Old Free 120 (Step 2 CK)

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https://drive.google.com/file/d/1RiP5PAi6BI4wfrfiLETsdId5n5LTrMHj/view?usp=sharing

Block 1:

1: A 42-year-old woman comes to the physician for an annual pelvic examination and Pap smear…

Alcohol

  • Middle-aged woman who is alone at home most of the day who presents with sleep disturbances and is found to have MCV at the upper limit of normal, mildly elevated LFTs with AST > ALT, and an increased alkaline phosphatase with increased gamma glutamyl transferase, most consistent with alcohol usage
  • Key idea: Alcohol use disorder often presents with sleep disturbances because alcohol leads to poor quality of sleep
  • Key idea: If a patient has an elevated alkaline phosphatase, then the next step is to measure gamma glutamyl transferase (GGT) to determine whether the elevated alkaline phosphatase is hepatobiliary in origin
  • Key idea: Elevated alkaline phosphatase with normal GGT more concerning for bone disorders/disease

2. A 56-year-old man has had the painful weeping rash shown for 2 days. He underwent…

Herpes zoster

  • Patient who is immunosuppressed and presents with a painful, vesicular rash involving the V1 dermatome, most consistent with herpes zoster
  • Key idea: Herpes zoster involving V1 (such as in this patient) can lead to herpes zoster ophthalmicus (which can lead to blindness and other vision problems)
  • Impetigo: Can also lead to a rash with honey-colored crust on the face, but more likely will involve the chin and area around the mouth and more commonly occurs in children

3. A sexually active 20-year-old woman has had fever, chills, malaise, and pain…

Haemophilus ducreyi

  • Painful genital ulcers(1) Herpes simplex virus: Small vesicles/ulcers on erythematous base with mild lymphadenopathy (2) Chancroid (H. ducreyi): Large, deep ulcers with a soft, friable base and severe suppurative lymphadenopathy
  • Painless genital ulcers: (1) Syphilis: Single ulcer with regular borders and hard base (chancre) (2) Lymphogranuloma venereum (Chylamydia trachomatis): Painless, shallow ulcers with painful fluctuant lymphadenopathy (buboes)

4. A 67-year-old woman comes to the physician 1 month after noticing a nontender nodule…

Excision of the lesion

  • Elderly patient with significant sun exposure (Florida, plays outdoor sports) who presents with a chronic, non-healing, expanding nodule on her hand with a central keratin core, most consistent with a keratoacanthoma
  • Keratoacanthomas are a variant of non-melanoma skin cancer and although many of them will spontaneously regress on their own over the course of months, they cannot be consistently distinguished from more dangerous forms of skin cancer and therefore are definitively treated with excision
  • https://dermnetnz.org/topics/keratoacanthoma/

5. A 67-year-old man is brought to the emergency department because of a 1-week history…

Adverse effects of medications

  • Elderly patient taking multiple medications who presents with non-specific symptoms and is found to have significant hyperkalemia to 7.3, most consistent with adverse effects of medications
  • Medications that can lead to hyperkalemia include:
    • Lisinopril: Blocks ACE –> Decreased Angiotensin 2 –> Decreased aldosterone –> Hyperkalemia)
    • Digoxin: Blocks Na/K ATPase, which normally pumps K+ into cell in exchange for pumping Na+ out of cell [the cell is a “banana in salt water”]
    • Spironolactone: Potassium-sparing diuretic that directly blocks aldosterone receptor, thus blocking the reabsorption of Na+ in exchange for K+ and H+
    • Metoprolol: Beta agonism leads to increased activity of Na/K ATPase, which is reason why patients with hyperkalemia can be treated acutely with albuterol to shift potassium into the cell

6. A 67-year-old woman comes to the physician for a follow-up examination. She had a pulmonary embolism…

Compression of the lateral femoral cutaneous nerve

  • Patient who is recovering from a retroperitoneal hematoma who presents with decreased sensation of the anterolateral thigh, most consistent with meralgia paresthetica that is due to compression of the lateral femoral cutaneous nerve
  • Key idea: Common causes of meralgia paresthetica include tight clothing and weight gain, but it can also be seen in the setting of a retroperitoneal or thigh hematoma
  • Common complication of IVC filters is recurrent pulmonary embolism with the filter acting as a nidus for blood clotting
  • Cerebral infarction and spinal cord infarction would be expected to lead to more diffuse neurological deficits
  • Vitamin B12 deficiency would lead to symmetrical neurological symptoms (most commonly in the distal lower extremities)
https://link.springer.com/chapter/10.1007/978-4-431-54660-3_53

7. A 2-week-old newborn is brought to the physician for a routine examination. His mother is concerned…

Reassurance

  • Mother brings in her 2-week-old newborn with concerns about her child’s development with an associated video showing a normal Moro reflex and growth parameters within normal limit, most consistent with normal development
  • Key idea: Generally in these questions, assume that patient is normal until proven otherwise!
  • Key idea: Moro reflex often present until ~3 months of age

8. An obese 33-year-old woman has had four 12-hour episodes of severe, sharp, penetrating…

Ultrasonography of the upper abdomen

  • Obese woman of childbearing age who presents with episodic, sharp RUQ pain most consistent with biliary colic
  • Key idea: Risk factors for cholesterol gallstones include the 4 F’s of Female, Fat, Fertile and Forty
  • HIDA scan (cholescintigraphy) is often not the answer on NBME exams, with its main indication being in a patient with suspected acute cholecystitis who had negative findings on RUQ ultrasound
  • Upper GI series useful for small bowel obstruction
  • Supine and erect x-rays of the abdomen useful in setting of suspected abdominal perforation with free air in the abdomen

9. Five years after being shot in the right thigh, a 21-year-old man comes to the emergency…

Arteriovenous fistula

  • Patient who was shot in the thigh and now has a persistent loud murmur, palpable thrill and buzzing sensation near the injury site, most consistent with an AV fistula
  • Key idea: 3 common blood vessel injuries to consider include (1) Hematoma: Palpable mass without a murmur or thrill (2) Pseudoaneurysm: Palpable mass with a murmur and a thrill (3) AV fistula: NO MASS but there will be a murmur and a palpable thrill and patient will often have signs of high-output heart failure (or in this case dilated varicose veins secondary to increased flow of blood from arteries directly into veins)

10. An 18-year-old primigravid woman comes for her initial prenatal visit at 16 weeks’ gestation…

Ultrasonography

  • A pregnant young woman who presents in the second trimester for her initial prenatal visit with an unclear date of conception who presents with increased AFP which is most likely due to inaccurate pregnancy dating
  • Causes of increased AFP: Under-estimation of gestational age, multiple gestations, ventral wall defects, neural tube defects and liver disease
  • Key idea: In setting of increased AFP, next best step in management is ultrasound to assess gestational age, viability, number of pregnancies, looking for defects, etc.

11. A previously healthy 34-year-old woman is brought to the physician because of fever…

Thrombotic thrombocytopenic purpura

  • Young previously healthy woman who presents with fever, headache, signs of hemolytic anemia (anemia, schistocytes, jaundice), thrombocytopenia and signs of renal disease with normal PT and PTT most consistent with thrombotic thrombocytopenia purpura
  • Mnemonic to remember the signs/symptoms of thrombotic thrombocytopenia purpura (TTP ) and hemolytic uremic syndrome (HUS) is Brain FART: Brain (neuro) symptoms, Fever, hemolytic Anemia, Renal disease and Thrombocytopenia
  • Schistocytes = Macroangiopathic hemolytic anemia (mechanical heart valve, aortic steonsis) or Microangiopathic hemolytic anemia (DIC, TTP, HUS, SLE, HELLP syndrome, hypertensive emergency)
  • DIC would lead to bleeding from multiple orifices and increased PT and PTT

12. A 16-year-old girl is brought to the physician because of intermittent pain and swelling of both…

Systemic lupus erythematosus

  • A previously healthy young woman presents with intermittent arthritis, oral ulcer, pancytopenia, signs of kidney damage and antibody studies consistent with SLE, most consistent with systemic lupus erythematosus
  • ANA is sensitive for SLE (good at ruling out SLE), whereas Anti-DNA antibodies and anti-Smith antibodies are specific for SLE (good at ruling out SLE)
  • Key idea: Mnemonic to remember signs/symptoms of lupus is RASH OR PLANE: Rash (often malar), Arthritis, Serositis (pericarditis, pleuritis), Hematologic disorders (pancytopenia), Oral ulcers, Renal disease, Photosensitivity, Libman-sacks endocarditis, ANA, Immunologic problems, Neurological disorders (seizures, psychosis)
  • Reactive arthritis: Can’t see (conjunctivitis), can’t pee (urethritis), can’t bend your knee (arthritis)
  • Disseminated gonococcal disease: Dermatitis, enthesitis and pustular dermatitis OR monoarticular purulent arthritis

13. A 27-year-old nurse comes to the emergency department because of nervousness, dizziness…

Measurement of serum insulin and C-peptide concentrations

  • Young nurse who presents with sympathetic hyperactivation that improves with orange juice or soft drinks who is found to have a low serum glucose concentration, most concerning for hypoglycemia episode
  • 2 causes of hypoglycemia to consider in a previously healthy patient includes insulinomas vs exogenous insulin administration, which can be distinguished by measuring a C-peptide level
  • Key idea: Our beta cells produce insulin by cleaving pro-insulin into insulin and C-peptide, so if a patient has an insulinoma that is producing high amounts of endogenous insulin then we would expect insulin AND C-peptide to be high // In contrast, exogenous insulin that is used to manage diabetics is purified insulin without C-peptide, so patients using exogenous insulin would be expected to have elevated insulin with LOW C-peptide levels
  • Key idea: The fact that this patient is a nurse (or any kind of healthcare worker) should increase your index of suspicion that they are using exogenous insulin
https://www.researchgate.net/figure/11-Proinsulin-C-Peptide-and-Insulin-112_fig9_315805089

14. A 15-year-old girl is brought to the physician 3 months after she had a blood pressure of 150/95 mm Hg…

Exercise and weight reduction program

  • Adolescent who presents with hypertension (increased blood pressure measured multiple times over multiple days) who is overweight with a normal cardiac and renal ultrasound, most consistent with essential hypertension
  • Key idea: Lifestyle interventions should ALWAYS be tried prior to pharmacological therapy for treatment of hypertension, especially in pediatric population
  • Measurement of urine catecholamines –> Pheochromocytoma (history of episodic palpitations, pallor, headaches and sweating)
  • Measurement of urine corticosteroid concentrations –> Cushing syndrome (hirsutism, oligomenorrhea, signs of insulin resistance, moon facies, buffalo hump, etc.)

15. A 3-year-old girl is brought to the physician because of fever and left ear pain for 3 days…

Mastoiditis

  • Young girl who has been treated for left otitis media but continues to have fever and left ear pain with her left ear being displaced forward and laterally, most consistent with mastoiditis
  • Acoustic neuroma –> Balance issues, hearing issues +/- involvement of the facial nerve
  • Labyrinthitis –> Patient with a URI who has persistent peripheral vertigo on the order of days
  • Rhabdomyosarcoma –> Malignant tumor derived from skeletal muscle that often presents as a mass composed of grape-like structures protruding from the vagina of a young girl
https://www.saintlukeskc.org/health-library/when-your-child-has-mastoiditis

16. A 62-year-old man comes to the physician because of a 3-month history of progressive fatigue…

Vasculitis

  • Patient presents with subacute upper respiratory symptoms (cough, sinus congestion), lower respiratory symptoms (hemoptysis) and glomerulonephritis (urinalysis –> blood + protein + RBC casts) found on labs to have a positive c-ANCA (antineutrophil cytoplasmic antibodies), most consistent with granulomatosis with polyangitis
  • Granulomatosis with polyangitis: Leads to renal, upper respiratory (chronic congestion, ear pain) and lower respiratory symptoms (shortness of breath, hemoptysis, etc.)
  • Distinguishing features between Granulomatosis with polyangitis and microscopic polyangitis are that GPA involves upper respiratory tract, is positive for c-ANCA, and has granulomas on pathology (as the name implies)
  • Positive c-ANCA = Granulomatosis with polyangitis
  • Positive p-ANCA = Microscopic polyangitis, eosinophilic granulomatosis with polyangitis (Churg-Strauss), Ulcerative colitis, primary biliary cirrhosis

17. A 2-month-old boy is brought to the physician because of a 6-week history of persistent diarrhea…

Decreased gluconeogenesis

  • 2-month old with chronic weight loss, jaundice, splenomegaly and lab findings of hypoglycemia with increased reducing substances in urine, most consistent with classic galactosemia
  • Key idea: Patients with classic galactosemia are unable to convert galactose-1-phosphate into glucose-1-phosphate and therefore all of their phosphate (and ATP) gets tied up as galactose-1-phosphate, leading to impaired gluconeogenesis
  • Key idea: Main way to differentiate between classic galactosemia and hereditary fructose intolerance is based on age of patient (newborns will only be drinking breast milk and therefore will get classic galactosemia, whereas patients who develop symptoms at 6 months-1 year are more likely due to hereditary fructose intolerance following introduction of some foods)
  • Test-taking tip: Patient has decreased glucose levels, so you can automatically eliminate decreased insulin secretion, increased glucagon secretion, increased gluconeogenesis, and insulin resistance because these would all lead to hyperglycemia

18. A previously healthy 42-year-old man is brought to the emergency department 1 day after the…

Ventilation-perfusion mismatch

  • Previously healthy patient who developed sudden onset dyspnea and pleuritic chest pain who is found to be hypoxemic with a primary respiratory alkalosis, most consistent with a V-Q mismatch in the setting of a pulmonary embolism
  • Pleuritic chest pain = Pulmonary embolism, pericarditis, pneumonia, and pneumothorax
  • Key idea: Patients who have experienced a PE will have a large area of dead space (ventilated but not perfused) that will lead to hypoxemia and patient will become tachypneic to try to compensate
  • Key idea: Increased tidal volume will lead to increased ventilation (leading to CO2 being blown off –> respiratory alkalosis) because CO2 levels vary linearly with tidal volume, whereas oxygenation will be only partially compensated because areas that are well-perfused will already have blood that is nearly completely oxygenated due to cooperativity of hemoglobin, and therefore no matter how hard they breathe they will not be able to increase oxygenation of blood within the well-perfused areas to make up for the large area of dead space

19. A 36-year-old nulligravid woman with primary infertility comes for a follow-up examination. She…

Endometriosis

  • Young woman presents with normal menses, infertility and severe dysmenorrhea, most consistent with endometriosis
  • Endometriosis: Implantation of endometrial tissue outside of the uterine cavity –> dysmenorrhea (due to inflammation of implanted endometrial tissue), dyschezia (due to inflammation of endometrial tissue within pouch of Douglas), immobile uterus (due to implantation on ligaments tethering uterus in place) and infertility (due to inflammation)
  • Key idea: Definitive diagnosis of endometriosis often necessitates laparoscopy
  • Patient has normal menses =/= Anovulation
  • Patient had normal hysterosalpingography =/= Intrauterine synechiae

20. A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks…

Decreasing myocardial contractility

  • Middle-aged male patient with recent MI and clear ASCVD risk factors who presents with chest pain on exertion, most consistent with stable angina
  • Stable angina = Oxygen demand of heart > Oxygen supply to heart
  • Primary ways to treat stable angina include decreasing preload (nitrates) or decreasing contractility (beta blockers)
  • Key idea: While beta blockers lead to decreased contractility (and therefore decreased oxygen demand of heart), it also lead to decreased HR –> increased diastolic filling time –> increased preload –> increased oxygen demand of heart and therefore is often combined with a preload reducing medication (such as nitrates)

21. Four days after undergoing open reduction and internal fixation of a fracture of the right femur…

Alcohol withdrawal

  • Patient on hospital day 4 after a motor vehicle accident who develops agitation and confusion unresponse to antipsychotics + hypertension + tremulousness most concerning for delirium tremens in the setting of alcohol withdrawal
  • Manifestations of alcohol withdrawal
    • 6-24 hrs since last drink: Anxiety, palpitations, tremors, insomnia
    • 12-48 hrs since last drink: Seizures, hallucinations
    • 48-96 hrs since last drink: Delirium tremens (confusion, fever, hypertension, hallucinations, diaphoresis)
  • Fat emboli –> Patient who develops respiratory distress, neurologic dysfunction and petechial rash 24-72 hours after inciting event (such as femur fracture)

22. A 9-year-old boy is brought to the physician because of progressive weakness and a purple-red discoloration…

Dermatomyositis

  • Pediatric patient presents with proximal muscle weakness (trouble climbing stairs, combing hair, etc.), malar rash, heliotrope rash (purple-red discoloration over cheeks and upper eyelids) and Gottron’s papules (flat-topped red papules over all knuckles) most concerning for dermatomyositis
  • Key idea: NBME will not use the words heliotrope rash, shawl sign, Gottron’s papules, etc. and therefore you need to know how the rash will be described

23. A 47-year-old woman with end-stage renal disease comes to the physician because of increased shortness…

Metabolic acidosis, respiratory compensation

  • Patient has a pH = 7.30 which is less than 7.35 and therefore represents an overall acidemia
  • Key idea: For acid-base questions, always use the PCO2 to determine whether the primary process is respiratory or metabolic
  • In this case, we see that the patient has a low PCO2 (normal value of 40), and therefore we know that the patient has a metabolic acidosis with respiratory compensation because a low PCO2 on its own would lead to an alkalemia
  • Key idea: Increased PCO2 –> Increased H+ in blood –> Acidosis
  • Nomenclature: -osis = process whereas -emia = status within the blood

24. A 37-year-old woman with AIDS comes to the physician because of a 1-month history of…

Cryptosporidium parvum

  • 4 common causes of diarrhea in AIDS:
    • Cryptosporidium: Severe watery diarrhea and weight loss
    • Microsporidium/Isosporidium: Watery diarrhea and crampy abdominal pain
    • Mycobacterium avium complex: Watery diarrhea with high fevers often >39C
    • Cytomegalovirus: Bloody diarrhea and abdominal pain +/- involvement of other organ systems
  • Salmonella enteritidis would not lead to 1 month of symptoms
  • Strongyloides is not a bad answer for this question to be honest, but for the NBME if you see AIDS then you should think of one of the 4 causes of diarrhea listed above

25. A previously healthy 24-year-old woman comes to the physician because of a low-grade fever…

Erythromycin

  • Young patient presents with a “walking pneumonia” (few clinical symptoms with concerning chest x-ray) which is most commonly caused by Mycoplasma pneumoniae and should be treated with a macrolide antibiotic (such as Erythromycin)

26. A 2-week-old newborn is brought to the physician because his lips have turned blue on three…

Tetralogy of Fallot

  • Features that are specific for Tetralogy of Fallot on NBME:
    • Cyanosis or sweating when feeding or crying
    • Cyanosis that improves when drawing knees to chest (kinks femoral arteries –> increased afterload –> decreases right to left shunting because of increased resistance within that pathway)
    • Boot-shaped heart on chest x-ray
  • Components of tetralogy of Fallot:
    • Pulmonic valve stenosis
    • Right ventricular hypertrophy
    • Ventricular septal defect
    • Overriding aorta

27. A 35-year-old woman is brought to the emergency department because of worsening pain and swelling…

Arthrocentesis of the knee

  • Young sexually active woman who presents with non-traumatic, unilateral knee pain that is unresponsive to NSAIDs found to have an erythematous, swollen, tender joint with an effusion, potentially concerning for septic arthritis
  • Key idea: Although patient does not have a fever, other components of her history and the significant morbidity associated with septic arthritis would prompt you to perform an arthrocentesis which has diagnostic and therapeutic value
  • Key idea: Most common organisms to cause a septic joint are Staph aureus and N. gonorrhea (which is more likely in this patient given her age)

28. Arthrocentesis is done. The synovial fluid is cloudy. Gram stain is negative. Analysis of the…

Culture for bacteria

  • Synovial fluid analysis with WBC count > 50,000 should make you highly concerned for a septic joint, and a WBC count > 100,000 virtually seals the diagnosis
  • We know that patient has a septic joint, but it would be important to try to culture for bacteria both so that we can determine the causative organism and to obtain antibiotic sensitivity data
  • Glucose measurement and protein level are more important in determining the etiology of a pleural effusion
  • Polarized light microscopy = Gout or pseudogout

29. A 17-year-old girl comes to the physician for an examination prior to entering college. She…

Potassium: Decreased // Bicarbonate: Increased

  • Young girl with binge-purge subtype of bulimia nervosa who would have a metabolic alkalosis (due to loss of H+ from vomited stomach acid and contraction alkalosis) and hypokalemia (Vomiting –> Hypovolemia –> Increased RAAS activation –> Increased aldosterone activity at collecting ducts –> Increased Na+ reabsorption in exchange for K+ and H+ secretion –> increased K+ loss in urine –> hypokalemia)
  • Key idea: Patients with anorexia nervosa can also display binge-purge behavior, but the BMI would be less than 18.5 (IMPORTANT CUT-OFF TO REMEMBER!)

30. A 67-year-old woman has had fatigue, dry skin, brittle hair, swelling of the ankles, and cold…

Chronic lymphocytic thyroiditis (Hashimoto disease)

  • Patient with basically every sign of hypothyroidism (fatigue, hair/skin changes, edema, cold intolerance, weight gain, prolonged reflex relaxation phase) and a diffusely enlarged non-tender thyroid gland, most consistent with Hashimoto thyroiditis
  • Key idea: Hashimoto thyroiditis is the most common cause of hypothyroidism in the Western world
  • Key idea: Hashimoto thyroiditis can lead to an initial hyperthyroid phase due to release of pre-formed thyroid hormone from the inflamed thyroid gland
  • Riedel thyroiditis –> Rock-hard thyroid gland

31. A 57-year-old man comes to the emergency department because of cramping in his hands and…

Vitamin D deficiency

  • Middle aged man with significant alcohol consumption and history of alcoholic pancreatitis (hospitalized twice for severe abdominal pain) who presents with signs of hypocalcemia in setting of weight loss with bulky foul-smelling stools, most consistent with vitamin D deficiency due to chronic pancreatitis
  • Patients with chronic pancreatitis lose endocrine functions of pancreas (often develop diabetes) and exocrine functions (lead to steatorrhea with malabsorption of fat-soluble vitamins)
  • While patients with chronic alcoholism can develop nutritional deficiencies such as hypomagnesemia (–> hypocalcemia and hypokalemia), in this patient the history of steatorrhea and recurrent pancreatitis raises index of suspicion for chronic pancreatitis

32. A hospitalized 57-year-old man has had severe progressive pain in his left knee since…

Pseudogout

  • Middle-aged man with recent acute illness who develops non-traumatic unilateral knee arthritis with normal lab values and knee x-ray showing calcification of the synovium, most consistent with pseudogout (calcium pyrophosphate disease)
  • Pseudogout commonly precipitated by surgery or medical illness
  • Distinguishing features of pseudogout > gout include chondrocalcinosis on imaging (such as with this patient) and synovial fluid analysis showing rhomboid, positively birefringent crystals
  • Key idea: Association between hemochromatosis and pseudogout is commonly tested on exam!

33. A 67-year-old woman comes to the physician because of easy bruising for 4 months. She has a…

Bone marrow aspiration

  • Elderly woman with history of treated lung cancer who presents with easy bruising in the setting of isolated thrombocytopenia who is found to have a negative serum antiplatelet antibody assay and therefore should be further worked up with a bone marrow aspiration
  • Key idea: Immune thrombocytopenia involves production of IgG against platelet antigens and is the most common cause of thrombocytopenia in children and adults, but our patient had a negative antiplatelet antibody assay and therefore needs to undergo further work-up
  • Key idea: Our patient with a history of cancer treated with radiation would be at increased risk of developing leukemia, which can lead to pancytopenia due to cancer cells overcrowding normal hematopoeitic precursors in the bone marrow and is a can’t miss diagnosis especially since the patient’s hemoglobin and leukocyte count are towards the lower end of normal

34. A 72-year-old woman with advanced ovarian cancer metastatic to the liver is brought to the…

Assess for suicidal ideation

  • Key idea: In patients showing signs of depression, you ALWAYS need to assess for suicidal and homicidal ideation because those are the most important immediate risks associated with depression that would necessitate involuntary treatment

35. A previously healthy 17-year-old girl comes to the emergency department because of a 5-day…

Intramuscular ceftriaxone and oral doxycycline

  • Healthy sexually active adolescent girl who presents with fever, lower abdominal pain and malodorous vaginal discharge found on exam to have purulent cervical discharge and cervical motion tenderness most consistent with pelvic inflammatory disease
  • Key idea: Most common pathogens to cause pelvic inflammatory disease are N. gonorrhea and C. trachomatis and therefore you would empirically treat for both with ceftriaxone + (doxycycline or azithromycin)
  • Key idea: Cervical motion tenderness can be be seen with pelvic inflammatory disease, ectopic pregnancy and endometriosis

36. A 57-year-old woman is brought to the emergency department 45 minutes after she fell after an…

History of gastrectomy

  • Middle-aged woman with history of partial gastrectomy who presents with tingling of her peripheral extremities, balance issues, pallor and lab findings demonstrating pancytopenia with an increased MCV most consistent with B12 deficiency in the setting of insufficient intrinsic factor production
  • Key idea: The only essential function of the stomach is production of intrinsic factor by parietal cells
  • Key idea: B12 deficiency leads to subacute combined degeneration, which often leads to problems with strength, fine touch, vibration and balance/cerebellar functions
  • Diabetes mellitus –> Autonomic insufficiency (orthostatic hypotension, gastroparesis, bladder atony, etc.)
https://www.intechopen.com/books/immunotherapy-myths-reality-ideas-future/vitamin-b12-could-it-be-a-promising-immunotherapy-

37. A 4-year-old boy with asthma becomes limp during treatment with inhaled albuterol in the…

Decrease in cardiac output

  • Young boy presenting with acute asthma exacerbation who is hypotensive with a thready pulse who has a chest x-ray with absent lung markings on right lung field with mediastinal shift towards left side, concerning for a tension pneumothorax
  • Key idea: Tension pneumothorax leads to hypotension due to kinking of the inferior vena cava due to build-up of intrathoracic pressure –> Decreased preload
  • Key idea: These patients can also develop a mucus plug, leading to atelectasis but would have a different chest x-ray finding (increased opacity of one lung field with mediastinal shift towards that side but NORMAL lung markings on unaffected side)

38. A 5-year-old girl is brought to the physician by her parents for evaluation of recurrent injuries…

Echocardiography

  • Young patient with signs of Marfan syndrome (joint pain, hyperflexible joints, increased arm:trunk ratio [“palms easily touching the floor with straight knees”], need for glasses [due to upward lens dislocation]) who also has chest pain with exertion and a midsystolic click at the apex concerning for mitral valve prolapse
  • Key idea: Patients with Marfan syndrome are prone to develop mitral valve prolapse and aortic aneurysm
  • Key idea: In this patient, we would pursue Echocardiograph > Aortic angiography because it is a much less invasive test and patient has an audible murmur which we would want to confirm with echo

39. A 47-year-old man comes to the physician 12 hours after the sudden onset of a severe occipital headache…

Subarachnoid hemorrhage

  • Middle-aged man with history of hypertension who presents with sudden onset headache and stiff neck which should increase concern for subarachnoid hemorrhage
  • Key idea: Meningismus (stiff neck associated with headache) can be seen both with meningitis and subarachnoid hemorrhage
  • Migraine –> Nausea, vomiting, aura, unilateral pulsating headache
  • Cluster headache –> Severe pain behind eye often in middle of night, occurs cyclically, leads to tearing and lacrimation, men > women

40. An 18-year-old man with a 12-year history of type 1 diabetes mellitus comes to the physician for…

Diabetic nephropathy

  • Young patient with history of poorly controlled T1DM (goal HbA1c often between 7-8%) who presents with signs of end-organ damage (retinal microaneurysms) also found to have an increased creatinine with proteinuria concerning for diabetic nephropathy
  • Key idea: Diabetes leads to preferential atherosclerosis of the efferent arteriole > afferent arteriole –> Increased GFR –> Glomeruli pounded with high pressures over time become leaky –> Microalbuminuria
  • Key idea: Due to the pathophysiology listed above, GFR can actually increase in early setting of diabetic nephropathy and for that reason presence of proteinuria > creatinine/BUN for monitoring for initial signs of diabetic nephropathy
  • Key idea: All patients with diabetes who show signs of proteinuria should be started on an ACE inhibitor or ARB

Block 2:

1: A 67-year-old woman comes to the physician because of dizziness for 6 weeks. when she stands…

Adjusting her medication regimen

  • Elderly patient with ASCVD risk factors who experiences light-headedness upon standing and is found to have unequal blood pressures in her arms found to have reverse flow in the vertebral artery with no evidence of occlusion consistent with vertebrobasilar insufficiency due to subclavian steal syndrome
  • Patient has occlusion of her left subclavian artery (most likely due to atherosclerosis) causing blood to flow from the right vertebral artery to the left vertebral artery to supply the subclavian artery distal to occlusion
  • Key idea: Antihypertensive therapy can worsen vertebrobasilar insufficiency, so this patient likely needs to hold her antihypertensive therapy (adjust her medication regimen)
  • Presentation of vertebrobasilar insufficiency: Light headedness, vertigo, vision changes, ataxia, drop attacks (sudden generalized weakness)
  • https://www.ncbi.nlm.nih.gov/books/NBK482259/
https://www.researchgate.net/figure/fig1_5856457

2. A previously healthy 27-year-old nulligravid woman comes to the emergency department…

Incision and drainage

  • Young sexually active woman with a tender, fluctuant mass medial to the left labium majus most consistent with a Bartholin duct abscess
  • Key idea: Although the majority of Bartholin duct cysts do not require intervention, in this patient who has a fluctuant (=abscess) tender mass we would proceed with Incision and drainage followed by placement of a Word catheter

3. A 65-year-old man is brought to the physician by his daughter because of decreased ability to perform…

Parkinson disease

  • Elderly patient with chronic loss of ability to do fine movements (fine detail drawing and buttoning shirts) with a video showing an asymmetric resting tremor most concerning for Parkinson disease
  • Features of Parkinson disease can be remembered by mnemonic TRAPS (resting Tremor, Rigidity, Akinesia, Postural instability, Shuffling gait)
https://mercedesentienza.files.wordpress.com/2015/06/parkinsons-disease.jpg

4. A 19-year-old man comes to the physician because of a 3-week history of malaise, generalized…

Intravenous methylprednisolone

  • Young previously healthy patient presenting with subacute lower extremity edema and dark urine with lab findings consistent with renal failure (increased BUN and creatinine) and glomerulonephritis (urinalysis with blood, protein, dysmorphic RBCs and RBC casts) with a renal biopsy showing signs of rapidly progressive (crescentic) glomerulonephritis, which needs to be immediately treated with corticosteroids (such as IV methylprednisolone)
  • Etiologies of Crescentic glomerulonephritis:
    • Linear Immunofluorescence = Goodpasture syndrome (often young healthy man with hemoptysis and glomerulonephritis)
    • Granular immunofluorescence = Post-streptococcal glomerulonephritis (particularly in adults) or diffuse proliferative glomerulonephritis (more common in lupus patients)
    • Absent immunofluorescence = Granulomatosis with polyangitis (upper respiratory symptoms, lower respiratory symptoms, glomerulonephritis), microscopic polyangitis (lower respiratory symptoms, glomerulonephritis), eosinophilic granulomatosis with polyangitis (asthma/sinusitis, glomerulonephritis, neuropathy)

5. A cohort study is conducted to compare the incidence of adverse effects of a recently approved…

Selection bias

  • Randomization >> Matching across several risk factors (baseline BP, age, gender)
  • Key idea: The reason that we randomize patients to groups is because we assume that it equally disperses potential confounding variables
  • Selection bias can be caused by (1) Inappropriate selection of study subjects (2) Poor retention of study subjects
  • Type 1 error = Rejecting the null hypothesis when it is actually true (i.e. thinking there is a difference when one does not actually exist)
  • Type 2 error = Failing 2 reject null hypothesis when it is actually false (i.e. thinking there is NO difference between groups when one actually exists)

6. A study is conducted to assess the effectiveness of a new drug for the treatment of type 2…

Chance of a type 2 error

  • Decreased study sample –> Decreased power –> Increased chance of a type 2 error (failing 2 reject the null hypothesis when it is actually false)
https://www.slideshare.net/ramachandrabarik/alpha-beta-and-power

7. A 32-year-old woman, gravida 2, para 1, at 8 weeks’ gestation comes to the physician for her first…

Preterm labor and delivery

  • 2 key risk factors for preterm labor include (1) History of preterm labor and (2) Short cervix
  • Key idea: Mothers carrying twins also tend to deliver early, often around 35-36 weeks
  • Risk factors for placental abruption: Tobacco use, cocaine/meth use, trauma, hypertension, pre-eclampsia
  • Fetal chromosome abnormality: Older mom (often >35 yo)
  • Twin transfusion syndrome: Can only be seen in monochorionic twins because they share a placenta

8. A 37-year-old man comes to the physician because of nonradiating low back pain for 3 days…

Regular activity

  • Young otherwise healthy man with low back pain after an exertional activity who has no neurological symptoms, normal vitals and paravertebral muscle spasm most consistent with a muscle strain
  • Key idea: Low back pain due to muscle strain should be managed with up to 6 weeks of NSAIDs and regular activity (strict bed rest should NOT be prescribed)
  • Indications for X-ray in setting of low back pain: Compression fracture, suspected malignancy, ankylosing spondylitis
  • Indications fo MRI in setting of low back pain: Cauda equina syndrome (urinary retention, absent reflexes, saddle anesthesia), suspected epidural abscess/infection, neurological symptoms

9. A previously healthy 47-year-old man comes to the physician because of a 6.8-kg (15-lb) weight loss…

Colonoscopy

  • Middle-aged man with chronic weight loss, changes to stool size/consistency, and a microcytic anemia with blood in his stool, which is concerning for colon cancer and should be evaluated with colonoscopy
  • Key idea: Iron deficiency anemia in an elderly/middle-aged man and post-menopausal woman should be considered colon cancer until proven otherwise!
  • Key idea: Routine colonoscopies typically begin at 50 years of age
  • Key idea: Iron deficiency anemia leads to increased red cell distribution width (because some RBCs get enough hemoglobin and are normal sized whereas some are microcytic, leading to a wide spread), whereas thalassemias have a decreased/normal red cell distribution width (because all RBCs are small)

10. A 6-year-old boy is brought to the emergency department 2 hours after injuring his arm when he fell…

Attention-deficit/hyperactivity disorder

  • Young boy who has frequent injuries with history of hyperactivity/inattentiveness in multiple settings most consistent with ADHD
  • Key idea: ADHD requires at least 6 months of hyperactive or inattentive symptoms before age 12 that occur in at least 2 settings

11. An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab…

Pericardiocentesis

  • Patient who sustained a stab wound to the chest who has Beck’s triad (hypotension, muffled heart sounds and jugular venous distention) most consistent with cardiac tamponade
  • Key idea: Patients with suspected cardiac tamponade who are hemodynamically unstable should receive an emergency pericardiocentesis
  • Normal breath sounds and midline trachea –> Rules out tension pneumothorax (in which case you would place a chest tube or perform needle thoracostomy)
  • Stab wound to the chest should make you highly consider (1) Tension pneumothorax (2) Cardiac tamponade [HIGH YIELD!!!]

12. A 27-year-old man comes to the physician for a routine health maintenance examination. He says…

Decreased conjugation of bilirubin

  • Young otherwise healthy man with mild scleral icterus, isolated indirect hyperbilirubinemia and negative work-up for alcoholism or hepatitis, most consistent with Gilbert disease (which is due to impaired conjugation of bilirubin within the liver, leading to build-up of unconjugated bilirubin)
  • Decreased excretion of bilirubin by hepatocytes –> Roter or Dubin-Johnson syndrome –> Direct hyperbilirubinemia + black liver (in Dubin-Johnson syndrome)
  • Hemolysis –> Indirect hyperbilirubinemia + anemia

13. A previously healthy 27-year-old man comes to the physician 4 weeks after noticing three nontender…

  • Young man with high-risk sexual behaviors who had three nontender flesh-colored lesions on his penis that turn white upon application of acetic acid (vinegar), most consistent with condyloma acuminata (genital warts) –> Cryotherapy, trichloroacetic acid
  • Key idea: Acetic acid is also used to in the setting of colposcopy in women with abnormal pap smear to try to identify dysplastic tissue due to HPV infection
  • Painful genital ulcers(1) Herpes simplex virus: Small vesicles/ulcers on erythematous base with mild lymphadenopathy (2) Chancroid (H. ducreyi): Large, deep ulcers with a soft, friable base and severe suppurative lymphadenopathy
  • Painless genital ulcers: (1) Syphilis: Single ulcer with regular borders and hard base (chancre) (2) Lymphogranuloma venereum (Chylamydia trachomatis): Painless, shallow ulcers with painful fluctuant lymphadenopathy (buboes)

14. Two days after admission to the hospital for congestive heart failure, an 82-year-old man is unable…

WBC: 20,000 // Needle-shaped crystals // No organisms

  • Elderly patient hospitalized with CHF who is likely receiving high amounts of diuretics (which lead to electrolyte/fluid shifts) who develops tenderness and redness of the let great toe most concerning for acute gout
  • Key idea: Inflammation of the great toe is very specific for gout on NBME exams
  • Normal joint: WBC <200
  • Non-inflammatory arthritis: WBC ~1000
  • Inflammatory arthritis: WBC ~5-50K (sometimes up to 100K)
  • Septic joint: WBC > 50K (often >100K)
  • Needle shaped crystals = Gout
  • Rhomboid shaped crystals = Pseudogout

15. A 77-year-old man is brought to the physician because of a 12-hour history of word-finding difficulty…

CT scan of the head

  • Elderly patient with active atrial fibrillation (history and currently has irregular pulse) who is not anticoagulated (aspirin is NOT enough) who presents with unilateral weakness with ipsilateral sensory deficits and Babinski sign most concerning for an embolic stroke from the left atrial appendage (that most likely embolized to the left MCA distribution)
  • Key idea: Patients with a suspected stroke should ALWAYS receive a non-contrast head CT in order to rule out a hemorrhage because (if they present soon enough) they will receive tPA which would lead to life-threatening bleeding if the patient actually had hemorrhage > stroke
  • Side note: Patients with suspected meningitis often receive head CT before lumbar puncture in order to rule out intracranial pathology that could increase risk of brain herniation due to lumbar puncture

16. A 37-year-old man with type 1 diabetes mellitus is admitted to the hospital because of inadequate…

Adhere to the patient’s wishes and discuss home-care options

  • Key idea: Patients are free to leave against medical advice (AMA) as long as they don’t have indications to hold a patient involuntarily such as (1) Threat to themselves (he denies suicidal ideation) (2) Threat to others (3) Grave disability (can’t obtain food, shelter, etc.) (4) Patient’s condition poses significant public health risks (meningococcal meningitis, tuberculosis, etc.) (5) Parents or guardians are refusing life-saving treatment for a minor

17. A 19-year-old college student comes to the physician because of progressive hair growth over…

Combination oral contraceptive

  • Young heavy woman with abnormal menses, clinical and biochemical signs of elevated androgens (acne, oily skin, coarse hair in androgen-sensitive areas) who has LH > FSH and elevated testosterone on labs most consistent with polycystic ovarian syndrome (PCOS)
  • Diagnostic criteria for PCOS require 2/3 of following:
    • Abnormal menses
    • Hyperandrogenism (clinical and/or biochemical)
    • Polycystic ovaries on sonographic examination
  • PCOS patient who does not wish to become pregnant: Dual estrogen-progestin OCPs
  • PCOS patient who wants to become pregnant: Clomiphene (antagonists at estrogen receptors in hypothalamus –> prevents normal feedback inhibition –> increased release of LH and FSH from pituitary –> stimulates ovulation)
  • Note: PCOS patients with all types of fertility goals would benefit from weight loss

18. A 14-year-old boy is brought to the office for an examination prior to participation on a basketball…

Approve basketball participation

  • Key idea: Patient has a normal cardiac exam; note that physiological splitting can be heard and occurs when the patient’s chest rises (inspiration)

19. A 65-year-old man who is quadriplegic as a result of multiple sclerosis is hospitalized for treatment…

Frequent turning

  • Patient who is quadriplegic (and therefore cannot adjust his lower extremities) has a small erythematous area of erythema over the sacrum with intact skin, most consistent with a Stage 1 pressure ulcer which at this stage can be managed with frequent turning
  • Stage 3 and 4 pressure ulcers often require wound care +/- surgical intervention
https://www.lvlawny.com/post/2017/10/23/staging-of-pressure-ulcers-bed-sores

20. A 37-year-old woman, gravida 5, para 4, at 34 weeks’ gestation comes to the emergency department…

Placenta previa

  • Pregnant G5P4 mother at 34 weeks’ gestation with painless vaginal bleeding which is almost always placenta previa
  • Key idea: Patient has a history of a C-section, which increases the risk of placenta previa because it decreases the normal surface area of the uterus for placental implantation, increasing the risk that the placenta will aberrantly implant over the cervical os
  • Key idea: Labor requires contractions AND cervical changes
  • Placental abruption –> Third trimester vaginal bleeding + abdominal/pelvic pain (often due to trauma, drug use, gestational HTN, etc.)
  • Amniotic fluid embolism –> Altered mental status, DIC, respiratory distress shortly after delivery
  • Ruptured uterus –> Sudden onset of abdominal pain during labor with palpable fetal parts on abdominal exam and loss of fetal station

21. A previously healthy 18-year-old man is brought to the emergency department because of abdominal…

Diabetic ketoacidosis

  • Young man who presents with GI symptoms and is found to have ketones in his blood and urine, an elevated glucose to 360 and an anion gap metabolic acidosis (135 – 98 – 16 = 21 > 12), most consistent with diabetic ketoacidosis
  • Key idea: Glucose levels in diabetic ketoacidosis often ~300-500 whereas glucose levels in hyperglycemic hyperosmolar state often >750
  • Alcoholic ketoacidosis: Somebody with a more significant alcohol use disorder who has ketones in blood/urine but a normal glucose

22. A 5-year-old boy is brought to the physician because of a 2-day history of fever and painful swelling…

Impaired phagocytic oxidative metabolism

  • Young boy with recurrent infections by catalase positive organisms with an abnormal NBT dye test most consistent with chronic granulomatous disease (which is due to impaired activity of NADPH oxidase –> impaired oxidative burst)
  • These patients are at increased risk for catalase positive organisms because these organisms use catalase to get rid of hydrogen peroxide that is generated due to normal metabolism, thereby preventing neutrophils from stealing that hydrogen peroxide to create bleach (HOCl)
  • Mnemonic for catalase positive organisms: BELCH SPANS (Burkholderia cepacia, E coli, Listeria, Candida albicans, H pylori, Staph aureus, Pseudomonas, Aspergillus, Nocardia, Serratia)
  • Key idea: These patients can have abnormal NBT dye test (decreased blue color) or abnormal dihydrorhodamine test (decreased green fluorescence)
  • Adenosine deaminase deficiency –> Severe combined immunodeficiency (failure to thrive, recurrent infections with all types of infections, etc.)
  • Defective opsonization –> Decreased immunoglobulins (often Bruton’s agammaglobulinemia)
  • Destruction of CD4 T lymphocytes –> HIV (Classic HIV associated infections of PCP pneumonia, thrush, etc.)
  • Developmental arrest of maturation of B lymphocytes –> Common variable immunodeficiency (often an adolescent or young adult with recurrent infections with encapsulated organisms due to impaired opsonization (Strep pneumo, H influenzae, Neisseria)
  • Dysmorphogenesis of the third and fourth pharyngeal pouches –> DiGeorge syndrome (CATCH-22 –> Cardiac abnormalities, Abnormal facies, Thymic aplasia, Cleft lip/palate, Hypocalcemia)
  • Impaired chemotaxis –> Leukocyte adhesion defect (recurrent abscesses without pus, delayed umbilical cord separation)
  • Absent tonsils and lymph nodes –> SCID or Bruton’s agammaglobulinemia
  • Recurrent Staph abscesses –> Chronic granulomatous disease, Leukocyte adhesion defect, Hyper-IgE syndrome
  • Absent thymus –> SCID or DiGeorge syndrome

23. A 52-year-old man comes to the physician with his wife because of a 1-year history of excessive daytime…

Polysomnography

  • Overweight middle-aged man presents with excessive daytime sleepiness in the setting of choking/gasping for breath while sleeping, most consistent with obstructive sleep apnea which is formally diagnosed via polysomnography
  • Risk factors for obstructive sleep apnea can be remembered by STOP-BANG mnemonic (Snoring, Tired, Observed snoring/chocking, Pressure (elevated BP), BMI >35, Age>50, Neck size > 16 cm and Gender (Male > Female))
  • Key idea: Polysomnography used to diagnose virtually all NBME sleep disturbance questions (obstructive sleep apnea, narcolepsy, REM sleep behavior disorder, etc.)

24. A 32-year-old man who is a jackhammer operator comes to the physician because of pain and swelling…

Axillary-subclavian venous thrombosis

  • Difficult question where you need to recognize/know association between jackhammer use and development of upper extremity DVTs or by eliminating other answer choices
  • Key idea: Upper extremity DVTs can often be seen in setting of central catheter, PICC line, thoracic outlet obstruction or sometimes spontaneously in young athletic males (basketball fans will remember that Brandon Ingram had an upper extremity DVT)
  • Deep venous valvular insufficiency –> dilated veins with edema of the upper extremity due to poor filling
  • Superficial thrombophlebitis –> Tender nodular thickening of the vein, often associated with pancreatic cancer
  • Superior vena cava syndrome –> similar to deep venous valvular insufficiency with swelling of the face as well
  • Thoracic outlet syndrome –> SVC syndrome with atrophy of intrinsic hand muscles due to compression of the lower trunk of the brachial plexus

25. A previously healthy 15-year-old boy is brought to the emergency department in August 1 hour after…

Administer intravenous fluids

  • Young patient who recently initiated strenuous physical activity in the heat of summer who presents with fever + altered mental status + hypotension concerning for heat stroke c/b hemodynamic instability
  • Tricky question because patients with heat stroke are often treated with rapid ice water immersion AND fluid resuscitation, but in this case the patient is hypotensive so you ALWAYS have to start with the ABCs (Airway, Breathing, Circulation)
  • Heat stroke: Due to impaired thermoregulation and characterized by CNS dysfunction
  • Heat exhaustion: No CNS dysfunction but caused by inadequate salt/water replacement

26. A 57-year-old woman comes to the physician because of an 8-week history of difficulty sleeping, fatigue…

Paroxetine therapy

  • Middle-aged woman with 8 week history with features of depression, generalized anxiety disorder and panic disorder, all of which have first-line treatment of SSRI (such as Paroxetine)
  • Key idea: Patients with depression who have active suicidal ideation AND a plan and access to means should be involuntarily hospitalized, but in this patient who has suicidal ideation without a plan involuntary hospitalization is not necessary
  • Donepezil therapy –> Acethylcholinesterase inhibitor used in Alzheimer’s disease
  • Diazepam therapy –> Can be used to acutely treat a panic attack or severe anxiety, but not used for chronic management

27. A previously healthy 22-year-old college student is brought to the emergency department by her parents…

Herpes simplex encephalitis

  • Previously healthy college-aged patient with fever, encephalopathy (confusion, difficulty thinking of words) and seizure who has an MRI with bitemporal hyperintensities and a lumbar puncture with a predominance of monocytes most consistent with HSV encephalitis
  • Key idea: Bitemporal hyperintensities is highly associated/specific for HSV encephalitis on NBME exam
  • CSF findings of bacterial meningitis: WBC > 1000, glucose<40, protein>250 and neutrophilic predominance
  • CSF findings of fungal meningitis: Elevated WBC count , low glucose, high protein, monocytic predominance
  • CSF findings of viral meningitis: WBC 10-500, Normal glucose (2/3 serum glucose), protein elevated but <150, and monocytic predominance
  • NBME LOVES to ask about HSV encephalitis!!!

28. A 6-year-old girl is brought to the physician because of a 1-month history of a recurrent pruritic rash…

Topical corticosteroid therapy

  • Young girl with bilateral itchy rash in the antecubital fossa, most consistent with atopic dermatitis
  • Key idea: Treated with topical corticosteroids (hydrocortisone, triamcinolone, etc.) and lotions/emollients

29. A 20-year-old man has had frequent upper respiratory tract infections over the past 4 years. He has…

Sweat chloride test

  • Young man with recurrent respiratory tract infections with daily purulent sputum (consistent with bronchiectasis) with low sperm count and an x-ray/spirometry consistent with obstructive lung disease, most consistent with bronchiectasis secondary to cystic fibrosis
  • X-ray shows hyperinflation –> Obstructive lung disease –> Asthma, COPD, bronchiectasis, obstructive sleep apnea
  • Chronic productive cough should make you think of bronchiectasis vs chronic bronchitis, with bronchiectasis more often leading to purulent sputum and chronic bronchitis being more closely associated with smoking (type of COPD)
  • 2 hereditary causes of bronchiectasis to consider includes (1) Cystic fibrosis (low weight due to fat malabsorption, low sperm count due to atrophy of the vas deferens (2) Kartagener’s (Dextrocardia, hearing problems, infertility due to impaired sperm mobility)

30. A 65-year-old woman has a 6-month history of progressive irritability, palpitations, heat intolerance…

Multinodular goiter

  • Elderly woman with clear hyperthyroid symptoms with a radioactive iodine uptake showing multiple areas of increased and decreased uptake, most consistent with multinodular goiter
  • Patient likely had a chronic goiter due to iodine deficiency which is a common predisposing factor for multinodular goiter
  • Key idea: “Hot” nodule (produces hyperthyroid symptoms) is less concerning for malignancy as compared to a “Cold” nodule (normal or hypothyroid symptoms)
  • Graves disease –> Diffusely increased uptake, graves ophthalmopathy, etc.
  • Toxic adenoma –> One area of increased uptake with decreased uptake everywhere else
  • T3 thyrotoxicosis (exogenous thyroid intake) –> Diffusely decreased uptake in thyroid gland because it does not need to produce thyroid hormone
  • Thyroiditis –> Diffusely decreased iodine uptake

31. A 4-year-old boy is brought for a follow-up examination. He has a history of chronic recurrent otitis…

Epithelial tissue proliferation

  • Child with chronic recurrent otitis media with ear exam showing a brown, irregular mass behind the tympanic membrane most consistent with a cholesteatoma (which is due to overgrowth of desquamated keratin debris within the middle ear space)
  • Key idea: Suspect a cholesteatoma in a patient with recurrent ear infections or chronic ear drainage despite appropriate antibiotic therapy

32. A 30-year-old woman comes to the physician because of intermittent throbbing headaches, sweating…

Adrenal medulla

  • Young otherwise healthy patient with recurrent episodes of headache, sweating, pallor and hypertension most consistent with a pheochromocytoma, which is a cancer of the catecholamine-producing chromaffin cells of the adrenal medulla
  • Key idea: Pheochromocytoma leads to episodes of the 4 P’s (Pain (headaches), Pressure (hypertension), Perspiration and Palpitations)
  • Patients with hyperthyroidism can have similar symptoms, but the symptoms would be constant > episodic

33. A 27-year-old woman comes to the office because of a 3-day history of progressive shortness of breath with…

Pulmonary embolism

  • Young woman with multiple hypercoagulability risk factors (OCPs, smoking history) who has acute progressive dyspnea, non-productive cough and normal vitals concerning for a pulmonary embolism
  • I personally did not hear anything grossly abnormal on the lung exam, but I am not 100% confident on that to be honest
  • Although patient has increased risk of hypersensitivity pneumonitis due to being a bird owner, the symptoms of HP typically include fever and it often improves within 24-48 hours

34. A previously healthy 37-year-old woman comes to the physician because of a 3-month history of episodes…

Paroxetine

  • Young otherwise healthy patient with episodes of anxiety, SOB, palipitations and numbness in her hands/feet with otherwise normal vitals, physical exam and labs, most consistent with panic disorder –> First-line treatment is SSRI
  • Symptoms of a panic attack can be broad and include abdominal pain, palpitations, pallor, nausea, intense fear of dying, lightheadedness, coughing, choking, chest pain, shortness of breath, sweating and shaking
  • Key idea: Patient presenting with an ACUTE panic attack can be managed with benzodiazepines, but benzodiazepines should not be used for chronic management
  • Normal vital signs (AKA no hypertension) –> Virtually rules out pheochromocytoma
  • Note: Perioral numbness or numbness in hands/feet can be seen in patients with an acute panic attack because they become tachypneic –> Blow off excess CO2 –> Respiratory alkalosis –> Less protons available to bind to negatively-charged binding sites on albumin –> More binding of free calcium to albumin binding sites –> Decreased free (metabolically active) calcium

35. An 82-year-old woman with a 20-year history of urinary incontinence has had a mild exacerbation…

Detrusor instability

  • Elderly woman with incontinence NOT related to activities that increase intra-abdominal pressure who has a normal physical exam and normal labs, most consistent with urgency incontinence (which is due to detrusor instability
  • Key idea: Stress incontinence due to urethral hypermobility or sphincter deficiency
  • Key idea: Neurogenic bladder can range from bladder atony to spastic bladder, but importantly these patients would have a clear neurological insult on NBME (Multiple sclerosis, stroke, etc.)
  • Key idea: Patient also likely has asymptomatic bacteriuria (bacteria in urine but no signs of UTI), which is common in elderly patients and is only treated in specific contexts (pregnant woman, man undergoing GU procedure, etc.)

46. A 4-year-old boy is brought to the physician because of temperatures to 39.4 C (102.9 F) for 8 days…

Intravenous immune globulin

  • Young boy with clear history for Kawasaki disease (CRASH and burn –> Conjunctivitis, desquamating Rash, cervical Adenopathy, Strawberry tongue, Hand-foot edema/changes, Fever for >5 days)
  • Patients with Kawasaki disease are treated with IVIG + Aspirin and the feared consequence is coronary artery aneurysms
  • Key idea: Important to distinguish from Scarlett fever which can also lead to fever and a strawberry tongue, but it will lead to a sandpaper rash in body folds, pallor around the mouth and it will NOT lead to conjunctivitis

37. A 70-year-old man comes to the physician because of fever, productive cough, and pleuritic chest…

Multiple myeloma

  • Elderly patient with recurrent pneumonia who also has spinal tenderness + hypercalcemia + anemia + lytic bone lesions most consistent with multiple myeloma
  • Patients with multiple myeloma are at increased risk for infections due to encapsulated organisms because the immunoglobulins they produce do not work well –> Impaired opsonization
  • Hypercalcemia due to metastasis to bone
  • Pleuritic chest pain –> Pericarditis, pneumothorax, pulmonary embolism, pneumonia
  • Tenderness to palpation of spine –> Osteomyelitis, vertebral compression fracture, or cancer metastatic to bone
  • Prostate cancer –> Osteoblastic bone lesions

38. For 8 weeks, a 52-year-old man with a 5-year history of type 2 diabetes mellitus has had deep burning…

Femoral popliteal stenosis

  • Femoropopliteal artery plaque –> Calf claudication
  • External iliac artery plaque –> Thigh and calf claudication
  • Aortoiliac plaque –> Gluteal, thigh and calf claudication + impotence (in a man)
https://www.pinterest.com/pin/101260691598036084/

39. A 64-year-old woman comes to the physician because of a 5-month history of increasing shortness…

Non-small cell lung carcinoma

  • Elderly patient with significant smoking history with chronic weight loss, progressive dyspnea and cough, enlarged supraclavicular lymph node found to have a right lower lobe lung mass with a smaller mass in the adrenal gland, most consistent with Non-small cell lung cancer
  • Key idea: Lung cancer classically metastasizes to the adrenal gland
  • Key idea: Supraclavicular lymphadenopathy is NEVER NORMAL (cancer until proven otherwise)
  • Sarcoidosis –> BIlateral hilar lymphadenopathy
  • Tuberculosis –> Affects the apex of the lung (higher V/Q rates –> more favorable for aerobic Tb organisms)

40. A 37-year-old woman comes to the emergency department because of a 3-day history of increasingly…

Nasogastric intubation

  • Young woman with a past abdominal surgery who presents with progressive abdominal pain, abdominal distention, and nausea/vomiting with increased small bowel gas on abdominal x-ray, most consistent with a small bowel obstruction 2/2 adhesions
  • Key idea: Most patients with small bowel obstruction can be managed conservatively with nasogastric decompression + fluids + NPO
  • Common causes of SBO: Adhesions, hernias, malignancy, IBD (Crohn’s), gallstone ileus
  • Key idea: If a patient with an SBO has changes in character of pain, fever, hemodynamic instability, peritoneal signs or leukocytosis/acidosis, those are signs that they may have a complicated SBO –> Urgent surgical laparotomy
  • Key idea: Can tell that we are looking at dilated small bowel because the lines perpendicular to bowel pass all the way through (whereas they only pass partially through in large bowel)
  • Key idea: Free air under the diaphragm or rebound/guarding –> Immediate laparotomy

Block 3:

1: A 35-year-old woman comes to the physician because of two 12-hour episodes of dizziness over…

Meniere’s disease

  • Young woman with episodic 12-hour episodes of rotatory vertigo with decreased hearing, sense of ear fullness and tinnitus most consistent with Meniere’s disease
  • Meniere’s disease –> Recurrent episodes lasting 20 minutes to 24 hours with unique features being hearing loss and tinnitus
  • BPPV –> Recurrent episodes last several seconds and are triggered by head movement
  • Vestibular neuritis –> One episode lasting on the order of days that often follows a viral URI
  • Vestibular neuritis + Unilateral hearing loss = Viral labyrinthitis

2. A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a history of rheumatic…

Mitral valve stenosis

  • Middle-aged patient with history of rheumatic fever and a cardiac murmur since adulthood presenting with progressive dyspnea and hemoptysis found to have an irregularly irregular heart rate with LA enlargement and a murmur in the third left intercostal space with an opening snap followed by a low-pitched murmur most consistent with mitral valve stenosis
  • Key idea: Almost all instances of mitral valve stenosis are secondary to rheumatic heart disease and on the NBME are often triggered by pregnancy (increased plasma volume –> worsening of mitral stenosis)
  • Mitral valve stenosis –> Blood backing up within LA –> LA dilation –> Increased risk of arrhythmias such as atrial fibrillation
  • Aortic valve insufficiency –> Blowing early-diastolic murmur at heart base associated with widened pulse pressure
  • Aortic valve stenosis –> Systolic crescendo-decrescendo murmur at right 2nd intercostal space with radiation to the carotids
  • Mitral valve insufficiency –> Holosystolic murmur at the heart apex
  • Tricuspid valve insufficiency –> Holosystolic murmur at the left sternal border often seen in an IVDU

3. A 45-year-old woman has a 2-week history of increased anxiety, abdominal discomfort, irritability…

Acute stress disorder

  • Patient who experienced an acutely stressful/traumatic experience who presents with <1 month of HARD symptoms (Hyperarousal, Avoidant behavior, Reliving experience, Disturbed mood/thinking)
  • Key idea: If symptoms last for >1 month, then patient has Post Traumatic Stress Disorder (PTSD)
  • Agoraphobia –> Fear of social spaces, often patient will not leave their home
  • Generalized anxiety disorder requires at least 6 months of symptoms
  • Patient has normal TSH so does not have hypothyroidism (despite dry skin/hair)
  • Panic disorder necessitates unprovoked panic attacks with at least 1 month of worry/anxiety about another attack, often leading to avoidant behavior, etc.

4. A 32-year-old woman, gravida 3, para 2, at 41 weeks’ gestation is admitted to the hospital in active labor…

Amniotic fluid embolism

  • Previously healthy patient who during delivery develops respiratory distress + altered mental status + DIC most consistent with amniotic fluid embolism
  • Risk factors for amniotic fluid embolism: Advanced maternal age, Gravida>5, C-section or operative delivery, placenta previa, placental abruption or pre-eclampsia
  • Toxic shock syndrome –> Young woman on her period (using tampons) or patient with nasal packing who develops diffuse erythematous rash, nausea/vomiting, hypotension

5. A healthy 4-year-old girl is brought for a well-child examination. A grade 2/6 systolic ejection murmur is heard along…

Atrial septal defect

  • Key idea: Fixed splitting of S2 = Atrial septal defect
  • Pathophysiology:
    • During expiration preload to the left side of the heart –> Increased blood movement from RA to LA –> Increased time for blood to pass through pulmonic valve –> Delayed P2 –> Splitting
    • During inspiration patient will have decreased movement across the LA, but just like in a patient with a structurally normal heart there is splitting of S2 upon inspiration
  • To remember the order of valve closure, use mnemonic Many Things Are Possible –> (S1) Mitral Tricuspid (S2) Aortic Pulmonic

6. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry…

Presynaptic neuromuscular junction

  • Elderly man with significant smoking history, unintentional weight loss and a hilar mass (= lung cancer) who presents with weakness of ocular and proximal muscles + absent reflexes + autonomic dysfunction (dry eyes/mouth) most consistent with Lambert-Eaton syndrome
  • Lambert-Eaton syndrome is a paraneoplastic syndrome associated with small cell lung cancer which leads to antibodies directed against Voltage-gated calcium channels in the presynaptic axon of the neuromuscular junction which leads to impaired release of acetylcholine into neuromuscular junction –> weakness
  • Key idea: Lambert-Eaton associated with small cell lung cancer, whereas myasthenia gravis associated with thymoma
  • Key idea: Features that point towards Lambert-Eaton over myasthenia gravis include absent reflexes, autonomic dysfunction and weakness that improves with repetitive use

7. A 19-year-old college student comes to the physician because of vaginal irritation and pain with urination…

Candidiasis

  • Young sexually active woman presenting with vaginal irritation/pain found on pelvic exam to have erythema of the vulva/vagina, thick white vaginal discharge and a pH of 4, most consistent with candidal vaginosis
  • Key idea: Recent antibiotic use (such as in this patient) can predispose to candidal vaginosis by disrupting normal vaginal flora
  • 3 main forms of vaginal infection and definitive features include:
    • (1) Bacterial vaginosis: Gray fishy discharge, pH > 4.5, no cervical/vaginal erythema, clue cells, treat with metronidazole or clindamycin
    • (2) Candidal vaginitis: White cottage cheese discharge, pH < 4.5, cervical/vaginal erythema, pseudohyphae and budding yeast, treat with oral or topical -azole drugs
    • (3) Trichomonal vaginitis: Greenish-yellowish discharge, pH > 4.5, cervical/vaginal erythema, motile trichomonads, treat with metronidazole

8. A 10-year-old boy is brought for a follow-up examination 2 days after he was seen in the emergency…

Carrying self-injectable epinephrine

  • Key idea: Anaphylactic shock should be treated with immediate administration of epinephrine often via an Epi-pen carried around by the patient
  • Key idea: Common for hypersensitivity reactions to become more severe over time as the body gets better at responding to the allergic trigger, so in this case we would be worried about hemodynamic and respiratory compromise in the setting of anaphylactic shock

9. A 37-year-old woman comes to the physician because of a 1-day history of throbbing facial pain…

Streptococcus pneumoniae

  • Young woman with fever + throbbing facial pain + purulent nasal discharge + tenderness to palpation over left cheek most consistent with bacterial sinusitis
  • Strep pneumo is the most common bacterial cause of MOPS infections (Meningitis, Otitis media, Pneumonia, Sinusitis)

10. A 62-year old woman with mild heart failure comes to the physician for a follow-up examination…

Measured outcomes were not important to patients

  • Key idea: Measured outcomes focused on changes to LVEF and and LV volumes, which are NOT clearly clinically significant

11. Which of the following conclusions is most strongly supported by the results…

Left ventricular end-systolic volume decreases by a greater amount in patients treated with spironolactone than in patients treated with placebo

  • In the LV end-systolic volume row within the chart, we can see that there was a statistically significant difference between spironolactone and placebo with a p-value less than 0.05
  • No conclusions about clinical effects of spironolactone can be drawn from this study (eliminates A and D)
  • Non-statistically significant difference in change in left ventricular mass, so we WOULD expect confidence interval of difference in change to include 0 (basically that no difference in change between two groups is a reasonable finding)
  • No mention of potassium thresholds in report (eliminates E)

12. A 42-year-old woman comes to the physician because of an 8-week history of intermittent nausea and…

Abdominal ultrasonography of the right upper quadrant

  • Fat, Fertile, Forty year old Female patient presents with intermittent episodes post-prandial RUQ pain radiating to right scapula most often after fatty meals, most consistent with biliary colic
  • Key idea: Biliary colic can be treated with elective laparoscopic cholecystectomy (due to risk of continued colic symptoms or potential risk of cholecystitis vs choledocolithiasis), but this patient should first be evaluated by RUQ ultrasound to confirm gallstones given that patient’s presentation is non-urgent
  • Key idea: Patients with complicated gallstone disease (acute cholecystitis, gallstone pancreatitis, choledocolithiasis) should undergo cholecystectomy within 72 hours of hospitalization
  • Key idea: Patients with choledocolithiasis should undergo ERCP

13. A 72-year-old woman with unresectable small cell carcinoma of the lung is brought to the emergency…

Nonphysiologic ADH (vasopressin) secretion

  • Patient with small cell carcinoma presenting with altered mental status found to have hyponatremia, most likely due to SIADH
  • Causes of SIADH: Small cell lung cancer, CNS trauma, Drugs (cyclophosphamide, etc.), Pulmonary pathologies (PNA, COPD, etc.)
  • Adrenal insufficiency would lead to hypoglycemia with electrolyte disturbances in setting of primary adrenal insufficiency particularly
  • Hyperaldosteronism –> Increased Na reabsorption in exchange for K and H secretion in the collecting duct –> Hypokalemia, Metabolic alkalosis

14. A 47-year-old man is brought to the emergency department 2 hours after the sudden onset of shortness of…

Aortic dissection

  • Middle-aged man with history compatible with myocardial infarction who also has aortic regurgitation murmurs and decreased femoral pulses concerning for an aortic dissection
  • Key idea: Aortic dissection can CAUSE myocardial infarction (if the dissection spreads to involve the coronary arteries)
  • Key idea: Features that favor aortic dissection over an acute coronary syndrome in patient presenting with MI symptoms include:
    • Aortic regurgitation (due to spread of dissection to involve aortic valve)
    • Stroke
    • Tamponade
    • Different blood pressure in both arms or asymmetric differences in pulses
    • Widened mediastinum on Chest X-ray

15. A 21-year-old woman comes to the physician for preconceptional advice. She is recently married and…

Beginning folic acid supplementation prior to conception

  • Key idea: All reproductive-aged women should take a folic acid supplement because it decreases the risk of neural tube defects in fetus (if patient becomes pregnant)

16. A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot…

Left tube thoracostomy

  • Young patient who sustained a gunshot wound that entered within the abdomen but exited in the left axillary line at the 4th rib who has developed hypotension and decreased breath sounds on the left, most concerning for a hemopneumothorax
  • Key idea: Patients with suspected tension pneumothorax should undergo immediate needle decompression whereas patients with a hemopneumothorax should undergo placement of a chest tube
  • Key idea: Intubation is CONTRAINDICATED in a patient with a pneumothorax

17. A 22-year-old man comes to the physician for a routine health maintenance examination. He feels well…

Persistence of a patent processus vaginalis

  • Young male patient presenting with a chronic asymptomatic scrotal mass that transiluminates, most consistent with a hydrocele (due to fluid accumulation within tunica vaginalis due to persistence of processus vaginalis connection between peritoneum and scrotum)
  • Key idea: Both testicular cancer and varicoele (dilation of pampiniform plexus) would NOT transiluminate
  • Cryptorchidism = Testicle that has not descended into scrotum, often found within inguinal canal
  • Testicular torsion –> Severe acute unilateral scrotal/groin pain + nausea/vomiting + loss of cremasteric reflex + abnormal lie of testicle

18. A 25-year-old woman comes to the physician because of a 2-month history of numbness in her right hand…

Ulnar nerve at the elbow

  • Patient with ulnar nerve neuropathy (tingling and numbness in ring and small fingers) that is worsened by palpation of the elbow, most consistent with ulnar nerve entrapment within the cubital tunnel at the elbow
  • Key idea: Ulnar nerve is most commonly entrapped at the elbow, which is commonly asked on NBME exams
  • We would also expect this patient to have weak flexion of the 4th and 5th digits

19. A 62-year-old woman comes to the physician for a routine health maintenance examination. On questioning…

Hypothyroidism

  • Patient with signs of hypothyroidism (fatigue, constipation, weight gain) who has elevated total cholesterol, LDL and triglycerides most consistent with hypothyroidism-related lipid abnormalities
  • Key idea: Hypothyroidism leads to elevated total cholesterol, LDL and triglyceride levels primarily by decreasing LDL receptor expression but also by reducing lipoprotein lipase expression
  • Key idea: Estrogen actually leads to increased HDL and decreased LDL, which is part of the reason that women have lower risk of CAD (especially pre-menopausal women)

20. Three days after hospitalization for diabetic ketoacidosis, an 87-year-old woman refuses insulin injections…

Offer insulin but allow the patient to refuse it

  • Elderly patient who appears to have decision-making capacity (communicates a choice, understands information provided, appreciates consequences, provides rationale for decision) who is asserting her rights to refuse treatment and whose wishes should be adhered to
  • Key idea: Patient does not have signs of depression necessitating psych evaluation
  • Key idea: Patient does not clearly want to leave the hospital, so she does not have to be discharged from the hospital just because she refuses one intervention

21. A 27-year-old man is brought to the emergency department by his sister because of increasing confusion…

Neuroleptic malignant syndrome

  • Young patient who recently began treatment with antipsychotic who presents with components of neuroleptic malignant syndrome which can be remembered with mnemonic Malignant FEVER –> Myoglobinuria, Fever, Encephalopathy, Vitals unstable, increased CK Enzymes, Rigidity
  • Delirium tremens –> Encephalopathy, sympathetic hyperactiviation, NO RIGIDITY or increased CK

22. A 52-year-old woman comes to the emergency department because of a 1-week history of low-grade fever…

CT scan of the abdomen with contrast

  • Middle-aged woman with presentation concerning for diverticulitis (subacute LLQ abdominal pain with low grade fever) who should be worked up with CT scan of the abdomen with contrast
  • Test of the stool for Clostridium difficile toxin –> Patient who has received antibiotics AND THEN developed profuse diarrhea (note: metronidazole is one of the main treatments of C. difficile)
  • ERCP –> Often used to evaluate biliary pathology, such as suspected choledocolithiasis
  • Colonoscopy –> Older patient presenting with microcytic anemia or blood in the stool

23. A 62-year-old white man comes to the physician because of an 8-month history of progressive pain and…

Phlebotomy

  • Elderly patient with signs of osteoarthritis (pain and stiffness of DIP joints worse at end of the day) but also has new-onset diabetes without being heavy (increased urination, increased serum glucose, BMI<25), dark brown skin, S3 heart sound, and mildly elevated LFTS most consistent with hemochromatosis which is treated with phlebotomy
  • Key idea: Classically leads to bronze diabetes but can also lead to hypogonadism, arthritis, dilated cardiomyopathy, liver abnormalities, etc.
  • Key idea: Hemochromatosis is a risk factor for development of hepatocellular carcinoma

24. A 62-year-old man comes to the physician because of a 2-month history of progressive fatigue and ankle…

Impaired contractility of the left ventricle

  • Middle-aged man with clear ASCVD risk factors (smoking, hypertension) who had an MI and presents with lower extremity edema, shortness of breath, JVD, lung crackles and an S3, which are all classic for heart failure
  • Key idea: Ischemia is the main risk factor for development of congestive heart failure, with other potential risk factors being alcohol, cocaine/meth, hemochromatosis, Chagas disease, high-output heart failure (anemia, hyperthyroidism, AV fistula), etc.
  • Key idea: Edema should make you think of disorders with the heart, kidneys or liver
  • Impaired forward flow –> backup of blood within left heart –> increased pulmonary capillary wedge pressure (marker of LA pressure)

25. A previously healthy 17-year-old girl comes to the physician because of a 2-month history of exercise…

Asthma

  • Young girl with family history of asthma presenting with episodic exercise-induced cough most consistent with cough-variant asthma
  • Key idea: Common triggers of asthma attacks include allergens, exercise, cold air, GERD, etc.
  • Key idea: Common causes of a chronic cough to consider include asthma, GERD, post-nasal drip and ACE inhibitors
  • GERD –> Post-prandial cough with burning sensation in chest often seen in older patients who are overweight
  • Post-nasal drip –> Patient with allergic rhinitis who has cough and sore-throat while sleeping found to have cobblestone appearance in posterior pharynx

26. A 42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to…

Endometrial biopsy

  • 42 year old woman with a family history of colon cancer and breast cancer (which should increase concern for Lynch syndrome or Peutz-Jegher syndrome) previously regular menses who presents with a 1-year history of metrorrhagia concerning for endometrial cancer given the patient’s family history
  • Key idea: Work-up could include transvaginal ultrasound looking for endometrial thickness >4 mm or you could proceed directly to endometrial biopsy
  • Colposcopy –> Follow-up abnormal pap smear
  • Cystoscopy –> Concern for bladder cancer or GU trauma
  • Progesterone challenge test –> Patient with secondary amenorrhea to determine whether it is due to anovulation (bleeding after progesterone challenge)

27. A 42-year-old woman is brought to the emergency department 10 minutes after being involved in a high-speed…

Laparotomy

  • Patient involved in a high-speed car accident who presents with hypotension found to have decreased breath sounds at left lung base with opacification of left lower lung field and loss of diaphragmatic shadow with drainage of greenish fluid upon placement of chest tube, most concerning for Diaphragmatic hernia
  • Key idea: Diaphragmatic hernia will ALWAYS BE ON THE LEFT SIDE because the liver protects the right diaphragm
  • Key idea: Although classically associated with esophageal rupture, drainage of green fluid upon placement of chest tube can also be seen in setting of diaphragmatic hernia (http://www.clinicsinsurgery.com/full-text/cis-v2-id1480.php)
  • Key idea: Empyema can also drain green fluid, but it is often associated with pneumonia and would not develop quite as quickly (>1 day)
https://www.journalacs.org/article/S1072-7515(04)00009-2/fulltext

28. A 15-year-old boy is brought to the physician because of fatigue since starting his freshman year of high…

Exercise program

  • Young obese boy with polyuria found to have acanthosis nigricans (sign of insulin resistance) found to have fasting serum glucose >125 and glucosuria, most consistent with type 2 diabetes
  • Key idea: Highlights a key principle around managing chronic conditions on the NBME, which is to always start with lifestyle interventions before moving to pharmacotherapy
  • Key idea: If a young patient develops diabetes, do NOT assume they have type 1 diabetes because a lot of children (especially now with high rates of obesity) are at risk for developing type 2 diabetes

29. A previously healthy 32-year-old man is brought to the emergency department after being found unconscious…

Arrange for the regional organ procurement organization to address the issue with the patient’s family

  • Key idea: Organ donation is primarily managed by organ procurement organizations rather than the hospitals themselves

30. A previously healthy 19-year-old college student comes to student health services 24 hours after the onset…

Ceftriaxone

  • Young college student presents with signs of meningitis (headache, stiff neck, sensitivity to light, etc.) most likely to have a bacterial meningitis based on CSF findings who more specifically has meningococcal meningitis based on gram-negative cocci on CSF gram stain and diffuse petechiae on exam
  • Key idea: Meningitis often empirically treated with ceftriaxone + Vancomycin, with N. meningitis being specifically targetted by ceftriaxone
  • CSF findings of bacterial meningitis: WBC > 1000, glucose<40, protein>250 and neutrophilic predominance
  • CSF findings of fungal meningitis: Elevated WBC count , low glucose, high protein, monocytic predominance
  • CSF findings of viral meningitis: WBC 10-500, Normal glucose (2/3 serum glucose), protein elevated but <150, and monocytic predominance

31. A 37-year-old woman is brought to the emergency department 45 minutes after she was found unconscious…

Acute tubular necrosis

  • Young woman who was found down secondary to opiates/cocaine who presents with signs of pressure ulcer + signs of rhabdomyolysis (elevated CK activity with urinalysis showing positive blood with no/rare RBCs and pigmented granular casts), which can predispose to acute tubular necrosis
  • Key idea: Important to know that rhabdomyolysis will lead to positive blood but absent RBCs on urine microscopy (VERY HIGH YIELD!!!)
  • Potential causes of ATN: Ischemia, aminoglycosides, radiocontrast, heavy metals, cisplatin/carboplatin, ethylene glycol (along with kidney stones), crush injury/rhabdomyolysis, and tumor lysis syndrome
  • Causes of drug-induced rhabdomyolysis: Statins, fibrates, colchicine, cocaine, drugs that lead to impaired mental status due to prolonged immobilization such as alcohol, opioids and benzodiazepines

32. A 22-year-old woman comes to the physician in October for a follow-up examination. She feels well…

Influenza virus vaccine

  • Key idea: All patients should receive an annual flu shot
  • Begin running for exercise or dietary modification incorrect because patient is normal weight with well-controlled HbA1c (<7%)
  • HPV co-testing is not performed until patient >30 because many young women have transient HPV infection that will be acutely cleared and clinically insignificant (worried about chronic HPV infection)
  • Mammography does not begin until around age 50 depending upon which task force/organization you adhere to

33. A 5-year-old boy is brought to the physician by his mother because of a 2-day history of a low-grade fever…

The findings are clinically insignificant but statistically significant

  • P value < 0.05 –> Statistically significant
  • Decrease in symptoms from 6.7 days –> 6.4 days likely clinically insignificant

34. During the past month, a 37-year-old woman has had epigastric pain 2 to 3 hours after eating and at night…

Na 130 // K 2.8 // Cl 88 // HCO3 32

  • Basically this question is asking “What would you expect the electrolytes to be in a patient with repetitive vomiting”
  • Vomiting –> Loss of HCl –> Low chloride and metabolic alkalosis
  • Vomiting –> Volume loss –> Increased RAAS activation –> Increased ADH and aldosterone production –> Hyponatremia (due to increased ADH) and hypokalemia (due to aldosterone –> increased Na reabsorption in exchange for K and H secretion and loss through urine)

35. A 27-year-old woman, gravida 2, para 1, at 12 weeks’ gestation comes to the physician for a prenatal visit…

Oral amoxicillin therapy

36. A 25-year-old man is brought to the emergency department after being discovered semiconscious and…

Heroin

  • Opiate intoxication –> Pinpoint pupils, altered mental status, respiratory depression
    • Key idea: Decreased respiratory rate is the most specific marker of opioid intoxication
  • Alcohol and barbiturates –> Ataxia, slurred speech, decreased inhibition
  • Cocaine –> Hypertension, tachycardia, mydriasis, chest pain, psychosis
  • LSD –> Hallucinations, mydriasis

37. A 32-year-old woman comes to the physician because of fatigue for 6 months. She has had progressively severe…

Iron deficiency

  • Young woman with history of Crohn disease complicated by an extensive abdominal operation who presents with fatigue and shortness of breath in the setting of a severe microcytic anemia and thrombocytosis most consistent with iron deficiency anemia
  • Key idea: Iron is typically absorbed in the duodenum, so this patient may have had surgery involving the duodenum –> Impaired iron absorption –> IDA
  • Key idea: Patient does NOT seem to have active Crohn’s disease, decreasing risk of anemia of chronic disease
  • Key idea: Thrombocytosis can be seen in both iron deficiency anemia and anemia of chronic disease
  • Key idea: Progressive dyspnea in a young woman should make you think of anemia often secondary to menstrual blood loss
  • Microcytic anemias (MCV < 80): Iron deficiency anemia, anemia of chronic disease, thalassemia, sideroblastic anemia (lead poisoning)

38. A 32-year-old man comes to the physician because he has had difficulty focusing on tasks at work and at home during…

Bipolar disorder

  • Patient with decreased need for sleep, increased energy, distractibility, talkativeness, and increased goal-oriented activity associated with mania/hypomania –> Bipolar disorder
  • Signs of mania/hypomania can be remembered by DIG FAST mnemonic –> Distractibility, Impulsivity, Grandiosity, Flight of ideas, Agitation/Activity, reduced Sleep and Talkativeness
  • Key idea: 3 key differences between a manic and hypomanic episode is that mania:
    • (1) Causes significant functional impairment or leads to hospitalization
    • (2) Episode lasting >7 days
    • (3) Presence of psychotic features
  • Antisocial personality disorder –> Chronic history of committing crimes, not adhering to laws or social rules, etc.
  • ADHD –> Inattentiveness or hyperactivity features in multiple settings in child under 12 years old
  • Borderline personality disorder –> Feelings of emptiness, unstable relationships, self-harming behaviors, etc.
  • Major depressive disorder –> Depressed mood and SIGECAPS

39. A 60-year-old man has had painful skin with exfoliation of the skin and mucous membranes for 1 day. He has been…

Toxic epidermal necrolysis

  • Middle-aged man who recently started new medications and presents with diffuse exfoliation of skin with mucous membrane involvement, concerning for Stevens Johnson Syndrome (<10% BSA area) vs Toxic epidermal necrolysis (>30% BSA)
  • Key idea: Antibiotics, anticonvulsants and allopurinol are commonly associated with drug reactions such as SJS/TEN, DRESS, erythema multiforme, etc.
  • Bullous pemphigoid –> Tense bullae in an elderly patient
  • Erythema multiforme –> Similar presentation to SJS/TEN but virtually ruled out in this patient due to lack of target lesions
  • Staph scalded-skin syndrome –> Infant with fever, irritability and sloughing skin rash
  • Pempigus erythematosus –> Malar rash + features of pempigus vulgaris (ruptured bullae)
  • https://www.youtube.com/watch?v=1ox28Jccl00&t=2385s

40. A 27-year-old woman comes to the physician because of a 3-year history of chronic diarrhea and intermittent, crampy…

Nortriptyline

  • Young otherwise healthy woman with diarrhea and crampy abdominal pain that is relieved with defecation and not associated with red flag signs most consistent with irritable bowel syndrome
  • IBS often treated with TCAs (such as Nortriptyline) or opiate-derived medications (such as Loperamide)
  • Irritable bowel syndrome is a diagnosis of exclusion and includes recurrent abdominal pain associated with:
    • Related to defecation
    • Changes in stool frequency
    • Changes in form/consistency of stool
  • Features that suggest IBS is NOT the cause of a patient’s symptoms include:
    • Rectal bleeding
    • Nocturnal abdominal pain
    • Weight loss
    • Abnormal lab findings (anemia, electrolyte disorders, etc.)
    • Family history of early colon cancer
    • Older age

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