CK- NBME 12 – Block 3 (Duplicate 2)

A 25-year-old man is brought to the emergency department by ambulance 25 minutes after his wife found him unconscious on the floor at home this morning. He was discharged from the military 3 months ago after he sustained a traumatic brain injury and underwent right below-the-knee amputation. Since his return, his family says he has had mood swings, aggressive behavior, and anxiety, which have prevented him from interacting with people. He has major depressive disorder and severe limb pain. His medications are amitriptyline, sertraline, oxycodone, and acetaminophen. Two days ago, he began a short-term course of alprazolam for persistent anxiety. His family says he generally has been adherent to his medication and cognitive behavioral therapy regimens. He does not smoke cigarettes. He drank four 12-oz beers weekly as a teenager; now he drinks eight 12-oz beers weekly. On arrival, he is somnolent and responds to painful stimuli only. Temperature is 36.7°C (98.0°F), pulse is 110/min, respirations are 10/min and shallow, and blood pressure is 85/60 mm Hg. Pulse oximetry on 4 L/min of oxygen by nasal cannula shows an oxygen saturation of 92%. Examination shows warm, dry, flushed skin. The pupils are mydriatic with nystagmus. Air movement is decreased in the lungs. Cardiac examination shows no abnormalities. The abdomen is soft. Bowel sounds are decreased. Patellar deep tendon reflexes are 3+ bilaterally. An overdose of which of the following is the most likely explanation for these findings?

A 29-year-old woman comes to the physician for a routine health maintenance examination. She has no history of serious illness and takes no medications. Menses occur at regular 28-day intervals, last 5 days, and are accompanied by mild cramps. Her last menstrual period was 3 weeks ago. She is sexually active and monogamous with one male partner. She has a copper IUD in place. Her blood pressure is 118/72 mm Hg. Physical examination shows no abnormalities. Pelvic examination shows an IUD string at the cervical os and a mildly tender right adnexal mass. Transvaginal ultrasonography shows a normal uterus and left adnexa and a 5-cm hemorrhagic cyst in the right adnexa. Which of the following is the most appropriate next step in management?

A 20-year-old primigravid woman at 28 weeks’ gestation is brought to the emergency department after she was involved in a high-speed motor vehicle collision. She was the restrained front seat passenger. She has no history of serious illness. Her pregnancy had been uncomplicated. She has moderate neck and back pain and abdominal tenderness. She appears confused. Her temperature is 37°C (98.6°F), pulse is 120/min, respirations are 24/min, and blood pressure is 100/58 mm Hg. The fetal heart rate is 140–150/min. Examination shows multiple facial contusions. Laboratory studies show a hematocrit of 32%, leukocyte count of 9000/mm3, and platelet count of 210,000/mm3. In addition to continuous fetal monitoring, which of the following is the most appropriate next step in management?

A 15-year-old boy is brought to the physician because of fatigue since starting his freshman year of high school 3 months ago. He often falls asleep during class. He urinates four to five times nightly and often has difficulty falling asleep again. He has no history of serious illness and takes no medications. He is at the 20th percentile for height and above the 95th percentile for weight and BMI. Vital signs are within normal limits. Examination shows a velvety, hyperpigmented macular rash over the neck and axillae. The remainder of the examination shows no abnormalities. Laboratory studies show:

This patient is at increased risk for which of the following complications of his current condition during the next 15 years?

A previously healthy 3-year-old boy who is scheduled for an elective operation begins to cry and cling tightly to his mother on arrival at the hospital. Which of the following is the most likely cause of this behavior?

A 19-year-old woman is brought to the emergency department by her mother 30 minutes after ingesting an unknown liquid she found in her parents’ utility room following an argument with her boyfriend. Immediately after swallowing the liquid, she telephoned her mother at work, who arrived at home 20 minutes later and found her daughter drooling and reporting severe upper chest pain. On arrival at the emergency department, the patient is in obvious distress and is drooling and unable to swallow. Temperature is 37.0°C (98.6°F), pulse is 120/min and regular, respirations are 20/min, and blood pressure is 148/90 mm Hg. Physical examination shows profuse clear drainage from the mouth and erythema and edema of the posterior oropharynx. Cardiopulmonary examination shows no abnormalities. Two large-bore intravenous catheters are inserted for fluid administration and a dose of intravenous hydromorphone is administered. The patient begins to feel more comfortable. Results of laboratory studies are within the reference ranges. Chest x-ray shows no abnormalities. Which of the following is the most appropriate management?

A 23-year-old male college student comes to the clinic for a follow-up visit 14 days after undergoing emergent splenectomy following a motor vehicle collision. The patient has resumed his regular diet and is ambulating normally. Medical history otherwise is unremarkable, and his only medication is acetaminophen as needed. The patient completed his Haemophilus influenzae type b vaccinations by age 18 months and his varicella, polio, and measles-mumps-rubella vaccinations by age 5 years; he received a human papillomavirus vaccination at age 11 years. Temperature is 37.0°C (98.6°F), pulse is 82/min, and blood pressure is 116/54 mm Hg. Abdominal examination shows a well-healing midline incision. Which of the following vaccinations is most appropriate to administer to this patient today?

A previously healthy 19-year-old college student comes to the emergency department because of a 3-day history of lower abdominal pain and vaginal spotting. Menses usually occur at regular 28-day intervals, but she cannot recall the date of her last menstrual period. She takes no medications. She is sexually active and uses condoms inconsistently. She appears pale but is alert and answers questions appropriately. Her pulse is 110/min, respirations are 22/min, and blood pressure is 80/50 mm Hg. Abdominal examination shows lower quadrant tenderness with marked guarding. Pelvic examination shows a soft uterus and adnexal tenderness greater on the right than on the left. Her hemoglobin concentration is 6.2 g/dL, hematocrit is 18%, and serum β-hCG concentration is 6645 mIU/mL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A 17-year-old boy is brought to the office by his parents because of changes in his behavior during the past 6 months. They say he has become withdrawn and moody and that his grades have declined. He has returned home from parties intoxicated three times during the past month. During a wedding reception 3 weeks ago, he was delirious, incoherent, and imbalanced. The patient says he drinks alcohol but that his drinking is not a problem and he can stop drinking whenever he wants. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, he is calm and cooperative. He reports no insomnia, hypersomnia, or suicidal ideation. Which of the following is the most likely diagnosis?

A 47-year-old woman comes to the physician because of a 9-month history of hot flashes, night sweats, and pain during sexual intercourse. Her last menstrual period was 1 year ago. Physical examination shows no abnormalities. Pelvic examination shows vaginal atrophy and no cervical mucus. A Pap smear and mammography show no abnormalities. Which of the following is the most appropriate next step in management?

One day after delivery of a healthy newborn at term, a 22-year-old woman, gravida 2, para 2, has fever. Pregnancy and delivery were uncomplicated. Her temperature is 39.4°C (103°F), pulse is 110/min, respirations are 22/min, and blood pressure is 125/70 mm Hg. Examination shows normal lochia rubra. The uterus is tender, and the fundus extends to the umbilicus. Her leukocyte count is 17,000/mm3 with a shift to the left. While awaiting results of additional laboratory studies, which of the following is the most likely causal organism?

A 67-year-old woman comes to the physician because of a 2-month history of perirectal pain that worsens with bowel movements and a thick, yellow rectal discharge. She has hypertension and psoriasis. Her medications are metoprolol and topical fluocinolone cream. There is no family history of serious illness. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 14/min, and blood pressure is 136/70 mm Hg. The abdomen is soft, nontender, and nondistended. Rectal examination shows brown stool. The skin of the posterior perineal wall is erythematous with a draining sinus tract. Test of the stool for occult blood is positive. Which of the following is the most likely diagnosis?

Twelve hours after discharge from the hospital, a 2-day-old male newborn is brought to the emergency department after having a seizure. His parents report that he stiffened, and his eyes rolled back for 3 or 4 minutes; then he went limp. He was delivered vaginally at term to a 20-year-old woman, gravida 1, para 1, following an uncomplicated pregnancy; his weight on delivery was 3062 g (6 lb 12 oz). The patient’s mother used to drink two glasses of wine each evening with dinner but stopped drinking alcohol when she learned she was pregnant at 4 weeks’ gestation. She has never smoked cigarettes or used illicit drugs. On arrival, the infant is awake but sluggish. Examination shows hypertelorism and low-set ears. The lungs are clear to auscultation. There are no murmurs. A chest x-ray shows a narrow mediastinum and a right-sided aortic arch. Which of the following is the most likely diagnosis?

A 2-year-old girl is brought to the physician for a well-child examination. She has had two urinary tract infections since birth. She has not had pain with urination or urinary frequency or urgency. Examination shows no abnormalities. Renal ultrasonography shows no obstruction. Voiding cystourethrography shows grade II vesicoureteral reflux. Which of the following is the most appropriate initial step to prevent future urinary tract infections in this patient?

A 4-year-old boy is brought to the physician by his mother because she is concerned that he is having difficulty making friends. The mother reports that he attends preschool but does not socialize with the other children and spends most of the time playing by himself. At school, he is only interested in blocks, reports how tall he can build towers, and resists other activities. At home, he spends hours building towers out of blocks in his room and becomes very upset if he is interrupted. He does not talk about any of his classmates; when his mother invites another child to the house, he has little interest in socializing. His mother reports that he understands directions and communicates without difficulty but has never been very affectionate. He is generally well behaved but will have a temper tantrum if a daily routine is altered or if furniture is rearranged. Pregnancy, labor, and delivery were uncomplicated, and he has reached all appropriate motor milestones for his age. His mother does not recall if language emerged somewhat later in him than it did for her daughter but notes that he makes his needs and wants known without any problem. He is neatly dressed. Physical examination shows no abnormalities. On mental status examination, he makes no eye contact with the physician and perseverates about the towers that he built in the waiting room. Which of the following is the most likely diagnosis?

Two days after undergoing urgent cesarean delivery because of a nonreassuring fetal heart tracing, a 37-year-old woman, gravida 1, para 1, has the onset of dysphoria, insomnia, and easy distractibility. Pregnancy was uncomplicated. She has no history of serious illness, and her only medication is a prenatal vitamin. Her paternal cousin had major depressive disorder, postpartum onset. The patient’s vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 97%. Physical examination shows no abnormalities. On mental status examination, she has an irritable mood and tired, concerned affect. Without treatment, which of the following is most likely to develop in this patient?

A 32-year-old woman with asthma comes to the physician because of a 3-month history of progressive wheezing and a cough that is occasionally productive of plugs of brownish sputum. She received the diagnosis of asthma 15 years ago. She has been taking an inhaled long-acting β-adrenergic agonist and inhaled glucocorticoid daily for 8 years and had good control of her symptoms until 3 months ago. She has no pets. She has no recent history of travel abroad or new occupational exposure. She appears well and is not in respiratory distress. Vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows no cyanosis. Scattered inspiratory and expiratory wheezes are heard. There is no clubbing or peripheral edema. Her leukocyte count is 20,000/mm3 (45% segmented neutrophils, 40% eosinophils, 12% lymphocytes, and 3% monocytes). Her serum IgE concentration is 2800 IU/mL. A chest x-ray shows alveolar infiltrates in the upper lungs bilaterally. Which of the following is the most likely diagnosis?

A 24-year-old woman comes to the office for an annual employment physical examination. She feels well. Medical history is unremarkable and she takes no medications. Vital signs are within normal limits. Physical examination discloses no abnormalities. As the physician is preparing to leave the examination room the patient asks, “Do you think having a romantic relationship with my gynecologist is all right?” Which of the following is the most appropriate response?

A healthy 52-year-old man comes to the physician for a routine total colonoscopy. He has no history of blood in his stool or rectal bleeding. There is no family history of colorectal polyps or cancer. He takes no medications and has never smoked cigarettes. Physical examination shows no abnormalities. Colonoscopy shows a 3-mm pedunculated polyp in the cecum. No other abnormalities are noted. The polyp is completely excised. Histopathologic evaluation shows dysplastic-appearing columnar epithelial cells confined by the basement membrane, lining a fibrovascular stalk. Which of the following is the most appropriate recommendation for future screening for colon cancer in this patient?

A healthy 18-month-old boy is brought for a well-child examination. He was born at 37 weeks’ gestation, needed no resuscitation, and had no neonatal problems. He was fed formula for the first 2 months of life, and then his mother substituted cow’s milk because of the expense of the formula. He has received no supplements or medications. Examination shows no abnormalities. This child is at greatest risk for which of the following?