NBME 14 – Block 2 (Duplicate Quiz)

A 24-year-old woman, gravida 1, para 1, comes to the physician because she has not had a menstrual period for 12 months and has been unable to conceive during this time. Her son was born by spontaneous vaginal delivery 18 months ago, and she breast-fed him for 6 months. One month after delivery, she had profuse vaginal bleeding and underwent emergency dilatation and curettage for retained placental fragments. She has not used any contraception since her delivery and currently takes no medications. She and her husband have sexual intercourse twice weekly. Analysis of the husband’s semen has shown no abnormalities. The patient’s vital signs are within normal limits. Physical examination shows no abnormalities. Pelvic examination shows a normal cervix, uterus, and adnexa. Laboratory studies show:

Pelvic ultrasonography shows normal ovaries, no free fluid in the pelvis, and no distinct endometrial stripe. Treatment with oral progesterone for 10 days produces no uterine bleeding. Which of the following is the most appropriate next step in management?

A previously healthy 7-year-old boy is brought to the office because of a 1-week history of diffuse, mild abdominal pain and bloody diarrhea. He has a constant urge to pass stools despite passing 10 small, bloody stools daily. During this time, he has had decreased oral intake. He last urinated 12 hours ago. He has not had fever or vomiting. No other family members are ill. The patient appears tired. His temperature is 37.7°C (99.8°F), pulse is 120/min, respirations are 26/min, and blood pressure is 120/85 mm Hg. Examination shows pallor and tacky mucous membranes. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard. The abdomen is soft and diffusely tender to palpation; there is no guarding or rebound. Examination of the perianal area shows no abnormalities. Laboratory studies show:

Which of the following is the most likely infectious agent?

A 42-year-old woman is brought to the emergency department by paramedics 30 minutes after she was struck by a car while she was riding her bicycle. She has no history of serious illness and takes no medications. She is alert and fully oriented. She has moderate left upper abdominal and flank pain. Temperature is 37.1°C (98.8°F), pulse is 118/min, respirations are 24/min, and blood pressure is 88/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. There is a 5 × 7-in, tender ecchymosis over the left upper abdominal quadrant and left flank. Bowel sounds are normal. The remainder of the physical examination shows no abnormalities. Neurologic examination shows no focal findings. After administration of 2 L of lactated Ringer solution, pulse is 105/min, and blood pressure is 95/70 mm Hg. Transfusion of 2 units of packed red blood cells is begun. Thirty minutes later, pulse is 80/min, and blood pressure is 124/80 mm Hg. Pulse oximetry on an Fio2 of 1.0 via nonrebreather face mask shows an oxygen saturation of 100%. CT scan of the abdomen shows a grade 3 splenic laceration. The patient is admitted to the surgical intensive care unit for nonoperative management. Three hours later, she has progressive difficulty breathing. Temperature is 37.2°C (99.0°F), pulse is 90/min, respirations are 30/min, and blood pressure is 110/70 mm Hg. Pulse oximetry now shows an oxygen saturation of 87%. On pulmonary examination, breath sounds and diffuse crackles are heard bilaterally. Heart sounds are normal. Abdominal examination is unchanged. Chest x-ray is shown. Which of the following is the most likely cause of this patient’s current condition?

A 77-year-old man with chronic obstructive pulmonary disease (COPD) comes to the physician for a follow-up examination. He had bronchitis 3 years ago treated with amoxicillin and prednisone. He has not been hospitalized during the past 3 years. He has a history of shortness of breath and cough but says these symptoms have subsided since he quit smoking cigarettes 5 years ago. His only medication is inhaled ipratropium. Pulmonary function testing shows an FVC of 85% of predicted and FEV1 of 75% of predicted. The patient says he heard about a new inhaled medication, called BreatheEZ, for management of COPD and asks if he would benefit from this medication. The physician recalls a recent randomized controlled trial evaluating the efficacy of BreatheEZ in 7500 patients with COPD. Patients were randomized to receive BreatheEZ or placebo and observed for 4 years. Data show:

Analysis shows a mortality rate of 12.2% for the patients receiving BreatheEZ and 15.4% for patients receiving placebo (hazard ratio of 0.79, 95% confidence interval of 0.63–0.98). Based on these data, which of the following is the most appropriate action regarding BreatheEZ for this patient?

A 15-year-old boy is brought to the office because of a 2-month history of increasingly frequent left lower thigh pain. The pain began after the patient injured his leg during a soccer game. He has no history of serious illness and takes no medications. Examination shows moderate tenderness of the lateral distal aspect of the left femur. His serum alkaline phosphatase activity is 550 U/L (N=130–525), and serum lactate dehydrogenase activity is 360 U/L (N=120–330). An x-ray of the left thigh is shown. In addition to an MRI of the left femur, which of the following is the most appropriate next step in diagnosis?

A 35-year-old man, who works as an orthopaedic surgeon, comes to the office because of a 1-day history of severe low back pain after lifting heavy furniture. He has no history of serious illness and takes no medications. He requests a prescription for oxycodone because he is scheduled to give a lecture at a national meeting tomorrow and is worried he will be in “too much pain” to participate without medication. Vital signs are within normal limits. Examination shows no abnormalities. Which of the following is the most appropriate next step in management by the physici

A 23-year-old man is brought to the emergency department after driving his automobile into a bridge abutment. Paramedics state that at the scene his blood pressure was 100/80 mm Hg, that he was alert, and that the steering wheel was broken. On examination in the emergency department now, he is stuporous, cyanotic, and hypotensive, and has distended neck veins. Breath sounds are absent bilaterally. The trachea is midline. Which of the following is the most appropriate initial management?

A 57-year-old man, who is an accountant, comes to the physician because of progressive shortness of breath during the past 6 months. He says he has difficulty breathing after walking more than one city block and when walking up one flight of stairs. He reports that during these episodes, he feels that he needs to breathe rapidly. He also has had a dry cough. He has not had chest pain, diaphoresis, nocturnal symptoms, or worsening of the symptoms when lying down. He has a 5-year history of hypertension treated with enalapril and hydrochlorothiazide. He has never smoked cigarettes. His temperature is 37°C (98.6°F), pulse is 89/min, respirations are 18/min, and blood pressure is 145/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Crackles are heard at both lung bases. A high-resolution CT scan of the chest shows a reticulogranular appearance at the bases bilaterally with minimal fibrosis. Pulmonary function tests show moderately severe decreased diffusion capacity. Examination of bronchoalveolar lavage fluid shows many segmented neutrophils that are negative for bacteria, fungi, and acid-fast bacilli. In addition to supplemental oxygen, administration of which of the following is the most appropriate next step?

A 57-year-old man comes to the physician because of severe right shoulder pain since having a generalized tonic-clonic seizure 3 days ago. He first noted the pain in the emergency department, where he was brought after the seizure. He reports no other history of shoulder pain or injury. He has a 40-year history of a seizure disorder treated with phenytoin; his only other medication is acetaminophen for shoulder pain. On examination, passive and active range of motion of the right shoulder elicits pain. External rotation of the right shoulder is limited to 10 degrees. An AP x-ray of the shoulder obtained in the emergency department 3 days ago showed no abnormalities. Which of the following is the most appropriate next step in management?