NBME Comprehensive Clinical Science 3 — Questions and Answers
Question 1: A 70-year-old woman with atrial fibrillation develops sudden right-sided weakness and slurred speech with symptom onset 2 hours ago. CT head excludes hemorrhage. What is the most appropriate next step?
- Start aspirin 325 mg immediately
- Administer IV alteplase (tPA) (Correct answer)
- Emergent mechanical thrombectomy
- Anticoagulate with IV unfractionated heparin
Correct answer: Administer IV alteplase (tPA)
IV tPA is indicated for ischemic stroke within 4.5 hours of symptom onset when intracranial hemorrhage has been excluded by CT.
Question 2: A 68-year-old man with COPD presents with worsening dyspnea and increased sputum. He uses accessory muscles. ABG shows pH 7.32, pCO2 58, pO2 55 on room air. What is the most appropriate respiratory intervention?
- High-flow oxygen via non-rebreather mask
- Non-invasive positive pressure ventilation (BiPAP) (Correct answer)
- Immediate intubation and mechanical ventilation
- Inhaled bronchodilators alone without ventilatory support
Correct answer: Non-invasive positive pressure ventilation (BiPAP)
BiPAP is first-line ventilatory support for acute COPD exacerbation with hypercapnic respiratory failure, reducing intubation rates and mortality.
Question 3: A 52-year-old woman presents with BP 222/134 mmHg, headache, and blurred vision. Fundoscopy shows papilledema. Creatinine rose from 0.9 to 2.3 mg/dL acutely. What is the most appropriate management?
- Oral amlodipine and discharge with urgent follow-up
- IV labetalol targeting a 25% MAP reduction in the first hour (Correct answer)
- IV nitroprusside to normalize BP within 1 hour
- Oral hydralazine and recheck BP in 4 hours
Correct answer: IV labetalol targeting a 25% MAP reduction in the first hour
Hypertensive emergency with end-organ damage requires IV antihypertensives to reduce MAP by 10–25% in the first hour—not to normotension, to avoid ischemia.
Question 4: A 30-year-old woman with epilepsy has been seizing continuously for 35 minutes despite lorazepam 4 mg IV given twice. What is the most appropriate next intervention?
- Repeat lorazepam 4 mg IV for a third dose
- IV levetiracetam or fosphenytoin (Correct answer)
- Emergent EEG before further medication
- Propofol infusion for refractory status epilepticus
Correct answer: IV levetiracetam or fosphenytoin
Benzodiazepine-refractory status epilepticus requires second-line agents such as IV levetiracetam, fosphenytoin, or valproate.
Question 5: A 58-year-old man with chronic alcohol use vomits bright red blood. BP is 88/60 and HR is 122. Two large-bore IVs are in place. What is the single most appropriate immediate next step?
- Emergent upper endoscopy for diagnosis and hemostasis
- IV fluid resuscitation with crystalloid and packed RBC transfusion (Correct answer)
- Vasopressin infusion to reduce portal pressure
- Emergent Sengstaken-Blakemore tube placement
Correct answer: IV fluid resuscitation with crystalloid and packed RBC transfusion
Hemodynamic resuscitation with IV fluids and blood transfusion must precede endoscopy in a hemodynamically unstable patient with active GI hemorrhage.
Question 6: A 40-year-old woman with lupus has been on hydroxychloroquine for 5 years. Which monitoring study is most important to perform annually?
- Liver function tests
- Ophthalmologic examination with visual field testing (Correct answer)
- CBC to monitor for agranulocytosis
- Pulmonary function tests
Correct answer: Ophthalmologic examination with visual field testing
Hydroxychloroquine can cause irreversible retinal toxicity that is dose- and duration-dependent, requiring annual ophthalmologic screening after 5 years.
Question 7: A 4-year-old girl presents with dysuria, frequency, and fever of 38.8°C. Urine culture grows >100,000 CFU/mL E. coli sensitive to trimethoprim-sulfamethoxazole. Renal ultrasound is normal. What is the appropriate treatment?
- IV ceftriaxone and hospital admission
- Oral trimethoprim-sulfamethoxazole for 7–14 days (Correct answer)
- Nitrofurantoin for 3 days
- Amoxicillin-clavulanate for 3 days
Correct answer: Oral trimethoprim-sulfamethoxazole for 7–14 days
Febrile UTI in a young child suggests upper urinary tract involvement; 7–14 days of oral antibiotics with appropriate sensitivity covers this adequately.
NBME Comprehensive Clinical Science 3
A 70-year-old woman with atrial fibrillation develops sudden right-sided weakness and slurred speech with symptom onset 2 hours ago.
CT head excludes hemorrhage.
What is the most appropriate next step?