NBME9 Flashcards
34-year-old F presents to the ED 1 hour after an episode of palpitations, sweating, and shortness of breath. The episode occurred while she was at her job. She thought that she was having a heart attack. She reports she has been under increased stress at work. This is her fourth visit to the emergency department during the past 3 weeks for similar symptoms. At each prior visit, workup and physical exam was normal.
Today her vitals are:
HR 88
RR: 16
BP 128/70
PE unremarkable. Labs normal including cardiac workup. An ECG shows sinus arrhythmia.
MSE: tense and fearful. linear thought process, no hallucination or delusions.
What is the most likely diagnosis?
A. Myocardial infarction
B. Cocaine intoxication
C. PTSD
D. Acute stress disorder
E. Panic disorder
F. Unstable angina pectoris
Panic disorder
Panic attacks feature acute fear or anxiety that peaks within minutes and are associated with four additional physical symptoms (eg, diaphoresis, chest pain, dyspnea) or associated mental states secondary to sympathetic overactivation. Panic disorder is an anxiety disorder characterized by recurrent panic attacks that are unexpected and associated with worry about future panic attacks or avoidance of panic attack triggers.
Per DSM V, panic attacks must be present for ≥1 month
Tx: CBT, SSRI (venlafaxine), benzo for acute
Acute stress disorder ≤1 month of symptoms after known stressful event
PTSD >1 month of symptoms, avoidance of triggers, known traumatic event (work stress doesn’t count)
A 23-year-old woman, gravida 1, para 1, comes to the office in January for a follow-up examination 6 weeks after term NSVD of her son. Pregnancy and delivery were uncomplicated. She says she has been tearful during the past 3 weeks and has not left the house since visiting relatives 2 weeks ago. She says she loves her son and husband, but she has not enjoyed spending time with them during the past 2 weeks. She wakes up every 3 hours at night to breast-feed her infant and is unable to sleep well even when her husband offers to care for their son. She spends most of the day in bed with her infant in a crib nearby; she gets up only to feed and change him. She has no history of serious illness, takes no medications, and has no known allergies. Physical examination shows no abnormalities. On mental status examination, she has a depressed mood and flat affect. She does not have suicidal or homicidal ideation. She has not had audio or visual hallucinations. Which of the following is the most likely diagnosis?
A. Bipolar disorder
B. Major depressive disorder
C. Postpartum psychosis
D. Seasonal affective disorder
E. Normal postpartum course
MDD
This patient demonstrates depressed mood, anhedonia (decreased enjoyment of socializing), and insomnia along with decreased social functioning (not spending time with her husband or baby outside of tending to her baby’s basic needs), making an major depressive disorder diagnosis likely.
Symptoms of major depressive disorder include ≥2 weeks of ≥5 of the following symptoms:
-depressed mood*
-anhedonia
-guilt or worthlessness
-difficulty concentrating
-psychomotor retardation or agitation
-suicidal thoughts
-neurovegetative symptoms (decreased energy, sleep disturbance, appetite disturbance)
postpartum blues can be part of a normal postpartum course but resolved within 2 weeks of delivery.
What is the illness script for delirium tremens?
What electrolyte abnormalities could you expect to find?
Alcoholic w/ 48 hours-1 week after last drink w/ presenting symptoms of:
-severe confusion and disorientation
-fluctuations in consciousness
-agitation
-visual or auditory hallucinations
- autonomic instability (fluctuations in HR and BP with hyperthermia).
Managed w/ benzodiazepines (eg, lorazepam) to address agitation and prevent the symptoms of withdrawal, along with fluids, nutritional supplementation of deficient vitamins and minerals, and frequent assessment including vital sign checks.
The vitamins that are commonly deficient in patients with alcohol use disorder include thiamine, folate, vitamin B , vitamin A, and vitamin B, and mineral deficiency of
magnesium, iron, and zinc.
The pathogenesis of hypomagnesemia is likely related to decreased oral intake and alcohol induced urinary excretion of magnesium.
what study metric incorporates morbidity and mortality into one?
DALY (disability-adjusted life years) is a metric of overall disease burden that takes into account years of life lost caused by death AND years of healthy life lost as a result of disability
what is a potential source of bias in retrospective studies like case-control studies that depend on reported data from participants as opposed to chart review?
Recall bias occurs when participants do not remember or omit details or experiences related to previous or related events. It is a potential source of bias in retrospective studies, especially those in which the exposure may have occurred many years ago, which is common when diseases under study have long latency periods.
How do you calculate the NNT from absolute risks of two groups?
ARR= RR control- RR intervention (in decimal form)
ie if RR control= 15% and RR intervention=13%, then
ARR=0.15-0.13=0.02
NNT=1/ARR = 1/0.02=50 in this example
Define attributable risk and how to calculate it
Attributable (excess) risk (AR) describes the risk of developing disease or the outcome under study that can be attributed to the exposure as compared to the risk that exists without the exposure.
AR= (incidence of exposed group) - (incidence of non exposed group)
AR = (a / (a + b)) - (c / (c + d))
a= exposed and have disease
b= exposed and don’t have disease
c= not exposed and don’t have disease
d= not exposed and have disease
Define relative risk and how to calculate it. What studies use RR? What about RRR?
Relative risk (RR) describes the difference in likelihood of the occurrence of a particular disease outcome between two groups of patients with or without a particular exposure.
Calculations of RR are commonly performed in cohort studies.
RR = (a / (a + b)) / (c / (c + d))
RR= (incidence of exposed) / (incidence of nonexposed)
RR values greater than 1.0 indicate an increased risk of developing disease in association with the exposure, whereas values less than 1.0 indicate a reduced risk of developing disease, and RR equal to 1.0 indicates that the disease outcome and the exposure are not associated in any particular direction.
Relative Risk Reduction= 1-RR
What cell type is most likely to be increased in a patient w/ bone pain, anemia, hypercalcemia, kidney dysfunction, and lytic bone lesions who is found to have a monoclonal gammopathy on protein electrophoresis?
Monoclonal B lymphocyte
Signs and symptoms of MM include bone pain, anemia, hypercalcemia, kidney dysfunction, and lytic bone lesions. B-lymphocytes are precursors to plasma cells, which secrete specific immunoglobulins of different classes and are considered terminally differentiated B-lymphocytes.
**MM is a malignancy caused by the neoplastic proliferation of a single plasma cell clone, which overproduces monoclonal immunoglobulin and light or heavy chains. These clonal immunoglobulins are secreted in high numbers and appear as a monoclonal spike on protein electrophoresis in the gamma region on protein electrophoresis. Diagnosis of multiple myeloma is suspected based on the presence of an M-protein spike in the presence of concerning symptoms, but is confirmed by bone marrow biopsy, which must demonstrate at least 10% clonal plasma cells.
A 67-year-old man w/ long history of poorly controlled HTN presenting w/ 1 hour after the onset of vertigo, nausea, and imbalance.
Vitals: pulse 70/min, respirations 20/min, and blood pressure 210/115 mm Hg.
Physical examination:
small left pupil, mild left ptosis, and nystagmus.
Neurologic examination: weakness of the left palate; Sensation to pinprick is decreased over the left side of the face and right extremities. Incoordination on finger-nose testing and heel-knee-shin testing on the left.
What artery is most likely affected?
G. L vertebral
Atherosclerotic disease leads to an increased risk of vertebral artery occlusion leading to a posterior circulation stroke (cerebral infarction). The brainstem, cerebellum, and occipital lobes are commonly affected. Patients typically present with vestibulocerebellar signs (ataxia, dysmetria, dizziness, imbalance, vertigo, vomiting, nystagmus), ipsilateral cranial nerve dysfunction (dysphagia, dysarthria, vertical or horizontal gaze palsies), contralateral hemiparesis (corticospinal tract damage), contralateral impairment in pain and temperature sensation (spinothalamic tract damage), or potential contralateral homonymous hemianopsia with macular sparing (occipital lobe involvement).
In posterior circulation strokes affecting the lateral pons, Horner syndrome may occur, which presents with ipsilateral ptosis, miosis (pupillary constriction), and ipsilateral facial anhidrosis.
If no hemorrhage is demonstrated on non-contrast CT scan of the head, acute management of posterior circulation strokes commonly involves tissue plasminogen activator therapy or thrombectomy.
Anterior spinal artery occlusion presenting symptoms
bilateral loss of pain and temperature sensation and motor function below the level of the lesion, along with autonomic dysfunction.
The anterior spinal artery supplies the bilateral corticospinal, spinothalamic, and autonomic tracts.
basilar artery occlusion presenting symptoms
The basilar artery is supplied by the vertebral arteries. Basilar artery occlusion commonly presents with acute, severe, bilateral corticospinal and corticobulbar dysfunction, leading to locked-in syndrome.
occlusion of anterior cerebral artery (ACA) presenting symptoms
contralateral hemiparesis and sensory deficit of the lower extremities.
What artery is occluded?
R homonymous hemianopia w/ macular sparing and Gerstmann syndrome (agraphia, acalculia, finger agnosia, and left-right disorientation).
Left posterior cerebral artery (PCA)
ipsilateral sensory loss of proprioception, fine touch, and vibration below the level of the lesion.
posterior spinal artery
occlusion
