NBME 4 step 3 practice exam Question and Answer

65 yo F has a 3 month hx of *increasing low back pain*. Had low back pain for past 3 yrs that's been treated w/NSAIDs and codeine. Now rated as 7/10 in severity. Pain radiates to both legs, worsens when walking or standing & Relieved when sitting. 1 YEAR AGO: X ray lumbosacral spine: mild osteoarthritis. Exam: 4/5 mm strength LE, hyporeflexia of knees&ankles b/, unsteady gait b/c of pain. No other abnormalities. Most appropriate diagnostic study of lumbosacral spine to order at this time? - *MRI* -prly b/c this pain is worse than the usual pain & neuro sx of hyporeflexia, decreased mm strength, and unsteady gait A couple comes to discuss the results of prenatal testing in current pregnancy. Screening test showed increased risk for having a child w/Down syndrome. Amniocentesis is suggested for her. Husband asks "When can we schedule the amniocentesis? I think that we should just get on w/it." Wife responds angrily, "That's easy for u to say. U haven't been carrying this baby for 4 months & u haven't felt it move like I have. Appropriate response? - "I know this is difficult news for both of u. I would like to know what both of u are thinking now" 3 y.o. boy is at 50th %tile for height&weight. Exam: hemihypertrophy of left side of body when compared to right. Palpable mass in LLQ. Labs: Hgb 12, Hct 36%, Urine: SG 1.020, WBC 0-1/hpf, RBC 10-20/hpf. U/S: left kidney mass. Dx? - *Wilms tumor* -most common RENAL malignancy in kids -age 5 -*Unilateral, PAINFUL, abdominal mass* -HTN, hematuria neuroblastoma - most common extracranial solid tumors in kids -painLESS abdominal mass -may have HTN Due to mass compressing renal artery and activating renin-angiotensin system -FLUSHING &SWEATING due to catecholamine hypersecretion -neural crest origin -involves adrenal medulla, sympathetic chain -median age 2 -*periorbital ecchymoses(orbital METASTASES)* -spinal cord compression from epidural invasion("dumbbell tumor") -opsoclonus-myoclonus syndrome DX: elevated catecholamine metabolites, small&round blue cells on histology, N-myc gene amplification 58 year old F has heavy substernal chest pain relieved by nitroglycerin & rest. Pain occurs w/exertion&accompanied by some SOB&sweating. 6 months ago: CABG. VSS. ECG: NSR w/*inverted T waves NEW in leads V4-V6.* next step in evaluation is to do which? - *Repeat coronary artery catheterization*-NOT order echo or MUGA scan -maybe b/c of NEW inverted T waves? 70 yo has 1 wk hx left eyelid droop. PMG COPD&Quit smoking 5 yrs ago. Troublesome pain radiating down left arm. Left ptosis w/small pupil on exam. Diagnostic study? - *CT scan thorax* -prly pancoast tumor 65 yo F had 2 min generalized tonic-clonic seizure that occured when asleep. PMH: HTN, breast cancer 2 yrs ago s/p lumpectomy, radiation therapy, adjuvant chemo 1 yr ago. Meds: lisinopril, tamoxifen.Pt is drowsy, not oriented to person,place,time. BP 160/95. Pulse ox 95%.Exam: right lower face drooping. Eyes conjugately deviated to left. Briskly withdraws LUE & both LE to noxious stimuli; there's no movement of RUE. Fingerstick BG 70, serum sodium concentration 130. CAUSE of seizure? - *Brain metastasis* prly from breast cancer -looks like she got a stroke strongest predisposing factor for prostate cancer - age (old) 32 yo F 6 day f/u for 12 cm lipoma removal from left lateral thigh. For past 2 days, she had swelling &mild increase in tenderness on and around incision site. Exam of incision site: bubble-like swelling underneath incision w/o erythema, drainage or lymphadenopathy. Area is ballotable & fluid wave on palpation.DX? - *Seroma*=pocket of clear serous FLUID -common after surgery -ballotable means significant effusion 28 yo F G1P1 at 33 wks gestation in active labor. RR 22. Exam: nontender abdomen. fundal height 36 cm. pelvic ultrasound shows pocket of amniotic fluid 91.5 mm. Underlying cause? - *Fetal esophageal atresia* (not fetal polycystic kidneys)