Need help for sugery NBME 3 q

[MudPhud20XX]

So I still can't figure out this q. I paraphrased.

1. 52 y/o female with no significant past MHx comes to the ER for 2 day hx of abdominal cramps and vomiting. She couldn't pass stool nor flatus during this period. She has never had this similar symptoms before. He had abdominal hysterectomy 10 yrs ago. Her temp is 37.7C, pulse is 110, bp is 140/70. Th lungs are clear to auscultations and percussion. Abdominal exam shows distention and mild tenderness but no peritoneal signs, bowels sounds active and in rushes. Labs are

hematocrit 42%
leukocyte count 11,500
serum
Na+ 140
Cl- 101
K+ 3.6
HCO3- 28
Urea nitrogen 40
glucose 110
creatinine 1.7

Which of the following is the most likely diagnosis?

A. acute cholecystitis
B. colon cancer
C. complete small bowel obstruction
D. ileus secondary to renal failure
E. perforated viscus

I chose D since creatinine is up. So is it C??? then why is the creatinine high?

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[lana62]

I chose D since creatinine is up. So is it C??? then why is the creatinine high?

Ileus by definition is caused by the failure of peristasis, so bowel sounds would be decreased. Creatinine is up due to prerenal AKI caused by dehydration (2 day hx of vomiting).

 

[MudPhud20XX]

Ileus by definition is caused by the failure of peristasis, so bowel sounds would be decreased. Creatinine is up due to prerenal AKI caused by dehydration (2 day hx of vomiting).

Thanks man. So active rushing bowel sound is referring to high pitch bowel sound thus obstruction?

 

[lana62]

Yep, looks like they try to use less common phrases.

 

[MudPhud20XX]

I got another q.

Healthy 52 y/o female comes in for follow up 1 month after the dx of HTN. She takes no med. Her temp is 37.6C, pulse 105, RR 18, bp 165/95. Exam shows 1 cm mass in the Rt. lobe of the thyroid gland. Other exams are normal. Ultrasonography of the thyroid gland shows a solid mass. A radionuclide scan of the thyroid gland shows increased uptake in the region of the mass. What is the most likely finding in this pt?

A. decreased serum TSH and increased T3, T4
B. increased serum TSH and decreased T3, T4
C. presence of thyroid stimulating immunoglobulins
D. TSH mediated increase in iodide uptake by the follicular cells
E. TSH mediated increase in the iodination of thyroglobulin
F. TSH mediated increase in thyroglobulin production by the follicular cells

So I don't know the answer yet, but I am leaning toward B. But why not D, E, F? They all sound correct too.

 

[EazyE1907]

I got another q.

Healthy 52 y/o female comes in for follow up 1 month after the dx of HTN. She takes no med. Her temp is 37.6C, pulse 105, RR 18, bp 165/95. Exam shows 1 cm mass in the Rt. lobe of the thyroid gland. Other exams are normal. Ultrasonography of the thyroid gland shows a solid mass. A radionuclide scan of the thyroid gland shows increased uptake in the region of the mass. What is the most likely finding in this pt?

A. decreased serum TSH and increased T3, T4
B. increased serum TSH and decreased T3, T4
C. presence of thyroid stimulating immunoglobulins
D. TSH mediated increase in iodide uptake by the follicular cells
E. TSH mediated increase in the iodination of thyroglobulin
F. TSH mediated increase in thyroglobulin production by the follicular cells

So I don't know the answer yet, but I am leaning toward B. But why not D, E, F? They all sound correct too.

i think the answer is A. but i might be wrong.

thought process: looks like she is hyperthyroid. RAIU says there is increase uptake. so this can be one of 3 things graves, toxic adenoma or multinodular goiter. q says a solid mass and uptake in the REGION of the mass. this sounds like it might be toxic adenoma since an adenoma shows up as uptake in one thyroid lobe.

 

[MudPhud20XX]

i think the answer is A. but i might be wrong.

thought process: looks like she is hyperthyroid. RAIU says there is increase uptake. so this can be one of 3 things graves, toxic adenoma or multinodular goiter. q says a solid mass and uptake in the REGION of the mass. this sounds like it might be toxic adenoma since an adenoma shows up as uptake in one thyroid lobe.

You are right man. I got confused my bad. So increased RAIU is "hot nodule" correct? So that can't be adenoma though right? I thought tumor gives you cold nodule, please correct me if I am wrong.

 

[MudPhud20XX]

You are right man. I got confused my bad. So increased RAIU is "hot nodule" correct? So that can't be adenoma though right? I thought tumor gives you cold nodule, please correct me if I am wrong.

Also, what is wrong with D, E, F? I mean they can lead to increased RAIU uptake right?

 

[EazyE1907]

Also, what is wrong with D, E, F? I mean they can lead to increased RAIU uptake right?

nah d, e , f all lead to decreased raiu uptake.

thyroid stimulating ig's are graves, and that would give you a diffuse uptake.

toxic adenoma can be hot or cold. hot is likely benign, cold is most likely to be malignant. both are STILL masses.

also remember the test done here is an radioactive iodine uptake. we are trying to figure out what is causing the hyperthyroid state.

an FNA or scintigraphy would be done to see whether the mass has malignant or benign potential

have you done uworld?? looks like you need to do some more reading. uworld has algorithms for this and many other stuff. i would suggest reading/memorizing the algorithm. would prolly be better to do this before approaching any nbme questions.

 

[MudPhud20XX]

1. 32 y/o male comes to ER 30 min after MVC. He was the restrained driver. On arrival, he is in severe resp distress. Breath sounds are decreased over the Lt. hemithorax. On physical exam, there is crepirant swelling over the face, neck, and hemithorax. Chest X-ray shows extensive subcutaneous air and a Lt. pneumothorax. After proper placement of a Lt. chest tube, the pt has a persistent large air leak. Which of the following is the most likely dx?

A. esophageal injury
B. open pneumothorax
C. ruptured bronchus
D. tension pneumothorax

So what's the significance of the persistent large air leak??? after proper chest tube placement?

2. 8 hrs after a surgery, a 50 y/o male's hemoglobin is 7.5. A transfusion of heterologous packed RBC begins. 2 hours later, the pt develops chills/fever. He gets 200 ml of transfusion. Temp is 39C, puls is 120, RR is 18, bp is 120/70. which one is the most likely explanation?

A. ABO incompatibility
B. Bacterial overgrowth in transfused blood
C. intravenous catheter infection
D. preformed antibodies to leukocyte antigens
E. Rh incompatibility

So isn't A and D the same thing? Don't we do the ABO matching to prevent preformed antibody rxn?

3. 12 days after admission, a young man with acute leukemia has the onset of pain/edema of the Rt. upper extremity. He just had a 7 day course of chemo 3 days ago. He had sodium bicarb and allopurinol and underwent placement of a Rt. atrial catheter. Pulse is 80, bp is 126/78. Rt upper extremity is approximately 1.5 times larger in circumference than the Lt. upper extremity. venous duplex ultrasonography of the Rt. upper extremity shows occlusion of the Rt. axillary and subclavian veins. Which of the following is the most likely cause of the pt's symptoms?

A. adverse effect of the chemo
B. arterial embolism
C. cellulitis
D. cervical rib syndrome
E. complication of the Rt. atrial catheter

 

[dfib slim]

1. 32 y/o male comes to ER 30 min after MVC. He was the restrained driver. On arrival, he is in severe resp distress. Breath sounds are decreased over the Lt. hemithorax. On physical exam, there is crepirant swelling over the face, neck, and hemithorax. Chest X-ray shows extensive subcutaneous air and a Lt. pneumothorax. After proper placement of a Lt. chest tube, the pt has a persistent large air leak. Which of the following is the most likely dx?

A. esophageal injury
B. open pneumothorax
C. ruptured bronchus
D. tension pneumothorax

So what's the significance of the persistent large air leak??? after proper chest tube placement?

The persistent air leak after chest tube placement means there is still an open connection between the pleural space and the outside. A ruptured bronchus would be a cause.

2. 8 hrs after a surgery, a 50 y/o male's hemoglobin is 7.5. A transfusion of heterologous packed RBC begins. 2 hours later, the pt develops chills/fever. He gets 200 ml of transfusion. Temp is 39C, puls is 120, RR is 18, bp is 120/70. which one is the most likely explanation?

A. ABO incompatibility
B. Bacterial overgrowth in transfused blood
C. intravenous catheter infection
D. preformed antibodies to leukocyte antigens
E. Rh incompatibility

So isn't A and D the same thing? Don't we do the ABO matching to prevent preformed antibody rxn?

Not the same thing. A is antibodies to RBCs and D is antibodies to WBCs. Looks like a febrile nonhemolytic transfusion reaction so D would be the answer.

3. 12 days after admission, a young man with acute leukemia has the onset of pain/edema of the Rt. upper extremity. He just had a 7 day course of chemo 3 days ago. He had sodium bicarb and allopurinol and underwent placement of a Rt. atrial catheter. Pulse is 80, bp is 126/78. Rt upper extremity is approximately 1.5 times larger in circumference than the Lt. upper extremity. venous duplex ultrasonography of the Rt. upper extremity shows occlusion of the Rt. axillary and subclavian veins. Which of the following is the most likely cause of the pt's symptoms?

A. adverse effect of the chemo
B. arterial embolism
C. cellulitis
D. cervical rib syndrome
E. complication of the Rt. atrial catheter

Upper extremity DVT caused by the R atrial catheter.

 

[MudPhud20XX]

Can anyone help me with this q? I am almost tempted to choose D, but I think it's a wrong answer

65 y/o male with premature ventricular contractions following elective repair of an inguinal hernia under spinal anesthesia. Exam shows a complete T3-4 spinal motor and sensory block. Pulse oximetry shows O2 sat of 95%, unchanged during the operation. ABG shows

pH 7.25
pCO2 55
pO2 75

ECG shows normal synus with nonspecific changes in PVCs. Which one is the most likely cause?

A. fluid overload
B. intraoperative MI
C. metabolic acidosis
D. total sympathetic blockade
E. ventilatory insufficiency

 

[dfib slim]

Can anyone help me with this q? I am almost tempted to choose D, but I think it's a wrong answer

65 y/o male with premature ventricular contractions following elective repair of an inguinal hernia under spinal anesthesia. Exam shows a complete T3-4 spinal motor and sensory block. Pulse oximetry shows O2 sat of 95%, unchanged during the operation. ABG shows

pH 7.25
pCO2 55
pO2 75

ECG shows normal synus with nonspecific changes in PVCs. Which one is the most likely cause?

A. fluid overload
B. intraoperative MI
C. metabolic acidosis
D. total sympathetic blockade
E. ventilatory insufficiency

So the first thing you need to do is understand this is an acid base question then determine what they have. A low pH with a high pCO2 suggests respiratory acidosis. Coupled with the neuro findings makes ventilatory insufficiency a nice choice. They are probably taking little shallow breaths leading to the hypoxemia and PVCs.

 

[MelMcT2009]

Can anyone help me with this q? I am almost tempted to choose D, but I think it's a wrong answer

65 y/o male with premature ventricular contractions following elective repair of an inguinal hernia under spinal anesthesia. Exam shows a complete T3-4 spinal motor and sensory block. Pulse oximetry shows O2 sat of 95%, unchanged during the operation. ABG shows

pH 7.25
pCO2 55
pO2 75

ECG shows normal synus with nonspecific changes in PVCs. Which one is the most likely cause?

A. fluid overload
B. intraoperative MI
C. metabolic acidosis
D. total sympathetic blockade
E. ventilatory insufficiency

I'd say E. he's got a respiratory acidosis, and electrolyte abnormalities are a common cause of arrhythmias.

If he did have total sympathetic blockade his EKG would have shown bradycardia. Even so, sympathetic blockade shouldn't cause PVCs.

 

[MudPhud20XX]

Thank you dfib and MelMc! Yes that makes sense now. I noticed that hypercapnia can cause PVC. Thank you all.

 

[MudPhud20XX]

1. 52 y/o man with 3 day hx of upper abdominal pain and bloating and 1 day hx of nausea/vomiting. Bismuth preparations and antacids have not relieved the nausea and vomiting. He has a hx of a duodenal ulcer treated with omeprazole. He takes no prescription meds. His pulse is 90 and regular, bp is 130/80. Cardiopulmonary exam shows no abnormalities.
The abdomen is distended with borborygmi in the epigastric area and a succussion splash. There is no rebound tenderness or guarding. Which of the following is the most likely explanation for these findings?

A. gastric mucosal irritation due to an enterovirus infection
B. mucosal action of ingested heat stable enterotoxins
C. perforation of a duodenal diverticulum
D. scarring and fibrosis of a duodenal ulcer crater
E. thrombosis of the superior mesenteric artery
--> with a hx of GERD, I am leaning toward C. but I am not sure, what is the significance of "borborygmi in the epigastric area and a succussion splash?"

2. health 82 y/o male comes to ER after 12 hours of having Lt. groin pain, nausea, vomiting. Temp is 39C, pulse is 110, bp is 90/60. Exam shows 5 cm, firm, tender, inguinal mass. WBC is 16,000 with a left shift. What is dx?

A. colon diverticulitis
B. femoral artery aneurysm
C. inguinal lymphadenitis
D. strangulated inguinal hernia
E. testicular torsion
--> sudden onset, high white count and temp, infection seems to be the right answer, so C???

 

[MelMcT2009]

1. 52 y/o man with 3 day hx of upper abdominal pain and bloating and 1 day hx of nausea/vomiting. Bismuth preparations and antacids have not relieved the nausea and vomiting. He has a hx of a duodenal ulcer treated with omeprazole. He takes no prescription meds. His pulse is 90 and regular, bp is 130/80. Cardiopulmonary exam shows no abnormalities.
The abdomen is distended with borborygmi in the epigastric area and a succussion splash. There is no rebound tenderness or guarding. Which of the following is the most likely explanation for these findings?

A. gastric mucosal irritation due to an enterovirus infection
B. mucosal action of ingested heat stable enterotoxins
C. perforation of a duodenal diverticulum
D. scarring and fibrosis of a duodenal ulcer crater
E. thrombosis of the superior mesenteric artery
--> with a hx of GERD, I am leaning toward C. but I am not sure, what is the significance of "borborygmi in the epigastric area and a succussion splash?"

2. health 82 y/o male comes to ER after 12 hours of having Lt. groin pain, nausea, vomiting. Temp is 39C, pulse is 110, bp is 90/60. Exam shows 5 cm, firm, tender, inguinal mass. WBC is 16,000 with a left shift. What is dx?

A. colon diverticulitis
B. femoral artery aneurysm
C. inguinal lymphadenitis
D. strangulated inguinal hernia
E. testicular torsion
--> sudden onset, high white count and temp, infection seems to be the right answer, so C???

Succession splash = gastric outlet obstruction. So I'd choose D

I'd also choose D for the second one. Inguinal lymphadenitis isn't going to cause him to be hypotensive.

 

[MelMcT2009]

Did you take this offline?

 

[teehees]

Agree with above D, D.

But to be honest I would have marked them to return to later

 

[MudPhud20XX]

Did you take this offline?

No I am taking it online. I will let you know if I get them wrong. Thanks everyone, I really appreciate it guys.

 

[MudPhud20XX]

I am really bad at this kind of q. any help is greatly appreciated.

6 hrs after sigmoid colectomy and colostomy for perforated diverticulitis, a 62 y/o female has had total postoperative urine output of 65 ml though foley catheter. Preoperatively, the pt had serum urea nitrogen of 45mg/dl and serum creatinine of 2. She has been getting 0.45% saline at 90ml/h since the operation. She is 157 cm tall and weighs 60kg. BMI is 24. pulse is 95, bp is 130/90. Serum electrolytes are normal and urine specific gravity is 1.028. Which is the next best step in management?

A. measurement of creatinine clearance
B. intravenous pyelography
C. renal perfusion scan
D. rapid administration of 500 ml of 0.9% saline
E. administration of IV fluids to replace insensible fluid losses only
F. administration of IV fluids to replace urine output only
--> So do we give more fluid or try to find if there is any leakage?

 

[lana62]

increased urine specific gravity suggests of prerenal cause, give D to confirm the most obvious cause of renal failure

 

[MudPhud20XX]

increased urine specific gravity suggests of prerenal cause, give D to confirm the most obvious cause of renal failure

yeah I chose B and got it wrong. D seems to be the right answer, but isn't 1.028 within the normal range of USG?

 

[MudPhud20XX]

No I am taking it online. I will let you know if I get them wrong. Thanks everyone, I really appreciate it guys.

So all of the answers you guys gave were correct. I still ended up 8 wrong, I will post some of them if I can't figure them out. thanks all!

 

[MudPhud20XX]

So I still can't figure out these qs:

1. 22 y/o male came to ER due to swollen, painful, plethoric Rt. lower extremity. he had 2 events of thrombophlebitis of the Rt. lower extremity, the 1st one 30 months ago, the second one 18 months ago. Venous duplex scan confirms DVT in the infrapopliteal veins.

most likely bleeding disorder is

A. anticardiolipin antiboides
B. antithrombin III def
C. fibrinogen abnormality
D. hemophilia
E. thrombasthenia
F. thrombocytopenia
G. thrombocytosis
H. von Willebrand dz
-->I chose A thinking antiphospholipid, but was wrong. So B I guess???

2. 22 y/o is brought to the ER 1 hour after the MVC. on arrival, pulse is 120, bp is 100/70, has multiple facial lacerations, which imaging is the best to screen cervical trauma?

A. CT scan
B. lateral x-ray
C. MRI
D. myelography
E. tomography
--> So I was pretty sure A was the right answer but was wrong, so C I guess? Dang this is tricky, can anyone explain this?

 

[lana62]

yeah I chose B and got it wrong. D seems to be the right answer, but isn't 1.028 within the normal range of USG?

Hypovolemic patients usually have a specific gravity >1.015 (source Urine specific gravity - Wikipedia). I usually assume high USG if >1.020. You can google more.

 

[lana62]

So I still can't figure out these qs:

1. 22 y/o male came to ER due to swollen, painful, plethoric Rt. lower extremity. he had 2 events of thrombophlebitis of the Rt. lower extremity, the 1st one 30 months ago, the second one 18 months ago. Venous duplex scan confirms DVT in the infrapopliteal veins.

most likely bleeding disorder is

A. anticardiolipin antiboides
B. antithrombin III def
C. fibrinogen abnormality
D. hemophilia
E. thrombasthenia
F. thrombocytopenia
G. thrombocytosis
H. von Willebrand dz
-->I chose A thinking antiphospholipid, but was wrong. So B I guess???

2. 22 y/o is brought to the ER 1 hour after the MVC. on arrival, pulse is 120, bp is 100/70, has multiple facial lacerations, which imaging is the best to screen cervical trauma?

A. CT scan
B. lateral x-ray
C. MRI
D. myelography
E. tomography
--> So I was pretty sure A was the right answer but was wrong, so C I guess? Dang this is tricky, can anyone explain this?

1. The clinical criteria of APS consist of vascular thrombosis and pregnancy morbidity. So for APS they should give you a women with multiple late-term pregnancy losses.
2. Approximately 85-90% of cervical spine injuries are evident in lateral view, making it the most useful view from a clinical standpoint (source Cervical Spine Fracture Workup: Imaging Studies, Other Tests).

 

[MelMcT2009]

So I still can't figure out these qs:

1. 22 y/o male came to ER due to swollen, painful, plethoric Rt. lower extremity. he had 2 events of thrombophlebitis of the Rt. lower extremity, the 1st one 30 months ago, the second one 18 months ago. Venous duplex scan confirms DVT in the infrapopliteal veins.

most likely bleeding disorder is

A. anticardiolipin antiboides
B. antithrombin III def
C. fibrinogen abnormality
D. hemophilia
E. thrombasthenia
F. thrombocytopenia
G. thrombocytosis
H. von Willebrand dz
-->I chose A thinking antiphospholipid, but was wrong. So B I guess???

2. 22 y/o is brought to the ER 1 hour after the MVC. on arrival, pulse is 120, bp is 100/70, has multiple facial lacerations, which imaging is the best to screen cervical trauma?

A. CT scan
B. lateral x-ray
C. MRI
D. myelography
E. tomography
--> So I was pretty sure A was the right answer but was wrong, so C I guess? Dang this is tricky, can anyone explain this?

Did they give you any more info for the first question? Like a history of not responding to Heparin? I dont think the info you gave is enough to choose one answer over another. You don't have to have a hx of pregnancy loss to dx Antiphospholipid syndrome. Its recurrent clots OR hx of multiple abortions. If thats all the info they gave you, I guess it would be a "play the odds" questions, in which you would have to know which was more common (and I dont lol).


For the second one, the answer is B as pointed out above. Even if you dont know the answer for sure, try to fall back on general principles. Screening tests are usually cheap and fast (don't want to be dropping a ton of money on someone you dont reallyyyyy think has it). So when in doubt, just choose the cheapest one 🙂

 

[MudPhud20XX]

1. The clinical criteria of APS consist of vascular thrombosis and pregnancy morbidity. So for APS they should give you a women with multiple late-term pregnancy losses.
2. Approximately 85-90% of cervical spine injuries are evident in lateral view, making it the most useful view from a clinical standpoint (source Cervical Spine Fracture Workup: Imaging Studies, Other Tests).

So what is the answer for #1? B?

 

[MudPhud20XX]

Did they give you any more info for the first question? Like a history of not responding to Heparin? I dont think the info you gave is enough to choose one answer over another. You don't have to have a hx of pregnancy loss to dx Antiphospholipid syndrome. Its recurrent clots OR hx of multiple abortions. If thats all the info they gave you, I guess it would be a "play the odds" questions, in which you would have to know which was more common (and I dont lol).


For the second one, the answer is B as pointed out above. Even if you dont know the answer for sure, try to fall back on general principles. Screening tests are usually cheap and fast (don't want to be dropping a ton of money on someone you dont reallyyyyy think has it). So when in doubt, just choose the cheapest one 🙂

No man, for #1 that's all the info they gave, I didn't omit anything. I hate these kind of vague q as a lot of NBME questions are like that.

 

[lana62]

Did they give you any more info for the first question? Like a history of not responding to Heparin? I dont think the info you gave is enough to choose one answer over another. You don't have to have a hx of pregnancy loss to dx Antiphospholipid syndrome. Its recurrent clots OR hx of multiple abortions. If thats all the info they gave you, I guess it would be a "play the odds" questions, in which you would have to know which was more common (and I dont lol).

I agree with you that in a real life we won't be comfortable to diagnose the condition with info given in the test question. As I mentioned, APS can present with vascular thrombosis, but we need some lab work to confirm it. We often have to play odds on the exam )) But APS is more prevalent in women and strongly associated with pregnancy losses. Vascular thrombosis in APS can be arterial, venous, or small-vessel thrombosis. Thrombosis may involve the cerebral vascular system, coronary arteries, pulmonary system, arterial or venous system in the extremities, etc. To diagnose APS they should give us at least one episode of arterial thrombosis. In a question we have a man with only a venous thrombosis (no strokes, PE), so we don't have enough info to diagnose him with APS.

So what is the answer for #1? B?

Yes, it's B. Confirmed online.

 

[dfib slim]

So what is the answer for #1? B?

I'd pick H. Most common cause of hereditary thrombophilia.

 

[MudPhud20XX]

I'd pick H. Most common cause of hereditary thrombophilia.

wait for real? vWD causes blood clots?

 

[dfib slim]

wait for real? vWD causes blood clots?

Arterial and venous thrombosis in patients with von Willebrand's disease: a critical review of the literature. - PubMed - NCBI
It's a rare presentation of a common inheritable condition. Just a guess. Seems like there should be something more to the question.

 

[MudPhud20XX]

I'd say E. he's got a respiratory acidosis, and electrolyte abnormalities are a common cause of arrhythmias.

If he did have total sympathetic blockade his EKG would have shown bradycardia. Even so, sympathetic blockade shouldn't cause PVCs.

quick, q, for this one, I was a bit thrown off by O2 sat being 95%, if resp acidosis is going on, shouldn't your O2 sat be lower than 95%? pls correct me if I am wrong. thanks! Below is the actual q.

65 y/o male with premature ventricular contractions following elective repair of an inguinal hernia under spinal anesthesia. Exam shows a complete T3-4 spinal motor and sensory block. Pulse oximetry shows O2 sat of 95%, unchanged during the operation. ABG shows

pH 7.25
pCO2 55
pO2 75

ECG shows normal synus with nonspecific changes in PVCs. Which one is the most likely cause?

A. fluid overload
B. intraoperative MI
C. metabolic acidosis
D. total sympathetic blockade
E. ventilatory insufficiency

 

[MudPhud20XX]

16 yo female came to ER after being stabbed in the ant. neck 30 min ago, large hematoma is evident and is pulsatile at the level of the thyroid cartilage. As she is being examined at the ER, the hematoma expands, which is the most appropriate initial step in management?

A. barium esophagography to r/o esophageal injury
B. endotracheal intubation
C. esophagoscopy to r/o esophageal injury
D. indirect laryngoscopy to determine vocal cord injury
E. tracheostomy

--> So I am debating btw B and E, but not sure which one is a better one, any thought?

 

[lana62]

quick, q, for this one, I was a bit thrown off by O2 sat being 95%, if resp acidosis is going on, shouldn't your O2 sat be lower than 95%?

I would look at pCO2 because its amount defines acidosis. By the way pO2 is low too. Revise significance of O2 sat vs pO2.

16 yo female came to ER after being stabbed in the ant. neck 30 min ago, large hematoma is evident and is pulsatile at the level of the thyroid cartilage. As she is being examined at the ER, the hematoma expands, which is the most appropriate initial step in management?

--> So I am debating btw B and E, but not sure which one is a better one, any thought?

There is no contraindications for intubation in Q stem. Revise indications for tracheostomy.

 

[MudPhud20XX]

37 year old comes to the emergency department 12 hours after the onset of abdominal pain, nausea, and decreased appetite. The pain is localized to the right lower quadrant of the abdomen. Her last menstrual period was 2 weeks ago. Her temperature is 38 C. The abdomen is tender to palpation in the right lower quadrant. Pelvic examination shows no purulent discharge and no cervical motion tenderness. Her leukocyte count is 13,500/mm3. Urinalysis shows several WBC/hpf. Which of the following is the most appropriate next step in management?

A) Colon contrast studies
B) Upper GI series with small bowel follow-through
C) Intravenous pyelography
D) Culdocentesis
E) Appendectomy
--> I am attempted to choose E, but shouldn't you get an image first??? Will B show appendicitis?

 

[MudPhud20XX]

37 year old comes to the emergency department 12 hours after the onset of abdominal pain, nausea, and decreased appetite. The pain is localized to the right lower quadrant of the abdomen. Her last menstrual period was 2 weeks ago. Her temperature is 38 C. The abdomen is tender to palpation in the right lower quadrant. Pelvic examination shows no purulent discharge and no cervical motion tenderness. Her leukocyte count is 13,500/mm3. Urinalysis shows several WBC/hpf. Which of the following is the most appropriate next step in management?

A) Colon contrast studies
B) Upper GI series with small bowel follow-through
C) Intravenous pyelography
D) Culdocentesis
E) Appendectomy
--> I am attempted to choose E, but shouldn't you get an image first??? Will B show appendicitis?

So E was the answer.

 

[MudPhud20XX]

still got this q wrong, I would really appreciate any help.

32 yo female comes to ER for 10 hr hx of increasingly severe, constant pain in her belly. she has nausea but no vomiting. she has SLE well controlled with prednisone. takes no other meds, temp is 38C, pulse 110, RR 16, bp 115/65. no scleral icterus. abdomen is soft tender to palpation over the Rt. upper q. with mild guarding w/o rebound. lab shows

Hg: 14
WBC count: 12000
seg neutrophils: 75%
bands: 10%
lymphocytes: 15%

results of liver function tests were normal. abdominal ultrasound shows a distended gallbladder with thickened wall and a gallstone lodged in the neck of the gallbladder. following administration of cefazolin and an iv infusion of lactated ringer solution, the pt is taken to OR for laparoscopic cholecystectomy. on induction with propofol, her bp suddenly drops to 60/40 and remains the same despite administration of an additional 500ml bolus of lacated ringer sol. what is the most appropriate next step in pharmacotherapy?

A. give diphenhydramine
B. give dopamine
C. give gentamicin
D. give hydrocortisone
E. dec the dose of propofol

--> FYI, B and E were wrong answers. I am leaning toward D thinking steroid may be able to inc bp, but no sure.

 

[MudPhud20XX]

still got this q wrong, I would really appreciate any help.

32 yo female comes to ER for 10 hr hx of increasingly severe, constant pain in her belly. she has nausea but no vomiting. she has SLE well controlled with prednisone. takes no other meds, temp is 38C, pulse 110, RR 16, bp 115/65. no scleral icterus. abdomen is soft tender to palpation over the Rt. upper q. with mild guarding w/o rebound. lab shows

Hg: 14
WBC count: 12000
seg neutrophils: 75%
bands: 10%
lymphocytes: 15%

results of liver function tests were normal. abdominal ultrasound shows a distended gallbladder with thickened wall and a gallstone lodged in the neck of the gallbladder. following administration of cefazolin and an iv infusion of lactated ringer solution, the pt is taken to OR for laparoscopic cholecystectomy. on induction with propofol, her bp suddenly drops to 60/40 and remains the same despite administration of an additional 500ml bolus of lacated ringer sol. what is the most appropriate next step in pharmacotherapy?

A. give diphenhydramine
B. give dopamine
C. give gentamicin
D. give hydrocortisone
E. dec the dose of propofol

--> FYI, B and E were wrong answers. I am leaning toward D thinking steroid may be able to inc bp, but no sure.

so the answer was D, so is this lupus flare? what the heck is going on here?

 

[MelMcT2009]

so the answer was D, so is this lupus flare? what the heck is going on here?

What important thing do you have to remember to do for patients on chronic steroids before surgery?

 

[MudPhud20XX]

What important thing do you have to remember to do for patients on chronic steroids before surgery?

right, sudden withdrawal from steroid can be a big issue, dang now it all makes sense. Thanks!