Step 2CK NBME Review Latest Updated Graded A

2mo infant is exclusively breastfed. What nutritional supplement? Correct Answer-Oral VitD to prevent rickets What HTN drug causes peripheral edema, flushing, dizziness? Correct Answer-CCB eg nifedipine 15yo girl wit ...

2mo infant is exclusively breastfed. What nutritional supplement? Correct Answer-Oral VitD to prevent rickets What HTN drug causes peripheral edema, flushing, dizziness? Correct Answer-CCB eg nifedipine 15yo girl with recurrent candida infections of skin and mucous membranes since childhood. Dx? Correct Answer-Chronic mucocutaneous candidiasis (T cell dysfunction) 57yoM with impotence for 1 year rand bronze colored skin. Ferritin concentration is 4050 NG/ml. Increased risk for what complication? Correct Answer-1. Liver (primary organ)--hepatocellular carcinoma 2. Others: pancreas (DM), heart (CHF), skin, thyroid (hypo), gonads, joints (arthritis) 87yo's daughter: "we want my mother to receive hospice care at home but no one wants her to die at home. Can she still have hospice services?" Correct Answer-Yes. Hospice can provide home based care and attempt to transfer the pt to another site before death. 32yoF with 4d of fever with lymphatic obstruction. PE: the left lower extremity is diffuse lay red and edematous from just below the knee to the ankle, with a sharp demarcation separating the erythematous area from the normal skin at the knee. The erythematous area is painful and hyperesthetic to touch. The left oral nodes are enlarged and painful. Dx and cause? Correct AnswerErysipelas - usually caused by group A strep - Tx: IM or oral penicillin/erythromycin 16yo girl with painful genital lesions or 2d. Lots of sexual partners. Exam shows two 3x3mm ulcerated lesions on the anterior vaginal vault. How prevent transmission with new partner? Correct AnswerConsistent condom use (NOT pharmacological treatment) 37yo primigravid at 25 weeks' gestation with confusion for 12 hours. Fever and intermittent nausea and vomiting over the past 2 weeks. No contractions, but decreased fetal movement. Family Hx of T1DM, seizure disorder. T 38.8, P 168/min, BP 187/84. Mildly enlarged thyroid gland. Lungs clear. 3/6 systolic ejection murmur. Fetal heart rate 182/min. Labs show: Hb 9.9, platelets 282k, Serum: Na 134, Cl 94, K 2.9, Thyroid-stimulating hormone 0.01, AST 33, LDH 112, Uric acid 5.4. Dx? Correct Answer-Thyroid storm - Precipitants: infection, DKA, stress (childbirth, trauma, surgery, illness) - Sx: fever, tachycardia, agitation, confusion, GI symptoms (n/v/d) - Tx: supportive therapy with IV fluids, cooling blankets, glucose; PTU ever y2h, follow with iodine; beta blockers to control HR; dexamethasone to impair t3 from T4 37yo F with 4-month history of numbness, burning, and tingling of the toes and soles of her feet. 3-year hx of recurrent mouth sores. Numerous oral apthous ulcers, genital ulcers, and several 2.5-cm red lesions over the left anterior tibial region. Photophobia. Ankle reflexes are absent. Proprioception and sensation to pinprick and vibration decreased in lower ext. Dx? Correct Answer-Behcet syndrome - autoimmune vasculititc disease - Sx: recurrent oral and genital ulcerations (usu painful), arthritis (knees, ankles), eye involvement (uveitis, optic neuritis, conjuncitivitis), CNS involvement (intracranial HTN, meningoencephalitis), fever, wt loss; erythema nodosum-like lesions, pseudofolliculitis - Dx: bx Tx: steroids *NOT polyarteritis nodosa - can be associated with hep B, HIV, drug reactions - Sx: fever, wt loss, myalgias, abdominal pain (bowel angina) - Dx: bx; elevated ESR and pANCA - Tx: corticosteroids (if severe, cyclophosphamide) 87yo F with fever for 1 day. Urinary catheter was placed 2 weeks ago. Has dementia, Alzheimer type, and is unable to communicate verbally. T 37.8 C, P 86/min, BP 120/74. Mucous membranes are moist and pink. Urinalysis shows: Color cloudy brown, Ph 8.8, Blood 2+, Glucose negative, Protein 2+, RBC numerous, wbc 20-25, Nitrites 3+, leuk esterase 3+, bacteria many. Gram stain shows gram-negative bacilli. Which would have prevented? Correct Answer-Use of incontinence briefs instead of the catheter (NOT changing catheter daily) 32yo M with AIDS with 1-week history of T to 40 C and cough. Current medications include trimethopimsulfamethoxazole and three antiretroviral agents. Moist crackles over right lung base. X-ray of the chest shows an infiltrate in the right lower lobe. Causal org? Correct Answer-Stretococcus pneumoniae (NOT Pneumocystitis jiroveci b/c taking prophylactic oral bactrim) 77yo F with lesions on her left arm for the past 2 months. Underwent modified radical mastectomy of the left breast for breast cancer 20 years ago complicated by chronic edema of the LUE. Two r-mm, raised, hard, purple lesions just above the left elbow. Dx? Correct Answer-Lymphangiosarcoma - rare malignant tumor which occurs in long-standing cases of primary or secondary lymphedema. It involves either the upper or lower lymphedematous extremities but is most common in upper extremities. 57yo F with 2-week history of progressive jaundice and a 5-kg weight loss. Dark urine and pale stools. No meds. BP 120/80. Gallbladder palpated in the RUQ. Urine dipstick is positive for bilirubin. Ultrasonography shows a dilated gallbladder and dilated intrahepatic and extrahepatic biliary ducts. No calculi. Next step? Correct Answer-CT scan of the abdomen (Obstructive jaundice due to carcinoma head of pancreas) - Courvoisier's sign: palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones. (NOT Lap Cholecystectomy) One hour after splenectomy, 42yo M has severe shortness of breath. Additional injuries include left rib and pelvic fractures. T 36.3, P 133/min, BP 80/60. Breath sounds are absent on the left. Bowel sounds are absent. Next step? Correct Answer-Needle thoracostomy (pneumothorax; severe) NOT CXR 67yo M with alcoholism. 15-year history of poorly controlled hypertension; takes hydrochlorothiazide, not compliant. BP 170/102. Funduscopic examination shows arteriovenous nicking and tortuosity of the arteries. Risk for? Correct Answer-MI - hypertensive retinopathy: AV nicking and tortuosity of the arteries NOT subarachnoid hemorrhage 32 year old woman with 1 month of diarrhea, 8lb weight loss, three to four semiliquid stools daily. No fever, abdo pain or rectal bleeding. Just returned from scuba diving in Mexico 6 weeks ago. Boyfriend is symptom free. Abdo and rectal exam are normal. What is organism? Correct Answer-Giardia lamblia NOT V cholerae (up to 15 stools per day) 37yo F from Guatemala with joint pain, swelling, and stiffness of her wrists and hands for 2 years. Ibupforen ineffective. No fever, cough, or weight lossl. Received all immunizations. BMI 20. Spleen tip is nontender and is palpated 4 cm below left costal margin. Grip strength is decreased. Labs: Hb 10, Leukocyte count 2.5k, Platelets 125k. Cause of the leukopenia? Correct Answer-Felty syndrome - disorder that involves rheumatoid arthritis, a swollen spleen, decreased white blood cell count, and repeated infections. It is rare. 37 yr old woman, sudden onset fever 7 days after splenectomy for ITP. T 102.4, mild distension and diffuse tenderness, no rebound, rigidity or guarding. No bowel sounds. Labs hg 9.8 Leuks 21,300 Platelet 105, 000, amylase 124. chest xray shows left pleural effusion. what is the most likely cause of the findings? Correct Answer-subphrenic abscess (Post-splenectomy subphrenic abscess, phrenic nerve impingement cause refered shoulder pain, abscess fits the Fever, Increase Leukocyte count) NOT pneumonia 3yo girl with fever and ear pain for 1 day. Has had clear nasal discharge and cough for 3 days. History of several ear infections and one episode of streptococcal pharyngitis over the past 12 months. Father smokes in the house, family has two cats. Swims frequently. T 38.5, P 110/min, BP 80/50. Clear nasal discharge, erythema and bulging of the right tympanic membrane, and erythema of the throat without exude. Recommendation to prevent recurrence? Correct Answer-Avoidance of passive smoke exposure sensitivity Correct Answer62yo M with fatigue for 9 weeks. Drinks moonshine. HCT 29%, MCV 78, and mean corpuscular hemoglobin concentration is 25%. Blood smear shows hypochromic, microcytic erythrocytes and normochromic, normocytic erythrocytes. Bone marrow shows greater than 10% normoblasts containing iron-laden mitochondria that surround the nucleus and appear as rings on Prussian blue staining. Iron and transferrin saturation increased. Cause? Correct Answer-Sideroblastic anemia - caused by abnormality in RBC iron metabolism - hereditary or acq (drugs eg INH, alcohol, chloramphenicol; exposure to lead; neoplastic disease) - Labs: increased serum iron and ferritin, normal TIBC, ringed sideroblasts in bone marrow - Tx: remove offending agents; consider pyridoxine NOT hemochromatosis 30yo F routine exam. 10-year history of type 1 diabetes mellitus. Microalbuminuria, her hemoglobin A1c is 7%, and serum Cr is 1.8. Intervention? Correct Answer-Administration of an angiotensin-converting enzyme (ACE) inhibitor NOT inc dose of insulin 19yo F at 32 weeks' gestation with 1-month history of a generalized rash that has not expanded or changed. No pruritis or fever. No prenatal care. Macular rash involving the palms, chest, back, abdomen, extremities, and soles. Causal oragnism? Correct Answer-Treponema pallidum NOT Rubella: "You drive CARS with your palms and soles" CA- Coxsackievirus A R- Rickettsia Rickettsii S- Syphilis (secondary) 22yo F with asthma. Treated for six acute episodes of wheezing and nonproductive cough during the past year. Last episode 1 mo ago. Sx exacerbated when outside during the spring and fall. On albuterol inhaler. Smoked daily for 5 years. X-ray of the chest normal. Which will reduce frequency of exacerbations? Correct Answer-- Fluticasone inhaler therapy (Not influenza vaccine) 6 month old boy, chronic constipation since the age of 1 week. Current Rx with rectal stimulation, glycerin suppositories, and 4 ounces of prune juice produces string-like stool every 4 days. No vomiting. Growth and development are appropriate for age. Abdominal exam shows distension, no tenderness. Rectal exam, no palpable stool in ampulla. What is next step in mangement? Correct Answer-Rectal manometry - Hirshsprung disease: Chronic progressive constipation with onset in infancy + abdominal distension + empty rectum 37yo M with 6-week history of the rash shown. Similar rash over the past 5 years resolved with Rx. Sun exposure, the rash becomes lighter than his tanned skin. Pharmacotherapy? Correct Answer-Selenium sulfide shampoo - tinea versicolor (pityriasis versicolor) fungal infection 82yo M with shortness of breath at rest, increasing malaise, generalized weakness, and depressed mood for 6 weeks. Bruises easily and has bleeding and inflammation of the gums. Hypertrophic, lichenified patches over the upper extremities. No memory loss. Dx? Correct Answer-- Vitamin C deficiency (Scurvy, malnutrition, easy bruising, bleeding gums) 62yo M 4 hours after sudden onset of vomiting and sever abdominal pain. Has had mild, intermittent epigastric pain, relieved with antacid use. No hx of serious illness. Smoked daily for 35 years. Appears diaphoretic and is in acute distress. T 38.4 C, P 100/min, BP 115/75. Bowel sounds are absent. Next step? Correct Answer-X-rays of the chest and abdomen (to visualize perforation