I am in the process of studying for my Step 2 and I got the following questions incorrect but I am unable to figure out why. Could anyone help me ?
Thanks in advance.
4. A 74-year-old woman has a myocardial infarction and is admitted to the intensive care unit. Her blood pressure has decreased from 148/74 mm Hg to 80/62 mm Hg. She is confused and has cool clammy skin. Arterial blood gas analysis is most likely to show which of the following?
A) l-typoxemia with normal pH
B) Primary metabolic acidosis
C) Primary metabolic alkalosis
D) Primary respiratory acidosis
E) Primary respiratory alkalosis (wrong)
17. A 77-year-old woman comes to the emergency department because of a 3-month history of shortness of breath when she climbs stairs. Her shortness of breath resolves after 5 minutes of rest. Her last episode was 3 days ago. She has not had chest pain, palpitations, orthopnea, cough, wheezing, swelling, or difficulty sleeping. She has hypertension and gastroesophageal reflux disease. Current medications include hydrochlorothiazide, omeprazole, and a multivitamin. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Her temperature is 37.2°C (99°F), pulse is 72/min, respirations are 12/min, and blood pressure is 144/92 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. There are jugular venous pulsations 3 cm above the sternal angle. The remainder of the examination shows no abnormalities. An ECG shows a left bundle branch block and no primary T-wave changes, which is unchanged from an ECG 1 year ago. Which of the following is the most appropriate next step to determine the cause of this patient's dyspnea?
A) Measurement of serum troponin I concentration
B) ECG exercise stress test
C) Exercise stress echocardiography
D) Ventilation-perfusion lung scans (wrong)
E) Coronary angiography
39. A 64-year-old woman with a 4-year history of type 2 diabetes mellitus controlled with insulin comes to the emergency department because of exertional chest pressure for 3 weeks. The first episode occurred while she was walking upstairs and was relieved by 5 minutes of rest. The second episode occurred 1 week ago while she was mowing the lawn and was relieved after 10 minutes of rest. She had two episodes yesterday, each lasting 15 minutes; both occurred with exertion and were accompanied by shortness of breath and nausea. Today she had a 10-minute episode starting while she was in the shower and another while she was walking into the emergency department. Examination and an ECG show no abnormalities. Which of the following is the most appropriate next step in management?
A) Self-monitoring of blood glucose concentration during the next episode of chest pain
B) Dipyridamole-thallium-201 scintigraphy
C) Exercise stress test within 24 hours (wrong)
D) Antianginal drug therapy now and an exercise stress test in 5 days
E) Admit the patient to the hospital
I was leaning towards stable angina for this patient's presentation since she has shortness of breath which resolves at rest. However, I got confused when it said she did not have chest pains.
If I was going by the stable angina diagnosis I am thinking she would need an ECG exercise stress test ( choice B). Any suggestions?
I really appreciate the help, if anyone has any ideas or other diagnosis.
I hope this helps. It helped me to look it up. Thanks for posting these questions. If, I'm wrong, please correct me as I am studying for my NBME Internal Medicine exam.
2 stress echo?
I think answer to the second one is stress echo. She has baseline LBBB so ECG may not be that useful to look for ischemia.
The last one is B. Got it correct.
A few more...
Thank you again to everyone who responded and help me out a lot. I was wondering if you would not mind checking the following questions and see if you can shed some light.
40. A 62-year-old woman comes to the physician because of a 3-month history of mildly increased shortness of breath. She has a 3-year history of chronic obstructive pulmonary disease. She smoked one pack of cigarettes daily for 40 years but quit 3 years ago when she was diagnosed. She has not required pharmacotherapy. Her temperature is 36.7°C (98°F), pulse is 86/min, respirations are 16/min, and blood pressure is 138/76 mm Hg. Pulmonary examination shows mildly decreased air movement; an occasional wheeze is heard. Arterial blood gas analysis on room air shows:
Pco2 40 mm Hg
Po2 74 mm Hg
Which of the following is the most appropriate next step in management?
A) Pulmonary rehabilitation
B) Home oxygen therapy
C) Ipratropium therapy
D) Prednisone therapy
E) Theophylline therapy
41. Two weeks after admission to the hospital for treatment of an unexplained fever, a 57-year-old man develops acute renal failure. Current medications include acetazolamide, lisinopril, heparin, amikacin, and naproxen. Examination shows 2+ pitting edema of the lower extremities below the midcalf level. Urinalysis shows a few \NBCs, epithelial cells, and numerous muddy brown casts. Which of the following medications is the most likely cause of his acute renal failure?
42. A 90-year-old woman comes to the physician because of a 1-month history of generalized itching and a decreased appetite resulting in a 4.5-kg (10-1b) weight loss. She has not had nausea or vomiting. She has a 30-year history of hypertension treated with hydrochlorothiazide and atenolol. She has no difficulty with normal activities of daily living and sleeps 8 hours nightly. She appears frail and is not in distress. She is 168 cm (5 ft 6 in) tall and weighs 40 kg (88 lb); BMI is 14 kg/m2. Her pulse is 70/min and regular, and blood pressure is 160/80 mm Hg. Examination shows excoriations over the upper and lower extremities. Mental status examination shows a normal affect. Cognition is intact. Laboratory studies show:
Hemoglobin 10 g/dL
Leukocyte count 4000/mm3
Na+ 138 mEq/L
K+ 5.9 mEq/L
Cl- 110 mEq/L
HCO3- 20 mEq/L
Ca 2+ 10.2 mg/dL
Urea nitrogen 45 mg/dL
Creatinine 3 mg/dL
Which of the following is the most likely cause of this patient's anorexia?
A) Adverse effect of atenolol
D) Major depressive disorder
E) Renal failure
43. A 52-year-old woman comes to the emergency department because of increasingly severe right knee pain since she tripped and fell outside her home 1 week ago. Initially, mild pain and swelling developed in the joint, but she was able to walk. The pain has worsened during the past 4 days, and she is now unable to bear weight on her right side. She has a 5-year history of type 2 diabetes mellitus treated with metformin. Her temperature is 37°C (98.6°F). Examination of the right knee shows warmth and a small effusion. Passive and active range of motion is limited by pain. The remainder of the examination shows no abnormalities. Her leukocyte count is 10,000/mm3, and serum erythrocyte sedimentation rate is 40 mm/h. An x-ray of the knee shows degenerative joint disease and osteopenia but no fracture. Which of the following is the most appropriate next step in diagnosis?
A) Serum rheumatoid factor assay
B) Triple-phase technetium 99m bone scan
C) MRI of the knee
D) Aspiration of the knee joint
E) Bone biopsy
40) Does the patient have an acute asthma exacerbation and needs prednisone?
41) Thought patient had acute tubular necrosis due to NSAIDS (most common toxin causing AKI from ATN) but it was wrong E, would it be caused by aminoglycosides B?
42) Side effect of Atenolol? but after 30 years of using it?
43)Read someone mention it would be joint aspiration? Why not a bone scan after the traumatic injury after a fall?
Thanks again in advance for any help.
Patient has worsening COPD which needs pharmacotherapy. I believe home oxygen therapy is used only when PaO2 is less 55. Steroids are used for acute exacerabation of COPD (after bronchodilators) she has a 3 month history of worsening COPD not acute exacerbation.
NSAIDs are not usually associated with ATN (muddy brown casts) but are more frequently associated with pre-renal AKI (clear urine sediment; remember the prostaglandin effect on afferent arteriole) or AIN. Aminoglycosides cause ATN typically after 5-10 days of exposure.
Looks like uremia due to renal failure.
Always rule out septic arthritis when there is monoarticular joint involvement with evidence of inflammation (especially after trauma). Imaging studies will not identify the organisms and the cell count in joint fluid is useful for differential Dx
Last edited by saxo; 07-05-2016 at 05:33 AM.
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Q4, 17, 39
Thank you so much for your help I really appreciate it.
4 and 17 agree with your reasoning thank you!
Q 39 I actually thought the same thing at first and picked B Dypiridamole-thalium.. but it was wrong. This is tricky i think someone mentioned she might need a bypass and thats why you would admit to the hospital?choice E?? maybe because of her progressive worsening of symptoms? any thoughts?
Q 40, 41, 42, 43:
The correct answer to Q41 is B Amikacin, that you! Quick question regarding Q41 I am still a bit confused there is a table in MTB third edition page 337 that mentions NSAIDS as a cause of ATN under toxins. Don't know if it was placed there by mistake just want to make sure that if I get another question like this I don't make the mistake of picking NSAID as a possible cause of ATN.
Thank you for all the help so far. Would you guys have any ideas about the following questions?
44. A previously healthy 67-year-old woman is admitted to the hospital because of fever, hypotension, and respiratory distress. Her temperature is 38.4°C (101.1°F), pulse is 112/min, respirations are 28/min, and blood pressure is 98/50 mm Hg. Diffuse crackles are heard on auscultation. A grade 2/6 systolic murmur is heard. The extremities are warm and well perfused. Pulmonary artery catheterization shows a cardiac output of 6 L/min (N=4-5), a left ventricular end-diastolic pressure of 11 mm Hg (N=5-12), and a pulmonary capillary wedge pressure of 14 mm Hg (N=5-16).
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 72%
Arterial blood gas analysis on room air:
Pco2 18 mm Hg
Poe 64 mm Hg
Which of the following is the most likely mechanism of this patient's respiratory failure?
A) Decreased hypoxic drive
B) Decreased myocardial contractility
C) Decreased pulmonary vascular flow
D) Increased pericardial pressure
E) Increased regurgitant mitral flow
F) Increased vascular permeability
Think this patient has septic shock, since there is decreased organ and tissue perfusion thought C would be the reason why she has respiratory failure however that's wrong. Any ideas?
I would not follow MTB to the point. It certainly has its share of mistakes. What I was taught during my renal rotation was virtually any drug cause AIN. NSAIDs are usually with pre-renal AKI 2/2 inhibition of prostaglandins at afferent (typically not tubulotoxic) while aminoglycosides are usually with ATN
Yes looks like septic shock. So F.Sepsis associated with markedly increased pro-inflammatory cytokines which cause vasodilation and increase vascular permeability
Any ideas on this one?
Thank one once more for all the help thus far. I was wondering if you could shed some light on this one.
45. A 62-year-old man is brought to the emergency department 24 hours after the onset of fever, right-sided abdominal pain, and confusion. He has no history of serious illness. Current medications include daily aspirin. He drinks one glass of wine daily. On arrival, he is oriented to person but not to place or time. He becomes light-headed on sitting up. His temperature is 38.7°C (101.7°F), pulse is 120/min, and blood pressure is 84/50 mm Hg while supine. Abdominal examination shows right lower quadrant tenderness with guarding and rebound; there is a suggestion of a mass. The upper and lower extremities are cool and clammy. Urinalysis shows no abnormalities.
Additional laboratory studies show:
Arterial blood gas analysis on room air shows:
Leukocyte count 25,400/mm3 with a shift to the left
Serum Na+ 140 mEq/L
K+ 4.5 mEq/L
Cl- 103 mEq/L
HCO3- 19 mEq/L
Urea nitrogen 40 mg/dL
Creatinine 1.6 mg/dL
Pco2 34 mm Hg
Po2 84 mm Hg
Which of the following serum concentrations is most likely to be increased in this patient?
C) Ethylene glycol
E) Lactic acid
Does this person have Cariogenic shock and that's why he would have increased lactic acid? Correct ans E
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Thank you so much.
Thank you so much for all the help so far. I am currently studying for Psychiatry and I have a set of questions on a separate post. I was wondering if you would not mind taking a look at them.
Here: Psychiatry Questions
Thank you in advance,
This Patient is most likely UNSTABLE angina , or possible Non STMI .. EKG is normal , only way to tell two apart is doing a series of enzymes test and manage from there after ..
Thank you for all the help so far. I was wondering if you could help my further understand the following questions.
P40. A 67-year-old woman, whose husband died 18 months ago, is admitted to the hospital because of severe headaches for 4 weeks. She is quiet and seems sad. She believes that she has brain cancer, deserves to be punished for her sins, and is being punished by God for past misdeeds. She has had fatigue and a 6.8-kg (15-lb) weight loss over the past 4 months. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely diagnosis?
A) Adjustment disorder with mixed disturbance of emotions and conduct
B) Delusional disorder
C) Major depressive disorder
E) Somatization disorder
P44. A 7-year-old girl is brought to the physician because her parents are concerned about her recent preoccupation with death. Her dog died 2 months ago, and since th time she has repeatedly asked her parents if they are going to die. When her mother travels, the daughter worries that the plane will crash. She has begun to talk wi her friends about the possibility of their parents dying. She continues to excel academically and participate in sports. Her pulse is 86/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Mental status examination shows a neutral mood and an appropriately reactive affect. Which of the following is the most likely explanation for these findings?
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Separation anxiety disorder
P47. A 27-year-old man comes to the physician because of anxiety about a major speech that he must deliver in 3 days. He has a great fear of public speaking and is convinced that his apprehension and tremulous delivery will damage his performance. He requests a tranquilizer to help with his anxiety. He takes theophylline and uses corticosteroid and albuterol inhalers for asthma. He has a family history of alcohol dependence. He does not drink alcohol or use drugs. His pulse is 66/min, respirations are 12/min, and blood pressure is 132/80 mm Hg. Examination shows normal findings.
For each patient with anxiety, select the most appropriate pharmacotherapy.
P50. An otherwise healthy 25-year-old man comes to the physician because he has a severe fear of flying and must attend an essential business meeting in Europe in 2 days. He has no substance abuse problems or other mental or physical problems.
For each patient with anxiety symptoms, select the most appropriate pharmacotherapy.
P40) MDD~complicated bereavement, C?
P50) specific phobia=benzo F?
P44) Is she presenting with age appropriate behavior?
P47) Performance anxiety part of social phobia, since he is asthmatic should avoid propranolol? but D is incorrect..which one would you give him? I thought lorazepam should stay away from since he has a dependency issue in his family.
Thank you all in advance,
A Few More
Thank you again for everything. I have a few more questions and I am hoping you could help me a bit.
4. A previously healthy 21-year-old woman comes to the physician 1 day after the sudden onset of severe right-sided chest pain that increases with deep inspiration, this period, she has had shortness of breath and difficulty taking a deep breath. She has had no cough. Yesterday, she returned from a 3-week vacation to the Andes Mountains. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her temperature is 38°C (100 4°F), pulse is 80/min, respirations are 14/min, and blood pressure is 100/70 mm Hg. Examination shows a faint, erythematous. macular, nonpruritic rash over the cheeks and trunk. There is dullness to percussion at the right lung base and an inspiratory rub with no crackles or wheezes. Which of the following is the most likely diagnosis?
A) Allergic granulomatous angiitis (Churg-Strauss syndrome)
B) Allergic pulmonary aspergillosis
C) Chronic bronchitis
G) Postintectious bronchospasm
H) Pulmonary embolism
J) Viral pleurisy
5. A 62-year-old woman is brought to the emergency department because of a 4-day history of increasingly severe upper back pain, progressive weakness of both legs, and tingling in her legs and feet. She has had episodes of urinary incontinence during this period. Six months ago she underwent a mastectomy for treatment of breast cancer, which was lymph node positive. Examination shows normal cranial nerves and normal strength in the upper extremities. Muscle strength in the lower extremities is 3/5 bilaterally with increased tone. Sensation to pinprick is mildly decreased over the midtrunk, and sensation to vibration is decreased in the lower extremities. Deep tendon reflexes are normal in the upper extremities and brisk in the lower extremities. Babinski sign is present bilaterally. Which of the following is the most appropriate next step in management?
A) Azathioprine therapy
C) Interferon therapy
D) Pyridostigmine therapy
E) Radiation therapy
F) Riluzole therapy
11. A 47-year-old man comes to the physician because of a 9-month history of constipation and a 2-month history of blood in his stool. His symptoms are partially relieved by stool softeners and laxatives. He has hypercholesterolemia treated with atorvastatin, and he had an appendectomy at the age of 26 years. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender with no palpable masses. Rectal examination shows external hemorrhoids; test of the stool for occult blood is positive. His hematocrit is 35%.
Which of the following is the most appropriate next step in diagnosis?
A) Tagged red blood cell scan
E) Flexible sigmoidoscopy
12. A 67-year-old man comes to the physician because of aching in the calves while walking during the past 2 months. The pain is relieved with rest. Examination shows decreased pedal pulses. The most likely cause of this patient's current symptoms is significant narrowing of which of the following vessels?
A) Abdominal aorta
B) Femoropopliteal arteries
C) Iliac arteries
D) Peroneal arteries
E) Tibial and peroneal arteries
21. An afebrile 32-year-old woman comes to the physician because of cramping abdominal pain and watery stools for 4 days. Examination shows no abnormalities. Her hemoglobin concentration is 12.5 g/dL, and leukocyte count is 8500/mm3. Examination of the stool shows no neutrophils. Which of the following is the most likely causal organism?
A) Enterotoxic Escherichia coil
B) Listeria monocytogenes
C) Shigella species
D) Staphylococcus aureus
E) Yersinia enterocolitica
30. Five days after undergoing an open splenectomy for immune thrombocytopenic purpura, a 57-year-old woman has the onset of shortness of breath. During the operation, dissection of the splenic hilum was difficult. Her only medication is morphine. Her temperature is 37.3°C (99.2°F), pulse is 80/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. The surgical wound appears normal. Breath sounds are decreased at the left lung base. Her leukocyte count is 15,600/mm3, platelet count is 112,000/mm3, and serum amylase activity is 90 U/L. Which of the following is the most appropriate next step in management?
A) X-rays of the chest
B) Ultrasonography of the abdomen
C) Intravenous antibiotic therapy
D) Intravenous immune globulin therapy
E) Systemic heparin therapy
F) Pulmonary angiography
36. A 25-year-old woman comes to the physician because of tremulousness and fatigue for 1 month. Her temperature is 37.2°C (99°F), and pulse is 120/min. She appears nervous. Ophthalmologic examination shows no abnormalities. The thyroid gland is barely detectable by palpation and is nontender. Iodine uptake is decreased.
A) Bacterial infection
B) lmmunoglobulin antagonism of the thyroid-stimulating hormone receptor
C) lmmunoglobulin stimulation of the thyroid gland
D) Iodine exposure
E) Neoplastic infiltration
F) Surreptitious administration of thyroxine
G) Viral infection
38. A 37-year-old woman with sickle cell disease comes to the physician because of a 24-hour history of fever, right upper abdominal pain after eating, and nausea. Her last sickle cell crisis was 4 months ago. Her only medication is folic acid. She is 168 cm (5 ft 6 in) tall and weighs 66 kg (145 lb); BMI is 23 kg/m2. Her temperature is 38.2°C (100.8°F), and pulse is 90/min. Examination shows mild scleral icterus. The abdomen is distended. Bowel sounds are decreased, and Murphy sign is present.
Laboratory studies show:
Leukocyte count 12,000/mm3
Serum Bilirubin, total 3 mg/dL
Alkaline phosphatase 60 U/L
Amylase 90 U/L
Lipase 40 U/L (N=14-280)
Ultrasonography of the abdomen shows cholelithiasis, pericholecystic fluid, and a normal-sized common bile duct.
Which of the following is the most likely diagnosis?
A) Acute cholecystitis
B) Acute pancreatitis
C) Acute viral hepatitis
E) Sickle cell crisis
43. A 52-year-old woman comes to the emergency department because of a 5-day history of continuous abdominal pain, nausea, and decreased appetite. Nine days ago, she underwent an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. She was discharged from the hospital 7 days ago. Her temperature is 38.2°C (100.8°F), pulse is 108/min, respirations are 20/min, and blood pressure is 102/64 mm Hg. Examination shows jaundice. Abdominal examination shows right upper quadrant tenderness. Bowel sounds are present throughout all quadrants.
Laboratory studies show:
Hemoglobin 12.2 g/dL
Leukocyte count 17,200/mm3
Serum Urea nitrogen 48 mg/dL
Glucose 186 mg/dL
Creatinine 1.5 mg/dL
Total bilirubin 7.2 mg/dL
Alkaline phosphatase 251 U/L
AST 84 U/L
Ultrasonography of the abdomen shows no fluid collections. Which of the following is the most appropriate next step in diagnosis?
A) CT scan of the abdomen
B) HIDA scan
C) Endoscopic retrograde cholangiopancreatography
D) Transhepatic cholangiography
E) Exploratory laparotomy
45. A 12-month-old boy is brought to the emergency department because of a 4-hour history of temperatures to 40.6°C (105°F) and irritability. He has had two previous infections during the past 8 months: pneumococcal bacteremia at the age of 4 months and periorbital cellulitis caused by Haemophilus influenzae type b at the age of 7 months. All recommended immunizations were administered at the appropriate ages. A lumbar puncture is performed; analysis of the cerebrospinal fluid shows a leukocyte count of 500/mm3 with 95% segmented neutrophils. A Gram stain of the fluid shows gram-positive diplococci.
For each child with infection, select the cell type most likely involved in the underlying condition.
A) B lymphocyte
G) T lymphocyte
4) Not really sure how to arrive to the answer, I believe it's J
5) I'm a bit confused, I thought this patient had MS so then it would be interferon therapy. But others mentioned the correct answer was E?
11) Correct answer I believe is colonoscopy, however I would have gone for anoscopy first, any thoughts as to why colonoscopy is the best answer?
12) I believe the correct answer is B, but I actually chose E any explanation as to why femoropopliteal arteries is the answer rather than Tibial and peroneal arteries ?
21) Not really sure how to get to the answer, read in another post that it was A
30) I believe chest X-ray is the right answer, is this the next step in management because the patient has decreased breath sounds?
36) Hyperthyroid patient ~ would iodine exposure make the patient hyperthyroid too? With a goiter or thyroid adenoma... Jod-Basedow phenomenon... Others said correct answer was F. I guess F makes more sense since the question stem mentions her thyroid gland is barely palpable... Due to suppression by the thyroxine intake?
38) I'm a bit confused between acute cholecystitis and cholangitis. Correct answer is A.
43) I think the correct answer is C. Is it because you want to check the pancreatic ducts? That would be the only possibility since she had a cholecystectomy?
45) Answer is B lymphocytes however I'm not really sure whether they are talking about Bruton agammaglobulinemia, CVID or just simple defective B lymphocyte response~ hence recurrent infections by encapsulated bacteria?
Please correct me if I am wrong. Really appreciate your help and input.
Last edited by DocMinion; 07-30-2016 at 07:19 PM. Reason: Added content.
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