Here is the explanation:

In Hypotonic hyponatremia- which is true hyponatremia, first check the serum osmolality, if <280 mOsm/kg.

Patient always have hypovolemia- (low intravascular volumes). Then, check urine sodium. If (less than 10 mEq/L) this implies that the kidneys are increasing sodium reabsorption to retain more Sodium in order to compensate for extrarenal losses such as diarrhea, vomiting, nasogastric suction, burns or pancreatitis.)

Therefore, diarrhea causes excess sodium and water loss in the gut causing hypovolemia and hypotonic hyponatremia.

Caveat: Always check the patient Urine sodium and serum osmolality to direct you in this case.

What about Hypernatremia?

If you get a question on the USMLE on hypernatremia, Check plasma concentration of sodium (if > 145 mmol/L). This refers to excess sodium concentration compared to water. This can result from water losses or sodium infusion.

Assess ECF volume clinically; In hypovolemic hypernatremia, extra-renal losses from diarrhea causes the patient to loss more water than sodium. Thus, patient has high sodium concentration intravascularly but still hypovolemic.

This is very common in elderly patients who do not have a good thirst reflex. If they develop diarrhea, they do not replace the fluids loss for the intestine by not drinking adequate oral hydration.

Caveat: In Hypernatremia induced by diarrhea; always check the if the patient is drinking enough fluids to replace lost fluids enterally

Dr Adeleke Adesina, DO
Emergency Medicine physician

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1. Knowledge gap. We all have limited abilities to memorize content, some students are great at memorization, while others are not.  The USMLE Step 1 and 2 are designed for the average medical student, therefore know your strength and weaknesses before studying for the exam. We recommend you understand concepts rather than memorize, because you can’t apply what you do not remember.
   

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2. Tendency to forget. We all have a tendency to forget concepts over time. Some faster, some slower. Normally this is not a problem as the rate of forgetting is usually small. Do not spend more than 6-8 weeks to study as a US med student and 3 months if you are an IMG. You will start forgetting the content you read after day 1 as you prolong your studying period. Avoid this!
   

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3. Recalling and Retaining Information. Retention and recall are not the same although they are related. Retention is how well you memorize the information while recall is being able to get it back out. Too often you can remember something but cannot recall it. The best way to retain information is by understanding mechanisms of diseases and pathophysiology. SmashUSMLE videos can help with retention. Recalling information is best practiced by constantly testing your knowledge from a question bank.
   

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4. Poor NBME assessment scores. You can’t study forever but students who rush to take the exam with low NBME scores usually perform poorly on the exam. If your NBME score are not what you want, do not take the test.
   

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5. Study skills. Good study skills help in understanding, memorization and retention. Good students usually have good study skills, which is why they tend to get better scores in the USMLE Step 1 and 2 CK. Acquire good study habits early so this can help you down the line.
   

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6. Poor Test-taking skills. How good you are at taking tests has a big impact on your scores. The test is difficult not only because the medical facts tested is hard, but a lot of times, because of the way the questions are constructed. Good test taking skills help make tough questions easier. Use our test taking strategies to improve this area.
   

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7. Physical endurance. All USMLE Steps are  a marathon not a hundred yard dash. Both the exam itself and the prep. We recommend you eat help, exercise and simulate real exam conditions when taking NBMEs during your prep time so that you can endure the lengthy 8 hour exam.

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I have been studying for the USMLE, 12 hour days for the past 4 weeks as I started to feel the burn out already. I was getting tired and wondering what did I get myself into. I have completed 70% of my Qbank and there is still lot of read. I thought about my friends, family and others who are just enjoying the summer weather. Looking at my friends on facebook enjoying life and going on vacation was very depressing. I thought to myself, will this be worth it in the end? It was a difficult time for me personally. But I will watch motivational video on youtube to inspire me. I ll pray to God for strength and will power to carry on. I will call my girlfriend at the time, now my wife who encourage me. Been locked inside my apartment for 8 weeks, only to go to the grocery store for a few minutes or exercise was a test of my endurance and discipline.

Studying for the USMLE taught me one thing: Its a marathon. Just like athletes start off strong while running a 5k, and half way they start to feel the fatigue build up in their muscles. But they continue to push harder and find the extra energy to get to the finish line. Studying for Step 1 or Step 2 was no  different for me. Quitting was not an option. I was already 100, 000 in student loan debt. I thought to myself, this one exam is the different between doing a specialty I love and settling for anything. If I am going to do something, I made up my mind to give it 120%.

I only have one shot at this to do it right the first time. If I fail the test, I can retake it, but I barely pass, its over. I made sure I took the right shot at the right time. As Michael Jordan did against the Cleveland cavaliers. It was his last shot and a game winning one.

If you are studying for this exam, you can relate to my story. You too can do it. It is hard, let no one fool you. But diamond has to go through a heat to become dazzling. So is the process of becoming a physician.

In the end, I scored a 225/97 on step 1 and 229/99 on Step 2 CK. It was well worth it. Today, I am a board certified emergency medicine physician. See my score report below.

No matter how frustrated you are with the process. Just stay positive and motivated. You can do it. Many people have come before and many will come long after you are done, this is your moment. Seize it! Go smash the USMLE exam.

Image reference: Micheal Jordan, The shot: http://airjordanshoeshq.com/michael-jordans-biography-and-statistics/

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A) Anserine bursitis
B) Baker’s cyst
C) Deep venous thrombosis
D) Prepatellar bursitis
E) Infrapatellar bursitis

Explanation

Correct Answer B. Baker’s Cyst
A Baker’s cyst occurs in the midline of the popliteal fossa and is often a complication of rheumatoid arthritis. The cyst represents a diverticulum of the synovial sac that protrudes through the joint capsule of the knee. The knee is composed of 12 different bursae.

Educational Objectives
A Baker’s cyst, also called a popliteal cyst, is usually the result of a problem with your knee joint, such as arthritis or a cartilage tear. Both conditions can cause your knee to produce too much fluid, which can lead to a Baker’s cyst.

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A) Influenza
B) Brucellosis
C) Aspergillosis
D) Mycobacterium bovis
E) M. tuberculosis

Explanation

Correct Answer D. Mycobacterium bovis
Most people are at very low risk for being infected with M. bovis. People at higher risk include individuals who work with cattle, bison, or cervids (e.g., deer or elk), or products from these animals such as hides, milk, or meat. Examples of occupations or hobbies that might put people at increased risk include ranching, dairy farming, working in a slaughterhouse or as a butcher, and hunting.

Educational Objectives
Not all M. bovis infections progress to TB disease, so there might be no symptoms at all. In people, symptoms of TB disease caused by M. bovis are similar to the symptoms of TB caused by M. tuberculosis; this can include fever, night sweats, and weight loss. Other symptoms might occur depending on the part of the body affected by the disease.

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A) Patent ductus arteriosus
B) Ventricular septal defect
C) Coarctation of the aorta
D) Atrial septal defect
E) Tetralogy of Fallot

Explanation

Correct Answer C. Coarctation of the aorta
Coarctation of the aorta is narrowing of the aorta usually just distal to the origin of the ductus arteriosus and subclavian artery. Patients may complain of epistaxis, head-ache, cold peripheral extremities, and claudication. Absent, delayed, or markedly diminished femoral pulses may also be found. The low arterial pressure in the legs in the face of hypertension in the arm is also a clue to the diagnosis. Chest radiograph in coarctation shows rib notching secondary to the dilated collateral arteries.

Educational Objectives
Coarctation of the aorta (CoA) is a relatively common defect that accounts for 5-8% of all congenital heart defects. Coarctation of the aorta may occur as an isolated defect or in association with various other lesions, most commonly bicuspid aortic valve and ventricular septal defect (VSD).

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A) Abducens Palsy
B) Nystagmus
C) Impaired convergence
D) Papilledema
E) Impaired upgaze

Explanation

Correct Answer B. Lateral beating movements of the eyes
Most rhythmic to-and-fro movements of the eyes are called nystagmus. Nystagmus has a fast component in one direction and a slow component in the opposite direction. Nystagmus with a fast component to the right is called right-beating nystagmus. Phenytoin (Dilantin) may evoke nystagmus at levels of 20 to 30 mg/dL. The eye movements typically appear as a laterally beating nystagmus on gaze to either side; this type of nystagmus is called gaze-evoked. If the patient has nystagmus on looking directly forward, he or she is said to have nystagmus in the position of primary gaze. Therapeutic levels for phenytoin are usually 10 to 20 mg/dL, and some patients develop asymptomatic nystagmus even within that range.

Educational Objectives

Ataxia, dysarthria, impaired judgment, and lethargy may also occur at toxic levels of phenytoin. Many other drugs also evoke nystagmus

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A) Hypoplasia
B) Hyperplasia
C) Metaplasia
D) Dysplasia
E) Ectopy

Explanation

Correct Answer E. Ectopy

Meckel diverticulum is the most common congenital anomaly of the small intestine, being present in 2% of the population. It forms due to incomplete obliteration of the omphalomesenteric duct that connects the midgut lumen and yolk sac cavity early in fetal life. Meckel diverticulum is connected to the ileum, and is located approximately 2 feet proximal to the ileocecal valve.

A variety of tissues have been found in Meckel diverticulum, including gastric, pancreatic, colonic, jejunal, duodenal and endometrial. The most common of these is gastric tissue, which is significant because gastric epithelium produces acid that can cause ulceration of adjacent tissues and lower GI bleeding. Meckel diverticulum most often presents with painless melena. The diverticulum may also become inflamed and simulate the clinical presentation of acute appendicitis.

Gastric, pancreatic, and other types of mucosa found in Meckel diverticulum are examples of ectopy (also called heterotopy). “Ectopy” is a term that identifies microscopically and functionally normal cells/tissues found in an abnormal location due to embryonic maldevelopment.

Educational Objectives
A number of ectopic tissues are found in Meckel diverticulum-most commonly, gastric epithelium. Gastric mucosa is present in 80% of cases of symptomatic Meckel diverticulum. Gastric acid production leads to ulceration and subsequent bleeding.

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A) Glaucoma
B) Cataract
C) Diabetic retinopathy
D) Macular degeneration
E) Xerophthalmia

Explanation

Correct Answer B. Cataract
A cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. Cataracts are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. A cataract can occur in either or both eyes. It cannot spread from one eye to the other. Cataract is the main cause of visual loss globally and is the most common eye problem associated with age. It can be treated surgically. Risk factors include hypertension, diabetes, exposure to ultraviolet radiation, and corticosteroid therapy.

Educational Objectives
Researchers suspect that there are several causes of cataract, such as smoking and diabetes. Or, it may be that the protein in the lens just changes from the wear and tear it takes over the years.

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The tests are hard enough and you have no reason to make it any harder on yourself by adopting study techniques most students are guilty of. If you are reading this, you are smart, resourceful, and fairly committed to your success.

We are with you.

For that reason, we came up with a tight-knit, easy-to-follow, and a no-nonsense plan to help you prepare better for your USMLE exams.

Research & Study

Even before you start studying for USMLE, understand what it takes to pass the test, the scores you’d need to aim for, and the subject you have to master. Trudging along blindly into your preparation mode doesn’t serve you any purpose.

The more you research about the exam, the study material, and how you intend to prepare for USMLE, the less you’d have to suffer later. The decisions you’d then make are going to well-informed, smart, and result-oriented.

Once you’ve done your preliminary research about USMLE itself, it’s time to look for the right partner to depend on for your studies. Go ahead and take a look at what we have on offer (and don’t forget to get 10% off when you opt for a paid plan).

Plan Your Study path

Staggered learning gets you staggered results (or no results at all). After all the work, time, and effort you’d essentially put in to your studies, you’d really not want results that you are not going to be proud of.

Open up that calendar (or opt to use Google Calendar if you are comfortable that way) and chalk out a time/date based plan to study. Mark your start dates, finish dates, and go granular if you have to on what you intend to achieve and when.

List down everything

The human brain is wired to drift.

We are capable of so many different thoughts and at the rate of too-many-thoughts-to-keep-track-of. You can’t afford to get distracted while you are studying for your USMLE tests. Practice creating lists to help mark your progress, tasks you’d need to complete, and set them all up with deadlines.

This disciplined approach might be hard for some of us who aren’t used to being organized. If you do manage to create lists and follow them, the results are spectacular and you’d want that, don’t you?

Reward Yourself Sometimes

Studying with focus is hard. We get it. Follow a routine of trying to reward yourself for every milestone you achieve. The practice of putting in the focus, followed by work, and then rewarding yourself is a self-fulfilling practice. It helps set the mood for intense study and preparation that you’ll need to ace USMLE exams.

If you are a member of our paid plan, we’ve made it easy for you to plan, study, and track your progress as you prepare for USMLE.

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