NBME form 2, need help with some questions

[istream]

3. 6 yo Syrian boy found to have bloodstains on pillow past three mornings. Crusted blood around left nostril. Symptoms came after resolution of illness characterized by fever and clear rhinorrhea. On PE, 3x4 mm eschar on nasal septum. Most appropriate treatment at this time?
a. alum to the left naris
b. beclamethasone to the nares twice a day
c. petrolatum to the nares twice a day
d. phenlyephrine to the nares twice a aday
e. silver nitrate to the area around eschar
D is wrong answer

15. 48 yo female, g4p4, comes for urine leakage when cough/sneeze/runs. First noted 11 years ago after first child, worsened sx during past yhear. PMH: depression, pyelonephritis. PSH: tubal ligation 9 years ago. Noted to have filmy pelvic adhesions between ovaries and bowel. No pelvic pain. Smoked one pack daily for 30 years. PE shows urethrocele in external genitalia. Pelvic exam showes 2nd degree cystocele and normal cervix. Uterine size is normal. Recatal exam shows 2nd degree rectocele. Which study to establish dx?
a. cystography
b. cystometrics
c. cystoscopy
d. iv urography
e. urine culture
D wrong answer

16. 19 year fold female has urinary frequency and urgency for 4 days. No PMH. Sexually active with one parter and used consoms. No menstrual period for 3 months. Menses irregular. Uterine size 12 week gestation. Urine pregnancy positive. UA WNL. Regarding frequency and urgency, what additional history to get?
a. daily fluid intake
b. family history of DM
c. medication use
d. previous UTI
e. no further history
A wrong answer, think D?

25. 92 yo female with pain in mid spine. Failed to respond to local heat, massage, NSAID. Pt has metastatic breast cancer. She says “I know im close to the end, I want to be comfortable here in my bed.
VS normal. Patient is cachectic, but cognitively intact. Left mastectomy scar is present. Tenderness over T8 with marked paravertebral spasm. Reflexes normal. Liver palpable 4 cm. In addition to opioid analgesic, which is most apprproriate?
a. alendronate
b. spinal brace
c surgical consult for vertebrolplasty
d. xrays of spine
e. laxative
B wrong answer

29. 67 yo male undergoes laparotomy and LOA for high grade SBO. Post op has emesis of 100cc bilious fluid. POD #1 temperate of 100.8, pulse 124, RR 34. Breathing is shallow and breath sounds associated with wheezing and diminished in both lung fields. Abdomen distended and tender. Whats dx?
a. aspiration pneumonitis
b. atelecstatis
c. postanesthesia respiratory insufficiency
d. pulm edema
e. PE
B wrong answer

67 yo male with metstatic lung CA has HA, vomiting, pain in extremities/abdomen for 2 days. Tumor metastasized to liver, lungs, bones, brain. Hospice care for one month. Meducations include 4mg IV dexmaethose 4x daily, morphine 10mg/hour by IV, 10 mg IV metoclpromade 6x daily. He is drowsy/moaning, responds to voices, follows commands with all extremities. Not oriented to place/time. VS: 98.6/ 110/60 /105/10. Chest auscultation with normal breat shounds and crackles in lung bcase. Liver enlarged and TTP. Abd soft, decreased bowel sounds. Diffuse tenderness over bones. Which is most appropriate change to medication?
a. Start IV cefuroxime
b. Start IV lorazepam
c. Start IV mannitol
d. Increase dexamethasone
e. Increase morphine infusion
D wrong answer

2. 50 yol woman for health eval. History of hypotension. Feeling well, no complaints. BP is 98/65. Fundscopic exam shows extreme cupping of optic discs, cup to disc ration 0.8, bilaterally and pink rims. Tonometry shows pressure of 16 (range 10-22mmHg). Which is most appropriate step?
a. LP
b. MRI Brain
c. Reeval in 4 weeks
d. Neuro referral
e. Ophthal referral
C wrong answer

3. 1 moth old female infant delivered at term, weighs 3500g, normal apgars, discharged at 36 hours, nursing q2-3 hours. PE shows happy, content infant with good muscle tone and color. 52 cm (25th) and 4000g (50th) head circumference (75th). Anterior fontanel soft and open, TM normal. Lungs clear, Heart RRR. Abd soft, ND. Spine curves to the left at midthoracic region. X1.5m hyperigmeented hairy patch of skin over the midthoracic spine. Genitali normal. Xray chest and back show unilateral unsegemneted bar at T5 and T6, 7 degree curvature. Which is appropriate next step?
a. 99m technetium bone scan
b. chromostome studies
c. referral to ortho
d. repeat xray in 6 months
e. spica cast
D wrong answer

8. 15 yo figure skater missed a jump and fell on knee 3 days ago. Knee hurts when pressed on kneecap and it looks swoell to patient. Patient cant jump. PE: local swelling and tenderness over patella. Full ROM, pain on attempts at extension of knee against resistance. No laxity on stress testing. Xray in ER is shown. Which is next step.
a. application of cylinder cast from ankle to midthigh
b. application of long leg cast
c. application of removable fabric knee immobilzaton splint
d. ice packs, analgesics, isometic quad strengthening
e. referral for ORIF
C wrong answer

12 2 motnh Hispanic infant born at 31 weeks, was in UC requiring ventilation therapy for 1 week after birth because of apnea of prematurity after weaning from vent. Pneumocardiogram priot discharge showed no abnormalities. DC 7 days ago with no apnea after being placed on theophylline which was DC
prior to discharge. Mother is concerned that she has irregular breathing, “sometimes she has long pauses where she doesn’t seem to breathe at all. Then she takes a deep breath and seems okay. I am worried about her. I cant sleep at night. I just sit by her crib and doze and keep my hand on her chest but last night I slepth through her 4am feeding. I know CPR so if she tops breating im sure I know wht to do, but im afraid something will happen and I wontk up to save her. VS 37, pulse 120, repsirations 40, weight 3200. In fant seens alter and comrtable, no abnormalities are noted on PE. Which is next step?
a. Order ecg as outpatient
b. Schedule repeat pneumocardiography today in observation unit
c. Schedule EEG
d. Send patient home with apnea monitor
e. Send patient home with close observation by mother
B wrong answer

16. 10 yo boy brought to office with itchy rash on right ankle. First notice din morhing while putting on socks. Small blisters have formed from scratching the rash with clear oozing transudate, no eema. Phograph shown. No other abnormalities. Which topical pharmacotherapy?
a. acyclovir
b. clotrimazole
c. erythromycin
d. hydrocortisone
e. mupirocin
E wrong answer

24. 24 yo female comes to office for eval fo recurrent HA that began 3 years ago. Initally HA were unilateral and throbbing nad occur premenstraully, but during past several months she has developed persistent bilateral frontal headache. She has had associated nausea and sensitivity to light, symptoms worsen premenstraully. HA is present throughout the day and does not affect sleeping habits. No triggers. She works as police officer and has job realted stress, missed several days of works because of HA. She takes OTC aspirin, tyelonl, caffeine 6 times daily. Diet poor and admits to eating mostly fast food. 3 year history of menstrual irregularity. VSS. CT head shows no abnormalities. Which is most responsible for worsening headache
a. analgesic overuse
b. dietary habits
c. menstrual irregularity
d. work related stress
C wrong answer

30. 45 yo Hispanic female, g4p4, comes for annual gyn exam. Menstral periods 3-4 month intervals, heavy, 10lb weight gain. No PMH, no meds. BMI 29. Exam: normal breast. Enlarged, globular uterus with no adnexal masses. Pelvic US shows thickened endometrial lining measuring 14mm. Without treatment, what will develop?
a. adenocarcinoma of ovary
b. endometrial hyperplasia
c. endometrial polyps
d. ovarian cysts
e. uterine myomata
E wrong answer

30 year old female with shortness of breath and numbness/tingling of finfers. IF ABG ordered, results would be what?
(PO2/PCO2/pH/HCO3)
a. 70/60/7.25/27
b. 40/60/7.37/33
c. 90/40/7.40/24
d. 110/25/7.50/19
e. 40/60/7.51/27
C wrong answer (this q annoyed me the most, no idea whats being tested, many ways to interpret, any insight greatly appreciated

33. 26 yo female with nausea/copious swatery diarrhea on awakening this morning. No emesis. 3 year old child and husband not sick. Shared all meals past 3 days. No PMH. BMI 24, VSS while supine bp 120/80 and pulse 95 and while sitting up pulse rises to 105, BP decreased to 110/65. Abdomen nontender, hyperactive bowel sounds. WBC 7600. Plain xray shows gas throughout small and large intestines, air fluid levels in small intestine. 1L LR given. Labs pending. While waiting results, patient has two watery BM. She says no longer feels nauseated. Whats next step?
a. Administer amoxicillin
b. Initiate oral fluid hydration
c. Obtain surgery consult
d. CT abdomen
e. Cultures of stool
D wrong answer.

9. 33 year old postal workers comes with 2 week history of low back pain radiating to right leg after lifting large bag of mail at work. She has been on bed rest and sx not improved. Given Tylenol/codein at time of injury, no rleif. VSS normal. Patient thin/anxious. Wringig her hand sand shifts in chair. Lungs calear. Back is not tender. Straight leg elevation causes pain in RLE above knee. What is management?
a. continued bed rest for 4 weeks
b. epidural steroid injection
c. hydrotherapy
d. ketorolac therapy
e. oxycodone therapy
B wrong answer

21. 24 yeard olf female with HA that began 1 day ago suddnel while exercising, involved entire head and most severe at onset, rating at 9/10, now 8. Mild photophobia and neck stiffness. She had had occasional headaches in the past, current headache feels different. Aspirin and tyelonl with codeine no relief. No PMH, no meds. Temp 100.4, pulse 90, RR 12, BP 120/90. Mild distress due to headache. Fundoscopic exam normal. Pain with stiffness and passive neck flesion. No neuro deficits. What is diagnosis?
a. acute bacterial meningitis
b. brain abscess
c. migraine
d. SAH
e. vertebral artery dissection
A wrong answer

23. 36 year old woman comes to office 6 weeks after giving birth via vaginal delivery. Past 24 hours has fevers and fatigue. Right breast more engorged than left, and is tender laterally. Right breast is firm, erythematous, indurated over outer quadrant. Milk is expressed from nipple and is not bloody or foul smelling. Left breast normal. Enlarged, tender lymph nodes in right axilla. In addition to warm soaks to affected area, most appropriate next step?
a. Aspirate indurated area
b. Oral antibiotic
c. Obtain mammography
d. Obtain ultrasound of right breast
e. Refer to surgeon
D wrong answer

24. 15 yo female brought to office by mother becaue of moderate heavy painless irregular vaginal bleeding lasting 10 days and ended 3 days ago. Menarche at age 12. PE normal. Hgb 15, urine pregnancy negative. Management?
a. combined OCP for 3-6 months
b. medroxyprogesteone therapy
c. obs for 3-6 months.
d. oral iron therapy
e. progestin only OCP for 3-6 months
A wrong answer

25.6 yo boy with three upper respiratory tract infections past 9 months with fever, sore throat, and ear infection. Height and weight at 25th percentile. PE normal. Tonsils moderately enlarged. Exam of ear shows no abnormalities, hearing normal. No obstruction in airway. Which is next step?
a. arrange for an elective adenoicetomy
b. arrange for elective tonsillectomy and adenoicetomy
c. arrange for tubes in middle ear
d. 6 months of penicillin
e. reassure family nothing to be done
B wrong answer

32. 18 year old ice skater with 50 eweight loss during 12 months, eats low carb, low calorie deit 12 months ago, stopped 4 weeks ago because of excessive weight loss. Now lack of appetite, unable to eat, weight loss continued. Menses regular, last 3-5 days. No smoking drugs. BMI 19, VSS normal. PE normal, Labs normal. In addition to nutritional counseing and dietary log, what else is approrpirate?
a. high calorie liquid nutritional supplements
b. Megestrol acetate therapy
c. Regular weight checks at office
d. supportive psychotherapy
e. reassurance only

Any help with these questions would be greatly appreciated!

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[thehundredthone]

Such vague questions.

3. 6 yo Syrian boy found to have bloodstains on pillow past three mornings. Crusted blood around left nostril. Symptoms came after resolution of illness characterized by fever and clear rhinorrhea. On PE, 3x4 mm eschar on nasal septum. Most appropriate treatment at this time?

c. petrolatum to the nares twice a day
D is wrong answer

It has already healed, now you just need to prevent the eschar from being pulled off again.

15. 48 yo female, g4p4, comes for urine leakage when cough/sneeze/runs. First noted 11 years ago after first child, worsened sx during past yhear. PMH: depression, pyelonephritis. PSH: tubal ligation 9 years ago. Noted to have filmy pelvic adhesions between ovaries and bowel. No pelvic pain. Smoked one pack daily for 30 years. PE shows urethrocele in external genitalia. Pelvic exam showes 2nd degree cystocele and normal cervix. Uterine size is normal. Recatal exam shows 2nd degree rectocele. Which study to establish dx?

a. cystography
b. cystometrics
c. cystoscopy
d. iv urography
e. urine culture
D wrong answer

Usually the cotton swab test is enough, but you can do cystometrics if needed to establish the pressures.

16. 19 year fold female has urinary frequency and urgency for 4 days. No PMH. Sexually active with one parter and used consoms. No menstrual period for 3 months. Menses irregular. Uterine size 12 week gestation. Urine pregnancy positive. UA WNL. Regarding frequency and urgency, what additional history to get?

a. daily fluid intake
b. family history of DM
c. medication use
d. previous UTI
e. no further history
A wrong answer, think D?

I don't know if you really need any other history. She's pregnant, she has a UTI.

25. 92 yo female with pain in mid spine. Failed to respond to local heat, massage, NSAID. Pt has metastatic breast cancer. She says “I know im close to the end, I want to be comfortable here in my bed.
VS normal. Patient is cachectic, but cognitively intact. Left mastectomy scar is present. Tenderness over T8 with marked paravertebral spasm. Reflexes normal. Liver palpable 4 cm. In addition to opioid analgesic, which is most apprproriate?

a. alendronate
b. spinal brace
c surgical consult for vertebrolplasty
d. xrays of spine
e. laxative
B wrong answer

Bisphosphonates are useful in reducing (further) bone events in metastatic cancer.

29. 67 yo male undergoes laparotomy and LOA for high grade SBO. Post op has emesis of 100cc bilious fluid. POD #1 temperate of 100.8, pulse 124, RR 34. Breathing is shallow and breath sounds associated with wheezing and diminished in both lung fields. Abdomen distended and tender. Whats dx?

a. aspiration pneumonitis
b. atelecstatis
c. postanesthesia respiratory insufficiency
d. pulm edema
e. PE
B wrong answer
With the history of the emesis, aspiration pneumonitis may be likely.

67 yo male with metstatic lung CA has HA, vomiting, pain in extremities/abdomen for 2 days. Tumor metastasized to liver, lungs, bones, brain. Hospice care for one month. Meducations include 4mg IV dexmaethose 4x daily, morphine 10mg/hour by IV, 10 mg IV metoclpromade 6x daily. He is drowsy/moaning, responds to voices, follows commands with all extremities. Not oriented to place/time. VS: 98.6/ 110/60 /105/10. Chest auscultation with normal breat shounds and crackles in lung bcase. Liver enlarged and TTP. Abd soft, decreased bowel sounds. Diffuse tenderness over bones. Which is most appropriate change to medication?

a. Start IV cefuroxime
b. Start IV lorazepam
c. Start IV mannitol
d. Increase dexamethasone
e. Increase morphine infusion
D wrong answer

Increase his analgesia given his pain.

2. 50 yol woman for health eval. History of hypotension. Feeling well, no complaints. BP is 98/65. Fundscopic exam shows extreme cupping of optic discs, cup to disc ration 0.8, bilaterally and pink rims. Tonometry shows pressure of 16 (range 10-22mmHg). Which is most appropriate step?

a. LP
b. MRI Brain
c. Reeval in 4 weeks
d. Neuro referral
e. Ophthal referral
C wrong answer

The normal cup disk ratio is 0.3.

3. 1 moth old female infant delivered at term, weighs 3500g, normal apgars, discharged at 36 hours, nursing q2-3 hours. PE shows happy, content infant with good muscle tone and color. 52 cm (25th) and 4000g (50th) head circumference (75th). Anterior fontanel soft and open, TM normal. Lungs clear, Heart RRR. Abd soft, ND. Spine curves to the left at midthoracic region. X1.5m hyperigmeented hairy patch of skin over the midthoracic spine. Genitali normal. Xray chest and back show unilateral unsegemneted bar at T5 and T6, 7 degree curvature. Which is appropriate next step?

a. 99m technetium bone scan
b. chromostome studies
c. referral to ortho
d. repeat xray in 6 months
e. spica cast
D wrong answer

This scoliosis is not going away, because there is a verterbal bar.

8. 15 yo figure skater missed a jump and fell on knee 3 days ago. Knee hurts when pressed on kneecap and it looks swoell to patient. Patient cant jump. PE: local swelling and tenderness over patella. Full ROM, pain on attempts at extension of knee against resistance. No laxity on stress testing. Xray in ER is shown. Which is next step.

a. application of cylinder cast from ankle to midthigh
b. application of long leg cast
c. application of removable fabric knee immobilzaton splint
d. ice packs, analgesics, isometic quad strengthening
e. referral for ORIF
C wrong answer

Either the midthigh or long leg cast.

12 2 motnh Hispanic infant born at 31 weeks, was in UC requiring ventilation therapy for 1 week after birth because of apnea of prematurity after weaning from vent. Pneumocardiogram priot discharge showed no abnormalities. DC 7 days ago with no apnea after being placed on theophylline which was DC
prior to discharge. Mother is concerned that she has irregular breathing, “sometimes she has long pauses where she doesn’t seem to breathe at all. Then she takes a deep breath and seems okay. I am worried about her. I cant sleep at night. I just sit by her crib and doze and keep my hand on her chest but last night I slepth through her 4am feeding. I know CPR so if she tops breating im sure I know wht to do, but im afraid something will happen and I wontk up to save her. VS 37, pulse 120, repsirations 40, weight 3200. In fant seens alter and comrtable, no abnormalities are noted on PE. Which is next step?

a. Order ecg as outpatient
b. Schedule repeat pneumocardiography today in observation unit
c. Schedule EEG
d. Send patient home with apnea monitor
e. Send patient home with close observation by mother
B wrong answer

Apnea monitors are used at home in apnea of prematurity.

16. 10 yo boy brought to office with itchy rash on right ankle. First notice din morhing while putting on socks. Small blisters have formed from scratching the rash with clear oozing transudate, no eema. Phograph shown. No other abnormalities. Which topical pharmacotherapy?

a. acyclovir
b. clotrimazole
c. erythromycin
d. hydrocortisone
e. mupirocin
E wrong answer

Probably atopic dermatitis.

24. 24 yo female comes to office for eval fo recurrent HA that began 3 years ago. Initally HA were unilateral and throbbing nad occur premenstraully, but during past several months she has developed persistent bilateral frontal headache. She has had associated nausea and sensitivity to light, symptoms worsen premenstraully. HA is present throughout the day and does not affect sleeping habits. No triggers. She works as police officer and has job realted stress, missed several days of works because of HA. She takes OTC aspirin, tyelonl, caffeine 6 times daily. Diet poor and admits to eating mostly fast food. 3 year history of menstrual irregularity. VSS. CT head shows no abnormalities. Which is most responsible for worsening headache

a. analgesic overuse
b. dietary habits
c. menstrual irregularity
d. work related stress
C wrong answer

Analgesic/Medication overuse headache. Note the change in pattern and character.

30. 45 yo Hispanic female, g4p4, comes for annual gyn exam. Menstral periods 3-4 month intervals, heavy, 10lb weight gain. No PMH, no meds. BMI 29. Exam: normal breast. Enlarged, globular uterus with no adnexal masses. Pelvic US shows thickened endometrial lining measuring 14mm. Without treatment, what will develop?

a. adenocarcinoma of ovary
b. endometrial hyperplasia
c. endometrial polyps
d. ovarian cysts
e. uterine myomata
E wrong answer

She already has endometrial hyperplasia, but the question could be getting at PCOS as a source.

30 year old female with shortness of breath and numbness/tingling of finfers. IF ABG ordered, results would be what?

(PO2/PCO2/pH/HCO3)
a. 70/60/7.25/27
b. 40/60/7.37/33
c. 90/40/7.40/24
d. 110/25/7.50/19
e. 40/60/7.51/27
C wrong answer (this q annoyed me the most, no idea whats being tested, many ways to interpret, any insight greatly appreciated

She's hyperventilating (hence the paresthesias). Her pCO2 would be lower than normal, although the bicarb in this option is a little lower than expected. C is nearly normal.

33. 26 yo female with nausea/copious swatery diarrhea on awakening this morning. No emesis. 3 year old child and husband not sick. Shared all meals past 3 days. No PMH. BMI 24, VSS while supine bp 120/80 and pulse 95 and while sitting up pulse rises to 105, BP decreased to 110/65. Abdomen nontender, hyperactive bowel sounds. WBC 7600. Plain xray shows gas throughout small and large intestines, air fluid levels in small intestine. 1L LR given. Labs pending. While waiting results, patient has two watery BM. She says no longer feels nauseated. Whats next step?

a. Administer amoxicillin
b. Initiate oral fluid hydration
c. Obtain surgery consult
d. CT abdomen
e. Cultures of stool
D wrong answer.

She's orthostatic, so she needs rehydration. Now that the nausea is gone, oral fluids are appropriate.

9. 33 year old postal workers comes with 2 week history of low back pain radiating to right leg after lifting large bag of mail at work. She has been on bed rest and sx not improved. Given Tylenol/codein at time of injury, no rleif. VSS normal. Patient thin/anxious. Wringig her hand sand shifts in chair. Lungs calear. Back is not tender. Straight leg elevation causes pain in RLE above knee. What is management?

a. continued bed rest for 4 weeks
b. epidural steroid injection
c. hydrotherapy
d. ketorolac therapy
e. oxycodone therapy
B wrong answer

Very vague question. Maybe she needs opioids because the herniation isn't responding to tylenol. The anxiousness and hand wringing is quite a strange thing to include here.

21. 24 yeard olf female with HA that began 1 day ago suddnel while exercising, involved entire head and most severe at onset, rating at 9/10, now 8. Mild photophobia and neck stiffness. She had had occasional headaches in the past, current headache feels different. Aspirin and tyelonl with codeine no relief. No PMH, no meds. Temp 100.4, pulse 90, RR 12, BP 120/90. Mild distress due to headache. Fundoscopic exam normal. Pain with stiffness and passive neck flesion. No neuro deficits. What is diagnosis?

a. acute bacterial meningitis
b. brain abscess
c. migraine
d. SAH
e. vertebral artery dissection
A wrong answer

Sudden onset, meningismus, "worst headache"/"different from other headaches" = SAH.

23. 36 year old woman comes to office 6 weeks after giving birth via vaginal delivery. Past 24 hours has fevers and fatigue. Right breast more engorged than left, and is tender laterally. Right breast is firm, erythematous, indurated over outer quadrant. Milk is expressed from nipple and is not bloody or foul smelling. Left breast normal. Enlarged, tender lymph nodes in right axilla. In addition to warm soaks to affected area, most appropriate next step?

a. Aspirate indurated area
b. Oral antibiotic
c. Obtain mammography
d. Obtain ultrasound of right breast
e. Refer to surgeon
D wrong answer

Mastitis needs antibiotics. This is not an abscess - that would have been palpable on examination.

24. 15 yo female brought to office by mother becaue of moderate heavy painless irregular vaginal bleeding lasting 10 days and ended 3 days ago. Menarche at age 12. PE normal. Hgb 15, urine pregnancy negative. Management?

a. combined OCP for 3-6 months
b. medroxyprogesteone therapy
c. obs for 3-6 months.
d. oral iron therapy
e. progestin only OCP for 3-6 months
A wrong answer

No management required if this is a single episode irregular bleeding. Observe to see if it's a change in pattern.

25.6 yo boy with three upper respiratory tract infections past 9 months with fever, sore throat, and ear infection. Height and weight at 25th percentile. PE normal. Tonsils moderately enlarged. Exam of ear shows no abnormalities, hearing normal. No obstruction in airway. Which is next step?

a. arrange for an elective adenoicetomy
b. arrange for elective tonsillectomy and adenoicetomy
c. arrange for tubes in middle ear
d. 6 months of penicillin
e. reassure family nothing to be done
B wrong answer

There's no indication that his tonsils/adenoids are causing the infections.

32. 18 year old ice skater with 50 eweight loss during 12 months, eats low carb, low calorie deit 12 months ago, stopped 4 weeks ago because of excessive weight loss. Now lack of appetite, unable to eat, weight loss continued. Menses regular, last 3-5 days. No smoking drugs. BMI 19, VSS normal. PE normal, Labs normal. In addition to nutritional counseing and dietary log, what else is approrpirate?

a. high calorie liquid nutritional supplements
b. Megestrol acetate therapy
c. Regular weight checks at office
d. supportive psychotherapy
e. reassurance only

I'm not sure she has a full blown eating disorder given that she stopped the diet after experiencing severe weight loss. But in a young female with this kind of history, it has to be high on the list, so supportive psychotherapy may be indicated.