USMLE Step 3 Question of the Week #495

495.  A 49-year-old obese female presents with abdominal pain.  Patient states the pain acutely onset several hours ago and describes it as constant, severe, localized around the umbilicus and radiating to her back.  She says the pain feels better if she is sitting up and bending slightly forward.   Patient also says she feels nauseous and vomited once after the pain began.  No relevant past medical or surgical history.  No current medications or allergies.  Review of systems is significant for several recent episodes of abdominal pain after eating.

On exam, the patient is in distress, sitting upright, and leaning slightly forward.  Vitals are temperature 38.3 °C (101.1 °F), blood pressure 110/78 mm Hg, pulse 105/min, respirations 25/min, and oxygen saturation 98% on room air.  Cardiac exam is normal.  Lungs are clear to auscultation.  Abdominal exam reveals tenderness to palpation in the periumbilical region.  Bowel sounds are diminished.

Laboratory values are:

Sodium                                                            140 mEq/L

Potassium                                                        4.0 mEqL

Chloride                                                          100 mEq/L

Bicarbonate                                                    25 mEq/L

BUN                                                                 35 mg/dL

Creatinine                                                       1.1 g mg/dL

Glucose (fasting)                                             90 mg/dL

Calcium                                                           7.0 mg/dL

Phosphorous                                                    4.1 mg/dL

Bilirubin, conjugated                                      1.5 mg/dL

Bilirubin, total                                                 3.0 mg/dL

AST (SGOT)                                                      325 mU/mL

ALT (SGPT)                                                      175 mU/mL

Alkaline Phosphatase                                      295 U/L

Amylase                                                          250 U/L

Lipase                                                              89 U/L

TSH                                                                  1.1 mIU/L

PTH                                                                  30 pg/mL

Troponin I (cTnI)                                             <0.02 ng/mL

Lactate Deydrogenase (LDH)                          750 U/L

C-reactive protein                                           45 mg/L

b-hCG                                                              <1 mIU/mL

 

WBC                                                                19,000 / mm3

RBC                                                                 4 x 106/mm3

Hematocrit                                                      45%

Hemoglobin                                                    13.0 g/dL

Platelet Count                                                 275,000 / mm3

Differential

Neutrophils (%)                                               85

Lymphocytes (%)                                             10

Monocytes (%)                                                5

Eosinophils (%)                                                3.5

Basophils (%)                                                   1.5

Chest and KUB x-rays, and EKG are unremarkable.

Aggressive fluid resuscitation and supplemental 100% oxygen are given.  Meperidine 150 mg intramuscularly is administered.  Abdominal ultrasound reveals the presence of a gallstone in the common bile duct (CBD).  Patient is kept NPO.

What is the next best step in management?


A. Contrast CT of the abdomen

B. Endoscopic retrograde cholangiopancreatography (ERCP)

C. Administer meropenem 1 g IV every 8 hours

D. Laparoscopic cholecystectomy

E. Magnetic resonance cholangiopancreatography (MRCP)

@hagemanGIstep2

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USMLE Step 3 Question of the Week #494

494.  A 45 year old man with a 20-year history of tobacco use presents to the emergency department after having repeated episodes of sharp, stabbing substernal pain with a dry, hacking cough over the last 2-3 days. The episodes last between 5-10 seconds. He first noticed them several days ago.They were not brought on by exertion and they did not improve with rest. He denies fever, shortness of breath, or tachypnea otherwise. He denies any recent sick contacts. The patient’s temperature is 99.2, heart rate is 72, blood pressure is 143/77. Cardiac exam reveals reveals regular rate and rhythm. There are no murmurs, rubs, or gallops. There are scant crackles throughout the lung fields. Laboratory findings are shown below:

WBC (x 10^3 cells/mL): 10.2
Hemoglobin (g/dL): 13.8
Hematocrit (%): 43.4
RBC (x 10^6/mL): 4.9
RDW (%): 13.2
MCV (fL/cell): 97
MCH (pg/cell): 31
MCHC (%): 36
Platelets (x 10^3): 310

Sodium (mEq/L): 141
Potassium (mEq/L): 4.2
Chloride (mEq/L): 105
Bicarbonate (mEq/L): 19
Creatinine (mg/dL): 1.1
Blood Urea Nitrogen (mg/dL): 23
Glucose, fasting (mg/dl): 78
Calcium (g/dL): 9.3
Calcium, ionized (mEq/L): 2.3

What is the best next diagnostic step?

A. Respiratory viral panel

B. EKG

C. Echocardiogram

D. Troponins

E. ANA

@khangstep2

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USMLE Step3 Question of the Week #493

#493. A 77-year-old male is brought into the Emergency Department after the staff at his nursing home witnessed a syncopal event. Once a week a barber comes to the nursing home to provide haircuts and shaving services. After the barber raised the head of the patient’s bed and started to shave his neck, the patient suddenly lost consciousness. The barber called for help, and the patient was regaining consciousness by the time staff arrived. Within a few minutes the patient was at his baseline mental status and did not lose control of his bladder or bowels or bite his tongue during the episode. The barber didn’t notice any abnormal movements by the patient but reports he was trying a new “natural” shaving foam this morning. The patient has a history of Parkinson’s disease and hypertension. He does not smoke or drink alcohol. Blood pressure is 124/84 mm Hg and heart rate is 92 beats/minute sitting and 128/82 mm Hg and 88 beats/minute after standing two minutes. What would be the next best step in management?

A. Immediate referral for permanent pacemaker

B. Carbamazepine

C. Referral to an Electrophysiologist

D. Carotid endarterectomy

E. Reassurance, education and clinical follow-up

cardio@jamesv

USMLE Step3 Question of the Week #492

#492.  A 37-year-old woman with a history of bulimia nervosa presents with chest pain. Patient describes it as a sharp pain, localized to the middle of the chest, and occurred acutely last night after vomiting.  Current medications are fluoxetine 60 mg orally daily and a daily multivitamin.

On physical exam, patient appears ill and diaphoretic.  Vital signs show temperature of 37 °C (98.6 °F), blood pressure of 135/85 mm Hg, pulse of 90 /min, respiratory rate of 30 / min, and oxygen saturation of 98% on room air.  Oropharynx is erythematous, dentition is poor and back molars show significant erosion.  There is dullness to percussion and diminished breath sounds over the lower lobe of the left lung.  Remainder of the physical exam is normal.   EKG and laboratory tests are normal.  Chest x-ray shows a small left pleural effusion and evidence of pneumomediastinum.

Which of the following is the definitive diagnostic step in this patient?

A. Esophagogastroduodenoscopy

B. Barium swallow study

C. Helical CT of the chest without contrast

D. Gastrografin swallow study

E. Thoracentesis

 

@card-hageman

USMLE Step 3 Question of the Week #491

#491.  A 65-year-old African-American male with a long-standing history of coronary artery disease and hypertension presents with shortness of breath and fatigue.  Patient says he feels fatigued throughout the day and that he can no longer walk across the room without being short of breath.  Patient states that symptoms onset a couple days ago and have steadily worsened.

Vitals are temperature 37 °C (98.6 °F), blood pressure 165/82 mm Hg, pulse 100/min, respirations 18/min, and oxygen saturation 97% on room air.  On physical exam, patient appears alert and in no apparent distress.  Cardiac exam reveals a load P2 and an S3 gallop.  Pulses are regular but have alternating strong and weak beats.  Mean jugular venous pressure is 12 cm H20.  Pulmonary exam reveals crackles in the lower lung fields bilaterally.  Extremities are cool to the touch and there is 2+ pitting edema bilaterally.

Laboratory tests show:

Sodium                                               120 mEq/L

Potassium                                           4.0 mEqL

Chloride                                               100 mEq/L

Bicarbonate                                         25 mEq/L

BUN                                                     45 mg/dL

Creatinine                                           1.0 g mg/dL

Glucose (fasting)                                90 mg/dL

Magnesium                                         1.7 mg/dL

Calcium                                               9.0 mg/dL

Phosphorous                                       4.1 mg/dL

Bilirubin, conjugated                           0.2 mg/dL

Bilirubin, total                                     1.0 mg/dL

AST (SGOT)                                          20 mU/mL

ALT (SGPT)                                          15 mU/mL

Alkaline Phosphatase                         80 U/L

WBC                                                    7000 / mm3

RBC                                                     5 x 106/mm3

Hematocrit                                          45%

Hemoglobin                                         15.0 g/dL

Platelet Count                                     250,000 / mm3

BNP                                                     750 pg/mL

NT-proBNP                                          1250 pg/mL

Troponin T (cTnT)                                0.05 ng/mL

Troponin I (cTnI)                                  0.03 ng/mL

Chest X-ray reveals evidence of pulmonary vascular congestion and pulmonary edema in the lung bases bilaterally.  EKG reveals Q wavs in leads V1 and V2, evidence of left ventricular hypertrophy and a left bundle branch block.  Transthoracic echocardiography reveals a LV ejection fraction of 25%, increased left ventricular wall thickness, moderate left atrial enlargement, and evidence of left anterior wall dyskinesis consistent with an old anterior wall myocardial infarction.

Patient is admitted to CCU and started on high flow 100% oxygen by nasal canula.  Carvedilol 25 mg orally twice daily, captopril 25 mg orally three times daily, furosemide 100 mg orally, and eplerenone 25 mg orally daily are initiated.

Which of the following is the next best step in management of this patient

A. Administer 1 L NS bolus and then NS + 20 mEq/L KCL IV at 115 mL/h

B. Initiate hydralazine 35 mg orally 3 times daily and isosorbide dinitrate 20 mg orally 3 times daily.

C. Restrict sodium intake to 5 g/day

D. Initiate digoxin 4 mcg/kg orally daily

E. Initiate diltiazem 150 mg orally daily

 

@card-hageman

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