Doctor Info

USMLE step 2 CK: Newborn with respiratory Distress -- CASE 2

2006-10-23T18:53:00.000-05:00

A term newborn born to a 32 year old primi mother by LSCS was found to be not feeding well at 1 hour of life.
H/O of GDM on diet control. No other significant history, LSCS was done electively for CPD.
Birth weight: 3.4 kg
Male
APGAR 8 at 1 & 9 at 5.

O/E -- Cry and activity moderate
HR -- 156/min
temp -- normal
RR -- 68/min and grunt present; SPO2 90 in room air
Respiratory and Cardiological exam noncontributory

Inx -- RBS -- 56 at 1 hour, grunt present.

XRAY --

What is the diagnosis ?

What is the management and in which condition do you get "spinnaker sail sign" ?

USMLE step 2 CK: Newborn with respiratory Distress

2006-09-23T00:36:00.000-05:00

A term baby with uneventful antenatal history and a normal vaginal delivery was found to be tachypneic soon after birth. Examination showed grunting, mild cyanosis,no murmurs and asymmetrical air entry.

An emergency X ray was taken in the labor room after passing an infant feeding tube.

What is the diagnosis ?

USMLE step 2 CK: New born with vomiting ?

2006-09-23T00:30:00.000-05:00

A new born presents with history of vomiting, decreased activity soon after birth.
After a clinical exam, a chest X-ray was taken. What is the diagnosis?

Double Bubble Sign - Duodenal atresia

USMLE Step 1 portions which are tested on USMLE step 2 CK

2006-09-23T00:21:00.000-05:00

Anatomy:

Visual field defects
Spinal cord tracts
Spinal Cord lesions
Brachial plexus injuries

Physiology:

Sleep changes in elderly
Hormone changes in menstrual cycle

Behavioral Science:

Ego defenses
Modes of Inheritance -- Genetics
Glycogen storage diseases

Microbiology:

Microbes causing food poisoning and Diarrhea
Systemic Mycoses
Hepatitis serologic markers
Hypersensitivity reactions
Transplant rejection – types

Pathology:

Paraneoplastic effects of tumors
Interpretation of tests in bleeding disorders
Hereditary hyperbilirubenimias
Pulmonary function tests interpretation
Heart murmurs
Acidosis with increased / normal Anion gap
Peripheral smears of Leukemias & Burkitt’s Lymphoma

Pharmacology:

HIV Therapy – Side effects
Anti psychotics – Side effects
Anti epileptics – Side effects
Metabolic changes with Thiazides and Furosemide
Heparin induced Thrombocytopenia

How To Score High In USMLE STEP 2 CK Exam

2006-09-23T00:09:00.000-05:00

It is comparatively more difficult to write a post on this topic as compared to step 1 exam. This is mainly due to the fact that USMLE step 2 CK exam is different from USMLE step 1 exam in many ways –

1) It is longer and more tiring – Stamina is a must!!
2) Some exam days the questions are very long and tough, hence day to day standards are different.
3) Some people due to unknown reasons who thought they did well got low scores.
4) Portion is much vaster in comparison to Step 1 exam.

Time Frame for preparation:

I prepared for 2 months studying on the average of 6 hours per day and for the last 3 weeks prior the exam date took leave and studied whole time.

Tips from my exam:
1) Medicine was tested maximum with Pulmonology and Cardiology being more represented.
2) Questions of all lengths and some with plenty of choices were encountered.
3) Step 1 knowledge was tested a bit and they could be answered without revision.
4) Time was just enough.
5) ECG’s and graphs were few and they were the standard ones.
6) Standard ending of many questions was “what would be the next step in management”.
7) Some times the same topic may be tested in the same exam more than one time, so stick to your answer , do not try to choose a different one each time.
8) Some blocks are harder than others, so don’t lose heart when you encounter a tough one.
9) Questions form all subjects are mixed together, so practice a few mixed blocks before the real exam e.g. NBME

How to attack the real exam???

1) Practice reading the last two lines first esp. when you are tackling a long question. You will save time and also be able to focus on what info you need to extract from the question
2) 2 weeks prior to the exam, adjust your sleep cycle, so that you are most fresh in the morning, get used to getting up by 6 am and studying from 8 am. Stop your afternoon naps or you will feel sleepy in the afternoon even on the test day.
3) Time management – You should have completed question 25 by 30 minutes or you will not be able to complete the paper.
4) Practice the FRED tutorial well, so that you can quickly go through it on the exam day and save time.
5) Block spacing: 2 – Break – 2 – Lunch – 1 – Break – 1 – Break – 1 -- Break – 1. This will ensure that you will be fresh in the afternoon when you tend to be more fatigued.

Review Books and Courses:

Kaplan notes – Very good but Medicine is a little too detailed, so it may look a lot to study especially for those preparing fresh.

Kaplan Q book – Good Questions but they are easier than the real exam.

Kaplan Q Bank – Another set form Kaplan, same standard as those from the Q book.

USMLE World – Over all questions are very good, more like the real exam, BUT there are mistakes, ambiguous questions and some very low yield topics have been added. But still I would recommend all to subscribe to it, to get a feel on how hard the real exam is.

NBME Tests – Useful for time management training only. Disadvantage is it does not give you the answers, so you are not learning much from it.

Crush the Boards – Highly rated but in my opinion a useless book, contains out dated facts. I am sure the only reason it is popular is people are not intimidated by its size.

Current Medical Diagnosis and Therapy – A very good book for reference and clearing of your doubts, but it is too vast to be used as a primary learning source.

First Aid for step 2 – The book is too comprehensive and low yield. The only good thing in this book is the pictures.

Platinum Vignettes – Good content but not in the model of the real exam. To be read if you really have time and money to spare.

High yield series – I liked the Obstetrics and Gynecology book and the Pediatrics book.

Blue prints series – It is meant to be used by persons who are studying from basics, too detailed.

High Yield topics Subject wise:

I have collected the high yield topics from each subject based on my personal experience and from people who have scored well on the exam. I chose a few level headed persons to eliminate the bias.

By bias I mean, I see many test takers tend to remember the questions they got wrong or found tough.

It does make me think of the 6 blind men trying to describe an Elephant. Each person had a different description of the elephant (Read Exam).

This list contains the topics one has to revise during the last 2 weeks prior to the exam.

Medicine – Over 50 percent of questions are from this subject. The chapters are arranged in the order of decreasing significance.

Pulmonology:

Pneumonia – Types and treatment
COPD – Treatment, Home Oxygen guidelines etc
Obstructive VS restrictive diseases – PFT
Pleural effusion – transudate vs. Exudate
Bronchiectasis –Diagnosis and Radiology findings
Pulmonary thromboembolism—Know treatment protocol well.
ARDS – Diagnosis esp. ABG findings.
Lung Cancer – Approach to solitary nodule.
Low yield topics are ABPA, Occupational lung diseases and Asthma.

Cardiology:

Angina – Printzmetal angina, unstable angina; Drugs used in treatment
MI – Enzymes, ECG changes, thrombolytic therapy, Localization of MI. Drugs used for treatment, Non Q MI, Complications of MI.
Congestive heart failure – treatment.
Valvular heart disease – Its treatment esp. indications of valve replacement / valvotomy.
Changes in Murmur with different maneuvers esp. squatting and Valsalva.
Cardiomyopathy – How to diagnose and pathophysiology.
Cardiac tamponade vs. Constrictive pericarditis.
ECG interpretation of AV Blocks, Tachy arrhythmias and metabolic abnormalities.
Management of AV Blocks, SVT, AF, Atrial flutter, VF, VT and PEA. Read ACLS guidelines for this topic.
Hypertension – Drugs for each age group and co morbid illness.

Endocrinology:

Hyperprolactinemia – Treatment
Diabetes insipidus – Nephrogenic vs. Neurogenic.
SIADH – Know everything about this.
Thyroiditis – Types
Hyperparathyroidism – Lab features.
Diabetes Mellitus – DKA, Late complications and factitious hyperinsulinism.
Cushing’s syndrome – Work up
Pheochromocytoma -- Diagnosis and Management
Addison’s disease – Diagnosis.

Nephrology and Electrolytes:

ABG interpretation
Acute tubular necrosis vs. Pre renal shut down
TTP
HUS
Nephritic and Nephrotic syndromes – Diagnosis and characteristic age groups / associations.
Indications of Dialysis.
Hypo / Hyper – natremia & -- Management
Hypo / Hyper – kalemia – ECG changes and management.
Nephrolithiasis
Secondary Hypertension – Workup and etiology.

Hematology:

Anemia – Diagnostic criteria for different subtypes
Hereditary spherocytosis – Interpretation of Osmotic fragility and peripheral smear recognition.
Leukemia -- Diagnostic criteria for different subtypes.
Multiple myeloma – Know clinical presentation
DIC – Clinical, Lab and Management.

Infectious diseases:

Meningitis & Encephalitis – Clinical , CSF findings and treatment
Otitis media
Lung Abscess – Clinical and radiology
Pneumonia – Types and treatment
Tuberculosis – Clinical features, Diagnosis, Treatment esp. prophylaxis.
Infectious Diarrhea and Food poisoning – Etiology.
STD – Know in and out.
Pyelonephritis – Investigation and management.
Osteomyelitis vs. Septic Arthritis – Diagnosis
Infective Endocarditis – Organisms and Prophylaxis
Opportunistic infections in AIDS.

Preventive Medicines:

Adult and Pediatric Vaccination schedules
Screening for cancer, lipid disorders etc.

Neurology:

Guillain barre syndrome
Head ache
Myasthenia gravis

Rheumatology:

Gout vs. Pesudo gout – diagnosis and treatment
Rheumatoid arthritis – diagnosis and treatment
SLE
Osteoarthritis – Diagnosis

Gastroenterology:

GERD – Diagnosis and treatment
Achalasia, Scleroderma , Diffuse esophageal spasm , Zenker diverticulum -- Diagnosis and treatment.
Esophageal Cancer -- Diagnosis and treatment.
Pseudo membranous colitis -- Diagnosis and treatment
Diverticulosis -- Diagnosis and treatment
GI Bleeding -- Diagnosis and treatment
Acute Pancreatitis – Diagnosis, complications and treatment
Viral Hepatitis – Diagnosis.
Wilson’s disease -- Diagnosis and treatment

Miscellaneous:

TCA, Salicylates, Carbon monoxide and Lead poisoning
Heat disorders – cramps, exhaustion, stroke etc.
Old Age -- Related changes & problems.

Pediatrics: There is considerable overlap between Medicine and Pediatrics. A high yield strategy of studying would be to read both together topics wise.
I have listed the topics unique to pediatrics which are high yield.

APGAR score
PKU & Galactosemia – Enzyme defect, screening and Clinical features
Neonatal drug wthdrawal
Respiratory distress in newborn – HMD, sepsis, Transient tachypnea of newborn, meconium aspiration syndrome and PPHN.
Congenital infections – TORCH
Tracheo esophageal fistula.
Breast milk vs. Cows milk – micronutrient differences and deficiency.
Developmental milestones
ADHD
Nocturnal enuresis
Autism vs. Asperger syndrome
Acetaminophen, Iron, salicylates and Lead poisoning
Meningitis – organisms.
Pertussis – Diagnosis and treatment.
Erythema infectiosum
Lyme’s disease
Rubella vs. Rubeola
Scarlet fever vs. Kawasaki’s disease – clinical, diagnosis, treatment and complications.
Congenital Immune deficiency disorders – Clinical features.
Pharyngitis
Croup vs. Epiglottitis – Diagnosis , treatment and organism.
Cystic Fibrosis
Congenital Heart disease – Identify the murmurs and clinical presentation
Congenital Pyloric stenosis
Intussusception
Post streptococcal nephritis
Congenital Adrenal Hyperplasia
Sickle cell anemia
Wilm’s tumor vs. Neuroblastoma
Neuro cutaneous syndromes – TS, NF, VHL etc.
Syndromes – Down, Turner, Fragile X, Prader Willi and Trisomy 18.

Psychiatry:

Ethics
Doctor patient relationship
Mood disorders – Criteria for diagnosis and treatment
Schizophrenia vs. Schizophreniform disorder
Delirium vs. Dementia – Etiology
Substance Abuse
Anorexia Nervosa vs. Bulemia Nervosa -- Criteria for diagnosis and treatment
Wild, Weird and Worried – Personality disorders
Anti psychotics – Uses and Side effects
Types of prevention
Sensitivity, Specificity, PPV & NPV
Case control vs. Cohort study – RR, AR, & OR
Normal Curve
Statistical tests – Where what is used?

Surgery & Orthopedics:

Trauma – Management of specific conditions
Post operative complications
GI Bleeding
Cholecystitis
C/A Colon
Pediatric Ortho – Leg Calve Perthe’s disease, Slipped capital femoral epiphysis and Nursemaid elbow

Obstetrics and Gynecology:

Triple marker test
NST & BPP interpretation
Syphilis in pregnancy
III rd Trimester bleeding – Diagnosis and Management
Abortion – Types
Preterm labor – Management
Hypertension in pregnancy – Diagnosis and Management
Fetal Heart rate monitoring and its interpretation
Forceps vs. Vacuum
Post partum Fever
C/A Cervix and Endometrium – Know diagnostic steps
Ovarian masses – Pre pubertal vs. Post pubertal – Diagnostic approach and Management
Ectopic pregnancy
Endometriosis – Diagnosis
Primary Amenorrhea – Workup
PCOD

Miscellaneous:

Orbital Cellulitis vs. Peri orbital cellulitis
Fundus pictures
CT scan of SDH ,EDH & IVH
Pictures of contact dermatitis, Meningococcemia
Pictures of Mediastinal widening.

Useful Web sites for Step 2 CK preparation:

1) USMLE world -- http://www.usmleworld.com/

2) American Academy of Family Medicine -- http://www.aafp.org/online/en/home.html

3) Obstetrics & gynecology -- Guidelines, reviews & position statements -- http://www.gfmer.ch/Guidelines/Obstetrics_gynecology_guidelines.php

4) Atlas of Dermatology -- http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/atlas.htm

5) Fundus pictures -- http://eyelearn.med.utoronto.ca/default.htm

6) Radiology tutor -- http://www.learningradiology.com/index.htm

7) Emergency Medicine -- http://www.ncemi.org/

8) ECG for Dummies -- http://www.anaesthetist.com/icu/organs/heart/ecg/

9) ECG Library -- http://www.ecglibrary.com/ecghome.html

How To Score High In USMLE STEP I Exam

2006-09-22T23:55:00.000-05:00

Hi all for the first post I have decided to re write a post which I had written for my friends who were preparing for USMLE STEP I.

After having gone through scores of posts of people who took their exam, I felt the need to share my attack plan for the exam.

This exam is unique in some aspects as compared to other exams:

1) No proper syllabus

2) Very long exam – 8 hours

3) Each Candidate gets a unique paper.

4) Results some how are inconsistent with the candidate’s past track record in academics.

Time Frame for preparation:

I prepared for 3 months studying on the average of 4 hours per day and for the last 3 weeks prior the exam date took leave and studied whole time.

Few points about my exam:

1) Most of questions were very clinical
2) They were very long
3) Pathology and anatomy were well tested
4) CT scans & electron microscopy were asked
5) There were lot of solid questions from Pediatrics (Inborn errors + genetics) & medicine.
6) Time was just enough
7) Some of the questions did test objective facts, so u need to memorize a little.

Tips from my side:

GENERAL:
1) First aid is high yield, you should master it well with the last week devoted exclusively to revising it.

2) What ever you read see the clinical implication of it and see how it can be framed as a question
3) BSS question bank and Kaplan Q bank were found to be very useful. Overall Kaplan Q bank is better.
4) Sleep well before the exam, exam is long and tiring. In case you need to go to another place to take the exam reach the place at least the previous morning.
5) Some of the questions do have a seemingly correct choice as the first choice, so read through all choices.
6) Try to finish the first 25 questions in 25 minutes OR u will run short of time.

ANATOMY:
For Anatomy the best review series is the high yield series. I particularly liked the High yield Gross Anatomy and Neuroanatomy. The high yield anatomy has an excellent foreword covering all the important topics to be read.

For embryology use Kaplan notes if available. Or just read the tables from High yield Embryology. Go through the pictures of Histology from JayDoc’s interesting web site.

Learn to read CT cross sectional cuts, I used material from the web Path website for it.

The base of skull is often tested; hence I used pictures from Keith L Moore Text book of anatomy.

PHYSIOLOGY:
Kaplan notes are a good source of review if available. If not use BRS physiology. The MCQ’s at each chapter end in this book are high yield.

CNS from this book is high yield.

MICROBIOLOGY:
Kaplan notes + tables & MCQ’s from Medical Microbiology & Immunology Examination and Board Review by Warren Levinson & Ernest Jawetz.

Immunoglobulin structure is high yield so read it well.

PATHOLOGY:
Goljan review of pathology is a very good book for review. First aid too has a decent review of pathology.

Learn all the standard pictures from Web Path. By standard I mean go through pictures of conditions you learnt in your text book.

BEHAVIORAL SCIENCE:
Every IMG'S nightmare can be best tackled by reading BRS Behavioral science well. Try to do as many questions as possible on this subject. Doctor patient relationship is highly tested.

For the AMG the High Yield Behavioral science may be enough.

PHARMACOLOGY:
Kaplan notes + plenty of questions, supplement your knowledge from any book on topics which u do not know. Try to understand all the concepts in pharmacodynamics / kinetics.

If you do not have Kaplan read First Aid and for reference use a book like K D Tripathi.

BIOCHEMISTRY:
First AID review is enough. Concentrate on all inborn errors of metabolism and enzyme kinetics from any book you are comfortable with. Moreover Biochemistry is low yield.

I found the questions on this web site very useful especially if you have time -- USUHS Medical Biochemistry Exams.

Another useful web site is by a professor from India -- Dr. Kusum K. Nagda, Ph.D.

This web site even has a weekly quiz based on USMLE model questions.

NetBiochem Topics: http://www-medlib.med.utah.edu/NetBiochem/titles.htm

This site has all the tables of enzymes which are heavily tested on the exam.

What to revise in the end:

1) First aid
2) Physiology, Pharmacology and Enzymes from Biochemistry. These are the most volatile high yield stuff for step 1 exam.
3) Selected pictures from Web Path i.e. those topics which are discussed, liver is high yield, DO NOT TRY TO SEE FULL WEB PATH
4) Do USMLE CDS at least once though it is not at all like the real exam
5)Relax & pray to God that your exam goes well.

Some useful Web sites for Step 1 preparation:

1) Microbiology and Immunology On-line from university of South Carolina: http://pathmicro.med.sc.edu/book/welcome.htm

2) Histology-World: http://www.histology-world.com/

3) Online Pharmacology exam from Kansas medical center: http://www.kumc.edu/research/medicine/pharmacology/CAI/menue.htm

4) Atlas of Histology from University of Illinois: http://www.med.uiuc.edu/histo/large/atlas/slides.htm
I like the section on electron microscopes.

5) Jay Doc Histoweb: http://www.kumc.edu/instruction/medicine/anatomy/histoweb/index.htm

6) Whole Brain atlas from Harvard: http://www.med.harvard.edu/AANLIB/home.html
I used it to study cross sectional anatomy.

7) Neuroanatomy from University of Utah: http://library.med.utah.edu/kw/animations/hyperbrain/pathways/
An excellent source to review and test your concepts in this topic.

8) WebPath from Florida State University College of Medicine: http://medlib.med.utah.edu/WebPath/webpath.html

9) Urbana Atlas of Pathology: http://www.med.uiuc.edu/PathAtlasf/titlepage.html

10) Genetics case studies: http://bob.usuhs.mil/biochem/problems/gencase/

11) NetBiochem Topics: http://www-medlib.med.utah.edu/NetBiochem/titles.htm
This site has all the tables of enzymes which are heavily tested on the exam.

12) Eukaryotic Gene Expression Problem Set: http://www.biology.arizona.edu/molecular_bio/problem_sets/mol_genetics_of_eukaryotes/eukaryotes.html Good MCQ’s worth going through.

13) An online text book of Biochemistry: http://web.indstate.edu/thcme/mwking/home.html

14) USUHS Medical Biochemistry Exams: http://bob.usuf2.usuhs.mil/biochem/exams/exams.html

15) Nagda’s Biochemistry Study Centre: http://home.123india.com/nbsc/index.htm

16) NBME Step 1 self assessment site: http://www.nbme.org/programs/sas/sas.asp
They only give a feed back but do not even tell whether our answers were correct or not.

17) Kaplan medical: http://www.kaptest.com/Kaplan/2/Medical_Licensing

18) Prep4usmle – a forum for clearing all your doubts: http://www.prep4usmle.com/