Neeraj’s Step-3 Notes

Neeraj’s Step-3 Notes
1.
Case of back pain with normal thorough physical & Neurological examination
excluding systemic and visceral disease Rx Supportive care and NSAID’s like
Acetominophen
2.
Rx Acute Prostatitis: Cotrim or Cipro(Fluoroquinolones)
3.
Low grade squamos intraepithelial lesions (LGSIL) or CIN I lesions usually
revert to normal except 10-15% which may progress. One may perform colposcopy
immediately or after 4-5 months.
4.
Livedo reticularis: Seen in cholesterol emboli syndromepurplish web of
discoloration over skin
5.
GERD  Rx first non-pharmacological measures like elevating head, avoid
eating before bed/Caffeine/Chocolates Fails H2 blockers Severe Ds not
responding Proton Pump inhibitors
6.
New born with FH of CF might have meconium plug syndrome involving
jejunum  Ba Enema has a therapeutic as well as diagnostic value  DDx Ileal
atresia
7.
OCP’s reduced GnRH  Reduced ovulation Reduced disruption of ovarian
germinal capsule  Reduced risk of ovarian CA(Nulliparity,HRT and ovulation
inducing drugs increase the risk)
8.
Parapneumonic effusion  Rx antibiotics and tube thoracostomy Empyema?
Decortication
9.
Hot tap water burns: Usually first degree burns presenting as erythematous
swollen skin  Run cold water over the area or hold a cool compress over it Apply
aloe vera cream and use aspirin/Ibuprofen for pain  Adv for setting water
temperature <120-130F
10.
Olfactory dysfunction: Caused by Brain tumors,Sinusitis,Rhinitis,Nasal
poly/Neoplasm,Hypothyroidsm and depression  PE  Neuro to assess odor
perception with alcohol  R/o Neoplasm with CT
11.
Acute renal failure due to Pre-Renal cause usually associated with
hypovolemia  Is associated with Sodium avid state as Kidney tries to retain water.
The urine Na+ will < 25mmol/L
12.
H/o encephalopathy is contraindication to TIPS.
13.
Pseudogout associated with calcium deposits in meniscus.It has close
association withhemachromatosis, Hypothyroidism, Hyperparathyroidism, and
Hypomagnesemia. Pseudogout + Pigmented skin + Raised liver enzymes/FH liver
failure Hemochromatosis
14.
DM + HTN  Drug of choice ACE inhibitors
15.
Patient with known PID develops tenderness and guarding s/o peritonitis
?Ruptured TO abscess  Immediate Surgery
16.
Hemodynamic subsets of Shock
CO
PAWP
SVR
Cardiogenic shock
Low
High
High
Hypovolemic
Low
low
High
Septic
High-Normal-Low
High
low
Extracardiac
Low
Normal or High
High
Obstructive Shock
17.
Surgical resection of Choledochal cyst is essential to prevent frequent
recurrent cholangitis and malignant degeneration.
Neeraj’s Step-3 Notes:Kaplan
1
18.
Suspected Insulinoma v/s Factitious disorder: Measure C-peptide  Low in
Factitious disorder  If found high  Measure Sulfonylurea levels to r/o possibility of
Factitious disorder before searching for insulinoma.
19.
Pulmonary HTN  Gold standard is cardiac catheterization Significantly low
DLCO + normal ventilatory pattern Rx O2 to prevent hypoxic vasoconstriction
Diuresis to control Rt heart functionAnticoagulant to prevent thromboembolic
events  INR 1.5-2.5  Add calcium channel blockers for vasodilatation
20.
alpha 1 antitrypsin deficiency  Counsel about alcohol  Accelerated
cirrhosis
21.
Post fracture fat embolism is usually soon after injury or surgery.Alcohol
withdrawal is mostly seen within 48hrs(max upto 10 days).DVT may occur even after
10days.
22.
Cat scratch fever(Bartonella Henslae)PapuleAxillary lyphadenopathy Rx
not required usually as it is self limiting except secondary infection with staph aureus
or complication with encephalitis Needle Biopsy of lymph node is required to
exclude lymphoma
23.
Recent onset of atrial fibrillation without any obvious cardiac cause should
raise the suspicion of hyperthyroidismit also stimulates bone resorption and
increased calcium.
24.
Wt gain  ?H/o smoking cessation, use of medicationBiochemical
evaluation
to
r/o
DM(Hyperglycemia)
or
Cushing
syndrome(Hyperglycemia,Hypokalemia/Chloremia,Metabloc
alkalosis
and
hypercholesterolemia)Apple shape body = Thick trunk/Thin limbs seen in crushing’s.
(Pear shape body = Thin torso and thick hips).
25.
Porphyria cutanea tarda  Screen for Hepatitis C and Iron overload Both
may lead to PCT and are treatable. (Hepatitis B associated PAN  Cutaneous
vasculitis)
26.
Minor illnesses with or without fever is not a contraindication to routine
immunization (both live and inactivated vaccines).
27.
Symptoms
of
hypoglycemia:
autonomic
response(tremors,palpitation,sweating) and neuroglycopenic response(nervous
system dysfunction like blurry vision,headache,confusion) usually manifest when
<45 mg/dl Causes postparandial,fasting,insulinoma and factitious
28.
Inspiratory chest pain + Leathery heart sounds on systole/diastole + Newly
enlarged heart  In post viral bronchitis/Illness  Pericarditis Rx NSAID’s
29.
Community acquired pneumonia due to pneumococci: Criteria to admit the
patient: (1) >65yrs age (2) significant co-morbidities like DM(3) Staph, anaerobe or
G-ive bacteria (4)Failure of OPD Tx(5) RR>30/HR >140/Hypotension/Po2<60(6)
Poor social support  DOC is Penicillin in Pneumococci but Vancomycin may be given
empirically till the sensitivity is available.
30.
Recurrent flash (rapid onset) pulmonary edema:Often responds to Lasix
DDx Transient MI,MR,AR and Renal artery stenosis(Patient of recent onset HTN and
episodes of flash pulmonary edema  Evaluate for RAS)
31.
Recurrent fungal and PCP infections  R/o HIV  Negative R/o T cell
immunodeficiency Order hypersensitivity skin testing.
32.
Want to conceive?  Start multivitamin + Folic acid at-least 1 month prior to
conception(USPSTF)
33.
Aura  Behavioral arrest /Motion less stare Automatism(picking movements
with hands,Chewing,swallowing)  Post ictal confusion = Complex partial
seizure. DDx Absence/Petit mal seizure(Automatism + LOC + Stare) = No
postictal confusion!
34.
Agitation in context of delirium DOC is haloperidol + Soft restrains/Dim
light
Neeraj’s Step-3 Notes:Kaplan
2
35.
CDC recommendation for admission in PID patients: (1) noncompliant/Followup not possible (2) Pregnancy with PID (3) Severe nausea /Vomiting (4) TO abscess
or peritonitis (5) Immuno-deficient (6) Failure to OPD Rx
36.
Chronic plaque psoriasis = Silvery/Pink well defined plaques at
Scalp,ear,elbow,knee,sacrum,ankle  Migratory glossitis(Moving locations) 
Onycholysis  Confirm with biopsy from scalp or elbow
37.
Typical trigeminal neuralgia is not a constant pain
38.
Rapid onset of hypoxia?  Interstitial fibrosis : Idiopathic(Hammond Rich
syndrome)  Rx O2 via nonbreathing mask
39.
Tinea Corporis(Ring worm): Elevated border with central clearing.
40.
Tinea Versicolor(Malassezia furfur):Macules of variegated colors(Even
hypopigmented) growing radially KOH preparation shows numerous hyphae
breaking into short rod shaped fragments with intermixed round spores(Spaghetti
meat balls appearance).
Spaghetti meat balls
Malassazia Furfur
41.
HTN = > 3 readings at separate occasions > 140/90mmHg
42.
Supratherapeutic INR = increased possibility of bleeding
43.
HIV patient with focal brain lesions = 70% Toxoplasmosis + 10-20%
Lymphoma  Empiric Tx for toxoplasmosis for 3-4 wks Deteriorates
clinically/Radiologically  Biopsy to R/o Lymphoma(CSF PCR for EBV is highly
specific and sensitive for primary CNS lymhoma)
44.
Post orthopedic operative procedure risk of DVT >> PE
45.
Physiological vaginal discharge: Clear to off white(yellow when it air dries on
undergarment),non-homogenous,cyclical,scanty-moderate,PH<4.5,
MicroscopicEpithelial cells with lactobacilli
46.
TUR Syndrome: During TURP irrigation fluid is absorbed thru venous channels
and lead to hyponatremia due to hypervolemia  Neurological manifestation like
color / visual changes. (A similar picture can be seen in hysteroscopic procedures).
47.
Isolated low HDL: DOC is Niacin followed by Fibrates.A moderate
cardiovascular exercise for 30mints x 5times/week also helpful.
48.
Lack of endocervical cells on pap smear: Improper sampling Low
risk(Monogamous relation,Normal early smears): Wait till next examination after 1
year High risk(Multiple partner,Abnormal paps): repeat the sample.
49.
Post SAH vasospasm usually responds to Nimodipine –No other CCB has been
proven to be helpful.
50.
Controlled asthma: (1) <2 rescue treatment of albuterol/week (2) <2 times
waking up in the night due to asthma/month (3) <2 canister/container of
albuterol/month  If not fitting into criteria  Go for Steroid MDI
51.
Patient on amitryptyline  Develops dilated pupil/non-reactive to
light/redness of conjunctiva? Acute angle closure glaucoma
Neeraj’s Step-3 Notes:Kaplan
3
52.
CD4+ count <200 start prophylaxis TMP/SMX for PCP
53.
High clinical suspicion of appendicitis  Go for exploratory laprotomy No
need to perform CT/USG It is acceptable to have 15% negative exploration rate.
54.
GPC (Giant papillary conjunctivitis): Cobble-stoning of palpebral conjunctiva
Seen in contact lens wearer  Discontinue lenses in acute phase.
55.
Stroke t-PA  Increased risk of intracranial hemorrhage Do not give
Aspirin/Heparin for 24hrs and review Neuro status every 1 hr for 24 hrsKeep BP
<180
56.
Internationally adopted children: Do not rely on records even if it is available
and immunize the child as per a schedule for an un-immunized child do not forget
to screen for Hepatitis C/B, HIV, Syphillis, TB and stool for ova/parasites.
57.
Acute arterial occlusion  Pulseless cold foot start IV heparin and prepare
for surgical embolectomy
58.
Osteoporotic compression fracture of vertebrae  Rx Calcitonin + HRT +
Calcium + Ibuprofen for pain
59.
It there is scale scrape it –Dermatological adage –a sound advice!
60.
Prognosis of Squamous cell CA of face is better then Squamous cell CA of lip.
61.
Suspected esophageal perforation  Normal contrast study with water
soluble agent  Repeat with barium to ascertain result or R/o perforation
62.
Chronic pancreatitis Splenic vein thrombosis selective splenic vein
hypertension may ensue Gastric varices without esophageal varices  Rx
Splenectomy
63.
Common nose bleed  Dry mucosa or Nose picking Pinch the nose + Apply
ice packs + Keep the area moist
64.
Wernicke’s encephalopathy triad =Ataxia + Confusion + Oculomotor
dysfunction(all component not always present) Require high clinical suspicion in
diagnosis and history+Neuro exam is sufficient to diagnose the same Thiamine
levels in body are not indicative of levels in brain hence not useful.
65.
Psychomotor agitation + Delirium + Autonomic instability(raised BP/HR) +
seizures = Delirium Tremens v/s Benzodiazepine withdrawl  Rx Supportive
measures + Benzodiazepine/Cholrdiazepoxide
66.
Tricyclic antidepressants do not have any withdrawal and can be stopped
abruptly
67.
Hepatopulmonary syndrome is a syndrome of shortness of breath and
hypoxemia caused by vasodilation(due to increased hepatic production or decreased
hepatic clearance of vasodilators, possibly involving nitric oxide) in the lungs of
patients with liver disease. Dyspnea and hypoxemia are worse in the upright
position. A useful diagnostic test is contrast echocardiography. IV microbubbles from
agitated saline that are normally obstructed by pulmonary capillaries rapidly transit
the lung and appear in the left atrium within 7 beats S/O Rt to Lt shunt.Other
diagnostic options are pulmonary arteriography and Tc scanning.Tx: Liver transplant
68.
Continue breast feeding even when on treatment for mastitis.
69.
Majority of cirrhosis in the world due to schistosomiasis but in US it is due to
alcohol & Hepatitis.
70.
Dilated pupils (Raised ICT?) + Coagulopathy(raised PTT) + Hypogycemia =
Fulminant Hepatic failure DDx  Acute viral hepatitis,HELLP syndrome,autoimmune
or Medications like acetaminophen(Most common cause of drug ingested fulminant
hepatic failure-Suspect when no previous medical history available).
71.
ONLY contraindication to testosterone therapy is CA prostate.
72.
Linezolid(Zyvox):New “oxazolidinone” antibioticused for multi-resistant
bacteria including streptococcus and methicillin-resistant Staphylococcus aureus
(MRSA)Inhibit protein synthesis by stopping the 30S and 50S subunits of the
Neeraj’s Step-3 Notes:Kaplan
4
ribosome from binding together MC side effect is Thrombocytopenis especially
when given >14days.
73.
Diagnosed with DM-II Go for yearly ophthalmology check ups soon after
diagnosis
74.
Burn patient  Increased non-junctional acetyl choline receptors Avoid
succinyl choline As it may lead to increased K+ causing cardiac arrest/death.
75.
Porphyria cutanea tarda
Blistering of the skin in areas that receive higher levels of exposure to sunlight with
scarring+ fragile skin + Milia(Tiny white papules)
Drugs like Naproxen may also precipitate event=Pseudoporphyria or Drug Induced
PCT
76.
Angiodysplasia of colon is associated with VW disease and aortic
stenosis(crescendo decrescendo murmur radiating to carotid)
77.
Superior vena cava syndrome  Most feared complication is upper airway
obstruction? Radiotherapy is Tx of choice
78.
Acutely deteriorating renal functions  Immediately evaluate potentially
Like
K+,PO4important
derangements
secreted/excreted
by
kidneys
Acidosis/Uremia(Irrespective of etiology) Electrolytes,Ca++,PO4-79.
Renal failure patient with baseline anuric  About 3 times/week dialysis run.
80.
Indirect hernias may manifest as a complication within 6 months of birth In
case detected late Should be operated soon after diagnosis without delay Explore
other side also and operate the occult hernia(Usually prresent)
81.
Occupational Vitiligo  De-pigmentation patch of skin resembling
autoimmune vitiligo Due to antioxidants often present in gloves or rubber
industry Fluorescent white patch on wood’s lamp
Neeraj’s Step-3 Notes:Kaplan
5
82.
Hematospermia Often due to nonspecific infections of urethra/Prostate/SV
Self limiting Reassurance
83.
During an outbreak of influenza aspirin is contraindicated  Reye’s syndrome
84.
Dermatomyositis  Myositis(Prograssive muscular weakness) Search
for Internal neoplasm?
Gottron papule:edema associated with erythematous papules over the knuckles
Heliotrope erythema: erythema and scaling over her eyelids(Lavender shade)
85.
Neutropenic enterocolitis Often localized to sigmoid colon Seen in patients
on chemo  Tx : Antibiotics + Bowel rest + Platelets+ Granulocyte stimulating
factor
86.
CA prostate : Confined to gland/Early stage  Prostectomy
87.
Metastatic CA prostate to spine  LHRH agonist (Leuprolide/Goserelin) or B/L
orchidectomy
88.
Post MI Indefinite Baby Aspirin
89.
Postpartum 3-4 days  Anxiety,Irritability,Confusion Postpartum blues
Resolve by 2 wks by itself.
90.
EBV/Infectious Mononucleosis=Few wks sore throat Strepto: Few days
91.
Kawasaki Ds: Fever>5dB/L conjunctival injectionstrawberry tongue +
Edematous soles/palms+ Desquamatous rash + Cervical LN + Thrombocytosis  Tx
Neeraj’s Step-3 Notes:Kaplan
6
Aspirin + IV gammaglobulin  Echocardiography to evaluate cardiac status  Most
Important complication is aneurysm of coronary artery(Steroid not required!)
Mortality is 0.05% only Long term aspirin?  Yearly influenza vaccine to avoid
Reye’s syndrome
92.
Cherry red lips ? CO poisoning  Methylene Chloride is a solvent used in
paint remover readily absorbed thry skin Hepatic metabolite COMeasure
carboxyHb  Use 100% supplemental O2  If carboxyHb levels > 25% use
hyperbaric O2 chamber.(Remember Methylene blue is for MethHb not carboxyHb)
93.
Hyperbaric O2 chambers for CO poisoning indications: (1) >25% carboxyHb
(2) Mental state changes(3) EKG showing Ischemia/Angina pain (4) Ph <7.2 (5)
Unconscious >20 mint(6)Preganancy with >15% carboxyHb Fetal Hb has more
affinity
94.
Post-infectious cerebellar ataxia : Unsteady broad base gait + Nystagmus
seen in children 25% have h/o varicella infection within 1 month prior
Resolution within weeks
95.
Scleroderma

Anti-topo-isomerase
I
antibodies:highly
specific
for
scleroderma(Association with interstitial lung ds)

Anti RNA polymerase I/II antibodies: Renal and skin involvement

Anti U3 RNP (Fibrillarin) antibodies: Pulmonary HTN

Remember anti PM scl antibodies seen in MYOSITIS not in scleroderma

CREST= Anti CENTRO mere
96.
Alkalosis + Hypokalemia + HTN =? Conn’s Measure Renin and aldosterone
levels
97.
Biphasic basal body temperature(Rise on 14th day Stays for 13 days and
drops after that and menses occur on next day) =Leutinization + Ovulation Sports
women often have altered ovulation due to decreased GnRH
98.
IHD = Leading cause of death in elderly >65
99.
Baby born to mother having HepB Surface antigen positive  Give hep B
vaccine + Immunoglobulins within 12 hrs at different sites  Repeat vaccine at 1 &
6 months
100. Patient allergic to penicillin may have allergy to cephalosporin in 7-8%
cases Perform skin penicillin test Negative results exclude such possibility
101. Mind it-even an annual check up of an adolescent includes a private interview
and nobody else can stay with her/him(including parents).
102. Funneling beer: A large funnel and a tube used to supply a large quantity of
beer at fast speed into the mouth
103. Erythema multiforme (also called erythema multiforme minor to distinguish it
from Stevens Johnson syndrome, which is sometimes known as erythema multiforme
major)asymptomatic skin patches appear like a target, i.e. three rings of red,
white and pink. Often the centre of the patch forms a fluid-filled blister that crusts
over within a few daysOften, the rash is accompanied by sores and blisters on the
lips HSV or medications may cause this  HSV related lesions are recurrent 
Topical steroid + Antihistaminic Use acyclovir to prevent recurrence.
Neeraj’s Step-3 Notes:Kaplan
7
Target Lesion: Red-white and pink rings/Bull’s eye
104. Predictor of Restrictive lung disease on PFT: Decresed FEV1 but FEV1/FVC is
normal (>80%) and there is disproportionate decrease in DLco(Diffusion capacity of
CO) as compared with TLC.(Proportional decrease s/o extra-throacic restrictions like
Kyphoscoliosis)
105. Lyme’s ds transmission requires about 24-28hrs attachment of Tick to the
body.
106. Discitis in Immunosuppressed might be due to many organism Start broad
spectrum antibiotic first  Take tissue from disc under fluoro guidance to ascertain
organism Blood culture though taken but has low yield
107. Eosinophilic pneumonia: Ac hypersensitivity reactionHypoxemic resp failure
+ Diffuse pulmonary opacities +>25% eosinophils on bronchoalveolar lavage +
eosinophilic infiltrates on lung biopsy Tx Methyprednisolone
108. Threatened abortions  There is no proven role of bed rest in prognosis! 
But do not forget to perform blood grouping in every case of any bleeding in
pregnancy (RhoGam?)
109. Rheumatoid ds might be associated with anemia of chronic ds
110. Asthma Prolonged expiration and increased TLCVentilator setting will
require sufficient time to exhale air and no overload over preexisting expanded
lungs Choose low tidal volume +slow respiratory rate(to allow time to expire) +
High flow rate on inspiration.
111. Tx Vitiligo: Topical steroid & Phototherapy
112. Milk line: along axilla and inguinal region Site for accessory nipple
113. Epidural catheter: To infuse drugs into epidural space for anesthesia +
analgesiaPatient receiving narcotics thru epidural catheter should not have IV
narcoticsIf “patient controlled analgesia” (via electronically controlled infusion
pump activated by patientas per the need) with IV morphine is required first
discontinue Hydromorphone in epidural mix.
Neeraj’s Step-3 Notes:Kaplan
8
114. Benzatropine is often added with high potency antipsychotics like haloperidol
with extrapyrimidal effects to avoid parkinson’s like symptoms.
115. First pregnancy earlier = Low risk of Breast CA
116. Platinum =ATN(Cisplatinum =Nephrotoxicity)
117. Screening for prostate CA in a patient with increased risk due to first degree
relative DRE at 50 yo age(African American 40 yrs) PSA soon after DRE(It
doesn’t elevate levels)
118. Suspected HPV infection in male(His partner detected with cervical dysplasia
on pap smear)No visible lesion Apply vinegar over anogenital area Invisible
lesions will turn white!(Hyperplasia =increased glycogen content + permeability)
119. Hydrocortisone=Glucocoticoid(regulated by pitutary) Mineralo = fludro
(Regulated by renin)
120. Nicotine is addictive and it is common to have about 5-6 attempts before
quitting it. At an average a significant wt gain of about 7-10 pounds is usual after
quitting.
121. DIC = Low platelets + Elevated PT/PTT
122. How to verify normally placed endotracheal intubation With a commercially
available, disposable, colorimetric “End Tidal co2 detector”  color changes using a
numerical scale measuring % carbon dioxide in exhaled gases
123. MC cause of jaundice in pregnancy =Hepatitis
124. Symptomatic Gall stones in pregnancy should be operated in second
trimester(Avoid first due to untoward effects to fetus) as most of tem may have
second attack before delivery.
125. PCP  Hypoxemia + Elevated LDH = S/O lysis of fungi and inflammation
leading to increased mortality and indication to use IV steroids/dexamethasone.
126. Sod Nitroprusside toxicity Cyanide + Sod Thiosulfate  Sod thiocyanide
 excreted from kidneys.
127. Rocky Mountain spotted fever: DOC is Doxycycline Although tetracyclines
should not be routinely prescribed to children younger than 8 years, the benefits far
exceed the risks in treating Rocky Mountain spotted fever (RMSF)Chloramphenicol
was previously recommended for use in children younger than 8 years (to avoid
teeth staining), but it poses a risk of permanent aplastic anemia and should be
avoided if at all possible Still used as DOC in pregnancy.
128. Accentuated fall in systolic BP with inspiration >10mm Hg Pulsus
paradoxus Cradiac temponade or severe asthma
129. DKAInsulin drives K+ and PO4 into intracellular space Hypokalemia and
hypophosphetemia the later may manifest as rhabdomyolysis +Hemolysis and
weakness.
130. Aspiration pneumonitis clinically improves within 24-48hrs and radiological
improvement seen after 7 days.
131. Referral to cardiac surgeon in a case of MR: <55% of LV ejection fraction or
>55mm dimension of LV end systolic.
132. Tracheal stenosis after an intubation should be about 1-2mm to cause
respiratory distress.Cricoid is at the level of C6 and we can not pass an endotracheal
tube at this level.
133. Antenatal visit at 28wks1.GTT 2. Blood typing in Rh –ive to give RhoGam
134. Ca++ containing antacids may combine fatty acids and cause absorption
difficult.(Steatorrhea)
135. Sick
sinus
syndromealternative
tachy
/bradycardiaasystoleTx
Pacemaker
Neeraj’s Step-3 Notes:Kaplan
9
136. Pelvic abscess in post operative phase manifest earliest as diarrhea after
7days with fever.
137. Nitric oxidevia inhalation acts thru cGMPselectively acts on pulmonary
HTN sparing systemic system.
138. Before you start Ribavarin or interferon +Ribavarin in a patient of Hep C
take a liver biopsy to ascertain prognosis.
139. Alk phos is useless test in pregnancy as it is secreted from placenta and
always raised.
140. Osler Weber
Rendu
syndrome:Hemorrhagic Telengiectasia(autosomal
dominant) around lips,oral/nasal mucosa and internal GI lining presenting as
bleeding,epistaxis or melena Manifest around 20-30 yrs
141. Msl injuryRhabdomyolysis Raised SGOT/LDHRenal failure/Eleveted
creatinine
142. Recurrent
unilateral
photophobia,pain
and
epithelial
staining
defectsHerpes?keratitis
Slit
lamp
shows
dendritic
ulcersRefer
to
ophthalmologist Tx
143. Diverticulitis in elderly should be operated with sigmoid colon resection after
>3 attacks/Fistula or abscess formationDiverticulitis in<50yrs/youngEven the
first attack is very severe and has tendency of recurrenceOperate after first attack
144. URTIUnilateral
conjunctivitis
presenting
with
redness,gritty
sensation,pain,crusting with periarticular nodes Viral etiology
145. PCOD DOC is OCP’sMetformin in patients want to conceive
146. Acneiform eruptionPapules & pustules resembling acne but not confined to
areas of acne vulagris(Involving trunk) All lesions in same stageSudden in
onset Many medications including steroids & cyclosporins are responsibleWhen
seen after shoert term steroid course called as steroid acneTx Tretinoin cream
147.
Pitreasis Rosea:
The herald
patch of pityriasis rosea is then followed by the appearance of multiple smaller oval
pink patches on the child's trunk, arms, and legs. These can be mildly itchy and can
linger for several weeks or months, but the child will otherwise have no symptoms
and pityriasis rosea is thought to be harmless. It is not known what causes pityriasis
rosea, but it may be cause by a virus or a reaction to a previous viral infection. No
treatment is usually required, except perhaps to control the itching if it is
bothersome.
Neeraj’s Step-3 Notes:Kaplan
10
Christmas Tree
appearance
148. Fruit juices which have sorbitol like pear/prune may relieve constipation.
149. Iron deficiency anemiaFeSo4 for 2-3 months +Iron rich diet with meat
150. Bloody diarrhea+Hypotension in an elderly?Ischemic colitisSigmoidoscopy
shows green mucosa with isolated depigmented patches.
151. DKA on insulin+Fluid+K Suddenly develops headache?Edema cerebral
Rx Mannintol
152. Type-I:Distal RTA (dRTA)failure of acid secretion by the alpha intercalated
cells of the cortical collecting duct of the distal nephronfailure to acidify the urine
to a pH of less than 5.3 even if the blood is too acidicclinical features of
DrtaNormal anion gap metabolic acidosis/acidemia,Hypokalemia,Urinary stone
formation,Nephrocalcinosis (deposition of calcium in the substance of the
kidney),Bone demineralisation (causing rickets in children and osteomalacia in
adults) . Type-II: Proximal RTA (pRTA) is caused by a failure of the proximal tubular
cells to reabsorb filtered bicarbonate from the urine, leading to urinary
bicarbonate wasting and subsequent acidemia. The distal intercalated cells function
normally, so the acidemia is less severe than dRTA and the urine can acidify to a pH
of less than 5.3. pRTA also has several causes, and may occasionally be present as a
solitary defect, but is usually associated with a more generalised dysfunction of the
proximal tubular cells called Fanconi's syndrome where there is also phosphaturia,
glycosuria, aminoaciduria, uricosuria and tubular proteinuria. The principal feature
of Fanconi's syndrome is bone demineralization (osteomalacia or rickets)
due to phosphate wasting Rx NaHco3
153. MiliariaHeat rashes due to prolonged bed restTurn frequently+Cooler
temperature
154. Low
Cardiac
outout(CO)+Normal
pulmonary
artery
wedge
pressure(PAWP)+High systemic vascular resistance(SVR) S/o extracardiac
obstructive shockTemponade/Tension pneumo/Pulmonary TE
Neeraj’s Step-3 Notes:Kaplan
11
155. 3-10% spina bifida patients have allergy to latex due to excessive exposure
to surgical processes in early life.
156. Mallet finger: Extended finger focibly flexed leading to avulsion of proximal
part of dorsal aspect of distal phalanxRequires extensor splinting 45wksComplication:Permanent swan neck deformity
157. Lithium level >4mEq/L requires emergent dialysis.
158. Aggressive diuresis in a case of ascites may cause renal failure and
hyperkalemia
159.
Anabolic hormones for longer duration may cause testicular atrophy.
160. Needle stick injury from a discrded needle in sandboxPostexposure
prophylaxix of HIV is controvertial.
161. Simple(No
loss
of
consciousness)
partial(a
part
of
brain
involved)seizure:Jerky movements of limbs with aura(Often described as weired
feeling)EEG to ascertain any further abnormality.
162. # radial head: (1) Non-displacedConservativeImmobilize for 1-2
weeks(Light posterior splint & Sling (2)Displaced or comminuted Surgical excision
of radial head with 24-48 hours (Child: ReductionClosed/Open reduction and
internal fixation Radial head is never excised in growing child as epiphysis removal
results in unequal forearm growth
163. Meneier’s disease: Tx Low salt diet + HCTZ
164. HSV 2 infection:Subclinical Viral shedding is documented even when the
lesions are not thereDuring lesions skin to skin transmission is well
documented(Condoms to not prevent transmission)Acyclovir will reduce the
duration of symptoms and viral excretion time.
165.
Chancroid:H.Ducery
The lesion begins as a soft, red papule. Within 1 to 2 days, it becomes pustular,
eroded, and ulcerated. The ulcer is usually 1 to 2 cm in diameter, painful, and
covered by a yellowish or gray exudates; it bleeds easily when scraped. The edges of
the ulcer are ragged and undermined. Chancroid does not have a vesicular stage. In
males the ulcer is typically located on the distal penis, but may occasionally occur in
the urethra and anal orifice. In females, the lesions tend to be localized to the vulva
but can also occur in the vaginal, perianal area, and cervix. Painful inguinal
lymphadenopathy and over-riding erythema is associated with chancroid in nearly
half of all cases in males, less often in female cases. The lymph nodes become
fluctuant, can spontaneously rupture, and drain pus.Tx Azithromycin single dose
166.
Fracture in cervical spine involving transverse foraminaVertebral artery
trauma? Dissection/ThrombosisAngiography
/Yolk
sac
tumourHCG
by
both
seminoma
&
167. AFPEmbryonal
nonseminomaRP nodes involvement s/o stage 2Supradiaphragmatic nodes s/o
satge 3Stage 1 seminoma requires orchidectomy + RT
168.
Roseola/Sixth Ds/Exanthema subitum:mild illness that mainly affects children
that will go away on its own. Roseola is caused by viruses of the herpes type6 or
Neeraj’s Step-3 Notes:Kaplan
12
7. Infected children have a few days of high fever followed by a rash as the fever
goes down. The rash usually lasts 1–2 days, or it may go away more quickly.
Child mostly appears well with some LN and rose pink macules involving trunk/neck.
169.
A 12-lead electrocardiogram obtained at a body temperature of
32°C.(Hypothermia) Note J wave of Osborn, which have an extra deflection a
the end of the QRS complex.
170. “Monitored bed units”:To regularly assess cardiac & respirstory systemsE.g
Postop orthopedic patient with intathecal morphine still have pain and requires more
IV morphineNeeds respiratory monitoring
171. Insulin like growth factor(IGF)-1 elevated at multiple occasionsconfirms
diagnosis of acromegaly.
172. Insulin dependent DM scheduled for operative procedureReduce the insulin
dose to 1/3-1/2 on the day of procedure as he/she is kept NPORegularly monitor
glucose levels and adjust it with insulin/Dextrose.
Neeraj’s Step-3 Notes:Kaplan
13
173. Vibrio vulnificus implicated in septicemia and does not cause diarrheaIII
gen cephalosporin +Minocycline(Synergistic effect)
174. MC cause of neurological deficit in an elderly is metabolic or toxic cause
especially glucose(improperly treated DM) or electrolyte imbalances.
175. Punctured wounds like bite should not be vigorously irrigated or debrided as it
may dislodge the infection deeper.Mx Augmentin or Cotrim+ClindamycineReview it
within 48hrs.
176. Patient in acute respiratory distress requires intubation but eaten food within
8hrs(In case of trauma within last 12hrs)Increased risk of aspirationPut pressure
on cricoids while inserting tubeOnce inserted inflate balloon to prevent from
aspirationCheck end tidal Co2
177. Scabies in one member of familyRx Permethrin to all irrespective of their
status of infestation and wash cloths/beddings in HOT water and dry in HOT
cycleTake scrapping after putting mineral oil to microscopically confirm mites.
178. Young nonsmoker patient developing recurrent DVT? Fcator V Leiden
deficiency
179. Dysnea on exertion/Nocturnal paroxysmal dyspnea are symptoms of Lt heart
failure while raised JVD/Edema/Hepatojuglar reflux are s/o Rt heart failure.
180. Resistant & recurrent candida vaginitis  Culture to R/o presence of C.
Glabarta
181. Safest position for an infant in a car is middle of back seat which is rear facing
till the age of 1year or 20ounds(Child upto 12 yrs back seat)
182. Propanolol may lead to depression.
Severe
respiratory
distressEmergency
183. Epiglottitis
intubationCricothyroidotomy
184. Co-oximeter measures levels % of carboxy/Meth/Oxy HbPulse oximeter
saturation/Arterial o2 pressure & satuartion are normal in CO poisoning(CarboxyHb
read by pulse oximeter as saturated)
185. OCP + Smoking = Stroke/MI
186. CA Cx stage IIB(Extension into parametrium) or more Tx RT External beam
radiation/Brachytherapy
187. Dialysis dysequilibrium syndromeSeen as neurologic symptoms like
confusion & headache soon after or during the first dialysisDue to cerebral
edemaTx Mannintol
188. Dx of crohn’s ds is often made with Upper GI barium study
189. Blalock Taussing Shunt for TOFTo improve pulmonary Bd supply
190. Relapsing Polychondritis: All cartilage areas can be affected, though in many
cases the disease will affect several areas where cartilage is found in the body, and
leave others entirely alone. Parts of the body with cartilage, and therefore potentially
affected by polychondritis, include the ears, nose, throat, heart valves and of course
all areas where musculo-skeletal tissues are connected by cartilage. Specific
resultant conditions may include Tracheomalacia and Vasculitis.Complication may
include aortic aneurysm.Tracheal narrowing is typical finding on Xray.Rx Steroid
191. To detect small pneumothorax CxR in maximum expiration to reduce the
lung volume.
192. Lithium may flare up psoriasis
193. AntiHCV antibody generally not detectable until 18wks after illness hence
negative antibody doesn’t rule out HCV infection in post transfusion hepatitis state.
194. Papules with central umblication covered with hemorrhagic crust in an HIV
patient ?Cutaneous cryptococcus
Neeraj’s Step-3 Notes:Kaplan
14
195. Native valve endocarditis empiric therapyVancomycin + Gentamycin(Also
for blodd culture negative endocarditis)
196. Predictor of poor outcome of Asthma: Earlier intubation or hospitaliztion and
use of steroid.
197. Billiary colic v/s Calculus cholecystitisRaised leucocytes absent in
former/Murphy’s sign –ive
198. APCKD DOC is ACE inhibitorSecond line Calcium Channel blockers(If
creatinine levels rise after ACE inhibitors)
199. Acute
angle
closure
glaucoma
Rx
Acetazolamide,Mannintol,Topical
Timolol/Pilocarpine.
200. Scheuermann's disease:form of juvenile osteochondrosis of the spine. It is
found mostly in teenagers and presents a significantly worse deformity than postural
kyphosis. Patients suffering with Scheuermann’s kyphosis cannot consciously correct
their posture. The apex of their curve, located in the thoracic vertebrae, is quite
rigid. The sufferer may feel pain at this apex, which can be aggravated by physical
activity and by long periods of standing or sitting; this can have a significantly
detrimental effect to their lives as their level of activity is curbed by their condition
and they may feel isolated or uneasy amongst their peers if they are children,
depending on the level of deformity. Also, the decreased level of height will
emphasize body fat around the intestines, making the person with Scheuermann's
kyphosis seem more heavy-set than normal. This can make children even more
uneasy, with a possibility of being harassed by peers, since they appear to be
"fatter" than other children. Whereas in postural kyphosis the vertebrae and disks
appear normal, in Scheuermann’s kyphosis they are irregular, often herniated, and
wedge shaped over at least three adjacent levels.The seventh and tenth thoracic
vertebrae are most commonly affected. It causes backache and spinal curvature. In
very serious cases it may cause internal problems and spinal cord damage. The
curvature of the back decreases height, thus putting pressure on internal organs,
wearing them out quicker than the natural aging process
Neeraj’s Step-3 Notes:Kaplan
15
201. Indications for tonsillectomy are recurrent tonsillitis(7 episode in one year or
5 each in two year or 3 each in three years), peritonsillar abscess and airway
obstruction/Dysphagia,swollen anterior cervical nodes,pertonsillar exudates
202. Aspiration
pneumonitis(chemical
pneumonitis)generally
responds
to
supportive careRequires antibiotic when progresses to pneumonia.
203. Severe pruritic rash not responding to steroids + low WBC’s?Idiopathic rash
of HIVCD4 counts
204. Flu Shots: All>50yrs, Chronically ill,Prenatal,Health care worker and someone
who asks for it!
205. Urethral discharge Mucoid:ChlamydiaPurulent:Gonococci
206. Villous adenomatous polyp has highest risk of CA while tubular has lowest.
207. Hamstring(Arising from inferior pubic rami) avulsion fracture(Seen as soft
tissue infiltration and callus) is common in hurdlers.
208. Pulmonary alveolar proteinosis -(PAP) is a rare lung disease in which
abnormal accumulation of surfactant occurs within the alveoli, interfering with gas
exchange. PAP can occur in a primary form or secondarily in the settings of
malignancy (especially in myeloid leukemia), pulmonary infection, or environmental
exposure to dusts or chemicals. Rare familial forms have also been recognized,
suggesting a genetic component in some cases.Bronchoalveolar lavage shows turbid
material which is PAS +ive.Tx Whole lung lavage
209. Variant angina common in (young asymptomatic)east-asians and associated
with migraines/Raynaud’s phenomenon.Tx CCB like Dilantin
210. Lumbar puncture headache: seen after LPPpt in sitting position and relieved
in supine position.
211. External skin tag protruding from anal skin margin with linear ulcer in the
posterior commisure in anal vergeFissure
212. Esophageal varicesBleed stopped(30-60% stop spontaneously)No active
lesionBanding +IV Octeoride(Causes vasoconstriction).
213. Retropharyngeal abscessH/o sore throat and exudates+Air in superior
mediastinum + Stridor
214. Pemphigus is an autoimmune disease of the skin and mucous
membranes(oral) that causes vesicles (blisters), bullae and raw sores. It may be
triggered by medications, such as penicillamine/Allopurinol.In pemphigus,
autoantibodies form against desmoglein. Desmoglein forms the "glue" that attaches
adjacent epidermal cells via attachment points called desmosomes. When
autoantibodies attack desmogleins, the cells become separated from each other and
the epidermis becomes "unglued", a phenomenon called acantholysis. This causes
blisters that slough off and turn into sores. In some cases, these blisters can cover a
significant area of the skin.Tx Steroids
215. SSRI cause headache and nausea initially and later may cause decreased sex
drive and prolonged time of orgasm.
216. Grave’s Disease in pregnancy DOC propylthiouracil.(Methamizole crosses
placenta/Radioactive iodine destroys fetal thyroid).
217. Patient using an alternative medication or an illegal drug Do not criticise
provide him a better alternative.
218. Diabetic foot ulcer may lead to necrotizing infection and a X-ray is mandatory
before debridment/incision or amputation is planned.(Simple incision or darinage is
not useful)
219. Polymyalgia rheumatica is an inflammatory condition of the muscles, which
causes pain or stiffness, usually in the neck, shoulders, and hips(Proximal
muscles).Most PMR sufferers wake up in the morning with pain in their
muscles.Anemia and an overall feeling of illness/slight fever are commonly
seen.Studies have shown that about 15% of people who are diagnosed with
Neeraj’s Step-3 Notes:Kaplan
16
polymyalgia rheumatica also have temporal arteritis, and about 50% of people with
temporal arteritis have polymyalgia rheumatica.ESR >100,Tx Steroids & NSAIDS
220. Metformin causes weight loss or stablization.
221. Leading cause of deaths in males between 15-25yrs is motor vehicle
accidents and 50% of which involves alcoholAvoid drinking and driving.
222. During long flight due to low oxygenation,altitude and humidification the gas
containg viscera may expand.Any body with recent intestinal obstruction,Volvulus or
abd surgeries should avoid long flights leading to a probable emergency.
223. Volvulus
not
treated
for
few
hours
+Leukocytosis
+
Fever
IschemiaResection
224. ST elevation MI Cardiac catheterizationDecision of stenting/plasty as
per the need.
225. Postop patient developed a new rash over dependent buttockSize matching
with size of dressing(DuoDerm: maintains a moist wound environment for optimal
healing.)Contact dermatitisTopical steroids
226. Baby born at >35 wks gestation in a Strep B + ive motherMother received
<2 doses of antepartum ampicillinLimited evaluation observation for 48hrs +
complete blood counts with diffrential required (>2doses= Only observation)
227. AIDS associated dementia =Rx HAART + Antidepressants
228. Varicella vaccine at 12months once
229. MC cause of erectile dysfunction is vascular disease in man >50yrs
230. Metabolic disorders are common in bulemic patients usually as Hypokalemia
and hypomagnesemia.
231. AF >48hrs needs anticoagulats for 3wks before opting for elective
cardioversion to avoid artrial thrombi.
232. Fisrt line Rx for migraineModerate to high dose NSAIDS + Environmental
control(e.g. dark quite room)
233. Screening of colon CA: (1) Asymptomatic without any risk factor Annual
DRE>40 yrs and annual FOBT + sigmoidoscopy every 3-5 yrs in >50 yrs age(2)
Symptomatic or Risk factors/Family history  Annual Colonoscopy
234.
Test PSA in high risk men >40 yrs >4ng/ml levels warrants biopsy
235. Sodium polystyrene sulfonate is the resin binding K+
236. Pyogenic granuloma is a relatively common benign vascular lesion(granulation
tissue) of the skin and mucosa whose exact cause is unknown. This misnamed entity
is neither infectious nor granulomatous. The lesion occurs as a solitary glistening red
papule or nodule that is prone to bleeding and ulceration.Pyogenic granuloma often
arises in pregnancy (or rarely with oral contraceptive usage), particularly on the
gingiva or elsewhere in the oral mucosa, and then is termed the "pregnancy tumor."
Removal of the lesion is indicated to alleviate any bleeding, discomfort, cosmetic
distress, and diagnostic uncertainty. A number of malignant tumors may
clinically mimic pyogenic granuloma, making histopathologic confirmation
important if the presentation is atypical. The precise mechanism for the
development of pyogenic granuloma is unknown. Trauma, hormonal influences, viral
oncogenes, underlying microscopic arteriovenous malformations, the production of
angiogenic growth factors, and cytogenetic abnormalities have all been postulated to
play a role.
Neeraj’s Step-3 Notes:Kaplan
17
Pyogenic granuloma on the hand. Courtesy of Jeffrey P. Callen, MD
237. Headache during pregnancy or post C-section Think of venous sinus
thrombosis
238. Gold standard to diagnose GB rupture is direct visualization with laproscopy.
239. Coagulopathy and decreased albumin =Synthetic liver ds?Cirrhosis
240. Only language development delay in a child? Hearing defect
241. Stool guaiac test:To detect the presence of fecal occult blood.It involves
feces, a thick piece of paper attached to a thin film coated with guaiac (which comes
from the Guaiacum tree), and hydrogen peroxide.When the hydrogen peroxide is
dripped onto the guaiac, it oxidizes the guaiac causing a color change. This oxidation
occurs very slowly. Heme, a component of hemoglobin found in blood, catalyzes this
reaction, giving a result in about 2 seconds.It detects distal neoplasm
best.Iron/Aspirin will not cause guaiac + test.
242. General anesthesia may ppt an episode of goutSuspect somebody with
severe pain in great toe after operative procedure and not responding to morphine.
243. During mechanical ventilation limit tidal volume <6cc/kg/Peak inspiratory
pressure(PIP)<35CM H2O in a critically ill patient.(Traditional Teaching TV >15 and
PIP >45 leads to ventilator induced lung injury)
244. Temporal lobe epilepsy could be simple partial or complex partial. Simple
Partial Seizures (SPS) involve small areas of the temporal lobe and do not affect
consciousness. These are seizures which primarily cause sensations. These
sensations may be mnestic such as déjà vu (a feeling of familiarity), jamais vu (a
feeling of unfamiliarity), a specific single or set of memories, or amnesia. The
sensations may be auditory such as a sound or tune, or gustatory such as a taste, or
olfactory such as a smell that is not truly present. Sensations can also be visual or
involve feelings on the skin or in the internal organs. The latter feelings may seem to
move over the body. Dysphoric or euphoric feelings, fear, anger, and other
sensations can also occur during SPS. Often, it is hard for persons with SPS of
TLE to describe the feeling. SPS are often called "auras," and are sometimes
thought to be preludes to more severe seizures. Complex Partial Seizures (CPS) by
definition are seizures which impair consciousness to some extent. This is to say that
they alter the person's ability to interact with others. They usually begin with an SPS,
but then the seizure spreads to a large portion of the temporal lobe and impairs
consciousness. Signs may include motionless staring, automatic movements of the
hands or mouth, inability to respond to others, unusual speech, or unusual
behaviors. Because judgement is impaired, persons experiencing CPS may not
legally drive vehicles for periods of time which are set by local governments
worldwide. Estrogen is known to exacerbate TLERefer to Neurologist
245. Hallmark of heatstroke is LOC with increased core body temperature.At first
start cooling measure and then collect urine/perform CT to make DDx.
246. Asymptomatic bacteriuria doesn’t require any treatment.
247. Nephrotic syndrome may increase the susceptibility to bacterial infection.
Neeraj’s Step-3 Notes:Kaplan
18
248. Pharmacotherapy should be offered to ALL smokers who want to quit-in the
INITIAL discussion itself.They reduce withdrawl symptoms and craving.
249. Pruritic urticarial papules and plaques of pregnancy (PUPPP), known in
United Kingdom as polymorphic eruption of pregnancy (PEP),[1] is a chronic
hives-like rash that strikes some women during pregnancy. Although extremely
annoying for its sufferers (because of the itch), it presents no long-term risk for
either the mother or unborn child. PUPPP frequently begins on the stomach and
spreads to the legs, feet, arms, chest, and neck. It spares umblicus.Treatment of
mild cases during pregnancy consists mainly of the application of topical moisturising
creams or aqueous/emmolient ointments. Class I or II corticosteroid creams and
ointments are used in more aggressive cases.
DDx Gestational Pemphigoid or Pemphigoid Gestationis (PG) is a rare
autoimmune blistering skin disease that occurs during pregnancy, typically in the
second or third trimester, and/or immediately following pregnancy. It was originally
called Herpes Gestationis because of the blistering appearance. Gestational
Pemphigoid is not associated with the herpes virus.It involves umblicus.
250. Meningococci prophylaxis Rifampicin,Ceftriaxone and cipro all three are
acceptable.However,children with splenia may require quadrivalent vaccine.
251. Fenfluramine is associated with valvular heart disaese and has been
discontinued.
252. Dislocation of knee and anterior cruciate ligament injury may be associated
with popliteal artery rupture.
253. Nov is a flu seasonFlu shots
254. Marcus Gunn pupil(afferent pupillary dfect):On swinging flash light the
affected eyes sees less light and pupil dilatesOptic nerve defect like
ischemia,neuritis or compression by a tumor.
255. Association of DM with skin diseases: (1)Scleroderma: A syndrome is
recognized with late onset DM+ Chronic scleroderma+obesity +High CVS ds
incidences(2)Candidiasis: along redundant skin folds(3)Necrobiosis Lipoidal
diabeticurom:seems to be marker of DMcharacteristically anterior and latral
legPlaques with irregular,flattened with eventually depressed atrophy.
Neeraj’s Step-3 Notes:Kaplan
19
256.
Fifth disease is one of several possible manifestations of infection by
parvovirus B19. The disease is also referred to as erythema infectiosum (meaning
infectious redness) and as slapped cheek syndrome, slapcheek, slap face or
slapped face
The bright red cheeks are a defining symptom of
the infection in children (hence the name "slapped cheek disease"). Occasionally the
rash will extend over the bridge of the nose or around the mouth. In addition to the
red cheeks, children often develop a red, lacy rash on the rest of the body, with the
upper arms and legs being the most common locations. The rash can last a couple of
days (some cases lasting for several weeks) and may itch. Patients are usually no
longer infectious once the rash has appeared.Teenagers and adults may present with
a self-limited arthritis.
The disease is usually mild, but in certain risk groups it can have serious
consequences:In pregnant women, infection in the first trimester has been linked
to hydrops fetalis, causing spontaneous abortion In people with Sickle-cell disease or
other forms of chronic hemolytic anemia, infection can precipitate an aplastic crisis
257. Rotavirus diarrhea are great problem in day care center.Child in whom the
stools are not contained within diaper should be excluded from day care until
diarrhea ceases.Washing hands is the most effective preventive measure.
258. Familial throid CAMedullary?
Neeraj’s Step-3 Notes:Kaplan
20
259. NHL Mets to extraocular mslsIV steroids to relieve edema
260. Duodenal perforationHypoactive or absent bowel sounds on auscultation.
261. Myeloproliferative diseasePolycythemia,myelofibrosis,Chronic myelogenous
leukemiaHyperviscosityRisk of Stroke
262. H.Pylori3x increase in gastric CA incidences.
263. Synchronized electrical cardioversion is the process by which an
abnormally fast heart rate or cardiac arrhythmia is terminated by the delivery of a
therapeutic dose of electrical current to the heart at a specific moment in the cardiac
cycle. Synchronized electrical cardioversion is used to treat hemodynamically
significant supraventricular (or narrow complex) tachycardias, including atrial
fibrillation and atrial flutter. It is also used in the emergent treatment of wide
complex tachycardias, including ventricular tachycardia, when a pulse is
present. Pulseless ventricular tachycardia and ventricular fibrillation are
treated with unsynchronized shocks referred to as defibrillation.
264. Chlodiazepoxide is usual drug of detoxification for alcoholic withdrawal and
delirium in uncomplicated caseWhen LFT’s raised or COPD is present it may
become even more long acting due to its metabolitesDOC in these complicated
cases Lorazepam(Excreted by kidney/Short acting/No active metabolite/No
respiratory depression).
265. African American with uncontrolled HTN has risk of aortic dissection.
266. Patient on long HRT still showing osteoporosisThink of Multiple Myeloma?
267. Suspected Thyroglossal cystpreoperative evaluationR/o Ectopic Thyroid
with Ultrasound
268. ProteinuriaOvernight
24hrs
protein
collection
shows
<150mg
ProteinOrthostatic proteinuria
269. Bacteremia <4wks Vaginal floraStrep B,Listeria & E.coliAmpicillin +
Cefotaxim
270. Iron deficiency anemiaIron TxReticulocyte count rise within 3days and
peaks within 10days.
271. Orbital floor # Most likely complication inferior rectus msl
blue
body
pinkwhole
272. APGAR:
Appearance(Blue/paleExt
pink),Pulse(absent<100>100),Grimace(No
of
limbsActive
responseGrimaceSneeze),Activity(NoFlexion
motion),Respiratory effort(NoneSlow irregularGood crying).
273. Newborn of a Koch’s motherTuberculin +Chest X-ray –iveStart Isoniazid
for 3 months and repeat Both tests againStill –iveDiscontinue INH otherwise
continue for 9months i.e. 6 moth more
274. Nappy rash is a common problem for neonates within the first few months of
life. Whilst the exact aetiology of nappy rash is not clear, it is felt to be due to
moisture in the nappy environment and from irritation from urine and stool. Many
infants will be affected by superinfection with Candida albicans.
Typically in Candidal nappy rash, there is erythema in the perineal region, with
satellite lesions which may coalesce. There is often an appearance of scale. In the
images to the left from the same baby, satellite lesions are seen. Note that there are
some lesions close to the umbilicus and extending around the flank. Swabs were
positive for Candida(Pseudohyphae and spores).Treatment primarily involves the use
of a topical agent such as nystatin or miconazole
Neeraj’s Step-3 Notes:Kaplan
21
Irritant diaper dermatitis:Spares intertrigoExpose to air Rx ZnO2Due to
soaps/Detergent.
275. Molar pregnancy after D&CFollow-up for 1 year with b-hcg to r/o
chorioCAShe should not be pregnantRx OCP’s
276. HIV ChildMMR at 12months and repeat after 4wksAll other household
children should also receive MMR irrespective of age.
277. Post-thyroidectomy bleeding and hematoma along capsule may lead to stridor
and cyanosis.
278. To assess fidelity of both nerve and msls(Neuromsl integrity)an
electromyogram is used.
279.
Ectopic B-hcg at day 4 and day 7fall of 15% on day 7successful
treatmentWeekly follow up
280. Establishing and quantifying amount of reflux24hrs PH monitoring
281. In Suspected Methanol poisoning measure serum osmolarityosmolar gap
>10mOsm
282.
Multiparous woman may have both pelvic floor dysynergia and anorectal
reduced sphincter tone leading to constipation and fecal incontinence
respectivelyAnorectal manometery(In case of dysnergia it is increased and
biofeedback training may help)
283. Post-therapeutic NeuralgiaIn post Shingles dermatome nonpainful stimulus
cause pain which is refered in surroundingUse Tricyclic antidepressants.
284. MMR vaccine should be given in children with egg allergiesThough they are
developed from chick embryo fibroblast but they have very less egg cross reacting
proteins.
285. Topical intranasal steroids are DOC for allergic rhinitis.
286. MVP is not a high risk valvular defect for procedures unless have MR Or
thickened flap(confirmed with Echo)In that case give antibiotic prophylaxis.
287. Age 33-44 have 3x increased incidences of ectopic when compared with 1524yrs.
288. Brachial aretry is an end artery with collateral distal to antecubital fossa.Its
thrombosis with indwelling catheter makes it a high risk artery.
289. Decompression sickness (DCS), the diver’s disease, the bends, or
caisson diseasefollowing a rapid ascentType 1 DCS can occur when bubbles
affect the tissues around skeletal joints.Decompression sickness might also present
as a skin (cutaneous) disorder. Nitrogen bubbles can cause mottling, lumps or a
rash. "Skin bends", as they are colloquially termed, are more common during
Neeraj’s Step-3 Notes:Kaplan
22
hyperbaric chamber 'dives' and when diving using a dry suit. Type 2 decompression
sickness reflects involvement of the Central Nervous System (CNS) and / or the
cardio-respiratory system.
290. Before a thorough pelvic examination a pap smear should be taken(if
indicated)to avoid contamination.First ect and then endocervix.
291. Post MI one can resume sexual activity after 2-4 wks of discharge.
292. Transferrin saturation is the aerliest test to become abnormal in
hemochromatosis.
293. Primary pulmonary HTN Test for vasodialtor response testing to ascertain
response to medication.
294. Neonatal jaundice 5mg/dl at 24hrs anf 15mg/dl at 3day is normal
Phototherapy when >15mg/dlExchange transfusion when >20 mg and/or not
responded to phototherapy.
295. Most of Vesicoureteric reflux grade 1 or 2 usually resolve spontaneously
Prophylactic Antibiotics only
296. Aspergilosis in neutropenic AMB IV
297. Pulmonary function tests showing increased diffusion capacity for CO s/o
blood in alveoli/hemorrhage.
298. Fat embolism O2 therapy/endotracheal tube.
299. Seborrheic keratosis consists of benign, verrucous (wart-like), often
pigmented, greasy lesions consisting of proliferating epidermal cells which usually
occur after the third decade.A common occurrence among black people is the
appearance of many small lesions on the face, known as dermatosis papulosa
nigra.Leser-Trelat sign, the explosive onset of multiple pruritic seborrheic
keratoses, often with an inflammatory base, can be an ominous sign of internal
malignancy, especially stomach/colon carcinoma.
300. Post chemotherapy persistent fever?Fungal(Multiple B/L lung nodules with
surrounding hemorrhage) or resistant G+ive organism
301. Hypervolemic hyponatremia Restrict Salt + Diuretics.
302.
Interstitial Fibrosis: Mildly progressive SOB with non-productive cough + Late
crackels with inspiration + No sign of CHF/Reactive airway ds like wheeze.
303. Side effects of testosterone therapy Exacerbation of sleep apnea ,
Erythrocytosis,and BPH/CA prostate exacerbation.
304. IgA nephropathy/Berger DsRecurrent Hematuria within few months
Picture of Nephrotic syndrome(Hyperlipidemia,Hypoalbuminia,Proteinuria)Mostly
benign course but 50% may develop renal failure by 20yrs.
305. Moraxella CatarrhalisG-ive dipplococci normal inhabitant of upper
respiratory tract.
306. Rapid lowering of serum glucose in DKA may lead to cerebral edema.
307. Contraception in postpartum periodProgestin only pill
308. During insertion of central line the dislodged wire may commonly lodge in
distal pulmonary artery/tip in Rt ventriclecardiac arrhythmia
309. Visit in woody area +Dry cough +Erythema nodusum Histoplasmosis
310. Highly suspected meningitisEmpiric antibiotic before neuroimaging.
311. Methotrexate is preferred DMARD over penicillamine due to more toxic side
effects of later one.
312. Hematemesis following prolonged use of NSAID’sIV access/Fluid and cross
matchgastric lavage to remove bloodContinued bleeding UGI endoscopy
313. C-ANCA + in 65-90% of Wegener’s Granulomatosis
314. Baby born to HBS Ag mother should receive Ig +Vaccine as soon as possible
after birth but breast feeding should be initiated irrespective of immunization.(It
doesn’t increase risk).
Neeraj’s Step-3 Notes:Kaplan
23
315. Hypernatremia due to dehydration and water deficitTreat with oral water
onlyHalf of the deficit within 12hrs and rest half in next 24hrsSerum Sodium fall
<12mEq/day
316. Advanced
RA
B/L
lung
nodules(Caplan
syndrome)+Neutropenia+Spleenomegaly Felt’y syndromeFailure of routine
therapyStart with azothioprine/Cyclophosphamide
HyperthyroidismThyroid
317. B/L
proptosis
+Anxiety
+Low
TSH
msls
may
compress
and
lead
to
optic
OphthalmopathyEdematous
neuropathyVision loss
318. Monoarticular arthritis in an adult should always be taken as septic unless
proven otherwise.
319. Nasal septal hematoma is a rare but potentially serious complication of
nasal trauma. Because the septal cartilage has no blood supply of itself and receives
all of its nutrients and oxygen from the perichondrium, untreated septal hematoma
may lead to destroyal of the septum. Immediate drainage is necessary. Septal
hematomas can cause a saddle nose deformity.
320. Rabdomyolysis Raised CPK and K+EKG changes peaked T wave
Stablize membrane wit Ca++
321. Conjunctivitis? R/o photophobia/decreased visual acuity or globe pain to
exclude keratitis/Iritis etc(Vision threatening conditions)
322. Nickel induced allergic contact dermatitisAreas around metals like button
alon pants(Periumblical),underneath watches/rings etc
323. Acute III N.plasy Dilated pupil +Extraocular msl abnormalities +
PtosisDeviated to down and outCompression? Aneurysm of PCA/PCOM or supr
cerebellarMRA/MR
324. Alendronate Esopahgeal irritation/UlcerationRemain upright for 30mint
after intakeTake empty stomach to avoid interactions
325. All patients abusing IV drugs are often constipated.
326. Cirrhotic not taking medication and confused ?Encephalopathy
327. Athlete's foot, also called Tinea Pedis, is a parasitic fungal infection of the
epidermis of the human footdermatophytesestimated to be the second most
common skin disease in the United States, after acne. Transmission from person
to personcommunicable diseasetransmitted in moist environments where
people walk barefoot, such as showers, bath houses, and locker rooms.It can also be
transmitted by sharing footwear with an infected person, or less commonly, by
sharing towels with an infected person.Transmission to other parts of the body
skin infections on other areas of the body, most often under toenails
(Onychomycosis) or on the groin (tinea cruris).
328. Isolated Bell’s plasy?Herpes Tx with Acyclovir
329. Stable CHFB-blockers and ACE inhibitors are known to decrease mortality.
330. Patient of >65yrs + AF Increased risk of Stroke x17 increase with Coexisting RHD
331. Abd wound dehiscence Due to poor facial healing Causes
bronchitis/Smoking,DM and poor wound closure techniqueusually seen after 7-10
days post-op as serous discharge
332. Concussion, ("to shake violently") is the most common and least serious
type of traumatic brain injurytemporarily interfere with the way brain worksdon't
always involve a loss of consciousness Usually mild and people usually recover
fullyTwo most common concussion symptoms are confusion and amnesia(may or
may not be preceded by a loss of consciousness)Late symptoms seen up-to 6
months like memory disturbance, personality changes, poor concentration and
irritabilityShould not return to sport for a week even if asymptomatic.
Neeraj’s Step-3 Notes:Kaplan
24
333. Child bumped his head  Thorough PE to R/o significant injury to head like
ecchymoses behind ear/blood from ear/depressed # Everything fine?  Keep him
under observation/Monitoring.
334. Cigarette smoking is associated with increased severity of Thyroid
ophthalmopathy Unilateral exophthalmos is possible in Grave’s ds
335. Risk factors for osteoporosis: Caucasian, advanced age, decreased gonadal
function, steroids, low calcium/Physical activity, LOW weight(Not obesity),first
degree relative.
336. Neutropenia(<500
counts)+Fever(single
oral
reading
>101.3F)Rx
Antipseudomnal antibiotic(3rd Gen cephalosporin like ceftazidime)Piperacillin has
developed wide resistance hence not used.
337. Zollinger Ellison? R/o co-existing MEN-I( Pitutary, Pancreas and
parathyroid)
338. In neuroleptic malignant syndrome anticholinergics like benzatropine are
contraindicated due to heat retention.
339. Lynch syndrome (hereditary nonpolyposis colorectal cancer :HNPCC) AD 
risk of proximal colon cancer + breast/ovarian/Endometrial CA. Biannual
colonoscopy >25yrspelvic examination/Endometrial Bx every 3years and
Mammography at early age.
340. In suspected sarcoidosis the skin and trans-bronchial lung biopsies have
supplemented mediastinal LN biopsies because of high yield/specificity and low
morbidity.
341. Respiratory distress in a new born Absent Lt lung sounds with “Gurgling” +
Displaced heart towards Rt  Diaphragmatic hernia?
342. Nursemaid elbow (Sub-luxation of radial head)Rx Supination with elbow
flexed.
343. Recurrent aspiration pneumonia: prevention Place NG tube, elevate head to
limit passive reflux, monitoring during all oral intake, choice of appropriate food
(thick liquids).
344. Schizoaffective disorder symptoms of a mood disorder(manic and/or
mixed and/or depressive episodes) + symptoms of schizophrenia(hallucinations,
paranoid or bizarre delusions or disorganized speech and thinking)  2 types: the
bipolar type and the depressive type. (Later has worse prognosis which can
result in a residual defect).
345. Fluoxetine once started continue indefinitely when patient had 2 or more
episodesafter single episode continue for about 6-9months after initial remission.
346. Amblyopia poor or indistinct vision in an eye that is otherwise physically
normal The problem is caused by either no transmission or poor transmission of
the visual image to the brain for a sustained period of dysfunction or during early
childhoodTwo imp causes (1)Strabismus(eyes are misaligned) and (2)Refractive
amblyopia (due to a difference in the refraction between the two eyes) Treatment of
strabismic or anisometropic amblyopia consists of correcting the optical deficit and
forcing use of the amblyopic eye, either by patching the good eye, or by instilling
topical atropine in the eye with better visionbest outcome is achieved if treatment
is started before age 5 (research has shown that children older than age 10 and
some adults can show improvement in the affected eye).
347. Feeding mother given with MetronidazoleIt is secreted in breast milk but
effect is not known on newbornSuggested to pump the milk for 24hrs and discard
itResume breast feeding after 24hrs.
348. Bilateral mandibular subcondylar fractures : "flail mandible" concomitant
loss of support of tongue muscles is thought to result in obstruction of the upper
airway
Neeraj’s Step-3 Notes:Kaplan
25
349. Best
noninvasive
test
to
confirm
suspected
pulmonary
HTN
Echocardiography Measures ventricular function and pulmonary artery pressure
>25mmHg at rest/>30mmHg at exercise
350. MC peri-operative complication of major vascular surgery like aortic aneurysm
repair is: MI
351. After 24-72hrs of SAH 25% of CT will be normalCSF Xanthochromia
352. Subclavian line could be associated with pneumothorax in 1-3% cases and
requires follow up with Chest X-ray.
353. Stanford Type-A dissection of aorta (Involving any part of ascending aorta)
requires urgent surgical interventionType-B Only B-blockers
354. Most significant factor determining risk of stroke is HTN-Treat it first.
355. External hemorrhoids (Symptomatic-Nonthrombosed):Sitz bath/Local steroid
and High fiber diet.
356. External hemorrhoids (Symptomatic and Thrombosed):Incise and evacuate
thrombus and compression to control bleed.
357. Hep-B core Ag is not a part of Hep vaccine and IgG against it represents a
remote infection.
358. OCP’s increased cervical mucosaPreventing spread of Gonococci into
endometrium and tubesReduced PID!
359. Viral meningitis is self limited and supportive care + Analgesics are sufficient.
360. Person with diastolic dysfunction  CHF+ Ejection Fraction >70% (!! More
than expected )These patients are prone to develop increased pulmonary pressure
in response of tachycardia of any cause Keep them B-blocked !
361. Erythema nodosum may present as nodules on tibia Over the period of time
lesion flattened leaving a hue like bruise(Purple/Blue)Search for Infectious
causeOCP’s may also cause EN!
362. Nail injury traversing through “Sneaker”(Casual athletic shoe) Risk of
Pseudomonas infection.
363. Multiple GI bleed/Bleeding diathesis DVT?  Do not give anticoagulants/put
Greenfield filter.
364. Indications for synchronized cardioversion in Tachycardias: Hypotension,CVS
instability, Pulmonary edema,ischemia/MI,Altered mental status.
365. Febrile seizure: (1) Simple: The setting is fever in a child aged 6 months to
5 years. The single seizure is generalized and lasts less than 15 minutes. The child
is otherwise neurologically healthy and without neurological abnormality by
examination or by developmental history. Fever (and seizure) is not caused by
meningitis, encephalitis, or other illness affecting the brain (2)Complex: Age,
neurological status before the illness, and fever are the same as for simple febrile
seizure. This seizure is either focal or prolonged (ie, >15 min), or multiple
seizures occur in close succession.
366. CF?  Need to eat in excess to gain weight Many women are infertile due
to tubal defects.
367. Taking cocaine in postpartum state Avoid breast feeding  otherwise baby
will have Growth retardation and neurologic damage.
368. Mantaux test : Interpretation of the Mantoux / PPD tuberculosis skin test depends on
the following:
Mantoux / PPD tuberculosis skin test results showing a raised bump measuring 5 mm
or greater is interpreted as a positive result in the following:
1. persons with weakened immune systems, such as those with HIV/AIDS
2. persons who have been exposed to persons with active TB/Healthcare staff
3. persons with fibrotic changes on chest x-rays/scans that are consistent with an
old TB infection
Neeraj’s Step-3 Notes:Kaplan
26
4.
persons with organ transplants and other immunosuppressed patients
(receiving the equivalent of > 15 mg/day of prednisone for > 1 month)
Mantoux / PPD tuberculosis skin test results showing a raised bump measuring 10 mm
or greater is interpreted as a positive result in the following:
1. persons recently (<5 years) arriving to the U.S. from a foreign country
2. persons who use injectable drugs but HIV -ive
3. persons who live or work in high-risk environments, such as cities and
crowded areas
4. persons who work in laboratories, especially Mycobacteriology
5. Children under the age of 4
6. Children and adolescents exposed to adults in high-risk environments
All other persons with test sites showing a raised bump of 15 mm or greater are
considered to have a positive test result.
Most important risk factor contributing in Prinzmetal angina(pain at rest not
responding to sublingual NG)Tobacco
369.
Neeraj’s Step-3 Notes:Kaplan
27
Few more small tips:
1. Hypertrophied heart with speckled pattern Amyloidosis
2. Tricyclic overdose Anticholinergic effects and respiratory depression
Leading to hypoventilationAim to treat is PH>7.45 by infusing Sod.
BicarbonateHyperventilation after intubation
3. Acute variceal bleedingOcteoride Nodalol has role in primary and sec
prevention of variceal bleed but not in acute episode.
4. Actinic keratosis (also called solar keratosis, or AK) is a premalignant
condition of thick, scaly, or crusty patches of skin. It is most common in fairskinned people who are frequently exposed to the sun, because their pigment
isn't very protective. It usually is accompanied by solar damage. Since some
of these pre-cancers progress to squamous cell carcinoma, they should be
treated.
5.
6.
7.
8.
9.
Patient surviving acute spontaneous bacterial peritonitisRisk of recurrent
infection for 1 year Prophylaxis Rx Levofloxacin
Rib fracture Insufficient chest expansion due to painShallow breathing
Retention of secretion Predisposed to infectionPneumonia
Colovesicle fistula is the commonest fistula formed due to
divertculitisPresents as pneumaturia
Bleeding esophageal varices 80% chances of rebleeding within 1 year
Medical Tx like B-blockers,Sclerotherapy and banding Surgical TIPS
Asthma flareDyspnea Hyperventilate to relieve asthmaPH >7.45 and
low PCo2
Neeraj’s Step-3 Notes:Kaplan
28
10. Urgent need to reduce ICT (E.g Tonsillar herniation due to SDH)Most rapid
method is hyperventilation with mechanical ventilator and intubation.
11. Patient on chronic steroid Adrenal insufficiency May not cop-up with acute
stress like pyelonephritis or infections Orthostatic
hypotension/Eosinophilia/Low glucose.
12. Ribavarin Most common side effect  “Hemolysis” Raised
bilirubinAbsolute CI for ribavarin Tx is CAD(Can be life threatening).
13. Tetanus immunization for adults:
 All people every 10 years
 Hx unknownGive vaccine in all wounds
 Patient received <3 doses in past 5yrs Give for all wounds
 3 shots in last 5 yrsNothing in any wound
 >5 years have been passed since last dosegive booster for all
wounds except clean/Minor wound
 Ig + Vaccine in all patient with major non-clean wounds with unknown
Hx or incomplete vaccination
14. DEXA: T score – to -2.5 is osteopenia and <-2.5 is osteoporosis.
15. Patient with cirrhotic ascites developed acute fever,Mental state changes,abd
pain or nonspecific complaints ?Spontaneous bacterial
peritonitisParacentesis  >500wbc/250PMN or Gram –ive bacteria or+
culture confirms DxIII Gen cephalosporin
16. Hyperglycemia may cause interference with FDG uptake and may lead to false
negative results on PET studies.
17. Menieres dsDiuretics and H1 agonist.
18. Breast engorgementTender rock hard breat + Fever Frequent feeding +
Pumping
19. Early catatractLens appears yellow brownLate :whiteIf patient is
comfortable with visionUse specksotherwise surgery
20. Effective contraception should be used one month before and after the use of
isotretinoin.
21. Polycystic kidneys: 50% will result in end stage kidneys by the age of 70
yrs 20% will have berry aneurysm  Associated diverticular ds also
possible.
22. Gastric Ulcer treated with triple regimen No dyspepsia Repeat endoscopy
to confirm healing as GASTRIC Ulcers have great tendency to develop
malignancy.
23. While operating testicular tumor don’t violate scrotal skinIt may disrupt
normal lymphatic pathway to RP nodes and may lead to metastasis of tumor
to Inguinal nodes (Drainage of scrotal skin) Orchidectomy from inguinal
approach!
24. Contrast induced ATN (Tubular cast in urine without RBC-often seen in
diabetics with baseline renal functions) can be prevented by giving acetylcysteine prior to IV contrast.
25. Primary pulmonary HTN  Decreased levels of Nitric Oxide
26. Suspicious of bacterial meningitis?  Immediately give IV ceftriaxone CSF
will be taken later (Do not delay treatment for CSF collection).
27. A diabetic suddenly developed dyspnea without chest pain still it can be MI
Diabetics may have MI without pain due to neuropathy.
28. Most common cause of nephritic proteinuria(Urinary proteins >3.5gms/1.73
m2) in adults is diabetic nephropathy(Most common non-diabetic cause if
Membranous glomerulonephropathy) Irrespective of magnitude ACE
inhibitors decrease protein excretion and prolong survival.
29. Methylphenidate Side effects: Appetite and wt loss, Insomnia
Neeraj’s Step-3 Notes:Kaplan
29
30. Any sexually active female or >18yrs should be essentially screened for
Chlamydia (Not Gonococcus!).
31. Down’s syndrome: Ligament laxity, Atlantoaxial subluxation,patellar
dislocation and hip instabilityScoliosis is not a contraindication to sports
participation !
32. Refeeding syndrome is a syndrome consisting of metabolic disturbances
that occur as a result of reinstitution of nutrition to patients who are starved
or severely malnourished. Patients can develop fluid and electrolyte disorders,
especially hypophosphatemia, along with neurologic, pulmonary, cardiac,
neuromuscular, and hematologic complications. Most effects result from a
sudden shift from fat to carbohydrate metabolism and a sudden increase in
insulin levels after refeeding which leads to increased cellular uptake of
phosphate.
33. COPDWhen to start home O2?  PaO2<55mmHg or O2 saturation <89%
at room O2 or ambulation (Value higher than this with polycythemia or corpulmonale).
34. Brachial v/s Ankle BP is the preferred first noninvasive evaluation for the case
of intermitten claudication.
35. Acute coronary syndrome= ST elevation MI, Non-ST elevation MI
,USA(Unstable angina) EKG + Fractional cardiac enzyme type of
MI/USA Rx Non ST elevation MI Aspirin,B-blocker,Heparin
36. Scleroderma patient presented with dyspnea  ILD V/s Pulmonary HTN 
PFT  Decreased DLCO + Restrictive pattern =ILD  Decreased DLCO + No
restrictive pattern = pulmonary HTN  assess Lt ventricular
function/Pulmonary systolic arterial pressure Contrast Echocardiography
Rx Options Nifidipine/CCB, Anticoagulant, Misoprostol/Epoprostenol,
Bosentan(Endothelial receptor antagonist) Put Rt cardiac catheter before
initiating any therapy to monitor response and consider another
therapyBosentan is CI in pregnancy(B-Hcg before initiating it).
37. Interval from the time of operation –return of flatus and bowel movement
=Ileus May be prolonged due to narcotic analgesic use like PCA(Pt
controlled analgesic) pumps  Tx NPO + NG tube
38. Gasgangrene(Feathery lucencies on X-ray) + Myonecrosis Cl. Perfringes
Rx Hyperbaric O2 + Antibiotic (Penicillin + Clindamycin)+Fluid replacement
+ Surgical debridment
39. HIV patient developed respiratory distress Respiratory isolation in separate
rooms.
40. How to exclude cervical injury after trauma?  Cx spine x-ray + Assessment
of pain by asking pt If the patient is intoxicated=do not remove cervical
collar as assessment is not possiblewait till he is able to communicate.
41. Neomycin is very common allergen (5% population) causing allergic
dermatitis.
42. Pulmonary TE  Begin LMW heparin + Warfarin Discontinue Heparin AFTER
2 DAYS of therapeutic INR is achieved.
43. Gout With liver & kidney disease  Avoid colchicine /NSAID’s Intrarticular
Steroid
44. In acute pancreatitis ideal nutritional approach is delivery of high protein/low
fat food directly to jejunum(Placing jejunal feeding tube).
45. Asymptomatic bactriuria generally doesn’t require treatment except in three
conditions: (1) Pregnant female (2) Renal transplant patient (3) Expected GU
procedure.
46. Recurrent chest infections in CF patients Antibiotic + Chest physiotherapy
to expel mucus plugs.
Neeraj’s Step-3 Notes:Kaplan
30
47. Child attending day care develop recurrent otitis media !
48. Acute suppurative parotitis a severe –life threatening condition might be seen
in debilitating patient remained dehydrated  due to stasis and infection of
StaphStart rehydration + Antibiotic against staph Surgical drainage if no
response within 12 hrs.
49. Normocytic anemia ?Reticulocyte counts  Raised =Bd lossLow =Marrow
failure.
50. Patient with indwelling catheter develops high fever Empirically cover
coagulase -ive and coagulase positive bacteria  Vanco + Genta
51. Household contacts of a patient (child putting fingers in mouth-fecoral
transmission) with Hepatitis A should receive Ig within 2 days of last
exposureChildren can return to day care after 7 days of onset of symptoms.
52. Ascetic patient on diuretics and compliant with medications still observing
increasing abdominal girth ? Probably not limiting salt intake.
53. “Heaped-up” appearance of flesh colored lesions on penis/Scrotum HPV
lesions/Genital warts.
54. Neurologic deficit in elderly R/o Metabolic or toxic causes first
55. HTN + Hypernatremia + Hypokalemia Conn’s?
56. Aortic valve area <0.7 cm2 is considered critical
57. How to confirm suspicion of Myasthenia Gravis  (1)Decremented response
on EMG on repetitive stimulation or (2)Antibody to Ach receptor
58. Spontaneous intracranial hypotension (SIH):Headache due to SIH is similar to
headache occurring after lumbar punctureCardinal featurespostural
headache and a low CSF pressuresubdural fluid collections on MRIRx Bed
rest and hydration
59. Acute febrile hemolytic reaction:Due to ABO mismatchManifest as Fever +
Chest pain + erythema at IV site + Hemoglobinuria
60. LAST TIP : PRAY TO GOD!
Good luck!
Neeraj’s Step-3 Notes:Kaplan
31