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10.
A 19-year-old African American man is brought to the emergency department by ambulance after he collapsed while playing basketball 45 minutes ago. The emergency medical technician reports that the patient had a transient loss of consciousness, during which time he fell to the floor and landed on his right side. The patient is now alert and oriented to time and place. He states that he has been in excellent health, does not take medication, and has not used illicit drugs or abused alcohol. The patient is 208 cm (6 ft 10 in) tall and he weighs 88 kg (195 lb); BMI is 20.4 kg/m2. Vital signs now are temperature 37.0°C (98.6°F), pulse 86/min, respirations 20/min, and blood pressure 142/92 mm Hg. The patient appears well-developed and has long, thin arms and legs. There is diffuse tenderness over the right lateral rib cage. His father, who was also tall, died 1 year ago from a dissecting aortic aneurysm. Which of the following additional findings on physical examination would best support the diagnosis?
A) Ectopia lentis
B) Exophthalmos
C) Focal alopecia
D) Micrognathia
E) Ulnar deviation of the fingers
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Ans: A
(nbme cert)
I wish many questions were straight forward like this  .... but no! I've heard they are coming loooong! So, let's be prepared 
Most Keyword questions are about MVP, Ectopia Lentis, Ao diss, Arachnodactyly
Marfan Syndrome
===========
Clinical Features:
Major criteria include four of eight typical skeletal manifestations, Ectopia lentis, Aortic root.
Major criteria for establishing the diagnosis in a family member include having a parent, child,
or sibling who meets major criteria independently, and the presence of a fibrillin-1 mutation that cause the Sd identified in a familial Marfan Sd patient.
* Aortic disease leading to the formation of aneurysmal dilation and dissection is the main cause of morbidity and mortality in Marfan syndrome.
* 60% to 70% of pts have Mitral Valve Prolapse (MVP) with regurgitation.
* Arachnodactyly occurs in 90% of patients
* Thoracic kyphosis may be associated with reduced lung capacity and residual volume that may lead to pulmonary insufficiency.
* Diminished bone mineral density has been reported in several patients.
* ECTOPIA LENTIS occurs in 50% to 80% of patients with Marfan Sd. Subluxation of the lens is usually bilateral and appears by age 5 years.
Firestein: Kelley's Textbook of Rheumatology, 9th ed. Copyright © 2012 Saunders.
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11.
A 52-year-old man with schizophrenia is brought to the emergency department by his wife because of a 1-week history of progressively worsening confusion. She says, "He has been talking to people who aren't there." He is being treated with monthly long-acting haloperidol injections, and daily benztropine, carbamazepine, and clonazepam. The patient's wife believes he has been taking his medications regularly. She further reports that he has been drinking more water than usual recently. The patient's vital signs are temperature 37.0°C (98.6°F), pulse 82/min, respirations 18/min, and blood pressure 118/72 mm Hg with no orthostatic changes. He appears well nourished and comfortable. He answers questions directly and confirms drinking more water than usual, but he is easily distracted and tangential. He is quietly talking to himself and appears to be responding to internal stimuli. There is no visible external evidence of trauma. He is able to move all extremities. Ocular movements appear normal. Results of laboratory studies are shown:
Serum …………………………………………Urine
Urea nitrogen 5 mg/dL…………….. Osmolality 111 mOsmol/kg H2O
Creatinine 0.4 mg/dL………………………. Na+
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11.
A 52-year-old man with schizophrenia is brought to the emergency department by his wife because of a 1-week history of progressively worsening confusion. She says, "He has been talking to people who aren't there." He is being treated with monthly long-acting haloperidol injections, and daily benztropine, carbamazepine, and clonazepam. The patient's wife believes he has been taking his medications regularly. She further reports that he has been drinking more water than usual recently. The patient's vital signs are temperature 37.0°C (98.6°F), pulse 82/min, respirations 18/min, and blood pressure 118/72 mm Hg with no orthostatic changes. He appears well nourished and comfortable. He answers questions directly and confirms drinking more water than usual, but he is easily distracted and tangential. He is quietly talking to himself and appears to be responding to internal stimuli. There is no visible external evidence of trauma. He is able to move all extremities. Ocular movements appear normal. Results of laboratory studies are shown:
Serum …………………………………………Urine
Urea nitrogen 5 mg/dL…………….. Osmolality 111 mOsmol/kg H2O
Creatinine 0.4 mg/dL………………………. Na+
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11.
A 52-year-old man with schizophrenia is brought to the emergency department by his wife because of a 1-week history of progressively worsening confusion. She says, "He has been talking to people who aren't there." He is being treated with monthly long-acting haloperidol injections, and daily benztropine, carbamazepine, and clonazepam. The patient's wife believes he has been taking his medications regularly. She further reports that he has been drinking more water than usual recently. The patient's vital signs are temperature 37.0°C (98.6°F), pulse 82/min, respirations 18/min, and blood pressure 118/72 mm Hg with no orthostatic changes. He appears well nourished and comfortable. He answers questions directly and confirms drinking more water than usual, but he is easily distracted and tangential. He is quietly talking to himself and appears to be responding to internal stimuli. There is no visible external evidence of trauma. He is able to move all extremities. Ocular movements appear normal. Results of laboratory studies are shown:
Serum …………………………………………Urine
Urea nitrogen 5 mg/dL…………….. Osmolality 111 mOsmol/kg H2O
Creatinine 0.4 mg/dL………………………Na+ < 10 mmol/L (N=27–287)
Na+ 117 mEq/L
K+ 3.9 mEq/L
Cl− 88mEq/L
HCO3− 24 mEq/L
Osmolality 257 mOsmol/kg H2O
Carbamazepine 1.0 μg/mL (therapeutic range=0.8–3.2)
Results of complete blood count are within the reference ranges. Toxicology screening of the urine and blood is negative. Which of the following is the most appropriate treatment?
A) Demeclocycline
B) Fluid restriction
C) Hydrochlorothiazide
D) 0.45% Saline
E) 0.9% Saline
F) 3% Saline
12.
A 48-year-old African American man comes to the emergency department because of severe indigestion. He has a history of chronic heartburn and says that he takes antacids "like candy." Past medical history also includes hypertension. The patient says he always has indigestion but he can usually get relief from antacids. Although the pain is characteristic of his usual indigestion, it is now more intense and is unrelieved with antacids. He has had no nausea, vomiting, or weight loss. He does not have a regular physician, although a physician he saw 2 months ago gave him refills on his proton pump inhibitor. Current medications include omeprazole, hydrochlorothiazide, and nifedipine. Now, in the emergency department, the patient appears uncomfortable. Vital signs are temperature 36.5°C (97.7°F), pulse 89/min, respirations 20/min, and blood pressure 152/93 mm Hg. Lungs are clear to auscultation. Cardiac examination is normal except for an S4. Abdomen is soft without organomegaly. There is tenderness in the epigastrium on deep palpation. Skin, extremity, and neurologic examinations are normal. Laboratory studies are obtained and results are shown:
Serum ……………………….. Blood
Amylase 35 U/L ………. Hematocrit 36%
Urea nitrogen 21 mg/dL ………… Hemoglobin 12.2 g/dL
Creatinine 1.4 mg/dL ………….. WBC 6500/mm3
Na+ 140 mEq/L ……………… MCV 89 μm3
K+ 3.9 mEq/L ……………… Platelet count 350,000/mm3
Cl− 109 mEq/L
HCO3− 26 mEq/L
Glucose 90 mg/dL
Lipase 28 U/L
Troponin T
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13.
A 17 year old boy is brought to ED by an ambulance 30 min after being found unconscious in his bathroom by fellow student. It is unknown how long the patient has been unconscious. Medical history is also unknown, during transportation to the hospital, the patient was given O2 via nasal cannula and IV Catheter was inserted. Vital signs at the ER T- 100; Pulse 112; RR: 6; BP 92/66. Pulse Oximeter on 2 liter/ min of O2 nasal cannula shows on O2 saturation of 88%. Exam of head shows no signs of trauma, pupils are 3mm in diameter and nonreactive to light. Neck is supple, he responds only to painful stimuli; the remainder of PE discloses no abnormalities, before initiating treatment it is most appropriate to notify which of the following?
A) County judge
B) Hospital attorney
C) Patient’s parents
D) Patient’s PCP
E) No notification is needed
Item 2 of 2
14. Which of the following is the most appropriate initial step?
A) Administer an intravenous bolus of 0.9% saline
B) Administer intravenous naloxone
C) Do lumbar puncture for cerebrospinal fluid analysis
D) Obtain CT scan of the head
E) Obtain toxicology screening of the urine
15.
A 67-year-old man comes to the emergency department because of a 2-day history of severe pain in his right knee. He rates the pain as a 9 on a 10-point scale and says it is unlike any pain he has ever experienced. He says he slipped on an icy sidewalk 2 weeks ago and skinned both knees, but the pain was not nearly as intense as it is now. He says his right knee has been "creaky" with occasional soreness for the past several years, which he attributes to his 40-year career as a postman. The patient retired 2 years ago but has remained active by walking 1 mile daily. Medical history is significant for type 2 diabetes mellitus, hypertension, and chronic bronchitis. Medications include ibuprofen, glyburide, hydrochlorothiazide, and inhaled budesonide and albuterol. He smoked one pack of cigarettes daily for 30 years but quit 5 years ago; he drinks one-half pint of whiskey daily. Vital signs are temperature 38.3°C (100.9°F), pulse 94/min, respirations 22/min, and blood pressure 178/92 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Skin is warm, dry, and without rash; there is some scaling on both elbows. The right knee is warm, edematous, erythematous, and painful to touch. Distal pulses are symmetric and strong. A small effusion is present and attempts to bend the leg at the knee cause pain. Sensation to pinprick is intact bilaterally in the upper and lower extremities. Results of laboratory studies are shown:
Blood
Hemoglobin 12.2 g/dL
WBC 14,500/mm3
Platelet count 194,000/mm3
Which of the following is the most likely working diagnosis?
A) Gonococcal arthritis
B) Gouty arthritis
C) Post-traumatic intra-articular bleeding
D) Psoriatic arthritis
E) Septic arthritis
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16.
A 28-year-old woman is brought to the emergency department by ambulance because she has had three seizures during the past hour. Her husband told paramedics that the seizures began with jerking of the right arm and leg, followed by jerking of all four extremities. One week ago, she sustained a closed head injury when she slipped on an icy sidewalk. The injury was treated in the emergency department with ice packs and observation. She has a history of hypertension and type 2 diabetes mellitus. She has smoked two packs of cigarettes daily for the past 13 years. On arrival, the patient is comatose. Pulse oximetry on room air shows an oxygen saturation of 97%. Vital signs are temperature 37.0°C (98.6°F), pulse 68/min, respirations 20/min, and blood pressure 180/95 mm Hg. Physical examination shows needle tracks on both upper extremities. Both eyes deviate to the right. Cardiac examination shows a grade 3/6 holosystolic murmur at the cardiac apex. During deep pain stimulation the patient is able to move the left extremities better than the right extremities. Deep tendon reflexes in the right extremities are brisk. Babinski sign is present on the right. Serum glucose concentration is 210 mg/dL. CT scan of the head shows a large ring-enhancing lesion in the posterior portion of the left frontal lobe. Which of the following is the most significant risk factor for development of this patient's condition?
A) Cigarette smoking
B) Closed head injury
C) Diabetes mellitus
D) Heroin abuse
E) Hypertension
17.
A 75-year-old woman of German descent is brought to the emergency department by her husband because of increasing confusion, constant headache, and nausea for the past 2 days. Five days ago she was evaluated in the emergency department following a head injury. A CT scan of the head showed a subdural hematoma. The patient was given oxycodone with acetaminophen and sent home to await liquefaction of the clot prior to surgical evacuation. On arrival at the emergency department today, the patient is oriented to person but not to place or date, and she repeatedly says, "I want to go home now." Her husband reports she has been drinking about 24 oz of liquid per day. Skin turgor appears normal. Vital signs are temperature 37.2°C (99.0°F), pulse 92/min, respirations 18/min, and blood pressure 95/60 mm Hg. On physical examination, there is no papilledema. Neurologic examination discloses no other abnormalities. Which of the following factors in this patient's history most strongly indicates the severity of her condition?
A) Abnormal CT scan of the head
B) Continuing headache
C) Duration of nausea
D) Increasing confusion
E) Low blood pressure
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18.
A 26-year-old man is brought to the emergency department by ambulance 20 minutes after he was stabbed in the right chest by a man on the street during a domestic dispute. On arrival, he is angry and appears distraught. He reports mild shortness of breath and says he has no other symptoms or injuries. There is an odor of alcohol on his breath. Paramedics initiated oxygen therapy and intravenous 0.9% saline at the scene. The patient's medical history is unremarkable. He takes no medications and says he does not use illicit drugs. Vital signs are temperature 37.0°C (98.6°F), pulse 92/min, respirations 24/min, and blood pressure 122/80 mm Hg. Pulse oximetry on 4 L of oxygen via nasal cannula shows an oxygen saturation of 99%. Auscultation of the lungs discloses normal breath sounds bilaterally. There is no palpable crepitus or tenderness. Petroleum gauze dressing is in place covering a 2-cm laceration in the right 4th intercostal space at the mid-clavicular line. The remainder of the physical examination shows no abnormalities. Chest x-ray is shown.
http://i42.photobucket.com/albums/e338/G...dbe950.png
Which of the following is the most appropriate next step?
A) Administer intravenous ciprofloxacin
B) Contact social services
C) Insert chest tube
D) Obtain CT scan of the chest
E) Suture the wound
19.
A 29-year-old man is brought to the emergency department by ambulance 45 minutes after a motor vehicle collision in which he was the restrained driver. Paramedics applied a cervical collar, placed him on a backboard, and began therapy with intravenous fluids en route to the emergency department. On arrival the patient is alert and oriented and reports neck pain. Vital signs are temperature 36.7°C (98.0°F), pulse 90/min, respirations 22/min, and blood pressure 110/70 mm Hg. Pulse oximetry on 100% oxygen via non-rebreather mask shows an oxygen saturation of 100%. Physical examination discloses tenderness of the neck and anterior chest wall with ecchymoses over the chest. There is no abdominal tenderness. Portable chest x-ray shows a widened mediastinal contour of the chest. In addition to x-rays of the cervical spine, which of the following is the most appropriate next step in evaluating this patient?
A) Abdominal ultrasonography
B) CT angiography of the chest
C) CT scan of the abdomen
D) Thoracic aortography
E) Transthoracic echocardiography
20.
A 30-year-old woman comes to the emergency department because of shortness of breath and numbness and tingling of her fingers. If arterial blood gas values were ordered, results would most likely show which of the following?
Po2 Pco2 pH HCO3−
(mm Hg) (mm Hg) (mEq/L)
A) 70 60 7.25 27
B) 40 60 7.37 33
C) 90 40 7.40 24
D) 110 25 7.50 19
E) 40 60 7.51 27
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11.
A 52-year-old man with schizophrenia is brought to the emergency department by his wife because of a 1-week history of progressively worsening confusion. She says, "He has been talking to people who aren't there." He is being treated with monthly long-acting haloperidol injections, and daily benztropine, carbamazepine, and clonazepam. The patient's wife believes he has been taking his medications regularly. She further reports that he has been drinking more water than usual recently. The patient's vital signs are temperature 37.0°C (98.6°F), pulse 82/min, respirations 18/min, and blood pressure 118/72 mm Hg with no orthostatic changes. He appears well nourished and comfortable. He answers questions directly and confirms drinking more water than usual, but he is easily distracted and tangential. He is quietly talking to himself and appears to be responding to internal stimuli. There is no visible external evidence of trauma. He is able to move all extremities. Ocular movements appear normal. Results of laboratory studies are shown:
Serum …………………………………………Urine
Urea nitrogen 5 mg/dL…………….. Osmolality 111 mOsmol/kg H2O
Creatinine 0.4 mg/dL………………………Na+ < 10 mmol/L (N=27–287)
Na+ 117 mEq/L
K+ 3.9 mEq/L
Cl− 88mEq/L
HCO3− 24 mEq/L
Osmolality 257 mOsmol/kg H2O
Carbamazepine 1.0 μg/mL (therapeutic range=0.8–3.2)
Results of complete blood count are within the reference ranges. Toxicology screening of the urine and blood is negative. Which of the following is the most appropriate treatment?
A) Demeclocycline
B) Fluid restriction
C) Hydrochlorothiazide
D) 0.45% Saline (not this one, by nbme)
E) 0.9% Saline
F) 3% Saline (not this one, by nbme)
Ans: B
Not verified but it fits for Tx of psychogenic polydipsia. Any comments on this?
Psychogenic polydipsia
Tx: Restrict water intake
Self-induced water intoxication should always be considered in the differential diagnosis of confusional states and seizures in schizophrenia patients; as many as 20% of schizophrenic patients drink water excessively. Medications such as Lithium and carbamazepine, which cause water retention, can aggravate these symptoms.
Gopal, Abilash; Ropper, Alexander; Tramontozzi, III, Louis (2011-05-23). Deja Review Psychiatry, 2nd Edition (Kindle Locations 1363-1366). McGraw-Hill Education. Kindle Edition.
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12.
A 48-year-old African American man comes to the emergency department because of severe indigestion. He has a history of chronic heartburn and says that he takes antacids "like candy." Past medical history also includes hypertension. The patient says he always has indigestion but he can usually get relief from antacids. Although the pain is characteristic of his usual indigestion, it is now more intense and is unrelieved with antacids. He has had no nausea, vomiting, or weight loss. He does not have a regular physician, although a physician he saw 2 months ago gave him refills on his proton pump inhibitor. Current medications include omeprazole, hydrochlorothiazide, and nifedipine. Now, in the emergency department, the patient appears uncomfortable. Vital signs are temperature 36.5°C (97.7°F), pulse 89/min, respirations 20/min, and blood pressure 152/93 mm Hg. Lungs are clear to auscultation. Cardiac examination is normal except for an S4. Abdomen is soft without organomegaly. There is tenderness in the epigastrium on deep palpation. Skin, extremity, and neurologic examinations are normal. Laboratory studies are obtained and results are shown:
Serum …………………………………..Blood
Amylase 35 U/L ..............……….Hematocrit 36%
Urea nitrogen 21 mg/dL …………Hemoglobin 12.2 g/dL
Creatinine 1.4 mg/dL ………….......WBC 6500/mm3
Na+ 140 mEq/L ……………… MCV 89 μm3
K+ 3.9 mEq/L ……………… Platelet count 350,000/mm3
Cl− 109 mEq/L
HCO3− 26 mEq/L
Glucose 90 mg/dL
Lipase 28 U/L
Troponin T < 0.002 μg/L (N
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