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nbme 7 Flashcards

1
Q

47 F

Why does she have postural hypotension?

A

Intravascular volume depletion

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2
Q

52 F
Personality changes since the death of her friend x 2 weeks
hx of depressive episodes
presenting with flight of ideas and pressured speech

A

Bipolar

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3
Q 
9 y/o M
low back pain x 4 months
Most severe in the morning
tenderness over SI joint
Decreased waist flexion
Elevated ESR
ABN lumbar Xray
A

Ankylosing spondylitis

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4
Q 
15 y/o F
low back pain x 2 months
dull ache present all day and night
Has required prolonged course of po prednisone for asthma
Cushingoid and hirsute
TTP over T11-L2
A

Compression fx

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5
Q 
42 y/o M
severe flank pain x 6hr
CVA tenderness
Pain responds to morphine
How do you manage him?
A

Discharge to home and encourage po fluid intake

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6
Q 
26 M
SOB x 3wk, bumps on legs x 1 wk
Red tender nodules over anterior leg
CXR - b/l hilar fullness
What sr abn would you expect?
A

Increased calcium

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7
Q

42 F
Weakness, lethargy, double vision x 2wks
CXR - upper anterior mediastinal mass
Dx?

A

Thymoma

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8
Q 
82 F
Metastatic breast cancer on home care
Severe back pain that responds to 5 mg Morphine q4h
However, pain returns after 2-3 hours
How do you manage her pain?
A

Increase morphine frequency to q3h

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9
Q 
66 M
Homeless
jaundice x 1 wk
20 lb weight loss
Alcoholic
Wasting, scleral icterus
Signs of cirrhosis
Mag - 0.8
Other sr abnormality?
A

Decreased calcium

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10
Q 
23 M
PPD 16mm
CXR - WNL
Negative sputum
Management?
A

Tx latent TB

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11
Q

27 M
unable to conceive with his wife who has kids from a previous relationship
Exam - ill-defined soft masses palpated b/l high in the scrotum
Dx?

A

B/l varicoceles

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12
Q

24 M
SOB 2 days s/p reduction of a femoral fx
Petechial hemorrhage over the chest and UE

A

Fat embolism

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13
Q

4 M
fever, cough, runny nose x 3 days
Heart murmur
Dx?

A

URI

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14
Q

24 F
amenorrhea x 7 years
anorexia x 8 years
Compared to other women her age, she is at increased risk for?

A

Osteoperosis

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15
Q

22 F
Presents in labor at term
Why did she have frequent UTIs during pregnancy?

A

Urinary stasis

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16
Q

foodborne illness
n/v 3-4 hrs after eating egg salad
How does the food become contaminated?

A

Inadequate refrigeration

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17
Q

17 F
severe acne x 4 months
What structure is involved?

A

pilosebaceous follicles

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18
Q 
62 M
6hr s/p CABG
SBP drops to 100mmHg
decreased UO
Wide mediastinum
What is the next step?
A

Surgical exploration of the mediastinum

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19
Q

37 F
Malaise, muscle aches, painful vulval blisters, vaginal discharge, dysuria x 3 days
New sexual partner 7 days ago
Vesicles and ulcers over labia, perineum, vulva, mons
How do you dx?

A

Culture for herpes simplex

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20
Q 
4 F
Cough, 5lb weight loss x 2 months
Crackles over RML
PPD -
Gastric aspirate has M. TB
How?
A

She has T lymphocyte dysfunction

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21
Q 
82 F
Visual loss in the L eye on awakening
PMH HTN
Fundoscopy - dilated retinal v. and widespread retinal hemorrhages intermixed w/ patches of white exudate
Dx?
A

Central retinal v. occlusion

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22
Q

62 F
difficulty swallowing solids, liquids x 3 months
Foul smelling breath
Next step in dx?

A

Barium swallow

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23
Q

14 M
BP 150/90
Never been high before
Next step?

A

Repeat BP in 4 wks

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24
Q 
50 F
SOB x 8 hrs
JVD, distant heart sounds
EKG alternating amplitude of QRS
Next?
A

Pericardial window

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25
Q 
42 F
1 day s/p removal of meningioma
now comatose
Na - 155
Dx?
A

Diabetes insipidus

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26
Q

32 F
abdominal pain, n/v x 6 hrs
Amylase - 1022
Next step in identifying the cause?

A

Measure Triglycerides

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27
Q

52 M
excruciating pain in the great toe, 10 days s/o LCC
Tx?

A

Indomethacin

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28
Q 
14m M
WCC
Not walking on his own
Stands for several seconds unassisted before falling to the floor
Next step?
A

Reassurance

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29
Q 
4m 
seizure
poor feeding, sleep x 2 days
tense anterior fontanele
b/l retinal hemorrhages
dx?
A

Child abuse

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30
Q

16 F
Mom wants contraception for daughter
Daughter has been staying out late and texting boys
daughter admits she doesn’t know why she is behaving the way she is.
Next step?

A

Family therapy

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31
Q

6 M
Cramping abdominal pain and R scrotal pain x 4 hours
R hemiscrotum is discolored with tenderness and swelling
Next step?

A

Operative procedure

NOT u/s

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32
Q

24 F
Intermittent double vision, ptosis x 3 wks
Difficulty chewing, swallowing x 1 week
pathophys?

A

Decreased Acetylcholine receptors

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33
Q 
37 M
Progressive weakness x 5 days
Started at ankles and has migrated to proximal muscles
URI 2 weeks ago
pathophys
A

Demyelination of axons

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34
Q

62 F
SOB x 12 hrs
She is treated for PNA and 4 days later her Sr Cr 3.6
What would have prevented her acute renal failure

A

IVF

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35
Q 
4 M
Fatigue after viral illness 3wks ago
Pale x 1 wk
Gums bled when he brushed his teeth
Pancytopenic
Next step in management?
A

Bone marrow aspiration

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36
Q

72 M
difficulty climbing stairs, rising from chair, combing hair x 3 months
Where is the abnormality?

A

Muscle

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37
Q 
27 F
HA, diffuse abdominal pain, n/v x 5 days
Worse with eating, relieved by vomiting
Febrile
Abdomen distended, diffusely tender, tympanitic
Decreased bowel sounds
NL amylase lipase
Dx?
A

SBO

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38
Q

18 F
Fatigue and jaundice x 3 days
Spherocytes on blood smear
Best way to prevent her syx?

A

Splenectomy

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39
Q

6m M
diaper rash x 3 days
2 cm honey crysted papular lesion
Tx?

A

Mupirocin ointment

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40
Q

47 F
ACTH therapy for MS x 2 days
Angry, irritated, pulling out lines, walking around
Tx?

A

Haloperidol

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41
Q 
18 F
37 wks gestation
Outbreak of Herpes 6 wks ago
No syx since
No ulcers on exam
Management?
A

Amniotomy and vag delivery

NOT c-section, intrapartum acyclovir

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42
Q 
47 F
MVA
Slightly widened mediastinum
C5 fx
What structure has the most threatening injury?
A

Thoracic aorta

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43
Q

19 M
Found standing in his neighbors house in the middle of the night
b/l nystagmus, constricted pupils, hypertonia, decreased sensation
What’s he on?

A

PCP

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44
Q

67 M
rectal bleeding x 1 mo
Colonoscopy - large ulcerating rectal mass
Bx - rectal cancer
what is the best research to find his treatment options?

A

RCT

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45
Q 
47 F
fever, n/v, severe HA x 24 hrs
T - 102.2
Weak RUE, nystagmus, Kernig sign
Next step?
A

Head CT

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46
Q 
72 F 
Indigestion while walking uphill or briskly
Improves with rest
Does not respond to anti acids
Next step?
A

Exercise stress test

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47
Q

22 F
Concerned about her risk for ovarian cancer d/t family hx
What is the best recommendation?

A

OCP’s

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48
Q 
57 M
Flank pain, hematuria x 3days
CVA tenderness
Ca - 10.9
Phos - 2.3
PTH - 1020
What is the most likely cause of his renal stone?
A

Increased urinary excretion of calcium

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49
Q 
25 F
27 wks gestation in labor
2 cm dilated, 70% effaced
GBS +
Next step?
A

IM betamethasone

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50
Q

32M
MDD, sensation of insects under his skin x 2wks
Exoriations all over his body
Tox screen would show?

A

Meth

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51
Q 
75 F
2hrs s/p perforated gastric ulcer reapir
Multifocal premature ventricular contractions
Meds - dig and diuretics
What electrolyte abnormality?
A

Decreased K

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52
Q 
55 F
metastatic breast cancer
Confused, obtunded
Barely arousable
Electrolyte abn?
A

Increase Ca

NOT Na

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53
Q 
17 F
MVA
Facial trauma, fx maxilla and mandible
Gurgling when she breathes
Next step?
A

Cricotyrotomy

NOT elevate head of bed
ETT was not an option

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54
Q

24 M

New sexual partner, painful ulcers on his penis

A

Genital Herpes

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55
Q 
67 F
4 days s/p R hemicolectomy
Serosanguineous fluid leakage from her incision
afebrile
Dx?
A

Wound dehiscence

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56
Q 
12m M
105 F x 4 hours
In the last 8 months: pneumococcal bacteremia, periorbital cellulitis (H. Flu)
Immunizied
Strep meningitis on LP today
He has an abn in which immune cell type?
A

B lymph

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57
Q 
12m M
3 major lifetime infections:
skin abscesses d/t Staph aureus
PNA and empyema 
Today skin abscess w/ Staph aureus
Likely has a defect in which immune cell?
A

PMN’s

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58
Q

57 F
n/v diarrhea, abd pain, weakness x 8 hours
32 hrs ago she was at a party with pork, shrimp, rice, canned jam
PE - muscle weakness
Dx?

A

Botulism

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59
Q 
37 F, EtOH
severe alcohol pancreatitis
Required intubation
CI WNL, elevated CVP
CXR - b/l diffuse hazy densities w/ cephalization of the pulm vasculature and perihilar fullness
Dx?
A

ARDS

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60
Q 
57 F
Pain in left groin and thigh over past year
20 degree hip flexion contracture
ROM intact but produces pain
Xray - narrowing of joint space
Dx?
A

OA

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61
Q 
43 M
PNA syx x 3 days
smoker
Increased tactile fremitus and dullness to percusion over L lung base
CXR consistent with LLL consolidation
Sputum - Small Gram - bacilli 
Etiology?
A

Haemophilus influenza

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62
Q 
42 F
Intermittent loss of urine x 3 weeks
Only occurs after voiding
3cm midline cystic tender mass in the midthird of the vagina
UA - WNL
post void volume - 50 mL
Dx?
A

Urethral diverticulum

NOT Vesicovaginal fistula, urethral syndrome, incontinence, neurogenic bladder

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63
Q

15 M
changes in behavior since transfering to a new school 4 months ago
withdrawn, sleeping poorly, 10lb weight loss, failing classes
Cooperative, flat affect.
Dx?

A

Major depressive disorder

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64
Q 
32 F
16 wks gestation
fever, waxing/waning consciousness x 6hrs
HCT 11%
PLT 52K
Cr - 3.5
Blood smear - schistocytes
A

Thrombotic thrombocytopenic purpura

ADAMTS-13, defieciency in vWF cleaving enzyme
platelet microthrombi -> fragmented RBC’s -> microangiopathic hemolytic anemia

Five syx:

  1. Low platelet count
  2. Microangiopathic hemolytic anemia (schistocytes)
  3. Neurologic changes (AMS)
  4. Impaired renal fxn
  5. Fever

Tx - plasma exchange

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65
Q

50 F
Megaloblastic anemia
Giving IF corrects her anemia
What caused her syx?

A

atrophic gastritis

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66
Q

32 F
PCOS, unable to conceive x 3 years
Appropriate pharma?

A

Clomiphene

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67
Q 
52F
abd pain, nausea, decreased appetite x 5 days
10 days s/p LCC
Jaundice, RUQ pain
Alk Phos - 251
NL U/s
Next step?
A

ERCP

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68
Q 
8hr M
Jaundice, respiratory distress
hepatosplenomegaly, petechiae
Hgb - 4
T bili - 15
Direct bili - 0.3
Dx?
A

Rh incompatibility

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69
Q

7 M
about to have a dental cleaning
Aortic valve replacement 1 year ago
At risk for bacterial endocarditis d/t?

A

Viridians streptococcus

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70
Q

32 M
burning substernal chest pain and sour taste x 3 months
Next step?

A

Trial of omeprazole

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71
Q 
47 M
Progressive weakness x 6 months
Mild dysphagia
atrophy of quads, deltoid
fasciculations
Babinsky + b/l
EMG and NCS likely to reveal?
A

fibrillation potentials in multiple muscles of multiple extremities

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72
Q

32 F
abd pain, watery diarrhea x 4 days
Most likely Etiology?

A

ETEC

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73
Q

11 F
new onset of body odor, irritibility
Tanner 2
Next step?

A

Education about puberty for kid and parents

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74
Q

22 M
exposed to unk gas
vomitting/diarrhea, miosis, copisous oral secretions, rhinorrhea, fasiculations
Clothing is being removed and skin washed.
Next step?

75
Q 
32 F
HA, joint pain, fatigue, fever x 2 weeks
Rash on calf 3 weeks ago
Serology + for berrelia burgodrferi
Next step?
A

Amoxicillin

Doxy was not a choice (ASA, metronidazole, prednisone, propanolol)

76
Q

57 F
Factor XI and IgA deficiency
Receives pRBCs and develops SOB, uticaria
Why?

A

Anaphylactic transfusion rxn

77
Q 
62 F
s/p resection of ovarian tumor
BUN -80
Cr - 5.7
Next step in identifying cause of ARF?
78
Q 
27 F, HIV +
Wants to know about immunizations
Had childhood vax
MMR vax - 4 yrs ago
Tetanus - 6 yrs ago
HBV Ab +
CD4 count is 450
What is appropriate for her to receive today?
A

Pneumococcal vax

HAV vax, HBV vax, MMR vax, Td vax, None necessary

79
Q 
75 M
confusion, lethargy x 2 days
Gardening in 100F weather prior to syx onset
T - 106.7
Creatine kinase - 8000
AST - 400
Dx?
A

Heat stroke

80
Q 
32 M
syncope while jogging
3/6 systolic murmur at LSB
Intensity increases when he stands from squatting position
Dx?
A

Hypertrophic obstructive cardiomyopathy

81
Q

54 M
90% stenosis of R ICA
Next step to prevent stroke?

A

Carotid endartectomy

82
Q 
36 F
postpartum hemorrhage after placental delivery
Fundus - 3 cm above umbilicus
placenta is torn but intact
Dx?
A

Uterine atony

83
Q

17 M
Unresponsive after using heroine at a party
rr - 6
Next step?

84
Q 
72 M
SOB x 3 days
PMH - HTN, CAD
b/l crackles and wheezes
CI - 2
pulm a. occlusion pressure - 28
pH - 7.49
PCO2 - 30
PO2 - 58
Next step?
85
Q 
67 M
difficulty walking
25 py smoker
3EtOH's QD
wide based gait, reel from side to side
No more than 3 steps heel to toe
What could have prevented this?
A

EtOH abstinence

86
Q 
27 M doc
stuck by a needle on pt + for HBV
doc was vax for HBV 2 years ago
serology shows adequate levels of antiHBV Ab
Next step?
A

No tx necessary

NO revax, NO IVIG, etc

87
Q 
67 M 
uncontrollable nosebleed x 6 hours
220/120 w/ abdominal bruit
Given ACEI to drop BP
Why did he respond?
A

No cleaving of C term peptide on angiotensin I

88
Q 
37 M
SOB, fatigue x 6 m
sleep apnea syx, BMI 59
pH - 7.32
PCO2 - 56
PO2 - 70
What explains his hypoxemia?
A

Alveolar hypoventilation

89
Q

4 M
Not using his L arm
Holds his LUE with elbow flexed, forearm pronated
Next step?

A

Supination of the forearm with elbow in slight flexion

dont image

90
Q 
10d M
6h s/p L toracotomy
restless while on vent
Given sedative
Next step?
A

Analgesic therapy

91
Q 
27 M
LOC x 1 min, pulse 45
occurred while at the morgue ID'ing his brother that died in a MVA
Seems fine now
Dx?
A

Vasovagal syncope

92
Q 
37 M
end stage Duchenne MD
Requests DNR with no further abx
Mental status seems fine
Next step?
A

Ask if the patient wants to discuss his decision with anyone else

(NO ethics committee, scheduling family meeting, transfer to SNF, or psych assessment)

93
Q

67 M
aching in his calves while walking
this is caused by significant narrowing of which vessels?

A

Femoropopliteal a.

94
Q 
25 F
20 wk gestation
severe epigastric pain radiating to the back x 12 hours
Vitals are stable
T - 100
Next step?
A

Measure Sr amylase

95
Q 
21 F
37 wk gestation
mild epigastric pain, HA x 24 hrs
150/98
DTR 3+
Urine protein 3+
Next step?
A

Measure PLT count

96
Q

37 F
progressive dysphagia x 6 months
Esophageal manometry - achlasia (Bird beak)
What does this mean for esophageal peristalsis and Lower esophageal sphincter tone

A

Peristalsis - decreased

Lower Esophageal sphincter tone - increased

97
Q

23 M
auditory hallucinations since his wife was killed x 1 wk
Keeps hearing his brothers voice even though he lives in another state
Dx?

A

Brief psychotic disorder

NOT Bereavement, PTSD, Schizoaffective disorder, Schizophrenia

98
Q

32 M
admitted for EtOH w/d
Day 2 - unable to move eyes laterally, wide based ataxic gate, b/l rectus palsies, horizontal nystagmus
Received dextrose and chlordiazepoxide during hospitalization
What is causing his syx?

A

Vitamin B1 (Thiamine)

Always B1 before glucose

99
Q

21 F
hospitalized for Guillain-Barre
Develops PNA w/ Gram + cocci, Gram - coccie, and Gram - bacilli
What could have prevented this?

A

Elevation of the head of the bed

100
Q 
14 M
L knee pain x 6 mo
exacerbated by jumping
Recent growth spurt
TTP over L tibial tubercle
Underlying mechanism?
A

Repeated microfracture of the tendon insertion

101
Q 
62 M 
painless rectal bleeding
Anoscopy - 5 cm ulcerated mass
bx - adenocarcinoma
Next step?
A

Colonoscopy to cecum

NOT radiation or resection

102
Q 
62 M 
tearing sensation in midchest
BP 180/100, 104 bpm
CXR - wide mediastinum
Next step?
A

IV labetalol

103
Q 
18 F
fever, obtunded x 12 hours
at summer camp
Meets SIRS
WBC elevated w/ L shift
Skin lesions over legs, chest abdomen big macular patches
Dx?
A

Meningococcemia

104
Q

37 M
hand/foot numbness x 10 months
Renovates houses
Pale MM
PE - weakness of dorsiflexion and loss of sensation in a stocking/glove pattern
Early tx with ? could have prevented this?

A

Calcium disodium edetate

105
Q 
34 F
L hemithorax pain x 2 days after movign heavy furniture
Worse w/ inspiration
TTP Lateral to the sternum on the L
Dx?
A

Costochondritis

NOT 10th rib fx

106
Q 
37 F
Sicle Cell Dz
RUQ pain, post prandial nausea
Scleral icterus
T - 100.8
U/s - cholelithiasis, pericholecystic fluid, NL CBD
Dx?
A

Acute cholecystitis

NOT cholangitis

107
Q 
67 M
fatigue, weakness x 3 mo
Sr Ur electrophoresis - monoclonal spike
Bx of Bone marrow - >50% plasma cells
CXR - radiolucency of ribs
More susceptible to infection with which organisms?
A

Strep pneumo

NOT Aspergillus, E. coli, HZV, M tb, PCP

108
Q

18 F
B syx x 5 weeks
exudative pharyngitis, splenomegaly
Dx?

A

EBV infection

109
Q

63 F
3 days s/p fixation of femoral fx
TTP over L calf
Next step?

A

Duplex scan

110
Q

72 F
increasing abdominal girth, 8lb weight gain x 2 months
Abd exam - fluid wave
Pelvic exam - 8 cm fixed nontender mass in cul-de-sac
Next step?

A

Exp Lap

NOT Therapeutic paracentesis

111
Q 
72 M
4 wks s/p 10 day course of quinolone therapy for UTI
PMH - schizoaffective disorder
Drinks 12-15 glasses of water/day
Dry MM
NA 122
Ur OsMo - 200
Why is he hyponatremic?
A

Psychogenic polydipsia

NOT SIADH

112
Q 
42 M
Pruritic rash on his back x 4 days
plumber, crawls under houses a lot
multiple erythematous serpinginous tracks on his back
Elevated WBC 
Dx?
A

Cutaneous larva migrans

113
Q 
37 F
irregular menses x 1 yr
BMI 24
Visual field testing shows outer field deficits b/l
MRI - pituitary micradenoma
Next step?
A

Bromocriptine

114
Q 
72 F
3hrs s/p AAA repair
CI - 1.2
MAP - 55 (L)
PCWP - 30 (H)
CVP - 28 (HH)
Pul a. pressure - 55/35 (H)
Dx?
A

Cardiogenic shock

115
Q 
27 M
Rash on neck, face, torse x 2 months
Flesh colored papules w/ central umbilication over the face etc
Molluscum conatgiosum
In addition to tx, Next step?
A

HIV testing

NO CBC, syphilis serology, viral culture

116
Q

47 M
constipation x 9 mo
Blood in stool x 2mo
Next step?

A

Colonoscopy

117
Q

37 F
3cm nontender fluctuant mass on L posterior vulva underlying the mucosa of the vestibule and external hymenal ring
Dx?

A

Bartholin duct cyst

118
Q 
8 M
sudden onset facial swelliing
\+ FHx of same
voice is hoarse
vitals stable
edema of lips and tongue, stridor
What is likely to be abnormal?
A

C1 esterase inhibitor

119
Q 
57 F
5 days s/p splenectomy for ITP
sudden SOB
Breath sounds decreased at L lung base
Next step?
120
Q 
50 M
3 days s/p hip replacement
Unable to move legs and is incontinent
Started right after removal of epidural catheter
Dx?
A

Epidural hematoma

121
Q 
32 M
Behavioral changes x 2 wks
Saw his friend die 
vivid dreams
difficulty concentrating
Dx?
A

Acute stress disorder

122
Q

42 M
scheduled for MRI
Freaks out, SOB, tunnel vision during MRI
Next step

123
Q 
82 F
Concerns for parkinsons
Difficult w/ word finding
Difficult to distinguish smells
Slowed in postural changes
Rotary nystagmus
High frequency hearing loss
What is the most concerning finding?
A

Brisk rotary nystagmus on lateral gaze

124
Q 
77 M
Progressive forgetfulness x 2 yrs
2+ pitting edema
DTRs 1+
Na - 130
Uninterested, responds slowly
MMSE 20/30
Most likely dx?
A

Hypothyroidism

DTR’s, hyponatremia

125
Q 
72 M
2 days s/p tx for cholecystitis
UO -15mL/3hr
Gram - bacteremia, DIC
Tx - cefoxitin, gentamicin
BP 90/64, 110 bpm
Sr Cr - 3
Most likely to have?
A

Brown muddy casts

ATN

Low BP makes ATN more likely than AIN

126
Q 
15 F
finger pain, swelling x 6 months
Erythema over cheeks
Low C3
ANA +
Urine: 1+ RBC, 4+ protein
Dx?
127
Q 
32 F
Progressive cough x 3 months
Occasionally tinged with sputum
PMH - asthma
Meds - albuterol, budesonide
End expiratory wheezing
Serum IgE - 1250
CXR - linear atelectasis at lung bases and thickened airways, irregular cystic opacities primarily in central distribution
Dx?
A

Allergic bronchopulmonary aspergillosis

128
Q 
72 M
progressive SOB x 4 days
JVD 6cm
b.l crackles
diminised carotid upsrokes
4/6 systolic murmur throughout the precordium w/ radiation to carotids
liver span 13 cm
Dx
A

Aortic stenosis

129
Q 
16 F
Suicide attempt
Dolls eye reflex present
AG - 20
pH - 7.32
PCO2 - 12
PO2 - 92
What is the substance?
130
Q 
27 F
39 wks gestation
3cm dilated, vertex -1
FHR - 130, late decels
Next step?
A

Cesarean delivery

131
Q

70 F
Peeling, scaling, cracking of R nipple x 2 mo
Dx?

A

Paget dz of the breast

132
Q

40 F
yellow discharge from L nipple
Can be expressed, no spontaneous d/c
Dx?

A

Physiologic discharge

133
Q 
14 M
Sickle cell trait
severe pain in L thigh and knee x 1 day
Unable to bear weight
NO joint line tenderness, effusion
L hip ROM limited by pain
NL knee xray 6 days ago
Next step?
A

Xray of the hip

134
Q 
42 F
Lift eye red on awakening
Like a burst blood vessel
No trauma
No change in vision
Next step?
A

Reassurance

135
Q

For a screening test 2 questions are considered a +ve

If it were changed so that 1 question was required What would happen to sensitivity and specificity?

A

Sensitivity would increase

Specificity would decrease

136
Q

72 M
Dyspnea x 6 wks
PMH DVT, PE/JVD, ascites, pitting edema LE
CXR - mild cardiomegaly, no pulmonary edema
What is the cause of his worsening condition?

A

Cor pulmonale

NOT ischemic heart dz, AS, MR, viral cardiomyopathy

137
Q 
19 M African American
6-12 hr episodes of watery diarrhea x 9 mo
abd cramps, bloating
diarrhea after meals since the age of 12
Dx?
A

Digestive enzyme deficiency

138
Q 
24F
38 wks gestation
Tx for GBS at 20 wks
2cm dilated, 80% effaced, vertex -1
What is the best way to prevent GBS for this pt?
A

IV penicillin G

139
Q 
17 M
severe pain on swallowing x 4d
IBU intermittently x 3 mo
smoker
no GERD syx
Dx?
A

Pill induced esophagitis

140
Q 
10 F
Fever, joint pain x 5 d
T 103F
Cardiac exam - gallop, 3/6 holosystolic murmur in 4th intercostal space and mid clavicular line
Throat swab grows step pyogenes
What explains her cardiac findings?
A

Mitral valve incompetence

141
Q 
42 F 
Fatigue, palpitations, anxiety x 3 mo
7lb weight loss, heat intolerance, increased BM's
lid lag, exophtalmos
TSH 0.1
T4 - 16
Diffuse uptake on thyroid scan
Next step?
A

po propythiouracil

142
Q 
72 F
hyponatremia x 3 days
admitted for cerebral infarction
On appropriate IVF
Na+ - 120
Sr Osmo - 255
Urine: Na - 50, Osmo - 358
Dx?
143
Q

60 M
2 mo f/u for upper GI bleeding
EGD shows a sliding hiatal hernia (type 1)
Next step?

144
Q 
2mo F
born at 34 weeks
Development is appropriate for corrected age
Has a cough, snot T 100F today
What is the plan for her vax?
A

Give all recommended immunizations for age

Do NOT delay until URI resolves

145
Q 
37 M
low back pain x 3 mo
pain increases w/ hyperextension
strength 5/5
Xray shows anterior displacement
Dx?
A

Spondylolithiasis

146
Q

18 F
Lump in neck x 1 month
3cm LN, spleen palpable
Abn lab finding?

A

Increased serum lactate dehydrogenase

Not decreased K, increased RBC, Increased Ca, Increased TSH

147
Q

82 M
CHF on f/u exam
meds - furosemide, lisinopril
BUN/Cr have increased since increasing furosemide at his appt 1 month ago. Why?

A

Decreased renal blood flow

NOT interstitial inflammation, ATN, or obstruction

148
Q 
57 M
Joint pain x 1 mo
purple rash on legs x 3 days
ALT - 156
Cryoglobulins +
HCV +
Tx?
A

Interferon - alpha

149
Q 
27 M
MVA
remains tachy, hypotensive after 3 L of crystalloid
LOC
Next?
A

Transfuse O- pRBCs

150
Q

65 M
episodes where he could not speak and transient blindess of the L eye
R handed
Where is the arterial stenosis?

151
Q 
20 M 
auditory hallucinations, odd behaviors x 12 mo
secluding himself
flat affect
Dx?
A

Schizophrenia

152
Q

4 M
gets chickenpox 8 hrs after visiting a newborn nursery
all the moms had chickenpox prior to pregnancy
Next step?

A

No intervention needed

153
Q 
32 F
vomiting, diarrhea, R sided pelvic pain x 2 days
T - 102.2
RLQ tenderness
WBC - 15K w/ L shift
US - no adnexal masses
Dx?
A

Appendicitis

154
Q

56 F
PMH - short bowel syndrome
Maculopapular rash, hair loss after hospital stay requiring TPN
What is the deficiency?

155
Q

study compares outcomes for hip fx at 2 horpitals
pts matched based on age and gender
Physicial fxn at 1 yr s/p much worse at one hospital
What is concerning?

A

Results are not adjusted for comorbidities

156
Q 
67 M
burning/achin in lower extremities x 3 wks
exacerbated by walking
improved with feet elevation
finger clubbing
Dx?
A

Bronchogenic carcinoma

157
Q

62 F
Increasingly sever upper back pain x 4 days
progressive leg weakness, tinging, urinary incontinence
6 mo s/p radical b/l mastectomy
Babinski b/l
Next step?

A

Radiation therapy

158
Q

47 M
n/v burning epigastric pain x 3 days
90/50, 128 bpm
What is causing his vitals?

A

Hypovolemia

159
Q 
M newborn
b/l clubfoot
did not move lower extremities or cry during needle stick
bladder is full
Dx?
A

Spinal dysraphism

160
Q 
21 F
sudden R sided chest pain x 1 day
worse with deep inspiration
Recent travel to the Andes
T - 100.4
Faint erythematous macular non pruritic rash over cheeks and trunk
dullness to percussion at RL base w/ inspiratory rub
Dx?
A

Viral pleurisy

161
Q 
27 F African American
34 wks gestation
lower abd pain x 6 hr, vag bleeding x 1 hr
FHR - 160
U/s - anterior placenta
Dx?
A

Abruptio placentae

162
Q 
25 F
tremulousness, fatigue x 1 mo
Thyroid detectable by palp and nontender
Iodine uptake is decreased
Dx?
A

Surreptitious administration of thyroxine

163
Q 
55 M
fever, neck pain, fatigue x 2wks
7lb weight loss
began 4 days s/p viral URI
Thyroid is diffusely enlarged and exquisitely TTP
ESR 110
Dx?
A

Viral infection

164
Q 
87 M
difficulty starting urinary stream, post void dribble x 1 yr
Enlarged prostate on exam
Orthostatic hypotension
Tx?
A

Finasteride

doxazosin would be contra d/t bp

165
Q

52 F
T2DM controlled with metformin
A1C 6.9
best way to prevent nephropathy?

A

Add lisinopril

166
Q 
52 F
progressive DOE x 2 wks
PMH - breast cancer s/p mastectomy x 8yrs
dullness to percusion over R lung base
Dx?
A

Pleural metastasis

167
Q

6w M
Forceps delivery
Head is rotated to the L with chin deviated to the R
2cm hard nontender oval mass on R side of neck
dx?

A

Fibrosis of the SCM (torticolis)

168
Q 
32 F
28 wks gestation
contractions x 4 hrs
cervix partially effaced
Tx?
A

Magnesium sulfate

NOT desmopressin, egonovine, mifepristone, misoprostal, oxytocin

169
Q

68 M
sudden onset of chest pain radiating to the arm x 3 hrs
ST elevations V2-V5
Dx?

170
Q

70 F
chest pain and weakness
Vtach on EKG

171
Q 
16 F
abdominal pain x 2 days
RLQ, high risk sex
Cervical motion tenderness, L sided adnexal tenderness
Dx?
172
Q 
7m M
persistnet fever x 4 days
prolonged bleeding after cicumcision
eczema, frequent thrus, OM, pneumococcal bacteriemia
Plt - 35 k
IGA - 100
IgG - 400
IgM - 15
IgE - 60
A

Wiskott-Aldrich syndrome

Xlinked recessive
Characterized by 1. eczema, 2. thrombocytopenia, 3. immune difficiency, 4. bloody diarrhea

173
Q

Study is designed to include prison population who will be rewarded with consideration for early parole. What is the problem?

A

Coercion of a vulnerable population

174
Q 
51 F 
acute R sided chest pain, SOB x 15m after placement of subclavian catheter
CXR - 10% apical PTX
Vitals stable
Next step?
A

Obs

NO chest tube

175
Q

62 M
fever, general muscle pain x 12 hours
On chemo with subclavian catheter in place
SIRS criteria
gram stain of blood - gram + cocci in clusters
Remove the catheter and give which abx?

176
Q 
22 M
difficulty sleeping, paranoia x 1 month
Odd paranoias
Utox -
Tx?
A

Olanzapine (only antipsychotic option)

177
Q

77 M
cough productive of blood tinged sputum x 15 m
Tachycardic, but vitals stable
Broncophony R lung
CXR - thin walled cystic spaces in RLL with some air fluid levels
Explanation?

A

Destruction and dilation of distal airways

178
Q 
3 F
father found her unconcious in gargae
running space heater all day, peeling paint
On arrival - cyanotic, diaphoretic, unresponsive
T - 99F, 100/60, 80, rr 48
rhinorrhea and drooling
Poor air entry, diffuse wheezing
DTR's absent
What was she exposed to?
A

Organophosphate

NOT CO, ethylene glycol, hydrocarbon, lead

179
Q

27 F
Pap - high grade squamous intraepithelial lesion
no previous hx
Next step?

A

Coloposcopy

180
Q 
42 F
L eye pain, decreasing vision x 2 days
severe vertigo, L arm clumsiness, difficulty walking 4 years ago that resolved spontaneously after 3 wks
Decreased visual acuity on L
Central scotoma and afferent pupillary defect, pallor L optic disc
Finger nose testing shows dysmetria
R pronator drift, R ankle clonus
Babinski b/l
What's causing her visual syx?
A

Optic neuritis

181
Q 
32 M
sudden onset confusion, agitation
Started new medication for schizoaffective disorder 5 days ago d/t auditory hallucinations
T 103.1, 160/100, 110, 28
Muscle rigidity
WBC - 15k
pCreatinine kinase - 950
Which NT is responsible?
182
Q

10 F
mild itchy rash spread from face to arms x 2 days
URI 1 wk ago
Rash - symmetric, maculopapular, reticular, erythematous, nonconfluent on face, arms and legs
Next step?

A

No tx is needed (Parvo)

183
Q

22 M
10 min tonic clonic seizure while running a marathon
T - 105
Foley yields red brown urine, 4+ hemoglobin, 4+ myoglibin, 2+ RBCs
Next step?

184
Q 
67 M 
Ulcer on anterior surface of leg x 2 wks
PMH - CHF, T2DM
5 cm ulcer w/ 3 mm red border
moderate edema from toes to midcalf b/l
lung crackles
dx?
A

Stasis dermatitis w/ ulcer

NBME (2 decks)

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