NBME 4 step 3 practice Exam with Complete Solutions

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? - ANSWER-*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? - ANSWER-"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? - ANSWER-*Wilms tumor* -most common RENAL malignancy in kids -age <5 -*Unilateral, PAINFUL, abdominal mass* -HTN, hematuria neuroblastoma - ANSWER-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? - ANSWER-*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? - ANSWER-*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? - ANSWER-*Brain metastasis* prly from breast cancer -looks like she got a stroke strongest predisposing factor for prostate cancer - ANSWER-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? - ANSWER-*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? - ANSWER-*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? - ANSWER-*Silicosis* asbestosis - ANSWER--construction & shipyard workers -20 yrs after initial exposure -dyspnea on exertion, cough, chest tightness, wheezing -chest CT: pulmonary fibrosis mesothelioma - ANSWER-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? - ANSWER-*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? - ANSWER-*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? - ANSWER-*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 placebo(5.8% vs 6.9% w/hazard ratio 0.84 and 95% CI of 0.7-0.99). However, More deaths occur in pts receiving preop BB than in those receiving a placebo (3.1% vs 2.3% w/hazard ratio of 1.33 and 95% CI of 1.03-1.74). How many pts need to be treated w/preop BB to cause 1 additional death? - ANSWER-*125* NOT 91 what supports dx of conduct d/o rather than dx of oppositional defiant d/o? - ANSWER-Physical aggressiveness toward others Randomized double blind clinical trial is conducted to compare the effects of taking vitamins on mortality. Over next 5 yrs, half of sample receive vitamins & other half receive placebo (control group). In F/U interview, investigator discovers 40% of control group had started to take multivitamins on their own as nutritional supplements. investigator chooses to keep initial randomized categorization for the analysis of outcomes. By using this approach, the investigator is adopting which of the following methods? - ANSWER-*intention to treat* 18 yo F has 6 month hx episodic dizziness. Episodes occur while sitting or standing but never when running. No menses for 2 yrs. BMI 17. BP 96/60, RR 12. Na 134, K 3.2, total protein 4.8, albumin 2.8. In addition to ECG, what else should be ordered at this time? - ANSWER-*bone densitometry** for Functional hypothalamic amenorrhea-exercise induced -even tho she's young, u can and should do this b/c she has athlete's triad and concern for osteoporosis/stress fractures -*decreased GnRH, LH/FSH, estrogen, bone mineral density* but total cholesterol & triglycerides increase for some reason -tx: increased caloric intake, estrogen, calcium, vitamin D. 75 yo M has 5 day hx mild-moderate back pain & Right flank pain w/radiation to right groin. During past 3 days: SOB & Significant swelling of both legs. Smoker. Exam: decreased breath sounds b/l, distended abdomen & diffusely tender w/loud systolic-diastolic bruit over mid-abdomen, hypoactive bowel sounds. 2+ edema b/l LE, extending up to umbilicus. Decreased femoral pulses b/l. Initial dx study? - ANSWER-*CT Scan abdomen* NOT renal u/s 64 yo AA has 1 month hx of fatigue &increasing lethargy. During this time, pt had worsening aches&pains that he thought were related to a new exercise program. Had increased thirst &urination during past 6 wks. Lost 9 kg(20 lbs) in last 6 months. Quit smoking 15 yrs ago. VSS. Pt is slow to respond to questions & Difficulty following 2-step commands. Exam: scattered petechiae & ecchymoses over LE. Ca 14.1, SCr 2.8, K 3.7, Hgb 10.5, WBC 4600, Plt 60,000. Underlying CAUSE of condition? - ANSWER-*paraproteinemia(monoclonal gammopathy)* not parathyroid adenoma -causes elevated total serum calcium due to increase in the BOUND CALCIUM Fraction but normal ionized calcium -not in young healthy ppl 40 yo M has mild pain in right elbow that started 3 wks ago after playing tennis w/a friend. Ibuprofen provided initial relief but then pain returned when he attempted tennis again 1 wk ago. 3/10 in severity. Point tenderness & mild swelling over lateral epicondyle right humerus. Painful ROM. No palpable effusion of elbow joint. Next step in evaluation? - ANSWER-*no further studies needed*-no X ray elbow needed 19 yo F has a 6 month hx of progressively worsening persistent HA. HA waxes&wanes and is most severe when she wakes up in AM. During past 2 wks, she had occasional brief episodes of darkening of vision in both eyes when she stands & noticed sound of her heartbeat in ears when lying down in quiet room. Gained 9 kg during past 2 yrs. BMI 32. VSS: BP 120/78. Dx is best supported by what physical exam finding? - ANSWER-*papilledema* NOT internuclear ophthalmoplegia -research this more! 12 yo F has 1 wk hx cough, nasal congestion, low grade fever. During the past 2 days, she also had moderately severe pain in left ear, which her mom treated w/OTC cerumen remover w/o relief. T 99.5F, P 70, R 14, BP 98/66. Exam: nasal congestion& erythema of left ear canal. Left TM is erythematous, bulging & multiple raised lesions. Dx? - ANSWER-*bullous myringitis* NOT otitis media w/effusion -research more major RF for alcoholism - ANSWER-*FAMILY Hx of alcoholism* not illicit drug use 81 yo M w/advanced dementia in Skilled nursing care facility has 3 wk hx facial rash. Unable to walk/talk/feed himself. PMH Hypothyroidism. BP 142/80. Erythema of both eyebrows, nasolabial folds, behind ears, mid sternum. intermittent twitching motions of arms. Which signs is most consistent w/underlying dermatologic dx in this pt? - ANSWER-*Flaking skin on scalp and face* -seborrheic dermatitis?? You are reading a study assessing whether ECG during graded treadmill exercise stress testing can predict clinically significant (75% or more) Coronary artery stenosis as shown by arteriography(gold standard). Subjects are men, ages 55-75 yo) w/chest pain who are referred to a cardiac center. Prevalence of greater than 75% stenosis in study group was 53%. Results of study shows: sensitivity 53%, PPV 89%, Specificity 92%, NPV 63%. Study said "in men, a positive multistage stress test is highly predictive of presence of significant coronary artery disease, but a negative stress test does NOT reliably r/o significant disease." You consider how exercise stress testing could be used to diagnose clinically significant coronary artery disease in pts in ur practice. In a 30 yo M w/chest pain, an exercise stress test would be likely to have which of the following features? - ANSWER-*lower PPV* b/c lower prevalence of heart disease in young men - answer is not higher negative predictive value b/c study said NPV is 63% b/c it says the study showed that positive stress test is highly predictive but negative stress test doesn't r/o disease=maybe lower PPV is better answer choice 17 yo AA high school student has severe right knee pain. " I was playing bball, went up for jump shot &When I Came down my knee twisted. I heard something pop & Felt this terrible pain." Exam: markedly swollen& tender knee. Able to actively extend it, although w/pain. Exam is made difficult by the swelling. X rays: confirms an effusion, they show a small avulsion fracture of lateral tibial plateau. Most likely dx is injury to which of the following structures? - ANSWER-*Anterior cruciate ligament* NOT medial meniscus 62 yo white woman has 24 hr hx progressive, severe SOB. 1 month ago, she began having episodes of severe SOB on bending over to pick up grandkids. Since that time, the frequency of episodes has increased to occur w/nearly every activity. During past 2 wks, pt noticed swelling in right arm&nagging dry cough. PMH mitral valve prolapse, HTN, T2DM. T 100.2F, P 60, RR 35, BP 130/76. Drinks 1 glass red wine daily. Exam: mild edema of face&Right UE, JVD, Palpable supraclavicular node. Diagnostic study? - ANSWER-chest x ray 29 yo M has 5 day hx worsening SOB, productive cough of yellow sputum, malaise, fatigue&fever. Bisexual w/3 male partners &1 male partner during past use, usually uses condoms. BMI 22, T 101F, RR 22. O2 sats 89%. Mildly tachypneic. Bilateral basilar crackles. ABG: pH 7.45, PO2 80, PCO2 32. Blood hct 45%, hgb 15, WBC 15,000. Chest x ray doesn't show obvious consolidation. Started on Supplemental O2