NBME Medicine 2 — Questions and Answers
Question 1: A 58-year-old man presents with 30 minutes of crushing substernal chest pain radiating to his left arm. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?
- Left anterior descending
- Right coronary artery (Correct answer)
- Left circumflex artery
- Left main coronary artery
Correct answer: Right coronary artery
ST elevation in II, III, and aVF indicates an inferior STEMI, which is most commonly caused by right coronary artery occlusion.
Question 2: A 65-year-old woman with a recent 6-hour flight presents with sudden onset dyspnea and pleuritic chest pain. Her D-dimer is elevated and HR is 112 bpm. Which finding on CT pulmonary angiography would confirm the diagnosis?
- Consolidation in the right lower lobe
- Intraluminal filling defect in the pulmonary vasculature (Correct answer)
- Pleural effusion
- Ground-glass opacities bilaterally
Correct answer: Intraluminal filling defect in the pulmonary vasculature
CT pulmonary angiography confirms pulmonary embolism by demonstrating an intraluminal filling defect within pulmonary vessels.
Question 3: A 22-year-old type 1 diabetic presents with vomiting, abdominal pain, and fruity breath. ABG shows pH 7.22, HCO3 10 mEq/L, glucose 480 mg/dL. What is the priority initial treatment?
- Sodium bicarbonate IV
- Insulin bolus IV
- IV isotonic saline fluid resuscitation (Correct answer)
- Potassium replacement only
Correct answer: IV isotonic saline fluid resuscitation
Fluid resuscitation with IV isotonic saline is the first priority in DKA to correct volume depletion before initiating insulin.
Question 4: A 70-year-old man with systolic heart failure (EF 30%) presents with worsening dyspnea and bilateral leg edema. His current medications include lisinopril and carvedilol. Which additional drug has been shown to reduce mortality in this patient?
- Digoxin
- Amlodipine
- Spironolactone (Correct answer)
- Hydralazine
Correct answer: Spironolactone
Spironolactone (an aldosterone antagonist) reduces mortality in patients with reduced EF heart failure when added to ACE inhibitor and beta-blocker therapy.
Question 5: A 67-year-old smoker with known COPD presents with worsened dyspnea and increased yellow sputum production. ABG shows pH 7.32, PaCO2 58, PaO2 54. What is the most appropriate initial oxygen target?
- SpO2 >98% via non-rebreather mask
- SpO2 88–92% via controlled low-flow oxygen (Correct answer)
- SpO2 >95% via Venturi mask at 60%
- No supplemental oxygen until intubated
Correct answer: SpO2 88–92% via controlled low-flow oxygen
COPD patients with hypercapnia should receive controlled low-flow oxygen targeting SpO2 88–92% to avoid suppressing the hypoxic respiratory drive.
Question 6: A 45-year-old woman reports fatigue, cold intolerance, constipation, and weight gain over 6 months. TSH is 18 mIU/L and free T4 is low. Which finding would most specifically indicate an autoimmune cause?
- Elevated TSH
- Positive anti-TPO antibodies (Correct answer)
- Low free T4
- Diffuse goiter on ultrasound
Correct answer: Positive anti-TPO antibodies
Positive anti-thyroid peroxidase (anti-TPO) antibodies are the hallmark of Hashimoto thyroiditis, the most common autoimmune cause of hypothyroidism.
Question 7: A 72-year-old man with hypertension presents with palpitations. ECG shows irregularly irregular rhythm with absent P waves. He has no prior anticoagulation history. CHA2DS2-VASc score is 3. What is the most appropriate management for stroke prevention?
- Aspirin 81 mg daily
- Warfarin with target INR 2–3
- Direct oral anticoagulant (e.g., apixaban) (Correct answer)
- No anticoagulation needed
Correct answer: Direct oral anticoagulant (e.g., apixaban)
A CHA2DS2-VASc score ≥2 in men with atrial fibrillation warrants anticoagulation; DOACs are preferred over warfarin for non-valvular AF due to better efficacy and safety profile.
NBME Medicine 2
A 58-year-old man presents with 30 minutes of crushing substernal chest pain radiating to his left arm.
ECG shows ST elevation in leads II, III, and aVF.
Which coronary artery is most likely occluded?