CK- NBME 11 – Block 3 (Duplicate 1)

A 32-year-old woman, gravida 1, para 1, comes to the physician for a postpartum examination 6 weeks after an uncomplicated vaginal delivery at home. She feels well, and her postpartum course has been uncomplicated. During her pregnancy, results of a serum rubella titer were reported as nonimmune. Physical examination today shows no abnormalities. Which of the following is the most appropriate next step in management?

A 32-year-old woman comes to the emergency department because of progressive shortness of breath during the past week. She now becomes short of breath after walking 10 feet. She says that she thinks she has had fever but has not taken her temperature. She does not think she has been in contact with any ill persons. She has smoked one pack of cigarettes daily for 15 years. She does not drink alcohol but has used intravenous heroin for 10 years; she rarely shares or sterilizes needles. She lives in Massachusetts and has not traveled outside of the state in 8 years. She is in mild respiratory distress. She is 168 cm (5 ft 6 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2. Her temperature is 38°C (100.4°F), pulse is 80/min, respirations are 18/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Diffuse crackles are heard bilaterally. There is no peripheral edema. After she walks 50 feet, her oxygen saturation decreases to 83%. Her leukocyte count is 4800/mm3 (70% segmented neutrophils, 2% bands, 26% lymphocytes, and 2% eosinophils). An x-ray of the chest shows diffuse alveolar infiltrates bilaterally. Which of the following is the most likely diagnosis?

A 67-year-old man with aortic stenosis comes to the physician for prophylaxis before undergoing a dental procedure. He has a history of aortic valve replacement; he is currently asymptomatic. He had an episode of hives several years ago after treatment with penicillin. Vital signs are within normal limits. Examination shows a grade 2/6, systolic ejection murmur; no gallops are heard. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate antibiotic for prophylaxis?

Thirty-six hours after cesarean delivery because of prolonged labor, a 22-year-old woman has abdominal cramping and nausea and vomiting. Her temperature is 38.8°C (101.8°F), pulse is 98/min, and blood pressure is 110/64 mm Hg. Examination shows diffuse lower abdominal tenderness with some voluntary guarding but no rebound. The incision is clean, dry, and intact. Her leukocyte count is 15,000/mm3. A urinary catheter is in place; urinalysis shows multiple RBCs. Which of the following is the most likely diagnosis?

A 9-year-old boy is brought to the physician by his mother because of a 1-month history of intermittent nonproductive cough. The cough is exacerbated with exercise and is worse at night. He has not had fever. The patient’s father received the diagnosis of asthma as a child. The patient’s temperature is 37.3°C (99.1 °F), pulse is 90/min, respirations are 22/min, and blood pressure is 108/70 mm Hg. Examination shows no other abnormalities. Pulmonary function tests are most likely to show which of the following findings in this patient?

A 19-year-old college student comes to the student health center for a physical examination prior to participation in a school intramural basketball league. She has been generally healthy. She says that she is a strict vegetarian and does not eat any meat, eggs, or dairy products. She takes an iron supplement daily. She takes no other medications. She is 162 cm (5 ft 4 in) tall and weighs 45 kg (100 lb); BMI is 17 kg/m2. Vital signs are normal. Physical examination shows no abnormalities. Which of the following additional supplements is most appropriate to recommend at this time?

A 72-year-old woman comes to the emergency department because of a 2-week history of increased thirst and frequent urination. She says that her symptoms have been getting worse. She drinks copious amounts of water and now urinates every 1 to 2 hours. She has hypertension controlled with ramipril. She had a myocardial infarction 6 years ago. On arrival, she appears dehydrated. Her temperature is 36°C (96.8°F), pulse is 110/min, and blood pressure is 100/70 mm Hg. Examination shows dry mucous

Hematocrit: 47%

Serum:

Na⁺: 125 mEq/L

K⁺: 3.5 mEq/L

Cl⁻: 95 mEq/L

HCO₃⁻: 24 mEq/L

Urea nitrogen: 30 mg/dL

Glucose: 700 mg/dL

Creatinine: 1.8 mg/dL

Which of the following is the most likely cause of this patient’s serum sodium concentration?

 A 4-year-old boy is brought to the physician because of scalp lesions that have been increasing in size during the past week. He went for a nature walk with his day-care class 10 days ago. Examination shows scattered papules with some scaly areas on the scalp; the surrounding hair is broken near the base with mild alopecia. Which of the following is most likely to have prevented this condition?

 A 24-year-old woman comes to the physician because of fever, headache, and purulent nasal discharge for 5 days. She has had recurrent sinus infections since the age of 17 years. She has a 3-year history of chronic nasal stuffiness and a morning cough productive of 2 to 3 teaspoons of purulent sputum daily. She was hospitalized for treatment of pneumonia 1 year ago. Her temperature is 37.8°C (100°F), pulse is 84/min, respirations are 16/min, and blood pressure is 110/72 mm Hg. Examination shows edema of the nasal mucosa and a creamy yellow nasal exudate. The lungs are clear to auscultation. The spleen tip is palpated at the left costal margin. Which of the following is the most appropriate next step to confirm the mechanism for the recurrent infections?

 An 18-year-old woman who is a US Army recruit comes to the troop medical clinic because of a 4-day history of increasingly severe cramping and swelling of her left foot. She began basic training 10 days ago. She had not been physically active before joining the army. Initially, she was able to keep up with the training regimen, but she soon developed pain in her forefoot as the intensity of the exercise increased. Vital signs are within normal limits. She is 165 cm (5 ft 5 in) tall and weighs 68 kg (150 lb); BMI is 25 kg/m2. Examination of the left foot shows tenderness to palpation of the dorsal aspect of the fifth metatarsal; there is minimal swelling. Movement of the involved toe elicits pain. X-ray of the left foot shows no abnormalities. Which of the following is the most appropriate next step in management?

A hospitalized 65-year-old woman is prepared for discharge 15 days after undergoing uncomplicated surgical repair of the ventricular septum following an anterior ST-segment elevation myocardial infarction. Her postoperative course has been uncomplicated. She has hypertension and hyperlipidemia. Her medications are clopidogrel, lisinopril, metoprolol, atorvastatin, and aspirin. Vital signs are within normal limits. Examination shows a clean, dry surgical incision. Echocardiography shows an ejection fraction of 50%. In addition to continuation of the medication regimen, which of the following interventions is most likely to decrease this patient’s risk for a repeat myocardial infarction?

 A 15-year-old girl is brought to the office by her father because of a 2-month history of yellowing of her eyes. She has no history of serious illness and takes no medications. She is at the 50th percentile for height, weight, and BMI. Vital signs are within normal limits. Examination shows conjunctival icterus. Serum studies show a total bilirubin concentration of 4 mg/dL and a conjugated bilirubin concentration of 3 mg/dL. Results of other liver function tests are within the reference ranges. Ultrasonography of the liver shows no abnormalities. Which of the following is the most likely diagnosis?

 Three days after undergoing open fixation of a right hip fracture, a 77-year-old woman has progressive edema of the right lower extremity. She has no history of serious illness. Her medications are oxycodone, enoxaparin, and docusate. Her temperature is 38.0°C (100.4°F), pulse is 72/min, respirations are 14/min, and blood pressure is 140/80 mm Hg. There is 3+ pitting edema of the right lower extremity from the foot to the hip. Which of the following is the most likely set of findings on venous duplex ultrasonography?

A 39-year-old woman, gravida 3, para 2, is brought to the emergency department because of a 3-hour history of moderate to severe abdominal cramps and vaginal bleeding with clots. Her last menstrual period was 9 weeks ago. Menses previously occurred at regular 30-day intervals and lasted 7 days. Her previous pregnancies and deliveries were uncomplicated. She has no history of serious illness and takes no medications. She is currently homeless and seeking shelter. Her temperature is 37.3°C (99.1 °F), pulse is 103/min, respirations are 14/min, and blood pressure is 130/82 mm Hg. Examination shows tenderness to palpation of the mid lower abdomen. Bowel sounds are normal. The uterus is tender to palpation and consistent in size with a 9-week gestation. Pelvic examination shows normal external genitalia, moderate clots in the vaginal vault, and a closed cervical os. There is no adnexal tenderness or masses. Her hemoglobin concentration is 7.9 g/dL. Pelvic ultrasonography shows an intrauterine pregnancy consistent in size with a 9-week gestation; no fetal heart motion; a small amount of fluid in the cul-de-sac; and a subchorionic hemorrhage. Which of the following is the most appropriate next step in management?

 A 57-year-old man with hypertension comes to the office for a routine examination. He feels well. Four years ago, he had basal cell carcinoma on his nose treated with excision. Colonoscopy 5 years ago showed a tubular adenoma. Fifteen years ago, he underwent appendectomy for appendicitis. His medications are hydrochlorothiazide, fish oil supplementation, and a multivitamin. He received the influenza virus vaccine 6 months ago and the tetanus-diphtheria-acellular pertussis vaccine 5 years ago. He does not smoke cigarettes. He drinks 8 to 16 oz of wine nightly and exercises four to five times weekly. He is 183 cm (6 ft) tall and weighs 86 kg (190 lb); BMI is 26 kg/m2. His pulse is 80/min, and blood pressure is 128/88 mm Hg. Examination shows scattered pale nevi over the chest and back. No other abnormalities are noted. Results of serum lipid studies from 6 months ago are shown:

Cholesterol, total: 201 mg/dL

HDL-cholesterol: 42 mg/dL

LDL-cholesterol: 120 mg/dL

Triglycerides: 180 mg/dL

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

A metropolitan city has a higher than average rate of obesity-related disability compared with other cities of similar size. The city’s director of public health would like to prevent future obesity-related complications for this city’s residents. Which of the following is the most appropriate strategy for primary prevention of obesity in this population?

 A 4-month-old girl is admitted to the hospital because of a 7-day history of progressive cough. During the past 2 days, the cough has been associated with gagging, difficulty breathing, and perioral cyanosis. Between coughing episodes, she is alert and not in respiratory distress. She was born at term following an uncomplicated pregnancy and spontaneous vaginal delivery. Her mother has a 3-week history of nonproductive cough treated with over-the-counter cough syrup. The patient receives no medications. She appears well nourished. Her temperature is 38°C (100.4°F), pulse is 120/min, and respirations are 45/min. Pulse oximetry on room air shows an oxygen saturation of 98%. The lungs are clear to auscultation, and air movement is good. During an observed coughing episode, the patient’s lips become cyanotic. Pulse oximetry on room air during the episode shows an oxygen saturation of 85%. Which of the following is the most likely infectious agent?

A 44-year-old woman comes to the office with her husband because of a 2-week history of an increasingly severe tremor in her right hand. She is right-handed. The tremor makes it difficult for her to brush her teeth or hold a coffee cup. She also has had a slowed gait during this time. She says she is afraid that she has Parkinson disease like her father. She has no history of serious illness and takes no medications. She works as an executive at an advertising firm. Her husband says, “My wife is coping as best she can, especially considering how stressful her work is.” Neurologic examination of the patient shows a resting tremor of the right hand. The tremor increases in severity on finger-nose testing. The tremor decreases when she manipulates a coin in her left hand. Her gait is slow, but balance is intact. The remainder of the examination shows no abnormalities. An MRI of the brain shows no abnormalities. Which of the following is the most likely diagnosis?

A 22-year-old woman is brought to the office by her parents because of a 9-month history of observing her eyebrows in mirrors for up to an hour at a time. She frequently stares at her eyebrows, sometimes separating the hairs with tweezers and examining the skin underneath. She never plucks them. Her behavior has caused her parents to have to remind her to eat meals and go to class. She has fallen behind in her schoolwork and has stopped calling her friends. She appears disheveled. She is 168 cm (5 ft 6 in) tall and weighs 57 kg (125 lb); BMI is 20 kg/m2. Physical examination shows no abnormalities. On mental status examination, she is alert and fully oriented. She is cooperative and articulate but makes poor eye contact. She describes her mood as “okay.” Her affect is flat. Her thought process is linear except when discussing her eyebrows. During the examination, she sees her reflection in a mirror and stares at her eyebrows. She says she is “reading” the hair follicle and direction patterns; she is worried that they might change, which would have dire consequences for her and her family. She says the “reading” may take much time because she often loses track of her progress and must begin again. Which of the following is the most likely diagnosis?

A healthy 15-year-old girl is brought to the office because she has never had a menstrual period. She takes no medications and has no known allergies. She is 152 cm (5 ft) tall and weighs 48 kg (105 lb); BMI is 21 kg/m2. Her blood pressure is 98/55 mm Hg. Breast and pubic hair development is Tanner stage 1. Pelvic examination shows normal-appearing external genitalia and a small uterus. Serum studies show a follicle-stimulating hormone concentration of 56 mlU/mL and luteinizing hormone concentration of 42 IU/mL. Which of the following is the most appropriate next step in diagnosis?