NBME 15- Block 3 (Duplicate 1)
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Question 1 of 20
1. Question
A 27-year-old woman comes to the emergency department because of a 1-week history of diarrhea. She has bipolar disorder treated with medication, but she cannot remember the name of the drug. Two weeks ago, she was feeling depressed and increased the dose she normally takes. She does not drink alcohol or use illicit drugs. Her temperature is 37°C (98.6°F), pulse is 72/min, respirations are 16/min, and blood pressure is 125/75 mm Hg. Physical examination shows a fine resting tremor of the hands. On mental status examination, she is oriented to person but not to place, date, or time. She makes several errors performing serial sevens and is unable to repeat seven digits forward and five in reverse sequence. Which of the following medications is the most likely cause of this patient’s symptoms?
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Question 2 of 20
2. Question
A 19-year-old man comes to the physician because of an 8-hour history of headache, stiff neck, and fever. His brother and sister died of a “brain infection.” The patient’s temperature is 39.4°C (103°F). He appears lethargic. Examination shows nuchal rigidity. Cerebrospinal fluid analysis shows a leukocyte count of 5000/mm3, a glucose concentration of 10 mg/dL, and a protein concentration of 140 mg/dL. Treatment with ceftriaxone is started, and his symptoms improve. Gram stain shows gram-negative cocci. Which of the following is the most appropriate next step in diagnosis?
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Question 3 of 20
3. Question
A 15-month-old girl is brought to the physician because of a 1-week history of symptoms of an upper respiratory tract infection. Her temperature is 38°C (100.4°F). On examination, she is alert and turns her head appropriately in response to sounds. The left external ear and canal appear normal. The left tympanic membrane is shown. There is minimal movement on pneumatic otoscopy. The right external ear, ear canal, and tympanic membrane appear normal. Which of the following is the most likely diagnosis?
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Question 4 of 20
4. Question
A 42-year-old woman comes to the physician for a follow-up examination 6 weeks after undergoing in vitro fertilization for male factor infertility. She has no history of serious illness. Physical examination shows no abnormalities. Pelvic examination shows vaginal atrophy and a small amount of discharge tinged with blood and mucus in the posterior vaginal vault. Bimanual examination shows no cervical motion tenderness. The uterus is midline, smooth, nontender, and consistent in size with a 10-week gestation. There is fullness and mild tenderness at the left adnexa. Endovaginal ultrasonography shows a twin gestation with one chorion and one amniotic sac; there are two separate embryos, each with a strong heartbeat. This patient’s fetuses are at greatest risk for which of the following?
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Question 5 of 20
5. Question
A 12-year-old girl is brought to the physician because of pain in the right thigh; the pain has been present for 2 months but has become markedly worse during the past 10 days. She also has had a low-grade fever for 1 week. Her temperature is 37.2°C (99°F). Examination of the right lower extremity shows tenderness in the middle of the thigh. The remainder of the examination shows no abnormalities. Her leukocyte count is 10,000/mm3. An x-ray of the right femur is shown. Without treatment, which of the following is most consistent with the natural history of this patient’s disorder?
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Question 6 of 20
6. Question
A 47-year-old man comes to the physician for a follow-up examination. He has a 1-year history of asthma poorly controlled with salmeterol, tiotropium, theophylline, β-adrenergic agonists, and short courses of prednisone. His temperature is 36.9°C (98.4°F), pulse is 84/min, respirations are 18/min, and blood pressure is 132/76 mm Hg. On pulmonary examination, diffuse expiratory wheezes are heard bilaterally. Previous x-rays of the chest have shown patchy infiltrates with a suggestion of central bronchiectasis. Results of laboratory studies show eosinophilia. Which of the following is the most appropriate next step in diagnosis?
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Question 7 of 20
7. Question
A 6-year-old boy is brought to the physician for a routine well-child examination prior to a scheduled dental extraction. He has a ventricular septal defect that has not required operative repair. He has no other history of serious illness. Vital signs are within normal limits. Examination shows multiple dental caries. There are no bruits or heaves on auscultation. A grade 1/6 holosystolic murmur is heard best at the lower left sternal border. Which of the following is the most appropriate pharmacotherapy for this patient prior to his dental procedure?
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Question 8 of 20
8. Question
A 57-year-old man is referred to a surgeon after he is diagnosed with an asymptomatic abdominal aortic aneurysm that is 5 cm in diameter. The average survival of untreated patients with aneurysms larger than 6 cm is 20 months. The mortality of patients with spontaneous out-of-hospital rupture of an aortic aneurysm is greater than 85%. Which of the following additional pieces of information will be most useful in assessing this patient’s need for an operation?
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Question 9 of 20
9. Question
A 27-year-old man with HIV infection comes to the emergency department because of a 10-day history of fever, chills, malaise, and cough productive of yellow sputum. He takes no medications. He appears chronically ill. His temperature is 38.9°C (102°F), pulse is 120/min, respirations are 22/min, and blood pressure is 102/60 mm Hg. Examination shows bitemporal wasting, a dry oropharynx, and white exudate over the oral mucosa. There is diffuse, nontender cervical lymphadenopathy. Coarse breath sounds are heard over the upper lobe of the right lung. The remainder of the examination shows no abnormalities. Laboratory studies 2 months ago showed a CD4+ T-lymphocyte count of 24/mm3 (Normal≥500) and plasma HIV RNA viral load of 350,000 copies/mL. Laboratory studies today show:
Hematocrit
27%
Leukocyte count
3200/mm3
Platelet count
145,000/mm3
CD4+ T-lymphocyte count
20/mm3
HIV RNA viral load
600,000 copies/mL
A chest x-ray and sputum smear are shown. Which of the following is the most likely causal organism?
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Question 10 of 20
10. Question
A 37-year-old man comes to the physician because of a 4-day history of sharp, right-sided chest pain and a 1-week history of cough. He rates his pain as a 7 on a 10-point scale. His cough was initially productive of clear sputum and associated with a runny nose but is now nonproductive. He reports difficulty sleeping and working because of his symptoms. He has no history of serious illness and takes no medications. He does not smoke cigarettes. He recently moved to the Ohio River Valley and has two young children. He works as a biologist studying plant viruses. One week ago, his children had upper respiratory tract infections. The patient appears comfortable but is unable to take deep breaths because of the cough. His temperature is 36.2°C (99.1°F), pulse is 78/min, respirations are 18/min, and blood pressure is 136/78 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination and a chest x-ray show no other abnormalities. Which of the following is the most likely diagnosis?
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Question 11 of 20
11. Question
A 54-year-old woman comes to the physician because of a 2-year history of episodes of nasal congestion and clear discharge, frequent sneezing, itchy eyes, and moderate “sinus pressure.” Her symptoms occur throughout the year. She has no history of asthma, hives, generalized swelling, or known allergies. She uses intermittent diphenhydramine with minimal relief. Her other medications are calcium and vitamin D supplementation. She does not have a pet. She has never smoked cigarettes. She lives on the fourth floor of a large apartment complex. She appears in no distress. Her temperature is 36.7°C (98°F), pulse is 68/min, respirations are 12/min, and blood pressure is 113/67 mm Hg. Examination shows pale, edematous nasal mucosa; no other abnormalities are noted. Which of the following is the most appropriate pharmacotherapy?
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Question 12 of 20
12. Question
A 36-year-old woman comes to the physician because of a 2-week history of sharp anal pain that began when she was exercising. During this time, her pain has decreased in severity but has not resolved; it occurs during bowel movements and is associated with small amounts of blood. She has not had itching or feelings of rectal fullness. She has no history of serious illness and takes no medications. She is sexually active with one male partner; she uses condoms consistently. Eight months ago, she vacationed in Mexico. Vital signs are within normal limits. A photograph of the anus is shown. A rectal examination cannot be performed because of pain. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
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Question 13 of 20
13. Question
A 2-year-old boy is brought to the physician by his mother because of a 1-week history of rectal tissue protruding from his anus when he strains vigorously during bowel movements. The tissue retracts spontaneously within 1 hour. His mother notes that his stools are hard. He has no history of serious illness and receives no medications. Immunizations are up-to-date. Growth and development are appropriate for age. The patient’s paternal uncle has a history of intermittent abdominal pain and diarrhea; he recently began a gluten-free diet on the advice of a friend. The patient’s family dog recently was treated for worms. Examination of the patient shows no abnormalities; the anus appears normal. Which of the following is the most appropriate next step in management?
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Question 14 of 20
14. Question
Two days after undergoing elective right hip replacement, a hospitalized 85-year-old woman is confused and agitated and attempts to pull the intravenous line out of her forearm. She does not recognize her visiting family members and thinks she is in the grocery store. She is told repeatedly that she has just had hip surgery and is in the hospital but remains confused and agitated. She has osteoarthritis. Her medications are acetaminophen and morphine. She drank two glasses of wine weekly for 30 years but stopped drinking alcohol 10 years ago. Prior to hospitalization, she performed all activities of daily living independently. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination shows a clean, dry surgical incision over the right hip. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. On mental status examination, she is oriented to person but not to place or time. She follows simple commands. Which of the following is the most appropriate next step in management?
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Question 15 of 20
15. Question
A 62-year-old woman with stage 4 chronic kidney disease comes to the physician for a routine examination. She feels well and was last seen by a physician 3 months ago. She also has type 2 diabetes mellitus and hypertension. Her medications are short- and long-acting insulin, simvastatin, enalapril, metoprolol, calcium carbonate, sodium citrate, sevelamer, and aspirin. Her temperature is 36.7°C (98°F), pulse is 58/min, respirations are 16/min, and blood pressure is 135/75 mm Hg. Cardiopulmonary and abdominal examinations show no abnormalities. Dorsalis pedis and posterior tibial pulses are palpable bilaterally. Monofilament testing shows decreased sensation over both feet. Proprioception is intact. Laboratory studies show:
Hemoglobin
8.5 g/dL
Hematocrit
27%
Mean corpuscular volume
85 µm3
Platelet count
165,000/mm3
Serum
Na+
135 mEq/L
K+
4.9 mEq/L
HCO3−
22 mEq/L
Ca2+
8.4 mg/dL
Urea nitrogen
40 mg/dL
Creatinine
3.6 mg/dL
Phosphorus
4.6 mg/dL
Estimated glomerular filtration rate
25 mL/min (N>60)
Before beginning erythropoietin therapy, which of the following is the most appropriate next step in management?
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Question 16 of 20
16. Question
A 25-year-old woman is admitted to the hospital because of a 1-week history of increasing ptosis, diplopia, slurred speech, and difficulty walking up stairs. She has a 3-year history of myasthenia gravis; her symptoms have been well controlled with prednisone during the past year. She has no other history of serious illness and takes no other medications. Examination shows fluctuating bilateral ptosis, disconjugate gaze, nasal speech, mild bilateral facial weakness, soft voice, and difficulty generating a cough. Muscle strength varies from 3/5 to 4/5 in the shoulders and hips. Which of the following is the most appropriate method of measuring this patient’s respiratory status during hospitalization?
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Question 17 of 20
17. Question
Four weeks after undergoing cardiac catheterization because of chest pain, a 60-year-old man comes to the physician because of a 3-day history of a rash over his legs. Six hours before catheterization, administration of 0.9% saline was begun and continued 24 hours postoperatively. He has a 25-year history of type 2 diabetes mellitus complicated by diabetic nephropathy and hepatitis C. His medications are insulin, lisinopril, simvastatin, metoprolol, and aspirin. A photograph of the rash is shown. Examination shows no other abnormalities. His serum creatinine concentration was 1.6 mg/dL before the procedure, 1.5 mg/dL 48 hours after the procedure, and 3.5 mg/dL at today’s visit. Urinalysis today shows numerous WBC/hpf and no casts. Which of the following is the most likely diagnosis?
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Question 18 of 20
18. Question
A 33-year-old woman, gravida 2, para 2, comes to the office for a health maintenance examination. Her pregnancies ended in spontaneous vaginal deliveries of healthy newborns at term. Her second pregnancy 3 years ago was complicated by gestational diabetes, which was controlled with diet. She has no other history of serious illness and takes no medications. She is sexually active and monogamous with her husband. She has no history of abnormal Pap smears; her last Pap smear was 2 years ago. Her mother was diagnosed with breast cancer at the age of 58 years. Her father had a hyperplastic polyp removed from his colon at the age of 51 years. There is no family history of heart disease or diabetes mellitus. Physical examination of the patient, including pelvic examination, shows no abnormalities. Which of the following is the most appropriate next step in management?
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Question 19 of 20
19. Question
A randomized study is conducted to assess the efficacy of two treatment regimens for acne vulgaris in 360 female high school students. The students are randomly assigned to receive an oral antibiotic and topical cream daily (Regimen A) or an oral contraceptive and topical cream daily (Regimen B). Adherence to each regimen is measured by monthly pill counts. After 3 months of therapy, results show adherence to Regimen A is 56% and adherence to Regimen B is 72% (P=0.04). The outcomes are shown:
Regimen A (%)
Regimen B (%)
P-Value
Subjective improvement
40
65
0.02
Erythema
72
82
0.32
Pruritus
14
18
0.45
Nausea
33
18
0.04
Headache
6
12
0.12
Which of the following best represents the number needed to treat with Regimen B for 3 months to create one additional patient benefit of subjective improvement?
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Question 20 of 20
20. Question
A 55-year-old man comes to the office because of a 6-month history of progressive shortness of breath and fatigue with activities of daily living. He now has shortness of breath when walking to the mailbox and when walking up stairs in his home. He smoked one and one-half packs of cigarettes daily for 40 years but quit 1 year ago. He has no history of serious illness and takes no medications. He is 185 cm (6 ft 1 in) tall and weighs 110 kg (242 lb); BMI is 32 kg/m2. His pulse is 100/min, respirations are 18/min, and blood pressure is 150/90 mm Hg. On cardiac examination, S2 is loud and there is an S4. A grade 2/6 holosystolic murmur is heard best at the lower left sternal border. The liver span is 12 cm. There is 2+ pitting edema of the lower extremities. An AP x-ray shows flattened diaphragms and an enlarged cardiac silhouette. A lateral view shows filling of the retrosternal airspace. Which of the following is the most appropriate next step in diagnosis?
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