NBME 6 Question

[kaleerkalut]

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Hi all,

For those that have taken form 6 or those that think they can help I'd appreciate some help figuring out the following questions:

1) 52 y/o 3-month history of increased urinary volume and frequency with 15 pound weight loss despite normal appetite with family history of HTN and type 2 diabetes. He is obese and BP 160/85. NONfasting glucose is 280. Which of the following is increased?

A. bicarbonate
B. glucagon
C. HDL
D. Insulin
E. Ketones

It's not A. It is either B or D but I can't figure out which. If answer is D due to developing type 2 diabetes, then why weight loss (this happens in type 1 but not type 2 I believe). If it is B from glucagonoma, then why the normal appetite.

2) 4 y/o boy with 3-days of fever, cough, and runny nose. 10%tile for weight. Temp 99.5. Skin warm and pink with normal cap refill and normal breath sounds. THIS IS THE ONE WITH THE AUDIO CLIP.

A. CHF
B. Pulm HTN
C. Pericarditis
D. URI
E. VSD

What did the audio clip show? I thought I heard a VSD but not sure (E is wrong). Was there a pericardial knock?

3) Guy that is postop and not producing urine despite 1 fluid bolus of NS. What is next best step?

Either give another bolus or put the foley back in.

4) 52 y/o man routine health maintenance. Smokes. Sedentary. Wants advice about starting exercise program. Father had MI at 62. 77 y/o mom and 51 y/o sister in good health. BMI 25. Pulse 80. RR 12. BP 140/90. In addition to measuring cholesterol, what is most appropriate next step before starting patient on exercise program?

A. CBC
B. Measure serum homocysteine
C. Exercise stress test
D. Spirometry
E. Cardiac cath

It's not D. Is it B? Can't think of why asymptomatic man would need CBC, stress test, or cardiac cath.

5) 67 y/o man 3-month history of right leg pain after walking. Smoker. BMI 28. Right leg shows shiny skin and decreased hair. Femoral pulse 3+. Popliteal pulse 2+. Dorsalis pedis 0. Posterior tibial pulse 0. Right ABI 0.6, left 0.9. In addition to smoking cessation, what is best next step?

A. Daily exercise program
B. Angioplasty
C. Ateriography
D. Femoropopliteal bypass grafting

Its not C. Is it D?

Thanks a ton in advance as I'm taking Step 2 very soon.

 

[umx]

I didn't take NBME 6 but I took a stab at the questions (answers in red below):

Hi all,

For those that have taken form 6 or those that think they can help I'd appreciate some help figuring out the following questions:

1) 52 y/o 3-month history of increased urinary volume and frequency with 15 pound weight loss despite normal appetite with family history of HTN and type 2 diabetes. He is obese and BP 160/85. NONfasting glucose is 280. Which of the following is increased?

A. bicarbonate
B. glucagon
C. HDL
D. Insulin
E. Ketones

It's not A. It is either B or D but I can't figure out which. If answer is D due to developing type 2 diabetes, then why weight loss (this happens in type 1 but not type 2 I believe). If it is B from glucagonoma, then why the normal appetite.

I would say D. Weight loss is a common manifestation of both types of diabetes. Plus, glucagonoma on a standardized test is likely to have the skin manifestations (necrolytic migratory erythema) to point you in that direction and away from diabetes (which is MUCH more common)

2) 4 y/o boy with 3-days of fever, cough, and runny nose. 10%tile for weight. Temp 99.5. Skin warm and pink with normal cap refill and normal breath sounds. THIS IS THE ONE WITH THE AUDIO CLIP.

A. CHF
B. Pulm HTN
C. Pericarditis
D. URI
E. VSD

What did the audio clip show? I thought I heard a VSD but not sure (E is wrong). Was there a pericardial knock?

Didn't take the test so I haven't heard the audio...

3) Guy that is postop and not producing urine despite 1 fluid bolus of NS. What is next best step?

Either give another bolus or put the foley back in.

Were his vitals normal? If so, probably put the Foley back in. If vitals weren't given, I'd still try putting the Foley back in; if you gave him another fluid bolus and he was obstructed, you could overdistend his bladder and cause damage.

4) 52 y/o man routine health maintenance. Smokes. Sedentary. Wants advice about starting exercise program. Father had MI at 62. 77 y/o mom and 51 y/o sister in good health. BMI 25. Pulse 80. RR 12. BP 140/90. In addition to measuring cholesterol, what is most appropriate next step before starting patient on exercise program?

A. CBC
B. Measure serum homocysteine
C. Exercise stress test
D. Spirometry
E. Cardiac cath

It's not D. Is it B? Can't think of why asymptomatic man would need CBC, stress test, or cardiac cath.

I'd probably go for the exercise stress test. You would rule out any possible pre-existing problems that might make exercise risky. Yes, he's asymptomatic but he's sedentary... he could easily become symptomatic if he started exerting himself more, especially in the setting of multiple CAD risk factors. EDIT: Just looked this up: "The American College of Cardiology and American Heart Association recommend exercise treadmill testing for asymptomatic patients with diabetes mellitus, men older than 45 years of age, and women older than 55 years of age before they undertake vigorous exercise"

5) 67 y/o man 3-month history of right leg pain after walking. Smoker. BMI 28. Right leg shows shiny skin and decreased hair. Femoral pulse 3+. Popliteal pulse 2+. Dorsalis pedis 0. Posterior tibial pulse 0. Right ABI 0.6, left 0.9. In addition to smoking cessation, what is best next step?

A. Daily exercise program
B. Angioplasty
C. Ateriography
D. Femoropopliteal bypass grafting

Its not C. Is it D?

There are only four indications for surgical/invasive management of peripheral vascular disease: severe refractory claudication that does not respond to conservative measures, tissue necrosis, infection, and rest pain. This patient does not fit any of the criteria, so he would not be a candidate for any invasive intervention (B or D). Arteriography is *only* performed *preoperatively;* you don't do A-grams if you're not planning on going in to fix things. Since you're not going to treat this man surgically, you'll instead prescribe empiric conservative treatment = daily exercise program (A).

Thanks a ton in advance as I'm taking Step 2 very soon.

 

[tjquinn]

Hi all,
2) 4 y/o boy with 3-days of fever, cough, and runny nose. 10%tile for weight. Temp 99.5. Skin warm and pink with normal cap refill and normal breath sounds. THIS IS THE ONE WITH THE AUDIO CLIP.

A. CHF
B. Pulm HTN
C. Pericarditis
D. URI
E. VSD

What did the audio clip show? I thought I heard a VSD but not sure (E is wrong). Was there a pericardial knock?

Thanks a ton in advance as I'm taking Step 2 very soon.

The answer is D, the audio was of a flow murmur

 

[Bagheera]

1) 52 y/o 3-month history of increased urinary volume and frequency with 15 pound weight loss despite normal appetite with family history of HTN and type 2 diabetes. He is obese and BP 160/85. NONfasting glucose is 280. Which of the following is increased?

A. bicarbonate
B. glucagon
C. HDL
D. Insulin
E. Ketones

I am going with E for this one..... from decreased insulin, the body then goes to make ketones for energy by using up fat as an energy source, hence his weightloss. I may be wrong. maybe someonelse can chime in.

 

[StrangerX]

1) 52 y/o 3-month history of increased urinary volume and frequency with 15 pound weight loss despite normal appetite with family history of HTN and type 2 diabetes. He is obese and BP 160/85. NONfasting glucose is 280. Which of the following is increased?

A. bicarbonate
B. glucagon
C. HDL
D. Insulin
E. Ketones

I am going with E for this one..... from decreased insulin, the body then goes to make ketones for energy by using up fat as an energy source, hence his weightloss. I may be wrong. maybe someonelse can chime in.

Are you saying this is Type I Diabetes?

Type I Diabetics wouldn't be obese at the onset of symptoms. They should be thin/normal weight unless they received insulin intensive therapy. Type II Diabetics have a stronger genetic component vs I and are more closely linked to obesity. Type II Diabetics are less ketosis prone. It gets more confusing if the question is asking about LADA.

 

[ipizzy]

1) 52 y/o 3-month history of increased urinary volume and frequency with 15 pound weight loss despite normal appetite with family history of HTN and type 2 diabetes. He is obese and BP 160/85. NONfasting glucose is 280. Which of the following is increased?

A. bicarbonate
B. glucagon
C. HDL
D. Insulin
E. Ketones

I am going with E for this one..... from decreased insulin, the body then goes to make ketones for energy by using up fat as an energy source, hence his weightloss. I may be wrong. maybe someonelse can chime in.

This man is unlikely to be a type 1 diabetic (he is obese and hypertensive, and has a family history of type 2 diabetes). Given he is most likely presenting with symptoms of new onset type 2 diabetes, he will have peripheral insulin resistance and therefore increased insulin levels. Type 2 diabetics produce enough insulin to prevent ketosis.

 

[Bagheera]

thanks guys for clearing that up though the weightloss in a type 2 DM pt still confuses me as to how its happening.. Can someone please explain how this patient lost 15 pounds in such a short amount of time with no change in appetite? if that weightloss wasnt there I would hve picked increased insulin no problem, but I guess I looked too much into the question.

 

[StrangerX]

Mainly from loss of muscle mass (http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Symptoms.aspx) and probably from loss of fluid too through osmotic diuresis. Not sure about the appetite, could be a distraction.

 

[Bbon]

Hi all,

For those that have taken form 6 or those that think they can help I'd appreciate some help figuring out the following questions:

1) 52 y/o 3-month history of increased urinary volume and frequency with 15 pound weight loss despite normal appetite with family history of HTN and type 2 diabetes. He is obese and BP 160/85. NONfasting glucose is 280. Which of the following is increased?

A. bicarbonate
B. glucagon
C. HDL
D. Insulin
E. Ketones

It's not A. It is either B or D but I can't figure out which. If answer is D due to developing type 2 diabetes, then why weight loss (this happens in type 1 but not type 2 I believe). If it is B from glucagonoma, then why the normal appetite.

2) 4 y/o boy with 3-days of fever, cough, and runny nose. 10%tile for weight. Temp 99.5. Skin warm and pink with normal cap refill and normal breath sounds. THIS IS THE ONE WITH THE AUDIO CLIP.

A. CHF
B. Pulm HTN
C. Pericarditis
D. URI
E. VSD

What did the audio clip show? I thought I heard a VSD but not sure (E is wrong). Was there a pericardial knock?

3) Guy that is postop and not producing urine despite 1 fluid bolus of NS. What is next best step?

Either give another bolus or put the foley back in.

4) 52 y/o man routine health maintenance. Smokes. Sedentary. Wants advice about starting exercise program. Father had MI at 62. 77 y/o mom and 51 y/o sister in good health. BMI 25. Pulse 80. RR 12. BP 140/90. In addition to measuring cholesterol, what is most appropriate next step before starting patient on exercise program?

A. CBC
B. Measure serum homocysteine
C. Exercise stress test
D. Spirometry
E. Cardiac cath

It's not D. Is it B? Can't think of why asymptomatic man would need CBC, stress test, or cardiac cath.

5) 67 y/o man 3-month history of right leg pain after walking. Smoker. BMI 28. Right leg shows shiny skin and decreased hair. Femoral pulse 3+. Popliteal pulse 2+. Dorsalis pedis 0. Posterior tibial pulse 0. Right ABI 0.6, left 0.9. In addition to smoking cessation, what is best next step?

A. Daily exercise program
B. Angioplasty
C. Ateriography
D. Femoropopliteal bypass grafting

Its not C. Is it D?

Thanks a ton in advance as I'm taking Step 2 very soon.

1. D - Type 2 diabetics overproduce insulin early on to compensate for the insulin resistance.
2. Missed that one too. It's not pericarditis, so that leaves A, B, D. Hard to say without hearing it again.
3. Didn't give me much to work with or to jog my memory of the question. If the question suggests there might be some kind of neurogenic bladder or outlet obstruction, then it would be to put the foley in.
4. C. I think you want to make sure exercise doesn't trigger ACS stuff. Which is important since you're evaluating him for starting an exercise program.
5. A. Exercise and smoking cessation are always the first two interventions for peripheral vascular disease.

 

[futuredoctor10]

1. D - Type 2 diabetics overproduce insulin early on to compensate for the insulin resistance.
2. Missed that one too. It's not pericarditis, so that leaves A, B, D. Hard to say without hearing it again.
3. Didn't give me much to work with or to jog my memory of the question. If the question suggests there might be some kind of neurogenic bladder or outlet obstruction, then it would be to put the foley in.
4. C. I think you want to make sure exercise doesn't trigger ACS stuff. Which is important since you're evaluating him for starting an exercise program.
5. A. Exercise and smoking cessation are always the first two interventions for peripheral vascular disease.

Yeah I think people are over-analyzing question 1 some, I thought what you said above.

With regards to PVD, you would do angiography/bypass if there is ABI < 0.4 or symptoms not resolving with medical management?

 

[drk]

How have people been scoring on Form 6 as compared to form 4 and 2? Difficulty level?

 

[CajunMD]

57yoF with breast ca mets to spine with elevated Ca:
a) cervical collar
b) PT
c) mithramycin
d) tamoxifen
e) cervical decomp and stabilization

 

[CajunMD]

S/p TBI with staring spells, lip smacking, auditory/olfactory hallucinations:
a) absence sz
b) complex partial sz
c) TIA
d) Tourette's
e) limbic encephalopathy

 

[Food]

Won't the NBME overlords strike down this thread, citing some draconian rules about how they control everything pertaining to a test, including your own personal memory of it, despite the fact that you paid an obscenely unjustified amount of money for it?

 

[eastcoastdr]

edit: nvm

 

[eastcoastdr]

57yoF with breast ca mets to spine with elevated Ca:
a) cervical collar
b) PT
c) mithramycin
d) tamoxifen
e) cervical decomp and stabilization

I put E, it didn't get marked wrong. If I remember correctly she had neuro signs indicating spinal cord compression.

 

[eastcoastdr]

S/p TBI with staring spells, lip smacking, auditory/olfactory hallucinations:
a) absence sz
b) complex partial sz
c) TIA
d) Tourette's
e) limbic encephalopathy

I put B, didn't get marked wrong. I believe that's exactly what complex partial seizures are known for: hallucinations (aduitory, visual, olfactory), automatisms (repeated coordinated movement), deja vu, imparied consciousness, post-ictal confusion. Arises from focal region, most commonly temporal lobe. --- (Info from Step up to step 2)

 

[medpack87]

The answer is D, the audio was of a flow murmur

I went for URI too and got it right. I didnt hear any murmurs on any auscultatory point though.

 

[Kaputt]

Just took form 6 as well.

2) 4 y/o boy with 3-days of fever, cough, and runny nose. 10%tile for weight. Temp 99.5. Skin warm and pink with normal cap refill and normal breath sounds. THIS IS THE ONE WITH THE AUDIO CLIP.

A. CHF
B. Pulm HTN
C. Pericarditis
D. URI
E. VSD

What did the audio clip show? I thought I heard a VSD but not sure (E is wrong). Was there a pericardial knock?

The heart sounds were normal, actually. The answer is D, URI.

 

[balboah]

Hi all,

Just took the form 6 too, and would appreciate your input to the following questions:

A 15-year-old girl is brought to the physician by her parents because of an 8-hour history of difficulty breathing. She has a history of asthma treated with oral montelukast and inhaled salmeterol and fluticasone. She has been hospitalized three times for exacerbation of asthma; the most recent hospitalization was 3 months ago. She appears to be in moderate distress. Examination shows labored breathing with intercostal retractions. Expiratory wheezes are heard. The patient says that she sometimes forgets to take her medication and does not believe that she needs it. Which of the following is the most appropriate next step to increase the likelihood that this patient will become compliant with her medication regimen?

A) Recommend that her parents reward or punish the patient based upon compliance
B) Negotiate a contract regarding medication compliance
C) Refuse to see the patient if she continues to be noncompliant
D) Begin clonidine therapy
E) Begin fluoxetine therapy
F) Begin methylphenidate therapy
G) Recommend psychiatric evaluation

A 32-year-old woman comes to the physician because she and her husband have been unable to conceive for 2 years. They have sexual intercourse every 2 days. Menarche was at the age 0114 years. Menses occur at irregular 35- to 50-day intervals and last 10 days; they are not painful. Menstrual flow is normal. She has no history of serious illness and takes no medications. She used an oral contraceptive for 16 years for menstrual cycle regulation but discontinued it 2 years ago. Her husbands sperm count is within the reference range. The patient is 152 cm (5 II) tall and weighs 72 kg (160 lb); BMI is 31 kg/rn2. Physical examination shows acne vulgaris over the face, upper shoulders, and back. The remainder of the examination, including pelvic examination, shows no abnormalities. Serum thyroid-stimulating hormone, free testosterone. dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone, and follicle-stimulating hormone concentrations are within the reference ranges. Which of the following is the most likely diagnosis?

A) Endometriosis
B) Turner
C) Hyper Prolactinemia
D) PCOS
E) Premature ovarian failure

A previously healthy 32-year-old woman comes to the physician because of a 10-day history of persistent cough that keeps her awake at night and is worse with physical activity. The cough is sometimes productive of white sputum in the early morning. Her symptoms began with an upper respiratory tract infection characterized by low-grade fever, sore throat, and malaise 10 days ago. Her only medication is an over-the-counter cough suppressant. She has smoked one pack of cigarettes daily for 16 years. She is employed as a skilled nursing care assistant. She is not in distress but has a rasping cough. Her temperature is 37.4°C (99.4°F), pulse is 78/mm, respirations are 12/mm, and blood pressure is 130/80 mm Hg. Examination shows no pharyngitis or facial tenderness. Scattered end-expiratory wheezes are heard bilaterally. Her peak expiratory flow rate is mildly decreased. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in pharmacotherapy?

A) Nonsedating oral antihistamine
B) Oral antibiotic
C) Inhaled 31adrenergic agonist
D) Inhaled anticholinergic
E) Inhaled mast cell stabilizer

Chose A but was wrong; wasn't sure about the diagnosis but went for post nasal drip, thus chose the H1 blocker


For each patient with papilledema, select the most likely diagnosis

A) Bacterial meningitis
B) Cerebral infarction
C) Cryptococcal meningitis
D) Glioblastoma multiforme
E) Herpes simplex encephalitis
F) Hypertensive encephalopathy
G) Idiopathic intracranial hypertension
H) Intracerebral hemorrhage
I) St. Louis encephalitis

A 25-year-old man with a history of intravenous drug use comes to the emergency department because of a progressive diffuse headache, generalized malaise, and low-grade fever for 2 months. During this period, he has had a poor appetite resulting in a 6.8-kg (15-lb) weight loss. His temperature is 38°C (1004°F). Examination shows neck stiffness. Mental status examination shows no abnormalities. Cranial nerve examination shows weakness of the lateral rectus muscle on the right and bilateral papilledema. A CT scan of the head with and without contrast shows moderate ventricular enlargement. Examination of cerebrospinal fluid shows:

Opening pressure 220 mm H20
Glucose 35 mg/dL
Protein 150 mg/dL
WBC 100/mm3
Lymphocytes 100%
RBC 1/mm3

Thanks so much for your help!

 

[stepck]

What is the answer for the ethics question ?

 

[avogrados number]

2. Is normal physiology splitting of S2

 

[drpisho]

ANSWERS IN BOLD

A 15-year-old girl is brought to the physician by her parents because of an 8-hour history of difficulty breathing. She has a history of asthma treated with oral montelukast and inhaled salmeterol and fluticasone. She has been hospitalized three times for exacerbation of asthma; the most recent hospitalization was 3 months ago. She appears to be in moderate distress. Examination shows labored breathing with intercostal retractions. Expiratory wheezes are heard. The patient says that she sometimes forgets to take her medication and does not believe that she needs it. Which of the following is the most appropriate next step to increase the likelihood that this patient will become compliant with her medication regimen?

A) Recommend that her parents reward or punish the patient based upon compliance
B) Negotiate a contract regarding medication compliance
C) Refuse to see the patient if she continues to be noncompliant
D) Begin clonidine therapy
E) Begin fluoxetine therapy
F) Begin methylphenidate therapy
G) Recommend psychiatric evaluation

I answered B and didnt show in my wrong ones.

A 32-year-old woman comes to the physician because she and her husband have been unable to conceive for 2 years. They have sexual intercourse every 2 days. Menarche was at the age 0114 years. Menses occur at irregular 35- to 50-day intervals and last 10 days; they are not painful. Menstrual flow is normal. She has no history of serious illness and takes no medications. She used an oral contraceptive for 16 years for menstrual cycle regulation but discontinued it 2 years ago. Her husbands sperm count is within the reference range. The patient is 152 cm (5 II) tall and weighs 72 kg (160 lb); BMI is 31 kg/rn2. Physical examination shows acne vulgaris over the face, upper shoulders, and back. The remainder of the examination, including pelvic examination, shows no abnormalities. Serum thyroid-stimulating hormone, free testosterone. dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone, and follicle-stimulating hormone concentrations are within the reference ranges. Which of the following is the most likely diagnosis?

A) Endometriosis
B) Turner
C) Hyper Prolactinemia
D) PCOS
E) Premature ovarian failure

A previously healthy 32-year-old woman comes to the physician because of a 10-day history of persistent cough that keeps her awake at night and is worse with physical activity. The cough is sometimes productive of white sputum in the early morning. Her symptoms began with an upper respiratory tract infection characterized by low-grade fever, sore throat, and malaise 10 days ago. Her only medication is an over-the-counter cough suppressant. She has smoked one pack of cigarettes daily for 16 years. She is employed as a skilled nursing care assistant. She is not in distress but has a rasping cough. Her temperature is 37.4°C (99.4°F), pulse is 78/mm, respirations are 12/mm, and blood pressure is 130/80 mm Hg. Examination shows no pharyngitis or facial tenderness. Scattered end-expiratory wheezes are heard bilaterally. Her peak expiratory flow rate is mildly decreased. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in pharmacotherapy?

A) Nonsedating oral antihistamine
B) Oral antibiotic
C) Inhaled 31adrenergic agonist
D) Inhaled anticholinergic
E) Inhaled mast cell stabilizer

Patient has acute COPD exacerbation

A) Bacterial meningitis
B) Cerebral infarction
C) Cryptococcal meningitis
D) Glioblastoma multiforme
E) Herpes simplex encephalitis
F) Hypertensive encephalopathy
G) Idiopathic intracranial hypertension
H) Intracerebral hemorrhage
I) St. Louis encephalitis

A 25-year-old man with a history of intravenous drug use comes to the emergency department because of a progressive diffuse headache, generalized malaise, and low-grade fever for 2 months. During this period, he has had a poor appetite resulting in a 6.8-kg (15-lb) weight loss. His temperature is 38°C (1004°F). Examination shows neck stiffness. Mental status examination shows no abnormalities. Cranial nerve examination shows weakness of the lateral rectus muscle on the right and bilateral papilledema. A CT scan of the head with and without contrast shows moderate ventricular enlargement. Examination of cerebrospinal fluid shows:

Opening pressure 220 mm H20
Glucose 35 mg/dL
Protein 150 mg/dL
WBC 100/mm3
Lymphocytes 100%
RBC 1/mm3

patient has features of either fungi or viral meningitis, crypto is more likely due to his immunosuppression and viral meningitis is less likely in this population.

 

[drpisho]

SOMEONE please help me with this one:

A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1 day. She is in the third week of second grade. Her temperature is 38.6 C (101.5 F). Examination shows an erythematous pharynx and slightly enlarged tonsils without exudate. There is no significant cervical lymphadenopathy. A rapid test for group A streptococcus is negative. Which of the following is the most appropriate next step in management?

A) Throat culture
B) Monospot test
C) Intramuscular penicillin therapy
D) Oral erythromycin therapy
E) Oral penicillin therapy

I believe the answer is A. but could someone please explain WHY?

 

[Wolverines83]

SOMEONE please help me with this one:

A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1 day. She is in the third week of second grade. Her temperature is 38.6 C (101.5 F). Examination shows an erythematous pharynx and slightly enlarged tonsils without exudate. There is no significant cervical lymphadenopathy. A rapid test for group A streptococcus is negative. Which of the following is the most appropriate next step in management?

A) Throat culture
B) Monospot test
C) Intramuscular penicillin therapy
D) Oral erythromycin therapy
E) Oral penicillin therapy

I believe the answer is A. but could someone please explain WHY?

rapid strep has high false negative rate. In other words, it doesn't rule out strep, but if it's positive it rules it "in" So a negative test doesn't mean no strep, you need to go to the culture to be sure it's not strep.

 

[Phloston]

rapid strep has high false negative rate. In other words, it doesn't rule out strep, but if it's positive it rules it "in" So a negative test doesn't mean no strep, you need to go to the culture to be sure it's not strep.

In other words, it's not a sensitive test. Screening tests need to be sensitive.

The other answers here don't really work.

Choice B is EBV (presents with exudate; notably the one virus that does).
Choice C is syphilis (and patients who aren't adherent to oral therapy).
Choice D is okay to use if the patient has a Hx of anaphylaxis to beta-lactams (although I'd probably choose azithro over erythro even in this case).
Choice E is a distractor. You'd start a kid empirically on amoxicillin to cover other things like H. influenzae. Only after you confirm the Dx is Step could you switch to straight-up penicillin, which is even more efficacious for Strep.

 

[Dhenki]

ANSWERS IN BOLD

A 15-year-old girl is brought to the physician by her parents because of an 8-hour history of difficulty breathing. She has a history of asthma treated with oral montelukast and inhaled salmeterol and fluticasone. She has been hospitalized three times for exacerbation of asthma; the most recent hospitalization was 3 months ago. She appears to be in moderate distress. Examination shows labored breathing with intercostal retractions. Expiratory wheezes are heard. The patient says that she sometimes forgets to take her medication and does not believe that she needs it. Which of the following is the most appropriate next step to increase the likelihood that this patient will become compliant with her medication regimen?

A) Recommend that her parents reward or punish the patient based upon compliance
B) Negotiate a contract regarding medication compliance
C) Refuse to see the patient if she continues to be noncompliant
D) Begin clonidine therapy
E) Begin fluoxetine therapy
F) Begin methylphenidate therapy
G) Recommend psychiatric evaluation

I answered B and didnt show in my wrong ones.

A 32-year-old woman comes to the physician because she and her husband have been unable to conceive for 2 years. They have sexual intercourse every 2 days. Menarche was at the age 0114 years. Menses occur at irregular 35- to 50-day intervals and last 10 days; they are not painful. Menstrual flow is normal. She has no history of serious illness and takes no medications. She used an oral contraceptive for 16 years for menstrual cycle regulation but discontinued it 2 years ago. Her husbands sperm count is within the reference range. The patient is 152 cm (5 II) tall and weighs 72 kg (160 lb); BMI is 31 kg/rn2. Physical examination shows acne vulgaris over the face, upper shoulders, and back. The remainder of the examination, including pelvic examination, shows no abnormalities. Serum thyroid-stimulating hormone, free testosterone. dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone, and follicle-stimulating hormone concentrations are within the reference ranges. Which of the following is the most likely diagnosis?

A) Endometriosis
B) Turner
C) Hyper Prolactinemia
D) PCOS
E) Premature ovarian failure

A previously healthy 32-year-old woman comes to the physician because of a 10-day history of persistent cough that keeps her awake at night and is worse with physical activity. The cough is sometimes productive of white sputum in the early morning. Her symptoms began with an upper respiratory tract infection characterized by low-grade fever, sore throat, and malaise 10 days ago. Her only medication is an over-the-counter cough suppressant. She has smoked one pack of cigarettes daily for 16 years. She is employed as a skilled nursing care assistant. She is not in distress but has a rasping cough. Her temperature is 37.4°C (99.4°F), pulse is 78/mm, respirations are 12/mm, and blood pressure is 130/80 mm Hg. Examination shows no pharyngitis or facial tenderness. Scattered end-expiratory wheezes are heard bilaterally. Her peak expiratory flow rate is mildly decreased. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in pharmacotherapy?

A) Nonsedating oral antihistamine
B) Oral antibiotic
C) Inhaled 31adrenergic agonist
D) Inhaled anticholinergic
E) Inhaled mast cell stabilizer

Patient has acute COPD exacerbation

A) Bacterial meningitis
B) Cerebral infarction
C) Cryptococcal meningitis
D) Glioblastoma multiforme
E) Herpes simplex encephalitis
F) Hypertensive encephalopathy
G) Idiopathic intracranial hypertension
H) Intracerebral hemorrhage
I) St. Louis encephalitis

A 25-year-old man with a history of intravenous drug use comes to the emergency department because of a progressive diffuse headache, generalized malaise, and low-grade fever for 2 months. During this period, he has had a poor appetite resulting in a 6.8-kg (15-lb) weight loss. His temperature is 38°C (1004°F). Examination shows neck stiffness. Mental status examination shows no abnormalities. Cranial nerve examination shows weakness of the lateral rectus muscle on the right and bilateral papilledema. A CT scan of the head with and without contrast shows moderate ventricular enlargement. Examination of cerebrospinal fluid shows:

Opening pressure 220 mm H20
Glucose 35 mg/dL
Protein 150 mg/dL
WBC 100/mm3
Lymphocytes 100%
RBC 1/mm3

patient has features of either fungi or viral meningitis, crypto is more likely due to his immunosuppression and viral meningitis is less likely in this population.

I don't understand how the patient in question 2 can have PCOS if free testosterone, LH, and FSH are normal. The pelvic exam was also normal, so I'm assuming the ovaries weren't enlarged. I see how the other answers don't fit the scenario either, but I'm having trouble understanding why this pt. would have PCOS. Can anyone clarify?

Thank you.

 

[ilovemed1]

I don't understand how the patient in question 2 can have PCOS if free testosterone, LH, and FSH are normal. The pelvic exam was also normal, so I'm assuming the ovaries weren't enlarged. I see how the other answers don't fit the scenario either, but I'm having trouble understanding why this pt. would have PCOS. Can anyone clarify?

Thank you.

^Wondering the same thing... the only thing i can think of is that you need +2/3 to make a clinical diagnosis; that is, infertility, androgen excess, anovulation.. but wouldn't normal labs throw that diagnosis out? idk..anyone else come up with a better explanation?

A few more questions from form 6...

1) 32 y/o lethargic and bored after giving birth 5 months ago. Stopped breast feeding 1 month ago. Her blood pressure is 122/80 mm Hg, pulse is 58/min, and respirations are 18/min. Physical examination shows no abnormalities. She remembers one out of three objects after 5 minutes. Her serum cholesterol concentration is 265 mg/dL. What would you measure next?
- estrogen (wrong)
- thyroid
-cortisol
-progesterone
-prolactin

Can someone explain this one?

2) Four days after undergoing resection of an obstructing sigmoid colon cancer and colostomy, a 47-year-old man has a temperature of39.3°C (102.8°F). During the procedure, a central venous catheter was inserted into the left subclavian vein. His pulse is 94/min, respirations are 20/min, and blood pressure is 128/70 mm Hg. The abdomen is soft and nontender. Examination of the colostomy shows no abnormalities. Blood cultures grow Staphylococcus aureus. Which of the following is the most likely source of the bacteria?

- central venous line (initially i thought this would be the answer but wouldnt it be s. epidermidis that would be the causative organism and not sa?)
- wound infx
- intra abdominal abscess (wrong)
- lungs
- urinary tract

thanks!!

 

[piaisthemater]

^Wondering the same thing... the only thing i can think of is that you need +2/3 to make a clinical diagnosis; that is, infertility, androgen excess, anovulation.. but wouldn't normal labs throw that diagnosis out? idk..anyone else come up with a better explanation?

A few more questions from form 6...

1) 32 y/o lethargic and bored after giving birth 5 months ago. Stopped breast feeding 1 month ago. Her blood pressure is 122/80 mm Hg, pulse is 58/min, and respirations are 18/min. Physical examination shows no abnormalities. She remembers one out of three objects after 5 minutes. Her serum cholesterol concentration is 265 mg/dL. What would you measure next?
- estrogen (wrong)
- thyroid
-cortisol
-progesterone
-prolactin

Can someone explain this one?

If I remember correctly she had some weight gain too? She was 1. lethargic 2. wt gain 3. bradycardic 4. increased cholesterol 5.decreased mentation---all pointing to hypothyroid