Step 3 Notes

UWorld Step 3 Notes
- Bile-salt induced diarrhea

o 5-10% of patients post cholecystectomy and patients with short bowel syndrome
o Secondary bile acids cause colonic stimulation when present in excess amounts
o Tx: bile salt-binding resins (eg cholestyramine)
- Hemoptysis 2/2 ??
o DDx: Acute bronchitis, trauma, infectious etiology, PE, cancer, cardiac (acute pulmonary
edema or hemoptysis)
o FSOM: CXR
 Clues to specific causes (malignancy, infection, heart disease)
- Acute COPD exacerbation
o Signs and symptoms
 Productive cough w/ green-yellow sputum, dyspnea, wheezing, hx of COPD
o FSOM if increased sputum  glucocorticoids, inhaled bronchodilators
 No clear benefit w/ expectorants (N-acetylcysteine) or systemic bronchodilators
(eg. Theophylline)
 Acute Bronchitis  NO ABX --- (if otherwise healthy b/c usually viral in etiology)
 If increased sputum purulence, sputum volume, increased dyspnea  YES ABX
 If on mechanical ventilation  YES ABX
 If fail outpatient therapy  hospital admission
- Acute Asthma Exacerbation
o ** (viral URI is common trigger)
o Clues:
 SOB, wheezing, coughing, drop in peak expiratory flow >20%
o FSOM: - SABA (albuterol) --- followed by systemic corticosteroids (Prednisone)
 Inhaled short-acting bronchodilators
 (SABA - albuterol)
 If symptoms persist  Systemic corticosteroids
 Prednisone 40mg daily – 5-10 days
o Shown to decrease asthma symptom relapse, SABA, and rate of
hospitalization
o What requires Hospital Admission?
 Severe asthma exacerbation
 Hypoxemia, difficulty speaking, use of accessory muscles, reduction in
peak expiratory flow > 50% from baseline
 If these symptoms present, should receive immediate emergency care
o WRONG ANSWERS
 No CXR
 Not needed for asthma exacerbation
 ** Unless evidence of concurrent PNA
o Eg. Fever, chest pain, increased sputum production, crackles,
dullness to percussion
 No Abx
 For COPD exacerbation w/ sputum and dyspnea
 Inhaled corticosteroids
 Used for chronic management of persistent asthma
 Not for acute management
 LABAs
 Used for chronic management, and only in combination w/ inhaled
corticosteroids
 No role for acute management
- Pancreatitis
o Most frequent single-item predictors of severity
 HCT >44% on admission
 Greater hemoconcentration from 3rd space losses
 BUN >20 on admission
 Increased risk of death
 ** Increases in BUN on serial measurements also associated with worse
outcomes
 AST > 250
 BMI >30
 Serum lipase > 1000 in adults (In children > 7 times upper limit of normal)
 ** Not triglyceride >1000
  associated with increased risk of acute pancreatitis, NOT disease
severity
o Ranson Criteria vs APACHE II score
 Ranson criteria, involves 11 different criteria (some of which cannot be
calculated until 48 hrs after admission)
 Shown to be poor predictor of severity
o APACHE II
 Improved predictive characteristics
o SIRS and BISAP (Bedside index for severity in AP)
 Also better than Ranson
- Afib w/ RVR
o Tx:
 1st: Rate-control
 BB or CCB
o BB --- Metoprolol or Atenolol
o CCB --- Diltiazem or Verapamil
o Rate-control improved ventricular filling  increases cardiac
output
o Goal: HR< 110
 ** Not for decompensated HF, hypotension, or bradyarrhythmias
 Because they have negative inotropic effects
- Biliary Colic
o Confirmed cholelithiasis on US
 Tx: Pain management and prophylactic, elective cholecystectomy
 Poor surgical candidate?  UDCA (Ursodeoxycholic acid)
- Meningococcal meningitis --- (antibiotic chemoprophylaxis)
o Which contacts requires antibiotic prophylaxis for meningococcal meningitis?
 Anyone w/ exposure to respiratory secretions
 Household contacts, person who intubates him, close contacts, child
care workers, person near patient >8hrs (eg airline traveler)
o What is the recommended antibiotic for meningococcal chemophophylaxis for close
contacts?
 Rifampin (4 doses orally)
 Pregnant?  Ceftraxone
 (Other options:  Cipro or IM ceftriaxone)
o Notes: Neisseria meningitidis acute bacterial meningitis
 Adolescents 2-18
 Nasopharyngeal epithelium
- HIV associated lipodystrophy vs adrenal hyperplasia / Cushing syndome
o Both have central humps and increased visceral fat…but w/ adrenal hyperplasia -->
there are other symptoms (proximal muscle weakness, facial plethora, easy bruising,
abdominal striae
 HIV associated lipodystrophy is associated w/ insulin resistance & dyslipidemia
- Tx for HIV patient w/ dyslipidemia  statin (ator, rosu, or prava)
- When to use Gemfibrozil (fibrates)

o Only to reduce risk of pancreatitis w/ triglycerides levels > 886
o ** Reduction of triglyceride s has not been shown to reduce CV risk
- Primary HIV infection VS infectious mononucleosis
o Both have unexplained, fever, fatigue, weight loss, LAD
 Exudative pharyngitis  Mono (** won’t see pharyngeal exudate w/ HIV)
 Diarrhea / rash HIV
- Mono (Epstein Barr)
o Tx: Supportive Care (NSAIDs)
 ** Acyclovir ONLY in immunocompromised patients
 ** Oral /IV prednisone ONLY for severe tonsillar enlargement w/ concern for
airway obstruction
- Rapid sequence intubation
o IV etomidate, succinylcholine, endotracheal intubation
 Rapidly acting sedative (etomidate, propofol, midazolam
 Paralytic (succinylcholine, rocuronium)
- EKG findings of PE
o New R bundle branch block (2/2 RV strain)
o Q waves and ST segment changes in the inferior leads
- Echo findings of PE
o Moderate Tricuspid Valve Regurgitation (w/ dilation of tricuspid valve annulus)
o RV dysfunction, decreased contractility, presence of RV thrombus
- When to use antiviral (Oseltamivir) for influenza?

o Patient’s who require hospitalization, severe progressive disease, underlying high-risk
medical conditions
o ** NEVER Adamantane / Rimantadine – high levels of resistance in US
- The best diagnostic test for esophageal perforation (Boerhaave Syndrome)

o esophagogram with water-soluble contrast (diatrizoate)
o CT scan of the chest is helpful but may not detect small tears or ruptures.
o Upper gastrointestinal endoscopy may worsen pneumomediastinum and should
generally be avoided in patients with suspected Boerhaave syndrome.
o This test provides a definitive diagnosis in 90% of cases. If the test is negative but
clinical suspicion is high, barium contrast can be used. Water-soluble contrast is
preferred as barium can produce further mediastinal irritation and injury in patients
with Boerhaave syndrome.
- Biliary Colic vs Acute Cholecystitis
o Both:
 RUQ pain, nausea vomiting
o Acute Chole
 PERSISTENT RUQ pain (>6hrs), leukocytosis, fever
 GB wall thickening, +PCF, sonographic murphy sign
o Biliary Colic
 TRANSIENT RUQ (<6hrs)
- Esmolol is an ultra-short acting beta-blocker that is used for rate control in patients with rapid
atrial flutter or fibrillation. It is not indicated in patients with PSVT.

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What are the signs and symptoms of acute pancreatitis?

What are the diagnostic criteria used to assess severity of acute pancreatitis?

UWorld Step 3 Notes

- Bile-salt induced diarrhea

- When to use Gemfibrozil (fibrates)

- When to use antiviral (Oseltamivir) for influenza?

- The best diagnostic test for esophageal perforation (Boerhaave Syndrome)

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