NBME 16 – Block 3 (Duplicate 1)

An 18-year-old woman is brought to the emergency department via ambulance 25 minutes after she sustained injuries during a motor vehicle collision in which her automobile was struck head-on by another vehicle. She was the restrained driver, and her airbag deployed. She was found unconscious in the wreckage and was extracted by paramedics. En route, she received advanced cardiac life support measures, including defibrillation and epinephrine. She was intubated and stabilized. On arrival, she is unresponsive. Temperature is 36.0°C (96.8°F), pulse is 95/min, respirations are 17/min, and blood pressure is 100/70 mm Hg. Physical examination shows severe bruising over the sternum. Bilateral crackles are heard. There is evidence of a right hip fracture but no evidence of head trauma. Transthoracic echocardiography shows severe mitral valve regurgitation. The patient’s blood pressure decreases to 90/40 mm/Hg, and there is atrial fibrillation and subsequent asystole. Despite appropriate intervention, the patient dies. Which of the following is the most likely cause of this patient’s death?

A state legislator plans to introduce a bill to eliminate a current law requiring that all motorcycle drivers wear helmets. The state public health association is lobbying against the bill, citing many studies supporting the use of motorcycle helmets for prevention of head trauma sustained in motor vehicle collisions involving motorcycles. Which of the following best describes the level of prevention mentioned in the studies cited by the state’s public health association?

A 65-year-old man comes to the office with this wife because of a 6-month history of increasingly severe headache accompanied by nausea. His wife says his personality has changed, and that he has been more apathetic during this period. He has no personal or family history of serious illness and does not use medications or other substances. Temperature is 37.0°C (98.6°F), pulse is 72/min, respirations are 16/min, and blood pressure is 125/80 mm Hg. He is awake and alert. Neurologic examination discloses optic atrophy in the right eye, papilledema in the left eye, and anosmia. The remainder of cranial nerve testing shows no abnormalities. Muscle strength is 5/5 in the upper and lower extremities bilaterally. Sensation to light touch, pinprick, and proprioception is intact. There are no cerebellar abnormalities and he walks with a normal gait. He is oriented to person, place, and time. MRIs of the brain with contrast are shown. Which of the following is the most likely diagnosis?

A 32-year-old primigravid woman at 28 weeks’ gestation comes to the emergency department 3 hours after an episode of bright red vaginal bleeding. Her pregnancy otherwise has been uncomplicated. She has no history of serious illness. Vital signs are within normal limits. Examination shows a uterus consistent in size with a 28-week gestation; the fetus is in a floating breech presentation. Ultrasonography shows a partial placenta previa with a normal volume of amniotic fluid. The fetus is consistent in size with a 28-week gestation. She is admitted to the hospital for observation. During the next 24 hours, there is no further bleeding, and the fetal status remains reassuring. Which of the following is the most appropriate next step in management?

A 27-year-old primigravid woman at 28 weeks’ gestation comes to the emergency department 3 hours after the onset of contractions. She has had no vaginal bleeding and has not had sexual intercourse recently. Her pregnancy had been uncomplicated. External fetal monitoring shows contractions every 3 minutes; the fetal heart rate is reassuring. Speculum examination shows no abnormalities. There is no blood in the vaginal vault. The membranes are intact. A fetal fibronectin assay (FFN) from the posterior vagina is negative. Digital examination shows a long, closed cervix. The physician informs the patient that her risk for delivery within the next 2 weeks is less than 1%. Which of the following factors makes FFN the most appropriate test for predicting the risk of preterm delivery in this patient?

An 83-year-old woman comes to the clinic because of a 1-year history of progressive shaking of both hands. The shaking is more pronounced with the right hand, particularly when she tries to hold an object or write. Her spouse has noted that her head also shakes intermittently. She has had no recent falls or changes in gait. Medical history is remarkable for essential hypertension, hypothyroidism, osteoarthritis of both knees, and major depressive disorder. Medications are hydrochlorothiazide, levothyroxine, and sertraline. She uses a four-wheeled walker for ambulation and is independent in all other activities of daily living. Family history is remarkable for Parkinson disease in her paternal grandfather. The patient occasionally drinks alcoholic beverages. She uses no other substances. She is 175 cm (5 ft 9 in) tall and weighs 61 kg (135 lb); BMI is 20 kg/m2. Temperature is 36.5°C (97.7°F), pulse is 82/min and regular, respirations are 16/min, and blood pressure is 132/65 mm Hg. The patient is alert and fully oriented. Muscle tone is normal and muscle strength is 5/5. Coordination testing discloses fast, repetitive shaking of the fingers and a side-to-side motion of the head. Gait is stable when ambulating with the walker. Which of the following is the most likely cause of these findings?

Three days after discharge following uncomplicated total abdominal hysterectomy and bilateral salpingo-oophorectomy for management of ovarian cancer, a 57-year-old woman comes to the emergency department because of a 3-hour history of progressive dyspnea and increasingly severe chest pain. She has no other history of serious illness and took no medications prior to admission. At the time of discharge, she was prescribed hydrocodone-acetaminophen. She does not smoke cigarettes. Temperature is 37.0°C (98.6°F), pulse is 112/min, respirations are 32/min, and blood pressure is 118/78 mm Hg. There is a clean, intact surgical incision over the abdomen. The remainder of the examination shows no abnormalities. Results of laboratory studies are shown:

Results of arterial blood gas analysis on 2 L/min of oxygen by nasal cannula are shown:

12-Lead ECG shows sinus tachycardia. Chest x-ray shows no abnormalities. CT scan of the chest shows a filling defect in one of the branches of the right pulmonary artery. Which of the following is the most appropriate next step in management?

An 18-month-old boy is brought to the emergency department because of a 2-day history of temperatures to 38.9°C (102.0°F). During the past 6 months, he has had four episodes of otitis media that resolved with amoxicillin therapy. He currently receives no medications. Immunizations are up-to-date. The patient is at the 10th percentile for length, weight, and head circumference. Temperature is 39.4°C (103.0°F), pulse is 130/min, and respirations are 36/min. Examination of the left knee shows swelling, erythema, and tenderness to palpation. Leukocyte count is 10,000/mm3 (N=6000–14,000), and absolute neutrophil count is 480/mm3 (N>500). Serum immunoglobulin concentrations are decreased, and B lymphocytes are absent. Culture of fluid aspirated from the knee grows Streptococcus pneumoniae, and the patient’s symptoms improve with intravenous ceftriaxone therapy. The patient’s mother reports that her maternal great uncle died of sepsis as a child. Which of the following is the most appropriate next step in management?

A 1-week-old girl is brought to the office by her father for a well-child examination. She has no history of serious illness and receives no medications. Vaccinations are up-to-date. She was born at 39 weeks’ gestation to a 29-year-old woman, gravida 1, para 1, following uncomplicated spontaneous vaginal delivery. Growth and development have been normal. She is 50 cm (20 in; 50th percentile) long and weighs 3400 g (7 lb 8 oz; 50th percentile); head circumference is 34.2 cm (13.5 in; 50th percentile). Vital signs are within normal limits. Examination discloses instability of the right hip on flexion when posterior pressure is applied to the femur. No other abnormalities are noted. Ultrasonography of the hips confirms the diagnosis. Which of the following is the most appropriate next step in management?

A 3-year-old girl is brought to the urgent treatment center by her father because of a 3-week history of rash on her face and buttocks; the rash is not itchy or painful. The father says they have not recently changed bath soaps or laundry detergents and have not begun eating any new foods recently. The patient is otherwise asymptomatic. She has no history of serious illness and receives no medications. The father says his daughter is a “very picky eater.” Vital signs and oxygen saturation are within normal limits. Examination shows a perioral rash with mild edema and erythema. The rash on the buttocks is more erythematous, but there are no satellite lesions or other signs of infection. The remainder of the examination discloses no abnormalities. Which of the following is the most likely diagnosis?

A 16-year-old boy is brought to the clinic because of a 3-month history of a 9.1-kg (20-lb) weight gain that he attributes to increased eating. His mother died in a motor vehicle collision 6 months ago. Since then, he says it takes him an hour to fall asleep, he wakes up at 4 am every morning, and he lies in bed not wanting to get out. He spends most of the day in his bedroom. He has missed 4 weeks of school and is failing some classes. He was an avid wrestler but is not participating this year. He says, “I just don’t care about anything. Eating is the only thing that seems to help.” He snacks throughout the day and has been eating double his normal portions at meals. He feels guilty about his increased eating and has been inducing vomiting four times weekly “so I don’t get fat.” He has been attending individual and family therapy during the past 4 months. He has no history of serious illness and takes no medications. He does not use nicotine products, drink alcohol, or use other substances. He is at the 25th percentile for height, 70th percentile for weight, and 84th percentile for BMI. Vital signs are within normal limits. He makes poor eye contact during the visit. Physical examination discloses no abnormalities. On mental status examination, he has a blunted and dysphoric affect and describes his mood as “whatever.” He has no suicidal ideation or thoughts of self harm. Which of the following is the most appropriate pharmacotherapy at this time?

A hospitalized 46-year-old woman undergoes uncomplicated vaginal hysterectomy and bilateral salpingo-oophorectomy for leiomyoma uteri and heavy menstrual bleeding. Estimated blood loss is 100 mL. Immediately following the operation, cystoscopy shows an intact bladder, a brisk urine jet from the left ureteral orifice, and no urine jet from the right ureteral orifice. Which of the following operative steps is the most likely cause of the cystoscopy findings?

Physicians at an outpatient clinic would like to increase the percentage of patients with type 2 diabetes mellitus treated in the clinic who undergo recommended annual diabetic foot examination. The baseline percentage of patients with type 2 diabetes mellitus in this patient population who underwent diabetic foot examination during the past year was 30%. The clinic would like to improve this number to greater than 70% during the next 6 months. Which of the following measurement tools is most appropriate for the physicians to track their progress?

A 45-year-old woman comes to the clinic to discuss the results of fiberoptic bronchoscopy performed 2 days ago for evaluation of a 6-month history of a progressively worsening cough. She was initially seen in the clinic 10 days ago after she had three episodes of blood-streaked sputum in 3 days. Chest x-ray and CT scan of the chest obtained at the initial visit showed a 2.5-cm centrally located opacity in the right upper lobe. Today, the patient says she feels well. Medical history is remarkable for hypertension; she underwent a hysterectomy 3 years ago for leiomyomata uteri. Her only medication is hydrochlorothiazide. The patient does not smoke cigarettes, drink alcoholic beverages, or use other substances. She is 170 cm (5 ft 7 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2. Temperature is 37.0°C (98.6°F), pulse is 75/min, respirations are 12/min, and blood pressure is 120/80 mm Hg. Physical examination discloses no abnormalities. Results of fiberoptic bronchoscopy show an endobronchial mass. Biopsy of the mass confirms the diagnosis. The mass is well differentiated. Which of the following is the most appropriate next step in management?

A 62-year-old man comes to the office because of increasing difficulty achieving an erection during the past 2 years; for 2 months, he has been unable to achieve an erection. Two years ago, he noted that he had no semen discharge with orgasm. He has a 13-year history of hypertension treated with lisinopril and a 20-year history of type 2 diabetes mellitus treated with metformin. He also takes atorvastatin. Pulse is 90/min, respirations are 16/min, and blood pressure is 155/92 mm Hg while sitting and 130/80 mm Hg while standing. Lungs are clear to auscultation. An S4 gallop is heard; there are no murmurs. Pedal pulses are intact. Prostate is symmetrically enlarged; there is no tenderness or nodules. Proprioception and sensation to vibration and light touch are decreased to the knees bilaterally. Ankle reflexes are absent bilaterally. Which of the following is the most likely diagnosis?

A 7-year-old girl is brought to the office by her parents because of a 7-week history of intermittent fever, joint pain, malaise, and an unintentional 2-kg (5-lb) weight loss, despite no change in appetite. She also has had progressive difficulty rising from a chair and walking up stairs during this time. Medical history is unremarkable. She takes no medications and has never been hospitalized. She is at the 50th percentile for height and 25th percentile for weight. Vital signs are normal except for a temperature of 38.0°C (100.4°F). Physical examination discloses the findings shown in the photographs. Muscle strength is 3/5 in the proximal aspects of the upper and lower extremities. When asked to walk across the examination room, the patient appears to walk on her toes. Which of the following is the most appropriate next step in diagnosis?

A 42-year-old man comes to the urgent care center because of a 1-month history of constipation and rectal bleeding. He says he has had to strain in order to have a bowel movement on most days. During this time, he has noticed bright red blood both on the toilet paper and streaking in his stools. Medical history is unremarkable and he takes no medications. He does not use other substances. Family history is unremarkable. The patient self-identifies as African American. He is 185 cm (6 ft 1 in) tall and weighs 90 kg (198 lb); BMI is 26 kg/m2. Vital signs are within normal limits. The patient appears well. Cardiopulmonary examination discloses no abnormalities. Abdomen is soft and nontender. Rectal examination shows multiple hemorrhoids with no active bleeding. Results of laboratory studies are shown:

In addition to treating the patient’s hemorrhoids, which of the following is the most appropriate next step in management?

Twenty-four hours after undergoing laparotomy for appendicitis, a 2-year-old girl receives morphine for pain management. Fifteen minutes later, she is somnolent. Her pulse is 80/min, respirations are 15/min, and blood pressure is 80/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 60%. The patient is administered naloxone and immediately awakens; pulse oximetry on room air now shows an oxygen saturation of 100%, and all vital signs are within normal limits. A root cause analysis of this adverse event should be designed to examine which of the following?

A 58-year-old woman comes to the office because of a 1-day history of pain and redness of her right great toe. She says the pain woke her from sleep last night. She rates the pain as a 7 on a 10-point scale. She has not had fever and there is no discharge from the toe. The patient has never had a similar episode in the past. She has not recently changed her diet. Medical history is remarkable for hypertension, hyperlipidemia, and osteoarthritis. Medications are losartan, hydrochlorothiazide, simvastatin, ezetimibe, and acetaminophen. She does not smoke cigarettes, drink alcoholic beverages, or use other substances. She is 160 cm (5 ft 3 in) tall and weighs 61 kg (135 lb); BMI is 24 kg/m2. Vital signs are within normal limits. Physical examination shows erythema, warmth, and tenderness to palpation at the metatarsophalangeal joint of the right great toe. Analysis of fluid aspirated from the right great toe is most likely to show which of the following?

Patient Information

Age: 47 years

Gender: F, self-identified

Race/Ethnicity: unspecified

Site of Care: clinic

History

Reason for Visit/Chief Concern: annual health maintenance examination

History of Present Illness:

• patient has no concerns

• requests routine screening blood work

• requests renewal of allergy medication prescriptions

• says her allergies are well controlled

Past Medical History:

• allergic rhinitis

Vaccinations:

• up-to-date

Allergies:

• no known drug allergies

Family History:

• mother: deceased at age 78 years from stroke; hypertension

• father: deceased at age 73 years from colon cancer

Psychosocial History:

• has smoked one pack of cigarettes daily for 30 years

• does not drink alcoholic beverages or use other substances

• lives with her husband and daughter

• works as a teacher

Physical Examination

• Appearance: well; no acute distress

• HEENT: no conjunctival icterus; PERRLA; ocular movements intact; moist oropharynx

• Pulmonary: clear to auscultation

• Cardiac: regular rhythm; no murmurs, rubs, or gallops

• Abdominal: nondistended; soft, nontender to palpation

• Extremities: no clubbing, cyanosis, or edema

Diagnostic Studies

• screening mammography obtained 6 months ago: no abnormalities

Question: In addition to recommending smoking cessation, which of the following is the most appropriate next step in management?