Archer Live Online USMLE Step3 CCS Workshops from www.CcsWorkshop.com
Archer is the only live CCS Workshop in which experienced Internal Medicine board certified physicians will teach you live how to apply unique high-yield CCS strategies to score the most in the CCS Component.
Archer online live step 3 reviews aims to bring USMLE step 3 courses on your desktop, at your doorstep! These highly successful live USMLE Step3 online reviews are an extension of our very popular and successful ” Dr.Red’s online ccs workshop, which has reached more than two thousand step3 takers in less than 12 months and has resulted in 98% pass rate. Archer Reviews have achieved a high success rate even with examinees with multiple attempts by our unique approach. These online reviews are done live and in a webinar format. You can stay at home and listen to lectures live and like in a virtual classroom, you can raise your hand and your question will be immediately answered by the instructor. This is a live online classroom which reduces the pain of flying several miles to attend live reviews. These are the only one in the market that offer successful step 3 lectures in this unique, live format. Archer's most successful endeavor has been Dr.Red’s CCS Workshop which has helped hundreds of examinees to pass easily by excelling on CCS component.
Archer's next CCS online workshop for the month of January 2010 will be on Sunday 01/24/2010 at 10 AM EST.
If you are interested in registering for this course, you can pay for the course on the website at http://www.shop.ccsworkshop.com. Upon payment of the registration fee, your registration request will be automatically approved and an approval e-mail will be sent to you. This approval notice will have a button “Join Webinar” in it. Clicking this button on the day of the workshop will open up the live workshop on your desktop
To participate in the workshop, you will need a computer with internet access. For the audio, you can use either your computer’s microphone or a telephone. You will use the phone for the voice and log in to the conference call while you watch the power-point slides and the CCS demonstration on your desktop via. our unique net meeting software. You can also just opt to use your computer’s microphone in which case you do not need a telephone. Then you will get to practice a case while we watch and analyze your approach and correct it.
CCS Workshop Includes :
1. Lecture on CCS Strategies
2. Live demonstration of CCS cases
3. Common mistakes committed by the examinees and preventing them
4. Tips to score extremely high on CCS
5. Follow-ups of office and ER cases
6. Efficient use of time, doing more stuff without advancing the clock
7. Avoiding invasive tests
8. Basic set of orders for emergency cases
9. The 5-minute screen – adding/ disconinuing the orders that can matter
10. Obtaing consults and their appropriateness
11. Differential diagnosis for common ER and office presentations and easy tips to get the most out of few orders.
12. Working on efficiency
13. Live practice of 15 to 20 CCS cases by the attendees in the workshop
14. A these in addition to –> 20 minutes of supervised practice of one CCS case by each attendee who volunteers to practice. About 15 to 20 Highyield CCS cases will be practiced. During this time, you will be thoroughly analyzed, corrected and given instantaneous feedback by our experienced faculty
The total course fee is $97 .Slots are limited at 45.
If you are interested in the course, you visit Archer's online store directly to pay : http://www.shop.ccsworkshop.com
If you have further questions, please directly contact support@ccsworkshop.com
Archer's other courses include very informative topic reviews and the high-yield rapid review – please check our website. Next 3-Day Step 3 Rapid Review is in March -2010. Archer theory reviews are now available as streaming videos so that you can start accessing them from the beginning of your step 3 preperation and fine tune your conceptual understanding.
Monday, September 7, 2009
Sunday, July 12, 2009
Nephrology for USMLE Step 3
Acid-Base disorders require understanding of the underlying pathophysiology as well as familiarity with some formulas. Several Acid-Base scenarios that can be tested on USMLE Step 3 are
A) Identifying the acid base disorder
B) Identifying the etiology of acid-base imbalance in an Multiple choice question by elimination process of other choices based on the acid-base characterestic.
C) Diagnosing mixed acid-base disorders by applying simple formulas
D) Causes and treatment of increased anion gap acidosis
E) Causes of Non-Gap Acidosis
F) Renal tubular acidosis and identifying the etiology of the RTA from subtle clues in the question stem.
G) Osmolar gap and using this concept to identify the etiology in metabolic acidosis and in toxicology.
Memorize the following formulas:
1) Anion gap = (Na+)-{(Cl-)+(Hco3-)}
Normal gap is 4 to 12.
Anion gap greater than 12 indicates increased anion gap metabolic acidosis. This indicates the presence of a foreign substance causing acid-base imbalance.
If there is acidosis ( low bicarb <>It is important to know the distinction because the causes of increased gap metabolic acidosis are different from non-gap acidosis. So, once you know whether the gap is increased or not, you can further focus only on the relevant causes.
Causes of Increased Gap Acidosis ( MUDPILES)
- Methanol (M)
- Uremia (U)
- Diabetic Ketoacidosis ( D)
- Paraldehyde, Propylene glycol ( P)
- Isoniazid ( I)
- Lactic acid (L)
- Ethylene Glycol (E)
- Salicylic acid ( S)
Causes of Non-Gap acidosis : The gap here is normal because when the hco3- drops, there is a compensatory increase in the chloride there by, keeping the gap normal. This indicates no foreign substance but it is because of the loss of bicarbonate either through the GI tract ( Diarrhea) or Renal system ( RTA). These causes are:
- Gastrointestinal loss of Bicarbonate : Diarrhea, small bowel fistulas, urinary diversion
- Renal causes : Renal tubular acidosis, renal insufficiency, hypoladosteronism.
- Recovery phase of DKA
Concept of Urine Anion Gap
Now, let us say you have a metabolic acidosis and the gap is normal --> you know that this is normal anion gap acidosis. But there are two important causes of normal gap acidosis as you have already seen earlier - GI vs. Renal . How do you differentiate between the two?
For this, you will need to know URINE ANION GAP
Urine Anion Gap (UAG) = {(urineNa)+(urineK+)}-(urine Cl-)
Normal values for UAG is -10 to +10.
A logical approach here is to look at the urine Na+. If urine Na+ is low ( which you would expect in dehydration, diarrhea etc), urine anion gap tends to be more negative and points towards GI losses ( such as diarrhea)
So, a UAG < -10 ( more negative gap) indicates a GI cause for Non Gap Acidosis where as a UAG > +10 indicates a Renal Tubular Acidosis.
If you have difficulty remembering this, remember neGUTive - negative UAG in bowel (GUT) causes.
Renal Tubular Acidosis ( RTA)
A normal gap metabolic acidosis with positive urine anion gap ( UAG) could be due to RTA. There are different types of RTA.
Type 1 ( distal)
Type 2 (proximal)
Type 4 (hyporeninemic hypoaldosteronism)
On the exam, once you identify a metabolic acidosis and then identify an RTA, you will be tested on the etiology of that RTA. So, it is important to know how to differentiate between different RTAs and their causes.
To differentiate between various RTAs, first look at the serum potassium. If K+ is high in an RTA , this is most likely Type 4 ( because low aldosterone causes decreased renal excretion of acid and potsssium) If the potassium is normal or low, then the RTA could be Type 1 (Distal) or Type II (Proximal). You will need to look at the urine pH to differentiate between Distal and Proximal RTA. Remember that Distal RTA can never acidify the urine so, the Urine pH is never less than 5.5. So, if a MCQ gives a urine pH of less than 5,5, you are most likely dealing with Proximal RTA.
Type 1 RTA - Distal RTA :
- Causes: autoimmune diseases ( scleroderma), hyperglobinemia states and hereditary
- Present with normal anion gap acidosis, urine pH >5.5, hypokalemia, hypercalciuria, nephrocalcinosis and stones
- Treatment: alkali i.e. K citrate
Type II RTA - Proximal RTA :
- Failure to reabsorb filtered bicarbonate in the proximal tubule
- Presents with Hypokalemia and normal gap acidosis
- Urine pH > 5.5, but it will be less than 5.5 once serum HCO3 is less than 16
- Causes: Multiple myeloma, Acetozolamide, Ifosfamide Lead, cadmium, copper
Type IV RTA - Hyporeninemic Hypoaldosteronism
- Causes: diabetes mellitus, HIV and tubulo-interstitial disease
- Present with hyperkalemia, normal anion gap acidosis and normal urine pH
Identifying Mixed Acid-Base Disorder in Metabolic acidosis
A) To understand if a patient has both increased anion gap acidosis and non-gap acidosis at the same time or metabolic acidosis + metabolic alkalosis at the same time, you will need to know the concept of "Delta Gap" . Delta gap is logically explained in the video clip below. Logically, if the serum bicarbonate (Hco3-) falls more than the change in the anion gap, then a patient has both non-gap+increased gap acidosis. If the serum bicarbonate falls less than the change in the anion gap, then the patient has mixed disorder - metabolic acidosis + metabolic alkalosis.
For example, if the anion gap is 20 --> you can say the change in the anion gap is 8 ( because normal anion gap is 12. ) In this scenario let us say if the MCQ gave serum hco3- as 10, drop in the serum bicarb here is 14 ( remember, for calculation normal serum bicarb is taken as 24. so, if it is 10 now, the drop in bicarb is obviously, 14). --> this means when your anion gap has increased by 8 your bicarb has fallen more than 8 i.e; by 14....that means some other factor apart from the factor responsible for increased gap acidosis is also contributing to acidosis here! - this suggests co-existing increased anion-gap+normal-gap acidosis . A classic example is diarrhea with shock - where diarrhea causes non gap acidosis but shock can lead to lactic acidosis which increases the gap - so, things can co-exist!
B) To understand if your patient has a mixed disorder of metabolic acidosis + respiratory acidosis or metabolic acidosis + respiratory alkalosis, you will need to be familiar with Winter's formula.
Winter;s formula :
Expected pCo2 = {1.5(Hco3-) +8} +/-2
If your patient has metabolic acidosis, you expect him to breathe fast and wash out the Co2 so as to maintain the pH in normal limits ...this is called "Compensation". Compensation brings the serum pH towards the normal but never makes it completely normal - so, if you are seeing a normal pH in a metabolic acidosis , you can right away say that you are dealing with a Mixed disorder rather than a compensation alone.
The expected Pco2 in the above formula is the one that is expected as a comprnsation if your patient has low bicarbonate or metabolic acidosis. You need to compare this expected Pco2 with the real value of Pco2 obtained on the arterial blood gases ( measured Pco2).
Pearls for answering questions on Mixed Disorders:
A) If measured Pco2 is lower than the expected Pco2, that means your patient is washing out more C02 than expected ---meaning, he has respiratory alkalosis co-existent with metabolic acidosis ( one example of such mixed disorder is Salicylate toxicity) .
B) If measured Pco2 is higher than expected Pco2, that means your patient is retaining Co2 which means he has a co-existent Respiratory acidosis along with metabolic acidosis ( eg: Cardiac arrest can cause such mixed acidosis because reduced respiratory drive causes CO2 retention leading to respiratory acidosis where as shock because of cardiac arrest causes lactic acidosis which is metabolic acidosis).
eg: If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between 30 to 34 ( see the above formula). However, let us say your patients Pco2 on the arterial blood gas is 20 --> you can call this metabolic acidosis + respiratory alkalosis. eg : Salicylate Toxicity
If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between 30 to 34 ( see the above formula). However, let us say your patients Pco2 on the arterial blood gas is 44 --> you can call this metabolic acidosis + respiratory acidosis. eg : Cardiac arrest
In this 35 minute clip, our instructing physician explains Hypercalcemia and Acid-Base disorders in simple terms. After listening to the clip, try to answer the self - assessment questions below.
Click Here
When the page opens, right click on the clip and "Zoom" to view full screen so as to have better audio/ video quality. These are on the web page itself so you may hear slight resound in the background unlike pay-per-view system which comes as a streaming video.
Self-Assessment Questions ( Copy right: USMLEGalaxy)
- will be posted soon!
A) Identifying the acid base disorder
B) Identifying the etiology of acid-base imbalance in an Multiple choice question by elimination process of other choices based on the acid-base characterestic.
C) Diagnosing mixed acid-base disorders by applying simple formulas
D) Causes and treatment of increased anion gap acidosis
E) Causes of Non-Gap Acidosis
F) Renal tubular acidosis and identifying the etiology of the RTA from subtle clues in the question stem.
G) Osmolar gap and using this concept to identify the etiology in metabolic acidosis and in toxicology.
Memorize the following formulas:
1) Anion gap = (Na+)-{(Cl-)+(Hco3-)}
Normal gap is 4 to 12.
Anion gap greater than 12 indicates increased anion gap metabolic acidosis. This indicates the presence of a foreign substance causing acid-base imbalance.
If there is acidosis ( low bicarb <>It is important to know the distinction because the causes of increased gap metabolic acidosis are different from non-gap acidosis. So, once you know whether the gap is increased or not, you can further focus only on the relevant causes.
Causes of Increased Gap Acidosis ( MUDPILES)
- Methanol (M)
- Uremia (U)
- Diabetic Ketoacidosis ( D)
- Paraldehyde, Propylene glycol ( P)
- Isoniazid ( I)
- Lactic acid (L)
- Ethylene Glycol (E)
- Salicylic acid ( S)
Causes of Non-Gap acidosis : The gap here is normal because when the hco3- drops, there is a compensatory increase in the chloride there by, keeping the gap normal. This indicates no foreign substance but it is because of the loss of bicarbonate either through the GI tract ( Diarrhea) or Renal system ( RTA). These causes are:
- Gastrointestinal loss of Bicarbonate : Diarrhea, small bowel fistulas, urinary diversion
- Renal causes : Renal tubular acidosis, renal insufficiency, hypoladosteronism.
- Recovery phase of DKA
Concept of Urine Anion Gap
Now, let us say you have a metabolic acidosis and the gap is normal --> you know that this is normal anion gap acidosis. But there are two important causes of normal gap acidosis as you have already seen earlier - GI vs. Renal . How do you differentiate between the two?
For this, you will need to know URINE ANION GAP
Urine Anion Gap (UAG) = {(urineNa)+(urineK+)}-(urine Cl-)
Normal values for UAG is -10 to +10.
A logical approach here is to look at the urine Na+. If urine Na+ is low ( which you would expect in dehydration, diarrhea etc), urine anion gap tends to be more negative and points towards GI losses ( such as diarrhea)
So, a UAG < -10 ( more negative gap) indicates a GI cause for Non Gap Acidosis where as a UAG > +10 indicates a Renal Tubular Acidosis.
If you have difficulty remembering this, remember neGUTive - negative UAG in bowel (GUT) causes.
Renal Tubular Acidosis ( RTA)
A normal gap metabolic acidosis with positive urine anion gap ( UAG) could be due to RTA. There are different types of RTA.
Type 1 ( distal)
Type 2 (proximal)
Type 4 (hyporeninemic hypoaldosteronism)
On the exam, once you identify a metabolic acidosis and then identify an RTA, you will be tested on the etiology of that RTA. So, it is important to know how to differentiate between different RTAs and their causes.
To differentiate between various RTAs, first look at the serum potassium. If K+ is high in an RTA , this is most likely Type 4 ( because low aldosterone causes decreased renal excretion of acid and potsssium) If the potassium is normal or low, then the RTA could be Type 1 (Distal) or Type II (Proximal). You will need to look at the urine pH to differentiate between Distal and Proximal RTA. Remember that Distal RTA can never acidify the urine so, the Urine pH is never less than 5.5. So, if a MCQ gives a urine pH of less than 5,5, you are most likely dealing with Proximal RTA.
Type 1 RTA - Distal RTA :
- Causes: autoimmune diseases ( scleroderma), hyperglobinemia states and hereditary
- Present with normal anion gap acidosis, urine pH >5.5, hypokalemia, hypercalciuria, nephrocalcinosis and stones
- Treatment: alkali i.e. K citrate
Type II RTA - Proximal RTA :
- Failure to reabsorb filtered bicarbonate in the proximal tubule
- Presents with Hypokalemia and normal gap acidosis
- Urine pH > 5.5, but it will be less than 5.5 once serum HCO3 is less than 16
- Causes: Multiple myeloma, Acetozolamide, Ifosfamide Lead, cadmium, copper
Type IV RTA - Hyporeninemic Hypoaldosteronism
- Causes: diabetes mellitus, HIV and tubulo-interstitial disease
- Present with hyperkalemia, normal anion gap acidosis and normal urine pH
Identifying Mixed Acid-Base Disorder in Metabolic acidosis
A) To understand if a patient has both increased anion gap acidosis and non-gap acidosis at the same time or metabolic acidosis + metabolic alkalosis at the same time, you will need to know the concept of "Delta Gap" . Delta gap is logically explained in the video clip below. Logically, if the serum bicarbonate (Hco3-) falls more than the change in the anion gap, then a patient has both non-gap+increased gap acidosis. If the serum bicarbonate falls less than the change in the anion gap, then the patient has mixed disorder - metabolic acidosis + metabolic alkalosis.
For example, if the anion gap is 20 --> you can say the change in the anion gap is 8 ( because normal anion gap is 12. ) In this scenario let us say if the MCQ gave serum hco3- as 10, drop in the serum bicarb here is 14 ( remember, for calculation normal serum bicarb is taken as 24. so, if it is 10 now, the drop in bicarb is obviously, 14). --> this means when your anion gap has increased by 8 your bicarb has fallen more than 8 i.e; by 14....that means some other factor apart from the factor responsible for increased gap acidosis is also contributing to acidosis here! - this suggests co-existing increased anion-gap+normal-gap acidosis . A classic example is diarrhea with shock - where diarrhea causes non gap acidosis but shock can lead to lactic acidosis which increases the gap - so, things can co-exist!
B) To understand if your patient has a mixed disorder of metabolic acidosis + respiratory acidosis or metabolic acidosis + respiratory alkalosis, you will need to be familiar with Winter's formula.
Winter;s formula :
Expected pCo2 = {1.5(Hco3-) +8} +/-2
If your patient has metabolic acidosis, you expect him to breathe fast and wash out the Co2 so as to maintain the pH in normal limits ...this is called "Compensation". Compensation brings the serum pH towards the normal but never makes it completely normal - so, if you are seeing a normal pH in a metabolic acidosis , you can right away say that you are dealing with a Mixed disorder rather than a compensation alone.
The expected Pco2 in the above formula is the one that is expected as a comprnsation if your patient has low bicarbonate or metabolic acidosis. You need to compare this expected Pco2 with the real value of Pco2 obtained on the arterial blood gases ( measured Pco2).
Pearls for answering questions on Mixed Disorders:
A) If measured Pco2 is lower than the expected Pco2, that means your patient is washing out more C02 than expected ---meaning, he has respiratory alkalosis co-existent with metabolic acidosis ( one example of such mixed disorder is Salicylate toxicity) .
B) If measured Pco2 is higher than expected Pco2, that means your patient is retaining Co2 which means he has a co-existent Respiratory acidosis along with metabolic acidosis ( eg: Cardiac arrest can cause such mixed acidosis because reduced respiratory drive causes CO2 retention leading to respiratory acidosis where as shock because of cardiac arrest causes lactic acidosis which is metabolic acidosis).
eg: If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between 30 to 34 ( see the above formula). However, let us say your patients Pco2 on the arterial blood gas is 20 --> you can call this metabolic acidosis + respiratory alkalosis. eg : Salicylate Toxicity
If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between 30 to 34 ( see the above formula). However, let us say your patients Pco2 on the arterial blood gas is 44 --> you can call this metabolic acidosis + respiratory acidosis. eg : Cardiac arrest
In this 35 minute clip, our instructing physician explains Hypercalcemia and Acid-Base disorders in simple terms. After listening to the clip, try to answer the self - assessment questions below.
Click Here
When the page opens, right click on the clip and "Zoom" to view full screen so as to have better audio/ video quality. These are on the web page itself so you may hear slight resound in the background unlike pay-per-view system which comes as a streaming video.
Self-Assessment Questions ( Copy right: USMLEGalaxy)
- will be posted soon!
Monday, June 29, 2009
What Predicts USMLE Step 3 Performance
As per this Study, the following variables predict USMLE step 3 performance :
1. Knowledge of clinical
science as measured on USMLE Step 2
exam
2. Having higher Step 2 Scores
3.The nature of the
residency training
4. Having a higher GPA
5. Residency training in a
broad-based specialty
Step 1 score did not predict Step 3 performance.
1. Knowledge of clinical
science as measured on USMLE Step 2
exam
2. Having higher Step 2 Scores
3.The nature of the
residency training
4. Having a higher GPA
5. Residency training in a
broad-based specialty
Step 1 score did not predict Step 3 performance.
Friday, June 26, 2009
Blog as a teaching tool
Can a weblog be used as an effective teaching tool to teach medicine?
Archer has introduced innovative teaching strategies in the past and has reached hundreds of students around the world via. online webinar teaching. With the introduction of USMLE 3 blog, Archer will now explore if social media such as blogs can be used as effective teaching tools to teach medical students and residents.
Blog as a teaching tool! Five reasons why it might be an efficient teaching tool :
A) Blogs are now a new fashion! Several students and young people often blog or micro-blog. Young students might not read as much as we would like them to, but they do blog!
B) What might look or sound very boring in a traditional classroom might gain a student's attention on a blog!
C) Blogs foster creativity and expression. Blog can make a student think, analyze and write thereby, serving as an effective leaning media!
D) Blogs can be monitored by the organizing teacher and a student's thought process as well as conceptual understanding can be caught in his posts and can be readily corrected.
E) A student might feel more at ease to post his thoughts in an anonymous name rather than opening up in a live classroom! When your identity is not being revealed, you will not hesitate to ask any question however stupid you think it might sound to others and that's exactly where a blog opens up a dialogue and corrects your conceptual understanding!
From time to time, Archer will post several topic discussions on the concepts that are frequently misunderstood by students preparing for USMLEs and by residents in Internal medicine as well Family practice programs. Archer will bring to this blog the most updated guidelines in medicine from several authentic journals and sources.
Through this approach, Archer will observe the student's response to see if weblogging is serving as an efficient tool to teach medical students and residents.
Tweet Archer
Archer has introduced innovative teaching strategies in the past and has reached hundreds of students around the world via. online webinar teaching. With the introduction of USMLE 3 blog, Archer will now explore if social media such as blogs can be used as effective teaching tools to teach medical students and residents.
Blog as a teaching tool! Five reasons why it might be an efficient teaching tool :
A) Blogs are now a new fashion! Several students and young people often blog or micro-blog. Young students might not read as much as we would like them to, but they do blog!
B) What might look or sound very boring in a traditional classroom might gain a student's attention on a blog!
C) Blogs foster creativity and expression. Blog can make a student think, analyze and write thereby, serving as an effective leaning media!
D) Blogs can be monitored by the organizing teacher and a student's thought process as well as conceptual understanding can be caught in his posts and can be readily corrected.
E) A student might feel more at ease to post his thoughts in an anonymous name rather than opening up in a live classroom! When your identity is not being revealed, you will not hesitate to ask any question however stupid you think it might sound to others and that's exactly where a blog opens up a dialogue and corrects your conceptual understanding!
From time to time, Archer will post several topic discussions on the concepts that are frequently misunderstood by students preparing for USMLEs and by residents in Internal medicine as well Family practice programs. Archer will bring to this blog the most updated guidelines in medicine from several authentic journals and sources.
Through this approach, Archer will observe the student's response to see if weblogging is serving as an efficient tool to teach medical students and residents.
Tweet Archer
Sunday, June 21, 2009
Cardiovascular Stress Test - USMLE Step 3
Cardiovascular stress test is a frequently tested topic on USMLE Step 3 as well as on cardiology section of Internal Medicine Boards. Students and residents often have questions on how to choose an appropriate stress test and on the concept behind the various types of stress tests. In this clip, Dr.Red ( Archer Review) explains the different modalities of stress and the preferred modalities in different situations.
Click Here
When the page opens up, "right click" on the video and "zoom" to view in full screen for good audio/video quality
Click Here
When the page opens up, "right click" on the video and "zoom" to view in full screen for good audio/video quality
Saturday, June 20, 2009
Approach to Hematuria - USMLE Step 3 Review
Approach to Hematuria is often a highly tested concept on USMLE Step 3 exam, USMLE Step 2CK as well as on IM and FP board exams. Some frequently tested scenarios include :
A. Identifying benign hematuria and its approach
B. Correct interpretation of "Dipstick" Hematuria
C. Evaluation of Asymptomatic Microscopic Hematuria in normal patient population vs. those at high risk for urological malignancy.
D. Test of choice for symptomatic hematuria ( Urolithiasis, Cystitis etc)
E. Evaluation of Asymptomatic Hematuria
F. If upper tract imaging for Asymptomatic Hematuria is chosen, what is the initial test of choice? - Many get confused about the initial test for upper tract imaging becauses several sources state several different things. Students are stuck between the choices CT urogram vs. Traditional Intravenos Pyelogram. The guidelines have been updated recently and there is an increasing trend towards CT Urogram even in asymptomatic hematuria ( please check the explaination below).
Here is a summary on how to approach Hematuria on your exam as well as in your office. All the recommendations are taken from AUA, American college of radiology guidelines on appropriate imaging choice.
Hematuria: The following Q and A aaproach will help you understand the principal concepts of Hematuria.
How do you test for Hematuria?
The initial office test that we use to detect hematuria is "Dipstick". Dipstick is highly sensitive but not specific. False negatives are very rare but false positives are common. Dipstick detects "BLOOD" but it does not say whether this "blood" is an RBC or a Pigment. Remember that pigments such as myoglobin ( as in rhabdomyolysis) or Hemoglobin ( as in hemoglobinuria, Black water fever) can stain as "Blood" on dipstick. So, please do not automatically assume that everything that stains as "blood" on a dipstick is an RBC. In order to know if there is true hematuria, the next step is to do urine microscopy. If the urine reveals RBCs then there is true hematuria. However, if the dipstick reads "blood" and if the urine did not reveal RBCs on microscopy then you are dealing with a pigment - either myoglobinuria ( rhabdomyolysis) or hemoglobinuria. At this point, if the CPK is also elevated it suggests that the etiology of blood on the dipstick is Rhabdomyolysis.
So, a dipstick hematuria should always be confirmed with urine microscopy!
If dipstick is negative for blood, it excludes abnormal hematuria ( false-negative results are unusual with dipstick testing).
Benign causes of "Red" urine but negative dipstick test - In some conditions, you may see a red urine resembling "Gross hematuria" but dipstick is negative for blood. This should not be called hematuria. This is just reddish discoloration of urine.
Occurs in :
a) Ingestion of red pigmented foods ( eg: beets, berries, rhubarbs, paprika)
b) Drugs like Rifampin or Phenazopyridine derivatives ( remember these drugs only cause reddish urine but NOT a positive dipstick).
c) Diseases such as "Porphyria"
Causes of a Positive Dipstick but no true Hematuria: Here Dipstick stains positive for blood but no RBCs in the urine
a) Myoglobinuria ( Rhabdomyolysis, vigorous exercise)
b) Hemoglobinuria ( Intravascular hemolysis)
Is the Hematuria associated with pain? - Understand the causes of painless hematuria are different from painful hematuria. Painless hematuria is often from tumors of the urinary tract, bladder cancer or glomerulonephritis. Painful hematuria is often associated with urolithiasis ( renal calculi) or inflammation/ infection of the bladder ( Cystitis).
What will be the approach to identify the source of Hematuria? - The work up for hematuria may involve invasive and expensive approaches. So, it is important to determine the nature of hematuria so that you can limit investigations to the real and pathological hematurias.
Gross Hematuria: Reddish or Tea colored urine, dipstick positive for blood and urine microscopy shows RBCs. Any patient with gross hematuria should always be referred for urological evaluation unless this is secondary to an infection. If a woman has gross hematuria but the urine dipstick also reveals leucoesterase or nitrite or if the woman has symptoms of UTI ( dysuria etc) or if the cultures are growing bacteria, this can be treated as UTI ( cystitis) with antibiotics with out referring for further evaluation. Even in this setting of infection, if there are risk factors for urological malignancy the patient should still be referred for further evaluation ( since hematuria from cancer can also be intermittent).
Runner's hematuria or March hematuria is another benign condition that presents as gross hematuria after a severe physical activity. In such cases, patients may be observed for resolution however, if the hematuria is persistent or if the patient has any risk factors for having a urological malignancy, must be referred to a urologist
Microscopic Hematuria: Grossly, urine looks normal. Dipstick positive for blood and urine microscopy reveals RBCs.
Microscopic Hematuria is often intermittent and most causes are usually benign. So, it is important to define a significant microscopic hematuria that requires further investigations.
Microhematuria is defined as three or more red blood cells per high-power microscopic field (RBCs/HPF) in two out of three properly collected and prepared specimens. Repeat urinalyses to establish whether significant hematuria is present must be done within 3 to 6 months of the initial test.
Minimal microhematuria ( i.e; one or 2 rbcs per HPF ) in asymptomatic young adults does not require any evaluation. ( many studies have indicated that small amounts of blood may be released into the urine of persons with no detectable pathology in the urinary tracts)
In patients with risk factors for having a urological malignancy, a microhematuria even in one or more samples must be considered significant and be evaluated.
Some benign causes of Microhematuria :
A) Exercise
B) Sexual activity
C) Menstruation
D) UTI
If UTI is present ( symptoms and dipstick for leucoesterase are clues that point towards infection) - treat it with antibiotics and repeat urinalysis after the infection has cleared.
E) Benign Prostatic Hypertrophy
F) Prostatitis
Now, carefully look for other charecterestics of urinalysis - Presence of other findings on the microscopic urinalysis such as RBC casts or Dysmorphic RBCs or proteinuria or the labs revealing elevated serum creatinine suggests a the hematuria is originating from the kidney/ glomerulus itself ( eg: Glomerulonephritis, IgA nephropathy). In such cases, the next step in evaluating hematuria is referral to a nephrologist ( not urologist) and a renal biopsy.
Further Approach to Microscopic Hematuria
Symptomatic Hematuria: In painful hematuria --> first rule out infection and renal colic. If infection is absent or if there is a pain similar to renal colic ( classic flank pain) - consider renal stones as the cause of Hematuria. The best initial step in evaluating the cause of painful hematuria that is not explained by UTI is Non-Contrast CT scan (Spiral CT) ( test of choice for imaging renal calculi).
In pregnant women, ultrasound can be performed to avoid radiation exposure.
Asymptomatic MicroHematuria : Patients without the classic flank pain of urolithiasis should be evaluated extensively. Once benign causes such as infection and the kidney ( glomerular) origin are ruled out, further approach should be defined based on the patient's risk profile.
A) For patients with low risk of urological disease, a less extensive work-up may be appropriate ( First do upper tract imaging and if this is negative, add urine cytology+cystoscopy).
B) If the patient is a high risk of having a urological malignancy, extensive work-up is needed ( see the risk factors below) --> Upper tract imaging + cystoscopy+ urine cytology all are needed. Urine cytology should be obtained in all patients with asymptomatic hematuria since it is an easy and non invasive step. Sensitivity of urine cytology is only 48% but remember that if it is positive it is highly specific for urological cancer ( 94% specificity)
Risk factors for urological cancer ( bladder ca):
1. Heavy somkers
2. Occupational exposure to aniline dyes
3. History of Gross hematuria
4. History of pelvic irradiation
5. Age > 40 years
6. Analgesic abuse
7. Presence of irritative voiding symptoms
8. Previous use of Cyclophosphamide ( increases the risk of bladder cancer where as ongoing use often causes hemorrhagic cystitis as a adverse effect)
What imaging studies should be done as initial step in evaluating Asymptomatic Hematuria?
For both high risk and low risk patients, upper tract imaging must be performed as an initial step. For upper tract imaging, CT urography ( i.e; non-contrast CT followed by contrast CT imaging from kidney to bladder) is best recommended initial test now to evaluate asymptomatic hematuria. CT urography is less affected by overlying bowel gas and is more sensitive for detecting small tumors and calculi than the IVP. Students often confuse this with other choices such as ultrasound and Intravenos pyelogram. IVP used to be the best preferred test for upper tract imaging in hematuria evaluation but now CT urogram is becoming the preferred method. IVP and ultrasound are good to image the urinary tract but they do not completely assess the renal parenchyma. If you order an IVP, you may eventually need to order a CT urogram again to image the parenchyma better - so, in order to avoid ordering multiple studies, CT urogram is recommended as the best initial test.
For complete access to streaming video lecture on Nephrology, visit PayPerView
Self -Assessment Questions ( Copy Right: USMLEGalaxy, LLC)
1. A 24 y/o athlete presents to your office with complaints of reddish discolation of urine. He claims that he has been exercising and running vigorously for the past two days. He is very determined to lose the extra weight that he has put up in the recent months and has been fasting in the nights for the past one week. His past medical history is significant for two abdominal surgeries which included laparotomy and appendicectomy in the past for intermittent severe abdominal pain. The patient does not smoke but does occassional consumes alcohol in binges. He did involve in one such alcohol binge last night. Physical examination is benign except for decreased power and reflexes in bilateral lower extremities. There is no rash. His urine specimen was grossly red in color. Urine dipstick was negative for protein, blood, leucoesterase and nitrite. Urine microscopy did not reveal any RBCs, WBCs or Casts. Serum creatinine and complete blood count are with in normal limits. A Creatinine Phosphokinase ( CPK) level has been ordered but is not yet available. The most likely cause of this patient's reddish urine is :
A) Rhabdomyolysis
B) Paroxysmal Nocturnal Hemoglobinuria
C) Acute Intermittent Porphyria
D) Need to obtain CPK level for correct diagnosis
E) Gross Hematuria
F) Glomerulonephritis
2) A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for trace protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals only 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4. The next step in approaching this patient's hematuria is:
A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Referral to Urologist
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and renal biopsy
F) Start emperic antibiotic therapy for UTI
3) A 65 y/o man with history of chronic smoking and COPD presents for follow up visit in your office after being discharged from the hospital about three weeks ago. The patient was admitted and treated in the hospital for community acquired pneumonia and COPD exacerbation. During his hospital stay he was noted to have microscopic hematuria on routine urinalysis. The patient denies any symptoms now. His COPD is well controlled on tiotropium inhaler. His allergies include Isoniazid and Penicillin. Past medical history is significant for a positive PPD test ( latent tuberculosis) for which he has been on treatment with Rifampin for past three months. Physical examination is benign. Labarotory investigations reveal a normal CBC and serum creatinine. Dipstick is positive for blood. A repeat urinalysis during this visit reveals persistent microscopic hematuria with 3 RBCs/HPF. A urine cytology has been ordered. The next appropriate step in evaluating this patient's hematuria is:
A) Repeat urinalysis in 3 months
B) Urine cultures
C) Intravenos pyelogram
D) CT urogram + Cystoscopy
E) Stop Rifampin
4) A 45 y/o woman presents to the Emergency room with complaints of severe flank pain and nausea. Patient's past medical history reveals chronic smoking and occupational exposure to aniline dyes. Physical examination reveals mild right costo-vertebral angle tenderness. The patient is afebrile. Labarotory investigations reveal urine dipstick positive for blood but negative for leucoesterase and nitrite. Urinalysis reveals numerous RBCs per HPF. There are no RBC casts or WBC casts. Urine HCG is negative. The next step in managing this patient's Hematuria is:
A) Start intravenos antibiotic therapy
B) Obtain Non Contrast CT scan
C) CT urogram + Cystoscopy
D) Intravenos pyelogram
E) Ultrasonography
5) A 32 y/o man presents to your office for a follow up of microscopic hematuria detected on previous visit. The patient is otherwise in very good health. He denies any symptoms such as gross red colored urine or dysuria or fever. He is not on any medications. He has no history of smoking or alcoholism. He works as a physician assistant. Physical examination is benign. A repeat urinalysis reveals 5RBCs/HPF. Other labs are within normal limits. A urine cytology has been ordered. The next step in approaching this patient's hematuria?
A) Repeat urinalysis in 3 months
B) Non contrast CT scan
C) CT urogram
D) Cystoscopy
E) CT urogram and cystoscopy
COPY RIGHT: USMLEGalaxy, LLC
ANSWERS TO SELF ASSESSMENT QUESTIONS:
1) Ans.C
Reddish discolration of urine with a negative dipstick for blood suggests that this red color is not from either a pigment globin ( hemoglobin or myoglobin) or a Red blood cell ( Hematuria). Such red colored urine with negative dipstick can be seen with drugs such as Rifampin, foods such as beets and substances like porpyrins in urine.
This patient also has sensory as well as motor neuropathy in his lower extremities, a typical manifestation of Acute intermittent porpyria attacks. The presence of peripheral neuropathy in patients with history of recurrent abdominal pains should raise the suspicion of Acute Intermittent Porphyria ( AIP). This patient had several severe abdominal pain episodes which were misdaiagnosed as appendicitis and he even underwent a futile laparotomy. Patients are pain free between the attacks. Fasting and drugs like phenobarbital, alcohol can precipitate AIP attacks. Unlike other porphyrias, rash is not typically seen in AIP.
A. is not the answer because dipstick would be positive for blood in rhabdomyolyisis
B. is not the answer because dipstick would be positive in hemoglobinuria
D. is not the answer since the diagnosis of reddish urine here is not in favor of myoglobinuria.
E. a negative dipstick and negative microscopic urinalysis rules out gross hematuria as a cause of this red urine
F. Negative dipstick for blood, negative urine microscopy and absence of RBC casts rule out glomerulonephritis as a cause of this patient's red urine
2. Ans. E.
The presence of red cell casts indicate glomerular origin of this patient's hematuria. Etiologies include various glomerulonephritis and hence, a renal biopsy is warranted.
A. is not the answer because here a positive dipstick is also followed by a positive urinalysis indicating true hematuria. A myoglobinuria will have positive dipstick but no RBCs on urine microscopy.
B. is not the answer because it does not add anything to elucidate the cause of this patient's hematuria. In view of concomitant presence of RBC casts, this patient's acute onset protein in the urine may be secondary to glomerulonephritis rather than DM nephropathy.
C. Presence of RBC casts indicate glomerual cause of hematuria. So, the patient should be referred to a nephrologist rather than a urologist
D. Repeating urinalysis in 3 months is appropriate for a new microscopic hematuria with out any features suggesting kidney involvement. Here hematuria is clearly glomerular in origin and requires further work up as soon as possible.
F. Is incorrect because this patient has no evidence of UTI. The patient's clinical features as well as urinalysis findings do not suggest a UTI. The patient has no fever or dysuria. Dipstick is negative for leucoesterase or nitrite. Urinalysis has no WBCs or WBC casts. Absence of all these make UTI an unlikely etiology of her hematuria.
3. Ans. D
This patient has significant microhematuria defines as 3 0r more RBCs/HPF established on two occassions. He also has high risk factors for having a bladder cancer or urological malignancy. So, both upper tract imaging in the form of CT urogram as well as bladder visualization in the form of cystoscopy are warranted in this patient.
A. is incorrect because the patient already had >3RBCs/HPF on two occassions already establishing the diagnosis of significant microhematuria.
B. is incorrect because this patients has no symptoms or lab findings suggesting UTI.
C. is incorrect because this patient is a high risk patient and requires both upper tract imaging as well as cystoscopy as an initial protocol. IVP is good for upper urinary tract imaging but does not adequately visualize the bladder. More over, recent recommendations favor CT urogram over IVP for upper tract imaging.
E. is incorrect. Rifampin causes red colored urine but does not cause positive dipstick or hematuria.
4. Ans. B
This patient's clinical features as well as hematuria on urinalysis suggest renal colic from possible urolithiasis. Non Contrast CT is the best and first imaging test of choice in evaluating renal calculi ( do not choose plain x-rays or ultrasound. Ultrasound is optimal only in pregnant patients).
A. is not correct as this patient has no evidence of pyelonephritis or UTI ( absent wbc casts, absent wbcs or fever, no leucoesterase or nitrite on dipstick)
C. is incorrect because CT urogram involves administration of contrast after a initial non contrast study. A non contrast CT is sufficient in most cases to evaluate the presence of stones ( except Indinavir stones in HIV positive patients on HAART where a contrast CT is preferred). Cystoscopy is not needed as acute flank pain with hematuria in this patient favors renal calculus more than a bladder cancer
D. IVP is incorrect since non contrast CT is the best test to visualize the stones
E. is incorrect because Non contrast CT is better than ultrasound in visualizing the renal calculi
5. Ans. A - in a healthy young individual with only one episode of microscopic hematuria a repeat urinalysis must be obtained to see if this is significant before proceeding to evaluate this patient with expensive and invasive investigations. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy. In high risk patients, both Upper tract imaging as well as Cystoscopy must be performed.
B. is incorrect as a repeat urinalysis should first be performed in this patient. Also, non contrast CT is not helpful in evaluating causes of painless microscopic hematuria.
C. is incorrect. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy. In high risk patients, both Upper tract imaging as well as Cystoscopy must be performed.
D. is incorrect. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy.
E. is incorrect. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy. In high risk patients, both Upper tract imaging as well as Cystoscopy must be performed.
A. Identifying benign hematuria and its approach
B. Correct interpretation of "Dipstick" Hematuria
C. Evaluation of Asymptomatic Microscopic Hematuria in normal patient population vs. those at high risk for urological malignancy.
D. Test of choice for symptomatic hematuria ( Urolithiasis, Cystitis etc)
E. Evaluation of Asymptomatic Hematuria
F. If upper tract imaging for Asymptomatic Hematuria is chosen, what is the initial test of choice? - Many get confused about the initial test for upper tract imaging becauses several sources state several different things. Students are stuck between the choices CT urogram vs. Traditional Intravenos Pyelogram. The guidelines have been updated recently and there is an increasing trend towards CT Urogram even in asymptomatic hematuria ( please check the explaination below).
Here is a summary on how to approach Hematuria on your exam as well as in your office. All the recommendations are taken from AUA, American college of radiology guidelines on appropriate imaging choice.
Hematuria: The following Q and A aaproach will help you understand the principal concepts of Hematuria.
How do you test for Hematuria?
The initial office test that we use to detect hematuria is "Dipstick". Dipstick is highly sensitive but not specific. False negatives are very rare but false positives are common. Dipstick detects "BLOOD" but it does not say whether this "blood" is an RBC or a Pigment. Remember that pigments such as myoglobin ( as in rhabdomyolysis) or Hemoglobin ( as in hemoglobinuria, Black water fever) can stain as "Blood" on dipstick. So, please do not automatically assume that everything that stains as "blood" on a dipstick is an RBC. In order to know if there is true hematuria, the next step is to do urine microscopy. If the urine reveals RBCs then there is true hematuria. However, if the dipstick reads "blood" and if the urine did not reveal RBCs on microscopy then you are dealing with a pigment - either myoglobinuria ( rhabdomyolysis) or hemoglobinuria. At this point, if the CPK is also elevated it suggests that the etiology of blood on the dipstick is Rhabdomyolysis.
So, a dipstick hematuria should always be confirmed with urine microscopy!
If dipstick is negative for blood, it excludes abnormal hematuria ( false-negative results are unusual with dipstick testing).
Benign causes of "Red" urine but negative dipstick test - In some conditions, you may see a red urine resembling "Gross hematuria" but dipstick is negative for blood. This should not be called hematuria. This is just reddish discoloration of urine.
Occurs in :
a) Ingestion of red pigmented foods ( eg: beets, berries, rhubarbs, paprika)
b) Drugs like Rifampin or Phenazopyridine derivatives ( remember these drugs only cause reddish urine but NOT a positive dipstick).
c) Diseases such as "Porphyria"
Causes of a Positive Dipstick but no true Hematuria: Here Dipstick stains positive for blood but no RBCs in the urine
a) Myoglobinuria ( Rhabdomyolysis, vigorous exercise)
b) Hemoglobinuria ( Intravascular hemolysis)
Is the Hematuria associated with pain? - Understand the causes of painless hematuria are different from painful hematuria. Painless hematuria is often from tumors of the urinary tract, bladder cancer or glomerulonephritis. Painful hematuria is often associated with urolithiasis ( renal calculi) or inflammation/ infection of the bladder ( Cystitis).
What will be the approach to identify the source of Hematuria? - The work up for hematuria may involve invasive and expensive approaches. So, it is important to determine the nature of hematuria so that you can limit investigations to the real and pathological hematurias.
Gross Hematuria: Reddish or Tea colored urine, dipstick positive for blood and urine microscopy shows RBCs. Any patient with gross hematuria should always be referred for urological evaluation unless this is secondary to an infection. If a woman has gross hematuria but the urine dipstick also reveals leucoesterase or nitrite or if the woman has symptoms of UTI ( dysuria etc) or if the cultures are growing bacteria, this can be treated as UTI ( cystitis) with antibiotics with out referring for further evaluation. Even in this setting of infection, if there are risk factors for urological malignancy the patient should still be referred for further evaluation ( since hematuria from cancer can also be intermittent).
Runner's hematuria or March hematuria is another benign condition that presents as gross hematuria after a severe physical activity. In such cases, patients may be observed for resolution however, if the hematuria is persistent or if the patient has any risk factors for having a urological malignancy, must be referred to a urologist
Microscopic Hematuria: Grossly, urine looks normal. Dipstick positive for blood and urine microscopy reveals RBCs.
Microscopic Hematuria is often intermittent and most causes are usually benign. So, it is important to define a significant microscopic hematuria that requires further investigations.
Microhematuria is defined as three or more red blood cells per high-power microscopic field (RBCs/HPF) in two out of three properly collected and prepared specimens. Repeat urinalyses to establish whether significant hematuria is present must be done within 3 to 6 months of the initial test.
Minimal microhematuria ( i.e; one or 2 rbcs per HPF ) in asymptomatic young adults does not require any evaluation. ( many studies have indicated that small amounts of blood may be released into the urine of persons with no detectable pathology in the urinary tracts)
In patients with risk factors for having a urological malignancy, a microhematuria even in one or more samples must be considered significant and be evaluated.
Some benign causes of Microhematuria :
A) Exercise
B) Sexual activity
C) Menstruation
D) UTI
If UTI is present ( symptoms and dipstick for leucoesterase are clues that point towards infection) - treat it with antibiotics and repeat urinalysis after the infection has cleared.
E) Benign Prostatic Hypertrophy
F) Prostatitis
Now, carefully look for other charecterestics of urinalysis - Presence of other findings on the microscopic urinalysis such as RBC casts or Dysmorphic RBCs or proteinuria or the labs revealing elevated serum creatinine suggests a the hematuria is originating from the kidney/ glomerulus itself ( eg: Glomerulonephritis, IgA nephropathy). In such cases, the next step in evaluating hematuria is referral to a nephrologist ( not urologist) and a renal biopsy.
Further Approach to Microscopic Hematuria
Symptomatic Hematuria: In painful hematuria --> first rule out infection and renal colic. If infection is absent or if there is a pain similar to renal colic ( classic flank pain) - consider renal stones as the cause of Hematuria. The best initial step in evaluating the cause of painful hematuria that is not explained by UTI is Non-Contrast CT scan (Spiral CT) ( test of choice for imaging renal calculi).
In pregnant women, ultrasound can be performed to avoid radiation exposure.
Asymptomatic MicroHematuria : Patients without the classic flank pain of urolithiasis should be evaluated extensively. Once benign causes such as infection and the kidney ( glomerular) origin are ruled out, further approach should be defined based on the patient's risk profile.
A) For patients with low risk of urological disease, a less extensive work-up may be appropriate ( First do upper tract imaging and if this is negative, add urine cytology+cystoscopy).
B) If the patient is a high risk of having a urological malignancy, extensive work-up is needed ( see the risk factors below) --> Upper tract imaging + cystoscopy+ urine cytology all are needed. Urine cytology should be obtained in all patients with asymptomatic hematuria since it is an easy and non invasive step. Sensitivity of urine cytology is only 48% but remember that if it is positive it is highly specific for urological cancer ( 94% specificity)
Risk factors for urological cancer ( bladder ca):
1. Heavy somkers
2. Occupational exposure to aniline dyes
3. History of Gross hematuria
4. History of pelvic irradiation
5. Age > 40 years
6. Analgesic abuse
7. Presence of irritative voiding symptoms
8. Previous use of Cyclophosphamide ( increases the risk of bladder cancer where as ongoing use often causes hemorrhagic cystitis as a adverse effect)
What imaging studies should be done as initial step in evaluating Asymptomatic Hematuria?
For both high risk and low risk patients, upper tract imaging must be performed as an initial step. For upper tract imaging, CT urography ( i.e; non-contrast CT followed by contrast CT imaging from kidney to bladder) is best recommended initial test now to evaluate asymptomatic hematuria. CT urography is less affected by overlying bowel gas and is more sensitive for detecting small tumors and calculi than the IVP. Students often confuse this with other choices such as ultrasound and Intravenos pyelogram. IVP used to be the best preferred test for upper tract imaging in hematuria evaluation but now CT urogram is becoming the preferred method. IVP and ultrasound are good to image the urinary tract but they do not completely assess the renal parenchyma. If you order an IVP, you may eventually need to order a CT urogram again to image the parenchyma better - so, in order to avoid ordering multiple studies, CT urogram is recommended as the best initial test.
For complete access to streaming video lecture on Nephrology, visit PayPerView
Self -Assessment Questions ( Copy Right: USMLEGalaxy, LLC)
1. A 24 y/o athlete presents to your office with complaints of reddish discolation of urine. He claims that he has been exercising and running vigorously for the past two days. He is very determined to lose the extra weight that he has put up in the recent months and has been fasting in the nights for the past one week. His past medical history is significant for two abdominal surgeries which included laparotomy and appendicectomy in the past for intermittent severe abdominal pain. The patient does not smoke but does occassional consumes alcohol in binges. He did involve in one such alcohol binge last night. Physical examination is benign except for decreased power and reflexes in bilateral lower extremities. There is no rash. His urine specimen was grossly red in color. Urine dipstick was negative for protein, blood, leucoesterase and nitrite. Urine microscopy did not reveal any RBCs, WBCs or Casts. Serum creatinine and complete blood count are with in normal limits. A Creatinine Phosphokinase ( CPK) level has been ordered but is not yet available. The most likely cause of this patient's reddish urine is :
A) Rhabdomyolysis
B) Paroxysmal Nocturnal Hemoglobinuria
C) Acute Intermittent Porphyria
D) Need to obtain CPK level for correct diagnosis
E) Gross Hematuria
F) Glomerulonephritis
2) A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for trace protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals only 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4. The next step in approaching this patient's hematuria is:
A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Referral to Urologist
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and renal biopsy
F) Start emperic antibiotic therapy for UTI
3) A 65 y/o man with history of chronic smoking and COPD presents for follow up visit in your office after being discharged from the hospital about three weeks ago. The patient was admitted and treated in the hospital for community acquired pneumonia and COPD exacerbation. During his hospital stay he was noted to have microscopic hematuria on routine urinalysis. The patient denies any symptoms now. His COPD is well controlled on tiotropium inhaler. His allergies include Isoniazid and Penicillin. Past medical history is significant for a positive PPD test ( latent tuberculosis) for which he has been on treatment with Rifampin for past three months. Physical examination is benign. Labarotory investigations reveal a normal CBC and serum creatinine. Dipstick is positive for blood. A repeat urinalysis during this visit reveals persistent microscopic hematuria with 3 RBCs/HPF. A urine cytology has been ordered. The next appropriate step in evaluating this patient's hematuria is:
A) Repeat urinalysis in 3 months
B) Urine cultures
C) Intravenos pyelogram
D) CT urogram + Cystoscopy
E) Stop Rifampin
4) A 45 y/o woman presents to the Emergency room with complaints of severe flank pain and nausea. Patient's past medical history reveals chronic smoking and occupational exposure to aniline dyes. Physical examination reveals mild right costo-vertebral angle tenderness. The patient is afebrile. Labarotory investigations reveal urine dipstick positive for blood but negative for leucoesterase and nitrite. Urinalysis reveals numerous RBCs per HPF. There are no RBC casts or WBC casts. Urine HCG is negative. The next step in managing this patient's Hematuria is:
A) Start intravenos antibiotic therapy
B) Obtain Non Contrast CT scan
C) CT urogram + Cystoscopy
D) Intravenos pyelogram
E) Ultrasonography
5) A 32 y/o man presents to your office for a follow up of microscopic hematuria detected on previous visit. The patient is otherwise in very good health. He denies any symptoms such as gross red colored urine or dysuria or fever. He is not on any medications. He has no history of smoking or alcoholism. He works as a physician assistant. Physical examination is benign. A repeat urinalysis reveals 5RBCs/HPF. Other labs are within normal limits. A urine cytology has been ordered. The next step in approaching this patient's hematuria?
A) Repeat urinalysis in 3 months
B) Non contrast CT scan
C) CT urogram
D) Cystoscopy
E) CT urogram and cystoscopy
COPY RIGHT: USMLEGalaxy, LLC
ANSWERS TO SELF ASSESSMENT QUESTIONS:
1) Ans.C
Reddish discolration of urine with a negative dipstick for blood suggests that this red color is not from either a pigment globin ( hemoglobin or myoglobin) or a Red blood cell ( Hematuria). Such red colored urine with negative dipstick can be seen with drugs such as Rifampin, foods such as beets and substances like porpyrins in urine.
This patient also has sensory as well as motor neuropathy in his lower extremities, a typical manifestation of Acute intermittent porpyria attacks. The presence of peripheral neuropathy in patients with history of recurrent abdominal pains should raise the suspicion of Acute Intermittent Porphyria ( AIP). This patient had several severe abdominal pain episodes which were misdaiagnosed as appendicitis and he even underwent a futile laparotomy. Patients are pain free between the attacks. Fasting and drugs like phenobarbital, alcohol can precipitate AIP attacks. Unlike other porphyrias, rash is not typically seen in AIP.
A. is not the answer because dipstick would be positive for blood in rhabdomyolyisis
B. is not the answer because dipstick would be positive in hemoglobinuria
D. is not the answer since the diagnosis of reddish urine here is not in favor of myoglobinuria.
E. a negative dipstick and negative microscopic urinalysis rules out gross hematuria as a cause of this red urine
F. Negative dipstick for blood, negative urine microscopy and absence of RBC casts rule out glomerulonephritis as a cause of this patient's red urine
2. Ans. E.
The presence of red cell casts indicate glomerular origin of this patient's hematuria. Etiologies include various glomerulonephritis and hence, a renal biopsy is warranted.
A. is not the answer because here a positive dipstick is also followed by a positive urinalysis indicating true hematuria. A myoglobinuria will have positive dipstick but no RBCs on urine microscopy.
B. is not the answer because it does not add anything to elucidate the cause of this patient's hematuria. In view of concomitant presence of RBC casts, this patient's acute onset protein in the urine may be secondary to glomerulonephritis rather than DM nephropathy.
C. Presence of RBC casts indicate glomerual cause of hematuria. So, the patient should be referred to a nephrologist rather than a urologist
D. Repeating urinalysis in 3 months is appropriate for a new microscopic hematuria with out any features suggesting kidney involvement. Here hematuria is clearly glomerular in origin and requires further work up as soon as possible.
F. Is incorrect because this patient has no evidence of UTI. The patient's clinical features as well as urinalysis findings do not suggest a UTI. The patient has no fever or dysuria. Dipstick is negative for leucoesterase or nitrite. Urinalysis has no WBCs or WBC casts. Absence of all these make UTI an unlikely etiology of her hematuria.
3. Ans. D
This patient has significant microhematuria defines as 3 0r more RBCs/HPF established on two occassions. He also has high risk factors for having a bladder cancer or urological malignancy. So, both upper tract imaging in the form of CT urogram as well as bladder visualization in the form of cystoscopy are warranted in this patient.
A. is incorrect because the patient already had >3RBCs/HPF on two occassions already establishing the diagnosis of significant microhematuria.
B. is incorrect because this patients has no symptoms or lab findings suggesting UTI.
C. is incorrect because this patient is a high risk patient and requires both upper tract imaging as well as cystoscopy as an initial protocol. IVP is good for upper urinary tract imaging but does not adequately visualize the bladder. More over, recent recommendations favor CT urogram over IVP for upper tract imaging.
E. is incorrect. Rifampin causes red colored urine but does not cause positive dipstick or hematuria.
4. Ans. B
This patient's clinical features as well as hematuria on urinalysis suggest renal colic from possible urolithiasis. Non Contrast CT is the best and first imaging test of choice in evaluating renal calculi ( do not choose plain x-rays or ultrasound. Ultrasound is optimal only in pregnant patients).
A. is not correct as this patient has no evidence of pyelonephritis or UTI ( absent wbc casts, absent wbcs or fever, no leucoesterase or nitrite on dipstick)
C. is incorrect because CT urogram involves administration of contrast after a initial non contrast study. A non contrast CT is sufficient in most cases to evaluate the presence of stones ( except Indinavir stones in HIV positive patients on HAART where a contrast CT is preferred). Cystoscopy is not needed as acute flank pain with hematuria in this patient favors renal calculus more than a bladder cancer
D. IVP is incorrect since non contrast CT is the best test to visualize the stones
E. is incorrect because Non contrast CT is better than ultrasound in visualizing the renal calculi
5. Ans. A - in a healthy young individual with only one episode of microscopic hematuria a repeat urinalysis must be obtained to see if this is significant before proceeding to evaluate this patient with expensive and invasive investigations. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy. In high risk patients, both Upper tract imaging as well as Cystoscopy must be performed.
B. is incorrect as a repeat urinalysis should first be performed in this patient. Also, non contrast CT is not helpful in evaluating causes of painless microscopic hematuria.
C. is incorrect. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy. In high risk patients, both Upper tract imaging as well as Cystoscopy must be performed.
D. is incorrect. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy.
E. is incorrect. If the repeat urinalysis also reveals microhematuria, upper tract imaging ( CT urogram) must be performed first in this low risk patient before proceeding to cystoscopy. In high risk patients, both Upper tract imaging as well as Cystoscopy must be performed.
Archer Review releases unique Pay-Per-View option for USMLE Step 3 Review
Archer Review releases Pay-Per-View option for those who missed out on their live reviews
Pay-Per-View enables you to watch the streaming video lectures for USMLE step 3 at your own convenience. These recordings are similar to the live webinar review in that you can see the powerpoint presentation running on your desktop screen while you also listen to the instructor's audio.
Archer Review answers some of the frequently asked questions regarding Pay-Per-View
Please see below
What is Pay-Per-View?
Pay-Per-View system allows you to access the streaming video lectures online at your convenience and watch them at your home on your own desktop. You may purchase the full length course or topic-wise access.
Can I watch a Demo?
Yes ! Contact us
What lectures for USMLE Step 3 do you currently offer via. Pay-Per-View?
The lectures that are currently available via. Pay-Per-View areA. Archer Full length ( 36 hours) USMLE Step 3 Review Course. B. Archer USMLE 3 Topic-Wise Lectures ( Hematology, Cardiology, Gastroenterology, Nephrology/Acid-base/Electrolytes, Pulmonology/Ventilators, Infectious diseases, Endocrinology, Neurology, Ethics, Rheumatology/ orthopedics/ sports medicine, Oncology, Preventive medicine, Psychiatry, Gynecology, Pediatrics and Dermatology )C. Lectures for USMLE Step2 CK will be available very soon.
What are these Video Lectures? Are they similar to your live reviews?
These streaming video lectures are the recordings of our live webinar sessions. These are exactly similar to our live review in that you can see both the powerpoint presentation ( a capture of the instructor's desktop screen) as well as listen to the audio in conjunction with the powerpoint presentation. This eliminates the need for looking at a hand out or notes while listening to the lecture as you can directly see the powerpoint running on your screen.
Are we provided with any hand-outs or lecture notes?
Yes, you will be provided with relevant Archer USMLE Step 3 notes by e-mail once you purchase the streaming video for a particular topic or for the entire review.
Is Pay-Per-View more expensive than live review?
At this time, the cost of live review as well as Pay-Per-View is similar.What are the benefits of Pay-Per-View over the Live review?Live review needs to be attended at a designated time. Pay-per-view can be watched at your convenience. In Pay-Per-View, you can pause and listen to a particular portion again. You can also listen to the same lecture almost one and half times with the "watch time" that we currently provide.
What are the limitations of Pay-Per-View when compared to Live Review?
During the live review, you can directly ask questions and talk with the instructor. There is no such possibility via. Pay-Per-View. However, you may send us questions by e-mail and our instructor will try and answer them in about 3 days.
What is "Watch Time"?
Watch time is the amount time you are provided to watch the lecture. You are approximately provided with a watch time that is 50% greater than the length of the review. This allows to rewind and replay certain portions of the lecture if you wish. Watch time will not expire when you exit the lecture. Any unused watch time will be stored in your account and you can use it on an other day. When you resume the lecture, make sure to forward the player to the point where you left off. You can also replay the previous session as long as you have sufficient watch time in your accountFor each lecture, you will be provided with the duration of the lecture and the "Watch time" when you begin.
Do I need any special system requirements to play these?
These are WMV files and will play with any Windows Media Player.
How about the Internet connection requirements?Dial-Up connections are ok but broad band connection is preferred for uninterrupted access.
If interested, please visit Pay-Per-View to sign up!
Pay-Per-View enables you to watch the streaming video lectures for USMLE step 3 at your own convenience. These recordings are similar to the live webinar review in that you can see the powerpoint presentation running on your desktop screen while you also listen to the instructor's audio.
Archer Review answers some of the frequently asked questions regarding Pay-Per-View
Please see below
What is Pay-Per-View?
Pay-Per-View system allows you to access the streaming video lectures online at your convenience and watch them at your home on your own desktop. You may purchase the full length course or topic-wise access.
Can I watch a Demo?
Yes ! Contact us
What lectures for USMLE Step 3 do you currently offer via. Pay-Per-View?
The lectures that are currently available via. Pay-Per-View areA. Archer Full length ( 36 hours) USMLE Step 3 Review Course. B. Archer USMLE 3 Topic-Wise Lectures ( Hematology, Cardiology, Gastroenterology, Nephrology/Acid-base/Electrolytes, Pulmonology/Ventilators, Infectious diseases, Endocrinology, Neurology, Ethics, Rheumatology/ orthopedics/ sports medicine, Oncology, Preventive medicine, Psychiatry, Gynecology, Pediatrics and Dermatology )C. Lectures for USMLE Step2 CK will be available very soon.
What are these Video Lectures? Are they similar to your live reviews?
These streaming video lectures are the recordings of our live webinar sessions. These are exactly similar to our live review in that you can see both the powerpoint presentation ( a capture of the instructor's desktop screen) as well as listen to the audio in conjunction with the powerpoint presentation. This eliminates the need for looking at a hand out or notes while listening to the lecture as you can directly see the powerpoint running on your screen.
Are we provided with any hand-outs or lecture notes?
Yes, you will be provided with relevant Archer USMLE Step 3 notes by e-mail once you purchase the streaming video for a particular topic or for the entire review.
Is Pay-Per-View more expensive than live review?
At this time, the cost of live review as well as Pay-Per-View is similar.What are the benefits of Pay-Per-View over the Live review?Live review needs to be attended at a designated time. Pay-per-view can be watched at your convenience. In Pay-Per-View, you can pause and listen to a particular portion again. You can also listen to the same lecture almost one and half times with the "watch time" that we currently provide.
What are the limitations of Pay-Per-View when compared to Live Review?
During the live review, you can directly ask questions and talk with the instructor. There is no such possibility via. Pay-Per-View. However, you may send us questions by e-mail and our instructor will try and answer them in about 3 days.
What is "Watch Time"?
Watch time is the amount time you are provided to watch the lecture. You are approximately provided with a watch time that is 50% greater than the length of the review. This allows to rewind and replay certain portions of the lecture if you wish. Watch time will not expire when you exit the lecture. Any unused watch time will be stored in your account and you can use it on an other day. When you resume the lecture, make sure to forward the player to the point where you left off. You can also replay the previous session as long as you have sufficient watch time in your accountFor each lecture, you will be provided with the duration of the lecture and the "Watch time" when you begin.
Do I need any special system requirements to play these?
These are WMV files and will play with any Windows Media Player.
How about the Internet connection requirements?Dial-Up connections are ok but broad band connection is preferred for uninterrupted access.
If interested, please visit Pay-Per-View to sign up!
Thursday, June 18, 2009
Hematology for USMLE Step 3
Please click on the above link for free access to 2hr30minute lecture on Hematology for USMLE Step 3. This access will cease on 6/20/2009
Monday, June 15, 2009
Thyroid Nodule Approach - USMLE Step 3 Review - Endocrinology Topic 1
Approach to Thyroid Nodules
Many students have questions about how to approach a Thyroid Nodule. The questions on thyroid nodule are often very highyield on Endocrinology portion of USMLE Step 3. Our experience showed that most students usually got them wrong and have wrongly interpreted the guidelines. Many books give different recommendations and students find it confusing. So, we made an attempt to briefly summarize the guidelines here. These recommendations are taken from most popular updated sources in medicine and american college of endocrinology guidelines.
A. Approach – Palpable Thyroid Nodule
Cold nodules are more likely to be malignant when compared to hot nodules ( hot/ functioning nodule virtually rules out malignancy)
1. If thyroid nodule palpable --> Get TSH First.
a) If High TSH – suggests cold nodule/ Hashimatos --> Get FNAC (source: NEJM)( AACE recommends ultrasound as the next step here because hashimatos may have benign nodularity that regress with therapy and ultrasound will help to see if there are suspicious features. If U/S suspicious, then FNAC is recommended. This may be optimal approach because hurthle cells of hashimatos may cause false positives on cytology if the FNAC is obtained from such benign nodule --> so, we would recommend that you choose ultrasound as your next step if that is there in your MCQ choices. If the choices have no ultrasound, choose FNAC as answer). Further approach will depend on FNAC results. For hypothyroidism issue - Treat with levothyroxine if overt hypothyroidism or if subclinical hypothyroidism that warrants treatment.
b) If TSH normal – suggests cold nodule - next step, get FNAC.
c) If TSH low - suggests Hot nodule ( toxic adenoma) but not confirmative (What if there is GRAVES in the surrounding tissue and this is a cold nodule?) - so, next step get RAIU scan. If RAIU scan shows Hot nodule treat with I131 ( if there is overt hyperthyroidism from this toxic adenoma) or just observation. Cold nodules are more likely to be malignant when compared to hot nodules ( hot/ functioning nodule virtually rules out malignancy). If RAIU shows COLD nodule, get FNAC.
Further Approach depends on FNAC results :
a) If FNAC is benign - Suppressive therapy with LT4 in some cases if cosmetically warranted
b) If FNAC is malignant/ suspicious - SURGERY
c) If FNAC is non-diagnostic - repeat FNAC. If repeat FNAC is again non-diagnosotic, surgery
B) Approach - Thyroid Incidentalomas
Thyroid Incidentalomas – These are those nodules ( not the palpable ones) detected on ultrasound such as when ultrasound was done for other purposes such as for other palpable thyroid abnormalities or during carotid artery imaging or ultrasound done for hyperparathyroidism).
The next step in such nodules discovered on the ultrasound depends upon the features of the nodule.
FNAC is indicated in such incidentally discovered thyroid nodules if :
- Nodule > 10 mm in diameter
- On ultrasound, if nodule has suspicious features of malignancy à hypoechoic, microcalcifications, irregular shape, blurred margin or increased vascularity
- If there are risk factors for thyroid cancer ( family history, childhood neck irradiation)
Copy rights: USMLEGalaxy, LLC. All rights reserved.
Many students have questions about how to approach a Thyroid Nodule. The questions on thyroid nodule are often very highyield on Endocrinology portion of USMLE Step 3. Our experience showed that most students usually got them wrong and have wrongly interpreted the guidelines. Many books give different recommendations and students find it confusing. So, we made an attempt to briefly summarize the guidelines here. These recommendations are taken from most popular updated sources in medicine and american college of endocrinology guidelines.
A. Approach – Palpable Thyroid Nodule
Cold nodules are more likely to be malignant when compared to hot nodules ( hot/ functioning nodule virtually rules out malignancy)
1. If thyroid nodule palpable --> Get TSH First.
a) If High TSH – suggests cold nodule/ Hashimatos --> Get FNAC (source: NEJM)( AACE recommends ultrasound as the next step here because hashimatos may have benign nodularity that regress with therapy and ultrasound will help to see if there are suspicious features. If U/S suspicious, then FNAC is recommended. This may be optimal approach because hurthle cells of hashimatos may cause false positives on cytology if the FNAC is obtained from such benign nodule --> so, we would recommend that you choose ultrasound as your next step if that is there in your MCQ choices. If the choices have no ultrasound, choose FNAC as answer). Further approach will depend on FNAC results. For hypothyroidism issue - Treat with levothyroxine if overt hypothyroidism or if subclinical hypothyroidism that warrants treatment.
b) If TSH normal – suggests cold nodule - next step, get FNAC.
c) If TSH low - suggests Hot nodule ( toxic adenoma) but not confirmative (What if there is GRAVES in the surrounding tissue and this is a cold nodule?) - so, next step get RAIU scan. If RAIU scan shows Hot nodule treat with I131 ( if there is overt hyperthyroidism from this toxic adenoma) or just observation. Cold nodules are more likely to be malignant when compared to hot nodules ( hot/ functioning nodule virtually rules out malignancy). If RAIU shows COLD nodule, get FNAC.
Further Approach depends on FNAC results :
a) If FNAC is benign - Suppressive therapy with LT4 in some cases if cosmetically warranted
b) If FNAC is malignant/ suspicious - SURGERY
c) If FNAC is non-diagnostic - repeat FNAC. If repeat FNAC is again non-diagnosotic, surgery
B) Approach - Thyroid Incidentalomas
Thyroid Incidentalomas – These are those nodules ( not the palpable ones) detected on ultrasound such as when ultrasound was done for other purposes such as for other palpable thyroid abnormalities or during carotid artery imaging or ultrasound done for hyperparathyroidism).
The next step in such nodules discovered on the ultrasound depends upon the features of the nodule.
FNAC is indicated in such incidentally discovered thyroid nodules if :
- Nodule > 10 mm in diameter
- On ultrasound, if nodule has suspicious features of malignancy à hypoechoic, microcalcifications, irregular shape, blurred margin or increased vascularity
- If there are risk factors for thyroid cancer ( family history, childhood neck irradiation)
Copy rights: USMLEGalaxy, LLC. All rights reserved.
Wednesday, June 10, 2009
Archer CCS Workshop Powerpoint - Free Access
The above link will take you to the webpage for free powerpoint slides of USMLE Step 3 CCS Workshop.
If you liked this powerpoint, please donate a dollar to help fund education of these kids
If you liked this powerpoint, please donate a dollar to help fund education of these kids
Saturday, June 6, 2009
What is USMLE Step 3 CCS Workshop ?
Archer CCS Workshop is an interactive online workshop where participants learn important Clinical Case Simulation strategies and practice cases as shown above in the demo under supervision. Each workshop is taught in a webinar event, allowing students to review CCS from the comfort of their own homes and to watch and practice CCS cases under supervision in a virtual classroom. Students save both time and money on their CCS review.
Each live CCS workshop is designed to strengthen students' approach to patient care. Students learns how to maximize the delivery of quality care in the 25 minute time allotted for each CCS simulation and how to follow through on critical CCS tasks.
The CCS workshop is set up as a combined lecture and hands-on learning environment. Every student gets to practice CCS and have his or her CCS methods analyzed by professionals.
A Typical CCS Session includes:
CCS strategies
Recognizing unstable vitals
Live demonstration of CCS cases
Common CCS mistakes and how to prevent them
Tips for scoring high on CCS
Follow-ups of office and ER cases
Efficient use of time
Avoiding invasive tests
Basic set of orders for emergency cases
Adding / discontinuing orders that matter
Obtaining consults and their appropriateness
Differential diagnosis for common ER and office presentations
How to schedule follow-up tests
Live and interactive practice of several highyield USMLE Step 3 CCS cases
The first three to four hours of the CCS workshop includes a lecture on the USMLE Step 3 CCS strategies mentioned above. At the end of this lecture, several very important Step 3 CCS cases are practiced in an interactive format. As one of the students practices the CCS case under supervision, others get to watch the case practice on their own desktop and ask questions like in a live classroom. Students receive immediate feedback and guidance from the instructor. The instructor carefully monitors students' approach to a CCS case and corrects any inadequacies.
High Yield USMLE Step 3 CCS Case List
1. DKA
2. Pulmonary embolism
3. Endometrial carcinoma
4. 1 day old Newborn Down’s baby presenting with vomiting/ Duodenal Atresia
5. Motor vehicle accident with splenic rupture
7. TIA
8. Acute Hepatitis A
9. Secondary Hypertension, Hypokalemia – adrenal mass
10. Minimal change disease: Child had scrotal swelling.
11. Constitutional growth delay in african american kid
12. Pericarditis
13. VSD
14. Acute MI
15. Osteoprosis with compression fractures
16. Gastritis secondary to NSAIDs use
17. New Onset DM type II
18. Pregnancy
19. Anaphylaxic reaction/ Shock
20. Adrenal Mass/ Hyperldosteronsim/ Hypokalemia/ Young woman presenting with leg cramps & weakness
21. Heat Stroke
22. Ovarian Teratoma
23. Inflammatory Bowel disease
24. Vaginal Bleeding secondary to Fibroids requiring hysterectomy. ( Woman 44 y/o)
25. cervical cancer26. Turners syndrome
27. UTI/Sepsis – 76 Y/o woman sent from NH for evaluation of altered mental status
28. Hepatic encephalopathy
29. Acute Cholecystitis
30. G6PD deficiency
31. Constipation, hypercalcemia, primary hyperparathyroidism
32. Pregnancy with asymptomatic bactiriuria
33. Back pain due to osteoporotic fracture – compression fracture
34. Bipolar disorder
35. Plulmonary embolism
36. Abdominal Anuersym Rupture presenting with backpain/ No Hypotension at presentation – Vitals stable, so you can get CT scan and then surgery consult.
37. Chalymadia trochmatis (in a male)/ Non gonococcal urethritis
38. Erosive esophagitis/ GERD
39. Panic Attack
40. Acute Asthma Attack – 14 Y/O female with wheezing, Sob
41. Obesity in a teenager
42. Toxic Shock syndrome/ Tampon use
43. Hyperglycemia/ new onset DM Type
44. fracture neck of femurs – 75 y/o female fell and sustained right hip fracture – Ortho consult, ORIF, fall prevention, hip protection devices, Osteoporosis screening, DVT prophylaxis
45. HIV with pcp and lymphoma
46. child abuse with sub dural hemorrhage
47. Tylenol overdose
48. Heat Stroke
49. Acute PID
50. Tricyclic Overdose {40 y.o. Arab male with no history know brought in the ER by a neighbour with uncounciousness and unresponsive state – he had some depression as per neighbour (TCA TOXICITY)}
51. Acute pancreatitis
52. Child with intusussception
53. Woman with multiple sclerosis ( comes with weakness and has nystagmus on neuron exam)54. Septic pulmonary emboli in IVD abuser.
55. Stable Angina
56. SLE
57. Pregnancy in a 44yr old women
58. Bacterial Meningitis in an infant
59. Juvenile Rheumatoid Arthritis
60. Anemia secondary to colon cancer
61. Alzheimer’s Disease(had to rule out other causes of dementia before makingthe diagnosis)
62. 50 + y.o. M with epigastric pain (erosive gastritis, had h/o long term NSAID use) – Has age criteria for EGD.
63. 40 y.o. M with IVDA and SOB with fever (Infective Endocarditis)
64. 4 yo. F with ANA +ve Arthritis65. 50 + y.o. F with high BP in office
66. 50 + y.o. F with Renal failure and family h/o ADAPKD, HIGH K+
67. Acute manic disorder
68. UTI with 12 week prenancy
69. chid abuse
70. acute diarrhea
71. Acute MI
72. CHILD ABUSE : 2 y/0 AA boy was brought with lethargy, CXR revealed multiple posterior rib fractures and CT head subdural hematoma —Child abuse, call child protection services and social work consult
73.) Eclampsia… presented with seizures and peripheral edema at 38 weeks pregnancy.( Magnesium sulfate, induce delivery, if still seizure – follow status protocol)
74) Uncontrolled DM type 2 – came with increased thirst and urination
75) HIV in a 25 y/o f with multiple partners – came with weightloss, fatigue and cough. Do HIV test, viral load, genotyping. Then cd4 count.
76) Acute pericarditis.
77). Right upper quadrant pain, cxr – pneumonia – right lower lobe – community acqd pneumonia
78) Dysfunctional uterine bleeding
79) Polymyalgia reheumatica
80) Trauma patient with cardiac tamponade
81) Pancreatic ca, old man with fatigue, weightloss – exam shows icterus – go ahead with CT
82) 9mos old baby with fever unknown cause all tests including cbc are negative ( Roseolum infantum)
83) hypothyroidism in a man
84) Post menopausal bleeding in a woman not on HRT/ benign endometrial hyperplasia85) cystitis
86) septic arthritis
87)gastric carcinoma
88)incomplete abortion
89)Atrial fibrillation
90) Diverticulitis
91) Dehydration/ Hypernatremia
92. 20 month old african american boy brought for fatigue and lethargy to office/ Fe deficiency
93. Acute Bacterial Prostatitis
94. ALL in a 5 year old/ 5 yr. old boy who came with weakness, disinterest in activity and lesion on leg.
95. Acute pericarditis – rx ( make sure to do echo, dont do unnecessary pericardiocentesis if there is mild to moderate pericarditis with out clinical or echocardiographic evidence of tamponade)
96. Osteoarthritis of the Knee ( if there is large joint effusion, always do arthrocentesis)
97. CIN III
98. Congestive heart failure in a post-op patient ( make sure they are not giving too much IV fluids in post op setting, I/O monitoring, daily weights, lasix, 2d echo, r/o MI, EKG, CXR, BNP – Lasix, if flash pulm edema, give morphine)
99. Hypercalcemia/ renal mass ( likely RCC) – Elderly man presenting with fatigue
100) Complete Heart Block - Woman coming with Motor Vehicle Accident/ only minor injuries on the arm , Vitals reveal Heart rate 38. - EKG shows complete Heart block
2. Pulmonary embolism
3. Endometrial carcinoma
4. 1 day old Newborn Down’s baby presenting with vomiting/ Duodenal Atresia
5. Motor vehicle accident with splenic rupture
7. TIA
8. Acute Hepatitis A
9. Secondary Hypertension, Hypokalemia – adrenal mass
10. Minimal change disease: Child had scrotal swelling.
11. Constitutional growth delay in african american kid
12. Pericarditis
13. VSD
14. Acute MI
15. Osteoprosis with compression fractures
16. Gastritis secondary to NSAIDs use
17. New Onset DM type II
18. Pregnancy
19. Anaphylaxic reaction/ Shock
20. Adrenal Mass/ Hyperldosteronsim/ Hypokalemia/ Young woman presenting with leg cramps & weakness
21. Heat Stroke
22. Ovarian Teratoma
23. Inflammatory Bowel disease
24. Vaginal Bleeding secondary to Fibroids requiring hysterectomy. ( Woman 44 y/o)
25. cervical cancer26. Turners syndrome
27. UTI/Sepsis – 76 Y/o woman sent from NH for evaluation of altered mental status
28. Hepatic encephalopathy
29. Acute Cholecystitis
30. G6PD deficiency
31. Constipation, hypercalcemia, primary hyperparathyroidism
32. Pregnancy with asymptomatic bactiriuria
33. Back pain due to osteoporotic fracture – compression fracture
34. Bipolar disorder
35. Plulmonary embolism
36. Abdominal Anuersym Rupture presenting with backpain/ No Hypotension at presentation – Vitals stable, so you can get CT scan and then surgery consult.
37. Chalymadia trochmatis (in a male)/ Non gonococcal urethritis
38. Erosive esophagitis/ GERD
39. Panic Attack
40. Acute Asthma Attack – 14 Y/O female with wheezing, Sob
41. Obesity in a teenager
42. Toxic Shock syndrome/ Tampon use
43. Hyperglycemia/ new onset DM Type
44. fracture neck of femurs – 75 y/o female fell and sustained right hip fracture – Ortho consult, ORIF, fall prevention, hip protection devices, Osteoporosis screening, DVT prophylaxis
45. HIV with pcp and lymphoma
46. child abuse with sub dural hemorrhage
47. Tylenol overdose
48. Heat Stroke
49. Acute PID
50. Tricyclic Overdose {40 y.o. Arab male with no history know brought in the ER by a neighbour with uncounciousness and unresponsive state – he had some depression as per neighbour (TCA TOXICITY)}
51. Acute pancreatitis
52. Child with intusussception
53. Woman with multiple sclerosis ( comes with weakness and has nystagmus on neuron exam)54. Septic pulmonary emboli in IVD abuser.
55. Stable Angina
56. SLE
57. Pregnancy in a 44yr old women
58. Bacterial Meningitis in an infant
59. Juvenile Rheumatoid Arthritis
60. Anemia secondary to colon cancer
61. Alzheimer’s Disease(had to rule out other causes of dementia before makingthe diagnosis)
62. 50 + y.o. M with epigastric pain (erosive gastritis, had h/o long term NSAID use) – Has age criteria for EGD.
63. 40 y.o. M with IVDA and SOB with fever (Infective Endocarditis)
64. 4 yo. F with ANA +ve Arthritis65. 50 + y.o. F with high BP in office
66. 50 + y.o. F with Renal failure and family h/o ADAPKD, HIGH K+
67. Acute manic disorder
68. UTI with 12 week prenancy
69. chid abuse
70. acute diarrhea
71. Acute MI
72. CHILD ABUSE : 2 y/0 AA boy was brought with lethargy, CXR revealed multiple posterior rib fractures and CT head subdural hematoma —Child abuse, call child protection services and social work consult
73.) Eclampsia… presented with seizures and peripheral edema at 38 weeks pregnancy.( Magnesium sulfate, induce delivery, if still seizure – follow status protocol)
74) Uncontrolled DM type 2 – came with increased thirst and urination
75) HIV in a 25 y/o f with multiple partners – came with weightloss, fatigue and cough. Do HIV test, viral load, genotyping. Then cd4 count.
76) Acute pericarditis.
77). Right upper quadrant pain, cxr – pneumonia – right lower lobe – community acqd pneumonia
78) Dysfunctional uterine bleeding
79) Polymyalgia reheumatica
80) Trauma patient with cardiac tamponade
81) Pancreatic ca, old man with fatigue, weightloss – exam shows icterus – go ahead with CT
82) 9mos old baby with fever unknown cause all tests including cbc are negative ( Roseolum infantum)
83) hypothyroidism in a man
84) Post menopausal bleeding in a woman not on HRT/ benign endometrial hyperplasia85) cystitis
86) septic arthritis
87)gastric carcinoma
88)incomplete abortion
89)Atrial fibrillation
90) Diverticulitis
91) Dehydration/ Hypernatremia
92. 20 month old african american boy brought for fatigue and lethargy to office/ Fe deficiency
93. Acute Bacterial Prostatitis
94. ALL in a 5 year old/ 5 yr. old boy who came with weakness, disinterest in activity and lesion on leg.
95. Acute pericarditis – rx ( make sure to do echo, dont do unnecessary pericardiocentesis if there is mild to moderate pericarditis with out clinical or echocardiographic evidence of tamponade)
96. Osteoarthritis of the Knee ( if there is large joint effusion, always do arthrocentesis)
97. CIN III
98. Congestive heart failure in a post-op patient ( make sure they are not giving too much IV fluids in post op setting, I/O monitoring, daily weights, lasix, 2d echo, r/o MI, EKG, CXR, BNP – Lasix, if flash pulm edema, give morphine)
99. Hypercalcemia/ renal mass ( likely RCC) – Elderly man presenting with fatigue
100) Complete Heart Block - Woman coming with Motor Vehicle Accident/ only minor injuries on the arm , Vitals reveal Heart rate 38. - EKG shows complete Heart block
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