step 3 19

Question 1

Slipped capital femoral epiphysis management

Answer 1

immediate surgical pinning

Question 2

salicylate toxicity presentation

Answer 2

nausea and vomiting, tachypnea with respiratory alkalosis, lactic acidosis, hyperthermia, and altered mental status

Question 3

most common cause of pathologic nipple discharge

Answer 3

papilloma

Question 4

management of family or parents who want futile care

Answer 4

involve ethics committee

Question 5

AK management

Answer 5

Cryodestruction is the most commonly employed method for treating solitary or few AKs. Biopsy is indicated for AK lesions that are >1 cm in diameter, indurated, ulcerated, tender, or growing rapidly, or for those lesions that fail to respond to appropriate therapy.

Question 6

horner syndrome presentation

Answer 6

ptosis, miosis, anhidrosis

Question 7

preferred initial treatment for preschool-age children with attention-deficit hyperactivity disorder

Answer 7

parent-child behavioral therapy

Question 8

management of failed response to stimulant for ADHD

Answer 8

• switch to different stimulant or switch to a nonstimulant medication such as atomoxetine or an alpha-2 adrenergic agonist.

Question 9

allergen responsible for most asthma cases

Answer 9

house dust mites

Question 10

management of patient refusing therapy

Answer 10

assess decision making capacity

Question 11

next step after testicle US shows findings concerning for cancer

Answer 11

serum tumor markers and screening CT scans is required.

Question 12

medicare subsections

Answer 12

Medicare part A covers primarily inpatient services. Part B covers outpatient services. Part C (Medicare Advantage) allows enrollment in private insurance plans. Part D covers prescription drugs.

Question 13

PE findings on physical exam

Answer 13

loud P2 and pleural friction rub on physical examination, hypoxemia, and small pleural effusion on chest x-ray (commonly due to inflammation from pulmonary infarct),

Question 14

length time bias

Answer 14

survival benefits of a screening test are overstated due to the detection of a disproportionate number of slowly progressive, benign cases.

Question 15

Indications for coronary revascularization

Answer 15

Patients with refractory angina despite maximal medical therapy
Patients in whom revascularization will improve long-term survival. This includes those with left main coronary stenosis and those with multivessel CAD (especially involving the proximal LAD) along with left ventricular systolic dysfunction.

Question 16

causes of lithium toxicity

Answer 16

narrow therapeutic index
volume depletion and drug interactions with thiazide diuretics, ACE inhibitors, and nonsteroidal anti-inflammatory drugs.

Question 17

management of lithium toxicity

Answer 17

dialysis

Question 18

hypoglycemia workup

Answer 18

A serum assay for oral hypoglycemic agents + serum insulin + C-peptide + proinsulin

Question 19

prenatal lab tests at 35-37 weeks

Answer 19

Group B Streptococcus culture

Question 20

prenatal lab tests at 24-28 weeks

Answer 20

Hemoglobin/hematocrit
Antibody screen if Rh(D) negative
50-g 1-hour GCT

Question 21

labs at initial prenatal visit

Answer 21

Rh(D) type, antibody screen
Hemoglobin/hematocrit, MCV
HIV, VDRL/RPR, HBsAg
Rubella & varicella immunity
Pap test (if screening indicated)
Chlamydia PCR
Urine culture
Dipstick for urine protein

Question 22

biomarker of window period in hep b

Answer 22

IgM anti-HBc

Question 23

management of patient with an isolated elevation of anti-HBc

Answer 23

• need to rule out false positive and assess acute infection

- LFT’s + IgM anti-hbc

Question 24

normal findings in acute grief

Answer 24

may wish to die to join the deceased and may also experience visions or hear the deceased person’s voice.

Question 25

Normal grief vs depression

Answer 25

normal grief can be differentiated from major depressive disorder in that the feelings of sadness revolve around the deceased and are less pervasive, typically occurring in waves following reminders of the person. Guilt and suicidal ideation are less common, and self-esteem is preserved. If thoughts of dying are present, they typically involve joining the deceased. Hearing the voice or seeing images of the deceased are also consistent with normal grief and do not indicate a psychotic disorder. This patient’s depression and thoughts of death revolve around her deceased husband and are not associated with feelings of worthlessness and hopelessness.

Question 26

lactational mastitis treatment

Answer 26

oral dicloxacillin and cephalexin.

Question 27

gold standard for hirschprung’s disease

Answer 27

Rectal suction biopsy (looking for absence of ganglion cells)

Question 28

hirschprungs vs. meconium ileus

Answer 28

hirschprungs has a transition zone between a normal or narrow caliber rectosigmoid (aganglionic segment) and a normally innervated but markedly dilated descending colon (Image).

Question 29

presentations of ED in diabetic patients

Answer 29

diminished testicular sensation, bladder dysfunction, and inability to masturbate.

Question 30

management of patient with bee or wasp sting allergy

Answer 30

referred to an allergist for venom immunotherapy

Question 31

management of asthma patient with thrush

Answer 31

observed for proper use of his inhaler, as the thrush may be a sign that he is using it improperly with a large amount of the medicine depositing in his oropharynx as opposed to passing into his lungs. A spacer device may be helpful for the patient if he is having trouble.

Question 32

strategies for SSRI induced ED

Answer 32

switching to the non-SSRI antidepressants bupropion or mirtazapine, augmentation with sildenafil or bupropion, and cautious dose reduction in patients taking high-dose SSRIs.

Question 33

when DEXA screening should happen

Answer 33

Bone density screening should begin at age 65 in women without risk factors. Postmenopausal women age <65 may be screened if they have risk factors such as body weight <58 kg (127 lb), chronic steroid use, smoking, malabsorptive disorders (eg, pancreatic insufficiency in cystic fibrosis), and parental history of hip fracture or personal history of low-impact fracture.

Question 34

levothyroxine management for patient with thyroid cancer

Answer 34

if large tumor, suppress to low normal, which has been shown to reduce risk of recurrence.

Question 35

otitis externa management

Answer 35

For mild OE with minimal erythema and edema, topical acidifiers (eg, acetic acid, Domeboro solution) for 7-10 days are usually adequate. For moderate OE with more significant pain, erythema, and edema (as in this patient), topical antibiotics (eg, ciprofloxacin, neomycin/polymyxin) are recommended.

Question 36

aspiration pneumonitis presentation

Answer 36

depressed level of consciousness, a history of vomiting, and respiratory distress shortly after an aspiration event

Question 37

dialysis indications

Answer 37

uremia, intractable hyperkalemia, hypervolemia, and metabolic acidosis.

Question 38

what are RCT’s used for?

Answer 38

efficacy of drugs and interventions. not powered enough to study for adverse effects, this is what postmarket surveillance is for.

Question 39

breast discharge differential

Answer 39

endocrine abnormalities (eg, hyperprolactinemia, thyroid disease), medications (eg, antipsychotics, gastric motility agents), stress, and excessive breast/nipple stimulation.

Question 40

pneumo management

Answer 40

If large and due to ventilator – chest tube.

Question 41

pneumothorax management system

Answer 41

assess for tension physiology (blood pressure, JVD, tracheal deviation).
If no tension signs → chest tube
if signs of tension → needle decompression

Question 42

restless leg syndrome workup

Answer 42

order ferritin (can be symptom of iron deficiency but don’t need to be anemic)

Question 43

management of pregnant patient with history of preeclampsia

Answer 43

aspirin is used for preeclampsia prevention and is started at 12 weeks gestation (thought to be due to increased platelet aggregation and vasoconstriction)

Question 44

first step in onychomycosis

Answer 44

KOH prep (psoriasis, lichen planus can mimic the appearance of onychomycosis, confirmation with potassium hydroxide (KOH) preparation or culture of nail scrapings is recommended)

Question 45

post MI orders

Answer 45

Dual antiplatelet therapy with ASA + clopidogrel or ticagrelor
Beta-blocker
statin
ACEi
Evaluation and risk stratification (eg, transthoracic echocardiogram, myocardial perfusion stress test, possibly coronary angiography).

Question 46

major depressive disorder criteria

Answer 46

> 2 weeks of at least 5 of 9 symptoms that include depressed mood plus SIGECAPS: Sleep disturbance, loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts

Question 47

how to reduce risk of opioid misuse

Answer 47

monitoring state prescription drug-monitoring program databases, performing random urine drug screening, and scheduling frequent follow-up visits.

Question 48

breast cyst management

Answer 48

• if asymptomatic, observe
• if symptomatic, FNA — if bloody, biopsy, if nonbloody and cyst resolves - repeat US in 4-6 weeks, if persistent biopsy

Question 49

periodic breathing in kids

Answer 49

physiologic pattern of breathing in young infants characterized by episodes of alternating pauses (5-10 seconds) in breathing and rapid breathing ( thought to be secondary to recurrent central apnea due to immaturity of the nervous system in infants up to age 6 months. There is no associated cyanosis, change in tone, or abnormal limb/eye movements)

Question 50

how to reduce snoring

Answer 50

• don’t drink before bed

- quite smoking

Question 51

STOP-bang test characteristics

Answer 51

poor positive predictive value but high negative predictive value for OSA

Question 52

cutoff for impaired vs normal EF

Answer 52

60%

Question 53

definition of primary and secondary mitral valve insufficiency

Answer 53

• mitral valve insufficiency that results from an intrinsic defect of the mitral valve apparatus (eg, leaflets, chordae tendineae)
• Secondary (or functional) MR refers to that occurring due to a disease process involving the left ventricle (eg, myocardial ischemia, dilated cardiomyopathy).