Question of the Week # 470

470) An 11-year-old with a history of asthma and seasonal allergies is currently using albuterol to manage asthma symptoms. Recently his use of albuterol has increased from 1-2 days per week to 4 times per week for several weeks, though does not experience his symptoms daily. On physical examination, you find that his vital signs are within normal limits. Auscultation of his lungs reveals mild end expiratory wheezing. Given his persistent symptoms, what change should be made to his current treatment regimen?

A. Add salmeterol twice daily

B. Add montelukast 10mg daily

C. Add fluticasone daily

D. Add formoterol + budesonide twice daily

E. Add tiotropium

Question of the Week # 469

A study is performed to evaluate the incidence of peri-operative stroke during a carotid endarterectomy based on whether the surgeon uses a shunt during the procedure or not. The authors calculate the odds ratio of suffering from stroke if the surgeon uses a shunt is 0.84 (95% CI: 0.72 – 1.12) compared to when the surgeon does not use a shunt. What is the most appropriate interpretation of this finding?
A. Use of shunt decreases risk of stroke by 84%
B. Use of a shunt does not decrease or increase risk of stroke
C. Use of shunt does not decreases the risk of stroke
D. Use of shunt decreases risk of stroke with a 0.84 odds ratio
E. Use of shunt decreases risk of stroke by 16%

USMLE Step 3 – New Format Results released 03/25 – CCS remains critical to pass.

Congratulations to everyone who passed! Results were held over the past 5 months and were just released. We just received over-whelming number of e-mails from our students reporting their scores and pass/ fail status. About 95% of our students have passed and that is very encouraging. This should allay the fears about new Step 3. New format Step 3 has increased representation of bio-statistics, epidemiology, ethics and preventive medicine/ screening guidelines. Number of students were actually quite worried about increased proportion of Bio-statistics questions but it appears like most of them have done really well on that part of the exam. Looking at some of the score reports even those who failed the exam have surprisingly done well on bio-statistics and other multiple choice questions. Failures predominantly happened again because of not placing enough emphasis on CCS preparation and scoring too low on the CCS. Improving on CCS and moving your performance graphs towards the right ( good to excellent performance) may help you pass much easily even when you do just average or slightly below-average on the MCQs. Scoring higher on CCS reduces your burden by easing off the requirement to answer more number of MCQs.

Check our prior analysis on step 3 score reports . This has not changed much on new Step 3. Please check the back portion of the score report of one of the students who failed with 184. Note how this student has failed despite doing fairly well on MCQs including the dreaded Bio-statistics ( Image below)  It goes on to prove CCS can not be neglected and you must score at least above average to do very well on step 3.


Question of the Week # 468

468) An 18-month-old girl is brought to the hospital by her parents because of a high fever and generalized “body shaking” 2 hours ago. The parents say that she was “pretty fussy” all day and her temperature at that time was 37.3 °C (99.2 °F). Over the past few hours, she began to “burn up,” with her temperature spiking to 39.7 °C (103.4 °F). They put her into her crib to go to sleep, and they heard “banging” coming from the baby monitor in their bedroom. When they arrived in her room 10 seconds later, her entire body was “shaking”. It lasted about 2 minutes, and did not recur. She was lethargic and drowsy for 5 minutes after the “shaking”. Nobody in the family has ever had a seizure before. Her temperature is 39.3 °C (102.8 F). Neurologic examination is unremarkable. A chest x-ray shows a left lower lobe consolidation.

A lumbar puncture shows:

Color clear

Glucose 55 mg/ml

Protein 22 mg/ml

Lymphocytes 4/ml

The parents are concerned about the severity of their daughter’s condition and what they can expect in the future. The most appropriate response is which of the following?

A. “Luckily, you got to the hospital in time to avoid complications such as hydrocephalus, hearing loss, speech or developmental delays, and mental retardation.”
B. “Since you do not have a family history of febrile seizures, chances are that she will go on to have idiopathic epilepsy.”
C. “This episode is due to her pulmonary infection, and it will never recur.”
D. “Your daughter will most likely have a complete recovery and there is only a very small chance that she will develop epilepsy.”
E. “Your daughter’s condition is very serious and a full evaluation for epilepsy is indicated at this time.”

Question of the Week # 467

A 32-year-old man comes in regularly because his back hurts. You suspect malingering because he continually requests narcotic pain relievers and imaging studies of his spine. He has come 5 times in the last 6 months with the same problem, typically stating that the pain improves with exercise and leaning forward but is worse at night; pain also occurs at times in his buttocks and does not improve with rest. On physical examination you find no abnormalities of the spine besides inflexibility of the lower spine when he leans forward. Neurological examination is normal, including the absence of pain on a straight-leg raise test. X-ray of the spine and sacroiliac joint is normal. All blood tests including rheumatoid factor, ESR, and C-reactive protein are normal. Today, he again claims to have only minimal improvement with ibuprofen. He is requesting narcotics and a “doctor’s note to get out of work.” What is the next best step in management?
A. MRI of the sacroiliac joint
B. Anti-cyclic citrullinated peptide (anti-CCP)
C. HLA-B27 testing
D. Methotrexate
E. Report to employer for malingering

Question of the Week # 466

466. A 60-year-old woman presents to the office with hoarseness, shortness of breath, cough, and bilateral ear pain for the past 3 days. She has experienced similar, but less severe symptoms in the past week. Her past medical history is significant for moderate arthritis of the knees ankles, and wrists for the past 20 years Vital signs are:
temperature 37 C (98.6 F)
blood pressure 120/90 mm Hg
pulse 82/min
Respirations 12 breaths/min

On physical examination, the external ears are tender to touch with the exception of the lobule of the ear. There is no hearing loss. There is a saddle-nose deformity. The lungs have minimal bibasilar rhonchi. Abdominal examination reveals a normal-size spleen and liver. The ankle and knee joints are tender but not erythematous. Chest x-ray demonstrates focal tracheal narrowing. Which of the following is the most appropriate management for this patient at this time?

A An arthrocentesis of the knee joint
B Order knee and ankle x-rays
C Prescribe corticosteroids
D Prescribe nonsteroidal anti-inflammatory drugs
E Schedule a bronchoscopy

Question of the Week # 465

465) A 6-year-old boy is brought to the emergency department 2 hours after he was bitten by a peer in kindergarten in a fight. The child’s mother is frantic and wants to “sue the center for allowing such behavior!” The child is up-to-date on his vaccinations. The other child is very healthy and his vaccinations are current. On physical examination, there is puncture wound on the right hand. You gently clean the wound and consult with the hand surgeon who says that there does not appear to be any damage to the nerves, muscles, tendons, or joints of the hand. What is the most appropriate next step?

A. close the wound with a suture
B. obtain a wound culture
C. provide ampicillin-sulbactam
D. send him home with a follow-up appointment within 48 hours
E. vigorously irrigate and debride the wound


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