USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERI, Exams of Nursing

Download USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERI and more Exams Nursing in PDF only on Docsity! USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Tx of IBS - CORRECT ANSWERS Best initial therapy: *Fiber* If fiber fails: Antispasmodic/anticholinergic agents. First line: 1. Dicyclomine 2. Hyoscyamine Secondline: 1. TCA's (amitriptyline) CCS, What test should you order for IBS? - CORRECT ANSWERS 1. Stool: stool guiac, leukocytes, cultures, ova & parasites. 2. Colonoscopy 3. Abdominal CT scan Umbilical hernia in newborns is associated with? - CORRECT ANSWERS Congenital hypothyroidism Screen with TSH (you should screen for TSH anyway) What three metabolic conditions do most states require newborn screening? - CORRECT ANSWERS 1. Phenylketonuria 2. Galactosemia 3. Hypothyroidism Antibiotics of choice in IBD - CORRECT ANSWERS Ciprofloxacin + Metrodinazole (they have some kind of immune modulatory effect) Middle-aged woman with itching and xanthelesmas = primary biliary cirrhosis. What is the best initial test, and the most accurate test? - CORRECT ANSWERS Initial: elevated ALP, normal bilirubin USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Accurate: antimitochondrial antibodies Liver Biopsy Antimitochondrial antibodies? - CORRECT ANSWERS Primary biliary cirrhosis Antismooth muscle antibody? - CORRECT ANSWERS Primary sclerosing cholangitis What condition accounts for most causes of primary sclerosing cholangitis? - CORRECT ANSWERS IBD What is the best initial test for primary sclerosing cholangitis? Most accurate? - CORRECT ANSWERS Initial: elevated ALP, *elevated bilirubin* Best: ERCP (beading of biliary system) Others: antismooth muscle antibody, ANCA positive Treatment for both primary biliary cirrhosis and primary sclerosing cholangitis? - CORRECT ANSWERS Ursodeoxycholic acid Young woman with hepatitis with thyroiditis or ITP, autoimmune hepatitis. Best initial test, and most accurate? - CORRECT ANSWERS Initial: ANA & antismooth muscle positive Best: Liver biopsy Other: liver/kidney microsomL antibody, SPEP (serum protein electrophoresis) with hypergammaglobulinemia Best initial test for hemochromatosis - CORRECT ANSWERS Serum iron, iron binding capacity (low), ferritin (high) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Best chemotherapy for MM - CORRECT ANSWERS 1. Melphalan + steroids 2. Thalidomide or lenalidomide 3. Bortezomib Best Tx for symptomatic Waldenostrom's (high IgM, hyperviscosity) - CORRECT ANSWERS Plasmapheresis Best chemotherapy for Waldenostrom's - CORRECT ANSWERS Rituximab (if CD20 positive) Fludarabine Chlorambucil (All used in CLL) Aplastic anemia best tx if bone marrow transplant is unavailable - CORRECT ANSWERS Antithymocytw globulin and cyclosporine Causes of aplastic anemia - CORRECT ANSWERS Chronic hep C and B Mostly idiopathic however What makes Hodgkin's lymphoma different from nonhodgkin's? - CORRECT ANSWERS Reed-Sternberg Cells Best next step in lymphoma? - CORRECT ANSWERS Excisional biopsy After you confirm the diagnosis with excisional biopsy (lymphoma) best next step? - CORRECT ANSWERS Determine stage with: CXR CT scan of chest, abd., pelvis, and head Bone marrow biopsy USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Asymptomatic lymphoma Stage 1 and 2 (1-2 LN only one side) best tx - CORRECT ANSWERS Radiation + low dose chemo Symptomatic or advanced dx lymphoma tx - CORRECT ANSWERS Chemotherapy Chemotherapy for Hodgkin's lymphoma - CORRECT ANSWERS ABVD Adriamycin Bleomycin Vinblastine Dacarbazine Chemotherapy for non-Hodgkin's - CORRECT ANSWERS CHOP Cyclophosphamide Hydroxyadriamycin Oncovin (vincristine) Prednisone Add rituximab if CD20 positive (test for anti-CD20 antigen) TX for acute ITP - CORRECT ANSWERS Prednisone TX for acute ITP with plt <20k with life threathening bleeding (head bleed or severe GI bleed) - CORRECT ANSWERS IVIG or RhoGAM Romiplostim and eltrompobag are? - CORRECT ANSWERS Thrombopoieitin analogs that stimulate megakaryocytes in ITP (used for chronic ITP without response to splenectomy) Reccurent episodes of ITP what should you do? - CORRECT ANSWERS Splenectomy No response to splenectomy in ITP - CORRECT ANSWERS Romiplostim or eltrompobag USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS When do you screen for hyperlipemia, and how often? - CORRECT ANSWERS Men 35+ Women 45+ Screen every 5 years Hypothyroidism management in pregnancy - CORRECT ANSWERS Increase levothyroxine dose Best emergency oral contraceptive (think post-rape) - CORRECT ANSWERS Ulipristal 2 standard deviations is how much percentage of data (biostatistics) And 3? - CORRECT ANSWERS 95% 99.7% Treatment of scabies - CORRECT ANSWERS Permethrin Treatment of scabies in HIV - CORRECT ANSWERS Oral ivermectin Treatment of atopic dermatitis - CORRECT ANSWERS Topical steroids Triamcinolone Topical tacrolimus can be used in areS such as eyelids or to avoid long-term steroids Criteria for proteinuria (parameters) in preeclampsia - CORRECT ANSWERS >300 mg 24 hour >0.3 protein/creatinine ratio Dipstick +1 or more USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS DO FNA if U/S is concerning or if TSH is normal/high MS best next step in management - CORRECT ANSWERS MRI If equivocal do lumbar puncture of IgG olgiclonal bands (however not necessary if MRI is abnormal) MS acute treatment - CORRECT ANSWERS IV steroids MS long-term treatment - CORRECT ANSWERS Beta-interferon or *glatiramer* MS and pregnancy... how is treatment modified, what special consideration should you have with them? - CORRECT ANSWERS MS tends to cool down with pregnancy and most treatments are not teratogenic. However, the patient is at higher risk of needing assisted delivery Spasticity in MS Tx. - CORRECT ANSWERS Baclofen (try physical therapy first) Fatigue in MS Tx. - CORRECT ANSWERS Amantadine (Try sleep hygiene and exercise) Neuropathic pain in MS Tx. - CORRECT ANSWERS gabapentin Urge urinary incontinence in MS - CORRECT ANSWERS anticholinergic (oxybutinin) [try Fluid restriction first] Hypopigmented spots, in combination with a family history of bilateral deafness - CORRECT ANSWERS NF-2 (deafness = bilateral acoustic neuroma) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Treatment of carpal tunnel - CORRECT ANSWERS Nocturnal wrists splints surgery when there is *motor weakness or atrophy of the thenar eminence* Large (>2 cm) *sessile* polyp found on colonoscopy, how long do you wait for the next colonoscopy? - CORRECT ANSWERS 2-6 months p. 204 MTB3 Adenocarcinoma found in a polyp removed by colonoscopy when do you follow up? - CORRECT ANSWERS 2-3 months p. 204 MTB3 1-2 Small (<1 cm) tubular adenomas found on colonoscopy, when do you follow up? - CORRECT ANSWERS 5 years p. 204 MTB3 Large adenoma (>2cm) without sessile features or 3-10 adenomas, or high grade-displasia or *villous* features found on colonoscopy... When do you do another follow-up colonoscopy? - CORRECT ANSWERS 3 years p. 204 MTB3 Tx of gout in patients with renal failure - CORRECT ANSWERS intra-articular steroids for single joint, oral steroids for multiple (clue: look for both an NSAID and colchicine in the answers since both are acceptable answers in acute gout) Best drug for HTN in patients with gout - CORRECT ANSWERS ARBs (losartan) they have a uricosuric effect USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS *avoid diuretics* Patient with COPD exacerbation, when should you give prophylactic oral antibiotics? - CORRECT ANSWERS Two or more = treat with abx 1. Increased dyspnea 2. Increased sputum volume 3. Increased sputum purulence (probably one of the only indications to treat acute bronchitis with antibiotics) Renal mass, polycythemia, flank pain in a smoker - CORRECT ANSWERS Renal cell carcinoma polycythemia = para neoplastic syndrome Sepsis in the first 24 hours (newborn) is most likely caused by - CORRECT ANSWERS Pneumonia GBS and E. Coli most common Listeria is also a possible cause Sepsis after the first 24 hours is most likely caused by - CORRECT ANSWERS Meningitis or bacteremia Treatment of neonatal sepsis - CORRECT ANSWERS Ampicillin + gentamicin Adding cefotaxime if meningitis is suspected Pancreatitis patient being treated for hypertension - CORRECT ANSWERS diuretics (thiazides or furosemide) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS (clozapine second line) RA symptoms and slightly positive RF following URI - CORRECT ANSWERS parvovirus (viral arthritis) Best next step when performing a physical exam with a patient that has testicular pain - CORRECT ANSWERS cremasteric reflex (if swelling only then transillumination test) Whipple's triad: hypoglycemia symptoms, low blood glucose, and symptom resolution after glucose administration. Findings of elevated insulin, C-peptide, and proinsulin levels. What is the next best step - CORRECT ANSWERS oral hypoglycemia agent screen (check if that patient is taking sulfonyureas or others on the side) If negative THEN you consider insulinoma. *Insulinoma* is EXTREMELY rare If it was exogenous insulin the C-peptide would be low ADPKD best screening/follow up test - CORRECT ANSWERS *blood pressure monitoring* (remember you only screen for berry aneurysms of the patient has family members with subarachnoid hemorrhage and ADPKD) Best screening test for ADPKD - CORRECT ANSWERS Ultrasound MCC otitis media in peds - CORRECT ANSWERS Strep pneumo Nontypeable H. flu Moraxella *best initial treatment is amoxicillin, second line augmentin (for augmentin look for patient having already taken amoxicillin)* USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Patient with Addison's who develops type 1 diabetes (look for diabetic ketoacidosis in the presentation). What does he have? - CORRECT ANSWERS Schmidt's syndrome ("polyglandular autoimmune failure) characterized by Addison's disease, type 1 diabetes, and autoimmune thyroid disease What is MODY (maturity-onset diabetes mellitus of the young) - CORRECT ANSWERS it's diabetes in young people with positive family history for diabetes (they DO NOT present with ketoacidosis) Hypothyroid patient who wants to be started on OCPs what should you do with her treatment? - CORRECT ANSWERS increase levothyroxine dose due to OCPs increasing TBG Treatment of C. Diff recurrence: 1) First recurrence 2) Second recurrence 3) Subsequent relapses - CORRECT ANSWERS 1) First recurrence - treat with metrodinazole again (vanco if severe*) 2) Second recurrence - treat with vancomycin for 6-7 weeks 3) Subsequent relapses - treat with fidaxomicin, and consider fetal microbiota transplant *severe disease = fever, WBC >15k, creatinine 1.5x baseline* Drugs that cause drug-induced lupus - CORRECT ANSWERS Hydralazine, procainamide, minocycline TNF-a inhibitors (infliximab, etanercept) among others Patient with fatigue, night sweats, arthralgias/arthritis, pleuritis/pleural effusion taking hydralazine (look for CHF) - CORRECT ANSWERS Drug-induced lups Drug-induced lupus best enxt step in management - CORRECT ANSWERS *ANA* test and anti-histone antibiodies USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Also remove the offending drug (if that's one of the answers) RF patient not responding to methotrexate + steroids (standard treatment) - CORRECT ANSWERS 1. Add infliximab or etarncepet 2. Switch to Cyclosporine (don't add it) Pharmacotherapy for infantile hemangiomas that may be disfiguring or located at sites that can cause impairment (eyelid, airway) - CORRECT ANSWERS Propanolol When to use osetalmavir - CORRECT ANSWERS 1. High risk patients (older than 65, pregnany, high risk cardiac or pulmonary disorders) 2. patients presenting before 48 hours Batter swallowed in the esophagus next step - CORRECT ANSWERS endoscopic removal it can cause corrosive injury (if it passed beyond the esophagus it's usually ok) When should you transfuse a patient with upper GI bleeding? - CORRECT ANSWERS Hgb <7 g/dL (few complications and reduces mortality when compared to transfusing at higher hemogolbins such as 8-9) If very severe anemia (chest pain, hypotension, etc. then transfuse to <9 g/dL, but minor symptoms such as lightheadedness and mild SOB wait for 7) Prengnat woman exposed to herpes but no symptoms next step - CORRECT ANSWERS type specific antibody testing for HSV-1 and HSV-2 to identify latent infection and treat with antiviral therapy at 36 weeks gestation *HSV IgG antibody screen* (if patient has history of HSV treat as you otherwise would at 36 weeks with antivirals, active lesions is indication of C/S) What two antihypertensive medications should be stopped the night ebfore surgery - CORRECT ANSWERS diuretics and ACEi (increased incidence of hypotension) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Treatment of ICP in trauma - CORRECT ANSWERS First-line: -Hyperventilation -Head elevation Second-line -Mannitol -Sedation and/or hypothermia Remember for acute abdomens such as appendecitis, bowel obstruction, cholecystitis always do the following - CORRECT ANSWERS NPO NG tube with suction IV fluids +/- antibiotics LCIS treatment - CORRECT ANSWERS Tamoxifen for 5 years (don't need surgery) DCIS treatment - CORRECT ANSWERS Lumpectomy + radiation, then tamoxifen for 5 years Management of pancreatic pseudocyst (painless vs painful) - CORRECT ANSWERS Painless - do not drain Painful drain if: >6cm and >6 weeks with surgical internal drainage or endoscopic drainage *if infected do percutaneous external drainage* Factorial design study - CORRECT ANSWERS A study that utilizes more than one intervention and also a combination (for example one drugs vs another drug and then also both) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Crossover study - CORRECT ANSWERS subjects are exposed to different treatments sequentially the subjects cross over from one study arm to another serving as their own controls Nested study - CORRECT ANSWERS retrospective observational study in which subsets of controls are matched to cases and analyzed for variables of interests Pragmatic study - CORRECT ANSWERS seeks to determine wether an intervention works in real-life conditions Pregnant patient with severe bipolar mania treat with - CORRECT ANSWERS IV haloperidol (ECT is for depression OR patients who fail haloperidol treatment with mania) How should you treat their urinary retention if they present with UTI + Urinary retention + BPH? - CORRECT ANSWERS *Suprapubic catheter* Men with BPH who have UTI most likely have prostatitis. Foley catheterization can cause bacteremia. Indications for antibiotic therapy of an abscess after I&D - CORRECT ANSWERS 1. Large >5 cm diameter 2. Multiple 3. Extensive surrounding cellulitis 4. Signs of systemic infection 5. Immunocompromised patients 6. Age <6 months Diagnosis and treatment of acalculous (no gallstones on imaging) biliary colic symptoms - CORRECT ANSWERS Cholecystokinin-stimulated cholescintigraphy to evaluate for functional gallbladder disorder USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS If patient has low gallbladder ejection perform elective cholecystectomy ("vesicula vaga") Treatment of eczema (pruritic scaly, blanching, erythematous lesions - atopic dermatitis) - CORRECT ANSWERS Emollients and topical steroids Depression can increase the risk of developing what medical condition? - CORRECT ANSWERS MI or CAD Spontaneous repeated leg movements that provide relief with unpleasant sensations that occur while at rest (patient that becomes agitated when remaining still, and has to stand and move to feel relief) - CORRECT ANSWERS Restless leg syndrome Causes of restless leg syndrome - CORRECT ANSWERS 1. Heridetary (autosomal dominant) 2. *Iron deficiency anemia* 3. Uremia (look for ESRD or CKD) 4. MS or Parkinson's 5. Pregnancy 6. Drugs (antidepressants, metoclopramide Treatment of restless leg syndrome - CORRECT ANSWERS 1. Avoiding aggravating factors (sleep deprivation, medications) 2. Iron supplementation *get a ferritin level in these patients* 3. Pharmacotherapy: pramipexole or ropinorole (dopamine agonists), second-line gabapentin. Post-extubation stridor treatment - CORRECT ANSWERS Due to laryngeal edema after extubation from direct mechanical damage to laryngela mucosa from intubation. Give glucocorticoids before extubation, and can give nebulized epinephrine. *If this fails then reintubate* Subchorionic hematoma management - CORRECT ANSWERS repeated ultrasounds (there is no treatment) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Hydrophobia is due to pharyngeal spasm that occurs when drinking water Why is screening for prostate cancer bad? - CORRECT ANSWERS because most people with prostate CA die from other things that aren't prostate CA, and it exposes people to needless biopsies and treatment Treatment of acute urticaria mild moderate severe - CORRECT ANSWERS Mild - H1 blocker Moderate - H1+H2 blocker (think pepcid + benadryl) Severe: add oral steroids Chronic urticaria (more than 6 weeks) treatment - CORRECT ANSWERS Daily 2nd gen anti- histamine (if it fails try one of the following: increase dose, add an H2 blocker, add an H1 blocker, add a leukotriene receptor antagonist or try a brief course of oral steroids) *chronic urticaria usually resolves in a few years with treatment* Most common complication/involvement of lumbrosacral myelomeningocele - CORRECT ANSWERS GU problems (*bladder dysfunction*) Child <24 months with UTI next step - CORRECT ANSWERS After antibiotics (>7 days) best next step is a renal and bladder ultrasound When should you do a voiding cystourethrogram in <24 month old with UTI - CORRECT ANSWERS 1. Recurrence 2. Febrile UTI 3. Renal ultrasound with abnormalities: USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS -Hydronephrosis -Renal scarring -High-grade vesicoureteral reflux -Obstructive uropathy Apathetic thyrotoxicosis - CORRECT ANSWERS Elderly patient with lethargy, confusion and depression, who is misdiagnosed with dementia *this is one of the reasons TSH is always done when evaluating for dementia* Treatment of serotonin syndrome - CORRECT ANSWERS Supportive therapy with sedation using benzodiazepines *cyproheptadine* if treatment fails What measures should you take with a patient who is going to be used for organ donation in terms of maximizing the viability of donor organs? - CORRECT ANSWERS Keep the patient euvolemic, normotensive, and *normothermic* (if cold then warm the patient) Systolic murmur with signs of volume overload (peripheral edema) and symptoms of dyspnea and fatigue with an ejection fraction of 55% would be bad in which type of murmur? - CORRECT ANSWERS Mitral regurgitation MR with symptoms needs Vascular surgery. Also if EF <60% it should be treated regardless of symptoms. In contrast aortic stenosis/regurgitation EF up to 50-55% is tolerated ESRD treatment of anemia - CORRECT ANSWERS Erythropoietin if Hgb <10 g/dL if all other tests are normal: -B12 & Folate -Iron Studies (ferritin, TIBC, serum iron, transferrin) -Reticulocyte count USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS *Always consider iron deficiency as a cause.* Look for <30% transferrin saturation and *ferritin <500 mg/dL (ferritin tends to go up due to dialysis and a normal or low normal value probably means iron deficiency) Treatment of Wernicke's encephalopathy - CORRECT ANSWERS thiamine *then* glucose Korsakoff syndrome (confabulation to fill in gaps in memory, psychosis). What can precipitate it, and what brain structure is damaged? **(both anterograde and retrograde amnesia occur with *anterograde being more common*) - CORRECT ANSWERS *Precipatated by giving glucose before thiamine in a patient with Wernicke's encephalopathy* Part that is damaged is the *mammillary bodies* and the talamus Best diagnostic test for PCP pneumonia (look for HIV patient with pneumonia and <200 CD4 count or very close to 200) - CORRECT ANSWERS *Induced sputum* If nothing is found in the sputum: *fiberoptic broncoscopy with bronchoalveolar lavage* Indications for corticosteroid use in PCP pneumonia - CORRECT ANSWERS PaO2 of <70 mmHg and/or Alveolar-arterial oxygen gradient of 35 mmHG or more Patient with bicuspid aortic valve (asymptomatic) next step - CORRECT ANSWERS Screen first degree relatives with echocardiography (can occur sporadically, but is usually *autosomal dominant with incomplete penetrance*) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS When can direct xa inhibitor be used for a-fib stroke/clot prophylaxis? - CORRECT ANSWERS For *non-valvular* a-fib This means you can't use it in mechanical valves or mild to severe valve disease xa inhibitors = dabigatran, rivaroxaban, apixaban WHen should palivizumab be used? - CORRECT ANSWERS 1. Preterm <29 weeks 2. CHronic lung disease of prematurity 3. Hemodynamically significant congenital heart disease Most common complication of RSV - CORRECT ANSWERS apnea or respiratory failure Treatment of RSV - CORRECT ANSWERS supportive care Nasal congestion/discharge & cough followed by wheezing/crackles, respiratory distress - CORRECT ANSWERS bronchiolitis most likely RSV Chronic treatment of cluster headaches - CORRECT ANSWERS verapamil Cardiac drugs that may be given with digoxin and cause digoxin toxicity - CORRECT ANSWERS verapamil, captopril, quinidine, amiodarone, spironolactone Breastfeeding failure jaundice - CORRECT ANSWERS First week of life -Lactation failure that results in decreased bilirubin elimination -Increased enterohepatic circulation -Suboptimal breast feeding -Signs of dehydration USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Breast milk jaundice - CORRECT ANSWERS starts around the first week peaks at the second week Due to high levels of beta-glucuronidase activity that deconjugates intestinal bilirubin. Normal infant examination (except for the jaundice). Breast feeding adequately Amaurosis fugax (sudden and transient monoocular blindness) next step - CORRECT ANSWERS carotid doppler (this finding usually seen in carotid artery atherosclerosis) When should DMARDs (*methotrexate*, hydroxychloroquine, sulfasalazine, leflunomide, azathiorpine etc.) be started in RA? - CORRECT ANSWERS erosive joint disease (seen on x- ray) Patient with symptoms of RA with negative RF? - CORRECT ANSWERS they have RF Can do anti-ccp antibodies Best way to diagnose pheochromocytoma? - CORRECT ANSWERS *plasma free metanephrine* 24-hour urine metanephrine* Allergen most frequently associated with asthma - CORRECT ANSWERS house dust mites Unique finding of disseminated gonoccocal infection (kid with joint pain and painful tendons) - CORRECT ANSWERS tenosynovitis Risk of donating kidneys in women - CORRECT ANSWERS future gestational complications (only slightly higher than the rest of the population) Overall, there is not much increase in complications except for the above USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Garlic like odor coming from clothes, bradycardia, skin flushing, miosis and wheezing. What's the diagnosis, and what is the best test? - CORRECT ANSWERS Organophosphate poisoning Best test is RBC cholinesterase Should herpes-zoster be treated? - CORRECT ANSWERS Yes with valacyclovir or acyclovir if less than 72 hours before onset What is external validity? - CORRECT ANSWERS It is how generalizable a study results are to other populations (a study done on blacks being used in whites) What is internal validy? - CORRECT ANSWERS Improved by randomization which helps with confounding variables ("Are we observing/measuring what we think we are observing/measuring?) What pattern of calcification raises the suspicion of lung malignancy in a nodule seen on CXR? - CORRECT ANSWERS eccentric calcification (area of asymmetric calcification) Patterns that are homogeneous or symmetrical indicate a benign cause First line treatment of dysmenorrhea - CORRECT ANSWERS NSAIDs (second-line OCPs) CHA2DS2 - CORRECT ANSWERS "CHADS-2 (remember age 65-74 = 1 point, 75+ = 2 points) Cardiac - CHF/MI 1 point Hypertension 1 point Age >75 2 points Diabetes 1 point Stroke/TIA 2 points Signs of severe aortic stenosis - CORRECT ANSWERS soft, single S2, diminished carotid pulse, and loud and late-peaking systolic murmur USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Switch to long-acting SUBQ insulin overlapping 1-2 hours When do you give bicarb in DKA? - CORRECT ANSWERS pH <6.9 When do you add dextrose to IV hydration in DKA? - CORRECT ANSWERS when serum glucose reaches <200 mg/dL Add potassium if K < 5.2, hold insulin if patient becomes hypokalemic (<3.3) When should you give phosphate in DKA? - CORRECT ANSWERS Serum phosphate <1.0, cardiac dysfunction, or respiratory depression (monitor calcium if you give it) Signs of lithium toxicity - CORRECT ANSWERS confusion, ataxia, neuromuscular excitability Drugs to clue you into chronic lithium toxicity? - CORRECT ANSWERS thiazide diuretics (chlorthalidone, hydrochlorothiazide), ACEi, NSAIDs *look for neurologic findings* Acute lithium toxicity = GI symptoms (N/V, diarrhea) Indications for hemodialysis in lithium intoxication - CORRECT ANSWERS > 4 or > 2.5 with symptoms or renal failure or Increasing level despite IV fluids Kid with failure to thrive, steatorrhea, and many lung infections - CORRECT ANSWERS Cystic fibrosis USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Treatment of keloids - CORRECT ANSWERS intralesional glucocorticoids (try serial injections if fails then do surgical excision) *Recurrence is common* CHF in a baby just born from a diabetic mother (pulmonary congestion, respiratory distress) - CORRECT ANSWERS hypertrophic inter-ventricular septum from the mother not controlling her glucose Glycogen stores in the myocardium causing hypertrophy (septum most commonly affected) *Treatment is supportive, since the anomaly will usually correct itself (the glycogen will deplete)* *hypoplastic left heart syndrome can occur but patients present without symptoms until the PDA closes, may need immediate heart transplant* Most common reason for someone to suddenly not be able to be cross-matched when receiving blood after receiving multiple transfusions - CORRECT ANSWERS development of alloantibodies What is dyspepsia? - CORRECT ANSWERS 1 or more of the following: Postprandial fullness, epigastric pain or burning, early satiety Next step in management in a patient with dyspepsia - CORRECT ANSWERS it depends on having alarm features *and/or* age >55 -age > 55 or alarm symptoms = do endoscopy No alarm features and young = do H. pylori testing if high prevalence (Europe, Asia, Latinoamerica) -*low prevalence, NSAIDs or classic GERD treat empirically with PPIs* USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Management of giardia outbreak - CORRECT ANSWERS Isolate and treat symptomatic patients Leave asymptomatic patients alone (don't isolate, and don't treat) Pathophysiology of hemoptysis CHF vs lung inflammation (bronchiectasis, pneumonia, COPD/bronchitis) - CORRECT ANSWERS Lung inflammation = inflammation and edema of the mucosa that leads to blood vessel infiltration and rupture of superficial blood vessels CHF = increased capillary pressure causing rupture of small vessels [For bronchiectasis look for a cause for airway damage with daily cough and mucopurulent sputum] [*chronic cough doesn't cause hemoptysis unless there's something else] Management of CIN 1 (LGSIL) 1) In women >24 2) In women 21-24 - CORRECT ANSWERS 1) In women >24 y/o: Colposcopy+ biopsy then observation every 6 months with Pap smear + HPV testing. Can stop after two years of consecutive negative testing. 2) Women 21-24 need a repeat PAP smear every year for two years (resume normal testing after two normal PAP smears). If it does not regress then you do colposcopy and biopsy Management of HGSIL (CIN 2 or 3) in women <25 years old, or young who desire pregnancy - CORRECT ANSWERS CIN 2 or 3 should be treated with excision or ablation of transformation zone. However, if they *desire pregnancy and/or are age <25* USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS *>24 weeks* wait to 32 weeks and do a C/S then do definitive treatment When do you do an endocervical curettage? - CORRECT ANSWERS all nonpregnant patients with abnormal pap smear Chronic smoker with non-resolving pneumonia, next step - CORRECT ANSWERS get a chest CT scan to check for an obstructing endobronchial malignancy First line treatment for essential tremor - CORRECT ANSWERS *propanolol* > primidone (barbiturate) > BZ's When should you use levodopa vs another dopamine agonist (pramipexole or bromocriptine)? - CORRECT ANSWERS Severe symptoms (affects quality of life) in patients age >65 Acute pericarditis post-STEMI treatment - CORRECT ANSWERS use high dose aspirin (other NSAIDs may increase risk of myocardial rupture) Echocardiographic signs of RV in massive PE - CORRECT ANSWERS decreased RV contractility, increased RV size, presence of RV thrombus, and tricuspid regurgitation Treatment of squamous cell carcinoma - CORRECT ANSWERS Mohs micrographic surgery or excision with 4mm margins Woman who takes seizure meds and wants to breast feed - CORRECT ANSWERS It's not a contraindication (but the meds to generally get secreted into the breast milk) Management of epilepsy in pregnancy. "Accidental" vs planned - CORRECT ANSWERS Literature is unsure of which anti-epileptic drug is most teratogenic (except for valproate) "Accidental" (found after she was pregnant) continue seizure medications and offer screening USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Planned - if taking valproate then switch *6 months* before pregnancy. If taking any other don't switch First line treatment in PCOS for infertility - CORRECT ANSWERS Weight loss > clomiphene (OCP is the treatment for patient's who don't want fertility, metformin is currently being studied as a PCOS treatment) Acute stress disorder vs PTSD - CORRECT ANSWERS PTSD >1 month Acute stress disorder is treated with BZ's for insomnia, and cognitive behavioral therapy Management of acute monoarticular gout in renal failure - CORRECT ANSWERS *intraarticular glucocorticoids* polyarticular use systemic steroids (don't use NSAIDs with renal disease) [Side note: colchicine is contraindicated if patient is taking azathiorpine due to severe leukopenia)] Hyperthyroidism, no thyroid tenderness, thyroid swelling, decreased uptake of radioactive iodine - CORRECT ANSWERS *Painless thyroiditis* that is self-limited AI destruction of thyroid follicles releasing thyroid hormone *Treat with propanolol* (no need for PTU or methimazole) BP medication to avoid in STEMI - CORRECT ANSWERS CCB's (nifedipine) [reflex tachycardia] USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Drugs that are ok: Statins, beta-blockers (with no CHF, bradycardia, or asthma), Side effects of carbamazepine in elderly patients (not bone marrow suppression) - CORRECT ANSWERS anti-cholinergic effects: glaucoma, urinary retention, constipation Kidney: SIADH (look for hyponatremia) When should airline pilots take viagra? - CORRECT ANSWERS 6 hours before flight due to blue-green color vision is affected in up to 3% of patients What is the kappa statistic - CORRECT ANSWERS quantitative measure of inter-rater reliability (inter-rater concordance). -1 is perfect disagreement, +1 is perfect disagreement. (think two doctors interpreting the same set of CT scans separately) measures *reliability* alpha in a study is? - CORRECT ANSWERS level of statistical significance Follow-up colonoscopy intervals after polypectomy - CORRECT ANSWERS Remember the ones to worry about are adenoma polyps (hyperplastic polyps that are <1cm can be followed up normally with colonoscopy in 10 years) *1-2 adenomas = 5 years* *3+ adenomas, >1cm polyp, adenoma with villous features or highg rade dysplasia = 3 years* What type of colonic polyp rings as bad? - CORRECT ANSWERS *sessile and large* (more than 2 cm) or with adenocarcinoma In these patients follow up colonoscopy is usually done in 3 months USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS *severe ophtalmopathy should be treated with thyroidectomy, *very large goiter, cancer, and pregnant patients are also indications for thyroidectomy How do you monitor thyroid function after radioactive iodine? - CORRECT ANSWERS total T3 and T4 (TSH levels remain suppressed for months) Common skin conditions and their associated pathologies - CORRECT ANSWERS Treatment of ITP - CORRECT ANSWERS *Steroids* in patients with bleeding or <30k platelets (the rest observe) *IVIG in patients needing a quick response or fail steroids (unfair to put both IVIG and steroids in the answer choices, look for a contraindication to steroids) *Rituximab is an adjuvant in refractory cases Chronic ITP: splenectomy Evaluation of cerebral palsy (child with persistent primitive reflexes, hyperreflexia, hypotonia then spasticity, gross motor delay, possible retardation, seizures) next step in diagnosis Look for "scissoring gait," in spasticity - CORRECT ANSWERS MRI Patients who develop HIT can they have heparin again? - CORRECT ANSWERS NO, never. they can't use any form of heparin Initial work-up for suspected PCOS - CORRECT ANSWERS 1. Testosterone & DHEA (rule out androgen secreting tumors) 2. LH & FSH (LH/FSH ratio >3:1 is diagnostic) 3. 17-hydroxyprogesterone 4. Pelvic ultrasound USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS (consider antipsychotics, antidepressants, high prolactin, pituitary adenoma, and hypothyroidism in the differential diagnosis) Further management check FBS and lipids Hirsutism treatment - CORRECT ANSWERS spironolactone Treatment of NMS (CCS) - CORRECT ANSWERS 1. Stop antipsychotic 2. Send patient to ICU 3. Start Dantrolene or DIazepam (muscle relaxants 4. Give bromocriptine (D2 agonist) *Get a CPK* What test/marker do you use to determine if a patient is infectious with TB? - CORRECT ANSWERS negative sputum smears 3 x negative smears = noninfectious (they may have it but they won't spread it) Where does diverticular bleeding come from? - CORRECT ANSWERS Erosion of the vasa recta in the diverticulum ("erosion of the artery") usually caused by it being exposed and damaged with fecaliths Who is the best donor for a patient (family wise) - CORRECT ANSWERS A full sibling (remember can't donate if you're <18) When should you treat Lyme disease with IV drugs? - CORRECT ANSWERS Use IV ceftriaxone USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Treat only with carditis, or a neurologic symptoms that is *not cranial nerve palsy* Best study to investigate an outbreak of an acute infectious disease - CORRECT ANSWERS case-control study Time-line of research study methods (review) - CORRECT ANSWERS Best initial treatment for warts inside of the vagina - CORRECT ANSWERS tricloroacetic acid (always start chemical first then move to ablation or excision if fails) If outside and not pregnant use podophyllin Patients with anal/ischiorectal abscesses should be treated with? What complication can they develop? - CORRECT ANSWERS Treat with *I&D* (if VERY large then go to OR) 50% of patients with anal abscesses develop *fistulas* Lichen planus next best step. What is it associated with? (White lesions in buccal mucosa, pruritic and violaceous papules in the flexor surfaces of the extremities) - CORRECT ANSWERS Next best step is biopsy Associated with hep c advanced liver disease USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Management? - CORRECT ANSWERS Skin biopsy to confirm diagnosis with a punch biopsy What test should you send in a patient who has lichen planus? - CORRECT ANSWERS Hep C antibodies (lichen planus may be a sign of advanced liver disease form hep. C) Patient with PE who develops fever what is your next step? - CORRECT ANSWERS Evaluate for pneumonia but *do not give antibiotics* Patients with PE develop fever, elevated WBC, and pulmonary opacities which can mimic pneumonia Stroke at a young age should raise the concern for? - CORRECT ANSWERS 1. Infection (endocarditis, meningitis, *secondary syphillis i.e. meningovascular syphillis*, varicella- zoster 2. Vasculitis 3. Drugs 4. Sickle-cell or hypercoagulable state 5. Cardiac causes: arrhythmia, patent foramen ovale, congenital heart disease How specific is low-dose chest CT screening (yearly in patients *55-80* who have a smoking history of >30-pack-year and have no quit for more than 15 years) - CORRECT ANSWERS Not specific at all less than 10% (false positive rate of 90%+) *However it has a benefit of 20% reduced mortality* What hemoglobin electrophoresis do you expect in sickle cell trait - CORRECT ANSWERS HbA 60%, HbS 40% If patient has beta-thalassemia as well maxmium HbA is 25% USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS *patients with sickle cell trait with anemia most likely have iron deficiency anemia* Patient with history of STDs or risky sexual behavior with rash in the palms and soles and neurological symptoms - CORRECT ANSWERS secondary syphilis Remember the test to confirm is a RPR or VDRL of CSF Young adult with episodes of incetious diarrhea and episodes of pneumonia - CORRECT ANSWERS IgA deficiency (do a measurement of Ig levels) Undiagnosed cystic fibrosis think <21 Varenicline contraindication (hint not seizures thats bupropion) - CORRECT ANSWERS major depression Bell's palsy treatment and management - CORRECT ANSWERS If from a Lyme-endemic area do Lyme serology Treat with corticosteroids (best chance of full recovery, takes 1-3 months to fully recover) For Bell's palsy look for facial signs in both upper and lower which indicates a peripheral cause First-orders in a CCS case of a patient who has altered mental status - CORRECT ANSWERS Labs: Toxicology screen and dextrose Treatment: Naloxone, thiamine, dextrose Supportive treatment: oxygen and fluids Indications for intubation in a patient who has burns - CORRECT ANSWERS 1) Burns inside nose or mouth USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS 2) Wheezing 3) Stridor 4) Burns inside the nose ormouth If a burn patient does not need to be intubated what is the next best step - CORRECT ANSWERS Give fluids! 4 mL x Kg x % of burn (half in 8 hours, other half in 16 hours) [babies have big heads so their heads are 18%, take 4.5% from each leg] Prophylactic antibiotics in third-degree burns? - CORRECT ANSWERS Yes, topical (MCC of late death = infection most common is S. aureus Hypothermic patient urgent step - CORRECT ANSWERS EKG looking for J-waves of Osborn (looks like ST-elevatioon *MCC of death is arrhythmia Eye erythema with fixed "mid-point" pupil, increased cup to disc size - CORRECT ANSWERS acute angle closure glaucoma treat with pilocarpine drops that constrict the pupil, and mannitol that is an osmotic diuretic (other treatments include: acetazolamide, lantanoprost, timolol) AMS and metabolic acidosis in a patient on a nitrprusside drip - CORRECT ANSWERS think cyanide toxicity, treat with hydroxycobalamin (with concomitant CO poisoning) or sodium thiosulfate if no CO poisoning USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS B/L effusions may be seen. Look for a preceding URI. Next step in diagnosis is an ultrasound show joint effusions or widening of the joint space Self-limited Treatment of cryoglobulinemia (look for renal disease, some sign of liver disease that could suggest hep. C and low complement levels) - CORRECT ANSWERS Treatment is anti-virals if patient has hep C If no hep. C patient may be initially treat with steroids and/or immunosuppressants Asymptomatic bacteriuria who do you treat? - CORRECT ANSWERS 1) Patient undergoing urologic procedure or hip arthroplasty 2) Pregnant patients DO NOT TREAT the elderly, non-pregnant women, diabetics, patients with spinal cord injury, patients with chronic indwelling urinary catheter Infant with anemia how to know it's iron deficiency vs thalassemia - CORRECT ANSWERS the Mentzer index (MCV/RBC ratio) Mentzer > 13 suggests iron deficiency Health care worker TB exposure next stpe in management - CORRECT ANSWERS do a PPD and compare in three months (checks if the patient may already have TB, and will confirm in three months if the patient got TB) Best treatment for invasive skin squamous cell carcinoma - CORRECT ANSWERS Surgery if patient does not want surgery, cryotherapy, electrosurgery or *radiation therapy* can work USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS 5-FU is for premalignant lesions and squamous cell carcinoma in situ Post-partum endometritis treatment - CORRECT ANSWERS clindamycin and gentamycin *Metrodinazole should not be used in breast feeding mothers Treatment of priapism - CORRECT ANSWERS Ice pack application > alpha adrenergic agonist (phenylephrine) When do you treat bacterial enteritis (fever + bloody diarrhea) in children? - CORRECT ANSWERS 1. <3 months 2. Invasive or severe disease 3. Immunocompromised patient 4. Cholera *rule out enterohemorrhagic E. coli* *therapy = hydraiton oral or IV* Patient who refuses HIV testing after needle-stick injury in a health care worker - CORRECT ANSWERS Treat with HIV prophylaxis anyway, and don't test Patient with renal failure and diabetes what two drugs should you avoid - CORRECT ANSWERS metformin and sulfonylureas (both metabolized exclusively by the kidneys) Most common corneal foreign body bacteria - CORRECT ANSWERS S. aureus (pseudomonas is for contact lenses) Patients with bicuspid aortic valve should be screened for - CORRECT ANSWERS thoracic aortic aneurysm (high risk of developing an aneurysm, dissection or dilation) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Unilateral headache + Horner syndrome (unilateral miosis and ptosis, anhidrosis = PAM) - CORRECT ANSWERS carotid artery dissection Preparation for lactose intolerance test - CORRECT ANSWERS fast for eight hours Maintenance treatment for sickle cell anemia - CORRECT ANSWERS 1. Vaccination 2. Penicillin prophylaxis until age 5 3. Folic acid supplementation 4. Hydroxyurea if patient has recurrent vasoocclusive events MELD score componenets - CORRECT ANSWERS bilirubin, INR and creatinine Sjrogen's syndrome patients are at risk for - CORRECT ANSWERS B-cell non-Hodgkin's lymphoma (look for a patient with a mass) What two tests are used for calculating the dose of anti-D immune globulin - CORRECT ANSWERS Rosette test = qualitative Kleihauer-Betke = quantitative Patient with symptoms suggestive of cholecystitis, but have negative ultrasound what is the next step? - CORRECT ANSWERS HIDA scan How should antenatal corticosteroids for premature labor be administered? - CORRECT ANSWERS Intramuscular Treatment of venous sinus thrombosis - CORRECT ANSWERS treat with heparin even if there is a hemorrhagic infarction (they are due to venous hypertension) Hypothermia summary - CORRECT ANSWERS *remember these patients have a ton of laboratory abnormalities, but don't be fooled unless there is evidence of severe disease you should continue to warm with warm IV fluids and external warming USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Metformin + IV contrast = - CORRECT ANSWERS recipe for lactic acidosis and kidney injury (stop metformin the day of contrast, and continue 2 days later after stable renal function is documented) Foreign body in the stomach - CORRECT ANSWERS do nothing about it. If it's *in the esophagus remove it* Requisites for vaginal delivery in HIV mother - CORRECT ANSWERS 1) Undetectable viral load (<1000) 2) HAART compliance Should you change antiretroviral treatment in an HIV patient? - CORRECT ANSWERS NO especially if she is stable (risk of HIV >teratogenesis) *If starting medications for the first time in the first trimester avoid efavirenz* (can cause neurotube defects. After the first 8 weeks efavirenz can be used *remember patient on HAART don't stop it high risk of drug resistance, and increased viral load* Indinavir (protease inhibitor) main side effect - CORRECT ANSWERS kidney stones Protease inhibitors in general side effects - CORRECT ANSWERS hyperglycemia and hyperlipidemia NRTI side effects in general - CORRECT ANSWERS lactic acidosis Didanosine and Stavudine (NRTI) can cause - CORRECT ANSWERS Pancreatitis and peripheral neuropathy Zidovudine main side effect - CORRECT ANSWERS anemia USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Tenofovir (NRTI) side effectt - CORRECT ANSWERS renal toxicity Flexible kyphosis (thoracic kyphosis that corrects with voluntary back hyperextension) management - CORRECT ANSWERS None does not lead to any adverse physical effects, and it corrects itself Scheuerman disease (structural disorder = nonflexible kyphosis, pain) - CORRECT ANSWERS Treat with exercise and brace Women age >45 with possible menopause (peri-menopause) who has irregular uterine bleeding next step - CORRECT ANSWERS Endometrial biopsy to make sure there is no endometrial hyperplasia or cancer *ultrasound for endometrial thickness is only for women who are fully post-menopausal* Normal thickness sis <4mm Management of pregnant women with ovarian cysts - CORRECT ANSWERS if persistently >5mm (may regress after trimester) remove in the second trimester due to high chance of torsion, rupture, hemorrhage etc. leading to preterm delivery or abnormal labor Hematochezia management (summary) - CORRECT ANSWERS Hemodynamically stable = colonoscopy. If no source then do upper endoscopy Hemodynamically unstable = Resuscitation, possible consult, if suspect UGIB get upper endoscopy if not do angiography -If patient improves after resuscitation get colonoscopy HIV Patient with odynophagia showing ulcers in the esophagus on upper endoscopy, and negative biopsy, culture and cytology (no CMV, no HSV, no candida) - CORRECT ANSWERS patient has aphthous ulcers and should be treated with prednisone *look for a patient already treated with fluconazole USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Rectal prolapse management - CORRECT ANSWERS If no full thickness (no concentric rings) treat medically with fiber, fluids, pelvic floor exercises) If full thickness (concentric rings, thick, protruding). Get surgery consult for evaluation of incarceration and gangrene Gestational diabetes summary - CORRECT ANSWERS Screen at 24-28 weeks with a 50g OGTT. If >140 proceed with 100g oral test Two or more values of: If >140 after 3 hours, >160 after 2 hours, >180 after 1 hour, >100 fasting then diagnose with gestational diabetes Target glucose levels in pregnancy - CORRECT ANSWERS fasting <100 1 hour postprandial <140 *if these are present after diet modifications start insulin* Alcoholic with weakness after being treated with fluids, thiamine and glucose - CORRECT ANSWERS hypophosphatemia (alcoholics are phosphate depleted even if levels are normal Refeeding decreases phosphate. Can lea to rhabdomyolysis causing weakness What test is used for identify drug overdoses rapidly? - CORRECT ANSWERS Urine immunoassay Recurrent pneumonia in an elderly smoker think - CORRECT ANSWERS endobronchial obstruction with possible bronchogenic carcinoma Dry powder chemical exposure next step - CORRECT ANSWERS brush off the powder AND THEN irrigate USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS *initiating HAART immediately carries a high risk of immune reconstitution inflammatory syndrome that can worsen the infection, and increase mortality* Management of sleep terrors` - CORRECT ANSWERS reassurance Dumping syndrome management (look got a patient post-gastrectomy having nausea, diarrhea, abdominal pain) - CORRECT ANSWERS management is a high protein diet and low carb diet Colon cancer screening in patient with first degree relative with cancer - CORRECT ANSWERS 40 y/o or 10 years before cancer diagnosis (don't be fooled by a number like 43, you start at 40) How should the pneumococcus vaccine be administered in adults? - CORRECT ANSWERS Sequential PCV13+PPSV23 (PCV13 first then then the PPSV23 in 6 months) in: 1) Patients age > 65 2) High-risk patients (asplenia, sickle cell, immunocompromised, *chronic kidney/ESRD*, cochlear implants, CSF leak) Administer PPSV23 *only* in heart, liver, lung, diabetics, current smokers, and alcoholics How should you adminster the pneumoccocus vaccine in children? - CORRECT ANSWERS *You give all children PCV13* Children at high risk also get PPSV23 (asplenia, chronic heart, lung immunocompromised etc.) Treatment of acute epistaxis - CORRECT ANSWERS Nostril pinching > topical vaso constrictor (oxymetazoline) > packing Most originate from the Kiesselbach's plexus (anterior nasal septum) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Acute rheumatic fever prophylaxis and treatment - CORRECT ANSWERS Treat with antibiotics and aspirin High risk of recurrence give antibiotic prophylaxis HIV patient not on HAART should be evaluated how often - CORRECT ANSWERS Every 3 months Lithium-induced hypothyroidism treatment - CORRECT ANSWERS Don't stop the medication, add levothyroxine Scrotal mass (any patient) next step - CORRECT ANSWERS Ultrasound if solid orchiectomy Treatment of psoriasis - CORRECT ANSWERS Mild-moderate = high-potency topical corticosteroids (bethamethasone, hint not hydrocortisone), and vitamin D derivatives Severe plaques ( >30% skin) = methotrexate or phototherapy Facial psoriasis = low potency steroids or topical tacrolimus Psoriatic arthritis = methotrexate Necrolytic migratory erythema (erythematous scaly rash with central clearing that is elevated and crusty - CORRECT ANSWERS Glucagonoma Also look for mild diabetes Anticoagulation with warfarin in pregnancy - CORRECT ANSWERS Switch for warfarin to LMWH in thr first trimester Second and third switch back to warfarin, before delivery discontinue and used unfractionated heparin (rapidly reversible) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS This is in patients with high risk for thrombus such as mechanical valve Patient went on a campaign trip now has ascending paralysis - CORRECT ANSWERS Neurotoxin producing tick next step is to look for it Treatment of cyanide poisoning - CORRECT ANSWERS Amyl nitrate and sodium thiosulfate If concomitant CO poisoning use hydroxycobamin Look for nitroprusside or smoke inhalation Methemoglobinemia - CORRECT ANSWERS Look for nitrates (nitroglycerin)or local anesthetics that end in -caine Treatment is methylene blue Tx. of CAP - CORRECT ANSWERS Cephalosporin + macrolide Ceftriaxone + azithromycin Pediatric sepsis <28 days va >28 days - CORRECT ANSWERS 1) first 28 days need GBS and E. Coli coverage. Ampicillin + gentamicin or cefotaxime (cefotaxime is preferred) 2) Over 28 days treat with ceftriaxone/cefotaxime and vancomycin. Cover for strep pneumo and neisseria Avoid ceftriaxone in the first 28 days due to possible worsening of hyperbilirubinemia USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Should you restart statin therapy in a patient who had elevated CK levels? - CORRECT ANSWERS Yes, after they normalize Treatment of CAP in children - CORRECT ANSWERS high-dose amoxicillin (look for lobar consolidation/focal lung findings. S. pneumo) If older child with bilateral lung findings azitrhomycin may be used (Mycoplasma) Classic measles (hint 3 C's) - CORRECT ANSWERS Coryza (nasal mucous membrane inflammation), cough, conjuctivitis Koplik spots are characteristic Look for maculopapular rash that starts on the face and spreads downward Rubella - CORRECT ANSWERS Look for maculopapular rash that starts on the face and goes down & posterior lymphadenopathy (others: fever, runny nose) *Look for acute arthritis in adults* Less sick than measles If you see metabolic acidosis in a DMII patient don't forget about a common medication that causes HAGMA!! - CORRECT ANSWERS metformin causes HAGMA with lactic acidosis Order IV fluids, ketones, lactate and ABGs Management of diabetes in pregnant women undergoing labor - CORRECT ANSWERS Give insulin as you always do do not reduce dose keep glucose level between 72-126 mg/dL High glucose levels = fetal hypoglycemia following delivery USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS People who require prophylaxis to Neisseria meningitidis exposure - CORRECT ANSWERS Basically anyone with direct exposure to respiratory secretions, more than >8 hours with the person within <3 feet Prophylaxis for meningococcal meningitis - CORRECT ANSWERS Rifampin or ciprofloxacin in patients who can't take rifampin (look for OCP use How long does a patient need to be treated with steroids to require tapering? - CORRECT ANSWERS <3 weeks glucocorticoids even at high dosages do not require tapering What is a mycotic aneurysm - CORRECT ANSWERS It is an infected aneurysm usually due to infective endocarditis (septic embolization, and vessel wall destruction They can occur in the brain causing neurological findings Also look for fever, headache, heart murmur Management of supratherapeutic warfarin - CORRECT ANSWERS <5 INR stop warfarin >5 INR stop warfarin, give vitamin K If bleeding give fresh frozen plasma Patients admitted for recent variceal bleeding should receive prophylaxis for - CORRECT ANSWERS SBP (can occur in up to 50% of patients) regimen = fluoroquinolone (ciprofloxacin) for 7-10 days Old man with orthostatic hypotension taking multiple medications suspect - CORRECT ANSWERS diuretics, alpha-blockers or nitrates as they cause Treatment of renal cell carcinoma based on the extent of the mass - CORRECT ANSWERS If confined to the renal capsule it is *stage I* and can be removed with *partial nephrectomy* USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Stage II (past the renal capsule, but not the Gerota's fascia) - radical neprhectomy is the best option Higher stages need radiation, chemotherapy and/or surgical debulking Tuberculosis treatment for pregnant patients - CORRECT ANSWERS Isoniazid, rifampin and ethambuotol for 9 months *avoid pyrazinamide* MEN 1 - CORRECT ANSWERS 3Ps Parathyroid, pancreatic tumor, pituitary tumor (pheochromocytoma, medullary thyroid carcinoma are MEN2 look for differentiation when a patient has hyperparathyroidism which is present in both MEN 1 and MEN2A Evidence of candida infection in diaper rash - CORRECT ANSWERS tomato-red papules, satellite papules, and compromise of the *genitocrural i.e. skin folds (intetrigo)* These need a topical antifungal agent such as nystatin or clotrimazole Displaced clavicle fracture treatment - CORRECT ANSWERS open reduction and internal fixation Non-displaced can be treat with figure eight slings Last test to confirm brain death in a patient (someone with no response to pain, coma, no pupillary reflex, no corneal reflex, no oculocephalic reflexes [caloric testing], and no gag reflex - CORRECT ANSWERS *apnea test* (no respiratory response with rising CO2) USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS There is no urgency in treating osteomyelitis Treat according to the culture Quinolones have good bone penetration Treatment of otitis externa - CORRECT ANSWERS Acetic acid to reacidify the ear, topical hydrocortisone and topical antibiotics' For malignant otitis externa get a MRI (it's really osteomyelitis). Treat with surgical debridement and antibiotics for pseudomonas Erysipelas treatment - CORRECT ANSWERS cephalexin, dicloxacillin, clindamycin Treatment of Jarish-Herxheimer reaction - CORRECT ANSWERS aspirin (don't stop treatment) Best test for neurosyphillis - CORRECT ANSWERS CSF FTA Best antibiotics for endocarditis - CORRECT ANSWERS vancomycin + gentamicin (empiric, taylor after blood cultures return) Indications for valce replaccement in endocarditis - CORRECT ANSWERS 1. Valve rupture 2. Abscess 3. Prosthetic valves 4. Fungal endocarditis 5. Embolic events despite antibiotic therapy Standard of care for HAART (what are the antivirals) - CORRECT ANSWERS Tenofovir (NRTI) + Emtricabine (NRTI) + efavirenz (NNRTI) -Efavirenz causes weird dreams, cannot be used in pregos during the first trimester USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Tenofovir + emtricabine + atazanavir or darunavir (protease inhibitor) is another option. Ritonavir is typically added to boost protease inhibitor levels HIV drugs summary - CORRECT ANSWERS Standard HAART treatment in pregnant women - CORRECT ANSWERS Zidovudine and lamivudine + lopinavir (ritonavir can be added) MARAVINOC - CORRECT ANSWERS CCR5 RECEPTOR BLOCKER (people who are "HIV immune" don't have this receptor) Toxoplasmosis treatment (HIV) - CORRECT ANSWERS pyrimethamine and sulfadiazine for 2 weeks, repeat CT scan to verify that the lesions are smaller (if unchanged performed biopsy because it's probably lymphoma Drug that can cause PML (other than HIV) - CORRECT ANSWERS natalizumab Diagnose PML by PCR of CSF for JC virus Malaria prophylaxis - CORRECT ANSWERS mefloquine (best treatment also) Atovaquone/proguanil is another choice Anticoagulant therapy in NSTEMI - CORRECT ANSWERS 1. Two antiplatelets (plavix + aspirin) 2. LMWH 3. Epitifibatide (GBIIb/IIIA inhibitor) Treatment of pulmonary edema - CORRECT ANSWERS FONM Furosemide USMLE STEP 3 REVIEW QUESTIONS AND ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS CORRECT VERIFIED BEST GRADED A+ FOR SUCCESS Oxygen nitrates Morphine Can add dobutamine or milironone Most common cause of SCD in exercising athletes (hint not HOCM) - CORRECT ANSWERS anomalous origin of the coronary artery CRITERIA for pneumonia admission - CORRECT ANSWERS C - Confusion U - Urea (BUN) R - Respiratory Rate >30 B - BP (hypotension) 65 (age) Ventilator associated pneumonia treatment - CORRECT ANSWERS 2 antipseudomonals + MRSA Meropenem or pip/tazo or cefepime + Gentamicin + Vancomycin or linezolid Positive PPD sequence - CORRECT ANSWERS DO chest x-ray if negative treat with INH six months If CXR is abnormal do a sputum staining for TB if positive treat with four drugs Peds meningitis empiric antibodies - CORRECT ANSWERS cefotaxime + vancomycin + ampicillin + IV dexamethesone