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| * NBME1 BL4 key corrections plsss...............! |
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Section 4:--
1. A previously healthy 52-year-old man comes to the emergency department because of hiccups for 1 week. He has smoked two packs of cigarettes daily for 30 years. He does not drink alcohol. He is alert and oriented. His temperature is 37 C (98.6 F), blood pressure is 150/95 mm Hg, pulse is 70/min, and respirations are 12/min. Physical and neurologic examinations show no abnormalities. His serum sodium level is 120 mEq/L. An x-ray film of the chest shows a right hilar mass. Which of the following is the most appropriate next step in treatment?
A
) Bisphosphonate therapy
B
) Calcitonin therapy
C
) Calcium therapy
D
) Dexamethasone therapy
E
) 5% Dextrose in 0.225% saline therapy
F
) 5% Dextrose in 0.45% saline therapy
G
) 5% Dextrose in water therapy
H
) Fluid restriction
I
) Hydrocortisone therapy
J
) Lactated Ringer's solution
K
) Mannitol therapy
L
) Potassium therapy
M
) 0.9% Saline therapy
N
) 3% Saline therapy
O
) Sodium bicarbonate therapy
2. A 67-year-old man comes to the physician because of a 6-month history of double vision, slurred speech, and difficulty swallowing liquids. Initially, his symptoms were intermittent but now occur daily and are worse at the end of the day. Over the past week, he has had shortness of breath with exertion. He has pernicious anemia treated with monthly vitamin B12 (cyanocobalamin) injections and autoimmune thyroid disease currently treated with thyroid replacement therapy. Examination shows bilateral ptosis and disconjugate gaze. There is bilateral facial weakness and hypernasal speech. The tongue is weak, and the gag reflex is reduced. Muscle strength is 4/5 in the proximal muscles of the upper and lower extremities. Deep tendon reflexes are 2+ diffusely. Babinski's sign is absent. Sensory examination shows no abnormalities. A CT scan of the chest is shown. Which of the following is the most likely diagnosis of this patient's intrathoracic lesion?
A
) Aspiration pneumonia
B
) Bronchogenic carcinoma
C
) Lung metastasis
D
) Sarcoidosis
E
) Thymoma
F
) Thyroid carcinoma
3. A 32-year-old man receiving intensive chemotherapy for Hodgkin's disease has a temperature of 39 C (102.2 F). His respirations are 40/min. Widespread crackles are heard in all lung fields. An x-ray film of the chest shows a diffuse alveolar and interstitial pattern. Which of the following is the most likely causal organism?
A
) Aspergillus species
B
) Candida albicans
C
) Coccidioides immitis
D
) Pneumocystis carinii
E
) Streptococcus pneumoniae
4. A 20-year-old African American man with sickle cell disease comes to the physician because of a 1-week history of shortness of breath on exertion, fatigue, and generalized weakness. He has had no fever, chills, night sweats, or cough productive of sputum. His only medication is oxycodone for joint pain. He weighs 68 kg (150 lb) and is 168 cm (66 in) tall. His temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 76/min, and respirations are 18/min. Examination shows no abnormalities. Laboratory studies show:
Hematocrit 20%
Mean corpuscular volume 110 μm3
Leukocyte count 2300/mm3
Reticulocyte count 1.8%
Which of the following is the most likely mechanism for these findings?
A
) Adverse drug reaction
B
) Atrophy of gastric mucosa
C
) Bacterial overgrowth in the small intestine
D
) Increased demand for folic acid
E
) Increased demand for vitamin B12 (cyanocobalamin)
F
) Malabsorption
G
) Vitamin B1 (thiamine) deficiency
5. A 44-year-old woman comes to the emergency department 2 days after being discharged from the hospital for abdominal pain; an exploratory laparoscopy showed no abnormalities. Over the past 5 years, she had been admitted to the hospital numerous times for the evaluation of a variety of symptoms; all work-ups had been negative. Her temperature is 39.2 C (102.6 F). Examination shows a reddened, indurated laparoscopic wound. She is admitted to the hospital and given intravenous antibiotics. On the second hospital day, a nurse witnesses the patient rubbing saliva into her laparoscopy site. Which of the following is the most likely diagnosis?
A
) Adjustment disorder with disturbance of conduct
B
) Conduct disorder
C
) Conversion disorder
D
) Factitious disorder
E
) Hypochondriasis
F
) Major depressive disorder
G
) Oppositional defiant disorder
H
) Somatization disorder
6. A 37-year-old woman is brought to the emergency department because she has been unable to see out of her right eye since awakening 2 hours ago. She states that any movement of the eye is painful. Examination shows visual acuity of 20/200 in the right eye and 20/20 in the left eye. The optic fundi are normal. The left pupil reacts normally to light. The right pupil is poorly reactive to direct light. The remainder of the eye examination shows no abnormalities. Which of the following is the most likely site of the lesion?
A
) Left optic nerve
B
) Left optic radiation
C
) Left optic tract
D
) Left visual cortex
E
) Optic chiasm
F
) Retina
G
) Right optic nerve
H
) Right optic radiation
I
) Right optic tract
J
) Right visual cortex
The response options for the next two items are the same. You will be required to select one answer for each item in the set.
For each patient with peripheral nerve dysfunction, select the most likely site of nerve injury.
A
) Axillary nerve
B
) Cervical nerve root at the cervical foramen
C
) Long thoracic nerve
D
) Median nerve above the elbow
E
) Median nerve at the elbow
F
) Median nerve at the wrist
G
) Musculocutaneous nerve above the elbow
H
) Musculocutaneous nerve at the elbow
I
) Musculocutaneous nerve at the wrist
J
) Radial nerve above the elbow
K
) Radial nerve at the elbow
L
) Radial nerve at the wrist
M
) Suprascapular nerve
N
) Thoracodorsal nerve
O
) Ulnar nerve above the elbow
P
) Ulnar nerve at the elbow
Q
) Ulnar nerve at the wrist
7.
A previously healthy 42-year-old carpenter comes to the physician because of a 6-month history of pain and numbness in his dominant hand that awakens him at night. He describes numbness in his long and index fingers after driving for extended periods of time. Examination shows minimal atrophy of the thenar muscles. There is normal sensation to light touch on the little finger and the palm of the right hand. Sensation to light touch is decreased at the tip of the thumb, index finger, and long finger. X-ray films of the right elbow and wrist show no abnormalities.
For each patient with peripheral nerve dysfunction, select the most likely site of nerve injury.
A
) Axillary nerve
B
) Cervical nerve root at the cervical foramen
C
) Long thoracic nerve
D
) Median nerve above the elbow
E
) Median nerve at the elbow
F
) Median nerve at the wrist
G
) Musculocutaneous nerve above the elbow
H
) Musculocutaneous nerve at the elbow
I
) Musculocutaneous nerve at the wrist
J
) Radial nerve above the elbow
K
) Radial nerve at the elbow
L
) Radial nerve at the wrist
M
) Suprascapular nerve
N
) Thoracodorsal nerve
O
) Ulnar nerve above the elbow
P
) Ulnar nerve at the elbow
Q
) Ulnar nerve at the wrist
8. A previously healthy 37-year-old man comes to the physician because of a 2-month history of pain in the forearm and little finger of his dominant hand; he has been working as a receptionist for 6 months. He describes numbness in his little finger and weakness of his grip. There is decreased sensation to light touch at the tip of the little finger. Paresthesias are elicited with compression of the cubital tunnel.
9. A 3-month-old boy is brought for a well-child examination. He has poor head control. Examination shows generalized hypotonia. The point of maximal impulse is at the left anterior axillary line. The liver edge is palpated 4 cm below the right costal margin. The spleen is not palpable. Which of the following is the most likely diagnosis?
A
) Congenital muscular dystrophy
B
) Glycogen storage disease, type II (Pompe's disease)
C
) GM1 gangliosidosis
D
) Infant botulism
E
) Ventricular septal defect
10. Over the past 3 months, a 30-year-old woman has had intermittent episodes of headache, palpitations, sweating, and irritability. Her blood pressure is 150/100 mm Hg while supine and 149/100 mm Hg while standing, and pulse is 90/min while supine and 110/min while standing. Examination shows no abnormalities except for pallor. Which of the following is the most likely location of this patient's lesion?
A
) Adrenal gland
B
) Brain
C
) Heart
D
) Kidney
E
) Thyroid gland
11. A 19-year-old man is brought to the emergency department 45 minutes after sustaining a single, large stab wound to the right upper quadrant of the abdomen. He is obtunded. His blood pressure is 60/palpable mm Hg, and pulse is 148/min. Breath sounds are equal bilaterally. Examination shows a 4-cm laceration in the right upper quadrant in the midclavicular line. The abdomen is distended. Which of the following is the most appropriate next step in management?
A
) X-ray films of the abdomen and pelvis
B
) Angiography
C
) Contrast study of the wound tract
D
) CT scan of the abdomen
E
) CT scan of the chest
F
) Laparoscopy
G
) Peritoneal lavage
H
) Laparotomy
I
) Local wound exploration
12. A 52-year-old woman comes to the physician because of decreased libido; this symptom began 8 months ago, after she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyomata uteri and menorrhagia. She has been taking hormone replacement therapy with conjugated estrogen since the operation. Examination shows a moist, rugated vagina. Which of the following is the most likely cause of these findings?
A
) Decreased androgens
B
) Decreased estrogen
C
) Decreased follicle-stimulating hormone (FSH)
D
) Decreased luteinizing hormone (LH)
E
) Decreased progesterone
F
) Decreased prolactin
G
) Increased androgens
H
) Increased estrogen
I
) Increased FSH
J
) Increased LH
K
) Increased progesterone
L
) Increased prolactin
13.
A 7-day-old newborn is brought for a well-child examination. He was born at home. His mother has taken acetaminophen for perineal discomfort. The newborn is breast-feeding well. He is at the 75th percentile for length and weight. Examination shows no abnormalities. After vaccination with hepatitis B, he has prolonged bleeding at the injection site. There is no family history of excessive bleeding. Laboratory studies show:
Hemoglobin 16 g/dL
Leukocyte count 6800/mm3
Segmented neutrophils 48%
Bands 2%
Lymphocytes 50%
Platelet count 280,000/mm3
Prothrombin time 20 sec (INR=1.6)
Partial thromboplastin time 60 sec
Which of the following is the most likely mechanism for these findings?
A
) Autoimmunization
B
) Bacterial toxic effect
C
) Factor VIII deficiency
D
) Factor IX deficiency
E
) Immunoglobulin deficiency
F
) Iron deficiency
G
) Pharmacologic effect
H
) Viral toxic effect
I
) Vitamin deficiency
J
) Zinc deficiency
14.
A 67-year-old man with long-standing signs and symptoms of congestive heart failure is admitted to the hospital because of progressive shortness of breath. Examination shows no other abnormalities. An x-ray film of the chest shows cardiomegaly, cephalization of blood vessels, and a right-sided pleural effusion. Which of the following sets of pleural fluid findings is most likely in this patient?
Leukocyte Segmented
Protein Glucose count neutrophils Monocytes
(g/dL) (mg/dL) (/mm3) (%) (%)
A
)
2.5
10
10,000
50
50
B
)
2.5
90
2000
60
40
C
)
3.8
40
30,000
80
20
D
)
4.5
60
10,000
20
80
E
)
4.5
90
2000
50
50
15. For 8 weeks, a 52-year-old man with a 5-year history of type 2 diabetes mellitus has had deep burning pain in the ball of his right foot and big toe when the foot is raised above chest level. He also has cramping in his right calf when he walks more than 50 feet. He has smoked two packs of cigarettes daily for 30 years. Femoral pulses are palpable; pedal pulses are absent. Which of the following is the most likely diagnosis?
A
) Aortoiliac stenosis
B
) Femoral popliteal stenosis
C
) Mononeuropathy
D
) Vasculitis
E
) Venous stasis
16. A 1-year study of a new drug to treat hypertension is conducted. One hundred patients with hypertension are enrolled; 50 patients are given the new drug and another 50 patients are given hydrochlorothiazide. All patients completed the trial. One noted unexpected effect is increased growth of scalp hair which occurred in those taking the new drug, a nonstatistically significant difference (p>0.10). This effect has also been reported in studies of other similar drugs in the new therapeutic class. The investigators of the study concluded that the new drug did not cause hair growth. Which of the following features of this study is most likely to affect the validity of this conclusion?
A
) Differential follow-up
B
) Lead time bias
C
) Length of the study
D
) Sample size
E
) Self-selection
17. A 38-year-old woman, gravida 2, para 1, at 38 weeks' gestation has had no fetal movement for 36 hours. Her prenatal course, prenatal tests, and fetal growth have been normal. Fetal heart tones are heard by Doppler. Which of the following is the most appropriate next step in management?
A
) Routine prenatal visit in 1 week
B
) Maternal hydration
C
) Nonstress test
D
) Immediate induction of labor
E
) Amniocentesis
18. A healthy 7-year-old boy is brought to the physician 1 week after he was exposed for several hours to a child with chickenpox. The patient and his healthy sister have not had chickenpox. They have not received varicella vaccine. Which of the following is the most appropriate management for the patient and his sister at this time?
A
) Administer acyclovir as prophylaxis
B
) Administer immune globulin, intravenously
C
) Administer aspirin therapy if vesicles appear
D
) Advise the parents to keep the siblings home from school to prevent exposing their classmates
E
) Inform the parents that a vesicular rash may appear at any time over the next 2 weeks
19. A 6-year-old boy is brought to the physician by his mother because of progressive visual loss over the past year. Over the past 2 years, he has had deterioration of his hearing, speech, writing, and intellectual performance. His maternal uncle had similar symptoms. Visual acuity is 20/200 bilaterally. Funduscopic examination shows optic atrophy. His hearing is markedly impaired. There is weakness and spasticity of all extremities. Deep tendon reflexes are extremely hyperactive. Babinski's sign is present bilaterally. On mental status examination, he is not oriented to place, year, month, or the names of his siblings. An MRI of the brain shows marked symmetric white matter disease involving all lobes. Diagnostic studies are most likely to show which of the following?
A
) Abnormally decreased serum cholesterol level
B
) Acanthocytes on blood smear
C
) An excess of very long chain fatty acids
D
) Normal nerve conduction studies
E
) Vitamin E deficiency
20. A 22-year-old primigravid woman at 16 weeks' gestation is brought to the emergency department because of progressive shortness of breath over the past 48 hours. Her temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 24/min. Scattered wheezes are heard. Pelvic examination shows a uterus that extends to the umbilicus. Fetal heart tones are absent. Her hematocrit is 32%, leukocyte count is 11,000/mm3, and serum β-hCG level is 300,000 mIU/mL. Pulse oximetry on room air shows an oxygen saturation of 92%. An x-ray film of the chest shows multiple round densities throughout all lung fields. Which of the following is the most likely diagnosis?
A
) Bacterial pneumonia
B
) Choriocarcinoma
C
) Pulmonary embolism
D
) Tuberculosis
E
) Viral pneumonia
21. A 42-year-old man comes to the physician because of progressive swelling of the legs over the past 2 months. He has a history of stage IIA Hodgkin's disease treated 1 year ago with radiation therapy to the neck and chest. His temperature is 37 C (98.6 F), blood pressure is 102/80 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows jugular venous distention that increases with inspiration. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced point of maximal impulse; heart sounds are distant. An early diastolic sound is heard at the apex. Abdominal examination shows mild distention with shifting dullness. The liver is pulsatile, and its edge is palpated 4 cm below the right costal margin. There is 2+ peripheral edema extending up to the knees. Which of the following is the most likely mechanism of this patient's increased central venous pressure?
A
) Constrictive pericarditis
B
) Cor pulmonale
C
) Left-sided congestive heart failure
D
) Mitral stenosis
E
) Tricuspid stenosis
22. A 5-year-old boy is brought to the emergency department 30 minutes after he fainted at home after standing up from a sitting position. His symptoms began 3 days ago with diarrhea and vomiting. He has had no urine output for 18 hours. He is alert but quiet. His temperature is 37.5 C (99.5 F), blood pressure is 75/45 mm Hg, pulse is 120/min, and respirations are 28/min. Examination shows dry lips and tenting of the skin. There is no abdominal tenderness. Bowel sounds are hyperactive. The remainder of the examination shows no abnormalities. His capillary refill time is 5 seconds. Intravenous bolus doses of 0.9% saline are administered. Bladder catheterization yields 5 mL of urine. Urinalysis is most likely to show which of the following?
A
) Blood
B
) Erythrocyte casts
C
) Hyaline casts
D
) Leukocyte casts
E
) Oxalate crystals
23.
A 2-year-old boy is brought to the physician because of fever and cough for 2 days. He had Streptococcus pneumoniae meningitis at the age of 1 year, S. pneumoniae bacteremia at the age of 18 months, and pneumonia at the age of 22 months. Two maternal uncles died before the age of 2 years from "infection." His temperature is 39.8 C (103.6 F), pulse is 150/min, and respirations are 60/min. Examination shows subcostal retractions on inspiration. Laboratory studies show:
Hemoglobin 10 g/dL
Leukocyte count 36,000/mm3
Segmented neutrophils 70%
Bands 20%
Lymphocytes 8%
Monocytes 2%
Platelet count 240,000/mm3
Serum
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