step 3 11

Question 1

major problem with TPN

Answer 1

high infection risk

Question 2

first step in management of congenital anomalies on step 3

Answer 2

look for other associated congenital conditions

Question 3

VACTER stands for…

Answer 3

vertebral, anal, cardiac, tracheal, esophageal, renal, radial

Question 4

esophageal atresia presentation

Answer 4

excessive salivation

choking spells

Question 5

anal atresia mangement

Answer 5

if fistula then delay repair until further growth

if no fistula, then colostomy

Question 6

congenital diaphragmatic hernia treatment

Answer 6

ET intubation, low-pressure ventilation, sedation, NG suction

Question 7

omphalocele

Answer 7

infant’s intestine or other abdominal organs are outside of the body because of a hole in the belly button (navel) area. The intestines are covered only by a thin layer of tissue and can be easily seen

Question 8

gastroschisis

Answer 8

similar to omphalocele but no protective membrane. bowel looks angry and matted

Question 9

congenital conditions presenting with double bubble sign on xray and bilious vomiting

Answer 9

annular pancreas, duodenal atresia

Question 10

clinically significant CVD defined as..

Answer 10

Acute coronary syndrome
Stable angina
Arterial revascularization (eg, CABG)
Stroke, TIA, PAD

Question 11

warfarin management for patient on amiodarone

Answer 11

reduce dose by 25%-50% to compensate for the increase in serum concentration of warfarin

Question 12

mechanical heart valve management

Answer 12

aortic valve
ASA 81 mg
IF no high risk features → warfarin goal INR 2.0-3.0
IF high risk features → warfarin goal INR 2.5-3.5
high risk features = (eg, atrial fibrillation, left ventricular dysfunction [ejection fraction <30%], prior thromboembolism, presence of hypercoagulable state)
mitral valve
ASA 81 mg
warfarin goal INR 2.5-3.5

Question 13

chronic pancreatitis management

Answer 13

Alcohol and smoking cessation + Fat soluble vitamin supplementation + Frequent small meals + return to care in 2 months → if failed conservative measures, then below management

Question 14

HH presentation

Answer 14

Skin

Hyperpigmentation (bronze diabetes)

Musculoskeletal

Arthralgia, arthropathy & chondrocalcinosis

Gastrointestinal

Elevated hepatic enzymes with hepatomegaly (early), cirrhosis (later) & increased risk of hepatocellular carcinoma

Endocrine

Diabetes mellitus, secondary hypogonadism & hypothyroidism

Cardiac

Restrictive or dilated cardiomyopathy & conduction abnormalities

Infections

Increased susceptibility to Listeria, Vibrio vulnificus & Yersinia enterocolitica

Question 15

causes of secondary hypogonadism

Answer 15

anabolic steroids, chronic glucocorticoid or opioid use, hyperprolactinemia, chronic kidney or liver disease, diabetes, and pituitary tumors

Question 16

test you can order to evaluate function of pancreas

Answer 16

fecal elastase

Question 17

gestational DM screening process

Answer 17

24-28 weeks gestation with the 1-hour 50-g glucose challenge test.
If over 140, confirm with 3-hour 100-g glucose tolerance test

Question 18

GDM treatment

Answer 18

First line: dietary modifications

Second line: insulin, metformin, glyburide

Question 19

target blood glucose levels in GDM

Answer 19

Fasting ≤95 mg/dL (5.3 mmol/L)
1-hour postprandial ≤140 mg/dL (7.8 mmol/L)
2-hour postprandial ≤120 mg/dL (6.7 mmol/L)

Question 20

neonatal complications of GDM

Answer 20

macrosomia, shoulder dystocia, hypoglycemia

Question 21

regular insulin duration

Answer 21

short-acting

Question 22

NPH insulin duration

Answer 22

intermediate

Question 23

WPW ECG

Answer 23

short PR interval, delta wave, and wide QRS complex

Question 24

pancreatic cyst management

Answer 24

EUS with biopsy if large, solid components

Question 25

down’s syndrome patients are at increased risk for…

Answer 25

• acute leukemia

- also –> Alzheimer-like dementia, autism, ADHD, depressive disorder, and seizure disorder

Question 26

subclinical hyperthyroidism management

Answer 26

Repeat TSH/T4/T3
IF at recheck, persistently <0.1 µU/mL OR age (>65) with comorbid conditions (heart disease, osteoporosis, nodular thyroid disease) → treat with antithyroid meds

Question 27

Problem with combination estrogen/progesterone

Answer 27

increases the risk for stroke, coronary heart disease, breast cancer, and venous thromboembolism. However, this risk is age-related, with a higher risk seen in women age >60. The risk of ischemic stroke is increased in all age groups, but the absolute risk in women age <60 is small.

Question 28

DM diagnosis

Answer 28

≥126 mg/dL = diabetes mellitus
≥200 mg/dL with symptoms of hyperglycemia = diabetes mellitus
≥200 mg/dL = diabetes mellitus

Question 29

toxic megacolon management

Answer 29

surgery consult
steroids
aggressive IVF

Question 30

thyroid nodule management

Answer 30

TSH and thyroid ultrasound
IF suspicious findings on US → fine-needle aspiration with cytology of the nodule.
IF TSH low → radionuclide thyroid scan.

Question 31

first step after cancer diagnosis generally

Answer 31

staging

Question 32

primary modality for initial staging of thyroid cancer

Answer 32

neck and cervical lymph nodes

Question 33

papillary thyroid tumor management

Answer 33

Patients with a small (<1 cm) papillary thyroid tumor may be treated with thyroid lobectomy. Total thyroidectomy is recommended for tumors >1 cm in diameter, tumor extension outside of the thyroid, distant metastases, and in patients with a history of head or neck radiation exposure.

Question 34

H pylori management

Answer 34

Triple therapy
If failed → quadruple therapy or sequential therapy involving distinct antibiotics should be used
RTC in 1 month (bring stool for fecal antigen testing)

Question 35

when you should be concerned about sexually coercive relationship

Answer 35

partner to teen is in position of power

Question 36

akathisia management

Answer 36

1) dose reduction and monitor for worsening

2) if dose reduction not possible, add propranolol

Question 37

difference between breast milk and breast feeding jaundice

Answer 37

• Breast milk jaundice is a common cause of unconjugated hyperbilirubinemia that peaks at age 2 weeks in well-appearing and healthy neonates. (enzyme in breast milk deconjugates intestinal bilirubin and increases enterohepatic circulation)
• In contrast, neonates with lactation failure typically present in the first week of life with jaundice, inadequate feeding, and dehydration. They don’t breastfeed so they don’t clear bilirubin. They’re also dehydrated for this reason.

Question 38

management of breastfeeding failure

Answer 38

Continue breastfeeding exclusively (resolves spontaneously)

Frequent follow-up and monitoring of the infant’s hyperbilirubinemia.

Question 39

Headache red flags

Answer 39

sudden/severe + onset after 40 + focal deficits on neurologic exam + fever/systemic symptoms + previous HA with change in frequency, severity

Question 40

first line therapy for cluster headaches

Answer 40

verapamil

Question 41

low potency topical steroid

Answer 41

hydrocortisone

Question 42

high potency topical steroids

Answer 42

triamcinolone, betamethasone

Question 43

first line for failure to thrive

Answer 43

detailed diet history to evaluate for inadequate or inappropriate nutrient intake.

Question 44

Most common cause of failure to thrive

Answer 44

inadequate calorie intake secondary to psychosocial stressors. These include poverty (eg, lack of access to food), lack of knowledge of appropriate feeding techniques (eg, excessive water-to-formula powder ratio), and poor parental/child relationship (eg, neglect, abuse).

Question 45

Management of PCP intoxication

Answer 45

First step: benzos (lorazepam)

Question 46

squamous cell carcinoma/ head and neck cancer treatment

Answer 46

combined chemotherapy and radiotherapy, also known as chemoradiotherapy (CRT), promises superior results over chemotherapy or radiotherapy alone. It not only increases the 5-year survival rate, but also renders some inoperable HNC cases operable after treatment.

Question 47

HIV exposure management

Answer 47

start triple drug HAART within 72 hours for 1 month

Question 48

barrett’s surveillance indication with GERD

Answer 48

Patients with a history of chronic gastroesophageal reflux disease (>5 years) or frequent symptoms and ≥2 risk factors (eg, male sex, central obesity) should be considered for endoscopic screening.

Question 49

management of intraoperative hypo and hypertension during surgery for pheochromocytomas

Answer 49

intravenous bolus of normal saline. Intravenous bolus of phentolamine is used for acute severe hypertension (not hypotension) during surgery for pheochromocytoma.

Question 50

RF’s for developing torsades with long QT

Answer 50

structural heart disease, bradyarrhythmias, women, elderly, coronary heart disease