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)


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 # 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

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