free 138 tutorial sequential question

[abelabbot]

a 34 year old man comes to the office because of a 24 hour history of cramps pain originating in the right flank and radiating to his groin. he describes the pain as the worst pain of his life and says he also has had nausea and one episode of vomiting. The patient appears muscular and is in mild distress. Vital signs now are temperature 37.8 c(100 F) pulse 120/min, and blood pressure 135/92 mm HG supine. Oral muscosa is dry. Auscultation of the lungs discloses no abnormalities. Cardiac examination discloses and s1, a physiologically split s2 with no gallops, and a 2/6 systolic ejection murmur. Abdominal examination discloses guarding in the right upper and lower quadrant, bowerl sounds are diminished. There is right sides costovertebral angle tenderness. Lab results: pro tine trace positive
leuko esterase trace positive
nitrie negative
wbc-4-8
rbc 25-30
hemoglob 15
web 10,500
creatinine1.1
bun 12
bilirub total .5
alk phos 120
ast 36
ast 28

Which of the following is the most likely diagnosis?

cholelethiasis

cystitis

pyelonephristis with proteus species

renal tubular acidosis

urolithiasis


(I think the answer is urolithiasis….Just wanted to confirm w everyone….i accidentally picked pyelneph w proteus cuz the proteus threw me off)

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[abelabbot]

the question that followed was


"While in the office, the patient passes a renal stone. He recovers and returns to the office 7 days later for followup. Analysis of the stone discloses that it contains calcium oxalate. Which of the following is the most appropriate next step?

begin therapy w thiazide diuretic -right answer I think-

begin therapy w low oxalate diet

recommend increased fluid intake

refer patient for lithotripsy

refer patient for urodynamic studies

 

[J ROD]

the question that followed was


"While in the office, the patient passes a renal stone. He recovers and returns to the office 7 days later for followup. Analysis of the stone discloses that it contains calcium oxalate. Which of the following is the most appropriate next step?

begin therapy w thiazide diuretic -right answer I think-

begin therapy w low oxalate diet

recommend increased fluid intake

refer patient for lithotripsy

refer patient for urodynamic studies

I think increasing fluids would be a better choice.

 

[abelabbot]

I think increasing fluids would be a better choice.

It can't be increased fluids…..it's almost automatic to pick thiazides since they retain calcium, thus preventing calciuria/calcium stones ...

 

[Apoplexy__]

I think increasing fluids would be a better choice.

+1. Not only did it say his mucous membranes were dry (dead giveaway in Q stems for dehydration), but I got a UWorld question on this where hydration was superior to a logical answer like giving thiazides (QID #816).

From UWorld: "By increasing fluid intake, patients can help prevent the formation of all types of all types of renal calculi."

 

[J ROD]

It can't be increased fluids…..it's almost automatic to pick thiazides since they retain calcium, thus preventing calciuria/calcium stones ...

I think it can. Fluids are usually the first thing with stones and then others. And he is dehydrated.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1455427/

 

[abelabbot]

Wow….and here I sounded so confident smh….Thanks for the reminder guys..Yeah I remember that concept in Uworld….I really hope I don't make mistakes like this on the exam….btw This updated Free 150 questions is NOT as easy as the previous years…this one involves a lil more thinking, obviously along with the easy questions..anyone else notice that?

 

[abelabbot]

+1. Not only did it say his mucous membranes were dry (dead giveaway in Q stems for dehydration), but I got a UWorld question on this where hydration was superior to a logical answer like giving thiazides (QID #816).

From UWorld: "By increasing fluid intake, patients can help prevent the formation of all types of all types of renal calculi."

So lets say if I get a question with the same symptoms pretty much except they mention nothing about the patient being dehydrated….and if the patient has calcium oxalate stones….should I go with thiazides, even if fluid intake is mentioned as another answer choice?

 

[abelabbot]

Is urolithiasis correct for my first question?

 

[Apoplexy__]

Wow….and here I sounded so confident smh….Thanks for the reminder guys..Yeah I remember that concept in Uworld….I really hope I don't make mistakes like this on the exam….btw This updated Free 150 questions is NOT as easy as the previous years…this one involves a lil more thinking, obviously along with the easy questions..anyone else notice that?

Don't worry about it man.

I felt pretty awful about the 2014 Free 150 (pdf form), which was probably very similar to what you're using. I don't think it's just you.

To answer your other two questions:
-I would actually still go with increased fluid intake. Besides the fact that the UWorld question didn't mention the patient was dehydrated at all and still expected you to manage the patient with increased fluids, it's kind of one of those "don't miss the big picture" things. Like working up a patient with amenorrhea by getting chromosomal studies, endometrial biopsy, and a hormone panel without first checking B-hCG.
-Yeah, urolithiasis. Loin --> groin pain is basically pathognomonic; I've never seen a question with that type of pain that wasn't urolithiasis. Also, the "worst pain of life" in a male is pretty indicative (they say it's the male equivalent of childbirth), as is the hematuria.

 

[J ROD]

Is urolithiasis correct for my first question?

yes

 

[abelabbot]

Don't worry about it man.

I felt pretty awful about the 2014 Free 150 (pdf form), which was probably very similar to what you're using. I don't think it's just you.

To answer your other two questions:
-I would actually still go with increased fluid intake. Besides the fact that the UWorld question didn't mention the patient was dehydrated at all and still expected you to manage the patient with increased fluids, it's kind of one of those "don't miss the big picture" things. Like working up a patient with amenorrhea by getting chromosomal studies, endometrial biopsy, and a hormone panel without first checking B-hCG.
-Yeah, urolithiasis. Loin --> groin pain is basically pathognomonic; I've never seen a question with that type of pain that wasn't urolithiasis. Also, the "worst pain of life" in a male is pretty indicative (they say it's the male equivalent of childbirth), as is the hematuria.

Great explanations! Very helpful! adding these hints into my first aid heh

 

[abelabbot]

+1. Not only did it say his mucous membranes were dry (dead giveaway in Q stems for dehydration), but I got a UWorld question on this where hydration was superior to a logical answer like giving thiazides (QID #816).

From UWorld: "By increasing fluid intake, patients can help prevent the formation of all types of all types of renal calculi."

hey can you help explain my new nbme 13 post related to sarc reticu. and calcium sequestration.