Step 2CK NBME Review
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
3yo girl with fever and ear pain for 1 day. Has had clear nasal discharge and cough for
3 days. History of several ear infections and one episode of streptococcal pharyngitis
over the past 12 months. Father smokes in the house, family has two cats. Swims
frequently. T 38.5, P 110/min, BP 80/50. Clear nasal discharge, erythema and bulging
of the right tympanic membrane, and erythema of the throat without exude.
Recommendation to prevent recurrence?
Avoidance of passive smoke exposure
sensitivity
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
3yo girl with fever and ear pain for 1 day. Has had clear nasal discharge and cough for
3 days. History of several ear infections and one episode of streptococcal pharyngitis
over the past 12 months. Father smokes in the house, family has two cats. Swims
frequently. T 38.5, P 110/min, BP 80/50. Clear nasal discharge, erythema and bulging
of the right tympanic membrane, and erythema of the throat without exude.
Recommendation to prevent recurrence?
Avoidance of passive smoke exposure
sensitivity
