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  1. #1
    marceverett is offline Junior Member 510 points
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    Questions from NBME Form 4.

    If you have not taken Form 4, please do not read this thread, you will lose the ability to assess your progress when you take it.
    Please post an answer and the explanation. Thanks so much.




    21.
    A 72-year-old man comes to the emergency department because of a 2-hour episode of loss of vision in the left eye. He has never smoked. Laboratory studies show:
    Hemoglobin
    20 g/dL
    Hematocrit
    62%
    Leukocyte count
    14,200/mm3
    Differential
    normal
    Mean corpuscular volume
    87.2 μm3
    Platelet count
    375,000/mm3
    Which of the following is the most appropriate initial therapy?


    A)Administration of allopurinol
    B)Administration of aspirin
    C)Administration of chlorambucil
    D)Administration of hydroxyurea
    E)Administration of warfarin
    F)Phlebotomy
    G)Splenectomy


    25.
    A 45-year-old man has had four episodes of involuntary twitching of the right foot. Following the last episodes, he had a tonic-clonic seizure. Which of the following structures on the left is the most likely origin of the seizure?
    A)Inferior frontal cortex
    B)Inferior temporal cortex
    C)Insular cortex
    D)Primary motor cortex
    E)Supplementary motor cortex

    30.
    A 77-year-old man has had repeated episodes of difficulty speaking, facial numbness, and clumsiness of the left hand. Doppler ultrasonography of his carotid arteries shows no abnormalities. Which of the following drugs is the most appropriate therapy to prevent future episodes?
    A)Aspirin
    B)Diflunisal
    C)Methyl salicylate
    D)Olsalazine
    E)Salicylic acid
    F)Salsalate
    G)Sodium salicylate
    H)Sulfasalazine

    3.
    A 23-year-old woman has skin blistering that results from a point mutation in a single gene. Epidermal cells in these patients become fragile and rupture. Which of the following is the most likely effect of the genetic mutation?
    A)Defective transport of vesicles from the centrosome to the cell membrane
    B)Disrupted assembly of keratin into intermediate filaments
    C)Lack of GTP required to form polymers of tubulin
    D)Phosphorylation of actin monomers to promote polymerization


    7.
    A 75-year-old man has a painless mass in the left upper anterior neck. Examination of tissue obtained on biopsy shows partial replacement of a lymph node by a neoplasm; the neoplasm is composed of cohesive sheets of polygonal cells with granular eosinophilic cytoplasm, prominent intercellular bridges, and pleomorphic round nuclei. Immunocytochemical preparations show a strongly positive reaction of the neoplastic cells to a high-molecular-weight keratin antibody. There is no reaction to antibodies against vimentin and leukocyte common antigen (CD45). Which of the following is the most likely diagnosis?


    A)Adenocarcinoma
    B)Malignant melanoma
    C)Non-Hodgkin lymphoma
    D)Sarcoma
    E)Squamous cell carcinoma


    32.
    A 78-year-old man comes to the physician because of progressive swelling of the right side of his face and neck and his right upper extremity. His right jugular vein is engorged. Which of the following diagnoses is most likely to be confirmed on an x-ray of the chest?


    A)Aortic arch aneurysm
    B)Mass in the upper lobe of the right lung
    CRight cervical rib
    D)Right pneumothorax
    E)Thoracic duct blockage in the posterior mediastinum

    48.
    A 28-year-old woman with AIDS has chronic diarrhea of unknown origin. After the failure of typical treatment approaches, subcutaneous injections of octreotide are begun. Which of the following best describes the therapeutic benefit of this structure analogy of somatostatin as compared with native somatostatin?

    A)Decreased lipid solubility
    B)Decreased volume of distribution
    C)Delayed onset of action
    DIncreased bioavailability
    E)Prolonged duration of action


    50.
    A 54-year-old man is brought to the emergency department because of a 2-week history of progressive shortness of breath with exertion and leg swelling. He now requires two pillows for sleeping because of shortness of breath when lying flat. He has had a 4.5-kg (10-lb) weight gain during this period. He has a 15-year history of type 2 diabetes mellitus and hypertension that are poorly controlled despite treatment with a variety of medications. Two months ago, he began receiving a new diabetic medication that has been titrated upward during the past month. Crackles are heard at the lung bases bilaterally. Cardiac examination shows an S3 gallop. There is 2+ peripheral edema of the lower extremities. Which of the following medications is the most likely cause of the new symptoms in this patient?

    A)Acarbose
    B)Glyburide
    C)Metformin
    D)Repaglinide
    E)Rosiglitazone


    21.
    Two hours after the onset of chest pain, a 48-year-old man comes to the emergency department. An ECG indicates acute myocardial ischemia. He receives tissue plasminogen activator as thrombolytic therapy. Which of the following adverse effects is most likely?
    A)Acute allergic reaction
    B)Hemorrhagic stroke
    CHypertensive crisis
    D)Pulmonary embolus
    E)Tonic-clonic seizure

    33.
    A 26-year-old woman with stable asthma wheezes when exposed to cats. Which of the following is the most appropriate prophylactic therapy?
    A)Inhaled cromolyn
    B)Inhaled ipratropium
    C)Oral cimetidine
    D)Oral corticosteroids
    E)Oral theophylline

    34.
    The largest proportional increase in left ventricular afterload and myocardial oxygen consumption is most likely to occur following a 20% increase in which of the following?
    A)Aortic pressure
    B)Coronary blood flow
    C)Heart rate
    D)Right atrial pressure
    E)Stroke volume

    45.
    A previously healthy 63-year-old man comes to the physician because of difficulty starting urination, decreased force and size of the urine stream, and dribbling when he tries to stop urinating. Cystoscopy shows hypertrophy and thickening of the bladder wall and dilation of the ureters. If untreated, which of the following sequelae is most likely?
    A)Renal papillary necrosis
    B)Retroperitoneal fibrosis
    C)Transitional cell carcinoma of the bladder
    D)Urethral diverticulum
    E)Urinary tract infection

    47.
    Which of the following is the role of iodine in the biosynthesis of thyroxine (T4)?
    A)It activates a membrane transporter that increases the import of tyrosine
    B)It is added to tyrosine residues in thyroglobulin in the first step of T4 biosynthesis
    C)It is covalently bound to free tyrosine to form T4
    D)It is an essential cofactor for thyroperoxidase

    49.
    An otherwise healthy 80-year-old man is scheduled for endoscopy for evaluation of rectal bleeding. A standard dose of midazolam is administered intravenously when the patient is admitted to the endoscopy suite. A few minutes later, he develops cyanosis and labored respirations and requires ventilation with an oxygenated resuscitation bag. An age-related increase in which of the following is the most likely cause of these adverse effects?
    A)Enterohepatic recycling
    B)Metabolite formation
    C)Plasma protein binding
    D)Sensitivity to sedatives
    E)Volume of distribution

    13.
    A 16-year-old girl is febrile and incoherent but able to indicate that she has severe lower abdominal pain. Pelvic examination shows a foul-smelling cervicovaginal discharge, and a septic abortion is suspected. Which of the following procedures is most appropriate for identifying the microbial agents causing her infection?
    A)Inoculation of anaerobic transport media at the bedside
    B)Inoculation of the specimen into tissue culture
    C)Quantitation of the bacteria in the discharge by using a calibrated inoculating loop
    D)Streaking a swab specimen onto Thayer-Martin media at the bedside
    E)Use of Löwenstein-Jensen and Sabouraud media for acid-fast bacteria and fungi, respectively

    32.
    A 34-year-old woman is brought to the emergency department after she collapsed when she returned from a nonstop flight from New Delhi to New York City. She has smoked 1 pack of cigarettes daily for 16 years. She is sexually active and uses an oral contraceptive. Her pulse is 125/min, and blood pressure is 75/50 mm Hg. Physical examination shows jugular venous distention. The lungs are clear to auscultation. Pulmonary artery catheterization shows a pulmonary systolic/diastolic arterial pressure of 50/25 mm Hg (N=15–30/3–12) and a pulmonary artery wedge pressure of 5 mm Hg (N=8–16). Which of the following is the most likely cause of her pulmonary hypertension?
    A)Decreased cardiac output
    B)Increased left atrial pressure
    C)Increased left ventricular diastolic pressure
    D)Increased pulmonary blood flow
    E)Increased pulmonary venous resistance
    F)Occlusion of left ventricular outflow tract
    G)Occlusion of pulmonary arteries
    H)Pericardial tamponade

    40.
    A 6-year-old girl who is recovering from a severe "strep" throat is brought to the physician because her urine has had a "smoky" appearance several times in the past week. Urinalysis shows trace amounts of blood and protein. Which of the following cell types initiates the repair mechanism necessary to resolve the proteinuria and hematuria?
    A)Erythrocytes
    B)Juxtaglomerular cells
    C)Mesangial cells
    D)Plasma cells
    E)Polkissen
    F)Proximal tubule epithelial cells


    48.
    Triiodothyronine (T3) is more potent than thyroxine (T4) for the treatment of hypothyroidism because of which of the following?
    A)Active transport into target cells
    B)Greater accumulation in mitochondria
    C)Greater receptor affinity
    D)Higher oral bioavailability
    E)Longer plasma half-life



    Last edited by marceverett; 07-31-2006 at 02:46 PM.

  2. #11
    md90's Avatar
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    Sensitivity can be defined as a susceptibility (am thinking allergy) whereas volume of distribution can be defined as the fluid volume through which the drug is distributed in the body.... for an elderly person, they decreased metabolism and renal clearance of the drug, causing the effects to last longer..;

    In this question, we have established that the person is elderly (80 years old) and he was given a standard dose of midazolam (versed); Now I'm assuming that a standard dose is what we give to healthy adults generally (usually 3-5mg/mL); My question: is this person have the effects b/c he is "sensitive" to the drug OR poor toleration due to decreased function brought on by the aging process?

    It's an interesting question and very thought-provoking.... thank you for the question...
    Last edited by md90; 08-01-2006 at 03:02 PM.
    "SLAM-DUNK THE STEPS"

    “Peace, it does not mean to be in a place where there is no noise, no trouble, or no hard work…..it means to be in the midst of those things and still be calm in your
    heart.”

  3. #12
    dchaos_g's Avatar
    dchaos_g is offline Junior Member 510 points
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    I came to the same answers as you md90 except in the following 3 Qs; here is my rationale for my answers -

    32. A 78-year-old man comes to the physician because of progressive swelling of the right side of his face and neck and his right upper extremity. His right jugular vein is engorged. Which of the following diagnoses is most likely to be confirmed on an x-ray of the chest?
    A)Aortic arch aneurysm
    B)Mass in the upper lobe of the right lung
    CRight cervical rib
    D)Right pneumothorax
    E)Thoracic duct blockage in the posterior mediastinum
    Answer: B, superior vena caval compression by the lung lesion
    (see this paper, where a very similar case is reported). Aortic arch aneurysm can cause SVC obstruction syndrome, but are often asymptomatic (40%), and many more present with chest or back pain. A cervical rib would not first present, I imagine, at age 78. Right pneumothorax would present differently (SOB, +/- trauma, resonant to percussion etc.) The literature and big, heavy books seem to mention thoracic duct obstruction in the context of an effect (of thoracic outlet syndrome), rather than a cause, and add an association with steatorrhea to the presentation.



    50. A 54-year-old man is brought to the emergency department because of a 2-week history of progressive shortness of breath with exertion and leg swelling. He now requires two pillows for sleeping because of shortness of breath when lying flat. He has had a 4.5-kg (10-lb) weight gain during this period. He has a 15-year history of type 2 diabetes mellitus and hypertension that are poorly controlled despite treatment with a variety of medications. Two months ago, he began receiving a new diabetic medication that has been titrated upward during the past month. Crackles are heard at the lung bases bilaterally. Cardiac examination shows an S3 gallop. There is 2+ peripheral edema of the lower extremities. Which of the following medications is the most likely cause of the new symptoms in this patient?
    A)Acarbose
    B)Glyburide
    C)Metformin
    D)Repaglinide
    E)Rosiglitazone
    Answer: E;

    Why? Acarbose--> flatulence;
    Glyburide --> increased potency in renal failure, so contraindicated (no mention in the Q of this patient's renal function);
    Metformin --> lactic acidosis;
    Repaglinide --> weight-gain ;
    Rosiglitazone --> Edema --> CHF in patients with long-standing DM2;



    32. A 34-year-old woman is brought to the emergency department after she collapsed when she returned from a nonstop flight from New Delhi to New York City. She has smoked 1 pack of cigarettes daily for 16 years. She is sexually active and uses an oral contraceptive. Her pulse is 125/min, and blood pressure is 75/50 mm Hg. Physical examination shows jugular venous distention. The lungs are clear to auscultation. Pulmonary artery catheterization shows a pulmonary systolic/diastolic arterial pressure of 50/25 mm Hg (N=15–30/3–12) and a pulmonary artery wedge pressure of 5 mm Hg (N=8–16). Which of the following is the most likely cause of her pulmonary hypertension?
    A)Decreased cardiac output
    B)Increased left atrial pressure
    C)Increased left ventricular diastolic pressure
    D)Increased pulmonary blood flow
    E)Increased pulmonary venous resistance
    F)Occlusion of left ventricular outflow tract
    G)Occlusion of pulmonary arteries
    H)Pericardial tamponade

    smoking decreases the effects of oral contraceptives and increase the chance of blood clot, vein, and heart problems... and this person has been sitting on a flight with little movement... her risk of DVT and thus pulmonary embolism is greatly elevated.... on this assumption my answer is G (occlusion of the pulmonary arteries);
    Last edited by dchaos_g; 08-02-2006 at 05:22 AM.

  4. #13
    wcb22 is offline Elite Member
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    yea, #32 was one i had a conflict with in my original answers. i'll go with B also.
    M.D., PGY-3 Internal Medicine

  5. #14
    marceverett is offline Junior Member 510 points
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    Quote Originally Posted by dchaos_g
    I came to the same answers as you md90 except in the following 3 Qs; here is my rationale for my answers -

    32. A 78-year-old man comes to the physician because of progressive swelling of the right side of his face and neck and his right upper extremity. His right jugular vein is engorged. Which of the following diagnoses is most likely to be confirmed on an x-ray of the chest?
    A)Aortic arch aneurysm
    B)Mass in the upper lobe of the right lung
    CRight cervical rib
    D)Right pneumothorax
    E)Thoracic duct blockage in the posterior mediastinum
    Answer: B, superior vena caval compression by the lung lesion
    (see this paper, where a very similar case is reported). Aortic arch aneurysm can cause SVC obstruction syndrome, but are often asymptomatic (40%), and many more present with chest or back pain. A cervical rib would not first present, I imagine, at age 78. Right pneumothorax would present differently (SOB, +/- trauma, resonant to percussion etc.) The literature and big, heavy books seem to mention thoracic duct obstruction in the context of an effect (of thoracic outlet syndrome), rather than a cause, and add an association with steatorrhea to the presentation.
    The problem I still have lies in the fact that only the right side of the face and right upper limb are obstructed for drainage. Wouldn't superior vena caval syndrome obstruct jugular venous flow bilaterally versus a compression of the thoracic duct if on the right side (which is another issue because it doesn't say right thoracic duct) would cause only the right side of the face and right upper extremity to be occluded.. ala first aid and all anatomy books.

  6. #15
    panera216 is offline Newbie 510 points
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    nbme test

    sorry. where do i take this NBME form 4 test ? thanks

  7. #16
    md90's Avatar
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    first to panera216, please go to www.nbme.org to find the exams that are given by NBME; There are four NBME exams and cost $49 or $45 each; each exam has four 50 questions and you can decide to take the exam either self-paced and/or exam situation; good luck to you...
    "SLAM-DUNK THE STEPS"

    “Peace, it does not mean to be in a place where there is no noise, no trouble, or no hard work…..it means to be in the midst of those things and still be calm in your
    heart.”

  8. #17
    md90's Avatar
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    32. A 78-year-old man comes to the physician because of progressive swelling of the right side of his face and neck and his right upper extremity. His right jugular vein is engorged. Which of the following diagnoses is most likely to be confirmed on an x-ray of the chest?
    A)Aortic arch aneurysm
    B)Mass in the upper lobe of the right lung
    CRight cervical rib
    D)Right pneumothorax
    E)Thoracic duct blockage in the posterior mediastinum
    Answer: B, superior vena caval compression by the lung lesion (see
    this paper, where a very similar case is reported). Aortic arch aneurysm can cause SVC obstruction syndrome, but are often asymptomatic (40%), and many more present with chest or back pain. A cervical rib would not first present, I imagine, at age 78. Right pneumothorax would present differently (SOB, +/- trauma, resonant to percussion etc.) The literature and big, heavy books seem to mention thoracic duct obstruction in the context of an effect (of thoracic outlet syndrome), rather than a cause, and add an association with steatorrhea to the presentation.


    I have narrowed the answers to two answers... B and E... b/c both have the possibility of obstruction but the only blockage for me for not picking B... would not the thyroid gland be affected also??? forget what I just wrote... I do agree with you... the answer is B... thanks for the question
    Last edited by md90; 08-02-2006 at 11:47 AM.
    "SLAM-DUNK THE STEPS"

    “Peace, it does not mean to be in a place where there is no noise, no trouble, or no hard work…..it means to be in the midst of those things and still be calm in your
    heart.”

  9. #18
    dchaos_g's Avatar
    dchaos_g is offline Junior Member 510 points
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    Quote Originally Posted by marceverett
    The problem I still have lies in the fact that only the right side of the face and right upper limb are obstructed for drainage. Wouldn't superior vena caval syndrome obstruct jugular venous flow bilaterally versus a compression of the thoracic duct if on the right side (which is another issue because it doesn't say right thoracic duct) would cause only the right side of the face and right upper extremity to be occluded.. ala first aid and all anatomy books.
    Thanks Mark. I had to go back and double-check this too on a Surgical Anatomy review site, but the thoracic duct enters on the Left side (it is an unpaired structure), so it would not be compressed in this case.



    Reference - http://www.instantanatomy.com

    Thanks to md90 also! This was fun - it is amazing how much revision you can squeeze out of some of these questions!
    Last edited by dchaos_g; 08-03-2006 at 06:20 AM.

  10. #19
    md90's Avatar
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    this question.. a student definitely had to know his/her anatomy of the body... and as dchaos g pointed out from the diagram is what I had to remember... thank you fellow vmders!!!!
    "SLAM-DUNK THE STEPS"

    “Peace, it does not mean to be in a place where there is no noise, no trouble, or no hard work…..it means to be in the midst of those things and still be calm in your
    heart.”

  11. #20
    Unregisteredds\fv Guest
    what about the other questions?

    who knows?

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