USMLE STEP 3 EDUCATIONAL OBJECTIVES

1. Young(<35) female w/ breast mass palpated as cystic lesion(small,

round, soft, mobile mildly tender), next step in mgmt? FNA; if young
and mass appears cystic, do FNA; if young and mass seems solid/too
small/not palpated, do US breast next to determine if bx needed
2. Best initial step in mgmt. of pt presenting w/ sx suggestive of
esophageal Ca? Barium swallow first before doing an endoscopy;
3. Squamous cells ca vs AdenoCA of Esophagus: Location, race and a/
RFs? Upper/middle esophagus, more common in in African Americans
and a/w smoking, alcohol and dietary factors VS. Lower 1/3 more
common in Caucasians and a/w barretts
4. Most accurate test to dx osteomyelitis in vertebrae and diabetic foot =
MRI
5. Most useful way to obtain a microbiologic dx in osteomyelitis pt =
culture deep tissue obtained by curettage as it correlates closely w/
cultures obtained from surgical resection of deep tissue
6. Prophylactic therapy of choice to prevent DVT in old lady s/p hip fx
while waiting for hip replacement? LMWH
7. Relative risk = measure of outcome in fu studies = risk of exposed
divided by unexposed
8. Attributable risk percentage(ARP) = measure of excess risk = (RR1)/RR or (risk exposed-risk unexposed)/risk exposed; estimates
proportion of the dsz in exposed subjects that is attributed to exposure
status
9. Population attributable risk percentage (PARP) = excess risk in the total
population, not only in the exposed subjects = (risk in total population
risk in unexposed)/risk in the total population; risk in total population
can be calculated if u know the risks and prevalence of exposure in
population
10.
Best response when pt behaves seductively/makes sexual
advances? Calmly establish definite boundaries that allow for
appropriate medical tx while maintaining professional doctor-pt
relationship.
11.
Type of personality d/o in pt w/ dramatic, sexually provocative
behavior along w/ unnecessary emotionality and attention seeking?
Histrionic PD
12.
Dating ur pts appropriate? No, as per AMA, terminate doctor-pt
relationship prior to entering a sexual/romantic relationship w/ pt; for
psychiatrist NEVER not even after no longer a pt of yours
13.
Ideal surgery candidates for hip replacement who will benefit
most? Elderly pts who were ambulatory prior to their hip fx; physician
should consider pts age, presence of comorbidities, functional status,
quality of life and personal values; if pt bedridden, benefits are
minimal; if pts has multiple comorbidities, risk may outweigh benefits;
pain alone is not an indication for surgery

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Classic presentation of Henoch-schloein purpura(HSP): usually
kids w/ abdominal pain, arthralgia, skin lesions (symmetric papules in
dependent area) and renal involvement; preceding URI in ~50%
15.
HR Young male w/ unprotected sex w/ prostitute 2 wks ago pts
presents w/ watery d/clikely dx, and tx? Non-gonococcal
urethritis(NGU) usually presents 5-10 days post-expsoure w/
watery/mucoid discharge compared to Gonoccocal urethritis which
presents 2-7 days after exposure w/ abundant purulent discharge; tx of
NGU = 90% pt responsive to 100 g doxycycline PO x 7 days or 1g
azithro PO x 1; if pt seems likely not to adhere to tx then give Azithro
16.
Treatment for NGU refractive to typical Abx therapy? Oral
Metronidazole 2 gm x 1 followed by and erythromycin 500 g q6h for 7
days OR Erythromycin monotherapy 800g q6h for 7 days; to tx
trichomonas and resistant NGU agents
17.
Most appropriate next step in mgmt. of a pt w/ sx suggestive of
RMSF and initial serology inconclusive? Start tx empirically w/
doxycycline for adults and children w/out waiting for confirmation of dx
to prevent fatal complications ie. thrombocytopenia; serologic testing
w/ indirect fluorescent ab, enzyme immunoassay or complement
fixation is not useful early as Abs are seen 7-10 days after onset;
continue tx for at least 3 days after fever reduced(defervescence);
alternative= chloramphenicol: high SE so only reserved for pregnant
and those unable to tolerate tetracycline
18.
One of the most suggestive sign of compartment syndrome =
pain out of proportion to the injury; other early signs = tightness,
weakness and pain w/ passive muscle motion; late signs = loss of
pulse, paralysis; very late signs = tissue ulcerations and necrosis;
compartment syndrome is a/w crush injuries, fractures, prolonged
external compression, burns, and snake bites;
19.
Most ominous sign of compartment syndrome = loss of arterial
pulse => no blood flow to extremity; muscle tissue fxn impaired after
2-4 hrs of ischemia and irreversible loss of fxn after 4-12 hrs; Nerve
tissue fxn impaired after 30 mins and irreversible loss after 12-24 hrs;
tx = splitting the cast and underlying padding which can dec. the
compartment pressure by 50%-85%.
20.
Best clinical sign to test for Achilles tendon rupture = positive
Thompson test; pt kneeling on chair/lying prone w/ feet hanging over
the edge, examiner squeezes the calf muscle; if foot responds, ie
plantar flex, test is neg. if No response = pos. test; tx = immediate
immobilization of the lowerleg and surgical repair the tendon ASAP;
Achilles tendon rupture presents w/ loud snap followed by excruciating
pain in calf
21.
Does the risk of turner syndrome increase for future children if
parents have a baby with it now? No. risk stays the same as that of
gen. population; turner syndrome presentation in newborn = edema of

dorsal feet and hands, short webbed neck and a cardiac murmur;
monosomy of X chromosome(45x); no barr bodies on buccal smear
22.
CDC guidelines for cervical ca screening for ALL women(including
lesbians): Generally speaking start at age 21, regardless of when pt
became sexually active and end at 65; for age 21-29 repeat pap smear
every 3 years; for 30-65 can do either routine at every 3 yrs or add
HPV co-testing and extend the interval to every 5 yrs;
23.
When to suspect HIT in pts receiving heparing anticoag? If pt has
thrombocytopenia, thrombosis w/ thrombocytopenia, or a >50% fall in
platelet count, 4-10 days after the initiation of tx; 2 types of HIT= type
1, mild less severe presents(w/in 2 days)no clinical sx just low platelets
that goes back to normal w/ tx d/c; type 2 severe, immune mediated
by formation of heparin-platelet factor 4 Ab complex, after 4-10 days of
start tx => thrombocytopenia and both venous/arterial thrombosis;
venous = dvt, PE, venous gangrene, & cerebral sinus thrombosis;
arterial = strokes, MI, limb & organ(kidney, mesenteric) ischemia;
24.
First and most imp. Next step in pt w/ suspected or documented
HIT = immediate cessation of exposure to all heparin products; also
stop warfarin until plts >100k; tx instead w/ direct thrombin inhibitors
= lepirudin(renal ex) or argatroban(liver ex) depending coexisting
conditions;
25.
Best way to prevent HIT = use LMWH instead of unfractionated
heparin as they are a/w lower incidence of HIT; Also limit heparin use
to less than 5 days to prevent AB response; minimize the duration of
heparin by initiating warfarin early- same time as (or w/in 24 hrs) of
heparin
26.
Young Pt presents w/ episodic palpitations, HA, HTN, diaphoresis,
anxiousPE = thyroid normal, appropriate next step? Confirm dx of
pheochromocytoma by biochemical tests like 24 hr urinary
metanephrines, free catecholamines and VMA(low sensitivity, high
speci) or plasma free metanephrines(b/c urine levels can be altered by
food/drugs like alpha blockers) levels; NEXT best step after
confirmation of dx = start pt on long acting noncompetitive alphablocker phenoxybenzamine for 10-14 days preoperatively b4 surgical
resection to control HTN and restore intravascular volume; CT/MRI
done while pt on alpha blockade for tumor localization. BBs given only
to pts after alpha blockade
27.
One of the most imp. Intraoperative complication of
pheochromocytoma tumor is hypotension; generally occurs after
removal of tumor which is followed by dec. in circulatory
catecholamanies and alpha blockade => sig. dec. in vascular tone; tx
= IV bolus of normal saline; if acute severe HTN during surgery = tx w/
IV bolus of phentolamine
28.
high specificity increases the positive predictive value(PPV);
29.
new pts should be addressed as ms. Smith or Mr. smith and
not by 1st name.

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