robin082006
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Topics: 471
Posts: 5,123
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My exam is near and I am revising NBME
They are my answers, not sure they are correct. Please post your ideas.
I will post 20 qs/days
FIRST 20 NBME QUESTIONS AND ANSWERS
1. An 83-year-old woman who has dementia, Alzheimer type, is brought to the office for a return visit by her daughter, with whom she lives. While intermittently somewhat confused, until recently the patient had been able to handle most of her activities of daily living. In the past month, however, she has shown little interest in eating and is awake most of the night. The daughter says the patient has been seeing things, especially at night. She has been accusing her daughter of stealing from her, and has also hit her daughter. The patient has fallen twice on her way to the bathroom at night. The daughter has been giving her diphenhydramine for 1 month to help her sleep, but she says it does not seem to be helping. You have also been treating the patient with ranitidine for esophageal reflux and with amitriptyline for depression. Vital signs are normal, and physical examination is unchanged from the last visit. Her mental status has deteriorated from her last visit 4 months ago. Today she is oriented only to name, does not seem to recognize you and appears to be visually hallucinating. Her daughter says she herself is overwhelmed and wonders if it is time to consider a nursing home for the patient. Which of the following is the most appropriate response?
A) "Her increased confusion may be due to her medicines. Let's explore that possibility first."
B) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."
C) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."
D) "It is a little premature for that. Let's try some home health services first."
E) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."
ANSWER: A
2. A 12-year-old boy is brought to the office by his parents for a follow-up visit after starting treatment with carbamazepine 3 months ago for temporal lobe seizures. He has been seizure-free since having attained a therapeutic serum carbamazepine level 2 months ago. He says that he feels well, is doing much better in school, and has no new symptoms or complaints. It is most appropriate to tell him and his parents that with this drug therapy, he will need monitoring to assess for which of the following conditions?
A
) Agranulocytosis
B
) Cardiac arrhythmias
C
) Gastric ulcers
D
) Proteinuria
E
) Renal failure
ANSWER:A
3. A 72-year-old professor emeritus comes to the office saying, "I am worried that I have Alzheimer's or small strokes or something." During the past year, he has noted increasing difficulty with his memory, especially for names, which has created several awkward moments professionally and socially. He adds, "I'll be doing fine, when all of a sudden my mind goes blank. I can't recall something I should easily know, and then suddenly it will come back to me a couple of minutes later." He complains that he frequently misplaces items like his keys, which is very unlike him. He also complains that his sleep is not restful anymore and that he tosses and turns all night. His wife has told him that she is not sleeping either, because he snores loudly. He says, "I'm tired much of the time, and I doze off whenever I try to read." He also complains of frequent headaches in the morning. Past medical history includes hypertension, which is well-controlled with diltiazem; peptic ulcer disease for which he takes ranitidine; and lumbar osteoarthritis, for which he takes ibuprofen. Height is 175 cm (5 ft 9 in) and weight is 72 kg (160 lb). Vital signs are: temperature 36.9°C (98.4°F), pulse 80/min and regular, respirations 12/min and blood pressure 158/100 mm Hg. Physical examination, including neurologic examination, is normal. He scores 29 out of 30 on the Mini-mental state test. Which of the following is the most appropriate next step?
A
) Order CT scan of the head
B
) Order electroencephalography
C
) Reassure him that his symptoms are probably normal
D
) Refer him for neuropsychological testing
E
) Refer him for polysomnography
ANSWER:E
4. An 8-year-old boy is brought to the office because of a 5-day history of fever, coryza and cough that coincides with an epidemic of influenza in the community. Today he is unable to walk because of pain in the calves. His mother has been giving him acetaminophen for fever and pain. Physical examination shows a temperature of 38.3°C (101.0°F). He is alert, interactive and well-hydrated. He has clear rhinorrhea, mild pharyngeal erythema and a clear chest. His calves are tender to palpation. Strength cannot be tested because of pain. Neurologic examination, including deep tendon reflexes, is normal. Which of the following is the most appropriate therapy?
A
) Acetaminophen, orally, as needed
B
) Amantadine, orally
C
) Immune globulin, intravenously
D
) Influenza virus vaccine, intramuscularly
E
) Prednisone, orally
ANSWER:A TRANSIENT MYOSITIS
5. A 55-year-old Hispanic welder comes to the office for an initial visit because of a lesion in his right eye that has been present for several months. During this time his right and left eyes have been increasingly sensitive to wind. He has not had double vision and has not seen "spots" in his field of vision. He says that he has been generally healthy and has not seen a physician during the past 30 years. He takes no medications. He does not wear corrective lenses. Family history is significant for blindness in his mother at age 77 years. The patient has smoked a half pack of cigarettes daily for the past 40 years, and he drinks an occasional six-pack of beer on weekends. Vital signs today are temperature 37.2°C (99.0°F), pulse 110/min, respirations 20/min, and blood pressure 140/85 mm Hg. Examination of the right eye discloses the finding shown in the photograph. Visual acuity is 20/40 in both eyes. Musculoskeletal examination discloses symmetric enlargement of the proximal and distal interphalangeal joints of both hands. The joints are firm to palpation and cool to the touch. The remainder of the physical examination is noncontributory. Which of the following is the most likely diagnosis?
A
) Corneal abrasion
B
) Glaucoma
C
) Keratitis
D
) Pterygium
E
) Stye
ANSWER
6. A 3-year-old African-American boy who is a new patient is brought to the office by his grandmother. She says, "He was OK until this afternoon, when he suddenly developed a fever. He's been spitting a lot. He keeps his mouth open and he refuses to lie down. He won't eat." You learn that the child has received only one set of vaccinations at the age of 2 months. Vital signs are: temperature 39.4°C (103.0°F), pulse 110/min, respirations 24/min and blood pressure 110/70 mm Hg. On physical examination the child sits in a tripod position and salivation is evident. Which of the following is the most appropriate next step?
A
) Administration of cefotaxime, intravenously
B
) Complete blood count and blood culture
C
) Determination of arterial blood gas values
D
) Immediate otorhinolaryngology consultation
E
) Lateral neck x-ray film
ANSWER
7. 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
ANSWER:E
The following vignette applies to the next 2 items.
A 6-month-old African-American girl is brought to the office in January for a well-child visit. She was born at 32 weeks' gestation after a pregnancy complicated by an incompetent cervix and premature labor. She has a 3-year-old brother. Her birth weight was 2700 g (6 lb). At birth, she had mild respiratory distress syndrome and required mechanical ventilation for 36 hours. She also has gastroesophageal reflux disease for which she is given ranitidine, daily. Vaccinations are up-to-date. Developmental milestones are appropriate for her adjusted chronological age. Head circumference and growth charts are shown.
Item 1 of 2
8. Regarding the results on the head circumference chart, which of the following is the most appropriate conclusion?
A
) The growth pattern is most likely due to neonatal intraventricular hemorrhage
B
) Her growth is normal for a premature infant
C
) An MRI should be done to rule out a brain tumor
D
) The parents' head circumferences should be measured to evaluate the infant for familial macrocephaly
E
) She should be examined for possible papilledema to rule out hydrocephalus
ANSWER:B
Item 2 of 2
9. Two weeks later the girl is brought back by her mother because of a runny nose and difficulty breathing for the past 3 days. The mother says, "She's up every 2 hours now, and last night she had a fever. I think her brother picked up a cold from preschool and gave it to her. I can't keep him away from her." Vital signs now are temperature 38.5°C (101.3°F), pulse 144/min, and respirations 60/min. On physical examination she is alert but in mild respiratory distress with slight nasal flaring. Auscultation of the chest discloses fine expiratory wheezes bilaterally, and mild intercostal retractions. Which of the following is the most likely cause of the infant's illness?
A
) Aspiration pneumonia
B
) Asthma
C
) Bronchopulmonary dysplasia
D
) Mycoplasma pneumoniae
E
) Respiratory syncytial virus
ANSWER:E
10. A 72-year-old woman comes to the health center for the first time because of palpitations for the past 3 weeks. She says she has felt tense and has had trouble sleeping. Vital signs are: temperature 37.0°C (98.6°F), pulse 104/min, respirations 18/min and blood pressure 142/80 mm Hg. Physical examination is normal except for a mild bilateral hand tremor. Electrocardiogram shows sinus tachycardia but is otherwise normal. Which of the following diagnostic studies will most likely rule out an organic cause for her symptoms?
A
) 2-Hour postprandial serum glucose concentration
B
) Echocardiography
C
) Holter monitoring
D
) Serum thyroid-stimulating hormone concentration
E
) Toxicologic screening of the urine
ANSWER
11. A 48-year-old man who smokes cigarettes has had progressive claudication in the left calf for the past month. He says the pain lasts about 5 minutes and then subsides. Physical examination shows absent pulses in the left foot and normal pulses in the right foot. Atrophic changes are noted in both legs. Doppler examination shows a 0.40 left ankle/brachial ratio; there is no change with exercise. Which of the following is the most likely diagnosis?
A
) Aortic occlusive disease
B
) Femoral popliteal occlusive disease
C
) Leriche syndrome
D
) Peripheral small-vessel occlusive disease
E
) Thromboangiitis obliterans
ANSWER:E
12. A 52-year-old Hispanic computer technician comes to the office because of a 3-week history of substernal chest discomfort when she climbs stairs or eats a heavy meal. She first noticed the discomfort after climbing two flights of stairs. The discomfort is nonradiating and sometimes only involves the left side of the chest. She has hypertension and type 2 diabetes mellitus. Current medications include metformin and an ACE inhibitor. She has recently had increased stress because her company is experiencing financial difficulty. Her husband receives medical disability benefits, and they are dependent on her income. Physical examination shows no abnormalities. Which of the following risk factors is most important to consider when assessing her chest pain?
A
) Age
B
) Diabetes mellitus
C
) Gender
D
) Hypertension
E
) Stress level
ANSWER:B
13. 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
ANSWER
14. A 38-year-old woman with systemic lupus erythematosus but no evidence of nephritis comes to the office because of a 3-week history of mood swings with crying spells, irritability and insomnia. She is especially upset because she has been yelling at her children "over small, everyday things." One month ago she started corticosteroid therapy. She is currently taking prednisone, 60 mg/day. Her other medications include an oral contraceptive (the same one for the past 6 years) and ibuprofen. She smokes one-half pack of cigarettes daily, drinks one to two beers 5 nights weekly and three cups of coffee each morning. Which of the following is the most appropriate intervention for her mood disturbance?
A
) Add amitriptyline at bedtime
B
) Discontinue the oral contraceptive
C
) Reduce the prednisone dosage
D
) Replace ibuprofen with acetaminophen
E
) Urge her to stop smoking and to reduce her alcohol and caffeine intake
ANSWER:C
15. A 76-year-old retired pharmacist is brought to the health center by his wife, who says, "He's afraid to go to sleep, Doctor. Tell him, Henry." He tells you that he was mugged and assaulted 1 week ago while he was out for a walk early in the morning. The patient proceeds to tell you that he has been having nightmares, not about the assault, but of being in vulnerable situations. He also feels anxious during the day but he is able to leave the house without difficulty. In addition to supportive therapy, which of the following pharmacotherapies is most appropriate to prescribe?
A
) Amitriptyline
B
) Clonazepam
C
) Diphenhydramine
D
) Gabapentin
E
) Risperidone
ANSWER:A
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
ANSWER:B
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
ANSWER:E
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
ANSWER:B
19. 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
ANSWER:E
20. A 58-year-old woman comes to the office for follow-up of fibromyalgia. You had been treating her for the past several years for nonspecific muscular aches and pains. In the past you noted that occasionally the pain could be reproduced on physical examination by applying pressure to certain muscles; however, these trigger points seemed to change on each physical examination. Fibromyalgia was diagnosed 3 months ago and amitriptyline therapy was started at that time. At a follow-up visit 3 weeks ago she showed little response to the amitriptyline therapy, and naproxen was added to her regimen. Today she returns to the office complaining that "every time I get the least little bump on my hands the skin seems to tear." Her physical examination is unchanged except for the lesions shown. Which of the following is the most appropriate management?
A
) Discontinue the amitriptyline
B
) Discontinue the naproxen
C
) Prescribe oral corticosteroids
D
) Prescribe topical corticosteroids
E
) Prescribe topical 5-fluorouracil
ANSWER:B
___________________
The Key to Succeed is Patience.
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| egomez2001
Forum Guru
Topics: 51
Posts: 930
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Thanks Robin , waiting for the other 20
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| gatita007
Forum Junior
Topics: 8
Posts: 65
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robin082006
Hi Robin
I am chaking them now...do you have the answers?
Cheers
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| Justice
Forum Fanatic
Topics: 117
Posts: 2,323
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Dear Robin,
thanks a lot for posting the Qs!!! Very helpful!!!
Shouldn't we pin then to the top of the list so everyone has it?
___________________
Don't live in a town where there are no doctors
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| adrenalin
Forum Senior
Topics: 20
Posts: 66
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hey guys m new here..plz tell me where do u get NBME ques..all m doin these days is usmle world..also how much score on world is required to pass step 3
any help wud b appreciated
thank you
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