nbme 4 step 3 practice exam

nbme 4 step 3 practice exam 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) 66 yo Irish American man has SOB on exertion for past 6 months, but now present when climbing 1 flight of stairs. +Dry cough. Retired 1 yr ago from job in *Stone* quarry. Exam: finger *Clubbing," end-expiratory crackles. CXR: fibronodular infiltrate in UPPER LOBES. Dx? - *Silicosis* asbestosis - -construction & shipyard workers -20 yrs after initial exposure -dyspnea on exertion, cough, chest tightness, wheezing -chest CT: pulmonary fibrosis mesothelioma - linked to asbestos exposure -dyspnea, chest pain -CXR: nodule thickening of pleura and/or obscuring of diaphragm 10 month old girl has 12 hr hx of intermittent colicky pain&vomiting. Dx 1 wk ago w/otitis media and 10 day course of amoxicillin started at that time. P 168, BP 82/46. Infant is fussy. Observed for 1 hr and d/c home. 12 hrs later, he's again brought to ED b/c sx have recurred. VS: 99.4F, P 170, RR 42, BP 84/46. Fussy &Crying. Tympanic membranes are dull but move w/insufflation. Oral exam: *Swollen gums & erupting teeth.* Skin exam: *1 bruise over right side of forehead and one on left leg*. Palpable fullness in LUQ. Rectal exam: formed stool w/mucus that's positive for occult blood. Explanation for condition? - *intussusception* 2 days postop mastectomy, 75 yo F has left hip pain & Unable to walk after falling on bathroom floor. BMI 27. Exam of LLE likely will show what? - *Shortening & external rotation of left leg* 69 yo F has 2 wk hx of productive cough of small amts of blood. Weight loss 3.2 kg during past month. During the past 7 yrs, she had increasing SOB & can't walk further than 3 blocks. Smoked for past 45 yrs. Retired from work as a nurse 4 yrs ago & spends her time driving around the country w/husband in recreational vehicle. BMI 22. VS: T 99.5F, P 80, RR 16, BP 140/86. Leg exam: varicose veins. Chest x ray done. Most appropriate diagnostic study at this time to order? - *CT Scan chest* -for possible lung cancer w/smoking hx & recent weight loss Randomized control trial done to assess efficacy of BB on pts undergoing major abd operations w/cardiac risk factors. Fewer pts receiving preop BB have a cardiac event than do pts receiving a