Official Step2CK High Yield Concepts Thread

[iBS1972]

I saw that there's an "official" thread for high yield concepts in the Step1 forum, so I think it would be a good idea to start a similar thread for Step 2CK. So, please post any important concepts that you think would be beneficial for everyone. Also, please feel free to use this thread for questions mainly about concepts. (There are many other threads that discuss resources, test experiences, Step 2CS, and advice, so please use this thread mainly for questions about content.) Enjoy!

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[aimskyhigh]

For #94 - Is she having septic arthritis?

#118 - Hypoparathyroidism can also cause hypocalcemia. I was stuck between B and D.

 

[aimskyhigh]

-Blood on medial aspect of each thigh, I was thinking there's a rupture of uterus & that's how blood got to that area. Why am I wrong?

 

[aimskyhigh]

I was between A, D, E,, but managed to get it right. Can't twin pregnancy lead to abruptio plancenta & twin tranasfusion syndrome? Ans is D.

 

[aimskyhigh]

Is the diagnosis IBS? What other meds can be used for this?

 

[Md Blast]

View attachment 220413
-Blood on medial aspect of each thigh, I was thinking there's a rupture of uterus & that's how blood got to that area. Why am I wrong?

Painless vaginal bleeding in third trimester is probably placenta previa which can also cause the fetus to be in transverse lie. The blood on her thighs is there because she is bleeding from her vagina. Uterine rupture would present with pain, palpable fetal parts, loss of fetal position(ex from 0 to -2)

 

[Md Blast]

View attachment 220412
#118 - Hypoparathyroidism can also cause hypocalcemia. I was stuck between B and D.

greasy foul smelling stool and weight loss makes you think malabsorption so you should think of the vitamins ADEK

 

[aimskyhigh]

She seems to have collection of fluid in her chest so I was thinking of throacotomy. Why would we do laprotomy?

I don't get why ans is D? What's the diagnosis here?

Why are platelet count increased? I got it right, its D.

 

[aimskyhigh]

For this question, I was thinking since pt has been vomiting for 2 days, shes likely to have compensation by decreasing HCO3 to maintain acidity in the body?
In acute vomiting <8 hours -- no compensation= decr CL ---- incr or normal HCO3, H & K--- volume loss-- incr Aldo = Na,
In chronic vomiting >8 hrs -- compensation = decr CL --- decr HCO3 --- incr in H & K, volume loss --- incr Aldo= incr Na.

A- Menstration at regular interval = able to ovulate so not A.
B- Possible -- but no mention of dyspareunia or dyschezia?
C- I don't know what that is.
D- Normal sperm count so nope.
E-Maybe due to PID?

 

[PianoMedic]

View attachment 220420
She seems to have collection of fluid in her chest so I was thinking of throacotomy. Why would we do laprotomy?


View attachment 220421
I don't get why ans is D? What's the diagnosis here?


View attachment 220422
View attachment 220423
Why are platelet count increased? I got it right, its D.

4. FWIW I got it wrong too. She ruptured her diaphragm, then we stuck a tube into her bowel. I wasn't a huge fan as lap vs thora is tough as a third year to understand, but my take is that the contents in the chest are bowel, and diaphragm repair would likely be easier from abdomen as fighting a lung that is being mechanically ventilated would be tough.

6. She has a partial small bowel obstruction, since she still has some bowel sounds. So go conservative first: IVF, NG tube to decompress, NPO. If it worsens or she goes peritoneal-->ex-lap.

9. I got this wrong, and my explanation for it isn't great. Maybe someone else can chime in? Answer is decreased gluconeogenesis. I was thinking about galactosemia or some other such nonsense. So kiddo has low bGlucose, and reducing substances in urine. Reducing substances I took as ketones. So he is taking fat and using that for energy since he has low blood glucose. If he isn't making any glucose to compensate for whatever is going on, then he'll have the low bG. So reduced gluconeogenesis. As I said, not a great explanation.

11. I always understood that platelets were an acute phase reactant, like CRP, so if they go up it can be a marker of increased inflammation. Chron's=inflammation-->elevated acute phase reactants.

108. This was a dichorio/diamnio twinning. AKA fraternal, or basically 2 sperm/2 eggs. So only increased risk factor for these kiddos is the preterm labor that happens in all twinning. They don't share placentas or amniotic sacs, so the other issues with twins don't come into play.

117. I looked in First Aid for Step 2 as I thought this was IBS and put Sertraline. FA says 1st line tx for IBS is TCAs and SSRIs. I thought it was kind of a bad question personally. However, they put an SNRI in there and generally you can't pick between SSRI/SNRI since they're usually considered equivalent, which would eliminate both of those answers-->TCA would technically be correct in this question. Not a perfect explanation but all I've got.

94. I didn't see this one when I just took it online... Looking it over, I'd guess septic arthritis since fever. It states she could finish the game when she injured it. If she broke it/tore ACL/PCL/Med Meniscus/MCL, etc, she shouldn't have been able to finish. And then she reports onset of symptoms 2 days prior to presentation with the injury a week before. This points more to septic arthritis, so tap that knee.

 

[PianoMedic]

Just saw the new questions:

15. She has been continually vomiting for 2 days. I took this as continually losing HCl for two days. In the renal tubules you then will try to hold onto as much H+ as possible, exchanging it for K+. However, you are still going to be net HCO3- up since she's still vomiting out HCl. Only one that has low Cl-, low K+, and high HCO3- is A.

16. She had a normal hysterosalpingogram which eliminates the tubal problem. Endometriosis can just be infertility and dysmenorrhea.

23. Not totally sure as this wasn't on my online form. US showed no abnormalities, so take that as gospel. Can't be leiomyoma or adenomyosis then. 1 year history, so not pregnancy. That leaves endometrial polyp, which might have been ruled out by normal US can't remember right now, or anovulation. No clue what the normals are for PRL and FSH/LH, but I'd go with anovulation.

 

[aimskyhigh]

Whats the diagnosis here?

Whats coal tar therapy for?
Is the dx atopic dermatitis?

My ddx were Kawasaki, Scarlet, or Coxsacki. ...

 

[iBS1972]

View attachment 220411
For #94 - Is she having septic arthritis?

View attachment 220412
#118 - Hypoparathyroidism can also cause hypocalcemia. I was stuck between B and D.

94: Yes, I believe she is having septic arthritis--the high temperature combined with the cardinal signs of inflammation suggests it's septic arthritis. Without the temperature though, you could also make an argument for trauma-induced etiology. I believe arthrocentesis would be best since the temperature points towards septic arthritis. In real life, xray will probably be done too.

108. This was a tough question. I think MdBlast is right in that greasy, foul-smelling stools suggest steatorrhea and malabsorption of fat-soluble ADEK vitamins. However, I do remember getting questions had similar presentation with hypocalcemic symptoms due to hypomagnesia in setting of chronic alcoholism. This is actually an important topic. So it would be great if you could look into this and kind of make a post about it or tell us what the answers say why it's not hypomagnesemia.

 

[iBS1972]

View attachment 220413
-Blood on medial aspect of each thigh, I was thinking there's a rupture of uterus & that's how blood got to that area. Why am I wrong?

Rupture of uterus is good thinking, but as MdBlast suggested, it would cause pain and tenderness (along with the loss of fetal station). The three things that cause painful bleeding in pregnancy are: ectopic bleeding, uterine rupture, abruptio placentea. Given that question mentioned no pain or tenderness, it's most likely placenta previa, one of the most common causes of painless vaginal bleeding in pregnant women. Amniotic fluid embolism would cause hemodynamic instability as well as some sort of preceding event (ex. injury, abruptio placentae, retention of uterine products). Vasa previa rupture would cause hemodynamic instability in fetus with sinusoidal waveform of fetal heart tracings.

 

[iBS1972]

4. FWIW I got it wrong too. She ruptured her diaphragm, then we stuck a tube into her bowel. I wasn't a huge fan as lap vs thora is tough as a third year to understand, but my take is that the contents in the chest are bowel, and diaphragm repair would likely be easier from abdomen as fighting a lung that is being mechanically ventilated would be tough.

6. She has a partial small bowel obstruction, since she still has some bowel sounds. So go conservative first: IVF, NG tube to decompress, NPO. If it worsens or she goes peritoneal-->ex-lap.

9. I got this wrong, and my explanation for it isn't great. Maybe someone else can chime in? Answer is decreased gluconeogenesis. I was thinking about galactosemia or some other such nonsense. So kiddo has low bGlucose, and reducing substances in urine. Reducing substances I took as ketones. So he is taking fat and using that for energy since he has low blood glucose. If he isn't making any glucose to compensate for whatever is going on, then he'll have the low bG. So reduced gluconeogenesis. As I said, not a great explanation.

11. I always understood that platelets were an acute phase reactant, like CRP, so if they go up it can be a marker of increased inflammation. Chron's=inflammation-->elevated acute phase reactants.

108. This was a dichorio/diamnio twinning. AKA fraternal, or basically 2 sperm/2 eggs. So only increased risk factor for these kiddos is the preterm labor that happens in all twinning. They don't share placentas or amniotic sacs, so the other issues with twins don't come into play.

117. I looked in First Aid for Step 2 as I thought this was IBS and put Sertraline. FA says 1st line tx for IBS is TCAs and SSRIs. I thought it was kind of a bad question personally. However, they put an SNRI in there and generally you can't pick between SSRI/SNRI since they're usually considered equivalent, which would eliminate both of those answers-->TCA would technically be correct in this question. Not a perfect explanation but all I've got.

94. I didn't see this one when I just took it online... Looking it over, I'd guess septic arthritis since fever. It states she could finish the game when she injured it. If she broke it/tore ACL/PCL/Med Meniscus/MCL, etc, she shouldn't have been able to finish. And then she reports onset of symptoms 2 days prior to presentation with the injury a week before. This points more to septic arthritis, so tap that knee.

108. twin-twin transfusion is only in monochorionic diamnoitic gestation.

117. resolution of symptoms after bowel movement suggests IBS (along with absence of other symptoms). I learned that TCAs are 1st line too, over SSRIs/SNRIs which is surprising because of their much greater side-effect profile, though I think the dosing is less than that used for depression. Also, if you're given scenarios of depression/PTSD/panic... SSRIs is first line, not SNRIs (even though as PianoMedic has stated that they are generally considered equilvant, but for testing purposes, SSRIs are considered better).

4. She's respiratory and hemodynamically unstable, so emergent surgery is warranted (ie. ex-lap). send her to OR immediately.
She has diaphragmatic herniation of bowel, compressing her heart, giving a cardiac tamponade-like picture (hypotension, tachycardia). chest tube into bowel gave bilious fluid.

6. SBO given XRay showing valvulae conniventes suggesting small bowel (vs. haustra which is large bowel). PianoMedic recs are appropriate. NG tube to decompress and remove remaining gastric contents, allowing bowel rest.
Note, SBOs often resolve by themselves so immediate/urgent surgery not recommended (vs. large bowel obstruction). Bowel sounds are not really that reliable. Hyperactive suggests obstruction, though late obstruction would result in hypoactive. Hypoactive on exams usually suggest ileus. Determine diagnosis by combining clinical presentation with exam findings.

9. PianoMedic gives good explanation.

11. I think PianoMedic is right. Though, it is surprising that it can rise that much.

 

[aimskyhigh]

I was stuck between B and E.

Diffusely exfoliating skin + oral mucousa involved after drug treatment, I was thinking of Pemphigus Vulgaris so I chose C. Ans is E. They didn't mention any skin sloughing or targetoid skin lesions
so I didn't go for TEN.

 

[iBS1972]

View attachment 220438
I was stuck between B and E.

View attachment 220455

Diffusely exfoliating skin + oral mucousa involved after drug treatment, I was thinking of Pemphigus Vulgaris so I chose C. Ans is E. They didn't mention any skin sloughing or targetoid skin lesions
so I didn't go for TEN.

28. I would go with E. MM is good thinking, but you really should see CRAB in exam questions. I don't think MM causes leukocytosis, as it is a problem of clonal immunoglobulins rather than leukocytes . Furthermore, I don't think you get fevers with MM either.

40. SJS/TEN is one of the side-effects of allopurinol. It is rare, but serious. That is just a fact you need to know. Whenever a problem presents with someone who just took a medication, always think about the medication as the potential cause.

 

[PianoMedic]

28. I would go with E. MM is good thinking, but you really should see CRAB in exam questions. I don't think MM causes leukocytosis, as it is a problem of clonal immunoglobulins rather than leukocytes . Furthermore, I don't think you get fevers with MM either.

40. SJS/TEN is one of the side-effects of allopurinol. It is rare, but serious. That is just a fact you need to know. Whenever a problem presents with someone who just took a medication, always think about the medication as the potential cause.

40. Question mentioned diffuse exfoliation of skin and serous fluid loss. Sounds very classic for SJS/TEN to me, especially with recent med history and mucosa involvement.

28. So this guy does have MM if memory serves. What they were getting at is MM is a plasma cell disorder, making gobs of one immunoglobulin. This means that they are functionally immunodeficient. 80,000,000 copies of IgG against last year's influenza virus isn't going to help against strep pneumo. And the bad plasma cancer cells are crowding out the other ones so they can't work right. So he has gotten a ton of infections in the last year. He is still able to mount a neutrophil response, appropriate for a bacterial infection, but not as effective as it could be. Add in lyric bone lesions and I like MM here.

Sent from my SM-P600 using Tapatalk

 

[aimskyhigh]

Painless vaginal bleeding in third trimester is probably placenta previa which can also cause the fetus to be in transverse lie. The blood on her thighs is there because she is bleeding from her vagina. Uterine rupture would present with pain, palpable fetal parts, loss of fetal position(ex from 0 to -2)

Oh man... I misunderstood, I thought the question was saying that blood was inside her thigh- internal bleeding, but that's just blood on her thigh from bleeding. Thank you for clearing things up.

 

[aimskyhigh]

4. FWIW I got it wrong too. She ruptured her diaphragm, then we stuck a tube into her bowel. I wasn't a huge fan as lap vs thora is tough as a third year to understand, but my take is that the contents in the chest are bowel, and diaphragm repair would likely be easier from abdomen as fighting a lung that is being mechanically ventilated would be tough.

6. She has a partial small bowel obstruction, since she still has some bowel sounds. So go conservative first: IVF, NG tube to decompress, NPO. If it worsens or she goes peritoneal-->ex-lap.

9. I got this wrong, and my explanation for it isn't great. Maybe someone else can chime in? Answer is decreased gluconeogenesis. I was thinking about galactosemia or some other such nonsense. So kiddo has low bGlucose, and reducing substances in urine. Reducing substances I took as ketones. So he is taking fat and using that for energy since he has low blood glucose. If he isn't making any glucose to compensate for whatever is going on, then he'll have the low bG. So reduced gluconeogenesis. As I said, not a great explanation.

11. I always understood that platelets were an acute phase reactant, like CRP, so if they go up it can be a marker of increased inflammation. Chron's=inflammation-->elevated acute phase reactants.

108. This was a dichorio/diamnio twinning. AKA fraternal, or basically 2 sperm/2 eggs. So only increased risk factor for these kiddos is the preterm labor that happens in all twinning. They don't share placentas or amniotic sacs, so the other issues with twins don't come into play.

117. I looked in First Aid for Step 2 as I thought this was IBS and put Sertraline. FA says 1st line tx for IBS is TCAs and SSRIs. I thought it was kind of a bad question personally. However, they put an SNRI in there and generally you can't pick between SSRI/SNRI since they're usually considered equivalent, which would eliminate both of those answers-->TCA would technically be correct in this question. Not a perfect explanation but all I've got.

94. I didn't see this one when I just took it online... Looking it over, I'd guess septic arthritis since fever. It states she could finish the game when she injured it. If she broke it/tore ACL/PCL/Med Meniscus/MCL, etc, she shouldn't have been able to finish. And then she reports onset of symptoms 2 days prior to presentation with the injury a week before. This points more to septic arthritis, so tap that knee.

Thank you!

For #117- Found good info:

IBS Rx: Irritable Bowel Syndrome - STEP2/3 Gastrointestinal - Step 2 & 3 - Medbullets.com

Treatment

• Psychiatric
  • patients need assurance from their physicians
• Place on a high fiber, low fat diet
• Antidiarrheal (loperamide) medications and antispasmodics
• TCA's (amitriptyline) - reserved as ultimate therapy

 

[aimskyhigh]

Just saw the new questions:

15. She has been continually vomiting for 2 days. I took this as continually losing HCl for two days. In the renal tubules you then will try to hold onto as much H+ as possible, exchanging it for K+. However, you are still going to be net HCO3- up since she's still vomiting out HCl. Only one that has low Cl-, low K+, and high HCO3- is A.

16. She had a normal hysterosalpingogram which eliminates the tubal problem. Endometriosis can just be infertility and dysmenorrhea.

23. Not totally sure as this wasn't on my online form. US showed no abnormalities, so take that as gospel. Can't be leiomyoma or adenomyosis then. 1 year history, so not pregnancy. That leaves endometrial polyp, which might have been ruled out by normal US can't remember right now, or anovulation. No clue what the normals are for PRL and FSH/LH, but I'd go with anovulation.

For #15- I didn't know HCO3 would still be up with continuous vomiting, I thought body would try to maintain the whole situation by decreasing it. This stuff always confuses me....

 

[aimskyhigh]

Whats the diagnosis here?


View attachment 220431
View attachment 220432

Whats coal tar therapy for?
Is the dx atopic dermatitis?


View attachment 220433
View attachment 220437
My ddx were Kawasaki, Scarlet, or Coxsacki. ...

Thank you guys for helping me with the explanations! NBMEs, CMS, and FRED questions take up so much time looking for answer, wish they would just provide the explanation.

Need help with #19, 20,21,& 24 ... please. Thank you!

 

[aimskyhigh]

https://forums.studentdoctor.net/attachments/upload_2017-6-19_20-57-38-png.220391/

For #63, should we always get some organization to handle organ transplant even if there's time limitation?

For #70, why would immersing the patient in ice water be bad?
https://forums.studentdoctor.net/attachments/upload_2017-6-19_21-8-54-png.220392/

 

[iBS1972]

For #15- I didn't know HCO3 would still be up with continuous vomiting, I thought body would try to maintain the whole situation by decreasing it. This stuff always confuses me....

Yeah, this is tricky. I think when questions ask you metabolic disturbances, it is better to assume that it's the acute phase unless otherwise stated.
Important metabolic disturbances:
Vomiting: Hypokalemic, hypochloremic, metabolic alkalosis
Diarrhea: Non-anion gap metabolic acidosis (also hypokalemic I believe)

 

[aimskyhigh]

Question from another forum, what's the dx here?

A 72-year-old woman comes to the emergency department because of a 1-day history of fever, chills, and cough. She had pneumococcal pneumonia 1 year ago. Her temperature is 39°C (102.2°F). Examination shows bronchial breath sounds at the right lung base with increased dullness and egophony. Her leukocyte count is 87,000/mm3 (15% segmented neutrophils, 82% lymphocytes, and 3% monocytes). A Gram stain of sputum shows gram-positive, lancet-shaped diplococci. Which of the following is most likely to confirm this patient's deficit in host defenses?

A) Assessment of segmented neutrophil function
B) Measurement of CD4+ T*lymphocyte count
C) Measurement of serum IgE concentration
D) Measurement of T*lymphocyte count
E) Quantitative immunoglobulin assay

 

[PianoMedic]

Sorry @aimskyhigh. Will try to get to them tomorrow. Took it today and my brain is toast.

 

[swk11]

Question from another forum, what's the dx here?

A 72-year-old woman comes to the emergency department because of a 1-day history of fever, chills, and cough. She had pneumococcal pneumonia 1 year ago. Her temperature is 39°C (102.2°F). Examination shows bronchial breath sounds at the right lung base with increased dullness and egophony. Her leukocyte count is 87,000/mm3 (15% segmented neutrophils, 82% lymphocytes, and 3% monocytes). A Gram stain of sputum shows gram-positive, lancet-shaped diplococci. Which of the following is most likely to confirm this patient's deficit in host defenses?

A) Assessment of segmented neutrophil function
B) Measurement of CD4+ T*lymphocyte count
C) Measurement of serum IgE concentration
D) Measurement of T*lymphocyte count
E) Quantitative immunoglobulin assay

So this is a lady with recurrent pneumococcal pneumonia and lymphocytosis. So you have to know what the primary defense against this type of infection is. Encapsulated organisms are taken out with IgG. Therefore, the answer should be E, regardless if what her underlying diagnosis is.

A) she would be infected with regular old non-encapsulated bacteria, presumably with diff high in segmented neutrophils.
B) she would be infected with fungi or viruses or opportunistic bugs
C) she would have APBA, allergies, or parasitic infection
D) similar to B

Hope that makes sense!

Sent from my XT1585 using SDN mobile

 

[aimskyhigh]

So this is a lady with recurrent pneumococcal pneumonia and lymphocytosis. So you have to know what the primary defense against this type of infection is. Encapsulated organisms are taken out with IgG. Therefore, the answer should be E, regardless if what her underlying diagnosis is.

A) she would be infected with regular old non-encapsulated bacteria, presumably with diff high in segmented neutrophils.
B) she would be infected with fungi or viruses or opportunistic bugs
C) she would have APBA, allergies, or parasitic infection
D) similar to B

Hope that makes sense!

Sent from my XT1585 using SDN mobile

Yes, that makes sense. Thank you!