Step 3 NBME qs with answers

1. A 64-year-old man is admitted to the intensive care unit with pneumonia and septic shock. Over the past 4 days, he has had increasing shortness of breath and fever. He has hypertension. Surgical history is significant for a previous cholecystectomy. Medications are amlodipine and hydrochlorothiazide.
On physical examination, temperature is 38.8 °C (98.8 °F), pulse rate is 110/min, respiratory rate is 22/min, and blood pressure is 85/50 mm Hg. Cardiac examination reveals a grade 2/6 systolic murmur. On pulmonary examination, there are crackles over the entire right lung field. There is trace pedal edema.
Laboratory studies on admission:
Laboratory StudiesGlucose 115 mg/dL (6.38 mmol/L)Blood urea nitrogen 22 mg/dL (7.86 mmol/L)Creatinine 1.4 mg/dL (123.79 μmol/L)Sodium 135 meq/L (135 mmol/L)Potassium 4.8 meq/L (4.8 mmol/L)Chloride 103 meq/L (103 mmol/L)Bicarbonate 10 meq/L (10 mmol/L)Albumin 3.8 g/dL (38 g/L)
Arterial blood gas studies (with the patient breathing room air):
pH 6.94PCO2 48 mm HgPO2 51 mm Hg
Which of the following conditions is most likely present in this patient?A Anion gap metabolic acidosisB Mixed non–anion gap metabolic acidosis and respiratory acidosisC Mixed anion gap metabolic acidosis and respiratory alkalosisD Mixed anion gap metabolic acidosis and respiratory acidosisE Mixed non–anion gap metabolic acidosis and respiratory alkalosis
2.A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL Triglycerides 300 mg/dL Glucose 118 mg/dL Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
A) Alcohol cessation B) Better control of diabetes C) Switch from captopril to calcium-channel blocking agent therapy D) Gemfibrozil therapy E) Thyroid replacement therapy
3. A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL Triglycerides 300 mg/dL Glucose 118 mg/dL Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
A) Alcohol cessation B) Better control of diabetes C) Switch from captopril to calcium-channel blocking agent therapy D) Gemfibrozil therapy E) Thyroid replacement therapy
4.A 23-year-old man comes to the physician because of a 1-month history of intermittent right-sided abdominal pain, nausea, and vomiting. He has sickle cell disease and has been treated severaltimes for painful crises. Examination of the abdomen shows tenderness to palpation of the light upper quadrant on inspiration.
Laboratorystudies show:
Hematocrit 25%Leukocyte count 11,000/mm3Serum Bilirubin Total 3.2 mg/dLDirect 0.3 mg/dLAlkaline phosphatase 56 U/L
Ultrasonography of the gallbladder shows a fillingdefect. Which of the following is the most likely cause of this patient's hyperbilirubinemia?
A) Aggregation of cholesterol in the gallbladder
B) Inhibition of glucuronosyltransferase
C) Lysis of erythrocytes
D) Malnutrition-induced cirrhosis
E) Neoplastic growth in the gallbladder
16. A 58-year-old white store manager comes to the office for a periodic health evaluation. You have been treating both the patient and his wife for the past 15 years. Today the patient is tearful and agitated. He says that he is having difficulty with his son, who is age 32 years and has schizophrenia. The son has been living intermittently in a group home or on the streets. The patient says that his son is noncompliant with his antipsychotic medications. Recently, the son has been calling the patient's house asking for money, which the patient suspects his son uses to buy alcohol and illicit drugs. It is most appropriate to advise the patient to do which of the following?
A
) Arrange an involuntary commitment to a psychiatric hospital for his son
B
) Ask his son's psychiatrist to adjust his medication
C
) Change his phone number
D
) Contact the local chapter of the National Alliance for the Mentally Ill for support and advice
E
) Obtain a restraining order against his son
17. A 20-year-old man comes to the health center because of ankle pain. Two days ago he sustained an inversion injury of his left ankle in a basketball game. He has been able to walk unassisted since the injury. Today he has pain and moderate swelling and discoloration over the lateral malleolus. Physical examination shows tenderness on palpation over the anterolateral corner of the ankle joint. He has had two similar injuries in the past. Which of the following is the most appropriate initial management?
A
) An ankle-strengthening exercise program
B
) Application of a long-leg cast for 3 weeks
C
) Application of a short-leg cast for 3 weeks
D
) Protected weight bearing
E
) Surgical repair of the ankle ligaments
18. A 52-year-old woman comes to the office because of a 4-day history of increasing pain of the right hip and thigh. The pain is exacerbated by lying on her right side while sleeping. She says the pain often awakens her and is accompanied by a burning sensation along the right side of her posterior thigh that radiates to her knee. She usually has stiffness and pain in the hip during the following morning that gradually diminishes as she walks around her house and does house chores. She says the pain is also triggered by sitting with her right leg crossed over the left leg. The patient is otherwise healthy and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses tenderness on deep palpation of the right trochanter. Which of the following is the most likely diagnosis?
A
) Arthritis of the hip
B
) Aseptic necrosis of the femoral head
C
) Bursitis
D
) Gout
E
) Osteosarcoma of the femoral head
8. An 18-year-old man comes to the health center because he has had pain in his right leg for the past 5 days. He says that he recently added jogging to his weight-lifting workouts, and he started running 5 miles per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and weighs 83 kg (185 lb). On physical examination he has moderate tenderness over the midtibia. X-ray of the leg will most likely show which of the following?
A
) A bone cyst
B
) Displaced fracture
C
) Metastatic disease
D
) Soft-tissue calcification
E
) Normal findings
9. A 47-year-old woman returns to the office because of gastrointestinal symptoms. She says, "I still have burning pain in my stomach that travels up my chest to my neck after I eat." During the past 5 years she has been treated with antacids, H2-blocking medications, proton pump inhibitors and motility agents, with only mild relief. She smokes one pack of cigarettes per day and drinks one cup of coffee in the morning. There is no family history of peptic ulcer disease. Previous endoscopies, the last of which was 6 months ago, have shown lower esophagitis secondary to reflux with healing ulcers and scarring. Gastric and duodenal cultures for Helicobacter pylori have been negative. Vital signs today are normal. Physical examination, including rectal examination, is normal. Which of the following is the most appropriate next step?
A) Consider an alternative pharmacotherapeutic regimen
B) Continue current treatment
C) Do esophageal pH monitoring
D) Obtain surgical consultation
E) Repeat endoscopy 10.A 19-year-old college student comes to the student health center because of palpitations, shortness of breath and a runny nose. He has asthma that he has treated with an over-the-counter cold preparation and an epinephrine metered-dose inhaler every 2 to 3 hours at night. He just used the bronchodilator in the waiting room. Vital signs are: temperature 38.2°C (100.8°F), pulse 82/min and respirations 18/min. He appears to be somewhat anxious and his breathing is labored. Auscultation discloses mildly diminished breath sounds in all lung fields accompanied by scattered wheezing. Which of the following is the most appropriate management?
A
) Add oral aminophylline therapy
B
) Admit him to the hospital for respiratory therapy
C
) Prescribe decongestant/antihistamine therapy
D
) Prescribe antihistamine therapy
E
) Substitute an albuterol nebulizer for the epinephrine
11. A 25-year-old man develops fever, muscle pain, and headache 1 week after being bitten by several ticks while camping near the Grand Canyon. The fever remits and he feels better in 7 days. Two to four days later, his symptoms recur. A Giemsa stain of a peripheral blood stain shows intracellular bacterium. Which of the following is the most likely explanation of the reoccurrence of symptoms?
A) Expression of endotoxin-like structures on the surface of the organism B) Migration of the organism from a tissue site to the blood stream C) Production of a toxin that had become suppressed during the infection D) Secondary infection by a different organism of the same species E) Variation of a major surface protein antigen of the organism
12> A 4-year-old girl is brought to the emergency department by her mother because of severe wrist pain. The girl was playing with her friends in her backyard and fell, breaking the fall with her outstretched hand. On physical examination there is slight swelling over the dorsal aspect of the wrist. X-ray films of the wrist are shown.
The findings are most consistent with which of the following?
A) Carpal navicular fracture
B) Cortical fracture of the radius
C) Fracture of the distal radius and ulnar growth plates
D) Fracture of the distal radius growth plate
E) Perilunate dislocation of the wrist
13> Which of the following is the most appropriate management?
A) Apply an elastic bandage and apply ice packs to the wrist
B) Do closed reduction of the fracture
C) Do closed reduction of the fracture and report the case to child protective services
D) Immobilize the forearm and hand in situ in a cast
E) Prepare for open reduction and internal fixation
14.A 10-year-old boy is brought to the emergency department because he developed hives and shortness of breath 10 minutes after being stung by an insect. His father tells you that he had a similar episode of dyspnea and urticaria 2 years ago. Physical examination now shows a frightened child who appears out of breath, has generalized urticaria and asks for help in a hoarse voice. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 36/min and blood pressure 70/40 mm Hg.
Which of the following is the most important first step in managing this patient?
A) Administer diphenhydramine, orally
B) Administer epinephrine, subcutaneously
C) Administer oxygen via face mask
D) Establish intravenous access
E) Obtain arterial blood gas values
15> After 10 minutes there is no change in his condition.
At this time, the most appropriate next step is to administer which of the following?
A) Diphenhydramine, orally
B) Dopamine, intravenously
C) Epinephrine, subcutaneously
D) Prednisone, orally
E) Ranitidine, orally
16.> A 56-year-old white executive is admitted to the hospital from the emergency department following a severe nosebleed. One month ago he had a brief viral illness after being exposed to an exanthem eruption of one of his grandchildren. At that time the patient was also referred to a urologist because of fatigue, low back pain, and urinary frequency. He was diagnosed with prostatitis, for which he has been taking sulfamethoxazole-trimethoprim for the past 12 days. He does not take any other medications. On arrival in the emergency department vital signs were: temperature 36.8°C (98.2°F), pulse 100/min, respirations 16/min, and blood pressure 120/66 mm Hg. The patient appeared pale with scattered areas of bruising on his limbs and body and a few petechiae. No lymphadenopathy or organomegaly was found. Results of laboratory studies obtained in the emergency department are shown:BloodUrineHematocrit 21%WBC 0/hpfHemoglobin 5.6 g/dLRBC 10–20/hpfWBC 2000/mm3MCV 102 ìm3Partial thromboplastin time 26 secPlatelet count 20,000/mm3Prothrombin time 12.8 secINR 1.3
Bone marrow biopsy shows marked hypocellularity.Which of the following is the most appropriate management?
A) Administer granulocyte colony-stimulating factor
B) Administer high-dose short-term corticosteroids
C) Administer parenteral broad-spectrum antibiotics
D) Begin transfusion with whole blood
E) Discontinue sulfamethoxazole-trimethoprim
17> Supportive measures are provided for the patient.
Which of the following is the most appropriate treatment recommendation for this patient at this time?
A) Chemotherapy
B) Follow-up evaluation in 1 week
C) Glucocorticoid therapy
D) Hematopoietic growth factor therapy
E) Stem cell transplant

18.Healthy 23 yr old comes to the office for health maintenance exam. She has no complaints, does not smoke or take alcohol. No signifincant family history. Vitals are within normal limits, PE is also normal. PAP shows ASCUS. What is the most appropriate next step?
1) Refer for colposcopy2) Set up repeat pap in 3 months3) Treat with Doxy and repeat pap in 3 weeks4) Reassure and repeat Pap in one yr5) Obtain HPV testing on sample
19.29 yr old F comes to your office for routine health maintenance exam. She has H/O migriane headache, smokes 1 pk of cigarettes every 3 days, drinks alocohol on weekends. Dad died of colon ca at 50, mom is diabetic. She is taking no meds, Vitals are within normal limits and physical exam is normal. PAP smear + for HSIL and satisfactory colposcopy + for CIN-2. What is the next step?
1) LEEP2) Cryosurgery3) Laser therapy4) Expectant management5) Cold Knife conization
1.2.A3.D4.C5.e6.c7.c8.e9.d10.B11.E121314 B15 C16 D17 C 18.5 19.1

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