Usmle Step 2 Questions #32

Front 1

1. Describe the management of a patient with hypertensive emergency. (FA2 p61, B&W p1)

Back 1

• Decrease the MAP by no more than 25% within 2 hours using IV agents or risk an ischemic event such as stroke or MI.
• Once a DBP of 100-105 mmHg is achieved, the patient can be switched to oral therapy with the goal of achieving a DBP of 85 mmHg over the next 2-3 months.

Front 2

2. What blood pressures define prehypertension? How should prehypertension be managed? (FA2 p58, B&W p2)

Back 2

• Prehypertension = SBP 120-139 or DBP 80-89
• If the patient’s SBP is > 130 or DBP > 80 and has diabetes, chronic kidney disease, end-organ damage, or cardiovascular disease then medical management with an antihypertensive is indicated.
• If none of the above comorbidities, then nonpharmacologic management with weight reduction, sodium restriction, increased physical activity, and avoidance of excess alcohol.

Front 3

3. What is the rational for dosing dexamethasone prior to or along with the first dose of antibiotics for empiric treatment of bacterial meningitis? (FA2 p212)

Back 3

• Dexamethasone when given with or prior to the first dose of antibiotic reduces the risk of neurologic sequela (eg, hearing loss) in children with meningitis, especially in the cases of H. influenzae type B or tuberculous meningitis.
• In adults with bacterial meningitis, dexamethasone dosed in the same manner as above reduces both morbidity and mortality especially in the case of pneumococcal meningitis.

Front 4

4. What is the treatment for onychomycosis? (B&W p402)

Back 4

• First confirm diagnosis by sending a nail clipping for pathologic diagnosis. Onychomycosis is only responsible for 50-60% of abnormal appearing nails.
• Lamisil and Sporonox have cure rates of only 60-70%
• Strongly consider pretreatment LFTs and mid-treatment LFTs
• Lamisil (terbinafine)
- fingernails 250mg po qd x6 wks
- toenails 250mg po qd x12 wks
(off-label dosing: 250mg qd x7d every 2-3m x 1yr may have better efficacy)
• Sporonox (itraconazole)
- fingernails 200mg po qd x8 wks, or 400mg qd for 1 week each month for 2m
- toenails 200mg po qd x12 wks, or 400mg qd for 1 week each month for 3m
• Fluconazole (Diflucan) 150mg once weekly x24 wks (consider for those with complicated med regimens) (efficacy not as good as Lamisil or Sporonox; cure only about 32%)
• Reassure pt that oral agents will continue to work after stopping use. It may take a few months to see complete resolution.
• Penlac Nail Lacquer (ciclopirox) x48wks has complete cure rate of only 7% which means 1 in 15 pts will have a favorable outcome.

Front 5

5. What treatment options are available for patients with acne vulgarus? (FA2 p88, B&W p381)

Back 5

• Topical Retinoid – normalizes follicular keratinization; examples include Retin-A (tretinoin), Differin (adapalene), and Tazorac (tazarotene)
• Topical Retinoid + Topical Antimicrobial (such as sulfacetamide, clindamycin, or dapsone)
• Topical Retinoid + Oral Antibiotic (such as tetracycline, minocycline, doxycycline, Bactrim, or azithromycin)
• Oral Contraceptive Pills in additional to one of the above in female patients
• Topical Retinoid + Benzoyl Peroxide + Topical and/or Oral Antibiotic
• Spironolactone (anti-androgenic) in addition to one of the above
• Oral Isotretinoin (Accutane) for 15-20 wks; used as a last resort

Front 6

6. What is considered a healthy amount of weight gain during pregnancy? (FA2 p299, B&W p225)

Back 6

• if BMI < 19.8 kg/m2 (underweight)  12.5 – 18 kg
• if BMI 19.8 – 26 kg/m2 (normal weight)  11 kg (25 pounds)
• if BMI > 26 kg/m2 (overweight)  7 – 11.5 kg
• if BMI > 29 kg/m2 (obese)  6 kg

Front 7

7. What exam and history components should be performed at every prenatal encounter? (not in FA2, B&W p225)

Back 7

• History components: headache, vision changes, facial or hand swelling, vaginal bleeding, fetal motion, contractions, loss of fluids, nausea/vomiting, painful urination, vaginal discharge, constipation
• Maternal vital signs and weight
• Uterine size and fetal heart rate
• Urinalysis for glucose and protein +/- LE and nitrates

Front 8

8. What congenital defects are associated with maternal zoster reactivation? (not in FA2 or B&W)

Back 8

none

Front 9

9. At what age should nocturnal enuresis be treated? What are the treatment options? (not in FA2 or B&W)

Back 9

• Enuresis cannot be diagnosed until 5 years of age (chronological and developmental).
• Treatment is usually delayed until the child is at least 7 years of age.
• First-line  Behavioral interventions:
- Start toilet training if not yet attempted.
- Motivational therapy (eg, star charts)
- Restrict fluids before bed (with a compensatory increase in daytime fluids)
- Nighttime chaperone to the toilet or scheduled wakening to void using alarm clock
- Enuresis alarm (pad with alarm device) in bed for classic conditioning. This is most effective long-term therapy.
• Second-line  Pharmacologic interventions:
- High likelihood of recurrence upon discontinuation
- Imipramine (Tofranil) for short-term (up to 6 weeks)
- Desmopressin (DDAVP) orally (FDA 12-2007  intranasal desmopressin is no longer indicated for enuresis due to risk of hyponatremic seizures)
- Indomethacin suppository

Front 10

Surgery
10. How is subclavian steal syndrome diagnosed? (B&W p221)

Back 10

Subclavian steal syndrome can be diagnosed using one of the following tests:
• Continuous wave Doppler or Duplex ultrasound – least expensive test, often used initially
• Magnetic resonance angiogram (MRA) – most accurate noninvasive test
• CT angiogram – usually only if contraindication to MRA and when ultrasound inconclusive
• Contrast angiogram

Front 11

11. What is the meaning of the following surgical terms? (not in FA2 or B&W)
Gastrostomy
Ileostomy
Colostomy
Laparoscopy
Laparotomy (AKA celiotomy)

Back 11

Gastrostomy - Surgical connection of the stomach to the skin of the abdominal wall for feeding

Ileostomy - Surgical connection of the ileum to the skin of the abdominal wall

Colostomy - Surgical connection of the colon to the skin of the abdominal wall

Laparoscopy - Visualization of the peritoneal cavity using a laparoscope

Laparotomy (AKA celiotomy) - Surgical incision into the abdominal cavity

Front 12

12. What might you see on neuroimaging of a patient with schizophrenia? (FA2 p396)

Back 12

• enlargement of the ventricles (lateral and third ventricles)
• some reduction in cortical volume

Front 13

13. What is the diagnostic criterion for schizophrenia? (FA2 p397, B&W p347)

Back 13

1. at least two of the following during a one month period:
• delusions (irrational belief that cannot be changed by rational argument)
• hallucinations (most common type is auditory)
• disorganized speech (eg, frequent derailment or incoherence)
• grossly disorganized or catatonic behavior
• negative symptoms (eg, flat affect, poverty of speech, lack of emotional reactivity)
(only one of the above is required if delusions are bizarre or hallucinations consist of a voice keeping a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other)
2. social / occupational dysfunction
3. duration of at least 6 months

Front 14

14. Describe the management of a patient that attempted suicide by theophylline overdose. (FA2 p462, B&W p454)

Back 14

• Activated charcoal 1g/kg (usually 50g) then 15g hourly (or 20g q2hrs) for 6-12hrs
• In order to prevent emesis of the charcoal, avoid ipecac and dose an H2-blocker and antiemetic as needed.
• Cardiac monitor for arrhythmias  ACLS drugs as needed
- Beta-blockers as needed for excess beta stimulation
- Lidocaine for ventricular arrhythmias
- Verapamil as needed for atrial fibrillation or multifocal atrial tachycardia (MFAT)
• If seizures  diazepam + barbiturate if necessary (phenytoin least effective in this scenario)
• Hemodialysis and/or hemoperfusion if one of the following:
- clinical unstable such as seizures, life-threatening hypotension, or arrhythmias
- plasma theophylline concentration > 100 mg/dL in acute intoxication
- plasma theophylline concentration > 60 mg/dL in chronic intoxication
- age > 60 and plasma theophylline concentration > 40 mg/dL in chronic intoxication

Front 15

15. What is the treatment for angioedema in anaphylaxis? (not in FA2 or B&W)

Back 15

• Airway, Breathing, Circulation
- Intubation immediately if respiratory distress, stridor, or impending airway compromise
• Stop the inciting agent
• Epinephrine 0.3 0.5 mg IM to the anterolateral thigh q5-15min as needed (adult dose)
• IV isotonic fluids (NS or LR) to maintain blood pressure
• H1 and H2 blockers for cutaneous symptoms (itching, hives)(does not help relieve airway obstruction)
• Albuterol as needed for bronchospasm not relieved by epinephrine