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Contributor score: 44

Comments ...

 +0  (step2ck_form6#44)

Diagnosis of pediatric hypertension requires ≥3 readings of SBP ≥130 or DBP ≥80. Given the information in the prompt, one reading does not warrant pharmacotherapy.

 +0  (step2ck_form6#20)

Emergency contraception with Plan B (levonorgestrel), which is effective up to 3 days after unprotected sexual intercourse.

Ulipristal and copper IUD can be used up to 5 days after.

 +0  (step2ck_form6#25)

Progressive respiratory difficulty and bilateral expiratory wheezes before age 50 with abnormal LFTs and a family history of "lung and liver problems" suggests alpha-1 antitrypsin deficiency. Pulmonary presentation is panacinar emphysema.

 +0  (step2ck_form6#10)

Pregnant woman with persistent nausea/vomiting and ketonuria suggests hyperemesis gravidarum. Although antiemetics do not treat this disorder, it can palliate symptoms.

 +0  (step2ck_form6#9)

Gonna write another answer to this since the other answer is so long.

Basically, holosystolic murmur over lower left sternal border in a newborn is most likely a VSD. The murmur from a VSD is due to left-to-right shunt from LV to RV.

In utero and early after birth, pulmonary arterial pressure is high, so the pressure gradient between LV and RV is low. The left-to-right shunt is therefore not that substantial.

As pulmonary growth progresses, the pulmonary arterial pressure decreases, which increases left-to-right shunting and increases the murmur.

 +0  (step2ck_form6#9)

Sharp chest pain, jugular venous distention, enlarged globular cardiac silhouette, and diffuse nonspecific ST-segment changes on EKG all point to pericardial effusion/cardiac tamponade.

Next best step would be to evaluate with echocardiography.

 +0  (step2ck_form6#13)

Next best step for maternal-sensed decrease in fetal movement is nonstress test. UWORLD also has a question on this with the same answer.

 +2  (step2ck_form6#3)

Since this patient is 1 day out of surgery, PO medications are not recommended, since this patient is very likely to have decreased bowel movements from abdominal surgery.

Moderate/severe postoperative pain is usually managed with short-acting opioids, since long-acting opioids have a higher risk of overdose and misuse. Based on the answer choices, patient-controlled IV morphine fits this criteria.

 +1  (step2ck_form6#14)

Congenital cardiomegaly (point of maximal impulse is deviated to the left) and hypotonia are both classic features of Pompe disease.

Although GM1 gangliosidosis can present with hepatomegaly and hypotonia, it is not associated with cardiomegaly.

 +0  (step2ck_form6#36)

Clinical picture sounds a lot like Wallenberg syndrome, which is classically due to posterior inferior cerebellar artery involvement leading to lateral medullary ischemia.

HOWEVER, vertebral artery dissection is another cause of Wallenberg syndrome and was also covered in one of the UWORLD questions with a similar presentation.

 +1  (step2ck_form7#16)

Calculated anion gap is 140-(104+6) = 30. This patient has a high anion gap metabolic acidosis.

Based on Winter's formula, adequate respiratory compensation would yield a PCO2 of 1.5*6 + 8 ± 2 = 17 ±2. Since this patient's actually PCO2 was lower, she also has a concomitant respiratory alkalosis.

Since salicylates stimulate respiratory drive and are part of the MUDPILES mnemonic, aspirin is the only answer choice that explains the high anion gap metabolic acidosis with respiratory alkalosis.

 +0  (step2ck_form7#10)

Let's break this down algorithmically.

Unilateral discharge in a patient >30 years warrants a mammography. Mammography for this patient was normal.

Next step should be to get a prolactin level, but the prompt didn't specify, so let's assume it was normal.

Given a normal mammography and presumed normal prolactin level, physiologic discharge would be the most likely diagnosis.

 +0  (step2ck_form7#17)

My two cents: Abdominal surgery for perforated gastric ulcer probably resulted in hypovolemia, leading to increased RAAS activity and contraction alkalosis. This leads to hypokalemia, which is a factor that predisposes to digoxin toxicity. PVCs are one of the most common digoxin-associated arrhythmias and are often the first sign of toxicity, completing the clinical picture described in this question.

 +0  (step2ck_form7#8)

Indications for CT scan before lumbar puncture: FAILS

  • Focal neurological deficit (as in this patient)
  • Altered mental status
  • Intoxication
  • Lesions in the brain near LP site
  • Seizures

 +1  (step2ck_form7#2)

"Bilateral varicoceles" is the only answer choice that is associated with male infertility and fits the description of bilateral masses palpated high in the scrotum. Scrotal varicosities increase the temperature around the testes, leading to impaired spermatogenesis.

Hydroceles are not associated with male infertility and typically involve swelling of the lower scrotum

 +0  (step2ck_form8#34)

An ulcerated base and a shiny, slightly raised border suggests BCC instead of SCC. Management of BCC is excisional biopsy with narrow margin (3-5 mm). If the lesion were SCC, management would be excisional biopsy with wide margin (5-10 mm).

 +21  (nbme22#50)
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Subcomments ...

submitted by medgirl11(5),

Amoxicillin course has not resolved pain + down/lateral displacement of auricle = abscess symptoms... use CT to visualize

tinylilron  I was thinking mastoiditis +1  
keyseph  Persistent pain from AOM with displaced ear and postauricular pain suggests mastoiditis, which is evaluated with a head CT. +  

submitted by tinylilron(5),

Can anyone explain the correct answer for this one?

submitted by chosened(2),

Can someone explain why this wouldn't be fat embolism and hence supportive treatment (via mechanical ventilation/ intubation)?

keyseph  Fat emboli usually occur from long bone fractures, not hip fractures. Altered mental status is also a common symptom of fat emboli, which is not seen here. Petechiae can also be present, but are not necessary to make the diagnosis. Regardless of this, this patient has a Wells score of at least 4 (HR >100, ≥3 days of immobilization, hemoptysis). If you think PE is the most likely diagnosis (I personally did), then this patient has a Wells score of 7. For any patient with dyspnea and a Wells score of ≥4, PE is likely, so you would heparinize and conduct a CTA or V/Q scan. +1  

Don't forget your sketchy!

carbamazapine is the anti-epileptic associated with blood dyscrasias, such as aplastic anemia and agranulocytosis

tinylilron  Isn't possible for folic acid deficiency and suppression of bone marrow by alcohol to be potential causes of the patient's decreased leukocyte count? +  
keyseph  Folic acid deficiency would not explain the disproportionate decrease in neutrophils. Yes, this is leukopenia, but more specifically, this is agranulocytosis, which is a side effect of carbamazepine. +  

submitted by sugaplum(376),

sounds like she has acute bronchitis; which is like inflammation/irritation of the airway, so there is narrowing Beta agonist will decrease the inflammation and open the airways up

boeboeboe  I think she more likely has asthma. Cough is worse at night and worse with physical activity. Key findings on exam: end-expiratory wheezes bilaterally. Responsive to b2-agonists. +2  
keyseph  There was a UWORLD question very similar to this that said the diagnosis was acute bronchitis. The next best step according to UWORLD was also to start empiric therapy with bronchodilators. So either way, the answer would be a SABA. +  

submitted by shastri96(4),

can someone please explain this ? why would we negotiate a contract with a minor ?

ronabobonafofona  Process of elimination question for me. The only other decent choice was A, but you wouldn't recommend "punishing" the patient if she doesn't comply. Maybe you just wouldn't offer her reward. Therefore, B makes the most sense. I think of it like trying to bargain with the girl -- "if you take the medication, then we'll do x for you". Something to incentivize good compliance. +  
keyseph  I agree that it was mainly by process of elimination to get to the right answer. Negotiating a contract is also the only answer that has some leeway to talk to the patient about why she doesn't believe she needs the medication. +  

submitted by ad54me(0),

This question is kinda bullshit because 4 weeks is basically a month...

keyseph  The event happened 4 weeks ago, but his symptoms have occurred for 2 weeks. +  

submitted by seagull(1573),

I was desperately looking for cellulitis. I never did see it. Some say I'm still looking for it to this day.

welpdedelp  Same lol. A question I had was I thought lymphangitis was supposed to precede some sort of injury, obv not lol but was the lymph node the main giveaway? +  
keyseph  I think the key distinguishing features are the red streaks leading to an area of local lymphadenopathy. Otherwise, cellulitis would be a viable option if given. +  

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hTsi si sulvbyioo a clcainli r.ltia fI oyu ownk uoy ear gttngei a d,gur tenh oyu are tno bdednli: st’i na -lonpbeeal i.rtla eheTr si no miindzntooaar as etreh is olny a nsileg netteatrm p.roug

charcot_bouchard  But they grouped them based on dosaged? +1  
keyseph  I think the key thing here is that the participants were told what treatment they would be receiving. This is in line with an open-labeled clinical trial. Open-labeled clinical trials can still be randomized and do not need a control (as in this case). +6  
drpee  Yeah, bad question IMO. Open-labeled trial can also be randomized... Since they didn't tell us how participants were selected for each group perhaps that's why C is better than D? +1  

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redvelvet  divalent cations interfere with the absorption of tetracyclines, not fluoroquinolones. anti-acids interfere with the absorption of fluoroquinolones. (like in this q, it's ca carbonate) +2  
keyseph  According to SketchyPharm, divalent cations also interfere with the absorption of fluoroquinolones +11  
nbmeanswersownersucks  Calcium carbonate is an antacid but it has Calcium in it....which is a divalent cation +2