USMLE Step 3 Question of the Week #495

495.  A 49-year-old obese female presents with abdominal pain.  Patient states the pain acutely onset several hours ago and describes it as constant, severe, localized around the umbilicus and radiating to her back.  She says the pain feels better if she is sitting up and bending slightly forward.   Patient also says she feels nauseous and vomited once after the pain began.  No relevant past medical or surgical history.  No current medications or allergies.  Review of systems is significant for several recent episodes of abdominal pain after eating.

On exam, the patient is in distress, sitting upright, and leaning slightly forward.  Vitals are temperature 38.3 °C (101.1 °F), blood pressure 110/78 mm Hg, pulse 105/min, respirations 25/min, and oxygen saturation 98% on room air.  Cardiac exam is normal.  Lungs are clear to auscultation.  Abdominal exam reveals tenderness to palpation in the periumbilical region.  Bowel sounds are diminished.

Laboratory values are:

Sodium                                                            140 mEq/L

Potassium                                                        4.0 mEqL

Chloride                                                          100 mEq/L

Bicarbonate                                                    25 mEq/L

BUN                                                                 35 mg/dL

Creatinine                                                       1.1 g mg/dL

Glucose (fasting)                                             90 mg/dL

Calcium                                                           7.0 mg/dL

Phosphorous                                                    4.1 mg/dL

Bilirubin, conjugated                                      1.5 mg/dL

Bilirubin, total                                                 3.0 mg/dL

AST (SGOT)                                                      325 mU/mL

ALT (SGPT)                                                      175 mU/mL

Alkaline Phosphatase                                      295 U/L

Amylase                                                          250 U/L

Lipase                                                              89 U/L

TSH                                                                  1.1 mIU/L

PTH                                                                  30 pg/mL

Troponin I (cTnI)                                             <0.02 ng/mL

Lactate Deydrogenase (LDH)                          750 U/L

C-reactive protein                                           45 mg/L

b-hCG                                                              <1 mIU/mL


WBC                                                                19,000 / mm3

RBC                                                                 4 x 106/mm3

Hematocrit                                                      45%

Hemoglobin                                                    13.0 g/dL

Platelet Count                                                 275,000 / mm3


Neutrophils (%)                                               85

Lymphocytes (%)                                             10

Monocytes (%)                                                5

Eosinophils (%)                                                3.5

Basophils (%)                                                   1.5

Chest and KUB x-rays, and EKG are unremarkable.

Aggressive fluid resuscitation and supplemental 100% oxygen are given.  Meperidine 150 mg intramuscularly is administered.  Abdominal ultrasound reveals the presence of a gallstone in the common bile duct (CBD).  Patient is kept NPO.

What is the next best step in management?

A. Contrast CT of the abdomen

B. Endoscopic retrograde cholangiopancreatography (ERCP)

C. Administer meropenem 1 g IV every 8 hours

D. Laparoscopic cholecystectomy

E. Magnetic resonance cholangiopancreatography (MRCP)


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USMLE Step 3 Question of the Week #494

494.  A 45 year old man with a 20-year history of tobacco use presents to the emergency department after having repeated episodes of sharp, stabbing substernal pain with a dry, hacking cough over the last 2-3 days. The episodes last between 5-10 seconds. He first noticed them several days ago.They were not brought on by exertion and they did not improve with rest. He denies fever, shortness of breath, or tachypnea otherwise. He denies any recent sick contacts. The patient’s temperature is 99.2, heart rate is 72, blood pressure is 143/77. Cardiac exam reveals reveals regular rate and rhythm. There are no murmurs, rubs, or gallops. There are scant crackles throughout the lung fields. Laboratory findings are shown below:

WBC (x 10^3 cells/mL): 10.2
Hemoglobin (g/dL): 13.8
Hematocrit (%): 43.4
RBC (x 10^6/mL): 4.9
RDW (%): 13.2
MCV (fL/cell): 97
MCH (pg/cell): 31
MCHC (%): 36
Platelets (x 10^3): 310

Sodium (mEq/L): 141
Potassium (mEq/L): 4.2
Chloride (mEq/L): 105
Bicarbonate (mEq/L): 19
Creatinine (mg/dL): 1.1
Blood Urea Nitrogen (mg/dL): 23
Glucose, fasting (mg/dl): 78
Calcium (g/dL): 9.3
Calcium, ionized (mEq/L): 2.3

What is the best next diagnostic step?

A. Respiratory viral panel


C. Echocardiogram

D. Troponins



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USMLE Step3 Question of the Week #493

#493. A 77-year-old male is brought into the Emergency Department after the staff at his nursing home witnessed a syncopal event. Once a week a barber comes to the nursing home to provide haircuts and shaving services. After the barber raised the head of the patient’s bed and started to shave his neck, the patient suddenly lost consciousness. The barber called for help, and the patient was regaining consciousness by the time staff arrived. Within a few minutes the patient was at his baseline mental status and did not lose control of his bladder or bowels or bite his tongue during the episode. The barber didn’t notice any abnormal movements by the patient but reports he was trying a new “natural” shaving foam this morning. The patient has a history of Parkinson’s disease and hypertension. He does not smoke or drink alcohol. Blood pressure is 124/84 mm Hg and heart rate is 92 beats/minute sitting and 128/82 mm Hg and 88 beats/minute after standing two minutes. What would be the next best step in management?

A. Immediate referral for permanent pacemaker

B. Carbamazepine

C. Referral to an Electrophysiologist

D. Carotid endarterectomy

E. Reassurance, education and clinical follow-up


USMLE Step3 Question of the Week #492

#492.  A 37-year-old woman with a history of bulimia nervosa presents with chest pain. Patient describes it as a sharp pain, localized to the middle of the chest, and occurred acutely last night after vomiting.  Current medications are fluoxetine 60 mg orally daily and a daily multivitamin.

On physical exam, patient appears ill and diaphoretic.  Vital signs show temperature of 37 °C (98.6 °F), blood pressure of 135/85 mm Hg, pulse of 90 /min, respiratory rate of 30 / min, and oxygen saturation of 98% on room air.  Oropharynx is erythematous, dentition is poor and back molars show significant erosion.  There is dullness to percussion and diminished breath sounds over the lower lobe of the left lung.  Remainder of the physical exam is normal.   EKG and laboratory tests are normal.  Chest x-ray shows a small left pleural effusion and evidence of pneumomediastinum.

Which of the following is the definitive diagnostic step in this patient?

A. Esophagogastroduodenoscopy

B. Barium swallow study

C. Helical CT of the chest without contrast

D. Gastrografin swallow study

E. Thoracentesis



USMLE Step 3 Question of the Week #491

#491.  A 65-year-old African-American male with a long-standing history of coronary artery disease and hypertension presents with shortness of breath and fatigue.  Patient says he feels fatigued throughout the day and that he can no longer walk across the room without being short of breath.  Patient states that symptoms onset a couple days ago and have steadily worsened.

Vitals are temperature 37 °C (98.6 °F), blood pressure 165/82 mm Hg, pulse 100/min, respirations 18/min, and oxygen saturation 97% on room air.  On physical exam, patient appears alert and in no apparent distress.  Cardiac exam reveals a load P2 and an S3 gallop.  Pulses are regular but have alternating strong and weak beats.  Mean jugular venous pressure is 12 cm H20.  Pulmonary exam reveals crackles in the lower lung fields bilaterally.  Extremities are cool to the touch and there is 2+ pitting edema bilaterally.

Laboratory tests show:

Sodium                                               120 mEq/L

Potassium                                           4.0 mEqL

Chloride                                               100 mEq/L

Bicarbonate                                         25 mEq/L

BUN                                                     45 mg/dL

Creatinine                                           1.0 g mg/dL

Glucose (fasting)                                90 mg/dL

Magnesium                                         1.7 mg/dL

Calcium                                               9.0 mg/dL

Phosphorous                                       4.1 mg/dL

Bilirubin, conjugated                           0.2 mg/dL

Bilirubin, total                                     1.0 mg/dL

AST (SGOT)                                          20 mU/mL

ALT (SGPT)                                          15 mU/mL

Alkaline Phosphatase                         80 U/L

WBC                                                    7000 / mm3

RBC                                                     5 x 106/mm3

Hematocrit                                          45%

Hemoglobin                                         15.0 g/dL

Platelet Count                                     250,000 / mm3

BNP                                                     750 pg/mL

NT-proBNP                                          1250 pg/mL

Troponin T (cTnT)                                0.05 ng/mL

Troponin I (cTnI)                                  0.03 ng/mL

Chest X-ray reveals evidence of pulmonary vascular congestion and pulmonary edema in the lung bases bilaterally.  EKG reveals Q wavs in leads V1 and V2, evidence of left ventricular hypertrophy and a left bundle branch block.  Transthoracic echocardiography reveals a LV ejection fraction of 25%, increased left ventricular wall thickness, moderate left atrial enlargement, and evidence of left anterior wall dyskinesis consistent with an old anterior wall myocardial infarction.

Patient is admitted to CCU and started on high flow 100% oxygen by nasal canula.  Carvedilol 25 mg orally twice daily, captopril 25 mg orally three times daily, furosemide 100 mg orally, and eplerenone 25 mg orally daily are initiated.

Which of the following is the next best step in management of this patient

A. Administer 1 L NS bolus and then NS + 20 mEq/L KCL IV at 115 mL/h

B. Initiate hydralazine 35 mg orally 3 times daily and isosorbide dinitrate 20 mg orally 3 times daily.

C. Restrict sodium intake to 5 g/day

D. Initiate digoxin 4 mcg/kg orally daily

E. Initiate diltiazem 150 mg orally daily



USMLE Step 1 Question of the Week #2

A 65-year-old male patient is brought to the emergency department by his relatives for sudden onset of shortness of breath. He was recently diagnosed with bronchogenic carcinoma of the small cell variety. He had come in with a history of coughing up blood on several occasions with a persistent cough. He had been smoking two packs of cigarettes a day for the last 20 years. Today he also complains of occasional headaches and a difficulty in seeing. He complains that these symptoms are more prominent in the morning when he wakes up from sleep. It subsides as the day progresses. Which of the following are the further physical findings the physician is expected to find in this patient?

A. Lower extremity edema along with distention of the superficial veins of the abdomen.

B. Edema and a purplish hue in the upper extremities, extending to the head.

C. Low blood pressure and a weak pulse, with extended jugular veins.

D. Breathing produces paradoxical movements in the chest.

E. Swelling of the feet with an increased shortness of breath as the patient lies down.

USMLE Step 1 Question of the week #1

Saturday challenge! Answer this  question. Here is how a typical Archer Step 1 Qbank interface looks, simulates USMLE Step 1 exam exactly. Try more at

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Archer USMLE Step 3 CCS Live Webinar – January 2018

Live Workshop/ Webinar date: JANUARY 27TH 2018

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Interactive practice of USMLE Step3 CCS Cases.

The most time efficient strategy to pass USMLE Step 3! A component of Archer Live USMLE Reviews. Schedule ( Starts at 10 AM CDT i.e; 11 AM EST)

10 AM to 10:15 AM – Intro on the Webinar functions

10:15 AM to 12:15 PM – Recognizing Unstable vitals. – General approach to ER cases– Real time vs. Simulated time – Strategies to keep Simulated time low (ER) – Demonstration of high scoring strategies

12:15 pm to 12:30 pm – Q and A session

12:30 PM to 1:30 PM – Office case manAgement principles – General approach to office cases – Indications for admisiion – Scheduling follow up tests – Navigating the clock with ease to score more. – Demonstration of office cases

1:30 PM to 2:30 PM – Q and A session

2:30 PM to 4:00 PM – Lunch break

4:00 PM to 5:30 PM – Practice of very High Yield cases with one on one Q and A sessions

5:30 PM to 5:45 PM – Break

5:45 PM to 7:45 PM – Practice of Very Highyield CCS cases

7:45 PM to 8:00 PM – Break

8:00 PM to 9:00 PM – Case Practice, discussion and wrap-up!

Can’t make it to the Webinar ? Have exam before next live session? :   PPV recordings of most high-yield CCS workshops are readily available at  Price: $88 and you may access those 24/7.

Interpreting Mixing studies – Hematology HigYield

via Interpreting Mixing Studies – Hematology Highyield Concept I

Interpreting Mixing Studies – Hematology Highyield Concept I


Archer USMLE Step 3 Blog

Approaching Prolonged PTT and understanding Mixing Studies : 


Question :  On a mixing study, the PTT corrects initially but gets prolonged again after incubation for 2 hours. What is this condition?

This description of mixing studies is consistent with presence of a temperature- and time-dependent anti-VIII inhibitor. It just means that the inhibitor is a warm reacting IgG antibody that requires one or two hour’s incubation at 37°C to be detected. If the PTT corrects initially but prolongs again after incubation (meaning if thePTT is at least 15% longer than the normal reagent plasma’s incubated PTT ) –> anti-VIII should be suspected. This can be confirmed by obtaining a Factor VIII level which will be low in case of presence of inhibitor. Further coinfirmation of Factor VIII inhibitor can be obtained by Bethesda Titer. In such cases, you should also carefully review patient’s prior bleeding history –…

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Question of the Week #490

490. An 18-year-old male presents to the Emergency Department for evaluation of chest pressure for an hour. The pain is radiating to his jaw. On examination, he is diaphoretic, and he complains of nausea. Past medical history is unremarkable. Urine reveals positive benzolegonine. Below is his ECG. What is the most likely cause of the patient’s symptoms?


A. Early repolarization

B. Ischemia

C. Cocaine induced myocardial infarction

D. Atrial fibrillation

E. Wolf-Parkinson-White Syndrome

Question of the Week #489

A 35 Year old woman presents for evaluation of recurrent headaches for the past few months.  Lately, she has been waking up with a headache almost daily though it tends to improve in the latter half of the day. She is frustrated as she can not even get some sleep during the attack since lying down makes her feel worse . She has associated nausea. She has transient attacks of light flashes  that resolve spontaneously. Her menstrual history is unremarkable. On physical examination, she has no neurological deficits. Funduscopic examination shown below: QBANK INSTA AD

Which of the following information, if elicited in the patient history, would increase the clinical suspicion of the diagnosis?

A)     Constipation

B)     Family history

C)      Recent weight gain

D)      Galactorrhea

E)   Urinary Incontinence

Question of the week # 488

A 31 Year old woman diagnosed with suspected diagnosis of Idiopathic intracranial hypertension underwent a lumbar puncture for diagnostic purposes. An MRI of the brain that was obtained prior to lumbar puncture did not reveal any structural abnormalities or mass effect. Laboratory investigations including coagulation parameters were normal. About 12 hours after the procedure, the patient complains of moderate to severe headache. Headache is mainly in the occipital region which increases while sitting up and improves on lying flat. She has two episodes of vomiting in the last one hour. She also complains of dizziness and ringing sensation in her ears.  Physical examination does not reveal any papilledema or focal neurological deficits.

Most appropriate next step in managing this patient?

A) Blood cultures

B) MRI of the Lumbar Spine

C) Non-Contrast CT scan of brain

D) Observation

E) Acetazolamide

USMLE Step 3 Question #487

487) 57-year-old male with a history of mild COPD has been using albuterol as needed to manage his COPD without any other maintenance medications. Recently he has been experiencing a greater degree of shortness of breath, wheezing and a productive cough. Pulmonary function tests demonstrate a FEV1 that is 60% of predicted. What is the next best step for management of his COPD?

A. Add budesonide to treatment regimen

B. Add rofilumast to treatment regimen

C. Add tiotropium to treatment regimen

D. Add tiotropium plus fluticasone to treatment regimen

E. Add carbocystine to treatment regimen


USMLE STep 3 Question #486

A 56-year-old male with Type II diabetes presents to you today for a follow-up visit. Three months prior his A1c was 8.9% and he was started on metformin. Today his A1c is 7.4%. He is significantly overweight with a BMI of 33. You would like to initiate another medication for glucose control, specifically one that does not carry a risk of weight gain. Which of the following drugs is weight neutral?

  • A.  Glimepride
  • B. Rosiglitazone
  • C.  Pioglitazone
  • D. Sitagliptin
  • E. Glyburide

USMLE Step 2CK Question #1

A 48-year-old homeless man presenting with severe abdominal pain. He has been hospitalized 6 times in the past year for similar complaints. Hospital records indicate multiple admissions with alcohol intoxication. The pain radiates to his back, and is accompanied by nausea and vomiting. The patient has a temperature of 103F, but does not permit an abdominal exam. Laboratory analysis indicates elevated gamma glutamyl transpeptidase and an AST/ALT ratio > 2. What is the most likely diagnosis?

A – Cholecystitis

B – Pancreatitis

C – Choledocholithiasis

D – Duodenal peptic ulcer

E – Gallbladder cancer

Question of the Week #485

485. A 10-year-old female presents with a 3 week history of cough.  Initially she had a runny nose and was tired with a slight cough but as the runny nose resolved the cough seemed to get worse.  She states that the cough is dry sounding and occurs during the day and night.  She describes having coughing spasms that occasionally end in vomiting but between episodes of coughing she is fine.  Her mom reports that during a coughing spasm she will gasp for air and sometimes make a “whooping” noise.  A nasopharyngeal swab confirms a diagnosis of Bordatella pertussis.  Which of the following is true?

A. Her 3-month-old brother should be treated with azithromycin as prophylaxis

B. She should be started on azithromycin for more rapid resolution of cough.

C. Her classmates should be treated with clarithromycin as prophylaxis

D. She will have lifelong natural immunity against Bordatella pertussis.

E. Her classmates should receive a Tdap booster regardless of their vaccination status

Question of the Week #484

A 50-year-old African american woman presents to your clinic with increased thirst and increased urination. You review her old records and it appears like she had a Chest X-ray in the ER last year that showed bilateral hilar lymphadenopathy. She was advised follow-up but she did not comply at that time. Upon examination, you discover some subcutaneous skin nodules and biopsy of one of these comes back positive for non-caseating granulomas.

Laboratory studies from a week ago show:

Hemoglobin 15.2gm%

Calcium : 11.6mg%

Creatinine : 1.0mg%

Which of the following investigations may explain the underlying mechanism of her Hypercalcemia?

A. Biopsy of Hilar Lymph Node

B. 25 Hydroxy Vitamin D Level

C. PTH related peptides

D. 1,25 di-hydroxy Vitamin D level

E. Serum Protein Electrophoresis

Question of the Week# 483

A 50-year-old previously healthy man comes to his physician for a scheduled follow-up examination. He works as an electrician, which involves a significant amount of physical activity when working. He says he also runs 5 miles twice a week and is on a low-fat, low-cholesterol diet. His father died of a ‘heart attack’ at the age of 54, and he has smoked one pack of cigarettes daily for the past 25 years. He denies alcohol or illicit drug use. He says he leads a low-stress lifestyle and has no complaints. His current medication include lisinopril. On presentation, his blood pressure is 135/85 mm Hg. Laboratory studies from a week ago show:

Total cholesterol     287 mg/dL

HDL                        65 mg/dL

LDL                        180 mg/dL

Which of the following is the best next step in patient care?

A Initiate drug therapy for control of his hyperlipidemia
B Educate the patient about diet and exercise and repeat the tests within 4 weeks
C Educate the patient about diet and exercise and repeat the tests within a year
D Initiate a mandatory low-fat diet for the patient
E No intervention is indicated


Question of the Week #482

A 63-year-old woman comes to the emergency department complaining of severe midabdominal pain. She reports that the pain has increased in intensity over the past few days. There has been no associated nausea or vomiting, no change in bowel habits, and no relief afforded by position changes. She is postmenopausal and does not take hormone replacement therapy. She has a 30-year history of hypertension, and has been noncompliant with her therapy of calcium channel blocker and thiazide diuretic. On examination her abdomen is obese but there is a suggestion of a nontender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following is the best next step in management?

A. Abdominal ultrasound
B. Abdominal CT scan without contrast
C. Abdominal CT scan with contrast
D. Angiography
E. Observation

Question of the Week #483


Beta-blockers reduce mortality in patients who have chronic heart failure, systolic dysfunction, and are on background treatment with diuretics and angiotensin-converting enzyme inhibitors. We aimed to compare the effects of carvedilol and metoprolol on clinical outcome.


In a multicenter, double blind, and randomized parallel group trial, we assigned 1511 patients with chronic heart failure to treatment with carvedilol (target dose 25 mg twice daily) and 1518 to metoprolol (metoprolol tartrate, target dose 50 mg twice daily). Patients were required to have chronic heart failure (NYHA II-IV), previous admission for a cardiovascular reason, an ejection fraction of less than 0.35, and to have been treated optimally with diuretics and angiotensin-converting enzyme inhibitors unless not tolerated. The primary endpoints were all-cause mortality and the composite endpoint of all-cause mortality or all-cause admission. Analysis was done by intention to treat.


The mean study duration was 58 months (SD 6). The mean ejection fraction was 0.26 (0.07) and the mean age 62 years (11). The all-cause mortality was 34% (512 of 1511) for carvedilol and 40% (600 of 1518) for metoprolol (hazard ratio 0.83 [95% CI 0.74-0.93], p=0.0017). The reduction of all-cause mortality was consistent across predefined subgroups. Incidence of side effects and drug withdrawals did not differ by much between the two study groups.


  1. To which of the following patients are the results of this clinical trial applicable?
    1. A 62-year-old male with primarily diastolic congestive heart failure.
    2. A 75-year-old female with systolic dysfunction and an EF of 45%.
    3. A 56-year-old male with NYHA class I systolic heart failure.
    4. A newly diagnosed 66-year-old male who has yet to begin treatment for his NYHA class II systolic heart failure.
    5. A 68-year-old male with NYHA class II systolic heart failure and EF 30%.


Question of the Week #482



Aldosterone blockade reduces mortality and morbidity among patients with severe heart failure. We conducted a double blind, placebo-controlled study evaluating the effect of eplerenone, a selective aldosterone blocker, on morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure.


Patients were randomly assigned to eplerenone (25 mg per day initially, titrated to a maximum of 50 mg per day; 3319 patients) or placebo (3313 patients) in addition to optimal medical therapy. The study continued until 1012 deaths occurred. The primary end points were death from any cause and death from cardiovascular causes or hospitalization for heart failure, acute myocardial infarction, stroke, or ventricular arrhythmia.


During a mean follow-up of 16 months, there were 478 deaths in the eplerenone group and 554 deaths in the placebo group (relative risk, 0.85; 95 percent confidence interval, 0.75 to 0.96; P=0.008). Of these deaths, 407 in the eplerenone group and 483 in the placebo group were attributed to cardiovascular causes (relative risk, 0.83; 95 percent confidence interval, 0.72 to 0.94; P=0.005). The rate of the other primary end point, death from cardiovascular causes or hospitalization for cardiovascular events, was reduced by eplerenone (relative risk, 0.87; 95 percent confidence interval, 0.79 to 0.95; P=0.002), as was the secondary end point of death from any cause or any hospitalization (relative risk, 0.92; 95 percent confidence interval, 0.86 to 0.98; P=0.02). There was also a reduction in the rate of sudden death from cardiac causes (relative risk, 0.79; 95 percent confidence interval, 0.64 to 0.97; P=0.03). The rate of serious hyperkalemia was 5.5 percent in the eplerenone group and 3.9 percent in the placebo group (P=0.002), whereas the rate of hypokalemia was 8.4 percent in the eplerenone group and 13.1 percent in the placebo group (P<0.001).

  1. Which of the following statements represents the most accurate interpretation of the results from the aforementioned clinical trial?
    1. There was no significant difference in the incidence of hyperkalemia between trial arms.
    2. There was no significant difference in the rate of sudden cardiac death between trial arms.
    3. Epleranone, when added to optimal medical therapy, decreases all cause mortality in patients with left ventricular dysfunction following myocardial infarction.
    4. The rate of hypokalemia was not significantly different between trial arms.
    5. The most common causes of death seen in enrolled patients over the course of this trial were non-cardiac in nature.

Question of the Week #481

A 90 year old man with history of advanced dementia is brought to hospital with aspiration pneumonia. This is his 5th episode of Aspiration pneumonia in the past 1 year. He is accompanied by his daughter who also happens to be his healthcare proxy. She wants to focus on her father’s comfort as the goal of care and requests no further diagnostic interventions and she would like to avoid further hospitalizations. She wants to know what would make him eligible to receive hospice care. Based on which of the following factors, can he be qualified for hospice?

A. His advanced age

B. Diagnosis of advanced dementia

C. Prognosis

D. His wishes to die at home

News from USMLE :

USMLE Step 3 Change in number of items and score delay

Beginning the week of January 18, 2016, the number of items on the Step 3 examination will decrease. There will be a delay in reporting scores for exams administered between January 18 and April 30, 2016. The target date for reporting Step 3 scores for most examinees testing during this time period is May 25, 2016.

Although this change will occur quickly at many test centers, there may be some locations where the transition takes longer to complete. The overall transition period should last approximately six weeks. Please note that:

  • The length of the testing days will not change.
  • Day 1 (Foundations of Independent Practice [FIP]) will continue to be an approximately 7-hour testing session, including time for breaks and tutorials.
  • Day 2 (Advanced Clinical Medicine [ACM]) will continue to be a 9-hour testing session, including time for breaks and tutorials.
  • Day 1 (FIP) will continue to be divided into six 60-minute blocks.
  • Each FIP block will have 38 to 40 multiple-choice questions (MCQs).
  • The total number of MCQs on the FIP portion of the examination will be 233.
  • Day 2 (ACM) will continue to be divided into six 45-minute blocks of MCQs, and 13 computer-based case simulations (CCS).
  • Each ACM MCQ block will have 30 items.
  • The total number of MCQ items on the ACM portion of the examination will be 180.
  • Scores on examination forms taken before and after the change – as well as scores on forms with different numbers of items – will be comparable; the possible variation in the number of items per form will be accounted for in scoring the examination.

Score reports for Step 3 are usually available within four weeks of testing. However, because of the change described above, as well as routine modifications to the test item pool, score reporting for most Step 3 examinations administered from January 18, 2016 through April 30, 2016 will take longer. As noted above, the target date for reporting Step 3 scores for most examinees testing during this time period is May 25, 2016.

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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

Question of the Week # 479

479. A 57 year old female presents for second opinion of a left breast lesion that had been diagnosed as ‘eczema’ by her regular nurse practitioner, which briefly improved after a short course of topical steroids. On physical exam there is an erythematous, scaly lesion involving the left breast. Image is shown below. Her last mammogram was a year ago and it was “fine”. She does not report any family history of breast cancer. What is the next step in the patient’s management?

image br rash

A – Bilateral breast ultrasound

B – Bilateral mammography and punch biopsy of nipple

C – Maintain regular annual mammography appointment

D – Oral corticosteroids

E – Left breast MRI

Question of the Week # 478

478) You are evaluating a 24-year-old female patient who presented with severe abdominal pain two hours prior to admission. She states the pain began in the periumbilical region and has moved to the low abdomen, and she had one episode of emesis with nausea, but no diarrhea. Her last menstrual period was normal and began 27 days ago. On examination, she has a temperature of 98.9, heart rate of 118 beats per minute, and respirations 20/min. Her blood pressure is 100/80. Examination of the abdomen reveals diffuse tenderness to palpation, and she is guarding moderately and has diminished bowel sounds. Complete blood count reveals a hemoglobin of 12 g/dL and a hematocrit of 38%. White blood cell count is 12,500/mm3 with a left shift. Urinalysis reveals 2-5 WBC/hpf. Which of the following is the next best step in management of this patient?

A. Flat and upright abdominal film

B. Pelvic ultrasound

C. Urine b HCG

D. CT abdomen and pelvis

E. Serum beta HCG

Question of the Week # 477

477) A 39-year-old woman presents to clinic with a history of long-standing right leg pain. She complains of “achy” pain at the hip radiating down her femur to the knee, which is exacerbated on exertion, especially with jogging more so than climbing stairs, but also present during rest. She takes acetaminophen for it, which helps her pain. Her past medical history is significant for systemic lupus erythematosus diagnosed at age of 20, for which she has been taking on and off oral prednisone. She does not smoke cigarettes but he drinks alcohol 2 or 3 times per week. She denies any drug use. Physical examination is significant for limited range of motion of the right hip, especially with external rotation. A plain x-ray shows a dulling of the femoral head but no other pathology. What is the next step in diagnosis?
A. Bone scan
B. CT scan
C. MRI scan
D. PET scan
E. Ultrasound

Question of the Week # 476

476. You are evaluating a 12 month old male patient for rhinorrhea and poor appetite. He is friendly and alert. His temperature today is 103.6 degrees Fahrenheit, and his examination is significant for clear nasal discharge and multiple small vesicles on the anterior tonsillar pillars and posterior palate. His examination is otherwise normal. He is accompanied by his mother who seems to be very concerned. The patient has been feeding well and all his developmental milestones have been timely so far. A complete blood count is normal.  Which of the following is his most likely diagnosis?

12 month old male patient for rhinorrhea and poor appetite, temperature 103.6 F.

12 month old male patient for rhinorrhea and poor appetite, temperature 103.6 F.

A. Hand, foot, and mouth disease

B. Apthous stomatitis

C. Herpangina

D. Stevens-Johnson syndrome

E. Kawasaki disease

Question of the Week # 475

A 2-week-old infant is brought to the office for a regular postnatal follow-up. She was born after an uneventful term pregnancy to a 29-year-old G2P2 woman. Mother reports that the infant is feeding well and seems active. No evidence of any fever. The parents are worried about the ‘rash’ that appeared over the infant’s left cheek. On examination, a lesion is noted on the infant’s left cheek as shown below. Vital signs are within normal limits. What is the most appropriate next step in management of this finding?


A Surgical excision of the entire lesion
B Biopsy of the lesion
C Laser removal of the lesion
D Reassurance and observation
E Topical 5-fluoro-uracil

Question of the Week #474

474. A cohort study is done concerning the relationship between exposure to oral contraception and the risk of breast cancer. 1000 women were followed from 2003 to 2007. Results are listed below:

Breast Cancer + Breast Cancer –
Oral contraceptive + 300 (a) 200 (b) a + b = 500

Probability of breast cancer among exposed: 300/500 = 0.6

Oral Contraceptive – 100 © 400 (d) c + d = 500

Probability of breast cancer among those not exposed = 100/500 = 0.2

a + c = 400 b + d = 600

Which of the following represents the absolute risk reduction of breast cancer in women who do not use oral contraceptives?

  1. 75%
  2. 67
  3. 40%
  4. 50%
  5. 30%

Question of the Week # 473

  1. You are reading a study that was conducted to evaluate IQ (intelligence quotient) scores for patients with bipolar disease. Ten patients did not complete the test. Two patients refused to begin the test. Results for the 94 patients who completed the test revealed an average IQ of 130 with a standard deviation of 20. Which of the following best represents the 95% confidence interval for this study?
  1. 4
  2. 2
  3. 1
  4. .05
  5. .1

Question of the Week # 472

A 9-year-old boy is brought to the hospital with a wound to his left hand. He was in a fight with peer who bit him. His past medical history is unremarkable and he takes no medications. He has no known allergies. On examination, the child is crying. There is a 2-cm wound over the dorsum of his palm. What is the most appropriate course of action?
A. Clean the wound and prescribe amoxicillin-clavulanate.
B. Clean the wound and prescribe doxycycline.
C. Clean the wound and prescribe ciprofloxacin.
D. Clean the wound, close it with interrupted sutures and prescribe ciprofloxacin.
E. Clean the wound, close it with interrupted sutures and prescribe amoxicillin-clavulanate.

Question of the Week # 471

A 14-year-old girl with a history of Crohn’s disease presents with 2-day history of feeling ‘feverish’, malaise, lower abdominal pain and non-bloody diarrhea. She has about 10 episodes of diarrhea daily. She has had three similar episodes in the past 7 years. She denies any recent travel or sick contacts, rush, cough or other symptoms of infection. She has no known allergies and does not take any medications currently. She has been taking 5-ASA, but stopped 6 months ago as she had been asymptomatic for 10 months before that. On presentation, the patient is afebrile with a body temperature of 101.0 F and appears ill. Her blood pressure is 120/80 mmHg and heart rate of 90 beats/minute.  Abdominal examination is remarkable for abdominal tenderness in the lower abdomen, but no rebound or guarding. A subsequent CT scan shows dilatation of the left colonic lumen, as well as a thickened colon wall with pericolic fat stranding, particularly in the left colon. The admitting team determines the patient’s presentation is due to exacerbation of her disease. The patient is started on 5-ASA, metronidazole and prednisone and her condition improves within 10 days when she is symptom-free. What is the most appropriate plan after her symptoms have resolved?

A)     Continue 5-ASA, taper prednisone and discontinue metronidazole
B)      Continue 5-ASA and prednisone, discontinue metronidazole
C)      Discontinue ASA-5 and metronidazole and continue prednisone for 4 weeks, followed by taper
D)     Recommend therapy with infliximab an instruct to take 5-ASA when she starts experiencing symptoms, discontinue prednisone and metronidazole
E)      Continue 5-ASA and metronidazole for at least 4 weeks, taper prednisone

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%

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

Question of the Week # 464

464) A 68 year old man with history of Diabetes Mellitus type II and diabetic gastroparesis  is evaluated in your office for lack of appetite, nausea, vomiting, weight loss and a feeling full after eating small amounts of food material. He has lost 10 lbs weight in past 2 months. He denies any rectal bleeding or melena. He does report some epigastric discomfort. On examination, he appears in no distress, blood pressure is at 120/80. Abdomen is mildly distended with slight tenderness in upper abdomen. Patient is admitted and started on IV hydration. A plain X-ray abdomen is shown below. Gastroenterology is consulted and an upper endoscopy is pending. What is the most appropriate evidence-based next step?


A) Arrange for Laparoscopy
B) Endoscopic removal
C) Give Coca-Cola
D) Give Pepsi or any other soda
E) Metoclopramide

Question of the Week # 463

463) A 48 year old woman presents to the emergency room with significant pain in the epi-gastrium and right upper quadrant. The pain has been persistent for the past 8 hours. She rates her pain at 8/10 in intensity. She reports some nausea but has not vomited. She has no jaundice. She denies any cough or burning urination or hematuria. On examination, she is obese, temperature is 99.9 F, blood pressure is at 120/80. She does not have any pallor or icterus. She lies still on the examination table since any movement aggravates her pain. She demands pain medication before you can examine her. An ultrasound of the abdomen is pending. What is the most appropriate next step?

A) Tell her that physical exam is done before analgesics since analgesia may obscure the diagnosis.
B) Give her morphine sulfate
C) Give her Meperidine
D) Obtain Urine drug screen
E) Tell her that you will not treat her pain without doing physical exam first

Question of the Week # 462

462) A 39 year old man is seen in your office for swelling of the abdomen and shortness of breath of several months’ duration. He is an active smoker and smoked about 1 pack per day for 20 years. He drinks alcohol occasionally. He denies any cough or fever. On examination, he is afebrile with a temperature of 98.1F , respiratory rate of 18/min, pulse 88/min and blood pressure at 120/70 mm Hg. Cardiac examination reveals regular heart sounds and no S3 gallop. Chest examination shows decreased breath sounds, increased antero-posterior diameter and hyper-resonance to percussion.  Abdominal exam is significant for fluid wave and shifting dullness. Liver is enlarged. No splenomegaly.

Labs reveal :

Hemoglobin : 14.2gm%

Serum creatinine 1.0mg%

Albumin 3.2gm%

Total bilirubin 1.0 mg%

Alkaline phosphatase 90 U/L

AST ( Aspartate aminotransferase) 160 U/L

ALT (Alanine aminotransferase) 190 U/L

Which of the following is most helpful in establishing the diagnosis

A. Serum Ferritin

B. Serum Ceruloplasmin leve

C. Anti-Actin and Smooth muscle antibodies

D. 2D Echocardiogram

E. Serum Alpha-1 anti-trypsin level.

Question of the Week # 460


A 65-year-old woman with a previous medical history of diabetes and rheumatoid arthritis underdoes an exploratory laparotomy for perforated sigmoid diverticulitis. Her postoperative stay is prolonged because of pneumonia, but is extubated on the fifth postoperative day and the next day discharged from the ICU to the floor. You are called by the nurse to check her wound as she noticed a new serous discharge. Her temperature is 37.0 C (98.6 F), pulse 100 beats/min, blood pressure 140/80 mm Hg, and blood glucose by finger stick 240 mg/dl. Abdomen is soft and non-tender. There is no induration, erythema, or crepitus of the wound. Copious amounts of serous brownish liquid are expressed from the wound on gentle pressure. Fluid is expressed spontaneously on coughing from both upper and lower parts of the wound. Which of the following is the most appropriate next step?
A. Start the patient on an insulin drip
B. Stop anticoagulation with subcutaneous heparin
C. Order dry dressings to be continued
D. Prescribe a 1-week course of antibiotics
E. Schedule the patient for wound exploration in the operating room

Question of the Week # 459

459) A 56-year-old man comes to the clinic complaining of postprandial nausea, occasional vomiting, and abdominal pain. Upon further questioning, he describes intermittent diarrhea and cramps, as well as diaphoresis, palpitations, and flushing. Three months ago he underwent resection of the distal stomach and proximal duodenum and gastrointestinal reconstruction due to complicated peptic ulcer disease. Prior to the operation, he had similar abdominal pain but it was usually relieved, not worsened with eating. Vital signs and physical examination are unremarkable. The most appropriate next step in the management of this patient is which of the following?
A. Begin a trial of somatostatin
B. Counsel the patient about his diet
C. Determine the patient’s gastrin level
D. Order a CT scan of the abdomen
E. Schedule a repeat endoscopy

Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration

Question of the Week # 457

A 33 year old gravida 2 para 1 female presents for prenatal care at 35 weeks gestation. She was previously seen at 8 weeks gestation for her only prenatal visit. She has had weight gain of only 21 pounds during her pregnancy, but reports her appetite has been good. She has experienced heat intolerance and fatigue for several months. Her heart rate is 112, blood pressure is 124/86 mm Hg. On examination, she has fullness in her neck and exhibits a fine tremor. You should advise this patient that her child will be at risk for which of the following complications ?

a. Thrombocytopenia
b. Macrocephaly
c. Heart failure
d. Heart block
e. Constipation

Question of the Week # 456

Your patient is a 48-year-old postmenopausal female with recent onset of stage I hypertension.  She has a history of osteoporosis. On exam, her blood pressure is 155/90, heart rate is 80 and regular, and respirations are 16. Cardiovascular examination is unremarkable. She has no other medical history. She has previously been controlling her hypertension with lifestyle modifications and diet. Which of the following medications is the best choice for initial pharmacological treatment of her hypertension?

A. Calcium channel blocker

B. Thiazide diuretics

C. Angiotensin receptor blocker

D. Alpha-adrenergic blocker

E. Angiotensin converting enzyme inhibitor

Question of the Week # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

Question of the Week # 454

Your patient presents at 33 weeks gestation. She is a 27 year old gravida 2 para 1 female with a previous pregnancy complicated by pre-eclampsia, with a vaginal delivery of a healthy infant at 37 weeks. Her current pregnancy has been uncomplicated, but today she is experiencing abdominal pain and uterine contractions that began 5 hours prior to presentation. She states that she has had some fluid leaking from her vagina since the previous evening, but denies vaginal bleeding, trauma, urinary urgency or frequency.

Her temperature is 101.6 degrees Fahrenheit. Blood pressure is 98/60, heart rate is 100/minute, with respirations of 18/minutes. On pelvic examination, she has clear fluid in the posterior fornix, which causes nitrazine paper to turn blue in color. She is dilated to 4 centimeters and her cervix is 60% effaced. Her uterus is diffusely tender on examination and the fetal heart rate is 175 beats per minute, with frequent accelerations. Maternal white blood cell count is 13,000/mm3.

What is the next step in the management of this patient?

A. Initiation of ciprofloxacin

B. Urine culture

C. Initiation of ampicillin and gentamycin

D. Cesarean delivery

E. Induction of labor.

Question of the Week # 453

Your patient is a gravida 1 para 0,  19 year old female at 33 weeks gestation that presents with a complaint of heavy vaginal bleeding and severe abdominal pain for an hour. Her pregnancy has been uneventful, and she is in good health, although she continues to smoke cigarettes, admitting to one pack per day.

Blood pressure is 110/80 with a heart rate of 110. The patient is afebrile, with respirations of 20/minute. Examination reveals a contracted uterus with a closed cervical os. The patient expels a large amount of blood from her closed cervix during the examination. Fetal heart rate monitoring reveals severe late decelerations. What is the best treatment option for this patient?

A. Expectant management with bed resT

B. Terbutaline

C. Oxytocin

D. Magnesium sulfate

E. Caesarean section delivery

Question of the Week # 452

Your patient is a gravida 2 para 2 female with a complaint of a vaginal discharge, vulvar irritation, and dysuria. Her symptoms have recurred 4 times within the past year. She had a recent urinary tract infection that was treated with ciprofloxacin, but is in otherwise good health. She is afebrile with normal vital signs, and pelvic examination reveals vulvar and vaginal erythema with a thick white discharge in the vaginal vault. KOH prep reveals pseudo hyphae. Which of the following treatments is most appropriate for this patient?


a. Oral fluconazole 150 mg x 1
b. Probiotic lactobacilli
c. No treatment is necessary
d. Oral Fluconozole induction followed by maintenance.
e. Topical miconazole x 7 days

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

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

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