NBME cases Flashcards
Headache, vomiting, alter mental status –> high on the DDX?
Increase ICP
Fractures taht go to the OR: (4)`
- depressed skull fx.
- severely displaced or angulated fx.
- any open fx. (bone sticking out of skin)
- femoral neck or intertrochanteric fx.
Common fractures:
shoulder pain s/p seizure or electrical shock?
posterior shoulder dislocation
Common fractures: arm outwardly rotated and numbness over deltoid?
anterior shoulder dislocation; d/t to axillary n. injury
Common fractures: old FLOOSH, distal radius displaced?
Colle’s fx
Common fractures: young Pt FOOSH, anatomic snuff box tender?
scaphoid fx.
Common fractures: “I swear, i just punched a wall…” ?
Metacarpal neck fracture “Boxers fx.” may need a K wire.
|| 12 hours after pancreatic abscess drainage, a 52 YOM with alcoholism becomes bradycardic and hypoxic and requires intubation. His FiO2 is 100, with a tidal volume of 1000 and PEEP of 2.5. He still has acidosis with O2 = 48 and CO2 of 40. Next step?
Increase PEEP
36 hours after admission for evaluation of diffuse abd pain, a 42 YOw is still obstipated. She has a
9yr history of scleroderma. Current temp is 100, P 110, RR22, BP 110/60. Abd is distended with
colon dilation and WBC 14k. Next step?
laparotomy (toxic megacolon)
37 YOw bruising on arms and abdomen x3w. ibuprofen for HA. afebrile. PE:eccymoses over upper extremities and trunk. Lungs CTAB, Labs: norm Hb, 6.8k WBC, 45k plt, Bleeding time is high (11),PT
normal. Bone marrow shows megakayocytes. Explanation for findings?
forumulation of antiplatelet antibodies
idiopathic thrombocytopenic purpura
A 42 YO is admitted to the hospital with a piece of meat lodged in the lower esophagus. With
difficulty is it removed with an endoscope. That evening the pt has a temp of 101. Most appropriate dx study?
water soluble contrast upper GI study(
concern for esophageal rupture after
endoscopy)
A 45 YOm has daily temps to 100.9 and 15 lb wt loss over 3 m. he has pallor, normal vitals and
normal CV and P exams except a low pitched disatolic rumble at the apex that dissappears when
he lies on his R side. Hb is 10. Most liekly dx?
Atrial myxoma ( cancer picture with diastolic rumble)
A hospitalized 72 YOM has not voided since catheter removal 8h ago. He had a sigmoid
colectomy for recurrent diverticulitis 2 d ago. He is currently receiving 5% dextrose and 0.45%
saline. His temp is 100.8. Most likely cause of inability to void?
- bladder outflow obstruction.
Some people develop obstruction after being
cath’d. The mass is most likely the bladder.
47 YOW comes in with a BMI of 67 , chafed skin on inner thighs, under breasts, twice requiring
admission for abtx for panniculitis. Also has thick curdy vaginal discharge.Best long term
management for this pt?
This lady has had life-threatening complications of obesity so she needs bypass
A 42 YOW comes in with sever ranghe hypertension and a bruit with hyperplasia of the right renal
artery. What is the mech of the patient HTN?
increased serum aldosterone
[or increased renin activity of right renal vein]
Routine mammorgraphy on a 52 YOw shows six stippled microcalcification in a cluster in the
upper outer quadrant of the left breast, not present 1 y ago. No lump. Next step?
needle localized open biopsy (not FNa)
[Needle localization is used when the doctor cannot feel the mass of abnormal tissue.]
87 YOM has sudden onset of SOB after emergent colon resection for obstructing Ca. T 100, HR
104, RR 32, BP 88/50. PE: JVD, crackles over midlungfields. NMRG.Liver span is 13. ECG shows ST elevation. Most likely Dx?
Cardiogenic schock (MI)
a 60 YOW has a sigmoid resection and colostomy for diverticulitis with rupture. That night she
becomes confused, oliguric and febrile. the area around the colostomy is indurated and crepitant.
Most likely causal organism?
Clostridium perfringens ( gas gangrene)
Pt with shoulder pain, ptosis, constricted pupils, and facial edema –> dx?
Superior Sulcus Syndrome from small cell carcinoma.
Pt with ptosis better after 1 minute of upward gaze–> dx?
Lambert Eaton syndrome from Small Cell Lung cancer. Ab to Pre-syn Ca2+ ch.
A 37 YOW comes w 3m of headaches. The headaches now occur daily and are relieved by
aspirin. Her pulse is 76, RR 12, BP 158/95. Surum Na: 140. Cl 100. K 2.6 (low) Ibcarb 34, BUN 9.
Dx?
aldosteronoma.
Primary HyperAldo = HTN and Low K+
A 62 YOW has difficulty swallowing liquidsand solid over the past month. 10 yr hx of dyspepsia,
substernal burning and occasional n/v. EG shows GE junction stricture and baretts esophagus.
Dx?
sliding hiatal hernia (much more common
than paraesophageal)
fluid resuscitation for burn patient in next 24 hours
4 weight % burn
18 YOM has pain in the R hip and flank after an autoaccident. He is stable. Exam shows
eccymosis over the iliac crest, and right flank abraisions. urinalysis shows gross blood. Ct cervical
spine is normal. next step?
CT scan of the abdomen with contrast
5 d after emergent sigmoid colectomy for perforated diverticulum , a 57 YOM has a temp of 104.
Lots of oxygen therpay and now has decr breath sounds at a lung base. Sputum shows many
leukocytes with G rods.
Most likely organism?
Psudomonas ( hospital acquied pneumonia)
Assymptomatic 72 YOW comes in with decreased renal fx. Elevation in Cr over last 3 days. got 2nd renal
transplant from 65 YO donor 1 m ago. Most likely explanation for decr renal fxx?
Failure to surpress class II antigen recognition in the host ( rejection)
52 YO nulligravid woman comes to physician due to 2 m of progressive abdominal swelling and
decr appetitie. She has astma treated with steroids and T2DM. Exam shows a fluid wave. An Ct
shows mulple pelvic masses and omental thickening. Most likely dx?
Ovarian adenocarcinoma causing peritoneal mets and omental caking
A 1 yr old boy has persistent cough, loose stools and facial rash for 2 m. 4lb wt loss. 50th
percentile for ht and 20th for wt. Temp is 37, pulse is 100 resp is 18. Ct shows tumor in panceas.
Most likely Dx?
VIPoma. especially with flushing. arises from
non beta islet cells of pancreas
A 67 YOW with ESRD, aterosclerodic CAD, T2DM undergoes formation of an AVF in left forearm under ax block. 24 hours later. SHe has SOB, , tacycardia, RR 38 with JVD. S3 and S4 are present. Most likely Dx?
high output congestive heart failure
[caused by fistulas]
a 27 YOw, HIV +, 6 m of nonbloody diarrhea now with bloody diarrhea. She has a high fever, and
a rigid abdomen. She ends up with an ileostomy for a perforated cecum and the path report shows
nuclear inclusion bodies in colon. Most likely organism?
CMV
A 47 yOM comes to physician for eval prior to an abdominal perineal resection fro rectal Ca. In last
6 y he has had left ankle swelling. Duplex shows chrinic occlusion of left iliac and femoal veins. Prior to surgery,
Most apporpiatemanagemnt for venus disease?
low does heparin prophylaxis ( these are
stable DVTs), just need to prevent new ones
a 62 YOW comes to the physisics with 3 w of progressive SOB, mild pain in right chest, and
nonproductive cough. 12 lb wt loss in last 3 m. She had br ca 6 years ago s/p mastectomy. She
appears cyanotic and cachectic. friction rub is heard on the right. breath sounds decreased on right with dullness to percussion. Dx?
malignant pleural effusion (lung mets)
A previosuly healthy 47 YOM comes in with 2 weeks of progressive abd swelling. PE shows distention and shifting dullness, bowel sounds are normal. There is no tenderness, masses or organomegaly.
Paracentesis: 50ml milky chylous fluid. Most likely cause?
lymphoma
8 YOG has sensation that something is in her left eye for 1d with photophobia and decreased
vision for 6h. Parents notice child frequently rubs eye. Exam shows tearing with erythema. Small
vesicle with erythematous base on conjunctiva. Dx?
herpes simplex conjuctivitis
66 YOW has acute vision loss in R eye x 1 h. No pain or previous hx. T2DM, HTN. Pupil does not
react to direct light but consensually reacts to light in opposite pupil. Movement is intact. PE: pallor of disc,
macular edema, thin arterioles, sausage-like narrowing of the retinal veins. Dx?
central retinal artery occlusion
77-year-old resident of a skilled nursing care facility is brought to the emergency department because of fever and vomiting for the past 2 days. She is alert but is
unable to give a history. She asks repeatedly for a drink of water. Her temperature is 38.60C (1 01.50F), and blood pressure is 100/60 mm Hg. Examination shows a
distended, nontender abdomen with sparse high-pitched bowel sounds. A supine x-ray of the abdomen shows multiple dilated loops of small bowel and gas within the
small-bowel lumen and within the liver. Which of the following is the most likely cause of these findings?
Cholecystoduodenal fistula with an impacted gallstone
Cholecystoduodenal fistula with an impacted gallstone.
this is gallstone ileus
Over past 6w, 30 YOW has increasing nervousness, sweating, insomnia. 10 lb wt loss .lump on
right side of thyroid. Pulse 110, BP 130/50, 4x4 cm mass on the R side of the thyroid gland, no
other thyroid tissue. Thyroid uptake only in area of nodule. Dx?
toxic thyroid adenoma
primary hyperaldosteronism (1 cm adrenal mass) - first line treatment
spironolactone
25 yo construction worker with fever and painful swollen right hand, traumatic laceration, beefy-red expanding margin and red streaks extending up the arm, axillary lymph nodes are palpable and tender
Lyphangitis from group A strep
6 yo boy, continuous murmur over pulmonary area, loud S2, and bounding peripheral pulses
- diagnosis
PDA
diastolic rumble at apex, opening snap
mitral stenosis
6 yo boy, continuous murmur over pulmonary area, loud S2, and bounding peripheral pulses
- diagnosis
patent ductus arteriosus
fever, severe pain at base of spine between the gluteal folds, erythema between gluteal folds over coccyx
- diagnosis
pilonidal abscess
lupus patient on chronic prednisone, taken to OR for cholecystectomy, on induction with propofol BP drops to 60/40, no change with IV fluids
- next step
- adminster hydrocortisone
LUPUS–>CHRONIC PREDNISONE TREATMENT–>adrenal insufficiency–>suddenly hypotension–> tx: replace steroids (during stress of surgery many patients on prednisone need higher doses)
lightheadedness and hunger in late evening and after exercise, glucose 25, insulin and C peptide increased
- diagnosis
insulinoma
ITP patient treated with prednisone and immune globulin for 6 weeks without relief, platelets 20k
- next step
splenectomy
Pt has biliuous vomiting and post-prandial pain. recently lost 200lbs. Dx?
SMA syndrome.
3rd part of duodenum compressed by AA and SMA.
72 yo with 4 months of hearing loss, ringing in right ear, unsteadiness, decreased movement of right side of face, sensation to temperature decreased on right side of face, weber localizes to left ear, MRI will show…
acoustic neuroma (vestibular schwannoma) (tumor of CN VIII)
[large tumors can compress CN V and CN VII]
52 yo 3 days of upper abdominal pain, bloating, NV, hx of duodenal ulcer, abdomen distended, borborygmi (gurgling caused by fluid in GI tract), succussion splash
- etiology
scarring and fibrosis of a duodenal ulcer crater
67 yo intermittent hematuria, fever, and fatigue for 2 months, 10 lb weight loss, hypercalcemia,
renal cell carcinoma
[hypercalcemia is a paraneoplastic syndrome]
3 week old with jaundice, direct bilirubin of 13
- diagnosis
biliary atresia ( newborn (2 weeks and above) presenting with elevated direct bilirubin (obstructive jaundice)
- [physiologic jaundice and breast milk jaundice involve indirect bilirubin and they occur earlier]
ketorolac (NSAID) causes acute renal failure
- mechanism
inhibited synthesis of prostacyclin [–> constriction of afferent arterioles]
22 yo with DVT, history of superficial thrombophlebitis
- etiology
anticardiolipin antibodies
[antiphospholipid syndrome?]
chronic pancreatitis, high glucose
- treatment
pancreatic enzyme replacement and insulin
Choledochal cysts Type 4: Cyst in intrahepatic ducts, is also known as? Tx?
Caroli Disease. Tx: liver transplant
26 yo, worsening intermittent abdominal cramps, diarrhea, weight loss, generalized abdominal tenderness, hyperactive bowel sounds, pronounced tenderness and a mass in the RLQ
- diagnosis
crohn’s disease
can have mass in RLQ
patient with antrectomy and Billroth II reconstruction for a perforated gastric ulcer 1 year ago, now with 3 months of loose stools, weight loss
- etiology
bacterial overgrowth
[GI tract surgeries that create a blind loop predispose to bacterial stasis and overgrowth due to abnormal motility and ineffective clearance of retained food and secretions]
Hepatitis with AST and ALT elevated s/p hemorrhage, surgery, or sepsis = dX?
Shock Liver
27 YOW brought to ED 30 mins after deep laceration on her back. What anaesthetic would
provide the longest anaesthesia?
bupivacaine
Previously healthy 42 YOM comes to physician because of 2 days of right knee pain and inability to extend knee. The
symptoms began when he was getting up from a low chair. His temp is. Exam of knee shows
tenderness to palpation along medial joint line and joint effusion. Dx?
torn meniscus
37 YOM comes with inability to conceive for 3 y. Wife had kids no problems in previous marrige. Pt
is healthy and well developed. irregular, ropy mass in upper left hemiscrotum. Results of semen
analysis are normal. Most likely cause of infertility?
varicocele
Dyspnea, myalgia, flank pain during transfusion. Urine is dark, blood in the surgical drain. Which test would you do to diagnose this?
This is an acute hemolytic transfusion reaction. Usually due to ABO mismatch. Repeat type and cross will confirm (probably a clerical error). Checking for DIC is also something you would do as it effects management, but the presence of DIC doesn’t confirm the diagnosis.
Bacterial Abcess of the liver is commonly d/t what 3 organisms?
E. coli,
bacteriodes
enterococcos
Tx surg drainage and ABX
Pt w/ necrotizing migratory erythema, esp on abdomen, buttocks, perineum. dX?
Glucagonoma
Pt with RUQ pain, profuse swearing and rigors, palpable liver dX?
Entamoeba histolytica.
Tx: Metronidaole. DO NOT drain
Pt from Mexico with RUQ pain and large liver cysts found on abd. ultrasound. Dx?
Enchinococcus.
hydratic cyst paracyte from dog feces.
Labs: eosinophilla, + casoni sking test.
Tx: albendazole –> surg, but need to remove ENTIRE cyst. if it ruptures -> anaphylasix.
42 YOM had 4x4 cm painless ulcer over right medial malleolus x 6m. He has a histroy of DVT that
occured during a femur fracture 30 years ago. Pedal pulses are palpable. 2+ edema of RLE. LLE
is normal. Most likely cause of ulcer?
venous valvular insudffioceicny
After MVC, 23 YOM is brought to ED. He was unrestrained driver. BP is 150/90.He has
retrosternal and interscapular chest pain, dyspnea, hoarseness. XR shows fracture of sternum and left first
rib, widening of superior mediastinum, caudal displacement of left main bronchus. Dx?
rupture of thoracic aorta
