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USMLE STEP 2
SECRETS
Third Edition
Theodore X. O’Connell, MD
Program Director
Family Medicine Residency Program
Kaiser Permanente Woodland Hills, Woodland Hills, California;
Assistant Clinical Professor
Department of Family Medicine
David Geffen School of Medicine at UCLA, Los Angeles, California;
Partner Physician
Southern California Permanente Medical Group, Woodland Hills, California
Adam Brochert, MD
Staff Radiologist
Eisenhower Medical Center
Rancho Mirage, California
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
USMLE STEP 2 SECRETS ISBN: 978-0-323-05713-4
Copyright © 2010, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
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Knowledge and best practice in this field are constantly changing. As new research and
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The Publisher
Library of Congress Cataloging-in-Publication Data
O’Connell, Theodore X.
USMLE step 2 secrets / Theodore X. O’Connell, Adam Brochert. – 3rd ed.
p. ; cm. – (Secrets series)
Rev. ed. of: USMLE step 2 secrets / Adam Brochert. 2nd ed. c2004.
Includes bibliographical references and index.
ISBN 978-0-323-05713-4
1. Clinical medicine–Examinations, questions, etc. I. Brochert, Adam. II. Brochert, Adam,
- USMLE step 2 secrets. III. Title. IV. Title: USMLE step two secrets. V. Series: Secrets series.
[DNLM: 1. Clinical Medicine–Examination Questions. WB 18.2 O18u 2010]
RC58.B76 2010
616.0076–dc22
2009039617
Acquisitions Editor: James Merritt
Developmental Editor: Christine Abshire
Publishing Services Manager: Hemamalini Rajendrababu
Project Manager: Sukanthi Sukumar
Marketing Manager: Jason Oberacker
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
DEDICATION
For Claire.
Welcome to the world, little one.
v
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CONTENTS
100 Top Secrets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Acid-Base and Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2. Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3. Biostatistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4. Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5. Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
6. Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
7. Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
8. Ear, Nose, and Throat Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9. Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
10. Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
11. Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
12. Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
13. General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
14. Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
15. Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
16. Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
17. Hematology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
18. Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
19. Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
20. Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
21. Laboratory Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
22. Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
23. Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
24. Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
25. Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
26. Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
vii
viii CONTENTS
27. Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
28. Orthopedic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
29. Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
30. Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
31. Preventive Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
32. Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
33. Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
34. Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
35. Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
36. Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
37. Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
38. Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
39. Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
40. Vitamins and Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
100 TOP SECRETS
These secrets are 100 of the top board alerts. They summarize the concepts,
principles, and most salient details that you should review before you take the Step
3 exam. Understanding of these Top Secrets will serve you well in your final review.
1. Smoking is the number-one cause of preventable morbidity and mortality in the United
States (e.g., atherosclerosis, cancer, chronic obstructive pulmonary disease).
2. Alcohol is the number-two cause of preventable morbidity and mortality in the United
States. More than half of accidental and intentional (e.g., murder and suicide) deaths involve
alcohol. Alcohol is the number-one cause of preventable mental retardation (fetal alcohol
syndrome); it also causes cancer and cirrhosis and is potentially fatal in withdrawal.
3. In alcoholic hepatitis the classic ratio of aspartate aminotransferase (AST) to alanine
aminotransferase (ALT) is greater than or equal to 2:1, although both may be elevated.
4. Vitamins: Give folate to reproductive-age women to prevent neural tube defects. Watch for
pernicious anemia, and treat with vitamin B12 to prevent permanent neurologic deficits.
Isoniazid causes pyridoxine (vitamin B6) deficiency. Watch for Wernicke encephalopathy
in alcoholics, and treat with thiamine to prevent Korsakoff dementia.
5. Minerals: Iron-deficiency anemia is the most common cause of anemia. Think of
menstrual loss in reproductive-age women and of cancer in men and older women if no
other cause is obvious.
6. Vitamin A is a known teratogen. Counsel and treat reproductive-age women appropriately
(e.g., take care in treating acne with the vitamin A analog isotretinoin).
7. Complications of atherosclerosis (e.g., myocardial infarction, heart failure, stroke,
gangrene) are involved in roughly one half of deaths in the United States. The primary risk
factors for atherosclerosis are age/sex, family history, cigarette smoking, hypertension,
diabetes mellitus, high LDL cholesterol, and low HDL cholesterol.
8. Diabetes leads to atherosclerosis and its complications, retinopathy (a leading cause of
blindness), nephropathy (a leading cause of end-stage renal failure), peripheral vascular
disease (a leading cause of limb amputation), peripheral neuropathy (sensory and
autonomic), and an increased incidence of infections.
9. Although hypertension is most often mild or moderate and clinically silent, severe
hypertension can lead to acute problems (known as a hypertensive emergency):
headaches, dizziness, blurry vision, papilledema, cerebral edema, altered mental status,
seizures, intracerebral hemorrhage (classically in the basal ganglia), renal failure/azotemia,
angina, myocardial infarction, and/or heart failure.
10. In milder cases, lifestyle modifications (e.g., diet, exercise, weight loss, cessation of
alcohol/tobacco use, elevation of head of bed) may be able to treat the following disorders
without the use of medications: hypertension, hyperlipidemia, diabetes, gastroesophageal
reflux disease (GERD), insomnia, obesity, and sleep apnea.
1
2 100 TOP SECRETS
11. Arterial blood gas analysis: In general, pH tells you the primary event (acidosis vs.
alkalosis), whereas carbon dioxide and bicarbonate values give you the cause (same
direction as pH) and suggest any compensation present (opposite of pH).
12. Exogenous causes of hyponatremia to keep in mind: oxytocin, surgery, narcotics,
inappropriate IV fluid administration, diuretics, and antiepileptic medications.
13. EKG findings in electrolyte disturbances: tall, tented T waves in hyperkalemia; loss of
T waves/T-wave flattening and U waves in hypokalemia; QT prolongation in hypocalcemia;
QT shortening in hypercalcemia.
14. Shock: First give the patient oxygen, start an IV line, and set up monitoring (pulse
oximetry, EKG, frequent vital signs). Then give a fluid bolus (1 L normal saline or lactated
Ringer solution) if no signs of congestive heart failure (e.g., bibasilar rales) are present
while you try to figure out the cause if it is not known.
15. Virchow triad of deep venous thrombosis: endothelial damage (e.g., surgery, trauma),
venous stasis (e.g., immobilization, surgery, severe heart failure), and hypercoagulable
state (e.g., malignancy, birth control pills, pregnancy, lupus anticoagulant, inherited
deficiencies).
16. Therapy for congestive heart failure: diuretics (e.g., furosemide), ACE inhibitors, and beta
blockers (for stable patients) are the mainstays of pharmacologic treatment. Be sure to screen
for and address underlying atherosclerosis risk factors (e.g., smoking, hyperlipidemia).
17. Cor pulmonale: right-sided heart enlargement, hypertrophy, or failure due to primary lung
disease (usually chronic obstructive pulmonary disease). The most common cause of right
heart failure, however, is left heart failure (not cor pulmonale).
18. In patients with atrial fibrillation, the main issues are ventricular rate (if needed, slow
the rate with medications) and atrial clot formation/embolic disease (consider
anticoagulation with warfarin).
19. Ventricular fibrillation requires immediate defibrillation pulseless ventricular tachycardia
is treated with defibrillation followed by epinephrine, vasopressin, amiodarone, and
lidocaine. If a pulse is present, treat with amiodarone and synchronized cardioversion.
20. Obstructive vs. restrictive lung disease: the FEV1/FEV ratio is the most important
parameter on pulmonary function testing to distinguish the two (FEV1 may be the same).
In obstructive lung disease, the FEV1/FEV ratio is less than normal. In restrictive disease
the FEV1/FEV ratio is often normal.
21. The most common cause of esophageal cancer: reflux disease ! Barrett metaplasia !
adenocarcinoma. Smoking and alcohol abuse are the second most common causes
(squamous cell carcinoma).
22. All gastric ulcers must be biopsied or followed to resolution to exclude malignancy.
23. Testing a nasogastric tube aspirate for blood is the best initial test to distinguish an upper
from a lower GI bleed, although bright red blood via mouth or anus is a fairly reliable sign
of a nearby bleeding source.
100 TOP SECRETS 3
24. Irritable bowel syndrome is one of the most common causes of GI complaints. Physical
exam and basic tests are by definition negative; this is a diagnosis of exclusion. The
classic patient is a young adult female with a chronic history of alternating constipation
and diarrhea.
25. Crohn disease vs. ulcerative colitis
Crohn Disease Ulcerative Colitis
Place of origin Distal ileum, proximal colon Rectum
Thickness of Transmural Mucosa/submucosa only
pathology
Progression Irregular (skip-lesions) Proximal, continuous from
rectum; no skipped areas
Location From mouth to anus Involves only colon, rarely
extends to ileum
Bowel habit Obstruction, abdominal pain Bloody diarrhea
changes
Classic lesions Fistulas/abscesses, Pseudopolyps, lead-pipe
cobblestoning, string sign colon on barium x-ray,
on barium x-ray toxic megacolon
Colon cancer risk Slightly increased Markedly increased
Surgery No (may make worse) Yes (proctocolectomy with
ileoanal anastomosis)
26. All forms of viral hepatitis can present similarly in the acute stage; serology testing
and history are needed to distinguish them. Hepatitis B, C, and D are transmitted
parenterally and can lead to chronic infection, cirrhosis, and hepatocellular
carcinoma.
27. Hereditary hemochromatosis is currently the most common known genetic disease in
white people. The initial symptoms (fatigue, impotence) are nonspecific, but patients often
have hepatomegaly. Screen with transferrin saturation test (serum iron/total iron binding
capacity) and ferritin level. Treat with phlebotomy after confirming the diagnosis with
genetic testing and liver biopsy.
28. Sequelae of liver failure: coagulopathy (that cannot be fixed with vitamin K),
jaundice/hyperbilirubinemia, hypoalbuminemia, ascites, portal hypertension,
hyperammonemia/encephalopathy, hypoglycemia, and disseminated intravascular
coagulation.
29. Pancreatitis is usually due to alcohol or gallstones. Patients present with abdominal pain,
nausea/vomiting, and elevated amylase and lipase. Treat supportively and provide pain
control. Complications include pseudocyst formation, infection/abscess, and adult
respiratory distress syndrome.
30. Jaundice/hyperbilirubinemia in neonates is usually physiologic (only monitoring
and follow-up lab tests are needed), but jaundice present at birth is always pathologic.
4 100 TOP SECRETS
31. Primary vs. secondary endocrine disturbances. In primary disorders (e.g., Graves,
Hashimoto, or Addison disease), the gland malfunctions, but the pituitary or another gland
and the central nervous system respond appropriately (e.g., TSH, TRH, or ACTH elevate or
depress as expected in the setting of a malfunctioning gland). In secondary disorders
(e.g., ACTH-secreting lung carcinoma, heart failure-induced hyperreninemia, renal failure-
induced hyperparathyroidism), the gland itself is doing what it is told to do by other
controlling forces (e.g., pituitary gland, hypothalamus, tumor, disease); they are the
problem, not the gland itself.
32. Corticosteroid side effects: weight gain, easy bruising, acne, hirsutism, emotional lability,
depression, psychosis, menstrual changes, sexual dysfunction, insomnia, memory loss,
buffalo hump, truncal and central obesity with wasting of extremities, round plethoric
facies, purplish skin striae, weakness (especially of the proximal muscles), hypertension,
peripheral edema, poor wound healing, glucose intolerance or diabetes, osteoporosis, and
hypokalemic metabolic alkalosis (due to mineralocorticoid effects of certain
corticosteroids). Growth can also be stunted in children.
33. Osteoarthritis is by far the most common cause of arthritis ( 75% of cases) and
usually does not have hot, swollen joints or significant findings if arthrocentesis is
performed.
34. Cancer incidence and mortality in the United States.
Overall Highest Incidence Overall Highest Mortality Rate
Male Female Male Female
1. Prostate 1. Breast 1. Lung 1. Lung
2. Lung 2. Lung 2. Prostate 2. Breast
3. Colon 3. Colon 3. Colon 3. Colon
35. Sequelae of lung cancer: hemoptysis, Horner syndrome, superior vena cava syndrome,
phrenic nerve involvement/diaphragmatic paralysis, hoarseness from recurrent laryngeal
nerve involvement, and paraneoplastic syndromes (Cushing, SIADH, hypercalcemia,
Eaton-Lambert syndrome).
36. Bitemporal hemianopsia (loss of peripheral vision in both eyes) is due to a space-
occupying lesion pushing on the optic chiasm (classically a pituitary tumor) until proven
otherwise. Order a CT or MRI of the brain.
37. Potential risks and side effects of estrogen therapy (e.g., contraception, postmenopausal
hormone replacement): endometrial cancer, hepatic adenomas, glucose intolerance/
diabetes, deep venous thrombosis, stroke, cholelithiasis, hypertension, endometrial
bleeding, depression, weight gain, nausea/vomiting, headache, weight gain, drug-drug
interactions, teratogenesis, and aggravation of preexisting uterine leiomyomas
(fibroids), breast fibroadenomas, migraines, and epilepsy. The risks of coronary artery
disease and breast cancer are increased with combined estrogen and progesterone therapy.
38. ABCD characteristics of a mole that should make you suspicious of malignant
transformation: asymmetry, borders (irregular), color (change in color or multiple colors),
and diameter (the bigger the lesion, the more likely that it is malignant). Do an excisional
biopsy of such moles and/or if a mole starts to itch or bleed.
100 TOP SECRETS 5
39. Bronchiolitis vs. croup vs. epiglottitis
Croup (Acute
Bronchiolitis Laryngotracheitis) Epiglottitis
Child’s age 0–18 months 1–2 years 2–5 years
Common Yes Yes No
Common Repiratory syncytial Parainfluenza virus Haemophilus
cause(s) virus ( 75%), (50–75% of influenzae,
Parainfluenza, cases), Influenza Staphylococcus
Influenza spp.,
Streptococcus
spp.
Symptoms/ Initial viral URI Initial viral URI Rapid progression
signs symptoms followed symptoms to high fever,
by tachypnea and followed by toxicity,
expiratory wheezing “barking” cough, drooling, and
hoarseness, and respiratory
inspiratory stridor distress
X-ray Hyperinflation Subglottic tracheal Swollen epiglottis
findings narrowing on on lateral
frontal x-ray neck x-ray
(steeple sign) (thumb sign)
Treatment Humidified oxygen, Humidified oxygen, Prepare to
bronchodilators bronchodilators establish an
(controversial), airway,
Ribavarin used for antibiotics (e.g.,
severe RSV third-generation
infection or high cephalosporin)
risk for RSV
infection.
40. Sequelae of streptococcal infection: rheumatic fever, scarlet fever, and poststreptococcal
glomerulonephritis. Only the first two can be prevented by treatment with antibiotics.
41. Multiple sclerosis should be suspected in any young adult with recurrent, varied
neurologic symptoms/signs when no other causes are evident. Best diagnostic tests: MRI
(most sensitive), lumbar puncture (elevated IgG oligoclonal bands and myelin basic
protein levels, mild elevation in lymphocytes and protein), and evoked potentials
(slowed conduction through areas with damaged myelin).
42. For the unconscious or delirious patient in the emergency department with no history or
signs of trauma: consider empiric treatment for hypoglycemia (glucose), opioid overdose
(naloxone), and thiamine deficiency (thiamine should be given before glucose in a
suspected alcoholic). Other commonly tested causes are alcohol, illicit or prescription
drugs, diabetic ketoacidosis, stroke, epilepsy or postictal state, and subarachnoid
hemorrhage (e.g., aneurysm rupture).
6 100 TOP SECRETS
43. Delirium vs. dementia
Delirium Dementia
Onset Acute and dramatic Chronic and insidious
Common causes Illness, toxin, withdrawal Alzheimer disease, multi-infarct
dementia, HIV/AIDS
Reversible Usually Usually not
Attention Poor Usually unaffected
Arousal level Fluctuates Normal
44. Always consider the possibility of pregnancy (and order a pregnancy test to rule
it out, unless pregnancy is an impossibility) in reproductive-age women before
advising potentially teratogenic therapies or tests (e.g., antiepileptic drugs, x-ray,
CT scan). Pregnancy is in the differential diagnosis of both primary and secondary
amenorrhea.
45. Anaphylaxis is commonly caused by bee stings, food allergy (especially peanuts
and shellfish), medications (especially penicillins and sulfa drugs), or rubber glove
allergy. Patients become agitated and flushed and shortly after exposure develop
itching (urticaria), facial swelling (angioedema), and difficulty in breathing.
Symptoms develop rapidly and dramatically in true anaphylaxis. Treat immediately by
securing the airway (laryngeal edema may prevent intubation, in which case do a
cricothyroidotomy, if needed), and give subcutaneous or IV epinephrine.
Antihistamines and corticosteroids are not useful for immediate, severe reactions that
involve the airway.
46. Cancer screening in asymptomatic adults
Cancer Procedure Age Frequency
Colorectal Colonoscopy or > 50 yr for all Every 10 years
studies
Flexible sigmoidoscopy Every 5 years
or
Double contrast barium Every 5 years
enema or
CT colonography or Every 5 years
Fecal occult blood test or Annually
Fecal immunochemical Annually
test or
Stool DNA test Interval uncertain
Colon, Digital rectal exam > 40 yr Annually
prostate
Prostate Prostate specific > 50 yr* Controversial, but
antigen test offer annually
(continued)
100 TOP SECRETS 7
Cancer Procedure Age Frequency
Cervical Pap smear Within 3 years If conventional
of onset of Pap test is used !
sexual test annually; every
activity or 2-3 years for women
age 21, 30 who have had
whichever three negative
comes first cytology tests.
If Pap and HPV
testing are used !
every 3 years if HPV
negative and
cytology negative.
Gynecologic Pelvic examination 21–64 yr Annually. Every 2–3
years after 3 normal
tests.
> 65 Annually. When to
stop is not clearly
established.
Endometrial Endometrial biopsy Menopause No recommendation
for routine
screening.
Breast Breast self-examination > 20 yr Benefits and
limitations should be
discussed, but
breast self
examination is no
longer
recommended by
the American
Cancer Society.
Breast Physical exam by doctor 20–40 yr Every 3 yrs
> 40 yr Annually
Breast Mammography > 40 yr Annually
Lung Sputum, chest Testing is not
x-ray, CT scan recommended for
asymptomatic
individuals, even if
they are high-risk.
*Start at age 45 in African Americans and at age 40 for patients with a first degree relative
diagnosed at an early age.
8 100 TOP SECRETS
47. Biostatistics calculations using a 2 2 table
Disease Test Name Formula
(þ) () Sensitivity A/(A þ C)
______________ Specificity D/(B þ D)
Test (þ) A B PPV A/(A þ B)
or ______________ NPV D/(C þ D)
Exposure () C D Odds ratio (A D)/(B C)
(Note: retrospective
studies)
______________ Relative risk [A/(A þ B)]/[C/(C þ D)]
(Note: prospective
studies)
Attributable risk [A/(A þ B)][C/(C þ D)]
48. The p-value reflects the likelihood of making a type I error, or claiming an effect or
difference where none existed (i.e., results were obtained by chance). When we reject the
null hypothesis (i.e., the hypothesis of no difference) in a trial testing a new treatment,
we are saying that the new treatment works. We use the p-value to express our confidence
in the data.
49. Side effects of antipsychotics: acute dystonia (treat with antihistamines or
anticholinergics), akathisia (beta blocker may help), tardive dyskinesia (switching to
newer agent may have benefit), parkinsonism (treat with antihistamines or
anticholinergics), neuroleptic malignant syndrome, hyperprolactinemia (may cause
breast discharge, menstrual dysfunction and/or sexual dysfunction), and autonomic
nervous system-related effects (e.g., anticholinergic, antihistamine and alpha1 receptor
blockade).
50. Asking about depression and suicidal thoughts/intent is important in the right setting
and does not cause people to commit suicide. Hospitalize psychiatric patients against their
will if they are a danger to self or others.
51. Drugs of abuse: potentially fatal in withdrawal include alcohol, barbiturates, and
benzodiazepines. Alcohol, cocaine, opiates, barbiturates, benzodiazepines, phencyclidine
(PCP), and inhalants are potentially fatal in overdose.
52. Pelvic inflammatory disease is the most common preventable cause of infertility in the
United States and the most likely cause of infertility in younger, normally menstruating
women.
53. Polycystic ovarian syndrome is classically associated with women who are “heavy,
hirsute, and [h]amenorrheic”. It is the most common cause of dysfunctional uterine
bleeding. Remember the increased risk of endometrial cancer due to unopposed
estrogen.
54. Fetal/neonatal macrosomia is due to maternal diabetes until proven otherwise. Use diet
and insulin (not oral agents) to treat maternal diabetes.
