NBME 15- Block 4

A 57-year-old man comes to the physician because of a 1-year history of an enlarging painless lesion on his nose. The lesion sometimes bleeds when he washes his face. He has no history of serious illness and takes no medications. His temperature is 36.8°C (98.2°F), pulse is 84/min, respirations are 16/min, and blood pressure is 128/78 mm Hg. Examination shows the lesion in the photograph and no other abnormalities. Which of the following is the most likely diagnosis?

A 57-year-old man with chronic hepatitis B comes to the physician because of a 6-month history of bruising of the arms and legs after minor trauma. He appears jaundiced. Examination shows palmar erythema and multiple 5-cm ecchymoses over the upper and lower extremities. No petechiae are seen. The spleen tip is palpated 2 cm below the left costal margin. There is gynecomastia and testicular atrophy. Laboratory studies are most likely to show which of the following sets of values?

A 57-year-old woman comes to the physician because she has had a sore throat for 3 days. She has not had any other symptoms. She has Graves disease treated with propylthiouracil and type 2 diabetes mellitus controlled with metformin and rosiglitazone. She takes daily ibuprofen and glucosamine for knee pain. There is no family history of serious illness. Her temperature is 37.3°C (99.2°F), pulse is 108/min, respirations are 14/min, and blood pressure is 123/74 mm Hg. There are multiple tender, enlarged lymph nodes in the anterior cervical chain. Examination of the oropharynx shows erythema and edema of the tonsils with no exudate. The remainder of the examination shows no abnormalities. A rapid streptococcal test is positive. Laboratory studies show:

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

A 6-month-old boy is admitted to the hospital for treatment of his second episode of Streptococcus pneumoniae sepsis within the past 5 weeks. He was treated for acute otitis media at the ages of 3 months and 4 months. He was delivered at term following an uncomplicated pregnancy and delivery. His maternal uncle died as an infant of Haemophilus influenzae type b sepsis and meningitis. The patient’s immunizations are up-to-date, and there have been no complications of immunizations. He is mildly irritable but easily consoled. His temperature is 38.5°C (101.3°F), pulse is 160/min, and respirations are 42/min. Examination shows no lymphadenopathy. Laboratory studies show:

His CD4+ and CD8+ T-lymphocyte counts are within the reference ranges. There are no CD19 B lymphocytes. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 16-year-old patient comes to the physician because she is concerned she may be pregnant. She has been sexually active with several male partners; her partners use condoms inconsistently. On questioning, she states that she has not had diarrhea or abdominal pain. Her last menstrual period was 10 weeks ago. She has celiac disease well controlled with diet. She does not smoke cigarettes and rarely drinks alcohol. Her diet consists of mostly meat, some dairy products, corn, potatoes, soda, and juice. She does not eat bread or pasta, does not drink milk, and rarely eats fruits or leafy vegetables. She appears pale. She is 162 cm (5 ft 4 in) tall and weighs 50 kg (110 lb); BMI is 19 kg/m2. Her blood pressure is 110/70 mm Hg. Examination shows warm skin. The thyroid gland is mildly enlarged. Cardiac examination shows no abnormalities. The abdomen is soft. Deep tendon reflexes are brisk. Laboratory studies show:

An anti-endomysial antibody test and a urine pregnancy test are positive. This patient’s fetus is at increased risk for which of the following?

A 28-year-old man with sickle cell disease is brought to the emergency department because of a 4-hour history of shortness of breath and increasingly severe chest pain. He has not had cough, fever, or chills. During the past 5 years, he has been hospitalized approximately twice yearly for treatment of sickle cell disease crises. He takes oxycodone to control pain. Last night, he drank four 12-oz beers. Typically, he drinks one 12-oz beer weekly. He smokes cigarettes only when he drinks beer. He appears to be in respiratory distress and in pain. His temperature is 37.2°C (99°F), pulse is 112/min, respirations are 30/min, and blood pressure is 144/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 85%. Examination shows conjunctival icterus and pale mucous membranes. The lungs are clear to auscultation. On cardiac examination, no murmurs are heard. Laboratory studies show:

A chest x-ray shows consolidation of the right middle and lower lobes. In addition to administration of 0.9% saline, hydromorphone, antibiotics, and oxygen, which of the following is the most appropriate next step in management?

A 52-year-old woman comes to the physician as a new patient because of a 5-day history of temperatures to 38.2°C (100.8°F) and cough productive of thick, gray-green sputum. She says the sputum is difficult to cough up. During the past 15 years, she has had similar symptoms twice yearly, which resolved after treatment with antibiotics. Because of lack of insurance during this time, she was treated at urgent care clinics. She has no known allergies and no history of serious illness. Her only medication is an over-the-counter cough suppressant. She does not smoke cigarettes or use illicit drugs. She drinks three glasses of wine weekly. She is 170 cm (5 ft 7 in) tall and weighs 91 kg (200 lb); BMI is 31 kg/m2. Her temperature is 38°C (100.4°F), pulse is 80/min, and blood pressure is 138/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. On pulmonary examination, there is an increased expiratory phase; rhonchi and faint wheezes are heard bilaterally. A CT scan of the chest is shown. Which of the following is the most likely diagnosis?

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?

A 4-year-old boy is brought to the office by his parents because of a 2-year history of sunburns and redness of both eyes. His parents say his skin becomes red and irritated after 15 minutes of sun exposure. Whenever he is outside, his eyes become red. Growth and development otherwise have been appropriate for age. Vaccinations are up-to-date. He is at the 50th percentile for height, weight, and BMI. His temperature is 37.0°C (98.6°F), pulse is 106/min, and respirations are 24/min. A photograph of the skin is shown. Ocular examination discloses injection of the conjunctival vessels without discharge bilaterally. Which of the following is most likely to develop in this patient during the next 10 years?

A 23-year-old woman comes to the emergency department because of a 3-month history of increasingly painful circumferential headaches that are most severe when she lies down. During this time, she also has had intermittent episodes of “grayed out” vision with constriction of her visual fields. The episodes last 5 seconds and resolve spontaneously. The patient was treated for Chlamydia trachomatis infection 2 years ago. She has no other history of serious illness and takes no medications. Her diet consists mainly of “junk food.” She appears anxious. She is 157 cm (5 ft 2 in) tall and weighs 124 kg (273 lb); BMI is 50 kg/m2. Her blood pressure is 165/82 mm Hg; other vital signs are within normal limits. Findings on funduscopic examination of the right eye are shown; similar findings are noted in the left eye. The remainder of the examination shows no abnormalities. Lumbar puncture is performed, and opening pressure is 39 cm H2O. Results of cerebrospinal fluid analysis are within the reference ranges. MRI of the brain and MR venography show no abnormalities. Which of the following is most likely to have prevented this patient’s current symptoms?

A clinician would like to increase the accuracy of diagnosing streptococcal pharyngitis among his pediatric patients in order to begin treatment sooner. He considers implementing a new diagnostic test for streptococcal pharyngitis and reviews the receiver operator characteristic (ROC) curve shown. Which of the following is the most likely clinical impact of using cut point C instead of cut point B as a positive test?