USMLE Step 2 CK With Complete Solution
Argatroban
Direct thrombin inhibitor
Contraindicated in Renal Insuficiency
Indicated in Liver Disease
Fondaparinux
Factor Xa inhibitor
Contraindicated in Liver failure
Indicated in Kidney Failure
Conditions associated to ITP
Lymphoma, leukemia, HIV, HCV, EBV, SLE, alcohol use, chemotherapy
lead poisoning
Mild (5-44): no med, repeat levels & relocation
Moderate (45-69): DMSA
Severe (>70): Dimercaprol + EDTA if encephalopathy
Sideroblastic anemia
Basophilic stippling in peripheral smear
Ringed sideroblasts only in bone marrow
B12 deficiency
MMA and homocysteine
Folate deficiency
Normal MMA and increased homocysteine
Warm AIHA
SLE, CLL, drugs
Cold AIHA
Mycoplasma, mononucleosis, walderstrom macroglobulinemia
Polycythemia vera
Hydroxyurea IFN
Ruxolitinib (JAK inh.)
acute leukemia
>20% blast cells
Pleural fluid in TB
Increased protein level (>4g/dL)
Increased lymphocytic leukocytosis
Decreased glucose levels
Decreased ph
Increased LDH levels (>500)
Uncomplicated pleural effusion
Negative culture and gram stain (no bacteria)
ph > 7.2
Glucose >60
WBC < 50.000
Management: ATB only
Complicated Pleural Effusion or Empyema
,ph < 7.2
Glucose <60
WBC > 50.000
Negative gram stain and culture ( FN due to low concentration of bacteria)
Management: chest tube + ATB
Severe PCP
Prednisone if: PaO2 <70 mmHg or an A-a gradient > 35
hyperlipidemia screening
Men > 35 and older
Women > 45
All at Higher risk for CAD >20 years
Fasting samples
Repeat every 5 years
Dyslipidemia
Total cholesterol >200 mg/dl
LDL >130 mg/dl
HDL <40 mg/dl
triglicerides >150 mg/dl
Hypertension screening
Age >18 at every visit
Patients >60 years: >150/90 mmHg
Patients <60 years: >140/90 mmHg
Patients >18 years + CKD or diabetes: >140/90 mmHg
Hypertensive Emergency
>180/120 mmHg + end-organ damage
- Malignant HTN: severe HTN + retinal hemorrhages, papilledema or exudates
- Hypertensive encephalopathy: severe HTN + cerebral edema or non-localizing
neurologic signs and symptoms
Osteoporosis Screening
Women >65
Start at 60 if decreased body weight or increased risk for fractures
PPSV23 Alone for age 19-64
Chronic heart, lung or liver disease, diabetes, smoker, alcoholics
Sequential PCV13 + PPSV23 for age 19-64
CSF leaks, choclear implants, sickle cell disease, asplenia, CKD, Inmunocompromised
Sequential PCV13 + PPSV23 for age >65
1 dose of PCV13 followed by PPSV23 at a later time
Marfan Syndrome
AD, Upward lens dislocation, normal intellect
Homocystinuria
AR, downward lens dislocation, intellectual disability
Criteria for Parathyroidectomy
Symptomatic hypercalcemia
Ca >11.5 mg/dL
,Renal Insufficiency
Age <50
Nephrolithiasis
Osteoporosis
Pregnant
Drugs that cause SIADH
Carbamazepine, Cyclophosphamide, SSRIs, antipsychotics, NSAIDs
Herpagina
3-10 yrs
Seasonal (summer/fall)
Ulcers and vesicles in posterior oropharynx
Tx: supportive
Herpetic gingivostomatitis
6mo-5yrs
No seasonality
Clusters of small ulcers on anterior oropharynx
Tx: oral acyclovir
Initial HIV screening
Age 15-65
Treatment of TB
another STD present
Pregnant
Occupational exposure to blood/fluids
Annual Screening for HIV
IV drug user + sex partner
Men who have sex with men
Sex for money
Partner of a HIV positive person
>1 partner since last HIV test
Homeless
Correctional facility incarceration
S4 heart sound
Atrial gallop sound (before S1)
Heard immediately after atrial contraction phase as blood is forced into a stiff ventricle
Normal: healthy older adults
Abnormal: younger adults, children, ventricular hypertrophy, acute myocardial infarction
S3 heart sound
Ventricular gallop sound (before S2)
Heard during rapid filling of ventricles in diastole
Turbulent blood flow due to increased volume
Normal: children, young adults, pregnancy
Abnormal: age >40, heart failure, restrictive cardiomyopathy, high-output states
Pediatric Depression Management
SSRIs: Fluoxetine DOC
PSOAS SIGN (to assess for appendicitis/peritonitis):
, Abdominal pain with hip extension
Hip flexion decreases pain
Adult ADHD Management
Stimulants: amphetamines and methylphenidate. Potential for misuse or addiction
Nonstimulant for those with addiction potential: Atomoxetine (DOC), bupropion and
TCAs
chorionic villus sampling
10-12 week; analyze fetal chromosomes
amniocentesis
15-20 weeks
Group B strep Prevention
Management: Intrapartum IV penicillin
Universal screening occurs at 35-37 weeks gestation
No screening: all women (+) GBS urine or rectovaginal culture during pregnancy
regardless of treatment, or previous baby with GBS sepsis
Unknown status + risk factors: preterm gestation (<37w), Membranes ruptures >18h,
maternal fever
hyperemesis gravidarum
Persistent vomiting + acute starvation (ketonuria) and weight loss (decrease in at least
5% of prepregnancy weight)
Management of Gestational Diabetes
-ADA diet, regular exercise, strict glucose monitoring (4xper day)
-Tight maternal glucose levels (FB 60-90, 1hr postprandial <140)
-Add insulin if dietary control is insufficient
- Fetal US at 18-20 w
- NST at 32 w if: taking insulin, macrosomia, previous stillbirth, hypertension
-NST at 26 w if: small vessel disease
-If poorly controlled: intrapartum insulin + induce labor at 39 w
- C section if >4500 gr
Gestational Hypertension
>20 weeks
Without significant proteinuria (<300mg/dL)
Chronic Hypertension during Pregnancy
<20 weeks
May develop superimposed preeclampsia (worsening BP and proteinuria)
Preeclampsia without severe symptoms
BP >140/90 mmHg at >20 weeks gestation + proteinuria (>300mg/24h or >0.3 urine
protein/creatinine ratio) and/or signs of end-organ damage
Asymptomatic
Delivery: >37 weeks
Preeclampsia with severe symptoms
SBP >160 mmHg or DBP >110 mmHg (2 times >4 hours apart)
Symptoms:
Argatroban
Direct thrombin inhibitor
Contraindicated in Renal Insuficiency
Indicated in Liver Disease
Fondaparinux
Factor Xa inhibitor
Contraindicated in Liver failure
Indicated in Kidney Failure
Conditions associated to ITP
Lymphoma, leukemia, HIV, HCV, EBV, SLE, alcohol use, chemotherapy
lead poisoning
Mild (5-44): no med, repeat levels & relocation
Moderate (45-69): DMSA
Severe (>70): Dimercaprol + EDTA if encephalopathy
Sideroblastic anemia
Basophilic stippling in peripheral smear
Ringed sideroblasts only in bone marrow
B12 deficiency
MMA and homocysteine
Folate deficiency
Normal MMA and increased homocysteine
Warm AIHA
SLE, CLL, drugs
Cold AIHA
Mycoplasma, mononucleosis, walderstrom macroglobulinemia
Polycythemia vera
Hydroxyurea IFN
Ruxolitinib (JAK inh.)
acute leukemia
>20% blast cells
Pleural fluid in TB
Increased protein level (>4g/dL)
Increased lymphocytic leukocytosis
Decreased glucose levels
Decreased ph
Increased LDH levels (>500)
Uncomplicated pleural effusion
Negative culture and gram stain (no bacteria)
ph > 7.2
Glucose >60
WBC < 50.000
Management: ATB only
Complicated Pleural Effusion or Empyema
,ph < 7.2
Glucose <60
WBC > 50.000
Negative gram stain and culture ( FN due to low concentration of bacteria)
Management: chest tube + ATB
Severe PCP
Prednisone if: PaO2 <70 mmHg or an A-a gradient > 35
hyperlipidemia screening
Men > 35 and older
Women > 45
All at Higher risk for CAD >20 years
Fasting samples
Repeat every 5 years
Dyslipidemia
Total cholesterol >200 mg/dl
LDL >130 mg/dl
HDL <40 mg/dl
triglicerides >150 mg/dl
Hypertension screening
Age >18 at every visit
Patients >60 years: >150/90 mmHg
Patients <60 years: >140/90 mmHg
Patients >18 years + CKD or diabetes: >140/90 mmHg
Hypertensive Emergency
>180/120 mmHg + end-organ damage
- Malignant HTN: severe HTN + retinal hemorrhages, papilledema or exudates
- Hypertensive encephalopathy: severe HTN + cerebral edema or non-localizing
neurologic signs and symptoms
Osteoporosis Screening
Women >65
Start at 60 if decreased body weight or increased risk for fractures
PPSV23 Alone for age 19-64
Chronic heart, lung or liver disease, diabetes, smoker, alcoholics
Sequential PCV13 + PPSV23 for age 19-64
CSF leaks, choclear implants, sickle cell disease, asplenia, CKD, Inmunocompromised
Sequential PCV13 + PPSV23 for age >65
1 dose of PCV13 followed by PPSV23 at a later time
Marfan Syndrome
AD, Upward lens dislocation, normal intellect
Homocystinuria
AR, downward lens dislocation, intellectual disability
Criteria for Parathyroidectomy
Symptomatic hypercalcemia
Ca >11.5 mg/dL
,Renal Insufficiency
Age <50
Nephrolithiasis
Osteoporosis
Pregnant
Drugs that cause SIADH
Carbamazepine, Cyclophosphamide, SSRIs, antipsychotics, NSAIDs
Herpagina
3-10 yrs
Seasonal (summer/fall)
Ulcers and vesicles in posterior oropharynx
Tx: supportive
Herpetic gingivostomatitis
6mo-5yrs
No seasonality
Clusters of small ulcers on anterior oropharynx
Tx: oral acyclovir
Initial HIV screening
Age 15-65
Treatment of TB
another STD present
Pregnant
Occupational exposure to blood/fluids
Annual Screening for HIV
IV drug user + sex partner
Men who have sex with men
Sex for money
Partner of a HIV positive person
>1 partner since last HIV test
Homeless
Correctional facility incarceration
S4 heart sound
Atrial gallop sound (before S1)
Heard immediately after atrial contraction phase as blood is forced into a stiff ventricle
Normal: healthy older adults
Abnormal: younger adults, children, ventricular hypertrophy, acute myocardial infarction
S3 heart sound
Ventricular gallop sound (before S2)
Heard during rapid filling of ventricles in diastole
Turbulent blood flow due to increased volume
Normal: children, young adults, pregnancy
Abnormal: age >40, heart failure, restrictive cardiomyopathy, high-output states
Pediatric Depression Management
SSRIs: Fluoxetine DOC
PSOAS SIGN (to assess for appendicitis/peritonitis):
, Abdominal pain with hip extension
Hip flexion decreases pain
Adult ADHD Management
Stimulants: amphetamines and methylphenidate. Potential for misuse or addiction
Nonstimulant for those with addiction potential: Atomoxetine (DOC), bupropion and
TCAs
chorionic villus sampling
10-12 week; analyze fetal chromosomes
amniocentesis
15-20 weeks
Group B strep Prevention
Management: Intrapartum IV penicillin
Universal screening occurs at 35-37 weeks gestation
No screening: all women (+) GBS urine or rectovaginal culture during pregnancy
regardless of treatment, or previous baby with GBS sepsis
Unknown status + risk factors: preterm gestation (<37w), Membranes ruptures >18h,
maternal fever
hyperemesis gravidarum
Persistent vomiting + acute starvation (ketonuria) and weight loss (decrease in at least
5% of prepregnancy weight)
Management of Gestational Diabetes
-ADA diet, regular exercise, strict glucose monitoring (4xper day)
-Tight maternal glucose levels (FB 60-90, 1hr postprandial <140)
-Add insulin if dietary control is insufficient
- Fetal US at 18-20 w
- NST at 32 w if: taking insulin, macrosomia, previous stillbirth, hypertension
-NST at 26 w if: small vessel disease
-If poorly controlled: intrapartum insulin + induce labor at 39 w
- C section if >4500 gr
Gestational Hypertension
>20 weeks
Without significant proteinuria (<300mg/dL)
Chronic Hypertension during Pregnancy
<20 weeks
May develop superimposed preeclampsia (worsening BP and proteinuria)
Preeclampsia without severe symptoms
BP >140/90 mmHg at >20 weeks gestation + proteinuria (>300mg/24h or >0.3 urine
protein/creatinine ratio) and/or signs of end-organ damage
Asymptomatic
Delivery: >37 weeks
Preeclampsia with severe symptoms
SBP >160 mmHg or DBP >110 mmHg (2 times >4 hours apart)
Symptoms:
