NBME Medicine Form 6 - Answers & Explanations

Updated: Mar 22

Author: Sagie Haziza & Gennadiy Guralnik

Editor: Jordan Abrams

1) Abnormal red blood cell membrane

• Hereditary spherocytosis: jaundice, anemia, high-normal MHCH, loss of central pallor

• ⊖ Direct Coombs rules out AIHA

• Cholecystectomy → chronic hemolysis → indirect bilirubin gallstones


2) Positive findings for anti-centromere antibody

• CREST syndrome: calcinosis cutis, Raynaud phenomenon, esophageal dysmotility,

sclerodactyly, telangiectasia


3) Syringomyelia

• Cystic cavity in spinal cord → block of anterior white commissure (spinothalamic tract) →

bilateral, cape-like loss of pain and temperature

• Fine touch sensation preserved

• Associated with Chiari 1 malformation


4) Ruptured papillary muscle

• Acute, usually within 3-5 days post MI

• Typically with RCA infarction (posteromedial papillary muscle)

• Clinical findings: Severe pulmonary edema, new holosystolic murmur


5) No further testing is indicated

• Normal BP (140/90)

• Hematocrit normal (42%)

• No RBC in urinalysis

• HR ↑ because of pain/SNS


6) Ambulatory ECG monitoring

• Indications: syncope, near syncope or dizziness occurring on a near daily basis

○ Palpitations

○ Afib for assessment of rate or rhythm control

○ Ectopic or premature atrial beats


7) Severity of hypoxemia

• COPD → ↑ shunting → ↑ hypoxic vasoconstriction → pulmonary hypertension (loud S2/P2,

prominent pulmonary arteries, JVD)


8) No further tests are indicated

• Preoperative cardiac assessment includes: ECG, echo and stress test

• Stress test is only indicated when the patient has poor functional capacity: breathless or

chest pain with activity


9) Jarisch-Herxheimer reaction

• Treatment for syphilis (or other spirochetes [eg, lyme disease, leptospirosis]) → toxin release from killed bacteria

• Clinical findings: acute onset fever, chills, myalgia


10) Metformin

• Diabetic patients with comorbid pneumonia have ↑ risk of lactic acidosis if taking

metformin

• Metformin is also contraindicated in patients with liver failure, renal failure or sepsis


11) Surgical excision of apocrine tissue

• Occlusion of follicular pilosebaceous unit → Hidradenitis suppurativa

• Commonly affects intertriginous skin areas (eg, axilla, groin)

• Treatment is early radical excision of affected area


12) Hydration

• Preventative measures for contrast induced kidney injury: peri-procedural saline

hydration, use lowest volume of contrast agent, hold NSAIDs


13) Acyclovir

• Acute (<1 week) fever, altered mental status, or focal neurological symptoms are consistent

with HSV meningitis

• Treatment: Acyclovir


14) Airway compromise

• Tonsillitis with massive edema may occlude airway


15) Intravenous administration of 0.9% saline

• Treatment for suspected variceal hemorrhage: place 2 large bore IV (volume resuscitation),

IV octreotide, Abx → Endoscopic therapy


16) 80%

• 80 positive infections on new stool test

• 100 positive infections on gold standard biopsy

• Sensitivity = 80/100


17) Washing the area of involvement

• After a needle stick injury, a patient with immunization to Hep B does not need vaccine/booster, but should sterilize the area


18) Inflammation caused by release of cytokine by effector and memory T lymphocytes

• Type 4 delayed hypersensitivity


19) Corticosteroids therapy

• ↓ platelets <30,000 or symptoms of ITP → treat with corticosteroids, IVIG or splenectomy if refractory

• Megakaryocytes seen on bone marrow aspiration


20) Chlamydia trachomatis

• Tender boggy prostate, WBCs on urinalysis, ⊖ culture in young patient

• Intracellular indicates chlamydia (vs. gonorrhea)



21) Ulnar nerve compression

• Ulnar nerve (C8-T1) insult → hypothenar atrophy + interosseous muscle

dysfunction (ab/adduction of fingers [paper slipping from fingers])


22) Swallowing study

• Oropharyngeal dysphagia clinical presentation: Chronic cough after meals, mild dysarthria,

history of multi infarct dementia

• Dx: video fluoroscopic barium swallow


23) Iron

• Anemia with hypochromasia (central pallor) is consistent with iron deficiency anemia

• Not sideroblastic (no basophilic stippling seen)

• Not megaloblastic (no hyper-segmented neutrophils)


24) Serum protein electrophoresis

• Multiple myeloma: hypercalcemia, renal failure, anemia, bone lytic lesions


25) Subcutaneous administration of enoxaparin

• Evidence of DVT on ultrasound→ enoxaparin is the next best step

• Warfarin takes several days to work and is not the best treatment


26) Lisinopril

• ACEi → ↓ mortality in HFrEF (heart failure with reduced ejection fraction)

• Metoprolol and spironolactone would not work well in an acute setting because they could

↓ cardiac output (CO)


27) Administration of calcium gluconate IV

• Parathyroid gland removal post surgery → tetany, cramps, seizures

• Treatment of hypocalcemia: calcium gluconate/chloride


28) Rhabdomyolysis

• Barbiturates → immobility → ↑ CK, ↑ phosphate → AKI → blood detected on urine

dipstick, but absent on microscopy = rhabdomyolysis


29) Anaerobic empyema

• Right lower lobe infiltrate + foul smelling fluid indicates aspiration (likely anaerobes)


30) Begin lisinopril therapy

• ACEi use in a patient with diabetes & hypertension → ↓ mortality

• ACEi → ↓ diabetic nephropathy progression


31) Alveolar destruction and fibrosis

• FEV1/FVC ratio < 0.7 = Obstructive disease

• Emphysema → alveolar destruction (↓ DLCO) → ↓ breath sounds


32) Full thickness biopsy

• Possible malignancy: size > 6mm, asymmetry, multiple color

• Biopsy and excision if diagnosis confirmed


33) Serum calcium concentration

• Ranson Criteria for pancreatitis

○ WBC > 16K

○ Age > 55

○ Glucose >200 mg/dL

○ AST > 250

○ LDH > 350


34) Oral ibuprofen

• Diffuse ST elevation/PR depression, pleuritic chest pain relieved while sitting up, friction

rub are consistent with pericarditis

• Treatment = ibuprofen (1st line), colchicine and glucocorticoids (2nd line)


35) Allergic bronchopulmonary aspergillosis

• Hypersensitivity response to Aspergillus growing in lung mucus

• Associated with asthma


36) Urine free cortisol concentration in a 24 hour specimen

• Weight gain, hirsutism, truncal obesity, striae, irregular menses, acne are consistent with

Cushing Syndrome


37) Prepatellar septic bursitis

• Unaffected Range of motion = extra-articular

• Red, swollen area overlying patella + fever = bursitis complicated with infection


38) Insufficient inhibition of neutrophil elastase

• Obstructive lung X-ray, spirometry in young patient, andfather’s early diagnosis of

emphysema is consistent with a1 antitrypsin deficiency


39) ↓ K+, ↓ Cl-, ↑ pH

• Vomit → GI loss of HCL, production of HCO3- → RAAS activation from hypovolemia → Loss of K+, reabsorption of HCO3-


40) Avascular necrosis

• Steroid treatment of Vasculitis predisposes to avascular necrosis

• Crescent sign on MRI



41) Acute tubular necrosis

• ↓ urine output

• Granular casts


42) Pap smear + PCP prophylaxis

• PCP prophylaxis with TMP-SMX in CD4+ <200, thrush or history of PCP

• Pap smear CD4+ <500


43) Switch from glyburide and metformin to intermediate acting insulin

• Creatinine is elevated after initial treatment. Lactic acidosis from metformin → muscle pain,

nausea, SOB

• HBA1C + glucose is still elevated after metformin trial à switch to insulin


44) Adverse effect of verapamil

• Constipation

• Diabetic patient without neuropathy is unlikely to have neuropathy of colon


45) Subclavian steal syndrome

• Stenosis/occlusion of the proximal subclavian artery → reversal of blood flow in the

ipsilateral vertebral artery → upper extremity ischemia (pain, fatigue, paresthesias) and/or

vertebrobasilar insufficiency (dizziness, ataxia, disequilibrium)


46) Prerenal azotemia

• BUN/CR ratio >20:1, urine sodium <20 after diarrhea


47) Renal biopsy

• History of IVDU (IV drug abuse), Hepatitis, blood 3+, protein 4+, presence of dysmorphic

RBC = membranoproliferative glomerulonephritis

• Biopsy for DX


48) Cigarette smoking

• Greatest increased risk for MI


49) Recurrence of breast cancer

• Hypercalcemia of malignancy >14 (greater than primary hyperparathyroidism [12-14])

• Breast, gynecological, squamous cell, renal cell carcinoma → PTHrP secretion

• Metastasis → Breast, multiple myeloma, lymphoma

• ↑ 1,25 OH Vitamin D: lymphoma


50) Weight loss

• ↑↑ BMI is the number one cause of osteoarthritis





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