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* nbme-5
 #141309  
  tea - 11/25/06 16:46
 
  11. A 10-year-old boy is brought to the office by his mother for a periodic health evaluation. He has been your patient for several years. Recently his teachers and his school counselor have recommended that he be treated with methylphenidate because of his disruptive behavior in the classroom. He has no past history of behavioral problems. Which of the following is the most appropriate advice to the mother?

A

) "Children with this problem may not have a very high IQ."

B

) "Children with this problem usually grow out of it by puberty."

C

) "I don't think he has attention-deficit disorder because he has not had problems in the past."

D

) "Let's get more information from the school."

E

) "Methylphenidate treatment will probably improve his grades."

12. A 24-year-old woman comes to the office for an initial prenatal visit. A home pregnancy test was positive 2 weeks ago. Her last menstrual period was 10 weeks ago. She has been healthy and has no significant medical history. She takes no medications. During the interview she becomes tearful and says, "My husband hit me several times 6 weeks ago and I'm afraid that it may happen again. He's become very loving now since he found out about the baby, but I'm still worried." Vital signs now are: temperature 36.9°C (98.4°F), pulse 80/min, respirations 20/min and blood pressure 110/70 mm Hg. Pelvic examination shows a 10-week size uterus and is otherwise normal. Ultrasonography confirms a 10-week gestation. Which of the following strategies is most appropriate?

A

) Provide her with the name and phone number of a shelter for battered women

B

) Reassure the patient that abusive behavior is less likely now that she is pregnant

C

) Recommend marital counseling

D

) Schedule an appointment with the husband to discuss his abusive behavior

E

) Tell her that you will report this to the police if it happens again

13. A 16-year-old boy and his mother come to the office because the mother is concerned that her son may have a drug problem. You have treated him in the past for mild intermittent asthma, and he currently uses an albuterol inhaler prior to exercise. You last saw him 1 year ago for a sports physical examination. At that time, he admitted to drinking alcohol on the weekends. He also admitted to marijuana use but had planned to quit using both before track season started. The mother says that her son now seems disinterested in school and other activities in which he was previously engaged. He has quit the track team, has become irritable, and he has a new set of friends whom his mother dislikes and describes as "druggies." She acknowledges that the boy's father, from whom she is divorced, has an alcohol abuse problem. The boy's older brother abused cocaine for 2 years but is now in a drug rehabilitation program. Prior to interviewing and examining the patient, the mother pulls you aside and asks you to test her son for drugs without informing him. Which of the following is the most appropriate response?

A

) Agree to do toxicologic screening but review the test results with the patient before giving the results to the mother

B

) Agree to do toxicologic screening only if, after discussing it with the patient, he agrees to the test

C

) Agree to do toxicologic screening without the patient's knowledge per his mother's request

D

) Decline to do toxicologic screening stating that you do not want to get caught between her and her son

E

) Decline to do toxicologic screening unless under a court order

The following vignette applies to the next 2 items.


A 75-year-old woman whom you treat for obstructive lung disease comes to the office because of thoracic back pain, which has been troubling her for several weeks. There is no specific history of trauma. Her current medications include ipratropium and inhaled albuterol. She no longer smokes cigarettes and she does not use alcohol. She underwent a mastectomy 10 years ago for breast cancer. Today, vital signs are normal. Her weight is unchanged from 1 year ago. On physical examination breath sounds are diminished in intensity but normal in quality. There is no tenderness over the spinous processes. Laboratory studies in the office show a normal complete blood count and erythrocyte sedimentation rate. A compression fracture of the thoracic spine is seen on a lateral chest x-ray film. After further discussion, the patient agrees to a trial of alendronate to prevent further fractures.

Item 1 of 2

14. Regarding alendronate therapy, the patient should be told which of the following?

A

) The medication should be chewed, rather than swallowed

B

) The medication should be taken at bedtime

C

) The medication should be taken with a full glass of water

D

) The medication should be taken with meals

E

) She should lie down immediately after taking the medication

Item 2 of 2

15. Four days later, the patient returns to the office complaining of chest pain, odynophagia and dysphagia. You decide to discontinue the alendronate. In addition, which of the following is the most appropriate diagnostic study?

A

) Electrocardiography

B

) Esophagoscopy

C

) Laryngoscopy

D

) MRI of the thoracic spine

E

) X-ray film of the lateral neck

16. A 69-year-old woman comes to the office because of left knee pain. She says, "For the past several years my left knee has been bothering me a bit but I have been getting by. However, for the past few days it has been killing me. I was at the outlet mall 2 days ago and I was fine, but yesterday I woke up with such knee pain that I could hardly walk." She denies injuring the knee. No other joints bother her this much although she notes that her right knee occasionally hurts. The pain does not improve with ibuprofen. She has hypertension controlled with hydrochlorothiazide and a β-blocking medication, and she has mild chronic renal failure. Serum creatinine concentration 3 months ago was 2.1 mg/dL. She is 168 cm (5 ft 6 in) tall and weighs 106 kg (233 lb). Physical examination today discloses moderate effusion of the left knee. The left knee is warm to touch compared with the right knee. Range of motion is normal but there is crepitus. There is no rash or erythema of the skin. X-ray films of both knees are shown. Arthrocentesis shows:


WBC 850/mL

Gram stain Negative

Microscopic No crystals seen under polarized light


Which of the following is the most likely diagnosis?

A

) Gout

B

) Osteoarthritis

C

) Osteoporosis

D

) Pseudogout

E

) Septic arthritis

17. A 46-year-old man with diabetes mellitus well controlled by diet alone returns to the office for a follow-up visit for migraines. You have been seeing him for the past year for the migraines, and about 2 months ago you prescribed a calcium-channel-blocking medication. His previous medications included ergotamine and propranolol, but they were discontinued because of lack of full effect. At today's visit he complains of ankle swelling. Physical examination is normal except for 2+ pitting edema. Which of the following is the most appropriate step at this time?

A

) Determine serum albumin concentration

B

) Discontinue his calcium-channel-blocking medication

C

) Order determination of protein excretion in a 24-hour urine sample

D

) Order echocardiography

E

) Prescribe a diuretic agent

18. A 27-year-old woman comes to the clinic because of chronic dermatitis involving both ear lobes. She has pierced ears and the rash is most marked around the insertion of her earrings. She should be advised to do which of the following?

A

) Avoid skin sensitizing soaps while wearing earrings

B

) Discontinue the use of metallic earring posts

C

) Have her ears repierced

D

) Soak her earrings in 70% alcohol for 24 hours before using them

E

) Wear clip-on earrings only

19. A 46-year-old woman whom you are treating for hypertension and hypothyroidism returns to the office for a follow-up visit. She denies dyspnea, orthopnea, nocturia or exertional chest discomfort. She states, "Doctor, I've recently found that my feet are swollen. It's becoming hard to get my shoes on. My feet don't really bother me, except that they look funny and make me feel self-conscious." The patient has no other medical problems. She has no allergies. She does not smoke cigarettes and she drinks a glass of wine every evening. Her medications are levothyroxine, extended-release nifedipine and enalapril. Blood pressure is 128/78 mm Hg. On physical examination there are no abnormalities of the skin. Neck veins are not distended. Pulmonary and cardiac examinations are normal. Liver and spleen are not palpable. She has 2+ pitting edema of both legs. The remainder of the examination is normal. Which of the following is the most likely explanation for the edema?

A

) The patient has deep venous thrombosis

B

) The patient has misreported her use of alcohol

C

) The patient has not been taking levothyroxine

D

) Use of enalapril

E

) Use of nifedipine

20. A 45-year-old man comes to the office because he has noted a lesion on his chest. He has been generally healthy and you last saw him 5 years ago for an insurance physical examination that was normal. Medical chart notes from that visit report that his skin examination was "normal." You do not recall a lesion being present in the area that he indicates. He is unaware of when the lesion first occurred, but it was noted by a friend at a health club who saw a television report about skin cancer. Physical examination shows a well-appearing man with brown eyes and fair complexion. Vital signs are normal. Skin examination is normal except for the 1-cm lesion on his lateral abdominal wall as shown. The factor that is the best predictor of this patient's prognosis is which of the following?

A

) Degree of variation in the color of the lesion

B

) Diameter of the lesion

C

) His complexion

D

) His eye color

E

) Measurement of lesion depth
 
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* Re:nbme-5
#571247
  pk007 - 11/25/06 18:17
 
  11.c
12.c
13.b
14.c
15.b
16.b
17.b
18.b
19.e
20.??b
 
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* Re:nbme-5
#571255
  tea - 11/25/06 18:20
 
  11d
12c
13b
14c
15a
16b
17b
18b
19e
20e
 
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* Re:nbme-5
#571784
  turtle - 11/26/06 13:06
 
  tea, i don't understand y marital counselling is most appropriate . the husband will most probably not agree. However, she should be given phone no to a place where she can go in case she gets abused again.

Also, after d/c alendronate, she's having chest pain but with odynophagia and dysphagia. the diagnostic study here should be esophagoscopy.
 
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* Re:nbme-5
#571802
  tea - 11/26/06 13:40
 
  q15 any cp, do ecg as first step, R/O most dangerous thing first.

about counselling, not sure ....a couple fight all the time,
" shelter", just doesn't sound right for me, if she is afraid to go home (I don't think that is her case), she can stay with her friends and family...what do you think?
 
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* Re:nbme-5
#571812
  tea - 11/26/06 13:49
 
  hey turtle, I read the q15 again, you and Pk are right, I read the q too fast, thought it was asking most apporiate next step.  
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* Re:nbme-5
#571890
  chirkut - 11/26/06 14:57
 
  17 ??c
isn't it better to investigate for nephropathy?
 
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* Re:nbme-5
#572498
  rich - 11/27/06 09:42
 
  my guess:
11 D
12 A
13 C
14 C
15B
16 B
17 B
18 B
19 E
20 E
 
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* Re:nbme-5
#572991
  prav - 11/27/06 18:14
 
  11d
12a
13a
14c
15b
16b
17b
18b
19e
20e

13)Could we not test for toxicology without consent

11)I think we shud get more info from school
 
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