nbme

Question 1

young otherwise healthy female presents with 2 day h/o F/C, L flank pain, N/V, leukocytosis, many WBCs in urine, initial ABX?

Answer 1

IV 3rd gen cephalasporin (ie ceftriaxone, cefotaxime, ceftazidime) for acute complicated pyelo (vomiting so must give IV not oral)

Question 2

pt presents w severe substernal chest pain, worse w inspiration, she is bent over at waist to decr pain, a short harsh diastolic sound is heard, nml lung sounds, no fever, RR and pulse are both upper nml, most likely Dx?

Answer 2

Pericarditis

Question 3

woman in 50s presents w 2month h/o pain/swelling in knees, also has stiffness- worse in AM, nml WBC count, ESR of 50, x-ray of knees shows osteopenia and subcartliganeous cysts around the joints, joint space intact.. Dx? Tx?

Answer 3

RA; ibuprofen

Question 4

Middle aged man presents with weight gain, incr space btwn teeth, he appears tall w big feet and frontal bossing.. measurement of what will confirm Dx?

Answer 4

serum IGF-1 (to confirm suspected Acromegaly)

Question 5

cephalization of pulm vessels?

Answer 5

vessels in upper chest become more prominent d/t pulm HTN

Question 6

Pt with poorly controlled HTN presents with SOB and wheezing for 2 days, has S3 gallop, 4+ pedal edema, JVD, crackles and wheezes, CXR shows cardiomegaly and cephalization of pulm vessels, SOB is due to?

Answer 6

pulm edema d/t CHF

Question 7

middle aged alcoholic is brought to ER 1hr after being found passed out in park, lateral gaze defect, wide based ataxic gate, BAC less than 0.1 .. need to administer?

Answer 7

Vit B1 ie thiamine (must give thiamine before glucose!!!)

Question 8

Previously healthy college student presents w productive cough and runny nose for 2 weeks, feels well btwn coughing episodes, has vomited from coughing so much, no fever, stable vitals, nml lung exam, most likely Dx?

Answer 8

Pertussis

Question 9

young adult w severe Hemophilia A has received factor VIII replacement since childhood, recently his bleeding has been poorly controlled, requiring more factor VIII to stop episodes, has nml platelet count and prolonged aPTT, next to to Dx cause of incr bleeding?

Answer 9

test for factor VIII inhibitor (vie Bethesda assay), should suspect inhibitor when bleeding episodes are refractory to usual therapy (would not need measure factor VIII conc b/c that is already known to be low in these pts)

Question 10

young adult has polyuria, blurred vision and rapid breathing for 1 day, is tachycardic and tachypneic, nml Na and K, HCO3 of 18, glucose 783, what is most likely cause of their acidosis?

Answer 10

accumulation of beta-hydroxybutyric acid (DKA)

Question 11

baseline ECG changes in some pts make stress ECG nondiagnostic since the baseline changes interfere with Dx of MI, thus these pts need what kind of test?

Answer 11

stress ECHO which can detect ischemia by new wall motion abnormalities (or stress radionuclide MPI)

Question 12

initial therapy of severe hypercalcemia (ie greater than 14) ?

Answer 12

Volume expansion w isotonic saline (0.9% saline), calcitonin and bisphosphonate (ie Zoledronic acid or pamidronate)

Question 13

pt with MDD presents w nocturnal incontinence 1mo after starting amitriptyline.. on exam he has lower abd distension, moderately enlarged smooth prostate, neuro intact, Cr of 1.6 .. cause of nocturnal incontinence is likely?

Answer 13

BPH combined with anticholinergic effects of TCA causing overflow incontinence

Question 14

midshaft fracture of humerus causes wrist drop due to injury of what n.?

Answer 14

radial

Question 15

Pt in 60s presents w pain in fingertips, plethora, and splenomegaly, labs: elevated Hb, WBCs, platelets, Po2 of 92, O2 sat 94.. likely Dx? next step in Mx?

Answer 15

Polycythemia vera;

Phlebotomy

Question 16

c/b rapid onset of severe vertigo, N/V, gait instability, possible unilateral hearing loss.. possible nystagmus and falls but no other neuro S/Sxs?

Answer 16

Vestibular Neuritis, or if there are hearing changes- known as Labyrinthitis

Question 17

rash, fever, eosinophil-ia/-uria, WBC casts, some WBCs, RBCs and protein also in urine

Answer 17

acute interstitial nephritis

Question 18

how does hypertrophic obstructive cardiomyopathy murmur change with valsalva?
with handgripping?

Answer 18

it increasese;

decreases

Question 19

defined by the presence of heavy proteinuria (more than 3.5g/24hrs), hypoalbuminemia (less than 3g/dL), and peripheral edema ?
(hyperlipidemia and thrombotic disease are also frequently observed)

Answer 19

Nephrotic Sy

Question 20

syndrome that falls inbetween the cognitive changes seen with aging and dementia

Answer 20

mild cognitive impairment

Question 21

Calcified pleural plaques in shipyard worker .. buzzwords for?

Answer 21

asbestosis

Question 22

middle-aged adult is brought to ER after collapsing at restaurant, Pt is very tachycardic, tachypneic and hypoTNsive, has labored breathing, diffuse bronchospasm and coughs continuously.. most likely Dx?

Answer 22

Anaphylactic shock

Question 23

Pt with UC presents with jaundice, fatigue and pruritus, has elevated bili, Alk phos, ALT, prolonged PT, is neg for Hep .. most likely Dx?

Answer 23

Primary SCLEROSING cholangitis (about 90% of pts with PSC also have UC)

Question 24

elderly man has syncopal episodes that occur without warning, no h/o illness, no meds, no exam findings.. next step in Dx?

Answer 24

ambulatory ECG monitoring

Question 25

Mx of pilonidal cyst/sinus?

Answer 25

first I and D, likely to recur, pts w chronic or recurrent disease need excision of sinus and all tracts

Question 26

Tx of hypotonic hyponatremia: if mild (Na 120-130mmol/L)?
if mod (Na 110-120mmol/L)?
if severe (Na less than 110 OR if symptomatic)?

Answer 26

mild- fluid restriction
Mod- loop diuretics, give w saline (to prevent renal conc of urine d/t high ADH)
Severe- hypertonic saline (but dont incr Na more than 8mmol/L in first 24hrs)

Question 27

A middle age pt on methylprednisolone for SLE presents with hip pain that started a couple months ago, is worse with weight bearing, pain with active and passive mvmt, walks w limp.. most likely Dx?

Answer 27

osteonecrosis (AKA avascular/ischemic necrosis) - biggest RF is high dose corticosteroid use and SLE is another RF (can be bilateral)

Question 28

these markers indicate what: HBsAg neg
anti-HBc neg
anti-HBs positive

Answer 28

pt is immune due to vaccination

Question 29

these markers indicate what: HBsAg neg
anti-HBc positive
anti-HBs positive

Answer 29

pt is immune due to natural infection (had acute hep B infection that has resolved)

Question 30

these markers indicate what: HBsAg neg
anti-HBc positive
anti-HBs neg

Answer 30

pt never had vaccine, is either in the window period when HbsAg drops and anti-HBs isn’t detected yet or had acute Hep B a long time ago and anti-HBs no longer detectable or has chronic hep B but HBsAg level is too low for detection

Question 31

most appropriate pharmacotherapy for woman with urge incontinence?

Answer 31

Oxybutynin (antimuscarinic)

Question 32

1st line pharmacotherapy for mild to med Sxs of BPH? (class and drug)

Answer 32

alpha-1-adrenergic antagonists ie terazosin, doxazosin, tamsulosin, alfuzosin

Question 33

these can be used for BPH by decreasing size of prostate, take 6-12mos to work

Answer 33

5alpha reductase inhibitors ie finasteride, dutasteride

Question 34

clinical Dx that should be suspected in pts with RA, neutropenia and splenomegaly (the RA is usually severe, long-standing and seropositive for both rheumatoid factor and anti-CCP)? the splenomegaly results in what other hematologic findings?

Answer 34

Felty Sy;

splenic sequestration results in anemia and thrombocytopenia

Question 35

pleural fluid is exudative if it meets any 1 of these 3 lights criteria

Answer 35

pleural fluid protein/serum protein greater than 0.5;
pleural fluid LDH/serumLDH greater than 0.6;
pleural fluid LDH more than 60 (2/3 of upper limit of nml)

Question 36

chylothorax? the fluid will be what color and contain high content of?

Answer 36

chyle/lymphatic fluid in pleural space from disruption/obstruction of thoracic duct or its tributaries;
typically milky, triglycerides (more than 110mg/dL)

Question 37

previously healthy man presents w HA, confusion, temp of 100.2, BP 140/86, mild icterus, Hg 8.4, thrombocytopenia, leukopenia, elevated BUN and Cr, smear shows fragmented RBCs, PT is nml, next step in Mx?

Answer 37

immediate plasma exchange this pt has TTP (Pentad: renal insuff, neuro manifs, fever, thrombocytopenia, microangiopathic anemia)

Question 38

these should be used to reduce the risk of systemic thromboembolism in pts w Afib w CHADSVASc score of 2 or more

Answer 38

warfarin or non-Vit-K antagonist anticoagulants (apixaban, dabigatran, rivoxaban)

Question 39

illness c/b arthralgias, weight loss, fever, diarrhea, possible skin pigmentation, PAS-positive lamina propria of small intestine is classic Bx finding

Answer 39

Whipple’s disease

Question 40

65yo F presents w back pain, found to have anemia, slightly elevated Calcium, incr BUN and Cr, urine sediment is bland except for a few granular casts, most likely cause?

Answer 40

Multiple myeloma- pts often have fatigue, weight loss bone pain, hypercalcemia, anemia, monoclonal protein accumulates and deposits in renal tubules as granular casts can eventually lead to nephrotic Sy

Question 41

highly malignant tumor MC in femur then tibia or humerus, typically in 1st or 2nd decades of life, central lytic lesion? classic radiographic appearance?

Answer 41

Ewings sarcoma; central lytic lesion w endosteal scalloping “onion-skin” then “moth-eaten”

Question 42

first step in Mx of symptomatic sinus bradycardia in adults

Answer 42

atropine

Question 43

MC malignancy Dxed in pts exposed to asbestos?

Answer 43

Bronchogenic carcinoma

Question 44

MC OB complication in pts w vonWillebrand disease is?

Answer 44

PPH

Question 45

presents w postcoital bleeding, mucopurulent discharge, and a friable cervix? empiric Tx?

Answer 45

Acute cervicitis MC d/t chlamydia and gonorrheae;

ceftriaxone and azithromycin/doxy

Question 46

first line Txs for ascites d/t cirrhosis?

Answer 46

furosemide and spironolactone

Question 47

pts w cirrhosis should be screened for esophageal varices how often and how? mainstay of primary Px for esophageal variceal hemorrhage?

Answer 47

EGD repeat yearly;

nadalol or propanolol or for larger ones endoscopic variceal ligation