No time today for all of these but let's work through a few:
Some q's from nbme 1 that i paraphrased and want answers/help with , please.
22 yo man GSW to r calf. Vitals are stable at presentation. entrance wound over medial part of posterior calf and no exit wound. calf is tense and painful. Passive movt of great toe exacerbates pain. Pulses are norml. Cap refill is 2 secs. NOrmal sensation. XR shows the bullet in the medial part of the posterior calf. WHich is the most appropriate step in mgmt?
a. MRI of calf
b. irrigation
c. femoral arteriography
d. surgical decompression
I picked c but that was wrong. I thought we had to see the vessels but I'm now thinking it's compartment syndrome? -- thus d? Or is it Irrigate b/c there's no major vessels in the medial posterior calf?
Young male, likely to have considerable muscle mass in his lower extremity. Pain with passive or minor movement is the hallmark of an acute compartment syndrome (ACS)in an extremity. The lower leg is a common site for ACS. He has pain with movement of the GT, likely with plantar movement. Which compartment contains the muscles for plantar flexion? Which compartment contains the bullet?
So of your choices:
- MRI; what's this going to tell you? Not much that will change management; not all bullets are MRI compatible.
- Irrigation: nothing wrong with washing out the wound but that's not going to fix his symptoms
- Femoral Ateriography: does he have any hard signs (or even soft) of major vascular injury? Are there major vessels in the medial aspect of the lower leg?
Answer is?
4 days after CABG, man has severe sudden pain in big toe. Had CP with exertion 10 days ago and was admitted to hospital, given ASA and hep for 3 days. Cardiac Cath showed 3 vessel dx. Uncomplicated procedure and post-op course. Vitals nml. New bruises over trunk and extremities (both UE and LE). Surgical site c/d/i. Labs show 12,000 WBC's, 8000 platelets, INR of 1/PT and PTT both wnl. What is the diagnosis?
a. cholest embol syndrome --> wrong
b. DIC
c. gout
d.HIT
e. ITP --> is this right? why...
First: Is it supposed to be 8,000 PLT or 80,000?
Does he any any risk factors for ITP? Probably not but let's not rule that out just yet. How does ITP manifest itself? He does have thrombocytopenia. He does have new eccymotic areas. Does he have any symptoms not consistent with ITP?
What do you know about HIT? Its a favorite surgical board question. Can it occur after 3 days of heparin use? What are the lab and physiologic changes seen with it?
DIC? PT/PTT are usually abnormal but may not be.
😛 They haven't really given you enough information to rule this in or out based on lab findings.
62 yo f with 3 weeks of progressive SOB, pain in R chest wall, nonprod cough and weight loss in past 3 months. Had R breast CA 6 yr ago tx'd with lumpectomy and XRT and chemo. Appears cachetic. RR 20/min, o2 sat of 90% at RA. TTP over R chest. Breath sounds decreased on R with dullness to percussion. Friction rub heard. Nml heart sounds. What is the most likely diagnosis?
a. chest wall recurrence? (is this right? how would this cause a friction rub?)
c. pericardial effusion
e. malignant pleural effusion
As you correctly note, chest wall recurrence is not going to give her the symptoms above. So let's rule that one out right away.
A patient with a prior history of malignancy (significant enough to need chemotherapy, so we're going to assume, 6 years ago prior to the days of the Oncotype, that she was node positive) who is now cachectic: you have to assume recurrent disease as your first priority.
Do any of the signs point to pericardial effusion? You didn't say whether this was a pericardial or pleural friction rub but I"ll assume the latter. Normal heart sounds? If she had a substantial effusion, you'd expect some changes but otherwise even with a moderate size pericardial effusion you can maintain normal heart sounds.
So what seems most likely? Patient with a malignancy 6 years ago, now with shortness of breath, cachexia, reduced breath sounds, friction rub, etc etc. Sounds like Choice e to me.
47 yo Dude with 2 days of Fever and increasing rectal pain. Has T2DM. Vitals (fever to 102 and bp 130/80). Tender mass at anal verge on 1 side. Hb is 9.6, Wbc 18K, glu is 350. Which is the most appropriate next step in mgmt?
b. CT Abd and Pelvis (i picked this, it was wrong. I thought we had to see either how deep this perirectal abscess went or if there was a mass to explain his Hb)
c. Flagyl
d. flex sig
e. I and D (is this right?)
Ok you've got a diabetic who's febrile and with a visible perirectal mass. How does a CT scan change your management (and are you sure the Hb is 9.6 or was that his HgA1c)? Antibiotics might be reasonable but they aren't your next step; even if they were is Flagyl the appropriate choice? This guy's sick, you need to do something to make that better.
