NBME 14 – Block 3
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Question 1 of 20
1. Question
A 52-year-old man comes to the physician because of a 2-week history of mild abdominal cramps and diarrhea containing blood and mucus. During this time, he also has had fecal urgency and mild pain with bowel movements. He is otherwise asymptomatic. He has hypothyroidism treated with levothyroxine. Vital signs are within normal limits. The abdomen is nondistended and nontender; there are no masses, and bowel sounds are normal. Test of the stool for occult blood is positive. Results of stool culture and testing of the stool for Clostridium difficile, ova, and parasites are negative. Colonoscopy shows 30 cm of continuously friable, erythematous rectal and sigmoid mucosa; no polyps or masses are noted. Which of the following is the most appropriate next step in management?
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Question 2 of 20
2. Question
A 32-year-old woman comes to the physician for a routine health maintenance examination. She had used a diaphragm for contraception for 10 years but switched to a combination oral contraceptive 6 months ago. She is 168 cm (5 ft 6 in) tall and weighs 70 kg (154 lb); BMI is 25 kg/m2. Her blood pressure has averaged 144/92 mm Hg on three visits during the past 3 months. Her pulse is 84/min, respirations are 18/min, and blood pressure now is 145/90 mm Hg. Examination shows no other abnormalities. Which of the following is the most appropriate next step in management?
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Question 3 of 20
3. Question
A 16-year-old boy is brought to the physician by his parents because of a 6-month history of excessive daytime sleepiness. He is tired after sleeping more than 10 hours at night. He frequently falls asleep during class, and, last week, he was involved in a motor vehicle collision after falling asleep while driving home from a party. He snores at night. His academic performance was good but has deteriorated to almost failing. Examination shows no abnormalities except for mildly enlarged tonsils. Polysomnography shows normal airflow and gas exchange, normal sleep stages with short REM latency, and poor sleep continuity with multiple brief arousals and four sustained awakenings. On the following day, multiple sleep latency testing shows REM episodes at the onset of sleep during three of four naps with a mean sleep latency of 1 minute. Which of the following is the most likely explanation for these findings?
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Question 4 of 20
4. Question
A 23-year-old primigravid woman at 18 weeks’ gestation comes to the physician because of a 3-week history of heat intolerance and an inability to sit quietly for more than a few minutes. She also has had five to six bowel movements daily and a 3.6-kg (8-lb) weight loss despite an increased appetite during this period. She is 168 cm (5 ft 6 in) tall and now weighs 55 kg (122 lb). Her temperature is 37°C (98.6°F), pulse is 133/min, respirations are 19/min, and blood pressure is 160/50 mm Hg. Examination shows diffuse thyroid gland enlargement and a fine tremor of the outstretched hands. The uterus is 18 cm from the pubic symphysis. Fetal heart tones are audible at 160/min. Her free thyroxine index is 14 (N=5–13). Which of the following is the most appropriate treatment for this patient?
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Question 5 of 20
5. Question
A 40-year-old woman comes to the office to establish care. She has felt well and reports no symptoms. Medical history is unremarkable and she takes no medications. Family history is remarkable for kidney stones in her mother. The patient’s vital signs are within normal limits. Examination shows no abnormalities. Initial serum laboratory studies show a calcium concentration of 11 mg/dL. Further testing shows a serum intact parathyroid hormone concentration of 75 pg/mL (N=10–60). Results of 24-hour urine collection show a calcium concentration of 50 mg. Which of the following is the most likely cause of this patient’s condition?
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Question 6 of 20
6. Question
A 27-year-old man with asthma comes to the physician as a new patient. He has a 10-year history of chronic cough productive of sputum and a 3-year history of intermittent diarrhea. He has nasal allergies. During the past 10 years, he has had numerous respiratory tract infections treated with antibiotics. He had three episodes of pneumonia during childhood. His medications are cetirizine, montelukast, and nasal fluticasone; he uses an albuterol inhaler four times daily. He does not smoke cigarettes. He is 170 cm (5 ft 7 in) tall and weighs 52 kg (115 lb); BMI is 18 kg/m2. Vital signs are within normal limits. Examination shows erythematous, boggy nasal mucosa. A few scattered rhonchi are heard in the lower lung fields bilaterally. Abdominal examination shows no abnormalities. Which of the following is the most appropriate next step in management?
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Question 7 of 20
7. Question
A study is conducted to assess the accuracy of a new rapid test to detect streptococcal pharyngitis. A total of 200 patients with sore throat undergo rapid testing; these results are compared with the results of subsequent throat cultures for group A β-hemolytic streptococcus. The results show:
Culture
+
−
Total
Rapid Test
+
45
10
55
−
5
140
145
Total
50
150
200
Which of the following best represents the prevalence of streptococcal pharyngitis within this population?
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Question 8 of 20
8. Question
A 77-year-old woman comes to the physician because of a 4-year history of a lesion over her forearm that has increased gradually in size. She works outdoors in her garden 3 days weekly and does not wear sunscreen, and she is concerned the lesion could be cancer. She has no history of serious illness and takes no medications. A photograph of the lesion is shown. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
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Question 9 of 20
9. Question
A 25-year-old man comes to the physician 2 hours after the sudden onset of sharp right buttock pain that radiates to the back of his knee. The pain worsens when he sits for a prolonged period or drives. He is able to walk. Use of over-the-counter ibuprofen has provided mild relief. He has no history of serious illness and takes no other medications. On examination, ipsilateral and contralateral straight-leg raise testing is positive. Muscle strength is normal throughout. Sensation is intact throughout. Which of the following is the most appropriate next step in management?
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Question 10 of 20
10. Question
A 2-year-old boy is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision. He was sitting unrestrained on his aunt’s lap in the front passenger seat during the collision, and the automobile’s air bags deployed on impact. Paramedics at the scene immobilized his spine with a cervical collar, and his head was taped to a backboard during transport to the hospital. He has no history of serious illness and receives no medications. On arrival, he is crying and moving all extremities. Temperature is 37.2°C (99.0°F), pulse is 120/min, respirations are 25/min, and blood pressure is 110/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination shows abrasions over the face and neck. No other abnormalities are noted. Which of the following is the most appropriate next step in management?
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Question 11 of 20
11. Question
A 52-year-old man comes to the physician 2 days after noticing that his eyes and skin appear yellow. Four days ago, he received the diagnosis of sinusitis and began treatment with trimethoprim-sulfamethoxazole. During the past 6 months, he has traveled to Nicaragua and Belize. He has been sexually active with 12 partners during the past 2 years and uses condoms inconsistently. He drinks three to four beers weekly. He does not smoke cigarettes or use illicit drugs. His temperature is 36.6°C (97.8°F), pulse is 72/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Examination shows generalized jaundice and a diffuse, macular, nonblanching rash over the chest and back. There is scleral icterus. Laboratory studies show:
Hemoglobin
13.2 g/dL
Serum
Bilirubin, total
5.5 mg/dL
Direct
2.2 mg/dL
Alkaline phosphatase
58 U/L
AST
372 U/L
ALT
250 U/L
HBsAg
negative
Hepatitis B surface antibody
positive
Which of the following is the most appropriate initial step in management?
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Question 12 of 20
12. Question
A previously healthy 37-year-old man comes to the physician because of a 2-day history of fever and persistent cough productive of yellow sputum. He has not had shortness of breath. He does not smoke. His temperature is 37.9°C (100.2°F), pulse is 88/min, respirations are 16/min, and blood pressure is 134/82 mm Hg. Scattered rhonchi are heard bilaterally. During the examination, he has an episode of severe coughing. An x-ray of the chest shows no abnormalities. In addition to treatment of this patient’s symptoms, which of the following is the most appropriate pharmacotherapy?
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Question 13 of 20
13. Question
A 17-year-old boy comes to the physician because of a scrotal mass that has become increasingly painful during the past 3 days. He is not certain how long the mass has been present. There is no history of trauma. He is sexually active with several partners and uses condoms inconsistently. Examination shows a tender mass posterior to the left testis. Which of the following is the most likely cause of these findings?
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Question 14 of 20
14. Question
A 52-year-old woman is admitted to the hospital for treatment of acute diverticulitis. After 2 days of intravenous antibiotic therapy, she has a temperature of 39.1°C (102.4°F) and abdominal rigidity. Her leukocyte count is 17,400/mm3 with 15% bands. The physician explains to the patient that she will need to undergo sigmoid colectomy and that, depending on the findings, she may require a colostomy. The patient agrees to the operation but refuses to undergo a colostomy. The patient’s husband is in the hospital but is not with the patient at this time. Which of the following is the most appropriate next step?
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Question 15 of 20
15. Question
A 16-year-old girl is brought to the physician because her parents are concerned about her eating habits. During the past 8 months, she has stopped eating meals with the family, expressed concern about her weight, and lectured the family about improving their dietary practices. The patient says that eating more nutritious foods has decreased her appetite. She says the fact that she has enough energy to be on the cross-country running and cheerleading teams shows she is eating appropriately. She worries she does not have the right body shape for fashionable clothes and thinks she would be more popular if she could dress better. She receives grades of A’s in school but worries she will not be able to maintain her grade point average because this year has been more challenging since she began taking several advanced-level classes. She says she has not been spending much time with friends because of schoolwork demands. The patient is 178 cm (5 ft 10 in) tall and weighs 53 kg (116 lb); BMI is 17 kg/m2. Vital signs are within normal limits. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and affect; the patient becomes anxious when discussing school performance and her weight. Which of the following is the most likely diagnosis?
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Question 16 of 20
16. Question
During observation of a surgical procedure, a physician notices the anesthesiologist falling asleep; the observing physician says the anesthesiologist’s name, and he wakes up and attends to the remainder of the operation appropriately. After the procedure, the physician approaches the anesthesiologist who states that he was up late last evening attending to an emergency procedure. The surgeon later informs the physician that this anesthesiologist frequently falls asleep in the operating room. Which of the following is the most appropriate next step for the physician?
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Question 17 of 20
17. Question
A 32-year-old woman comes to the physician because of a 1-week history of tenderness and swelling of her neck. She has no history of serious illness. Her only medication is an oral contraceptive. Her temperature is 38.1°C (100.5°F), pulse is 95/min, respirations are 18/min, and blood pressure is 110/70 mm Hg. Examination of the neck shows no masses. The thyroid gland is slightly enlarged and tender. No nodules are palpated. The remainder of the examination shows no abnormalities. Serum studies show a thyroid-stimulating hormone concentration of 0.3 μU/mL and thyroxine (T4) concentration of 11.5 μg/dL. Antithyroid antibodies are not detected. A 131I thyroid scan shows decreased uptake. Which of the following is the most likely diagnosis?
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Question 18 of 20
18. Question
Seven days after cesarean delivery for arrest of descent, a 27-year-old woman, gravida 1, para 1, remains in the hospital because of spiking temperatures to 39.2°C (102.5°F) since delivery. Treatment with broad-spectrum antibiotics has not resolved the fever. She feels well when she does not have a fever. Laboratory studies at 35 weeks’ gestation were positive for Streptococcus agalactiae (group B), and she was treated with intrapartum penicillin. Her temperature now is 38.3°C (101°F). Examination shows no abnormalities. Which of the following is the most likely diagnosis?
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Question 19 of 20
19. Question
A 72-year-old woman comes to the physician because of generalized fatigue for 1 week. During this period, she has occasionally had light-headedness on standing up quickly. She has not had chest pain or shortness of breath. She has hypertension and coronary artery disease. Current medications include amlodipine and hydrochlorothiazide. She is alert and oriented to person, place, and time. Her temperature is 37°C (98.6°F), pulse is 38/min, respirations are 14/min, and blood pressure is 80/40 mm Hg. Crackles are heard at both lung bases. S1 and S2 are normal. A grade 2/6 systolic murmur is heard best at the fourth left intercostal space with radiation to the carotid arteries. There is no peripheral edema. An ECG is shown. Which of the following is the most appropriate next step in management?
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Question 20 of 20
20. Question
A previously healthy 5-year-old boy is brought to the office by his mother because of the sudden onset of severe abdominal pain 1 hour after he ate dinner. He receives no medications. Immunizations are up-to-date. He was adopted at birth, and there is no information available about his biological family history. His temperature is 38.3°C (100.9°F), pulse is 100/min, respirations are 20/min, and blood pressure 85/60 mm Hg. Examination shows conjunctival icterus. There is guarding and moderate tenderness to palpation of the right upper quadrant. The spleen tip is palpable. Results of laboratory studies are shown:
Hemoglobin
8.3 g/dL
Leukocyte count
11,000/mm3
Reticulocyte count
7%
Serum total bilirubin
4 mg/dL
Direct antiglobulin (Coombs) test result is negative. A blood smear shows small, uniform, spherical erythrocytes. Which of the following is the most likely cause of this patient’s abdominal pain?
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