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Master the Boards: USMLE Step 3, Second Edition ISBN 978160714-843-2

Please note the following updates and corrections:


Page Change
xiv Top 2 paragraphs (Step 3 examination structure):
Day 2 includes 144 items divided into 4 blocks of 36 questions. You will have 45 minutes to complete
each of these blocks. The time allotted for these blocks is 3 hours. The second day also includes 4
hours for 12 clinical case simulations (CCS), preceded by a 10-minute tutorial. CCS cases vary in
duration from 10 to 25 minutes. As with the first day, a minimum of 45 minutes of break time is
allocated for the day.
Traditional multiple-choice questions may be either single-item questions, multiple-item sets, or
cases. As of February 2012 the multiple-choice component also includes items with an associated
pharmaceutical ad or abstract. Each pharmaceutical ad or abstract will appear as a 2- or 3-item set.
You will see no more than 5 of these new item sets in your examination. Blocks with these new
item types will now contain 46 to 47 items in the block to allow more time for the new question
type. You will be notified at the beginning of the block if a new item set is included.
10 Sinusitis line 4: Streptococcus pneumoniae, . . .
15 Gonorrhea medications table: Cefixime oral deleted; no longer recommended by CDC.
27 Callout box: Echinocandins such as caspofungin . . .
28 Mycobacterium line 7, treatment: Clarithromycin and ethambutol . . .
89 Treatment #2 (acute severe hypercalcemia): Loop diuretics increase calcium excretion by the
kidney if urine is not being produced through hydration alone.
94 Treatment line 2 (pheochromocytoma): Without alpha blockade, patients blood pressure can
significantly rise intraoperatively.
162 Last line: They directly stimulate megakaryocytes.
235 Treatment line 2 (cryoglobulinemia): . . . ribavirin, and boceprevir or telaprevir.
237 Bullet 2: . . . loss of antithrombin III, protein C, and . . .
241 Euvolemic Status bullet 4: . . . drops sodium by 1.6 points for each . . .
285 Breathing bullet 1 deleted: Increase the oxygen concentration and flow rate.
286 Hypovolemic shock sub-bullet 1 deleted: The case will describe a pale, cold . . .
287 New callout box (trauma to localized sites): All impaled objects are to be removed in the OR
under a controlled setting.
288 Basal Skull Fracture bullet 3, sentence 2 deleted: Steroids will resolve the symptoms.
289 (1) Line 3 after practice question: . . . referred to as the lucid interval, but then . . .
(2) Acute Subdural Hematoma bullet 2 (management), sentence 1 deleted: Conservative
management is done with steroids.
(3) Three new callout boxes:
Epidural biconvex middle meningeal artery lucid interval.
Subdural crescent shaped bridging veins gradual loss of consciousness.
To rule out bleeds in the brain, order CT scans without contrast. Blood and contrast look
the same on CTs, giving a false positive.
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290 (1) New callout box (elevated ICP): Hyperventilation causes vasoconstriction and decreased
blood volume in the brain, lowering ICP.
(2) Management, Second-line measures sub-bullet 1, furosemide deleted: Mannitol: Use
very cautiously; it can reduce cerebral perfusion
292 (1) Diagnostic Testing (GI perforation): Diagnose with a supine and erect chest x-ray . . .
(2) Treatment, bullet 2 replaced:
IV antibiotics such as:
metronidazole and Cipro
second-generation cephalosporins (cefotetan or cefoxitin)
ampicillin-sulbactam
piperacillin-tazobactam
293 (1) New callout box (esophageal perforation): Classic presentation for perforation is after
endoscopy.
(2) New bullet after bullet 2 (obstruction): High-pitched bowel sounds
(3) New callout box (obstruction): Gastrografin is water soluble, unlike barium, which is
caustic if it extravasates.
294 (1) Text replaced under Diagnostic Testing (acute diverticulitis): The most accurate diagnostic
test is CT with contrast to look for abscess or free air. Fat stranding is common around the
inflamed bowel.
(2) New callout box (obstruction): Colonoscopy is absolutely contraindicated in acute
diverticulitis, as it raises the risk of perforation.
295 (1) Treatment (acute pancreatitis), pseudocyst sub-bullet 1 replaced:
If painless: Do not drain.
(2) Treatment (acute appendicitis), bullet 1 replaced:
Administer IV antibiotics before appendectomy:
Cipro AND metronidazole
Ampicillin/sulbactam
Levofloxacin AND clindamycin
Cefoxitin OR cefotetan
(3) New callout box (acute pancreatitis):
Amylase = highest sensitivity
Lipase = highest specificity
(4) New callout box (acute appendicitis):
Rovsings sign: palpation of LLQ increases the pain felt in RLQ.
298 (1) New callout box (acute cholecystitis): Murphys sign: pain on palpation of RUQ during
exhalation
(2) New callout box (acute ascending cholangitis): Reynoldss pentad: jaundice, fever,
abdominal pain, altered mental status, and shock

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299 (1) New content added above Pre/Postoperative Care:
Fecal Incontinence
Fecal incontinence is involuntary passage of bowel contents for at least one month in a
patient age > 3.
The diagnosis is made through a combination of clinical history combined with flexible
sigmoidoscopy or anoscopy (best initial test). The most accurate test is anorectal
manometry. Patients with a history of anatomic injury should undergo endorectal
manometry.
Treatment
Best initial treatment: Combine bulking agents (e.g., fiber) with biofeedback techniques
(e.g., control exercises and muscle strengthening exercises). The best next step is
endoscopic injection of dextranomer/hyaluronic acid in an effort to create a pseudo-
sphincter. This technique has reduced incontinence episodes by 50 percent. If this fails,
colorectal surgery is needed.
(2) First practice question deleted (A 72-year-old man . . .).
305 Imperforated Anus changed to Anal Atresia.
309 Meckel Diverticulum line 3: . . . lower abdomen. Surgical resection is the best therapy.
311 New callout box (fracture mgt): Tinels sign has greater specificity than Phalens sign.
314 (1) New callout box (plantar fasciitis): The pain in plantar fasciitis feels like a tack in the
bottom of the foot and resolves quickly after walking.
(2) Answer to practice question replaced (urologic emergencies):
Answer A. The most likely diagnosis is orchitis/epididymitis, so starting antibiotics is the best next
step in management.
315 Acute Epididymitis bullet 1: . . . with ceftriaxone and doxycycline.
317 (1) New callout box (aortic aneurysm):
Abdominal aortic aneurysm (AAA): one-time screening by ultrasonography in men age 6575 who
have ever smoked
(2) Answer choice A replaced in practice question: ACE inhibitors.
319 Arteriosclerotic Occlusive Disease bullet 2: the use of cilostazol and aspirin.
321 (1) At delivery bullet 1, text deleted (management of the newborn): 1 percent silver nitrate
eye drops or
(2) Before discharge (management of newborn), new bullets added:
Administer hepatitis B vaccine if mother is HBsAg negative
If mother is HBsAg positive, administer hepatitis IVIG along with the hepatitis B vaccine
325 Practice question line 1: . . . newborn boy who is jittery 30 minutes after a bath.
327 New callout box (RDS treatment): Lucinactant is the first synthetic peptide-containing
surfactant approved for treatment of neonatal RDS.
332 Lower callout box deleted (A lumbar puncture . . .).
333 Treatment bullets replaced (neonatal sepsis):
Empiric treatment of sepsis is to prescribe ampicillin and gentamicin until 48-to 72-hour cultures
are negative.
If meningitis is possible, add cefotaxime.
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334 (1) Diagnostic Testing bullet 2 (seizures): phosphorus deleted.
(2) Treatment bullets replaced with new paragraph (seizures):
Correct the underlying cause, including electrolyte abnormalities. For acute seizure, use lorazepam
or diazepam (rectally). Treatment for chronic seizures depends on type; with absence seizures, use
ethosuximide.
340 Enuresis lines 35:
. . . is more common in boys who are usually continent, occurring within 2 years of daytime
continence; address with behavior therapy. Diurnal enuresis (daytime wetting) is more common in
girls and is associated with a higher rate of urinary tract infections (UTIs). The most common causes
of diurnal enuresis are diabetes insipidus, UTI, seizure, constipation, and abuse.
341 Treatment section replaced (enuresis):
Best initial treatment: Behavioral and motivational therapy (limit liquids, use a bed alarm, never
punish the child) cures two thirds of patients.
If behavioral therapy fails: imipramine and desmopressin (to decrease the volume of urine
produced).
342 (1) Line 5 deleted (immunizations): Concurrent antimicrobial therapy.
(2) Bullet 3 replaced (influenza and yellow fever vaccine):
Yellow fever vaccine: Egg allergy does contraindicate.
Influenza vaccine: Egg allergy is no longer a contraindication. Patients 6 months with a known
egg allergy should receive trivalent inactivated influenza vaccine (TIV) followed by a 30-minute
observation period in a facility prepared to recognize and treat anaphylaxis. For patients with a
history of severe anaphylaxis to eggs should be referred to an allergy specialist to receive TIV.
343 (1) Active Immunizations table, hepatitis row: Hepatitis B: Ig plus vaccine; given at birth, 1
month, and 6 months
(2) Specific Routine table, hepatitis bullet 2: First dose of hepatitis B vaccine (HBV) . . .
347 (1) Top callout box: Best prevention against bronchiolitis . . .
(2) Prevention (bronchiolitis), 2 sentences appended:
High-risk patients include those with bronchopulmonary dysplasia and those born preterm.
General prevention methods include hand-washing, avoiding secondhand smoke, and avoiding sick
contacts.
350 New paragraph added after Treatment, bullet 4 (cystic fibrosis):
Ivacaftor (VX-770) is the first approved cystic fibrosis (CF) therapy that restores the function of a
mutant CF protein. It is recommended for all patients age 6 and older who carry at least one copy
of the G551D mutation. It has been shown to decrease sweat chloride levels, improve FEV
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,
decrease pulmonary symptoms and exacerbations, and improve weight gain.
New callout box (cystic fibrosis treatment):
G551D mutation is present in ca. 5% of CF patients and interferes with activation of CFTR chloride
channel. All CF patients should undergo genotyping to determine whether they carry the G551D
mutation.
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353 Hypertension sentence 1 replaced:
Hypertension in pediatrics is based on the nomogram and falls into 4 categories:
Normal: 90 percent
Pre-hypertension: > 90 to 95 percent
Stage I: > 95 to 99 percent
Stage II: 99 percent + BP 5 mm Hg
354 Diagnostic Testing (hypertension), kidney evaluation sub-bullet 4 deleted: Angiography for
plasma renin activity in renal veins and IVC
355 Lines 89 deleted (hypertension treatment): In the case of an adolescent with severe
hypertension . . .
356 Bullets appended to HUS box:
Monitor blood pressure for 5 years.
Monitor renal function with BUN/creatinine for 23 years after HUS.
357 (1) Lines 13 deleted.
(2) GERD practice question lines 5 6: . . . most appropriate intervention? (pharmacological
deleted)
(3) Last line (GERD practice question): e. Behavioral therapy
358 Last 2 sentences of practice question answer replaced (lines 58):
When this fails . . . and esophagitis. H2-receptors are considered first line in children because of
the safety profile. However, proton pump inhibitors tend to be more effective in suppressing
gastric acid production.
360 Last 5 lines replaced (pediatric UTI treatment):
Obtain voiding cystourethrogram (VCUG) and renal ultrasound in:
o Children of any age with 2 febrile UTI or
o First febrile UTI with any of the following:
Family history of renal or urological disease
Poor growth
Hypertension
Organism other than E. coli
361 (1) Answer choice B replaced in practice question: Trimethoprim-sulfamethoxazole.
(2) Answer explanation line 1: Amoxicillin deleted.
368 Diagnostic Testing bullet 2 (lead poisoning): Blood lead level (BLL) 5 mcg/dL is acceptable.
369 Treatment bullet 2, sub-bullet 1 (Hb disorders): . . . beginning at 3 months until 5 years . . .
380 (1) Practice question line 3: . . . < 2.2 MoM). Her test showed an elevation in maternal serum
alpha fetoprotein. On examination . . .
(2) Second Trimester table, diagnostic significance bullet 5: Trisomy 18
381 Practice question: A 38-year-old woman (G2 P1) is at 27 weeks gestation.
382 Head The Complicated Pregnancy replaced with Third Trimester Bleeding and following text
deleted to end of page.
383 Abruptio Placenta last sentence deleted: Amniotomoy and induction of labor decrease the
risk of DIC.
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384 Lines 24:
. . . segment. Types of placenta previa are complete previa (the placenta covers the entire os),
incomplete previa (the cervical os is only partially covered) and marginal (the placenta is near
but does not cover the os).
Placenta Accreta
If placental implantation occurs over . . .
Last 2 lines:
The following table summarizes causes and management of third-trimester bleeding.
386 Treatment bullet 1 (GBS): Intrapartum IV ampicillin
387 Toxoplasmosis:
(1) Prevention bullet 2 deleted: Perform a viral culture . . .
(2) Management bullet 1, sentence 2 deleted: If IgM and IgG are positive . . .
(3) Management bullet 2, line 2: . . . fetal/neonatal infection via amniocentesis.

Varicella:
(4) Practice question deleted.
(5) Prevention bullet 1: (Varivax III) deleted.
(6) Bullet 2:
Postexposure prophylaxis: VariZIG (purified human immunoglobulin with high levels of
antivaricella antibodies) within 10 days of exposure. VariZIG does not prevent infection . . . the
virus. (Note: VZIG is no longer available.)
388 Bullet 1 replaced (varicella treatment):
Maternal varicella (uncomplicated): Oral acyclovir to mother plus VariZIG to mother and
neonate
389 (1) Diagnostic Testing (CMV) bullet 2 deleted: Perform a viral culture . . .
(2) Treatment bullet appended:
CMV hyperimmune globulin may reduce the risk of congenital infection in pregnant women
with primary CMV infection.
(3) Practice question answer, sentence 2 deleted: The only other infection-related . . .
390 (1) Diagnostic Testing bullet 2 (HSV): of maternal blood (not screened routinely) deleted
(2) Prevention bullet 2 (HSV): . . . transmission if mother has active HSV lesion).
(3) Prevention bullet 3 deleted: Manage expectantly . . .
(4) Bottom callout box: Continue antiretrovirals in all pregnant patients.
391 (1) Prevention and Treatment (HSV) bullets 12 & related sub-bullets:
Triple-drug therapy (which must include ZDV):
Start triple therapy immediately, regardless of CD4 and viral load, to decrease risk
of transmission.
Intravenous intrapartum ZDV if viral load is high at time of delivery.
Combination ZDV-based ART for 6 weeks after delivery.
Give the infant prophylaxis against HIV, with 6 weeks of zidovudine
(2) Diagnostic Testing (syphilis) bullet 1, or MIIA-TP deleted.

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392 (1) Callout box added (HBV): HBeAg (+) prenatal transmission = 8090%
(2) Practice question answer: Mothers who are (+) for HBsAg, anti-HBe antibody, and . . .
393 Prevention (HBV) sub-bullet 2: . . . passive immunization and vaccine
395 (1) Maintenance therapy sub-sub-bullets (valvular disease treatment):
o First line therapy is methyldopa or labetalol (alpha and beta blocker that
preserves blood flow to uterus and placenta).
o Second line therapy is nifedipine (calcium channel blocker).
o Combination ZDV-based ART for 6 weeks after delivery.
(2) Sub-bullet 11 lines from bottom:
Never give ACE inhibitors, ARBs, or renin inhibitors, or start thiazide . . .
398 Hypercoagulable States last bullet deleted: Thrombolytics are used in . . .
399 Diabetes in Pregnancy bullet 4: Glyburide and metformin have been used . . .
400 Neonatal Problems section deleted (6 lines).
401 Practice question deleted (including diagnosis & treatment bullets).
402 (1) Second-Trimester Methods and Complications sections deleted (12 lines).
(2) Practice question deleted.
(3) Table added, bottom of page:

Spontaneous Abortion m
Type Ultrasound Finding Treatment
Complete No products of conception; cervix
closed
Follow up with -hCG
Incomplete Some products of conception
present; cervix closed
Dilation and curettage (D&C)
Inevitable Products of conception present;
intrauterine bleeding; dilation of
cervix
Medical induction or D&C
Threatened Products of conception present;
intrauterine bleeding; no dilation of
cervix
Bed rest
Missed Fetus is dead but remains in uterus Medical induction or D&C
Septic Infection of the uterus D&C and IV levofloxacin and
metronidazole


415 Table last row, Management: PO nafcillin / Breastfeeding should be continued
418 Treatment line 1 replaced: No treatment is necessary. Surgical removal can be done if the
mass is growing.
420 Established risk factors box: bullet 3 deleted (Benign breast disease, . . .); bullet 6 deleted
(Higher socioeconomic status)
424 Management table, row 2 deleted: Presurgical shrinkage . . . N/A
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425 Table, Management item 2 deleted: Give HRT (estrogen PLUS progesterone)
426 (1) Management (simple cyst) bullet 1 replaced:
Transvaginal or transabdominal ultrasound to assess initial visit. If it is asymptomatic, no
further follow up is necessary.
(2) Bilateral Ovarian Enlargement through end of page deleted.
427 (1) During Pregnancy section deleted (11 lines).
(2) Last bullet deleted: Use of perineal talc powder
428 Practice question deleted.
430 Bullets under What is the frequency of screening? (cervical cancer):
If <30 and average risk, every 3 years with cytology only
If >30 and average risk, every 3 years with cytology only or every 5 years with co-testing
(cytology + HPV)
434 (1) Cervicitis line 3: . . . give oral azithromycin and IM ceftriaxone.
(2) Treatment bullets replaced (Acute Salpingo-oophoritis):
Outpatient: One dose of IM ceftriaxone plus doxycycline
Inpatient: IV cefotetan or cefoxitin plus doxycycline
435 (1) Treatment, #1 (tubo-ovarian abscess): . . . give cefoxitin and doxycycline.
(2) Treatment bullet 1 (outpatient antibiotics): Previous outpatient treatment failure, . . . (text
deleted: Acute salpingo-oophoritis in a nulligravida or adolescent patient,)
(3) Practice question deleted.
449 Malignant section of table deleted (3 columns).
459 New callout box:
Phrenia > 6 months
Phreniform > 1 month but < 6 months
460 Rule out other bullets changed:
Drug screen is the best initial test in a patient with psychosis.
Temporal lobe epilepsy can present . . . (text deleted: Look for signs or symptoms of
seizure.)
462 2 new callout boxes:
Olanzapine has the greatest weight gain of any of the antipsychotics.
Risperidone affects 6 receptors:
5HT
D1
D2
1
2
H1
468 New callout box: Buspirone is a serotonin 5-Ht1A receptor partial agonist.
469 New callout box (major depressive disorder, treatment):
In patients with unipolar psychotic depression, the combination of an antidepressant and an
antipsychotic is more effective than monotherapy with either drug.

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470 New section and callout box for bipolar disorder:
Treatment
First-line treatment: monotherapy with lithium, lamotrigine, or risperidone (oral or
intramuscular)
Second-line treatment: aripiprazole, divalproex, quetiapine, and olanzapine
Patients with multiple recurrences require combination therapy.
Always include psychotherapy and cognitive behavioral therapy in treatment plan.
Avoid teratogenic drugs such as lithium, valproate, and carbamazepine in female patients.
Box: Lithium can lead to Ebsteins anomaly and diabetes insipidus.
473 New callout box (indications for ECT): ECT is safe in pregnancy.
476 Neuroleptic Malignant Syndrome line 4: . . . consciousness, elevated CPK, and . . .
478 Management (hypochondriasis) bullet 2: Schedule regular routine visits with the same doctor.
488 New section (substance use disorders):
Treatment
Naltrexone implant has been shown to be effective in long-term treatment of opioid
dependence, alcohol dependence, and (most recently) poly-drug dependence.
Acamprosate and disulfiram have been used in alcohol dependence.
Antidepressants are the wrong answer for patients with alcohol dependence without a comorbid
mental disorder.