USMLE World Step 3: Set #4 Questions And
Answers With Latest Solution
Which is compatible with brain death:
-absence of respiratory drive for 3 mins off the ventilator
- irreversible absence of cerebral and brain stem reflexes Correct Answer: irreversible absence of
cerebral and brain stem reflexes; the absence of respiratory drive must be for 8 minutes
Brain death criteria Correct Answer: - neuro exam showing absent cerebral and brainstem reflexes -
pupillary, corneal, oculocephalic, oculovestibular (caloric), sucking, swallowing, and extensor
posturing
- absence of confounding factors aka intoxication with drugs or major endocrine/ electrolyte
disturbances
- evidence of a devastating cause via brain imaging
Is it possible to see spontaneous limb movements in people with brain death? Correct Answer: YES
Saw palmetto is an alternative medicine most commonly used to treat Correct Answer: BPH; there's
no evidence it works, however
Ginseng, garlic, ginkgo biloba, and saw palmetto all have the risk of the side effect of ___________
Correct Answer: bleeding
"non-ejection click" is a buzzword for which valvular murmur Correct Answer: mitral valve prolapse
Typical sound of mitral valve prolapse Correct Answer: non ejection click followed by systolic murmur
(which is mitral regurgitation)
The click and murmur occur later in systole if the L ventricular end diastolic volume increases, and it
may disappear entirely if the LVEDV is large enough (i.e., squatting, supine leg raise)
In botulism, are sensations intact? What about reflexes? Correct Answer: sensations are intact
(botulism inhibits release of acetylcholine, so it spares sensory tracts)
Reflexes are diminished or absent
A child is diagnosed with night terrors. They recently moved to a new city. Best advice for mother is:
- he will likely experience these nightmares until he adjusts to his new home
- his condition will most likely resolve spontaneously over 1-2 years
- these episodes should resolve as soon as he gets adequate sleep Correct Answer: his condition
will most likely resolve spontaneously over 1-2 years
Do sleep terrors have REM sleep? Correct Answer: No; it is a non-rapid eye movement arousal
disorder
,Describe sleep terrors epidemiology and symptoms Correct Answer: they occur between ages 4-12.
It is self-limiting, resolving over 1-2 years.
It arises during the first third of sleep. The child awakens abruptly with a scream, a frightened
expression, and signs of autonomic arousal.
The child is unable to recall the episode in the morning
Are you allowed to accept travel compensation from pharmaceuticals? What about an honorarium (a
payment)? What about pre-made slides at a presentation? Correct Answer: Yes to travel
compensation and an honorarium
No to pre-made slides
44 yo M comes in for concern for hepatitis infection. He donated blood at an office event and received
a letter a few days later saying that hepatitis performed on his sample was positive. He used injection
drugs in his 20s but not since then.
Lab results are:
AST 15
ALT 16
Hep A igg +
Hep C AB +
Hep B sag neg
Hep B s AB neg
HIV ab neg
Next best step:
- initiate antiviral therapy because the patient has chronic hep C
- it is unclear if the patient has hep c; further investigation is required Correct Answer: it is unclear if
the patient has hep c; further investigation is required
2 other scenarios besides his having hep c are possible:
1) he USED to have hep C but CLEARED IT spontaneously (that happens)
2) it's a false positive result
You need HCV RNA to DEFINITIVELY DIAGNOSE ACTIVE HEP C
Are patients with proven Hep C via RNA in the blood candidates for antiviral treatment? Correct
Answer: Yes
Which one has vaginal ph > 4.5; trichomonas or gardnerella ? Correct Answer: BOTH
Describe the appearance of trichomonas, versus gardenerella Correct Answer: TRICH: pear-shaped
motile organisms on wet mount
GARDNERELLA: CLUE CELLS
, The best way to prophylax vs fat embolism in setting of fracture
- early immobilization and operative correction
- LWMH
- breathing exercises Correct Answer: early immobilization and operative correction
The classic triad of fat embolism Correct Answer: respiratory insufficiency
Neurologic impairment
Petechial rash
Rx for + tuberculin skin test with - CXR Correct Answer: Any of the following is acceptable:
1) isoniazid mono therapy for 9 months
2) rifampin for 4 months
3) isoniazid and rifapentine weekly for 3 months
A 32 yo F with SLE comes to office for follow up. Symptoms of SLE well controlled on
hydroxychloroquine
Labs:
BUN 36
Creatinine 2
U/A: 2+ protein, 20-30 RBC, RBC casts.
2 months ago chemistry and u/a were WNL
Best next step:
- cyclophosphamide and methylprednisolone
- high dose prednisone
- methylprednisolone
- pulsed cyclophosphamide
- renal biopsy Correct Answer: renal biopsy
ALL SLE RENAL DISEASE (aka lupus nephritis) TREATMENTS ARE DICTATED BY THE RESULTS
OF THE RENAL BIOPSY, not by the creatinine, BUN, etc
Mild disease require no RX
Moderate disease requires moderate immunosuppression
Severe disease may require severe immunocuppression
An 18 month old boy has a lead level of 25. Although there's no indication to give succumier (why
not?), the patient is at increased risk for:
- acute encephalopathy
- cognitive impairment
- constipation
Answers With Latest Solution
Which is compatible with brain death:
-absence of respiratory drive for 3 mins off the ventilator
- irreversible absence of cerebral and brain stem reflexes Correct Answer: irreversible absence of
cerebral and brain stem reflexes; the absence of respiratory drive must be for 8 minutes
Brain death criteria Correct Answer: - neuro exam showing absent cerebral and brainstem reflexes -
pupillary, corneal, oculocephalic, oculovestibular (caloric), sucking, swallowing, and extensor
posturing
- absence of confounding factors aka intoxication with drugs or major endocrine/ electrolyte
disturbances
- evidence of a devastating cause via brain imaging
Is it possible to see spontaneous limb movements in people with brain death? Correct Answer: YES
Saw palmetto is an alternative medicine most commonly used to treat Correct Answer: BPH; there's
no evidence it works, however
Ginseng, garlic, ginkgo biloba, and saw palmetto all have the risk of the side effect of ___________
Correct Answer: bleeding
"non-ejection click" is a buzzword for which valvular murmur Correct Answer: mitral valve prolapse
Typical sound of mitral valve prolapse Correct Answer: non ejection click followed by systolic murmur
(which is mitral regurgitation)
The click and murmur occur later in systole if the L ventricular end diastolic volume increases, and it
may disappear entirely if the LVEDV is large enough (i.e., squatting, supine leg raise)
In botulism, are sensations intact? What about reflexes? Correct Answer: sensations are intact
(botulism inhibits release of acetylcholine, so it spares sensory tracts)
Reflexes are diminished or absent
A child is diagnosed with night terrors. They recently moved to a new city. Best advice for mother is:
- he will likely experience these nightmares until he adjusts to his new home
- his condition will most likely resolve spontaneously over 1-2 years
- these episodes should resolve as soon as he gets adequate sleep Correct Answer: his condition
will most likely resolve spontaneously over 1-2 years
Do sleep terrors have REM sleep? Correct Answer: No; it is a non-rapid eye movement arousal
disorder
,Describe sleep terrors epidemiology and symptoms Correct Answer: they occur between ages 4-12.
It is self-limiting, resolving over 1-2 years.
It arises during the first third of sleep. The child awakens abruptly with a scream, a frightened
expression, and signs of autonomic arousal.
The child is unable to recall the episode in the morning
Are you allowed to accept travel compensation from pharmaceuticals? What about an honorarium (a
payment)? What about pre-made slides at a presentation? Correct Answer: Yes to travel
compensation and an honorarium
No to pre-made slides
44 yo M comes in for concern for hepatitis infection. He donated blood at an office event and received
a letter a few days later saying that hepatitis performed on his sample was positive. He used injection
drugs in his 20s but not since then.
Lab results are:
AST 15
ALT 16
Hep A igg +
Hep C AB +
Hep B sag neg
Hep B s AB neg
HIV ab neg
Next best step:
- initiate antiviral therapy because the patient has chronic hep C
- it is unclear if the patient has hep c; further investigation is required Correct Answer: it is unclear if
the patient has hep c; further investigation is required
2 other scenarios besides his having hep c are possible:
1) he USED to have hep C but CLEARED IT spontaneously (that happens)
2) it's a false positive result
You need HCV RNA to DEFINITIVELY DIAGNOSE ACTIVE HEP C
Are patients with proven Hep C via RNA in the blood candidates for antiviral treatment? Correct
Answer: Yes
Which one has vaginal ph > 4.5; trichomonas or gardnerella ? Correct Answer: BOTH
Describe the appearance of trichomonas, versus gardenerella Correct Answer: TRICH: pear-shaped
motile organisms on wet mount
GARDNERELLA: CLUE CELLS
, The best way to prophylax vs fat embolism in setting of fracture
- early immobilization and operative correction
- LWMH
- breathing exercises Correct Answer: early immobilization and operative correction
The classic triad of fat embolism Correct Answer: respiratory insufficiency
Neurologic impairment
Petechial rash
Rx for + tuberculin skin test with - CXR Correct Answer: Any of the following is acceptable:
1) isoniazid mono therapy for 9 months
2) rifampin for 4 months
3) isoniazid and rifapentine weekly for 3 months
A 32 yo F with SLE comes to office for follow up. Symptoms of SLE well controlled on
hydroxychloroquine
Labs:
BUN 36
Creatinine 2
U/A: 2+ protein, 20-30 RBC, RBC casts.
2 months ago chemistry and u/a were WNL
Best next step:
- cyclophosphamide and methylprednisolone
- high dose prednisone
- methylprednisolone
- pulsed cyclophosphamide
- renal biopsy Correct Answer: renal biopsy
ALL SLE RENAL DISEASE (aka lupus nephritis) TREATMENTS ARE DICTATED BY THE RESULTS
OF THE RENAL BIOPSY, not by the creatinine, BUN, etc
Mild disease require no RX
Moderate disease requires moderate immunosuppression
Severe disease may require severe immunocuppression
An 18 month old boy has a lead level of 25. Although there's no indication to give succumier (why
not?), the patient is at increased risk for:
- acute encephalopathy
- cognitive impairment
- constipation
