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My Notes for USMLE

Hi there! My name is Renata. I'm an IMG (International Medical Graduate) from Peru. These are
my notes on Step 1, Step 2CK & Step 2CS. Feel free to reblog them, correct me and share your
personal notes.

**Disclaimer**

This blog claims no credit for any images posted on this site unless otherwise noted. If there is an
image appearing on this blog that belongs to you and do not wish for it appear on this site, please
let me know and it will be promptly removed. Any medical discussions on this blog are for
educational purposes only, I am not your medical provider and cannot tell you what to do with your
health issues. Please do not use the info found here as a substitute for your physician's advice.

Thanks! Have fun studying!

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usmlepathslides:

Pseudomembranous colitis due to Clostridium difficile

Note the shaggy membrane due to toxin-induced damage of the mucosa and submucosa.

Best initial test: stool C. diff toxin assay or PCR

Most accurate test: endoscopy looking for pseudomembranes (not done, bc the toxin assay
is good enough)

Tx: 

1. Oral metronidazole. 
2. Resolution but days later recurrence? Retreat with metronidazole. 
3. No resolution after first course of metronidazole? Switch to oral vancomycin or
fidaxomicin

 usmlepathslides #ID #GI #IM #USMLE #step 2ck

40 notes
#handwritten #GI #IM #step 2ck #colon cancer screening #colon cancer #USMLE
usmlepathslides:

Familial polyposis

This autosomal dominant condition is associated with multiple tubular adenomas and
tubulovillous tumors in the colon. The patient has greater than 100 polyps and is at risk for
colon cancer. There is an association with the APC tumor suppressor gene.

 usmlepathslides #GI #IM #step 2ck #USMLE

usmlepathslides:

Villous adenoma

This is a microscopic section of a villous adenoma. Note the long stalk-like papillary
projections of the tumor. These tumors are typically sessile and have a high incidence of
malignant transformation.

 usmlepathslides #GI #IM #step 2ck #USMLE

usmlepathslides:

Tubular adenoma

This is a microscopic section of a neoplastic polyp arising from the colon mucosa. The
polyp is pedunculated and is composed of colonic glands which have lost many of the
normal goblet cells. This is called an adenomatous change.

 usmlepathslides #GI #IM #USMLE #step 2ck

usmlepathslides:

Dermatitis herpetiformis

Nnote the vesicular lesion on the elbows. This skin disorder has a high association with
celiac disease.

 usmlepathslides #dermatology #IM #GI #USMLE #step 2ck

mynotes4usmle:

Copper accumulation in liver, brain and eyes (Descemet Membrane = Kayser-

Fleischer ring)
Decreased ceruloplasmin blood levels.
Chromosome 13, WD gene, ATP7B gene (encondes for Copper transporting
ATPase)
Lesion in basal ganglia, especially putamen
Tx: penicillamine, zinc acetate.
Symptoms: tremor, asterixis, parkinsonian sx, chorea, neuropsychiatric, fatty
changes, hepatitis, cirrhosis.

Best initial test: 

Slit-lamp examination for Kayser-Fleischer rings (brown ring around eye due to copper
deposition)

Most accurate test: 

Penicillamine challenge => abnormal increased amount of urinary copper excreation after
Penicillamine.

MNEMONIC: 

Winston is a cop that likes “putas” 

Winston: sounds like Wilson

cop: copper accumulation
putas: putamen

(puta means whore in Spanish, this is just the way I remember it don’t judge me)
Originally posted by thomasellis

 mynotes4usmle #GI #IM #USMLE #step 2cx

Primary Sclerosing Cholangitis (PSC)

mynotes4usmle:
 Unknown etiology
Chronic Biliary tract disease
Segmental inflammation and fibrosing destruction of INTRA & EXTRAHEPATIC
BILE DUCTS.
Micro: concentric bile duct “onion skin” fibrosis, ducts “beaded-appereance” (in
cholangiogram) due to segmental stenosis   & periductal chronic inflammation

Males
Hypergammaglobulinemia (IgM)
Associated with: Ulcerative Colitis.
Complications: Secondary Biliary Cirrhosis, Cholangiocarcinoma

Most accurate test: 

Magnetic resonance cholangiopancreatography (MRCP)

This is the ONLY cause of cirrhosis for which a biopsy is NOT the most accurate test.

 mynotes4usmle #GI #USMLE #IM #step 2ck

Primary Biliary Cirrhosis (PBC)
mynotes4usmle:

Autoimmune
Chronic liver disease
Inflammation + Granulomas => destruction of INTRAHEPATIC BILE DUCTS

Females, middle-aged
Increased Anti Mitochondrial Antibodies - AMA (90%)

Increased IgM
Associated with other autoimmune diseases (CREST, RA, celiac disease)

Most accurate test: liver bx

 mynotes4usmle #IM #USMLE #GI #step 2ck

usmlepathslides:

Diverticulitis, pelvic CT

Diverticulitis classically occurs in elderly individuals with a history of constipation. High

intrababdominal pressures from straining against hard stools cause small mucosal and
submucosal intestinal herniations through the bowel wall, forming outpouching called
diverticulosis. These commonly form in the rectosigmoid colon. When these outpouchings
get inflammed or infected, diverticulitis occurs. Clinical presentation includes left lower
quadrant pain, nausea, vomiting and a history of constipation. Diverticulitis is sometimes
called left sided appendicitis. 

 usmlepathslides #GI #IM #USMLE #step 2ck

usmlepathslides:

Barium enema with diverticulosis

Note the numerous outpouchings.

 usmlepathslides #GI #IM #USMLE #step 2ck

usmlepathslides:

Diverticulosis

This gross specimen demonstrates the development of diverticuli where the artery
penetrates the muscular wall of the colon.

 usmlepathslides #GI #IM #USMLE #step 2ck

I GET SMASHED for Acute Pancreatitis

medicalstate:

Idiopathic: Hypertensive sphincter or microlithiasis

Gallstones (45%)

Ethanol (35%)

Tumours: Pancreas. Ampulla. Choledochocele

Scorpion stings

Microbiological

Bacteria: Mycoplasma. Campylobacter. TB. M. avium intracellular. Legionella.

Leptospirosis
Viral: Mumps. Rubella. Varicella. Viral hepatitis. CMV. EBV. HIV. Coxsackie virus.
Echovirus. Adenovirus
Parasites: Ascariasis. Clonorchiasis. Echinococcosis

Autoimmune: SLE. Polyarteritis nodosa. Crohn’s

Surgery or trauma

Manipulated sphincter of Oddi (ERCP). Post cardiac surgery. Blunt trauma to

abdomen. Penetrating peptic ulcer

Hyperlipidemia 

(TG >11.3 mmol/L; >1000mg/dL). Hypercalcemia. Hypothermia

Emboli or ischemia

Drugs or toxins

Azathioprine. Mercaptopurine. Furosemide. Estrogen. Methyldopa. H2blockers.

Valproic acid. Antibiotics. Acetaminophen. Salicylates. Methanol.
Organophosphates. Steroids
Acute Pancreatitis in CT scan. Note edema around pancreas.

Sentinel loop of bowel on abdominal XR

 medicalstate #IM #GI #USMLE #step 2ck

Tx for IBD
Acute exacerbations: Budesonide, prednisone

Severe recurrence after stopping steroids: azathioprine, 6-MP

Chronic mantainance of remission: 5-ASA derivates (mesalamine:
asacol for UC, pentasa for CD, rowasa for rectum UC)

Perianal disease in Chron's: metronidazole + ciprofloxacin

Fistulae or severe/unresponsive to previous tx: anti-TNF

(infliximab, adalimumab)

Always: Calcium, Vit D

Fistulae nonresponsive to medical tx: surgery

Surgery: effective in UC (cures it), not in CD . CD indication only

with bowel obstruction (but it recurs in the site of surgery)

#GI #USMLE #IM #step 2ck

usmlepathslides:

Ulcerative colitis

This slide is a gross specimen from a case of UC.  Note the hemorrhagic ulcerated
appearance of the mucosa and the continuous involvement without skip areas.

 usmlepathslides #GI #USMLE #IM #step 2ck

usmlepathslides:

Crohn’s disease

This slide demonstrates cobblestone change in the mucosa of the colon.

 usmlepathslides #GI #USMLE #IM #step 2ck

Comb sign of Crohn's disease - radiology video tutorial (CT)

radiologysigns:

Comb sign - seen in active Crohn’s disease. It describes prominent mesenteric vessels

extending towards inflamed segments of small bowel like the teeth of a comb. The
appearance is due to a combination of vascular distension and mesenteric fibrofatty
proliferation. It can be seen on both CT and MRI.

Other important radiologic sign to remember is the “string sign” on a barium swallow XR

due to wall thickening, which narrows the contrast-filled lumen.
 radiologysigns Source: radiopaedia.org #GI #IM #USMLE #step 2ck #radiology

radiologysigns:

Lead pipe sign - describes the rigid and featureless appearance of the colon in
chronic ulcerative colitis. The sign is due to a complete loss of haustral markings and
usually a degree of uniform luminal narrowing due to chronic bowel wall thickening. It is
classically described on barium enema studies however it is also often seen with CT, MRI
and plain radiography. 

CLEUDO summary: ULCERATIVE COLITIS in the COLON with the LEAD PIPE 

 radiologysigns Source: radiopaedia.org #GI #IM #USMLE #step 2ck #radiology

usmlepathslides:

Chronic pancreatitis, abdominal x-ray

Note the diffuse collections of opacification outlining the length of the pancreas. These are
calcium deposits due to chronic pancreatitis and are picked up on AXR. Pancreatitis
classically presents with upper abdominal pain that radiates to the back as well as a
history of bulky, greasy, foul smelling stools and weight loss. 

 usmlepathslides #GI #IM #USMLE #step 2ck

homo-medicus:

There are numerous white, friable micropustules in a cobblestone pattern on labial and
buccal mucosae, as well as ulcerations and hemorrhagic crusting. These findings were
confirmed to be pyostomatitis vegetans, an oral manifestation of inflammatory bowel
disease. The lesions resolved following treatment with dapsone.

Other derm findings associated with IBD are:

Erythema nodosum [X]

Pyoderma gangrenosum [X]

 mynotes4usmle #dermatology #IM #GI #USMLE #step 2ck

 alpha 1 antitrypsin deficiency

mynotes4usmle:

alpha 1 antitrypsin deficiency (by canadaqbank)

 mynotes4usmle Source: youtube.com #pulmonology #USMLE #step 2ck #GI #IM

Whipples disease mnemonic

medicowesome:

Mini post of the day!

Whipples disease responds to antibiotics like ceftriaxone and TMP-SMX.

“Whip Whipples with antibiotics.”

W: Caused by T. Whippleii

Hip: Reminds me of arthralgias

P: For PAS positive macrophages

L: Lymphadenopathy

E: Eye findings

 medicowesome Source: medicowesome.blogspot.in #GI #mnemonic #mnemonics

#microbiology
cluelessmedic:

Diaphragmatic Hernia

affects up to 1 in 4000 births, commonly L sided

loops of bowel in chest, displacement of mediastinum
often diagnosed on antenatal ultrasound scan
present with respiratory distress
Features - reduced air entry, displaced apex beat + heart sounds
management —> large NG tube + suction, surgical correction
high mortality due to pulmonary hypoplasia

 cluelessmedic Source: learningradiology.com #GI #pediatrics #USMLE

cluelessmedic:

Omphalocele

an abdominal wall defect where the some abdominal organs remain outside the
abdomen covered by a sac of peritoneum
can be associated with cardiac abnormalities 

om P halocele   covered    by    P eritoneum

 cluelessmedic Source: dynamic.psu.ac.th #GI #Embryology #USMLE #pediatrics #peds

compoundfractur:

Mallory-Weiss Syndrome vs. Boerhaave’s Syndrome

 aspiringdoctors-blog Source: medcomic.com #Mallory-Weiss Syndrome

#Boerhaave’s Syndrome #GI #USMLE

diseasesinthreewords:
 Zenker’s diverticulum, in three words:

1. Cricopharyngeal muscle. The hernia folds backwards behind this muscle creating a
nice little pouch.
2. Dysmotility. That means that there is incoordination between the contractions of the
upper esophagus sphincter and contraction in the pharynx. The tubing would love to
see the contractions (after swallowing) move ahead towards the stomach, but they
don’t-rolling continuously behind the cricopharyngeal muscle (right behind Adam’s
apple).
3. No endoscopy. There’s always the temptation to do endoscopy to patients with
difficulty swallowing. First: barium swallow (seen in the image here, from
Wikimedia), which will show the little pouch staying filled with fluid.

 usmle1mikmonics #GI #USMLE #pathology #Zenker's diverticulum

usmlepathslides:

Menetrier’s disease

Note the giant rugal folds.

Patients lose protein in the mucus secretions.

Hyperplasic gastropathy
Increased proliferation of mucus-producing cells => huge rugal folds!
Increased mucus prod. => protein loss from excessive gastric secretions
Consequences: hypoalbuminemia, edema

 usmlepathslides #GI #USMLE #pathology #menetrier's disease

Hereditary Hyperbilirrubinemias MNEMONIC

Bb Metabolism and Pathology: here

#Biochemestry #pathology #GI #USMLE #mnemonics

Zenker’s Diverticula.
yasasiihitogomi:
Cricopharyngeus is the lowest part of inferior pharyngeal constrictor muscle.

i.e. It lies at the junction of the inferior pharyngeal constrictor and cervical esophagus,
posteriorly at about the level of C5-C6. 

Zenker’s Diverticulum
 Herniation proximal to cricopharyngeus.
Occur due to cricopharyngeal muscle dysfunction (weakness)
False diverticulum = herniation of mucosa and submucosa through muscular layer

This is another diverticulum, but it is a “true" divertivculum

Midesophageal Diverticulum = Rokitansky’s Diverticulum.

 May be formed in response to pull from fibrous adhesions following lymph node
infection (usually TB)
True diverticulum  = contains all 3 esophageal layers
Or, may form from increased intraluminal pressure and be pulsion diverticula

True diverticulum?

There are 3 “True diverticulum".

1. Gastric Diverticulum
2. Midesophageal Diverticulum (see above)
3. Meckel’s diverticulum

 yasasiihitogomi #GI #USMLE

homo-medicus:

There are numerous white, friable micropustules in a cobblestone pattern on labial and
buccal mucosae, as well as ulcerations and hemorrhagic crusting. These findings were
confirmed to be pyostomatitis vegetans, an oral manifestation of inflammatory bowel
disease. The lesions resolved following treatment with dapsone.

 ob-nurse--at-your-cervix #GI #pathology #inflammatory bowel disease #dermatology

Mnemonics: Causes Acute pancreatitis

icva:
 Mnemonic: GET SMASHED

G allstones

E thanol (very important)

T rauma

S teroids

M umps

A utoimmune (PAN)

S corpion stings

H yperlipidemia / H ypercalcemia

E RCP

D rugs

 icva #GI #USMLE #mnemonics

Osteomas

* Benign neoplasm.

* Skull and facial bones.

* If extends to sinuses or orbit => Hyperostosis frontalis interna (last 2 pics)

* Assoc. with Gardner Sd (2°,3°,4°,5° pics) 

Jaw osteomas
Multiple colonic polyps
Epidermal inclussion cysts
Skin Fibromatosis.
#musculoskeletal #GI #gardner sd #pathology #osteomas #osteoma #USMLE

ALCOHOLIC HEPATITIS

Mallory bodies are highly eosinophilic and thus appear pink on H&E stain. The bodies
themselves are made up of intermediate keratin filament proteins that have
been UBIQUINATED, or bound by other proteins such as heat shock proteins, or p62.

#GI #pathology #liver #hepatitis #alcoholic hepatitis

Cronic Hepatitis (>6 months)

Hep B => ground glass hepatocytes (black arrows)

Persitent: inflammation confined in portal tracts

Active: inflammation in parenchima

#GI #pathology #hepatitis #USMLE

AMEBIC LIVER ABSCESS

 Entamoeba histolytica
Necrotic abscess wit brown pastelike material: “Anchovy paste”
Tx: metronidazole

#GI #Pathology #Entamoeba histolytica #liver abscess #parasitology #USMLE

Acute Viral Hepatitis (<6 months)

Councilman bodies => apoptotic hepatocytes

#GI #pathology #hepatitis #USMLE

Hepatitis Viruses Mnemonic

 P residential   H onor  F ree  D.C.

Virus & Lab

A = P icornavirus, naked capside, RNA, anti-HAV-IgM

B = H epadnavirus, enveloped, DNA, anti-HBc IgM, HBsAg, HBeAg

C = F lavivirus, enveloped, RNA, anti-HVC ELISA

D = D efective, enveloped circular RNA, anti-HDV ELISA

E = C alcivirus, naked capsid, RNA, -

EDIT!!!

Hep E used to be Calcivirus. Now is Hepevirus ==> Hep E virus

New Mnemonic then:       P lease,  H elp!  F riends  D on’t  H urt

P icornavirus => Hep A

H epadnavirus => Hep B

F lavivirus => Hep C

D efective => Hep D

H epevirus => Hep E

#GI #pathology #hepatitis #hepatitis viruses #HAV #HBV #HCV #HDV #HEV #virology
#USMLE #mnemonics
Secondary Biliary Cirrhosis (SBC)
EXTRAHEPATIC DUCTS OBSTRUCTION => increased intrahepatic ducts pressure,
hence:injury, fibrosis, bile stasis

Gallstones
Billiary Stricture (PSC)
Chronic Pancreatitis
Pancreatic Head Carcinoma

Complication: ascending cholangitis

#GI #pathology #biliary tract disease #SBC #secondary biliary cirrhosis #USMLE

Primary Biliary Cirrhosis (PBC)

Autoimmune
Chronic liver disease
Inflammation + Granulomas => destruction of INTRAHEPATIC BILE DUCTS

Females, middle-aged
Increased Anti Mitochondrial Antibodies - AMA (90%)
 Increased IgM
Associated with other autoimmune diseases (CREST, RA, celiac disease)

#PBC #AMA #GI #pathology #primary biliary cirrhosis #biliary tract disease #USMLE

Primary Sclerosing Cholangitis (PSC)

Unknown etiology
Chronic Biliary tract disease
Segmental inflammation and fibrosing destruction of INTRA & EXTRAHEPATIC BILE
DUCTS.
Micro: concentric bile duct “onion skin” fibrosis, ducts “beaded-appereance” (in
cholangiogram) due to segmental stenosis   & periductal chronic inflammation
 Males
Hypergammaglobulinemia (IgM)
Associated with: Ulcerative Colitis.
Complications: Secondary Biliary Cirrhosis, Cholangiocarcinoma

#Biliary Tract Disease #GI #Pathology #PSC #primary sclerosis cholangitis #USMLE
BILIARY TRACT DISEASE FEATURES

Jaundice
Pruritus
Dark urine

Light stools
HepatosplenoMGL
Fever, chills, RUQ abdominal pain in advanced disease
LAB: increased direct Bb, Alkaline Phosphatase, cholesterol.

#GI #pathology #Biliary tract #Biliary tract disease #USMLE

radiologysigns:

Caput medusae - a clinical and radiological sign seen in severe portal hypertension. It

describes distended and engorged paraumbilical veins radiating from the umbilicus
across the abdominal wall to join systemic veins creating portal-systemic anastomoses.
The appearance is reminiscent of Medusa, a gorgon of Greek mythology, who was
encountered and defeated by Perseus. Pictured is ‘Medusa’ by Caravaggio painted in
1595.  

 radiologysigns Source: radiopaedia.org #GI #pathology #cirrhosis #radiologysigns

#USMLE
Bb Metabolism (in ESPAÑOL) and Hereditary Hyperbilirubinemias

Indirect hyperbilirubinemia (unconjugated)

No Bb uptake => Gilbert’s Sd (triggers: infx, fasting, stress)
Complete absence of UGT (UridinoDiPhospate-Glucoronyl Transferasa) => Crigler-
Najjar type I (babies, jaundice, kernicterus, death)

Decreased UGT  => Gilbert’s Sd, Crigler-Najjar type II (type II needs phenobarbital,
stimulates UGT synthesis)
Direct Hyperbilirubinemia (conjugated)
Mutation of cMOAT (Canalicular Multispecific Organic Anion Transporter) hence,
defective direct Bb excretion => Dubin Johnson (black liver) and Rotor Sd (not black
liver)
#GI #pathology #physiology #Bb #hyperbilirubinemias #jaundice #USMLE #handwritten
#Biochemestry
SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

most common type in the world

upper and middle 1/3
African Americans >>> Caucasians
Risk Factors: ABCDEF-T

A chalasia / A lcohol

B arret’s esophagus

C igarrete smoking / C eliac Disease

D iverticuli (Zenker’s) / D rugs

E sophageal webs (Plummer-Vinson Sd) / E sophagitis

F amilial

T ylosis 

ADENOCARCINOMA OF THE ESOPHAGUS

Most common in the USA

Lower 1/3
Caucasians >>> African Americans
Risk Factors: Barret’s esophagus, dysplasia

#GI #esophagus #pathology #squamous cell carcinoma #adenocarcinoma #USMLE

#mnemonics

GI Tract
INNERVATION

Intrinsic: Auerbach & Meissner Plexus (*) 

Extrinsic: Autonomic Parasympathetic (stimulatory: sensory fibers) & Sympathetic
(inhibitory: pain fibers)

(*) mutation of neural crest cells, affects its migration into the gut, hence no Auerbach or
Meissner plexus => HIRSCHPRUNG DISEASE
GALT Malfunction: Inflammatory Bowel Disease

Chron disease:  ileum

Ulcerative colitis: rectum

Crohn’s disease. Any part of the gastrointestinal tract can be affected, but most commonly,
the terminal ileum, cecum, peri-anal area and colon. It is characterized by the presence of
segments of normal bowel between affected regions, known as ‘skip’ lesions. The
intersection of linear ulcers with islands of normal or oedematous mucosa might produce a
’cobblestone’ appearance.
Ulcerative colitis. the inflammatory process invariably involves the rectum and extends
proximally in a continuous fashion, yet remains restricted to the colon. Sometimes, it is
limited to the rectum as 'ulcerative proctitis’.

Histology

Crohn’s disease. A transmural (affecting all layers of the bowel wall), dense infiltration of
lymphocytes and macrophages; presence of granulomas in up to 60% of patients; fissuring
ulceration and submucosal fibrosis (see left-hand figure).

Ulcerative colitis. Inflammation affects superficial (mucosal) layers with infiltration of

lymphocytes and granulocytes and loss of goblet cells. Presence of ulcerations and crypt
abscesses (see right-hand figure).

LIVER

Blood flow into thee liver: 75% PORTAL VEIN, 25% Hepatic Artery
Blood flow out of the liver: Hepatic Veins + IVC

FEEDING & SATIETY

Lateral hypothalamus: feeding

Ventro medial hpt: satiety

#GITract #Innervation #Biology #Embryology #GALT #Pathology #Histology #GI #USMLE

#Pediatrics #peds