Nassi Nasi Step 2 CK Notes [11348]

Nasi’s notes for USMLE Step 2 CK 1.The typical presentation of a thrombosed external hemorrhoid is an acute onset of very severe perianal pain, particularly when walking and sitting. 2. You know that external hemorrhoid is below the dentate line. internal hemorrhoids arise above the dentate line.

3. thrombosed external hemorrhoid requires immediate incision and evacuation of the clot to provide symptomatic relief. Pressure by compression is usually all that is needed to control the bleeding. 4..Sitz baths, applying a topical steroid cream, and increasing fiber intake are the usual treatment for symptomatic external hemorrhoids that are not thrombosed. 5..as a rule alwayes remember that external hemorrhoid s hurts but donot bleeding(opossit internal hemorrhoids) 6.typical picture of pyloric stenosis.,Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic metabolic alkalosis from the persistent vomiting. remeber if they give a child with intermittent spitting up think about pyloric stenosis. 7.abrupt onset of colicky abdominal pain in childeren <2 years ,think about intussusception! what's the etiology? The exact cause is unknown. However, it is associated with Meckel's diverticulum, cystic fibrosis, polyps, and Henoch-Schonlein purpura. remeber A barium enema or air enema is both diagnostic and therapeutic. 8.Remember In any patient with dysphagia that is progressive for only solids, it suggests a growing and obstructive lesion. The history of tobacco and alcohol use, puts person at a much higher risk of carcinoma. The two ways to diagnose this are a barium swallow study, which will show the mucosal mass, or an upper endoscopy study to directly visualize and biopsy the lesion. 9.Remember Esophageal manometry is used to evaluate dysphagia caused by motility disorders. These typically present with dysphagia for solids and liquids and may or may not be progressive. 10.Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status. 11.. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea.

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Nasi’s notes for USMLE Step 2 CK 12.. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound.

13.Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad). 14.The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel. 15.

Patients with ulcerative colitis are at high risk for toxic megacolon, which is also

associated with Clostridium difficile colitis 16.. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel.

17.spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin

18.. Lead levels over 10 mg/dL are considered abnormal. 19.Remeber Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects.



Nasi’s notes for USMLE Step 2 CK 20.congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia. 21 key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions. 22.Remember in a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid. BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid. 23.The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler's diarrhea ,treatment ciprofloxacin if symptoms persistent. 24.The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole

25.infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur. 26.Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor.

27.Remember sudden onset of right upper quadrant pain associated with nausea and vomiting and history right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air. 28.The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram. .

29.Remember Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis.

30.The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequ

31.in superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS.

32.Remember in

patients with known lung cancer, a biopsy of the mass causing the SVCS is

usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis). 33.Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women.

34.Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset. Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden outcropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid.

35.The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma.

36. Remeber anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium. 37.Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and Behçet's disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae.

38. hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.) 39.Remember treatment of CMV retinitis in HIV if Gancyvlovier dosen't work is FOSCARNET(can cuase renal toxicity).



Nasi’s notes for USMLE Step 2 CK 40.Asperger disorder it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development. 41.Spondylolysis is a defect seen in the pars interarticularis portion of the lamina.Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level.Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers) 42.Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.

43..Remember The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax, 44.young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis. 45.Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations. 46.Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis. 47.whenever the terms "coin-shaped" or "discoid" are used to describe a patient's skin lesions in a question you should think about nummular dermatitis. 48.Remeber symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question(they never mention stright forward A.F). In addition, are at high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel.

49.BUT Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease. 50.malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor.

51.Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status and blood in the CSF are virtually diagnostic of ruptured berry aneurysms. Note the characteristic hyperdensity on CT of the suprasellar cistern, indicating blood in the subarachnoid space. Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding. 52.PBC is due to an autoimmune destruction of intrahepatic bile ductules, and the diagnosis is made by liver biopsy. The serology that should be checked is the antimitochondrial antibody. Primary biliary cirrhosis is often seen in individuals with other autoimmune diseases, such as Sjögren syndrome, pernicious anemia, and Hashimoto thyroiditis. 53.Myasthenia gravis is an autoimmune disease in which antibodies directed against the acetylcholine receptor of the muscle side of the neuromuscular junction block the ability of the receptor to bind to acetylcholine. Remember insulin resistance is also produced by a similar mechanism, i.e. antibodies to insulin receptors block the receptors' ability to bind to insulin 54.The first step in the approach to a patient with a community-acquired pneumonia is to categorize condition according to the American Thoracic Society guidelines (1993), which are based on severity of illness, age, comorbidities, and the need for hospitalization. the criteria for hospitalization (one of the following is needed: respiratory rate > 30 breaths/min, room air PaO2< 60 mm Hg, O2 saturation less than 90% on room air, or bilateral or multiple lobes involved), and older than 60 years.

55.normal value for the anion gap is 12 ± 4 mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes mellitus, alcoholism, starvation), renal failure Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK with retained sulfate and phosphate, drugs or metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of protein anions, and dehydration (hemoconcentration).

56.Remember Subcutaneous unfractionated heparin is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis ,you should use warfarin. 57.Remember Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly affect skeletal, smooth, and cardiac muscles. Skeletal muscle effects can include weakness, cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac muscle effects include premature ventricular and atrial contractions, tachyarrhythmias, and AV block. Additional ECG changes can include ST segment depression, increased U wave amplitude, and T wave amplitude less than U wave.

58.Basal cell carcinoma affects sun-exposed areas, particularly the mid and upper face, in patients lacking protective pigmentation. One of its morphologic forms is that of a raised, waxy, pale lesion that grows very slowly and doesn't metastasize to lymph nodes. 59.Key for Keratoacanthoma : grows very rapidly in a matter of weeks and has a scaly, rough appearance, with a core of keratin. If untreated, it eventually sloughs off. 60.Squamous cell carcinoma is usually an ulcer, rather than a nodule. In the face, it favors the lower lip. If present for several years, lymph node metastasis can sometimes occur. 61.euthyroid sick syndrome, which occurs in many seriously ill patients who do not have clinical hypothyroidism. especially in ICU 61. The TSH level is usually most helpful in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4 may be normal or decreased. 62.Remember hepatorenal syndrome occurs during the end stages of cirrhosis and is characterized by diminished urine output and low urinary sodium. In the setting of end-stage liver disease, renal vasoconstriction occurs, and the distal convoluted tubule responds by conserving sodium. Unless the renal function is allowed to deteriorate further, liver transplantation will reverse this vasoconstriction and kidney function will return to normal.



Nasi’s notes for USMLE Step 2 CK then when ever you have cirrhosis with reanal faiuler the most appropriate treatment is LIVER TRANSPALNTION! 63.In beta thalassemia, a reduced production of beta chains occurs with normal amounts of alpha production 64.A shock-like pain upon percussion on the volar aspect of the wrist (Tinel sign) is a characteristic sign of Carpal tunnel syndrome ,,is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia.

65.Fibrositis , also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved. 66.Reflex sympathetic dystrophy describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant). 67.Femoral pseudoaneurysms represent an important vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses make this diagnosis likely. The diagnosis can be confirmed by ultrasound of the groin.(it was exam question of one of my friend). 68.Cholesterol emboli syndrome is also an important complication to recognize in the postcatheterization patient. It usually presents, however, with skin findings in the distal extremities of livedo reticularis, ischemic ulcerations, cyanosis, gangrene, or subcutaneous nodules. 69.Remember Another important complication of cardiac catheterization via the femoral artery is a retroperitoneal bleed . This complication presents, however, as either new back pain, an unexplained drop in the hematocrit, or purpura over the flanks. 70.what is piriformis syndrome?? As you may recall from your anatomy, the piriformis is the small muscle that crosses the greater sciatic foramen, cutting it into two spaces as the muscle passes from the edge of the sacrum to the greater trochanter. The sciatic nerve comes out of the greater sciatic foramen below the piriformis, and is liable to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. Treatment is usually to teach the patient to avoid maneuvers that set off the symptoms. Some patients have been helped by corticosteroid Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK injection near the site where the piriformis muscle crosses the sciatic nerve; this therapy is thought to work by reducing the fat around the muscle and thereby increasing the available space in the area. 71.in Adison disease Laboratory findings include hyponatremia (due to aldosterone deficiency), hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.

72.HIV encephalitis, clinically known as AIDS dementia complex, . The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS. 73. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases . 74.HIV myelopathy manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord.

75.Progressive multifocal leukoencephalopathy consists of multifocal areas of myelin destruction. These changes would be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals. 76.Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia 77.Individuals with herpes zoster are contagious and can spread the VZV virus. 78.Decreased esophageal peristalsis and decreased LES pressure :SCLERODERMA , These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus.

79.Patients with this erythema infectiosum (Fifth disease) are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 80.If a pergnant woman was in contact with a patient with fifth disease during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy. 81.Most authorities think that it is appropriate to initiate a progestin-only method of contraception immediately postpartum. It has no impact on lactation or the quality of breast milk.

82.The triad of miosis, respiratory depression, and coma is suggestive of opioid intoxication 83.Phenelzine is an antidepressant monoamine oxidase inhibitor (MAOI) that causes hypertensive crises and the serotonin syndrome (hypertension, tachycardia, fever, coma, and possibly death) when combined with tyramine-containing food (cheese) and serotonin-altering drugs.Pseudoephedrine and other nasal decongestants, bronchodilators, amphetamines can cause severe hypertension when monoamine oxidase is inhibited and should be avoid. 84.the classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles. 85.Fiberoptic bronchoscopy is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation. then remeber if you have a patient with hemoptysis with past history of smoking ,your first step is CXR even if he/she is normal right now!but!!!!!!!Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker.

86.Complications of ovarian torsion include infection, peritonitis, sepsis, adhesions, chronic pelvic pain, and infertility due to the loss of the viability of the torsed ovary. 87.Remember One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation.



Nasi’s notes for USMLE Step 2 CK 88.The pathophysiology of ITP: involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen. 89.Remember an extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients. 90.Multifocal glioblastoma multiforme (GBM) , the most frequent malignant primary brain neoplasm, manifests as an ill-defined mass in the white matter. 91.Wernicke encephalopathy is characterized by nystagmus progressing to ophthalmoplegia, truncal ataxia and confusion. 92.Korsakoff syndrome refers to alcohol-related amnesia and confabulation. WernickeKorsakoff syndrome is due to vitamin B1 deficiency, which is often seen in chronic alcoholics. This deficiency results in degeneration of periaqueductal gray matter. 93.Remember Huntington disease autosomal dominant condition is caused by an unstable expansion of a CAG trinucleotide repeat and MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images. 94.The pathologic substrate of this condition(Huntington disease ) is degeneration of the striatal neurons, especially those in the caudate nucleus. 95.the pathogenesis of stress-induced gastritis:Diffuse gastric mucosal vasoconstriction 96.Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation, is common in carcinoid patients and is the result of toxic damage to the heart 97.Ondansetron, a 5-hydroxytryptamine3 antagonist, is the most potent antiemetic available for chemotherapy-induced vomiting.It has side effects only infrequently, the most common being constipation. 98.Copper deficiency can present with anemia and neutropenia, Zinc deficeincy will present with alopecia, impaired wound healing , dermaititis, selenium def will present with dilated cardiomyopathy 99.Bernard-Soulier syndrome is an autosomal recessive disease of platelet adhesion which causes prolonged bleeding times in the presence of normal platelet counts. These patients' platelets cannot bind to subendothelial collagen properly because of a deficiency or dysfunction of the glycoprotein Ib-IX complex. Clinically the patients have impaired hemostasis and recurrent severe mucosal hemorrhage. The only treatment for an acute episode is a transfusion of normal platelets. This patient has a slightly decreased hemoglobin due to blood loss. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 100.Von Willebrand's disease causes increased bleeding times with normal platelet counts. It is the most common inherited bleeding disorder, caused by a defect in von Willebrand factor, which aids the binding of platelets to collagen. Even though the platelets themselves are normal, binding is impaired, thus a platelet transfusion would not correct the problem. Cryoprecipitate, a plasma fraction rich in von Willebrand factor, would help in the case of von Willebrand's disease, but would not help with Bernard-Soulier syndrome. Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2x) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the upper body, or reduced development of the lower extremities. 101..Lymphoma is well known to develop specifically in the late stage of Sjögren's syndrome. Common manifestations of this malignant condition include persistent parotid gland enlargement, purpura, leukopenia, cryoglobulinemia, and low C4 complement levels. 102.if they give you a farmer patient presents with acute-onset pulmonary symptoms, including wheezing, with no other medical problems and was recently handling hay.think about farmer's lung, a hypersensitivity pneumonitis caused by Actinomyces. In this disorder moldy hay with spores of actinomycetes are inhaled and produce a hypersensitivity pneumonitis. The disorder is seen most commonly in rainy periods, when the spores multiply. Patients present generally 4 to 8 h after exposure with fever, cough, and shortness of breath without wheezing. Chest radiograms often show patchy bilateral, often upper lobe infiltrates. The exposure history will differentiate this disorder from other types of pneumonia.

103.The Women's Health Initiative (WHI) demonstrated that estrogen-progestin therapy in Postmenopausal can reduce the risk of hip fractures by 34%. However, the WHI also demonstrated that estrogens are associated with a 30% increase in myocardial infarction, a 40% increase in stroke, a 100% increase in venous thromboembolism, and a 25% increase in breast cancer. In the WHI study there was no overall effect of estrogen-progestin therapy on mortality, probably because of the balance between the detrimental cardiovascular effects and the beneficial effects (in addition to fractures, there was a beneficial effect on the development of colon cancer).harrison new eddition!

104. Remember Pain, loss of function (without clear-cut sensory or motor deficits), and a Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK localized autonomic impairment are called reflex sympathetic dystrophy (also known as shoulder-hand syndrome or causalgia). Precipitating events in this unusual syndrome include myocardial infarction, shoulder trauma, and limb paralysis. In addition to the neuropathic-type pain, autonomic dysfunction, possibly resulting from neuroadrenergic and cholinergic hypersensitivity, produces localized sweating, changes in blood flow, and abnormal hair and nail growth as well as edema or atrophy of the affected limb. Treatment is difficult; however, anticonvulsants such as phenytoin and carbamazepine may be effective, as they are in other conditions in which neuropathic pain is a major problem. 101. Remember when a patient has acute attacke with Renal faiuler the best drug for treatment would be either oral prednisone or steroids injected into the joint. He should not receive NSAIDs because he has renal insufficiency. Rofecoxib, a COX-2 inhibitor, can also be detrimental to renal function and should not be used in this setting. 102.remember Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs). In the small interphalangeal joints of the fingers, central erosions may be seen within the joint space 105.HTN+Glocuma treatment?B blocker 106.Remember Addiction has identifiable risk factors, including genetic factors. The most well-established risk factors for addiction are family history and male sex. 105 in cocain toxi serum and urine tests are useful when they are positive, but they are of limited utility when they are negative because of the short duration of detectability of cocaine (6 to 8 hours) and cocaine metabolites (2 to 4 days). Cocaine does not produce compensatory adaptations in brain regions that control somatic functions and therefore does not produce dependence. Dependence and, therefore, withdrawal are not produced by highly addictive compounds such as cocaine. 107.The benzodiazepines (e.g., chlordiazepoxide, diazepam, lorazepam, and oxazepam) are the safest and most effective medications for treatment of alcohol withdrawal 108.glucagonoma and gastric adeno ca are associated with acanthosis nigric 109.nasopharyngeal ca also burkitts lymphoma t8:14 are associated with EBV 110.Findings in Von Recklinghausen's disease: ... café-au-lait spots, neural tumors, Lisch nodules (pigmented iris hamartomas), skeletal disorders (scoliosis), and increased tumor susceptibility 111.Findings of Cri-du-chat syndrome: ... microcephaly, severe MR, high pitched crying/mewing -(Cri-du-chat is French for cry of the cat), cardiac abnormalities Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 112.Pathogenesis of Cystic Fibrosis: ... defective Cl- channel --> secretion of abnormally thick mucus that plugs lungs, pancreas, and liver --> recurrent pulmonary infections (Pseudomonas species and Staph aureus), chronic bronchitis, bronchiectasis, pancreatic insufficiency (malabsorption and steatorrhea), meconium ileus in newborns. 113.Which gene is affected in Fragile X? ... methylation and expression of the FMR 1 gene is affected in this X-linked disorder

114.2 skin conditions in AIDS patients one is a bacterial infection and another viral cause both look similar? kaposi's sarcoma-HHV 8 AND BACILLARY ANGIOMATOSIS-caused by bartonella henselea 115.urticaria you get subcutaneous edema and angioedema you get mucosal edema 116.Genetic anticipation of Fragile X syndrome may be shown by what? Triplet repeat (CGG)n 117.Huntington gene involved and triplet repeat CAG ,chromosome 4p 118.: Kidney cancer is a neoplastic condition that can initially appear with many different paraneoplastic manifestations. The initial presentation may include hypertension, flank mass, gross or microscopic hematuria, hypercalcemia, fever, weight loss, and/or polycythemia. This polycythemia is the presenting sign in 3% of cases of kidney cancer. In kidney cancer, polycythemia is secondary to a hypersecretion of tumor cytokines, including renin. The patient's erythropoietin level is usually high. Surgical removal of the cancer resolves the polycythemia. , full evaluation is important in patients presenting with polycythemia and hematuria. Kidney cancer is an important differential diagnosis of secondary polycythemia.

119.Remember esophagitis in HIV often presents with belly or epigastric pain that could be caused by CMV or herpes simplex, but Candida most common (80%-90%); treat empirically with fluconazole 100 to 200 mg/day 120.Cryptococcal meningitis in HIV minority of patients have meningeal signs; most have only fever and headache; obtain head CT and lumbar puncture (LP); elevated opening pressure most common abnormality; cerebrospinal fluid (CSF)—can be normal; most have normal glucose; only 50% of patients have elevated protein; minority of patients have white blood cells in CSF; india ink simple test that detects 75% of cases; cryptococcal antigen >90% sensitive, but results take 1 to 2 days at most institutions how do you treat?Treatment: treat with amphotericin B; flucytosine added in patients with severely elevated pressures; fluconazole as maintenance for rest of life Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 121.Remember LDH: nonspecific test; appears to be consistently greatly elevated in PCP; PCP unlikely if LDH normal (in HIV ) 122.Remember Pneumocystis carinii pneumonia (PCP) less common now because many patients receiving medical care get prophylaxis for this organism; P carinii now considered closer to fungi than to protozoa; bacterial pneumonia now more common than PCP 123.Antiretroviral treatment for HIV: no consensus on when to start; indications include acute HIV infection, symptomatic HIV infection, CD4 count <350 cells/µL, high viral load (ie, >55,000 copies/mL 124.Kaposi’s sarcoma: reddish/purplish lesions can be located anywhere (internal or external); characteristic appearance of sharp demarcation (HSV8) Hairy leukoplakia: tends to occur on side of tongue; cannot be scraped off like thrush; related to Epstein-Barr virus 125.What 2 neoplasms are associated with AIDS? ... 1. Aggressive malignant lymphomas (non-Hodgkins) 2. Kaposi's sarcoma 126.What 2 neoplasms are associated with Tuberous sclerosis (facial angiofibroma, seizures, and mental retardation)? ... 1. Astrocytoma 2. Cardiac rhabdomyoma 127.What are a common histopathological finding of meningiomas? ... Psammoma bodies. These are spindle cells concentrically arranged in a whorled pattern

128.What are ependymomas? ... Ependymal cell tumors most commonly found in the 4th ventricle. May cause hydrocephalus 129.Reason why Pregnant women get more chances of UTI: Increase in ventilation rate causes respiratory alkalosis: This causes renal compensation for and causes alkaline urine. This provides a good growth media 130. Remember the normal values of Non pregnant women does not apply to pregnant women. In pregnant women, the upper limts of BUN and Serum creatinine should be 10 and 0.5 respectively. If a pregnant woman has a serum creatinine of 1.5, then it can only mean 2 things: Either she has a kidney disease or it could be due to hyper coagulation which is seen only in Preeclampsia 131: What constitutes a positive SLR sign to diagnose radiculopathy? SLR is positive if the maneuver REPRODUCES THE PATIENT'S USUAL PAIN .The patient may describe pain in the low back,buttocks, post. thigh or lower leg. But the key feature is reproduction of the patient's usual pain. Other factors such as muscle stiffness can mimic radicular pain. SLR is used to detect lesions of L5 and S1 roots and sciatic nerve. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK Reverse SLR (passive extension of leg with patient standing)-for L2-L4 roots and femoral nerve Crossed SLR-Performance of maneuver on one leg produces pain in the opposite leg or buttocks-The nerve or nerve root lesion is always on the side of the pain. For all these tests, the key feature is REPRODUCTION OF PATIENT'S ORIGINAL PAIN. (source: Harrison') 132.How do you manage a patient with non massive9less than 100 cc in 24 hour) hemoptysis? The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially. If the chest x-ray is normal and the patient has risk factors for cancer, like smoking a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary. 133.Remember Once a biopsy diagnosis of cervical intraepithelial neoplasm has been made, an appropriate treatment option is a loop electrosurgical excision procedure, and the most common complication being postoperative bleeding. 134.Remember Patients with dural sinus and cerebral venous thrombosis can present with headaches, stroke-like symptoms, and/or seizures. There are multiple etiologies including dehydration, sepsis, and trauma. In addition, hypercoagulable states such as sickle cell disease, leukemia, and pregnancy are also predisposing factors. Because the symptomatology of a dural sinus thrombosis is nonspecific, imaging studies play a critical role in the diagnosis. On non-contrast enhanced head CT, a cord sign or tubular hyperdensity may be seen in the acute setting along with cortical and subcortical hemorrhage due to venous stasis and infarction. The treatment of choice during pregnancy is intravenous heparin. Unfractionated heparin and low molecular weight heparin (LMWH) do not cross the placenta and are considered safe for the fetus, but must be administered parenterally.

135.alwayes remember Children with sickle cell disease, despite splenomegaly, have reduced function of the reticuloendothelial system, (functional asplenia). Therefore, in a sickle cell patient with a fever, it is important that broad spectrum antibiotics are instituted as soon as possible to protect against septicemia from encapsulated organisms such as H. influenzae, Pneumococcus, and Neisseria. 136.Heat stroke can occur in athletes who exert themselves in conditions of high humidity and temperatures. Clinical signs of this condition include a core body temperature of >40.5 C (or



Nasi’s notes for USMLE Step 2 CK 105 F), profuse sweating, and mental status changes. Patients with exertional heat stroke are at risk for disseminated intravascular coagulation and rhabdomyolysis 137.Treatment for rhabdomyolysis involves intravenous saline infusions to maintain a high urine output and alkalization of urine with a target pH of 7-8 to prevent myoglobin deposition. 138.remember aortic dissecting aneurysm caused by degeneration of tunica media-cystic medial necrosis 139.Remember cardiac rupture most common 4-7 days post MI. ventricular free wall rupture leads to cardiac tamponade 140.Remember New onset serous discharge from a laparotomy wound should raise the suspicion of wound dehiscence. 141.Remember acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness: Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should also be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performed after the IOP is controlled. 142.treatment of Acne rosacea,avoiidng exogenouse factor,topical metronidazole ,no response give tetracycline

143.Risk factors for TOA include IUD use, multiple sexual partners, and previous episodes of pelvic inflammatory disease.ntravenous cefoxitin is used because it is an antimicrobial agent that is active against Gram-negative and anaerobic organisms, the predominant bacteria found in these abscesses what wwill you see in sono?trasonography of the pelvis demonstrates a complex, cystic mass containing multiple septations and internal echoes in the left adnexa. 144.A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a oneway valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure 145.A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan. in trension pneumothorax The ventilation perfusion scan demonstrates lack of ventilation and perfusion .



Nasi’s notes for USMLE Step 2 CK 146.how do you manage a syncopal episode in a yaoung healthy adult? when a young, healthy, athletic patient had a syncopal episode, which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome. 147. Remember,Higher prevalence enhances positive predictive value. Simply put, if more people actually have the disease, then a positive test result has a higher probability of being true. Note that for the reasons described here, diagnostic tests always have a higher positive predictive value than screening tests. 148.Remember The definition of chronic sinusitis is a sinus infection greater than 3 months. The most common etiology is infectious and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms although certain imaging studies are very useful. The only imaging study to consider is a sinus CT. If positive, the maxillary or ethmoid sinuses will be opacified. 149.Remember Women who have very low body fat and/or participate in intense exercise are known to have a decrease in gonadotropin releasing hormone (GnRH), which in turn results in a diminished release of follicle stimulating hormone (FSH) and leuteinizing hormone (LH). Ovulatory dysfunction is responsible for approximately 20-25% of infertility cases. 150.Septic shock is characterized by decreased blood pressure despite euvolemia and is often seen with severe infection, especially with Gram-negative organisms. Release of inflammatory mediators is responsible for decreasing SVR. Patients are thought to be in a hyperdynamic state with increased cardiac output. Volume status is reflected by PAWP and is classically normal but can be normal, low, or high depending on the aggressiveness of hydration.

151.Decreased CI, increased SVR, and normal PAWP is an example of cardiogenic shock. This is common with cardiac tamponade or myocardial infarction. It should be thought of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR is increased in an effort to maintain blood pressure. The PAWP is normal in these patients since volume is typically not the primary problem



Nasi’s notes for USMLE Step 2 CK 152.Hypovolemic shock is demonstrated by a low cardiac index, an increased SVR, and a decreased PAWP. Simply, CI and PAWP are low because there isn't enough blood volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt to increase blood pressure.

153.Obstructive shock, characterized decreased CI and normal SVR and PAWP , is typically caused by massive pulmonary embolus. Supportive care with IV fluids and vasoconstrictors along with possible embolectomy is indicated. Note: The only indication for embolectomy is hemodynamic instability. 154.Remember the presentation of painless jaundice is highly suspicious for a pancreatic head mass and in particular adenocarcinoma of the pancreas. Adenocarcinoma of the pancreas accounts for more than 90% of pancreatic malignancies and jaundice is present in about 65% of patients. Risk factors for pancreatic adenocarcinoma include smoking and diabetes. The best initial evaluation for pancreatic masses is by CT of the abdomen and pelvis. 155.Remember Lorazepam is a short acting benzodiazepine with no active metabolites. Lorazepam is metabolized to the glucuronide form and excreted by the kidneys. The drug is tapered over 4-6 days for detoxification purposes. It is safe in patients with severe liver damage, and it won't compromise respiration in severe COPD 156.Chlordiazepoxide is a long-acting benzodiazepine that is used for detoxification from alcohol in uncomplicated cases. It has several metabolites that are long acting, thus making it difficult to efficiently manage the detoxification without risking the accumulation of drug and its metabolites because of impaired liver metabolism. In patients with severe COPD, it can compromise respiration secondary to sedative effects.

157.Remember renal vein thrombosis. Most commonly occurs in Membranous glomerulonephritis. 158. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis. This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. Tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors. 159.The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur,



Nasi’s notes for USMLE Step 2 CK approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated. 160.Remember he two live vaccines, MMR and the varicella vaccine, are not recommended for use before the first birthday, but should be given the first time the child sees the doctor after 12 months of age. 161.Remember The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma. 161. Laboratory data for multiple myeloma includes anemia, an elevated creatinine from secondary renal dysfunction, and elevated IgA and IgG levels and hypercalcemia. 162.alwyes remember bone scan has a low sensitivity for myeloma lesions and has no role in its workup. Do not confuse a bone survey which is a series of x-rays evaluating all of the bones with a bone scan which is a nuclear medicine scan. NO!NO!NO!NO BONE SCANE FOR MULTIPLE MYELOMA!!!!!!!!!!!!!!!!!!!!!! 163. a postoperative pelvic abscess: This condition may occur after abdominal surgery, and presentation usually occurs after postoperative day 7. Diarrhea is frequently the earliest manifestation of abscess formation. . A fluctuant mass is a common finding on physical exam, and a rectal exam should be performed on all postoperative patients who are at risk for developing an abscess. A postoperative abscess will frequently cause an ileus, as manifested by vomiting, abdominal distention, decreased bowel sounds, and radiographic findings. Although the clinical grounds may provide you with the diagnosis of abscess, imaging studies should be undertaken to localize the fluid collection and aid in drainage. A CT scan probably has the highest yield compared to the other imaging modalities. Besides localizing the abscess, a CT scan will aid in the drainage of the fluid collection. 164.APGAR is a named after Virginia Apgar, M.D. who came up with a rating system for neonates at delivery. One helpful mnemonic is A: appearance, P: pulse, G: grimace or response to catheter in nostril, A: activity or tone, and R: respiratory effort. Each category is rated from 0-2. 165.Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections. 166.After a myocardial infarction, normal sexual activity can typically be resumed 2-4 weeks after discharge from the hospital. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 167.some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a "blueberry muffin" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect. 168.Remember Toxoplasma gondii is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth will develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash. 169.Varicella-zoster infection in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death. 170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%. The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%. 171.Remember

when ever you use niacin you should monitor liver function and plasma

glucose carefully. when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL

172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.

173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.

170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%. The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%. 171.Remember

when ever you use niacin you should monitor liver function and plasma

glucose carefully. when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL

172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.

173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest. 174. Remember white cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD. 175.The treatment of unstable atrial fibrillation (atrial fibrillation associated with hypotension, myocardial ischemia, congestive failure, etc.) is immediate synchronous cardioversion, in an attempt to immediately restore sinus rhythm. 176.Churg-Strauss vasculitis: Prednisone should be started at a moderate dose, along with a bisphosphonate to prevent osteoporotic fractures,in initial therapy no cyclophosphamid,...



Nasi’s notes for USMLE Step 2 CK 177.Remember Major depression need not present as classic dysphoria or sadness.It may present as irritability particularly in children and adolescent. 178.know pictures of fundoscopy ( glaucoma, DM, and cmv) skin (herpes zoster) ecg (1st degree block) preop. 179.IN DM with sports this is what we do… check ketone.. if positive ,, he cant participate until ketones are gone… in DM insulin is decreased with snacks during break….check glucose before and after sports is also a recoomendation 180.black male with HTN + DM .what HTsive med do u give? …..Ace inhibitor….*htn plus diabetes

181.“BILATERAL”renal a. stenosis with HTN, what med do you use to tx HTN… Answer is calcium channel blocker…. If it was unilateral stenosis then ACE inhibitors 182.A male pt with thumb base pain what is dxa. De querene tensovitis is the answer… treatment is nsaid and intrathecal steroids. 183.a pregnant rh- do not know father what is next? test rh titer now 184.primigravida 28 weeks, rh negative ,husband positive anti lewis antibody positive what next 1)give anti rhd 2.dont give anti rhd 3.do amniocentesis, answer,,,, DON’T DO ANYTHING… 185.During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him: 1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno) Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnza… ZANAMIVIR is the best treatment it covers both A and B) 186.Know exact inetrvals for pap smear (cervical cancer screening), breast cancer screeing, prostate cancer screening and colorectal cancer. This is very important topic many Q in this topic

187.How do you treat Cocaine abuser with 210/115 BP? Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and



Nasi’s notes for USMLE Step 2 CK Phentolamine 1 mg IV No beta blockers like propranolol

188. Remember Bilious vomiting in an infant means that there is a malrotation with volvulus until proven otherwise. The radiographic findings of the cecum in the left upper quadrant confirms this clinical diagnosis. An upper gastrointestinal series would likely show a bird-beak deformity of the midgut where there is volvulus of the gut around a mesenteric "Ladd" band.

189.Remember about 20% of malrotation with volvulus is associated with duodenal atresia, annular pancreas, or a duodenal diaphragm. About 33% of cases present in the first week of life and 85% present in the first year of life. The hallmark of malrotation is ischemia of the midgut as the superior mesenteric vein and the superior mesenteric artery are occluded by the twisting mesentery. Immediate surgery is necessary to prevent death or the loss of much of the bowel. 190.Intussusception typically presents in infants from 4 months to 2 years of age, with alternating lethargy and irritability, colicky abdominal pain, and currant jelly stools. In addition, there is usually a right lower quadrant mass on abdominal x-ray. 191. The presence of tamponade is suggested by the presence of diminished heart sounds and pulsus alternans (a beat to beat variability in the QRS amplitude) on EKG. 192.It 's useful to note that the shock typically associated with sepsis, anaphylaxis, and neurogenic shock is associated with vasodilation, and hence, with warm extremities. 193.complication of polycytemia vera: 1.Hyperuricemia due to increased rbc turnover is common in patients with polycythemia vera, and these patients are at increased risk of gout. 2.Both arterial and venous thrombosis are common in polycythemia vera. The Hct is directly related to the risk of thrombosis. This association between Hct and risk of thrombosis forms the basis for the treatment recommendation to keep the Hct less than 46%. The platelets are derived from the neoplastic clone and may not function normally 3.Approximately 15-20% of patients with Polycythemia vera eventually develop myeloid metaplasia. Myeloid metaplasia is characterized by gradual replacement of the marrow space with fibrosis, and movement of hematopoiesis into the spleen and liver. The spleen and liver become massively enlarged, and the patient becomes progressively pancytopenic

194. Polycythemia vera :Neoplastic hematopoietic stem cell,CBC in Polycythemia vera: Hct Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK and often WBC and platelets are increased ,reatment: Phlebotomy or hydroxyurea or 32P to keep Hct below 46% ,Decreased or low normal erhtropoitine 195. Secondary Polycythemia:

disorder Due to tissue hypoxia causing an appropriate

increase in Epo production, or to renal or hepatic disease causing an inappropriate increase in Epo production ,Only Hct is increased ,Treatment is usually not required,Normal or increased erhtropoithine 196.Hyperuricemia: An elevated uric acid level can result from gout, renal failure or an increased production of uric acid secondary to high rates of cell turn over such as in patients with hematologic malignancies. it may also be seen during treatment of these malignancies with chemotherapy when the rapid destruction of cells releases large amounts of uric acid into the blood, so called "tumor lysis."

197.Whenever u see an HIV positive patient on pentamidine with seizure think ((pentamidine induced hypoglycemia..and check bld glc!!)) 198. Efavirenz contraindicated in pregnancy 199.Hypocalcemia, hypomagnesemia, hyperphosphatemia. Renal impairment progressing to renal failure. side effect of foscarnet also remember other drugs like Other drugs that affect the kidneys like amphotericin B and pentamidine should be avoided.

200.). The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient's history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis.

201.the age of 18 months, most children will have developed a specific set of skills which can be divided into: social, self-help, gross motor, fine motor, and language. Social skills at this age include greeting people by saying "hi" or something similar, giving hugs and kisses, and playing patty-cake. Self-help involves drinking from a cup and feeding self with a spoon. Gross motor skills include walking without help and beginning to run. Fine motor skills would include scribbling with a crayon and stacking 2 blocks. Language skills should encompass talking in single words, asking for food or drink with words, and following simple instructions.



Nasi’s notes for USMLE Step 2 CK 202.Histoplasma capsulatum is a dimorphic fungus ,it is endemic to the Ohio, Missouri, and Mississippi River valleys , T lymphocytes are crucial in limiting the extent of infection. Susceptibility to dissemination is increased markedly with impaired cellular host defenses. A thorough social and occupational history is essential in the initial evaluation. Travel or residence in an endemic area or activities involving bats or birds, whether recent or remote, should aid in the differential. Determine if the patient has a drug history or comorbid condition that is contributing to an immunocompromised state. 203.temporomandibular joint (TMJ) disorder, which is a very common disorder that can usually be detected by palpating the area just in front of the tragus. Joint clicking may be found when the patient opens and closes his mouth. Symptoms of TMJ include orofacial pain, a noisy joint, and restricted jaw function. 204.remember treatment for preventing recurrence of HBV after liver transplant is HBV Ig + Lamivudine 205.Hairy-cell leukemia: B-cell leukemia -tartrate resistant acid phosphatase -give cladribine for treatmen. 206. Rx acute attacks of migrains : Rizatriptan 207.Rx acute attack of migrains lasts for longer than 48 hours or r frequently recurrent : ergotamine 208.Rx rhabdomyolysis : osmotic diuresis + bicarbonate 209.Low Ca, high P, high PTH=secondary hyperPTH due to renal failure -lung cancer: high PTH-related peptide, high Ca, low P -primary hyper PTH: high Ca, low P, high PTH -multiple mieloma: high Ca, low to normal PTH

210.HIV patient pneumonia-MC is still pneumococcus In PCPpneumonia=>no pleural effusions In PCPpneumonia=>no pleural effusions

211.A new born with central cynosis ,apex palpated on the rt and scaphoid abdomen,neonatologist suspects diaphragmatic hernia? whats the next step to do?



Nasi’s notes for USMLE Step 2 CK do orogastric suction and can operate after 2/3 days because the lungs are hypoplastic and u allow them to be mature

212.42 yo M, repeated LL clots ? Dx? (factor V laiden deficiency) 213.. M with superficial varicose veins, discoloration of LL ? cause? (increased hydrostatic pressure in the v/s) 214.M fall off a ladder & hit with the ladder, 3-4 Ds later comes with abd pain, tense & tender, abd XR shows fluid under both side diaphragm ? Dx ?( splenic rupture) 215.9 mo, said to be fell off couch, have different color bruises all over, withdrawn, can’t sit or stand without support, <5th % ? what next? (skeletal survey) 216.. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis. 217.In the 2001 update of their screening recommendations, the U.S. Preventive Services Task Force strongly recommended routine screening for chlamydia in all sexually active women aged 25 and younger, as well as in asymptomatic women older than 25 who are at high risk. 218.intermittent claudication, which is a sign of peripheral vascular disease. Patients often complain of pain during exertion that is relieved by rest. Noninvasive evaluation is usually recommended initially and consists of determining the ratio of ankle to brachial arterial pressures. The ankle/brachial artery ratio is determined by measuring and comparing the 2 blood pressures. If the ratio is less than 1 (greater than or equal to 1 is considered normal), peripheral artery disease is present 219. Remember Vancomycin is used in febrile and neutropenic patients in addition to ceftazidime when the patient has an indwelling central vascular catheter 220. Chest pain, fever, tachycardia, subcutaneous emphysema, dysphagia, and dyspnea are suggestive of an esophageal perforation. An esophageal perforation may result from endoscopic procedures, external trauma, esophageal disease, and spontaneous perforation from violent bouts of emesis. Prompt recognition of an esophageal perforation is necessary to prevent delayed complications. Whenever a perforation is suspected, a contrast study should be performed with water-soluble contrast material. If this study does not demonstrate the perforation, it should be repeated with barium. Barium is more accurate for a delineating esophageal leakage. Contrast studies not only help in diagnosing esophageal rupture but also document the level of injury, which has important implications for treatment.



Nasi’s notes for USMLE Step 2 CK 221.Topical steroid and phototherapy are the two main therapeutic modalities in treating vitiligo. 222.the presence of a central venous catheter for 6 days in an intensive care unit (ICU) dictates strong consideration of catheter-associated sepsis, for which staphylococci are the most common cause. The absence of inflammatory changes at the site of catheter insertion is not uncommon in the presence of catheter-associated bacteremia. Because methicillinresistant strains of staphylococci are common in many ICUs, vancomycin must be a component of the antibiotic regimen to cover these pathogens. Genta-micin is used to cover the less frequent possibility of gram-negative catheter-associated sepsis and is indicated because the patient is in septic shock. 223.The diagnosis of common variable immunodeficiency (CVI) should be suspected in any patient with abnormally recurrent or severe bacterial infections of the upper or lower respiratory tract. Early diagnosis of CVI is important because immunoglobulin replacement therapy can prevent recurrent infections and associated chronic tissue damage. It is important to consider other conditions that may predispose a patient to recurrent respiratory tract infections, such as allergies and anatomic abnormalities, when evaluating a patient for suspected humoral immunosuppression. The laboratory tests for CVI consist of measuring serum immunoglobulin levels, including subclasses of IgG. In addition to quantitative measurements of serum immunoglobulins, it is important to evaluate the patient’s ability to produce specific IgG antibodies to protein and polysaccharide antigens. The decision to treat patients with immunoglobulin replacement therapy is based on the frequency and severity of recurrent infections and a demonstrated failure to mount functional antibody responses, rather than on the absolute level of serum IgG. 224. Adrenoleukodystrophy: 1.X linked ds 2.cha by visual loaa,spasticity,mental retardation. 3.there is failure of meta of long chain fatty acid. Rx-Dietary restriction of long chain fatty acid 225.Remember The psychiatric manifestations of hypothyroidism include fatigue, depression, lethargy, psychomotor retardation, poor concentration, and forgetfulness. 226.Remember Spironolactone has an anti-aldosterone effect and therefore predisposes a patient to hyperkalemia. (Remember that hyperkalemia is an important stimulus for the secretion of aldosterone.)



Nasi’s notes for USMLE Step 2 CK 227.Remember Acetaminophen can predispose susceptible patients to renal failure through tubular injury (acetaminophen is a metabolite of phenacetin, a known tubular toxin. 228.Remember MRI with gadolinium is considered the most sensitive test for detecting microadenoma. The test can reveal microadenomas in 20% of normal women. 229.Achalasia is a neurogenic esophageal disorder thought to be caused by a malfunction of the myenteric plexus of the esophagus. The result is denervation of the distal esophageal muscle with resulting impaired esophageal peristalsis. The characteristic findings on esophageal manometry are diminished or absent peristalsis in the body of the esophagus and a high resting lower esophageal pressure 230.remember To rapidly assess for the possibility of antifreeze ingestion, the physician can evaluate the patient's urine under a Wood's lamp for fluorescence. Manufacturers of ethylene glycol-containing antifreezes typically add fluorescein to the mix, which will fluoresce under a Wood's lamp 231.Remember Evaluating the optic discs for hyperemia is typically reserved for suspected methanol toxicity, since methanol is metabolized to formic acid, which can cause irritation of the optic nerve 232.Remember whenever they asked about vulvar heart disease ,look at BP ,if it's wide,you should consider AR! 233.Mitral stenosis presents with a diastolic rumbling murmur heard at the apex of the heart AR:blowing diastolic murmur heard loudest at the left sternal border 234.Acute cholecystitis is the result of cystic duct obstruction, and this would be best demonstrated by a HIDA scan. 235.Remember skin tags, more formally known as acrochordons 236.Remember silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. Intravenous pyelogram (IVP) will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer. Thus, both procedures are needed. 237.Remember There is no need for prophylaxis for IE when the cardiac lesion is due to prior coronary artery surgery, mitral valve prolapse without regurgitation, prior rheumatic fever or Kawasaki disease without valvulopathy, presence of a pacemaker, isolated secundum atrial septal defect, surgically repaired septal defect or patent ductus arteriosus, or physiologic heart murmurs. 238.remember some procedures require no prophylaxis for endocarditis regardless of the type of cardiac lesion. These include dental procedures that do not induce bleeding, endotracheal Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK intubation, tympanotomy tube insertion, cesarean section, uncomplicated uterine procedures in the absence of infection, and cardiac catheterization. 239.Remember Increasing anemia in a previously well-maintained immunosuppressed patient is suggestive of parvovirus B19 infection, especially with an associated reticulocytopenia. Occasionally giant pronormoblasts may be seen on the peripheral blood smear. A bone marrow examination may confirm the absence of erythroid progenitor cells and exclude other pathology, but is not required to diagnose parvovirus B19 infection. The diagnosis should be confirmed by the detection of parvovirus B19 antigen or significant levels of parvovirus B19 DNA in serum by (PCR). 240.Remember paitent with kawasaki have conjunctival involvment but in scarlet fever no conjunctival !! 241.HHv6:Roseola HHV7:pitrias rosea HHv8:kaposi sarcoma 242.Erythema multiforme,exfoliative dermatitis& the Stevens-Johnson syndrome r potentially life-threatening drug reactions of sulfa agent. 243.Remember The risk of contracting meningococcal disease among household members and childcare and nursery school contacts is considered high enough to warrant chemoprophylaxis. Rifampin, ceftriaxone, and ciprofloxacin r the 3 recommended agents used as chemoprophylaxis for invasive meningococcal disease. 244.inhalant intoxication is characterized by euphoria,belligerence,apathy,impaired judgment,dizziness,nystagmus,incoordination,slurred speech,unsteady gait,lethargy,depressed reflexes,psychomotor retardation,tremor,muscle weakness,diplopia.Stupor,coma may occur. 245.Good q:A 48 yo woman has a 3yr history of gradually progressive writhing movements of her extremities,emotional lability,aggressive outbursts& memory impairment.Mental status exam reveals a withdrawn& irritable woman who speaks only in monosyllables.Which of the following is the most appropriate pharmacologic intervention? A:benztropine B:carbamazepine C:chlorpromazine D:haloperidol E:lorazepam D:haloperidol Case of Huntington dementia



Nasi’s notes for USMLE Step 2 CK 246.A preterm infant required positive pressure ventilation for 3mo,and developed bronchopulmonary dysplasia.After discharge from the hospital,the child was noted to have intermittent episodes of acute respiratory distress& wheezing unresponsive to bronchodilator therapy.The most appropriate diagnostic test in this case is: a:Cxray b:a serum theophyline level c:an ABG determination d:an echocardiogram e:bronchoscopy

A. e:bronchoscopy It’s the diagnostic test of choice,characteristic findings on bronchoscopy in this infant include narrowing of the airway by abnormal growth of tissue,tracheomalacia or bronchomalacia or both 247.Remember Steroids, especially intraarticular steroids,r very effective when NSAIDs and Colchicine (which are the treatment of choice for acute gout)r contraindicated.In this pt,CRF is a relative contraindication to NSAID & rofecoxib use.So,intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects. 248.Neuromelanin are found in substantia nigra & locus ceruleus and they disappear in Parkinson's dz. 249.which type of brain tumor can be spread by CSF ? medulloblastoma 250.Remember germinoma, as common in pineal gland area, give Parinaud's. Brain stem glioma give (usually benign pilocytic astrocytoma) may give locked-in syn.

251.which lesion can be induced by aneurysm of Posterior communicating artery of Circle of Willis ? which lesion can be induced by aneurysm of Anterior communicating artery of Circle of Willis ? 1.3rd nerve palsy 2.bitemporal lower quandrantinopia

252.)CHF due to aortic regurgitation=>give diuretics, ACE inhibitors, digoxin, NOT Betablockers-which prolong the diastole=>increased regurgitation



Nasi’s notes for USMLE Step 2 CK 253.Malaria-P.vivax-fever every 48h P.ovale-fever every 72h P. falciparum=>no periodicity -starts with intens chills, then the hot phase, then 2-6h later-vomitting, low BP, tahicardia -anemia, splenomegaly -hystory of past similar complaints when in Africa 254.Babesiosis-RBC cell parasite -from ticks -varies frrom asymptomatic to severe anemia, jaundice and renal failure -seen in splenectomised patients or with HbSS diseases 255.)TB can appear in HIV patients even with CD4>200/ul -no need of hystory of close contacts 256.Case of SYSTEMIC MASTOCYTOSIS which there's proliferation of mast cells in the skin,liver,spleen,BM&lymph nodes. It can occur at any age,no FH+,and atopy is not increased in these pts. the cutaneous lesions of urticaria pigmentosa respond to trauma with urtication and erythema(Darier's sign) diagnosis with clinical findings&Ph.E,and lab findings:A 24 hr urine collection for histamine,histamine and PGD2 metabolites is the most common noninvasive procedure.confirmtion of diagnosis with tissue diagnosis. Rx:symptom/sign directed approach:H1&H2 antihistamines 257.an associated hypogammaglobulinemia is an underlying cause for infection & ,serum beta2-microglobulin is the single most powerful predictor of survival and can substitute for staging: SEEN IN MM 258.Remember Pts with DM&CRF and multiple organ failure can develop acalculous cholecystitis.Acalculous cholecystitis is characterized by the absence of gallstones and sometimes even biliary sludge.These pts may not present with classical signs of cholecystitis, because of associated diabetes mellitus and multiple organ failure.US may fail to show evidence of gallstones or obvious signs of cholecystitis.A CT scan of the abdomen and pelvis will reveal a thickened gallbladder wall, pericholecystic fluid, gas within the gallbladder wall, and evidence of surrounding inflammation. 259.Afetr abdom. aortic aneurysm repair and blood in the stool=>suspect ischemic colitis=> do sigmoidoscopy/colonoscopy to assess coloniv viability, if CT scan is inconclusive, BUT NOT Barium enema=>can cause perforation Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 260.In SLE=> non-erosive arthritis In RA=erosive arthritis:indication for starting Methotrexate 261.Patient of IPPV who deteriorates=>do CXR to rule out barotrauma 262.Kallmann's syndrome-46,XX -anosmia -hypogonadotropic hypogonadism -absent pubic, axillary hair -absent breasts -amenorrhea 263.Acute liver failure-appears within 8 weeks from the start of the injury Fulminant hepatitis=acute liver failure+hepatic encephalopathy 264.factor XI deficiency it's largely confined to Ashkenazi-Jewish populations.Spontaneous bleeding may occur in homozygotes:epistaxis,menorrhagia or bleeding after dental procedures or surgery.Hemarthroses as in hemophilia A or B r unusual 265.ts with factor XIII defeciency usually bleed in the neonatal period from their umbilical stump or circumcision 266.Remember i t’s recommended that during nursing home outbreaks of influenza,both amantadine& immunization should be given to those who haven’t received annual immunization 267.remember whenever you suspect venous sinus thrombosis.MRV is the best noninvasive test to confirm this diagnosis.Pregnancy& postpartum state r RFs for it. 268.In neurofibromatosis type 2, when suspect acoustic neuroma=> first do MRI with gadolinium=best test, then surgery to remove the tumor 269.Solitary brain metastasis=>surgical resection, followed by whole brain irradiation Multiple brain metastasis=>palliative brain irradiation 270.)Eaton-Lamber Syndrome=>auto-antib. against gated Ca channels -small-celllung cancer -treat by plasmapheresis+immunossupressive therapy 271.To diagnose lutheal phase defect=>endometrial biopsy which shows loss of endometrial maturation by more than 2 days as compared to normal 272.Remember Juvenile angiofibroma is a highly vascular fibrous tumor that classically affects adolescent males and appears to be related to androgenic stimulation. It manifests with recurrent epistaxis.



Nasi’s notes for USMLE Step 2 CK 273.Mutation of an X-linked gene coding for a tyrosine kinase is the underlying molecular mechanism leading to X-linked agammaglobulinemia of Bruton, a syndrome characterized by inability of pre-B cell precursors to mature into B-lymphocytes. Humoral immune deficiency thus manifests 274. Mutations of the autosomal gene encoding adenosine deaminase represent the most common cause of the recessive form of severe combined immunodeficiency disease (SCID), encompassing a heterogeneous group of conditions characterized by deficiency of both T- and B-cell mechanisms. SCID may be autosomal dominant, autosomal recessive, or X-linked. Mutations of the X-linked gene coding for a cytokine receptor subunit represent the most common cause of the autosomal dominant form of SCI. 275.Remember

Children with hypospadias are prone to urinary tract infections and other

urinary tract anomalies.don't forget U/A and Sono

276.Remember One of the most important reasons for steatorrhea in newborns is bile acid deficiency. Bile acids are very important in normal absorption of fat, which constitutes a major portion of an infant's calories intake. Unfortunately, the bile acid pool in neonates is very small when compared with that in adults. In addition, neonates often lose an excessive amount of bile acids in their stools. This results in physiologic steatorrhea because of poor absorption of fat. Preterm infants, have an even smaller bile acid pool and are more likely to have steatorrhea because of poor fat absorption. This will result in poor weight gain. The solution to this problem is to substitute medium-chain triglycerides (MCTs) in the formula for long-chain triglycerides (LCTs), because, unlike LCTs, MCTs do not require bile acids for absorption. 277. Inhalant abuse such as model glue, correction fluid, spray paint, and gasoline, to achieve an altered mental state. It is a common health problem in adolescence. The effect of inhaling a large quantity of hydrocarbons has been described as "quick drunk" because it resembles alcoholic intoxication. Initially, euphoria develops; then, lightheadedness and agitation. Disorientation, ataxia, and dizziness might develop with increasing intoxication. In extreme cases, generalized weakness, hallucinations, and nystagmus can occur. Abusers often show deterioration in school performance, disturbance of family relationships, and increased risk-taking behaviors. 278.Remember Encephalopathy is the major chronic morbidity following chronic inhalant abuse. and also keep in mind that a good history is essential because there is no drug screen test that can detect inhalant hydrocarbons. 279.Atrial myxoma=>systemic signs, dyspnea, like mitral stenosis, but no opening snap, murmur changes with position=>high risk of embolization Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 28o.A 2 month old infant can lift its head to 45 degrees, eyes follow to the midline, vocalizes, smiles and has a state of half-waking consciousness 281.The ability to lift the head to 90 degrees, eyes crossing the midline, laughing and slight awareness of the caregiver are characteristic childhood development landmarks of a 4 month old infant. 282. 6-month old infant can roll over, grasp a rattle, turn to voice, feed self and separate the world into a "parent" and "not parent" world. 283.Remember The combination of female sex and breech presentation results in developmental dysplasia of the hip in 1 in 35 such births. 284.Remember PCP is a hallucinogen that causes CNS stimulation (hypertension, tachycardia, brisk reflexes, hyperthermia). Other hallucinogens such as LSD and mescaline cause dilated pupils but PCP has an effect of constricting pupils. Seizures and coma are more common with PCP and intracranial hemorrhages have been reported. 285.Marijuana ingestion or inhalation(toxication) causes relatively benign symptoms that include euphoria, hunger, tachycardia and injected conjunctivae. Pupils usually remain normal. 286.Screening for prostate cancer: ->40 years=yearly rectal exam ->50 years=PSA=rectal exam -if abnormal=>transrectal US, then niddle biopsy, then bone scan for staging 287.Intelectualization=transforming an unpleasant event into a purely intellectual problem Rationalization=offering rational explanations in an attempt to justify undesirable attitudes, impulses, beliefs-ex. a guy is rejected from getting jobs at various interviews says that he saved money because the commute was paid by his interogators... 288.Internuclear ophtalmoplegia=demyelinization of medial longit. fasciculus -sign of MS 289.Cervical spondylosis-chronic neck pain, limited rotation and lateral bending of head -sensory deficit due to osteophyte-induced radiculopathy 290.Constitutional delay of growth is suggested by a child who is growing at a normal or mildly decreased rate. The patient is delayed in pubertal development, and the bone age significantly lags behind the chronologic age. 291.Familial short stature is characterized by a child with short parents, by a bone age consistent with the chronologic age, and by a growth curve that follows the normal pattern even though it is significantly below the 3rd percentile.



Nasi’s notes for USMLE Step 2 CK 292.Malrotation is usually caused by the presence of a volvulus, which presents with sudden onset of bilious vomiting, abdominal distention, rectal hemorrhage, peritonitis, and shock. It is a surgical emergency. 293 . Pyloric stenosis :It is caused by hypertrophy and hyperplasia of the antrum of the stomach, resulting in obstruction. 294.The most common cause of urethral obstruction in males is posterior urethral valves. It typically results in urinary obstruction and vesicoureteral reflux.it will cause bedwetting day and night,FTT, enlarge bladder!Voiding cystourethrogram is the definitive diagnostic test. 295. Marfan syndrome is an autosomal-dominant disorder The genetic defect results in abnormal synthesis and secretion of fibrillin, Patients with Marfan syndrome often have involvement in the skeletal, ocular, and cardiovascular systems. Most of the morbidity and mortality with this disease are related to the cardiovascular manifestations; patients develop aortic root dilatation. This may be associated with aortic insufficiency and aortic arch dissection. They may also have mitral valve prolapse . Aortic root, aortic valve, and mitral valve replacement may be needed during the lifetime of the patient. Patients with Marfan syndrome may frequently complain of chest pain; these patients must be viewed as having aortic dissection until proven otherwise. In this population, a spontaneous pneumothorax is another potential cause of chest pain. 296. beta-blockers clearly slow the progression of aortic root dilatation in those with mild aortic root dilatation in Marfan syndrom.. Exercise should be limited to aerobic activities. Patients must avoid contact sports that cause acceleration-deceleration injury and isometric maneuvers that tend to increase central blood pressure. Aerobic activity is encouraged, but those with established aortic root dilatation should have adequate heart rate control with betablockers.

297.)Brown recluse spider-deep bite, ulcer with a necrotic center and erythematous halo, treat by local excision Black widow spider=>abdominal rigidity, muscle cramps, nausea, vomitting, no local ulcer -treat by Ca gluconate, muscle relaxants 298.Pneumonia post bone marrow transplant=>think CMV -not immediate, comes in about 2 weeks to 2 years post-transplant 299.Asymptomatic Paget disease=>no treatment -symptomatic (lytic lesions or skullinvolvement)=>biphosphonates=CHOICE 300.If isolated proteinuria detected=>repeat distick testing at least twice more; then if still ()=>reassurance; if (+)=>check 24h urinary proteins, BUN, Cr Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 301.Venous ulcers=>medial aspect of foot Arterial ulcers=>lateral........................ 302.Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory) -mediated by immune complexes from gonococcemia 303.Foreign body aspiration=sudden onset of resp. distress, afebrile, interstitial retractions -do direct laryngoscopy+rigid brochoscopy -one lung is hyperinflated, the other is hypoinflated 304.Remember throwing a ball overhead is most consistent with the motor development of a 24-month-old child 305. Building a tower is a good way to assess a child's motor function.3 cubs 15 4 cubs 18 7 cubs 24 306.Osteoid osteoma is a small benign tumor of the bone that frequently affects the tibia. The tumor is usually unilateral and manifests with nocturnal pain, which awakens the child and is promptly relieved by aspirin or NSAIDs 307.Stress fractures affect small bones that normally have a thin cortical bone. When subjected to repeated mechanical stress, such as marching, skiing, ballet dancing, etc., the bone accumulates microfractures that eventually result in chronic pain and swelling. Metatarsal bones are the most frequently affected. 308.Osteosarcoma is a malignant bone tumor affecting children and adolescents. Unilateral bone pain in the segment involved (usually proximal tibia or distal femur) or pathologic fracture is the usual mode of presentation 309.Remember In children, the most common cause of stridor is laryngomalacia. 310.Renovascular disease is the most frequent cause of hypertension in young children. Ailments such as polycystic kidney disease, congenital vascular disease, tumors and infections can all lead to hypertension, and a urologic evaluation is imperative. 311.ALwayes remember For patients with persistent asthma symptoms, inhaled corticosteroid is the treatment of choice 312.In acute CHF, treatment should begin immediately. IV furosemide is the drug of choice because its onset is very rapid. It can provide quick symptomatic relief and improve respiratory distress. Angiotensin-converting enzyme inhibitors are used for the long-term management of patients with CH. 313.Measles is associated with subacute sclerosing panencephalitis, a chronic encephalitis of the central nervous system manifested by progressively bizarre behavior and decline in cognitive function. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 314.Bell palsy, a postinfectious allergic or immune demyelinating facial neuritis. Epstein-Barr virus is the preceding infection in approximately 20% of cases.However, herpes simplex virus, Lyme disease caused by Borrelia burgdorferi and mumps have been associated with Bell palsy too. 315.microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable. The warning should be heeded, and an anomaly sought. The first, noninvasive test should be the sonogram. 316.Neurofibromatosis is a multisystem genetic disorder. The features of this condition are more than six café-au-lait spots, two or more neurofibromas, axillary freckling, optic gliomas, iris hamartomas (Lisch nodules), and osseous lesions. There is almost always a first-degree relative with neurofibromatosis. 317.An infant with HLH(hypoplastic left heart) syndrome has a hyperdynamic precordium because the enlarged right ventricle is contracting against systemic pressure. The infant also has a loud, or even palpable, second heart sound (S2) because the pulmonary artery acts as the aorta by pumping blood to the systemic circulation through the ductus arteriosus. The high end-systolic pressure markedly enhances S2. The flow from the right ventricle to the pulmonary artery is not turbulent; therefore, there is usually no significant murmur heard on auscultation. When the ductus closes, or when the pulmonary vasculature resistance falls, the flow to the systemic circulation will decrease, causing greatly diminished peripheral pulses. Management includes infusion of prostaglandin E1 and administration of room air while on a ventilator. Prostaglandin E1 may open the ductus arteriosus and restore systemic blood flow. Administration of room air or even hypobaric oxygen (FiO2 less than 21%) and the use of muscle relaxants can prevent hyperventilation and subsequent pulmonary vasodilation, thus reversing systemic hypoperfusion and metabolic acidosis. 318. Osteoid osteoma usually affects patients between the ages of 5 and 24 years. This lesion can occur in almost any bone, although it is most common in the lower extremities. Osteoid osteoma also may occur in the posterior elements of the spine. Patients usually present with pain, which is characteristically worse at night and relieved with aspirin. the pain is now managed with naproxen or ibuprofen. The process may cause growth disturbances, such as leg length discrepancy or bowing of an extremity, or scoliosis. Radiographs usually show a sclerotic lesion and sometimes a localized lytic defect or nidus (<1 cm in diameter) within the sclerotic bone. The nidus is best demonstrated with CT. 319.Ewing sarcoma is a malignant tumor of bone arising in medullary tissue. It most often occurs in cylindrical bones. Prominent symptoms include pain, fever, and leukocytosis. Radiographs have a typical "onion skin appearance." Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 320.Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and inattention lasting at least 6 months. To make the diagnosis, the disorder must have started before age 7, and six signs each of inattention and impulsivity/hyperactivity need to be present in both home and school. 321.the presence of IgG against hepatitis A could mean a previous infection and is not diagnostic of a current infection. there is no chronic hep A. 322.CMV infection : Heterophile Ab test is negative 323.-Cyclophosphamide: ovarian fibrosis in 1/5 femals. Also bladder problems 324.Reloxafine: drug use for osteoprosis, inc HDL, dec LDL, doesn’t tx hot flash 325.Remember CLL : stage I (lymphocytosis & lymphadenopathy) req no tx 326.Membranous nephropathy : . Among infections, cuases #1 is Hep B #2 syphilis 327.Remember whenever you see MI in yuong age think :-Familial hypercholesterolemia Fam hx, xanthoma, AD mutation in LDL receptor gene . 327.Autoimmune Hep : liver biopsy shows lymphocytic portal inflammation w/ early bridging necrosis. Type I (classic) assoc. w/ antinuclear & antismooth Ab. Type II (common in W European descent) has Ab to circulating liver-kidney microsomes 328.Wiskott Aldrich synd: XR immunodef triad of thrombocytopenia, eczema, recurrent infection. T & B cell defect. Inc risk of ALL & lymphoma. Tx is splenectomy, continued antibiotics, IVIG, bone marrow transplant 329.Poststreptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. Itusually follows a streptococcal pharyngitis by 1-2 weeks and a streptococcal skin infection by 2-3 weeks Laboratory values are usually significant for markedly decreased complement levels (C3 and C4), hypo- or hypernatremia, and a blood urea nitrogen elevated disproportionately to the creatinine. In order to diagnose poststreptococcal glomerulonephritis with certainty, there needs to be evidence of a preceding streptococcal infection such as an elevated ASO or streptozyme.

33o.Total anomalous pulmonary venous return is characterized by the pulmonary veins forming a confluence behind the left atrium, and draining into the right atrium. Complete mixing takes place in the right atrium, with a right-to-left shunt through the foramen ovale to the left side of the heart. Often, no murmur is heard on cardiac examination, although a short systolic murmur is sometimes heard. ECG often reveals right atrial enlargement and right ventricular hypertrophy. The chest roentgenogram often shows a normal heart size with Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK pulmonary edema. If there is obstruction to pulmonary venous return, as is almost always present with veins draining inferior to the diaphragm, cyanosis can be very prominent. Definitive treatment is surgical anastomosis of the pulmonary vein to the left atrium. don't forget figure 8 or snow man! 331.Hypoplastic left heart syndrome is characterized by underdevelopment of the left ventricle and the ascending aorta. Typically, there is obstruction at the mitral valve, causing all pulmonary venous blood to shunt through either an ASD or a patent ductus arteriosus (PDA) into the right atrium. Total systemic blood flow is channelled through the ductus arteriosus from the pulmonary artery. As the ductus closes, these infants present with shock because systemic blood flow is significantly reduced. these paitents have ,HEPAtO SPLENEMEGALLY,CARDIOMEGALLY,DYSPENEA,CYANOSIS 332.PDA causes symptoms of pulmonary congestion, dyspnea, widened pulse pressure, and bounding arterial pulsation because aortic blood flow is shunted from left to right. 333.PS causes a harsh systolic murmur easily audible over the upper left sternal border. There is a significant right-to-left shunt because the large VSD allows unrestricted flow from the right ventricle to the left ventricle, causing cyanosis. 334.In which disease polymerisation of microtubules in leukocytes is the primary defect and what are its effects? Cheideck-Higashi Phagolysosome defect leads to infection with Staph, 335.Acid base disorder seen in a case of cardiorespiratory arrest?

first, resp acidosis becos of arrest of resp after a time later, metabolic acidosis as tissue hypoxia going on 336.Gaucher's: Tay-Sachs': Niemann-Pick's:

glucocerebroside ganglioside sphingomyelin

337.actinic keratoses (AK), which are common lesions seen on sun-exposed skin. AKs are a cutaneous dysplasia of epidermis that may undergo malignant transformation. They typically occur in middle-aged and elderly adults. AKs can be macules or papules, and often have a hyperkeratotic, adherent scale. The "cutaneous horn" is caused by an abnormal growth pattern of the cells within the AK, that resembles an animal horn. The treatment includes cryosurgery, surgical excision, pathologic evaluation, and topical therapy. 338.keratoacanthoma is a rapidly growing nodule that has keratinous debris in the center. It is related to squamous-cell carcinoma. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 339.Because of its toxicity, especially in elderly patients and patients with liver and renal dysfunction, colchicine is not used frequently to treat acute gout. 340.High levels of cisapride (or astemizole, among other drugs) can cause prolonged QT intervals, torsades de pointes, ventricular tachycardia, and death. cisapride levels can be especially high when their metabolism is inhibited by ritonavir. 341.The patient with trichomoniasis often has a purulent vaginal discharge and some vaginal and cervical erythema (strawberry cervix). Wet smear is the most useful test and is approximately 80% sensitive for Trichomonas 342.Bacterial vaginosis presents as a gray, homogeneous, foul-smelling vaginal discharge with a pH exceeding 4.5, an amine odor when sodium or potassium hydroxide is added to the discharge, and clue cells in the exudate (vaginal epithelial cells coated with bacteria 343.remember

Patients with suspected sexually transmitted diseases are good candidates for

HIV serologic screening, but HIV infection does not appear to increase the risk of vulvovaginal candidiasis, trichomoniasis, or bacterial vaginosis. 344. Escherichia coli (EHEC): Bloody diarrhea, abdominal cramping, and absence of fever are common, and the disease tends to occur in previously healthy people who consumed underheated ground beef 345.From most transmissible to least transmissible, the pathogens are: hepatitis B (e antigenpositive)—about 30% to 40% of needlesticks; hepatitis C—about 3%; HIV—about 0.25%; and hepatitis A—almost never (transmission can occur during the initial viremic phase of infection only). 346..Remember Cryptococcal meningitis can occur in immunologically normal patients with no underlying disease. 347.Patients with moderately advanced to advanced immunosuppression from HIV may develop a syndrome of fever, mild hepatitis, and elevated angioma-like skin lesions cause by Bartonella henselae.The skin lesions can resemble Kaposi’s sarcoma, but the biopsy specimen shows characteristic findings of Bartonella infection, including Warthin-Starry–stained organisms. 348.The evaluation of health-care workers at the time of exposure to blood should include an HIV antibody test (ELISA) and testing for protection against hepatitis B. 349.Remember In 60% of patients with cervical intraepithelial neoplasm (CIN) the lesion resolves spontaneously; only 1% of patients have lesions that progress to cancer. The remaining patients have a chronic infection. HPV infection leading to CIN is acquired by sexual intercourse, although the male partner is usually not aware of a penile lesion, and HPV can be transmitted to new sexual partners. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 350.Alwayes remember Some patients with rapidly progressive meningococcemia and meningococcal meningitis may have a normal cerebrospinal fluid examination on first presentation. !!!then suspect clinically start ceftriaxone and don't care the CSF!!! 351.what is the pathophys of idiopathic pulm fibrosis? its the immune complex mediated activation of alverolar macrophages .....probably related to locally generated immune comples, alveolar macrogphages become activated and the produce several mediatores that recruite and induce fibroblast proliferationand ca . clues which are imp are chest auscultation reveals coarse dry crackes and on chest x ray retucilar or reticulonodular disease..ct ground glass apperarance....pft's restrictive pattern 352.hypersen pneumonitis is type III hypersentsitivity 352.Remember Like their younger counterparts, patients older than 60 years who are not immunosuppressed contract pneumonia caused by the usual pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae. More important, advanced age is associated with infections due to Staphylococcus aureus and enteric gram-negative bacilli. Empiric antibiotic coverage for pneumonia among persons in this age group should include agents active against these pathogens.

353.Remeber Sarcoptes scabiei: The most effective way to confirm the diagnosis is to place a drop of mineral oil on a suspected area, and unroof the burrow hole with a needle or scalpel and examine the scrapings under the microscope. The patient should be treated with permethrin cream and close contacts should be treated, even if asymptomatic. after DIAgnosis establish now you can treat and ......but not before scraping the lesions and evaluating them under the microscope.IT IS NOT A CLINICAL DIAGNOSIS! 354.2 situation that you can see WBC cast: pyelonephritus and alergic interstial nephritus 355.by which mechanism cyclosperin cuase HTN?and what's the treatment of HTN in this situation? renal vasoconstriction& sodium retention.RX--ca+ blockers 356.giving ACE and NSAID with each other can cuase decrease in GFR and RF,by which mechanism?? angiotensin II causes constriction at efferent arteriole. ACEI causes dilatation of that arteriole. so that renal blood flow is increased. But GFR and Filtration fraction are decreased as there is decreased filtration pressure.



Nasi’s notes for USMLE Step 2 CK renal PG dilate afferent arterial tone. NSAID causes afferent arteriolar constriction. so that decreased Renal bld flow and GFR => renal shut down 357.pathogenes of Alport syndrome: collegen type IV for GBM 358.which diuretic cuase dissolved uric acid stones? uric acid is less soluble than its urate salt,and decreasing the urinary PH increase concentration of the uric acid form,becuase ACTAZOLAMID increase urinary PH ,it can be used to dissolved uric acid stone. 359.what's Tx(treatment) of Goodpasture's syndrome? tx wegner granolomatosis? plasmapharesis - gotta get rid of antiglomerular basement membrane antibodies, steroids+cyclophosphamid for Wegners granulomatosis 360.)Impaired consciousness, even following a first seizure=>do CT scan without contrast 361.Guillain-Barre syndrome is an acquired demyelinating neuropathy that usually follows a viral respiratory infection or immunizations. It is characterized by ascending weakness. Sensation is intact. A main diagnostic clue is absent deep tendon reflexes -not EEG 361.Alwayes Remember Heart size is usually normal early in the course of common congenital heart diseases. This is true of coarctation of the aorta, aortic stenosis, pulmonic stenosis, tetralogy of Fallot, and tricuspid atresia. In transposition of the great vessels, however, a roentgenogram will show a large, egg-shaped heart with a narrow supra-cardiac stalk 362.Pneumonia that does not respond to beta-lactamines=>suspect Legionella -diagnose by urinary Legionella antigen (ELISA) 363.Remember most common cause of hematuria in children is infection, which should be ruled out by culture unless the history strongly suggests another cause. Other causes include post-streptococcal glomerulonephritis, neoplasms, stones 364.Remember A hydrocele of the tunica vaginalis testis occurs frequently at birth but usually resolves in a few weeks or months. No treatment is indicated during the first year of life unless there is a clinically evident hernia. A simple scrotal hydrocele without communication with the peritoneal cavity and no associated hernia should be excised if it has not spontaneously resolved by the age of 12 months. 365.The current mainstay of treatment for metastatic prostate cancer is androgen deprivation therapy using a leuteinizing hormone-releasing hormone (LHRH) agonist such as leuprolide or goserelin or by performing a bilateral orchiectomy. Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 366.Remember

hep B with membranous and hep c with membrano proliferative

367.Neurological Features of Sjogren’s Syndrome: Small vessel strokes Encephalitis Dementia Peripheral neuropathy – may be sensory, motor or mixed Seizures Aseptic meningitis 368.alwyes remember one of the important neurologic manifestaion of Vasculitis is peripheral neuropathy,especially in CSS! 369.asthma+eosinophilia +peripheral neuropaythy DX?? CSS(UW). 369.Differentiating Parkinson’s disease and essential tremor Age – Parkinson’s tends to come on later in life Location – Essential tremor is more generalised and symmetrical. It often affects the head and voice. First degree relatives – More commonly affected in essential tremor Associated neurological signs – rigidity, bradykinesia in Parkinson’s, usually none in essential tremor. Response – Parkinson’s will respond to L-Dopa, anticholinergics and dopamine agonists. Essential tremor is often responsive to alcohol, benzodiazepines and beta-blockers Writing – Parkinson’s sufferers often demonstrate micrographia, while essential tremor often involves tremulous writing. 370.which malignancy you can see in wiskott aldrich syndrme?NHL 371 .what is the cuase of death in NF1 in future? Sarcoma 372.remember recent trials have indicated that a combination of unfractionated heparin plus a platelet glycoprotein IIb/IIIa inhibitor is superior to heparin alone in reducing morbidity and mortality in patients with acute coronary syndromes. 373.The asymptomatic patient with Descending thoracic aortic aneurysms

is treated

medically until the size of the aneurysm is 5 to 6 cm or symptoms present. Medical management includes aggressive blood pressure control,(B blocker and nitroproside), serial imaging for evaluation of size (diameter), and close follow up for symptom onset.



Nasi’s notes for USMLE Step 2 CK 374.Remember there is a increase incidence of CAD in premenopuse women with SLE!(due to imune complex) also chronic use of corticosteroid can cuase hyperglycemia and hyperlipedemia! 375.S. epidermidis, is the single most common cause of catheter-acquired sepsis and the most usual coagulase-negative staphylococcus,cover it with Vancomycin 376.Rifampin is an inducer of cytochrome P-450 enzyme systems and causes to decrease the plasma concentrations of protease inhibitors in HIV paitent!!BE CAREFUL!! 377. MCcune albright sd :precocius puberty, aromatase enz def, cystis in bone + cafe auliat spots 378.Remember The diagnosis of pesudo tumor cerebri can be made only after intracranial causes for increased intracranial pressure have been excluded by MRI (tumor, venous sinus thrombosis, ventricular outflow obstructive lesions) and a lumbar puncture documents an elevated opening cerebrospinal fluid pressure. 379.Remember Carbidopa is combined with levodopa to minimize peripheral side effects of levodopa, with nausea being the most common side effect.

380.Toxoplasmosis is the most common cause of intracranial mass lesions in patients with AIDS. It typically develops subacutely over several days with the onset of fever, headache, mental status changes, and focal neurologic signs. The diagnosis of cerebral toxoplasmosis relies on a high index of clinical suspicion, neuroimaging, serologic studies, and response to a therapeutic drug trial. MRI with gadolinium is the neuroimaging test of choice to detect small lesions. Multiple lesions with ring enhancement, edema, and mass effect suggest a diagnosis of toxoplasmosis. However, no clinical or radiologic feature absolutely differentiates cerebral toxoplasmosis from a primary central nervous system lymphoma, which is the other major cause of intracranial mass lesions in patients with AIDS,put the paitent on empiric therapy with pyrimethamine, folinic acid, and sulfadiazine for 8 weeks,no response!!!do biopsy! 381.Remember Premonitory symptoms in patients with syncope include a sensation of impending unconsciousness, often accompanied by nausea, a sense of warmth, and diaphoresis. Syncope often results in atonia and collapse; however, opisthotonic posturing and clonic jerks can also occur. Pallor is a characteristic feature. Syncope usually lasts 10 to 30 seconds. Recovery of cognition is relatively rapid following syncope compared with recovery following a generalized tonic-clonic seizure. 382.good example of ethics:Old Spanish lady with CHF, she doesn’t speak English, has a caregiver daughter speaking English & a clergyman visiting her for religious talks speaking both E



Nasi’s notes for USMLE Step 2 CK & S? How would u discuss with her for further Mx?answer: (get a fluent translator not a friend or family member 383. Giant cell arteritis (temporal arteritis) is a relatively common necrotizing granulomatous systemic arteritis t. The diagnosis should be considered in any person older than 50 years of age who has a new form of headache, abrupt loss of vision, polymyalgia rheumatica, unexplained fever or anemia, and an elevated erythrocyte sedimentation rate. Visual loss, which is preceded by amaurosis in only 15% of patients, occurs in up to 40% of those with giant cell arteritis if left untreated. 384.The clinical manifestations of dermatomyositis include proximal muscle weakness that evolves over weeks or months and an erythematous, violaceous rash over the eyelids, bridge of the nose, and cheeks. About one third of patients have violaceous papules over the dorsal interphalangeal joints known as Gottron’s papules. Dermatomyositis appears to be associated with a malignancy in 6% to 45% of patients, especially patients over 40 years of age.Based on available information, there appears to be a temporal association between dermatomyositis and malignancy. In women with dermatomyositis and ovarian carcinoma, the tumor is at an advanced stage and of uniform epithelial origin. In children, dermatomyositis is often associated with vasculitis,not malignancy!!!!!!!!!!!!!!!!!!!! 385. Remembber The exact pathophysiology of hepatic encephalopathy is unknown, but patients frequently respond to measures that lead to a reduction of hyperammonemia. Such measures include dietary protein restriction and lactulose administration. Gastrointestinal bleeding is an important precipitant of hepatic encephalopathy and should be ruled out by upper endoscopy. 385.Keep on back of your mind Although hypoglycemia should be avoided in patients with hepatic encephalopathy, but if you see for example BG - 56 ,don't rush to give Glucose ,,thiamine should be administered prior to any glucose load in an alcoholic or otherwise malnourished patient to avoid precipitating Wernicke’s encephalopathy. 386.Remember Hypertonic saline should not be administered to patients with chronic liver disease and hyponatremia because of the risk of central pontine myelinolysis in this population.

387. weakness , dizziness, dysarthria, and dysphagia. These symptoms are highly suggestive of posterior circulation ischemia involving the brain stem. In addition, evidence of bilateral pyramidal tract findings (bilateral extensor plantar responses), oculovestibular dysfunction



Nasi’s notes for USMLE Step 2 CK (unilateral nystagmus), and cranial nerve involvement (unilateral tongue weakness). The basilar artery and its branches supply most of the brain stem. 388.The posterior cerebral artery supplies the ipsilateral occipital lobe and medial temporal lobe. 389. Remember Patients with ALS generally present with muscle weakness and commonly note “muscle twitches” representing fasciculations. An electromyogram (EMG) is the most important confirmatory test for ALS.

390.The clinical triad of Wernicke’s encephalopathy is confusion, ataxia, and abnormalities of eye movement. However, the complete triad is uncommonly noted. Although the disorder is usually associated with chronic alcoholism, Wernicke’s encephalopathy can occur in any malnourished individual. It has been described in patients with anorexia nervosa, in patients with cachexia secondary to underlying malignancy, as a complication of gastrectomy and gastric stapling, and in patients receiving chronic hemodialysis. Once the diagnosis is suspected, thiamine, 100 mg intravenously, should be administered promptly. It is important to administer thiamine prior to or during a glucose load in a malnourished patient, as exacerbations of Wernicke’s encephalopathy can occur if thiamine is not administered first. 391.Essential tremor causes a posture- or action-related tremor that usually involves the upper extremities, the head, or the voice. Other family members may have a similar disorder. A positive response to ethanol ingestion is often noted. Treatment options include betablocking agents such as propranolol. Primidone, an anticonvulsant medication, is also effective. Patients should be told that primidone, even at low doses, may cause an idiosyncratic reaction that is similar to an influenza syndrome. Nausea, vomiting, and significant malaise may occur for 24 to 48 hours and then rapidly dissipate. Other treatment options for essential tremor include clonazepam and gabapentin 392.Remember the contrast used in catheterization procedure contains iodine! and iodine tends to worsen hyperthy cuased by autonomous nodules, wheres it inhibits the release of thyroid hormon in patients with autoimmune thyroid disease such as Graves. 393.Middle cerebral artery (MCA) occlusion: "Difficulty with A-B-Cs in M-C-A" A-Apraxia B-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia) C-Contralateral Clumsiness of arm, face. -- Leg is somewhat spared. M-Memorization difficulties C-Calculation difficulties A-Aphasia with language-dominant hemispheral involvement Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 394.A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D -Dizziness -Diplopia -Dysarthria -Dysphagia 395.Root values of reflexes are 1,2,3,4,5,6,7,8 - S1-2 ankle, L3-4 knee, C5-6 biceps/supinator, C7-8 triceps 396.Argyle Robertson Pupil • Accomodation Reflex Present - Pupillary Reflex Absent. 397.Amantadine and rimantadine are active against influenza A only. A new class of compounds, the neuraminidase inhibitors, is active against influenza A and B viruses. The neuraminidase inhibitors are also effective for prophylaxis of influenza A and B infections. 398.Remeber CA125 level is a useful parameter for assessment of the response of ovarian cancer patients to chemotherapy and for detection of relapse. not for helping in diagnose 399. extensionof inflammed synovium in the popliteal space:mechanism of baker cyst 400.Focal glomerulosclerosis is the most common pattern of idiopathic nephrotic syndrome in black Americans, and treatment with a prolonged course of glucocorticoids is successful in up to 50% of patients 401. Recent studies have shown that classic Bartter’s syndrome is often due to a genetic mutation in the Na-K-2Cl transporter located in the thick ascending limb of Henle. This is the transporter that is inhibited by loop diuretics. Gitelman’s syndrome has a similar clinical presentation but is due to a genetic defect in the neutral Na-Cl transporter in the distal tubule. Thiazide diuretics inhibit this transporter. These two disorders are clinically distinguished by the presence of hypercalciuria in Bartter’s syndrome and hypo-calciuria in Gitelman’s syndrome. 402.Remember As with other metastatic tumors, breast cancer tends to produce multiple lesions that are most commonly located at the junction of the white matter and gray matter. These lesions are characteristically surrounded by a significant amount of edema; occasionally, the edematous area is out of proportion with the size of the metastasis 403.Remember Both astrocytomas and oligodendrogliomas are tumors situated within the brain parenchyma. Both types tend to present as solitary masses without clearly defined margins. Edema, although frequently present, is less significant than the cerebral edema associated with metastatic disease. 404.Remember Meningiomas arise from the dura and the arachnoid villa of intracranial and spinal spaces. These are slow-growing tumors; patients usually present with either symptoms Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK of a space-occupying lesion or seizures of new onset. Radiologically, these tumors are characterized by their extraparenchymal location and the fact that they have a density similar to that of surrounding brain tissue. Of interest, women with breast cancer are known to have an increased incidence of meningiomas. Prognosis of meningiomas is in general excellent; surgical excision tends to be curative. Meningiomas that are difficult to excise completely (e.g., those located at the base of the brain) or that have anaplastic features are more likely to recur. For such patients, postsurgical radiation therapy is recommended. 405.Remember Prostate cancer almost never metastasizes to the brain 406.The red cell mass of less than 36 ml/kg, reduced oxygen levels, and low-normal plasma volume seen in this patient suggest a diagnosis of Gaisböck syndrome.(secendory polycytemia) Gaisböck syndrome, or relative polycythemia, is often seen at an earlier age (45 to 55 years) than polycythemia vera. In the male population in the United States, 5% to 7% have Gaisböck syndrome. Those affected are usually middle-aged, obese, hypertensive men who may also be heavy smokers. 407.Remember There are several mechanisms by which drugs can induce hemolysis; two well-recognized mechanisms are immunologic mediation (e.g., hemolysis caused by penicillin and methyldopa) and an increase in oxidative stress on red cells. Oxidative stress can occur as a result of hemoglobins becoming unstable or through a decrease in reduction capacity (as would result from G6PD deficiency). 407.understand that patients with polycythemia vera who are older than 70 years should be treated with a myelosuppressive agent such as hydroxyurea in combination with phlebotomy ,, combination of hydroxyurea and phlebotomy has been demonstrated to be an effective therapeutic regimen in controlling the hematocrit in most patients with polycythemia vera and in lowering the risk of thrombosis that occurs with use of phlebotomy alone. 408.then remember hydroxyurea is generally used for (PV) in patients older than 70 years or for those who have previously had a thrombotic event or who require high-maintenance phlebotomy. 409.If exposed to measles, all HIV-infected infants, children, and adolescents, as well as children of unknown infectious status born to HIV-infected women, should receive 0.5 mL/kg (maximum dose, 15 mL) of immune globulin intramuscularly, regardless of their immunization status, because it is impossible to know in a timely fashion if the child has protective antibody. If the person exposed to measles is receiving intravenous immune globulin (IGIV) (400 mg/kg) and 3 weeks have elapsed since the last dose, the person should receive IG (0.5 mL/kg) or IGIV (400 mg/kg) as soon as possible.



Nasi’s notes for USMLE Step 2 CK 410. Isoniazid deprees the GABA neurotransmiters R in the brane=seizure.Pyrydoxon work opposite 411.Osteoarthritis of lumbar spine.: Referred pain from the lower lumbar facet joints or intervertebral discs is often reported by the patient as hip pain, with localization to the buttock and lateral thigh. The pain is characteristically aggravated by maneuvers that increase the force brought to bear on these joints, particularly spine extension as well as lateral bending or rotation toward the painful side. Pain over the spine may or may not be present, but even in its absence, there may be paravertebral muscle spasm contributing to reduced spine motion 412.Pain resulting from hip joint pathology is usually felt in the groin and anterior thigh. Hip motion, particularly rotation, is usually painful 413.Remember mitral regurgitation secondary to left ventricular dilatation(cardiomypathy dilated) and systolic dysfunction. The mechanism of mitral regurgitation in this setting appears to be lateral displacement of the papillary muscles, resulting in inadequate leaflet coaptation. Afterload reduction therapy with an angiotensin-converting enzyme inhibitor results in a decrease in ventricular dimension and improvement in papillary muscle alignment, so that many patients have a substantial reduction in regurgitant severity 414. Rapid exclusion (or diagnosis) of aortic dissection is essential. Transesophageal echocardiography has a high sensitivity and specificity for aortic dissection and can be performed rapidly at the patient’s bedside. Therapy with a b-blocker to decrease blood pressure and heart rate should be initiated immediately and continued during the transesophageal examination. If an ascending aortic dissection is present, prompt surgical intervention is indicated; 415. putament hemorrhage cause deviation of both eyes to the side of the lesion (away from hemiparesis), but the sizes of pupils are normal 416.thalamus hemorrhage, although the sizes of the pupils are small; both eyes are deviated inward and look at nose 417.patients with cerebellum hemorrhage have a normal size of pupils and they are unable to look toward the side of the lesion 418.Remember Prochlorperazine (Compazine) is frequently used to treat nausea and emesis in some patients. Side effects of this medication, including extrapyramidal reactions (e.g., catatonia), are treated best by antiparkinsonian medications such as benztropine 419.Remember Bupropion is the antidepressant of the choices listed that has the fewest adverse sexual side effects



Nasi’s notes for USMLE Step 2 CK 420. Concrete thinking is described as literal thinking that shows a lack of understanding of the nuances of meaning. These individuals lack the ability to use metaphors. for example

if

asks the patient what the proverb "Don't cry over spilled milk" means what??. The patient answers that if you spill what you cook, you have to do it all over again. 421.what do u find in bipsy of wilms? spindl shaped cell, striated muscle, anaplasia, fibrillar inclusions in histo of nephroblastoma 422.Pathophysiology: In Graves disease, B- and T-lymphocyte–mediated autoimmunity are known to be directed at 4 well-known thyroid antigens, thyroglobulin, thyroperoxidase, sodium-iodide symporter, and the TSH receptor. However, the TSH receptor itself is the primary autoantigen of Graves disease and is responsible for the manifestation of hyperthyroidism. In this disease, the antibody and cell-mediated thyroid antigen-specific immune responses are well defined. The transference of hyperthyroidism by TSH receptor antibodies in (1) healthy subjects by transfer of serum from patients with Graves disease and (2) the passive transfer of TSH receptor antibodies to the fetus in pregnant women are direct proof of an autoimmune disorder mediated by autoantibodies

423.Physical findings that are unique to Graves disease but not associated with other causes of hyperthyroidism include ophthalmopathy, acropachy, and pretibial myxedema 424.During pregnancy, both T-cell and B-cell function are diminished, and the rebound from this immunosuppression is thought to contribute to the development of postpartum thyroid syndrome also Acute stress-induced immunosuppression may be followed by immune system hyperactivity, which could precipitate autoimmune thyroid disease. This may occur during the postpartum period, in which Graves disease may occur 3-9 months after delivery.

425.VERY HIGH YIELD: A summary of the differential diagnosis of thyrotoxicosis is a follows: Graves disease: Special features include diffusely enlarged thyroid, thyroid bruits, ophthalmology, pretibial myxedema, and the presence of TSIs. Subacute thyroiditis: Special features include a history of antecedent respiratory tract infection, neck tenderness, elevated sedimentation rate, low or absent radioactive iodine uptake, and a self-limited course.



Nasi’s notes for USMLE Step 2 CK Silent thyroiditis: Special features include painless thyroiditis, which may be seen in postpartum women (postpartum thyroiditis); a self-limited course; and low radioiodine uptake. Multinodular toxic goiter: Special features include a propensity to occur in elderly individuals and multiple nodules palpated or observed after thyroid scans. Toxic adenoma: Special features include a solitary palpable nodule and a "hot" nodule observed after a thyroid scan. Factitious thyrotoxicosis: Special features include no goiter, a low thyroglobulin level, and low radioiodine uptake. Iatrogenic thyrotoxicosis: The special feature is a history of thyroid hormone intake. Iodide-induced thyrotoxicosis: The special feature is a propensity to occur in patients with a history of nodular thyroid disease who have been exposed to iodine-containing contrast agents or drugs such as amiodarone. TSH-secreting pituitary adenoma: Special features include inappropriately elevated or normal TSH levels in the face of elevated free levothyroxine (T4) and free triiodothyronine (T3) levels, evidence of other pituitary hormone deficiencies, elevated alpha subunit level, and compressive symptoms. Beta human choriogonadotropin–induced thyrotoxicosis: Special features include a positive pregnancy test result, a history of hydatidiform mole, choriocarcinoma, and embryonal carcinoma of the testis. Also, rarely, it may be observed in normal gestation. 426.How do u diff Toxic epidermal necrolysis from SSSS? TEN is more benign than SSSS biopsy diff them: in ssss: split granular layer....in TEN full thickness involvem 427.Intraoperative and postoperative hemorrhage is a significant problem in the patient with polycythemia vera. Despite thrombocytosis, these patients have a hemorrhagic tendency generally ascribed to a qualitative deficiency of the platelets. Elective surgery should be postponed until the hematocrit and platelet count reach normal levels. Alkylating agents, such as busulfan or chlorambucil, are effective in this regard. In the emergency situation, phlebectomy should be performed prior to operation and also an especially careful hemostatic technique should be employed 428.Significant drop in estrogen leves right after delivery, can cause all changes in women mood- so called postparatum blues.

429.remember forceps may be used in face presentation with a mentum anterior presentation(chin facing toward the maternal pubic symphysis.) ; in such a case, vacuum is Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK contraindicated BUT opposed to forceps, the vacuum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues. 430.Remember When unvaccinated susceptible personnel are exposed to varicella, they are potentially infectious 10 to 21 days after exposure, and exclusion from duty is indicated from the tenth day after the first exposure through the 21st day after the last exposure, or until all lesions are dry and crusted if varicella occurs. 431.if vaccinated health care personnel are exposed to varicella, they may be serotested immediately after exposure to assess the presence of antibody. If they are seronegative, they may be excluded from duty or monitored daily for development of symptoms. Exclusion from duty is indicated if symptoms (fever, upper respiratory tract symptoms, or rash) develop. 432.The routine postexposure use of VZV immune globulin (VZIG) is not recommended among immunocompetent health care personnel. VZIG can be costly, does not necessarily prevent varicella, and may prolong the incubation period by a week or more, thus extending the time that personnel will be restricted from duty. The use of VZIG may be considered for immunocompromised (e.g., HIV infected) or pregnant health care personnel. 433.It is essential to detect and treat chlamydial infection during pregnancy because maternal chlamydial infection is associated with several complications of pregnancy including preterm premature rupture of the membranes (PPROM) and preterm labor. 434. Remember Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death.

435. Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin): 1. at 28 weeks of gestation, 2.within 72 hours after the birth of an Rh-positive infant, 3.after a spontaneous abortion, 4. after invasive procedures such as amniocentesis. 5.threatened abortion, 6.antenatal bleeding, 7.external cephalic version, or abdominal trauma.

436.The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL-especially in cases such as manual removal of the placenta or placental abruption (as this patient had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. 437. An apt test is used to differentiate fetal from maternal blood. It can be used in the diagnosis of vasa previa or with neonatal melena. 438.Among adults with acute community-acquired bacterial meningitis, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, and Listeria monocytogenes are the most common pathogens. The possibilities of highly penicillin-resistant S. pneumoniae and L. monocytogenes should be considered (especially if the patient has underlying diabetes and liver disease). Although ceftriaxone is appropriate for susceptible S. pneumoniae, it would not be adequate for highly penicillin-resistant strains; thus, vancomycin should be given until definitive microbiologic results are available. The patient's advanced age and underlying medical conditions (i.e., diabetes, liver disease) predispose him to L. monocytogenes infection. Ampicillin is the antibiotic of choice for Listeria infections and should also be given empirically then Alwyes remember elderly paitent >60 years especially if with Diabet and liver disease comes with bacterial mengitis COVER HIM WITH AMPI+VANCO+CEFTRIX 439.keep in your mind!! Listerial meningitis typically occurs in elderly patients, immunocompromised persons, or patients with serious underlying medical conditions (e.g., liver disease or diabetes).The CSF Gram stain is positive in only approximately 30% of patients with listerial meningitis (as compared to 60% to 90% of patients with meningitis caused by other bacteria). In addition, approximately 25% of patients with listerial meningitis have a lymphocytic predominance in the CSF (an uncommon finding in meningitis caused by other types of bacteria). The antibiotic of choice for listerial meningitis is ampicillin (or trimethoprim-sulfamethoxazole for the penicillin-allergic patient 440.Spinal epidural abscess must be considered early in any patient with fever and localized back pain, because delay in diagnosis and treatment can lead to serious neurologic sequelae. Injection drug users are at increased risk .your next step?? MRI (if available) is the best choice for delineating an epidural abscess. If MRI is unavailable, CT should be performed 441.Remember Although many patients with spinal epidural abscess have concomitant vertebral osteomyelitis, spinal x-rays are not sensitive enough to exclude the diagnosis. and



Nasi’s notes for USMLE Step 2 CK also A bone scan would not adequately differentiate vertebral osteomyelitis from epidural abscess. 442.Remember In addition to I.V. antibiotics, the most important element of therapy for spinal epidural abscess is urgent surgery for drainage of pus and removal of granulation tissue

443.Remember The low-probability ventilation-perfusion scan results do not alter the probability of PE. Therefore, further diagnostic workup is necessary. Lower-extremity ultrasound should be the next step before empirical anticoagulation therapy or more invasive testing such as pulmonary arteriography is administered. 444.Vena cava filter placement is more effective than heparin anticoagulation in preventing recurrent VTE in the short-term it is best reserved for patients with recurrent VTE whose anticoagulation therapy is inadequate at the time; in patients with significant risk of bleeding; and in patients with a life expectancy of less than 2 years. 445.mechanism by which chronic disease can cause anemia : Anemia of chronic disease is generally associated with conditions that release cytokines (tumor necrosis factor-a, interleukin-1, and other inflammatory cytokines). These cytokines decrease erythropoietin production, decrease the levels of iron released from the reticuloendothelial system, and increase serum ferritin levels 446.Remember Alcohol abuse can cause a reversible form of sideroblastic anemia, and stopping alcohol is an important aspect of patient care. 447.AVM is the most common subarachnoid space hemorrhage in children and history of seizure or migrain like headache is characterestic. 448.keratoacanthoma, Mimics skin cancer (especially Squamous cell carcinoma) rapid onset and growth (1 month) almost never happens is SCC. Lesion spont involutes in a few months and requires no treatment 449.Rhinoviruses, which cause about 50% of colds, and coronaviruses, which cause 10% to 20%, are the most important pathogens with regard to the common cold. 450Adenoviruses : pharyngoconjunctival fever, which is often contracted while swimming in contaminated water. In addition to transmission by direct contact with respiratory secretions or infectious aerosols, fecal-oral transmission can occur. Infection may be acquired by pharyngeal inoculation or conjunctival inoculation from contaminated water. The incubation period for adenovirus infection of the respiratory tract is usually 4 to 7 days. Adenovirus respiratory disease typically causes moderate to severe, sometimes exudative, pharyngitis and



Nasi’s notes for USMLE Step 2 CK tracheobronchitis. Fever and systemic symptoms are often prominent, and rhinitis, cervical adenitis, and follicular conjunctivitis are common. 451.Name 3 possible findings in non-REM sleep.? Sleepwalking, night terrors, and bedwetting 452.Name 4 physiological actions found in REM sleep.? Increased/variable pulse, rapid eye movements, increased/variable blood pressure, and penile/clitoral tumescence 453.Lung cancer=>think of paraneoplstic syndrome=>muslce strengh diminuished bilaterally, more proximal than distal -normal reflexes -increase in CK, (+) EMG -pathology is located in the muscle membrane. 454.Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory) -mediated by immune complexes from gonococcemia. 455.)Pneumonia post bone marrow transplant=>think CMV -not immediate, comes in about 2 weeks to 2 years post-transplant 456.To detect the benefit of lung resection=>do PFT, especially FEV1 457.)Status epilepticus=> treat by general anesthesia+intubation 458.when u have P value > .1 means u r power ( p value ) is LOW! mean ur number of samples r LOW ! cause ur power is low!! 459.HSP is an IgA-mediated autoimmune vasculitis, which can cause tissue damage as a result of immune complex formation. Deposition of these immune complexes in the kidneys can lead to nephritis, which is the leading cause of permanent sequelae from HSP. End-stage renal disease is an uncommon but possible outcome. It is important to perform frequent urinalyses for early detection of kidney involvement. 460.Pathogenes of A Zencker's diverticulum is a pharyngoesophageal pulsion diverticulum that occurs at the point of transition between the oblique fibers of the thyropharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle. A hypertrophied cricopharyngeus muscle is thought to predispose the development of the diverticulum at this transition point. 461.cardiac output = 3-7 liters/ min CO in cardiogenic shock is decreased; whereas CO in overload (eg. bld transfusion) will increase by increasing the mean circulatory filling pressure but it does not cause enhanced performance of heart. Ref : Kaplan Q bank Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK 462.Remember Some antibiotics should not be used during pregnancy :. These include tetracyclines (adverse effects on fetal teeth and bones, congenital defects), quinolones (various congenital defects), trimethoprim in the first trimester (facial defects, cardiac abnormalities), and chloramphenicol and sulfonamides in the last trimester (Gray syndrome; hemolytic anemia in mothers with glucose-6-phosphate dehydrogenase [G-6-PD] deficiency, jaundice, and kernicterus, respectively). 463.how should we manage truma to neck zone! be careful about 2 things! first is it gunshot or stab wound? odes he stabe or unstable!? NOW RULE! .if you have a penetrating truma to neck(can be gun shot or stab wound) + UNSATBLE paitent go for surgery without any doubt and forget any ZONE! 2,if you have a GUNSHOT to middle ZONE don't think the paitent is stable or not send him for surgery! 3.If you have a STAB WOUND to MIDDLE ZONE!first look the paitent is stable or not! if stable just observe for 12 hours no need for surgery or any expensive workup! ok middle Zone is clear?

!we talked about both gunshot and stab wound in middle ZONE!

now let's go to upper zone! GUN shot to upper zone first do arterigraphic diagnosis and managment! if paitent is stable! if paitent is not stable you know the rule! now stab wound to upper zone paitent stable and asymptomatic!just observe! if unsatble surgery! now move to base of the neck! GUNSHOT and stable! do arterography,esophagogram,esophagoscopy,broncoscopy ,then surgery! if unstable you know ,surgery! stab wound in neck of zone I have no idea becuause kaplan didn't mention! 464.Remember TSH levels are very helpful in confirming the diagnosis of the hyperthyroid state, but are not the best parameter to follow in patients undergoing treatment for thyrotoxicosis.Serum T4 levels are the best parameter to follow; they are readily available and relatively inexpensive, and allow for careful monitoring of the effects of antithyroid drug therapy. 465.The appropriate evaluation of the hypothalamic–pituitary–adrenal axis is a postcosyntropin measurement of serum cortisol; cortisol levels fluctuate widely due to the Copyright © 2003-2005 ValueMD, Inc. All rights reserved.


Nasi’s notes for USMLE Step 2 CK pulsatility of this hormone, and therefore random measurements are not useful. The appropriate evaluation of the hypothalamic–pituitary–thyroid axis is a free thyroxine index (or dialysis free T4) because the TSH concentration is often normal in central hypothyroidism. The hypothalamic–pituitary–gonadal axis in men is best evaluated by measuring serum total testosterone 466.Alwyes remember There is significant variation in sperm counts on semen analysis, and a single abnormal test should never be used to document infertility.Repeat it again!!!!before you say he is infertile!!!!!! 467.Treatment for Gonococcal conjunctivitis =>>> Ceftriaxone Prevention =>>> erythro topical 468.Adrenal Leukodystrophy (ALD) USMLE LOVE TO ASK!!!!!!! Clinical Sx: The disease usually presents in males age 5-10 years old with a gradual disturbance in gait and slight intellectual impairment. There is usually rapid progression with hypotension, seizures, visual complaints, and difficulty in swallowing appearing with time. Abnormal skin pigmentation or other signs and symptoms of adrenal insufficiency may become apparent before CNS symptoms. In some cases, adrenal symptoms never appear. Etiology/Pathophysiology: Classic ALD and the adult variant adrenomyeloneuropathy (AMN) are X-linked diseases in which there is deficiency of lignoceroyl-CoA ligase, a perioxisomal enxyme needed for the degradation of very long chain fatty acids (VLCFA). Pathology: White matter diseases are usually classified as demyelinating or dysmyelinating diseases. Dysmyelinating diseases such as ALD are inherited enzymatic deficiencies that cause abnormal formation or increased breakdown of myelin. Demyelinating diseases result in the loss of normally formed myelin by processes such as infection, chemotherapy, radiation, and autoimmune disorders such as multiple sclerosis. The diagnosis of ALD is made by the assay of plasma, red cells, or cultured fibroblasts for increased amounts of VLCFA. Imaging:The classic presentation on CT is low attenuation in the central occipital white matter that extends into the splenium of the corpus callosum.



Nassi Nasi Step 2 CK Notes [11348]

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