"Obscure" USMLE Step 1 questions?

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Domenech

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Guys have you encountered any obscure stuff on your Step1 exams that you rather thought would not appear on your exam? I read AggieSean's experience and he quoted three things that appeared on his exam: Aeromonas Hydrophila, MecA gene, Scabies Rx. I searched for MecA gene in Kaplan and Warren Levinson's book but I didn't find it. It was there on wikipedia though, a full article. Again Aeromonas hydrophila is not dealt with in kaplan; Levinson only has 4 or 5 lines and that's it.

Although these would be rare, but still anything new you encountered and might want to share specifically here? For instance it took me the whole UWSA1 to realize number needed to treat should be studied at all costs :laugh:
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there were one or two questions i couldnt figure out even after i left and perused a textbook on the subject.

e.g. what happens after unilateral pulmonary artery embolism and i had to choose between acute right ventricular dilation and ventricular arrhythmia. Maybe i'm dumb but i didn't find any conclusive answer anywhere.

apparently they both happen and the incidence of both is related to the degree of blockage of the pulmonary circulation in general, but nothing i read wanted to try to get more definitive than that. I went with arrhythmia on the test just because my gut told me unilateral blockage wasn't enough increased resistance to acutely dilate.
 
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VoiceofReason said:
there were one or two questions i couldnt figure out even after i left and perused a textbook on the subject.

e.g. what happens after unilateral pulmonary artery embolism and i had to choose between acute right ventricular dilation and ventricular arrhythmia. Maybe i'm dumb but i didn't find any conclusive answer anywhere.

apparently they both happen and the incidence of both is related to the degree of blockage of the pulmonary circulation in general, but nothing i read wanted to try to get more definitive than that. I went with arrhythmia on the test just because my gut told me unilateral blockage wasn't enough increased resistance to acutely dilate.
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I thought that if you have a huge embolus, like a saddle embolus, you will get an arrhythmia and die almost immediately. I imagine dilation as being in a smaller artery and something that develops over time. Sound right?
 
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I don't think your heart can really dilate that quickly. I mean its not like a balloon or something. If it tried to acutely dilate it would rupture first.
 
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Well, I am going to go against the trend here and I thought acute ventricular dilation:

Because when I think PE I think acute cor pulomonale (at least that is my gut reaction)

And I know that often you get EKG changes with Pulmonary embolism (S1Q3T3) but these are just changes and not arrythmias

The article on cor pulmonale indicates its ventricular dilation:
http://en.wikipedia.org/wiki/Cor_pulmonale

Thoughts?

P.S. The only arrythmia I can think of they could mention (if they mentioned it specficially---is a RBB)

P.P.S. This all fall apart if its a saddle embolism, but you don't die of a arrythmia in saddle embolism... there is NO return of blood to the left side of your heart and your cardiac output becomes essentially zero
 
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i dont know but its a little comforting to see that other people don't think its cut and dry either. what made me eventually choose arrhythmia is i felt like they were trying to tell me something with the 'unilateral' rather than 'saddle' embolus.

i checked tintinalli's because i thought it was probably the best place to find "sequelae to watch out for" in PE and if i recall they said asystole/pulseless-electrical-activity happens but nobody knows why, .. as well as acute RV dilation. The terms that i've found used are 'massive' and 'submassive' embolus with respect to dilation but the definitions of these terms are awful and almost useless.

*hangs head*
 
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VoiceofReason,

You need to stop beating yourself up about these things. What's done is done.

I didn't see but how were your practice scores before the exam?
 
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FutureDoc4 said:
VoiceofReason,

You need to stop beating yourself up about these things. What's done is done.

I didn't see but how were your practice scores before the exam?
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i didn't take any actually because i thought the utility of them was too low to expend the energy. Thats just my opinion -- I can expand on that if you care.

Thusly I only took the school sponsored CBSE about a month and a half before my test (that time period following the CBSE was protected studying time). And I got a 220.

i know it probably seems like im beating myself up but im ok i guess, relatively. I went into it wanting to score high but in reality i just need an average score (225ish) to be competitive for the specialties im looking at -- and im fairly certain i pulled that off.
 
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I'm just hoping the test doesn't throw any of the weird basic science stuff USMLEworld has pulled up tonight. I got a question on Gibbs free energy. I haven't seen that since the MCAT!
 
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Fiddlergirl said:
I'm just hoping the test doesn't throw any of the weird basic science stuff USMLEworld has pulled up tonight. I got a question on Gibbs free energy. I haven't seen that since the MCAT!
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Holy what???? :(

Sometimes even while doing NBMEs, you get a question you wonder, oh that's in the course content too!

Weird.
 
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FutureDoc4 said:
VoiceofReason,

You need to stop beating yourself up about these things. What's done is done.

I didn't see but how were your practice scores before the exam?
Click to expand...

Yeah I agree, this thread isn't to make you reflect on those crappy questions but just what crap has actually appeared. So relax and enjoy :thumbup:

And you have me thinking about that pulmonary embolus.:smuggrin:
 
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Domenach - Yeah, it was a strange question. I also got a question that required you to know the pKas for an amino acid. Weird night.
 
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I got a gibbs free energy question on a CBSE so there's a chance they might go there.

if I get a Q on Step 1 about amino acid pKas I will go crazy.. no way should they expect us to spend time on that..
 
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I had this tip when reading Examkrackers for the MCAT, and I think it may apply well here. There is a reason why it takes so long to score these. The look at distributions of every question and curve/standardize accordingly. So if you find some obscure question that is not found in any textbooks, chances are that a lot of people found it hard too (i.e. the 9% right questions on UWorld). Chances are that is a experimental question or it is just taken into account then the score is standardized.
 
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greg1184 said:
I had this tip when reading Examkrackers for the MCAT, and I think it may apply well here. There is a reason why it takes so long to score these. The look at distributions of every question and curve/standardize accordingly. So if you find some obscure question that is not found in any textbooks, chances are that a lot of people found it hard too (i.e. the 9% right questions on UWorld). Chances are that is a experimental question or it is just taken into account then the score is standardized.
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Well that must actually be the real reason for those types of questions but still, when it does appear, there's always that slight feeling of frustration as well as urgency to make sure you study it.

pKa's ........ Darn that means go back study amino acids :(

Well it wouldn't really hurt to add pka, Gibbs free energy and lac operon to study schedule. Should not take a lot of time.
 
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Domenech said:
Must be that definitely. Probably has.....3 pkas? or 2?
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It has 3, and if I recall correctly, the choices weren't even drastically different (to reinforce the concepts vs the details). It was something like:

1) 2.5, 6, 8.5
2) 3, 6, 9
3) 2.9, 6.4, 10


You get the picture. I'm just pulling numbers out of the air but it was that kind of thing. Unless I'm just misremembering.
 
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GuyWhoDoesStuff said:
It has 3, and if I recall correctly, the choices weren't even drastically different (to reinforce the concepts vs the details). It was something like:

1) 2.5, 6, 8.5
2) 3, 6, 9
3) 2.9, 6.4, 10


You get the picture. I'm just pulling numbers out of the air but it was that kind of thing. Unless I'm just misremembering.
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If I am not mistaken, one response had a neutral pH in the middle as an answer, and that was the correct choice. I felt like I was taking an orgo test.
 
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greg1184 said:
I had this tip when reading Examkrackers for the MCAT, and I think it may apply well here. There is a reason why it takes so long to score these. The look at distributions of every question and curve/standardize accordingly. So if you find some obscure question that is not found in any textbooks, chances are that a lot of people found it hard too (i.e. the 9% right questions on UWorld). Chances are that is a experimental question or it is just taken into account then the score is standardized.
Click to expand...

The same argument can be made for those questions that you find ridiculously simple (where you'll find 90% of people answering it correctly). In the end, I think it all balances out... no sense in ruminating on such things we are just not meant to understand!
 
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badasshairday said:
Guys. Take your amino acid pKa's discussion to the MCAT forum. I'm sure they will gladly help... and with ease. lol.
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lol. I wander over to the mcat forum from time to time and am just amazed that how little I know about any of that stuff anymore. Talk about irrelevant material.

I did get a delta G question on an nbme I think. Luckily all you needed to know was that negative means it goes to the right.
 
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turkeyjerky said:
lol. I wander over to the mcat forum from time to time and am just amazed that how little I know about any of that stuff anymore. Talk about irrelevant material.

I did get a delta G question on an nbme I think. Luckily all you needed to know was that negative means it goes to the right.
Click to expand...


A few of my classmates and I were talking about what we thought we'd get on the MCAT if we took it this summer instead of Step I.

I don't think it'd be pretty.
 
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FutureDoc4 said:
Well, I am going to go against the trend here and I thought acute ventricular dilation:

Because when I think PE I think acute cor pulomonale (at least that is my gut reaction)

And I know that often you get EKG changes with Pulmonary embolism (S1Q3T3) but these are just changes and not arrythmias

The article on cor pulmonale indicates its ventricular dilation:
http://en.wikipedia.org/wiki/Cor_pulmonale

Thoughts?

P.S. The only arrythmia I can think of they could mention (if they mentioned it specficially---is a RBB)

P.P.S. This all fall apart if its a saddle embolism, but you don't die of a arrythmia in saddle embolism... there is NO return of blood to the left side of your heart and your cardiac output becomes essentially zero
Click to expand...

Based on the two choices we are given, I would go for acute dilatation as well, which is more possible to be presented as "acute" than v arr in this case.
What were the other choices?
 
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coralfangs said:
Based on the two choices we are given, I would go for acute dilatation as well, which is more possible to be presented as "acute" than v arr in this case.
What were the other choices?
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Do you mean acute right heart failure? Because I'm not sure dilatation is ever really an acute thing, whereas a ventricular arrhythmia, like Vtach, is VERY acute. I would think that multiple subclinical microemboli would eventually result in increased pulmonay resistance, and chronic right heart failure (with eccentric hypertrophy/volume overload and dilatation).
 
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My younger brother took the MCAT last week. I took a look at the practice tests he was taking, and realized that I never saw any of that stuff again after I walked out of that testing center. I remember my orgo professor claiming that all those reactions would be used all the time in med school. Hah.
 
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coldweatherblue said:
I got a gibbs free energy question on a CBSE so there's a chance they might go there.

if I get a Q on Step 1 about amino acid pKas I will go crazy.. no way should they expect us to spend time on that..
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I remember that one and I was so happy when I saw it. Sad that I remember college physics better than I do certain system pathophys...
 
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In DIT, he specifically spoke about the pKa, the lac operon, and Gibbs free energy. So I would definitely study these things. If you're banking on a bunch of people missing these, many of the people who took DIT won't. And a lot of people use DIT. Just a heads up.
 
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kissmyasthma99 said:
In DIT, he specifically spoke about the pKa, the lac operon, and Gibbs free energy. So I would definitely study these things. If you're banking on a bunch of people missing these, many of the people who took DIT won't. And a lot of people use DIT. Just a heads up.
Click to expand...

learn this junk because any question involving these is extremely basic and essentially free points for those who bothered to glance at it.
 
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I had a Gibbs free energy on the real thing a few days ago. Still don't know how that's important for the practice of medicine, but I got it right anyways.
 
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somebody wanna explain that Gibbs Free Energy question from NBME 7 to me real quick? Pretty sure I got it wrong, ha. All I could remember was that negative delta-G meant that the reaction happened spontaneously in the "forward" direction.
 
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Nesiritide said:
I had a Gibbs free energy on the real thing a few days ago. Still don't know how that's important for the practice of medicine, but I got it right anyways.
Click to expand...

Oh well a LOT of things we get on Step 1 aren't really critical to the practice of medicine. But they'd still throw all of that crap in the real exam. :smuggrin:

Lac operon is definitely very important and a great concept to learn :thumbup: Something that single handedly brought a Nobel Prize for three French scientists in 1965 has got to be very important, you'd think.
 
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cushie said:
I don't know the exact question, but here is a basic explanation of delta-G.

So say the reaction was A-->B.
--Delta-G is negative if the reaction is energetically favorable, i.e. spontaneous, in the "forward direction", i.e., A-->B.
--Delta-G is positive if the reaction is energetically unfavorable, i.e., non-spontaneous, in the forward direction.
--Delta-G is zero if the reaction is energetically equal moving in either direction.

Kapish??
Click to expand...

hehe, thanks.. but what is the relevance of multiple delta-g values or more than one equation? You add them together ... or?
 
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Fiddlergirl said:
My younger brother took the MCAT last week. I took a look at the practice tests he was taking, and realized that I never saw any of that stuff again after I walked out of that testing center. I remember my orgo professor claiming that all those reactions would be used all the time in med school. Hah.
Click to expand...

He wanted you students to study. Sometimes works. Definitely does on me.
 
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VoiceofReason said:
there were one or two questions i couldnt figure out even after i left and perused a textbook on the subject.

e.g. what happens after unilateral pulmonary artery embolism and i had to choose between acute right ventricular dilation and ventricular arrhythmia. Maybe i'm dumb but i didn't find any conclusive answer anywhere.

apparently they both happen and the incidence of both is related to the degree of blockage of the pulmonary circulation in general, but nothing i read wanted to try to get more definitive than that. I went with arrhythmia on the test just because my gut told me unilateral blockage wasn't enough increased resistance to acutely dilate.
Click to expand...

There is a Uw q - # 1584- quote:
PE raises pulmonary resistance and increases RV afterload which may cause RV failure , it also creates a suddden drop in perfusion leading to V/Q mismatch
So I think the answer is Acute right ventricular dilation-
:love:
 
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Acute right heart failure is a principal cause of circulatory collapse and death in patients with massive pulmonary embolism (PE). The purpose of this study was to investigate if helical computed tomography (CT) could contribute to the assessment of the right ventricle (RV) in those with massive PE. Over an 8-month period 79 helical CT pulmonary angiograms were performed to investigate suspected PE. Emboli were demonstrated in 28 (35%) patients and seven (9%) were considered to have had a major thromboembolic event. The CT scans of all patients were evaluated using parameters derived in the axial plane (maximum minor axis RV and LV dimensions, RV:LV minor axis ratio and RV wall thickness). Acute right ventricular dilatation with an RV:LV ratio> 1.5:1 (range 1.6:1-2.3:1, mean 2:1) was found in all seven patients who had sustained major PE. In the remaining group of 21 with lesser degrees of embolism no patient had an RV:LV ratio > 1.1:1 (range 0.8-1.1, mean 1.0). To our knowledge, this CT sign has not been described before. CONCLUSION: Helical CT can identify acute RV dilatation in addition to making the primary diagnosis in patients with massive PE. This observation may help identify those at greatest risk of a second fatal event and facilitate therapeutic strategy.

http://www.ncbi.nlm.nih.gov/pubmed/9766724
 
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PentaDoc said:
Acute right heart failure is a principal cause of circulatory collapse and death in patients with massive pulmonary embolism (PE). The purpose of this study was to investigate if helical computed tomography (CT) could contribute to the assessment of the right ventricle (RV) in those with massive PE. Over an 8-month period 79 helical CT pulmonary angiograms were performed to investigate suspected PE. Emboli were demonstrated in 28 (35%) patients and seven (9%) were considered to have had a major thromboembolic event. The CT scans of all patients were evaluated using parameters derived in the axial plane (maximum minor axis RV and LV dimensions, RV:LV minor axis ratio and RV wall thickness). Acute right ventricular dilatation with an RV:LV ratio> 1.5:1 (range 1.6:1-2.3:1, mean 2:1) was found in all seven patients who had sustained major PE. In the remaining group of 21 with lesser degrees of embolism no patient had an RV:LV ratio > 1.1:1 (range 0.8-1.1, mean 1.0). To our knowledge, this CT sign has not been described before. CONCLUSION: Helical CT can identify acute RV dilatation in addition to making the primary diagnosis in patients with massive PE. This observation may help identify those at greatest risk of a second fatal event and facilitate therapeutic strategy.

http://www.ncbi.nlm.nih.gov/pubmed/9766724
Click to expand...

Thank you :love:
 
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I had a scabies question on my exam - the info was in RR, and I remember specifically reading it multiple times when studying because I wasn't originally sure what scabies was. So I thought it was interesting and read it a bunch.

I also had genital warts question right towards the end of the exam - I was feeling weak, happy to be almost done, and the last thing I needed was a gross looking pubic fro with warts projected on my screen. Ug.
 
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astrocreep96 said:
I had a scabies question on my exam - the info was in RR, and I remember specifically reading it multiple times when studying because I wasn't originally sure what scabies was. So I thought it was interesting and read it a bunch.

I also had genital warts question right towards the end of the exam - I was feeling weak, happy to be almost done, and the last thing I needed was a gross looking pubic fro with warts projected on my screen. Ug.
Click to expand...


I think you're the second person to mention a scabies question. Perhaps I should go read up on that (I can't recall what you treat them with off the top of my head, but I'd know it if I saw it).
 
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pottymouth said:
premethrin or something like that... which is also used to crabs and lice.
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Permethrin is the first line. Ivermectin can also be used (the drug also used for Onchocera Volvulus and Strongyloides Stercoralis). For pregnant women and children = use Sulphur in Petroleum.

Thanks to Aggie, there was a question on mechanism of Acamprosate. So be sure to read up all those drugs used up in Alcohol programmes :)
 
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coldweatherblue said:
I got a gibbs free energy question on a CBSE so there's a chance they might go there.

if I get a Q on Step 1 about amino acid pKas I will go crazy.. no way should they expect us to spend time on that..
Click to expand...

For the record, I did have a Gibbs free energy question on my step which I took today.

It listed three reactions (Glucose + P --> Glucose-6-P; Glucose + P --> Glucose-1-P; and ATP --> ADP). Gave the free energies and asked which reactions combo would be spontaneous. Super easy.
 
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GuyWhoDoesStuff said:
I think you're the second person to mention a scabies question. Perhaps I should go read up on that (I can't recall what you treat them with off the top of my head, but I'd know it if I saw it).
Click to expand...

I did have a scabies question on my test, now that I think about it. It was pretty easy: gave the presentation and asked for the bug.

I also had a gross picture of an angiomyolipoma (at least that's what I think it was) and like 5 questions later a classic presentation for TS in a question asking for the diagnosis (where they also mentioned angiomyolipomas).
 
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GuyWhoDoesStuff said:
Was it histidine? I got that question a few days ago. Ridiculous.
Click to expand...

The exam writers may be attempting to bring our attention to the fact that Histidine is an important buffering amino acid (more so than even the others, as it is one of the positively charged AAs,essential and key for major enzyme catalysis). This is really the only reason to integrate a basic memory recall question that.
 
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