Aster USMLE Step 3 Notes Aster USMLE Step 3 Notes [80899]

Aster USMLE Step 3 Notes Aster USMLE Step 3 Notes [80899] -...

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Unformatted text preview: ASTER's USMLE Step3 Notes Recommended Study Material for Step3 Textbooks 1.Crush the Boards [5 days] 2.Swanson's Family Practice [15-20 days] 3.Ethics in Medicine (U of W site) [1 day] 4.Biostatistics [2 days] 5.Blueprints in OBG [2 days] 6.Blueprints in Peds [2 days] 7.Compass Surgery & Trauma Notes [1 day] CCS 1.USMLE 2003 CD (Software Tutorial + Sample Cases) 2.KAPLAN CCS TUTORIAL 3.VETAN'S LIST OF CCS CASES (list of recent cases) MCQs 1.Swanson's Family Practice 2.USMLE 2003 CD – sample MCQs 3.Kaplan Step3 CD – 200 sample MCQs 4.NMS Review – 750 questions 5.Kaplan Qbank for Step3 Page 1 of 94 May 19, 2003 Aster's USMLE Step3 Notes Critical aortic stenosis: virtually zero chance of successful CPR. Gout with h/o peptic ulcer disease: Rx of choice – colchicine (not indomethacin) pseudocyst <6w: external rainage >6w: internal drainage St. John's Wort: is a herbal medication with some efficacy in treatment of depression (no FDA Approval) Vaginal d/c pH < 4.5 : Consider Candida ph > 4.5 : Consider Bacterial Vaginosis Maternal Smoking / Alcohol: Symm IUGR Maternal HTN: Symm IUGR Physiological Jaundice / Exaggerated Physio / Breast Milk Jaundice: no risk of Kernicterus Kernicterus occurs @ 1% x Birth Wt. (in grams) [Bilirubin Level] PKU screen can be negative at 48hrs of life (requires a repeat screen after 48 hrs. to confirm) Maternal SLE: Congenital Lupus & 3rd degree Ht. Block (Anti-Ro) Respi Failure: <60 mmHg O2 >60mHg CO2 Maternal Solvent Abuse: assoc. with nail hypoplasia PDA closure achieved by Indomethacin NEC: Pneumatosis Intestinalis Neonatal CMV: confirm by isolation of virus from urine Transplacental spread is highest in primary HSV, Page 2 of 94 May 19, 2003 Aster's USMLE Step3 Notes very low in recurrent HSV Breast Milk (cf. Cow's Milk) high carboydrate low protein low iron, but more bioavailable inadequate Vit. D, Vit. K supplement Iron @ > 6 m in exclusively breast fed Infants of Diabetic Mothers with proteinuria, hematuria: ? Renal Vein Thrombosis (ass. with maternal DM) Transfusion Reactions: Febrile Reaction: WBCs in Donor Blood (Acetaminophen) Anaphylaxis: Proteins in donor blood (Antihistaminics, SQ Epinephrine) Hemolysis: Mismatch (Hydration & Diuresis) Infantile Colic: (Wessel Criteria) 3 m child; 3 hrs/day; >3 days/week; > 3 wks. duration ADHD: 1.Methylphenidate / Dextroamph / Mg Pemoline 2.TCA / SRI (second line) 3.Don't use Benzodiazepines 4.consider “drug holiday” on weekends ACEIs contraindicated in preg. HyperTG Rx: Gemfibrozil Hypercholesterolemia (Drug Rx): >190: 0-1 risk factors >160: >= 2 risk factors >130: CAD equivalent / CAD if > 15% reduction reqd: “statins” if < 15% reduction reqd: (Low HDL) Niacin (normal HDL) Cholestyramine Obesity in Children Triceps Skin Fold Thickness OCP induced hepatic adenomas : tendency to rupture (Surgical resection) Page 3 of 94 May 19, 2003 Aster's USMLE Step3 Notes ELISA â-hCG (Urine) is (+) 14 d post conception RIA â-hCG (Serum) is (+) 14 d post conception Symptomatic Gallstones: Lap Cholecstectomy Ca. Tail of Pancreas: Poorest Prognosis Lobular Ca in situ is not premalignant Digitalis Toxicity is enhanced by: HYPERcalcemia, HYPOkalemia, HYPOmagnesemia Infant of HIV + mother (steps to derease transmission) 1.Intrapartum I/V AZT 2.LSCS delivery 3.AZT prophylaxis to child x 6 m 4.No breastfeeding 5.HIV test at 6m - 12 m Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervain's Disease) Rx for Chlamydial Ophthalmia: ORAL Erythromycin (to prevent chlamydial pneumonia) Commonest Hernia: Indirect Inguinal Hernia T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG CPK-MM is increased in hypothyroidism (proximal myopathy) Fetal Weight Determination: HC, BPD, AC, FL Fetal Age Determination: Transcerebellar Diameter RA: associated with atlanto-axial subluxation (“drop” attacks) PTE: (A-a) O2 gradient is always abnormal even if PaO2 is normal [highly sensitive] Page 4 of 94 May 19, 2003 Aster's USMLE Step3 Notes Fever 24-48 hrs. Postop: #1 Atelectasis (D)EH / (B)CP / BR Pneumococcal Vaccination is required in CSF Leak Nephrotic Syndrome: Fatty Casts Pyelonephritis: WBC Casts Cystitis: WBCs GN (PSGN): RBC Casts CRF: Broad Casts Cold Antibody: IgM - Inravascualr Hemolysis Warm Antibody: IgG - Extravascular Hemolysis Addison's: ACTH Simulation Test Cushing's: Dexamethasone Suppresion Test Conn's: Salt Loading Response Diabetes Insipidus: Water Deprivation Test Hemophilia A: aPTT increased, BT normal vWD: aPTT increased; BT increased (Ristocetin Cofactor Assay) Factor VII def.: PT increased, BT normal Aspirin: prolonged BT, no effect on CT spiking fever despite antibiotics, 1 wk. postLSCS ?Septic Pelvic Thrombophlebitis (Mx: i/v Heparin) Mx of Myesthenia Gravis: PYRIDOSTIGMINE (not PHYSOSTIGMINE cuz of CNS effects) vWD & Aortic Stenosis: ass. with Angiodysplasia Alcoholic Cirrhosis: â-gamma bridge d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease screening for malabsorption: 24 hour fecal fat ? Penicillamine increases survival in Scleroderma Page 5 of 94 May 19, 2003 Aster's USMLE Step3 Notes Congenital Syphilis may be associated with severe osteochondritis. Child may refuse to move limbs (Pseudoparalysis of PARROT) Abciximab: decreases restenosis rates post-PTCA PTCA: no effect on morbidity or mortality Diabetes Mellitus : assocation with hyperTG First line management of newly diagnosed diabetic: DIET (not drugs) DM+HTN: ACEIs Hypercalcemia: I/V Hydration + Loop Diuretics Obesity: BMI>27g/m2 or 120% of ideal body weight Caloric Intake increase: 300 Cal (Pregnancy); 50 Cal (Lactation) Pulmonary Embolism: i/v Heparin COPD excacerbation: H.flu, Pneumo., Moraxella Long term stabilization of exercize induced asthma: Salmetrol & Zafirlukast Severe acute asthma: < 50% best PEFR Moderate acute attack: 60-80% best PEFR Mild acute attack: >80% best PEFR #1 community acq. pneumonia: S. pneumoniae Ideal sputum sample: <10 epi./HPF & many PMNs GERD: Transient relaxation of LES Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD) Esophageal Ca.: most common type is AdenoCa. (Barrett's Esophagus) Sulfasalazine: effective in UC & Crohn's colitis / ileocolitis Page 6 of 94 May 19, 2003 Aster's USMLE Step3 Notes (not small-bowel Crohn's) Celiac Sprue: villous atrophy & reactive crypt hyperplasia Dermatitis Herpetiformis (Mx: Dapsone) H. pylori association: DUODENAL > GASTRIC –Serology (Past or Present Infection) –Fecal Antigen Detection (False [-] with PPI) –Urease Breath Test (False [-] with PPI) Triple Therapy, esp. for non-NSAID ass. ulcers 1st episode of PUD: emperical therapy (H2 -> PPI) Recurrent PUD: H. pylori eradication Infectious mononucleosis EBV, Sore Throat, LN, Splenomegaly Atypical Lymphocytes (also in CMV) Monospot (+): positivity wanes with time Serology: increased Anti-EA; increased Anti-VCA IgM â blockers decrease variceal bleed in portal HTN Ascites: Salt Restriction, Diuretic: Spironolactone narcotic analgesic switching use 1/5 equianalgesic dose Graves': Rx – Radioactive Iodine children & pregnant: Propylthiouracil WHO analgesic stepladder 1st LINE Aspirin, Acetaminophen, NSAIDs 2nd LINE Hydrocodone Codeine 3rd LINE Page 7 of 94 May 19, 2003 Aster's USMLE Step3 Notes Morphine Sulfate Hydromorphone Fentanyl Methadone Ca. ass. cachexia & anorexia: Prednisone, Magestrol Agitated Depression Rx: sedating TCA (not SSRI) Rx of choice for narcotic induced costipation: Lactulose Nephropathy Incidence: IDDM (40%) > NIDDM (20%) but #1 cause of Diab. Nephropathy is NIDDM ('cuz NIDDM prevalence is much higher than IDDM) Prevalence Inreases: PPV of test increases (NPV of negative test decreases) Screening for GDM Oral 50g Glucose: Bl. Glu. @ 1 hr. > 140mg% (+) F/U with Oral 100g Glu. 3 hour GTT values > 105 (0h) / 190 (1h) / 165 (2h) / 145 (3h) Obese Diabetic: Diet/Wt.Loss -> Metformin (ass. With Lactic Acidosis) Insulin in DM Initial dose: 15-20 U 2/3 of total : AM dose (2/3 regular, 1/3 intermediate) 1/3 of total : PM dose (2/3 regular, 1/3 intermediate) Conn's syndrome Mx Adenoma: Sx resection B/L hyperplasia: Spironolactone "cold nodules" on thyroid scan: ? Malignant #1 Thyroid Study: Serum TSH (yields max. info.) Multiple Sclerosis: 2 attacks more than 24 hours apart > 1 area of damage (Oligodendrocyte damage) m/c variant: relapsing-remitting type Page 8 of 94 May 19, 2003 Aster's USMLE Step3 Notes CSF mononuclear pleocytosis, CSF IgG increase Oligoclonal Banding of CSF IgG Myelin Breakdown Metabolites Headache on stopping NSAIDs: Analgesic withdrawl headache Jaw Claudication & Scalp Tenderness: GCA ESR increased Visual Loss Start Glucocorticoids without waiting for Bx results Aspirin in febrile children: Reye's Syndrome Continue anticonvulsants till seizure free for 4 years Menorrhagia with hemodynamic compromise: i/v conjugated estrogen normal Hb in women: 12.0 normal Hb in pregnancy: 11.0 (1st & 3rd trimester) 10.5 (2nd trimester) m/c variant of Hodgkin's : Nodular Sclerosis Hodgkin's: Supraclav. node NHL: epitrochlear node / likely to be extranodal Osteoarthritis Joint space narrowing sclerosis subchonral cysts osteophytes (mere osteophytes are not OA) OA: Isometric exercizes are better than isotonic CFS: T cell activation -> CNS effect of cytokines nonREM sleep anomaly (also seen in Fibromyalgia) Gout prophylaxis: required for recurrent attacks (not indicated after first attack) Page 9 of 94 May 19, 2003 Aster's USMLE Step3 Notes Strep Sore Throat Rx: can prevent Rh. Fever NOT PSGN!!! Potassium sparing diuretics can cause severe hyperkalemia in CRF SULINDAC: NSAID with no nephrotoxicity Asymp. Bacteruria in Pregnancy : Treat with antibiotics [Amoxycillin is safe] (high risk of pyelonephritis) Give Chlamydia Rx in Gonorrhea -> i/m Ceftriaxone + PO Doxycycline Biophysical Profile : TBMAN Tone, Body Movements, Breathing, AFI, NST Early Deceleration: Head Compression Variable Deceleration: Cord Compression Late Deceleration: Uteoplacental insufficiency GU+NGU: 1 g Azithromycin stat ACNE Mx –Benzoyl Peroxide –Topical Tretinoin –Topical Antibiotics –Systemic Antibiotics –Systemic Isotretinoin Acne Rosacea Mx Topical Metronidazole -> Systemic Antibiotic [Benzoyl peroxide & Tretinoin can aggravate rosacea] Female Infertility (Hormonal) Hyper-estrogenic: CLOMIPHENE CITRATE Hyper-PRL: Bromocriptine (PIH) Narcotic Dependence: Methadone replacement Page 10 of 94 May 19, 2003 Aster's USMLE Step3 Notes External Hemorrhoids: Excision with elliptical incision Internal Hemorrhoids: Banding 2nd trimester eclampsia: Molar pregnancy Molar pregnancy: hyperemesis gravidarum Most important obstetric measurement: Diagonal Conjugate (at least 11.5 cm) Amniotomy: perform after enagement of fetal head Rx of HTN in preg.: á-methyldopa, hydralazine BP reduction goal in pre-eclampsia: Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental perfusion) #1 maternal disease causing IUGR: Maternal HTN #1 cause for 1st tri. abortions: Chromosomal ab(n) Postpartum Blues: < 2 weeks Postpartum Depression: > 2 weeks Major Depression: >= 5 symptoms for > 2 weeks Mania: >= 3 symptoms for > 1 week Primary Type 1 Osteoporosis: # vertebrae Primary Type 2 Osteoporosis: # neck femur HRT Progesterone required only if uterus is present Estrogen: dec. LDL, inc. HDL Progesterone: inc. LDL, dec. HDL Estrogen's cardioprotective effects of estrogen are not mediated through cholesterol. Estrogen promotes EDRF synth. In vascular endothelium Repeat Pap: if reqd., no sooner than 6 weeks Hormonal contraception if h/o DVT/PE (+): Norplant & DMPA (Progesterone based), not OCPs Page 11 of 94 May 19, 2003 Aster's USMLE Step3 Notes Jarisch Herxheimer reaction: Syphilis Rx (chills) HPV: condyloma acuminata HPV 18: fastest progression to Ca. Cx Acute Epididymitis: #1 cause: Chlamydia trachomatis #1 bacterial cause: E. coli (m/c in >40 y age) Depression: Cognitive Psychotherapy + SSRI Drug Rx of Bipolar Disorder: Li, Carbamazepine, Valproate, Gabapentin, Lamotrigine (ass. With SJS) Lithium: Hypothyroidism, NDI Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia Drug Dependence: WITHDRAWL & TOLERANCE Mx of DTs –Intermediate acting BZDs (Diazepam) –IV saline (no glucose containing fluids) –IV thiamine BZD in Hepatic Enceph.: Oxazepam Fluid Deficit in Burns = 4mL/kg x %BSA (Parkland Formula) 1st degree: 2nd degree: clean, sulfadizine, nonadhesive dressing 3rd degree: refer to plastic surgeon for escharotomy Heat Cramps: ORS Heat Exhaustion: IV Fluids Heat Stroke: neurological dysfunction & absence of sweating (may not be dehydrated) Hypothemia: Osborne (J) wave on EKG Mild: (32-35 C) Passive External Rewarming Page 12 of 94 May 19, 2003 Aster's USMLE Step3 Notes Moderate: (27-32 C) Active External Rewarming Severe: (< 27C) Active Core Rewarming Depression: Cognitive Psychotherapy Anxiety Dsorders: Behavioral Psychotherapy Adjustment Disorder: Supportive Psychotherapy Social phobia: bea blockers & assertive training Specific phobia: systematic desensitization Panic: SSRI & Alprazolam (short T1/2) –Na Lactate can mimic a panic attack –use alprazolam for panic, not GAD –may be associated with rebound anxiety OCD: (associated with anxiety) SSRI OC PD: insight-oriented psychotherapy Somatization Disorder: 4 Pain, 2 GI, 1 sexual symptoms (associated with abuse in childhood) Depression: SSRI + Cognitive Psychotherapy “Atypical” depression: MAOIs are first-line Generalized Anxiety: Buspirone (selective anxiolytic) Sexual Dysfunction Young Males: Premature Ejaculation (Mx: start and stop penile stimulation, not SSRIs) Older Males: #1 Erectile Dysfunction Females: #1 Hypoactive Sexual Desire Young males with sexual dysfunction: Psychogenic Older males with sexual dysfunction: Organic The PATIENT is the head of the healthcare team ADHD associated with: Conduct Disorder and Oppositional Defiant Disorder (also with Tourette's Syndrome) Page 13 of 94 May 19, 2003 Aster's USMLE Step3 Notes ADHD with (+) h/o or F/H tics DO NOT USE STIMULANTS Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bile unchanged. (does not enhance conjugation) Water Supply > 1 ppm fluoride: No supplementation Retrocecal Appendicitis: poorly localized pain Appendicitis #1 cause : lymphoid hyperplasia Mx: Surgery Yersnia enterocolitis can mimic appendicitis Painkillers & antibiotics can alter presentation Preg. With appendicitis: atypical location of pain Elderly: higher chances of perforation Appendiceal abscess: Delay surgical intervention If on lap., some other cause is found – do an appendectomy anyway, to prevent confusion in future Oral Dissolution of Gallstones URSODIOL single floating cholesterol stones in functioning g.b. Asymp. Gallstones: DO NOTHING Symptomatic Gallstones: Lap. Cholecystectomy #1 complication of Lap Chole: Bile Duct Injury Choledocholithiasis: ERCP with sphincterotomy idications of ERCP: –small stones –dilated CBD –palpable stones in CBD –jaundice Plantar Warts: Cryosurgery Venereal Warts: Podophyllin (not in pregnancy) Cullen's Sign: periumbilical discoloration Grey Turner Sign: flank discoloration Page 14 of 94 May 19, 2003 Aster's USMLE Step3 Notes #1 radiological signs in pancreatic disease acute pancreatitis: sentinel bowel loop chronic pancreatitis: pancreatic calcification Crucifer intake reduces Colon Ca. Ca. risk of polyps is dependent on villous content #1 risk factor for pancreatic ca. : smoking #1 cause for chronic low back pain: idiopathic –bed rest has no role –no need for imaging (X-Ray / CT / MRI) –prescribe an exercize program (can temporarily excacerbate symptoms) Acetohydroxamic acid: urease inhibitor (acidifies urine in patients with struvite stones) HTN with BPH: Terazocin (á blocker) Vestibular Neuronitis: NO hearing loss Meniere's Diseass: Tinnitus, Vertigo, Hearing Loss Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo Acute Bacterial Sinusitis: Pneumococcus no role of imaging (Dx by h/o & PE) ? antibiotics – PO Amox x 7-10 days Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf. other TCAs Alzheimer's Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors Polymyalgia Rheumatica: Oral Steroids GCA: I/V Seroids Elderly black HTN: CCB & Thiazide Diuretics Parkinson's with Tremor has a better prognosis than pts. with symptoms of Postural Instability & Gait Disturbance Page 15 of 94 May 19, 2003 Aster's USMLE Step3 Notes Perform Postvoid Residual Urine measurement on every elderly patient with Urinary incontinence to r/o Urinary Retention Alzheimer's & Parkinson's cause Detrusor Hyperreflexia : URGE INCONTINENCE @ high risk for pressure ulcers: reposition q2h low-risk patients: reposition q6h USPSTF –prenatal ultrasound not mandatory –? role of PSA & DRE in screening of asymptomatic individuals Hyperlipidemia screening: NONFASTING SERUM CHOLESTEROL if elevated: do a FASTING LIPID PROFILE á-FP estimation at 5-17 weeks to r/o NTD –increased: ultrasound (can detect 80% anomalies) –decreased: does not necessarily indicate Downs' QUIT SMOKING before starting Nicotine replacement Transdermal Nicotine Replacement: 21mg -> 14mg -> 7mg [Pts. with CAD, start with 14 mg.] [Nicotine is vasoconstrictor, risk of MI] Pesticide exposure has been linked to Prostate Cancer HTN increases the risk of stoke > CAD 2% reduction in CAD for every 1% decrease in serum cholesterol Cancer mortality is increasing stroke/CAD mortality is decreasing HAART drug interactions “statins”, Antihistaminics, Ergot alkaloids AIDS in infants: better prognosis cf. adults d/o/c for malaria prophylaxis: MEFLOQUIN once-a-week (1 w before travel & 6 weeks after) Page 16 of 94 May 19, 2003 Aster's USMLE Step3 Notes Influenze A: adults Influenza B: children Influenza epidemics: Influenza A Influenza vaccine: A & B Amantidine protects only against “A” (Rimantidine preferred in patients with renal failure) Oseltamivir (Tamiflu®) protects against both “A” & “B” Annual influenza vaccination for age > 65 y #1 cause of traveler's diarrhea: ETEC Cardiac Arrest: 1st step – initiate 911 call Cardiac Arrest in Children: Assess, 1 min. on CPR Initiate 911 call Mx of Respiratory Acidosis: Increase Ventilation (Use of NaHCO3 is not wise to Mx Respi. Acidosis) 1-person CPR: 15:2 2-person CPR: 5:1 symptom to treatment time: <60 minutes ED to needle time: <30 minutes A. Fib.: (Unstable): Sync. Cardioversion V. Fib.: Async. Defib. [200 -> 300 -> 360 mJ] SVT: Vagal Maneuvres -> Adenosine V.Tac.: Lidocaine, Procainamide, Bretylium V.Tac.: (Unstable): Cardiovert V. Fib: Defibrillate, Epinephrine Defibriallate again Lidocaine 2nd line antiarrhythmic Asystole: Immediate transcutaneous pacing Epinephrine -> Atropine -> Consider Bicarbonate Page 17 of 94 May 19, 2003 Aster's USMLE Step3 Notes Use intra-osseous route in age < 6 years DKA Insulin 0.1U/kg/hr + NS Add K+ when Blood Glucose approaches 250, shift to 5%D m/c cause of abdo. Pain in elderly: CONSTIPATION Use activated charcoal with 70% sorbitol in poisonings Cuffed ETT for age > 7yrs #1 Poisoning: OTC Analgesics Naloxone: Short acting Naltrexone: Long acting (used in rehab programs, not acute overdose) Urticaria: Subcutaneous edema Angioedema: Mucosal edema Colles' #: Dinner Fork abnormality (Splint in Neutral position) Suspected Scaphoid # & X-Ray (-) APPLY THUMB SPICA CAST anyway Ankle Inversion Injury - Lateral Ligament Sprain - Anterior Talofibular Ligament McMurray Test: –Meniscal Tear –Joint Line Tenderness Lachman Test: Anterior Cruciate Ligament Injury Dislocation of Shoulder: –Anterior Page 18 of 94 May 19, 2003 Aster's USMLE Step3 Notes –associated with axiallry artery injury NBT (-) : CGD (SXR) -> IFN-gamma Prostatic Mets.: BONE SCAN > SKELETAL SURVEY MYELOMA: SKELETAL SURVEY (Bone Scan is useless, does not detect lytic lesions) #1 cause of death in myeloma: Pulmonary or UTI Duration of Maintenance Pharmacotherapy for depression (even for single episode) should be at least 6 months. Desert Rheumatism: C immitis Mx – Conservative Rx required only for dissemination / lung lesions #1 Kidney stones: Calcium Oxalate (radiopaque) [Square Crystals] URIC ACID stones are radiolucent CYSTINE crystals in urine are always pathological Crohn's: associated with gallstones & kidney stones [increased absorption of oxalates from the gut] #1 complicatin of chickenpox: 2º skin infection Postop Fever @ 24 hours: atelectasis Postop Fever @ 5-10 days: wound infection (early wound infection: clostridia / pesudomonas) Neonatal Meningitis: S. agalactiae (Gp B Strep) C1 esterase inhibitor deficiency: –hereditary angiodema –depleted C4 levels –Mx: FFP/e-ACA/Stanozolol –Maintain: ANDROGENS (inc. synthesis) Suspect endometrial cancer: gynecological referral for enometrial biopsy Page 19 of 94 May 19, 2003 Aster's USMLE Step3 Notes Pap misses 60% of endometrial Ca. Cryoprecipitate: replaces Fibrinogen & Factor VIII FFP: replaces all coagulation factors Reversal of warfarin action: FFP (chronic: Vit. K) Reversal of heparin action: Protamine sterile subdural effusions: H. influenzae meningitis pneumonia with effusion / empyema: Staph. aureus Lipase is more sensitive and specific than amylase Serum amylase elevated for 2-4 days Urinary amylase elevated for 7-10 days #1 cause of sensorineural hearing loss: PRESBYACUSIS #1 cause of conductive hearing loss: OTOSCLEROSIS osteomyelitis after foot puncture wound: Pseudomonas Acromegaly –Inability to supress glucose –no stimulation of GH with levodopa –paradoxical increase of GH with TRH #1 intracranial mass lesion: METASTASIS #1 brain malignancy (adult): Glioblastoma multiforme #1 brain malignancy (child): Astrocytoma adult: supratentorial children: infratentorial (#1 supratentorial in children is craniopharyngoma) SVC Syndrome: Think Bronchogenic Ca. AML with DIC: M3 variant of AML AML with gum chloromas: M5 variant of AML Hairy Cell Leukemia: TRAP+ (Rx: Cladribine) Page 20 of 94 May 19, 2003 Aster's USMLE Step3 Notes Port Wine Stain: Sturge Weber Syndrome CSF has a higher Cl- content compared to plasma Rocky Mountain Spotted Fever: Dx – Indirect IF Rx – DOXYCYCLINE (< 8y: Chloramphenicol) Neurofibromatosis: > 6 cafe au lait spots [or 1 spot > 5cm] Tuberous Sclerosis: Cardiac Rhabdomyomas Angiomyolipoma of Kidney Subungal Fibromas Decreased Haptoglobin: Intravascular Hemolysis Very Severe Extravascular Hemolysis OSTEOPOROSIS: Serum Ca++ & PO43- are normal Testicular Torsion: affected testis lies horizontally Mx – Surgical Fixation of BOTH Testes Torsion of Testicular Appendix: BLUE DOT Mx – Exploration of other scrotum not required m/c Thyroid Malignancy: Papillary Ca. Thyroid MEN Syndrome: Medullary Syndrome Hematogenous Spread: Follicular Ca. Patella dislocates laterally Mx PTSD with Group Psychotherapy (not BZD : high risk of BZD abuse) Fever without Focus: #1 cause: Occult Bacteremia due to Pneumococcus due to Otitis Media Page 21 of 94 May 19, 2003 Aster's USMLE Step3 Notes Signs of Occult Bacteremia: Temp > 40C WBC < 5000 or WBC > 15000 Acute Otitis Media: Strep. pneumoniae (Amoxicillin) #1 Pediatric Gastroenteritis: Rotavirus #1 Pediatric (Bacterial) Gastroenteritis: C. jejuni Recurrent Otitis Media: –definition: >3 in 6 months or >4 in 1 year –Amox prophylaxis -> Myringotomy & Tubes Indications of Tonsillectomy: –1 episode of Quinsy (Peritonsillar abscess) –> 7 proven streptococcal pharyngitis –airway obstruction decreases recurrent sore throat, not URI Suspected Strep Sore Throat: Sore throat, fever, cervical LN, tonsillar exudates Only 15% of sore throats are streptococcal Rapid Strep. Test (HIGH SPECIFICITY) even If (-), start treatment & perform a throat swab Simple Diarrhea No role of Stool Culture: Stool Culture indicated only if: –bloody diarrhea –persistent diarrhea –(+) tenesmus –h/o foreign travel Mx: Oral Rehydration Solution (not juices or carbonated beverages) Children with no dehydration – age-appropriate diet Gp A â-hemolytic Streptococci are usually susceptible to Penicillin (this is not the case with Staphylococci) Strep viridans sensitive to Ampicillin + Gentamycin German Measles (Rubella) Page 22 of 94 May 19, 2003 Aster's USMLE Step3 Notes Measles (Rubeola) Roseola infantum (Exanthem subitum) HHV 6 high fever, rash appears after fever subsides Lead levels > 10 : environmental abatement start chelation therapy @ higher levels (? > 25) single umbilical artery associated with renal ab(n) Caput crosses midline; cephalhematoma does not HbS Disease: Prophylactic Penicillin till 5y age Stranger Anxiety: 6-9m Separation Anxiety: 12-15m Encopresis: >4 y Enuresis: >5 y Simple Febrile Seizures: –Single Seizure –Nonfocal –< 15 minutes durations –associated with high fever –Rx: antipyretics (NOT ANTICONVULSANTS) –F/H (+) –Can recur Meningococcal Contacts: Rifamp/Cipro prophylaxis (#1 cause) Seasonal Allergic Rhinitis-Ragweed (#1 cause) Perennial Allergic Rhinitis-House Dust Mite Choanal Atresia –cyanosis with feeding –relieved by crying Dog & Cat Bite: P multocida (Rx: Amox-Clav) Cat scratch disease: Bartonella henselae Cushing's Syndrome: #1 Iatrogenic Cushing's Disease: #1 Pituitary Microadenoma Page 23 of 94 May 19, 2003 Aster's USMLE Step3 Notes Dx: 24 hour urinary free cortisol to diff. Pituitary & adrenal cause: Overnight DST Pick's Disease: Dementia / atrophy of frontal & anterior temporal lobes [early psychiatric manifestations] Dementia with Lewy bodies: (Alzheimer's + Parkinsonism features) DO NOT USE ANTIPSYCHOTICS [they can excecerbate parkinsonism features] Dialysis Dysequilibrium Syndrome: associated with rapid correction of uremia HTN in elderly African Americans: CCB + Diuretics HTN in young African Americans: Diuretics Paget's Disease of the bone: extent is delineated by Tc 99 scan Wounds < 12 hours old, clean: primary closure Wounds > 12 hours old, contaminated: debridement and secondary closure concomitant use of I/v heparin with thrombolysis: Ac. anterior MI & Left Venticular Thrombus Pts. with non-Q wave MI & previous CABG do not benefit considerably from thrombolysis High risk features post-MI 1. Post MI angina 2. Non Q Wave MI 3. CHF 4. LVEF < 40% 5. > 10 PVCs / min e/o Significant Ischemia on Exercize Stress Test: 1.ST segment depression 2.< 6 METS work [email protected] < 70% predicted maximum heart rate 4.Hypotensive Response Page 24 of 94 May 19, 2003 Aster's USMLE Step3 Notes LDL is the most important “lipid” risk factor for CAD Cholesterol: < 200, 200-240, > 240 LDL: < 130, 130-160, > 160 treatment of choice for hypercholesterolemia: DIET Basilar & Hemiplegic Migraine DO NOT use SUMATRIPTAN (also c.i. in IHD/MI, Pts on SSRI/MAOI/Li) Acute A. Fib.: (Stable) â-blockers & CCB (Unstable) Sync. Cardioversion Obesity is a risk factor for Endometrial Ca. Surgical intervention for obesity : BMI > 40 kg/m2 Heparin: keep PTT 1.5-2.0 x control Warfarin: keep PT 1.5-1.8 x control Enoxaparin (LMWH): No PTT monitoring required COPD : smooth muscle hyperplasia (as in asthma), but Methacholine challenge test is negative REID INDEX: ratio of thickness of bronchial glands to bronchial wall thickness (increased in chronic bronchitis) Nicotine enhances growth of H. flu Most effective long term pharmacotherapy for COPD: Ipratropim bromide COPD excecacerbations: H. flu, Pneumococcus, Moraxella LONG TERM HOME OXYGEN THERAPY Only Rx in COPD that enhances survival indications: –Resting PaO2 < 55 mmHg –Resting PaO2 < 60 mmHg with tissue hypoxia (cor pulmonale / polycythemia) Page 25 of 94 May 19, 2003 Aster's USMLE Step3 Notes Acute Bronchitis in healthy non-smoker: no Investigations, no treatment (no antibiotics) Early phase of asthma: primary mediators Late phase of asthma: secondary mediators Prophylaxis of exercize induced asthma: Albuterol Long term stabilization of exercize induced asthma: Salmetrol (long acting) + Zafirlukast Mycoplasma pneumonia: –minimum physical findings –B/L lower lobe infiltrates –Cough (+) –Mx: Macrolide Cold Agglutinins (IgM) Inravascular hemolysis Pnenumonia in elderly debilitated alcoholic: Lower Lobe: Strep pneumoniae Upper lobe: Klebsiella (currant jelly sputum, hemoptysis, cavitatory lesion) Normal Semen analysis vol. 2-5 mL sperm conc. > 20 million / mL morph > 30% normal motile > 50% motile #1 cause of dysphagia: lower esophageal ring (in the absence of risk factors for esophageal cancer) Systemic Sclerosis associated with severe GERD UC (Dx): Colonoscopy Crohn's (Dx) : air contrast barium enema Alcoholic Hepatitis: AST >> ALT (ratio > 2.0) Malignant Neuropathic Pain Sharp Stabbing: Rx anticonvulsants (Carbamazepine) Dull Aching: Rx TCA (Desipramine) Page 26 of 94 May 19, 2003 Aster's USMLE Step3 Notes Mx of Chemotherapy induced Emesis: ONDANSETRON Pain control : round-the-clock dosing > cf. PRN TPN: no mortality/morbidity benefit in cancer pts. Vestibular Nausea Rx: Cyclizine Radiotherapy assoc. diarrhea: Loperamide / Codeine Narcotic induced constipation: LACTULOSE #1 symptom in avanced cancer is weakness (ASTHENIA) SSRIs can make agitated depression worse (Use sedating TCA & Anxiolytic PRN) #1 metabolic derangement with advanced malignancy: ++ (long PR, decreased QT, wide T waves) –hyperCa Type 1 DM is HLA DR3/DR4 associated Type 2 DM - Obesity & Family History OHAs –Biguanides decrease Glucose production & increase peripheral utilization (Metformin) –Sulfonylureas stimulate Insulin release (Glibenclamide) –Glitazones DECREASE INSULIN RESISTANCE (Troglitazone) –á-glucosidase inhibitors decrease carbohydrate absorption (Acarbose) MODY –pts. are normal to underweight –< 40 years age –AD inheritance –F/H (+) in 50%Dx of DM Diagnosis of Diabetes Mellitus Page 27 of 94 May 19, 2003 Aster's USMLE Step3 Notes –FBS (2 values) > 126 mg% –RBS (1 value) > 200 mg% –GTT (100g oral glucose): 2 hour value > 200 mg% Li induced NDI : stop Li -> start Carbamazepine #1 feature of Cushing's: Truncal Obesity (90%) Pathophysiology of Migraine: CNS Platelet aggregation with Serotonin release Very Severe Migraine (abortive): SUMATRIPTAN Moderately severe Migraine (abortive): DHE Status migrainous: migraine lasting > 72 hours Cluster Headaches: Sumatriptan / O2 inhalation New onset seizure < 40 y age: #1 Idiopathic > 40 y age: #1 Brain Tumor Discontinue anticonvulsants after seizure-free for 4y (confirmed by absence of epileptiform activity on EEG) Grand mal: Phenytoin Petit mal: Ethosuximide Thrombotic Stroke: slow and continuing (m/c variety) Embolic Stroke: sudden #1 risk factor for CVA: HTN CEA for Symptomatic Carotid Artery stenosis > 70% Fe deficiency anemia (most sensitive Ix): S. Ferritin #1 inherited bleeding disorder: vWD Inherited hypercoagulable state Factor V Leyden (most common) Prot C def. / Prot. S def. Anti-thrombin III deficiency Page 28 of 94 May 19, 2003 Aster's USMLE Step3 Notes Anti-PL antibodies: can cause arterial thrombosis TTP: do NOT give platelet transfusion vWD: Factor VIII (cryoppt.) DIC: FFP COX-2 (Celecoxib): less GI side effects cf. NSAIDs Exercize program in OA Graded, Active Exercize, Isometric Fibromyalgia –tenderness in 11 of 18 defined –r/o comorbid depression points –ass. with sleep disorder (á-nonREM sleep anomaly) -> also in CFS Mx of Chronic Fatigue Syndrome: –NSAIDs –nonsedating TCAs Both FIBROMYALGIA & CHRONIC FAIGUE SYNDROME have á-nonREM sleep anomaly GOUT prophylaxis: only for recurrent attacks (> 2-3 attacks) [not after first atack] #1 cause of Chr. Renal Failure: DM Mx of uncomplicated UTI: 3 days of TMP-SMX Artificial Donor Insemination –Store semen for 6 months –Check donor for HIV @ 6 m –If still (-), proceed with insemination #1 step in Obstructive Sleep Apnea: Weight Reduction BZD can worsen Obstructive Sleep Apnea Narcolepsy Mx: –Methylphenidate Page 29 of 94 May 19, 2003 Aster's USMLE Step3 Notes –Dextroamphetamine –Mazindol (TCA) Long T1/2 BZD are associated with lower incidence of rebound anxiety (e.g. Flurazepam) Bisphosphonates Oral - to be taken in the morning on empty stomach with 8 oz of water (to prevent esophagitis) Alendronate (FDA approved) Etidronate (less efficacious) Pamidronate (I/V infusion) SERMs (Raloxfene): –Estrogenic on Bone / Lipids –Anti-estrogenic on Uterus & Breats Marjolin Ulcers: squamous cell ca. in old scars Immunosuppression is a risk facor for Sq Cell Ca. PRCA (Pure red cell aplasia) may be associated with thymoma Aplastic Anemia causes <3% fall in Hct / week [>3% fall in Hct / week: Hemolysis / Hemorrhage] Hereditary Spherocytosis: –AD –Spectrin –Microcytosis –increased MCHC, increased Osmotic Fragility –Lifelong FOLATE supplementation –Rx: SPLENECTOMY PNH: –acquired defect in DAF Sugar Water Test –prone to hepatic & mesenteric vein thrombosis –may progress to Aplastic Anemia / AML –Dx: Blody Nipple d/c: DUCT EXCISION (no role of ductography) Page 30 of 94 May 19, 2003 Aster's USMLE Step3 Notes G6PD def.: older RBCs are deficient in enzyme, hemolysis is self-limited G6PD def. (Mediterranean Variant): all cells are deficient - severe and chronic hemolysis MYELOFIBROSIS: –poikilocytosis –giant abnormal platelets –dry bone marrow tap “Clustered Polymorphic Microcalcification” on Mammography is s/o Breast Cancer Mammography is never a substitute for BIOPSY. Mammo is for detection of other lesions and screening the contralateral bereast. It does not rule-in or rule-out cancer HbSC disease: –increased incidence of Proliferative Retinopathy –decreased vaso-occlusive and pain crisis Fever in Neutropenia: consider infectious Rx of acute promyelocytic leukemia: RETINOIC ACID Serum LDH is a prognostic marker in Lymphomas multiple myelomas with no paraprotein : 1% (very aggressive) TTP & HUS: normal coagulation studies (cf. DIC) Uremia is asscoaited with qualitative platelet defect Hemophilia with low platelet count: ??? HIV associated immune-thrombocytopenia Hemophilia with no improvement with Factor VIII infusion: ??? suspect Factor VIII Inhibitor activity [Serum Mixing Test] Mx: Steroids or Cyclophosphamide Vit. K dep. factors: Factor II, VII, IX, X (Vit. K def.: corrected by Vit. K administration) Page 31 of 94 May 19, 2003 Aster's USMLE Step3 Notes Liver Disease: decreased vit. K dependent factors & Factor V (coagulopathynot corrected by Vit. K administration) 1 Unit of Packed Red Cells 300 mL volume = 200 mL of Red Cells raises Hc by 4% When Typo “O” blood is being used (universal donor): use packed red cells, not whole blood Constipation <50y: increase fiber or osmotic laxatives >50y: FOBT If (+), Colonoscopy (Sigmoido/Ba enema) Mayonnaise/Salad Dressing: S. aureus food poisoning Small Bowel Diarrhea: Voluminous, Bloating Large Bowel Diarrhea: small volume, LLQ Cramps Methylene Blue stain of stool detects Fecal Leukocytes Follow-up Rx of DKA with ANION GAP (not serum Ketones) –ketone estimation detects only acetate and acetoacetate –the predominant ketone in DKA is b-HAP –as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum ketones might suggest "paradoxical" worsening ketonemia Osmotic Diarrhea: decreases with fasting Fecal Fat > 10g/24hours : s/o Malabsorption UGIH #1 Peptic Ulcer #2 Variceal Bleed (#1 cause of death from UGIH) LGIH #1 (>50y) Diverticulosis (#2: Angiodyslasia) LGIH Dx <50y: Anoscopy or Sigmoidoscopy >50y: Colonoscopy (Sigmoido/Ba enema) Page 32 of 94 May 19, 2003 Aster's USMLE Step3 Notes Ascitic Flluid: SAAG > 1.1 [Portal HTN] Spontaneous Bacterial Peritonitis –> 500 cells / ìL –> 250 PMNs / ìL –Total Protein < 1g / dL –Mx: i/v Ceftriaxone (no anaerobic cover required) –prophylactic FLUOROQUINOLONES to prevent recurrences Familial Mediterranean Fever: –Turks, Armenians, Arabians –recurrent abdominal pain (resembles acute surgical abdomen) –attacks resolve in 24-48 hours –associated with serositis & pleuritis –recurrent attacks cause secondary amyloidosis –Rx: COLCHICINE Uncomplicated GERD: H2 blockers (1st line) -> PPI Complicated GERD: PPI (1st line) Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic Portosystemic Shunt) –associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, âblockers) Non-invasive tests for H. pylori –serology (past & present infection) –fecal antigen detection –urea breath testing PPI can cause False (-) fecal antigen & breath test Duodenal ulcers heal faster than gastric ulcers Long term PPI Rx not required in PUD Long term PPI Rx required in GERD H. pylori eradication: PPI / Amox / Clarithromycine 50% of H pylori isolates are Metronidazole-resistant •10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD Page 33 of 94 May 19, 2003 Aster's USMLE Step3 Notes Rx of Whipple's Disease: TMP-SMX for 1 year Giardiasis can cause Lactase deficiency Ogilvie's: acute colonic pseudo-obstruction Gastric malignancy #1 Gastric adenocarcinoma #2 B-cell lymphoma Celiac Sprue increased incidence of intestinal T-cell lymphomas Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary 5-HIAA) •increased right sided valvular lesions Abdominal Pain relieved by defecation: IBS Cl. difficile: watery diarrhea (Dx: Toxin Assay) Budesonide: high potency steroid low systemic side efects (due to high first pass metabolism) useful in nflammatory bowel disease When UC/CD diff. is difficult UC: pANCA (+) CD: ASCA (antbodies to s. cerevisiae) UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC) APC Gene: –AD –Polyps -> Adenomatous Polyps -> Ca –small bowel polyps (low malignant potential) & gastric polyps (no malignant potential) may also be found FPC: begin screening colonoscopy @ 12-20 y age Peutz Jeghers: –colonic polyps have no malignant potential –increased extraintestinal malignancies Page 34 of 94 May 19, 2003 Aster's USMLE Step3 Notes (Breast, Gonads, Pancreas) HPNCC: –Colorectal Ca (+) (few, flat, fast-progressing adenomas) –40% lifetime risk of endometrial cancer Right sided Colon Ca: Bleeding Left sided Colon Ca: Obstruction Hep D superinfection is more severe than co-infection HAV infection: may have relapses Acute Hepatic Failure: Encephalpathy in < 8w Subacute Hepatic Failure: Enceph. in 8w - 6m Chr. Hepatitis: > 6m Anti-HCV: EIA -> if (-) -> confirmatory test RIBA Chronic HBV: IFN-á or LAMIVUDINE Chronic HCV: IFN-á or RIBAVARIN Chronic HCV infection: ass. with cryoglobulinemia and Type2 DM (NIDDM) Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y enterocolitica infections Dx of Budd Chiari syndrome: Duplex Doppler U/S Left Heart Failure: increased liver enzymes (ischemic injury) Right Heart Failure: increased Bilirubin & Ascites (>> periph. edema) Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis Mx: Splenectomy #1 organism causing pyogenic liver abscess: E. coli Page 35 of 94 May 19, 2003 Aster's USMLE Step3 Notes OCP associated Liver Adenoma (Mx: RESECTION even for asymptomatic cases) Meperidine: least Sphincter of Oddi spasm UC with pruritus: consider PSC S. amylase can be increased in MUMPS ue to salivary gland involvement without involvement of pancreatic gland [but S. Lipase would be normal in cases of extrapancreatic elevation of amylase] Antibiotic of Choice in Pancreatic Infections: IMIPENEM Tamoxifen: decreases Breast Ca. / increases Endometrial Ca. SERMs (Raloxifene): decreases Breast Ca. / decreases Endometrial Ca. Medical Adrenalectomy Aminoglutethemide + Corticosteroids HRT after Breast Ca. -> Raloxifene IgE is not involved in anapylactoid reactions (e.g. radiocontrast allergy) CD3 : pan B cell marker CD19: pan T cell marker Dx of CREST syndrome is clinical (not based on anti-centromere antibody) Of all HLAs - HLA-DR compatibility is essential for long term graft survival Cyclosporin: decreases CMI & decreases IL-2 (T-cell activation) Steroids: decrease CMI Cyclophosphamide: decreases CM as well as HMI IFN-á: HCL, HepB & C, Kaposi's, CML IFN-â: Multiple Scerosis IFN-ã: CGD Page 36 of 94 May 19, 2003 Aster's USMLE Step3 Notes Acidosis due to Organic Acids is not assoc. with HyperK+ (cuz they freely permeate the cell membrane) Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONI's Commonest TA: Type IV RTA (Hyperchloremic Hyperkalemic metabolic acidosis) Thyroid Scan: I-123 Thyroid Ablation: I-131 Prerenal Azotemia: BUN/Cr > 20.0 L4: Knee Jerk & Sensory on Medial Calf S1: Akle Jerk & Lateral Foot PIVD L5 compression: DORSIFLEXION of foot affected PIVD S1 compression: PLANTAR FLEXION of foot affected [Ca][PO4] > 64 : predictive of metastatic calcification Mx of Myedema Coma: 300-500 microg bolus of i/v thyroid hormone followed by 50 microgram daily Panhypoptuitarism presenting with Myxedema coma: –first give HYDROCORTISONE –then THYROID REPLACEMENT (to prevent Adrenal Crisis) Allopurinol potentiates the action of Azathioprine: if used together, reduce Azathioprine dose by 75% Routine PIVD: MRI not indicated (conservative Mx – resolve in 1-4 weeks) PIVD with neurological deficits: MRI Page 37 of 94 May 19, 2003 Aster's USMLE Step3 Notes Lumbar Spinal Stenosis: –Discomfort in Thighs on walking / standing –pedal pulses preserved (PSEUDOCLAUDICATION) –Ix: MRI Phaeochromocytoma Urinary Catecholamines: sensitive Urinary Metanephrine: specific Urinary VMA: least useful Mx of Fibromyalgia: TCA (NSAIDs are ineffective) #1 functional pituitary adenoma: PROLACTINOMA Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support / NSAIDs) SLE ANA- sensitive Anti-Sm: specific Ant-dsDNA: correlates with disease activity #1 vitamin deficiency: Vit. D Polymyositis associated dysphagia: oropharyngeal (striated muscle) Scleroerma associated dysphagia: esophageal (smooth muscle) Muscle Biopsy findings in Dermatomyositis: lymphoid infiltrate AROUND muscle fascicles Muscle Biopsy findings in Polymyositis: lymphoid infiltrate INSIDE muscle fascicles Ix of choice: Muscle Biopsy (not EMG/NCV) Woman with Joint Pains and Dental Caries : Sjogren's syndrome GCA: associated with increased incidence of Thoracic Aortic Aneurysms Page 38 of 94 May 19, 2003 Aster's USMLE Step3 Notes Ank. Spond. vs. SI joint involvement in Psoriasis: lack of calcification in Psoriasis Prompt Rx of NGU: associated with decreased indcidence of REITER's Whipple's: Joint symptoms precede GI symptoms Synovial Fluid WBC count < 200 normal < 2000 noninflammatory (OA) 2000-50000 Rheumatoid Arthritis 50000-100000 Septic / Gout > 100000 Septic #1 Septic Arthritis: N gonorrheae #1 non-gonococcal arthritis: S. aureus #1 with IVDU/arthroscopy/prosthesis: S epidermidis Recurrent Gonococcal Arthritis: ? C5-C8 deficiency #1 cause of Osteomyelitis: S. aureus #1 renal involvement after URI: IgA nephropathy (1-2 days after URI) PSGN occurs 1-3 weeks after Strep. infection Nephrotic Syndrome: #1 (Children): MCD #1 (Adults): MGN Dialysis :acquired renal cysts (? malignant pot.) Enthesopathy: inflammation of Ligaments / Tendons (Ankylosng spondylosis / Reactive Athritis) Polycystic Kidney Disease: associated with Berry aneurysms in circle of Willis (SAH) Multile Myeloma & Kidney: Page 39 of 94 May 19, 2003 Aster's USMLE Step3 Notes Myeloma Kidney - LIGHT CHAIN Renal Toxicity (light chains are not detected by urine protein dipstick) Renal Amyloidosis - Heavy Chains excreted (heavy chains are detected by urine protein dipstick) Aging: decreasd GFR but S. Cr. remains constant ('cuz Lean Body Muslce Mass decreases too) Initial Hematospermia: Prostate Terminal Hematospermia: Seminal Vesicle RBCs: Hematuria WBCs: Cystitis RBC Cast: GN WBC Cast: APN, Pyelonephritis Acute Bacterial Prostatitis: NO Prostatic Massage or Catheterization Chronic Bacterial Prostatitis: Prostatic massage -> C/S of expressed secretions (Mx: TMP-SMX) Ureteral Stones < 6mm: Conservative Mx for 6 weeks Asymptomatic Renal Stones: Conservative F/U with serial X-Rays Symptomatic Renal stones (Fever/Pain/UTI): –< 3cm: ESWL –> 3cm: PCNL Urinary Incontinence: Total: Sx Stress: Sx is curative (Kegel/Pessary/Estrogen) Urge: Antispasmodic / Anti-Ach / TCA Overflow: Catheterize Sildenafil (Viagra) c.i. in patients on Nitroglycerine Right Ventricular Infarction: Nitroglycerine precipitates HYPOTENSION Page 40 of 94 May 19, 2003 Aster's USMLE Step3 Notes Mx: I/V Fluids 70y old man with urinary obstruction and backache: ? Prostatic Ca with mets Prostatic Biopsy: U/S guided biopsy > finger-guided Prostatic Ca: Transrectal U/S = MRI for staging (CT has no role) Prostatic Mets: Radionuclide Bone Scan > X-Ray Ix for suspected Bladder Ca.: CYSTOSCOPY MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID ADENOMA Testicular Neoplastic Mass: Children: Embryonal Cell Ca. Adult: Seminoma > 50y: Lymphoma Intracranial H'age (< 48h. duration): CT without contrast is superior to MRI Cerebellar Vermis: Axial ataxia Cerebellar Hemisphere: “IPSILATERAL” Appendicular Ataxia Frontal Lobe Lesions: Personality Changes Temporal Lobe Lesions: Hallucinations/ deja vu / emotional changes Parietal Lobe Lesions: cortical sensory loss (astereognosis) Occipital Lobe Lesions: macular sparing field defects & UNFORMED VISUAL HALLUCINATIONS Page 41 of 94 May 19, 2003 Aster's USMLE Step3 Notes Acoustic Neuroma: first symptom is IPSILATERAL hearing loss To measure severity of ASTHMA attack: Peak Expiratory Flow Rate [PEFR] (not ABG) Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR (intention tremor) Myerson's Sign: 2 per second tap on nose -> sustained blinking (seen in Parkinsonism) Shy-Drager: Parkinsonism + Autonomic Insufficiency + Neurological Deficits Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED Pseudobulbar Palsy (UMN): TONGUE SPARED ALS : UMN + LMN Peripheral Neuropathy: AXONAL (NCV normal) DEMYELINATION (NCV decreased) TT Leprosy: Neuropathy in area of skin lesions LL Leprosy: Neuropathy > Skin Lesions Tarsal Tunnel Syndrome Pain, Paraeshesiae on bottom of foot (Sparing of the HEEL) Cervical Rib: –Thenar Wasting –Pain & Numbness on medial 2 fingers (ulnar side of forearm) Myotonic Dystrophy: –AD –stiffness –cataracts Page 42 of 94 May 19, 2003 Aster's USMLE Step3 Notes –baldness Mx - Quinine, Phenytoin, Procainamide Neuropathy: DISTAL ± Sensory Loss NM Junction: Fluctuating Deficits Myopathy: PROXIMAL weakness (NO sensory loss) non-enhancing white matter lesions without mass effect (in AIDS): PML Ix of Valvular Ht. Disease: ECHO foll. by Catheterization (definitive Dx) ILD –Non-productive Cough –Exertional Dysnea –Fine Expiratory Crackles –decreased DL CO –increased A-a gradient –gold standard for diagnosis: LUNG BIOPSY Dx of Malignant Mesothelioma: Pleural Biopsy 100% of small cell ca. occur in smokers Complicated Parapneumonic Effusions –Gross Pus –Gram Stain (+) –Glucose < 50 mg% –Pleural Fluid pH < 7.0 Severe Hyperkalemia Mx: Calcium Gluconate Mx of Mg toxicity: Calcium Gluconate 1st test in asymptomatic hematuria: URINE CULTURE -> IVP 1st test in suspected pneumonia: CXR -> Sputum C/S Currant jelly sputum: Klebsiella Rusty sputum: Pneumococcus Smokers / COPD: H. influenzae Page 43 of 94 May 19, 2003 Aster's USMLE Step3 Notes Interstitial infiltrates: Mycoplasma Empyema / Rapidly progressive: Staph. aureus Pneumonia Rx: Community acquired: Macrolide > 60y or COPD/smoker: 2nd gen cephalosporin Nosocomial: 2nd / 3rd gen cephalosporin ICU (severe): Macrolide + Antipseudomonadal Uncomplicated UTI: 3 day course of TMP-SMX Native Valve Endocarditis - S. viridans [â-lactam + aminoglycoside] Prosthetic Valve Endocarditis (Early) - S. epidermidis [Vancomycin + Aminoglycoside] Prosthetic Valve Endocarditis (Late) - S. viridans [Vancomycin + Aminoglycoside] IVDU - S. epidermidis / S. aureus [Vancomycin + Aminoglycoside] IE prophylaxis: - Amox 2g 1 hr. before Dental / GI / GU procedures - penicillin allergy -> Clarithromycin Don't delay antibiotics in Meningococcal meningitis (even if LP is not done) HAART: AZT+3TC & Indinavir AIDS - avoid all live vaccines except MMR Abdo. Pain: 1st investigation - AXR UC: Pseudopolyps, Crypt Abscesses CD: Skip Lesions, Fistulae ddI can cause Pancreatitis Page 44 of 94 May 19, 2003 Aster's USMLE Step3 Notes RA: PIP involvement (DIP sparing) OA: DIP involvement Ix of choice in Osteoporosis: DEXA scan Vaginal Candidiasis: Topical Miconazole / Systemic Fluconazole (recurrent) (Oral agents eliminate rectal reservoir of yeast) Trichomoniasis: PO Metronidazole 2g stat (Rx male partner also) Bacterial Vaginosis: PO Metronidazole 250-500mg x 7 days (cf. single dose in Trichomoniasis) Pap shows LGSIL (F/U reliable): repeat Pap 4-6 months later Women Smokers should always have annual Pap Primary Dysmenorrhea: within 2 years of menarche Prostaglandins –arteriolar spasm –uterine hypoxia –Mx: (sexually active): OCP's –Mx (sexually inactive / OCP c.i.): NSAIDs –inreased #1 cause of DUB: Anovulatory Cycles Mx: Hormonal Therapy===>Endometrial Ablation Severe acute DUN with orthostatic hypotension I/V Conjugated Estrogen #1 STD: Chlamydia trachomatis Ectopic (hemodynamically stable / no rupture): Methotrexate Ectopic (Unstable / rupture): Page 45 of 94 May 19, 2003 Aster's USMLE Step3 Notes Salpingectomy or Salpingotomy OCPs: decrease Gonococcal STD may increase Chlamydial STD (cervical ectropion) Vaginal Spermicides: decrease Gonococcal & Chlamydial STD (no effect on HIV transmission) Breastfeeding & OCPs: can use. Use low-dose OCPs ('cuz of effect on milk production, not because of infant safety consideration. Estrogens do pass into milk in small quantity, but they are safe) Hormonal Contraception for h/o DVT/PE: Norplant & Depo-Provera [no OCP's] PID in-patient: I/V Cefoxitin or Cefotetan + Doxycycline out-patient: I/M Ceftriaxone + PO Probenecid + PO Doxycycline Depression: Cognitive Psychotherapy Adjustment Disorder: Supportive Psychotherapy Anxiety Disorder: Behavioral Psychotherapy Antidepressant Ladder: –SSRI –another antidepressant (except MAOIs) –best tolerated agent + LiCO 3 –MAOIs –ECT Lab Test for Cocaine: Urine Benzoylecgonine (Cocaine metabolite) Genital Herpes transmission occurs even in asymptomatic state (Acyclovir decreases freq. of recurrences) H'agic crust on "molluscum" like lesions in HIV pts. : Cutaneous Cryptococcosis Page 46 of 94 May 19, 2003 Aster's USMLE Step3 Notes HPV (Genital Warts) Heaperd up lesions flesh colored lesions on penis female partner has increased risk of Ca. Cx Leprosy with painful red patches on extremities that become nectrotic and ulcerate: LUCIO REACTION (seen in unreated leprosy, responds to Steroids) Excessive use of Aluminium containin laxatives: risk factor for postmenopausal osteoporosis KOH Prep "meatball-and-spaghetti" appearance: Tinea versicolor binge eating and purging behavior (even without depression) : SSRI Factitious Disorder : assoc. with child abuse Somatoform Pain Disorder: limit analgesic use best managed in a multi-disciplinary pain clinic Rx of choice for Panic Disorder: PAROXETINE [dependence might develop with Alprazolam] Mx of Social Phobia: â-blockers + ASSERTIVE TRAINING Mx of OCD: SSRI [Fluvoxamine] Clomipramne is no longer the first line drug Mx of PTSD: >1m; assoc. with life-threatening event Group Psychotherapy Anorexia nervosa: 75% have Depression, 25% have OCD Buckman's 6 steps of Breaking Bad News 1. Getting started 2. find out how much the pt. knows 3. find out how much the pt. wants to know 4. share the info. a) Give Warning Shot 5. respond to pt.'s feelings 6. Plan F/U - give hope Page 47 of 94 May 19, 2003 Aster's USMLE Step3 Notes Skew: depends on direction of tail (not hump) ± 1 SD 68% ± 2 SD 95% ± 3 SD 99.7% To increase power of a test: inrease sample size Nominal or Ordinal Data: Non-parametric Tests [Chi Square] Interval or Ratio Data: Parametric Tests [T-test, Z-test, F-test] Correlation coefficient Ordinal Data: Spearman Rank Order Interval or Ratio Data: Pearson product-moment r=correlation coeeficient r2 (square)=coefficient of determination (proportion of variation in one variable explained by variation in other) Causality is only proven by properly conducted experimental studies A test can only be 100% sensitive and specific if there is no overlap between measurements in normal and diseased states Higher the prevalence of a disease: Higher the PPV of a (+) test Lower the NPV of a (-) test Untreated apendicitis in young female can cause infertility (peritoneal adhesions) Appendiceal abscess: delay Sx till inflammation has subsided [the acute process has been walled off] Cholangitis (ass. with CBD stones): ERCP with Sphincterotomy + Lap Chole. Skin Suture: cutting needle Page 48 of 94 May 19, 2003 Aster's USMLE Step3 Notes Deeper Layer Suture: Taper Needle Ingrown Toe Nail first episode: antibiotics, elevation of edge -> wedge resection recurrent: Nail Removal Anal Fissure: Local Steroid Cream / Sitz Bath Anaesthetic of choice for skin lesion removal: Lidocaine + Adrenaline (No Adrenaline for fingers and nails) #1 type of breast Ca.: Infiltrating Ductal Ca. (80%) Mx of Fibrocystic Disease: Low Dose OCP Mx of Fibroadenoma: Biopsy (Excisional) Danger Signs in Chronic Low Back Pain - Bowel or Bladder dysfunction - Impotence - Ankle clonus - NIGHT PAIN - Weight Loss - Lymph Node enlargement - Buttock claudication - New Onset in age > 50 y No imaging for routine chronic low back pain Mx of Chronic LBP: TCA's have the best cost/benefit ratio [Muscle relaxants and NSAIDs have low effectiveness] Dx of Childhood PCKD: > 2 cysts in EITHER Kidney Dx of Adult PCKD: > 5 cysts in EACH Kidney C/I to thrombolysis - Sx < 2 weeks - Unconrolled HTN - Aortic Dissection - h/o CVA / 'aic stroke / CNS tumor / AVM - prolonged traumatic CPR - allergy to thrombolytic agents Page 49 of 94 May 19, 2003 Aster's USMLE Step3 Notes - pregnancy Risk Stratification in Unstable Angina (Outpt.) Low - Onset < 2 weeks (Telemetry) Medium - Onset < 2 weeks, Pain > 20 minutes but resolved @ present (CCU) High - Rest Pain > 20 minutes and not resolved @ present (CHF / Pulm. Edema / ST changes / Mitral Regurg.) 1st episode of syncope / low risk of heart disease: NO FURTHER EVALUATION Emperical Rx for IE: Nafcillin + Ampi + Genta (add Rifampin for Prosthetic Valve) IE prophylaxis not reqd. for: 1. small ASD of secundum type 2.MVP without Mitral Regurg. Acute Asthma: Give Albuterol, O2, steroids -> assess response (PEFR, O2 sat.) Good Response PEFR > 80% of best (discharge with â-agonist) Moderate Response PEFR 60-80% of best (hospitalize and continue medications, O2) Poor Response PEFR < 50% of best (ICU admission) (prepare for Intubation if silent chest, altered sensorium, respiratory failure) Chronic Asthma Mild Intermittent: <2/week, nocturnal symp. < 2/month (Inh â2-agonist) Mild Persistent: >2/week, nocturnal symp. >2/month (Inh â2-agonist + Anti-LT) Moderate Persistent: Daily, PF 60-80% (Inh â2-agonist + Inh. Steroids/Inh. long acting â2-agonist) Page 50 of 94 May 19, 2003 Aster's USMLE Step3 Notes Severe Persistent: Continuous, PF<60% (Inh â2-agonist + Inh. Steroids + Inh. long acting â2 / Anti LT) SPN: Conservative Mx Age < 45, nonsmoker, no inrease in size, size < 4cm Psoriasis: Pustular: ACITRETIN Plaques: –Emollients / Keratolytics / Corticosteroids –Tar / Calcipotriol / Anthracin –UVB –PUVA –Methotraxeate / Cyclosporin –Hydroxyurea Rx of Onychomycosis: PO Terbinafine Acute Mastoiditis develops 2-3 w after acute otitis Mx: Ceftriaxone / Sx drainage Acute Bacterial Sinusitis: Pneumococcus Chronic Bacterial Sinusitis: S. aureus most serious form of sinusitis: FRONTAL sinusitis d/o/c for Alzheimer's : DONEPEZIL (OD dosing, no liver toxicity) Upper Lips: BCC > SCC Lower Lips: SCC > BCC RCA stenosis: Saphenous grafts Anterior Duodenal Ulcers: Perforation Posterior Duodenal Ulcers: Bleeding Acute Meseteric Ischemia: Embolization Chronic Mesenteric Ischemia: Atherosclerosis Page 51 of 94 May 19, 2003 Aster's USMLE Step3 Notes Carcioid: Appendix > Ileal (Ileal have higher chances of metastasis) #1 GI malignancy: HCC (not colorectal Ca.) #1 Liver neoplasm: Cavernous hemangioma #1 Breast Lesion: Fibrocystic Disease #1 Breast Malig.: Infiltrating Ductal Ca. Indications for Hormonal Therapy for Breast Ca. - Postmenopausal - Nodes - ER + Aortic Aneurysms Thoracic: Type A: Sx Type B: Sx if > 6 cm Abdominal: Sx if > 5cm #1 Congenital Heart Disease: VSD #1 Cyanotic Heart Disease: TOF ASD: Fixed Splitting of S2 Biliary Atresia: Jaundice @ 2 wks of life, dark urine & acholic stools Rx: Surgery (Roux-en-y portoenterostomy) Neck Injuries: Zone I : Arteriography -> Sx Zone II : Sx Zone III : Arteriography -> Sx Mortality in Burns = Age + % BSA 1st degree: Leave Open 2nd degree: Clean,Sulfadiazine,nonadhesive dressing 3rd degree: Escharotomy + Skin Grafting Sprain: Ligament Pull Page 52 of 94 May 19, 2003 Aster's USMLE Step3 Notes Strain: Muscle Pull # Neck Humerus: Axillary Nerve Damage # Shaft Humerus: Radial Nerve Damage Quick Neuro Exam AVPU: Alert Responds to Verbal Stimulus Responds to Pain Unresponsive Rescusitation: O2, 2 large bore IV lines, IV fluids, EKG - 100 mg Thiamine - 1 amp 50% Dextrose - 0.4 mg Naloxone C/I to Foley's Catheter: (do retrograde urethrogram) 1. Blood at tip of urethral meatus 2. Perineal Eccymoses Abdo. Trauma #1 Injury in Blunt Trauma: Spleen #1 Injury in Penetrating Trauma: Small Bowel Indications for Exploratory Laparatomy in Abdo. trauma 1. Shock with Abdo. Injury 2. Pneumoperitoneum 3. Gunshot 4. (+) DPL - Blood - RBC > 100,000/mL - WBC > 500/mL - Food - Bile - Bacteria Referral for Burns - 3rd degree burns > 10% BSA, < 10 y, > 50 y - 2nd degree burns > 20% BSA - Electrical burns / Chemical burns Page 53 of 94 May 19, 2003 Aster's USMLE Step3 Notes - Inhalation Injury - Perineal burns - Radiation burns #1 symptom of Parkinsonism: Tremor (Resting) Benign Essential Tremor –Intention Tremor –Familial –Head Nodding –temporary decrease with alcohol intake S. pneumoniae: Rx - Macrolide or newer Quinolone (Levofloxacin / Gatifloxacin) Majority of elderly patients with sepsis: URINARY TRACT is the culprit #1 cause of death in hospitalized elderly: UTI #1 cause of death in institutionalized pts.: Bacterial Pneumonia #1 cause of Urinary Incontinence: Urge Incontinence Clean pressure ulcers with Normal Saline (avoid Povidone-Iodine, Hydrogen Peroxide etc.) Unimmunized with infected wounds 3 TT + 1 ATS Stroke mortality is higher in WHITES than in BLACKS indications for pneumococcal vaccine 1. Splenectomy 2. Sickle Cell 3. > 65 y 4. Chr. Cardio / Pulmonary / Renal Disease 4. Hodgkin's Disease Continued Gastric Lavage for : PCP overdose #1 Foods causing angioedema: Nuts / Seafood #1 Drug causing allergy: Aspirin Electronic Fetal Monitoring & Intermittent Auscultation of Fetal Heart have similar outcomes Page 54 of 94 May 19, 2003 Aster's USMLE Step3 Notes NST (Non-stress Test) > 2 accelerations (in 20 minutes) 15 bpm lasting > 15 sec CST >= 3 consecutive late decelerations in 10 minutes < 20w. POG with HTN: Essential HTN (not PIH or pre-eclampsia) Pre-eclampsia: Bed Rest / (L) lateral position / pharmacotherapy [á-methyldopa / labetalol] #1 indicator of perinatal outcome in IUGR is: presence of vertical pocket of Amniotic Fl > 3 cm 0-8 weeks : Embryo 8w-term : Fetus 0-14 weeks: 1st Trimester [Routine Ix] 14-28 weeks: 2nd Trimester [GDM Screen] 28-40 weeks: 3rd Trimester [GBS Culture] <24 weeks: Previable 24-27 weeks: Preterm 37-42 weeks: Term > 42 weeks: Post-term Cervical Incompetence: - Cerclage @ 12-14 weeks, till 36-38 weeks POG Bishop Score: <= 5: Prime (with Prostaglandins) > 8: Induce Labor #1 cause of PPH: Uterine Atony Preterm ROM: @ < 37 weeks POG Page 55 of 94 May 19, 2003 Aster's USMLE Step3 Notes Premature ROM: > 1 hr before onset of labor Prolonged ROM: > 18 hours before onset of Labor (Mx: Antibiotics) Mastitis in breasftfeeding: continue breastfeeding, Cloxacillin Early Breast Milk Jaundice –Exaggerated Physiological Jaundice –Onset < 4 days of life Late Breast Milk Jaundice –Breast Milk Jaundice –Onset 4-14 days –competitive inhibition of glucuronyl ransferase by nonesterified long chain fatty acids in reast milk –Mx: Stop breastfeeding for 2-3 days / Give Formula Milk [Jaundice comes down quickly] -> Resume Breastfeeding Any jaundice @ Birth is PATHOLOGICAL Success of Contraceptives Norplant > OCPs > Barrier Norplant: quick return to fertility DMPA: 18 months for fertility to return Complete Mole: Diploid; 46, XX; has higher malignant potential Kernicterus never occurs with: –physiological jaundice –exaggerated physiological jaundice –breast milk jaundice Features of Pathological Jaundice: –present @ birth –increase in bili. > 5 mg/dL/day on first day –Bili. >12 mg/dL [term] or Bili. >14mg/dL [preterm] –persists > 1 week of life –Conjugated Bili. > 1 mg/dL @ any time Page 56 of 94 May 19, 2003 Aster's USMLE Step3 Notes Wessel Criteria for Infantile Colic Unexplained Crying: –> 3 hr/day,> 3 d/week, > 3 weeks, 3 m old child –Do Urinanalysis –Reassure –No treatment necessary –Bottle-fed infants have higher incidence –Dicyclomine: risk of apnea After a feed, allow "burping" and lay the child on (R) side of abdomen Introduce Solid Foods @ 6 months age Vaginal pH < 4.5: Candida Vaginal pH > 4.5: Bacterial Vaginosis Transfusion Reactions Fever: Leukoagglutination (donor WBCs) Mx: acetaminophen Anaphylaxis (donor proteins,severe in IgA-deficiency) Mx: Epinephrine, Steroids Hemolysis (ABO mismatch) Mx: stop transfusion, hydration & diuresis Familial Short Stature: NORMAL BONE AGE Constitutional Delay: DELAYED BONE AGE Short Stature with Webbed Neck is seen both in Turner's (XO) & Noonan's (normal Sex chromosomes) Budesonide has proven to be beneficial in Croup (along with racemized epinephrine) Rx of choice for AOM in primary practice: Amox ===> Cefaclor (if no response to Amox) Transmission of Common Cold: Indirect Spread is more important than Aerosol spread Absolutely no antibiotics in common cold (even if patient demands it!) Page 57 of 94 May 19, 2003 Aster's USMLE Step3 Notes Erysipelas: Gp. A â-hemolytic Srep. Impetigo: Staph. or Strep. [Bullous - Staph.] Coxsackie A16: Hand Foot Mouth Disease Pitryasis rosea: Herald Patch PNEUMONIA 2 wks: GBS 2 wks - 4 m: Chlamydia trachomatis #1 Bacterial: Strep. pneumoniae 4 months - 4 years: Mycoplasma pneumoniae #1 Bacterial: Strep. pneumoniae > 4 years: VIRAL #1 bacterial: Strep. pneumoniae Antibiotic Rx of Occult Bacteremia does not decrease the occurence of meningitis Yersenia entercolitica: can mimic acute appendicitis (no Rx necessary - self limiting) ROTAVIRUS G/E is preceded by URI symptoms Rec. Abdo. Pain Syndrome - 10% prevalence - school phobia - no organic signs - no Rx necessary Growing Pains - B/L deep pains - can awaken child from sleep Mx: exercize program SCFE –overweight and sedentary "teenage" BOY –Groin Pain/ Knee Pain Dx: X-Ray Mx: Surgical fixation Page 58 of 94 May 19, 2003 Aster's USMLE Step3 Notes LCP –Avascular necrosis of femoral head –LIMP –hip pain or referred knee pain (knee is NOT TENDER to palpation) Osgood Schlatter –tenderness over tibial tubercle –aggraveated by activity –occurs in pysically actve males around puberty Mx: Limit activity, NSAIDs; (if severe) Knee immobilization splint Teenager with knee pain aggravated by climbing stairs: Patellofemoral Syndrome Child with Limp / Hip Pain - preceded by URI - Fever (+) - normal ESR TOXIC SYNOVITIS [Sterile Hip Effusion] Mx: Rest / NSAIDs (NO ANTIBIOTICS) Foot dorsiflexes easily banana shaped sole: Congenital calcaneovalgus kidney bean shaped sole: Metatarsus adductus Intoeing patella points forward: Internal Tibial Torsion patella points medially: Excessive Femoral Anteversion (#1 cause of intoeing in children) CTEV: inability to dorsiflex Mx: progressive serial casts, posteromedial release of heel cord #1 substance of abuse: Alcohol Nocturnal Enuresis –> 4 years –majority of children do NOT have any physical or psychiatric disorder –Mx: Behavioral modification Bell / Buzzer system d/o/c: dDAVP (no longer IMIPRAMINE) Page 59 of 94 May 19, 2003 Aster's USMLE Step3 Notes Encopresis: > 4 y. Enuresis: > 5 y. Allergic Rhinitis: –Hyperemic Nasal Mucosa –Clear Discharge –Bluish-purple rings around eyes (SHINERS) –Ix: Nasal smear for Eosinophils –Mx: elimination / inra-nasal corticosteroids Child with rash on introduction of "whole milk": Atopic Dermatitis Mx: Cow Milk ----> Formula Milk ----> Soy Milk (Cow milk allergic might show allergy to soy milk, too) Diaper Rash –Candidal: Satellite lesions –Seborrheic –Primary Irritant Dermatitis: maceration with sparing of henitocrural folds (Mx: frequent changing, washing, no occlusive plastic pants, ZINC OXIDE, NO ANTIBIOTICS) Innocent Murmur in Children –prevalence: 50% –accentuated by sitting, anxiety, fever, tachycardia –mid to low sternal border –systolic –no thrill –vibratory or musical in quality [Still's Murmur] Common Cold: Steam Inhalation provides superior relief of nasal congestion cf. antihistaminics •Decongestants (sympathomimetics) : can cause CNS overstimulation •Cough Suppressants (Dextromethorphan) : can cause respiratory depression in children #1 complication of sickle cell disease Painless Hematuria (Paillary Necrosis) Page 60 of 94 May 19, 2003 Aster's USMLE Step3 Notes Priapism in Sickle Cell Disease > 6 hrs. : Hospitalize no effect on future erectile function may respond to Nifedipine / NTG Complications of Sickle Cell Disease - Hemolytic Crisis - Vaso-occlusive crisis - Aplastic Crisis - Splenic sequestration crisis - CVA - Renal Papillary Necrosis - LOwer extremity skin ulcers - Proliferative retinopathy Mx of HbS disease –Oxygenation –Pneumococcal vaccination –FOLATE supplementation –Prophylactic antibiotics (Penicillin till age 5) –Narcotic analgesia for pain crisis –CVA: Exchange transfusion –Painless Massive Hematuria: e-ACA –HydroxyUrea for frequent vaso-occlusive crisis –Bone Marrow Transplantation (Age < 16, availability of Bone Marrow Donor) STROKE / TIA in Sickle cell disease is an indication for exchange transfusion to keep the HbS < 50% HbS disease 'per se' can lead to restrictive lung disease -> hypoxemia -> increased sickling tendency Avoid use of MEPERIDINE in severe chronic pain (short T1/2) Malignant Hyperthermia: Mx-Dantrolene Symp. AORTIC STENOSIS: high perioperative risk In preop pts. with A. Fib. : achieve rate control In preop pts. on Diuretics : Get Electrolyte Levels Page 61 of 94 May 19, 2003 Aster's USMLE Step3 Notes Avoid elective surgery in patients with significant hepatic dysfunction Indications for Intra-op Insulin - IDDM : any surgical procedure - NIDDM on Insulin : any surgical procedure - NIDDM on OHA : major surgical procedure Prophylactic preop antibiotics only decrease the incidence of wound infection (no effect on postop pneumonia, UTI, sepsis) : CEFAZOLIN is a good choice elderly with repeated falls with dementia / seizures: look for chronic SDH stool impaction can cause urinary incontinence Breast Cancer with BRCA1 gene: Better prognosis Breast Cancer with HER2/neu gene: POOR prognosis Kaposi's: HHV8 (Male Homosexuals) Cyclophosphamide: Mesna Methotrexate: Leucovorin Cisplatin: Amifostine Doxorubicin: Dexrazoxane Mx of chemotherapy induced dry mouth: Pilocarpine Hcl 5-10 mg PO TDS Assessment of Doxorubicin toxicity: MUGA scan Neutropenia: requires antibiotic prophylaxis for G(-) / fungus Competent individuals @ the end of life have right to refuse nutrition and hydration Cutaneous absorption of drugs is 3 times more in children than in adults Topical drugs c/i in pregnancy 1. Podophyllin 2. Isotretinoin 3. Lindane Page 62 of 94 May 19, 2003 Aster's USMLE Step3 Notes most appropriate initial investigation in â-Thalassemia: CBC with red cell indices SLE: decreased C3/C4 Dumping Syndrome post-Bilroth II - Dietary modification - Octrotide - (fails) Bilroth I conversion 75%-95% of AAAs are infra-renal - Dx: U/S abdo. Food poisoning: < 6 hrs. after food intake - S. aureus (mayonnaise / salad dressing) - B. cereus (fried rice) > 16 hours / poultry consumption: C. jejuni Carbamazepine intoxication - QRS prolongation : predisposes to - QT lengthening Defib. followed by pulseless electrical activity - Hypovolemia - Hypoxia - cardiac tamponade - pneumothorax - massive pulmonary embolism - drug toxicity - hyperkalemia - acidosis - massive MI Coarctation of aorta is associated with Bicuspid aortic valve in 70% cases Page 63 of 94 May 19, 2003 Aster's USMLE Step3 Notes #1 cause of GI h'age following AAA repair is: Colonic Ischemia (not stress gastritis) Early onset wound infections: Strep / Clostridium Dementia: Visuospatial: Alzheimer's Gait disturbance / Urinary Incontinence: NPH Delayed DTR: Hypothyroidism Myoclonus: CJD (Creutzfeld Jacob Disease) Alzheimer's with agitation: use HALOPERIDOL (not BZDs -> they can aggravte agitation) Testicular tumors –#1 seminoma –increased incidence in cryptorchidism –metastatize to retroperitoneal nodes –inguinal nodes involved only with scrotal spread –Children: Embyonal Cell Ca. –Adults: Seminoma –> 50 y: Lymphoma –Dx: Testicular Ultrasound (no BIOPSY) Mx: Inguinal exploration & cross clamping of cord & Orchiectomy Pregnancy: –increased tidal volume –decreased BP (decreased TPR – progesterone) –Hb decreases (dilutional effect) TV U/S > sensitive cf. Abdo. Scan for ectopic preg. Fat Embolism: associated with Eosinophilia & Lipiduria Shoulder Pain Rotator Cuff Injury: best elicited by positioning of the reater tubercle of humerus beneath acromion Subacromion bursitis: elicited by palpation over deltoid Biceps tendinitis: aggravated by flexion or supination of elbow Acromioclavicular arthritis: Page 64 of 94 May 19, 2003 Aster's USMLE Step3 Notes elicited by crossed arm adduction against resistance RANSON CRITERIA at admn. @ 48 hours Age > 55 Fall in Hct > 10% WBC > 16000 Fluid deficit > 6L Bl. Glu > 200 S. Ca++ < 8.0 LDH > 350 PaO2 < 60 mmHg AST > 250 BUN increase > 5 mg/dL Base deficit > 4 mEq/L Rx of sigmoid volvulus: Sigmoidoscopy (Sx required if s'copy fails) Hemodialysis in CRF –Uremia –Pericarditis –Acidosis –Hyperkalemia –Unresponsive Volume Overload AIDS Chemoprophylaxis CD4 < 200: PCP CD4 < 100: Cryptococcus CD4 < 50: MAIC Cryptococcal Meningitis: very high CSF pressure (serial lumbar punctures may be warranted) #1 cause of inracranial mass lesions: Metastasis (not primary brain tumor) #1 benign liver neoplasm: HEMANGIOMA (not Hepatic Adenoma) Propylthiouracil: can cause agranulocytosis smoking is a relative c.i. to OCPs - not absolute #1 cause for osteomyelitis: S. aureus Bed Rest has no proven benefit in chronic low back pain & threatened abortion Page 65 of 94 May 19, 2003 Aster's USMLE Step3 Notes Significant Hematuria: > RBCs/HPF Significant Pyuria: > 10 WBCs/HPF increased PEEP causing hypotension/hypoxemia -> consider pneumothorax Confirm erythema nodosum by SKIN BIOPSY (Conservative Mx) -> Steroids for persistent Pain Change in Antipsychotics should be done within 2-4 weeks, if no desired effect Ice should not be applied on snake bite site -> can delay efflux of venom by causing vasoconstriction Severity of AS: late peaking murmur & delayed and weak carotid upstroke Hymenoptera anivenom is not available Even after treating anaphylaxis with S/Q Epinephrine -> monitor patient in ED (patient is not risk-free, complications can develop) #1 cause of fever in AIDS, without overt symptoms: MAC (Rx Ethambutol + Clarithromycin) #1 cause of Seizures in AIDS: TOXOPLASMOSIS #1 cause of dysphagia in AIDS: Candidal Esophagitis Suspected child abuse: inform child protective services (Hospitalize only if child's conition requires it) ITP : improvement with splenectomy but platelet counts falls again (Ix: radionuclide spleen scan for splenic remnant) HSP: usually remits in 1 week (Mx is conservative) - Leukocytoclastic vasculitis #1 cause of hematuria after URI: IgA nephropathy ABI < 0.4 - sever vaso-occlusive disease Mx: surgical revascularization Page 66 of 94 May 19, 2003 Aster's USMLE Step3 Notes Oliguria in hospitalized pt. -> assess pulmonary wedge pressure (to diff. hypovolemia and ATN) Fibrinogen is the most abundant acute phase reactant (responsible for increased ESR) Age, Myeloma, Macroglobulinemia, Hypoalbuminemia increase ESR Number-needed-to-screen is reciprocal of absolute risk reduction Celiac Sprue: dermatitis herpetiformis Mx: Dapsone Localization of extra-adrenal phaeo: MIBG scan suspected phaeo 1.catecholamine levels 2.if levels elevated, Imaging (imaging, done first, will lead to detection of incidental adrenal masses – high prevalence) Preop prep in Phaeo full á blockade followed by â blockade (not vice versa) Antidote for Mg toxicity is Calcium Gluconate Mild pre-eclampsia: Bed Rest and Monitoring Severe pre-eclampsia: Hospitalization, Control of HTN, MgSO4 infusion Dx of Hemachromatosis (Gold Standard): Hepatic Iron Index (not HFE Gene analysis) #1 cause of TEN : Adverse Drug Reaction Rapid Correction on HypoNa: CPM Frozen shoulder = adhesive capsulitis takes months to regain full function (steroid injections can hasten recovery) Orchiopexy in Cryptorchidism @ 1 year age Orchiopexy deceases the proportion of seminomatous malignancies - but total risk of malignancy stays the same Page 67 of 94 May 19, 2003 Aster's USMLE Step3 Notes Urine dipstick only detects albumin, 24 urinary protein assessment detecs all proteins (Myeloma light chains will not be detected by dipstick) Bone scan has no role in lytic lesions of myeloma Hypotension in Meningococcemia: Waterhouse-Frederrikson syndrome Macrolide antibiotics prolong QT interval: V.Tac.->Syncope Kartagener's: Sinusitis / Bronchiectasis / Infertility / Situs inversus Disulfiram : slow excretion from the ody. Adverse reactions can occur even 1-2 weeks after cessation of therapy. Disulfiram is not an option for long term alcohol abstinence Statin therapy: monitor LFTs regularly (CPK only if rhabdmyolysis is suspected) Intravascular Catheter related infection : Staph. epidermidis / S. aureus (use Vancomycin, cultures pending) Arterial Clots: Anti-PL antibody Venous Clots: #1 inh. cause: Factor V Leyden Postcoital contraception: is not 100% effective (Progestin-only Pills are safer than OCPs) HIRUDIN: is a direct thrombin inhibitor approved for use in pts. with Heparin-induced Thrombocytopenia Pulmonary Embolism: CXR is usally NORMAL #1 finding on EKG: Sinus Tachycardia - Hampton's Hump: seen in Pulmonary Infarction - Westermark's Sign: sign of Pulmonary Oligemia Meningococcemia: seen in C5-C8 deficiency Meningococcal vaccine: Polysaccharide vaccine (A,C,Y,W135) Page 68 of 94 May 19, 2003 Aster's USMLE Step3 Notes Neutropenia with Fever: (Neutropenia = < 500/mcL) suspect Pseudomonas Piperacillin/Tazobactam & Gentamycin (or Ceftazidime) if central line is present: Add Vancomycin [Continue antibiotics even if cultures are negative] Indomethacin: can decrease amniotic fluid production Indications for CONIZATION 1. non-visualization of transformation zone 2. "pap" worse than bopsy 3. AdenoCa. 4. (+) endocervical cuerettage 5. Microinvasion on Bx (+) F/H is not a risk factor for Ca. Cx Neuroblastoma metastasis: can cause periorbital ecchymosis / proptosis - increased urinary VMA - N-myc gene PEPTO-BISMOL: affects platelet function (can prolong bleeding time) "popcorn" calcification in SPN : Hamartoma Mx of SIADH: Fluid Restriction Mx of malignant SIADH: Demeclocycline "pop" or snap in knee : ACL tear [Knee Immobilization / Crutches] post-URI abdo pain / vomiting / RUQ mass in a child: ? Intussusception [Barium Enema - Rx & Dx] Legitimate Vanco. use : â-Lactam resistant Staph. epidermidis Page 69 of 94 May 19, 2003 Aster's USMLE Step3 Notes Vit. A toxicity can cause Hypercalcemia Gatsric ulcers: located on lesser curvature within 1cm of gastric antrum Adrenal Mass > 4cm & High Hounsfiled Values: high chance of being malignant Most ensitive test for Cushing's: 24 hour urinary cortisol (levels are subject to diurnal variation) Bilroth II: Afferent Loop Syndrome (Pain after meal ingeston) Mx: Bilroth I conversion, roux-en-y gastrojejunostomy Blind Loop syndrome (bacerial overgrowth, malabs.) Mx: antibiotics â-Thalassemia major: HbF increased â-Thalassemia trait: HbA2 increased Risk of Postop DVT #1 Elective Knee Arthroplasty #2 Elective Hip Arthroplasty #3 Hip # Repair highest risk with ELECTIVE KNEE ARTHROPLASTY Cocaine use assoc. MI: combination of spasm and plaque rupture (don't assume spasm is the cause, do angiography) Pappenheimer's Bodies: Iron inclusions in RBCs Rhabdomyolysis: Hypocalcemia, Hyperkalemia, Hyperphosphatemia Diverticulosis: #1 complication - BLEEDING 85% bleeds stop spontaneously (#1 complication is not Diverticultis) DIVERTICULITIS: –Polymicrobial Page 70 of 94 May 19, 2003 Aster's USMLE Step3 Notes –Broad spectrum antibiotics –no barium enema / colonoscopy h/o Malig. Hyperthermia with succinylcholine: use NITROUS OXIDE in future anesthesia Chronic Fatigue with normal physical exam: DEPRESSION INVENTORY -> Thyroid studies IE -> Mycotic Aneurysm -> Bleeding -> SAH [embolization of bacteria to the brain) IFN-â: decreases relapse frequency in MS First Episode of DVT: Heparinize -> Warfarin for 3-6m (INR 2.0-3.0) Recurrent DVT: Lifelong "Warfarin" [if Warfarin is not tolerated : ENOXAPARIN] Fever / Sore Throat / Atypical Lymphocytes (without LN / Splenomegaly / MonoSpot) : CMV Colles' #: splinting in NEUTRAL postion (not in FLEXED position) PSA levels in Prostatic Ca. correlate with lymphatic spread Antibiotics in postpartum endometritis: I/V Imipenem / Cilastatin Vaginal Delivery in Breech 1. FRANK BREECH 2. Fetal Weight between 2000-3000g 3. Gynecoid Pelvis Rx of Catatonia: Lorazepam Incisions done for pre-existing infections and abscesses are considered INFECTED WOUNDS Severe Depression with Psychosis: Mx with ECT Page 71 of 94 May 19, 2003 Aster's USMLE Step3 Notes Hypertensive Heart Disease: S4 Gallup (LVH) Depo-provera: - associated with Irregular bleeding (use conjugated estrogen x 7 days to control bleeding) Peak CPK levels: give idea about size of an infarct (no prognostic value) Nephrolithiasis with increased Creatinine: IVP can not be done (No I/V CONTRAST in the setting of renal dysfn.) Renal and Bladder Ultrasound Scan, instead HTN in Graves' disease: Rx with â-blockers Anti-Ro: associated with neonatal Lupus (resolves in 6 months) and Congenital Heart Block Lupus anticoagulant –anti-PL –recrrent abortions –thrombotic state (arterial –"in vitro" increased PTT + venous) (doesn't correct with mixing) –Russel Viper Venom Time Doxepin (a TCA) is useful in chronic urticaria suspected ADHD: get psychometric tests Misleading Low Sodium is caused by Hyperglycemia Mx of acute mountain sickness: acetazolamide Dx of Sarcoidosis: –Biopsy –Kveim test is obsolete –ACE levels are elevated in 50% pts. Rx of Brown Recluse Spider Bite: DAPSONE Middle Ear Effusion persisting for 4-6 months following an adequate course of Page 72 of 94 May 19, 2003 Aster's USMLE Step3 Notes antibiotics, with significant hearing loss (especially bilateral), is an indication for myringotomy and insertion of tympanostomy tubes. Chlamydial Ophthalmia: Rx with SYSTEMIC ERYTHROMYCIN (to prevent chlamydial pneumonia) Appropriate Initial Test for suspected B12 def: Serum B12 levels (many patients have normal CBC and normal indices) fruity breath odor: ketosis prolonged latent phase of labor : –therapeutic rest & sedation (usually morphine). –No Oxytocin / No Amniotomy DtaP contra-indications: 1.previous febrile reaction: fever > 105 F 2.h/o seizures (F/H of seizures is not a contra-indication) Rx of choice for SVC syndrome: Radiation First HiB vaccine @ 2 months age Female > 40y with abnormal vaginal bleeding Endometrial Bx to r/o Endo. malig. Atrial Flutteris not a serious arrhythmia, but cardioversion should be attempted in the presence of CHF. Atrial Flutter due to Digitalis toxicity: PACEMAKER Anorexia nervosa: BUN increase Low Platelet Count Leukopenia with relative lymphocytosis elevated serum carotene levels Legionaire's disease: Page 73 of 94 May 19, 2003 Aster's USMLE Step3 Notes Person-to-person spread has not been documented Childhood obesity is not a predictor for adult obesity long-term Rx of obesity in children : usually fails Thoracic outlet syndrome: appearance on numbness and paraesthesiae with arm abducted to 90 degrees and externally rotated (not defined by the disappearance of radial pulse) Postmenopausal with stress incontinence: Kegel exercizes, pessary, estrogen replacement Retractile Testes: –exaggerated cremasteric reflex –temporary –resolves in adolescence –no increased risk of malignancy Flail Chest: Intubation & Assisted ventilation (Strapping of Chest may lead to hypoxia & atelectasis) Vaginismus is involuntary contraction Behcet's: cutaneous hypersensitivity 60-70% will develop a sterile pustule within 48 hours of any aseptic injection epidydimitis -> check age of pt. < 35: Chlamydia, Gonococcus > 35: E.coli Gold stadard for diagnosis of melanoma: BIOPSY Treatment of alcoholism in wife-batterers does not treat battering behavior Pt. with hemoptysis and normal chest film: Fibre-optic bronchoscopy (PPD is not indicated) F/U COPD progression with FEV1 Page 74 of 94 May 19, 2003 Aster's USMLE Step3 Notes Tick paralysis (neuro-toxin mediated): 10% mortality prompt resolution if tick is identified and removed Let children attend funerals, if they want to. They should be accompanied by adults who can provide comfort and support Hyperparathyroidism: inc. incidence of Pseudogout NIACIN: can be associated with hepatotoxicity rear-facing infant seats should be on the back seat. < 12 y children: ride secured on car backseat Headache onset with exertion, such as weight-lifting: serios sign (look for CNS malformations & vascular malformations) Minocycline: has anti-inflammatory action (has been used in Rheumatoid Arthritis) Gynecomastia in adolescence: Observation Long standing Gynecomastia: SURGERY HCM: EKG is abnormal (LVH, WPW, abnormal Q wves) Ticlopidine: has been associated with neutropenia Immediate gastric lavage is ot indicated in strychnine poisoning Continuous gastric lavage: PCP overdose Not all persons with anaphylaxis will have a repeat reaction when exposed again to the agent. Repeat reactions are usually less severe. Head, Neck, Face sutures: leave in place for 3-5 days (rapid healing) Eclampsia: MgSO4 (no role of anticonvulsants) Clonidine withdrawl: Hypertensive Crisis Page 75 of 94 May 19, 2003 Aster's USMLE Step3 Notes The woman's need for physical intimacy often increases during pregnancy. Abstention from intercourse in the last month of normal pregnancy is not necessary Valsalva maneuver decreases the venous return to the heart, thereby decreasing cardiac output. This decreases murmurs due to AS, MR, PS, but increases the murmur due to HCM FOBT testing does not decrease the mortality from colorectal carcinoma #1 symptom in vaulvar carcinoma: Pruritus Of the anticonvulsant, VAPROATE has the least effect on hepatic enzymes and therefore has the least impact on decreasing the efficacy of OCP's Gilbert's syndrome: lower levels of unconjugated bilirubin cf. Crigler Najjar (6-45 mg/dL) Menopause: Serum FSH increased Estradiol decreases, and Estone becomes predominant estrogen. Infiltration of local anesthetic agents (less pain): –warm solution –small needles –slow infiltration –addition of bicarbonate to the mixure Mg-containing antacids in CRF: can cause magnesium toxicity Postherpetic neuralgia: higher incidence in older pts. ANA titre < 1:160 is common in healthy older people Orthostatic hypotension: Drop in Systolic > 20 mmHg Drop in Diastolic > 10 mmHg Mx: discontinue any drugs that might be responsible -> arise slowly -> elastic stockings -> Fludrocortisone B pertussis is being recognized as a cause of persistent cough in adults. (associated with dysnea, tingling sensation in throat) d/o/c for Giardiasis in children: Furazolidone Page 76 of 94 May 19, 2003 Aster's USMLE Step3 Notes Tinea capitis: Oral Griseofulvin poor response to topical medication Males with impotence, decreased libido & decreased testosterone: order a prolactin level (r/o pituitary adenoma) Pre-term infants: normal response to immunization (although they have relative immunodeficiency) Drug indiced LE: anti-histone antibodies [ANA (+), Anti-dsDNA absent] –hydralazine, isoniazid, procainamide, penicillamine –Mx: discontinue medication + short-course of glucocorticoids –disease lasts < 6 months –ANA may remain (+) –most lupus inducing drugs can be safely used in SLE, if no alternative exists HCM: sudden death in athletes Dx: Echo Rx: â-BLOCKERS Valsalva maneuver increases murmur ITP: low platelet, BM aspiration shows numerous megakaryocytes Risk of suicide: Female Physicians > general females Physicians' risk of suicide Psychiatrists > Ophthalmologist > Anesthesiologist Anaphylaxis: Epinephrine Juvenile Rheumatoid Arthritis: very few patients are left with disabilty / deformity. At least 50% remit fully and majority regain normal function Urticaria > 48 h : Skin Biopsy to r/o Urticarial Vasculitis Mobitz Type II Heart Block: Mx is PACEMAKER Page 77 of 94 May 19, 2003 Aster's USMLE Step3 Notes Stage IA Hodgkin's: Radiotherapy alone is effective Total Hip replaement: –immediate relief –perioperative anticoagulation –successful (no need for revision in 90%) –bone resorption is a major concern for long-term stability of implant Pressure Ulcers: Stage I: Nonblanching Erythema Stage II: Broken Skin with partial thickness skin loss Stage III: Full tickness skin loss (extension into subcutaneous fat) Stage IV: Extension into Muscle or Bone "kennel cough" is produced by a canine Bordetella Risk factor for domestic abuse: female gender Trochanteric bursitis –presents with a deep, dull, aching pain –burning & tingling in lateral upper thigh –worse with activity –excacerbated by sitting cross-legged with affected leg The mortality rate for pneumococcal pneumonia is same for the past 50 years SKIN SWELLING with Bee sting: local reaction [not anaphylaxis] Rx of Restless Leg Syndrome: Clonazepam Alendronate: Pill-induced esophagitis TCA withdrawl symptoms (cholinergic symptoms) : best managed with Benzotropine (Anti-Ach) Aspartame is c.i. in children with PKU Page 78 of 94 May 19, 2003 Aster's USMLE Step3 Notes Diaphragm & spermicidal jelly: insert upto 2 hrs before intercourse and leave in place for 6 hrs after intercourse (for repeated intercourse, re-apply jelly) Asthmatics who require â2-agonists > once/day; can be prescribed inhaled glucocorticoids Psoriasis in infancy: begins n diaper area (the area of greatest trauma) Labia minora adhesions: –not present @ birth –acquired condition –no urinary retention –not assoc. with other anomalies –surgical correction has a 100% recurrence rate –estrogen cream can lyse the adhesions Carbidopa/Levodopa do not alter the progression of Parkinson's disease Chronic Choleystitis with Cholelithiasis is frequently non-visualized on ultrasound. Umbilical hernia in a child < 6m Mx: Conservative [Strapping is ineffective] (usually disappear by 1 year of age) Surgery for strangulated hernia; persisting beyond 4y Increased Postop Cardiac Death –S3 Gallop –h/o MI in the past 6 months –Frequent PVCs –Aortic Stenosis Supression of lactation: breast inder & cold pack [Bromocriptine is not approved for this purpose] Cardiac Pacemaker: does not warrant IE prophylaxis Pubertal development in an adolescent girl: Thelarche, Pubic Hair, Growth spurt, Menarche (Growth spurt precedes Menarche) Page 79 of 94 May 19, 2003 Aster's USMLE Step3 Notes Most sensitive and specific means of diagnosing appendicitis is history and physical exam. (not CT or U/S) In stroke, overzealous antihypertensive medications can reduce cerebral perfusion and increase tissue damage. Scabies in young children: Permethrin [Lindane not approved] Wheezing in children may also be due to GERD A single sexual encounter with a person with genital warts carries a 60% chance of transmission. Transmission occurs in asymptomatic state too. Hydrocephalic children: –increased developmental disabilities –lower IQ –learning deficits –defective verbal abilities –memory and visual problems Chlamydial infections: Azithromycine & Doxycycline have equal efficacy #1 cause of hematemesis in healthy newborn: comiting of swallowed maternal blood Clinical privileges to physicians are granted by the GOVERNING BODY of the hospital New onset LBBB may be an indication for thrombolysis even in the absence of characteristic ST elevation of MI Dexfenfluramine: 1º Pulmonary Hypertension Transdermal NTG Patches: Rapid Tolerance Oropharyngeal dysphagia in elderly: ? early Parkinson's Paget's disease of bone: –Head Enlargement Page 80 of 94 May 19, 2003 Aster's USMLE Step3 Notes –Deafness –Nerve compression –increased urinary hydroxyproline –increased alkaline phosphatase HIDA scan: Cholecystitis (+) –nonvisualization of the GB –visualization of CBD & Bowel Leading cause fo mental retardation in US: Fetal Alcohol Syndrome Rotavirus G/E: decreased incidence in breast fed infants. None of the antibodies that develop after the first attack are protective Grade 1 Vesico ureteral reflux: prophylactic antibiotics and double voiding of urine Sodium Nitroprusside infusion: may increase Thiocyanate levels to toxic range (delirium, tinnitus, blurred vision) Allergic bronchopulmonary aspergillosis is treated by corticosteroids (not ANTIFUNGALS) Childhood autism: Echolalia, minimal eye contact, repetitive behavior serum digoxin levels elevation can be seen in pts. treated with oral verapamil Recurrent Zoster is rare Cocaine > Coronary Spasm (free basing can lead to loss of eyebrows/eyelashes) Measles vaccine significantly reduces the chances of developing SSPE Influenza A is usually sensitive to Amantidine (resistance occasionally seen in institutionalized pts.) Synovial Fluid in OA : High Viscosity Children with diarrhea who are not dehydrated should be give age appropriate diet Page 81 of 94 May 19, 2003 Aster's USMLE Step3 Notes Loperamide: contra-indicated in children Secondary Amenorrhea: give Progestin Challenge Rapidly Progressive Periodonitis (with good dental hygiene) might be suggestive of HIV / AIDS Hyperosmolar nonketotic coma: –require less insuin for correction (cf. DKA) –Fluid deficit is larger (cf. DKA) (10 L) –patients are older –can also occur in Type 1 DM The hypochondriac believes that his fears about disease are totally realistic. He also believes that physicians are not acting in his best interests by disputing the reality of these fears. Hypochondriacs: poor response to antidepressants Old age: Vital Capacity decreases Functional Residual Capacity increases Arterial Oxygen Tension slowly declines with age Pasturella multocida: Rx Amox-Clav (Pn allergy: Doxycycline) [NOT ERYTHROMYCIN] Place PPD on all individuals being admitted to a nursing home. Persons with doubtful reactions should be tested a second time within 1-2 weeks (boosted reaction). This second reading should be taken as the baseline reading for that person. Tennis Elbow : Lateral Epicondylitis (usually acquired occupationally) Obesity lowers aminoglycoside volume of distribution necessitating decrease in dosage Primary indication of joint replacement in OA: Severe Pain Page 82 of 94 May 19, 2003 Aster's USMLE Step3 Notes Postcoital test : best done in midcycle Adhesive bands are now the most common cause of intestinal obstruction for all age groups (strangulated hernias are the m/c cause in children) Rx for ANUG (acute necrotizing ulcerative gingivitis) PENICILLIN Vasoldilators of choice for CHF ACEIs Use of TCAs in patients with glaucoma can precipitate acute angle-closure attacks (antcholinergic properties) The only absolute contra-indication to breast feeding is GALACTOSEMIA Major abdominal trauma in 3rd trimester pregnancy: evaluate for placental abruption & preterm labor [electronic fetal monitoring: obtain reactive NST] Transient cortical blindness due to mild head traums usually recovers (benign outcome) Pneumococcal vaccine: not before 2 years of age #1 cause of microscopic hematuria in elderly is BPH Polychlorinated Biphenyls: skin rash called Chloracne Ludwig's angina: infection of the deep fascial space of the submandibular space (early airway compromise) Mx: Intravenous steroid cover Wilson's disease confirmed by inability to incorp. a copper isotope into Ceruloplasmin Patients with procaine allergy usually tolerate Lidocaine (amide group) well Always inject insulin in skin of non-exercized areas (to prevent exercize-induced hypoglycemia). If the lefg is used as injection site, insulin absorption will be enhanced with running leading to hypoglycemia. Page 83 of 94 May 19, 2003 Aster's USMLE Step3 Notes Celecoxib: not to be used in patients with SULFA allergy Passengers with stable medical conditions requiring low-flow oxygen cannot bring their own oxygen on aircrafts according to Federal Air Regulations concerning hazardous cargo. Most air carriers will provide O2 for a fee Do not fly within 3 weeks of a MI No air travel with term pregnancy OCD –SSRI –Response prevention & in vitro exposure Don't give OPV to a child whose sibling is immunodeficient Post MI Risk Stratification is done with an Exercize Stress Test (for patients who can exercize). For patients who can not exercize, a Pharmacological stress testing or Dobutamie Echo is indicated (both are less sensitive than Exercize Stress Testing) Continue ASPIRIN in the post-MI period Antiplatelet agent Post-stent placement: Clopidogrel (ADP receptor inhibitor) Abciximab (anti-IIb/IIIa) (decrease restenosis rates) The choice of agents in asthma therapy is determined by frequency of asthma symptoms The presentation & management of acute cholecystitis in pregnant patients is the same as in non-pregnant population (Lap Cholecystectomy). Fetal otcome is the best in 2nd trimester Hyperactive children: hypoperfusion in frontal lobes NPH: order CT scan head to r/o ICSOL (confirm NPH by documentation of improvement in symptoms with serial lumber punctures) Severe pre-eclampsia: Page 84 of 94 May 19, 2003 Aster's USMLE Step3 Notes –delivery @ term –MgSO4 for seizure prophylaxis –antihypertensives for BP control –MgSO4 is not an antihypertensive. –Control of BP alone does not obviate the need for seizure prophylaxis Suspected PCP in AIDS: Obtain a Chest X-Ray Migraine prophylaxis: â-blockers Migraine treatment: Sumatriptan Somatization disorders: 1st step in Mx avoid un-necessary Ix & medical/surgical treatment Community acquired pneumonia: S pneumoniae Rx: Macrolide (Clarithromycin) Patient presents to the office with unstable angina: 1st step: Chew & Swallow Aspirin Vaginal douching > 3-4 times / month: associated with alteration of vaginal flora and increased incidence of PID Prolonged survival in CHF: ACEI's A fecal gram stain is always positive for bacteria and is not indicative of any pathology. Inflammatory Bowel Disease: Fecal Leukocytes(+) Gold standard for Dx of IBD: COLONOSCOPY Critical Aortic Stenosis: Valve Repair Surgery (Valvuloplasty in high risk due to other co-morbidity) Spinal metastasis: Emergent Radiotherapy COPD patient who still smokes: #1 step is smoking cessation (immediate effect on declining lung function) COPD patients should receive annual influenza vaccine (not HiB vaccine, it is only given to children) Page 85 of 94 May 19, 2003 Aster's USMLE Step3 Notes Dx of Adenomyosis: MRI (most accurate) (U/S has lower sensitivity and specificity) Abnormal Vaginal Bleeding: Periodic, abnormal flow: Anatomic cause Irregularly Irregular: Endocrine cause Routine screening of asymptomatic population for dyslipidemia: NONFASTING SPOT CHOLESTEROL Screening of population with CAD/risk factors: FASTING LIPID PROFILE (non fasting random spot cholesterol not indicated) Patient must have quite smoking 15 years ago for it to not count as a risk factor for CAD Digoxin with or without a nodal blocking agent (beta-blocker) is effective in achieving rate control in Atrial Fibrillation Chronic A.Fib.: associated with enlarged Left atrium Medical emergency in a physician's office: 1st step is to initiate call to “911” beta-blockers improve outcome in patients at cardiac risk undergoing noncardiaovascular surgery Mx of HTN in patients with migraine: â-blockers Renal Failure: is associated with calcium wasting & secondary hyperparathyroidism (Calcium supplementation is beneficial) Patient with syphilis & penicillin allergy: Do a penicillin skin test to confirm & perform desensitization if necessary uncomplicated UTI: –perform urinalysis –Oral TMP-SMX (3 days) –no need for urine cultures Page 86 of 94 May 19, 2003 Aster's USMLE Step3 Notes The occurrence of PVCs post-MI is associated with increased mortality & morbidity. Treatment of asymptomatic PVC's with anti-arrhythmics is not indicated. (Such treatment is itself associated with increased mortality) No role of prophylactic anti-arrhythmics post-MI Initiate Calcium supplementation even in cases of prolonged secondary amenorrhea Exercize-induced amenorrhea –low adipose tissue –estrogen biosynthesis shifts to 2-hydroxylation with increased synthesis of catechol estrogens –catechol estrogens compete with catecholamines for COMT –results in inreased dopamine –dopamine decreases GnRH release –results in secondary amenorrhea –whatever the age, OCPs (for HRT) & calcium supplementation are required to prevent bone loss Mx of psychotic depression: ECT Post-void urinary volume estimation: Straight Urinary Catheterization (U/S is inaccurate in estimating bladder volumes) All GDM patients should be tested @ 6w post-partum with 2-hr (75g Glucose) Oral GTT GDM is a risk for DM unrelated to pregnancy (regardless of glycemic control in GDM) Klebsiella penumonia –necrotizing pnemonia –hospitalized patients / aspiration / post-stroke & alcoholics –currant-jelly sputum (bloody) Staph aureus: causes cavitatory pneumonia (associated with rapidly progressive effusions & empyema) Colon Cancer screening: –FOBT annually –Colonoscopy q10y Page 87 of 94 May 19, 2003 Aster's USMLE Step3 Notes –Sigmoidoscopy q5y PSA estimation is not recommended for Prostatic cancer screening (if at all one test has to be done, it should be Digital Rectal Examination) Chronic Uterine prolapse: –first fit a pessary –prescribe estrogen cream –later proceed to surgery (surgical failure rate is high when performed in the presence of dry atrophic mucosa) In any patient with pain of cardiac origin: EKG (to differentiate between Ischemia & Infarction) Inhaled corticosteroids: long-term stabilization of severe asthma (beta-agonists provide only symptomatic relief) Hypotensive response to NTG drip in patients with inferior ischemia: Right Ventricular Failure (Mx: Stop NTG, Start I/V crystalloids) suspected anemia: 1st Ix – CBC suspected Fe deficiency anemia: Serum Ferritin levels Normocytic anemia: 1st Ix – Reticulocyte count h/o GI bleeds with DVT: not a candidate for anticoagulation Alcohol induced dilated cardiomyopathy: #1 step – stop alchol intake to halt progression Polycythemia vera: increased risk of stroke Valsalva maneuvre: decreases pre-load Jedrassik maneuvre: decreases after-load Valsalva decreases HCM murmur, Jedrassik increases HCM murmur Ankle – Brachial Index: < 0.5 suggests severe ischemia (surgical revascularization required) Page 88 of 94 May 19, 2003 Aster's USMLE Step3 Notes MVP without MR: no IE prophylaxis required [absence of MR to be documented by Echo] Pilonidal Cyst: infection of hair follicles in sacrococcygeal area. Mx: removal of hair / I&D Elderly with Knee “locking”: Medial Meniscal Tear “pop” in he knee: ACL tear pain in lateral knee, athlete: Iliotibial Band Syndrome COPD @ any stage, smoking cessation in beneficial Painless Testicular Enlargement –? Malignancy [Embryonal/Seminoma/Lymphoma] –Ultrasound, no Biopsy –spreads to retroperitoneal nodes, if inguinal nodes (+), suspect scrotal invasion –Sx: Inguinal approach, not Scrotal (Orchiectomy) Evaluation of lung malignancy: CECT (IV contrast) Dermatomyositis: search for occult malignancy Most testicular varicoceles are on the left side Neomycine allergy: 5% of population (Treat with Steroids). It is a Type IV hypersensitivity reaction SCC Lip Risk factor: Smoking > Sunlight exposure Hydrocele: typically idiopathic (No Rx required). Persistent hydrocele: Refer to Urology for Sx Tuberous Sclerosis: Skull X-Ray to look for intracranial calcifications AFP increase: NSGCT b-hCG increase: Seminoma & NSGCT Li-induced hypothyroidism: Mx – levothyroxine (not discontinuation of Lithium) Latest recommendation advise Influenza vaccination for >50y instead of >65y Page 89 of 94 May 19, 2003 Aster's USMLE Step3 Notes suspected Pseudotumor cerebri: LP (inc. CSF pressure) complex partial seizure: aura, behavioral arrest, automatisms Myesthenia gravis: CT Chest to r/o Thymoma Propranolol is associated with depression Fluoxetine takes 6-8 weeks to act ! Asplenia: PneumoVax / HiB / Influenza vaccine Headache excacerbated by position & exertion: increased ICT (? mass lesion) Mitral Regurgitation 1.Transthoracic Echocardiography 2.If quantification reqd.: TEE 3.Gold Standard for any valvular disease: Cardiac Catheterization Suspected Anemia: next step – CBC MICROCYTIC ANEMIA, to Dx Fe.-def anemia: SERUM FERRITIN (Gold. Std.: Bone Marrow Bx) NORMOCYTIC ANEMIA, next step: RETICULOCYTE COUNT GI side effects are common with oral FeSO4. They are not an indication for discontinuing therapy. Always assess response (% Retics) after Iron Therapy. OCPs can prevent anemia, they do not treat established Iron deficiency anemia. (Rx: Iron) ABI < 0.5: s/o significant PVD (Sx revascularization) Steroid Rx in suspected GCA: start without waiting for ESR / Temporal Artery Bx results Excessive Cow's Milk Intake: Fe. Def. Anemia Pericarditis: Diffuse ST elevation Page 90 of 94 May 19, 2003 Aster's USMLE Step3 Notes Factor V Leyden: Lifelong Warfarin Prophylaxis beta-blockers in stable CHF: decrease mortality DVT with h/o UGIH: no prophylaxis (?IVC Filter) Critical Aortic Stenosis: Mx – Valve Repair (Valvulopalsty only for high risk cases) Esophageal Varices: BANDING TIPS is for portal decompression before Transplant. Not used as a primary procedure only for Eso. Varices Chronic Malabsorption in Pancreatitis: Mx – non-enteric coated Pancreatic enzyme with H2 blockers Child < 2 years with symp. Inguinal Hernia: Contralateral Exploration indicated GERD: –non-pharmacological measures –emperical pharmacological measures (H2 / PPI) –if fail, do Esophageal 24 hr. pH monitoring probe kept 5 cm proximal to LES pH<4 for >5 minutes or >9% of total time –followed by UGIE & Surgical Mx if needed Irritable Bowel Syndrome is a Dx of exclusion 12 weeks of GI symp. In preceding 12 months Gilbert's: jaundice may only be noticed in the times of stress / infection or fasting (Unconj.) Anal Fissure: Steroid Cream & Sitz Bath Stress is a trigger of IBS, not cause Biliary colic: RUQ pain following meals Cholecystitis: RUQ Pain / Murphy's / Fever / Leuko. Cholangitis: RUQ Pain / Fever / Jaundice False (+) Guaiac stools: meats & vegetables containing peroxidases (Inorganic Iron Page 91 of 94 May 19, 2003 Aster's USMLE Step3 Notes does NOT cause False (+)) F/H Duodenal Ulcers with Hypercalcemia: MEN I HNPCC: Mx – subtotal colectomy with TAHBSO Child with Constipation: Mx prune / pear juice (sorbitol) Rectum devoid of stool: Hirschsprung's Rectum full of hard stool: Fecal Impaction Graves': Cigarette smoking increases ophthalmic involvement (advise patients to quit smoking) Smoking Cessation: 1.success usually takes 5-6 attempts 2.associated with weight gain 3.counsel patients at each visit 4.pharmacotherapy should be offered to all 5.relapse rates decrease after 6m of abstinence suspected Phaeo: first step is alpha-blockade with phenoxybenzamine (before Bx / FNAC) #1 side effect of radioactive Iodine: hypothyroidism Glitazones – asociated with liver toxicity (LFT's) Hypothyroidism with macrocytosis & hyperlipidemia: 1st step is THYROID hormone replacement (might correct macrocytic anemia & decrease lipid levels) Infection in suppressed adrenal axis due to chronic use of exogenous steroids (refractory hypotension) : administer stress dose of i/v steroids Cholesteatoma: CT scan of temporal bone (Mx: Sx) CN III palsy with pupillary involvement: MRI Child attending day care with viral conjunctivitis: Page 92 of 94 May 19, 2003 Aster's USMLE Step3 Notes remove from daycare till symptoms subside Fifth Disease: child is infectious before onset of rash Mx of epistaxis: pressure, no need to tilt head upwards Alk. Phosphatase is norally increased in pregnancy Med. Mx of Ectopic: MTX (b-hCG sample on Day 4 & 7, 15% decrease in level) LGSIL = CIN I (most lesions resolve spontaneously) Newborns can lose upto 10% of their weight in 1st wk Breast – Cystic Mass clear : discard bloody : send for cytology Delayed age at 1st preg: increased risk of Ca. Breast Polycystic Ovaries: 1st step: OCP's Churg-Strauss: (+) pANCA #1 extra-renal manifestation of adult PCKD: Colonic Diverticular Disease (not Intracranial Berry Aneurysms: seen in 15%) Nephrotic Syndrome in adult with recurrent hematuria: IgA nephropathy HSP: self limiting. Do urinanalysis (r/o kidney involv.) Cisplatin: nephrotoxic Never prescribe prescription drugs over the phone, especially if the patient is “new” (call for evaluation) F/H (+) of HTN: ? Adult PCKD Biopsy has no role for Diagnosis of RCC. If suspected, refer for Sx management (Bx only if e/o metastasis present) Page 93 of 94 May 19, 2003 Aster's USMLE Step3 Notes Nephrotic Syndrome with HTN: start ACEI's (no role of high-protein diet in nephrotic syndrome) DEXA: T-score: cf. Normal healthy young population Z-score: cf. Age matched conrols Osteoporosis is defined by the T-score Rx (HRT + Bisphosphonates) indicated if: –T < 2.5 or –T < 1.5 with presence of risk factors Smallpox Rx: Cidofovir Smoking cessation: Mortality reduced to ½ in first year and smoking caeses to be a risk factor 15 years after quitting Infants: always rear facing on backseat < 12y: always on rear seat Fertility returns as early as 1-2 weeks after cessation of OCP use. Tinea capitis: KOH prep (Ix) not Wood's lamp, all species don't show fluorescence Postherpectic neuralgia: Mx – TCA (Acyclovir decreases PHN when given prophylactically) Toxic megacolon in U/C: –high mortality rate –Ix: AXR –Mx: NPO/NG/Rectal Tube/Antibiotics –Sx if doesn't resolve in 2-5 days Peptic Ulcer disease with Gout: acute Rx – colchicine (NSAIDs can not be used) Necrobiosis Lipoidal Diabeticorum: DM plaques with depressed atrophy on anterolateral leg Parkinson's patients hould be referred to neurologist Anosmia: r/o neoplasm/#/sinusitis (CT/MRI) Page 94 of 94 May 19, 2003 Aster's USMLE Step3 Notes Endometriosis: –abdominal pain –dyspareunia –painful defecation –dysuria –GI upset with periods –Ix: Laparoscopy Influenza vaccine is indicated in healthcare workers @ any age alpha-1-AT def.: avoid smoking & alcohol (to prevent emphysema & cirrhosis) PUPPP: Pruritic Urticarial Papules & Plaques of Pregnancy –no umbilical involvement –Mx: conservative Impetigo herpetiformes: rare form of pustular psoriasis –acute onset –febrile –erythematous plaques surrounded by sterile pustules Herpes Gestationis: –autoimmune nd or 3rd trimester onset –2 –involves umbilicus –recurs in subsequent pregnancies Routine rectal examination does not lead to elevation of PSA (levels can be done on the same visit as DRE) Uncomplicated varicella in preg., Conservative Mx Hematuria without UTI: next step – contrast study LiCO3 can excacerbate psoriasis TT in past 5y: No Rx reqd. Page 95 of 94 May 19, 2003 Aster's USMLE Step3 Notes TT in past 5-10y: prone wound: T toxoid clean wound: No Rx TT > 10y ago prone wound: T toxoid clean wound: No Rx Post-PE: maintain INR between 2.0 & 3.0 If > 3.0 (no e/o ICH): admit / give Vit. K (heparinize if INR falls to 2.0) If e/o ICH: give FFP to replenish clotting factors Thioridazine: prolongation of QT interval PPD(+): obtain CXR to r/o active infection before starting INH prophylaxis Chronic Steroid Use: –osteopenia –Avascular Necrosis of Femoral Head (not due to osteopenia) avoid trauma, slow taper of steroids Relapsing Polychondritis –Ear (Painful external ear) –Nose –Larngeal Inflammation (focal narrowing) with airway obstruction –can be associated with aortic aneurysms –Mx: STEROIDS Avascular Necrosis of Scaphoid: Sx Pinning (X-Ray: sclerosis) #1 cause of U/L vocal cord paralysis: Lung Ca. Prostatic Mets.: respond to andrigen deprivation for the first 2-3 years and then become resistant >6m with exclusive b.f. : Iron Supple. Breast Feeding (Hormonal Contra.): Progestin-only minimal effect on milk quality & quantity Page 96 of 94 May 19, 2003 Aster's USMLE Step3 Notes Uterus & Cx reach normal size: 6 wks post-partum (IUCD & Diaphragm can be used) If one FBS > 126, send another sample (Dx of DM) MMR immunization is assoc. with simple febrile reaction. Can be associated with seizures too. Gingko biloba used with warfarin: severe bleeding tendency Give MMR to children with egg allergy (contains cross-reacting egg protein but in very small quantity) Varicella vaccine @ 12 months suspected Giardiasis: send stool for ova/parasite before starting treatment Shell fish intake: associated with Hep. A Rx of Clostridial infection: Penicillin & Clindamycin Neonatal Sepsis: Ampicillin + Cefotaxime Meningococcal disease with persistent hypotension: Give I/V hydrocortisone (Waterhouse-Frederickson) SBP prophylaxis: Levofloxacin Acute post-infectious cerebellar ataxia: –ataxia / nystagmus –post varicella infection (1m later) –acute onset, resolves –Mx: conservative Pulmonary Coccidiomycosis: Pap smear of fresh expectorate is diagostic Meningococcal prophylaxis: Rifampin/Ceftriaxone/Ciprofloxacin Immunosuppressed: increased risk of fungal sinusitis (high mortality rate, intracranial compli., Ampho-B) Page 97 of 94 May 19, 2003 Aster's USMLE Step3 Notes After toilet, wipe front to back (decreases UTI inci.) Candida Diaper Rash: Topical Nystatin Primary Irritant Dermatitis: Zinc Oxide Rx of viral pericarditis: NSAIDs Rotavirus vaccine is no longer FDA approved (due to incidence of intussusception in recipients) Ant-HCV is (+) 18 weeks after infection Newborn with (+) TB contact should be given INH prophylaxis for 3 months irrespective of CXR/PPD status. If at 3 months PPD(+), continue for 6 more months (else stop INH) Pruritus ani: E.vermicularis (Mebendazole) Mandatory seat belt laws decrease MVA mortality Smoking cessation counseling should be provided to all patients regardless of age, duration, previous attemps. (decreases cardiovascular mortality) HSV transmission may not be prevented by condoms: skin-to-skin transmission occurs too. G(-) diplococci in Otitis: Moraxella (usually Penicillin resistant, use penicillinase resistant antibiotics) MMR is not contra-indicated in AIDS Dog Bite infection Rx with Amox-clav for puncture wounds or bites on hand (for non-infected wounds: local care) Home air humidifiers favor growth of house dust mite Post GA Sx hoarseness of voice: evaluate by ENT Mx aspiration pneumonia: Clindamycin (anaerobic cover) Page 98 of 94 May 19, 2003 Aster's USMLE Step3 Notes Breastfeeding mother with Trichomoniasis: Give MNZ one dose stat, discard milk for 24 hours Air Travel: decreased cabin pressure –decreased pO2 can cause hypoxemia, CAD patients have increased risk of MI –decreased pressure leads to expansion of gases. (problematic for patients with volvulus, GI surgery, recent intestinal obstruction) Female patients with CF may be infertile (plugging of fallopian tubes) Inpatient Rx for community acquired pneumonia: Malignancy, AIDS, cardiopulmonary/renal/liver disease PSA is not present in ejaculate. Butejaculation can increase PSA levels transiently for 48 hours Hemoptysis workup: –Chest X-Ray –Bronchoscopy –HRCT Chlamydial/Gono. Epidydimitis can be treated with a 10 day course of Ofloxacin PSA > 4.0ng/mL: required prostatic biopsy (esp. with F/H prostatic Ca.; 30% risk of Prostatic Ca. When PSA levels are > 4.0ng/mL). But no evidence that screening with PSA is beneficial suspected esophageal perf.: esophagoscopy with water soluble contrast Anabolic Steroids: Acne/Testicular Atrophy/Liver Dyfn./Depression IV contrast is contra-indicated in renal dysfn. Contrast nephropathy can be prevented by prior administration of N-acetylcysteine Dx of Sarcoidosis: Skin / Transbronchial Bx [Kveim is obsolete, Ca/ACE levels unreliable] Postop Sensory loss: EMG (Ix) Physiotherapy has role in motor weakness only Occupational Vitiligo: affects persons who work in rubber clothes, rubber gloves or handle phenolic or antioxidant chemicals Page 99 of 94 May 19, 2003 Aster's USMLE Step3 Notes Seborrheic Keratosis: Stuck-on appearance 100's of Seborrheic keratoses (Leser-Trelat sign) search for internal malignancy BZD in OLD patients: Oxazepam (hepatic excretion) BZD in Liver Disease: Lorazepam (renal excretion) Severe pain in OA is indication for joint replacement Hyperpigmented lesions with velvety appearance on nape & axillae: Acanthosis nigricans [associated with DM, obesity, Cushing's] Nursemaid's elbow: Mx – supination of forearm with elbow flexed (No cast necessary) Acne Blackheads: open comedones Whiteheads: closed comedones Supraclavicular node: BIOPSY Axillary node in female: Mammography -> Bx 3-10% of patients with spina bifida are hypersensitive to latex (also to foods like banana, chestnut, avocado, kiwi): SPINA BIFIDA – LATEX ALLERGY Osler Weber Rendu: epistaxis, GI bleed (lesions on lips/nose/tongue/palatepalm/sole) (chronic blood loss anemia) Chronic plaque psoriasis: Scale Bx Mx of autoimmune vitiligo: Steroids+Phototherapy Time released oxycodone: can be abused by drug-seekers (snorting or injecting crushed pill) prevention of recurrent erythema multiforme minor: ACYCLOVIR Bullae / Papules on Hand with Naproxen intake: Page 100 of 94 May 19, 2003 Aster's USMLE Step3 Notes r/o Porphyria cutanea tarda / pseudo-porphyria (order urine porphyrin & hepatic panel) Kyphosis with thoracic vertebrae wedging: Scheurmann's Kyphosis Tracheal deviation with impinging neck mass: consult thoracic surgery for securing airway Agitation in Delirium: d/o/c low dose Haloperidol When giving i/v high-dose Haloperidol, add Benzotropine to prevent Parkinson's symptoms Benzotropine is c.i. In Malignant Neurolept Syndrome (anticholinergic, leads to worsening of hyperthermia) If a child is to be given long-term salicylates, prior Influenza vaccination is recommended (to prevent Reye's syndrome) Post-MI: chest pain (aggravated by supine posture, relieved by sitting and leaning forward): Dressler's (Pericarditis) Emergent Pericardial Drainage: V5 EKG guided Postpartum psychosis: increased risk of infanticide Pt. with A.Fib.: require anticoagulation before cardioversion (if anticoag. c.i.: TEE to r/o mural thrombus) AIDS: primary CNS lymphoma CSF EBV PCR estimation is highll sensitive & specific If patient with altered sensorium has no DPAHC: do not use relatives for consent Post-SAH deterioration: mediated by vasospasm (prevent by NIMODIPINE) Page 101 of 94 May 19, 2003 Aster's USMLE Step3 Notes diffuse osteoporosis despite HRT / inc. infections ??? Myeloma MVA with Quadriplegia with h/o recent Sx: DVT prophylaxis required but anticoag. c.i. (use IVC Filter) Post-MI: absolute bedrest required only for 12 hours. Patients can begin graded activity after 12 hours. Submaximal EST @ discharge Maximal EST @ 2-4 weeks Sexual activity after 2-4 weeks #1 complication of vascular Sx: MI No Verapamil / Diltiazem in WPW ass. SVT (sync. Cardioversion) tPA use in stroke: monitor neuro. Q1h (high risk of intracranial h'age) suspected Conn's in 2º HTN: 1st step – CT abdo. (not Renal Vein Renin Levels), CT yields more info. Definitive Mx of Hepatorenal Synd.: Liver Transplant Diverticulitis with Pneumaturia: Mx – Sx (Colovesical Fistula) <50y Diverticulitis: Sx after 1st episode > 50y Diverticulitis: Sx after 3rd episode UGIH: i/v Octreotide (Splanchnic vaso-constriction) Malignant Otitis Externa: CT scan of temporal bone (Mx: i/v antibiotics) Rapid Rx of DKA: risk of cerebral edema Radio. Dx of Pleural Effusion: X-Ray in decubitus view Page 102 of 94 May 19, 2003 Aster's USMLE Step3 Notes Elderly with Bloody Diarrhea & patchy mucosal depigmentation (with other e/o atherosclerosis): Ischemic colitis (Mx - Bowel Rest & Hydration) Dural Venous Sinus Thrombosis (headache/seizure): Ix: CT Mx: Anticoag. Infants of GBS (+) mothers who received <2 doses of ampicillin: Take CBC/Bl.Culture & observe for 48hrs. Nephrolithiasis with Hydronephrosis with Urosepsis: #1 step is DECOMPRESSION Percutaneous Nephrostomy Tube Insetion (Antibiotics alone will not help) Mx of Neonatal UTI: i/v Ampi + Genta Neonatal Adrenal H'ages (B/L): sign of birth trauma (F/U with rpt. U/S in 1-2 weeks) Urinary retention with Renal Dysfn.: Catheterize (Decompress tract) Competent pregnant female may refuse diagnostic or surgical procedure that may be therapeutic, even life-saving, for the fetus (Patient autonomy) Previous abortion & OCP use are not risk factors for ectopic pregnancy Breast engorgement: Continue breast feeding (Use warm compresses) – antibiotics not needed An intact pulse distal to injury DOES NOT R/O compartment syndrome Ix – measure compartment pressure Mx – fasciotomy Lap Chole in Pregnancy: best results in 2nd trimester discoloration of synovial fluid indicates infection Acute onset of renal dysfn. - look at BUN/C next step: estimate electrolytes Page 103 of 94 May 19, 2003 Aster's USMLE Step3 Notes Children, with delayed passage of meconium, born to mothers who recv'd MgSO4 prepartum: MECONIUM PLUG SYNDROME “bubbly” appearance on radiographs (not synonymous with meconium ileus) Ix & Mx: Water-soluble contrast Biliary vomiting in infant: VOLVULUS until proved otherwise (Mx – Sx) Muddy Brown Casts in urine: ATN (Contrast nephropathy is a common cause, prevent by prior administration of Nacetylcysteine) #1 Sensitive test for proper intubation: End-tidal colume CO2 detection (colorimetric) 1st step after insertion of ETT (>7y): inflate cuff, auscultate (or check end-tidal CO2) Any anatomical defect in airway, get thoracic surgery consult before securing airway Ix for Latent TB: PPD Ix for Active TB: Sputum AFB Stain RA+Splenomegaly = Felty's severe disease, might require immunosuppressive agents like cyclophosphamide / azathiprine for Rx Patient on ventilator: acidosis & hypercarbia: increase Tidal Volume hypoxic respi.failure (ARDS, cardiogenic pulmonary edema): increase PEEP Apiration penumonia: Right Lower Lobe, foul smelling, anaerobic cover reqd. Selective pulmonary vasodilator: NO (Nitric Oxide) Page 104 of 94 May 19, 2003 Aster's USMLE Step3 Notes Evaluation of TMJ: MRI Heliox: mixture of Helium + Oxygen (used for oxygen delivery in severe bronchoconstriction, it has better laminar flow) Cystic Fibrosis with pneumonia: Aggressive chest physiotherapy to clear secretions Steroid acne: papules & pustules –steroid induced –atypical site –Mx: Tretinoin (no need to stop steroids) –also with: anabolic steroids, Iodide, Bromides, Li If unable to intubate after repeated attempts: Surgical Airway Access (No Resusci. without airway) Increased survival with ARDS: ventilator setting of TV < 6cc/kg bdy weight Alkali ingestion: –UGI study with water soluble contrast –if (-) can be repeated with Barium –Early endoscopy (endoscopy in acute ingestion might cause perforation) post-AAA repair, loss of sensation but intact proprioception: Anterior Spinal Artery occlusion (posterior cord spared) Catheter associated sepsis: Remove catheter, start broad spectrum antibiotics if still spiking fever (add fungal cover) Post-heart transplant chest pain / dysnea / fever ? Mediastinitis (Mx: broad-spectrum antibiotics) Post-thyroidectomy STRIDOR: ? Arterial bleed (call vascular surgeon, will open neck @ bedside – do ot attempt to open neck yourself) Post-thyroidectomy hoarseness of voice: Recurrent Laryngeal Nerve injury Page 105 of 94 May 19, 2003 Aster's USMLE Step3 Notes IJV line: associated with Carotid Bleed (if bleed occurs, and neck is tense, call vascular surgeon) Subclavian Line: associated with pneumothorax Guide wire loss while inserting central line: #1 complication – arrhythmia (call interventional cardiologist or radiologist for guide wire removal) post-GI Sx, ileus, LLQ mass, localized tenderness with some air under diaphragm (Pelvic Abscess) –some air under diaphragm post-op may be normal, does not necessarily indicate perforated viscus TURP syndrome: associated with hyonatremia (aborption of irrigating fluid) Alcohol withdrawl: Day 3 Fat Embolism: shortly after Long Bone # DVT: risk increases with duration of immobilization Nitroprusside : CN toxicity (Mx-Na thiocyanate) Mx of MethHb: Methylene Blue Rib #: shallow rapid respiration (due to chest pain): associated with higher incidence of atelectasis Patients receiving epidural narcotics should not receive I/V narcotics till epidural narcotics have stopped #1 cause of wound dehiscence: poor surgical closure DPL may not reveal retroperitoneal processes LGV: suppurative inuinal adenitis (1º lesion: herpetiform vesicle or erosion on glans) Chancroid: Painful punched out lesion –Syphilitic chancre can appear after appearance of chancroid 'cuz the incubation period of syphilis is longer than chancroid –Mx: Ceftriaxone / Azithromycin Page 106 of 94 May 19, 2003 Aster's USMLE Step3 Notes Granuloma inguinale: –seprenginous ulceration of groin/genitalia/anus –granulomatous tissue –beefy red / bleeds easily Acute suppurative parotitis: –S aureus –high mortality rate –seen in post-op patients with poor oral hygiene –fever with preauricular swelling Fastest way to achieve androgen deprivation (for prostatic mets.) is B/L orchiectomy (castrate level testosterone in 3 hours) – Leuprolide can take 30 days to achieve castrate level testosterone INR > 3.0, dysnea, no fever/leuko, increased Dlco: Dx is Pulmonary Hemorrhage AIDS with PML: start HAART (improves survival) –no Rx for PML (caused by JC virus) Post-LP: c/o postural headache –Post-LP headache –Mx: remain horizontal Broca's aphasia: broken speech, comprehension intact Wernicke's: “word salad” 1st episode of vasovagal syncope: reassure (get EKG) recurrent vasovagal syncope: TILT TABLE TEST Neuro. deficits in hypoglycemia: give I/V Dextrose SAH: Early CT can be normal, if CT does not agree with clinical suspicion – do CSF analysis TIA: 1st step – auscultate carotid If bruit (+): do Duplex U/S If Stenosis > 70% - CEA TCA overdose: admit to ICU Page 107 of 94 May 19, 2003 Aster's USMLE Step3 Notes (high risk of arrhythmia) Bell's palsy: Mx ?Conserv. / Acyclovir & Prednisone Li levels > 4.0mEq/L – urgent hemodialysis Bifrontal headache, OK when supine, worse on getting up : Intracranial Hypotension (? Dural tear – exertion) Meningitis with Papilledema: No LP Pt. with A.Fib on warfarin with increased INR with stroke: CT Head : if non-h'agic – tPA CT Head : h'agic – administer FFP & Vit.K Acute arterial occlusion: start i/v heparin + prepare for Sx embolectomy Pt. in ED with asystole: Transcutaneous pacing severe CAD & brady alternating with tachy: Sick Sinus Syndrome Pt. with uncontrolled HTN with chest pain & unequal blood pressure in R & L arm: Acute Aortic Dissection (Dx: CT) Mx - 1st step – lower systolic to < 100-120 mmHg HbS disease with fever: ADMIT (high risk of sepsis) CT can detect pericardial effusion, only ECHO can detect cardiac tamponade Dx of IE: isolation of organism from 2 separate sites FFP transfusion is also blood group matched anemia, t'penia, fever, renal dysfn., neuro ab(n): TTP (Mx: Plasmapheresis) Sigmoid volvulus: forms an omega loop can be reduced with sigmoidoscopy Page 108 of 94 May 19, 2003 Aster's USMLE Step3 Notes Abdo exam: 1st step is AUSCULTATION eavluation of any acute abdomen: check hernial sites DM with hearing loss / pain / granulation in external auditory canal: Malignant Otitis Externa (Pseudomonas) Mx – I/V Antibiotics Frontal sinusitis: can lead to a subperiosteal abscess (Pott's puffy tumor) Adult PCKD: cysts are found in kidneys, aso in liver PID with severe pain / guarding / mass: TOA ? Ruptured Child < 1 m with fever > 100F send Blood / Stool / CSF to r/o Sepsis Epiglottitis: Intubate (in OR by Anesthetist) Avoid NSAID use in renal insufficiency Acute Gout with PUD / recent Bleed: Colchicine Acute Gout with Renal Failure (NSAIDs and Colchicine are both unsafe) Intra-articular steroids HZ Ophthalmicus: ORAL Acyclovir Rx human bites with antibiotics Rx rat bites with Penicillin (rat bite fever) Pain remover: absorbed by skin, metabolized to CO in liver, can lead to CO poisoning 100% O2 vs Hyperbaric Oxygen therapy Indications for Hyperbaric O2 therapy in Carbon Monoxide poisoning –CarboxyHb > 40% –CarboxyHb > 25% with neuro. symptoms Page 109 of 94 May 19, 2003 Aster's USMLE Step3 Notes CarboxyHb > 15% in pregnancy (HbF has a high affinity for CO and fetal CO levels are 10-15% higher than maternal levels) to detect small pneumothoarx: end-expiratory CXR Radial Head #: heals faster with early mobilization Clearing Cx Spine: X-Rays and Examination Clearing involves response from patient. Therefore, a patient in altered sensorium with suspected Cx spine injury can not have hi Cx spine cleared !!! Antibiotics improve outcome in COPD flare A Living Will with DNR orders needs to be verified by the hospital's legal / social work dept. Penile chordee: CONGENITAL, fibrosis of tunica albuginea – increased curvature of penis Peyronie's disease: ACQUIRED, fibrosis of tunica albuginea – increased curvature & palpable plaques evaluation of rotator cuff injuries: MRI Diabetic Foot Ulcer: X-Ray to detect air Mx: Debridement DVT/PE: start i/v heparin & warfarin. Stop heparin 2 days after attaining therapeutic INR Pemphigus: acantholysis, Nikolsky sign (+) In patients @ high-risk for aspiration, apply cricoid pressure while intubating Fall from height & landing on feet: increased incidence of calcaneal & vertebral #'s Mx of acute prostatitis: Fluoroquinolones / TMP-SMX prostatic massage / no catheterization –no Page 110 of 94 May 19, 2003 Aster's USMLE Step3 Notes e-mail additions / revisions / suggestions to: [email protected] Page 111 of 94 May 19, 2003 ...
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