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Retired NBME Step 2 CK Form 6 Answers

step2ck_form6/Block 3/Question#36 (reveal difficulty score)
Three days after being hospitalized for ...
Heparin therapy ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: pulm inc

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 +3  upvote downvote
submitted by โˆ—medicalmike(82)
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Normal V/Q scan rules out PE, regardless of pretest probability.

Low-risk V/Q scan in a low-risk patient rules out PE (unusual scenario for V/Q scan since D-dimer also appropriate)

High-risk V/Q scan in a high-risk patient confirms PE (this patient).

Any other combination warrants additional testing with CT angio.

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 +1  upvote downvote
submitted by chosened(1)
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Can someone explain why this wouldn't be fat embolism and hence supportive treatment (via mechanical ventilation/ intubation)?

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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, โ‰ฅ3 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 โ‰ฅ4, PE is likely, so you would heparinize and conduct a CTA or V/Q scan. +3
jlbae  The femur is a long bone, but I agree with everything else you said +2
lubdub  Feel free to judge, but I just realized in the last few weeks that when they say 'broke her hip' they're talking about the femur not the pelvis. +3
jmorga75  I was going to make a comment about how Fat emboli don't usually present until a at least 24 hours after surgery, but on review it seems Uworld is inconsistent. Qid 3503/4561/12173/16061 - 24-72 hours after injury, Qid 4234 and Amboss- 12-24 hours after injury. Furthermore, being pedantic has lost me more points that it has ever gotten me. +



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submitted by โˆ—sassy_vulpix(23)
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Isn't pulmonary angiography the gold standard for PE detection?

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lubdub  Yep, but not needed if the pretest probability is high (think wells) and the V/Q is suggestive of PE. Thats enough evidence to treat. +1



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