Professional Documents
Culture Documents
Exam section 1:
Ankylosing spondylitis
Child who presents with inflammatory back pain (worse upon waking in morning) with
involvement of sacroiliac joint and decreased flexion at waist (2 features that are highly
associated/specific for ankylosing spondylitis) and elevated ESR (further supporting
inflammatory back pain) with imaging showing vertebral body squaring and fusion of
sacroiliac joint, most consistent with ankylosing spondylitis
Key idea: Back pain that is worse upon waking in morning = Inflammatory back pain
= PAIR diagnoses: Psoriatic arthritis, Ankylosing spondylitis, Inflammatory bowel
disease, Reiter/Reactive arthritis (at least on NBME exams)
Compression fracture
Patient with “indigestion” who has exertional chest pain that is unrelated to eating or
relieved by antacids, racing concern for stable angina that should be worked up by
exercise stress test
Barium swallow
Older woman with dysphagia to solids and liquids with intermittent regurgitation of
undigested food and halitosis, most consistent with achalasia which can be worked up
with barium swallow (or esophageal manometry)
Key idea: Dysphagia to solids AND LIQUIDS is due to problems with esophageal
motility, whereas dysphagia with solids that later leads to dysphagia to liquids more
associated with obstructing mass lesions (cancer, esophageal stricture, etc.) that should be
worked up with endoscopy
Reassurance
Key idea: Normal age for child to begin walking is between 12 and 15 months
Triglycerides
Splenectomy
Pilosebaceous follicles
Key idea: In a patient presenting with hypertension (particularly a child), you always
should start with a trial of lifestyle interventions (playing sports in this patient’s case) before
thinking about using blood pressure medications
Presentation is most consistent with myasthenia gravis (young woman or older man
presenting with dysphagia, dysarthria and eye weakness that is worse at the end of the day),
which is caused by antibodies attacking acetylcholine receptors and leading to reduced
acetylcholine receptors
Decreased release of Ach from motor nerve terminals = Lambert-Eaton syndrome
Degeneration of muscle fibers = Muscular dystrophy
Demyelination of axons
Patient <24 hours after CABG who develops hypotension, decreased urine output,
decreased cardiac output and a widened mediastinum, concerning for mediastinal bleed
Key idea: Post-op patients with acute hemodynamic instability almost always will
require surgical exploration/correction (especially in NBME questions)
Muscle
Young, otherwise healthy man presents with severe flank pain, CVA tenderness and
hematuria with pain that is responsive to morphine, most consistent with kidney stone
Key idea: Patients with a kidney stone that is <10 mm and/or not causing urosepsis
or renal failure can often be medically managed with hydration, pain control, alpha blockers
and straining urine (to look for passage of stone)
Middle-aged woman with CKD (likely due to type 2 diabetes) who presents with
symptoms (fever, cough, abnormal CXR) concerning for pulmonary embolism vs community-
acquired pneumonia (fever, CXR finding) who also has poor oral intake during her hospital
stay; during the course of her hospital stay she receives a CT angiogram to work-up potential
pulmonary embolism and is later found to have an acute kidney injury most likely due to
contrast nephropathy (form of acute tubular necrosis) in the setting of low fluid intake
Key idea: Contrast nephropathy is a feared complication of imaging studies with
contrast, particularly among patients with baseline renal insufficiency (such as this patient), and
many studies have found that IV fluid administration prior to contrast administration can be
useful for decreasing the risk of developing contrast nephropathy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954945/
Thymoma
Young woman + weakness affecting the eyes + anterior mediastinal mass = myasthenia
gravis secondary to thymoma
Key idea: Myasthenia gravis associated with thymoma, whereas Lambert-Eaton
associated with small cell lung cancer
Woman at 37 weeks’ gestation presenting in labor who has history of genital herpes
but currently does not have lesions or prodromal symptoms and therefore can
undergo vaginal delivery
Key idea: Women with history of HSV should begin acyclovir prophylaxis at 36 weeks
gestation and women with active HSV lesions or prodromal symptoms during labor
should have a Cesarean delivery performed
Indomethacin
Urinary stasis
As the uterus enlarges, it can begin to press upon nearby structures, including
the urethra –> Impaired bladder emptying –> urinary stasis –> nidus for infection
Mupirocin ointment
Child abuse
Common injuries highly associated with child abuse include retinal hemorrhages and
intracranial injury (particularly subdural hematoma due to shearing of bridging veins with
violent shaking)
Can also commonly see long-bone spiral fractures or rib fractures, but importantly
the NBME will at times try to trick you by having a parent bring in an infant with a history
incompatible with bone fractures who has osteogenesis imperfecta
Key idea: One of the other presentations is if the parent’s story does not fit known
developmental milestones (saying that a 2 month old rolled off a table when children typically
do not roll until ~4 months)
Decreased calcium
Family therapy
Thoracic aorta
Bipolar disorder
Diabetes insipidus
Patient with recent brain surgery who has developed hypernatremia with dilute urine
and polyuria, consistent with diabetes insipidus (most likely central due to brain surgery)
Causes of central diabetes insipidus (decreased ADH release): Pituitary tumor, trauma,
surgery, autoimmune disease, ischemic event
Causes of Nephrogenic diabetes insipidus (decreased responsiveness of kidney to
ADH): Inherited, hypocalcemia, hypokalemia, lithium, demeclocycline
Note: Excessive ADH production and renal salt wasting would lead to hyponatremia,
0.9% is isotonic (so wouldn’t lead to significant electrolyte changes), and hyperaldosteronism
leads to normal Na+ levels due to aldosterone escape
Operative procedure
Middle-aged woman with potential infectious disease (fever) leading to one week of
uncontrolled hyperglycemia who has signs of orthostatic hypotension (drop in systolic BP
>20 or diastolic BP >10 when moving from sitting to standing) and is found to
have glucosuria, most consistent with intravascular volume depletion due to glucose
acting as an osmotic agent and leading to polyuria
Key idea: Infections often lead to increased insulin requirement by causing
a reactionary hyperglycemia
Middle-aged patient with a history of metastatic breast cancer who presents with triad of
hypotension, jugular venous distention and distant heart sounds who also has electrical
alternans and pericardial effusion, all consistent with a diagnosis of pericardial tamponade
often secondary to breast cancer metastasis to the pericardium
Key idea: Although cardiac tamponade is often confirmed with an echocardiogram, if
your index of suspicion is high you would proceed directly to therapeutic pericardial window
due to significant morbidity/mortality associated with condition
34. A 4-year-old boy has had increasing fatigue since a viral illness…
Key idea: While physicians should be on the look-out for signs of opioid addiction in
patients receiving pain medications, in patients with metastatic cancer to bone it is common
for them to develop tolerance and for the pain to progress, so their requests for increased
pain management are valid and should be managed through a palliative care lens
Mild cancer pain: Acetaminophen, NSAIDs
Moderate cancer pain: Weak opioids (codeine, hydrocodone, tramadol)
Severe cancer pain: Strong short-acting opioids (morphine, hydromorphone) –> Long-
acting opioids (fentanyl, oxycodone) and short-acting opioids for breakthrough pain
37. Two days after beginning ACTH therapy for multiple sclerosis…
Haloperidol
Bilateral varicoceles
Did not have access to media player, but the patient’s presentation is consistent with a
URI
CHF: Cyanosis, delayed capillary refill, etc.
Idiopathic pulmonary hypertension: Lower extremity edema, congestive hepatopathy,
loud P2, RV heave
Pericarditis: Febrile, friction rub, etc.
VSD: Often asymptomatic until later age, will lead to a systolic ejection murmur in the
lower left sternal border
Increased calcium
Young man presents with fever, erythema nodosum (painful, red, tender nodules on
anterior shins) and bilateral hilar fullness, most consistent with sarcoidosis
Key idea: Sarcoidosis (like other forms of granulomatous disease) is associated
with hypercalcemia because of increased activity of 1-alpha hydroxylase leading to
increased production of activated vitamin D –> hypercalcemia, hyperphosphatemia
Ddx for erythema nodosum: Sarcoidosis, Strep infections, tuberculosis, inflammatory
bowel disease, Behcet disease, endemic fungal disease (cocci, histo)
Key idea: If patient has erythema affecting both legs, then cellulitis is virtually ruled
out! (bilateral cellulitis very rare)
T-lymphocyte dysfunction
Young child with non-reactive skin testing for multiple antigens (which is a type 4
hypersensitivity process dependent upon T cells), raising concern for T lymphocyte
dysfunction
Key idea: Patients with HIV can have a falsely-negative PPD in the setting of M.
tuberculosis because they have low T cell function and impaired Type 4 HS reaction
Antibody deficiency = Bruton’s agammaglobulinemia = Recurrent infections with
encapsulated infections
Complement deficiency = Recurrent Neisseria infections
Impaired chemotaxis = Leukocyte adhesion deficiency = Recurrent abscesses without
pus, delayed wound healing, delayed umbilical cord separation
Impaired respiratory burst = chronic granulomatous disease = Recurrent skin abscesses
and infections with catalase positive organisms (Staph, Pseudomonas, Aspergillus, Nocardia,
Serratia, etc.)
Splenic dysfunction (sickle cell disease, trauma patient) = Encapsulated infections (Strep
pneumo, H. influenzae, Neisseria)
Osteoporosis
PCP
Unilateral vision loss + Dilated retinal veins and widespread retinal hemorrhages on
fundoscopy (“blood and thunder” appearance) = Central retinal vein occlusion
Central retinal artery occlusion = Cherry-red spot on fundoscopy
Corneal abrasion = Positive Fluorescein staining, sensitivity to light, pain
Glaucoma = Bilateral lens opacity and glare from lights
HSV conjunctivitis = Dendritic ulcers
Optic neuritis = Optic disk pallor
Exam section 2:
Older man with significant smoking and drinking history who presents with signs
of cerebellar dysfunction (ataxia, wide-based gait), most consistent with alcoholic
cerebellar degeneration (degeneration of Purkinje cells in cerebellar vermis –> Truncal
dyscoordination with impaired gait and postural incoordination with preserved limb coordination)
2. A 27-year-old male physician is inadvertently struck with a…
No treatment necessary
Analgesic therapy
Haemophilus influenzae
Middle-aged man with significant smoking history and signs of pneumonia (fever,
pleuritic chest pain, productive cough, shortness of breath, increased tactile fremitus and
dullness to percussion) who has sputum gram stain showing gram-negative bacilli, most
consistent with H. influenzae
Pseudomonas aeruginosa would also lead to gram-negative bacilli, but would be more
common in a cystic fibrosis patient
N. meningitidus –> Gram-negative cocci
Strep pneumo –> Gram positive diplococci
6. A previously healthy 57-year-old man comes to the emergency…
Young man with exertional syncope who has a systolic ejection murmur at the left
sternal border that increases with decreased preload –> HOCM
Key idea: Only 2 heart murmurs that increase in intensity with decreased preload
(sitting to standing, diuretics, etc.) are HOCM (decreased preload –> increased
obstruction) and Mitral valve prolapse (decreased preload –> less taut chordae tendinae –>
earlier prolapse)
Atropine
Amoxicillin
Young patient with headache, arthritis, fever several weeks after a red rash who has IgM
antibodies (indicator of recent infection) positive for Borrelia burgdorferi, most consistent
with Lyme disease
Lyme disease often treated with doxycycline, but in pregnant women and children it is
often treated with amoxicillin or cefuroxime (due to teratogenic effects of doxycycline)
Osteoarthritis
Older woman without signs of inflammation (no fever, normal ESR) who
has asymmetric groin pain (indicative of hip pathology) with an x-ray showing joint-space
narrowing particularly between the left femoral head and acetabulum, consistent with
osteoarthritis
Pathology in the hip –> Groin pain (HIGH YIELD!!!!)
Features of osteoarthritis –> Joint cysts/osteophyte, subchondral sclerosis, joint-space
narrowing
Carotid endarterectomy
Genital herpes
B lymphocyte
Neutrophil
Botulism
Previously healthy middle-aged woman who had home-canned foods who presents with
GI symptoms, ocular symptoms, and autonomic symptoms with normal deep tendon reflexes,
most consistent with Botulism
Key idea: Adult-onset botulism associated with consumption of canned foods,
whereas infant-onset botulism (floppy baby syndrome) associated with consumption of honey
and exposure to dust (construction site, etc.)
Guillain-Barre syndrome –> Ascending weakness over course of weeks associated with
sensory symptoms and loss of deep tendon reflexes
Myasthenia gravis –> Often does not present acutely, would not present with autonomic
symptoms and history often includes weakness that worsens with continued use, associated
with thymoma
Lambert-Eaton syndrome –> Often does not present acutely, presents with autonomic
dysfunction and diminished/absent deep tendon reflexes, and improves with continued use,
associated with small cell lung cancer
Uterine atony
Patient presenting with preterm labor < 32 weeks: (1) Betamethasone (for fetal lung
development) (2) IV penicillin (if GBS positive or unknown) (3) Magnesium (neuroprotective for
baby) (4) Tocolytic (to stop contractions)
Active labor: Contractions AND cervical changes
C-section would only be indicated if there were signs of intramniotic infection, fetal
instability or maternal instability
Note: Patients should receive intravenous antibiotics rather than oral antibiotics in a
patient who is GBS positive or GBS unknown
Vasovagal syncope
Clomiphene
PCOS patient who does not wish to become pregnant: Dual estrogen-progestin
OCPs
PCOS patient who wants to become pregnant: Clomiphene (antagonists at estrogen
receptors in hypothalamus –> prevents normal feedback inhibition –> increased release of LH
and FSH from pituitary –> stimulates ovulation)
Note: PCOS patients with all types of fertility goals would benefit from weight loss
Enterotoxic Escheria coli
Determine if the patient wants to discuss his decision with anyone else
Key idea: Normal for patients with terminal illness to feel sad about their situation, but
also important to look out for full-blown major depressive disorder
Should not force patient to discuss his plans with family, but important to determine
whether patient would like other important stakeholders to be involved in the discussion
Young patient with atraumatic elbow pain holding extremity with elbow flexion and
forearm in pronation with no obvious signs of injury, which is most consistent with a Radial
head subluxation (Nursemaid’s elbow) which commonly occurs when young children have
their arm pulled and the radial head gets trapped beneath the annular ligament
Key idea: Can be treated by hyperpronation of forearm or by supination of forearm
with flexion of elbow
26. A 7-year-old boy is brought for an examination prior to a…
Viridans streptococci
Key idea: Patients with abnormal heart valves are prone to developing endocarditis
during periods of bacteremia, with dental work and toothbrushing leading to transient
bacteremia with Viridans streptococci
Key idea: Staph aureus (IVDU, bacteremia) leads to acute endocarditis (days),
whereas Viridans streptococci (dental work) leads to subacute endocarditis (weeks)
Atrophic gastritis
https://www.m
emorangapp.com/flashcards/130443/USMLERx/
28. A previously healthy 47-year-old man comes to the physician…
Fibrillation potentials in multiple muscles of multiple extremities
Young man with chronic weakness who has UMN lesions (Babinski sign) and LMN
lesions (atrophy, fibrillations), most consistent with amyotrophic lateral sclerosis (ALS),
which leads to fibrillation potential in multiple muscles on electromyography
Key idea: ALS often presents with weakness in hands, difficulty swallowing (like in this
patient), and changes to voice
Pneumococcal vaccine
Additional vaccination requirements for patients with HIV include (1) Vaccination for
hepatitis B unless they have documented immunity (2) Strep Pneumo PCV13 followed by
the 23-valent PPSV23 8 weeks later and again in 5 years and at age 65 (3) Meningococcal
vaccine with boosters every 5 years
Note: Patients should receive one Tdap vaccine as an adult followed by boosters every
10 years
Key idea: Patient is displaying normal teenager behavior and her symptoms are not
causing her distress or leading to societally-inappropriate behavior (causing fires,
stealing, etc.)
Decreased potassium
Key idea: Digoxin toxicity can lead to premature PVCs (along with other
arrhythmias), with digoxin toxicity being more prevalent in setting of hypokalemia (less
potassium to compete with digoxin for binding to the Na/K ATPase)
Increased calcium
Metastatic breast cancer –> Bone involvement –> Hypercalcemia –> Hypercalcemic
crisis –> Oliguria/anuria and mental status changes (somnolence or coma)
Key idea: Hypercalcemic crisis often only seen when calcium levels are > 14 mg/dL,
and calcium levels often do not reach levels > 14 mg/dL except for in setting of malignancy
Middle-aged woman with recent lap chole presenting with five days of fever, jaundice,
and RUQ tenderness with labs showing a leukocytosis with cholestatic pattern (Alkaline
phosphatase >> AST), most concerning for acute cholangitis that needs to be rapidly
evaluated with an ERCP (associated with significant morbidity/mortality)
Key idea: Acute cholangitis –> Fever, jaundice, RUQ pain (Charcot’s triad) +
hypotension, altered mental status (Reynold’s pentad)
Key idea: Even though patient has had cholecystectomy, they can still develop acute
cholangitis due to a residual stone in the common bile duct or a retained gallstone in the
cystic duct stump
Urethral diverticulum
Woman with urinary incontinence exclusively after voiding found to have a cystic, tender
mass in the vagina and a low post-void residual volume, suggestive of a urethral diverticulum
Interstitial cystitis: Discomfort/pain in bladder + Urinary frequency/urgency
Vesicovaginal fistula: Continuous loss of urine with clear fluid found in the vagina
https://www.youtube.com/watch?
v=OsvxoMl62q8
35. An 8-hour-old newborn develops jaundice and respiratory…
Rh incompatibility
Key idea: Patients with symptoms of GERD who are under 50 years old with
symptoms for <5 years, no cancer risk factors and no alarm symptoms (melena,
hematemesis, weight loss, anemia, dysphagia/odynophagia, etc.) should receive a trial of PPI
therapy
Key idea: Patients who are 50+ years old with symptoms for >5 years or cancer risk
factors or alarm symptoms would first receive an endoscopy
Wound dehiscence
Alveolar hypoventilation
Young patient with known heroin use who presents with altered mental status and
hypoventilation, most consistent with heroin overdose
Opioid overdose should be treated immediately with naloxone (short-acting opioid
receptor antagonist), and use medications such as naltrexone (long-acting opioid
antagonists), methadone (long-acting opiate) or buprenorphine (partial opioid agonist) to
prevent relapse
Flumazenil –> Benzodiazepine overdose
Patient with severe pancreatitis who develops hypoxia, hypotension with elevated right-
sided pressures and normal left-sided pressures and a severely increased A-a gradient, most
consistent with acute respiratory distress syndrome
PAO2 = (713 x 0.6) – (PaCO2/0.8) = 428 – (38/0.8) = 428 – 48 = 380 >> 12 –>
Increased A-a gradient
Congestive heart failure –> Decreased cardiac index and increased PCWP
Causes of ARDS: Sepsis, aspiration, pneumonia, trauma, pancreatitis
Heat stroke
Methamphetamine is associated with a sensation of insects crawling on the skin –> skin
picking
Technical term is delusional parasitosis
Renal ultrasonography
Middle-aged woman with a recent GU surgery who develops a significant AKI with a
BUN:creatinine ratio < 15 with a bland urinalysis, most concerning for a post-renal AKI
secondary to ureteral damage, which would be worked-up with a renal ultrasound looking
for hydronephrosis
Key idea: GU surgeries in women are highly associated with damage to the ureters,
which can lead to a post-renal AKI (VERY HIGH YIELD FOR NBME EXAMS!)
Diuretic therapy
Cricothyrotomy
Exam section 3:
Costochondritis
Patient with history of increased activity + localized pain to the anterior chest
that worsens with movement, deep inspiration and cough + Tenderness to palpation of
affected area = Costochondritis
Key idea: Self-limiting over a matter of weeks, but may persist for up to a year
Cor pulmonale
Patient with progressive dyspnea with signs of right-sided heart failure (JVD, ascites,
pitting edema but no pulmonary edema) and a history of DVT/PE, most consistent with cor
pulmonale secondary to Group 4 pulmonary hypertension
Group 1 pulmonary hypertension = Pulmonary arterial hypertension (pre-capillary)
[familial, toxins, connective tissue disease, etc.]
Group 2 PH: Left-sided heart failure
Group 3 PH: Chronic lung disease (COPD, OSA, asthma, etc.)
Group 4 PH: Chronic thromboembolic disease
Group 5 PH: Other causes [anemia, sarcoidosis, etc.]
Aortic stenosis or Mitral regurgitation = Systolic murmur on exam
Ischemic heart disease = Chest pain vs heart failure (pulmonary edema on chest x-ray)
Viral cardiomyopathy = Acute dyspnea, chest pain, fever
Patient who experienced a stressful event 1 week ago who has experienced auditory
hallucinations of a somebody who was not killed, most consistent with brief psychotic
disorder
Key idea: Bereavement can lead to auditory hallucinations from the decesased, but
should not lead to such a decline in functioning as is seen in this vignette
Symptoms of psychosis: Delusions, hallucinations, disorganized speech,
disorganized/catatonic behavior, negative symptoms (flat affect, etc.)
Brief psychotic disorder: At least 1 positive symptom for less than 1 month (often
associated with stress)
Schizophreniform disorder: At least 2 psychosis symptoms for 1 month with decline
in functioning between 1 month to 6 months
Schizophrenia: At least 2 psychosis symptoms for 1 month with decline in
functioning for at least 6 months
Psychogenic polydipsia
Older patient who has been drinking 12-15 glasses of water daily and has a history
of schizoaffective disorder found to have hyponatremia with low urine sodium and low
urine osmolality, most consistent with psychogenic polydipsia
Key idea: Despite UWorld claims, urine osmolality does NOT need to be below 100 to
diagnose psychogenic polydipsia
Key idea: Antipsychotics can commonly lead to dry mouth (as is seen in this patient),
making a patient feel thirsty
Cesarean delivery
Bromocriptine therapy
Intravenous labetalol
Older male patient with tearing chest pain radiating to the pack, different upper
extremity blood pressures, aortic regurgitation murmur and a widened mediastinum on
CXR, all of which are consistent with aortic dissection
Key idea: Beta-blockers (such as labetalol) are particularly useful in setting of aortic
dissection because the force of blood being ejected from the LV and hitting the aorta can further
propagate the tear, with beta blockers leading to reduced contractility and reduced force of
blood ejection against the aorta
Colonoscopy
Key idea: Patients get their first screening colonoscopy at 50 years old, so in this patient
with bowel changes (constipation) and anemia (which cannot be fully explained by
hemorrhoids), the next best step would be a colonoscopy
C1 esterase inhibitor
16. An 18-year-old woman has had fever for 12 hours and obtundation…
Meningococcemia
Young woman who has been in a confined space with others (summer camp, college,
etc.) who presents with fever, altered mental status, hypotension and purpuric skin
lesions, most consistent with meningococcemia
Toxic shock syndrome –> Diffuse erythroderma
Lyme disease –> Erythema chronica migrans (“bulls-eye rash”)
17. Three days after open reduction and internal fixation of a right…
Duplex scan
Patient with recent surgery who presents with tightness/tenderness of the left calf,
most concerning for a DVT (which should be worked-up with a duplex ultrasound)
https://en.wikip
edia.org/wiki/Virchow%27s_triad
18. A 15-year-old girl is brought to the physician because of finger…
Young female patient with arthritis, malar rash, decreased hemoglobin and WBC count,
low complement, positive ANA and urinalysis consistent with a glomerulonephritis, most
consistent with systemic lupus erythematous
Mixed connective tissue disease: Autoimmune disease with variable features of SLE,
systemic sclerosis and polymyositis that is characterized by Raynaud phenomenon, dactylitis,
arthritis and inflammatory myopathy +/- other features
Aspirin
Patient who attempted an overdose who has a mixed anion-gap metabolic acidosis
(140 – 104 – 6 = 30 > 12) with a significant respiratory alkalosis, most consistent
with aspirin/salicylate poisoning
Number of yes answers needed for positive test moves from 2 –> 1 will lead
to decreased false negatives (increased sensitivity) and increased false
positives (decreased specificity)
Key idea: Low false negative –> high sensitivity (of patients with disease, how many test
positive), whereas low false positive –> high specificity (of patients without disease, how many
test negative)
Vitamin B1 (thiamine)
Acute cholecystitis
Patient with sickle cell disease presenting with fever, RUQ pain, mild scleral icterus
and positive Murphy sign (specific for acute cholecystitis on NBME exams) with an
ultrasound showing cholelithiasis and pericholecystic fluid, most consistent with acute
cholecystitis
Key idea: Acute cholecystitis classically does NOT lead to jaundice or
hyperbilirubinemia, but this patient has another reason to have jaundice because sickle cell
disease –> chronic hemolysis –> unconjugated hyperbilirubinemia
Risk factors for cholesterol gallstones: Female, Fat, Forty, Fertile
Risk factors for bilirubin gallstones –> Chronic hemolysis
Cholangitis –> Negative Murphy sign, signs of cholestasis (alkaline phosphatase >
ALT/AST), dilated common bile duct
Cardiogenic shock
Patient with a major aortic injury who presents with decreased cardiac index,
hypotension, increased pulmonary capillary wedge pressure, increased CVP and
increased PA pressure with ECG changes most consistent with cardiogenic shock
Distributive shock (sepsis, anaphylaxis) –> Increased cardiac index, decreased PCWP,
decreased SVR
Hypovolemic shock –> Decreased cardiac index, decreased PCWP, increased SVR
CHF –> Pulmonary edema, lower extremity edema, elevated JVP, etc.
Physiologic discharge
Aortic stenosis
32. A 42-year-old man has had a pruritic rash on his back for 4 days…
https://dermnet
nz.org/topics/cutaneous-larva-migrans/
33. A 72-year-old woman comes to the physician because of an increase…
Exploratory laparotomy
Older woman with history of breast cancer found to have increasing abdominal girth,
ascites and a fixed non-tender adnexal mass most concerning for ovarian cancer
Key idea: Advanced ovarian cancer often spreads to the abdominal cavity,
so exploratory laparotomy with cancer resection and inspection is needed for surgical
staging
Key idea: Image-guided biopsy is contraindicated, as it can predispose to abdominal
cavity seeding
Key idea: Ascites in a postmenopausal woman is always pathologic and is the origin
of the typical symptoms of early satiety, weight gain, etc. seen in advanced ovarian cancer
34. Three days after hospitalization for treatment of severe muscle weakness…
Patient with severe muscle weakness who has developed fever, hypoxia, new
infiltrates in the middle/lower lobes and a polymicrobial infection via bronchoscopy, most
consistent with aspiration pneumonia
35. A 67-year old man comes to the physician because of easy fatigability…
Streptococcus pneumoniae
Intravenous penicillin G
37. A 14-year-old boy who has sickle cell trait is brought to the emergency…
Young patient with sickle cell trait presenting with 1-day of atraumatic thigh and knee
pain with limited hip range of motion, concerning for avascular necrosis of the left hip
Causes of avascular necrosis: CASTS Bent LEGS (Corticosteroids, Alcohol, Sickle
cell disease, Trauma, SLE, “the Bends”, LEgg-Calve-Perthes disease, Gaucher disease, SCFE
Older patient with dementia, decreased DTRs, non-pitting edema of the lower
extremities and slow movements, most consistent with hypothyroidism
Huntington disease –> Dementia, depression, chorea
Multi-infarct (vascular) dementia –> Step-wise dementia with focal neurologic defects
(weakness, sensation, etc.)
Pernicious anemia –> Atrophic gastritis + B12 deficiency (lower extremity weakness,
paresthesias, sensory disturbances, etc.)
Syphilis –> Lymphadenopathy, diffuse rash involving the palms and soles
Lorazepam therapy
Patient with a recent surgery who develops dyspnea, decreased localized breath
sounds, and a leukocytosis most concerning for a hospital-acquired pneumonia, which should
be worked-up with chest x-ray
Pulmonary angiography (pulmonary embolism): Tachycardia, signs of DVT, hemoptysis,
etc.
Key idea: Important to rule out multiple masses, as that could affect surgical
approach/management
Previously healthy young woman with dysphagia to solids and liquids with upper
endoscopy showing retained secretions in the esophagus with barium swallow showing “bird’s
beak sign”, all of which is most consistent with achalasia
Key idea: Achalasia characterized by absence of esophageal peristalsis and
impaired relaxation of lower esophageal sphincter
43. Three days after undergoing total hip replacement, a 50-year-old…
Epidural hematoma
Patient who recently had an epidural catheter removed who has developed inability to
move his legs and urinary incontinence, most consistent with an epidural hematoma –>
spinal cord compression –> lower extremity weakness and overflow incontinence due to
impaired bladder contraction
Femoropopliteal arteries
Reassurance
Otherwise healthy woman with an atraumatic, asymptomatic red eye upon waking, most
consistent with subconjunctival hemorrhage
Key idea: Often results due to simple trauma from rubbing eyes vigorously and violent
coughing spells, but on NBME often apparent upon waking
Key idea: Managed by observation because it typically resolves within 24-48 hours
Exam section 4:
1: An 82-year-old man with congestive heart failure (CHF) comes to the
physician…
CHF patient with increased diuretic dosage –> Too much fluid is pulled off –> Decreased
effective circulating volume –> AKI (pre-renal, acute tubular necrosis)
Key idea: When taking care of a patient with decompensated heart failure, important to
balance correcting volume overload with risk of causing an AKI
Older man presenting with acute substernal chest pain radiating to his left arm
(classic for MI), diaphoresis and an EKG showing ST elevation in leads 1, V2-V6, consistent
with an anterior MI (left anterior descending involvement)
Ventricular tachycardia
Older woman with known CAD who presents with acute chest pain, weakness and
dyspnea who is found to be hypotensive with an ECG with a rate of 150 (2 big boxes b/w
QRS complexes) and a wide QRS (>120 ms), most consistent with ventricular tachycardia
likely secondary to coronary ischemia
Schizophrenia
Young male patient (perfect demographic for onset of schizophrenia) who presents
with 1 year of auditory hallucinations and negative symptoms, most consistent with
schizophrenia
TSH is normal, so patient would not have psychosis secondary to thyroid dysfunction //
Urine toxicology is normal so would not be substance-induced psychotic disorder
Brief psychotic disorder: 3 days to 1 month
Schizophreniform disorder: 1 month to 6 months
Schizophrenia: >6 months
Dopamine
Previously healthy child with 2 day history of a “slapped cheek” rash that has spread to
the reset of the body, low-grade fever and malaise, most consistent with Parvovirus
B19 which is not treated with medication
Key idea: Although Parvovirus most associated with “slapped cheek” rash, it also can
lead to reticular, erythematous rash on their extremities and trunk
Reminder: Parvovirus B19 associated with development of aplastic anemia
Patient who is asymptomatic with a hiatal hernia that can be managed with observation
Key idea: Patients with a symptomatic hiatal hernia (GERD), should be treated
with PPIs or H2 blockers
Olanzapine therapy
Young male patient (classic demographic for schizophrenia) with history of marijuana
use (which increases risk for development of schizophrenia) who presents with 1-month of
delusions (contaminated food), auditory hallucinations and impaired functioning (school
performance deteriorated), most consistent with schizophreniform disorder –> Treat with
antipsychotic (of which olanzapine is the only one listed)
Appendicitis
Young woman with 2-day history of fever, nausea/vomiting, RLQ abdominal pain with
rebound and a neutrophilic leukocytosis, most consistent with acute appendicitis
Negative ultrasound for adnexal mass –> Not adnexal torsion, corpus luteum cyst,
degenerating leiomyoma uteri, tubo-ovarian abscess, etc.
Interferon-alfa
Abruptio placentae
15. A 16-year-old girl has had increasingly severe abdominal pain for 2 days…
Adolescent girl who is sexually active with inconsistent contraceptive use who presents
with fever, pharyngeal erythema and tenderness in the RLQ with cervical motion tenderness
and a negative pregnancy test, most consistent with pelvic inflammatory disease (with likely
gonorrhea co-infection of the throat)
Cervical motion tenderness: Pelvic inflammatory disease or ectopic pregnancy
(negative pregnancy test rules it out)
Disseminated gonococcemia: Dermatitis, oligoarthritis, and enthesitis OR
monoarticular septic arthritis
Pleural metastases
Middle aged woman with history of breast cancer presenting with subacute dyspnea on
exertion with dullness to percussion over the lower half of the right lung (consistent with pleural
effusion) with no other sides of volume overload, most consistent with pleural effusion
secondary to metastatic carcinoma
Pericardial tamponade: Hypotension, jugular venous distention, distant heart sounds,
pulsus paradoxus
RLL pneumonia: Fever, cough, etc.
17. A 56-year-old woman with short-bowel syndrome caused by mesenteric…
Zinc
Young previously healthy woman with a large (>1 cm), firm supraclavicular lymph
node and splenomegaly, most consistent with Hodgkin lymphoma (which is associated
with an increased LDH)
Key idea: Enlarged supraclavicular lymph node is never normal!
Key idea: Hodgkin lymphoma also commonly associated with pruritis (particularly on
the NBME exam)
19. A 6-week-old boy is brought to the physician for his first well-child
examination…
6 week old newborn who had a difficult delivery via forceps who now has his head
rotated to the left with contralateral chin deviation with a nontender mass in the right
side of the neck, most consistent with torticollis
Torticollis: Neck mass + ipsilateral head tilt + contralateral chin deviation
https://www.correctivechiropractic.co
m/blog/can-chiropractic-help-torticollis-infants-children/
20. A 3-year-old girl is brought to the emergency department after her father…
Organophosphate
Young child who was unsupervised with chemicals and presents with cyanosis,
diaphoresis, miosis, rhinorrhea, drooling, signs of bronchoconstriction, and increased bowel
sounds, all of which is associated with organophosphate poisoning –> Decreased
acetylcholinesterase activity –> Increased acetylcholine –> Increased parasympathetic
functions, increased sweating, muscle paralysis (due to repetitive stimulation)
Key idea: Treated with atropine (muscarinic receptor antagonist)
and pralidoxime (regenerates acetylcholinesterase)
Lead poisoning would not present acutely
Ethylene glycol –> Anion-gap metabolic acidosis and kidney injury (classically renal
stone)
Carbon monoxide poisoning –> Cherry-red skin, head, altered mental status
Magnesium sulfate
Woman with history of preterm labor who presents with preterm labor (contractions AND
cervical changes) at 28 weeks’ gestation and therefore should receive (1) Betamethasone
(promote lung development) (2) Magnesium sulfate (neuroprotective for baby, tocolytic
effects (3) Tocolytics (4) IV Penicillin if GBS positive or unknown
Delivery at <32 weeks: See above
Delivery at 32-34: (1) Betamethasone (promote lung development) (2) Tocolytics (3) IV
penicillin if GBS positive or unknown
Delivery at 34-37: (1) Betamethasone (promote lung development) (2) IV penicillin if
GBS positive or unknown
22. A male newborn has bilateral clubfoot deformity. He was born at term
following…
Spinal dysraphism
Male newborn who has lower limb paralysis and numbness with a full bladder, most
consistent with a spinal cord injury affecting the lower extremities
Spinal dysraphism = Type of neural tube defect
Cerebral palsy: Delayed motor milestones, comorbid seizures/intellectual disability,
abnormal muscle tone
Muscular dystrophy: Waddling gait, hip weakness, Gower sign in a toddler
Young woman with subacute palpitations, anxiety, weight loss, heat intolerance,
diarrhea, lid lag and exophthalmos with a large, nontender thyroid gland with diffuse
increased uptake and low TSH with increased T4 levels, most consistent with Graves’
disease
Graves disease and other forms of hyperthyroidism should be treated
with propylthiouracil or methimazole
Key idea: All causes of hyperthyroidism can lead to lid lag and lid
retraction secondary to sympathetic activation of the superior tarsal muscle, but Graves
specifically leads to exophthalmos and impaired extra-ocular motion due to
glycosaminoglycan deposition behind the eyes
https://www.aa
fp.org/afp/2016/0301/p363.html
24. A 42-year-old woman is brought to the emergency department because of…
Optic neuritis
Hypovolemia
Patient with a 3-day history of profuse nausea/vomiting after significant alcohol
consumption who now presents with abdominal pain, hypotension, tachycardia and cool/clammy
skin, most consistent with hypovolemic shock
Cardiogenic shock: Signs of volume overload (jugular venous distention, lower
extremity edema, etc.)
Septic shock: Could be seen if patient had sign of perforation (guarding,
rebound) and patient would likely have warm and dry skin (because cardiac output is
normal/increased and peripheral arterioles are dilated)
26. An otherwise healthy 37-year-old man comes to the physician because of…
Spondylolisthesis
Viral pleurisy
Previously healthy young patient presenting with severe pleuritic chest pain, shortness-
of-breath, mild fever and a faint erythematous rash, consistent with a viral syndrome leading
to viral pleurisy and a viral exanthem
Key idea: Pleural friction rub = Pleural inflammation = Pleurisy (similar to how
pericardial friction rub = pericarditis)
Pill-induced esophagitis
Patient who has been taking ibuprofen (NSAIDs) who presents with painful swallowing
with no other findings, most concerning for pill-induced esophagitis
Causes of pill-induced esophagitis: Tetracyclines, Bisphosphonates, potassium
chloride, NSAIDs, Iron
Zenker diverticulum: Older patient with halitosis, regurgitation of food +/- palpable neck
mass
Colposcopy
Negative pap smear: Repeat screen in 3 years (or 5 years with HPV co-testing in
women 30-65 years old)
Atypical squamous cells of undetermined significance (ASCUS): Either perform
HPV testing or repeat pap within 6 months
Abnormal pap smear (LSIL or worse): Confirmatory colposcopy –> Cryotherapy or
loop electrosurgical excision procedure (LEEP) if patient has local ectocervical disease vs.
Cone biopsy if patient has local endocervical disease
Child with strep throat (throat culture and increased ASO titer) who presents with joint
pain and a new 3/6 holosystolic murmur at the midclavicular line, most consistent
with mitral valve regurgitation caused by rheumatic heart disease
Rheumatic heart disease: JONES criteria (Joint pain, O for heart (endocarditis,
myocarditis, pericarditis), subcutaneous Nodules, Erythema marginatum, and Sydenham chorea
Systolic murmurs (left-sided): Aortic stenosis vs mitral regurgitation
33. A 4-year-old boy develops chickenpox 8 hours after visiting her newborn…
No intervention is necessary
34. An 87-year-old man comes to the physician because of a 1-year history of…
Finasteride
Older man with nocturia, hesitancy, and uncontrollable leaking after the end of urination
who is found to have an enlarged prostate on exam, most consistent with benign prostatic
hyperplasia
2 potential treatments are (1) 5-alpha reductase inhibitors (finasteride, dutasteride):
Lead to reduced conversion of testosterone –> DHT –> Less BPH over the course of
months (2) Alpha-1 selective inhibitors (-zosin and tamsulosin): Relaxation of the bladder
internal sphincter –> less urethral resistance when voiding
Key idea: -zosin drugs (NOT TAMSULOSIN) also have blood pressure effects
(because alpha-1 receptors lead to arteriolar constriction) and commonly lead
to orthostatic hypotension and dizziness, so in this patient with orthostatic hypotension
due to autonomic dysfunction, we would opt for tamsulosin or a 5-alpha reductase inhibitor
35. A 67-year-old man has had an ulcer on the anterior surface of the leg just
above…
Elderly patient with previous mitral valve dysfunction and history of CHF who presents
with bilateral lower extremity edema and an ulcer on the lower medial extremity, most
consistent with a venous stasis ulcer
3 main types of lower extremity ulcers include (1) Neuropathic ulcers: Seen in diabetic
patient, occur on the sole of the foot especially where lots of pressure is placed while walking
(such as proximal to big toe) (2) Arterial ulcers: Patient with signs of peripheral vascular
disease (claudication, shiny hairless legs) who has ulcer with necrosis often at tips of the toes
(3) Venous ulcers: Often seen in patient with chronic lower extremity edema and leads to
ulceration on the medial aspect of the leg
36. A study is proposed to assess the effectiveness of a new vaccine for the
prevention…
37. A previously healthy 67-year-old man has had an aching burning sensation
in…
Bronchogenic carcinoma
Older patient with clubbing and painful arthropathy of large joints in the lower
extremity relieved by elevation, most consistent with hypertrophic pulmonary
osteoarthropathy secondary to lung cancer
Key idea: Next best step would be chest x-ray to look for lung cancer
Elderly man with vasculopathic risk factors (elevated cholesterol, type 2 diabetes) who
presents with transient blindness of the left eye (suggestive of amaurosis fugax due to
embolic phenomenon ipsilaterally on the left side) and an episode of aphasia (suggestive of
embolic phenomenon affecting the left side of the brain where Broca’s area is located) also
found to have a Hollenhorst plaque in the left eye, all of which is consistent with carotid artery
stenosis of the left internal carotid artery throwing off small plaques
Key idea: Internal carotid artery will become the anterior cerebral artery and the
middle cerebral artery
Key idea: Amaurosis fugax is highly associated with carotid artery stenosis and is due to
occlusion of the ophthalmic artery, which is the first branch off the INTERNAL carotid
artery
Radiation therapy
Older woman with known history of metastatic breast cancer (lymph node
positive) who presents with progressive back pain with lower extremity UMN weakness
(positive Babinski, brink reflexes) and lower extremity numbness/tingling, concerning for
metastases to the vertebral bodies leading to spinal cord compression
Key idea: Bone metastatic disease should be managed with radiation therapy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5421962/
Observation
Vancomycin
These patients have a small thyroid because chronically low TSH leads to low levels of
thyroid stimulation and have low iodine uptake into the thyroid because the thyroid is not
actively producing thyroid hormone (thyroid hormone is coming into body exogenously)
Key idea: We would expect this patient to have low TSH because of negative feedback
of exogenous T3/T4 upon anterior pituitary
Ophthalmic examination is normal = Not Graves disease
https://www.aa
fp.org/afp/2016/0301/p363.html
43. A 55-year-old man comes to the physician because of fever, neck pain, and…
Viral infection
44. A 7-month-old boy is brought to the physician because of a 4-day history of…
Wiskott-Aldrich syndrome
46. A health status survey compares the clinical outcomes of patients treated…
Process of elimination: Study period of 1 year does not seem short, results are
significant (p < 0.05), study is likely well-powered with sample size >500 and the focus of the
study is clinical (physical functioning, mobility)