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q18) B
B) Prescribe hydrochlorothiazide therapy
nbme cert.

This patient already had the chance to try lifestyle modifications since he was first diagnosed with HTN. Normally we should give the pt 3-6m for lifestyle modifications before we proceed with medical tx. We should start HCTZ now.

Systolic Hypertension is related with worst out come lowering systolic pressure has been shown to reduce the risk for stroke by 30%, MI by 23%, and overall CV mortality by 18%; it also reduces heart failure admissions and slows the progression of dementia.

19.

A 4-year-old boy is brought to the office by his 21-year-old mother because he is complaining of something in his nose, and she thinks he has stuck something up into it. The mother says her son has never received any vaccinations because she thinks they are unsafe. He last saw a physician 2½ years ago, at which time he was treated for strep throat. The mother says he is generally healthy but has become increasingly irritable during the past few months. She says, "He is a very picky eater and mainly eats popcorn and mayonnaise sandwiches." He is 94 cm (3 ft 1 in; 5th percentile) tall and weighs 13 kg (29 lb; 5th percentile). Vital signs are temperature 36.8°C (98.2°F), pulse 90/min, respirations 18/min, and blood pressure 100/65 mm Hg. The patient appears pale and small. Nasal passages are also pale. Two pieces of popcorn are removed from near his left middle nasal concha. The remainder of the physical examination is most likely to show which of the following?

A) A cardiac flow murmur
B) Papular rash
C) Rhonchi
D) Splenomegaly

q19)
A) A cardiac flow murmur
nbme cert.

This patient comes for a foreign object in nose but he is a neglected child, no vaccinations and the very young mother doesn't know any better how to take a good care of her kid
He had Strep infection in the past, I doubt she followed the 10 days rule treatment with the Amoxicillin. This kid might have sequelae from Rheumatic fever, so A can be a good choice.

20.
A 10-month-old white girl is brought to the office by her mother for a well-child visit. The mother says, "She has been very grumpy for the past month. Her stomach seems to hurt her a lot and she has a lot of gas. Her bowel movements have been runny, too." The child has not been vomiting and is generally passing two to three loose stools daily. She has been otherwise healthy. She drinks 24 to 32 oz of soy-based formula daily and eats a wide variety of solid foods. She was previously breast-fed. She started walking 3 days ago and has normal developmental, motor, and verbal skills. Vaccinations are up-to-date. At age 6 months, length was 70 cm (28 in; 90th percentile) and weight was 8.5 kg (19 lb; 90th percentile). Today, length is 73 cm (29 in; 80th percentile) and weight is 9 kg (20 lb; 50th percentile). Vital signs are temperature 37.0°C (98.6°F), pulse 111/min, respirations 26/min, and blood pressure 88/48 mm Hg in the right upper extremity. The child is awake and alert. Abdomen is protuberant and gas-filled. There is no organomegaly. Bowel sounds are hyperactive. Muscle mass is diminished in all extremities and in the buttocks. Neurologic examination discloses no abnormalities. Determination of serum tissue transglutaminase antibody concentrations confirms the diagnosis. The mother says, "Is this a condition she's going to outgrow?" Which of the following is the most appropriate response?

A) The course of her daughter's condition is unpredictable; her daughter should be observed closely to see what happens
B) Her daughter is unlikely to outgrow her condition, but medications are available that will allow her to eat wheat without problems
C) Her daughter is unlikely to outgrow her condition regardless of therapy
D) Her daughter will likely outgrow her condition with desensitization with small amounts of wheat products
E) While her daughter is unlikely to outgrow her condition, she will most likely be able to tolerate more wheat in her diet as she gets older

q20)

Ans: C) Her daughter is unlikely to outgrow her condition regardless of therapy
nbme cert.


Celiac Disease is managed only by avoiding food containing gluten - Gluten free diet.
Complications: GI Lymphomas.

21.
A 47-year-old woman comes to the office for the first time because, she says, "During the past 3 months since Christmas, I've been getting these terrible headaches and I've just been so tired." She and her husband moved to the area 6 months ago and are living in an old house in the country. She says that until recently, she rarely had a headache and has been generally healthy. She seems to have more headaches during the weekends and she feels better at work. She has been taking oral contraceptives for many years. She does not smoke cigarettes and she drinks one glass of wine weekly. She is 163 cm (5 ft 4 in) tall and weighs 54 kg (120 lb); BMI is 21 kg/m2. Vital signs are temperature 36.2°C (97.2°F), pulse 90/min, respirations 14/min, and blood pressure 110/60 mm Hg. Physical examination discloses no abnormalities. At this time, it is most important to inquire about which of the following?
A) Family history of migraine
B) Hobbies
C) Household water source
D) Marital discord
E) Type of household heating

22.
A 54-year-old woman comes to the office because of intermittent dizziness for the past 3 weeks. She says, "When I roll over in bed, it feels like the room is spinning for a minute, particularly when I turn my head to the left." During these dizzy spells, she has not had diplopia, numbness, or weakness. Medical history is unremarkable and the patient takes no medication. She is 155 cm (5 ft 1 in) tall and weighs 57 kg (125 lb); BMI is 24 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 72/min, respirations 12/min, and blood pressure 120/70 mm Hg. With the patient supine on the examination table, turning her head to the left provokes a 30-second episode of the sensation of environmental rotation after a 15-second delay; during this episode, rotatory nystagmus occurs briefly. Repeating this maneuver a second time produces similar, but milder findings. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate initial diagnostic study?
A) Audiometry
B) Brain stem auditory evoked potential
C) Electronystagmography
D) MRA of the vertebral arteries
E) MRI of the brain and internal auditory canals with contrast
F) No diagnostic studies are indicated


23.
A previously healthy 48-year-old woman comes to the office because of difficulty sleeping and recurring nightmares during the past 4 weeks. She says she narrowly escaped a terrorist attack and that she misses her colleagues who were killed during the attack. She states, "I feel so angry all the time." She also notes that she has been easily distracted and has had difficulty meeting deadlines at work. She has been avoiding family and friends and has found little pleasure in recreational activities she used to enjoy. She does not take any medication. Vital signs and physical examination are normal. In addition to referring her for psychological counseling, the most appropriate management is to prescribe which of the following?
A) Amitriptyline
B) Lorazepam
C) Sertraline
D) Tranylcypromine
E) No pharmacotherapy is indicated at this time

24.
A 12-year-old girl with systemic lupus erythematosus (SLE) diagnosed 1 year ago is brought to the office by her parents for a routine follow-up visit. Since the diagnosis was made, the patient has been treated with prednisone, methotrexate, and hydroxychloroquine with good response. She has continued to report occasional mild frontal headaches, fatigue, and arthralgias; however, results of serial laboratory studies obtained during the past 2 months have been within the reference ranges. Her parents state that the child has missed 20 days of school during the past 4 months; the mother says, "We don't like to send her to school when she's not feeling well. Besides, with her condition, we're concerned about sending her to school where she could be exposed to children with contagious illnesses." The patient says that she misses seeing her friends when she misses so much school. She is 150 cm (59 in; 50th percentile) tall and weighs 42 kg (93 lb; 50th percentile). Vital signs are temperature 37.2°C (99.0°F), pulse 80/min, respirations 14/min, and blood pressure 110/72 mm Hg. Physical examination discloses no abnormalities except for mild discomfort on passive motion of her elbows, wrists, and knees. Results of her most recent laboratory studies obtained 2 weeks ago are shown:
Blood
Hemoglobin 12.5 g/dL
WBC 4500/mm3
ESR 20 mm/h
Serum antinuclear antibody (ANA) titer was 1:1280; her ANA has been stable for three consecutive months. Which of the following is the most likely underlying cause of this patient's excessive school absences?
A) Depression
B) Exacerbation of SLE symptoms
C) Malingering
D) School phobia
E) Vulnerable child syndrome

25.
A 55-year-old man with congestive heart failure comes to the office for a follow-up examination. He has had a 4.5-kg (10-lb) weight loss during the past 6 weeks and a 9-kg (20-lb) weight loss during the past year. He also has been having shortness of breath with minimal exertion. He has not had nausea, vomiting, diarrhea, or change in appetite. Four weeks ago, echocardiogram showed an ejection fraction of 15%. Current medications include digoxin, furosemide, spironolactone, lisinopril, and metoprolol. He smoked two packs of cigarettes daily for 20 years but stopped 1 year ago. He is 183 cm (6 ft) tall and weighs 61 kg (135 lb); BMI is 18 kg/m2. He appears cachectic. Vital signs are temperature 36.9°C (98.4°F), pulse 100/min, respirations 28/min, and blood pressure 100/60 mm Hg. Examination shows bitemporal wasting. Crackles are heard at both lung bases. S1 and S2 are normal; an S3 is heard. Liver span is 12 cm. Examination of the upper and lower extremities shows atrophy of the muscles. There is 3+ pitting edema of the ankles. Which of the following is the most appropriate management of his weight loss?
A) Oral nutritional supplementation
B) Physical therapy
C) Placement of a percutaneous endoscopic gastrostomy tube
D) Total parenteral nutrition
E) Use of an appetite stimulant

q21)
E) Type of household heating
nbme cert.

This patient has symptoms of CO poisoning, inquiring about the heating source is the next step.

q22)

F) No diagnostic studies are indicated

Please someone confirmed.


This is a Benign positional vertigo, Vertigo related to head movements. The Dix–Hallpike test is positive, nystagmus is a normal response when doing this test. Therefore no additional Dx tests are indicated. Tx is with Meclizine.

q23)
C) Sertraline
nbme cert.

Acute stress disorder < within 1 month of stressor>
Tx: BZD for anxiety symptoms, SSRI and other antidepressants can help for long term theraoy.

q24)
Ans: E) Vulnerable child syndrome
nbme cert.

Vulnerable child syndrome (VCS) refers to the combination of the parental view that their child is at increased risk for death despite the child's objective health and the resulting behavior problems in the child. Although risk factors for the development of the syndrome have been outlined, the variability in the development of VCS has not been explained.