Page 5

Page 5 (questions 22-30)

Click right here to enter the discussion group!

We should try to discuss the questions at the end of the book which was given to us for USMLE step III. You will see the questions below, and they will be added one question at a time (depending on my call schedule), and then hopefully somebody will post a discussion of the question/answer on the discussion group. If there is any problems with the discussion group above, write to me: calvin@studynow.com and I can post your answers in the discussion group at a later time.

22. A 69 year old Chinese-American man with diabetes mellitus had a myocardial infarction 2 years ago. He has had exertional angina since then and has been taking propranolol. During the past few days he has had one episode of pain at rest, two episodes postprandially and one at night. The electrocardiogram is unchanged. The preferred treatment would consist of

a) admitting him immediately for cardiac monitoring and adjustment of therapy
b) admitting him immediately for coronary artery bypass surgery
c) decreasing the dosage of propranolol and adding nitrates and salicylate
d) increasing the dosage of propranolol and having him return in 1 week
e) resting from work, sedation at night and digitalization

Chis Responds:

69 y/o pt with a PMH significant for past MI 2 years ago and exertional
angina thereafter. Consults for:
* increase in number of episodes
* apparition of angina at rest.
*******************************************
This pt's course has rapidly accelerated within the past few days and
can now be considered to have "Unstable Angina." By all means keep the
Beta-Blockers. Its well-known that these meds decrease the risk for
future cardiac events.
*******************Answer is (A)**********************
He must first be admitted to document any ischemic changes, and in what
area(s)/territories they are taking place.
******************************************************
I would then add nitrates to this pt's anti-anginal regimen, and if he's
not receiving ASA (300mg) add that as well... but taking into his
history of known MI, I might be hesistant to wait for another
potentially lethal anginal episode and begin treatment ASAP.

In light of his rapidly progressive course I would like to cath this
fellow, and keep the CABG as a later option depending on how many
vessels are compromised.
* Pearl: if only 1-2 vessels is severely affected then PTCA
" > 2 " then CABG.

Taken from the EAST trial at Emory U., Atlanta.

23. A 38 year old woman who is single mother of two small children comes to the office saying that she feels "halfway tired all the time." Her physical examination is unremarkable and unchanged from 1 year ago. Toward the end of the visit she says anxiously, "My children just don't listen. They make me so angry that I feel out of control sometimes." She pauses. "Yesterday my 7 year old daughter talked back to me and I slapped her in the face." Her eyes fill with tears. The most accurate statement concerning this patient is that she

a) should be reported to child abuse authorities
b) was clearly a victim of child abuse herself
c) would benefit from antidepressant medication
d) would benefit from family counseling
e) would exhibit better self-control if she were married

24. A woman telephones because her 7 month old infant is irritable and has a temperature of 39.6 C (103.2 F) with persistent vomiting. Upon questioning, she reports that the infant's neck is supple. Further diagnostic work-up should be based on the need to rule out

a) bacterial meningitis
b) bacterial pneumonia
c) hamartoma of the hypothalamus
d) herpetic encephalitis
e) viral respiratory infection

Chis Responds:

7 m/o infant's mother consults for:
- Fever (39.6 C)
- irritability and vomiting
******************************
This ominous triad should obligate the MD who first sees this child to
R/O Meningitis first and foremost since this is treatable disease, and
the implications of a delayed diagnosis are grave. (A)

According to the baby's age: hemphilus influenze is a prime suspect as
the irrepresable pneumococcus and meningococcus are less frequent in
this age.

Why not ask "Mom" if junior has had fever prior to the present syndrome
? If the pt was older I would ask for "earaches" too.
Pearl: Otitis media + meningitis --> R/O Hemophilus Influenzae.

As far as a PE goes, an otoscopy in an irritable infant is very
difficult and often poorly done, but it can provide an important clue as
to the etiology of the meningitis. In any case an L.P. is warrented and
will ultimately reveal the culprit's identity.

The baby's fontanelle might be bulging, but outright signs of meningism
(ie. nucal rigidity) are infrequently observed in infants.

Ceftriaxone is the abx of choice.
****************************************
Why the other aren't:
- encephalitis: no signs of focalization &/or convulsions (can occur in
bacterial meningitis as well)
- Viral URI: no cough, rinorrhea are documented
- pneumonia: no respiratory distress noted
- hamartoma of the hypo: ???

25. (25-26) Earlier today, you examined a 16 year old boy who came to the office for a school physical examination. He had no complaints or medical problems. He said he is sexually active, has had three different sex partners and that he "sometimes" uses condoms. He had no complaints of dysuria or penile discharge. You know that he would be reluctant to consent to evaluation for asymptomatic urethritis with urethral swabs because of fear of discomfort. In trying to determine how to screen for this prevalent problem, you recall a recent study that compard a new urethritis screening test -- the first part voided urine (FPV) -- to the "gold standard' of urethral culture. In this study, 50 asymptomatic male adolescents provided the first 10 mL of a voided urine specimen (FPV), and urethral swabs were taken for culture of Chlamydia trachomatis and Neisseria gonorrhoeae,. The FPV specimens were spun down, and the sediment was examined microscopically under high power. Twenty-one of 23 (91%) subjects whose FPV showed more than 10 WBC/hpf had positive urethral culture for C. trachomatis or N. gonorrhoeae compared with only 1 of 27 (4%) FPV negative subjects with a positive culture.

25. The most accurate statement about the data is:

a) The FPV is not a helpful screening test because its sensitivity depends on the frequency of urethritis
b) The FPV is not a useful screening test because of its low positive predicitive value
c) No conclusions can be drawn from the data because the samble size is insufficient
d) The sensitivity of the FPV in identifying culture positive urethritis is greater than 90%
e) The specificty of the FPV in identifying patients who do not have urethritis is less than 90%

26. For a variety of reasons you decide not to institute the FPV as a screening test in your practice. In coming to this decision, you have realized that the most important factor contributing to the positive predictive value of the FPV is the

a) correlation coefficient
b) incidence of urethritis in your patient practice
c) lack of reproducibility
d) prevalence of urethritis in your patient practice
e) reliability factor of the test

27. A 45 year old man comes to the office for a follow up visit. He has a history of low back pain following a lifting accident at work 3 years ago. Until now his pain has been confined to the lumbosacral region, and he has had no numbness or presthesia in his lower extremities. Today he reports a sensation of pain shooting down the posterolateral aspect of his left thigh, extending medially to his left great toe. The pain is made worse by coughing. The patient's history suggests

a) actue muscle strain
b) chronic lumboscral strain
c) degenerative lumbosacral arthritis
d) intervertebral disc herniation
e) spinal stenosis

Acute lumbar disk herniation, rupture, or extrusion represents an acute episode in a chronic degenerative process. Patients may have a history of chronic episodic low back pain.

Diagnosis

Pain usually begins abruptly, often with trivial trauma such as sneezing. The pain is often described as stabbing or shooting, worse with sneezing or coughing, and often incapacitatingly severe. Radiation in the distribution of the sciatic nerve is common. The physical findings are similar to those of degenerative disk disease, with the addition of severe paravertebral muscle spasm. Sciatic stretch tests may be positive. Neurologic function, including sensation and deep tendon reflexes, is intact. X-rays and the results of laboratory studies are usually normal.

Treatment & Disposition

Acute lumbar disk herniation usually requires complete bed rest and narcotic analgesics (for the first day or so). Additional measures are as described for chronic degenerative disk disease, above (ie, aspirin, nonsteroidal anti-inflammatory agents, muscle relaxants). Unless ideal support is available at home, the patient requires hospitalization. Bed rest is frequently required for 3-4 weeks, although most patients are significantly improved within 2 weeks.

28. A 67 year old retired carpenter who has been you patient for many years calls the office to complain of a new symptom. He says that when he walks fast or wlaks uphill, usually while playing golf, he has pain in his left calf that disappears with rest. He is overweight, he smokes cigarettes, and he drinks one beer on weekdays and two six-packs on the weekend. You have been treating him with lovastatin for a slightly elevated serum cholesterol concentration. He has never been able to follow your prescribed diet very well. You can tell this patient that the most likely reversible factor related to his pain is his

a) cigarette smoking
b) intake of saturated fats in his diet
c) use of alcohol
d) use of verapamil
e) weight

Explanation by Chris:

67 y/o pt with PMH significant for obesity and hypercholesterolemia,
smoking presents with recent acute onset of unilateral calf pain while
making a slight - medium effort walking, that resolves spontaneously
with rest.
***********************
Dx: Pveripheral Vascular Disease.
***********************
Risk Factors:
- Diabetes Mellitus
- Hypercholesterolemia
- Smoking
***********************
We are not informed of any PE findings, such as skin discoloration on
the affected extremity, femoral-popliteal-pdeial pulses, bruits, pallor
of extremity when elevated etc..A treadmill test might be helpful to
document first hand the condition, and a Doppler-Duplex study as well,
although this pt may require an invasive study (ie. angiography) to
determine the extent of atherosclerotic compromise. If severe he may
ultimately be subjected to a SRV or PTA.

Tx: Cessation of smoking, exercise therapy, improve lipid profile and
Trental (pentoxiphylline).

Px: Only 50% pts have this condition stabilize or improve. 50% have
coexistent CAD.

Chris

29-30. A 17 year old boy is brought to the office by his mother who says that he has been increasingly withdrawn and preoccupied for several weeks. He has been sleeping poorly nad has refused to leave the house for the past week because he believes he is being followed. When his father insisted he attend school this morning, the patient threatened him with a knife. The patient is sweating, has dialated pupils and is obviously fearful.

29. Rapport with this patient can be best established by asking:

a) "Are you hearing voices?"
b) "Do you have a special mission to accomplish?"
c) "Do you think you are being persecuted?"
d) "How do you feel others are treating you?"
e) "Who do you think is following you?"

30. After admission to the hospital, the most appropriate first intervention is to

a) administer haoloperidol
b) arrange a conference with the family
c) order CT scan of the head
d) order toxicologic screening of the urine
e) prescribe diazepam therapy, intramuscularly

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