A few NBME 4 questions

[pardonme]

78 year old man with symptoms of SVC syndrome (facial edema etc) Etiology?
A)Aortic arch aneurysm
B)Mass in the upper lobe of the right lung
CRight cervical rib
D)Right pneumothorax
E)Thoracic duct blockage in the posterior mediastinum

What is the best rx for a woman w/ stable asthma who wheezes when exposed to cats?
A)Inhaled cromolyn
B)Inhaled ipratropium
C)Oral cimetidine
D)Oral corticosteroids
E)Oral theophylline

A healthy 80 year old dude is given midazolam for rectal bleeding and develops severe resp depression. An increase in what caused this?
A)Enterohepatic recycling
B)Metabolite formation
C)Plasma protein binding
D)Sensitivity to sedatives
E)Volume of distribution

45 year old chick has 4 episodes of left leg twitching, the last of which was followed by a tonic-clonic seizure. what is the location of orgin of the seizure?
A)Inferior frontal cortex
B)Inferior temporal cortex
C)Insular cortex
D)Primary motor cortex
E)Supplementary motor cortex

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[pardonme]

no thoughts?

 

[richse]

78 year old man with symptoms of SVC syndrome (facial edema etc) Etiology?
A)Aortic arch aneurysm
B)Mass in the upper lobe of the right lung
CRight cervical rib
D)Right pneumothorax
E)Thoracic duct blockage in the posterior mediastinum

What is the best rx for a woman w/ stable asthma who wheezes when exposed to cats?
A)Inhaled cromolyn (couldn't find answer in FA so I went by this)
B)Inhaled ipratropium
C)Oral cimetidine
D)Oral corticosteroids
E)Oral theophylline

A healthy 80 year old dude is given midazolam for rectal bleeding and develops severe resp depression. An increase in what caused this?
A)Enterohepatic recycling
B)Metabolite formation
C)Plasma protein binding
D)Sensitivity to sedatives (not sure about this one, seems correct according to this)
E)Volume of distribution

45 year old chick has 4 episodes of left leg twitching, the last of which was followed by a tonic-clonic seizure. what is the location of orgin of the seizure?
A)Inferior frontal cortex
B)Inferior temporal cortex
C)Insular cortex
D)Primary motor cortex (not sure about this but just a logical guess here based on the aura)
E)Supplementary motor cortex

pretty sure the first three are right, the last one is a guess.

 

[pardonme]

pretty sure the first three are right, the last one is a guess.

word.

after further research, i disagree with the first one. Superior sulcus tumors invade the sympathetic chain and cause horners. SVC syndrome is caused by impaired drainage into the SVC, so an aortic arch aneurysm seems like the more anatomically correct answer to me.

yeah, for the second one i wanted to say corticosteroids because they are first line, but the possible answer is oral corticosteroids instead of inhaled. thus, cromolyn seems like the best answer.

 

[richse]

word.

after further research, i disagree with the first one. Superior sulcus tumors invade the sympathetic chain and cause horners. SVC syndrome is caused by impaired drainage into the SVC, so an aortic arch aneurysm seems like the more anatomically correct answer to me.

yeah, for the second one i wanted to say corticosteroids because they are first line, but the possible answer is oral corticosteroids instead of inhaled. thus, cromolyn seems like the best answer.

They said upper lobe mass, but it doesn't mean it would have to be a pancoast's tumor with horners. The right upper lung seems like the anatomically right place to have SVC syndrome. If it helps, FA has SVC syndrome as a common symptom of lung tumor.

Either way, I still think the tumor fits way more than an aortic arch aneurism. That answer would most likely include someone with marfans, untreated syphilis, and/or aortic regurg.

Edit, I found this and now I don't know which answer I would go with because both seem very possible:
William Hunter first described the syndrome in 1757 in a patient with syphilitic aortic aneurysm. In 1954, Schechter reviewed 274 well-documented cases of superior vena cava syndrome (SVCS) reported in the literature; 40% of them were due to syphilitic aneurysms or tuberculous mediastinitishttp://emedicine.medscape.com/article/784277-overview. In more recent times, these infections have gradually decreased as the primary cause of superior vena cava (SVC) obstruction. Lung cancer, particularly adenocarcinoma, is now the underlying process in approximately 70% of the patients with superior vena cava syndrome (SVCS). However, up to 40% of the causes are due to nonmalignant causes.

Since they generally go with current trends I'd hope that lung cancer is the answer.