Just before the year ended, I pounded through a 160-question online exam to get enough CME credits for this cycle to keep my license. Stupid to leave it to the last minute like that, I know, but it happens. I’ve been sharing some absolutely painful questions from that exam. These are questions exactly like you’ll see. You won’t see many of them, but be aware, they’re coming.
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A 73-year-old with a history of moderate emphysema is brought to the emergency department with fever and obtundation. Examination reveals a thin woman with dry mucous membranes, tachypnea, and scattered rhonchi with wheezes. Abdomen is soft, bowel sounds are hyperactive, she winces with deep palpation of the suprapubic area. Remainder of the exam is unremarkable. What is the most likely diagnosis?
a. Urinary tract infection
b. Ruptured abdominal viscus
c. Cerebrovascular accident
d. Pneumonia
e. Encephalitis
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ARRGGGG!!!! What the #$%**!? I’m down to two, lickety split:
UTI – maybe
Ruptured abdominal viscus? That sounds bad
CVA – not with the info given
Pneumonia – maybe
Encephalitis – nope
Ok, so is it UTI or pneumonia? Coin toss and UTI is my answer choice.
WRONG
The answer is pneumonia.
Here’s the explanation given:
The two most common causes of fever and mental status changes in the elderly are pneumonia and UTI. The history of emphysema and lung sounds support a diagnosis of pneumonia. Suprapubic tenderness may indicate a UTI, but it is less likely in this patient. A ruptured viscus would cause pain and rigidity of the abdomen. Encephalitis or a stroke would likely cause focal neurologic findings.
These are tough and extremely frustrating, but the key is to not NEED these to be right. Don’t be needy. Get enough right that if you got this one, it’s just a bonus. How do you get the easy ones right? Simple, practice with The Final Step.
Brian Wallace
