Step 2 Ck Day 7/90

Front 1

A patient comes in with dysphagia…
• Best 1st test is a
• Next best test is

Back 1

Best 1st test is a barium swallow
Next best test is endoscopy (can be dx and
allow for bx of suspicious masses or tx in
dilation of peptic strictures or injecting botox
for achalasia).

Front 2

____________is the test of choice for achalasia.

Back 2

Manometry

Front 3

______________is the test of choice for
GERD.

Back 3

24 pH monitoring

Front 4

If HIV+ (CD <100) or otherwise
immunocompromised- what gi??

Back 4

remember candida,
CMV and HSV esophagitis

Front 5

Bad breath & snacks in
the AM

Dx
Tx

Back 5

Zenker’s diverticulum.
Tx w/ surgery

Front 6

Zenker is T or False Diverticulum?

Back 6

False. Only contains mucosa

Front 7

Dysphagia to liquids & solids.
Dx
Tx
Associated with

Back 7

Front 8

Epigastric pain worse after
eating or when laying down
cough, wheeze, hoarse.
Dx
Tests
Tx

Back 8

GERD. Most sensitive test is 24-hr pH
monitoring. Do endoscopy if “danger signs”
present. Tx w/ behav mod 1st, then antacids,
H2 block, PPI.

Front 9

Indications for surgery? for gERD

Back 9

bleeding, stricture, Barrett’s, incompetent LES,
max dose PPI w/ still sxs, or no want meds

Front 10

Dysphagia worse w/ hot &
cold liquids + chest pain that
feels like MI w/ NO regurg

Back 10

Front 11

If hematemesis (blood occurs
after vomiting, w/ subQ
emphysema). Can see pleural
effusion w/ ↑amylase
Dx
Next best test
Tx

Back 11

Front 12

If gross hematemesis
unprovoked in a cirrhotic
w/ pHTN.
Dx
If Hypovolemic shock?
Tx of choice?

Back 12

Front 13

If progressive
dysphagia/wgt loss.

Dx? (which kind?)
Best first test?

Back 13

Esophageal Carcinoma
Squamous cell in
smoker/drinkers in the
middle 1/3.
Adeno in ppl with long
standing GERD in the
distal 1/3.

Best 1st test?
barium swallow, then
endoscopy w/ bx, then
staging CT.

Front 14

A patient comes in with MEG pain…
• #1 cause is

Tx

Back 14

#1 cause is non-ulcerative dyspepsia. Dx of
exclusion. Tx w/ H2 blocker and antacid.

Front 15

A patient comes in with MEG pain…
If GERD sxs predominate-
Tx

Back 15

- tx empirically w/ PPI for
4 wks then re-evaluate.

Front 16

A patient comes in with MEG pain…
If biliary colic sxs predominate
best test?

Back 16

RUQ sono

Front 17

A patient comes in with MEG pain…
If hx of stones or drinking
test?

Back 17

check amylase and
lipase and CT scan is best imaging for pancreas.

Front 18

A patient comes in with MEG pain…
Danger sxs warrant _________ work up-

what are the danger sx?

Back 18

Danger sxs warrant endoscopic work up-
– >50 y/o, hx of smoking and drinking, recent
unprovoked weight loss, odynophagia, Fe-def anemia
or melena.

Front 19

Gastric Ulcers-
Sx
Tests
Tx

Back 19

Gastric Ulcers- MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids
– Double-contrast barium swallow shows punched out lesion w/
regular margins. EGD w/ bx can tell H. pylori, malign, benign.
– Tx w/ sucralfate, H2-block, PPI. Surgery if ulcer remains s/p
12wks treatment.

Front 20

Duodenal Ulcers-
Sx
Associated with
Tx
Tests

Back 20

MEG pain better w/ eating
– 95% assoc w/ H. pylori
– Healthy pts < 45y/o can do trial of H2 block or PPI
– Can do blood, stool or breath test for H. pylori but endoscopy
w/ biopsy (CLO test) is best b/c it can also exclude cancer.
– Tx H. pylori w/ PPI, clarithromycin & amoxicillin for 2wks. Breath
or stool test can be test of cure.

Front 21

Acute Cholecystitis-
Sx
Best 1st test
Tx

Back 21

Front 22

Choledocothithiasis-
Sx
Test

Back 22

– Same sxs + obstructive jaundice, high bili, alk phos
– U/S will show stones. Do cholecystectomy or ERCP to
remove stone.

Front 23

Ascending Cholangitis-
Sx
Tx

Back 23

– RUQ pain, fever, jaundice (+hypotension and AMS)
– Tx w/ fluids & broad spec abx. ERCP and stone removal.

Front 24

Cholangiocarcinoma-
Risk factors
Tx

Back 24

rare. RF are primary sclerosing
cholangitis (UC), liver flukes and thorothrast exposure. Tx w/
surgery.

Front 25

Chronic Pancreatitis-
Sx
Can cause...

Back 25

– Chronic MEG pain, DM, malabsorption (steatorrhea)
– Can cause splenic vein thrombosis

Front 26

Adenocarcinoma- (of pancreas)
Sx
Dx
Tx

Back 26

– Usually don’t have sxs until advanced. If in head of pancreas 
Courvoisier’s sign (large, nontender GB, itching and jaundice).
Trousseau’s sign = migratory thrombophlebitis.
– Dx w/ EUS and FNA biopsy
– Tx w/ Whipple if: no mets outside abdomen, no extension into
SMA or portal vein, no liver mets, no peritoineal mets

Front 27

A patient comes in with diarrhea… NEXTnext

Back 27

next

Front 28

If hypotensive, tachycardic

Back 28

Give NS first!

Front 29

# 1 cause of diarrhea

Back 29

Viral is #1 cause --> rota in daycare kids, Norwalk on cruise
ships

Front 30

A patient comes in with diarrhea
what test??

Back 30

Check fecal leukocytes --> tells invasion. Stool cx is best test

Front 31

If bloody diarrhea
what bugs?

Back 31

consider EHEC, shigella, vibrio
parahaemolyticus, salmonella, entamoeba histolytica

Front 32

diarrhea + If hx of picnic

Back 32

B. ceres, staph food poisoning. 1-6hrs

Front 33

diarrhea + If hx of abx use

Back 33

check stool for c. diff toxin antigen

Front 34

diarrhea + If foul smelling, bulky, malnourished

Back 34

consider Sprue,
chronic pancreatitis, Whipple’s dz, CF if young person.

Front 35

diarrhea + If accompanied by flushing, tachycardia/ hypotension

Back 35

consider carcinoid syndrome (metastatic).
– *Can cause niacin deficiency! (2/2 using all the tryptophan to
make 5HT) Dementia, Dermatitis, Diarrhea.

Front 36

A patient presents w/ fatigue, petechiae,
infection bone pain and HSM…
NEXT

Back 36

nexxt

Front 37

If >20% blasts?

Back 37

Defines Acute Leukemia on Biopsy

Front 38

CALLA or TdT?

Back 38

ALL. Most common cancer in kids.

Front 39

Auer Rods,
myeloperoxidase,
esterase?

Back 39

AML. More common in adults. RF = rads
exposure, Down’s, myeloprolif.
*M3 has Auer Rods and causes DIC upon tx

Front 40

Tartate resistant acid
phosphatase,
↓monos & CD11 and
CD22+?

Back 40

Hairy Cell Leukemia. See enlarged
spleen but no adenopathy.
Hairy Cells have numerous
cytoplasmic projections on smear.
Tx w/ cladribine 5-7day single course

Front 41

Tx of ALL?

Back 41

Danorub, vincris, pred. Add intrathecal MTX for CNS
recurrence. BM transplant after 1st remission.

Front 42

Tx of AML?

Back 42

Danorub + araC. If *M3  give all trans retinoic acid

Front 43

A patient presents w/
fatigue, night sweats,
fever, splenomegaly and
elevated WBCs w/ low
LAP and basophilia?

Dx
Tx

Back 43

CML- 9:22 transloc  tyrosine kinase

Tx w/ imantinib (Gleevec), inhibits
tyrosine kinase. 2nd line is bone
marrow transplant.

Front 44

Asymptomatic elevation
in WBCs found on routine
exam – 80% lymphs.
Dx?
If Lymphadenopathy -
If Splenomegaly
If Anemia
If Thrombocytopenia

Back 44

CLL

If Lymphadenopathy - Stage 0 or 1 need no tx- 12 yrs
till death

If Splenomegaly - Stage 2 tx w/ fludrabine
If Anemia - blast crisis???? Tx???
If Thrombocytopenia - Stage 3 or 4 tx w/ steroids

Front 45

Enlarged, painless, rubbery
lymph nodes

Back 45

Think Lymphoma

Front 46

Drenching night sweats,
fevers & 10% weight loss.

Back 46

“B-symptoms” = poor prognosis along w/
>40, ↑ESR and LDH, large mediastinal LND

Front 47

Best initial test?

Back 47

Excisional lymph node biopsy

Front 48

Next best test?

Back 48

Staging Chest/Abdominal CT or MRI. If still unsure,
staging laparotomy is done. Bone marrow bx (esp for NHL

Front 49

Orderly, centripetal spread
+ Reed Sternberg cells?

Back 49

Hodgkin’s Lymphoma

Front 50

Type w/ best prognosis?

Back 50

Lymphocyte predominant

Front 51

More likely to involve
extranodal sites? (spleen,
BM)

Back 51

Non-hodgkin’s Lymphoma

Front 52

Staging?

Back 52

I = 1 node group, II = 2 groups, same side of diaphragm,
III = both sides of diaphragm, extension into organ. IV = BM or liver

Front 53

Treatment?

Back 53

I/II get rads
III/IV get ABVD chemo

Front 54

Other hematologic randoms…
NEXT

Back 54

next

Front 55

Bone pain, “punched out
lesions” on *x-ray*, hyper Ca
– Best 1st test-
– Confirmatory test-
– Tx-

Back 55

Front 56

Dizziness, HA, hearing/vision
problems and monoclonal
IgM M-spike.

Back 56

Waldenstrom Macroglobulinemia

Front 57

No sxs, immunoglobulin
spike found on routine exam

Back 57

MGUS

Front 58

Older pt w/ generalized
pruritis and flushing after
hot bath. Hct of 60%.
Dx
Best 1st test
Tx

Back 58

Polycythemia Vera
Check epo, make sure it isn’t secondary. (PSG, carboxy-Hb)
Scheduled phlebotomy. Hydroxyurea can prevent thromboses