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  #1  
Old 07-18-2016
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Default Help please CMS Medicine Form 4

1. A 56-year-old woman has a 1-day history of epigastric pain and vomiting. She has scleral icterus and a tender epigastrium.

Laboratory studies show:
Leukocyte count 14,200/mm3
Neutrophils 78%

Serum Bilirubin
Total 4.4 mg/dL
Direct 3.3 mg/dL

Triglycerides 210 mg/dL
Amylase 1350 Somogyi U/dL (N=60160)
Alkaline phosphatase 320 Bodansky U/dL (N=2.04.5)

Ultrasonography shows dilation of intrahepatic ducts. Which of the following is the most likely cause of her condition?
A) Alcoholism
B) Cholecystitis
C) Choledocholithiasis
D) Hepatoma
E) Pancreatic carcinoma (WRONG)

2. A 72-year-old woman comes to the emergency department because of a 1-day history of fever, chills, and cough. She had pneumococcal pneumonia 1 year ago. Her temperature is 39C (102.2F). Examination shows bronchial breath sounds at the right lung base with increased dullness and egophony. Her leukocyte count is 87,000/mm3 (15% segmented neutrophils, 82% lymphocytes, and 3% monocytes). A Gram stain of sputum shows gram-positive, lancet-shaped diplococci. Which of the following is most likely to confirm this patient's deficit in host defenses?

A) Assessment of segmented neutrophil function (WRONG)
B) Measurement of CD4+ T*lymphocyte count
C) Measurement of serum IgE concentration
D) Measurement of T*lymphocyte count
E) Quantitative immunoglobulin assay

3. A 24-year-old man comes to the physician for a follow-up examination. Two months ago, he was seen for a red, scaly rash over his groin. A 6-*week course of topical clotrimazole resolved the rash completely, but it recurred 2 days ago. He is sexually active with one partner and uses condoms consistently. Examination shows an erythematous, excoriated rash over the groin and a similar rash over the instep of the left foot. A KOH preparation of a skin scraping shows hyphae. Which of the following is the most likely cause of this patient's recurrent infection?

A) Autoinfection
B) Clotrimazole resistance
C) Impaired cellular immunity (WRONG)
D) Impaired humoral immunity
E) Reinfection from a sexual partner

4. A previously healthy 42-year-old woman comes to the physician 2 days after she noted a mildly tender bump on her neck. She has not had fever, chills, cough, sore throat, or palpitations. She has smoked approximately one-half pack of cigarettes daily for 20 years. She underwent a hysterectomy 2 years ago. Her only medication is conjugated estrogen. She is in no acute distress. She is 178 cm (5 ft 10 in) tall and weighs 57 kg (125 lb); BMI is 18 kg/m . Her temperature is 37C (98.6F), pulse is 82/min, and blood pressure is 120/78 mm Hg. Examination of the neck shows a 2-*cm lesion on the left lobe of the thyroid gland. There is no cervical lymphadenopathy. Her serum thyroid-stimulating hormone concentration is 1.5 μU/mL, and serum free thyroxine concentration is 1.4 ng/dL (N=0.92.1). Which of the following is the most appropriate next step in management?

A) Reexamination and repeat thyroid function tests in 1 month (WRONG)
B) Measurement of thyroid radioactive iodine uptake
C) CT scan of the neck
D) Fine-needle aspiration of the lesion
E) Partial thyroidectomy

5. 5. A 32-year-old woman is admitted to the hospital 8 hours after the onset of nausea and vomiting and epigastric abdominal pain that radiates to her back. She has had two similar episodes during the past 2 months. She has no other history of serious illness. She does not drink alcohol. Abdominal examination shows moderate epigastric tenderness.
Laboratory studies show:
Hemoglobin 12.5 g/dL
Hematocrit 38%
Leukocyte count 15,400/mm3
Platelet count 326,000/mm3
Serum amylase 1450 U/L

Ultrasonography of the gallbladder shows no abnormalities. A CT scan of the abdomen is shown (go to imgur*dot*com/TO83aZy). Which of the following is the most appropriate next step in diagnosis?

A) HIDA scan
B) Endoscopic retrograde cholangiopancreatography
C) Esophagogastroduodenoscopy (WRONG)
D) Mesenteric angiography
E) Percutaneous transhepatic cholangiography

6. A 20-year-old woman comes for a routine health maintenance examination. Her temperature is 37C (98.6F), pulse is 80/min, respirations are 12/min, and blood pressure is 110/70 mm Hg. The S2 is split and fixed. A grade 2/6 systolic murmur is heard at the third intercostal space. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?

A) Aortic insufficiency
B) Atrial septal defect
C) Mitral insufficiency
D) Patent ductus arteriosus
E) Pulmonic insufficiency
F) Tetralogy of Fallot
G) Tricuspid insufficiency
H) Ventricular septal defect (WRONG)

7. A 72-year-old woman is brought to the emergency department by her daughter because of a 3-day history of progressive confusion and lethargy. She underwent bilateral hip replacement 6 years ago. She takes no medications except for aspirin as needed for osteoarthritis. She is unable to answer questions. Her temperature is 36.2C (97.2F), pulse is 110/min and regular, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a supple neck. The lungs are clear to auscultation. Cardiac examination shows no murmurs or gallops. The abdomen is soft with no guarding; bowel sounds are present but hypoactive. Deep tendon reflexes are 1+ bilaterally. Babinski sign is absent. Serum studies show:
Na+ 135 mEq/L
Cl− 100 mEq/L
K+ 4.2 mEq/L
HCO3− 22 mEq/L
Urea nitrogen 52 mg/dL
Glucose 602 mg/dL
Creatinine 2.4 mg/dL

Which of the following is the most likely diagnosis?
A) Alcoholic ketoacidosis
B) Central diabetes insipidus
C) Diabetic ketoacidosis (WRONG)
D) Lactic acidosis
E) Myxedema
F) Nephrogenic diabetes insipidus
G) Nonketotic hyperosmolar state
H) Salicylate toxicity
I) Syndrome of inappropriate secretion of ADH (vasopressin)
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  #2  
Old 07-18-2016
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8. A 72*-year-*old nursing home resident is brought to the emergency department because of abdominal pain and bloody stools for 3 days. She has dementia, Alzheimer type, and a long*standing history of constipation treated with psyllium and docusate. She is in no apparent distress. Her temperature is 39C (102.2F), pulse is 88/min, respirations are 18/min, and blood pressure is 150/80 mm Hg. Abdominal examination shows left lower quadrant tenderness and distention. Rectal examination shows blood and no masses. She is not oriented to place or time. Which of the following is the most likely diagnosis?

A) Campylobacteriosis
B) Celiac disease
C) Clostridium difficile colitis
D) Colon cancer
E) Diverticulitis
F) Diverticulosis
G) Irritable bowel syndrome
H) Ischemic colitis
I) Salmonellosis
J) Shigellosis
K) Ulcerative colitis
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  #3  
Old 07-18-2016
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Quote:
Originally Posted by doc2530 View Post
1. A 56-year-old woman has a 1-day history of epigastric pain and vomiting. She has scleral icterus and a tender epigastrium.

Laboratory studies show:
Leukocyte count 14,200/mm3
Neutrophils 78%

Serum Bilirubin
Total 4.4 mg/dL
Direct 3.3 mg/dL

Triglycerides 210 mg/dL
Amylase 1350 Somogyi U/dL (N=60–160)
Alkaline phosphatase 320 Bodansky U/dL (N=2.0–4.5)

Ultrasonography shows dilation of intrahepatic ducts. Which of the following is the most likely cause of her condition?
A) Alcoholism
B) Cholecystitis
C) Choledocholithiasis
D) Hepatoma
E) Pancreatic carcinoma (WRONG)

2. A 72-year-old woman comes to the emergency department because of a 1-day history of fever, chills, and cough. She had pneumococcal pneumonia 1 year ago. Her temperature is 39C (102.2F). Examination shows bronchial breath sounds at the right lung base with increased dullness and egophony. Her leukocyte count is 87,000/mm3 (15% segmented neutrophils, 82% lymphocytes, and 3% monocytes). A Gram stain of sputum shows gram-positive, lancet-shaped diplococci. Which of the following is most likely to confirm this patient's deficit in host defenses?

A) Assessment of segmented neutrophil function (WRONG)
B) Measurement of CD4+ T*lymphocyte count
C) Measurement of serum IgE concentration
D) Measurement of T*lymphocyte count
E) Quantitative immunoglobulin assay

3. A 24-year-old man comes to the physician for a follow-up examination. Two months ago, he was seen for a red, scaly rash over his groin. A 6-*week course of topical clotrimazole resolved the rash completely, but it recurred 2 days ago. He is sexually active with one partner and uses condoms consistently. Examination shows an erythematous, excoriated rash over the groin and a similar rash over the instep of the left foot. A KOH preparation of a skin scraping shows hyphae. Which of the following is the most likely cause of this patient's recurrent infection?

A) Autoinfection
B) Clotrimazole resistance
C) Impaired cellular immunity (WRONG)
D) Impaired humoral immunity
E) Reinfection from a sexual partner

4. A previously healthy 42-year-old woman comes to the physician 2 days after she noted a mildly tender bump on her neck. She has not had fever, chills, cough, sore throat, or palpitations. She has smoked approximately one-half pack of cigarettes daily for 20 years. She underwent a hysterectomy 2 years ago. Her only medication is conjugated estrogen. She is in no acute distress. She is 178 cm (5 ft 10 in) tall and weighs 57 kg (125 lb); BMI is 18 kg/m . Her temperature is 37C (98.6F), pulse is 82/min, and blood pressure is 120/78 mm Hg. Examination of the neck shows a 2-*cm lesion on the left lobe of the thyroid gland. There is no cervical lymphadenopathy. Her serum thyroid-stimulating hormone concentration is 1.5 μU/mL, and serum free thyroxine concentration is 1.4 ng/dL (N=0.9–2.1). Which of the following is the most appropriate next step in management?

A) Reexamination and repeat thyroid function tests in 1 month (WRONG)
B) Measurement of thyroid radioactive iodine uptake
C) CT scan of the neck
D) Fine-needle aspiration of the lesion
E) Partial thyroidectomy

5. 5. A 32-year-old woman is admitted to the hospital 8 hours after the onset of nausea and vomiting and epigastric abdominal pain that radiates to her back. She has had two similar episodes during the past 2 months. She has no other history of serious illness. She does not drink alcohol. Abdominal examination shows moderate epigastric tenderness.
Laboratory studies show:
Hemoglobin 12.5 g/dL
Hematocrit 38%
Leukocyte count 15,400/mm3
Platelet count 326,000/mm3
Serum amylase 1450 U/L

Ultrasonography of the gallbladder shows no abnormalities. A CT scan of the abdomen is shown (go to imgur*dot*com/TO83aZy). Which of the following is the most appropriate next step in diagnosis?

A) HIDA scan
B) Endoscopic retrograde cholangiopancreatography
C) Esophagogastroduodenoscopy (WRONG)
D) Mesenteric angiography
E) Percutaneous transhepatic cholangiography

6. A 20-year-old woman comes for a routine health maintenance examination. Her temperature is 37C (98.6F), pulse is 80/min, respirations are 12/min, and blood pressure is 110/70 mm Hg. The S2 is split and fixed. A grade 2/6 systolic murmur is heard at the third intercostal space. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?

A) Aortic insufficiency
B) Atrial septal defect
C) Mitral insufficiency
D) Patent ductus arteriosus
E) Pulmonic insufficiency
F) Tetralogy of Fallot
G) Tricuspid insufficiency
H) Ventricular septal defect (WRONG)

7. A 72-year-old woman is brought to the emergency department by her daughter because of a 3-day history of progressive confusion and lethargy. She underwent bilateral hip replacement 6 years ago. She takes no medications except for aspirin as needed for osteoarthritis. She is unable to answer questions. Her temperature is 36.2C (97.2F), pulse is 110/min and regular, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a supple neck. The lungs are clear to auscultation. Cardiac examination shows no murmurs or gallops. The abdomen is soft with no guarding; bowel sounds are present but hypoactive. Deep tendon reflexes are 1+ bilaterally. Babinski sign is absent. Serum studies show:
Na+ 135 mEq/L
Cl− 100 mEq/L
K+ 4.2 mEq/L
HCO3− 22 mEq/L
Urea nitrogen 52 mg/dL
Glucose 602 mg/dL
Creatinine 2.4 mg/dL

Which of the following is the most likely diagnosis?
A) Alcoholic ketoacidosis
B) Central diabetes insipidus
C) Diabetic ketoacidosis (WRONG)
D) Lactic acidosis
E) Myxedema
F) Nephrogenic diabetes insipidus
G) Nonketotic hyperosmolar state
H) Salicylate toxicity
I) Syndrome of inappropriate secretion of ADH (vasopressin)
1. C
Epigastric pain/tenderness + conjugated hyperbilirubinemia + markedly elevated amylase and ALP = gallstone pancreatitis (gallstone blocking common bile duct)

2. D?
This one is tricky. So all we have is 2 episodes of pneumococcal pneumonia in an elderly patient with markedly elevated white count (predominantly lymphocytes). Looks like leukemia or lymphoma, can't make out which type with the info.

3. A
Taenia cruris is frequently present with taenia pedis. Looks like this taenia pedis was not diagnosied initially leading to recurrence.

4. D
Always rule out thyroid cancer in an elderly euthyroid patient with a solitary thyroid nodule.

5. B
She has recurrent episodes of acute pancreatitis with mass lesion on CT = pancreatic cancer. ERCP for decompression.

6. B
Fixed split S2 = ASD (the murmur described is a systolic flow murmur across pulmonary valve due to left to right shunting)

7. G
Elderly + altered mental status + markedly elevated glucose + normal anion gap (135-100+22 = 13) = nonketotic coma. Looks like she has renal damage from diabetes as well.
Classic case for DKA is a child or adoloscent with elevated glucose + metabolic acidosis with elevated anion gap due to ketoacids + abdominal pain +/- altered mental status
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  #4  
Old 07-18-2016
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Steps History: 1+CK+CS
Posts: 638
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Default

Quote:
Originally Posted by doc2530 View Post
8. A 72*-year-*old nursing home resident is brought to the emergency department because of abdominal pain and bloody stools for 3 days. She has dementia, Alzheimer type, and a long*standing history of constipation treated with psyllium and docusate. She is in no apparent distress. Her temperature is 39C (102.2F), pulse is 88/min, respirations are 18/min, and blood pressure is 150/80 mm Hg. Abdominal examination shows left lower quadrant tenderness and distention. Rectal examination shows blood and no masses. She is not oriented to place or time. Which of the following is the most likely diagnosis?

A) Campylobacteriosis
B) Celiac disease
C) Clostridium difficile colitis
D) Colon cancer
E) Diverticulitis
F) Diverticulosis
G) Irritable bowel syndrome
H) Ischemic colitis
I) Salmonellosis
J) Shigellosis
K) Ulcerative colitis
E
Elderly + acute onset abdominal pain with LLQ tenderness + fever + past Hx of constipation = acute diverticulitis
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