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Old 07-09-2011
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Question USMLE Step 3 MCQs 1 - 5

1. While brushing her hair, a 25-year-old woman notices an apparent thinning scalp patch located immediately above and behind her left ear. As she carefully sweeps away overlying hair that is concealing the true extent of the patch, she is shocked to find that the region is almost completely bare. The woman has never noticed any significant hair loss before. There is no history of serious illness or positive testing for sexually transmitted disease (STD). There is no recent travel or unusual environmental exposure. The woman takes no medications including birth control pills and has a history of regular menstrual periods. She underwent first trimester elective abortion 1 month ago. Physical examination is notable for a moderately well-defined oval 5 x 8 cm (2 x 3 inch) peach colored, denuded region in the left occipito-parietal region of the scalp. No scarring, erythema crusting or other abnormality of the region is apparent. The few hairs that are present are not broken but under inspection with a hand held magnifying glass, have a clearly visible tapering of their proximal ends. There are no other areas of hair loss on the scalp, which is otherwise healthy appearing and abundant. No other hair bearing areas appear thinned or denuded. The remainder of the basic physical examination is normal. What additional physical examination or laboratory study is most strongly indicated?
A. Close inspection of the nail beds
B. Fasting blood glucose
C. Manual traction applied to hair tuffs bordering the denuded area
D. Thyroid stimulating hormone (TSH) level
E. Wood lamp inspection of the denuded region

2. A 24-year-old man visits a primary care physician after suffering, in his words, years of “cruddy lung problems”. Since the age of 18 the man has suffered from episodes of cough and wheeze 4 to 5 times per year. At age 19 years he sought evaluation for his respiratory difficulties at his university health center where he was assigned a provisional diagnosis of asthma. He received a prescription for albuterol inhaler and was scheduled for pulmonary function testing (PFT). The albuterol had no apparent beneficial effect and the man resolved to “simply live with his condition” and elected to forego further medical evaluation. His cough and wheeze have persisted with stable frequency and severity, but for the past year the man's formerly dry cough has become progressively more productive and occurs throughout the day. Initially sputum production was a “couple of tablespoons per day” but the volume has steadily increased to its present amount of about a “quarter of a cupful” per day. There is no accompanying fever or other symptoms. The man has never smoked and takes no medications. Vital signs are normal and physical examination is remarkable for scattered crackles and wheezing on inspiration and expiration. There is no cyanosis clubbing or edema and no abnormal jugular venous distension. Cardiac examination is normal. Organomegaly and hepatojugular reflux are absent. A sputum sample is obtained and after a few minutes a thin layer of small yellowish-white granules are observed to have settled to the bottom of the collection receptacle. Blood samples are drawn for additional work-up. A high resolution computed tomography (CT) scan is performed that shows bilateral central bronchial wall thickening with internal bronchial diameters greater than 1.5 times that of adjacent bronchial arterial vessels. What pharmacotherapy will most likely improve this patient's long-term outcome?
A. Aerosolized recombinant DNase
B. Alpha-1-protease inhibitor
C. Methotrexate
D. Prednisone
E. Voriconazole


3.A 63-year-old man with a history of alcoholism is seen by his family physician for a regular scheduled health maintenance examination. Today he has no complaints including itchiness, skin discoloration or increasing abdominal girth. Medical history is psoriasis and two hospitalizations for acute alcohol withdrawal. The man has been completely abstinent of alcohol use since the last hospitalization 4 years ago. Most recent medical evaluation was 2 years ago. At that time, vital signs and physical examination were within normal limits except for his usual psoriatic plaques on his knees, bilateral palmar contractures, scattered abdominal spider angiomatae and gynecomastia. Screening laboratory values were within laboratory reference range. Screening colonoscopy was normal. Today the man has no complaints except for a poor appetite and an unintentional 6.8 kg (15 lbs) weight loss over the past 6 months. Vital signs are normal and physical examination unchanged compared to the last examination except for mild-moderate diminished muscle mass. The notable abnormality detected by screening laboratory tests is an alpha-feto-protein (AFP) value of 1100 ng/mL. Hepatic ultrasound (US) imaging studies are obtained that show a 3 cm upper right lobe nodular lesion with overall pan-hepatic background changes consistent with early alcoholic cirrhosis. Doppler phase studies show complete patency of the portal vein. What nest step in management is most strongly indicated?
A. Bone scan
B. Chest X-ray (CXR)
C. Fine needle biopsy
D. Head computed tomography (CT) scan
E. Triphasic hepatic CT scan

4. A 23-year-old man seeks evaluation from his primary care physician for complaints of fatigue and easy bruising. He denies fever, nausea, vomiting, headache or other complaints. Medical, family, social and environmental exposure histories are unremarkable. The man takes no medications. Vital signs are: temperature 37.1 °C (98.7 °F), blood pressure (BP) 125/65 mm Hg, heart rate 102 beats/minute and respiration 17 breaths/minute. Physical examination shows a tired pale appearing man of normal stature in no acute distress. Skin has pallor with several 2-4 cm diameter ecchymotic lesions on the dorsum of the hands and forearms; otherwise there are no pigmentary abnormalities of the skin. Head exam is normal, conjunctivae are pale, pupils are equal round and reactive to light and accommodation, cranial nerve function II-XII is grossly intact. Fundoscopic examination is unremarkable. Physical examination is unremarkable and distal pulses are bounding and tendon reflexes are 1 + throughout. Complete blood count (CBC) shows neutrophils 500 cells/uL, and platelets 20k cells/uL. Corrected reticulocyte count is 0.5%. Bone marrow biopsy shows moderate hypocellularity with hematopoietic cells comprising 20% of residual cells. Hepatitis (A, B, C), cytomegalovirus (CMV), human immunodeficiency virus (HIV), Epstein-Barr virus (EBV) serologies, and autoantibody testing for collagen vascular diseases are negative. Hemoglobin (Hb) electrophoresis shows elevated Hb f and red cell I antigen levels. What additional screening test or procedure will most likely detect a serious coexistent disease in this patient?
A. Flourescein activated cell sorter profile (FACF)
B. Peripheral blood diepoxybutane incubation
C. Radiometric cobalamin absorption test (Schilling test)
D. Red cell adenosine deaminase assay
E. Serum and urine protein electrophoresis

5. A 50-year-old woman is driven to the emergency department (ED) by her husband after the woman suffers 6 hours of constant and worsening right upper quadrant (RUQ) pain accompanied by nausea and one episode of vomiting. She has not experienced this pain before. Medical history is insulin dependent diabetes mellitus (DM). Medications are regular and NPH insulin administered on a flexible regimen. Vital signs are temperature 37.7 °C (99.9 °F), blood pressure (BP) 140/90 mm Hg, heart rate 95 beats/minute, respirations 17 breaths/minute, shallow and with obvious splinting. Skin is cool and damp without rashes or discoloration. Neurologic examination is non-focal. There is no scleral icterus. Throat is clear and neck is supple without abnormal mass or carotid bruit. Chest is clear to auscultation and percussion. Cardiac examination reveals borderline regular rate tachycardia and no rubs, gallops or murmurs. Abdomen is non-distended with moderate epigastric and RUQ tenderness. There is no guarding or rebound elicited on palpation. No masses or pulsations are present. Bowel sounds are diminished. Rectal and pelvic examinations are normal. Stool sample is guiac negative. Extremities show no cyanosis, clubbing or edema. Distal pulses and deep tendon reflexes are 1+ throughout. Screening laboratory values are within reference range including blood glucose, hemoglobin (Hb) H1ac, complete blood count (CBC), liver panel, serum bilirubin levels and urinalysis. An ultrasound (US) examination shows gallbladder wall thickening of 5 mm with no calcifications, no signs of stones in the gallbladder or ductal system and no signs of gas in the gallbladder wall or lumen. Hepatobiliary scintigraphy is performed and confirms the diagnosis suggested by the US study. The patient insists on medical management, if it is an acceptable medical option, and additionally on outpatient management rather than hospitalization, if this is also an acceptable medical option. What is a reasonable management plan, given the patient's strong preferences?
A. Discharge to home with antibiotics, analgesics and instructions for follow-up care. Strongly recommend elective cholecystectomy within the next 6 months
B. Further evaluation by endoscopic retrograde cholangiopancreatectomy (ERCP) and revaluation based on results of the study
C. Hospitalization and emergent (within 72 hours) transhepatic cholecystotomy drainage tube placement
D. Hospitalization and medical management with narcotic analgesia, antibiotics and daily intravenous CCK (cholecystekinin). No surgical intervention if patient condition resolves within 72 hours
E. Immediate cholecystectomy
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bebix (01-06-2012)

Old 11-23-2011
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Question Are there answers to these good questions?

????????????? Answers available??????????????
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hionlyf (07-31-2012)
Old 11-26-2011
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Q 1 : The case is that Of Alopecia Areata. I believe C should be the answer .this is just my guess.
Q2 : Case is of possible Allergic Broncho-Pulmonary Aspergillosis. Answer D
Q3 : 1st thing to note is local spread and then distal spread. Therefore E
Q4 : This was hard one had to do some reasearch. answer B
Q5 : Acalculous cholecystitis. Answer E
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The above post was thanked by:
bebix (01-06-2012), hionlyf (07-31-2012)



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