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29.
A newborn is transferred to the neonatal intensive care unit soon after delivery because of respiratory distress. She has been intubated and mechanically ventilated since birth. She was born at 35 weeks' gestation via emergency cesarean delivery to a 37-year-old woman, gravida 4, para 3, and her 42-year-old husband. Apgar scores were 1 and 6 at 1 and 5 minutes, respectively. The pregnancy was complicated by type A gestational diabetes. Prenatal testing was limited to fetal ultrasonography at 20 weeks' gestation. Amniocentesis and maternal serum triple screening were declined. Family history is unremarkable. There are three healthy siblings, ages 4, 6, and 8 years. The patient is 44 cm (17 in; 25th percentile) long, and weighs 1.8 kg (4 lb; 10th percentile for corrected gestational age), and head circumference is 30 cm (12 in; 10th percentile). Physical examination discloses mottled skin and a small face for cranial size. There is a cleft of the secondary palate. Ears are small and dysplastic. The sternum is short. Lungs are clear to auscultation. Cardiac examination discloses a high-pitched, grade 2/6 systolic murmur. The hands and feet appear as shown in the photographs. Muscle tone is increased. Pulse oximetry on an Fio2 of 1.0 shows an oxygen saturation of 80%.
http://i42.photobucket.com/albums/e338/G...203%20PICS
Which of the following is the most appropriate next step in diagnosis?
A) Chromosomal analysis
B) Determination of arterial blood gas values
C) Echocardiography
D) MRI of the brain
E) Skeletal survey
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30.
A previously healthy 3-year-old boy is in the pediatric intensive care unit for treatment of a fractured femur and closed head injury sustained yesterday when he was struck by an automobile. Upon admission, pentobarbital, lidocaine, rocuronium, and atropine were administered to facilitate endotracheal intubation. The patient was then treated with large doses of morphine and lorazepam for control of agitation and pain. Now, this morning, temperature is 35.0°C (95.0°F) and blood pressure is 55/35 mm Hg. Physical examination discloses absence of brain function. Which of the following is the most accurate statement concerning this patient?
A) Brain death cannot be assessed at this time
B) The patient can be considered as an organ donor at this time
C) The patient can be declared brain dead with no further investigation or examination
D) The patient's medications have no bearing on the determination of brain death
E) stat electroencephalogram showing no cortical activity would be diagnostic of brain death
31.
A 22-year-old white man is admitted to the hospital because of a 2-day history of fever, night sweats, and chills. He says he has used intravenous heroin for the past 2 years, most recently 5 days ago. Medical history is unremarkable and he takes no medications. Vital signs are temperature 38.9°C (102.0°F), pulse 130/min, respirations 22/min, and blood pressure 120/60 mm Hg. The patient is alert but appears tired. His skin is flushed. Physical examination shows multiple intravenous track marks with red streaks in both arms. There is nontender cervical adenopathy. Auscultation of the chest discloses a grade 2/6 systolic ejection murmur. Chest x-ray discloses no abnormalities. Results of laboratory studies are shown:
Blood
Hemoglobin 14.0 g/dL
WBC 18,000/mm3
Platelet count 450,000/mm3
Blood cultures are obtained and show no growth after 24 hours. Immediate management is most likely to be influenced by results of which of the following studies?
A) CD4+ T-lymphocyte count
B) Cervical lymph node biopsy
C) CT scan of the chest
D) Serum HIV antibody study
E) Transesophageal echocardiography
32.
A 62-year-old man who sustained a stab wound to the abdomen is in the hospital after undergoing uncomplicated right colectomy with ileostomy 5 days ago. His postoperative course has been uneventful. The patient now has developed nausea and vomiting and has been unable to keep fluids down for the past 12 hours. Vital signs are temperature 37.2°C (99.0°F), pulse 102/min, respirations 17/min, and blood pressure 115/60 mm Hg. The stab wound site and surgical incision sites are intact and clean with no erythema. The ostomy is viable with minimal fluid and no gas within the ostomy appliance. X-ray of the abdomen discloses a dilated stomach with gas in the small and large intestines. Results of serum laboratory studies are shown:
Serum
Calcium 10.2 mg/dL
Na+ 130 mEq/L
K+ 3.6 mEq/L
Cl− 95 mEq/L
Glucose 352 mg/dL
Magnesium 1.8 mEq/L
Phosphorus 3.1 mg/dL
Urinalysis shows 2+ glucose. In addition to intravenous hydration and placement of a nasogastric tube, which of the following is the most appropriate management?
A) Fleet enema
B) Intravenous cefazolin therapy
C) Intravenous insulin therapy
D) Upper gastrointestinal study with small bowel follow-through
E) Observation only
33.
An alcohol-dependent, 46-year-old man is admitted to the hospital because of his first episode of acute pancreatitis. On physical examination he is short of breath and has marked tenderness over his abdomen. Which of the following would be the most compelling indication for admitting this patient to the intensive care unit for observation?
A) Serum ALT concentration of 300 U/L
B) Serum amylase concentration of 500 U/L
C) Arterial Po2 of 52 mm Hg while breathing room air
D) Leukocyte count of 14,500/mm3
E) Serum glucose concentration of 500 mg/dL
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34.
An 82-year-old woman is transported from the nursing care facility to the hospital for evaluation of a fever. The facility's staff reported that the patient's temperature was 39.4°C (103.0°F) 2 hours ago. En route to the emergency department the paramedics started an intravenous line and administered 800 mL of 0.9% saline. The patient is noncommunicative. Medical history is significant for hypertension, congestive heart failure, and multiple strokes with residual right-sided hemiparesis and contractures. Current medications include enalapril, furosemide, 81-mg aspirin, and a multivitamin. Vital signs are temperature 39.9°C (103.8°F), pulse 112/min, respirations 24/min, and blood pressure 78/42 mm Hg. Pulse oximetry shows an oxygen saturation of 89% while breathing room air. The patient appears ill. She is cachectic and pale and has contractures of all extremities. Auscultation of the lungs discloses bilateral basilar crackles. Abdominal examination discloses no distention or rigidity. There is a stage I decubitus ulcer on both heels but no other rash or lesions are noted. Which of the following is the most likely underlying cause of this patient's current blood pressure?
A) Endogenous catecholamine depletion
B) Endogenous corticosteroid depletion
C) Myocardial ischemia
D) Peripheral vasodilation
E) Volume depletion
35)?
Oh boy!  for some reason I missed this question but reading the next one, this was some diagnosis that should be informed to the patient's wife. HIV? I am not sure Sorry!
36.
Item 2 of 2
He asks you to keep his diagnosis confidential. The patient then decides to postpone the operation. In the hallway outside his room you encounter the patient's wife. She is very angry at the cancellation of the operation. She accosts you and demands an explanation. Which of the following is the most appropriate response?
A) "I will walk back with you while you ask your husband."
B) "The operating room schedule was disrupted with an emergency."
C) "Your husband asked me not to say."
D) "Your husband's blood tests were abnormal."
E) "We have identified a serious new condition."
End of 2nd block!
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29.
A newborn is transferred to the neonatal intensive care unit soon after delivery because of respiratory distress. She has been intubated and mechanically ventilated since birth. She was born at 35 weeks' gestation via emergency cesarean delivery to a 37-year-old woman, gravida 4, para 3, and her 42-year-old husband. Apgar scores were 1 and 6 at 1 and 5 minutes, respectively. The pregnancy was complicated by type A gestational diabetes. Prenatal testing was limited to fetal ultrasonography at 20 weeks' gestation. Amniocentesis and maternal serum triple screening were declined. Family history is unremarkable. There are three healthy siblings, ages 4, 6, and 8 years. The patient is 44 cm (17 in; 25th percentile) long, and weighs 1.8 kg (4 lb; 10th percentile for corrected gestational age), and head circumference is 30 cm (12 in; 10th percentile). Physical examination discloses mottled skin and a small face for cranial size. There is a cleft of the secondary palate. Ears are small and dysplastic. The sternum is short. Lungs are clear to auscultation. Cardiac examination discloses a high-pitched, grade 2/6 systolic murmur. The hands and feet appear as shown in the photographs. Muscle tone is increased. Pulse oximetry on an Fio2 of 1.0 shows an oxygen saturation of 80%. Which of the following is the most appropriate next step in diagnosis?
A) Chromosomal analysis
B) Determination of arterial blood gas values
C) Echocardiography
D) MRI of the brain
E) Skeletal survey
Ans: A) Chromosomal analysis
I marked C but it came wrong by NBME. Any other ideas?
This baby has features that are commonly seen in Trisomy 18 (Edward's Sd) but the mottled skin could also be due to a TORCH infection. A karyotype would be a good 1st step to manage this case.
Trisomy 18 syndrome,
2nd mc autosomal chromosomal aberxsration in humans, after trisomy 21 (Down Sd)
The major features include:
- IUGR
- Microcephaly, characteristic craniofacial features (prominent occiput, short palpebral fissures, malformed and low-set ears, small mouth, narrow palate, and micrognathia)
- Clenched hands (index over 3rd, 5th over 4th)
- Short sternum, low arch pattern of the dermal ridges on the fingertips
- Severe cardiac malformations (VSD, ASD< PDA)
- Rocker bottom feet, hammer toe
- Omphalocele
- Renal abnormalities
- Mental retardation are other features.
Keywords:
Low-set malforemed ears, clenched fist, rocker bottom feet. Omphalocele. Do not survive 1st year.
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q30) A
A) Brain death cannot be assessed at this time
You can not perform neurological physical exam while the patient is under high doses of morphine and benzodiazepine.
(E is wrong by nbme)
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q31)
Ans) E
(confirmed by NBME)
A case of Endocarditis, we have to study valves here, so an Echo would be nice.
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q32
Ans) C
C) Intravenous insulin therapy
(correct by nbme feedback)
Keep patient hydrated, decompress with NGT and maintain blood glucose at normal levels, we need to give Insulin to the patient.
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q33)
Ans: C
C) Arterial Po2 of 52 mm Hg while breathing room air
(correct by nbme)
Respiratory complications are common in acute pancreatitis, so, maintaining a good ventilation perfusion on these patients is vital to avoid worsening of his condition.
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34.
An 82-year-old woman is transported from the nursing care facility to the hospital for evaluation of a fever. The facility's staff reported that the patient's temperature was 39.4°C (103.0°F) 2 hours ago. En route to the emergency department the paramedics started an intravenous line and administered 800 mL of 0.9% saline. The patient is noncommunicative. Medical history is significant for hypertension, congestive heart failure, and multiple strokes with residual right-sided hemiparesis and contractures. Current medications include enalapril, furosemide, 81-mg aspirin, and a multivitamin. Vital signs are temperature 39.9°C (103.8°F), pulse 112/min, respirations 24/min, and blood pressure 78/42 mm Hg. Pulse oximetry shows an oxygen saturation of 89% while breathing room air. The patient appears ill. She is cachectic and pale and has contractures of all extremities. Auscultation of the lungs discloses bilateral basilar crackles. Abdominal examination discloses no distention or rigidity. There is a stage I decubitus ulcer on both heels but no other rash or lesions are noted. Which of the following is the most likely underlying cause of this patient's current blood pressure?
A) Endogenous catecholamine depletion
B) Endogenous corticosteroid depletion
C) Myocardial ischemia
D) Peripheral vasodilation
E) Volume depletion
Ans: D
This is septic shock
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35)?
Oh boy! for some reason I missed this question but reading the next one, this was some diagnosis that should be informed to the patient's wife. HIV? I am not sure Sorry!
36.
Item 2 of 2
He asks you to keep his diagnosis confidential. The patient then decides to postpone the operation. In the hallway outside his room you encounter the patient's wife. She is very angry at the cancellation of the operation. She accosts you and demands an explanation. Which of the following is the most appropriate response?
A) "I will walk back with you while you ask your husband."
B) "The operating room schedule was disrupted with an emergency."
C) "Your husband asked me not to say."
D) "Your husband's blood tests were abnormal."
E) "We have identified a serious new condition."
q36) ans: A
In this case we first give the chance to our patient to comunicate the problem to his wife.
This block is ended!!!
WoooHooo!!!  Finally!
Now Block 3 and let's do this fast!
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