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

Archer Step 1 Qbank interface


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Archer USMLE Step 3 CCS Live Webinar – January 2018

Live Workshop/ Webinar date: JANUARY 27TH 2018

Regsiter at

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!

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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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