1 ) The 72 y/o F with dementia asking to sign out against medical advice...MMSE is 25....I picked "Allow the patient to sign out and document in her records that she should remain at the hospital" and it was wrong....Not sure what is the correct answer. Is it "Assess her decision making capacity"? or "Discharge and schedule a f/u after 2 days"?
Assess decision making capacity. Patients with neuropsychiatric illness that make medical decisions against their own health should be evaluated for decision making capacity.
2) The cause of anorexia..I picked hyperkalemia haphazardly (did not have time) and it was wrong...I did not really understand the case!
The 90 yr old with generalized pruritis right? The answer is in the lab values. BUN and Cr are way high, and her electrolytes are all being retained. Uremia is causing pruritis and anorexia. Answer is renal failure.
3) 37 y/o woman w heartburn unresponsive to anti-acids, diarrhea and painful digital edema....Has Raynaud's in her fingers too..Choices: Amyloidosis, scleroderma, SLE, Carcinoid, or ZE Syndrome...I picked the latter and it was wrong...What is the case here? Painful digital edema!!
Yeah, scleroderma, like notbobtrustme said.
4) The DM question. I know this have already been discussed here...But want to make sure about some facts here...No need for ACE-I/ARB antagnosits if there is no proteinuria? In other words, aside from the ideal BP that has been discussed above, which is more important, ACE-I or Anti-lipids?
Answer is actually enalapril here. But I'd basically ignore this question and just follow UWorld since this Q tests on old guidelines. Like you're saying, UWorld directly contradicts this Q in QID 4336. Don't worry, I got questions similar to this one on my real deal FM shelf and they were very straightforward.
5) The transudative pleural effusion (due to CHD), what to do find in the effusion? I picked the neutrophil count > 1000 and it was wrong! I thought it was an easy question since 3 choices were those of exudative effusion criteria and eryrthrocyte count > 15,000! Explain please!!
I didn't get this one right, but they're simultaneously testing Light's criteria and the qualities of normal pleural fluid. The answer is serum glucose = pleural fluid glucose. For your own knowledge, here are 3 normal characteristics of pleural fluid:
-RBC < 1000
-WBC < 1000
-Pleural glucose = serum glucose
And here are Light's criteria, any one of which indicate exudative effusion:
-Pleural albumin >50% of serum albumin
-Pleural LDH >60% of serum LDH
-Pleural LDH > 200
Also, a pleural fluid pH < 7.2 is indicative of empyema.
6) The two item set....One case of 15 y/o girl with 2 week chest pain under left breast...I picked reassurance and it was correct...but what is the case here? Muskuloskeletal?!
The second case was 32 y/o woman with 2 week chest pain worse at night, improves by sitting up or walking 10 minutes...Has mild tenderness in the right upper quadrant....What is the case here? The question asks for the next management step!
First is reassurance, second is H2-blockers.
Not too sure if they really wanted you to obtain an actual diagnosis on the first one. I think the idea is that it could be anything (e.g. MSK, period cramps, fibrocystic disease, etc.) and that given her profile, it's highly unconcerning. As for the second, it's GERD and H2-blockers are the only sensible treatment for her case (PPIs aren't an answer choice).
7) A case of obstructive lung disease...His brother had a lung transplant for COPD...asking about the mechanism of the disease...I thought it's COPD and picked "Destructive changes in bronchial wall elastic and muscular layer....it was wrong!!
What notbobtrustme said. This guy doesn't smoke, yet he has COPD. The answer is the one that refers to an abnormality of antiprotease.
8) RA with hx of methotrexate...CBCs shows leukopenia....I thought it's drug induced myelofibrosis...wrong...Is it CLL? Platelets are normal and lymphocytes are high...so probably CLL?
Felty syndrome: RA + neutropenia. Note that lymphocytes weren't actually high (just a relative increase), since the overall WBC count was low.
9) Pilonidal sinus....I always learned in surgery that you do wide excision and leave it to hear by 2 intention...Got it wrong! Is it surgical drainage?
Surgical drainage is the answer. I was fortunate enough to not know what you're referring to at the time of taking this test, so I just thought abscess --> drain. I suppose the logic is that you would drain the abscess first, then excise the pilonidal tract. I've never gone wrong by answering I+D for every abscess question, basically.
10) That crazy Rash q...Is it avoidance of sunscreen?
Sorry, still have no idea.
11) SOB for 5 days...Had upper resp infection 2 weeks ago...on physical exam has JV distension, S3, pitting edema....Is it dilated cardiomyopathy from myocarditis? So Lasix?
Yep. Furosemide is very often the answer anytime someone has symptomatic CHF and you're asked what to do next.
