NBME Ccmsa Form 5 PDF

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Block 1 1. A 3-month old infant ome is brought to the office by his mothe tion for treatment of an abscess at a previous intravenous site. This was the patient’s second serious infection n. She says his temperature this morning was 3 nd he has not shown i g today. He was born at term. Physical examination at birth showed hocardiography obtained at arch. The infant is 50cm (20 in; 10th rd percentile) long and weighs 4593 g (10 lb 2 oz; 3 percentile); head circumference is 38 cm (15 in; 3rd percentile). Vital signs now are temperature 40/min, respirations 28/min, and blood pressure 92/58 mm Hg. Physical examination disclos t. You suspect the infant has a cellulitis and arrange hich of the follow fections? A. B. C. D. E.

Congenital heart defect Hypogammaglobulinemia Insufficiently treated prior infection Malnutrition

2. A

y is brought to the office by his . The episode last es, after which t, dur rd. He did not seek medical attention at the time. On questioning now in the office, he says that since the accident he has had intermi each. Vital signs are normal. Physical examination discloses no abnormalities. Which of the follow p in evaluation?

A. B. C. D. E.

EEG C. Observation at home Observation in the hospital with plans to reevaluate if he has another syncopal episode X-ray of the cervical spine with swimmer’s view

3. A omes to the office for evaluation of his blood pressure, which recently showed two sparate readings of 180/74 mm Hg and 176/78 mm Hg You review this chart and see that his last visit was 3 years ago, at which time his blood pressure was 164/80 mm Hg. He currently takes no medication. He is 183 cm (6ft) tall and weighs 79 kg (175 lb), BMI is 24 kg/m^2. Physical examination is normal except for a blood pressure of 170/80 mm Hg. You recommend an exercise program and diet modification with decreased salt intake. At a follow0up visit 3 months later he has lost 2.2 kg (5 lb). He says he restricted his salt intake, however, his blood pressure remains elevated at 168/70 mm Hg. You recommend a trial of pharmacotherapy. You have reviewed the results of a randomized controlled trial assessing the effects of antihypertensive treatment to r y, 4736men and women with elevated systolic blood pressure were random , or ca ication. Patients were monit rs. The effects of treatment on blood pressure are shown in the table below. Change in blood pressure (mean mm Hg +/- standard deviation) Assignment Systolic Diastolic Placebo -2 +/- 4.2 +1.5 +/- 3.6 Diuretic -12.2+/-6.8* -3 +/- 4.2 Beta-blocking medication -14.3 +/- 10.7** +0.8 +/- 6.9 *p = 0.002, **p 50 years Previous history of cancer Unexplained weight loss Failure of 1 month of anti-inflammatory medication No relief with bed rest Duration of pain > 1 month

sensitivity

Specificity 0.07

0.31 0.15

0.94

0.90

0.46

The medical history that is most suggestive of cancer as a cause of this patient’s back pain is which of the following? A. Age B. C. 4-month duration of pain D. Relief with bedrest E. Weight loss 3. A

is brought to the emergency department by the

o. The patient says that his knee buc tackle and he had excruciating knee pain. The trainer says, “I think his knee might have been dislocated and then relocated while I manipulated it on the football field.” The patient says he has been in excellent health and does not take medication. Vital signs are temperature 37.0 C (98.6 F), pulse 92/min, and respirations 14/min. Physical examination discloses a well-nourished young man who complains of severe pain in his right knee. There is marked softtissue sw lf. The knee teriorly. The . Distal neurovascular examination is normal. A. B. C. D. E.

Rupture of gastrocnemius Rupture of the patella tendon Tear of the collateral ligament Tear of the meniscus

4.

A Sh

s in the hospital following an emergency operation for repair of a gitated, and she repor in. She has a histor

intrav respiration

blood pressu

Serum Urea nitrogen Creatinine Na+ K+ ClHCO3Glucose

70 mg/dL

She received ly. Vital signs are temperature 37.0 C (98.6 F), pulse 96/min, ults of laboratory studies are shown:

Urine output during the past 8 hours is 300 mL. The patient’s current condition is most likely caused by which

A. B. C. D. E.

Diabetic ketoacidosis Hypovolemia Narcotic overdosage Sepsis

5. A the office after b r. The patient’s medical history is otherwise unremarkable and he takes no medications. He smoked one pack of cigarettes A. B. C. D. E.

Coal mine Cotton mill Grain elevator Power company

The following vignette applies to the next 2 items: A 62-year old man comes to the office for follow-up of benign prostatic hypertrophy (BPH), which was diagnosed 1 week ago. He had described a 5-month history of increased nocturia, double voiding, and decreased strength of urinary flow; he had not had these symptoms before. He has no personal family history of prostate cancer. He takes no medications and he has no allergies. Physical examination 1 week ago was remarkable for an enlarged prostate without nodularity. Urinalysis and prostate specific antigen tests were normal. Today, he has brought some newspaper articles about saw palmetto and wonders about its use in treatment of his symptoms. You recall a recent met this study, saw palmetto was co re shown. Saw Palmetto Versus Placebo in the Symptomatic Treatment of Benign Prostatic Hypertrophy Treatment Improvement in Symptoms Placebo Saw Palmetto Statistical Significance Patient-reported 191/330 (58%) 242/329 %) 01 Physician-assessed 100/262 (38%) 165/262 %) 1 Item 1 of 2 6. Which of the following is the ? A. B. Patient-reported symptoms are more improved than are physician-assessed symptoms C. Statistical significance is not important compared with symptom improvement D. Statistically significance changes in physician-assessed symptoms do not result in decreased symptoms for patients E. No conclusion can be drawn from the present information

Item 2 of 2 7. Based on the physician-assessment data, the number of patients who need to be treated with saw palmetto to show significant improvement in one patient is which of the following? A B. C. D. E.

6 12 25 38

8. A old female newborn, who was born at approximately 38 weeks’ gestation, is noted in the newborn nursery to be jittery and persistently crying. The newborn’s 18 r, gravida 1, para 1, underwent uncomplicated spontaneous vaginal delivery 24 hours ago and did not receive prenatal care. The newborn’s APGAR scores were8 and 9 at 1 and 5 minutes, respectively. Physical examination at the time of birth disclosed no abnormalities. Now, vital signs are temperature 37.) C (98.6 F), pulse 160/min, and respirations 50/min. Pulse oximetry on room air shows an oxygen saturation of 99%. The infant xamination discloses no other abnormalities. Serum glucose concentration is within the reference range. Toxicology screening of the meconium and urine is obtained; results of meconium screening are pending. hich of t the newborn’s mother? A. B. C. D.

“Cocaine was found in your baby’s urine, thus we need to call social services” “It is important that you share all medical information with us when we ask.” “Your baby is addicted to cocaine and will need to be treated.” “Your baby was acting differently from what was expected, so we ordered tests.”

9. A brought to the office by his parents because of th . Pregnancy and delivery were normal, but during the and forehead. Treatment with 1% hydrocortisone cream controlled the rash. The patient’s growth and development have been normal. He is the third child in the family and both of his siblin ma; one sibling als s. Vital signs today are axillary temperat . The patient is fussy. Physical examination discl hotography. There is no adenopathy. The remainder of the physical examination discloses no abnormalities. The most a wing?

A. B. C. D. E.

Bacterial culture of the skin Biopsy of the skin KOH preparation of the skin Scabies preparation of the skin

10. A

egun is, three times weekly, se. He is having a great deal of difficulty tolerating dialysis and complying with the diet, and he has been missing school frequently. His nephrologist recommends switching to home peritoneal dialysis and evaluating the patient for a renal transplantation. You are the primary care physician for the boy’s family, which includes his 48 her, his 8and his 6-y f whom are healthy. All three family members are compatible with the patient’s parents are divorced, and the whereabouts of the father are 36-year-oldpaternal aunt also has a compatible blood type but no antigens in common. The patient’s parents are divorced, and the whereabouts of the father are unknown. The mot hildren.

A. B. C D. E.

Brother Father Paternal aunt Sister

11. A

n returns to the health center for reevaluation of c During a previous visit oday the patient says, “The medicine you prescribed helped my runny nose and itchy eyes, but now I have trouble hearing; it sounds like people around me are talking in a barrel.” The patient has a histor ea. He works in He has smoked one pack of cigarettes daily for 10 years. He has a family history of hearing loss. The patient is 175 cm (5 Ft 9 in) tall and weighs 91 kg (200 lb); BMI is 30 kg/m^2. Today vital signs are normal. Physical examination shows intact tympanic membranes that ar isible meniscus. Nasal turbinates ar wi udate. The remainder of the physical examination shows no abnormalities. Which of the t’s history is most consistent with the patient’s

A. B. C. D. E.

Cigarette smoking Exposure to lung machinery Family history of otosclerosis Sleep apnea

12. A 45-year-old womanis admitted to the hospital because of pain and swelling in her right calf.Medical history is significant for systemic lupus erythematosus with a lupus anticoagulant. Current medications include prednisone, celecoxib, and iron supplements. She is 163 cm (5ft 4 in) tall and weighs 68 kg (150 lb);BMI is 26 kg/m^2. Vital signs are temperture 36.1 C (97.0 F), pulse 70/min respirations 18/min, and blood pressure 117/75mm Hg. Heart and lung examinations disclose no abnormalities. There is livedo reticularis on both legs. The right calf is swollen and painful to palpation. There is minimal erythema. Duplexultrasonography of the legs shows a right0sided deep venous thrombosis (DVT). Low-molecular-weight heparin and warfarin are initiated, and you explain to the patient that she should be able to go home in the next 24 hours after learning how to self0inject her medication. You c trial comparing administration of outpatient low-molecular-weight heparin (LMWH) to administration of standard intravenous unfractionated hepari tal.

DVT recurrence (%) Bleeding (%) Death (%) Length of stay (days) A. B. C. D. E.

LMWH 5.3% 0.5% 6.9% 1.1

IVUFH 6.9% 2.0% 8.0% 5

p value 0.31 0.56 0.72

IVUFH is associated with significantly more DVT recurrence than LMWH LMWH causes death in 6.9%of patients LMWH is safer than IVUFH There is a 56% chance that IVUFH causes less bleeding than LMWH

13. A 7 is admitted to the hospital because of lives alone, she has a history of sch and has recently becom esult of several sma s. She refus hip. On mental status examination, she e. She recalls only one of three objects after 5 minutes and cannot pe s. She denies auditory hallucinations. She knows that she on. When asked why she is refusing the operation, she says, “Radiotransmitting equipment was placed inside me 20 years ago when I had my gallbladder out.” The clinical feature most pertinent to a judgment about her competence to refuse the opera

A. B. C. D. E. F.

Deficiencies in attention and calculation Deficits in short-term memory Diagnosis of schizophrenia Diagnosis of schizophrenia History of multiple infarcts

14. Two tests are being evaluated to identify chlam diagnosis is made by culture. The following results are found: Number with chlamydial infection (Total = 40) Test X Abnormal Normal Test Y Abnormal Normal

tested. Definitive

Number without Chlamydial Infection (Total = 160)

35 5

15 145

30 10

5 155

Which of the following i A. B. C. D. E.

cervix. Two hundred w

is evaluating?

Test X is superior to test Y The sensitivity of test X is 70% (35/50) The specificity of test Y is 75% (30/40) Test X is more specific than test Y

15. A 68-y dmitted to the hospital for evaluatio tia. His daughter says that he has lived with her and her family for the past 2 years, and that during the past 3 months she has noticed that he seems dista en called. He is able to move about the hospital room in his wheelchair. He is relu k, and when he does, he is clumsy and ha 8/hpf and presence of leukocyte esterase. Serum studies, including vitamin B12 (cobalamin) and folate concentrations, VDRL, and thyroid function studies, are all within the reference ranges. CT scan of the . Lumbar puncture for examinatio is. Oral ci itiated. One day lat hims most likely explanation for the patient’s improvement? A. B. C. D. E.

Consumption of a nutritious meal Oral ciprofloxacin therapy Recovery from the phenomenon of “sun-downing” Withdrawal from an environmental contaminant

16. A 25-year-old to ha

as admitted to the hosp tis, continue On admission he patient had reported a he also had had sion. She had not had nausea, diarrhea, or shortness of breath. The patient’s temperature on admission was 38.4 C (101.2 F). Results of a clean-catc microscopic examination. Intravenous ampicillinsulbactam therapy was initiated and ultrasonography of the abdomen was scheduled for today. Medical history is otherwise unremarkable and the patient’s only medication is an oral contraceptive. She is sexually active with one male partner and does not use condoms. Vital signs are temperature 38.3 C (101.0 F), pulse 110/min, respirations 18/min, and blood pressure 136/78 mm Hg. Physical examination discloses regular tachycardia and continued tenderness to palpation of the right upper quadrant. Murphy sign is not present. The remainder of the physical examination, including pelvic examination, discloses no abnormalities. Results of laboratory studies obtained this morning are shown: Serum Blood ALT 50 U/L Hematocrit 36% AST 52 U/L Hemoglobin 11.0 g/dL 3 Alkaline phosphatase 100 U/L WBC Bilirubin, total 0.8 mg/dL Neutrophils, segmented Protein Neutrophils, bands 1% Albumin 3.6 g/dL Platelet 365, 000 mm3 Ultrasonography of the abdomen shows p le. The gallbladder, biliary tracts, and hepatic parenchyma appear normal. There is no pericolic fluid. g is the most likely causal organism of this patient’s illness A. B. Enterococcus faecalis C. Escherichia coli D. Streptococcus agalactiae

17. A 2 cation teacher comes to the office because she is con regnancy. Her husband has a 6year-old healthy child from a previous marriage. The patient has had , one o. She is healthy and takes no medications. There are and she is concerned about potential neural tube deformities with her own pregnancy. She hands you an article from the ows: • • • • •

The risk for neural tube defects in t is 1/1000 The risk for neural tube defects in the first pregnancy is 0.7/1000 After t use, the risk for neural tube defects increases to 3/1000 Folic acid (4 mg) taken daily prior to conception and during the first trimester decreases the rate of neural tube defects by 72% The risk for neural tube defect 28 years

Based on these data, which of the following is the most accurate statement regarding her fetus’s risk for neural tube

A. B. C. D. E.

Because of her age and two miscarriages her risk is greater than 1/1000 Because of her miscarriages her risk is increased to 2/1000 If she does not take folic acid, her risk is 0.7/1000 The risk is so small that is not worth consideration

18.

who was born at home is brought to the emergency department by her mother because of oozing of blood from the umbilical cord stump. She was born via spontaneous vaginal delivery at 38 weeks’ gestation to a 28-year-old woman who has two . The mother, who ha d remains on D order, had no prenatal care. There was no prolonged rupture of membranes at the time of delivery. There is no history of bleeding disorders in the mother’s family, and the baby’s father is unknown. The neonate weighs 2835 g (6lb 4 oz) and appears generally healthy. Physical examination shows There is no hepatosplenomegaly or audible murmur. Which of the osis? A. B. C. D. E.

Disseminated intravascular coagulation Folic acid deficiency Isoimmune thrombocytopenia Protein C deficiency

19. A

es to the office because of . He sm Physical examination shows i. X-ray of the chest is shown. The mechanism

A. B. C. D. E.

Abnormality of chloride receptors Deficiency of 1-antitrypsin Heightened airway reactivity to inhaled irritants and antigens Immune-complex formation

20. A rth t lb) newborn at 30 weeks’ gestation. The girl has had no prenatal care. She is unmarried an baby. The newborn is admitted to the neo care unit. The mother’s vital signs are temperature 37. C (98.6 F), pulse 80/min, respirations 14/min, and blood pressure 100/68 mm Hg. On interview, the girl er. It is following? A. B. C. D. E.

The girl’s parents The newborn’s father The police No notification is necessary

l weeks of blurry vision. She says, “I just got my eyes checked last month. My vision was fine then.” For years she has struggled with being overweight, often gaining

“Don’t you think you should be “Have you been intolerant of cold weather recently?” “Tell me what has been going on in your life for the past 4 months” “Why have you failed to lose weight?” “You have brought on diabetes because you have been unable to control your eating.”

Which of the following is the most appropriate conclusion about this patient’s condition?

your patient for 10 years and you have been treating her for type 2 diabet -month period of depression following the death of her husband 7 years ago. She has been in otherwise good health. On further questioning, she says she has symmetric tingling or prickling sensation of both her legs. Pulse is 96/min and blood pressure is 110/68 mm Hg. On physical examination the patients edentulous and the anterior half of her tongue is smooth and reddened. Her skin is pale. Heart and lung examinations are normal. Abdomen is obese without organomegaly. The rectal examination is normal and test of the stool for occult blood is negative. Results of initial laboratory studies are shown: Serum Blood Folate 6.5ng/mL (N=1.89-9.0) Hematocrit % Vitamin B12 mL (N=100-700) Hemoglobin dL Iron 50 g/dL (N = 50-170) MCV m3 Iron Binding Capacity 250 g/dL (N – 200-300) MCHC Hb/cell Urinalysis Normal Examination of the tics? A. B. C. D. E.

Crescent-shaped with pointed ends Elliptical, oval or cigar-shaped; there are variations in shape Spur-like or thorny projections on the surface; they look like underwater mines A target with hemoglobin deposited in the center forming the target

25. A progr respirations most likely A. B. C. D. E.

with a history

se is admitted to the hospital because of nosis. Vital signs are temperature 5 F),pul /min, nd blood pressure Auscultation of the chest discloses rales in th . Pulmonary capill mmHg. Which of the following is the nsion?

Increased cardiac output Increased pulmonary vascular resistance Left ventricular outflow obstruction Obstruction of the airway

26. A ght to the office for a tion. He is the second child of...