Things I keep forgetting — USMLE Step 2 CK Notes

Dx of Aortic Dissection: ECHO If unstable; CT Angiography if stable

Dx of coarctation: ECHO

Dissection-> CT/TEE

AAA -> CT/US

Biggest RF for asthma: Fam Hx

Pubertal Delay in M: Lack of testicular enlargement (Tanner 2) by age 14

Pubertal Delay in F: Lack of breast development or pubic hair (Tanner 2) by age 13

No menarche by age 15

DI: Serum Na high/norm (v low in psychogenic)

UOsm > 600 after deprivation = functional ADH (suggests primary polydipsia)

Seminoma: only beta hCG elevated (Elevated AFP in non seminoma)

Postpartum atony

Uterine massage > oxytocin/misoprostol >Tranexamic acid > Carboprost/ergot

Synchronised Cardioversion: Low Energy

Unstable arrhythmia (hemodynamically unstable): AF, A Flutter, SVTs, VT w a pulse

Unsynchronized Cardioversion (defibrillation): PEA

V Fib/V Tach (pulseless) —> hypotension

PEA includes VT VFib and asystole (flatline)

Hemodynamically unstable includes active bleeding

Norm Hb: 2 alpha and 2 beta (HbA)

Constitutional Growth Delay

Bone age < Real age

Child likely to have norm adult height —-> tracks on 5th to 10th percentile

Familial Short Stature: Bone age = Real age

Bone age > Real age

Obesity (d/t oestrogen)

Precocious puberty, CAH, neoplasm, Hyperthyroidism

Low basal LH ——>> GnRH stimulation test: High LH ——->> Central precocious puberty

Low LH ——>> Periph precocious puberty

Rinne and Weber: S U C cAl

Ac>bc normal conduction and midline

Oestrogen-progestin Contraceptive: Pros/cons

Benefits: Menstrual regulation; Hyperandrogenism tx (acne, hirsutism)

Risks: Cervical cancer increased risk

Labour progression in active phase: 1.2 -1.5 cm dilation every hr

Urine specific gravity 1.005 to 1.030

P < 0.05 significant

Haemophilus is GN

Digoxin Toxicity: HYPERKALAEMIA

—-> more likely in setting of hypokalaemia: Premature ventricular beats, U waves etc

Alkalosis: Dissociation of H+ from albumin —> Increased calcium binding to ALBUMIN

—->> hypocalcaemia

Clindamycin not good at aerobic GN —> Tx anaerobic GN; Staph, Strep …

Lytic lesions = MM (increased risk of infection so often concurrent)

Blastic/sclerotic lesions —> Prostate cancer

MCL tear: Medial joint line tenderness w/o effusion

Cushings: Initial Screening tests: Overnight low dose dexamethesone suppression test

CORTISOL: 24hr urinary cortisol excretion/Morn serum

Ulcerative Colitis: Crypt Abscess; pseudopolyps; no granulomas; Crohns: skip lesions; noncaseating granulomas; cobblestoning

Stroke: Tx: Thrombolysis within 3-4.5 hours —-> aspirin if out of time

Heparin and warfarin not used in acute stroke

MI: PCI: Door to balloon < 90min by skilled personnel (only available at specialised centres)

STEMI Sx developed <12hrs (6 BEST)

PE: heparin -> DOAC + WARFARIN LT

Acute limb Ischaemia: IV HEP

Tx: Skeletal muscle can tolerate 6 hrs ischemia (thrombolytic window): embolectomy

HF w reduced EF —-> EF <40% (norm 55-70)

PCWP < 12 (= pulm A occlusion P) CVP estimates RA P and Preload (<5) ## Pulm A P <25/10

In MI only aspirin, Beta blockers and ACE Inhibitors reduce mortality BBs and ACEI in HF do

Low V/Q —> High CO2

Rupture of IV septum: Step up in O2 concentration from RA to RV —-> normally 75-80%; day

5+

Ventricular Aneurysm: Persistent ST elevation HTN: First Line DOCs: Thiazides and beta blockers; smoking has no effect

Triple Therapy: PPIs; clarithromycin; amoxicillin/metronidazole

Quadruple Therapy (Hx of Macrolide exposure or Pen allergy)

PPI; bismuth; metronidazole; tetracycline

PO Abs -> Oral

PN nutrition-> IV

Pneucoccus Vaccine

Age 19-64. AGE >65

PPSV23 ALONE: moderate risk Sequential PCV13+PPSV23

Chronic disease of heart, lung or liver

Current smoker or DM

PCV13+PPSV23: v high risk pt. Sequential PCV13+PPSV23

CSF leaks; asplenia

Immunocompromised eg HIV or cancer

CKD

Rash involving palms and soles:

Measles; Kawasaki; TSS; Syphilis; Rocky Mountain; Hand Foot n Mouth

• 2.  4.       6.        1.         4-6.             11-12.         16-18

2. 2. D.       B.        M.        Very.           TADA (7).     MEN booster

R. A

D. D. D. D. HUMAN

R. H. R. I. MEN

I. H. M

H. P. H. P.

I. I V

P. P

I

Aerobic GNs: aminoglycosides

Anaerobic GN: Clindamycin/metronidazole

Gram Positives (MRSA and strep): Vancomycin

Aminopenicillins: increased GN coverage but less effective against anaerobes

Pen no good against staph

Clindamycin also tx gram positives

PCN ALT: STD -> Doxy; RF -> Macrolide

P450

Inducers: Anti epileptics inc barbs; chronic alcohol; griseofulvin; St. John’s; rifampin;

sulfonylureas

Inhibitors: Valproate; Abs and antifungals; Isoniazid; Amiodarone; Juice; Quinidine; PPIs

Fetal malposition: occipital anterior ideal

Subgaleal Hemorrhage: orbital ridges to nape of neck and level of ears

-> rupture of emissary veins upon scalp traction during delivery

Can progress to hypovolemic shock and DIC

Tx: Supportive -> Volume resuscitation and coagulation correction

Caput Succedaneum: Edema that crosses suture lines Above periosteum -> Prolonged fetal head engagement/operative delivery

Osteosarcoma Poor response to radiotherapy

2 months -> Social smile, starts to coo;

6 months -> Roll over; sit with support; crawl; stranger anxiety

9 months -> Sit unsupported; walk with hand held; object permanence

15 months -> Walk alone; build 3 cube tower and scribble with crayon

2 years -> 2-3 word sentences

Spinal cord -> UMN

CT Angiograpy CI if renal disease

Least: Intermittent: Sxs twice a wk, night cough <2 x month!

Avoid BBs in COPD etc

Winters formula calculates expected PCO2 with respiratory compensation: (HCO3 X 1.5) + 8 +/- ## 2

Granuloma inguinale: Painless and no LAD

Symmetrical Growth restriction d/t infections in early preg/fetal chromo abnormalities Asym growth restriction: HTN, Cigarrettes, Cocaine etc

Hx of HSV should receive prophylactic acyclovir/valcyclovir at 36 wks

Neuroleptic Malignant Syndrome: “lead pipe” rigidity, elevated CPK;K+

Tx: Dantrolene (muscle relaxant); Bromocriptine if refractory

SEROTONIN syndrome: Myoclonic jerks, hyperreflexia ==> bilateral Babinski;

Serotonin discontinuation syndrome ——> flu like sx, GI distress, dysphoria, fatigue

ITP Steroids FIRST

Ultrasound indications: < 2-years-old with a first febrile UTI

Not appropriately responding to antimicrobial treatment of UTI

Kids with recurrent UTIs

Family history of renal or urologic disease

Voiding cystourethrogram indication: 2 or more febrile UTIs in children

Anomalies seen on renal ultrasound

High fever with pathogen other than E. coli

Projection: Attributing ones own feelings to another

Trisomy 18: Edwards Syndrome

Clenched hands with overlapping 2nd and 5th digits (with hypoplastic nails); Prominent occiput

Trisomy 13: Patau Syndrome: Cleft Palate

Significant eye abnormalities; Postaxial Polydactyly; Cutis aplasia (focal absence of scalp skin)

Fetal alcohol -> small palpebral cf upslanting in Downs

Increased cup/disc ratio (cupping of optic disc) >0.6

Triple drug regimen HAART targets HIV rep at 3 different points in rep process:

2 Nucleoside reverse transcriptase inhibitors (requires phosphorylation) and 1 of:

Nonnucleoside reverse transcriptase inhibitor: nevaripine; envirenz

Protease inhibitor (-navir)

Lichen sclerosis has perianal involvement

Inevitable Abortion: No passage of products of conception; No cardiac activity

Diaphragm rupture - loss of shadow!

EMPIRICAL CAP Tx: Macrolide Or Doxycycline

If there are Risk Factors for MDR S Pneu ADD Antipneumococcal beta lactam:

-> Amoxacillin (+/- clavulanic)/ ceftriaxone Or mono therapy: Resp fluoroquinolone (moxifloxacin or levofloxacin)

Inpatient CAP: IV Macrolide/Doxy + IV antipneumococcal beta lactam:

Or mono tx: Resp fluoroquinolone (IV)

Do Congenital Presentations too: TORCH and Heart

Intellectualisation -> focusing on non emotional aspects

Focal tenderness: Osteomyelitis (norm X-RAY); compression fracture (improves w rest); epidural abscess; metastatic cancer (no improvement w rest)

AIS -> no ovaries

Immuno!

Haem stable can tolerate further imaging