If there’s one fact that bears repeating when it comes to USMLE test prep, it’s that there’s no substitute for doing countless questions. Literally thousands of questions and explanations. Multiple question banks, questions by day, questions by night…question after question after question!
And yet, just plowing through Qbanks isn’t enough. To really crush it on exam day, you’ll also want to outline your approach to questions, as well as the content contained therein.
If you’re wondering what I mean, I’ll show you a systematic approach to doing USMLE questions that’ll save you time and energy during the exam.
Let’s see how it works by going through an example together.
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Breaking Down a USMLE Sample Question
A 52-year-old man, who hasn’t visited the doctor since childhood, comes to the ED after an unwitnessed fall at home. He maintained consciousness throughout. He can only ambulate around his house, and over the course of the last 2 months, he has gained 14 lbs, despite no change in diet. He occasionally takes Tylenol for headaches. He has no significant family history, has smoked a pack a day for 30 years, and drinks a 6 pack of beer every day after work. He is missing work because of the fatigue and shortness of breath. He is normothermic, HR 100bpm, respirations 18/min, and BP 95/60. He is saturating 91% on 4 L nasal cannula. On exam, his lungs have crackles to the mid scapula, he has an S3 heart sound, no murmurs, and 2+ pitting edema to the mid shin bilaterally. What would be seen on echocardiography?
A) Pericardial effusion
B) Dilated cardiomyopathy
C) LV hypertrophy
D) Paradoxical septal motion
E) Regional wall motion abnormality
Alright, let’s break down a 5-step systematic approach for answering this:
Step 0 (This is important!)
Collect yourself and take a breath before every question. You want to put the last question away and devote all of your mental space to the one before you. This deliberate half-second exercise will give you renewed clarity and focus for each question you approach.
Step 1: Glean what you can from the first sentence!
Now that you’re focused, extract all the information you can from the first sentence of the vignette. The first sentence will set the stage for the scenario (i.e., outpatient hospital, or emergency), the patient demographic, and the chief complaint. Here we’re dealing with a middle-aged man, removed from the medical system, who’s fallen.
Step 2: Start wondering about potential diagnoses.
At this point, you want your subconscious to form the loosest of differentials. Someone falls—did this happen because of a physical weakness (musculoskeletal issue), a cardiac problem (low blood flow to brain), or a neurological one (seizure, balance problem/gait disturbance)? We don’t have to narrow down any explicit diagnoses. We’re merely honing in on what might be going on.
Step 3: Read the final question.
Now, in order to figure out the answer to this question, you must know what kind of question you’re being asked. And where do we find the question being asked? It’s in the last line of the vignette. So skip from the first sentence to the final question: “What would be seen on echocardiography?” Now we understand our mission: figure out the echocardiographic findings in a 52-year-old man who fell down.
The jump from the opening sentence towards the question asked is an important one, because it further aligns you with the task. You don’t have to worry about acute intoxications, or CT head findings, or electrolytes. You need to worry about echo findings, and you can focus on this task when you read the remainder of the stem.
Step 4: Read the rest of the question.
We can now begin to use all of the “meat” and data in the question to connect the dots from fall to echo.
What other clues have been provided?
Shortness of Breath:
Is this primarily a lung problem? Perhaps, but we’re looking at echo findings. So I’m already thinking fluid overload, heart failure, arrhythmia, etc.
Weight Gain:
It’s hard to gain 14 lbs from overeating over a short period of time. The patient is holding onto fluid, which could be from a kidney problem (not making urine, so the fluid hangs out in the interstitium). Or it could be a heart problem, (not pushing that blood into the kidneys for filtration and making urine). Again, since we’re cardiac oriented, we can focus on the heart.
Smoking History:
The patient has a 30 pack-year smoking history and alcohol use disorder. Any lifetime smoker with shortness of breath means COPD exacerbation has to be in the differential. But everything so far has led us to a cardiac problem. Remember, long-term alcohol use causes heart problems/failure, so perhaps we’re starting to pin down the problem.
Hypoxia, Weight Gain, and Low Blood Pressure:
HR is borderline fast, BP is low, and we’re unequivocally hypoxic. Hypoxia + weight gain/fluid overload is screaming pulmonary edema. Combined with a low blood pressure, almost certainly heart function is poor, causing fluid back up into the lungs.
Step 5: Assemble the big picture.
Crackles and an S3 heart sound. We’ve got heart failure folks! Throw in some pitting edema to cinch the diagnosis.
But the USMLE is too smart to give you heart failure as an answer. What finding would we see in an alcohol induced cardiomyopathy? Alcohol traditionally causes a dilated cardiomyopathy, answer choice B.
Why does this approach work?
This question is really great at illustrating the methodology of jumping from chief complaint to end-of-stem question. You can see how we channeled our energy on reading the vignette through a cardiac lens, and it helped us land on an answer.
If the final question was something about CT chest findings, you’d approach the question in a similar manner, considering what the patient’s thorax would look like. The same enlarged heart would be there, but we would also be thinking about pleural effusions and pulmonary edema, secondary to fluid overload, secondary to a heart whose pumping is not up to snuff.
Summary of the Method:
To summarize:
0. Take a breath and clear your mind.
1. Learn what you can from the first sentence of the vignette.
2. Let your mind start wondering about potential diagnosis.
3. Read the question sentence at the end to see what’s being asked of you.
4. Read the rest of the question.
5. Gather all the details and assemble the big picture!
Final Thoughts
This systematic approach will help you arrive at the right answer. Remember, it’s not just about plowing through lots of Qbanks (though that’s important)! You need a way of handling questions that makes you a smarter and more efficient test-taker. In the end, that’s what leads to success on the USMLEs.
Now armed with this method, get out there and do some more USMLE practice questions!
And for extra (free!) content to help you with USMLE prep, check out these other posts on the blog:
