Foundations of independent practice for 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 24-year-old woman is brought to the emergency department after a witnessed generalized tonic-clonic seizure lasting 2 minutes. She has now been actively seizing for 6 minutes since arrival. IV access is in place. Glucose is 96 mg/dL. What is the most appropriate immediate treatment?

1. Observation for a further 10 minutes to see whether the seizure self-terminates Wrong and dangerous. Beyond 5 minutes seizures are less likely to stop on their own and neuronal injury accumulates with duration.
2. Intravenous lorazepam correct Correct. Status epilepticus is defined by a seizure lasting 5 minutes or more, and a benzodiazepine is the first-line treatment. Lorazepam is preferred intravenously for its longer duration of action within the central nervous system compared with diazepam.
3. Intravenous dextrose 50% Reasonable if hypoglycemia were suspected, but her glucose is documented as normal, so this treats nothing.
4. Immediate rapid sequence intubation and general anesthesia That is the third-line step for refractory status after benzodiazepine and a second-line agent have failed.
5. Intravenous fosphenytoin as the first agent Wrong order. Fosphenytoin, levetiracetam or valproate are second-line agents given after a benzodiazepine, not instead of one.

The point: Status epilepticus: benzodiazepine at 5 minutes, second-line antiseizure medication at around 20 minutes, anesthesia for refractory disease. Check glucose, sodium, calcium, pregnancy status and toxicology. In pregnancy, consider eclampsia and give magnesium.

Source: American Epilepsy Society guideline — treatment of convulsive status epilepticus American Epilepsy Society · tier 2, specialty society or college

A 28-year-old woman comes to your clinic with a black eye. She says she walked into a door. You notice bruises of varying ages on her upper arms. Her partner has accompanied her to the appointment and answers several questions on her behalf. What is the most appropriate next step?

1. Tell her she must leave the relationship today for her own safety Counterproductive. The period around leaving is the most dangerous, and directive instruction removes the autonomy that safety planning depends on.
2. Arrange to interview the patient alone, in private, before any further discussion correct Correct. A person experiencing intimate partner violence cannot disclose safely in front of the person who may be causing harm. Creating a private, routine-seeming opportunity to speak alone is the necessary first step, and separating them without alerting the partner requires a natural pretext.
3. Document the injuries and take no further action Documentation matters, particularly photographs and precise descriptions, but doing only that misses the intervention.
4. Report to law enforcement immediately without discussing it with her Reporting requirements for intimate partner violence in competent adults vary by state, and acting without her involvement can escalate danger and destroy her trust. Children in the household and vulnerable adults are separate mandatory reporting situations.
5. Ask her directly about abuse while her partner is present Wrong and potentially dangerous. Asking in front of the partner may provoke retaliation afterwards and will almost certainly produce a denial.

The point: Intimate partner violence: interview alone, ask directly and non-judgementally, validate, assess immediate safety including weapons and children, offer resources, document objectively, and respect her decision about timing. Screening is recommended for women of reproductive age.

Source: USPSTF — screening for intimate partner violence; AMA Code of Medical Ethics US Preventive Services Task Force · tier 1, national regulator or guidance