Discuss NBME Form 2 Block 4 - grazie

[ArchivalUser]

Are you sure about 7A???

Someone else said the answer is D by NBME feedback.

This is un elders guy, unstable with a common bile duct of 9 mm. We should do ERCP now.

[ArchivalUser]

i think unstable pt need urgent decompression of cbd by ercp.

[ArchivalUser]

@grazie.....7....D as CBD is dilated,it indicates obstruction,pt is 71 yo but he is medically fit, so answ is ..ERCP.

[ArchivalUser]

common bile duct measuring 9 mm in diameter-> stone impaction, need to remove by ERCP

[ArchivalUser]

I just came back

ok, 7)

7.
A 70-year-old man is brought to the emergency department by his son because of a 2-day history of right upper quadrant abdominal pain, chills, and confusion. He has vomited twice during this time despite decreased food intake. He has hypertension controlled with hydrochlorothiazide. Medical and surgical history is otherwise unremarkable. Vital signs are temperature 40.2°C (104.4°F), pulse 110/min, respirations 18/min, and blood pressure 100/60 mm Hg. The patient appears seriously ill without evidence of jaundice. Abdominal examination discloses tenderness to palpation over the liver without guarding. Results of laboratory studies are shown:
Serum ………………………………….. Blood
Amylase 350 U/L ………………….. WBC 16,500/mm3 with prominent immature forms
Bilirubin, total 2.1 mg/dL ………………. Neutrophils, segmented 42%
Neutrophils, band 25%
Serum urea nitrogen and creatinine concentrations are within the reference ranges, as are results of liver function tests. Ultrasonography of the abdomen shows multiple stones in the gallbladder and a common bile duct measuring 9 mm in diameter. Intravenous fluids and a broad-spectrum antibiotic are administered. Which of the following is the most appropriate next step?
A) Cholecystectomy
B) Cholecystostomy
C) CT scan of the abdomen
D) Endoscopic retrograde cholangiopancreatography
E) HIDA scan

I don't have this confirmed
But sure it's not E, or C, or B

So there is A and D left.
If you say it was D) the answer confirmed, then that's it D)

Review:
=====

If D is the answer... This is the key: "Ultrasonography of the abdomen shows multiple stones in the gallbladder and a common bile duct measuring 9 mm in diameter"

Choledocholithiasis
The optimal treatment for common duct stones depends on the level of local expertise in endoscopy and surgery. In general, the presence of obstructive jaundice with a dilated common bile duct should lead promptly to preop-erative ERCP with sphincterotomy and stone extraction. Once the bile duct has been cleared, the patient can undergo a routine laparoscopic cholecystectomy within 1 or 2 days.

Thank you guys, if D is confirmed by nbme, we just go with it

Runge MD PhD, Marschall S.; Greganti MD, M. Andrew (2010-09-22). Netter's Internal Medicine, 2 (Netter Clinical Science) (Kindle Locations 12027-12031). Butterworth-Heinemann. Kindle Edition.

[ArchivalUser]

Thanks for that guys that was Team Work

[ArchivalUser]

8.
A 6-year-old boy with autistic disorder is brought to the emergency department by his parents 20 minutes after his right arm got caught in a truck door. The arm is swollen and bruised and the patient is in moderate pain. His parents appear to be concerned about his injury. Vital signs are temperature 37.0°C (98.6°F), pulse 110/min, and respirations 24/min. Physical examination discloses contusion on the dorsal and ventral surfaces of the right forearm; no open lacerations are present. The arm is tender to palpation. X-rays of the right forearm show no fracture, but significant soft tissue swelling is noted. Which of the following is the most likely serious complication of this patient's condition?

A) Compartment syndrome
B) Hematoma formation
C) Median nerve palsy
D) Secondary infection
E) Volkmann contracture

[ArchivalUser]

Ans of q8:
A) Compartment syndrome
(nbme cert)


COMPARTMENT SD

Clinical Signs of Compartments Syndrome: 6 P’s
* Pain out of proportions to the injury
* Pain with passive ROM
* Paresthesias
* Paresis
* Pallor
* Pulseless

Tx: The first step in management is Emergency Fasciotomy. 

[ArchivalUser]

9.
A 68-year-old woman comes to the emergency department via ambulance at the recommendation of her primary care physician because of an abnormal ECG obtained 2 hours ago. The patient says she has not been feeling well for the past 7 to 10 days. She has had generalized weakness, fatigue, and nausea and is "just not herself." Medical history is remarkable for diabetes mellitus and hypertension. She refuses to take any medications. She says she watches her diet and is healthy. Vital signs are temperature 37.0°C (98.6°F), pulse 86/min, respirations 18/min, and blood pressure 160/90 mm Hg. The patient appears ill. Auscultation of the chest discloses no abnormalities. Abdomen is soft and nontender with normoactive bowel sounds. ECG is shown.
http://i42.photobucket.com/albums/e338/G...dbe24d.png

Which of the following is the most likely explanation for the ECG findings?

A) Acute myocardial infarction
B) Hypothyroidism
C) Pericarditis
D) Pulmonary embolism
E) Renal failure

[ArchivalUser]

Q-9

Ans) E


the most remarkable finding here are the very tall, peaked T waves in some precordial leads. This strongly suggests Hyperkalemia. QRS widening and peaked T wave are all examples of ECG abnormalities that may simply be due to hyperkalemia.
From the options I will go with E, Renal failure.

Any other comments?