Internal Medicine: NBME 1 and 2 thread

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
52 y/o tripped and fell on knee. pain worsened last 4 days, ROM now limited by pain. Leukocytes 10k, ESR 40, x-ray shows DJD but no fracture. physical exam- warm and small effusion

A RF assay
B technetium bone scan
C MRI
D Tap it
E Biopsy

62 y/o woman 3 month SOB, 3 yr hx COPD, 40 pack yr hx, pulm exam- decreased air movement, occasional wheeze ABG pH 7.41, CO2 40 O2 74

A Pulm rehab
B Home O2
C Ipratropium
D Prednisone
E Theophylline

Members don't see this ad.
 
Last edited:
52 y/o tripped and fell on knee. pain worsened last 4 days, ROM now limited by pain. Leukocytes 10k, ESR 40, x-ray shows DJD but no fracture. physical exam- warm and small effusion

A RF assay
B technetium bone scan
C MRI
D Tap it
E Biopsy

Bro, you gotta tap dat. The stem mentions warmth + tenderness + effusion over the joint. Plus, she's diabetic. Even if you got that MRI, it would just say "inflammatory/infectious process" and you'd still need the synoviocentesis to differentiate from gout (or even pseudogout because of DJD).

62 y/o woman 3 month SOB, 3 yr hx COPD, 40 pack yr hx, pulm exam- decreased air movement, occasional wheeze ABG pH 7.41, CO2 40 O2 74

A Pulm rehab
B Home O2
C Ipratropium
D Prednisone
E Theophylline

Iptratropium. She's not on any COPD treatment at this point; 1st step in COPD management is generally pharmacological. We start with anticholinergics in COPD. Prednisone is only for acute exacerbations (with abx thrown in) and theophylline is like 3rd line if indicated at all. Home O2 is something Step 2 loves to test on, but has strict O2 sat/pO2 requirements which you should look up because they're high yield. Pulm rehab is a BS choice that doesn't test your understanding of COPD management and therefore would never be the answer on the USMLE.
 
thank you brofessor
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Another question is basically about preventing asthma relapses. That is cromolyn right? Choices ABX, roids, theophylline, cromolyn, ipratropium

I feel like there's always a question where the person has a BMI 50-60 where the answer is weight reduction lol

DKA Insulin Bolus vs NS, I thought you did both?
 
Last edited:
Another question is basically about preventing asthma relapses. That is cromolyn right? Choices ABX, roids, theophylline, cromolyn, ipratropium

Ipratropium, actually. While in COPD, all you basically need to know for Step 2 regarding inhalers is to use anticholinergics, asthma management is a little trickier. You could memorize this BS, or you could just remember:
-1st line: SABA prn
-2nd line (when symptoms >2 days/week or >2 nights/month -- yeah this is actually important, they walk the line): Add ICS
-3rd line (when the patient is obviously refractory and has severe asthma -- they don't walk the line at this step): Add LABA

Or they could do what they did in this question and say "this patient is still sick on a SABA, what's next?". Theophylline and cromolyn are never the answer, contrary to Step 1. Steroids (oral, not inhaled) are only in acute exacerbations along with O2 and magnesium, and abx play no role in asthma (contrast to COPD exacerbations).


I feel like there's always a question where the person has a BMI 50-60 where the answer is weight reduction lol

Yeah, BMI > 50 with any comorbidities and the answer is without fail bariatric surgery haha.


DKA Insulin Bolus vs NS, I thought you did both?

You're right, insulin + NS + potassium. This is one of those BS questions that delineates between things that are simultaneously done in real life. I think the answer was insulin because they're probably wanting you to understand which most directly treats the underlying disease process.
 
Last edited:
excelente gracias
 
  • Like
Reactions: 1 user

oh ya and the only thing was I put ipratropium for that question and got it wrong. so not sure if its roids or cromolyn that they are looking for there.
 
couple more

Overweight 65 y/o M , smokes 1 pack daily, bro died of cerebral infarct, BP is 150/102, grade 2 hypertensive retinopathy, PMI displaced 2 cm lateral. what is best initial lab test
A plasma renin
B serum aldosterone
C creatinine
D urine metanephrine
E Urinary sodium/creatinine

previously healthy 67 y/o F admitted b/c fever, hypotension and resp distress. temp 101.1 pulse 112 rr 28 bp 98/50. diffuse crackles. 2/6 systolic mumur. extremities warm and well perfused. CO 6, LVEDP 11 PCWP 14 . leukocytes 18k, ABG pH 7.3 CO2 18 PO2 64

what is mechanism for resp failure

A decreased hypoxic drive
B decreased contractility
C decreased pulm vasc flow
D increased pericardial pressure
E Increased regurgitatnt mitral flow
F Increased vascular permeability

The first - nothing is screaming to get corrected immediately (BP isn't emergent, no acute/severe end organ damage) & no info to suspect 2ndary HTN initially, so get Cr to assess renal fxn & help determine choice for initial anti-hypertensive.

The second - looks like ARDS in the setting of septic shock. The CO, LVEDP & wedge are normal/high normal & perfusion is ok, so cardiac fxn is appropriate. No reason to think the murmur is new or the causative factor of pulm symptoms in the setting of normal cardiac fxn. Pathogenesis of ARDS: excessive inflammatory/immune response -> increased pulm vasc permeability -> pulm edema.
 
oh ya and the only thing was I put ipratropium for that question and got it wrong. so not sure if its roids or cromolyn that they are looking for there.

Oh geez, my bad man. Could have sworn I had ipratropium put and that I got it right, but I actually looked back and I got the answer wrong putting cromolyn (I took this 1+ year ago). So it's probably steroids. Maybe by "prevent a relapse" they're referring to having another acute exacerbation, and by extension are asking what helps treat those acute exacerbations.
 
oh ya and the only thing was I put ipratropium for that question and got it wrong. so not sure if its roids or cromolyn that they are looking for there.

Oh geez, my bad man. Could have sworn I had ipratropium put and that I got it right, but I actually looked back and I got the answer wrong putting cromolyn (I took this 1+ year ago). So it's probably steroids. Maybe by "prevent a relapse" they're referring to having another acute exacerbation, and by extension are asking what helps treat those acute exacerbations.

Yeah should be steroids. The preferred 1st line therapy in asthmatics who need a daily controller medication on top of a rescue inhaler is low dose inhaled corticosteroids.
 
Yeah should be steroids. The preferred 1st line therapy in asthmatics who need a daily controller medication on top of a rescue inhaler is low dose inhaled corticosteroids.

Cool. Where did you learn that?
 
Cool. Where did you learn that?
Came up yesterday as I'm on my family med rotation. There is a stepwise chart of management HERE (pg 5, can see the same chart on UTD if you have access from your computer).
 
Came up yesterday as I'm on my family med rotation. There is a stepwise chart of management HERE (pg 5, can see the same chart on UTD if you have access from your computer).

Oh, are you referring to inhaled steroids? The question in this NBME was referring to oral steroids.
 
Members don't see this ad :)
Oh, are you referring to inhaled steroids? The question in this NBME was referring to oral steroids.
Oh lol oops. Sounds like could still be steroids though based on what's written in this thread. Shrug, sorry for muddling things up in here. :p
 
Oh lol oops. Sounds like could still be steroids though based on what's written in this thread. Shrug, sorry for muddling things up in here. :p

Oh no worries. Just a weird question. If I got it again on the USMLE, I still probably wouldn't pick oral steroids.
 
Also HIV+ man with CD4< 110 which test to assess for opportunistic infection?
thought PCP - xray - wrong

Has to be more information. There aren't really any scenarios where you "test to assess" for opportunistic infections without symptoms.
 
Oh no worries. Just a weird question. If I got it again on the USMLE, I still probably wouldn't pick oral steroids.

Oral steroids are indicated when high-dose inhaled steroids + SABA + other crap still isn't working. Ipratropium is for COPD, not really for asthma. Steroids (inhaled or oral) is the only thing that reduces exacerbations.

@kirbymiester what did you match into brah? I got 2CK coming up in about a month. Gonna channel all my genius SDN bros and hope for the best.
 
Last edited:
  • Like
Reactions: 1 user
Oral steroids are indicated when high-dose inhaled steroids + SABA + other crap still isn't working. Ipratropium is for COPD, not really for asthma. Steroids (inhaled or oral) is the only thing that reduces exacerbations.

@kirbymiester what did you match into brah? I got 2CK coming up in about a month. Gonna channel all my genius SDN bros and hope for the best.

Rads. Freakin dream come true man.

Shoot me a message if you need anything at all.
 
  • Like
Reactions: 1 user
The choices were micro nutrients. I think the answer was zinc.

zinc
cobalt
copper
manganese
selenium

Yea that's Zinc. So for that one HIV question the patient doesn't have any symptoms? You don't usually screen for PCP.. you just prophylax below 200.
 
Q1. 22 yr with closed head injury in Motor vehicle collision. Has ecchymosis over the frontal region. Serum Na: 120, Urine Osmolality is 340. What is the next step?
- Is this SIADH? so fluid restriction?

Q2. 37 yr man 1 mnth hx of left hip pain. On dialysis for 6 yrs because of hypertensive nephropathy. X ray: nondisplaced fracture, what is the cause?
- would this be deficient mineralization of osteoid?

Q3. 27 yo women 2 months of fatigue. Has excessive menstration. What are the lab abnormalities?
- this would be mean red cell volume? why cant increased reticulocyte count also work?

Q4. 57 yo male with acute renal failure. develops what looks like is ATN, gives you list of meds
- Amikacin?

Q5. 76 old man collapses at home. Dx acute anterior wall MI. pulse: 103, systolic BP: 80. gray + clammy skin. heart tones muffled. Likely cause of hypotension?
- 3rd degree Heart block
- decreased Intravascular volume
- decreased myocardial contraction (this correct?)
- decreased vent filling pressure
- pulm edema?

Q6. 37 yo man with 2 hx of abdominal cramps + diarrhea, vmotted blood twice. takes ibuprofen after knee injury. Pulse: 130, BP 11/70. resp: 22. dark tarry stool. two liters of 0.9% saline given. Hematocrit 18%. What is the next step in management?
- Additional 2L of 0.9 saline
- FFP
- Octreotide
- packed RBCs
- H2 blocking agent
Can someone explain this answer to me? thanks

Thanks for the help
 
form 1:

9. 37 yo w/ chronic RF, multiple episodes of hypotension during HD. PEx: distended neck veins, clear lungs, distant heart sounds w/ no murmor or gallop. Echo w/ large pericardial effusion. which of the following signs is a/w the cause of hypotensive episodes?
-apical systolic murmur
-paradoxical pulse
-auscultatory gap
-widened pulse pressure
.....explanation w/ answer appreciated!!

32 yo man totally health comes in for physical. last exam 5 years ago somewhere else. nl exam. no PMHx of PFHx. most appropriate screening?
-test of occult blood
-serum cholesterol
-ECG
*not a CBC....thinking EKG just to have a baseline? no idea, though

77 yo F. 1 yr of progressive swelling of ankles and 3 mo of DOE.
HTN-HCTX, PAT-CCB, hypothyroid-levothyroxine.
pex: no JVD, lungs clear, large varicose veins on LE w/ hair loss and mild hyperpigmentation.
o2 sat 90% on ambulation.
nl CXR. VQ shows 2 subsegmental perfusion defects and no ventilation abnormalities, Echo w/ mitral annular calcifications.
most likely explaination for pts dyspnea?
-cardiac emoboli 2/2 intermittent arrhythmia
-coronary ischemia
-LV diastolic dysfunction
-recurrent PE

46 yo on vent s/p sx for duodenal ulcer repair 3 wks ago. temp 103.6, HR 11, bp 90/50. wbc 18,300. cardiac output 8.9 (4-5 nl) and central venous P 15 (nl 5-8). being aggressively rescusitated w/ fluids. most appropriate next step?
-admin dexamethasone
-blood transfusions
-broad spec abx
*thinking, broad spec abx, septic secondary to what??

thanks for any help given or explanations offered. and happy new year!
 
Q1. 22 yr with closed head injury in Motor vehicle collision. Has ecchymosis over the frontal region. Serum Na: 120, Urine Osmolality is 340. What is the next step?
- Is this SIADH? so fluid restriction?

Q2. 37 yr man 1 mnth hx of left hip pain. On dialysis for 6 yrs because of hypertensive nephropathy. X ray: nondisplaced fracture, what is the cause?
- would this be deficient mineralization of osteoid?

Q3. 27 yo women 2 months of fatigue. Has excessive menstration. What are the lab abnormalities?
- this would be mean red cell volume? why cant increased reticulocyte count also work?

Q4. 57 yo male with acute renal failure. develops what looks like is ATN, gives you list of meds
- Amikacin?

Q5. 76 old man collapses at home. Dx acute anterior wall MI. pulse: 103, systolic BP: 80. gray + clammy skin. heart tones muffled. Likely cause of hypotension?
- 3rd degree Heart block
- decreased Intravascular volume
- decreased myocardial contraction (this correct?)
- decreased vent filling pressure
- pulm edema?

Q6. 37 yo man with 2 hx of abdominal cramps + diarrhea, vmotted blood twice. takes ibuprofen after knee injury. Pulse: 130, BP 11/70. resp: 22. dark tarry stool. two liters of 0.9% saline given. Hematocrit 18%. What is the next step in management?
- Additional 2L of 0.9 saline
- FFP
- Octreotide
- packed RBCs
- H2 blocking agent
Can someone explain this answer to me? thanks

Thanks for the help

First one-Fluid restriction. This is euvolemic hyponatremia.
Second one-Deficient mineralization of osteoid (renal failure-Vit D deficiency-decreased Ca and P absorption so bone is not ossified).
Third one-Most likely has Fe deficiency anemia so MCV should be low. Is not a hemolytic anemia if you're literally bleeding out.
Fourth one-Yes, Amikacin is an aminoglycoside and hence can cause ATN. Almost chose Naproxen but NSAIDs generally cause pre-renal AKI instead of intrarenal AKI.
Fifth one-Decreased myocardial contractility-the MI has gone for too long, myocardium is dead.
Sixth one-Give Packed RBCs, Hb < 7 (21% hematocrit) so transfusion is indicated.
 
Top