NBME Form 3 Block 5
Finally on this thread
Kat, Alexa, Perception, please stay with me, this is the last one
Ufff!
Let's do it!
1.
A 20-year-old African American man with sickle cell disease comes to the office because of a 1-week history of intermittent burning pain in his chest and stomach. The patient says the chest pain is nonradiating and is relieved by eating. Medical history is significant for several hospital admissions for pain crises, pneumonia, acute chest syndrome, and right hip pain caused by aseptic necrosis. During his last hospitalization, the patient was advised to undergo total right hip replacement but he declined the operation because of the associated postoperative pain. The patient has been taking acetaminophen three to four times daily for hip pain, but 1 week ago, he added ibuprofen twice daily to his regimen because of increased pain. Today the patient does not appear acutely ill. He walks with a limp. Vital signs are temperature 37.0°C (98.6°F), pulse 78/min, respirations 12/min, and blood pressure 106/82 mm Hg. On physical examination, range of motion of the right hip is limited and unchanged from previous examinations. There is no tenderness to palpation over the costochondral cartilage. Palpation over the epigastrium discloses mild tenderness. The abdomen is scaphoid and symmetric. Bowel sounds are active. Stool in the rectal vault is brown and tests negative for occult blood. At this time, which of the following is the most appropriate diagnostic study?
A) Insertion of a nasogastric tube to check for occult blood
B) Supine and upright x-rays of the abdomen
C) Upper endoscopy
D) Upper gastrointestinal barium study
E) No diagnostic studies are indicated
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
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
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
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
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
7.
A 42-year-old white woman returns to the office because she has had intermittent headaches, sore throat, dysuria, fatigue, and difficulty sleeping during the past 10 months. She has been evaluated by numerous physicians during this period, and this is her third visit to your office in 6 months. She says her symptoms are worse than they were at her last visit 3 months ago. She says her hair and skin are dry and her legs feel weak. She notes that approximately 1 month ago a new copy machine was installed in the hallway outside her office. Since that time she has had almost daily headaches at work and increasing inability to think clearly. She reports that she no longer pumps her own gas because the smell of gasoline causes severe headaches. Physical examinations during the past two visits have disclosed no abnormalities. Throat culture was negative for β-hemolytic streptococci. MRI of the brain done 4 months ago was normal. Fasting laboratory study results from previous visits are shown:
Serum Blood
Glucose 80 mg/dL ESR 14 mm/h
TSH 3.5 μU/mL Hematocrit 37.6%
Urinalysis Normal
The patient is 168 cm (5 ft 6 in) tall and weighs 66 kg (145 lb); BMI is 23 kg/m2. Her weight has been stable. Vital signs are temperature 36.6°C (97.8°F), pulse 86/min, respirations 18/min, and blood pressure 106/60 mm Hg. Optic disc margins are sharp and there is no neck stiffness. Neurologic examination discloses good strength in both lower extremities. Mental status seems normal, although when asked to recall three objects she says, "I just can't remember." She refuses to do serial 7's because she says, "I've always been terrible at math." At this time, which of the following is the most appropriate diagnostic study?
A) EEG
B) Electromyography of the lower extremities
C) Lumbar puncture for examination of cerebrospinal fluid
D) Repeat MRI of the brain
E) No additional testing is necessary
8.
A 2-week-old newborn is brought to the office by her mother for her first well-child visit. The newborn was born at 37 weeks' gestation following normal pregnancy and uncomplicated delivery. Birth weight was 2300 g (5 lb; 5th percentile). Apgar scores were 8 at 1 minute and 9 at 5 minutes. The mother is breast-feeding her daughter and reports that the infant is now feeding more eagerly than she had been initially. The newborn is 46 cm (18 in; 5th percentile) in length and weighs 2500 g (5.5 lb; 5th percentile); head circumference is 32.5 cm (13 in; 5th percentile). Vital signs are temperature 37.0°C (98.6°F), pulse 126/min, and respirations 32/min. On physical examination, skin is faintly jaundiced but sclerae are not icteric. There is no rash other than some mild perineal inflammation. The anterior fontanel is patent. A white reflex is noted in the right eye; the left eye has a red reflex. There are no heart murmurs. Liver edge is palpable. Genitalia are normal. Which of the following is the most appropriate initial step?
A) Determination of total serum bilirubin concentration
B) Discontinuation of breast-feeding
C) MRI of the brain
D) Ophthalmologic consultation
E) Paired TORCH titers
9.
A 4-year-old girl who has been your patient since she was age 2 years is brought to the office by her mother because of burning on urination for the past 2 days. Her mother says, "She is going to the bathroom all the time and she has to go right away—all of a sudden." The mother notes that the child's urine has a strong odor. Her urinary stream has been normal. She has not had vomiting, bed-wetting, or daytime wetting or leaking. She has two siblings, neither of whom has had a urinary tract infection. She is 94 cm (3 ft 1 in; 10th percentile) tall and weighs 20 kg (45 lb; 95th percentile). Vital signs are temperature 37.0°C (98.6°F), pulse 80/min, respirations 20/min, and blood pressure 98/52 mm Hg. The child is well developed, pleasant, and cheerful. Abdominal examination discloses no masses, tenderness, or organomegaly. Genitourinary examination shows normal female genitalia. You suspect a urinary tract infection. A catheterized urine specimen is positive for nitrite and bacteria. The most likely cause of this infection is which of the following?
A) Neurogenic bladder
B) Poor toilet hygiene
C) Posterior urethral valves
D) Sexual abuse
E) Systemic bacteremia
10.
A 10-year-old boy with HIV infection is brought to the office by his mother because of a low-grade fever, headache, green nasal discharge, and ear pain for the past 2 days. He has had no weight loss and, until today, no change in his activity level. The patient's HIV infection is well controlled. He takes zidovudine and abacavir that are managed by his infectious disease specialist. Vital signs are temperature 37.6°C (99.7°F), pulse 100/min, respirations 22/min, and blood pressure 105/60 mm Hg. Physical examination discloses a right tympanic membrane that is erythematous and has poor mobility. There is minimal maxillary sinus tenderness. The remainder of the examination shows no abnormalities. X-ray of the sinuses is shown. The patient's mother asks if this new development is serious. Which of the following is the most appropriate response to the mother?
A) Antibiotics will cure his maxillary sinusitis and otitis media
B) He is most likely seriously ill with central nervous system lymphoma
C) He might have middle ear rhabdomyosarcoma with sinus extension that can be successfully treated
D) He will need to be hospitalized for administration of intravenous antibiotics to treat the sinus osteomyelitis
E) The medications have predisposed him to invasive aspergillus infection that is most difficult to treat
1E....not sure
2D....unilateral nostril affected
3C....wandering symptoms
4B....fears of further attacks,
5C..ecg...>CCF
6....no clue
7E....i think...GAD
8D.....retinoblastoma??
9B.....poor toilet hygiene..??
10A...evidenece of sinusitis and ottitis media.???
folks and grazie,katmd,alexa...v good morning and pl come for my rescue. thanks
Sorry didn't see this give me 2 mins
1. C wrong by NBME !! I think E and just give him PPis GERD Right?
2.D NBME CERT
3. C NBEM CERT
4. C NBME CERT
5. A NBME CERT
6. D NBME CERT
7. E NBME CERT
8. D NBME CERT
9. B NBME CERT
10. A wrong by name but I'm not sure if last min i changed it to D
ehh sorry about this one
I'm so sorry 4 is B NBME cert whoops sorry typed to fast
DOC....actually thank you v much
4....yah it is B as you said.
10..if A iswrong then D seems wright as you said.
thanks again.let us see others opinions
yes lets see what else is coming
to discuss
1.
A 20-year-old African American man with sickle cell disease comes to the office because of a 1-week history of intermittent burning pain in his chest and stomach. The patient says the chest pain is nonradiating and is relieved by eating. Medical history is significant for several hospital admissions for pain crises, pneumonia, acute chest syndrome, and right hip pain caused by aseptic necrosis. During his last hospitalization, the patient was advised to undergo total right hip replacement but he declined the operation because of the associated postoperative pain. The patient has been taking acetaminophen three to four times daily for hip pain, but 1 week ago, he added ibuprofen twice daily to his regimen because of increased pain. Today the patient does not appear acutely ill. He walks with a limp. Vital signs are temperature 37.0°C (98.6°F), pulse 78/min, respirations 12/min, and blood pressure 106/82 mm Hg. On physical examination, range of motion of the right hip is limited and unchanged from previous examinations. There is no tenderness to palpation over the costochondral cartilage. Palpation over the epigastrium discloses mild tenderness. The abdomen is scaphoid and symmetric. Bowel sounds are active. Stool in the rectal vault is brown and tests negative for occult blood. At this time, which of the following is the most appropriate diagnostic study?
A) Insertion of a nasogastric tube to check for occult blood
B) Supine and upright x-rays of the abdomen
C) Upper endoscopy
D) Upper gastrointestinal barium study
E) No diagnostic studies are indicated