Aster's USMLE Step3 Notes

Discussion in 'Step 3' started by DLC, Nov 7, 2004.

  1. DLC

    DLC Guest

    Aster's USMLE Step3 Notes

    USMLE Step3 Notes

    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
    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
    6.www.familypractice.com





    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 H
    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 (gluteal. 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)



    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]

    Aster's USMLE Step3 Notes-Fever 24-48 hrs. Postop: #1 Atelectasis
    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: gluteal. 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











    Aster's USMLE Step3 Notes- May 2003
    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 exercise 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



    Aster's USMLE Step3 Notes- May 2003
    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
    Morphine Sulfate, Hydromorphone, Fentanyl, Methadone



    Aster's USMLE Step3 Notes- May 2003
    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




    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)





    Aster's USMLE Step3 Notes- May 2003
    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


    Aster's USMLE Step3 Notes- May 2003
    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




    Aster's USMLE Step3 Notes- May 2003
    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), Temp. >104
    Mx- cooling fan/blank, check CPK




    Hypothemia: Osborne (J) wave on EKG
    Mild: (32-35 C) Passive External Rewarming
    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)
    ADHD with (+) h/o or F/H tics
    DO NOT USE STIMULANTS



    Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bileunchanged. (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

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    Posted: Sun May 25, 2003 4:33 pm Post subject: Ast-page15

    --------------------------------------------------------------------------------

    Aster's USMLE Step3 Notes- 2003
    Grey Turner Sign: flank discoloration
    #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

    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)

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