USMLE Step 2 Review

GASTROENTEROLOGY

 * Hematemesis severe bleeding features : CaN Have Severe Hematemsis

Clot in vomitus

Nasogratic tube blood

Hypotension and tachycardia

Systolic BP drop > 10 mm HG, PP rise > 20 Beats/minute when changing posture from standing to sitting -- orthostatic hypotension

Hematochezia

Definition of a severe attack. A STATE: Anemia less than 10g/dl. Stool frequency greater than 6 stools/day with blood. Temperature greater than 37.5. Albumin less than 30g/L. Tachycardia greater than 90bpm. ESR greater than 30mm/hr.
 * Ulcerative colitis:

Extra GI differential diagnosis : V.O.M.I.T.I.N.G:  Vestibular disturbance/ Vagal (reflex pain).  Opiates Migrane. Metabolic (DKA, gastroparesis, hypercalcemia).  Infections.  Toxicity (cytotoxic, digitalis toxicity).  Increased ICP. Ingested alcohol Neurogenic. psychogenic Gestation By: Anil Pandit (Manipal College of Medical Sciences; Pokhara, Nepal)
 * Vomiting:

causes '''I G.E.T.. S.M.A.S.H.E.D''': Irradiation (x-rays). Gallstones. Ethanol. Trauma.
 * Pancreatitis (acute):

Steroids Mumps Autoimmune (PAN) Scorpion stings Hyperlipidemia./Hypercalcemia ERCP Drugs (including azathioprine and diuretics). • Note: 'Get Smashed' is slang in some countries for drinking, and ethanol is an important pancreatitis cause.

surgical indications I ..C.H.O.P 
 * IBD: 

Infection Carcinoma Haemorrhage Obstruction Perforation • "Chop" convenient since surgery chops them open.

extraintestinal manifestations A PIE SAC: Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing of fingertips
 * Hereditary Nonpolyposis Colorectal Cancer (HNPCC) cause is DNA mismatch repair DNA mismatch causes a bubble in the strand where the two nucleotides don't match. This looks like the ensuing polyps that arise in the colon.
 * IBD:

pH level-With vomiting both the pH and food come up. With diarrhea both the pH and food go down.
 * Digestive disorders:

" Please Make Tummy Better ": Proton pump inhibitor Metronidazole Tetracycline Bismuth Alternatively : TOMB: Tetracycline Omeprazole Metronidazole Bismuth
 *  H. Pylori treatment regimen (rough guidelines): 

common causes for increased levels HOT Liver: Hemolysis Obstruction Tumor Liver disease
 * Bilirubin:

complications PAST Colitis: Pyoderma gangrenosum Ankylosing spondylitis Sclerosing pericholangitis Toxic megacolon Colon carcinoma
 * Ulcerative colitis:

Charcot's triad/ Conjugated bilirubin increase Hepatic abscesses/ Hepatic (intra/extra) bile ducts/ HLA B8, DR3 Obstruction Leukocytosis Alkaline phosphatase increase Neoplasms Gallstones Inflammatory bowel disease (ulcerative colitis) Transaminase increase Infection Sclerosing
 * Cholangitis features CHOLANGITITS:

FEE : Fever, Epigastric & RUQ pain, Emesis & nausea
 * Charcot's triad (gallstones)

" HaemoChromatosis Can Cause Deposits Anywhere ": Hypogonadism, Cancer (hepatocellular), Cirrhosis/Cardiomyopathy, Diabetes mellitus, Arthropathy.
 *  Haemachromatosis complications 

criteria PANCREAS : PaO2 below 8, Age >55, Neutrophils: WCC >15, Calcium below 2, Renal: Urea >16, Enzymes: LDH >600; AST >200 Albumin below 32, Sugar: Glucose >10 (unless diabetic patient)
 * Pancreatitis: 

Ranson criteria for pancreatitis : At admission "GA LAW" (GA is abbreviation for the U.S. state of Georgia): Glucose >200, AST >250, LDH >350, Age >55 y.o., WBC >16000
 * Pancreatitis:

Ranson criteria for pancreatitis : initial 48 hours "C & HOBBS" (Calvin and Hobbes): Calcium < 8, Hct drop > 10% , Oxygen < 60 mm , BUN > 5 , Base deficit > 4 , Sequestration of fluid > 6L
 * Pancreatitis:

Ranson criteria for pancreatitis at admission LEGAL: Leukocytes > 16.000, Enzyme AST > 250, Glucose > 200, Age > 55, LDH > 350
 * Pancreatitis:

Bleeding
 * GIT symptoms: BAD ANAL S#H!T

Abdominal pain

Dysphagia

AAbdominal bloating

NNausea & vomiting

AAnorexia/ Appetite changes

LLethargy

SS#!ts(diarrhea)

#Heartburn

Increased bilirubin (jaundice)

Temperature (fever)


 * Crohn's disease: morphology and symptoms : CHRISTMAS

Cobblestones (Radiology appearance)

High temperature

Reduced lumen

Intestinal fistulae,Infliximab

Skip lesions

Transmural (all layers, may ulcerate)

Malabsorption

Abdominal pain

Submucosal fibrosis

Correction needed
Dysphagia: differential DISPHAGIA: Disease of mouth and tonsils/ Diffuse oesophageal spasm/ Diabetes mellitus Intrinsic lesion Scleroderma Pharyngeal disorders/ Palsy-bulbar-MND Achalasia Heart: eft atrium enlargement Goitre/ myesthenia Gravis/ mediastinal Glands Infections American trypanosomiasis (chagas disease)

Dry mouth: differential "DRI": •2 of each: Drugs/ Dehydration Renal failure/ Radiotherapy Immunological (Sjogren's)/ Intense emotions ---Anil Pandit Manipal College of Medical Sciences, Pokhara, Nepal//

Liver failure: decompensating chronic liver failure differential HEPATICUS: Haemorrhage Electrolyte disturbance Protein load/ Paracetamol Alcohol binge Trauma Infection Constipation Uraemia Sedatives/ Shunt/ Surgery ---Jude McSharry University College Hospital Galway//

Cirrhosis: causes of hepatic cirrhosis HEPATIC: Hemochromatosis (primary) Enzyme deficiency (alpha-1-anti-trypsin) Post hepatic (infection + drug induced) Alcoholic Tyrosinosis Indian childhood (galactosemia) Cardiac/ Cholestatic (biliary)/ Cancer/ Copper (Wilson's) ---Dr. Chetan Wasekar//

Hepatic encephalopathy: precipitating factors HEPATICS: Hemorrhage in GIT/ Hypokalemia Excess protein in diet Paracentesis Alkalosis/ Anemia Trauma Infection Colon surgery Sedatives ---Dr. Chetan Wasekar//

Diabetic ketoacidosis: precipitating factors • 5 I's: Infection Ischaemia (cardiac, mesenteric) Infarction Ignorance (poor control) Intoxication (alcohol) ---James Thomas//

Whipple's disease: clinical manifestations SHELDA: Serositis Hyperpigmentation of skin Eating less (weight loss) Lymphadenopathy Diarrhea Arthritis ---Pedro Tulio Universidade Federal do Rio de Janeiro, Brazil//

Celiac sprue gluten sensitive enteropathy: gluten-containing grains BROW: Barley Rye Oats Wheat • Flattened intestinal villi of celiac sprue are smooth, like an eyebrow. ---Jack A. Pasquale, MD St. George's University, School of Medicine//

Liver failure (chronic): signs found on the arms CLAPS: Clubbing Leukonychia Asterixis Palmar erythema Scratch marks//

Splenomegaly: causes CHIMP: Cysts Haematological ( eg CML, myelofibrosis) Infective (eg viral (IM), bacterial) Metabolic/ Misc (eg amyloid, Gauchers) Portal hypertension

-GI- Vomiting: extra GI differential VOMITING: Vestibular disturbance/ Vagal (reflex pain) Opiates Migrane/ Metabolic (DKA, gastroparesis, hypercalcemia) Infections Toxicity (cytotoxic, digitalis toxicity) Increased ICP, Ingested alcohol Neurogenic, psychogenic Gestation

Whipple's disease: clinical manifestations SHELDA: Serositis Hyperpigmentation of skin Eating less (weight loss) Lymphadenopathy Diarrhea Arthritis

Haemachromatosis complications "HaemoChromatosis Can Cause Deposits Anywhere": Hypogonadism Cancer (hepatocellular) Cirrhosis Cardiomyopathy Diabetes mellitus Arthropathy

Pancreatitis: criteria PANCREAS: PaO2 below 8 Age >55 Neutrophils: WCC >15 Calcium below 2 Renal: Urea >16 Enzymes: LDH >600; AST >200 Albumin below 32 Sugar: Glucose >10 (unless diabetic patient)

Cholangitis features CHOLANGITITS: Charcot's triad/ Conjugated bilirubin increase Hepatic abscesses/ Hepatic (intra/extra) bile ducts/ HLA B8, DR3 Obstruction Leukocytosis Alkaline phosphatase increase Neoplasms Gallstones Inflammatory bowel disease (ulcerative colitis) Transaminase increase Infection Sclerosing

IBD: extraintestinal manifestations A PIE SAC: Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing of fingertips

Digestive disorders: pH level With vomiting both the pH and food come up. With diarrhea both the pH and food go down.

Bilirubin: common causes for increased levels "HOT Liver": Hemolysis Obstruction Tumor Liver disease

IBD: surgery indications "I CHOP": Infection Carcinoma Haemorrhage Obstruction Perforation • "Chop" convenient since surgery chops them open.

H. Pylori treatment regimen (rough guidelines) "Please Make Tummy Better": Proton pump inhibitor Metronidazole Tetracycline Bismuth • Alternatively: TOMB: Tetracycline Omeprazole Metronidazole Bismuth

Hereditary Nonpolyposis Colorectal Cancer (HNPCC) cause is DNA mismatch repair DNA mismatch causes a bubble in the strand where the two nucleotides don't match. This looks like the ensuing polyps that arise in the colon. • See diagram.

Charcot's triad (gallstones) "Charcot's Triad is 3 C's": Color change (jaundice) Colic (biliary) pain, aka RUQ pain Chills and fever

Charcot's triad (gallstones) "Charge a FEE": Charcot's triad is: Fever Epigastric & RUQ pain Emesis & nausea

Ulcerative colitis: complications "PAST Colitis": Pyoderma gangrenosum Ankylosing spondylitis Sclerosing pericholangitis Toxic megacolon Colon carcinoma

Crohn's disease: morphology, symptoms CHRISTMAS: Cobblestones High temperature Reduced lumen Intestinal fistulae Skip lesions Transmural (all layers, may ulcerate) Malabsorption Abdominal pain Submucosal fibrosis Show Details / Rate It  ---Samuel Atom Baek-Kim

Celiac sprue gluten sensitive enteropathy: gluten-containing grains BROW: Barley Rye Oats Wheat • Flattened intestinal villi of celiac sprue are smooth, like an eyebrow. Show Details / Rate It  ---Jack A. Pasquale, MD St. George's University, School of Medicine

Diabetic ketoacidosis: precipitating factors • 5 I's: Infection Ischaemia (cardiac, mesenteric) Infarction Ignorance (poor control) Intoxication (alcohol) Show Details / Rate It  ---James Thomas

Liver failure (chronic): signs found on the arms CLAPS: Clubbing Leukonychia Asterixis Palmar erythema Scratch marks Show Details / Rate It  ---Jason

Pancreatitis: Ranson criteria for pancreatitis: at admission "GA LAW" (GA is abbreviation for the U.S. state of Georgia): Glucose >200 AST >250 LDH >350 Age >55 y.o. WBC >16000 Show Details / Rate It  ---Anonymous Contributor

Pancreatitis: Ranson criteria for pancreatitis: initial 48 hours "C & HOBBS" (Calvin and Hobbes): Calcium < 8 Hct drop > 10% Oxygen < 60 mm BUN > 5 Base deficit > 4 Sequestration of fluid > 6L Show Details / Rate It  ---Anonymous Contributor

Hepatic encephalopathy: precipitating factors HEPATICS: Hemorrhage in GIT/ Hyperkalemia Excess protein in diet Paracentesis Acidosis/ Anemia Trauma Infection Colon surgery Sedatives Show Details / Rate It  ---Dr. Chetan Wasekar

Cirrhosis: causes of hepatic cirrhosis HEPATIC: Hemochromatosis (primary) Enzyme deficiency (alpha-1-anti-trypsin) Post hepatic (infection + drug induced) Alcoholic Tyrosinosis Indian childhood (galactosemia) Cardiac/ Cholestatic (biliary)/ Cancer/ Copper (Wilson's)

Pediatrics
Measles: complications "MEASLES COMP" (complications): Myocarditis Encephalitis Appendicitis Subacute sclerosing panencephalitis Laryngitis Early death Sh!ts (diarrhoea) Corneal ulcer Otis media Mesenteric lymphadenitis Pneumonia and related (bronchiolitis-bronchitis-croup)

Sturge-Weber syndrome: hallmark features Sturge-Weber: 1. Seizures 2. PortWine stain

Guthrie card: diseases identified with it "Guthrie Cards Can Help Predict Bad Metabolism": Galactosaemia Cystic fibrosis Congenital adrenal hyperplasia Hypothyroidism Phenylketonuria Biotidinase deficiency Maple syrup urine disease

Croup: symptoms 3 S's: Stridor Subglottic swelling Seal-bark cough

Ataxia-Telangiectasia (AT): common sign AT: Absent Thymus

Cerebral palsy (CP): most likely cause CP: Cerebral Palsy Child Premature • The premature brain is more prone to all the possible insults.

Vacterl syndrome: components VACTERL: Vertebral anomalies Anorectal malformation Cardiac anomaly Tracheo-esophageal fistula Exomphalos (aka omphalocele) Renal anomalies Limb anomalies

Guthrie card: diseases identified with it GUTHRIE: Galactosaemia Urine [maple syrup urine disease] THyRoid [hypothyroidism] Inborn Errors of metabolism [eg: PKU]

Duodenal atresia vs. Pyloric stenosis: site of obstruction Duodenal Atresia: Distal to Ampulla of vater. Pyloric stenosis: Proximal to it.

Bilirubin: phototherapy BiLirUbin absorbs light maximally in the BLUe range.

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Williams syndrome: features WILLIAMS: Weight (low at birth, slow to gain) Iris (stellate iris) Long philtrum Large mouth Increased Ca++ Aortic stenosis (and other stenoses) Mental retardation Swelling around eyes (periorbital puffiness)

Russell Silver syndrome: features ABCDEF: Asymmetric limb (hemihypertrophy) Bossing (frontal) Clinodactyly/ Cafe au lait spots Dwarf (short stature) Excretion (GU malformation) Face (triangular face, micrognathia)

Dentition: eruption times of permanent dentition "Mama Is In Pain, Papa Can Make Medicine": 1st Molar: 6 years 1st Incisor: 7 years 2nd Incisor: 8 years 1st Premolar: 9 years 2nd Premolar: 10 years Canine: 11 years 2nd Molar: 12 years 3rd Molar: 18-25 years

Cyanotic heart diseases: 5 types • Use your five fingers: 1 finger up: Truncus Arteriosus (1 vessel) 2 fingers up: Dextroposition of the Great Arteries (2 vessels transposed) 3 fingers up: Tricuspid Atresia (3=Tri) 4 fingers up: Tetralogy of Fallot (4=Tetra) 5 fingers up: Total Anomalous Pulmonary Venous Return (5=5 words)

Cyanotic congenital heart diseases 5 T's: Truncus arteriosus Transposition of the great arteries Tricuspid atresia Tetrology of Fallot Total anomalous pulmonary venous return

Head circumference with age • Remember 3, 9, and multiples of 5: Newborn 35 cm 3 mos 40 cm 9 mos 45 cm 3 yrs 50 cm 9 yrs 55 cm

Weights of children with age Newborn 3 kg 6 mos 6 kg (2x birth wt at 6 mos) 1 yr 10 kg (3x birth wt at 1 yr) 3 yrs 15 kg (odd yrs, add 5 kg until 11 yrs) 5 yrs 20 kg 7 yrs 25 kg 9 yrs 30 kg 11 yrs 35 kg (add 10 kg thereafter) 13 yrs 45 kg 15 yrs 55 kg 17 yrs 65 kg

Hemolytic-Uremic Syndrome (HUS): components

"Remember to decrease the RATE of IV fluids in these patients":

Renal failure Anemia (microangiopathic, hemolytic) Thrombocytopenia Encephalopathy (TTP)

Cough (chronic): differential When cough in nursery, rock the "CRADLE": Cystic fibrosis Rings, slings, and airway things (tracheal rings)/ Respiratory infections Aspiration (swallowing dysfunction, TE fistula, gastroesphageal reflux) Dyskinetic cilia Lung, airway, and vascular malformations (tracheomalacia, vocal cord dysfunction) Edema (heart failure)

Cystic fibrosis: presenting signs CF PANCREAS: Chronic cough and wheezing Failure to thrive Pancreatic insufficiency (symptoms of malabsorption like steatorrhea) Alkalosis and hypotonic dehydration Neonatal intestinal obstruction (meconium ileus)/ Nasal polyps Clubbing of fingers/ Chest radiograph with characteristic changes Rectal prolapse Electrolyte elevation in sweat, salty skin Absence or congenital atresia of vas deferens Sputum with Staph or Pseudomonas (mucoid)

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Cystic fibrosis: exacerbation of pulmonary infection CF PANCREAS: Cough (increase in intensity and frequent spells) Fever (usually low grade, unless severe bronchopneumonia is present) Pulmonary function deterioration Appetite decrease Nutrition, weight loss CBC (leukocytosis with left shift) Radiograph (increase overaeration, peribronchial thickening, mucus plugging) Exam (rales or wheezing in previously clear areas, tachypnea, retractions) Activity (decreased, impaired exercise intolerance, increased absenteeism) Sputum (becomes darker, thicker, and more abundant, forming plugs)

Pyloric stenosis (congential): presentation Pyloric stenosis is 3 P's: Palpable mass Paristalsis visible Projectile vomiting (2-4 weeks after birth)

Cyanotic heart diseases: 5 types • 5 T's: Tetralogy of Fallot Transposition of the great arteries Truncus arteriosus Tricuspid atresia, pulmonary aTresia Total anomalous pulmonary venous drainage

Breast feeding: benefits ABCDEFGH: • Infant: Allergic condition reduced Best food for infant Close relationship with mother Development of IQ, jaws, mouth • Mother: Econmical Fitness: quick return to pre-pregnancy body shape Guards against cancer: breast, ovary, uterus Hemorrhage (postpartum) reduced

Perez reflex Eliciting the PErEz reflex will make the baby PEE.

WAGR syndrome: components WAGR: Wilm's tumor Aniridia Gential abnormalities Mental retardation

Haematuria: differential in children ABCDEFGHIJK: Anatomy (cysts, etc) Bladder (cystitis) Cancer (Wilm's tumour) Drug related (cyclophosphamide) Exercise induced Factitious (Munchausen by proxy) Glomerulonephritis Haematology (bleeding disorder, sickle cell) Infection (UTI) In Jury (trauma) Kidney stones (hypercalciuria)

Vitamin toxicities: neonatal Excess vitamin A: Anomalies (teratogenic) Excess vitamin E: Enterocolitis (necrotizing enterocolitis) Excess vitamin K: Kernicterus (hemolysis)

Rubella: congenital signs "Rubber Ducky, I'm so blue!" (like the "Rubber Ducky" song): Rubber: Rubella Ducky: Patent Ductus Arteriosus, VSD and pulmonary artery stenosis. I'm: Eyes (cataracts, retinopathy, micropthalmia, glaucoma). Blue: "Blueberry Muffin" rash (extramedullary hematopoesis in skin +purpura) • Also, deafness, growth retardation, and some more.

Pediatric milestones in development 1 year: -single words 2 years: -2 word sentences -understands 2 step commands 3 years: -3 word combos -repeats 3 digits -rides tricycle 4 years: -draws square -counts 4 objects

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Gastroschisis: usual location GasTRoscHIsis usually occurs on the RIGHT side of the umbilicus. (Unscramble the letters).

Milk protein: women vs. cows Woman: Whey (mostly) Cow: Casein (mostly)

Short stature: differential ABCDEFG: Alone (neglected infant) Bone dysplasias (rickets, scoliosis, mucopolysaccharidoses) Chromosomal (Turner's, Down's) Delayed growth Endocrine (low growth hormone, Cushing's, hypothyroid) Familial GI malabsorption (celiac, Crohn's) Please paste any resources and commonly tested information freely distributed by your medical school to help your prepare for the USMLE Step 2 here. If you wish you can indicate which school provided these resources.

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