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

Differential

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)

@hagemanGIstep2

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.

Read the original post at http://www.usmle.org/announcements/default.aspx

#USMLE STEP3

Question of the Week # 190

190) A 45 year old man presents to your office for follow up of his dyslipidemia that was diagnosed 6 month. His lipid panel at that time was consistent with high Total cholesterol , Low HDL and high triglyceride levels. He was instructed on dietary modification. He presents for a follow up visit today and reports that he had been strictly compliant with reduced fat diet. His social history is significant for smoking 1 pack per day for the past 25 years . He reports drinking about 1 pint vodka per day for past 10 years. He read on an online magazine  that drinking alcohol would boost his “Good” cholesterol. At this time, a repeat fasting lipid profile reveals:

Total Cholesterol : 250mg%

HDL cholesterol : 35mg%

Triglycerides: 500mg%

The most important step at this time to address his lipid abnormalities:

A) Niacin

B) Gemfibrozil

C) Fenofibrate

D) Alcohol cessation

E) Smoking cessation

Question of the Week # 189

189) A 38 year old woman presents for follow up visit of right leg weakness. Her history is significant for episodes of diplopia and right sided weakness that recurred thrice in the last 3 months. These presentations were also associated with concomitant urinary incontinence and ataxia. Her most recent hospitalization for such an episode was three weeks ago. She was discharged after her symptoms improved upon using intravenous steroids. An MRI brain taken during the initial episode revealed multiple white matter lesions in the peri-ventricular area. Today, she feels well except for minimal weakness in her right leg. Most appropriate drug that should be administered to this patient to reduce the frequency and severity of these recurrences?

A) Methyl dopa

B) Interferon Beta

C) Methyl Prednisolone

D) Interferon Alpha

E) Intravenos Immunoglobulin ( IVIG)

Question of the Week # 188

188) A 24 year old woman is evaluated for a history of chronic anemia. Her history is significant for anemia for the past 7 years. She has been treated with oral iron supplements in the past with out any response. She denies any  gastrointestinal bleeding. Her menstrual cycle is 3 days in duration and her menses have been scant for the past 5 years. There is no family history of anemia or bleeding disorder or cancer. Physical examination is unremarkable. Laboratory investigations reveal :

Hemoglobin : 10.6gm%

MCV: 68fl ( normal 80 to 100)

WBC : 8.8K/μl

Platelets: 230k/μl

Red Cell Distribution Width : 12.8% ( 10.2 to 14.5%)

Reticulocyte count : 6% ( normal 0.5% to 1.5%)

Which of the following are most helpful in diagnosing this patient’s anemia?

A) Serum ferritin

B) Bone marrow biopsy

C) Direct Coombs’ test

D) Hemoglobin Electrophoresis

E)  Anti-endomysial antibodies

Question of the Week # 187

187) A 34 year old obese man presents with complaints of cough of 3 months’ duration. His cough is non-productive and occurs daily. It is worse in the night. He also reports a need to clear his throat constantly. He denies any nasal congestion. He denies smoking or alcohol. He also reports a chronic history of heart burn for which he uses over the counter antacids intermittently. He works as a nurse in a health care facility. He denies any fever or night sweats or weightloss. On examination, throat is normal in appearance with out any exudate or eythema. Lungs are clear to auscultation. A Chest X-ray is normal. The most appropriate initial diagnostic step in evaluating his cough is :

A) Tuberculin skin test

B) Methacholine challenge

C) Albuterol trial

D) Omeprazole trial

E) 24 Hour esophageal  pH monitoring

Question of the Week # 186

186) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She has difficulty speaking for the past 3 months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:

Most appropriate next step in management of this patient:

A) Stop Lisinopril

B) Start Levothyroxine

C) Intubation

D) Abdominal fat pad biopsy

E) Serum immunoelectrophoresis

Question of the Week # 185

185) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She reports difficulty speaking for the past three months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:

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

A) Free thyroxine

B) Serum immunoelectrophoresis

C) Rheumatoid factor

D) ACE Level

E) Bradykinin level

Question of the Week # 183

183) A 65 year old woman  presents  with a white plaque on her vulva. It is associated with occasional itching. She has no other hypo-pigmented lesions on her body.  She denies any post-coital bleeding. Physical examination reveals a white colored plaque on the vulva. The lesion is atrophic, thin with a crinkled surface and is well-demarcated. There is atrophy of the labia minora. Most appropriate next step in managing this patient?

A) Topical Corticosteroids

B) Fluconazole

C) Vulvar Biopsy

D) HPV testing

E) Topical Testosterone

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 # 173

173) A 52 year old African-american woman is seen in the office during a regular follow-up visit. Her history is significant for diabetes mellitus and hypertension. Her medications include Aspirin, Glipizide, atorvastatin and losartan. She states that she stopped taking diuretic because it increased her frequency of urination that it interfered with her active lifestyle.

On examination, blood pressure is 152/94 mm Hg seated and standing.  Her physical examination is normal.  Laboratory values reveal microalbuminuria  of 250mg/24hours and a serum creatinine concentration of 1.3mg/dl. Based on the findings above, her blood pressure medications should be optimized to achieve which of the following targets?

A)     < 140/90

B)      < 135/85

C)      <130/80

D)     <120/70

E)      <130/90

Question of the Week # 172

172)  A 44 year old obese woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She has mild nausea. On physical examination, there is tenderness in right upper quadrant which increases with deep breath. Her liver function tests are normal; WBC count is 24,000/µl with neutrophilic predominance. Amylase and Lipase are with in normal limits. An ultrasound of the gall bladder reveals gall stones but there is no pericholecystic fluid or any other sonographic evidence of acute cholecystitis. Sonographic murphy’s sign is absent. The most appropriate next step in managing this patient:

A)     Percutaneous Cholecystostomy

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)     Magnetic Resonance CholangiOpancreatography ( MRCP)

 

Question of the Week # 171

171)  A 54 year old woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She denies any fever, nausea or vomiting.

On physical examination, there is mild tenderness in right upper quadrant. Her liver function tests reveal an AST (SGOT) 160U/L ( N= 5 to 40U/L) , ALT (SGPT) 240U/L( N= 8 to 55U/L)  , Alkaline phosphatase 110 U/L ( 40 TO 130U/L) , Total Bilirubin 1.2mg%.  An ultrasound of the gall bladder does not reveal any gall stones or pericholecystic fluid and shows a common bile duct diameter of 9mm (normal 6mm). The most appropriate next step in managing this patient:

A)     Hepatitis Serology

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)      Magnetic Resonance CholangiOpancreatography ( MRCP)

Question of the Week # 170

170) A 41 year old woman is evaluated in the office for 20lb weight loss over the last three months. She has a history of Hodgkin’s disease involving mediastinal and cervical lymph nodes and was treated with chemotherapy and Involved field radiation therapy at the age of 12.  She is born in the USA and never traveled outside United States. Her recent tuberculin skin test was 2mm about 1 month ago. Recent mammogram was normal. She denies any night sweats or pruritus. She reports chronic cough over the last 6 months associated with intermittent mild hemoptysis. On physical examination, there is no peripheral lymphadenopathy. A Chest X-ray is shown below:

 

 

 

 

 

 

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

A)     Tuberculosis

B)      Long term sequel of Hodgkin’s therapy

C)      Recurrent Hodgkin’s disease

D)     Radiation fibrosis

E)      Radiation Pneumonitis

Question of the Week # 169

169) A 77 year old woman is brought by her son for evaluation in your office for excessive forgetfulness.  Her son discovered that the patient has become increasingly forgetful over the last two years. She has difficulty managing her finances. She lives alone, drives her own car and prepares her own meals. As per son, several recent new dents were noted on her mother’s car. She is dressed well and is comfortable. Visual acuity on examination is 20/100 in both eyes and is partially corrected with glasses. She also has a fixed visual field deficit that is persistent for past one year due to a cerebrovascular accident. Rest of the physical including sensory and motor functions are grossly normal. She scores 25/30 on Mini-Mental Status examination.

The most appropriate recommendation regarding her driving at this time:

A)           Limit driving to day-time only

B)            Unrestricted driving

C)            Complete cessation of driving

D)           On-Road performance based driving test

E)            Adaptive devices for safe driving

Question of the Week # 168

168) A 70 year old woman with history of Hypertension, Diabetes mellitus, severe osteoarthritis and Macular degeneration is seen during a follow-up visit. He was seen a month ago in your office for evaluation of his driving capacity. At that time, he was noted to have significant impairment of vision and motor skills. His visual impairment persisted despite corrective glasses. He also uses cane to walk and has persistent deficits of left sided weakness and hemi spatial inattention secondary to a stroke 8 months ago. He was subsequently referred to driving rehabilitation specialist and was deemed unsafe to drive. During his visit 2 weeks ago, he has been counseled and was instructed to stop driving. While talking him about his transportation, he tells you that he drove himself to the clinic today.

Your most appropriate response at this time:

a) “When do you think it’s an appropriate time for a person to stop driving?”

b)  Let’s talk about some of your concerns regarding retiring from driving

c) I am wondering, is there someone whom you trust, and who would tell you when they thought it was unsafe for you to continue driving?

d) “You are a threat to others while driving on the road”

e) “I have a duty to protect you and so, I will have to report you to DMV”

f) “Let me refer you to Driving Rehabilitation so that they can help you with adaptive devices”

Question of the Week # 167

167)  A 77 year old woman is brought by her son for evaluation in your office for excessive forgetfulness.  Her son discovered that the patient has become increasingly forgetful over the last two years. She has difficulty managing her finances. She lives alone, drives her own car and prepares her own meals. As per her son, several recent new dents were noted on her mother’s car. She is dressed well and is comfortable. Visual acuity on examination is 20/40 in both eyes. She has seen her ophthalmologist recently and was prescribed corrective glasses which correct her vision to normal. She is compliant with using her glasses during driving. Rest of the physical including sensory and motor functions are grossly normal. She scores 25/30 on Mini-Mental Status examination.

The most appropriate recommendation regarding her driving at this time:

A)     Limit driving to day-time only

B)      Unrestricted driving

C)      Complete cessation of driving

D)     Referral to Driving Rehabilitation Service

E)     Start therapy for Alzheimer’s

Question of the Week # 166

166) A 42 year old woman with history of lupus nephritis presents with complaints of pain in her right thigh. Pain increases on walking and standing. Her kidney disease is under control on Prednisone maintenance for past one year. She denies any recent trauma. On physical examination, she is noted to have a right sided limp on walking. Her Hip X-ray is shown below:

The most likely etiology for the condition shown above:

A)           Renal insufficiency

B)            Secondary Hyperparathyroidism

C)            Systemic Lupus Erythematosus

D)           Vitamin D deficiency

E)            Prednisone therapy

Question of the Week # 165

165) A 42 year old woman with history of lupus nephritis presents with complaints of pain in her right thigh. Pain increases on walking and standing. Her kidney disease is under control on Prednisone maintenance for past one year. She denies any recent trauma. On physical examination, she is noted to have a right sided limp on walking. Her Hip X-ray is shown below:

 

 

 

 

 

 

 

 

The most likely diagnosis is:

A)     Osteosarcoma

B)      Osteonecrosis

C)      Lupus arthritis

D)     Osteoarthritis

E)      Osteoporosis

Question of the Week # 164

164) A 64 year old man is seen in the Emergency room for sharp sub sternal chest pain that started few hours ago. The pain increases on coughing and deep breathing. His history is significant for Acute Myocardial Infarction about 6 weeks ago. At that time, he was treated with percutaneous coronary intervention and stent placement. On physical examination, temperature is 100F, Heart rate 88/min, and Blood pressure 110/70 mm Hg. Pulsus paradoxus is 8mm Hg and lungs are clear to auscultation. A chest X-ray reveals enlargement of cardiac shadow. The most appropriate treatment for this patient’s presentation:

A) Pericardiocentesis

B) Oral Ibuprofen

C) Oral Prednisone

D) Metoprolol

E) Cardiac catheterization to evaluate stent re-occlusion

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

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