USMLE Forum Archives - USMLE Step 2 CK - IM 22
IM 22
TheOne - 12-06-06 11:50
A 30-year-old professional bodybuilder comes to the physician complaining of 4 weeks of worsening fatigue, low-grade fevers, and myalgias, as well as the gradual onset of jaundice over the past week. He admits to unprotected anal sex 4 months earlier after a championship bodybuilding event. He denies any other homosexual activities. He has no other medical problems and is on no medications. On physical examination, he appears acutely ill, with a temperature of 38.3 C (100.8 F), a blood pressure of 120/65 mm Hg, and a pulse of 124/min.
He is deeply icteric and has multiple excoriations over his entire body. His liver edge is smooth and very tender and measures 15 cm in the midclavicular line. There is no shifting dullness, and a spleen tip is palpable 5 cm below the left costal margin. Stool is brown and negative for occult blood, and there is no peripheral edema. Which of the following laboratory findings would most likely indicate the worst prognosis?
A. Prothrombin time of 20.8 seconds
B. Aspartate aminotransferase (AST) of 999 U/L
C. Alanine aminotransferase (ALT) of 12,630 U/L
D. Total bilirubin of 29.3 mg/dL
E. White blood cell count of 28,500/mm3
TheOne - 12-06-06 11:50
A 30-year-old professional bodybuilder comes to the physician complaining of 4 weeks of worsening fatigue, low-grade fevers, and myalgias, as well as the gradual onset of jaundice over the past week. He admits to unprotected anal sex 4 months earlier after a championship bodybuilding event. He denies any other homosexual activities. He has no other medical problems and is on no medications. On physical examination, he appears acutely ill, with a temperature of 38.3 C (100.8 F), a blood pressure of 120/65 mm Hg, and a pulse of 124/min.
He is deeply icteric and has multiple excoriations over his entire body. His liver edge is smooth and very tender and measures 15 cm in the midclavicular line. There is no shifting dullness, and a spleen tip is palpable 5 cm below the left costal margin. Stool is brown and negative for occult blood, and there is no peripheral edema. Which of the following laboratory findings would most likely indicate the worst prognosis?
A. Prothrombin time of 20.8 seconds
B. Aspartate aminotransferase (AST) of 999 U/L
C. Alanine aminotransferase (ALT) of 12,630 U/L
D. Total bilirubin of 29.3 mg/dL
E. White blood cell count of 28,500/mm3
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#2
Re: IM 22
TheOne - 12-11-06 11:41 The correct answer is A. This patient has probable acute hepatitis. Features specifically suggesting acute hepatitis include his jaundice, itchiness leading to multiple excoriations, tender enlarged liver, and palpable spleen tip. He reports no risk factors for hepatitis A infection, such as drinking water in a foreign country with periodic epidemics of hepatitis A. He does have a risk factor for hepatitis B, which can be transmitted through blood products (now rare because of blood screening), contaminated syringes among drug users, and sexual contact (particularly when involving the rectum). The findings of a coagulopathy or of an encephalopathy confer the worst prognosis in patients with an acute viral hepatitis. Most patients with hepatitis B, even with severe laboratory abnormalities, may be followed conservatively so long as they do not develop a coagulopathy or exhibit signs of encephalopathy. These findings, in fact, suggest the possibility of fulminant hepatic failure.
Although the transaminases may rise to very high levels (choices B and C), they are not of prognostic value in viral hepatitis.
Similarly, severe jaundice (choice D) is of limited prognostic value, as is leukocytosis (choice E).
#4
Re: IM 22 babbu5508 - 07-08-10 01:17 A. Prothrombin time of 20.8 seconds
the patient is suffering from hepatitis probably sexually transmitted and coagulopathy is the indicator of worst prognosis
#5
Re: IM 22 dopamine - 07-08-10 02:28 I think its Bilirubin. Acc to kings college criteria Non-Acetoaminophen Induced FHF Either PT>100 sec or any 3 of the following
1. Age<10 yrs or>40 yrs
2. Etiology: Non A,B hepatitis,Halothane hepatitis, Idiosyncratic drug reactions
3.Duration of jaundice before onset of encephalopathy> 7 days
4.PT> 50 sec
5.SERUM BILIRUBIN>18mg/dl
In the above ques only Bilirubin Fits in the criteria.
All of these conditions are irrespective of encephalopathy.
#6
Re: IM 22 bingousmle - 07-09-10 01:08 i will go fro prothrombin because it suggests that the function of liver is compromised and all other choices are indicators of hepatic damage..
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