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.
Monday, June 29, 2009
Sunday, June 28, 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.
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!
Pay-Per-View - Archer Videos
Archer Review releases Pay-Per-View option for those who missed out on their live USMLE Step 3 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 Click Here - Cardiology Demo
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 Click Here - Cardiology Demo
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!
Archer launches PayPerView for USMLE Step 3 audio/video lectures
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!
Archer launches PayPerView for USMLE Step 3 audio/video lectures
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!
Pay-Per-View - Archer Videos
Archer Review releases Pay-Per-View option for those who missed out on their live USMLE Step 3 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 Click Here - Cardiology Demo
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 Click Here - Cardiology Demo
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.
Sunday, June 14, 2009
Thyroid Nodule - Endocrinology
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. 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)
Self-Assessment Questions :
1. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?
A. Ultrasound of thyroid
B. TSH level
C. Fine Needle Aspiration ( FNAC)
D. Observation
E. Suppressive therapy with levothyroxine
2. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:
A. Radio iodine therapy ( RAI)
B. Partial thyroidectomy
C. Total thyroidectomy
D. Life long levothyroxine + Total Thyroidectomy + RAI therapy
E. Total Thyroidectomy + Life long levothyroxine
F. Partial thyroidectomy + life long levothyroxine
3. A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family. The next best step in evaluation of the nodule :
A. Suppressive therapy with levothyroxine
B. FNAC
C. Lobectomy with isthmectomy
D. Observation
E. Radio iodine therapy
Answers:
Q1. B
Q2. D
Q3. B
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. 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)
Self-Assessment Questions :
1. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?
A. Ultrasound of thyroid
B. TSH level
C. Fine Needle Aspiration ( FNAC)
D. Observation
E. Suppressive therapy with levothyroxine
2. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:
A. Radio iodine therapy ( RAI)
B. Partial thyroidectomy
C. Total thyroidectomy
D. Life long levothyroxine + Total Thyroidectomy + RAI therapy
E. Total Thyroidectomy + Life long levothyroxine
F. Partial thyroidectomy + life long levothyroxine
3. A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family. The next best step in evaluation of the nodule :
A. Suppressive therapy with levothyroxine
B. FNAC
C. Lobectomy with isthmectomy
D. Observation
E. Radio iodine therapy
Answers:
Q1. B
Q2. D
Q3. B
Copy rights: USMLEGalaxy, LLC. All rights reserved.
Thyroid Nodule - Endocrinology
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. 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)
Self-Assessment Questions :
1. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?
A. Ultrasound of thyroid
B. TSH level
C. Fine Needle Aspiration ( FNAC)
D. Observation
E. Suppressive therapy with levothyroxine
2. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:
A. Radio iodine therapy ( RAI)
B. Partial thyroidectomy
C. Total thyroidectomy
D. Life long levothyroxine + Total Thyroidectomy + RAI therapy
E. Total Thyroidectomy + Life long levothyroxine
F. Partial thyroidectomy + life long levothyroxine
3. A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family. The next best step in evaluation of the nodule :
A. Suppressive therapy with levothyroxine
B. FNAC
C. Lobectomy with isthmectomy
D. Observation
E. Radio iodine therapy
Answers:
Q1. B
Q2. D
Q3. B
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. 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)
Self-Assessment Questions :
1. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?
A. Ultrasound of thyroid
B. TSH level
C. Fine Needle Aspiration ( FNAC)
D. Observation
E. Suppressive therapy with levothyroxine
2. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:
A. Radio iodine therapy ( RAI)
B. Partial thyroidectomy
C. Total thyroidectomy
D. Life long levothyroxine + Total Thyroidectomy + RAI therapy
E. Total Thyroidectomy + Life long levothyroxine
F. Partial thyroidectomy + life long levothyroxine
3. A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family. The next best step in evaluation of the nodule :
A. Suppressive therapy with levothyroxine
B. FNAC
C. Lobectomy with isthmectomy
D. Observation
E. Radio iodine therapy
Answers:
Q1. B
Q2. D
Q3. B
Copy rights: USMLEGalaxy, LLC. All rights reserved.
Thursday, June 11, 2009
Cardiology Sample PPT
Stress Test
Sample Powerpoint slides from Archer USMLE Step 3 Rapid Review - Cardiology. Click Here
The video/ audio lecture for the powerpoint above will be uploaded soon!
Sample Powerpoint slides from Archer USMLE Step 3 Rapid Review - Cardiology. Click Here
The video/ audio lecture for the powerpoint above will be uploaded soon!
Step 3 Review - Details
Archer Online Step III review is the most unique way to listen & participate in the live reviews with out leaving your home. This innovative lectures have reached about 800 people in the last 6 months and have achieved a very high success rate. It is our practice to mail a survey to the attendees after each Rapid Review and CCS Workshop – about 100% of our attendees rated us “Very helpful”, “Extremely patient”, ” Very affordable” and “Very focused and highyield”. Almost 95% felt that they did not need any other review material for step 3 preperation apart from our powerpoint slides and live lectures.
The review is very affordable at $295 ( $50 off for early registrants until May 12th 009) and includes 26 hours of rapid live lectures and all the high-yield study material for all the topics mentioned below. The idea of the rapid review is to focus on most frequently tested Step3 clinical topics which are usually not clearly explained in many review books that are available on the market. This review intends to make step3 live lectures extremely affordable and easily accessible for everyone.
The rapid review online virtual classroom will be in the same way as CCS Workshop. You can raise your hand when you have a question and your question will be answered at the end of each sub section. We recommend you to write down all the questions as the topic lecture runs. At the end of each sub-section, our teaching physician will be available for you to answer your questions. This course is three-day cumulative session of about 26 hours long, stresses on high-yield topics and step3 questions. No extensive details – you will be provided with explainations on the concepts that are exactly needed to pass and score high on this exam. You will be quizzed during the session with sample questions after the topic Review. Extremely interactive with personal attention placed on each and every attendee. After you sign up, you will be provided with high-yield study material in a power-point format.
Our first two Rapid reviews were 2-day long (20 hours) in duration. But with a desire to cover more topics, we extended it now to 3-day (26 hour) long review in April 2009 ( 4/17 to 4/19). This review worked out very well and received a huge applause from the attendees. At this time the plan is to do this review on June 12th, 13th and 14th in the following format spread over 26 hours in three days.
Each day starts at 10 AM EST ( except Day I)
Day I – Friday ( 3 Hours) – June 12th 2009
7:00 PM to 9:00 PM EST – Preventive Medicine ( Topics – Smoking cessation, vaccinations, Lipid screening, Antibiotic prophylaxis prior to surgery, prevention of osteoporosis, steroid induced osteoporosis, Cancer screening discussed under oncology, AAA screening)
9:00 PM to 10:00 PM EST – Psychiatry/ ethics
DAY II Saturday(11.5 hours ) – June 13th 2009
10 to 12:30 pm – Cardiology
12:30 to 1:00 PM – Lunch BREAK
1:30 to 3:00 pm – Endocrinology
3:00 to 5:00 pm – Gastroenterology
5:00 to 5:15 – Break
5:15 to 7:15 – Pulmonary/ventilators/ critical care
7:15 to 8:45 – Infectious Diseases
8:45 to 9:00 – Break
9:00 to 9:30 – Dermatology
DAY III Sunday ( 11.5 hours) – June 14th 2009
10:00 to 12:00 – Nephrology/ Acid Base
12:00 to 1:30 – OBGYN ( Very Highyield only)
1:30 to 2:00 – Lunch Break
2:00 to 3:30 – Rheumatology/ Orthopedics/ Sports Medicine
3:30 to 5:30 – Hematology/ Oncology (cancer screening)
5:30 to 5:45– Break
5:45 to 8:00 – Pediatrics, Highyield only
8:00 to 8:15 – Break
8:15 to 9:30 – Neurology
This is a very extensive course and the price that has been set is too low to make it affordable to everyone including an IMG as well as to a medical student.. In view of price being set too low, we will not be able to do the session if a minimum number of 20 is not reached. Our last two Rapid Reviews have reached a maximum capacity of 70. Please send us an e-mail if you are interested. You will receive an invoice for $295 for this two day course and also for all the teaching slides that will be e-mailed to you in a PPT format. As soon as you sign up, you will me mailed our updated Archer rapid review notes in a powerpoint format. However, we may be adding several more highyield concepts to this notes by June 2009. In that case, we will send you the updated version of the notes again by e-mail a week before rapid review. You can also sign up for this course via. our online store at http://www.shop.ccsworkshop.com
The minimum number of enrollees is 20 and the maximum is 70.
If you have any questions, please feel free to contact us at support@ccsworkshop.com
The review is very affordable at $295 ( $50 off for early registrants until May 12th 009) and includes 26 hours of rapid live lectures and all the high-yield study material for all the topics mentioned below. The idea of the rapid review is to focus on most frequently tested Step3 clinical topics which are usually not clearly explained in many review books that are available on the market. This review intends to make step3 live lectures extremely affordable and easily accessible for everyone.
The rapid review online virtual classroom will be in the same way as CCS Workshop. You can raise your hand when you have a question and your question will be answered at the end of each sub section. We recommend you to write down all the questions as the topic lecture runs. At the end of each sub-section, our teaching physician will be available for you to answer your questions. This course is three-day cumulative session of about 26 hours long, stresses on high-yield topics and step3 questions. No extensive details – you will be provided with explainations on the concepts that are exactly needed to pass and score high on this exam. You will be quizzed during the session with sample questions after the topic Review. Extremely interactive with personal attention placed on each and every attendee. After you sign up, you will be provided with high-yield study material in a power-point format.
Our first two Rapid reviews were 2-day long (20 hours) in duration. But with a desire to cover more topics, we extended it now to 3-day (26 hour) long review in April 2009 ( 4/17 to 4/19). This review worked out very well and received a huge applause from the attendees. At this time the plan is to do this review on June 12th, 13th and 14th in the following format spread over 26 hours in three days.
Each day starts at 10 AM EST ( except Day I)
Day I – Friday ( 3 Hours) – June 12th 2009
7:00 PM to 9:00 PM EST – Preventive Medicine ( Topics – Smoking cessation, vaccinations, Lipid screening, Antibiotic prophylaxis prior to surgery, prevention of osteoporosis, steroid induced osteoporosis, Cancer screening discussed under oncology, AAA screening)
9:00 PM to 10:00 PM EST – Psychiatry/ ethics
DAY II Saturday(11.5 hours ) – June 13th 2009
10 to 12:30 pm – Cardiology
12:30 to 1:00 PM – Lunch BREAK
1:30 to 3:00 pm – Endocrinology
3:00 to 5:00 pm – Gastroenterology
5:00 to 5:15 – Break
5:15 to 7:15 – Pulmonary/ventilators/ critical care
7:15 to 8:45 – Infectious Diseases
8:45 to 9:00 – Break
9:00 to 9:30 – Dermatology
DAY III Sunday ( 11.5 hours) – June 14th 2009
10:00 to 12:00 – Nephrology/ Acid Base
12:00 to 1:30 – OBGYN ( Very Highyield only)
1:30 to 2:00 – Lunch Break
2:00 to 3:30 – Rheumatology/ Orthopedics/ Sports Medicine
3:30 to 5:30 – Hematology/ Oncology (cancer screening)
5:30 to 5:45– Break
5:45 to 8:00 – Pediatrics, Highyield only
8:00 to 8:15 – Break
8:15 to 9:30 – Neurology
This is a very extensive course and the price that has been set is too low to make it affordable to everyone including an IMG as well as to a medical student.. In view of price being set too low, we will not be able to do the session if a minimum number of 20 is not reached. Our last two Rapid Reviews have reached a maximum capacity of 70. Please send us an e-mail if you are interested. You will receive an invoice for $295 for this two day course and also for all the teaching slides that will be e-mailed to you in a PPT format. As soon as you sign up, you will me mailed our updated Archer rapid review notes in a powerpoint format. However, we may be adding several more highyield concepts to this notes by June 2009. In that case, we will send you the updated version of the notes again by e-mail a week before rapid review. You can also sign up for this course via. our online store at http://www.shop.ccsworkshop.com
The minimum number of enrollees is 20 and the maximum is 70.
If you have any questions, please feel free to contact us at support@ccsworkshop.com
Cardiology Sample PPT
Stress Test
Sample Powerpoint slides from Archer USMLE Step 3 Rapid Review - Cardiology. Click Here
The video/ audio lecture for the powerpoint above will be uploaded soon!
Sample Powerpoint slides from Archer USMLE Step 3 Rapid Review - Cardiology. Click Here
The video/ audio lecture for the powerpoint above will be uploaded soon!
Step 3 Review - Details
Archer Online Step III review is the most unique way to listen & participate in the live reviews with out leaving your home. This innovative lectures have reached about 800 people in the last 6 months and have achieved a very high success rate. It is our practice to mail a survey to the attendees after each Rapid Review and CCS Workshop – about 100% of our attendees rated us “Very helpful”, “Extremely patient”, ” Very affordable” and “Very focused and highyield”. Almost 95% felt that they did not need any other review material for step 3 preperation apart from our powerpoint slides and live lectures.
The review is very affordable at $295 ( $50 off for early registrants until May 12th 009) and includes 26 hours of rapid live lectures and all the high-yield study material for all the topics mentioned below. The idea of the rapid review is to focus on most frequently tested Step3 clinical topics which are usually not clearly explained in many review books that are available on the market. This review intends to make step3 live lectures extremely affordable and easily accessible for everyone.
The rapid review online virtual classroom will be in the same way as CCS Workshop. You can raise your hand when you have a question and your question will be answered at the end of each sub section. We recommend you to write down all the questions as the topic lecture runs. At the end of each sub-section, our teaching physician will be available for you to answer your questions. This course is three-day cumulative session of about 26 hours long, stresses on high-yield topics and step3 questions. No extensive details – you will be provided with explainations on the concepts that are exactly needed to pass and score high on this exam. You will be quizzed during the session with sample questions after the topic Review. Extremely interactive with personal attention placed on each and every attendee. After you sign up, you will be provided with high-yield study material in a power-point format.
Our first two Rapid reviews were 2-day long (20 hours) in duration. But with a desire to cover more topics, we extended it now to 3-day (26 hour) long review in April 2009 ( 4/17 to 4/19). This review worked out very well and received a huge applause from the attendees. At this time the plan is to do this review on June 12th, 13th and 14th in the following format spread over 26 hours in three days.
Each day starts at 10 AM EST ( except Day I)
Day I – Friday ( 3 Hours) – June 12th 2009
7:00 PM to 9:00 PM EST – Preventive Medicine ( Topics – Smoking cessation, vaccinations, Lipid screening, Antibiotic prophylaxis prior to surgery, prevention of osteoporosis, steroid induced osteoporosis, Cancer screening discussed under oncology, AAA screening)
9:00 PM to 10:00 PM EST – Psychiatry/ ethics
DAY II Saturday(11.5 hours ) – June 13th 2009
10 to 12:30 pm – Cardiology
12:30 to 1:00 PM – Lunch BREAK
1:30 to 3:00 pm – Endocrinology
3:00 to 5:00 pm – Gastroenterology
5:00 to 5:15 – Break
5:15 to 7:15 – Pulmonary/ventilators/ critical care
7:15 to 8:45 – Infectious Diseases
8:45 to 9:00 – Break
9:00 to 9:30 – Dermatology
DAY III Sunday ( 11.5 hours) – June 14th 2009
10:00 to 12:00 – Nephrology/ Acid Base
12:00 to 1:30 – OBGYN ( Very Highyield only)
1:30 to 2:00 – Lunch Break
2:00 to 3:30 – Rheumatology/ Orthopedics/ Sports Medicine
3:30 to 5:30 – Hematology/ Oncology (cancer screening)
5:30 to 5:45– Break
5:45 to 8:00 – Pediatrics, Highyield only
8:00 to 8:15 – Break
8:15 to 9:30 – Neurology
This is a very extensive course and the price that has been set is too low to make it affordable to everyone including an IMG as well as to a medical student.. In view of price being set too low, we will not be able to do the session if a minimum number of 20 is not reached. Our last two Rapid Reviews have reached a maximum capacity of 70. Please send us an e-mail if you are interested. You will receive an invoice for $295 for this two day course and also for all the teaching slides that will be e-mailed to you in a PPT format. As soon as you sign up, you will me mailed our updated Archer rapid review notes in a powerpoint format. However, we may be adding several more highyield concepts to this notes by June 2009. In that case, we will send you the updated version of the notes again by e-mail a week before rapid review. You can also sign up for this course via. our online store at http://www.shop.ccsworkshop.com
The minimum number of enrollees is 20 and the maximum is 70.
If you have any questions, please feel free to contact us at support@ccsworkshop.com
The review is very affordable at $295 ( $50 off for early registrants until May 12th 009) and includes 26 hours of rapid live lectures and all the high-yield study material for all the topics mentioned below. The idea of the rapid review is to focus on most frequently tested Step3 clinical topics which are usually not clearly explained in many review books that are available on the market. This review intends to make step3 live lectures extremely affordable and easily accessible for everyone.
The rapid review online virtual classroom will be in the same way as CCS Workshop. You can raise your hand when you have a question and your question will be answered at the end of each sub section. We recommend you to write down all the questions as the topic lecture runs. At the end of each sub-section, our teaching physician will be available for you to answer your questions. This course is three-day cumulative session of about 26 hours long, stresses on high-yield topics and step3 questions. No extensive details – you will be provided with explainations on the concepts that are exactly needed to pass and score high on this exam. You will be quizzed during the session with sample questions after the topic Review. Extremely interactive with personal attention placed on each and every attendee. After you sign up, you will be provided with high-yield study material in a power-point format.
Our first two Rapid reviews were 2-day long (20 hours) in duration. But with a desire to cover more topics, we extended it now to 3-day (26 hour) long review in April 2009 ( 4/17 to 4/19). This review worked out very well and received a huge applause from the attendees. At this time the plan is to do this review on June 12th, 13th and 14th in the following format spread over 26 hours in three days.
Each day starts at 10 AM EST ( except Day I)
Day I – Friday ( 3 Hours) – June 12th 2009
7:00 PM to 9:00 PM EST – Preventive Medicine ( Topics – Smoking cessation, vaccinations, Lipid screening, Antibiotic prophylaxis prior to surgery, prevention of osteoporosis, steroid induced osteoporosis, Cancer screening discussed under oncology, AAA screening)
9:00 PM to 10:00 PM EST – Psychiatry/ ethics
DAY II Saturday(11.5 hours ) – June 13th 2009
10 to 12:30 pm – Cardiology
12:30 to 1:00 PM – Lunch BREAK
1:30 to 3:00 pm – Endocrinology
3:00 to 5:00 pm – Gastroenterology
5:00 to 5:15 – Break
5:15 to 7:15 – Pulmonary/ventilators/ critical care
7:15 to 8:45 – Infectious Diseases
8:45 to 9:00 – Break
9:00 to 9:30 – Dermatology
DAY III Sunday ( 11.5 hours) – June 14th 2009
10:00 to 12:00 – Nephrology/ Acid Base
12:00 to 1:30 – OBGYN ( Very Highyield only)
1:30 to 2:00 – Lunch Break
2:00 to 3:30 – Rheumatology/ Orthopedics/ Sports Medicine
3:30 to 5:30 – Hematology/ Oncology (cancer screening)
5:30 to 5:45– Break
5:45 to 8:00 – Pediatrics, Highyield only
8:00 to 8:15 – Break
8:15 to 9:30 – Neurology
This is a very extensive course and the price that has been set is too low to make it affordable to everyone including an IMG as well as to a medical student.. In view of price being set too low, we will not be able to do the session if a minimum number of 20 is not reached. Our last two Rapid Reviews have reached a maximum capacity of 70. Please send us an e-mail if you are interested. You will receive an invoice for $295 for this two day course and also for all the teaching slides that will be e-mailed to you in a PPT format. As soon as you sign up, you will me mailed our updated Archer rapid review notes in a powerpoint format. However, we may be adding several more highyield concepts to this notes by June 2009. In that case, we will send you the updated version of the notes again by e-mail a week before rapid review. You can also sign up for this course via. our online store at http://www.shop.ccsworkshop.com
The minimum number of enrollees is 20 and the maximum is 70.
If you have any questions, please feel free to contact us at support@ccsworkshop.com
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.
USMLE Step 3 CCS Workshop - Highyield CCS Case Practice
High Yield USMLE Step 3 CCS Case Discussions : Some of the very highyield CCS cases are practiced in detail in Archer CCS Workshops. To view interactive demonstrations and guidelines on how to approach each of these CCS cases, you may visit Archer USMLE Step 3 Review Archer CCS Intensive prep option has demonstration on most of these cases as it includes recorded versions of eight of our CCS Workshops covering about 50 CCS cases.
You may post your queries relating to management of the CCS cases under comments sections. We will promptly review them and offer you management strategies.
Notice: Archer USMLE Blog is a place to discuss all your queries related to USMLE Step 3 exam and Clinical Case Simulations in general. This is not a place to post copyrighted materials and such posts are strictly prohibited.
You may post your queries relating to management of the CCS cases under comments sections. We will promptly review them and offer you management strategies.
Notice: Archer USMLE Blog is a place to discuss all your queries related to USMLE Step 3 exam and Clinical Case Simulations in general. This is not a place to post copyrighted materials and such posts are strictly prohibited.
Friday, June 5, 2009
A typical CCS Workshop session
If you're getting ready to take the USMLE Step 3, you must study and practice CCS prior to the exam. CCSWorkshop.com provides live interactive reviews of CCS. 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.
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 student 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 the students' approach to a CCS case and corrects any inadequacies.
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.
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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 student 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 the students' approach to a CCS case and corrects any inadequacies.
Highyield 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 cancer
26. 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 making
the 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 Arthritis
65. 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 hyperplasia
85) cystitis
86) septic arthriti
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
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 cancer
26. 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 making
the 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 Arthritis
65. 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 hyperplasia
85) cystitis
86) septic arthriti
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
A typical CCS Workshop session
If you're getting ready to take the USMLE Step 3, you must study and practice CCS prior to the exam. CCSWorkshop.com provides live interactive reviews of CCS. 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.
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 student 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 the students' approach to a CCS case and corrects any inadequacies.
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.
| |
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 student 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 the students' approach to a CCS case and corrects any inadequacies.
USMLE Step 3 CCS case Discussions - Highyield
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The materials (i.e., test questions, clinical computer simulations, and standardized patient cases) of the USMLE, NBME’s self-assessment program and NBME subject examinations are copyrighted. Publishing any ‘remembered’ materials or replicas of these materials on Archer USMLE Blog (or any other forum) is an unauthorized reproduction of NBME’s materials, constitutes copyright infringement and is strictly prohibited. Any violation of NBME ‘s copyrights and trademarks can not only lead to legal sanctions, but can also have professional consequences. Medical students and medical school graduates, prospective students, examinees of the USMLE, NBME Self Assessment examinations and subject examinations are reminded that they are bound to the terms they agreed to follow regarding disclosure of intellectual property prior to the administration of one of these examinations. Failure to adhere to the terms of these policies will subject an individual to various penalties.
The materials (i.e., test questions, clinical computer simulations, and standardized patient cases) of the USMLE, NBME’s self-assessment program and NBME subject examinations are copyrighted. Publishing any ‘remembered’ materials or replicas of these materials on Archer USMLE Blog (or any other forum) is an unauthorized reproduction of NBME’s materials, constitutes copyright infringement and is strictly prohibited. Any violation of NBME ‘s copyrights and trademarks can not only lead to legal sanctions, but can also have professional consequences. Medical students and medical school graduates, prospective students, examinees of the USMLE, NBME Self Assessment examinations and subject examinations are reminded that they are bound to the terms they agreed to follow regarding disclosure of intellectual property prior to the administration of one of these examinations. Failure to adhere to the terms of these policies will subject an individual to various penalties.
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