NBME medicine practice test 2023 (solved)

previously healthy 57yo M with 1mo hx of pain at multiple sites on back, arms, legs. bone scan shoes hyperdensities in multiple sites - Answer- bone metastasis 77yo F with 3mo SOB and edema. O2 sat 96%, 90% at rest. VQ scan shows subsegmental perfusion defects - Answer- Recurrent pulmonary emboli Empiric abx therapy for pt with central venous catheter and infectious sx - Answer- vancomycin, cefazolin, ceftazidime, ciprofloxacin, and gentamicin DM1 pt presenting unresponsive tachycardic, bradypneic. Management? - Answer- Give D5W - hypoglycemic episode. 24yo M post ACL surgery with asx jaundice, total bili 3.5, direct(conjugated) 0.2 - Answer- Gilbert syndrome 19yo F with primary amenorrhea, anosmia, Tanner stage 2 breasts, sparse pubic hair and normal cervix - Answer- Kallman syndrome - hypogonadotropic hypogonadism use of theophylline in asthma - Answer- substitute for LABA when ineffective. For patients whose symptoms are not controlled with conventional doses of inhaled glucocorticoids; more effective than increasing the dose of inhaled glucocorticoids. use of ipratropium bromide in asthma - Answer- use in ED for acute exacerbation breathing treatments use of cromolyn sodium in asthma treatment - Answer- for mild persistent asthma with allergic triggers preferred tx for relapse prevention in asthma exacerbation - Answer- short term oral corticosteroids Pt with decreased energy, weight loss, hypotension. Hyponatremia, hyperkalemia - Answer- Perform an ACTH stimulation test for adrenal insufficiency Sx of episodic hypotension in patient with pericardial effusion - Answer- Exaggerated decline of BP during systole - pulsus paradoxus (2/2 cardiac tamponade or pericarditis) Abx for men with UTI and c/f prostatits - Answer- Ciprofloxacin Abx c/i for UTI in men? - Answer- Nitrofurantoin is commonly used for lower UTI in women, avoid this agent in men with prostatitis because of concern about poor tissue penetration and risk of adverse effects from prolonged use first line treatment for gout - Answer- NSAIDs (indomethacin) 72yo F with previously controlled HTN p/w HTN and abdominal bruit - cause? - Answer- RAAS activation, 2/2 renal artery stenosis maintenance recommendation for pts with nonvalvular a fib - Answer- anticoagulation with warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban More effective than aspirin alone and ASA plus clopidogrel Increasing bone pain, local swelling, +/- pathologic fracture Elevated alk phos XR shows lytic lesion (early) then thickened boned with accentuated trabeculae at 1+ sites. Late: dense bone. Radionuclide scan shows increased focal uptake - Answer- Paget's Disease of the bone - increased bone turnover 37yo M with nonproductive cough, weight loss. Hx of uveitis. CXR shows hilar adenopathy, PPD negative - Answer- sarcoidosis intermittent hematuria in s/o lung cancer and an enlarged prostate - Answer- malignant transformation of epithelial cells Periorbital edema, Menorrhagia, Proximal muscle weakness and tenderness Weight gain Hyponatremia Hypercholesterolemia Mild elevation in Creatine Kinase - Answer- Check TSH - likely hypothyroid SOB Chest pain with exertion VSS Slow rising, sustained carotid pulse Displaced apical beat Harsh systolic murmur, peaks late - Answer- Bicuspid aortic valve most common lung ca in non smokers - Answer- adenocarcinoma of the lung lung cancers and smoking risk - Answer- small cell lung cancer- almost exclusively in smokers non small cell: adeno - most common non-smoking lung ca; squamous - most common lung cancer, seen in smokers, paraneoplastic 3 major causes of polyuria not in s/o DM - Answer- primary polydipsia, which is primarily seen in adults and adolescents central DI nephrogenic DI 2/2 defect in water balance leading to the excretion of large volumes of dilute urine (urine osmolality usually below 250 mosmol/kg) increased water intake middle-aged women and psych patients, including those taking a phenothiazine, which can lead to the sensation of a dry mouth. Can also be induced by hypothalamic lesions that directly affect the thirst center, eg in sarcoidosis - Answer- Primary polydipsia aka psychogenic Deficient secretion of antidiuretic hormone (ADH). - Answer- Central DI (also called neurohypophyseal or neurogenic DI) Causes of central DI - Answer- Most often idiopathic (possibly due to autoimmune injury to the ADH-producing cells) Trauma, pituitary surgery, or hypoxic or ischemic encephalopathy Rare familial cases Normal ADH secretion but varying degrees of renal resistance to its water-retaining effect. - Answer- Nephrogenic DI Causes of nephrogenic DI - Answer- Severe enough to produce polyuria: Hereditary nephrogenic DI in children, and chronic lithium ingestion and hypercalcemia in adults. Acquired causes are often at least partially reversible with cessation of the offending drug or correction of hypercalcemia Differentiate DI in adults - Answer- Central: abrupt onset Nephrogenic or primary: gradual Low plasma Na concentration (less than 137 mEq/L) with a low urine osm (eg, less than one-half the plasma osmolality) - Answer- Water overload due to primary polydipsia. High-normal plasma sodium concentration (greater than 142 mEq/L, due to water loss) particularly if the urine osmolality is less than the plasma osmolality - Answer- points toward DI Water deprivation test and DI - Answer- Primary: no change with desmopressin, should be 800 urine osm Nephrogenic: no change with desmopression, stays 300 Central: improves with desmopression, goes from 300 to 800 37yo F with 1 yr of heartburn, intermittent diarrhea with wt loss and Raynaud's. VSS normal, painful fingertip edema - Answer- Scleroderma Goldman Criteria for risk of periop MI - Answer- History: Age 70; MI within 6 mos (MI age) Exam: Sx of CHF or AoS (CHFAS) EKG: arrythmia or 5+ PVCs (=) Condition: lung, renal or liver dz, bedridden Operation: emergency? peritoneal, thoracic, aortic Biggest predictor is CHF exam, second is prior MI within 6 mos Rx for BPH and hair loss 5-alpha reductase inhibitor - Answer- Finasteride aks Propecia Cholinergic agonist For postop and postpartum urinary retention and neurogenic bladder - Answer- Bethanechol For BPH and HTN (not first line) Not recommended for geriatric - Answer- Terazosin, tamsulosin Antispasmodic, for overactive bladder in women, antimuscarinic - Answer- Oxybutynin HBV serology - vaccinated - Answer- Anti HBSurface Negative core, negative surface antigen HBV serology- susceptible - Answer- Surface antigen and ab and core ab all negative chronic vs acute HBV infection by serology - Answer- acute: postive surface antigen, positive core ab, positive IgM for core, negative surface ab chronic: same as above but NEGATIVE IgM core HBV serology: Negative surface antigen, Postive core antibody, negative surface antibody - Answer- -recovering from acute infection*** -distant immunity with low surface ab level -may be susceptible, false positive core ab -chronically infected with low surface antigen undetectable Farmworker with sudden HA, N/V, dizziness. Hypotensive with pinpoint pupils. - Answer- Decreased synaptic activity of cholinesterase 2/2 Organophosphorus compounds Bind acetylcholinesterase (AChE); inhibition leads to an overabundance of acetylcholine at the neuronal synapses and the neuromuscular junction. Give atropine to compete with ACh and then with -oxime to restore cholinesterase activity Triad of rheumatoid arthritis (RA), neutropenia, and splenomegaly - Answer- Felty syndrome RA: severe, erosive, and seropositive for RF and/or ACPA Neutropenia - absolute neutrophil counts 2000 Hypogonadism with Low T and normal FSH, LH - Answer- Secondary hypogonadism Check PRL, thyroid, cortisol, iron and MRI Hypogonadism with low T, and high FSH, LH - Answer- Primary hypogonadism - get a karyotype (Klinefelter most common) Cholesterol guidelines for adults - Answer- Screen every 5 years for normal pts Goal 200 200-239 = borderline, 240= high vestibular neuritis aka - Answer- labyrinthitis Vertigo, acute onset Viral prodrome Ability to ambulate Hearing intact Resolves spontaneously over week, +/- corticosteroids - Answer- Vestibular neuritis aka labyrinthitis no significant vertigo unilateral hearing loss or tinnitus - Answer- acoustic neuroma aka schwannoma grows slowly over time, more equilibration vertigo, unable to stand or walk +nystagmus - Answer- cerebral infarction most common cause of travelers diarrhea - Answer- Enterotoxigenic E coli - ETEC EHEC vs ETEC - Answer- EHEC = hrmorrhiagic, bloody Parasitic illness, often asx Subacute blood and mucus diarrhea - Answer- E histolytica GPC rods in well controlled HIV+ PNA pt - Answer- Tx with ceftriaxone to cover MRSA PSA coverage only for GNR culture, lung abnormalities,COPD Nerve most commonly injured in midshaft humerus fx - Answer- Radial Nerve injury findings in midshaft humerus fracture - Answer- Radial nerve: most common; weakness of wrist, finger, and thumb extension and some weakness of elbow supination. Test with "thumbs up" Median: uncommon; loss of hand and finger flexion with damage to anterior interosseus nerve; "OK sign," Ulnar nerve: rare; inability to abduct and adduct the fingers. "peace sign" possible hx Retinoblastoma Few/no systemic sx Large soft tissue mass, large and tender to palpation. Elevated alk phos, LDH,ESR - Answer- predisposing to soft tissue cancers/sarcoma e.g. osteosarcoma. osteosarcoma elevated LDH = bad px most common sites for osteosarcoma - Answer- the metaphyseal region of the long bones.