INFORMAZIONI

 

10 Quiz di Clinical Sciences(Clinical Knowledge)

Provate a fare questi quiz che sono stati selezionati perche' sono molto rappresentativi sia come grado di difficolta' che
come argomenti trattati. In bocca al lupo! Break a leg!

Questi quiz  sono per la maggior parte presi da: 
Appleton & Lange- Practice Tests, USMLE Step 2- Practice tests, Joel Goldberg, ISBN 0-07-137740-9
Questo testo consigliabile per le ottime spiegazioni delle risposte. Si puo ordinare da www.amazon.com o www.Barnes&Noble.com 

 

  1. A 50 year-old woman, an unrestrained passenger in an automobile accident, is brought into the emergency department by paramedics. She had direct impact of her face against the windshield. She has significant facial lacerations extending into the oral cavity and obvious facial fractures, with instability  of the midface. She is cyanotic and in acute respiratory distress because of tongue edema, secretions, and aspiration of blood. Airway patency needs to be secured quickly. What is the safest approach to provide an adequate airway for her?

        a) Tracheostomy
        b) nasotracheal intubation
        c) cricothyroidotomy
        d) endotracheal intubation
        e) oxygen (4 L) by way of nasal cannula

 

Questions 2-3

      A 52 year old man from China is known to have chronic liver disease secondary to hepatitis
      B infection. He has recently felt unwell and his hemoglobin level has increased from 13g/dL
      to 19.5 g/dL.

  1. In which of the following is sexual transmission common but needs another infectious agent before becoming clinically apparent?

        a) Hepatitis A
        b) hepatitis B
        c) hepatitis C
        d) hepatitis D
        e) hepatitis E

3.    The blood test most likely to be helpful in the diagnosis of the current problem is:

        a) Alkaline phoshatase
        b) alpha-fetoprotein
        c) AST
        d) AST/ALT  ratio
        e) unconjugated bilurubin

 

  1.  A 47 year-old man presents to your office with a decline in his exercise tolerance over the last month and the new onset of peripheral edema. On physical examination , his liver edge is smooth and palpable 5 cm below the costal margin. He ha an increase in jugular venous pressure during inspiration. He gives a  history of Stage II Hodgkin's disease, treated approximately 20 years before with radiotherapy.What is further evaluation likely to reveal?

        a) A massively enlarged heart
        b) a pericardial knock
        c) atrial fibrilation
        d) renal failure
        e) ST elevations

5. Cardiovascular disease in women:

        a) is the second leading cause of death after breast cancer
        b) is 4.5. more likely to be fatal in the first year after symptomatic MI than in men
        c) causes the same symptoms that it does in men, primarily typical angina
        d) can be satisfactorily evaluated with ECG treadmill testing
        e) occurs at the same age as it does in men

  1. A 26 year old man is brought to the psychiatric emergency department by his parents, who are worried about his behavior. In 3 weeks, he has missed 8 days of work and has been witnessed performing bizarre behaviors, including cocking his head to the sky for minutes at a time as if listening to someone talking to him and refusing to sit in any chair except one close to the door and backed against the wall. When asked why he has not been reporting to work he says "They are all in on it there" His parents tell you they are concerned because their son was usually outgoing and personable, but he has not left the house except  to go to work for a month. On the interview he appears tense and makes little eye contact.
    The most appropriate diagnosis for this patient is:

        a) Major depressive disorder
        b) paranoid schizophrenia
        c) paranoid personality disorder
        d) schizophreniform disorder
        e) social phobia

7.  The most appropriate therapy for this patient is:
          a) insight-oriented psychotherapy
          b) haloperidol
          c) lorazepam
          d) fluoxetine
          e) behavioral therapy

  1. A 38 year-old patient is admitted in active labor. She previously delivered a 4000-g fetus without difficulty. The fetus has an estimated weight of 4,800 g. A protraction disorder of labor is diagnosed. The baby is in right occiput posterior position. The patient has pushed for 3 hours. Heavy molding is present. The caput is at +1.5 station. Clinical pelvimetry performed in early labor was consistent with a clinically adequate android pelvis. 
    The recomendation for the management of this patient should be:

        a) expectant management with oxytocin augmentation
        b) outlet forceps delivery
        c) low forceps delivery
        d) midpelvic forceps delivery
        e) cesarean section

  1. A 14 year-old girl with acute abdominal pain is evaluated in the emergency department. A plain film of her abdomen is performed, revealing a normal gas pattern, but a calcification in her left lower quadrant appears.The calcification resembles a tooth. The most likely explanation for this finding is:

        a) she swallowed a tooth
        b) artifact
        c) a fecalith that looks like a tooth
        d) a dermoid cyst
        e) diverticulum

  1. A 20 year-old man  who recently moved to the area came to the general medical clinic complaining of insommnia, lack of appetite, vague muscle aches, lack of zest, and feelings of sadness and loneliness. The examining first year resident made the diagnosis of adjustment disorder with depressed mood and sympathized with the patient for his not yet having made new friends. Two weeks later, the young man returned, reporting: "I did like you said, and now we are in trouble" He said he had found a friend, a young girl who was a minor and the local sheriff's daughter. On their first date, they proceeded to have sex in the living room of the sheriff's home and made enough noise to be caught. The examining doctor best response at this time would be:

        a) "What do you mean we?"
        b) "I didn't tell you to do anything"
        c) "You sure goofed up"
        d) " Tell me more about what happened"
        e) How are we going to get out of this mess?"


        



PASSING SCORE CLINICAL SCIENCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RISPOSTE

  1. The answer is c. Cricothyroidotomy is the safest way to obtain an airway in an emergency department setting. Tracheostomy can be more time consuming and more prone to complications, especially by less experienced persons. Nasotracheal and endotracheal intubation can cause significant iatrogenic complications. Administration of oxygen by way of nasal cannula would be ineffective.
    Nell' USMLE Clinical Sciences ci sono moltisime domande su emergenze chirurgiche e mediche. Spesso chiedono quale sia la first step nel trattamento

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  1. The answer is d. Hepatitis B and D are most commonly transmitted sexually in the United States. Hepatitis D infection does not become symptomatic without coinfection by hepatitis B. Hepatitis B is endemic in many areas of Asia.
    Questa e la tipica domanda 'facile"" che puo confondere se ci si ragiona troppo sopra

 

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  1. The answer is b. Hepatoma is the most likely diagnosis in this man. In China it is estimated that the lifetime risk of hepatoma in people with hepatitis B is close to 40%. Alpha-fetoprotein elevations over 500 to 1000 ug/L in the absence of a colonic tumour, germ cell tumor, or pregnancy suggest hepatoma.
    Molti quiz riguardano malattie infettive dei paesi da cui provengono i nuovi emigrati. (Vietnam, Cina, Russia, Paesi Arabi) Il fatto che venga sottolineata la nazionalita' del paziente e' sicuramente un suggerimento ( e non un dettaglio inutile)

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  1. The answer is b. In patients with constrictive pericarditis, ventricular filling is suddendly checked at the end of the early diastolic pressure dip, and therefore a loud heart sound ( pericardial knock) is heard. Atrial fibrillation is common in long standing cases, but this patient has relatively new symptoms. The heart size is normal or only midly enlarged. Renal failure is more often associated with pericardial effusions. ST elevations are suggestive of myocardial strain or infarct.
    Questa domanda presenta difficolta' soprattutto a coloro che non hanno una esperienza clinica di vari reparti, o che non siano dei cardiologi. Molti studenti hanno commentato sulla "difficolta''" delle domande di cardiologia.  

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  1. The answer is b. Cardiovascular disease is the leading cause of death and is more likely to present with atypical angina. Onset of the disease is typically one decade later than in men. Evaluation is best initiated with thallium treadmill or stress echocardiografy
    Vi sono molte domande su  le statistiche delle patologie piu comuni nel mondo occidentale.Spesso queste riguardono gruppi specifici (donne, afroamericani, immigrati)

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  1. The answer is d. This patient is exihibiting classic positive and negative symptoms, and age of onset, of paranoid  schizophrenia: bizarre behaviors, probable autitory hallucinations, paranoid delusions, a decline in daily function. Presence of psychosis (auditory hallucinations, a delusional system) rules out a personality disorder or social phobia. Similarly the lack of feeling of worthlessness, trouble sleeping, suicidal ideation makes major depressive diagnosis a less fitting cause. However DSM-IV requires a persistence of symptoms of at least 6 months forthe diagnosis of schizophrenia, so the most appropriate diagnosis at this time is schizophreniform disorder.
    Questa e' una classica domanda di psichiatria. Presenta molte espressioni idiomatiche in  Inglese: "cocking his head to the sky" (voltando la testa verso il cielo) , o "They are all in on it there" (Sono tutti d'accordo, li) che aiutano moltissimo nella diagnosi. Bisogna ricordare che le definizioni del DSM-IV sono importantissime per questo esame, soprattutto per quanto riguarda diagnosi come la schizzofrenia (il comportamento patologico del paziente deve essere presente per piu di 6 mesi.)  Molti studenti hanno anche riscontrato che le domande di Clinical Sciences sono spesso lunghe.

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  1. The answer is b. The patient will most benefit from the administration of an antipsychotic such as haloperidal. In the presence of psychosis especially paranoid delusions, insight oriented and behavioral therapy would be counterproductive.  Lorazepam, a benzodiazepine, might sedate the patient and calm him down but would do nothing to control his psychotic  symptoms.Fluoxetine, a member of the serotin-specific reuptake inhibitor (SSRI) family of antidepressants, would also be of little or no help to the patient.
    Bisogna conoscere la psicofarmacologia molto bene sia per le Clinical Sciences che le Basic Sciences. La psichiatria USA e' basata su protocolli molto precisi.

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  1. The answer is e. The use of oxytocics increases the risk of uterine rupture. This patient has several characteristics consistent with cephalopelvic disproportion (CPD) The combination of the arrest with the suspected CPD is best treated by cesarean  section. Athough the caput is at + 1.5 station, this fetal head is probably not engaged. The use of forceps would likely result in a high application, which is contraindicated. The outcome would most likely be fetal and maternal trauma. The midpelvic       forceps delivery of a macrosomic fetus places the mother and baby at a significant risk for birth trauma including shoulder dystocia
    Molti studenti sono rimasti colpiti dalla difficolta' delle domande di Ostetricia, bisogna studiare benissimo il management del parto vaginale, e le complicazioni.

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  1. The answer is d. Dermoid cysts or cystic teratomas in adolescent girls are the most common ovarian tumor in children or adoloscents. These tumors contain tissue form all three germ layers, including skin, hair, sebaceous glands, and teeth. They may enlarge and produce symptoms of torsion or peritonitis.It is less common for an adolescent to unknowingly swallow  tooth.
    La maggior parte delle domande di pediatria sono su le piu comuni malattie infettive, neonatologia, trauma, o su le comuni patologie viste da pediatri di base.

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  1. The answer is d. It is important for the psychiatric interviewer to establish rapport with the patient and to give the patient  a chance to answer open-ended questions. It is also important not to feel defensive while interviewing or not to insult the patient, causing him or her to become defensive.
    Anche nelle Clinical Sciences ci sono domande sul comportamento medico paziente. Alcune sono di questo genere,  vale sempre la regola di far parlare il paziente (o con una domanda o con un esortazione, Tell me.....) anche in questa  domanda la conoscenza delle espressioni idiomatiche e' importante :You sure goofed up, (L'hai combinata grossa)

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Passing score: 7 domande corrette su 10  

 

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Bibliography

Appleton & Lange- Practice Tests, USMLE Step 2- Practice tests, Joel Goldberg, ISBN 0-07-137740-9

1) question 80, pag, 14, 34
2) question 52, pag, 10,30
3) question 53, pag, 10,30
4) question 36, pag, 8,29

5) question 123, pag 21,38
6) question 95, pag, 17,35
7) question 95, pag, 17,35
8) question 122, pag 146,166
9) question 131, pag, 62,80
10) question 40, pag 132,155