NBME 10

Question 1

What screening needs to be completed before starting TNF-a inhibitor therapy? i.e. for ulcerative colitis

Answer 1

Tuberculosis (due to risk of reactivation with latent infection)

Question 2

Treatment of sickle cell anemia

Answer 2

Aggressive pain control, rehydration with IV fluids, supplemental oxygen

Question 3

Shortness of breath after receiving large volume transfusion (4 units)

Answer 3

Transfusion related cardiac overload (TACO)

Question 4

Young woman with headache for 2 days and confusion followed by seizure (Fever, AMS, seizure, focal neurologic deficits (aphasia, hemiparesis))?

Answer 4

Herpes simplex encephalitis

***temporal lobe findings on imaging

Question 5

Stroke risk factors and tPA timeline eligibility

Answer 5

smoking, HTN, diabetes, carotid or atherosclerotic disease, hypercoagulability, afib, old age

• less than 4.5 hours- if you don’t know for sure they AIN’T a candidate

Question 6

Unilateral lymaphadenopathy (single lymph node on neck purplish in hue that expands over weeks to months, biopsy showing granulomas( in immunocompetent child

Answer 6

Mycobacterium spp.

Question 7

What meds do you avoid in right-sided heart failure?

Answer 7

Nitrates and opioid analgesics

Question 8

PAD vs. venous insufficiency

Answer 8

PAD: pain better with dangling leg, ulcers on lateral side of leg (distal digits more likely); hair loss/shiny skin

venous insufficiency: pain better with leg elevation, ulcers on medial side of leg (near medial malleolus)
- venous varicosities, bronze discoloration of leg, leg heaviness/swelling

Question 9

What testing should a pregnant woman with prior intrauterine fetal demise go through?

Answer 9

serial ultrasounds throughout pregnancy, screening for complicating medical conditions, non stress testing starting in 3rd trimester

Question 10

What test is used to determine diabetic patient’s risk for diabetic nephropathy?

Answer 10

measurement of urine albumin concentration

diabetic nephroapthy begins as microalbuminuria and progresses to macroalbuminuria then to CKD

Question 11

What can depress the progress of diabetic nephropathy?

Answer 11

ACE inhibitors

Question 12

Cytomegalovirus presentations in immunocompromised people (severe ulcerative colitis, solid-organ/bone marrow transplantation, HIV/AIDs)

Answer 12

Colitis, retinitis, esophagitis, encephalitis, pneumonia

• *Intracellular inclusion bodies on histologic exam
  tx: ganciclovir, acyclovir

Question 13

Work up for new-onset afib

Tx: diltiazem (non-dihydropiridine CCB), metoprolol, anticoagulation for those with risk of stroke

Answer 13

Should assess for all reversible causes of afib.

Risk for afib: HTN, coronary artery disease, structural heart or valvular disease, PE, lung disorders (COPD, obstructive sleep apnea), stimulant abuse, hyperthyroidism

Initial evaluation: TSH, high amounts of alcohol intake

Question 14

Acetaminophen or ketorolac for osteoarthritis?

Answer 14

Acetaminophen

Ketorolac is IM or IV so not good long term AND NSAID use not good long term b/c risk gastritis, peptic ulcer disease, diminished kidney function

Question 15

Normal BMI

Answer 15

18.5-24.9

Question 16

Multiple cholesterol emboli syndrome

Answer 16

Localized petechiae, lived reticularis, blue toe syndrome from emboli moving from larger arteries to smaller distal arteries (purplish black lesions over toes)

• histology of skin lesions would have needle-shaped clefts
• risk factors for dislodging clots= cardiac catheterization, aortic dissection
• *labs include increased creatinine and eosinophilia
• maltese crosses on UA (lipid droplets)

Question 17

Initial step in management of peritonsillar abscess?

Answer 17

Immediate need aspiration to prevent airway compromise

- Then start IV antibiotics

Question 18

Asthma lung study findings

FEV1:FVC ratio:

Answer 18

FEV1:FVC ration= decreased
Increased residual volume/total lung capacity (air trapping)
- decreased peak expiratory flow rate

Question 19

Restrictive lung disease FEV1:FVC ratio

Answer 19

Increased (decreased compliance leads to greater initial expiratory force)

Question 20

Most common pathogen of suppurative parotitis?

Answer 20

Staph aureus

Question 21

Imaging presentation of sigmoid volvulus

Answer 21

Dilated, air-filled sigmoid colon

Question 22

Patient on chronic steroids for dz w/ either recent surgery, trauma, or infection presenting with hypoglycemia, altered mental status, hyponatremia, tachycardia, and abnormal vasodilation

Answer 22

Consider adrenal crisis

Question 23

Caustic esophagitis initial work/up and tx

Answer 23

EGD to assess for severity; if mild- liquid diet, if severe- NPO for 72 hours then repeat EGD

• NBME says gastric lavage with NG tube not widely recommended

Question 24

Patient with hx breast adenocarcinoma presenting with focal to generalized tonic-clonic seizure, gaze preference, right lower facial droop, motor weakness, hypereflexia?

Answer 24

Brain metastasis

**lung, breast, colon, renal cell, melanoma

Question 25

Person who appears to have gonorrhoeae has negative cultures- what do you do?

Answer 25

Keep current regimen- cultures imperfectly sensitive

Question 26

Presentation and tx of pericarditis

Answer 26

Positional chest pain when leaning forward; ECG with diffuse ST segment elevations and/or PR segment depressions - patients with hypotension/hypoxia should be evaluated with Echo to determine if there is pericardial effusion Tx- high dose aspirin or NSAIDs with colchicine

Question 27

How to lower likelihood of aspiration in patients with swallowing dysfunction?

Answer 27

Thickened liquids

Question 28

Postpartum patient with signs of thyroiditis-- tx?

Answer 28

Metoprolol/propranolol --> post partum thyroiditis usually presents with hyperthyroidism followed by hypothyroidism or hypothyroidism alone that usually goes away within a year; tx above helps

Question 29

First line therapies for patients in cardiogenic shock

Answer 29

dobutamine, norepinephrine, dopamine - at middle doses dopamine stimulates B1 receptors and augments cardiac output

Question 30

What must be known in order to calculate NPV or PPV?

Answer 30

Disease prevalence; both vary with disease prevalence

Question 31

TCA overdose sxs and tx

Answer 31

Sxs: confusion, delirium, cardiac toxicity (prolonged QT interval), anticholinergic toxicity (dry mouth, sedation, constipation, hallucinations, delirium, flushed skin, visual disturbances, dilated pupils) Tx w/ sodium bicarb for cardiac toxicity and IV fluids for hypotension

Question 32

Tx of acute MS flare vs. outside of flare

Answer 32

Acute: dexamethasone Outside: interferon beta

Question 33

Stroke risk factors - by importance level

Answer 33

``` Age= strongest nonmodifiable risk factor HTN= strongest modifiable risk factor ``` - smoking, diabetes, atherosclerotic disease, hypercoagulability, afib

Question 34

Von willebrand disease presentation

Answer 34

mucosal bleeding in setting of normal platelet count, PT time, decreased factor VIII and increased bleeding time -prolonged PTT can occur sometimes due to decrease in VIII (vwf transports VIII in plasma, degrades rapidly when unbound) - Hemophilia A and inhibitor to factor VIII would present with MARKEDLY increased PTT

Question 35

Felty Syndrome

Answer 35

Suspect in patients w/ uncontrolled seropositive RA that present with neutropenia, pleurisy, new-onset fevers, and splenomegaly - Rituximab= tx of choice

Question 36

L4 radiculopathy vs common peroneal neuropathy

Answer 36

L4 - Foot dorsiflexion, diminished patellar reflex, decreased sensation over medial aspect of leg - Peroneal- food dorsiflexion (foot drop), eversion; sensory dorsal foot and LATERAL leg

Question 37

Who receives antibiotic prophylaxis prior to dental procedures?

Answer 37

Tx- amoxicillin Previous hx endocarditis, prosthetic valves, unprepared congenital cyanotic heart disease, valvular disease in transplanted heart

Question 38

Antibiotics contraindicated in pregnancy

Answer 38

Fluroquinolones, tetracyclines

Question 39

Imaging for PE

Answer 39

Spiral CT (CT angiography) NOT pulmonary angiography

Question 40

When should tdap vaccine be administered during pregnancy?

Answer 40

Between 27-36 weeks, every pregnancy | ***if patient acquires wound at any gestational age and has not had tDAP in 10 years, should receive it then

Question 41

Risk factors for endometrial cancer?

Answer 41

Age over 45 years, obesity, nulliparity, diabetes, genetics

Question 42

Patient with hx umbilical artery catheterization presents with persistent hypertension

Answer 42

Renal artery thrombosis --> decreased afferent blood flow-->increased renin--> increased aldosterone--> hypertension

Question 43

Management of foreign body aspiration

Answer 43

flexible or rigid bronchoscopy

Question 44

Loperamide

Answer 44

Anti-diarrheal agent

Question 45

Pituitary micro adenoma causing prolactin secretion

Answer 45

Treat with bromocriptine first and then resect if refractory to tx