Your FREE USMLE Step 3 Flashcards 2026 – 300+ Cards

Still SCORED — a three-digit numeric score (minimum 200 since Jan 1, 2024), unlike Step 1, which is now Pass/Fail only.

Two days, taken separately at a Prometric center: Day 1 (FIP) and Day 2 (ACM).

Foundations of Independent Practice (FIP).

Advanced Clinical Medicine (ACM).

200 on the three-digit scale (raised from 198, effective Jan 1, 2024).

About 412 multiple-choice questions plus roughly 13 computer-based case simulations (CCS).

232 multiple-choice questions in 12 blocks of 30 minutes; about a 7-hour session.

About 180 multiple-choice questions in 9 blocks plus about 13 CCS cases; about a 9-hour session.

Computer-based Case Simulation — an interactive patient-management format unique to Step 3 (Day 2); you manage a simulated patient over advancing clock time.

About 13 cases, each allotted up to 10 or 20 minutes of real time.

No — there are no multiple-choice options; you type orders (history, exams, tests, treatments) and the patient evolves.

The free practice software from USMLE that mimics the CCS interface; practice it before exam day so mechanics never cost points.

The Federation of State Medical Boards (FSMB) is the registration entity for Step 3.

Must have passed Step 1 and Step 2 CK and hold an MD or DO degree; IMGs must also be ECFMG certified.

During residency, often the intern (PGY-1) year.

Patient MANAGEMENT and clinical decision-making for unsupervised practice — what you DO, not just what you know.

Day 1 MCQ, Day 2 MCQ, and the CCS cases combine into one three-digit score and pass/fail outcome.

Highest of the Steps (takers already passed 1 and 2 CK): roughly 98% US/Canadian MD, ~96% DO, ~88% international.

Criterion-referenced; examinees generally need to answer about 60% of items correctly.

Maximum 4 attempts at any Step; no more than 3 within 12 months; a passed Step cannot be retaken.

Step 1 = knowledge, Step 2 CK = diagnosis, Step 3 = management/decision-making.

Only Step 3 (Day 2). Step 1 and Step 2 CK are multiple-choice only.

Appropriate, timely, and safe management is rewarded; unnecessary, invasive, or risky orders are penalized — as in real care.

Advancing the simulated clock on an unstable patient before treating the immediate threat.

Cases play out in the office, emergency department, and inpatient ward/ICU; you can move the patient between them.

Proportion of diseased who test positive (true-positive rate). A negative on a sensitive test rules OUT disease (SnNout).

Proportion of healthy who test negative (true-negative rate). A positive on a specific test rules IN disease (SpPin).

1 − sensitivity.

1 − specificity.

Probability that a test-positive person truly has disease. Rises with prevalence.

Probability that a test-negative person is truly disease-free. Falls with prevalence.

No — they are intrinsic to the test. Predictive values DO change with prevalence.

1 ÷ absolute risk reduction. Lower NNT = more effective treatment.

1 ÷ absolute risk increase. Higher NNH = safer treatment.

Risk in control group − risk in treatment group.

Risk in exposed ÷ risk in unexposed; derived from a cohort study.

Odds of exposure in cases ÷ odds in controls; from a case-control study. Approximates RR for rare outcomes.

1 − relative risk; the proportional reduction in risk from treatment.

The randomized controlled trial (RCT).

Follows exposed vs unexposed forward in time; yields incidence and relative risk. Can be prospective or retrospective.

Compares cases (with disease) to controls (without) for past exposure; yields an odds ratio. Good for rare diseases.

Measures exposure and disease at one point in time; yields prevalence. Cannot establish causation.

Incidence = new cases over time; prevalence = existing cases at a point. Long-duration disease raises prevalence.

Rejecting a true null hypothesis — a false positive. Conventionally set at 0.05.

Failing to reject a false null hypothesis — a false negative.

1 − beta; the probability of detecting a true effect. Increases with larger sample size and effect size.

Probability of obtaining the observed result (or more extreme) if the null hypothesis were true; <0.05 is conventionally significant.

If it crosses 1.0 (RR/OR) the result is not statistically significant; for a difference, crossing 0 means not significant.

Sensitivity ÷ (1 − specificity); independent of prevalence. >10 strongly raises post-test probability.

Systematic error from how subjects are chosen (e.g., Berkson bias, healthy-worker effect).

Cases remember exposures differently from controls; classic in case-control studies.

Screening detects disease earlier, falsely lengthening apparent survival without changing outcome.

Screening preferentially detects slow, indolent disease, overstating screening benefit.

A third variable associated with both exposure and outcome that distorts the association; control by randomization, matching, or stratification.

The effect of an exposure differs across levels of a third variable (a real finding, reported by subgroup — not a bias to eliminate).

Analyze participants in their assigned group regardless of adherence; preserves randomization and reduces bias.

More patients must be screened than treated to prevent one outcome; NNT contextualizes screening benefit.

Mean = average (sensitive to outliers); median = middle value (robust); mode = most frequent value.

Tail to the right; mean > median > mode (e.g., income, length of stay).

Standard deviation ÷ √n; shrinks as sample size grows.

Lowering a test threshold raises sensitivity but lowers specificity, and vice versa (ROC curve).

Estimated likelihood of disease before testing; combined with likelihood ratios to get post-test probability.

Compares the rate of an event over time between groups in survival analysis; like RR but accounts for time.

Pools results from multiple studies for greater power; quality depends on the included studies (garbage in, garbage out).

Systematic uses explicit, reproducible methods to find and appraise all evidence; narrative is expert opinion-driven.

Internal = results are correct for the study sample; external (generalizability) = results apply to other populations.

Prefer a HIGH-sensitivity test to screen (few false negatives); confirm a positive with a HIGH-specificity test.

Adjusted analysis accounts for confounders; a large change between crude and adjusted estimates suggests confounding.

Positive studies are more likely to be published, biasing meta-analyses; assessed with a funnel plot.

Plots survival probability over time; the log-rank test compares two survival curves.

Autonomy, beneficence, non-maleficence, and justice.

Capacity, disclosure (diagnosis, intervention, risks, benefits, alternatives), understanding, and voluntariness.

Capacity is a clinical, decision-specific judgment by a physician; competency is a global legal determination by a court.

Yes — respecting autonomy, a capacitated patient may refuse even life-saving treatment.

Emergencies, waiver by the patient, therapeutic privilege, and care of a patient who lacks capacity (use surrogate/advance directive).

Minors can often consent for emergencies, STIs, contraception, pregnancy, substance use, and if emancipated.

A patient's prior instructions (living will) or designated proxy guiding care when they lack capacity.

A surrogate decides what the patient WOULD have wanted, not what the surrogate prefers.

Typically: healthcare proxy/POA, then spouse, adult children, parents, siblings (varies by state).

Disclose honestly and promptly to the patient; transparency is ethically required even if no harm occurred.

Maintain confidentiality except for reportable conditions, threats to others (Tarasoff), child/elder abuse, and certain infections.

A clinician may have a duty to protect an identifiable third party from a serious, credible threat by a patient.

The option that talks WITH the patient — explore concerns, give honest information, respect a capacitated choice; avoid paternalism/deception.

Assess capacity, explore reasons, educate, and ultimately respect a capacitated refusal — document the discussion.

Understand the information, appreciate it applies to them, reason about options, and communicate a consistent choice.

A minor who is married, in the military, financially independent, or court-declared; can consent like an adult.

Ethically and legally equivalent; both are permissible at a capacitated patient's or surrogate's direction.

Physicians are not obligated to provide care that cannot achieve its goal; communicate compassionately and involve ethics consult if needed.

When they conflict, a capacitated patient's autonomous, informed choice generally prevails.

Decline gifts that could impair judgment or create conflicts of interest; disclose relevant conflicts.

Report a colleague impaired by substances or illness to protect patients (to the supervisor or physician health program).

Use a stepwise approach (e.g., SPIKES): private setting, assess understanding, deliver clearly, respond to emotion, plan.

A patient-centered counseling style that elicits the patient's own motivation to change behavior.

Accidents happen when latent system weaknesses (holes) line up; layered defenses prevent most errors.

Active = at the sharp end (the person doing the task); latent = system/design failures upstream.

A retrospective, systematic review of an adverse event to find and fix underlying causes.

A prospective method to anticipate and prevent failures in a process before they occur.

Near miss = reaches no patient; adverse event = causes harm; sentinel event = serious, reportable harm.

Distinguishes blameless human error from reckless behavior; encourages reporting without punishing honest mistakes.

A design that prevents an error (e.g., a connector that only fits the correct port); a strong system safeguard.

System fixes (forcing functions, checklists, CPOE with decision support) beat reminders, education, or blaming individuals.

Reduces transcription and dosing errors, especially with clinical decision support.

A team pause to confirm correct patient, procedure, and site — prevents wrong-site surgery.

Plan-Do-Study-Act: small, iterative tests of change to improve a process.

Documenting that a capacitated patient declined a recommended intervention after understanding the risks.

Thiazide diuretic, ACE inhibitor or ARB, or calcium channel blocker (CCB).

Prefer an ACE inhibitor or ARB (renoprotective).

Stage 1: 130-139/80-89 mmHg; Stage 2: ≥140/90 mmHg (confirm with repeat/out-of-office readings).

Severe BP elevation with end-organ damage; lower BP with IV agents, by ≈10-20% in the first hour (avoid overcorrection).

Beta-blocker or non-dihydropyridine CCB (diltiazem, verapamil) for most patients.

Guided by the CHA2DS2-VASc score; higher score favors oral anticoagulation to prevent embolic stroke.

Immediate synchronized cardioversion (hypotension, chest pain, heart failure, altered mentation).

CHF, Hypertension, Age ≥75 (2), Diabetes, Stroke/TIA (2), Vascular disease, Age 65-74, Sex category (female).

ARNI (or ACE inhibitor/ARB) + beta-blocker + aldosterone antagonist + SGLT2 inhibitor; add a loop diuretic for congestion.

Beta-blockers, ACE inhibitor/ARB/ARNI, aldosterone antagonists, SGLT2 inhibitors, and hydralazine-nitrate in select patients.

Oxygen, IV loop diuretic, and vasodilators (nitroglycerin) if hypertensive; treat the precipitant.

Aspirin + ECG immediately, then reperfusion — PCI within 90 minutes (or fibrinolysis if PCI unavailable).

Aspirin, oxygen if hypoxic, nitroglycerin, and anticoagulation; add a P2Y12 inhibitor and statin.

Antianginals (beta-blocker, nitrates, CCB) plus risk-factor control (aspirin, statin, BP, smoking cessation).

Clinical ASCVD, LDL ≥190, diabetes age 40-75, or elevated 10-year ASCVD risk; high-intensity for ASCVD.

Myopathy/rhabdomyolysis and transaminase elevation; check a baseline lipid panel and address muscle symptoms.

Atropine first; transcutaneous pacing if refractory; pacemaker for high-grade block.

Antiarrhythmics (amiodarone, procainamide); cardiovert if unstable; defibrillate pulseless VT/VF.

Thyroid (hypo- or hyper-), pulmonary fibrosis, hepatotoxicity, corneal deposits, blue-gray skin; monitor TFTs, LFTs, PFTs.

INR (target 2-3 for most indications, 2.5-3.5 for mechanical mitral valves).

aPTT (or anti-Xa); reverse with protamine.

Harsh crescendo-decrescendo systolic murmur radiating to carotids; symptoms (angina, syncope, dyspnea) → valve replacement.

Fever + new murmur; obtain blood cultures and echo; empiric antibiotics then tailor; surgery for complications.

Pleuritic chest pain better leaning forward, diffuse ST elevation; treat with NSAIDs + colchicine.

Pharmacologic (LMWH/heparin) or mechanical prophylaxis based on risk; a high-yield CCS order.

Inhaled short-acting bronchodilators, systemic corticosteroids, antibiotics if purulent sputum; controlled oxygen (SpO2 88-92%).

Over-oxygenation can blunt respiratory drive and worsen CO2 retention; target SpO2 88-92%.

Inhaled long-acting bronchodilators (LABA/LAMA), inhaled steroids in select patients, smoking cessation, pulmonary rehab, vaccines.

Inhaled short-acting beta-agonist + ipratropium, systemic steroids, oxygen; assess severity and response.

Inhaled corticosteroid is the controller backbone; step up with LABA; reassess control and technique.

Obstructive: low FEV1/FVC ratio (asthma, COPD). Restrictive: normal/high ratio with low volumes (fibrosis).

Risk-stratify (Wells); D-dimer if low probability, CT pulmonary angiography if higher; treat with anticoagulation.

Consider systemic thrombolysis (or embolectomy) in addition to anticoagulation.

Empiric amoxicillin or doxycycline (or a macrolide); a respiratory fluoroquinolone if comorbidities.

Beta-lactam plus a macrolide, or a respiratory fluoroquinolone; use severity scores (CURB-65) to guide site of care.

Thoracentesis with Light's criteria to classify transudate vs exudate.

Small and stable: observation with oxygen. Large or symptomatic: needle aspiration or chest tube; recurrence may need pleurodesis.

Varenicline (most effective), bupropion, and nicotine replacement; combine with counseling.

Diet, exercise, weight loss first; statin is first-line drug; ezetimibe or PCSK9 inhibitor if goals unmet.

Confirm with repeated proper measurements; screen for secondary causes if young, severe, or resistant.

Uncontrolled on 3 drugs (incl. a diuretic); add spironolactone and evaluate for secondary causes (e.g., primary aldosteronism).

Exertional syncope, family history of sudden death, abnormal ECG → cardiac workup (structural/arrhythmic cause).

No longer routine for most adults; individualize based on ASCVD risk and bleeding risk (favor in selected 40-59-year-olds).

Avoid initiating during acute decompensation; start once euvolemic and stable.

ACE inhibitors cause cough/angioedema via bradykinin; switch to an ARB if cough is intolerable.

Reassess for PE, pneumonia, fluid overload, or pneumothorax; a common CCS reassessment trigger.

Rate control and anticoagulation like atrial fibrillation; consider cavotricuspid isthmus ablation (often curative).

Murmur ↑ with Valsalva; avoid dehydration and high-intensity competitive sport; beta-blockers; screen relatives.

Stable chest pain with intermediate pretest probability; choose imaging stress if the ECG is uninterpretable.

Metformin (plus lifestyle).

SGLT2 inhibitors and GLP-1 receptor agonists; add for atherosclerotic disease, heart failure, or chronic kidney disease.

≥6.5% diagnoses diabetes (or fasting glucose ≥126, 2-hour OGTT ≥200, or random ≥200 with symptoms).

HbA1c <7% for most adults; individualize (looser in frail/elderly, tighter in young/healthy).

Avoid in significant renal impairment (eGFR <30) and around iodinated contrast; risk of lactic acidosis.

Annual urine albumin-to-creatinine ratio and eGFR; treat with an ACE inhibitor/ARB and an SGLT2 inhibitor.

Levothyroxine; titrate to a normal TSH; recheck TSH about every 6 weeks after dose changes.

Methimazole, radioactive iodine, or surgery; beta-blocker for symptoms.

Elevated TSH with normal free T4; treat if TSH >10, symptomatic, or pregnant/planning pregnancy.

TSH and ultrasound; fine-needle aspiration based on size and sonographic risk features.

Low cortisol with high ACTH; hyperpigmentation, hyperkalemia, hyponatremia; treat with hydrocortisone + fludrocortisone.

Confirm hypercortisolism (24-hour urine cortisol, late-night salivary cortisol, dexamethasone suppression), then find the source.

Hypertension with hypokalemia; elevated aldosterone-to-renin ratio; consider in resistant hypertension.

Calcium gluconate (cardioprotection), insulin + glucose and beta-agonist (shift), then removal (diuretics, dialysis, binders).

Peaked T waves → widened QRS → sine wave; give IV calcium immediately to stabilize the membrane.

Assess volume status and serum osmolality; correct slowly (≤8 mEq/L per 24 h) to avoid osmotic demyelination.

Euvolemic hyponatremia with concentrated urine; treat with fluid restriction; identify the cause (drugs, lung/CNS disease).

Low perfusion (volume loss, heart failure); BUN/Cr >20, FENa <1%; treat the underlying cause and restore volume.

Tubular injury (ischemia, contrast, drugs); muddy-brown casts, FENa >2%; supportive care and remove the insult.

Obstruction (e.g., BPH, stones); diagnose with bladder scan/ultrasound; relieve the obstruction (catheter, stent).

Control BP and glucose, ACE inhibitor/ARB and SGLT2 inhibitor, manage anemia/bone disease, avoid nephrotoxins.

Acidosis, Electrolytes (refractory hyperkalemia), Intoxications, Overload (fluid), Uremia (pericarditis, encephalopathy).

Analgesia (NSAIDs), hydration, and antiemetics; stones <5 mm usually pass; alpha-blocker for medical expulsive therapy.

Uncomplicated cystitis: nitrofurantoin, TMP-SMX, or fosfomycin; treat pyelonephritis with fluoroquinolone or ceftriaxone.

Treat only in pregnancy or before urologic procedures; otherwise do not treat.

Lifestyle changes and a proton pump inhibitor; alarm features (dysphagia, weight loss, bleeding) → endoscopy.

Test and treat H. pylori; stop NSAIDs; PPI therapy; endoscopy for bleeding or alarm features.

Two large-bore IVs, fluids/blood, IV PPI, and urgent endoscopy; octreotide and antibiotics if variceal.

Stop the offending antibiotic; treat with oral vancomycin or fidaxomicin (not metronidazole first-line now).

Diagnose with lipase + clinical/imaging; treat with IV fluids, analgesia, and early enteral nutrition; find the cause (gallstones, alcohol).

Ascites (diuretics, paracentesis), variceal bleeding (banding, beta-blocker), SBP (antibiotics), encephalopathy (lactulose).

Ascitic fluid neutrophils ≥250/mm3; treat with cefotaxime; add albumin to reduce renal injury.

Treat with lactulose (and rifaximin); identify precipitants (GI bleed, infection, electrolyte derangement).

5-ASA, corticosteroids for flares, and steroid-sparing agents (immunomodulators, biologics) for maintenance.

Often managed with antibiotics (or supportive care in mild cases); colonoscopy after resolution to exclude malignancy.

Primary hyperparathyroidism (outpatient) and malignancy (inpatient); treat severe cases with IV fluids then bisphosphonates.

Bisphosphonates first-line; ensure adequate calcium and vitamin D; consider denosumab or anabolic agents in high risk.

Annual dilated retinal exam and comprehensive foot exam; daily foot inspection — a continued-care health-maintenance staple.

Basal-bolus mimics physiology; check potassium and renal function; insulin shifts potassium into cells.

Episodic hypertension, headache, palpitations, sweating; alpha-blockade BEFORE beta-blockade, then surgery.

Causes refractory hypokalemia and hypocalcemia; replace magnesium to correct them.

Calculate the anion gap; high gap = MUDPILES; normal gap = bicarbonate loss (diarrhea, RTA).

Trough levels (or AUC) and renal function; risk of nephrotoxicity.

Hydration and minimizing contrast in at-risk patients (CKD, diabetes); hold nephrotoxins.

Blood cultures and lactate, broad-spectrum antibiotics within 1 hour, and IV crystalloid resuscitation.

Norepinephrine is first-line if hypotension persists after fluid resuscitation.

Give antibiotics promptly after drawing cultures — early antibiotics save lives.

A rising lactate signals tissue hypoperfusion; trend it to assess resuscitation response.

IV fluids, insulin infusion, and potassium repletion; treat the precipitant; close the anion gap before SC insulin.

Insulin drives potassium into cells; giving it when potassium is low can cause fatal hypokalemia.

Profound hyperglycemia with severe dehydration, minimal ketosis; aggressive fluids, insulin, electrolytes.

Intramuscular epinephrine — before antihistamines or steroids; also airway, oxygen, IV fluids.

Non-contrast CT to exclude bleed; tPA within window if eligible; thrombectomy for large-vessel occlusion; control glucose/BP.

Lower to <185/110 before thrombolysis; otherwise permissive hypertension in ischemic stroke.

ABCs and glucose; benzodiazepine first (lorazepam), then a second-line agent (levetiracetam, fosphenytoin, valproate).

Two large-bore IVs, fluids and blood products, reverse coagulopathy, and urgent endoscopy.

Support oxygenation/ventilation (NIV or intubation), identify cause; ARDS uses low-tidal-volume lung-protective ventilation.

Needle decompression then chest tube immediately — clinical diagnosis, do not wait for imaging.

Aspirin + ECG now; reperfuse STEMI; anticoagulate; manage arrhythmia and hemodynamics.

Anticoagulation plus systemic thrombolysis (or embolectomy) if hemodynamically unstable.

N-acetylcysteine (use the nomogram to time-stratify); prevents NAPQI-mediated hepatotoxicity.

Naloxone; support ventilation; repeat dosing as needed due to short half-life.

Supportive care; flumazenil rarely used (can precipitate seizures, especially in chronic users).

Mixed respiratory alkalosis and anion-gap metabolic acidosis; alkalinize urine; dialysis if severe.

100% oxygen (hyperbaric in severe cases); pulse oximetry is falsely normal — check carboxyhemoglobin.

Wide QRS and arrhythmia; give IV sodium bicarbonate.

Bradycardia and hypotension; treat with calcium, glucagon, high-dose insulin-euglycemia therapy.

Anion-gap acidosis; treat with fomepizole and dialysis.

Cholinergic toxidrome (SLUDGE); treat with atropine and pralidoxime.

IV calcium first (membrane stabilization), then insulin/glucose and beta-agonist to shift, then removal.

Hypocalcemia (citrate), hyperkalemia, hypothermia, and coagulopathy; warm products and monitor electrolytes.

Medical emergency; obtain cultures and start empiric broad-spectrum antibiotics (antipseudomonal) immediately.

Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; hydration, allopurinol or rasburicase, monitor electrolytes.

Consumption of clotting factors and platelets; treat the underlying cause; replace products if bleeding.

Hypotension and shock; give IV hydrocortisone and aggressive fluids immediately — do not wait for testing.

Fever, tachycardia, agitation; beta-blocker, thionamide, iodine (after thionamide), and steroids.

Severe hypothyroidism with hypothermia and altered mental status; IV levothyroxine and stress-dose steroids.

Lower BP gradually (about 10-20% in the first hour) with IV agents to avoid hypoperfusion.

6 Ps (pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis); anticoagulate and revascularize urgently.

Pain out of proportion, pain on passive stretch; emergent fasciotomy — do not wait for pulselessness.

Severe pain, rapid spread, crepitus; emergent surgical debridement plus broad-spectrum antibiotics.

Painful red eye, mid-dilated fixed pupil, vision loss; lower IOP urgently; ophthalmology emergency.

Joint aspiration before antibiotics; empiric antibiotics and drainage to prevent joint destruction.

Vancomycin + ceftriaxone (+ ampicillin if Listeria risk); add dexamethasone; do not delay antibiotics for imaging/LP.

SSRIs (with psychotherapy); allow several weeks for effect; assess suicide risk.

Ask directly about ideation, plan, intent, and means; ensure safety; hospitalize if high risk.

Agitation, hyperreflexia, clonus, hyperthermia from serotonergic drugs; stop the agent, supportive care, cyproheptadine.

Rigidity, hyperthermia, autonomic instability from antipsychotics; stop the drug, cool, dantrolene/bromocriptine.

Mood stabilizers (lithium, valproate) or atypical antipsychotics; avoid antidepressant monotherapy (mania risk).

Narrow therapeutic index; monitor levels, renal and thyroid function; tremor, ataxia, and confusion signal toxicity.

First-line SSRIs/SNRIs and CBT; avoid long-term benzodiazepines.

Benzodiazepines (symptom-triggered); thiamine before glucose; watch for delirium tremens.

Confusion, ataxia, ophthalmoplegia from thiamine deficiency; give IV thiamine BEFORE glucose.

Medication-assisted treatment: buprenorphine, methadone, or naltrexone, with counseling.

Stimulants (methylphenidate, amphetamines) are first-line; behavioral therapy in young children.

Atypicals cause weight gain, dyslipidemia, and diabetes; monitor weight, glucose, and lipids.

Cholinesterase inhibitors and memantine modestly help; address safety, caregivers, and reversible causes.

Identify and treat the underlying cause; reorient and avoid restraints; use antipsychotics sparingly for severe agitation.

Carbidopa-levodopa for symptomatic motor disease; dopamine agonists in younger patients.

Acute: triptans and NSAIDs; prophylaxis (frequent attacks): beta-blockers, topiramate, or CGRP antagonists.

Evaluate with EEG and MRI; antiepileptic therapy based on seizure type and recurrence risk.

Acute peripheral facial nerve palsy (forehead involved); treat with corticosteroids (± antivirals); eye protection.

Relapsing neuro deficits separated in time and space; acute relapse → steroids; disease-modifying therapy long-term.

Ascending paralysis and areflexia; treat with IVIG or plasmapheresis; monitor respiratory status.

Urgent evaluation (ABCD2), neuroimaging, carotid and cardiac assessment; start antiplatelet and statin.

Blood type/Rh, CBC, rubella, HIV, hepatitis B, syphilis, urine culture, and Pap as indicated.

Start 0.4 mg daily before conception (higher if prior neural tube defect) to prevent neural tube defects.

Screen at 24-28 weeks with a glucose challenge; manage with diet, then insulin if needed.

New hypertension + proteinuria (or end-organ signs) after 20 weeks; magnesium sulfate for seizure prophylaxis; deliver definitively.

Magnesium sulfate to control/prevent seizures, blood pressure control, and delivery.

Give anti-D immune globulin (RhoGAM) at 28 weeks and after delivery of an Rh-positive infant.

Positive pregnancy test with adnexal pain/bleeding; methotrexate if stable/criteria met, surgery if ruptured/unstable.

Most commonly uterine atony; fundal massage, uterotonics (oxytocin), and escalate to procedures if needed.

Progestin-only methods are preferred while breastfeeding; avoid estrogen early postpartum (VTE risk).

Begin at age 21; cytology every 3 years, or co-testing/HPV testing per guidelines from age 25-30.

Exclude pregnancy; evaluate structural and hormonal causes; endometrial biopsy if risk factors for hyperplasia/cancer.

For bothersome vasomotor symptoms in appropriate candidates; weigh VTE, stroke, and breast cancer risks.

Treat empirically (ceftriaxone + doxycycline ± metronidazole) to preserve fertility; low threshold to treat.

Lifestyle, combined oral contraceptives for cycle/androgen control, and metformin/letrozole for metabolic/fertility goals.

NSAIDs, colchicine, or corticosteroids; do not start or stop urate-lowering therapy during an acute flare.

Urate-lowering therapy (allopurinol) for recurrent attacks, tophi, or stones; titrate to target urate.

Symmetric small-joint inflammation; start a DMARD (methotrexate) early to prevent joint destruction.

Multisystem autoimmune disease; hydroxychloroquine for most; immunosuppression for organ involvement.

PMR: shoulder/hip stiffness, low-dose steroids. GCA: headache/vision loss, HIGH-dose steroids urgently to save vision.

Conservative care and activity as tolerated; imaging only with red flags (neuro deficit, cancer, infection, trauma).

Saddle anesthesia, urinary retention, bilateral leg weakness; emergent MRI and surgical decompression.

Exercise, weight loss, topical/oral NSAIDs and acetaminophen; joint replacement for refractory disease.

Septic: very high WBC, positive culture. Gout: negatively birefringent needle crystals. Pseudogout: positively birefringent rhomboids.

Treat with antibiotics covering streptococci and S. aureus; mark borders and reassess; rule out abscess (needs drainage).

Drug reaction with mucosal involvement and skin sloughing; stop the drug, supportive (burn-unit) care.

Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolving; biopsy suspicious lesions.

BCC: pearly papule with telangiectasias (most common). SCC: scaly/ulcerated, can metastasize; both UV-related.

Topical corticosteroids and vitamin D analogs; phototherapy or systemic/biologic agents for extensive disease.

Severe unilateral periorbital pain with autonomic signs; acute: high-flow oxygen and triptans.

Peripheral (BPPV, vestibular neuritis) is benign; central (stroke) has neuro signs — image if central features.

Median nerve compression; nocturnal hand numbness; splinting first, then steroid injection or surgery.

Thunderclap headache; non-contrast CT, then LP if CT negative; neurosurgical/neuro-IR management.

Can be an early marker of cardiovascular disease; assess risk factors; PDE5 inhibitors (avoid with nitrates).

Insulin-driven shift of phosphate, potassium, and magnesium into cells when feeding a malnourished patient; can cause arrhythmias.

Start low calories (about 10-20 kcal/kg/day), advance slowly, and monitor/replace electrolytes (especially phosphate).

Hypophosphatemia — replace phosphate before and during feeding.

Wernicke-Korsakoff and wet beriberi (high-output heart failure); give thiamine before glucose in at-risk patients.

Macrocytic anemia with neurologic signs (subacute combined degeneration); check methylmalonic acid; replace B12.

Macrocytic anemia WITHOUT neurologic signs; common in alcohol use and pregnancy.

Causes osteomalacia/rickets and secondary hyperparathyroidism; supplement with vitamin D and calcium.

Night blindness and xerophthalmia; excess is teratogenic and causes pseudotumor cerebri.

Poor wound healing, bleeding gums, perifollicular hemorrhage; treat with vitamin C.

Elevated PT/INR and bleeding; common in malabsorption and newborns (give vitamin K at birth).

The 3 Ds: dermatitis, diarrhea, dementia.

Poor wound healing, dysgeusia, alopecia, and a perioral/acral rash.

Prefer enteral when the gut works ('if the gut works, use it'); parenteral nutrition for nonfunctional GI tracts.

Identify at-risk patients (poor intake, weight loss, chronic disease); involve dietitians and prevent refeeding syndrome.

Lifestyle first; add pharmacotherapy (GLP-1 agonists) or bariatric surgery based on BMI and comorbidities.

Age 45 for average-risk adults (USPSTF), continuing through 75; options include colonoscopy or stool-based tests.

Proceed to colonoscopy — a positive FIT or stool DNA test requires diagnostic colonoscopy.

Mammography; USPSTF recommends starting at age 40 (biennial) for average-risk women.

Age 21-29 cytology every 3 years; age 30-65 co-testing or HPV testing per guidelines.

Annual low-dose CT for adults 50-80 with a 20 pack-year history who currently smoke or quit within 15 years.

One-time ultrasound for men 65-75 who have ever smoked.

DXA scan in women 65+ (and younger postmenopausal women with risk factors).

Annual influenza; Tdap/Td booster; COVID-19 per guidance; check the current CDC schedule each year.

Recommended for adults 65+ and younger adults with certain conditions; follow the current CDC schedule.

Recombinant zoster vaccine for adults 50+ (two doses).

Routine at ages 11-12, catch-up through 26 (and shared decision-making through 45).

Avoid live vaccines (MMR, varicella) in pregnancy and significant immunocompromise.

Use the 5 A's (Ask, Advise, Assess, Assist, Arrange); offer pharmacotherapy plus counseling at every visit.

Screen with validated tools (AUDIT-C); provide brief intervention for unhealthy use.

Screen adults 35-70 who are overweight or obese for prediabetes and type 2 diabetes.

Screen adults 18+ with office BP, confirming with out-of-office measurement before diagnosis.

Screen all adults (and adolescents) with a validated tool such as the PHQ-9 when systems support follow-up.

Adults 40-75 with ≥1 risk factor and a 10-year ASCVD risk of 10% or more (selectively at 7.5-10%).

Update screening, immunizations, and counseling — a core continued-care management task on Step 3.

Reduces neural tube defects at the population level; individual supplementation before conception adds further protection.