Step 2 CK NBME Form 4

Edited
Block 1
D (recurrent candidal infections >> impaired cell .1
mediated immunity)
A (reassuring pattern) .2
E (normal pressure hydrocephalus >> .3
impairment of the higher mental control of the
bladder which basically inhibits the voiding reflex)
A (post-streptococcal acute glomerulonephritis) .4
D (hostility towards authority without gross .5
moral violations)
B (high BP plus papilledema) .6
E (Multiple sclerosis) .7
C (the patient is psychotic so her demand for an .8
abortion cannot be allowed. Haloperidol can be
used in pregnancy if the benefit to the mother
clearly outweighs the potential fetal risk
D (Crohn's disease predisposes to fibrotic .9
strictures)
D (Slipped capital femoral epiphysis) .10
E (RSV infection) .11
A (facial edema + linked with history of food .12
intake)
E (hint: irregular mobile mass in the right upper .13
quadrant)
B (blood cultures to confirm endocarditis. Blood .14
cultures should always be collected before
antibiotic treatment begins.)
D (chronic pancreatitis. amylase and lipase .15
may or may not be elevated. pancreatic enzyme
replacement therapy to relieve steatorrhea.)
B (increased intracranial pressure plus growth .16
retardation plus visual difficulty >>

craniopharyngioma fits)
F (joint aspiration >> first step in management .17
of a swollen, tender joint)
D NSAIDS (Osgood Schlatter Disease: .18
Osteochondrosis of the tibial tubercle Tx: Kaplan
notes say immobilization of the knee in an
extension (or ) Cylinder cast for 4 6 weeks. Books
also mention NSAIDs as part of treatment.
Apparently the correct answer on online NBME,
informed by a commenter, is D - NSAIDs)
A (pulmonary embolism, Spiral CT scan .19
preferred over pulmonary angiography)
E (restrictive pattern on PFTs) .20
B (Intussception >> contrast enema is .21
diagnostic and therapeutic)
D (oral-esophageal candidiasis in HIV >> .22
Fluconazole)
G (Diabetes mellitus) .23
B (Febrile neutropenia) .24
D .25
A (only 40% of original participants remain) .26
F (patient was well-controlled on Paroxetine >> .27
best option is to resume it)
G (hint: masses vary in size with her menstrual .28
cycle)
C .29
A ( diastolic decrescendo murmur )
A .30
B (Systolic murmur radiating to carotids is .31
classic for aortic stenosis.)
D (Metronidazole for pseudomembranous .32
colitis)
D .33
A (L to R shunt >> increased pulmonary blood .34
flow)
A (subarachnoid haemorrhage can lead to .35

diabetes insipidus)
F (vitamin D supplementation is recommended .36
for all breastfed infants)
D (patient fulfills criteria of Major Depression. .37
Note the marked anhedonia >> no longer enjoys
the taste of food)
A (von Willibrand disease) .38
A (specific trigger, doesn't fulfill criteria of .39
Major Depression)
A (Urge incontinence) .40
D (N0 M0 indicates that the tumor removal was .41
most likely complete, therefore metastatic diseases
is unlikely. Plus patient's smoking history also is
risk factor for primary lung cancer.)
A (Hemochromatosis) .42
D .43
C (alzeimers Dementia) .44
B (Postal worker >> high risk for bioterrorism. .45
Cutaneous anthrax eschar is characteristic)
E (ankle edema >> well known side effect of .46
Nifedipine)
Block 2
E (positive ANA and dsDNA) .1
C (ST elevation on ECG at lead 2 3 AvF) .2
G (Tension pneumothorax) .3
B handwashing practices. B .4
C (Naproxen >> nephrotoxicity) .5
E .6
C (looks like alcohol withdrawal) .7
D (Hydatidiform mole) .8
B (obesity, papilledema, bifrontal headaches) .9
B (hyperkalemia with ECG changes >> Ca .10
Gluconate)

D (GI obstruction, first step NG decompression) .11

B (depression history + mania episode now) B .12
A .13
A (2 year h/o productive cough >> Chronic .14
Bronchitis. O2 sat: 90% >> Blue Bloater)
A (smoking is a contraindication for OCPs) .15
C (Foreign body ingestion >> bronchoscopy) .16
M low TSH high blood pressure M .17
C (Isoniazid neurotoxicity preventable by .18
administration of B6)
B (hyperglycemia can cause hyponatremia) .19
E (elderly patient, hematocrit too low, transfuse .20
RBC. We don't use 5% Dextrose water or 0.45%
saline for resuscitation, we use 0.9% Saline, which
isn't given among options)
A (oral & genital ulcers plus erythema .21
nodosum)
C (Erysipelas) .22
D (MRI shows a mass obstructing CSF outflow .23
from the ventricles. Choice E is wrong. Choroid
plexus papilloma most commonly occurs in
Children, and even Choroid plexus papilloma itself
can cause obstruction to CSF flow depending on its
location)
E (cystic fibrosis) .24
B (Endometriosis. Clues >> infertility, .25
dysparunea)
C .26
A skin hyperpigmentation A .27
C (typical position of venous ulcers + skin .28
discolouration (lipodermatosclerosis) plus there r
varicose vein near the knees if u look closely)
B (NSAID induced (pseudo)allergic reaction. .29
Avoid aspirin)
C (best option) .30

A (peripheral arterial disease makes .31

atherosclerotic process most likely)
E (essential tremor >> propranolol) .32
C (poorly controlled HTN >> increased risk of .33
MI)
B (CA of head of pancreas) .34
D (most common agent of septic arthritis>> .35
staph aureus) D
E (mitotic figures means high proliferation, plus .36
infiltrating into surrounding muscle)
E
C (long-standing lymphedema >> .37
lymphangiosarcoma)
A (avoid permanent/prolonged catheterization .38
wherever possible)
D (shallow respiration, ) D.39
B (Nursemaid's elbow, radial head subluxation. .40
treatment is gentle supination and flexion)
D( heptic amboebiasis) D.41
I (travel history plus fever and splenomegaly> .42
suspect malaria) I
B .43
A (diffuse enlarged uterus >> adenomyosis, .44
in contrast, leiomyoma has asymmetrically
enlarged uterus)
E (pt is already on TMP SMX, so less chance of .45
pneumocystis, and this is lobar pneumonia,
pneumocystis shows interstitial pneumomnia>>
bilateral infiltrates on x ray)
A (warm compresses would provide most quick .46
symptomatic benefit. Compression stockings and
enoxaparin therapy are valid options but would not
help with the pain.)
Block 3

B (Fragile X syndrome).1
E (Neuroleptic Malignant Syndrome) .2
C (small cell carcinoma >> SIADH) .3
E (pt took medoxyprogesterone intermittently .4
means she is on oestrogen therapy alone for some
time and now she is having post-menopausal
bleeding, we need to rule out Ca endometrium) E
B .5
D (clue: she comes in the fall) .6
A ( 5mins after giving penicillin) A .7
B (The most common cause of lymphangitis in .8
humans is Streptococcus pyogenes)
B (dorsum of the foot sensory supply is .9
peroneal N) B
A (neonatal tetanus) .10
D (Dextrose water is not used for resuscitation; .11
use normal saline or ringer lactate)
C (selenium sulfide shampoo can be used for .12
treatment of tinea versicolor)
B (long bone fracture) B.13
B (young female, low platelet count, absent .14
other physical findings) B
E (postpartum, sudden onset of dyspnea after .15
ambulataion, hypoxia) E
A (look for air under the diaphragm) .16
D (It cannot be excessive Vitamin D because .17
serum phosphorus is below normal)
B diabetes nephropathy, microalbuminuria
B .18
B travel, abdominal bloating, steatorrheoa
.19
B
Q (rings on Prussian blue) .20
H ( anemia on chronic renal failure)
H .21
E (anemia plus the whole spectrum of .22
leuopoiesis visible in peripheral smear plus
thrombocytosis, plus philadephia chromosome )

E
J (no prenatal care plus macular rash involving .23
palms and soles >> think Syphilis)
E (referred pain to left shoulder plus left pleural .24
effusion makes subphrenia abscess more likely )
C (blood at urethral meatus >> look for .25
urethral injury)
B (Tinea capitis. Can be transmitted by direct .26
contact or through sharing of combs, hats and
clothing.)
A (sudeen urge to void + couldnt make it in .27
time to toilet >> urge incontinence) A
B (septic shock) .28
C .29
A (pale mucosa, cobblestoning) .30
D (contrast nephropathy can be decreased with .31
proper hydration)
E (Hirschsprung disease) .32
C .33
A (passive smoking increases the incidence of .34
ear and throat infections in children)
A .35
E .36
D thiazide side effect>> hypokalemia, >> .37
muscle weakness
D
A (Normal aging. She doesn't have dementia. .38
MMSE score of 27 is normal.)
A ( white thin woman>> high risk for OP) A.39
D ( impending sense of doom) D .40
C (Juvenile rheumatoid arthritis) .41
G (elderly patient with platelet count normal .42
and mucosa and skin bleeding>> collagen defect>
due to VIt C deficiency) G
C ( RA plus splenomegaly plus leukopenia) C.43

C (Ambulatory ECG monitoring is not used to .44

diagnose angina)
F (Epiglottitis) .45
B (Febrile seizure) .46
Block 4
D ( sudden deterioration in dementia in elderly< .1
history of hypertension, barbinski sign on left>>
points towards stroke) D
E (Mitral Stensis >> Increased pulmonary .2
venous pressure)
D (Late decelerations >> fetal hypoxia, .3
placental insufficiency)
D .4
C (Start HAART with CD4 below 350 and .5
Pneumocystis prophylaxis with CD4 below 200)
B (Patient fulfills criteria of Major Depression. .6
Start antidepressants.)
C (Polycythemia Vera) .7
E (pneumocystic carnii) E.8
C (suspicion of Mastoiditis) .9
E (clues >> pharmacist, advised to lose .10
weight)
B (Epididymo-orchitis in a sexually active .11
young male)
D (Acne vulgaris) .12
C .13
D (Abdominal angina. Widespread .14
atherosclerosis makes it likely.)
C .15
E .16
C (Granulosa cell tumor >> excess estrogen) .17
C (Acute poststreptococcal glomerulonephritis .18
>> low C3)

A (Hereditary Angioedema. C4 is also .19

decreased in Hereditary Angioedema, but C1
Estrase Inhibitor's deficiency is the primary
pathophysiology. So while C4 is also the correct
answer, I believe we should prefer C1 Estrase
Inhibitor given the causative role it plays in the
disease. )
E .20
A (Alzheimer's dementia >> decreased .21
acetylcholine)
A (dry mucous membrances, dilated pupils, .22
flushed appearance)
A (Doxorubicin >> cardiotoxicity) .23
E .24
B (patient most likely stopped taking .25
prednisone)
G .26
F .27
B .28
B .29
E .30
B .31
E (her rising PCO2 indicates impending .32
respiratory failure)
B .33
D .34
C (Pelvic Inflammatory Disease) .35
F .36
A .37
G (Myasthenia gravis) .38
F (obstructive sleep apnea) .39
E .40
A (vegetarian diet predisposes her to B12 .41
deficiency)
D .42

B .43
G (buzzword: bag of worms) .44
C (embolism of cardiac myxoma) .45
B .46
Ps I m not original author of those answers.
But I got 15 incorrrects in NBME 4 online and
I reviewed them with another frd who did
online and doublechecked those answers,
modify and added some explanations. In the
hope that this helps ppl who wanna do it
offline. U can trust answers in here, 99%,
(only 3 answers I m not 100% sure) all
.checked and confirmed with online
.Pls keep me in ur prayers
..Dr.katherine
28/5/2014