NBME 15- Block 4 (Duplicate 1)

A 64-year-old woman with hypertension comes to the physician because of a 6-month history of moderate midepigastric pain that worsens with eating. During this time, she has had an 8.2-kg (18-lb) weight loss despite no change in appetite. She has four to six bowel movements daily, typically after eating. Her only medication is hydrochlorothiazide. She has smoked one-half pack of cigarettes daily for 40 years and drinks two martinis daily. She is 168 cm (5 ft 6 in) tall and weighs 59 kg (130 lb); BMI is 21 kg/m2. Her temperature is 36.9°C (98.4°F), pulse is 90/min, respirations are 14/min, and blood pressure is 136/70 mm Hg. Examination shows several telangiectasias over the chest. There is no scleral icterus. Abdominal examination shows mild epigastric tenderness to palpation. No masses are noted. Bowel sounds are normal. Laboratory studies show:

An x-ray of the abdomen is shown. Which of the following is the most likely diagnosis?

A 42-year-old man comes to the physician for a health maintenance examination. He runs 30 miles weekly and recently completed his third marathon. He works as an airline pilot. He has no history of serious illness and takes no medications. His father had a myocardial infarction at the age of 54 years. The patient’s pulse is 56/min, respirations are 12/min, and blood pressure is 110/60 mm Hg. Examination shows no abnormalities. An ECG is shown. Which of the following is the most appropriate next step in management?

A 52-year-old man comes to the office for a follow-up examination 4 months after undergoing allogeneic stem cell transplant for acute myelogenous leukemia. He has had five to six loose, watery stools during the past 3 days. He has a 3-week history of an itchy rash over his face, chest, upper back, and arms. He reports that he has continued to have fatigue and mild dryness of the eyes and mouth since his last visit 1 month ago. He has not had fever, night sweats, or cough. The patient and the donor tested positive for cytomegalovirus before the transplant. The patient has no other history of serious illness. His medications are tacrolimus, prednisone, mycophenolate, trimethoprim-sulfamethoxazole, and acyclovir; he has had no adverse effects. Vital signs are within normal limits. Examination shows a faint macular rash without scaling across the face, chest, upper back, and upper extremities. There is no lymphadenopathy. The eyes are mildly dry, and the sclerae are erythematous. Cardiopulmonary examination shows no abnormalities. Serum studies show:

Results of a complete blood count, measurement of serum electrolyte concentrations, and renal function tests are within the reference ranges. Which of the following is the most likely diagnosis?

An 11-year-old boy is brought to the office by his parents because of a 2-day history of dark urine. Five days ago, he had a mild upper respiratory tract infection, which resolved spontaneously. He has not had pain with urination. He has not had sick contacts. He had frequent episodes of otitis media during infancy. He failed a hearing test at school 6 months ago, and his parents plan to schedule audiometry. He has no other history of serious illness and receives no medications. Immunizations are up-to-date. Growth and development are appropriate for age. The patient’s maternal uncle has end-stage renal disease. The patient’s temperature is 37°C (98.6°F), pulse is 80/min, respirations are 12/min, and blood pressure is 100/70 mm Hg. Examination shows no abnormalities. Urinalysis shows:

Which of the following is the most likely diagnosis?

A 48-year-old man comes to the emergency department 6 hours after the sudden onset of severe right-sided chest pain that increases with inspiration. He also has had shortness of breath during this time. Ten days ago, he sustained a nondisplaced right ankle fracture while playing basketball. He was taken to the emergency department, and a cast was placed on his right lower extremity. He has hypertension treated with amlodipine and has been taking ibuprofen for ankle pain. His temperature is 37.2°C (98.9°F), pulse is 110/min and regular, respirations are 32/min, and blood pressure is 90/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Cardiac examination shows no other abnormalities. There is splinting of the right hemithorax. The remainder of the examination shows no abnormalities. Which of the following sets of cardiac output and systemic vascular resistance findings is most likely to be found in this patient?