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Old 01-11-2013
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Question NBME form 2 Block 3, 4....need few answers

BLOCK 3

3. Over the past 4 years, a 40-year-old woman has had increasing episodes of loss of urine and difficulty emptying her bladder. She has had no dysuria. She has a 30-year history of type 1 diabetes mellitus. She weighs 66 kg (145 lb) and is 175 cm (69 in) tall. Pelvic examination shows a moderate cystocele. Postvoiding catheterization yields 700 mL of clear urine. Which of the following is the most likely cause of the patient's genitourinary symptoms?
A) Carcinoma of the bladder
B) Detrusor instability
C) Neurogenic bladder
D) Urethral diverticulum
E) Uterine prolapse


6. A 2-month-old boy is brought to the physician because of a 6-week history of persistent diarrhea and vomiting, most pronounced after formula feedings. He has had a 113-g (4-oz) weight loss since birth. He currently weighs 3100 g (6 lb 13 oz) and is 51 cm (20 in) in length. He appears irritable. Examination shows jaundice. The lungs are clear to auscultation. No murmurs are heard. The liver is palpated 2 to 3 cm below the right costal margin, and the spleen is palpated 1 to 2 cm below the left costal margin.

Laboratory studies show:
Serum Glucose 35 mg/dL Bilirubin (total) 2.3 mg/dL Urine Glucose negative Reducing substances 3+
Which of the following is the most likely mechanism of these findings?
A) Decreased gluconeogenesis
B) Decreased insulin secretion
C) Increased glucagon secretion
D) Increased gluconeogenesis
E) Increased insulin secretion
F) Insulin resistance



17. A previously healthy 24-year-old woman is brought to the physician by her husband because of several episodes of loss of consciousness over the past 4 days. Her husband reports that during episodes, she jerks her arms and legs wildly. Each episode lasts up to 1 hour; between episodes, her behavior is normal. She is planning to move to another state because of her husband's work. She has been extremely anxious and upset about the move because she will have to leave her mother, who was recently diagnosed with breast cancer. There is no family history of seizure disorder. Her temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 18/min. Neurologic examination shows no abnormalities. Electroencephalography shows normal findings during an episode of shaking.
Which of the following is the most likely underlying cause? A) Catatonia
B) Complex partial seizure
C) Conversion reaction
D) Dissociative fugue
E) Malingering
F) Tonic-clonic seizure


26. A 57-year-old man with multiple myeloma comes to the physician because of a 12-hour history of fever, sharp chest pain with deep inspiration, and cough productive of blood-tinged sputum. His temperature is 38.3 C (101 F), blood pressure is 120/78 mm Hg, pulse is 112/min, and respirations are 28/min. Crackles are heard at the right lung base. His hemoglobin level is 9.2 g/dL, leukocyte count is 2600/mm3, and platelet count is 96,000/mm3. Empiric antibiotics should be directed against which of the following organisms?
A) Listeria monocytogenes
B) Neisseria meningitidis
C) Pseudomonas aeruginosa
D) Streptococcus bovis
E) Streptococcus pneumoniae


37. A 72-year-old man is brought to the physician by his daughter because of painless jaundice for 1 month. His wife died 10 years ago, and his daughter is his only child. Before examining the patient, the daughter asks to speak privately with the physician and asks that she be given the results of any tests. She specifically requests that he not be given any "bad news." The patient is alert. His vital signs are within normal limits. Examination shows scleral icterus and jaundice. There is mild abdominal tenderness on palpation. He is oriented to person, place, and time. A CT scan of the abdomen shows a pancreatic mass with bile duct obstruction and probable metastatic lesions in the liver.
Which of the following is the most appropriate next step?
A) Abide by the daughter's wishes
B) Ask the patient if he wishes to discuss his test results, preferably with his daughter present
C) Tell the daughter it is a legal requirement to tell the patient any and all results of medical testing
D) Consult with the hospital attorney
E) Ask another physician to take over the patient's care
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Old 01-11-2013
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Default Block 4

9)...A previously healthy 67-year-old woman is brought to the emergency department by paramedics 40 minutes after the sudden onset of shortness of breath while shopping. She is unable to provide additional medical history. She is in severe respiratory distress. Her temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 120/min and regular, and respirations are 24/min. Examination shows marked jugular venous distention. Diffuse crackles are heard throughout all lung fields. Cardiac examination shows an enlarged point of maximal impulse and normal S1 and S2; there is an S3. Abdominal examination shows no abnormalities. There is no edema of the lower extremities.
Laboratory studies show: Hematocrit 38% Leukocyte count 12,000/mm3 Platelet count 350,000/mm3
Arterial blood gas analysis on 5 L/min of oxygen: pH 7.5 PCO2 16 mm Hg PO2 64 mm Hg

A) Acute gastrointestinal bleeding
B) Adrenal insufficiency
C) Aortic valve rupture
D) Cardiac tamponade
E) Congestive heart failure
F) Pneumonia
G) Pulmonary embolism
H) Sepsis

30. A 75-year-old man with a 3-year history of progressive cognitive impairment due to dementia, Alzheimer's type, has had nocturnal disorientation for 2 weeks. He lives at home with his wife. He is otherwise healthy and takes no medications. Physical examination shows normal findings. He is disoriented to time and place, has poor short-term memory, is unable to do simple arithmetic, and has a poor understanding of general information.
Which of the following is the most appropriate initial step in management? A) Increase in home nighttime lighting
B) Prescription for chloral hydrate
C) Prescription for diazepam
D) Prescription for haloperidol
E) Use of nighttime mechanical restraints

35. A 76-year-old man has had fatigue and loss of interest in daily activities over the past 4 months. He sleeps poorly and has had a 4.5-kg (10-lb) weight loss during this period. He states that he has probably lived long enough. His blood pressure is 110/78 mm Hg, and pulse is 68/min. Examination shows a slow return of deep tendon reflexes. Measurement of which of the following serum levels is the most appropriate next step in management?
A) Calcium
B) Creatinine
C) Glucose
D) Testosterone
E) Thyroid-stimulating hormone

38. Six months after the delivery of her fourth child, a 37-year-old woman undergoes laparoscopic tubal ligation. Menses occur at regular 28-day intervals. During the operation, she is found to have a small dark lesion in the cul-de-sac and filmy adhesions surrounding the ovaries. A biopsy specimen of a cul-de-sac lesion confirms the diagnosis of endometriosis. Which of the following is the most appropriate next step in management? A) Danazol therapy
B) Gonadotropin-releasing hormone agonist therapy
C) Oral contraceptive therapy
D) Total abdominal hysterectomy and bilateral salpingo-oophorectomy
E) No further treatment indicated

43. A 4-month-old boy is brought to the physician because of a 2-day history of fever and progressive redness around his right eye. He has had persistent diarrhea and oral candidiasis since birth and was treated for pneumococcal pneumonia at the age of 2 months. He appears ill. His temperature is 39 C (102.2 F), pulse is 130/min, and respirations are 25/min. Examination shows violaceous preseptal (periorbital) cellulitis and oral candidiasis.
Laboratory studies show: Hemoglobin 10 g/dL Leukocyte count 3000/mm3 Segmented neutrophils 85% Lymphocytes 15% Platelet count 350,000/mm3 Serum IgA <5 mg/dL IgG 300 mg/dL IgM <5 mg/dL
Which of the following is the most likely diagnosis?
A) AIDS
B) Chronic granulomatous disease
C) Severe combined immunodeficiency
D) Thymic-parathyroid dysplasia (DiGeorge syndrome)
E) X-linked agammaglobulinemia

45. A 2-year-old girl has had fever and bloody diarrhea for 10 days. A stool culture obtained 7 days ago grew Salmonella species sensitive to amoxicillin. A blood culture was negative. Despite beginning oral amoxicillin therapy 4 days ago, her diarrhea has persisted. Current examination shows no other abnormalities except for a temperature of 38.6 C (101.5 F). Which of the following is the most likely explanation for the failure of amoxicillin to improve her symptoms?
A) Amoxicillin does not alter the course of Salmonella enteritidis
B) Amoxicillin has caused pseudomembranous colitis
C) Amoxicillin is absorbed at the level of the jejunum, leaving no drug to be delivered to the colon
D) Oral amoxicillin is not absorbed into the systemic circulation in the presence of diarrhea
E) Salmonella has expressed an inducible -lactamase that inactivates amoxicillin
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Old 01-11-2013
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Block:3

3) C) Neurogenic bladder .

4) A) Decreased gluconeogenesis.

17) E) Malingering.

26) C) Pseudomonas aeruginosa

37) B) Ask the patient if he wishes to discuss his test results, preferably with his daughter present.
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Block:4

9) G) Pulmonary embolism

30) A) Increase in home nighttime lighting

35) E) Thyroid-stimulating hormone

38) B) Gonadotropin-releasing hormone agonist therapy

43) C) Severe combined immunodeficiency

45) E) Salmonella has expressed an inducible -lactamase that inactivates amoxicillin .
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Quote:
Originally Posted by anomali View Post
BLOCK 3

C) Neurogenic bladder

A) Decreased gluconeogenesis
C) Conversion reaction

E) Streptococcus pneumoniae
B) Ask the patient if he wishes to discuss his test results, preferably with his daughter present :banghead:
Quote:
Originally Posted by anomali View Post
normal S1 and S2 rules out aortic valve rupture+ABG with hypoxia & alkalosis
E) Congestive heart failure

[B]30. E) Use of nighttime mechanical restraints

35. A) Calcium

38. C) Oral contraceptive therapy

43 C) Severe combined immunodeficiency

45. C) Amoxicillin is absorbed at the level of the jejunum, leaving no drug to be delivered to the colon


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Old 01-12-2013
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Default block 3

6).....whats the diagnosis.....Von gierke's disease????

17).....why not malingering????

26)...is step pneumo MCC of sepsis on MM..???? the guy is Neutropenic right...so in that scenario Pseudomonas is a better choice.....just my thought
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Default Block 4

9)...agree with smanthrav.....normal S1 n S2 essentially rules out aortic valve rupture..answer has to be CHF.

30)....@aknz.......why A...????? can u elaborate plz

35)....testing calcium levels is correct i feel.......Hypothyroidism is not a/w weight loss

38)....@smanthrav....why OCP's..?????....she has a small patch with flimsy adhesions, dont u think its better not to treat this endometriosis..?

43)....Y not AIDS...???? i'm confused on this....why his IgG levels are elevated or rather normal???

45)....i read this here http://pediatrics.aappublications.or.../1125.abstract
A would be a better option..any thoughts?
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Quote:
Originally Posted by anomali View Post
6).....whats the diagnosis.....Von gierke's disease????
Its galactosemia dude.
Quote:
Originally Posted by anomali View Post
38)....@smanthrav....why OCP's..?????....she has a small patch with flimsy adhesions, dont u think its better not to treat this endometriosis..?
sorry..my bad, didnt pay much attention to the question. I wouldnt treat it either and here's why
Quote:
Originally Posted by anomali View Post
43)....Y not AIDS...???? i'm confused on this....why his IgG levels are elevated or rather normal???
Those are mommy's IgG. And AIDS doesnt often present right from birth like it did here. That was my reasoning, anyway
Quote:
Originally Posted by anomali View Post
26)...is step pneumo MCC of sepsis on MM..???? the guy is Neutropenic right...so in that scenario Pseudomonas is a better choice.....just my thought
MM=barely any immunoglobulins=high susceptibility to infections from capsulated organisms. This guy's barely into the "official" neutropenia zone(1500 neutrophils) and while I might be wrong, I think Pseudomonas isn't the right option to pick in this question. Whats the right answer?
Quote:
Originally Posted by anomali View Post
17).....why not malingering????
I don't see much gain from her pretending to feign seizures. The fact that the question mentioned she was very anxious kinda made me go for conversion disorder. And now you asked, I just found this online. Psychogenic Nonepileptic Seizures
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Quote:
Originally Posted by anomali View Post
9)...
30)....@aknz.......why A...????? can u elaborate plz
http://www.mayoclinic.com/health/alzheimers/HQ00218

Quote:
Reduce hazards. Remove tripping hazards, such as throw rugs and extension cords. Install night lights to aid nighttime wanderers. Put gates at stairwells to prevent falls.
urggh I knew I picked the wrong option.
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Old 01-13-2013
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Quote:
Originally Posted by smanthrav View Post

MM=barely any immunoglobulins=high susceptibility to infections from capsulated organisms. This guy's barely into the "official" neutropenia zone(1500 neutrophils) and while I might be wrong, I think Pseudomonas isn't the right option to pick in this question. Whats the right answer?
I searched it online and found the correct option to be Strep pneumo.....ur reasoning seems to fit in here....
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Quote:
Originally Posted by smanthrav View Post
http://www.mayoclinic.com/health/alzheimers/HQ00218



urggh I knew I picked the wrong option.
I found this while searching online.......the nigh time confusion in demented patients is labelled "Sundowning"...

http://www.mayoclinic.com/health/sundowning/HQ01463
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  #12  
Old 03-10-2013
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Default HElp

A
) Measurement of serum a1-antitrypsin level

B
) Methacholine challenge test

C
) Quantitative measurement of serum antibody levels

D
) Sweat chloride test

E
) Ventilation-perfusion lung scans


32-year-old woman comes to the physician because of
a 4-month history
of fatigue, cough, and shortness of breath with
exertion. She has had
two episodes of pneumonia and one episode of severe
sinusitis over the
past 2 years. She has never smoked. She takes no
medications.
Crackles are heard at the left lung base. An x-ray
film of the chest shows a
left lower lobe infiltrate and scarring of the right
base.





What is the diagnosis?
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Old 03-10-2013
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Quote:
Originally Posted by fadi551 View Post
A
) Measurement of serum a1-antitrypsin level

B
) Methacholine challenge test

C
) Quantitative measurement of serum antibody levels

D
) Sweat chloride test

E
) Ventilation-perfusion lung scans


32-year-old woman comes to the physician because of
a 4-month history
of fatigue, cough, and shortness of breath with
exertion. She has had
two episodes of pneumonia and one episode of severe
sinusitis over the
past 2 years. She has never smoked. She takes no
medications.
Crackles are heard at the left lung base. An x-ray
film of the chest shows a
left lower lobe infiltrate and scarring of the right
base.





What is the diagnosis?
C
) Quantitative measurement of serum antibody levels
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  #14  
Old 03-10-2013
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Quote:
Originally Posted by aknz View Post
C
) Quantitative measurement of serum antibody levels


thanks but
what is the diagnosis?
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  #15  
Old 03-12-2013
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Quote:
Originally Posted by fadi551 View Post
thanks but
what is the diagnosis?
I think it is common variable immunodeficiency.
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