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  #1  
Old 08-04-2012
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Wink Some Tips for the Step 2 CK Exam

Hai
Please add here the general tips u gets while preparing for Step 2 CK..

Some I got are.

1. Never Refer the patient.. if there is a choice to refer to some one like psychatrist its not the answer.

2. Conservative medical treatment before the surgical treatment.

3. Pain on moving fingers after trauma --- ocmpartment syndrme.

Last edited by cingulate.gyrus; 08-04-2012 at 08:39 AM.
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1.after doing 50% UW.....i noticed u can refer the pt.to otolaryngologist or ophthalmologist for the conditions u think need more detailed evaluation.

2.surgical management is taken only after deciding whether pt.is good surgical candidate or not,whether or not pt. is suffering from any medical problems that r contraindication for surgery.Otherwise do conservative management.

3.If in any question(whether of medicine,surg., or psychiatry) there is a female of child-bearing age,do view it from the point of obs and gynae first , then decide on the basis of respective speciality.

4.I have also noticed many of the diseases in pediatric need only REASSURANCE TO PARENTS...make a note of these conditions..it will help u......

5.Any African-American case-Think 1st of sickle cell anemia...

6.In all or most of the congenital heart diseases, the most accurate test is ECHOCARDIOGRAPHY (mostly) and CARDIAC CATHETRIZATION(in some)

7.Always rule out pregnancy first in most of the questions of obs-gynae if female of child bearing age comes to you.

All i remember is this much..Correct me If m wrong
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1) Sometimes the answer is really that simple, dont over think it.

2) Pay attention to the patient's age.

3) Pay attention to the meds they are on.

4) If they are IV drug users, think of the possibility of HIV, Hep C or endocarditis while answering the question.

5) If they are African American, think of sickle cell, G6PD, or sarcoidosis.

6) If they are Middle Eastern, and its heme, think of thal.

7) If they had surgery, assume they are on anti coag, if a few days later, platelets drop, think HIT, even if they never specifically mentioned giving them heparin.

8) High BMI in a young woman with infertility issues, think PCOS.

9) Young person that passes out a few days later, post a URI, even if they dont give you lab values, add DKA to your differential.

10) An old person falls...even if they give you a hip XR, or any XR as an option, your 1st option is to check their heart.

11) With hyperkalemia, 1st thing is to protect the heart, so give calcium gluconate.

12) Pt has seizures, and given meds, assume they are having rhabdo, even if question doesnt state so.

13) Person with back pain, look at age, if elderly, think osteo, degenerative, metastatic ca, aortic dissection. If hx of alcohol, or taking certain meds, think pancreas. Look and see, if acute or chronic.

14) Person on mech vent, think of complications, like barotrauma. 1st thing after intubating is do CXR to make sure its placed correctly.

15) young kid with sore throat, look at WBC to determine if bacterial or viral.

16) older kid with sore throat and cervical lymph, assume EBV.

Ok enough, need to go study, exam in a few days
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Next Best Steps....

Usual CK questions..

Male with pelvic fracture hemature....Retrograde urithrogram.
Female with pelvic fracture and hematuria ---Cystogram.
Blunt trauma chest with shock- Chest xray.
Blunt trauma abdomen - in shock - usg abdomen
Blunt trauma abdomen - hemodynamicaly stable - CT Abdomen.
Plevic injury and shock due to pelvic injury - Arteriogram.
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Quote:
Originally Posted by cingulate.gyrus View Post
Next Best Steps....

Usual CK questions..

Male with pelvic fracture hemature....Retrograde urithrogram.
Female with pelvic fracture and hematuria ---Cystogram.
Blunt trauma chest with shock- Chest xray.
Blunt trauma abdomen - in shock - usg abdomen

Blunt trauma abdomen - hemodynamicaly stable - CT Abdomen.
Plevic injury and shock due to pelvic injury - Arteriogram.
Next best step for in shock is always ABC's.. never imaging/dx studies.
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Quote:
Originally Posted by K06100 View Post
1.after doing 50% UW.....i noticed u can refer the pt.to otolaryngologist or ophthalmologist for the conditions u think need more detailed evaluation.

2.surgical management is taken only after deciding whether pt.is good surgical candidate or not,whether or not pt. is suffering from any medical problems that r contraindication for surgery.Otherwise do conservative management.

3.If in any question(whether of medicine,surg., or psychiatry) there is a female of child-bearing age,do view it from the point of obs and gynae first , then decide on the basis of respective speciality.

4.I have also noticed many of the diseases in pediatric need only REASSURANCE TO PARENTS...make a note of these conditions..it will help u......

5.Any African-American case-Think 1st of sickle cell anemia...

6.In all or most of the congenital heart diseases, the most accurate test is ECHOCARDIOGRAPHY (mostly) and CARDIAC CATHETRIZATION(in some)

7.Always rule out pregnancy first in most of the questions of obs-gynae if female of child bearing age comes to you.

All i remember is this much..Correct me If m wrong
hi
can u please evaluate some condition in pediatrics with come with answer REASSURANCE .
please.
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Quote:
Originally Posted by usmleimg View Post
hi
can u please evaluate some condition in pediatrics with come with answer REASSURANCE .
please.
read the post here

http://www.usmle-forums.com/usmle-st...essurance.html
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--non bilious projectile vomiting in an infant, do US, its pyloric stenosis, even if you dont palpate a mass.

--painless bleeding in an infant--Meckel's, diagnose with a tech 99 scan

--currant jelly stool, colicky pain and bilious vomiting in an infant, do US, its intussception.

--vomiting after 1st feed, its a tracheoesophageal fistula (esophageal atresia). Careful of aspiration pneumonia, do CXR

--failure to pass meconium within 24-48hrs, Hirschsprung,no innervation in distal bowel. Can lead to bowel obstruction. Assoc with Down's syndrome.

--OCD, treat with SSRI
--Generalized anxiety disorder, worries about everything, treat with buspirone.
--Social phobia, before an event, can take propanolol.
--With Olanzapine (and others), worry about weight gain
--Clozapine, worry about agranulocytosis
--Leukomoid reaction vs CLL, in CLL, LAP is decreased.
--smudge cells, think CLL
--In trauma, always remember your ABC

--elderly man wakes up to pee, and falls down, think orthostatic hypotension.
--elderly man goes to pee, and passes out while peeing, think vasovagal syncope.

--African American, with hematuria, think sickle cell trait.
--with sickle cell, if no sign of joint pain, then its not osteomyelitis, and Salmonella. Think more S. pneu

--long jaw, big ears, big testes, think Fragile X. Autosomal dominant, trinucleotide repeats. Mental retardation.

--Turner usually 45XO, webbed neck, streak ovaries, wait till puberty to remove gonads.

--Kallmann usually 46XX

--Middle age pt with suddent chest pain, normal EKG and stress test. Normal barium esophagram (sometimes cork screw esophagus) and endoscopy. Think esophageal spasm, Do a manometry, normal LES seen. Treat with Ca2+ blockers.

Last edited by Lena; 08-04-2012 at 04:41 PM.
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Quote:
Originally Posted by Lena View Post
--currant jelly stool, colicky pain and bilious vomiting in an infant, do US, its intussception.
I think you do a Ba enema here which is both diagnostic and therapeutic.

Quote:
Originally Posted by Lena View Post
--Turner usually 45XO, webbed neck, streak ovaries, wait till puberty to remove gonads.
Why remove gonads in Turner ?
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Quote:
Originally Posted by Lena View Post
1)

5) If they are African American, think of sickle cell, G6PD, or sarcoidosis.
and SLE.............
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Quote:
Originally Posted by Novobiocin View Post
I think you do a Ba enema here which is both diagnostic and therapeutic.
No, the 1st initial test is an US. Barium is the most accurate.
From MTB CK



Quote:
Originally Posted by Novobiocin View Post
Why remove gonads in Turner ?

Thats in UW, you do it as a prophylaxis for gonadoblastoma
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Quote:
Originally Posted by patelMD View Post
Next best step for in shock is always ABC's.. never imaging/dx studies.
Absolutely ..

I mean next best step in evaluation..correction..
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Quote:
Originally Posted by Lena View Post
No, the 1st initial test is an US. Barium is the most accurate.
From MTB CK
Latest MTB 3 Page 360:
Best Initial test---Plain X-Ray abodomen
Most accurate-- Air Enema (Both diagnostic & therapeutic)



Quote:
Originally Posted by Lena View Post
Thats in UW, you do it as a prophylaxis for gonadoblastoma
Gonadoblastoma and Turner syndrome

Quote:
Gonadoblastoma can be evident even at an early age in streak gonads with Y mosaicism and may be bilateral. We recommend prophylactic laparoscopic gonadectomy of streak gonads in patients with TS who carry a Y mosaic genotype, because fertility is not an issue, surgical morbidity is minor and there may be a high potential for malignant transformation of gonadoblastomas in this population.
Maybe in patients with streak gonads with Y mosaicism
Quote:
occurrence of gonadoblastoma is low in the Turner syndrome population. We propose that future studies be undertaken to focus on the incidence of gonadoblastoma in the presence of Y chromosome material in all diagnosed females with Turner syndrome. This study emphasizes the need for prospective unbiased studies.

Last edited by Novobiocin; 08-04-2012 at 07:38 PM.
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I agree with novobiocin for tx + dx of intussecption, its enema.

As for removing gonads from turners pt, Lena has mentioned what is said in UW. Frankly, I'd trust UW over MTB anyday, depends on your personal preference I guess?
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this is an epic thread .thanks to all .very useful
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the points mentioned above are based on uworld .but kaplan qbank has a question based on almost all the above points ,i guess kaplan qbank is good.
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Quote:
Originally Posted by patelMD View Post
I agree with novobiocin for tx + dx of intussecption, its enema.

As for removing gonads from turners pt, Lena has mentioned what is said in UW. Frankly, I'd trust UW over MTB anyday, depends on your personal preference I guess?
i am doing UW for the second time, and i came this question again a few days ago, and interestingly,UW has removed this question!! it said that the UW is no more responsible for the Explanation of this question bla bla..
so yes Novobiocin is right here. for now jus discard, whatever UW has to say on this!
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Quote:
Originally Posted by shyangel18 View Post
i am doing UW for the second time, and i came this question again a few days ago, and interestingly,UW has removed this question!! it said that the UW is no more responsible for the Explanation of this question bla bla..
so yes Novobiocin is right here. for now jus discard, whatever UW has to say on this!


The precious was wrong? *heart broken*
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Next best Step in Evaluation


Older Age Epigastric pain + guaic , weight loss – OGD scopy
Clinically Peripheral vascular disease – ABI ( Angle – brachial index) Arteriogram.
Old age GI bleeding – Scopy (Colonoscopy for Lower and OGD upper)
Abdomin pathology best investigation – CT abdomen.
Post operative adhesion – CT Abdomen
Miscentric ischemia – Ct Abdomen.
Signs of peritonitis – Explorative laparotomy.

Pancreatic malignancy with mets – Conservative treatment (As mortality as hagh as 100%)

Impotence - DOC - Sildinafil contraindicated in patient on nirtroglycerin containing drugs..

Pheochromocytoma –
presence mainly epinephrine – MRI for adrenal gland.
Presence mainly Norepinephrine – MIBG Scan for localizing extra adrenal site.


Young female – exquisite pain bright red bleeding on toilet paper after defecation pain in cough and sitting – Anal fissure.
Management
Acute – WASH regimen.(Conservative)
Chronic – Lateral Spincherectomy/Botulinum injection.
Diverticulitis with colo vesical fistula – CT abdomen.

Post operative.

Fever.
Day 1 – Atelectasis.
Day 3 – UTI.
Day 5 – DVT
Day 7 – Wount infection,
Day – 10 Deep abscuss.
Code( wind, Water ,Waking,Wound, Where ?)

Post operative confusion

Day 1 – ABG.
Post operative confusion anfter 1 -2 week – slow onset – ARDS .
Alcoholic post operative confusion – Delerium trementts – Rx benzodiazepam.
Neurosugury – post operative confusion – Hyponatremia – SIADH.
Cirrhotic patient – post operative confusion after portocaval anastomosis – Hyperammonimia

Post operative instinal obstr –

Upto Day 5 Paralytic ileus.
After day 5 – Ct Abdomen – post operative adhesion.

H/o Enucleation of eye presence with liver metastasis after 20 – 30 yrs – Malignant melanoma. –tumour marker thyrosinas

Trigger finger , Quervain’s disease, Dupuytrens contractures – Rx Steroid injection.
Felon – emergency surgical drainage
Game keepers hand – casting.
Jersey and mallet finger - - splining.
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Thank you very much to everyone who is posting their inputs and to those who will keep on contributing. This is a wonderful thread .
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I love this thread! Thanks so much everyone! Very useful!
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Quote:
The timing of fever relative to the postoperative day (POD) will indicate the most likely cause. The five W's of postoperative fever - Wind, Water, Walking, Wound and Wonder drugs - as a useful memory tool could help a physician when he is following patients after surgery.

POD 1-2: Wind: Atelectasis (without air) often cause fever. Reasons include being on a ventilator, inadequate sighs during surgery and (in the general surgery patient) incisional pain on deep breathing. This is treated with incentive spirometry because there is evidence that deep inspiration prevents atelectasis better than just coughing .

POD 3-5: Water: Urinary tract infections (UTIs) are common here. Foley catheters are sometimes still in place. POD 4-6: Walking: Deep venous thrombosis can occur. This is more of a problem in patients undergoing pelvic orthopedic or general surgery than in head and neck surgery. Subcutaneous low dose heparin and venous compression devices reduce the incidence of thromboembolization . Walking the patient on POD1 is the best way to prevent this complication.

POD 5-7: Wound : Most wound infections occur during this period. Preoperative antibiotics are important to prevent or reduce the risk of infection in head and neck surgery that crosses mucosal linings.

POD 7+: Wonder drugs : Drugs can cause fevers.(Note that in obstetrics and gynaecology, this W is "womb" and it precedes "Wonder drugs").

Noninfectious causes must be considered with infectious causes in the postoperative patient because fever resulting from infection and trauma (i.e., surgery) are produced through the release of similar cytokines. However, fever in patients without evidence of infection occurred closer to the surgical procedure and lasted for a shorter time than did fever resulting from infection. Therefore, empiric antibiotic therapy may not be necessary in these cases, when the fevers are not associated with infections.
It's like a Hurricane:
First, the Wind then the Rain (Water) then you run (walk) then you trip and fall (Wound), and you Wonder what happened
now just add the day it presents with ascending odd numbers 1 3 5 7 (10 for abscess)
For drug there is no day, can be from day one, you suspect drugs after you rule out other causes.

Last edited by Novobiocin; 08-05-2012 at 08:22 AM.
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Some more Next best step in evaluation..and most propable diagnosis



General Surgury.

An rectal area lesions not healing – inflammatory bowel disease -Chrons disease - Cholonoscopy


Anaemia , jaundice , distented GB – Ca ampula of vater - ERCP

Colicystitis- USG if Normal- HiDA scan (GB will not be visualized).

Acute ascentifng Colangitis.- Next step Emergency ERCP &decompression.

Breast.

Young female

firm rubbery mass – Fibro adenoma –FNAC – Sonography.
Mass rapidly growing – gaint fibrocystic adenoma,.
mass slowly growing Recently rapid growth – Cystadenoma phylloids – Tissue diagnosis and marginal free excession.
Mass come and go –fibocystic disease – mammography – FNAC- Fluid – bloody cytology- mass persists – biopsy.

Blood in nipple.

Young – intraductal papilloma. -Mammogram -( -ve) – Resection of duct under galactogram or retroalveolar exploration.


Old age Breast mass – Mammographically guided core biopsy.

Treatment of breast cancer.

Tumour < 2 cm – Lumbactomy followed by radiation.
Tumour large or below nipple MRM sentnal node biopsy.
Lobular Ca and Medullary Ca.—Same Rx as Infiltra ductal Ca.
& if
Nodes + ve Chemo.
& if
Hormone +ve --> Premenopo – Tamoxafin,
-->post menoposal - Anastasol

CIN – Lumbectomy and radiation ,
several area MRM no need for lymph node excession.


Non operable Br Ca. – Chemo to shrink and surgery.

Thyroid nodule generally – FNAC –malignant/indeterminate – surgery.
FNAC Follicular cells – Lobectomy – Frozen section – Total thyroidectomy.
Parathyroid adenoma – Serum Calcium – PTH –Sestamibi –surgury.
Cushing syndrome – Low dose dexamethasone suppression – 24 hr urinaty cortisol – highdose dexa suppression test - +ve – MRI brain. –ve – MRI adrenal.
Ulcer 1st and 2nd portion of duodenum – Zolinger Ellison – Serum gastrin –Ct with vascular and GI contrast – Surgury.
Hypoglycemia – cpepitde – insulinoma – CT abdomen with vascular and G I contrast.
Migratory necrolytic dermatitis – Glucogonoma – CT abdomen with vascular and GI contrast.- Surgury ,
Somatostatin in inoperable caset.

Hyperaldosteronism features –Aldoserone level , Renin.—lying down and sitting up –Respond to postural change – nonsurgical. – aldactone.
Noresponse to postural change – MRI /Ct Surgury.

Renovascular hypertension – Duplex Study of renal artery. then
Young patient – renal arteriogram and stending ,
Older patient – depends on comorbid condition.


New born Excessive salivation – Insert NG xray - Tracheo -oesophagal fistula - Rule out VACTERAL
Newborn with absent Anus – x ray upside down with metal in anus - Rule out Vacteral.
CDH – Wait 36 hrs for Feotal circulation to change and surgery.Meanwhile ET PPV NG , sedation.

Malrotation – Emergency Surgury.
osophagaeal Ruptures and mchonium ileus Gastrographin enema better than Barium

Lung CA .
Coin lesion in X ray Non invasive 1st – Sputum cytoplogy and CT scan chest.
Small cell Ca – Chemo radiation.
Non Small cell – Surgury.

.
Vascular Surgury.


Arm exercise vetigo – Subclavian steel – Arteriogram – surgical by graph.
Aortic aneurism – sonogram.- 6 cm repair , 4 observe.
Dissection of aorta.
Ascenting – operative procedure.
Discending – conservative.
Carotid duplex scan 70 % occlusion – carotid enteractictomy.
Skin.

Basalcell ca Full thickenss bx.




GIT

Barrets Oesophagus. -Medical managent – Continued symptoms – Fundoplication.
Achalasia – Barium Swallow and confirm by manomatry.
Ca Oesophagus – Barrium swallow- endoscopy and Biopsy – Ct Scan for Mets.
Hematomesis – endoscopy.
Suspected oesophagal perforation(Boerhaave or iatrogenic) – Gastrographin Swallow.
Ca stomach – Endoscopy Bx – Ct for mets.
Post operative adhesion – obstrc- conservative care.
Evidence of mesenteric ishchemia – emergency explorative surgery.
Intestinal obstr after incarcerated hernia – Urgent surgery.
Carcinoid syndrome – Urin 24 hrs HIAA- CT for mets – resection.

Rt sided Colon Ca – Anaemia and fainting – Colonoscopy Bx – Blood transfusion – Rt hemicolectomy.
Lt Sided Colon Cancer –Bloody movement as blood ouside stool , Constipation, Stool of narrow caliber – Endoscopy & Bx.
Flexible proctosigmoidoscopy- Full colonoscopy- Surgury.

Toxic megacolon – emergency surgery.
Pseudomembranious enterocolitis – diagnosis stool toxin. DOC – Metronidazole, vanco (altern).

Hemorrhoids.

Rule out Cancer 1st –Proctosigmoidoscopy-
Internal haemorrhoid – rubberband ligation.
External haemorrhoid/Prolapse – Surgury.

Anal fissure
Cancer to be ruled out- examine under anaesthesia-medical management – botulin toxin – lateral sphincerotomy.


Biliary Tree

Hepatoma and hepatic mets from CA colon – Ct Scan with contrast.

Liver abscess

Amoebic c liver abscess – metronidazole( No Need for surgury)– Serology for amebic titer.
Pyogenic liver abscess - Drainage percutaneous

Slow bleeding into biliary tract and jaundice – periampullary carcinoma.

Pancreas.


Acute edematous pancreatitis & Acute haemorrhagic pancreatitis.- Intense supportive care-serial CT abdomen and drainage of developing abscess in cae of haemorrhagic pancreatitis.

Spiking fever in haemorrhagic pancreatitis – developing abscess.

Epigastric mass –n alcoholic and post trauma – Pancreatic psedocyst –inve – CT , Ct guided aspiration –endoscopic cystogastrostomy.

Chronic pancreatitis- Stopping alcohol replacement of enzymes- Evaluation – ERCP for looking anatomy of pancreatic duct.


Trigeminal neuralgia – MRI rule out secondary - cause

Prenancy asymptomatic bacteruria(25,00 – 1,00,000) – to be treated.

Patient on steroid – post operative confusion hyponatemia and hyperkalemia – adrenal insufficiency.

Case history with summary giving GCS score with GCS < 8 -- ET intubation


Painless exophylic growth on penis that doesnot respond to conservative Rx – Biopsy – Sqm cell Ca.
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The above post was thanked by:
K06100 (08-14-2012), riya rai (08-07-2012), sameerkhan (08-07-2012), step_enhancer (08-08-2012)



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