20 Questions = 16 written by me + 4 from The New Free 120

Goal is to spend roughly 5 minutes/question

Poll from the audience. Then I’ll discuss it and answer questions.
Q1
A previously healthy 65 yo male comes to the physician because of a 7 month history of progressively
worsening exertional dyspnea, dry cough, and fatigue. At the age of 57, he had a colonoscopy that was
unremarkable. He worked as a shipyard manager before retiring 6 years ago. He has no history of serious
illness and takes a daily multivitamin. He smoked half a pack of cigarettes in college but stopped after he
got married. His pulse is 92/min and regular, respirations are 21/min, and blood pressure is 135/85.
Examination shows perioral cyanosis and digital clubbing with bibasilar soft, fine crackles heard on lung
auscultation. On cardiac exam, a faint systolic sound is heard at the right second intercostal space. There
is 2+ bilateral lower extremity edema. Chest X-Ray is notable for prominent, reticular interstitial
markings at the lung bases with reduced lung volumes. Which of the following is the most likely finding
on further diagnostic imaging in this patient?

a. Upper lobe cavitary infiltrate with an ipsilateral pleural effusion

b. Ground glass opacification with honeycombing and traction bronchiectasis
c. Pleural thickening with associated calcifications and lower lobe predominant fibrosis
d. Diffuse interstitial infiltrates with bilateral hilar adenopathy
e. Rightward shift of mediastinal structures with increased left lung radiolucency
f. Lobar consolidation with loss of interstitial lung markings

Q2
A 59 year old female is brought to the emergency department for acute onset dyspnea, palpitations, and
shortness of breath. Her symptoms began shortly after she received news that she was furloughed from
her job as a store manager. She had an upper respiratory infection three years ago that resolved without
antibiotic therapy. She is otherwise healthy and takes no daily medications. Her vaccinations are up to
date. On physical examination, the patient has a temperature of 98.6F, blood pressure is 155/80, and pulse
is 89/min. There is no heart murmur and the lungs are clear to auscultation. Lab studies are significant for
a serum troponin of 3.4 ng/ml (nl < 0.4ng/ml). An obtained EKG demonstrates normal sinus rhythm with
non-specific acute T wave changes. Immediate cardiac catheterization shows normal coronary arteries. A
systolic ventriculogram is shown below.

From LIFTL.com
Which of the following is the most likely diagnosis?
a. Non ST elevation myocardial infarction.
b. Acute viral myocarditis.
c. Takotsubo cardiomyopathy.
d. Variant (formerly Prinzmetal) angina
e. Tachycardia induced cardiomyopathy

Q3
A 29 year old female is evaluated in the hospital for worsening symptoms of asthma. She was initially
evaluated 4 days ago in the emergency department for dyspnea with wheezing, chest tightness, and
profound respiratory difficulty. Symptoms persisted despite use of multiple courses of an albuterol inhaler
and parenteral methylprednisolone which necessitated hospitalization. She has a 12 year history of asthma
and typically has multiple exacerbations every year that require prolonged use of oral corticosteroids.
Current medications are albuterol and budesonide/formoterol inhalers, prednisone, and zafirlukast. On
physical examination, blood pressure is 125/93 mm Hg, pulse rate is 99/min, and respiratory rate is
21/min. Oxygen saturation is 100% on 2L/min of oxygen delivered by nasal cannula. BMI is 27. Chest
examination demonstrates a monotone wheeze on inspiration with a prolonged expiratory phase. Lab
studies including a comprehensive metabolic panel, complete blood count, and serum IgE are within
normal limits. Chest radiograph and pulmonary lab spirometry is normal. Which of the following
represents the most appropriate next step in management?
a. Increase dose of daily prednisone
b. Add theophylline to her current regimen
c. Laryngoscopy
d. Polysomnography
e. CT scan of the sinuses

Q4
A 69 yo M is evaluated for new onset abdominal pain and fever. He was brought to the hospital 6 days
earlier with worsening mental status changes. In the emergency room, he was profoundly hypotensive and
tachycardic which necessitated ICU transfer. He was diagnosed with and treated for pneumococcal sepsis
and became hemodynamically stable 2 days after Cefepime therapy and judicious normal saline
administration. He has a history of hyperlipidemia, type 2 diabetes, and moderate hypertension. His
medications are cefepime, rosuvastatin, enalapril, insulin aspart, and insulin detemir. On physical exam,
the patient is alert. T is 102.1, blood pressure is 92/55 mmHg, pulse is 121/min, and respiratory rate is
25/minute. Abdominal exam is notable for significant tenderness on palpation of the right upper quadrant.
Lab studies reveal a leukocyte count of 17500/uL and a total serum bilirubin of 0.8 g/dL. An ultrasound
obtained confirms the diagnosis. Which of the following represents the most appropriate next step in
management?
a. Placement of a cholecystostomy tube.
b. Magnetic Resonance Cholangiopancreatography
c. Endoscopic ultrasound with biopsy
d. Hepatobiliary iminodiacetic acid scan
e. Ultrasound examination of the right upper quadrant
f. Endoscopic retrograde cholangiopancreatography

Q5
A 42 year old male in hospice is being evaluated for clinical depression. He was diagnosed with widely
metastatic colon cancer 3 years ago and has undergone 4 rounds of combination chemotherapy, 1 round
of immunotherapy, and radiotherapy. CT of the abdomen and pelvis is consistent with multiple
hypodense lesions in the right and left hepatic lobe. Recent discussions with his oncologist and palliative
care team indicate a life expectancy measured in weeks. On physical exam, the patient demonstrates
extensive lower extremity weakness and fatigue. He is unable to recall 3 words after 5 minutes and has
difficulty with serial 7s. He has a flat affect and according to his home health aide, is withdrawn and
tearful in the mornings. Previously hopeful after positive results from immunotherapy, the patient now
reports feeling worthless and hopeless. When asked about his mood, he states: “I am a burden to my
family and friends, they shouldn’t have to suffer because of my cancer”. Current medications include
patient controlled hydromorphone, oxycodone, dronabinol, polyethylene glycol, and eszopiclone. Which
of the following represents the most appropriate next step in management?
a. Fluoxetine
b. Cognitive behavioral therapy
c. No treatment given the patient’s terminal course
d. Methylphenidate
e. Sertraline

Q6
A 69 year old male presents to the emergency department with a 2 month history of generalized pruritus
and anorexia. He has lost 23 Lbs over this period. Physical exam is notable for a generalized yellowing of
his skin. Computed tomography of the abdomen and pelvis with intravenous contrast shows multiple
enhancements in the body and tail of the pancreas with lesions encasing the superior mesenteric artery.
The patient appears sad as the physician discusses his prognosis and life expectancy. He requests that the
physician not tell his wife to whom he has been married for 40 years. During rounds the next morning, the
physician is accosted by the patient’s wife. “What is wrong with my husband? He seems moody and has
not said anything to me”. What is the best physician response in this scenario?

a. “I’m sorry but I cannot discuss your husband’s condition with you”
b. “Your husband unfortunately has a life limiting illness with a poor prognosis, please keep the
details of this conversation private”
c. “Your husband is fully informed about his health issues, he can tell you anything he feels you
need to know”
d. “Tell me more about why you want to know your husband’s diagnosis”
e. “Let me speak to the risk management committee, I’ll get back to you this afternoon”

Q7
A 45-year-old woman with a history of renal transplantation presents with a 3 day history of profuse non-
bloody diarrhea, abdominal pain, and high fevers. She received her kidney transplant 7 years ago from a
living, unrelated donor for polycystic kidney disease and has since had only one episode of rejection. Her
donor was cytomegalovirus (CMV) IgG negative, and she was CMV IgG positive before the transplant.
Her chronic medications include low dose prednisone, cyclosporine, and mycophenolate mofetil which
has been unchanged for the last 6 years. She recently got a job as a research coordinator at a major
academic institution and has been working with hamsters. There is diffuse tenderness to palpation of the
abdomen on physical exam. She has a fever to 103, heart rate 62/min, blood pressure 149/77, and a
moderate leukocytosis. Which of the following is the most likely diagnosis?
a. Irritable bowel syndrome
b. Salmonellosis
c. Medication side effect
d. Transplant related Crohn’s disease
e. Norovirus Gastroenteritis
f. Cytomegalovirus Colitis

Q8
A 79 year old man presents with several months of epigastric pain, weight loss, dyspnea on exertion, and
fatigue. The patient was diagnosed with autoimmune gastritis 7 years ago and has been receiving weekly
Vitamin B12 injections. He had a colonoscopy 3 years ago that was notable for extensive sigmoid
diverticulosis. His comprehensive metabolic panel from today reveals a hematocrit of 21% and a mean
corpuscular volume (MCV) of 69 fl. Which of the following malignancies is most likely responsible for
his symptoms?
a. Gastric adenocarcinoma.
b. Colon cancer
c. Mucosa associated lymphoid tissue (MALT lymphoma)
 d. Pancreatic adenocarcinoma.
e. Primary myelofibrosis.
f. Myelodysplastic syndrome.

Q9
A 70 year old man with diabetes mellitus controlled with an oral agent presents for routine follow up. His
other medical problems include hypertension for which he takes enalapril, and benign prostatic
hyperplasia which has been well controlled with as needed tamsulosin. On review of his records, you note
a gradual decrease in his hematocrit over the last four years. Results of comprehensive labs obtained are
shown below.

WBC 6500/mm 3 (4000-10500)

Hematocrit 27% (36-48%)
Mean Corpuscular Volume 89 fl (80-100)
Red Blood Cell Distribution Width 15 (10-14)
Platelets 320,000/mm3 (150,000-400,000)
Blood urea nitrogen 40 mg/dl (10-26)
Creatinine 1.7 mg/dl (0.7-1.3)
Lactate dehydrogenase 200/ul (105-240)

What is the most likely etiology of the patient’s anemia?

a. Side effect of enalapril
b. Anemia due to marrow replacement by metastatic malignancy
c. Colonic malignancy
d. Iron deficiency anemia
e. Erythropoietin deficiency
f. Combined folate and B12 deficiency

Q10
A 73-year-old woman has been admitted to the hospital for fever, cough, dyspnea, and hypoxemia. She
has a history of hypercalcemia secondary to primary hyperparathyroidism and has on many occasions
refused surgical intervention. Chest radiograph shows a lobar infiltrate, and sputum cultures grew gram
positive diplococci. She is diagnosed with pneumococcal pneumonia and treated with moxifloxacin based
on antibiotic sensitivities. Her clinical status improves markedly. On hospital day 6, just prior to
discharge, she develops rapid onset painful swelling in the left wrist associated with redness and warmth
of the involved extremity. She is afebrile, normotensive, and does not appear to be in a toxic condition.
The left wrist is red, warm, swollen, and very painful with active or passive motion. Several left
metacarpophalangeal (MCP) joints are similarly involved, but the right hand and wrist are completely
normal. Blood cultures since her initial admission have all returned negative. Plain radiographs of her
wrists are shown below.
What is the most likely diagnosis?
a. Acute pseudogout arthritis
b. Seronegative rheumatoid arthritis of the elderly
c. Wrist fracture
d. Wrist osteoarthritis
e. Streptococcus pneumoniae septic arthritis

Q11
A 32-year-old previously healthy woman presents to the outpatient clinic with 5 months of progressively
achy hands, wrists, elbows, knees, ankles, and feet. Symptoms are worse in the morning and are
alleviated by physical activities. Functionally, she is finding it difficult to perform her duties as a hair
stylist because of reduced manual strength and dexterity. Indomethacin has provided minimal relief. She
reports fatigue but no other associated symptoms. Prior history is notable only for uterine leiomyomas,
treated by myomectomy at age 30. The patient denies any history of tobacco use, and her alcohol intake is
minimal. Physical examination reveals redness, warmth, and swelling of multiple proximal
interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, both wrists, both ankles, and both knees.
Her examination is otherwise normal. Laboratory analysis reveals a normal comprehensive metabolic
profile and normal complete blood count with differential. Rheumatoid factor (RF), anti cyclic
citrullinated peptide (anti-CCP) antibodies, and antinuclear antibodies (ANA) are not detectable. CRP is
14 mg/dl (normal < 6). Plain film radiographs of the hands reveals swelling of the soft tissues around the
affected joints but no other abnormalities. Which of the following is the most appropriate first step in the
pharmacological management of this condition?
a. Biweekly intravenous rituximab infusions
b. Daily milnacipran for pain
c. Once weekly dosing of methotrexate
d. Twice daily doxycycline for 7 days
e. Repeat RF, anti-CCP, and ANA antibody testing.

Q12. From The New Free 120 by the NBME

Q13 From The New Free 120 by the NBME

Q14 From The New Free 120 by the NBME

Q15
A 31 year old woman at 24 weeks gestation presents with an 8 week history of progressively worsening
dyspnea and palpitations. She is now dyspneic at rest and has to sleep upright in a chair. On examination,
her heart rate is 111 beats per minute with an irregular rhythm. Her blood pressure is 89/65. The first
heart sound is louder than the second heart sound at the base. There is a high pitched, discrete, early
diastolic sound that follows the second heart sound. There is a diastolic rumbling murmur heard over the
apex with the patient positioned in the left lateral decubitus position. Pulmonary auscultation reveals
bibasilar rales. The patient’s jugular venous pressure is 17 cm H2O. Which of the following represents
the most likely diagnosis?
a. Pregnancy associated cardiomyopathy.
b. Pulmonary embolism.
c. Mitral stenosis.
d. Thyroid storm.
e. Normal changes of pregnancy.

Q16
A 39-year-old woman comes to her psychiatrist for her 6 month visit. She has a 3 year history of
hypertension, neuropathic pain, and generalized anxiety disorder well controlled with enalapril and
duloxetine. She reports a new increase in her anxiety along with palpitations over the preceding 10 days,
and her blood pressure has been trending higher than usual at approximately 147/85. They were
previously in the 135-140/70 mm Hg range. She has been under a lot of pressure in her job as the CEO of
a Fortune 500 company which she states has increased her anxiety. She denies tobacco, alcohol, and illicit
drug use. Plasma metanephrines ordered are < 0.10 nmol/L (0-0.49) and plasma normetanephrines are 1.4
nmol/L (0-0.90). Which of the following best represents the most likely cause of the elevated
normetanephrine levels in this patient?
a. Posterior mediastinal paraganglioma
b. Enalapril use
c. Illicit use of methamphetamine
d. Pheochromocytoma
e. Duloxetine use

Q17
A 39 year old female comes to the physician with a chief complaint of upper back pain for the past 5
weeks. The pain is 3/10 in severity. She does not recall having any trauma, urinary incontinence, or leg
weakness. She had similar symptoms 1 year ago at which time a T2 compression fracture was visualized
by spinal imaging. A dual energy X-ray absorptiometry scan at the time showed a T score of -2.9 at the
lumbar spine and -2.6 at the femoral neck. She received a prescription for ibandronate which significantly
improved her pain symptoms. She has a regular 28 day menstrual cycle. Her other medical problems
include hypothyroidism and mild hypertension well controlled with daily levothyroxine and metolazone.
She also takes a daily multivitamin. She has no family history of diabetes or osteoporosis. She does not
use tobacco, alcohol, or illicit drugs. Her blood pressure is 149/85, and pulse is 82/minute. BMI is 41
kg/m2. There are no skin rashes. Physical examination is notable for localized tenderness at the T5
vertebral body. The remainder of the physical exam is unremarkable.
Laboratory studies are as follows:
Complete Blood Count
Hemoglobin-14 g/dl
Platelets-390,000/uL
Leukocytes-4900/uL

Basic Metabolic Panel/Other labs

Serum protein electrophoresis-No monoclonal spike
Creatinine-1.1 mg/dl
Calcium-10.1 mg/dl
Thyroid Stimulating Hormone-1.7 mu/L
Vitamin D (25-hydroxycholecalciferol)-45 ng/ml
Urine calcium-250 mg/24 hr (nl: 100-300)
Liver Function Tests-Within normal limits
Thoracic spine radiograph: New T5 compression fracture

Which of the following is the best next step in the management of this patient?
a. Switch to teriparatide
b. Check anti-gliadin antibodies
c. Perform bone marrow biopsy
d. Perform overnight dexamethasone suppression test
e. Daily oral calcitonin tablets

Q18 From The New NBME Free 120

Q19
A 65-year-old male comes to his primary care physician with a 2 week history of hematuria. Other than
an unintentional 20 Lb weight loss over the last 3 months, he has no other complaints. He worked on a
shipyard for 20 years as a plumber before retiring 5 years ago. His physical exam is unremarkable with no
evidence of suprapubic pain or pressure. His prostate is smooth and nontender on digital rectal exam. His
medical history is notable for granulomatosis with polyangiitis which has been well controlled with
appropriate therapy. He smoked 2 cigarettes everyday over a 1 month period while studying abroad in
China 49 years ago. He occasionally has a glass of wine with dinner. Urinalysis is positive for gross
hematuria but negative for nitrites, leukocyte esterase, and dysmorphic red cells. Which of the following
historic factors is the most significant risk factor for this patient’s condition?
a. Occupational history
 b. History of smoking
c. Medication exposure
d. History of alcohol use
e. Prostate malignancy

Q20
A 50 year old female presents with a large left breast mass. Physical exam is notable for skin dimpling,
nipple retraction, and a leathery “orange peel” appearance of her left breast. The patient has a long history
of depression that has been well controlled with Paroxetine. Her mood and affect are appropriate. She
tells you that she is not interested in knowing the diagnosis. Which of the following represents the most
appropriate physician response in this scenario?
a. Tell the patient the diagnosis and encourage her to consider immediate treatment
b. Respect the patient’s wishes and do not tell her the diagnosis
c. Verbalize to the patient that you think it’s best for her to know the diagnosis
d. Call the patient’s husband and tell him the diagnosis
e. Ask the patient why she does not want to know the diagnosis
f. Consult the healthcare systems’ risk management committee