NBME 11 question

[Master Deep]

Can anyone whos done NBME 11 explain how to figure out the serum protein electrophoresis question. 12 yr old boy admitted to hospital because of lethary, hip pain and fever. hes been admitted many times becaues of pneumonia. And then it gives the diff kinds of serum protein electrophoresis.
Thanks!

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[nkhan]

Can anyone whos done NBME 11 explain how to figure out the serum protein electrophoresis question. 12 yr old boy admitted to hospital because of lethary, hip pain and fever. hes been admitted many times becaues of pneumonia. And then it gives the diff kinds of serum protein electrophoresis.
Thanks!

I've done 11 but it's been a while, I didn't miss this question (just looked--so I'm unable to see the actual question)...sounds like sickle cell though due to the pneumonia, hip pain, etc. (remember they have autosplenectomy which predisposes them to S. Pneumo, H. Flu, Neisseria (SHiN) etc.

Can you post more about what the question was asking ??

 

[AnotherMember]

Can anyone whos done NBME 11 explain how to figure out the serum protein electrophoresis question. 12 yr old boy admitted to hospital because of lethary, hip pain and fever. hes been admitted many times becaues of pneumonia. And then it gives the diff kinds of serum protein electrophoresis.
Thanks!

The kid had a history of pneumonias and current blood cultures grew staph aureus. I believe the answer was the protein electrophoresis that demonstrated hypogammaglobulinemia. Probably deficiency in bruton's tyrosine kinase.

 

[Master Deep]

to nkhan- that was the entire question, then they just showed the different electrophoresises

to antohermember- how does the agammaglobulinemia graph look?? also does Brutons have hip pain?

 

[AnotherMember]

to nkhan- that was the entire question, then they just showed the different electrophoresises

to antohermember- how does the agammaglobulinemia graph look?? also does Brutons have hip pain?

The answer looked similar to this:

 

[sgod34]

I think in regards to protein electrophoresis all they expected us to know was since Bruton's has agammaglobulinemia, we should identify it with the protein electrophoresis showing gamma-globulin flattening, versus a spike in conditions like MGUS or Multiple Myeloma. I doubt they expect us to know much more in terms of electrophoresis.

 

[Master Deep]

Thanks everyone for your input!

 

[ArcGurren]

Flat gamma globulin peak = BTK deficiency (Bruton's Agammaglobulinemia) due to lack of B cell development.

High gamma globulin peak = MGUS, Multiple Myeloma or Waldenstrom's macroglobulinemia (the latter is less high yield but the vignette would have something about high viscosity blood oozing from some orifice, whereas multiple myeloma you'd have lytic bone lesions, MGUS you have no symptoms and it's incidental finding).

Flat alpha-1 peak = alpha-1 antitrypsin deficiency.

That's pretty much all I know that you can diagnose from an electrophoresis.

 

[Master Deep]

I have another question about NBME 11... There was a picture of a girls butt and there was a red circular rash. The rash had a darker red circle in the middle and then a lighter red color all over her buttock.
"A 12 year old girl is brought to the physician because of a rash on her left buttock for the past 2 days. The rash developed after the family returned from a 2 week long early summer vacation in Maine. Vital signs normal. The patients infection is taxonmically and morphologically most similar to the infectious agent of which of the following conditions?"
Bacilliary angiomatosis
Chancroid
Leptospirosis
Lymphogranuloma vereneum
Q fever

 

[nkhan]

I have another question about NBME 11... There was a picture of a girls butt and there was a red circular rash. The rash had a darker red circle in the middle and then a lighter red color all over her buttock.
"A 12 year old girl is brought to the physician because of a rash on her left buttock for the past 2 days. The rash developed after the family returned from a 2 week long early summer vacation in Maine. Vital signs normal. The patients infection is taxonmically and morphologically most similar to the infectious agent of which of the following conditions?"
Bacilliary angiomatosis
Chancroid
Leptospirosis
Lymphogranuloma vereneum
Q fever

It's lyme disease that she has (camping history, bull's eye rash and in Maine)--which is due to a spirochete (Borrelia Burgdorferi) & leptospira is a spirochete also which is the taxonomical relationship they are trying to describe

 

[Master Deep]

It's lyme disease that she has (camping history, bull's eye rash and in Maine)--which is due to a spirochete (Borrelia Burgdorferi) & leptospira is a spirochete also which is the taxonomical relationship they are trying to describe

ohhh lol i was trying to convince myself it wasnt the bulls eye rash. hahaha thanks!

 

[TalkingHeads]

A) A 30 something guy who runs daily and complains of pain. He miisses appts , doesn't take his medication, and continues to run.. then returns to doc complaining of sadness regarding his pain.

Histrionic? Dependent? Passive-Aggressive? Obsessive-Compulsive?

B) For Multiple Myeloma pts with accompanying renal deficiency, would you have increased renal phosphorus? If so, would that increase your PTH to increase secretion (or is it decreased due to hypercalcemia)?

C) Person gets a PPD test to determine previous infection with Tb, results show a 25mm area of induration at 48 hrs.. which cells predominate?

I though Cyt-T with type 4 HS... but no! Other choices were macrophage, B-Cells, neutrophils, eosinophils

Thank you!

 

[nkhan]

A) A 30 something guy who runs daily and complains of pain. He miisses appts , doesn't take his medication, and continues to run.. then returns to doc complaining of sadness regarding his pain.

Histrionic? Dependent? Passive-Aggressive? Obsessive-Compulsive?

B) For Multiple Myeloma pts with accompanying renal deficiency, would you have increased renal phosphorus? If so, would that increase your PTH to increase secretion (or is it decreased due to hypercalcemia)?

C) Person gets a PPD test to determine previous infection with Tb, results show a 25mm area of induration at 48 hrs.. which cells predominate?

I though Cyt-T with type 4 HS... but no! Other choices were macrophage, B-Cells, neutrophils, eosinophils

Thank you!

A) Passive Agressive

He's trying to make the doctor mad without actually doing him harm. Key thing is he was missing his appointments (one hint) and then continuing not to take his medication (another hint) leading us to think that he is non-compliant despite complaining about his pain etc.

B) I thought MM was associated with hypercalcemia (primary via cytokines--RANKL, etc. ) which would result in a lower PTH and thus a higher phosphate level? I think the hypercalcemia and amyloid lead to the renal failure (which could later produce higher phosphate levels also), can you post the entire question again I don't recall all the details of that q.


C) Macrophage, they are the APC's in this case and present Ag via MHC I/II & secrete IL-12 which activate CD4/CD8 T cells which come in and kill the guys. But the macrophage I think is the predominant cell (same with a granuloma--I've seen that asked before also).

 

[greatnt249]

C) Macrophage, they are the APC's in this case and present Ag via MHC I/II & secrete IL-12 which activate CD4/CD8 T cells which come in and kill the guys. But the macrophage I think is the predominant cell (same with a granuloma--I've seen that asked before also).

It's only been 48 hours, so my guess is that neutrophils would be the predominant cell located in the induration during the acute inflammatory phase.

 

[nkhan]

It's only been 48 hours, so my guess is that neutrophils would be the predominant cell located in the induration during the acute inflammatory phase.

What he said is incorrect , you check a PPD after 48h to see if a granuloma is formed (in which case macrophages predominate, Type IV HS is classic for PPD). If it was neutrophils you would expect a pyogenic rx (ie acute inflammatory response, which is not the case in a PPD).

Read here for more info if you wish:

http://www.microrao.com/micronotes/tuberculin.htm

 

[greatnt249]

What he said is incorrect , you check a PPD after 48h to see if a granuloma is formed (in which case macrophages predominate, Type IV HS is classic for PPD). If it was neutrophils you would expect a pyogenic rx (ie acute inflammatory response, which is not the case in a PPD).

Read here for more info if you wish:

http://www.microrao.com/micronotes/tuberculin.htm

My mistake; my memory of the timeline of the acute inflammation process needs to be jogged, I guess.

 

[nkhan]

My mistake; my memory of the timeline of the acute inflammation process needs to be jogged, I guess.

No problem hopefully it's +1 for you on boards. Good luck.

 

[512TA]

C) Macrophage, they are the APC's in this case and present Ag via MHC I/II & secrete IL-12 which activate CD4/CD8 T cells which come in and kill the guys. But the macrophage I think is the predominant cell (same with a granuloma--I've seen that asked before also).

i was thinking of B cells (Th-2 response)?? is 25cm for an enduration not a bit too much

 

[TalkingHeads]

Sorry for the delay, here's the question

45 year old women present with 2 month history of nausea, fatigue, wt loss and bone pain. She has renal insufficiency, high BP and pitting edema. Cr 4mg/dL and BUN 55mg/dL. X-ray shows osteoid seams and subperiosteal erosions..

now, this is an up/down arrow question.
Ca (incr), assuming that she has either MM or hyper PTH
Phosphate, I wasn't sure (I put incr). She has renal insufficiency so I'm not sure how much PTH would work here.
PTH (incr) with the osteoid seams and erosions
Vit D (incr), due to PTH activation or (decr) with neg. feedback?

help?

 

[sgod34]

She has renal insufficiency so Vit D would have to be decreased due to decreased 1a-hydroxylase.

 

[ArcGurren]

Sorry for the delay, here's the question

45 year old women present with 2 month history of nausea, fatigue, wt loss and bone pain. She has renal insufficiency, high BP and pitting edema. Cr 4mg/dL and BUN 55mg/dL. X-ray shows osteoid seams and subperiosteal erosions..

now, this is an up/down arrow question.
Ca (incr), assuming that she has either MM or hyper PTH
Phosphate, I wasn't sure (I put incr). She has renal insufficiency so I'm not sure how much PTH would work here.
PTH (incr) with the osteoid seams and erosions
Vit D (incr), due to PTH activation or (decr) with neg. feedback?

help?

Just took it, and got the question wrong too mostly because of my own stupidity and putting low calcium

I think everything else is right except the Vitamin D - it would be decreased due to renal dysfunction and lack of 1 alpha hydroxylase.

 

[Encephalectomy]

Just took it, and got the question wrong too mostly because of my own stupidity and putting low calcium

I think everything else is right except the Vitamin D - it would be decreased due to renal dysfunction and lack of 1 alpha hydroxylase.

Hi guys,

I think that in this one it is renal osteodystrophy, so low ca, high phosphorus, high pth, low 1,25 vitamin D

A few questions of my own...

Would you have a normal cbc with bruton's? I thought that you had no/low circulating b-cells, but I guess maybe this wouldn't really be apparent in a normal cbc?

African american boy with recurrent neisseria meningitidis infections

complement deficiency or sickle cell?


Which best supports plasmid mediated transfer of resistance?
Transfer succeptible to DNase

Transfer requires cell to cell contact

Transfer requires transformation competent recipient strain

 

[nkhan]

Hi guys,

I think that in this one it is renal osteodystrophy, so low ca, high phosphorus, high pth, low 1,25 vitamin D

A few questions of my own...

Would you have a normal cbc with bruton's? I thought that you had no/low circulating b-cells, but I guess maybe this wouldn't really be apparent in a normal cbc?

African american boy with recurrent neisseria meningitidis infections

complement deficiency or sickle cell?


Which best supports plasmid mediated transfer of resistance?
Transfer succeptible to DNase

Transfer requires cell to cell contact

Transfer requires transformation competent recipient strain

#1) Not completely sure but I think it is normal since the problem is in B cell maturation (aka this is also called X linked agammaglobunemia) --there certainly is a deficiency in Ig so that if you do an electrophoresis you won't see the globulin peaks you normally would. I don't really think that the CBC would be altered (since the prob. is in B cell maturation--therefore their #'s wouldn't be altered) but I'm not totally sure.

#2) It depends on what the whole question said, did he have recurrent pain etc. or only neisseria infections? As neisseria is an encapsulated organism and the spleen is atrophic after a certain age in sickle cell patients (his age would be helpful as well). If he was really young I would say due to C5-9 def. if he is older I would say due to the autosplenectomy in sickle cell.

#3) Cell cell contact. First answer was talking about transformation (taking up DNA from environment--thus Dnase prevents it), Third was talking about transformation also. (see below pic for plasmid conjugation transfer)

 

[Encephalectomy]

thanks dude, you rock! The nesserria patient was 17, but had no other symptoms which I think is a good way of thinking about it (and I thought I was set with assuming that african-americans on the boards always had sarcoid, g6pd, or sickle cell).

I think what tripped me up on the bacteria question is that you can transfer plasmids via transformation and can technically transfer non plasmid DNA via sex pili. However I totally agree with you and cell/cell contact/sex pilus is definitely classic for plasmids.

 

[ArcGurren]

For recurrent Neisseria infection I put complement deficiency - I didn't get that one in my "wrong" answers so I'm assuming it was right. Even if African American you can't simply assume sickle cell without other symptoms (recurrent acute attacks of pain in bone due to infarctions, frontal bossing, etc).

 

[usmlesaga]

Can someone please explain what happens when alveolar ventilation and C02 both double in excerise what happens to arterial 02?

Also, what stimulates VEGF?

the answer choices were:

a) increase or decrease endostatin
b) increase/decrease po2
c) increase/decrease pC02
d) increase/decrease in thrombospondin

Q) A patient with ALL given methotrexate, what is the MOA of the drug?

a)DNA polyermase
d)adenosine deaminase
c)thymidylate synthase
d)HGPRT
e) Xanthine oxidase

Q) A 5 y.o girl developing breasts? Given an IV bolus of GNFH. What drug can be given to stop previous puberty?

a)leuprolide
b) tamoxifen
c)spironolactone
d) ketoconazole
e) testosterone
f) progesterone
g) ACTH
h) hydrocortisone

Q) 60 yr old has pain, erthyema and swelling of the big toe. Which enzyme is defecient?

a) deficient aminotransferase
b) deficient HGPRT
c) glucose 6 phosphatase
d) glutathione peroxidase
e) no enyzme or renal defect

Thanks!

 

[Encephalectomy]

Can someone please explain what happens when alveolar ventilation and C02 both double in excerise what happens to arterial 02?


Also, what stimulates VEGF?
hypoxia induces Hif--> increased VEGF

the answer choices were:

a) increase or decrease endostatin
b) increase/decrease po2
c) increase/decrease pC02
d) increase/decrease in thrombospondin

Q) A patient with ALL given methotrexate, what is the MOA of the drug?

a)DNA polyermase
d)adenosine deaminase
c)thymidylate synthase-methotrexate inhibits dihydrofolate reductase, no THF, no thymidilate synthase activity
d)HGPRT
e) Xanthine oxidase

Q) A 5 y.o girl developing breasts? Given an IV bolus of GNFH. What drug can be given to stop previous puberty?

I got this one wrong also, If a bolus of GnRH induces a >2 fold increase in LH/FSH, then the patient has central precocious puberty, which means that I think you can treat it with leuprolide

a)leuprolide
b) tamoxifen
c)spironolactone
d) ketoconazole
e) testosterone
f) progesterone
g) ACTH
h) hydrocortisone

Q) 60 yr old has pain, erthyema and swelling of the big toe. Which enzyme is defecient?

a) deficient aminotransferase
b) deficient HGPRT-can cause gout but is rare and would have other symptoms
c) glucose 6 phosphatase
d) glutathione peroxidase
e) no enyzme or renal defect

patient has gout. the vast majority of patients with gout don't have a bonafida enzyme/renal defect just a lifetime of delicious things like lobster, scotch, and purine filled bloody steaks

Thanks!

hey dude, here are my answers, I think their right, but maybe others can confirm.

 

[titan25]

a 20 years old comes with complain of numbness, burnt his hand and decreased sensation of temp of upper where is the lesion in spinal cord

i thought it syringomylia and kept ans as spinothalamic track whats the answer is it anterior white comissure

2 renal vein excess oxygen compared venous oxygen of other organs why

3 why mitochondria produces its own tRNA

 

[titan25]

what is the anwer for two CT q

one a bullet injury , abdomen cavity full of blood, which organ is damaged...

other heart right margin tumour in women with breast cancer which part is affected ...is it thorasic duct

other one a obesce patient operated a bag should kept around stomach then bag should pass through

a person with heamorhoides ,cycles a lot comes with difficulty in erection and pain in the back

 

[Encephalectomy]

what is the anwer for two CT q

one a bullet injury , abdomen cavity full of blood, which organ is damaged...

need more info, i think it was a question about peritoneal vs retroperitoneal structures

other heart right margin tumour in women with breast cancer which part is affected ...is it thorasic duct

the answer is phrenic nerve

other one a obesce patient operated a bag should kept around stomach then bag should pass through

lesser omentum

a person with heamorhoides ,cycles a lot comes with difficulty in erection and pain in the back
nerve compression in perineum

.

 

[Encephalectomy]

a 20 years old comes with complain of numbness, burnt his hand and decreased sensation of temp of upper where is the lesion in spinal cord

i thought it syringomylia and kept ans as spinothalamic track whats the answer is it anterior white comissure

yes

2 renal vein excess oxygen compared venous oxygen of other organs why

most organs get blood based on their oxygen demands, but the kidney gets 25% of the CO so that it can filter the blood, but not because it uses 25% percent of the oxygen

3 why mitochondria produces its own tRNA
has own genetic code with different codons

.

 

[titan25]

hi thanks a lot for reply immediately

one hepatosites are damaged in hepatities due to direct effect....is it due to cytotoxic T cell as it is viral infection

a person with heamorhoides ,cycles a lot comes with difficulty in erection and pain in the back
options r luboscral strain or compramised blood supply from pampiniform pluxes , damaged supply of nerve and veins to errectile tissue

one a bullet injury , abdomen cavity full of blood, which organ is damaged patient diaphoretic with BP 80 /60 haemocrit 20... entery wound mid left of abdome

i think answer will be spleen as kidney ,adrenal,tail of pancreas are retroperitoneal

 

[Encephalectomy]

hi thanks a lot for reply immediately

one hepatosites are damaged in hepatities due to direct effect....is it due to cytotoxic T cell as it is viral infection

correct, hep B is not directly cytotoxic, and the hepatocyte death is due to cd8 mediated cell killing

a person with heamorhoides ,cycles a lot comes with difficulty in erection and pain in the back
options r luboscral strain or compramised blood supply from pampiniform pluxes , damaged supply of nerve and veins to errectile tissue

one a bullet injury , abdomen cavity full of blood, which organ is damaged patient diaphoretic with BP 80 /60 haemocrit 20... entery wound mid left of abdome

i think answer will be spleen as kidney ,adrenal,tail of pancreas are retroperitoneal

correct, the key here is that the 'abdominal cavity' is full of blood which means that the bleeding needs to be from a peritoneal organ

.

 

[usmlesaga]

deleted

 

[ScubaStarved]

http://www.thefreedictionary.com/lithiasis

Less snarky:
Choledocholithiasis -> stone lodged in CBD, producing obstructive pattern of liver enyzymes (transaminitis and direct hyperbili)

CBD obstruction is more general, and may be due to pancreatic cancer, pancreatitis, iatrogenic from ERCP, Mirizzi syndrome, and so on.

 

[ArcGurren]

Can someone please explain the following from NBME 11:

Q. 70 yr man with dark urine, white stools, has jaundice, abdomen shows no irregularities, soft tissue mass in pancreas. What is causing the jaundice?

A) cholelithiasis
B) common bile duct obstruction
C) pancreatic bile duct obstruction
D) Liver mets
E) porta hepata mets

IF the answer is A - can someone please explain the difference btwn that and ans B?

Thank you.

I think I said B because cholelithiasis isn't a soft tissue mass? Dark urine suggests a bilirubinemia and acholic stools suggests an obstruction. It's not C because you don't have evidence of pancreatitis, D and E are a little ridiculous, and a stone would be a hard mass.

Was that not the answer? I forget, I took the exam a couple weeks back.

 

[ArcGurren]

http://www.thefreedictionary.com/lithiasis

Less snarky:
Choledocholithiasis -> stone lodged in CBD, producing obstructive pattern of liver enyzymes (transaminitis and direct hyperbili)

CBD obstruction is more general, and may be due to pancreatic cancer, pancreatitis, iatrogenic from ERCP, Mirizzi syndrome, and so on.

*facepalm* read it wrong. Thanks.

 

[sgod34]

I would think the answer is B, because to have a pancreatic lesion the obstruction/stones would have to be in the common bile duct to obstruct the spincter of oddi/ampula of vater, where cholelithiasis is stones inside the gallbladder which would not affect the pancreas.

 

[pilottodoctor]

loving it

 

[ar2388]

clearly i dont know my anatomy.. any idea what the answer is to this one?

6 weeks after undergoing open carpal tunnel release operation, 44 yr old woman .... an intraoperative nerve injury is suspected. which of the following nerves is likely injured in this pt?

a) dorsal sensory branch of the ulnar n
b) lateral cutaneous nerve of the forearm
c) palmar cutaneous branch of the median n
d) recurrent motor branch of the median n
e) sensory branch of the radial n

i thought d...?

 

[ar2388]

and this one...
20 r old man is brought to the ER 4 hrs after gunshot wound to forearm during hunting accident. exploratory operation shows that the tendon of the flexor carpi radialis is severed and there is a communuted fracture of the distal radius, ..... functional loss would be insiginficant?

a) flexor capri ulnaris
b) flexor digitorum profundus
c) flexor digitorum superficialis
d) palmaris longus
e) pronator teres


i thought c.. but its not haha

 

[ar2388]

and this.. man why cant i figure these out myself?

500 reciefve the new drug and 500 receive placebo. results show average duration of recurrent HSV outbreaks with new drug is 1 week compared with 2 weeks for placebo. which of the followiing outcomes is most liklely

a) incidence decrease by half
b - incidence double
c - prevalence decrease by half
d- prevalcen double.

is it c?

 

[SeekerOfTheTree]

I think for your second question it is palmaris longus becuase its absence would have no impact on people. It is absent in a small percent of the population anyways.

 

[SeekerOfTheTree]

I think for your third question c would be right. Did it say it was wrong? Incidence would be new cases and the drug doesn't protect against those. The only thing it does is reduce the duration of symptoms by 1/2 so that if at any point in time you measure the prevalence of the disease it would be reduced by 1/2 because infections would be symptomatic half as long. It is kind of a wierd question because you aren't really curing it so is it talking about prevalence of an active infection?

 

[ar2388]

.

 

[SeekerOfTheTree]

I don't know why but for your first question I want to say c because it seems like it would be a sensory issue and the thenar eminance is innervated by the lateral branch of the cutaneous. I didn't want to say c and look stupid becuase it's wrong...I have self esteem issues.

 

[sgod34]

clearly i dont know my anatomy.. any idea what the answer is to this one?

6 weeks after undergoing open carpal tunnel release operation, 44 yr old woman comes to doc with new sx of numbness in the right hand. when asked about the exact location of these sx, she points to area over the right thenar eminence. percussion of the area between the flexor carpi radialis and palmaris longus tendons at the distal palmar wrist crease produces a painful shock like sensation radiating into the affected area of the palm. an intraoperative nerve injury is suspected. which of the following nerves is likely injured in this pt?

a) dorsal sensory branch of the ulnar n
b) lateral cutaneous nerve of the forearm
c) palmar cutaneous branch of the median n
d) recurrent motor branch of the median n
e) sensory branch of the radial n

i thought d...?

It's Palmar Cutaneous branch of Median, which supplies SENSORY to the thenar/palmar area upto the base of the lateral 3 digits. Sensory to the lateral 3 .5 digits is Common Palmar Digital branch of the Median. The Recurrent MOTOR branch of the Median n supplies motor innervation to the 3 thenar muscles.

 

[ar2388]

I think for your third question c would be right. Did it say it was wrong? Incidence would be new cases and the drug doesn't protect against those. The only thing it does is reduce the duration of symptoms by 1/2 so that if at any point in time you measure the prevalence of the disease it would be reduced by 1/2 because infections would be symptomatic half as long. It is kind of a wierd question because you aren't really curing it so is it talking about prevalence of an active infection?

ah thanks. i chose incidence decrease by half but then realized that was def not right

 

[ar2388]

It's Palmar Cutaneous branch of Median, which supplies SENSORY to the thenar/palmar area upto the base of the lateral 3 digits. Sensory to the lateral 3 .5 digits is Common Palmar Digital branch of the Median. The Recurrent MOTOR branch of the Median n supplies motor innervation to the 3 thenar muscles.

oh jeez.. thanks. haha. i need to read better.

 

[SeekerOfTheTree]

I think with codeine you actually get a physical dependence whereas with the dex it's more mental. So there is abuse potential for both but codeine is much worse so b would still be right.