nbme f2 b2 - grazie

[ArchivalUser]

This thread is to solve qs from NBME FORM 2 Block 2
I will post the questions and we can discuss the answers. I took the test with feedback so, at least I know some of them are right or wrong for sure

Please write a little explanation to the questions so we can all benefit from these questions. At least we know we are reading just high yield stuff.

Let's get started...

[ArchivalUser]

1.

A 78-year-old man is recovering in the hospital 2 hours following right upper lobectomy for carcinoma of the lung. The patient appears alert and in pain, but his speech is unintelligible. Vital signs are temperature 36.0°C (96.8°F), pulse 100/min, respirations 20/min, and blood pressure 140/80 mm Hg. Physical examination discloses flaccid right upper and lower extremities. Neurologic examination prior to the operation showed no abnormalities. Which of the following is the most appropriate next step?

A) Administration of heparin
B) Administration of streptokinase
C) CT scan of the head without contrast
D) Duplex ultrasonography of the carotid arteries
E) X-ray of the chest

[ArchivalUser]

CC

[ArchivalUser]

Ans: C
C) CT scan of the head without contrast
(Right by nbme feedback)

This is a case of cerebral embolism “Stroke”, occurring immediately after right upper lobectomy. We need to be sure of this so we order a head CT Scan.

LUNG SURGERY COMPLICATIONS: Most severe intraoperative complications are related to the injury of major pulmonary vessels, and most of these complications occurred during upper lobectomy.
Major Lobectomy Complications: Lobar torsion after lung surgery, Serious infection, Significant bleeding, Stroke


Head CT Scan:
NON CONTRAST: For trauma, headache, stroke. Pretty much most things.
CONTRAST: Utilized for evaluation of infection (meningeal enhancement, abscess) or tumor (mets)
However, contrast enhanced head CT is significantly inferior to MRI for these indications and we do very few contrast enhanced Head CTs; the only exception is CT Angiogram of the head for evaluation of Aneurysm, Thrombosis, or Dissection.

[ArchivalUser]

2.

A 3-year-old girl is admitted to the hospital because of a 10-day history of temperature greater than 38.9°C (102.0°F). Her parents state that her eyes have looked red since the fever began, and she has developed a nonpruritic rash over her torso and extremities during this time. The child has been irritable but has not had headache or neck stiffness. She has not been exposed to any illnesses. Vaccinations are up-to-date. She has a history of mild asthma, for which she uses a metered-dose albuterol inhaler with a spacer. The child lives at home with her parents, two brothers, a cat, and two birds. Vital signs on admission are temperature 39.9°C (103.8°F), pulse 114/min, respirations 26/min, and blood pressure 100/65 mm Hg. Conjunctivae are erythematous, but there are no visible exudates. Examination of the tongue and lips shows marked erythema. Cervical lymph nodes are enlarged bilaterally. A macular rash is noted on her chest and around her groin. The skin on her fingertips is peeling. Which of the following is the most likely diagnosis?

A) Cat-scratch disease
B) Hand-foot-mouth disease
C) Kawasaki disease
D) Listeriosis
E) Staphylococcal scalded skin syndrome




3.

An obese 48-year-old woman with diabetes mellitus and chronic renal failure is admitted to the hospital because of an open fracture of the left tibia associated with significant soft tissue damage. Laboratory studies are normal except for serum creatinine concentration of 2.8 mg/dL. On the third day in the hospital she develops confusion, dyspnea, and bulbar conjunctiva. Petechiae are noted around the base of her neck and in the fingernail beds. She has been receiving subcutaneous heparin injection, 5000 U every 12 hours since admission. She appears in mild distress and is talking nonsensically. Vital signs are temperature 37.9°C (100.2°F), pulse 120/min, respirations 24/min, and blood pressure 120/68 mm Hg. Pulse oximetry on oxygen via nasal cannula shows an oxygen saturation of 72%. Lungs are clear. Heart rate is regular and without murmur or gallop. Abdomen is soft and nontender. The patient's left leg is bandaged and splinted but her toes are warm and pink; she is able to move them on command. Her right lower extremity is obese but otherwise normal. Results of stat laboratory studies are shown:

Serum --------------------------Blood

Urea nitrogen 52 mg/dL .... Hematocrit 30%
Creatinine 3.2 mg/dL ........... Hemoglobin 9.8 g/dL
Na+ 134 mEq/L .................. WBC 17,500/mm3
K+ 3.6 mEq/L ................... Platelet count 78,000/mm3
Cl– 95 mEq/L
HCO3– 22 mEq/L
Glucose 210 mg/dL

AP x-ray of the chest and ECG show no change from admission. Ventilation-perfusion lung scans are indeterminate for pulmonary embolism. Which of the following is the most likely explanation for these findings?


A) Adult respiratory distress syndrome
B) Fat embolism
C) Lactic acidosis
D) Ketoacidosis
E) Septic shock

[ArchivalUser]

2. C
3. B

[ArchivalUser]

Q2.-
C) Kawasaki disease
(right by nbme feedback)

KAWASAKI DISEASE:

Large and medium vessel disease vasculitis
Dx:
40°C = > 104°F, for > 5 days

***Kawasaki disease and scarlet fever may both present with “strawberry tongue,” rash, desquamation of the hands and feet, and erythema of the mucous membranes. However, children with scarlet fever have normal lips and no conjunctivitis.

TREATMENT:
* ASPIRIN & IVIG: High-dose Aspirin (for inflammation and fever) and IVIG (to prevent aneurysms)
* ECHOCARDIO: 2D echocardiogram and EKG (baseline) and then follow up
* Anticoagulant (Warfarin), for high risk thrombosis (High platelets)

>>>NO STEROIDS!!!

Patients die of: Coronary Artery Thrombosis secondary to Aneurysms.

[ArchivalUser]

Kawasaki disease vasculitis of medium sizes artery
Rx ivig and high dose steroid immediately prevent coronary artery involvement.
Echo should be done for dx repeat 2 wks and 6 wks .

[ArchivalUser]

oneexam,
You are right! thanks for correcting my mistake

Large Vessel Vasculitis is with:
Giant cell (temporal) arteritis
Takayasu's arteritis

Medium-Sized Vessel Vasculitis:
Polyarteritis nodosa
Kawasaki disease


Small Vessel Vasculitis:

Granulomatosis with polyangiitis
Allergic granulomatosis with polyangiitis
Microscopic polyangiitis
Henoch-Schönlein purpura
Essential cryoglobulinemic vasculitis
Cutaneous leukocytoclastic angiitis



Firestein: Kelley's Textbook of Rheumatology, 9th ed. Copyright © 2012 Saunders, An Imprint of Elsevier

[ArchivalUser]

3.

An obese 48-year-old woman with diabetes mellitus and chronic renal failure is admitted to the hospital because of an open fracture of the left tibia associated with significant soft tissue damage. Laboratory studies are normal except for serum creatinine concentration of 2.8 mg/dL. On the third day in the hospital she develops confusion, dyspnea, and bulbar conjunctiva. Petechiae are noted around the base of her neck and in the fingernail beds. She has been receiving subcutaneous heparin injection, 5000 U every 12 hours since admission. She appears in mild distress and is talking nonsensically. Vital signs are temperature 37.9°C (100.2°F), pulse 120/min, respirations 24/min, and blood pressure 120/68 mm Hg. Pulse oximetry on oxygen via nasal cannula shows an oxygen saturation of 72%. Lungs are clear. Heart rate is regular and without murmur or gallop. Abdomen is soft and nontender. The patient's left leg is bandaged and splinted but her toes are warm and pink; she is able to move them on command. Her right lower extremity is obese but otherwise normal. Results of stat laboratory studies are shown:

Serum --------------------------Blood

Urea nitrogen 52 mg/dL .... Hematocrit 30%
Creatinine 3.2 mg/dL ........... Hemoglobin 9.8 g/dL
Na+ 134 mEq/L .................. WBC 17,500/mm3
K+ 3.6 mEq/L ................... Platelet count 78,000/mm3
Cl– 95 mEq/L
HCO3– 22 mEq/L
Glucose 210 mg/dL

AP x-ray of the chest and ECG show no change from admission. Ventilation-perfusion lung scans are indeterminate for pulmonary embolism. Which of the following is the most likely explanation for these findings?


A) Adult respiratory distress syndrome
B) Fat embolism
C) Lactic acidosis
D) Ketoacidosis
E) Septic shock

Ans) B
*right answer by nbme feedback

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 396). Kaplan. Kindle Edition.

FAT EMBOLISM

Fracture of the long bone allows for fat to escape as little vesicles and cause
occlusion of vasculature throughout the body. The most common bone is the
femur. Onset of symptoms is within 5 days of the fracture. The patient will
present with:
· Confusion
· Petechial rash on the upper extremity and trunk
· Shortness of breath and tachypnea with dyspnea

Diagnostic Tests
· ABG will show P02 under 60 mm Hg.
· Chest x-ray will show infiltrates.
· Urine analysis may show fat droplets.


Treatment
Treatment for fat embolism requires oxygen to keep P02 over 95%.
If the patient becomes severely hypoxic, intubation followed by mechanical ventilation is necessary.