NBME Answers : step_prep3's page

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Obese middle-aged patient with daytime fatigue and a likely reactive polycythemia (chronic hypoxia –> increased EPO production –> increased Hgb/Hct) in the setting of obstructive sleep apnea +/- obesity hypoventilation syndrome
Obstructive sleep apnea requires polysomnography for formal evaluation

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Young woman with a nontender thyroid mass/nodule that is 2 cm in size, requiring fine needle aspiration biopsy
Key idea: All thyroid nodules should be worked up with a TSH and thyroid ultrasound, with thyroid nodules greater than 2 cm in diameter or thyroid nodules greater than 1 cm with high-risk sonographic features (irregular markings, microcalcifications, etc.) should undergo fine needle aspiration biopsy
Key idea: The thyroid gland is highly vascular, which is why you would always use a fine-needle aspiration biopsy for evaluation
Key idea: Mass in the neck that moves with swallowing = Thyroid or thyroglossal duct cyst
Key idea: Hypofunctional or “cold” thyroid nodule has a higher risk of malignancy as compared to a hyperfunctional “hot” thyroid nodule

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ht3 sooo you're saying to get TSH first...so why would the answer not be thyroid function tests..? +3

nbmesuxugh I thought that too but the question is asking to establish the diagnosis not the next best step! just be careful on test because I have seen tricky questions like that +11

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A previously healthy young man with recent life stressors who presents with sudden onset of blindness in one eye with a completely normal physical exam (including tests demonstrating that he can in fact see out of that eye), most consistent with conversion disorder
Testing will often involve a neurologist and psychiatrist

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Middle-aged man found to have elevated blood pressure for the first time, and therefore should be initially managed with a trial of lifestyle modifications

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kalam The answer is not because of lifestyle modifications being the next step, but mostly because the diagnosis of hypertension requires multiple things: in-office HTN + having patient take blood pressure at home periodically and then follow up in the office. The only time an isolated single time of high blood pressure can immediately be diagnostic of hypertension is BP >180/>120 (urgency or emergency, OR >160/>100 + evidence of end organ damage. +5

tinylilron I feel like we do re-evaluation in 3 months... or is 1 month the new guidelines? +

tinylilron looks like I may be wrong because he has a stage 2 hypertension https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults +

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Previously healthy young woman who presents with heavy menstrual bleeding and easy bruisability found to have thrombocytopenia with bone marrow aspirate showing increased number of megakaryocytes, with platelet count responsive to prednisone, most consistent with idiopathic thrombocytopenia
Key idea: Immune thrombocytopenia caused by platelet antibodies and is often associated with a preceding viral infection
Impaired platelet production = Aplastic anemia = Pancytopenia

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Thymus is normal in children < 3 years of age and commonly leads to “sail sign” due to triangular shape

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step_prep3 https://www.slideshare.net/airwave12/chest-x-ray-positioning +

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Key idea: Ingestion of household bleach is often considered a benign ingestion, whereas ingestion of industrial-grade bleach is very severe/morbid

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Key idea: Most common causes of elevated AFP in a pregnant patient are under-estimation of gestational age, fetal demise, multiple gestations, ventral wall defects, neural tube defects and liver disease
Key idea: Next step in management of elevated AFP is ultrasound to assess gestational age, viability, number of pregnancies, and assess for defects

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cbrazell92 I thought US dating was less accurate after the 1st trimester which made me not pick that...ugh. +

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Newborn who has trouble swallowing and handling secretions, most consistent with a suspected tracheoesophageal fistula which can be tested by passing an NG tube

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Signs of zinc deficiency: Alopecia, dermatitis, scaly skin around mouth/eyes, abnormal taste, impaired wound healing
Signs of copper deficiency: Hematologic abnormalities (microcytic anemia, leukopenia) and myeloneuropathy
Iron deficiency: Microcytic anemia

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bobson150 Not to mention this is Wilson's disease... this guy should have tons of copper lying around +4

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Modifiable risk factors for osteoporosis: Excessive alcohol intake, sedentary lifestyle, smoking
Non-modifiable risk factors for osteoporosis: Advanced age, postmenopausal woman, low body weight

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Elderly nursing home patient presents with altered mental status, fever, hypotension, warm extremities and a positive urinalysis (pyuria if >10 WBC/hpf), most consistent with urosepsis (infection leading to peripheral vasodilation and distributive shock)
Key idea: Distributive shock (anaphylaxis, sepsis, CNS injury) is the only type that will lead to warm and dry skin
Key idea: Patient needs to have symptoms in order to be diagnosed with UTI > Asymptomatic bacteriuria in the setting of a positive urinalysis, but in addition to dysuria and suprapubic tenderness, altered mental status is often attributed to UTI and considered a symptom

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Pain in the hips/thighs that is exacerbated by walking and improves with leaning forward with normal posterior tibial pulses, most consistent with pseudoclaudication due to spinal stenosis
Claudication: Patient will have risk factors for peripheral vascular disease (diabetes, HTN, smoking, etc.), reduced lower extremity pulses, reduced lower extremity temperature, pain classically in the calves, reduced hair on legs
Pseudo-claudication (spinal stenosis): Positional (improves with flexion), classically affects buttocks and thighs, may be associated with back pain

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seagull Cannot a herniated lumbar disk lead to spinal stenosis? asking for a friend. +1

mycoplasma yes, it can cause stenosis. +

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Key idea: Diverticulitis classically leads to dull LLQ pain, nausea/vomiting, alteration in bowel habits and bladder symptoms (sterile pyuria, dysuria, etc.) +/- tender LLQ mass
Key idea: Diverticulitis treated with bowel rest and antibiotics (ciprofloxacin + metronidazole) and followed up 4-8 weeks later with colonoscopy (colonic malignancy can mimic the presentation and CT findings seen in diverticulitis)
Key idea: Indications for surgery in setting of acute diverticulitis (1) Emergency operation (peritonitis, abscess, etc.) (2) Any patient who has survived 2 episodes of acute diverticulitis should have elective removal of affected area to prevent recurrence

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danielle359x Pneumaturia=fistula=probably diverticulitis +5

yb_26 colovesical fistula can occur is setting of diverticulitis, Crohn's disease, malignancy +1

jurrutia The posts from step_prep3 are consistently less useful than the subcoments +2

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Blighted ovum = Anembryonic pregnancy = fertilized egg attaches to uterine wall but the embryo does not develop during the first trimester

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jlbae TIL what a blighted ovum is +7

akjs16 = missed abortion? +

gigantichawk UpToDate describes this as "Early Pregnancy Loss" with "Blighted Ovum" being an archaic term. +

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Pregnant patient with type 2 diabetes with signs of poorly controlled blood glucose while on metformin, therefore requiring step-up in therapy to include insulin
Target blood glucose levels in gestational diabetes mellitus are fasting glucose < 95, 1-hour postprandial glucose < 140 and 2-hour postprandial glucose < 120
Key idea: Treatment options in gestational diabetes are (1st-line) Dietary modification (2nd-line) Insulin, metformin

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link981 I only got this one right because there is a question in Uworld that is similar +

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Young woman with hypertension, headaches and a renal arteriography showing an 80% obstructive lesion, most consistent with fibromuscular dysplasia leading to renal artery stenosis
Key idea: Although fibromuscular dysplasia most commonly leads to resistant hypertension due to renal artery involvement, cerebrovascular fibromuscular dysplasia also a common presentation (headache, tinnitus, dizziness, TIA, amaurosis fugax, etc.)

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Young woman with suspected UTI who has symptoms that are refractory to 2 courses of antibiotics and urethral tenderness on physicial exam, most consistent with urethritis which is most commonly caused by N. Gonorrhea or Chlamydia trachomatis
Key idea: On the NBME, when it says that a woman is sexually active and uses oral contraception, that means that they do not need condoms and are at increased risk for STIs
Key idea: Empiric urethritis treated with azithromycin + ceftriaxone, gonorrhea positive only treated with azithromycin + ceftriaxone and chlamydia positive only treated with azithromycin only

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Elderly man with imaging showing metastatic pancreatic cancer also found to have a stable abdominal aortic aneurysm
Median survival of metastatic pancreatic cancer is 3-6 months, so the patient would most likely die from cancer before having any negative effects from the aneurysm, so repair of aneurysm has risks > benefits for this specific patient
Indications for abdominal aorta aneurysm repair in healthy patient: (1) > 5.5 cm in diameter (2) expansion of at least 0.5 cm in 6 months and/or 1 cm per year (3) symptomatic (abdominal pain, flank pain, limb ischemia)

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bobson150 It's frustrating that they'd expect us to know prognosis at this level. I know metastatic pancreatic cancer is bad news bears, but the AAA fits criteria for repair (in a healthy person) +13

ishockk Wait so if his aneurysm was symptomatic would you repair it? what are the clauses for (not) repairing? they should mention that in surgery fundamentals! +1

fuckyoudie this answer definitely seems like it could be argued. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076160/, the annual risk of rupture for an aneurysm of his size is 20-40%. Dying by exsanguinating into your own abdomen does not seem like a very pleasant way to die, and so it doesn't seem out of the question to fix his AAA to prevent that particular outcome, development of further symptoms. I could see this question becoming quickly out of date as chemotherapeutics for pancreatic cancer and AAA repair technology get better. +4

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Causes of rapid-onset food poison (< 6 hours) are due to ingestion of pre-formed toxin and are most commonly caused by Staph aureus (cream-based food such as egg salad) or Bacillus cereus (reheated rice syndrome)
Clostridium perfringens (improperly cooked/stored meat) is another cause of food poisoning, but often occurs 6-24 hours after ingestion because patients ingest spores which need germinate in digestive tract to secrete toxin

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jj375 In case you were like me and made this mistake --> 8 hours ago she ate something, but been vomiting for 6 hours. Therefore started vomiting 2 hours after ingestion --> so its staph aureus preformed toxin +

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Teenage wrestler (wrestler should always make you think of tinea infection!) who has an erythematous, scaly, pruritic, annular rash with raised-edges most consistent with tinea corporis
The most common dermatophyte organisms include Trichophyton, Microsporum, and Epidermophyton

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Young patient with concern for IBD (increased stool frequency, signs of inflammation [fatigue, weight loss], bloody stools) who presents with ill-appearance, fever, hypotension, abdominal distention and an X-ray showing dilated transverse colon, consistent with toxic megacolon in setting of ulcerative colitis
Key idea: Toxic megacolon associated with ulcerative colitis and C. diff colitis
Colonic pseudo-obstruction often seen in elderly patient who is post-op and/or received opiates, diverticulitis leads to LLQ pain in an elderly patient, and ischemic colitis leads to “pain out of proportion” in a patient with risk factors (atrial fibrillation, endocarditis, etc.)

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killuashi Would toxic megacolon only show up in one part of the bowel? Shouldn't the whole bowel be dilated in toxic megacolon and not just the transverse colon? +1

ht3 ^I thought that too but also isn't toxic megacolon painful...? or nah? +

danielle359x Toxic megacolon is typically most prominent in the transverse colon. According to UpToDate, 82% of cases present with pain. I feel like they didn't need to emphasize twice that the patient had no pain, but that's NBME for you... +1

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Patient with Cushing’s triad (bradycardia, hypertension and irregular respirations) which is a sign of elevated intracranial pressure with a CT scan showing a high-density peri-ventricular hemorrhage, most consistent with a hypertensive bleed
Key idea: Common causes of brain bleeds include trauma, hypertension and cerebral amyloid angiography

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seagull Bathrooms are very common areas of falling for the elderly/everyone. However, those tend to result in intracranial hematomas. This is a very significant brain bleed. HTN is classically associated with lacunar infarcts which honestly are not as massive as shown. THis might be a ruptured berry aneurysm from HTN but we couldn't know for sure. Not a great question but he has pre-existing HTN so I guess we'll go with it. +6

saffronshawty bruh, i straight up thought that was a tumor lol +21

lindasmith462 I still dont get how this isnt' amyloid angiopathy - its the most common cause of spontaneous parenchemal hemorrhage in pts >60 (sure this guy is only 57 but NBME loves to give just off age ranges) and is especially seen in people doing routiene activity - HTN would have to be a SUDDEN increase in blood pressure - which he doesnt have a history suspicious for..... like if they said he was running or something sure +2

aoluwatayo according to FA step 1, Intraparenchymal haemorrhage is most commonly caused by HYPERTENSION( charcot-bouchard microaneurysm).occuring in basal ganglia > thalamus > Pons > Cerebellum. Other causes are; Amyloid angiopathy in elderly, vasculitis and neoplasm +

osler_weber_rendu Amyloid angiopathy is commonly restricted to one lobe acc to UW +

merpaperple I thought this was a tumor too. Brain tumors look more like discrete solid masses (eg https://radiologyassistant.nl/img/containers/main/brain-tumor-systematic-approach/a5097978407bd7_calcification-2.jpg/0f040f73ea87585a751f39222d4a0b1c.jpg). Intracranial hemorrhage is more diffuse and "fluffy" (eg https://media.sciencephoto.com/image/c0271775/800wm) +1

adong lol i feel like that second pic has more well defined borders. tbh i think the best way is probably to look at the intensity of the lesion. for bleeds it's almost as white as the skull bone +1

beans123 bright white is blood on these scans +

drzed if it was a brain tumor, it would be intraventricular, which means that it would be an ependymoma. Those tumors are not only slow growing (not explaining his sudden onset of symptoms), but more common in children. You can't have a tumor the size of half your brain SUDDENLY knock you out--it would be a gradual development of symptoms. +1

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Newborn with cyanosis found to have a heart murmur and hypoxia unresponsive to supplemental oxygen, which is consistent with a severe intracardiac shunt)
Patient should be treated with alprostadil (or another prostaglandin analog) in order to keep the PDA open until the heart defect can be operatively managed

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seagull Doesn't it take like 2-7 days for the duct to close? Why is this hour old newborn already cyanotic? +1

kingfriday early cyanosis might be consistent with transposition of the great vessels and those can be associated with ejection murmurs and a loud S2 +3

welpdedelp Following ABCs, why wouldn't you intubate first? I understand shunt doesn't get corrected, but it would seem you would still take control of airway since kid seems to be crashing. +

quaranqueen I think that intubation wouldn't make a difference if it's transposition of the great arteries because the oxygenated blood would just end up going back to the right heart and back through its closed circuit +2

etherbunny Start prostaglandin early to prevent the duct from closing, don't wait until it starts to close. The child is already cyanotic because they have intracardiac mixing of deoxygenated and oxygenated blood. They are unresponsive to oxygen; delivery of even more oxygen via intubation wouldn't help because the problem lies not in delivery of well-oxygenated blood to the heart, but that it gets mixed with deoxygenated blood before being pushed out to the systemic circulation. Drugs for intubation and laryngoscopy could cause also further cardiovasular instability. Delivery of extra oxygen can actually make things worse through pulmonary vasodilation, leading to "steal" of cardiac output to the lungs rather than pushing it out to the systemic circulation. +5

akjs16 Does the murmur mean there's a VSD? Then why we still need the ductus arteriosus open? +

charcot_bouchard systolic ejection murmur at apex...not vsd..that HSM at left sternal border +

drzed It doesn't matter what the cause of the murmur is. If all they told you was "baby is blue at birth and oxygen does not help" you immediately know it's an intracardiac shunt, which means intubating will not help (because all that is doing is delivering oxygen closer to the lungs, but the problem is an intracardiac shunt!) +1

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Lisinopril is an ACE inhibitor that leads to decreased angiotensin 2, and therefore leads to decreased vasoconstriction, decreased Na/H20 reabsorption in the kidney, decreased aldosterone and decreased ADH, all of which can lead to decreased blood pressure

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Elderly patient with vasculopathic risk factors (hypertension, diabetes, smoking) presenting with acute shortness of breath, diaphoresis and pallor found to have hypotension and pulmonary edema with ECG findings of ST elevation in the anterolateral leads (I, avL, V2-V6), most consistent with myocardial infarction complicated by cardiogenic shock
Aortic dissection would lead to pain radiating to the back and X-ray would show widening of the mediastinum

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