STEP 2 CS CASES......MUST READ

LATEST CASES

1. Enuresis

History:

When did it start?
How frequently does he wet the bed? How many times per week?
When does this happen? Only at night or at daytime too?
Have you tried any interventions or drugs before?
Does he drink or eat much late-night?
Do you know the volume of the urine?
What is the color of his urine?
Do you notice any blood in the urine?
Does he have any urgency for urination?
Does he have any other urination problem?
Does he snore?
Does he wake up during the night?
Is there any major stress for him?
How does he behave in school?
Is there any environmental changes related to wetting?
Ask HLHUGS
Is there anybody on your family has the same problem?
Ask PHSAM
Birth history, regular check up, immunization.

Counseling and Closure

Bed-wetting is much more common than most people believe, so there is no reason for you or your child to feel embarrassed or guilty. (Enuresis often runs in families.)

Bedwetting usually goes away on its own. Almost all kids who wet the bed eventually stop. But until it does, it can be embarrassing and uncomfortable for your child. So it's important to provide emotional support and reassurance during this process.

There are something may help: Reassure your child that bedwetting is a normal part of growing up and that it's not going to last forever.
It may comfort your child to hear about other family members who also struggled with it when they were young.
Tell your kid not to drink anything after dinner
Remind your child to go to the bathroom before bedtime.
When your child wakes with wet sheets, have your child help you change the sheets. Explain that this isn't punishment, but it is a part of the process. It may even help your child feel better knowing that he or she helped out.

There could be other possibilities causing bedwetting, like an infection of urinary system. Would you please bring your child here? So I can give him a complete physical exam and order urine test.

DD Work-ups
Monosymptomatic primary nocturnal enuresis Genital exam
Secondary enuresis UA
UTI Urine culture
Constipation First-morning urine specific gravity
Sleep apnea U/S- renal
Functional bladder disorder


2. Picky eater case

History taking:

1. How old is your son?
2. How long has he been a picky eater?
3. Why do you think you son is a picky eater?
4. Is his picky eating habit getting worse or getting better ?
5. Has he ever eaten well when he got really hungry?
6. Does he watch TV before dinner?
7. Does he have any pain in his belly?
8. Does he have any problems with his bowel movement?
9. How many times a week does he have bowel movements?
10. How many children do you have?
11. How much time do parents spend time with him?
12. Who takes care of your child when you are working?
13. What kind of house do you live?
14. Has your family moved recently?

Ask HLHUGS. PHSAM, Birth history, daycare, regular checkup and immunization shots

Well, Mrs. X, thank you very much for answering my question. Is there anything else you would like to tell me about?

Ok, I would like to give you my impression right now. First let me summarize what you have just told me. ???.. Is that right?

Mrs. X, based on the information you told me, I think your son may be experiencing a habitual eating disorder, however, we also need to exclude some other possibilities, such as lead-poisoning or iron-deficiency anemia. For that reason, I would like to examine him personally and order some tests on him before I make any diagnosis or give any advises. Is it convenient for you to bring him here? (Provide help if she can not bring his son to the hospital)

Alright, then, I will see you once you get to the hospital. Take care.

D/D: Work-ups
1. Habitual eating disorder 1. CBC and electrolytes
2. Lead poisoning 2. Serum lead level
3. Iron-deficiency anemia 3. Stool for OVA and parasites
4. Fiber-lack diet
5. Parasitic Infections




3. Hallucination Case

History:

1. Onset ( How long have you been having this problem)
2. Would you tell me more about it? What did you hear/see?
3. Is it always there or does it come and go?
4. Frequency (how often..)
5. Course ( getting worse or better)
6. Do you have any idea what might be causing of it?
7. Is there any warning signs before you hear/see it?
8. Do you feel someone is controlling you?
9. Does it affect your daily activities?
10. How is your relationship with your friends and family members?

Ask FACE SLIPS(Qs for depression), HLHUGS, PHSAM FOSS(my own mnemonics for ROS and History, equal to those in FA and UW)

always ask about social support.

PE: MMSE, Hearing and visional exam, quick neurological exam, Heart and Chest

Counseling:

Need to interview family members and close friends for more information
Quit recreational drugs, it may be one of the causes of the hallucinations he experiences
Provide support groups and recommend staying at hospital if he is confused or not stable.


D/D Work-ups
1. Schizophrenia 1. CT-head
2. Brief psychotic disorder 2. TSH
3. Drug-induced hallucination 3. CBC
4.Thyroid Disease 4. UA and toxicity
5. Electrolyte imbalance
6. Grief reaction/PTSD

2008 - Latest IMG friendly Hot list

NEW ( 2009) IMG Friendly Hospitals

Alabama:
Stringfellow Hospital, Anniston, Alabama (GC)

California:
Alameda County Hospital, Highland, CA
Kern Medical Center, CA
St Mary's Hospital, San Francisco, CA
University of California, San Francisco, CA
USC, Los Angeles, CA

Connecticut:
Bridgeport Hospital, Bridgeport, CT (H1,J1,GC)
Danbury Hospital, Danbury, CT (H1,J1,GC)
Hospital of St Raphael, CT (H1,J1,GC)
Norwalk Hospital, Norwalk, CT (H1,J1,GC)
St Vincent's Medical Center, Bridgeport, CT (H1,J1,GC)
University of Connecticut, Farmington, CT (J1,GC)

District of Columbia (Washington, DC):
District of Columbia General Hospital, Washington, DC
Howard University Hospital, Washington, DC (H1,J1,GC)
Providence Hospital, Washington, DC (H1,J1,GC)

Illinois:
Cook County Hospital, Chicago, IL (H1,J1,GC)
Chicago Medical School/FUHS, Chicago, IL
Illinois Masonic Medical Center, Chicago, IL
Jackson Park Hospital, Chicago, IL(GC)
Mercy Hospital, Chicago, IL (J1,GC)
Ravenswood Hospital, Chicago, IL (J1,GC)
Rush Copley Medical Center, Aurora, IL (J1,GC)
Rush Presbyterian Hospital, Chicago, IL (J1,GC)
Rush Westlake, Melrose Park, IL (J1,GC)
St Francis hospital, Evanston, IL (H1,J1,GC)
University of Illinois at Urbana Champaign, IL (GC)
University of Illinois at Chicago, Chicago, IL (J1,GC)
University of Illinois/Michael Reese Hospital, Chicago, IL (J1,GC)
University of Illinois at Peoria, IL

Maryland:
Franklin Square Hospital, Baltimore, MD
Good Samaritan Hospital, Baltimore, MD
Harbor Hospital, Baltimore, MD (H1,J1,GC)
Maryland General Hospital, Baltimore, MD (H1,J1,GC)
Prince George's Hospital, Cheverly, MD (GC)
St Agnes Health Care, Baltimore, MD (J1,GC)

Michigan:
Henry Ford Hospital, Detroit, MI (J1,GC)
Hurley Med Center/MSU , Flint, MI (J1,GC)
McLaren Regional Medical Center, Flint, MI
Mid-Michigan Medical Center, Midland, MI
Providence Hospital, MI (J1,GC)
Saginaw Cooperative Hospitals, Saginaw, MI
St Joseph's Mercy Hospital, Pontiac, MI (H1,J1,GC)
St John Hospital, Detroit, MI (J1,GC)
Wayne State University, Detroit, MI (J1,GC)
William Beaumont Hospital, Royal Oak, MI (J1)

Missouri:
St Mary's Hospital, St. Louis, MO
St Lukes Hospital, St. Louis, MO

New Jersey:
Atlantic City Medical Center, Atlantic City, NJ (J1,GC)
Englewood Hospital/Mount Sinai, Englewood, NJ
Jersey City Medical Center/Mount Sinai, Jersey City,
NJ Jersey Shore Medical Center, Neptune, NJ (GC)
Monmouth Med Center, Long Branch, NJ (J1,GC)
Mountainside Hospital, Montclair, NJ
Muhlenberg Hospital , Plainfield, NJ (J1,GC)
Overlook Hospital, Summit, NJ (GC)
Raritan Bay Med Ctr., Perth Amboy, NJ
St Barnabas Medical Center, Livingston, NJ (GC)
St Joseph's Medical Center, Paterson, NJ (GC)
St Francis Med Ctr, Trenton, NJ
UMDNJ, Camden, NJ (J1,GC)
UMDNJ, Newark, NJ (GC)
UMDNJ, New Brunswick, NJ (J1,GC)
UMDNJ, Piscataway, NJ

New York:
Albert Einstein/ Jacobi Med Ctr., Bronx, NY (H1,J1,GC)
Bronx Lebanon Hospital, Bronx,
NY Brooklyn Hospital, Brooklyn, NY (GC)
Brookdale University Hospital, Brooklyn, NY
Cabrini Hospital, New York, NY
Catholic Med Center., Jamaica, NY (GC)
Lincoln Medical and Mental Health Center, Bronx,
NY Maimonides Hospital, Brooklyn, NY (H1,J1,GC)
Metropolitan Hospital/NY Medical College, NY (J1,GC)
New York Hospital and Medical Center of Queens/Cornell U., Flushing, NY
New York Methodist Hospital/ Wyckoff Heights, Brooklyn, NY (H1,J1,GC)
NYU VA Medical Center, NY New York
Flushing Hospital, Flushing, NY
Sound Shore Hospital/NY Medical College, New Rochelle, NY
Saint Barnabas Hospital, Bronx, NY (GC, J1, H1)
St Lukes Hospital, New York, NY (J1,GC)
St Joseph's Hospital, NY
St John's Episcopal South Shore Hospital, Fair Rockaway, NY (H1,J1,GC
SUNY at Brooklyn, NY (H1,J1,GC)
SUNY at Buffalo, Buffalo, NY (H1,J1,GC)
SUNY at Syracuse, NY (J1,GC)
Winthrop University Hospital, Mineola, NY (J1,GC)
Woodhull Medical Center, Brooklyn, NY (J1,GC)

Nevada:
University of Nevada, Reno, NV
University of Nevada, Las Vegas, NV

Ohio:
Fairview Hospital, Cleveland, OH (J1,GC)
Good Samaritan Hospital, Cincinnati, OH
Jewish Hospital of Cincinnati, Cincinnati, OH
Meridia Huron Hospital, East Cleveland, OH (H1,J1,GC)
Mount Sinai Hospital, Cleveland, OH

Pennsylvania:
Abington Memorial Hospital, Abington, PA (H1,J1,GC)
Allegheny General Hospital, Pittsburgh, PA (J1,GC)
Easton Hospital, Easton, PA Frankford Hospital, Philadelphia PA (H1,J1,GC)
Frankford Hospital, Philadelphia, PA
Guthrie Healthcare, Sayre, PA
Lehigh Valley Hospital, Allentown, PA
Mercy Hospital, Pittsburgh, PA MCP
Hahnemann University Hospital, Philadelphia, PA
Pinnacle Health/ Polyclinic Hospital, Harrisburg, PA
UPMC Health System/ Shadyside Hospital, PA

Rhode Island:
Miriam Hospital of Brown University, Providence, RI (J1,GC)
Roger Williams Hospital, Providence, RI

Texas:
Texas Tech University, Amarillo, TX
Texas Tech University, Odessa, TX
Texas Tech University, El Paso, TX (J1,GC)

Virginia:
University of Virginia, Roanoke Salem, VA (J1,GC)

West Virginia:
West Virginia University Hospital, WV (J1,GC)

Wisconsin:
Sinai Samaritan Medical Center, Milwaukee.

FIRST AID KITS

First Aid Kits for USMLE exams are most important and concise materials to read and do a quickly
revise the materials. First aid is available for all the steps.
Here are few links for the first aid to usmle-

100 BUZZ WORDS FOR STEP 2 CK

BUZZ WORDS These secrets are 100 of the top board alerts. They summarize the concepts, principles, and most salient details that you should review before you take the Step 2 exam. Understanding of these Top Secrets will serve you well in your final review- 1. Smoking is the number-one cause of preventable morbidity and mortality in the U.S.(e.g., atherosclerosis, cancer, chronic obstructive pulmonary disease). 2. Alcohol is number-two cause of preventable morbidity and mortality in the U.S. More than half of accidental and intentional (e.g., murder) deaths involve alcohol. Alcohol is the number-one cause of preventable mental retardation (fetal alcohol syndrome); it also causes cancer and cirrhosis and is potentially fatal in withdrawal. 3. In alcoholic hepatitis the classic ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) is > 2:1, although both may be elevated. 4. Vitamins: Give folate to reproductive-age women to prevent neural tube defects. Watch for pernicious anemia, and treat with vitamin B 12 to prevent permanent neuro-logic deficits. Isoniazid causes pyridoxine (vitamin B6) deficiency. Watch for Wernicke enecephalopathy in alcoholics, and treat with thiamine to prevent Korsakoff dementia. 5. Minerals: Iron-deficiency anemia is most common cause of anemia. Think of men- strual loss in reproductive-age women and of cancer in men and older women if no other cause is obvious. 6. Vitamin A is a known teratogen. Counsel and treat reproductive-age women appro- priately (e.g., take care in treating acne with the vitamin A analog isotretinoin). 7. Complications of atherosclerosis (e.g., myocardial infarction, heart failure, stroke, gangrene) are involved in roughly one-half of deaths in the U.S. The primary risk fac- tors for atherosclerosis are age/sex, family history, cigarette smoking, hypertension, diabetes mellitus, high LDL cholesterol, and low HDL cholesterol. 8. Diabetes leads to atherosclerosis and its complications, retinopathy (a leading cause of blindness), nephropathy (a leading cause of end-stage renal failure), peripheral vascu-lar disease (a leading cause of limb amputation), peripheral neuropathy (sensory and autonomic), and an increased incidence of infections. 9. Although hypertension is most often mild or moderate and clinically silent, severe hyper-tension can lead to acute problems (known as a hypertensive emergency): headaches, dizziness, blurry vision, papilledema, cerebral edema, altered mental status, seizures, intracerebral hemorrhage (classically in the basal ganglia), renal failure/azotemia, angina, myocardial infarction, and/or heart failure. 10. In milder cases, lifestyle modifications (e.g., diet, exercise, weight loss, cessation of alcohol/tobacco use, elevation of head of bed) may be able to "cure" the following disorders without the use of medications: hypertension, hyperlipidemia, diabetes, gastroesophageal reflux disease (GERD), insomnia, obesity, and sleep apnea. 11. Arterial blood gas analysis: In general, pH tells you the primary event (acidosis vs. alka- losis), whereas carbon dioxide and bicarbonate values give you the cause (same direction as pH) and suggest any compensation present (opposite of pH). 12. Exogenous causes of hyponatremia to keep in mind: oxytocin, surgery, narcotics, inap- propriate IV fluid administration, diuretics, and antiepileptic medications. 13. EKG findings in electrolyte disturbances: tall, tented T waves in hyperkalemia; loss of T waves/T-wave flattening and U waves in hypokalemia; QT prolongation in hypocal- cemia; QT shortening in hypercalcemia. 14. Shock: First give the patient oxygen, start an IV line, and set up monitoring (pulse oxime- try, EKG, frequent vital signs). Then give a fluid bolus (1 L normal saline or Ringer's lac- tate) if no signs of congestive heart failure (e.g., bibasilar rales) are present while you try to figure out the cause if it is not known. 15. Virchow's triad of deep venous thrombosis: endothelial damage (e.g., surgery, trauma), venous stasis (e.g., immobilization, surgery, severe heart failure), and hypercoagulable state (e.g., malignancy, birth control pills, pregnancy, lupus anticoagulant, inherited deficiencies). 16. Therapy for congestive heart failure: diuretics (e.g., furosemide and ACE inhibitors) and beta blockers (for stable patients) are the mainstays of pharmacologic treatment. Be sure to screen for and address underlying atherosclerosis risk factors (e.g., smoking, hyperlipidemia). 17. Cor pulmonale: right-sided heart enlargement, hypertrophy, or failure due to primary lung disease (usually chronic obstructive pulmonary disease). The most common cause of right heart failure, however, is left heart failure (not cor pulmonale). 18. In patients with atrial fibrillation, the main issues are ventricular rate (if needed, slow the rate with medications) and atrial clot formation/embolic disease (consider anticoagulation). 19. Ventricular fibrillation requires immediate defibrillation; ventricular tachycardia is treated with amiodarone or lidocaine unless the patient is unstable (then defibrillate). 20. Obstructive vs. restrictive lung disease: the FEV,/FEV ratio is the most important parameter on pulmonary function testing to distinguish the two (FEV, may be the same). 21. The most common cause of esophageal cancer: reflux disease -* Barrett metaplasia -*• adenocarcinoma. Smoking and alcohol abuse are the second most common causes (squamous cell carcinoma). 22. All gastric ulcers must be biopsied or followed to resolution to exclude malignancy. 23. Testing a nasogastric tube aspirate for blood is the best initial test to distinguish an upper from a lower GI bleed, although bright red blood via mouth or anus is a fairly reliable sign of a nearby bleeding source. 24. Irritable bowel syndrome is one of the most common causes of GI complaints. Phys- ical exam and basic tests are by definition negative; this is a diagnosis of exclusion. The classic patient is a young female adult with a chronic history of alternating con- stipation and diarrhea. 25. Crohn disease vs. ulcerative colitis CROHN'S DISEASE ULCERATIVE COLITIS Place of origin Distal ileum, proximal colon Rectum Thickness of pathology Transmural Mucosa/submucosa only Progression Irregular (skip-lesions) Proximal, continuous from rectum; no skipped areas Location From mouth to anus Involves only colon, rarely extends to ileum Bowel habit changes Obstruction, abdominal pain Bloody diarrhea Classic lesions Fistulas/abscesses, cobblestoning,Pseudopolyps, lead-pipe colon on string sign on barium x-ray barium x-ray, toxic megacolon Colon cancer risk Slightly increased Markedly increased Surgery No (may make worse) Yes (proctocolectomy with ileoanal anastomosis) 26. All forms of viral hepatitis can present similarly in the acute stage; serology testing and history are needed to distinguish them. Hepatitis B, C, and D are transmitted par- enterally and can lead to chronic infection, cirrhosis, and hepatocellular carcinoma. 27. Hereditary hemochromatosis is currently the most common known genetic disease in white people. The initial symptoms (fatigue, impotence) are nonspecific, but patients often have hepatomegaly. Screen with transferrin saturation test (serum iron/total iron binding capacity) and ferritin level. Treat with phlebotomy after confirming the diagnosis with genetic testing and liver biopsy. 28. Sequelae of liver failure: coagulopathy (that cannot be fixed with vitamin K), jaundice/ hyperbilirubinemia, hypoalbuminemia, ascites, portal hypertension, hyperammone- mia/encephalopathy, hypoglycemia, and disseminated intravascular coagulation. 29. Pancreatitis is usually due to alcohol or gallstones. Patients present with abdominal pain, nausea/vomiting, and elevated amylase and lipase. Treat supportively, and avoid mor- phine (which causes sphincter of Oddi spasm) for pain control. Complications include pseudocyst formation, infection/abscess, and adult respiratory distress syndrome. 30. Jaundice/hyperbilirubinemia in neonates is usually physiologic (only monitoring and follow-up lab tests are needed), but jaundice present at birth is always pathologic. 31. Primary vs. secondary endocrine disturbances. In primary disorders (e.g., Graves, Hashimoto, or Addison disease), the gland malfunctions, but the pituitary or another gland and the central nervous system respond appropriately (e.g., TSH, TRH, or ACTH elevate or depress as expected in the setting of a malfunctioning gland). In secondary disorders (e.g., ACTH-secreting lung carcinoma, heart failure-induced hyperreninemia, renal fail- ure-induced hyperparathyroidism), the gland itself is doing what it is told to do by other controlling forces (e.g., pituitary gland, hypothalamus, tumor, disease); they are the prob- lem, not the gland itself. 32. Corticosteroid side effects: weight gain, easy bruising, acne, hirsutism, emotional lability, depression, psychosis, menstrual changes, sexual dysfunction, insomnia, memory loss, buffalo hump, truncal and central obesity with wasting of extremities, round plethoric facies, purplish skin striae, weakness (especially of the proximal mus- cles), hypertension, peripheral edema, poor wound healing, glucose intolerance or dia- betes, osteoporosis, and hypokalemic metabolic alkalosis (due to mineralocorticoid effects of certain corticosteroids). Growth can also be stunted in children. 33. Osteoarthritis is by far the most common cause of arthritis (> 15% of cases) and usu- ally does not have hot, swollen joints or significant findings if arthrocentesis is per- formed. 34. Cancer incidence and mortality in the U.S. OVERALL HIGHEST INCIDENCE OVERALL HIGHEST MORTALITY RATE Male Female Male Female 1. Prostate 1. Breast 1. Lung 1. Lung 2. Lung 2. Lung 2. Prostate 2. Breast 3. Colon 3. Colon 3. Colon 3. Colon 35. Sequelae of lung cancer: hemoptysis, Horner syndrome, superior vena cava syn- drome, phrenic nerve involvement/diaphragmatic paralysis, haorseness from recurrent laryngeal nerve involvement, and paraneoplastic syndromes (Gushing, SIADH, hyper- calcemia, Eaton-Lambert syndrome). 36. Bitemporal hemianopsia (loss of peripheral vision in both eyes) is due to a space- occupying lesion pushing on the opic chaism (classically a pituitary tumor) until proven otherwise. Order a CT or MRI of the brain. 37. Potential risks and side effects of estrogen therapy (e.g., contraception, post- menopausal hormone replacement): endometrial (and possibly breast) cancer, hepatic adenomas, glucose intolerance/diabetes, deep venous thrombosis, cholelithi- asis, hypertension, endometrial bleeding, depression, weight gain, nausea/vomiting, headache, weight gain, drug-drug interactions, teratogenesis, and aggravation of pre- existing uterine leiomyomas (fibroids), breast fibroadenomas, migraines, and epilepsy. 38. ABCD characteristics of a mole that should make you suspicious of malignant trans- formation: asymmetry, borders (irregular), color (change in color or multiple colors), and diameter (the bigger the lesion, the more likely that it is malignant). Do an exci- sional biopsy of such moles and/or if a mole starts to itch or bleED 59. Always perform ultrasound before pelvic exam in the setting of third-trimester bleed- ing (in case placenta previa is present). 60. Uterine atony is the most common cause of postpartum bleeding and is typically due to uterine overdistension (e.g., twins, polyhydramnios), prolonged labor, and/or oxy- tocin usage. 61. Acute abdomen pathology localization by physical exam AREA ORGAN (CONDITIONS) Right upper quadrant Gallbladder/biliary (cholecystitis, cholangitis) or liver (abscess) Left upper quadrant Spleen (rupture with blunt trauma) Right lower quadrant Appendix (appendicitis), pelvic inflammatory disease (PID) Left lower quadrant Sigmoid colon (diverticulitis), pelvic inflammatory disease (PID) Epigastric area Stomach (peptic ulcer) or pancreas (pancreatitis) 62. The "6 Ws" of postoperative fever: water, wind, walk, wound, "wawa," and weird drugs. Water stands for urinary tract infection, wind for atelectasis or pneumonia, walk for deep venous thrombosis, wound for surgical wound infection, "wawa" for breast (usually relevant only in the postpartum state), and weird drugs for drug fever. In patients with daily fever spikes that do not respond to antibiotics, think about a post- surgical abscess. Order a CT scan to locate, then drain the abscess if one is present. 63. ABCDEs of trauma (follow in order if you are asked to choose): airway, breathing, circulation, disability, and exposure. 64. Six rapidly fatal thoracic injuries that must be recognized and treated immediately: 1. Airway obstruction (establish airway) 2. Open pneumothorax (intubate and close defect on three sides) 3. Tension pneumothorax (perform needle thoracentesis followed by chest tube) 4. Cardiac tamponade (perform pericardiocentesis) 5. Massive hemothorax (place chest tube to drain; thoracotomy if bleeding doesn't stop) 6. Flail chest (consider intubation and positive pressure ventilation if oxygenation inadequate) 65. Neonatal conjunctivitis may be caused by chemical reaction (in first 12-24 hours of giving drops for prophylaxis), gonorrhea (2-5 days after birth; usually prevented by prophylactic drops), and chlamydial infection (5-14 days after birth; often not pre- vented by prophylactic drops). 66. Glaucoma is usually (90%) due to the open-angle form, which is painless (no "attacks") and asymptomatic until irreversible vision loss (that starts in the periphery) occurs. Screening is thus important. Open-angle glaucoma is the most common cause of blindness in African Americans. 67. Uveitis is often a marker for systemic conditions: juvenile rheumatoid arthritis, sar- coidosis, inflammatory bowel disease, ankylosing spondylitis, Reiter syndrome, multi- ple sclerosis, psoriasis, or lupus. Photophobia, blurry vision, and eye pain are common complaints. 68. Bilateral (though often asymmetric) painless gradual loss of vision in older adults is usually due to cataracts, macular degeneration, or glaucoma, which can be distin- guished on physical exam. Presbyopia is a normal part of aging and affects only near vision (i.e. accomodation). 69. Compartment syndrome, usually in the lower extremity after trauma or surgery, causes the "6 Ps": 1. Pain (present on passive movement and often out of proportion to injury) 2. Paresthesias (numbness, tingling, decreased sensation) 3. Pallor (or cyanosis) 4. Pressure (firm feeling muscle compartment, elevated pressure reading) 5. Paralysis (late, ominous sign) 6. Pulselessness (very late, ominous sign) Treat with fasciotomy to relieve compartment pressure and prevent permanent neurologic damage. 70. Peripheral nerve evaluation NERVE MOTOR FUNCTION SENSORY FUNCTION CLINICAL SCENARIO Radial Wrist extension Back of forearm, back of hand Humeral fracture (watch for wrist drop) (first 3 digits) Ulnar Finger abduction Front and back of last 2 digitsElbow dislocation (watch for "claw hand") Median Pronation, thumb Palmar surface of hand (first Carpal tunnel syndrome, opposition 3 digits) humeral fracture Axillary Abduction, lateral Lateral shoulder Upper humeral dis- rotation location or fracture Peroneal Dorsiflexion, eversion Dorsal foot and lateral leg Knee dislocation (watch for foot drop) 71. Pediatric hip disorders NAME AGE EPIDEMIOLOGY SYMPTOMS/SIGNS TREATMENT CHD At birth Female, first-borns, breech Barlow's and Ortolani's Harness delivery signs LCPD 4-10yr Short male with delayed Knee, thigh, groin pain, Orthoses bone age limp SCFE 9-13 yr Overweight male adolescent Knee, thigh, groin pain, Surgical pinning limp CHD = congenital hip dysplasia, LCPD = Legg-Calve-Perthes disease, SCFE = slipped capital femoral epi- physis. Note: All of these conditions may present in an adult as arthritis of the hip. 72. Avoid lumbar puncture in a patient with head trauma or signs of increased intracra- nial pressure. Perform CT scan without contrast instead. 73. In children, 75% of neck masses are benign (e.g., lymphadenitis, thyroglossal duct cyst), but 75% of neck masses in adults are malignant (e.g., squamous cell carcinoma and/or metastases, lymphoma). 74. Manage carotid artery stenosis > 70% with carotid endarterectomy, <> 100 beats/min Respiratory effort None Slow, weak cry Good, strong cry Muscle tone Limp Some flexion of extremitiesActive motion Reflex irritability* None Grimace Grimace and strong cry, cough, and sneeze Color Pale, blue Body pink, extremities blueCompletely pink * Reflex irritability usually is measured by the infant's response to stimulation of the sole of the foot or acatheter put into the nose. 83. Diuretics are a common cause of metabolic derangement. Thiazide diuretics cause cal- cium retention, hyperglycemia, hyperuricemia, hyperlipidemia, hyponatremia, hypokalemic metabolic alkalosis, and hypovolemia; because they are sulfa drugs, watch out for sulfa allergy. Loop diuretics cause hypokalemic metabolic alkalosis, hypovolemia (more potent than thiazides), ototoxicity, and calcium excretion; with the exception of ethacrynic acid, they also are sulfa drugs. Carbonic anhydrase inhibitors cause metabolic acidosis, and potassium-sparing diuretics (e.g.. spironolactone) may cause hyperkalemia. 84. Overdoses and antidotes POISON OR MEDICATION ANTIDOTE Acetaminophen Acetylcysteine Cholinesterase inhibitors Atropine, pralidoxime Quinidine or tricyclic anti- Sodium bicarbonate (cardioprotective) depressants Iron Deferoxamine Digoxin Normalize potassium and other electrolytes; digoxin antibodies Methanol/ethylene glycol Ethanol Benzodiazepines Flumazenil Beta blockers Glucagon Lead Edetate (EDTA); use succimer in children Copper or gold Penicillamine Opioids Naloxone Carbon monoxide Oxygen (hyperbaric in cases of severe poisoning) Muscarinic blockers Physostigmine 85. Aspirin/NSAID side effects: GI bleeding, gastric ulcers, renal damage (e.g., interstitial nephritis, papillary necrosis), allergic reactions, platelet dysfunction (life of platelet for aspirin, reversible dysfucntion with NSAIDs), and Reye syndrome (aspirin given to child with viral infection). Aspirin overdose can be fatal and classically leads to both metabolic acidosis and respiratory alkalosis. 86. Central pontine myelinolysis (brainstem damage and possibly death) may result from overly rapid correction of hyponatremia. 87. Due to cellular shifts, alkalosis and acidosis can cause symptoms of potassium and/or calcium derangement (e.g., alkalosis can lead to symptoms of hypokalemia or hypocalcemia). In this setting, pH correction is needed (rather than direct treat- ment of the calcium or potassium levels). Magnesium depletion can also make hypocalcemia and hypokalemia unresponsive to replacement therapy (until magne- sium is corrected). 88. Adult patients of sound mind are allowed to refuse any form of treatment. Watch for depression as a cause of "incompetence." Treat depression before wishes for death are respected. 89. If a patient is incompetent (including younger minors who lack adequate decision- making capacity) and an emergency treatment is needed, seek family member or court-appointed guardian to make health care decisions. If no one available, treat as you see fit in an emergency, or contact the courts in a nonemergency setting. 90. Respect patient wishes and living wills (assuming that they are appropriate) even in the face of dissenting family members, but take time to listen to family members' concerns. 91. Always be a patient advocate and treat patients with respect and dignity, even if they refuse your proposed treatment or are noncompliant. If patients' actions puzzle you, do not be afraid to ask them why they are doing or saying what they are. 92. Break doctor-patient confidentiality only in the following situations: • The patient asks you to do so. • Child abuse is supected. • The courts mandate you to do so. • You must fulfill the duty to warn or protect (if a patient says that he is going to kill someone or himself, you have to tell the someone, the authorities, or both). • The patient has a reportable disease. • The patient is a danger to others (e.g., if a patient is blind or has seizures, let the proper authorities know so that they can revoke the patient's license to drive; if the patient is an airplane pilot and a paranoid, hallucinating schizophrenic, authorities need to know). 93. Causes of "false" lab disturbances: hemolysis (hyperkalemia), pregnancy (elevated sedimentation rate and alkaline phosphatase), hypoalbuminemia (hypocalcemia), and hyperglycemia (hyponatremia). 94. EKG findings of myocardial infarction: flipped or flattened T waves, ST-segment elevation (depression means ischemia; elevation means injury), and/or Q waves in a segmental distribution (e.g., leads II, III, and AVF for an inferior infarct). ST depres- sion may also be seen in "reciprocal'Vopposite leads. 95. Drugs that may be useful in the setting of acute coronary syndrome: aspirin, mor- phine, nitroglycerine, beta blocker, ACE inhibitor, HMG-CoA reductase inhibitor, gly- coprotein Ilb/IIIa receptor inhibitors, heparin, and tissue-plasminogen activator (t-PA; strict criteria for use). 96. Cholesterol management guidelines (numbers in the chart represent mg/dl) TWO OR MORE NO CHD RISK FACTORS TWO OR MORE CHD RISK FACTORS INTERVENTION Total cholesterol <> 239 Total cholesterol > 200 Do fasting lipoprotein analysis (gives LDL) LDL <> 189 LDL > 159 Medications CHD = coronary heart disease, LDL = low-density lipoproteins. *Unless HDL <35> 30 yr Associated body habitus Thin Obese Development of ketoacidosis Yes No Development of hyperosmolar stateNo Yes Level of endogenous insulin Low to none Normal to high (insulin resistance) Twin concurrence <50%>50% HLA association Yes No Response to oral hypoglycemics No Yes Antibodies to insulin Yes (at diagnosis) No Risk for diabetic complications Yes Yes Islet-cell pathology Insulitis (loss of most B cells)Normal number, but with amyloid deposits Remember, however, that these findings may overlap. 98. Hypertension classification SYSTOLIC BP* DIASTOLIC BP* (mm Hg) (mmHg) CLASSIFICATION <120> 100 Stage II hypertension *Classification is based onthe worst number (e.g., 168/6m0m Hg considered stage II hypertension even though diastolic pressure inormal)s. 99. Word associations (not 100%, but help when you have to guess): BUZZ PHRASE OR SCENARIO CONDITION Friction rub Pericarditis Kussmaul breathing (deep, rapid breathing) Diabetic ketoacidosis Kayser-Fleischer ring in the eye Wilson's disease Bitot's spots Vitamin A deficiency Dendritic corneal ulcers on fluorescein stainHerpes keratitis of the eye Cherry-red spot on the macula without Tay-Sachs disease hepatosplenomegaly Cherry-red spot on the macula with Niemann-Pick disease hepatosplenomegaly Bronze skin plus diabetes Hemochromatosis Malar rash on the face Systemic lupus erythematosus Heliotrope rash (purplish rash on the eyelids)Dermatomyositis Clue cells Gardnerella vaginalis infection Meconium ileus Cystic fibrosis Rectal prolapse Cystic fibrosis Salty-tasting infant Cystic fibrosis Cafe-au-lait spots with normal IQ Neurofibromatosis Cafe-au-lait spots with mental retardation McCune-Albright syndrome or tuberous sclerosis Worst headache of the patient's life Subarachnoid hemorrhage Abdominal striae Cushing's syndrome or pregnancy Honey ingestion Infant botulism Left lower quadrant tenderness/rebound Diverticulitis Children who torture animals Conduct disorder Currant jelly stools in children Intussusception Ambiguous genitalia and hypotension 21-Hydroxylase deficiency in girls Cat-like cry in an infant Cri-du-chat syndrome Infant weighing more than 10 pounds Maternal diabetes Anaphylaxis from immunoglobulin therapy IgA deficiency Postpartum fever unresponsive to broad- Septic pelvic thrombophlebitis spectrum antibiotics Increased hemoglobin A2 and anemia Thalassemia Heavy young woman with papilledema and Pseudotumor cerebri negative CT/MR scan of head Low-grade fever in the first 24 hours after surgerAtelectasiys Vietnam veteran Posttraumatic stress disorder Bilateral hilar adenopathy in a black patient Sarcoidosis Sudden death in a young athlete Hypertrophic obstructive cardiomyopathy Fractures or bruises in different stages Child abuse of healing in a child Absent breath sounds in a trauma patient Pneumothorax Shopping sprees Mania Constant clearing of throat in a child or teenagerTourette's syndrome Intermittent bursts of swearing Tourette's syndrome Koilocytosis Human papillomavirus or cytomegalovirus Rash develops after administration of ampicillinEpstein-Barr virus infection or amoxicillin for sore throat Daytime sleepiness and occasional falling downNarcolepsy (cataplexy) Facial port wine stain and seizures Sturge-Weber syndrome 100. Signs and syndromes SIGN/SYNDROME EXPLANATION Babinski's sign Stroking the bottom of the foot yields extension of the big toe and fanning of other toes (upper motor neuron lesion) Beck's triad Jugular venous distention, muffled heart sounds, and hypotension (cardiac tamponade) Brudzinski's sign Pain on neck flexion with meningeal irritation (meningitis) Charcot's triad Fever/chills, jaundice, and right upper quadrant pain (cholangitis) Courvoisier's sign Painless, palpable gallbladder plus jaundice (pancreatic cancer) Chvostek's sign Tapping on the facial nerve elicits tetany (hypocalcemia) Cullen's sign Bluish discoloration of periumbilical area (pancreatitis with retroperitoneal hemorrhage) Cushing's reflex Hypertension, bradycardia, and irregular respirations (high intracranial pressure) Grey-Turner's sign Bluish discoloration of flank (pancreatitis with retroperitoneal hemorrhage) Homan's sign Calf pain on forced dorsiflexion of the foot (deep venous thrombosis) Kehr's sign Pain in the left shoulder (ruptured spleen) Leriche's syndrome Claudication and atrophy of the buttocks with impotence (aortoiliac occlusive disease) McBumey's sign Tenderness at McBumey's point (appendicitis) Murphy's sign Arrest of inspiration during palpation under the rib cage on the right (cholecystitis) Ortolani's sign/test Abducting an infant's flexed hips causes a palpable/audible click (congenital hip dysplasia) Prehn's sign Elevation of a painful testicle relieves pain (epididymitis vs. testicular torsion) Rovsing's sign Pushing on left lower quadrant then releasing your hand produces pain at McBurney's point (appendicitis) Tinel's sign Tapping on the volar surface of the wrist elicits paresthesias (carpal tunnel syndrome) Trousseau's sign Pumping up a blood pressure cuff causes carpopedal spasm (tetany from hypocalcemia) Virchow's triad Stasis, endothelial damage, and hypercoagulability (risk factors for deepvenous thrombosis)

USMLE Official and Important Links

www.ECFMG.org
www.USMLE.org
www.NBME.org
www.FSMB.org

USMLE Step 3 Guide

What is USMLE Step 3 ?
Step 3 is designed to see whether student/ resident can apply the medical knowledge in managing the patients after making a diagnosis. It goes a step further from Step 2 where emphasis is mainly on the diagnosis of the medical condition. Here examinee is expected to make a diagnosis and properly manage the patient too. USMLE Step 3 is designed to assess whether a medical school graduate can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine. Graduates of US medical schools typically take this exam at the end of the first year of residency. Foreign medical graduates can take Step 3 before starting residency in about ten U.S. states, as this exam helps to get the H1 visa for the residency.

Step 3 is a two-day examination. Each day of testing must be completed within eight hours. The first day of testing includes 336 multiple-choice items divided into blocks, each consisting of 48 items. Examinees must complete each block within sixty minutes.

The second day of testing includes 144 multiple-choice items, divided into blocks of 36 items. Examinees are required to complete each block within forty-five minutes. Approximately 3 hours are allowed for these multiple-choice item blocks. Also on the second day are nine Clinical Case Simulations, where the examinees are required to 'manage' patients in real-time case simulations. Examinees enter orders for medications and/or investigations into the simulation software, and the condition of the patient changes accordingly. Each case must be managed in a maximum of 25 minutes of actual time.

About USMLE

United States Medical Licensing Examination
The United States Medical Licensing Examination is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB and the National Board of Medical Examiners (NBME). Medical doctors are required to pass before being permitted to practice medicine in the United States of America. It consists of three steps; all three must be passed before a physician is eligible to apply for a license to practice medicine.

The USMLE steps are:

USMLE Step 1
USMLE Step 2-CK
USMLE Step 2-CS
USMLE Step 3

STEP 2 CS Guide

What is USMLE Step 2 ?
This exam is to see whether the medical student can use the medical knowledge to diagnose and identify various problems encountered in medicine. USMLE Step 2 is designed to assess whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision. US medical students typically take Step 2 during the fourth year of medical school. Step 2 is further divided into two separate exams.

1. USMLE Step 2-CK
2. USMLE Step 2 CS

USMLE Step 2-CS
USMLE Step 2-CS is designed to assess clinical skills through simulated patient interactions, in which the examinee interacts with standardized patients portrayed by actors. Each examinee faces 12 Standardized Patients (SPs) and has 15 minutes to complete history taking and clinical examination for each patient, and then 10 more minutes to write a patient note describing the findings, initial differential diagnosis list and a list of initial tests. Administration of the Step 2-CS began in 2004.

The examination is offered in five cities across the country:

Philadelphia (PA)
Chicago (IL)
Atlanta (GA)
Houston (TX)
Los Angeles (CA)

The result of the exam takes about 2 months and it is always better to plan it early enough to get the desired date for the exam as most of the exam centers are full and dont have dates available for next 3-4 months. Before 2004, a similar exam, the Clinical Skills Assessment (CSA) was used to assess the clinical skills of foreign medical graduates.

Step 2 CK Guide

USMLE Step 2
This exam is top see whether the medical student can use the medical knowledge to diagnose and identify various problems encountered in medicine. USMLE Step 2 is designed to assess whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision. US medical students typically take Step 2 during the fourth year of medical school. Step 2 is further divided into two separate exams.

1. USMLE Step 2-CK
2. USMLE Step 2 CS

USMLE Step 2-CK

USMLE step 2 CK can be taken before the Step 1 also. USMLE Step 2-CK is designed to assess clinical knowledge through a traditional, multiple-choice examination. It is a 9 hour exam consisting of 8 blocks of 46 or 47 questions each. The subjects included in this exam are clinical sciences like Internal Medicine, Surgery, Pediatrics, Psychiatry and Obstetrics & Gynecology.

Step 3 CCS - Golden Advice

Best way is to practice the software as many times as you can. Here's something to help you on your approach for CCS exam.

LOGICAL APPROACH TO ANY CCS CASE :

First ------ Take a deep breath and select 'Start Case' button to begin.
You will see the case introduction.
Wait!
Note on the erasable board:
1. Setting
2. Age of the patient
3. Race of the Patient
4. Sex of the patient

Then click 'OK' and you will see the initial vital signs.
Wait!
Note on the erasable board: Stable or unstable?
Then click 'OK' and you will see the initial history.
Wait!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Think !!!!!!!!!!!!!!!!!!!!!!
and write on the erasable board: Differential Diagnosis : Allergies Habits – smoking , alcohol , drugs , etc. Anything worrisome?
Then ask: Is the patient stable or is it an emergency? A clue to this would be in the history - for emergency cases, you will see only the basic history of present illness and not the detailed history (social, past, etc). All other history will be 'unobtainable'.
If unstable, do a EMERGENT physical exam. No emergency case should get a full physical exam - it's an emergency!! For the EMERGENT physical, choose the 'general appearance' and the relevant system. If needed, add one or two relevant systems.
After you note the results of the EMERGENT physical, stabilize patient immediately: Airway – Intubation? Breathing – Oxygen mask? Chest tube? Circulation – IV fluids? Dopamine? Drugs – Naloxone? Dextrose? Thiamine? IV Access?
Then ask: Does the patient's condition correlate to the setting? Emergency or unstable patient in office needs to go to the ER immediately!! Change location if necessary. After the patient is stable and in the right setting, proceed to 'Interval/follow-up history' and a more detailed RELEVANT physical exam.
BUT If the patient is already a STABLE case in the right setting, proceed straight to the RELEVANT physical exam. Then ask: Is the case limited to one particular system? Like Asthma or MI? Choose the particular system and a few related systems, based on the most likely diagnosis. Is the case not limited to one particular system?
Choose a COMPLETE physical exam. This option is available on the top of the physical exam choices. Examples of such cases include Case for Annual Physical Exam, Child Abuse, Depression, Asymptomatic Hypertensive for Office Management, etc. Note the significant findings on the physical exam and go back to your erasable paper and revise your Differential Diagnosis. Strike out those which are less likely and add those are more likely.
Then -- keeping the Differential Diagnosis in mind, consider the labs to be done. When considering labs use this mnemonic:
I B U O P
I – Imaging –> X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.
B – Blood –> CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.
U – Urine –> Urinalysis, Toxicology Screen, Ketones, etc.
O – Others –> Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pulse oximetry, Biopsies, etc.
P – Pregnancy test –> For any female of reproductive age presenting with abdominal or pelvic symptoms, or trauma.

When ordering labs, consider:
Is this test time-effective/time-consuming? Choose time-effective.
Is this test initial screening/confirmatory? Choose initial screening.
Is this test cheap/expensive? Choose cheap.
Is this test non-invasive/invasive? Choose non-invasive.
Then ask:
Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might satisfy the above criteria but will not tell you anything useful.
Are there any specific tests for this condition? Examples are Cardiac Enzymes for MI, Sweat Chloride test for Cystic Fibrosis, etc.
Are the tests in the right order? Example – Pulse Oximetry before ABG, CT before Spinal Tap, etc. Order the labs using the Order button.
Then advance clock to the 'Next Available Result'. Understand the results.
Ask: Is the diagnosis clear or do I need any confirmatory tests? If diagnosis is clear, start treatment. If confirmation is needed, order confirmatory tests and then start treatment. Treatment :
Determine if the patient is in the right setting. If patient is in office and needs to be admitted, change location to ward. If patient is in ward and is in a serious condition, change location to ICU. If case is admitted, order: IV access (unless IV drugs are not indicated) – Type 'IV Access'. Vital Signs – Type Vitals and click on 'Every 1,2, 4 or 6 hours' depending on the condition of patient. Activity – Type 'Bed Rest' and choose 'Complete bed rest' or 'Bed rest with bathroom privileges' or type restrain and choose 'Restrain patient in bed'. Diet – Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order 'Diet' and you will see the list of options, choose which is the best for this case. Tubes – NG Tube? Foley's catheter? Fluids – Saline, Ringer, etc. Type 'Fluids' and choose which is the best for this case. Urine output – Type 'Urine Output' and choose frequency. There is no option for Input/output chart. Medications : Stop! Check for allergies on erasable board! Order standard drugs for this case. Decide IV or Oral. Decide bolus or continuous. Decide frequency. Labs : Additional labs to confirm diagnosis? Labs to monitor? Cardiac Monitor? Pulse Oximetry? Consults : Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social worker, etc.
Then move clock!
Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours/12 hours/1 day/2 days/1 week.
Do Interval/follow-up history. Understand the results of the labs. Then ask: Has the patient's condition changed significantly? If yes, change locations.
If the condition has improved, move the patient to the next location in the order ER --> ICU --> Ward --> Office/Home.
If the condition has worsened, move the patient to the next location in the order Home/Office --> Ward/ER or Ward/ER --> ICU.
If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/Home): Stop unnecessary medications and change IV medications to oral. Discontinue IV fluids. Remove tubes. Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant. Patient education or counseling or diet specific and vital to this case.
Type 'patient education' and 'counsel' and see if anything is relevant to this specific case.
Type 'Diet' and see if anything is relevant to this specific case. By this time, the 5 minute screen will appear!
Then type 'counsel' and choose the relevant things. You can choose multiple things at a time. See your erasable board for any worrisome habits like alcohol or smoking!
Type 'patient education' and choose the relevant things. You can choose multiple things at a time

STEP 1 Guide

What is USMLE Step 1 ?
USMLE Step 1 is the first step towards residency in US. It assesses whether medical school students or graduates understand and can apply important concepts of the sciences basic to the practice of medicine. It covers the following subjects: Anatomy, Physiology, Biochemistry, Genetics, Behavioral Medicine, Statistics, Microbiology (including Parasitology), Ethics, Pathology, Pharmacology, Histology, Immunology, Molecular Biology, and Epidemiology. US medical students usually take Step 1 at the end of the second year of medical school. It is an eight-hour computer-based exam consisting of 350 multiple-choice questions (MCQs) divided into seven blocks each consisting of 50 questions. Each block must be finished within an hour. The remaining hour is break time. An optional tutorial about how to use the computer program of the exam is offered at the beginning of the exam and takes 15 minutes. This time is deducted from the hour of allotted break time.

The scores are reported with a three digit score and a two digit score. As of January 1, 2007, the passing score has been raised to 185 from a previous score of 182. The average score is approximately 215. If the student passes the exam, he or she may not repeat the exam to achieve a higher score. But if a student fails the exam, the exam can be taken multiple times.

The scores are valid for 7 years after taking the exam. While not recommended by the creators of the USMLE, the Step 1 score is frequently used in medical residency applications as a measure of a candidate's likelihood to succeed in that particular residency (and on that specialty's board exams). More competitive residency programs usually accept applications with higher Step 1 scores. The Step 1 exam is arguably the hardest and most important examination a medical student will take during his/her career .