step 3 12

Question 1

cause of otitis-conjunctivitis syndrome

Answer 1

nontypeable H influenza

Question 2

hepatorenal syndrome management

Answer 2

Confirm with volume challenge (to confirm not secondary to intravascular volume depletion)
If no improvement in creatinine, hepatorenal is confirmed
octreotide and midodrine or norepinephrine
Albumin x 3 days.
*see uptodate article

Question 3

rosacea management

Answer 3

IF only erythema and telangiectasias –> topical brimonidine and avoidance of factors which trigger flushing (eg, hot or spicy foods, alcohol, extreme temperatures, emotional distress).
IF papular or pustular lesions –> topical metronidazole or azelaic acid. Oral antibiotics are considered for more severe or refractory cases.

Question 4

most frequent complication of rosacea

Answer 4

ocular rosacea. Complications frequently include a burning or foreign body sensation, blepharitis, keratitis, conjunctivitis, episcleritis, and recurrent chalazion.

Question 5

presentation of cerebral palsy

Answer 5

premature infant + hypertonia, hyperreflexia (eg, sustained clonus), and delayed motor milestones.

Question 6

cerebral palsy workup

Answer 6

brain MRI

Question 7

bedwetting management

Answer 7

Urinalysis to rule out secondary causes
Lifestyle changes:
Minimize fluid intake before bedtime
Avoid sugary/caffeinated beverages
Void before bedtime
Institute reward system (eg, “gold star” chart)
GOLD STANDARD = Enuresis alarm
Desmopressin therapy

Question 8

pyloric stenosis presentation

Answer 8

age 3-6 weeks with projectile vomiting with feeds.

Question 9

management of GERD in infants

Answer 9

reassurance and lifestyle modifications. Upright positioning after feeds, burping during feeds, and frequent, small-volume feeds are first-line interventions.

Question 10

treatment of nonfunctioning pituitary adenoma (leading to amenorrhea)

Answer 10

trans-sphenoidal pituitary surgery

Question 11

lyme arthritis treatment and prognosis

Answer 11

28-day course of oral doxycycline or amoxicillin. Prognosis is favorable, and most patients recovery completely.

Question 12

treatment of active TB in pregnant women

Answer 12

• multi-drug therapy + pyridoxine (vitamin B6) supplementation to prevent INH-induced neurotoxicity
• close monitoring

Question 13

first step in management of neonatal polycythemia

Answer 13

recheck with sample from venous blood

Question 14

endoscopy findings with pernicious anemia

Answer 14

absent rugae in fundus

Question 15

management of patient on warfarin during pregnancy

Answer 15

low-molecular-weight heparin in the first trimester.
IF high risk of thromboembolism (eg, those with mechanical heart valves) –> warfarin in the second and third trimesters. Before delivery –> Unfractionated heparin (rapid reversibility)

Question 16

management of giardia outbreak

Answer 16

tell affected individuals to refrain from recreational water venues

Question 17

management of levothyroxine during pregnancy

Answer 17

increase dose

Question 18

Aspirin indications

Answer 18

1) diabetics

2) people aged 45-79 when benefit outweighs risk of GI bleed

Question 19

presentation of TB effusion + diagnosis

Answer 19

• exudative + elevated adenosine deaminase

- diagnose with a pleural biopsy

Question 20

other lab often positive with parasites

Answer 20

FOBT

Question 21

bicuspid aortic valve management

Answer 21

Echo for all first degree relatives

Question 22

bicuspid aortic valve management

Answer 22

FIRST STEP: Echo for all first degree relatives (see below)
Follow up echo every 1-2 years
Balloon valvuloplasty or surgery

Question 23

graves management during pregnancy

Answer 23

Propylthiouracil should be used in the first trimester because of concerns of teratogenic effects with methimazole. Patients should be switched to methimazole for the second and third trimesters because of potential liver failure in patients taking propylthiouracil.

Question 24

when to taper steroids

Answer 24

after three weeks (takes this long to suppress HPA axis) + development of cushingoid appearance

Question 25

why is metformin usually used for type 2 diabetics?

Answer 25

improves the action of insulin

Question 26

type 1 diabetes management

Answer 26

Basal-bolus insulin: Long-acting (eg, glargine) once or twice daily to provide baseline coverage
Premeal bolus insulin: Short-acting (eg, regular) or rapid-acting insulin prior to meals.

Question 27

strep throat treatment

Answer 27

amoxicillin or penicillin

Question 28

treatment of pediatric constipation

Answer 28

↑ Dietary fiber & water intake
Limit cow’s milk intake to <24 oz
Laxatives
± Suppositories, enema

Question 29

complications of pediatric constipation

Answer 29

Anal fissures
Hemorrhoids
Enuresis/urinary tract infections

Question 30

presentation of pediatric constipation

Answer 30

Painful/hard bowel movements
Stool withholding
Encopresis

Question 31

pneumocystis jirovecci diagnosis and management

Answer 31

Induced sputum culture
If negative, repeat (sensitivity is low 50%-90%)
ABG:
Steroids if pO2<70 or A-a gradient >35
IF USING PRIMAQUINE OR DAPSONE TEST FOR G6PD DEFICIENCY

Question 32

neurocardiogenic syncope management

Answer 32

provide education and reassurance about the benign nature and prognosis,
advise patients to avoid potential triggers of syncope.
IF recurrent episodes, physical counterpressure maneuvers during prodromal phase (can abort or delay an episode of syncope)

Question 33

electrophoresis pattern with SCD

Answer 33

hemoglobin S with absent hemoglobin A

Question 34

definition of recurrent UTI

Answer 34

(>2 infections in 6 months or >3 infections in 1 year)

Question 35

protein levels in meningitis viral vs. bacterial

Answer 35

mildly elevated in viral, very high in bacterial

Question 36

cryptococcal meningitis management

Answer 36

1) Induction - amphotericin B and flucytosine for >2 weeks (until symptoms abate and CSF is sterilized)
2) Consolidation - weeks 2-8: transition to high-dose oral fluconazole for 8 weeks
3) Maintenance - lower-dose oral fluconazole for >1 year to prevent recurrence
IF elevated ICP → serial LP’s to reduce pressure

Question 37

reactive arthritis management

Answer 37

Repeat testing for infection
Abx, target pathogen
NSAIDs
if no response → intraarticular steroids or sulfasalazine

Question 38

ABO hemolytic disease of newborn management

Answer 38

exchange transfusion if severe

if moderate, phototherapy and IV hydration

Question 39

how to reduce risk of fat embolism

Answer 39

Early immobilization and operative fixation of fractures

Question 40

ITP clinical features

Answer 40

If isolated thrombocytopenia (coags normal, other labs normal) with no obvious cause → high pretest of ITP

Question 41

cause of ITP

Answer 41

platelet autoantibodies

Question 42

ITP management

Answer 42

Observation if cutaneous symptoms AND platelets ≥30,000/mm3

Glucocorticoids or IVIG if bleeding or platelets <30,000/mm3

Question 43

refeeding syndrome management

Answer 43

Replace phosphate (ALWAYS PO), potassium, magnesium, and thiamine PRIOR to starting feeds.

Question 44

dyspepsia definition

Answer 44

chronic/recurrent pain or fullness in the epigastric area without significant heartburn

Question 45

dyspepsia management

Answer 45

IF age 55 or alarm symptoms → EGD
IF younger than 55 AND from endemic area treat empirically for Hpylori
IF NSAID/COX-2 use → discontinue agent OR add acid suppression

Question 46

definition of labor arrest

Answer 46

no fetal descent (ie, no change in fetal station) after nulliparous patients push for >3 hours without an epidural (or >4 hours with an epidural).

Question 47

NPH management

Answer 47

• LP

- then most get a VP shunt

Question 48

chronic cough workup in kids

Answer 48

absent obvious infection – CXR + spirometry

Question 49

cleft lip rule of tens

Answer 49

Reconstruction of the cleft lip is generally performed at approximately three months of age, according to the rule of ‘10:’ 10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin.