USMLE Forum Archives - USMLE Step 2 CK - continuation of questions
continuation of questions
Youngdoctor - 10-19-08 01:44
1)A 40-year-old white male, health care worker presented with several week history of arthralgias, malaise, and fatigue. He also noticed crops of palpable purpura. Biopsy results of the purpura revealed leukocytoclastic vasculitis and IgM and C3 deposits around the small blood vessels. Diagnosis of mixed cryoglobulinemia is entertained. His vitals are stable and he is afebrile. What is the most appropriate next step in the management? A. Hepatitis-C RNA assay
B. Hepatitis-B serology
C. ELISA for HIV I and II
D. Serum immunoelectrophoresis
E. C-ANCA
2)A 60-year-old male who emigrated from Russia comes to you with complaints of dizziness, fatigue and weight loss. A review of systems reveals that the patient experiences daily fevers and cough. He does not use tobacco alcohol or drugs. He does not take any medication. His blood pressure is 108/64 mmHg while standing. His respiratory rate is 14/miri and is unlabored. Laboratory studies reveal the following:
Chemistry panel
Serum sodium 130 mEq/L
Serum potassium 5.9 mEq/L
Chloride 102 mEq/L
Serum creatinine 0.8 mg/dL
Blood glucose 58 mg/dL
Complete blood count
Hemoglobin 10.0 g/L
Platelets 430.000/mm3
Leukocyte count 4,500/mm3
Neutrophils 46%
Lymphocytes 45%
Eosinophils 9%
Chest x-ray shows a right upper lobe cavity. Which of the following acid-base disturbances is expected in this patient?
A. Elevated anion gap metabolic acidosis
B. Normal anion gap metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis
E. Respiratory alkalosis
3)An 87 years old man with hypertension and hyperlipidemia is brought to the emergency department complaining of severe headache and high fever. Further history reveals neck stiffness, photophobia, nausea and vomiting. He has no HiV risk factors. His temperature is 101F, bp is 100/70mm, pulse is 123/min and respirations are 16/min. He has no respiratory distress. The eyes bothers his eyes and he has neck stiffness. There is no edema of the optic disc on fundoscopy. his cranial nerves are intact and there are no heart murmurs. His lungs are clear to auscultation. He has no odema. He has neck pain and resistance to movements. He draws his legs up when the neck is flexed. he has a strength of 5/5 in four extremities with normoactive reflexes. Which is the most accurate sequence to be followed next?
A. Begin treatment with ceftriaxone, dexamethasone and ampicillin. Send him for a ct and do a lumbar puncture
B. Begin treatment with cetriaxone and send him for a pre lumbar puncture Ct head
C. Perform LP and begin tx with ampicillin and ceftriaxone
D. perorm Lp and begin treatment with ampicillin, ceftriaxone and dexamethasone
E. Start antibiotics only when culture reports of the LP are available
4)A 49-year-old male is brought to the hospital by his
family because of confusion and dehydration. The family
reports that for the last 3 weeks he has had persistent
copious watery diarrhea that has not abated with the use
of over-the-counter medications. The diarrhea has been
unrelated to food intake and has persisted during fasting.
The stool does not appear fatty and is not malodorous.
The patient works as an attorney, is a vegetarian,
and has not traveled recently. No one in the household
has had similar symptoms. Before the onset of diarrhea,
he had mild anorexia and a 5-lb weight loss. Since the
diarrhea began, he has lost at least 10 pounds. The physical
examination is notable for blood pressure of 100/70,
heart rate of 110/min, and temperature of 36.8°C
(98.2°F). Other than poor skin turgor, confusion, and
diffuse muscle weakness, the physical examination is
unremarkable. Laboratory studies are notable for a normal
complete blood count and the following chemistry
results:
Na+ 146 meq/L
K+ 3.0 meq/L
Cl– 96 meq/L
HCO3
– 36 meq/L
BUN 32 mg/dL
Creatinine 1.2 mg/dL
A 24-h stool collection yields 3 L of tea-colored stool.
Stool sodium is 50 meq/L, potassium is 25 meq/L, and
stool osmolality is 170 mosmol/L. Which of the following
diagnostic tests is most likely to yield the correct diagnosis?
A. Serum cortisol
B Serum TSH
C. Serum VIP
D. Urinary 5-HIAA
E. Urinary metanephrine
5)A 52 years old caucassian male presents to the physican for a routine health check up. He has been relatively well and has no new complaints. he denies fatigue, weight loss and polyuria. His only complaint is that he has to hold the news paper farther away to be able to read it. he has no problem with seeing distant objects. He has not had any eye pain or red eye. His past history is unremarkable and he does not take any medication. His fundoscopic examination is normal. Head and neck examination, chest, CVS are unremarkable as is abdominal examination. He is referred to an opthalmologist for visual acuity and glaucoma screening. How often should the glaucoma screening be performed on him
A. every 3-5 years
B. Every 3-5 years starting at 60
C. Every 10 years
D. every year
E. once only
Lets do some good discussions
Youngdoctor - 10-19-08 01:44
1)A 40-year-old white male, health care worker presented with several week history of arthralgias, malaise, and fatigue. He also noticed crops of palpable purpura. Biopsy results of the purpura revealed leukocytoclastic vasculitis and IgM and C3 deposits around the small blood vessels. Diagnosis of mixed cryoglobulinemia is entertained. His vitals are stable and he is afebrile. What is the most appropriate next step in the management? A. Hepatitis-C RNA assay
B. Hepatitis-B serology
C. ELISA for HIV I and II
D. Serum immunoelectrophoresis
E. C-ANCA
2)A 60-year-old male who emigrated from Russia comes to you with complaints of dizziness, fatigue and weight loss. A review of systems reveals that the patient experiences daily fevers and cough. He does not use tobacco alcohol or drugs. He does not take any medication. His blood pressure is 108/64 mmHg while standing. His respiratory rate is 14/miri and is unlabored. Laboratory studies reveal the following:
Chemistry panel
Serum sodium 130 mEq/L
Serum potassium 5.9 mEq/L
Chloride 102 mEq/L
Serum creatinine 0.8 mg/dL
Blood glucose 58 mg/dL
Complete blood count
Hemoglobin 10.0 g/L
Platelets 430.000/mm3
Leukocyte count 4,500/mm3
Neutrophils 46%
Lymphocytes 45%
Eosinophils 9%
Chest x-ray shows a right upper lobe cavity. Which of the following acid-base disturbances is expected in this patient?
A. Elevated anion gap metabolic acidosis
B. Normal anion gap metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis
E. Respiratory alkalosis
3)An 87 years old man with hypertension and hyperlipidemia is brought to the emergency department complaining of severe headache and high fever. Further history reveals neck stiffness, photophobia, nausea and vomiting. He has no HiV risk factors. His temperature is 101F, bp is 100/70mm, pulse is 123/min and respirations are 16/min. He has no respiratory distress. The eyes bothers his eyes and he has neck stiffness. There is no edema of the optic disc on fundoscopy. his cranial nerves are intact and there are no heart murmurs. His lungs are clear to auscultation. He has no odema. He has neck pain and resistance to movements. He draws his legs up when the neck is flexed. he has a strength of 5/5 in four extremities with normoactive reflexes. Which is the most accurate sequence to be followed next?
A. Begin treatment with ceftriaxone, dexamethasone and ampicillin. Send him for a ct and do a lumbar puncture
B. Begin treatment with cetriaxone and send him for a pre lumbar puncture Ct head
C. Perform LP and begin tx with ampicillin and ceftriaxone
D. perorm Lp and begin treatment with ampicillin, ceftriaxone and dexamethasone
E. Start antibiotics only when culture reports of the LP are available
4)A 49-year-old male is brought to the hospital by his
family because of confusion and dehydration. The family
reports that for the last 3 weeks he has had persistent
copious watery diarrhea that has not abated with the use
of over-the-counter medications. The diarrhea has been
unrelated to food intake and has persisted during fasting.
The stool does not appear fatty and is not malodorous.
The patient works as an attorney, is a vegetarian,
and has not traveled recently. No one in the household
has had similar symptoms. Before the onset of diarrhea,
he had mild anorexia and a 5-lb weight loss. Since the
diarrhea began, he has lost at least 10 pounds. The physical
examination is notable for blood pressure of 100/70,
heart rate of 110/min, and temperature of 36.8°C
(98.2°F). Other than poor skin turgor, confusion, and
diffuse muscle weakness, the physical examination is
unremarkable. Laboratory studies are notable for a normal
complete blood count and the following chemistry
results:
Na+ 146 meq/L
K+ 3.0 meq/L
Cl– 96 meq/L
HCO3
– 36 meq/L
BUN 32 mg/dL
Creatinine 1.2 mg/dL
A 24-h stool collection yields 3 L of tea-colored stool.
Stool sodium is 50 meq/L, potassium is 25 meq/L, and
stool osmolality is 170 mosmol/L. Which of the following
diagnostic tests is most likely to yield the correct diagnosis?
A. Serum cortisol
B Serum TSH
C. Serum VIP
D. Urinary 5-HIAA
E. Urinary metanephrine
5)A 52 years old caucassian male presents to the physican for a routine health check up. He has been relatively well and has no new complaints. he denies fatigue, weight loss and polyuria. His only complaint is that he has to hold the news paper farther away to be able to read it. he has no problem with seeing distant objects. He has not had any eye pain or red eye. His past history is unremarkable and he does not take any medication. His fundoscopic examination is normal. Head and neck examination, chest, CVS are unremarkable as is abdominal examination. He is referred to an opthalmologist for visual acuity and glaucoma screening. How often should the glaucoma screening be performed on him
A. every 3-5 years
B. Every 3-5 years starting at 60
C. Every 10 years
D. every year
E. once only
Lets do some good discussions
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#1
Re: continuation of questions mohhaider - 10-19-08 02:16 For 1 I think it's B.
Thanks again for your contribution ,but I think it's better to post each case in a single thread so as to discuss them separately .
#2
Re: continuation of questions sackatdoc - 10-19-08 06:49 1.hepatitis C is associated with cryoglobinurias
2. metabolic acidosis with normal anion gap,picture is like addisons disease, but cant relate with history and findings
3. answer is C, NO DEXAMETHASONE at this stage
4.carcinoid tu,5- HIAA??
5,not sure,every 3-5 years
#3
Re: continuation of questions usmlefever3 - 10-19-08 10:21 1.answer should be hepatitis c rna assay as there is very strong relation between essential mixed cryoglobulinaemia and hep C
2.now no idea abt this one .just can guess metabolic acidosis as radiologic findngs are pointing towards some lung pathology
3.this seems to be meningitis and intrestingly i checked harrison for its teartment i found dexamethasone given with emperical therapy and this can be done just prior to LP as it wont change the CSF counts
so i will go with option a
4. this seems to be a case of VIPoma which is also known as Verner-Morrison syndrome and pancreatic cholera .as the patient has huge amount (3L)of watery diarroea it seems to be VIP oma.
so i will go for serum VIP
5.absolutely no idea abt this.
#4
Re: continuation of questions
Youngdoctor - 10-20-08 02:27 
posted by sackatdoc on 10-19-08 06:49
1.hepatitis C is associated with cryoglobinurias
2. metabolic acidosis with normal anion gap,picture is like addisons disease, but cant relate with history and findings
3. answer is C, NO DEXAMETHASONE at this stage
4.carcinoid tu,5- HIAA??
5,not sure,every 3-5 years
1.hepatitis C is associated with cryoglobinurias
2. metabolic acidosis with normal anion gap,picture is like addisons disease, but cant relate with history and findings
3. answer is C, NO DEXAMETHASONE at this stage
4.carcinoid tu,5- HIAA??
5,not sure,every 3-5 years
For Sackatdoc,
Question number one. Why you think this is Heptitis with acute stage?
#5
Re: continuation of questions Youngdoctor - 10-20-08 02:28 Also , i have some thoughts why it is with IgM state. The diagnosis of "hepatitis C" is rarely made during the acute phase of the disease because the majority of people infected experience no symptoms during this phase of the disease.
#6
Re: continuation of questions Youngdoctor - 10-20-08 03:43 for Q1) Type II cryoglobulins account for 50-60% of reported cases. They usually have a polyclonal component, usually IgG, and a monoclonal component, usually IgM, which has an RF function. The IgM can recognize intact IgG or either the Fab region or Fc region of IgG fragments. This is why most type II cryoglobulins are IgM-IgG complexes.
These proteins may be present in mycoplasma pneumonia, multiple myeloma, certain leukemias, primary macroglobulinemia, and some autoimmune diseases, such as systemic lupus erythematosus and rheumatoid arthritis. This is also found occasionally as a symptom in 35% of chronic hepatitis C infections.[5] It is important to note that these two different, yet highly representative, clinical syndromes generally reflect different types of underlying CG:
Hyperviscosity is typically associated with CG due to hematological malignancies and monoclonal immunoglobulins. "Meltzer's triad" of palpable purpura, arthralgia and myalgia is generally seen with polyclonal CGs seen in essential-, viral-, or connective tissue disease-associated CG.
Although, types II and III are strongly associated with infection by the hepatitis C virus.
I will go for serum electrophoresis. Because we need to differentiate from other diseases. Let any one can rule out the explanation. Please contribute your ideas.
#7
Re: continuation of questions Youngdoctor - 10-20-08 04:09 For Q2) cause of normal anion gap with metabolic acidosis:-
Normal anion gap
Causes include:
longstanding diarrhea (bicarbonate loss)
pancreatic fistula
uretero-sigmoidostomy
Renal tubular acidosis (RTA)
intoxication:
ammonium chloride
acetazolamide (Diamox)
bile acid sequestrants
isopropyl alcohol
renal failure (occasionally)
#8
Re: continuation of questions sackatdoc - 10-20-08 05:13 posted by Youngdoctor on 10-20-08 02:27
For Sackatdoc,
Question number one. Why you think this is Heptitis with acute stage?
For Sackatdoc,
Question number one. Why you think this is Heptitis with acute stage?
i dont think it is hepatitis at all, thats why i want to get the test done coz the symptomatic cases should be treated,and the link that you mentioned can present as symptom in 35%of cases,once found out would like to treat hepatitis c
what you want to differentiate it with, name them
then diagnosis is made with biopsy already, and there is no need to differentiate now,what is the real agenda here is to protect the patient from the acute hepatic failure which he might have in comming years if left untreated
i strongly doubt if you find this as answer
#9
Re: continuation of questions niusha - 10-20-08 09:39 It's horrible ...to many questions in one page...by the way what's the reference?
#10
Re: continuation of questions sackatdoc - 10-21-08 04:25 Niusha brace yourself for CK, THESE ARE STILL 5!!! there you get 48 questions each in 7 blocks, literally you get crazy, of course they are not on 1 page all together, but very lengthy, some of them you have to scroll right down upto the end
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