelling (Foley) Catheter is indicated at the second (some say third) consecutive catheterization.

[Kaplan Notes, Surgery]

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Postoperative Urinary Retention (POUR)

Urinary retention is common after anesthesia and surgery, reported incidence of between 5% and 70%. Comorbidities, type of surgery, and type of anesthesia influence the development of Postoperative Urinary Retention (POUR).

ULTRASOUND has been shown to provide an accurate assessment of urinary bladder volume and a guide to the management of POUR.

Recommendations for Urinary catheterization in the perioperative setting vary widely. Inappropriate management of POUR may be responsible for bladder overdistension, UTI, and catheter-related complications.


[The Journal of the American Society of Anesthesiology, Inc.]

[ArchivalUser]

NBME CK FORM 1 BLOCK 1
Q-19

19. A 67-year-old woman comes for a routine health maintenance examination. She exercises regularly. She is not sexually active. At her last visit 1 year ago, her serum cholesterol level was 180 mg/dL, and fasting serum glucose level was 80 mg/dL; a Pap smear and mammography showed normal findings. Two years ago, flexible sigmoidoscopy showed no abnormalities. Today, she weighs 63 kg (140 lb) and is 165 cm (65 in) tall. Her blood pressure is 120/80 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient?

A ) Pap smear
B ) Measurement of serum cholesterol level
C ) Measurement of serum glucose level
D ) Mammography
E ) Flexible sigmoidoscopy

[ArchivalUser]

Answer: D) Mammography

Pap Smear not required because of age and no risk factors. Mammogram is done every year after 50y.

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BREAST CANCER SCREENING

Screening mammography should be done as follows:
Age 40: Begins
Ages 40–50: Every 1–2 years
Ages 50+: Every year

When a mammogram shows an abnormality, it should be followed up by a BIOPSY. The biopsy will both show the cancer, if present, and allow testing for the presence of Estrogen and Progesterone receptors.
[Fischer, Master the Boards Step 3]

Start Pap smears at age 21y. Frequency should be every 3 years until age 65. Stop at age 65, unless there has been no previous screening.
[Fischer, Master the Boards Step 3]

[ArchivalUser]

NBME CK FORM 1 BLOCK 1
Q-20

20. A 24-year-old woman comes to the physician because of constant, severe pain in her neck, shoulders, and back for 3 months. She has been unable to enjoy her usual activities because of the pain. Use of over-the-counter ibuprofen and aspirin has not relieved her symptoms. She has a history of irritable bowel syndrome. Examination shows multiple tender spots over the neck, shoulders, and lumbar spine. Range of motion of all joints is full. There is no evidence of synovitis. Fluorescent serum antinuclear antibody and rheumatoid factor assays are negative. Which of the following is the most likely diagnosis?

A ) Ankylosing spondylitis
B ) Fibromyalgia
C ) Polymyalgia rheumatica
D ) Polymyositis
E ) Seronegative rheumatoid arthritis

[ArchivalUser]

B) FIBROMYALGIA
Look for a woman (10 times more common in females) with muscle aches and stiffness with trigger points on palpation and nonrefreshing sleep. Depression and anxiety are common.

DIAGNOSTIC TESTING All blood tests are normal. There is no objective evidence of disease. This is a pain syndrome with tender trigger points. These tender points are located at: Occiput (2), Low cervical (2), Trapezius (2), Supraspinatus (2), Second rib (2), Lateral epicondyle (2), Gluteal (2), Greater trochanter (2), Knee (2)

TREATMENT Treat symptoms with the following: Exercise Tricyclic antidepressants, such as amitriptyline, pregabalin, or gabapentin

[Fischer, Master the Boards Step 3]

[ArchivalUser]

20)pregablin the best initial therapy
tca such as amitryptyline are effective but has more adverse effect

[ArchivalUser]

FIBROMYALGIA

Treatment:
A multidisciplinary approach is most effective. Patient education is essential. Patients can be comforted that they have a diagnosable syndrome treatable by specific though imperfect therapies and that the course is not progressive.
Cognitive behavioral therapy, including programs that emphasize mindfulness meditation is often helpful.

There is modest efficacy of amitriptyline, fluoxetine, duloxetine, milnacipran, chlorpromazine, cyclobenzaprine, pregabalin, or gabapentin.

*** AMITRIPTYLINE*** is initiated at a dosage of 10 mg orally at bedtime and gradually increased to 40–50 mg depending on efficacy and toxicity. Less than 50% of the patients experience a sustained improvement. Exercise programs are also beneficial. NSAIDs are generally ineffective. Tramadol and acetaminophen combinations have ameliorated symptoms modestly in short-term trials. Opioids and corticosteroids are ineffective and should not be used to treat fibromyalgia. Acupuncture is also ineffective.

[CURRENT Medical Diagnosis and Treatment 2012, Fifty-First Edition]

[ArchivalUser]

Thanks for making me review drpred! I checked on my Current 2012 and found this, is always good to have this concepts clear

My sources are MTB, KAPLAN, DEJA VU, but for more deep and current concepts also last editions of Harrison and Current 2012, I don't want to rely on anything else that might not be accurate.

[ArchivalUser]

NBME CK FORM 1 BLOCK 1
Q-21

21. A 57-year-old man is brought to the emergency department 30 minutes after he was found on the floor of his house; he has left hip pain and shortness of breath. He has renal failure but has missed his last two dialysis treatments. His renal failure was caused by inadvertent ingestion of ethylene glycol. His renal function did not improve, and he is currently on the transplantation list. Medications include amlodipine and doxazosin. On arrival, his temperature is 37.5 C (99.5 F), blood pressure is 150/100 mm Hg, pulse is 95/min and regular, and respirations are 24/min. His breathing is rapid and deep. Crackles are heard in the lung bases. Examination shows a soft abdomen. Bowel sounds are normal. The left lower extremity is externally rotated.
Laboratory studies show:
Serum
Na+ 135 mEq/L
Cl– 102 mEq/L
K+ 7.1 mEq/L
HCO3– 12 mEq/L

Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula:
pH 7.22
PCO2 31 mm Hg
PO2 61 mm Hg
An ECG shows peaked T-waves. It will be at least 45 minutes before dialysis can be started.

Which of the following is the most appropriate next step in management?

A) Observation until dialysis is initiated
B) Intravenous calcium gluconate
C) Intravenous glucose and insulin
D) Intravenous 0.9% saline
E) Intravenous sodium bicarbonate
F) Rectal sodium polystyrene sulfonate (Kayexalate)

[ArchivalUser]

Answer Q21:
B) Intravenous calcium gluconate

This is a severe case of Hyperkalemia, so treat the problem: First stabilize the cell membrane potential, give Calcium Gluconate.

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HYPERKALEMIA TREATMENT

Severe Hyperkalemia (EKG abnormalities, such as peaked T-waves)
Treat as follows:
*** Administer Calcium Gluconate IV to protect the heart.
** Follow with Insulin and Glucose intravenously.

Moderate Hyperkalemia (No EKG Abnormalities)
Treat as follows:
*** Administer Insulin and Glucose IV.
** Use Bicarbonate to shift K+ into the cell when acidosis is the cause of the Hyperkalemia or there is Rhabdomyolysis, Hemolysis, or another reason to Alkalinize the Urine.
** Kayexelate (K+ Binding Resin) is administered po orally to remove K+ from the body. This takes several hours.

[Fischer, Master the Boards Step 3]