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 -
62yo M with fatigue for 9 weeks. Drinks moonshine. HCT 29%, MCV 78, and mean
corpuscular hemoglobin concentration is 25%. Blood smear shows hypochromic,
microcytic erythrocytes and normochromic, normocytic erythrocytes. Bone marrow shows
greater than 10% normoblasts containing iron-laden mitochondria that surround the
nucleus and appear as rings on Prussian blue staining. Iron and transferrin saturation
increased. Cause? - Sideroblastic anemia
- caused by abnormality in RBC iron metabolism
- hereditary or acq (drugs eg INH, alcohol, chloramphenicol; exposure to lead; neoplastic
disease)
- Labs: increased serum iron and ferritin, normal TIBC, ringed sideroblasts in bone marrow
- Tx: remove offending agents; consider pyridoxine
NOT hemochromatosis
30yo F routine exam. 10-year history of type 1 diabetes mellitus. Microalbuminuria, her
hemoglobin A1c is 7%, and serum Cr is 1.8. Intervention? - Administration of an
angiotensin-converting enzyme (ACE) inhibitor
NOT inc dose of insulin
19yo F at 32 weeks' gestation with 1-month history of a generalized rash that has not
expanded or changed. No pruritis or fever. No prenatal care. Macular rash involving the
palms, chest, back, abdomen, extremities, and soles. Causal oragnism? - Treponema
pallidum
NOT Rubella:
"You drive CARS with your palms and soles"
CA- Coxsackievirus A
R- Rickettsia Rickettsii
S- Syphilis (secondary)
22yo F with asthma. Treated for six acute episodes of wheezing and nonproductive cough
during the past year. Last episode 1 mo ago. Sx exacerbated when outside during the spring
and fall. On albuterol inhaler. Smoked daily for 5 years. X-ray of the chest normal. Which
will reduce frequency of exacerbations? - - Fluticasone inhaler therapy
(Not influenza vaccine)
6 month old boy, chronic constipation since the age of 1 week. Current Rx with rectal
stimulation, glycerin suppositories, and 4 ounces of prune juice produces string-like stool
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 -
62yo M with fatigue for 9 weeks. Drinks moonshine. HCT 29%, MCV 78, and mean
corpuscular hemoglobin concentration is 25%. Blood smear shows hypochromic,
microcytic erythrocytes and normochromic, normocytic erythrocytes. Bone marrow shows
greater than 10% normoblasts containing iron-laden mitochondria that surround the
nucleus and appear as rings on Prussian blue staining. Iron and transferrin saturation
increased. Cause? - Sideroblastic anemia
- caused by abnormality in RBC iron metabolism
- hereditary or acq (drugs eg INH, alcohol, chloramphenicol; exposure to lead; neoplastic
disease)
- Labs: increased serum iron and ferritin, normal TIBC, ringed sideroblasts in bone marrow
- Tx: remove offending agents; consider pyridoxine
NOT hemochromatosis
30yo F routine exam. 10-year history of type 1 diabetes mellitus. Microalbuminuria, her
hemoglobin A1c is 7%, and serum Cr is 1.8. Intervention? - Administration of an
angiotensin-converting enzyme (ACE) inhibitor
NOT inc dose of insulin
19yo F at 32 weeks' gestation with 1-month history of a generalized rash that has not
expanded or changed. No pruritis or fever. No prenatal care. Macular rash involving the
palms, chest, back, abdomen, extremities, and soles. Causal oragnism? - Treponema
pallidum
NOT Rubella:
"You drive CARS with your palms and soles"
CA- Coxsackievirus A
R- Rickettsia Rickettsii
S- Syphilis (secondary)
22yo F with asthma. Treated for six acute episodes of wheezing and nonproductive cough
during the past year. Last episode 1 mo ago. Sx exacerbated when outside during the spring
and fall. On albuterol inhaler. Smoked daily for 5 years. X-ray of the chest normal. Which
will reduce frequency of exacerbations? - - Fluticasone inhaler therapy
(Not influenza vaccine)
6 month old boy, chronic constipation since the age of 1 week. Current Rx with rectal
stimulation, glycerin suppositories, and 4 ounces of prune juice produces string-like stool
