NBME Clinical Mastery Series Medicine Form 1

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PeurtoRico

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49. A 37 year old woman with chronic renal failure has multiple episodes of hypotension during hemodialysis. Examination shows distended neck veins, clear lung fields and distant heart sounds with no audible murmur or gallop. Echocardiography shows a large pericardial effusion. Which of the following signs is associated with the cause of hypotensive episodes?

A) Atypical systolic murmur
B) Auscultatory gap
C) Paradoxical pulse
D) S4
E) Widened pulse pressure

I marked B and that's wrong. On re-reading, I think it should be C: Paradoxical pulse. Any thoughts, jury?
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Thanks a bunch!
So here are a few more:

For each patient with jaundice, select the most likely diagnosis:

a) acute hepatitis
b) alpha-1 antitrypsin deficiency
c) biliary atresia
d) cholangiocarcinoma
e) choledocholithiasis (that's what I marked, and is wrong)
f) Gilberts
g) G6PD deficiency
h) Liver abscess
i) Peptic ulcer disease

2. A 25 year old woman comes to the physician because of a 5 day history of fatigue, nausea, and decreased appetite. Her temp is 37 C, Pulse 86/min, BP 110/50. She is told that she has a viral infection and is sent home. One week later, she returns because of continued fatigue and jaundice. Now her pulse is 80/min, respiratory 12/min, and BP 110/64. Examination shows scleral icterus. CVS examination normal. Liver edge is palpable 1cm below the right coastal margin, and is slightly enlarged, smooth and tender to palpation. Labs show:
Hb 13.2
Total bili 4.2
Direct bili 3.6
Alk Phos 120
AST 350
ALT 280
LDH 410

Could it be A or H?
 
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6. A 42 year old woman comes to the physician because of a 4 month history of weakness in the right hand and a 2 month history of weakness in the left leg. She has had occasional twitching of muscles in all 4 extremities that she attributes to nervousness. She has migraines treated with sumatriptan. No family history of neurologic disease. Examination shows atrophy and weakness of the hands more on the right than on the left. frequent random twitching in the shoulder girdle muscles and the left foot drop. DTRs markedly increased in the extremities. Babinski is present on the right. Jaw reflex is brisk. Her speech is slurred. Sensory exam normal. Her CK is 335. Nerve conduction studies show no abnormalities. EMG shows acute and chronic denervation in several muscles of all extremities. Most likely diagnosis?

A) Amyotrophic lateral sclerosis (could that be it?)
B) Cervical myelopathy
C) inclusion body mysositis
D) multiple sclerosis (i chose this and is the wrong answer)
E) Polymyositis
 
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43. A 52 year old man with alcoholism is brought to the ED because he has been unable to move his extremities for the last 4 hours. He is awake and alert. Exam shows slight swelling of the lower extremities. He has oliguria. Bladder cath yields only a small quantity of urine that is positive for blood by dipstick. Diagnosis?

A) Botulism
B) Cerebral infarction
C) Conversion disorder
D) Familial periodic paralysis
E) Guillain Barre (This is wrong)
F) Hypokalemia
G) Myasthenia
H) Rhabdomyolysis (I wonder this could be right?)
I) Spinal cord compression
 
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PeurtoRico said:
43. A 52 year old man with alcoholism is brought to the ED because he has been unable to move his extremities for the last 4 hours. He is awake and alert. Exam shows slight swelling of the lower extremities. He has oliguria. Bladder cath yields only a small quantity of urine that is positive for blood by dipstick. Diagnosis?

A) Botulism
B) Cerebral infarction
C) Conversion disorder
D) Familial periodic paralysis
E) Guillain Barre (This is wrong)
F) Hypokalemia
G) Myasthenia
H) Rhabdomyolysis (I wonder this could be right?)
I) Spinal cord compression
Click to expand...

It has to be H. Nothing else makes sense here. Its clearly not anything else from what I can see.
 
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PeurtoRico said:
6. A 42 year old woman comes to the physician because of a 4 month history of weakness in the right hand and a 2 month history of weakness in the left leg. She has had occasional twitching of muscles in all 4 extremities that she attributes to nervousness. She has migraines treated with sumatriptan. No family history of neurologic disease. Examination shows atrophy and weakness of the hands more on the right than on the left. frequent random twitching in the shoulder girdle muscles and the left foot drop. DTRs markedly increased in the extremities. Babinski is present on the right. Jaw reflex is brisk. Her speech is slurred. Sensory exam normal. Her CK is 335. Nerve conduction studies show no abnormalities. EMG shows acute and chronic denervation in several muscles of all extremities. Most likely diagnosis?

A) Amyotrophic lateral sclerosis (could that be it?)
B) Cervical myelopathy
C) inclusion body mysositis
D) multiple sclerosis (i chose this and is the wrong answer)
E) Polymyositis
Click to expand...


I chose E and it was wrong too....The CK is high!
 
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I did not understand the screening question of the 30 y/o man. I picked glucose and it was wrong!
 
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The 25 diabetic guy (not DKA for sure)....I picked 1 liter of 0.9 saline and it was wrong....Is it 5% dextrose? If yes, why? What is the case here!!
 
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Oh that answer is cholesterol. I picked that and got it right. I think cholesterol screening begins at 35 for men, but he was 32 so I don't know why that's right… maybe it was the closest. If you come across screening guidelines for cholesterol, please post it up here as well. Thanks!
And the second answer is dextrose 5% because it was hypoglycemia.
 
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And the jaundice one was acute hepatitis only? I was just thinking that the conjugated fraction is way too high for acute viral hepatitis but that fits the best too…
 
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And the ethics question, was it "Do not administer tPA because it is medically contraindicated in this case"?
The bone scan one, is it "Bone mets"? OA and hyperparathyroidism are wrong.
Ingested spores for the C.diff one?
Diuretic abuse for the diabetic guy? If so, why does he have a fever!
Thanks!
 
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PeurtoRico said:
And the ethics question, was it "Do not administer tPA because it is medically contraindicated in this case"?
The bone scan one, is it "Bone mets"? OA and hyperparathyroidism are wrong.
Ingested spores for the C.diff one?
Diuretic abuse for the diabetic guy? If so, why does he have a fever!
Thanks!
Click to expand...

No, C.diff isn't ingested spores. They put that in there to make you pick it, thinking that Clostridium=spores. Which is true, but for Botulism. The answer should be electrolyte imbalance, at least I think it is.
 
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C.diff IS spread by spores as well… that's how healthcare workers get it, which is why we wash our hands after seeing a C.diff+ patient. This patient had h/o hospitalization, where she could have picked up spores from. I marked colonic perf since C.diff can do it, but that was WRONG!
If people can start putting up what they marked to this question and whether it was right/wrong, we can trace the right answer :-/
 
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PeurtoRico said:
C.diff IS spread by spores as well… that's how healthcare workers get it, which is why we wash our hands after seeing a C.diff+ patient. This patient had h/o hospitalization, where she could have picked up spores from. I marked colonic perf since C.diff can do it, but that was WRONG!
If people can start putting up what they marked to this question and whether it was right/wrong, we can trace the right answer :-/
Click to expand...

Oh okay..then maybe it could be ingested spores then. Yeah see this is what I hated about the Clinical Mastery series. No freaking answer key :(. Can you put up that C.diff question? I may have been thinking about another one.
 
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A 67-year-old woman comes to the physician because of a 2-day history of passing 12 watery stools daily. She has no other history of abnormal bowel function. Two weeks ago, she was treated in the hospital with antibiotic therapy for right lower lobe pneumonia. She had a myocardial infarction 5 years ago. She underwent a total abdominal hysterectomy 18 years ago for bleeding leiomyomata uteri. She has a 20-year history of rheumatoid arthritis. Current medications include prednisone and aspirin. She appears lethargic. Her temperature is 39.1°C (102.4°F), pulse is 120/min, respirations are 18/min, and blood pressure is 98/68 mm Hg. Examination shows decreased skin turgor. Abdominal examination shows distention and right lower quadrant tendemess with voluntary guarding. Laboratory studies show. Hemoglobin 11.8 g/dL Hernatocrit 36% Leukocyte count 18,900/rnm Platelet count 325,0000mm Serum Na. 149 mEq/L K 3.1 mEq/L Cl- 90 mEq/L HCO5- 32 mEq/L
Flexible sigmoidoscopy shows pseudomembranes. Which of the following is the most likely cause of this patient's current symptoms?
A) Autoimmunity
B) Bowel ischemia
C) Electrolyte imbalance
D) Inflammatory bowel disease
E) Ingested spores
F) Perforation of the colon
 
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PeurtoRico said:
A 67-year-old woman comes to the physician because of a 2-day history of passing 12 watery stools daily. She has no other history of abnormal bowel function. Two weeks ago, she was treated in the hospital with antibiotic therapy for right lower lobe pneumonia. She had a myocardial infarction 5 years ago. She underwent a total abdominal hysterectomy 18 years ago for bleeding leiomyomata uteri. She has a 20-year history of rheumatoid arthritis. Current medications include prednisone and aspirin. She appears lethargic. Her temperature is 39.1°C (102.4°F), pulse is 120/min, respirations are 18/min, and blood pressure is 98/68 mm Hg. Examination shows decreased skin turgor. Abdominal examination shows distention and right lower quadrant tendemess with voluntary guarding. Laboratory studies show. Hemoglobin 11.8 g/dL Hernatocrit 36% Leukocyte count 18,900/rnm Platelet count 325,0000mm Serum Na. 149 mEq/L K 3.1 mEq/L Cl- 90 mEq/L HCO5- 32 mEq/L
Flexible sigmoidoscopy shows pseudomembranes. Which of the following is the most likely cause of this patient's current symptoms?
A) Autoimmunity
B) Bowel ischemia
C) Electrolyte imbalance
D) Inflammatory bowel disease
E) Ingested spores
F) Perforation of the colon
Click to expand...

This sounds like C.diff colitis because of the antibiotic use, not ingested spores.
 
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Abx use would have been my answer but nothing else fits here :/. The only other thing i could come up with was C.diff d/t spore ingestion. colonic perf fits beautifully but that's the wrong answer, lol.
 
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PeurtoRico said:
@cali, can you confirm the ethics question please? It's "do not administer tPA because it is medically contraindicated"?
Click to expand...

I marked this answer(tPA contraindicated) and it was correct. Regarding the other question answer is ingested spores. Pseudomembranes --> C difficile--> also spread by spores in hospitalization setting
 
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PeurtoRico said:
And the jaundice one was acute hepatitis only? I was just thinking that the conjugated fraction is way too high for acute viral hepatitis but that fits the best too…
Click to expand...
Yeah Hepatitis....What I really learned from those NBME master forms that you don't need to have 100% fit scenario....You will find some signs/symptoms contrary to the whole case, but still go with it! The septic shock questions says it....The CVP is high, but this only occurs in cardiogenic shock
 
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PeurtoRico said:
And the ethics question, was it "Do not administer tPA because it is medically contraindicated in this case"?
The bone scan one, is it "Bone mets"? OA and hyperparathyroidism are wrong.
Ingested spores for the C.diff one?
Diuretic abuse for the diabetic guy? If so, why does he have a fever!
Thanks!
Click to expand...

Yes. Bone mets. Multiples lesions on both femurs, and humerus. The other bone thing question is osteomyelitis, I picked increased bone turnover it was correct
Not sure of the C.diff thing...made me crazy
Nah....the Diabetic question was hyperosmolar...Was very tricky...I answered it osmotic diuresis and it's correct
 
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The two questions of HTN in a woman:

1- She has a bruit...does it mean the correct answer is "renin-angiotensin system" because of presumed fibromuscular stenosis?

2- I picked mineralocortocoids and was correct...but really don't know why...that the only choice left after elimination of other choices....Labs fit...but the case scenario is horrible
 
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yes fibromuscular stenosis in that first case. I really can't recall the second case you're talking about, but didn't get it marked wrong either.
 
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Dactino said:
I marked this answer(tPA contraindicated) and it was correct. Regarding the other question answer is ingested spores. Pseudomembranes --> C difficile--> also spread by spores in hospitalization setting
Click to expand...
Thanks. Did you actually mark that and it got right then? Or it's now your second guess after getting it wrong? Lol. Just to be sure that I really know the right answer.
 
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That's my best bet. Fits the age and gender too but more importantly, radiograph showed "increased cortical thickness" which you get in Pagets. And Pagets has increased bone turnover.
 
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F, pseudo membranous colotis is complicated my toxic megacolon... + the pt has guarding and distention
 
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that would make sense only that everyone i know, marked this and this was the WRONG answer on NBME. I guess with colonic perf, the patient would be a lot more toxic looking and there will be DIFFUSE tenderness.
 
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The question of antibiotics. I answered it correctly (Vancomycin), but what is the case? I thought may to protect from meningitis?
 
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Omg, I haven't done form 2 for medicine yet, so I wanna shield my eyes to form 2 questions. Will do it at some point next week- exam in 3 weeks and I am left with 45% UW still.
 
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In addition to Ceftazidime, what antibiotics you need to add? There were several antiiotics and the last choice was "no need for additional one"
 
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Oh these questions haunt me while I sleep every night and I recalled this question you're talking about. I think it was CF patient being admitted for PNA and they had started ceftazidime already, and asked what other abx should be added. We'll add Vanco to give MRSA coverage. That kid had been in and out of hospital and would need to be covered for MRSA pneumonia.
 
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PeurtoRico said:
Oh these questions haunt me while I sleep every night and I recalled this question you're talking about. I think it was CF patient being admitted for PNA and they had started ceftazidime already, and asked what other abx should be added. We'll add Vanco to give MRSA coverage. That kid had been in and out of hospital and would need to be covered for MRSA pneumonia.
Click to expand...

Not seeing the question, but with the details that you have provided, starting Vanco makes sense.
 
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PeurtoRico said:
@CaliAtenza , were the questions on the real deal of the same LENGTH as on UW? Was just wondering if I need to practice doing questions even faster.
Click to expand...

I would say yes, they were about the same length. They just seem longer because of the time crunch and needing to go through them all.
 
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What does the jury have to say about this from form 1:

A 77-year-old woman comes to the physician because of a 1-year history of progressive swelling of the ankles and a 3-month history of shortness of breath with exertion. She has not had chest pain, orthopnea, or paroxysmal dyspnea. She takes hydrochlorothiazide for hypertension, verapamil for paroxysmal atrial tachycardia, and levothyroxine for hypothyroidism. Her blood pressure is 145/72 mmHg, pulse is 78/min and regular, and respirations are 18/min. there is no jugular venous distention. The lungs are clear to auscultation. Examination shows large superficial venous varicosities on the lower extremities and moderate ankle and pedal edema bilaterally. There is loss of hair and mild hyperpigmentation over the legs. Oxygen saturation is 96% at rest and 90% with exertion. An X-ray of the chest and ECG shows no abnormalities. Ventilation-perfusion lung scans show two subsegmental perfusion with defects but no ventilation abnormalities. Echocardiography shows mitral annular calcifications.

Which of the following is the most likely explanation for this patient’s dyspnea?


A Cardiac emboli secondary to intermittent arrhythmia
B Coronary ischemia (wrong answer)
C Left ventricular diastolic dysfunction
D Mitral insufficiency
E Recurrent pulmonary emboli

Someone said C, but I have failed to UNDERSTAND this question altogether.
 
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