NBME CBSE REAL EXAM 200 QUESTIONS AND ANSWERS LATEST (usmle step 1)MEDICAL EXAMINATION GRADED A

NBME CBSE REAL EXAM 200 QUESTIONS AND ANSWERS LATEST (usmle step 1)MEDICAL EXAMINATION GRADED A 70yo M dies in a motor vehicle collision. Was undergoing evaluation for occult blood in the stool. Photo of transverse colon shown. Dx? - correct answer -Tubular adenoma 38yo M with 1-week hx of watery, itchy eyes and a runny nose. Physical shows inflamed nasal mucosa. No congestion in lower lung. Pharmacotherapy? - correct answer - Loratadine 16yo girl with 3-day hx of fever, nonproductive cough, and fatigue. T 38.3, P 88/min, BP 102-70. PE shows pale conjunctivae. CXR shows bilateral interstitial infiltrates. Blood spontaenously agglutinates while awaiting transport to the laboratory. Antibody isotypes causing agglutination? - correct answer -IgM 24yo M with small tender blisters on his penis 3 days after unprotected sex. Photograph shown. Causal agent? - correct answer -HSV-2 42yo F with 3-year hx of an intermittent facial rash, including the forehead, eyelids, nose, and cheeks. Rash seems to be getting worse since she moved from New York to Florida last year. Spicy foods precipitate a flushing reaction that seems to exacerbate the rash. PE shows erythema over the nose and cheeks, with scattered telangiectasias and a few papules. Dx? - correct answer -Rosacea 53yo M returned from Africa, has fever, headache, and abdominal discomfort. Received appropriate vaccinations prior to the trip. T 39.4C. A wright-stained peripheral smear shown. Dx? - correct answer -Malaria 68yo F with T2DM and hypertension that has been poorly controlled despite hydrochlorothiazide treatment. BP 150/96, Labs show serum glucose concentration of 130 and proteinuria. In addition to current Rx, which is most appropriate pharmacotherapy? - correct answer -Lisinopril 66yo M with stage IV colon cancer with 3-day hx of severe diarrhea after receiving chemotherapy with fluorouracil, leucovorin, and Irinotecan. prescribed opioid antidiarrheal agent with no CNS effects. Which med? - correct answer -Loperamide 35yo M in ED with 2-hour hx of sever fatigue and dizziness. Had profuse, watery diarrhea for 8 hours despite a lack of oral intake. Recently returned from a medical relief trip to a remove village in Honduras. T 36.7 C, P 122/min, BP 90/50. PE shows dry skin and decreased capillary refill. Stool for occult blood is negative; stool is gray and turbid. Gram stain shows gram-negative, comma-shaped bacteria; no erythrocytes of leukocytes. MOA of toxin? - correct answer -Activation of adenylyl cyclase 59yo F with gradual onset of lack of muscle control in her left arm and leg. Sx 1 mo ago after dx with metastatic breast cancer. PE shows ataxia of left upper and lower extremities. Muscle strength, DTR, sensation, proprioception normal. Metastatic tumor in which location? - correct answer -cerebellum Newborn delivered at 38 weeks' gestation weighs 1800 g. PE shows petechial rash, microcephaly, and hepatosplenomegaly. Serologic test for CMV: IgG + in mother, + in newborn; IGM - in mother, + in newborn. Explanation? - correct answer -Congenital cytomegalovirus infection Female newborn is delivered at 38 weeks' gestation. Apgar 8 and 8 at 1/5 min. PE shows a bulging, fluod0filled mass approximately 5 cm in diameter in the midline over the lumbosacral region. No spontaneous movements of the lower extremities. Abnormality most likely occurred because of abnormal development during which periods of postconception (in days)? - correct answer -15 to 40 64yo M in ED 3 hours after SOB with exertion and extreme fatigue. Has ischemic heart disease. P 125/min, BP 105/60. ECG shows atrial fibrillation. Intravenous ibutilide is administered. Ten minutes later, ECG shows normal sinus rhythm. Risk for which drug effect in the next 6 hours? - correct answer -torsades de pointes 65yo F with 20-year hx of osteoarthritis of the hands now has pain radiating down the distal anterior thigh, knee, medial leg, and food. Bony outgrowth of vertebrae compressing one of the spinal nerves is suspected. Nerve root in which intervertebral foramina is effected? - correct answer -L3 to L4 38yo M with 3-year hx of T2DM. Taking an oral antihyperglycemic agent, he has tried diet and exercise. BMI 32. PE normal. Hb A1c is 10%. Physician recommends initiation of insulin injections. Responds, "I know that insulin would help control my blood sugar. But a lot of people in my family have diabetes, and insulin made them really sick at times. Patient is at which stage of change? - correct answer -contemplation 24yo M with 2-day history of an itchy rash on his arms and legs. Returned from a camping trip in the woods 5 days ago. PE shows edematous, erythematous rash with linear vesicles. Cause is activation of which cell types? - correct answer -T lymphocytes 70yo M from china with poorly differentiated monoclonal carcinoma of the nasopharynx. DNA probes of neoplastic cells are most likely to detect genome of which virus? - correct answer -EBV Epidemiologic study of aniline dye, 500 workers with bladder cancer and 200 workers without. Exposed to aniline dyes/Have Bladder cancer: Yes/Yes (250), Yes/No (50), No/Yes (250), No/No (150). Odds ratio? - correct answer -3 24yo M with hx of IVDA could not be aroused. Friend reports that the patient injected himself with a drug 6 hours ago. Labs show drug concentration of 0.3. Assuming firstorder one-compartment kinetics, has a half-life of 2 hours, and a volume of distribution of 200 L in this patient. What is quantity of drug (in mg) injected? - correct answer -480 Compound is taken up by bacterial cells. No energy is necessary for uptake, and the compound is not concentrated in the cell. Which describes this mechanism of transport? - correct answer -carrier-mediated diffusion Newborn has male genital ducts but female external genitalia. Cytogenetic analysis shows a 46,XY karyotype, and genetic testing shows a mutation of the gene encoding 5alpha-reductase. In absence of this mutation, labia majora would have been? - correct answer -scrotum Study designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in patients with CHF. Sixty patients with CHF are recruited. Each assigned by coin toss to one of two groups. Design? - correct answer -randomized clinical trial 12yo boy immersed up to his neck in 60F water for 20 minutes. Physiological changes? - correct answer -Central blood volume INCREASED, ADH (vasopressin) DECREASED, Atrial Natriuretic Peptide INCREASED? C (block3, q23) Randomized controlled study of 2000 patients with insomnia is conducted to evaluate the efficacy of a new medication to treat this condition. Ten subjects from both the control and treatment groups do not complete the study are not included in the analysis. Treatment group able to fall asleep 5 minutes faster than control (p=0.001). Neither group report an improvement in quality of life. Conclude that new med is efficacious in treating insomnia. Type of error? - correct answer -Failure to distinguish between statistical significance and clinical significance 18mo girl. Separation of the umbilical cord was delayed after birth. Has had four severe skin infections Staphylococcus aureus; No pus formation at infection sites. Persistent leukocytosis in absence of infection. Mechanisms impaired? - correct answer -leukocyte adhesion and transmigration 50yo M with increasing cough for 6 month and hemoptysis for 1 week. Smoked 1 pack per day for 32 years. Plays squash, swims. CXR shows a 3 x 4-cm hilar mass. Cytologic examination of sputum shows a non-small cell carcinoma. Tells patient he has lung cancer. The patient responds, "How can this be happening to m? I eat right and exercise." Appropriate response? - correct answer -"It must be difficult for you to accept this diagnosis when you feel healthy." 32yo M with 6-month hx of low back pain and stiffness, worse in morning and improve during the day; the pain radiates to his buttocks but not down his legs. Back stiffness if he sits for prolonged periods. Which to confirm diagnosis? - correct answer -X-rays of the sacroiliac joints 17yo boy with 8-kg weight gain during the past year. No medical illness. BMI is 32. He asks, "Do you think that my weight gain is inherited from my father?" Appropriate response? - correct answer -"Yes, your weight gain can be caused by genes and environment combined." 52yo M neighbors have reported that he has been confused and not taking care of himself. 4-mo Hx of diarrhea. PE shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. Diagnosis? - correct answer -pellagra 80yo F with suspected temporal arteritis (TA). ESR is 100, Pretest probability for TA is 50% in this patient. In the evaluation of TA, ESR has a sensitivity of 99% and specificity of 60%. Based on the results of the ESR testing, most appropriate next step? - correct answer -Additional testing to confirm the diagnosis of TA Sequence surrounding the first two exons of the human beta-globin gene shown, with exons in bold. Translation start codon is underlined. A mutation from G-->A at position 355 is most likely to lead to beta-thalassemia by which mechanism? - correct answer - Disruption of normal splicing by creation of a new 3' splice site? 42yo M in ED because of a 10-day history of progressive fever, SOB, and nonproductive cough. 20-kg weight loss. Immigrated to USA from the Ivory Coast 4 years ago. Temp 38C. Lungs clear, CXr shows diffuse interstitial infiltrate. Silver stain obtained via bronchoscopy shows Pneumocystis jiroveci (formerly P. carinii). High dose prednisone and trimethoprim-sulfamethoxazole is initiated, and workup for HIV infection is done. HIV ELISA positive, HIV western blot positive, CD4 22; HIV viral load <50. Explanation? - correct answer -Infection with HIV-2 27yo F with vaginal bleeding for 3 weeks. First pregnancy ended with a spontaneous abortion 8 months ago. No Rx since dilatation and curettage at that time. PE shows enlarged uterus, beta-hCG markedly increased. Ultrasonagraphy of pelvis shows material within the endometrial cavity and no intrauterine pregnancy. CT scan shows a necrotic intrauterine mass and metastatic nodules in the lungs. Site of Origin? - correct answer -trophoblastic tissue 65yo M emigrated from Brazil with 8-month history of shortness of breath and fatigue, edema of lower ext. CXR shows cardiomegaly. endomyocardial biopsy specimen shows myofiber necrosis with a mixed inflammatory infiltrate of PMNs, T lymphos, s, and eosinophils. Causal org? - correct answer -Trypanosoma cruzi 40yo F with mole on her back that has increased in size during past 4 months. PE shows raised irregular lesion with variegated black-tan pigmentation and ill-defined margins. Pleomorphic, hyperchromatic cells within clear islands that tend to collapse. Extends from epidermis into papillary dermis. Dx? - correct answer -melanoma 42yo farmer has a 7-mm red scaly plaque on helical rim of left ear. Photomicrograph shown. Dx? - correct answer -actinic keratosis 30yo F training for a marathon, running 20 miles/day. Fasting glucose is 60. After her glucose stores have been depleted, which organ, in addition to liver, releases glucose? - correct answer -kidney Male newborn at 28 weeks'. Given ventilatory support with up to 80% oxygen for the next 72 hours, but dies of resp. failure. Cause is inadequate secretion from which labeled cell types? - correct answer -D. type II pneumocyte (produces surfactant) 9yo girl with poor growth during the past year. < 3rd %ile for height and at 10th percentile for weight. PE normal. Visual field testing shows bitemporal hemianopia. Labs show GH deficiency. MRI shows calcified cystic mass in suprasellar region. Tumor derived from? - correct answer -Diverticulum of the roof of the embryonic oral cavity 28yo F G1P1 with 2-day history of a painful mass in her right breast. Delivered healthy female newborn 3 weeks ago, and been breast-feeding since. T 37C, PE shows 3-cm tender mass surrounded by an area of erythema beneath the right areola. Causal org? - correct answer -staph aureus 3yo boy with bacterial colitis caused by Salmonella enterica serovar arizonae. Which factor accounts for recruitment of PMNS to inflammatory site by intestinal epithelial cells? - correct answer -IL-8 27yo F with fever, malaise, abdominal pain, and vaginal d/c for 4 days. LMP 5 days ago. Had ectopic 1 year ago. T 38.3 C, bilateral lower quadrant tenderness with rebound and guarding. Pelvic exam with cervical motion tenderness and bilateral adnexal tenderness WBC 18k. Pregnancy test neg. Dx? - correct answer -Gonorrhea (PID) 20M with 3-month hx of progressive thirst (drinking a lot of fluids) and urinary frequency during past 3 days. U/A shows specific gravity less than 1.006. Most likely has dysfunction of which endocrine structure? - correct answer -posterior pituitary gland (ADH) 21yo M in ED with excruciating anal pain for 4 hours. Exam shows 15-mm, blue tinged rounded mass at anal margin. Represents thrombus in a tributary of which blood vessel? - correct answer -inferior rectal vein 6-week-old girl with 6-day hx of vomiting small amount of milk 2 to 3 times daily. 50%ile for length and weight. Cause? - correct answer -Immature lower esophageal sphincter 37yo M with 4-day hx of diarrhea and abdominal pain, worse in past 24h, with waterybrown stools. Completed a 10-day course of amoxicillin for a sinus infection 5 days ago. Stool shows: Fecal fat negative; ova and parasites negative; Cx for infx negative; C. Diff toxin positive. Which pathologic findings present in intestinal tract? - correct answer - Pseudomemnbranes of fibrin and inflammatory debris 28yo M in ED 30 minutes after SOB. 3-year hx of cocaine abuse. T 38.1, P 100/min, BP 150/45. PE: diminished pulses in left upper extremity. Crackles heard over all lung fields. 2/6 diastolic murmur at left sternal border. CXr shows a widened aortic arch. Dx? - correct answer -Dissecting aneurysm 1-week-old girl. screening showed a possible defect in fatty acid oxidation. PE normal. Next step? - correct answer -Measurement of serum acylcarnitine concentrations 79yoM 30 minutes after LOC for 30 seconds. Alert, but dizzy. No urinary or fecal incontinence. Pulse 40/min, BP 92/56. PE shows no tongue biting. Lungs clear, Variable intensity S1. Oriented X3. ECG shows a third-degree atrioventricular block. Next step? - correct answer -Insertion of transvenous pacemaker 55yo M with chronic bronchitis in ED after being unresponsive. Found bottles of albuterol, ampicillin, codeine, and theophylline bedside. T 37.2 C, p 112/min, respirations are 6/min, BP 95/60. Acute Rx should include? - correct answer -naloxone 50yo man has persistent cough for 2 months. He has had a 5 kg (11 lb) weight loss. He is a farmer and on itraconazole 4 weeks for histoplasmosis from chicken coops. Medications: hydrochlorothiazide, enalapril, atenolol, omeprazole, and metoclopramide for hypertension and gastroesophageal reflux. Thin. Physical exam otherwise normal. Itraconazole interacts with which drug and account for lack of effect of itraconazole? - correct answer -omeprazole 20yo man with 6-hour difficulty breathing and vomiting. 10-year history of type 1 diabetes on insulin. Pulse 90, respirations 30 and deep, bp 90/60. Physical shows dehydration. Labs: Na+ 130, K+ 6.5, HCO3 5, glucose 500, pH 7.2, pCO2 25 mm Hg. Which compound stimulated hormone-sensitive lipase in adipocytes causing accumulation of metabolites causing acidosis? - correct answer -epinephrine Physician sad to inform patient of progression of carcinoma to the terminal phase. Physician's face makes patient cry and ask, "It's bad news, isn't it?" Which is best response? - correct answer -"Yes, it is." 75yo man 2-year history of decreased force of urinary stream, urinate several times throughout night. BUN 55, Cr 5.0. Ultrasound shows bilateral hydronephrosis and dilated ureter. Mechanism of renal failure? - correct answer -Increased hydrostatic pressure in Bowman space 4yo boy two bacterial urinary tract infections past year. Physical exam normal. Radiologic studies show dilation of left ureter and renal pelvis, minimal left-sided renal function. Left nephrectomy done. Photo: dilated renal pelvis and ureter. Which is cause of renal disease? - correct answer -congenital urethral obstruction 45yo man poorly controlle