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NBME Medicine Form 2 - Answers & Explanations

Updated: Nov 16, 2019

1) Enalapril • ACEi are protective against diabetic glomerulonephropathy

2) Idiopathic central diabetes insipidus • 50-100% increase in UOsm w/ DDAVP = Central DI • UOsm > 600 after deprivation = functional ADH (suggests primary polydipsia)

3) Amikacin • Aminoglycosides are nephrotoxic

4) Ambulatory ECG monitoring • Unexplained syncope without prodrome suggests arrhythmia as the cause

5) Bronchitis • Ronchi (low pitch = upper airway) are bronchiole airway sounds

• CAP would have CXR findings of consolidation/infiltrate

• Rales (crackles) + fever → pneumonia

6) Bicuspid aortic valve

• Systolic murmur peaking in late systole = crescendo-decrescendo murmur = Aortic Stenosis (causing slow-rising, sustained carotid pulse)

• Coarctation → brachial/femoral delay

• Rheumatic valve disease = MR w/ holosystolic murmur at apex

• VSD → holosystolic murmur w/ thrill at LSB

7) Measurement of serum creatinine concentration

• This patient already has signs of end-organ damage (HTN retinopathy) → screen other organs as well

• Serum creatinine indicates renal functioning

8) Decreased synaptic activity of cholinesterase

• Organophosphate toxicity

9) Administration of hepatitis B vaccine • IgM anti-HBc may be the sole maker of infection during the window period

10) Chronic myelogenous leukemia (CML) • Basophilia and Metamyelocytes < myelocytes = CML • No basophilia and Metamyelocytes > myelocytes = leukemoid reaction

11) PPD skin test • Patients with HIV should be screened for TB (regardless of CD4 count)

• If screening is positive → CXR to determine if latent or active

12) Duplex ultrasonography of the carotid arteries • U/S is cheaper than arteriography • Arteriography can cause embolization and risk another stroke

• CT with no abnormalities → no need for MRI

13) Decreased sensitivity, Increased specificity • Raising the cutoff point increases false negatives (decreases sensitivity) and decreases false positives (increases specificity)

14) Oxybutynin • Muscarinic antagonist that reduces bladder spasms and urge urinary incontinence (overactive bladder)

15) Abnormality of antiprotenase resulting in destruction of alveolar supporting structures

• Panacinar emphysema (alpha1-antitrypsin deficiency) → lower lobe destruction

• Centracinar emphysema (smoking induced) → upper lobe destruction

16) Increased vascular permeability

• ↑ CO with normal PCWP and LVEDV = distributive shock (most likely septicemia based on vitals and WBC)

• Inflammatory response → vasodilation → vascular content seeps into extravascular space → inability of oxygen to pass through → ↓ PO2

17) Empyema • Light’s criteria - fluid is exudative if ≥ 1 of the following is met:

• Pleural effusion protein/serum protein ratio > 0.5 • Pleural effusion LDH/serum LDH ratio > 0.6 • Pleural effusion LDH > 2/3 the upper limit of normal for serum LDH

• Empyema has pH < 7.2 (uncomplicated parapneumonic effusion has pH > 7.2)

• Not uncomplicated because gram-positive diplococci

18) Felty Syndrome • Rheumatoid arthritis + neutropenia + splenomegaly

19) Renal Failure • ESRD → uremic pruritis → scratching & excoriations • Kidney normally clears leptin; ESRD → ↑ leptin → anorexia

20) Prednisone therapy • Anti-smith antibodies = SLE

21) Adenocarcinoma of the lung • Most common primary lung cancer; more common in women and nonsmokers

• Peripherally located

22) Karyotype analysis • Klinefelter syndrome (XXY) → testicular atrophy, gynecomastia, tall, female hair distribution, developmental delay

23) Variant angina pectoris

• Aka prinzmetal or vasospastic angina → recurrent episodes of angina at rest

24) Abdominal paracentesis • Suspected spontaneous bacterial peritonitis in patients with cirrhosis that develop fever and change in mental status

• Suspected SBP → perform paracentesis → initiate empiric therapy with 3rd generation cephalosporin

25) Zinc

• Deficiency → ↓ alopecia, pustular skin rash, hypogonadism, impaired wound healing, impaired taste, immune dysfunction

26) Packed red blood cells • Hematocrit of 18% ≈ Hemoglobin of 6

• Hemoglobin < 7 → pRBC

27) Intravenous administration of 0.9% saline • Hypercalcemia → confusion; tx with fluids and calcitonin (short term) and bisphosphonates (long term)

• Indication for dialysis - AEIOU

• Acidosis, Electrolyte derangements (hyperkalemia), Intoxication (eg, ethylene glycol), Overload (of volume), Uremia

28) Varicella-zoster virus • Closely groups cluster = dermatomal distribution

29) Decreased myocardial contractility

• Immediately after an MI, the myocardium is stunned and won’t contract

• Stunned myocardium wont push out blood → atria pushing blood into an already filled ventricle → S3

30) Oral administration of an H2-receptor blocking agent

• Upright positioning alleviating symptoms → GERD

• Murmur is benign

31) Reassurance only

• Mid systolic click = MVP

• There is an association between MVP and anxiety (possibly → tachypnea), so all patients should be reassured about the benign nature of the condition

32) Pancreatitis • Presents with fever, tachycardia, hypotension, abdominal tenderness

• Alcoholism → ↑ risk • Saponification → hypocalcemia

• Complications include GI bleeding

33) Intravenous 0.9% saline • Short-term tx of hypercalcemia = normal saline hydration + calcitonin

• Restoring intravascular volume promotes urinary calcium excretion

• Long-term tx of hypercalcemia = bisphosphonates

34) Ipratropium therapy

• This anti-cholinergic is first line treatment in COPD exacerbation

35) MI within the past 6 months • This is a contraindication for surgery

36) Intravenous furosemide • JVD, bilateral crackles → pulmonary congestion/edema • Diuretics should be given to stop this patient from drowning in their own fluid

37) Avoidance of contact with weeds

• Linear vesicles 1 day after = allergic contact dermatitis (type IV HSR)

• Sporotrichosis takes days-weeks for a papule to form before spreading along lymphatic channel

38) Measurement of serum thyroid-stimulating hormone (TSH) concentration

• Heavy menstrual bleeding, weight gain, ↑ cholesterol, and myopathy are consistent with hypothyroidism

39) Decreased mean red cell volume • Heavy bleeding → ↓ Fe → Iron deficient anemia → ↓ MCV

40) Assess the patients decision making capacity • If a patient is having delusions, it would be practitioner malfeasance to let them leave AMA

41) Glucose concentration approximately equal to serum glucose concentration

• Cardiac insufficiency → transudate • Low glucose = exudative

42) 50% for each child, since PKD is autosomal dominant • This patient has a spontaneous, de novo, mutation (parents do no have it)

• The AR form is lethal very early on in life - this patient has the AD form

43) Surgical drainage • Pilonidal abscess should be drained surgically

• Wide excision if recurrent

44) Systemic sclerosis (scleroderma)

• Raynaud's + GI dysmotility and reflux are consistent with scleroderma

45) Aspiration of the knee joint

• Fall → hemarthrosis

• Blood is inflammatory to synovium → mild elevation in ESR (would be higher in a septic knee)

46) Osteonecrosis • Steroids → ↑ risk of avascular necrosis

• Crescent sign on right femoral head

47) Monospot • Teenager with sore throat, exudative pharyngitis and splenomegaly

48) Deficient mineralization of osteoid

• CKD → ↓ vitamin D → osteomalacia

• The acidosis in renal failure impairs the alkaline environment needed for bone mineralization

49) Fluid restriction • D5W + half NS → iatrogenic hypervolemic hyponatremia

• If asx, tx with fluid restriction (+/- salt tablets) • If altered mental status, 3% saline to slowly bring levels up

50) Clindamycin • Alcoholism → ↑ aspiration of oral anaerobes (which are higher in number in patients with poor dentition) → foul-smelling pneumonia with air-fluid levels

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So the new guid line indicate:

1- Good blood pressure control <130/80 with ACEI or ARBs.

2- Statin to be started in pts with CKD,

a- over the age of 65. Or,

b-18-49 of age with hx ''CAD, DM, or prior stork.

I did pick Statin as well. But I think the question rooting toward DM complication on the kidney which is ACEI, In Meantime, Statin is cardiovascular protective.

I think is badly written question,


Caleb Cantrell
Caleb Cantrell
Jul 14, 2020

According to Uworld statin therapy indicated in pt > 40 y/o w/ DM no matter the lipid levels. ACE-I are used in DM with Ualbumin/creatinine ratio > 30

recommendations may have been different when the test was made

Answer to 1 would be statin


Nerdy kakarot
Nerdy kakarot
May 28, 2020

@ MOHAMED FADEEL in diabetic pt, target LDL is less than 100. This pt has 95 LDL. Also, ACEi are given in DM pt even in the absence of HTN


Mameisia Kabia
Mameisia Kabia
Apr 01, 2020

Should 37 be "avoidance of contact with rose thorns" rather than weeds if the reaction is caused by sporotrichosis?


Mohamed Fadeel
Mohamed Fadeel
Feb 16, 2020

In q 1 the patient is diabetic more than 45 yo so statins are indicated whatever the LDL level right?

besides he is not hypertensive and no evidince of proteinuria so why to give ACEi?

also thanks for all the effort!

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