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1)Location: Office
Presenting complaint: A 25-year old white female presents with burning

Vitals: Pulse: 80/min, B.P: 130/80 mm Hg, Temp:990F, R.R:14/min, Height: 67

inches (167.5 cm), Weight: 79 Kg (173.8 lbs).
HPI: A 25-year-old personal secretary at a local office presents with the

complaints of three days of burning micturition, urgency, and frequency. She
had to pass urine 10 times yesterday. She also complains of suprapubic

discomfort. There is no vaginal discharge, fever, hematuria, or flank pain. She
has no previous history of STD or UTI. ROS is unremarkable. She has no known

allergies. Medications: None. SH: She is a personal secretary at a local office.
She has been married for five years and has no children. She has been smoking

10 cigarettes for the last seven years and drinks alcohol on weekends. She is
sexually active in a monogamous relation with her husband. They have not been

practicing contraception. Her last menstrual period was 3 weeks ago.
How do you approach this case?

This young female has dysuria. Her dysuria may be due to acute pyelonephritis,
acute cystitis, acute pelvic inflammatory disease, acute urethritis, or acute

cervicitis. You should come up with the differential diagnosis of a dysuria in a
young woman. Now, perform a focused physical examination on this patient.

Order physical examination:
Pelvic exam

Here are the findings:
Suprapubic tenderness present

Normal Pelvic examination
No Urethral and vaginal discharge
No costovertebral angle tenderness

Small discussion:
This is probably a straightforward case of acute cystitis. The patient has no

systemic signs of infection. So, she probably does not have acute
pyelonephritis. A patient with pyelonephritis usually presents with a history
of fever, chills, and flank pain. For acute uncomplicated pyelonephritis, oral

ciprofloxacin for out-patients or IV ceftriaxone for hospitalized patients is
appropriate therapy. The duration of treatment is usually 14 days. This patient
is in a monogamous relationship with her husband and there is no history of
vaginal discharge, so conditions like acute urethritis, cervicitis or acute PID
are highly unlikely. A single oral dose of azithromycin or a 7-day course of
doxycycline can be administered for chlamydial genital tract infections. For
gonococcal genital tract infections, a single IM injection of ceftriaxone is the

treatment of choice. Begin therapy for acute cystitis after confirming the
diagnosis of acute cystitis by demonstrating pyuria on urine analysis. Cultures

are generally not required for acute uncomplicated cystitis. Treatment with
3-day TMP-SMZ is appropriate.

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fluorescent antibody of induced sputum. If sputum induction is nondiagnostic or
cannot be performed, then fiberoptic bronchoscopy with bronchoalveolar lavage

(BAL) is recommended, with or without a transbronchial biopsy.

Repeatedly positive ELISA should be confirmed with western blot to make the
diagnosis of HIV. PCP is often associated with CD4 count of less than 200

cells/mm3 and an elevated lactate dehydrogenase level (LDH). The TMP-SMX remains
the initial drug of choice. Mild PCP is treated oral

trimethoprim-sulfamethoxazole. Patients with severe pneumonia or those who
cannot tolerate the drug orally should receive intravenous therapy. High-dose
therapy is associated with hyperkalemia (Trimethoprim acts as a potassium

sparing diuretic).

When to use steroids?
Corticosteroids along with TMP-SMX have significantly decreased the mortality

associated with PCP, when used in moderate to severe cases of PCP. It is used
when a Pa O2 is 70 mmHg or less, and/or an A-a O2 gradient of 35 mmHg or more on

room air

When to admit the patient?
Mild-to-moderate disease - Patients usually have milder symptoms and

nontoxic in appearance. They are not hypoxic; CXR may even be a normal.
Outpatient TMP-SMX is the treatment of choice.

Moderate-to-severe disease - Patients presents with severe respiratory distress,
and hypoxemia. CXR may be markedly abnormal. Inpatient management with IV

TMP-SMX should be considered. Admit patient to ward for moderate to severe
disease (ICU if patient unstable).

ABG, stat

LDH, routine
TMP-SMX, PO (use IV if hypoxemia is present)

Western blot testing for HIV

PaO2 is 77mmHg
Positive western blot for HIV

Once the diagnosis of HIV infection has been established, CD 4 count and viral

load should be measured to assess the severity of the disease and rate of

All HIV patients should get the following investigations:
CBC with diff, at the time of diagnosis and for every 3-6 month intervals

(30-40 % of HIV patients will have anemia, leukopenia, lymphopenia, and

SMA 12 should be obtained initially as it will be useful as baseline.
Yearly VDRL or RPR - Because of high association of coinfection

All patients should be checked for hepatitis serology, which include HBsAg,
anti-HBc, and anti-HCV.

Toxoplasma serology is useful to begin prophylaxis and to differentiate it
from other neurological complications.

The CDC recommends routine testing with PPD initially and annually in high
risk patients if the initial test is negative.

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1. BMP Q 2-4 hours, then Q 8-12hours, then Q day
2. ABG Q 2 hoursx2

After 4 hrs
1. Stop 0.9% NS and give ½ Normal saline, IV, continuous
Monitor potassium deficiency and add IV potassium chloride as needed

Consider antibiotics if the precipitating cause is an infection, get a chest X-ray, sputum gram stain, and
culture/sensitivity; obtain blood cultures, U/A and urine cultures.

Once nausea is decreased, start oral fluids.
Once the patient is stabilized transfer to ward/floor.

The ComputerUSMLE step 3 General information:

This section is intended for those preparing for the USMLE Step 3 examination.
We have tried to put all of the important information into one place, so it’s

easily accessible for you.
First of all, don't believe those who say the Step 3 is easy. It may be easy

for AMG for a variety of reasons, but not so for IMGs. The exam is difficult,
but doable. You should plan ahead and study as much as you can. How much time

you need depends on your situation. If you have taken step-2 a few years ago
and have not studied since, you probably need more time. If, on the other

hand, you completed your step 2 a few weeks or months ago, then you need less
time. Most applicants study between two-four months.

After figuring out your timetable, you need to get a few good sources to
study. There are lots of books, CDs, and study courses available for step 3.

Obviously, you won’t have enough time to read all of them. You should select a
couple of sources and stay with them. Most books or CDs give you the same
information in different styles or formats, but the material is basically the

same. You need some reference books to look things up. CMTD and Washington
manuals are pretty good sources.

The Computer Based Case Simulations (CCS) currently comprises about 25% of the

Step 3 examination. At this time, it consists of ten cases with 20- 25 minutes
assigned to each case.

Examinees manage the case without prompting, using a variety of diagnostic and
treatment options. As simulated time passes, the patient's status will change

based on the response to your management decisions. Acute cases may need to be
managed in a short period of time, while patients with chronic problems will

require management over weeks or months of simulated time.
Each case begins with a brief description of the patient's appearance and
reason(s) for the visit. You may be following patients in both inpatient and

outpatient settings. To do well on this part of the Step 3, it is imperative
that you practice with the USMLE's CCS software. You can download the software

You will be judged on the actions taken, their sequencing, and timing. One

measure of your score will be whether the patient was subjected to unnecessary
testing or therapy. Also, an important consideration and evaluation will be
whether the patient was placed at serious risk as a result of your action or

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