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q1)
Ans) E
E) No diagnostic studies are indicated

please someone verify by nbme


This seems a case of duodenal ulcer "...The patient says the "chest pain" is nonradiating and is relieved by eating." but the definitive dx will be done by an upper endoscopy.

In gral young patients with epigastric pain and most likely to have Peptic Ulcer disease are started with medications, H2 blockers or PPI's, if the symptoms persist then we proceed with an Endoscopy.

In patients older than 45 with alarm symptoms like weightloss, FOBT or dysphagia, Endoscopy should be performed first.

Kaplan, IM (CK)

2.
A 4-year-old boy is brought to the office by his mother, who has noted a malodorous, purulent discharge from the boy's right nostril during the past 2 weeks. The mother reports that the child has no history of trauma, fever, nose bleeds, or cough, and has been otherwise healthy. An over-the-counter decongestant-antihistamine combination has provided no improvement of his symptoms. Medical history is unremarkable and vaccinations are up-to-date. Vital signs are temperature 37.6°C (99.7°F), pulse 90/min, and respirations 14/min. Physical examination shows a symmetric external nose with no apparent deformities. Nasal septum is intact. Left naris is patent and mucosa is normal. A yellow, malodorous discharge is noted in the right naris. Which of the following is the most likely diagnosis?
A) Allergic rhinitis
B) Cerebrospinal rhinorrhea
C) Chronic sinusitis
D) Foreign body in nose
E) Nasal polyps

2.
A 4-year-old boy is brought to the office by his mother, who has noted a malodorous, purulent discharge from the boy's right nostril during the past 2 weeks. The mother reports that the child has no history of trauma, fever, nose bleeds, or cough, and has been otherwise healthy. An over-the-counter decongestant-antihistamine combination has provided no improvement of his symptoms. Medical history is unremarkable and vaccinations are up-to-date. Vital signs are temperature 37.6°C (99.7°F), pulse 90/min, and respirations 14/min. Physical examination shows a symmetric external nose with no apparent deformities. Nasal septum is intact. Left naris is patent and mucosa is normal. A yellow, malodorous discharge is noted in the right naris. Which of the following is the most likely diagnosis?
A) Allergic rhinitis
B) Cerebrospinal rhinorrhea
C) Chronic sinusitis
D) Foreign body in nose
E) Nasal polyps

Ans: D
D) Foreign body in nose
nbme cert.


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Nasal foreign bodies (NFBs) are commonly encountered in emergency departments, especiallyin Pediatric area, also in persons with mental retardation or psychiatric illness.
Bleeding is the mc complication reported, although it is characteristically minimal and resolves with simple pressure.
The foreign body itself may cause irritation to the patient; however, morbidity is primarily caused by the resulting inflammation, mucosal damage, and extension into adjacent structures. Reported complications include the following:
• Sinusitis
• Acute otitis media
• Nasal septal perforation
• Periorbital cellulitis
• Meningitis
• Acute epiglottitis
• Diphtheria
• Tetanus

3.
A married, 34-year-old African American woman comes to the office. She says, "During the past 5 to 6 weeks I have had recurrent headaches." She indicates the left side of her forehead with her left hand. She tells you, "Sometimes the fingers of my right hand tingle and I feel dizzy. At other times I've experienced weakness in my left hand. But the thing that scares me the most is that I've had double vision." Physical examination is consistent with ophthalmoplegia. Which of the following is the most likely diagnosis?

A) Conversion disorder
B) Migraine
C) Multiple sclerosis
D) Muscle-contraction headaches
E) Panic attack

q3)

Ans: C) Multiple sclerosis
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MS
pat often presents with CNS abnormalities such as visual problems, ataxia or diplopia that resolved spontaneously but later return. OPTIC NEURITIS is the common initial presentation (Patients often present with acute or subacute unilateral decrease or loss of vision. Central vision tends to be most affected, and orbital pain with eye movement is common).
MRI, best initial test> multiple asymmetric periventricular white matter plaque
If doubts with MRI, then LP > mild incr in proteins, WBC

4.
A 32-year-old automobile body shop owner, whom you have seen for periodic health evaluations, returns to the office because of episodic chest tightness, palpitations, and shortness of breath. He has gone to the emergency department three times in the past month because of these symptoms. The episodes are sudden in onset, last 15 to 20 minutes, and leave him feeling exhausted. He constantly worries about having another episode. Repeated ECGs and cardiac enzyme studies have been negative for cardiac ischemia. The patient had a series of similar episodes 5 years ago and at that time an exercise stress test was normal. He has no family history of coronary artery disease. He runs 4 to 5 miles, three times weekly. He does not smoke cigarettes. Today, vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 24/min, and blood pressure 140/90 mm Hg. Cardiac and pulmonary examinations are normal. Which of the following is the most likely diagnosis?

A) Hyperthyroidism
B) Panic disorder
C) Paroxysmal atrial tachycardia
D) Prinzmetal angina
E) Surreptitious cocaine use


q4)
ANS: B
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Panic disorder
Is the diagnosis when the case describes brief attacks of intense anxiety with autonomic symptoms (Chest discomfort, palpitations, SOB, sweating, trembling, fear of dying, numbning or tingling in the hands or feet, nausea, fear of chocking, fear of dying, dizziness.

Episodes occur regularly, without an obvious precipitant and in the absence of other psychiatric illness.

Treatment is cognitive-behavioral therapy and/ or relaxation training and desensitization. Relaxation and desensitization may be more useful when agoraphobic symptoms are present.
Medications include SSRIs (e.g., fluoxetine), benzodiazepines (e.g., alprazolam, clonazepam), imipramine, and MAOIs (e.g., phenelzine).

5.
A 68-year-old African American woman who is a well-known patient returns to the office because, she says, "My legs are swollen and the right one has been really bothering me for the past 3 days." The patient tells you that she also has been having mild orthopnea but no chest pain. You have been treating her for several years for stable coronary artery disease and congestive heart failure. Daily medications include 81-mg aspirin, metoprolol, lisinopril, and furosemide. She also uses a nitroglycerin patch daily. The patient leads a sedentary lifestyle. Vital signs now are temperature 37.0°C (98.6°F), pulse 72/min and regular, respirations 18/min, and blood pressure 152/90 mm Hg. She is 165 cm (5 ft 5 in) tall and weighs 75 kg (165 lb), which is 1.5 kg (3 lb) more than at her last visit; BMI is 28 kg/m2. The patient appears healthy and is in no acute distress. Auscultation of the lungs discloses rare crackles at both lung bases. Edema is present in both lower extremities but is more pronounced in the right lower extremity. There is no tenderness to palpation of the lower extremities. Distal pulses are normal. Which of the following is the most appropriate initial study?
A) Doppler ultrasonography of the legs
B) Echocardiography
C) ECG
D) Thallium scan
E) No studies are indicated at this time

q5)


Ans: A
A) Doppler ultrasonography of the legs

This patient has CHF, her current problem shows an exacerbation of it but the right leg edema more pronounced on the right leg should guide us to investigate a possible DVT, so Doppler of lower limbs is indicated.

q5)

Ans: A) Doppler ultrasonography of the legs
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6.
A 52-year-old computer programmer comes to the health center for a preemployment physical examination before starting a new job. He says, "I've been healthy all my life. I never go to the doctor." Medical history is significant for an appendectomy at age 15 years. He has smoked one pack of cigarettes daily for about 30 years and he drinks two bottles of beer per day. He leads a sedentary lifestyle. He takes no medications except over-the-counter antacids for heartburn. His father died at age 67 years of colon cancer and his mother, who is age 77 years, has a history of a myocardial infarction with coronary artery bypass grafting at age 63 years. The patient's 55-year-old brother had a myocardial infarction at age 49 years. The patient is 168 cm (5 ft 6 in) tall and weighs 98 kg (220 lb); BMI is 36 kg/m2. Vital signs are temperature 36.4°C (97.5°F), pulse 100/min, respirations 20/min, and blood pressure 170/100 mm Hg. Physical examination shows no abnormalities except for obesity. Results of a fasting serum lipid profile obtained 1 week ago are shown:
Cholesterol
Total 247 mg/dL
HDL 22 mg/dL
LDL 155 mg/dL
Triglycerides 300 mg/dL
You review the current laboratory data and assess the patient's health risks. His cardiovascular risk will be reduced most by which of the following?
A) Antihypertensive medication
B) Exercise program
C) Lipid-lowering medication
D) Smoking cessation
E) Weight-loss program

Ans: D
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Smoking Cessation

Tobacco use is the most common cause of avoidable cardiovascular mortality worldwide; therefore, not surprisingly, smoking cessation is one of the most popular methods in management of cardiovascular risk in the general population and in patients with Chronic Kidney Disease. Smoking is estimated to contribute as much as 36% and 19% of the population-attributable fraction or risk for MI and stroke, respectively. Whereas many national guidelines mention the role of smoking cessation, the continued high rate of smoking in many dialysis populations suggests that there are still gains to be made from a focus on this area, particularly in patients with CKD who do not require dialysis and in patients with diabetes, who carry the highest risks.