USMLE Step 3
Practice Test 11 for USMLE Step 3: real questions and explanations from the Varsity Tutors practice-test pool.
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A 72-year-old man on warfarin for PE 4 months ago (unprovoked) presents with sudden headache and confusion. He reports no chest pain or dyspnea. Risk factors include age and prior DVT; no malignancy. Regimen: warfarin with target INR 2.0–3.0; last INR 3.1 one week ago. Today vitals: BP 168/92, HR 88. Labs: INR 4.9, platelets 200k, creatinine 1.2 mg/dL (eGFR 66 mL/min/1.73 m²). What complication is this patient at greatest risk for given their current therapy?
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A 72-year-old man on warfarin for PE 4 months ago (unprovoked) presents with sudden headache and confusion. He reports no chest pain or dyspnea. Risk factors include age and prior DVT; no malignancy. Regimen: warfarin with target INR 2.0–3.0; last INR 3.1 one week ago. Today vitals: BP 168/92, HR 88. Labs: INR 4.9, platelets 200k, creatinine 1.2 mg/dL (eGFR 66 mL/min/1.73 m²). What complication is this patient at greatest risk for given their current therapy?
Explanation: This question tests the understanding of pulmonary embolism management and anticoagulation follow-up in a clinical context relevant to USMLE Step 3. The principle focus is on applying clinical guidelines for anticoagulation management and recognizing complications arising from therapy. In this scenario, factors such as the patient's sudden headache, confusion, elevated INR of 4.9, and hypertension are critical for decision-making. The correct answer addresses these factors by identifying intracranial hemorrhage as the greatest risk due to supratherapeutic anticoagulation, demonstrating the application of clinical guidelines for recognizing serious bleeding complications. A common distractor might suggest recurrent PE, which fails to consider that elevated INR increases bleeding rather than thrombotic risk. To prepare for similar questions, students should focus on understanding anticoagulation management guidelines, recognize symptoms indicative of complications, and practice applying this knowledge to case scenarios.
HPI/PP Visit: 31F G2P2, 7 weeks postpartum, reports severe headaches and blurry vision for 2 days. Pregnancy had gestational hypertension without severe features; no meds. Exam: BP 168/110, reflexes brisk; no focal deficits. UA: protein 2+. She is breastfeeding and asks if symptoms can wait until next clinic day. Interpregnancy: wants reliable contraception. 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 severe headaches, blurry vision, and elevated blood pressure. The clinical scenario highlights the need for evaluation of postpartum preeclampsia. The correct answer is based on ACOG guidelines which recommend administering antihypertensives and evaluating for postpartum preeclampsia in such situations to ensure optimal patient outcomes. A common distractor might suggest reassuring that preeclampsia resolves after delivery, which fails to address the key aspect of care by ignoring the risk of late-onset preeclampsia. 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 9-year-old boy is brought for a well-child check. His father, age 42, recently had a myocardial infarction. The boy's mother has type 2 diabetes. The child is asymptomatic. His BMI is at the 70th percentile for age. Blood pressure is 105/65 mm Hg. The remainder of his examination is normal.
According to current guidelines, which of the following is the most appropriate screening to perform at this visit?
Explanation: The American Academy of Pediatrics recommends targeted lipid screening for children between 2 and 10 years of age who have risk factors for dyslipidemia. A key risk factor is a family history of a parent having a cardiovascular event before age 55. This patient's father had an MI at age 42, making a fasting lipid panel the appropriate screening test. Universal screening is recommended for all children between ages 9 and 11, so he qualifies on that basis as well. (B) Screening for type 2 diabetes is recommended for overweight or obese children with additional risk factors, starting at age 10 or the onset of puberty. This child's BMI is normal (not ≥85th percentile), so routine diabetes screening is not yet indicated despite his family history. (C) A screening ECG is not recommended for asymptomatic children, even with a family history of premature heart disease, unless there is concern for a specific heritable arrhythmia or cardiomyopathy. (D) Screening is clearly indicated due to the strong family history.
A 40-year-old G3P3 woman is being discharged on postpartum day 3 after an emergency cesarean section for fetal distress. Her BMI is 35 kg/m². She has no personal or family history of venous thromboembolism (VTE). She is medically stable and ambulating without difficulty. According to ACOG guidelines, what is the most appropriate recommendation regarding VTE prophylaxis upon discharge?
Explanation: This patient has multiple risk factors for postpartum VTE, including age ≥35, obesity (BMI ≥30), and emergency cesarean delivery. The combination of these factors places her at high risk. ACOG guidelines recommend considering prophylactic anticoagulation (e.g., low-molecular-weight heparin) for 7-10 days after discharge for patients with multiple significant risk factors. Ambulation alone is not sufficient mitigation of this high risk. Aspirin is not used for VTE prophylaxis in this setting, and home pneumatic compression devices are not standard care.
An 84-year-old man with dementia, coronary artery disease, and chronic kidney disease is discharged from the hospital to home after a fall. His new medication list includes 14 medications, including a newly started direct oral anticoagulant. He lives with his 82-year-old wife who has significant visual impairment. Which of the following interventions is most likely to prevent a serious adverse drug event in the week following discharge?
Explanation: This patient has multiple high-risk features for a post-discharge adverse event: polypharmacy, a new high-risk medication (anticoagulant), cognitive impairment, and a caregiver with functional limitations. A home visit by a nurse or pharmacist (C) is the most robust intervention. It allows for direct medication reconciliation (comparing home meds to the discharge list), patient/caregiver education, and assessment of the home environment for safety. While the other options are components of good transitional care, they are less comprehensive and immediate. A faxed summary (A) doesn't ensure action, a large-print list (B) doesn't solve cognitive/complexity issues, and a 2-week follow-up (D) is too delayed.
A 38-year-old woman with a BMI of 42 kg/m² and a history of polycystic ovary syndrome (PCOS) presents for a well-woman exam. She has oligomenorrhea with menses every 3-4 months. She is not seeking pregnancy and is not using contraception.
Which intervention is most effective for the primary prevention of endometrial cancer in this patient?
Explanation: This patient has multiple risk factors for endometrial hyperplasia and cancer due to chronic anovulation (from PCOS) and obesity, leading to prolonged exposure to unopposed estrogen. The most effective method for endometrial protection is to provide a progestin. A levonorgestrel-releasing IUD provides excellent, continuous, local progestin to the endometrium, which counteracts the proliferative effects of estrogen, induces endometrial atrophy, and significantly reduces her risk of endometrial cancer. While lifestyle changes are crucial, they may not be sufficient to regulate her cycles, and endometrial protection is needed now. Screening with ultrasound or biopsy are diagnostic tools for suspected pathology, not primary prevention strategies.
A 50-year-old man with schizophrenia, T2DM, and obesity is managed by PCP and psychiatry. Background: On olanzapine; A1c rising; misses labs; limited insight. Current status/Plan: PCP considering metformin intensification; psychiatry considering antipsychotic switch. Team: PCP, psychiatrist, clinic RN, pharmacist, case manager. Coordination: Need shared plan for metabolic monitoring and medication changes. Transition plan: Regular case conferences proposed. Which strategy best supports coordination between primary and specialist care for this chronic disease management?
Explanation: This question tests the ability to manage care coordination and transitions in primary care as per USMLE Step 3 standards. Effective care coordination involves seamless communication among healthcare providers and ensuring continuity of care, which is crucial for patient safety and reducing readmissions. In the given scenario, the patient's transition plan must include specific follow-up actions like shared plans and conferences, with responsibilities clearly assigned to prevent gaps in care for this schizophrenia and diabetes patient. The correct answer demonstrates the application of these principles by ensuring appropriate follow-up and clear communication among the care team through coordinated monitoring. A common distractor might suggest single-team management or avoiding discussions, which often leads to fragmentation of care and metabolic complications. Teaching strategies include reinforcing the importance of clear documentation, regular team meetings, and involving the patient in the care plan to ensure adherence and satisfaction. Encourage students to practice scenario-based planning to visualize transitions effectively, emphasizing integrated mental-physical health care.
A 47-year-old man on long-term anticoagulation for PE 3 months ago (provoked by long-haul flight and obesity) presents with new pleuritic chest pain and dyspnea on exertion. He is taking apixaban 5 mg twice daily; he admits missing several evening doses over the last week. No hemoptysis. Vitals: BP 132/80, HR 108, RR 22, SpO2 93% RA. Exam shows mild right calf tenderness. Labs: INR 1.1, creatinine 0.9 mg/dL (eGFR 95 mL/min/1.73 m²), troponin negative. He has no contraindications to contrast. What is the most appropriate next step in management for this patient?
Explanation: This question tests the understanding of pulmonary embolism management and anticoagulation follow-up in a clinical context relevant to USMLE Step 3. The principle focus is on applying clinical guidelines for anticoagulation management and recognizing complications arising from therapy. In this scenario, factors such as the patient's missed apixaban doses, new pleuritic chest pain, dyspnea, tachycardia, and hypoxia are critical for decision-making. The correct answer addresses these factors by suggesting CT pulmonary angiography to evaluate for recurrent pulmonary embolism, demonstrating the application of clinical guidelines for suspected recurrence in nonadherent patients. A common distractor might suggest reassurance without imaging, which fails to consider the risk of recurrence due to missed doses. To prepare for similar questions, students should focus on understanding anticoagulation management guidelines, recognize symptoms indicative of complications, and practice applying this knowledge to case scenarios.
A 79-year-old man with severe peripheral artery disease and a history of a 6.0 cm abdominal aortic aneurysm underwent an endovascular aneurysm repair two weeks ago. He presents to the clinic today with nausea, poor appetite, and worsening blood pressure control. Laboratory studies show a serum creatinine of 2.8 mg/dL (baseline 1.2 mg/dL). Physical examination is notable for a purplish, reticular, lace-like rash on his feet. A complete blood count reveals a peripheral eosinophilia of 8%. Which of the following is the most likely diagnosis?
Explanation: This patient's presentation is classic for cholesterol crystal embolization syndrome (atheroembolism), a complication of angiography or vascular surgery in patients with severe atherosclerosis. Manipulation of the aorta can dislodge cholesterol crystals that embolize to small arteries. The classic triad includes acute or subacute renal failure, livedo reticularis (the described rash), and peripheral eosinophilia. The timing of onset, typically weeks after the inciting procedure, helps distinguish it from contrast-induced nephropathy, which occurs within days.
A 62-year-old African American man with a new diagnosis of hypertension presents for management. He has no other chronic medical conditions. His average blood pressure from three separate office visits is 155/95 mmHg. You are discussing treatment goals with him. According to the 2017 ACC/AHA guidelines for the prevention, detection, evaluation, and management of high blood pressure, which of the following is the recommended blood pressure goal for this patient once treatment is initiated?
Explanation: The 2017 ACC/AHA guidelines redefined hypertension and established new treatment goals. For adults with confirmed hypertension and known cardiovascular disease or a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher, a blood pressure target of less than 130/80 mmHg is recommended. For adults without these risk factors, a target of <130/80 mmHg may be reasonable. The previous JNC8 guideline recommended <140/90 mmHg for this patient, and <150/90 mmHg for patients over 60, making these common but outdated distractors. A goal of <120/80 mmHg is generally not recommended as a target, although it was a goal in the SPRINT trial for a specific high-risk population.
A 36-year-old G2P2 woman presents 6 months postpartum with persistent fatigue, difficulty losing weight, and an inability to breastfeed since delivery. Her second delivery was complicated by a severe postpartum hemorrhage requiring multiple blood transfusions. Since the delivery, she has not had a menstrual period. Physical examination is unremarkable. A deficiency in which of the following hormones is the most likely primary cause of her symptoms?
Explanation: This patient's history of severe postpartum hemorrhage followed by lactation failure, amenorrhea, and fatigue is a classic presentation of Sheehan syndrome, or postpartum pituitary necrosis. The ischemic injury to the pituitary gland leads to deficiencies of multiple pituitary hormones. The inability to breastfeed (agalactia) is a direct result of prolactin deficiency. Amenorrhea is due to gonadotropin (FSH/LH) deficiency, and fatigue can be caused by TSH and/or ACTH deficiency. Prolactin deficiency is one of the earliest and most common manifestations.
A 68-year-old man is hospitalized after an ischemic stroke that resulted in moderate left-sided hemiparesis and dysphagia. He is now medically stable and requires intensive rehabilitation. He is motivated, has a supportive wife, and their home can be modified for accessibility. The case manager is discussing discharge options with the physician and family.
Which discharge destination is most appropriate to maximize this patient's functional recovery?
Explanation: An acute inpatient rehabilitation facility (IRF) is the most appropriate setting. IRFs are required to provide at least 3 hours of intensive therapy per day, 5 days a week, under the close supervision of a rehabilitation physician. Given the patient's acute stroke, motivation, and potential for significant functional gain, he is an ideal candidate for this high-intensity level of care. A SNF provides less intensive therapy. A LTACH is for patients with complex medical needs requiring extended hospitalization. Home health therapy is not intensive enough for a patient with moderate deficits immediately post-stroke.
A 71-year-old man with chronic CAD is admitted with a non-ST-elevation myocardial infarction (NSTEMI). He undergoes successful PCI with a drug-eluting stent to the obtuse marginal artery. His ejection fraction is preserved at 55%. His home medications included aspirin and atorvastatin. At discharge, he is prescribed aspirin, clopidogrel, atorvastatin, and lisinopril.
Which of the following additional medications should be prescribed for long-term secondary prevention?
Explanation: Beta-blockers are a cornerstone of post-MI care. They have been shown to reduce mortality, reinfarction, and sudden cardiac death. They should be initiated in all patients post-MI unless contraindicated. The benefit is most established in patients with reduced ejection fraction, but they are still recommended for at least three years in patients with preserved EF. Aldosterone antagonists like spironolactone (A) and eplerenone (D) are indicated post-MI only in patients with an LVEF ≤40% and either heart failure symptoms or diabetes. Long-acting nitrates (C) are used for symptom control of angina and do not provide a mortality benefit.
A 63-year-old man has CKD stage 4 for 6 years from diabetes; he follows low-sodium diet and takes losartan 100 mg daily, amlodipine 10 mg daily, insulin, and atorvastatin. He reports no symptoms. BP is 130/76 mm Hg. Exam shows mild pedal edema. Labs: creatinine 3.0 mg/dL, eGFR 20 mL/min/1.73 m², K 4.7 mEq/L, HCO3 22 mEq/L, Ca 8.8 mg/dL, phosphate 5.1 mg/dL, PTH 320 pg/mL. Which complication is this patient at highest risk for?
Explanation: This question tests chronic kidney disease management skills, specifically focusing on identifying risks for mineral bone disorder complications 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 elevated PTH and hyperphosphatemia indicate secondary hyperparathyroidism, increasing risk for bone disease. The correct choice, secondary hyperparathyroidism with renal osteodystrophy, accurately reflects current guidelines for recognizing CKD-MBD risks in stage 4, demonstrating the student's understanding of appropriate clinical interventions. A common distractor may suggest rapidly progressive GN, which is unlikely without acute changes, highlighting a frequent misconception. To improve understanding, students should focus on guidelines for CKD complications, regularly review PTH and phosphate levels, and practice predicting long-term risks in renal patients.
A 38-year-old man who is 9 months post-kidney transplant presents with a progressive rise in his serum creatinine from a baseline of 1.5 mg/dL to 2.4 mg/dL over the past 6 weeks. He has no other symptoms. His immunosuppressive regimen is tacrolimus, mycophenolate, and prednisone. A quantitative urine PCR is positive for BK polyomavirus with a viral load of 100,000 copies/mL. A renal biopsy is pending. What is the most appropriate initial management step?
Explanation: This patient has BK virus-associated nephropathy (BKVAN), a significant cause of allograft dysfunction. The cornerstone of management is a reduction in overall immunosuppression to allow the host immune system to clear the virus. This is typically achieved by first reducing or discontinuing the antimetabolite agent (mycophenolate mofetil or azathioprine). Increasing immunosuppression would worsen the viral replication. Antiviral agents like cidofovir have significant toxicity and are reserved for severe cases unresponsive to immunosuppression reduction. Switching to sirolimus has been studied but is not the standard initial step.
A 44-year-old woman who was treated for a large, bilateral pulmonary embolism 8 months ago with a 6-month course of rivaroxaban now presents with progressive exertional dyspnea. Her oxygen saturation is 96% on room air. An echocardiogram reveals an estimated right ventricular systolic pressure of 60 mmHg and right ventricular dilation. What is the most appropriate next step in diagnosis?
Explanation: This patient's presentation is highly suspicious for chronic thromboembolic pulmonary hypertension (CTEPH), a serious complication of acute PE. The initial screening test of choice for CTEPH is a ventilation-perfusion (V/Q) scan due to its high sensitivity; a normal V/Q scan essentially rules out CTEPH. While CTPA may show signs of chronic PE, it is less sensitive than a V/Q scan. Right heart catheterization is the gold standard for confirming the diagnosis of pulmonary hypertension and assessing its severity, but it is an invasive procedure performed after non-invasive screening suggests the diagnosis. A six-minute walk test assesses functional capacity but is not diagnostic.
A 14-year-old girl with oligoarticular juvenile idiopathic arthritis (JIA) has been treated with weekly methotrexate for two years. For the past 12 months, she has had no signs of active arthritis on examination, and her inflammatory markers are normal. She has had no uveitis on routine ophthalmologic screening. Her parents ask if she can stop her medication.
What is the most appropriate counseling regarding her methotrexate therapy?
Explanation: The management of JIA involves achieving and then maintaining remission. While a 12-month period of inactive disease is an excellent milestone, current consensus suggests continuing the disease-modifying antirheumatic drug (DMARD) for a period of sustained remission (often 6-12 months) before attempting a gradual taper. Discontinuing abruptly after achieving remission is associated with a high rate of disease flare. Therefore, continuing the medication for a further period before considering a trial of weaning is the most prudent approach.
HPI/PP Visit: 36F G2P2, 6 weeks postpartum, requests contraception. History: prior DVT 5 years ago after surgery; completed anticoagulation. Not breastfeeding. No other risks. Wants a “low-maintenance” option. Interpregnancy: plans no more children but unsure about permanent methods. 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 contraception in a patient with prior DVT. The clinical scenario highlights the need for low-thrombotic risk methods. The correct answer is based on CDC guidelines which recommend offering levonorgestrel IUD or etonogestrel implant in such situations to ensure optimal patient outcomes. A common distractor might suggest prescribing combined oral contraceptives for cycle control, which fails to address the key aspect of care by increasing thrombotic risk. 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 48-year-old woman is evaluated 4 months after a kidney transplant. Her immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and a tapering dose of prednisone. She reports increased thirst and urination. Laboratory studies show a fasting blood glucose of 152 mg/dL and a hemoglobin A1c of 7.4%. She had no history of diabetes prior to her transplant. This patient's condition is most likely a side effect of which two of her medications?
Explanation: New-onset diabetes after transplantation (NODAT) is a common metabolic complication. The risk is significantly increased by certain immunosuppressive agents. Both glucocorticoids (prednisone) and calcineurin inhibitors (especially tacrolimus) are known to be diabetogenic. Prednisone induces insulin resistance, while tacrolimus is directly toxic to pancreatic beta cells. Mycophenolate mofetil is not significantly associated with the development of NODAT. Therefore, the combination of tacrolimus and prednisone is the most likely cause of this patient's hyperglycemia.
History & Lifestyle: 25-year-old woman for wellness visit. • Sexually active with multiple partners; inconsistent condom use. • No prior HIV test. • No injection drug use. • No symptoms. Family History: Noncontributory. Preventive Care Review: Vaccines reviewed; Pap up to date. She asks if HIV testing is recommended without symptoms.
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 25-year-old woman with multiple partners has no prior HIV test, the recommended screening is one-time HIV Ag/Ab test, aligning with USPSTF guidelines. Choice A is correct because it matches USPSTF recommendations for screening all adults aged 15-65 at least once. Choice D is incorrect because it suggests no screening unless symptomatic, ignoring routine recommendations. 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 67-year-old man with chronic kidney disease stage G3b (eGFR 42 mL/min/1.73m²), type 2 diabetes, and hypertension has no prior history of cardiovascular disease. His fasting lipid panel shows an LDL cholesterol of 135 mg/dL. What is the most appropriate management for his dyslipidemia?
Explanation: According to the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, adults aged 50 years or older with CKD and an eGFR less than 60 mL/min/1.73m² but not on dialysis should be treated with a statin or statin/ezetimibe combination. This recommendation is based on their high cardiovascular risk, irrespective of the baseline LDL cholesterol level. A moderate-intensity statin like atorvastatin 20 mg is an appropriate choice.
History & Lifestyle: 10-year-old girl presents for school physical. • No chronic disease; no meds. • Up to date on vaccines except influenza this season. • Lives with grandmother who smokes indoors. Family History: Asthma in sibling. Preventive Care Review: No respiratory symptoms; normal exam. Parent asks what preventive action best reduces future health risk.
What is the next best step in preventive care 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 10-year-old girl is exposed to indoor secondhand smoke, the next best step is counseling the household on eliminating secondhand smoke exposure, aligning with AAP and USPSTF guidelines. Choice A is correct because it matches recommendations to reduce secondhand smoke to prevent respiratory issues and other risks. Choice D is incorrect because it suggests vaping as safer, which is not recommended and poses risks. 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.
An 88-year-old woman with end-stage renal disease, advanced dementia, and severe peripheral vascular disease is admitted with uremic encephalopathy. The medical team discusses renal replacement therapy with her son, who is her healthcare proxy. The son is concerned that chronic hemodialysis will be a significant burden and may not improve his mother's quality of life, given her cognitive and functional decline. He asks about other options. What is the most appropriate response?
Explanation: This question tests your understanding of shared decision-making and ethical approaches to life-sustaining treatments in patients with multiple serious comorbidities. When facing complex end-of-life decisions, the goal is to align medical interventions with the patient's values and goals while avoiding both premature abandonment of potentially beneficial care and inappropriate prolongation of suffering. The time-limited trial approach in option D represents best practice in this scenario. It acknowledges the uncertainty about whether dialysis will meaningfully improve this patient's quality of life while respecting the family's concerns about treatment burden. A time-limited trial allows the team to assess her response to dialysis over a defined period (typically weeks to months) and then reevaluate based on functional improvement, symptom relief, and quality of life measures. Option A is inappropriately coercive and fails to engage in meaningful shared decision-making. While uremia can be fatal, presenting death as inevitable without dialysis doesn't address the family's legitimate concerns about treatment burden versus benefit. Option B, while potentially informative, doesn't directly address the family's specific concerns or provide a clear path forward. Statistical data alone rarely resolves difficult individual decisions. Option C incorrectly assumes that dementia automatically disqualifies someone from dialysis. While advanced dementia affects prognosis and quality of life considerations, it doesn't create an absolute contraindication. Remember that time-limited trials are valuable tools when the benefit-burden ratio of an intervention is unclear. They provide a structured way to "try and see" while maintaining the option to discontinue if goals aren't met.
A 7-year-old boy with sickle cell disease (HbSS) is seen for a health maintenance visit. He is taking penicillin prophylaxis and folic acid. His medical history is notable for three hospitalizations for vaso-occlusive pain crises in the past 18 months, with the most recent being 4 months ago. His last transcranial Doppler ultrasound was normal. His spleen is not palpable.
Which of the following interventions is most likely to reduce the frequency of his pain crises?
Explanation: Hydroxyurea is a disease-modifying therapy that increases the production of fetal hemoglobin (HbF), which interferes with the polymerization of sickle hemoglobin. It is indicated for children with sickle cell anemia (HbSS) who experience frequent vaso-occlusive crises (typically defined as ≥3 moderate-to-severe crises in a 12-month period). This patient meets the criteria, and initiating hydroxyurea is the most effective intervention to reduce the frequency of both pain crises and acute chest syndrome.
A 39-year-old man who is treated with oral naltrexone 50 mg daily for alcohol use disorder is brought to the emergency department after a fall. He has a displaced bimalleolar ankle fracture and is in 10/10 pain. He took his naltrexone dose this morning.
Which of the following is the most appropriate initial approach to managing his acute pain?
Explanation: Naltrexone is a competitive opioid antagonist that will block the effects of standard doses of opioid analgesics like morphine. The most effective strategy is to use non-opioid modalities. A combination of a systemic non-opioid analgesic (like ketorolac) and regional anesthesia (like a popliteal and saphenous nerve block for an ankle fracture) can provide excellent pain control without relying on opioid receptors. While very high doses of potent opioids might overcome the blockade, this is a high-risk strategy. Delaying analgesia is unethical. Standard opioid doses will be ineffective.