nbme 4 step 3 practice exam with complete solutions

65 yo F has a 3 month hx of *increasing low back pain*. Had low back pain for past 3 yrs that's been treated w/NSAIDs and codeine. Now rated as 7/10 in severity. Pain radiates to both legs, worsens when walking or standing & Relieved when sitting. 1 YEAR AGO: X ray lumbosacral spine: mild osteoarthritis. Exam: 4/5 mm strength LE, hyporeflexia of knees&ankles b/, unsteady gait b/c of pain. No other abnormalities. Most appropriate diagnostic study of lumbosacral spine to order at this time? - Answer- *MRI* -prly b/c this pain is worse than the usual pain & neuro sx of hyporeflexia, decreased mm strength, and unsteady gait A couple comes to discuss the results of prenatal testing in current pregnancy. Screening test showed increased risk for having a child w/Down syndrome. Amniocentesis is suggested for her. Husband asks "When can we schedule the amniocentesis? I think that we should just get on w/it." Wife responds angrily, "That's easy for u to say. U haven't been carrying this baby for 4 months & u haven't felt it move like I have. Appropriate response? - Answer- "I know this is difficult news for both of u. I would like to know what both of u are thinking now" 3 y.o. boy is at 50th %tile for height&weight. Exam: hemihypertrophy of left side of body when compared to right. Palpable mass in LLQ. Labs: Hgb 12, Hct 36%, Urine: SG 1.020, WBC 0-1/hpf, RBC 10-20/hpf. U/S: left kidney mass. Dx? - Answer- *Wilms tumor* -most common RENAL malignancy in kids -age <5 -*Unilateral, PAINFUL, abdominal mass* -HTN, hematuria neuroblastoma - Answer- most common extracranial solid tumors in kids -painLESS abdominal mass -may have HTN Due to mass compressing renal artery and activating renin-angiotensin system -FLUSHING &SWEATING due to catecholamine hypersecretion -neural crest origin -involves adrenal medulla, sympathetic chain -median age <2 -*periorbital ecchymoses(orbital METASTASES)* -spinal cord compression from epidural invasion("dumbbell tumor") -opsoclonus-myoclonus syndrome DX: elevated catecholamine metabolites, small&round blue cells on histology, N-myc gene amplification 58 year old F has heavy substernal chest pain relieved by nitroglycerin & rest. Pain occurs w/exertion&accompanied by some SOB&sweating. 6 months ago: CABG. VSS. ECG: NSR w/*inverted T waves NEW in leads V4-V6.* next step in evaluation is to do which? - Answer- *Repeat coronary artery catheterization*->NOT order echo or MUGA scan -maybe b/c of NEW inverted T waves? 70 yo has 1 wk hx left eyelid droop. PMG COPD&Quit smoking 5 yrs ago. Troublesome pain radiating down left arm. Left ptosis w/small pupil on exam. Diagnostic study? - Answer- *CT scan thorax* -prly pancoast tumor 65 yo F had 2 min generalized tonic-clonic seizure that occured when asleep. PMH: HTN, breast cancer 2 yrs ago s/p lumpectomy, radiation therapy, adjuvant chemo 1 yr ago. Meds: lisinopril, tamoxifen.Pt is drowsy, not oriented to person,place,time. BP 160/95. Pulse ox 95%.Exam: right lower face drooping. Eyes conjugately deviated to left. Briskly withdraws LUE & both LE to noxious stimuli; there's no movement of RUE. Fingerstick BG 70, serum sodium concentration 130. CAUSE of seizure? - Answer- *Brain metastasis* prly from breast cancer -looks like she got a stroke strongest predisposing factor for prostate cancer - Answer- age (old) 32 yo F 6 day f/u for 12 cm lipoma removal from left lateral thigh. For past 2 days, she had swelling &mild increase in tenderness on and around incision site. Exam of incision site: bubble-like swelling underneath incision w/o erythema, drainage or lymphadenopathy. Area is ballotable & fluid wave on palpation.DX? - Answer- *Seroma*=pocket of clear serous FLUID -common after surgery -ballotable means significant effusion 28 yo F G1P1 at 33 wks gestation in active labor. RR 22. Exam: nontender abdomen. fundal height 36 cm. pelvic ultrasound shows pocket of amniotic fluid 91.5 mm. Underlying cause? - Answer- *Fetal esophageal atresia* (not fetal polycystic kidneys) 66 yo Irish American man has SOB on exertion for past 6 months, but now present when climbing 1 flight of stairs. +Dry cough. Retired 1 yr ago from job in *Stone* quarry. Exam: finger *Clubbing," end-expiratory crackles. CXR: fibronodular infiltrate in UPPER LOBES. Dx? - Answer- *Silicosis* asbestosis - Answer- -construction & shipyard workers -20 yrs after initial exposure -dyspnea on exertion, cough, chest tightness, wheezing -chest CT: pulmonary fibrosis mesothelioma - Answer- linked to asbestos exposure -dyspnea, chest pain -CXR: nodule thickening of pleura and/or obscuring of diaphragm 10 month old girl has 12 hr hx of intermittent colicky pain&vomiting. Dx 1 wk ago w/otitis media and 10 day course of amoxicillin started at that time. P 168, BP 82/46. Infant is fussy. Observed for 1 hr and d/c home. 12 hrs later, he's again brought to ED b/c sx have recurred. VS: 99.4F, P 170, RR 42, BP 84/46. Fussy &Crying. Tympanic membranes are dull but move w/insufflation. Oral exam: *Swollen gums & erupting teeth.* Skin exam: *1 bruise over right side of forehead and one on left leg*. Palpable fullness in LUQ. Rectal exam: formed stool w/mucus that's positive for occult blood. Explanation for condition? - Answer- *intussusception* 2 days postop mastectomy, 75 yo F has left hip pain & Unable to walk after falling on bathroom floor. BMI 27. Exam of LLE likely will show what? - Answer- *Shortening & external rotation of left leg* 69 yo F has 2 wk hx of productive cough of small amts of blood. Weight loss 3.2 kg during past month. During the past 7 yrs, she had increasing SOB & can't walk further than 3 blocks. Smoked for past 45 yrs. Retired from work as a nurse 4 yrs ago & spends her time driving around the country w/husband in recreational vehicle. BMI 22. VS: T 99.5F, P 80, RR 16, BP 140/86. Leg exam: varicose veins. Chest x ray done. Most appropriate diagnostic study at this time to order? - Answer- *CT Scan chest* -for possible lung cancer w/smoking hx & recent weight loss Randomized control trial done to assess efficacy of BB on pts undergoing major abd operations w/cardiac risk factors. Fewer pts receiving preop BB have a cardiac event than do pts receiving a placebo(5.8% vs 6.9% w/hazard ratio 0.84 and 95% CI of 0.7-0.99). However, More deaths occur in pts receiving preop BB than in those receiving a placebo (3.1% vs 2.3% w/hazard ratio of 1.33 and 95% CI of 1.03-1.74). How many pts need to be treated w/preop BB to cause 1 additional death? - Answer- *125* NOT 91 what supports dx of conduct d/o rather than dx of oppositional defiant d/o? - Answer- Physical aggressiveness toward others Randomized double blind clinical trial is conducted to compare the effects of taking vitamins on mortality. Over next 5 yrs, half of sample receive vitamins & other half receive placebo (control group). In F/U interview, investigator discovers 40% of control group had started to take multivitamins on their own as nutritional supplements. investigator chooses to keep initial randomized categorization for the analysis of outcomes. By using this approach, the investigator is adopting which of the following methods? - Answer- *intention to treat* 18 yo F has 6 month hx episodic dizziness. Episodes occur while sitting or standing but never when running. No menses for 2 yrs. BMI 17. BP 96/60, RR 12. Na 134, K 3.2, total protein 4.8, albumin 2.8. In addition to ECG, what else should be ordered at this time? - Answer- *bone densitometry** for Functional hypothalamic amenorrhea-exercise induced -even tho she's young, u can and should do this b/c she has athlete's triad and concern for osteoporosis/stress fractures -*decreased GnRH, LH/FSH, estrogen, bone mineral density* but total cholesterol & triglycerides increase for some reason -tx: increased caloric intake, estrogen, calcium, vitamin D. 75 yo M has 5 day hx mild-moderate back pain & Right flank pain w/radiation to right groin. During past 3 days: SOB & Significant swelling of both legs. Smoker. Exam: decreased breath sounds b/l, distended abdomen & diffusely tender w/loud systolic-diastolic bruit over mid-abdomen, hypoactive bowel sounds. 2+ edema b/l LE, extending up to umbilicus. Decreased femoral pulses b/l. Initial dx study? - Answer- *CT Scan abdomen* NOT renal u/s 64 yo AA has 1 month hx of fatigue &increasing lethargy. During this time, pt had worsening aches&pains that he thought were related to a new exercise program. Had increased thirst &urination during past 6 wks. Lost 9 kg(20 lbs) in last 6 months. Quit smoking 15 yrs ago. VSS. Pt is slow to respond to questions & Difficulty following 2-step commands. Exam: scattered petechiae & ecchymoses over LE. Ca 14.1, SCr 2.8, K 3.7, Hgb 10.5, WBC 4600, Plt 60,000. Underlying CAUSE of condition? - Answer- *paraproteinemia(monoclonal gammopathy)* not parathyroid adenoma -causes elevated total serum calcium due to increase in the BOUND CALCIUM Fraction but normal ionized calcium -not in young healthy ppl 40 yo M has mild pain in right elbow that started 3 wks ago after playing tennis w/a friend. Ibuprofen provided initial relief but then pain returned when he attempted tennis again 1 wk ago. 3/10 in severity. Point tenderness & mild swelling over lateral epicondyle right humerus. Painful ROM. No palpable effusion of elbow joint. Next step in evaluation? - Answer- *no further studies needed*-no X ray elbow needed 19 yo F has a 6 month hx of progressively worsening persistent HA. HA waxes&wanes and is most severe when she wakes up in AM. During past 2 wks, she had occasional brief episodes of darkening of vision in both eyes when she stands & noticed sound of her heartbeat in ears when lying down in quiet room. Gained 9 kg during past 2 yrs. BMI 32. VSS: BP 120/78. Dx is best supported by what physical exam finding? - Answer- *papilledema* NOT internuclear ophthalmoplegia -research this more! 12 yo F has 1 wk hx cough, nasal congestion, low grade fever. During the past 2 days, she also had moderately severe pain in left ear, which her mom treated w/OTC cerumen remover w/o relief. T 99.5F, P 70, R 14, BP 98/66. Exam: nasal congestion& erythema of left ear canal. Left TM is erythematous, bulging & multiple raised lesions. Dx? - Answer- *bullous myringitis* NOT otitis media w/effusion -research more major RF for alcoholism - Answer- *FAMILY Hx of alcoholism* not illicit drug use 81 yo M w/advanced dementia in Skilled nursing care facility has 3 wk hx facial rash. Unable to walk/talk/feed himself. PMH Hypothyroidism. BP 142/80. Erythema of both eyebrows, nasolabial folds, behind ears, mid sternum. intermittent twitching motions of arms. Which signs is most consistent w/underlying dermatologic dx in this pt? - Answer- *Flaking skin on scalp and face* -seborrheic dermatitis?? You are reading a study assessing whether ECG during graded treadmill exercise stress testing can predict clinically significant (75% or more) Coronary artery stenosis as shown by arteriography(gold standard). Subjects are men, ages 55-75 yo) w/chest pain who are referred to a cardiac center. Prevalence of greater than 75% stenosis in study group was 53%. Results of study shows: sensitivity 53%, PPV 89%, Specificity 92%, NPV 63%. Study said "in men, a positive multistage stress test is highly predictive of presence of significant coronary artery disease, but a negative stress test does NOT reliably r/o significant disease." You consider how exercise stress testing could be used to diagnose clinically significant coronary artery disease in pts in ur practice. In a 30 yo M w/chest pain, an exercise stress test would be likely to have which of the following features? - Answer- *lower PPV* b/c lower prevalence of heart disease in young men - answer is not higher negative predictive value b/c study said NPV is 63% b/c it says the study showed that positive stress test is highly predictive but negative stress test doesn't r/o disease=maybe lower PPV is better answer choice 17 yo AA high school student has severe right knee pain. " I was playing bball, went up for jump shot &When I Came down my knee twisted. I heard something pop & Felt this terrible pain." Exam: markedly swollen& tender knee. Able to actively extend it, although w/pain. Exam is made difficult by the swelling. X rays: confirms an effusion, they show a small avulsion fracture of lateral tibial plateau. Most likely dx is injury to which of the following structures? - Answer- *Anterior cruciate ligament* NOT medial meniscus 62 yo white woman has 24 hr hx progressive, severe SOB. 1 month ago, she began having episodes of severe SOB on bending over to pick up grandkids. Since that time, the frequency of episodes has increased to occur w/nearly every activity. During past 2 wks, pt noticed swelling in right arm&nagging dry cough. PMH mitral valve prolapse, HTN, T2DM. T 100.2F, P 60, RR 35, BP 130/76. Drinks 1 glass red wine daily. Exam: mild edema of face&Right UE, JVD, Palpable supraclavicular node. Diagnostic study? - Answer- chest x ray 29 yo M has 5 day hx worsening SOB, productive cough of yellow sputum, malaise, fatigue&fever. Bisexual w/3 male partners &1 male partner during past use, usually uses condoms. BMI 22, T 101F, RR 22. O2 sats 89%. Mildly tachypneic. Bilateral basilar crackles. ABG: pH 7.45, PO2 80, PCO2 32. Blood hct 45%, hgb 15, WBC 15,000. Chest x ray doesn't show obvious consolidation. Started on Supplemental O2 and IVF. Results of serum HIV test are pending. Most likely working dx? - Answer- *pneumocystis pneumonia* NOT streptococcal pneumonia 45 yo F has mouth sores intermittently during past 4-5 wks. Longstanding hx of intermittent diarrhea, abd pain, bloating for which she hasn't sought care in past. Had difficulty maintaining her weight despite following regular diet. Appears thin. BMI 18. Exam: 3 small ulcers of oral mucosa. Hct 30.5%, hgb 9.7. PBS: microcytic erythrocytes. Underlying cause? - Answer- *an immune response to gliadin proteins* celiac dx? 65 yo F has 14 kg weight loss in 2 months. Felt blue & decreased appetite and little exercise tolerance. used to walk 1 mile daily but now she can barely walk 1 block. Serum CA 124, CBC, PBS, Serum antinuclear antibody assary and serum RH assay obtained 1 wk ago WNL. BMI 21. AST 94, ALT 82, Alk phos 175. Diagnostic study? - Answer- *CT Scan abdomen* 28 yo M neurosurgery resident has 3 day hx of worsening fatigue. He's been working long hrs & staying up late studying for exams. Receive a subq influenza vaccine 1 wk ago. Has 12 month old child at home who attends daycare 5 days/week. The child has been home w/a fever, URI sx, diarrhea for past 5 days. begins to report chest pain & Then collapses. He doesn't lose consciousness. T 100.4F, P 110, RR 20, BP 88/54, Pulse ox o2 sats 92%. Exam: muffled heart sounds. Echo: global impairment in myocardial contractility. Likely source of transmission? - Answer- patient's child 78 yo AA man w/severe dementia has 30 minute hx acute respiratory distress. Son who has durable POA made decision not to intubate in case of future infxns. Pt has another infxn now and has respiratory distress. Next step? - Answer- *Administer IV morphine* but don't intubate or place pt in reverse trendelenburg position* 68 yo F has progressive weakness & numbness in arms &Spasticity in legs for past 3 wks. Neck pain&Diffuse arthralgias in extremities. 20 yo Hx RA for which she takes etanercept & celecoxib. BMI 18. VSS. Mm strength 3/5 in UE and 4/5 LE. Reflexes 3+ in all extremities. Babinski sign present b/l. Sensation to vibration is severely decreased in LE. CAUSE of worsening condition? - Answer- *atlantoaxial subluxation* NOT vasculitis of CNS Mom of 8 yo boy asks if the school vision screening is effective or not even tho it's not done by a doctor. Recent study showed school vision screening is 68% sensitive and 92% specific. Correlation coefficient between visual acuity and refraction results was 0.74. Incidence of myopia increased w/age & no child who failed vision screening was able to pass in following yrs w/o correction lenses. Conclusion abt this data? - Answer- school screening is effective in ID kids who need corrective lenses 65 yo F has 18 yr hx of DM and 2 yr hx of DM nephropathy. Takes intermediate-acting and short-acting insulin before bfast and dinner and enalapril for HTN. BG Concentrations between 70-130 but several readings every wk are less than 60 at various times of day. Asymptomatic at the time monitoring showed hypoglycemia. Eats 3 meals and snack before bedtime. Pulse is 74 when sitting and 94 when standing. BP 142/84 sitting, 118/76 standing. Sensation is decreased over feet. SCr increased to 2.4 from 1.8. HgA1c 5.9% from 6.7% 6 months ago. Explanation for discrepancy between glucometer readings & pt's sx? - Answer- *lack of hypoglycemic sx* 15 yo F has intermittent asthma since 6 yo. Missed 8 days of school in last 4 months and mom hears her daughter coughing&wheezing but daughter doesn't admit to any problems. She's been hanging out a lot at her new best friend's house. When interviewing this pt, what's appropriate to ask? - Answer- "is asthma worse when visiting ur friend?" 57 yo M has 6 wk hx weakness & Tingling sensation in arms & legs and persistent cramping pain in calves. VSS: BP 138/100. Pt takes no meds. 1+ pitting edema ankles. Mm strength 4/5 UE and LE. Na 142, K 2.8, HCO3 33. Next step in evaluation? - Answer- *Plasma aldosterone-renin ratio* not captopril challenge DX Maybe Conn's syndrome/primary hyperaldosteronism due to hypokalemia-there should be HTN Tho 65 yo F postop resection of right colon w/primary anastomosis for carcinoma of hepatic flexure. Postop-required prolonged vent support b/c of poor respiratory exchange. POD2: while vent is at FiO2 0.5 and PEEP 10, she abruptly becomes hypoxic and hypotensive. Pt is obese and smoked 1 ppd past 30 yrs. CAUSE for this episode? - Answer- *PE* not ARDS -recent surgery, obese, hypotension, hypoxic, 32 yo Chinese american M w/GERD has been taking lansoprazole for 1 yr w/good results until 3 months ago when he started having intermittent episodes of apprehension, perspiration, and intense substernal chest pain that radiates to his throat. Episodes wake up between midnight-6AM and last 5-10 minutes. Don't occur during day. ECG Cardiac enxymes normal. EXercise stress test w/ECG normal. Sublingual nitroglycerin tablet produced immediate relief of sx. Smoker. DX? - Answer- prinzmetal variant angina RCT to show efficacy of cholesterol-lowering medication compared w/diet and exercise alone. In a study, a total of 48 individuals, ages 35-65 yrs, are randomly assigned to either the treatment group or control group in equal distribution. Target goal for serum total cholesterol concentration is less than 150 after 3 months of treatment. At end of study, 20 subjects in treatment group and 8 subjects in control group achieved the target serum total cholesterol concentration (P<0.05). Absolute risk reduction of hypercholesterolemia indicated in this study? - Answer- 0.5 NOT 0.25 1 day old newborn became increasingly cyanotic during past 4 hrs. O2 therapy hasn't improved sx. Delivered at 36 wks gestation via C section for fetal distress to 39 yo F who received little prenatal care.Apgar 6 and 8. Birth wt 6 lb 3 oz, 30th percentile. P 125, RR 68, Pulse ox 100% oxygen shows O2 sats 74%. Exam: total body cyanosis and pansystolic heart murmur. CXR: increased prominence of pulmonary vessels. ECG normal. Explanation for cyanosis? - Answer- Transposition of great vessels 74 yo M has 3 month hx of worsening productive cough, exercise induced SOB, right sided CP that worsens w/deep breathing. Lost 4.5 kg during past month and is a former smoker. Exam: crackles b/l, decreased breath sounds right base, clubbing of digits. CXR: pleural thickening more prominent on right than left, large right pleural effusion. What will differentiate malignant from benign cause of lung disease? - Answer- *thoracoscopic lung and pleural biopsy* NOT thoracentesis 24 yo M has 2 day hx agitation and difficulty sleeping. T 100.0F, P 100. Pupils dilated and reactive to light. Claims he is God and speaks rapidly, jumping from topic to topic. UDS negative. Serum thyroid studies pending. Opthalmoscopic exam shown. Next step in dx? - Answer- CT Head 5 yo Boy has 2 day hx fever and respiratory distress. This is 4th episode of PNA in past 3 yrs. "It's always on right side that he gets PNA". T 102 F, P 100, RR 36, BP 100/60. Exam: audible wheezing, mild intercostal and subcostal retractions. reduced breath sounds in right mid-lower chest region. DX? - Answer- Foreign body in bronchus 25 yo F has facial pain that began after she was hit in jaw by a ball during hockey game 1 wk ago. Pain is at side of face in front of right ear. Unable to open mouth wife and occasionally hears clicking/popping sound in joint. Muliple caries as child and braces as a teen. Exam: muscular tenderness over masseter mm and near its attachment adjacent to mandibular fossa on right side. What's appropriate to consider in assessing the need for additional screening? - Answer- *Recent trauma to jaw* 63 yo M takes risperdal for schizophrenia. other meds: benztropine, fluphenazine, lisinopril, albuterol. normal skin turgor. sodium 124. urine Na 145 WNL, osmolality 82. why hyponatremia? - Answer- excessive water intake (NOT SIADH) 19 yo Mexican american F "noticed skin on elbows&knees are red, drug&Itchy-been swimming in pool and wonder if im allergic to chlorine.* finger stiff&slightly sweollen. Exam of skin on elbows and knees will show what? - Answer- dry red patches of skin covered w/silvery scales -psoriasis? 2 month old infant has 2 days hx of bloody stools. Infant normally has 4-5 soft yellow stools daily. Bottle fed cow milk protein-based formula since birth and now drinks 4-5 oz of formula every 3 hours. He somtimes spits up but gains weight appropriately. Exam: mildly erythematous patches of eczema on LE> Hyperactive bowel sounds. Positive occult blood test. Dx? - Answer- cow milk protein allergy(not meckel) 3 week old female newborn has difficulty breathing. Newborn was unresponsive w/ataxic respirations. intubated and had tonic-clonic seizure en route to ED. treated w/diazepam and seizure stopped. Now on arrival to ED, shes unresponsive to noxious stimuli. P 160, T 98.6F, BP 80/45. Pulse ox 100%. Skin clammy&Cool. *Multiple flame hemorrhages in both retinas.* anterior fontanelle firm& full. Cap refill time 3 seconds. Order what? - Answer- *CT Head* not serum electrlyte and glucose concentrations 26 yo is 30 wks gestation has nocturnal coughing & wheezing for past 4-6 wks. Sx worse in morning. OCcasionally productive cough w/clear mucus and sometimes has hoarseness and throat irritation. NO fever. OCcasional dyspepsia releived w/OTC antacids. Mom&brother have atopic allergies w/hay fever and she had some wheezing episodes as a kid. there's been 2 dogs in her household for 2 yrs now. *stopped smoking when pregnant.* exam: few coarse expiratory wheezes and rhonchi. Dx? - Answer- *GERD* not bronchitis brain death signs - Answer- absence of corneal reflex 55 yo Filipino American says indomethacin no longer relieves gout pain. Prescription label shows medication to be 3 yrs old and has failed to follow up or to continue meds as directed. "I take them until my joints don't hurt then save some for next time." Exam: large firm prominence over left patella that's nontender but "prevents me from kneeling to clean my flower beds." X ray left knee: punched out erosions of patella w/overhanding edge of cortex. Joint is preserved w/o effusion and normal mineralization of bone. SCr 1.4, uric acid 9.2, calcium 9.5. CAUSE of findings? - Answer- tophaceous deposit (no osteochondroma) Full term newborn delivered to mom who had limited 3 prenatal visits. Head circumference is 30 cm (<5th percentile). VS: T 99.4F, P 140, RR 40. Liver palpated 3 cm below right costal margin and spleen is palpated 1 cm below left costal margin. WBC 5200, plt 150,000. CT show looks like periventricular calcifications. What will confirm child's diagnosis? - Answer- *urine culture for cytomegalovirus* 3 yo boy has been progressively frequent & severe jerking movements of extremities & Eyes during past week. VSS. Lemon-sided mass in abdomen in LUQ.Child has frequent involuntary eye movement in wide excursion and random myoclonic jerking movements of all extremities. NEuro exam shows moderate ataxia. Dx? - Answer- neuroblastoma 78 yr F has been recieving IVF and antibiotics for urinary sepsis for 3 days, now has increased abd girth. Now is lethargic and icteric. RR 28. abdomen is distended and fluid wave present. Abd paracentesis done: serum protein albumin 2.8, ascitic fluid protein albumin 2.4, WBC 420/mm3. next step? - Answer- ceftriaxone complication of abortion - Answer- bleeding 21 yo F has 1 wk hx severe worsening pelvic pain and 24 hr hx nausea, fever, chills. Unable to have intercourse b/c of pain. T 100.9F, P 108, RR 18. Nondistended abdomen w/ tenderness in RLQ.Pelvic exam: cervical motion tenderness and tender 4 cm right adnexal mass. hgb 13.9. WBC 15,000. Hct 36.8. negative beta hcg. Pelvic u/s: right adnexal, complex 4.5 cm mass w/air-fluid level. Blood flow to ovary is normal. next step? - Answer- *IV antibiotic therapy* not laparoscopy pregnant woman smokes and does cocaine. what will this result in her baby having? - Answer- signs of drug withdrawal 28 yo AA F is 12 wks gestation and has lupus. 2 month hx fatigue and mild arthralgia. urine protein 3+, RBC 2+, WBC 2+, 24 hr protein 3 g. Creatinine 2.9. most appropriate immunesuppressive tx? - Answer- prednisone 16 yo high school football player has severe, acute scrotal pain that started 3 hrs ago when sitting in bedroom. Had similar, milder episode 2 days ago which was attributed to trauma during previous fball practice. Improved but never fully subsided. Not sexually active without urethral d/c. In great discomfort. Left testis very tender to palpation. Left cord thicker than right cord and very step? - Answer- obtain immediate surgical consult 86 yo F cut right leg yday w/garden tool. Unsure about previous vaccines. Exam: 3 cm long, slightly tender, irregular wound just above lateral malleolus right foot. Some soil and plant material in wound. BP 142/88. Random BG test 124. Hga1c last week 7.1%. After cleansing wound & Removing all foreign material, most appropriate step? - Answer- *Wound debridement & Daily dressing changes* NOT suturing -also give tetanus and diptheria toxoids vaccine and tetanus immune globulin 9 yo bow hasa grade 1/6 systolic murmur heard along left sternal border and is getting checked before he can play football. appropriate statement to mom? - Answer- he can participate on football team-likely benign murmur -diastolic murmurs are always pathologic tho 6 yo boy w/juvenille rheumatoid arthritis wants to play soccer but mom is concerned abt arthritis and possible damage to joints. he just has mild tenderness in his wrists. response to mom? - Answer- no physical activity restrictions at this time 78 yo F has progressive loss of function of left side of body for past 24 hrs. BP 200/110. Left arm and leg flaccid. Immediate management? - Answer- general supportive care w/gradual control of BP 20 month old girl brought in b/c there was a bat flying around the bedroom in which child was sleeping. Girl was not crying and appeared undisturbed. What should be done? - Answer- request that bat be tested for rabies 17 yo boy fell into a pond thru ice. Immersed at least 40 minutes. Pulseless and unresponsive at the scene. Intubated and CPR done. Rectal temp 28C(82.4F) and palpable SBP 50 mm during chest compressions. Pupils measure 5-6 mm b/l and nonreactive. Gag, corneal and oculocephalic reflexes absent. Neuro exam: diffusely poor mm tone, absence of DTRs, no babinski sign. Fine ventricular fibrillation. FiO2 1.0 and ABG: pO2 50, PCO2 45, pH 6.9, Warmed IV