USMLE Step 2 CK: Next Step in Management

high-grade reflux in females that persists into adulthood with no clear secondary cause
surgical repair
multiple 2nd trimester spontaneous abortions
cervical cerclage
erythematous knee with effusion and fever
arthrocentesis [ need to tell apart gout from septic arthritis]
spontaneous pneumothorax in a tall young man
supplemental oxygen
clue cells seen in vaginal swab in a fertile woman
oral metronidazole
acute open-angle glaucoma
1)beta-2-antagonist eye drops i.e. timolol, betaxolol
2) carbonic anhydrase inhibitors
3) if medication fails, then a trabeculoplasty or trabeculectomy can improve aqueous drainage
chronic sinusitis refractory to medical Tx or neurological deficits
CT scan of the face (coronal section)
someone with tinnitus, progressive hearing loss, and multiple episodes of vertigo
dietary restrictions- particularly of caffeine, salt, and tobacco (Meniere’s disease)
someone that comes in with headaches and shows papilledema in the opthalmic exam
CT scan of the head non-contrast – r/o mass
treament for scabies
Scaphoid fracture that is negative on X-ray
spica cast and re-evaluate in 2~3 weeks
3-hour old infant with poor feeding who vomits green material and has a double-bubble on KUB
decompression of the GI tract…requires nasogastric tube
mini-mental status exam of <24
neuropsychologic testing to rule-out alzheimer’s (other causes of dementia)
cord compression confirmed with CT-spine
dexamethasone ( before MRI of the spine to gold-standard confirm cord compression)
Pulmonary edema in acute CHF exacerbation
100% O2 therapy
Pulmonary edema in acute CHF exacerbation after 100% O2 therapy
IV furosemide
supraventricular tachycardia with HR=160 bpm with p-wave preceding all QRS sinus rhythm
Vagal manuevers first -carotid massage, then valsalva , then pharmacological-CCBs or adenosine
Asymptomatic aortic stenosis
Hydrocholorothiazide to reduce preload
Hypertension with underlying diabetes type 2
ACE-inhibitor or ARB
Syncope with normal vitals and no previous episodes
Check the electrolytes and medications – thiazide diuretics can cause hypokalemia and arrythmia
PR interval=o.3 sinus rhythm normal
Nothing, no management needed; PR>0.2 is first degree heartblock
A-fib secondary to hypertension for >48 hours
Diltiazem; rate control + anticoagulant
A patient presents with hypertension and chest pain on exertion
IV nitroglycerin for lowering the blood pressure
Palpitations with underlying lung disease i.e. COPD
72 hr Holter monitor
Angina symptoms
Beta-blockers – they increase the threshold of angina
Posterior anterolateral MI and Percutaneous coronary intervention
teenage patient grunting and blinking many times a day for at least 1 year
prinzmetal angina
calcium channel blockers or nitrates (also for esophageal spasm)
Lambert Eaton Syndrome
radiation and chemotherapy as it is the manifestation of a pre-existing small cell carcinoma of the lung.
stroke outside the 3 hour period but within 6 hours
intra-arterial tPA administration
osteopenia in an elderly patient
calcium, vitamin D, and weight-baring exercise
tracheobronchial rupture
bronchoscopy (flexible or rigid)
abdominal pain out of proportion to clinical findings
Guillane Barre Syndrome
plasmapheresis or IVIG with admission to ICU
shoulder dystocia on observing the Turtle sign(retraction of head back into perineum)
McRoberts maneuver – flexion of mother’s thighs against her abdomen
central retinal artery occlusion
ocular massage with high flow oxygen
nephrogenic diabetes insipidus
free water and hydrochlorothiazide
carbon monoxide poisoned pregnant lady with carboxyhemoglobin >15%
hyperbaric oxygen (oxygen >100%)
flu-like illness with cherry red lips; multiple family membersl; carboxyhemoglobin <25%
100% oxygen
a digoxin user with a potassium of 5.5 mg/dL
Digibind (Fab fragment
Wernicke’s Encephalopathy
thiamine, then glucose ( in that order)
Alcohol withdrawal
fluid resuscitation, thiamine, dextrose, folate, benzodiazepines(diazepam, chlordiazepoxide)
septic arthritis
ceftriaxone + vancomycin
prophylaxis against acute limb ischemia in a person with a-fib
acute febrile non-hemolytic transfusion reaction
discontinue transfusion, give IV acetaminophen
acute cholecystitis
IV fluids, pain medication, and cholecystectomy within 72 hours
abscess size >3cm
CT-guided percutaneous drainage
single 2cm nodule on Chest X-ray in a 25 yo male
check old Chest-X-ray to compare size or presence of the nodule.
ulcer that is not infected and does not involve the bone
how to diagnose hepatorenal syndrome
IV colloid challenge , if no improvement then positive for hepatorenal syndrome
Primary light chain amyloidosis
mephalan and prednisone
local baldness
severe acute pancreatitis >30% necrosis on MRI
imipenem followed by percutaneous needle biopsy
pseudocyst on CT-abdomen
if expanding or pain symptoms, then drain it. otherwise leave it alone.
elderly patient with intermediate to high risk factors for coronary artery disease
stress test
needle-stick and unvaccinated for HepB
give HepB IV-IgG and HepB vaccine
MRI contraindicated in suspicious looking equivocal X-ray
Technetium bone scan
man comes in with a painless chancre on the penis
swab the exudate and perform dark-field microscopy
vesicles on skin and mucous membranes which erode into ulcers with inguinal lymphadenopathy
Tzanck positive
methods of treating genital warts
cryotherapy , lasers, trichloroacetic acid or podophyllin
imiquimod(originally for basal cell , acktinic akeratosis) , no side effects
acute viral pericarditis recurrence prevention
pericardial effusion
pericardial window placement or pericardiocentesis
pneumonia, dyspnea, dry cough fever chest pain in HIV patient
Bronchoscopy with alveolar lavage
dysuria, suprapubic pain, and hematuria continue despite empiric antibiotics for UTI
CT-scan of the abdomen and pelvis
the first test to determine beta-thalassemia anemia in genetic counseling
complete blood count in the female (if no abnormality found, then there is no need for hemoglobin electrophoresis testing; if abnormal then test the partner)
no menarche in a 15 year old with no medical problems and Tanner stage 1 with a uterus
measure serum FSH (do not measure estrogen because the lack of breast development already tells you there is a lack of it)
dog bite with suspicion of rabies
quarantine the dog for 10 days; if asymptomatic the whole time, then no need for management (post-exposure prophylaxis)
pinpoint calcifications in a newborn whose mother owns a cat
pyramethamine and sulfadiazine (Treats toxoplasmosis)
peripartum cardiomyopathy – biventricular cardiac failure
supportive care
eisenmenger’s syndrome in a pregnant woman
avoid hypotension give pressors
Rheumatic mitral stenosis in a pregnant woman
decrease the heart rate to allow time for blood to fill the left ventricle; reduce the IV fluid volume
pregnant woman of 16 weeks gestation with fasting blood glucose of 140 mg/dL
do quadruple marker screen assess for neural tube defects – specifically caudal regression syndrome – she has overt diabetes mellitus.
Estimated fetal weight is >4.5kg by sonogram
perinatal management of gestational diabetes
IV D5w with insulin drip maintain glucose within 80-100mg/dL
non-reactive stress test
vibroacoustic stimulation- wake up the baby because most commonly non-reactive ST due to the baby sleeping
non-reactive stress test with positive contraction stress test
delivery the baby immediately
fibromuscular dysplasia
percutaneous angioplasty with stent placement
4 month old boy with leg-length discrepancy and positive Ortolani test
U/S of the hip followed by Pavlik Harness (splint that holds hip in flexion and abduction) – prevents extension and adduction
45 yr old woman overdosed on pills comes in with tinnitus, fever, and tachypnea
aspirin intoxiciation – supportive care, activated charcoal, IV hydration, bowel irrigation
moderate intoxication =>IV sodium bicarbonate to alkalinize the urine and promote excretion
severe intoxication => hemodialysis
suspicion in an immigrant man with hypopigmented skin patch with loss of sensation. Had a flu-like illness 1 month prior.
perform a skin biopsy -> top ddx is Lepromatous leprosy.
A man with mediastinal widening on chest X-ray and equal blood pressures on both arms and moderate pericardial effusion
Trams esophageal echo
5 day old newborn has lost 7% of their body weight
follow up 10-14 days to see if baby has regained it (normal loss of fluid due to labor and in-utero)
skin lesions in a patient with celiac disease
dapsone (Tx for dermatitis herpetiformis)
clinical suspicion for abnormal uterine bleeding
endometrial biopsy
reproductive-age woman with widespread pain ,fatigue, poor-sleep, frequent headaches and tenderness to palpation of her neck, shoulders and back. Vitals and labs are normal.
exercise program with aerobic conditioning (Tx for fibromyalgia). Medications – duloxetine, TCAs are a secondary measure.
1 month old boy with a harsh holosystolic murmur over the left lower sternal border
echocardiography – he has a VSD
infant with symmetric descending paralysis, drooling and constipation, poor suck and gag reflex also seen
botulism immuneglobulin + supportive therapy(respiratory support, NGT feeding)
Lichen sclerosus
admission to inpatient ward with febrile neutropenia
cafe au lait spots with sensorineural hearing loss
MRI with gadolinium (suspect acoustic neuroma)
MI status post CABG post-op day 5 small pericardial effusion with fever, tachycardia, a-fib.
drainage, surgical debridement and antibiotics ( acute mediastinitis)
DVT identified on ultrasound
CT scan of abdomen, chest, and pelvis – search for any embolism
IV fluids, mannitol and bicarbonate
Baseline EKG changes on patient with SSx of stable angina
Stress echocardiography instead of exercise treadmill stress test — (echo you need to have a normal EKG reading at rest)
presence of bilateral popliteal artery aneurysms
CT Abdomen -> 25% chance of abdominal aortic aneurysm present.
CPR and epinephrine(lowers defibrillation threshold, increases myocardial and cerebral blood flow) ; defibrillation does not work for asystole
hepatorenal syndrome
midodrine and octreotide
Needlestick from an HIV infected person
Triple HAART therapy for 28 days
pancreatic cancer with elevated direct bilirubin
endoscopic stent to relieve jaundice from extrahepatic cholestasis
positive whiff test
amine production with KOH prep = bacterial vaginosis — Tx –> clindamycin or metronidazole
symptoms of malabsorption returning from a foreign country
Tx empirically with metronidazole. i.e. giardiasis, amoebiasis.
skin rash in a person with gluten-intolerance
dapsone for dermatitis herpetiformis
patient with hypothermia at 32-35C, 28-32C, and 27C degrees
general – IV hot crystalloid for hypotension with endotracheal intubation in comatose patients.

32-35 degrees – dry and cover with blankets
28-32 degrees – warm bath, heating pad, blankets
<28 degrees - pleural, peritonealwarm irrigation -internal rewarming

recurrent coughs with mucopurulent sputum
CT scan – bronchiectasis – dialated bronchiolar airways
microcytic, hypochromic anemia in an otherwise healthy adult
test for stool occult blood – because the most common cause of iron-deficiency anemia is GI blood loss. Otherwise, colonoscopy is indicated because it has a higher sensitivity and specificity
meningitis in people age 2-50
vancoymcin + 3rd generation cephalosporin
meningitis in people older than 50
vancomycin + ampicillin + 3rd generation cephalosporin
infection post-neurosurgery shunt
vancomycin + 4th generation cephalosporin (cefepime)
meningitis in an immunocompromised state
vancomycin + ampicillin + 4th generation cephalosporin(cefepime)
infection after penetrating trauma to the skull
vancomycin + 4th generation cephalosporin (cefepime)
Tx of carcinoid syndrome
octreotide for symptomatic patients before surgery
patient has blood cultures that grow Streptococcus bovis and has vegetations on mitral valve
perform colonoscopy NOT FOBT- colonoscopy is more sensitive and specific
patient had a Hx of flu ten days earlier but now has increased tactile fremitus in LLL of the lung and a fever
Tx: anti-staph penicillin i.e. methicillin, oxacillin, dicloxacillin, naficillin – most common organism is Staph aurues post-influenza pneumonia.
patient with a PMH of drug addiction and addiction comes in with severe pain from a motor vehicle accident. What analgesic do you give him?
Give him IV morphine. It doesn’t matter what his drug abuse history is. Physicians never undertreat pain even with a risk of abuse.
lupus nephritis
1. mycophenolate mofetil
2. cyclophosphamide + corticosteroids
3. azathioprine + corticosteroids
MALT lymphoma restricted to the mucosa with no lymph node involvement
PPI + clarithromycin + amoxicillin ( most common cause is H-pylori) then use
multiple consecutive PVCs without symptoms

what if you DO have symptoms with multiple consecutive PVCs?

observation; if multiple consecutive PVCs with symptoms then you give beta-blockers first, then amiodarone as a second-line therapy.
cancer-related anorexia and/or cachexia symptoms
megestrol acetate ( progesterone analogs) they are superior to cannabinoids
positive PPD test in HIV patients
isoniazid + vitamin B6 for 9 months.
unstable patient with narrow-complex tachycardia
DC cardioversion stat
supraventricular tachycardia = narrow complex tachycardia
patient with flank pain gets abdominal imaging showing 6mm calculus in distal right ureter. No hydronephrosis seen. IV hydration and analgesics started. What is the next step?
alpha-1 receptor blocker i.e. tamsulosin – acts at the distal ureter lowering muscle tone and reduces ureteral spasm from stone impaction.
elderly patient with abnormal gait, incontinence and dementia showing enlarged lateral ventricles on CT scan
1. serial large volume lumbar punctures
2. ventriculoperitoneal shunting if symptoms relieved
by sequential CSF removal by the lumbar punctures
painless hematuria with elevated hemoglobin, 50 pk-yr smoking history
CT Scan of the Abdomen
symmetrical pain and stiffness in the neck, shoulders, and hip with elevated ESR
low dose prednisone ( Polymyalgia Rheumatica)
widened pulse pressure, irregular breathing, and elevated ICP
intubation with possible ventilation, elevated head of the bed , mannitol
symmetric descending flaccid paralysis that started with dry mouth and diplopia
administer antitoxin with high clinical suspicion simultaneously with collecting specimens identify in stool, serum or gastric lavage -> botulinum toxin.
hypertonic extremities with lockjaw
(1)admit to ICU immediately,
(2) diazepam, and give
(3)1x dose of IM tetanus immunoglobulin
(4) active immunization with Td(tetanus/diptheria toxoid)
empiric osteomyelitis Tx
cephalosoprins, fluoroquinolones, vancomycin, linezolid, daptomycin, and clindamycin
rifampin for biofilm penetration

If gram negative suspected add aminoglycoside +/- beta lactam

septic arthritis in an immunocompetent adult
IV beta lactamase resistant penicillin –> oxacillin OR 1st generation cephalosporin ; MRSA coverage -> vancomycin
septic arthritis in a immunocompromised adult
broad spectrum antibiotic – 3rd generation cephalosporin OR aminoglycoside ; consider pseudomonal coverage with aminoglycoside + extended spectrum pencillin
(1) freezing lesions with liquid nitrogen
(2) salicylic acid daily topically applied for several weeks
(3) 5-FU cream – retinoic acid cream for flat warts
(4) surgical excision OR laser therapy
(5) podophyllin for genital warts
molluscum contagiosum
(1) curettage
(2) podophyllin drops
(3) cantharidin
(4) cryosurgery
silvery scales on knees and elbows
corticosteroids are first line
calcipotriene and calcitriol – 1st/ 2nd line
tazarotene ( vit A derivative)
anthralin (anthracene derivative – smoke carcinogen)
young woman with tender breast mass on the upper outer quadrant. LMP was three weeks ago. She has no family history of breast cancer.
Ask her to come back after the menstrual period and ask her to take note if the size of the mass has decreased after the menstrual period. Otherwise ultrasound, FNA, and excision biopsy would be the option.
acute exacerbation of COPD
IV methylprednisolone 1-2x doses followed by oral therapy for 5 days.
allergic conjunctivitis
olopatadine, azelastine
non-herpes viral conjunctivitis
supportive therapy, warm compresses
collapsed gestational sac with no fetal heart tone on transvaginal ultrasound in a hemodynamically stable female at 8 wks gestation
follow-up outpatient ; no suction and curretage.
meningitis in a 55 year-old man
3rd gen. cephalosporin + vancomycin + ampicillin + dexamethasone
bruit left periumbilical region on auscultation in middle-aged man with hypertension
captopril renal scan
eye pain with Hx of occupational trauma
tetracaine for pre-op anesthesia prior to Fluorescein slit lamp examination
elderly male comes in with 1 episode of syncope with no smoking history BP equal on both arms and widened mediastinum and pericardial effusion on chest X-ray
transesophageal echocardiogram –> it could be a type A retrograde aortic dissection , so the BP could be normal.
frostbite injuries
rapid rewarming with warm water
high blood pressure in an otherwise healthy woman of child-bearing age
1st step: discontinue oral contraceptive pills
2nd step: diet and exercise
3rd step: introduce thiazide diuretic
5mm radiolucent stone in the ureter
potassium citrate –> uric acid is soluble at high pH
elderly male with history of recurrent aspiration presents with neck mass and RLL consolidation
barium esophagram to rule out Zenker’s diverticulum,
CT scan of neck is indicated for airway obstruction by foreign object; bronchoscopy is 2nd line.
postpartum fever with leukocytosis and non-foul smelling bloody vaginal discharge
reassurance. You don’t even need empirical antibiotics. Endometritis requires the presence of foul smelling lochia
acute exacerbation of COPD
non-invasive positive end expiratory pressure for 2hours
acute exacerbation of COPD with failed NPPV trial
mechanical intubation
malignant hypertension
lower BP 10-20% in the first hour , then 5-15% across the next 23 hours.
hypertension diagnosed in a young individual
suspicion for co-arctation of the aorta –> check for radio-femoral delay..associated with Turner’s, bicuspid aorta, and VSD.
adnexal mass in a postmenopausal woman.
transvaginal ultrasound AND CA-125 serum marker
progressive back pain in prostate cancer patient with previous orchiectomy
radiation therapy (the answer is NOT flutamide or any medical management)
white cloudy dialysate with tender abdomen in a patient getting peritoneal dialysis.
trial of antibiotics cefazolin and ceftazidime; if refractory, then remove the catheter.
positive Tinel’s sign and flick test
First line: wrist splint
2nd line: injected glucocorticoids
3rd line: surgery
fever, hypertension and tachycardia along with altered mental status
give Librium ( chlordiazepoxide) the patient is going through EtOH withdrawal
post-ictal metabolic acidosis on admission
wait 60-90 min. for the metabolic acidosis to resolve, then redraw labs. No need for immediate medical intervention.
Failure of MALToma to regress after eradication of H-pylori with triple therapy
CHOP therapy – cyclophosphamide, adriamycin, vincristine, and prednisone +/-bleomycin
woman in her thirties whom results for for AchR antibodies test came back positive
CT scan of the anterior mediastinum — a thymoma is more specific than a Tensilon(Edrophonium) test
opening snap with diastolic rumble in a patient who had a respiratory illness with joint pain an swelling recently
IM benzathine penicillin G once a month for 5 years or until 21 years old (whichever is longer) for rheumatic fever + carditis

rheumatic fever + carditis but no proven heart or valve disease (echocardiogram/clinical) – 10 years or until 21 yrs old – whichever one is longer

rheumatic fever + carditis, heart or valve disease = 10 yrs or until 40 years old

precocious puberty showing elevated LH at baseline
MRI of the brain – need to rule out central vs. peripheral gonadotropin dependent precocious puberty
cat bite with puncture wound showing no debris or active bleeding in a patient with recent Td vaccination <5 yrs
amoxcillin-clavulanate for Pasteurella multocida
dyspnea and tachycardia in a pregnant woman with low pretest probability of P.E. chest X-ray
d-dimer in a pregnant patient has high false negative rate; need to perform V/Q scan to rule out P.E. If V/Q is equivocal then perform CT angiogram.
urge incontinence
bladder training ; 2nd line is oxybutynin(anticholinergic) and mirabegron(beta-3 adrenergic agonist @ the detrusor)
gas gangrene infection
IV penicillin – 24 million units per day
1 or 2 coronary vessel stenosis
angioplasty and stent followed by Gp2b3a inhibitor i.e. tirofiban or abiciximab
postmenopausal woman with pruritis of the vulvar region that is refractory to medical management
vulvar biopsy.
history of cancer with suspicion of bony metastasis i.e. back pain
radionuclide bone scan ( X-ray of the back is to rule out other causes of bone pain because radionuclide bone scan has high sensitivity BUT low specificity)
suspicion for SLE; which lab test first
anti-nuclear antibody first because of high sensitivity; use anti-dsDNA antibody as a confirmation test because of high specificity
amytrophic lateral sclerosis
riluzole – glutamate receptor antagonist
moderate-to-severe restless leg syndrome
1st line – pramipexole, ropinirole
2nd line – alpha-2-delta calcium channel agonists i.e. gabapentin enacarbil
mild restless leg syndrome
1) iron supplementation if serum ferritin <75 2) supportive measures - heating pad exercise 3) avoid triggers - sleep deprivation, medications
sore throat two weeks after starting PTU for treatment of Graves disease
stop PTU. It is causing the agranulocytosis
person with a core body temperature of 88 degrees F, bradycardia and hypotension
active rewarming with blankets – hypothermia will slow the heart and the blood vessel vascular resistance.
patient brought to E.R. after smoke inhalation from a burning building
100% oxygen by facemask – first suspicion is carbon monoxide poisoning.
recent gastrectomy with nausea, diarrhea, abdominal pain and palpitations
manage diet — dumping syndrome – small frequent meals, avoiding simple sugars, increase fiber and protein, drink fluids during rather than after meals.
patient with Hx of tonic-clonic seizures comes in post-seizure 15 min. ago and has a pH of 7.2. confused and appears confused. anion gap is elevated.
This patient has post-ictal lactic acidosis. No management for the first two hours and draw second labs. a pH >7.1 does not require intervention. If value <7.1 then IV sodium bicarbonate is indicated.
unilateral renal artery stenosis 80%
treat initially with ACE-I or ARBs. stenting and surgical revascularization is reserved for patients with resistant HTN or flash pulmonary edema or refractory heart failure due to severe HTN
patient shows morning glucose of 300mg/dL consistently; they deny any late night snacks
make them record their blood sugar at 3am – to determine Somogyi (rebound hyperglycemia 2/2 hypoglycemia) or Dawn effect (cortisol and growth hormone effects)
PCP intoxication
benzodiazepines – midazolam, diazepam, or lorazepam ; 2nd line is haloperidol
R supraclavicular lymph node biopsy shows squamous cell carcinoma cells
do a panendoscopy because the cancer is coming from larynx, bronchus or esophagus most likely.
nausea and vomiting caused by chemotherapy
ondansetron + Fosaprepitant + dexamethasone ( 5HT3 antagonist and NK-1 antagonist) dexamethasone mechanism unclear.
condyloma acuminata – patient wants self-treatment
imiquimod (induction of IFN-alpha leading to reduction in HPV viral DNA synthesis). Canthardin and Podophyllin require in-office administering of the drug.
vomiting, lethargy, dehydration, with posturing in a 10 month old infant
IV dexamethasone; increased ICP can counteract vasogenic edema – corticosteroids have an anti-inflammatory and membrane stabilizing effect
pediatric patient 4 years old has PPD <5mm but lives in the same house as someone who has
isoniazid _ vit B6 along with follow up PPD test in 8-12 week- the kid is still exposed to T.B.
agitation and chest pain in someone with acute-onset chest pain who recently used cocaine
benzodiazepine –> use diazepam
patient comes in with tearing chest pain radiating to the back, has a moderate pericardial effusion and happens to be hemodynamically stable
CT angiogram – definitive test for aortic dissection
an unchanged consolidation in the right lower lobe of the lung after multiple bouts of pneumonia
CT scan of the chest — concern for malignancy. Bronchoscopy is most commonly for biopsy of hilar centrally located masses.
adnexal mass palpated in a post-menopausal woman
need to obtain a serum CA-125 ( pelvic U/S would have been the first intervention in a pre-menopausal woman)
temporal lesions on MRI in a male with seizure. He also has a fever and altered mental status
empirical treatment with IV acyclovir. If IV acyclovir fails , then lumbar puncture is warranted.
male in his 20s diagnosed with HOCM, refractory to beta blockers and calcium channel blockers
vomiting in a young child with olive-shaped mass in the epigastric region
correct the metabolic alkalosis first, then consult for surgery for pyloromyomectomy

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