Question Bank Featuring more than 650 questions, our Internal Medicine QBank is second to none. Our team has worked tirelessly to bring you the most comprehensive review for your IM board exam on the market, and we're fanatical about keeping our questions up-to-date. MedQuest's QBank system lets you tailor practice tests to every need; we can deliver anything from a comprehensive time pressure marathon that will keep you up all night to a twenty question quiz on one subject that you can take on your phone while you're standing in line. Oh, did we mention you can take practice tests on your phone? Get 12 hours of LIVE comprehensive high yield medical lectures with the Master of Medical Education. Conrad Fischer for 12 rocking hours in which he connects the basic science and clinical science. These are the MOST likely subjects to appear on your USMLE Step 1 or COMLEX Part 1 exam.
The Cases are designed to incorporate multiple knowledge areas for USMLE and COMLEX. Each case extracts all the Pathology AND Pharmacology AND Physiology AND Microbiology AND Biochemistry AND Immunology you will find in each disease. THIS IS the most up-to-date pharmacology question bank with clear and easy to understand explanations, thereby ensuring higher scores on USMLE Step 1/COMLEX Level 1. Unlike other question banks, MedQuest’s Pharmacology and Applied Therapeutics Question Bank delivers contemporary pharmacologic information in a manner relevant to clinical practice.
Latest drug approvals. Most commonly prescribed drugs and their mechanisms of action. Side effects and black box warnings. Drug and food interactions. Step-by-step calculations. Pharmacokinetics/pharmacodynamics.
Most common wrong answers. Next best steps in the management of the case. Detailed explanations of both the correct answer and the incorrect answer options. “Sequential” question style that mirrors actual testing. Continuous drug updates as new drugs are FDA approved Over 300 Questions!. THE CASES ARE ENTIRELY BASED ON MAXIMUM QUESTION EXTRACTION!! Over 2,000 all Brand New Questions!
Fischer, the author of Master the Boards USMLE Step 2 CK has written or edited every question! Every disease covered! Every question subject extracted! Be SURE you are ready for Step 2 with the author of the best-selling Step 2 book in the world! Every mistake YOU MIGHT MAKE anticipated, detected and prevented! What happens if you get stuck and have a question ABOUT the question?
All medical content questions are answered PERSONALLY by Dr. Fischer and his team!.
BRAND NEW VIDEOS! You are not alone This is the first educational device specifically designed for new third and fourth year students to guide them through what they are expected to know on a daily basis on their medicine rotation. 7/10 surveyed 3rd year medical students say they don't know what to study for the Internal Medicine Clerkship Exam? (Sonpal et al 2014) Do the NBME and COMSAE shelf exams for Internal Medicine have you stressed out? Then you need Top Shelf Internal Medicine. The Most High Yield Course available targeting the NBME and COMSAE shelf exams for 3rd year MS and OMS students. for COMLEX 1/2/3 + COMAT. Video Course Our OMM review video lecture series prepares you in just 7 hours of extremely high yield OMM material taught via Medquest’s unique learning style.
Instructed by OMM Teaching Fellow Phil Koehler and Chris Paras, DO you will master OMM for the boards and even learn some cool techniques for the wards. Topics stressed in this course are Cranial, Costal, Innominates, Sacrum, Short-leg Syndrome, Psoas Syndrome, Special Tests, Treatment Techniques, etc. In short it covers all the subjects DO students find most difficult.
There are numerous clinical correlations and interactive multiple choice questions throughout the presentations to keep you engaged. The course includes over 2 hours of live demonstrations of OMT which are useful for clinical rotations and the COMLEX PE!
The goal is to solidify the basic knowledge you have learned in class and get you to the next level of understanding. for COMLEX 1/2/3 + COMAT. Question Bank This OMM QBank is comprehensive with in depth explanations. It features 125 multiple choice and matching questions and is constantly growing in quantity.
Not only will it test your knowledge base but it will teach you concepts and expand on your level of understanding. Therefore if you miss the question you will thoroughly comprehend the concept using the explanation. It also contains questions of all difficulty levels and is a great review for all levels of COMLEX and COMAT exams.
It is a great high yield - 'score points' review for these exams. Are you starting internship, feeling lost and overwhelmed?
A third or fourth year medical student who wants to stand out on rotations and be remembered during residency interviews? Or are you an international graduate, looking for insight into the American hospital system? Created by renowned medical educator Chris Paras, and in conjunction with Conrad Fischer, this course is designed to relieve your anxiety about life in the hospital and teach what you need to know to succeed. Get in shape with Boot Camp, and perform like a rock star!
Create your own Plus Program. Combine programs and SAVE. Call 1-800-KAP-TEST to enroll. Receive up-to-the-minute live in-person instruction from the leaders in test prep. Access the world's best faculty live online from anywhere and get full On Demand access.
Autocad civil 3d 2013 english x32 64 bit) crack. Study at your own pace and interact with your peers in our full-service study centers. Instantly access and repeat content anywhere, anytime. 12-DAY SCHEDULE.
Access over 100 hours of lectures with our most time-efficient schedule. 12-DAY SCHEDULE.
Access over 100 hours of lectures with our most time-efficient schedule. CUSTOMIZE YOUR STUDY PLAN. 1 and 3 month options. CUSTOMIZE YOUR STUDY PLAN. 1 and 3 month options.
SUPPLEMENTAL VIDEO. Access lectures on patient safety, quality improvement, and the CCS. SUPPLEMENTAL VIDEO. Access lectures on patient safety, quality improvement, and the CCS. COMPLETE View over 100 hours of concise, engaging video lectures. COMPLETE View over 100 hours of concise, engaging video lectures. MASTER FACULTY.
There are no better instructors teaching these disciplines. MASTER FACULTY.
There are no better instructors teaching these disciplines. LECTURE NOTES.
Get 2 updated volumes in print and ebook packed with easy-to-understand images and tables. LECTURE NOTES. Get 2 updated volumes in print and ebook packed with easy-to-understand images and tables. DIAGNOSTIC TEST. Quickly understand your strengths and opportunities with our 150 questions.
DIAGNOSTIC TEST. Quickly understand your strengths and opportunities with our 150 questions. Know where you stand with over 250 questions to assess your progress in each discipline. Know where you stand with over 250 questions to assess your progress in each discipline. Eliminate test-day anxiety with over 900 exam-like questions and complete explanations QBANK. Eliminate test-day anxiety with over 900 exam-like questions and complete explanations MED ADVISING.
Get one-on-one guidance, including a personalized study plan and residency timeline. MED ADVISING. Get one-on-one guidance, including a personalized study plan and residency timeline. STUDY CENTER. Enjoy comfortable, convenient locations with fast internet, quiet labs, and support from staff and peers. STUDY CENTER.
Enjoy comfortable, convenient locations with fast internet, quiet labs, and support from staff and peers. I20 ELIGIBLE FACILITY.
You are welcome to study in New York, Chicago, Miami, Los Angeles, or Houston. I20 ELIGIBLE FACILITY. You are welcome to study in New York, Chicago, Miami, Los Angeles, or Houston.Offer valid 12:01am ET on January 12, 2018 and ends at 11:59 p.m. ET on February 28, 2018 to new students when products are paid in full and full payment is received. Eligible products for $1,000 off offer include: USMLE® Step 1 and Step 2 CK Live Online. Eligible products for $500 off offer include USMLE Step 3 Live Online. Offer valid for first time students.
Discount may not be combined with any local or other member discounts. USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). COMLEX-USA® is a registered trademark of The National Board of Osteopathic Medical Examiners, Inc. Until Your Test® access limited to 12 months. Test names and other trademarks are the property of the respective trademark holders.
None of the trademark holders are endorsed by nor affiliated with Kaplan or this website. Kaplan is authorized under federal law to enroll non-immigrant alien students.
Kaplan centers are authorized under Federal law to enroll nonimmigrant alien students. Your Designated School Official (DSO) will advise you about important policies related to your.
Many friends asked me about USMLE Step 2 Lectures published in 2008/2009. Unfortunately, I have not heard of these videos on the grey market. Kaplan Step 2 Videos have been released in 2002/2003. Although some people keep referring to them as 2006 or even 2007 step 2 kaplan lectures, in reality this is 2002/2003 Step 2 Lectures. On the other side - medicine is not IT science and is not changing every 3 years.
So, stick to whatever materials you have and keep fingers crossed. Good luck in your Exam!
The links below provide feedback on diagnostic and management steps for the sample Step 3 Computer-Based Case Simulations. These also appear at the end of the practice cases. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for each case. Orientation Feedback for Tension Pneumothorax In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 65-year-old man is brought to the emergency department by ambulance because of acute chest pain and respiratory distress.
Initially the presentation and reason for visit suggest a broad differential diagnosis, but the limited available history narrows the differential. The patient had an acute onset of right-sided chest pain 10 minutes before the ambulance arrived.
He rates the pain as an 8 on a 10-point scale. The pain is excruciating, sharp, and increases with respiration. The patient appears pale and in marked respiratory distress.
He is moaning and holding his hands over the right side of his chest. Vital signs show tachypnea, tachycardia, and low blood pressure. Physical examination shows no breath sounds; there is tracheal deviation, jugular venous distention, hyperresonance to percussion on the right side of the chest, faint heart sounds, and weak peripheral pulses. The skin is pale, cool, and diaphoretic. The remainder of the physical examination is unremarkable. The patient's illness, at this point, seems most consistent with an intrathoracic process.
The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. Timely diagnosis and management are essential in this case. An optimal, efficient diagnostic approach would include quickly performing a targeted physical examination that includes chest/lung and cardiovascular examination, cardiac monitoring, and assessing oxygen saturation by pulse oximetry.
Treatment should be initiated immediately before the patient’s condition worsens. Ordering anything that might delay treatment (eg, a 12 lead ECG, arterial blood gases, or a portable chest x-ray) would be suboptimal in this case if ordered before the patient’s condition is stabilized. As soon as the absent breath sounds and exam findings consistent with tension pneumothorax are discovered, optimal treatment would include performing a needle thoracostomy for decompression followed by a chest tube insertion for lung reexpansion.
A chest x-ray should be ordered to confirm appropriate tube placement and lung reexpansion. The patient’s blood pressure and respiratory rate should be closely monitored until the patient’s condition has stabilized.
Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:. Bronchodilators. Complete blood count. Electrolytes.
Analgesics. Intravenous fluids Examples of suboptimal or poor management would include failure to examine the chest, admission before treatment, failure to order a chest x-ray after inserting the chest tube and/or needle thoracostomy, delay in treatment to reexpand the lung, or absence of treatment. In this acute presentation, timing is critically important.
An optimal approach would include completing the above diagnostic and management actions as quickly as possible. Delaying diagnosis or treatment and pursuing alternative diagnoses with tests such as a lung scan will waste valuable time and could be harmful or even fatal to the patient.
Other examples of treatments that would waste time, subject the patient to unnecessary discomfort or risk, and add no real benefit to this patient include:. CT before lung reexpansion.
Intubation. Pulmonary function testing. Thrombolytic therapy. Orientation Feedback for Rheumatoid Arthritis (20-minute case) In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 32-year-old woman comes to the office because of knee pain and swelling.
From the chief complaint, the differential diagnosis is broad. It includes osteoarthritis, infectious arthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), gout, and psoriatic arthritis. The comprehensive history, however, narrows the differential. The patient has experienced increasing fatigue and generalized weakness during the past 4 months.
She developed generalized aches and morning joint stiffness during the past 8 weeks and, more recently, pain and intermittent swelling of both wrists, and of the proximal metacarpophalangeal joints, as well as bilateral knee swelling. These signs and symptoms are highly suggestive of a chronic systemic inflammatory process. Physical examination shows bilateral swollen, warm, and tender wrist, proximal metacarpophalangeal, and knee joints, and bilateral ballotable patellae. Other physical findings are unremarkable. In the absence of other findings, the patient’s illness, at this point, seems most consistent with rheumatoid arthritis. While the presence of certain clinical features is helpful in excluding other connective tissue diseases and osteoarthritis, further diagnostic evaluation is appropriate to confirm the presumptive diagnosis and establish the severity of the disease.
The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach to diagnosis would include performing an appropriate physical examination (including extremities/spine, chest/lung, cardiovascular, abdominal, skin, HEENT/neck, and lymph node examinations). A rheumatoid factor test or a cyclic citrullinated peptide antibody (Anti-CCP) test would support the diagnosis of rheumatoid arthritis. The diagnostic workup would also include a complete blood count, arthrocentesis with relevant synovial fluid studies (cell count, crystals, and bacterial culture), an antinuclear antibody assay, and an erythrocyte sedimentation rate or C-reactive protein test.
These tests serve to assess the severity of the disease and consider the likelihood of SLE, gout, an infectious process, or reactive arthritis. In addition, joint x-rays would provide a baseline assessment. In adult patients, an optimal approach to treatment would focus on relieving pain, decreasing inflammation, preventing or slowing joint damage, and improving function. It is important to manage the acute phase of the disease and to address the long-term care of the patient in this case. Optimal treatment would include a combination of a nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid with a disease-modifying antirheumatic drug (DMARD) for comprehensive therapeutic treatment.
Administration of a DMARD, eg, methotrexate or etanercept, prevents or slows joint damage, and improves joint function. An NSAID or corticosteroid relieves pain and decreases inflammation essential to provide interim symptom relief while the selected DMARD takes effect. To prevent deformity and loss of joint function, the patient would be advised to exercise appropriately. Or, a referral would be made for physical or occupational therapy. In this case simulation, when NSAID or corticosteroid treatment is initiated, the patient regularly reports both joint and systemic improvements.
Therefore, ordering a rheumatology consult or additional monitoring is appropriate but optional during the time frame of this simulation. Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include:. Chlamydia trachomatis tests. Neisseria gonorrhoeae tests. Antibody, anti-single-stranded DNA.
Thyroid studies. Urinalysis. Uric acid, serum Examples of suboptimal management of this case would include delay in diagnosis or treatment, or treatment with NSAIDS or corticosteroids alone. Treatment with salicylates would also be considered suboptimal management in this case. Although they would temporarily relieve pain when administered in high doses, there are other agents with fewer adverse effects that would be better treatment options. Examples of poor management would include failure to order any physical examination or failure to treat rheumatoid arthritis. Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information include:.
Arthroscopy. Synovial biopsy While many case scenarios run for a relatively short period of simulated time, a matter of hours or days, this scenario runs for a longer period of time, weeks. This illustrates the importance of allowing sufficient time for the patient to respond to treatment and emphasizes monitoring and long-term management. Orientation Feedback for Ascending Aortic Dissection (20-minute case) In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 65-year-old woman comes to the emergency department because of chest pain. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows the differential.
The patient is experiencing sharp, left-sided chest pain that radiates to her left jaw and to her back. The pain began abruptly 45 minutes before the patient came to the emergency department.
She is now short of breath and mildly nauseated. She has a history of hypertension for the past 5 years that is being appropriately treated with medication. There is no history of any previous episodes of chest pain either at rest or on exertion. The absence of fever, chills, cough, or pleural rub suggests that the problem is not an infectious pulmonary process. Physical examination shows hypertension and tachycardia with bounding central and peripheral pulses. The patient is anxious, diaphoretic, and in severe distress from chest pain.
Cardiovascular examination reveals a prominent and sustained apical impulse, and an indistinct S2 with S4 audible at the apex, and a grade 2/6 diastolic decrescendo murmur heard best at the left sternal border. HEENT/neck examination shows grade II arteriovenous nicking on funduscopic examination. The remainder of the physical examination is unremarkable. The patient’s illness, at this point, would seem most consistent with a coronary or aortic abnormality with associated aortic regurgitation.
In this case, the sudden onset of radiating chest pain along with the bounding pulses, widened pulse pressure, aortic murmur, and long history of hypertension are highly suggestive of the diagnosis of ascending aortic dissection. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including cardiovascular, chest/lung, and neurologic/psychiatric examinations), ordering a 12 lead electrocardiography (ECG), and a portable chest x-ray.
Optimal medical therapy would include stabilizing the patient with intravenous (IV) beta blockers to lower both blood pressure and heart rate. Suboptimal treatment would include other antihypertensive agents.
Lastly, IV narcotic analgesic administration to alleviate pain is important. Street fighter ex plus download. The patient's cardiovascular status should be monitored with a cardiac monitor or by ordering repeat vital signs. Some measure of oxygen saturation is also indicated. Once stable, some form of chest imaging that would assess for an aortic dissection (including computed tomography (CT) of the chest with contrast, cardiac computed tomography angiography (CTA) with contrast, echocardiography, transesophageal echocardiography (TEE), magnetic resonance imaging (MRI) of the chest, or cardiac MRI with gadolinium) is needed. The diagnostic workup should also include blood tests for serum creatinine (basic metabolic profile or complete metabolic profile) to assess kidney function, electrolytes to check sodium and potassium concentrations, a complete blood count (CBC) to look for signs of anemia and infection, serum creatine kinase or serum troponin I (cardiac enzymes) to rule out myocardial compromise, and a blood group and crossmatch. Once the ascending aortic dissection is discovered and aortic root involvement confirmed, optimal treatment should include open heart surgery, endovascular aortic aneurysm repair (EVAR), thoracotomy or cardiothoracic surgery, or general surgery consult.
In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first 2 hours of simulated time). Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:. Admitting the patient to the inpatient ward or intensive care unit. Angiocardiography, right and left sides of the heart. Antibiotics Suboptimal management of this case would include ordering additional physical examination components that would add no relevant information, administering an IV antihypertensive without a beta blocker, neglecting to order indicated blood tests, or a delay in diagnosis or treatment. It would be suboptimal to order anything unnecessary that would waste time, even if the test or procedure were not invasive or risky (eg, lung scan).
Examples of poor management would include failure to order any physical examination, failure to order an imaging study that would reveal the dissection, failure to administer an antihypertensive agent, or failure to order surgical intervention. Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk include:. Changing the location to the outpatient office or sending the patient home. Chest tube. Exercise ECG.
Heparin. Laparotomy. Needle thoracostomy. Stress echocardiography. Thrombolytics. Warfarin.
![]()
Orientation Feedback for Asthma (20-minute case) In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 4-year-old boy is brought to the office because of increasing shortness of breath during the past 3 days. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient has been wheezing and has a cough that has been worsening.
Step 2 Ck Forum
The mother says that the wheezing seems to get worse after the patient plays outside but resolves shortly after he comes inside. The patient has a history of frequent episodes of 'wheezy bronchitis' and ear infections. When the patient was 2 years old, he was hospitalized for 1 week for similar symptoms and treated with intravenous antibiotics and oxygen. At age 18 months, the patient had pressure equalizing tubes inserted.
The patient also has a history of allergy to pollen and atopic dermatitis. Physical examination shows slight tachycardia. Chest/lung examination reveals bilateral, mild, intercostal retractions, hyperresonance on percussion, and bilateral expiratory wheezes with prolonged expiratory phase, and no crackles. HEENT/neck examination shows pale, boggy, edematous nasal mucosa without nasal flaring. Skin examination reveals dry, scaly patches in the antecubital areas. The remainder of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with an obstructive pulmonary disease process.
In this case, the increased coughing and wheezing, as well as the history of frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including HEENT/neck, chest/lung, cardiovascular, and abdominal examinations) and addressing oxygen status by ordering pulse oximetry or oxygen therapy. Treating the patient’s respiratory distress with optimal inhalation bronchodilators (such as albuterol or levalbuterol), as well as optimal oral (PO) steroids, is essential.
Optimal management should also include counseling the patient/family about asthma care and the side effects of medication. Monitoring the patient’s respiratory status by ordering a chest/lung examination after treatment is also important. In this acute presentation, timing is important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first 12 hours of simulated time). Orientation Feedback for Diabetes with ketoacidosis; E. Coli sepsis (20-minute case) In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.
In this case, a 31-year-old woman is brought to the emergency department by her roommate because of lethargy, nausea, and vomiting. From the chief complaints, the differential diagnosis is broad and includes the many causes of acutely altered mental status. However, the comprehensive history narrows the possible differential diagnoses, making uncontrolled diabetes very likely. The patient has been experiencing nausea and vomiting for the past 24 hours and has been unable to eat during that time. During the past hour, she has become drowsy and lethargic. She has a history of type 1 diabetes mellitus, for which she normally takes insulin multiple times daily.
PHOTO MODE VIDEO MODE TIME LAPSE MODE 2.
![]()
However, she has had no insulin during the past 24 hours. The patient’s roommate says that the patient experienced some chills yesterday. The patient appears drowsy, lethargic, and acutely ill. Physical examination reveals elevated temperature, tachypnea, tachycardia, and hypotension. Cardiovascular examination shows thready central and peripheral pulses. Skin examination reveals poor turgor. HEENT/neck examination shows dry mucous membranes.
Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses. Neurologic/psychiatric examination shows that the patient is lethargic but oriented. Taken together, the history and physical examination findings support the initial impression of complications of type 1 diabetes mellitus. In this particular patient, the history of type 1 diabetes mellitus presenting with prolonged nausea and vomiting and lethargy and drowsiness, combined with the physical examination findings of fever, thready pulses, tachycardia, signs of dehydration, and diffuse abdominal tenderness are highly suggestive of the diagnosis of diabetic ketoacidosis due to infection and inadequate insulin.
The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including chest/lung, cardiovascular, abdominal, and neurologic/psychiatric examinations), and ordering a serum glucose test using a glucometer and a urinalysis or complete blood count (CBC) to check for signs of infection. Stabilizing the patient with optimal intravenous (IV) fluids (eg, Lactated Ringer solution or normal saline solution) to improve hydration, and treating the patient empirically with a broad-spectrum IV or intramuscular (IM) antibiotic to cover the most likely sources of infection are important.
Once the serum glucose result is obtained, starting IV insulin to treat the hyperglycemia is critical. The patient’s cardiovascular status should be monitored by ordering repeat vital signs or by changing the patient’s location to the inpatient unit or intensive care unit. The diagnostic workup should also include arterial blood gas analysis to assess acidosis, bacterial blood culture to identify the organism before administering empiric antibiotics, and serum electrolyte measurements (ie, potassium) to assess the severity of dehydration. Serum creatinine or urea nitrogen measurements (basic metabolic profile or complete metabolic profile) to assess kidney function are indicated.
Continued monitoring of the patient’s serum glucose, electrolytes, particularly potassium, and arterial blood pH after treatment is also important. In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time). Orientation Feedback for Eclampsia (10-minute case) In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.
In this case, a 25-year-old woman at 38 weeks’ gestation comes to the emergency department after suffering a seizure with loss of consciousness about 10 minutes earlier. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient is gravida 1, para 0, and has been receiving routine prenatal care. The pregnancy has been uncomplicated so far. She has had a severe headache for the past 3 days, and her feet have appeared swollen during the past 2 to 3 weeks. She has no previous history of seizures, and there is no history of hypertension or renal or neurologic disease. The patient is conscious but appears confused.
Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure. Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses. There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation. There is marked vasospasm on funduscopic examination with normal disc margins and a minor tongue laceration. Abdominal examination shows a gravid uterus with a fundal height of 37 cm.
Estimated fetal weight is 2700 g (6 lb). The fetus is cephalic by palpation with a fetal heart rate of 144 beats/min. Genital examination reveals an edematous vulva. The cervix is dilated to 1 cm and 50% effaced. Extremities/spine examination shows 4+ pitting edema in both lower extremities to the midthigh region. Neurologic/psychiatric examination shows that the patient is conscious but oriented to person and place only. Deep tendon reflexes are 4+ with bilateral clonus at the ankles.
The remainder of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with a neurologic or cardiovascular abnormality, possibly pregnancy-associated. In this pregnant patient, the new onset of seizure, elevated blood pressure, lower extremity edema, and hyperactive reflexes are highly suggestive of the diagnosis of eclampsia. The computer-based case simulation database contains thousands of possible tests and treatments.
Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a targeted physical examination (including skin, HEENT/neck, chest/lung, cardiovascular, abdominal, genital, extremities, and neurologic/psychologic examinations) and ordering a complete blood count (CBC) to rule out hemolysis. Stabilizing the patient with intravenous (IV) magnesium sulfate to prevent another seizure, plus an IV optimal antihypertensive (hydralazine or beta blockers) to reduce blood pressure, is important. Once the patient’s condition is stabilized, it is imperative to deliver the fetus either by stimulating contractions using optimal uterotonics, by performing a cesarean delivery, or by consulting obstetrics/gynecology. The fetal heart rate should be watched until delivery by ordering a fetal monitor.
Some measure of the patient’s urine output is also indicated. The diagnostic workup should also include a urinalysis and blood tests for the following: serum creatinine or urea nitrogen (basic metabolic profile or comprehensive metabolic profile) to assess kidney function; electrolytes to check sodium and potassium levels; liver enzymes; and platelet count to diagnose HELLP syndrome.
In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time). Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:. Arterial blood gases or Pulse oximetry. Fibrin breakdown products. Thrombin time, plasma Examples of poor management would include failure to order a neurologic/psychiatric examination, failure to administer an antihypertensive agent, failure to monitor the fetus or mother, or administering a suboptimal seizure medication (phenobarbital).
Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:. Changing the location to the outpatient office or sending the patient home. Mifepristone PO.
CT, abdomen/pelvis. Carboprost IM. Alprostadil IV. Dilatation and curettage.
Comments are closed.
|
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |