| * NBME 2 /Block 3/Q21-Q46: please share answers
||21. A previously healthy 85-year-old man has had abdominal distention, decreased caliber of stools, and decreased appetite over the past 2 weeks and a 9-kg (20-lb) weight loss over the past 3 months. On sigmoidoscopy, he is found to have a constricting adenocarcinoma of the sigmoid colon; imaging studies show three 1-cm metastases to the liver. Which of the following is the most appropriate next step in management?
A) No treatment
B) Radiation therapy
D) Combination radiation therapy and chemotherapy
E) Resection of the colon tumor
22. An 8-year-old girl with asthma is brought to the physician 1 week after an acute exacerbation treated with a 5-day taper course of oral prednisone. This was her first asthma attack of the fall season. Medications include an inhaled corticosteroid daily and a bronchodilator metered-dose inhaler as needed. Her last immunizations were at the age of 5 years prior to entering kindergarten. Her temperature is 37 C (98.6 F), pulse is 92/min, and respirations are 28/min. Examination shows
end-expiratory wheezing with forced expiration. Administration of which of the following vaccines is most appropriate at this visit?
A) Haemophilus influenzae type b
B) Influenza virus
D) 23-Valent pneumococcal
23. A 27-year-old man is brought to the hospital by family members because he has remained in his room for 3 days. He has refused to go to work or eat with the family, and he expresses concern
that family or friends may try to kill him. One week ago, he was despondent when his girlfriend of 5 years abruptly ended their relationship. He has no history of psychiatric illness. Which of the following is the most likely diagnosis?
A) Adjustment disorder with depressed mood
B) Bipolar disorder
C) Brief psychotic disorder
D) Dysthymic disorder
E) Schizoaffective disorder
24. A 35-year-old primigravid woman at 20 weeks' gestation comes to the physician because of vaginal pressure and a watery, pink vaginal discharge for 1 day. Her temperature is 37.5 C (99.5
F). The uterus is palpated at the umbilicus. Fetal heart rate is 140/min. Speculum examination shows that the upper vagina is filled with bulging, shiny, smooth membranes. The cervix cannot be palpated. Which of the following is the most likely mechanism for these findings?
A) Abruptio placentae
B) Cervical incompetence
C) Premature labor
D) Uterine anomaly
E) Uterine infection
25. A previously healthy 45-year-old woman has had fever and progressive confusion over the past 2 days. She is now unable to perform activities of daily living. Her temperature is 38 C (100.4 F). She is oriented only to person. There is no rash, and the neck is supple. A CT scan of the head shows normal findings. Cerebrospinal fluid analysis shows:
Leukocyte count 20/mm3
Glucose 45 mg/dL
Protein 110 mg/dL
Which of the following is the most likely diagnosis?
A) Bacterial meningitis
B) Acute alcohol intoxication
C) Brain stem infarction
D) Cerebral infarction
E) Cryptococcal meningitis
F) Enterovirus infection
G) Hepatic encephalopathy
H) Herpes simplex encephalitis
I) Huntington's disease
K) Lyme disease
26. A 57-year-old man with multiple myeloma comes to the physician because of a 12-hour history of fever, sharp chest pain with deep inspiration, and cough productive of blood-tinged sputum. His temperature is 38.3 C (101 F), blood pressure is 120/78 mm Hg, pulse is 112/min, and respirations are 28/min. Crackles are heard at the right lung base. His hemoglobin level is 9.2 g/dL, leukocyte count is 2600/mm3, and platelet count is 96,000/mm3. Empiric antibiotics should be directed against which of the following organisms?
A) Listeria monocytogenes
B) Neisseria meningitidis
C) Pseudomonas aeruginosa
D) Streptococcus bovis
E) Streptococcus pneumoniae
27. A 19-year-old primigravid woman is brought to the emergency department because of a 4-hour history of heavy vaginal bleeding. She has vomited daily for the past month. Her last menstrual
period was 15 weeks ago. She has not received prenatal care. She takes no medications.
Her temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 20/min. Abdominal examination shows a uterus consistent in size with a 20-week gestation with no adnexal masses or tenderness. There is pedal edema. A serum pregnancy test is
positive. Urinalysis shows 1+ protein. Which of the following is the most likely cause of this patient's vaginal bleeding?
A) Abruptio placentae
B) Ectopic pregnancy
C) Hydatidiform mole
28. A 40-year-old man has the sudden onset of excruciating head and neck pain while carrying books from the basement to the attic. His temperature is 37 C (98.6 F), blood pressure is 130/90
mm Hg, and pulse is 90/min. He has photophobia and develops eye pain with lateral eye movements. His neck is markedly stiff and cannot be passively flexed. He has diffuse hyperreflexia in all extremities with normal strength and sensation. Plantar reflexes are flexor bilaterally.
Which of the following is the most likely diagnosis?
A) Cervical osteoarthritis
C) Ruptured cervical disc
D) Subarachnoid hemorrhage
29. A 59-year-old woman comes to the emergency department because of shortness of breath for 2 days. She had stage II breast cancer 5 years ago treated with lumpectomy, radiation, and
chemotherapy. Her temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, and respirations
are 24/min. Examination shows jugular venous distention. Heart sounds are distant. Which of the following is the most appropriate next step in management?
A) Antibiotic therapy
B) Anticoagulant therapy
C) Intravenous digoxin therapy
D) Intravenous furosemide therapy
F) Radiation therapy
30. A 57-year-old man comes for a routine follow-up examination. He has a 10-year history of an intermittent facial rash. He has been taking propranolol for 2 months for hypertension. Examination shows several erythematous pustules and papules involving the nose and central face. There are telangiectasias at the base of the papules. Which of the following is the most likely explanation for these findings?
A) Acne rosacea
B) Acne vulgaris
C) Basal cell carcinoma
D) Discoid lupus erythematosus
E) Seborrheic dermatitis
31. A 42-year-old man comes to the physician because of malaise, muscle and joint pain, and temperatures to 38.4 C (101.1 F) for 3 days. Three months ago, he underwent cadaveric renal
transplantation resulting in immediate kidney function. At the time of discharge, his serum
creatinine level was 0.8 mg/dL. He is receiving cyclosporine and corticosteroids. Examination shows no abnormalities. His leukocyte count is 2700/mm3, and serum creatinine level is 1.6 mg/dL;
serum cyclosporine level is in the therapeutic range. A biopsy of the transplanted kidney
shows intracellular inclusion bodies. Which of the following is the most appropriate next step in management?
A) Increase the dosage of corticosteroids
B) Increase the dosage of cyclosporine
C) Begin amphotericin therapy
D) Begin ganciclovir therapy
E) Begin heparin therapy
32. A 5-month-old boy is brought to the physician because of a 24-hour history of fever, cough, noisy breathing, and difficulty feeding. His symptoms began 3 days ago with nasal discharge,
mild cough, and chest congestion. He appears somewhat irritable and is crying. His temperature is 38.5 C (101.3 F), pulse is 108/min, and respirations are 32/min and shallow with a prolonged expiratory phase. On examination, the throat appears normal. A few small anterior and
posterior cervical nodes are palpable. Both eardrums are pink but have normal landmarks and
mobility. There is good air entry with diffuse bilateral expiratory wheezes on auscultation. An x-ray film of the chest shows hyperinflation. Which of the following is the most likely pathogen?
B) Haemophilus influenzae
C) Mycoplasma pneumoniae
D) Respiratory syncytial virus
E) Streptococcus pneumoniae
33. Three days after undergoing a right hipreplacement for rheumatoid arthritis, a 77-year-old man is brought to the physician because of a 2-day history of pain, burning, and itching of his left eye and left side of his forehead. He has the sensation that there is a speck of dirt in his left eye. Current medications include prednisone and methotrexate. Examination of the left eye shows conjunctival injection and swelling of the upper eyelid. There is an erythematous rash over the left side of the forehead and tenderness to palpation from the upper eyelid to the vertex. A photograph of the rash is shown. Which of the following is the most appropriate next step in management?
A) Measurement of erythrocyte sedimentation rate
B) MRI of the brain with contrast
C) Acyclovir therapy
D) Corticosteroid therapy
E) Lumbar puncture
34. A 54-year-old man with chronic obstructive pulmonary disease undergoes a total hip arthroplasty for avascular necrosis of the femoral head. On the second postoperative day, he has
diffuse, profound weakness and vomiting. His blood pressure is 85/50 mm Hg, and pulse is 100/min. The operative site is clean and dry, with minimal output from the drains. Hemoglobin level is 13.8 g/dL, serum sodium level is 132 mEq/L, and serum potassium level is 5.8 mEq/L. Which of the
following is most likely to confirm the diagnosis?
A) Measurement of serum thyroid-stimulating hormone level
B) Direct antiglobulin (Coombs') test
C) ACTH stimulation test
D) Ventilation-perfusion lung scans
35. A previously healthy 47-year-old nulliparous woman is brought to the emergency department by ambulance because of acute low back pain radiating to the right posterior leg for 2 hours. The pain began when she bent over at work to retrieve a file from the lowest drawer of a filing cabinet. She does not smoke cigarettes or drink alcohol. Examination shows right paraspinous muscle spasm and pain in the lower back with right straight-leg raising at 30 degrees. She says that she plans to file a claim for a work-related injury. Which of the following findings is the strongest risk factor for a prolonged episode of pain in this patient?
A) Arrival for care in an ambulance
B) Claim that pain is work-related
E) Positive straight-leg raising test
F) Radiation of the pain into the posterior lower extremity
36. A healthy 27-year-old woman comes to the physician for an annual examination. She is concerned about her risk for an abnormal Pap smear in the future. A history of use of which of the
following would increase her risk for cervical cancer?
B) Cervical cap
37. A 72-year-old man is brought to the physician by his daughter because of painless jaundice for 1 month. His wife died 10 years ago, and his daughter is his only child. Before examining the patient, the daughter asks to speak privately with the physician and asks that she be given the results of any tests. She specifically requests that he not be given any "bad news." The patient is alert. His
vital signs are within normal limits. Examination shows scleral icterus and jaundice. There is mild abdominal tenderness on palpation. He is oriented to person, place, and time. A CT scan of the abdomen shows a pancreatic mass with bile duct obstruction and probable metastatic
lesions in the liver. Which of the following is the most appropriate next step?
A) Abide by the daughter's wishes
B) Ask the patient if he wishes to discuss his test results, preferably with his daughter present
C) Tell the daughter it is a legal requirement to tell the patient any and all results of medical testing
D) Consult with the hospital attorney
E) Ask another physician to take over the patient's care
38. A 66-year-old man has had numbness and tingling in the hands and feet for 2 weeks. He lives in a homeless shelter and is well fed. He has been treated for pulmonary tuberculosis for 4 months with isoniazid, rifampin, ethambutol, and pyrazinamide. He is compliant with his medication regimen but continues to abuse alcohol. His temperature is 37 C (98.6 F), blood pressure is 136/76 mm Hg, pulse is 72/min, and respirations are 20/min. He is well nourished but depressed and irritable.
There is decreased sensation to pain and touch in the hands and feet in a stocking-glove distribution. Which of the following is the most likely nutritional deficiency?
A) Folic acid
C) Vitamin A
D) Vitamin B1 (thiamine)
E) Vitamin B2 (riboflavin)
F) Vitamin B6
G) Vitamin B12 (cyanocobalamin)
H) Vitamin C
I) Vitamin D
J) Vitamin E
K) Vitamin K
39. A 63-year-old man is brought to the emergency department 3 hours after the acute onset of severe right-sided flank pain. He has a 9-year history of gout. His blood pressure is 110/84
mm Hg, pulse is 78/min, and respirations are 16/min. Examination shows normal bowel sounds
and no abdominal tenderness or masses. Urinalysis shows 40 erythrocytes/hpf. Intravenous pyelography confirms a right ureteral calculus. Which of the following is the most likely underlying
mechanism of this patient's urolithiasis?
A) An increase in urinary pH
B) Damage to the epithelial lining of the ureters
C) Lack of inhibitors of crystal formation
D) Presence of urease-splitting bacteria
E) Urinary supersaturation with uric acid
40. A 27-year-old nulligravid woman comes to the physician for preconceptional counseling. She has a mechanical mitral heart valve and chronic rheumatoid arthritis. Her cardiac status is New York Heart Association Class II. She feels well. Current daily medications include warfarin, prednisone, and acetaminophen with codeine. Examination shows no abnormalities except for audible clicking from the heart valve. Which of the following is the most appropriate advice for this patient?
A) Chemical dependency counseling before pregnancy
B) Discontinuation of anticoagulant therapy during pregnancy
C) Discontinuation of prednisone during pregnancy
D) Switching from warfarin to heparin before pregnancy
E) No change in treatment before or during pregnancy
41. A 60-year-old man comes to the physician because of difficulty sleeping and concentrating and a 5-kg (10-lb) weight loss over the past 3 months. He also has become withdrawn. He has had
chronic pain since sustaining fractures of the left lower extremity, pelvis, and several ribs in a motor vehicle collision 2 years ago. He has a previous history of alcohol abuse. He takes a nonsteroidal
anti-inflammatory drug. Which of the following is the most appropriate pharmacotherapy?
D) Lithium carbonate
42. An 82-year-old man comes to the physician because of a 3-day history of low back pain that radiates to the right leg. He also has had a lesion over the right shin and weakness of the right
foot. He began taking prednisone 2 weeks ago for acute bronchitis. He has chronic obstructive pulmonary disease, benign prostatic hypertrophy, and glaucoma. Examination shows numerous papular and vesicular lesions over the right anterior and posterior shin. There is weakness of
right knee flexion, ankle dorsiflexion, plantar flexion, eversion, and inversion; the right ankle reflex is absent. Sensation to pinprick and cold is decreased over the right lower extremity. Which of the
following is the most likely causal organism?
A) Borrelia burgdorferi
B) Epstein-Barr virus
C) Herpes simplex virus 1
E) Treponema pallidum
F) Varicella-zoster virus
43. A 30-year-old woman comes to the physician because of long-standing unhappiness that may have started when she was rejected by her classmates as a teenager. She says that although she
has good days, many days are dominated by negative thoughts about herself. She appears somewhat sad and tends to be readily critical of herself. Although she sleeps satisfactorily, she often finds her energy level decreased by the end of the day. She also has been forgetful. She weighs 59 kg (130 lb) and is 157 cm (62 in) tall. Physical examination and laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?
A) Adjustment disorder with depressed mood
B) Depersonalization disorder
C) Dissociative identity disorder
D) Dysthymic disorder
F) Major depressive disorder
G) Schizoaffective disorder
For each patient with cough, select the most appropriate next step in diagnosis.
A) Measurement of serum a1-antitrypsin level
B) Methacholine challenge test
C) Quantitative measurement of serum antibody levels
D) Sweat chloride test
E) Ventilation-perfusion lung scans
44. A 27-year-old woman comes to the physician because of intermittent episodes of shortness of breath and cough over the past 4 months. She says that cold weather and exercise can precipitate her symptoms. Examination shows no abnormalities. The lungs are clear to auscultation
and percussion. An x-ray film of the chest and spirometry show no abnormalities. C) Quantitative measurement of serum antibody levels
45. A 32-year-old woman comes to the physician because of a 4-month history of fatigue, cough, and shortness of breath with exertion. She has had two episodes of pneumonia and one episode of severe sinusitis over the past 2 years. She has never smoked. She takes no medications. Crackles are heard at the left lung base. An x-ray film of the chest shows a left lower lobe infiltrate and scarring of the right base.
46. A 32-year-old man is brought to the emergency department 30 minutes after being involved in a motor vehicle collision. He was the restrained driver. On arrival, he is alert and has shortness of breath. His blood pressure is 80/50 mm Hg, pulse is 130/min, and respirations are 30/min. Examination shows jugular venous distention and abrasions over the left hemithorax. The trachea is deviated to the right. Breath sounds are absent on the left. Which of the following is the most likely cause of the hypotension?
A) Cardiogenic shock
B) Congestive heart failure
C) Decreased systemic vascular resistance
D) Decreased venous return
E) Hypovolemic hypoperfusion
F) Increased systemic vascular resistance