Step3 39

Question 1

Pancreatitis diagnosis

Answer 1

2 out of 3

Classical symptoms

Elevated amylase or lipase >3x normal

Imaging consistent with pancreatitis (not useful <72hrs)

Question 2

Top 3 causes of Acute pancreatitis

Answer 2

Gallstone disease

Alcohol

Hypertriglyceridemia

Hypercalcemia
Drugs: valproic acid, diuretic
Infections: CMV, HIV, ascariasis
Trauma, ischemia,

Question 3

Valvulopathy related to Rheumatic Heart disease, location and description of the murmur

Answer 3

Mitral stenosis

Low pitch rumble, diastolic murmur with an opening snap

5th-6th rib with mid-clavicular line

Question 4

Diagnosis of brain death

Answer 4

Pg. 284 First aid

Prerequisites
Neuro exam
Apnea test

Imaging

Question 5

Approach to hypoglycemia workup

Answer 5

1. Wipple triad must be present: hypoglycemia + symptoms + resolution of symptoms after glucose administration
2. Order: exogenous vs. pancreatic origin
   Insulin, proinsulin, c-peptide
3. If C-peptide and proinsulin are elevated, order: tumor vs. medication
   Hypoglycemic drug essay (sulfonylurea, meglitinide)
4. If no hypoglycemic drug was found, order a CT

Question 6

When do you a 72hrs fasting test for a hypoglycemia workup?

Answer 6

In a patient that you suspect has hypoglycemic episodes but, had normal glycemia on examination

Fasting should reduce insulin levels.

If insulin remains elevated or inappositely normal, an insulin-secreting tumor should be suspected

Question 7

When do you do a mixed-meal challenge test

Answer 7

You do it on patients with hypoglycemic symptoms after eating

Question 8

Diagnosis of vasovagal syncope

Answer 8

Clinical

Tilt test if the diagnosis is not clear

Question 9

Restless leg syndrome associations

Answer 9

Iron deficiency anemia

Uremia (ESRD, CKD)

Diabetes

Medications (antidepressants, metoclopramide)

MS, Parkinsons

Pregnancy

Question 10

Treatment of restless leg syndrome

Answer 10

Iron supplementation if Ferritin <75

Mild:
Avoid triggers (medication, sleep deprivation)
Massages

Moderate/Severe:
Dopamine agonist: pramipexole, ropimirole (FIRST LINE)
Calcium channel ligand: gabapentin
Benzodiazepine/Levodopa for intermittent cases only

Question 11

Evaluation and management of a pancreatic cyst

Answer 11

Endoscopic ultrasound with aspiration for biopsy

If malignant: surgery (if eligible)
Head: pancreatoduodenectomy
Tail: tumor resection

Question 12

Evaluation of Medullary carcinoma of the thyroid

Answer 12

Calcitonin
CEA
Neck ultrasound (look for metastasis)
RET mutations (MEN 2 association)
Look for additional tumors: 
Parathyroid
Pheochromocytoma (needs to be ruled out before surgery with plasma and 24-hr urine metaneprhines

Question 13

Opiates contraindicated in children

Answer 13

Tramadol and codeine

Question 14

Accidental needle stick with an HIV positive patient but with undetectable viral load

Answer 14

3 drug treatment for 4 weeks (doesn’t matter if viral load is low)

Check 6 weeks and 4 months to see if seroconversion

Question 15

Most common HIV post-exposure prophylaxis regimen and HIV patient

Answer 15

Post-exposure prophylaxis
Tenofovir + Emtricitabine + Raltegravir

For HIV patient
Tenofovir + Efavirenz + Emtricitabine

Question 16

Late-onset depression increases the risk of what?

Answer 16

Alzheimer and vascular dementia

Question 17

Treatment of hidradenitis suppurative

Answer 17

ALL PATIENTS: weight loss, skin cleaning, smoking cessation

MILD:
Topical clinda
Intralesional steroids and oral antibiotics for flare-ups

MODERATE: nodular, sinus tracks, and scaring
Tetracyclines: doxy
Clynda + rifampin for refractory cases

SEVERE: diffuse, extensive sinus tracks
TNF alpha inhibitors: infliximab
Oral retinoids
Surgical resection

Question 18

Circinate balanitis

Answer 18

Extra-articular manifestation of Reactive arthritis

Painless ulcers with no associated lymphadenopathies (vs. LGV and syphilis)

Lesions of LGV disappear in days
Lesions of syphilis disappear in3-6 weeks
Lesion of Circinate balanitis may persist for months

If the patient has a hx of chlamydia, perform NAAT in urine. The penile lesion does not have organisms

Question 19

Risk factor for patellar tendon rupture and management

Answer 19

Fluoroquinolone treatment

Strong quadriceps contraction with the foot firmly planted and the knee in partial flexion (eg, pivot, landing)

Management is surgery

Question 20

Osgood-Schlatter knee

Answer 20

A childhood repetitive use injury that causes a painful lump below the kneecap (tibial tuberosity)

Osgood-Schlatter disease affects children experiencing growth spurts. Children who play sports in which they regularly run and jump are most at risk

Question 21

Positive stress test features (8)

Answer 21

CLINICAL:
Angina at a low workload
Poor exercise capacity
Drop in systolic BP
Chronotropic incompetence

EKG:
>1mm ST depression (flat or downslope)
ST depression at low workload
ST elevation in leads with no Q waves
Tachyarrhythmias

Question 22

Medical treatment for CAD

Answer 22

Aspirin
Statins
B-blockers

Question 23

Indications for steroids use in Pneumocystis infection

Answer 23

PaO2 < 70

or

A-a gradient >35

Question 24

Diagnostic testing for Pneumocystis infection

all

Answer 24

CBC
BMP
ABG
LDH
Sputum and stain
Chest x-ray
HIV Elisa
Bronchoalveolar lavage if sputum induction fails