Step 2CK NBME Review questions & answers Latest with
complete solutions
NBME 4 -
2mo infant is exclusively breastfed. What nutritional supplement? - Oral VitD to
prevent rickets
What HTN drug causes peripheral edema, flushing, dizziness? - CCB eg nifedipine
15yo girl with recurrent candida infections of skin and mucous membranes since
childhood. Dx? - Chronic mucocutaneous candidiasis (T cell dysfunction)
57yoM with impotence for 1 year rand bronze colored skin. Ferritin concentration
is 4050 NG/ml. Increased risk for what complication? - 1. Liver (primary organ)--
hepatocellular carcinoma
2. Others: pancreas (DM), heart (CHF), skin, thyroid (hypo), gonads, joints
(arthritis)
87yo's daughter: "we want my mother to receive hospice care at home but no one
wants her to die at home. Can she still have hospice services?" - Yes. Hospice can
provide home based care and attempt to transfer the pt to another site before death.
32yoF with 4d of fever with lymphatic obstruction. PE: the left lower extremity is
diffuse lay red and edematous from just below the knee to the ankle, with a sharp
demarcation separating the erythematous area from the normal skin at the knee.
The erythematous area is painful and hyperesthetic to touch. The left oral nodes are
enlarged and painful. Dx and cause? - Erysipelas
- usually caused by group A strep
- Tx: IM or oral penicillin/erythromycin
16yo girl with painful genital lesions or 2d. Lots of sexual partners. Exam shows
two 3x3mm ulcerated lesions on the anterior vaginal vault. How prevent
transmission with new partner? - Consistent condom use (NOT pharmacological
treatment)
,37yo primigravid at 25 weeks' gestation with confusion for 12 hours. Fever and
intermittent nausea and vomiting over the past 2 weeks. No contractions, but
decreased fetal movement. Family Hx of T1DM, seizure disorder. T 38.8, P
168/min, BP 187/84. Mildly enlarged thyroid gland. Lungs clear. 3/6 systolic
ejection murmur. Fetal heart rate 182/min. Labs show: Hb 9.9, platelets 282k,
Serum: Na 134, Cl 94, K 2.9, Thyroid-stimulating hormone 0.01, AST 33, LDH
112, Uric acid 5.4. Dx? - Thyroid storm
- Precipitants: infection, DKA, stress (childbirth, trauma, surgery, illness)
- Sx: fever, tachycardia, agitation, confusion, GI symptoms (n/v/d)
- Tx: supportive therapy with IV fluids, cooling blankets, glucose; PTU ever y2h,
follow with iodine; beta blockers to control HR; dexamethasone to impair t3 from
T4
37yo F with 4-month history of numbness, burning, and tingling of the toes and
soles of her feet. 3-year hx of recurrent mouth sores. Numerous oral apthous
ulcers, genital ulcers, and several 2.5-cm red lesions over the left anterior tibial
region. Photophobia. Ankle reflexes are absent. Proprioception and sensation to
pinprick and vibration decreased in lower ext. Dx? - Behcet syndrome
- autoimmune vasculititc disease
- Sx: recurrent oral and genital ulcerations (usu painful), arthritis (knees, ankles),
eye involvement (uveitis, optic neuritis, conjuncitivitis), CNS involvement
(intracranial HTN, meningoencephalitis), fever, wt loss; erythema nodosum-like
lesions, pseudofolliculitis
- Dx: bx
Tx: steroids
*NOT polyarteritis nodosa
- can be associated with hep B, HIV, drug reactions
- Sx: fever, wt loss, myalgias, abdominal pain (bowel angina)
- Dx: bx; elevated ESR and pANCA
- Tx: corticosteroids (if severe, cyclophosphamide)
87yo F with fever for 1 day. Urinary catheter was placed 2 weeks ago. Has
dementia, Alzheimer type, and is unable to communicate verbally. T 37.8 C, P
,86/min, BP 120/74. Mucous membranes are moist and pink. Urinalysis shows:
Color cloudy brown, Ph 8.8, Blood 2+, Glucose negative, Protein 2+, RBC
numerous, wbc 20-25, Nitrites 3+, leuk esterase 3+, bacteria many. Gram stain
shows gram-negative bacilli. Which would have prevented? - Use of incontinence
briefs instead of the catheter (NOT changing catheter daily)
32yo M with AIDS with 1-week history of T to 40 C and cough. Current
medications include trimethopim-sulfamethoxazole and three antiretroviral agents.
Moist crackles over right lung base. X-ray of the chest shows an infiltrate in the
right lower lobe. Causal org? - Stretococcus pneumoniae (NOT Pneumocystitis
jiroveci b/c taking prophylactic oral bactrim)
77yo F with lesions on her left arm for the past 2 months. Underwent modified
radical mastectomy of the left breast for breast cancer 20 years ago complicated by
chronic edema of the LUE. Two r-mm, raised, hard, purple lesions just above the
left elbow. Dx? - Lymphangiosarcoma
- rare malignant tumor which occurs in long-standing cases of primary or
secondary lymphedema. It involves either the upper or lower lymphedematous
extremities but is most common in upper extremities.
57yo F with 2-week history of progressive jaundice and a 5-kg weight loss. Dark
urine and pale stools. No meds. BP 120/80. Gallbladder palpated in the RUQ.
Urine dipstick is positive for bilirubin. Ultrasonography shows a dilated
gallbladder and dilated intrahepatic and extrahepatic biliary ducts. No calculi. Next
step? - CT scan of the abdomen (Obstructive jaundice due to carcinoma head of
pancreas)
- Courvoisier's sign: palpably enlarged gallbladder which is nontender and
accompanied with mild painless jaundice, the cause is unlikely to be gallstones.
(NOT Lap Cholecystectomy)
One hour after splenectomy, 42yo M has severe shortness of breath. Additional
injuries include left rib and pelvic fractures. T 36.3, P 133/min, BP 80/60. Breath
sounds are absent on the left. Bowel sounds are absent. Next step? - Needle
thoracostomy (pneumothorax; severe)
, NOT CXR
67yo M with alcoholism. 15-year history of poorly controlled hypertension; takes
hydrochlorothiazide, not compliant. BP 170/102. Funduscopic examination shows
arteriovenous nicking and tortuosity of the arteries. Risk for? - MI
- hypertensive retinopathy: AV nicking and tortuosity of the arteries
NOT subarachnoid hemorrhage
32 year old woman with 1 month of diarrhea, 8lb weight loss, three to four
semiliquid stools daily. No fever, abdo pain or rectal bleeding. Just returned from
scuba diving in Mexico 6 weeks ago. Boyfriend is symptom free. Abdo and rectal
exam are normal. What is organism? - Giardia lamblia
NOT V cholerae (up to 15 stools per day)
37yo F from Guatemala with joint pain, swelling, and stiffness of her wrists and
hands for 2 years. Ibupforen ineffective. No fever, cough, or weight lossl. Received
all immunizations. BMI 20. Spleen tip is nontender and is palpated 4 cm below left
costal margin. Grip strength is decreased. Labs: Hb 10, Leukocyte count 2.5k,
Platelets 125k. Cause of the leukopenia? - Felty syndrome
- disorder that involves rheumatoid arthritis, a swollen spleen, decreased white
blood cell count, and repeated infections. It is rare.
37 yr old woman, sudden onset fever 7 days after splenectomy for ITP. T 102.4,
mild distension and diffuse tenderness, no rebound, rigidity or guarding. No bowel
sounds. Labs hg 9.8 Leuks 21,300 Platelet 105, 000, amylase 124. chest xray
shows left pleural effusion. what is the most likely cause of the findings? -
subphrenic abscess (Post-splenectomy subphrenic abscess, phrenic nerve
impingement cause refered shoulder pain, abscess fits the Fever, Increase
Leukocyte count)
NOT pneumonia
complete solutions
NBME 4 -
2mo infant is exclusively breastfed. What nutritional supplement? - Oral VitD to
prevent rickets
What HTN drug causes peripheral edema, flushing, dizziness? - CCB eg nifedipine
15yo girl with recurrent candida infections of skin and mucous membranes since
childhood. Dx? - Chronic mucocutaneous candidiasis (T cell dysfunction)
57yoM with impotence for 1 year rand bronze colored skin. Ferritin concentration
is 4050 NG/ml. Increased risk for what complication? - 1. Liver (primary organ)--
hepatocellular carcinoma
2. Others: pancreas (DM), heart (CHF), skin, thyroid (hypo), gonads, joints
(arthritis)
87yo's daughter: "we want my mother to receive hospice care at home but no one
wants her to die at home. Can she still have hospice services?" - Yes. Hospice can
provide home based care and attempt to transfer the pt to another site before death.
32yoF with 4d of fever with lymphatic obstruction. PE: the left lower extremity is
diffuse lay red and edematous from just below the knee to the ankle, with a sharp
demarcation separating the erythematous area from the normal skin at the knee.
The erythematous area is painful and hyperesthetic to touch. The left oral nodes are
enlarged and painful. Dx and cause? - Erysipelas
- usually caused by group A strep
- Tx: IM or oral penicillin/erythromycin
16yo girl with painful genital lesions or 2d. Lots of sexual partners. Exam shows
two 3x3mm ulcerated lesions on the anterior vaginal vault. How prevent
transmission with new partner? - Consistent condom use (NOT pharmacological
treatment)
,37yo primigravid at 25 weeks' gestation with confusion for 12 hours. Fever and
intermittent nausea and vomiting over the past 2 weeks. No contractions, but
decreased fetal movement. Family Hx of T1DM, seizure disorder. T 38.8, P
168/min, BP 187/84. Mildly enlarged thyroid gland. Lungs clear. 3/6 systolic
ejection murmur. Fetal heart rate 182/min. Labs show: Hb 9.9, platelets 282k,
Serum: Na 134, Cl 94, K 2.9, Thyroid-stimulating hormone 0.01, AST 33, LDH
112, Uric acid 5.4. Dx? - Thyroid storm
- Precipitants: infection, DKA, stress (childbirth, trauma, surgery, illness)
- Sx: fever, tachycardia, agitation, confusion, GI symptoms (n/v/d)
- Tx: supportive therapy with IV fluids, cooling blankets, glucose; PTU ever y2h,
follow with iodine; beta blockers to control HR; dexamethasone to impair t3 from
T4
37yo F with 4-month history of numbness, burning, and tingling of the toes and
soles of her feet. 3-year hx of recurrent mouth sores. Numerous oral apthous
ulcers, genital ulcers, and several 2.5-cm red lesions over the left anterior tibial
region. Photophobia. Ankle reflexes are absent. Proprioception and sensation to
pinprick and vibration decreased in lower ext. Dx? - Behcet syndrome
- autoimmune vasculititc disease
- Sx: recurrent oral and genital ulcerations (usu painful), arthritis (knees, ankles),
eye involvement (uveitis, optic neuritis, conjuncitivitis), CNS involvement
(intracranial HTN, meningoencephalitis), fever, wt loss; erythema nodosum-like
lesions, pseudofolliculitis
- Dx: bx
Tx: steroids
*NOT polyarteritis nodosa
- can be associated with hep B, HIV, drug reactions
- Sx: fever, wt loss, myalgias, abdominal pain (bowel angina)
- Dx: bx; elevated ESR and pANCA
- Tx: corticosteroids (if severe, cyclophosphamide)
87yo F with fever for 1 day. Urinary catheter was placed 2 weeks ago. Has
dementia, Alzheimer type, and is unable to communicate verbally. T 37.8 C, P
,86/min, BP 120/74. Mucous membranes are moist and pink. Urinalysis shows:
Color cloudy brown, Ph 8.8, Blood 2+, Glucose negative, Protein 2+, RBC
numerous, wbc 20-25, Nitrites 3+, leuk esterase 3+, bacteria many. Gram stain
shows gram-negative bacilli. Which would have prevented? - Use of incontinence
briefs instead of the catheter (NOT changing catheter daily)
32yo M with AIDS with 1-week history of T to 40 C and cough. Current
medications include trimethopim-sulfamethoxazole and three antiretroviral agents.
Moist crackles over right lung base. X-ray of the chest shows an infiltrate in the
right lower lobe. Causal org? - Stretococcus pneumoniae (NOT Pneumocystitis
jiroveci b/c taking prophylactic oral bactrim)
77yo F with lesions on her left arm for the past 2 months. Underwent modified
radical mastectomy of the left breast for breast cancer 20 years ago complicated by
chronic edema of the LUE. Two r-mm, raised, hard, purple lesions just above the
left elbow. Dx? - Lymphangiosarcoma
- rare malignant tumor which occurs in long-standing cases of primary or
secondary lymphedema. It involves either the upper or lower lymphedematous
extremities but is most common in upper extremities.
57yo F with 2-week history of progressive jaundice and a 5-kg weight loss. Dark
urine and pale stools. No meds. BP 120/80. Gallbladder palpated in the RUQ.
Urine dipstick is positive for bilirubin. Ultrasonography shows a dilated
gallbladder and dilated intrahepatic and extrahepatic biliary ducts. No calculi. Next
step? - CT scan of the abdomen (Obstructive jaundice due to carcinoma head of
pancreas)
- Courvoisier's sign: palpably enlarged gallbladder which is nontender and
accompanied with mild painless jaundice, the cause is unlikely to be gallstones.
(NOT Lap Cholecystectomy)
One hour after splenectomy, 42yo M has severe shortness of breath. Additional
injuries include left rib and pelvic fractures. T 36.3, P 133/min, BP 80/60. Breath
sounds are absent on the left. Bowel sounds are absent. Next step? - Needle
thoracostomy (pneumothorax; severe)
, NOT CXR
67yo M with alcoholism. 15-year history of poorly controlled hypertension; takes
hydrochlorothiazide, not compliant. BP 170/102. Funduscopic examination shows
arteriovenous nicking and tortuosity of the arteries. Risk for? - MI
- hypertensive retinopathy: AV nicking and tortuosity of the arteries
NOT subarachnoid hemorrhage
32 year old woman with 1 month of diarrhea, 8lb weight loss, three to four
semiliquid stools daily. No fever, abdo pain or rectal bleeding. Just returned from
scuba diving in Mexico 6 weeks ago. Boyfriend is symptom free. Abdo and rectal
exam are normal. What is organism? - Giardia lamblia
NOT V cholerae (up to 15 stools per day)
37yo F from Guatemala with joint pain, swelling, and stiffness of her wrists and
hands for 2 years. Ibupforen ineffective. No fever, cough, or weight lossl. Received
all immunizations. BMI 20. Spleen tip is nontender and is palpated 4 cm below left
costal margin. Grip strength is decreased. Labs: Hb 10, Leukocyte count 2.5k,
Platelets 125k. Cause of the leukopenia? - Felty syndrome
- disorder that involves rheumatoid arthritis, a swollen spleen, decreased white
blood cell count, and repeated infections. It is rare.
37 yr old woman, sudden onset fever 7 days after splenectomy for ITP. T 102.4,
mild distension and diffuse tenderness, no rebound, rigidity or guarding. No bowel
sounds. Labs hg 9.8 Leuks 21,300 Platelet 105, 000, amylase 124. chest xray
shows left pleural effusion. what is the most likely cause of the findings? -
subphrenic abscess (Post-splenectomy subphrenic abscess, phrenic nerve
impingement cause refered shoulder pain, abscess fits the Fever, Increase
Leukocyte count)
NOT pneumonia
