HIGH YIELD Family Medicine Review for StEp 2 CK & Shelf Exam

Let's discuss extremely high yield infectious disease topics and go through some questions that will increase your score on exam day.

What is the typical empiric treatment for patients with human bite wounds? Augmentin. Human bite wounds are typically polymicrobial with both anaerobic and aerobic organisms. It's also important to note that these wounds are typically left open to drain and heal by secondary intention because there is a higher risk of infection with closure of the wound.

What is the likely causative microorganism in an alcoholic sailor that develops high-grade fever hours after cutting his foot while sailing in the ocean? The cut is surrounded by erythema and dark-colored bullae with streaking erythema extending proximally up the limb. Vibrio vulnificus. So, this is found in marine environments and causes severe disease. For example, patients can present with rapidly progressive septicemia or even necrotizing fasciitis. Being infected with this microorganism is especially common in patients with liver disease.

What are the two most common causes of secondary bacterial pneumonia? Strep pneumoniae and Staph aureus. So, patients with secondary bacterial pneumonia typically present with worsening fever and pulmonary symptoms after initial symptomatic improvements.

What is the likely diagnosis in a patient with recently diagnosed infective endocarditis that now presents with fever and left-sided chest or abdominal pain? CT reveals a left-sided pleural effusion and splenomegaly with a splenic fluid collection. So, the most likely diagnosis is a splenic abscess secondary to infective endocarditis. So, splenic abscesses usually present with a triad of fever, leukocytosis, and left upper quadrant abdominal pain, and treatment is with antibiotics plus a splenectomy.

Which heart valve is most frequently involved in bacterial endocarditis? The mitral valve.

Which heart valve is most frequently involved in bacterial endocarditis in IV drug users? The tricuspid valve. And recall that this is associated with organisms such as Staph aureus, Pseudomonas, and Candida.

What is the most common symptom of bacterial endocarditis? Fever. So, you can recall the signs or symptoms of bacterial endocarditis with the mnemonic FROM JANE: F - fever, R - Roth spots, O - Osler nodes, M - murmur, J - Janeway lesions, A - anemia, N - nail bed hemorrhages, E - emboli.

What is the likely diagnosis in an afebrile farmer with right upper quadrant pain and a smooth, round hepatic cyst with septations and eggshell calcifications on ultrasound? Echinococcus granulosus infection. So, recall that this is a cestode. Patients with this infection can present with a lack of fever and cystic lesions. However, for an infection with Entamoeba histolytica, these patients would be febrile with a smooth, cystic, subcapsular mass.

What is the likely result of the following serologic tests in a patient vaccinated against Hepatitis B? So, the question is basically asking if a patient is vaccinated against Hepatitis B, what changes would you see in the Hepatitis B surface antigen, the Hepatitis B surface antibody, and the Hepatitis B core antibody? So, in vaccinated patients, the surface antigen would be negative, the surface antibody would be positive, and the core antibody would be negative. Oh, I remember this concept is that for persons that are immune due to immunization, they have the antibodies, which would be positive. So, those positive antibodies make you anti-sick. You can't get sick because you're vaccinated or immunized against Hepatitis B. So, that's one way to remember this.

What is the likely result of the following serologic tests in a patient naturally immunized against Hepatitis B? Well, the Hepatitis B surface antigen is negative, Hepatitis B surface antibody is positive, and the Hepatitis B core antibody is also positive. So, how you can remember this is when you see that the core antibody is positive, this means that the patient has come across Hepatitis B. So, a positive core antibody means that the patient has come across Hepatitis B. So, that's either a previous or ongoing infection. And as previously discussed, when the surface antibody is positive, then you are anti-sick. So, you can't really get sick from it. So, those two things are positive when you are naturally immune to Hepatitis B. So, it's very important that you know the difference between the test results for when a patient has received a vaccine against Hepatitis B versus, you know, natural immunization against Hepatitis B. So, you can just rewind that and put it again, just really emphasize this fact.

What is the likely result of the following serologic tests in a patient with chronic Hepatitis B? The surface antigen is positive, the surface antibody is negative, and the core antibody is positive. So, let's break this down. So, in chronic Hepatitis B, it makes sense that the core antibody would be positive because, remember, a positive core antibody means that you have come across Hepatitis B. So, whether that is a previous or ongoing infection. So, that would, of course, be positive in chronic Hepatitis B. If your Hepatitis B surface antigen is positive, that means that you are sick with Hep B. That can be either an acute or chronic infection. So, Hepatitis B surface antigen means that you're sick with Hep B. So, that will be positive in a patient with chronic Hepatitis B.

What antibody is typically positive during the window phase of Hepatitis B infection? IgM anti-HBc.

Infants born to mothers with active Hepatitis B should be managed with what? Well, first, they need the Hepatitis B vaccine and the immunoglobulin at birth. After they receive these two, then they can go on to get their routine Hepatitis B vaccines at two and six months. It's very important that you check serologies three months after the third dose of the vaccine, so that's around nine months, to see if the infant is infected with hepatitis or not.

What is post-exposure prophylaxis for Hepatitis B exposure? So, if you are non-immune, then you need to give immunoglobulin and the vaccine. However, if you are immune, then don't give anything at all. So, non-immune means that they are unvaccinated or have an incomplete response to initial vaccination. So, you give the immunoglobulin for immediate protection while the vaccine is also given, but this takes time to build a response.

What is the likely causative organism in a male that presents with dysuria, urinary frequency, and mucopurulent discharge? Gram stain and urine culture are negative. Chlamydia. So, recall that the Gram stain shows gram-negative cocci in 95% of cases of gonococcal arthritis.

What is the likely diagnosis in a sex worker that presents with fever, chills, polyarthralgia, and pustules on the chest and extensive surfaces of the forearms? Disseminated gonococcal infection.

How is the diagnosis of mucormycosis established? Sinus endoscopy with biopsy and culture.

What is the likely diagnosis in a young patient that presents with two days of fever, altered mental status, seizures, and the lumbar puncture findings below? So, the opening pressure is normal, protein is also normal, red blood cells and white blood cells are high, and there is a lymphocyte predominance (so, 90%). The most likely diagnosis is Viral Encephalitis, for example, due to HSV.

What type of catheterization is recommended for patients with a neurogenic bladder to reduce the risk of catheter-associated UTI? Clean intermittent catheterization. This refers to the insertion and removal of a clean urinary catheter every four to six hours, and this can be performed by the patient or a caregiver.

What is the likely causative organism in a patient that develops osteomyelitis after stepping on a rusty nail? The nail penetrated shoes and pierced the heel. Pseudomonas. So, Staph aureus and Pseudomonas are responsible for most deep infections following puncture wounds. The sole of a shoe, though, it's very warm and moist and is a hospitable environment for Pseudomonas. So, that's why Pseudomonas is more likely than Staph aureus in this specific scenario.

What is the recommended treatment for Legionnaires' disease? Macrolides or respiratory fluoroquinolones such as levofloxacin and moxifloxacin.

What is the next step in management for a patient being treated with RIPE therapy for TB for the past month that develops mild elevations in AST and ALT? Continue with current treatments and monitor the LFTs. Subclinical hepatotoxicity is common within the first few weeks of isoniazid therapy. It is typically self-limited and resolves without intervention. Significant hepatotoxicity, however, warrants switching treatment regimens.

What is the next step in management for a patient with suspected ventilator-associated pneumonia with a chest x-ray demonstrating lobar infiltrates? Gram stain and culture of respiratory secretions. So, this should be obtained prior to administering empiric antibiotics.

What is the likely diagnosis in an HIV patient with a CD4 count of 25 that presents with three weeks of fever, night sweats, abdominal pain, diarrhea, and weight loss? Chest x-ray, CMV serology, and PPD are all negative. Disseminated Mycobacterium avium complex (MAC) infection. So, TB and CMV are less likely due to the fact that they have a normal chest x-ray and also that the CMV serology is negative.

What is the next step in management for a patient with HIV and a CD4 count of 85 that presents with dysphagia and substernal burning? White plaques that are easily removable are present on the palate. Oral fluconazole. So, if symptoms don't improve with this medication, then endoscopy would be warranted.

Let's take a closer look at how to interpret the serologic tests for Hepatitis B because this is extremely high yield and it can be a bit confusing. So, we need to think about the antigens and the antibodies for Hep B because they mean completely different things. Let's first focus on the antigens. When you think about the antigens, I want you to think of this phrase: "Antigens, they make you sick and easily spread the disease." Antigens make you sick and easily spread the disease. So, the Hepatitis B surface antigen, that means that you are sick with Hep B. This sickness could be either due to acute or chronic Hepatitis B infection. Hepatitis B e antigen means that you easily spread the disease. So, this antigen refers to the replication and transmissibility of Hepatitis B. So, remember, when you think of antigens, think of the phrase that antigens make you sick and easily spread the disease. So, the surface antigen means that you're sick, whether acute or chronic, with Hepatitis B. The E antigen means that you easily spread the disease. Okay, so just pause the video or take a screenshot and really commit this to memory. But now let's move on to the antibodies. So, the antibodies are basically the opposite of the antigens. So, the surface antibody means that you are anti-sick. You can't get sick from Hepatitis B because you are immune from either receiving the vaccine or immune from recovery of a previous Hepatitis B infection or exposure. The E antibody means that you're anti-easily spread. So, you don't easily spread Hepatitis B. There's low transmissibility. However, for the core antibody, that means that you have come across Hepatitis B before. So, this could be due to an acute infection. If there's an acute infection, then what you'll see is a positive IgM Hepatitis B core antibody. However, if it's a chronic infection, you'll see a positive IgG Hepatitis B core antibody. So, the surface antibody is anti-sick. You are immune, either from receiving the vaccine or recovery from a previous infection. Hepatitis E antibody means that they're anti-easily spread. There's a low transmissibility. The core antibody means that you have come across Hepatitis B before. And whether that's an acute or chronic infection. Okay, I know that that's broken down a bit more easily. Let's do three practice questions. Two of them you've seen before, but one of them is completely new. So, let's go through this together.

The question asks, what is the likely result of the following serologic tests in a patient vaccinated against Hepatitis B? So, this should look very familiar to you, but let's go through it together. So, the Hepatitis B surface antigen is negative. Remember that the surface antigen means that you are sick with Hep B, but the fact that it's negative means that there's no active infection. The Hepatitis B surface antibody is the opposite of the antigen and it is positive. So, remember that the Hepatitis B surface antibody is anti-sick. So, the fact that it is positive means that this patient is immune from either recovery from a previous infection or by receiving the vaccine. The Hepatitis B core antibody is negative. So, the Hepatitis B core antibody means that you have come across Hepatitis B before. So, this could be either an acute or chronic infection, but it's negative. So, that means that there is no previous or ongoing infection. So, to sum it all up, in a patient that is vaccinated against Hepatitis B, you would expect to see a positive Hepatitis B surface antibody because that is anti-sick and that means that you are immune from either the vaccine or recovery. Okay, great.

Now let's move on to question number two of this short practice test series. What is the likely result of the following serologic tests in a patient naturally immunized against Hepatitis B? Again, this one should look a bit familiar to you. So, the Hepatitis B surface antigen is negative. So, remember that Hepatitis B surface antigen means that you are sick with Hepatitis B, but it's negative in this patient, so there is no active infection. The Hepatitis B surface antibody is positive. Remember that the Hepatitis B surface antibody means anti-sick. It's the opposite of the antigen. So, the fact that it is positive means that this patient is immune from either receiving the vaccine or recovery. The Hepatitis B core antibody is also positive. The Hepatitis B core antibody means that the patient has come across Hepatitis B. This could be either an acute or chronic infection. So, the fact that it's positive means that the patient had a previous infection. So, in a patient that is naturally immunized against Hepatitis B, you would see positive Hepatitis B surface antibodies, means that they're anti-sick, so they have some sort of immunity going on, and the Hepatitis B core antibody would also be positive because that's referring to the previous infection that they had that made them naturally immunized. Right.

Now let's move on to the brand new question. What is the likely cause of the following serologic test results? So, right here we have the Hepatitis B surface antigen, which is positive. So, remember this refers to the patient being sick with Hep B. So, yes, they have an active infection going on here. Hepatitis B surface antibody is negative. So, that means that they are anti-sick. They do not have any immunity from the vaccine or from previous recovery. The Hepatitis B core antibody is positive. Remember that this core antibody means that the patient has come across Hep B before. So, yes, this patient has had a previous infection or an ongoing infection. Also, very important, the IgM anti-HBc is also positive, and this means that the patient has an acute ongoing infection. So, when we take a closer look at this, we can see that the surface antigen is positive, so they have an active infection. The core antibody is also positive, meaning that they have a previous or ongoing infection. But we also see that the IgM anti-HBc is positive. Remember, IgM acute, IgG chronic. IgM acute, IgG chronic. So, the most likely cause of these serologic results is that this patient has an acute Hepatitis B infection.

What is the likely diagnosis in a hemodynamically unstable patient that presents with fever, vomiting, and a diffuse maculopapular rash on the trunk and extremities? The patient recently had anterior packing in the emergency department for a nosebleed. Toxic shock syndrome. The organism most commonly involved is Staph aureus, and patients can develop toxic shock syndrome if they did not remove a tampon or if they did not remove nasal packing. So, you can see cases like this, especially when you're preparing for a Step 3 CCS cases. So, think about toxic shock syndrome if a patient presents with these symptoms and signs.

What is the likely diagnosis in a patient with a recent UTI that presents with fever, back pain, vocal tenderness over the L4-L5 vertebrae, and paraspinal muscle spasm? Vertebral osteomyelitis. So, this can present in patients that have a hematogenous spread of a UTI. An initial workup includes doing a CBC, blood cultures, ESR, CRP, and plain spinal x-rays or MRI. So, the MRI, of course, is more accurate than the x-ray, and it can be confirmed with an open or CT-guided biopsy.

What is the treatment of choice in a pregnant patient with syphilis who has a penicillin allergy? Intramuscular penicillin G. Because a patient needs to be desensitized. Penicillin is the treatment of choice for syphilis, even in pregnancy, regardless of drug allergies. So, remember that there are two types of penicillin. You can have penicillin G and penicillin V. So, how you can remember which is which is by saying "hit the G for the STD."

A patient presents with recurrent UTIs more than three months with transient improvement with antibiotics and painful ejaculation. Urine culture shows bacteriuria. What is the diagnosis and treatment? So, the diagnosis would be chronic bacterial prostatitis, and you treat with six weeks of fluoroquinolone or TMP-SMX. So, chronic bacterial prostatitis is usually due to E. coli going via the urethra to the prostate, and diagnosis requires a urinalysis before and after a prostatic massage. This urinalysis would reveal urine leukocytosis or bacteria. If there's a negative urine culture, it is chronic prostatitis or chronic pelvic pain syndrome.

What is the likely diagnosis in an immunocompromised patient with fever, pleuritic chest pain, cough with hemoptysis, and CT showing nodular with surrounding ground-glass opacities on CT? Invasive aspergillosis.

What is the treatment of choice of invasive aspergillosis? IV voriconazole.

What is the recommended treatment for patients with cryptococcal meningoencephalitis? Amphotericin B plus flucytosine. So, you typically give them these two medications for more than two weeks and until asymptomatic and you get a negative CSF. After you reach these parameters, you want to follow up by giving fluconazole for more than a year.

Which organism can cause profuse watery diarrhea due to germination of spores? Clostridium difficile. So, recall that this organism is a spore-forming gram-negative and aerobic bacteria that releases exotoxins A and B. It's also transmitted via the fecal-oral route.

What is the treatment of choice of croup? If it's mild, you want to give cool mist and steroids. If it's moderate, meaning that there is stridor at rest, then give steroids and nebulized racemic epinephrine.

What pathogens most commonly cause croup and epiglottitis? Croup is most commonly caused by parainfluenza virus, while epiglottitis is most commonly caused by H. influenzae. Of course, this is rapidly changing because of the Hib vaccine. There are other organisms that can cause this condition. If you know them, then leave them in the comment section below.

What is the treatment of choice of pyelonephritis in pregnant patients? Well, you can use drugs such as cephalexin and fosfomycin. But what's very, very important is that you do not use fluoroquinolones to treat pyelonephritis in pregnant patients. Recall that fluoroquinolones have teratogenic effects and can cause damage or deformation of cartilage.

What is the treatment of choice of uncomplicated outpatient pyelonephritis and uncomplicated inpatient pyelonephritis? For uncomplicated outpatient pyelonephritis, you can give oral fluoroquinolone such as ciprofloxacin. However, for uncomplicated inpatient pyelonephritis, you want to give ceftriaxone.

When is breastfeeding contraindicated? Active tuberculosis, maternal HIV infection, herpetic breast lesions, active varicella infection, chemotherapy or radiation therapy, active alcohol use, galactosemia. So, as you can tell with this list, most of these are maternal contraindications, like things that are going on with the mom that would cause her not to be able to breastfeed or recommend it not to breastfeed at this time. However, the only one that is an infant or neonate contraindication is galactosemia. So, that's very high yield to note.

What is the recommended treatment for confirmed gonorrhea infection? Single dose azithromycin and IM ceftriaxone.

What condition can a positive tourniquet test indicate? Dengue fever. So, this is associated with a positive tourniquet test, which results in petechiae after blood pressure cuff inflation.

What is the best prognostic marker for primary CNS lymphoma? Degree of immunosuppression or CD4 count.

What is the next step in management for a patient found to have positive HCV antibodies? HCV RNA testing. So, hepatitis C antibodies are positive in the acute and chronic phases of the infection, previous Hep C infection, or simply false positives. So, we need to confirm with PCR testing of RNA. So, basically, to diagnose Hep C, you need both positive serology and a positive HCV RNA levels.

What prophylactic medication should be initiated in a patient who is beginning high-dose immunosuppression therapy following a renal transplant? Trimethoprim for PCP and ganciclovir or valganciclovir for CMV.

How would you treat these conditions? Uncomplicated outpatient treatment of community-acquired pneumonia and uncomplicated inpatient treatment of community-acquired pneumonia. Like, which antibiotics would you give these patients? Well, for uncomplicated outpatient treatment of community-acquired pneumonia, you give amoxicillin or doxycycline. For uncomplicated inpatient treatment of CAP, you can give ceftriaxone and a macrolide such as azithromycin or fluoroquinolone monotherapy. So, if you're preparing for a USMLE Step 3 exam, concepts like these are extremely high yield because examiners expect you to somehow confuse the different medications used based on if the pneumonia is complicated or uncomplicated or if it's treated inpatient or outpatient. So, very important to take a note of this.

What is the treatment of choice of strep throat? A 10-day course of penicillin or amoxicillin, which prevents acute rheumatic fever. So, treating group A strep pharyngitis does prevent rheumatic fever. However, it does not prevent post-strep glomerulonephritis. It basically prevents the worst one, which is rheumatic fever.

A *canella* is a gram-negative anaerobe commonly found in what situation or when would patients be infected with this organism? Human bites. So, human bites in general are polymicrobial in nature. You can be infected with organisms such as Viridian's, Strep, Staph, and various anaerobes when you're bitten by a human. However, if you see that the patient is infected with an organism such as Pasteurella, then you want to consider a cat or dog bite. So, this isn't a question, but a high-yield learning point that I want you to commit to memory, and that's the fact that rhinosinusitis is more commonly caused by viral organisms. So, it does not require treatment with antibiotics. However, you should consider antibiotic treatment if any one or more of these are seen, and that includes symptoms lasting greater than 10 days without improvement, symptoms are severe (for example, fever greater than 102, purulent mucus, or facial pain for more than three days), also if the viral upper respiratory tract symptoms worsen after initial improvements. So, if you see any one of these things, the likely diagnosis is acute bacterial rhinosinusitis, which is treated with oral antibiotics such as amoxicillin. It's also high-yield to know that patients with rhinosinusitis do not require additional imaging unless there are signs of extension into the central nervous system or orbits.

What is the treatment of choice of acute bacterial rhinosinusitis? Oral antibiotics. So, if you're just bringing attention to my mini-lecture on rhinosinusitis, then you most definitely already knew the answer to this. But let's move on.

What is the treatment of choice of a breastfeeding patient with trichomonas vaginalis? A single dose of oral metronidazole (2 mg), and then you want to discard the breast milk for 24 hours after you give the patient this medication. So, metronidazole can enter breast milk, causing loose stools and candidiasis in exposed infants. Also, it's ideal that, just like for any other trichomonas vaginalis infection, whether pregnant or not, you always want to treat the partner.

What is the next best step in a patient with ongoing dysuria despite giving azithromycin for non-gonococcal urethritis? Repeat urethral fluid Gram stain. So, there are other organisms that can cause non-gonococcal urethritis that are not responsive to azithromycin.

What is the most likely diagnosis in an immigrant from Africa who develops cystitis with symptoms of dysuria, urinary frequency, and terminal hematuria and peripheral eosinophilia? Schistosomiasis. So, this condition has the greatest prevalence in Africa and is diagnosed with urine sediment microscopy, which identifies the eggs. Once you confirm diagnosis, you want to treat with praziquantel.

How can you confirm the correct placement of an endotracheal tube? First, you can check for the endotracheal tube depth. Second, you can look for chest excursions. If they're equal bilaterally, you can also auscultate the chest, listening for bilateral equal breath sounds, or you can even do a chest x-ray. So, typically, patients will present with right mainstem bronchial intubation on exam day. Signs of this include respiratory distress due to hypoventilation, diminished or absent breath sounds on the left side. Another common exam question is asking what is the best way to differentiate between the tube being placed in the esophagus or into the trachea, and the answer that examiners prefer is capnography.

No, this is a concept that students commonly mix up, which is the treatment of a tension pneumothorax versus a simple pneumothorax. So, let's take a minute and think about how would you treat these conditions. So, for a tension pneumothorax, you use needle decompression. But for a simple pneumothorax, you would do a chest tube insertion.

In what condition would you see acute perioperative hypercapnic and hypoxic respiratory failure? So, this can occur due to obstructive sleep apnea. So, patients with obstructive sleep apnea are at increased risk of this condition, specifically for procedures involving sedation, neuromuscular blockers, opioids, or anesthesia. So, respiratory failure occurs in these patients. It usually presents or results from hypoventilation and it is also associated with a respiratory acidosis.

Which organ is most commonly involved in laryngotracheitis? The parainfluenza virus. So, how patients would typically present is with inspiratory stridor, a barking cough, and hoarseness. So, to treat these patients, you have to know whether or not stridor is present. So, if it is mild with no stridor at rest, then the treatment is humidified air and maybe some steroids. However, if their symptoms are moderate or severe with stridor at rest, then you will give steroids and nebulized epinephrine. It's very important that you remember this key fact when treating patients with this condition: always look to see whether or not they have stridor at rest to determine the best treatment option for that patient. And to prevent this condition, contaminate surfaces. You can use proper ventilation and hand washing as well. To diagnose it, it is typically a clinical diagnosis. However, if diagnosis is unclear, you can do a PA neck x-ray that can show the steeple sign due to subglottic narrowing. That's very high yield because if examiners want to be not so kind and test you on, you know, supraglottic or subglottic, just know that in this condition, it is subglottic narrowing.

Which organism causes bronchiolitis? RSV. So, symptoms typically occur in the winter in patients that are around two years old. They present with nasal congestion, rhinorrhea, coarse breath sounds, wheezing, and crackles. So, these patients with respiratory distress, apnea, hypoxia, or even dehydration should be hospitalized and on contact and droplet precautions to prevent the spread of this condition. To treat it, it is usually supportive with IV fluids, nasal bulb suctioning, and humidified oxygen. Again, this is another condition that is typically diagnosed clinically. But if a patient is experiencing a breakthrough RSV infection in infants who received the monoclonal antibody medication, palivizumab, then they need to receive NAT testing (nucleic acid amplification testing). And in these patients, the RSV infection provides acute immunity and protection, and at that point, the palivizumab can be discontinued. So, some complications that can be seen in patients with bronchiolitis, specifically if the patient is less than two months old, are apnea and respiratory failure. They can also experience recurrent wheezing. However, if they are older or a full-term healthy infant, then you don't typically see any complications in those patients. So, as I mentioned before, to prevent this condition, you can give a monoclonal antibody, palivizumab, for infants that are less than 29 weeks gestation, who have a chronic lung disease or prematurity, or who have a hemodynamically significant congenital heart disease.

What is the most likely cause of recurrent pneumonia in an elderly smoker? Bronchogenic carcinoma. So, a carcinoid tumor is a cause of endobronchial obstruction in younger, non-smoking patients. However, if it is an older patient, like in this case, you would suspect a bronchogenic carcinoma. Other causes to consider for non-resolving pneumonia are bronchoalveolar cell carcinoma, lymphoma, eosinophilic pneumonia, and BOOP or bronchiolitis obliterans organizing pneumonia. Even drugs such as amiodarone can also cause non-resolving pneumonia, and that, of course, is very high yield. Just make sure that you know everything about amiodarone: the mechanism of action, all of the different complications when it is used, everything like that. It is an extremely high-yield drug.

So, what is the best confirmatory test in this patient? And remember, we're referring to the elderly smoker with the recurring pneumonia. So, the best confirmatory test is a flexible bronchoscopy. So, please note that this question is asking the best confirmatory test, right? If it was the best next step, then you could say a CT. But because it's the best confirmatory test, it is definitely the flexible bronchoscopy.

What is the diagnostic test of choice in a patient with renal failure and a modified Wells score greater than 4 on a ventilation-perfusion scan? If the patient did not have renal failure, then you could go ahead and do a CT angiogram of the chest. But it's very important that you look for like the BUN, the creatinine, those in any evidence of renal failure in a patient that presents with symptoms or signs of a pulmonary embolism because that's one way that, you know, the examiners like to tackle this is knowing which test is best for a patient with renal failure and without renal failure. So, of course, you have to know the modified Wells score. Remember that if they have a score greater than 4, then a PE is very likely, while a score of less than 4 is unlikely for a PE. So, a patient would be assigned three points if they have clinical signs of a DVT and if an alternate diagnosis is less likely. They'd be assigned a score of 1.5 if they had a previous PE or DVT, a heart rate greater than 100, and a recent surgery or immobilization, and they'd be assigned one point if they have hemoptysis or cancer.

So, this is a bit of a yes or no question. Do asymptomatic asthma patients have abnormal PFTs? No, they don't. They have normal PFTs.

What type of lung cancer is associated with SIADH? Small cell carcinoma. So, in these patients, they present with a normal volume hyponatremia where the sodium is less than 120. So, remember that ADH usually concentrates urine or causes water retention. So, in SIADH, there will be water retention, of course, and loss of sodium and potassium. And the treatment for patients with this condition is water restriction. Another high-yield fact to note is that there are some drugs that actually blunt the response of the collecting tubule cells to ADH. One such drug is lithium. So, lithium can blunt the response of ADH, and of course, another high-yield and Step 1 throwback is that ADH acts on the collecting tubule. So, since ADH usually concentrates urine, if lithium is being taken by the patient, it blunts the action of this ADH, so it can't concentrate urine. So, what happens is that they have dilute urine.

So, if you see an increased respiratory drive in patients with chronic opioid therapy or who are receiving chronic opioid therapy, what can you suspect? And you can suspect an acute underlying non-opioid-related disease process because, remember, opioid therapy causes respiratory depression, not an increased respiratory drive.

So, how the equation presents if they had a ventilator-associated pneumonia? Well, they would have fever, increased secretions, worsening pulmonary infiltrates, and an increase in requirements for ventilator support occurring more than 48 hours after mechanical ventilation. So, ventilator-associated pneumonia is a common complication of ARDS or ALI. It is most commonly caused by a microaspiration of purulent or pharyngeal organisms, and as a result, other signs that these patients can present with include leukocytosis, tachypnea, and decreased oxygenation. So, to diagnose these patients, you can do a tricky bronchial aspirate for culture or respiratory sampling, and doing these diagnostic tests helps you to really tailor the antibiotic therapy that is needed for patients experiencing this condition.

What is the most helpful in diagnosing recurrent pneumonia in a patient with Parkinson's disease? A videofluoroscopic swallowing study. So, to treat this type of pneumonia, you would have to give the patient broad-spectrum antibiotics with anaerobic coverage, for example, clindamycin, and other specific interventions that you could use would be thickened liquids and modified swallowing techniques.

What are some common causes of post-operative hypoxemia? So, if it's immediately after surgery, you want to suspect airway obstruction or edema that can present with stridor due to endotracheal intubation or pharyngeal muscle laxity. Another cause is a residual anesthetic effect, and these patients present with a decreased tidal volume, also have a normal A-a gradient, and the hypoxemia corrects with supplemental oxygen. Other causes of post-op hypoxemia include bronchospasm that presents with wheezing. You also have pneumonia, which is typically one to five days post-op, and then atelectasis, which is two to five days post-op, and it's most common in patients who undergo thoracoabdominal surgeries and they have retained secretions. Another cause of hypoxemia is pulmonary embolism.

At what diameter would a solitary pulmonary nodule actually be considered to be a mass? And that is if it's more than three centimeters. So, a solitary pulmonary nodule more than two centimeters independently correlates with a greater than 50% chance of malignant probability.

What is the chest x-ray that reviews a solitary pulmonary nodule? And that is to compare the previous x-rays or CT scans. And this is high yield. Everyone prepared for a Step 2 CK or the Step 3 exam would have known the answer to this question at this point. So, if the solitary pulmonary nodule has changed in size or appearance from the previous imaging, or if no previous image is available, then the next step would be to do a CT of the chest.

Okay, now just a quick pop quiz: benign or malignant, or solitary pulmonary nodules? So, if it's spiculated, benign or malignant? Malignant. Heterogeneous pulmonary nodules, benign or malignant? Benign. Ground glass nodule, malignant? Malignant. So, this is a high-yield factor or slide for you to know. This. Take some time right now and really commit this to memory. And if you've reached this far in the video and you have not liked the video yet, please take a moment to pop that like button, hit subscribe, and that notification bell so that you will never miss another high-yield video like this.

Now we're going to look at some factors that increase the malignant probability of solitary pulmonary nodules, and this is: large size, female sex, advanced patient age, family or personal history of lung cancer, an upper lobe location of the nodule, and active or previous smoking. It's very high yield to know that nodules more than 0.8 centimeters require additional management or surveillance, while nodules less than 0.6 centimeters are unlikely to be malignant. So, if a patient presents with a pulmonary nodule that is 0.9 centimeters and they ask what is the best next step, you want to look at an option that has additional management or surveillance for that patient.

So, let's take a closer look at inhalation injury treatment. So, all patients with inhalation injury should receive supplemental oxygen. If the patient is stable with concerning features but no strong indicators for inhalation injury, then you can do a bedside fiber optic laryngoscopy. However, if this patient is unstable with strong indications for inhalation injury, then you'd want to do an endotracheal intubation. It's very important to note that strong indicators for airway injury would include oropharyngeal blistering or hypoxia or other such features. Another high-yield fact to note is that when you do a fiber optic laryngoscopy, this provides visualization of the supraglottic structures, and if oropharyngeal erythema, blistering, or edema is present, then airway stabilization with intubation should be strongly considered.

What is the preferred agent to use for awake intubation? Ketamine. So, ketamine provides sedation, amnesia, and analgesia. It causes a sympathetic surge by inhibiting the reuptake of catecholamines, and that increases the blood pressure and causes bronchial smooth muscle relaxation, which are additional benefits in this patient who would require awake intubation. So, if a patient specifically has bronchospasm and they need to be intubated, using ketamine would be greatly beneficial for that patient since it does cause bronchiole smooth muscle relaxation.

So, a more in-depth question is, why is awake intubation preferred over rapid sequence intubation in patients with difficult airways? This is a basic discussion question. So, just take a moment and really think about that. But basically, during rapid sequence intubation, the patient is fully paralyzed, causing loss of all upper airway tone, all protective airway reflexes, and respiratory drive. So, if intubation is unsuccessful, which can happen in patients with difficult airways, the patient can rapidly become hypoxic and experience cardiac arrest. If you choose to do rapid sequence intubation. So, this is why an awake intubation is preferred because the patient can independently maintain their upper airway tone and spontaneous ventilation as well.

Next question: In an emergency situation, which is better, a tracheostomy or cricothyroidotomy? And if you said cricothyroidotomy, then you are correct. So, this procedure should be done in hypoxic, unstable patients who cannot be oxygenated or ventilated due to an upper airway obstruction.

What are some risk factors for extubation failure? So, we have weak cough, poor instruction, poor mental status, older than 65 years old, comorbid conditions, pneumonia as an initial cause of respiratory failure is another risk factor too, and if they have a positive fluid balance 24 hours prior to extubation. Another high-yield fact on this page. So, if you want to pause it and just commit this to memory, then go right ahead. If not, let's move on to even more high-yield concepts.

So, what are some symptoms or signs of impending respiratory failure? And that includes a pH less than 7.35 and a PaCO2 greater than 45, hypoxemia, and respiratory rate greater than 25 per minute for two hours, and clinical signs of respiratory failure.

What is the next best step in a patient with post-extubation stridor? This is reintubation and mechanical ventilation. So, laryngeal edema presents with post-extubation stridor and respiratory failure. Risk factors for collateral edema, we kind of brushed on that before, but that includes female gender and prolonged duration of intubation. So, administration of a multiple-dose regimen of steroids prior to extubation can prevent laryngeal edema and extubation failure.

What are the predictors of 30-day mortality in pulmonary embolism? Hypotension, tachycardia, tachypnea, hypothermia, hypoxemia, altered mental status, and history of cancer, as well as a patient older than 80 years old. So, all of those predictors I just mentioned are clinical predictors. There are also radiological predictors such as right ventricular dysfunction, and you have lab predictors such as troponin and BNP. So, a high-yield fact to commit to memory is that if a patient presents with fever, a low PCO2, and respiratory alkalosis due to tachypnea, then this patient could very well have acute PE. So, this is a high-yield fact because examiners like to throw fever in there to make you second-guess yourself and think, oh, maybe it's pneumonia or some infectious cause, but fever does present in quite a number of patients with pulmonary embolism. So, remember that fact.

When is an inferior vena cava filter indicated in a patient with a pulmonary embolism? Anticoagulation is contraindicated or ineffective, low cardiopulmonary reserve, recurrent pulmonary embolism on anticoagulation. So, filters may also be placed prophylactically in patients who are unlikely to tolerate another PE.

Now we're going to look at the management of PEs. So, all patients with PE should receive anticoagulation unless they have contraindications. They should also receive thrombolysis if they have a PE with hypotension and a low bleeding risk. They should also receive embolectomy if they have shock or failed thrombolysis with persistent hypotension.

So, now we're going to take a closer look at post-intensive care syndrome. So, some risk factors for this condition include ARDS, ICU delirium, prolonged mechanical ventilation, symptoms of a major depressive disorder, PTSD, decreased mobility and independence, decreased attention and memory. To manage patients with these conditions, you prevent with early physical therapy participation, and you treat the psychiatric symptoms as well.

And now we're going to look closer at pulmonary contusions. So, these patients typically present with chest pain, shortness of breath, hemoptysis, and respiratory symptoms may be delayed for 24 hours from the time of injury. And to diagnose patients with a pulmonary contusion, you will have a chest x-ray showing irregular, localized opacifications at the site of injury. It's important to know that CT scan is more diagnostically sensitive. And to treat these patients, you want to provide them with adequate pain control to avoid hypoventilation and also provide supportive care such as pulmonary hygiene, such as chest physiotherapy and suctioning, as well as supplemental oxygen and ventilatory support. So, symptoms typically resolve within three to five days. It is extremely high yield that you do not confuse pulmonary contusions with ARDS. So, ARDS describes a non-cardiogenic pulmonary edema that typically results from a systemic disease process such as pancreatitis, sepsis, or lung injury, while of course, a pulmonary contusion is seen after trauma or injury.

So, what are the guidelines for lung cancer screening? Well, it is recommended that you do a yearly low-dose CT scan of the chest if the patient is between 50 to 80 years old and if they have greater than a 20 pack-year smoking history and currently smoking or quit smoking less than 15 years ago.

So, we're going to look at the pulmonary function test results and how you can manage patients with asthma. Do you admit them or discharge them? So, if it is greater than 70%, you would discharge home. If it is between 40 to 69%, you would admit to the ward. If it is less than 40%, you would admit to ICU. It's very important to know that signs of impending respiratory failure include confusion, drowsiness, depressed respiratory drive, and severe hypoxemia.

What is the current diagnostic criteria for ABPA? An elevated Aspergillus-specific IgE with elevated total IgE, a positive Aspergillus-specific IgG, eosinophilia, a positive skin test reactivity for Aspergillus. And to treat these patients, you would give them systemic glucocorticoids and antifungal therapy with either fluconazole or itraconazole.

So, when you think about post-operative pulmonary complications, what conditions give rise to or what conditions are associated with the greatest risk factor for developing post-op pulmonary complications? Well, these conditions include COPD, heart failure, sleep apnea, and current smoking. So, post-operative pulmonary complications are common after thoracic and upper abdominal surgery due to reduced lung volumes from diaphragmatic dysfunction and splinting. So, common post-op pulmonary complications include atelectasis, infection, hypoxia, and respiratory failure. And patients can do incentive spirometry and deep breathing exercises post-op to increase lung volumes and diminish the chances of getting atelectasis.

How is the A-a gradient affected in atelectasis? It is increased due to intrapulmonary shunting. So, atelectasis typically occurs two to five days post-op, and symptoms include increased work of breathing or hypoxemia. Chest x-ray also reveals linear opacifications in the bilateral lung bases. And to treat these patients, if they have minimal respiratory secretions, then CPAP. However, if they have copious purulent secretions, then aggressive pulmonary hygiene such as chest physiotherapy and suctioning is highly, highly recommended.

So, what are some diagnostic features of tuberculosis pleural effusions? Well, first, they are lymphocytic and exudative pleural effusions. Patients will have elevated adenosine deaminase levels, and pleural biopsy with histopathologic demonstration can show pleural granulomas.

So, if a patient is being treated with steroids for a condition, what are some indications for glucocorticoid cessation? First is that therapeutic benefit has been achieved. Second is that they may be experiencing uncontrolled side effects such as hypertension. And third, severe complications such as steroid-induced psychosis. Another high-yield fact to note is that HPA axis suppression is more likely in prolonged steroid use, that is, to reduce more than three weeks, or with higher doses, or with even administration of steroids. So, if steroids are being prescribed for more than three weeks of daily use, then at that point, you definitely want to recommend that these patients receive tapering of their steroids and not just suddenly stopping.

So, what is the STOP-BANG survey for OSA? Snoring, tiredness, observed apneas or choking spells, blood pressure elevated, BMI greater than 35, age greater than 50, neck size in men greater than 17 inches, women greater than 16 inches, and gender male. So, that is the STOP-BANG survey for obstructive sleep apnea.

What is the drug of choice in a patient with PE? One milligram of epinephrine every three to five minutes. So, remember that you give epinephrine in PE. However, if a patient is bradycardic but they do have a pulse, that's when you can give IV atropine because IV atropine is indicated in symptomatic bradycardia with like hypertension and heart failure, or they have to have a pulse. So, sinus bradycardia in the absence of a pulse represents PE and not a symptomatic bradycardia. So, that's an important distinction to be aware of when reading to these very long clinical vignettes on exam day. Another high-yield drug to note is sodium bicarbonate, which is useful for cardiac arrest due to hyperkalemia, metabolic acidosis, or TCA overdose.

What is the most likely diagnosis of non-resolution of pneumonia in a patient with an extensive smoking history and obstructing endobronchial malignancy? So, the next best step in management in a patient that presents like this is a chest CT scan, which can help diagnose conditions like a malignancy, as well as other causes of non-resolving pneumonia such as an abscess or empyema.

What is the treatment of choice of acute bronchitis? Symptomatic treatment. So, typically, antibiotics are not recommended in these patients, and you can diagnose a patient with acute bronchitis if they have a cough lasting greater than five days, or even up to three weeks, and it occurs due to a preceding viral respiratory infection.

What are signs of COPD exacerbation? Increased dyspnea, increased sputum volume, increased sputum purulence.

What is the diagnostic test of choice in an unstable patient with a suspected massive PE? An emergency bedside echo. So, a CT angiogram is unsafe in hemodynamically unstable patients.

Unstable patients. So whenever looking at the next best test, always check to see whether or not the patient is stable or not, because that would definitely let you know which answer would be the best answer choice for that patient.

What Echo findings are likely to be seen on Echo in a patient with a massive acute PE? A small, underfilled left ventricle. Also, it's important to note that an acute rise in right ventricular afterload causes right ventricular dilation too.

So, what is decoupling or decoupling in organ donation? What is that concept refer to? Well, that is a fact that physicians typically only discuss like if a patient has a brain death. However, organ donation is then discussed by the organ procurement organization. So the physician does not discuss brain death. So the treating physician would not talk to the patient's family about the patient being brain dead and then immediately mentioning organ donation. This is done differently. So physicians discuss that, "Hey, their loved one is, um, brain dead." And then you have organ donation discussions being done by the organ procurement organization. So it's important to know that the duties of the treating physician is to discuss impending death with a family, provide care until death, and also to defer any donor discussions to the, um, the OPO. And the duties of the OPO is to assess donor eligibility, discuss donation with the family, and provide support and counseling as well.

So now we're going to take a closer look at cough variants as well. So patients with this condition have a chronic non-productive cough that is worse at night, and wheezing and rhonchi are typically absent. And this condition is triggered by exercise, forced expiration, and allergen exposure. Upper airway cough syndrome. While patients with this condition have rhinorrhea and or post-nasal drip.

What is the most reliable test for confirming tracheal rather than esophageal endotracheal tube placement? Well, if you're this far in the lecture here, then you definitely know the answer to this, because I said it first for the first question. The answer is capnography. So a normal waveform with all four phases on capnogram indicates correct ET placement, while a flat waveform indicates improper esophageal placement. You can also do a, um, okay, litmus paper test. So if carbon dioxide is present, the litmus paper changes from purple to yellow, and this lets you know that the tube is in the trachea. Where if there is no color change, then that means it is in the esophagus.

What is pulmonary cachexia syndrome, or how do these patients present? Well, they present with a loss of lean muscle mass associated with chronic lung disease. They have a BMI less than 20 or experience weight loss greater than 5% of their body weight.

What is the most important factor in determining the prognosis of patients with COPD? FEV1.

What is the test of choice for the evaluation of tension pneumothorax in the acute setting? Bedside ultrasound.

Which interventions are the most important ways to maximize viability of organs for donation? Maintain euvolemia by administering IV fluids and desmopressin. So desmopressin reduces the diuretic impact of central diabetes insipidus. It also provides inotropic or pressure support to maintain the blood pressure. And you can also use warm air blankets to help maintain the temperature as well.

What lab tests should be done before and after initiation of TPN? So patients on TPN are at high risk of developing hypophosphatemia, which is a prominent manifestation of refeeding syndrome, a condition that develops due to fluid and electrolyte shifts when chronically malnourished patients are re-initiated on adequate nutrition. So patients with refeeding syndrome are at risk of developing seizures, rhabdomyolysis, and life-threatening cardiovascular complications. So it's very important that before and after you initiate TPN, that you will look or assess the serum phosphate levels.

What is the major cause of hypoxemia in patients with COPD? So patients with hypoxemia who have COPD, this is due to V/Q mismatch. And this is actually worse than if the patient has COPD exacerbations. And typically, if you give supplemental oxygen in these patients, the hypoxemia will improve primarily by increasing the oxygen exchange in the lung regions that have a low V/Q ratio.

Are popcorn calcifications or hamartomas benign or malignant? They are benign.

How do you manage newborns with TTN? Supportive care, because they have self-resolution in one to three days. So some risk factors for TTN include C-sections, prematurity, and maternal diabetes. These patients typically present with tachypnea, increased work of breathing, and clear breath sounds. On chest x-ray, you will see hyperinflation or a flat diaphragm, fluid in the fissures, and prominent vascular markings or even mild cardiomegaly.

What are the best initial steps in treating patients who have isolated habitual snoring? Smoking cessation, if they are smokers, as well as elimination of alcohol intake before bedtime. Basically, any habits that they perform that could be causing snoring, they need to stop it. And that's the best initial step for stopping isolated habitual snoring.

And what is the most likely diagnosis in a two-year-old with painless hematochezia and a positive technetium-99 scan? Meckel's diverticulum.

Where does technetium-99 concentrate in patients with Meckel's diverticulum? The parietal cells of the diverticulum and stomach.

What is the treatment of choice of a pregnant patient who is incidentally found to have gallstones and is asymptomatic? No treatment is needed because most pregnancy-related gallstones resolve spontaneously within two months of delivery.

What is the treatment of choice of a pregnant patient with symptoms of recurrent biliary colic or acute cholecystitis? Cholecystectomy. So it's very important that you take a closer look at how these patients present. In the previous question, we had a pregnant patient and their gallstones were incidentally found and they had absolutely no symptoms, so no treatment was needed. However, in this question, the patient has symptoms of her recurrent biliary colic or acute cholecystitis. So the treatments are the management of these patients change based on their presentation. Very high yield to know this.

What is the next best step in the management of an anal abscess? Incision and drainage. Antibiotics are also needed if the patient has diabetes, immunosuppression, extensive cellulitis, or valvular heart disease.

Patients with anal abscesses are at greatest risk of developing which condition? A fistula.

Which organism can cause profuse watery diarrhea due to germination of spores? C. difficile. So recall that this organism is spore-forming, gram-positive, and an anaerobic bacteria. It releases exotoxins A and B, and it is transmitted through the fecal-oral route.

Injury to the vagus nerve during gastric surgery can result in which condition? Gastroparesis.

What is the next best step in a patient that swallowed a fish bone and experiences dysphagia? A flexible endoscopy.

What is first-line treatment for GERD in an infant with appropriate weight gain? Reassurance and lifestyle modification. So this can include upright positioning after feeds, burping during feeds, frequent small volume feeds. It's important to note that GER has peak symptoms at four months and self-resolves by age 12 to 18 months. H2 receptor antagonists like famotidine are indicated in patients with GERD who have poor weight gain, are irritable despite lifestyle modifications, or a trial of a diet free of cow's milk. So again, it's important to look at the symptoms or the clinical findings of these patients. So if there's an infant with appropriate weight gain, I'm just in reassurance and lifestyle modification. But if the weight gain is not appropriate, then you may have to consider giving H2 receptor antagonists.

What is the diagnostic test of choice of pyloric stenosis? Abdominal ultrasound.

What is the most likely diagnosis in a patient that has very umbilical abdominal pain and diarrhea each time they eat ice cream but have no symptoms when they eat cheese? Lactose intolerance. So this is pretty straightforward, but examiners like to mention different dairy products where their patient may have symptoms when they consume ice cream but none with cheese, and it's just a way of trying to confuse you and to choose another answer. But basically, cheese and live culture yogurt have less lactose content and tend to cause few or no symptoms. It's also important to recall that celiac disease can also present with GI distress, however, they also present with growth failure and weight loss.

A hemodynamically stable elderly patient presents with painless blood per rectum after IV fluids, type and crossmatch. What is the next step in management? Colonoscopy. Recall that diverticulosis patients present with painless hematochezia in an elderly patient. However, for diverticulitis, they have left lower quadrant pain, fever, no blood per rectum, and a colonoscopy is contraindicated due to a risk of perforation.

Is the BUN to creatinine ratio greater than 20:1 in upper GI bleeds? Yes. However, in lower GI bleeds, it is normal. So that's an important fact to remember. BUN to creatinine ratio greater than 20:1, think upper GI bleed. If it's a normal ratio, think lower GI bleed.

What is the underlying cause of indirect inguinal hernia? Failed obliteration of the processus vaginalis.

What are the two most common causes of blood-streaked stools in a well-appearing infant less than six months old? Anal fissures or non-IgE-mediated food protein-induced allergic proctocolitis. It is also important to note that the latter condition is most common in age one to four weeks.

What is the next best step in a breastfed infant who has FPIAP? Recall that FPIAP is the condition that we just talked about, food protein-induced allergic proctocolitis. The next best step is to eliminate common triggers from the maternal diet, for example, dairy and soy. Soy-based formula is not recommended due to the potential cross-reactivity between cow's milk and soy protein.

What is the next first step in a formula-fed infant who has FPIAP? Hypoallergenic formula or hydrolyzed formula.

What is the prognosis for patients with FPIAP? Tolerance of offending protein by age one. So typically for these patients, their symptoms resolve within two weeks of dietary elimination of the food allergen.

If ultrasound findings are absent or inconclusive for acute cholecystitis, what is the next best step? HIDA scan.

Which condition causes isolated gastric varices and left-sided portal hypertension and congestive splenomegaly? Hepatic vein thrombosis.

If a patient presents with clinical features of acute pancreatitis, what is the best next step in establishing this diagnosis? Serum blood tests only. It's important to note that two of the three are required to diagnose acute pancreatitis: the first being acute onset of persistent severe epigastric pain, second, elevation of serum lipase or amylase greater than three times the upper limits of normal (of course, lipase is more specific), and third, characteristic findings of pancreatitis on abnormal imaging, which can be contrast-enhanced CT scan or MRI.

What is the next best step in management in a patient that drinks alcohol with clinical features of acute pancreatitis, elevated lipase, and normal abdominal ultrasound? Lipid panel. So if alcohol or gallstones isn't the cause of acute pancreatitis, then you need to evaluate for hypertriglyceridemia with a serum lipid panel.

What is the most likely diagnosis in a patient who is being treated for acute pancreatitis, then they develop fever, leukocytosis, hypotension, and right upper quadrant abdominal pain? Infected pancreatic necrosis. So the diagnosis for this condition, you need to do an abdominal CT scan with contrast. And for treatment, you can give meropenem or fluoroquinolone and metronidazole.

What is the standard composition of enteral feeding of calories per kilogram per day and grams per kilogram per day in a patient with adequate baseline nutrition? 30 calories per kilogram per day and 1 gram per kilogram per day for protein. Or protein-lower calorie enteral feeds can also be considered for patients with severe malnutrition in order to prevent refeeding syndrome.

What is the best diagnostic test in a patient with rapid onset, very umbilical pain, benign exam findings, and an anion gap metabolic acidosis and a recent MI? Abdominal CT angiography, because we're thinking that this patient may have acute mesenteric ischemia.

Which artery is most commonly occluded in AMI or acute mesenteric ischemia? The superior mesenteric artery.

Which antihypertensives can cause pancreatitis? Thiazides, such as hydrochlorothiazide, and most loop diuretics, such as furosemide.

What is the underlying cause of eosinophilic esophagitis? Chronic Th2-mediated inflammatory response triggered by food antigen exposure.

What is the treatment of choice of eosinophilic esophagitis? First-line treatment is elimination diet of the triggers, PPI, and also a topical glucocorticoids, example, for example, fluticasone sprayed and swallowed.

What is the first step in management of infectious gastroenteritis? Rehydration. So typically, if the patient has non-bloody diarrhea, consider a viral cause. But if they do have bloody diarrhea, then consider a bacterial cause.

What vitamin deficiencies may be seen in small intestinal bacterial overgrowth? While these patients typically present with bloating, flatulence, chronic watery diarrhea, and possible signs and features of malabsorption, they have a low vitamin B12 due to bacterial consumption and high folate due to bacterial synthesis.

What diagnostic tests can diagnose SIBO or small intestinal bacterial overgrowth? Carbohydrate breath testing, endoscopy with duodenal aspirate or culture.

What is the treatment of choice of SIBO? Oral antibiotics, for example, rifaximin, ciprofloxacin, and doxycycline.

What are risk factors for SIBO? Anatomic abnormalities such as strictures after surgery, motility disorders due to diabetes or scleroderma, immunodeficiency due to IgA deficiency, chronic pancreatitis, or gastric hypochlorhydria.

What CTs can reveal in a patient with colonic ischemia? Colonic wall thickening and fat stranding.

What is the first step in evaluation and management of chronic diarrhea? A comprehensive history, in addition to a comprehensive stool test and routine lab tests.

What other tests should be done to investigate the cause of chronic diarrhea? Well, that should be in addition to a comprehensive history and routine lab tests: stool for microscopy, electrolytes, and fat content. So chronic diarrhea is loose stool with or without increased frequency for greater than four weeks.

What type of anemia is most commonly seen in Celiac disease? Microcytic anemia.

Is the stool osmotic gap high or low in Celiac disease? High. Recall that patients with Celiac disease present with greasy, large, bulky diarrhea and weight loss, as well as osmotic diarrhea.

What will GI endoscopy with biopsy reveal in a patient with celiac disease? Villous atrophy, loss of normal villous architecture, increased intraepithelial lymphocytes, crypt hyperplasia.

What is the most likely diagnosis in a patient with a history of GERD who presents with dysphagia to solids and no alarm symptoms? Esophageal strictures.

How do you manage a patient with celiac disease? A gluten-free diet, treat any nutritional deficiencies present, bone loss prevention, pneumococcal vaccine, and also give dapsone if dermatitis herpetiformis is present. So some nutritional deficiencies that patients with celiac disease can have include deficiencies of iron, calcium, vitamin D, folic acid, and thiamine. For bone loss prevention, you can obtain a DEXA scan at diagnosis of celiac disease, then repeat the DEXA scan one year later if osteopenia was present.

What is the most likely diagnosis in a patient with cirrhosis, mental status changes, and diffuse abdominal pain? Spontaneous bacterial peritonitis. Extremely high yield to know this.

How would the following be affected in a patient with SBP or spontaneous bacterial peritonitis? So the PMNs would be greater than 250, protein less than 1 gram, SAAG greater than 1.1.

What is the next best step in management of a patient diagnosed with SBP? IV antibiotics and albumin. So IV albumin is given to decrease the incidence of renal failure and reduce mortality in patients with SBP. Empiric antibiotics are also given, most commonly third-generation cephalosporins. Also, fluoroquinolone can be given for prophylaxis of SBP. So I had like three different slides on this because this topic is extremely high yield, especially for your surgery shelf. It can be seen in your internal medicine shelf, and of course, on the USMLE exam as well.

What is the most likely diagnosis in a 62-year-old with occult GI bleeding and a small cherry-red lesion seen on colonoscopy? Angiodysplasia.

Angiodysplasia bleeding risks are higher in patients with which condition or conditions? End-stage renal disease, aortic stenosis, and von Willebrand disease.

Why can insulin be used to treat elevated triglyceride levels associated with pancreatitis? Well, insulin can be used because it activates lipoprotein lipase, which increases the movement of triglycerides out of the plasma, thus preventing further pancreatic damage. So if patients have a severe form of this condition, such as fever, tachycardia, leukocytosis, lactic acidosis, or hypercalcemia, you can do apheresis. It's also important that you provide supportive measures such as IV fluids, pain control, and antiemetics. You can also give fibrates such as fenofibrates or gemfibrozil to prevent recurrence.

What is the most commonly used calculation to predict 90-day mortality in patients with liver disease? Model for End-Stage Liver Disease or MELD.

What values are used to calculate the MELD score? Serum bilirubin, INR, serum creatinine, sodium. So the MELD score has largely replaced the Child-Pugh score, which predicted one to two-year mortality. But it's very important that you take a closer look at these different criteria because you can see a clinical scenario where a patient has liver disease and they ask you which value would indicate the the mortality for this patient or predict outcome for this patient with liver disease, and they can list different lab findings. It's very important that you know that you're looking out for the serum bilirubin, INR, serum creatinine, and sodium.

What is the most likely complication in a patient who is hospitalized due to a variceal bleed? Spontaneous bacterial peritonitis. So to manage these patients, you can give prophylaxis, which is IV ceftriaxone for seven days, then transition to TMP-SMX or an oral fluoroquinolone if the patient is ready for discharge prior to the completion of the intravenous antibiotic course. So like I said, we need to give seven days of IV ceftriaxone. However, let's say that they are ready for discharge on the fourth day of IV ceftriaxone. So in that case, you can switch to oral fluoroquinolone so that they can complete their antibiotic course.

What is the most common cause of ascites in the United States? Hepatic cirrhosis.

How do you calculate the SAAG gradient? Serum albumin minus the ascitic fluid albumin. So it's important that you know for the gradient, we are subtracting and we are not dividing. Serum albumin minus the ascitic fluid albumin.

SAAG greater than 1.1 indicates what condition? Portal hypertension.

What conditions are associated with SAAG greater than 1.1? Congestive heart failure, cirrhosis, alcoholic hepatitis.

What conditions are associated with SAAG less than 1.1? Peritoneal carcinomatosis, peritoneal tuberculosis, nephrotic syndrome, pancreatitis, serositis. So it's very important that you can like name or think of these conditions when you see or you have to calculate an SAAG. So if it's less than 1.1, think of these conditions listed on the screen. However, if it's greater than 1.1, you want to think of CHF, cirrhosis, and alcoholic hepatitis.

What tests can be done after four weeks of treatment to confirm H. pylori eradication? Urea breath or fecal antigen testing. It's important to note that H. pylori serology tests evaluate the presence of antibodies, which can be present after the eradication of H. pylori. So to evaluate or confirm H. pylori eradication, we would want to avoid H. pylori serology tests and instead do urea breath or fecal antigen testing.

What drugs are most commonly used in triple therapy for H. pylori? Omeprazole, clarithromycin, and amoxicillin.

True or false: Breastfed infants have decreased stool frequency after the first month of life. True.

What electrolyte imbalances facilitate hepatic encephalopathy precipitation? Hypovolemia, hypokalemia, and metabolic alkalosis. So hypovolemia is one of the most common precipitants of hepatic encephalopathy. And for hypokalemia, what this does is facilitate the conversion of ammonium to ammonia. And what the metabolic alkalosis does is decrease the urinary loss of ammonia. So basically, the hypokalemia and the metabolic alkalosis, they really increase the ammonia levels. So it's important to remember this fact that elevated ammonia can lead to hepatic encephalopathy.

How often is colonoscopy recommended for patients with FAP who have not undergone prophylactic colectomy? Annual colonoscopy.

Patients with greater than 20 milliliters polyps that are removed piecemeal should undergo a second look colonoscopy within how many months? Six months.

Five to ten adenomatous polyps less than 10 millimeters, tubular adenomas greater than 10 millimeters, villous or tubulovillous histology, high-grade dysplasia require repeat colonoscopy in how many years? So basically, this question is asking if you see any of these conditions, how often do you have to repeat colonoscopy? Three years.

If there are greater than 10 adenomas, how often will colonoscopy need to be repeated?

What are the stimulant drugs used to treat ADHD? Methylphenidates, amphetamines. So how I remember it is that if the drugs have "ph" in it, then they are stimulants. But if they don't have "ph" in it, like clonidine, then they are non-stimulants.

What is the treatment of choice of leptospirosis? Doxycycline. Recall that this medication is also used to treat Lyme disease. If the patient is greater than 8 years old, if they are less than 8 years old, then we use amoxicillin. Doxycycline can also be used to treat Rocky Mountain spotted fever.

What are the drugs of choice for endometriosis? So this can be remembered with the mnemonic ECG. Endometriosis is treated with clindamycin and gentamicin. ECG: Clindamycin and Gentamicin.

For which antitussive is a codeine analog and may cause serotonin syndrome? Dextromethorphan.

What drugs can cause digitalis toxicity if they are used together? Amiodarone, verapamil, quinidine. So acute toxicity with digitalis can present with GI symptoms such as anorexia, nausea, vomiting, abdominal pain. While chronic symptoms present with neurological symptoms such as blindness, weakness, and scotomas.

What diuretic can worsen or cause gout? Loop diuretics.

What drug is a mucolytic and an antidote for acetaminophen overdose? N-acetylcysteine.

What condition can present after six days of phenylephrine use? Rebound congestion. Recall that phenylephrine and pseudoephedrine are alpha agonists that are used as nasal decongestants. However, when you use these medications, it can result in hypertension and CNS stimulation and anxiety.

What drugs can cause agranulocytosis? Well, you can remember this as AC. So anti-thyroid medications, clozapine, carbamazepine, chloramphenicol. So you can remember with this image right here of the three air conditioners. I also recall that chloramphenicol can cause gray baby syndrome.

Which drugs can cause photosensitivity? Sulfonamides, amiodarone, and tetracycline. You can remember this by saying "I sat for a photo."

What is first-line treatment for bulimia? Fluoxetine, which is an SSRI.

What are three herbal supplements that can increase the risk of bleeding? Garlic, ginseng, and ginkgo biloba. Probably pronounced those incorrectly, but let's look at the spelling here on the screen.

Which anti-diabetic should be held before doing a CT with contrast? Metformin. Recall that metformin is a biguanide, and one of its very famous adverse side effects is that it can lead to lactic acidosis. So because of this risk of lactic acidosis in patients with metformin, the contrast can further potentiate this lactic acidosis, making it very dangerous for patients. So what is recommended is that metformin is withheld from the patient before doing an imaging test that requires contrast.

Which drug can be used in the management of chronic myeloid leukemia? Imatinib.

What is an antidote for this substance? Fresh frozen plasma, vitamin K.

What is the drug of choice for leishmaniasis? Sodium stibogluconate or amphotericin B. Recall that this condition is transmitted by sand flies.

What drugs can cause pulmonary fibrosis? Bleomycin, amiodarone, methotrexate. I'm sure that you can list other drugs that cause pulmonary fibrosis. Please list them in the comment section below.

What is the treatment of choice of pertussis? A macrolide. So this is also used for prophylaxis for close contacts as well.

What drugs can cause drug-induced parkinsonism? Dopamine receptor antagonists, and of course, metoclopramide has some dopamine blocking effects as well. And it's important to note that these drugs can also lead to neuroleptic malignant syndrome.

What is first-line treatment for trigeminal neuralgia? Carbamazepine. It inhibits neuronal high-frequency firing by reducing the ability of sodium channels to recover from inactivation. So it's very important that I mentioned the mechanism of action here because this question is so common on exams and on the USMLE. So instead of listing carbamazepine, they've started to list the mechanism of action of the drug instead. So just take a closer look at this and commit this to memory.

What antihypertensive agents are safe to be used during pregnancy? Hydralazine, labetalol, alpha-methyldopa. And a lot of people remember this by saying "Hypertensive Moms Love Nifedipine." Hypertensive for hydralazine, Moms for methyldopa, Love for labetalol, and N for nifedipine. Hypertensive Moms Love Nifedipine. Very high yield to know this.

What are signs of phenytoin toxicity? Nystagmus and gait unsteadiness.

What anti-anginal agent is used to treat chronic exertional angina refractory to conventional medical therapy? Ranolazine.

How do you manage someone with HIT or heparin-induced thrombocytopenia? Stop heparin, then administer a direct thrombin inhibitor.

What is the treatment of choice of pyelonephritis? Ceftriaxone.

Which anti-diabetic drugs increase the risk of UTIs? The antidiabetic drugs with "flozin" in it. So that's dapagliflozin and empagliflozin.

What is the first-line treatment for malignant hyperthermia? Dantrolene. This blocks receptors and prevents the release of calcium into the cytoplasm of skeletal muscle fibers.

What possible side effect can result from using statins and fibrates, for example, atorvastatin and gemfibrozil? Well, this increases the risk of myopathy in patients being treated for hyperlipidemia.

What is the drug of choice for mastitis? Naproxen or dicloxacillin. So mastitis is most commonly caused by Staphylococcus aureus. In patients with mastitis, present with fever and unilateral breast tenderness.

What is the equipment of choice for carcinoid syndrome? Octreotide.

What is the treatment of choice for close contacts of meningitis patients? Rifampin or ceftriaxone or ciprofloxacin. So let's say that a patient has meningitis and they were in close contact with a patient that is pregnant. Which of these medications would be appropriate to give that pregnant patient? Leave it in the comment section below.

Which drugs cause weight loss? GLP-1 agonists, such as exenatide, and DPP-4 inhibitors, such as the gliptins.

What is the treatment of choice for a UTI in a pregnant patient? Nitrofurantoin or fosfomycin. It's very high yield that you remember that you should not give drugs such as ciprofloxacin because they have teratogenic effects. So no fluoroquinolones for pregnant patients.

How do you treat a patient that presents with clinical features of this condition? Basically, you want to take care of your ABCs. Um, so you want to secure the airway, provide IV fluids. And the first-line treatment is with atropine. However, if the patient is refractory to atropine or isn't seeing the clinical improvements, then you can go ahead and give glucagon. So for patients with this condition, they present with bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock. So typically, IV glucagon is second-line if there is profound or refractory hypotension.

What is the treatment of choice of otitis externa? Fluoroquinolones.

What vaccine should patients who take eculizumab receive? These patients should be vaccinated against Neisseria. And basically, you need to remember that eculizumab is a monoclonal antibody against C5. So patients who take this medication or patients with terminal complement deficiency should receive their vaccine against meningitis, specifically for Neisseria, because the complement is needed to basically fight or combat this organism.

What is the mechanism of action of vincristine? It inhibits polymerization of microtubules. Another high-yield thing that examiners like to test is the adverse side effects of vincristine, and that is it can cause peripheral neuropathy.

What is the treatment of choice of otitis media? Amoxicillin and clavulanic acid or cefuroxime. So recall that for otitis externa, it is treated with fluoroquinolones, while for otitis media, it is treated with amoxicillin and clavulanic acid or cefuroxime. This is very high yield, particularly for patients who are not patients, for applicants who are doing the USMLE Step 3, especially for Day 1, you can be heavily tested on antibiotics. If you want to see a higher review on antibiotics, let me know in the comment section below.

What class of drugs cause cartilage damage? Fluoroquinolones, such as ciprofloxacin and levofloxacin.

Administration of sodium nitroprusside can cause the accumulation of what element? Cyanide. So it's very important to look out for, you know, excessive accumulation of cyanide presenting in patients because, for example, if a patient comes in and they have hypertensive emergency and you administer nitroprusside, you need to be aware of this adverse side effect. Another common cause of cyanide poisoning is a house fire, and these patients usually present with lactic acidosis, altered mental state, and cherry-red macula.

What vitamin can be used in the treatment of methemoglobinemia? High-dose ascorbic acid. So basically, to manage this condition, you need to discontinue any medication or drug that could be causing it. And also, you need to give methylene blue. However, it's high yield that you remember that methylene blue is contraindicated in cases such as G6PD deficiency. Basically, methylene blue acts to reduce methemoglobin to hemoglobin, and vitamin C is also a reducing agent.

What is the first-line treatment for toxoplasmosis? So to treat this condition, you would need to use these drugs listed here.

What is a potential side effect or complication of using fibrate derivatives and bile acid binding resins? They increase the risk of cholesterol gallstones.

What is the best next step in a patient who is in anaphylactic shock and that is unresponsive to their first dose of epinephrine? Give another dose of epinephrine.

What are early signs of toxicity with this drug? GI symptoms such as nausea and vomiting, lethargy, respiratory depression, and QT prolongation.

What is the treatment of choice of histoplasmosis, blastomycosis, sporotrichosis, and coccidioidomycosis? Itraconazole.

Which antiretroviral causes vivid dreams? Efavirenz.

What is the treatment of choice of Entamoeba histolytica? Metronidazole. So recall that patients with Entamoeba histolytica can present with bloody diarrhea and liver abscesses.

Is doxylamine more sedating than desloratadine? Yes. So recall that the second-generation antihistamines are less sedating. So remember these, um, or this concept with the "S"s. So basically, doxylamine is a first-generation H1 blocker, while desloratadine is a second-generation H1 blocker. So second-generation H1 blockers are less sedating. So how examiners test this concept is, for example, you have an elderly patient and they need to be treated with an antihistamine, and they will list drugs and they are all antihistamines, and you have to determine which one is less sedating because typically for elderly patients, you want to give them those less sedating drugs.

What is the drug of choice for nightmares and PTSD? Prazosin. Prazosin is an alpha blocker that was initially used to treat hypertension, but now it's more commonly used to manage symptoms of BPH and nightmares associated with PTSD. And if you like this type of content, please be sure to pop that like button, hit subscribe, and the notification bell so that you never miss another video like this. Now let's begin an overview of the female reproductive system.

Which of the following is the next best step in management in a patient who has a breast biopsy that reveals LCIS? Excisional biopsy.

What is first-line therapy for premenstrual syndrome and premenstrual dysphoric disorder? SSRIs.

Patients with PMDD and PMS are at increased risk of developing which condition? Primary mood and anxiety disorders.

What is the most effective contraceptive method? Progestin subdermal implants. It has an efficacy rate that is greater than 99% and it is effective for three years.

What is the most likely diagnosis in a premenopausal woman with unilateral bloody nipple discharge and no associated lumps or lymphadenopathy? Intraductal papilloma.

What breast imaging is best in a 31-year-old woman with a breast lump? Mammogram plus an ultrasound. So if a patient is less than 30 years old, typically you'll only need to do an ultrasound. But if they're older than 30, you definitely have to do a mammogram.

When is nipple discharge considered pathologic, or what are some features of pathologic nipple discharge? It is spontaneous, unilateral, and persistent.

What is the most likely diagnosis in a 32-year-old female with material hot flashes, high FSH, low estrogen, and a negative pregnancy test? Primary ovarian insufficiency. So the diagnosis of primary ovarian insufficiency is confirmed through the lab results of a high FSH and low estrogen. Patients with this condition should undergo testing for adrenal antibodies, TSH, karyotype analysis as well. To manage these patients, you typically can give them estrogen therapy, and you'd also need to add progestins if they have an intact uterus.

If a Pap smear reveals HSIL, what is the next step in management? Colposcopy.

What is the most common cause of irregular menstrual bleeding in adolescence? Anovulation. So typically at monarchy, adolescents can experience anovulation or just irregular periods for one to two years. The treatment for these patients includes reassurance and observation.

What is the most common side effect of combined OCPs? Breakthrough bleeding.

What is the first-line management for vulvodynia? Pelvic floor physiotherapy and cognitive behavioral therapy. So vulvodynia is a chronic condition that lasts more than three months, or that occurs in the absence of a specific disorder.

Which condition presents with amenorrhea, hypoestrogenism, and a low BMI? Functional hypothalamic amenorrhea. So the clinical presentation for this condition includes amenorrhea, exercise, relative caloric deficiency, stress fractures, amenorrhea, and infertility. So the hormone levels that you suspect to see in the patient with this condition include low GnRH, low FSH and LH, and low estrogen. So long-term consequences of this condition include low bone mineral density, high triglycerides, and high total cholesterol. Recall that estrogen is typically protective against having high cholesterol. So in patients that are post-menopausal or hypoestrogenic states, they are at risk of having high total cholesterol. The treatment for these patients include increased caloric intake, estrogen, calcium, and vitamin D.

What risk factor is associated with the highest increase in the risk of pelvic inflammatory disease? Multiple sexual partners.

What is the next best step in management in a patient with urge incontinence that does not improve with lifestyle modifications? Anti-muscarinic medications. So anti-muscarinic medications improve bladder capacity and they also inhibit the detrusor muscle contraction during bladder filling by blocking ACh release in the bladder. Examples of anti-muscarinic medications used to treat urge incontinence include oxybutynin and tolterodine.

So this next question is in a true or false format. True or false: Left-sided ovarian torsion is more common. False. Right-sided ovarian torsion is actually more common. So the reason for this is because the rectosigmoid colon occupies the space around the left ovary, so that kind of limits the room for it to experience torsion on the left side. However, on the right side, where it is more common, this is due to a greater length of the right utero-ovarian ligament.

Which drugs reduce the efficacy of OCPs? Cytochrome P450 inhibitors or cytochrome P450 inducers? Inducers. So cytochrome P450 inducers reduce the efficacy of OCPs. For example, anti-seizure medications such as valproates.

What is the mechanism of action of ovulation induction agents letrozole and clomiphene? Letrozole inhibits aromatase. It also inhibits the conversion of androgens to estrogens. While clomiphene depletes hypothalamic estrogen receptors.

What are contraindications for progestin-releasing IUDs? Breast cancer, active pelvic infections, and severe uterine cavity distortion. So knowing the contraindications of different contraceptive methods are extremely high yield for exam day. So let's do another one.

What are contraindications for copper IUDs? Wilson's disease, active pelvic infections, severe uterine cavity distortion.

What post-exposure prophylaxis is given for SA? Doxycycline, ceftriaxone, metronidazole, tenofovir. Well, tenofovir and Hep B vaccine if unvaccinated.

What is the first step in infertility evaluation? Semen analysis. So infertility is a couple's inability to conceive after more than 12 months of appropriately timed unprotected intercourse. Other diagnostic tests to evaluate poor infertility include assessing ovulatory function. So you can assess for ovulatory function by doing a mid-luteal phase or day 21 progesterone level. You can also assess their ovarian reserves. You can do this by doing a day 3 FSH and estradiol levels. You can also do a clomiphene citrate challenge, antral follicle count, and anti-mullerian hormone. You can also assess the fallopian tube patency by doing a hysterosalpingogram, and you can also do a uterine cavity evaluation through a sonohysterogram.

What is the screening recommendation for an 18-year-old sexually active woman? Annual screening for gonorrhea and chlamydia.

What substance causes abdominal pain in primary dysmenorrhea? Excess prostaglandins.

What is the most likely diagnosis in a post-menopausal woman with new onset pelvic pressure, uterine mass, and ascites? Uterine sarcoma. So risk factors of a uterine sarcoma include tamoxifen use and pelvic radiation, and the treatment of this condition is with hysterectomy.

What are risk factors for gestational trophoblastic neoplasia? Hydatidiform mole and maternal age greater than 40.

What is the treatment of choice of vulvar lichen sclerosus? Super potent steroid ointments. So this is a benign chronic condition that causes thinning of the vulvar skin. In hypoestrogenic populations, such as for example, prepubertal girls and postmenopausal women, can experience this condition because they are in a hypoestrogenic state.

What type of headache is an absolute contraindication for combined OCPs? Migraines with aura. So other absolute contraindications include active breast cancer, active or severe liver disease, thromboembolism, thrombophilia (for example, antiphospholipid antibody syndrome), severe hypertension, ischemic heart disease, stroke, a patient that is older than 35 and smoking more than 15 cigarettes per day, or if the patient is less than three weeks postpartum.

What is the first-line contraceptive method for adolescents? Long-acting reversible contraception. Of course, you have to also recommend barrier methods as well.

What is the most likely diagnosis in an adolescent female with a single unilateral rubbery breast mass associated with cyclic changes with menses? A fibroadenoma. So this is most common in the upper outer quadrant and it is seen or can be associated with premenstrual tenderness, cyclic changes in size, and is managed with observation and repeat examination.

What is the treatment of choice of acute uterine bleeding in a hemodynamically stable patient? OCPs with high-dose estrogen. So recall that estrogen promotes hemostasis through further proliferation of the endometrium and repairing the bleeding sites. You can use IV conjugated estrogens if the patient cannot tolerate oral medications or if they continue to bleed despite oral therapy.

At what age is cervical cancer screening started in an immunocompetent, sexually active woman? 21. So you typically stop cervical cancer screening once they're older than 65 years old and their previous tests have been negative. And it usually starts screening at age 21. So from age 21 to age 29, you can do cytology every three years. And age 30 to 39, you can do cytology every three years as well, or cytology plus HPV testing every five years. If the patient is HIV positive, then you'd want to do an annual Pap smear every year until there are more than three normal results, and then you can transition into doing a normal routine testing.

What is the most likely diagnosis in a patient two weeks post-hysterectomy with painless, continuous, clear vaginal discharge? A vesicovaginal fistula. So risk factors for this fistula include pelvic surgery, pelvic irritation, prolonged labor or childbirth trauma, and gynecologic malignancy. So on a physical exam, you could see an area that is red and it looks like granulation tissue. So red granulation tissue.

What is the first-line management for patients with symptomatic leiomyomas who wish to preserve fertility? Combined OCPs and progestin-releasing IUDs.

What is the most likely diagnosis in a patient who received hCG treatment one week ago and presents now with nausea, vomiting, abdominal pain, ascites, and bilaterally enlarged ovaries? Ovarian hyperstimulation syndrome. So these patients may present with multi-organ failure, specifically renal failure, electrolyte imbalances, hypercoagulability, and hemoconcentration. So the workup you need to do include a CBC, serum electrolytes, coagulation studies, beta-hCG, pelvic ultrasound, chest x-ray, and echo. And in order to manage these patients, we want to correct any electrolyte imbalances, paracentesis or therapeutic, and thrombosis prophylaxis as well. Another thing I want to highlight here is that patients typically receive hCG treatments when they're undergoing treatment for infertility.

Is a vaginal pessary used to treat stress incontinence or pelvic organ prolapse? Pelvic organ prolapse. Other treatment options for pelvic organ prolapse include weight loss, pelvic floor exercises, and surgical repair.

What are risk factors for vulvar cancer? Tobacco use, vulvar lichen sclerosus, immunodeficiency, paracervical cancer, and VIN and/or CIN. If you enjoyed this type of content, please be sure to pop that like button, hit subscribe, and the notification bell so that you never ever miss another video like this.

At what age is puberty considered to be delayed if no secondary sexual characteristics are present? In boys, age 14. In boys, and in girls, it would be age 12. Another high-yield concept to note is that constitutional delay is associated with a delayed bone age on X-ray of the wrist.

At what age should patients with cryptorchidism be referred for surgery? By age 6 months. So early orchiopexy before age one optimizes fertility potential and testicular growth. And some complications of cryptorchidism includes hernias, specifically inguinal hernias, testicular torsion, subfertility, and testicular cancers.

What is the initial test of choice for evaluating a testicular mass? A bilateral scrotal ultrasound. And if ultrasound reveals a solid lesion, further workup with serum tumor markers such as alpha-fetoprotein and beta-hCG are required, as well as screening with CT scans. Patients with a solid testicular mass have to undergo a radical inguinal orchioectomy to establish a tissue diagnosis. And if the mass is found to be cancerous, then what the treatment would be is a radical orchioectomy plus chemotherapy. Knowing testicular diseases is extremely high yield for the USMLE Step 2 and the USMLE Step 3. And one such condition is infectious epididymitis or orchitis, and this can be treated with a dose of intramuscular ceftriaxone and 10 days of doxycycline. To diagnose this condition, it can be confirmed with urinalysis and urine testing for Neisseria gonorrhea and chlamydia.

What is the management for patients with balanitis? Foreskin hygiene, sitz baths, topical treatments such as antifungals or antibiotics. A diabetes screen for a candidal infection without risk factors, for example, diaper dermatitis and recent antibiotic use. So let's just take a step back for a moment. Balanitis is an inflammation of the glans penis, and patients typically present with pain, tenderness, or pruritus associated with erythema and lesions on the glans as well. So if you see a clinical vignette and a patient has these symptoms, then you should suspect that they have balanitis, and you can manage them with what you see on the slide here. So one of the most common fungal pathogens that can cause this condition is Candida, and this should be especially suspected when there is thick white discharge present around the glans penis, and diagnosis can be confirmed by the presence of budding yeast on microscopy. And just to clarify the last point on this slide, so if a patient presents and you think it's a candidal infection because they have the white thick discharge, however, they have no reason to antibiotic use, they have no history of diaper dermatitis, and then what you can do is also screen for diabetes as well. Okay, let's move on to the next question.

What is the best way to assess for testicular injury in a patient with severe scrotal pain and swelling after scrotal trauma? A scrotal ultrasound.

What reflex is classically absent in testicular torsion? The cremasteric reflex. So recall that a positive cremasteric reflex is when the testicle reflexively elevates on stroking of the upper inner thigh.

In which age group is prostate cancer screening not recommended? Age less than 55 or older than 70 or with a life expectancy that is less than 10 years. So in those situations, prostate cancer screening is not recommended. Typically, you can screen for prostate cancer with the PSA, and that can be considered in patients ages 55 to 69.

What are the benefits of neonatal circumcision? Decreased UTI in the first year of life and decreased risk of penile phimosis, reduced risk of acquiring some STIs and HIV.

What is the most frequent complication of TURP? Retrograde ejaculation.

How do you manage priapism lasting greater than four hours? Corporeal aspiration followed by irrigation with cold saline, and you can also give intracorporeal injections of an alpha agonist such as phenylephrine. Another high-yield concept is that you can diagnose ischemic priapism by confirming it with a blood gas analysis of a corporeal aspirate.

The risk of which condition remains increased after orchiopexy? Malignancy. So it's important to note that relative to patients or the population without a history of cryptorchidism, patients with cryptorchidism do have an increased risk of malignancy.

How does chronic prostatitis present? Well, the patient will more likely be experiencing dysuria for more than three months, pain in the genitourinary region, and pain during ejaculation. So if you suspect a patient has chronic prostatitis, you can do a urinalysis and culture before and after a prostate massage, and the test usually shows pyuria greater than 20 with no organisms.

How do you treat chronic prostatitis or chronic pelvic pain syndrome? Alpha blockers, antibiotics, and anti-inflammatory medication. So let's take a closer look at an email.

What is the likely diagnosis in an African-American patient that presents with dark urine that stains positive with this stain after being treated for urinary tract infection? G6PD deficiency. So this condition is common in African-American patients and it is associated with medications such as antibiotics like trimethoprim. So you can see that they have a positive stain, and this indicates the presence of hemosiderin in the urine due to hemolysis. The hemolytic episodes seen in patients with G6PD deficiency are often precipitated by infection or medications.

Now let's take a closer look at another question. What is the likely diagnosis in an African-American male that develops dark urine, fatigue, and jaundice after being treated with trimethoprim, also peripheral smear reveals bite cells and a G6PD activity assay that is normal? So this is another question that brings out some high-yield facts about G6PD deficiency. So as previously mentioned, it is commonly seen after patients develop an infection or some sort of stress or taking new medications. However, you should not be thrown off if you see that the G6PD activity assay is normal, because in patients that are having a current hemolytic reaction or presentation due to G6PD deficiency, the assay can be normal. It doesn't have to be a low G6PD activity that's seen. But if you look at the overall clinical vignette of the dark urine, the fatigue, and the jaundice after being treated with a specific antibiotic, you have to suspect G6PD deficiency.

What is the likely underlying cause of microcytic anemia in a patient with chronic kidney disease that recently began after starting EPO therapy? Well, this would be iron deficiency anemia. So this is extremely high yield. If a patient has chronic

Kidney disease and they develop pneumonia, and they are now taking an EPO agent. They can develop iron deficiency, iron deficiency anemia. This is because when they're given the EPO, this can lead to a depletion of iron stores during hematopoiesis after the administration of EPO.

Another important fact that you must remember is that if a patient is taking an EPO agent due to a chronic kidney disease-induced anemia, they can develop worsening or new hypertension because of this agent. The hypertension typically presents two to eight weeks after starting the EPO agent. So, the risk of hypertension in these patients is increased by large doses and a rapidly rising hemoglobin. Once you treat this hypertension, you need to make sure that the EPO doses afterwards are decreased with a goal of slowly increasing the hemoglobin. So, you don't want to just go back to the dose that they were on where the hypertension was seen.

Another high-yield fact is that the treatment of choice for iron deficiency in patients on dialysis is IV iron.

What is the most appropriate screening test in a preconception patient with a family history of thalassemia? A complete blood count. So, if there is an anemia with a reduced MCV, then further testing is required, such as an HB electrophoresis test. So, let's say that a patient presents with mixed clinical features of iron deficiency anemia and thalassemia. One way of distinguishing between these conditions is by calculating the Mentzer index. So, if it's less than 13, this is minor thalassemia. If it's greater than 13, it's iron deficiency anemia. And you can calculate this index by, well, dividing the MCV by the red blood cell count. So, how I remember it is by using the eyes. So, the index increases greater than 13 in iron deficiency anemia.

Some high-yield causes of iron deficiency anemia in young children include excessive intake of cow's milk, namely more than 24 ounces per day, delayed introduction of solids, cereal-rich diet, prematurity, and lead exposure. To treat these patients, you want to give them iron supplementation. And of course, I know that there are many other causes for iron deficiency anemia in young children that you could name and feel free to leave that in the comment section below.

After iron supplementation is begun for iron deficiency anemia, the first marker of improvement is an increase in reticulocyte count. So, if a patient has iron deficiency anemia, you may also see thrombocytosis. So, this can be seen in response to a low red blood cell count. This is because megakaryocytes and erythrocytes share a common progenitor cell.

Another high-yield fact is that pernicious anemia is the most common cause of vitamin B12 deficiency. What is the likely underlying cause of anemia in a patient with a history of a gastrectomy that presents with a shiny tongue, pale palmar creases, and laboratory evidence of hemolysis? Vitamin B12 deficiency. So, there can be a deficiency due to the loss of intrinsic factor.

What hematologic pathology is characterized by normocytic anemia with a low reticulocyte count in preterm infants? Anemia of prematurity. So, you need to suspect anemia of prematurity in premature infants with a low red blood cell count, or low reticulocyte count rather, and low hemoglobin. Anemia can be seen in premature newborns due to impaired ability to produce adequate EPO, a shorter red blood cell lifespan, and frequent phlebotomy in the NICU.

We already talked about the Mentzer index. Another way that you can identify or confirm the diagnosis of beta-thalassemia minor is that if you see an isolated increase in HbA2 greater than 3.5%.

What is the recommended anticoagulation for a pulmonary embolism in a patient with severe renal insufficiency? Unfractionated Heparin followed by Warfarin. Recall that low molecular weight Heparin and Factor 10A inhibitors are not recommended in renal insufficiency because they are metabolized by the kidneys. So, you'd want to avoid these two drugs in patients who have severe renal insufficiency. But you would give unfractionated Heparin followed by Warfarin because Warfarin is the preferred long-term oral anticoagulant in renal disease patients, but it needs to be bridged first with unfractionated Heparin.

So, if a patient presents with thrombocytopenia, namely platelets decreased by greater than 50%, timing in that there's a drop in platelet count five to ten days after exposure to Heparin, thrombosis or skin necrosis or other causes of thrombocytopenia are not present, you want to think about Type 2 HIT. So, how examiners like to test this is that they would give you the CBC of a patient, maybe it's like five days apart, maybe you see one on admission and then another CBC analysis like five days later, and you see this massive dip in platelets. You want to think about Type 2 HIT.

What class of anticoagulants are used to treat HIT? Direct thrombin inhibitors.

In tumor lysis syndrome, you'll see electrolyte abnormalities such as hyperphosphatemia, hyperkalemia, hyperuricemia. And in order to treat these patients, you need aggressive IV fluid hydration, uric acid reduction with agents such as rasburicase, and treatment of any present electrolyte abnormalities. So, patients can develop spontaneous tumor lysis syndrome if they have hematologic conditions or malignancies with a high tumor burden or rapid replication rate. It presents with acute kidney injury due to tubular obstruction. That is extremely high yield. Tubular obstruction. So, uric acid and calcium phosphate stones can cause kidney injury as well.

Another high-yield fact that you want to know is that if you see a high red blood cell distribution width, think about iron deficiency anemia. If you see an elevated MCHC, think about hereditary spherocytosis.

Patients with polycythemia are most commonly asymptomatic. But if they do have symptoms, what you will see are like plethora, skin redness, distress, irritability, hyperbilirubinemia, and hypoglycemia. To treat these patients, you give IV fluids, glucose, and partial exchange transfusion. What is the recommended treatment for symptomatic neonates with polycythemia? Partial exchange transfusion. So, blood is removed and exchanged for normal saline to normalize the hematocrit. Asymptomatic infants may be managed with rehydration.

So, let's go through some miscellaneous but extremely high-yield facts. What is the recommended pharmacologic treatment for patients with cancer-related anorexia-cachexia syndrome? Progesterone analogs are preferred, or corticosteroids. Also, you can give synthetic cannabinoids for patients with HIV cachexia, but they are not very useful for patients with cancer-related anorexia-cachexia syndrome.

Another high-yield fact that you can see on your USMLE Step 1, Step 2 CK exam, or even on your pediatric shelf, is this syndrome. So, if you see a combination of a vascular tumor, such as a hemangioendothelioma, and consumptive thrombocytopenia, this is indicative of Kasabach-Merritt syndrome. So, it's very common in large or rapidly growing tumors that may trap platelets, causing severe thrombocytopenia.

Exertional hemoglobinuria, or march hemoglobinuria, is a form of intravascular hemolysis commonly seen in runners. The exact pathogenesis is unknown, but it's thought to be due to mechanical destruction of red blood cells in the feet during strenuous exercise.

If a patient does a PET scan with FDG, what can happen is that the neoplastic cells have a high metabolic rate and they take up this tracer on PET scan. And you can see that because the radiotracer is excreted through the kidneys, that the tracer basically builds up or enhances the urinary collecting system.

A topic that examiners love to test and you are guaranteed to see on your USMLE Step 1, Step 2 CK, and your Step 3 is sickle cell disease. So, let's go through some high-yield facts on this condition.

What is the likely diagnosis in a child with a history of sickle cell disease that presents with hypovolemic shock in the setting of left upper quadrant tenderness and an enlarged spleen? Splenic sequestration and hypovolemic shock occurs due to pooling of red blood cells within the spleen.

Hydroxyurea is a useful drug in the treatment of sickle cell anemia because it increases levels of HbF, or hemoglobin F, to greater than 15%. And recall that increased hemoglobin F dilutes the modes of hemoglobin S, thus decreasing pain crises, the need for transfusions, and episodes of acute chest syndrome.

What is the most common cause of a pediatric stroke? Sickle cell disease. What is the most common cause of sepsis in patients with sickle cell disease? Strep pneumoniae. So, in order to treat this, you need to use a broad-spectrum empiric antibiotic such as ceftriaxone, and this should be given to patients with sickle cell disease presenting with sepsis.

Another high-yield fact that examiners love to test is on dactylitis. So, this condition presents at age 6 months to 4 years with an acute onset of pain and symmetric swelling of the hands and feet.

Patients with sickle cell disease can also develop an impairment in the kidneys' ability to concentrate urine, causing patients to develop nocturia. This can be seen in patients with sickle cell anemia and sickle cell trait. So, what happens in this condition is that red blood cells sickle in the vasa recta, impairing free water reabsorption and concurrent exchange. Normal serum sodium is maintained due to an intact ADH.

In patients with sickle cell disease, chronic damage and auto-infarction typically causes functional asplenia. By age five, the risk of sepsis in patients with splenectomy is more than 30 years.

What is the most common complication of sickle cell trait? Painless hematuria, or microscopic hematuria, and this can be microscopic or gross. Again, this condition is seen due to the sickling of the red blood cells in the renal medulla.

Now, let's take a closer look at complications of chronic hemolytic anemia in sickle cell patients. These include baseline bilirubin increase, anemia, increased reticulocyte count, folate deficiency, and iron deficiency anemia.

So, if a patient with sickle cell disease presents in severe vaso-occlusive pain, then you want to give them opiates, and it has to be given IV. Which one of the following opioids is appropriate for a child with a vaso-occlusive crisis? Is it A) oxycodone, B) tramadol, or C) codeine? And the correct answer here is A) oxycodone. So, children less than 12 years old metabolize codeine and tramadol very quickly, causing extremely elevated levels of these drugs, which can lead to respiratory depression and even death.

What is the likely diagnosis in a five-day-old baby that did not receive perinatal care and presents with easy breathability with an elevated prothrombin time? Vitamin K deficient bleeding. So, this is previously known as hemorrhagic disease of the newborn, and this deficiency occurs due to a combination of poor placental transfer, absent gut flora, immature liver function, and inadequate levels of vitamin K in breast milk.

What is the likely diagnosis in an alcoholic patient that begins bleeding from an IV site on post-op day 7 after having emergency surgery? Lab results reveal an anemia with elevated PT and PTT and normal platelet counts. Vitamin K deficiency. Acutely ill patients with underlying liver disease can become vitamin K deficient in 7 to 10 days, especially if they receive broad-spectrum antibiotics. PTT can be normal or elevated.

What screening tests would be useful for evaluating an elderly patient with chronic arm pain and anemia and back pain? Serum or urine protein electrophoresis. This is the best initial test, or free light chain analysis.

A patient is diagnosed with multiple myeloma. What imaging should be performed? A full body x-ray or skeletal survey looking for lytic bone lesions or pathological fractures. So, you want to do a skeletal survey and not a bone scan. A bone scan is helpful in diagnosing osteoblastic activity, but in multiple myeloma, they have little bone activity. So, in that case, for multiple myeloma, do a skeletal survey.

What is the likely diagnosis in a patient with a past medical history of Hodgkin lymphoma after doing chemotherapy and radiation who presents with cough, dyspnea, and chest pain? A secondary malignancy. So, patients who have been treated for Hodgkin lymphoma have a considerably higher risk of developing a secondary cancer compared to the general population, and most common sites for the secondary malignancy include lung, breast, thyroid, bone, and the GI system.

What is the likely diagnosis in a child with a family history of anemia that presents with Coombs-negative hemolytic anemia, jaundice, and an enlarged spleen? Hereditary spherocytosis.

What is the likely diagnosis in a child that presents with scattered petechiae with isolated thrombocytopenia and enlarged platelets following a viral infection? Immune thrombocytopenia. So, if you see a clinical vignette where a child had a viral infection recently and now they have this isolated thrombocytopenia, think about ITP. So, this most commonly occurs in children ages two to five years old following a viral infection. With ITP, they can have skin manifestations only, and they may require observation regardless of platelet count because ITP is a self-limiting condition. You treat patients with ITP by giving them IVIG or corticosteroids.

What two viruses should be tested for in an asymptomatic patient with idiopathic thrombocytopenic purpura? HIV and hepatitis C. Recall that to treat ITP, platelet transfusions are reserved for life-threatening hemorrhage.

What is the likely diagnosis in a child that presents with short stature, hypoplastic thumbs, and an aplastic macrocytic anemia? Anemia.

What is the likely diagnosis in an adolescent with a history of Hemophilia A that presents with gradually worsening pain and limited motion of his knee? Hemophilic arthropathy. So, patients with recurrent bleeding can have a buildup of hemosiderin or iron deposition, leading to synovitis and fibrosis within the joints. However, the risk of developing this condition is significantly reduced with prophylactic factor concentrates.

Patients with hemophilia can develop what is called an inhibitor development. This condition should be suspected when a patient with hemophilia A is on factor replacement therapy and develops increased bleeding frequency or has hemorrhage refractory to treatment. So, to treat patients with an acute bleed in a patient with inhibitor development, this involves bypassing products such as recombinant activated Factor VII or activated prothrombin complex concentrates. These agents work downstream in the coagulation cascade to promote clotting without the need for Factor VIII.

Patients with TTP present with fever, anemia, renal failure, thrombocytopenia, and neurologic manifestations. TTP is a life-threatening condition and must be treated emergently with plasma exchange. Plasma exchange removes the patient's plasma and replaces it with donor plasma. This replenishes ADAMTS13 and removes the autoantibodies. Without emergent PEX, the mortality rate is approximately 90%.

A patient with acute iron poisoning will present with abdominal pain, hematemesis, diarrhea, shock, and liver necrosis. You can also note an iron gap, metabolic acidosis, elevated serum iron, radio-opaque pills on abdominal x-ray. You can treat these patients with deferoxamine and whole bowel irrigation. Deferoxamine is a chelation agent that binds free iron, forming a complex that can be renally excreted.

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