NBME 12 discussion

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Its gotta be ITP because...

aplastic anemia will present with pancytopenia

acute leukemia you will see blasts in the smear

DIC has prolonged PT and PTT

Also with normal PT and PTT, and vastly decreased platelets (along with easy bruising and bleeding) it seems to be the only answer choice that fits the clinical vignette. Im too lazy to look up how TTP presents but I'd assume also with elevated PT and PTT?

Originally Posted by whoknows2012

Its gotta be ITP because...

aplastic anemia will present with pancytopenia

acute leukemia you will see blasts in the smear

DIC has prolonged PT and PTT

Also with normal PT and PTT, and vastly decreased platelets (along with easy bruising and bleeding) it seems to be the only answer choice that fits the clinical vignette. Im too lazy to look up how TTP presents but I'd assume also with elevated PT and PTT?

TTP would be decreased PC and increased BT with schistocytes and increased LDH with renal, CNS, fever, microangiopathic hemolytic anemia, thrombocytopenia

question...lady with jaundice and mass at head of pancreas. Which procedure releaves the jaundice?

Cholecystectomy
stent into common bile duct
stent into hepatic duct
stent into main pancreatic duct
Stent into cystic duct
placement of transjugular portosystemic shunt

Had no clue..

Also the one where The guy was stroked out with a CT of the head. I put Cholesterol plaque. Was the Most predisposing factor Hypertension?

And finally

THe guy undergoes a laparscopic cholecystectomy. Which thing cant the surgeon inspect?

Ileum
Jejunum
Pancreas
stomach
transverse colon(wrong).

I originally had pancreas but changed it.

Originally Posted by winkleweizen

question...lady with jaundice and mass at head of pancreas. Which procedure releaves the jaundice?

Cholecystectomy
stent into common bile duct
stent into hepatic duct
stent into main pancreatic duct
Stent into cystic duct
placement of transjugular portosystemic shunt

Had no clue..

Also the one where The guy was stroked out with a CT of the head. I put Cholesterol plaque. Was the Most predisposing factor Hypertension?

And finally

THe guy undergoes a laparscopic cholecystectomy. Which thing cant the surgeon inspect?

Ileum
Jejunum
Pancreas
stomach
transverse colon(wrong).

I originally had pancreas but changed it.

Head of the pancreas obstructs CBD.

I think the other question is asking about what is retroperitoneal. Pancreas is mostly retroperitoneal.

Originally Posted by kstreet

Head of the pancreas obstructs CBD.

I think the other question is asking about what is retroperitoneal. Pancreas is mostly retroperitoneal.

THanks ya


Mother F. I knew it was getting at retroperitoneal but for some reason i was thinking transverse was retro and the ascending and descending werent. Got it mixed up

Originally Posted by kstreet

A 54 yo woman comes to the doc for a follow up exam. 2 months ago she was dx'd with hypertension and rx'd with hydrochlorothiazide. BP today is 150/100 compared with 165/108 two months ago, and serum K is 3.2 vs 4.5 two months ago. Addition of which of the following medications is most likely to further decrease bp and restore K to normal?

A. Atenolol
B. Furosemide
C. Losartan
D. Nifedipine
E. Prazosin


A 25 yo man is lost in the desert for 1 week with plenty of water but no food, what changes in enzyme activity and molecule concentrations in live is most likely in this pt.

Up and Down arrows for

Fructose 2,6, bisphosphate
Glucose 6-phosphatase
PEP Carboxykinase
Pyruvate Kinase


Thanks for the help!

on the fasting one, this is liver specific right? I'm gonna go with:

At a week you are pretty well spent and mostly using keto acids yea?
Hmm so you definitely are NOT doing glycolysis - so

F2,6BP down
Pyruvate kinase down

But are you doing gluconeogenesis? I think you still are.

G6Pase up
PEPCK up


opinions welcome

Section 1:
29. Women doesn't have menstral period for 3 months. Lost 20lbs weight since mother's death. Is it altered GnRH hormone pulses or premature ovarian failure?

Section 2:
9. 30 weeks Pregnant women with lower left sternal border murmur and splitting of S2 that is more pronounced with inspiration. What is the best explanation? Is this a normal physiologic response? (sounds normal to me... like a high output cardiac murmur and a normal split S2)

21. Boy has coughing, wheezing and rapid breathing? Upper respiratory infection 2 days ago. Inspiratory/Expiratory wheezes. Decreased tactile fremitus. Asthma or Bronchitis? Leaning towards post-infectious bronchitis but not sure.


Section 3:
43. How does nictine stimulate pleasure and addition? Via the opiod receptors in the midbrain or dopmaine in the nucleus accumbens?

Section 4:
18. A 6 hour old female newborn has a harsh systolic murmur at the left upper sternal border. Findings on physical examination are otherwise unremarkable. Three hours later, the murmur has a diastolic component. Twelve hours later, there is no murmur, and ultrasonography discloses no cardiac abnormalities. Whcih fo the following is the most likely cause of the murmur.
Is this typical of PDA? What explains the switch between the systolic and diastolic if so?

Originally Posted by RapplixGmed

Section 1:
29. Women doesn't have menstral period for 3 months. Lost 20lbs weight since mother's death. Is it altered GnRH hormone pulses or premature ovarian failure?

Section 2:
9. 30 weeks Pregnant women with lower left sternal border murmur and splitting of S2 that is more pronounced with inspiration. What is the best explanation? Is this a normal physiologic response? (sounds normal to me... like a high output cardiac murmur and a normal split S2)

21. Boy has coughing, wheezing and rapid breathing? Upper respiratory infection 2 days ago. Inspiratory/Expiratory wheezes. Decreased tactile fremitus. Asthma or Bronchitis? Leaning towards post-infectious bronchitis but not sure.


Section 3:
43. How does nictine stimulate pleasure and addition? Via the opiod receptors in the midbrain or dopmaine in the nucleus accumbens?

Section 4:
18. A 6 hour old female newborn has a harsh systolic murmur at the left upper sternal border. Findings on physical examination are otherwise unremarkable. Three hours later, the murmur has a diastolic component. Twelve hours later, there is no murmur, and ultrasonography discloses no cardiac abnormalities. Whcih fo the following is the most likely cause of the murmur.
Is this typical of PDA? What explains the switch between the systolic and diastolic if so?

29) altered GNRH
9) yeah i think this must be normal. I missed this too
21) Pretty sure it was asthma
43) Dopamine in nucleus accumbens
16) Its PDA no clue if its typical haha. The way the question reads I dont think it says it switches from Systolic to Diastolic...i think it ADDS a diastolic thus being "a continuous machine like murmur".









Now i have one. The lady with a stroke and a big white thing in her brain on MRI...so was it due to hypertension and if so was that a rupture of a berry aneurysm then?

Originally Posted by winkleweizen

29) altered GNRH
9) yeah i think this must be normal. I missed this too
21) Pretty sure it was asthma
43) Dopamine in nucleus accumbens
16) Its PDA no clue if its typical haha. The way the question reads I dont think it says it switches from Systolic to Diastolic...i think it ADDS a diastolic thus being "a continuous machine like murmur".









Now i have one. The lady with a stroke and a big white thing in her brain on MRI...so was it due to hypertension and if so was that a rupture of a berry aneurysm then?

It was an AVM

Originally Posted by SlaveOfTCMC

It was an AVM

Thanks, how do you know?

45 yo man has symptoms of MI. Pulse is 100, RR = 14, BP is 170/100, and has a grade 3 holosystolic mumur heard at cardiac apex. After MONA, , BP decreases to 120/60 and reauscultation fails to detect murmur. What is most likely cause?
Is is acute aortic valve insufficiency or Papillary muscle ischemia?
I chose papillary muscle ischemia, but i think some people said answer was aortic valve insufficiency.

Originally Posted by wannabedocta

45 yo man has symptoms of MI. Pulse is 100, RR = 14, BP is 170/100, and has a grade 3 holosystolic mumur heard at cardiac apex. After MONA, , BP decreases to 120/60 and reauscultation fails to detect murmur. What is most likely cause?
Is is acute aortic valve insufficiency or Papillary muscle ischemia?
I chose papillary muscle ischemia, but i think some people said answer was aortic valve insufficiency.

I went with pap ischemia. Aortic insufficiency doesn't make any sense since the murmur is systolic.

Originally Posted by Scean

on the fasting one, this is liver specific right? I'm gonna go with:

At a week you are pretty well spent and mostly using keto acids yea?
Hmm so you definitely are NOT doing glycolysis - so

F2,6BP down
Pyruvate kinase down

But are you doing gluconeogenesis? I think you still are.

G6Pase up
PEPCK up


opinions welcome

Def, you got this one. I think I mixed up Pyruvate Kinase with Pyruvate Carboxylase on this one.

Originally Posted by kstreet

Def, you got this one. I think I mixed up Pyruvate Kinase with Pyruvate Carboxylase on this one.

Actually nix that...at a week the pt would be in starvation state. The following from Rapid Review Biochem:

After 3-5 days of fast, body increases reliance on ketones/FFA.

Liver metabolism in starvation state, the rate of gluconeogenesis decreases as supply of AA carbon skeletons from muscle protein decreases.

Glycerol released by lipolysis in adipose supports a low level of glunconeogenesis in the liver, which is only tissue that contains glycerol kinase.

Glycerol ->Glycerol 3P -> DHAP ->>> Glucose

FFA Oxidation continues at a high lvl

Acetyl CoA acummulates as TCA cycle slows down. Elevated Acetyl CoA is shunted to ketones. This ketoacidosis is hallmark of starvation state.

Increased Epi from stress with very low insulin increases activity of hormone sensitive lipase, which further stimulates stores fat.

Muscle breakdown decreases as demand for blood glucose is reduced due to a reduction in gluconeogenesis.

Early in starvation FFA and ketones are used by muscles. Later in starvation, muscle primary fuel is FFA as ketones are spared for brain.

Brain increasingly uses ketones as a way to spare glucose for RBC.




OK, so long story short

In the liver I think you would see a decrease in all hormones, because liver would basically only be functioning to make glucose from glycerol and ketones from FFA. Maybe only an increase in Glucose 6 Phosphatase b/c it's the only enzyme being used within the glycerol -> glucose pathway?

two quick questions that havent been covered, thanks in advance:

1.) 16 yo type 1 diabetic with weight loss, low BMI, and increased HbA1c: What's she doing? Decreasing her insulin doses or restricting caloric consumption (decreasing insulin would make sense but wouldnt restricting caloric consumption boost her gluconeogenesis pathways and raise her blood glucose levels too or is that a stretch haha?)

On another note, lets say her HbA1c decreased (which is what i initially misread the question as saying) along with the weight loss: would the problem be overexercise or restricting calories or could it be either?

2.) man with premature ejaculation: do you give him an ssri or viagra?

Originally Posted by Pete Sampras

two quick questions that havent been covered, thanks in advance:

1.) 16 yo type 1 diabetic with weight loss, low BMI, and increased HbA1c: What's she doing? Decreasing her insulin doses or restricting caloric consumption (decreasing insulin would make sense but wouldnt restricting caloric consumption boost her gluconeogenesis pathways and raise her blood glucose levels too or is that a stretch haha?)

On another note, lets say her HbA1c decreased (which is what i initially misread the question as saying) along with the weight loss: would the problem be overexercise or restricting calories or could it be either?

2.) man with premature ejaculation: do you give him an ssri or viagra?

1) didnt the stem say she found out that she could stay skinny if she stopped taking her insulin?

2) SSRI was the answer, http://www.medpagetoday.com/Urology/...sfunction/4066

This is probably a simple question - but I can't quite figure it out.

Child with signs and symptoms of diabetes (weight loss, excessive urination, fruity odor). Blood glucose = 600ish. What would you expect to be decreased?

Serum potassium, serum acetone, pCO2, pO2, serum triglycerides, BUN

Thanks guys.

Originally Posted by Curb

This is probably a simple question - but I can't quite figure it out.

Child with signs and symptoms of diabetes (weight loss, excessive urination, fruity odor). Blood glucose = 600ish. What would you expect to be decreased?

Serum potassium, serum acetone, pCO2, pO2, serum triglycerides, BUN

Thanks guys.

I think the answer was pCO2 because he is in DKA so first thing is resp compensation. So your potassium in the serum is high because all the H's are trying to go inside. Serum acetone is high because you are breaking down fats. pO2 is high because you are hyperventilating. Triglycerides and BUN should be high too because of fat and protein breakdown. I think this is right. Please feel free to correct me.

Originally Posted by SeekerOfTheTree

I think the answer was pCO2 because he is in DKA so first thing is resp compensation. So your potassium in the serum is high because all the H's are trying to go inside. Serum acetone is high because you are breaking down fats. pO2 is high because you are hyperventilating. Triglycerides and BUN should be high too because of fat and protein breakdown. I think this is right. Please feel free to correct me.

Ahhh... yeah I knew it was something really basic I was forgetting. Thanks!

Help me! I have a few questions. Kidney was my best and this one wrecked my world.

30) Basically a 56 year old guy with 80/40 BP is in Sugar overload and is unconscious on a bathroom floor.

Na is 133
K is 6.7
Glucose is 900
Creatine 3.8

PH is 6.98
PCO2 is 13
PO2 is 128

The question was which of the following best represents the renal comp response to the acid-base findings in thsi patient?

A) Decreased H secretion into the tubule
B) Decreased proximal tubule HCO3 reabsoprtion
C) Decreased titratable acid excretion
D) Increased HCO3 excretion
E) Increased NH4CL excretion

I talked myself out of E. Can someone help explain?

Does anyone remember the girl with MS that has been in remission for 2 years. She had a PH of 7.12 and a PCO2 of 76. Her PO2 sucked too at 50. She as stuporous and in and out but could be aroused by stimuli. Not sure what kind of stimuli they were using to arouse her but it worked. On top of that she was only taking 8 breaths per minute. The answer choices were
A) ARDS
B) Aspiration pneumonia
C) Opiod overdose
D) Pulmonary Embolism
E) Upper airway obstruction

It is no way that it is C right? I mean they wouldn't just make it an opiod overdose would they? I couldn't figure out what to pick because there had to be something causing her to not breathe much.

Last Question. Some 41 year old lady with renal artery stenosis. They ask the systemic hypertension in this patient is directly mediated by vasoconstrictor that emerges from which of the following?

A) Adrenal medullary chromaffin cells
B) Glomerular afferent arteriole
C) Glomerular efferent arteriole
D) Pulmonary vasculature
E) Renal Juxtaglomerular cells

Should the anser be the pulmonary vasculature because Angio II is being made there thanks to ACE?

Originally Posted by SeekerOfTheTree

Help me! I have a few questions. Kidney was my best and this one wrecked my world.

30) Basically a 56 year old guy with 80/40 BP is in Sugar overload and is unconscious on a bathroom floor.

Na is 133
K is 6.7
Glucose is 900
Creatine 3.8

PH is 6.98
PCO2 is 13
PO2 is 128

The question was which of the following best represents the renal comp response to the acid-base findings in thsi patient?

A) Decreased H secretion into the tubule
B) Decreased proximal tubule HCO3 reabsoprtion
C) Decreased titratable acid excretion
D) Increased HCO3 excretion
E) Increased NH4CL excretion

I talked myself out of E. Can someone help explain?

Does anyone remember the girl with MS that has been in remission for 2 years. She had a PH of 7.12 and a PCO2 of 76. Her PO2 sucked too at 50. She as stuporous and in and out but could be aroused by stimuli. Not sure what kind of stimuli they were using to arouse her but it worked. On top of that she was only taking 8 breaths per minute. The answer choices were
A) ARDS
B) Aspiration pneumonia
C) Opiod overdose
D) Pulmonary Embolism
E) Upper airway obstruction

It is no way that it is C right? I mean they wouldn't just make it an opiod overdose would they? I couldn't figure out what to pick because there had to be something causing her to not breathe much.

Last Question. Some 41 year old lady with renal artery stenosis. They ask the systemic hypertension in this patient is directly mediated by vasoconstrictor that emerges from which of the following?

A) Adrenal medullary chromaffin cells
B) Glomerular afferent arteriole
C) Glomerular efferent arteriole
D) Pulmonary vasculature
E) Renal Juxtaglomerular cells

Should the anser be the pulmonary vasculature because Angio II is being made there thanks to ACE?

30) you are trying to compensate for the acidosis and how can you do that...squirt some H+ into the lumen which can then be made to NH4Cl(titratable acid) and you piss it out.

The girl did indeed overdose on opiods, what else out of those options would cause resp depression? I guess she was taking the opiods for pain from the MS.


And to your last question...i think its a pretty crappy question I put Afferent arteriole cause i figured Renin was more DIRECT then the other options, but the answer was pulm vasculature which would release ACE causing conversion of ACEI to ACEII. I dont think ACE would really be considered as directly mediating it, but they do so meh.

Originally Posted by winkleweizen

30) you are trying to compensate for the acidosis and how can you do that...squirt some H+ into the lumen which can then be made to NH4Cl(titratable acid) and you piss it out.

The girl did indeed overdose on opiods, what else out of those options would cause resp depression? I guess she was taking the opiods for pain from the MS.


And to your last question...i think its a pretty crappy question I put Afferent arteriole cause i figured Renin was more DIRECT then the other options, but the answer was pulm vasculature which would release ACE causing conversion of ACEI to ACEII. I dont think ACE would really be considered as directly mediating it, but they do so meh.

Thanks man. I talked myself out of those answers thinking, it can't be that. That pulm vasculature one was a curve ball. Stupid NBME people. I hate them.

Originally Posted by ArcGurren

Few questions which I feel like I shouldn't have missed but did... oh well:.....

5. 3 month old boy with hypoglycemia, hypoketonemia, lactic acidosis, and hypercholesterolemia 4 hours after feeding; giving glucagon does not increase blood glucose and only worsens lactic acidosis by increasing lactate; what enzyme deficiency is this?

Answers: Fructose 1,6 bisphosphatase, Galactose 1 phosphate uridyltransferase, glucose-6-phosphatase, alpha 1,4 glucosidase, MCAD deficiency (said MCAD deficiency, was between this and glucose-6-phosphate)

Sorry if this is answered already, I just took this yestterday so I stayed out of this discussion. I didn't see it answered on this page.

I think 5 is Decreased Glucose-6-Phosphatase. This looks a lot like Von Gierke's. Severe low blood sugar, big liver, and high lactate.

Originally Posted by mastamark

Sorry if this is answered already, I just took this yestterday so I stayed out of this discussion. I didn't see it answered on this page.

I think 5 is Decreased Glucose-6-Phosphatase. This looks a lot like Von Gierke's. Severe low blood sugar, big liver, and high lactate.

Yes you are right

MOreover, hypoketonemia makes fatty acid metabolism less likely, and MCAD deficiency would have those dicarboxylic acids.

17 year old M 2 months post bone marrow transplant shows up with fever and crackles. lung biopsy is shown.

decreased function of which cell type predisposed the patient:

dendritic
eosiniphils
macs
neuts
T

anyone?
i think the biopsy is supposed to help with this, but i am terrible at pictures.

--lol typing this out made me realize that it is interstitial pneumonia which could be viral, so probably tcells?

Originally Posted by reedman

17 year old M 2 months post bone marrow transplant shows up with fever and crackles. lung biopsy is shown.

decreased function of which cell type predisposed the patient:

dendritic
eosiniphils
macs
neuts
T

anyone?
i think the biopsy is supposed to help with this, but i am terrible at pictures.

Depends on what the pic shows. My assumption would be that dendritic, eosinophils, macs, and neutros would all come from the bone marrow so any kind of fungal or bacterial infection would get smoked. If it is a viral infection the T cells might be the ones lacking. I can't remember it without the picture. I keep wanting to say T cells because pre transplant they would have to kill those off in both host and receiver because those would try to attach the bone marrow from the host. Anybody have any thoughts? Am I talking out of my other end here?

If it's fungal then it could be neutrophils too. Did the picture show branching hyphae by any chance?

Originally Posted by reedman

17 year old M 2 months post bone marrow transplant shows up with fever and crackles. lung biopsy is shown.

decreased function of which cell type predisposed the patient:

dendritic
eosiniphils
macs
neuts
T

anyone?
i think the biopsy is supposed to help with this, but i am terrible at pictures.

--lol typing this out made me realize that it is interstitial pneumonia which could be viral, so probably tcells?

The biopsy showed the cowdry bodies of CMV. T-cells are deficient.

Originally Posted by RapplixGmed

The biopsy showed the cowdry bodies of CMV. T-cells are deficient.

word. i went back and saw it. for some reason the photos are hard for me. if somebody asked "is this CMV?" i would have said yes, but i didn't think to look for it at the time.

Long-time lurker. First-time poster. I thought NBME 12 was the hardest of all the NBMEs, so I have a few questions. Thanks in advance for helping me out! Good luck to everyone studying and taking their test this month!!


1. 30 y/o female with 7 week history of palpitations and shortness of breath. Her pulse was high and respiratory rate was high. Non-palpable thyroid, no exophthalmos, TSH was low, T4 was slightly elevated, Iodine uptake was low, thyroglobulin was low, thyroglobulin antibodies low.

Answer choices: exogenous use of levothyroxine, lymphocytic infiltrate of thyroid gland, mutation activation in the TSH receptor, stimulation by cytokines of B lymphocytes against thyroid antigens, tumor production of bHCG

2. 20 y/o female who ingested a ton of acetaminophen after her boyfriend broke up with her (she had only been on 2 dates with him). She said “I loved him more than anything in my life. I was going to marry him. Now I hate his guts.” She tells the physician “You’re the only one who has understood how I feel.” What’s the personality disorder?

Answer choices: borderline, dependent, histrionic, narcissistic, obsessive-compulsive

3. 16 month old girl who has arm in pronation after her brother pulled her to keep her from crossing the street. Any motion of the right elbow produces pain.

Answer choices: dislocation of shoulder, fracture of distal radius and ulna, Salter-Harris type I fracture of the humerus, septic arthritis, sublaxation of the radial head

4. 55 y/o male who was shoveling snow and collapsed. He had weakness and tingling in upper and lower extremities before he collapsed. Now he has positive Babinski on left. CT shows brain bleed on the right. What’s the strongest predisposing risk factor?

Answer choices: cholesterol plaque, cigarette smoke, DVT, hypertension, vasculitis

5. 24 y/o female who has been vomiting for 4 hours. 2 day hx of fatigue and dizziness on standing. Heartburn for 3 months, antacids provided some relief. Pulse and respiration are high. BP is 90/75. She’s anemic. What is most likely to be decreased?

Answer choices: Alveolar PO2, Arterial O2-carrying capacity, Arterial oxyhemoglobin saturation, Arterial P50 (partial pressure), Arterial PO2. I think it’s arterial PO2 because she’s in metabolic alkalosis, but I’m not sure. The anemia threw me off.

6. There was a question about an elderly woman with Alzheimer’s and they wanted to know where the lesion was. I guess the answer was hippocampal formation, but why not the basal forebrain? I know the hippocampus is involved in memory, but the basal forebrain is the location of the basal nucleus of Meynert which is where ACh is made. Help!

7. Woman gets a cochlear implant. The prosthesis converts sound energy into electrical signals which stimulate which of the following?

Answer choices: auditory nerve endings in the cochlea, cochlear nerves as it enters the pons, inner hair cells of the cochlea, olivocochlear efferent axons that innervate outer hair cells, oval window of the cochlea

8. 35 y/o female with embolus in left pulmonary artery after surgery. What change would be seen after lysis of the clot?

Answer choices: decreased LV pressure, decreased pulmonary venous pressure, decreased RV pressure, increased LA pressure, increased pulmonary artery pressure, increased RA pressure

Originally Posted by browni

Long-time lurker. First-time poster. I thought NBME 12 was the hardest of all the NBMEs, so I have a few questions. Thanks in advance for helping me out! Good luck to everyone studying and taking their test this month!!


1. 30 y/o female with 7 week history of palpitations and shortness of breath. Her pulse was high and respiratory rate was high. Non-palpable thyroid, no exophthalmos, TSH was low, T4 was slightly elevated, Iodine uptake was low, thyroglobulin was low, thyroglobulin antibodies low.

Answer choices: exogenous use of levothyroxine, lymphocytic infiltrate of thyroid gland, mutation activation in the TSH receptor, stimulation by cytokines of B lymphocytes against thyroid antigens, tumor production of bHCG

2. 20 y/o female who ingested a ton of acetaminophen after her boyfriend broke up with her (she had only been on 2 dates with him). She said “I loved him more than anything in my life. I was going to marry him. Now I hate his guts.” She tells the physician “You’re the only one who has understood how I feel.” What’s the personality disorder?

Answer choices: borderline, dependent, histrionic, narcissistic, obsessive-compulsive

3. 16 month old girl who has arm in pronation after her brother pulled her to keep her from crossing the street. Any motion of the right elbow produces pain.

Answer choices: dislocation of shoulder, fracture of distal radius and ulna, Salter-Harris type I fracture of the humerus, septic arthritis, sublaxation of the radial head

4. 55 y/o male who was shoveling snow and collapsed. He had weakness and tingling in upper and lower extremities before he collapsed. Now he has positive Babinski on left. CT shows brain bleed on the right. What’s the strongest predisposing risk factor?

Answer choices: cholesterol plaque, cigarette smoke, DVT, hypertension, vasculitis

5. 24 y/o female who has been vomiting for 4 hours. 2 day hx of fatigue and dizziness on standing. Heartburn for 3 months, antacids provided some relief. Pulse and respiration are high. BP is 90/75. She’s anemic. What is most likely to be decreased?

Answer choices: Alveolar PO2, Arterial O2-carrying capacity, Arterial oxyhemoglobin saturation, Arterial P50 (partial pressure), Arterial PO2. I think it’s arterial PO2 because she’s in metabolic alkalosis, but I’m not sure. The anemia threw me off.

6. There was a question about an elderly woman with Alzheimer’s and they wanted to know where the lesion was. I guess the answer was hippocampal formation, but why not the basal forebrain? I know the hippocampus is involved in memory, but the basal forebrain is the location of the basal nucleus of Meynert which is where ACh is made. Help!

I think the question was trying to get at why she was having memory problems not the pathogenesis of Alz...I think.

7. Woman gets a cochlear implant. The prosthesis converts sound energy into electrical signals which stimulate which of the following?

Answer choices: auditory nerve endings in the cochlea, cochlear nerves as it enters the pons, inner hair cells of the cochlea, olivocochlear efferent axons that innervate outer hair cells, oval window of the cochlea

8. 35 y/o female with embolus in left pulmonary artery after surgery. What change would be seen after lysis of the clot?

Answer choices: decreased LV pressure, decreased pulmonary venous pressure, decreased RV pressure, increased LA pressure, increased pulmonary artery pressure, increased RA pressure

I believe these are right. If I am wrong someone correct me.

3 questions:

Question directs you attention to the boys tongue and red cheeks. What does he have? I just rmb: Kawasaki, ARF, and Scarlet Fever.

Young mice and older mice. Older mice showed a deficient immunological response. This is due to deficiency of what? Mac, PMN, lymphocytes (I think.. and others)

They want to do a study of setting up a registry to see who needs a colonoscopy and if it can reduce colon ca. In doing so, they found reduce mortality. What is it about this study that supports the study? Ans: Accuracy, precision, external validation, face validation, and one more that eludes me...

Thanks!

Originally Posted by fuzzywuz

3 questions:

Question directs you attention to the boys tongue and red cheeks. What does he have? I just rmb: Kawasaki, ARF, and Scarlet Fever.

Young mice and older mice. Older mice showed a deficient immunological response. This is due to deficiency of what? Mac, PMN, lymphocytes (I think.. and others)

They want to do a study of setting up a registry to see who needs a colonoscopy and if it can reduce colon ca. In doing so, they found reduce mortality. What is it about this study that supports the study? Ans: Accuracy, precision, external validation, face validation, and one more that eludes me...

Thanks!

THe first one is kawasaki...I think they mentioned something about coronary vessels if we are thinking of the same question.

Dont remember the second question...you would have to give me the whole stem

Last one is external validation.

Thanks, SeekerOfTheTree! Some of the answers are so obvious now! It's like...DUH, what was I thinking?!

Going back, I realize I made a lot of stupid mistakes. Several that I missed were asking about concepts that I understand, but I just read too quickly or tripped myself up by over-thinking. Hopefully I can avoid that on test day!

18 month old boy is bought to ER after 20 minutes sudden onset dificulty breathing while playing outside. Ausculation of chest shows decrease air movement on right and wheezes are heard. Which of the following.
a-anaphylactic reaction
b-bronchiolits
c-foreign body aspiration
d-pneumonia
e-spontaneous pneumo (wrong)

I think its c- based that he didnt have a fever-hes a kid and its on the right where we dont hear breath sounds...
anyone?

Originally Posted by MDbear

18 month old boy is bought to ER after 20 minutes sudden onset dificulty breathing while playing outside. Ausculation of chest shows decrease air movement on right and wheezes are heard. Which of the following.
a-anaphylactic reaction
b-bronchiolits
c-foreign body aspiration
d-pneumonia
e-spontaneous pneumo (wrong)

I think its c- based that he didnt have a fever-hes a kid and its on the right where we dont hear breath sounds...
anyone?

Yes this is indeed the answer.

Your instincts are correct for choosing C.

Remember a paraseptal emphysema (leading to spontaneous pneumothorax) tends to occur in 20 year olds .

thank you fors such a quick response! you are right...sometimes the age alone tells you the diagnosis..

heres a few that are bothering me

1. 3 yr old brought to ER pain in r leg after fall, 6mnth hx intermittent pain in legs at night, unable to keep up with peers while playing, eval shows fracture r fib, also gluteal musc weakness. Measurement of which can confirm dx?

ESR, CK, Hydroxyproline, IG, RF.....i chose hydroxyproline, assuming he had bone breakdown...what does he have?

2. 45 yo female hx of MS, remssion 2 yrs, presents ER stupor, temp 99, pulse 72, RR 8, BP 116/66, dec lung volumes, CTA, breath sounds distant, minimal gag reflex, when aroused combative and moves all 4 extremities, ph 7.12, pco2 76 po2 50

ARDS, Aspire Pneum, Opiod, PE, Upper airway obstruct....chose upper airway...but looking at vitals prob opiod..if so why are her breath sounds distant?

3. The 56 yr old alcoholic w fould stool, weight loss, sever abd pain, drinks bottle of wine, temp 98, epigastric tender, glucose 150, pancreatic calcif.. What decreased to cause sx?

bile acid synth, colonic bact, duodenal ph, fecal elastase, 7a hydroxylase

4. What hemodynamic changes occur lysis of PE?

dec. LV press, dec. pulm ven press, dec RV press, inc LA press(wrong), inc Pulm Art press, inc RA press?

5. 7 day old swelling eyelids w discharge for 2 days, treated w silver nitrate at birth, copious purulent discharge, chemosis bilaterall, giemsa shows blue intracytoplasmic inclusion, culture grows no pathogen.. What does he have?

Adeno, Chlamydia trachomatis(i thought silver nitrate prevents this), coxsackie, Neiss gonorrh, pseudomans aeur, rubella?

thanks all

Originally Posted by dizzfire

heres a few that are bothering me

1. 3 yr old brought to ER pain in r leg after fall, 6mnth hx intermittent pain in legs at night, unable to keep up with peers while playing, eval shows fracture r fib, also gluteal musc weakness. Measurement of which can confirm dx?

ESR, CK, Hydroxyproline, IG, RF.....i chose hydroxyproline, assuming he had bone breakdown...what does he have?

2. 45 yo female hx of MS, remssion 2 yrs, presents ER stupor, temp 99, pulse 72, RR 8, BP 116/66, dec lung volumes, CTA, breath sounds distant, minimal gag reflex, when aroused combative and moves all 4 extremities, ph 7.12, pco2 76 po2 50

ARDS, Aspire Pneum, Opiod, PE, Upper airway obstruct....chose upper airway...but looking at vitals prob opiod..if so why are her breath sounds distant?

3. The 56 yr old alcoholic w fould stool, weight loss, sever abd pain, drinks bottle of wine, temp 98, epigastric tender, glucose 150, pancreatic calcif.. What decreased to cause sx?

bile acid synth, colonic bact, duodenal ph, fecal elastase, 7a hydroxylase

4. What hemodynamic changes occur lysis of PE?

dec. LV press, dec. pulm ven press, dec RV press, inc LA press(wrong), inc Pulm Art press, inc RA press?

5. 7 day old swelling eyelids w discharge for 2 days, treated w silver nitrate at birth, copious purulent discharge, chemosis bilaterall, giemsa shows blue intracytoplasmic inclusion, culture grows no pathogen.. What does he have?

Adeno, Chlamydia trachomatis(i thought silver nitrate prevents this), coxsackie, Neiss gonorrh, pseudomans aeur, rubella?

thanks all

1) it's Duchenne's. Yeah I know I didn;t know about the fracture correlation (i found it in a paper). But the rest of the symptoms screamed Duchenne's. They simply didn't explicitly say Gower's manuerver or mention a fibrofatty replacement. (answer serum CK)

2) The answer is opioid overdose. The serum blood gases and respiratory depression are fairly clear.

Moreover, opioids are often used for the chronic pain that MS patients experience. Yeah I know chronic pain is not part of First AId's SIIIN mnemonic, but it is there. Google up a paper.

3) It's not fecal elastase (though that was a tempting answer) Others have posited that this was a gastrinoma.

4) After you lyse a large PE, pulmonary artery flow resumes and the RV ventricle is no longer backed up (hence pressure goes down)

5) The answer was Chlamydia. Expanded feedback didnt mark me wrong. I thought the same about the silver. Unsure why exactly.

Originally Posted by dizzfire

heres a few that are bothering me

1. 3 yr old brought to ER pain in r leg after fall, 6mnth hx intermittent pain in legs at night, unable to keep up with peers while playing, eval shows fracture r fib, also gluteal musc weakness. Measurement of which can confirm dx?

ESR, CK, Hydroxyproline, IG, RF.....i chose hydroxyproline, assuming he had bone breakdown...what does he have?

2. 45 yo female hx of MS, remssion 2 yrs, presents ER stupor, temp 99, pulse 72, RR 8, BP 116/66, dec lung volumes, CTA, breath sounds distant, minimal gag reflex, when aroused combative and moves all 4 extremities, ph 7.12, pco2 76 po2 50

ARDS, Aspire Pneum, Opiod, PE, Upper airway obstruct....chose upper airway...but looking at vitals prob opiod..if so why are her breath sounds distant?

3. The 56 yr old alcoholic w fould stool, weight loss, sever abd pain, drinks bottle of wine, temp 98, epigastric tender, glucose 150, pancreatic calcif.. What decreased to cause sx?

bile acid synth, colonic bact, duodenal ph, fecal elastase, 7a hydroxylase

4. What hemodynamic changes occur lysis of PE?

dec. LV press, dec. pulm ven press, dec RV press, inc LA press(wrong), inc Pulm Art press, inc RA press?

5. 7 day old swelling eyelids w discharge for 2 days, treated w silver nitrate at birth, copious purulent discharge, chemosis bilaterall, giemsa shows blue intracytoplasmic inclusion, culture grows no pathogen.. What does he have?

Adeno, Chlamydia trachomatis(i thought silver nitrate prevents this), coxsackie, Neiss gonorrh, pseudomans aeur, rubella?

thanks all

1. Pt has duchenne's muscular dystrophy. Think pain, weakness, esp central weakness (gluteal), you want to check CK.

2. Opiod, no respiratory effort will cause distant breath sounds.

3. decreased pH, no bicarb production by pancreas

4. decreased RV pressure. Reduction in pulmonary resistance will decrease RV pressure. (overload of RV is why people die suddenly in PE so this is an important point)

5. This is definitely chlamydia. When did you go to med school? its been known since the 80s that silver nitrate doesn't work very well for preventing chlamydia opthalmia.

Originally Posted by RapplixGmed

5. When did you go to med school? its been known since the 80s that silver nitrate doesn't work very well for preventing chlamydia opthalmia.

My medical school wants all of us to be primary care physicians and serve the North Eastern Pennsylvania.

One of my classmates was even "strongarmed" by the dean in a public function. The [former] dean approached him and asked him "so you plan to stay in NEPA?" under incredible duress.

Originally Posted by SlaveOfTCMC

The [former] dean approached him and asked him "so you plan to stay in NEPA?" under incredible duress.

Wow it would suck to be in that position.

any thoughts on which organ can't be seen? pancreas, stomach, transverse colon, ileum, jejunum...

Originally Posted by ruraldr

any thoughts on which organ can't be seen? pancreas, stomach, transverse colon, ileum, jejunum...

Pancreas. (most of its retroperitoneal)

#3--I answered E-cadherin and got it as a wrong answer.....

Originally Posted by Scean

1. serratus anterior. Level is above split of trachea (corina/carina?) so its pretty high and very lateral. Too lateral for pec, rhomboid not around there.

2. Influenzae have segmented genomes for reassortment. hemmaglutinin is a major source of immune defense (and subsequently, variation by the virus). H1N1 = hemagglutinin # Neuroaminidase #. hemagglutin is the ADHESION one; so yea immunity to that halts the infection before it starts. A change = lots of ppl infected.

3. E Cadherin --> cadherins are calcium dependent components of Demosomes which are cell-cell adhesions (vs hemidesmosomes which use integrins and are cell-BM adhesion)

4. Defibrillators all over the place. Effect almost immediate. excercise, stress, smoking all help; but more long term/big picture.

5. yea, steroid = nuclear receptor

6. I actually cant remember what I put; there were a couple quesitons on this. Maybe grief/depression --> low dopa/sertonin --> more prolactin --> less GnRH? or was it primary ovarian (i think there was a question for each)

7. High fiber. normo-Anemia = GI bleed, colicky due to ischemic large bowel (splenic flexure), necrotic tissue infected for fever. Large bowel infarct - local pain vs small bowel is diffuse. Alcohol would be cirrhosis RUQ instead of LLQ


My thoughts. I'm pretty confident on most of em', ha.

Originally Posted by reedman

word. i went back and saw it. for some reason the photos are hard for me. if somebody asked "is this CMV?" i would have said yes, but i didn't think to look for it at the time.

Did not even look at the picture. anytime you see transplant just think T cells surpressed.

Originally Posted by ruraldr

#3--I answered E-cadherin and got it as a wrong answer.....

I put E cadherin and got it right? lol one of us is confused..

Originally Posted by winkleweizen

I put E cadherin and got it right? lol one of us is confused..

The Winkleweizen is right. I got it right as well and answered the same thing. But in my defense I am always confused.

Originally Posted by SlaveOfTCMC

1) didnt the stem say she found out that she could stay skinny if she stopped taking her insulin?

2) SSRI was the answer, http://www.medpagetoday.com/Urology/...sfunction/4066

For #2--doesn't it seem strange to have a question ask about a drug that isn't even FDA approved?

Which vessel would have elevated BP if there is a liver mass? (It was shown on a picture) -- hepatic, renal, suprarenal, gastric (or sometihng else.. and a few others..)

Originally Posted by SeekerOfTheTree

The Winkleweizen is right. I got it right as well and answered the same thing. But in my defense I am always confused.

are we talking about the same question? breast mets? After a talk with some classmates we think the answer might be the metalloproteinases....