NBME Medicine Form 4 - Answers & Explanations

Updated: Aug 28, 2020

1) X-ray of the chest • Clubbing of fingers & toes = hypertrophic osteoarthropathy

2) Hypercarbia • O2 supplementation → ↓ respiratory drive → retained CO2 (hypercarbia)

3) Mycoplasma pneumoniae • young, non-productive cough, low grade fever with patchy or diffuse interstitial infiltrate = atypical mycoplasma pneumonia

• CXR looks worse than the patient feels

4) Legionella pneumophila • Pneumonia + diarrhea = legionnaires disease • Pulse temperature dissociation (fever with relative bradycardia)

5) Renal artery stenosis • Carotid bruit = atherosclerosis of carotid artery; atherosclerosis in one vessel indicates multi vessel disease → RAS secondary to atherosclerosis

6) Erythropoietin • Corrected reticulocyte count is ~1.2%, meaning there is not enough marrow stimulation • Chronic kidney disease → ↓ EPO production

7) Pamidronate • Short term treatment of hypercalcemia is normal saline and calcitonin

• Long term treatment of hypercalcemia is bisphosphonates

8) Drug induced neutropenia • PTU and methimazole → neutropenia

9) Villous atrophy in the small bowel • D-xylose depends only on viable mucosa (not enzymatic breakdown) for absorption in the proximal small bowel • Celias disease → villous blunting → ↓ D-xylose absorption

10) Three-drug antiretroviral therapy only

• Start antiretrovirals straight away regardless of CD4 count

• Need to use three because of increased resistance

• No need for P. jiroveci prophylaxis because CD4 count >200

11) Direct current countershock • Direct current countershock = DC cardioversion • Wide QRS complex = ventricular tachycardia → shock

12) Choledocholithiasis

• This patients high amylase indicates there is a blockage at the pancreatic duct, and the elevated direct bilirubin indicates a blockage of the common bile duct

13) Left medial longitudinal fasciculus • The right PPRF send a signal to the left medial rectus via the left MLF; weakness of left adduction upon right gaze indicates a problem at the left MLF

14) Calcification of a bicuspid aortic valve • Systolic ejection murmur at the young age of 19 indicates a congenital cause

• Aortic stenosis (due to calcified bicuspid aortic valve) → ↑ LV pressure → hypertrophy and stiffening of the LV → S4

15) Supraspinatus tendon • Pain over lateral deltoid, awaking at night (lying on affected shoulder) and pain elicited from abduction against resistance = rotator cuff pathology

16) Acute tubular necrosis

• 3+ blood with no RBC’s → rhabdo → myoglobinuria → ATN

17) Seborrheic dermatitis • Usually appears on hairy areas (eg, scalp behind ears, beard, etc.)

• Greasy looking yellowish scaly rash • Associated with HIV & Parkinson disease

18) Switch from heparin to direct thrombin inhibitor therapy • Heparin-induced thrombocytopenia → stop all heparin products and start a direct thrombin inhibitor or fondaparinux

19) Gout

• Chronic alcohol use with asymmetric arthritis

20) MRI of the lumbosacral spine

• Compression of sacral nerves by tumor → Cauda Equine syndrome (B/L paralysis and numbness of LE, urinary incontinence (overflow), saddle anesthesia, absent DTRs below the knee)

• MRI is the modality of choice to diagnose nerve root compression

21) α1-antitrypsin deficiency

• Increased lucency at lung bases in young patient → panacinar emphysema

22) Hodgkin disease

• Single enlarged LN, pruritis, and absence on pharyngeal erythema make Hodgkin disease more likely than mono

• Pathologic lymphocytes are confined to affected nodes (unless a leukemic transformation occurs) which is why leukocyte count is not elevated

23) Addition of lisinopril to the medication regimen • ACEi → ↓ glomerular hyper-filtration associated with DM

24) Lisinopril therapy

• Hemorrhagic stroke are commonly caused by HTN

• Although weight reduction of 10kg lowers BP by 5-20 mmHg, this patient has already suffered a complication of HTN and must be treated aggressively with BP medication (while he continues to make lifestyle changes)

25) Nonketotic hyperosmolar state

• Glucose > 600 = HHS

26) Autoinfection • Reinfected himself from scratching his foot and then touching his groin area

• Resistance is unlikely since the rash went away with the first treatment

27) Autonomous T4 production

• Toxic adenoma

28) Discharge home with home hospice care • Without treatment, the life expectancy for stage IV non-small cell lung carcinoma is < 6 months

29) Upper endoscopy

• Alarm symptoms (dysphagia, weight loss, or anemia) → EGD

30) Rhabdomyolysis

• 2+ blood with no RBCs = myoglobinuria from rhabdo

31) Prosthetic aortic valve • Adenocarcinoma (hypercoagulable state) and prosthetic valves both require anticoagulation, but prosthetic valves require a higher INR - prosthetic valves have a higher chance of throwing a clot

32) Fine-needle aspiration of the lesion

• Cancer risk factors → FNA

• Normal or elevated TSH → FNA

• Low TSH → Iodine 123 scintigraphy (cold nodules → FNA, hot nodule → treat hyperthyroidism)

33) Weight loss • Weight loss → ↓ pressure on joints → ↓ risk of OA

34) Prerenal azotemia • Na < 10, FENa < 1, BUN/CR ration >20

35) Obstruction of the small bowel • ↑ bowel movement = SBO, ↓ bowel movement = ileus • Multiple bowel procedures → ↑ risk of adhesions (#1 cause of SBO)

36) Paroxysmal ventricular tachycardia • Suspect cardiac etiology in someone with hx heart disease and abnormal EKG (Q waves are from previous MI)

37) Influenza virus

• Should be given annually

38) Increasing the dose of lisinopril • Lisinopril is kidney protective and lowers BP - her BP remains above the goal of <140/<90

39) Atrial septal defect

• Fixed split S2

40) Decreased vascular compliance

• ↑ age → stiffening of vessels → ↓ compliance

41) Debridement of the ulcer

• Area of necrosis (eschar) needs to be removed

42) Chlamydia trachomatis • Need giemsa stain to visualize chlamydia (gram stain does not work)

• Would show intracellular organisms if it were Neisseria gonorrhoeae

43) Oral contraceptive therapy • OCPs prevent endometrial hyperplasia due to unopposed estrogen in PCOS

• Clomiphene or metformin can be used to induce ovulation

44) Group B at year 3-4

Steepest negative slope = biggest decline in survival

• The survival rate in any year for any group is the slope of the survival curve during that time period for that group. Group B at year 3-4 has the most negative slope which translates to biggest decline in survival, or poorest survival rate.

45) Labetalol • Decreases HR, BP and LV contractility (less aortic wall stress) • Nitro/hydralazine lower BP via vessel wall dilation, which can cause further stress and exacerbate the tear on the aorta

46) Laryngoscopy and endotracheal intubation

• This patient has epiglottitis - the airway must be secured

47) Quantitative immunoglobulin assay

• CLL → hypogammaglobulinemia

48) Chest x-ray

• Pulmonary barotrauma can occur if the diver fails to expel air from lungs during ascent; as he swims up to the surface the volume of gas expands → pneumothorax

49) Endoscopic retrograde cholangiopancreatography (ERCP)

• Symptomatic pseudocysts are drained with ERCP

50) Diverticulitis • Chronic constipation, LLQ pain, tenderness, bloody stools, fever

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