NBME 7 question

[PediatricsRocks]

A 57-year-old man with asthma comes to the emergency department 30 minutes after the onset of severe shortness of breath and left-sided chest discomfort while cross-country skiing. He has no history of similar symptoms. He also has major depressive disorder and hypertension. Current medications include albuterol, fluticasone inhaler, fluoxetine, and lisinopril. His temperature is 37 deg C (98.6F), pulse is 110/min, respirations are 30/min, and blood pressure is 130/70 mmHg. On auscultation, awheezes are hear taht are more prominent on the right side than on the left. Cardiac examination shows normal ......etc etc..................WHich of the following conditions is the most likley cause of the patient's acute dyspnea? There was a CXR associated with this question.
A. Asthma
B. Myocardial ischemia
C. pleural effusoin
D. pneumothorax
E. pulm infarction.

WHich one is the answer and why?

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[PediatricsRocks]

Here's another question:

A 56 yo woman with squamous cell CA of lung has had fatigue, weakness, right flank pain, anorexia, and constipation for 6 weeks. Exmination shows hematuria. The msot likely cuase of these Sx is scretion of which of the following substances by the CA?
A. ACTH
B. Bombesin
C. Calcitonin
D. EPo
E. Hcg
f. nonsuppressible insulin-like activity
g. PTHrp

I'm pretty sure the answer is PTHrp since it's a squamous cell CA, but what accounts for her Sx?

 

[jmayer]

Here's another question:

A 56 yo woman with squamous cell CA of lung has had fatigue, weakness, right flank pain, anorexia, and constipation for 6 weeks. Exmination shows hematuria. The msot likely cuase of these Sx is scretion of which of the following substances by the CA?
A. ACTH
B. Bombesin
C. Calcitonin
D. EPo
E. Hcg
f. nonsuppressible insulin-like activity
g. PTHrp

I'm pretty sure the answer is PTHrp since it's a squamous cell CA, but what accounts for her Sx?

excess PTH --> excess calcium --> kidney stones (flank pain + hematuria) + constipation

 

[username456789]

Here's another question:

A 56 yo woman with squamous cell CA of lung has had fatigue, weakness, right flank pain, anorexia, and constipation for 6 weeks. Exmination shows hematuria. The msot likely cuase of these Sx is scretion of which of the following substances by the CA?
A. ACTH
B. Bombesin
C. Calcitonin
D. EPo
E. Hcg
f. nonsuppressible insulin-like activity
g. PTHrp

I'm pretty sure the answer is PTHrp since it's a squamous cell CA, but what accounts for her Sx?

Hypercalcemia and a stone.

 

[Gozar]

I'm pretty sure that I did the first one by simple exclusion.

A. Asthma
B. Myocardial ischemia - cardio exam was normal
C. pleural effusion - not seen on CXR
D. pneumothorax - not seen on CXR
E. pulm infarction - there would be way more than "left sided discomfort"

My knee jerk is asthma anyways, and I don't have any notes about that question so I got it right. I mean, the guy is on fluticasone (flonase) and an albuterol inhaler - he has to have asthma that was exacerbated when he decided to go outside and do something aerobic.

 

[Sol Rosenberg]

Pretty sure the CXR showd a pretty obvious left pneumothorax, if I am remembering this one correctly. The history was a little misleading (with the wheezes in there for asthma, but only on the right side) but the CXR cinched it (no wheezes on left side because that lung was collapsed)

 

[username456789]

Pretty sure the CXR showd a pretty obvious left pneumothorax, if I am remembering this one correctly.

Yup.

 

[Ableton]

Pretty sure the CXR showd a pretty obvious left pneumothorax, if I am remembering this one correctly. The history was a little misleading (with the wheezes in there for asthma, but only on the right side) but the CXR cinched it (no wheezes on left side because that lung was collapsed)

I was debating between the pneumothorax and asthma. It was really hard to tell by just the CXR by itself... I had a hard time deciding if that actually was the trachea that was deviated.

I went with asthma and got it wrong, so I guess it's pneumothorax. Anyone know for sure?

 

[aashkab]

i haven't done this test but isn't asthma also supposed to have bilateral wheezes? so you could eliminate that as a choice? just based on the question stem.

 

[Sol Rosenberg]

I got it right. Look at the left side of the CXR again. There were no lung markings, and a crumpled up lung near the left midline. I don't recall any tracheal deviation, but there might've been some. I remember seeing the same CXR in RR Path. while I wad doing my final review. I don't have RR in front of me, or else I would post the page #

 

[eddie13231]

I got it right. Look at the left side of the CXR again. There were no lung markings, and a crumpled up lung near the left midline. I don't recall any tracheal deviation, but there might've been some. I remember seeing the same CXR in RR Path. while I wad doing my final review. I don't have RR in front of me, or else I would post the page #

Just wanted to second this. Took the exam yesterday and it was indeed pneumothorax: these is asymmetry on the L side- you can see the lung all crumpled up and can see its opaque outline. There was actually a similar question on UWSA #2 I think.