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* nbme-3
 #141274  
  tea - 11/25/06 14:36
 
  22. A 3-year-old girl is brought to the emergency department by her father because of vomiting. He reports that her medical history is unremarkable except for a viral infection 1 month ago, during which she had a mild fever and was irritable for 2 days. She recovered quickly and was well until 3 days ago, when she seemed more thirsty than usual and did not eat as much solid food as she had before. She began vomiting last night and was lethargic today. She is afebrile, pulse is 180/min and respirations are 40/min and deep. On physical examination she is lethargic but responds to touch. Which of the following abnormalities is most likely on further physical examination?

A

) Acetone-smelling breath

B

) Hepatomegaly

C

) Multiple bruises of various stages of healing

D

) Nuchal rigidity

E

) An olive-sized mass in the right upper abdominal quadrant

23. A 71-year-old retired oil refinery worker comes to the emergency department at 2:00 AM because of inability to urinate for the past 6 hours. He says he is having abdominal discomfort and that he has had a decreased urinary stream and urinary dribbling for the past 4 months. Vital signs are: temperature 36.5°C (97.7°F), pulse 103/min and blood pressure 140/90 mm Hg. His lower abdomen is mildly tender and the urinary bladder can be percussed at 2 cm below the umbilicus. Rectal examination shows an enlarged, firm, smooth prostate. Neurologic examination is normal. Which of the following is the most appropriate initial management?

A

) Admit the patient to the short-stay unit for observation

B

) Do a suprapubic cystostomy and drain the bladder

C

) Insert an indwelling urinary catheter

D

) Order pelvic ultrasonography

E

) Order retrograde cystourethrography

24. A 15-year-old girl is brought to the emergency department by her sister. The patient is 36 weeks pregnant and is very upset. She says, "I don't feel the baby move like I used to. Something's wrong!" She has had no prenatal care. A fetal nonstress test is obtained and is nonreactive. Which of the following is the most appropriate first step?

A

) Assess biophysical profile

B

) Determine her hemoglobin concentration

C

) Determine her serum glucose concentration

D

) Induce labor

E

) Order amniocentesis to determine fetal maturity

he following vignette applies to the next 2 items.


A 56-year-old white executive is admitted to the hospital from the emergency department following a severe nosebleed. One month ago he had a brief viral illness after being exposed to an exanthem eruption of one of his grandchildren. At that time the patient was also referred to a urologist because of fatigue, low back pain, and urinary frequency. He was diagnosed with prostatitis, for which he has been taking sulfamethoxazole-trimethoprim for the past 12 days. He does not take any other medications. On arrival in the emergency department vital signs were: temperature 36.8°C (98.2°F), pulse 100/min, respirations 16/min, and blood pressure 120/66 mm Hg. The patient appeared pale with scattered areas of bruising on his limbs and body and a few petechiae. No lymphadenopathy or organomegaly was found. Results of laboratory studies obtained in the emergency department are shown:

Blood

Urine

Hematocrit 21%

WBC 0/hpf

Hemoglobin 5.6 g/dL

RBC 10-20/hpf

WBC 2000/mm3

MCV 102 μm3

Partial thromboplastin time 26 sec

Platelet count 20,000/mm3

Prothrombin time 12.8 sec

INR 1.3

Bone marrow biopsy shows marked hypocellularity.

Item 1 of 2

25. Which of the following is the most appropriate management?

A

) Administer granulocyte colony-stimulating factor

B

) Administer high-dose short-term corticosteroids

C

) Administer parenteral broad-spectrum antibiotics

D

) Begin transfusion with whole blood

E

) Discontinue sulfamethoxazole-trimethoprim

Item 2 of 2

26. Supportive measures are provided for the patient.


Which of the following is the most appropriate treatment recommendation for this patient at this time?

A

) Chemotherapy

B

) Follow-up evaluation in 1 week

C

) Glucocorticoid therapy

D

) Hematopoietic growth factor therapy

E

) Stem cell transplant


27. An 87-year-old woman is brought to the emergency department by ambulance. Her friend found her lying in bed in her home about one-half hour ago. She had been incontinent of urine and had also vomited. The patient has a history of degenerative joint disease, hypertension and chronic obstructive pulmonary disease. The paramedics brought in her medications, which include felodipine, naproxen, albuterol inhaler, ipratropium inhaler, prednisone, theophylline and ciprofloxacin. On questioning the woman she says she has a headache and nausea, but she is not able to give a more coherent history. She appears restless, tremulous and agitated. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 26/min and blood pressure 110/65 mm Hg. Physical examination is normal except for mild expiratory wheezing. Chest x-ray film is normal. Which of the following is the most likely cause of her symptoms?

A

) Exacerbation of chronic obstructive pulmonary disease

B

) Gastroenteritis

C

) Migraine

D

) Stroke

E

) Theophylline toxicity

28. A 53-year-old white man is brought to the emergency department by emergency medical services after he crashed his car into a tree. He was not wearing a seatbelt. Upon arrival in the emergency department the patient is clearly drunk but he is cooperative during the examination. Vital signs are: temperature 37.0°C (98.6°F), pulse 110/min, respirations 18/min and blood pressure 110/75 mm Hg. Physical examination shows generalized tenderness over the lower abdomen and pelvis. Neurologic examination is normal. X-ray films of the cervical spine, chest and pelvis are normal, as is CT scan of the head. On reexamination 3 hours later, no urinary output has been recorded. The patient is unable to produce a urine sample. He has received 1400 mL of lactated Ringer solution since the accident. Foley catheter is placed and yields 5 mL of bloody urine. X-ray film obtained after placement of the Foley catheter is shown. Which of the following is the most appropriate next step?

A

) Foley catheter drainage for 10 days

B

) Observation only

C

) Percutaneous nephrostomy

D

) Suprapubic catheter drainage

E

) Surgical repair

29. A 17-year-old white girl is brought to the emergency department after she was struck by a car while riding her bicycle. She was wearing a helmet. She is awake, alert, and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 18/min, and blood pressure 107/60 mm Hg. Pulse oximetry shows an oxygen saturation of 96% while breathing room air. Physical examination shows no cervical spine tenderness. Breath sounds are clear. Abdominal, pelvic, and neurologic examinations are normal. Screening x-rays of the lateral cervical spine and pelvis are normal. Chest x-ray is shown. Which of the following is the most likely diagnosis?

A

) Aortic rupture

B

) Flail chest

C

) Hemothorax

D

) Perforated viscus

E

) Pulmonary contusion

The following vignette applies to the next 3 items.


You are notified that your patient, a 26-year-old pregnant woman, has been brought by ambulance to the emergency department after she was in an automobile accident. The vehicle in which she was a passenger was broad-sided by another car. She was in the front passenger seat and was wearing a lap/shoulder belt. You have known the patient for 10 years. She is at 34 weeks' gestation with her second pregnancy; she has one child. The nurses attach an external fetal monitor immediately upon the patient's arrival. When you arrive, the patient's vital signs are: pulse 110/min, respirations 18/min and blood pressure 120/80 mm Hg. The fetal heart rate is 150/min with occasional accelerations to 160/min and no decelerations. The monitor shows uterine contractions about every 7 minutes. The patient states that her only discomfort is from the contractions. She says, "They feel like the hard ones from the end of labor with my other baby." On physical examination, the abdomen is very tender to palpation. On speculum examination, there is a small amount of bright red blood oozing from the cervix, which is long and closed. The patient asks you how long she will have to stay in the hospital.

Item 1 of 3

30. Which of the following is the most appropriate response at this time?

A

) "We need to monitor both you and the baby and do some additional tests before I can answer your question."

B

) "You are in preterm labor from the accident. We will try to stop the contractions with medication, and you can go home later today."

C

) "You seem a little shaken up, but the baby is fine. I want you to go home but remain in bed the rest of the day."

D

) "You seem a little shaken up. Even though the baby seems fine, I would like to keep you overnight for observation."

E

) "You will need to stay here until the baby is delivered."

Item 2 of 3

31. While you are talking with the patient, she has a severe contraction that lasts for 5 minutes. Fetal heart tones decrease to 60/min. Which of the following is the most appropriate action at this time?

A

) Determine fetal scalp pH

B

) Give the mother oxygen by face mask and magnesium sulfate by slow intravenous push

C

) Prepare for immediate cesarean delivery

D

) Place an internal fetal scalp electrode

E

) Rupture the membranes artificially for vaginal delivery

Item 3 of 3

32. The appropriate action is undertaken. The patient asks you if she would have been better off if she had not been wearing a seatbelt. Which of the following is the most appropriate answer?

A

) "If your car has an air bag, you should not use the seat belt when you are pregnant. But if your car does not have an air bag, we still recommend you use the seat belt."

B

) "We prefer that pregnant women not wear seat belts because, in case of accidents, the belt can cause more harm than it prevents."

C

) "Pregnant women should use seat belts until about 28 weeks' gestation. After that, the abdomen is so large that the belt can cause the kind of problem you experienced."

D

) "The problem you had was caused from the forces of the accident. You might have been injured more seriously without a seat belt."

E

) "Your problem was that you were sitting in the front passenger seat, which is the most dangerous seat in the car. If you had sat in a different seat, this would not have happened."


33. A 47-year-old man is brought to the emergency department because of the sudden onset of chest pain. On cardiac examination, which of the following physical findings is suggestive of ischemia?

A

) Early diastolic murmur at the base

B

) A late systolic murmur at the apex

C

) Mid-systolic click

D

) Pericardial knock

E

) Pulsus paradoxus

34. A 23-year-old woman comes to the emergency department because of fever. She was diagnosed with acute lymphoblastic leukemia 2 weeks ago, and chemotherapy was initiated 3 days later. She has received all of the chemotherapy as an outpatient. Several hours prior to admission she developed a single episode of shaking chills, which spontaneously resolved. Vital signs are temperature 38.4°C (101.1°F), pulse 108/min, respirations 16/min, and blood pressure 120/80 mm Hg. She is in mild distress. Partial alopecia is noted, and a Hickman catheter is in place. Results of stat complete blood count are obtained and shown:


Blood



Hemoglobin

8.5 g/dL

WBC

950/mm3

Platelet count

80,000/mm3


Urinalysis shows no abnormalities. Two sets of blood cultures are obtained. Which of the following is the most appropriate next step?

A

) Administer a single dose of antibiotics and discharge with oral antibiotics

B

) Admit her to the hospital

C

) Discharge her on G-CSF (filgrastim)

D

) Monitor vital signs in the emergency department

E

) Remove the Hickman catheter and discharge with oral antibiotics

The following vignette applies to the next 2 items.


An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure. Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3-5 area in the midline, which is slightly swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.

Item 1 of 2

35. Which of the following is the most accurate statement?

A

) An epidural abscess has developed

B

) The epidural block has worn off

C

) The original injection was subdural

D

) A radiculopathy has developed at a different level

E

) She is having a reaction to the anesthetic

Item 2 of 2

36. Which of the following is the most appropriate next step?

A

) Administer an analgesic and diphenhydramine

B

) Administer an analgesic, intravenously, and arrange myelography

C

) Contact the anesthesiologist about repeating the epidural block

D

) Reassure the patient and have her make an appointment with the orthopedist for tomorrow

E

) Request an emergency MRI of the spine
================================================================================
1. A 76-year-old retired plumber comes to the office with his wife because he has had progressive memory loss during the past year. His wife tells you that he has recently gotten lost in his home at night. He has also had urinary incontinence, about which he says, "It must be because of my big prostate." The patient's wife is concerned that he walks differently and often staggers, but he has not fallen. He now uses a cane. He tells you that he has recently used his wife's lorazepam for insomnia. One of his four siblings has significant memory loss. Vital signs are normal. Physical examination shows good orientation. During the mental status examination, he recalls only one of three items after 3 minutes, he is unable to do serial threes or sevens, and there is evidence of impaired judgment. He has mild ataxia with a tendency to fall to the left if he does not have support. Which of the following is the most likely presumptive diagnosis?

A

) Dementia, Alzheimer type

B

) Normal-pressure hydrocephalus

C

) Parkinson dementia

D

) Pseudodementia due to depression

E

) Reversible drug-induced dementia

2. A 52-year-old woman comes to the office because of difficulty falling asleep. She says that she retires to her bedroom at 7:00 PM and watches television while lying on her bed. She turns out the light and the TV at 11:00 PM but lies awake until at least 2:00 AM. She then sleeps soundly until 7:00 AM when she gets up to go to work. She is divorced and lives alone. She takes no medications. Her physical examination is normal. Which of the following is the most appropriate management?

A

) Advise her to avoid watching TV in bed

B

) Advise her to drink a warm beverage before going to bed

C

) Advise her to exercise lightly at 9:00 PM

D

) Prescribe flurazepam

E

) Prescribe temazepam

3. A 7-year-old girl is brought to the office by her mother because the girl has been awakening regularly at night in considerable distress about 1 hour after falling asleep. The mother describes her as being extremely fearful and inconsolable during these episodes. Her mother says, "She cries out something about a figure in a dark cape who is chasing after her and wants to turn her into stone. A few minutes later, she is able to go back to sleep and remembers little of what has happened the next morning." She has been in excellent health and has achieved appropriate developmental milestones. She is doing well in school and has a number of friends and playmates. She is 121 cm (4 ft) tall and weighs 22 kg (48 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 60/min, respirations 18/min and blood pressure 100/70 mm Hg. Physical examination shows a normally developed and well-nourished girl. Physical and neurologic examinations are normal. Which of the following is the most likely diagnosis?

A

) Cataplexy

B

) Central sleep apnea

C

) Major depressive disorder

D

) Nightmares

E

) Night terrors

4. An 8-year-old boy is brought to the health center by his parents because of a 2-day history of sore throat and fever. Temperature is 38.3°C (101.0°F) and pulse is 88/min; other vital signs are normal. Physical examination shows erythema of the posterior pharynx; the tonsils are enlarged and there are a few spots of whitish exudate on the left tonsil. A few small, nontender posterior cervical lymph nodes are palpable. There is no rash. Rapid streptococcal test is negative. Which of the following is the most appropriate next step?

A

) Administer intramuscular penicillin

B

) Obtain a throat culture

C

) Obtain acute-phase serum for antistreptolysin-O titer

D

) Prescribe azithromycin

E

) Reassure the patient's parents that he has a viral illness

5. A 16-year-old Latino boy comes to the health center because of ear pain for the past 2 days. He has been working at a local restaurant 30 to 40 hours per week through a school-sponsored vocational education program. His father left his family when the patient was a young child, and his mother died 1 year ago of breast cancer. He was declared an emancipated minor by the court after his mother's death, and he now rents a room in a home in his neighborhood. He has received care at the health center in the past for episodic illnesses and vaccinations before his mother died. Which of the following is the most accurate statement regarding obtaining consent for treatment today?

A

) Can be seen because he is likely to have an infectious disease and signed consent is not necessary

B

) Can be seen because his deceased mother gave signed consent for services in the past

C

) Can be seen if he signs a consent for services

D

) Cannot be seen because he has a living parent whose signed consent is required

E

) Cannot be seen without consent of the court that awarded emancipated minor status

6. A 67-year-old man comes to the office because of a 1-week history of increasing cough productive of small amounts of clear sputum and shortness of breath on exertion. He has smoked one and one-half packs of cigarettes per day for the past 40 years. He quit smoking 14 months ago when he was told that he had severe lung disease. He appears to be in no acute distress. He cannot speak in full sentences without taking a breath, and he purses his lips when exhaling. The patient is 170 cm (5 ft 7 in) tall and weighs 57 kg (125 lb); BMI is 20 kg/m2. The physical examination is most likely to show which of the following?

A

) Accessory muscle use

B

) An audible, right-sided S3

C

) Cyanosis of the extremities

D

) Lower extremity edema

E

) Wide splitting of S2

7. A 32-year-old African-American woman with a history of major depressive disorder comes to the health center because of palpitations and dizziness for the past week. She has been taking fluoxetine for the past 3 years and had been doing well until her mother died several months ago. At that time she became despondent with frequent crying and inability to sleep at night. Six weeks ago her psychiatrist increased the dose of fluoxetine but she did not think it helped. A friend recommended St. John's wort, which she began taking several weeks ago. She also takes calcium carbonate daily, occasional antihistamines for seasonal allergies, and amoxicillin-clavulanate, which was prescribed 10 days ago by another physician for a sinus infection. Vital signs now are: temperature 37.2°C (99.0°F), pulse 90/min, respirations 18/min and blood pressure 140/90 mm Hg. On physical examination she is somewhat tremulous. Thyroid is normal and chest is clear. Cardiovascular examination discloses a regular rhythm with slight tachycardia. Abdominal and neurologic examinations are normal. Which of the following is the most likely cause of her symptoms?

A

) Anxiety reaction due to her mother's death

B

) Hyperthyroidism

C

) Interaction between fluoxetine and amoxicillin-clavulanate

D

) Interaction between fluoxetine and antihistamines

E

) Interaction between fluoxetine and St. John's wort

8. A 54-year-old African-American dispatcher comes to the office because of hip and leg pain. You have treated the patient for diabetes mellitus, emphysema and obesity. His diabetes is controlled with diet and insulin therapy and is managed by his wife who is a registered nurse. He has a 30-year history of smoking two packs of cigarettes per day and he does not want to stop. For the past 4 months he has been taking aspirin with each meal to relieve his hip and leg pain. His wife drops him off at work in the morning; he walks to the hospital to ride home with his wife. He states he has no pain at rest but walking for a few blocks causes his whole left leg to ache. Which of the following is the most likely cause of his symptoms?

A

) Osteoarthritis

B

) Peripheral neuropathy

C

) Peripheral vascular insufficiency

D

) Sciatic nerve radiculopathy

E

) Spinal stenosis

9. A 74-year-old woman comes to the office because of constipation and blood-streaked stools for the past 3 days. She has had a 4.5-kg (10-lb) weight loss and anorexia for the past few months. She has a temperature of 37.0°C (98.6°F). Abdominal examination is normal. Rectal examination is normal except for the presence of occult blood on examination of the stool. Leukocyte count is 9000/mm3. Which of the following is the most likely diagnosis?

A

) Carcinoma of the cecum

B

) Carcinoma of the sigmoid colon

C

) Ischemic colitis

D

) Pseudomembranous enterocolitis

E

) Ulcerative colitis

10. A 46-year-old white woman returns to the office for follow-up of abdominal pain. Two weeks ago, she came to the office because of constipation and passing two to three loose stools with mucus per day. Physical examination at that time was normal. Her weight has remained the same and temperature has been normal. She has never had an abdominal operation. Lower gastrointestinal barium study and flexible sigmoidoscopy are normal. Complete blood count is normal. Today, you review the results with the patient. Which of the following is the most appropriate recommendation to the patient?

A

) Antianxiety medication

B

) Antispasmodic medication

C

) Consultation with a gastroenterologist

D

) Consultation with a psychiatrist

E

) Fiber supplementation

11. A 10-year-old boy is brought to the office by his mother for a periodic health evaluation. He has been your patient for several years. Recently his teachers and his school counselor have recommended that he be treated with methylphenidate because of his disruptive behavior in the classroom. He has no past history of behavioral problems. Which of the following is the most appropriate advice to the mother?

A

) "Children with this problem may not have a very high IQ."

B

) "Children with this problem usually grow out of it by puberty."

C

) "I don't think he has attention-deficit disorder because he has not had problems in the past."

D

) "Let's get more information from the school."

E

) "Methylphenidate treatment will probably improve his grades."

12. A 24-year-old woman comes to the office for an initial prenatal visit. A home pregnancy test was positive 2 weeks ago. Her last menstrual period was 10 weeks ago. She has been healthy and has no significant medical history. She takes no medications. During the interview she becomes tearful and says, "My husband hit me several times 6 weeks ago and I'm afraid that it may happen again. He's become very loving now since he found out about the baby, but I'm still worried." Vital signs now are: temperature 36.9°C (98.4°F), pulse 80/min, respirations 20/min and blood pressure 110/70 mm Hg. Pelvic examination shows a 10-week size uterus and is otherwise normal. Ultrasonography confirms a 10-week gestation. Which of the following strategies is most appropriate?

A

) Provide her with the name and phone number of a shelter for battered women

B

) Reassure the patient that abusive behavior is less likely now that she is pregnant

C

) Recommend marital counseling

D

) Schedule an appointment with the husband to discuss his abusive behavior

E

) Tell her that you will report this to the police if it happens again

13. A 16-year-old boy and his mother come to the office because the mother is concerned that her son may have a drug problem. You have treated him in the past for mild intermittent asthma, and he currently uses an albuterol inhaler prior to exercise. You last saw him 1 year ago for a sports physical examination. At that time, he admitted to drinking alcohol on the weekends. He also admitted to marijuana use but had planned to quit using both before track season started. The mother says that her son now seems disinterested in school and other activities in which he was previously engaged. He has quit the track team, has become irritable, and he has a new set of friends whom his mother dislikes and describes as "druggies." She acknowledges that the boy's father, from whom she is divorced, has an alcohol abuse problem. The boy's older brother abused cocaine for 2 years but is now in a drug rehabilitation program. Prior to interviewing and examining the patient, the mother pulls you aside and asks you to test her son for drugs without informing him. Which of the following is the most appropriate response?

A

) Agree to do toxicologic screening but review the test results with the patient before giving the results to the mother

B

) Agree to do toxicologic screening only if, after discussing it with the patient, he agrees to the test

C

) Agree to do toxicologic screening without the patient's knowledge per his mother's request

D

) Decline to do toxicologic screening stating that you do not want to get caught between her and her son

E

) Decline to do toxicologic screening unless under a court order

The following vignette applies to the next 2 items.


A 75-year-old woman whom you treat for obstructive lung disease comes to the office because of thoracic back pain, which has been troubling her for several weeks. There is no specific history of trauma. Her current medications include ipratropium and inhaled albuterol. She no longer smokes cigarettes and she does not use alcohol. She underwent a mastectomy 10 years ago for breast cancer. Today, vital signs are normal. Her weight is unchanged from 1 year ago. On physical examination breath sounds are diminished in intensity but normal in quality. There is no tenderness over the spinous processes. Laboratory studies in the office show a normal complete blood count and erythrocyte sedimentation rate. A compression fracture of the thoracic spine is seen on a lateral chest x-ray film. After further discussion, the patient agrees to a trial of alendronate to prevent further fractures.

Item 1 of 2

14. Regarding alendronate therapy, the patient should be told which of the following?

A

) The medication should be chewed, rather than swallowed

B

) The medication should be taken at bedtime

C

) The medication should be taken with a full glass of water

D

) The medication should be taken with meals

E

) She should lie down immediately after taking the medication

Item 2 of 2

15. Four days later, the patient returns to the office complaining of chest pain, odynophagia and dysphagia. You decide to discontinue the alendronate. In addition, which of the following is the most appropriate diagnostic study?

A

) Electrocardiography

B

) Esophagoscopy

C

) Laryngoscopy

D

) MRI of the thoracic spine

E

) X-ray film of the lateral neck

16. A 69-year-old woman comes to the office because of left knee pain. She says, "For the past several years my left knee has been bothering me a bit but I have been getting by. However, for the past few days it has been killing me. I was at the outlet mall 2 days ago and I was fine, but yesterday I woke up with such knee pain that I could hardly walk." She denies injuring the knee. No other joints bother her this much although she notes that her right knee occasionally hurts. The pain does not improve with ibuprofen. She has hypertension controlled with hydrochlorothiazide and a β-blocking medication, and she has mild chronic renal failure. Serum creatinine concentration 3 months ago was 2.1 mg/dL. She is 168 cm (5 ft 6 in) tall and weighs 106 kg (233 lb). Physical examination today discloses moderate effusion of the left knee. The left knee is warm to touch compared with the right knee. Range of motion is normal but there is crepitus. There is no rash or erythema of the skin. X-ray films of both knees are shown. Arthrocentesis shows:


WBC 850/mL

Gram stain Negative

Microscopic No crystals seen under polarized light


Which of the following is the most likely diagnosis?

A

) Gout

B

) Osteoarthritis

C

) Osteoporosis

D

) Pseudogout

E

) Septic arthritis

17. A 46-year-old man with diabetes mellitus well controlled by diet alone returns to the office for a follow-up visit for migraines. You have been seeing him for the past year for the migraines, and about 2 months ago you prescribed a calcium-channel-blocking medication. His previous medications included ergotamine and propranolol, but they were discontinued because of lack of full effect. At today's visit he complains of ankle swelling. Physical examination is normal except for 2+ pitting edema. Which of the following is the most appropriate step at this time?

A

) Determine serum albumin concentration

B

) Discontinue his calcium-channel-blocking medication

C

) Order determination of protein excretion in a 24-hour urine sample

D

) Order echocardiography

E

) Prescribe a diuretic agent

18. A 27-year-old woman comes to the clinic because of chronic dermatitis involving both ear lobes. She has pierced ears and the rash is most marked around the insertion of her earrings. She should be advised to do which of the following?

A

) Avoid skin sensitizing soaps while wearing earrings

B

) Discontinue the use of metallic earring posts

C

) Have her ears repierced

D

) Soak her earrings in 70% alcohol for 24 hours before using them

E

) Wear clip-on earrings only

19. A 46-year-old woman whom you are treating for hypertension and hypothyroidism returns to the office for a follow-up visit. She denies dyspnea, orthopnea, nocturia or exertional chest discomfort. She states, "Doctor, I've recently found that my feet are swollen. It's becoming hard to get my shoes on. My feet don't really bother me, except that they look funny and make me feel self-conscious." The patient has no other medical problems. She has no allergies. She does not smoke cigarettes and she drinks a glass of wine every evening. Her medications are levothyroxine, extended-release nifedipine and enalapril. Blood pressure is 128/78 mm Hg. On physical examination there are no abnormalities of the skin. Neck veins are not distended. Pulmonary and cardiac examinations are normal. Liver and spleen are not palpable. She has 2+ pitting edema of both legs. The remainder of the examination is normal. Which of the following is the most likely explanation for the edema?

A

) The patient has deep venous thrombosis

B

) The patient has misreported her use of alcohol

C

) The patient has not been taking levothyroxine

D

) Use of enalapril

E

) Use of nifedipine

20. A 45-year-old man comes to the office because he has noted a lesion on his chest. He has been generally healthy and you last saw him 5 years ago for an insurance physical examination that was normal. Medical chart notes from that visit report that his skin examination was "normal." You do not recall a lesion being present in the area that he indicates. He is unaware of when the lesion first occurred, but it was noted by a friend at a health club who saw a television report about skin cancer. Physical examination shows a well-appearing man with brown eyes and fair complexion. Vital signs are normal. Skin examination is normal except for the 1-cm lesion on his lateral abdominal wall as shown. The factor that is the best predictor of this patient's prognosis is which of the following?

A

) Degree of variation in the color of the lesion

B

) Diameter of the lesion

C

) His complexion

D

) His eye color

E

) Measurement of lesion depth

21. A 34-year-old primigravid woman at 24 weeks' gestation returns to the office to discuss results of a fasting serum glucose study and hemoglobin A1c obtained during a visit 2 weeks ago. Medical history is significant for infertility, oligomenorrhea, and hirsutism. She conceived 3 months after starting treatment with metformin; she discontinued metformin at 10 weeks' gestation. She currently takes only a prenatal multivitamin supplement. Her mother, a maternal aunt, and a paternal aunt have type 2 diabetes mellitus. The patient is 168 cm (5 ft 6 in) tall and weighs 118 kg (260 lb); BMI is 42 kg/m2. Vital signs are: temperature 37.0°C (98.6°F), pulse 82/min, respirations 15/min, and blood pressure 112/64 mm Hg. Fasting serum glucose concentration is 120 mg/dL and hemoglobin A1c is 7.5%. Which of the following is the most appropriate management?

A

) 1200-Calorie American Diabetes Association diet

B

) Glyburide therapy

C

) Insulin therapy

D

) Reinitiating metformin therapy

E

) Rosiglitazone therapy

22. A 28-year-old African-American woman comes to the office because of low back pain and decreased urine output. She is a semiprofessional basketball player and she is married. She had one pregnancy 12 years ago that was uncomplicated and resulted in vaginal delivery of a term female neonate. Medications include oral contraceptive pills and a corticosteroid inhaler for asthma. She is 182 cm (6 ft) tall and weighs 88 kg (195 lb). Physical examination is normal except for a palpable lower abdominal mass that extends to the umbilicus. Speculum examination discloses a 3-cm ulcerative lesion circumferentially around the external cervical os. Bimanual examination shows a firm, nodular, central pelvic mass filling the pelvis and extending cephalad to the umbilicus. Rectovaginal examination confirms these findings. Stool is negative for occult blood. Which of the following is the most appropriate recommendation?

A

) Arrange for laparoscopy

B

) Do a cervical biopsy

C

) Do an endometrial biopsy

D

) Increase Pap smear screening to every 3 months

E

) Obtain pelvic ultrasonography

The following vignette applies to the next 3 items.


A 61-year-old woman comes to the office because of a 3-month history of urinary incontinence. You have been providing care for her and her husband since they moved to your area 2 years ago. She has a history of diabetes mellitus that was first diagnosed 2 years ago and has been very well managed by diet alone. She currently takes lorazepam at night for sleep and calcium and vitamin D supplements to prevent osteoporosis. She has declined hormone replacement therapy in the past because of a concern about breast cancer. She denies dysuria or problems with incontinence after sneezing or laughing, but she says, "When I try to pass urine, there usually isn't much, but I have to go again a few minutes later. And then, at other times, I just lose control and wet myself. I recently saw a television program on this and I think I have stress incontinence." Vital signs are: temperature 36.9°C (98.4°F), pulse 64/min, respirations 16/min and blood pressure 158/72 mm Hg. She weighs 93 kg (205 lb) and is 163 cm (5 ft 4 in) tall. Physical examination is normal except for moderate vaginal mucosal atrophy. Urinalysis done in the office shows no signs of infection.

Item 1 of 3

23. Which of the following factors in this patient's history or physical examination suggests a diagnosis other than stress incontinence as the cause for this patient's symptoms?

A

) Absence of dysuria

B

) Diabetes mellitus

C

) Increased body mass index

D

) Pattern of urination

E

) Vaginal mucosal atrophy

Item 2 of 3

24. The most appropriate next step in management is to suggest which of the following?

A

) Increased fluid consumption at night

B

) Referral for bladder ultrasonography

C

) Replacement of lorazepam with diphenhydramine at night for sleep

D

) Scheduled voiding

E

) Use of a pessary

Item 3 of 3

25. The patient follows your suggestion. She returns to the office in 3 weeks and reports that she was recently incontinent while shopping with friends. She states, "I've never been so embarassed in my life! Frankly, I don't think I'm better off than when I saw you last time, and now I'm afraid to leave the house." Which of the following is the most appropriate response to the patient's comment?

A

) "Are you ready to use estrogen therapy now?"

B

) "Have you ever thought of using adult disposable diapers? They are very effective."

C

) "I understand your concern. Let's discuss this further and develop a plan."

D

) "I'm sorry to hear this. I'll refer you to a urologist right away."

E

) "These things happen. I'm sure you can understand you're growing older."


26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?

A

) Determine serum estrogen concentration

B

) Order antibody studies for syphilis and HIV

C

) Prescribe an oral anti-trichomonal medication and antifungal cream

D

) Question the patient regarding the circumstances surrounding her recent break-up

E

) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge

27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?

A

) CT scan of the head

B

) Electromyography and nerve conduction studies of the left upper extremity

C

) Measurement of serum B12 (cobalamin) concentration

D

) MRI of the cervical spine

E

) Radionuclide bone scan

28. A 32-year-old woman, gravida 3, para 2, who is at 38 weeks' gestation, is brought to the office by her coworker 15 minutes after the patient appeared to have had a seizure at work. The coworker says the patient was working at her computer when she suddenly fell to the floor, began shaking, and had incontinence of urine. She was unresponsive to voice until approximately 5 minutes after the episode. The patient has received routine prenatal care throughout her pregnancy. She has a history of mild, persistent asthma treated with corticosteroid inhalers. Vital signs on arrival are temperature 36.7°C (98.0°F), pulse 100/min, respirations 22/min, and blood pressure 160/110 mm Hg. The patient is alert but disoriented to time and place. She has no recollection of the episode. Physical examination shows bruising of her left arm and a bite on the lower lip. Which of the following is the most accurate statement regarding the risk of harm to the fetus?

A

) The fetus is at risk for developing intrauterine hypoxia

B

) The fetus will die unless it is delivered immediately

C

) The risk to the fetus depends on any coexisting respiratory condition

D

) The risk to the fetus is minimal because the seizure was short-lived

E

) The risk to the fetus will not be increased if the seizure does not recur

29. A 30-year-old African-American woman returns to the office for a second prenatal visit. She is 12 weeks pregnant and this is her first pregnancy. Results of laboratory studies that were ordered at her first visit show:


Blood

Hematocrit 28%

Hemoglobin 9.2 g/dL

Hemoglobin electrophoresis

Hemoglobin A1 64%

Hemoglobin S 32%

Hemoglobin A2 4%

Mean corpuscular hemoglobin (MCH) 26 pg/cell

Mean corpuscular hemoglobin concentration(MCHC) 32% Hb/cell

Mean corpuscular volume (MCV) 74 μm3


Which of the following is the most likely cause of her anemia?

A

) α-thalassemia trait

B

) β-thalassemia trait

C

) Iron deficiency

D

) Physiologic anemia of pregnancy

E

) Sickle cell trait

30. A 17-year-old girl brings her 4-day-old neonate to the health center 1 day after discharge from the hospital. She says, "I don't think my baby is getting enough milk. He wants to nurse every 2 hours and my nipples are sore and cracked. I feel miserable." The neonate was born via vaginal delivery without complications, following a normal pregnancy. His birth weight was 3317 g (7 lb 5 oz). Physical examination shows a vigorous, active neonate with a strong sucking reflex. He has a wet diaper on arrival and has had two stools since this morning. There is jaundice of the face. In order to support this new mother during this early stage of breast-feeding, which of the following is the most appropriate advice to the patient?

A

) Feed the neonate on only one breast at each feeding to ensure complete emptying of the breast

B

) Insert as much of the areola as possible into the neonate's mouth to improve latching

C

) Not feed the neonate more than every 3 hours to allow for better milk production

D

) Offer formula after each feeding to ensure that the neonate is getting enough milk

E

) Switch to formula for 5 days to assist with healing of her nipples

31. A 19-year-old African-American college student comes to the student health center because of pain in her right knee and fever. She says the pain began about 4 days ago, and she does not recall injuring her knee. Her only medication is an oral contraceptive pill. She is generally healthy. Vital signs are: temperature 37.7°C (99.8°F), pulse 96/min, respirations 20/min and blood pressure 120/72 mm Hg. She appears uncomfortable. Physical examination is normal except for her right knee, which is red, swollen and tender with a tense effusion. Which of the following tests is most likely to support the diagnosis?

A

) Cervical cultures

B

) MRI of the knee

C

) Plain x-ray film of the knee

D

) Serum antinuclear antibody titer

E

) Serum uric acid concentration

32. A 62-year-old woman who was discharged from the hospital several hours ago following evaluation of optic neuritis now has swelling of her ankles. Prior to admission, the patient had a 3-day history of loss of vision and poor color perception in her right eye. Visual acuity on admission was less than 20/200 in her right eye and was 20/40 in her left eye. The remainder of the physical examination was noncontributory. Blood pressure on admission was 140/80 mm Hg. The patient had been otherwise healthy and had been taking no medications. She has never worn corrective lenses. Family history is significant for thyroid disorder. During her hospital stay, the patient received intravenous methylprednisolone therapy for the past four days. Vital signs today are temperature 37.2°C (99.0°F), pulse 100/min, respirations 14/min, and blood pressure 150/95 mm Hg. Physical examination shows ankle edema but is otherwise unchanged from physical examination done on admission. Laboratory studies are obtained. Which of the following serum laboratory study results is most likely in this patient?

A

) Decreased magnesium concentration

B

) Decreased sodium concentration

C

) Increased calcium concentration

D

) Increased glucose concentration

E

) Increased potassium concentration

33. A 30-year-old white woman comes to the office for a periodic health evaluation. At this visit she asks you about a DNA test that she has heard about that can detect the presence of the adult polycystic kidney disease (APKD) gene in asymptomatic carriers. She has a family history of APKD. She has had no symptoms. Her blood pressure is normal, and renal ultrasound 2 months ago was normal. Serum creatinine concentration obtained 2 months ago was 0.9 mg/dL. Before obtaining blood for this test, it is important to explain to this patient that a positive test result would mean which of the following?

A

) She is certain to develop renal failure

B

) She may be eligible for disability

C

) She may have difficulty obtaining life insurance in the future

D

) She should avoid becoming pregnant

E

) She should be monitored for development of liver disease

34. A pharmaceutical representative regularly comes to your office about once a month. Her company has introduced a new prescription nonsteroidal anti-inflammatory drug (NSAID) and she has brought samples today. You overhear your receptionist ask the representative to leave some samples for her own use. If the representative leaves the samples for the receptionist, the most significant concern regarding this situation is that it does which of the following?

A

) It constitutes practicing medicine without a license

B

) It diverts samples intended for use by patients

C

) It may constitute a liability risk

D

) It promotes the use of a more expensive drug over available alternative medications

E

) It provides the representative the opportunity to exert undue influence

35. A 54-year-old woman comes to the office for her annual health maintenance examination. At her last visit 11 months ago she reported hot flushes but says they have now resolved. She takes no medications. She is employed as an executive for a computer manufacturing company. Her stress level has increased during the past 9 months because of her company's financial difficulties and she now smokes two packs of cigarettes daily. She is 170 cm (5 ft 7 in) tall and weighs 63 kg (140 lb), which is an increase of 4 kg (9 lb) since her last visit. She plans to begin an intensive aerobics program to stop her weight gain. The patient should be advised that initiation of this exercise program will put her most at risk for which of the following?

A

) Arthritis

B

) Exercise-induced asthma

C

) Gastroesophageal reflux disease

D

) Stress fractures

E

) Stroke

36. A 78-year-old retired autoworker from Puerto Rico is brought to the office by his son because of a 4- to 7-kg (9- to 15-lb) weight loss in the past few months. You have been treating this patient for hypertension with hydrochlorothiazide for the past 3 years. Today he reports that he eats only one or two bites of food and feels full and that he has a low energy level. He feels he is just "too old." He has never smoked cigarettes and rarely drinks alcoholic beverages. Which of the following is the most appropriate question to elicit further history that would be helpful in the differential diagnosis of this patient?

A

) "Are you having headaches?"

B

) "Did you stop taking your medication?"

C

) "Have you had a change in bowel habits?"

D

) "Have you had any visual changes lately?"

E

) "What has been going on in your life recently?"
 
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* Re:nbme-3
#571184
  tea - 11/25/06 16:59
 
  please only put your answers of q22-36 (starting at the top) here. another block, q1-36 will be repeated in NBME-4,5,6,7, for people esay to check and discuss. sorry for the trouble.  
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* Re:nbme-3
#571240
  pk007 - 11/25/06 18:12
 
  22.b
23.d
24.d
25.c
26.d
27.d
28.b
29.c
30.b
31.a
32.d
33.a
34.c
35.d
36.c
 
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* Re:nbme-3
#571399
  tea - 11/25/06 21:49
 
  22a
23d
24a
25d
26d
27e
28d
29e
30a
31b
32d
33e
34b
35a
36e
 
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* Re:nbme-3
#572085
  chirkut - 11/26/06 18:38
 
  22 a
23c
24a
25e
26e
27e
28d
29
30a
31b
32d
33a
34-
35a
36e
 
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