Now in full color, this powerful study guide provides valuable experience in working through the patient cases you will be presented on exam day. Our active learning questions reinforce must-know concepts with hundreds of high-yield clinical images and illustrations. Chapters are keyed to Dr. With an easy-to-follow bulleted presentation of must-know diseases and disorders, this one-of-a-kind study companion offers the most current overview of all core areas on the boards. This high-yield review delivers a thorough exam preparation guide for the USMLE Step 2 CS, offering a solid review of frequently test CS cases, along with proven study and exam strategies for clinical encounters.
Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include:. Examples of suboptimal management of this case would include delay in diagnosis or treatment, or treatment with NSAIDS or corticosteroids alone. Treatment with salicylates would also be considered suboptimal management in this case. Although they would temporarily relieve pain when administered in high doses, there are other agents with fewer adverse effects that would be better treatment options.
Examples of poor management would include failure to order any physical examination or failure to treat rheumatoid arthritis. With the availability of effective treatment for rheumatoid arthritis and concerns about opioid addiction, narcotic analgesics should have a limited role in treatment. Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information include:.
While many case scenarios run for a relatively short period of simulated time, a matter of hours or days, this scenario runs for a longer period of time, weeks. This illustrates the importance of allowing sufficient time for the patient to respond to treatment and emphasizes monitoring and long-term management.
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In this case, a year-old woman comes to the emergency department because of chest pain. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows the differential. The patient is experiencing sharp, left-sided chest pain that radiates to her left jaw and to her back. The pain began abruptly 45 minutes before the patient came to the emergency department. She is now short of breath and mildly nauseated.
She has a history of hypertension for the past 5 years that is being appropriately treated with medication. There is no history of any previous episodes of chest pain either at rest or on exertion. The absence of fever, chills, cough, or pleural rub suggests that the problem is not an infectious pulmonary process. Physical examination shows hypertension and tachycardia with bounding central and peripheral pulses.
The patient is anxious, diaphoretic, and in severe distress from chest pain. In this case, the sudden onset of radiating chest pain along with the bounding pulses, widened pulse pressure, aortic murmur, and long history of hypertension are highly suggestive of the diagnosis of ascending aortic dissection.
Optimal medical therapy would include stabilizing the patient with intravenous IV medications to lower both blood pressure and heart rate. Suboptimal treatment would include other antihypertensive agents. Lastly, IV narcotic analgesic administration to alleviate pain is important. The patient's cardiovascular status should be monitored with a cardiac monitor or by ordering repeat vital signs. Some measure of oxygen saturation is also indicated.
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Once stable, some form of chest imaging that would assess for an aortic dissection including computed tomography CT of the chest with contrast, cardiac computed tomography angiography CTA with contrast, echocardiography, transesophageal echocardiography TEE , magnetic resonance imaging MRI of the chest, or cardiac MRI with gadolinium is needed. The diagnostic workup should also include blood tests for serum creatinine basic metabolic profile or complete metabolic profile to assess kidney function, electrolytes to check sodium and potassium concentrations, a complete blood count CBC to look for signs of anemia, serum creatine kinase or serum troponin I cardiac enzymes to rule out myocardial compromise, and a blood group and crossmatch.
Once the ascending aortic dissection is discovered and aortic root involvement confirmed, optimal treatment should include open heart surgery, endovascular aortic aneurysm repair EVAR , thoracotomy or cardiothoracic surgery, or general surgery consult. An optimal approach would include completing the above diagnostic and management actions as quickly as possible ie, during the first 2 hours of simulated time.
Suboptimal management of this case would include ordering additional physical examination components that would add no relevant information, administering an IV antihypertensive without a beta blocker, neglecting to order indicated blood tests, or a delay in diagnosis or treatment. It would be suboptimal to order anything unnecessary that would waste time, even if the test or procedure were not invasive or risky eg, lung scan. Examples of poor management would include failure to order any physical examination, failure to order an imaging study that would reveal the dissection, failure to administer an antihypertensive agent, or failure to order surgical intervention.
Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk include:.
In this case, a 4-year-old boy is brought to the office because of increasing shortness of breath during the past 3 days. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient has been wheezing and has a cough that has been worsening. The mother says that the wheezing seems to get worse after the patient plays outside but resolves shortly after he comes inside. When the patient was 2 years old, he was hospitalized for 1 week for similar symptoms and treated with intravenous antibiotics and oxygen. At age 18 months, the patient had pressure equalizing tubes inserted.
The patient also has a history of allergy to pollen and atopic dermatitis. Physical examination shows slight tachycardia.
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Skin examination reveals dry, scaly patches in the antecubital areas. The patient's illness, at this point, would seem most consistent with an obstructive pulmonary disease process. In this case, the increased coughing and wheezing, as well as the history of frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma. In this acute presentation, timing is important.
An optimal approach would include completing the above diagnostic and management actions as quickly as possible ie, during the first few hours of simulated time. Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:. In this case, a year-old woman is brought to the emergency department by her roommate because of lethargy, nausea, and vomiting. From the chief complaints, the differential diagnosis is broad and includes the many causes of acutely altered mental status.
However, the comprehensive history narrows the possible differential diagnoses, making uncontrolled diabetes very likely. The patient has been experiencing nausea and vomiting for the past 24 hours and has been unable to eat during that time. During the past hour, she has become drowsy and lethargic. She has a history of type 1 diabetes mellitus, for which she normally takes insulin multiple times daily. However, she has had no insulin during the past 24 hours. Many of the question banks that are available for purchase also offer a free trial or a free 'light' version.
Step 1 Question Banks Available for Purchase. Medical Schools and Health Science Libraries. Forums and 'Unofficial' Sites. These types of resources can provide useful tips for studying but should be viewed with a critical eye. The Library of the Health Sciences - Peoria does not monitor or endorse any of these resources. Lorene King, Academic Skills Specialist, has compiled this detailed listing of some of the available commercial prep programs. Surgisphere Use this link to log into our subscription to Surgisphere.
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