thank you so much @AloD. a few questions which i had:
the question about the 8-year old with seizures who has been seizure free for 18 months with daily phenytoin. kids parents forget to give him phenytoin when he went to the sleep over and he had an episode. what's the most appropriate advice to give to the parents?
1. obtain blood phenytoin concentrations --> clearly wrong
2. give single dose of diazepam and continue phenytoin as usual
3. have him come home now and take two doses of phenytoin
4. should take one dose of phenytoin to him and give it to him
5. wean him off --> clearly wrong
i picked 2, but correct answer is 4. i'm guessing 2 is the better choice for status epilepticus?
78 year old f with BP of 200/110 and progressive loss of function on the left side of her body for the past 24 hours. what's the management?
1. IV nitroprusside
2. general supportive care with gradual control of BP
3. intubate and mechanival ventilaton
4. rapid anticoagulation --> need to do a CT first to see to see if it's hemorrhagic or nonhemo before starting meds.
5. right carotid thromboendarterectomy --> wrong. doesn't mention anything about % of stenosis.
i picked 1, but answer is 2. is 2 just an overall better answer, because 1 is still correct according to sources.
87 year old female in nursing home with mild dementia. spends most of her time reading novels. physical exam is normal. oriented to person, place, and time. when asked if she would consent to a cataract operation, patient agrees she would like to see better. which of the following is the most accurate statement about patient's opthalmologic condition?
a. family's wishes should override patient's wishes --> clearly wrong
b. her age is contraindication to a cataract operation
c. an operation is likely to result in improvement in her functional status
d. she's high risk for adverse outcomes from cararact operation
e. likely to be hospitalized for a cataract operation --> wrong
i chose b, but answer was c. looking back b and d are basically the same answer somewhat. i don't see how C is the right answer.
83 year old man brought in by daughter w/ c/c of suddenly becoming confused and doesnt remember things in 1 week. wife recently admitted to hospital due to hip fracture. daughter is staying with dad while mom is in rehab. blood tests are ordered. RPR is positive. what's the best way to tell if this problem is acute or chronic?
a. arrange consult with neurologist
b. check response to empiric ginkgo biloba --> clearly wrong
c. check serum antitremponemal antibody tites
d. interview family and friends more extensively
e. order an mri of the brain
picked a, but d is the right answer. doesn't that seem more tedious compared to A and more cost effective than interviewing "family and friends".
15 year old girl has asthma for past 6 years. mother says she hears her daughter coughing and wheezing, but daughter won't admit to any problems. during past 4 months, she has missed 8 days of school due to her asthma. patient has a new best friend whom she has been seeing frequently during this period of time at the other girl's home. while interviewing the pt, it's most appropriate to do which of the following?
a. ask her about her relationship with her mother
b. ask about substance abuse
c. ask if asthma gets worse when visiting her friend
d. ask if shes getting enough sleep
e. review school grade
i thought it was b, thinking peer relations and missing school, perhaps its drug use, but answer is C. makes no sense.
58 year old m with gastric CA admitted due to dehydration secondary to nausea and vomiting. underwent stomach resection 6 weeks ago. iv fluids are started which helps his nausea. weighs 118lbs today. vitals are 98.6F, pulse is 88, respirations are 16, BP is 105/60. as he's prepared for dicharge, he asks if theres any complementary or alternative treatment that might help his nausea. he should be referred to which of the following?
a. acupuncturist
b. massage therapise
c. practioniner of healing touch therapy
d. practitioner of homeopathy
e. reflexologist
chose b as it seemed the most legit from the others, but correct answer is A, smh.
are majority of the questions on step 3 the level of difficulty of the last four questions?
65 year old f POD 2 after right colectomy is on PEEP of 10cm with fio2 of 0.5. abruptly becomes hypoxic and hypotensive. pt is obese and has smoked one pack of cigs per day for past 30 years. which of the following most likely caused her episode.
a. ARDS
b. atelectasis --> POD 2, but clearly wrong.
c. bronchopneumonia
d. CHF
e. PE
i chose b since it was POD 2, but right answer is E.
Pt comes to ED due to 24 hour hx of progressive SOB. in past 2 weeks shes noticed right extremity swelling and nagging dry cough. pmhx of MVP, HTN, and type 2 DM. takes HCTz and rosiglitazone. presents to ED with edema of the face, right upper extremity, JVD, and palpabale supraclavicular nodes. what's the most appropriate diagnostic text
a. ct
b. doppler carotid
c. doppler upper extremitities
d. v/q scan
e. xray
i got this right, but what's causing this? is it mvp which potentially causing her congestive heart failure being exacerbated by the rosiglitazone?
72 year old man brought to the ED with daughter because of 1 day hx of mild confusion and agitation and increasing SOB. pt has a 7yr history of COPD and has production of green sputum, during past 3 days. vitals are 99F, pulse of 92, respirations of 24, and bp of 118/72. pulse ox is 88%. auscultation shows soft wheezes and prolonged expiratory phase. what's the most appropriate initial mgmt?
a. aminophylline therapy
b. amox-clavulanate therapy
c. endotracheal intubation
d. hepatin
e. noninvasive positive pressure ventilation
chose B because i was thinking he's getting an infection on top of his COPD due to change in sputum color. answer is E. any explanations?
another question about COPD in pt with 30 year hx of COPD. patient has low grade fever for past 4 to 5 days and recently starting producing yellowish sputum. his albuterol-ipratropium inhaler ran out 2 days ago. he's smoked cigs for past 40 years. vitals are 99.9F, pulse of 116, respirations of 26, bp of 122/66. pulse ox is 84% auscultation has decreased breather sounds and 1+ pitting edema in lower extremities. in addition to starting o2 therapy, what else should he be started on?
a. albuterol
b. ceftriaxone
c. furosemide
d. levofloxacin
e. metoprolol
chose D thinking he was getting an infection but answer is A.
Same thing for the next question, after oxygen he should get what? Bronchodialators - they work the fastest.
50 year old w/ alcoholic cirrhosis admitted due to bleeding esophageal varices. treated successfully. several days later has left upper quadrant, left shoulder, and left costal margin pain. worse with deep breathing. vitals are 102, pulse is 100, respirations are 20, bp is 140/90. abdominal exam discloses hepatosplenomegaly. whats the most appropriate next initial step?
a. iv antibiotic therapy
b. heparin therapy
c. mechanical ventilatory support
d. portacval shunt
e. repeat variceal sclerosis
chose d, but answer is A. i hope this isn't SBP.
Just as a heads up u may want to paraphrase those questions and answer choices in accordance with rules of SDN and NBME.
Kid with seizure d/o - i think he had a missed dose and was successfully seizure free on phenytoin - diazapam would be considered for 5min + for gen seizure - missed dosage should be given as soon as possible.
Stroke patient with high BP - you want permissive hypertension for cerbral perfusion - nitroprusside is indicated for hypertensive emergency or for cases requring rapid correction of BP. Its also been 24 hours - too late for a lot of interventions.
87 year old with cataracts and other health issues - yes she should get vision corrected - being able to see better would improve anyones qualify of life. reduce risk of falls/accidents, improve mobility, allow her to do more thing such as "activities of daily living".
83 yo brought in by daughter - interview other family. The daughter has only recently been with the family member and most common of sequelae dementia is chronic. And it is actually the cheapest option, you still have to pay the neurologist for a consult.
Worsening asthma - query most common reasons for flare ups - allergens, mites, dust, smoking, - could all be present at her friends house where she is spending an increased amount of time.
Gastric CA being referred to alternative therapy - I guess this is a throwback question - I guessed massage therapy as well here. I suppose that acupuncture can help in some way via nerve block for pain (would like some feedback if anyone has)
65 year old on POD 2 - One thing they wanna hammer into you is that PE/DVT can and will occur despite being on prophylaxis. Smoking is a clue, vitals points towards saddle type embolus, and POD day 1-2 atlectasis will have fever, sob, but the ddx changes when you see changes in hemodynamic statuses. There are a few of these types questions - definitly know causes of fever in the post op state, days they are likely to happen and their management, as well as settings for intubation, tidal volume, peep, resp rate, fio2, etc.
Pt with cough and SOB - This is a throwback to step 1/step 2 - you will want to make association of the anatomical structures mentioned, and look for relevant clues in the question stem. Its likely a description of superior vena cava syndrome due to a broncial mass. Other way they can test this is by describing horner syndrome, cough, right arm swelling, etc.
72 yo man with SOB - main point of the question is INITIAL management - remember your ABC's - his o2 sat is 88%, hes having acute copd exacerbation episode - so you want to hook him up to non-invasive oxygen first.
Same thing for the next question, after oxygen he should get what? Bronchodialators - they work the fastest.
50 yo cirrhotic pt. Definitely do some case studies on SBP and management in relation to cirrhosis, bleeding varices, and presences of ascites - In general - if you have bleeding varices with cirrhosis or ascites, the likelihood they will develop SBP is high - almost definite - they should be started on IV abx - 3rd gen cephalosporin and quniolones (don't quote me on that).
I apologize for the spelling errors or if something wasn't clear - I hope it was somewhat helpful.
