USMLE STEP 2 CK
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A 68-year-old man with metastatic lung cancer is brought to the emergency room by his daughter, who reports that his father has been increasingly confused and lethargic over the past week. He denies any recent head trauma or any other medical problems. He reports taking chemotherapy but no other medications. On physical examination, his vital signs are stable, no jugular venous distension is present, and cardiac and lung exams are unremarkable. A CT scan does not show any brain metastases.
Laboratory results show:
Sodium: 124 mEq/L
Potassium: 4.6 mEq/L
Chloride: 102 mEq/:L
Bicarbonate: 22 mEq/L
What is the most appropriate next step in managing this patient?
A. Administer diuretics and water orally
B. Administer isotonic saline through a peripheral IV
C. Vascular malformation
D. Subacute infarction
E. Cerebral abscess
A 13-year-old male comes to the emergency room with a one-day history of nausea and vomiting. He says that yesterday, he began having pain around his belly button and skipped dinner. Today, he felt nauseated. His mother thought he had a fever and kept him home from school. He says the pain moved to his right lower quadrant and, "it hurts there when I press it." On exam, he shows rebound tenderness and guarding in his right lower quadrant, 1/3 of the way between the right iliac crest and the umbilicus. A CBC shows an elevated white blood cell count to 14.2. What is the most appropriate next step?
A. Antibiotics to cover gram-negative organisms
C. CT scan
D. Stool guaiac exam
E. Ultrasound of abdomen
A 42-year-old woman with a history of rheumatoid arthritis and seasonal allergies comes to your clinic complaining of pain, erythema, and swelling "on the hard part of my ears." When questioned, she also describes a low-grade pain in her chest, over her costochondral joints. Which of the following is the most likely diagnosis?
A. Ankylosing spondylitis
C. Reiter syndrome
D. Relapsing polychondritis
A 64-year-old man with a history of hypertension, well controlled on medication, reports feeling increasingly tired over the past year. He reports some weight loss without any changes in diet or exercise. He also mentions that he has been having very thin stools but no frank blood. He takes no medication. Physical exam shows a pale, thin man in no acute distress, with a mildly elevated heart rate. Rectal examination is positive for occult blood. Hematocrit is 24%, but all other laboratory values are within normal limits. Which is the best next step in diagnosis?
A. Abdominal x-ray
D. Exploratory laparoscopy
A 46-year-old woman is hospitalized for agitation, restlessness, and poor sleep. She has been complaining of headaches recently and has gained 14 pounds over four months. She denies any illicit drug use, pain, or recent illnesses. Her blood pressure is 162/114 and her heart rate is 90/min. Her laboratory findings are the following:
Sodium 142 mEq/L
Potassium 3.2 mEq/L
Chloride 98 mEq/L
Bicarbonate 26 mEq/L
BUN 12 m/dL
Creatinine 0.9 mg/dL
Glucose 205 mg/dL
Calcium 9.4 mg/dL
Which of the following is the most likely cause of this patient’s hypertension?
A. Adrenal cortical disease
B. Adrenal medullary disease
D. Renal parenchymal disease
E. Renal vascular stenosis
A 49-year-old male is being treated for a PE. On the 6th day of hospitalization, he is found to have a platelet count of 69000/mm3. Heparin therapy is stopped immediately to prevent which of the following complications?
A. Arterial thrombosis
B. Heart failure
C. Liver failure
D. Severe bleeding
E. Vertebral collapse
A 29-year-old man with a CD4 count of 190 presents with a dry cough, fever for 2 weeks and shortness of breath, worsened when climbing stairs. His laboratory workup revealed a lactate dehydrogenase (LDH) level of 540. His blood pressure is 125/86. A chest X-ray is ordered and can be seen in the image. Which of the following is the most likely cause of the patient’s problems?
A. Congestive heart failure
B. Pneumocystis jiroveci
C. Escherichia coli
D. Septic shock
E. Streptococcus pneumoniae
A 3-month old female is brought to the pediatric emergency room by her mother, who says the baby, "just doesn't seem right." On exam, you see a tired-appearing baby lying in her mother's arms who cries weakly when you begin to examine her. You note that her mucous membranes are moist, her anterior fontanelle is bulging, and she is tachycardic to 160. She also has a rash in the distribution of her diaper. What is the most important test for you to obtain at this point?
A. Blood culture
C. CSF Analysis
E. Urine culture
A 6-year-old girl is being evaluated for short stature. She is at the 12th percentile for height and the 34th percentile for weight. Vital signs are within normal limits. And physical exam shows widely spaced nipples and a high arched palate. Karyotyping shows 45XO. Which is she most at risk of developing?
A. Bipolar disorder
B. Breast cancer
C. Mental retardation
D. Mitral valve prolapse
A 40-year-old Caucasian male with a chronic history of paranoid schizophrenia presents to the mental health clinic. He tells you that his wife stole his bottle of risperidone, which he believes caused him to experience more frequent and intense auditory hallucinations. He says the voices tell him to kill his wife because she cannot be trusted. He admits to having homicidal thoughts about his wife but denies any specific plan for harming her. He requests a refill of his risperidone. What is the most appropriate next step?
A. Admit the patient to the psychiatric ward
B. Call the patient’s wife before filling the risperidone prescription
C. Increase his dose of risperidone
D. Refill his prescription of risperidone and call his wife after he leaves
E. Refill prescription without calling his wife, he does not have a plan to harm her