IM NBME FORM 4 EXAM QUESTIONS
WITH 100% RATED CORRECT ANSWERS.
72 yo - burning, aching pain in distal ext for 3 wks
> pain exacerbated by lowering ext; relieved by elevation
PE: tenderness/swelling of fingers and wrist/knee/ankle/toe joints; overlying skin warm/erythematous;
clubbing of fingers/toes
most likely to be abnormal? - Correct Answer -X-ray of the chest
clubbing of fingers and toes = hypertrophic osteoarthropathy
HOA - syndrome of clubbing of the digits, periostitis of the long (tubular) bones, and arthritis
Emma Holiday - this suggests underlying lung malignancy
56 yo - 1 day of epigastric pain/vomiting
PE: scleral icterus; tender epigastrium
labs: inc WBC (inc neutrophils); inc BR 4.4 (direct 3.3); inc triG (210); inc amylase (1350); ink alk phos
(320)
US: dilation of intrahepatic ducts
most likely cause of condition? - Correct Answer -choledocholithiasis
aka gallstones in CBD
symptoms when present: +Murphy's sign; +inf (inc WBC, fever); RUQ/epigastric pain; jaundice
dx:
> RUQ US: initial study; dilated ducts
> ERCP/MRCP: gold standard
tx:
> NPO, IVF, IV AB
> ERCP
> lap cholecystectomy in severe cases
,> f/u: ball-valve effect - stone going back/forth
high amylase = blockage at panc duct
inc direct BR = blockage of CBD
inc alk phos = cholestatic pattern of dz (and eliminates all liver options)
32 yo - progressive sensory loss for 1 wk
> initially: feet felt numb > slowly ascended symmetrically to umbilicus
> urinary urgency/freq; nocturia
> tight band-like sensation around midabd region
PE: slowing of L.eye ADduction during saccadic movement of eyes to the right; diffuse hyperreflexia;
sens to pinprick dec to level of umbilicus
most likely explanation for slowing of L.eye ADduction is a lesion where? - Correct Answer -left medial
longitudinal fasciculus
homegirl has internuclear ophthalmoplegia - MS
lesion in MLF results in ipsi medial rectus palsy on attempted lat gaze (ADduction defect) and horizontal
nystagmus of ABducting eye (CL to side of lesion)
> lac rectus > CNVI nuclei > CL MLF > med rectus
diplopia can occur
MS features involve different areas of the CNS - inability to attribute them all to one localizing lesion
other features: transient sens deficits (MC initial presentation); fatigue; motor symptoms
(weakness/spasticity); cerebellar/cerebral involvement; loss of bladder control; ANS involvement
(impotence/constipation); neuropathic pain
mgnt: acute flares - high-dose IV corticosteroids; chronic - IFN (glatiramer, tingolimod); symptomatic
(baclofen, gabapentin, bethanechol/amitriptyline)
58 yo - extreme fatigue and malaise for 3 wks
> 5 wks ago: toothache - root canal procedure
PMHx: cardiac murmur (noted at 19 yo)
100F
P: 110/min
PE: lungs clear; 2/6 sys murmur - 2nd R.ICS, S4, ejection click
, labs: dec Hgb; WNL WBC (inc segs, bands); inc ESR 90
UA: blood pos
blood cxs obtained
most likely underlying cardiac abnormality? - Correct Answer -calcification of a bicuspid aortic valve
pay attention to how they describe the murmur - systolic, at 2nd R.ICS
murmur at young age of 19 yo - congenital cause
AS > inc LV pressure > hypertrophy and stiffening of LV > S4
bad toothache is prob hinting to endocarditis
> bacteria (prob S.viridans) traveled from teeth and caused vegetations on calcified/already diseased AV
dx: Duke criteria
> major: sustained bacteremia; endocardial involvement or new valvular regurg
> minor: predisposing condition (abnormal valve); fever; vascular phenomena; immune phenomena
(glomerulonephritis, Osler nodes, Roth spots, RF); + blood cx or + echo not meeting major criteria
> require 2 major, 1 major + 3 minor, or 5 minor
30 yo - recurrent aching R.shoulder pain by reaching overhead
> occurs at night in bed
> most prominent in area of deltoid
PE: elicited by ABduction of shoulder against resistance
most likely site of underlying condition? - Correct Answer -supraspinatous tendon
homeboy prob tore his rotation cuff
when you add resistance to ABduction - differentiate bet deltoid and supraspinatus
pain on overhead ABduction due to impingement of supraspinatus tendon bet acromion and humerus
pts may localize the pain to the lat deltoid and often describe pain at night esp when lying on the
affected shoulder
life table shown - compares natural dx hx of groups A and B
which group at which time has poorest 1 yr survival rate? - Correct Answer -group B at year 3-4
sorry you need the actual picture for this (% survival on y-axis and yrs on x-axis)
WITH 100% RATED CORRECT ANSWERS.
72 yo - burning, aching pain in distal ext for 3 wks
> pain exacerbated by lowering ext; relieved by elevation
PE: tenderness/swelling of fingers and wrist/knee/ankle/toe joints; overlying skin warm/erythematous;
clubbing of fingers/toes
most likely to be abnormal? - Correct Answer -X-ray of the chest
clubbing of fingers and toes = hypertrophic osteoarthropathy
HOA - syndrome of clubbing of the digits, periostitis of the long (tubular) bones, and arthritis
Emma Holiday - this suggests underlying lung malignancy
56 yo - 1 day of epigastric pain/vomiting
PE: scleral icterus; tender epigastrium
labs: inc WBC (inc neutrophils); inc BR 4.4 (direct 3.3); inc triG (210); inc amylase (1350); ink alk phos
(320)
US: dilation of intrahepatic ducts
most likely cause of condition? - Correct Answer -choledocholithiasis
aka gallstones in CBD
symptoms when present: +Murphy's sign; +inf (inc WBC, fever); RUQ/epigastric pain; jaundice
dx:
> RUQ US: initial study; dilated ducts
> ERCP/MRCP: gold standard
tx:
> NPO, IVF, IV AB
> ERCP
> lap cholecystectomy in severe cases
,> f/u: ball-valve effect - stone going back/forth
high amylase = blockage at panc duct
inc direct BR = blockage of CBD
inc alk phos = cholestatic pattern of dz (and eliminates all liver options)
32 yo - progressive sensory loss for 1 wk
> initially: feet felt numb > slowly ascended symmetrically to umbilicus
> urinary urgency/freq; nocturia
> tight band-like sensation around midabd region
PE: slowing of L.eye ADduction during saccadic movement of eyes to the right; diffuse hyperreflexia;
sens to pinprick dec to level of umbilicus
most likely explanation for slowing of L.eye ADduction is a lesion where? - Correct Answer -left medial
longitudinal fasciculus
homegirl has internuclear ophthalmoplegia - MS
lesion in MLF results in ipsi medial rectus palsy on attempted lat gaze (ADduction defect) and horizontal
nystagmus of ABducting eye (CL to side of lesion)
> lac rectus > CNVI nuclei > CL MLF > med rectus
diplopia can occur
MS features involve different areas of the CNS - inability to attribute them all to one localizing lesion
other features: transient sens deficits (MC initial presentation); fatigue; motor symptoms
(weakness/spasticity); cerebellar/cerebral involvement; loss of bladder control; ANS involvement
(impotence/constipation); neuropathic pain
mgnt: acute flares - high-dose IV corticosteroids; chronic - IFN (glatiramer, tingolimod); symptomatic
(baclofen, gabapentin, bethanechol/amitriptyline)
58 yo - extreme fatigue and malaise for 3 wks
> 5 wks ago: toothache - root canal procedure
PMHx: cardiac murmur (noted at 19 yo)
100F
P: 110/min
PE: lungs clear; 2/6 sys murmur - 2nd R.ICS, S4, ejection click
, labs: dec Hgb; WNL WBC (inc segs, bands); inc ESR 90
UA: blood pos
blood cxs obtained
most likely underlying cardiac abnormality? - Correct Answer -calcification of a bicuspid aortic valve
pay attention to how they describe the murmur - systolic, at 2nd R.ICS
murmur at young age of 19 yo - congenital cause
AS > inc LV pressure > hypertrophy and stiffening of LV > S4
bad toothache is prob hinting to endocarditis
> bacteria (prob S.viridans) traveled from teeth and caused vegetations on calcified/already diseased AV
dx: Duke criteria
> major: sustained bacteremia; endocardial involvement or new valvular regurg
> minor: predisposing condition (abnormal valve); fever; vascular phenomena; immune phenomena
(glomerulonephritis, Osler nodes, Roth spots, RF); + blood cx or + echo not meeting major criteria
> require 2 major, 1 major + 3 minor, or 5 minor
30 yo - recurrent aching R.shoulder pain by reaching overhead
> occurs at night in bed
> most prominent in area of deltoid
PE: elicited by ABduction of shoulder against resistance
most likely site of underlying condition? - Correct Answer -supraspinatous tendon
homeboy prob tore his rotation cuff
when you add resistance to ABduction - differentiate bet deltoid and supraspinatus
pain on overhead ABduction due to impingement of supraspinatus tendon bet acromion and humerus
pts may localize the pain to the lat deltoid and often describe pain at night esp when lying on the
affected shoulder
life table shown - compares natural dx hx of groups A and B
which group at which time has poorest 1 yr survival rate? - Correct Answer -group B at year 3-4
sorry you need the actual picture for this (% survival on y-axis and yrs on x-axis)
