Don’t open this file unless you’ve already taken the NBME.

The IDs at the top of each question are taken from elhusseinyusmleprep.com"

First Block.

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113489

• Cardinal (transverse cervical) ligament

  • Connects cervix → pelvic side wall

  • Contains uterine artery and vein

  • Important in hysterectomy: uterine artery is ligated here

    “Water under the bridge” mnemonic: the ureter passes under the uterine artery within the cardinal ligament as it courses through the pelvis.

    

• Broad ligament: Fold of peritoneum that comprises the mesosalpinx (a subdivision of broad ligament that suspends Fallopian tubes), mesometrium (a subdivision of broad ligament that suspends uterus), and mesovarium (a subdivision of broad ligament that suspends ovaries).

• Suspensory ligament of ovary (infundibulopelvic ligament)

  • Connects ovary → pelvic side wall

  • Contains ovarian artery and vein

  • Clinical relevance: Ovarian torsion typically involves twisting of this ligament, often due to a large adnexal mass → occlusion of blood supply → acute pelvic pain and ovarian ischemia

    

• Uterosacral ligament

  • Connects posterior cervix & uterus → sacrum

  • Provides posterior support to the uterus

  • affected in endometriosis

    

• Round ligament of the uterus

  • Fibromuscular band from superolateral uterus → inguinal canal → labia majora; remnant of gubernaculum.
  • During pregnancy, stretching from uterine enlargement and relaxin can cause mild, self-limited pain, often triggered by sudden movements; not associated with preterm labor and requires no treatment.

  

  

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113491

• Subacute, progressive cognitive decline (memory loss, difficulty concentrating, word-finding difficulty) is classic for HIV-associated neurocognitive disorder.
• Poor ART adherence → uncontrolled HIV replication in the CNS.
• MRI with diffuse, bilateral white matter hyperintensities favors HIV encephalopathy (not a focal mass).
• Perivascular distribution of cells on biopsy is characteristic of HIV encephalopathy (macrophages/microglia).
• Occurs in advanced AIDS, often after opportunistic infections (eg, recent P. jirovecii pneumonia).

A) Cryptosporidiosis : Causes chronic watery diarrhea, not CNS disease, No brain MRI or biopsy findings consistent with this diagnosis.

C) HIV protease inhibitor toxicity : Causes metabolic effects (lipodystrophy, insulin resistance), Does not cause progressive cognitive decline or white matter lesions.

D) Lymphoma : Primary CNS lymphoma presents with focal neurologic deficits, MRI typically shows ring-enhancing mass lesions, not diffuse white matter disease.

E) Pneumocystis jirovecii infection : Primarily causes interstitial pneumonia, not CNS pathology, No association with diffuse white matter brain lesions.

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113492

• Skin color differences between light and dark skinned individuals are not due to more melanocytes.
• Both patients have about the same number of melanocytes per unit area of skin.
• Darker skin contains more melanosomes within keratinocytes.
• In dark-skinned individuals, melanosomes are larger, more numerous, and more widely distributed.
• These differences make skin appear darker and protect against UV damage.

Melanocyte = the factory (makes melanin)

Melanosome = the package (holds melanin)

Same melanocytes in everyone

Different melanosomes = different skin colour

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113493

• Portal hypertension causes increased pressure in the portal venous system, leading to formation of esophageal varices via portosystemic anastomoses.

• Esophageal varices are dilated, thin-walled submucosal veins in the distal esophagus that can rupture suddenly and cause massive, fatal bleeding.

• Patients often present with painless hematemesis and hemorrhagic shock, as seen in this case.

• Gross pathology shows tortuous, bulging veins, and microscopy shows dilated venous channels beneath intact mucosa.

• The most common underlying cause of portal hypertension is cirrhosis, although the stem doesn’t need to mention liver disease for the diagnosis.

• Esophageal carcinoma→ causes moderate bleeding not as severe as this patient.

  

  

  Portal hypertension → ↑ hydrostatic pressure → ascites (primary). Low oncotic pressure from hypoalbuminemia RAAS activation → expands plasma volume → worsens fluid leakage.

  

  

  

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113494

• Both curves reach the same steady-state concentration, meaning clearance and bioavailability are the same in obese and normal-weight patients.
• The obese patient takes longer to reach steady state (dashed curve rises more slowly), which reflects a longer half-life.
• Half-life is directly proportional to volume of distribution (Vd)
• In obesity, lipophilic drugs distribute into adipose tissue, increasing Vd.
• So the obese patient has a greater volume of distribution, causing slower accumulation but the same final steady-state level.
• Slower rise = longer time to steady state

B) Higher clearance : If clearance were higher, the steady-state concentration would be lower, The graph shows both patients reach the same steady state, so clearance is unchanged.

C) Lower bioavailability: Lower bioavailability would also lead to a lower steady-state concentration. Since final concentrations are equal, bioavailability is the same.

D) Slower absorption rate: Slower absorption affects time to peak, not time to steady state. Time to steady state depends on half-life, not absorption rate.

E) Shorter half-life : A shorter half-life would cause the drug to reach steady state faster, not slower. The obese patient reaches steady state more slowly → longer half-life, not shorter.

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113502

• Combined oral contraceptives (estrogen-containing) significantly increase the risk of thromboembolism and cardiovascular events in smokers.
• Women ≥35 years old who smoke should avoid estrogen-containing oral contraceptives due to increased risk of MI and stroke.
• The risk is dose-dependent with smoking, but any smoking in this age group is a contraindication.
• Obesity increases baseline VTE risk but is not an absolute contraindication to OCPs by itself.
• Family history of breast cancer after menopause is not a contraindication to OCP use.

Age ≥35 + smoking → contraindication to combined oral contraceptives History of DVT or PE or known thrombophilia → contraindication History of stroke or myocardial infarction → contraindication Migraine with aura → contraindication Uncontrolled hypertension → contraindication Estrogen-dependent malignancy (eg, breast cancer) → contraindication Active liver disease or hepatic adenoma → contraindication Pregnancy → contraindication Prolonged immobilization or major surgery → contraindication Severe hypertriglyceridemia → contraindication

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