Archer USMLE Step 3 Blog

Question of the week # 311

2012-01-17T15:33:00.000-08:00

311) A 3 year old male child is brought to the emergency room by his mother after he fell from his tricycle and sustained an injury to his head . The child was found to be alert and awake after the fall, however, he reported mild pain on the right side of his head. His mother noted a small bruise and swelling over the right side of his scalp. There is no history of vomiting or nausea. He has no past history of convulsions or epilepsy. Family history is unremarkable. At this time, child is quiet and reports mild headache. On examination, he is alert and awake. He is not in distress. There is small contusion on the fronto-parietal aspect of his scalp. There is no evidence of hematoma. Palpation does not reveal any depressed fracture. Neurological examination is normal with out any deficits. Rest of the physical exam is normal. Which of the following is the most appropriate management at this time?

A) Contact Child Protection Services

B) Perform Head CT scan

C) Admit to Hospital

D) Observe at home

E) Skull X-rays

Question of the week # 310

2012-01-17T12:38:00.000-08:00

310) A 28 year old man is admitted with abdominal pain and diarrhea of one day duration. Abdominal pain is diffuse in nature, mild to moderate and is associated with cramps and vomiting. He reports having had recurrent attacks of abdominal pain and diarrhea for several months. His past medical history is significant for Vitiligo and Hypothyroidism. He denies any allergies, atopy or Asthma. Family history is unremarkable. On examination, his mucous membranes and dry and he appears moderately dehydrated. He is afebrile, Blood pressure is 90/60 mm HG, heart rate 120/min, Respiratory rate 18/min. There is no peripheral lymphadenopathy. Skin examination reveals hypopigmented patches consistent with Vitiligo on his chest and the extremities. Abdominal examination is benign , Spleen is not palpable. CT scan of the chest, abdomen and pelvis are normal. Stool anlaysis performed several times during his previous episodes did not reveal any evidence of parasitic infection or leukocytes or blood. Laboratory investigations and peripheral smear are shown below:

WBC 6.0k/µl

Differential: Neutrophils 45%, Lymphocytes 34% ( N = 20 to 40%), Monocytes 6%, Eosinophils 15% ( normal range 1 to 4%)

Hemoglobin 14.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV) 84 fL

Platelet count 310k/µl

Stool Ova and Parasites negative

TSH 4 μIU/ml ( 0.3 - 5.0 uIU/ml)

Which of the following diagnoses is most likely explanation for the patient's clinical presenation?

A) Giardiasis

B) Addison's disease

C) Vitiligo

D) Chronic Myeloid Leukemia

E) Lymphoma

Question of the Week # 309

2012-01-09T00:21:00.000-08:00

309) A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears, nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations. His past medical history is significant for hypertension and diet controlled diabetes. His medications include hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae. Which of the following is the most appropriate management of his dizziness?

A) Discontinue Hydrochlorthiazide

B) Cervical Collar

C) Cerumen Disimpaction

D) Increase Diuretics and add Meclizine

E) Methylprednisolone

Question of the Week # 308

2012-01-09T00:10:00.000-08:00

308) A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears, nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations. His past medical history is significant for hypertension and diet controlled diabetes. His medications include hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae. Which of the following is the most likely explanation for his Vertigo?

A) Orthostatic Hypotension

B) Vertebral artery occlusion from cervical spondylosis

C) Cerumen Impaction

D) Meniere's disease

E) Labyrinthitis

Question of the Week # 307

2012-01-05T22:09:00.000-08:00

307) A 35 year old woman is evaluated in your office during an antenatal visit. Her last menstrual period was 8 weeks ago. She tells you that 2 weeks after she missed her regular menstrual period she checked herself with home pregnancy kit and tested positive. She works in a day-care center. She is concerned now because she received Rubella vaccination 4 weeks ago after an exposure to a sick child without knowing that she was pregnant. She read about the dangers to fetus on the internet and is very worried. Physical examination is benign.

Which of the following is the most appropriate course of action?

A. Refer her to medical termination of pregnancy
B. Tell her that there is a high established risk to fetus and she should strongly consider termination of pregnancy
C. Counsel her about theoretical risk to fetus and continue pregnancy care
D. Administer Rubella immunoglobulin
E. Reassure her that there is no risk to fetus.

Question of the Week # 306

2012-01-05T21:54:00.000-08:00

306) A 32 year old man with history of immune thrombocytopenic purpura is evaluated in your office during a follow up visit. His previous treatments include intravenous immunoglobulin (IVIG) and steroids for his immune thrombocytopenia. He has responded to IVIG in the past however, the response was transient despite steroid maintenance. The patient was maintained on steroids for 2 months initially and achieved a sub-optimal response with peak platelet count reaching 30k/µl. He began very slow steroid taper over the last 4 weeks but his platelets have dropped to 8k/μl again during the taper. Hence, the patient is scheduled for Splenectomy. On examination, he has no bleeding or echymoses. Platelet count today is 10k/μl. Which of the following is the most appropriate step in preparing this patient for surgery?

A) Pneumococcal , Meningococcal and HIB vaccines 1 week prior to surgery

B) Pneumococcal and meningococcal vaccines 2 weeks prior to surgery

C) Pneumococcal, Menigococcal and HIB vaccines 2 weeks prior to surgery

D) Daily oral Penicillin Prophylaxis

E) No vaccines required in adults

Question of the week # 305

2012-01-04T17:45:00.000-08:00

305) You have recently been posted by your employer to serve as a school physician in a school that is few miles away from your office. The school has about 250 students of whom 55% are girls and the rest are boys. The school teacher reports that they have not had a scoliosis screening program in place and wonders if you can implement such a program in the school. Which of the following is the most appropriate course of action?

A) Arrange scoliosis screening for all students between 10 and 16 years of age.

B) Arrange scoliosis screening for all students 10, 12, 14 and 16 years of age.

C) Contact the school nurse and review skills for scoliosis screening procedures.

D) Visually inspect for severe curves only when the back is examined for other reasons.

E) Screen girls for scoliosis at 15 years of age and boys at 16 years of age.

Question of the week # 304

2012-01-04T17:43:00.000-08:00

304)

A 16-year-old male who presents to your office for his regular health checkup and for clearance before participation in then high school basketball team. During the physical examination, you note a mild convexity in the thoracic region of his spine with forward flexion at the hips. You ask him to lean forward with his feet together and bend 90 degrees at the waist. Based on your clinical examination, you estimate a lateral spinal curvature of about 5 degrees. You discuss these findings with the patient and his mother. Which of the following is the most appropriate action?

A. Recommend back-strengthening exercises.

B. Refuse medical clearance for participation in sports.

C. Order a radiograph of the back to quantify the curvature

D. Observation alone.

E. Refer for orthopedic consultation.

Question of the week # 303

2012-01-03T23:20:00.000-08:00

303) A 11 year old girl is evaluated in your office for progressing lateral curvature of her spine. She denies any back pain or neurological symptoms. Her mother is very concerned about the child's appearance. On physical examination, there is gross convexity in the thoracic region of her spine with forward flexion at the hips. There is no tenderness or neurological deficits. An x-ray of the spine reveals 25º curvature ( cob angle) . Which of the following is the most appropriate management at this time?

A) Repeat Clinical exam and x-rays at 6 months

B) Refer to orthopedic evaluation

C) Bracing

D) Spinal fusion surgery

E) Recommend back strengthening exercises

Question of the week # 302

2012-01-03T22:58:00.000-08:00

302) A 16 year old girl is evaluated in your office for one day duration of fever, cough and left pleuritic chest pain. On examination, her temperature is 100.5F, respiratory rate is 18/min, pulse 100/min and blood pressure 120/60 mm hg. Breath sounds are decreased in the left lower lobe. A Chest x-ray is obtained which reveals left lower lobe infiltrate. Incidentally, a 7 ° lateral curvature is seen on the chest x-ray. The patient is started oral azithromycin for her pneumonia and is discharged home. Which of the following is the most appropriate management for her incidentally discovered scoliosis?

A) Clinical follow up alone

B) Repeat x-rays every 6 months

C) Refer to orthopedic surgery

D) Bracing

E) No follow up required

Question of the week # 301

2012-01-03T21:28:00.000-08:00

301) A five month old male infant is brought to the out patient department for evaluation of one month history of recurrent vomiting, diarrhea and skin rash . The baby was delivered normally at term with out any complications. Mother reports that she breastfed him for four months and recently has been feeding him exclusively with formula. Mother reports that the baby vomits intermittently after each feed and develops raised, red welts on his skin after each feeding. There is no blood or bile in the vomitus. Vomiting occurs within 30 minutes after feeding. Suckling is normal. He also has mucousy, loose stools for the past three weeks with no blood. There is no history of cough, cold or fever. On examination, the infant in no apparent distress and vitals are normal. Abdominal examination is benign with out any palpable masses or peristaltic waves. Rest of the physical is normal. Laboratory investigations reveal Hb: 13.2 gm%; Haematocrit: 35%; WBC: 9,200/μl ; Platelets: 225,000/μl, Na 132 meq/L; K 3.8 meq/L; Cl 92 meq/L; albumin 4.6g%. Urinalysis is normal. Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Lactose free formula

C) Start hydrolyzed formula feeds

D) IgE Radio-allergosorbent test

E) Observation

Question of the week # 300

2012-01-03T18:14:00.000-08:00

300) A 14 year old girl is evaluated in your office for moderate headache of one month duration . She denies any blurred vision, neck stiffness or fever. She is accompanied by her mother who reports that her performance at school has progressively declined over the last few months and she has deepening of voice for the past 4 months. On examination, Pulse 80/min; Temperature: 98.4F and Blood pressure: 135/100 mm of Hg. There is excessive hair on her face. Rest of the physical is normal except for faint purplish marks on her abdomen. Laboratory investigations including complete blood count, comprehensive metabolic panel and Urine analysis are within normal limit. Which of the following is the most appropriate next step ?

A) 24 hour urinary cortisol

B) MRI brain

C) CT scan of the abdomen

D) Dexamethasone Suppression Test

E) Plasma catecholamines

F) Urine Drug Screen

Question of the week # 299

2012-01-03T17:06:00.000-08:00

299) A 10 month old male infant is brought by his concerned mother to the Emergency room with complaints of vomiting and bloody diarrhea. Mother reports that he suffered from "stomach flu" symptoms about 1 week ago which resolved spontaneously. He had 4 episodes of vomiting since yesterday and has been crying intermittently every 15 minutes. There is no blood or bile in the vomitus. He had four loose stools with blood in it. There is no history of fever or cough or cold. His past medical history is unremarkable. On examination, temperature is 98.4F, pulse 112, respiratory rate 30/min and blood pressure at 80/50 mm hg. Oral mucosa appear moist and skin turgor is adequate. Abdomen is soft with no palpable masses. Bowel sounds are present. Stool guaiac is strongly positive. Stool is sent for cultures and abdominal x-rays are obtained. An x-ray image is shown below:

Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Gastrograffin enema

C) Surgery

D) Rectal tube placement

E) Flexible sigmoidoscopy

Question of the week # 298

2012-01-01T22:35:00.000-08:00

298) A 6 year old boy presents to your office with a limp on the right side. He denies any falls or trauma. Mother reports that the limp has been present for several weeks. She reports that the patient was seen in the Emergency Room when the limp was first observed. X-rays obtained at that time were normal and so, he was discharged. There is no history of fever. He denies any pain. Family history is unremarkable. On examination, he is afebrile . His right lower extremity appears one inch shorter than the left. Upon standing and walking, his pelvis appears to be tilted towards the left. Which of the following is most likely to be abnormal in this condition?

A) External rotation of hip

B) Tibial tuberosity

C) X-ray of the Knee

D) Erythrocyte Sedimentation Rate

E) Internal rotation and abduction of hip

Question of the week # 297

2012-01-01T20:04:00.000-08:00

297) A 64 year old man is seen in the office for pre-operative evaluation of right inguinal hernia repair. His past medical history is significant for diabetes and recurrent right foot cellulitis. His most recent episode of right foot cellulitis was 2 weeks ago for which he received a 2 week course of oral antibiotics. His surgery is scheduled within one week. On examination, he is afebrile. He has reducible right inguinal hernia and bilateral lower extremity stasis dermatitis. His laboratory investigations reveal:

Platelet Count 240k/μl ( Normal 150–400k/μl)

Prothrombin time 22 seconds ( Normal 10 to 13 secs)

Partial Thromboplastin time : 34 sec ( Normal 22 to 37 secs)

Which of the following is the most appropriate action at this time?

A) Obtain PTT mixing studies

B) Administer Oral Vitamin K

C) Intravenous Fresh Frozen Plasma

D) Intravenous Factor VIII

E) Von Willebrand Factor Assay

2011 in review

2011-12-31T15:35:00.000-08:00

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here's an excerpt:

The Louvre Museum has 8.5 million visitors per year. This blog was viewed about 100,000 times in 2011. If it were an exhibit at the Louvre Museum, it would take about 4 days for that many people to see it.

Click here to see the complete report.

Question of the week # 296

2011-12-30T15:24:00.000-08:00

296) A 6 month old Asian infant is brought by his concerned aunt for evaluation of dark blue areas on the child's buttocks. She says she was called to baby-sit the infant since his mother found a new job 2 days ago. She noted the rash and became suspicious that the child may have been abused. The mother arrives in Emergency room an hour later and reports that the rash has been present since birth. The mother is divorced and lives alone with the child. On examination, there are bluish-green patches on bilateral buttocks and on the lower back. They are irregular in shape and margins are indistinct. There is no swelling or tenderness. An image of the skin findings is shown below:

Which of the following is the most appropriate next step ?

A) Order Skeletal Survey

B) Reassure that rash may fade away in few years

C) Contact Child Protection services

D) Obtain Coagulation parameters

E) Obtain Platelet count

Question of the week # 295

2011-12-30T14:54:00.000-08:00

295) A 10 year old boy is brought to your office for evaluation of rash in bilateral axillae and groin for the past 2 months. He denies any itching or any other skin rashes. However, he reports that the area has become progressively rough to touch. He is otherwise, healthy. On examination, there are reddish brown patches in bilateral axillae and groin. There is maceration and scaling in the web spaces between the toes of bilateral feet. Rest of the examination is normal. A KOH mount is obtained and is negative. Wood's lamp examination reveals coral red fluorescence. A picture of the rash is shown below:

Which of the following is the most appropriate next step ?

A) Topical corticosteroid

B) Topical Selenium Sulfide

C) Oral erythromycin

D) Topical Clotrimazole

E) Oral Metronidazole

Question of the week # 294

2011-12-29T22:56:00.000-08:00

294) A 71 year old woman presents to the emergency room with complaints of bright red bleeding per rectum. She denies any abdominal pain, nausea or vomiting. She has a history of paroxysmal atrial fibrillation. Her medications include aspirin and beta blocker. About 10 days ago, she had a screening colonoscopy. She had a 3cm polyp in the sigmoid colon which was removed at that time. She reports that she did not experience any bleeding immediately after polyp removal and is concerned about this episode that occured so many days after the procedure. On physical examination she is afebrile . Abdominal examination is benign. Rectal examination reveals bright red blood and no palpable hemorrhoids. Patient is anxious about her diagnosis. Which of the following is the most appropriate statement?

A) " Your bleeding is mostly secondary to ischemic colitis"

B) " Bleeding can occur up to two weeks after polypectomy".

C) " Your bleeding is related to Aspirin use".

D) " We will have to repeat colonoscopy to confirm that a cancer has not been missed"

E) " You will need diagnostic laporoscopy to evaluate the cause"

Question of the week # 293

2011-12-29T22:08:00.000-08:00

293) A 70 year old man is evaluated in the emergency room for abdominal pain , fever, nausea and vomiting that began 8 hours after he underwent a screening colonoscopy. The pain is severe and is mostly in the left lower quadrant of the abdomen. He reports that his colonoscopy procedure was uneventful except that he had a 2cm sessile polyp which was removed during the procedure. He denies any rectal bleeding. On examination, temperature is 102 F, blood pressure 100/60 mmHg, pulse 120, respiratory rate 28/min. Abdominal examination reveals severe tenderness, guarding and rigidity in the left lower quadrant. Laboratory investigations show:

WBC 28k/µl with left shift

Hemoglobin 13.5 g/dL

Mean cell volume (MCV) 84 fL

Platelet count 310k/µl

Which of the following is most important next step in management?

A) Obtain urgent surgical consult

B) Rectal tube placement

C) Serum amylase level

D) Supportive care alone

E) Barium enema

Question of the week # 292

2011-12-29T21:36:00.000-08:00

292) A 66 year old man is evaluated in the emergency room for abdominal pain and fever. The patient underwent a screening colonoscopy in the outpatient Gastroenterology clinic 8 hours ago and had a 3cm sessile polyp removed. He complains of moderate pain in left lower quadrant that started one hour ago. He denies nausea or vomiting or rectal bleeding. On examination, temperature is 100.8F, blood pressure 140/90 mmHg, pulse 102, respiratory rate 20 bpm. Abdominal examination reveals tenderness and guarding in the left lower quadrant. There is no rigidity or rebound tenderness. His laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits. Which of the following is the most appropriate next step in managing this patient?

A) Exploratory Laporotomy

B) Rectal tube placement

C) Flexible sigmoidoscopy

D) CT Scan of the Abdomen

E) Conservative management

Question of the week # 291

2011-12-27T22:39:00.000-08:00

291) A 66 year old man with past medical history of hypertension and type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection. On the times that he does have an erection, they are very soft. He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship. He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been "perfect". A Hemoglobin A1C 2 weeks ago was 6.0gm% . He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

Question of the week # 290

2011-12-27T22:08:00.000-08:00

290) A 72 year old man with history of Diabetes Mellitus and peripheral vascular disease is evaluated in your office for impotence. He denies any premature ejaculation and states that he can not even attain an erection. Further studies confirm erectlie dysfunction secondary to organic causes. The patient denies any history of angina in the past. His medications include Aspirin, Clopidogrel, Glargine insulin and Lispro. His most recent HGBA1C was 6.5%. You offer him sildenafil for erectlie dysfunction. He is now concerned about the possible side effects. Which of the following is the most common side effect of sildenafil?

A) Headache

B) Nasal congestion

C) Diarrhea

D) Blurred vision

E) Flu like symptoms

Question of the week # 289

2011-12-27T20:56:00.000-08:00

289) A 32 year old male athlete is evaluated in the office for bilateral breast enlargement. He is a state champion in running and is scheduled to participate in the national level running championship in few weeks. He is very concerned about his appearance. He denies using any illicit drugs or exogenous androgens or aromatase inhibitors is seen in the office during a routine follow up visit. His past medical history is unremarkable. Physical examination reveals gynecomastia bilaterally. His laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 18.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV) 84 fL

Platelet count 310k/µl

Which of the following is most useful in establishing the diagnosis?

A) Erythropoetin level

B) Urine Drug Screen

C) Serum Total Testosterone

D) Urine Testosterone/ Epitestosterone ratio

E) Serum Free Testosterone

Question of the week # 288

2011-12-27T18:44:00.000-08:00

288) A 38 year old caucasian man is seen in the office during a routine follow up visit. His past medical history is significant for testicular non-seminomatous germ cell tumor diagnosed 9 months ago and was treated with radical orchiectomy of left testicle and chemotherapy. He completed chemotherapy 6 months ago and achieved a complete response. His tumor markers and imaging studies 3 months after completion of therapy were normal. He complains of decreased sexual drive and energy. He denies smoking tobacco or alcohol. He uses Marijuana on a daily basis but quit 2 months ago. His family history is unremarkable. Physical examination shows absent left testicle. Rest of the physical is normal. Serum alpha-fetoprotein is normal. Beta HCG is elevated at 15U/L ( Normal < 5 U/L) . A chest X-ray , CT scan of the abdomen and pelvis are normal. His routine laboratory investigations including complete blood count are within normal limits. Which of the following is most likely reason for his elevated Beta-HCG?

A) Recurrent tumor

B) Marijuana Use

C) Hypogonadism

D) Chemotherapy effect

E) Hyperthyroidism