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Retired NBME Step 2 CK Form 8 Answers

step2ck_form8/Block 3/Question#31 (reveal difficulty score)
An 82-year-old woman comes to the emergency ...
Heparin therapy ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: cardio

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submitted by โˆ—step_prep2(66)
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  • An elderly woman with atrial fibrillation who is not on anticoagulation presents with an acutely cold, painful foot with absent pulses, most consistent with critical limb ischemia secondary to an embolus from the left atrial appendage in setting of afib
  • Key idea: Patients with suspected acute limb ischemia should be treated with immediate initiation of anticoagulation, most often IV heparin

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kingfriday  Aye i coulda sworn i got a uworld question that told me to do an exercise program. I guess since this person has ABSENT pulses and cold extremities those are red flag features for us to just jump straight to treatment. +3
osler_weber_rendu  That question gives exercise only in the absence of hard signs. Any 1 hard sign (absent pulses here) = Acute Limb Ischemia ---> heparin +2
lilmonkey  (: I also remember that question. That was about a smoker with long-lasting chronic claudication without acute features. When atherosclerosis develops slowly without complete immediate occlusion of the main artery there is a time to exercise to develop collaterals to keep blood supply to distal parts (the same principle works with CAD). If there is an acute onset of pain and all the signs and symptoms of acute embolus - prompt medical intervention is needed. +1



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submitted by โˆ—thajoker(21)
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Wtf, Wells Criteria for DVT says always do confirmation thru US/D-Dimer before treating...

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jd1  @thajoker It's not a DVT (vein), it's an arterial embolus which needs Heparin EM, (DVT would not have absent pulses or be cold b/c the blood is stuck inside vs with an artery the blood can't get in (also AFIB makes you think arterial anyway) @kingfriday management of an acute episode is different from chronic arterial embolus where assessment would start with an ABI and management would start with exercise. In an acute episode, patient needs EM heparin and likely thrombectomy after +15
thajoker  lol brain fart, thank you for this +4
drzed  Just to add on to this, if you are fairly certain that a person is having a PE, you would actually heparinize them FIRST and then test LATER (at least, as per up-to-date). +1



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