Question of the Week # 450 and #451

450) A 74 year old man with poorly controlled Diabetes Type II presents to your office with complaints of severe right ear pain since yesterday night. The Pain was particularly worse in the night and interfered with his sleep. He took some Advil but pain persisted. He also reports headache on right temporal aspect. On examination, his right external auditory canal is slightly red and swollen and extremely tender to touch. There is some white debris and granulation tissue at the junction of bone and the cartilage. Laboratory studies show normal WBC count with no left shift. Which of the following additional tests is useful in supporting the diagnosis? 

A) Comprehensive metabolic panel

B) Erythrocyte Sedimentation Rate

C) Anti-nuclear antibodies

D) Hemoglobin A1C.

E) Screening nares for MRSA ( Methicillin Resistant Staph. Aureus)

451) What is the most important next step in management?

A) Oral Cephalexin

B) Surgical resection

C) Intravenous Ciprofloxacin

D) Intravenous Ceftriaxone

E) Ciprofloxacin ear drops

Taking the restructured USMLE STEP 3 ? Starting NOVEMBER 2014, Step 3 undergoes some changes!

Archer USMLE Theory Courses have placed huge emphasis on Preventive Medicine, Ethics, Patho-physiology which are going to be tested even more frequently on restructured USMLE Step 3.

Please note USMLE Step 3 CCS will be administered on Day 2 and content , software and format of CCS will remain the same as before!! You may access CCS Workshop at CCS Workshop 

Changes to USMLE 2014 – 2015
As medicine and medical education have changed over the years, so have USMLE examinations evolved since they were first administered in 1992. This is a brief summary of planned changes for the next few years.


What WILL change?

Beginning November 3, 2014, examinees will:

 Be able to take the exam on two consecutive or non-consecutive days;

 NOT need to apply for Step 3 under the eligibility requirements of a specific medical licensing authority;

 See increased numbers of items that assess an expanded range of competency-based content, including foundational science essential for effective healthcare; biostatistics, epidemiology, and population health; literature interpretation; medical ethics; and patient safety. The two exam days will be named Step 3 Foundations of Independent Practice (FIP) and Step 3 Advanced Clinical Medicine (ACM).

What WILL NOT change?

The Step 3 exam will continue to:

 Focus on knowledge and application of the biomedical and clinical sciences necessary for independent patient care;

 Include multiple-choice questions and computer-based case simulations;

 Be administered over two days, for a total time comparable to current testing time;

 Result in a single score (with graphical performance profile information) and a single pass/fail outcome after completion of both examination days.

 Be administered at Prometric test centers throughout the United States.

Important to Note : ( Taken from USMLE Official website) :

 Applications for the restructured Step 3 examination will be accepted starting on August 4, 2014.

 No Step 3 examinations will be administered during most or all of October 2014.

 Administration of the restructured Step 3 exam will begin on November 3, 2014.

 There will be a score delay following introduction of the restructured Step 3 examination on November 3, 2014. The duration of the score delay will be determined by examinee volume during the early months of exam administration. Based on historic trends, we estimate that scores for Step 3 exams taken on or after November 3, 2014 will be released in April 2015.


Question of the Week # 448 and 449

Q448  ) A 78 year old man presents to emergency room with severe pain in his right lower extremity. Pain began after he stumbled and fell on a sidewalk. He does not report pain anywhere else and did not lose consciousness. No tingling or numbness in either extremity. He reports inability to bear weight because it is extremely painful. His past medical history is significant for coronary artery disease and hypertension. He does report about 8lbs weight-loss in the past 1 month.  On examination, he is afebrile. There is tenderness in the right thigh area. Laboratory investigations reveal Hemoglobin 10.5gm%, Platelet count 110k/ul, Calcium at 10.4 mg/dl ( N = 9.0 to 10.5 mg/dl) , Serum creatinine 2.0 mg/dl, Total protein 4.5 gm/dl, Albumin 2.0gm/dl and Ferritin 200 ng/ml.  Liver function tests including Alkaline phosphatase are within normal limits. Whole body bone scan is negative for any lesions. Serum protein electrophoresis is normal with out any monoclonal spike.

An x-ray of the femur is shown  below :


448) Which of the following is most helpful in diagnosing this condition?

A) Colonoscopy

B) DEXA scan

C) 24 hour urine electrophoresis

D) Vitamin D level

E) Parathyroid hormone level


449) Which of the following is likely to explain the patient’s findings?

A) Metastatic colon cancer

B) Multiple Myeloma

C) Osteoporosis

D) Secondary Hyperparathyroidism

E) Metastatic Prostate cancer

Question of the Week # 447

447) A 54 year old caucasian man is seen in your office for initial visit examination. He recently moved from Texas to your town and would like to establish care with you. He has no significant past medical problems except for Gastro-Esophageal Reflux Disease for twenty years. He previously suffered hearburn symptoms that were controlled with over the counter ranitidine . Later, his symptoms became refractory and he was started on omeprazole by his previous physician. He currently takes 20 mg of Omeprazole and is very happy that he has been asymptomatic for the past 1 year.  He has had colonoscopy 2 years ago and this was normal. His father died of Colon cancer at the age of 70. He does not smoke.

Which of the following is the most appropriate action at this time ?

A) Instruct him to continue Omeprazole and follow up in 1 year.

B) Refer to gastroenterology for Upper Endoscopy

C) 24 hour Esophageal pH monitoring

D) Stool Guaic test and Flexible Sigmoidoscopy

E) Stool test for H.Pylori antigen

Question of the Week # 446

446) A 64 year old woman presents to your office with productive cough and fever for the past three days. About two months ago, she was admitted for pneumonia. Past medical history is significant for Rheumatoid arthritis. Her medications include hydroxychloroquine and prednisone. Previously, she was treated with Azathiprine for about 6 years.

On examination, temperature is 101F, blood pressure 120/80 and heart rate of 106/min.  Chest examination reveals decreased breath sounds at left lower lobe. No hepatomegaly, spleen tip is palpable. Chest X-Ray reveals left lower lobe consolidation  Labs reveal WBC 1000/µl with differential count showing neutrophils of 30% and Hemoglobin 9.9 gm%

Which of the following is the most likely explanation for the patient’s presentation?

A) Hypogammaglobulinemia from Rheumatoid arthritis

B) Marrow suppression by Hydroxychloroquine

C) Marrow toxicity by Azathiprine

D) Myeloproliferative disorder

E) Felty Syndrome

Question of the Week # 445

445) A 45 year old african-american man presents to the emergency room with altered mental status. His past medical history is significant for skin nodules. One of the nodule was recently biopsied and it revealed non-caseating granuloma. On examination, his oral mucosae are dry.  Blood pressure is 90/60 . Skin examination  reveals multiple scattered skin nodules about 1 to 2cm in diameter. Chest X-ray reveals bilateral hilar adenopathy.   Laboratory Studies reveal

WBC 5400/µl

HGB: 11.8 gm%,

Platelets : 300k/µl

Calcium 14.2gm%

Creatinine 3.2mg%

Phosphorous 2.2mg%

He is started on agressive intravenous hydration. In addition to the above  measures, you should also proceed with  intervention directed to towards which of the following at this time ?

A) Reducing serum phosphorous

B) Reducing serum parathyroid hormone

C) Reducing Blood Calcitrol level

D) Promoting loop diuresis

E) Direct removal of calcium by Hemodialysis

Question of the week # 444

444) A 25 year old woman is seen by you today due to an abnormal blood count. Three weeks ago, she volunteered for blood donation and a complete blood count that was drawn at that time showed abnormal values. She has regular menstrual periods with normal flow. Her last menstrual period was one week ago.  Her previous blood count was done several years ago and she is unaware of being told they were abnormal. A complete blood count is as follows :

WBC 550/µl

HGB: 12.1 gm%

MCV 84 fl

Platelets : 800k/µl ( Normal 140k to 340k/ul)

Differential count : Neutrophils : 64% Lymphocytes 30% Monocytes 4%

Which of the following is the most important next step?

A) Obtain Bone Marrow Biopsy

B) Order Transferrin Saturation

C) Obtain Jak-2 Mutation Analysis

D) Obtain Arterial Blood Gases

E) Start her on Aspirin


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