Question of the week # 480

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

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.

High-yield Archer Question bank and lectures now available at


Question of the Week # 461

Q461) A clinical trial is evaluating an investigational new drug (Drug A) as compared with standard therapy (Drug B) in patients presenting to the emergency department with myocardial infarction (MI). The study enrolled a total of 3,000 subjects, 1,500 in each study arm. Follow-up was conducted at 45 days post-MI. The following are the results of the trial:

Endpoints Drug A Drug B P-Value

·         Death from cardiovascular causes

134 210 0.03

·         Hyperkalemia

57 70 0.4

What is the relative risk of death from cardiovascular cause? (Round to the nearest whole number)

A. 36%
B. 42%
C. 57%
D. 64%
E. 72%

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

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