NBME 6

extraintestinal ssx of IBD

little girl with septic knee in pain. control pain or arthrocentesis?

low pleural protein in CHF.

stopped taking lorazepam 3 days ago. feels anxious. PTSD or d/c lorazepam?

pericardial tamponade NBSIM? (no pericardiocentesis)

myocardial contusion.(h/o of trauma to chest, and increase PCWP means the left atrial filling pressure is increased shows blood is not moving forward from the heart)

lithium pt measure what at 4 months? cr vs TSH?

neg strept test NBSIM

gallstone ileus mimics?

A 20-year-old man comes for a routine health maintenance examination. He has a 15-year history of difficulty relaxing his hands after tightly gripping objects or after shaking hands. His father has cataracts and frontal baldness. Examination shows thin forearms. There is moderate weakness of the hands and difficulty releasing after gripping with his hands. Which of the following is the most likely diagnosis? A) Amyotrophic lateral sclerosis B) Cervical spondylosis C) Multiple sclerosis D) Myasthenia gravis E) Myasthenic (Lambert-Eaton) syndrome F) Myotonic muscular dystrophy G) Polymyalgia rheumatica H) Polymyositis I) Progressive neuropathic (peroneal) muscular atrophy

muddy brown cast

Papilledema indicates malignant HTN. Tx is with IV labetalol, nitroprrusside or nicardipine.

A 67-year-old man comes to the emergency department 1 hour after the onset of vertigo, nausea, and imbalance. He has a 20-year history of poorly controlled hypertension. His pulse is 70/min, respirations are 20/min, and blood pressure is 210/115 mm Hg. Examination shows a small right pupil, mild right ptosis, and nystagmus. Neurologic examination shows weakness of the right palate. Sensation to pinprick is decreased over the right side of the face and left extremities. There is incoordination on finger-nose testing and heel-knee-shin testing on the right. Which of the following arteries is most likely to be occluded? A) Anterior spinal G) Left vertebral B) Basilar H) Posterior spinal C) Left anterior cerebral I) Right anterior cerebral D) Left internal carotid J) Right internal carotid E) Left middle cerebral K) Right middle cerebral F) Left posterior cerebral L) Right vertebral

11. A 67-year-old woman is hospitalized because of abdominal pain and persistent copious vomiting for 24 hours. Two weeks ago, she was hospitalized for treatment of atrial fibrillation; after cardioversion to a normal sinus rhythm, she began treatment with warfarin. Yesterday at a follow-up visit, her INR was 6, and her medication was discontinued. She takes no other medications. Her temperature is 37 C (98.6 F), blood pressure is 100/78 mm Hg, pulse is 120/min and regular, and respirations are 20/min. The abdomen is distended and moderately tender; there is voluntary guarding in the epigastrium. There are no masses, organomegaly, or obvious hernias. Rectal examination shows no abnormalities. Test of the stool for occult blood is negative. Her hemoglobin level has decreased from 13 g/dL yesterday to 7.8 g/dL today. An ECG shows a normal sinus rhythm. Which of the following is the most likely explanation for this patient's abdominal symptoms? A) Internal small-bowel herniation B) Intestinal ischemia from a cardiac embolus C) Intramural hematoma of the proximal small bowel D) Intussusception of the small bowel E) Malrotation of the small bowel

a 4 week old newborn is brought to the physician because of increasing difficulty feeding, poor weight gain, and excessive perspiration since birth. She was born at term after an uncomplicated pregnancy and delivery and weighed 3500g (7 lb 11 oz); initial examination showed no abnormalities. Family history is noncontributory. She currently weighs 3800 g (8 lb 6 oz). Her temperature is 37 C (98.6 F), pulse is 160/min, and respirations are 80/min and labored. A grade 2/6 holosystolic murmur is heard over the lower left sternal border. The lungs are clear to auscultation. A chest x-ray shows cardiomegaly with increased pulmonary vascular markings. An ECG shows right ventricular hypertrophy. Which of the following is the most likely explanation for the absence of the murmur on initial examination? a)High pulmonic vascular resistance b) high systemic vascular resistance c) low pulmonary vascular resistance d) low systemic vascular resistance e) patent ductus arteriosus (wrong)

A 32-year-old woman comes to the physician because she and her husband have been unable to conceive for 2 years. They have sexual intercourse every 2 days. Menarche was at the age of 14 years. Menses occur at irregular 35- to 50-day inten/als and last 10 days; they are not painful. Menstrual flow is normal. She has no history of serious illness and takes no medications. She used an oral contraceptive for 16 years for menstrual cycle regulation but discontinued it 2 years ago. Her husband's sperm count is within the reference range. The patient is 152 cm (5 ft) tall and weighs 72 kg (160 lb); BMI is 31 kg/mi'. Physical examination shows acne vulgaris over the face, upper shoulders, and back. The remainder of the examination, including pelvic examination, shows no abnormalities. Serum thyroid-stimulating hormone, free testosterone, dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone, and follicle-stimulating hormone concentrations are within the reference ranges. Which of the following is the most likely diagnosis? A) Endometriosis B) turners C) PCOD D) hyperprolactinoma E) Prematureevarian-failure

A previously healthy 52-year-old man comes to the emergency department because of hiccups for 1 week. He has smoked two packs of cigarettes daily for 30 years. He does not drink alcohol. He is alert and oriented. His temperature is 37 C (98.6 F), blood pressure is 150/95 mm Hg, pulse is 70/min, and respirations are 12/min. Physical and neurologic examinations show no abnormalities. His serum sodium level is 120 mEq/L. An x-ray film of the chest shows a right hilar mass. Which of the following is the most appropriate next step in treatment? A ) Bisphosphonate therapy B ) Calcitonin therapy C ) Calcium therapy D ) Dexamethasone therapy E ) 5% Dextrose in 0.225% saline therapy F ) 5% Dextrose in 0.45% saline therapy G ) 5% Dextrose in water therapy H ) Fluid restriction I ) Hydrocortisone therapy J ) Lactated Ringer's solution K ) Mannitol therapy L ) Potassium therapy M ) 0.9% Saline therapy N ) 3% Saline therapy O ) Sodium bicarbonate therapy

33. A 6-month-old girl is brought to the physician because of poor feeding and labored breathing for 2 months. She has had recurrent respiratory tract infections since birth. Examination shows a to-and-fro murmur in the second left intercostal space, a loud S2, bounding peripheral pulses, and a widened pulse pressure. Which of the following is the most likely diagnosis? A) Atrial septal defect (ostium primum type) B) Atrial septal defect (ostium secundum type) C) Atrioventricular canal D) Coarctation of the aorta E) Hypoplastic left heart syndrome F) Patent ductus arteriosus G) Tetralogy of Fallot H) Transposition of the great arteries I) Tricuspid atresia J) Ventricular septal defect

Q-35 A newborn is in severe respiratory distress immediately following delivery. She was born at 35 weeks' gestation to a 35-year-old woman, gravida 2, para 1, aborta 1, who did not receive prenatal care. The newborn's pulse is 60/min, and respirations are irregular and labored. Examination shows pallor with perioral cyanosis, anasarca, hepatosplenomegaly, and scattered petechiae. Cord blood hemoglobin is 4 g/dL, and reticulocyte count is 18%. A direct antiglobulin (Coombs') test is positive. Which of the following sets of blood groups is most likely in the mother and her newborn? Mother Newborn A) A, Rh-positive O, Rh-positive B) A, Rh-positive O, Rh-negative C) A, Rh-negative O, Rh-negative D) O, Rh-positive O, Rh-negative E) O, Rh-negative O, Rh-positive

An asymptomatic 47-year-old man comes for a preemployment examination. He has never been hospitalized. He is a computer programmer, and he plays handball once weekly. His maternal grandmother had type 2 diabetes mellitus, and a paternal uncle had heart disease. The patient's blood pressure is 126/80 mm Hg. Examination shows no abnormalities. His total serum cholesterol level is 225 mg/dL. Which of the following is the most appropriate next step in management? A) Step 2 American Heart Association cardiac diet B) Serum lipid studies while fasting C) Exercise stress test D) Oral cholestyramine and niacin therapy E) Oral pravastatin therapy at bedtime

A previously healthy 67 year old man comes to the physician because of a 3-month history of right leg pain after walking two blocks. He has smoked two packs of cigarettes daily for 50 years. He is 165cm (5ft 5in) tall and weighs 77 kg (170lb); BMI is 28 kg/m2. Examination of the right lower extremity shows shiny skin and decreased hair growth. Peripheral pulses are: Femoral Popliteal dorsis pedis posterior tibial Right 3+ 2+ 0 0 Left 3+ 2+ 2+ 2+ The right ankle brachial index is 0.6 (N>1), and the right answer is daily exercise programleft is 0.9. In addition to smoking cessation, which of the following is the most appropiate next step in management? 1- daily exercise program 2- Angioplasty 3- Arteiography 4. Femoropopliteal bypass grafting

A 5-year-old boy is brought to the emergency department 30 minutes after he fainted at home after standing up from a sitting position. His symptoms began 3 days ago with diarrhea and vomiting. He has had no urine output for 18 hours. He is alert but quiet. His temperature is 37.5 C (99.5 F), blood pressure is 75/45 mm Hg, pulse is 120/min, and respirations are 28/min. Examination shows dry lips and tenting of the skin. There is no abdominal tenderness. Bowel sounds are hyperactive. The remainder of the examination shows no abnormalities. His capillary refill time is 5 seconds. Intravenous bolus doses of 0.9% saline are administered. Bladder catheterization yields 5 mL of urine. Urinalysis is most likely to show which of the following? A ) Blood B ) Erythrocyte casts C ) Hyaline casts D

A 6-month-old girl is brought to the physician for a routine health maintenance examination. She was born with a lumbosacral myelomeningocele which was successfully repaired at 2 days of age. The anterior fontanelle is 6 x 8 cm and bulging, and the posterior fontanelle is 3 x 4 cm and bulging. She has severe motor and sensory deficits involving both lower extremities. A head growth chart shows the following values: Age Head circumference (cm) Birth 34.2 1 month 36.6 2 months 38 4 months 44 6 months 47 Which of the following is the most likely cause of increased intracranial pressure? A) Acute cerebral edema B) Decreased absorption of cerebrospinal fluid C) Dilation of cerebral arteries D) Intracranial mass lesion E) Obstruction of lateral sinus F) Obstruction of superior vena cava G) Obstruction of cerebrospinal fluid flow H) Overproduction of cerebrospinal fluid ) Leukocyte casts E ) Oxalate crystals

A 72-year-old man comes to the physician with his wife because of chronic abdominal pain and headaches for 4 months. His wife states that he has become more forgetful over the past 6 months. He has a history of gout. He has smoked one pack of cigarettes daily for 50 years and drinks 10 oz of homemade whiskey daily. He takes no medications. His temperature is 36.8 C (98.3 F), blood pressure is 160/98 mm Hg, pulse is 74/min, and respirations are 16/min. Neurologic examination shows mild short-term memory loss and decreased sensation to pinprick in the distal extremities. He has an ataxic gait. There are gouty tophi on the dorsal aspect of the left elbow. Laboratory studies show: Hematocrit 33% Mean corpuscular volume 70 μm3 Serum Urea nitrogen (BUN) 17 mg/dL Glucose 90 mg/dL Creatinine 2 mg/dL Uric acid 14 mg/dL Which of the following is the most appropriate next step in management? A) Measurement of blood lead level B) Measurement of serum porphobilinogen level C) CT scan of the abdomen D) MRI of the brain E) Carbidopa-levodopa therapy

A 20-month-old girl is brought to the physician because of fever and cough for 2 days. She has had several similar episodes since the age of 4 months. Three months ago, she and her family visited her grandmother in Finland for 2 weeks. She is at the 25th percentile for length and 5th percentile for weight. She appears thin and pale. Her temperature is 38 C (100.4 F), pulse is 150/min, and respirations are 40/min. Examination shows mild clubbing. Wheezing and bilateral crackles are heard at the lung bases. An x-ray film of the chest shows streaky densities bilaterally with mild hyperinflation.

gout flare trt

A previously healthy 52-year-old man comes to the physician because of a 3-month history of increased urinary volume and increased urinary frequency at night. He has had a 6.8-kg (15-lb) weight loss during this period despite no change in appetite. His father has hypertension, and his mother has hypertension and type 2 diabetes mellitus. He currently weighs 95 kg (210 lb) and is 178 cm (70 in) tall. His blood pressure is 160/85 mm Hg in both arms. Examination shows no other abnormalities. His nonfasting serum glucose level is 280 mg/dL. Which of the following serum levels is most likely to be increased in this patient? A ) Bicarbonate B ) Glucagon C ) HDL-cholesterol D ) Insulin E ) Ketones

8. One day after an uncomplicated spontaneous vaginal delivery, a 23-year-old woman, gravida 1, para 1, has the onset of loss of small amounts of urine. She received epidural anesthesia during labor and delivery. Examination shows an episiotomy without evidence of hematoma. She is voiding 50 to 75 mL of urine at a time. Postvoid residual volume is 300 mL. A ) Detrusor instability B ) Interstitial cystitis C ) Overflow incontinence D ) Stress incontinence E ) Urethra diverticulum F ) Urinary fistula 1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step? A ) X-ray films of the abdomen B ) Comparison of abdominal fluid amylase with serum amylase activity C ) Gram's stain of abdominal fluid D ) Ultrasonography of the abdomen E ) CT scan of the abdomen and pelvis 30. One month after undergoing an uneventful renal transplant for chronic renal failure secondary to glomerulonephritis, a 38-year-old woman is hospitalized because of increased serum urea nitrogen (BUN) and creatinine levels. Prior to transplantation, she had been receiving hemodialysis for 3 years. Current medications include cyclosporine and prednisone. Examination shows no abnormalities. Over the past 48 hours, urine output has remained stable. Both renal biopsy and a radionuclide scan confirm the diagnosis of acute rejection. Which of the following is the most effective treatment? A) Immediate discontinuation of cyclosporine B) Increased dosage of corticosteroids C) Diuresis and alkalinization of the urine D) Renal dialysis for 1â€"2 weeks E) Transplant nephrectomy 20. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry eyes and mouth. He also has had a 10.4-kg (23-lb) weight loss over the past 4 months despite no change in appetite. He has smoked one and a half packs of cigarettes daily for 50 years. He drinks 4 oz of alcohol daily. He has peptic ulcer disease and emphysema. Medications include cimetidine, theophylline, and low-dose prednisone. Examination shows mild ptosis. He has a barrel-shaped chest. Breath sounds are distant. There is moderate weakness of the proximal muscles of the lower extremities. Reflexes are absent. He has difficulty rising from a chair. Sensory examination shows no abnormalities. An x-ray film shows a hyperinflated chest and a 3 x 4-cm mass in the right hilum. His neurologic findings are most likely due to a lesion involving which of the following? A) Muscle membrane B) Parasympathetic nervous system C) Peripheral nerve D) Presynaptic neuromuscular junction E) Sympathetic nervous system 22. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants. Examination shows genital condylomata acuminata in the perineal, peri-introital, labial, and anal areas. Some of the pedunculated condylomata appear to have caused the bleeding. She has no visible intravaginal condylomata or vaginal or anal tears. Her mother has a palmar wart on her hand but no history of condylomata acuminata. Her mother has a boyfriend who does not live with them and who has never been left alone with the girl. They live with the mother's 27-year-old brother who only baby-sits the children when they are asleep. Which of the following is the most appropriate next step in management? A) Psychiatric assessment of the mother B) DNA typing of the mother's palmar wart for papillomavirus C) Treatment of the mother's palmar wart D) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the child E) Laser therapy of the condylomata acuminata in the child 24. A previously healthy 52-year-old woman comes to the physician because she has had a large pimple on her right hand for 2 weeks that has failed to heal. She resides in southeastern USA where she owns a nursery and garden shop. Examination shows a painless red papule on the hand with several nontender subcutaneous nodular lesions above it. Which of the following is the most likely diagnosis? A) Blastomycosis B) Candidiasis C ) Coccidioidomycosis D ) Histoplasmosis E ) Sporotrichosis 33. Four hours after undergoing a cesarean delivery at term followed by tubal ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-controlled epidural analgesia has been moderately effective for pain. Her blood pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are decreased bilaterally. No murmurs are heard. Abdominal examination shows distention and tenderness. Bowel sounds are absent. The incision is intact with no drainage. She is disoriented to person, place, and time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of the following is the most likely cause of the hemodynamic changes? A) Epidural-related hypotension B) Insufficient intraoperative fluid replacement C) Postoperative intra-abdominal hemorrhage D) Supine hypotensive syndrome E) Underestimated intraoperative blood loss 41. A 27-year-old primigravid woman at 38 weeks' gestation is admitted in labor. Her pregnancy has been uncomplicated, and a routine prenatal visit 2 days ago showed no abnormalities. On admission, fetal heart tones cannot be heard. Ultrasonography shows little amniotic fluid, fetal edema, and no evidence of a fetal heartbeat. After 1 hour, she delivers a 3175-g (7-lb) stillborn infant; examination of the infant shows no obvious abnormalities except for mild edema. The placenta and membranes appear normal. Which of the following is the most appropriate immediate course of action? A) Notify the hospital liability department B) Obtain consent for fetal organ donation from the parents C) Recommend autopsy of the infant D) Tell the mother not to worry since she can get pregnant again E) Tell the parents that there is a 1 in 4 chance of recurrence in future pregnancies