USMLE Step 3

You are the admitting physician for a 71-year-old woman with community-acquired pneumonia. She is alert. Blood urea nitrogen 32 mg/dL, respiratory rate 32, blood pressure 88/54 mmHg. What is her CURB-65 score and the implied disposition?

1. Score 4 — admit, consider intensive care assessment correct Correct. She scores for urea above 19 mg/dL, respiratory rate 30 or above, systolic below 90, and age 65 or over. Confusion is absent. A score of 3 or more indicates severe pneumonia warranting admission and critical care review.
2. Score 5 — immediate intubation required Overcounts, since she is alert so the confusion point does not apply. A high score indicates critical care assessment, not automatic intubation.
3. Score 2 — consider short-stay observation Undercounts. Recheck each component: urea, respiratory rate, blood pressure and age all score here.
4. Score 3 — discharge with oral antibiotics and next-day review Both the arithmetic and the disposition are wrong. Any score of 3 or above means admission.
5. Score 1 — outpatient management is appropriate Substantially undercounts, and outpatient management would be unsafe given her hypotension and tachypnea.

The point: CURB-65: Confusion, Urea above 19 mg/dL, Respiratory rate 30 or more, Blood pressure below 90 systolic or 60 or less diastolic, age 65 or over. Severity scores support judgement rather than replacing it.

Source: ATS/IDSA guideline — community-acquired pneumonia in adults IDSA / American Thoracic Society · tier 2, specialty society or college

A 54-year-old woman on your panel has an LDL of 168 mg/dL, blood pressure 138/84 mmHg, is a non-smoker and has no diabetes. Her 10-year ASCVD risk is 9.2%. She is unsure about starting a statin. What is the most appropriate management?

1. Engage in a risk discussion and offer a moderate-intensity statin, considering coronary artery calcium scoring if she remains undecided correct Correct. She is in the intermediate-risk band, where guidelines call for a clinician–patient risk discussion rather than an automatic prescription, and coronary artery calcium scoring is the recognized tiebreaker.
2. Lifestyle modification alone and recheck in 5 years Too passive. A 9.2% ten-year risk with an LDL of 168 warrants an active conversation now, and five years is far too long.
3. Order a PCSK9 inhibitor Reserved for very high-risk patients or familial hypercholesterolemia inadequately controlled on maximally tolerated statin plus ezetimibe.
4. Start ezetimibe as first-line therapy Ezetimibe is add-on therapy when a statin is insufficient or not tolerated.
5. Start high-intensity statin therapy immediately without further discussion Wrong intensity and wrong process. High-intensity statins are for clinical ASCVD, LDL at or above 190, or high estimated risk.

The point: ASCVD primary prevention bands: below 5% low, 5 to 7.4% borderline, 7.5 to 19.9% intermediate (risk discussion, moderate-intensity statin, CAC if undecided), 20% or above high. Step 3 tests the conversation as much as the drug.

Source: ACC/AHA guideline on the primary prevention of cardiovascular disease American College of Cardiology / AHA · tier 2, specialty society or college