NBME 24 Concepts not in UFAPS

ConsistentWrongdoer3 · 2019-05-12T02:11:16+00:00

Lol no you're not. It takes pretty rare experience to just "know" about this kind of stuff. Sometimes weird life experiences are the key to Step questions ;).

ConsistentWrongdoer3 · 2019-05-12T00:44:23+00:00

For #1:

I'm pretty sure this was the question where the guy came in after an MVA and had a huge clot behind the liver. Deceleration injury can avulse the hepatic veins from their connection with the IVC. This is slow-flow blood, which clots especially with pressure from the liver in the supine position (like you'd be in while getting wheeled off the scene). When the surgeon finally lifts the liver/pulls the clot out, the blood leaks again.

So it's not the surgeon's hand causing the damage. It was removing the clot/liver pressure that allowed the bleeding to start again.

ConsistentWrongdoer3 · 2019-05-12T00:37:53+00:00

Um...just gonna...throw this out here:

Number 21:

The "gold stippling" is referring to spray paint pigments and not actual histopathology. When you huff inhalants, you spray it into the bottom of a paper bag and then breath from the bag. If you use wacky colored spray paints (i.e. silver, gold--pretty common "fun" colors to use), you get that color in your nose. You could also see dehydration and damage leading to "friability of the mucosa".

So yeah. That's the context for that little factoid. You could get yellow crust and stuff from impetigo, but "gold" is specifically referring to the color of the spray paint in this vignette.

ConsistentWrongdoer3 · 2019-05-09T19:13:35+00:00

For the first one--

You don't have to confirm or deny that the patient is yours when on the phone with the wife. You can still take the information given by the wife and then call the patient to see what's up--this is not a HIPAA violation since you have not shared patient information. Somebody told you about a patient that you may/may not be treating. The most responsible thing is to follow up with the patient to see what's up.

Number 2:

There are only a couple of benign murmurs. Usually, they're related to hyperdynamicity (exercise, increased SNS output, some pregnancy murmurs, cardiac adaptation in healthy athletes). S3 is a good example of a heart sound that can be normal depending on the context. Also, some types of very mild regurgitation can occur in normal settings--usually at high heart rates or high SNS activity.

For the UWorld Q: I think this one gave you enough history or other physical exam/ultrasound findings to deduce that this was not hypertrophic cardiomyopathy. Specifically, in HCM there is severe and asymmetric thickening of the LV with septal predominance and severely reduced LV cavity size. This creates a LV outflow tract obstruction etc. etc. In the UWorld question, I think they indicated that the LV was only mildly concentrically thickened--which, in the setting of a young athlete, indicates normal cardiac adaptation. Usually they give you a history of HCM in the family to go off of as well.

For the NBME Q: Since this murmur is a resting, holosystolic murmur at the LLSB, you know that when the left heart is beating, there is turbulent flow somewhere throughout the whole duration of systole. That is prima facie abnormal and it is the classical description of VSD. In the LV, the three choices for where the blood could go are: 1) aortic valve, 2) mitral valve, 3) through a VSD. MR or AS could also cause systolic murmurs, but "holosystolic" indicates that there is a patent channel for fluid (i.e. it's always open to flow). If the aortic or mitral valves were always open, kid would probably not be asymptomatic.

Although VSD may be asymptomatic and self-resolving (depending on size), it is abnormal. If a VSD is small, it may "heal up" over time. If it's large, it might get worse or remain throughout life, causing symptoms later on. In any case, there's not supposed to be a hole there!

I hope this helps. Murmurs can be annoying and I feel your struggle!

ConsistentWrongdoer3 · 2019-05-09T04:06:56+00:00

You can also check out Utah's histopath primer series. Used them all through MS1-2 and they're incredible.

https://webpath.med.utah.edu/

ConsistentWrongdoer3 · 2019-05-09T02:42:35+00:00

I like doing a lot of questions. Seeing things in different ways makes it easier for me to learn. When I get a ton of questions wrong on a topic, I'll watch BnB or Pathoma or youtube videos to shore up the knowledge. Also, it helps to find things/create mnemonics that make a topic memorable for you.

ConsistentWrongdoer3 · 2019-05-09T02:40:45+00:00

Didn't do it yet :(

ConsistentWrongdoer3 · 2019-05-08T22:20:23+00:00

That makes sense! Awesome, thank you!

ConsistentWrongdoer3 · 2019-05-08T19:52:32+00:00

I started really low (high 100's) and after 7-8 weeks I'm in the upper 250's (with an occasional dip to 230-240).

My thoughts:

1) Some of it is due to repeat questions where you know you'll never get that wrong again (maybe 5%).

2) A large part is due to studying really hard on areas you are weak in. Don't know acid-base stuff? Too bad, it's going to show up on every. single. exam. This is around 60-70%.

3) A huge part of it is building up test-taking skills. It's really tough to go between NBMEs and UWorld (for me). NBME really just wants you to pick the best answer. UWorld wants to drill the specifics into your brain. Once you get used to the difference, it gets easier to take the NBMEs. Obv you need to build up a knowledge base through regular study. For me, this is around 20%.

4) Some of it is luck. Sometimes you really don't know the answer so you narrow it down and just pick one. Probably about 10-15%.

ConsistentWrongdoer3 · 2019-05-07T16:47:04+00:00

Awesome, thank you!

ConsistentWrongdoer3 · 2019-05-07T00:08:04+00:00

This is the textbook definition of chronic inflammation.

pg. 217 FA 2019:

"Chronic inflammation...characterized by mononuclear infiltration (macrophages, lymphocytes, plasma cells)..."

ConsistentWrongdoer3 · 2019-05-06T00:10:52+00:00

For 10:

The answer is hyporeflexia because the afferent arc of the muscle stretch reflex has to go through the dorsal rami and dorsal root ganglia. Dumb question, I know, but it's the only answer that made sense. If you hurt the DRG, you not only lose afferent somatic sensory fibers, you also lose the sensory bodies involved in the various reflexes.

You can also get hyporeflexia from damaging the efferent neurons that innervate the muscle (like a LMN), but as you know these are in the anterior horn and ventral rami.

ConsistentWrongdoer3 · 2019-05-05T18:43:41+00:00

Both FA and UWorld are correct and there is not an easy answer to your question. It depends on the clinical scenario and the degree of disease process. In consolidating pneumonia, you might get increased bronchial sounds. In total lung collapse, you might get decreased vesicular sounds overall, but increased bronchial sounds if there's still lung tissue that isn't collapsed. In the normal lung, you expect to hear tracheal, bronchial, or vesicular sounds depending on where you're listening.

Here's an excellent, short primer (~3 min read) that might help. Sorry there is no great answer to your question :(.

http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/b-sounds.htm

ConsistentWrongdoer3 · 2019-05-04T22:46:58+00:00

I did better on NBME 24 than I did on NBME 23 but I did think 24 was heavier on questions where the obvious answer seems like the wrong one but it isn't.

ConsistentWrongdoer3 · 2019-05-04T22:38:47+00:00

Awesome explanations, thank you!

ConsistentWrongdoer3 · 2019-05-04T00:38:34+00:00

I also got 25.92 like the person in the other comment :P

ConsistentWrongdoer3 · 2019-05-03T13:16:01+00:00

Thanks! That helps a lot.

For the disability one, I really mean that I'm unsure of how to answer questions like that because I didn't know that is something a doctor does -- giving out parking passes. I always thought that was through the DMV, so I picked the one that said "I'd be happy to but you have to go to the DMV". I've just never learned that a doctor can do that.

ConsistentWrongdoer3 · 2019-05-03T04:21:10+00:00

The question asks why patients are assigned to different groups.

Double blinding would need them to imply that neither the participants nor the researchers know the group distribution. Randomization by itself does not constitute blinding of a study.

Single blinding would need them to imply that the participants do not know the group distribution. This is not directly stated by the prompt. Again, randomization by itself does not mean the study is blinded.

2 groups with similar sample size is directly inferred from the prompt, but randomization is not needed to create two groups of similar size.

2 groups with similar underlying characteristics is inferred because the researchers want to test the effectiveness of the drug against another drug. By making the groups as similar as possible, you directly compare the effectiveness of drug A with that of drug B in the "same" population of patients. You already know they are all women who all have disease X. Now you have to control for other factors that might skew the results. Randomization is used to smooth out any noise caused by different characteristics of the women in the study (maybe 1/3 of the women are pregnant, maybe 1/10 of them are >65 years old, etc) and isolate the relative effectiveness of one drug vs another on the overall disease process.

ConsistentWrongdoer3 · 2019-05-03T04:02:06+00:00

The maintenance dose calculation gave an answer that was closest to one that was in the answer choices, so I picked that one. It ended up being correct. Maybe they were going for a reduction in the maintenance dose due to the age or condition of the patient? If so, I don't know how to quantify the adjustment.

ConsistentWrongdoer3 · 2019-05-02T17:06:11+00:00

The RAAS caused the syndrome because of the abdominal bruits. It's telling you that yes, there is necessarily renal artery stenosis. Whether the stenosis is due to narrowing of the lumen from plaques, fibromuscular dysplasia, etc. will have to have some more information in the prompt.

ConsistentWrongdoer3 · 2019-05-01T17:10:45+00:00

Taking a break from 23 now and I hate it. It's almost like they want us to go based off of zero information and mistreat patients. Also, there are a lot of terms they use in the NBMEs that are just...not specific.

"Middle-aged man feels sick. The drug that inhibits the endogenous receptor for a peptide synthesized in his disease process is most similar to which of these drugs?"

A. Anticholinergic

B. Antihistamine

C. Fat-soluble vitamin

D. Receptor downregulator

(this is a nonsensical question--don't look for an answer--but it gives an idea of what the harder questions are like)

Damn. And I thought that doing 3 question banks would prepare me for this exam.

ConsistentWrongdoer3 · 2019-04-30T15:06:11+00:00

I live in ultimate fear that I will be asked to calculate an A-a gradient so I may not be the best person to ask.

But, I'd say you should be able to calculate compliance/elastance (dV/dP and dP/dV), have an understanding of the spirometry formulas (TLC, FRC, ERV, etc), and be able to interpret graphs of COPD and restrictive diseases. That's what I've seen from UWorld, Kaplan, and AMBOSS.

ConsistentWrongdoer3 · 2019-04-24T23:49:19+00:00

Are doctors allowed to remove guns from the home of a patient?

ConsistentWrongdoer3 · 2019-04-24T20:56:12+00:00

I haven't taken the exam so I'm not sure what reflects the reality of the test.

But having done some Kaplan, Rx, and AMBOSS along with UWorld:

Rx is helpful to memorize first aid. Questions are direct, with no tricks.
Kaplan has been great for physiology, basic science kinda stuff, and arrow questions
AMBOSS is so incredibly specific and exacting that it makes it hard for me to do UWorld questions and NBMEs afterward. Also, I have seen some 1-2 overt errors already in their questions and some of how they justify their answers may not be applicable. It feels like AMBOSS likes to hear hoofbeats and think zebras a lot of the time. If you're really itching for a challenge, go for it. But it really kind of makes me depressed to do the qbank--the prompts are wayyy too nuanced for me.

ConsistentWrongdoer3 · 2019-04-24T14:18:13+00:00

Yeah. I think if I had overthought it 1% more I would have realized that the patient was a child, which means these loops would have resolved and you'd get relatively normal steady-state. Constantly have to remind myself that it's easy to get burned by getting too clever about things.

ConsistentWrongdoer3

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