NBME 15- Block 1 (Duplicate 1)

A 57-year-old woman with cirrhosis secondary to chronic hepatitis C is hospitalized because of tense ascites. Her medications are propranolol, furosemide, and spironolactone. On admission, her serum creatinine concentration is 1 mg/dL. Five liters of ascitic fluid is removed on therapeutic paracentesis. Intravenous furosemide and oral spironolactone therapy are begun. During the next 2 days, the patient has a 3.6-kg (8-lb) weight loss. Her pulse is 85/min and regular, and blood pressure is 100/65 mm Hg. Examination shows scleral icterus. Breath sounds are decreased at both lung bases. Abdominal examination shows moderate ascites. Laboratory studies show:

In addition to discontinuing spironolactone and furosemide, which of the following is the most appropriate next step in management?

A previously healthy 20-year-old man is brought to the emergency department because of a 12-hour history of increasing fever and confusion. He has never seen a physician. He takes no medications. His temperature is 40°C (104°F), pulse is 110/min, respirations are 18/min, and blood pressure is 100/70 mm Hg. On arrival, he is delirious. Examination shows a diffuse rash over the body. A photograph of the rash is shown. There is moderate nuchal rigidity. The remainder of the examination shows no abnormalities. Immunization against which of the following is most likely to have prevented this patient’s condition?

A 62-year-old woman comes to the physician because of a 2-day history of moderate left-sided lower abdominal pain. She also has had nausea and loss of appetite during this time. She has not had vomiting. She has hypertension well controlled with hydrochlorothiazide. Her temperature is 38.4°C (101.1°F), pulse is 98/min, respirations are 14/min, and blood pressure is 120/78 mm Hg. Abdominal examination shows tenderness to palpation of the left lower quadrant; there is no guarding or rebound. Bowel sounds are decreased. Rectal examination shows no abnormalities. Test of the stool for occult blood is negative. Laboratory studies show:

Results of other laboratory studies are within the reference ranges. Chest and abdominal x-rays show no abnormalities. Which of the following is the most appropriate next step in management?

A 47-year-old man comes to the physician for a follow-up examination. He has hypertension treated with ramipril and gout treated with allopurinol. He has not had a gout flare during the past 6 months. His only other medication is aspirin. He is 180 cm (5 ft 11 in) tall and weighs 109 kg (240 lb); BMI is 34 kg/m2. His blood pressure is 152/95 mm Hg. Examination shows truncal obesity. Six months ago, his serum creatinine concentration was 1.4 mg/dL. Serum studies today show:

Which of the following is the most appropriate additional pharmacotherapy?

A 21-year-old woman is brought to the emergency department because of a 3-day history of vomiting and malaise and a 6-day history of abdominal cramping. One week ago, she had a medically induced abortion at 44 days’ gestation, with use of oral mifepristone and vaginal misoprostol. She has no history of serious illness and takes no medications. She follows a vegetarian diet. She appears ill. Temperature is 39.0°C (102.0°F), pulse is 151/min, respirations are 32/min, and blood pressure is 89/56 mm Hg. Physical examination discloses coarse breath sounds, a soft, nondistended abdomen, and 1+ pitting edema. Results of laboratory studies are shown:

Blood cultures grow gram-positive rods. Which of the following infectious agents is the most likely cause of these findings?

A 65-year-old woman is admitted to the hospital because of a 1-day history of fever, and edema and erythema of the right arm. She says that overnight her right arm began throbbing and the redness worsened. She also had chills and increasingly severe arm pain throughout the night. Her temperature reached 38.9°C (102°F) at home. One year ago, she had stage II breast cancer treated with right partial mastectomy, lymphadenectomy, and radiation therapy. She was treated with a compression sleeve for lymphedema of the right upper extremity postoperatively. She has osteoarthritis of the shoulders and hands, which limits the use of her upper extremities. She says her symptoms have always been present since the operation, but the swelling has worsened since yesterday. Her temperature is 38.3°C (101°F), pulse is 88/min, respirations are 14/min, and blood pressure is 150/80 mm Hg. Examination shows a bright red, well-demarcated area from 3 cm below the elbow to 3 cm above the ulnar prominence; it is exquisitely tender to light touch. The patient has moderate tenderness to palpation of the right upper extremity. There are no open areas over the skin or fingers. Laboratory studies show:

Which of the following is the most likely infectious agent?