Step 2 CK CCSSA NBME Form 7
Updated: Aug 28, 2020
Authors: Susan Basharkhah
Editor: Jordan Abrams
Practice exam: myNBME
Please note: The HY Medicine is in no way affiliated with the Federation of State
Medical Boards (FSMB) or the National Board of Medical Examiners® (NBME®)
BLOCK 1
1) Family therapy
• Goal of family therapy is to ↓ conflict, help family members understand each other’s needs and to help the family cope with the internally destructive forces
2) Triglycerides
• TAGs > 1,000 → acute pancreatitis
3) Splenectomy
• Spherocytes + ↑ mean corpuscular hemoglobin concentration (MCHC) = hereditary spherocytosis → sxs improve with splenectomy
4) Surgical exploration of the mediastinum
• Widened mediastinum on CXR after CABG is consistent with aortic dissection
5) Small bowel obstruction
• Severe SBO presents with:
• ↓ bowel sounds
• Distended and tympanic abdomen
• Postprandial pain
• Pain relieved with vomiting (relieves some intra-abdominal pressure)
• SBO initially has high pitched bowel sounds but a complete obstruction has ↓ or absent bowel sounds
6) Indomethacin
• Acute gout attack (swelling, erythema, tenderness of great toe)
• Celecoxib (COX-2 inhibitor) can help with gout but a non-selective COX inhibitor (Indomethacin) would be better because COX-1 inhibitor also prevents hemostasis (no build up of uric acid at a single site)
• 2nd line for acute gout attack = colchicine
7) Thoracic aorta
• Bruising and tenderness over sternum = blunt thoracic injury
• Isthmus of thoracic aorta is most vulnerable location to deceleration injuries → thoracic aortic aneurysm (widened mediastinum)
• Dx: CT angiography
8) Bone marrow aspiration
• Pancytopenia → perform bone marrow aspiration to see if this is aplastic anemia or cancer
9) Exercise stress test
• Indigestion while walking briskly or uphill that is relieved by rest is consistent with angina (especially given that her sxs are not related to eating and aren’t relieved by antacids)
• Pretest probability of CAD is intermediate in women with typical aging age 30-50 or atypical angina ≥ age 50
10) Barium swallow
• Zenker diverticulum presents with dysphagia, regurgitation, and halitosis
• Dx: barium esophagram or esophageal manometry
11) Amniotomy and vaginal delivery
• No current genital herpes outbreak → can safely deliver vaginally
• Have to rupture the still intact membranes (amniotomy)
• Pregnant women with a history of genital HSV infection should receive prophylactic acyclovir or valacyclovir beginning at 36 weeks of pregnancy
12) Urinary stasis
• High levels of progesterone during pregnancy → relaxation of ureters and bladder → urinary stasis
13) Mupirocin ointment
• Crusted, papular, honey colored lesions with clear discharge is consistent with impetigo
14) Bipolar disorder
• Remember “DIG FASTER”
• Manic episode (marked impairment) + depressive episode = Bipolar I
15) Culture for herpes simplex
• Painful vulvar blisters (vesicles, pustules, or ulcers) + systemic symptoms (malaise, myalgia) = HSV
• Genital herpes can be diagnosed with viral culture or PCR
16) Haloperidol
• Corticosteroid psychosis
17) Intravascular volume depletion
• Vitals show orthostatic hypotension
• Glucosuria-induced osmotic diuresis
18) Central retinal vein occlusion (CRVO)
• CRVO = acute or subacute U/L vision loss that is usually noted upon waking in the morning
• Risk factors: old age and HTN
• Venous occlusion → venous dilation
• CRVO is associated with a “blood and thunder” appearance (diffuse hemorrhage) and cotton wool spots (patches of white exudate)
• The key difference between CRAO and CRVO is the presence of hemorrhages. If there is no artery (CRAO) then there is no blood flow → therefore NO hemorrhages. If there is no vein (CRVO) then there is still blood coming in via the artery but the path out is obstructed → hemorrhages
• In CRAO on fundoscopic examination you will see diffuse ischemic retinal whitening, pale optic disc, cherry red fovea, and boxcar segmentation of blood in retinal veins
19) Pilosebaceous follicles
• Blockage and/or inflammation of pilosebaceous units → Acne vulgaris
20) Child abuse
• Bilateral retinal hemorrhages and neurological abnormalities (eg, poor feeding, sleeping more than usual) suggest shaken baby syndrome
21) Repeat BP measurement in 4 weeks
• Has had normal BP before most recent measurement
• HTN diagnosis requires two separate elevated BP measurements
22) Decreased calcium
• Alcoholic with low serum magnesium will also have low serum calcium
• Hypomagnesemia → PTH resistance and ↓ PTH secretion with subsequent hypocalcemia
23) IVF therapy
• Contrast-induced nephropathy could have possibly been prevented with IVF
• Had the creatinine bump been purely from hypovolemia (volume depletion/poor intake), then it would have been apparent on admission
24) Bilateral varicoceles
• Tortuous dilation of the pampiniform plexus
• Common cause of male infertility
25) Fat embolism syndrome
• Triad: respiratory distress, neurologic dysfunction, petechial rash
• Common after fracture of a long bone (contains marrow [eg, femur]) or orthopedic surgery
• Presence of petechiae helps to differentiate fat embolism from ARDS
• In fat embolism syndrome will see respiratory alkalosis vs. metabolic acidosis in ARDS
26) Osteoporosis
• Anorexia → ↓ GnRH → ↓ LH, FSH → ↓ estrogen → amenorrhea and bone loss (→ ↑ risk of osteoporosis)
27) Ankylosing spondylitis
• ‘Bamboo spine’ = fusion of vertebral bodies with ossification of intervertebral discs
• Presents with limited spinal mobility (eg, ↓ flexion at the waist), morning stiffness that improves with activity, and tenderness of sacroiliac joint
28) Compression fracture
• Prolonged corticosteroid use (eg, prednisone) → osteoporosis → ↑ risk of vertebral compression fracture
29) Pericardial window
• Treatment for cardiac tamponade (JVD, distant heart sounds, hypotension + electrical alternans) = pericardiocentesis
30) CT scan of the head
• Meningitis → have to rule out increased intracranial pressure since the patient’s optic fundi can’t be visualized
• Focal neurological findings (eg, nystagmus, right upper extremity weakness) suggests ↑ intracranial pressure (ICP)
• Head CT should be performed prior to lumbar puncture to rule out causes of ↑ ICP (eg, hemorrhages, masses)
• “FAILS” mnemonic for when to get CT before LP (would give empiric abx before going to CT)
• F = Focal neurological deficits
• A = Altered mental status
• I = immunocompromised
• L = space occupying Lesion (will have papilledema)
• S = seizures
31) Diabetes insipidus
• Removal of brain tumor likely caused central DI → lack of ADH → hypovolemic hypernatremic and does not respond to fluids (high urine output)
32) T lymphocyte dysfunction
• PDD = a Type IV Hypersensitivity Reaction (requires T cells to be functional for these tests to be reactive)
• Non-reactive PPD in the presence of Mycobacterium tuberculosis infection suggests inadequate delayed type hypersensitivity reaction and T-cell dysfunction
33) Muscle
• Statin-induced myopathy with associated proximal muscle weakness
• Decreased coenzyme Q10 synthesis (involved in muscle cell energy production)
34) Upper respiratory tract infection
• Split S2 is heard during inspiration (which is physiologic) and S3 (which is physiologic in children). Lungs are clear and he is well perfused
35) Treatment of latent TB now
• ⊕ PPD but ⊖ CXR → isoniazid + pyridoxine (B6) for 9 months
36) PCP
• Phencyclidine (PCP) intoxication: agitation, psychosis, disorientation, and nystagmus
• Agitation and aggression can be managed with a benzo
37) Thymoma
• Myasthenia gravis (weakness, lethargy, diplopia) is associated with myasthenia gravis
38) Decreased Ach-Receptors
• Myasthenia gravis: autoantibodies to postsynaptic ACh receptors at the NMJ → destruction and internalization of ACh receptors
• Diplopia and ptosis that are worse at the end of the day
• ↓ release of Ach from motor nerve terminals → flaccid paralysis seen in Botulism
39) Demyelination of axons
• Guillain-Barre syndrome → inflammation and demyelination of peripheral nerves and motor fibers
• Presents with ascending weakness and diminished/absent DTRs following a recent respiratory or GI infection
• Tx: IVIG or plasmapheresis
40) Increase the frequency of dose to every 3 hours
• She says it’s moderately effective but loses its effectiveness 3 hours after each dose → so make this the dosing regimen
41) Inadequate refrigeration of the implicated food
• Nausea and vomiting 3-4 hours after ingestion of egg salad so it is likely due to enterotoxins (if it were due to the bacteria itself then the inoculation time would be longer)
42) Increased calcium
• Erythema nodosum (tender, red nodules on the anterior shins) + B/L hilar lymphadenopathy (fullness) on CXR = sarcoidosis
• Sarcoidosis → ↑ 1α-hydroxylase vitamin D activation in macrophages of non-caseating granulomas → ↑ calcium
43) Discharge and encourage fluid intake
• Most kidney stones pass spontaneously
44) Operative procedure
• Incarcerated inguinal hernia = medical emergency (don’t waste time getting the doppler u/s)
45) Reassurance
• Most children walk their first steps independently by 12 months
• However, children <15 months that do not yet walk is normal (children >15 months that do not walk should be evaluated)
46) Randomized controlled clinical trial
• Randomized controlled clinical trials study the effect of a medication compared to a placebo or an existing standard of care medication. Therefore will be helpful in devising a treatment strategy
• The other options listed are observational studies only
BLOCK 2
1) No cleaving of C-terminal peptides on angiotensin I
• Angiotensin-converting enzyme (ACE) inhibitors decreased the conversion of Angiotensin I to Angiotensin II in the lung
2) Oral contraceptive therapy
• These will prevent ovulation; ↓ ovulation, → ↓ risk of ovarian cancer
3) Genital herpes
• Painful vesicles on an erythematous base
4) Analgesic therapy
• Poor baby is in a lot of pain, she just had a major surgery (thoracotomy)
5) Acute respiratory distress syndrome
• Non-cardiogenic (PCWP <12) pulmonary edema in the setting of severe pancreatitis and suggestive CXR findings
6) Trial of omeprazole therapy
• Burning substernal chest pain that is worse at night + a sour taste in mouth is consistent with GERD
7) Pneumococcal vaccine
• She is immunocompromised and therefore falls in the special category of people < 65 years old that should get the pneumococcal vaccine
8) Botulism
• Nausea/vomiting + bulbar symptoms (blurry vision, diplopia, miosis)
• Descending flaccid paralysis after ingestion of preformed botulinum toxin (likely from the home-canned foods)
9) Naloxone
• Need to reverse opioid overdose ASAP
10) Increased urinary excretion of calcium
• Hyperparathyroidism → Hypercalcemia
• This patient’s high-normal calcium level is due to the secretion of calcium into the urine
11) Hypertrophic obstructive cardiomyopathy
• Systolic murmur that increases with ↓ preload (eg, standing or valsalva) and ↓ afterload
12) Fibrillation potentials in multiple muscles of multiple extremities
• Combined UMN (eg, Babinski) and LMN (eg, fasciculations) degeneration is consistent with Amyotrophic lateral sclerosis (ALS)
• ALS shows fibrillations pattern representing acute denervation and large, long duration complexes representing chronic denervation
13) Wound dehiscence
• Superficial wound dehiscence presents in the 1st postoperative week with leakage of serosanguinous fluid
• Obesity → ↑ risk in patients with abdominal incisions
14) Vasovagal syncope
• Emotional response to viewing his dead brother’s body
• Emotional distress → excessive vagal (PSNS) tone → cardioinhibitory response → hypotension and bradycardia
• Pulse of 45/min (bradycardia) during the event helps rule out hypoglycemia as the cause of syncope
15) Supination of the forearm with the elbow in slight flexion
• This is nursemaid’s elbow (aka radial head subluxation)
16) Uterine atony
• Uterine atony is the most likely cause of postpartum hemorrhage in a patient with an enlarged uterus (uterus should be at the level of the umbilicus or lower after birth [this patients fundus is palpated 3cm above the umbilicus])
• The normal fundal height postpartum should be less than 2 cm, a fundal height of 3 cm indicates a boggy uterus (uterine atony)
• Fetal weight >4000g → ↑ risk of uterine atony
• Placenta appears complete but torn (r/o retained placental tissue)
• Uterine atony is the most common cause of postpartum hemorrhage
17) Atrophic gastritis
• Loss of parietal cells → loss of intrinsic factor → unable to absorb Vitamin B12 in the terminal ileum
• Correction of Schilling test with administration of oral intrinsic factor suggests that this patients megaloblastic anemia was due to lack of intrinsic factor, rather than a dietary deficiency
18) Osteoarthritis
• Describes pain over the course of a year which is a pretty long time (osteonecrosis would present much more acutely)
19) Urethral diverticulum
• Post-void dribbling associated with a tender, vaginal cystic mass
• Normal postvoid residual volume (< 150 mL for females) and urinalysis exclude other causes of incontinence
20) Diuretic therapy
• Flash pulmonary edema (B/L crackles) secondary to HF (low cardiac index means that the blood is not being pumped forward → so it is backing up in the lungs → causing a high pulmonary artery pressure
21) Carotid endarterectomy
• This is indicated if ≥ 70% stenosis of the carotid artery and the patient is symptomatic (or ≥ 80% stenosis if patient is asymptomatic)
22) IM administration of betamethasone
• Baby is <37 weeks gestational age = lungs are severely underdeveloped
23) Methamphetamine
• Formication = you feel like bugs are crawling on you
• Tooth decay and excoriations (from skin picking) are common signs of meth abuse
24) Abstinence from alcohol
• Heavy alcohol use → purkinje cell (cerebellar vermis) damage → alcoholic cerebellar degeneration → truncal ataxia (eg, impaired tandem walking)
• Tx: alcohol cessation
25) Renal ultrasonography
• Given her ↑↑ BUN and Cr, you need to assess if there is hydronephrosis causing obstructive postrenal azotemia
26) Viridans streptococcus
• Viridans group streptococci (eg, Streptococcis sanguinis, mitis, oralis, mutans, sobrinus, and milleri) are associated with infective endocarditis after gingival manipulation (eg, going to the dentist)
• Artificial valve → ↑ risk of endocarditis
27) Heat stroke
• Temperature >104 with CNS dysfunction (eg, altered mental status, confusion)
• Muscle tone would be increased if anticholinergic poisoning
28) Major depressive disorder
• Withdrawn, poor sleep, daytime fatigue (lack of energy), academic performance has deteriorated (poor concentration), flat affect (psychomotor retardation) → meets the criteria for MDD
• 5/9 SIG E CAPS, ≥ 2 weeks
29) Endoscopic retrograde cholangiopancreatography
• This patient with persistent abdominal pain after cholecystectomy likely has post-cholecystectomy syndrome
• ERCP should be used to directly visualize and find a causative factors
30) Atropine
• Needed to reverse the organophosphate poisoning (will reverse all the symptoms except seizures)
• However, organophosphate agent induced seizures should be treated with a benzodiazepine. Prophylactic diazepam has been shown to decrease neurocognitive dysfunction after organophosphate poisoning
31) Haemophilus influenzae
• Haemophilus influenzae is a gram ⊖ coccobacilli
• Pseudomonas aeruginosa is a gram ⊖ bacilli associated with ventilator acquired pneumonia
• Neisseria meningitidis = gram ⊖ diplococci
• Escherichia coli = gram ⊖ bacilli (doesn’t cause pneumonia)
32) Clomiphene
• Treatment of choice to induce ovulation in a patient with PCOS that is trying to get pregnant
33) Anaphylactic transfusion reaction
• Caused by recipient anti-IgA antibodies
• Rapid onset of shock, urticaria and respiratory distress (eg, swelling of tongue and throat) in the setting of IgA deficiency
• Anaphylaxis is an acute condition involving the skin/mucosa and either respiratory or cardiovascular
34) B lymphocyte
• Multiple infections with encapsulated organisms, in the setting of appropriate immunization suggests B-lymphocyte dysfunction
• ↓ Ig → ↓ complement activation → ↓ opsonization → ↑ susceptibility to encapsulated organisms
35) Neutrophil
• Abscess growing catalase positive bacteria = NADPH oxidase deficiency
36) Cricothyrotomy
• Gurgling sounds when she breathes means she’s about to lose her airway → intubation needed, however she has facial fractures
37) Amoxicillin
• Best choice of those listed for acute lyme disease (tetracyclines can also be used unless patient is pregnant or a child ≤ 8 years old)
• IV ceftriaxone is TOC for disseminated lyme disease
38) Rh incompatibility
• Hydrops fetalis
39) Thrombotic thrombocytopenic purpura
• Fever, anemia, thrombocytopenia, renal involvement (eg, ↑ creatinine concentration), neurologic dysfunction (eg, waxing and waning consciousness)
40) Decreased potassium
• Digoxin toxicity → new cardiac arrhythmias (eg, premature ventricular contractions)
• ↓ potassium → ↑ risk of digoxin toxicity
41) Increased calcium
• Bone metastasis (eg, breast cancer) → hypercalcemia of malignancy
• Severe hypercalcemia (>12) → confusion and delirium
42) No treatment necessary
• If you get a needle stick while drawing blood from someone that tests positive for the HepB surface antigen, you do not need any treatment if YOU have adequate concentrations of anti-HepB antibodies (because this indicates you have immunity to Hep B)
• Patient with known Hep B immunity who is exposed to the disease → give reassurance
• Patient with unknown immunity who is exposed to the disease → give HBIG and HepB vaccine
43. Enterotoxic E. coli
• She has traveler’s diarrhea aka non-inflammatory, watery diarrhea
• ETEC (Enterotoxic Escherichia coli) is the most common cause of water diarrhea
• Yersinia and Shigella both cause dysentery (bloody diarrhea)
44) Alveolar hypoventilation
• Pickwickian syndrome (obesity hypoventilation syndrome)
• Obesity → hypoventilation → ↑ PaCO2 during daytime
45) Determine if the patient wants to discuss his decision with anyone else
• Respect the patient’s wishes and his autonomy and figure out his motive’s while trying to understand where he is coming from
46) Education about puberty for the child and parents
• Normal pubertal changes
BLOCK 3
1) Epidural hematoma
• His (acute onset) symptoms suggest cord compression (secondary to a hematoma) likely due to his anticoagulation therapy with enoxaparin
2) Aspirin
• Toxicity causes an initial respiratory alkalosis followed by a metabolic acidosis
• He has an appropriate urine sodium and osmolality which indicates that his kidney function is intact
• Excessive oral intake of fluid in the absence of physiologic stimulus to drink. May include psychogenic polydipsia secondary to psychosis or other mental disorders or non-psychogenic varieties
4) Streptococcus pneumoniae
• This is the most common cause of community acquired pneumonia (PNA)
5) Lorazepam
• This is the treatment of choice to acutely terminate sxs of anxiety (tachycardia, tachypnea)
6) Blood 1+, Protein 1+, RBC 0-5, WBC 0-5, Pigmented granular Casts + renal tubular epithelial cells
• Findings are consistent with Acute Tubular Necrosis
7) Elevation of the head of the bed
• This helps to prevent aspiration pneumonia
8) Cesarean delivery
• Recurrent late decelerations indicate fetal distress
• Medical conditions must be excluded prior to diagnosing a psychiatric condition
• This patient's bradycardia and hyporeflexia suggest hypothyroidism
10) Calcium disodium edetate
• This is an indicated treatment for lead poisoning
11) Vitamin B1 (thiamine)
• Patient has a history of alcoholism and presents with ataxia & nystagmus
12) Cor pulmonale
• Perivascular changes secondary to recurrent small PE → ↑ pulmonary vascular resistance → ↑ pressure in the pulmonary circuit → ↑ RV afterload → dilatation and/or hypertrophy of the right heart
• Will present as pure right sided HF (JVD, dyspnea, ascites, LE pitting edema, cardiomegaly but NO pulmonary edema (pulmonary edema is associated with left sided HF)
13) IV labetalol
• Pt presents with aortic dissection (tearing sensation in midchest that radiates to his back and HTN)
• Tx: IV beta blockers (eg, labetalol) → ↓ heart rate, ↓ BP, and ↓ LV contractility
14) Acute cholecystitis
• RUQ abdominal pain after eating + nausea
• U/S shows cholelithiasis (she has a h/o of sickle cell disease so these are likely to be pigment gallstones 2/2 hemolysis) + pericholecystic fluid (a sign of inflammation)
15) Bartholin duct cyst
• Bartholin glands are located on the lateral sides of the vulva. They secrete mucus and can become obstructed leading to a cyst or abscess that causes pain, tenderness and dyspareunia
• Physical exam:edema and inflammation of the area with a deep fluctuant mass
16) Brief psychotic disorder
• Sxs of schizophrenia (for this patient that includes auditory hallucinations and disorganized thinking) but sxs must last less than 1 month and patient returns to baseline functioning after the episodes
17) Exploratory laparotomy
• A fixed, non-tender mass in the cul-de-sac causing ascites (positive fluid wave) is likely to be ovarian cancer
• Diagnosis and treatment depend on removal via laparotomy
• Meigs syndrome is associated with a triad of: ascites, pleural effusion, and ovarian tumor; surgical removal of the tumor leads to a resolution of sxs
18) Measurement of serum amylase activity
• Epigastric pain that radiates to the back is characteristic of acute pancreatitis
19) Measurement of platelet count
• HTN and proteinuria in a pregnant woman > 20 weeks gestation who also presents with epigastric pain and headache is concerning for HELLP syndrome → check platelet count (in this case you would expect the platelet count to be low)
20) Digestive enzyme deficiency
• Primary lactase deficiency (age-dependent decline after childhood) is common in people of African, Asian or Native American decent
• Celiac disease is more common in Northern Europeans
21) Costochondritis
• The pain began after physical exertion (moving heavy furniture), is pleuritic (worse with inspiration) and is reproducible (tenderness to palpation lateral to the sternum)
22) Duplex scan
• Pt is 3 days post op → perfect timing for a possible DVT (tightness and tenderness to palpation of the left calf)
23) Colonoscopy
• He has a ⊕ FOBT
24) Bromocriptine therapy
• Prolactinomas should be managed conservatively with dopaminergic agents (eg, bromocriptine) before surgery is considered (eg, transphenoidal resection)
25) Reassurance
• Subconjunctival hemorrhage will spontaneously resolve
• Given that she has perfect visual acuity and no eye pain best no treatment is indicated
26) IV penicillin G
• She is in active labor and has a history of GBS UTI → intrapartum prophylaxis with penicillin is indicated
27) Brisk rotatory nystagmus on left lateral gaze
• Decreased upward gaze is a common finding in the elderly. While rotary nystagmus can be due to a number of etiologies (eg., MS, midbrain lesions, medulla involvement)
28) Repeated microfracture at the tendon insertion
• An active teenager has tenderness and swelling over the left tibial tubercle and the pain is worse with jumping = Osgood-Schlatter Disease (aka tibial tubercle apophysitis)
29) Esophageal peristalsis ↓, Lower esophageal sphincter tone ↑
• On Manometry, achalasia presents with ↑ LES resting pressure, incomplete LES relaxation, and ↓ peristalsis of distal esophagus (due to atrophy of smooth muscle in the lower esophagus)
30) Increased sensitivity, decreased specificity
• Lowering the cutoff point means → catch more of the true positives → ↑ sensitivity at the expense of having more false positives (which causes the specificity to ↓)
31) XR of the L hip
• Young obese patient with severe pain in the knee and hip
• Since there are no signs of inflammation, his pain is likely due to slipped femoral capital epiphysis SCFE (hip pain can present as referred hip and/or knee pain)
32) Aortic stenosis
• Diminished carotid upstrokes = LV is pumping out a ↓ cardiac output (since the stenotic aortic valve requires a lot of pressure to overcome and open) b. A systolic murmur that radiates to the carotids = AS
33) Meningococcemia
• Fever, headache, and neck stiffness (nuchal rigidity) suggest meningitis
• If due to N. meningitidis, patient will also likely have myalgia and a petechial or purpuric rash
34) SLE
• ↓ C3, ⊕ ANA, arthralgias, rash over cheeks, UA highly suggestive of SLE (SLE is a clinical diagnosis need to have 4 of the 11 diagnostic criteria)
35) Allergic bronchopulmonary aspergillosis (ABPA)
• Productive cough with occasional hemoptysis, ↑ eosinophils and serum IgE (asthmatics are more likely to develop ABPA), CXR findings of linear atelectasis (bronchiectasis) and cystic opacities (possible mucus plugging)
• Chronic exposure to Aspergillus can result in ABPA, presenting with asthmatic symptoms or sinusitis, especially in patients with a history of asthma or cystic fibrosis. It is primarily managed with glucocorticoid therapy
36) Cutaneous larva migrans
• ↑ eosinophil count suggests a parasitic infection even though the stool O&P is negative
• He is presenting with a cutaneous manifestation (which explains why there is nothing in his stool) of a nematode infection → pruritic, erythematous lesion that looks like it is composed of many small lines (or serpiginous tracks),which indicates a cutaneous migration of larvae and a resulting allergic reaction to parasites
37) C1 esterase inhibitor
• A deficiency of C1 esterase inhibitor → buildup of bradykinin (potent vasodilator) → hereditary angioedema and edema secondary to ↑ vascular permeability (but no pruritus)
38) Femoropopliteal arteries
• Narrowing of vessels proximal to claudication site
• Aorta or iliac artery narrowing would cause claudication of thigh and hip muscles as well (not present in this patient)
39) Colonoscopy to the cecum
• Anoscopy only allows visualization of the anal canal
• Therefore, the next best step is something that allows visualization of the entire area (that might be cancerous)
40) HIV antibody testing
• Disseminated molluscum contagiosum (flesh colored papules with a central umbilication) suggest the patient is immunocompromised
41) Paget disease of the breast
• Paget’s = ductal carcinoma (usually adenocarcinoma - either in situ or invasive) → erythematous, scaly, or vesicular rash affecting the nipple and areola
• Typically presents with Pruritus, burning, & nipple retraction → lesion eventually ulcerates → blood-tinged nipple discharge
• Think Paget’s when a post menopasual woman presents with breast changes that could be mistaken for eczema (like this patient that presents with peeling, scaling and cracking of the right nipple)
42) Physiologic discharge
• She has no masses or calcifications on breast exam or mammography, suggesting she has no actual pathology of the breast
43) XR of the chest
• Postoperative atelectasis after a splenectomy (which places her at ↑ risk of infection with encapsulated organisms such as S. Pneumoniae) in combination with ↓ breath sounds and leukocytosis suggests possible consolidation from pneumonia
• CXR is next best step as it is inexpensive and quick
44) Cardiogenic shock
• ↑ RA pressure (preload), ↑ PCWP (preload), ↓↓ Cardiac index (pump function)
45) Acute stress disorder
• Develops after a traumatic event (eg, witnessing a close friend die in a motor vehicle collision) and sxs last > 3 days but < 1 month (same sxs as PTSD but the key difference is the duration of sxs and how soon they occur after inciting event)
• This patient has dissociative amnesia (he does not remember much about the incident), hyperarousal and intrusive thoughts (recurrent nightmares, waking up in a sweat, sleep disturbance), avoidance/withdrawal (does not want to socialize with friends), negative mood (flat affect)
46) EBV infection
• Exudative pharyngitis, cervical lymphadenopathy, and splenomegaly → suggest infectious mononucleosis which is commonly due to EBV (positive heterophile test) or less commonly CMV (negative heterophile test)
BLOCK 4
1) Dopamine
• Antidopaminergic medications used to treat schizoaffective can cause neuroleptic malignant syndrome (fever, HTN, muscle rigidity and elevated serum CK)
2) The results are not adjusted for comorbidities
3) Pleural metastases
• Breast cancer commonly metastasizes to the lungs
4) Organophosphate
• Diaphoresis, bradycardia, hypotension, bronchoconstriction (poor air entry and wheezing), increased bowel sounds, rhinorrhea and drooling all suggest increased Ach levels secondary to organophosphate poisoning
5) Pelvic inflammatory disease
• Multiple sexual partners with inconsistent condom use, abdominal pain, fever, leukocytosis, and cervical/adnexal tenderness in the setting of a ⊖ pregnancy test all suggest PID
6) Finasteride
• BPH tx: alpha-1 antagonists (eg, tamsulosin, doxazosin, terazosin) and 5-alpha-reductase inhibitors (eg, finasteride, dutasteride)
• Alpha-1 antagonists cause orthostatic hypotension, and are therefore contraindicated for patients that have existing orthostatic hypotension secondary to autonomic dysfunction
7) Give all recommended immunizations for age
• Premature infants should be immunized according to their chronological age. Vaccine doses should not be reduced for preterm or low-birth-weight infants (with the exception of Hep B vaccine which cannot be administered to premature infants if they weigh less than 2000g
8) Destruction and dilation of the distal airways
• Bronchiectasis - patient with productive cough and recurrent pneumonia; on CXR will see multiple cysts and bronchial crowding (however these findings are nonspecific)
9) Mitral valve incompetence
• GAS pharyngitis → acute rheumatic fever → holosystolic murmur in the 4th ICS at the MCL (murmur of mitral regurgitation)
10) Magnesium sulfate
• This is the treatment of choice for neuroprophylaxis if delivery occurs before 32 weeks of gestation
11) Viral infection
• Postviral inflammation → Subacute thyroiditis (de Quervain thyroiditis)
• Tender goiter, fever, hyperthyroid symptoms
12) Surreptitious administration of thyroxine
• Decreased radioiodine uptake suggests either Thyroiditis or exogenous thyroid hormone
• Duration of hyperthyroid symptoms and non-palpable thyroid suggests surreptitious thyroxine (eg., weight loss pills that contain bovine thyroxine)
13) Pill induced esophagitis
• Esophageal mucosal irritation secondary to oral medications
14) Schizophrenia
• 1 year history of auditory hallucinations and bizarre behaviors
15) Transfusion of group O, Rh-negative packed red blood cells
• Patient still unstable after infusion of 3L crystalloid
• Acute hemolytic transfusion reaction - after blood transfusion the patient remains tachycardic and hypotensive (remember that group O blood will have anti-A and anti-B antibodies)
16) Radiation therapy
• Radiation is indicated for cancers that have metastasized to the spine
17) Olanzapine therapy
• Atypical antipsychotics are the treatment of choice for schizophreniform
18) No intervention is necessary
• The mothers all have a history of chickenpox prior to pregnancy → therefore they will all have immunity to varicella virus and protective IgG antibodies will be transferred to the babies via the placenta
19) Colposcopy
• If pap smears shows high grade squamous intraepithelial lesion the next step depends on the patient’s age
• If 21-24 yrs → colposcopy → if CIN II or CIN III → excisional or ablative treatment
• If > 24 yrs → colposcopy or loop electrosurgical excision (LEEP) is indicated
20) No pharmacotherapy is indicated at this time
• The rash described is that of Erythema Infectiosum (aka 5th’s disease due to parvovirus B19)
21) Interferon-alpha
• Mixed cryoglobulinemia is associated with HCV infection
22) Fibrosis of the sternomastoid muscles
• Congenital muscular torticollis
• Contracted SCM muscle → head tilted toward affected muscle, chin points away from contracted muscle
• Treatment involves early physiotherapy and passive positioning
23) Hypovolemia
• Skin is cool and clammy, iindicates that SVR is high in an effort to divert blood flow away from the extremities to maintain perfusion to vital organs
• Extensive vomiting a common cause of hypovolemia
24) Abruptio placentae
• Painful third trimester vaginal bleeding
25) Appendicitis
• RLQ tenderness with rebound, fever, and leukocytosis with no adnexal masses on U/S (which rules out ovarian torsion)
26) Increased serum LDH activity
• Firm rubbery LN is likely a lymphoma, ↑ cell turnover → ↑ serum LDH
27) Observation
• Subclavian catheter is in good position,so there is no need to adjust or remove it
• Pneumothorax (PTX) is a common complication of placing a subclavian catheter, but this patient's PTX is small and she is not presenting with signs of respiratory distress
• A small PTX (<20% in size) with no signs of respiratory or circulatory collapse will resolve spontaneously; 100% O2 will accelerate resorption of ai
28) Add lisinopril to the medication regimen
• ACEi are renal protective for patients with DM
29) Observation
• The ulcer has healed so there is no medical treatment indicated at this time
• Sliding hiatal hernias (type 1) are treated medically (unless refractory)
• Paraesophageal hernias (type 2) treated surgically because of the risk of strangulation
30) Bronchogenic carcinoma
• This is likely hypertrophic osteoarthropathy (a paraneoplastic syndrome secondary to to lung cancer)
• Presents with clubbing of fingers/toes and swelling/pain in joints/long bones
31) Wiskot-Aldrich syndrome
• X-linked disorder that presents with recurrent infections, eczema and thrombocytopenia, ↓ IgM
32) Decreased renal blood flow
• Patient has CKD so his BUN/Cr ratio is showing an intrinsic kidney problem
• Patient then has furosemide added changing the ratio from 8.3 to 10.4 - this increase in ratio could suggest CKD with superimposed prerenal azotemia
• Glomerulonephritis would show RBC casts
• Interstitial nephritis would show WBC casts & eosinophils
• Tubular Necrosis would show granular casts
33) Oral propylthiouracil therapy
• She is presenting with signs and sxs of hyperthyroidism (fatigue, palpitations anxiety, weight loss, heat intolerance, increased bowel movements)
• Confirmed by ↓ TSH and ↑ T4 as well as ↑ uptake on thyroid scan
34) IV 0.9% saline
• If a patient is suspected of having myoglobinuria or rhabdomyolysis they should immediately be started on IV hydration
• Creatine Kinase (CK) level > 5000 = an absolute indication for hospital admission and aggressive IV hydration → vigorous IV hydration prevents precipitation of myoglobin in the urine → therefore brik diuresis will prevent ATN 2/2 nephrotoxic
35) Spinal dysraphism
• Malformations in the dorsum of the embryo, such as neural tube defects
36) Zinc
• Zinc deficiency classically presents with acral or periorificial dermatitis, alopecia and diarrhea
• Zinc deficiency also causes impaired wound healing, hypogonadism, and an altered sense of taste and smell
37) Stasis dermatitis with ulcer
• Venous ulcers (caused by chronic venous insufficiency) classically develop superior to the medial ankle and are often associated with skin changes (eg, hyperpigmentation) and unilateral edema
38) Coercion of a vulnerable population
• Prisoners (along with children, eldery, and pregnant) are considered vulnerable populations. In this example, prisoners are coerced/persuaded to participate in exchange for early parole
39) Vancomycin
• Patient has a ⊕ culture showing gram-positive cocci in clusters (likely S. aureus) and he has a subclavian catheter → most appropriate antibiotic is one that has gram-positive coverage as well as MRSA coverage
40) Optic neuritis
• Eye pain and ↓ vision suggest optic neuritis
• Optic neuritis + relative afferent pupillary defect suggest multiple sclerosis (MS)
41) Spondylolisthesis
• A condition in which a vertebral body slips forward in relation to the vertebra beneath
• Most commonly involves L5 slipping over S1
• Most commonly affects children, adolescents, and in individuals > 50 years of age
• Can be asymptomatic or cause lumbar pain on exertion, gait problems, radiculopathic pain, or urinary incontinence
42) Acute MI
• EKG shows ST segment elevation in leads V2-V6
43) Ventricular tachycardia
• EKG shows 2 wide QRS complexes in a row with a rate of > 120
44) Internal carotid artery
• The bright yellow plaque seen on funduscopic examination is likely a thrombotic atherosclerootic plaque that has dislodged from the ICA
• Of the arteries listed, only the ICA branches into vessels that feed the brain and eye (ie, retinal artery), leading to transient blindness
45) Viral pleurisy
• Acute onset pleuritic chest pain (increases with inspiration), SOB, fever, and an inspiratory rub all suggest acute pericarditis
46) Inappropriate ADH
• Hyponatremia with Uosm >300
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