USMLE forum
 
USMLE Forum
Step 1
Step 2 CK
Step 2 CS
Matching & Residency
Step 3
Classifieds
 
Archives
 
 
  <<   < *  Step 3   *  >   >>  

* nbme-11
 #141512  
  tea - 11/26/06 16:26
 
  1. A 76-year-old woman is admitted to the hospital after a fall at her home earlier in the day. She has been followed in your practice for several years and is in generally good health. She drinks socially, does not smoke and has been active in senior citizen groups. She takes ibuprofen occasionally for pain, but no other medications. On admission she is alert and oriented, and complains only of pain in her left leg. Her temperature is 36.1°C (97.0°F), pulse is 72/min and regular, and blood pressure is 140/85 mm Hg. X-ray films taken upon arrival show a fracture of the left femoral shaft. Surgical repair of the fracture is done the next morning. The patient receives 2 U of packed erythrocytes during the procedure. Postoperative medications include morphine, prophylactic cephalothin and low-dose warfarin. On the evening of the operation, the patient becomes combative, begins to hallucinate and has a brief, generalized seizure. A fine petechial rash is noted on her chest. Which of the following is the most likely cause of her seizure?

A

) Antibiotic allergy

B

) Blood transfusion reaction

C

) Fat emboli

D

) Hemorrhagic stroke

E

) Unrecognized cerebral concussion

2. A 72-year-old woman with metastatic rectal cancer is admitted to the hospital because of weakness and altered mental status. She has bilateral ureteral stents due to prior obstruction from the cancer. She has been using a fentanyl patch for several weeks. Physical examination on admission is notable for lethargy and 3-mm reactive pupils but no focal neurologic signs. She is afebrile and has a blood pressure of 120/82 mm Hg. Laboratory studies show serum urea nitrogen (BUN) concentration of 60 mg/dL and a serum creatinine concentration of 6.2 mg/dL. Serum bilirubin concentration is normal. One week ago serum BUN concentration was 30 mg/dL and serum creatinine concentration was 3.0 mg/dL. Which of the following is the most likely explanation for her altered mental status?

A

) Fentanyl intoxication

B

) Hepatic encephalopathy

C

) Hypercalcemia

D

) Uremia

E

) Urosepsis

3. A 54-year-old African American woman has been in the intensive care unit (ICU) for the past 10 hours because she has failed to regain consciousness after passing out at a restaurant 11 hours ago. Upon initial arrival at the emergency department the patient's friend stated that the patient had remarked about the sudden onset of a terrible headache and neck stiffness while they were having lunch. A few minutes after the onset of the headache, she became confused, vomited, and lost consciousness. She regained consciousness briefly en route to the hospital, but she has been unconscious since admission. On arrival she was intubated and mechanically ventilated and transferred to the ICU, where intravenous fluids were started. Vital signs are: pulse 110/min and blood pressure 174/96 mm Hg. She exhibits no spontaneous movement and is unresponsive to verbal or painful stimuli. Lung fields are clear to auscultation. CT angiogram confirms subarachnoid hemorrhage from a ruptured cerebral aneurysm and impaired intracranial circulation. The family should be counseled regarding which of the following?

A

) The futility of continued life support

B

) The need for screening of first-degree relatives for aneurysms

C

) The need for them to sustain hope

D

) The need to have a guardian ad litem appointed to make informed decisions about the patient's care

E

) The probability that the patient will not regain consciousness

4. A previously healthy 3-year-old boy is admitted to the hospital through the emergency department because he has been having generalized seizures. He had a fever this morning and had one seizure at home and another on the way to the emergency department. While in the emergency department he had several additional seizures that were controlled with intravenous lorazepam. Vital signs on arrival at the emergency department were temperature 39.6°C (103.3°F), pulse 110/min, respirations 24/min, and blood pressure 85/60 mm Hg. Physical examination showed no abnormalities except for left otitis media and lethargy. Intravenous phenytoin was administered. Spinal fluid examination, serum electrolyte concentrations and complete blood count were normal. Now in the hospital, the patient has another seizure. The patient is managed appropriately and the seizure stops. When discussing this child's management and prognosis with the parents, it is most appropriate to counsel them about which of the following?

A

) Their child has an increased risk for attention-deficit/hyperactivity disorder

B

) Their child has an increased risk for developing a brain tumor

C

) Their child is likely to be developmentally delayed

D

) Their child will have a seizure every time he has a fever

E

) Their child will probably become seizure-free as he becomes older

5. A 21-year-old Asian-American man who sustained a closed head injury in a motorcycle accident is admitted to the hospital. He is intubated and is receiving mechanical ventilation in the intensive care unit. On repeat physical examinations during the next 2 days, he shows no clinical signs of cerebral activity and has no spontaneous respiration. His pupils are fixed in mid-position and he has no vestibulo-ocular reflexes. Electroencephalograms obtained 24 hours apart have nearly flat tracings. His driver's license indicates his desire to be an organ donor. When you inform his parents that he is brain dead, you remind them of his donor statement and request permission to harvest usable organs. The parents are shocked; they say they are unaware of his desire to be an organ donor and refuse to grant permission. Because the patient meets the clinical criteria for brain death, which of the following is most appropriate?

A

) Explain how their son's death can contribute to another person's life

B

) Have a potential organ recipient talk with the family

C

) Obtain a court order authorizing removal of usable organs

D

) Order cerebral angiography to convince the parents that their son is brain dead

E

) Proceed with organ removal because the patient is an adult

6. A 52-year-old woman is admitted to the hospital for diagnostic evaluation of a slight aphasia and change in her personality, as noted by her husband. CT scan of the head discloses a 3-cm mass in the left temporal lobe and a 5-cm mass in the right frontal lobe. Because she is a chronic cigarette smoker, you have been obtaining annual chest x-ray films, which have been reported as normal. Her chest x-ray film on admission today is reported as showing a "2-cm spiculated mass in the left subapical region." No reference is made to comparing this film with the prior films. The radiologist then calls you and admits to you that the lesion was present on her prior films but it was overlooked. Which of the following is the most appropriate next step?

A

) Agree with the radiologist that informing the patient and her family will do more harm than good

B

) Ask the radiologist to inform the patient and her family of the problem

C

) Compliment the radiologist for finding what will probably be the primary lesion accounting for the two CNS lesions

D

) Consult with your attorney regarding avoidance of litigation for yourself

E

) Inform the radiologist of your responsibility to inform the patient and her family of the problem

The following vignette applies to the next 2 items.


While making rounds in a rehabilitation facility, you see a 76-year-old white woman who has been your patient for 25 years. One month ago she was diagnosed with metastatic non-small cell carcinoma of the lung with metastases to the other lung, liver and brain. She now has moderate left hemiparesis that limits walking. She also has multiple, asymptomatic, deep venous thrombi of both legs that are being treated with a vena caval filter. Despite discussion with the patient and her family about her illness, her son tells you that she is apparently unaware that her condition is terminal.

Item 1 of 2

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

A

) Arranging transfer to the in-patient psychiatric ward

B

) Beginning anxiolytic therapy

C

) Discussing the prognosis again with the patient

D

) Encouraging the family to discuss the patient's prognosis with her

E

) Explaining to the son that it is inappropriate for you to speak about his mother's illness

Item 2 of 2

8. The patient is not in severe pain and she currently has no respiratory distress. She has chosen not to have further intervention and she probably has about 3 months to live. Her husband is an active 75-year-old man with recently diagnosed type 2 diabetes mellitus. Two of their three sons live 1 hour away. The patient has many concerned neighbors and friends. The patient's family asks for your advice regarding appropriate care for her for the remainder of her illness.


Which of the following is the most appropriate recommendation?

A

) Continued care in the rehabilitation center until she is able to ambulate on her own

B

) Home health care for as long as she qualifies for skilled nursing services

C

) Home hospice care with physical therapy

D

) Placement under intermediate (nonskilled) care in a local nursing home

E

) Placement under skilled care in a local nursing home

9. An 18-year-old woman gave birth to a healthy neonate 72 hours ago. The woman now has the acute onset of tachypnea. Vital signs are normal. Diffuse wheezing is noted on auscultation of the chest. Chest x-ray film is normal. Electrocardiogram shows evidence of right heart strain. Which of the following is the most likely diagnosis?

A

) Adult respiratory distress syndrome

B

) Aspiration pneumonia

C

) Bronchopneumonia

D

) Congestive heart failure

E

) Pulmonary embolism

10. A 34-year-old woman undergoes a middle ear operation with oral intubation and general anesthesia. During the 4-hour procedure she was in a semi-lateral position with her head maximally turned to the right and her chin tucked on her chest. She awakens normally at the end of the procedure and is extubated without difficulty. Approximately 30 minutes later she appears anxious and is sitting upright. She leans forward and says, "I'm not getting enough air." Her voice is barely audible and very hoarse and she appears to be struggling to take a deep breath. Vital signs are: pulse 94/min, respirations 28/min and blood pressure 128/72 mm Hg. Oxygen saturation is 92% with an FIO2 of 0.4. Oxygen flow is maximally increased and O2 saturation is 93%. Auscultation of the chest discloses bilateral breath sounds with crowing sounds on inspiration and expiration. Which of the following is the most appropriate pharmacotherapy?

A

) Midazolam

B

) Naloxone

C

) Nebulized racemic epinephrine

D

) Neostigmine

E

) Succinylcholine

11.

A 67-year-old man with a history of poorly controlled hypertension is admitted to the hospital because of increasing fatigue, weight loss and dyspnea on exertion for the past 6 weeks. Medical history includes tonsillectomy, adenoidectomy, mitral valve commissurotomy and a sigmoid colon resection for diverticulitis. Vital signs are: pulse 90/min, respirations 14/min and blood pressure 190/100 mm Hg. The patient appears chronically ill but is in no acute distress. Laboratory studies show:


Serum


Urine


Na+

140 mEq/L

WBC

0/hpf

K+

4.5 mEq/L

RBC

4/hpf

Cl-

100 mEq/L



HCO3-

25 mEq/L




Which of the following is the most likely finding on echocardiography?

A

) Ejection fraction of 60%

B

) Left ventricular wall thickening

C

) Pericardial fluid

D

) Septal dyskinesia

E

) Thoracic aortic aneurysm
 
Report Abuse

 
 

* Re:nbme-11
#572185
  tea - 11/26/06 21:00
 
  1c
2d
3e
4e
5a
6e
7c
8c
9e
10c
11b
 
Report Abuse

* Re:nbme-11
#594667
  incision - 12/21/06 11:25
 
  10) i am not sure about answer..but y racemic epinephrine
i feel that the patient is heading towards intubation..so
either SC or midazolam
11) no idea
 
Report Abuse

* Re:nbme-11
#594713
  drzx - 12/21/06 12:08
 
  tea r those the right answers?
i was thinking
1c
2d
3d
4e
5e
6e
7c
8c
9e
10c
11b

Incision as she is in resp ditress with fio2 93% midazolam which is a central resp depressant will be avoided. epinephrine seems right because her resp tract will be relaxed................. B2 agonist
 
Report Abuse

* Re:nbme-11
#594796
  incision - 12/21/06 13:45
 
  drzx
what is the reason for respiratory distress after lateral position with chin tucked in...
 
Report Abuse

* Re:nbme-11
#595902
  ant1982 - 12/22/06 17:51
 
  the respiratory distress seems to be due to angioneurotic edema,which is quite common following anesthesia..or probably this cud also be an edema of the laynx secondary to local irritation caused by the et tube in the odd position..
there s a hoarsness of voice and crowing of resp sounds, which most likely is due to the edema of larynx..

and this is the reason why epinephrine wud be effective in this condition as it causes resorption of the fluid in the airway into the airway vessels and also causes a vasocontrictive effect on the airway vessels to reduce the edema..


any corrections?
 
Report Abuse

* Re:nbme-11
#596260
  incision - 12/23/06 02:23
 
  that convinces me...
 
Report Abuse

* Re:nbme-11
#596728
  drswapna - 12/23/06 23:49
 
  hi tea,
do u have all the NBME Qs? if yes ...can u email it?
 
Report Abuse

          Page 1 of 1          

[<<First]   [<Prev]  ... Message ...  [Next >]   [Last >>]

 
Logon to post a new Message/Reply
 
 
 
 
 

 

 

Google
  Web USMLEforum.com
 

Step 1 Step 2 CK Step 2 CS Matching & Residency Step 3 Classifieds
LoginUSMLE LinksHome