NBME 16 help

[shubz123]

Hi all,

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[Apoplexy__]

Thanks a lot kirbymeister, I appreciate the response.

To question 1-1 however, your reasoning would make sense if that's what they were asking. It seems though that the question is asking more why the occult blood test is inappropriate in this situation. And since occult blood tests have low specificity as stated in your response, it seems like it should be the correct answer.

And about 4-10, it's still odd to me. I guess I don't understand what unbalanced chromosomal translocation means...why would all her eggs be affected? It seems with mosaicism, at least some of her eggs would be viable. Still, this is one of the oddest presentations I've seen.

And I made a pretty cool connection from reading your explanation and thinking about the endocardial cushion question. A lot of the internal Down syndrome pathology can actually be explained by impaired neural crest migration! I don't think I've read this as an explanation in FA/Pathoma/Goljan... but it makes sense

Ah, I see your logic with 1-1. Here's what I'm trying to get at: In a screening test, all that matters is sensitivity. So when comparing two tests, the one that is not picked is inappropriate because it has inferior sensitivity. I suppose an analogy would be: in the issue of hammering in a nail, a screwdriver is inappropriate not because a screwdriver is a poor surgical tool (which it is) but because a screwdriver is a poor hammer.

A comparison between chromosomal translocation and gonadal mosaicism:
-Chromosomal translocation: Somewhere early in the mother's development, she stuck most of chromosome 16 onto 20 (just for an example). All the cells in her body have this malformation:
16, --
20, 20+16
So when she forms oocytes, it could either be:
16, 20
--, 20 (monosomy 16 embryo)
16, 20+16 (trisomy 16 embryo)
--, 20+16
We don't know whether the spontaneous abortions were all monosomy, all trisomy, or some trisomy/some monosomy, and we don't know the karyotype of the live disfigured baby. But we do know that chromosomal translocation can produce both spontaneous abortions and a disfigured baby.
-Gonadal mosaicism: This would be the case where most of the mother's cells are a normal 46, XX but ALL of her oocytes are, say 45, XO. Every time she becomes pregnant, she will have the same chromosomal deficit. The thought process to rule out gonadal mosaicism was to understand that the history of spontaneous abortions was probably due to the same defect, so a new live birth meant that the baby did not have the defect; you then had to say that gonadal mosaicism can't produce two distinct lines of oocytes.

Definitely a tough question.

 

[Apoplexy__]

53 yo alcoholic, homeless man comes to ed by police. appears cachectic, fever. clubbing of fingers, breath smells, missing teeth, numerous cavities. has increased fremitus, dullness to percussion, and tubular breath sounds in right lower lung. leukocyte count 11.4k. sputum grows purulence, gram + cocci in chains, and gram - bacilli. x ray shows cavitation in right lower lung lobe with surrounding infiltrate. sputum will likely grow which of the following?

chlamydophila pneumonia, haemophilus influenza, mycoplasma pneumonia, strep pneumon, normal oral flora

Normal oral flora. Homeless person + poor dentition + lung infection = aspiration pneumonia. Aspiration involves infection with normal oral flora.

 

[afrothunderman1]

Answers in blue

Thank you! You guys are awesome! Hope everyone kills this exam!

 

[afrothunderman1]

12. Sigmoid colon mass revealing adenocarcinoma. Which LNs would it mets to?
--> Inferior mesenteric, Internal iliac, Left colic, Pararectal, Superficial inguinal


Guys isn't this inferior mesenteric?????????!!! (Internal iliac should be wrong no?)

 

[afrothunderman1]

.

 

[Apoplexy__]

12. Sigmoid colon mass revealing adenocarcinoma. Which LNs would it mets to?
--> Inferior mesenteric, Internal iliac, Left colic, Pararectal, Superficial inguinal


Guys isn't this inferior mesenteric?????????!!! (Internal iliac should be wrong no?)

Yeah, definitely. I'm 95% sure I put IMA and it wasn't in incorrects...but you're saying otherwise?

1) a 36 yr old man comes to doc cuz of a 2 hr history of pain and swelling of right calf. He has no shortness of breath or chest pain. he completed an 18 hr flight trip. Theres an occlusion of right femoral vein. Drug with which mech of action should be used? is it activation of antithrombin III?

activation of antithrombin III, activation of cyclooxygenase, activation of ferrochelatase, inhibition of glycoprotein IIb/IIIa- receptor expression, inhibition of vitamin k reductase

Wasn't this question asking about outpatient therapy in particular? I seem to remember the answer being warfarin from some hint that it was a drug you were going to send him home with. So VitK reductase.

2) a 44 yr old man comes to doc cuz of a 2 mo history of abdominal pain and diarrhea. Pain reduced temporarily after eating and by using antacids, Phys exam shows epigastric tenderness. Lab studies show serum gastrin concentration of 500 pg/ml(N=50-100) and gastric acid secretion of 80 mEq/h (N=6-49). Whats the most definitive treatment at this time to decrease patients risk for complications? Is it organ antibiotic therapy(since i think its h pylori)

low protein diet, oral antibiotic therapy, oral antihistamine therapy, sectioning the vagus nerve to the stomach, surgical removal of suspected tumor


Zollinger-Ellison syndrome. Check out that crazy gastrin level. Answer = surgical removal of suspected tumor.


3) 38 yr old lady undergoes choleystectomy w anesthesia. She awakens postoperatively, is nauseated, and vomites three times in 20 minutes. Whats the treatment for nausea and vomiting in this patient? Im stuck b/w ondansetron and scopolamine, altho i really think its ondansetron because that works on the ctz, where the vomiting centers are located, and scopolamine is usually for motion sickness.

diphenhydramine, dronabinol, loperamide, ondansetron, scopolamine


Ondansetron. Good for post-chemo AND post-surgical. I dunno why, but the NBME has a massive hard-on for this drug.


4) 5 yr old boy comes to doc cuz of 8 mo history of recurrent middle ear and upper resp infections. history of impaired motor and cognitive function. he has hepatosplenomegaly. cultured skin fibroblasts shows inclusion bodies and deficiency in activity of n-acetylglocosamine 1 phosphtransferase. cell secret large amount of acid hyrolases in culture medium. these enzymes are unable to target which organelle? is it lysosomes?

endoplasmic reticulum, lysosomes, mitochondria, nucleus, peroxisomes

Lysosomes. This is I-cell disease.


5) a 31 yr old woman has invasive squam cell carcinoma of cervix. Biopsy of cervix shows tumor cells express hpv, type 16 antigens. which of the following cells recognizes and kills these virus infected tumor cells? Is it t lymphocytes? I really think its this..

dendritic cells, macrophages, myeloid precursors, plasma cells, t lymphocytes

Yep, T lymphocytes. Tumor cells are killed by CD8+ T cells and NK cells; better answer between the two (if you're unlucky) is CD8+ T cells.


6)35 yr old woman comes to the doc cuz of sharp intermittent chest pain that develops suddenly, is sometimes exacerbated by deep breathing, and can be deceased by leaning forward. She has a 2 month history of pain and swelling in her hands and knees along with morning stiffness that usually lasts 1 hour. Pulsus paradoxes is less than 10 mm hg. Auscultation of the chest shows a harsh scratchy sound that is pressent in both systole and diastole. There is warmth, swelling, and tenderness of the metacarpophalangeal joints and knees. whats responsible for chest pain in this patient? It’s pericarditis right?

costochondritis, ischemic heart disease, mitral valve prolapse, pericarditis, pulmonary fibrosis

Yep, pericarditis. Given away by "present in both systole and diastole".


7) a 27 year old man with acute myelocytic leukemia receives high dose cyclophosphamide in preparation for hematopoietic stem cell transplantation. the administration of which of the following is most likely to decrease the toxicity from this chemotherapy regimen? mesna right?

acetylcysteine, activated charcoal, deferoxamine, mesna, sodium bicarbonate

Yep, mesna.


8) 52 old man w 3 week history of increased thirst and urinary freq. had 10 lb weight loss. has hypertension and hyperlipedemia trted w pravastatin and matoprolol. he’s 5’11, mildly ill, weights 240lb. vmi is 34 kg/m. Pulse is 94/ min , respiratoins are 16/min and bp is 130/80. exam shows no other abnormalities. Whats increased in this patient? Is it fasting serum glucose concentration?

fasting serum glucose concentration, glycogen synthesis in muscle, insulin mediated glucose disposal rate, serum calcium concentration, serum hdl cholesterol concentration, urine sodium concentration

I don't really remember this one, but yeah I think it's fasting serum glucose.


9)a 48 yr old woman comes to the doc cuz of irregular menstual periods and hot flashes…thinning of vaginal tissue…what will labs show? I think its increased fsh cuz i think in u world they mentioned that fsh increase is indicator for menopause? Or maybe I’m mixing something else up

decreased adrenocorticotropic hormone, decreased luteinizing hormone, decreased thyroid stimulating hormone, increased follicle stimulating hormone, increased prolactin

Exactly, increased FSH from menopause.

10) Little girl brought into er..basketball hit her…tooth stuck in throat…greatest risk for aspiration of tooth in which lobe of lung? is it right upper or right lower

left upper, lingual, left lower, right upper, right lower

Right lower. FA pg. 595 (2014 ed)

Thanks a lot !

Answers in quote, yo

 

[afrothunderman1]

No i think someone put the wrong answer on the forum. It def should be IMA.

 

[tantacles]

53 yo alcoholic, homeless man comes to ed by police. appears cachectic, fever. clubbing of fingers, breath smells, missing teeth, numerous cavities. has increased fremitus, dullness to percussion, and tubular breath sounds in right lower lung. leukocyte count 11.4k. sputum grows purulence, gram + cocci in chains, and gram - bacilli. x ray shows cavitation in right lower lung lobe with surrounding infiltrate. sputum will likely grow which of the following?

chlamydophila pneumonia, haemophilus influenza, mycoplasma pneumonia, strep pneumon, normal oral flora

Normal oral flora. He's an alcoholic, and he has an abscess in the lower right lung. Classic aspiration pneumonia.

 

[kween]

1) a 36 yr old man comes to doc cuz of a 2 hr history of pain and swelling of right calf. He has no shortness of breath or chest pain. he completed an 18 hr flight trip. Theres an occlusion of right femoral vein. Drug with which mech of action should be used? is it activation of antithrombin III?

activation of antithrombin III, activation of cyclooxygenase, activation of ferrochelatase, inhibition of glycoprotein IIb/IIIa- receptor expression, inhibition of vitamin k reductase

Kirby, are you 100% on this quest.
I think i put activation of antithrombin for this one and it wasn't in my incorrects.
I believe he has a DVT and DOC is heparin for immediate anticoagulation.
Warfarin has a later onset of action

8) 52 old man w 3 week history of increased thirst and urinary freq. had 10 lb weight loss. has hypertension and hyperlipedemia trted w pravastatin and matoprolol. he’s 5’11, mildly ill, weights 240lb. vmi is 34 kg/m. Pulse is 94/ min , respiratoins are 16/min and bp is 130/80. exam shows no other abnormalities. Whats increased in this patient? Is it fasting serum glucose concentration?

fasting serum glucose concentration, glycogen synthesis in muscle, insulin mediated glucose disposal rate, serum calcium concentration, serum hdl cholesterol concentration, urine sodium concentration

Yea, Kirby is right.
Seems like patient has metabolic syndrome

Correct me if I'm wrong

 

[afrothunderman1]

Correct me if I'm wrong

thank you kween

 

[afrothunderman1]

.

 

[kween]

1)An animal study is conducted to assess the effects of smoking on pulmonary defense and maintenance mechanisms. For 1 week, normal
male rats are exposed to levels of cigarette smoke comparable to those encountered by humans who smoke cigarettes. Results of
pulmonary testing are compared with baseline levels obtained the week before the smoke exposure. Which of the following sets of changes
is most likely to be observed? The combo I came up with isn’t one of the answer choices I’m sure you guys also felt that you’d get an increase in mucus proaction and alveolar macro function nd decrease in activity of airway cilia

Mucus Production and Secretion up/down

Alveolar Macrophage Function up/down

Activity of Airway Cilia up/down

mucus up
macrophage down
cilia down

2) old african lady w hypertension n type 2 diabetes mellitus. she’s 5’6 weights 192 lbs BMI is 31 kg.Her treatment reg includes hydrochlorothiazide. However her bp has averaged 140/90 mmhg. Lab studies show evidence of microalbuminuria. Whats the best drug to add? is it irbesartan(i was thinking ace inhibitor because i think anything that blocks angio-aldost is great for this situation but since they only had a sartan drug, i would think it’s that?)

amlodipine, clonidine, irbesartan, propranolol, terazosin

DOC for DM and HTN = ACEi / ARBS, CCB, diuretics (in this order)
so yea sartan drug

3)38 yo woman comes to physician for pre-employment exam; she has no history of serious illness; she takes no meds; her vitals are normal; PE shows no abnormalities

Lab studies show: Hb 8.2, Hct 25%, MCV 69, leukocytes 5900, retic 0.8%, platelets 350K

Most likely DX = ?

Aplastic anemia r/o MCV 80-100

Iron-deficiency

Sickle cell r/o MCV 80-100

B-thal minor

B12 deficiency r/0 MVC >100

Iron deficiency right??

yup, was down to iron def and b-thal,
but i picked iron def and was right
Anyone know how else I was supposed to distinguish iron def and beta thal from the labs provided?

4)diagram of the ribcage..systolic murmur loudest at pointed marked by x…which cardiac abnormality causing murmur? This one was aortic valve stenosis right?
aortic valve regurg, aortic valve stenosis, mitral valve regurg, mitral valve stenosis, pulmonic regurg, pulmonic stenosi, tricus regurg, tricus stenosis

5)old man w sudden right sided weakness…right perioral droop. muscle strength 4/5 on right. babinski present on the right. ct scan of head shows normal. week later, ct shows small area of hypo density involving left internal capsule consistent w loss of tissue. which cell types most likely to clear necrotic tissue in this area? Microglial cells right?

astrocytes, microglial cells, neurons, oligodendrocytes, satellite cells

microglial = macrophage in brain

6) secretary has 8 yr history of intermittent headache. They begin w flashing lights in right visual field followed 20 min later by a unilateral throbbing headache accompanied by nausea and committing. They occur around the time of her menses. Which of the following is the most likely diagnosis? is it intracranial mass cuz its a prolactinoma, the most common pituitary tumor?

cluster headache, inracranial mass, migraine, tension type headache

nausea and vomiting correlating with her menses, i believe are migraine auras. Triggered by flashing lights.

7)21 yr old girl 2 week history of blood tinged vomiting. 2 yr history of self induced committing 3 times weekly after eating food. she’s 5’3 and weights 137lb, BMI is 24 kg/m. What drug to give? is it medroxyprogesterone acetate because her hypothal-pituitary adrenal axis is messed up?

fluoxetine, haloperidol, lorazepam, medroxyprogesterone acetate, sibutramine

bulimic girl. who is sad and wants to loose weight, give her the happy pill - SSRI = Fluoxetine

8)50 yr old dude w progressive bulge in abs for past 6 mo. He’s had no changes in bowel habits. Midline hernia above umbilicus that can’t be reduced by gently pushing on it. Operative repair of hernia is initiated. Which of the following extacellular matrix components is required to increase the tensile strength of this patients postoperative abdominal incision? no frikkin idea

collagen, elastin, fibronectin, hyaluronan, laminin

I think this is collagen, Not 100% sure tho

Ans in blue

 

[Missorleans]

When you get down to beta thal and iron deficiency, remember iron deficiency is much more common, and if they wanted you to pick a thalassemia they'd probably tell you her ethnicity.

 

[afrothunderman1]

.

 

[witzelsucht]

1 - follicular atrophy. neg feedback
2- lung. squamous lung ca -> hypercalcemia. cea points away from colon. renal would be a good alternative but not on list
3 - fancy way of saying c-anca/pr3-anca. if you did nazi this answer you should study more
4 - low sens. screening test -> sensitivity
5 - syrinx. go with your gut
6 - inrease width i think?
7 -lamellar bodies
8 - i think t4 collagen
9 - cox

 

[tantacles]

1) lady needs advice on losing weight. she’s been taking thyroxine to lose weight. her thyroid function is normal. Findings on histopathologic exam of thyroid gland?

c cell hypoplasia, columnar metaplasia, follicular atrophy, glandular hypertrophy, squamous metaplasia

Atrophy. By taking thyroxine, she'll cause TSH levels to go down, which will reduce thyroid stimulation.

2) older dude has excision of brain mass(pic in question) he’s smoked a pack of cigs for the past 50 yrs. bp 130/90. labs: polycythemia, hypercalciemia, microscopic hematuria. immunstaiing positive for epithelial membrane antigen and negative for cea. whats the site of the primary neoplasm?

colon, kidney, liver, lung, lymph node, prostate, testis?

Kidney or lung, but I would probably go for kidney on this one. He's a smoker, which is a risk factor for both. Hypercalcemia points to PTHrP production by either a squamous cell carcinoma of the lung or a renal cell carcinoma, but the polycythemia points more to renal cell carcinoma since renal cell carcinoma can produce EPO.

3) 28 yr old lady has 1 week history of fever/chills. she had 10 lb weight loss during that time. 5 year history of chronic sinusitis and gone thru operations for sinus obstruction. appears mildly distressed. she’s 5’5 and weights 110. vmi 18 and temperature is 102F. diminished nasal septa. chest X-ray w multiple pulmonary nodules. antibodies against proteinase 3(REMEMBER THIS FROM UWORLD!) whats the diagnosis?

good pasture syndrome, nasopharyngeal cancer, rheumatoid arthritis, sle, weighers granulomatosis(is it this?)

Don't remember. I probably said Wegener's, though, because of the nasal and lung involvement and the fact that I think proteinase 3 is in neutrophils, so C-ANCA.

4) ladies' bro and mom have colon cancer. patient prefers stool be tested for blood but doc says its not appropriate because he’s concerned about what regarding that test?

low sensitivity, low specificity, potential for false positive result(is this it?), uncertain negative predictive value, uncertain positive pred. value

Low sensitivity. For diseases that will kill you quickly if not treated (like colon cancer), you want a more sensitive initial (screening) test.

5) lady burned herself while cooking for past few months. loss of pain and temp sensation in both upper extremities and portion of trunk from clavicles to below the nipples. touch, vibratory, proprioception are normal. wasting of small muscles of hand. mdi of head and spine will show what? this is syringomyleia so is it syrinx?

dilated 3rd ventricle causing damage to both sides of thalamus, edema in post central gyro on both sides secondary to multiple strokes, sclerotic plaques bilaterally in anterolateral white matter of spinal cord, syrinx of central region of spinal cord from c4 to t5, tumors compressing lateral funiculi of the spinal cord at c4?

Syrinx: She has a cape-like distribution of pure sensory impairment.

6) 48 yr man evaluated for possible hypertension. after 10 measurements, patients average diastolic bp is 11 mmhg, and standard deviation is 8 mmhg. If four rather than 10 msurments of mean bp are made, which is the expected impact on size of 95% CI about mean blood press?

change but the direction can’t be predicted, decrease in width, increase in width, remain the same

Increase in width. Lower sample size => Less certainty about where the mean actually lies => wider confidence interval.

7) newborn male tachypneic and hypoxemic. what altered structure changes in type 2 pbeumocytes is most likely cause of patients condition?

abundant rough er, decreased numbers of lamellar bodies, distinct junctional complexes with adjacent type 1 pneumocytes, numerous microvilli, reticular fibers

Decreased lamellar bodies. Lamellar bodies are secretory organelles. The type II pneumocytes make surfactant, and this infant has respiratory distress syndrome, so they're not secreting as much.

8) 30 yr old w hemoptysis, dyspnea, weakness, hematuria. bronchoscopy shows diffuse plum hemorrhages bilaterally. he has focal glomerular necrosis w crescent formation and linear deposition of IgG and c3 in glomerular capillary loops. which of the following is responsible for his disease?

autoantibodies against host cell basement membranes, deposition of immunoglobulin light chains and amyloid in endothelial cells, glomerular and alveolir injury due to circulating immune complexes, mutations in the genes encoding type iv collagen in the lung and kidney, polyclonal activation of cd8 t lymphocytes and natural killer cells

Crescentic => RPGN. Often caused by goodpasture's, which is Abs against basement membrane. It often has lung involvement as well.

9) 3 lb female born w rough grade 2/6 continuous machine like murmur along left sternal border, increased precordial activity and bounding peripheral pulses. treatment will inhibit activity of which of the following enzymes?

angiotensin converting enzyme, cycloocygenase, guanylyl cyclase, nitric oxide synthase, phospholipase a2

Indomethacin closes the PDA by inhibiting production of PGE2, which is an arachidonic derivative and therefore made by Cyclooxygenase (COX). Therefore, COX is the answer.

 

[tantacles]

2- lung. squamous lung ca -> hypercalcemia. cea points away from colon. renal would be a good alternative but not on list

Kidney is on the list.

 

[witzelsucht]

my bad, read it too fast. kidney cancer doesnt go to brain tho. 50% of brain mets are lung. anti-BM antibodies also correct, not t4 collagen.

 

[afrothunderman1]

Thank you guys

 

[tantacles]

my bad, read it too fast. kidney cancer doesnt go to brain tho. 50% of brain mets are lung. anti-BM antibodies also correct, not t4 collagen.

Kidney cancer CAN go to the brain. I mean, why couldn't it?

Polycythemia, though, points AWAY from squamous cell CA of the lung. It's a specific paraneoplastic syndrome of the kidney.

 

[witzelsucht]

well wikipedia says it doesnt. but 50% of brain are from lung either way. blood pathway, etc

 

[witzelsucht]

also polycythemia could be from his lung cancer superimposed on COPD from smoking all them ciggggs (hypoxia mxsm)

 

[tantacles]

well wikipedia says it doesnt. but 50% of brain are from lung either way. blood pathway, etc

From FA 2012:

Common Metastases:

To brain: Lung > Breast > Kidney > Skin (melanoma)

I'm not arguing that lung isn't the most common metastasis. Just that renal cell carcinoma makes more sense given the history we have.

 

[afrothunderman1]

What do you guys think of these questions. Our friends in the thread were unsure about them.

1) 25 y/o woman w/ history of irregular menstrual periods, deep voice, hirsutism, acne. Serum studies of insulin, testosterone, and lutenizing hormone show what?

PCOS so fasting insulin, testosterone, and LH all increased right?


2) (You may need to look at pic for this. Don’t know how to attach it). 4o yr old lady diagnosed with immune thrombocytopenic purport resistant to corticosteroid trtmnt will undergo operation to fix this condition. What organ should be removed? So the spleen pretty much. It’s B right?

a,b,c, d, e


3)50 yr old dude w progressive bulge in abs for past 6 mo. He’s had no changes in bowel habits. Midline hernia above umbilicus that can’t be reduced by gently pushing on it. Operative repair of hernia is initiated. Which of the following extacellular matrix components is required to increase the tensile strength of this patients postoperative abdominal incision? no frikkin idea

collagen, elastin, fibronectin, hyaluronan, laminin

 

[tantacles]

What do you guys think of these questions. Our friends in the thread were unsure about them.

1) 25 y/o woman w/ history of irregular menstrual periods, deep voice, hirsutism, acne. Serum studies of insulin, testosterone, and lutenizing hormone show what?

PCOS so fasting insulin, testosterone, and LH all increased right?

Yes.

2) (You may need to look at pic for this. Don’t know how to attach it). 4o yr old lady diagnosed with immune thrombocytopenic purport resistant to corticosteroid trtmnt will undergo operation to fix this condition. What organ should be removed? So the spleen pretty much. It’s B right?

a,b,c, d, e

Spleen, yes.

3)50 yr old dude w progressive bulge in abs for past 6 mo. He’s had no changes in bowel habits. Midline hernia above umbilicus that can’t be reduced by gently pushing on it. Operative repair of hernia is initiated. Which of the following extacellular matrix components is required to increase the tensile strength of this patients postoperative abdominal incision? no frikkin idea

collagen, elastin, fibronectin, hyaluronan, laminin

Collagen is my best guess. Remember that scar formation has two stages. After a week you get granulation tissue. Then, over the next month, you get replacement of Type III collagen with type I collagen, which creates the mature scar.

 

[afrothunderman1]

Yes.


Spleen, yes.




Collagen is my best guess. Remember that scar formation has two stages. After a week you get granulation tissue. Then, over the next month, you get replacement of Type III collagen with type I collagen, which creates the mature scar.

oh wow so thats the principle they were getting at with the last question. Yeah I remember that from pathoma

 

[afrothunderman1]

.

 

[kween]

1) 39 yr old lady w rheum.arthritis. Trtment with multiple meds, including prednisone and methotrexate hasn’t been effective. Next step in treatment is drug that blocks effects of which of the following cytokines? TNF a right?

interferon gamma, interleukin 2(IL-2), IL-4, IL-10, Tumor necrosis factor-a inhibitors

2) Pic of anus, surrounding is red. 28 yr lady comes to doc cuz of 3 wk history of intermittent anal itching, pain w dedication, bright red blood w wiping. She admits to intermitting constipation. Whats the cause of the lesion? Is it venous hypertension?

candidiasis, lymphatic obstruction, tinea cruris, varicella zoster virus infection, venous hypertension

external hemorrhoids = painful

3) guy laughs..food irritates…guy coughs…(the vocal cord question)….the vocal cords are closed during swallowing, open after laryngeal irritation, and open while couging right? so closed during swalloing, open, and open?

closed with swallowing and laryngeal irritation, open with coughing

4) guy comes to doc to get opioids for back pain..doc says to use over the counter meds..dude becomes pissed…whats the appropriate action by doc? Is it determine which drugs have been prescribed for the patient in the past?

determine which drugs have been prescribed for the patient in the past, obtain serum toxicology screening on the patient, order an mdi of the spine, prescribe only a 2 week course of a narcotic medication for the patient, refer the patient to a drug addiction program

we have to determine his hx to know whether or not his drug seeking

5) 62 yr old man w moderate splenomegaly but no lymphadenopathy. lymphocytes have cytoplasmic projections and positivity for acid phosphatase even in the presence of tartrate. diagnosis? hairy cell leukemia?

acute lymphoblastic leukemia, acute myelogenous leukemia, chronic lymphocytic leukemia, chronic myelogenous leukemia, hairy cell leukemia, infectious mononucleosis

TRAP+ = Hairy cell

6) 2 groups given general anesthesia. group x given isoflrane at 1.5 times MAC for this drug. group y anesthesia induced by administering combo of isoflurane and nitrous oxide, each at .75 times mac for that drug. the onsite of anesthesia is faster in group y than in group x. different responses due to what proper of isoflu and NO? is it minimal alveolar concentration?

blood:gas partition coefficient, brain: blood partition coefficient, brain:gas partition coefficient, hepatic metabolism, lipid solubility, minimal alveolar concentration, molecular weight?

saw this in a previous page, but can't really explain

Thanks <3

Answers in quote

 

[afrothunderman1]

Answers in quote

Thank you kween. Can you please explain this question to me whenever you get a chance 3) guy laughs..food irritates…guy coughs…(the vocal cord question)….the vocal cords are closed during swallowing, open after laryngeal irritation, and open while couging right?

you had mentioned it was : closed with swallowing and laryngeal irritation, open with coughing How come its this? Thank you

 

[afrothunderman1]

Also if someone can explain this 6) 2 groups given general anesthesia. group x given isoflrane at 1.5 times MAC for this drug. group y anesthesia induced by administering combo of isoflurane and nitrous oxide, each at .75 times mac for that drug. the onsite of anesthesia is faster in group y than in group x. different responses due to what proper of isoflu and NO?

blood:gas partition coefficient <- please explain why that is the answer.

 

[afrothunderman1]

 

[kween]

Thank you kween. Can you please explain this question to me whenever you get a chance 3) guy laughs..food irritates…guy coughs…(the vocal cord question)….the vocal cords are closed during swallowing, open after laryngeal irritation, and open while couging right?

you had mentioned it was : closed with swallowing and laryngeal irritation, open with coughing How come its this? Thank you

Here was my thinking. Anyone can correct me if I'm wrong.

Vocal cords are within larynx above trachea. Epiglottis which is above trachea closes it off when swallowing to prevent food from going down trachea to irritate vocal cords = coughing and choking.

In the event that food does go down the trachea (wrong pipe), it needs to be expelled. The reflex to expel the food is coughing, when coughing you want the pipe to be open soo the food can be regurgitated.

IMMEDIATELY after a laryngeal irritation, the first reflex is to close. A process trying to stop the food from doing down the wrong way.

 

[Missorleans]

35 y/o man with burning abdominal pain after meals. epigastric tenderness and abdominal CT shows pancreatic mass. Immunohistochemical labeling of neoplastic cell has antibodies against?

a. amylase b. gastrin c. glucagon d. human pancreatic polypeptide e. insulin f. lipase g. serotonin h. somatostatin i. VIP


Gastrin, excess gastrin from a gastrinoma is causing ulcers (hinted by epigastric tenderness)


and


1. Gastrin. They wanted your thought process to be: Gastritis + pancreatic mass = Zollinger-Ellison --> Neoplastic cells have an abundance of gastrin.




We get antibodies against gastrin in ZE syndrome??? The heck??!?? I am confused…..Or is the question just trying to be fancy but simply asking what is increased in ZE syndrome, hence why they say (antibody to determine whats causing the problem should detect what substance? answer gastrin. Is that what they mean? lol..meaning they are using antibody to figure out whats wrong w the patient...hence the antibody determines its the increased gastrin from the gastrinoma causing the problem

They're basically describing immunohistochemistry. Detect cells making a ton of gastrin with a gastrin antibody.

 

[afrothunderman1]

 

[Missorleans]

1) A 62 yr old man comes to the physician for a follow up examination. Two weeks ago, he was discharged from the hosp after sustaining MI. He smokes 2 packs of cigarettes and drinks 4 12 oz beer daily. His diet mostly consists of cured meats and fast food. He does not exercise. The pt. tells the physician, "I know that I need to make some changes in how I live so that my heart can be healthier. I just don't have the willpower to quit smoking and drinking and all that stuff right now." Which of the following best describes this patient's stage of behavioural change? Is this contemplation?



Precontemplation, Contemplation, Preparration, Action, Maintenance

I thought precontemplation but I don't remember what I put for this question and someone earlier said they put contemplation and it wasn't in their incorrects.



2) 51 yr old woman w/ pheochromocytoma. preoperative treatment w propranolol prescribed to decrease tachycardia. which drug should be admins. before starting propranol? Is it phenoxybenzamine?



atenolol, clonidine, nifedipine, phenoxybenzaminem sildenafil?

Phenoxybenzamine. This and the association with MEN is the only questions we seem to get about pheos.




3) 70 yr old lady brought to er by husband 45 min after he found her unresponsive. She has anxiety disorder trted w/ diazepam. She recently started taking over the counter med for heart burn. she only responds to painful stimuli. interaction with which drug causing this prob? i know its a cytp450 inhibitor so is it cimetidine or ranitidine?

calcium carbonate, cimitidine, famotidine, magnesium trisilicate, ranitidine

Cimetidine, the others don't inhibit P450, which is why she's had a benzo overdose.




4) 67 yr old lady hip replacement operation has shortness of breath and pain of back with deep breathing. She’s anxious..calf shows erythma…has large embolism occluding blood flow. Answer is dead space right since its a perfusion defect? I skipped out on details in the question because i figured you’d remember which question this was.

dead space, diffusion abnormality, hypoventilation, low fi02, shunt,

Yes, dead space. Air is coming in but gases aren't being exchanged.

 

[afrothunderman1]

Thank you very much missorleans

 

[afrothunderman1]

 

[afrothunderman1]

.

 

[kween]

lol i should've started off w/ an easier nbme. Oh well.

1) 59 old man history of fevers he ache. pdf of csf shows herpes simplex virus. give drug that inhibits which enzyme? acyclovir so DNA polymerase correct?

dna polymerase, neuraminidase, protease, reverse transcriptase, RNAase A

yup MOA of Acyclovir = monophosphorylates thymidine kinase and inhibit viral DNA polymerase

2) woman w 6 mon history of burning abdominal pain that occurs 1-2 hrs after eating…sweats and lightheadedness when standing…bp in 105/70mmhg while standing….epigastric tenderness….ct scan of abs shows 2 cm mass on prix duodenum….gastrin released by tumor cells stimulates which labeled cells in the photomicrograph shown to release hydrogen ions? This one had a pic..no idea help plz

a,b,c,d,e

This is ZE syndrome - gastrin secreting mass of the of pancreas or duodenum causing ulcers = hence the burning abdominal pain.
Recurrent abdominal ulcers = blood loss, hence drop in BP.
Function of gastrin = increase gastric H secretion. H+ comes from parietal cells (so we have to identify the parietal cell)
Which i think is B

3) 4 month boy w recurrent sinopulmonary infections since birth. Phys exam shows hypo pigmentation of skin, eyes, hair, ecchymoses over trunk and extremities. Blood smear shows giant granules in neurtophils and eosinophils. I know this is chediak higashi lol but still wanna double check


acute myeloblastic leukemia, ataxia telangiectasia, chediak higashi syndrome, leukocyte adhesion deficency, sezary syndrome

Chediak higashi - recurrent infections + partial albinism + peripheral neuropathy

4) 12 yr old girl immigrated to us from central africa has 5 wk history of severe abdominal pain and vomits blood. temperature is 100F pulse is 110/min, respirations are 27/min, and BP is 112/65 mmHg. Phys exam shows hepatosplenomegaly and abdominal ascites. Leukocyte count slightly above normal..photo of the stool specimen shown. Whats the appropriate pharmacotherpay for this poor girl?

fluconazole, levofloxacin, metronidazole, praziquantel, trimeth-sulfameth

I just think most parasites (bendy worms) are killed by -bendazoles (bendy drugs) or praziquantel

5) 62 yr old man has pain in the left hip for 3 wks. X-ray of ship shows 4.5 cm destructive osteoblastic lesion w an associated fracture in proximal femur and 2 separate similar smaller lesions in the bony pelvis. Needle core biopsy of femur shows metastatic carcinoma. Whats the most likely primary site of the cancer? prostate right cuz of the clues? if its not this then lung(most common metastasis site)


colon, kidney, lung, pancreas, prostate

i think he has mets to the bone. and the most common site of primary cancer is Prostate, breast > lungs > thyroid, testes (FA pg 224 2013)

6) Lady in study..steroid hormone in saliva…regular 28 day cycle with ovulation at day 14..during test, lab study shows increased estradiol and decreased progesterone..what day was this hormones measure?

day 12 right cuz estrogen peaks right before ovulation…and i rmr there being low progesterone during that phase..


day 1, day 6, day 12, day 18, day 26

i missed this one, i was stuck between day 6 (wrong) and day 12. so maybe day 12 is correct

7) 78 yr old man fever, chills, fatigue, shortness of breath, 12 lb weight loss over past month. Underwent urinary catheterization 6 wk ago for prostatic obstruction. Temperature is 101.3F, pulse is 100/min, respirations are 14/min, and bp is 160/80mmhg. Soft sa and normal s2 . Grade 2/6 diastolic murmur is maximal in second left intercostal space accentuated when patient leans forward with held expiration. Diagnosis? This has to be prostatitis right?


bacterial endocarditis, peritonitis, prostatis, pulmonary embolus, viral pnemonia

i got this wrong also, but from earlier post someone said:
his cathether - think e. feacalis predisposing to subacute endocardotis

And the question from above #1, i think the answer is contemplation.
I put precontemplation and it was wrong
According to earlier posts from kirby, precontemplation = denying any problem exists, contemplation = acknowledging there is a problem but doing nothing.

Is this your first nbme? when is your test?

 

[afrothunderman1]

And the question from above #1, i think the answer is contemplation.
I put precontemplation and it was wrong
According to earlier posts from kirby, precontemplation = denying any problem exists, contemplation = acknowledging there is a problem but doing nothing.

Is this your first nbme? when is your test?

Thank you kween and yes it is. 3-5 months depending on how well my studies go.

 

[afrothunderman1]

6) Lady in study..steroid hormone in saliva…regular 28 day cycle with ovulation at day 14..during test, lab study shows increased estradiol and decreased progesterone..what day was this hormones measure?
day 12 right cuz estrogen peaks right before ovulation…and i rmr there being low progesterone during that phase..

day 1, day 6, day 12, day 18, day 26

After estrogen surge, Lh causes ovulation. Progesterone is no where before ovulation because there is no egg (Remember, pro-gestation, no egg, no gestation, no progesterone!)

Kween this is for the question you wanted to know

 

[CherryRedDracul]

53 yo alcoholic, homeless man comes to ed by police. appears cachectic, fever. clubbing of fingers, breath smells, missing teeth, numerous cavities. has increased fremitus, dullness to percussion, and tubular breath sounds in right lower lung. leukocyte count 11.4k. sputum grows purulence, gram + cocci in chains, and gram - bacilli. x ray shows cavitation in right lower lung lobe with surrounding infiltrate. sputum will likely grow which of the following?

chlamydophila pneumonia, haemophilus influenza, mycoplasma pneumonia, strep pneumon, normal oral flora

Specifically, the bacteria grown in culture are most likely Peptostreptococcus (Gram +), Fusobacterium, Prevotella, and Bacteroides (Gram -).

 

[afrothunderman1]

.

 

[kween]

2) previously healthy 52 yr old lady has 2 mo history of progressive difficulty swallowing, double vision, and slurred speech. pays exam shows ptosis of the eyelids and waddling gait. muscle strength shows fatigable weakness of the neck, arms, hands, and fingers. Repetitive nerve stimulation shows a 25% decrease in muscle action potentials in several muscles. Which of the following mechanisms is the most likely cause of this patients disease? Obv myasthenia gravis but can’t decide between the first two options altho i think its the second option

binding of acetylcholine by an antibody, binding of antibody to the acetylcholine receptor, deceased acetylcholine production, decreased release of acetylcholine from the receptor, decreased reuptake of acetylcholine

myasthenia gravis = autoantibody to nicotinic ACh receptor (this is in first aid)

4)5 yr old stares blankly into space for several seconds. doesn’t respond to questions during these episodes. pays exam shows no abnormalities. reg shows 1-3 second hurts of 3 sec spike and wave activity. no abnormal motor movements are observed during this reg activity. therapy is ethosuximide cuz its absent seizure correct?

carbamazepine, ethosuximide, gabapentin, phenobarbital, phenytoin

this is classic absent seizures. Rx = ethosuximide.

5) 5 year old boy brought to the ER. with vomiting and sleepiness, he had a flu like illness 5 days ago that she treated with aspirin. Serum studies show increased ammonia, lactate, and transaminase levels. what's the most likely cause of the patient's coma?

a) cerebral edema

b) metabolic alkalosis (wrong)

c) subarachnoid hemorrhage

d) venous sinus thrombosis

e) viral encephalitis

kid probably has Reye's syndrome but why isn’t the answer viral encephalitis?? is it cerebral edema? someone wrote this explanation The answer is A. It would be Reye syndrome which leads to hepatic encaphalopathy. The mitochondrial damage is in the liver. Here i'm a little bit hazy but hopefully google should find something that can confirm or elucidate but: Liver damage --> hyperammonemia --> hepatic encephalopathy --> astrocyte swelling. I tried looking for that uworld id but it doesn't exist for me. But FA2014 pg 361 has it leading to hepatoencephalpathy

Cerebral edema - Reyes syndrome that leads to hepatic encephalopathy (not VIRAL encephalopathy)
According to wiki (search hepatic encephalopathy), the most common cause of coma and death is cerebral edema

6)a 24 year old african american man comes to the physician because of a 3 month history of red bumps on his face and chin. he says that the bumps are itchy and painful. physical examination shows hyper pigmented papules over the cheeks, jawline, and neck. which of the following is the most likely diagnosis?

A) acne vulgaris

B) cutaneous lupus Erythematosus

C) Keloids

D) pseudofolliculitis barbae

E) Rosacea

someone wrote

“The answer is D) the guy has razor burn and African americans get it frequently”

yup

answer what i could in blue quote

 

[afrothunderman1]

answer what i could in blue quote

thank you very much

 

[afrothunderman1]

.

 

[tantacles]

2)60 yr old w no history of bleeding has coagulation testing prior to coronary artery bypass grafting. His prothrombin time is 11.5 sec (INR=1.0) <-whats inr?

and activated partial thromboplastin time is 160 secs. which of following inflammatory responses is most likely to be abnormal in this patient?

c5a generation, histamine release, kallikrein formation, phagocytosis, platelet aggregation

Kallikrein formation is my best guess. Factor 12 (Hageman factor) is part of the intrinsic pathway (PTT), and it activates bradykinin which leads to kallikrein formation.

3) 28. 27 y/o with hodgkins gets bone marrow transplant. two weeks after transplant, develops an erythematous, maculopapular rash, diarrhea, and elevated serum liver enzymes and bilirubin. no evidence of infection or drug reaction found. what's the mechanism of these symptoms? It’s graft vs host so answer should be c right?

a-donor macrophages secreting cytokines and affecting host cells

b-donor plasma cells ellaborating antibodies against host cells

c-donor t lymphocytes reacting against host cells

d-host macrophages secreting cytokines and affecting donor cells

e-host plasma cells ellaborating antibodies against donor cells

f-host t lymphocytes reacting against donor cells

It's graft vs host. The grafted cells are having an immune response against the transplant recipient. This is why she's presenting with systemic symptoms and not those confined to the transplanted material.

4) 6 month boy history of recurrent upper and lower resp infections, has hypocalcemia and trted w calcium supplementation. He went operative repair of coarctation of aorta in newborn period. He has broad nasal bridge and dysplastic pinnae. cause of infections? this is digeorge so answer is t lymphocyte deficiency right?

hyper ivm deficiency, hypo cellular bone marrow, igE deficiency, igG deficiency, t-lymphocyte deficiency

Yup. t-lymphocyte deficiency. Parathyroids are gone and thymus is gone.

5)

The question that looked at pulmonary artery and lymphatic flow and asked which increases flow... anyone know the right answer? This is why I'm confused: both (a) endothelin-1 and (b) phenylephrine vasoconstrict (I had put A which was wrong); and both (c) decreasing inspired O2 and (d) increasing inspired CO2 essentially cause hypoxia --> pulmonary vascular constriction and dilation else where in body (e) IV infusion of 0.9% saline for 5 minutes (a few articles i read said that isotonic saline can increase lymph flow, not sure about time frame though) and finally (f) IV albumin (this I know is wrong because hyperproteinemia decreases flow


IS it “intravenous infusion of .9% saline for 5 minutes)

Yes. The best way to increase lymph flow is to give a hypotonic solution. It will increase the hydrostatic pressure and decrease the plasma oncotic pressure, both of which will lead to fluid extravasation and thus lymph flow (to get it back into circulation.

6)

20 year old woman comes severe dysuria and painful vulvar rash for 2 days, what is the organism ?? How do u know exactly which one it is here?? Iknow HPV causes vulvar infectinos but it is painless, was very lost here

candida alb, clamh tracho, group b strep, hepatitis b, herpes simplex, human papilloma, neisseria gonorrhea, parvovirus, treponema pallidum, trichomonas vaginial, varicela zoster

Vulvar rash sounds like candida, but I'm not sure. Is this the only information? was she on antibiotics or something? I'm not 100% certain.

7)27 yr lady , 24 hr history pain w urination and frequency of urine. sexually active w one guy and takes oral contraceptive. does’t use condoms. no abnormalities on pays exam. has suprapubic tenderness. So I’m guessing the oral contraceptives cause candida overgrowth just like antibiotics?(or is that antibiotics only).

candida albicans, e coli, human papilloma, neisser gonnarhea, trep pallidum[/quote]

Based on history, she has PID or a UTI, so it's either n. gonorrhea or e. coli. Suprapubic tenderness and increased frequency sounds like a UTI, so E. coli. PID would probably have a discharge.

8

) chemotherapy regimen for 55 yr old w non hodgkin lymphoma is vinblastine. normal function of whoch cells and tissues resistant to this agent? vinblastine attacks rapidly dividing cells so since heart cells don’t divide, is the answer ventricular cardiac muscle fibers?

cortical thymocytes, enterocytes in duodenal crypts, erythroblasts in the bone marrow, keratinocytes in the epidermal stratum basal, ventricular cardiac muscle fibers

yup. Heart cells don't divide. All of the other ones are labile.

 

[tantacles]

Oh, and I'm pretty sure the first kid has asthma, so probably leukotriene mediated. Remember that zafirlukast, montelukast, and zileuton all beat down leukotrienes in one way or another.

 

[tantacles]

Also, err on the side of less rather than more formatting. You don't need to bold every question, and it messes up the quote function.

 

[afrothunderman1]

Oh, and I'm pretty sure the first kid has asthma, so probably leukotriene mediated. Remember that zafirlukast, montelukast, and zileuton all beat down leukotrienes in one way or another.

Got it! Thank you so much! Oh wow didn't realize it messed up the formatting