usmle step 1-3......... www.cuckorea.com

[호주사랑]

 

USMLE Step 1

 A 32-year-old construction worker arrives in the emergency department after an accident on the job. The tendon of the biceps brachii at the elbow has been severed by a laceration that extends 2 cm medially from the tendon. Which of the following structures is likely to have been injured by medial extension of the laceration?

(A) Brachial artery

(B) Musculocutaneous nerve

(C) Profunda brachii artery

(D) Radial nerve

(E) Ulnar nerve

A 52-year-old man presents to his physician after a community health screening test reveals a fasting glucose of 170 mg/dL. Physical examination is remarkable for bronze skin pigmentation, hepatomegaly, splenomegaly, and limitation of motion in the second and third metacarpophalangeal joints of both hands. A liver biopsy obtained from the patient is shown above. The man has no known history of hemolytic anemia and takes daily multivitamins without minerals. Which of the following pigments is most likely present in the man's liver?

(A) Bilirubin

(B) Carotene

(C) Ferritin

(D) Lipofuscin

(E) Melanin

A 57-year-old woman with a history of hypertension and arthritis is referred to a rheumatologist for eval‎uation. A complete blood count (CBC) is normal, and a mini-chem panel shows no electrolyte abnormalities. Her erythrocyte sedimentation rate (ESR) is elevated, and an antinuclear antibody test (ANA) is positive. Further antibody studies are performed, and the results are shown below.

Which of the following diseases is suggested by these results?

Anti histones ( high titer)

Anti double stranded DNA, Anti single stranded DNA, Anti SSA, Anti SSB, Anti SCL70, Anti smith, Anti centromere, Anti RNP : not detected

(A) CREST syndrome

(B) Diffuse form of scleroderma

(C) Drug-induced lupus

(D) Sjogren syndrome

(E) Systemic lupus erythematosus

During a fight, a 32-year-old man is hit on the back of the neck with a chair. A CT scan reveals a bony fragment that penetrated the lateral portion of the dorsal columns. Which of the following functions would most likely be affected by this lesion?

(A) Fine motor control of the ipsilateral fingers

(B) Motor control of the contralateral foot

(C) Sweating of the ipsilateral face

(D) Proprioception from the ipsilateral leg

(E) Vibratory sense from the ipsilateral arm

A 15-year-old high school student and several of her friends ate lunch at a local Chinese restaurant. They all were served the daily special, which consisted of sweet and sour pork with vegetables and fried rice. All the girls developed nausea, vomiting, abdominal pain, and diarrhea within 6 hours of eating lunch. Which of the following organisms is the most likely cause of these symptoms?

(A) Bacillus cereus

(B) Clostridium botulinum

(C) Clostridium perfringens

(D) EHEC (enterohemorrhagic Escherichia coli)

(E) Staphylococcus aureus

(F) Vibrio cholerae

USMLE Step 2 CK

 A 42-year-old homeless man with no history of prior surgery presents with frequent vomiting and no passage of stool or flatus in the past 24 hours. His temperature is 100.8F. Physical exam reveals a tympanitic abdomen and a tender erythematous mass in the right groin. WBC count is 21,000, and an x-ray shows multiple air-fluid levels with no air visualized in the colon. Which of the following is the most appropriate next step in the management of this patient?< /SPAN>

(A) Colonoscopy to rule out obstructing carcinoma of ileocecal valve

(B) Incision and drainage of the groin mass

(C) Nasogastric suction and observation

(D) Passage of a nasogastric tube and schedule for immediate surgery

(E) Sedation and manual reduction of incarcerated hernia followed by observation

 A 5-year-old boy presents with dysphagia. He began complaining of a sore throat 5 hours ago and was unable to swallow solid food. He had gone to bed but awoke 3 hours later frightened, hot, and having difficulty breathing. On physical exam, his temperature is 103.2F, heart rate is 100, and respiratory rate is 42. The boy is frightened, sitting forward in his father's lap with his neck extended, and drooling with his tongue protruding from his mouth. Both inspiratory and expiratory stridor are prominent. Which of the following is the most appropriate next step in the management of this pati ent?

(A) Arterial blood gas analysis to assess degree of respiratory compromise

(B) Complete physical examination to identify other signs of illness

(C) Focused exam of oropharynx to identify the cause of his respiratory distress

(D) Immediate monitored transfer to the operating room for the placement of an artificial airway

(E) Immediate administration of aerosolized racemic epinephrine to reduce airway obstruction

Matching

(A) Amytal interview

(B) Buspirone

(C) Diazepam

(D) Electronconvulsive therapy

(E) Fluoxetine

(F) Haloperidol

(G) Lithium carbonate

(H) Nortriptyline

(I) Phenelzine

(J) Propranolol

(K) Trazodone

(L) Yohimbine

For each patient below, select the therapy most likely responsible for the observed side effect.

 A 70-year-old man being treated in an inpatient psychiatric unit develops short-term amnesia for the past 3 weeks. He has an impaired ability in simple arithmetic and cannot execute three-step commands.

 A 20-year-old patient in the psychiatric emergency room becomes violent. After treatment, he develops a sustained, powerful contraction of the right sternocleidomastoid muscle.

USMLE STEP 3

 A 31-year-old obese female with a history of asthma comes to your office complaining of severe shortness of breath and wheezing. She produces from her purse a number of active medications including a beclomethasone metered dose inhaler (MDI) and salmeterol MDI. She also appears to be taking zafirlukast daily. She tells you that she has been hospitalized many times for asthma flares and was once intubated. Her review of systems is pertinent for asthma attacks of increasing severity over the past few weeks but she denies any fever, cough, chills, or pleuritic chest pain. On exam, the p atient demonstrates audible expiratory wheezes with a markedly prolonged expiratory time. Her respiratory rate is 20-24/min and she is acutely short of breath, using accessory muscles of respiration to breathe. Her vital signs are otherwise stable. Which of the following is the most beneficial management of this patient?

(A) Obtain a chest radiograph to rule out pneumonia

(B) Obtain a peak flow estimate

(C) Albuterol nebulizer therapy in the office

(D) Refer the patient to the local hospital for admission

(E) Refer the patient to the local emergency room for eval‎uation and treatment

 A 69-year-old man is brought to the clinic for progressively worsening memory loss and confusion. The patient has a long history of hypertension and coronary artery disease. He has not seen a physician in a number of years and has not been taking any medications. The family reports a step-wise decline in his cognitive function over the past few years. He has long periods where he appears stable and then suddenly worsens over a few days. On physical examination, he is a thin but not cachectic appearing man with a blood pressure of 185/110 mm Hg. His physical examination is notable for a faint carotid pulsation on the left with a prominent right carotid bruit. He has an S4 gallop on precordial examination.

Which of the following is the appropriate first step in the management of this patient?

(A) Initiate donepazil therapy

(B) Initiate atenolol therapy

(C) Initiate warfarin therapy

(D) Order a carotid ultrasound study

(E) Order a head CT scan

 A 43-year-old African-American man comes to the clinic for the first time as part of a neighborhood-screening program for hypertension. He reports that he has no past medical history but has not seen a physician routinely for the past ten years. He smokes two packs of cigarettes per day but denies ethanol or any substance abuse. He takes no medicines regularly. The nurse measures his blood pressure as 165/90 mm Hg in the left arm while sitting. The physician has a long discussion with the patient concerning the possibility that his blood pressure has been elevated for some time and t hat he may need medical therapy in order to lower it to appropriate levels. A careful physical examination is performed looking for possible end-organ manifestations of long-standing untreated hypertension. Which of the following signs is suggestive of long standing hypertension?

(A) S3 gallup

(B) Abdominal bruit

(C) Carotid bruit

(D) S4 gallup

(E) Systolic ejection murmur

 A 19-year-old gravida 0 presents to the student health center complaining of lower abdominal pain and urinary urgency of three days duration. She has not had this condition before. She is sexually active, and sometimes uses condoms for contraception. She has intercourse about three times a week; her last intercourse was three days ago. Her last menstrual period was three weeks ago. Her periods are regular at 28-day intervals, and last about 5 days. She does not have any gastrointestinal symptoms. Her temperature is 101` (38.3`), pulse 100, respirations are 20/min, and her blood press ure is 100/60. On physical examination, the abdomen is soft, but there is tenderness to deep palpation in both lower quadrants with slight rebound tenderness as well. The liver, kidney, and spleen are not palpable. Bowel sounds are active. The vulva is clean; there is no evidence of discharge or irritation. The vaginal is well supported, uninflamed, and clean. The cervix is nulliparous, and there is a mucopurulent discharge in the os. A cervicovaginal PAP smear is taken. Cultures are also taken from the vagina and cervix. There is tenderness to cervical motion. The uterus is of normal size, shape and position. The adnexa are difficult to palpate, and are not well felt, but there is bilateral tenderness. Rectovaginal examination is confirm‎atory. Trichomonads are identified on microscopic examination of vaginal secretions. Her white blood count is 10,000 with a left shift; urinalysis shows 1-2 WBC, trichomonads, and 1+ proteinuria. Which of the following is the next best step in her management?

(A) Admit to the hospital for parenteral antibiotic treatment

(B) Begin 7 days of metronidazole, 500 mg TID po for the patient and her partner

(C) Order ceftriaxone 250 mg IM and doxycyline 100 mg b.i.d. po for 10 days

(D) Prescribe acetaminophen for pain and intermittent heat to the lower abdomen; re-eval‎uate when cultures return

(E) Schedule for a transvaginal ultrasound

 On the morning of the second day after delivering a 3,500-g infant, a 16-year old gravida 1, para 0 develops a temperature of 101?F (38.3캜). Her antepartum course was unremarkable. Membranes ruptured shortly after hospital admission and the onset of labor was spontaneous but desultory. Oxytocin augmentation was necessary. The first stage of labor was 22 hours; the second stage was 3 hours and 45 minutes. Delivery of the vertex was expedited by vacuum forceps over an intact perineum under pudendal block anesthesia. The placenta delivered spontaneously. Since delivering, she had been ambulating and eating well. Physical examination reveals a temperature of 102캟 (38.8캜), a pulse of 108 bpm, respirations 22/min, and a blood pressure of 110/60. Breasts are full with moderate colostrum secretion from the nipples. The abdomen is soft; there is no liver, kidney, or spleen palpable. The perineum is clean, and the lochia rubra has a foul odor. Pelvic examination is within normal limits for postpartum status except for uterine tenderness to motion and foul lochia. Examination of the extremities, including previous intravenous sites, is within normal limits. Which of the following is the next best step in her management?

(A) Begin oral methylergonovine, encourage fluid intake, re-eval‎uate in four hours

(B) Culture the lochia and start acetaminophen; await culture report

(C) Initiate imipenem/cilastatin intravenous therapy

(D) Order a CBC, encourage fluid intake, re-eval‎uate in four hours

(E) Start a first-generation cephalosporin orally

태그저장 취소

“침술, 메디칼 안된다”

- 미국 한의사(=침구사)는 더욱 기반확보에 큰 어려움을 겪을 듯!

가주 예산삭감 정책에 밀려

* 캘리포니아 주지사가 침치료를 보험지급에서 제외한다고 한 조치는 새삼스러운 것이 아니다. 본래 캘리포니아 주에서 한의사로 자칭하는 침구사란 면허증은, 의료보조인의 지위이다. 하지만 캘리포니아 침구사 면허증은  민간자격증인 NCCAOM 보다는 훨씬 권위가 높은 주정부 면허증 이다. 때문에 의사에게만 지급하는 의료보험을, 침치료를 전담하는 침구사(의료보조인)에게는 지급되지 않는 것은 당연한 법규정이라고 보는 시각이 많아졌다.

아직도 한국에서 미국 침구사 캘리포니아 면허증을 한의사로 잘못 인식하여, 정식 의사로 분류될 것이라는 혼돈을 하고 침구사 면허 시험을 준비하는 분들이 가끔 보이고 있다.  미국으로 건너가 낭패당하는 사태를 미연에 방지하기 위하여,  적극적인 미국 동양의학 제도의 실상을 계도하는 조치가 절실하다.  

또한 미국, 캐나다에서는 역시 자연의학 NMD 의사가 대체의학의 대표적인 의료인 직업으로 자리잡고 있다는 사실을 알려 보다 많은 한국 개업 한의사가 아메리카에서 의료인으로 대접받는 기반을 확보할 수 있도록 홍보를 해야 할 필요가 있다.

 --------------------------------------

지난달 아놀드 슈워제네거 캘리포니아 주지사가 서명한 2009~2010년 예산안에 정부보조 의료보험 메디칼(Medi-Cal)에서 침 치료 혜택을 제외하는 내용이 포함된 것으로 밝혀졌다.

캘리포니아 주정부는 400억달러가 넘는 재정적자를 해결하기 위해 전 부서에 걸쳐 총 150억달러에 이르는 긴축재정과 예산삭감 정책을 발표했고, 침 치료를 메디칼 대상에서 제외하는 내용이 포함됐다.

침 치료의 메디칼 폐지는 오는 7월1일부터 실시되며 침 치료 외에도 카이로프랙틱 치료와 심리상담, 검안, 치과 치료 등도 메디칼 대상에서 제외됐다.

가주한의사협회(회장 김갑봉)는 “침 치료는 지난 80년대부터 메디칼 대상으로 포함돼 저렴한 진료비와 우수한 치료효과로 환자와 보험사 모두에게 이득을 주었다”며 “어렵게 명맥을 유지해 오던 메디칼 침 치료 커버리지가 중단됨에 따라 한의사들은 물론 환자들도 피해를 입게 됐다”고 밝혔다.

메디칼은 침 치료를 선택 수혜사항으로 분류해 환자 1인당 최고 30달러까지 진료비 수가를 지급해 왔다. 가주한의사협회 남형각 사무국장은 “주정부가 메디칼 침 치료에 대해 지급하는 진료비가 1회에 5.75달러에 불과하다”며 “메디칼 침치료 폐지는 경제적인 문제보다는 정부 의료보험인 메디칼이 침 치료를 제외하면서 일반 의료보험에도 영향을 미치는 것이 더 중대한 문제”라고 지적했다.