NBME EXAM 2023 A+

NBME 2023 A+ 25 yo F at 27 weeks w/ severe contractions x6 hours, vaginal spotting, contractions every 2-3 mins w/ FHR 130 and no decels, cervic 1-2 cm and 70% effaced, GBS is positive. next step? - IM beclamethasone THEN later can give penicillin man w/ 15 yr hx of difficult relaxing hands after tightly gripping objects or shaking hands, difficulty releasing after gripping w/ hands. dx? - myotonic muscular dystrophy pt unable to see out of R eye since awakening 2 hrs ago. visual acuity 20/200 in R eye and 20/20 in L. R pupil poorly reactive to light. where is site of lesion? - R optic nerve 6 mo old w/ poor feeding, labored breathing, to and fro murmur in 2nd L itnercostal space, loud S2, bounding peripheral pulses, widened pulse pressure. dx? - patent ductus arteriosus recurrent lymph node infxns w/ staph a in a kid. what is dx and mechanism? - chronic granulomatous dz -- impaired phagocytic oxidative metabolism pt hyperkalemic bc missed 2 dialysis appointments. EKG w/ peaked t waves. next step? - IV calcium gluconate -- THEN can give insulin but this works within minutes hyaline casts vs WBC casts? - -WBC casts: interstitial nephritis and pyelonephritis -hyaline casts: AKI 4 yo M in MVC, RR 32 w/ grunting and restractions, hypoxic on ABG, CXR 4 hrs later shows diffuse infiltrates on R side. dx? - pulmonary contusion asymptomatic 57 yo M smoker, bruit in RUQ, no masses, BUN 23, Cr 1.4. what is cause of bruit? - accumulation of lipids in arterial wall -- renal artery stenosis 52 yo F w/ decreased libido, underwent TAH and bilateral salpingo-oophorectomy for leiomyomata uteri and menorrhagia. on hormone replacement + estrogen since sx. exam w/ moist, rugated vagina. what is cause? - decreased androgens/testosterone -- due to oophoreectomy = decreased androstenedione and DHEA = aka hypergonadotropic hypogonadism ant pituitary works ovaries don't 67 yo F w/ afib on warfarin, INR 6 so meds stopped, next day she had abdominal pain and vomiting x24 hours, Hgb 13 -- 7.8. cause? - intramural hematoma of proximal small bowel -- rare complication of warfarin 67 yo M w/ 1 hours of vertigo, nausea, imbalance, small R pupil, mild R ptosis, nystagmus, weakness of R palate, sensation to pinprick is decreased over R face and L extremities + incoordination of finger to nose and heel-shin. where is occlusion? - R vertebral 77 yo F w/ cramping abdominal pain and distention w/ n/v. no hx of abdominal sx. afebrile, tachy. distended abdomen w/ mild diffuse tenderness. BS are high pitched. x-ray of abdomen shows air fluid levels in SB and liver but no gas in colon or free air. dx? - gallstone ileus -- air in billiary tree/liver even though all other signs sound like SBO 18 mo old has not used L arm since he fell while walking & holding hands w/ sister. he is holding LUE at side w/ forearm pronated. no tenderness of LLE, restricted movement of elbow. next step? - passive hypersupination of forearm -- nurse maid elbow aka radial head dislocation (can also hyperpronate) asthmatic teen w/ asthma attack, she hast not been taking her meds. what is best way to get her to be compliant - negotiate a contract regarding med compliance 5 mo old w/ persistent wheezing since birth, well-nourished, wheezing w/ extension of neck. what is cause? - compression of airway by vascular ring -- malformation of aorta so wraps around trachea, improves w/ neck extension -- sx *largyngomalacia improves in prone position not extension* heavy cigarette smoker w/ hiccups. Na+ 120. CXR w/ R hilar mass. next step? - fluid restriction -- SIADH from small cell lung CA female w/ herberden's nodes, generalized weakness x2 weeks. BUN 41 and Cr 4. what is cause? - ATN -- from chronic NSAIDs 32 yo F brought to ED after MVC, agitated, SOB, tachy, RR30, hypotensive, breath sounds absent on R, L sounds normal, CXR w/ opacification of R hemithorax. cause? - hemothorax IVDU w/ papilledema, LP w/ high proteins, low glucose, 200 cells. dx? - fungal meningitis -- cryptococcal -- prolly has AIDS 52 yo F w/ difficulty sleeping through the night since son graduated HS 2 months ago and found out he is gay, obsesses about this, feels SOB and tachy during these episodes, worried about her son, is on leave from work. dx? - adjustment disorder w/ anxiety *NOT PANIC DISORDER* 16 yo M episode of left arm shaking that lasted 3 mins, fever, disoriented, LP w/ 120 WBC and 300 RBC, low glucose, high protein. cause? - viral infxn -- likely HSV encephalitis -- RBCs in CSF without a history of trauma is highly suggestive of HSV encephalitis pt w/ n/v for 48 hours what will his labs look like? - hypokalemia, hypochloremia 44 yo G4P4 w/ 9 mo loss of small amounts of urine will running, pelvic exam shows 2nd degree cystourethrocele. what is cause of her incontinence? - stress incontinence from prolapsed bladder 23 yo F one day s/p SVD starts having small amounts of urine loss, had an episiotomy, voiding 50-75 mL at at time, post void residual = 300 mL. cause? - overflow incontinence what drug can cause neutropenia? - carbamezipine 87 yo F w/ dementia, presents w/ flu like symptoms, cough x1 week, fever, crackles in R lung base, CXR w/ infiltrate at right L base, what is cause of pts PNA? - decreased gag reflex -- aspiration PNA 42 yo M progressive swelling of legs, hx of stage IIA hodgkin dz 1 yrs ago treated w/ rads, hypotension, JVD that increased w/ inspiration, heart sounds distant, ascites, what is mechanism of pt's increased central venous pressure? - constrictive pericarditis -- hx of radiation + Kussmaul sign