NBME IM Practice Exam with complete solutions

HIV positive male, stopped taking antiretrovirals 6 mo ago. Febrile. On CXR, nodular density in the left upper lung field posteriorly. What is the most likely to confirm the diagnosis? - Answer- Biopsy and culture of the lung mass. 67 yo female, 2 weeks s/p sigmoid colectomy. On Levofloxacin and flagil. Has a fever, but clean wound and no leukocytosis. Most likely cause of fever? - Answer- Drug Allergy 42 yo woman, 6-mo hx mild bloating and diarrhea. Large, foul-smelling stools daily. 11 kg weight loss, but no changes in diet or appetite. Exam shows mild temporal wasting and beefy red tongue. Scattered ecchymoses and trace edema over LE. Positive IgA antibody. Low albumin. Diagnosis? - Answer- Gluten-sensitive enteropathy 32 yo woman, previously healthy. 6 weeks SOB, fatigue, intermittent palpitations. S2 widely split and fixed. 2/6 SE murmur and cardiac base. RVE, dilate pulmonary artery, increased pulmonary vascularity. Incomplete RBBB. Reason for findings? - Answer- Chronic volume overload on the right ventricle 25 yo female, fatigue, nausea, decreased appetite. Told that she had viral infection and sent home. Vitals fine. Returns with jaundice. Tender liver edge. High Tbili and Dbili, moderately high LFTs (400) and alk phos. High LDH. Diagnosis? - Answer- Acute hepatitis 52 yo female, 2 day hx of painful rash on her abdomen. Currently undergoing chemo for non-hodgkin lymphoma. Temp is 38.5, vesicular rash over the left and right lower quadrants. Next step? - Answer- IV acyclovir 77 yo female. One year hx progressively swelling ankles, 3 mo hx SOB w/ exertion. No chest pain/orthopnea/PND. Has HTN, Paroxysmal atrial tachycardia, hypothyroidism. PE shows large superficial venous varicosities on LE and moderate ankle and pedal edema. Normal CXR and ECG. V/Q scan shows two subsegmental perfusion defects, but no ventilation abnormalities. Reason for dyspnea? - Answer- Recurrent pulmonary emboli Healthy 32 yo male. Routine exam. Last exam 5 years ago. Normal exam. Most appropriate screening? - Answer- Serum cholesterol 40 yo healthcare worker. PPD test positive, clear CXR. Next step in management? - Answer- Administration of isoniazid 37 yo, painful bumps on right index finger. No hx serious illness, she is a respiratory therapist. Tx? - Answer- Oral acyclovir 82 yo male, 2 months of decreased energy. 3.2 kg weight loss, loss of appetite. Soft BP. Hyponatremic, hyperkalemic, BUN high, Cr high. Next step? - Answer- ACTH stimulation test Obese woman, painful, erythematous, edematous left knee. XR shows narrowing of the medial joint space and subchondral bone sclerosis. What would have prevented this? - Answer- Weight reduction First step in gout tx? - Answer- Indomethacin 28 yo female w/ SOB/wheezing/2 days of cough. Recurrent episodes of asthma, URIs, otitis media, frequent diarrhea. Diagnosis? - Answer- IgA deficiency 25 yo male, found unconscious in street. Was jogging before falling. T1DM. Does not respond to verbal stimuli. Vitals okay. Next step? - Answer- 50% dextrose in water (HYPOGLYCEMIA!) 21 yo male. Underwent surgery. No sxs except scleral icterus. Only abnormal lab is high total bili. Dx? - Answer- Gilbert Syndrome 62 yo male, sudden onset left hemiparesis that resolves completely in 2 hours. Right carotid bruit. Next step? - Answer- Duplex u/s of carotids 62 yo female, 2 days of confusion. Has HTN and TIIDM. Normal exam. Hct 24, leukocytes 3400, serum Ca 13, creatinine 2, total protein 9.5. Next step? - Answer- IV 0.9% saline 47 yo female, routine exam. TIIDM. She is on glipizide. what would further reduce risk for diabetic complications? - Answer- Enalapril 27 yo male, fatigue and loss of appetite for 2 weeks. Mom has hemachromatosis. Tender liver edge. Hep B core antigen is positive. Total bili 4.4. What would have prevented jaundice? - Answer- Hep B vaccine 27 yo male, HIV positive. CD4 110, positive toxo IgG, positive hep B surface antibody. Best next step to assess patient's risk for illness related to opportunistic infections? - Answer- PPD skin test 42 yo w/ 10 year hx RA, has d/c'd methotrexate. Leukopenia w/ high lymphocytes, low platelets. Reason for pancytopenia? - Answer- Felty Syndrome 32 yo female, rash on face/neck/hands. Was weeding. Bright red papules, vesicles, and bullae, some in linear pattern. What would have prevented rash? - Answer- Avoidance of contact w/ weeds 27 yo woman, hip pain that is most severe w/ weight bearing. takes ibuprofen occasionally and has SLE. See x-ray...cause? - Answer- Osteonecrosis. 25 yo farmworker, sudden onset headache/dizziness/nausea/vomiting. Generalized weakness, diaphoresis, pinpoint pupils. Most likely mechanism? - Answer- Decreased synaptic activity of cholinesterase 27 yo HIV positive female, fever/SOB/right-sided CP/productive cough. T-lymph count of 400, T 39.8, pulse 120, RR 28, soft pressures. Bronchial breath sounds/egophony over lower right lobe posteriorly. Dullness to percussion. Right lower lobe consolidation. Segmented neutrophils and GP diplococci. Tx? - Answer- Ceftriaxone 36 yo male, fever/chills/abd pain/dark urine. Last time, resolved w/ abx. 8 month hx pruritus, 6 year hx UC treated w/ sulfasalazine. T 39.3, jaundic and epigastric tenderness w/out masses or rebound. Liver firm and slightly tender. Increased PT, Increased total protein, increased globulin, increased Tbili and Dbili, alk phos, and ALT. Negative hepatitis. Dx? - Answer- Sclerosing cholangitis 37 yo male, fever and rash for 2 days. Just completed 6 weeks of nafcillin for staph endocarditis. Afebrile. Faint maculopapular rash. UA? - Answer- eosinophils, rare WBC, 2+ protein, 30 wbc/hpf, trace glucose 47 yo male, 4 days abd bloating/flatulence/diarrhea 6-12 times even with loperamide. Watery, non-bloddy, foul smelling. Recently travelled to ME. Organism? - Answer- ETEC 23 yo AA male, 2 mo increasing pain and swelling above right knee. No hx trauma or fever. Had retinoblastoma as child and tx w/ enucleation. Moderate swelling in distal femur. Very high alk phos, xray shows lytic lesion w/ periosteal new bone at margins. Dx? - Answer- Osteosarcoma 42 yo woman, 3 days dizziness and difficulty w/ balance. Nausea and mild decrease in appetite. Tympanic membranes dull bilaterally/distorted light reflex. Dx? - Answer- Labrynthitis 67 yo male, pain of fingertips for one month. Exam shows plethora and splenomegaly. Hgb 20.2, leukocytes 14,500. Next step in management? - Answer- Phlebotomy 52 yo female, 2 months pain and swelling in knees. Increased ESR. XR shows osteopenia and subcartilaginous cysts around joints. Pharmacotherapy? - Answer- Ibuprofen 57 yo female post MVA. Right upper shows swelling and crepitus. Able to actively extend proximal and PIP and DIP joints, but not MTP joints. Has midshaft fracture of humerus. Diagnosis? - Answer- Radial nerve injury 64 yo female, 4 year hx TIIDM. Exertional chest pressure for 3 weeks. Increasingly frequent and with less exertion each time. Next step? - Answer- Admit the patient to the hospital Break in esophagus w/ contrast. Next step? - Answer- Operative repair 72 yo female, 1 mo hx progressive SOB and fatigue. No chest pain. Moderate respiratory distress. P 100 bpm, RR 22. JVD present. Crackles halfway up bilaterally. 2/6 SE murmur on left sternal border. S3 present. 2+ edema of LE. Hgb 5, BUN 28, Cr 1/2, Protein 1+. Enlarged cardiac silhouette w/ pulmonary vascular congestion, nonspecific ST changes. Trace mitral regurgitation w/ EF 70. Most likely cause? - Answer- High-output heart failure 74 yo female w/ MI. Blood pressure decreases from 148/74 to 80/62. Confused and has cool, clammy hands. ABG would show what? - Answer- Primary metabolic acidosis 35 yo female, collapsed at restaurant. P 120, RR 30, BP 90/60. Breathing is labored, but she can speak. Diffuse bronchospasm, coughs continuously. Dx? - Answer- Anaphylactic shock 82 yo male, mechanically ventilated for COPD exacerbation. No urine since removal of a catheter 12 hours ago. Most likely diagnosis? - Answer- Acute-urethral obstruction 48 yo male, alcoholism, found down in park. Lateral gaze defect, wide-based ataxic gait. BAC less than 0.1. Which is best intervention? - Answer- Vitamin B1 ST-segment elevation in V2-V6 with S3 and S4? - Answer- MI 42 yo female, mildly tender bump on neck, 2 cm lesion on left lobe of thyroid. Next best step in management? - Answer- FNA 19 yo male, pain w/ urination and watery discharge, sexually active, mucopurluent/whitish discharge on exam. Gram stain of discharge shows segmented neutrophils without intracellular organisms. Most likely organism? - Answer- Chlamydia 24 yo woman, obese, reduce risk for osteoarthritis? - Answer- Weight loss 58 yo male, extreme fatigue and malaise for 3 weeks. Toothache 5 weeks ago treated w/ root canal. Hx of cardiac murmur noted at age 19. Pulse 110. Grade 2/6, SE murmur at right second intercostal space, S4, ejection click. Hgb 9.3, ESR 90, urine blood positive. Underlying cardiac abnormality? - Answer- Calcification of aortic valve 32 yo nulligravid woman, irregular me