- Is USMLE Step 3 scored or pass/fail?
- Still SCORED — a three-digit numeric score (minimum 200 since Jan 1, 2024), unlike Step 1, which is now Pass/Fail only.
- How many days is USMLE Step 3?
- Two days, taken separately at a Prometric center: Day 1 (FIP) and Day 2 (ACM).
- What is Day 1 of Step 3 called?
- Foundations of Independent Practice (FIP).
- What is Day 2 of Step 3 called?
- Advanced Clinical Medicine (ACM).
- Step 3 minimum passing score
- 200 on the three-digit scale (raised from 198, effective Jan 1, 2024).
- Total questions on Step 3
- About 412 multiple-choice questions plus roughly 13 computer-based case simulations (CCS).
- Day 1 (FIP) structure
- 232 multiple-choice questions in 12 blocks of 30 minutes; about a 7-hour session.
- Day 2 (ACM) structure
- About 180 multiple-choice questions in 9 blocks plus about 13 CCS cases; about a 9-hour session.
- What is the CCS?
- Computer-based Case Simulation — an interactive patient-management format unique to Step 3 (Day 2); you manage a simulated patient over advancing clock time.
- How many CCS cases on Step 3?
- About 13 cases, each allotted up to 10 or 20 minutes of real time.
- Does the CCS have answer choices?
- No — there are no multiple-choice options; you type orders (history, exams, tests, treatments) and the patient evolves.
- Primum CCS software
- The free practice software from USMLE that mimics the CCS interface; practice it before exam day so mechanics never cost points.
- Who registers candidates for Step 3?
- The Federation of State Medical Boards (FSMB) is the registration entity for Step 3.
- Step 3 eligibility
- Must have passed Step 1 and Step 2 CK and hold an MD or DO degree; IMGs must also be ECFMG certified.
- When do most people take Step 3?
- During residency, often the intern (PGY-1) year.
- What does Step 3 emphasize vs earlier Steps?
- Patient MANAGEMENT and clinical decision-making for unsupervised practice — what you DO, not just what you know.
- How is the Step 3 score combined?
- Day 1 MCQ, Day 2 MCQ, and the CCS cases combine into one three-digit score and pass/fail outcome.
- Step 3 first-time pass rate
- Highest of the Steps (takers already passed 1 and 2 CK): roughly 98% US/Canadian MD, ~96% DO, ~88% international.
- Percent correct needed to pass Step 3
- Criterion-referenced; examinees generally need to answer about 60% of items correctly.
- Step 3 attempt limit
- Maximum 4 attempts at any Step; no more than 3 within 12 months; a passed Step cannot be retaken.
- Competency shift across USMLE
- Step 1 = knowledge, Step 2 CK = diagnosis, Step 3 = management/decision-making.
- Which Step has the CCS?
- Only Step 3 (Day 2). Step 1 and Step 2 CK are multiple-choice only.
- CCS scoring principle
- Appropriate, timely, and safe management is rewarded; unnecessary, invasive, or risky orders are penalized — as in real care.
- Biggest avoidable CCS mistake
- Advancing the simulated clock on an unstable patient before treating the immediate threat.
- Step 3 care settings
- Cases play out in the office, emergency department, and inpatient ward/ICU; you can move the patient between them.
- Sensitivity
- Proportion of diseased who test positive (true-positive rate). A negative on a sensitive test rules OUT disease (SnNout).
- Specificity
- Proportion of healthy who test negative (true-negative rate). A positive on a specific test rules IN disease (SpPin).
- False-negative rate
- 1 − sensitivity.
- False-positive rate
- 1 − specificity.
- Positive predictive value (PPV)
- Probability that a test-positive person truly has disease. Rises with prevalence.
- Negative predictive value (NPV)
- Probability that a test-negative person is truly disease-free. Falls with prevalence.
- Do sensitivity/specificity change with prevalence?
- No — they are intrinsic to the test. Predictive values DO change with prevalence.
- Number needed to treat (NNT)
- 1 ÷ absolute risk reduction. Lower NNT = more effective treatment.
- Number needed to harm (NNH)
- 1 ÷ absolute risk increase. Higher NNH = safer treatment.
- Absolute risk reduction (ARR)
- Risk in control group − risk in treatment group.
- Relative risk (RR)
- Risk in exposed ÷ risk in unexposed; derived from a cohort study.
- Odds ratio (OR)
- Odds of exposure in cases ÷ odds in controls; from a case-control study. Approximates RR for rare outcomes.
- Relative risk reduction (RRR)
- 1 − relative risk; the proportional reduction in risk from treatment.
- Gold standard for causation
- The randomized controlled trial (RCT).
- Cohort study
- Follows exposed vs unexposed forward in time; yields incidence and relative risk. Can be prospective or retrospective.
- Case-control study
- Compares cases (with disease) to controls (without) for past exposure; yields an odds ratio. Good for rare diseases.
- Cross-sectional study
- Measures exposure and disease at one point in time; yields prevalence. Cannot establish causation.
- Incidence vs prevalence
- Incidence = new cases over time; prevalence = existing cases at a point. Long-duration disease raises prevalence.
- Type I error (alpha)
- Rejecting a true null hypothesis — a false positive. Conventionally set at 0.05.
- Type II error (beta)
- Failing to reject a false null hypothesis — a false negative.
- Statistical power
- 1 − beta; the probability of detecting a true effect. Increases with larger sample size and effect size.
- p-value
- Probability of obtaining the observed result (or more extreme) if the null hypothesis were true; <0.05 is conventionally significant.
- 95% confidence interval (for a ratio)
- If it crosses 1.0 (RR/OR) the result is not statistically significant; for a difference, crossing 0 means not significant.
- Likelihood ratio positive
- Sensitivity ÷ (1 − specificity); independent of prevalence. >10 strongly raises post-test probability.
- Selection bias
- Systematic error from how subjects are chosen (e.g., Berkson bias, healthy-worker effect).
- Recall bias
- Cases remember exposures differently from controls; classic in case-control studies.
- Lead-time bias
- Screening detects disease earlier, falsely lengthening apparent survival without changing outcome.
- Length-time bias
- Screening preferentially detects slow, indolent disease, overstating screening benefit.
- Confounding
- A third variable associated with both exposure and outcome that distorts the association; control by randomization, matching, or stratification.
- Effect modification
- The effect of an exposure differs across levels of a third variable (a real finding, reported by subgroup — not a bias to eliminate).
- Intention-to-treat analysis
- Analyze participants in their assigned group regardless of adherence; preserves randomization and reduces bias.
- Number to screen
- More patients must be screened than treated to prevent one outcome; NNT contextualizes screening benefit.
- Mean vs median vs mode
- Mean = average (sensitive to outliers); median = middle value (robust); mode = most frequent value.
- Positively (right) skewed distribution
- Tail to the right; mean > median > mode (e.g., income, length of stay).
- Standard error of the mean
- Standard deviation ÷ √n; shrinks as sample size grows.
- Sensitivity vs specificity trade-off
- Lowering a test threshold raises sensitivity but lowers specificity, and vice versa (ROC curve).
- Pretest probability
- Estimated likelihood of disease before testing; combined with likelihood ratios to get post-test probability.
- Hazard ratio
- Compares the rate of an event over time between groups in survival analysis; like RR but accounts for time.
- Meta-analysis
- Pools results from multiple studies for greater power; quality depends on the included studies (garbage in, garbage out).
- Systematic review vs narrative review
- Systematic uses explicit, reproducible methods to find and appraise all evidence; narrative is expert opinion-driven.
- External vs internal validity
- Internal = results are correct for the study sample; external (generalizability) = results apply to other populations.
- Screening test choice
- Prefer a HIGH-sensitivity test to screen (few false negatives); confirm a positive with a HIGH-specificity test.
- Crude vs adjusted analysis
- Adjusted analysis accounts for confounders; a large change between crude and adjusted estimates suggests confounding.
- Publication bias
- Positive studies are more likely to be published, biasing meta-analyses; assessed with a funnel plot.
- Kaplan-Meier curve
- Plots survival probability over time; the log-rank test compares two survival curves.
- Four principles of medical ethics
- Autonomy, beneficence, non-maleficence, and justice.
- Elements of informed consent
- Capacity, disclosure (diagnosis, intervention, risks, benefits, alternatives), understanding, and voluntariness.
- Capacity vs competency
- Capacity is a clinical, decision-specific judgment by a physician; competency is a global legal determination by a court.
- Can a patient with capacity refuse life-saving care?
- Yes — respecting autonomy, a capacitated patient may refuse even life-saving treatment.
- Exceptions to informed consent
- Emergencies, waiver by the patient, therapeutic privilege, and care of a patient who lacks capacity (use surrogate/advance directive).
- Minor consent exceptions
- Minors can often consent for emergencies, STIs, contraception, pregnancy, substance use, and if emancipated.
- Advance directive
- A patient's prior instructions (living will) or designated proxy guiding care when they lack capacity.
- Substituted judgment
- A surrogate decides what the patient WOULD have wanted, not what the surrogate prefers.
- Surrogate decision-maker order
- Typically: healthcare proxy/POA, then spouse, adult children, parents, siblings (varies by state).
- Disclosing a medical error
- Disclose honestly and promptly to the patient; transparency is ethically required even if no harm occurred.
- Confidentiality and its limits
- Maintain confidentiality except for reportable conditions, threats to others (Tarasoff), child/elder abuse, and certain infections.
- Duty to warn (Tarasoff)
- A clinician may have a duty to protect an identifiable third party from a serious, credible threat by a patient.
- Best response on an ethics item
- The option that talks WITH the patient — explore concerns, give honest information, respect a capacitated choice; avoid paternalism/deception.
- Patient who refuses recommended care
- Assess capacity, explore reasons, educate, and ultimately respect a capacitated refusal — document the discussion.
- Decisional capacity criteria
- Understand the information, appreciate it applies to them, reason about options, and communicate a consistent choice.
- Emancipated minor
- A minor who is married, in the military, financially independent, or court-declared; can consent like an adult.
- Withholding vs withdrawing care
- Ethically and legally equivalent; both are permissible at a capacitated patient's or surrogate's direction.
- Futile treatment
- Physicians are not obligated to provide care that cannot achieve its goal; communicate compassionately and involve ethics consult if needed.
- Beneficence vs autonomy conflict
- When they conflict, a capacitated patient's autonomous, informed choice generally prevails.
- Gifts from patients / industry
- Decline gifts that could impair judgment or create conflicts of interest; disclose relevant conflicts.
- Impaired colleague
- Report a colleague impaired by substances or illness to protect patients (to the supervisor or physician health program).
- Breaking bad news
- Use a stepwise approach (e.g., SPIKES): private setting, assess understanding, deliver clearly, respond to emotion, plan.
- Motivational interviewing
- A patient-centered counseling style that elicits the patient's own motivation to change behavior.
- Swiss-cheese model
- Accidents happen when latent system weaknesses (holes) line up; layered defenses prevent most errors.
- Active vs latent error
- Active = at the sharp end (the person doing the task); latent = system/design failures upstream.
- Root-cause analysis (RCA)
- A retrospective, systematic review of an adverse event to find and fix underlying causes.
- Failure mode and effects analysis (FMEA)
- A prospective method to anticipate and prevent failures in a process before they occur.
- Near miss vs adverse event vs sentinel event
- Near miss = reaches no patient; adverse event = causes harm; sentinel event = serious, reportable harm.
- Just culture
- Distinguishes blameless human error from reckless behavior; encourages reporting without punishing honest mistakes.
- Forcing function
- A design that prevents an error (e.g., a connector that only fits the correct port); a strong system safeguard.
- Highest-reliability error prevention
- System fixes (forcing functions, checklists, CPOE with decision support) beat reminders, education, or blaming individuals.
- Computerized provider order entry (CPOE)
- Reduces transcription and dosing errors, especially with clinical decision support.
- Time-out before surgery
- A team pause to confirm correct patient, procedure, and site — prevents wrong-site surgery.
- Quality improvement (PDSA cycle)
- Plan-Do-Study-Act: small, iterative tests of change to improve a process.
- Informed refusal
- Documenting that a capacitated patient declined a recommended intervention after understanding the risks.
- Hypertension first-line drugs
- Thiazide diuretic, ACE inhibitor or ARB, or calcium channel blocker (CCB).
- Hypertension in diabetes with albuminuria
- Prefer an ACE inhibitor or ARB (renoprotective).
- Stage 1 vs stage 2 hypertension
- Stage 1: 130-139/80-89 mmHg; Stage 2: ≥140/90 mmHg (confirm with repeat/out-of-office readings).
- Hypertensive emergency
- Severe BP elevation with end-organ damage; lower BP with IV agents, by ≈10-20% in the first hour (avoid overcorrection).
- Atrial fibrillation rate control
- Beta-blocker or non-dihydropyridine CCB (diltiazem, verapamil) for most patients.
- Anticoagulation in atrial fibrillation
- Guided by the CHA2DS2-VASc score; higher score favors oral anticoagulation to prevent embolic stroke.
- Unstable atrial fibrillation
- Immediate synchronized cardioversion (hypotension, chest pain, heart failure, altered mentation).
- CHA2DS2-VASc components
- CHF, Hypertension, Age ≥75 (2), Diabetes, Stroke/TIA (2), Vascular disease, Age 65-74, Sex category (female).
- HFrEF guideline-directed therapy
- ARNI (or ACE inhibitor/ARB) + beta-blocker + aldosterone antagonist + SGLT2 inhibitor; add a loop diuretic for congestion.
- Drugs that reduce mortality in HFrEF
- Beta-blockers, ACE inhibitor/ARB/ARNI, aldosterone antagonists, SGLT2 inhibitors, and hydralazine-nitrate in select patients.
- Acute decompensated heart failure
- Oxygen, IV loop diuretic, and vasodilators (nitroglycerin) if hypertensive; treat the precipitant.
- STEMI management
- Aspirin + ECG immediately, then reperfusion — PCI within 90 minutes (or fibrinolysis if PCI unavailable).
- Acute coronary syndrome initial meds
- Aspirin, oxygen if hypoxic, nitroglycerin, and anticoagulation; add a P2Y12 inhibitor and statin.
- Stable angina management
- Antianginals (beta-blocker, nitrates, CCB) plus risk-factor control (aspirin, statin, BP, smoking cessation).
- Statin indications
- Clinical ASCVD, LDL ≥190, diabetes age 40-75, or elevated 10-year ASCVD risk; high-intensity for ASCVD.
- Statin monitoring/adverse effects
- Myopathy/rhabdomyolysis and transaminase elevation; check a baseline lipid panel and address muscle symptoms.
- Bradycardia / symptomatic AV block
- Atropine first; transcutaneous pacing if refractory; pacemaker for high-grade block.
- Stable ventricular tachycardia
- Antiarrhythmics (amiodarone, procainamide); cardiovert if unstable; defibrillate pulseless VT/VF.
- Amiodarone toxicities
- Thyroid (hypo- or hyper-), pulmonary fibrosis, hepatotoxicity, corneal deposits, blue-gray skin; monitor TFTs, LFTs, PFTs.
- Warfarin monitoring
- INR (target 2-3 for most indications, 2.5-3.5 for mechanical mitral valves).
- Heparin (unfractionated) monitoring
- aPTT (or anti-Xa); reverse with protamine.
- Aortic stenosis
- Harsh crescendo-decrescendo systolic murmur radiating to carotids; symptoms (angina, syncope, dyspnea) → valve replacement.
- Infective endocarditis
- Fever + new murmur; obtain blood cultures and echo; empiric antibiotics then tailor; surgery for complications.
- Pericarditis
- Pleuritic chest pain better leaning forward, diffuse ST elevation; treat with NSAIDs + colchicine.
- DVT prophylaxis in hospitalized patients
- Pharmacologic (LMWH/heparin) or mechanical prophylaxis based on risk; a high-yield CCS order.
- COPD exacerbation management
- Inhaled short-acting bronchodilators, systemic corticosteroids, antibiotics if purulent sputum; controlled oxygen (SpO2 88-92%).
- Why limit oxygen in COPD?
- Over-oxygenation can blunt respiratory drive and worsen CO2 retention; target SpO2 88-92%.
- COPD maintenance therapy
- Inhaled long-acting bronchodilators (LABA/LAMA), inhaled steroids in select patients, smoking cessation, pulmonary rehab, vaccines.
- Asthma exacerbation
- Inhaled short-acting beta-agonist + ipratropium, systemic steroids, oxygen; assess severity and response.
- Asthma stepwise control
- Inhaled corticosteroid is the controller backbone; step up with LABA; reassess control and technique.
- Obstructive vs restrictive PFTs
- Obstructive: low FEV1/FVC ratio (asthma, COPD). Restrictive: normal/high ratio with low volumes (fibrosis).
- Pulmonary embolism diagnosis
- Risk-stratify (Wells); D-dimer if low probability, CT pulmonary angiography if higher; treat with anticoagulation.
- Massive PE with hemodynamic instability
- Consider systemic thrombolysis (or embolectomy) in addition to anticoagulation.
- Community-acquired pneumonia (outpatient)
- Empiric amoxicillin or doxycycline (or a macrolide); a respiratory fluoroquinolone if comorbidities.
- CAP requiring admission
- Beta-lactam plus a macrolide, or a respiratory fluoroquinolone; use severity scores (CURB-65) to guide site of care.
- Pleural effusion workup
- Thoracentesis with Light's criteria to classify transudate vs exudate.
- Spontaneous pneumothorax management
- Small and stable: observation with oxygen. Large or symptomatic: needle aspiration or chest tube; recurrence may need pleurodesis.
- Smoking cessation pharmacotherapy
- Varenicline (most effective), bupropion, and nicotine replacement; combine with counseling.
- Hyperlipidemia lifestyle + drug
- Diet, exercise, weight loss first; statin is first-line drug; ezetimibe or PCSK9 inhibitor if goals unmet.
- Hypertensive disorder workup
- Confirm with repeated proper measurements; screen for secondary causes if young, severe, or resistant.
- Resistant hypertension
- Uncontrolled on 3 drugs (incl. a diuretic); add spironolactone and evaluate for secondary causes (e.g., primary aldosteronism).
- Syncope red flags
- Exertional syncope, family history of sudden death, abnormal ECG → cardiac workup (structural/arrhythmic cause).
- Aspirin for primary prevention
- No longer routine for most adults; individualize based on ASCVD risk and bleeding risk (favor in selected 40-59-year-olds).
- Beta-blocker contraindication in heart failure
- Avoid initiating during acute decompensation; start once euvolemic and stable.
- ACE inhibitor cough vs ARB
- ACE inhibitors cause cough/angioedema via bradykinin; switch to an ARB if cough is intolerable.
- New oxygen requirement on the ward
- Reassess for PE, pneumonia, fluid overload, or pneumothorax; a common CCS reassessment trigger.
- Atrial flutter management
- Rate control and anticoagulation like atrial fibrillation; consider cavotricuspid isthmus ablation (often curative).
- Hypertrophic cardiomyopathy
- Murmur ↑ with Valsalva; avoid dehydration and high-intensity competitive sport; beta-blockers; screen relatives.
- Cardiac stress test indication
- Stable chest pain with intermediate pretest probability; choose imaging stress if the ECG is uninterpretable.
- Type 2 diabetes first-line drug
- Metformin (plus lifestyle).
- Diabetes drugs with CV/renal benefit
- SGLT2 inhibitors and GLP-1 receptor agonists; add for atherosclerotic disease, heart failure, or chronic kidney disease.
- HbA1c diagnostic threshold
- ≥6.5% diagnoses diabetes (or fasting glucose ≥126, 2-hour OGTT ≥200, or random ≥200 with symptoms).
- Diabetes glycemic target
- HbA1c <7% for most adults; individualize (looser in frail/elderly, tighter in young/healthy).
- Metformin contraindications
- Avoid in significant renal impairment (eGFR <30) and around iodinated contrast; risk of lactic acidosis.
- Diabetic kidney disease screening
- Annual urine albumin-to-creatinine ratio and eGFR; treat with an ACE inhibitor/ARB and an SGLT2 inhibitor.
- Hypothyroidism treatment
- Levothyroxine; titrate to a normal TSH; recheck TSH about every 6 weeks after dose changes.
- Hyperthyroidism (Graves) options
- Methimazole, radioactive iodine, or surgery; beta-blocker for symptoms.
- Subclinical hypothyroidism
- Elevated TSH with normal free T4; treat if TSH >10, symptomatic, or pregnant/planning pregnancy.
- Thyroid nodule workup
- TSH and ultrasound; fine-needle aspiration based on size and sonographic risk features.
- Primary adrenal insufficiency (Addison)
- Low cortisol with high ACTH; hyperpigmentation, hyperkalemia, hyponatremia; treat with hydrocortisone + fludrocortisone.
- Cushing syndrome workup
- Confirm hypercortisolism (24-hour urine cortisol, late-night salivary cortisol, dexamethasone suppression), then find the source.
- Primary aldosteronism
- Hypertension with hypokalemia; elevated aldosterone-to-renin ratio; consider in resistant hypertension.
- Hyperkalemia management
- Calcium gluconate (cardioprotection), insulin + glucose and beta-agonist (shift), then removal (diuretics, dialysis, binders).
- ECG of hyperkalemia
- Peaked T waves → widened QRS → sine wave; give IV calcium immediately to stabilize the membrane.
- Hyponatremia approach
- Assess volume status and serum osmolality; correct slowly (≤8 mEq/L per 24 h) to avoid osmotic demyelination.
- SIADH
- Euvolemic hyponatremia with concentrated urine; treat with fluid restriction; identify the cause (drugs, lung/CNS disease).
- Acute kidney injury — prerenal
- Low perfusion (volume loss, heart failure); BUN/Cr >20, FENa <1%; treat the underlying cause and restore volume.
- Acute kidney injury — intrinsic (ATN)
- Tubular injury (ischemia, contrast, drugs); muddy-brown casts, FENa >2%; supportive care and remove the insult.
- Postrenal AKI
- Obstruction (e.g., BPH, stones); diagnose with bladder scan/ultrasound; relieve the obstruction (catheter, stent).
- Chronic kidney disease management
- Control BP and glucose, ACE inhibitor/ARB and SGLT2 inhibitor, manage anemia/bone disease, avoid nephrotoxins.
- Indications for urgent dialysis (AEIOU)
- Acidosis, Electrolytes (refractory hyperkalemia), Intoxications, Overload (fluid), Uremia (pericarditis, encephalopathy).
- Nephrolithiasis acute care
- Analgesia (NSAIDs), hydration, and antiemetics; stones <5 mm usually pass; alpha-blocker for medical expulsive therapy.
- UTI in nonpregnant woman
- Uncomplicated cystitis: nitrofurantoin, TMP-SMX, or fosfomycin; treat pyelonephritis with fluoroquinolone or ceftriaxone.
- Asymptomatic bacteriuria treatment
- Treat only in pregnancy or before urologic procedures; otherwise do not treat.
- GERD management
- Lifestyle changes and a proton pump inhibitor; alarm features (dysphagia, weight loss, bleeding) → endoscopy.
- Peptic ulcer disease
- Test and treat H. pylori; stop NSAIDs; PPI therapy; endoscopy for bleeding or alarm features.
- Upper GI bleed initial care
- Two large-bore IVs, fluids/blood, IV PPI, and urgent endoscopy; octreotide and antibiotics if variceal.
- C. difficile infection
- Stop the offending antibiotic; treat with oral vancomycin or fidaxomicin (not metronidazole first-line now).
- Acute pancreatitis
- Diagnose with lipase + clinical/imaging; treat with IV fluids, analgesia, and early enteral nutrition; find the cause (gallstones, alcohol).
- Cirrhosis complications
- Ascites (diuretics, paracentesis), variceal bleeding (banding, beta-blocker), SBP (antibiotics), encephalopathy (lactulose).
- Spontaneous bacterial peritonitis
- Ascitic fluid neutrophils ≥250/mm3; treat with cefotaxime; add albumin to reduce renal injury.
- Hepatic encephalopathy
- Treat with lactulose (and rifaximin); identify precipitants (GI bleed, infection, electrolyte derangement).
- Inflammatory bowel disease flare
- 5-ASA, corticosteroids for flares, and steroid-sparing agents (immunomodulators, biologics) for maintenance.
- Diverticulitis (uncomplicated)
- Often managed with antibiotics (or supportive care in mild cases); colonoscopy after resolution to exclude malignancy.
- Hypercalcemia (most common cause)
- Primary hyperparathyroidism (outpatient) and malignancy (inpatient); treat severe cases with IV fluids then bisphosphonates.
- Osteoporosis treatment
- Bisphosphonates first-line; ensure adequate calcium and vitamin D; consider denosumab or anabolic agents in high risk.
- Diabetes foot/eye care
- Annual dilated retinal exam and comprehensive foot exam; daily foot inspection — a continued-care health-maintenance staple.
- Insulin regimen basics
- Basal-bolus mimics physiology; check potassium and renal function; insulin shifts potassium into cells.
- Pheochromocytoma
- Episodic hypertension, headache, palpitations, sweating; alpha-blockade BEFORE beta-blockade, then surgery.
- Hypomagnesemia
- Causes refractory hypokalemia and hypocalcemia; replace magnesium to correct them.
- Metabolic acidosis approach
- Calculate the anion gap; high gap = MUDPILES; normal gap = bicarbonate loss (diarrhea, RTA).
- Vancomycin monitoring
- Trough levels (or AUC) and renal function; risk of nephrotoxicity.
- Contrast-induced nephropathy prevention
- Hydration and minimizing contrast in at-risk patients (CKD, diabetes); hold nephrotoxins.
- Sepsis early bundle
- Blood cultures and lactate, broad-spectrum antibiotics within 1 hour, and IV crystalloid resuscitation.
- Septic shock vasopressor
- Norepinephrine is first-line if hypotension persists after fluid resuscitation.
- Don't delay antibiotics in sepsis
- Give antibiotics promptly after drawing cultures — early antibiotics save lives.
- Lactate in sepsis
- A rising lactate signals tissue hypoperfusion; trend it to assess resuscitation response.
- DKA management
- IV fluids, insulin infusion, and potassium repletion; treat the precipitant; close the anion gap before SC insulin.
- Why check potassium before insulin in DKA?
- Insulin drives potassium into cells; giving it when potassium is low can cause fatal hypokalemia.
- Hyperosmolar hyperglycemic state
- Profound hyperglycemia with severe dehydration, minimal ketosis; aggressive fluids, insulin, electrolytes.
- Anaphylaxis first action
- Intramuscular epinephrine — before antihistamines or steroids; also airway, oxygen, IV fluids.
- Acute ischemic stroke
- Non-contrast CT to exclude bleed; tPA within window if eligible; thrombectomy for large-vessel occlusion; control glucose/BP.
- Stroke blood pressure (for tPA)
- Lower to <185/110 before thrombolysis; otherwise permissive hypertension in ischemic stroke.
- Status epilepticus
- ABCs and glucose; benzodiazepine first (lorazepam), then a second-line agent (levetiracetam, fosphenytoin, valproate).
- GI bleed resuscitation
- Two large-bore IVs, fluids and blood products, reverse coagulopathy, and urgent endoscopy.
- Acute respiratory failure
- Support oxygenation/ventilation (NIV or intubation), identify cause; ARDS uses low-tidal-volume lung-protective ventilation.
- Tension pneumothorax
- Needle decompression then chest tube immediately — clinical diagnosis, do not wait for imaging.
- Acute coronary syndrome (unstable)
- Aspirin + ECG now; reperfuse STEMI; anticoagulate; manage arrhythmia and hemodynamics.
- Massive PE
- Anticoagulation plus systemic thrombolysis (or embolectomy) if hemodynamically unstable.
- Acetaminophen overdose antidote
- N-acetylcysteine (use the nomogram to time-stratify); prevents NAPQI-mediated hepatotoxicity.
- Opioid overdose antidote
- Naloxone; support ventilation; repeat dosing as needed due to short half-life.
- Benzodiazepine overdose
- Supportive care; flumazenil rarely used (can precipitate seizures, especially in chronic users).
- Salicylate toxicity
- Mixed respiratory alkalosis and anion-gap metabolic acidosis; alkalinize urine; dialysis if severe.
- Carbon monoxide poisoning
- 100% oxygen (hyperbaric in severe cases); pulse oximetry is falsely normal — check carboxyhemoglobin.
- Tricyclic antidepressant overdose
- Wide QRS and arrhythmia; give IV sodium bicarbonate.
- Beta-blocker / CCB overdose
- Bradycardia and hypotension; treat with calcium, glucagon, high-dose insulin-euglycemia therapy.
- Methanol/ethylene glycol poisoning
- Anion-gap acidosis; treat with fomepizole and dialysis.
- Organophosphate poisoning
- Cholinergic toxidrome (SLUDGE); treat with atropine and pralidoxime.
- Hyperkalemia emergency
- IV calcium first (membrane stabilization), then insulin/glucose and beta-agonist to shift, then removal.
- Massive transfusion complications
- Hypocalcemia (citrate), hyperkalemia, hypothermia, and coagulopathy; warm products and monitor electrolytes.
- Neutropenic fever
- Medical emergency; obtain cultures and start empiric broad-spectrum antibiotics (antipseudomonal) immediately.
- Tumor lysis syndrome
- Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; hydration, allopurinol or rasburicase, monitor electrolytes.
- DIC
- Consumption of clotting factors and platelets; treat the underlying cause; replace products if bleeding.
- Adrenal (addisonian) crisis
- Hypotension and shock; give IV hydrocortisone and aggressive fluids immediately — do not wait for testing.
- Thyroid storm
- Fever, tachycardia, agitation; beta-blocker, thionamide, iodine (after thionamide), and steroids.
- Myxedema coma
- Severe hypothyroidism with hypothermia and altered mental status; IV levothyroxine and stress-dose steroids.
- Hypertensive emergency target
- Lower BP gradually (about 10-20% in the first hour) with IV agents to avoid hypoperfusion.
- Acute limb ischemia
- 6 Ps (pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis); anticoagulate and revascularize urgently.
- Compartment syndrome
- Pain out of proportion, pain on passive stretch; emergent fasciotomy — do not wait for pulselessness.
- Necrotizing fasciitis
- Severe pain, rapid spread, crepitus; emergent surgical debridement plus broad-spectrum antibiotics.
- Acute angle-closure glaucoma
- Painful red eye, mid-dilated fixed pupil, vision loss; lower IOP urgently; ophthalmology emergency.
- Septic arthritis
- Joint aspiration before antibiotics; empiric antibiotics and drainage to prevent joint destruction.
- Meningitis empiric therapy
- Vancomycin + ceftriaxone (+ ampicillin if Listeria risk); add dexamethasone; do not delay antibiotics for imaging/LP.
- Major depressive disorder first-line
- SSRIs (with psychotherapy); allow several weeks for effect; assess suicide risk.
- Suicide risk assessment
- Ask directly about ideation, plan, intent, and means; ensure safety; hospitalize if high risk.
- Serotonin syndrome
- Agitation, hyperreflexia, clonus, hyperthermia from serotonergic drugs; stop the agent, supportive care, cyproheptadine.
- Neuroleptic malignant syndrome
- Rigidity, hyperthermia, autonomic instability from antipsychotics; stop the drug, cool, dantrolene/bromocriptine.
- Bipolar disorder maintenance
- Mood stabilizers (lithium, valproate) or atypical antipsychotics; avoid antidepressant monotherapy (mania risk).
- Lithium monitoring/toxicity
- Narrow therapeutic index; monitor levels, renal and thyroid function; tremor, ataxia, and confusion signal toxicity.
- Generalized anxiety disorder
- First-line SSRIs/SNRIs and CBT; avoid long-term benzodiazepines.
- Alcohol withdrawal
- Benzodiazepines (symptom-triggered); thiamine before glucose; watch for delirium tremens.
- Wernicke encephalopathy
- Confusion, ataxia, ophthalmoplegia from thiamine deficiency; give IV thiamine BEFORE glucose.
- Opioid use disorder treatment
- Medication-assisted treatment: buprenorphine, methadone, or naltrexone, with counseling.
- ADHD treatment
- Stimulants (methylphenidate, amphetamines) are first-line; behavioral therapy in young children.
- Antipsychotic metabolic monitoring
- Atypicals cause weight gain, dyslipidemia, and diabetes; monitor weight, glucose, and lipids.
- Dementia (Alzheimer) treatment
- Cholinesterase inhibitors and memantine modestly help; address safety, caregivers, and reversible causes.
- Delirium management
- Identify and treat the underlying cause; reorient and avoid restraints; use antipsychotics sparingly for severe agitation.
- Parkinson disease treatment
- Carbidopa-levodopa for symptomatic motor disease; dopamine agonists in younger patients.
- Migraine treatment
- Acute: triptans and NSAIDs; prophylaxis (frequent attacks): beta-blockers, topiramate, or CGRP antagonists.
- Seizure first unprovoked
- Evaluate with EEG and MRI; antiepileptic therapy based on seizure type and recurrence risk.
- Bell palsy
- Acute peripheral facial nerve palsy (forehead involved); treat with corticosteroids (± antivirals); eye protection.
- Multiple sclerosis
- Relapsing neuro deficits separated in time and space; acute relapse → steroids; disease-modifying therapy long-term.
- Guillain-Barre syndrome
- Ascending paralysis and areflexia; treat with IVIG or plasmapheresis; monitor respiratory status.
- TIA workup
- Urgent evaluation (ABCD2), neuroimaging, carotid and cardiac assessment; start antiplatelet and statin.
- Prenatal first-visit labs
- Blood type/Rh, CBC, rubella, HIV, hepatitis B, syphilis, urine culture, and Pap as indicated.
- Folic acid in pregnancy
- Start 0.4 mg daily before conception (higher if prior neural tube defect) to prevent neural tube defects.
- Gestational diabetes screening
- Screen at 24-28 weeks with a glucose challenge; manage with diet, then insulin if needed.
- Preeclampsia
- New hypertension + proteinuria (or end-organ signs) after 20 weeks; magnesium sulfate for seizure prophylaxis; deliver definitively.
- Eclampsia management
- Magnesium sulfate to control/prevent seizures, blood pressure control, and delivery.
- Rh-negative mother
- Give anti-D immune globulin (RhoGAM) at 28 weeks and after delivery of an Rh-positive infant.
- Ectopic pregnancy
- Positive pregnancy test with adnexal pain/bleeding; methotrexate if stable/criteria met, surgery if ruptured/unstable.
- Postpartum hemorrhage
- Most commonly uterine atony; fundal massage, uterotonics (oxytocin), and escalate to procedures if needed.
- Contraception for the postpartum patient
- Progestin-only methods are preferred while breastfeeding; avoid estrogen early postpartum (VTE risk).
- Cervical cancer screening
- Begin at age 21; cytology every 3 years, or co-testing/HPV testing per guidelines from age 25-30.
- Abnormal uterine bleeding workup
- Exclude pregnancy; evaluate structural and hormonal causes; endometrial biopsy if risk factors for hyperplasia/cancer.
- Menopause hormone therapy
- For bothersome vasomotor symptoms in appropriate candidates; weigh VTE, stroke, and breast cancer risks.
- Pelvic inflammatory disease
- Treat empirically (ceftriaxone + doxycycline ± metronidazole) to preserve fertility; low threshold to treat.
- PCOS management
- Lifestyle, combined oral contraceptives for cycle/androgen control, and metformin/letrozole for metabolic/fertility goals.
- Gout acute flare
- NSAIDs, colchicine, or corticosteroids; do not start or stop urate-lowering therapy during an acute flare.
- Gout chronic management
- Urate-lowering therapy (allopurinol) for recurrent attacks, tophi, or stones; titrate to target urate.
- Rheumatoid arthritis
- Symmetric small-joint inflammation; start a DMARD (methotrexate) early to prevent joint destruction.
- Systemic lupus erythematosus
- Multisystem autoimmune disease; hydroxychloroquine for most; immunosuppression for organ involvement.
- Polymyalgia rheumatica vs giant cell arteritis
- PMR: shoulder/hip stiffness, low-dose steroids. GCA: headache/vision loss, HIGH-dose steroids urgently to save vision.
- Low back pain (no red flags)
- Conservative care and activity as tolerated; imaging only with red flags (neuro deficit, cancer, infection, trauma).
- Cauda equina syndrome
- Saddle anesthesia, urinary retention, bilateral leg weakness; emergent MRI and surgical decompression.
- Osteoarthritis management
- Exercise, weight loss, topical/oral NSAIDs and acetaminophen; joint replacement for refractory disease.
- Septic vs gout vs RA joint fluid
- Septic: very high WBC, positive culture. Gout: negatively birefringent needle crystals. Pseudogout: positively birefringent rhomboids.
- Cellulitis
- Treat with antibiotics covering streptococci and S. aureus; mark borders and reassess; rule out abscess (needs drainage).
- Stevens-Johnson syndrome / TEN
- Drug reaction with mucosal involvement and skin sloughing; stop the drug, supportive (burn-unit) care.
- Melanoma ABCDE
- Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolving; biopsy suspicious lesions.
- Basal vs squamous cell carcinoma
- BCC: pearly papule with telangiectasias (most common). SCC: scaly/ulcerated, can metastasize; both UV-related.
- Psoriasis treatment
- Topical corticosteroids and vitamin D analogs; phototherapy or systemic/biologic agents for extensive disease.
- Cluster headache
- Severe unilateral periorbital pain with autonomic signs; acute: high-flow oxygen and triptans.
- Vertigo (peripheral vs central)
- Peripheral (BPPV, vestibular neuritis) is benign; central (stroke) has neuro signs — image if central features.
- Carpal tunnel syndrome
- Median nerve compression; nocturnal hand numbness; splinting first, then steroid injection or surgery.
- Subarachnoid hemorrhage
- Thunderclap headache; non-contrast CT, then LP if CT negative; neurosurgical/neuro-IR management.
- Erectile dysfunction workup
- Can be an early marker of cardiovascular disease; assess risk factors; PDE5 inhibitors (avoid with nitrates).
- Refeeding syndrome
- Insulin-driven shift of phosphate, potassium, and magnesium into cells when feeding a malnourished patient; can cause arrhythmias.
- Refeeding syndrome prevention
- Start low calories (about 10-20 kcal/kg/day), advance slowly, and monitor/replace electrolytes (especially phosphate).
- Most feared refeeding electrolyte
- Hypophosphatemia — replace phosphate before and during feeding.
- Thiamine (B1) deficiency
- Wernicke-Korsakoff and wet beriberi (high-output heart failure); give thiamine before glucose in at-risk patients.
- Vitamin B12 deficiency
- Macrocytic anemia with neurologic signs (subacute combined degeneration); check methylmalonic acid; replace B12.
- Folate deficiency
- Macrocytic anemia WITHOUT neurologic signs; common in alcohol use and pregnancy.
- Vitamin D deficiency
- Causes osteomalacia/rickets and secondary hyperparathyroidism; supplement with vitamin D and calcium.
- Vitamin A deficiency
- Night blindness and xerophthalmia; excess is teratogenic and causes pseudotumor cerebri.
- Vitamin C deficiency (scurvy)
- Poor wound healing, bleeding gums, perifollicular hemorrhage; treat with vitamin C.
- Vitamin K deficiency
- Elevated PT/INR and bleeding; common in malabsorption and newborns (give vitamin K at birth).
- Niacin (B3) deficiency (pellagra)
- The 3 Ds: dermatitis, diarrhea, dementia.
- Zinc deficiency
- Poor wound healing, dysgeusia, alopecia, and a perioral/acral rash.
- Enteral vs parenteral nutrition
- Prefer enteral when the gut works ('if the gut works, use it'); parenteral nutrition for nonfunctional GI tracts.
- Malnutrition screening in hospital
- Identify at-risk patients (poor intake, weight loss, chronic disease); involve dietitians and prevent refeeding syndrome.
- Obesity management
- Lifestyle first; add pharmacotherapy (GLP-1 agonists) or bariatric surgery based on BMI and comorbidities.
- Colorectal cancer screening start age
- Age 45 for average-risk adults (USPSTF), continuing through 75; options include colonoscopy or stool-based tests.
- Positive stool-based CRC test
- Proceed to colonoscopy — a positive FIT or stool DNA test requires diagnostic colonoscopy.
- Breast cancer screening
- Mammography; USPSTF recommends starting at age 40 (biennial) for average-risk women.
- Cervical cancer screening interval
- Age 21-29 cytology every 3 years; age 30-65 co-testing or HPV testing per guidelines.
- Lung cancer screening
- Annual low-dose CT for adults 50-80 with a 20 pack-year history who currently smoke or quit within 15 years.
- Abdominal aortic aneurysm screening
- One-time ultrasound for men 65-75 who have ever smoked.
- Osteoporosis screening
- DXA scan in women 65+ (and younger postmenopausal women with risk factors).
- Adult immunization staples
- Annual influenza; Tdap/Td booster; COVID-19 per guidance; check the current CDC schedule each year.
- Pneumococcal vaccination
- Recommended for adults 65+ and younger adults with certain conditions; follow the current CDC schedule.
- Shingles (zoster) vaccine
- Recombinant zoster vaccine for adults 50+ (two doses).
- HPV vaccination
- Routine at ages 11-12, catch-up through 26 (and shared decision-making through 45).
- Live vaccine cautions
- Avoid live vaccines (MMR, varicella) in pregnancy and significant immunocompromise.
- Tobacco cessation counseling
- Use the 5 A's (Ask, Advise, Assess, Assist, Arrange); offer pharmacotherapy plus counseling at every visit.
- Alcohol screening
- Screen with validated tools (AUDIT-C); provide brief intervention for unhealthy use.
- Diabetes screening (USPSTF)
- Screen adults 35-70 who are overweight or obese for prediabetes and type 2 diabetes.
- Hypertension screening
- Screen adults 18+ with office BP, confirming with out-of-office measurement before diagnosis.
- Depression screening
- Screen all adults (and adolescents) with a validated tool such as the PHQ-9 when systems support follow-up.
- Statin primary prevention (USPSTF)
- Adults 40-75 with ≥1 risk factor and a 10-year ASCVD risk of 10% or more (selectively at 7.5-10%).
- Health maintenance at every visit
- Update screening, immunizations, and counseling — a core continued-care management task on Step 3.
- Folate fortification rationale
- Reduces neural tube defects at the population level; individual supplementation before conception adds further protection.
