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)


Question of the Week # 184

Q184)  A 10 year old boy is evaluated in the emergency room after he tripped over and fell during a basketball game. There is no history of loss of consciousness. He denies any injury except  some pain in the occipital area of the skull.  He also reports chronic fatigue. A routine skull x-ray is obtained for evaluation and is shown below:

Which of the following is most likely to be associated with these incidental skull x-ray findings ?

A) Monoclonal gammopathy

B) Pituitary tumor

C) Hemolysis

D) Paget disease

E) Glioma

Question of the Week # 182

Q182) A 65 year old woman  presents  with a white plaque on her vulva. She has no other hypo-pigmented lesions on her body.  She reports history of repeated itching in the area for past several years. She has seen by her gynecologist in the past. Repeated evaluation did not reveal any infection or candidiasis. She says the lesion has not changed in appearance but the itching bothers her. She denies any vaginal bleeding.  Physical examination reveals a raised white colored plaque on the vulva. There are excoriations adjacent to and overlying the lesion. Most likely diagnosis:

A) Lichen Sclerosus

B) Lichen Simplex Chronicus

C) Lichen planus

D) Vulvar Cancer

E) Vitiligo

Question of the Week # 180

Q180) A 35 year old woman presents with a 3-week history of nodular lesions on her lower legs. She states that he had similar lesions that appeared few years ago and spontaneously resolved . She denies any recent infection except for an upper respiratory infection for which he was treated with antibiotics 2 weeks ago. She is currently not on any medications. He denies any weightloss or diarrhea or constipation. She has no cough or night sweats. Physical examination revealed erythematous nodular swellings on the anterior lower legs. The lesions are tender to palpation.




The most common etiology of these lesions world-wide:

A) Tuberculosis

B) Inflammatory bowel disease

C) Sarcoidosis

D) Diabetes Mellitus

E) Streptococcal infection

F) Herpes Simplex Virus

Question of the Week # 179

Q179) A 48  Year old woman is evaluated in your office for a skin eruption that appeared three days ago. Her past medical history is significant for Rheumatoid arthritis for which she uses Methotrexate. She recently had increasing joint pain and she was placed on ibuprofen which takes about three times daily. Her joint pain is well controlled now.  She is now concerned about the skin eruption that is predominantly distributed on her arms, hands and feet. The eruption is painless.  On examination, there is no joint swelling or tenderness, range of motion in the joints is normal. Skin examination reveals the lesions as shown in the image below.

The most appropriate management option for this patient:

A)     Observation

B)      Stop Ibuprofen

C)      Start Acyclovir

D)      Intra-lesional corticosteroids

E)      Anti-citrullinated pep-tide levels

Question of the Week # 178

Q177) A 55-year-old white woman is seen in your office for a 6-month  history of slowly enlarging lesions on both lower extremities. She is otherwise healthy. The lesions are painless. She denies any trauma to these areas. Her past medical history is significant for diabetes mellitus diagnosed 2 years ago and rheumatoid arthritis. Her medications include Metformin, Enalapril and Methotrexate. On skin examination, she has  2 cm yellow, smooth, firm centrally depressed plaques involving the thighs and knees. Image is shown below









The most likely underlying etiology :

A) Drug-induced

B) Rheumatoid arthritis

C) Diabetes Mellitus

D) Malignancy

E) Sarcoidosis

Question of the Week # 177

Q177) A 52 Year old obese man is evaluated in your office during a routine annual visit.  He denies any fatigue or recent weight changes. He has normal appetite and physically active. He had a colonoscopy 1 year ago that was normal. On physical examination, he is obese with a BMI of  34. Skin examination reveals the findings shown in the image below :










Which of the following is most likely to be seen in this patient?

A) Diabetes Mellitus, Type I

B) Gastric cancer

C) Increased Insulin levels

D) Hyperthyroidism

E) Addison’s disease

Question of the Week # 176

Q176) A 48 Year old woman is evaluated in your office for a skin eruption that appeared few days ago. She has a history of Non-Hodgkin’s lymphoma that was treated 2 years ago and is in remission. A PET ( positron emission tomography) scan that was performed 3months ago did not reveal any evidence of recurrent disease. She also reports recurrent episodes of genital herpetic lesions which  resolve spontaneously. Her most recent genital herpetic eruption was 4 weeks ago and it was self-limited. At this time, she is concerned about a skin eruption that is predominantly distributed on her arms, hands and feet.  On examination, there is no peripheral lymphadenopathy. Genital examination is normal with out any vesicles or papules. Skin examination reveals the lesions as shown in the image below.










The most appropriate management option for this patient:

A)     Observation

B)      Repeat PET/CT scan

C)      Start Acyclovir

D)     Biopsy of the lesion

E)      Start antihistamine

Question of the Week # 175

Q175) A 28 Year old man is evaluated in your office during a pre-employment health check-up . His history is notable for severe hypertension for which he was started on beta blocker a year ago. He says he stopped the medication 6 months ago because it interfered with his sexual activity. On examination his blood pressure is 172/94. Cardiovascular examination revealed a systolic murmur that radiates to the back and associated with ejection click. Brachio-femoral delay in pulses is noted. The patient is agreeable to restart antihypertensive therapy. The most appropriate management option for this patient:

A)     Cardiac catheterization with Stenting

B)      Percutaneous coronary intervention

C)      Surgery

D)     Medical management of Hypertension

E)      Aortic valvulotomy

Question of the Week # 76, 77, 78

76) A 65 year-old man with history of recently diagnosed metastatic colon cancer being treated with chemotherapy is admitted to the hospital with constipation and vomiting. His colon cancer was diagnosed by colonoscopy 2 months ago when he presented with massive GI bleeding. At this admission, patient is diagnosed with bowel obstruction secondary to descending colon cancer and underwent a palliative left hemicolectomy to provide symptomatic relief. He has no occult or gross GI bleeding at this time. On the sixth post-operative day, you are called by the nurse because the patient’s blood pressure is 80/40. His heart rate is 82, respiratory rate 24 and temperature of 100.6. The patient is given Normal saline bolus. A CXR is normal. EKG reveals a prominent S wave in lead I, a Q wave and inverted T wave in lead III. Of note, a pre-operative EKG was completely normal. First set of cardiac enzymes are negative. A bedside 2D echo reveals global hypokinesis of the right ventricle. A repeat blood pressure obtained after normal saline bolus is still low at 70/40. The most likely etiology of the shock in this patient is :

A) Hypovolemia
B) Septic shock
C) Acute myocardial infarction leading to cardiogenic shock
D) Acute pulmonary embolism
E) Tension Pneumothorax

77) Most important next step in treating this patient’s shock?

A) Continued fluid boluses
B) Antibiotics and pressor support with dopamine
C) Intra-aortic balloon counter-pulsation followed by urgent cardiac catheterization.
D) Anticoagulation with heparin
E) Tissue plasminogen activator ( tpA)
F) Embolectomy
G) Chest tube placement.
H) Inferior vena cava filter

78) The patient was appropriately treated. The discharge recommendations should include :
A) Inferior venacava filter
B) Life-long low-molecular weight heparin
C) Life-long coumadin
D) Hypercoagulability testing
E) Compression stockings

Question of the Week – Wk#1

Archer will start  “Question of the Week” series starting today. Every week Archer Review will post most challenging questions that include close distractors in the choices that are often tested on USMLE Step 3.

Question of the Week – July 29th 2010

1. A 15 year old boy presents to emergency room with severe lower abdominal pain that awoke him from sleep about 5 hours ago. The pain is sharp and radiating to the left thigh. While in the emergency room, the patient has one episode of vomiting. He denied any fever, dysuria or chills. Physical examination reveals normal vitals with blood pressure 100/60 and temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender to palpation. Cremasteric reflex is present on the right but absent on the left. Most important next step in managing this patient :
a. CT scan Abdomen and Pevlis
b. Testicular Ultrasound
c. Surgical Exploration
d. Intravenos Antibiotics
e. Plain X-Ray KUB

Answer will be posted with in 3 days. You may submit your responses and analysis as a comment to this post.

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