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* NBME-13..end
 #141514  
  tea - 11/26/06 16:30
 
  25. You assist in the delivery of a neonate born to a couple who have been your patients for the past 7 years. The husband is 50 years old and the wife is 45 years old. The wife had been offered maternal serum triple-marker screening and amniocentesis during the pregnancy because of her advanced age, and she had declined the testing. At the delivery, the neonate has features suggestive of Down syndrome. Apgar score is 9 at 1 minute and 9 at 5 minutes. Initial physical examination demonstrates no cyanosis and no heart murmur. In the delivery room, which of the following is the best initial statement to make to the parents?

A

) "Do you remember the tests we discussed early in your pregnancy?"

B

) "I am concerned about your infant because she may have Down syndrome."

C

) "I am sorry to have to tell you this, but I suspect your baby has Down syndrome."

D

) "We are going to have to take the baby to the nursery for some tests."

E

) "Your daughter is doing well, but I am concerned about some of her physical features."

26. A 26-year-old primigravid woman at 38 weeks' gestation is admitted to the hospital because she is in labor; contractions occur every 3 minutes and last 60 seconds. The patient's prenatal course has been uncomplicated. Labor curve is now normal and fetal heart rate tracing shows good variability with an occasional mild deceleration. Her patient chart indicates that a previous physician thought she might have a platypellic pelvis. She is now 10-cm dilated. The fetus is at +1 station with a mentum-anterior face presentation. Which of the following is the most appropriate management at this time?

A

) Deliver the child vaginally after manually rotating the fetus to a mentum-posterior presentation

B

) Deliver the child vaginally with the aid of forceps

C

) Deliver the child vaginally with the aid of vacuum extraction

D

) Deliver the child vaginally without intervention

E

) Deliver the child via emergency cesarean delivery

27. A full-term, 3402-g (7-lb 8-oz) neonate aspirated meconium at delivery. Apgar score is 3 at 1 minute and 3 at 5 minutes. He is intubated and assisted ventilation is established using a respirator. His condition stabilizes for 30 minutes but the arterial blood gas values suddenly deteriorate. Which of the following is the most appropriate first step?

A

) Auscultate the chest

B

) Check the respirator settings

C

) Increase the oxygen flow

D

) Recheck the arterial blood gas values

E

) Reposition the endotracheal tube

28. A 56-year-old man who is alcohol-dependent is admitted to the hospital because of fever, encephalopathy and increasing abdominal girth. The patient has no family and has been living on the street. An abdominal paracentesis is consistent with spontaneous bacterial peritonitis, which is treated with antibiotic therapy. During the next 10 days, the patient's renal function deteriorates and his serum creatinine concentration increases to 11.3 mg/dL, with a serum urea nitrogen (BUN) concentration of 144 mg/dL. He becomes progressively more obtunded, develops respiratory failure and is intubated. He requires vasopressors to maintain his blood pressure. There is general agreement from the gastrointestinal and renal services that he will not recover and that further treatment, including dialysis, is futile. The patient is thrashing about in bed, moaning and grimacing periodically. Which of the following is the most appropriate next step in management?

A

) Do a liver biopsy to identify the cause of the patient's liver failure

B

) Initiate lactulose treatment to reduce his encephalopathy

C

) Initiate analgesic therapy to palliate the patient's apparent discomfort

D

) Stop all antibiotic therapy to reduce the chance of further renal toxicity

E

) Stop all medical treatment

The following vignette applies to the next 2 items.


A 38-year-old woman is admitted to the hospital for an elective breast-reduction operation. She is in good health and has never been admitted to the hospital or had previous operations. Her only medication is an oral contraceptive pill. Shortly after the administration of general anesthesia she develops muscular rigidity, temperature increases to 40.6°C (105.0°F), pulse increases to 130/min and blood pressure decreases from 110/70 mm Hg to 80/40 mm Hg. Arterial blood gas values show:


PO2

60 mm Hg

PCO2

40 mm Hg

pH

7.12

Total CO2

18 mm Hg

O2 saturation

88%

Item 1 of 2

29. Which of the following is the most appropriate intravenous pharmacotherapy to administer at this time?

A

) Dantrolene

B

) Diazepam

C

) Epinephrine

D

) Magnesium sulfate

E

) Succinylcholine

Item 2 of 2

30. Which of the following is the most likely cause of this reaction?

A

) Abnormal increase in intracellular calcium

B

) Hypothalamic dysfunction

C

) Hypovolemia

D

) Inability to sweat

E

) Inhibition of protein synthesis

The following vignette applies to the next 2 items.


You are asked to see a 63-year-old woman who is in the hospital after undergoing an operation 4 days ago for a displaced tibia-fibula fracture. The operation was uncomplicated. Preoperative chest x-ray film was normal. She has a transurethral urinary catheter, which was placed during the operation 4 days ago. Today she has a temperature of 37.9°C (100.2°F). Laboratory studies disclose mild leukocytosis. Urinalysis shows greater than 100 WBC/hpf and many bacteria. You suspect that she has a urinary tract infection.

Item 1 of 2

31. Which of the following would have been the most appropriate method of preventing a urinary tract infection in this patient?

A

) Cleaning the perineum twice daily with povidone-iodine

B

) Irrigating the bladder every 8 hours

C

) Removing the catheter immediately post-operation

D

) Treating the patient with prophylactic antibiotics

E

) Using only silver-coated urinary catheters

Item 2 of 2

32.

Incidence of Bacteruria Related to Catheter Use

Study Randomized Suprapubic Catheter Transurethral Catheter Odds Ratio +95% CI

A No 2/25 21/31 0.04(0.01-0.24)

B Yes 10/48 20/44 0.32(0.11-0.86)

C Yes 2/32 16/34 0.08(0.01-0.41)

D Yes 8/32 5/40 1.87(0.48-8.01)

*CI=confidence interval


A Colleague suggests to you that suprapubic catheters can decrease a patient's risk for bacterial colonization. You identify four studies in the medical literature that compare the incidence of bacteruria in patients with a transurethral catheter versus patients with a suprapubic catheter. The study results are shown. Which of the following is the most important criterion related to the validity of these data?

A

) Confidence interval

B

) The number of patients with bacteriuria

C

) Odds ratio

D

) Sample size

E

) Study design


The following vignette applies to the next 2 items.


A 67-year-old woman with a 2-month history of cough was admitted to the hospital after chest x-ray film and CT scan showed a lung mass with suspected mediastinal extension. Biopsies obtained during bronchoscopy and mediastinoscopy showed poorly differentiated squamous cell carcinoma in the peritracheal lymph nodes. A pulmonary consultant has determined that the tumor is inoperable, and that the only available treatment is palliative radiation therapy. The patient has been informed of the diagnosis by you and others, but when you see her now in your office she seems unclear about what she has been told.

Item 1 of 2

33. Given the patient's uncertainty about the details of her diagnosis, which of the following is the most appropriate next step?

A

) Ask the pulmonologist to explain the diagnosis to her

B

) Assume that she is depressed and begin antidepressant pharmacotherapy

C

) Give her the phone number for the American Cancer Society

D

) Recommend that she bring family members with her to her visit next week

E

) Recommend that she obtain a second opinion

Item 2 of 2

34. The patient returns to the office for follow-up 2 weeks later. She requests copies of her medical records and angrily states, "Doctor, I think you're wrong. I've been praying and I know I don't have cancer." Which of the following is the most appropriate response?

A

) "I told you that all of your years of smoking would put you at risk for lung cancer."

B

) "I would be happy to go over all of the reports with you; I appreciate that this is a difficult diagnosis to accept."

C

) "The request for medical records can only come through your attorney."

D

) "The sooner you accept this diagnosis, the sooner we can get on with appropriate therapy."

E

) "We are having a case conference later today with the pulmonary and radiation therapy specialists; maybe you would like to attend to hear their opinions about your disease."

35. A 45-year-old homeless man is admitted to the hospital because of myalgias and jaundice. He has no known past medical history and denies alcohol or drug abuse. Vital signs are: temperature 37.1°C (98.8°F), pulse 90/min, respirations 18/min and blood pressure 117/75 mm Hg. On examination he appears malnourished. Pupils are round and reactive with scleral icterus. Dentition is poor. Gums are swollen and friable. Neck is supple without adenopathy or bruits. No jugular venous distention is noted. Lungs are clear. Cardiac examination demonstrates a normal S1 and S2 with a 2/6 systolic murmur at the left sternal border. Abdomen is distended, but otherwise normal. Examination of the skin discloses diffuse perifollicular hemorrhages on the legs with purpura and ecchymosis. There is no clubbing or cyanosis of the hands, but splinter hemorrhages of the nail beds are noted. Neurologic examination shows normal cranial nerves. Sensation to touch in the legs is decreased, bilaterally. Laboratory studies show:


Serum



Blood



AST

120 U/L

Hemoglobin

9.2 g/dL

Bilirubin

4.2 mg/dL

WBC

5500/mm3




MCV

82 μm3




Platelets

234,000/mm3




PTT

23 sec




PT

12 sec




INR

1.05


Which of the following is the most likely underlying cause for this patient's symptoms and laboratory findings?

A

) Acute viral hepatitis

B

) Endocarditis

C

) Vitamin C deficiency

D

) Hemochromatosis

E

) Vitamin K toxicity

36. An 8-hour-old neonate, who was born via cesarean delivery at 38 weeks' gestation, is in the neonatal unit. The cesarean delivery was done due to fetal distress. The mother is a healthy 25-year-old woman and this was her first pregnancy. There were no complications during the pregnancy, but bloody amniotic fluid was noted at the time of delivery. The neonate's Apgar score was 8 at 1 minute and 9 at 5 minutes; points were taken off for color only. At 30 minutes of age the infant was noted to have some mild grunting and tachypnea. These symptoms resolved spontaneously during approximately a 40-minute period, but the on-call physician ordered a complete blood count and blood culture for suspected sepsis. Because the symptoms resolved so quickly, no antibiotic therapy was started. You are now satisfied that further pursuit of infectious problems is not indicated. The neonate appears normal, and the mother's initial attempts at breast-feeding seem successful. Laboratory studies on the neonate return and are normal except for a hematocrit of 40% (N=4565). Maternal and infant blood type are both O, Rh-positive. The best course of action at this time is to do which of the following?

A

) Obtain hematology consultation

B

) Obtain serum iron studies, including total iron-binding capacity

C

) Order an Apt test on the neonate's stool

D

) Order hemoglobin electrophoresis

E

) Repeat the hematocrit determination
 
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* Re:NBME-13..end
#572021
  anand11anupa - 11/26/06 17:37
 
  25 e
26e
27a28c
29a,30a,31 d, 32 a, 33 b, 34 b, 35b,36e
 
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* Re:NBME-13..end
#572196
  tea - 11/26/06 21:21
 
  25e
26d
27e
28c
29a
30a
31d
32d
33d
34e
35c
36e
 
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