NBME 8

Question 1

woman with hyperbilirubinemia (persistent)

mc cause?

Answer 1

Gilbert syndrome - deficiency of UDP glucourynltransferase
mild - can be asymptomatic or cause mild jaundice
induced by stress, alcohol, fasting
no tx needed

Question 2

CF of aortic dissection

remember it can also cause MI when involving coronary arteries

Answer 2

Sudden and severe tearing/ripping pain
Location:
Anterior chest (ascending) or back (descending)
Interscapular or retrosternal pain
Neck and jaw
migrates as the dissected wall propagates caudally
Hypertension
Asymmetrical blood pressure and pulse readings between limbs
Syncope, diaphoresis, confusion
A heart murmur (an aortic regurgitation in a proximal dissection)

Question 3

Relative Risk Reduction
RR
ARR

Answer 3

1 - relative risk
1 - ( incidence exposed/incidence in unexposed)

ARR = incidence in unexposed - incidence in exposed

ARR= difference 
RRR= proportion

Question 4

how do you treat small cell lung Ca?

Answer 4

chemotherapy and radiation- cant do surgery cause the cells are too small for the surgeon to see

all other lung CA –> surgery

Question 5

exposure to coal, gold, nickel – shortness of breath and masses in upper lobes think of?

Answer 5

pneumoconiosis

DD: asbestosis - lower lobes! - associated with shipbuilding roofing
silicosis - sandblasting mines - upper lobes too
beryliosis - aerospace and manufacturing - upper lobes too
idiopathic pulmonary fibrosis - you get honeycomb lung - common in smokers and older ppl

Question 6

OCD treatment?

Answer 6

First line treatment in OCD is SSRIs + CBT (exposure and response prevention); second-line treatments include SNRIs and clomipramine

Question 7

indications for endometrial biopsy ?

Answer 7

any woman >45 with AUB 
<45 with AUB and...
1. failed medical management 
2. Lynch syndrome - ovarian. endometrial and colon CA 
3. unopposed estrogen ( PCOS , obesity)

Question 8

Prophylaxis for migraine headaches

Answer 8

lifestyle changes, BB, CCB, topiramate, valproate, amitryptilline

Question 9

Psychogenic polydipsia vs. SIADH vs. DI

Answer 9

DI = High serum Na - high serum osmo - either ADH lacking or kidneys not responding to ADH - either way all the water is filtering through and not being resabosrbed
SIADH and Psychogenic polydypsia - LOW Na+ in serum = low serum osmo
in SIADH - too much ADH diluting serum - urine will be concentrated - high urine osmo
Psychogenic polydypsia - urine will not be concentrated- peeing out water too - urine dilute- low serum and urine osmo

Question 10

3 types of lower extremity ulcers

Answer 10

(1) Neuropathic ulcers: Seen in diabetic patient, occur on the sole of the foot especially where lots of pressure is placed while walking (such as proximal to big toe)
(2) Arterial ulcers: Patient with signs of peripheral vascular disease (claudication, shiny hairless legs) who has ulcer with necrosis often at tips of the toes
(3) Venous ulcers: Often seen in patient with chronic lower extremity edema and leads to ulceration on the medial aspect of the leg

Question 11

explain how COPD can lead to PAH and cor pulmonale

Answer 11

In most capillary beds of the body, decreased oxygen leads to vasodilation in order to facilitate more bloodflow to the area to maintain perfusion, but the lungs are the one exception in which decreased oxygen leads to constriction of blood vessels feeding that area so that blood is preferentially sent to well-oxygenated portions of the lung to minimize V/Q mismatch, but can lead to cor pulmonale in patients with COPD because their entire lungs are poorly oxygenated, leading to diffuse vasoconstriction and increased afterload on right ventricle

Question 12

infectious cause of low back pain?
RFs?
bext next step?

Answer 12

Spinal epidural stenosis
Rf: IV drug use, diabetes mellitus, alcohol use d/o, invasive procedures and immunosupression
best next step is MRI
MRI useful when infxn, cauda equina or sensory/motor deficits

also remember vertebral osteomyelitis - if focal tenderness **

Question 13

dark necrotic bowel picture in pt with untreated afib

Answer 13

arterial embolus

dd: pseumembranes, SBO, LBO

Question 14

Abx prophylaxis to prevent surgical site infections

Answer 14

see picture on computer

Question 15

mechanism behind urge incontinence

Answer 15

detrusor hyperactivity/instability

Question 16

tx for carpal tunnel syndrome

Answer 16

wrist splint

Question 17

Middle-aged man with fever, lymphadenopathy and splenomegaly found to have elevated leukocyte count with increased eosinophils, myeloblasts, metamyelocytes and myelocytes most concerning for?

Answer 17

chronic myeloid leukemia
Key idea: Ways to differentiate between chronic myeloid leukemia and a leukemoid reaction include leukocyte alkaline phosphatase (LAP) levels (elevated in leukemoid reaction and decreased in CML), looking for basophilia (present in CML) and looking at the types of neutrophil precursors present (metamyelocytes > myelocytes in leukemoid reaction and metamyelocytes < myelocytes in CML)
Note: Metamyelocytes are more mature than myelocytes
Key idea: Can often tell they type of leukemia based on patient demographics with ALL seen in patients 0-14, AML seen in patients 15-60, CLL seen in patients 60+ and CML seen in patients 40-59

Question 18

pediatric brain tumor that presents with drop mets to spinal cord; malginant; can compress 4th ventricle causing noncommunicating hydrocephlaus and truncal ataxia bc arises in cerebellum

Answer 18

medulloblastoma

other childhood brain tumors: PEMPC
pilocytic astrocytoma, ependymoma, medulloblastoma, pinealoma, craniopharyngeoma

Question 19

treatment for neonatal sepsis

Answer 19

IV ampicillin and gentamycin

mcc: strep agalactiae, ecoli and listeria

Question 20

Herberden nodes(DIP) and Bouchards (PIP) seen in?

Answer 20

Osteoarthtitis

morning stifness lasts <30 mins

Question 21

complications of PCOS

Answer 21

Cardiovascular events
Type 2 diabetes mellitus
Endometrial cancer
Increased miscarriage rate

Question 22

CF of hemochromatosis

Answer 22

General symptoms: fatigue, lethargy
Organ-specific symptoms
Liver
Hepatomegaly
Cirrhosis
Increased risk of hepatocellular carcinoma
Pancreas: signs of diabetes mellitus (polydipsia, polyuria)
Skin: hyperpigmentation, bronze skin
Pituitary gland: hypogonadism, erectile dysfunction, testicular atrophy, loss of libido, amenorrhea
Joints: arthralgia (typically symmetrical arthropathy of the MCP joints II and III); (accumulation of calcium pyrophosphate)
Heart
Cardiomyopathy
Restrictive cardiomyopathy
Dilated cardiomyopathy (reversible)
Cardiac arrhythmias: paroxysmal atrial fibrillation (most common), sinus node dysfunction, complete AV block, atrial and ventricular tachyarrythmias, and sudden cardiac death
Congestive heart failure

Question 23

Young woman with previously regular menses presents with a late menstrual period, RLQ abdominal pain with adnexal tenderness, and elevated beta-hCG with a complex adnexal mass on ultrasound, most consistent with?

Answer 23

uncomplicated ectopic pregancy

Tx: methotrexate therapy

Question 24

Elderly woman who presents after an episode of amaurosis fugax (painless transient monocular vision loss caused by a small embolus in the ophthalmic artery) with hollenhorst plaques and an area of ischemia in the optic disc next best step?

Answer 24

carotid duplex ultrasonography

Question 25

iron studies in anemia of chronic dz?

Answer 25

Low iron, low TIBC, and high Ferritin

ferritin is an acute phase reactant so increased in inflammatory conditions

Question 26

Risk factors for asthma?

Answer 26

Family history of asthma
Past history of allergies
Atopic dermatitis
Low socioeconomic status

*childhood exposure to 2nd hand smoke also increases risk

Question 27

Rfs for placental abruption

Answer 27

Maternal hypertension, Maternal pre-eclampsia/eclampsia, prior placental abruption, cocaine use, tobacco use, abdominal trauma

Question 28

Anembryonic pregnancy = fertilized egg attaches to uterine wall but the embryo does not develop during the first trimester

Answer 28

blighted ovum

Question 29

dull LLQ pain, nausea/vomiting, alteration in bowel habits and bladder symptoms (sterile pyuria, dysuria, etc.) +/- tender LLQ mass

Answer 29

diverticulitis

remember they can have bladder symptoms too

Question 30

CT scan showing a high-density peri-ventricular hemorrhage, most consistent with a hypertensive bleed

Answer 30

Chronic arterial hypertension → lipohyalinosis of lenticulostriate vessels, which supply the basal ganglia → formation and rupture of Charcot-Bouchard microaneurysms → lacunar strokes (ischemia) of the basal ganglia
Putamen most commonly affected
Other locations: thalamus (second most common) and infratentorial parts of the brain (e.g., pons, cerebellum)