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Step 2 CK (CCSSA) Form 6
Step 2 CK (CCSSA) Form 6
Exam Section 1:
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.
X-ray of upper GI tract with contrast indicated in setting of suspected malrotation with
volvulus (newborn with abdominal pain + bilious vomiting + distention)
Corticosteroid enemas sometimes used in ulcerative colitis
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
IBD should always be suspected in a young adult without a clear trigger (international
travel, etc.) who presents with increased bowel movements, especially if stools are covered with
blood and/or patient has associated abdominal pain
Diseases associated with erythema nodosum = IBD, tuberculosis, systemic fungal
infections (cocci, etc.), sarcoidosis, Behcet’s disease, strep pharyngitis (most common trigger)
Important to distinguish IBD from IBS because both can present in young adults and
both can be described as having increased frequency of mucus-covered stools. Features that
point towards IBS include lack of blood in stools, abdominal pain that is relieved with defecation
and alternating periods of constipation and diarrhea
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.
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/RecommendationState
mentFinal/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
Classic presentation of mitral stenosis on NBME exams (rheumatic heart disease, worse
with pregnancy, murmur description with diastolic snap-murmur)
Over time, mitral stenosis will lead to increased pressures in the left atrium which will
back up into the lungs and the right side of the heart, eventually leading to right-sided heart
failure; this knowledge coupled with the right ventricular lift (which occurs because the RV
experiences hypertrophy secondary to increased pulmonary artery pressure) points to elevated
pulmonary artery pressure
Diastolic filling time decreased (takes longer for mitral valve to open) and LV end-
diastolic pressure also decreased/normal because of less blood flow from LA to LV
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
Presentation most consistent with a hemangioma of the skin, which commonly grows
during the first year of life but involutes on its own within 5 years
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.qu
ora.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…
One of the most common causes of female infertility, especially in overweight women
Diagnosis requires 2 out of 3 of the following criteria: (1) Clinical and/or biochemical
hyperandrogenism (2) Oligomenorrhea (3) Polycystic ovaries on pelvic ultrasound /// Our patient
has clinical hyperandrogenism (acne vulgaris) and oligomenorrhea (irregular menses)
Key idea: Although often associated with insulin resistance and ultimately associated
with development of Type 2 diabetes, insulin resistance is not formally included in diagnostic
criteria
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
Alcohol and benzodiazepine withdrawal lead to similar clinical syndromes with increased
autonomic activity (tremors, anxiety, sweating, agitation, etc.) because prolonged use of these
medications leads to downregulation of GABA receptors, such that removal of GABA agonists
(alcohol, benzo’s) leads to relatively decreased inhibitory activity from ligand binding to GABA
receptors
Key idea: Withdrawal often leads to the opposite effects of intoxication with drug
(Example: Opiate use leads to constipation and pinpoint pupils, whereas opiate withdrawal
leads to diarrhea and mydriasis)
https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal
Autosomal dominant trinucleotide repeat disease (father also affected) that classically
leads to myotonia (difficulty relaxing muscles, most classically gripping)
+ CTG (Cataracts, Toupee (early balding) and Gonadal atrophy
Key idea: These patients also commonly have psychosocial symptoms (irritability,
tired during day, etc.)
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.)
Patient has persistent wheezing despite treatment with bronchodilators, meaning that
asthma is unlikely
3 causes of chronic stridor/wheezing in a newborn/infant
include laryngomalacia (inspiratory stridor/wheezing that worsens when feeding, crying or
supine and improves when prone), vascular ring (biphasic stridor/wheezing that improves
with neck extension) and airway hemangioma (worsening biphasic stridor over first year of
life in patient with concurrent skin hemangioma)
Patients with proetin-induced allergic proctocolitis secondary to milk consumption often
have bloody stools in setting of other allergic conditions (allergies, eczema or asthma)
3. A 37-year-old man is brought to the emergency department 6…
Laparotomy
Patient presented with a COPD exacerbation without overt infection (normal WBC with
normal neutrophil count, afebrile) and then after receiving IV methylprednisolone (strong
systemic steroid) developed a neutrophilic leukocytosis despite clinical improvements
Key idea: Two common causes of a neutrophilic leukocytosis are infection and systemic
steroid use
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
Classically leads to cardiomegaly and hypotonia (including poor head control) in a young
child
Muscular dystrophy would often present later on (toddler) and wouldn’t lead to heart
symptoms early on in disease course
GM1 gangliosidosis [similar to Tay-Sachs (progressive neurodegeneration)] and infant
botulism wouldn’t lead to heart symptoms
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.)
Viral infection
Patient presents with signs of encephalitis (altered mental status, emotional lability,
fever, etc.) with CSF findings consistent with a viral infection (elevated WBC count with
lymphocytic predominance, elevated protein and normal glucose), most consistent with HSV
encephalitis
Fungal infection CSF: Elevated WBC count with lymphocytic predominance
with decreased glucose
Bacterial infection CSF: Highly elevated WBC
count (>1000) with neutrophilic predominance with decreased glucose
Normal CSF findings: WBC 0-5, Glucose 40-70 (2/3 serum glucose levels), Protein < 40
Key idea: Patients with suspected HSV encephalitis should be started on empiric IV
acyclovir while awaiting PCR results and/or before brain MRI
Patient with psychosocial distress causing impairment following a discrete stressor who
does not meet criteria for more serious psychiatric diagnoses
Key idea: Adjustment disorder develops within 3 months of identifiable stressor and
should last no longer than 6 months
Key idea: Treated with psychotherapy (CBT) +/- adjunctive pharmacotherapy for
anxiety, insomnia, etc.
17. An 8-year-old girl with type 1 diabetes mellitus is brought to…
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
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”)
Young, otherwise healthy patient with intermittent constipation and intermittent diarrhea
with no inflammatory/systemic signs (fever, weight loss, etc.) and normal exam
Key idea: Patients with IBS can have foul-smelling, mucus-coated stools
Key idea: Features inconsistent with IBS include rectal bleeding, nocturnal abdominal
pain, weight loss, grossly abnormal lab findings (anemia, etc.), and older age
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
Stress incontinence
Overflow incontinence
Anovulation
Pap smear
Key idea: Abnormal total cholesterol levels should always be followed by fasting LDL
levels because treatment is based on LDL and HDL levels/thresholds
Reassurance
Key idea: Pulling effect/feeling is common complaint in the post-partum for patients who
underwent C-section and is due to healing fibrosis around the wound site
No fever, wound erythema/purulence, or feeling of hematoma/seroma beneath the
wound site
Note: Women are often advised to avoid exercise or sexual activity for at a minimum of
6 weeks after C-section
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
Nonstress test
If a patient presents with decreased fetal movement, first perform a non-stress test to
look at fetal heart rate (110-160 beats/min), variability (consistent and not too much, but not
none at all) and acceleration (15/15 2 in 20: heart rate should rise by at least 15 beats/min for
at least 15 seconds at least 2 times in 20 minutes)
If that test result is abnormal, then perform a non-stress test with acoustic
stimulation and assess the same way you assess non-stress test (rate, variability and
acceleration)
Abnormal non-stress test with stimulation means you should perform a biophysical
profile, which is similar to APGAR and assigns a score from 0 to 2 in 5 categories (non-stress
test result, amniotic fluid index, fetal breathing, fetal movements and fetal tone)
Unequivocal biophysical profile (greater than 2 but below 8) should be followed up
with contraction stress test to look for late decelerations (decelerations begin at same time
that contractions occur) and/or bradycardia (HR < 110 bpm)
Intraductal papilloma
Most common cause of unilateral bloody nipple discharge, and often presents without
mass or lymphadenopathy
PCP
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.)
Patient has an X-linked condition (2 maternal uncles affected) that leads to recurrent
infection with encapsulated bacteria (Strep pneumoniae) with labs showing normal lymphocyte
count with very low immunoglobulins, most consistent with X-linked (Bruton’s)
agammaglobulinemia
Patient should receive treatment of acute infection and IV immunoglobulin infusion in
order to make up for lack of endogenous immunoglobulin production
Carotid ultrasonography
Patient with vasculopathic risk factors (hypertension and poorly controlled diabetes) who
presents with recurrent embolic phenomenon to brain all from the same side (will lead
to ipsilateral visual problems (amaurosis fugax) and contralateral weakness (due to MCA
involvement))
Key idea: Amaurosis fugax is highly associated with carotid artery disease
Distribution most consistent with median nerve, and the history of patient with recurrent
use of hands (carpenter) with pain and numbness at night most consistent with carpal tunnel
syndrome, which is due to compression of median nerve at the wrist
Key idea: Carpal tunnel syndrome leads to spared sensation to the palm because
the palmar cutaneous branch enters the hand external to the carpal tunnel
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://teachm
eanatomy.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
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
Presentation is most consistent with myasthenia gravis (tends to affect young women
and older men and classically leads to dysphagia, dysarthria and eye weakness that is worse at
the end of the day)
Key idea: Patients with myasthenia gravis should be treated with an
acetylcholinesterase inhibitor (most often pyridostigmine), but they should also have a CT scan
performed because in about 15% of cases the cause is a thymoma and some patients will be
cured following removal of the thymoma
Note: If patient with weakness is described in vignette and they give you some
sort of chest imaging, you should have high index of suspicion for myasthenia gravis
(associated with thymoma) or Lambert-Eaton (associated with small cell lung cancer)
https://www.pe
nnmedicine.org/for-health-care-professionals/for-physicians/physician-education-and-
resources/clinical-briefings/2019/march/medical-and-surgical-management-of-myasthenia-
gravis-and-thymoma
30. A 42-year-old woman comes to the physician because of right…
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
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)
Patient with chronic alcoholism present with confusion, ataxia and ophthalmoplegia,
most consistent with Wernicke encephalopathy secondary to thiamine deficiency
Key idea: On the NBME exam, patient with alcoholism = patient with malnutrition and
vitamin deficiencies (among other associations)
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)
Haloperidol decanoate
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
3. A 15-year-old boy is brought to the emergency department…
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
Sporothrix schenckii is a dimorphic fungus found in decaying plant matter and soil with
can often lead to an ulcerative skin papule with proximal lesions along lymphatic chain in
patients with exposure to plants (often in gardeners)
Patient with history of poorly controlled T2DM with signs of autonomic neuropathy
(gastroparesis) presents with intermittent urinary incontinence found to have a post-void
residual volume of 500 mL most consistent with overflow incontinence secondary to poor
bladder contraction
Key idea: Post-void residual > 150 mL is a sign of urinary retention
Key idea: Autonomic neuropathy can be seen in late-stage diabetes and can manifest
as problems with esophageal motility (dysphagia), gastric emptying (gastroparesis), intestinal
function (constipation), blood pressure (orthostatic blood pressure unresponsive to fluids) and
bladder function (acontractile bladder, incontinence)
Gastric bypass
Patient is a middle-aged woman with a BMI of 75, poorly controlled type 2 diabetes and
significant limitations in activities of daily living due to obesity who is compliant with her diet and
medications and has been unsuccessful at losing weight on her own who would be a candidate
for gastric bypass
Indications for gastric bypass: Patient with multiple failed attempts to lose weight with
adequate ability to follow-up and adhere to a plan who also has (1) BMI > 40 or (2) BMI >35
with obesity-related comorbidity (Type 2 diabetes, obstructive sleep apnea, obesity
hypoventilation syndrome, debilitating osteoarthritis, cardiomyopathy, coronary artery
disease)
Note: Interestingly, bariatric surgery in patients with comorbid type 2 diabetes has been
found to significantly improve and even cure type 2 diabetes in a significant proportion of
patients (https://care.diabetesjournals.org/content/34/Supplement_2/S361)
Catecholamine-producing tumor
Young patient with neurofibromatosis who presents with episodes of headaches and
flushing who is found to have elevated blood pressure, most consistent
with pheochromocytoma
Neurofibromatosis Type 1: Cafe-au-lait spots, intellectual disability, cutaneous
neurofibromas, Lisch nodules, optic glioma, Pheochromocytomas, seizures (often secondary
to meningioma)
Neurofibromatosis type 2: Leads to bilateral (2) vestibular schawannomas, affects
both (2) eyes (juvenile cataracts and leads to 2 other types of brain tumor (meningioma,
ependymoma
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
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)
18. A 20-year-old African American man with sickle cell…
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
Although it is normal for women to have nausea/vomiting during the first trimester, when
they are having severe, persistent vomiting with signs of dehydration and orthostasis, >5% loss
of pre-pregnancy weight, or lab findings of ketonuria (pathognomonic of hyperemesis
gravidarum > normal pregnancy nausea) then they have hyperemesis gravidarum
Patients with hyperemesis gravidarum should be admitted to the hospital and treated
with antiemetics and intravenous fluids
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
Middle-aged woman with risk factors for gallstones (Female, Forty, Fertile) and history
consistent with biliary colic who presents with nausea, vomiting, epigastric and RUQ tenderness
and lab findings of elevated lipase and amylase most consistent with gallstone pancreatitis
Key idea: 2 main causes of pancreatitis are gallstones and alcohol, with elevated
triglycerides leading to pancreatitis only when triglyceride levels are >1000-2000
Key idea: In setting of gallstone pancreatitis, important to make sure patient does not
have concomitant ascending cholangitis (fever, RUQ pain, jaundice, hypotension, altered
mental status) because then patient would require urgent ERCP + antibiotics
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
Four options for emergency contraception include (1) Copper IUD (most effective) (2)
Ulipristal (3) Levonorgestrel (“Plan B”) (4) Oral contraceptives
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
Older woman who received an upper endoscopy with associated procedure presents
with severe chest pain, hematemesis, crepitus in the neck and positive blood in the GI tract
most consistent with an esophageal perforation
Key idea: Best diagnostic test would be esophagography with water-soluble contrast
and patient should be treated with IV antibiotics, PPIs and emergency surgery
Contrast with Mallory-Weiss tear, which is a partial tear and therefore would not lead to
crepitus and would often lead to more profound hematemesis
Choriocarcinoma
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
Image demonstrates serosal lining, hair and a tooth/bone and therefore is consistent
with a teratoma (tumor made up of several different types of tissue)
Key idea: Most common cause of an adnexal mass in a young woman is a teratoma,
and it can be associated with ovarian torsion
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
Infant presenting with grunting and breathing difficulty found to be hypocalcemic with
absent thymic shadow and infection with an organism commonly seen in patients with HIV and
other forms of cellular (T cell) deficiency, most consistent with DiGeorge syndrome
Mnemonic for symptoms for CATCH-22: Cardiac abnormalities (often Tetralogy of
Fallot), Abnormal facies, Thymic aplasia, Cleft palate/lip, Hypocalcemia (secondary to
parathyroid a/dysgenesis)
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)
Healthy patient with increased calcium and decreased phosphorous, most consistent
with elevated PTH levels with the most common cause being primary hyperparathyroidism
Key idea: Parathyroid hormone leads to increased calcium and decreased
phosphorous, whereas vitamin D leads to increased calcium and increased phosphorous
Key idea: If patient had a positive protein gap (total protein – albumin > 4 g/dL), then
you would have higher index of suspicion for multiple myeloma and would perform a serum
protein electrophoresis
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