step 2 ck nbme form 3 - radonc

[ArchivalUser]

I had my exams (Step 2 CK) on 30th April. I want to thank this great forum for all the wonderful discussions from all the participants. You guys have been fantastic! I learnt so much from here.

My advice to IMG™s taking this exam is, stick to what you have learnt in your medical school. Medicine is the same whether you are in USA or UK or China or India. And once you know your stuff from medical school, look at the questions (do lots of them “ NBME, usmleworld, etc) and work on your weaknesses. I stuck to this strategy for this monstrous exam.
Better still, if you have your own strategy, you should follow that.

Another advice is: be wary of what you read here. As much as I have learnt so much from this forum, I have also met people who pretend to score 99 and then try to sell study materials to you, eg notes, courses, etc. Some big commercial courses have their agents operating in this forum, doing their promotion. Just read with caution.

I would like to post my answers to Step 2 CK NBME form 3. I got 800 (full score), which I think means that I got most, if not all, of the questions correct. You can argue about the answers to these questions with other doctors day-in day-out, antagonize about the choices (C is right, but B can also be right ), and the both of you could be right. But ultimately there is one best answer.

If you think you have been helped by the answers, I have a favour to ask. Please take a few minutes to send it to other people that you know are preparing for this exam. Thank you.

[ArchivalUser]

NBME 3 BLOCK 1

1. A 12-year-old girl with chronic renal failure has had persistent epistaxis for 15 days. Laboratory studies show:

Hemoglobin 7.2 g/dL
Platelet count 175,000/mm3
Bleeding time 12 min
Prothrombin time 12 sec
Partial thromboplastin time (activated) 30 sec
Serum urea nitrogen (BUN) 125 mg/dL

Which of the following is the most likely cause of the epistaxis?
O A) Acquired platelet dysfunction
O B) Circulating immune complexes
O C) Erythropoietin deficiency
O D) Factor III deficiency
O E) Hypocalcemia

A

2. A 57-year-old woman comes to the physician because of depressed mood and daily crying episodes since the death of her father 6 weeks ago. She has had difficulty concentrating, decreased libido, and a 3.2-kg (7-Ib) weight loss during this period. She is less interested in her usual activities but continues to work productively. She sleeps for about 8 to 10 hours every night. Over the past 2 weeks, she has been smoking and drinking more frequently, she now smokes one-half pack of cigarettes daily and drinks two to three glasses of wine every other day. She has no history of serious illness and takes no medications. She is 163 cm (5 ft 4 in) tall and weighs 80 kg (176 Ib), BMI is 30 kg/m2. Her temperature is 37°C (98.6°F), pulse is 641min, and blood pressure is 108160 mm Hg. The remainder of the examination shows no abnormalities. Mental status examination shows a sad mood and restricted affect. Her speech is normal in rate and rhythm. There is no evidence of suicidal ideation or hallucinations. She can recall three of three objects after 5 minutes. Long-term memory is intact. Which of the following is the most likely diagnosis?

O A) Alcohol dependence
O B) Bereavement
O C) Bipolar disorder
O D) Cyclothymic disorder
O E) Dysthymic disorder
O F) Major depressive disorder
O G) Malingering

B

3. An 80-year-old man is brought to the emergency department on an 80-degree day 2 hours after a syncopal episode while playing golf. He plays golf twice weekly. An ECG obtained at his last examination 6 months ago showed occasional premature ventricular contractions (PVCs). On arrival, his temperature is 38°C (100.4°F), blood pressure is 150/90 mm Hg, pulse is 80/min and regular, and respirations are 22/min. Cardiac examination shows a grade 3/6, late-peaking systolic ejection murmur. No bruits are heard over the carotid arteries, but the upstrokes are delayed. Which of the following is the most likely cause of the syncope?

O A) Aortic stenosis
O B) Heat stroke
O C) Hypertensive cardiomyopathy
O D) Platelet emboli
0 E) PVCs

A

4. Five days after sustaining a 6-cm laceration through the skin and subcutaneous tissue of the left upper extremity with a clean knife, a 52-year-old man has increasing tenderness in the area of the laceration. Treatment at the time of injury included cleansing and dressing of the wound. The wound is now erythematous, and yellow pus is expressed when pressure is applied. Which of the following is the most likely mechanism for the accumulation of pus?
O A) Chemotaxis
O B) Dysplasia
O C) Hyperoxia
O D) Metaplasia
0 E) Vasoconstriction

A

5. Twenty-four hours after splenectomy for blunt trauma sustained in a motor vehicle collision, a previously healthy 25-year-old man has oliguria and pain at the incision site. Intraoperative complications included a 30-minute period of hypotension and a total blood loss of 2.5 L requiring 4 units of packed red blood cells. Currently, his temperature is 38°C (100.4°F), blood pressure is 120180 mm Hg, pulse is 1001min, and respirations are 14/min. Central venous pressure is 8 cm H 2O (N=5-8). The lungs are clear to auscultation, and breath sounds are heard bilaterally. Abdominal examination shows no distention, bowel sounds are absent. A Foley catheter is in place, and over the past 3 hours, his urine output has been 20 mL/h. Laboratory studies show a hematocrit of 28%, a serum urea nitrogen (BUN) level of 30 mg1dL, and a serum creatinine level of 2.5 mgfdL, serum electrolyte levels are within normal limits. Which of the following is the most likely explanation for these findings?
O A) Acute tubular necrosis
O B) Foley catheter malfunction
O C) Hypervolemia
O D) Transfusion reaction
0 E) Ureteral injury

A

6. A 32-year-old man comes to the physician for a second opinion regarding an enlarged cervical lymph node that he noted 6 weeks ago. He has not had pain or tenderness but has been unable to return to work despite normal findings on a biopsy of the node 4 weeks ago. He had a mild upper respiratory tract infection 1 month ago. His maternal uncle recently died of lymphoma. He states that cancer runs in his family, and that for the past several years he has thought that he will have some kind of cancer eventually. Which of the following is the most likely diagnosis?
O A) Asthma
O B) Conversion disorder
O C) Factitious disorder
O D) Hypochondriasis
O E) Malingering
O F) Pulmonary embolus
0 G) Somatization disorder

D

7. A 32-year-old woman, gravida 3, para 2, at 40 weeks' gestation is admitted to the hospital in labor. Vaginal and anal cultures at 36 weeks' gestation were positive for group B streptococcus. She has no known drug allergies. Which of the following is the most appropriate pharmacotherapy for this patient before delivery?
O A) Intravenous azithromycin
O B) Intravenous clindamycin
O C) Intravenous penicillin
O D) Oral amoxicillin and clavulanate
O E) Oral erythromycin
O F) No treatment until after delivery

C

8. A 38-year-old woman comes to the physician because of a low-grade fever and generalized rash for 4 days. She is currently receiving cefazolin therapy for chronic osteomyelitis. Her temperature is 38.2°C (100.8°F), blood pressure is 1501108 mm Hg, and pulse is 1001min. There is a faint diffuse maculopapular rash. Examination of the back shows no costovertebral angle tenderness. Cardiac and pulmonary examinations show no abnormalities. Laboratory studies show:

Leukocyte count 10,8001mm3
Segmented neutrophils 60%
Bands 8%
Eosinophils 4%
Lymphocytes 20%
Monocytes 8%

Serum
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1.6 mg/dL
Urine
WBC 121hpf
RBC 81hpf
RBC casts none
WBC casts rare

Eosinophils are found in the urine sediment. Which of the following is the most likely explanation for these findings?

O A) Acute tubular necrosis
O B) Fibromuscular dysplasia
O C) Interstitial nephropathy
O D) Polyarteritis nodosa
O E) Pyelonephritis
O F) Wegener's granulomatosis

C

9. A healthy 60-year-old woman comes to the physician for a routine examination. She has no history of illness over the past year and has never had an operation. She takes no medications. Menopause occurred 6 years ago. She weighs 57 kg (125 lb) and is 160 cm (63 in) tall. Pelvic examination shows atrophic external genitalia and a small, midpositioned uterus. The left ovary is 3 x 3 cm, the right ovary is not palpable. Which of the following is the most appropriate next step in management?

O A) Reexamination in 1 month
O B) Reexamination in 1 year
O C) Obtain patient's medical records
O D) Measurement of serum progesterone level
O E) Pelvic ultrasonography

E
Normally, on physical examination, the ovaries are 2-3 cm in young women and not palpable in postmenopausal women.

10. On the fifth day of a 7-day cruise in the western Caribbean, a 37-year-old woman develops headaches, fever, chills, abdominal discomfort, and watery diarrhea over a 12-hour period. Many other passengers and crew members have had similar symptoms. Her temperature is 37°C (98.6°F). Abdominal examination shows diffuse tenderness without rebound, bowel sounds are hyperactive. Her leukocyte count is 11,000/mm3. Gram's stain of a stool specimen shows a small number of neutrophils. A stool culture grows Salmonella enteritidis. Two days after treatment with bismuth subsalicylate and oral rehydration, her symptoms subside. Which of the following is the most appropriate immediate measure to prevent further spread of this pathogen?

O A) Cancellation of shore leave for all crew members
O B) Elimination of seafood and shellfish from the ship's menu
O C) Exclusive use of pasteurized eggs
O D) Hyperchlorination of the ship's drinking water
O E) Reassignment of all food-handling personnel to other duties
O F) Treatment of all affected persons with doxycycline

E

11. A 57-year-old man with a 10-year history of type 2 diabetes mellitus comes to the physician fora routine examination. His last office visit was 6 months ago. He feels well. Current medications include enalapril and glyburide. He is 168 cm (5 ft 6 in) tall and weighs 84 kg (185 Ib), BMI is 30 kg/mZ. His pulse is 60/min, and blood pressure is 100/70 mm Hg. Funduscopic examination shows soft and hard exudates. Laboratory studies show
Hemoglobin Al. 12%
Serum
Urea nitrogen (BUN) 23 mg/dL
Creatinine 1.4 mg/dL
Urine protein 1+
Which of the following is the most appropriate additional pharmacotherapy?

O A) Atenolol
O B) Captopril
O C) Hydrochlorothiazide
O D) Metformin
0 E) Verapamil

D

12. An 82-year-old man is brought to the physician by his neighbors because he looks ill." They say that he subsists primarily on hot dogs and canned meats and that his slovenly habits have attracted rats to the neighborhood. He does not drink alcohol but is forgetful. Examination shows a pleasant, dirty, confused man who appears thin. He has diffuse purpura on his legs and perifollicular inflammation. Which of the following is the most likely cause of these findings?
O A) Aplastic anemia
O B) Leukemia
O C) Rat-bite fever
O D) Scurvy
O E) Warfarin ingestion

D

13. A 6-month-old girl is brought to the physician because of fever, cough, and coryza for 1 day. Her pulse is 1001min, and respirations are 501min. Her cough is harsh and sounds like a dog's bark. There is inspiratory stridor and intercostal retractions. Which of the following is the most likely diagnosis?
O A) Asthma
O B) Bacterial tracheitis
O C) Bronchiolitis
O D) Foreign body in the small airways
O E) Foreign body in the trachea
O F) Laryngotracheobronchitis
O G) Pneumonia
O H) Pneumothorax
0 I) Pulmonary edema

F


14. An 80-year-old man has had poor balance for 6 months. He has a history of hypertension treated with hydrochlorothiazide. His blood pressure is 136/86 mm Hg. Neurologic examination shows mild tremor of the hands when his arms are outstretched and decreased
vibratory sensation at the knees. Deep tendon reflexes of the quadriceps and gastrocnemius-soleus muscles are hyperactive. Babinski's sign is present bilaterally. He is unable to stand with his eyes closed. Which of the following is most consistent with normal
age-related changes?

O A) Babinski's sign
O B) Hyperactive deep tendon reflexes of the gastrocnemius-soleus muscles
O C) Inability to stand with the eyes closed
O D) Reduced vibratory sensation at the knees
0 E) Tremor of the outstretched hands

E

15. A previously healthy 6-month-old boy is brought to the physician because of a 12-hour history of vomiting and diarrhea. He vomits after all feedings, the vomitus does not contain blood or bile. His mother says that he has had fewer wet diapers than usual during this period. He appears dehydrated and is crying without tears. He is at the 50th percentile for length and 30th percentile for weight. He appears lethargic. His temperature is 38°C (100.4°F), pulse is 180/min, and blood pressure is 60/40 mm Hg. Examination shows sunken eyes, dry mucous membranes, and a sunken anterior fontanel. Arterial blood gas analysis on room air shows:
pH 7.2
PCO2 38 mm Hg
PO2 90 mm Hg

Which of the following is the most likely explanation for this patient's arterial blood gas findings?
O A) Excessive metabolic acid formation
O B) Impaired ventilation
O C) Increased chloride loss (àincrease HCO3 which is not the case here)
O D) Increased CO2 concentration in the extracellular fluid
0 E) Increased metabolic acid produced by the gastrointestinal tract

A

16. A 42-year-old man is brought to the emergency department because of a 2-day history of muscle spasms and jaw stiffness. He is sexually active with three partners and uses condoms inconsistently. He has a 5-year history of intravenous heroin use. He appears irritable. His temperature is 38.8°C (101.8°F), pulse is 120/min, and blood pressure is 152/96 mm Hg. Physical examination shows facial and paraspinal muscle spasms and rigidity; stimulation of the muscles results in paroxysmal spasms. Mobility of the jaw is decreased. Neurologic examination shows hyperreflexia. Which of the following is most likely to have prevented this condition?
O A) Consistent condom use
O B) Botulism antitoxin therapy
O C) Prednisone therapy
O D) Rifampin therapy
O E) Tetanus toxoid vaccination
0 F) Vitamin B1 (thiamine) supplementation

E

17. A 72-year-old woman comes to the physician because of increasing episodes of urinary incontinence over the past 6 months. Her incontinence usually occurs at night, she feels no sensation to urinate prior to the episodes. The episodes are less frequent if she schedules her trips to the bathroom and restricts liquid intake several hours prior to bedtime. She has a 20-year history of type 2 diabetes mellitus. Current medications include metformin and glyburide. Funduscopic examination shows mild retinopathy. Pelvic examination shows normal vaginal mucosa. Sensation to pinprick is decreased in a stocking-glove distribution. Urinalysis shows 1 + protein and no leukocyte esterase or nitrites. Which of the following is the most likely cause of this patient's urinary symptoms?

O A) Functional incontinence
O B) Hypersensitivity of the detrusor muscle
O C) Overflow of urine from large residual volumes
O D) Urethral atrophywith loss of urethrovesical angle
O E) Normal aging

C

18. An afebrile 2-year-old boy has had right ear pain for 3 days. He has been swimming everyday for the past week. Purulent fluid is draining from the right external ear canal, and manipulation of the pinna is painful. No abnormalities are noted on visualization of tympanic membranes. Which of the following is the most likely causal organism?
O A) Haemophilus influenzae type b
O B) Moraxella catarrhalis
O C) Pasteurella multocida
O D) Pseudomonas aeruginosa
O E) Streptococcus pneumoniae

D

19. Over the past 2 weeks, a 60-year-old man has had shortness of breath on exertion. He also has paroxysmal nocturnal dyspnea with two-pillow orthopnea. He has taken aspirin daily since a myocardial infarction 3 years ago. He has a history of atrial fibrillation well controlled with digoxin and type 2 diabetes mellitus treated with diet. His blood pressure is 136188 mm Hg, pulse is 98/min and irregular, and respirations are 20/min. Jugular-venous pressure is increased. Breath sounds are decreased over the right lung base.. there is dullness to percussion. Cardiac examination shows an S. gallop. There is 2+ edema of the lower extremities. Pulse oximetry shows an oxygen saturation of 90%. Which of the following is the most appropriate next step in diagnosis?
O A) X-ray film of the chest
O B) Ambulatory ECG monitoring
O C) Thallium stress test
O D) Echocardiography
O E) Ventilation-perfusion lung scans

A

20. A 47-year-old woman comes to the emergency department because of severe abdominal pain for 3 hours. The pain began after a 2-week drinking binge. She has a 15-year history of alcoholism. She has no history of jaundice or hepatitis. Current medications include multivitamins and iron. Her temperature is 38°C (100.4°F), blood pressure is 110/80 mm Hg, and pulse is 110/min. Examination shows mild jaundice and diffuse spider angiomata over the trunk and abdomen. The liver is tender to palpation. A complete blood count shows mild anemia with normal red cell indices. Ultrasonography of the abdomen shows normal-sized hepatic ducts. Which of the following is the most likely set of laboratory findings?

Total Indirect Alkaline
Bilirubin Bilirubin Phosphatase Reticulocyte
(mg/dL) (mg/dL) (U/L) (ALT, GPT) (U/L) Count (%)
O A) 2 0.9 80 30 1.2
O B) 3 2.8 70 30 1.0
O C) 3 2.8 80 20 3.0
O D) 4 2.0 800 200 1.5
O E) 4 1.0 150 400 1.0

E

21. A 3-month-old boy is brought to the physician in January because of difficulty breathing, clear nasal discharge, and cough for 24 hours. His temperature is 37.6°C (99.6°F), blood pressure is 88/54 mm Hg, pulse is 168/min, and respirations are 60/min. Bilateral wheezing, prolonged expiration, and a grade 2/6 systolic murmur along the left sternal border are heard. The liver is palpated 3 cm below the right costal margin. An x-ray film of the chest shows bilateral hyperinflation and no cardiomegaly. Which of the following is the most likely diagnosis?
O A) Adenovirus pneumonia
O B) Congestive heart failure
O C) Influenza A virus pneumonia
O D) Respiratory syncytial viral bronchiolitis
O E) Staphylococcal pneumonia
0 F) Status asthmaticus

D

22. A 22-year-old woman comes to the physician because of diffuse constant headaches and vision problems for 3 months, the headaches are worse in the morning when she awakens from sleep. She also has had brief episodes of loss of vision in both eyes. She has had an 18-kg (40-Ib) weight gain over the past year. She now weighs 100 kg (220 lb) and is 163 cm (64 in) tall. Visual acuity is 20/30 bilaterally. Visual fields are full, but the blind spots are enlarged bilaterally. Funduscopic examination shows marked blurring of the optic disc margins bilaterally. The remainder of the neurologic examination shows no abnormalities. Which of the following is the most likely diagnosis?
O A) Amaurosis fugax
O B) Central retinal vein occlusion
O C) Glaucoma
O D) Macular degeneration
O E) Migraine
O F) Nutritional optic neuropathy
O G) Optic neuritis
O H) Pituitary adenoma
O I) Pseudotumor cerebri
0 J) Temporal arteritis

I

23. A 32 yo man with 1-year history of constant worries about his financial situation and health despite his success.

A. Buspirone

24. A 49-year-old man has had progressive shortness of breath over the past year. He now has dyspnea after walking up one flight of stairs. He has fine crackles bilaterally on auscultation of the lungs. Spirometry shows:

Vital capacity (VC) decreased
FEV1 decreased
Ratio of FEV, to VC increased

Arterial blood gas analysis on room air:
pH 7.42
PCO2 60 mm Hg
PO2 34 mm Hg

Which of the following is the most likely diagnosis?
0 A) Asthma
p B) Bronchiectasis
o C) Chronic bronchitis
p D) Emphysema
p E) Pulmonary fibrosis

E

25. A previously healthy 24-year-old woman, gravida 3, para 3, is brought to the emergency department because of deep, sharp, intermittently severe pain in the left lower quadrant of the abdomen for 2 hours. Her last menstrual period was 3 weeks ago. She takes no medications. She is in obvious distress and is lying on her left side with her lower extremities drawn up against her abdomen. Her temperature is 37°C (98.6°F), blood pressure is 140/70 mm Hg, and pulse is 125/min. Abdominal examination shows rigidity and tenderness. Pelvic examination shows a 12-cm mass in the left lower quadrant of the abdomen. Which of the following is the most appropriate next step in management?

O A) Ultrasound-guided aspiration
O B) Dilatation and curettage
O C) Exploratory laparotomy
O D) Hysterectomy

C

26. Fourteen hours after admission to the hospital for treatment of severe hypertension, a 32-year-old woman has stridor. On admission, she was given captopril. She appears anxious. Her blood pressure is 140/85 mm Hg, pulse is 140/min, and respirations are 32/min. Examination shows swelling of the lips and tongue. Diffuse stridorous wheezes are heard on auscultation. There is diminished air movement. Which of the following is the most appropriate next step in management?

p A) Observation only
p B) Measurement of serum captopril level
O C) Measurement of serum IgE level
o D) X-ray film of the chest
0 E) Tracheal intubation

E

27. A 65-year-old woman has had progressive irritability, palpitations, and heat intolerance for 6 months. She has had a 7-kg (15-Ib) weight loss during this period. She has had a neck mass for more than 10 years. 1311 scan shows an enlarged thyroid gland with multiple areas of increased and decreased uptake. Which of the following is the most likely diagnosis?
O A) Graves' disease
O B) Multinodular goiter
O C) Thyroiditis
O D) Toxic adenoma
0 E) Triiodothyronine (T3) thyrotoxicosis

B

28. 19 yo man has fever, headache, sore throat, swelling of cervical LN™s for 5 days.

C. EBV

For each patient with chronic knee pain, select the most appropriate next step in management.

C A) Anterior cruciate ligament reconstruction
C B) Arthroscopic partial meniscectomy
C C) Quadriceps strengthening exercises
C D) Sympathetic blockade
C E) Total knee replacement
C F) Upper tibial osteotomy

29. 18 yo woman. Answer C

30. A 70-year-old man comes to the physician because of knee pain that has been present for 10 years. He is unable to comfortably walk further than one block and has difficulty sleeping because of the pain. He has pain on both medial and lateral sides of the knee. Range of motion is from 15 to 100 degrees, there is a bowleg deformity when he stands.

E

31. A 55-year-old man with alcoholic cirrhosis is hospitalized for 2 weeks in April for treatment of gastrointestinal bleeding. His last immunization for diphtheria-tetanus (Td) was 6 years ago. Which of the following is the most appropriate management prior to discharge?

O A) Administration of immune globulin
O B) Inactivated poliovirus vaccine
O C) Influenza virus vaccine
O D) Pneumococcal vaccine
0 E) Td toxoids

D

32. One week after cholecystectomy for acute cholecystitis, a 57-year-old woman comes to the physician because of a 1-day history of abdominal cramps and watery, green, foul-smelling diarrhea. She finished a 7-day course of cefoxitin 3 days ago. She appears dehydrated. Her temperature is 39.8°C (103.6°F), pulse is 115/min, and blood pressure is 105/70 mm Hg. Abdominal examination shows moderate distention and diffuse tenderness, there is no guarding. Test of the stool for occult blood is positive, the stool contains leukocytes. Her hemoglobin level is 10.8 g/dL, and leukocyte count is 39,000/mm3. The patient is admitted to the hospital, and administration of intravenous fluids is begun. Which of the following is the most appropriate next step in pharmacotherapy?
O A) Intravenous amphotericin
O B) Intravenous ampicillin, clindamycin, and gentamicin
O C) Intravenous corticosteroids
O D) Oral diphenoxylate and atropine
0 E) Oral metronidazole

E

A picture here

33. A 32-year-old comes to the physician because of painless growths around her anal region that she first noticed 4 months ago. Over the past 10 years, she has had sexual intercourse with multiple partners. She has a 4-year history of Crohn's disease. Medications include sulfasalazine and metronidazole. Her father has psoriasis. A photograph of the lesions is shown. Examination shows no other abnormalities. Which of the following is the greatest risk factor for this condition?
O A) Crohn's disease
O B) Family history of psoriasis
O C) Multiple sexual partners
O D) Treatment with metronidazole
0 E) Treatment with sulfasalazine

C

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with dysphagia, select the most likely diagnosis.

O A)Achalasia
O B)Adenocarcinoma of the esophagus
O C)Candidal esophagitis
O D) Diffuse esophageal spasm
O E) Polymyositis
0 F)Refluxesophagitis
0 G)Scleroderma (systemic sclerosis)
0 H)Squamous cell carcinoma of the esophagus
0 I)Viral esophagitis


34. A 42-year-old man with an 8-year history of intermittent difficulty swallowing solids and liquids has had increasingly severe exacerbations because of stress over the past 6 months. He also has nocturnal regurgitation and cough. Esophageal motility studies show failure of relaxation of the lower esophageal sphincter.

A

For each patient with dysphagia, select the most likely diagnosis.

¢ A) Achalasia 0 F)Refluxesophagitis
Q B) Adenocarcinoma of the esophagus 0 G)Scleroderma (systemic sclerosis)
p C) Candidal esophagitis 0 H)Squamous cell carcinoma of the esophagus
p D) Diffuse esophageal spasm 0 I)Viral esophagitis
0 E) Polymyositis

35. A 45-year-old woman has had generalized weakness for 1 year, increasing difficulty walking up stairs over the past 6 months, and difficulty swallowing for 1 month. Examination shows weakness of the proximal muscles of the extremities. Ear, nose, and throat examinations and manometry show decreased contractions of the pharynx with decreased upper esophageal tone.

E

36. A 42-year-old man with hypertension is brought to the emergency department 1 hour after the onset of chest discomfort, severe headache, irritability, and confusion. His blood pressure is 2201148 mm Hg. Examination shows papilledema. Urinalysis shows blood. An ECG shows ischemic changes with left ventricular hypertrophy. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?

O A) Atenolol
O B) Captopril
O C) Diltiazem
O D) Furosemide
O E) Guanethidine
O F) Hydralazine
O G) Losartan
O H) Methyldopa
O I) Nitroprusside
O J) Prazosin
0 K) Thiazide diuretic

I

37. A 2-year-old girl is found floating facedown in a swimming pool. On rescue, she immediately coughs and breathes spontaneously. She is conscious and oriented. Without treatment, which of the following is the most likely outcome for this child?
A) Complete recovery
B) Development of acute respiratory distress syndrome
C) Hemolysis
D) Pulmonary hypertension
E) Severe neurologic deficit

A

38. A 25-year-old woman has had daily cough and wheezing for 4 months. She has had difficulty sleeping because of her symptoms. Inspiratory and expiratory wheezes are heard with a slightly prolonged exhalation phase. Rz Adrenergic agonist therapy by inhalation is begun. She is still mildly symptomatic during the day with bronchospastic episodes occurring three times weekly at night. Which of the following medications should be added to the regimen?
O A) Inhaled glucocorticoids
O B) Inhaled ipratropium
O C) Oral erythromycin
O D) Oral furosemide
0 E) Oral theophylline

A

39. Five years after being shot in the right thigh, a 21-year-old man comes to the emergency department because of a busing sensation adjacent to the scar. At the time of the initial wound, he was discharged after 6 hours of observation with no fractures or soft-tissue
swelling. A loud murmur is heard on auscultation, there is a thrill. He has dilated varicose veins with incompetent valves in the lower leg. Which of the following is the most likely diagnosis?
O A) Arterial spasm
O B) Arteriovenous fistula
O C) Deep venous thrombosis
O D) Occlusion of the superficial femoral artery
O E) Pseudoaneurysm

B

40. A study is conducted to investigate the prevalence of past infection with genital herpes among students attending a large coeducational Midwestern university. After obtaining informed consent, the study participants undergo antibody testing for herpes simplex virus 2 (HSV). Which of the following is the most important factor in determining the validity of a positive test?

A) The number of sexual partners of the student
B) The proportion of students infected with HSV
C) The proportion of students with negative tests
D) The proportion of students with positive tests
E) The total number of students screened

B

41. During a routine examination, a 20-year-old man is found to have a firm, bilaterally enlarged thyroid gland and lymphadenopathy. His father died of thyroid cancer at the age of 40 years. Which of the following hormones is most likely associated with this patient's findings?
O A) ACTH
O B) ADH (vasopressin)
O C) Aldosterone
O D) Calcitonin
O E) Growth hormone
O F) G3-hCG
O G) Insulin
O H) Parathyroid hormone
O I) Thyroid-stimulating hormone
0 J) Thyroxine (T4)

D

42. Twelve days after sustaining a cerebral infarction, a 72-year-old man has fever and cough. Initial symptoms included inability to move his right arm and leg, swallow, speak, or respond to questions. He has been receiving a diet of pureed foods since he recovered his ability to swallow 3 days ago. He is wearing false teeth. His temperature now is 38.8°C (101.8°F), blood pressure is 135/85 mm Hg, pulse is 94/min, and respirations are 28/min. Examination shows moderate weakness of the facial muscles and right extremities. Gag reflex is absent. Breath sounds are decreased, and there is dullness to percussion over the right lung base posteriorly. An x-ray film of the chest shows an infiltrate in the posterior basal segment of the right lung. Which of the following is most likely to prevent recurrence of this patient's lung condition?
O A) Removal of false teeth
O B) Suppression of gastric acid production
O C) Chronic antibiotic prophylaxis
O D) Administration of metoclopramide to increase gastrointestinal motility
O E) Insertion of a feeding jejunostomy tube

E

43. A previously healthy 72-year-old man is brought to the physician because of two episodes of transient paresis in the left arm during the past 2 days; each episode lasted for 3 to 4 minutes. No bruits are heard over the carotid arteries, and there are no cardiac murmurs. Carotid duplex ultrasonography and confirmatory arteriography show a 30% stenosis of the internal carotid arteries bilaterally. Which of the following is the most appropriate next step in management?
A) Aspirin therapy
B) Heparin therapy
C) Nifedipine therapy
D) Placement of a carotid endovascular stent
E) Carotid endarterectomy

A

44. A 35-year-old man with a 10-year history of persistent hallucinations and delusions comes for a follow-up examination. He has been treated with haloperidol, chlorpromazine, and fluphenazine with minimal relief of symptoms. He is currently taking haloperidol. On
examination, he walks slowly with no arm swing and has no facial movements. Which of the following is the most likely cause of his motor behavior?
O A) Excess limbic y-aminobutyric acid activity
O B) Increased serum prolactin level
O C) Nigrostriatal dopamine blockade
O D) Noradrenergic depletion in the frontal lobe
O E) Ventral tegmental dopamine blockade

C

45. An 82-year-old woman comes to the physician because of a 2-month history of progressive shortness of breath with exertion and a 3-week history of right upper quadrant abdominal discomfort. She has chronic obstructive pulmonary disease, hypertension, and
rheumatoid arthritis. Medications include methotrexate, hydrochlorothiazide, naproxen, albuterol metered-dose inhaler, and aspirin. Examination shows pallor. Breath sounds are decreased. The liver is enlarged, firm, and mildly tender. Test of the stool for occult blood is positive. Her hematocrit is 27%, and mean corpuscular volume is 76 pm3. A CT scan of the abdomen shows multiple hypodense lesions in the liver. Which of the following is the most likely diagnosis?
O A) Cholangiocarcinoma
O B) Hepatocellular carcinoma
O C) Lymphoma
O D) Metastatic colon cancer
O E) Metastatic lung cancer
O F) Metastatic pancreatic cancer

D

46. On routine health maintenance examination, a 23-year-old man has a systolic murmur. There is no family history of heart disease. His blood pressure is 110170 mm Hg, and pulse is 601min. Cardiac examination shows a point of maximal impulse in the fifth intercostal
space at the midclavicular line, there is a normal S1 and a split, fixed S2. A grade 216, systolic ejection murmur is heard at the left sternal border, there is no change with inspiration, Valsalva's maneuver, or hand grip. An exercise stress test shows no abnormalities. Which of the following is the most likely cause of this patient's cardiac murmur?
O A) Aortic stenosis
O B) Atrial septal defect
O C) Hypertrophic cardiomyopathy
O D) Mitral valve prolapse
O E) Ventricular septal defect

B

[ArchivalUser]

BLOCK 2

1. For the past 10 years, a 28-year-old woman has followed a strict diet that prohibits dairy products, meat, fish, and fowl. On routine examination, her hematocrit is 30%, and mean corpuscular volume is 122 pm3. Which of the following is the most
appropriate next step in diagnosis?

O A) Erythrocyte folate determination
O B) Serum iron and total iron-binding capacity determinations
O C) Serum thyroid hormone determination
O D) Serum urea nitrogen (BUN) determination
O E) Serum vitamin B12 (cyanocobalamin) determination

E

2. A 47-year-old man comes to the physician because of a persistent nonproductive cough for 3 months. He has not had fever, rhinorrhea, or nasal congestion. He was seen by a physician 3 months ago for the cough and treated with amoxicillin and an over-the-counter cough medication. He has a 3-month history of hypertension well controlled with lisinopril. He is in no distress. He weighs 79 kg (175 lb) and is 178 cm (70 in) tall. His temperature is 37.1°C (98.8°F), blood pressure is 130178 mm Hg, pulse is 721min and regular, and respirations are 161min. Examination shows no abnormalities. A complete blood count and x-ray films of the chest show no abnormalities. Which of the following is the most appropriate next step in management?

O A) X-ray films of the sinuses
O B) Discontinue lisinopril therapy
O Q Add a beclomethasone inhaler to the medication regimen
O D) Add ciprofloxacin to the medication regimen
O E) Add hydrocodone to the medication regimen

B

3. A 12-year-old girl is brought to the physician by her mother because she is concerned about her daughter's difficulty making friends and socializing. Her development and adjustment had been normal until 6 months ago when she began to refuse to use restrooms at school or eat in the cafeteria. Her mother describes her as a quiet, serious child who does not readily interact with other people. Her teachers report that her concentration varies. at times, she appears to be daydreaming. On examination, she is reserved but pleasant and appears to be of normal intelligence. Her speech is normal in rate and rhythm. She says that she is concerned that her voice will fail her if she has to read aloud in class. Which of the following is the most likely diagnosis?

O A) Attention-deficitthyperactivity disorder, inattentive type
O B) Autistic disorder
O C) Expressive language disorder
O D) Oppositional defiant disorder
O E) Selective mutism
O F) Social phobia
O G) Age-appropriate behavior

F

A picture here for q4

4. A 25-year-old woman is brought to the emergency department 45 minutes after being hit in the right eye with a tennis ball. She has severe pain and decreased vision in the injured eye. Visual acuity is 201400 on the right. A photograph of the eye is shown. Which of the following is the most likely diagnosis?
O A) Acute angle-closure glaucoma
O B) Anterior iritis
O C) Cataract
O D) Hyphema
O E) Hypopyon

D

5. A 44-year-old woman is brought to the emergency department 40 minutes after being stabbed in the left groin. Her blood pressure is 128/84 mm Hg, pulse is 100/min, and respirations are 16/min. Examination of the wound shows a small hematoma and no external bleeding. Popliteal and pedal pulses are palpable in the left lower extremity below the injury. Lacerations of the femoral artery and vein are found and repaired. Two days postoperatively, she has progressively severe pain of the left lower extremity and swelling of the leg from the knee down. Which of the following is the most likely cause of her new symptoms?

O A) Arterial embolism
O B) Compartment syndrome
O C) Lymphatic disruption from the injury
O D) Thrombosis of the femoral vein
0 E) Wound hemorrhage

B

6. The crude mortality rate for coronary artery disease in Community A is twice the crude mortality rate for coronary artery disease in Community B. The age-standardized mortality rates for coronary artery disease in the two communities are the same. These findings are most consistent with which of the following inferences?

A) Coronary artery disease mortality in the elderly is higher in Community A than Community B
B) Coronary artery disease mortality in young adults is higher in Community A than Community B
C) The population of Community B is younger than the population of Community A
D) The proportionate mortality from coronary artery disease is higher in Community A than Community B
E) The two communities have similar age distributions

C

7. An otherwise healthy 28-year-old man comes to the physician because of a dry hacking cough for 3 months. A routine examination 6 months ago showed no abnormalities. His paternal grandfather had colon cancer. Examination today shows normal findings. An x-ray film of the chest shows a large anterior mediastinal mass. Which of the following is the most likely origin of this neoplasm?
O A) Colon
O B) Kidney
O C) Prostate
O D) Stomach
0 E) Testicle

E

A testis tumor may become metastatic and manifest with large retroperitoneal and/or chest lesions, while the primary tumor is nonpalpable. Scrotal ultrasonography may locate the primary tumor. Histopathology of the primary testis often shows a focus of tumor surrounded by fibrous scar, termed burned-out testis cancer.

8. A 50-year-old man has a cardiac arrest during sexual intercourse. He is promptly resuscitated and recovers uneventfully from an acute anterior wall myocardial infarction. At discharge from the hospital, he and his wife inquire about the safety of future sexual intercourse. Which of the following is the most appropriate advice?
O A) Psychiatric consultation is necessary
O B) Sexual intercourse should be performed while wearing an ambulatory ECG monitor
O C) Sexual intercourse will be safe when exercise tolerance improves
O D) They should wait 3 months before having sexual intercourse
O E) They should have sexual intercourse as soon as possible to overcome the fear of another event

C

9. A 68-year-old woman with terminal metastatic breast cancer is living at home with her son. She has a living will requesting that she be allowed to "die in peace." She is unresponsive to voice and has not had any food or liquids for 3 days. Her son disagrees with her decision not to accept further therapy, including chemotherapy, antibiotics, hospitalization, and enteral or parenteral nutrition. Which of the following is the most appropriate next step in management?
p A) Abide by the decisions of the next of kin
p B) Obtain a court order to allow additional therapy to be given
O C) Start enteral feedings
p D) Admit her to the hospital
0 E) No further intervention

E

10. A 57-year-old woman comes to the physician for a follow-up examination. She has a 5-year history of hypercalcemia, which was diagnosed with routine laboratory studies, and her serum calcium levels have ranged from 10.8 mg/dL to 11.5 mg/dL. She declined further evaluation in the past because she "felt well." She takes no medications. Her last menstrual period was 7 years ago. She maintains a weight of 67 kg (148 lb) and is 170 cm (67 in) tall, BMI is 23 kg/m2. Her blood pressure is 126/80 mm Hg, and pulse is 66/min. Examination shows no abnormalities. Which of the following is the most appropriate next step to assess her risk for fracture?

O A) 24-Hour urine collection for measurement of collagen cross-links excretion
O B) Bone densitometry
O C) Bone-specific measurement of serum alkaline phosphatase activity
O D) Posteroanterior and lateral x-ray films of the thoracic spine and hips
O E) Biopsy of the iliac crest

B

11. A 30-year-old woman, gravida 4, para 3, is admitted to the hospital in labor at 38 weeks' gestation. The cervix is 4 cm dilated. Contractions occur every4 minutes. The fundal height is 40 cm. The membranes are intact. The fetal lie cannot be determined by abdominal examination, and no presenting part is palpable in the pelvis. Which of the following is the most appropriate next step in management?

O A) Ultrasonography
O B) Administration of oxytocin
O C) Administration of tocolytic drugs
O D) Amniotomy
O E) Cesarean delivery

A

12. Six days after undergoing a laparoscopic cholecystectomy for acute cholecystitis, a 35-year-old woman comes to the physician because of fever and abdominal pain for 3 days. She is jaundiced. Her temperature is 38°C (100.4°F). Abdominal examination shows distention and incisions that are healing normally. Leukocyte count is 12,000/mm3, and total serum bilirubin level is 7.9 mg/dL. Which of the following is the most likely cause of the jaundice?

O A) Anesthetic-related hepatitis
O B) Common bile duct injury
O C) Fulminant hepatic failure
O D) Reaction to perioperative antibiotics
O E) Subhepatic abscess

B

13. A 9-year-old boy is brought to the physician because of progressive weakness and a purple-red discoloration over his cheeks and upper eyelids over the past 8 weeks. His symptoms began shortly after a camping trip, and he now is unable to climb stairs, walk long distances, comb his hair, or dress himself. His mother says that she was careful to apply his sunscreen on the trip and can recall no tick bites or exposure to poisonous plants. His only medication is a topical corticosteroid for several dry, scaly patches of the skin. He appears weak and lethargic. He is at the 75th percentile for height and 25th percentile for weight, he has had no change in his weight since his last examination 9 months ago. His temperature is 37.7°C (99.8°F), blood pressure is 110/68 mm Hg, pulse is 105/min, and respirations are 28/min. Examination of the skin shows a purple-red discoloration over the cheeks and eyelids, periorbital edema, erythematous plaques and scales over the elbows and knees, and flat-topped red papules over all knuckles. There is generalized weakness and atrophy of the proximal muscles. Which of the following is the most likely diagnosis2

O A) Dermatomyositis
O B) Duchenne's muscular dystrophy
O C) Eczema
O D) Lyme disease
O E) Psoriasis
O F) Rocky Mountain spotted fever
O G) Seborrhea
0 H) Systemic lupus erythematosus

A

14. An 82-year-old man is brought to the emergency department because of the sudden onset of confusion 48 hours ago. His family says that he previously had been functional and independent. His temperature is 37.5°C (99.5°F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 12/min. The skin is warm and clammy. Bowel sounds are hypoactive, and there is guarding and tenderness in the right lower quadrant of the abdomen. Examination of the heart, lungs, and extremities shows no abnormalities. He is drowsy but arousable and oriented to person but not place or time. There are no focal deficits. Which of the following is the most likely
diagnosis?
O A) Appendicitis
O B) Colon cancer
O C) Meningitis
O D) Pneumonia
0 E) Urinary tract infection

A

15. Two hours after emergency cholecystectomy, a 48-year-old woman has an oxygen saturation of 84% and a PO2 of 56 mm Hg on 2 Lfmin of oxygen via nasal cannula. Her blood pressure is 120180 mm Hg, and respirations are 16/min. Decreased breath sounds are heard on the right, and there is decreased excursion on inspiration bilaterally. There is minimal dullness over the right base. Examination shows no jugular venous distention or pedal edema. An x-ray film of the chest shows increased density over the right lower lung field, the tracheal, mediastinal, and cardiac silhouettes are shifted to the right. The right lung field appears considerably smaller than the left lung field. Which of the following is the most likely cause of these findings?
O A) Atelectasis
O B) Pleural effusion
O C) Pneumonia
O D) Pneumothorax
0 E) Pulmonary embolism

A

16. A 47-year-old man comes to the physician because of low-grade fever and malaise for 3 months. He was infected with hepatitis B 25 years ago. He appears well nourished but ill. His temperature is 37.7°C (99.8°F), blood pressure is 110170 mm Hg, pulse is 801min, and respirations are 121min. Examination shows slight jaundice and hepatomegaly. The spleen is not palpable, and there is no ascites or dependent edema. Serum studies show:

Total bilirubin 3 mg1dL
Alkaline phosphatase 160 U!L
Aspartate aminotransferase (AST, GOT) 230 U!L
Alanine aminotransferase (ALT, GPT) 275 U!L

Serum a-fetoprotein level is markedly increased. Ultrasonography of the right upper quadrant of the abdomen shows a 5-cm, solid lesion in the right lobe of the liver. Biopsy is most likely to show which of the following?
O A) Focal nodular hyperplasia
O B) Hepatic adenoma
O C) Hepatocellular carcinoma
O D) Metastatic adenocarcinoma
0 E) Regenerating liver nodule

C

17. A previously healthy 30-year-old woman has had a painless lump in her neck for 2 days. Her mother was treated for a thyroid tumor at the age of 35 years. Her 28-year-old sister has an increased serum calcitonin level but no thyroid mass. Examination shows a palpable thyroid nodule. Her serum calcitonin level is increased. Which of the following diagnoses should be excluded prior to surgical treatment of the thyroid gland?
O A) Adrenocortical carcinoma
O B) Lung carcinoma
O C) Ovarian carcinoma
O D) Parathyroid carcinoma
O E) Pheochromocytoma

E

18. A 67-year-old man comes to the physician because of a 1-month history of shortness of breath with exertion, easy fatigability, and mild ankle swelling. Five years ago, he underwent successful chemotherapy with doxorubicin for lymphoma. Moist crackles are heard throughout both lungs. An S3 is heard. The liver edge is palpated 4 cm below the right costal margin. There is 2+ pitting edema of the pretibial region, ankles, and feet. Which of the following is the most likely underlying cause of this patient's symptoms?
O A) Aortic sclerosis
O B) Cardiotoxicity
O C) Cirrhosis
O D) Mediastinal obstruction
0 E) Pneumonitis

B

The response options for the next two items are the same. You will be required to select one answer for each item in the set.

For each patient with vaginal bleeding during pregnancy, select the most likely diagnosis.

O A)Abortion of a blighted twin
O B)Cervicitis
O C)Ectopic pregnancy
O D)Focal decidual necrosis
O E) Gestational trophoblastic disease
0 F) Incomplete abortion
0 G) Ovarian torsion
0 H) Ruptured ovarian cyst
0 I) Threatened abortion

19. A 23-year-old woman, gravida 2, para 0, has had vaginal spotting and abdominal cramps for 2 days. Her last menstrual period was 8 weeks ago. A home pregnancy test was positive 2 weeks ago. She underwent a salpingectomy4 years ago following an ectopic pregnancy. Examination shows a closed cervix, an enlarged uterus, and no adnexal masses. Transvaginal ultrasonography shows an empty uterus. Serum 3-hCG level is 8000 mIU1mL.

C

20. A 25-year-old woman has had painless vaginal postcoital bleeding for 2 hours. Her last menstrual period was 10 weeks ago. A pregnancy test is positive. There is a small amount of dark blood in the vaginal canal. She has a reddened, friable cervical os.

I

21. A previously healthy 62-year-old man comes to the physician because of a 1-year history of numbness and weakness of the right hand. He is a carpenter and has no history of injury to his hand. Examination shows wasting of muscle mass in the first web space. Sensation to touch is decreased along the ring and little fingers. There is weakness of abduction and adduction of the fingers. Which of the following is the most likely site of nerve injury?
O A) Axillary nerve
O B) Long thoracic nerve
O C) Median nerve above the elbow
O D) Median nerve at the elbow
O E) Median nerve at the wrist
O F) Musculocutaneous nerve above the elbow O G) Musculocutaneous nerve at the elbow
O H) Musculocutaneous nerve at the wrist
O I) Radial nerve above the elbow
O J) Radial nerve at the elbow
O K) Radial nerve at the wrist
O L) Suprascapular nerve
O M) Thoracodorsal nerve
0 N) Ulnar nerve at the elbow

N

22. A 45-year-old man comes to the physician for a follow-up visit. He has had recurrent ulcer disease for 8 years, his symptoms are currently relieved with antacid therapy. He had one episode of bleeding 1 year ago that required a blood transfusion. He appears pale. His hemoglobin level is 10.6 g/dL, mean corpuscular volume is 78 pm3, and reticulocyte count is 0.8%. Which of the following additional laboratory findings is most likely?

Serum Iron Iron-binding Capacity (TIBC) Saturation of Serum Ferritin
(pg/dL) (pg/dL) (N=250-400) TIBC (%) (ng/mL)
O A) 30 120 25 50
O B) 40 360 11 10
O C) 60 180 33 80
O D) 80 200 40 120
0 E) 100 150 67 600

B

23. A 6-year-old girl is brought to the physician because of a 1-day history of vomiting, headache, and weakness. One month ago, she underwent resection of an astrocytoma and placement of a ventriculoatrial shunt for residual hydrocephalus, her postoperative course had been uncomplicated. Currently, she is drowsy and irritable. Her temperature is 37.5°C (99.5°F), blood pressure is 126/54 mm Hg, pulse is 82/min, and respirations are 24/min. Funduscopic examination shows papilledema. Reflexes are brisk with hypertonia in the lower extremities.

Which of the following is the most likely underlying mechanism for these symptoms?

O A) Carcinomatous infiltration of cerebrospinal fluid
O B) Malfunction of ventriculoatrial shunt
O C) Overproduction of cerebrospinal fluid from a choroid plexus papilloma
O D) Recurrence and extension of the astrocytoma
O E) Thrombosis of the superior sagittal sinus

B

The response options for the next three items are the same. You will be required to select one answer for each item in the set.

For each patient with a respiratory problem, select the most appropriate next step in management.

O A)Administration of BCG vaccine
O B)Administration of an inhaled bronchodilator
O C)Administration of oxygen
O D)Arterial blood gas analysis
O E)Bronchoscopy
O F)Culture of the pharynx for bacteria
O G)Direct laryngoscopy
O H) Gastric washings for acid-fast bacteria
O I) Intravenous infusion of saline
O J) Isoniazid and rifampin therapy O K) Lumbar puncture
O L) Measurement of serum aspirin level
O M) Subcutaneous administration of epinephrine.
N) Viral culture of respiratory secretions
00) X-ray films of the chest
O P) X-ray films of the neck

24. A previously healthy 8-year-old boy is brought to the emergency department because of swelling of the lips and difficulty breathing for 20 minutes. The symptoms began when he was helping his father clean the gutters on their house. He appears anxious. His temperature is 37.2°C (99°F), pulse is 1201min, and respirations are 50/min. Pulse oximetry shows an oxygen saturation of 96%. His lips and eyes appear puffy. He has subcostal and intercostal retractions. Auscultation of the chest shows diffuse bilateral wheezing.

M

25. A 16-year-old girl is brought to the emergency department because of heavy breathing for 8 hours, and vomiting and ringing in the ears for 1 hour. She recently broke up with her boyfriend and has been threatening to hurt herself. She appears somnolent but is arousable and answers questions appropriately. Her temperature is 37.5°C (99.5°F), pulse is 88/min, and respirations are 50/min. Pulse oximetry shows an oxygen saturation of 96%. She has no retractions, nasal flaring, or cough. The lungs are clear to auscultation.

L

26. A previously healthy 6-year-old boy is brought to the physician for a follow-up examination after a PPD skin test produced an induration greater than 15 mm. He has had no cough or fever. He has a good appetite and is at the 50th percentile for height and weight. He appears well. His temperature is 37.2°C (99°F), pulse is 88/min, and respirations are 18/min. The lungs are clear to
auscultation.

O

27. A 25-year-old nulligravid woman comes to the emergency department because of severe pain in the right lower quadrant of the abdomen for 4 hours. She has had no nausea, vomiting, fever, or chills. Three weeks ago, a right adnexal mass was found on routine examination. Her last menstrual period was 3 days ago. Her temperature is 37.2°C (99°F), blood pressure is 110/70 mm Hg, and pulse is 92/min. Pelvic examination shows right adnexal tenderness. Hemoglobin level is 13 g/dL, and leukocyte count is 9000/mm3. Pelvic ultrasonography shows a small amount of free fluid in the cul-de-sac. Which of the following is the most likely cause of the pain?
O A) Appendicitis
O B) Endometriosis
O C) Ovarian hemorrhage
O D) Ruptured ovarian cyst
O E) Torsion of the adnexa
0 F) Tubal obstruction

D

28. A 15-year-old boy comes to the physician because of acne over his face for 1 year. He prefers not to use any oral medications. Examination shows 10 to 15 pustules. Which of the following is the most effective treatment for this patient's symptoms?

p A) Avoidance of chocolate, fatty foods, and caffeine
p B) Use of benzoyl peroxide soap
O C) Vigorous scrubbing of affected areas
p D) Application of vitamin A and vitamin E to affected areas
p E) Ultraviolet light therapy

B

29. A 3-year-old boy with acute lymphoblastic leukemia has had fever for 3 days. He completed his last course of chemotherapy 6 days ago. He has had no malaise, rash, or anorexia and has had no known contact with sick children in preschool. He appears well. His temperature is 38.6°C (101.5°F), blood pressure is 75160 mm Hg, pulse is 100/min, and respirations are 22/min. Examination shows normal findings. Laboratory studies show:
Hemoglobin 10.1 g/dL (N=11.5-15.5)
Leukocyte count 2200/mm3
Segmented neutrophils 5%
Bands 1%
Lymphocytes 65%
Atypical lymphocytes 11%
Monocytes 18%
Platelet count 35,000/mm3

Which of the following is the most appropriate next step in management?

O A) Schedule a follow-up visit and discharge without medication
O B) Observe him in the office for 3 hours, discharge without medication if examination remains unchanged
O C) Discharge him with oral broad-spectrum antibiotic therapy
O D) Admit him to the hospital for observation
O E) Admit him to the hospital for intravenous broad-spectrum antibiotic therapy

E

30. A 72-year-old woman is brought to the emergency department 1 hour after the sudden onset of right facial droop and weakness of the right arm and leg. She takes captopril for hypertension and daily aspirin. Her blood pressure is 150/90 mm Hg, pulse is 80/min, and respirations are 161min. Examination shows a left carotid bruit and right central facial paralysis. There is moderate expressive aphasia. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate initial pharmacotherapy?
O A) Oral ticlopidine
O B) Oral warfarin
O C) Sublingual nifedipine
O D) Intravenous nitroprusside
O E) Intravenous tissue plasminogen activator

E

31. A previously healthy 37-year-old woman comes to the physician because of a 3-month history of episodes of severe anxiety, shortness of breath, palpitations, and numbness in her hands and feet. Her vital signs are within normal limits. Physical examination shows no abnormalities. Thyroid function studies and an ECG show no abnormalities. Which of the following is the most appropriate pharmacotherapy?
A) Lithium carbonate
B) Methylphenidate
O C) Olanzapine
p D) Paroxetine
0 E) Valproic acid

D

32. A 37-year-old nulligravid woman comes to the physician because she has not been able to conceive for 2 years. Her 40-year-old husband has a child by a previous marriage. Her last menstrual period was 6 weeks ago, menses have occurred at increasingly infrequent intervals over the past year. Fifteen years ago, she was treated for one episode of Chlamydia trachomatis infection. She weighs 59 kg (130 lb) and is 170 cm (67 in) tall. Examination shows no abnormalities. Serum studies show:

R-hCG

[ArchivalUser]

BLOCK 2 continued ...

30. A 72-year-old woman is brought to the emergency department 1 hour after the sudden onset of right facial droop and weakness of the right arm and leg. She takes captopril for hypertension and daily aspirin. Her blood pressure is 150/90 mm Hg, pulse is 80/min, and respirations are 161min. Examination shows a left carotid bruit and right central facial paralysis. There is moderate expressive aphasia. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate initial pharmacotherapy?
O A) Oral ticlopidine
O B) Oral warfarin
O C) Sublingual nifedipine
O D) Intravenous nitroprusside
O E) Intravenous tissue plasminogen activator

E

31. A previously healthy 37-year-old woman comes to the physician because of a 3-month history of episodes of severe anxiety, shortness of breath, palpitations, and numbness in her hands and feet. Her vital signs are within normal limits. Physical examination shows no abnormalities. Thyroid function studies and an ECG show no abnormalities. Which of the following is the most appropriate pharmacotherapy?
A) Lithium carbonate
B) Methylphenidate
O C) Olanzapine
p D) Paroxetine
0 E) Valproic acid

D

32. A 37-year-old nulligravid woman comes to the physician because she has not been able to conceive for 2 years. Her 40-year-old husband has a child by a previous marriage. Her last menstrual period was 6 weeks ago, menses have occurred at increasingly infrequent intervals over the past year. Fifteen years ago, she was treated for one episode of Chlamydia trachomatis infection. She weighs 59 kg (130 lb) and is 170 cm (67 in) tall. Examination shows no abnormalities. Serum studies show:

R-hCG

[ArchivalUser]

Sorry, technical problem ...

[ArchivalUser]

Sorry, I don't know why it cuts off at Qn 32. But here is the rest of the questions and answers.


Continued ... block 3 (Note that these are questions and answers to Step 2 CK NBME form 3, which contains a total of four blocks, each having 46 qn's)

BLOCK 3 ANSWERS

1. D. I think this is fibromyalgia.
2. E
3. A
4. E “ CF carrier state
5. C “ suspect malignant disease
6. E “ MVP causing mitral regurgitation
7. D “ hypercalcaemia, likely due to lung CA
8. D
9. D
10. E “ septic arthritis

11. A
12. B “ CRF due to DM
13. F “ spinal cord injury, with possible bowel injury
14. F
15. E
16. E “ chronic pancreatitis
17. B
18. B
19. C “ organophosphate poisoning, cholinergic intoxication
20. B “ maxillary sinusitis

21. C
22. D
23. E
24. E
25. B
26. B “ lumbar muscle strain (simple back pain)
27. A “ In septic shock, cardiac contractility is decreased because of inflammatory cytokines and other toxic stuff.
28. D
29. B
30. D

31. A
32. E
33. B
34. E
35. B
36. B
37. C
38. F
39. D
40. D

41. C
42. C
43. H
44. B
45. A
46. D

You can obtain the corresponding question from http://rapidshare.com/files/114849006/Binder1.pdf

[ArchivalUser]

BLOCK 4 ANSWERS

1. A
2. D “ asymptomatic but multiple cardiac risk factors
3. C “ pulmonary hypertension, secondary to CF
4. E
5. B
6. D “ CRF, due to DM
7. A
8. B
9. D
10. C

11. E
12. E
13. F
14. A
15. C
16. A
17. A
18. B “ AVM™s can lead to congestive cardiac failure due to high volume of circulating blood
19. B
20. E

21. E
22. D
23. E
24. A
25. A “ Parkinson™s disease
26. C
27. C
28. B “ Febrile neutropaenia needs AP aminogycoside + (AP penicillin or AP cephalosporin)
29. B
30. A

31. C
32. D
33. A
34. C
35. B
36. D
37. M
38. G
39. C
40. C

41. A
42. B “ Polycystic Ovarian Syndrome
43. A
44. E
45. B
46. A

You can download the corresponding questions from
http://rapidshare.com/files/114856959/Binder2.pdf

Good luck!

[ArchivalUser]

thanks alot radonc

[ArchivalUser]

thanks alot RADONC....goodluc 4 match.....folks how could we miss this...
MBME 3--------800 score...tremendous..lets store the answers

[ArchivalUser]

wow thank you so much