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* nbme-1
 #141269  
  tea - 11/25/06 14:34
 
  1. A 75-year-old retired landscape architect is brought to the emergency department after the police found him wandering around the city. He was unable to tell them who he was or where he lived. He has a long history of poorly controlled hypertension. He had two strokes several months ago from which he partially recovered. He can walk but his left arm remains weak. Pertinent family history indicates that his father, a successful businessman, committed suicide at age 72 years. Which of the following is the most likely diagnosis?

A

) Bipolar disorder, manic episode

B

) Major depressive disorder

C

) Vascular dementia

D

) Dementia, Alzheimer type

E

) Schizophrenia

2. A 37-year-old woman comes to the emergency department because of a 2-day history of weakness in her left foot which has caused her to accidentally stub the toes of her left foot several times. She reports no other symptoms and is otherwise generally healthy. Medical history is unremarkable except for an episode of blurred vision 1 year ago that resolved on its own. She takes no medications and does not smoke cigarettes or drink alcoholic beverages. Physical examination shows a left footdrop but is otherwise noncontributory. Neurologic examination shows hyperreflexia of the deep tendon reflexes in all extremities. CT scan of the head shows no abnormalities. Lumbar puncture is done. Examination of this patient's cerebrospinal fluid is most likely to show which of the following?

A

) Elevated glucose

B

) Elevated IgG

C

) Elevated neutrophil count

D

) Elevated protein

E

) Positive VDRL

3. A 55-year-old African-American woman is transported to the emergency department by paramedics. She was sitting at the dinner table, and suddenly said to her husband, "I have a terrible headache." She then dropped her fork and slumped in her chair. The husband went to her aid, and she said, "I can't move my right side." He then called emergency medical services. On arrival the patient is alert and oriented. She is holding her head and is in obvious distress. Vital signs are: pulse 101/min, respirations 28/min and blood pressure 190/118z mm Hg. The patient's husband tells you that she has been treated for hypertension for the past 10 years and that she has a 25-year history of simple migraines that occur every 3 to 4 months. On physical examination the patient has an obvious right hemiparesis with an associated hemisensory deficit and hyperreflexia. Blood is drawn for laboratory studies, electrocardiography is done and CT scan of the head is ordered. Her husband asks, "What do you think happened, Doctor?" Based on her clinical presentation and past medical history, which of the following is the most likely cause?

A

) Cerebellar hemorrhage

B

) Complicated migraine

C

) Embolic cerebral infarct

D

) Intracerebral hemorrhage

E

) Subarachnoid hemorrhage

4. A 36-year-old firefighter is trapped in a burning building when his air supply runs out. When the rescuers find him 15 minutes later, he is breathing spontaneously and has a pulse, but he is unresponsive. There is no evidence of acute traumatic injury. He is resuscitated with 100% oxygen via a nonrebreathing face mask. He gradually becomes conscious, and by the time he reaches the emergency department, he is awake, alert and complains only of a headache. On arrival in the emergency department arterial blood gas values while breathing 100% oxygen show:


PO2

493 mm Hg

PCO2

29 mm Hg

pH

7.53

Carboxyhemoglobin

30%


Which of the following is the most appropriate management at this time?

A

) Admit the patient for careful monitoring of his airway

B

) Begin phenytoin therapy by intravenous loading

C

) Have the patient rebreathe 100% oxygen at 10 L/min

D

) Intubate the patient in order to allow controlled mechanical ventilation

E

) Measure the concentration of carbon monoxide in his blood

5. A 23-year-old rugby player is brought to the emergency department by his teammates after sustaining blunt trauma to the left infra-orbital area during a game. The patient complains of significant periorbital pain and says, "I'm seeing flashing lights." Physical examination discloses periorbital swelling. Pupils are equal and reactive. Visual acuity is 20/20 in the right eye and 20/40 in the left eye. Which of the following is the most appropriate step?

A

) Discharge and follow-up with an ophthalmologist within 24 hours

B

) Discharge with a nonsteroidal anti-inflammatory drug (NSAID) and an eye patch

C

) Discharge with corticosteroid eyedrops and a nonsteroidal anti-inflammatory drug (NSAID)

D

) Discharge with pain medication and application of ice packs

E

) Immediate consultation with an ophthalmologist

6. A 19-year-old white college student is brought to the emergency department by her two roommates because of shortness of breath. The roommates tell you that her symptoms came on suddenly about one hour after they picked her up at the airport where she had arrived after a 6-hour flight from visiting her parents. The patient has rapid and shallow breathing, and with difficulty she tells you, "I can't get my breath and I'm having pains in my chest. My face is numb. I think I'm dying. Do something. Do something!" She says she has never had an experience like this before. She always has been healthy and she takes no medications except for combination oral contraceptive therapy. Physical examination is normal except for tachypnea and tachycardia. Electrocardiogram shows sinus tachycardia but is otherwise normal. Arterial blood gas values while breathing room air show:


PO2

99 mm Hg

PCO2

30 mm Hg

pH

7.44


Which of the following is the most appropriate long-term pharmacotherapy?

A

) Bupropion

B

) Gabapentin

C

) Lorazepam

D

) Metoprolol

E

) Paroxetine

The following vignette applies to the next 2 items.


A 58-year-old white man comes to the emergency department because of chest heaviness for the past 45 minutes associated with shortness of breath and a sense of doom. He has not seen a physician since he was 18 years old. He smokes approximately two packs of cigarettes per day. He takes no prescription medications. He has had increasing heartburn recently and he has been taking eight to twelve antacid tablets daily during the past 3 weeks. He is mildly nauseated and diaphoretic. Vital signs are: temperature 37.2°C (99.0°F), pulse 98/min, respirations 20/min and blood pressure 160/96 mm Hg. Electrocardiogram shows that ST-T segment changes are indeterminate. You are aware of a new blood test, CQ, that can diagnose an acute myocardial infarction (MI) more quickly than the creatine kinase isoenzymes. The receiver operating characteristic (ROC) curve for CQ is shown in the exhibit for four cut-off points. You believe the likelihood of an acute MI is high in this patient and you want to minimize the chance of a false negative.

Item 1 of 2

7. Which of the following is the most appropriate cut-off point on the ROC curve?

A

) A

B

) B

C

) C

D

) D

E

) It cannot be determined with the data provided

Item 2 of 2

8.

The cut-off point at which the test performance for CQ is most accurate in the detection of an acute MI is which of the following?

A

) A

B

) B

C

) C

D

) D

E

) It cannot be determined from an ROC curve

End of Set

9. A 67-year-old man is brought to the emergency department in ventricular fibrillation. His rectal temperature is 26.7°C (80.0°F). Among the following criteria, the patient should be declared dead when defibrillation fails after which of the following?

A

) Rapid endotracheal intubation and administration of 100% oxygen

B

) Restoration of a normal core temperature

C

) Restoration of a normal oral temperature

D

) 1 hour of core rewarming

E

) 20 minutes of warming, externally

10. A 19-year-old white woman is brought to the emergency department by her mother because of intractable emesis. She has a past history of bulimia and according to her mother has been under the care of a psychiatrist. She apparently was well until 1 day ago when she developed emesis and an inability to tolerate liquid and solid foods. Although she takes no medications other than oral contraceptives, she admits to occasional use of both laxatives and ipecac. She denies the use of alcohol or of illicit drugs and says she has experienced no previous symptoms of chest pain, heartburn, hematemesis or fever. Physical examination shows a well-nourished woman with normal vital signs. No lesions are evident on inspection of the skin, but turgor is poor. The thyroid is flat, nontender and without masses. On auscultation of the lungs, moist rales are present at the bases bilaterally. The point of maximal impulse of the heart on the chest wall is 7 cm from the lower left sternal margin in the sixth intercostal space. There is no evidence of an S4 although an S3 is heard. A soft systolic murmur is heard at the apex without a diastolic component. Jugulovenous distention is present 3 cm above the suprasternal notch at 45 degrees' elevation of the chest. The abdomen is soft and a tender liver edge extends 3 cm below the right costal margin. Pitting edema is present in both legs to the mid-calf bilaterally. Laboratory studies show a serum creatinine concentration of 4.2 mg/dL and serum urea nitrogen (BUN) of 88 mg/dL. Urinalysis shows renal tubular epithelial cell casts. Chest x-ray film shows cardiomegaly, central hilar vascular congestion and cephalization of blood flow. Which of the following is the most likely explanation for cardiac decompensation and renal failure in this patient?

A

) Bulimic cardiomyopathy

B

) Cocaine intoxication

C

) Hypothyroidism

D

) Myocardial ischemia

E

) Myocarditis
 
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* Re:nbme-1
#571097
  pk007 - 11/25/06 15:20
 
  really tough tea, anyway trying....
1.c
2.b
3.d
4.d
5.e
6.d
7.??
8.??
9.b
10.??
 
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* Re:nbme-1
#571288
  tea - 11/25/06 18:51
 
  1c
2d
3d
4a
5e
6e
7-
8-
9b
10a
 
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* Re:nbme-1
#571461
  chirkut - 11/25/06 23:18
 
  1c
2b
3e
4d
5e
6e
7-
8-
9-
10a
 
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* Re:nbme-1
#571633
  tea - 11/26/06 08:32
 
  Pk and chirkut or anyone,
can you tell me why your answer is b-IgG? what disease is that? I was thinking of MS. Thanks
 
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* Re:nbme-1
#571857
  cartick007 - 11/26/06 14:28
 
  Answer for Q4 should be C, continue the oxygen therapy. Please check the eMedicine for carbon monoxide intoxication.  
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* Re:nbme-1
#571860
  cartick007 - 11/26/06 14:31
 
  Hi, there, I am new here and I have not taken step 3 yet. So does NMBE Qbank provide answers? It seems from your discussion the answer is NO.

Thank for reply from you guys.
 
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* Re:nbme-1
#571896
  chirkut - 11/26/06 15:06
 
  is 10lr/min ok?
to giv hyperbaric O2, do we need intubation ? is that same as mechanical ventilation?
thx
 
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* Re:nbme-1
#572210
  tea - 11/26/06 21:47
 
  In ccs, you order intubation, need to order ventilation also,
hyperbaric for very severe case
for this patient I will more concern about later airway edema due to burn-close fire enviroment .
 
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* Re:nbme-1
#573108
  prav - 11/27/06 20:24
 
  Typical findings in MS and acute disseminated encephalitis include 0-50 mononuclear cells on cell count, 25% elevated protein, normal glucose level, selective increase in immunoglobulin G (eg, oligoclonal bands, free kappa chains)

Cardiomyopathy in bulimia is due to ipecac consumption...... i did not know that
 
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* Re:nbme-1
#573116
  prav - 11/27/06 20:28
 
  Amyloid angiopathy is the cause of intracerebral hge in older people.

Why is subarachnoid not the answer?
 
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