Deja Review USMLE Step 2 CK, 2nd Edition

50-y/o chronic alcoholic presents with worsening DOE, orthopnea, and paroxysmal nocturnal dyspnea; PE: laterally displaced apical impulse; echocardiogram: four-chamber dilation, mitral a

DEJA REVIEW TM USMLE Step 2 CK

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Chief ResidentDepartment of NeurosurgeryUniversity of Michigan Medical School

Ann Arbor, Michigan

Khashayar Mohebali, MD

Chief Resident, Clinical InstructorDivision of Plastic and Reconstructive Surgery

Department of SurgeryUniversity of California, San Francisco San Francisco, California

Peter F Aziz, MD

Fellow-Pediatric CardiologyDepartment of PediatricsChildren’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania

Susie Lim, MD

Clinical InstructorObstetrics and GynecologyKaiser Permanente NorthwestPortland, Oregon

Copyright © 2010, 2006 by John H Naheedy, Daniel A Orringer, Khashayar Mohebali, Peter F Aziz, and Susie Lim Allrights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may bereproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior writtenpermission of the publisher.

ISBN: 978-0-07-163941-5

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—Susie

Emily Y Fukuchi, MD

Resident

Department of Obstetrics and GynecologyUniversity of California, San FranciscoSan Francisco, California

Chapters: Internal Medicine, Surgery

Karen A Kinnaman, MD

University of Michigan Medical SchoolAnn Arbor, Michigan

Chapter: Obstetrics and Gynecology

Resident, Emergency MedicineHarbor UCLA Medical CenterUniversity of California Los AngelesSUNY Upstate Medical UniversityClass of 2008

Déjà Review™ USMLE Step 2 CK has been scrutinized and edited to produce a second edition that is even higher yield and

easier to use than the first Outstanding medical students, who have recently taken Step 2, revised the original text to ensurethe material covered herein is complete and current The authors, now with a combined 30 years of experience in themedical field, have also edited the manuscript to emphasize the clinical relevance of the core concepts covered in Step 2

We are confident that our efforts have produced one of the most useful guides for Step 2 review available today

Step 2 of the United States Medical Licensing Examination (USMLE) tests the senior medical student’s ability to apply thebasic principles of clinical medicine However, before you can apply those principles, you must be able to rapidly recall acore body of essential facts This is why the Déjà Review series is the most efficient, well-organized, portable, and aboveall, high-yield resource to prepare students for the USMLE As recent graduates who have taken Step 2, we are confidentthat we have compiled a novel review guide that promotes rapid recall of all of the essential facts necessary for success onthis examination We also realize that a solid foundation in these principles will allow you to make a smooth transition intoyour residency

ORGANIZATION

All concepts are presented in a question and answer format that covers the key facts on hundreds of common anduncommon diseases The material is divided into chapters covering the six major divisions of clinical medicine: internalmedicine, surgery, neuroscience, psychiatry, OB/GYN, and pediatrics We have also included a brief emergency medicinechapter that addresses topics not covered under emergent conditions in each of the other chapters

However you choose to study, we hope you find this resource helpful during your preparation for the USMLE Step 2 andthroughout your clinical rotations Best of luck!

John H Naheedy, MD Daniel A Orringer, MD Khashayar Mohebali, MD

Peter F Aziz, MD Susie Lim, MD

The authors would like to thank the following individuals for their invaluable contributions to this text and their efforts inmaking this a useful resource for students:

Percutaneous transluminal coronary angioplasty (PTCA)

What are the indications for coronary artery bypass grafting?

Angina refractory to medical therapy, severe left main disease, and triple vessel coronary disease (or double vesseldisease in a diabetic)

Thrombolytics including tissue plasminogen activator or streptokinase

What intervention is indicated in patients during an MI who fail or cannot tolerate thrombolytic therapy?

PTCA

What are the clinical manifestations of right ventricular MI?

ECG inf changes, hypotension, clear lungs, jugular venous distension (JVD), right ventricular lift, tricuspid valveregurgitation

65-y/o male with metastatic colon cancer and a new murmur consistent with mitral regurgitation

Nonbacterial thrombotic endocarditis

30-y/o female with SLE

50-y/o chronic alcoholic presents with worsening DOE, orthopnea, and paroxysmal nocturnal dyspnea; PE: laterally displaced apical impulse; echocardiogram: four-chamber dilation, mitral and tricuspid regurgitation

Alcoholic dilated cardiomyopathy

35-y/o male with FH of sudden cardiac death presents with DOE and syncope; PE: double apical impulse, S4 gallop, holosystolic murmur at apex and axilla; echo: left ventricular hypertrophy and mitral regurgitation

Hypertrophic cardiomyopathy

40-y/o black male with h/o HTN presents with chest pain, dyspnea, and severe headache; PE: BP = 210/130 in all four extremities, flame-shaped retinal hemorrhages, papilledema; labs: negative vanillylmandelic acid (VMA) and urine catecholamines, and cardiac enzymes

Malignant HTN

15-y/o female presents 1 month after a sore throat with fever and joint pain CBC shows leukocytosis Labs: ASO+

Rheumatic fever

35-y/o female with a h/o rheumatic fever presents with worsening DOE and orthopnea; PE: loud S1, opening snap, and low-pitched diastolic murmur at the apex; CXR: left atrial enlargement

Mitral stenosis

65-y/o male presents with 1-h h/o substernal pressure and pain with radiation into the jaw and left arm, nausea, and diaphoresis; PE: S4 gallop; labs: ↑ troponin and CK-MB; ECG: ST elevation in leads aVL, V1-V4

Empiric therapy: macrolide (Azithromycin), fluoroquinolone (Levofloxacin), or tetracycline (Doxycycline)

Organisms: S pneumoniae, M pneumoniae, C pneumoniae, H influenzae, and respiratory viruses

Community-acquired pneumonia in a healthy patient >60 y/o or with comorbidities (CHF, COPD, DM, alcoholic, renal or liver failure)

Empiric therapy: Second-generation cephalosporin (eg, cefuroxime) and amoxicillin; add erythromycin if

60-y/o with a 50 pack-year h/o smoking presents with fever and cough productive of thick sputum for the past 4 months; PE: cyanosis, crackles, wheezes; w/u: Hct= 48, WBC= 12,000; CXR: no infiltrates

60-y/o patient in days 4 status post (s/p) total knee replacement has the sudden onset of tachycardia, tachypnea, sharp chest pain, hypotension; arterial blood gas (ABG): respiratory alkalosis; ECG: sinus tachycardia; venous duplex US: clot in right femoral vein

Pulmonary embolus

40-y/o white male presents with chronic rhinosinusitis, ear pain, cough, dyspnea; PE: ulcerations of nasal mucosa, perforation of nasal septum; w/u: ↑ (c-ANCA), red cell casts in urine; biopsy of nasal lesions: necrotizing vasculitis and granulomas

65-y/o man who lives in nursing home presents with headache, lethargy, confusion, nausea, vomiting, diarrhea, and abdominal pain; PE: high fever and relative bradcardia; labs: hyponatremia, ↑ liver enzymes, ↓ phosphate, azotemia, ↑ creatinine kinase

A patient with recent h/o antibiotic use for sinus infection presents with fever, bloody diarrhea, and abdominal pain; PE: tender abdominal examination, guaiac positive stool; w/u: leukocytosis; colonoscopy: tan nodules seen attached to erythematous bowel wall with superficial erosions

19-y/o Jewish female with h/o chronic abdominal pain presents with recurrent UTIs and pneumaturia; PE: diffuse abdominal pain; CT: enterovesical fistula; colonoscopy: skip lesions of linear ulcers and transverse fissures giving cobble-stone appearance to mucosa

Crohn’s disease

28-y/o homosexual male presents with RUQ pain, fever, anorexia, N/V, dark urine, and clay-colored stool; PE: jaundice, tender hepatomegaly; w/u: ↑↑ AST/ALT, ↑ bilirubin/ALP, normal WBC

Acute viral hepatitis

54-y/o male with h/o HCV presents with increased abdominal girth, jaundice, and altered mental status; PE: asterixis, scleral icterus, hemorrhoids, bilateral lower extremity edema, ascites, and caput medusae; w/u: pancytopenia, ↑AST/ALT/ALP/bilirubin; US: nodular liver

Prostate cancer (lung cancer is the leading causes of cancer death in men, followed by prostate cancer) What digital rectal examination (DRE) finding suggests prostate cancer?

25-y/o-Asian male presents with N/V, and colicky right flank pain; PE: acute distress and costovertebral angle (CVA) tenderness; w/u: hematuria and discrete radiopacities on abdominal XR

Renal stones

45-y/o with documented h/o aortic atheromatous plaques presents with recent onset, severe left flank pain, and hematuria; abd CT: wedge-shaped lesion in the left kidney

Renal infarct

55-y/o with long h/o DM presents with increasing fatigue and edema; PE: ↑ BP, retinopathy, and pitting edema; w/u: severe proteinuria and glycosuria

Metabolic acidosis (ethylene glycol toxicity)

6-y/o boy presents with hematuria and worsening vision; PE: corneal abnormalities, retinopathy, sensorineural hearing loss; w/u: hematuria with dysmorphic red cells

Alport syndrome

3-y/o boy with h/o recent URI presents with facial edema; PE: ascitic fluid in abdomen and pedal edema; w/u:

Minimal change disease

70-y/o male recently started on an ACE inhibitor presents with weakness, N/V, and palpitations; PE: areflexia; ECG: tall, peaked ↓ waves and wide QRS complex

Polycystic kidney disease

12-y/o male with h/o sore throat 2 weeks ago presents with low urine output and dark urine; PE: periorbital edema; w/u: hematuria, ↑ BUN and Cr, ↑ ASO titer

85-y/o male presents with back pain, weight loss, and weak urinary stream; PE: palpable firm nodule on DRE; w/u: ↑ PSA (5 ng/mL)

Drug-induced erectile dysfunction (ED)

22-y/o male with h/o cryptorchism presents with painless enlargement of L testes; PE: L scrotal swelling and a palpable mass; w/u: ↑ AFP

Testicular cancer (endodermal sinus tumor)

16-y/o male with recent h/o gastroenteritis 2 days ago presents with episodic brown urine; PE: unremarkable; w/u: hematuria, mild proteinuria, normal C3

Abdominal pain, vomiting, Kussmaul respirations, fruity/ acetone breath odor, anion gap metabolic acidosis, and mental status changes usually precipitated by stress (infection, drugs, MI, or noncompliance with insulin therapy)

32-y/o female with h/o recurrent PUD presents with episodes of hypocalcemia and nephrolithiasis; w/u: fasting hypoglycemia, ↑ gastrin levels, and hypercalcemia

MEN 1

70-y/o presents with episodal HTN, nephrolithiasis, and diarrhea; PE: ↑ BP, thyroid nodule; w/u: ↑ calcitonin levels, ↑ urinary catecholamines

MEN 2

A female patient presents with bone pain, kidney stones, depression, and recurrent ulcers; w/u: hypercalcemia, hypophosphatemia, and hypercalciuria

Hyperparathyroidism

35-y/o female presents with weight gain, irregular menses, and HTN; PE: ↑ BP, weight in face and upper back,