Question of the Week # 445

445) A 45 year old african-american man presents to the emergency room with altered mental status. His past medical history is significant for skin nodules. One of the nodule was recently biopsied and it revealed non-caseating granuloma. On examination, his oral mucosae are dry.  Blood pressure is 90/60 . Skin examination  reveals multiple scattered skin nodules about 1 to 2cm in diameter. Chest X-ray reveals bilateral hilar adenopathy.   Laboratory Studies reveal

WBC 5400/µl

HGB: 11.8 gm%,

Platelets : 300k/µl

Calcium 14.2gm%

Creatinine 3.2mg%

Phosphorous 2.2mg%

He is started on agressive intravenous hydration. In addition to the above  measures, you should also proceed with  intervention directed to towards which of the following at this time ?

A) Reducing serum phosphorous

B) Reducing serum parathyroid hormone

C) Reducing Blood Calcitrol level

D) Promoting loop diuresis

E) Direct removal of calcium by Hemodialysis

Question of the Week # 422

422) A 54-year-old man with history of Diabetes Mellitus and End-Stage Renal Disease is evaluated in your office during a follow up visit after undergoing hemo-dialysis in the morning. He has been dependent on Hemo-Dialysis  for past four years and undergoes dialysis thrice a week. He reports recurrent epigastric abdominal pain that is burning in quality which is relieved by taking over the counter antacids. He denies any pain at this time. He denies any nausea or vomiting. He has no history of alcohol use or smoking. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. Laboratory investigations are as follows:

WBC  8.0K/µL

Hemoglobin 10.5gm%

Serum amylase 200 IU/L ( N =  25 to 160 U/L)

Serum Lipase 150 IU/L (Normal = 25 to 80U/L)

AST  30 IU/L

ALT 40 IU/L

Total bilirubin 0.6gm%

Alkaline Phosphatase 80IU/L .

Which of the following is indicated in this patient at this time?

A) Ultrasound of the Gall Bladder

B) Nothing by mouth and IV hydration

C) No further investigations or treatment

D) Endoscopic Retrograde Cholangio Pancreatography

E) CT scan of the Abdomen

Question of the Week # 348

348)  A 6 year old boy is evaluated in your office for complaints of generalized swelling of his body. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 3 weeks.  He does not have any significant past medical problems  There is no history of fever or sore-throat. He denies shortness of breath or cough. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. He appears comfortable. His face is grossly swollen. There is mild ascites. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell or casts. A 24 hour Urine total protein is obtained and it shows proteinuria at  7.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  He is advised to start sodium restricted diet. Which of the following management options is most appropriate next step for this patient?

A) Admit and start Albumin infusion

B) Corticosteroid Trial

C) Renal Biopsy

D) Obtain Anti-Streptolysin O titer

E) Furosemide

Question of the Week # 347

347)  A 34 year old man is recently diagnosed with Stage IIA Hodgkin’s  lymphoma and has received one cycle of chemotherapy with Adriamycin, Bleomycin, Vinblastine and Dacarbazine. He is scheduled to receive three more cycle followed by involved field radiation therapy.  One week after his first cycle of chemotherapy, he presents to your office with increasing swelling of his legs. He denies any fever, chest pain, rash or shortness of breath. On examination, breath sounds are decreased in bilateral lower lungs. There is 2+ edema in his lower extremities. Laboratory investigations show reduced albumin at 2.5gm%. Urinalysis reveals 3+ proteinuria with out any evidence o red cells or red cell casts. A MUGA ( Multigated Acquisition Scan) has been ordered to evaluate his cardiac function and results are pending. Which of the following is most likely explanation of his presentation?

A) Adriamycin Cardiomyopathy

B)  Allergic interstitial nephritis

C) Focal Segmental Glomerulosclerosis

D) Bleomycin nephrotoxicity

E) Minimal Change Disease

Question of the Week # 346

346)  A 54 year old woman presents to your office with progressively increasing swelling of her bilateral lower extremities and abdominal distension.  She denies any fever, cough or shortness of breath. Her medical history is significant for hypertension and osteoarthritis. She takes Enalapril and Hydroclorthiazide for her hypertension and Ibuprofen for osteoarthritis on a daily basis . She denies any rash. On examination,  she is afebrile,  Blood pressure 130/80 mm Hg and respiratory rate is 18/min . Auscultation reveals reduced breath sounds on both sides. Abdominal exam is remarkable for shifting dullness  consistent with ascites.  Lower extremities reveal gross edema up until the level of knees.  Urinalysis shows no eosinophils or redcells or casts,  3+ proteinuria, no nitrite or leukoesterase. Urine total protein is 6.0 gm/24 hours. Serum total protein 4.0gm% , albumin 2.0gm%. SGOT, SGPT and Alkaline phosphatase are within normal limits. Serum creatinine is o.8mg%.   Skin examination si normal with out any rash. Which of the following management options is most appropriate next step for this patient?

A) Discontinue Enalapril

B) Renal Biopsy

C) Discontinue Ibuprofen

D) Furosemide

E) Obtain Anti-Nuclear Antibodies

F) Trial of Corticosteroids

Question of the Week # 345

345)  A 8 year old boy is brought to the Emergency room by his mother with complaints of  shortness of breath. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 4 weeks. She scheduled an appointment with his pediatrician in the upcoming week however, she brought him to the ER today because he started getting distressed because of breathing difficult. The patient does not have any significant medical problems and mother reports he has always been a “good kid” at the school.  There is no history of fever or sore-throat. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg (Standing) , 108/60 ( Lying Down) and Heart Rate 92/min ( Standing), 88/min (Lying Down). He is tachypneic with respiratory rate is 26/min and is using accessory muscles. His face is grossly swollen. Breath sounds are reduced on both sides and there is massive ascites with scrotal edema. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell casts or hematuria. Urine total protein is 8.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  A chest X-ray shows bilateral pleural effusions. Which of the following management options is most appropriate next step for this patient?

A) Renal Biopsy

B) Corticosteroid Trial

C) Furosemide

D) Furosemide with Albumin infusion

E) Consult Nephrology

Question of the Week # 336

336) A 21 year old hispanic woman is evaluated in your office for recently diagnosed Hypertension. On previous two visits, her blood pressure was 150/90 mm HG. She denies any family history of Hypertension.  Her Past medical history is significant for multiple Urinary tract infections and enuresis as a child. She has no other complaints. On examination, her repeat blood pressure is 148/92 mm HG. There are no abdominal bruits. Ultrasonography reveals scarring of  both kidneys. Which of the following is an important feature of this condition?

A) Positive Anti-DsDNA

B) Strong Genetic Pre-disposition

C) Association with Berry aneurysms

D) Postural Hypotension

E) Abdominal Striae

Question of the Week # 330

330) A 55 year old man is brought by the EMS to the emergency room in a disoriented state. The patient has alcohol smell on his breath. Reviews of his past records reveal history of chronic alcohol abuse. His girlfriend arrives in the ER few minutes later and she reports that the patient has not been eating anything because he has been drinking heavily and vomiting over the past three days. On examination, he is afebrile, blood pressure 130/82 mm Hg, RR 18/min and Pulse 82/min. When the nurse attempts to check blood pressure, the patient develops carpo-pedal spasm (Trousseau sign). Chest is clear to auscultation.

Laboratory investigations reveal:

Ethanol level 140mg%

Serum Sodium 142 meq/L

Serum Potassium 3.2meq/L

Serum Chloride 106meq/L

Calcium 6.2 mg% (N = 9.0 to 10.5)

Bicarbonate 25 meq/L

Creatinine 1.2 mg%

Albumin 3.9 gm% (N = 3.5 to 5.0 gm %)

Patient is treated with Calcium gluconate and then, another dose of calcium chloride. Repeat serum calcium level is 5.8mg%. Trousseau sign is still positive.

Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Ionized Calcium

B) Obtain Serum Magnesium Level

C) Obtain Paratharmone level

D) Start potassium chloride

E) Obtain Vitamin D level

Question of the Week # 320

320)  A 65 – year-old woman is evaluated in your office during a follow-up visit. Her medical problems include Diabetes mellitus type II and hypertension. She is being managed on oral metformin, glyburide and hydrochlorthiazide. Her most recent hemoglobin A1C is 6.5%.  Her urine was negative for microalbumin three months ago. Her past medical history is significant for hospitalization for angioedema which occured after initiation of  Enalapril three years ago. Physical examination is unremarkable. The patient requests if she can be started on Angiotensin Receptor Blocker ( ARB) because she read about its beneficial effects in preventing kidney damage in diabetics. Which of the following is the most appropriate response?

A) “You are correct. I will start you on ARB”

B) ” You can not be started on ARB because of history of Angioedema”

C)  “You can start ARB but need pre-medication with steroids”

D)  ” You can start ARB but there is a small risk of Angioedema”

E)  ” Hydralazine/ Nitrate combination offers similar reno-protective effect as ARB”

Question of the Week # 319

319)  A 64-year-old man with history of diabetes mellitus and end-stage renal disease is admitted for complaints of weakness and contractures in his extremities associated with tight and thickened skin. He denies any past history of finger or toe discoloration on exposure to cold. He is dialysis dependent and undergoes hemodialysis three times in a week. His most recent dialysis was a day ago. His symptoms started 3 days prior to presentation and have progressively worsened. Three weeks prior to admission , the patient had a transient ischemic attack. An MRI with Gadolinium performed at that time did not reveal any abnormalities. He denies any neurological symptoms at this time. The patient’s medications upon admission include Aspirin, Insulin Glargine and Lisinopril. On physical examination, the patient appears chronically ill. He is afebrile,  blood pressure 120/70 mmHg and pulse rate was 82/minute. Skin examination reveals diffuse nonerythematous thickening and tightening of the skin over the abdomen, arms and legs. Chest and the face are spared. There are contractures in upper and lower extremities extremely limiting the range of motion of the involved joints. Erythrocyte sedimentation rate and C-reactive protein are elevated. Calcium is 8.0mg% and phosphorous 4mg% with calcium – phosphorous product of  32. An image of his upper extremity is shown below

Which of the following is the most likely diagnosis?

A) Systemic sclerosis

B) Calciphylaxis

C) Nephrogenic Systemic Fibrosis

D) Cryoglobulinemia

E) Eosinophilc Fascitis

Question of the Week # 318

318)  A 55 year old woman underwent a debulking surgery with total abdominal hysterectomy, Salpingo-oophorectomy, omentectomy and appendicectomy for a recently diagnosed Stage IIIC  Epithelial Ovarian Cancer. Her intra-operative course was complicated by severe blood loss and she received about 15 units of Packed Red Blood Cells. She is currently in the intensive care unit. Six hours after surgery, her blood pressure drops to 80/50 mm Hg. On examination, she is afebrile. She is drowsy but can be awakened. She denies any chest pain or shortness of breath. She has muscle tremors. Chest is clear to auscultation. Abdominal sutures are intact with no clinical evidence of Hematoma. An electrocardiogram is shown below:

Which of the following is the most likely explanation of the patient’s acute findings?

A) Hyperkalemia

B) Acute Myocardial Infarction

C) Circulatory Overload

D) Transfusion Associated Acute Lung injury

E) Citrate Toxicity

Question of the Week # 317

317)  A 68-year-old african-american man with history of NYHA Class III congestive heart failure  presents to your office for a follow up visit. His other medical problems include Hypertension, Stage II chronic kidney disease and Coronary artery disease. During his office visit three months ago , she was noted to have moderate hyperkalemia. At that time, his medications were adjusted which involved discontinuation of spironolactone and dose-reduction of ACE inhibitor. His other medications included Atenolol and Aspirin. She reports that she was admitted to hospital two weeks ago with severe hyperkalemia.  He denies any complaints at this time. A serum potassium level is 4.5mEq/l , serum creatinine 1.8mg% and most recent echocardiogram revealed a left ventricular ejection fraction of 35%  . His current medications include Atenolol, Hydrochlorthiazide and Aspirin. Which of the following is the most appropriate next step?

A) Re-start ACE inhibitor at a lower dose

B) Start Angiotensin Receptor Blocker (ARB)

C) Start Hydralazine and Isosorbide

D) Continue current medications

E) Start Spironolactone

Question of the Week # 316

316)  A 72-year-old man was admitted to the hospital with right leg deep vein thrombosis. He has a history of prostate cancer, well-controlled diabetes and mild renal insufficiency. His baseline creatinine is usually between 1.4 to 1.6mg%. His laboratory investigations at admission were normal except for increased creatinine at 1.4mg% . Venous doppler showed leg femoral deep vein thrombosis in femoral vein. He was started on Heparin drip and oral warfarin.  Three days after admission, the patient develops persistent hyperkalemia (6.5 to 7.0 mEq/l). Rest of his electrolytes are normal and renal function is at his baseline. His INR ( International Normalized Ratio) is 1.4. There are no EKG abnormalities. His Urine Osmolality is 300mOsm/kg, Urine K 20 mmol/L and Serum Osmolality 280 mOsm/kg.  He is given insulin and dextrose therapy however, hyperkalemia persists. Which of the following is the most appropriate next step in management?

A) Start Kayexalate

B) Discontinue Heparin and Start Enoxaparin

C) Discontinue Heparin and place Green field filter

D) Hemodilaysis

E) Intravenous Sodium bicarbonate

Question of the Week # 315

315)  A 64-year-old man with history of diabetes mellitus is evaluated in your office during a follow-up visit . He was admitted to the hospital one week ago because of incidentally discovered high serum potassium of 7.0mEq/L on his routine labs. He has history of hypertension and Stage I chronic kidney disease . His medications prior to the hospital admission included glyburide and enalapril. However, Enalapril was discontinued and he was started on hydrochlorthiazide during that admission. He denies any complaints at this time. A serum potassium level is 4.5mEq/l , serum creatinine 1.8mg% and urinalysis reveals proteinuria. 24 hour urine collection reveals 300mg proteinuria/24hrs. Which of the following is the most appropriate next step?

A) Re-start Enalapril at 50% of  previous dose

B) Start Losartan

C) Start Hydralazine and Isosorbide

D) Start Spironolactone

E) Renal biopsy

 

Question of the Week # 314

314)  A 70-year-old man presented to the Emergency room with a 2-day history of increased thirst and frequency of urination. He reports generalized muscle weakness. His past medical history is significant for hypertension, diabetes mellitus and Stage III chronic kidney disease. His medications include Insulin Glargine, Lispro insulin, Enalapril , Atenolol and Spironolactone.  Laboratory investigations reveal

Blood glucose 400mg%

Sodium 130 mEq/L

Potassium 7.5 mEq/L

Bicarbonate 26mEq/L

Chloride 100mEq/L

Creatinine 4.2mg%

An electrocardiogram is shown below:

 

Which of the following is the most appropriate next step?

A) Reduce the dose of Enalapril

B) Hemodialysis

C) Insulin Intravenous

D) Calcium Gluconate IV

E) Sodium biacrbonate IV

Question of the Week # 229

229 )  A 70-year-old white man with history of poorly controlled type 2 diabetes mellitus and hypertension is evaluated in the emergency room for severe pain in the right thigh. The patient has a coronary artery disease for which he underwent cardiac catheterization with percutaneous coronary intervention 2 days ago. He denies any chest pain or shortness of breath.  On physical examination, temperature is 99.2F, HR 120/min and blood pressure is 80/40 mm Hg.  There is erythema at the site of  cardiac catheterization in the femoral area. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 1.8mg% one week ago. Which of the following is the most likely diagnosis?

A)  Toxic shock syndrome

B)  Atheroembolism

C)  Contrast Nephropathy

D) Ruptured femoral artery pseudo-aneurysm

E)  Retroperitoneal bleeding

Question of the Week # 228

228 )  A 70-year-old white man  with type 2 diabetes mellitus and hypertension is evaluated in the emergency room for lacy purplish discoloration of the lower extremities that developed few hours ago. He reports diffuse bodyaches and low grade fever. He denies chest pain or shortness of breath. His past medical history is significant for coronary artery disease for which he underwent cardiac catheterization with percutaneous coronary intervention one week ago.  He has a history of chronic atrial fibrillation for which he is on 5mg coumadin daily. His most recent INR has been therapeutic at 2.5. Physical examination reveals lacy purplish pattern on bilateral lower extremities shown in the image below.

The site of cardiac catheterization in the femoral area is clean and healing with out any tenderness or erythema. Neurological examination is normal. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 1.8mg% one week ago. Hemoglobin and platelet count are within normal limits. WBC count is 12.6k/µl with neutrophils 70%, bands of 2% , eosinophils 18% and lymphocytes 10%. Which of the following is the most likely diagnosis?

A)  Toxic shock syndrome

B)  Atheroembolism

C)  Contrast Nephropathy

D)  Anti-Phospholipid antibody syndrome

E)  Cryoglobulinemia

Question of the Week # 72

A 55 y/o african american man with newly diagnosed Stage B prostate cancer undergoes radical prostatectomy and is referred to you from surgical clinic for routine follow up. The patient requests how often he should follow up with you and what tests he would need. Your best response is:

A) You do not need any follow up because you had a local cancer that was completely resected
B) PSA need to be tested every six months for 5 years and thereafter, every year
C) Bone scan to evaluate metastasis is needed every year
D) Digital Rectal Exam every year to look for local recurrence
E) You need endocrine therapy before we proceed further

Archer USMLE Step 3 CCS Workshop – August 22, 2010

Archer USMLE Step 3 CCS Workshop – August 22, 2010

Archer online live step 3 reviews aims to bring USMLE step 3 courses on your desktop, at your doorstep! These highly successful live USMLE Step3 online reviews are an extension of our very popular and successful ” Dr.Red’s online ccs workshop, which has reached more than two thousand step3 takers in less than 12 months and has resulted in 98% pass rate. Archer Reviews have achieved a high success rate even with examinees with multiple attempts by our unique approach. These online reviews are done live and in a webinar format. You can stay at home and listen to lectures live and like in a virtual classroom, you can raise your hand and your question will be immediately answered by the instructor. This is a live online classroom which reduces the pain of flying several miles to attend live reviews. These are the only one in the market that offer successful step 3 lectures in this unique, live format. Archer’s most successful endeavor has been Dr.Red’s CCS Workshop which has helped hundreds of examinees to pass easily by excelling on CCS component.

Archer’s next CCS online workshop for the month of January will be on Sunday 8/22/2010 at 10 AM EST.

If you are interested in registering for this course, you can pay for the course on the website at http://www.shop.ccsworkshop.com. Upon payment of the registration fee, your registration request will be automatically approved and an approval e-mail will be sent to you. This approval notice will have a button “Join Webinar” in it. Clicking this button on the day of the workshop will open up the live workshop on your desktop

To participate in the workshop, you will need a computer with internet access. For the audio, you can use either your computer’s microphone or a telephone. You will use the phone for the voice and log in to the conference call while you watch the power-point slides and the CCS demonstration on your desktop via. our unique net meeting software. You can also just opt to use your computer’s microphone in which case you do not need a telephone. Then you will get to practice a case while we watch and analyze your approach and correct it.

CCS Workshop Includes :

1. Lecture on CCS Strategies
2. Live demonstration of CCS cases
3. Common mistakes committed by the examinees and preventing them
4. Tips to score extremely high on CCS
5. Follow-ups of office and ER cases
6. Efficient use of time, doing more stuff without advancing the clock
7. Avoiding invasive tests
8. Basic set of orders for emergency cases
9. The 5-minute screen – adding/ disconinuing the orders that can matter
10. Obtaing consults and their appropriateness
11. Differential diagnosis for common ER and office presentations and easy tips to get the most out of few orders.
12. Working on efficiency
13. Live practice of 15 to 20 CCS cases by the attendees in the workshop
14. A these in addition to –> 20 minutes of supervised practice of one CCS case by each attendee who volunteers to practice. About 15 to 20 Highyield CCS cases will be practiced. During this time, you will be thoroughly analyzed, corrected and given instantaneous feedback by our experienced faculty

The total course fee is $97 .Slots are limited at 35.
If you are interested in the course, you visit Archer’s online store directly to pay : http://www.shop.ccsworkshop.com

If you have further questions, please directly contact support@ccsworkshop.com

Archer’s other courses include very informative topic reviews and the high-yield rapid review – please check our website.. Archer theory reviews are now available as streaming videos so that you can start accessing them from the beginning of your step 3 preperation and fine tune your conceptual understanding to score maximum on the Multiple Choice Questions on USMLE Step 3

Excerpts from Archer Rapid Review – Nephrology by Dr.Red

this is a 30 minute clip from recent Archer USMLE Step 3 Rapid review quickly summarizing electrolyte imbalance and acid-base

The above embedded video is not displaying the video. For access to full video+ audio, click here : Nephrology

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