02-16-2009, 09:16 AM
Hi guys, these are 8 Q from NBME exam, can u answer it for me? thanks in advance.
An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure. Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3“5 area in the midline, which is slightly swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.
Item 1 of 2
35. Which of the following is the most accurate statement?
Your browser may not support display of this image. A ) An epidural abscess has developed
Your browser may not support display of this image. B ) The epidural block has worn off
Your browser may not support display of this image. C ) The original injection was subdural
Your browser may not support display of this image. D ) A radiculopathy has developed at a different level
Your browser may not support display of this image. E ) She is having a reaction to the anesthetic
36. Which of the following is the most appropriate next step?
Your browser may not support display of this image. A ) Administer an analgesic and diphenhydramine
Your browser may not support display of this image. B ) Administer an analgesic, intravenously, and arrange myelography
Your browser may not support display of this image. C ) Contact the anesthesiologist about repeating the epidural block
Your browser may not support display of this image. D ) Reassure the patient and have her make an appointment with the orthopedist for tomorrow
Your browser may not support display of this image. E ) Request an emergency MRI of the spine
9. A 67-year-old man is brought to the emergency department in ventricular fibrillation. His rectal temperature is 26.7°C (80.0°F). Among the following criteria, the patient should be declared dead when defibrillation fails after which of the following?
Your browser may not support display of this image. A ) Rapid endotracheal intubation and administration of 100% oxygen
Your browser may not support display of this image. B ) Restoration of a normal core temperature
Your browser may not support display of this image. C ) Restoration of a normal oral temperature
Your browser may not support display of this image. D ) 1 hour of core rewarming
Your browser may not support display of this image. E ) 20 minutes of warming, externally
32. A 62-year-old woman who was discharged from the hospital several hours ago following evaluation of optic neuritis now has swelling of her ankles. Prior to admission, the patient had a 3-day history of loss of vision and poor color perception in her right eye. Visual acuity on admission was less than 20/200 in her right eye and was 20/40 in her left eye. The remainder of the physical examination was noncontributory. Blood pressure on admission was 140/80 mm Hg. The patient had been otherwise healthy and had been taking no medications. She has never worn corrective lenses. Family history is significant for thyroid disorder. During her hospital stay, the patient received intravenous methylprednisolone therapy for the past four days. Vital signs today are temperature 37.2°C (99.0°F), pulse 100/min, respirations 14/min, and blood pressure 150/95 mm Hg. Physical examination shows ankle edema but is otherwise unchanged from physical examination done on admission. Laboratory studies are obtained. Which of the following serum laboratory study results is most likely in this patient?
Your browser may not support display of this image. A ) Decreased magnesium concentration
Your browser may not support display of this image. B ) Decreased sodium concentration
Your browser may not support display of this image. C ) Increased calcium concentration
Your browser may not support display of this image. D ) Increased glucose concentration
Your browser may not support display of this image. E ) Increased potassium concentration
27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?
Your browser may not support display of this image. A ) CT scan of the head
Your browser may not support display of this image. B ) Electromyography and nerve conduction studies of the left upper extremity
Your browser may not support display of this image. C ) Measurement of serum B12 (cobalamin) concentration
Your browser may not support display of this image. D ) MRI of the cervical spine
Your browser may not support display of this image. E ) Radionuclide bone scan
26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?
Your browser may not support display of this image. A ) Determine serum estrogen concentration
Your browser may not support display of this image. B ) Order antibody studies for syphilis and HIV
Your browser may not support display of this image. C ) Prescribe an oral anti-trichomonal medication and antifungal cream
Your browser may not support display of this image. D ) Question the patient regarding the circumstances surrounding her recent break-up
Your browser may not support display of this image. E ) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge
22. A 28-year-old African-American woman comes to the office because of low back pain and decreased urine output. She is a semiprofessional basketball player and she is married. She had one pregnancy 12 years ago that was uncomplicated and resulted in vaginal delivery of a term female neonate. Medications include oral contraceptive pills and a corticosteroid inhaler for asthma. She is 182 cm (6 ft) tall and weighs 88 kg (195 lb). Physical examination is normal except for a palpable lower abdominal mass that extends to the umbilicus. Speculum examination discloses a 3-cm ulcerative lesion circumferentially around the external cervical os. Bimanual examination shows a firm, nodular, central pelvic mass filling the pelvis and extending cephalad to the umbilicus. Rectovaginal examination confirms these findings. Stool is negative for occult blood. Which of the following is the most appropriate recommendation?
Your browser may not support display of this image. A ) Arrange for laparoscopy
Your browser may not support display of this image. B ) Do a cervical biopsy
Your browser may not support display of this image. C ) Do an endometrial biopsy
Your browser may not support display of this image. D ) Increase Pap smear screening to every 3 months
Your browser may not support display of this image. E ) Obtain pelvic ultrasonography
13. A 16-year-old boy and his mother come to the office because the mother is concerned that her son may have a drug problem. You have treated him in the past for mild intermittent asthma, and he currently uses an albuterol inhaler prior to exercise. You last saw him 1 year ago for a sports physical examination. At that time, he admitted to drinking alcohol on the weekends. He also admitted to marijuana use but had planned to quit using both before track season started. The mother says that her son now seems disinterested in school and other activities in which he was previously engaged. He has quit the track team, has become irritable, and he has a new set of friends whom his mother dislikes and describes as "druggies." She acknowledges that the boy's father, from whom she is divorced, has an alcohol abuse problem. The boy's older brother abused cocaine for 2 years but is now in a drug rehabilitation program. Prior to interviewing and examining the patient, the mother pulls you aside and asks you to test her son for drugs without informing him. Which of the following is the most appropriate response?
Your browser may not support display of this image. A ) Agree to do toxicologic screening but review the test results with the patient before giving the results to the mother
Your browser may not support display of this image. B ) Agree to do toxicologic screening only if, after discussing it with the patient, he agrees to the test
Your browser may not support display of this image. C ) Agree to do toxicologic screening without the patient's knowledge per his mother's request
Your browser may not support display of this image. D ) Decline to do toxicologic screening stating that you do not want to get caught between her and her son
Your browser may not support display of this image. E ) Decline to do toxicologic screening unless under a court order
An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure. Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3“5 area in the midline, which is slightly swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.
Item 1 of 2
35. Which of the following is the most accurate statement?
Your browser may not support display of this image. A ) An epidural abscess has developed
Your browser may not support display of this image. B ) The epidural block has worn off
Your browser may not support display of this image. C ) The original injection was subdural
Your browser may not support display of this image. D ) A radiculopathy has developed at a different level
Your browser may not support display of this image. E ) She is having a reaction to the anesthetic
36. Which of the following is the most appropriate next step?
Your browser may not support display of this image. A ) Administer an analgesic and diphenhydramine
Your browser may not support display of this image. B ) Administer an analgesic, intravenously, and arrange myelography
Your browser may not support display of this image. C ) Contact the anesthesiologist about repeating the epidural block
Your browser may not support display of this image. D ) Reassure the patient and have her make an appointment with the orthopedist for tomorrow
Your browser may not support display of this image. E ) Request an emergency MRI of the spine
9. A 67-year-old man is brought to the emergency department in ventricular fibrillation. His rectal temperature is 26.7°C (80.0°F). Among the following criteria, the patient should be declared dead when defibrillation fails after which of the following?
Your browser may not support display of this image. A ) Rapid endotracheal intubation and administration of 100% oxygen
Your browser may not support display of this image. B ) Restoration of a normal core temperature
Your browser may not support display of this image. C ) Restoration of a normal oral temperature
Your browser may not support display of this image. D ) 1 hour of core rewarming
Your browser may not support display of this image. E ) 20 minutes of warming, externally
32. A 62-year-old woman who was discharged from the hospital several hours ago following evaluation of optic neuritis now has swelling of her ankles. Prior to admission, the patient had a 3-day history of loss of vision and poor color perception in her right eye. Visual acuity on admission was less than 20/200 in her right eye and was 20/40 in her left eye. The remainder of the physical examination was noncontributory. Blood pressure on admission was 140/80 mm Hg. The patient had been otherwise healthy and had been taking no medications. She has never worn corrective lenses. Family history is significant for thyroid disorder. During her hospital stay, the patient received intravenous methylprednisolone therapy for the past four days. Vital signs today are temperature 37.2°C (99.0°F), pulse 100/min, respirations 14/min, and blood pressure 150/95 mm Hg. Physical examination shows ankle edema but is otherwise unchanged from physical examination done on admission. Laboratory studies are obtained. Which of the following serum laboratory study results is most likely in this patient?
Your browser may not support display of this image. A ) Decreased magnesium concentration
Your browser may not support display of this image. B ) Decreased sodium concentration
Your browser may not support display of this image. C ) Increased calcium concentration
Your browser may not support display of this image. D ) Increased glucose concentration
Your browser may not support display of this image. E ) Increased potassium concentration
27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?
Your browser may not support display of this image. A ) CT scan of the head
Your browser may not support display of this image. B ) Electromyography and nerve conduction studies of the left upper extremity
Your browser may not support display of this image. C ) Measurement of serum B12 (cobalamin) concentration
Your browser may not support display of this image. D ) MRI of the cervical spine
Your browser may not support display of this image. E ) Radionuclide bone scan
26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?
Your browser may not support display of this image. A ) Determine serum estrogen concentration
Your browser may not support display of this image. B ) Order antibody studies for syphilis and HIV
Your browser may not support display of this image. C ) Prescribe an oral anti-trichomonal medication and antifungal cream
Your browser may not support display of this image. D ) Question the patient regarding the circumstances surrounding her recent break-up
Your browser may not support display of this image. E ) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge
22. A 28-year-old African-American woman comes to the office because of low back pain and decreased urine output. She is a semiprofessional basketball player and she is married. She had one pregnancy 12 years ago that was uncomplicated and resulted in vaginal delivery of a term female neonate. Medications include oral contraceptive pills and a corticosteroid inhaler for asthma. She is 182 cm (6 ft) tall and weighs 88 kg (195 lb). Physical examination is normal except for a palpable lower abdominal mass that extends to the umbilicus. Speculum examination discloses a 3-cm ulcerative lesion circumferentially around the external cervical os. Bimanual examination shows a firm, nodular, central pelvic mass filling the pelvis and extending cephalad to the umbilicus. Rectovaginal examination confirms these findings. Stool is negative for occult blood. Which of the following is the most appropriate recommendation?
Your browser may not support display of this image. A ) Arrange for laparoscopy
Your browser may not support display of this image. B ) Do a cervical biopsy
Your browser may not support display of this image. C ) Do an endometrial biopsy
Your browser may not support display of this image. D ) Increase Pap smear screening to every 3 months
Your browser may not support display of this image. E ) Obtain pelvic ultrasonography
13. A 16-year-old boy and his mother come to the office because the mother is concerned that her son may have a drug problem. You have treated him in the past for mild intermittent asthma, and he currently uses an albuterol inhaler prior to exercise. You last saw him 1 year ago for a sports physical examination. At that time, he admitted to drinking alcohol on the weekends. He also admitted to marijuana use but had planned to quit using both before track season started. The mother says that her son now seems disinterested in school and other activities in which he was previously engaged. He has quit the track team, has become irritable, and he has a new set of friends whom his mother dislikes and describes as "druggies." She acknowledges that the boy's father, from whom she is divorced, has an alcohol abuse problem. The boy's older brother abused cocaine for 2 years but is now in a drug rehabilitation program. Prior to interviewing and examining the patient, the mother pulls you aside and asks you to test her son for drugs without informing him. Which of the following is the most appropriate response?
Your browser may not support display of this image. A ) Agree to do toxicologic screening but review the test results with the patient before giving the results to the mother
Your browser may not support display of this image. B ) Agree to do toxicologic screening only if, after discussing it with the patient, he agrees to the test
Your browser may not support display of this image. C ) Agree to do toxicologic screening without the patient's knowledge per his mother's request
Your browser may not support display of this image. D ) Decline to do toxicologic screening stating that you do not want to get caught between her and her son
Your browser may not support display of this image. E ) Decline to do toxicologic screening unless under a court order