CK- NBME 10 – Block 4

A 37-year-old woman comes to the physician because of a 1-year history of irregular menses. During this time, menses have occurred at irregular 3-month intervals and have lasted for 10 days with moderately heavy flow. She has no history of serious illness and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2. Her temperature is 37.1 °C (98.7°F), pulse is 70/min, respirations are 12/min, and blood pressure is 90/50 mm Hg. Visual field testing shows outer field deficits bilaterally. A milky white discharge can be expressed from both breasts. The remainder of the examination, including pelvic examination, shows no abnormalities. Test of the stool for occult blood is negative. Her serum prolactin concentration is 40 ng/mL. An MRI of the brain shows a pituitary microadenoma. Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 2, para 2, comes to the physician requesting advice regarding contraception. She states that she does not want to have any more children, but neither she nor her husband wishes to undergo a permanent sterilization procedure at this time. She requests a contraceptive method that has the lowest failure rate for the first year of use. Her second child was born 6 weeks ago at term after an uncomplicated pregnancy and delivery. Her infant is exclusively breast-fed. The patient has no history of serious illness and takes no medications. She has not had sexual intercourse for 2 months. Examination shows no abnormalities. Which of the following is the most appropriate contraceptive method for this patient at this time?

A 27-year-old nulligravid woman comes to the physician because of a 3-month history of intermittent abdominal cramps and diarrhea. She has not had blood or mucus in her stool. She reports that the symptoms usually occur after eating, are exacerbated by caffeine and stress, and are relieved by bowel movements. Changing her diet and avoiding dairy products have not improved her symptoms. She has two to three bowel movements daily. Examination shows mild generalized tenderness and increased bowel sounds. Which of the following is the most appropriate initial pharmacotherapy?

A 16-month-old girl is brought to the emergency department after the sudden onset of difficulty breathing and cough at a birthday party. She has not had fever, vomiting, diarrhea, runny nose, congestion, or a decrease in appetite or activity level. Immunizations are up-to-date. There are no known sick contacts, and there is no family history of serious illness. She appears healthy but is in moderate respiratory distress. She is at the 50th percentile for length and weight. Her respirations are 40/min; other vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 96%. Pulmonary examination shows minimal subcostal retractions; no wheezes or crackles are heard. Breath sounds are mildly decreased over the right upper lung fields. The remainder of the examination shows no abnormalities. An AP chest x-ray shows normal findings. Which of the following is the most appropriate next step in management?

A 3-month-old girl has had increased blood pressure measurements since admission to the hospital for pneumonia and bronchiolitis 2 days ago. She was born at 26 weeks’ gestation because of premature labor and weighed 750 g (1 lb 10 oz) at birth. During the first 2 days of life, an umbilical artery catheter was used to monitor her blood pressure. She had several episodes of hypotension that resolved after administration of fluid boluses. She remained in the neonatal intensive care unit for management of respiratory distress and poor weight gain until the age of 10 weeks, when her vital signs had stabilized and condition had improved. At that time, she was discharged home on 0.5 L/min of oxygen. Her current medications are a multivitamin with iron and budesonide. She appears well developed and well nourished but is in respiratory distress. She weighs 3005 g (6 lb 10 oz). Her temperature is 37°C (98.6°F), pulse is 160/min, respirations are 70/min, and blood pressure is 128/86 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. On pulmonary examination, crackles over the left lung base and scattered bilateral expiratory wheezes are heard. On cardiac examination, a grade 1/6, systolic ejection murmur is heard best at the upper left sternal border. The abdomen is soft and nontender. Femoral pulses are 2+ bilaterally. Serum studies are most likely to show which of the following sets of findings?

A 32-year-old woman comes to the physician because of a 4-day history of fever. She has had swelling and redness of her left leg during this period. She has a history of chronic lymphedema in both legs. She is 165 cm (5 ft 5 in) tall and weighs 107 kg (235 lb); BMI is 39 kg/m2. Her temperature is 38.5°C (101.3°F). The left lower extremity is diffusely red and edematous from just below the knee to the ankle, with a sharp demarcation separating the erythematous area from the normal skin at the knee. The erythematous area is painful and hyperesthetic to touch. The left femoral nodes are enlarged and painful. Which of the following is the most likely cause of this patient’s illness?

A 27-year-old man comes to the physician because of a 3-month history of episodes of palpitations, light-headedness, and tightness in his chest and throat. During the episodes, he feels an impending sense of doom and fears that he might die or “go crazy.” For the past 6 weeks, he has worried constantly that there is something wrong with his heart and that the symptoms will recur. He recently ended a 3-year relationship. He is a high school teacher. Physical examination shows no abnormalities. Mental status examination shows an anxious affect. Which of the following is the most likely diagnosis?

A 27-year-old man is brought to the emergency department by friends because of fever and chills since beginning treatment with penicillin and azithromycin 4 hours ago for a sexually transmitted disease. He has no history of serious illness and has no known allergies. On arrival, he appears ill. His temperature is 39.4°C (103°F), pulse is 120/min, and blood pressure is 90/52 mm Hg. Examination shows rigors. Which of the following is the most likely explanation for this patient’s current symptoms?

A 21-year-old college student comes to the physician for a follow-up examination. Seven days ago, a biopsy specimen of a cervical lymph node showed Hodgkin disease, and 2 days ago, an abdominal CT scan showed enlarged para-aortic lymph nodes. Examination today shows no abnormalities except for cervical adenopathy. He asks the physician, “What are my chances?” The physician recalls a recent well-designed study that showed 80% of patients with stage III Hodgkin disease survive more than 5 years. Which of the following is the most appropriate physician response?

A study is conducted to evaluate the effects of smoking on birth weight at term. Four cohorts of 10 pregnant patients each are identified on the basis of cigarette use. In cohort 1, patients smoke less than one pack of cigarettes daily; in cohort 2, patients smoke one to less than two packs of cigarettes daily; and in cohort 3, patients smoke two or more packs of cigarettes daily during pregnancy. The control group consists of patients who have never smoked cigarettes. Results of the study show the following birth weights:

Which of the following is the most accurate interpretation of these results?

A 68-year-old woman comes to the physician for an examination prior to undergoing total right hip replacement. Preoperative ECG shows a P wave area greater than 4 milliseconds x mV in lead II, findings consistent with enlargement of the left atrium. A recently published study that compares several ECG criteria for left atrial enlargement (LAE) with a reference standard of cardiac CT scanning shows that this criterion has a sensitivity of 73% and a specificity of 19%. Which of the following conclusions is most appropriate based on these data?

randomized controlled trial is conducted to examine the benefit of using graduated compression stockings for prevention of deep venous thrombosis (DVT) in patients
hospitalized for conditions other than cerebral infarction. An additional agent, heparin or low-molecular-weight heparin, is used for prophylaxis in some patients. Results show:

Which of the following best represents the relative risk reduction of DVT using graduated compression stockings as a preventive measure compared with no prophylaxis?

A 57-year-old man is brought to the emergency department by police 40 minutes after he was found wandering around a train station in a confused state. On arrival, he appears drowsy. His temperature is 37°C (98.6°F), pulse is 72/min, respirations are 14/min, and blood pressure is 135/80 mm Hg. Physical examination shows bilateral nystagmus and a disconjugate lateral gaze. His gait is unsteady and broad based. On mental status examination, he speaks in fragmented sentences and is often incoherent. He can recall zero of three objects after 5 minutes. He is oriented to person but not to place and time. Serum studies show:

Na⁺: 140 mEq/L

K⁺: 4 mEq/L

Cl⁻: 104 mEq/L

HCO₃⁻: 25 mEq/L

AST: 70 U/L

ALT: 64 U/L

γ-Glutamyltransferase: 55 U/L (N = 0–30)

A urine toxicology screening is negative. His blood alcohol concentration is 0 mg/dL. Which of the following is the most appropriate initial step in management?

A 67-year-old woman comes to the physician because of a 10-day history of left buttock pain that radiates down her left leg. She describes the pain as shooting and burning. She has a 2-year history of multiple myeloma poorly responsive to chemotherapy. Treatment with oxycodone-acetaminophen (two tablets every 6 hours) has not completely relieved her pain; she rates it as a 5 on a 10-point scale. She lives alone and can perform activities of daily living independently. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. Examination shows no tenderness to palpation over the lower spine. There is hyperesthesia to light touch over the left thigh. Muscle strength and sensation are intact. Which of the following is the most appropriate pharmacotherapy?

A 27-year-old man comes to the physician for a routine follow-up examination. He has a 22-year history of type 1 diabetes mellitus controlled with daily insulin. He measures his blood glucose concentration once weekly. He has not developed diabetic complications. He does not smoke or drink alcohol. He has an active lifestyle. His pulse is 87/min, and blood pressure is 120/78 mm Hg. Cardiac examination shows no abnormalities. Deep tendon reflexes are brisk and symmetric. His hemoglobin A1c is 6.5%. Which of the following is the most appropriate screening recommendation at this time?

A 27-year-old woman comes to the physician because of a 6-month history of decreased bleeding with menses. She is otherwise asymptomatic. Menses occur at regular 28-day intervals and last for 3 days with light spotting. Her only medication is an oral contraceptive for the past 5 years. Physical examination, including pelvic examination, shows no abnormalities. Which of the following is the most appropriate next step in management?

A 49-year-old nulligravid woman with type 2 diabetes mellitus comes to the office because of an 18-month history of increasingly heavy irregular menstrual periods. Today, she reports vaginal spotting. Menses occur at 10- to 12-day intervals and last 5 to 7 days; she has to change a regular tampon every 4 to 6 hours. She is 170 cm (5 ft 7 in) tall and weighs 104 kg (230 lb); BMI is 36 kg/m2. Pelvic examination shows a slightly enlarged uterus without adnexal masses. Which of the following is the most appropriate next step in diagnosis?

A 37-year-old woman, gravida 2, para 1, at 15 weeks’ gestation comes to the physician for her first prenatal visit. She has felt well except for mild nausea for the past 4 weeks. She delivered a healthy newborn 5 years ago; pregnancy and delivery were uncomplicated. She has no history of serious illness or operative procedures. Physical examination shows no abnormalities. The uterus is consistent in size with a 13-week gestation. The patient inquires about amniocentesis but is concerned about any adverse effects. If this patient undergoes amniocentesis, she is at increased risk for which of the following complications?

A 30-year-old primigravid woman at 26 weeks’ gestation comes to the office for a routine prenatal visit. Her pregnancy has been complicated by first-trimester vaginal bleeding. She is otherwise healthy and takes no medications. Her pulse is 90/min, respirations are 20/min, and blood pressure is 100/72 mm Hg. Examination shows a fundal height of 27 cm. The fetal heart rate is 150/min. Laboratory studies show:

Hematocrit: 33%

Leukocyte count: 9500/mm³

Platelet count: 220,000/mm³

Blood group: O, Rh-negative

1-hour glucose tolerance test: 120 mg/dL (N < 135)

Serum anti-D antibody screening: positive, 1:8

The blood group of the fetus’s father is unknown. Which of the following is the most likely diagnosis?

A 29-year-old woman, gravida 2, para 1, at 32 weeks’ gestation is brought to the emergency department 30 minutes after cutting her left index finger while cooking. She has been applying pressure, but the bleeding has not stopped. She has no history of serious illness, and her only medication is a prenatal vitamin. Vaccinations were up-to-date at the birth of her first child 14 months ago. The patient’s vital signs, including oxygen saturation, are within normal limits. Examination shows a 2-cm superficial laceration over the left index finger. Fetal heart tones are normal. The remainder of the examination shows no abnormalities. The laceration is sutured. Which of the following is the most appropriate vaccine to administer at this time?