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* nbme-12
 #141513  
  tea - 11/26/06 16:27
 
  The following vignette applies to the next 2 items.


You have been treating a 5-month-old child in the neonatal intensive care unit (NICU). He was delivered at 26 weeks' gestation by cesarean delivery because of premature rupture of membranes. The mother is 18 years old and is unemployed. There are two other children in the home. The father is not living with them, and he has not been in contact with the mother. The mother rarely visits the NICU. The infant had severe respiratory distress syndrome at birth and required dopamine for blood pressure support. His condition progressed to pulmonary interstitial emphysema and bronchopulmonary dysplasia by 4 weeks of age. At 4 months of age he required a tracheostomy and medication for control of his blood pressure. Now, at 5 months of age, the boy has a cardiac arrest requiring resuscitation and placement of chest tubes. He then develops seizures that are eventually controlled with medication. The neonatologist feels that the child will always require life support. The mother refuses to discuss the possibility of withdrawing life support. Her insurance is Medicaid. The hospital bill for this child is now $350,000.

Item 1 of 2

12. To guide further treatment at this time, it is most important to assess which of the following?

A

) The extent of neurologic injury

B

) The financial impact on the family

C

) The mother's level of understanding of the child's prognosis

D

) Whether another family member is better suited to make decisions about the patient's care

E

) Your state's law regarding futile care

Item 2 of 2

13. One week later the mother and the attending physician are unable to reach an agreement on the management plan. Which of the following is the most appropriate next step?

A

) Ask the court to appoint a guardian

B

) Defer major decisions until the father can be located

C

) Have the social worker contact Medicaid regarding further coverage

D

) Involve the hospital bioethics committee

E

) Maintain the patient on a respirator but transfer him out of the NICU

14. A 42-year-old African-American man with hepatitis C is admitted to the hospital for evaluation of a 3-day history of fever and right upper quadrant abdominal pain. The pain is steady and does not change with position. He has had associated nausea but has not vomited. He has a history of alcohol dependence but has not had an alcoholic beverage since being diagnosed with hepatitis C 4 years ago. He does not take any medications. On admission, vital signs are: temperature 38.5°C (101.3°F), pulse 115/min, respirations 24/min and blood pressure 100/60 mm Hg. Physical examination shows scleral icterus. Abdominal examination discloses mild distention and right upper quadrant tenderness to palpation; the liver spans 25 cm. There is no rebound tenderness and bowel sounds are normal. Ultrasonography of the right upper quadrant shows three small gallstones, dilated right and left intrahepatic ducts and normal common bile duct. Laboratory studies show:


Serum



Blood



ALT

650 U/L

Hematocrit

35%

AST

442 U/L

WBC

22,000/mm3

Alkaline phosphatase

342 U/L

PT

14 sec

Bilirubin

7.0 mg/dL

PTT

28 sec

Na+

140 mEq/L

INR

1.2

K+

4.2 mEq/L





Cl-

104 mEq/L





HCO3-

23 mEq/L






Fluid resuscitation is begun. Which of the following is the most appropriate next step?

A

) Biopsy of the liver

B

) Cholecystectomy

C

) CT scan of the abdomen

D

) Endoscopic retrograde cholangiopancreatography with st

15. A 16-year-old Mexican American girl who is 28 weeks pregnant comes to the health center with her boyfriend because of epigastric pain radiating to her back. She says, "I have had pain for many days, especially after eating." She has been taking acetaminophen for the pain several times a day for the past week. She admits to drinking an occasional bottle of light beer. She has been receiving prenatal care at the health center. Vital signs today are temperature 37.5°C (99.5°F), pulse 110/min, respirations 15/min, and blood pressure 110/70 mm Hg. Height is 157 cm (5 ft 2 in) and weight is 90 kg (200 lb). Physical examination shows scleral icterus and epigastric and right upper quadrant tenderness. Uterus is appropriately enlarged for her gestational stage. The patient is admitted to the hospital for observation. Results of laboratory studies are shown:


Serum



ALT

55 U/L

AST

58 U/L

Alkaline phosphatase

350 U/L

Amylase

3000 U/L

Bilirubin



Total

7.3 mg/dL

Direct

5.9 mg/dL

Lipase

475 U/L (N=10140)


These laboratory results are most indicative of which of the following?

A

) Acetaminophen-induced hepatic necrosis

B

) Alcoholic pancreatitis

C

) Biliary pancreatitis

D

) Hepatitis C infection

E

) Mononucleosis

16. A 22-year-old woman is in her 5th hospital day following admission for evaluation of severe right lower quadrant abdominal pain. During the previous 8 months, she has had episodes of abdominal pain with associated recurrent diarrhea, which sometimes contained blood. The pain and diarrhea became increasingly severe during the 5 days prior to admission. During that time, she lost 2 kg (5 lb) and had a temperature to 39.0°C (102.0°F). Abdominal examination on admission disclosed a right lower quadrant mass. Blood hemoglobin concentration was 15.5 g/dL and leukocyte count was 24,000/mm3. Colonoscopy showed linear ulcerations with discontinuous areas of inflammation. Biopsy of the lower intestine disclosed noncaseating granulomas. Serum antibody test to Saccharomyces cerevisiae was positive. Treatment with intravenous hydrocortisone therapy was begun. Today, the patient's abdominal pain and diarrhea are resolved. Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 12/min, and blood pressure 122/74 mm Hg. The abdomen is soft and nontender to palpation; bowel sounds are normal. Which of the following is the most appropriate pharmacotherapy for this patient?

A

) Azathioprine

B

) Mesalamine

C

) Metronidazole

D

) Prednisone

E

) Ranitidine

The following vignette applies to the next 2 items.


A 28-year-old man who lives in a small rural township is admitted to the hospital because of gastrointestinal bleeding. On admission the patient is pale and has orthostatic hypotension. Hemoglobin concentration is 8 g/dL. His condition is stabilized. Emergent upper endoscopy shows a visible gastric vessel, which is treated appropriately.

Item 1 of 2

17. Specific additional history should be obtained regarding which of the following?

A

) Consumption of alcoholic beverages

B

) Family history of cancer

C

) Source of drinking water

D

) Travel history

E

) Use of tobacco products

Item 2 of 2

18. Which of the following is the most appropriate laboratory study?

A

) Antibodies for Helicobacter pylori

B

) Vitamin B12 (cyanocobalamin) concentration

C

) Ferritin concentration

D

) Gastrin concentration

E

) Iron concentration


19. A 74-year-old woman is admitted to the hospital for treatment of a hip fracture. Her only medical problem is chronic insomnia; she told the nurse, "I have taken sleeping pills for years." Two days after the operation she has a tonic clonic seizure. Vital signs now are: temperature 38.0°C (100.4°F), pulse 110/min and blood pressure 180/100 mm Hg. She is confused, has diaphoresis and is trembling. Which of the following is the most likely diagnosis?

A

) Barbiturate withdrawal

B

) Diphenhydramine withdrawal

C

) Propoxyphene withdrawal

D

) Pulmonary embolus

E

) Stroke

20. You have just returned from a trip out of town and learn that your long-time patient with end-stage chronic obstructive pulmonary disease has been hospitalized and is on a ventilator. On the way to the intensive care unit to visit him, you are informed that the patient has just died. On your way into the patient's room you meet the patient's 68-year-old wife. Which of the following is most appropriate to say to her?

A

) "How do you feel?"

B

) "I am sorry for your loss."

C

) "I know you are upset."

D

) "What happened while I was gone?"

E

) "Your husband didn't suffer."

21. A 3-day-old Latina infant is in the hospital awaiting routine physical examination. She was born to a 28-year-old woman by cesarean delivery at term because of breech presentation. She is the woman's first child and the pregnancy was uncomplicated. The infant weighed 3686 g (8 lb 2 oz) at birth. Physical examination discloses asymmetry in the number of thigh skin folds and uneven knee levels when the hips and knees are flexed. Barlow test is done and a palpable "click" is felt in the left hip. Without prompt treatment, this child is at increased risk for which of the following?

A

) Dysplasia of the hip

B

) Femoral head anteversion

C

) Legg-Calve-Perthe disease

D

) Metatarsus adductus

E

) Slipped capital femoral epiphysis

The following vignette applies to the next 2 items.


An 83-year-old woman is admitted to a nursing home for ongoing management of Parkinson disease. Her husband can no longer care for her at home because she is moderately demented, has difficulty walking, has fallen several times and has urinary incontinence. She has difficulty swallowing her pills, and she needs assistance with feeding. Despite her husband's attentive care, she has lost 9 kg (20 lb), going from 47.1 kg (104 lb) to 38 kg (84 lb) during the past 9 months. After 2 weeks in the nursing home, the nursing staff notes that the patient frequently eats and drinks very little and often coughs after she swallows. Her current medications include fluoxetine, selegiline, carbidopa-levodopa, trazodone, estrogen and sorbitol. Vital signs now are: temperature 36.4°C (97.6°F), axillary; pulse 88/min; respirations 18/min and blood pressure 102/84 mm Hg, supine. Physical examination shows a frail and thin woman. Voice is soft and low. Chest is clear to auscultation. Heart rate is regular without murmurs or gallops. Abdomen is soft and nontender with decreased bowel sounds. Rectal examination is normal. She is generally stiff with low amplitude tremors at rest. Laboratory results show:


Serum



BUN

47 mg/dL

Creatinine

1.9 mg/dL

Na+

161 mEq/L

K+

3.9 mEq/L

Cl-

120 mEq/L

HCO3-

24 mEq/L


When the nursing home calls you with the laboratory results, the office staff informs you that the patient's husband telephoned earlier that afternoon and "fired" you from the case. There are no written notes from the staff and you have not spoken to the husband yourself.

Item 1 of 2

22. The most appropriate next step is to contact which of the following?

A

) Husband and give him the names of other physicians who attend patients in the nursing home

B

) Husband and inform him of the laboratory results, their implications and management options

C

) Nursing home and inform them that you are no longer the patient's physician

D

) Nursing home and initiate nasogastric rehydration in the facility

E

) Nursing home and order the immediate transfer of the patient to the hospital

Item 2 of 2

23. Which of the following complications is most likely to develop if her hypernatremia is corrected too quickly?

A

) Disseminated intravascular coagulation

B

) Intravascular hemolysis

C

) Pontine myelinolysis

D

) Pulmonary edema

E

) Seizures


24. A 68-year-old woman with stage IV ovarian cancer is in the hospital following initial staging and a debulking operation. She refuses chemotherapy and the physician agrees to follow her wishes. This is an example of which ethical principle?

A

) Authority

B

) Autonomy

C

) Beneficence

D

) Justice

E

) Nonmaleficence
 
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* Re:nbme-12
#572095
  drsandeep7 - 11/26/06 18:47
 
  12)c
13)a
14)d
15)c
16)b
17)a
18)b
19)a
20)d
21)a
22)?
23)e
24)b
 
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* Re:nbme-12
#572189
  tea - 11/26/06 21:05
 
  12e
13a
14c
15c
16d
17a
18b
19c
20b
21a
22b
23e
24e
 
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