NBME 17 discussion

[fatwalletuab]

Can you guys correct me on this
----------------------------------------------------------------------
8.old woman with DVT. Platelet dropped significantly after a week of tx. Drug of action?
a. activate tissue plasminogen -----action of tPA
b. Interferes with carboxylation of coag factors ----action of warfarin
c. irreversibly inactivate COX -----Aspirin
d. Potentiates the action of antithrombin iii (correct answer, action of Heparin, and this is Heparin induced Thrombocytopenia HIT)
e. selectively inhibits factor Xa (Heparin does thrombin factor 2 and factor Xa)
---------------------------------------------------------------
14.ER doctor successfully delivered a baby, womanis now having severe bleeding. Pelvic exam shows an ope cervix and heavy vaginal bleeding. Ligation of a branch of which of the following arteries is most appropriate?
a. external iliac (gives femoral and inferior epigastric artery)
b. internal iliac ( Correct answer I think, bcz Uterine artery is a branch of internal iliac artery)
c. internal pudendal (supplies the external structure, but also a branch of internal iliac)
d. median sacral (supply coccyx)
e. Obturator (gives blood supply to the leg obturator muscles)
----------------------------------------------------------------------------
16. A patient cries ad says it's a bad news, isn't it?! when a doc is about to tell him the progression of carcinoma to the terminal phase. Most appropriate response?
a. How have you been since the last time I saw you?
b. lets talk about hte positive aspect first
c. look on the bright side of things
d. tell me how you are feeling
e. there are other people who have it alot worse than you
f. Yes it is
g. you've had several years better off than many others with this disease.

I was debating on A or D. I picked D and it's wrong....is that bcz it didn't end with a question mark? wth
------------------------------------------------------------------------------------------
32. A guy with chrons disease. You give antibiotics and prednisone, he got better in 3 weeks, in addition to resolving the infection, the most likely MOA of this pharmacotherapy is which of the following?
a. antibody binding
b. complement activity
c. mast cell degranulation
e. neutrophil function
f. T-lymphocyte function

I marked e. but it's wrong....so I'm guessing T-lymphocyte fumction F? as to decrease T and B cell couns. However, neutrophil count is increased.
----------------------------------------------------------------------------------
10. 45 year old lady diagnosed with invasive ductal cell CA breast . she was started on tamoxifen and serum analysis showed decreased conc. of enoxifen the active metabolite of prodrug tamoxifen. Genetic analysis showed homozygous presence of CYP450 2D6*4 alleles. WHich of following best represents the likelihood that this patient sister has same alleles?
1.0% 2. 25% 3. 50% 4. 75% 5 100%
Can anyone solve for this one??? thanks!
--------------------------------------------
49. Old man with 2 year history of decrased force of his urinary stream and increase frequency. BUN is 55 and Creatinine is 5. Ultrasound of Urinary tract shows bilateral hydronephrosis and dilated ureters. What is the mechanism of this patient's renal failure?
a. Decreased hydrostatic pressure in the glomerular capillary
b. decreased renal plasma flow
c. Increased hydrostatic pressure in Bowman space
d. Precipitation of protein in the renal tubules
e. Precipitation of uric acid in the renal tubules
---------------------------------------------------------------------
4. A 27 yo woman with fever, malaise, abdominal pain, vaginal discharge for 4 days. Pregnancy test is negative, Leukocyte count is up. Bilateral lower quadrant tenderness with rebound and guarding. Pelvic exam shows cervical bilateral adnexal tenderness. Most likely diagnosis?
a. appendicitis
b. bacterial vaginosis
c. Chancroid
d. Diverticulitis
e. Gonorrhea
f. Herpies genitalis
g. Trichomonias

Gonorrhea...I picked chancroid on the exam...because I thought chancroid can have those bubonic thing bilaterally....i guess the answer is gonorrhea?!
-------------------------------------------
6. A study is designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in pts with CHF. 60 pts with CHF are recruited for the study. Each subject is assigned by coin toss to one of two groups (standard care or standard care plus coenzyme). Which of the following best describe this study design?
a. case-control
b. case-series
c. Crossover
d. Cross-sectional
e. Historical cohort
f. Randomized clinical-trials

I'm guessing F. is the correct answer bcz by giving q10, you're giving a treatment (intervention) to the study. And the coin toss gives the randomness.

a. Case-control: have 2 groups, one health as the control and one diseased. Trying to evaluate the risk factor. So the example will be: 60 pt with CHF drink more and smoke more. Healthy individuals smoke and drink less. Risk factors are smoking and drinking alcohols.
d. Cross-sectional: snap shot, trying to find out in a population who have CHF. You know the prevalence but not incidence.
e. I don't think it is either retrospective or prospective
----------------------------------------------------------------------
A guy completed amoxillin develop watery-brown stools in the past 24 hours. Clostridium difficile toxin is positive. Pathological finding is most likely to be present?
a. Bacterial Overgrwoth of the colonic surface
b.Flask-shaped ulcers in the colon
c. Giardia trophozoites linning the duodenal mucosa
d. Necrotizing granulomatous inflammation
e. PEsudomembranes of fibrin and inflammatory debris

They want us to pick e. But I have seen many qbank and wiki sources say a). Can someone tell me why not AAAAAAAAAAAAAAA??
---------------------------------------------------------
A 1 week old girl screening sho a possible defectin fatty acid oxidation, physical exam shows no abnormality. Which of the following is the most appropriate next step in diagnosis?
a. arterial blood gas analysis
b. measurement of serum acylcarnitine conc.
c. measurement of serum amino acid conc.
d. measurement of serum electrolyte conc.
e. measurement of serum lactic acid conc.
--------------------------------------------------------------
34. 40 yo woman has a mole on her back that has increased in size during the past 4 mo. PE shows Raise irregular lesion with variegated black-tan pigmentation and ill-defined margins. Examination of tissue from the tissue shows pleomorphic, hyperchromatic cells within clear islands that tend to coalesce and are present at all levels of the epidermis, with extension into the paipillar dermis. What is it?
a. basal cell carcinoma
b. blue nevus
c. cafe au lait spot
d. intradermal nevus
e. lentigo simplex
f. melanoma
g. seborrheic keratosis

I think it is f melanoma

-------------------------
7. A 42 year farmer has a 7mm red scaly plaque on helical rim of left ear . A photomicrograph of tissue obtained on biopsy of plaque is shown. whats the diagnosis ( Picture was shown)
a. Actinic keratosis b. Basal cell CA c. Keratocanthoma d. Malignant melanoma e. Merkel cell CA

I think it's a. actinic keratosis

---

Members don't see this ad.

 

[accessdenied]

Hey guys,
I need your advice.
My exam is on 16/6, I did NBME 17 yesterday and got 226 which made me down, I was hoping a score in the high 230s!.
my previous scores were:
20/4 NBME 16: 202
11/5 UWSA1: 234
14/5 NBME 15: 224
1/6 UWSA2: 248
6/6 NBME 17: 226

Thanks in advance.

 

[seminoma]

So I was torn on that question about CYP450 inheritance. I just googled and saw that it's AR, but aren't CYP mitochondrial enzymes? So shouldn't it be mitochondrial inheritance?

 

[byaaaaaaah23]

***

 

[seminoma]

Can you post a little more info about the question? I don't really remember that one.

Breast cancer patient being treated with tamoxifen. Her sister also has breast cancer being treated with tamoxifen. You run some P450 test on the current patient and find she is homozygous for reduced function in a specific cyp enzyme. What is the likelihood that her sister has the same defect? 0, 25, 50, 75, 100 percent.

 

[byaaaaaaah23]

Hey guys,
I need your advice.
My exam is on 16/6, I did NBME 17 yesterday and got 226 which made me down, I was hoping a score in the high 230s!.
my previous scores were:
20/4 NBME 16: 202
11/5 UWSA1: 234
14/5 NBME 15: 224
1/6 UWSA2: 248
6/6 NBME 17: 226

Thanks in advance.

I thought 17 was the hardest of the NBMEs if that makes you feel any better. Analyze your score report and see where your weaknesses were on that test compared to past NBMEs. Hit those hard for the next few days. Remember that the UWSAs are rumored to overpredict your real score so I wouldn't really use them in that manner. Good luck!

 

[byaaaaaaah23]

***

 

[dfib slim]

Breast cancer patient being treated with tamoxifen. Her sister also has breast cancer being treated with tamoxifen. You run some P450 test on the current patient and find she is homozygous for reduced function in a specific cyp enzyme. What is the likelihood that her sister has the same defect? 0, 25, 50, 75, 100 percent.

This one was weird. I picked 25% and got it right.

They didn't give any info for the parents so I just figured there are 4 possibilities for the sisters genotype, AA, Aa, aA, and aa. Both parents must have at least one recessive allele and AR disorders are most often rare so I figured both parents were heterozygous.

 

[seminoma]

Well you can't really predict a percent chance of inheritance for mitochondrial inheritance right? So if that was the case, there is no correct answer that you can solve for. So I would assume AR since that's more common than AD? That's all I got, sorry Either way, I don't think CYP enzymes are mitochondrial.

Can't you? 100% inheritance for mitochondrial genes. I realize now what my mistake was. P450 is in the smooth ER, not in the mitochondria. You probably already knew that, which is why my question didn't make any sense to you (because I was wayyyy off, lol). There are mitochondrial cytochromes, but not the P450 ones.

 

[seminoma]

Forgive me for not searching. Too lazy, crunched for time .

3 year old with sickle cell, 2-3 week history of fever, pain in foot, 15k white count with PMN predominance. Diagnosis osteomyelitis or avascular necrosis?

70 something year old man with transverse colon polyp on biopsy. Hyperplastic polyp or tubular adenoma?

38 year old woman with 1 (maybe 2) kids with painful menses, has to stay home once every 2 months because of pain. Palpable mildly enlarged left ovary, retroflexed uterus. US shows many polyps in left ovary, one peritoneal polyp. Family history of infertility. Diagnosis PCOS, proliferative endometrial tissue, mucinous adenocarcinoma, germ cell tumor, stromal tumor?

 

[CodeRedDew]

Forgive me for not searching. Too lazy, crunched for time .

3 year old with sickle cell, 2-3 week history of fever, pain in foot, 15k white count with PMN predominance. Diagnosis osteomyelitis or avascular necrosis? Osteomyelitis

70 something year old man with transverse colon polyp on biopsy. Hyperplastic polyp or tubular adenoma? I thought this question was very controversial as hyperplastic polyps are the most common type of polyps. I was back/forth between the two and in the end, I went with tubular adenoma and it wasn't in my incorrects.

38 year old woman with 1 (maybe 2) kids with painful menses, has to stay home once every 2 months because of pain. Palpable mildly enlarged left ovary, retroflexed uterus. US shows many polyps in left ovary, one peritoneal polyp. Family history of infertility. Diagnosis PCOS, endometrial hyperplasia, mucinous adenocarcinoma? Retroflexed uterus + painful menses = endometriosis (from UW)

 

[seminoma]

17 year old overweight/obese kid asks you if he "inherited it" from his dad (dad and paternal uncle both obese). What do you tell him?

"No, let's look at your environment because it's incidental that your dad is overweight" <-- picked that one
"Yes, your weight could be from genes and environment" <-- thought this was fair too. DM2 linked to obesity linked to overweight etc.. but they didn't say he or his dad/uncle had DM so I figured it was better not to assume.

*

Cool dude, thanks a lot. I went with tubuloadenoma too because I remembered FA said hyperplastic are usually small and most commonly in the rectosigmoid (and the question had a huge polyp in the transverse colon).

Thanks for the explanation about retroflexed uterus. Didn't know that, but ended up going with endometriosis too.. only because I thought she was a little young for mucinous cystadenocarinoma (though the peritoneal cyst lead me toward that diagnosis) and didn't think PCOS would be unilateral. The other thing was family history. Not sure is endometriosis a/w genetics?

 

[seminoma]

Just did a search. Surprised nobody asked about the MLF/INO question. If the Right eye doesn't adduct then it's a Right INO and the Right MLF is damaged, correct?

Can someone please explain the changes in lung function in a healthy 70 y/o female ?
why does the arterial PO2 goes down and why does the A-a dif increases ???
thanks

Wasn't really sure about this one either, but I knew that A-a difference would definitely not decrease so that left only 2 possible answer choices. I also figured that PaO2 would definitely not increase.. which left only 1 answer. My guess is that old people develop fibrosis over the years from constant insults from the environment. So A-a increases because of diffusion impairment. A-a up --> PaO2 reduced.

Can anyone remember what the third part of that question was?

193/200 was a 269

Good to know! Anyone else know how many they got wrong and is willing to share? I'd like to know how many I got wrong and I'm kicking myself for not paying the extra $10.

 

[dfib slim]

Just did a search. Surprised nobody asked about the MLF/INO question. If the Right eye doesn't adduct then it's a Right INO and the Right MLF is damaged, correct?

Yes

Wasn't really sure about this one either, but I knew that A-a difference would definitely not decrease so that left only 2 possible answer choices. I also figured that PaO2 would definitely not increase.. which left only 1 answer. My guess is that old people develop fibrosis over the years from constant insults from the environment. So A-a increases because of diffusion impairment. A-a up --> PaO2 reduced.

Can anyone remember what the third part of that question was?

I think the 3rd part was RV? The A-a grad was increased and PaO2 was decreased.

Good to know! Anyone else know how many they got wrong and is willing to share? I'd like to know how many I got wrong and I'm kicking myself for not paying the extra $10.

Answers are bolded. If you don't get the extended feedback what does it show you? 190/200 is a 264

 

[sloop]

Just did a search. Surprised nobody asked about the MLF/INO question. If the Right eye doesn't adduct then it's a Right INO and the Right MLF is damaged, correct?

This was my understanding. I read the neuro chapter of FA2014 last night and that's what it said. Haven't gone through the entire review and seen if I got that question right, though.

Good to know! Anyone else know how many they got wrong and is willing to share? I'd like to know how many I got wrong and I'm kicking myself for not paying the extra $10.

17 wrong = 254 FWIW.

 

[seminoma]

Answers are bolded. If you don't get the extended feedback what does it show you? 190/200 is a 264

Yeah, it was RV, good call. It shows you the boxes/stars thing, your 3-digit out of 800, and the table for converting that score to a 3-digit step1 score.

So maybe ~3 questions per 5 points?

 

[IceCastle]

My experience is n=1, but NBME 17 overestimated my score by 16 points (my real score was 250). UWSA 2 was more accurate in my experience.

 

[seminoma]

My experience is n=1, but NBME 17 overestimated my score by 16 points (my real score was 250). UWSA 2 was more accurate in my experience.

How far apart did you take UWSA2 and NBME17?

 

[IceCastle]

How far apart did you take UWSA2 and NBME17?

I think I took UWSA2 three weeks before NBME17. To be honest, I think that NBME 17 really hit my strengths, but I have also seen other people crush it and end up scoring 10-15 points lower on the real thing. Just don't get cocky if you do well on 17 like I did.

 

[seminoma]

I think I took UWSA2 three weeks before NBME17. To be honest, I think that NBME 17 really hit my strengths, but I have also seen other people crush it and end up scoring 10-15 points lower on the real thing. Just don't get cocky if you do well on 17 like I did.

Hmm, well I only scored 8 points higher on NBME17 than UWSA2 so hopefully I'll be somewhere close to both.

 

[seminoma]

1.Was the venous catheter infection question enterococcus? Gram positive cocci in chains and pairs, non-hemolytic, catalase negative.

2. 14 year old boy with problems in school, bilateral temporal headaches, and on drugs. Was it inhaled glue? Ethanol was the other answer I was considering. Figured glue is easy to get and would cause similar symptoms though. Really bad at these, and FA doesn't help me much.

3. Crack cocaine addict comes in with 2 hour history of chest pain. Last cocaine consumed 6 hours ago. What do you do for him? (I think this was on NBME 17, but maybe it was the UWSA2 I took day before yesterday). Admit him for possible myocardial ischemia. Admit him for cocaine detox. Counsel about quitting cocaine and send him home.

4. The question with all the lung auscultation/exam findings. Was it pleural effusion?

5. Question about lady with sarcoid that asked which would be increased in serum. 1,25VitD was an answer (presumably the correct one), but calcitonin was also an answer choice. Wouldn't calcitonin be increased too?

Also regarding that 70 year old lady's lung question. FA page 603 "Compliance increases in normal aging". So that explains that.

 

[lovemango]

1.Was the venous catheter infection question enterococcus? Gram positive cocci in chains and pairs, non-hemolytic, catalase negative.

2. 14 year old boy with problems in school, bilateral temporal headaches, and on drugs. Was it inhaled glue? Ethanol was the other answer I was considering. Figured glue is easy to get and would cause similar symptoms though. Really bad at these, and FA doesn't help me much.

3. Crack cocaine addict comes in with 2 hour history of chest pain. Last cocaine consumed 6 hours ago. What do you do for him? (I think this was on NBME 17, but maybe it was the UWSA2 I took day before yesterday). Admit him for possible myocardial ischemia. Admit him for cocaine detox. Counsel about quitting cocaine and send him home.

4. The question with all the lung auscultation/exam findings. Was it pleural effusion?

5. Question about lady with sarcoid that asked which would be increased in serum. 1,25VitD was an answer (presumably the correct one), but calcitonin was also an answer choice. Wouldn't calcitonin be increased too?

Also regarding that 70 year old lady's lung question. FA page 603 "Compliance increases in normal aging". So that explains that.

1. Enterococcus

2. Inhaled glue

3. Admit for possible myocardial ischemia

4. If it was this question: ↓ breath sounds, dullness to percussion, ↓ tactile fremitus, no adventitious sounds = pleural effusion

5. I think 1,25 vit D is the better answer due to upregulation of 1a-hydroxylase by macrophages. Calcitonin doesn't usually play a role at physiologic levels and even when increased in diseases like medullary carcinoma of the thyroid, I'm not sure what effect it has. From Costanzo: "In contrast to PTH, calcitonin does not participate in the minute-to-minute regulation of the plasma Ca2+ concentration in humans."

None of these were in my incorrects.

 

[seminoma]

1. Enterococcus

2. Inhaled glue

3. Admit for possible myocardial ischemia

4. If it was this question: ↓ breath sounds, dullness to percussion, ↓ tactile fremitus, no adventitious sounds = pleural effusion

5. I think 1,25 vit D is the better answer due to upregulation of 1a-hydroxylase by macrophages. Calcitonin doesn't usually play a role at physiologic levels and even when increased in diseases like medullary carcinoma of the thyroid, I'm not sure what effect it has. From Costanzo: "In contrast to PTH, calcitonin does not participate in the minute-to-minute regulation of the plasma Ca2+ concentration in humans."

None of these were in my incorrects.

Thanks a lot. All make sense, I guess the sarcoid question was just making sure that you knew the mechanism of hypercalcemia and, if you didn't, then there was a reasonable answer (high calcitonin 2/2 high calcium) there for you to pick and get it wrong lol.

 

[lovemango]

Thanks a lot. All make sense, I guess the sarcoid question was just making sure that you knew the mechanism of hypercalcemia and, if you didn't, then there was a reasonable answer (high calcitonin 2/2 high calcium) there for you to pick and get it wrong lol.

Haha, yeah, taking NBMEs has taught me to stop overthinking and just go with the simplest answer.

 

[seminoma]

Haha, yeah, taking NBMEs has taught me to stop overthinking and just go with the simplest answer.

Any chance you remember the question about the person who develops gynecomastia after being on hCG therapy?

32 year old man develops swelling/tenderness in both breasts. He had surgical removal of pituitary adenoma 2 years ago and has been on thyroid and steroid therapy since then. Recently started on hCG. Mechanism of the gynecomastia?

Answers all had a target tissue and an effect.

 

[lovemango]

Any chance you remember the question about the person who develops gynecomastia after being on hCG therapy?

32 year old man develops swelling/tenderness in both breasts. He had surgical removal of pituitary adenoma 2 years ago and has been on thyroid and steroid therapy since then. Recently started on hCG. Mechanism of the gynecomastia?

Answers all had a target tissue and an effect.

Yup, I debated over that one for awhile. The answer was hcG acting on receptors in the testicles due to the similarity with LH → effect on testosterone (and presumably conversion to estrogen leads to gynecomastia).

 

[seminoma]

Yup, I debated over that one for awhile. The answer was hcG acting on receptors in the testicles due to the similarity with LH → effect on testosterone (and presumably conversion to estrogen leads to gynecomastia).

Nice, that's what I went with as well. Only got it because of goljan audio.

 

[nighthawk4900]

Anyone know the answer to this one:

A previously healthy 42-yo amek is brought to the ED by his wife because of a 5hr history of fever Lab studies:


Leuko: 15,000
segs: 35%
bands 40%
lymphocytes: 25%
platelets 50k

Urea nitrogen: 28mg
creatinine: 2.8

The pt's symptoms are most likely directly attributable to systemic release of which of the following cytokines
a) IL1 and IFN alpha
b) IL1 and IFN gamma
c) IL1 and TNF alpha
d) IL4 and IFN alpha
e) IL4 and IFN gamma
f) IL4 and TNF alpha



can someone walk me through the thought process here? and if the kidney function has anything to do with it?

 

[byaaaaaaah23]

**

 

[nighthawk4900]

This is just testing if you know the acute phase reactant cytokines. Answer is b. I got this by remembering Dr. Sattar saying IL-1 for fever (thus acute phase), so that eliminates d-f. IFN-alpha is released by virus-infected cells, and TNF-alpha is involved in making granulomas, leaving b) as the answer. To me, this was an either you know it or you don't kinda question.

Thanks, but I'm confused because FA says TNF-alpha is a mediator of septic shock, causes leukocyte recruitment and vascular leak? that seems applicable here?

 

[seminoma]

Thanks, but I'm confused because FA says TNF-alpha is a mediator of septic shock, causes leukocyte recruitment and vascular leak? that seems applicable here?

I picked C as well. The main cytokines in septic shock are IL-1, TNF-a, and IL-12. No doubt about it.

Not sure about the kidneys. I would have expected a prerenal picture (hypoperfusion), but the BUN/Cr looks more like intrarenal. Not sure of the pathogenesis, but intrarenal kidney injury plus septic shock = multiorgan dysfunction syndrome.

 

[lovemango]

This is just testing if you know the acute phase reactant cytokines. Answer is b. I got this by remembering Dr. Sattar saying IL-1 for fever (thus acute phase), so that eliminates d-f. IFN-alpha is released by virus-infected cells, and TNF-alpha is involved in making granulomas, leaving b) as the answer. To me, this was an either you know it or you don't kinda question.

The answer is C (IL-1 and TNF alpha). It wasn't in my incorrects.

 

[starstarie]

Haha, yeah, taking NBMEs has taught me to stop overthinking and just go with the simplest answer.

This is like the understatement of the year. Seriously every time I start thinking at all more than my gut answer, it's wrong. It's so strange because it goes against just about every test I've taken ever. Haha

 

[starstarie]

17 year old overweight/obese kid asks you if he "inherited it" from his dad (dad and paternal uncle both obese). What do you tell him?

"No, let's look at your environment because it's incidental that your dad is overweight" <-- picked that one
"Yes, your weight could be from genes and environment" <-- thought this was fair too. DM2 linked to obesity linked to overweight etc.. but they didn't say he or his dad/uncle had DM so I figured it was better not to assume.

+1 for this... anyone know what the official answer is?

 

[byaaaaaaah23]

**

 

[dfib slim]

17 year old overweight/obese kid asks you if he "inherited it" from his dad (dad and paternal uncle both obese). What do you tell him?

"No, let's look at your environment because it's incidental that your dad is overweight" <-- picked that one
"Yes, your weight could be from genes and environment" <-- thought this was fair too. DM2 linked to obesity linked to overweight etc.. but they didn't say he or his dad/uncle had DM so I figured it was better not to assume.

+1 for this... anyone know what the official answer is?

I put "Yes, your weight could be from genes and environment" and it wasn't in my incorrects.

 

[seminoma]

I put "Yes, your weight could be from genes and environment" and it wasn't in my incorrects.

Damn, got that one wrong then.

What about the kid who spent an hour in 60*F water and the answers were up/down arrows for ADH and ANP? I figured ADH would be high and ANP would be low? Can't remember the third part of the answer choices, but I didn't have any idea what was going on. My only thought was that he'd want to retain as much water as possible..

 

[dfib slim]

Damn, got that one wrong then.

What about the kid who spent an hour in 60*F water and the answers were up/down arrows for ADH and ANP? I figured ADH would be high and ANP would be low? Can't remember the third part of the answer choices, but I didn't have any idea what was going on. My only thought was that he'd want to retain as much water as possible..

I figured the kid's blood would shunt to his core to keep him warm so it would "appear" like he had too much fluid. ADH down, ANP up, and I forgot the other. Wasn't in my incorrects.

 

[seminoma]

I figured the kid's blood would shunt to his core to keep him warm so it would "appear" like he had too much fluid. ADH down, ANP up, and I forgot the other. Wasn't in my incorrects.

Nice dude, that's probably exactly what would happen!

 

[seminoma]

Can someone talk me through the sickle cell kid with osteomyelitis in his foot?

I struggled to choose between osteomyelitis and avascular necrosis for several reasons.

Things supporting osteomyelitis.
Location (strange for AVN to be in the toes/feet in this pt)

Things supporting AVN
Kid is only 3 years old so he's not asplenic yet, right?

I ended up choosing osteomyelitis because I was thinking fever+pain+white count was more suggestive of osteomyelitis, but I'm not completely sure that AVN doesn't present with fever+pain+white count too..

 

[lovemango]

I figured the kid's blood would shunt to his core to keep him warm so it would "appear" like he had too much fluid. ADH down, ANP up, and I forgot the other. Wasn't in my incorrects.

I think the other part of the answer was increased central blood volume, which fits with your explanation

 

[lovemango]

Can someone talk me through the sickle cell kid with osteomyelitis in his foot?

I struggled to choose between osteomyelitis and avascular necrosis for several reasons.

Things supporting osteomyelitis.
Location (strange for AVN to be in the toes/feet in this pt)

Things supporting AVN
Kid is only 3 years old so he's not asplenic yet, right?

I ended up choosing osteomyelitis because I was thinking fever+pain+white count was more suggestive of osteomyelitis, but I'm not completely sure that AVN doesn't present with fever+pain+white count too..

I think it's the fever and WBC count that points more towards osteomyelitis. I had a hard time choosing between the two, but I looked up avascular necrosis on UptoDate just now and it says pain is the most common presenting symptom with no mention of systemic symptoms like fever or increased WBC count.

 

[Radiolucent]

Can someone talk me through the sickle cell kid with osteomyelitis in his foot?

I struggled to choose between osteomyelitis and avascular necrosis for several reasons.

Things supporting osteomyelitis.
Location (strange for AVN to be in the toes/feet in this pt)

Things supporting AVN
Kid is only 3 years old so he's not asplenic yet, right?

I ended up choosing osteomyelitis because I was thinking fever+pain+white count was more suggestive of osteomyelitis, but I'm not completely sure that AVN doesn't present with fever+pain+white count too..

This happens a lot on the real thing as well: you see one answer that fits, but wait.. there's also that other answer that could also present this way - which to choose?

When you have something you know vs something that you maybe know/are unsure of - pick the former.

Like you said; location AND the high leukocytosis + fever --> more likely an infectious process.

 

[seminoma]

Cool, thanks guys. UW seemed to make a really big deal about the histopath of the spleen in sickle cell patients of various ages and in the back of my mind I was thinking that the NBME was testing that concept and only trying to trick you with fever+leukocytosis.

Classic overthinking because of UW?

 

[CodeRedDew]

Cool, thanks guys. UW seemed to make a really big deal about the histopath of the spleen in sickle cell patients of various ages and in the back of my mind I was thinking that the NBME was testing that concept and only trying to trick you with fever+leukocytosis.

Classic overthinking because of UW?

Classic. I found a little gem someone mentioned in a prior thread: The answer to a step 1 question is USUALLY the least complicated path. So if you're justifying one answer ONLY after you've made several leaps of logic to justify it, then chances are that probably isn't the answer. Of course there will be exceptions, but for the most part, I don't think the Step 1 is the type of exam that is trying to purposefully trick you vs. UWorld which is a learning assessment tool.

 

[starstarie]

I figured the kid's blood would shunt to his core to keep him warm so it would "appear" like he had too much fluid. ADH down, ANP up, and I forgot the other. Wasn't in my incorrects.

See I went at it with the freshwater being hypotonic and causing a fluid shift out. It clearly was not the right way to think about it, although I thought it was pretty clever at the time haha

 

[starstarie]

This happens a lot on the real thing as well: you see one answer that fits, but wait.. there's also that other answer that could also present this way - which to choose?

When you have something you know vs something that you maybe know/are unsure of - pick the former.

Like you said; location AND the high leukocytosis + fever --> more likely an infectious process.

Yeah, on the real thing they want the most obvious choice. Most of the time I'll catch myself thinking "we'll this could fit too..." just stop there and stick with the original. End of story.

 

[Sportsmeddoc]

Just as a summary, what conditions will not respond to 1 L of isotonic saline. In the question it is basically describing a distributive shock (from early sepsis), so I'm assuming the problem is that you would also need to add pressors in order to fix the actual problem (decreased systemic vascular resistance). But would this be true in all sepsis, where 1 liter of saline would give you an insufficient increase in BP, what other conditions would look like this.

 

[aacrualword]

1. A previously healthy 35-year-old man has become increasingly depressed, impulsive, and difficult over the past year. He grimaces intermittently and has rigid, jerking, purposeless movements of the fingers. Which of the following historical factors is most relevant in establishing a diagnosis?
A
Dietary deficiency
B
Exposure to environmental toxins
Family history of a similar illness
D
Pet with an unexplained illness
E
Tick bite
F
Travel to a foreign country

Cant figure this one out for the life of me, any help appreciated

 

[CodeRedDew]

1. A previously healthy 35-year-old man has become increasingly depressed, impulsive, and difficult over the past year. He grimaces intermittently and has rigid, jerking, purposeless movements of the fingers. Which of the following historical factors is most relevant in establishing a diagnosis?
A
Dietary deficiency
B
Exposure to environmental toxins
Family history of a similar illness
D
Pet with an unexplained illness
E
Tick bite
F
Travel to a foreign country

Cant figure this one out for the life of me, any help appreciated

Family hx - Depression, grimacing/choreic movements = Huntingtons

 

[aacrualword]

Few more, any help is greatly appreciated!

1. A 15-year-old girl who recently emigrated from India is brought to the physician because of several lesions on her neck for 2 weeks. Physical examination shows a hypopigmented, hypoesthetic area over the left side of the forehead and 4-cm lesions on the neck. A biopsy specimen of a lesion shows acid-fast bacilli. Which of the following best explains why the causal organism results in dermal rather than in visceral infections?
A
) CO2 requirement
B
) Innate antibacterial compounds
C
) Lipid content
D
) Oxygen tolerance
E
) Temperature sensitivity

2. An 80-year-old man with type 2 diabetes mellitus is brought to the physician because a 2-month history of severe constipation. Use of over-the-counter laxatives has not relieved his symptoms. Abdominal examination shows distention. Colonoscopy shows no abnormalities. This patient most likely has dysfunction of which of the following nerves?
A
) Hypogastric
B
) Inferior rectal
C
) Pelvic splanchnic
D
) Perineal
E
) Sacral sympathetic


3. A 52-year-old man is brought to the physician by a social worker because his neighbors have reported that he has been confused and not taking care of himself. He has a 4-month history of diarrhea. Physical examination shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. The patient is mildly disoriented and has poor long-term memory and paranoid ideation. Which of the following is the most likely diagnosis?
A
) Beriberi
B
) Pellagra
C
) Scurvy
D
) Wernicke syndrome
E
) Whipple disease
I totally missed this one, but cant definitively decide now b/t Whipples and Pellagra...

4. A 27-year-old woman comes to the physician because of fever, malaise, abdominal pain, and vaginal discharge for 4 days. Her last menstrual period ended 5 days ago. She had an ectopic pregnancy 1 year ago. Her temperature is 38.3°C (101°F). Abdominal examination shows bilateral lower quadrant tenderness with rebound and guarding. Pelvic examination shows cervical motion tenderness and bilateral adnexal tenderness. Her leukocyte count is 18,000/mm3. A pregnancy test is negative. Which of the following is the most likely diagnosis?
A
) Appendicitis
B
) Bacterial vaginosis
C
) Chancroid
D
) Diverticulitis
E
) Gonorrhea
F
) Herpes genitalis
G
) Trichomoniasis


5. A 62-year-old man develops a pericardial friction rub 3 days after an acute myocardial infarction. Which of the following is the most likely cause of the friction rub?
A
) Cardiac tamponade
B
) Fibrinous pericarditis
C
) Left ventricular failure
D
) Mitral valve prolapse
E
) Purulent pericardial effusion

6. A 40-year-old woman comes to the physician because of a 1-year history of episodes of crampy abdominal pain, intermittent diarrhea, and rectal bleeding with passage of mucus. She is 173 cm (5 ft 8 in) tall and weighs 55 kg (120 lb); BMI is18 kg/m2. Abdominal examination shows diffuse tenderness with no rebound tenderness. Sigmoidoscopy shows a few diffuse ulcers. Which of the following is the most appropriate initial pharmacotherapy for this patient?
A
) Amoxicillin
B
) Bismuth subsalicylate
C
) Loperamide
D
) Octreotide
E
) Sulfasalazine
Is this not UC?

7. A 42-year-old woman comes to the physician because of a 1-month history of abdominal pain, especially after eating fatty meals. She is 180 cm (5 ft 11 in) tall and weighs 100 kg (220 lb); BMI is 31 kg/m2. Physical examination shows jaundice and tenderness of the right upper quadrant of the abdomen. An increase in which of the following liver functions is most likely in this patient?
A
) Cholesterol synthesis
B
) Conjugation of bilirubin
C
) Deamination of amino acids
D
) Glycogen synthesis
E
) Secretion of angiotensinogen
Thanks for the help!