I've had to pinch myself a few times in the last 2 days because it has hardly sunk in that USMLE step 2ck is over!
Day 0, I was 45mins flight away from home, totally psyched up, ready as I could be and knowing that my loved ones were back home praying for me. I got up early, prayed, exercised, got dressed, made sandwiches for my breaks, read 1 or 2 pages of MTB to wake my brain cells and had a good proteinous breakfast. On my way out of the hotel, I sat down for about 10mins at the computer station and just scrolled through week 2 of this mental map (the week with the highest number of posts), nodding along. Those highlights bounced back and forth in my brain as I did the 10mins walk to the exam centre.
Generally, the exam went very well save for the intermittent drilling noise coming from outside the window at the prometric centre. It was distracting at first but when I talked to the proctor after block 1 and learnt that there was nothing they could do about it, (not even to change my seat to one farther from the window!), I told myself :" You can do this, the noise is now part of the exam and you just have to surmount it!" After that I wasn't as bothered by the noise. Nine hours went by quickly and before you knew it I was on my way back to my hotel room saying "thank you God" and telling Hubby (on the phone) how it went.
Well, the 4weeks wait is on...
I prepared for this USMLE step using U world, MTB, Kaplan Qbank, a few Kaplan videos and many online resources. One tool which was however extremely useful to me was this blog which I started about a month to the exam, when I was feeling like I needed some form of 'decongestion' or was it 'info organisation'? Whatever it was, trying to put down the most important facts about each condition or concept was really helpful in consolidating what I knew well and identifying what I didn't know enough about. Also, the product of my mental mapping (this blog) was good for quick revision anywhere internet was available. I hope someone else will also find it useful.
To all those at the stage that I was when I started this blog, good luck!
My USMLE CK Mental Map
-Last few days of preparation for my Step 2 USMLE -Clinical Knowledge Exam
Wednesday, May 30, 2012
Saturday, May 26, 2012
PPD Interpretation
Classification of the Tuberculin Skin Test Reaction
An induration of 5 or more millimeters is considered positive in -HIV-infected persons -A recent contact of a person with TB disease -Persons with fibrotic changes on chest radiograph consistent with prior TB -Patients with organ transplants -Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or longer, taking TNF-a antagonists) | An induration of 10 or more millimeters is considered positive in -Recent immigrants (< 5 years) from high-prevalence countries -Injection drug users -Residents and employees of high-risk congregate settings -Mycobacteriology laboratory personnel -Persons with clinical conditions that place them at high risk -Children < 4 years of age - Infants, children, and adolescents exposed to adults in high-risk categories | An induration of 15 or more millimeters is considered positive in any person, including persons with no known risk factors for TB. However, targeted skin testing programs should only be conducted among high-risk groups. |
Friday, May 25, 2012
OGTT
Normal values
75-gram 2 Hour oral glucose tolerance test
> 200 mg/dL = Diabetes
FOR GESTATIONAL DIABETES,
50-gram 1 hour oral glucose tolerance test
100-gram 3 hour oral glucose tolerance test
75-gram 2 Hour oral glucose tolerance test
- Fasting 60 -100 mg/dL
- 1 hr: less than 200 mg/dL
- 2 hrs: less than 140 mg/dL.
> 200 mg/dL = Diabetes
FOR GESTATIONAL DIABETES,
50-gram 1 hour oral glucose tolerance test
- 1 hour: < or =140 mg/dL
100-gram 3 hour oral glucose tolerance test
- Fasting: less than 95 mg/dL
- 1 hour: less than 180 mg/dL
- 2 hour: less than 155 mg/dL
- 3 hour: less than 140 mg/dL
Random facts (statistics)
Differential loss to follow up: Attrition. A type of selection bias found in cohort studies
Reliability: repeatability of a measure
Validity: absence of bias
Bias: systematic error
Selection bias: deferential access to study population (from selection process, respodents no longer available at the end, attrition etc)
Confounding: unfair comparison
Volunteer bias: type of selection bias, the tendency for one's health to influence decision to participate in a study
Information bias: occurs when the means of obtaining information from cases and controls differ
Reliability: repeatability of a measure
Validity: absence of bias
Bias: systematic error
Selection bias: deferential access to study population (from selection process, respodents no longer available at the end, attrition etc)
Confounding: unfair comparison
Volunteer bias: type of selection bias, the tendency for one's health to influence decision to participate in a study
Information bias: occurs when the means of obtaining information from cases and controls differ
Hazards ratio, Relative risk
HR = Probability of event in treatment grp/Probability of event in control group
RR = Probability of event in treatment grp/Probability of event in control group
Exactly! same formular!
Hazard ratio is actually a type of Relative risk (a.k.a Risk ratio)
The difference?
HR is instantaneous while RR is culmulative.
RR can only be calculated at the end of the study while HR can be calculated at different points in time. Hazard ratios are calculated using the survival analysis technique. This keeps track of the number of subjects who haven't had the event (e.g death) at a particular time.
Again, HR is an estimate of RR
HR of 1 means the rate of occurrence of the event in treatment/intervention grp is same as in control/placebo grp
HR >1 means event occurs more in the intervention grp
HR <1 means event occurs less in the intervention grp
To convert a HR to probability,
Probability of event occurring = HR/1+ HR
So, HR of 1 is a probability of 50%. A 50:50 chance, i.e treatment and placebo grps are the same in terms of outcome
RR = Probability of event in treatment grp/Probability of event in control group
Exactly! same formular!
Hazard ratio is actually a type of Relative risk (a.k.a Risk ratio)
The difference?
HR is instantaneous while RR is culmulative.
RR can only be calculated at the end of the study while HR can be calculated at different points in time. Hazard ratios are calculated using the survival analysis technique. This keeps track of the number of subjects who haven't had the event (e.g death) at a particular time.
Again, HR is an estimate of RR
HR of 1 means the rate of occurrence of the event in treatment/intervention grp is same as in control/placebo grp
HR >1 means event occurs more in the intervention grp
HR <1 means event occurs less in the intervention grp
To convert a HR to probability,
Probability of event occurring = HR/1+ HR
So, HR of 1 is a probability of 50%. A 50:50 chance, i.e treatment and placebo grps are the same in terms of outcome
Wednesday, May 23, 2012
Regarding asthma treatment
Practice recommendations
|
Oral corticosteroids are used in acute exercerbations not for long term management.
Neonatal conjuctivitis
"Silver eyed on day 1
Gon home within 7 days
only to return after a week
with trachs on his chlam
and again in a month
when the herpes showed up!"
Day 1:Chemical conjuctivitis
Day 3-7: Gonococcal
After wk 1: Chlamydia
After 3wks: Herpes
Monday, May 21, 2012
Countdown
7 days to go!
Wao! excited actually...
Kaplan q bank scores were initially lower than I expected but have improved now, I have a simulated exam to take when today dawns but first, I've got to catch some sleep!
Wao! excited actually...
Kaplan q bank scores were initially lower than I expected but have improved now, I have a simulated exam to take when today dawns but first, I've got to catch some sleep!
Friday, May 18, 2012
Remember
In constrictive pericarditis and tamponade, catheterisation shows the same diastolic pressure in all 4 chambers!
Reye syndrome
Encephalopathy following an acute viral illness in a child due to aspirin use
high level of ammonia
liver biopsy shows fatty changes
No treatment. supportive care: correct hypoglycemia, anti emetics, electrolytes etc
high level of ammonia
liver biopsy shows fatty changes
No treatment. supportive care: correct hypoglycemia, anti emetics, electrolytes etc
Rash involving hands and feet
Most rashes don't involve hands and feet. If an acute illness with rash involves hands and feet, think of
- Syphilis (secondary)
- Rocky mountain spotted fever (centrifugal rash)
- Coxsackie virus (hand, foot and mouth disease)
Remember
Pronator drift is a sign of upper motor neurone lesion
Patient is asked to hold out both arms at shoulder level, fully extended with forearms supine, and hold the position.
If the patient is unable to hold the position and the forearm pronates, then pronator drift is positive and the patient most likely has a contralateral pyramidal tract (UMN) lesion.
Closing the eyes accentuates it.
Patient is asked to hold out both arms at shoulder level, fully extended with forearms supine, and hold the position.
If the patient is unable to hold the position and the forearm pronates, then pronator drift is positive and the patient most likely has a contralateral pyramidal tract (UMN) lesion.
Closing the eyes accentuates it.
School phobia
School phobia is a seperation anxiety disorder.
It must be present for at least 4 weeks
It must be present for at least 4 weeks
Order of changes at Puberty
At puberty, it's time to TAG along!
Girls:
Thelarche - breast development (usually the first sign of Gonardache -onset of true central puberty)
Adrenarche: axillary hair and Pubarche- pubic hair (Adrenarche:can preceed true puberty)
Growth acceleration
Then Menarche
Boys:
Testicular growth (due to gonardache)
Adrenarche : axillary and pubic hair
Growth acceleration
Then Spermache
Girls:
Thelarche - breast development (usually the first sign of Gonardache -onset of true central puberty)
Adrenarche: axillary hair and Pubarche- pubic hair (Adrenarche:can preceed true puberty)
Growth acceleration
Then Menarche
Boys:
Testicular growth (due to gonardache)
Adrenarche : axillary and pubic hair
Growth acceleration
Then Spermache
Remember
If u see migratory thrombophlebitis, look for visceral malignancies.
Remember
FeNa> 2% = intrinsic renal disease i.e acute tubular necrosis or acute interstititial nephritis
In prerenal azotemia e.g due to dehydration, FeNa is <1%, urine sodium is <20mEq/L, urine osmolality> 500mEq/L
Kidney reabsorbs Na and water to compensate for the hypovolaemia or hypotension.
In prerenal azotemia e.g due to dehydration, FeNa is <1%, urine sodium is <20mEq/L, urine osmolality> 500mEq/L
Kidney reabsorbs Na and water to compensate for the hypovolaemia or hypotension.
Pneumococcal vaccine indications for adults
age >65yrs
Chronic diseases (hrt disease, lung disease, DM, cochlear implants, CSF leak, SCD, alcoholism)
Immunosuppressive diseases (HIV/AIDS, MM, Lymphomas,Leukemias, Chronic renal failure, organ transplant, nephrotic syndrome etc)
Immunosuppressive therapy (long term steroids, chemotherapy, radiotherapy)
Smokers
Asthmatics
Nursing home residents
Splenectomized individuals
Chronic diseases (hrt disease, lung disease, DM, cochlear implants, CSF leak, SCD, alcoholism)
Immunosuppressive diseases (HIV/AIDS, MM, Lymphomas,Leukemias, Chronic renal failure, organ transplant, nephrotic syndrome etc)
Immunosuppressive therapy (long term steroids, chemotherapy, radiotherapy)
Smokers
Asthmatics
Nursing home residents
Splenectomized individuals
TOF
Tetralogy of Fallot
Pulmonary stenosis+ VSD+overriding aorta+RVH
Cyanotic congenital heart disease (The 5 Ts. others are TGA, Truncus arteriosus, Total anomalous pulm venous return, Tricuspid atresia)
Right to left shunt leads to mixing
May not be cyanotic at birth
Difficulty feeding, polycythaemia, finger clubbing, dyspnoea, FTT, murmur
Tet spells
sudden, marked increase in cyanosis followed by syncope ,often precipitated by crying, feeding or exercise , may also occur on waking up.
It is due to an increase in rt to left shunting of unoxygenated blood following a decrease in systemic vascular resistance or increased pulmonary vascular resistance, favouring the "right to left to aorta shunt"
It can be relieved by squatting or placing child in knee chest position (This increases afterload thus allowing more blood to go thru pulmonary circulation rather than systemic)
Chest x ray shows boot shaped heart and decreased pulmonary vascular markings.
Pulmonary stenosis+ VSD+overriding aorta+RVH
Cyanotic congenital heart disease (The 5 Ts. others are TGA, Truncus arteriosus, Total anomalous pulm venous return, Tricuspid atresia)
Right to left shunt leads to mixing
May not be cyanotic at birth
Difficulty feeding, polycythaemia, finger clubbing, dyspnoea, FTT, murmur
Tet spells
sudden, marked increase in cyanosis followed by syncope ,often precipitated by crying, feeding or exercise , may also occur on waking up.
It is due to an increase in rt to left shunting of unoxygenated blood following a decrease in systemic vascular resistance or increased pulmonary vascular resistance, favouring the "right to left to aorta shunt"
It can be relieved by squatting or placing child in knee chest position (This increases afterload thus allowing more blood to go thru pulmonary circulation rather than systemic)
Chest x ray shows boot shaped heart and decreased pulmonary vascular markings.
Tangier disease
Tangerines in the throat!
Aut recessive, rare
Deficiency of ABCA1 transporter needed to transport cholesterol out of cells
Low serum cholesterol, No cholesterol to pick up leading to low HDL
cholesterol accumulation in cells and tissues
Enlarged, yellow or orange tonsils, premature artherosclerosis, hepatosplenomegaly, corneal clouding
Aut recessive, rare
Deficiency of ABCA1 transporter needed to transport cholesterol out of cells
Low serum cholesterol, No cholesterol to pick up leading to low HDL
cholesterol accumulation in cells and tissues
Enlarged, yellow or orange tonsils, premature artherosclerosis, hepatosplenomegaly, corneal clouding
nursing-resource.com |
Thursday, May 17, 2012
TTP or HUS?
Both are microangiopathic hemolytic anemias
Both present with
Altered mental status is more prominent in TTP
Acute anuric renal failure is more prominent in HUS
less specific is that HUS more in children while TTP more in adults
Both present with
- Thrombocytopenia
- hemolytic anemia (low hct, schistocytes, unconjugated hyperbilirubinemia, high LDH etc)
- Acute renal insufficiency (high BUN)
- Fever
- Altered mental status
Altered mental status is more prominent in TTP
Acute anuric renal failure is more prominent in HUS
less specific is that HUS more in children while TTP more in adults
Wednesday, May 16, 2012
Colles fracture
Fall on outstretched hand,
Fracture of distal radius and ulna, dorsal angulation= dinnerfork deformity
Tmt: closed reduction and long arm cast involving wrist and elbow works well
Fracture of distal radius and ulna, dorsal angulation= dinnerfork deformity
Tmt: closed reduction and long arm cast involving wrist and elbow works well
de Quervain tenosynovitis
Tendons involved can be remembered by ALEB (ALL Exclusively Breastfeeding mothers!)
Abductor pollicis Longus and Extensor policis Brevis
Remember, it occurs commonly in new mothers due to the awkward way they support the baby's head with their hand e.g during breastfeeding. It can also be occupational (washer woman, carpenters, musicians, office workers)
The Finkelstein test is positive
Abductor pollicis Longus and Extensor policis Brevis
Remember, it occurs commonly in new mothers due to the awkward way they support the baby's head with their hand e.g during breastfeeding. It can also be occupational (washer woman, carpenters, musicians, office workers)
The Finkelstein test is positive
© Cork Emergency Medicine 2013. |
Bell's palsy
a post infectious demyelinating facial neuritis.
Associated infections include:
Herpes simplex
Varicella zoster
EBV
Lyme dx (Borrelia)
Associated infections include:
Herpes simplex
Varicella zoster
EBV
Lyme dx (Borrelia)
Selective Estrogen Receptor Modulators
Clomifene: @ hypothalamus: antagonist
Raloxifene: @breast :antagonist @bone: agonist @uterus: antagonist
Tamoxifene: @breast :antagonist @bone: agonist @uterus: agonist
Others include: femarelle, toremifene etc.
All reduce risk of breast cancer
All reduce risk of postmenopausal osteoporosis
Tamoxifene increases risk of endometrial cancer
SERMs increase risk of DVT
Clomifene used for treatment of infertility(anovulation)
Raloxifene used for treatment of Osteoporosis and breast cancer
Tamoxifene used for treatment of breast cancer
Raloxifene: @breast :antagonist @bone: agonist @uterus: antagonist
Tamoxifene: @breast :antagonist @bone: agonist @uterus: agonist
Others include: femarelle, toremifene etc.
All reduce risk of breast cancer
All reduce risk of postmenopausal osteoporosis
Tamoxifene increases risk of endometrial cancer
SERMs increase risk of DVT
Clomifene used for treatment of infertility(anovulation)
Raloxifene used for treatment of Osteoporosis and breast cancer
Tamoxifene used for treatment of breast cancer
Tuesday, May 15, 2012
Dieulafoy lesion
Upper GI bleeding with no risk factors and normal endoscopy findings: suspect Dieulafoy lesion- a submucosal vessel that fails to divide into capillaries but bleeds intermittently and retracts under the mucosa during non bleeding periods.
Fanconi anemia
Autosomal recessive
Aplastic anemia
Pancytopenia
Hyperpigmentation
Short stature
microcephaly
hypogonadism
upper limb anomalies
Cure is BM transplant
Aplastic anemia
Pancytopenia
Hyperpigmentation
Short stature
microcephaly
hypogonadism
upper limb anomalies
radswiki.net |
Glaucoma screening
> 40yrs with risk factors: every year
>40 but <60yrs, no risk factors: every 3-5 yrs
>60yrs , no risk factors: every 1-2 yrs
Risk factors for glaucoma include:
Black race
High IOP
DM
Family history
Severe eye injury
Myopia
Chronic corticosteroids
Hypothyroidism
>40 but <60yrs, no risk factors: every 3-5 yrs
>60yrs , no risk factors: every 1-2 yrs
Risk factors for glaucoma include:
Black race
High IOP
DM
Family history
Severe eye injury
Myopia
Chronic corticosteroids
Hypothyroidism
Treatment of Primary pulmonary hypertension
Mgt:
IV vasodilator challenge (prostacyclin, NO, adenosine) in order to decide definitive treatment
Definitive treatment:
If responsive to vasodilator challenge, start Calcium channel blockers. Try for at least 3-6months, if no response use prostacyclin
If no response to vasodilator challenge, other modalities including Transplant depending on the NYHA classification
Anticoagulation for all patients (Warfarin)
IV vasodilator challenge (prostacyclin, NO, adenosine) in order to decide definitive treatment
Definitive treatment:
If responsive to vasodilator challenge, start Calcium channel blockers. Try for at least 3-6months, if no response use prostacyclin
If no response to vasodilator challenge, other modalities including Transplant depending on the NYHA classification
Anticoagulation for all patients (Warfarin)
Monday, May 14, 2012
Remember
Neonate turns blue when feeding, turns pink when crying = choanal atresia
may be part of the CHARGE Syndrome
Coloboma
Heart defects
Atresia of the choanae
Retardation (mental)
Genitourinary anomalies
Ear anomalies
suspect if you can't pass an intranasal catheter, confirm with contrast CT.
may be part of the CHARGE Syndrome
Coloboma
Heart defects
Atresia of the choanae
Retardation (mental)
Genitourinary anomalies
Ear anomalies
suspect if you can't pass an intranasal catheter, confirm with contrast CT.
pseudoseizures
Psychogenic non epileptic seizure
Triggered by emotional stress
Normal EEG
Normal prolactin level following episode unlike in neurogenic seizure in which prolactin is elevated within 20 minutes of seizure.
There may be side to side head movement, pelvic thrusting, eyes may be closed, no post ictal confusion or incontinence
Very easy to be taken as malingearing.
Tmt is psychotherapy +/- antidepressants. Do not use anticonvulsants.
Triggered by emotional stress
Normal EEG
Normal prolactin level following episode unlike in neurogenic seizure in which prolactin is elevated within 20 minutes of seizure.
There may be side to side head movement, pelvic thrusting, eyes may be closed, no post ictal confusion or incontinence
Very easy to be taken as malingearing.
Tmt is psychotherapy +/- antidepressants. Do not use anticonvulsants.
Subscribe to:
Posts (Atom)