USMLE Step 3 (Fach) / UWorld CCS (Lektion)

UWorld CCS

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• Neonatal sepsis – Orders - Supplemental oxygen (keep saturations ≥ 94%) - IV access - CBC with differential, stat - BMP with differential, stat - Blood cultures, urine cultures, CSF cultures - CSF (glucose, protein, cell count, gram stain) - Chest x-ray - CRP
• Neonatal sepsis – Order floors - Vital signs q4 - Continuous cardiorespiratory monitoring - Diet 'no oral' if respiratory rate is > 60 - IVF D5 j NS at maintenance rate - Ampicillin 100 mg/kg/day divided q 8h (can be changed to amoxicillin 50-80 mg/kg/day divided q)- Cefotaxime 150 mg/kg/day divided q 8h - Inputs/Outputs - CBC with diff, BMP q daily
• Alcohol intoxication w/ hypoglycemia - D50, 1 ampulle, IV - IVF Normal Saline bolus 500cc, then at maintenance - Blood alcohol level (BAL) - Urine and serum toxicology panel - BMP, stat - CBC, stat - Accuchecks q 1h until stable - Admit to observation unit/floor - Continuous cardiorespiratory monitoring - IVF D5 S NS with 20 meq/L KCL at maintenance - NPO until awake - BMP in AM - Repeat BAL in 12 hours
• Subarachnoid hemorrhage – Orders - IV access, stat - CT head (without contrast), stat - ESR, stat (temporal arteriitis) - IV Ketorolac, stat (pain medication) After confirmed diagnosis:- Admit ICU- Continuous cardiac monitoring- Pulse oxymetry, q 2h- NPO- Complete bed rest- Urine output- Neurochecks q 1h- CBC with diff, stat- BMP, stat and daily- EKG 12-lead, one time, for baseline- PT/INR- PTT- Neurosurgery consult, stat- Normal saline, IV, continuous- Acetaminophen with codeine, oral, continuous for pain- Stool softener, oral, conitinuous (prevent straining)- Nimodipine, oral, continuous for 21 days- Omeprazol, oral, continuous- Pneumatic compression devices
• Hyperthyroidism – Orders - CBC with diff, stat- BMP, stat- EKG 12-lead, stat- Serum TSH- Serum free T3 and T4 After diagnosis:- 24-hour radioiodine uptake Review order:- Propanolol, oral, continuous- Methimazole, oral, continuous- Follow-up in 4 weeks. Advise to stop methimazole 4 days prior to follow up. Review order:- CBC with diff- Stop methimazole- Radioiodine, one time- Follow-up in 4 weeks
• COPD exacerbation – Orders - Pulse oximetry q4h- Supplemental oxygen therapy at 2 lpm by nasal cannula- IV access- IV fluids at 100 cc per hour with normal saline- Urine outputs q 4h- Vitals q4h- Activity: Bed rest with bathroom privileges- Chest x-ray PA and lat, stat- Blood cultures, stat- Coughed sputum sample for gram stain, culture and cytology- CBC with diff, stat- BMP, stat- Begin antibiotic therapy with Levofloxacin orally or IV after cultures obtained- Albuterol and ipratropium nebulized treatments q6h and albuteral q2h PRN for shortness of breath
• Suspicion of lung cancer – Orders - CT chest- Sputum cytology- Biopsy of suspicious lymph nodes - Flexible fiberopic bronchoscopy: Biopsy taken when any endobronchial lesion is noted- Pleural biopsy if pleural effusion is present- Mediastinoscopy and anterior mediastinostomy when there is suspicion of mediastinum involvment of the tumor- Transthoracic FNA biopsy under CT or fluoroscopic guidance when a peripheral pulmonary nodule is present - Consult pulmonary medicine/cardiovascular surgery - CBC with diff and BMP, daily- Supplemental oxygen therapy
• Lung cancer – Orders - Pulmonary function tests (PFTs)- Liver function tests (LFTs)- Serum calcium, stat- CT of the abdomen and pelvis- MRI brain with and without contrast- Bone scan- Consult oncology- Consult radiation oncologist- Quit tobacco use- Supplement diet with high protein nutritional shakes- Consider changing albuterol/ipratropium nebulizer to MDI (metered dose inhalers)
• Suspected meningitis – Orders - Pulse oximetry stat and q2h- IV access- IV NS, 100 cc/hr- NPO except medications- Complete bed rest- DVT prophylaxis (Type Pneumatic compression stockings)- Vitals q2h- Urine output q2h- Head elevation- Blood cultures, stat- Urinalysis, stat- CBC with diff, stat and Q day- BMP stat and Q day- PT/INR, stat- PTT, stat- Promethazine (Phenergan), IV PRN for vomiting- Acetaminophen, oral, PRN for pain and fever Once blood cultures are obtained:- IV ceftriaxone, continuous (14 days)- IV vancomycin, continuous (14 days)- Lumbar puncture, stat- Send the CSF for glucose, protein, cell count, gram stain, fungal stain, culture, and sensitivity
• Neutropenic fever – Orders - Complete physical exam - IV access- CBC with diff, stat- Blood culture, stat- U/A, Urine culture & sensitivity, Gram stain, stat- Sputum Gram stain and cultures (if the patient has symptoms)- Comprehensive metabolic panel, stat- Chest x-ray, PA and lat- Ceftazidime, IV, continuous Treatment:- Vitals q4h- Regular diet- Activity as tolerated- Acetaminophen, oral, as needed (do not give continuously, as you have to monitor whether he is responding to antibiotics or not)- CBC with diff, daily- Consider PT/PTT for baseline if there is a risk of developing DIC- Consider the use of Neupogen (G-CSF)- Re-examine patient q6h
• Ordering lab frequency DKA:- Fingerstick q1h- BMP q4h Sepsis:- CBC q24h Acute coronary syndrome:- Troponin q4h
• Consultation Colon cancer:- GI consult- Oncology consult- General surgery consult Fall:- Neurology consult- Cardiology consult- Orthopedics consult (if any fracture)
• Closure orders - Seat belt- Safe sex - Alcohol counseling- Smoking cessation- Illicit illegal drug use - Pap smear- Mammography - Inflenza vaccine- Pneumococcal vaccine - Drug side effect- Drug compliance - Exercise- Colonoscopy - Advance directive (for all patients > 60 years)
• Orders for surgical patients - NPO- IV access- CBC with diff- BMP- UA- PT/PTT- Type and screen- IV cefazolin - IV morphine- IV Phenergan- Abdominal US/X-ray- Stop warfarin/heparin- Surgery order- Surgical consult
• New-onset heart failure – Orders - B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide assay- Complete blood count- Serum electrolyte measurement- Kidney function tests- Liver chemistry tests- Glucose and lipid levels- Serum thyroid-stimulating hormone
• Pediatrics - feeding Do not give PO feeds if RR >60 and respiratory distress
• Meningitis treatment <1 month:- Ampicillin - gentamycin+/- 3rd generation cephalosporin, e.g. cefotaxime Avoid ceftriaxone given increased risk for kernicterus 1 month-50 years- Ceftriaxone/Cefotaxime- Vancomycin >50 years, alcoholism- Ceftriaxone- Vanc- Ampicillin to cover Listeria Neutropenia, head trauma, neurosurgery - ceftazidime to cover for pseudomonas Narrowing:- Gram negative bacilli -> ceftriaxone- Gram positive cocci in clusters -> nafcillin- Pseudomonas -> ceftazidime- MRSA -> vanc
• ABCs initial management Pulse O2 Supplemental oxygen Continuous cardiorespiratory monitoring Finger glucose IV access
• Labs prior to succimer therapy LFTs Erythrocyte protoporphyrin
• Neutropenic fever Monotherapy: Ceftazidime, cefepime, imipenem, meropenem Double coverage: Aminoglycoside + extended spectrum anti-pseudomonal penicillin When to add vanc:- No response after 2-3 days- Hypotension, mucositis, skin/catheter site infection, MRSA When to add anti-fungals (amphotericin b):- No response after 5-7 days with persistent fevers  If becomes afebrile in 3 days, narrow to cefixime or quinolone
• Toxic shock from tampon - Order gram stain and culture from tampon
• Sickle cell crisis - Oxygen- IV- EKG- CBC, BMP- Type and screen- Infectious workup: BCx, RCx, UA- CXR- Antibiotics: Cefuroxime (if <8 yo), azithromycin- Incentive spirometry- Nebulizers - IV morphine- IV fluids (D4 1/4 NS)
• Prenatal lab tests - CBC- BMP- Rhesus, T&S- UA- Urine culture- Rubella titer- RPR- HIV Elisa- HbsAg- Chlamydia- Pap smear
• Ulcerative colitis - CBC, BMP, LFTs, PTT/PT- Stool ova, parasites, WBC, culture- ESR Imaging:- Sigmoidoscopy + rectal biopsy Medications:- Mesalamine- Loperamide- Dicyclomine- Dietary consult
• Irritable bowel syndrome - CBC- BMP- ESR- FOBT- Stool ova/parasites/WBC/culture- Fecal fat 72h- TSH General approach- Reassurance, patient education- High fiber diet, lactose free diet Pharmacologic (symptomatic)- Loperamide- Dicyclomine, hyoscolamine- Biofeedback, relaxation
• Dementia - CBC- BMP- LFT- TSH- Vitamin B12, folate- CT scan Therapy- Anticholinesterase inhibitor (eg donezepil)- Vitamin E - Counsel patient and family- Medication- Occupational therapy- Cognitive rehabilitation- Support groups- Good nutrition- No driving- Medic alert bracelet- Advance directive- 
• Hypertensive emergency 1. Rule out stroke with head CTDiagnostic: CBC, BMP, UA, EKG, lipid profile STAT 2. Lower BP- First line: IV nitroprusside- Alternatives: IV labetalol, nicardipine 3. Transfer to ICU- Complete bedrest- NPO- Urine output 4. Arterial line for BP
• Hypertensive emergency 1. Rule out stroke with head CTDiagnostic: CBC, BMP, UA, EKG, lipid profile STAT 2. Lower BP- First line: IV nitroprusside- Alternatives: IV labetalol, nicardipine 3. Transfer to ICU- Complete bedrest- NPO- Urine output 4. Arterial line for BP
• Panic attack Emergent:- IV access- EKG- Cardiac monitor- Pulse ox- Oxygen- Glucometer Labs:- CBC, BMP- TSH- Urine toxicology- UA- CXR- Cardiac enzymes Therapy:- Alprazolam, sublingual- Reassurance
• TIA - CBC, BMP- Glucose- EKG- NCHCT- Carotid dopplers- TTE- Lipid profile, HbA1c- MRI, MRA head Therapy:- IV access- Aspirin + clopidogrel- Vascular surgery consult with Carotid endarterectomy(NPO, PT, PTT, cefazolin)- Cefazolin- Counseling: Smoking cessation, no alcohol, regular exercise, diabetic diet, med compliance, BP control, DM control
• Pelvic inflammatory disease Diagnostic tests:- HCG- CBC, BMP, LFTs- Gram stain (cervix), pH- UA, Urine C+S- CRP- Cervical chlamydia and gonorrhea culture- HIV and RPR- Pap smear Treatment:- Inpatient: Cefoxitin IV + doxycycline IV- Outpatient: Ceftriaxone IM (x1) + doxycycline (x14 days)
• Hemophilia - CBC, BMP LFTs (stat)- PTT, PT, bleeding time (stat)- Factor VIII, IX, XI Therapy:- Factor VIII- Counseling (no aspirin, avoid contact sports, patient/family counseling)- Consult, genetics
• Blunt abdominal trauma - C-spine immobilzation- IV access- NSS 0.9%- Pulse ox, oxygen- Cardiac monitor- BP - CBC, BMP, LFTs- Amylase, lipase- PT/PTT, T&S for possible surgery- ABG- EKG- CXR, Abdominal CT, spine x-ray- HCG - Surgery consult

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