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kaplan Step 1 Item Strategies How to answer Qbanks
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1, A 16-year-old girl comes from a very religious family and denies any sexual activity. She has severe
acne unresponsive to previous treatment of conventional therapy. Which of the following laboratory studies
should be performed by prior to prescribing isotretinoin?
A) Lipid profile
B) Liver function studies
C) Measurement of serum urea nitrogen (BUN)
D) Complete blood count
E) Measurement of urine b-hCG
STRATEGY: Understanding what's really being asked. You are dealing with a young woman who may be
sexually active, therefore, it is always necessary to check for pregnancy before prescribing a drug.
Knowing this, you could correctly answer this item (E) without knowing much if anything about the specific
properties of isotretinoin.
2, A 30-year-old woman with no significant past medical history presents with serosanguinous discharge
from one of her breasts. She is not lactating and has no family history of breast disease. Physical exam
reveals a moderate amount of serosanguinous discharge expressed from the left nipple. Cytological exam
of the fluid is negative. What is the most appropriate next step in management?
A) Advise the patient to return in 6 months for re-evaluation
B) Obtain a mammogram
C) Perform a chest x-ray
D) Perform an excisional biopsy of the retroareolar area
E) Perform a needle biopsy of the retroareolar area
STRATEGY: This item illustrates one of the common themes in clinical items--understanding the proper
sequence of lab ordering. Here, while a mammogram may not provide definitive diagnostic information
about the patient's problem, it is standard procedure to order a mammogram before ordering more
invasive or expensive tests.
3. A 4-year old boy is admitted with respiratory difficulty. He has had several previous admissions for
pneumonia. History is significant for the failure to pass meconium at birth. Temp is 101.1 F, respiration
rate is 35. Physical exam reveals a thin, malnourished boy < Sth percentile for height and weight. Rales
heard over the left lower lobe and percussion over the region is dull. Sputum culture
grows Pseudomonas aeruginosa. Which test would confirm the diagnosis?
A) Bronchoscopy
B) Chloride sweat test
C) CT scan of the thorax
D D-xylose absorption test
E) Pulmonary function tests
STRATEGY: This item illustrates the USMLE policy of portraying diseases in their most classical
presentation. The boy's history and symptoms are textbook indications of CF, so the answer is B. Notice
also, however, that as with many other clinical items, one doesn't receive direct credit for knowing what
the boy has, but for reaching that conclusion THEN using that knowledge to answer what's actually being
asked, which is what test would clinch that diagnosis,
4, An 8-year-old boy is seen for a routine check-up. His vaccinations are current and he has been healthy.
The child is at the Sth percentile for height and at the 20th percentile for weight. His thumbs are
disproportionately small compared to his other digits. There are several round, smooth, flat, light-brown
areas ranging in size from 3 to 5 cm on his trunk and extremities. For which of the following genetic
disorders is the child most likely at risk?
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A) Down's syndrome
B) Fanconi's syndrome
€) Fetal alcohol syndrome
D) Trisomy 18
C) Cri du chat
STRATEGY: If you have even the most general knowledge of the symptoms of Down's, Fetal alcohol,
‘Trisomy 18 and Cri du chat, then it is obvious that these severe syndromes would have been evident and
diagnosed long before this child reached the aac of 8. By exclusion, then, if not through knowledge of
Fanconi's syndrome, this would be the best answer (B)
5, A 62-year old man is complaining of fatigue of 4 months duration. He was recently seen by another
physician for nephrolithiasis. He takes no medications and is otherwise healthy, except for mild
hypertension controlled with diet, CBC is normal. Which of the following lab values would suggest primary
hyperparathyroidism?
A) Decreased calcium, decreased phosphorus, and increased parathyroid hormone
B) Decreased calcium, increased phosphorus, and increased parathyroid hormone
) Increased calcium, decreased phosphorus, and increased parathyroid hormone
D) Increased calcium, increased phosphorus, and increased parathyroid hormone
E) Increased calcium, decreased phosphorus, and decreased parathyroid hormone
STRATEGY: This item illustrates how even on Step 2 or Step 3, you could be asked basic science
information. This item also shows how a straightforward endocrine physiology question (The final sentence
in the stem), can be made to "look" clinical but attaching a vignette introduction. But none of that
information Is necessary to answer the question, The correct answer is C.
6. A 52-year old man with a ten year history of hypertension complains of abdominal and back pain for the
past 6 months, a 10 pound weight loss and greasy, foul-smelling stools. He smokes 2 packs of cigarettes
and drinks a pint of whiskey/day. On physical exam, he is afebrile with mild epigastric tenderness but no
guarding, rigidity, or distension. Bowels sounds are present and rectal exam is normal. Hematocrit: 48%,
sodium: 141 mEq/L, potassium: 3.9 , mEq/L, glucose: 148 mg/dl, ALT: 16, AST: 24, albumin: 4.7 g/dl,
prothrombin time: 11 seconds. Chest x-ray is normal, abdominal plain film shows pancreatic calcifications,
Which of the following is most likely responsible for his weight loss?
A) Alcoholic hepatitis
B) Duodenal ulcer
C) Gastric ulcer
D) Pancreatic insufficiency
E) thiamin deficiency
STRATEGY: People who have really struggled to do well on multiple choice exams before often carry
around some emotion about having to take these kinds of tests. Sometimes they feel items are designed
to trick them into choosing wrong answers. Here, such experiences would lead to avoiding answer D
because the stem lists “pancreatic calcifications," so the suspicious test-taker reasons that this couldn't
possibly be the correct answer and must be there to lure them. They choose another answer, and get the
item wrong. Notice also how the true distractors (wrong answers) each agree with some part of the
findings or history clues--the patient drinks heavily, so A and E relate to this fact. The patient has
abdominal symptoms, so B and C relate to those symptoms. In a well-written test, nearly every distractor
fits at least part of the stem information, but only the correct answer fits ALL the clues given in the stem.
7. A neonate has a flat, dark-pigmented area of skin over the sacral region.
The area is roughly oval, has a clearly defined border, and differs from,
surrounding skin only in ‘color. Which of the following is the most
likely diagnosis?
A) Diastematomyelia
B) Mongolian spot
C) Nevus flammeus
D) Pilonidal cyst
E) Spina bifida
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STRATEGY: Using reasoning strategies doesn't ever guarantee a correct answer. However, they allow you
to extrapolate from what you recall to the specifics of a given question. Here, if you didn’t know the
answer (B), you could still probably eliminate E as the findings would be more drastic for spina bifida. You
might also reason that it wouldn't be a cyst as the stem states that the area differs only in color and with
a cyst, you would expect there to be a palpable mass as well. Knowing some word structure might help
you eliminate C because flammeus suggests either redness or heat, which aren't present in the stem
clues. This would leave you with a guess between A or B and B is correct. Over a long test, using these
techniques yields more correct guesses and a higher score.
8, A 55-year-old woman with no significant medical history complains
of difficulty in keeping her balance. Cranial nerve, motor and mental
status exam are all within normal limits. There is diminished
proprioception in the joints of all 4 extremities, with a greater deficit
‘on the right side, She is able to stand with a narrow base with her arms
extended and eyes open. However, when she stands in a similar manner with
her eyes closed, she immediately begins to fall. Which of the following is
the most likely site of the lesion?
A) Cerebellum
B) Cerebral cortex
) Peripheral nerve
D) Posterior column
E) Pons
STRATEGY: I used a combination of strategies to figure out this item, even though I've never
studied neuroanatomy. This is 2 problem with balance, so for that reason, it isn't likely to be C because
peripheral nerves aren't CNS. It also isn't likely to be B, since the cortex functions involve higher order
thought and this is a balance or coordination, not a thought disrupting problem. The correct answer is D,
and I chose it because of a mnemonic I heard from a med student many years ago, that the body, like a
temple, stands because of its "columns."
9. A 20-year-old football player is sent to the campus health clinic by his coach after
complaining of neck pain following a hard tackle during
practice. He has a normal neurological exam, but his posterior neck is
tender. Which of the following would be the best initial step in management?
A) Administer non-steroidal anti inflammatory agents
B) Apply a hard-cervical collar and immobilize his spinal cord
C) Apply a soft cervical collar and order bed rest
D) Send him to the hospital for cervical spine x-ray
E) Apply ice directly to the affected area
STRATEGY: This item illustrates the theme of recognizing potentially serious findings and dealing with them
first. The test-writer has hidden the seriousness, though, by making the situation a campus clinic rather
than an emergency room. Use a systematic decision-making process by asking yourself first, What do I
know? In this case, do I really know the extent of the young man's injuries here? No? Then it is wisest to
act cautiously by applying a hard collar until the injuries can be further explored at a hospital (answer B).
10. A 52-year-old physician whom you know socially has taken secobarbital, 2 g daily, for 7 years despite
several attempts to stop using the drug. He has been abstinent from alcohol for 10 years. The patient
weighs 72 kg (158 Ib). Exam shows no abnormalities. Which of the following is the most appropriate next
course of action?
A) Detoxification as an outpatient and referral for group treatment
B) Discontinuation of secobarbital and prescription for a benzodiazepine
in equivalent doses
C) Hospitalization for detoxification
D) Psychotherapy
E) Suggest that he gradually reduce the dosage of secobarbital
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