IM NBME Form 3 Exam with correct
Answers
19 yo - f/u acne vulgares
PMHx: migraines (3 yrs); early signs of cataracts
FHx: hyperchol; IBD
SHx: sex active; doesn't use contraception
PE: active acne vulgaris on face
> various tx failed to control acne
> asks for prescription for isotretinoin
this therapy is CI for this pt bc of what historic finding? - Answers -sexual activity without
contraception
isotretinoin - teratogenic
those who are given isotretinoin need to be on 2 effective forms of contraception for at
least 1 month prior to drug initiation and cont contraception for at least 1 month after
before giving the drug w/in 1 wk - prog test
> repeat this during tx
23 yo AA man - 2 months of inc pain and swelling above R.knee
> no trauma, recent fever
PMHx: retinoblastoma (infancy - tx w/ enucleation)
98.6F
PE: mod swelling of distal femur; mild tenderness to palp w/ mod discomfort on weight
bearing
labs: alk phos 1350
x-ray of R.femur: lytic lesion w/ periosteal new bone at margins
most likely dx? - Answers -osteosarcoma
osteoSarComa = Sunburst + Codman's triangle
> periosteal bone rx (from elevation of periosteum) = Codman's triangle
RF: Paget dz of bone, bone infarcts, radiation, familial retinoblastoma, Li-Fraumeni
syndrome
> homeboy had retinoblastoma as an infant
commonly affects metaphysis of long bones (esp knees)
presents as painful enlarging mass or path features
peak incidence of primary tumor in males < 20 yo
27 yo AA woman - 1 wk of tight sensation in chest and nonproductive cough
> cough freq at night
> breathing txs in ED for acute SOB twice during past 3 months
~ told to stop smoking
PMHx: freq URIs
,no meds
SHx: smokes 1 pack qd for 10 yrs
vitals: stable
PE: end-exp wheezes BL
CXR: gucci
most likely underlying cause of symptoms? - Answers -activation of mast cells
asthma exacerbated by smoke
bronchodilator therapy reversing the SOB is the key finding here
> this is how you differentiate bet asthma and COPD
symptoms typically worse at night
features: SOB, wheezing, chest tightness, cough
associated triggers include tobacco smoke
27 yo - 3 hrs of muscle swelling/tenderness of L.thigh
> minimal trauma
PMHx: severe hemophilia A
> tx factor VIII replacement for bleeding episodes since childhood
over recent months: bleeding poorly controlled
> inc doses of factor VIII have been req to stop bleeding episodes
labs: dec plt 125,000; aPTT > 120 sec
next step in dx of pt's inc bleeding? - Answers -test for factor VIII inhibitor
during mixing study: normal plasma is added to plasma from hemophiliac pt
> clotting def should correct - PTT returns to normal
> factor inhibitors won't correct - PTT will fail to normalize if factor VIII inh is present
idiopathic development of inh
will require larger infusions of factor VIII in the future due to this inh
think hemophilia when you see "boys w/ hemarthrosis"
27 yo man - inc freq episodes of int vomiting over last 3 wks
> occurs w/in 1 hr after eating
> partially digested food
> no blood noted
> appetite seems unaffected
> stops eating before completes meal
> 8 lb weight loss - last 6 months ago
PMHx: mod mental retardation; seizure disorder (phenytoin)
vitals: stable
PE: speech not intelligible
PE: 3x4 cm of alopecia in R.occipitoparietal area of scalp; bowel sounds present; abd
musculature voluntarily contracts w/ palp; no organomegaly/masses palp; minimal
contractors in upper/lower ext; inc muscle tone
most likely dx? - Answers -gastric bezoar
mental retardation + area of alopecia + frequent vomiting > gastric bezoar
bezoar = mass trapped in the GI system
pt is pulling his hair out and ingesting it > accumulation of foreign materials in stomach
and impaired gastric emptying - gastroparesis
, stupid ass question since I've literally never seen this word before
27 yo - total serum chol 190
no FHx of HTN or premature CAD
> grandma dx w/ T2DM at 65 yo
general dietary advice + education concerning RFs + what else for mgnt? - Answers -
repeat measurement of serum cholesterol concentration in 5 years
chol < 200 is normal
another answer choice talks about recommending a chol-lowering diet - but you talking
about dietary advice is basically that already
LOVE THIS SHITTY QUESTION
27 yo - 1 day of fever, SOB, R-sided chest pain, and cough productive of yellow-brown
sputum
PMHx: HIV pos
> compliant
> 1 month ago: CD4 count 400; plasma HIV viral load undetectable
SHx: no illicit drugs
103.6 F
P: 120/min
RR: 28/min
BP: 90/40 mmHg
PE: bronchial breath sounds and egophony over RLL posteriorly; dullness to percussion
Pox: 93% on room air
CXR: RLL consolidation
Gram stain: segs and gram-pos diplococci
cx of sputum/blood: pending
supplemental O2 + IVF + and what pharmacotherapy? - Answers -ceftriaxone
numerous gram-pos diplococci = S.pneumo
tx: 3rd gen cephalosporin
classic presentation: fever + productive cough + consolidation on CXR
MC bug CAP: S.pneumo
other bugs in CAP:
> M.catarrhalis
> H.flu - COPD/smoker
> Klebsiella and anerobes - aspiration
> S.aureus - post-viral
> Legionella - immunocompromised
HAP: Pseudomonas, MRSA
immunocompromised: TB, fungal, PCP
insidious onset fever and cough w/ BL infiltrates on CXR = atypical PNA
30 yo - ED 2 hrs after onset of severe substernal chest pain (inc w/ respiration)
> distressed and bent over at waist to dec pain
> no hx of cough, chills, fever
PMHx: SLE
Answers
19 yo - f/u acne vulgares
PMHx: migraines (3 yrs); early signs of cataracts
FHx: hyperchol; IBD
SHx: sex active; doesn't use contraception
PE: active acne vulgaris on face
> various tx failed to control acne
> asks for prescription for isotretinoin
this therapy is CI for this pt bc of what historic finding? - Answers -sexual activity without
contraception
isotretinoin - teratogenic
those who are given isotretinoin need to be on 2 effective forms of contraception for at
least 1 month prior to drug initiation and cont contraception for at least 1 month after
before giving the drug w/in 1 wk - prog test
> repeat this during tx
23 yo AA man - 2 months of inc pain and swelling above R.knee
> no trauma, recent fever
PMHx: retinoblastoma (infancy - tx w/ enucleation)
98.6F
PE: mod swelling of distal femur; mild tenderness to palp w/ mod discomfort on weight
bearing
labs: alk phos 1350
x-ray of R.femur: lytic lesion w/ periosteal new bone at margins
most likely dx? - Answers -osteosarcoma
osteoSarComa = Sunburst + Codman's triangle
> periosteal bone rx (from elevation of periosteum) = Codman's triangle
RF: Paget dz of bone, bone infarcts, radiation, familial retinoblastoma, Li-Fraumeni
syndrome
> homeboy had retinoblastoma as an infant
commonly affects metaphysis of long bones (esp knees)
presents as painful enlarging mass or path features
peak incidence of primary tumor in males < 20 yo
27 yo AA woman - 1 wk of tight sensation in chest and nonproductive cough
> cough freq at night
> breathing txs in ED for acute SOB twice during past 3 months
~ told to stop smoking
PMHx: freq URIs
,no meds
SHx: smokes 1 pack qd for 10 yrs
vitals: stable
PE: end-exp wheezes BL
CXR: gucci
most likely underlying cause of symptoms? - Answers -activation of mast cells
asthma exacerbated by smoke
bronchodilator therapy reversing the SOB is the key finding here
> this is how you differentiate bet asthma and COPD
symptoms typically worse at night
features: SOB, wheezing, chest tightness, cough
associated triggers include tobacco smoke
27 yo - 3 hrs of muscle swelling/tenderness of L.thigh
> minimal trauma
PMHx: severe hemophilia A
> tx factor VIII replacement for bleeding episodes since childhood
over recent months: bleeding poorly controlled
> inc doses of factor VIII have been req to stop bleeding episodes
labs: dec plt 125,000; aPTT > 120 sec
next step in dx of pt's inc bleeding? - Answers -test for factor VIII inhibitor
during mixing study: normal plasma is added to plasma from hemophiliac pt
> clotting def should correct - PTT returns to normal
> factor inhibitors won't correct - PTT will fail to normalize if factor VIII inh is present
idiopathic development of inh
will require larger infusions of factor VIII in the future due to this inh
think hemophilia when you see "boys w/ hemarthrosis"
27 yo man - inc freq episodes of int vomiting over last 3 wks
> occurs w/in 1 hr after eating
> partially digested food
> no blood noted
> appetite seems unaffected
> stops eating before completes meal
> 8 lb weight loss - last 6 months ago
PMHx: mod mental retardation; seizure disorder (phenytoin)
vitals: stable
PE: speech not intelligible
PE: 3x4 cm of alopecia in R.occipitoparietal area of scalp; bowel sounds present; abd
musculature voluntarily contracts w/ palp; no organomegaly/masses palp; minimal
contractors in upper/lower ext; inc muscle tone
most likely dx? - Answers -gastric bezoar
mental retardation + area of alopecia + frequent vomiting > gastric bezoar
bezoar = mass trapped in the GI system
pt is pulling his hair out and ingesting it > accumulation of foreign materials in stomach
and impaired gastric emptying - gastroparesis
, stupid ass question since I've literally never seen this word before
27 yo - total serum chol 190
no FHx of HTN or premature CAD
> grandma dx w/ T2DM at 65 yo
general dietary advice + education concerning RFs + what else for mgnt? - Answers -
repeat measurement of serum cholesterol concentration in 5 years
chol < 200 is normal
another answer choice talks about recommending a chol-lowering diet - but you talking
about dietary advice is basically that already
LOVE THIS SHITTY QUESTION
27 yo - 1 day of fever, SOB, R-sided chest pain, and cough productive of yellow-brown
sputum
PMHx: HIV pos
> compliant
> 1 month ago: CD4 count 400; plasma HIV viral load undetectable
SHx: no illicit drugs
103.6 F
P: 120/min
RR: 28/min
BP: 90/40 mmHg
PE: bronchial breath sounds and egophony over RLL posteriorly; dullness to percussion
Pox: 93% on room air
CXR: RLL consolidation
Gram stain: segs and gram-pos diplococci
cx of sputum/blood: pending
supplemental O2 + IVF + and what pharmacotherapy? - Answers -ceftriaxone
numerous gram-pos diplococci = S.pneumo
tx: 3rd gen cephalosporin
classic presentation: fever + productive cough + consolidation on CXR
MC bug CAP: S.pneumo
other bugs in CAP:
> M.catarrhalis
> H.flu - COPD/smoker
> Klebsiella and anerobes - aspiration
> S.aureus - post-viral
> Legionella - immunocompromised
HAP: Pseudomonas, MRSA
immunocompromised: TB, fungal, PCP
insidious onset fever and cough w/ BL infiltrates on CXR = atypical PNA
30 yo - ED 2 hrs after onset of severe substernal chest pain (inc w/ respiration)
> distressed and bent over at waist to dec pain
> no hx of cough, chills, fever
PMHx: SLE
