CK- NBME 12 – Block 3

A 57-year-old man comes to the emergency department because of a 3-week history of headaches that have been increasing in severity and frequency. He also has a 2-week history of progressive blurred vision in both eyes. He has not had pain in the eyes. His last visit to a physician was 10 years ago because of pain in his fingers; at that visit, he was told he had high blood pressure. His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 12/min, and blood pressure is 200/110 mm Hg. Repeat blood pressure measurements are 210/112 mm Hg and 214/114 mm Hg. Findings on funduscopic examination are shown. Examination shows ulnar deviation of both hands and several swollen interphalangeal joints. His fasting serum glucose concentration is 160 mg/dL. Which of the following is the most likely underlying cause of this patient’s symptoms?

A case-control study is conducted to assess the effect of dietary fat intake on the occurrence of sudden cardiac death. One hundred fifty cases and controls are matched by age, sex assigned at birth, race, and history of hypertension, hypercholesterolemia, and cigarette smoking. Dietary intake history of the cases is obtained from the next of kin. Results show an odds ratio of 1.6 with a 95% confidence interval of 1.2 to 1.9. The authors conclude that there is a relationship between dietary fat intake and sudden cardiac death. Which of the following raises the most concern about the authors’ conclusion?

A 67-year-old woman comes to the physician because of a 2-month history of hoarseness. She has not had any other symptoms. She has no history of serious illness and takes no medications. She has smoked one pack of cigarettes daily for 45 years. Examination, including examination of the oropharynx, shows no abnormalities. Which of the following is the most appropriate next step in management?

A 57-year-old man is admitted to the hospital because of fever, shortness of breath, and cough productive of yellow sputum. He has prostate cancer metastatic to the bone; his only symptom from the cancer is occasional back pain well controlled with oral acetaminophen and hydrocodone. At his last appointment 6 months ago, his serum prostate-specific antigen assay was stable, and his disease had not progressed. He plays golf several times each week and enjoys traveling with his wife. His advance directive states that he does not want intubation or mechanical ventilation unless he has an acute illness with a reasonable chance of recovery to a good quality of life. He is lethargic and unable to communicate. His temperature is 38.9°C (102°F), pulse is 100/min, respirations are 30/min, and blood pressure is 148/92 mm Hg. Pulmonary examination shows shallow, rapid breathing. He is using accessory muscles of respiration. Inspiratory crackles are heard at the right upper and lower lung fields. Arterial blood gas analysis on 100% oxygen shows:

An x-ray of the chest shows diffuse right-sided infiltrates. Which of the following is the most appropriate next step in management?

A 77-year-old man comes to the physician because of a 3-day history of passing air and fecal material during urination. He has a long-standing history of intermittent constipation. His last examination was 20 years ago. He has smoked two packs of cigarettes daily for 55 years. He is 183 cm (6 ft) tall and weighs 70 kg (155 lb); BMI is 21 kg/m2. Vital signs are within normal limits. Abdominal examination shows mild distention. Bowel sounds are decreased. Rectal examination shows a diffusely enlarged prostate. There is no stool in the rectal vault. Laboratory studies show:

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

A 25-year-old man comes to the physician 2 hours after the sudden onset of sharp right buttock pain that radiates to the back of his knee. The pain worsens when he sits for a prolonged period or drives. He is able to walk. Use of over-the-counter ibuprofen has provided mild relief. He has no history of serious illness and takes no other medications. On examination, ipsilateral and contralateral straight-leg raise testing is positive. Muscle strength is normal throughout. Sensation is intact throughout. Which of the following is the most appropriate next step in diagnosis?

A 16-year-old girl is brought to the physician by her mother because of an 8-month history of irregular menstrual periods, acne, and facial hair. Menarche was at the age of 12 years. Menses occur at irregular 35- to 42-day intervals; they last 1 week, and the flow is heavy. Moderate cramps on the first 2 days are relieved with ibuprofen therapy. The patient had recurrent urinary tract infections until the age of 10 years. She has no other history of serious illness and takes no other medications. She is 163 cm (5 ft 4 in) tall and weighs 77 kg (170 lb); BMI is 29 kg/m2. Her temperature is 36.9°C (98.4°F), pulse is 78/min, respirations are 20/min, and blood pressure is 128/84 mm Hg. Examination shows scattered papules, pustules, and comedones over the face. There is sparse, coarse hair over the chin. The neck is supple; there is no thyromegaly. Breast examination shows no masses. Breast and pubic hair development are sexual maturity rating (SMR) stage 5. Serum studies are most likely to show an increased concentration of which of the following?

A 49-year-old woman comes to the physician for preoperative examination before she undergoes cholecystectomy. During the past 3 years, she has had recurrent cholecystitis and multiple gallstones. She has not had shortness of breath, difficulty swallowing, or hoarseness. She has rheumatoid arthritis with morning stiffness and widespread joint swelling. Her medications are methotrexate, folic acid, and prednisone. Vital signs are within normal limits. Examination shows nodules over the extensor aspect of the upper extremities. There is swelling of the wrists, metacarpophalangeal joints of the hands, and knees; there are swan neck deformities of the fingers. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management to decrease this patient’s risk for operative complications?

A 32-year-old woman, gravida 1, para 1, comes to the physician because of spontaneous discharge from her nipples during the past 3 months. She discontinued breast-feeding her child 1 year ago. She takes no medications. Menses occur at regular 28-day intervals. On physical examination, a milky white discharge can be expressed from both nipples. Examination shows no other abnormalities. Her fasting serum prolactin concentration is 40 ng/mL. The most appropriate next step in diagnosis is measurement of which of the following serum concentrations?

A 57-year-old man comes to the physician for a follow-up examination. One year ago, he sustained a myocardial infarction. He has coronary artery disease, hypertension, and type 2 diabetes mellitus. His medications are atorvastatin, lisinopril, metformin, metoprolol, and aspirin. He has smoked one-half pack of cigarettes daily for 25 years. He is 178 cm (5 ft 10 in) tall and weighs 97 kg (213 lb); BMI is 31 kg/m2. He feels well. His pulse is 62/min, and blood pressure is 145/78 mm Hg. Examination shows no other abnormalities. Laboratory studies show a hemoglobin A1c of 6.5% and serum LDL-cholesterol concentration of 110 mg/dL. Serum electrolyte, urea nitrogen, glucose, and creatinine concentrations are within the reference ranges. The physician recommends smoking cessation. Addition of which of the following is the most appropriate next step in pharmacotherapy?

A 60-year-old woman with osteoarthritis of the right knee comes to the office to discuss treatment options, including total knee replacement. Medications are naproxen and 81-mg aspirin. Vital signs are within normal limits. Examination shows edema of the right knee; range of motion of the right knee is decreased. Results of laboratory studies are within the reference ranges. The patient asks the physician about the success and complication rates associated with total knee replacement at the local university hospital. Which of the following types of studies is most appropriate for the physician to reference to answer this patient’s question?

A 72-year-old woman comes to the office with her son because of a “strange mole” on her back that she first noticed 6 months ago. The patient’s son says he thinks it has enlarged during the past month. The patient says the mole is mildly itchy but not painful, and she has not had bleeding from the area. She has not had any weight loss or changes in appetite. Medical history is unremarkable, and she takes no medications. The patient has spent a lot of time outside by her son’s new swimming pool during the past summer months. Vital signs are within normal limits. A photograph of the lesion is shown. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate diagnostic study at this time?

A 27-year-old woman is brought to the emergency department because of a 2-day history of fever, pain with urination, and progressive generalized weakness. She has systemic lupus erythematosus complicated by nephritis. Current medications include prednisone and cyclophosphamide. Her temperature is 39.4°C (103°F), pulse is 122/min, respirations are 24/min, and blood pressure is 88/62 mm Hg. Examination shows warm, flushed skin. There is moderate suprapubic and right flank tenderness. Her leukocyte count is 18,000/mm3 (80% segmented neutrophils, 5% bands, 1% eosinophils, 1% basophils, 10% lymphocytes, and 3% monocytes). Urinalysis shows 100 WBC/hpf. A Gram stain shows numerous gram-negative rods. Intravenous administration of piperacillin and tazobactam and 2 liters of 0.9% saline is started. Thirty minutes later, her pulse is 124/min, and blood pressure is 92/68 mm Hg. Which of the following is the most appropriate next step in management?

A 72-year-old man comes to the physician because of a 3-month history of progressive shortness of breath, nonproductive cough, and fatigue. During this period, he has had early satiety resulting in a 2.3-kg (5-lb) weight loss. He has no known sick contacts. He has a 20-year history of chronic obstructive pulmonary disease and a 10-year history of hypertension. Current medications are an inhaled bronchodilator and an oral thiazide diuretic. He has smoked one pack of cigarettes daily for 50 years. He is in mild respiratory distress. He is 165 cm (5 ft 5 in) tall and weighs 52 kg (115 lb); BMI is 19 kg/m2. His temperature is 37°C (98.6°F), pulse is 103/min, respirations are 20/min, and blood pressure is 130/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 87%. Examination shows no scleral icterus. There is jugular venous distention. Breath sounds are distant. There is a right ventricular heave and a loud S2. A grade 2/6 systolic murmur is heard best over the left sternal border. The liver is tender, smooth, and pulsatile. There is no peripheral edema. His hematocrit is 50%, leukocyte count is 4500/mm3, and platelet count is 200,000/mm3. Which of the following is the most appropriate next step in management?

Four days after admission to the hospital for treatment of a myocardial infarction, a 72-year-old woman has the sudden onset of shortness of breath and confusion. She has atrial fibrillation, type 2 diabetes mellitus, essential hypertension, and hypercholesterolemia. Her medications are diltiazem, quinapril, metformin, and simvastatin. She has smoked one pack of cigarettes daily for 50 years and has drunk one glass of wine daily for 52 years. She is anxious and oriented to person but not to place or time. Her temperature is 35°C (95°F), pulse is 116/min and irregularly irregular, respirations are 30/min, and blood pressure is 92/58 mm Hg. Pulse oximetry on 100% oxygen by face mask shows an oxygen saturation of 91%. The skin is cool to the touch. Examination shows jugular venous distention. Decreased breath sounds are heard in the lung bases bilaterally. Scattered expiratory wheezes and crackles are heard bilaterally. A rub is heard in the lower lobe of the left lung. There is 2+ pretibial and pedal edema bilaterally. Laboratory studies show:

Arterial blood gas analysis shows:

An ECG is shown. A chest x-ray shows cardiomegaly and pulmonary infiltrates, and pleural effusions bilaterally. Which of the following is the most appropriate next step in diagnosis?

A 2-month-old girl is brought to the clinic by her mother for a well-child examination. The mother says her daughter is exclusively breast-fed; it takes 1 hour to complete a feeding, and her daughter sweats during feedings. The patient is at the 10th percentile for weight; she was at the 50th percentile at her last examination 6 weeks ago. Other growth parameters have remained stable at the 50th percentile. Vital signs are within normal limits. The lungs are clear to auscultation. On cardiac examination, a grade 3/6 systolic murmur is heard best at the lower left sternal border. The liver edge is palpated 5 cm below the right costal margin. Which of the following is the most likely cause of this patient’s failure to thrive?

A 67-year-old man comes to the emergency department because of a 12-hour history of increasingly severe generalized, cramping pain that began in his left groin and spread to his abdomen. The patient rates the pain as a 10 on a 10-point scale. He previously has noted a hernia in the left groin area. He says, “Normally I can push it back in, but this time I couldn’t. I was going to wait and make an appointment with my primary care doctor, but I couldn’t tolerate the pain.” He has hypertension treated with verapamil and hydrochlorothiazide. The patient appears uncomfortable. Temperature is 37.4°C (99.3°F), pulse is 96/min, respirations are 20/min, and blood pressure is 140/95 mm Hg. Cardiac examination discloses an S4 gallop. Bowel sounds are increased, and the abdomen is soft with moderate, diffuse tenderness. A tender mass is present in the left groin extending into the scrotal sac, and the skin overlying the groin is erythematous. Results of laboratory studies are shown:

The physician contacts the on-call surgeon to see the patient. The surgeon instructs the physician to attempt reduction of the hernia and to call back if unsuccessful. Which of the following is the most appropriate next step in management?

A 55-year-old man comes to the office because of a 2-month history of moderate right shoulder pain. The patient says the pain occurs whenever he raises his right arm straight up in front of him or up from his side. He also reports decreased strength in his right shoulder. He says he injured his right shoulder 35 years ago during a college football game when he was hit by another player and landed shoulder-first on the ground. After the injury, he had pain in the shoulder that resolved in 3 days without treatment. He has not had any subsequent injuries to the shoulder. Medical history otherwise is unremarkable, and he takes no routine medications. Vital signs are normal. Physical examination discloses inability to resist downward pressure on the right arm when it is held straight out in front with the thumb pointing downward. Which of the following imaging studies of the right shoulder is most likely to confirm the diagnosis?

A 25-year-old woman is brought to the emergency department 45 minutes after the onset of dizziness. Her symptom began after she consumed 1800 mL of water during a contest in which participants tried to drink the most water in 15 minutes. She has no history of serious illness and takes no medications. On arrival, she is alert and fully oriented. Her pulse is 88/min and regular, respirations are 16/min, and blood pressure is 110/80 mm Hg. Examination, including neurologic examination, shows no abnormalities. Laboratory studies show:

Administration of which of the following is the most appropriate next step in management?

A previously healthy 57-year-old man is brought to the emergency department immediately after being involved in a head-on motor vehicle collision. He was the driver and was wearing a seat belt with a shoulder strap. On arrival, he is alert and oriented to person, place, and time. He says that he does not think he had loss of consciousness but feels sore all over his body. His temperature is 36.7°C (98°F), pulse is 100/min, respirations are 14/min, and blood pressure is 140/70 mm Hg. Pulse oximetry on 2 L/min of oxygen via nasal cannula shows an oxygen saturation of 99%. Physical examination and an ECG show no abnormalities. A chest x-ray is shown. Which of the following is the most likely diagnosis?