Usmle Step 3 Ccs

Front 1

30yo F with knee, wrist pain, morning stiffness

DDx? Dx? Optimal approach including tx?

Back 1

DDx: OA, infectious arthritis, RA, SLE, gout and psoriatic arthritis

Dx: RA

Optimal management: PE (extremities, CV, lungs, abd, skin, HEENT and lymph nodes), RF or anti-CCF, CBC, arthrocentesis, ANA, ESR, CRP and joint XRs

Rx: NSAID or steroid + DMARD (methotrexate or etanercept)

Front 2

65yo F with L sided CP, HTN, tachycardia w/ bounding central and peripheral pulses, diastolic decrescendo murmur

Dx? Optimal approach?

Back 2

Dx: aortic dissection

Optimal approach: ECG 12 lead, portable CXR, stabilize with IV BB + another antihypertensive, IV morphine, continuous cardiac monitor, pulse ox. Once stable - CT chest w/contrast, echo or MRI. W/U: BMP, CBC, CPK, cardiac enzymes, d-dimer and type & crossmatch. Thoracotomy or dissection repair

Front 3

4yo M w/ SOB for 3 days, coughing & wheezing esp after playing outside, h/o pollen allergy and atopic dermatitis

Dx? Optimal approach?

Back 3

Dx: asthma

Optimal approach: targeted PE (HEENT, lung, CV and abd), pulse ox, O2 therapy, bronchodilators (albuterol) and steroids (betamethasone) are essential. Include - counseling family on asthma care, med side effects, chest exam after treatment

Front 4

65yo M w/ sharp R-side CP and respiratory distress. No breath sounds on R lung exam.

Dx? Optimal approach?

Back 4

Dx: pneumothorax

Optimal approach: focused PE, then needle thoracostomy followed by chest tube. CXR to confirm tube placement. Important to minimize W/U before needle decompression

Front 5

31yo F w/ lethargy, N/V, h/o DM1. On exam, fever, tachypnea, tachycardia and hypotension. No insulin for 24hrs.

Dx? Optimal approach?

Back 5

Dx: DKA

Optimal approach: focused PE (lung, CV, abd & neuro/psych), serum random glucose, UA, CBC, IVF (NS or Ringer's), broad spectrum abx (cephalosporin or fluoroquinolone). Once serum glucose is obtained, IV insulin and cardiac monitor. Include ABG, blood cx and BMP. Continue monitoring glucose, electrolytes, pH after treatment

Front 6

25 yo F at 38wks gestation to ED after seizure w/ LOC. Exam shows tachycardia, low-grade fever, and HTN.

Dx? Optimal approach?

Back 6

Dx: eclampsia

Optimal approach: focused PE (skin, HEENT, lung, CV, abd, genital, extremities, neuro), CBC, IV mag sulfate, IV antihypertensive (hydralazine or BB). Immediate delivery - vaginally (use oxytocin or misoprostol PRN) or C-section. Measure pt urine output. Include - BMP and PT/PTT.

Front 7

Don't forget about pt comfort. How do you manage pt in pain, nauseous, constipated, with diarrhea or insomnia?

Back 7

Pain: IV morphine
Nausea: IV phenergan or ondansetron
Constipation: PO docusate
Diarrhea: PO loperamide
Insomnia: PO temazepam

Front 8

25F with urinary frequency and burning. LMP 24 days ago. No fever, N/V/D, or flank pain.

Optimal approach?

Back 8

Focused PE. bhCG (positive), UA (positive nitrite and leukocyte esterase), urine cx

Uncomplicated cystitis - TMP-SMX 3 days
Complicated - TMP-SMX 7 days
If pregnant, nitrofurantoin PO, prenatal vitamins

Front 9

List prenatal labs

Back 9

Blood type, antibody screen, Rh type, CBC with diff, BMP, Pap smear, rubella status, syphilis screen (VDRL or RPR), UA and urine culture, hep B surface ag, HIV counseling and testing, chlamydia testing

Don't forget about counseling, prenatal vitamins, iron sulfate and folic acid

Front 10

28M with bright red blood per rectum; also has colicky abd pain. Older brother has UC. Smoker.

Optimal approach?

Back 10

Dx: UC

Focused PE (gen, skin, HEENT, CV, lungs, abd, rectal, extremities). CBC, BMP, stool for O&P/WBC/culture, LFTs, PT/PTT, ESR, sigmoidoscopy and rectal biopsy,

Rx: mesalamine, loperamide, dicyclomine (anti-cholinergic), dietary consult, counseling, smoking cessation

Front 11

26F with amenorrhea and abd pain. LMP 7 wks. Currently sexually active with husband and practices safe period for contraception. H/o 2 episodes of PID.

Optimal approach?

Back 11

Dx: Ectopic pregnancy/PID

Focused PE. b-hCG (positive) stat. NPO, VS Q1hr, IV access, IV NS, complete bedrest, quantitative b-hCG, transvaginal US, type and crossmatch, blood group and Rh, CBC, PT/PTT, BMP, LFTs, cervical GC cx (abx if positive) - all stat orders.

Tx: ob/gyn consult, PO MTX, IV morphine

F/u orders: cancel NPO, VS, IV access, IV NS and complete bedrest. Order rest at home. Counseling.

Front 12

Management of ectopic pregnancy

Back 12

If hemodynamically unstable - IV access/NS, type and cross - transfuse as needed, continuous BP monitoring, PT/PTT, b-hCG and pelvic US, consult sx or ob/gyn for laparotomy

If hemodynamically stable - r/o rupture, b-hCG quantitative. Perform transvaginal US
- If b-hCG > 1500 and US shows intrauterine preg, ectopic is unlikely
- If US is equivocal and b-hCG +, then repeat test in 2 days
- If b-hCG > 1500 and US shows adnexal mass < 3.5cm, give MTX (contra in renal/liver failure and breast feeding). Mass > 3.5cm or MTX contra then perform laparoscopy. Give Rhogam to Rh neg pts

Front 13

27F with 3mo h/o abd pain and altered bowel habits (diarrhea and constipation). No ill contacts. Sexually active with husband only. LMP 1wk.

Back 13

Dx: IBS

Complete PE. CBC, BMP, TSH, FOBT, EST, stool O&P/WBC/Cx, 72hr stool fat, Pap - routine. Send home.

Return in 1 wk - order lactose free diet, high fiber, loperamide, biofeedback, reassurance, relaxation exercise, counseling. F/u in 2 wks.

Front 14

40F c/o insomnia, easy fatigability, and feelings of worthlessness. She also reports feelings of guilt and hopelessness, and is unable to concentrate. Lack of appetite, no pleasure in her normal activities. Recent loss of loved one 2 mos ago.

Optimal approach?

Back 14

Dx: major depression

Complete PE. CBC, BMP, TSH, B12 - routine. Fluoxetine PO. Counseling. Appt in 10 days.

Next appt: interval f/u, PE. Schedule an appt in 14 days.

Front 15

Vaginal discharge, pruritus management?

Back 15

Trichomonas - presents with a frothy, yellow-green discharge and strawberry cervix. Motile flagellated organism.
- Tx: metronidazole (avoid alcohol). Treat partner

BV - presents with a white/gray discharge and fishy odor
- Tx: metronidazole (avoid alcohol)

Vag candidiasis - itching, white curd-like discharge
- Tx: miconazle/clotrimazole suppositories or vaginal cream

Orders: vag pH, wet mount, vag gram stain, Pap, GC cx, UA

Front 16

75M with gradual worsening of forgetfulness. Poorly groomed, difficulty with activities of daily living (ADLs). Paranoid features (accused son of mixing poison in his food). No med problems.

Optimal approach?

Back 16

Dx: Alzheimer's

Orders: complete PE. CBC, BMP, LFT, TSH, B12/folate, CT head or MRI brain - routine. Send home. Appt in 7 days

Rx: donepezil (cholinesterase inhibitors), olanzapine for delusions. F/u in 6wks.

Front 17

65M with severe SOB and wheezing; h/o COPD, yellow malodorous sputum. Smoker.

Optimal approach?

Back 17

Dx: COPD exacerbation

Orders: emergency orders (elevate head, cardiac monitor, pulse ox, O2, IV access), focused PE (gen, HEENT, lungs, CV, abd, extremities), PEFR (peak expiratory flow rate) Q1hr, CXR, ABG, ECG, CBC, and BMP - all stat

Rx: albuterol continuous; if PEFR and O2 sat are low add ipratropium nebs, IV methyl-prednisone, PO or IV antibiotics

Final orders: counseling, flu/Pneumovax vaccines, smoking cessation

Front 18

43F to ED c/o severe RUQ. Pain started after breakfast. She is nauseated and vomited 1X. Similar episode last year.

Optimal approach?

Back 18

Dx: acute cholecystitis

Orders: focused PE. Order: CBC, BMP, LFTs, serum amylase/lipase, blood cx, abd XR, abd US - stat

Rx: IV access + NS, NGT, NPO, IV piperacillin-tazobactam, ketorolac IM and phenergan IV - stat

Order: bedrest with bathroom privileges, consult sx, PT/PTT, type and crossmatch

Clock: advance 8-12hrs until patient improves and becomes afebrile.

Order: laparoscopic cholecystectomy, counseling

Front 19

Management of any diabetic patient

Back 19

HbA1C, Accucheck, mention drug compliance, diabetic foot care, regular Accuchecks at home, diabetic diet, if chronic pt, ophthalmology consult for fundoscopy

Front 20

5 minutes left... what to do?

Back 20

RATED SEX
Reassurance, Alcohol, Tobacco, Exercise, Diet
Seat belt, Educate pt/family, X (Safe sex)

Convert or cancel all IV meds
Order LFT/lipid profile to assess drug side effects

Front 21

Child with high lead level. Now what?

Back 21

Must check "serum venous lead level" to confirm.
If > 70, must admit immediately and give dimercaprol and EDTA.

Must check house for lead - order "lead abatement agency" and "lead pain assay" upon discharge

Front 22

Acute abdomen patient with suspected perforation. What abx to give?

Back 22

Triple therapy - gentamycin, ampicillin, and metronidazole

Front 23

Any bleeding patient, what should you order?

Back 23

PT/PTT, blood type and crossmatch

Front 24

Patient with GI distress or is at risk for aspiration (elderly with AMS). What should you order?

Back 24

Head elevation, aspiration precautions

NPO - in case of surgery

Front 25

All children given gentamycin... what should you order?

Back 25

Hearing test, and check BUN/Cr before and after treatment

Front 26

All ICU patients get what for stress ulcer prophylaxis?

Back 26

IV omeprazole

Front 27

Patient > 50 yo, no h/o colonoscopy or FOBT. What should you order?

Back 27

DRE, FOBT, and sigmoidoscopy or colonoscopy. Remember to bowel prep - NPO, IVF, and order "polyethylene glycol"


In males, add prostate exam and a PSA

Front 28

Patients with terminal disease. Don't forget what?

Back 28

Advanced directives

Front 29

Patients with diarrhea. What should you order?

Back 29

Stool ova and parasites, white cells, culture, c. diff antigen

Front 30

What is the standard pre-op set of orders?

Back 30

NPO, IV access, NSS, blood type and crossmatch, analgesia, PT/PTT, pneumatic compression stockings, Foley catheter, urine output, CBC and appropriate antibiotics (Keflex, metronidazole/ciprofloxacin, imipenem)

Front 31

Patient in anaphylaxis and on a beta-blocker for HTN. What should you give first?

Back 31

Beta-blocker will decrease efficacy of epinephrine so glucagon is given to neutralize BB.

Front 32

Orders for suspected dementia patients

Back 32

Head CT, B12, folate, TSH, fasting glucose, depression index, CBC, BMP, UA, LFT

If history indicates, VDRL/RPR and HIV ELISA

Front 33

After thoracocentesis, what should you order?

Back 33

Send effusion and peripheral blood sample for LDH, protein and pH of effusion

Front 34

Vaginal discharge. Orders?

Back 34

KOH prep, saline (wet) prep, vaginal pH, chlamydia/GC culture

Front 35

Colon, pancreatic, liver, ovarian cancer markers?

Back 35

CEA, CA19-9, AFP, CA125

Front 36

Infant < 3 mo with fever. Orders?

Back 36

Assume sepsis and culture blood, urine, sputum, and CSF

Front 37

Patient with Mobitz II or complete heart block. What to do?

Back 37

Order immediate "transcutaneous pacemaker" then a cardiology consult to place a "transvenous pacemaker."

Front 38

OD patient. Don't forget to order the following...
If suicidal, then add:

Back 38

Urine tox, gastric lavage, activated charcoal
Suicidal patients: admit, sign "suicide contract," order "suicide precautions"

Front 39

Alcoholic ketoacidosis patient. Orders?

Back 39

IV dextrose, NSS, and thiamine

Front 40

If CXR shows effusion, what is the next step

Back 40

Next step is decubitus CXR

Front 41

Respiratory trouble? Orders:

Back 41

Suction of secretions, nebulized albuterol, ipratropium, IV methylprednisolone, PEFR/RFT/FEV1, chest PT, percussion therapy, and ABG