free 138 tutorial sequential question

Discussion in 'Step I' started by abelabbot, 05.20.14.

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  1. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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    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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  3. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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    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
     
  4. J ROD

    J ROD Watch my TAN walk!! Lifetime Donor 10+ Year Member

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    I think increasing fluids would be a better choice.
     
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  5. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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

    Apoplexy__ Blood-and-thunder appearance Bronze Donor 2+ Year Member

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    +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."
     
    Last edited: 05.20.14
  7. J ROD

    J ROD Watch my TAN walk!! Lifetime Donor 10+ Year Member

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    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/
     
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  8. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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    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?
     
  9. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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    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?
     
  10. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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    Is urolithiasis correct for my first question?
     
  11. Apoplexy__

    Apoplexy__ Blood-and-thunder appearance Bronze Donor 2+ Year Member

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    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.
     
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  12. J ROD

    J ROD Watch my TAN walk!! Lifetime Donor 10+ Year Member

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    yes
     
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  13. abelabbot

    abelabbot Banned Banned Account on Hold 2+ Year Member

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

    abelabbot Banned Banned Account on Hold 2+ Year Member

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

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