USMLE 2 Rapid Review

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"Sawtooth" P waves

Classic ECG finding in atrial flutter.

Angina is new, is worsening, or occurs at rest

Definition of unstable angina.

ACEI

Antihypertensive for a diabetic patient with proteinuria.

Hypotension, distant heart sounds, and JVD

Beck's triad for cardiac tamponade.

β-blockers, digoxin, calcium channel blockers

Drugs that slow AV node transmission.

Niacin

Hypercholesterolemia treatment that → flushing and pruritus.

Anticoagulation, rate control, cardioversion

Treatment for atrial fibrillation.

Immediate cardioversion

Treatment for ventricular fibrillation.

Dressler's syndrome: fever, pericarditis, ↑ ESR

Autoimmune complication occurring 2-4 weeks post-MI.

Treat existing heart failure and replace the tricuspid valve

IV drug use with JVD and holosystolic murmur at the left sternal border. Treatment?

Echocardiogram (showing thickened left ventricular wall and outflow obstruction)

Diagnostic test for hypertrophic cardiomyopathy.

Pulsus paradoxus (seen in cardiac tamponade)

A fall in systolic BP of > 10 mmHg with inspiration.

Low-voltage, diffuse ST-segment elevation

Classic ECG findings in pericarditis.

BP > 140/90 on three separate occasions two weeks apart

Definition of hypertension.

Renal artery stenosis, coarctation of the aorta, pheochromocytoma, Conn's syndrome, Cushing's syndrome, unilateral renal parenchymal disease, hyperthyroidism, hyperparathyroidism

Eight surgically correctable causes of hypertension.

Abdominal ultrasound and CT

Evaluation of a pulsatile abdominal mass and bruit.

> 5.5 cm, rapidly enlarging, symptomatic, or ruptured

Indications for surgical repair of abdominal aortic aneurysm.

Morphine, O2, sublingual nitroglycerin, ASA, IV β-blockers, heparin

Treatment for acute coronary syndrome.

Abdominal obesity, high triglycerides, low HDL, hypertension, insulin resistance, prothrombotic or proinflammatory states

What is the metabolic syndrome?

Exercise stress treadmill with ECG

Appropriate diagnostic test? ■ A 50-year-old male with angina can exercise to 85% of maximum predicted heart rate.

Pharmacologic stress test (e.g., dobutamine echo)

Appropriate diagnostic test? ■ A 65-year-old woman with left bundle branch block and severe osteoarthritis has unstable angina.

Angina, ST-segment changes on ECG, or ↓ BP

Signs of active ischemia during stress testing.

ST-segment elevation (depression means ischemia), flattened T waves, and Q waves

ECG findings suggesting MI.

Prinzmetal's angina

A young patient has angina at rest with ST-segment elevation. Cardiac enzymes are normal.

CHF, shock, and altered mental status

Common symptoms associated with silent MIs.

V/Q scan

The diagnostic test for pulmonary embolism.

Protamine

An agent that reverses the effects of heparin.

PT

The coagulation parameter affected by warfarin.

Hypertrophic cardiomyopathy

A young patient with a family history of sudden death collapses and dies while exercising.

Oral surgery—amoxicillin; GI or GU procedures—ampicillin and gentamicin before and amoxicillin after

Endocarditis prophylaxis regimens.

Pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia

The 6 P's of ischemia due to peripheral vascular disease.

Stasis, hypercoagulability, endothelial damage

Virchow's triad.

OCPs

The most common cause of hypertension in young women.

Excessive EtOH

The most common cause of hypertension in young men.

Seborrheic keratosis

"Stuck-on" appearance.

Psoriasis

Red plaques with silvery-white scales and sharp margins.

Basal cell carcinoma

The most common type of skin cancer; the lesion is a pearly-colored papule with a translucent surface and telangiectasias.

Impetigo

Honey-crusted lesions.

Cellulitis

A febrile patient with a history of diabetes presents with a red, swollen, painful lower extremity.

Pemphigus vulgaris

+ Nikolsky's sign.

Bullous pemphigoid

- Nikolsky's sign.

Acanthosis nigricans. Check fasting blood sugar to rule out diabetes

A 55-year-old obese patient presents with dirty, velvety patches on the back of the neck.

Varicella zoster

Dermatomal distribution.

Lichen planus

Flat-topped papules.

Erythema multiforme

Iris-like target lesions.

Contact dermatitis

A lesion characteristically occurring in a linear pattern in areas where skin comes into contact with clothing or jewelry.

Pityriasis rosea

Presents with a herald patch, Christmas-tree pattern.

Alopecia areata (autoimmune process)

A 16-year-old presents with an annular patch of alopecia with broken-off, stubby hairs.

Pityriasis versicolor

Pinkish, scaling, flat lesions on the chest and back. KOH prep has a "spaghetti-and-meatballs" appearance.

Asymmetry, border irregularity, color variation, large diameter

Four characteristics of a nevus suggestive of melanoma.

Actinic keratosis

Premalignant lesion from sun exposure that can → squamous cell carcinoma.

Lesions of 1° varicella

"Dewdrop on a rose petal."

Seborrheic dermatitis. Treat with antifungals

"Cradle cap."

Acne vulgaris

Associated with Propionibacterium acnes and changes in androgen levels.

Herpes simplex

A painful, recurrent vesicular eruption of mucocutaneous surfaces.

Lichen sclerosus

Inflammation and epithelial thinning of the anogenital area, predominantly in postmenopausal women.

Squamous cell carcinoma

Exophytic nodules on the skin with varying degrees of scaling or ulceration; the second most common type of skin cancer.

Hashimoto's thyroiditis

The most common cause of hypothyroidism.

High TSH, low T4, antimicrosomal antibodies

Lab findings in Hashimoto's thyroiditis.

Graves' disease

Exophthalmos, pretibial myxedema, and ↓ TSH.

Iatrogenic steroid administration. The second most common cause is Cushing's disease

The most common cause of Cushing's syndrome.

Hypoparathyroidism

A patient presents with signs of hypocalcemia, high phosphorus, and low PTH.

Signs and symptoms of hypercalcemia

"Stones, bones, groans, psychiatric overtones."

1° hyperaldosteronism (due to Conn's syndrome or bilateral adrenal hyperplasia)

A patient complains of headache, weakness, and polyuria; exam reveals hypertension and tetany. Labs reveals hypernatremia, hypokalemia, and metabolic alkalosis.

Pheochromocytoma

A patient presents with tachycardia, wild swings in BP, headache, diaphoresis, altered mental status, and a sense of panic.

α-antagonists (phentolamine and phenoxybenzamine)

Should α- or β-antagonists be used first in treating pheochromocytoma?

Nephrogenic diabetes insipidus (DI)

A patient with a history of lithium use presents with copious amounts of dilute urine.

Administration of DDAVP ↓ serum osmolality and free water restriction

Treatment of central DI.

SIADH due to stress

A postoperative patient with significant pain presents with hyponatremia and normal volume status.

Metformin

An antidiabetic agent associated with lactic acidosis.

1° adrenal insufficiency (Addison's disease). Treat with replacement glucocorticoids, mineralocorticoids, and IV fluids

A patient presents with weakness, nausea, vomiting, weight loss, and new skin pigmentation. Labs show hyponatremia and hyperkalemia. Treatment?

< 7.0

Goal hemoglobin A1c for a patient with DM.

Fluids, insulin, and aggressive replacement of electrolytes (e.g., K+)

Treatment of DKA.

They can mask symptoms of hypoglycemia

Why are β-blockers contraindicated in diabetics?

Observational bias

Bias introduced into a study when a clinician is aware of the patient's treatment type.

Lead-time bias

Bias introduced when screening detects a disease earlier and thus lengthens the time from diagnosis to death.

Confounding variable

If you want to know if race affects infant mortality rate but most of the variation in infant mortality is predicted by socioeconomic status, then socioeconomic status is a _____.

Sensitivity

The number of true positives divided by the number of patients with the disease is _____.

Out

Sensitive tests have few false negatives and are used to rule _____ a disease.

Highly sensitive for TB

PPD reactivity is used as a screening test because most people with TB (except those who are anergic) will have a +PPD. Highly sensitive or specific?

Higher prevalence

Chronic diseases such as SLE—higher prevalence or incidence?

Higher incidence

Epidemics such as influenza—higher prevalence or incidence?

Prevalence

Cross-sectional survey—incidence or prevalence?

Incidence and prevalence

Cohort study—incidence or prevalence?

Neither

Case-control study—incidence or prevalence?

High reliability, low validity

Describe a test that consistently gives identical results, but the results are wrong.

Cohort studies can be used to calculate relative risk (RR), incidence, and/or odds ratio (OR). Case-control studies can be used to calculate an OR

Difference between a cohort and a case-control study.

The incidence rate (IR) of a disease in exposed − the IR of a disease in unexposed

Attributable risk?

The IR of a disease in a population exposed to a particular factor ÷ the IR of those not exposed

Relative risk?

The likelihood of a disease among individuals exposed to a risk factor compared to those who have not been exposed

Odds ratio?

1 ÷ (rate in untreated group − rate in treated group)

Number needed to treat?

Patients with IBD; those with familial adenomatous polyposis (FAP)/hereditary nonpolyposis colorectal cancer (HNPCC); and those who have first-degree relatives with adenomatous polyps (< 60 years of age) or colorectal cancer

In which patients do you initiate colorectal cancer screening early?

Prostate cancer is the most common cancer in men, but lung cancer causes more deaths

The most common cancer in men and the most common cause of death from cancer in men.

68%, 95.5%, 99.7%

The percentage of cases within one SD of the mean? Two SDs? Three SDs?

Number of live births per 1000 population

Birth rate?

Number of live births per 1000 women 15-44 years of age

Fertility rate?

Number of deaths per 1000 population

Mortality rate?

Number of deaths from birth to 28 days per 1000 live births

Neonatal mortality?

Number of deaths from 28 days to one year per 1000 live births

Postnatal mortality?

Number of deaths from birth to one year of age per 1000 live births (neonatal + postnatal mortality)

Infant mortality?

Number of deaths from 20 weeks' gestation to birth per 1000 total births

Fetal mortality?

Number of deaths from 20 weeks' gestation to one month of life per 1000 total births

Perinatal mortality?

Number of deaths during pregnancy to 90 days postpartum per 100,000 live births

Maternal mortality?

False. Patients may change their minds at any time. Exceptions to the requirement of informed consent include emergency situations and patients without decision-making capacity

True or false: Once patients sign a statement giving consent, they must continue treatment.

No. Parental consent is not necessary for the medical treatment of pregnant minors

A 15-year-old pregnant girl requires hospitalization for preeclampsia. Should her parents be informed?

Conflict of interest

A doctor refers a patient for an MRI at a facility he/she owns.

The patient is a danger to self, a danger to others, or gravely disabled (unable to provide for basic needs)

Involuntary psychiatric hospitalization can be undertaken for which three reasons?

False. Withdrawing and withholding life are the same from an ethical standpoint

True or false: Withdrawing life-sustaining care is ethically distinct from withholding sustaining care.

When there is no rationale for treatment, maximal intervention is failing, a given intervention has already failed, and treatment will not achieve the goals of care

When can a physician refuse to continue treating a patient on the grounds of futility?

Treat immediately. Consent is implied in emergency situations

An eight-year-old child is in a serious accident. She requires emergent transfusion, but her parents are not present.

Real threat of harm to third parties; suicidal intentions; certain contagious diseases; elder and child abuse

Conditions in which confidentiality must be overridden.

When treatment noncompliance represents a serious danger to public health (e.g., active TB)

Involuntary commitment or isolation for medical treatment may be undertaken for what reason?

Treat because the disease represents an immediate threat to the child's life. Then seek a court order

A 10-year-old child presents in status epilepticus, but her parents refuse treatment on religious grounds.

A patient's family cannot require that a doctor withhold information from the patient

A son asks that his mother not be told about her recently discovered cancer.

Emergent laparotomy to repair perforated viscus, likely stomach

Patient presents with sudden onset of severe, diffuse abdominal pain. Exam reveals peritoneal signs and AXR reveals free air under the diaphragm. Management?

Diverticulosis

The most likely cause of acute lower GI bleed in patients > 40 years old.

HIDA scan

Diagnostic modality used when ultrasound is equivocal for cholecystitis.

Acute pancreatitis

Sentinel loop on AXR.

Fat, female, fertile, forty, flatulent

Risk factors for cholelithiasis.

Murphy's sign, seen in acute cholecystitis

Inspiratory arrest during palpation of the RUQ.

Campylobacter

Identify key organisms causing diarrhea: ■ Most common organism

Clostridium difficile

Identify key organisms causing diarrhea: ■ Recent antibiotic use

Giardia

Identify key organisms causing diarrhea: ■ Camping

ETEC

Identify key organisms causing diarrhea: ■ Traveler's diarrhea

S. aureus

Identify key organisms causing diarrhea: ■ Church picnics/mayonnaise

E. coli O157:H7

Identify key organisms causing diarrhea: ■ Uncooked hamburgers

Bacillus cereus

Identify key organisms causing diarrhea: ■ Fried rice

Salmonella

Identify key organisms causing diarrhea: ■ Poultry/eggs

Vibrio, HAV

Identify key organisms causing diarrhea: ■ Raw seafood

Isospora, Cryptosporidium, Mycobacterium avium complex (MAC)

Identify key organisms causing diarrhea: ■ AIDS

Yersinia

Identify key organisms causing diarrhea: ■ Pseudoappendicitis

Crohn's disease

A 25-year-old Jewish male presents with pain and watery diarrhea after meals. Exam shows fistulas between the bowel and skin and nodular lesions on his tibias.

Ulcerative colitis

Inflammatory disease of the colon with ↑ risk of colon cancer.

Uveitis, ankylosing spondylitis, pyoderma gangrenosum, erythema nodosum, 1° sclerosing cholangitis

Extraintestinal manifestations of IBD.

5-aminosalicylic acid +/− sulfasalazine and steroids during acute exacerbations

Medical treatment for IBD.

Mallory-Weiss—superficial tear in the esophageal mucosa Boerhaave—full-thickness esophageal rupture

Difference between Mallory-Weiss and Boerhaave tears.

RUQ pain, jaundice, and fever/chills in the setting of ascending cholangitis

Charcot's triad.

Charcot's triad plus shock and mental status changes, with suppurative ascending cholangitis

Reynolds' pentad.

↓ protein intake, lactulose, neomycin

Medical treatment for hepatic encephalopathy.

Establish the ABCs

First step in the management of a patient with acute GI bleed.

Hemolytic-uremic syndrome (HUS) due to E. coli O157:H7

A four-year-old child presents with oliguria, petechiae, and jaundice following an illness with bloody diarrhea. Most likely diagnosis and cause?

HBV immunoglobulin

Post-HBV exposure treatment.

TB medications (INH, rifampin, pyrazinamide), acetaminophen, and tetracycline

Classic causes of drug-induced hepatitis.

Biliary tract obstruction

A 40-year-old obese female with elevated alkaline phosphatase, elevated bilirubin, pruritus, dark urine, and clay-colored stools.

Femoral hernia

Hernia with highest risk of incarceration—indirect, direct, or femoral?

Confirm the diagnosis of acute pancreatitis with elevated amylase and lipase. Make patient NPO and give IV fluids, O2, analgesia, and "tincture of time"

A 50-year-old man with a history of alcohol abuse presents with boring epigastric pain that radiates to the back and is relieved by sitting forward. Management?

TICS—Thalassemia, Iron deficiency, anemia of Chronic disease, and Sideroblastic anemia

Four causes of microcytic anemia.

Fecal occult blood test and sigmoidoscopy; suspect colorectal cancer

An elderly male with hypochromic, microcytic anemia is asymptomatic. Diagnostic tests?

Sulfonamides, antimalarial drugs, fava beans

Precipitants of hemolytic crisis in patients with G6PD deficiency.

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