Professional Documents
Culture Documents
Explanations
Explanations
Intussusception often presents in a child 6-36 months old with abdominal pain
relieved by drawing knees to the chest +/- bloody diarrhea +/- vomiting. In setting of
suspected intussusception, next best step is a contrast/air enema which is both
therapeutic and diagnostic.
Decreased androgens
Ovaries not only produce estrogens, but also produce androgens that play a
central role in libido (among other things)
Young patient who presents with acute signs of heart failure (elevated JVP,
bilateral basilar crackles, displaced PMI, S3, lower extremity edema, etc.) most likely
represents myocarditis, especially in setting of recent viral URI
Asymmetric septal hypertrophy = HOCM = Sudden cardiac death or exertional
syncope in young adult
Bicuspid aortic valve with stenosis presents as symptomatic AS (syncope,
angina, dyspnea) often in a 50-60 year old
Sjogren syndrome
Right vertebral
Crossed signs of decreased pinprick sensation over opposite sides of face and
body = Pathology in the brainstem IPSILATERAL to side where face pinprick sensation
is lost
Other aspects of patient’s presentation are consistent with Wallenberg
syndrome (stroke of lateral medulla), including vertigo, ataxia and weakness of the
palate
Key idea: If patient with suspected brainstem stroke has symptoms that localize
to nucleus ambiguus (motor vagal nucleus that when damaged can present as
dysphagia, hoarseness, and dysarthria) then you are almost certainly dealing with
a lateral medullary syndrome
Although lateral medullary syndrome most often associated with
stroke/hemorrhage involving the Posterior Inferior Cerebellar artery (PICA), important
to remember that the PICA comes off the vertebral artery (reason why vertebral
dissections can present with lateral medullary syndrome)
Appetite for non-nutritive substances (such as ice, hair, cornstarch on its own) =
pica
Most commonly associated with iron deficiency anemia, with other clues in the
stem being the mild pallor on physical exam and leiomyomata uteri (which often lead to
heavy menstrual bleeding)
Mitral stenosis
Patient with ascites who presents with diffuse abdominal pain/tenderness + fever
+ leukocytosis = Spontaneous bacterial peritonitis
Diagnosis of SBP is actually typically made after paracentesis if the ascitic fluid
has >250 PMNs (neutrophils) per mL
Although we often think of Spontaneous Bacterial Peritonitis (SBP) as being a
disease exclusively seen in patients with cirrhosis, in reality it can affect patients with
any conditions that lead to ascites (fluid in the abdomen), with patients who
undergo peritoneal dialysis being at higher risk given the fact that significant
opportunities for contamination during catheter exchanges, etc.
11. A 32-year-old woman comes to the physician because of…
Thyroid-stimulating hormone
Insulin
Clinical picture consistent with Type 2 diabetes (older overweight man with
polyuria, nocturia and increased non-fasting serum glucose concentration)
Key idea: Early on in Type 2 diabetes, insulin levels are high because the
pancreas is trying to make up for the insulin-resistance
Key idea: Later on in Type 2 diabetes (on the scale of years after initial
diagnosis), insulin levels become low as the beta cells become burned out from
overproducing insulin for so long and secondary to amylin deposition within pancreas
(amyloidosis)
All sexually active women 24 and younger should receive STI testing, regardless
of whether they have been monogamous with only one partner
https://www.uspreventiveservicestaskforce.org/uspstf/document/Recommendatio
nStatementFinal/chlamydia-and-gonorrhea-screening
Hyaline casts
Hyaline casts are the most common type of urinary cast and are often seen in
setting of dehydration or vigorous exercise; they can be seen in healthy individuals
Erythrocyte casts = RBC casts = Glomerulonephritis (such as post-strep
glomerulonephritis)
Leukocyte casts = WBC casts = Pyelonephritis and acute interstitial nephritis
Tube thoracostomy
Tall, young men are prone to spontaneous pneumothorax, with the chest x-ray in
this stem showing a right-sided pneumothorax (vascular lines don’t extend to periphery
and you can actually see a clear outline of the collapsed lung within the lung field)
A small (<2 cm), stable, asymptomatic pneumothorax can often be managed
conservatively with observation (https://www.nejm.org/doi/10.1056/NEJMoa1910775)
The patient in this stem is symptomatic and having difficulty breathing, so in this
case we would want to either perform a tube/needle thoracostomy
-ostomy = making a hole, whereas -otomy = cutting
Vitamin B1 (thiamine)
Patient most likely has poison oak/ivy, which presents >1 day after exposure
(Type 4 hypersensitivity) and will lead to a sharp line between rash and unaffected skin
Patients do not receive prophylaxis against poison oak/ivy
Cat scratch can lead to cat scratch fever, which leads to lymphadenopathy but
will not lead to vesicles/bullae
No intervention is necessary
https://clinicalgate.com/infantile
-hemangiomas-and-vascular-malformations/
25. A 3-year-old boy is brought to the physician because of a 7-day…
Language development: Babies “coo” around 2 months but don’t laugh until 3-4
months
Psychosocial development: Babies smile around 2 months, but won’t reach for
toys until 3-4 months
Corticosteroid therapy
Presentation most consistent with temporal arteritis (older patient with headache,
jaw claudication, elevated ESR and tender, enlarge temporal arteries)
Key idea: Because of risk for blindness and imperfect sensitivity of temporal
artery biopsy (because disease only affects section of temporal artery so biopsy may
miss affected segment), patients with suspected temporal arteritis should begin
empiric treatment with corticosteroids BEFORE temporal artery biopsy is
performed
Patient’s blood pressure has dropped, pulse has gone up and hematocrit has
dropped relative to intraoperative values, pointing to bleeding after surgery
https://www.q
uora.com/How-much-blood-do-you-have-to-lose-to-start-feeling-dizzy-and-cause-a-
hypovolemic-shock
29. A 32-year-old woman comes to the physician because of a 1-year…
Patient has missed several days of dialysis and was found down in his house
(which can lead to rhabdomyolysis), giving this patient 2 reasons to have metabolic
acidosis with hyperkalemia
Hyperkalemia can lead to abnormal heart rhythms that can lead to patient death,
so patients who have hyperkalemia with one of the following three features should
first receive calcium gluconate to stabilize the cardiac membrane prior to trying to
reduce potassium levels: (1) Potassium > 7.0 (2) ECG changes (Peaked T waves, PR
prolongation and QRS widening, disappearance of P wave) (3) Rapidly rising potassium
due to tissue breakdown or tumor lysis syndrome
Discontinuation of lorazepam
Pulmonary contusion
Patient with blunt thoracic trauma who presents <24 hours later with
symptoms (tachypnea, tachycardia, hypoxia) and/or CT/CXR infiltrates over affected
area (patchy, alveolar)
Key idea: Important to differentiate from ARDS, which can have similar
presentation but often occurs 24-48 hours after trauma
Cystic fibrosis
Pulmonary tuberculosis
Patient with clear exposure (Albania and other Eastern European countries are
endemic TB countries) showing signs of infection (cough and fever) with adenopathy
Pulmonary aspergillosis would more commonly be seen in somebody who is
immunocompromised (acute angioinvasive aspergillosis) or somebody with cystic
fibrosis or asthma (allergic bronchopulmonary aspergillosis)
Huntington’s disease
Patient between 40-60 years old often with family history of disorder or unknown
family history who presents with triad of chorea, depression and dementia
Key idea: Patients can also commonly have psychosis
Gallstone ileus
Patient has signs of a small bowel obstruction (abdominal distention, abdominal
pain, vomiting, high-pitched bowel sounds with air-fluid levels on x-ray)
Most common causes of small bowel obstruction are adhesions, hernia and
malignancy, but this patient has air in the liver which is basically pathognomonic for
gallstone ileus (can also have air in the biliary tree)
References: Netter’s Atlas of
Human Anatomy
44. A 67-year-old man is examined 3 days after undergoing…
Incidence
Incidence > Prevalence because you are concerned about development of new
cases (primary prevention)
Incidence = Number of new cases over a time period
Prevalence = Number of cases in the population
Mortality, case fatality and hospitalization would be more reflective of tertiary
disease prevention efforts
Exam section 2:
Patients who are adequately vaccinated against hepatitis B vaccine will have
negative HBsAg, positive HGsAb and negative Hepatitis B core antibody (positive Hep
B core antibody = past or current infection)
Patient is adequately protected against Hepatitis A due to presence of IgG
antibodies, which can be the result of vaccination or past infection
Key idea: Indications for Hep A vaccination are chronic liver
disease or increased risk of contracting disease (men who have sex with men,
IVDU, travel to country where hepatitis A is prevalent, etc.)
Laparotomy
Unable to access media for this question, but patient likely had a no murmurs or
a soft systolic ejection murmur in the setting of a clinical URI
CHF = S4 heart sound and crackles/rales (patient would have signs of edema)
Idiopathic pulmonary hypertension: Loud S2 and RV heave (patient would have
chronic progressive dyspnea)
Pericarditis: Three-component friction rub (history would involve positional chest
pain)
Ventricular septal defect: Common heart abnormality that would lead to a systolic
murmur over the left lower sternal border, but would not explain the patients fever,
cough and runny nose
Arthrocentesis
In children with new development of joint pain, two major diagnoses to consider
are septic arthritis and transient synovitis
Our patient’s presentation more consistent with septic arthritis due to fever and
refusal to bear weight, and therefore patient requires immediate drainage of joint
space even before administering antibiotics because of risk for persistent damage to
joint
Transient synovitis: Afebrile, history of previous viral URI, normal ESR, normal
WBC, normal joint aspiration, self-limited condition
Fibromyalgia
Older patient with sudden onset back pain unrelated to activity with signs of
blood loss (pale, tachycardic, diaphoretic) who also has calcifications anterior to
vertebral bodies on X-ray (aorta sits just anterior to vertebral bodies)
Latex products
Patient with new job as a medical assistant (where she likely needs to where
latex gloves) has developed a new rash on her hands, most consistent with allergic
contact dermatitis
Key idea: Latex allergy seen in 1-5% of population and is seen at higher rates
closer to 10% in individuals with chronic occupational exposure to latex (medical
workers, etc.)
15. A previously healthy 16-year old boy is brought to the…
Viral infection
Young patient involved in a motor vehicle accident who initially developed thigh
pain and now has impaired consciousness with signs of hemodynamic instability most
consistent with traumatic bleeding into the thighs, leading to hypovolemia
Key idea: Hematocrit can be normal during acute hemorrhage due to loss of
equal parts of red cells and plasma, and may not drop until patient has received volume
resuscitation
Key idea: Potential sites of bleeding in setting of traumatic hemorrhagic shock
that can accommodate lots of bleeding are “Blood on the floor and 4 more”: (1) Floor
(obvious external bleeding) (2) Chest (3) Abdomen (4) Pelvis (5) Thigh
Patients have the autonomy to decide whether or not they want to hear results of
their own medical tests
Multiple myeloma
Multiple myeloma = Bone pain (often in the back) + Lytic bone changes on
imaging + Anemia (due to plasma cells crowding out other hematopoeitic cells in bone
marrow) + Elevated calcium concentration (due to lytic bone lesions) + Rouleaux
formation on peripheral smear (due to sticky immunoglobulin proteins causing RBCs to
stack up)
Key idea: If you see a patient with signs of kidney disease (elevated
creatinine/BUN) and hypercalcemia, you should have a high index of suspicion
for multiple myeloma because most other forms of kidney disease lead to
hypocalcemia (due to binding of phosphate to calcium and reduced vitamin D activation)
Hemothorax
Opacities involving an entire lung lobe most consistent with collapsed lung tissue
(atelectasis) vs. accumulation of blood/fluid/pus within that space
In this patient involved in a traumatic situation + signs of hemodynamic instability
(tachycardic, borderline hypotensive) with complete opacification of right hemithorax
and absent breath sounds on right most consistent with hemothorax
Pneumothorax would lead to lung lucency (increased air), diaphragmatic hernia
almost always left sided (due to liver protecting right diaphragm) and ruptured bronchus
often leads to persistent pneumothorax and/or pneumomediastinum
Constrictive pericarditis
Constrictive pericarditis = Patient with history of chest radiation + right-sided
heart failure + Pericardial knock (early diastolic sound that can mimic S3 resulting from
loss of pericardial elasticity during ventricular filling) + Kussmaul’s sign
Common causes of constrictive pericarditis include radiation therapy, cardiac
surgery, connective tissue disorder, tuberculosis and viral pericarditis
Jugular venous distention that increases with inspiration = Kussmaul’s sign =
Constrictive pericarditis, right heart failure/infarction, restrictive cardiomyopathy
Key idea: Patients with constrictive pericarditis or other forms of global diastolic
dysfunction (restrictive cardiomyopathy) more commonly present with signs of right
heart failure because the right heart is responsible for filling whereas the left heart is
responsible for squeezing
Cor pulmonale = Right-sided heart failure due to primary lung disease
(COPD, ILD, etc.)
Fluid restriction
Patient with significant smoking history presents with right hilar mass +
hyponatremia = SIADH due to small cell lung cancer
Note: Hiccups could either be secondary to hyponatremia or could be due to
lung mass irritating the diaphragm
Mild symptoms of SIADH (sodium >120, lethargy): Fluid restriction +/- salt tablets
Severe symptoms of SIADH (sodium <120, seizures, coma): Hypertonic (3%)
saline
Key idea: Don’t want to correct hyponatremia too quickly in order to avoid
osmotic demyelination syndrome (“low to high, the pons will die”)
Avoidance of analgesics
Patient’s with Alzheimer’s disease are very prone to aspiration pneumonia both
due to dysphagia and problems protecting their airway due to decreased gag
reflex and impaired consciousness
Clues to aspiration pneumonia = Older patient (often demented) who presents
with pneumonia in the right lung base (most common location due to right mainstem
bronchus being wider, shorter and more vertical)
https://www.ncbi.nlm.nih.gov/pubmed/14577062
Patient has normal sexual development and is not sexually active, so no reason
for any of the lab tests or procedures
Important to discuss pregnancy prevention in adolescents, even in patients who
are not yet sexually active
31. A 57-year-old woman with breast cancer comes to the physician…
Stress incontinence
Overflow incontinence
Pap smear
Reassurance
39. A 23-year old woman has pain, cramping, and swelling of the…
Tricuspid regurgitation
Cryptococcal meningitis
Patient with risk factors for immunosuppression (IVDU can lead to HIV due to
needle sharing) presents with signs of increased intracranial pressure (papilledema
and weakness of lateral rectus muscle [CN 6 palsy]) and meningitis (headache, fever,
neck stiffness) with CSF findings consistent with a fungal etiology (elevated WBC
count with lymphocytic predominance, low glucose)
Key idea: Cryptococcal meningitis classically leads to meningitis symptoms +
signs of elevated ICP + umbilicated skin lesions
Note: Elevated ICP preferentially leads to a CN 6 palsy is a contested issue with
two potential explanations: (1) It has the longest intracranial course and therefore is
prone to stretching in setting of elevated ICP (2) CN 6 emerges straight from brain
stem rather than obliquely/transversely like other cranial nerves, and is therefore more
prone to compression by backward brain displacement in setting of elevated ICP
Throat culture
Pharyngitis and fever without viral URI symptoms in a young child always
concerning for Strep throat, which requires rapid strep test followed by throat culture if
negative [NO EMPIRIC TREATMENT IN KIDS]
Key idea: In adults, patients risk of Strep throat is stratified based on Centor
criteria [(1) Fever by history (2) Tender anterior cervical lymphadenopathy (3) Tonsillar
exudates (4) Absence of cough], and with patients receiving no testing (scores 0-1),
rapid strep test followed by throat culture if negative (2-3) or empiric antibiotics (4+)
Key idea: In contrast, CENTOR criteria are not applied to children, with
children who have potential signs of strep throat (exudative pharyngitis, palatal
petechiae) and NO viral symptoms (cough, rhinorrhea, conjunctivitis, oral ulcers)
receiving a rapid antigen test followed by throat culture if rapid strep test is
negative (i.e. all children receive diagnostic tests and none are treated empirically)
Exam section 3:
Presentation most consistent with testicular cancer, with germ cell tumor being
the most common cause
Testicular mass that does not transiluminate = Cancer or varicocele
Varicocele would not lead to a discrete mass, but rather a “bag of worms” feeling
and it would decrease in size when patient placed in supine position due to
increased venous return to heart
Testicular mass that does transiluminate = hydrocele or spermatocele
Key idea: Oftentimes patients discover masses after trauma to that area
because they are paying more attention to the area, so don’t automatically write-off the
mass as being the result of trauma (for example, many NBME questions have patients
finding breast masses after trauma to area)
Echocardiography
Staphylococcus aureus
Nonstress test
Intraductal papilloma
Most common cause of unilateral bloody nipple discharge, and often presents
without mass or lymphadenopathy
Carbamazepine therapy
WBC differential shows severe neutropenia even though patient likely has an
active infection, which is most consistent with a diagnosis of agranulocytosis
3 drug classes that are associated with agranulocytosis include (1)
Carbamazepine (antiseizure) (2) Clozapine (antipsychotic) and (3)
Methimazole/Propylthiouracil (anti-thyroid)
Key idea: Classic presentation of agranulocytosis is sore throat + fever + low
neutrophil count
Note: Patient also has a mildly elevated MCV, which is likely secondary to
significant alcohol exposure
Malabsorption
Amphotericin B
12. Two days after admission to the hospital for treatment of severe…
Memory loss
NBME loves to ask about complaints in elderly patients to assess whether you
know which changes are physiological vs. pathological (same with newborns and
developmental milestones)
In this patient, all of the findings are normal except for the memory loss because
it has only been present for 1 month, which does not correspond with the typical picture
of Alzheimer’s
Patients with suspected cognitive impairment are often worked up with cognitive
tests (MOCA, MMSE, Mini-Cog), Lab testing (CBC, B12, TSH, BMP +/- syphilis)
and Imaging (CT or MRI of brain)
Key idea: Mild cognitive impairment = short-term memory/cognitive problems
that are concerning to patient/family but that DON’T affect daily life or ADLs (using
phone, driving, cooking, etc.)
Carotid ultrasonography
https://www.anatomynote.
com/human-anatomy/nerves-system/median-nerve-ulnar-nerve-radial-nerve-innervation-area-in-
hand/
Patient has numbness and weakness in the distribution of the 5th finger and 1/2
of the 4th finger, which is consistent with the ulnar nerve
Key idea: Most common site of ulnar nerve compression is at the
elbow because it can be compressed when the elbows are resting while sitting at a
desk, driving, etc., and is especially relevant in this patient who has paresthesias with
compression of the cubital tunnel (which is where ulnar nerve passes by the elbow)
https://teachme
anatomy.info/upper-limb/nerves/ulnar-nerve/
20. An 18-year-old man comes to the physician for an initial…
Patient has presentation consistent with somatic symptom disorder, although this
patient also has features of psychosocial distress (hopeless, fatigue, etc.) concerning
for depression with somatic symptoms
Key idea: In patients with depression, always ask about suicidal
ideation/plan/intent
Patient who presents with non-specific lethargy, confusion and muscle cramps
found to have severe hyponatremia with a lung mass most consistent with Small cell
carcinoma complicated by SIADH
Weight-loss program
Most important risk factor for back pain and osteoarthritis is obesity
Answer would not be limiting physical activity because patients with acute back
pain are actually advised to remain active and to avoid bed rest
Patient is in severe pain after a major surgery, and therefore would benefit from
use of opiate medications
A common form of pain control in the hospital is placing patients on patient-
controlled IV morphine where the patient is allowed to self-administer doses, but the
physician team can put limits as to the frequency and total amounts of morphine that
are administered
Aspirin-codeine is more appropriate for mild-moderate pain, and transcutaneous
fentanyl patches are a form of long-acting opiates that are not used in the post-op
patient but rather in patients with chronic pain needs (example: patient with metastatic
cancer with painful bony mets)
Heparin therapy
Post-op patient who has been bed-bound for multiple days has developed
dyspnea and hemoptysis with V/Q scan showing areas of mismatch, most consistent
with acute pulmonary embolism
Key idea: The first step in management of acute PE is administration of an
anticoagulant, most often heparin (assuming patient has no absolute contraindications
such as active bleeding, hemorrhagic stroke, etc.)
Some patients who are hemodynamically unstable (which is not the case here)
will also receive thrombolysis either through use of fibrinolytics or interventional
radiology procedures, but even these patients are often first started on a heparin drip
while definitive diagnostic tests (such as CT-PE) are performed
https://www.uptod
ate.com/contents/image?imageKey=PULM%2F57249~PULM%2F99762&topicKey=PULM
%2F8265&source=see_link
27. A 32-year-old woman comes to the physician because of …
Clue cells
Patient has grayish vaginal discharge with pH > 4.5, which is most consistent
with bacterial vaginosis, and therefore we would expect clue cells
3 main forms of vaginal infection and definitive features include (1) Bacterial
vaginosis [gray fishy discharge, pH > 4.5, no cervical/vaginal erythema, clue cells, treat
with metronidazole or clindamycin] (2) Candidal vaginitis [white cottage cheese
discharge, pH < 4.5, cervical/vaginal erythema, pseudohyphae and budding yeast, treat
with oral or topical -azole drugs] (3) Trichomonal vaginitis [greenish-yellowish
discharge, pH > 4.5, cervical/vaginal erythema, motile trichomonads, treat with
metronidazole
Key idea: Patients with claudication (such as this patient who has significant
vasculopathic risk factors and has leg pain with exercise) should first be optimized
with smoking cessation + daily exercise program + statin + aspirin
Key idea: Decision to pursue revascularization in stting of peripheral vascular
disease is NOT dependent on ABI cut-off and instead is indicated in setting of (1)
Rest pain (2) Ischemic ulceration (arterial ulcer) (3) Gangrene
Claudication: Patient will have risk factors for peripheral vascular disease
(diabetes, HTN, smoking, etc.), reduced lower extremity pulses, reduced lower extrmity
temperature, pain classically in the calves, reduced hair on legs
Pseudoclaudication (spinal stenosis): Positional (improves with flexion),
classically affects buttocks and thighs, may be associated with back pain
Thymoma
Patient who had gallbladder removed 2 months ago presents with right-sided
abdominal pain, clinical jaundice, cholestatic pattern of LFTs (increased direct bilirubin
and increased alkaline phosphatase) along with dilated intrahepatic biliary ducts, most
consistent with a retained stone within the common bile duct that needs to be
investigated and treated by ERCP
Key idea: Although patient had gallbladder removed, patients can sometimes
have residual stones within the gallbladder remnant, cystic duct or common bile duct
that remain behind and can cause pathology
Key idea: ERCP indicated in setting of choledocolithiasis because of its
association with acute cholangitis and the morbidity/mortality associated with that
disease
Note: HIDA scan (cholescintigraphy) is often not the answer on NBME exams,
with its main indication being in a patient with suspected acute cholecystitis who had
negative findings on RUQ ultrasound
31. A 37-year-old woman, gravida 2, para 1, at 12 weeks’ gestation…
The two most important risk factors for preterm labor include (1) History of
previous preterm labor (2) Short cervical length (<2 cm in patient without history
of preterm labor or <2.5 cm in patient with history of preterm labor)
Eczema herpeticum
Patient with baseline atopic dermatitis (atopic patient [allergic rhinitis] with
erythema and lichenification over antecubital and popliteal fossae) who presents with
acute painful, umbilicated vesicles over sites of atopic dermatitis is most consistent
with eczema herpeticum caused by HSV-1
Note: Patient is a wrestler, which in NBME language means they have high risk
of being exposed to skin infection because they are rolling around on sweaty mats
Key idea: Four infectious complications of atopic dermatitis include (1) Eczema
herpeticum [HSV-1, painful vesicular rash] (2) Impetigo (Staph or Strep, painful
pustules with honey-colored crust) (3) Molluscum contagiosum (Poxvirus, umbilicated
flesh-colored papules) (4) Tinea corporis (Tricophyton, pruritic patch with central
clearing and raised border with overlying scale)
Key idea: Young, otherwise healthy women should not present with severe
essential hypertension, and it should make you have a high index of suspicion for
secondary hypertension (fibromuscular dysplasia, hyperaldosteronism, coarctation of
the aorta, Cushing’s syndrome, hypo/hyperthyroidism, pheochromocytoma, etc.)
In this patient, her labs demonstrate a hypokalemic metabolic alkalosis, which is
consistent with a state of elevated RAAS activity either secondary to poor renal
perfusion (question would tell you a bruit is present) or endogenous, inappropriate
production of aldosterone
Thoracentesis
Older patient with significant smoking history and subacute weight loss who
appears chronically ill presents with a large left-sided pleural effusion and should
therefore receive thoracentesis in order to determine the etiology of the effusion (which
is most likely malignant)
Note: Only reason to not get a thoracentesis in the setting of a new pleural
effusion is if you have very high index of suspicion for heart failure and the patient’s
effusion responds well to diuretic therapy
Key idea: Pleural effusion with malignant cells seen on cytology in setting of lung
cancer consistent with Stage 4 disease because it is caused by metastasis of lung
cancer to the pleura and not by pleural fluid production triggered by the primary
lung cancer
Key idea: When trying to decide where to sample/biopsy in setting of suspected
cancer, one of the considerations (in addition to risk of procedure and access to site)
includes trying to select the site that would enable the most up-staging of the
cancer because it has important prognostic and therapeutic implications; in this case, if
the pleural fluid is found to have malignant lung cancer cells, then the patient has
automatic Stage 4 disease
Young female patient with autoimmune history presents with fatigue, weakness,
abdominal complaints and generalized hyperpigmentation found to have eosinophilia,
hyponatremia, hyperkalemia and metabolic acidosis on labs, most consistent
with Addison’s disease which should be worked up with an ACTH stimulation
test (would typically lead to increased cortisol levels in healthy patient but will lead to a
less robust response in patient with Addison’s disease)
Key idea: High cortisol/steroid states lead to increased neutrophil count,
decreased lymphocyte count and decreased eosinophil count, so patients with
Addison’s disease have the opposite
Key idea: Addison’s disease leads to primary failure of adrenal gland, such that
the aldosterone-producing cells are also affected, leading to the hyperkalemia,
hyponatremia and metabolic acidosis because aldosterone typically works at collecting
tubule to reabsorb sodium in exchange for potassium and protons
Key idea: Hyperpigmentation (in addition to hyperkalemia) helps to distinguish
primary from secondary/tertiary adrenal failure because in primary adrenal failure
(Addison’s) the pathology is in cortisol production by the adrenal, so there will be less
negative feedback of cortisol on the pituitary, leading to increased production of ACTH,
with increased production of ACTH also leading to increased production of melanocortin
because they share the same precursor protein, with melanocortin leading to
hyperpigmentation [contrast with secondary/tertiarty adrenal failure where ACTH is low]
Myocardial contusion
Patient involved in a motor vehicle accident presents with severe chest pain,
hypotension and arrhythmia and decompensates further with administration of fluids
(because patient is basically in cardiogenic shock and cannot handle increased
volume), most consistent with myocardial contusion in setting of blunt cardiac
injury
Myocardial infarction would lead to ST-segment changes, pulmonary contusion
would primarily lead to respiratory symptoms and traumatic rupture of the aorta would
lead to severe hemodynamic instability and likely a positive response to fluids (although
most of these patients die in the field due to the high volume of blood loss they
experience)
Vitamin B1 (thiamine)
Older man with back pain, tenderness over spine, and osteoblastic vertebral
lesions most consistent with metastatic prostate cancer
Mnemonic for causes of osteoblastic bone metastases: Holster, Point, Shoot
and Blast the enemy – Hodgkin lymphoma, Prostate cancer, Small cell lung cancer
lead go osteoblastic lesions
Question stem tells us that patient has increased intracranial pressure secondary
to hydrocephalus (increasing head circumference with bulging fontanelles)
Epidemiologically the most common cause of hydrocephalus in an infant
is aqueductal stenosis (obstruction of CSF flow from the 3rd ventricle to the 4th
ventricle) and this patient may have additional CSF flow obstruction secondary to an
Arnold Chiari type 2 malformation (associated with myelomeningocele)
Arnold-Chiari type 1 malformation associated with syringomyelia, whereas
Arnold-Chiari type 2 malformation associated with myelomeningocele (with this patient
has)
40. A 47-year old man is admitted to the hospital after threatening…
Haloperidol decanoate
Newborn born to mother without prenatal care who has previously been pregnant
(G2P1) is found to have anasarca (diffuse body edema) with significant edema and
positive direct Coombs’ test, most consistent with Rh hemolytic disease
Key idea: Anasarca/hydrops fetalis occurs due to high output heart failure
secondary to profound anemia seen in Rh hemolytic disease
Key idea: ABO incompatibility will not present with as severe of a presentation
because majority of maternal antibodies against other AABO blood groups are IgM and
do not readily cross the placenta (contrast with acquired Rh-targeting antibodies in Rh-
negative mother who has been exposed to Rh-positive blood which are IgG and can
easily cross the placenta)
Potential causes of anasarca or hydrops fetalis: Rh-hemolytic disease,
parvovirus/CMV infection of mother, hemoglobin Barts disease (severe form of alpha
thalassemia), etc.
Laparotomy
2 key indications for an exercise stress test include (1) History compatible with
coronary artery disease (angina, etc.) (2) Risk stratification prior to starting
exercise plan
Spirometry would be used to evaluated dyspnea and cardiac catheterization
would only be used if patient had positive exercise stress test
All patients (HIV or not) should receive the annual Influenza vaccine and the
Tdap every 10 years
Additional vaccination requirements for patients with HIV include (1) Vaccination
for hepatitis B unless they have documented immunity (2) Strep Pneumo PCV13
followed by the 23-valent PPSV23 8 weeks later and again in 5 years and at age
65 (3) Meningococcal vaccine with boosters every 5 years
Aortic incompetence
Patient with Marfanoid habitus (tall, long arms, long fingers) presents with heart
symptoms and is found to have bounding peripheral pulses (consistent with widened
pulse pressure) and an early diastolic murmur without clear localization most consistent
with aortic regurgitationt/incompetence
Key idea: Patient’s with Marfan’s syndrome are prone to aortic aneurysm, with a
thoracic aneurysm leading to widening of the aortic valve ring with resulting aortic
incompetence
Note: Localization of aortic regurgitation murmur can sometimes help to
detemine the location of the pathology, with loudest murmur at right sternal border most
consistent with aortic root disease and loudest murmur at left sternal border most
consistent with primary valvular disease
Presentation most consistent with mastoiditis (patient with acute otitis media who
develops pain behind the ear with displacement of the auricle
Patients with mastoiditis should be worked-up with CT scan of the head in order
to look for potential complications such as abscess that would affect management
Patients with pure mastoiditis without abscess: IV antibiotics
Patients with mastoiditis and abscess: IV antibiotics +/- tympanostomy or
mastoidectomy
Exam section 4:
Confounding variables
Patients in the lorazepam group were much more likely to receive a paralytic
agent, which is an important confounder and calls into question the internal validity of
the study
Key idea: Randomization is often performed in studies with the idea that it swill
equally disperse potential confounders between the control and treatment arms of the
study
Patient with chronic urinary hesitancy and frequency who is afebrile is found to
have an enlarged nontender prostate and a positive urinalysis (pyuria and bacteria),
most consistent with asymptomatic bacteriuria in the setting of BPH
Key idea: For men, BPH with bladder outlet obstruction is reported to be the
major predisposing factor for the development of asymptomatic bacteriuria (positive
urinalysis but asymptomatic) because it leads to urine stasis
Infection of epididymis would lead to unilateral posterior testicular pain improved
with testicular elevation, infection of urethra would lead to UTI symptoms (dysuria,
suprapubic tenderness), and acute prostatitis would lead to systemic symptoms (fever,
chills, malaise)and tender prostate on DRE
Orthostatic hypotension
Older patient recently started on anticoagulation therapy who has been passing
dark bloody stools for 2 days presents with loss of consciousness upon standing found
to have hypotension and tachycardia on exam, most consistent with orthostatic
hypotension
Key idea: Orthostatic hypotension formally diagnosed if patient has drop in blood
pressure by at least 20 systolic and/or at least 10 diastolic upon standing OR if patient
has consistent light-headedness or LOC upon standing
Sporotrichosis
Gastric bypass
Catecholamine-producing tumor
Patients who have a near-drowning event are still at risk for morbidity/mortality
from delayed or secondary drowning hours to days later
The underlying pathophysiology is related to inflammation secondary to the
aspiration of water into the lung, and the way that I remember the association between
near-drowning and ARDS is that the inhaled water washes away the surfactant leading
to ARDS, analogous to how preterm newborns can have neonatal respiratory distress
syndrome due to low surfactant levels
Tetralogy of Fallot
12. Over the past 3 months, a 30-year-old woman has had intermittent…
Adrenal gland
Middle-aged woman with risk factor for vertebral compression fracture (long-term
prednisone use) presents with sudden onset back pain and tenderness to percussion
over the spine, most consistent with a vertebral compression fracture
Key idea: Vertebral compression fracture comes in 2 flavors (1) Chronic
fracture: Painless with progressive kyphosis and loss of stature (2) Acute
fracture: Low back pain with decreased spinal mobility + tenderness at affected level
Key idea: Causes of point tenderness over vertebral body include compression
vertebral fracture, osteomyelitis and metastatic disease to vertebral bone
Muscle strain
Young man who developed back pain after lifting heavy equipment and who
has paraspinal tenderness (muscles run along either side of spine) with negative
straight-leg testing and no neurological symptoms, most consistent with muscle
strain (most common cause of back pain in young otherwise healthy people)
Indomethacin
Middle-aged man who presents with atraumatic right knee arthritis found to have
cloudy synovial fluid with a WBC count of 9000 (normal synovial fluid has <200 WBCs)
and negatively birefringent, needle-shaped crystals which are classic for acute gout
Key idea: Acute gout should be treated with NSAIDs (often indomethacin) and
patients should NOT be started on chronic gout drugs (allopurinol, probenecid, etc.)
until the acute flare has resolved because these drugs can lead to rapid shifts in uric
acid levels that can exacerbate/cause a new flare
Note: Patients can sometimes be given oral or intra-articular steroids, but
NSAIDs are tried first due to lower risk and good effectiveness in the majority of patients
Although terminology has fallen out of favor in some neurology spheres, simple
seizures lead to no loss of consciousness and complex seizures lead to loss of
consciousness (like this patient who has staring spells where he smacks his lips and
does not respond)
Patient has a partial seizure rather than a generalized seizure because he does
not show tonic-clonic movements and his aura of smelling burnt rubber and hearing an
intense hissing localizes to the temporal lobe, which is the most common cause/site of
partial seizures
Important to contrast with absence seizures, which often last for less than 20
seconds (in contrast to 30-90 seconds of partial seizures) and are accompanied
by simple automatisms (eyelid fluttering, lip smacking)
Young man with sickle cell anemia who presents with a macrocytic anemia with
an abnormally low reticulocyte count, most likely due to folate deficiency
Key idea: Folate deficiency often related to (1) Chronic hemolysis (such as in
sickle cell disease) (2) Poor dietary intake (such as in alcoholic) (3)
Malabsorption (such as in gastric bypass or tropical sprue) and (4)
medications (methotrexate, phenytoin, etc.)
Emphysema
Young man with family history of “lung and liver problems” and 25 pack-year
smoking history presenting with chronic progressive shortness of breath with expiratory
wheezes found to have elevated LFTs on exam, most consistent with emphysema in
the setting of alpha-1 antitrypsin syndrome
Key idea: Alpha-1 antitrypsin is a co-dominant disorder, with homozygous
patients developing emphysema and cirrhosis and heterozygous patients being highly
prone to emphysema with smoking
Young otherwise healthy woman with no family history of ovarian cancer who
presents with a unilateral tender adnexal mass while in the luteal phase of her
menstrual cycle, most consistent with a functional ovarian cyst
Key idea: Best next step would be repeating the exam during the proliferative
phase of the menstrual cycle, where we would expect the mass to go away or improve
after ovulation has taken place and the egg has been released
Key idea: Patients with a persistent mass or a similar presentation in an older
patient should have full work-up performed
Lichen sclerosus
Description is most compatible with lichen sclerosus because the vulvar thinning
is diffuse (rather than discrete area of pathology seen in patient with vulvar carcinoma)
Antiemetic therapy
Nitroprusside
Patient with blood pressure > 180/20 and papilledema and encephalopathy
(confusion, headache, etc.) most consistent with hypertensive encephalopathy
Key idea: Potential treatments of hypertensive emergency/encephalopathy
include (1) Nitroprusside (2) Labetalol (3) Fenoldopam (4) Clevidipine, nicardipine
Gallstone pancreatitis
Operative treatment
Young otherwise healthy patient with hypertension should prompt high index of
suspicion for a secondary cause of hypertension (fibromuscular dysplasia,
hyperaldosteronism, coarctation of the aorta, Cushing’s syndrome,
hypo/hyperthyroidism, pheochromocytoma)
In this patient who has increased muscular build and stronger pulses in the upper
extremities and signs of LV hypertrophy on ECG (secondary to chronically increased
afterload), the most likely diagnosis is coarctation of the aorta which
requires operative treatment
Child with a genetic X-linked disorder (maternal uncle had similar symptoms)
found to have a variety of neural symptoms and diffuse white matter disease on MRI,
consistent with Adrenoleukodystrophy (rare peroxisomal disorder of beta-ooxidation
that leads to VLCFA buildup in adrenal glands, white matter of brain and testes)
Patient with bipolar disorder who was started on lithium and has experienced
weight gain most consistent with a picture of lithium-induced hypothyroidism
Key idea: Patients on lithium should have regular TSH monitoring every 6-12
months regardless of symptoms
Key idea: Lithium is associated with hypothyroidism, nephrogenic diabetes
insipidus, chronic kidney disease and hyperparathyroidism
Elderly woman with bland diet with bleeding gums, ecchymoses and perifollicular
hemorrhages, which are the classic symptoms seen in scurvy (vitamin C deficiency)
Pathophysiology involves problem in collagen synthesis because vitamin C
involved in hydroxylation of proline and lysine
Lorazepam
Patient’s presentation is consistent with a panic attack (leads to combination of
paresthesias, palpitations, abdominal pain, nausea, intensee fear of dying/losing
control, light-headedness, chest pain, choking, sweating, shaking and shortness of
breath), with panic disorder being acutely treated with benzo’s (such as lorazepam)
and prophylactically/chronically treated with SSRIs
Note: Patients often develop tingling around the lips secondary to hypocalcemia
which occurs because patients begin to breathe rapidly and deeply, leading to a
respiratory alkalosis, which leads to more calcium binding to negatively-charged
albumin, leading to a drop in free calcium
Empyema
Child who has been incompletely treated for pneumococcal pneumonia who
presents with high fever, nonproductive cough and diminished breath sounds over lower
lung fields with dullness to percussion (suggestive of some form of pleural effusion),
most consistent with an empyema
Bronchopleural fistula often seen after trauma, lung abscess often seen
secondary to aspiration, pleurodynia leads to sudden sharp chest pain and
pneumothorax would lead to diminished breath sounds with hyperresonance to
percussion
Esophageal perforation
Young pregnant woman who presents with enlarged uterus (uterus to umbilicus
consistent with gestational age of 20+ weeks), absent fetal heart tones, severely
elevated beta0hCG and chest x-ray showing multiple densities (“cannonball
metastases”) most consistent with choriocarcinoma
Key idea: Rare diagnosis that can develop during pregnancy, after delivery or
after abortion
Key idea: Can be associated with symptoms related to increased hCG due to
alpha subunit of hCG being the same as the alpha subunit of LH, FSH and TSH,
including early pre-eclampsia, hyperemesis gravidarum, hyperthyroidism and theca-
lutein cysts
No pharmacotherapy is indicated
Children with hypertension (BP > 95th percentile) are primarily treated
with lifestyle changes (weight loss, low-sodium diet, regular physical activity)
Indications for treatment of hypertension in children: (1) Symptomatic
hypertension (headaches, etc.) (2) secondary hypertension (3) end-organ damage
(4) diabetes (5) hypertension refractory to lifestyle changes
Key idea: In both children and adults, lifestyle interventions should be thoroughly
tried before getting medications on board in setting of hypertension
Elderly man with chronic diabetes found to have signs of CKD (elevated BUN
and creatinine) and albuminuria who could have benefitted from an ACE inhibitor or
ARB
Key idea: Two most common causes of CKD include hypertension and diabetes,
with diabetes leading to nephropathy because it leads to preferential arteriosclerosis of
the efferent arteriole > afferent arteriole, thus leading to high pressure in glomerulus,
resulting elevated GFR and damage to glomerulus over time (ACE inhibitor or ARB can
reduce this damage by dilating the afferent arteriole, leading to a decreased GFR)
Key idea: ACE inhibitors or ARBs should be initiated at onset of
microalbuminuria in all diabetic patients
Patient’s have the right to decline when offered information about their health or
lab results
Brain abscess
Elderly patient with a history of aortic valve replacement presents with fever, new
systolic murmur and signs of septic emboli to the brain, most consistent with infective
endocarditis
Although brain abscess is a rare complication of endocarditis (1-7%), it is a
feared complication of septic emboli to the brain and is more likely to occur than the
other options listed
Vitamin D deficiency
Young patient with malabsorption (intermittent diarrhea with weight loss and fat in
the stool) who has low calcium and phosphorous levels, which is most consistent with
vitamin D deficiency
Key idea: Vitamin D responsible for calcium and phosphorous absorption from
the GI tract (contrast with PTH which leads to increased calcium and decreased
phosphate)
Key idea: Fat soluble vitamins are vitamins A, D, E and K
Young healthy woman who has bloody stools with severe pain and an anal
fissure on physical exam, most consistent with an anal fissure
Key idea: Most anal fissures can be managed conservatively with anesthetic
ointment and stool softeners (highly associated with mild constipation, as is the case
with our patient)
Patient with renal transplant who develops increased BUN and creatinine on
order of weeks to months most concerning for acute transplant rejection (which is
confirmed by biopsy in this patient)
Key idea: First-line treatment for acute rejection are steroid boluses vs.
antilymphocyte agents vs. antithymocyte serum
Patient with risk factor for lead poisoning (homemade whiskey) presents with
abdominal pain, neurologic symptoms, and a microcytic anemia, which are the three
classic symptoms of lead poisoning
Key idea: Potential buzzwords that should trigger thought of lead poisoning
include battery factory, homemade whiskey, renovating old house, etc.
Note: While not a high-yield association, lead poisoning can lead to worsening of
gout