CK- NBME 11 – Block 4 (Duplicate 1)

A 23-year-old woman comes to the physician because of a 2-day history of several small, painful lesions over the vulva. She has no history of medical or gynecologic illness. She has a history of six lifetime sexual partners and became sexually active with her current partner 6 weeks ago; she uses condoms inconsistently. Examination shows ulcerations over the external genitalia that are tender to touch. She is concerned that she might have a sexually transmitted disease and that this might endanger future pregnancies. This patient should be advised that she is at increased risk for which of the following pregnancy outcomes?

A 62-year-old woman comes to the physician because of a 6-month history of increasing pain in her right thumb, especially with use. She now has difficulty with daily activities such as opening jars. She is right-handed. Ten years ago, she received the diagnosis of breast cancer and underwent mastectomy followed by chemotherapy. Evaluation 2 years ago showed no evidence of recurrence. She has type 2 diabetes mellitus controlled with metformin. Examination shows severe tenderness to palpation at the base of the right thumb. Muscle strength is 3/5 on abduction of the thumb due to pain. Sensation to pinprick is intact over the thumb. Which of the following is the most likely diagnosis?

A 42-year-old woman comes to the physician because of a 1-year history of increased drinking and difficulty swallowing because of a dry mouth. She also has noticed swelling of her cheeks and has had more dental cavities than usual during this period. She has no history of serious illness. She takes no medications. Vital signs are within normal limits. Examination shows enlarged parotid glands; slightly red eyes; and dry, cracked lips. Which of the following is the most appropriate next step in management?

A randomized controlled trial shows that a new fecal occult blood test (FOBT) leads to an 80% decrease in the relative risk for death due to colorectal cancer. Which of the following additional information is most useful in understanding the impact of this test?

 A 4-month-old boy is brought to the office by his mother because of a 1 -month history of feeding problems. The mother says her son often vomits after feeding and hiccups frequently. She also notes that he sometimes arches his back after feeding and appears to be in pain. The infant’s diet consists primarily of cow milk-based formula, with occasional infant cereal and fruits. He is fed six times daily. Medical history is unremarkable and he takes no medications. Vaccinations are up-to-date. The patient is at the 10th percentile for length, weight, and head circumference. Vital signs are normal. Physical examination discloses no abnormalities. Which of the following is the most likely preliminary diagnosis?

A 62-year-old woman is brought to the physician by her children 1 week after they noticed a large lesion on her right shoulder. She has lived alone since her husband died 6 months ago, and her family has recently become concerned that she is not caring for herself adequately. She says she thinks she has had the lesion for 1 year and that it has been increasing in size. She underwent renal transplantation 5 years ago and has taken prednisone and cyclosporine since then. She underwent radiation therapy on her face for treatment of acne as a teenager. Her sister died of skin cancer 3 years ago at the age of 65 years. The patient has smoked one pack of cigarettes daily for 45 years. She was employed as a landscaper for 25 years. She appears disheveled and is poorly groomed. Examination shows a 5-cm lesion on the posterior right shoulder. A photograph of the patient’s back is shown. Which of the following is the most likely cause of the lesion?

A 27 year old primigravid woman at 20 weeks gestation comes to the physician for her first prenatal visit. Examination shows a uterus consistent in size with a 10 week gestation. Laboratory studies show:

Hemoglobin: 10.5 g/dL

Mean corpuscular hemoglobin: 27.8 pg/cell

Mean corpuscular hemoglobin concentration: 29% Hb/cell

Mean corpuscular volume: 75 µm³

Leukocyte count: 10,000/mm³

Platelet count: 174,000/mm³

Which of the following is the most likely diagnosis?

A previously healthy 4-year-old boy is brought to the physician because of a 3-day history of fever, cough, and runny nose. He has not had wheezing, vomiting, or diarrhea. He is at the 75th percentile for height and 10th percentile for weight. His temperature is 37.5°C (99.5°F). The skin is warm and pink. Capillary refill time is 2 seconds. Examination shows clear rhinorrhea. Breath sounds are normal. Cardiac examination is shown. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

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A 6-year-old girl with a history of delayed motor and language development is brought to the physician by her parents because of three episodes of “staring off” during the past 5 weeks. During the episodes, she turns her head to the left, extends her left arm, and does not respond to questions; each episode lasts 2 minutes. After the episode, she is confused and wants to sleep. She was born at term following an uncomplicated pregnancy and spontaneous vaginal delivery. Examination shows no dysmorphic features. There are a few hypopigmented macules over the abdomen and lower extremities. Language development is at the level of a 3-year-old child. An MRI of the brain is shown. Which of the following is the most likely diagnosis?

A study is conducted to determine the efficacy of cervical cerclage to prevent preterm birth. Pregnant patients at 16 weeks’ gestation are enrolled, and their cervical length is measured transvaginally by ultrasonography. If cervical length is found to be less than 25 mm, the patient is offered cerclage or bed rest. Patients are observed until delivery, and outcome data are collected. Which of the following is the best description of this type of study?

A 67-year-old woman, gravida 5, para 5, is admitted to the hospital because of a 6-month history of increasingly severe abdominal pain and distention and difficulty eating. During the past 2 weeks, she has had increased abdominal girth. She also has had a 4-day history of nausea and vomiting. Ten years ago, she had breast cancer treated with bilateral mastectomy; she took tamoxifen therapy for 6 years. Her pulse is 68/min, respirations are 20/min, and blood pressure is 124/72 mm Hg. Breath sounds are decreased at the lung bases. The abdomen is distended, tense, and tender; there is a fluid shift. The genitalia are normal. On bimanual examination, a midline pelvic mass is palpated and several 1-cm nodules are palpated along the rectovaginal septum. Laboratory studies show:

Hemoglobin: 10.2 g/dL

Serum urea nitrogen: 10 mg/dL

Serum creatinine: 1 mg/dL

CA 125: 2270 U/mL (normal <35)

Following surgical removal of the masses, which of the following is the most appropriate next step in management?

A previously healthy 32-year-old woman comes to the physician because of a 3-month history of intermittent milky discharge from her breasts. During the past year, menses have occurred at irregular 15- to 32-day intervals. She takes no medications. Her mother and sister were diagnosed with pituitary tumors at the ages of 50 and 44 years, respectively; they also have increased serum calcium concentrations. The patient’s temperature is 36.9°C (98.4°F), pulse is 90/min and regular, respirations are 14/min, and blood pressure is 156/70 mm Hg. On examination, milky discharge is expressed from both breasts. The remainder of the examination, including funduscopic examination and visual field testing, shows no abnormalities. Serum studies show:

Na⁺: 140 mEq/L

K⁺: 3.9 mEq/L

Cl⁻: 109 mEq/L

Ca²⁺: 12.4 mg/dL

Urea nitrogen: 30 mg/dL

Glucose: 90 mg/dL

Creatinine: 1.2 mg/dL

Total protein: 9 g/dL

Albumin: 4.8 g/dL

Phosphorus: 2 mg/dL

Intact parathyroid hormone: 90 pg/mL (normal 10–65)

Prolactin: 140 ng/mL

β-hCG: <5 mIU/mL

In addition to bromocriptine therapy, which of the following is the most appropriate next step in management?

A 67-year-old man is brought to the emergency department because of a 20-minute history of palpitations, dizziness, and fatigue. He has hypertension controlled with hydrochlorothiazide and lisinopril. His pulse is 110/min and irregular, respirations are 18/min, and blood pressure is 126/70 mm Hg. Examination shows no other abnormalities. An ECG shows atrial fibrillation. Which of the following is the most appropriate next step in management?

An 82-year-old woman is brought to the emergency department 30 minutes after collapsing at a shopping center. She was intubated at the scene. On admission, she is comatose and requires mechanical ventilation. Her pulse is 120/min, respirations are 12/min, and blood pressure is 90/60 mm Hg. She does not respond to painful stimuli. Thirty minutes later, her granddaughter comes to the hospital and shows the physician an advance directive signed by the patient requesting no intubation or “artificial means to prolong life.” Which of the following is the most appropriate next step in management?

An 18-year-old woman comes to the physician because of a 3-day history of fatigue and yellow eyes. She has a history of mild anemia but is otherwise healthy. Her 16-year-old brother also has mild anemia. Her temperature is 36.7°C (98°F), pulse is 82/min, respirations are 14/min, and blood pressure is 105/60 mm Hg. There is scleral icterus. Examination shows multiple, 1-cm, cervical lymph nodes that are mildly tender.

Hemoglobin: 8.6 g/dL

Mean corpuscular hemoglobin concentration: 38% Hb/cell

Reticulocyte count: 8%

Serum total bilirubin: 3 mg/dL

A direct antiglobulin (Coombs) test is negative. A blood smear is shown. Which of the following is most likely to have prevented this patient’s current symptoms?

 An 8-year-old boy is brought to the physician 1 hour after the sudden onset of facial swelling. He has had an upper respiratory tract infection and sore throat for the past 2 days. He has a history of six similar episodes since birth requiring hospitalization; two of the episodes required endotracheal intubation. All episodes presented the same except for one episode of facial swelling that began after he fell and cut his lip. He has no known allergies. His father, several paternal aunts, and some paternal cousins have had similar episodes. He appears anxious, and his voice is hoarse. His axillary temperature is 36.9°C (98.4°F), pulse is 110/min, respirations are 28/min, and blood pressure is 120/84 mm Hg. Examination shows edema of the lips and tongue; there is no tenderness, erythema, pain, or itching. Mild inspiratory stridor is heard. Which of the following serum studies is most likely to be abnormal?

A 62-year-old man is brought to the emergency department 4 hours after the sudden onset of vomiting and severe abdominal pain. During the past year, he has had mild, intermittent epigastric pain, which is relieved with antacid use. He has no history of serious illness. He has smoked one and one-half packs of cigarettes daily for 35 years. He drinks one to two alcoholic beverages daily. He appears diaphoretic and is in acute distress. His temperature is 38.4°C (101.1 °F), pulse is 100/min, respirations are 18/min, and blood pressure is 115/75 mm Hg. The abdomen is rigid and tympanitic to percussion over the liver. There is severe diffuse tenderness. Bowel sounds are absent. Which of the following is the most appropriate next step in diagnosis?

 A 6-year-old boy is brought to the physician by his parents because of a 3-day history of progressive pain, swelling, and redness around his right eye. The swelling began on his right upper eyelid and has now spread to the whole eye. He says that it hurts when he moves his eyes. He also has had fever and headache during this period. He has a 2-week history of cough and nasal congestion. He takes no medications. Immunizations are up-to-date. His temperature is 38.1°C (100.6°F), pulse is 110/min, respirations are 22/min, and blood pressure is 130/70 mm Hg. Examination shows exophthalmos of the right eye; the upper and lower eyelids are erythematous and edematous. The erythema does not extend beyond the superior orbital rim. He cannot fully abduct his right eye on lateral gaze. The remainder of the examination shows no abnormalities. A CT scan of the head is shown. Which of the following is the most likely diagnosis?

A 47-year-old woman comes to the physician for a routine health maintenance examination. She has a 2-year history of venous insufficiency and notes daily swelling of her ankles that worsens in the evening. She takes no medications. Her pulse is 80/min, and blood pressure is 160/100 mm Hg. Cardiopulmonary examination shows no abnormalities. Examination of the lower extremities shows 2+ edema and increased pigmentation. Which of the following antihypertensive drugs would most likely exacerbate this patient’s swelling?

An asymptomatic 37-year-old woman comes to the physician for a routine health maintenance examination. She has a history of asthma exacerbated by nonsteroidal anti-inflammatory drugs. She has smoked two packs of cigarettes daily for 20 years. Her current medications include inhaled isoetharine and an oral contraceptive. She is 152 cm (5 ft) tall and weighs 50 kg (110 lb); BMI is 22 kg/m2. Her blood pressure is 140/88 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate recommendation to prevent stroke in this patient?