The Next Best Step Vignettes (USMLE Step 2 CK)
compare to previous chest x-ray ✔️✔️when you find a pulmonary nodule on chest x-ray
Pulmonary angiogram (gold standard), but usually used in CT pulmonary angiography or CT with
contrast ✔️✔️most accurate test in PE
NO LIP
Nitrates
Oxygen
Loops
Ionotropic drugs (dobutamine)
Positioning (blood pools in the legs)
BNP > 400 ✔️✔️tx acute CHF
V/Q scan ✔️✔️if the patient cannot have CT angio then what imaging do you use to dx the PE
CT chest/abdomen/pelvis and PET to look for mets ✔️✔️next best step after finding a brain tumor on
MRI
pleural:serum protein > 0.5
pleural:serum LDH > 0.6
pleural LDH > 2/3 serum LDH ✔️✔️Light's criteria for pleural effusion
LABA's ✔️✔️what type of asthma treatment should never be used alone
1. clinical scenario - unable to count to 10, use of accessory muscles, etc
2. O2 < 50
,3. CO2 > 50
* rule of 50's* ✔️✔️when should you intubate
histoplasmosis ✔️✔️ohio missipi
cocciodes ✔️✔️southwest US
Wind - atelectasis
Water - UTI
Wound - wound infection
Walking - DVT
Wonder drugs -stuff we give them ✔️✔️W's of post-op fever
broncheoalveolar carcinoma ✔️✔️repeat lung infections in the same area in patient older than 40
years old
CHADS2 > 2
CHF
HTN (140/70)
Age > 75
DM
Stroke/tia previous (2 pts) ✔️✔️requirement for anticoagulation in afib
amiodorone ✔️✔️tx for v tach with a pulse
BB and CCB ✔️✔️rate control a fib
< 48 hours - cardioversion
,> 48 hours - get TEE to look for intracardiac clot and then cardiovert/ otherwise rate control + anticoag
✔️✔️tx of a fib
1. abdominal x-ray to look for pneumoperitoneum
2. if so, then immediate surgery, if no then move to contrast enema -
a. if shows microcolon- meconium illeus- Gastriffin enema
b. if shows dilated macrocolon with taper- Hirshprung - recal biopsy ✔️✔️work up of bilous emesis
(progressive hip pain - can have normal physcial exam and x-ray findings early on) - chronic
corticosteriods - high RF - get MRI of the hip ✔️✔️next best step for avascular necrosis of the hip
halothane and succinylcholine - tx dantrolene ✔️✔️which anesthetics are associated with malignant
hyperthermia? tx
cerebellum ✔️✔️in what part of the brain is the intention tremor
UMN ✔️✔️bulbar symptoms are associated with UMN or LMN
atropine, if non-responsive then epi/dopamine or transcutaneous pacing ✔️✔️tx of persistent
bradycardia
amiodorone (always check LFT's, PFT's, and TFT's) ✔️✔️tx of ventricular tachy with a pulse
IV glucagon, K, and insulin ✔️✔️tx of suspected BB overdose
decrease in arterial elasticity ✔️✔️cause of isolated systolic hypertension
1. ACE -/ ARB
2. BB
, 3. spiranolactone ✔️✔️confer a decrease in mortality in CHF patients
no BB (crazy high BP), but yes to lorazepam ✔️✔️which drug should be given in a patient with
cocaine-induced MI
BB/ CCB ✔️✔️rate control afib
adenosine ✔️✔️tx of supraventricular tachy
procanimide (look for the delta wave) ✔️✔️tx of Wolf -parkinson white
pulmonary veins ✔️✔️where does afib originate
symptomatic - 70-99
assymptomatic 60-99 ✔️✔️when is CEA recommended
IV fouresemide ✔️✔️tx of flash pulmonary edema in the context of an MI
for original one - Troponin T, then for second CK-MB ✔️✔️what marker do we use to diagnose a
reinfarction
compression US ✔️✔️high pretest probability DVT
BUN/creat > 20 ✔️✔️how to determine pre-renal failure
restrictive ✔️✔️cardiac calcifications
nausea/vomiting/diahrea, and confusion and weakness, can get colored vision changes
✔️✔️symptoms of digoxin tox
compare to previous chest x-ray ✔️✔️when you find a pulmonary nodule on chest x-ray
Pulmonary angiogram (gold standard), but usually used in CT pulmonary angiography or CT with
contrast ✔️✔️most accurate test in PE
NO LIP
Nitrates
Oxygen
Loops
Ionotropic drugs (dobutamine)
Positioning (blood pools in the legs)
BNP > 400 ✔️✔️tx acute CHF
V/Q scan ✔️✔️if the patient cannot have CT angio then what imaging do you use to dx the PE
CT chest/abdomen/pelvis and PET to look for mets ✔️✔️next best step after finding a brain tumor on
MRI
pleural:serum protein > 0.5
pleural:serum LDH > 0.6
pleural LDH > 2/3 serum LDH ✔️✔️Light's criteria for pleural effusion
LABA's ✔️✔️what type of asthma treatment should never be used alone
1. clinical scenario - unable to count to 10, use of accessory muscles, etc
2. O2 < 50
,3. CO2 > 50
* rule of 50's* ✔️✔️when should you intubate
histoplasmosis ✔️✔️ohio missipi
cocciodes ✔️✔️southwest US
Wind - atelectasis
Water - UTI
Wound - wound infection
Walking - DVT
Wonder drugs -stuff we give them ✔️✔️W's of post-op fever
broncheoalveolar carcinoma ✔️✔️repeat lung infections in the same area in patient older than 40
years old
CHADS2 > 2
CHF
HTN (140/70)
Age > 75
DM
Stroke/tia previous (2 pts) ✔️✔️requirement for anticoagulation in afib
amiodorone ✔️✔️tx for v tach with a pulse
BB and CCB ✔️✔️rate control a fib
< 48 hours - cardioversion
,> 48 hours - get TEE to look for intracardiac clot and then cardiovert/ otherwise rate control + anticoag
✔️✔️tx of a fib
1. abdominal x-ray to look for pneumoperitoneum
2. if so, then immediate surgery, if no then move to contrast enema -
a. if shows microcolon- meconium illeus- Gastriffin enema
b. if shows dilated macrocolon with taper- Hirshprung - recal biopsy ✔️✔️work up of bilous emesis
(progressive hip pain - can have normal physcial exam and x-ray findings early on) - chronic
corticosteriods - high RF - get MRI of the hip ✔️✔️next best step for avascular necrosis of the hip
halothane and succinylcholine - tx dantrolene ✔️✔️which anesthetics are associated with malignant
hyperthermia? tx
cerebellum ✔️✔️in what part of the brain is the intention tremor
UMN ✔️✔️bulbar symptoms are associated with UMN or LMN
atropine, if non-responsive then epi/dopamine or transcutaneous pacing ✔️✔️tx of persistent
bradycardia
amiodorone (always check LFT's, PFT's, and TFT's) ✔️✔️tx of ventricular tachy with a pulse
IV glucagon, K, and insulin ✔️✔️tx of suspected BB overdose
decrease in arterial elasticity ✔️✔️cause of isolated systolic hypertension
1. ACE -/ ARB
2. BB
, 3. spiranolactone ✔️✔️confer a decrease in mortality in CHF patients
no BB (crazy high BP), but yes to lorazepam ✔️✔️which drug should be given in a patient with
cocaine-induced MI
BB/ CCB ✔️✔️rate control afib
adenosine ✔️✔️tx of supraventricular tachy
procanimide (look for the delta wave) ✔️✔️tx of Wolf -parkinson white
pulmonary veins ✔️✔️where does afib originate
symptomatic - 70-99
assymptomatic 60-99 ✔️✔️when is CEA recommended
IV fouresemide ✔️✔️tx of flash pulmonary edema in the context of an MI
for original one - Troponin T, then for second CK-MB ✔️✔️what marker do we use to diagnose a
reinfarction
compression US ✔️✔️high pretest probability DVT
BUN/creat > 20 ✔️✔️how to determine pre-renal failure
restrictive ✔️✔️cardiac calcifications
nausea/vomiting/diahrea, and confusion and weakness, can get colored vision changes
✔️✔️symptoms of digoxin tox
