NBME Answer Keys

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Step 2 CK NBME Form 3

Block 1 1. A (Platelet count normal, Bleeding time prolonged) 2. B (hints: continues to work productively, sleeps 8-10 hours, no suicidal ideation, duration < 2 months) 3. A (Heat stroke is defined as a body temperature of greater than 40.6 C (105.1 F) due to environmental heat exposure with lack of thermoregulation. This patient has a temperature of 38 C only. Murmur points towards option A.) 4. A 5. A (oliguria with increased BUN & Creatinine [ratio < 20] following an episode of 30 min hypotension] 6. D 7. C 8. C (eosinophils in urine sediment plus generalized rash) 9. E 10. C (Salmonella enteritidis is not transmitted by feco-oral transmission; the main source of its infection is infected eggs, especially when they are eaten raw and undercooked) 11. D (uncontrolled diabetes with obesity) 12. D 13. F (hint: dog's bark like cough) 14. E (reflexes are depressed in elderly, vibratory sense is reduced in toes and ankles, not knees. tremor of outstretched hands may be seen in otherwise healthy elderly.) 15. B (answer provided by a commenter: "the answer isnt A, as A means the pt has ANION GAP ACIDOSIS..which he obviously doesn't as acidosis is due to diarrhea. I wud say its B, as his pCO2 should b low in case of metabolic acidosis, he's retaining it despite acidosis, means its a resp prob as well.") 16. E 17. C (incontinence is not a part of normal aging; diabetes lose the sensation of full bladder, making C most likely) 18. D (malignant otitis externa) 19. A 20. E (Alcoholic hepatitis. Reticulocyte count should be normal, so option C is out. ALT has to be elevated, so it has be either D or E. Since hepatic ducts are normal, ALP can't be raised as much as 800, ruling out option D. Therefore E is the answer.) 21. D 22. I 23. A (Buspirone for GAD) 24. E (only option that gives a restrictive pattern on PFTs) 25. C 26. E (Angioedema) 27. B 28. C (atypical lymphocytes >> Infectious Mononucleosis) 29. C (hypermobility [Ehlers-Danlos syndrome] >> recurrent patellar dislocation >> Tx: Quadriceps strengthening exercises] 30. E (severe osteoarthritis affecting patient's quality of life >> total knee replacement) 31. D (April, not the right time for Influenza vaccine. Pneumococcal indicated.) 32. E (Pseudomembranous colitis) 33. C (Genital warts) 34. A 35. E (Polymyositis >> proximal muscle weakness. In scleroderma there is loss of peristaltic movement in the lower 2/3rd of esophagus, including LES. While in polymyositis there are absent pharyngeal contractions and decreased upper esophageal sphincter pressures [http://www.myositis.org/pdf/Gastrointestinal% 20Ebert.pdf]) 36. I (Hypertensive emergency >> Sodium nitroprusside. Other options: Nicardipine, Fenoldopam, Hydralazine, Labetalol) 37. A (the girl immediately coughs and breathes spontaneously without resuscitation >> good prognosis) 38. A 39. B (history of trauma + murmur & thrill + tinnitus + vericose veins) 40. B (prevalence affects positive predictive value) 41. D (calcitonin represents the classical clinical marker for medullary thyroid carcinoma) 42. A/B/E (This question is up for debate it appears. I thought: absent gag reflex is no more considered a reliable indicators of aspiration risk. Dentures increased the

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NBME Answer Keys

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risk of aspiration pneumonia. A commenter gave his feedback: I think the right answer might be E. There are studies out there about aspiration prevention by jejunostomy tube placement. At the same time, aspiration risk is increased with poorly fitted dentures or missing teeth. This patient has false teeth, which by itself do not predispose to aspiration. I think A might be a distractor. Another commenter thinks it is B: the most commonly used method used to prevent aspiration that ive seen in hospitals is GIVING ANTACIDS, the dentures r not unhygienic or ill fitting, so dats out..) 43. A (TIA >> aspirin) 44. C 45. D (Anemia in elderly >> Colon cancer. Mets in Liver.) 46. B (split fixed S2) Block 2 1. E (long history of a strict diet) 2. B (lisinopril side-effect) 3. F 4. D (hyphema: blood in anterior chamber of eye) 5. D (DVT. It cannot be Compartment syndrome because that requires a prolonged period of ischema and in this patient distal pulses were always palpable.) 6. C 7. E (testicular cancer can have metastasis to anterior mediastinum) 8. C (No waiting is necessary after MI to resume sex, but it is not for the reason that is stated in option E. That leaves C as the best answer. D is wrong.) 9. E 10. B 11. A (determine fetal lie by US if examination doesn't reveal) 12. B 13. A (flat-topped red papules over knuckles >> "Gottron's papules") 14. A 15. A 16. C (Hep B, raised AFP) 17. E (MEN II. It causes Parathyroid adenoma/hyperplasia, not carcinoma.) 18. B (Doxorubicin >> cardiotoxicity) 19. C (Ectopic pregnancy. Normal HCG level at 7-8 weeks LMP is: 7, 650 - 229,000 mIU/ml, therefore this patients HCG is not excessive. Transvaginal US shows Empty uterus (if it was Gestational Trophoblastic Disease, it would have shown homogenous intrauterine echoes or snow-storm appearance) Absence of adnexal mass does not rule out ectopic pregnancy. Patient has a previous history of ectopic pregnancy, which makes her high risk.) 20. B (description of cervical os points towards cervicitis. For threatened abortion, it is crucial to know whether the cervix is closed or not, information which the question doesn't give.) 21. N 22. B 23. B 24. M [subcutaneous epinephrine is the treatment for anaphylaxis/angioedema. Source: UW, step up to medicine] 25. L (tinnitus, increased respiration, suicide threat >> aspirin toxicity. diagnose with serum aspirin level.) 26. O (positive PPD, follow with chest X ray) 27. D 28. B 29. E (febrile neutropenia) 30. E 31. D 32. E (very high FSH and LH) 33. D (fever and joint pain with history of a course of dicloxacillin + urticarial rash, generalized lymphadenopathy >> serum sickness. A is a distractor because Infectious Mononuclesis treated with Ampicillin/Amoxicillin may develop a red, diffuse rash) 34. A 35. C (Hepatitis A vaccine or IG should be given to a previously unvaccinated household and sexual contacts of persons with serologically confirmed hepatitis A) 36. B (ECG changes due to hyperkalemia >> Ca Gluconate) 37. B 38. C 39. C (Patient already had a high serum cholesterol level in past, so confirm now with fasting lipid studies. LDL is a more specific cardiac risk factor than total serum cholestrol.) 40. K 41. A (normal, normal) 42. G

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NBME Answer Keys

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43. A (Congenital adrenal hyperplasia) 44. B 45. A 46. B Block 3 1. C (Atypical depression with a history of bulemia >> drug of choice is Fluoxetine. Phenelzine is more effective for atypical, but has more side-effects so 2nd line, plus this patient has history of bulemia, which makes Fluoxetine better option. Some people think it is a case of Fibromyalgia and Imipramine should be the answer, but without the mention of tender points, I consider it doubtful.) 2. E 3. A 4. E 5. C (suspicion of Pancreatic Cancer) 6. E 7. D (Tx of hypercalcemia >> infusion of 0.9% saline +/- loop diuretic) 8. B (looks like the rational choice, also given that the question is meant to be about Medical Ethics. Some people think that D is correct answer, to test for ADPKD.) 9. D 10. E 11. A 12. B 13. F 14. F 15. E 16. E 17. B (In prolonged or arrested active phase if contractions are inadequate (adequate: every 2-3 min. this patient has every 8 min) Tx is augmentation with oxytocin. If uterine contractions are inadequate >> C section) 18. B (Gallstones most likely cause of acute pancreatitis) 19. C (insecticide poisoning. opiates would cause pinpoint pupils but also respiratory depression.) 20. B 21. C (Patient has no history of bleeding problems and takes no medications which rules out all choices except C >> surgical bleeding) 22. D 23. E 24. E 25. B 26. A (Exercise reduces future muscle spasms and sprains. Back brace would limit his spine movements, but there is nothing wrong with his spine.) 27. B (In the early stage of septic shock, cardiac contractility increases and preload & afterload decrease) 28. D 29. B 30. D 31. A 32. E (hint >> the month November) 33. B 34. E 35. B (asymmetry in radical pulses) 36. B 37. C 38. F (Seborrheic keratosis >> stuck on appearance) 39. D 40. D 41. C (Chondrocalcinosis >> pseudogout) 42. C 43. H (Syndenham Chorea) 44. B (Patient's Magnesium level is below normal 1.5 - 2.5 mg/dL) 45. A 46. D Block 4 1. A 2. D (Before starting a vigorous excercise program, individuals over the age of 45 years with two or more risk factors and those between 35 years to 44 years with more than two risk factors for coronary artery disease must undergo a maximal exercise stress test after a thorough physical examination, even if they feel normal and have no symptoms.) 3. C

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NBME Answer Keys

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4. E 5. B (Infants are very commonly prone to anal fissures) 6. D 7. A (follow ABC) 8. B (chronic analgesic use) 9. D 10. C 11. E 12. E 13. F (retinal artery embolism) 14. A (pre-ductal or ductal coarctation of aorta) 15. C 16. A 17. A (hyperkalemia, hyperpigmentation of palmar creases) 18. B 19. B (best explanation) 20. E 21. E 22. D 23. E (tropical sprue) 24. A 25. A (Parkinson's disease) 26. C 27. C (lucid interval) 28. B (febrile neutropenia >> Aminogycoside + [AntiPseudomonal penicillin or AP cephalosporin]) 29. B 30. A 31. C 32. D 33. A 34. C (learning disability commonly associated with ADHD) 35. B (emergency contraception >> high dose OCP) 36. D 37. M 38. G 39. C (Cystic fibrosis patients have decreased sperm count) 40. C 41. A 42. B (Polycystic Ovarian Syndrome) 43. A (hint for Lyme Disease: Long Island) 44. E 45. B (subclavian steal syndrome) 46. A

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5/4/2013