NBME 19 Exam with Complete Solutions

76 yo man 30mins severe substernal chest pain while arguing with brother. 3 sublingal nitroglycerin no relieve. 5y h/o ischemic heart disease. P110, R20, BP120/80. Cardiac exam normal. EKG ST elevation at leads I, aVl, and V4-V9. What happened during argument with brother? - ANSWER-Coronary vasospasm due to alpha 1 stimulation 40yo G0 women delivered newborn. CVS at 15 wks results male chromosome fetus. Physical exam show female external genitals and absent internal genitals. Mutation prevent response to what? - ANSWER-Testosterone 13yo girl grew 3in over summer. What accounts for increased Ca absorption? - ANSWER-Hormones derived from 7-dehyrocholesterol 56 yo man lethargy. No meds, no postural hypotention, no edema. Na: 125. Others normal. Dx? - ANSWER-Small Cell Carcinoma of lungs 15 yo girl received BMT 1 year ago due to AML. Now karyotype 46, XY. Dx? - ANSWER-Nonautologous donor 23yo women strenuous exercise. X-sectional area of pulmonary microcirculation? - ANSWER-increased, as a result of distention and recruitment of microvessels 33yo woman had weakness of right lower 2/3 of face. Where is brain lesion? - ANSWER-Primary motor cortex 30 yo man and 24 yo woman genetic counseling. Man's brother has type 1 oculocutaneous albinism (AR). Single gene disorder 1/40,000 in population. Pedigree shown. What are the odds? - ANSWER-q= sqr. rt of 1/40000 = 1/200 pq= 1/200 / 2= 1/100 1/100 that mom is a heterozygote 2/3 that dad is a carrier AR disease= 1/4 of offspring affected (1/100) (2/3) (1/4)= 1/600 Chemical disrupts tight junction between cells in the testes. Autoimmune response to products of germ cells entered circulation. What cells disrupted? - ANSWER-Sertoli cells 25 yo woman w/ AIDS in ICU treated for sepsis by Cryptococcus neoformans. Drug? - ANSWER-Amphotericin B 27yo man 4 days of cough producing blood-tinged sputum. BP160/100. Creatine: 4.8, erthyrocyte casts in urine. IgG deposites in IF microscopy. What glomerulus histologic abnormalities? - ANSWER-Crescent formation 48yo man. 3 yrs ago removed right kidney and adrenal gland of encapsulated renal cell carcinoma. 2 annual exams normal. No EtOH and no smoking. P75, BP130/88. Physical exam normal. Serum mild increased bilirubin, ALT, AST and ALP. CT abdomen shows widening hepatic venules. Radiographic fluorography pressure: R Atria: 5, Hepatic vein: 25, Hepatic wedge: 30. Dx? - ANSWER-Budd-Chiari Syndrome 48 yo man in hospital for idiopathic pulmonary hypertension. 6 months progressive dyspnea. Cadiac catheterization show decreased in cardiac function. Whats increased? - ANSWER-RV afterload Growing polypeptide is in P position. What is next? - ANSWER-binding of aminoacyl-tRNA to the A site. 65 yo man low back pain. Multiple osteoblastic lesions in vertebrae on x ray. Whats increased in serum? - ANSWER-PSA 43 yo man severe hip pain after fall. 15y h/o RA. Fracture and marked osteopenia of hip on xray. What drug responsible? - ANSWER-Prednisone 35 yo man w/ HIV. 2 yrs of HAART. Physical exam thin extremeties, wide abdominal girth, and buffalo hump on upper back. Labs: CD4: 43, viral load: 1190, glucose: 110, cholesterol: 225, Triglycerides: 260. Glucose tolerance test is abnormal. Cause? - ANSWER-Protease inhibitor 80 yo woman SOB and fatigue. Dx severe aortic stenosis. Undergoes AV replacement. After operation, dicumarol is given, result in prolonged PT. Cause? - ANSWER-Induces a vitamin K deficiency state 23 yo woman DVT at 6 months pregnant. IV heparin started. 7 days later platelet count: 44,000. Dx? - ANSWER-Antiplatelet antibodies 52 yo man 30mins of substernal chest pain. Pain persisted even w/ 3 doses of sublingual nitroglycerin. P90, BP114/70. Diaphoresis. Lungs clear. S4, ST elevation in inferior leads. IV morphine started. 1 min later develops generalized pruritus. P120, BP90/50. Physical exam facial flushing. What substance cause new symptoms? - ANSWER-Histamine 19 yo man stabbed in abdomen. Denies starting fight and intends to "get even". Incarcerated for past 3 yrs for armed robbery but says he was "set up". Dx? - ANSWER-Antisocial personality disorder 45 yo man major depressive disorder. Taking Fluoxetine. Increased risk of serotonin syndrome w/ what in food? - ANSWER-Tryptophan 40yo man increased malaise, nausea, abdominal pain and light colored stools. Tenderness to RUQ. Bilirubin:4, ALP: 180, AST: 1500, ALT: 1700. HBeAg, HBsAg, HBV-DNA, IgM anti-HBc antigen: positive. Further observation shows CD8 T cells bind to antigens resulting in liver injury. Where's antigen from? - ANSWER-Hepatocytes 52 yo man severe headache, anxiety, sweating and palpitations. Well controlled HTN w/ clonidine and HCTZ, but ran out of Rx 3 days ago. P120, BP170/110, Physical exam diaphoresis. What happens after injection of propranolol? - ANSWER-Decreased CO and increased TPR B-agonists act to increase CO and vasodilate SM ABG values in a resting patient. PO2: 96, PCO2: 40, A O2 content: 12% (N=20), Mixed V PO2: 36 (N=40), Mixed V O2 content: 8% (N=15). Dx? - ANSWER-Anemia (only decrease O2 content) Neck irradiation risk factor for thyroid cancer study. Identified a group of patients with thyroid and similar group of patients without thyroid. History of prior neck irridation is obstained from each group. Study type? - ANSWER-Case control Investigator experient prevented 3rd pharyngeal pouches from forming in mouse embryo. Which organs failed to develop? - ANSWER-Thymus, inferior parathyroids Microtubule-associated (MAP-1C) ATPase (dynein) production blocked in neuronal cell body. What neuronal process is reduced? - ANSWER-Retrograde axonal transport Graph shows rate of breakdown by phosphorylase in the presence and absence of AMP. Based on data, the action of AMP? - ANSWER-Allosteric activator 39yo police man w/ 6m headache, muscle aches and fatigue. 1m crampy epigastric pain, which he think its stress. Become increasingly irritable and distractible while instructing people at firing range. Wife reports irritable and forgetful at home. Vitals normal. Neuro exam shows b/l distal motor weakness of extremities and impaired concentration. Memory function intact. Hemoglobin: 11, Hematocrit: 36%, MCHC: 31%, MCV: 78. Blood smear? - ANSWER-Basophilic stippling (lead poisoning) 20m girl T101 and upper respirator infection. Condition worsens and develops dyspnea and cyanosis. Crackles heard on chest auscultation. CXR show cardiac enlargement. Hemoglobin, hematocrit and WBC count is WNL. Cardiac arrest day after admission and dies. Autopsy finding is diffused lymphocytic infiltrate in the myocardium w/o evidence of inclusion bodies or microorganisms. Dx? - ANSWER-Coxsackievirus Skin from male mouse grafted on back of female. Within 2 wks graft becomes necrotic and must be removed. What cells responsible? - ANSWER-CD8+ T lymphocytes 41 yo woman at 34wk gestation has amniocentesis due to uncontrolled HTN. Amnionic fluid shows decreased lecithin:sphingomyelin of 1.5:1 (N=3:1). What condition to newborn born at this time? - ANSWER-Decreased FRC 49yo woman ask risk of osteoporosis. Mother had osteoporosis and bone fractures after menopause. Pt work as landscaper and plays tennis 3/wk. no smoking, drinks 1 glass wine/wk, no meds. Wt: 121lbs. what more info needed for evaluation of osteoporosis? - ANSWER-Diet history 25 yo woman request prenatal diagnosis at 12 wk b/c sister has infant w/ Down. Woman karyotype is 45,XX,t(14q21q). what test needed? - ANSWER-Chronic villi sampling When is CVS done vs amniocentesis? - ANSWER-CVS is done between 10-13 weeks Amniocentesis is done between weeks 15-20 Study conducted to determine effects of drug X on Airflow, Phrenic nerve activity and Abdominal. Tracing shown. Drug increases phrenic nerve activity and decreases abdominal pressure. Whats drug X? - ANSWER-Tubocurarine 25 yo man severe pain on left side chest after falling off ladder. Pain sharp, stabbing and more intense when pt is coughing or takes deep breath. CXR shows 4 rib fracture on left. No pneumothorax. Whats pattern of respirator change? RR, TV, Airway resistance - ANSWER-RR: increase TV: decrease Resistance: no change 45 yo w/ chronic alcohol dependence w/ 3 days of foul smelling brownish sputum. Pt has severe episodes of LOC and binging past month. Which CRX is his? - ANSWER-Look for cavities with air fluid levels 74 yo man for f/u. 5 yrs ago MI and taking thyroid replacement meds for 25ys for hypothyroidism. Past BP normal. Today BP200/115. Physical exam continuous systolic/diastolic bruit over right posterior flank. Labs normal. Dx? - ANSWER-RAS (bruit is key) 26yo woman 3m pain and stiffness of both hands. Physical exam shows swelling and redness of PIP joints. Xray shows joint space narrowing and marginal erosions of PIP joints. DIP joints spared. Biopsy show? - ANSWER-Synovial pannus formation--> RA 45 yo man lost in Rockty mountains for 10days. 11lb lost. Glucose concentration 92. Serum glucose constant because glucose synthesized in liver and? - ANSWER-Gluconeogenesis--> also occurs in the kidney 43 yo woman 3 day black tarry stools. Taking ASA for 1 wk for sprained ankles. Which steps is inhibited. - ANSWER-Arachidonic acid--> Prostaglandin G2 Aspirin is a COX inhibitor 24yo woman severe vomiting, flushing and headache after wine. Taking med for Trichomonas vaginalis. Whats drug? - ANSWER-Metronidazole --> inhibits acetaldehyde DH Isolated skeletal muscle is isolated w/ glucose bath. Muscle is contracted w/ electrical stimulation. What intracellular decrease indicates fatigue? - ANSWER-pH Lactate will increase, lowering the pH 24 yo man sharp left chest pain and dyspnea 4 hrs ago. CXR shows pneumothorax. Whats cause of CXR finding? - ANSWER-Loss of negative IPP 65 yo man w/ prostate cancer has severe fatigue and bone pain. Suspect metastasis to bone. Androgen ablation therapy recommended for relief using IM monthly leuprolide and daily PO flutamide. Why? - ANSWER-Flutamide blocks the initial androgen action of leuprolide. 30yo woman visual difficulty. 3 yo h/o MS. Vitals normal. When lights off, both pupils 6mm, ambient light pupils 4mm. Light at left eye, both pupils 2mm. light on right eye, both pupils 4mm. where is lesion? - ANSWER-Light reflex is mediated by CN II and III This would result from a right optic nerve lesion. 19yo woman 1st prenatal visit, feels well w/ some spotting. 10wk gestation by dates. Uterus is englarged to level of umbilicus. Beta HCG = 350,000. Dx? - ANSWER-Mole 31 yo man 4 hr severe right flank cramping pain radiating to groin. Pain 10/10. T99, P90, R20, BP130/88. R flank tender to percussion. Tx is given and pt stabilized. Whats dietary change decrease risk? - ANSWER-Increased fluids 69 yo woman tremor in hands. Muscle tone increased, difficulty stopping abruptly when moving forward. Short shuffling gait. Affect is blank. Neurotranmitter system most likely result these symptoms at where in brain? - ANSWER-Substantia nigra 22 yo man lost during hiking. He survives by eating plants. One plant causes nausea and vomiting. Which structure cause his vomiting? - ANSWER-Area postrema 46yo man suffers DCS while SCUBA. Small gas bubble form in spinal vessels supplying dorsal white matter of upper thoracic spinal cord. What neuro Sx? - ANSWER-Discriminative sensation of lower extremities 24 yo woman studied for renal function. Her renal O2 consumption is 20ml/min. Which function uses most O2? - ANSWER-Tubular reabsorption 22 yo man involve in MVC. BP not detectable on arrival. BP returns to normal with IV fluids and PRBC. X lap shos lacerated spleen and liver. Splenectomy and liver repaired. 24 hr later, urine output is 350cc. Dx? - ANSWER-ATN 23 yo woman w/ vagina sore. Sexually active, inconsistent condom use. Pelvic exam nontender ulcer on vulva. Spirochetes positive on dark field. Whats biopsy histology? - ANSWER-Obliterative endarteritis w/ lymphocytes and plasma cells. 6m male infant h/o severe viral and bacterial infections. Dx as SCID. Which enzyme deficient? - ANSWER-ADA Rifampin MOA. - ANSWER-RNA 17yo boy collapsed while working as traffic controller on hot summer day. At 4yo had numerous skin grafts due to full thickness burns on 30% of body. Examine shows hyperthermia. Dx? - ANSWER-Burn scars and skin grafts lack eccrine glands, limit sweating 30yo woman pap smear w/ high intraepithelial lesion undergoes cervical biopsy. What location of tumor cell is consistant as in situ? - ANSWER-Superficial to the BM 18yo women with sever, painful blistering after day at beach. Which antibiotic cause photosensitivity? - ANSWER-Tetracycline 52yo woman with non-small cell carcinoma treated w/ cisplatin. What other drug needed? - ANSWER-Ondansetron Man w/ light complexion develops ulcerated nodule on face under the sun. biopsy shows invasive squamous cell carcinoma. What is DNA damage? - ANSWER-Pyrimidine dimers 47yo man w/ rheumatic valve disease w/ chest pain and difficulty breathing. ECG shows acute MI. Examination shows systolic murmur with increased pressure as mitral valve closes. Pressure tracing shown. Dx? - ANSWER-MR--> ruptured chordae tendinae 8yo girl lost of consciousness. Family travel in truck overnight and girl slept in truck bed. She was difficult to arouse, with severe headache and nausea. Vomit during transit to hospital. P150. Perioral Cherry red skin. Tx? - ANSWER-CO poisoning--> give O2 2 yo boy 2 days fever, cough. h/o Strep. Pneumoiae and multiple ear and sinus infection since birth. T101. No tonsillar tissue. Crackels heard in lower right lung. Dx? - ANSWER-XLA 45yo woman fever, cough, runny nose, sore throat, muscle aches. Moderately ill. T101. Cardiopulmonary exam normal. Influenza virus antigen positive. Tx? - ANSWER-Neuraminidase inhibitor Immunocompromised patients, positive PPD skin test changed from 10mm of induration to 5mm. whats effect on incidence and prevalence? - ANSWER-Both will increase 52 yo woman with CAD with right dominant coronary circulation. After angioplasty of circumflex artery. Which structure receive blood flow? - ANSWER-LV Asking about LCX Mouse thymocyte obtained from normal active bone marry was altered to express bcl-2 and combined with normal marrow cells was injected into mice w/ destroyed active marrow. Control mouse with destroyed marrow was injected w/ normal marrow only. After recovery, whats different between mouse? - ANSWER-Decreased apoptosis 35yo woman 3 months fatigue. Vegan for 12 yrs. Loss of vibratory sensation of lower distal extremities. Labs. Hemoglobin 9.1, MCV:114. Dx? - ANSWER-Vitamin B12 def 40yo man with cardiac phonogram shown. Holosystolic murmur during systole. Dx? - ANSWER-MR 6 wk boy with projectile vomiting. Nothing change symptoms. No bile in vomit. Dehydrated, stools decreased. Metabolic alkalosis. Dx? - ANSWER-Pyloric stenosis Labs with pyloric stenosis - ANSWER-Increased HCO3- Low K+ Decreased Cl- 5 yo woman stage 4 breast cancer need meds for severe pain. Drugs A-E graph shown, Log Dose vs Response(pain relief). Which med best? - ANSWER-Best efficacy= highest curve Highest potency= shifted to the left 52 yo man w/ hypercholesterolemia tx w/ lovastatin. Gemifibrozil added. 2 wks later develop renal failure. Dx? - ANSWER-Myoglobinuria 54yo man for exam. P80, R14, BP140/95. Physical exam normal. ACE inhibitor given. Where is MOA in kidney? - ANSWER-Efferent arteriole 60yo woman 1 yr involuntary rhythmic jerking of right leg and foot. Increased right ankle jerk reflex. Babinski sign + on right. MRI shows 2cm round lesion at interhemispheric fissure at the central sulcus. Dx? - ANSWER-Meningioma 35yo man want to donate kidney to his sister who is T1DM and chronic renal failure. Healthy, physical exam normal. How likely his HLA type is a match? - ANSWER-1:4 60 yo man 20y h/o HTN with SOB and fatigue. P80, BP100/70. Physical exam shows peripheral cyanosis. Crackels heard bilateral lungs. Cardiac exam shows S3. 2+ pitting ankle edema. Whats CO and CVP findings? - ANSWER-CO: decreased CVP: increased Ankle edema= sign of right heart failure 11 yo boy pain in right mid-thigh. Warm and tenderness around mass. Femur XR shows solitary mid-diaphyseal osteolytic lesion w/ permeative margins. Lesion surrounded with layers of reactive bone. Biospy composed of poorly differentiated sheets of small, uniform, hyperchromatic cells w/ highly nuclear:cytoplasmic ratio, scant stroma and no visible matrix. Dx? - ANSWER-Ewing sarcoma Ewing sarcoma mutation - ANSWER-t(11;22) Where is Ewing sarcoma located? - ANSWER-Diaphysis Where is osteosarcoma located? - ANSWER-Metaphysis Surrounded by small blue cells and concentric layers of reactive bone - ANSWER-Ewing sarcoma Pleomorphic neoplastic cells producing new woven bone - ANSWER-Osteosarcoma Oral fluid therapy used to tx vibrio cholerae. Which membrane transport stimulated? - ANSWER-Na+-glucose symporter 16 yo girl 2 day h/o thick, yellow vaginal discharge and burning urination. Pt does not want parents to know she's sexually active. T98, P80, BP 110/70. Exam shows mucopurulent discharge at the cervical os and friability. Uterus is small, firm and nontender. No adnexal mass or external vaginal lesion. Stain Gram negative diplococci in pairs with greater than 30WBC. Urine WNL. Test for gonorrhea and chlamydia ordered. Action? - ANSWER-Prescribe antibiotic without telling parents 59 yo woman yellow skin and dark urine. Return from Asia 3 wks ago. Physical exam shows jaundice. IgM anti hepatitis E antibodies. Whats different between HAV and HEV? - ANSWER-Mortality in pregnant women 53 yo man w/ angina pectoris tx w/ nitroglycerin. MOA? - ANSWER-Increases cGMP 32 yo woman absent tactile fremitus, hyperresonance on percussion and absent breath sounds at left lung base. Dx? - ANSWER-Left pneumothorax 36 yo woman w/ T2DM. taking sulfonylurea. BMI: 32. Physical exam shows Acanthosis nigricans. Tx with metformin. MOA? - ANSWER-Inhibits hepatic gluconeogenesis Autopsy of 20yo women died of MVC 8hrs ago. Greats amount of alveolar endothelial surface covered by what cells in lungs? - ANSWER-Type I pneumocytes 26yo woman losts 290 lb after jejunoileal bypass . Fecal fat excretion excessive. Deficiency? - ANSWER-Fat soluble vitamins--> A, D, E, K Members of same family have progressive dementia, major depressive disorder and movement disorder. Autosomal dominant trait with great variability of symptom severity and age at onset. Dx? - ANSWER-# of trinucleotide repeats 27yo woman treated pneumococcal pneumonia with penicillin become afebrile and improved pulmonary function. Then she became jaundiced and anemia with increased reticulocyte count and increased unconjugated bilirubin. Test? - ANSWER-Direct Coombs test--> hemolytic anemia Induction of galactorrhea by metoclopramide? Dx? - ANSWER-Stimulation of release of prolactin from adenohypophysis 67yo man dx of primary lung carcinoma metastasis to adrenal glands, liver and bone. 8Kg wt loss, cachexia and muscles wasting. Conjugation of what protein cause breakdown of muscle proteins? - ANSWER-Ubiquitin 20yo man in MVC. Contusion to chest and abdomen. Unsteady gait and slurred speech. Admitted for damage to spleen. 3rd night became restless and having generalized tonic-clonic seizures. Dx what substance withdraw and treatment? - ANSWER-Ethanol, Diazepam 30yo woman with Marfan with tearing chest pain. 1 yr ago echocardiogram show aortic root to be 5.5cm. Stopped taking propranolol 1 yr ago. P120, BP80/40. Physical exam show JVD 6cm above sternal angle. Maximum impulse is not palpable and heart sound cannot be distinguished. What's cardiac catheterization findings? - ANSWER-Cardiac index: decreased PCWP: normal CVP: normal SVR: increased 30yo man with urinary incontinence after tx of left pelvis fracture. Physical exam show distended bladder, absence of micturition reflex. After bladder fills to capacity, overflow of urine occurs through urethra by few drops. What other nerve injury? - ANSWER-Pelvic nerves Involuntary