USMLE Step 3
Practice Test 10 for USMLE Step 3: real questions and explanations from the Varsity Tutors practice-test pool.
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During a well-woman exam for a 48-year-old patient, she receives a call. After hanging up, she appears distressed and tells you her 12-year-old niece was just diagnosed with an HPV-related throat cancer. She then asks if her own 14-year-old son, who has not been vaccinated, should get the "girl's vaccine."
What is the most appropriate response?
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During a well-woman exam for a 48-year-old patient, she receives a call. After hanging up, she appears distressed and tells you her 12-year-old niece was just diagnosed with an HPV-related throat cancer. She then asks if her own 14-year-old son, who has not been vaccinated, should get the "girl's vaccine."
What is the most appropriate response?
Explanation: This question tests communication and knowledge of HPV vaccination. The most appropriate response is to validate the patient's concern and provide accurate information. The HPV vaccine is highly effective at preventing infections that cause multiple types of cancer, including cervical, anal, vulvar, vaginal, penile, and oropharyngeal cancers. It is strongly recommended for all adolescents, both boys and girls, ideally at age 11-12, before they are exposed to the virus. Distractor B is incorrect; the vaccine is highly effective in boys and prevents cancer. Distractor C is incorrect; vaccination is most effective when given before the onset of sexual activity. Distractor D is incorrect; HPV-related oropharyngeal cancers are increasing in incidence, and the 9-valent vaccine protects against the types that cause the majority of them.
A 66-year-old man on warfarin for a PE has an INR of 4.5 at a routine follow-up visit. He has no signs of active bleeding. He reports that he recently took a course of ciprofloxacin for a urinary tract infection. What is the most appropriate next step in management?
Explanation: When managing warfarin overdose, your approach depends on the degree of INR elevation and presence of bleeding. This patient has a supratherapeutic INR (4.5) without active bleeding, likely due to ciprofloxacin inhibiting warfarin metabolism through CYP450 interactions. For INR levels between 4.5-10 without bleeding, the standard approach is to hold warfarin temporarily and monitor closely. The INR will naturally decrease as warfarin's effect wanes (warfarin has a half-life of 36-42 hours). This allows for safe correction without risking overcorrection that could lead to thrombotic complications. Choice D is correct because holding warfarin and rechecking INR in 1-2 days allows controlled monitoring of the INR decline while maintaining anticoagulation benefits as the ciprofloxacin effect diminishes. Choice A (oral vitamin K 2.5 mg) would be appropriate for INR >10 without bleeding, but risks overcorrection and warfarin resistance for several days. Choice B ignores the dangerous INR elevation - continuing warfarin could worsen the coagulopathy, and avoiding all antibiotics isn't realistic long-term management. Choice C (FFP transfusion) is reserved for life-threatening bleeding or emergency surgery needs, as it's expensive, carries transfusion risks, and provides only temporary reversal. Key strategy: Remember the INR thresholds for warfarin management: 3-5 without bleeding = hold doses and monitor; 5-9 without bleeding = hold and consider low-dose vitamin K; >9 or any bleeding = vitamin K; life-threatening bleeding = vitamin K plus FFP/PCC.
A 70-year-old man with a long history of poorly controlled hypertension presents for follow-up 3 months after a deep intracerebral hemorrhage located in the basal ganglia. His neurologic deficits have partially improved. His blood pressure in the clinic today is 155/95 mmHg. He is currently taking amlodipine 10 mg daily.
Which of the following is the most critical intervention for the secondary prevention of hemorrhage in this patient?
Explanation: Hypertension is the single most important modifiable risk factor for spontaneous deep intracerebral hemorrhage (ICH). The location in the basal ganglia is classic for a hypertensive bleed. Aggressive blood pressure control is the cornerstone of secondary prevention. The ATACH-2 and INTERACT2 trials support a target systolic blood pressure of <130-140 mmHg. Initiating aspirin is contraindicated as it would increase the risk of recurrent hemorrhage. While alcohol is a risk factor, BP control is paramount. A vascular malformation is less likely in this location and age group.
A 68-year-old man with a 40-pack-year smoking history and severe COPD (GOLD stage 3, group E) is seen for follow-up in the ambulatory clinic. His post-bronchodilator FEV1 is 42% of predicted. He is currently managed with a combination inhaler containing fluticasone, umeclidinium, and vilanterol (ICS/LAMA/LABA). Despite adherence to this regimen, he has had two exacerbations requiring hospitalization in the past 10 months. He describes a chronic productive cough with copious sputum daily. His blood eosinophil count is 150 cells/µL.
In addition to his current therapy, which of the following is the most appropriate intervention to reduce the risk of future exacerbations in this patient?
Explanation: This patient has severe COPD with a chronic bronchitis phenotype (daily productive cough) and continues to have frequent exacerbations despite optimal triple therapy (ICS/LAMA/LABA). According to GOLD guidelines, for patients with an FEV1 < 50% and chronic bronchitis, adding roflumilast, a phosphodiesterase-4 inhibitor, is recommended to reduce exacerbations. His eosinophil count is < 300 cells/µL, making ICS benefit less certain, but he is already on it. Roflumilast is the most appropriate next step for his specific phenotype.
A 26-year-old woman who is 14 weeks pregnant presents for her first prenatal visit. She has a history of opioid use disorder and has been stable on buprenorphine/naloxone 12/3 mg daily for the past year. She is concerned that the naloxone component will harm the fetus and requests to be switched to a different medication.
What is the most appropriate response and management plan?
Explanation: The most appropriate initial step is to provide education and reassurance. Naloxone has very poor sublingual and oral bioavailability and is not expected to cause fetal harm. Both buprenorphine and methadone are considered standards of care in pregnancy. For a patient already stable on a buprenorphine/naloxone combination product, continuing it is a safe option. While switching to a buprenorphine monoproduct is a reasonable alternative that some guidelines suggest, it is not mandatory, and the initial step should be education. Tapering off medication during pregnancy is strongly discouraged due to high relapse rates, which pose a greater risk to the mother and fetus. Unnecessarily switching to methadone introduces risks associated with changing medications.
A 45-year-old woman with moderate persistent asthma has been well-controlled for the past year on a medium-dose inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combination inhaler. She reports using her albuterol inhaler less than once a month and has had no nocturnal awakenings or exacerbations. She is concerned about the long-term side effects of her medications. Her FEV1 is 95% of predicted.
What is the most appropriate next step in the management of this patient's asthma?
Explanation: According to asthma management guidelines (e.g., GINA), when a patient's asthma has been well-controlled for at least 3 months, step-down therapy should be considered to find the minimum effective dose to maintain control and reduce long-term side effects. The most appropriate step-down for a patient on a medium-dose ICS/LABA is to reduce it to a low-dose ICS/LABA. Discontinuing the controller medication entirely is inappropriate, and switching to ICS alone removes the LABA that may be contributing to control. Continuing the current dose without attempting a step-down is not optimal.
During a 4-month well-child visit, a father reports that he has been adding rice cereal to the infant's bottle to help him 'sleep through the night.' He also mentions giving the infant 2-3 ounces of water daily because he is worried about dehydration in the warm weather.
Which of the following is the most appropriate response regarding these practices?
Explanation: This response correctly addresses two common and potentially harmful parenting misconceptions. First, adding cereal to a bottle is not recommended as it does not improve sleep, can lead to overfeeding, and poses a choking risk. Second, infants under 6 months of age receive all their hydration needs from breast milk or formula and should not be given supplemental water; doing so can lead to oral water intoxication and hyponatremia. The other options are incorrect as they either endorse a harmful practice or provide inappropriate alternative advice.
A 68-year-old woman has CKD stage 4 for 6 years from hypertension; she avoids NSAIDs and follows a low-sodium diet. Medications include lisinopril 20 mg daily, amlodipine 10 mg daily, and furosemide 40 mg daily. She reports no palpitations or weakness. BP is 134/78 mm Hg. Labs: creatinine 3.4 mg/dL, eGFR 17 mL/min/1.73 m², K 5.7 mEq/L, HCO3 22 mEq/L. ECG is normal. Which medication adjustment is most appropriate for this patient?
Explanation: This question tests chronic kidney disease management skills, specifically focusing on evidence-based management of hyperkalemia while preserving RAAS inhibition in CKD patients. Chronic kidney disease management involves regular monitoring of renal function, adjusting medications based on kidney status, and managing complications like anemia and electrolyte imbalances. In the presented vignette, the patient's hyperkalemia with beneficial ACE inhibitor use indicates the need for a potassium binder to continue therapy. The correct choice, adding patiromer to maintain ACE inhibitor therapy, accurately reflects current guidelines for managing CKD stage 4, demonstrating the student's understanding of appropriate clinical interventions. A common distractor may suggest stopping lisinopril permanently, which sacrifices renoprotection, highlighting a frequent misconception. To improve understanding, students should focus on guidelines for hyperkalemia in CKD, regularly review binder options, and practice balancing electrolyte control with optimal therapy.
A 22-year-old man with a 4-year history of IBD presents to the emergency department with 3 days of worsening abdominal pain, nausea, and vomiting. On examination, there is a tender, palpable mass in the right lower quadrant. An abdominal CT scan reveals a 5-cm inflammatory mass (phlegmon) involving the terminal ileum with associated small bowel obstruction.
This patient's underlying inflammatory bowel disease is most likely which of the following?
Explanation: The presence of a phlegmon, transmural inflammation, stricturing disease, and small bowel involvement (terminal ileum) are all characteristic features of Crohn disease. Ulcerative colitis is a mucosal disease limited to the colon and does not typically cause phlegmons or small bowel obstruction. Microscopic colitis causes watery diarrhea and has normal endoscopic findings. Indeterminate colitis is used when features overlap, but this presentation is strongly suggestive of Crohn disease.
A 13-year-old girl presents for her annual check-up. Her mother is concerned because she has not yet had her first menstrual period, while most of her friends have. On physical examination, the patient has Tanner stage 2 breast development and Tanner stage 2 pubic hair. Her height and weight are at the 50th percentile for her age.
Which of the following is the most appropriate next step in management?
Explanation: The normal sequence of female puberty is thelarche (breast budding), followed by pubarche (pubic hair development), a growth spurt, and finally menarche. Menarche typically occurs about 2 to 2.5 years after the onset of thelarche, usually during Tanner stage 3 or 4 of breast development. This patient, at Tanner stage 2, is at the beginning of her pubertal development. It is entirely normal that she has not yet reached menarche. Therefore, the most appropriate action is reassurance. A workup for delayed puberty or primary amenorrhea is not indicated at this time.
History & Lifestyle: 50-year-old male for routine health maintenance. • Smokes 1 pack/day x 30 years. • Drinks socially; no IV drug use. • Monogamous with wife. Family History: Father MI at 55. Preventive Care Review: No prior hepatitis C screening; born 1975. No known liver disease. Vaccines otherwise current. He asks whether any “one-time” screening labs are recommended.
Based on the vignette, which screening test is recommended for this patient?
Explanation: This question tests understanding of preventive care and screening in primary care (USMLE Step 3). Preventive care involves applying evidence-based guidelines to recommend appropriate screenings and lifestyle modifications. In this vignette, the 50-year-old man born in 1975 has no prior hepatitis C screening, the recommended screening is one-time hepatitis C antibody testing, aligning with USPSTF guidelines. Choice A is correct because it matches USPSTF recommendations for one-time screening in all adults aged 18-79. Choice B is incorrect because it suggests monthly hepatitis B DNA screening, which is not indicated without known infection or risk. For teaching, emphasize the importance of staying updated with guidelines, identifying patient-specific risk factors, and prioritizing screenings that provide the greatest benefit. Encourage students to practice applying guidelines in varied scenarios to build confidence in clinical decision-making.
A 29-year-old man with no past medical history is admitted to the ICU with fulminant myocarditis. His ejection fraction is 10%, and he is in cardiogenic shock requiring an intra-aortic balloon pump (IABP) and three vasopressors. He develops anuria and his lactate remains elevated at 9 mmol/L despite these interventions. The patient's family asks if he will need a heart transplant.
Which of the following factors is the most immediate and critical determinant of his short-term prognosis and candidacy for advanced therapies?
Explanation: In fulminant myocarditis with severe cardiogenic shock, the patient is on a trajectory toward needing advanced mechanical support (e.g., ECMO, VAD) as a bridge to recovery or transplant. The most critical factor that would preclude these life-saving interventions and determine a futile outcome is the development of irreversible end-organ damage from the prolonged shock state. Severe anoxic brain injury is the most devastating and absolute contraindication. While myocardial recovery (A) is the ultimate goal, the decision to escalate therapy must be made before it is known. Identifying the virus (C) rarely changes acute management. Suitability for anticoagulation (D) is a consideration but is secondary to the presence of severe, irreversible organ failure.
A 25-year-old graduate student with obsessive-compulsive disorder has been treated with fluoxetine for the past 16 weeks. The dose was gradually increased and has been at 80 mg daily for the past 8 weeks. He has also been engaged in weekly exposure and response prevention (ERP) therapy. Despite these interventions, he continues to spend 3-4 hours per day on compulsive rituals and experiences significant distress. His symptoms remain severe.
Which of the following is the most appropriate next pharmacologic step?
Explanation: The correct answer is B. This patient has treatment-resistant OCD, defined as a failure to respond to an adequate trial of a first-line agent (an SSRI at maximum tolerated dose for at least 8-12 weeks) plus ERP. The most evidence-based next step is to augment the SSRI with an atypical antipsychotic, such as risperidone or aripiprazole. Switching to clomipramine (A), a tricyclic antidepressant, is another option, but augmentation is often preferred to preserve the partial response from the SSRI. Increasing the fluoxetine dose beyond the typical maximum (C) is not evidence-based. Augmentation with buspirone (D) has limited evidence for OCD.
A 55-year-old man is evaluated 6 months after a severe ischemic stroke. He has developed significant right-sided spasticity, especially in his elbow flexors and wrist flexors. This is causing painful muscle spasms and a clenched fist, which interferes with hygiene and dressing. Physical therapy and stretching exercises have provided minimal relief.
Which of the following is the most appropriate next step in management?
Explanation: This patient has focal spasticity that is causing pain and functional impairment. For this indication, botulinum toxin injection into the affected muscles is a first-line treatment. It works by inhibiting acetylcholine release at the neuromuscular junction, causing targeted muscle relaxation. Oral medications like baclofen or diazepam can be used but often cause systemic side effects such as sedation and generalized weakness before achieving a therapeutic effect on focal spasticity. While physical therapy is essential, it is not sufficient for severe cases.
HPI/PP Bleeding: 30F G1P1, 4 weeks postpartum, increased bleeding after initial improvement. No fever. Ultrasound shows echogenic material within endometrial cavity with vascularity. Hemodynamically stable. Interpregnancy: wants future fertility and asks about recurrence prevention. What is the most appropriate next step in management for this patient?
Explanation: This question tests understanding of postpartum and interpregnancy care within the context of obstetrics and gynecology for USMLE Step 3. Postpartum care involves managing the recovery of the mother, addressing complications, and planning for future pregnancies. Key elements include physical recovery, mental health, and family planning. This case involves specific postpartum challenges such as increased bleeding with ultrasound evidence of retained products. The clinical scenario highlights the need for obstetric consultation. The correct answer is based on ACOG guidelines which recommend consulting obstetrics for retained products management and close follow-up in such situations to ensure optimal patient outcomes. A common distractor might suggest reassuring that ultrasound findings are expected postpartum, which fails to address the key aspect of care by risking ongoing hemorrhage. To teach this concept effectively, emphasize evidence-based guidelines and integrate patient-centered care approaches. Encourage practice in evaluating postpartum care needs through simulated case studies and reviewing current guidelines.
A 70-year-old man with a history of myocardial infarction three years ago presents for follow-up. He is being evaluated for elective inguinal hernia repair. He has been stable, with no angina for over a year, and can climb two flights of stairs without symptoms. His medications include aspirin, atorvastatin, carvedilol, and enalapril. His vital signs are stable. ECG shows Q waves in the inferior leads, unchanged from previous.
What is the most appropriate recommendation regarding his cardiac management before surgery?
Explanation: This patient is scheduled for a low-to-intermediate risk non-cardiac surgery. According to the ACC/AHA guidelines for perioperative cardiovascular evaluation, if a patient has a good functional capacity (≥4 metabolic equivalents [METs], e.g., climbing two flights of stairs), no further cardiac testing is needed, regardless of their cardiac history. The patient is asymptomatic and on optimal medical therapy. Therefore, he can proceed with the scheduled surgery. Performing stress testing (B), echocardiography (C), or angiography (D) would not change management and is not indicated.
A primary care physician is managing a 50-year-old patient with alcohol use disorder, major depressive disorder, and chronic kidney disease stage 4 (eGFR 25 mL/min/1.73 m²). The patient is sober but struggles with cravings. His depression is well-managed with sertraline. He is interested in medication-assisted treatment for AUD.
Given this patient's comorbidities, which medication for alcohol use disorder should be avoided?
Explanation: When managing alcohol use disorder in patients with multiple comorbidities, you must carefully consider how each medication is metabolized and whether it's contraindicated in specific conditions like kidney disease. Acamprosate (D) should be avoided in this patient because it's primarily eliminated by the kidneys unchanged. With an eGFR of 25 mL/min/1.73 m², this patient has stage 4 chronic kidney disease, and acamprosate is contraindicated when creatinine clearance falls below 30 mL/min due to risk of drug accumulation and toxicity. Let's examine why the other options are safer choices: Naltrexone (A) is metabolized by the liver, not the kidneys, making it appropriate for patients with renal impairment. However, you'd want to ensure this patient doesn't have significant liver disease from alcohol use. Gabapentin (B), while requiring dose adjustment in kidney disease, can still be used safely with appropriate monitoring and reduced dosing. Disulfiram (C) is metabolized hepatically and doesn't require renal dose adjustment, though it requires careful patient selection due to its mechanism of causing unpleasant reactions with alcohol consumption. The patient's depression and sobriety status don't contraindicate any of these medications, but the severe kidney impairment is the decisive factor here. Study tip for Step 3: Always check renal function when prescribing any medication. Acamprosate is one of the few psychiatric medications that's primarily renally eliminated rather than hepatically metabolized—remember this exception when managing addiction in CKD patients.
The parents of a 6-year-old boy are concerned about his persistent nighttime bedwetting. He has never had a consistent period of nighttime dryness. He is otherwise healthy, has no daytime urinary symptoms, and has achieved developmental milestones appropriately. His physical examination, including neurologic and genital exams, is normal. A urinalysis is negative for glucose, protein, and signs of infection.
Which of the following is the most appropriate initial management strategy?
Explanation: This child has primary monosymptomatic nocturnal enuresis, which is bedwetting in a child who has never achieved nighttime dryness and has no other lower urinary tract symptoms. In a 6-year-old, this is often a developmental issue. The first-line management is education, reassurance, and positive reinforcement (motivational therapy). The family should be counseled that it is common and not the child's fault. (A) Pharmacotherapy like desmopressin is considered a second-line treatment, typically reserved for older children (≥7 years) or when initial behavioral therapies fail and the enuresis is causing significant distress. (B) Bladder training is used for daytime incontinence or bladder overactivity, not isolated nocturnal enuresis. (D) While modest fluid restriction in the evening (1-2 hours before bed) is reasonable, severe restriction throughout the afternoon is unnecessary and can lead to dehydration.
A 32-year-old woman presents for follow-up 3 months after being diagnosed with a pulmonary embolism. The event occurred six weeks after she started taking a combined oral contraceptive pill. She has completed a 3-month course of apixaban and is asymptomatic. She has no family history of blood clots. Which of the following is the most accurate statement regarding testing for inherited thrombophilias?
Explanation: This patient had a pulmonary embolism provoked by a major, modifiable risk factor (oral contraceptives). The standard treatment is a finite course (3 months) of anticoagulation. Testing for inherited thrombophilias is generally not recommended in this setting because the results would not change the management plan. The presence of a thrombophilia would not extend the duration of therapy for a clearly provoked event. Regardless of thrombophilia status, she will be advised to avoid estrogen-containing contraceptives in the future.
A 35-year-old woman who underwent a Roux-en-Y gastric bypass 3 years ago presents to the emergency department with a 12-hour history of severe, cramping, periumbilical abdominal pain and non-bilious vomiting. On examination, she is tachycardic to 120/min and has diffuse abdominal tenderness without peritoneal signs. A plain abdominal x-ray is unremarkable.
Explanation: When you encounter post-bariatric surgery patients with acute abdominal pain, think systematically about the unique complications these procedures create. Roux-en-Y gastric bypass creates several potential spaces where bowel can become trapped, making internal hernias a significant long-term risk. This patient's presentation strongly suggests internal hernia with small bowel obstruction. The severe, cramping periumbilical pain with non-bilious vomiting is classic for small bowel obstruction. The tachycardia indicates physiologic stress, while the absence of peritoneal signs suggests obstruction without perforation. Crucially, plain abdominal x-rays are often normal in early small bowel obstruction, especially when caused by internal hernias where bowel loops can appear deceptively normal on plain films. Option B, marginal ulcer at the gastrojejunostomy, typically presents with epigastric pain, often related to eating, and may cause hematemesis or melena rather than this obstruction pattern. Option C, gastric dumping syndrome, occurs shortly after eating and involves cramping with diarrhea, sweating, and palpitations - not the sustained severe pain described here. Option D, acute calculous cholecystitis, would cause right upper quadrant pain with possible Murphy's sign, not periumbilical cramping. For Step 3, remember that internal hernias are the most common cause of bowel obstruction in post-Roux-en-Y patients, often presenting months to years after surgery. When plain films are unremarkable but clinical suspicion is high, CT scan is the next step. Don't be fooled by normal plain films in suspected small bowel obstruction.
A 55-year-old woman is undergoing a slow taper from clonazepam, which she had been taking for 10 years for anxiety. Her dose was reduced one week ago. She calls the office reporting a significant increase in anxiety, insomnia, and palpitations over the past two days, coinciding with a major conflict at her job. She is requesting an increase in her clonazepam dose.
What is the most appropriate short-term management advice for this patient?
Explanation: When managing benzodiazepine withdrawal, you must distinguish between withdrawal symptoms and situational anxiety exacerbations. This patient presents a classic scenario where external stressors (job conflict) coincide with an ongoing taper, making symptom attribution challenging but crucial for appropriate management. The correct approach is A) holding the taper and reinforcing coping skills. When patients experience increased symptoms during benzodiazepine withdrawal that coincide with identifiable stressors, the most therapeutic response is stabilization rather than escalation. Holding at the current dose prevents further physiological destabilization while allowing time to address the situational trigger through non-pharmacologic interventions. This maintains progress toward the ultimate goal of discontinuation. B is problematic because adding lorazepam introduces a shorter-acting benzodiazepine, which can complicate withdrawal from the longer-acting clonazepam and potentially worsen rebound symptoms. C represents regression in treatment by increasing the dose back to previous levels, essentially restarting the entire process and reinforcing the patient's dependence on medication for stress management. D is excessive since the patient isn't experiencing severe withdrawal symptoms (seizures, delirium, severe autonomic instability) that would warrant inpatient detoxification. For Step 3, remember that benzodiazepine management questions often test your ability to balance patient comfort with treatment goals. Look for scenarios where external stressors complicate withdrawal—the answer typically involves stabilization and enhanced psychosocial support rather than medication adjustments. Avoid choices that represent treatment regression or unnecessary escalation of care.
A 50-year-old man with a first unprovoked pulmonary embolism is completing a 6-month course of anticoagulation with apixaban. He has an intermediate bleeding risk and is uncertain about continuing therapy indefinitely. What is the most appropriate use of D-dimer testing to assist in shared decision-making?
Explanation: In patients with a first unprovoked VTE who are stopping anticoagulation, a D-dimer level can help stratify the risk of recurrence. The test should be performed approximately one month after discontinuing therapy. A negative result is associated with a lower risk of recurrence, and this information can support a decision to remain off anticoagulation. A positive result suggests a higher risk, favoring resumption of therapy. Measuring D-dimer while on anticoagulation is not useful as the drug suppresses D-dimer formation.
History & Lifestyle: 50-year-old male presents for routine exam. • Smokes 1 pack/day x 30 years. • No prior HIV test; monogamous currently. • No STI symptoms. Family History: Father with CAD. Preventive Care Review: Vaccines updated; planning colon cancer screening. He asks if HIV testing is still recommended at his age.
Based on the vignette, which screening test is recommended for this patient?
Explanation: This question tests understanding of preventive care and screening in primary care (USMLE Step 3). Preventive care involves applying evidence-based guidelines to recommend appropriate screenings and lifestyle modifications. In this vignette, the 50-year-old man has no prior HIV test and asks if recommended, the screening is HIV Ag/Ab at least once, aligning with USPSTF guidelines. Choice A is correct because it matches USPSTF recommendations for one-time screening in all adults aged 15-65. Choice C is incorrect because it suggests no screening after age 50, but guidelines include up to 65. For teaching, emphasize the importance of staying updated with guidelines, identifying patient-specific risk factors, and prioritizing screenings that provide the greatest benefit. Encourage students to practice applying guidelines in varied scenarios to build confidence in clinical decision-making.
A 77-year-old man with stable CAD on aspirin, metoprolol, and atorvastatin is hospitalized for a diverticular bleed. His hemoglobin is stable after transfusion, and a colonoscopy shows no active bleeding. He is ready for discharge. His cardiologist and gastroenterologist are discussing the plan for his aspirin.
Which of the following is the most appropriate recommendation for managing his aspirin therapy?
Explanation: For patients with stable CAD who experience a GI bleed, the risk of a major adverse cardiac event from discontinuing aspirin often outweighs the risk of re-bleeding, especially once the source is controlled. Guidelines recommend resuming aspirin as soon as it is considered safe from a GI perspective, which is often before discharge or immediately upon discharge. To mitigate the risk of a future bleed, a proton pump inhibitor (PPI) should be co-administered. Discontinuing aspirin permanently (A) would increase his cardiovascular risk. Switching to clopidogrel (B) is not superior to aspirin plus a PPI for preventing re-bleeding and may even carry a similar risk. Withholding aspirin for an extended period (D) unnecessarily exposes the patient to thrombotic risk.
A 28-year-old woman with a 5-year history of ileocolonic Crohn disease has been managed with azathioprine. For the past 3 months, she reports increasing abdominal pain, non-bloody diarrhea, and a 4-kg weight loss. Her C-reactive protein is 25 mg/L (normal <5 mg/L) and fecal calprotectin is 800 mcg/g (normal <50 mcg/g). Thiopurine metabolite testing shows 6-thioguanine nucleotide (6-TGN) levels in the therapeutic range.
Which of the following is the most appropriate next step in her management?
Explanation: This patient has active Crohn disease despite being on an optimized dose of azathioprine (as evidenced by therapeutic 6-TGN levels). This represents a failure of immunomodulator monotherapy. The next step is to escalate therapy by adding a biologic agent, such as the anti-TNF agent infliximab. Increasing azathioprine is incorrect as levels are already therapeutic. Switching to another immunomodulator like methotrexate is less effective than escalating to a biologic. Budesonide is used for short-term induction of remission but does not address the need for a change in long-term maintenance strategy.