Match 2023 Free Mock interview: Resiyay.org (Join group for updates https://www.reddit.

com/r/Resiyay/)
Free CK Notes: https://tinyurl.com/3wpmfy89

Derived from DI Podcasts Reddit and dedicated med students: Use Table of Contents on Left
Contains: Alternative Nbme Vocabulary + Risk Factors (General, Elderly, Military) + Vaccines + Screening + Weird Social Science Topics

Alternative Nbme Vocabulary

Imaging
❖ Virtual Colonoscopy = CT Colonography
❖ Laparoscopy = minimally invasive surgical procedure which is sometimes referred as keyhole surgery as it uses a small incision
❖ Laparotomy = large incision in the abdomen to facilitate a procedure (i.e. exploratory laparotomy)

General
❖ Psammoma bodies= laminated calcifications
❖ Never event —> Sentinel event
❖ Near miss —> close call
❖ Proteinase-3-ANCA-->cANCA
❖ Myeloperoxidase-ANCA-->pANCA
❖ Convex bilateral soles-->Rocker-bottom feet
❖ Childhood-onset fluency disorder-->Stuttering
❖ Synthetic cathinones-->Bath Salts
❖ Bruton agammaglobulinemia: X-linked agammaglobulinemia
❖ Reflex sympathetic dystrophy = Complex regional pain syndrome
❖ Leukotriene receptor = CYSLT1 receptor

CVS
❖ Kawasaki= Mucocutaneous LN syndrome or Lymphocytic Myocarditis
➢ Rash on palms/soles OR edema of hands & feet OR desquamation of skin
❖ Defibrillation —> unsynchronized cardioversion
❖ Direct current cardioversion or direct current countershock → synchronized cardioversion
❖ Unstable angina, NSTEMI, STEMI -> acute coronary syndrome

Pulmonary
❖ Polysomnography = Sleep study
❖ CT Angiography = Spiral CT Scan (if question mentions Pulmonary angiography– that does not mean CT angiography)

Endocrine

GI
❖ Exploratory laparotomy —> exploratory celiotomy
❖ Palpable cord -> thrombophlebitis (Migratory thrombophlebitis associated with visceral cancers–Pancreatic)
❖ Colonic dilation due to inflammatory cells → Toxic Megacolon
❖ Congenital Megacolon → Hirschsprung’s Disease
❖ Pseudomembranous colitis → C difficile colitis
❖ Lithogenic bile → Gallstones

Infectious Disease
❖ Tinea capitis—> Trichophyton tonsurans, Microsporum canis, Microsporum audouinii

Reproductive
❖ Intrauterine synechiae--> Asherman Syndrome
❖ Mullerian agenesis: Mayer-Rokitansky-Kuster-Hauser syndrome
❖ PCOS -> Stein-Leventhal MSA -> Shy-Drager (not sure if this is correct??)
❖ Testicular insensitivity to Testosterone → Androgen Insensitivity Syndrome
❖ Submucosal myoma = leiomyoma uteri = uterine fibroids

Opht
 Neurology
❖ Embolic Stroke of Undetermined Source = Cryptogenic Stroke (formerly named)
❖ Neural tube defects= spinal dysraphism – includes Spina bifida occulta
❖ Simple partial seizure —> focal seizure without loss of awareness
❖ Acute inflammatory demyelinating polyneuropathy —> Guillain Barré
❖ Werdnig Hoffman disease → Spinal muscle atrophy type -1
❖ Multi system atrophy → Shy Drager Syndrome
➢ Loss of sweating is a characteristic feature. Postural hypotension, with dizziness and weakness on standing or
walking. In the male impotence is an early symptom and sphincter disturbances are also common. The
condition is slowly progressive and has a poor prognosis.
❖ Hereditary motor and sensory neuropathy -> Charcot-Marie Tooth disease
❖ Hereditary hemorrhagic telangiectasias -> Osler Weber Rendu Syndrome
❖ Multi-infarct dementia = Vascular Dementia
❖ Encephalotrigeminal Angiomatosis = Sturge-Weber Syndrome
❖ Von Recklinghausen's disease = Neurofibromatosis 1

Psych
❖ Hysterical amnesia = Dissociative amnesia
❖ Hepatolenticular degeneration = Wilson's Disease
❖ Frontotemporal dementia = Pick Disease

MSK
❖ Osteosarcoma – Osteogenic sarcoma
❖ Osgood-Schlatter disease —> traction apophysitis, tibial osteochondritis
❖ Heterotropic changes in muscle → Myositis ossificans
❖ Pyogenic arthritis -> septic arthritis
❖ Pain improves when raising arm above head -> cervical radiculopathy
❖ Meralgia Paresthetica > lateral femoral cutaneous nerve compression
❖ Axillary-subclavian venous thrombosis = upper extremity DVT due to repetitive microtrauma (jackhammer operator)

Renal
❖ Nephrotic syndrome= lipoid nephrosis fatty casts on UA
❖ HIV-associated nephropathy -> Focal segmental glomerulosclerosis
❖ IgA nephropathy- 2-6 days after URI = Synpharyngitic nephropathy
❖ Thiazide diuretics —> Metolazone, Chlorthalidone, -iazide
❖ Struvite stones —> triple phosphate stones, magnesium ammonium phosphate stones
❖ Wilson disease —> hepatolenticular degeneration

Hem/Onc
❖ Von Willebrand Factor Disease -> Impaired Hemostasis
 Risk Factors
A/w= Associated with MC = most common MCC = most common cause MCCOD = MC Cause of death
MIPF = most important px factor MSC = most serious complication ML = most likely MLM: Most likely mechanism
NBSIM = Next best step in management

General RF
#1 RF in development of pressure ulcers → immobility

Association of infectious agents with neoplasms

1. Cervical/anal/head and neck/vocal cord cancers → HPV (HIV increases risk of Cervical Cancer)
2. Kaposi Sarcoma → HHV-8
3. Bacillary angiomatosis → Bartonella henselae (similar presentation to Kaposi, also in HIV)
4. Hodgkin’s Lymphoma → EBV (Reed-sternberg cells)
5. Burkitt’s Lymphoma → EBV (8;14 translocation, starry sky)
6. Lymphomas after transplant → EBV
7. Opportunistic Infections post transplant → CMV (Prophylactic Valganciclovir)
8. MALToma → H pylori
9. HCC → Hep B + C

CVS
MI test needed in dx of IE → Blood culture (prior to Echo)

MIPF in pt with CAD → Left ventricular function

MC complication of left atrial thrombus → embolization

#1 RF for AFib → Mitral stenosis

#1 RF for Mitral stenosis → Rheumatic fever
Most likely initial presentation in Rheumatic Fever → migratory polyarthritis
Most serious complication (MSC) + MCCOD of Acute rheumatic fever → myocarditis
#1 RF for MR → mitral valve prolapse
MC valvular complication a/w Marfan syndrome → Mitral valve prolapse
MCC of death in Ehlers Danlos syndrome → aortic dissection

MI physical exam finding in dx of AS → pulsus parvus et tardus (delayed upstroke in carotid pulse)

#1 RF for AAA development→ smoking

MC complication of AAA → rupture
Greatest predisposing risk factor to rupture of AAA → diameter of aneurysm
Most important modifiable RF for CAD → smoking
Screen AAA → men + 65-75yo + smoker. If >5.5 cm → surgery. Or >0.5cm/6 mos or 1 cm/yr growth

#1 RF for ED→ CVD

Hyperlipidemia screen → men: every 5 year >35yo men; women: every 5y > 45 yo
MI predictor of survival in aortic coarctation → Age of defect repair

#1 RF for stroke and aortic dissection → HTN

MC complication of Chronic HTN → LVH
MCCOD in hx of chronic HTN → Acute MI
MCC of HTN in young reproductive age female → OCP use

MSC in low BMI pt → ventricular arrhythmia from hypokalemia

MCC of arrhythmia in STEMI → premature ventricular contraction

MI disease associated with central sleep apnea → heart failure

Most common mutation (chromosome) that gives rise to HOCM → Chromosome 11

DERM
Most damaging UV radiation to skin → UVB
#1 RF for SCC → cumulative sun exposure
Most likely malignant complication in pt on chronic immunosuppressant → SCC of skin
MC malignancy in kidney transplant recipient → SCC of the skin

Most important prognostic factor in pt with melanoma → depth of invasion “Breslow depth”
ML determination of Melanoma spread→ breslow depth
ML subtype of melanoma in a pt with a dark complexion → acrolentigenous melanoma

MC complication of ganglion cyst resection → recurrence

ML outcome of actinic keratosis → resolution of disease
MCC of folliculitis → S. aureus (hot tub—Pseudomonas)
MCC of skin abscess → S. aureus
MCC of impetigo → S. Aureus

ML inciting factor in pt with erythema multiforme → Recurrent herpes simplex virus infection
MSC of Perineal cellulitis → necrotizing fasciitis —may progress to Fournier’s gangrene
In a person with necrotizing fasciitis include Clindamycin in the Abx regimen
ML inciting factor for TEN/SJS → drugs
Most likely barrier to proper healing of wound → persistent infection

#1RF for Hidradenitis Suppurativa → Smoking (not hygiene) + Obesity, Diabetes Mellitus

PULM
Lung CA → low dose CT
Men and women, 55-80 who have >20pp smoking hx, who currently smoke + less than 15 yr since quitting.
MCC cancer a/w asbestos exposure → Bronchogenic carcinoma
Mesothelioma has no relation to smoking — psammoma bodies

MI goal in mgmt. of COPD → smoking cessation

Which pneumoconiosis increases risk of TB → Silicosis

#1 RF in development of lung disease related to asbestos → cumulative exposure to asbestos fibers.
MI factor in determining TB treatment success → adhering to treatment regimen

2 MC complications of influenza? → Primary influenza pneumonia, Secondary bacterial superinfection

MC infectious precipitant of an acute COPD exacerbation → H. influenza

#1 RF for ARDS → Sepsis

*COVID19 vaccine is an mRNA vaccine
Very low oxygenation → PaO2/FiO2 very low → Whiteout lungs
Tx: ventilator, low tidal volumes and high PEEP (which are lung protective strategies)
Make them prone – lie them on bellies in ICU
Mortality rate ARDS 40% - that’s why so many people are dying of COVID

Most important factor in preventing lung injury when using a ventilator → mechanical ventilation with lung protective
strategies. I.E low TV

3 complications of O2 therapy? → Bronchopulmonary dysplasia, Retinopathy of prematurity, IVH (Divine doesn’t consider this a
complication but he still mentions it)

#1 RF OSA in Kids? Adenotonsillar hypertrophy (Adenoid + Tonsillar hypertrophy)

#1 RF OSA in Adults? Obesity

#1 RF Aspirin-exacerbated respiratory distress? Nasal polyps

Aspirin is irreversible COX 1&2 inhibitor so more flux via lipooxygenase pathway form more leukotrienes →
Bronchoconstriction
Tx: Leukotriene Receptor inhibitor- Montelukast or Zafirlukast OR Lipooxygenase inhibitor- Zileuton (SE:
Hepatotoxic)
Another name for Leukotriene receptor=CYSLT1 receptor

MLM in patients with normal O2 sat and perioral cyanosis after TMP-SMX? Methemoglobinemia (strong oxidizing agent)
Drugs:
TMP-SMX
Nitrate: MI patient—chest pain, CAD
Dapsone: PCP prophylaxis (allergic to TMP-SMX), Leprosy Tx, Dermatitis herpetiformis
All iron is in ferrous form (Fe2+) but if a powerful oxidizing agent add (becoming more positive) becomes ferric iron
(Fe3+ cannot carry O2) --> cyanotic
TX= Methylene blue, Vit C, Cimetidine (H2 blocker)

ENDOC
Most common arrhythmia in hyperthyroidism → A fib
Controlling blood glucose only decreases microvascular risks associated with retinopathy, neuro, and nephropathy, not
macrovascular like CAD and stroke.
#1 RF for papillary thyroid cancer → prior chest/neck radiation
MLCP in pt dx with primary hyperparathyroidism → nephrolithiasis

MSC of acromegaly → Death from dilated cardiomyopathy

MCCOD in acromegaly → Heart failure

MLM of disease in pt presenting with signs of hypopituitarism → pituitary adenoma

MC complication of DM (esp T1) → Insulin-induced hypoglycemia

Most important mechanism underlying hyperglycemia in T1DM → Gluconeogenesis

MC pancreatic neuroendocrine tumor in pt with Hx of MEN1 → Gastrinoma

ML symptom that would trigger initial presentation in pt with MEN1 → Sx of hypercalcemia
MLCP in MEN2 → Medullary thyroid cancer

Environmental/Poisoning
MCC of cyanide poisoning → House fire
MCCOD in pt struck by lightning → Cardiorespiratory arrest

GI
MC infectious cause of odynophagia (painful swallowing) → Candida albicans

Biggest RF in iron deficiency anemia pt with h/o H.Pylori→ PUD

ML vessel involved in bleeding gastric ulcer→ Left gastric A
MC artery involved in bleeding duodenal ulcer → Gastroduodenal A (also involved in duodenal hematoma in children post
trauma)

ML clinical complication of barett-s esophagus → Esophageal ulcers w/ strictures

#1 RF for esophageal adenoCa → Barrett’s esophagus which is caused by GERD

MC complication of Appendicitis → Periappendiceal abscess

MC complication of cholelithiasis → biliary colic

Diabetic with RUQ may have gangrenous cholecystitis → Emergent cholecystectomy
NBSIM of Acalculous cholecystitis → Percutaneous cholecystostomy (avoid cholecystectomy due to high mortality risk)

#1 RF for cholangiocarcinoma in US → Primary sclerosing cholangitis

Ranson’s criteria for pancreatitis (criteria for admission to ICU)

GA LAW:
Glucose >200 (Divine says 100 but 200 according to Uptodate)
AST >250
LDH > 350
Age >55
WBC >16000
48 hours post admission → C and HOBBS
HypoCalcemia <8 mg/dL
Hematocrit dropping by >10%
O2 sat <60 mmHg
BUN increase on admission
Base deficit >4 mg/dL
Six liters of fluid needed in 48 hr period
MCC of acute pancreatitis in America → Gallstone “Lithogenic bile”
MCC chronic pancreatitis → Alcoholism
No. 1 RF for chronic pancreatitis in a child → Cystic fibrosis
MI therapeutic step in mgmt. of acute pancreatitis → IV fluid resuscitation
MC complication seen within weeks of acute pancreatitis → Pancreatic pseudocyst
#1 RF for pancreatic adenocarcinoma → Smoking
MCC of esophageal varices → Portal HTN
MCCOD in cirrhosis → Rupture of esophageal varices
MCC of cirrhosis in kids → Alpha 1 AT def
MCC of fatty change in liver → chronic alcoholism
ML cause of abnormal LFTs on routine labs → non-alcoholic fatty liver disease
#1 RF for hepatic adenoma → OCP use
#1 prevention of Hepato cellular carcinoma → Hep B vaccination (Hep B helps against Hep D)
2 #1 RF in development of HCC → Cirrhosis + Hep B infx
#1 RF for liver angiosarcoma → Vinyl chloride exposure
#1 RF Budd Chiari? Hypercoagulopathy = Polycythemia vera (then PNH, OCP + Smoking, Nephrotic syndrome)

MIPF in mesenteric ischemia → bowel infarction

MI complication of peritoneal dialysis → peritonitis

#1-2 RF for development of C. diff colitis → hospitalization and Abx

MCC of osmotic diarrhea → lactase deficiency

MLM of treatment failure in pt placed on gluten free diet for celiac’s disease → non-adherence
MI oncologic association in long term celiac disease → small bowel lymphoma (enteric associated T-cell lymphoma)

MC complication of meckel’s diverticulum → bleeding

MSC of hirschsprung disease → death due to enterocolitis from super dilated bowel
MC complication of diverticulosis → diverticulitis
MSC of UC → toxic megacolon

ML finding on further eval of 55 yo male presenting with Hb of 8, mcv 60 → Polyps/CRC

MIPF in determining outcome of treatment in colon ca → Stage at diagnosis
Colon CA Screening Guidelines → Colonoscopy is gold standard
Normally: Colonoscopy q 10 years from 50-75 yo or CT Colonography q5 years
UC pt’s: starting 8 years after diagnosis then every 1-2 years after.
If FHx colon cancer: Age 40 years or 10 year prior to family member’s age at diagnosis.
FAP pt’s: q 1 year starting at 10-12 yo

HE/ONC
Most common gene mutation seen in malignancy → p53 mutation
Most important prognostic factor in cancer→ stage of tumor (TNM staging). #1-Metastasis (whether or not cancer has
metastasized) >> LN involvement
Osteosarcoma staged by MRI
MC complication of terminal disseminated malignancy → Cachexia

MSC of SCD → acute chest syndrome

MCC of anemia in alcoholic → anemia of chronic disease (be careful not to pick megaloblastic)
ML trigger of hemolytic ep in G6PD → acute infection

MCC of thrombocytopenia in healthcare setting → use of heparin

#1RF Vit K def in hospitalized pt = broad-spectrum ABX (Warfarin leads to functional Vit K deficiency and Abx further
exacerbate by killing GI flora)
Plt dysfxn most likely presenting clinical complaint → nose bleeds
ML cause of perioral cyanosis and normal O2 saturation in pt on oxidizing agent/drugs → Methmoglobinemia
All iron is in ferrous form (Fe2+) but if a powerful oxidizing agent add (becoming more positive) becomes ferric iron (Fe3+
cannot carry O2) --> cyanotic
TX= methylene blue, vit C, Cimetidine (H2 blocker)
#1 RF → Nitrate (MI patient—chest pain, CAD)
TMP-SMX
Dapsone: PCP prophylaxis (allergic to TMP-SMX), leprosy Tx, dermatitis herpetiformis
Favorable prognostic factor in an individual with ALL → presence of t(12;21) translocation
Most important prognostic factor in a pt with Hodgkin’s L → clinical stage of disease not type
Slow vs. fast drug acetylators and osteosarcoma AKA osteogenic sarcoma
Good prognostic factors for Hodgkin’s?
Young person > older person
More lymphocytes
Fewer Reed Sternberg cells

#1 RF DIC → Sepsis

MC complication of BM transplant → GVHD (CD8 mediated)

MCC of infx in BMT → aspergillus (put on voriconazole). #2 is candida.
MCC of infx in solid organ transplant (heart, kidney, lung, pancreas) → candida
MCC of infx overall in transplant recipient → CMV
Most likely cause of rejection in transplant pt → acute rejection

MC malignancy in kidney transplant recipient → SCC of the skin

Most likely malignant complication in pt on chronic immunosuppressant → SCC of skin

ML infx due to blood transfusion → CMV infection (don’t choose HEP C)

MSC in pt receiving blood transfusion in the first 6-12 hours → Transfusion associated circulatory overload. (^ risk in CKD)

ML malignant complication of pt exposed to radiation → acute leukemia. (papillary thyroid only if radiation is to head and neck)
ML reproductive complication of receiving systemic chemotherapy → hypogonadism
#1 RF for uterine sarcoma → radiation therapy to pelvis

Mets
Most likely bone to have mets from cancer elsewhere in body → vertebral column
Top 2 malignancies a/w mets to vertebrae? #1: Breast cancer #2: Prostate ca (osteoblastic mets)
Most likely primary malignancy a/w mets to liver → lung cancer
Most likely primary malignancy a/w mets to brain → lung cancer
Most likely primary malignancy a/w mets to lung → breast cancer
Most likely primary malignancy in child with multiple bone mets → neuroblastoma

ID
Diabetic pt with mucormycosis of sinuses → give Ampho B + debride extensively
MCC CAP → Strep. Pneumo
MCC UTI→ E.coli

MSC of tetanus → pneumonia and cardiac arrest

MLCP of superficial dermatophytosis → tinea pedis
(ps. If pt has nail fungus or tinea capitis → tx with oral agent, oral terbinafine/itraconazole)
MC STI in US → chlamydia
Pt from Hawaii with conjunctivitis → Leptospirosis (Tx: Doxycycline)

MC HIV serotype in the U.S. → HIV-1

MLM of transmission of HIV in US → men having sex with men
Most likely cause of infx in HIV pt CD4 count of 25 → PCP pneumonia or systemic candida infx
MCC of pneumothorax in HIV pt → PCP infx
Most likely cause of HIV in Healthcare worker → Needlestick injury
Most common neoplastic complication of HIV → Kaposi sarcoma

Immunology
MC complication a/w chronic granulomatous disease → Pneumonia
MCC of infx in burn pts → P. aeruginosa sepsis

MSK
MLCP of relapsing polychondritis (inflammation of cartilage) → red hot painful ear
MIPF in preserving neurologic function in spinal cord compression → early diagnosis

#1 RF for OSA → obesity

#1 modifiable RF for knee OA → obesity
MI non-pharmacologic intervention in mgmt. of osteoarthritis → exercise

Common RF for osteoporosis → Low BMI

MLCP in pt with MG → ptosis

2 biggest RF for carpal tunnel syndrome → pregnancy and RA
MC extra-articular manifestation of ankylosing spondylitis → anterior uveitis
ML cause of knee pain in pt <45 yrs → Patellofemoral pain syndrome
Young female + pain on walking up or down the stairs + chronic poorly localized anterior knee +
atrophy of quadriceps + pain on isometric (tonic) contraction of quadriceps, eg squatting, lunging)

ML cause of pain at inferior heel → plantar fasciitis (+ calcaneal spurs)

MCCOD in SLE → ischemic heart disease

MCCOD in SLE → Infx from immunosuppression
Most likely organ to dev complication in pt with lupus → kidney
Lupus Ab that has the strongest association with kidney disease → Anti ds-DNA Ab
MC cardiac finding in SLE→ fibrinous pericarditis
MCC of Drug induced lupus → procainamide (used for WPW)

MC presenting complaint a/w dx of scleroderma → raynaud's phenomenon (skin most commonly involved).
MCCOD in Systemic sclerosis → respiratory failure

MLCP in pt with paget’s disease → bone pain

Malignancy that may develop in the future in retinoblastoma pt → osteosarcoma

RENAL
MCCOD in CKD → CV Disease./ arrhythmia followed by infection
MCCOD in ADPKD → CV Disease (not SAH!)
MSC of extra-renal ADPKD → rupture of intracranial aneurysm (contradicts ep #37?>I think it means most serious
complication where most likely cause of death is CVD)

MCCOD in pt with kidney transplant → CV disease

No.1 RF for ESRD in US → Diabetes

Diabetic pt with pyelonephritis not responsive to Abx → obtain a repeat CT to rule out pyelonephritis complications
(i.e perinephric abscess/emphysematous pyelonephritis)
MC complication of systemic amyloidosis → renal failure
ML finding on ECG in pt with cardiac amyloidosis → low voltage

MCC of nephrotic syndrome in African Americans → FSGS

MCC of nephrotic syndrome in Caucasians → Membranous nephropathy
MCC of nephrotic syndrome in kids → Minimal change disease

ML Renal complication associated w/ SCD → symptomatic hematuria (seen in sickle cell trait also)
#1 RF for hyperphosphatemia → Chronic renal failure

ML renal complication associated with aminoglycoside → ATN

Most likely clinical presentation in pt on HCTZ w/ EKG showing prolonged QT interval + U wave → muscle weakness and
fatigue due to hypokalemia
MCC of DI → use of lithium

ML Mets of Wilms tumor? Lungs

ML Mets of Neuroblastoma? Bone *Neuroblastoma also calcify

#1 RF for General RCC? Smoking

Paraneoplastic syndrome- produces EPO
Can cause L varicocele
Histo-clear cells
Most likely mets= lungs (wilms tumor likes to metastasize to lungs as well)
Most important predictor of prognosis = renal vein route to systemic circulation
Most important prognostic factor in pt with RCC → invasion of renal vein
ML complication of VHL → bilateral RCC
Pt has RCC now, smoked for 2 yrs
10 yrs ago had tumor extracted from cerebellum (hemangioblastoma) that was calcified
Calcifications in mass in cerebellum in pt w/high Hct=hemangioblastoma produce EPO polycythemia
ML Mets of RCC? Lungs

#1 RF for bladder cancer → smoking

#1 RF bladder CA aka transitional cell carcinoma of bladder? Smoking
#1 RF for Egyptians with squamous cell carcinoma of the bladder? Schistosoma haematobium
Pt from Egypt lost weight over 3 mo blood in urine. On bladder biopsy- keratin pearls.
Transitional cells under stress from S. haematobium undergo metaplasia squamous epithelium dysplasia
SCC with keratin pearls +/- hyperCa 2/2 SCC production of PTHrP
RF of urinary incontinence→
Age and multiple vaginal deliveries (stress incontinence)
Diabetes→ overflow incontinence
MS→ urge incontinence

MC complication of Upper UTI → hydronephrosis

ML site of obstruction in nephrolithiasis → ureter or UVJ
MC complication of BPH → obstructive uropathy

MLM in Pt with hyponatremia and increased urine osmolality → ectopic ADH production

Pregnancy
All pregnant women 1st prenatal visit → screen syphilis, asymptomatic bacteriuria, HIV
Pregnant + pyelonephritis = Treat + Nitrofurantoin prophylaxis for the rest of pregnancy
Rh immunoglobulin screen → 28-32 wks + within 72 hours of delivery. Determine dose → kleihauer-betke test
#1 RF for endometritis → C-section
#1 RF for placenta previa → prior C-section
#1 RF for preeclampsia → prev hx of Preeclampsia/ nulliparity
#1 RF for uterine inversion → Prior inversion
#1 RF for ectopic pregnancy → hx of ectopic pregnancy and smoking (affects cilia)
#1 RF for chorioamnionitis → prolonged rupture of membranes
HY RF to preterm labor → bacterial vaginosis
#1 RF for Cervical incompetence → cervical conization procedure or LEEP
#1 RF for fetal macrosomia → gestational diabetes or preexisting diabetes
#1 RF for shoulder dystocia → fetal macrosomia
#1 RF for elevated maternal serum alpha-fetoprotein → Incorrect pregnancy dating
MCC of placental abruption → trauma/cocaine
Combined Contraception (Triphasic contain Estrogen) CI: Hepatic adenoma, Smoking, Factor 5 Leiden
Copper IUD CI: Wilson’s disease
RF for Asherman’s syndrome→ history of uterine curettage
MC pregnancy-related complication a/w Anti-phospolipid Ab’s → recurring spontaneous abortions (Elevated PTT)
Prophylactic Heparin
MC complication a/w first 20 wks of pregnancy → spontaneous abortion

Mom
MC ovarian mass in pregnancy → Corpus luteum cyst
MLM behind increased insulin resistance in pregnancy → human placental lactogen

Baby
MC complication in first few hours of life in baby of diabetic mom → hypoglycemia (islet cell hyperplasia)
MCCOD 1mo – 1 year → SIDS
#1 RF for SIDS → Smoking (passive) > Prematurity > Prone sleeping

#1 Complication in a kid with white reflex? RB gene mutation

Osteosarcoma – mostly in Knee aka Osteogenic sarcoma

REPRODUCTIVE
Female
Breast CA Screening → every year from 40 yo. USPSTF →every 2 years start at 50 until age 75
#1 RF for Breast Cancer → Age (higher chance of spontaneous genetic mutations) #2: Increased Estrogen exposure
MIPF of Breast Ca. → 1. number of axillary LN “spread”. 2. Size of tumor
#1 RF for Prostate and Breast Ca → Age

#1 RF for Cervical cancer → HPV

Cervical CA screen → every 3 years 21-29 regardless of sexual activity. >30-65 → HPV + pap every 5 years
ML initial clinical presentation of Cervical Ca → Abnormal vaginal bleeding
MCCOD in Cervical cancer → Renal failure esp ureters (cancer spreads there)
MIPF of cervical cancer → 1. stage at which it’s diagnosed. 2. Involvement of pelvic/paraaortic LN
#1 RF for Endometrial cancer → unopposed estrogen> endometrial hyperplasia
#1 RF for Ovarian cancer → FHx of OCa.
#1 RF Uterine Sarcoma → Prior radiation

MLM behind Endometriosis → reverse menses thru fallopian tubes

No.1 RF for female infertility/ectopic pregnancy → PID + scarring from previous PID

Of the 3 main causes of vaginitis, the sexually transmitted one is → Trichomonas

Male
MCC of impotence >50 years → Vascular insufficiency
Cremasteric reflex present = Sacral input working

Deformities/Congenital infections
MC complication of cleft lip/palate → Chronic OM/ speech problems
Boy with a genetic mutation most likely pathogenesis → Enzyme defect
Mechanism of disease in 25 yo 6ft male, infertile, micropenis → Klienfelters (genetic nondisjunction—seminiferous tubule
dysgenesis)

PSYCH
#1 RF for suicide is prior suicide attempt

NEURO
MIPF in retinal detachment → time to surgical intervention to fix

MSC of ICP → Brain herniation

#1 RF for intracerebral hmg → HTN

MCC of rapidly progressive dementia → Creutzfeldt-Jakob Disease

#1 RF for peripheral neuropathy in US → diabetes

MCC of noncommunicating hydrocephalus in neonate → stricture/ obstruction in cerebral aqueduct of sylvius
Any pt with CNS infx MLM of disease → hematogenous spread
#1 RF for optic neuritis → MS
MCC of blindness in HIV → CMV retinitis
Pt with NF2 requires regular hearing screening + annual brain MRIs from ~10 yrs – 4 th decade of life.
Pt with NF1 → screen for optic nerve gliomas
Common complication of sturge-weber syndrome →seizures, developmental delay
MLM of disease in status epilepticus → low level of antiepileptic drug

ALCOHOLICS
#1 RF for fasting hypoglycemia in US → Alcoholism

Random
MC anterior mediastinal mass → thymoma
MC middle mediastinal mass → Lymphadenopathy
MC posterior mediastinal mass → neurogenic tumor/ schwannoma

MCCOD 1 – 44 years → Motor vehicle accidents

MCCOD in ICU → septic shock

MLC of sepsis in hospitalized pt → indwelling catheter. MC bug is e coli

A pt that is nauseous/vomiting → don’t place on bipap or cpap.

MLM behind weight increase in hospitalized pts → increased total body sodium → due to increased blood volume and
hydrostatic pressure in blood stream
MCC of Vit K deficiency in hospitalized pt → use of Abx
No.1 RF for development of pressure ulcers → increased pressure on capillaries
Pt admitted to hospital in US over 65 yrs; most likely dx on admission → CHF
In a hospitalized pt with “bones, groans, psychiatric overtones” (hypercalcemia) → malignancy

A pt about to die, family comes in and you must speak to them → don’t ask close ended questions, ask how much they know,
how much they want to know. Pick an answer that encourages conversation. *Respond with a question*

ELDERLY RF
1. 50yo: Zoster (Shingles) vaccine
2. 65yo: Pneumococcal 23V vaccine
3. Check vision, hearing, fall risk, ur. Incontinence
4. MC Valvular abnormality in elderly → AS
5. MCC of blindness in elderly → macular degeneration
6. Polypharmacy- review meds for adverse effects and reduce falls
7. BEERS criteria
8. Look out for Elderly abuse
9. Assess functional ability- assess ADLs
10. Basic and instrumental ADLs
1. Basic: Things that you need to live independently
2. Instrumental: “Instruments needed” Things that you need to interact w/ society — make own food, make
own meds, manage finances
11. MMSE to evaluate cognitive functioning ( abN <24)
12. Mini-Cog--> tell pt a series of words then draw a clock then recall the words
13. Check TSH, B12, meds, S. Na, BNP if they have cognitive dysfunction
14. MCC of hearing loss in elderly → presbycusis (high freq hearing loss first)
15. Best screening test to determine hearing loss-> take history then whispered voice test then audiometry
16. Access for Presbyopia, macular degeneration, cataracts
17. Rule out depression in the elderly esp in CKD, stroke, CAD pts; older pts have a greater risk of suicide than younger
18. We don’t always use SIGECAPS for elderly; instead ask have you felt depressed/sad/low and ask have you lost
interest in the past 2 wks?
19. SSRI is D.O.C. do NOT pick TCA (coz of S/E profile)
20. Fall risk assessment→ ask for h/o problems w/ gait or balance in past year, do a get up and go test (normal is 10-11sec
and don’t use hands, abN is >20 sec)
21. Interventions that dec fall risk-> exercise, physiotherapy, Vit D supplementation
22. Urge incont./ overactive bladder (hypertonic detrusor)-> bladder training is the best Tx, biofeedback, oxybutynin,
tolterodine (best avoided in elderly; Tolterodine can cause close angle glaucoma)
23. Elderly women, G6P6 (multiple deliveries)-> Keigel’s exercise, sling procedure
24. Overflow incont. (hypotonic detrusor)-> self catheterization, timed voiding
25. Functional incont. (cognitive problems or arthritis where they can’t move fast enough)--> need caregiver
26. Living will aka Advanced Directive
27. Surrogate decision maker--> use next of kin (spouse then adult children then parents then siblings then other
relatives)
28. Health care proxy (DPOA durable power of attorney)—make only medical decisions when patient is incapacitated;
power declined once patient is capable of decisions
29. Full power of attorney—make decisions beyond medical decisions
30. POLST (physical orders for life sustaining)—> what pt requires in emergency situation (intubate, Abx, etc); a
health care provider has to be present when pt is signing this
31. Palliative care < 6 mos prognosis--> initiate Hospice care (can be at home)
32. Elderly pt driving h/o mild dementia or is taking benzo, TCA or h/o vision problems or h/o falls, ambulation
issues, degenerative dz who can have trouble moving neck side to side-> report to DMV
33. Pressure ulcer--> old pt, sensory issues, chronic illness, stool or ur incontinence, vascular dz all RF for developing
Pressure/ Decubitus Ulcer.
1. To prevent it, reduce pressure points by using air beds, reduce friction, reduce shearing forces
2. 4 stages:
1. Stage 1- erythema on skin, non blanchable
2. Stage 2- lose partial thickness of skin epi and dermis
3. Stage 3- subcut tissue is exposed but no involvement of fascia/bone/musc/tendon—debridement
4. Stage 4 – involvement of fascia, muscle, tendon or bone; give them as much nutrition as possible, consider
debridement for stage 3 and 4 ulcer, apply occlusive dressings

TERATOGEN
Chemotherapy
Isotretinoin: Messes up HOX genes (where appendages are placed as body develops)
Statins: Prevent cholesterol synthesis in fetus
Ergotamine: Vasoconstriction
Warfarin
Benzodiazepines
Danazol (used for endometriosis)
Cyclophosphamide (Renal Agenesis, Cleft Palate, no digits at birth)
Methotrexate (inhibits Dihydrofolate reductase) → Can cause abortion of fetus, neural tube defects
ACEi (Renal Agenesis + Oligohydramnios → Limb development issues, hypoplastic facie)
Valproic Acid (Neural Tube defects, Cardiac problems, Cleft lip/cleft palate, hepatotoxi)
DES: ( Adenocarcinoma (Clear Cell) Carcinoma of the Vagina, Anatomical uterine anatomy- T shaped uterus)
TMP-SMX (Trimethoprim-Sulfamethoxazole) Folate synthesis inhibitor
Pyrimethamine-Sulfadiazine (Used for toxoplasmosis) Folate synthesis inhibitor

Lady has been on acne medication for a few years, lost to follow up, and gets pregnant.
What is the most likely defect in the fetus?
Isotretinoin messes up HOX genes → where appendages are placed on the body as it develops
Prior to using Isotretinoin (or other Vitamin A derivative oral medication), must be on 2 forms of contraception

Diabetic patient gets pregnant. Patient is taking oral hypoglycemic medications, statins, and other medications for her
diabetes. Which medications are most dangerous to the fetus?
STATINS should never be given to a pregnant woman
HMG-CoA reductase inhibitor if given to a pregnant women will also prevent cholesterol synthesis in fetus

The woman is on medication for migraines. Contraindicated in pregnancy?

Ergotamine (Ergot derivatives)
 Severe vasoconstriction of placental arteries --> IUGR (intrauterine growth restriction) and possible fetal demise
May cause uterine contractions (premature labor)

Other medication for migraines

Acute treatment: Sumatriptan
Chronic treatment (8 or more migraines a month): Beta blocker, TCA, topiramate

Woman is an IV drug user, comes into the clinic during her 3rd trimester complaining of sharp abdominal pain, fresh bright
blood from vagina. Dx?
Abruptio Placentae (Placental abruption) due to cocaine usage
Cocaine: Powerful sympathomimetic; constricts all blood vessels --> ischemia to placenta --> possible fetal demise
Asymmetric intrauterine growth restriction (Head/torso small, arms and legs normal)

Symmetric Intrauterine growth restriction (whole torso proportionally small)

Common in TORCHESZ infections, chromosomal abnormalities

Pregnant Patient with a prosthetic valve. What drug CANNOT be given to the mother?
WARFARIN: can cause fetal hemorrhage, fetal bone damage, fetal brain bleeds
You can use heparin/LMWH in pregnancy safely: LMWH = Unfractionated = dalteparin, enoxaparin

Benzodiazepines contraindicated in pregnancy

In Eclampsia/Preeclampsia, Magnesium Sulfate used (benzodiazepines a 2nd line therapy)

Patient who wants to get pregnant is currently on treatment for Endometriosis. What medication(s) must be discontinued?
Danazol (Excellent for endometriosis), Pro-androgenic drug
Male fetus: precocious puberty
Female fetus: virilization

Woman on therapy for Rheumatoid Arthritis (well controlled) and wants to become pregnant. What therapy needs to be
stopped in pregnancy?
Methotrexate (inhibits Dihydrofolate reductase) → Can cause abortion of fetus, neural tube defects

IV drug user pregnant patient has delivered recently. Newborn is found to have a VSD (holosystolic murmur heard in the
left sternal border) and a hypoplastic/smooth/thin philtrum, microcephaly, intellectual disability. ML Dx?
Fetal Alcohol Syndrome (Mother has also been drinking during her pregnancy)
Most common cause of preventable intellectual disability
If VSD uncorrected --> may lead to Eisenmenger syndrome (reversal of the left to right shunt)

Down Syndrome: Thin upper lip, sharp Palpebral fissures, single palmar crease (also in Fetal Alcohol Syndrome)

Antihypertensives to AVOID in pregnancy:

ACE-Inhibitors/ARBs (Angiotensin converting enzyme inhibitors/Angiotensin II Receptor Blockers)
Renal Agenesis --> Amniotic fluid depletion --> Limb development issues, hypoplastic facies
Oligohydramnios (Woman is 33 weeks’ gestation, fluid index is less than 5 cm)

Patient who has a history of granulomatosis with polyangiitis (Wegner’s Granulomatosis). What medication must be
discontinued prior to pregnancy?
Cyclophosphamide (alkylating agent)
Renal Agenesis, Cleft Palate, no digits at birth

NO CHEMOTHERAPY for pregnant patients

Mother during her pregnancy took an older medication she once used for a UTI. Newborn does not respond to sound, does
not turn head towards stimulus. Drug? Aminoglycoside (Gentamicin, “-icin”)
Newborn is experiencing ototoxicity (cannot hear)
Aminoglycosides used to treat Meniere’s disease (can ablate CN VIII)

If you suspect a child has hearing loss --> perform audiometry

Classic clue: Language Delays (child most likely has hearing issue), might have normal vocabulary

Antiepileptic drugs should NEVER be given during pregnancy (Phenytoin, Valproic Acid)
Valproic Acid: Neural Tube defects, Cardiac problems, Cleft lip/cleft palate, hepatotoxic

If a woman has been on an antiepileptic drug, and now becomes pregnant. Doctor is considering lowering the
dose/discontinuing medication. Patient begins to have seizures again.
Put the woman BACK on the antiepileptic (unless it’s Valproic Acid)
If on Valproic acid --> find a different antiepileptic
Antiepileptic safe in pregnancy: Lamotrigine (Also approved for Bipolar Depression)

35-year-old lady, has had multiple 1st and 2nd trimester abortions. TVUS shows a T-shaped uterus
Woman was exposed to DES (Diethylstilbestrol) in her life/fetal period
DES side effects: Adenocarcinoma (Clear Cell) Carcinoma of the Vagina, Anatomical uterine anatomy

Pregnant woman had the Ixodes tick infection (borrelia burgdorferi; Lyme disease), and took medication for the infection.
Newborn having bone development issues, tooth discoloration
Tetracycline toxicity: Tetracyclines bind divalent ions well (antacids chelate tetracyclines, rendering them
ineffective)

Lyme Disease
Less than 8-year-old patient: AMOXICILLIN/macrolide (NO tetracyclines)
Rocky Mountain Spotted Fever Infection
EVERYONE gets a tetracycline (children and pregnant women included)

Immigrant mother who delivers a child, baby has circulatory collapse with ashen-gray skin discoloration. Dx?
Gray Baby syndrome
Mother has been treated with chloramphenicol
Medication rarely used in the USA, used in the developing world
Used for Pregnant mom with rocky mountain spotted fever (Otherwise: Doxycycline)

Pregnant mother with toxoplasma infection --> Treat with Spiramycin

Child born with hypoplastic limbs, distal limbs connected to shoulder (feet connected to hip, hands connected to shoulder).
Dx: Phocomelia
Due to Thalidomide exposure

Pregnant Patient with history of Grave’s disease, newborn has an absence of hair in a localized spot on the head. Dx?
Aplasia Cutis
Due to PTU (propylthiouracil) and Methimazole (thyroid medications)

Which Antidepressant is contraindicated in pregnancy?

Paroxetine → Can lead to pulmonary Hypertension in the newborn
Most other SSRIs safe in pregnancy

Person with a history of mania (bipolar disorder), treated with lithium

Teratogenic effect: Atrialization of the right ventricle (Ebstein’s anomaly)
If a woman is pregnant and has a mood disorder, can be put on antipsychotics (instead of lithium)

Gestational Diabetes: BIG PROBLEM

Fetal problems associated: VSDs, Transposition of the Great Vessels, Caudal regression syndrome (Sirenomelia)
Insulin inhibits synthesis of surfactant --> Neonatal Respiratory Distress Syndrome
Hyperinsulinemia in mother leads to inhibition of surfactant in baby (Beta pancreatic islet cells undergo
hyperplasia
in the developing fetus) --> excess insulin production in fetus --> surfactant production decreased)
Insulin excess can cause hypocalcemic seizures in a newborn
Insulin excess can cause hypoglycemic seizures in a newborn
Insulin excess can lead to underdevelopment of left colon growth
Failure to pass meconium (in an infant of a diabetic mother)
Small left colon syndrome
Pathophysiology: (hypoglycemia-induced release of glucagon)

Newborn (less than 1 year old)/Pregnant woman: Do NOT give Live-attenuated vaccine
MMR vaccine, Varicella vaccine, Intranasal influenza vaccine
Single exception: Rotavirus vaccine (can be given to infants)

Child born to a mom with active Hepatitis B infection --> give newborn Hepatitis B surface antigen and Hepatitis B vaccine
If a child develops Hepatitis B, 90% likely to develop chronic Hepatitis B
Give Hepatitis Immunoglobulin AND hepatitis B vaccine (to infant and mother)

Child born to a mom with HIV --> give newborn Zidovudine (AZT)

MILITARY
TBI
A. Prevent in general: Wear seatbelts, helmets
B. Epidemiology: More common in Males > Females
C. Avoid
a. NEVER give steroids in traumatic brain injury
D. Classification
a. Classify TBI (traumatic brain injury) by severity using GCS
i. ≥13 mild TBI = Concussion
ii. 9-12 moderate
iii. ≤8 severe TBI
E. Preferred Imaging → MRI
F. Brain region affected
a. Pathognomonic → diffuse axonal injury (also seen in rapid acceleration-deceleration injury)
b. Anterior temporal lobes + orbital frontal cortex most susceptible to damage
G. Complications
a. Central diabetes insipidus can occur after TB
b. Most common cognitive impairment after TBI → Memory loss
c. Post concussive syndrome → neuropsych symptoms in a post TBI (mild) pt
i. Headache, dizziness, inc sensitivity to light and sound, anxiety, depression
d. Second impact syndrome → a second ep of TBI after a mild TBI → persistently vegetative or die
H. Increased Intracranial pressure
a. Cushing Reflex: Bradycardia, HTN (widened pulse pressure), Irregular respirations
b. Management
i. Hyperventilation is the fastest measure to lower ICP but can only be used for short term
 ii. Mannitol can be used as well to lower ICP, but is contraindicated in CHF
iii. Hypertonic saline is another option but risks hypernatremia.
I. Management
a. Keep TBI patients normothermic
b. Prevent Complications: N-Acetyl Cysteine
c. Reduce risk of death: Tranexamic acid within the first 3 hrs to pts of TBI
d. After discharge from hospital for TBI → send pt to rehab

PTSD
A. Avoid
a. Don’t give benzodiazepines to PTSD especially in veterans (coz it worsens it)
b. Don’t pick debriefing (a meeting to question someone, typically a soldier or spy, about a completed mission or
undertaking) as a treatment
B. Brain region affected
a. Small volume of hippocampus
C. RF
a. Military sexual trauma W >> M→ is the biggest risk factor for PTSD among servicemen/women
D. Complications
a. Exaggerated response to dexamethasone suppression test seen
b. Abnormal low cortisol and high catecholamines in urine due to a maladaptive hyperadrenergic response
c. Homelessness is very common in veterans
d. MC comorbidity in veteran is substance use disorder (commonly alcohol) → Highest risk can be decades after service
e. Alcohol abuse is very common post PTSD
i. Rx SSRIs (sertraline, fluoxetine, paroxetine), venlafaxine
ii. Pts tend to have distress, autonomic hyperactivity on re-experiencing triggers
iii. It usually arises from an interpersonal trauma vs natural disaster (eg. rape vs earthquake)
f. 4 months pharm Rx does NOT apply to ASD (acute stress disorder, where symptoms last <1 month)
E. Outcome
a. Good: Pre-deployment planning (medical insurance etc.), communication with family while deployed
b. Poor: Poor mental heath in family, behavorial disorders in children, high risk of suicide, divorce etc in families
of deployed servicemen/women
F. Management
a. Nightmares: use Prazosin
b. CBT (cognitive behavioral therapy) of choice for PTSD, OCD, specific phobias→ Exposure therapy (PTSD + OCD
+ Phobia)
c. Eye movement therapy? A structured therapy that encourages the patient to briefly focus on the trauma
memory while simultaneously experiencing bilateral stimulation (typically eye movements), which is associated
with a reduction in the vividness and emotion associated with the trauma memories

1. Dermatology
MLCP of military pt with anthrax → cutaneous anthrax

Pt. is a 31 y/o male who is active military who came back from Afghanistan (Iraq, Saudi Arabia, Peru etc.) 2 to 3 weeks ago.
On his arm (or anywhere typically on upper extremities) there is a painless, purplish ulcerating papule.

● Dx: Leishmaniasis
○ Transmission: Sandfly
○ How to diagnose? Skin Biopsy
○ Treatment: Amphotericin B or Paromomycin
2. RSM from Mexico, ME, North/East Africa, South America, Asia (“tropical areas”) has fevers, weight loss pancytopenia,
hepatosplenomegaly, DARK SKIN LESIONS
1. → Leishmaniasis (visceral form due to donovani), carried by sandflies, may see amastigotes on microscopy from tissue
biopsy
 2. Rx with sodium stibogluconate or amphotericin B.

3. Vaccines/protection for military personnel:

1. MMRV, Tdap, typhoid, influenza, polio, hep A + depending on location may give (yellow fever, anthrax,
smallpox).
2. DEET on skin and permethrin on clothes as repellants
3. If medic→ Hep B
4. Sexually active→ Hep B
5. Outbreak of meningitis→ N. meningitidis, use ceftriaxone or ciprofloxacin for treatment and rifampin ppx for all
close contacts.
2. Returning service member (RSM) returning from Egypt with hematuria or portal hypertension:
1. Schistosomiasis (hematuria→ haematobium) or (Portal htn. → mansoni)
3. MCC of diarrhea in military → Norovirus
4. Peace keeping mission in Africa with bleeding, petechiae, contact with WILD ANIMALS, or dead bodies
1. → Ebola or Marburg viruses, spread via fomites or body fluids. No Rx.
5. RSM with very high fevers, rash, bad myalgias (bone break fevers), bleeding (FOBT + stools, epistaxis, petechiae,
hematuria, gingival bleeding), positive tourniquet test (petechiae below blood pressure cuff), ALT elevated maybe AST,
usually in a south American country, thrombocytopenia
1. → Dengue hemorrhagic fever (aedes mosquito)
2. Bug causes increased capillary permeability
6. Chikungunya fever does not cause hemorrhage; identical to dengue but without the hemorrhage. Do not confuse
Dengue and Chikungunya.
7. Zika is usually in a woman with a child who has microcephaly and intracranial calcifications.
8. Yellow fever → jaundice, hepatomegaly not present in dengue. Re-hydrate these patients and give supportive care.
9. RSM from Russia, China, Korea, or stationed at Utah, New Mexico, Arizona, Colorado, had contact with mice (deer
mouse, “worked in barn”) presenting with high fever, myalgias/flu-like symptoms, bilateral INTERSTITIAL pulmonary
edema
1. → Hantavirus (can have hemorrhage as well). No known treatment.
10. RSM from Hawaii or navy has conjunctival injection, jaundice
1. → Leptospirosis. (Tx: Doxycycline)
2. Particularly bad form = WEIL’s Disease (anemia, very high creatinine, jaundice)
i. → attacks the liver and kidneys. Use doxycycline for prevention
3. Patient going to a place with a high incidence of leptospirosis
i. → give doxycycline as prophylaxis
11. RSM with Hemoptysis, widened mediastinum ± necrotic ulcer on neck
1. → Anthrax (poly d glutamate capsule). Can present as Hemorrhagic mediastinitis
2. → widened mediastinum on CXR
3. Rx with doxycycline or fluoroquinolone. There is a vaccine available for service members.
12. Malaria PPX (asia, Africa, ME)
1. → atovaquone + proguanil, or mefloquine, primaquine (for vivax and ovale- tertian fever, have hypnozoite form), or
chloroquine (high resistance), or doxycycline.
1. P. malariae = quartan fever
2. P. falciparum = fever at odd intervals (most severe manifestations → cerebral malaria, pulmonary edema, renal
failure)
3. Before primaquine treatment for p vivax or ovale, check those patients (men, X-linked inheritance) for G6PD
deficiency.
2. RSM with exposure to animal or animal products or unpasteurized milk, undulant fevers and PROFUSE SWEATING
1. → Brucellosis, requires very low dose to get infected, tends to recur after treatment
2. Rx with doxy and rifampin
3. If recurring give aminoglycosides (“-cin”)
3. Cattle or sheep birth, pneumonia or chest pain (due to culture -ve endocarditis)
1. → Q fever due to Coxiella Burnetii. Do not confuse Q fever with brucellosis (pneumonia is unique to Q fever)!
4. Contact with dogs/cats/pigs and one of the most common causes of bloody diarrhea
1. → Campylobacter jejuni (Keep in mind, association with Gullian barre syndrome and Reiter's syndrome-Reactive
arthritis)
5. RSM with fever, neck rigidity, headache, myalgia, LP → Opening pressure is not high, WBC not high (but + lymphocytes),
protein is not high, not high glucose
1. → West Nile virus.
6. RSM with trouble swallowing (achalasia), chronic constipation (megacolon or hirschsprung), S3 heart sound (dilated
cardiomyopathy)
1. → Chagas disease, spread by reduviid bug, specific→ periorbital edema (Romana sign)
2. Rx: nifurtimox, benznidazole.
15. RSM→ worked with turtles or pets, or lots of eggs or poultry and presents with bloody diarrhea, increased WBC (mostly
neutrophils)→ Nontyphoidal or enteritidis salmonella→ DON’T TREAT IT.
16. RSM→ Presents with chronic cough, fever, hemoptysis, night sweats right upper lobe infiltrate/cavitary lesion on CXR
1. Treatment = RIPE regimen for 2 months then drop 2 and continue with rifampin and isoniazid
2. DON’T forget the B6 vitamin.

VACCINES
Ep 250
● Two big types of vaccines
○ Live attenuated
■ Bug that has been severely weakened, but retains ability to infect cells.
■ Generates a T-Cell response
■ No real need to give boosters
■ Ex
● MMR
● Varicella
● Zoster
○ Adults >60 yo
○ Contraindicated in immunocompromised
● Intranasal influenza vaccine
● Oral polio
● Zostavax Herpes zoster
● Yellow fever
● Rotavirus
○ Live attenuated are not usually given to those < 1yo
■ The rule does NOT apply to rotavirus
■ Kids receive a vaccine at 2,4,6 months.
○ Most dangerous complication? Intussusception. Contraindications:
■ If pt has had it in the past intuss
■ Hx of meckel’s
■ IgA nephropathy (or HSP)
■ Contraindicated
● Pregnant women
● < 1 y/o (exception: rotavirus)
● CD <200 (immunodeficiency)
○ Killed/Inactivated vaccine
■ Destroyed bug but you keep antigenic parts, which generates a response from immune
system
■ Generates Humoral response
■ Need to give boosters
■ Ex
● Hep A
● Hep B
○ Given to Healthcare workers
○ Pt is a newborn with a mom that has HepB surface antigens +
■ For Baby: HepB vaccine + HepB immunoglobulin
 ● Given in opposite extremities (prevent vaccines binding
with Ig)
● Tdap → toxoid
○ 1 dose Tdap + Td booster every 10 years
■ Tdap in every pregnancy at 27-36 weeks
● Pneumococcal-13
○ See below
● Meningococcal
○ Teens going to college
○ Military recruits
○ Eculizumab (monoclonal Ab against C5)
○ Terminal complement deficiency
● Influenza (injection)
● Polio (injection)
● Shingrix Herpes zoster
○ Toxoid vaccine
■ Toxin from bug that can act on receptors in the body to generate antibody response
● Two types of influenza
○ Inactivated → Intramuscular
○ Live-attenuated → Intranasal. Inhaled as mist
● PCV-13 and PPSV-23
○ PCV13 is taken by everybody!
○ PCV-13
■ Conjugated. Pneumococcal “C”onjugated
● B + T cell response
■ Always taken FIRST before 23
● Mnemonic aid: 13 comes before 23.
○ PPSV 23
■ Polysaccharide
● Humoral response (No T cells)
■ Given for those > 65 y/o
○ <65 yo with certain conditions → PCV13 then after 8 weeks PPSV23
■ Asplenic*
■ Sickle cell (functionally asplenic)*
■ Immunocompromised*
● HIV
● CKD
● Nephrotic syndrome *functional cause of immunodeficiency
● Transplant
● Hematologic malignancy
● Bruton, SCID, CVID
■ Cochlear implant
● Older person on test.
● Alport syndrome
■ Chronic CSF leak
■ *get second dose of PPSV23 5 years later (eventually have a PPSV23 after 65yo)
○ <65 yo with chronic disease → just PPSV23
■ DM
■ Smoking
■ Heart disease
■ Lung disease
■ Liver disease
■ Alcoholism
 ○ >65 yo → just PPSV23 OR PCV13 then after 1 year PPSV23
● Asplenic or functionally asplenic → vaccinate against encapsulated organisms
○ Strep pneumo
○ H. flu
○ Neisseria meningitidis
● Healthcare Works
○ Hep B vaccine

● Vaccines in kids
○ Approximate rule but works a lot:
■ Most pediatric patients are at least 3 doses
● But not always true
■ Most are given at 2, 4, 6 months of age.
● Those that don’t follow this rule?
○ Live attenuated vaccines!
○ Hep B vaccine
■ Need to get it before you leave the hospital.
■ Three doses
● First dose at birth
● Second dose: within 2 months of birth
● Third dose is between 6-18 months of age
○ Rotavirus vaccine obeys second rule
■ 3 doses of vaccines given at 2,4, and 6 months.
○ DTap vaccine
■ 5 doses with extra information to know.
● 3 doses at 2, 4, and 6 months
● 4rth dose: ~ 15-18 months of age
● 5th dose: 4-6 y/o
■ When you’re older:
● TDap (Adolescent)
 ● TD booster q10 years
○ H. Flu Type B vaccine
■ 3 doses
● 1st dose: 2 months
● 2nd dose: 4 months
● 3rd dose: 12-15 months
○ PCV-13 vaccine
■ 4 doses
● 1st dose: 2 months
● 2nd dose: 4 months
● 3rd dose: 6 months
● 4th dose: 12 - 15 months
○ Polio vaccine
■ Four doses
● 1st dose: 2 months
● 2nd dose: 4 months
● 3rd dose: 6 months
● 4rth dose: 4-6 y/o
○ Influenza vaccine
■ Every year.
■ Less than a year old do NOT give intranasal.
○ Specialized live-attenuated
■ MMR and varicella
■ Group both together with the same vaccine schedule.
■ Two doses
● 1st dose: 12-15 months
● 2nd dose: 4-6 y/o
○ Hep A vaccine
■ Two doses
● 1st dose within 2 y/o
● 2nd dose: 6 months after 1st dose
■ Later given in adolescence

○ 10-18 y/o
■ Meningococcal vaccine
● Two doses
○ First dose: 11-12 y/o
○ Second dose: 16 y/o
● Teens going to college
● Military recruits
○ HPV vaccine
■ Can give starting from 9-26 y/o
■ Girls age 9-26
■ Boys 11-21
■ Men-sex-Men 11-26
○ Zoster vaccine
■ Not the same as varicella
■ Get zoster at age of 50
● Two doses (6 months apart)
○ Pregnancy
■ Women supposed to get TDAP vaccine at every pregnancy
● Within 27-36 weeks
○ Pt splenectomy (Sickle cell, trauma)
■ PCV-13 and PPSV-23, strep pneumo, H flu, and neisseria meningitidis
 ○ Timeline between PCV-13 and PPSV-23
■ Wait between two months between both vaccines
○ Pt. has sickle cell/splenectomy in addition to above those patients need
■ Amoxicillin or penicillin until they reach the age of 5.
○ Egg allergy
■ Avoid Yellow fever (Everything else is fine, yes - even MMR!!)
■ Influenza vaccine can have allergic reaction too (nbme)

SCREENING
Ep 325

1. PREGNANCY
First Appointment Screening
Gestational Diabetes
· Start screening at 24 weeks with 1 hour glucose test and
If positive follow with 3-hour glucose tolerance test
HIV
· At first prenatal visit
· Retest for HIV in the Third Trimester. (super special so tested twice)
HBV
· At first prenatal visit
Hep B Surface Antigen.
Syphilis
· At first visit
Asymptomatic bacteria: Increase risk of preterm labor and delivery. (Nonpregnant asymptomatic not treated)
· Treated with nitrofurantoin or 1st/2nd gen cephalosporin or Amoxicillin
· Test of cure
Group B STREP
35-37 weeks anal and vaginal

Women’s RH status and antibody status (BY INDIRECT COOMBS TEST)

· Rhogam at 28 weeks and second dose within 3 days postpartum

2. SMOKERS
· Screen for AAA (Abdominal aortic aneurysm)
o Between ages 65-75
o Only men!!!
o If you have smoked as a male or have a family history of AAA
o With an ultrasound
o If more than 5.5 cm you need intervention (endovascular repair of some sort)
· Screen for Osteoporosis
o Screen in woman
o Normally you start screening with DEXA scan at age 65 for the general population.
o But in smokers you can start screening for osteoporosis at younger age
o You can also screen for osteoporosis at less than 65 if:
§ Very thin like with Anorexia Nervosa
§ Premature ovarian failure
· Lung Cancer
o You need to be between ages 50-80
o Have a 20 or more pack-year history
o Currently smoking or have quit less than 15 years ago.
o Screen with a low dose CT scan and you only do it 3 times every year
§ If you screen 3 times year after year and it is negative you can stop

3. SPECIAL GENETIC DISEASES

Familial Hypercholesterolemia
· People get MI at age 25
· People have LDL receptor mutation generally
· Remember rule of 3 → Start checking LDL cholesterol at age of 3, 9 and 18
o You will continue to screen but not tested on NBME

Inflammatory Bowel Disease (Both of them)

· You start screening for colon cancer 8 years after making the initial diagnosis.
o Continue screening every 1-3 years after that
· You have a small exception of rule:
o If they are diagnosed with primary sclerosing cholangitis
They need to be screened for colon cancer at the time of diagnosis.
§ Then you continue screening every 1-2 years

Lynch Syndrome
Px tend to have microsatellite instability problems
Start COLON cancer screening at age of 20 “C before E in alphabet”
o Continue every 1-2 years
o Make sure you go straight to COLONOSCOPY
o You can give aspirin as a prophylaxis!!!
· They have other cancers as well
o Start ENDOMETRIAL cancer screening cancer at age 30
§ Continue every 1-2 years
§ Endometrial biopsy or sampling
§ You offer a prophylactic (THBSO) total hysterectomy with bilateral salpingo-oophorectomy after child bearing
due to astronomic risk of endometrial cancer and ovarian cancer
Patients with MEN 2A or 2B
· Its not a matter of if but when will you get a medullary thyroid cancer
· You offer a prophylactic thyroidectomy!!!
Familial Adenomatous Polyposis
APC gene mutation-> Polyps -> Kras mutation-> p53 mutation-> Adenocarcinoma
· Start colon cancer screening at age 10 years
· Continue every year
BRCA Mutations
Breast cancer screening guidelines
· Between ages 25-29 you deserve an annual breast mammogram
· If you are over the age of 30 you deserve
o Annual breast MRI and annual mammography
4. Risky Sexual Group
· Individuals with HIV
· Men that have sex with men
· Sex workers
· IV drug users
Screening guidelines
· If you are between ages 15-64
· You deserve annual HIV
· Screen for syphilis every three months
· Screen for Chlamydia and gonorrhea
o You only screen women, DO NOT SCREEN MEN!
o You screen higher risk patients annually no matter the age
o ALL patients (not only high risk) younger than 24 need annual testing
o Non risky patients don’t need to be screened for these two annually after age of 24
· Screen for Hep B surface antigen every year
o Also screen the antivaxxers every year for hep b

5. Metabolic Diseases
Hypertension
· Screening is started at age 18 through 40 every 3-5 years
· After age 40 you screen every 1-2 years
o Prevalence and incidence increases dramatically over age 40
Diabetes
o Fasting blood glucose
o Oral glucose tolerance test
o HbA1c
· Obese individuals between age 40-70 years old → Screen every 6 months
· Hypertension over 135/80 and over age 45 → Needs screening every 6 months!!!!

Osteoporosis
· Screening at age 65 for Women only
 You can also screen for osteoporosis at less than 65 if:
§ Smoker
§ Very thin like with Anorexia Nervosa
§ Premature ovarian failure
· DEXA scan looking at t score
o -2.5 or less → Start on Bisphosphonates
o Needs treatment
Hyperlipidemia
There are three screening guidelines separated into groups:
Everyone gets initial screening at age 20
For metabolic disease the screening guidelines gets more frequent the older you become.
· Men
o Ages 20-45: Every 5 years
o Ages 45-65: Every 1 to 2 years
o Over age 65: Every single year

· Women
o Risk increases more after menopause
o Ages 20-55 every 5 years
o Ages 55-65: Every 1-2 years
o Older than 65: Every years

· Diabetics
o You screen every year, the end!
o If LDL is 70mg/dl or higher they will be placed on a high intensity statin like Rosuvastatin or Atorvastatin.
6. Cancer Screening
Colon Cancer
· Start screening at age 45
· Family hx → age 40 OR 10 years before dx of relative (whichever is earlier)
· Many ways to screen:
o Colonoscopy every 10 years
o Flexible sigmoidoscopy every 5 years
o Flexible sigmoidoscopy every 10 years + Fecal immune test (FIT) every year
o Fecal Immunotest or fecal occult blood test every year.
o CT colonography (Virtual colonoscopy) every 5 years will start to be implemented.
§ CT scan that has certain protocols that make it highly sensitive for detecting colon cancer.
If any of the tests other than colonoscopy show an alteration, the next best step is to DO A COLONOSCOPY
WITH BIOPSY!!!
Breast Cancer
The problem is NBME uses ACS so know both of them, the question stem will probably give you enough
information to know both of them
American Cancer Society: Mammogram Start at age 40 and then do it every year
USPSTF guidelines: Mammogram: Ages 50-75 then every 2 years
Cervical Cancer

· Age <21 → NO Pap

○ Age 21-29 → Pap q3y
○ Age 30 - 65→
■ Pap every 3 years
■ Co-testing Pap q5y
○ HIV or immunodeficiency → yearly Pap
■ HIV
 ■ Especially T cell deficiencies like DiGeorge
○ Hysterectomy for benign reasons → no screening
○ Hysterectomy for endometrial hyperplasia/cancer→ Pap of vaginal cuff
○ Hysterectomy for cervical cancer → continue doing pap smears until 20 years post surgery
· Stop screening at 65:
o No history of cervical cancer
o No history or severe Pap smear HSIL OR CIN 3
§ If they did then you need to have 3 negatives in a row
§ Or 2 pap smears plus HPV contesting in a row
Children
Patients with Language difficulties:
· Screening hearing with audiometry
All kids between ages 3-5 years old
· Screen for amblyopia-> Lazy eye

7. Miscellaneous
Women Less than 24 years old: Screen annually for gonorrhea and chlamydia ONLY IN women
Who needs to be screened for Hep B?
Need to be screened every year
· Patients who receive multiple blood transfusions or are constantly on dialysis
· Long term chemotherapy or long-term immunosuppressive therapy due to transplant.
· With hepatitis b surface antigen
All people between ages Hep C 18-79 once
Screening for depression
· Easy questionnaire:
o PHQ-9
o Beck depression inventory

Weird Social Sciences Topics

Ep 132

● Pt with terminal lung cancer in hospice that’s not really eating. What meds can you give them?
○ Megestrol (progestin analog)
○ dronabinol (cannabinoid)
○ corticosteroids
○ don’t improve survival or reduce morbidity

● Pt with terminal lung cancer in hospice with depression. What meds would you try?
○ Stimulants: methylphenidate
○ If super anxious, consider benzo
○ SSRIs will take too long to act

● Pt with metastatic malignancy complains of SOB. What meds would you try?
○ Opioids (e.g. morphine) + bowel regimen

● Pt on chemo with severe n/v. What meds would you try?

○ Ondansetron (serotonin receptor antagonist)
 ■ Adverse effect? QT prolongation

● Pt with terminal GBM. Days to week to live. Feels nauseous in the context of increased ICP. NBS?
○ Glucocorticoids to reduce ICP

● Pt with burning & tingling in extremities (neuropathic pain). What meds would you try?
○ TCAs
○ SNRI (e.g. duloxetine)
○ Gabapentin/pregabalin

● Pt with cancer pain & hx of depression on treatment. Pt was started on pain med and started to have fevers +
myoclonus → serotonin syndrome 2/2 tramadol
○ Tramadol is usually not a good choice for cancer pain because it’s not that strong and has lots of
interactions

● Pt with widely metastatic cancer to liver & kidneys presents with severe pain. What pain med would you
consider?
○ Fentanyl patch
○ Avoid morphine in liver & kidney disease

● Pt with bad cancer pain. Morphine dose was increased at last visit. Pt returns and is still in severe pain.
NBS?
○ Increase dose or frequency of their opioid regimen

● Pt with metastatic malignancy in hospice complains of pain. What drug should be avoided?
○ Meperidine – Why? Can cause seizures

● Physician that smells of alcohol. NBS?

○ Report it to higher authority (e.g. the supervisor, ethics committee, medical board)
○ Order of approach:
■ Speak to physician → Local physician program (at local or hospital level) → Medical Board
● If fraudulent situation (physician over prescribing physical therapy to self owned facility) → Go straight to
Medical Board

● Pt is being treated for cancer with intent to cure. Can they receive palliative care? YES
○ Palliative care does NOT preclude life-prolonging therapy
○ Contrast with hospice care (physician must determine that pt has less than 6 months to live before
they can start hospice)

● A medical error was made. NBS?

○ Admit error to pt
○ Data suggests that the most likely outcome is the physician NOT getting sued

● Physician-assisted suicide
○ Illegal in every state

● 60-70s yo pt that is very ill. Some medical therapies remain but the pt is not interested. NBS?
○ Respect the pt’s wishes as the pt
■ Understands the situation
■ Understands the risks & benefits
■ Communicates their choice clearly

● Pt requests a therapy that is not standard of care and won’t affect outcomes. NBS?
○ No obligation to administer futile therapy
● Pt requests abortion. The physician doesn’t feel comfortable performing the procedure. NBS?
○ Transfer care of the pt to another physician who can perform the procedure

● Old senile person that isn’t taking meds as prescribed. Keeps getting admitted for problems that result
from inability to take care of himself/herself. NBS?
○ Appoint legal guardian

● Adolescent < 18 yo → parents make decisions regarding medical care

○ Exceptions:
■ Substance abuse
■ Mental health
■ Reproductive health

● Capacity vs. competence

○ Capacity
■ Criteria: understands the situation, understands the risks & benefits, clearly
communicates a decision to provider
■ Determined by physician
■ Examples of when pts lack decision-making capacity:
● Delirium/AMS
● Under the influence of drugs
○ Competence
■ Determined by legal system

● 23 yo M that overdosed on opioids, now comatose in the hospital. Next-of-kin decides to withdraw care
because pt said “I don’t want to be on life support.” What principle was followed?
○ Substituted judgment

● Pt is comatose. Surrogate decision maker is deciding between treatment option A and option B. They
choose option A because the physician provides that data that it produces better outcomes in some
regard. What principle was followed?
○ Best interest standard
○ What they

● The physician treating unresponsive trauma pt John Doe does what is medically indicated in the situation.
What principle was followed?
○ Best interest standard

● Pt previously designated someone as their healthcare POA. They will make decisions on the pt’s behalf if
the pt can’t make decisions for himself.

● What is a living will?

○ Document where pt outlines certain interventions that they would/would not want

● What is the surrogate decision-maker order if there is no healthcare POA designated

○ Spouse → adult children → parent → adult sibling

● Following HIPPA laws

○ Don’t disclose pt’s information to family members without their authorization
○ Exceptions:
■ Protecting pt (e.g. protect pt from killing themselves)
■ Protecting general public (e.g. homicidal ideation)
■ Following the law
● Resident is finishing shift and is getting ready to handoff to night team.
○ Handoff should happen in person
○ Provide key pieces of information in a standardized fashion
■ Use if-then statements
■ Key active problems
■ Key medications
■ Labs to f/u

● If a medical error occurs, what is the first thing that should happen? Analyze the error!
○ Fishbone/Ishikawa diagram
■ Keep identifying factors that contributed to the error

● Core principle of QI? PDSA cycle

○ P = plan (planning the intervention)
○ D = do (putting the intervention into practice)
○ S = study (study the results)
○ A = act (refine the intervention)

● Diagnostic errors
○ Pt was cough + dyspnea + CP. Physician that has seen that presentation before and previous pt ended
up having pneumonia. Physician assumes that this pt must also have pneumonia. → availability bias
○ Pt presents with certain set of sxs. They were previously hospitalized for the same sxs and a diagnosis of
PNH was made. Resident assumes that sxs are again due to PNH → anchoring bias
■ Depending too heavily on an initial piece of information or the first idea that came to mind
○ Resident coming onto nightshift is assigned a pt that was just admitted by the attending. The resident
doesn’t question the diagnosis or think of other possibilities. → blind obedience bias
○ Pt presents with cough + fever + CP. CXR shows consolidation. Resident says “this must be
pneumonia” and doesn’t consider other things → premature closure

● Pt is undergoing IPV at home. What screening method could be employed to detect IPV?
○ HITS (does your partner hurt, insult, threaten, or scream at you?)
○ HARK (humilitation, afraid of partner, rape, kick)
○ STAB (slapped, threatened,

● Pt addicted to opioids
○ Tx? Suboxone (buprenorphine/naloxone)
● Pt going through opiate withdrawal
○ Tx? Clonidine

● Pt that is trying to quit smoking. What tx would you consider?

○ Nicotine replacement therapy
○ Bupropion (NDRI)
■ Contraindications: eating disorder
○ Varenicline (nicotinic receptor partial agonist)
○ Most effective? Combination > varenicline > bupropion > NRT
○ Never choose e-cigarette on NBME
● Screening tools for alcohol abuse
○ FIRST quantify their drinking
○ Definition of “at risk drinking”
■ Woman OR >65 yo: >7 drinks/week or >3 drinks/one sitting
■ Man : >14 drinks/week or >4 drinks/one sitting
○ THEN employ formal screen
 ■ CAGE
● Cut Down
● Annoyed
● Guilt
● Eye opened
■ AUDIT-C is better than CAGE
○ Clues that suggest alcoholism on NBMEs:
■ Megaloblastic anemia (MCV > 100)
■ High GGT
■ AST/ALT > 2:1
○ Signs/sxs of alcohol withdrawal → give benzons
■ E.g. alcoholic hallucinosis, DTs
○ Remember thiamine before glucose if alcoholic comes to ED
■ This avoids precipitating Wernicke-Korsakoff syndrome
○ If person is delirious because they are withdrawing from EtOH
■ Don’t give antipsychotic (anti-dopaminergic agent) because this can cause seizures
■ Tx? Benzos