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* Step 3 June 2020 Journal
  usmlejourney2015 - 04/30/20 16:47
  Hello everyone! I will be posting my progress and also some important points that I will learn everyday.

Thank you.
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* Re:Step 3 June 2020 Journal
  carotid19 - 05/01/20 15:29
  great ! doing the same thing ! good luck  
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* Re:Step 3 June 2020 Journal
  usmlejourney2015 - 05/03/20 11:28
  I am doing random uworld blocks so will be adding random notes here. If you prefer topic wise notes lmk and I will see what I can do.

***DISCLAIMER***- These are my personal notes and no copyright infringement is intended. This may seem silly but better to say it than not, any points found in these notes are not medical advice that you should always consult your healthcare provider for any treatment or questions you may have regd. your condition.

Please lmk if these notes are beneficial at all, so that I can modify them accordingly and lmk whether I should continue or not. Thanks!

- Oxybutynin - Anticholinergic --> high risk of delirium and falls esp. in elderly

- Elderly - using lorazepam--> ppt. falls-->stop lorazepam -->few days later -->if pt. p/w (presents with) confusion,restlessness,tremors and autonomic instability --> think about benzo withdrawal--> have to start diazepam for immediate need and then slowly taper because withdrawal is potentially life threatening.

-statin myopathy- symptomatic pts. stop statins; asymptomatic pts. when to stop statin? --> when CK is >10x the upper limit of normal. how and when to restart? --> recheck CK levels before starting statins and start only if levels normalize. Also, we must r/o (rule out) exercise induced myopathy before stopping statins.

- PMR- it is actually a problem of joint,bursae and tendons; Rx- low dose steroids and most of the time these agents give good response. If pt.'s are not responding to steroids that means, it probably is not PMR, think of something else. PMR and GCA (Polymyalgia Rheumatica; Giant Cell Arteritis) can occur together often. If you suspect GCA in a pt. w/ PMR start high dose steroids immediately b/c obviously preventing blindness takes precedence. If otherwise, start steroids only after checking ESR levels. Why check esr before Rx?--> let's say you start steroids, and then check esr --> esr is corrected, so how would you know? (similar to the concept of drawing blood from 2 different sites before starting antibiotics in septicemia.)

- Pressure ulcers - when to start aggressive Rx? -- stage 3 and beyond ulcer. what is a stage 3 ulcer? --> as soon as you see fat, start debridement and special dressings; This doesn't mean you have to wait for the fat to appear obviously, if stage 1 or 2, then just use moist dressing.

-What is the Rx of allergic contact dermatitis? -->beclomethasone and fluocinonide; if for whatever reason, steroids cannot be used, then use topical tacrolimus;

-Hepatorenal syndrome-->Rx is correct liver problem such as hepatitis; If that is not possible, short term Rx is Norepi+albumin+IV Vasopressin.

-Benign cystic teratoma - do laporotomy b/c - when the teratoma enlarges to more than 5cm in size, there is risk of ovarian torsion. In 1/5th of pt.'s dermoids may be present so examine the opp,ovary during surgery very closely.

-Some things that may point to a tuube placement in the bronchus --> hypercapnia, hypoxia &/or pneumonia.

-When you see FSH/LH elevation in young children-- think about 2 things 1. ant.pituitary tumor or 2.problem with hpa axis.
Whenever you have high estrogen that is not related to ant.pituitary you will see Low FSH and Low LH

-If an 18yr old, or 27yr old has had hx or radiation due to cancer in the past, will you screen for breast cancer? Apparently you do! What is the imaging of choice? I used to think u/s before 30 and Mammo after 30. But, in this specific scenario w/ this hx, we have to do an MRI!

- When infant is diaphoretic and cyanotic while feeding and has crescendo-decres murmur think of 2 things only TOF and TGA.(TOF - Tetrology of Fallot; TGA- Transposition of Great Arteries) how would you differentiate b/w the two? simple! TGA - baby dies (unfortunately) TOF - baby lives. (source: OME)
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* Re:Step 3 June 2020 Journal
  carotid19 - 05/06/20 19:21
  Hi! great job! nice notes!
i dont used to type much ! but lest do this !im doing MTB only at this time...
one question :
-hepatorenal syndrome - in the setting of portal hypertension ,results from reduction in renal blood flow during dilatation of splanchnic vasculature , tx: withdrawal of diuretics , volumen expansion w IV albumin and Vasoconstrictors .....
Vasopressinn? can you explain please . may due to splanchnic vasoconstriction?! dont consider withdrawal of diuretics, why?

-so, the difference between NMS , MH and SD (Heat sydromes- all can present with high temperature, AMS, Rabdo,Seizures but NMS presents also with hyppreflexia, normal pupils , hx used of pschy meds.MH normal pupils, hx of used anesthetics .SD , pupilary dilatation, hyperreflex, hx used MAOI, Linezolid,Triptans

-ASA toxicity first medullary>tachypnea>decrease co>respiratory alkalosis> then metabolic acidosis
-Ethilene Glycol toxicity > Metabolic acidosis with high AG

-Alkalinization of urine works in : Toxicity of ASA, TCA, Phenobarbital

-Licoride, inhibit 11Boh dehydrogenase, preventing conversion of cortisol to cortisone, increase levels of corticol> mineralocorticoids resceptos> hypertension, hypokalemia and metabolic alkalosis

....tomorrow going to do Oncology , doing MTB and reviewing USMLE World notes for now!

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* Re:Step 3 June 2020 Journal
  usmlejourney2015 - 05/11/20 11:57
  @carotid19 - to simply answer your question, perhaps administering vasopressin is a quicker way than withdrawing diuretics (if i understand correctly). Vasopressin terminates splanchnic blood flow-->not only stops the varices, but also normalizes arterial pressure -->improving kidney function. As a vasoconstrictor it would stop the varices as opposed to withdrawal of diuretics.

have you looked at this?

Please do enlighten us if you have a more appropriate explanation.


Maternal AFP during pregnancy is measure between 15-20 weeks gestation. If it is high, we have to repeat it. If it is persisitent, then do a transabominal (better than transvaginal) u/s for visualization. If u/s cannot find the defect, then do amniocentesis for AFP and Acetylcholinesterase.

- Macrosomia - erb duchenne palsy, clavicular fracture.

-Pulmonary edema, hypotension are side effects of tocolytic exposure. (32 weeks indomethacin can be used, >32week of gestation, nifedepine should be used)

-Indications of bariatric surgery - BMI>35 with comorbidities like DM,HTN, OSA otherwise, BMI>40. As far as pregnancy is concerned, since the bowel is being removed during this procedure, absorption of nutrients like folate and B12 is lost, wait 1yr before conception. Request pt. to use OCP's during this period.

- Pregnancy+Bipolar 1 --> acute manic episodes --> if lithium cannot be used, use haloperidol. quetiapine, risperidone,olanzapine can also be used. The risk of teratogenic effects with Lithium is real but low. Last resort is always ECT

-vaginal progesterone can be used to prevent preterm labor in pts. with short cervix, ( 1.Prevents neonatal rds 2.Decreases risk of Intraventricular hemorrhage 3.decreases risk of necrotizing enterocolitis.

-Ocular melaonoma --> very large and extrascleral extension--> enucleation/radiation therapy.
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* Re:Step 3 June 2020 Journal
  usmlejourney2015 - 05/12/20 18:27

-Infantile Colic= Sx resolve in 3-4 months; reassure parents; If blood appears in stools, then work it up for possible intususception. (Sx of colic include inconsolable crying for hours before stopping)

-Hashimoto - Increased risk of thyroid lymphoma

- Ashermann Syndrome - Do hysteroscopy and adhesiolysis (it is a complication of D & C)

-For pregnant patients --> U/S is the study of choice for kidney stones.

-What is the whipples triad of Insulinoma? 1) low blood sugar after exercise or exertions + 2)Hypoglycemia during a n episode + 3)Relief of sx with glucose/D5W

-enzyme deficiencies:
1. G6PD def - absence of reduced glutathione
2.Lead poisoning - Inhibition of ALA Dehydratase
3.AIP - defect of phosphobilinogen deaminase
4. Orotic Aciduria - 5' Uridine Monophosphate deficiency (Orotic aciduria --> p/w megaloblastic anemia
and/or urethral obstruction)

- Barretts esophagus - no dysphagia then repeat endoscopy in 3-5 years; low grade dysplasia then repeat endoscopy in 6 -12 months; High grade dysplasia then endoscopic ablation immediately;

-Oral thrush - white spots that scrape off -- 1. Nystatin or Clotrimazole troches 2. If that doesn't work, then try oral fluconazole

- Celiac improves within 2 weeks of starting gluten free diet. If symptoms recur or persist, first thing to do is counsel patient about diet and check if gluten has been completely eliminated from the diet. If diet is gluten free and patient is compliant, then do endoscopy to pursue alternate diagnose or secondary cause of symptoms. Long term complications of celiac include - osteopenia and anemia. Also, when you diagnose celiac dx, get DEXA scan.

-Variceal bleed-->pt. admitted to hospital--> potential complications in this specific order 1.Infection (Spontaneous bacterial peritonitis) 2.Hepatic encephalopathy 3.Renal Failure; so pt. with variceal bleed admitted to hospital should be on fluoroquinolones as prophylaxis for 7-10 days

-How often should we measure blood counts for patients on clozapine? --> 1. First 6months every week, next 6months every other week and then once a month.

-Breast implants are safe, no side effects in terms of breast feeding or cancer risk. The only thing is the capsular contracture and scarring, so for this reason, women who receive breast implants, should be advised to undergo mri every 2-3 years, if at all such case is presented in ccs, remember to do mri screen.

-Neonatal polycythemia - Rx only if symptomatic; IV fluids,glucose, partial exchange transfusion.

-Collagenous colitis - characteristic nocturnal diarrhea

-Anthracycline mediated cardiotoxicity --> do MUGA scan or Radionuclide ventriculography before each chemotherapy session to find out about ejection fraction. If EF
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* Re:Step 3 June 2020 Journal
  umped - 05/13/20 01:14
  I am in too guys
great notes thanks
will add notes too
keep up studying and motivating each other
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* Re:Step 3 June 2020 Journal
  usmlejourney2015 - 05/14/20 17:16
  - Small bowel obstruction - If there is air in the distal colon then it is not a complete obstruction. Treatment is conservative management by IV hydration, NG suction and correction of electrolytes; If patient is unstable or there it is severe, then surgical management can be done. A rectal tube is however, not indicated in SBO.

-NG Tube placement is avoided on the other hand in esophageal varices because it can cause the varices to bleed.Rx is IV octreotide for variceal hemorrhage as it decreases splanchnic blood flow and therefore decreases portal venous pressure.
What are the long term mortality reducing agents in Rx of esophageal varices?
1.Betablockers and 2. Endoscopic surveillance.
so how often would you do endoscopic surveillance? If the pt. doesn't have varices once every 3yrs. If the pt. has small varices, once every 2 yrs. If the patient has had some sort of complication of cirrhosis then endoscopy should be done every years. so 3-->2-->1::no varices-->mild varices-->severe;
In some patients with esophageal varices, hydralazine and nitrate combination can be used only if they have CHF and decreased Ejection fraction.

-Pt.'s on long term steroids for more than 3-6months bone densitometry should be performed once a year as long as they are taking steroids. They should also be supplemented with Vitamin D and calcium and also add bisphosphonates only if the osteoporosis risk is high.

-Frozen shoulder - no need for imaging; loss of active and passive ROM. Other conditions like bursitis, cuff tear passive ROM is preserved. In Rx frozen shoulder - mild sx trial of exercise therapy for 2-3 months and then steroid injection if exercise is not working.

-Peri infarct pericarditis -- don't have to treat, it is self resolving. If sx are severe or it is very uncomfortable for the patient, then give aspirin high dose tid. **Don't use naproxen** so 2 types of pericarditis where naproxen is to be avoided --> 1.peri infarct pericarditis (because it will impair the healing process) and 2.uremic pericarditis (because dialysis is more appropriate and naproxen isn't really going to help because uremia is the cause)

-DRE (digital rectal exam) has low PPV so, not really useful and is not recommended anymore even with PSA.
pts. w/ prostate cancer likely to die of other causes.

-what is the agent of choice in scleroderma renal crisis? -- oral captopril. After starting ACE inhibitor if you have mild elevation in creatinine, still you don't have to stop ace inhibitor.

-inflammatory myopathy like polymyositis --> first do antibodies, if you don't get an answer then do muscle biopsy for conifirmation of dx. Interstitial lung disease is common in patients with polymyositis.

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* Re:Step 3 June 2020 Journal
  usmlejourney2015 - 05/17/20 19:13
  Notes -

- Panic attack Rx -SSRI after trying out relaxation techniques

-CCS tip - Cardiac Tamponade suspicion - Early intervention (Pericardiocentesis) before diagnostic testing (CBC, CMP,UA etc.) due to the life threatening nature of the condition.

-Blood Transfusion Rxns

1. Anaphylactic - seconds to mins. IgA deficient recipient.
2.Acute Hemolytic - Acute hemolytic (ABO incompatibility) and Graft vs host
+ve coomb's seen in --> acute hemolytic and delayed hemolytic
If the patient is having severe respiratory symptoms after transfusion --> it can only mean one thing (for testing purposes) --> TRALI
Earliest -- anaphylactic Late - delaaaayed hemolysis and Graft vs Host

(If you have better ways to remember the transfusion reactions --> please post and help us all)

-Physiologic jaundice is associated with anemia T/F?
false, it is not

- Physiologic jaundice doesn't occur in 24hrs after birth T/F?
false, it is usually pathologic if it occurs after 24hrs of life.

-G6PD (Pathologic) jaundice occurs during 2nd and 3rd day of life T/F?
G6PD co occurs with anemia obviously.

How do you differentiate G6PD from ABO incompatibility jaundice?

- G6PD as we said occurs on day 2 and 3 and is coomb's negative
-ABO occurs in the first 24hrs of life and is coomb's positive.

-Breast milk jaundice - indirect bilirubin is high. No anemia is seen. increased enterohepatic circulation.

-if there is high calcitonin in pts. who had thyroid removed, then there could be a secondary cancer with mets, so what do you do?

ct scan of chest and neck.

-Rx of acute chest syndrome associated pneumonia?

ceftriaxone and azithromycin.

- in prostate cancer that doesn't respond to hormones, and pt. has localized bone mets, you give ___________?

External beam radiation therapy.
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* Re:Step 3 June 2020 Journal
  carotid19 - 05/19/20 23:53
  hi ! great notes ...i thought we go direct to ECT in pregnant patients! now i know that


- Hydroxychloroquine, ( immunomodulatory , alkalinizes vacuolar and lysosomal PH ), SE: renal damage , retinopathy and QT prolongation
- Anakinra (IL-1 Inhibitor), Neutropenia
- Sulfasalazine , Rash, hepatitis
- Colchicine ( inhibits leukocyte mobility), diarrhea and aplastic anemia
- Methotrexate ( inhibits DHFR) , liver toxicity, Pulmonary fibrosis , bone marrow suppression.
- Galeazzi and Monteggia fractures :“MUGGER”, MU – M Ulnar fracture with Radial dislocation and GR- Radial fracture and ulnar dislocation
- ANCA: C-Anca (cytoplasma) anti-proteinase3 and P-Anca (perinuclear) anti-myeloperoxidase
- C- ANCA-Granulomatosis with polyangiitis (Wegener). 5C / Cyclophosphamide/C-ANCA/C-nose shape/C- cavitary? lungs (nodules )/…TRIAD; Upper +Lower +renal
- P_ANCA: Eosinophilic Granulomatosis with polyangiitis (churg strauus ): TRIAD : asthma/allergic rhinitis +Eosinophilia + renal involvement
- P-ANCA Myositis polyangiitis
- Dermatomyositis and Polymyositis, BOTH : elevated cpk + elevated aldolase + weakness+ Biopsy + difference : Dermatomyositis : skin findings
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* Re:Step 3 June 2020 Journal
  usmlejourney2015 - 05/24/20 18:09
  Awesome! Great points! These are very important rapid review facts!  
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