Arrows Flashcards
(255 cards)
1
Q
Fever of 104 + abdo distension in C diff. Dx and Tx
A
toxic megacolon
laparotomy
2
Q
Hx of surgery + high-pitched bowel sounds or acute-onset abdo symptoms
A
small bowel obstruction
3
Q
Cardiac ischemia + need to evaluate
A
ECG stress test first-line
4
Q
Cardiac ischemia + abnormal baseline ECG (e.g., BBB)
A
Echo stress test (need normal ECG to do ECG stress test)
5
Q
Cardiac ischemia + patient can’t exercise
A
dobutamine + ECG/echo
6
Q
ECG shows diffuse ST-segment elevations
A
pericarditis
7
Q
Pericarditis Tx
A
NSAID, or steroid, or colchicine
8
Q
Central chest pain worse when supine; better when leaning forward
A
pericarditis
9
Q
Lateral chest pain after viral infection + increased CK
A
pleurodynia (intercostal muscle spasm)
10
Q
ST-segment depressions in the anterior ECG leads
A
posterior MI
11
Q
High hemoglobin +/- pruritis after shower +/- plethora +/- splenomegaly
A
polycythemia vera
12
Q
High hemoglobin + low EPO
A
polycythemia vera
13
Q
Pruritis after shower
A
basophilia
14
Q
High hemoglobin + lung disease / low pO2
A
secondary polycythemia (high EPO)
15
Q
Polycythemia + hypercalcemia + smoker + red urine
A
RCC (paraneoplasic EPO + PTH-rp)
16
Q
Blurry vision or Raynaud or pain in fingers or headache
A
hyperviscosity syndrome: Waldenstrom macroglobulinemia or polycythemia
17
Q
Hereditary spherocytosis genetics and tx
A
AD, ankyrin or spectrin or band protein deficiency
splenectomy
18
Q
Treatment for ITP
A
steroids, then IVIG, then splenectomy
19
Q
Abx (clindamycin, beta-lactam, cephalosporin) + diarrhea
A
C. difficile
20
Q
Dx of C. diff
A
stool AB toxin test, not stool culture
21
Q
Tx of C. diff
A
vancomycin, not metronidazole
22
Q
36M + long-bone fractures + petechiae on the chest
A
fat embolism
23
Q
Motor vehicle accident (MVA) + paradoxical breathing (chest moves outward with exhalation; inward with inhalation)
A
flail chest
24
Q
MVA + rib fractures + underlying infiltrates in lung + low O2 sats
A
pulmonary contusion
25
MVA + no rib fractures + non-central chest pain + pulmonary infiltrates underlying the painful area
pulmonary contusion
(resources will say “white out of the lung” for pulmonary contusion, but this is buzzywordy and never shows up on actual NBME material)
26
MVA + pulmonary infiltrates + low O2 sats + bolus of normal saline given, resulting in worsening of O2 sats
pulmonary contusion (contused lung is very sensitive to fluid overload)
27
MVA + bruising/pain over the sternum +/- rib fractures
myocardial contusion
28
MVA + bruising/pain over sternum + pulmonary infiltrates + O2 sats get worse when saline is given
myocardial contusion
(“Wait, but I thought you said that latter finding means pulmonary contusion” it does, and it’s HY for pulmonary contusion, but “bruising/pain over the sternum” wins if it’s listed; this is on a 2CK NBME)
29
Electrolyte abnormality in rhabdo
hyperkalemia (cell lysis + renal failure bc myoglobin causes acute tubular necrosis)
30
40s male + hematuria + hemoptysis
Goodpasture syndrome
31
Antibodies in Goodpasture
Anti-GBM (anti-collagen IV)
32
Dx of Goodpasture
antibodies first, but confirmatory is renal biopsy showing linear immunofluorescence
33
Mnemonic Goodpasture syndrome
“2, 3, 4… 2, 3, 4… 2, 3, 4. The Goodpasture is marching in the field, 2, 3, 4!” Type 2 hypersensitivity (autoantibodies against one’s own cells + receptors) against the alpha-3 chains of type 4 collagen
34
Neonate born at <34 weeks gestation + difficulty breathing; Dx and what is deficient in this patient
NRDS
lamellar bodies - specialized organelles within type II pneumocytes that produce
surfactant
35
Neonate born at <34 weeks’ gestation + difficulty breathing; Dx and lecithin / sphingomyelin ratio and elastic recoil of
NRDS
These kids have decreased lecithin/sphingomyelin ratio (i.e., <2.0)
elastic recoil is increased in NRDS due to lack of surfactant; surfactant normally prevents the hydrostatic forces of the alveoli from causing collapse.
36
woman giving birth at 33 weeks’ gestation was given a bolus of corticosteroids 12 hours ago. They ask for next best step
“bolus of corticosteroids.” Sounds weird because they said it was just done, but she needs two boluses
In order to prevent NRDS, a pregnant woman giving birth <34 weeks’ gestation must be two boluses of corticosteroids within 24 hours of parturition, which accelerate fetal lung maturity.
37
Neonate born at <34 weeks’ gestation + difficulty breathing; Dx and Tx
NRDS
For management, 2CK wants tactile stimulation first, then place under warming lights. This sequence is HY. Then give exogenous surfactant and oxygen.
38
30F + pancreatitis + ARDS; following complete resolution of the ARDS, what is most likely to be increased in this patient’s lungs?
surfactant protein D (marker of lung injury); weird, but know it because it’s on NBME.
39
Tx for arterial insufficiency
exercise regimen first, THEN cilostazol (phosphodiesterase 3 inhibitor)
40
What must you do before starting the exercise regimen in the Tx of arterial insufficiency
ECG stress test to ascertain patient’s exercise tolerance
41
Medial malleolus ulcer + hyperpigmentation of lower legs; Dx?
chronic venous insufficiency
42
Punched-out ulcer on foot + intermittent claudication; Dx?
arterial insufficiency (peripheral
vascular disease)
43
What causes venous insufficiency?
valvular incompetence (most commonly familial), resulting in
venous reflux + insufficiency
44
Treatment for erysipelas + cellulitis
oral dicloxacillin or oral cephalexin, both agents cover Staph + Strep; penicillin only covers Strep.
45
Severe skin infection involving fascial planes + cutaneous crepitus; organism?
Clostridrium perfringens causing necrotizing fasciitis (polymicrobial, but the C. perfringens causes the gas gangrene leading to cutaneous emphysema / crepitus).
46
Tx for nec fasc
surgical debridement + IV broad-specrum Abx with anaerobic coverage.
47
Perineal gangrene in 50M diabetic. Dx and tx
Fournier gangrene - do surgical debridement.
48
17M comes to emergency with cellulitis + getting worse + holding amoxicillin canister he got from GP; Dx?
improper Abx treatment; should have received oral dicloxacillin or oral cephalexin outpatient, cellulitis must have been caused by Staph not Strep.
49
17M comes to emergency with cellulitis + getting worse + holding amoxicillin canister he got from GP; dx and what do you do?
dx: improper Abx treatment; should have received oral dicloxacillin or oral cephalexin outpatient, cellulitis must have been caused by Staph not Strep.
what do you do: Stat dose of IV flucloxacillin or IV cephazolin (inpatient equivalents of oral dicloxacillin + oral cephalexin).
50
Why doesn’t amoxicillin or penicillin cover Staph?
Most community Staph (not MRSA; just MSSA) produces beta-lactamase, so much give beta-lactamase-resistant beta-lactam (diclox and fluclox are steric; drugs like nafcillin and oxacillin are typically used for osteomyelitis; 6 weeks nafcillin is classic for confirmed MSSA endocarditis).
51
17M comes to emergency with cellulitis + getting worse + holding amoxicillin canister he got from GP; dx and what do you do?
Stat dose of IV flucloxacillin or IV cephazolin (inpatient equivalents of oral dicloxacillin + oral cephalexin).
52
Why doesn’t amoxicillin or penicillin cover Staph?
Most community Staph (not MRSA; just MSSA) produces beta-lactamase, so much give beta-lactamase-resistant beta-lactam (diclox and fluclox are steric; drugs like nafcillin and oxacillin are typically used for osteomyelitis; 6 weeks nafcillin is classic for confirmed MSSA endocarditis).
53
Renal issue + beta-lactam or cephalosporin
interstitial nephropathy (aka tubulointerstitial nephritis), WBCs on dipstick (eosinophils on Homer-Wright staining).
54
40F + found in street with hypothermia + rewarmed in hospital + picture is shown of her feet and they’re red; what electrolyte are we most worried about?
hyperkalemia, reperfusion injury causes oxygen radicals that increase the risk of rhabdo, especially in alcoholics.
55
Stress incontinence cause
Weakened pelvic floor muscles resulting in loss of urine with increased abdominal pressure (coughing, sneezing, laughing), Hx of multiple pregnancies classic, but often too easy of a descriptor and they won’t say that; l they’ll say there’s “downward movement of the vesicourethral junction with
coughing
56
USMLE might ask you which muscle is not strengthened by Kegel exercises
internal anal sphincter, even if you have zero clue about Kegel
exercises, bear in mind internal sphincters (urethral + anal) are under sympathetic control, you
can’t voluntarily strengthen a muscle not under somatic (voluntary) control
57
Stress incontinence next best step in Mx?
pelvic floor (Kegel) exercises, if insufficient, do mid-urethral
sling; do not give medications for stress incontinence (HY!)
58
50M + severe upper back pain + 3/6 holo-diastolic murmur loudest after S2; Dx and cause of murmur?
aortic dissection
classically pain radiating back between the scapulae; retrograde propagation of the dissection can cause aortic root dilation with aortic regurgitation (decrescendo holo-diastolic murmur)
59
50M + severe upper back pain + 3/6 holo-diastolic murmur loudest after S2; Dx and CXR?
aortic dissection; classically pain radiating back between the scapulae
CXR shows widening of the mediastinum
60
50M + severe upper back pain + 3/6 holo-diastolic murmur loudest after S2; Dx and tx?
Aortic dissection; classically pain radiating back between the scapulae
give labetalol to decrease shearing forces
61
50M + severe upper back pain + 3/6 holo-diastolic murmur loudest after S2; Dx and RFs?
Aortic dissection; classically pain radiating back between the scapulae
increased risk in connective tissue disorders such as Marfan and Ehlers-Danlos; greatest risk factors are hypertension and cocaine use.
62
25M + rash on palms and soles + receives antibiotic Tx with drug he has received in the past; following current Tx, now has fever, tachycardia, and tachypnea; what’s the most likely diagnosis?
Jarisch-Herxheimer reaction; answer can also be written as “reaction to lysis of spirochetes”; patient has secondary syphilis (Treponema pallidum), as indicated by the palms/soles rash; Tx is with penicillin G; lysis of spirochetes can cause anaphylaxis-like immune response known as J-H reaction.
63
32F + G1P0 + third trimester + itchy hives-like eruptions within abdominal striae; Dx + Tx
pruritic urticarial papules and plaques of pregnancy (PUPPP);(usually primigravid); cause is unknown, presents as pruritic hives-like eruption within striae
Tx is with topical emollients; for severe cases, topical steroids can be given; resolves spontaneously within a week of delivery.
64
25F + G1P0 + third trimester + itchy palms + soles; Dx + way to diagnosis?
intrahepatic cholestasis of pregnancy (ICP); usually occurs third trimester; pruritis, particularly of palms + soles
diagnosis is achieved by ordering serum bile acids (elevated)
65
25F + G1P0 + third trimester + itchy palms + soles; Dx + tx?
Tx = ursodeoxycholic acid (ursodiol); important to note that ICP is associated with increased risk of third-trimester spontaneous abortion – i.e., it is
not benign; delivery at 35-37 weeks may be considered; if bile acid levels normal, new literature suggests waiting until 39 weeks is acceptable.
66
32F + 30 weeks’ gestation + 10-day Hx of nausea and generalized itching + bilirubin 2.1 mg/dL + ALT/AST/ALP all normal
intrahepatic cholestasis of pregnancy; no mention of palms + soles itching in vignette.
67
36F + G1P0 + 36 weeks’ gestation + nausea/vomiting + jaundice + high bilirubin + high ALT and AST + no mention of pruritis of palms/soles; Dx and cause?
acute fatty liver of pregnancy
caused by deficiency of long-chain 3-hydroxyacyl-CoA dehydrogenase (sounds absurdly pedantic but asked on Obgyn shelf); often fatal
68
29F + G1P0 + 2nd or 3rd trimester + intensily itchy eruption around umbilicus that spreads outward; Dx + Tx?
herpes gestationis (gestational pemphigoid); not HSV, but instead an idiopathic autoimmune phenomenon
Tx = topical steroids.
69
36F + G1P0 + 36 weeks’ gestation + nausea/vomiting + jaundice + high bilirubin + high ALT and AST + no mention of pruritis of palms/soles; Dx and Tx?
acute fatty liver of pregnancy
Tx is IV hydration + hepatology/high-risk obgyn consults + delivery.
70
31F + Hx of ITP + has splenectomy + platelet count goes back to normal; 6 months later, she has low platelets again; why?
accessory spleen; 10% of people have a second, accessory spleen
that is less than a centimeter in size; after splenectomy, the accessory spleen can grow in size; if the USMLE Q gives you ITP that was definitively managed with splenectomy, but then the ITP “comes back,” the answer is accessory spleen
71
49M + long history of alcoholism + presents with smelly stools + pancreatic enzymes are normal; Dx and Tx?
chronic pancreatitis, exocrine pancreas insufficiency due to repeated bouts of acute pancreatitis; pancreatic enzymes low or low-normal; steatorrhea from lack of lipases in pancreatic secretions
Tx with pancrelipase.
72
49M + alcoholism + had pancreatitis a week ago and recovered well with bedrest; now has fever + leukocytosis + increased serum lipase and amylase; diagnosis and Tx?
pseudocyst; this is a common complication of acute pancreatitis; called a pseudocyst because it doesn’t have actual walls; the pancreatic parenchyma encases the fluid collection
Tx: can be drained internally via ERCP (2CK surg NBME).
73
Vomiting a few hours after eating meat
S. aureus preformed heat-stable toxin
74
Vomiting (or any unusual Sx like bloody diarrhea) + eating custards, creams, potato salad
S. aureus preformed HS toxin, the type of food in this scenario “wins” over the weird bloody
diarrhea finding, bear in mind typical bloody-diarrhea-inducing gram (-) rods like EHEC, Yersinia
enterocolitica, Campylobacter, Shigella, Salmonella have ~1-3-day incubation period); iow, if you get sick on the scale of hours from food, S. aureus preformed toxin is likely
75
17M + on the crew team + repeated water exposure; how best to prevent otitis externa?
in contrast, how what used for cerumen (wax) buildup.
prophylactic alcohol-acetic acid drops
in contrast, carbamide peroxide drops are for cerumen (wax) buildup.
76
10-month-old female + fussy + fever + no movement of left tympanic membrane on pneumatic otoscopy; Dx?
otitis media
the wrong answer is otitis media with effusion; immobility of tympanic membrane = most sensitive finding for otitis media – i.e., if a Q tells you the tympanic membrane is mobile, the Dx is not OM
77
8M + Hx of ear infection one month ago + slightly reduced hearing in one ear + otoscopy shows fluid behind the tympanic membrane + afebrile and well-appearing; Dx + Tx?
otitis media with effusion (serous otitis media); fluid accumulation seen occasionally in middle ear after resolution of OM (need not be recurrent OM)
Tx is observation, as will usually self-resolve in 4-8 weeks.
78
7M + otoscopy reveals squamous proliferation seen behind tympanic membrane; Dx + Tx?
cholesteatoma; will gradually grow and invade inner ear, causing irreversible hearing loss
Tx is surgical excision.
79
2F + fever 103 + tugging on pinna + pinna is displaced upward and outward + tenderness of mastoid process; next best step, likely dx, and Tx?
NBS: CT of the temporal bone; sounds incredibly wrong to do a CT on a kid in this scenario, but this is the answer on the Peds NBME
Dx: mastoiditis (malignant otitis externa) is sometimes associated with a temporal bone fluid collection that must be drained to prevent brain abscess; MRI or CT must be done; x-ray is the wrong answer
Tx: fluid collection must be drained as best answer; IV broad-spectrum antibiotics are then administered.
80
Tx of otitis externa
topical ciprofloxacin + hydrocortisone drops
81
Prophylaxis for otitis externa (i.e., in someone with continued water exposure, like crew)
topical alcohol-acetic acid drops
82
Most common cause of otitis media?
Strep pneumoniae
83
Tx of otitis media?
oral amoxicillin only
84
Tx of recurrent OM
amoxicillin/clavulanate
85
When to do tympanostomy tube?
three or more OM in 6 months, or 4 or more in a year
86
Most common cause of otitis externa?
Pseudomonas
87
Tx of otitis externa?
topical ciprofloxacin + hydrocortisone drops.
88
8M + Hx of asthma + recent dysphagia to solids + upper endoscopy shows many concentric rings; Dx? endoscopy? Biopsy?
eosinophilic esophagitis with dysphagia and/or weight loss in patient with asthma
endoscopy shows “trachealization” of the esophagus
biopsy shows dense eosinophil infiltrates.
89
6F + attended summer camp for one month + comes home with peach-colored papules with central umbilication; Dx?
molluscum contagiosum.
90
4M + itchy head + small oval areas of alopecia on scalp; most likely causal organism? Dx and tx? Reduce risk?
Trichophyton tonsurans
Dx is tinea capitis (cradle cap)
Tx with oral griseofulvin for patient only
Reduce risk by not sharing hats (three Qs on the peds forms right there).
91
16M + large red, non-vesicular rash on the chin; Q asks for Dx and cause based on image
impetigo
don’t go chasing HSV or tinea faciei; Often confused with herpes: If they show you image of young kid in particular with lip lesions, it’s usually impetigo
caused by S. aureus or Group A Strep (S. pyogenes)
92
11M + 7-day-Hx of yellow crusties around his lips + red urine; what’s the mechanism
“antigen-antibody immune complex” (PSGN) caused by Strep impetigo (be aware that S. aureus exceeds Group A Strep for both bullous and non-bullous impetigo).
93
11M + yellow crusties on face; Tx?
topical mupirocin (USMLE will not force you to choose between topical mupirocin and oral dicloxacillin / cephalexin for bullous impetigo; I point this out because more extensive impetigo can be managed with oral Abx, but NBME wants mupirocin; if the latter is not listed, choose oral dicloxacillin or oral cephalexin; these orals have MSSA coverage; amoxicillin and penicillin do not).
94
30M + rheumatoid arthritis + overdosed on methotrexate in suicide attempt + now has massive hepatonecrosis; the liver can regenerate via which of the following cellular mechanisms?
recruitment of cells from G0 into cell cycle; when there is hepatocellular damage, remaining cells in
G0 (quiescent phase) will enter G1 of the cell cycle and begin replication; the wrong answer is stem cells entering G1 of cell cycle; this is because stem cells aren’t activated into G1; it is merely the case that other hepatocytes exist in G0, not undergoing replication, and are then stimulated into G1 for replication.
95
Protozoan is a unicellular eukaryote. GI protozoa and method of cyst acquisition
ECG, Entamoeba histolytica, Cryptosporidium parvum, and Giardia lamblia: all GI protozoa that are acquired via cysts in water (i.e., they are water-borne).
If “water-borne” and “fecal-oral” are both listed as answers, USMLE wants “water-borne” as means of acquisition
96
Bloody diarrhea in person who went to Mexico
Vs
Watery diarrhea in person who went to Mexico
Vs
Steatorrhea in person who went to Mexico (Steatorrhea = bloating + extremely foul smelling stool that floats; steatorrhea is due to malabsorptive diarrhea)
Bloody diarrhea - Entamoeba histolytica
Vs
Watery diarrhea - Cryptosporidium parvum
Vs
Steatorrhea - Giardia lamblia
97
Entamoeba histolytica presentation
- Bloody diarrhea in person who went to Mexico
- Can cause “flask-shaped ulcers” in the small bowel and liver abscess.
98
Entamoeba histolytica LM findings
Demonstrates “erythrophagocytosis,” where RBCs can be seen within it on LM.
99
Tx Entamoeba histolytica
Intraluminal parasite Tx Entamoeba histolytica
Treat with metronidazole.
Iodoquinol kills intraluminal parasite
100
Cryptosporidium parvum presentation
Watery diarrhea in person who went to Mexico.
101
Dx and staining
Cryptosporidium parvum - Appears as acid-fast cysts (same stain as TB).
102
Cryptosporidium parvum course and Tx in immunocompetent and HIV
Self-limiting in immunocompetent persons; Tx = supportive care.
Chronic diarrhea in HIV; Tx = nitazoxanide.
103
Giardia lamblia Presentation
Acquired via fresh water lakes / scuba diving.
104
Flagellated protozoan. USMLE wants you to know the images for both the cyst
as well as the flagellated trophozoite.
Cyst form of Giardia. Not dramatic.
Trophozoite form of Giardia.
105
Giardia lamblia Tx
Tx = metronidazole
106
Dx?
Giardia lamblia - Flagellated protozoan. USMLE wants you to know the images for both the cyst as well as the flagellated trophozoite form of Giardia.
107
Dx?
Giardia lamblia - Cyst form of Giardia. USMLE wants you to know the images for both the cyst as well as the flagellated trophozoite form of Giardia.
108
Giardia lamblia Tx et i
Tx = metronidazole
109
42F + in hospital for surgery two days ago + shortness of breath + HR 92 + ECG shows no abnormalities; the medication she needs has what MOA?
activation of anti-thrombin;
heparin is drug given; diagnosis is pulmonary embolism; sinus tachycardia is most common finding on ECG (normal ECG + HR = sinus tachycardia); after heparin, do spiral CT of chest for diagnosis; do V/Q scan first in pregnant women.
110
Circular lesion in pancreas seen in pancreatitis; dx and NBS
pseudoabscess
ERCP to drain internally
111
High ALP + high direct bilirubin + high amylase or lipase
gallstone pancreatitis = choledocholithiasis
112
High ALP + high direct bilirubin + high amylase or lipase + remote Hx of cholecystectomy
sphincter of Oddi dysfunction
(can’t be a stone cuz the gallbladder was removed ages ago)
113
High ALP + high direct bilirubin + normal amylase or lipase in someone with recent cholecystectomy
choledocholithiasis (retained stone in cystic duct that descended, but not distal to pancreatic duct entry point)
114
Dx and Tx of choledocholithiasis
ERCP
115
High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy
pancreatic cancer
116
Dx of pancreatic cancer
CT abdo with contrast
117
High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy + CT is negative. Dx and NBS?
cholangiocarcinoma
(Bile duct cancer. Answer on USMLE if the vignette sounds like pancreatic cancer but they tell you in the last line CT is negative.)
Answer is ERCP as next best step.
118
cholangiocarcinoma (Bile duct cancer) RFs
Smoking is risk factor, same as pancreatic cancer.
Can be caused by Clonorchis sinensis (trematode).
119
High ALP + high direct bilirubin + normal amylase or lipase + diffuse pruritis + high cholesterol
primary biliary cirrhosis (PBC)
120
High ALP + high direct bilirubin + normal amylase or lipase + autoimmune disease (in pt or family)
PBC
121
Dx of PBC
anti-mitochondrial Abx next best step
liver biopsy is confirmatory
122
Recent cholecystectomy + fever + abdo pain
post-op bile leak
123
Imaging to view liver or pancreas
CT with contrast
124
High ALP + high direct bilirubin + normal amylase or lipase + CT shows cystic lesion in bile duct. Dx and Tx?
choledochal cyst
do simple excision of cyst (cholangiocarcinoma not cystic + CT can be negative)
125
Imaging to view gallbladder in suspected cholecystitis only if USS negative
HIDA scan
126
Imaging to view bile ducts
ERCP or MRCP (choose ERCP > MRCP if both listed)
127
Imaging to view gallbladder
Ultrasound
128
Cholelithiasis dx with and mnemonic
Dx with abdo ultrasound
fat, forties, female, fertile
129
Biliary colic + fever
cholecystitis
130
Cholelithiasis + cholecytitis tx
cholecystectomy
131
Pt has cholelithiasis + cholecytitis, but Pt doesn’t want surgery or is pregnant
ursodeoxycholic acid (ursodiol)
132
Abdo USS negative in suspected cholecystitis
HIDA scan
133
Gall bladder doesn’t light up on HIDA scan
confirms cholecystitis
134
Cholelithiasis in pregnancy mechanism
- Progesterone also slows biliary peristalsis, increasing risk of biliary sludging and cholesterol stone formation.
- Estrogen upregulates HMG-CoA reductase, increase hepatic cholesterol synthesis, thereby
Increasing risk of stone formation.
135
54M + progressive shortness of breath for four months + ascites + edema of lower extremities +
bilateral pleural effusions + ejection fraction of 55%; what’s the mechanism for this patient’s
increased fluid in the lungs?
decreased plasma colloid osmotic pressure (decreased plasma oncotic pressure); this refers to either renal (nephrotic syndrome) or hepatic disease
(decreased production of albumin); wrong answer is “increased capillary hydrostatic pressure” because ejection fraction is normal (55-70); this is normally the answer for pulmonary edema from left heart failure; “increased vascular permeability” would be the correct answer in ARDS (bilateral pulmonary infiltrates), infection (i.e., pneumonia +/- sepsis), or pulmonary embolism (local inflammation).
136
Painful third-trimester bleeding following MVA or cocaine use; Dx?
abruptio placentae
137
50M + heavy smoker + Hx of HTN + BMI of 30; Q wants to know best way to decrease diabetes risk in this patient
weight loss
smoking cessation is wrong answer. For development of type II diabetes, maintaining a normal BMI is most crucial. The answer can also sometimes be “low calorie diet” for these Qs; “low carb carbohydrate diet” is wrong answer.
138
Normal ejection fraction is
55-70
139
Dx and cause
140
Dx and cause
Aplasia cutis congenita - Absence of skin on an area of scalp
can be caused by teratogens such as methimazole
141
“What is abruptio placentae?”
Abruption (separation) of the placenta in utero.
142
abruptio placentae presentation
- Causes third-trimester painful bleeding, or painful cramping.
- Deceleration injury (i.e., car accident, fall) and cocaine use are known risk factors.
143
When to give RhoGAM? Normal and exceptions?
- If Rh(-), give RhoGAM at 28 weeks and again at delivery.
- Also give RhoGAM if any interventions (e.g., amniocentesis), or if there’s complications like spontaneous abortion or abruptio placentae.
- If 2nd pregnancy onward, if Rh (-) woman is found to have titers against Rh, do not give RhoGAM
during the pregnancy, since it’s too late.
144
Grey/whitish patchy/rough area on the vulva or perineum; Dx + Tx?
lichen sclerosus
must do punch biopsy first to rule out SCC; if confirmed LS, do topical steroids; if SCC, surgically excise.
145
Dx
Classically described as “The Ps”-purple, pruritic, polygonal papules; however Qs need not mention they’re pruritic; you just need to know hepatitis C + red/purple skin lesions = lichen planus.
146
hepatitis C + red/purple skin lesions
lichen planus
147
65M + intermittent bloody diarrhea + now has fever of 104F + abdominal pain + high leukocytes; Dx and method for dx
toxic megacolon
Dx with AXR, not colonoscopy!
if you scope, patient will perforate and die AXR will show dilated bowel (e.g., one NBME Q says “12-cm cecum”); in general, know that AXR is done when you’re looking for gas.
148
55M + BMI of 33 + poorly controlled diabetes (type I or II) + 3 months of burning in throat; Dx
diabetic gastroparesis, NOT GERD (woahhh crazy)
first pharm Tx metoclopramide, not PPIs. If metoclopramide not listed, choose erythromycin (motilin receptor agonist).
Regarding gastroparesis, the USMLE vignette will make an explicit point about bad diabetic disease, i.e., peripheral edema (renal insufficiency due to decreased oncotic pressure from albuminuria) +/- cataracts (osmotic damage from intracellular sorbitol) +/- urinary retention (neurogenic bladder due to osmotic denervation leading to hypocontractile detrusor) +/- they simply say HbA1C of 12% (diabetes is 6.5% or greater; prediabetic is 6-6.49). There will be no question as to whether they want gastroparesis vs simple GERD.
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UC cause toxic megacolon, which presents as SIRS and sometimes low BP in a patient with UC. They might say abdominal x-ray shows a 12-cm cecum (NR 3-8). Tx if normal BP vs unstable?
If the patient has normal BP, NBME for 2CK wants steroids first for toxic megacolon. If the patient is unstable, go straight to laparotomy.
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Wide-complex tachyardia
ventricular tachycardia (VT)
151
Narrow-complex tachy
SVT
152
Tx for SVT
vagal/carotid massage first; if doesn’t work, then adenosine
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Tx of VT
anti-arrhythmics, e.g., amiodarone
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Tx of SVT or VT in setting of coma / unconsciousness
direct-current countershock
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Dx, originates from, and tx
Premature ventricular complex (PVC)
Note on the above strip, we have a wide complex (meaning ventricular in origin) that occurs earlier (hence premature). What they do on the NBME is show you this strip and ask where this abnormality originates from, then the answer is just “ventricle.”
Don’t treat PVCs on USMLE.
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NBME for 2CK has x as the answer for patient with AF who has hemodynamic instability (i.e., low BP).
“electrical cardioversion”
What you need to know is: sometimes AF can trigger “rapid ventricular response,” where HR goes >150 and low BP can occur
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Tx for PCOS
if high BMI, weight loss first always on USMLE
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Tx for PCOS if they ask for meds and/or weight loss already tried
OCPs (if not wanting pregnancy);
clomiphene (if wanting pregnancy)
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PCOS increases risk of what
endometrial cancer (unopposed estrogen)
160
Tx of prostate cancer
flutamide + leuprolide together (if they force a sequence, choose F then L).
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Tx of acute gout
indomethacin (NSAID) first on USMLE; then steroids, then colchicine
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Tx of acute gout if indomethacin + steroids not listed
colchicine
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Tx of acute gout in pt with renal insufficiency or Hx of renal transplant
steroids
164
Tx of chronic gout (decrease recurrence)
allopurinol or febuxostat (xanthine oxidase inhibitors)
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Never give which drug to pt with Hx of uric acid stones or over producer
probenecid (uricosuric)
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What are rasburicase / pegloticase
urate oxidase analogues - cleave uric acid directly
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12-hour-old male + abdomen is distended with a midline mass; Dx?
posterior urethral valves
most common genitourinary (GU) abnormality in neonatal males - thin membrane(s) in
the urethra preventing the outflow of urine.
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2-day-old male + urinary dribbling + decreased urinary output + 6-cm suprapubic mass; Dx
posterior urethral valves
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3-month-old boy + fever + pyuria + few bacteriuria; next best step in Dx and likely Dx?
renal ultrasound
Dx most likely pyelonephritis (few bacteria typical on U/A despite pyuria); must do renal and bladder ultrasound for all kids age 2-24 months who have febrile UTI - screens for congenital genitourinary tract abnormalities.
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6-month-old boy + one-day Hx of fever + pyuria + E.coli grown from urine culture + Abx initiated + renal ultrasound shows no abnormalities; next best step?
voiding cystourethrogram
(check for posterior urethral valves)
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What is phimosis vs paraphimosis?
phimosis = inability to retract the foreskin
paraphimosis = inability to reduce (put back) the foreskin.
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Neonatal male with PUV; next best step in Dx? Tx?
voiding cystourethrogram.
Tx must do surgery.
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34M falls on balance beam + saddle injury + blood at urethral meatus; Dx + next best step in Mx?
urethral injury
do retrograde urethrogram
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16M + skiing accident + bruising and/or pain over a flank + red urine; Dx + next best step in Mx?
kidney injury (renal contusion)
must do CT with contrast, not ultrasound. This is exceedingly HY on surgery forms and sounds wrong (i.e., “why would you do CT with contrast in someone with suspected renal injury if contrast can cause nephrotoxicity?”) - great question, but CMS/NBME/USMLE still want CT with contrast, so don’t pick ultrasound.
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Association between osteoporosis and celiac disease
Vitamin d malabsorption in celiac disease can increase risk of osteoporosis
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16M + skiing accident + bruising and/or pain over a flank + no gross blood of urine (i.e, urine not red); next best step in Mx?
urinalysis to look for blood (super HY)
If urinalysis shows blood, do CT
scan to check for renal injury. If U/A negative, renal injury unlikely, so choose “no further
investigations indicated,” not CT.
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16M + skiing accident + bruising and/or pain over a flank + urinalysis is normal; next best step?
no further investigations indicated
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3M + ran into corner of table + 1-day Hx of increasingly severe abdominal pain + vitals normal +
examination shows 2x2cm mass in the midline + serum lipase and amylase both elevated; next best step?
CT of abdomen
Dx = traumatic pancreatitis.
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Kid falls on outstretched arm + pain over anatomical snuffbox + x-ray is negative; next best step in Mx?
thumb-spica cast, x-ray is often negative in scaphoid fracture; must cast to prevent scaphoid avascular necrosis - re-x-ray in 2-3 weeks.
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5-8-year-old boy + sickle cell disease + painful limp + x-ray is negative + bone scan confirms diagnosis
USMLE wants you to know that x-ray can be negative initially in avascular necrosis, but bone scan or MRI can also pick it up.
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27M + from Pennsylvania + Hx of splenectomy + RBCs show intraerythrocytic rings; diagnosis?
Babesia; causes Malaria-like hemolytic disorder in patients who’ve never left the United
States; ring forms and Maltese crosses can be seen within RBCs; if the Q tells you the patient went to Africa, choose malaria, not Babesia. But if the patient didn’t leave the US, malaria is the wrong answer.
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Patient has lateral thigh pain; Dx?
meralgia paresthetica due to lateral femoral cutaneous
nerve entrapment
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Patient has lateral hip pain when palpated, when abducting against resistance, or when standing on that foot; Dx?
greater trochanteric syndrome (gluteus medius or minimus tendonopathy)
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Patient has “locking” or “catching” of the knee; Dx?
meniscal tear
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Kid + bloody diarrhea + petechiae + red urine; Dx?
hemolytic uremic syndrome (HUS) caused by EHEC O157:H7 or Shigella
HUS = triad of thrombocytopenia + schistocytosis (microangiopathic
hemolytic anemia) + renal insufficiency; toxin will inhibit ADAMTS13 in afferent arterioles + cause endothelial damage, platelet consumption + clumping (thrombocytopenia) - RBCs shear as they pass by the platelet clumps (schistocytosis).
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How does HUS contrast with TTP?
TTP is caused by a mutation that results in defective ADAMTS13,
or antibodies against ADAMTS13, resulting in the inability to cleave vWF multimers, platelet clumping, similar progression as HUS. One of the points of contrast is that TTP is not toxin-induced, and TTP also tends to be a pentad of the HUS findings + fever + neurologic signs.
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30-month-old boy + fever 101F + loose, bloody stools + tonic-clonic seizure; Dx?
shigellosis on Peds NBME; wrong answers are HUS and “idiopathic seizure disorder.”
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14F + lower abdominal cramps and intermittent knee pain for 6 weeks + 6-10 bloody stools per day + WBCs and platelets elevated + arthrocentesis is normal; Dx? NBS to Dx? Tx?
ulcerative colitis (UC) - IBD frequently associated with arthritis; high WBCs characteristic of autoimmune flares; thrombocytosis can be seen in infections and/or autoimmune flare
next best step in Dx = colonoscopy
Tx is initially with 5-ASA compounds (mesalamine) and steroids; colectomy can be curative in severe cases.
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16M + mouth ulcer + bloody diarrhea; Dx?
Crohn disease - mouth to anus; mouth ulcers are HY.
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13F + went running outside in hot weather + very exhausted + body temp 102.2F + pulse 100; Dx? Important contrasting presentation?
heat exhaustion (high body temp + no end-organ damage/failure)
in contrast, heat stroke = high body temp + end-organ damage; acanthocytes in blood smear = liver failure (HY for heat stroke); acanthocytes not limited to abetalipoproteinemia
190
Renal cancer in children?
Wilms tumor
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3M + painless flank mass + no other info; Dx? NBS Dx?
Wilms tumor
“ultrasonography of the abdomen.”
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6M + painless flank mass + seizure + MRI of brain shows periventricular nodules; Dx
Tuberous sclerosis with renal angiomyolipoma.
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Anything else about Wilms tumor?
increased incidence in horseshoe kidney in Turner syndrome
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Horseshoe kidney key point?
not only increased risk of Wilms tumor, but the kidney gets caught under the IMA. USMLE Step 1 likes this factoid for some dumb reason.
195
What is WAGR complex? Cause?
Wilms tumor, Aniridia, Genitourinary malformation, Retardation
caused by WT1 gene mutation
196
What is Denys-Drash syndrome?
Wilms tumor + male pseudohermaphroditism (secondary sex characteristics are female; primary sex characteristics are male); caused by WT1 gene mutation.
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Neonate born at 4800g + macroglossia + omphalocele + visceromegaly; child is most likely to develop what?
hypoglycemia
Beckwith-Wiedemann syndrome
Wilms tumor + neonatal hypoglycemia + macrosomia / macroglossia + hemihypertrophy +/-omphalocele; caused by WT2
gene mutation.
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Comment on AR vs AD polycystic kidney disease.
ARPKD is chromosome 6 and a pediatric. condition; it’s associated with hepatic fibrosis.
ADPKD is chromosome 16 and presents in 30s or 40s; associated with HTN and circle of Willis saccular (berry) aneurysms.
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4F + third case of pyelonephritis + high creatinine; most likely cause of high Cr?
“congenital urinary tract obstruction” or “vesicoureteral reflux”
Dx is chronic pyelonephritis - caused by recurrent acute pyelonephritis - chronic pyelo is characterized by “thyroidization of kidney” + blunting and scarring of renal calyses.
200
9F + Hx of recurrent pyelonephritis and simple UTIs + BP of 160/100; next best step in Mx? Likely dx?
“measurement of serum urea nitrogen and creatinine concentrations”
Likely chronic pyelonephritis leading to renal scarring + disruption of renal microvasculature + upregulation of RAAS.
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6M + dancing eyes + HTN + lesion visualized in posterior mediastinum on CXR; Dx?
neuroblastoma
students says wtf? can occur anywhere in the median sympathetic chain, although classically intra-abdominal. Dancing eyes = opsoclonus-myoclonus syndrome.
202
Neuroblastoma; how to Dx?
on NBME is “urinary homovanillic acid (HVA) and
vanillylmandelic acid (VMA); mIBG scan may also be used; n-myc gene.
203
48M + MVA + has severe pain and/or bruising over the sternum; Dx? NBS?
myocardial contusion
do an ECG + monitor in hospital due to high risk of arrhythmia. Get troponins.
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72F + 6-month Hx of small painless papule from a chickenpox scar on her chin; Dx?
Marjolin ulcer (squamous cell carcinoma), SCC growing from previous scar or burn site.
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34F + painless lump on dorsal aspect of proximal hand; Dx? Tx?
ganglion cyst
Tx = needle drainage
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Pic is shown of cavitating lung cancer; what’s the diagnosis?
squamous cell carcinoma; can present with cavitary/cavitating lesion.
207
74M + lesion on cheek showing neoplastic cells with dense pigment granules; what’s the diagnosis?
melanoma
Sounds like pigmented BCC, but USMLE wants melanoma for this description. BCC histologically can be described as having islands and nests of basophilic cells; squamous cell carcinoma has keratin pearls and intercellular bridges.
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Close quarters or military barracks or cruise ship + watery diarrhea
Norwalk virus
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Child <5 years + watery diarrhea
rotavirus
210
Few organisms causing bloody diarrhea
Shigella
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Diarrhea + Guillain-Barre syndrome
Campylobacter
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Bloody diarrhea + appendicitis-like pain (pseudoappendicitis) in a child
Yersinia enterocolitica
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Bloody diarrhea + reactive arthritis in an adult
Y. enterocolitica, Campylobacter, Shigella, Salmonella
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GBSyndrome CSF?
albuminocytologic dissociation (high protein + normal cells)
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GBSyndrome Dx?
electromyography + nerve conduction studies (on NBME)
216
Dx and tx
Classically pearlescent / slightly translucent; talengiectasias common; borders can
sometimes be described as “heaped up” or “rolled”; may or may not be ulcerated.
Treatment for skin cancers on cosmetically sensitive areas such as the eyelid or nose can be managed with Mohs micrographic surgery (on NBME).
217
Dx and presentation
SCC
Ulcerated lesion in the setting of a patient who’s had actinic keratoses – i.e., Q says patient has had scaly red areas on forehead for many years + now has recent ulceration.
SCC will not have telangiectasias or pearlescence/translucency (as with BCC)
218
Most important prognostic factor for melanoma
depth of lesion
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Risk factor for SCC apart from the sun
USMLE is obsessed with immunodeficiency and smoking, even for cutaneous SCC
220
C. difficile acquired via
acquired via consumption of spores.
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C. difficile type of diarrhea and abdominal pain
Can be watery or bloody diarrhea on NBME.
Can also cause LLQ cramping (not RLQ as with Yersinia).
222
28-year-old with LLQ cramping and bloody diarrhea 7 days after starting oral antibiotics
C. diff; wrong answer is
Yersinia
223
Gastric cancer histo
signet-ring cells that contain mucin
224
Gastric cancer Grossly
can cause a linitis plastica, which is a leather bottle appearance to the stomach
225
Gastric metastases can spread hematogenously to
the ovaries. These will show up as bilateral ovarian lesions that show, you guessed it, signet-ring cells that contain mucin
226
MALT lymphoma is a B cell lymphoma that can be caused by
H. pylori. This does not have signet ring cells.
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PE findings associated with gastric cancer
Acanthosis nigricans can be associated with gastric cancer (even though most of the time, it just means insulin resistance).
Virchow node (Troisier sign) - palpable supraclavicular lymph node that can reflect visceral malignancy, especially gastric cancer.
228
SBP is answer on USMLE when they give you diffuse abdominal pain and fever in one of the three following scenarios:
1) cirrhosis; 2) recent peritoneal dialysis; 3) nephrotic syndrome
Shifting dullness” or a “fluid wave” are buzzy for ascites, but questions will often omit these descriptors from stems. What they care about is you identifying when a patient either has a major risk factor for ascites, or are aware of peritoneal intervention as the cause for the presentation.
229
Patient has cirrhosis + abdo pain + fever. Dx?
SBP
they don’t have to mention a fluid wave, but you just have to
infer, “Well he/she clearly has major risk factor for ascites, so this sounds like SBP.”
230
Kid with minimal change disease (nephrotic syndrome) has abdo pain + fever
spontaneous bacterial peritonitis
231
Next best step in diagnosis SBP is
abdominal paracentesis
This refers to aspiration of fluid from the peritoneal cavity. Do not confuse this with pericardiocentesis
232
After the paracentesis is done for SBP, NBS?
USMLE wants a very specific order for what to do next. Choose “white cell count and differential” first if it’s listed, followed by “gram stain and culture of the fluid.”
This order is important because “gram stain and culture of the fluid” is abcorrect answer in one Q but wrong answer in another Q, where “white cell count and differential” is correct to do first.
The reason white cell count and differential is done first is because SBP is diagnosed when paracentesis shows >250 WBCs/µL.
233
ascites in patient with cirrhosis (no mention fever or abdominal pain) and paracentesis shows 900 WBC//µL. Dx and tx?
SBP and ceftriaxone
234
Tx SBP
Treatment is ceftriaxone.
235
Upper GI series use
Congenital midgut volvulus in pediatrics; will show a corkscrew.
236
Patient over the age of 50 who has 6-12+ months of unexplained dry cough
Idiopathic pulmonary fibrosis
(Usual interstitial pneumonitis)
237
Idiopathic pulmonary fibrosis
(Usual interstitial pneumonitis)
FEV1/FVC
Textbook restrictive lung disease, with normal or increased FEV1/FVC. The reason for the FEV1/FVC being greater than in obstructive lung disease is radial traction
238
Idiopathic pulmonary fibrosis
(Usual interstitial pneumonitis) CXR/CT
CXR and CT scan show “reticular” or “reticulonodular” pattern.
239
For Idiopathic pulmonary fibrosis (Usual interstitial pneumonitis), After the CXR and spirometry are performed, NBS?
“high-resolution CT of chest” as answer for next best step
“Honeycombing” = reticular / reticulonodular pattern.
New 2CK NBME wants “lung biopsy” as answer to confirm diagnosis of interstitial lung disease (i.e., idiopathic pulmonary fibrosis) after imaging
240
Patient over 50 with increasing fatigue and shortness of breath over 6-12 months, with only 1 month of cough, where it initially sounds like heart failure, and they’ll say CXR shows “interstitial markings”. Patient has “ FEV1/FVC showing restrictive pattern”
Idiopathic pulmonary fibrosis (Usual interstitial pneumonitis)
Vignette can also mention loud P2 (means pulmonary hypertension) with “dry inspiratory crackles heard bilaterally.”
241
Tx on 2CK Idiopathic pulmonary fibrosis (Usual interstitial pneumonitis)
pirfenidone, anti-fibrotic agent that inhibits TGF-b-mediated synthesis of collagen
242
Methotrexate (Dihydrofolate reductase inhibitor) used
1st-line DMARD for RA + 1st
-line oral agent for psoriasis that fails topicals
243
Methotrexate SE and tx
Causes pulmonary fibrosis (and hepatotoxicity and neutropenia).
Toxicity can be mitigated with “leucovorin rescue,” aka folinic acid (not folic acid).
244
If the fetus is breech, NBS?
external cephalic version, which is attempting to manually shift a fetus from breech to cephalic engagement is attempted at 36-38 weeks before Caesar.
After 38 weeks, the fetus is often
sufficiently large where risk of uterine rupture increased. If ultrasound or Leopold maneuvers (abdominal palpation techniques to determine fetal lie) determine the fetus is breech or transverse after 38 weeks, NBME wants Caesar as next best step.
245
x-ray in 5-year-old shows “contracted capital femoral epiphysis”
LCP, not SCFE. As I said above,
“contracted” is HY for LCP. In this case, the younger age + the word “contracted” win over the words “femoral capital epiphysis.”
246
Legg-Calve-Perthes etiology
idiopathic avascular necrosis of the femoral head.
etiology for the avascular necrosis is known (i.e., Gaucher, sickle cell, corticosteroids), then the diagnosis is just “avascular necrosis,” not LCP
247
5-8 years old with hip pain. Dx
LCP
248
5-8 years old with hip pain. DX and NBS?
LCP
First step in diagnosis is hip x ray, which will show a “contracted” or flattened femoral head. The word “contracted” is HY and synonymous with avascular necrosis.
If x-ray is negative, diagnose with bone scan or MRI (on 2CK Peds form).
249
5-8 years old with hip pain. DX and Tx?
LCP
Tx = hip replacement.
250
LCP
Student says, “No idea what I’m looking at.” Relax. If we try to imagine on this x-ray, the right femoral head (left side of image) looks “contracted” or “flattened.” Once again, this is HY and buzzy for avascular necrosis.
251
LCP
Exam can also show an MRI. In this case, the right femoral head (left side of image) appears hypointense (more black). The necrotic / lack of bone in the black superior portion of the femoral head means the remaining white part of the femoral head is “flattened” or “contracted.” The left femoral head (right side of image) shows a small area of necrosis as well (black medial portion).
252
Primary amenorrhea is the absence of menarche in girls 13 years of age or older with no secondary sex characteristics (or 15 year or older with secondary sex characteristics). Next important question is presence of uterus. Significance for NBS?
If absent, karyotype analysis (looking for Mullerian Agenesis (XX) or androgen insensitivity syndrome (XY))
If presents, NBS is FSH.
If FSH high, then looking for either Turner (XO) or primary ovarian insufficiency (XX)
If FSH normal, imperferote hymen
If FSH low, measure prolactin and TSH. If TSH and prolactin high: hypothyroidism. If TSH normal and prolactin high, prolactinoma. If both normal, functional hypothalamic amenorrhea
253
Standard tx for UTI
Trimethoprim, trimethoprim/sulfamethoxazole (TMP/SMX), or nitrofurantoin are standard treatments for UTI.
254
Trimethoprim SE
Hyperkalemia
Elevated creatinine (no change in GFR)
