CK- NBME 12 – Block 2 (Duplicate 1)

A 47-year-old woman comes to the physician because of a 3-week history of moderate pain in her arms and legs. She states that her “bones ache” in all joints both at rest and with movement. She has hypertension, hyperlipidemia, and type 2 diabetes mellitus well controlled with diet. Current medications include hydrochlorothiazide and simvastatin. Her sister has Sjögren syndrome, and her mother has coronary artery disease. The patient does not smoke and drinks one glass of wine daily. Her blood pressure is 144/80 mm Hg. Cardiopulmonary examination shows no abnormalities. There is tenderness to palpation over the wrist, metacarpophalangeal, knee, and ankle joints. Clubbing of the fingers and toes is noted. A chest x-ray shows a left upper lobe mass with perihilar lymphadenopathy. X-rays of the tibia and fibula show periostosis. Which of the following is the most likely diagnosis?

A 58-year-old man with an 8-year history of schizoaffective disorder, manic type, is brought to the clinic for a follow-up examination. Two weeks ago, he was hospitalized for a manic episode. Risperidone was added to his medication regimen; the dosage was increased to the maximum recommended prior to discharge. At that time, neurologic examination showed mild cogwheel rigidity. There was no evidence of tremors. Muscle strength was 5/5. He has no other history of serious medical or psychiatric illness. His other medications are valproic acid and clonazepam. Today, examination shows drooling, masked facies, and decreased blinking. He has a slow, shuffling gait with decreased arm swing. The remainder of the examination shows no abnormalities. Mental status examination shows normal speech and a mildly anxious mood. There is no evidence of psychosis. Which of the following is the most appropriate next step in management?

A 67-year-old man with metastatic lung cancer comes to the physician because of malaise and lethargy during the past 3 days. Medications are ibuprofen and lisinopril. He appears cachectic but is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 102/min, respirations are 13/min, and blood pressure is 105/75 mm Hg. Examination shows decreased skin turgor. The remainder of the examination shows no abnormalities. Laboratory studies show:

Which of the following is the most appropriate initial pharmacotherapy?

A 47-year-old man is brought to the emergency department because of severe left groin pain since he fell 2 hours ago. He is unable to walk because of the pain. He does not have pain in other joints. He has a 20-year history of ulcerative colitis. His only medication is daily prednisone. On examination, any attempts at range of motion of the left hip elicit pain. Muscle strength is intact distally and in the right lower extremity. Distal pulses are 2+. An x-ray of the pelvis and left lower hip shows moderate loss of joint space and diffuse osteopenia. Which of the following is the most appropriate next step in management?

A 74-year-old woman is brought to the clinic by her family because of a 7-month history of progressive confusion and urinary incontinence. During the past year, she has had multiple falls; she sustained wrist fractures 1 year ago and a left tibia fracture 3 months ago. She has hypertension, osteoporosis, and depression. She is evasive when asked how much alcohol she drinks. She appears frail. Vital signs are within normal limits. Physical examination shows a wide-based gait and marked ataxia. She is unable to attempt the Romberg test. Cranial nerve examination shows nystagmus and an inability to move her eyes horizontally. On cognitive testing, she recalls zero of three objects after 5 minutes. Laboratory studies show:

Which of the following is the most likely diagnosis?

Eight days after he was involved in a motor vehicle collision in which he was the restrained driver, a hospitalized 28-year-old man has hypertension. He underwent extensive reconstructive orthopaedic operations for injuries to his left clavicle, shoulder, and femur and exploratory laparotomy for a ruptured spleen. Urine toxicology screening on admission was positive for Δ9-tetrahydrocannabinol, cocaine, and opiates. He was intubated and mechanically ventilated during the procedures and was extubated on hospital day 4. He receives oral acetaminophen-oxycodone as needed. His blood pressure has been 180/110 mm Hg; it decreases to 150/80 mm Hg when he receives his pain medication. An abdominal bandage covers the surgical incision. The nurse tells the physician that the patient rates his pain as a 10 on a 10-point scale and is constantly asking for pain medications. Which of the following is the most appropriate next step in pharmacotherapy for this patient’s hypertension?

A 37-year-old primigravid woman at 16 weeks’ gestation comes to the physician to discuss the results of amniocentesis. She has an IQ of 70. She is employed as a housekeeping assistant in a hotel and has been married to a coworker for 6 months. She has no family history of serious illness. Karyotype analysis of the fetus showed trisomy 21. Her pregnancy has been otherwise uncomplicated. She is informed of the abnormalities associated with the fetal genotype and still wants to continue the pregnancy. Which of the following is the most appropriate next step in management?

A 29-year-old male US Navy veteran comes to the local Veterans Affairs clinic because of a 2-week history of purulent drainage from a small opening at the site of amputation of his left arm. For the past 10 days, he has had increasing pain, tenderness, and redness at the wound site. Thirteen months ago, the patient sustained a traumatic amputation of the left arm below the elbow when an improvised explosive device detonated while he was on a combat mission in the Middle East. Management at that time consisted of aggressive surgical debridement of the residual limb, which has healed slowly; a small part of the wound appeared to heal incompletely. The patient appears well. Vital signs are within normal limits. Examination of the left upper extremity shows a 3-mm opening in the scar with surrounding erythema; the site is draining purulent material. The remainder of the examination shows no abnormalities. Which of the following studies is most likely to confirm the diagnosis?

A 2-year-old girl is brought to the physician because of a 2-week history of difficulty walking and intermittent crossing of the eyes. She also has had three to four episodes of watery diarrhea daily during this time. She has not had fever or vomiting. She has no history of serious illness and receives no medications. She is alert but irritable and tearful; she clings to her mother during the examination. She is at the 50th percentile for length, 25th percentile for weight, and 50th percentile for head circumference. Her pulse is 100/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. The abdomen is soft and nontender; a smooth, firm mass is palpated over the right upper quadrant. Neurologic examination shows rapid, chaotic, multidirectional saccades of the eyes. There are jerking motions of the extremities, which are exacerbated by intentional movement. There is truncal ataxia, and the patient is unable to sit or walk without assistance. Which of the following is the most likely underlying cause of this patient’s symptoms?

Three days after admission to the hospital for acute bacterial endocarditis, a 62-year-old man has shortness of breath that began 5 minutes ago while walking for the first time since admission. On admission, he had a 10-day history of fever; examination showed splinter hemorrhages and normal heart sounds without murmurs. His current pulse is 110/min, respirations are 24/min, and blood pressure is 100/50 mm Hg. Crackles are heard over both lung bases. S1 and S2 are soft; there is an S3. A new grade 2/6, early diastolic murmur is heard at the apex and the left sternal border, and a grade 4/6, systolic ejection murmur is heard best in the carotids and at the left sternal border. Which of the following is the most appropriate next step in management?

A study is proposed to investigate the effectiveness of a third-generation cephalosporin for the treatment of streptococcal pharyngitis. The study will include children between the ages of 5 and 10 years. They will be randomly assigned to receive treatment with a cephalosporin, penicillin, or a placebo. Informed consent will be obtained from one parent. The principal investigator offers a $50 finder’s fee to any medical resident who identifies a possible study participant. Which of the following features of this study is of greatest potential concern?

A 27-year-old woman comes to the physician for a follow-up examination. She has a 5-month history of temperatures to 38.3°C (101°F) and a cough productive of phlegm and mucous plugs. She has severe asthma treated with high doses of prednisone. She has had numerous visits to the emergency department since childhood because of uncontrolled symptoms. Expiratory wheezes are heard bilaterally. Laboratory studies show:

An x-ray of the chest shows patchy bilateral upper lobe infiltrates that have shifted in location since an x-ray was taken 4 months ago. A CT scan of the chest shows central bronchiectasis without lymphadenopathy. This patient is most likely to have an immediate response to which of the following on skin testing?

A 4-year-old boy undergoes splenectomy to control bleeding from injuries sustained in a motor vehicle collision. His postoperative course is uncomplicated, and he receives pneumococcal and meningococcal vaccinations in preparation for his discharge home. After discharge, which of the following is the most appropriate follow-up intervention to decrease this patient’s risk for subsequent infection?

A 22-year-old nulligravid woman with cystic fibrosis comes to the physician because she would like to conceive within the next year. She has not been hospitalized in the past 3 years. Her disease is well controlled with antibiotics, vigorous bronchial drainage, bronchodilators, and nutritional support including pancreatic enzyme replacement. She is 155 cm (5 ft 1 in) tall and weighs 38 kg (83 lb); BMI is 16 kg/m2. Her pulse is 96/min, and blood pressure is 138/86 mm Hg. Examination shows no other abnormalities except for a prolonged expiratory phase. Her husband is healthy and has no family history of cystic fibrosis. She should be told that she will most likely require which of the following during pregnancy?

A 6-month-old girl is brought to the emergency department by her parents because of a 2-day history of temperatures to 39.4°C (103.0°F), irritability, decreased oral intake, and vomiting. She has no history of serious illness and receives no medications. She has not received any vaccinations. She appears acutely ill and is lethargic. Temperature is 38.9°C (102.0°F), pulse is 170/min, respirations are 60/min, and blood pressure is 70/45 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Examination discloses a bulging fontanel and decreased responsiveness. Lumbar puncture is performed. Results of cerebrospinal fluid analysis are shown:

Broad-spectrum antibiotic and corticosteroid therapy is initiated. Which of the following is the most likely long-term complication of this patient’s condition?

A 16-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She is 147 cm (4 ft 10 in) tall and weighs 52 kg (115 lb); BMI is 24 kg/m2. Her temperature is 37.1°C (98.8°F), pulse is 70/min, respirations are 14/min, and blood pressure is 110/60 mm Hg. Breast and pubic hair development is sexual maturity rating stage 1, and there is scant axillary hair. Pelvic examination shows no abnormalities. Her serum follicle-stimulating hormone concentration is 62 mIU/mL. Which of the following is the most appropriate next step in management?

A 7-year-old boy is brought to the physician because of a 4-day history of a dry, mildly itchy rash. The rash began as a small, pink, oval area on his chest and progressed to scaly, red patches over his arms, legs, and body. His mother applied calamine lotion and a topical corticosteroid cream without relief. He is currently taking amoxicillin for streptococcal pharyngitis diagnosed 4 days ago. He has no other history of rash or serious illness. He is alert and cooperative and in no acute distress. The pharynx is pink, and the tonsils are slightly enlarged with no exudate. The neck is supple with no adenopathy. A photograph of the rash over the trunk is shown. Which of the following is the most likely diagnosis?

A 3-month-old girl is brought to the physician because of constipation. She was born at home at term following an uncomplicated pregnancy and weighed 3118 g (6 lb 14 oz). She has not had routine well-child examinations. She is unable to hold her head up, does not roll over, and does not smile. She is at the 10th percentile for length, 5th percentile for weight, and 75th percentile for head circumference. The posterior fontanel is 2 cm in diameter. The tongue is large and protuberant. Which of the following is most likely to confirm the diagnosis?

A 32-year-old man comes to the office for a routine examination. He was diagnosed with HIV infection 7 years ago and began antiretroviral therapy 6 years ago. He received the appropriate immunizations at the time of diagnosis. He has tolerated his medication regimen well. He used illicit intravenous drugs for 5 years but stopped 7 years ago. He is in a monogamous relationship with one female partner; they use condoms consistently. Examination shows no abnormalities. His CD4+ T-lymphocyte count is 645/mm3 (Normal≥500), and plasma HIV viral load is 1000 copies/mL. Which of the following immunizations is most appropriate to administer at this time?

A 24-year-old man with protein C deficiency comes to the physician because of a 1-week history of yellowing of his skin. Three months ago, he had a mesenteric infarction and required resection of all but 45 cm of the proximal small bowel. The remainder of the jejunum was anastomosed to the colon. He receives total parenteral nutrition at home. He takes no medications. Examination today shows generalized jaundice. Laboratory studies show:

Which of the following is the most likely cause of this patient’s hyperbilirubinemia?