CK- NBME 12 – Block 2

A 22-year-old woman comes to the physician because of a 2-day history of severe shortness of breath. Over the past week, she has been taking ibuprofen for fever, chills, and muscle pain. She has no history of serious illness and takes no other medications. Her temperature is 38.4°C (101.1°F), pulse is 105/min and irregular, respirations are 28/min, and blood pressure is 70/50 mm Hg. Examination shows jugular venous distention. Crackles are heard throughout both lung fields. An S3 gallop is heard. Pulses are decreased in the upper and lower extremities. An x-ray of the chest shows cardiomegaly and perihilar fluid. An ECG shows frequent premature ventricular contractions. Echocardiography shows cardiomegaly with normal valve function and an ejection fraction of 18%; her estimated cardiac output is 1.4 L/min (N=4–5). Which of the following is the most likely diagnosis?

A study is conducted to determine if a hemoglobin A1c greater than 15% predicts diabetic retinopathy. Results show that 88% of all patients without diabetic retinopathy had a hemoglobin A1c below 15%. Which of the following is the most accurate interpretation of these results?

A 13-year-old girl is brought to the physician by her mother because of a 3-day history of pain and pressure in her face, itchy eyes, and decreased hearing in both ears. She has not had fever, chills, muscle pain, or nausea. Acetaminophen has not relieved her symptoms. She takes no other medications. One year ago, she had a similar episode and was successfully treated with azithromycin therapy at an urgent care center, and her mother requests another prescription for azithromycin. The patient’s two brothers have well-controlled asthma. Her vital signs are within normal limits. Examination shows a supple neck with a few shotty lymph nodes in the upper cervical chain. The conjunctivae have a cobblestone appearance. The inferior nasal turbinates are edematous. The tympanic membranes are injected bilaterally. There is moderate mucus in the posterior pharynx. The tonsils are not enlarged. The lungs are clear to auscultation. Which of the following is the most appropriate next step in management?

A 76-year-old woman is scheduled to undergo right knee arthroscopy at an ambulatory surgery center. Before the procedure begins, the surgical team confirms the identity of the patient, the procedure being performed, the side and site of the procedure, the patient’s position, and the availability of needed equipment. The procedure is then completed without complications, and the patient is discharged home 4 hours later. Which of the following is most likely increased at this center as a result of the pre-procedure actions of the surgical team?

Immediately after extubation following a total thyroidectomy, a 72-year-old woman has stridor and shortness of breath. She has a history of transient ischemic attacks and coronary artery disease. Her only medication is aspirin. She appears to be in distress and is gasping for air. Her pulse is 100/min, respirations are 35/min, and blood pressure is 170/100 mm Hg. Examination shows an intact surgical incision and no ecchymosis. Breath sounds are decreased bilaterally. Arterial blood gas analysis on 40% oxygen by face mask shows:

Which of the following is the most likely diagnosis?

A 46-year-old man with hypertension comes to the physician for a routine examination. When the physician enters the room, the patient says the office staff were talking about him in the waiting room. The patient has declined antihypertensive therapy in the past; today, he declines it again, saying “it does not matter because the world is going to end soon.” He does not drink alcohol or use illicit drugs. He lives alone and has minimal contact with his family. He says he has one friend and spends his free time playing video games. He works at home for an accounting firm. He appears fearful and older than his stated age. He wears an overcoat and woolen hat although the outside temperature is 80°F. His pulse is 80/min and regular, and blood pressure is 140/98 mm Hg. Limited physical examination shows no abnormalities. On mental status examination, he has a euthymic mood and odd affect. He makes minimal eye contact with the physician and appears anxious when questioned. He says he has not had anxiety or changes in mood. Cognition is intact, and answers to questions are appropriate. His thought process is linear. He reports no hallucinations. Results of laboratory studies are within the reference ranges. Which of the following is the most likely diagnosis?

A 4-year-old girl is brought to the office by her mother because of a 1-week history of vaginal itching. The mother says her daughter is scratching her vaginal area frequently and the area appears irritated. The patient has not had fever, pain with urination, or urinary frequency. She has been toilet-trained for 1 year. The mother is not concerned about sexual abuse. When questioned alone, the patient says that no one has touched her inappropriately. Examination shows erythema of the vaginal area. There is no vaginal discharge, foul odor, bleeding, tears, or ecchymoses. Which of the following is the most appropriate next step in management?

An 87-year-old man comes to the physician because of a 2-day history of visual changes in his right eye. He notices that the lines of his daily crossword puzzle look curved, and the blinds in his apartment appear wavy. He wears magnifying lenses for reading. There is no pain in his eye, no photophobia, and no history of trauma to the area. He had cataract removal from the right eye 5 years ago. There is no history of serious illness. On examination, visual acuity is 20/200 in his right eye and 20/100 in his left eye. The right pupil is irregular, but it is reactive to light. The left pupil is round and reactive. This examination finding is unchanged since his cataract operation. Palpation of both globes through closed eyelids shows no abnormalities. His lenses appear clear. Which of the following is the most appropriate next step in diagnosis?

A 27-year-old woman comes to the office for a health maintenance examination. She says she feels well. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Examination shows no lymphadenopathy. A 2-cm nodule is palpated in the left lobe of the thyroid gland. The remainder of the examination shows no abnormalities. Results of laboratory studies, including measurement of serum thyroid-stimulating hormone concentration, are within the reference ranges. Which of the following is the most appropriate next step in management?

A healthy 16-year-old girl comes to the physician for a school physical examination. She is sexually active with one partner and does not use contraception. She has smoked one pack of cigarettes daily for 2 years. She is 163 cm (5 ft 4 in) tall and weighs 70 kg (156 lb); BMI is 27 kg/m2. Physical examination shows no abnormalities. Which of the following behavioral modifications is most likely to have the greatest impact on mortality in this patient during the next 10 years?

An 82-year-old woman who resides in a skilled nursing care facility is transferred to the hospital because of a 2-day history of fever and cellulitis of the left side of her face. She is hemiparetic, aphasic, and unable to swallow. She is fed through a gastrostomy tube. She has congestive heart failure, type 2 diabetes mellitus, hypertension, hyperlipidemia, major depressive disorder, and osteoporosis. Her medications are furosemide, metoprolol, digoxin, glyburide, lisinopril, carvedilol, atorvastatin, amitriptyline, alendronate, and 81-mg aspirin. She appears ill and moans frequently. Her temperature is 39.1°C (102.4°F), pulse is 84/min, respirations are 24/min, and blood pressure is 112/72 mm Hg. A firm, exquisitely tender mass is palpated from the left cheek to the angle of the mandible; this area is also erythematous and edematous. The left pinna appears normal, and the otic canal is not inflamed. The mouth is dry. Bilateral basilar crackles are heard. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The gastrostomy tube is in place with no inflammation. Her leukocyte count is 28,000/mm3 (78% segmented neutrophils, 18% bands, and 4% lymphocytes), and serum glucose concentration is 168 mg/dL. A chest x-ray shows cardiomegaly; there are bilateral basilar increased markings and atelectasis in the left lung base but no focal infiltrates. Which of the following is the most likely cause of this patient’s fever?

A hospitalized 42-year-old man has chills and a temperature of 38.3°C (101°F) 1 hour after transfusion of packed red blood cells for treatment of anemia secondary to a bleeding duodenal ulcer. He has never received a blood transfusion in the past. He has no known allergies. He is pale and flushed. He is 178 cm (5 ft 10 in) tall and weighs 79 kg (175 lb); BMI is 25 kg/m2. His pulse is 98/min and regular, and blood pressure is 128/82 mm Hg. Examination shows no abnormalities. The most appropriate next step in management is administration of which of the following?

A 77-year-old woman comes to the office because of a 1-year history of frequent urinary incontinence during the day and at night. The incontinence is not associated with coughing or sneezing, and she does not have urinary urgency before the episodes. She has not had pain with urination or vaginal discharge. She has a 10-year history of type 2 diabetes mellitus well controlled with metformin. Her other medications are atorvastatin and lisinopril. Examination shows some wetting of an absorbent pad that she is wearing. Results of laboratory studies are shown:

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

A 71-year-old man is brought to the emergency department because of a 1-week history of increasingly severe pain in his left third toe. During the past 36 hours, he has not slept because of the pain. He has coronary artery disease, hypertension, and hyperlipidemia. Six years ago, he had a myocardial infarction. He has never undergone an operation. His medications are ramipril, labetalol, and aspirin. Acetaminophen and ibuprofen have provided no pain relief. He smoked one pack of cigarettes daily for 40 years but quit 6 years ago. He appears uncomfortable. His pulse is 84/min, and blood pressure is 170/90 mm Hg. A 4-cm, pulsatile, nontender mass is palpated in the left inguinal region. The left third toe is necrotic and exquisitely tender to palpation; there is no erythema or drainage. Pedal pulses are 2+ on the left. The remainder of the examination shows no abnormalities. A CT scan of the abdomen and pelvis is shown. In addition to intravenous analgesic therapy, which of the following is the most appropriate next step in management?

A 37-year-old woman comes to the physician requesting assistance in applying for disability income. She fell at home 12 months ago and left her job at a day-care center because of subsequent low back pain. She received the diagnosis of major depressive disorder 8 months ago; her sleep, appetite, and mood have improved with citalopram therapy. Her only other medication is ibuprofen. She asks the physician to document a permanent and total disability on an application form for disability income so that she will have the financial resources to start college education on a full-time basis. She explains that she will become depressed again if she resumes her stressful job as a child-care provider. She does not appear to be in distress. She is 157 cm (5 ft 2 in) tall and weighs 68 kg (150 lb); BMI is 27 kg/m2. Her temperature is 37°C (98.6°F), pulse is 64/min, and blood pressure is 108/60 mm Hg. Examination of the back shows no tenderness; range of motion of the lumbar spine is full. Neurologic examination shows no abnormalities. The physician will not fill out the form. In addition to informing the patient, which of the following is the most appropriate next step in management?

A 67-year-old woman comes to the physician because of a 1-year history of a nonproductive cough and progressive shortness of breath with exertion. Her symptoms were not a problem at first, but she now has trouble walking her dog because of shortness of breath after walking one-half block. She has not had fever or any other symptoms. She has no history of serious illness and takes no medications. She does not smoke. She retired from her position as an executive secretary 5 years ago. Vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination shows no cyanosis. Fine, dry crackles are heard at both lung bases. Examination of the hands shows clubbing. There is no peripheral edema. A chest x-ray shows fine linear opacities in the lower third of the lungs bilaterally. A CT scan of the chest confirms an interstitial pattern. Pulmonary function tests show an FVC of 48% of predicted and a diffusion capacity of the lung for carbon monoxide of 55% of predicted. Which of the following is the most appropriate next step in diagnosis?

A 2-year-old boy is brought to the physician for a follow-up examination 2 weeks after being treated for an ear infection. He has been treated for six episodes of acute otitis media and one episode of pneumonia since birth. Three months ago, he underwent placement of tympanostomy tubes. He currently takes no medications. He appears well. He is at the 75th percentile for length and 25th percentile for weight. Examination shows several 0.5- to 1-cm, firm, nontender, mobile lymph nodes in the anterior cervical chain. Tympanostomy tubes are in place bilaterally without discharge. Laboratory studies show:

Which of the following is the most appropriate next step in management?

A 42-year-old woman comes to the physician because of nausea and vomiting and abdominal cramping and swelling over the past 12 hours. She takes an oral contraceptive. She underwent an appendectomy 5 years ago. Abdominal examination shows distention and moderate tenderness without guarding. An x-ray of the abdomen is shown. Which of the following is the most likely diagnosis?

A 17-year-old boy is brought to the emergency department by his mother because of a 20-minute episode of severe chest pain and sweating that started 1 hour ago while he was watching television. On arrival, he is alert and repeatedly expresses concern that something is “very wrong.” He reports that during the episode, his heart was “pounding,” he felt short of breath, and he was sure he was having a heart attack and was going to die. One month ago, he had a similar episode that occurred in the evening 30 minutes after his high school football practice. At that time, results of laboratory studies and an ECG obtained in the emergency department showed no abnormalities. After the initial episode, he quit the football team, and he has continued to limit his physical activity because he is afraid of bringing on another episode. He reports no insomnia or changes in appetite. His mother states that he was diagnosed with an innocent heart murmur at the age of 6 months, but it has not been noted on examinations since the age of 1 year. His paternal grandfather died of a myocardial infarction 3 years ago at the age of 68 years. The patient takes no medications. He does not smoke cigarettes, drink alcohol, or use illicit drugs. He performs well in school. He is 180 cm (5 ft 11 in) tall and weighs 73 kg (161 lb); BMI is 23 kg/m2. His temperature is 37.0°C (98.6°F), and blood pressure is 130/83 mm Hg. No murmurs are heard on cardiac examination. The remainder of the examination shows no abnormalities. ECG is shown. Which of the following is the most likely diagnosis?

A 72-year-old man comes to the physician for a routine health maintenance examination. Abdominal examination shows a nontender, pulsatile mass in the epigastrium. Abdominal ultrasonography shows a 7.2-cm aneurysm. The physician reviews several studies of patients with abdominal aneurysms that are greater than 7 cm in size. The rupture rate is estimated to be 20% per year. Following rupture of an abdominal aneurysm, one half of patients die before reaching a hospital. For patients who do reach a hospital, the perioperative mortality rate is approximately 50%. The mortality rate for patients who undergo elective repair of an aneurysm is 5%. After discussing the risks and benefits of surgical repair of the aneurysm, the patient decides not to undergo an operation. Which of the following best represents this patient’s risk for mortality from rupture of the aneurysm during the next year?