So my nbme12's score was 202. I got 25% of the questions wrong. A lot of the questions were like the ones I thought I got them right and was a surprise to me. I would really appreciate any help. I also put down my answers and my reasoning of choosing them.
1. 4. A 65 yr old woman with severe sensorineural hearing loss undergoes surgical placement of a cochlear implant. This neural prosthesis converts sound energy to electrical signals, which results in stimulation of which of the following structures?
A. auditory nerve endings in the cochlea
B. cochlear nerve as it enters the pons
C. inner hair cells of the cochlea
D. olivocochlear efferent axons that innervate outer hair cells
E. oval window of the cochlea
--> I chose C and got it wrong. Any idea?
Read up about this, I also missed this one. its how a cochlear implant works.
2. A 20 yr old woman is brought to the emergency dept by her roommate 30 min after she ingested a large quantity of acetaminophen tablets during a suicide attempt. The physician asks her why she tried to kill herself. She replies tearfully, "My boyfriend told me that he doesn't want to see me again, and he won't return any of my phone calls. I loved him more than I've loved anyone else in my entire life. I was going to marry him! Now I hate his guts for what he's done to me. I just wanted to die." On further questioning, the physician learns that she had only two dates with this man.
She tells the physician, "I just can't bear being alone. But I can tell that you understand. You're the only doctor who's ever understood how I fell." This pt most likely has which of the following types of personality disorders?
A. borderline
B. dependent
C. histrionic
D. narcissistic
E. obsessive compulsive
--> I chose B, and got it wrong. Any idea?
Suicidal female after having only gone out on TWO dates. this is a red flag for severe emotional instability/lability, and in terms of the group B aka "Bad to the Bone" personality disorders listed in FA 2015, this is classic BPD. in dependentPD, these people end up in abusive relationships but thats very different from actually inflicting self-abuse. also another clue in this vignette is the sentence I bolded (see above), you'll recognize splitting.
3. A 14 yr old boy is brought to the physician's office b/c of
decreased appetite and abdominal pain over the past 3 weeks. His mother says that during the same time he has
withdrawn from everyone and
sleeps constantly. He describes his symptoms vaguely. Physical exam is normal. During further hx-taking, it is most critical for the physician to obtain which of the following?
A. developmental hx
B. family hx of affective disorders
C. orientation to time, place, and person
D. school hx
E. suicidal ideation or attempts
--> I chose A and got it wrong, so perhaps B? what are the important clues from the question stem?
See the words I've bolded above. this boy has features of depression, and in every single patient in which depression is suspected, you must screen for suicidal ideations/attempts, it is the most critical action to take.
4. A 67 yr old woman has transient ischemic attacks. She cannot
tolerate aspirin. Which of the following drugs is an appropriate alternative cerebral infarction prophylaxis in this pt?
A. acetaminophen
B. clopidogrel
C. dipyridamole
D. ibuprofen
E. tissue plasminogen activator
--> I chose C dipyridamole thinking that this was the closest to aspirin since it blocks platelet aggregation just like aspirin, but I got it wrong. So I guess I had to choose another NSAID right? So D is the answer then?
If this lady is unable to tolerate aspirin, then she wouldn't tolerate any other NSAID, since MOA is all the same. Now we need to give something which blocks platelets since that is a basic management following any vascular event (TIA, CVA, etc). Acetaminophen works centrally and wouldnt have any effect on platelets. Ibuprofen is same thing as aspirin so she wont be able to tolerate it. TPA is not a drug used prophylactically. It is also CI with a history of a hemorrhagic stroke (this is just one CI, there are numerous others). Clopidogrel is an ADP receptor antagonist which prevents platelet activation and degranulation. Specifically, it inhibits P2Y12 subtype of ADP (somebody on this forum mentioned you need to know that, so know that).
5. A 48 yr old woman comes to the physician b/c of a 1 yr hx of progressive ringing in her Rt. ear. She also felt dizzy while exercising. Neurologic exam shows dysmetria of the Rt. upper and lower extremities. Muscle strength and somatosensory function testing of all extremities shows no abnormalities. Audiometry shows moderate hearing loss in the Rt. ear. An MRI of the brain is most likely to show a mass compressing which of the following labeled structures in the photograph of a cross section of the brain stem?
View attachment 199258
So the unilateral hearing loss and dysmetria indicate CN8 and cerebellum lesion so A is the answer right?
Yes A is correct.
6. A 29 yr old man comes to the physician b/c of a 4 month hx of premature ejaculation. He states that about half of the time, he ejaculates prior to sexual intercourse, and the other half of the time, he ejaculates immediately on vaginal penetration. Physical exam shows no abnormalities. If pharmacotherapy is indicated, which of the following is the most appropriate?
A. atropine
B. cyproheptadine
C. paroxetine
D. sildenafil
E. trazodone
--> I chose D since I thought it is used for also premature ejaculation, but I got it wrong.
So perhaps the answer is cyproheptadine for SSRI this pt may be taking? I would damned if that's the answer! lol!
Sildenafil is not given for premature ejaculation, it is used for erectile dysfunction. Cyproheptadine is an antagonist/ partial agonist depending on the receptor at many receptors, one of which is serotonin. it can be used if someone has OD on SSRIs. this is a classic question where you must know drug MOA and side effects, and exploit a certain side effect to possibly treat the patient. SSRIs are known to delay ejaculation, sometimes even cause anorgasmia but it is a reasonable approach for patients with premature ejaculation.
7. A 30 yr old woman comes to the physician b/c of a 7 week hx of palpitations and shortness of breath with exertion. Her pulse is 116/min, and respiration are 25/min. Physical exam shows a non-palpable thyroid gland; there is no exopthalmos. Serum studies show:
TSH: 0.01 uU/ml
FT4: 2.6 (N=0.8-2.4)
123 I uptake: 1% at 24 hr (N=8%-30%)
Thyroglobulin: <0.5 (N=2-55)
Thyroglobulin antibodies: <0.5 IU/ml
A. exogenous use of levothyroxine
B. lymphocytic infiltration of the thyroid gland
C. mutation activation in the TSH receptor
D. stimulation by cytokines of B lymphocytes against thyroid antigens
E. tumor production of B-human chorionic gonadotropin
--> I chose C and got it wrong. Since her FT4 is high, I was thinking hyperthyroidism, toxic multinodular goiter.
She has a non-palpable thyroid gland, that would (at least for USMLE purposes) rule out any cause for a goiter, since by definition, a goiter is a swelling of the neck due to an enlarged thyroid gland. this question is tricky since she clearly has hyperthyroidism evidenced by symptoms and labs. Big clue here is the 123 I uptake which is low. this is seen in exogenous use of levothyroxine.
8. A 21 yr old man comes to the emergency dept in the winter b/c of
headache, nausea, and
dizziness for 4 hours. He has not had fever, chills, or shortness of breath. He has no hx of major medical illness. He lives in a
basement apartment of a three story house; no one else in the house has similar symptoms. He smokes 2 packs of cigarettes daily. Physical exam shows no abnormalities. Which of the following pathophysiologic processes best explains this pt's symptoms?
A. acidosis causing shifting of the oxyhemoglobin dissociation curve to the Rt.
B. activation of nicotinic receptors in locus caeruleus
C. cerebral arteriolar constriction caused by increased carbon dioxide conc in the blood
D. competitive inhibition of oxyhemoglobin formation
E. inactivation of cytochrome oxygenase by cyanide
--> I chose C and got it wrong. Now I'm thinking perhaps CO poisoning so perhaps D is the answer?