CK- NBME 11 – Block 1 (Duplicate 2)

A 77-year-old woman, gravida 4, para 4, is admitted to the hospital for treatment of pneumonia. On hospital day 4, she has an episode of severe coughing, after which she states that she has had involuntary loss of urine. She states that she feels like “something is bulging” from her vagina. Her four pregnancies were uncomplicated and ended in spontaneous vaginal deliveries. Menopause occurred 25 years ago. She has not had postmenopausal bleeding and has never received hormone therapy. Her temperature is 37°C (98.6°F), pulse is 75/min, respirations are 18/min, and blood pressure is 140/90 mm Hg. Abdominal examination shows no abnormalities. The external genitalia are atrophic but otherwise normal. The anterior vaginal segment is descended halfway past the hymenal ring. Speculum examination shows a normal cervix. The uterus is small, nontender, and anteflexed, and there are no adnexal masses. Rectal examination shows no abnormalities. Which of the following is the most likely diagnosis?

A 1-day-old female newborn is examined in the nursery. She was born at term to a 31-year-old primigravid woman following an uncomplicated spontaneous vaginal delivery. The mother has systemic lupus erythematosus; she was asymptomatic during pregnancy, and her only medication was a prenatal vitamin. The patient’s Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 50/min, and blood pressure is 75/45 mm Hg. Examination shows no abnormalities. An ECG is shown. Which of the following is the most appropriate next step in management?

A 6-month-old boy is brought to the physician because of dry scaly skin for 2 weeks. Over the past 3 months, he has had recurrent episodes of otitis media treated with amoxicillin. There are scattered petechiae over the entire body and mild generalized eczema. Examination shows cervical lymphadenopathy and hepatosplenomegaly. His platelet count is 25,000/mm3. Which of the following is the most likely diagnosis?

A previously healthy 4-year-old boy is brought to the emergency department by his parents 1 day after they noticed that he was not using his left arm. There is no known injury to the arm. He appears comfortable but resists any attempt to move the affected arm because of pain. He holds the left upper extremity with the elbow flexed and the forearm in pronation. There is no evidence of injury. Radial pulses are normal. Sensation is full over the affected extremity. Which of the following is the most appropriate next step in management?

A 57-year-old man comes to the physician because of an 8-month history of a nonproductive cough. He has had a 4.5-kg (10-lb) weight gain during the past 6 months despite no change in appetite. He has hypertension treated with atenolol. He has smoked one pack of cigarettes daily for 39 years. He is 175 cm (5 ft 9 in) tall and weighs 98 kg (216 lb); BMI is 32 kg/m2. His temperature is 37.1°C (98.8°F), pulse is 84/min, respirations are 16/min, and blood pressure is 152/98 mm Hg; one year ago, his blood pressure was 132/78 mm Hg. Examination shows purple striae over the abdomen. His serum potassium concentration is 3.4 mEq/L, and fasting serum glucose concentration is 119 mg/dL. An x-ray of the chest shows a right upper lobe nodule. In addition to a biopsy, which of the following is the most appropriate next step in diagnosis?

 A 67-year-old man comes to the physician because of a 6-month history of aching in his thighs and buttocks after he walks 200 feet. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 140/90 mm Hg. Femoral and distal pulses are absent bilaterally. Serum studies show a urea nitrogen concentration of 30 mg/dL and creatinine concentration of 1.5 mg/dL. He undergoes aortic arteriography. Three days later, his serum creatinine concentration is 2.8 mg/dL. Administration of which of the following prior to the arteriography is most likely to have prevented progression of this patient’s renal insufficiency?

A 2-month-old boy is brought to the physician for a well-child examination. He was born at term following an uncomplicated pregnancy, labor, and delivery. He has been breast-feeding six to eight times daily since birth. He smiles and lifts his head. He is at the 50th percentile for length, 75th percentile for weight, and 25th percentile for head circumference. Examination shows no abnormalities. His mother asks for nutritional recommendations. Which of the following is the most appropriate recommendation for the infant?

 A 37-year-old primigravid woman at 9 weeks’ gestation is admitted to the hospital because of progressive nausea and vomiting. Her symptoms began at 6 weeks’ gestation but have worsened so that she can no longer keep food or fluids down. Her temperature is 36.9°C (98.4°F), pulse is 105/min, respirations are 16/min, and blood pressure is 110/60 mm Hg. Examination shows a uterus consistent in size with a 9-week gestation. Her serum thyroid-stimulating hormone concentration is 0.4 pU/mL. Which of the following is the most appropriate next step in management?

A 22-year-old primigravid woman at 15 weeks’ gestation comes to the physician for her first prenatal visit. She has no history of serious illness, and pregnancy has been uncomplicated. Examination shows a uterus consistent in size with a 20-week gestation. Ultrasonography shows twins, both male, with a single placenta and no membrane between the fetuses. This patient should be advised that there is an increased risk for which of the following?

During a routine annual examination, an asymptomatic 46-year-old man is found to have a 1-cm prostatic nodule. Physical findings are otherwise normal. Which of the following is the most appropriate next step in management?

A 6-month-old boy is brought for a follow-up examination because of chronic constipation since the age of 1 week. Current treatment with rectal stimulation, glycerin suppositories, and 4 ounces of prune juice produces one firm string-like stool every 4 days. He was breast-fed until 2 weeks of age and then switched to a cow’s milk-based formula. His current diet also includes cereals, fruits, and pureed vegetables. He has no vomiting but does occasionally spit up after meals. Growth and development are appropriate for age. Immunizations are up-to-date. Abdominal examination shows distention with no tenderness. Rectal examination shows no palpable stool in the ampulla. Which of the following is the most appropriate next step in management?

A 25-year-old woman comes to the physician because of shortness of breath, marked malaise, weakness, and fatigue for 4 hours. She felt well until 24 hours ago when she developed muscle soreness after an unusually strenuous physical workout; she took ibuprofen for the pain 1 hour before her symptoms began. She has a history of frequent migraines that have been prevented by taking metoprolol (twice daily) over the past month. Her blood pressure is 100/70 mm Hg. Examination shows facial flushing and mild periorbital edema. Multiple wheezes are heard throughout the lung fields. Avoidance of which of the following substances is most likely to prevent recurrence of a similar episode?

A 3-day-old newborn is brought to the physician because of jaundice. The mother states that he was born at home. His temperature is 37°C (98.6°F), pulse is 130/min, respirations are 40/min, and palpable systolic blood pressure is 55 mm Hg. Examination shows bilateral eyelid swelling with copious purulent secretions. Administration of which of the following is most likely to have prevented this condition?

A 37-year-old man comes to the physician for a follow-up examination. He was diagnosed with HIV infection 3 weeks ago. He is asymptomatic and takes no medications. His temperature is 37.2°C (99°F), pulse is 100/min, and blood pressure is 100/60 mm Hg. Examination shows no abnormalities except for erythematous scaling at the hairline and the nasolabial folds. His CD4+ T-lymphocyte count is 160/mm3 (Normal>500), and plasma HIV viral load is 25,000 copies/mL. Which of the following is the most appropriate pharmacotherapy?

Twenty-four hours after admission to the hospital for a head injury sustained in a motor vehicle collision, an unconscious 23-year-old man has increased urine output. His urine output was 40 mL/h to 60 ml/h during the first 10 hours after admission and has been 450 mL/h during the past 3 hours. On admission, CT scan of the head showed multiple fractures of the facial bones and base of the skull with a minor intracranial hemorrhage. He has no history of serious illness. He is receiving 0.9% saline (75 mL/h). His pulse is 96/min, and blood pressure is 103/68 mm Hg. There is no jugular venous distention when supine. The lungs are clear to auscultation. Heart sounds are normal. There is no peripheral edema. Laboratory studies show:

Serum

Na⁺: 148 mEq/L

K⁺: 4.1 mEq/L

Cl⁻: 102 mEq/L

HCO₃⁻: 28 mEq/L

Glucose: 95 mg/dL

Creatinine: 1 mg/dL

Urine osmolality: 105 mOsmol/kg H₂O

Which of the following is the most appropriate next step in management?

A case-control study is conducted to determine if the relationship between estrogen replacement therapy (ERT) and the risk for breast cancer is affected by estrogen formulation. Cases consist of 705 women with a history of breast cancer; controls consist of 692 randomly selected, age-matched women. All participants range in age from 50 to 74 years. Researchers record the following ERT data from participants: cumulative dosage, type of formulation, and the duration of treatment. Researchers also record patient height and weight, family history of breast cancer, and reproductive history. Results show that the type of estrogen formulation does not affect the risk for breast cancer. Which of the following raises the most concern regarding the validity of this conclusion?

A 42-year-old woman comes to the physician because of decreased energy, apathy, and difficulty sleeping since being fired from her job 3 weeks ago. Since then, she has awakened at 4 AM daily and has been unable to fall back asleep. She also has crying spells every morning. During the past 6 months, she has had a 3.2-kg (7-lb) weight loss. She has no history of serious illness and takes no medications. Her father committed suicide at the age of 52 years. The patient is 170 cm (5 ft 7 in) tall and weighs 69 kg (152 lb); BMI is 24 kg/m2. Physical examination shows no abnormalities. On mental status examination, she is sad and tearful. Her speech is soft and goal directed. She says that she has not thought about suicide and does not want to die. Laboratory findings, including a complete blood count, serum electrolyte concentrations, and serum thyroid- stimulating hormone concentration, are within the reference range. Which of the following is the most appropriate next step in management?

A 62-year-old woman is scheduled for discharge 3 days after admission to the hospital for a small infarction in the distribution of the left middle cerebral artery. Her presenting symptom of mild weakness of the right upper and lower extremities has gradually resolved during the past 3 days. On admission, echocardiography and ambulatory ECG monitoring showed no abnormalities. She has a 5-year history of hypertension treated with hydrochlorothiazide and atenolol. She has no other personal history of serious illness. She has never smoked. Vital signs are within normal limits. Cardiac examination shows a regular rhythm and no murmurs. Neurologic examination shows no focal findings. In addition to aspirin therapy, which of the following is the most appropriate pharmacotherapy to prevent recurrent cerebral infarction in this patient?

A 57-year-old woman with atrial fibrillation comes to the physician because of a 2-week history of pain with urination, urinary frequency, and blood-tinged urine. She underwent hysterectomy for endometriosis at the age of 45 years. Current medications include estrogen replacement, digoxin, and warfarin. Her temperature is 36.7°C (98°F). Examination shows no abnormalities. Which of the following is the most likely diagnosis?

 An asymptomatic 47-year-old woman comes to the physician for a routine health maintenance examination. She has no history of rheumatic fever. She takes no medications. Her pulse is 70/min, and blood pressure is 150/60 mm Hg. A grade 2/6 decrescendo murmur that begins after S2 is heard at the left sternal border. Which of the following is the most likely diagnosis?