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Welcome to carolebaskin’s page.
Contributor score: 35


Comments ...

 +0  (step2ck_free120#40)

Young woman with long history of crampy abd pain, diarrhea, + relieved by defection, without red flag symptoms.

It's IBS

Tricyclics can be used for IBS; they help with pain and can help with diarrhea


Could also have used antispasmodics like dicyclomine and hyoscyamine for the pain

For diarrhea, can also use loperamide or other antidiarrheals

For constipation type IBS try fiber, osmotic laxatives, lubiprostone


 +1  (step2ck_free120#20)

Eeaaasy there, partner. They said they don't want insulin and you're gonna kick them to the curb?

One step at a time, bud.

Offer the insulin, let them refuse (they seem to have capacity), but who ever said anything about discharging them.

Where would they go!?

Haven't they been through enough?


 +0  (step2ck_free120#37)

Hypercalcemia + lytic spinal lesions = multiple myeloma

What about the fever, leukocytosis, and consolidation?

MM predisposes to infection! It's PNA.


 +0  (step2ck_free120#24)

This is Paget-Schroetter disease

An upper extremity thrombosis triggered by extreme activity.

He's a fit young jackhammerer just trying to do his jackhammer thing


 +0  (step2ck_free120#18)

A P T M

There's a physiologic splitting on inspiration in the pulmonic area

It's not pulmonic stenosis because there's no associated murmur. You would expect crescendo-decrescendo murmur, increase on inspiration, systolic ejection click, widened split of S2. All we hear is split S2.

Let the poor kid BALL


 +0  (step2ck_free120#15)

He's probably having an ischemic stroke

But you can't be sure!

First step is non-con CT


Other wrong answers:

  • Don't do an LP until you know there is no bleed; they could herniate!

  • EEG has no place in acute stroke w/u

  • Carotid duplex US helps find source of stroke, but doesn't help in acute w/u

  • angiography maybe later


 +0  (step2ck_free120#30)

Hashimoto thyroiditis

  • early stage transient hyperthyroidism
  • progresses to subclinical hypothyroidism
  • then finally overt hypothyroidism

This patient has clear signs of hypothyroidism (dry skin, brittle hair, periph edema, temp intolerance, weight gain, bradycardia, lethargy, etc)

Most common cause of noniatrogenic hypothyroidism


 +0  (step2ck_free120#17)

Infant with persistent diarrhea, vomiting after feeds, weight loss, hepatosplenomegaly, jaundice and +reducing substances

Classic Galactosemia

From step 1: Galactokinase deficiency, phosphate trapping


 +0  (step2ck_free120#13)

Classic factitious disorder Q

Health care worker (nurse) with dramatic hypoglycemia and some signs of mental illness (+ risky drinking, + stress, + young woman)

To check for exogenous insulin, look for C-peptide.

C-peptide is a cleavage byproduct of endogenous insulin production. If high insulin and normal or low C-peptide --> exogenous insulin = factitious disorder

Kind of a Step 1 question


 +1  (step2ck_free120#11)

Meets the 5 FAT RN criteria:

  • fever
  • anemia
  • thrombocytopenia
  • renal symptoms
  • neuro symptoms

Also, Indirect hyperbilirubinemia and increased LDH should tip you off to MAHA


 +0  (step2ck_free120#10)

Increased AFP can be due to

1) neural tube defects

2) abdominal wall defects

3) multiple gestations

Do an ultrasound to r/o (3)


 +0  (step2ck_free120#7)

The video shows a normal Moro reflex. This is a primitive "hang on for your life!" reflex.

Asymmetric Moro is associated with clavicle fracture or brachial trauma 2/2 shoulder dystocia.


 +0  (step2ck_free120#4)

This is a keratoacanthoma.

It's a cup shaped squamous cell carcinoma that's filled with keratin debris. It rapidly grows then usually spontaneously regresses. But, it's still an SCC, so we should excise.


 +1  (step2ck_free120#2)

Dewdrop on a rose petal appearance in a CN V1 dermatomal distribution. Rash is painful and weeping. Immunocompromised host (s/p chemo)


Wrong answers

Impetigo: honey colored crusting lesion related to group A strep infection

Pyoderma gangrenosum: think green cheese; usually a single large round ulcer. Rapidly progresses from small papule or pustule to large painful ulcer with purulent, violaceous border. Associated with IBD (crohn disease, UC, RA, trauma). Most commonly lower limbs.

Syphilis: Causes a few types of skin lesions: chancre, gummas, etc. Chancre: most common, painless, genital. Doesn't really fit the story here anyway.

SLE: doesn't fit


 +1  (step2ck_form8#29)

(E) Pneumothorax

Benzo overdose --> intubation --> airway trauma --> pneumothorax


Wrong answers

(A) Aspiration PNA is possible with individuals prone to loss of consciousness, but would not be so acute! She was intubated then crashed 20 minutes later.

(B) Kerley B lines are indicative of pulmonary edema

(C) Pericardial effusion is characterized by Beck's Triad of hypotension, distended neck veins, and muffled heart sounds. And would not explain unilateral diminished breath sounds.

(D) pleural-based hump-shaped density probably describes a Hampton hump, which a wedge-shaped opacity in peripheral lung with its base at a thoracic wall. Caused by pulmonary infarction.


 +0  (step2ck_form6#33)

At baseline:

  • measure Cr, Ca, UA, BUN, thyroid function

Then,

  • monitor TSH q6-12m and supplement with T4 rather than discontinue lithium

 +0  (step2ck_form6#12)

Treatment for acute kidney rejection is steroid + antithymocyte


 +0  (step2ck_form6#22)

Upper extremities more muscular and diminished pulses in lower extremities

Midsystolic or continuous systolic murmur that radiates to the back

= coarctation of the aorta

Treat surgically with surgical decompression


 +1  (step2ck_form6#40)

A classic

There are 4 murmur characteristics described and tetra logy of fallot has 4 problems (PROVe)

  1. P ulmonary infundibular stenosis
  2. R V hypertrophy
  3. O verriding aorta
  4. V SD --> holosystolic murmur + mid-diastolic at apex (due to increased MV flow) + thrill (in small VSD due to turbulence)

Single S1 from reduced pulmonic component (remember, MTAP, MT = S1, AP = S2)


 +0  (step2ck_form6#32)

Looses urine when coughs or sneezes

DDx

  • overflow
  • stress

Multiple peripheral neuropathy indicators + high postvoid residual = overflow


 +0  (step2ck_form6#33)

Clue cells = gardnerella = grayish discharge and does change pH (>4.5)

Others

  • Ferning = pregnancy / rupture of membranes, but she does not have male partners, so less likely

  • Budding yeast = candida = grayish, but does not change the vaginal pH (<4.5)

  • leukocyte sheets = ? Maybe erosive lichen planus / lichenoid vaginitis ?

  • Trich = green discharge, does change pH (>4.5)


https://vulvovaginaldisorders.com/the-four-pillars-of-vulvovaginal-diagnosis/table-elevated-ph/#prettyPhoto[6]/0/

spiroskeet  Reason for pH >4.5 is that Gardnerella outcompete Lactobacilli fauna, which (as their name implies) pump out acid +

 +1  (step2ck_form6#15)

Don't get Addison's confused with Cushing's!

Young woman with eosinophilia, hyponatremia, hyperkalemia, lethargy, confusion, hyperpigmentation, etc, etc

Think Addison's = Primary Adrenal Insufficiency

Test with ACTH stimulation test

vs Cushing's which you test with dexamethasone suppression test


 +0  (step2ck_form6#7)

Before undergoing vigorous exercise an exercise stress test should be performed in those with cardiac risk factors (smoker, family history, male, etc.)


 +0  (step2ck_form6#21)

Don't forget your sketchy!

carbamazapine is the anti-epileptic associated with blood dyscrasias, such as aplastic anemia and agranulocytosis


 +0  (step2ck_form6#22)

History of allergies think eczema

In young adults eczema in the flexor surfaces = antecubital and popliteal fossae

Umbilicated, erythematous, painful vesicles and active skin inflammation = superimposed herpes

--> eczema herpeticum


 +0  (step2ck_form6#45)

Before starting statin therapy, measure LDL levels with FASTING lipid profile!

This person has borderline high cholesterol


 +0  (step2ck_form6#22)

Non-bilious vomit in a young boy a few weeks old

  • can't be lactose intolerance (switched to soy)
  • mustard colored stool

Would also expect

  • olive sized abdominal mass
  • succession splash on auscultation

Non-bilious ddx

  • pyloric stenosis
  • TEF

Bilious ddx

  • duodenal atresia
  • annular pancreas
  • malrotation/volvulus
  • intestinal atresia

 +2  (step2ck_form6#44)

Elimination

(a) ARDS is bilateral

(b) aspiration PNA is too quick (4 hours!) and is usually consolidated

(c) fat embolism is more common with long bone fractures (e.g., femur) -- if you hear chest is bruised, think chest first

(d) hemothorax is usually more acute, but I suppose possible especially if you're thinking flail chest with sharp ribs causing puncture. But, x-ray would be more consolidated

(e) pulmonary contusion fits. You have trauma, initially normal ABG, chest bruising, and unilateral diffuse consolidation a few hours later

drdoom  very neat. very structured. to-the-point, practical breakdowns. but also great use of typographical elements ... 🤔 too neat for emergency medicine. maybe gen surg? too good natured for ob/gyn .. hmmm, maybe future peds surg? okay, that's my final answer: peds surg. +1
drdoom  no, wait .. i’m revising to peds specialty. probably peds nephro. final answer. +1

 +0  (step2ck_form6#22)

Androgens are responsible for libido in both sexes!

Also, can't be estrogen because they're on HRT and vagina is moist and rugated, indicating adequate estrogen


 +2  (step2ck_form6#15)

I hear woods and well demarcated, spreading, pruritic rash and I think poison ivy

Another way to get there: here's no fever but he is v v itchy, so think type IV HSR

Abrupt, sharp line of demarcation, no systemic signs, and mention of environmental exposure should make you think less of strep skin infections

So we're thinking some contact in the forest and we're back at poison ivy or some other allergen

Can treat with antihistamine, but what about prevention? Avoid the woods.

Google bullous poison ivy


 +1  (step2ck_form6#45)

Cramping abdominal pain with distention, N/V should make you think SBO

Air-fluid levels in the small bowel but no gas in the colon tells you it's an upper GI issue

Hyperactive bowel sounds + pneumobilia = gallstone ileus

Very few things put air in the liver


 +0  (step2ck_form6#31)

young woman with abrupt onset painful eye movements + decreased acuity + poor reactivity = optic neuritis = MS

Also notice they said the right pupil is poorly active to direct light

So maybe there's a Marcus Gunn pupil, which is when there's decreased bilateral pupillary constriction when light is shone directly into the affected eye, relative to the unaffected eye


 +0  (step2ck_form6#11)

Remember, thyroiditis also causes hyperlipidemia

Increased LDL receptors +/- triglycerides due to increased LPL activity

Post-partum + cholesterol + lethargy + boredom + sleep issues + memory = thyroid

Would also expect hypnatremia, weight gain

Postpartum thyroiditis usually hyperthyroid followed by hypothyroid


 +0  (step2ck_form6#26)

This is tricky because of the normal hormone levels

Usually PCOS has LH:FSH > 3:1

But, both can still be within the reference ranges!

Normal for females

  • FSH: 4-30 premeno, 10-90 midcycle, 40-250 postmeno
  • LH: 5-30 follicular, 75-150 midcycle, 30-200 postmeno

Also, testosterone often, but not always, elevated


 +1  (step2ck_form6#39)

PDA gives continuous machine like murmur that crescendos at S2, so loud S2

Agree with sugaplum;

widened pulse pressure => PDA in newborn or regurg in adult

To and fro murmur = wave like = swishing back and forth = PDA

close with indomethacin


 +0  (step2ck_form6#18)

This guy has a gallop, not a specific murmur, so it can't be (b) bicuspid AV or (e) MVP

SOB + peripheral edema + JVD + crackles = HF, so that rules out (a) and leaves (c) or (d)

(c): The hypokinesia of the LV apex would be more likely for a distal LAD occlusion or some other post MI HF, but this is a 27M and he had a recent "bad cold," so think viral

(c) diffuse hypokinesia and dilation of the ventricles describes dilated cardiomyopathy, which is especially common after cocksackie B

Treatment is supportive.

kingfriday  adding on, i believe dyskinesia of the LV apex [apical ballooning] can also occur in the setting of takatsubos (occurs after emotional stress) +

 +0  (step2ck_form7#34)

Recurrent pneumonia + productive cough sometimes blood tinged = bronchiectasis

vs chronic bronchitis

1) x-ray shows signs of airway thickening (eg, "tram-track" sign, "ring" sign) vs. chronic bronchitis has a normal CXR.

2) hemoptysis is seen in bronchiectasis

3) mucopurulent sputum

4) smoking → bronchitis; infections → bronchiectasis


Bronchophony = a type of pectoriloquy


 +0  (step2ck_form7#34)

Recurrent pneumonia + productive cough sometimes blood tinged = bronchiectasis

vs chronic bronchitis

1) x-ray shows signs of airway thickening (eg, "tram-track" sign, "ring" sign) vs. chronic bronchitis has a normal CXR.

2) hemoptysis is seen in bronchiectasis

3) mucopurulent sputum

4) smoking → bronchitis; infections → bronchiectasis


Bronchophony = a type of pectoriloquy


 +0  (step2ck_form7#46)

Spinal dysraphism usually presents at birth

vs

Cerebral palsy usually presents in childhood with missed milestones


SD presents with foot deformities and neuro abnormalities


 +0  (step2ck_form7#11)

Give to mothers at risk for delivery <32 weeks gestation

Decreases risk of cerebral palsy in infants

Also, it is a tocolytic that competes with Ca2+ for muscle depolarization (myometrium)


 +0  (step2ck_form7#27)

Claudication of calf only → PVD of femoropopliteal distribution

aortoiliac → butt, thigh, calf pain

femoropopliteal → calf pain (most commonly superficial femoral artery)

tibiofibular → foot pain

according to cheesy dorian


 +0  (step2ck_form7#7)

MR. AS S

  • Mitral Regurg
  • Aortic Stenosis
  • = Systolic

Systolic murmur so, MR or AS

"throughout the precordium with radiation to the carotids"

Aorta radiates to the carotids --> AS


 +1  (step2ck_form7#22)

Remember eosinophilia: DNAAACP or "D N triple A CP"

  • D rugs
  • N eoplasia
  • A llergic
  • A sthma
  • A ddison's disease or A drenal insufficiency
  • C onnective tissue disease (e.g., scleroderma)
  • P arasite

Fire ants don't cause eosinophilia*

Ascaria is a pulmonary helminth and O and P is positive

Scabies usually in the webs of fingers and causes mite burrows and papules

Cutaneous larva migrans causes intensely pruritic serpiginous lesions anywhere that has come in contact with contaminated sand or soil

Serpiginous = hooks on your foot = hookworms

(*Or do they???

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096327/)


 +1  (step2ck_form7#26)

Tricky! Yes, fecal occult blood test would pick up hemorrhoid blood and this is a male <50yo, so case closed right?

Wrong! Hematocrit = 35% --> hgb = 35/3 = 11.7 < 13.5 (normal)

Why is he anemic? Do a colonoscopy.


 +3  (step2ck_form7#44)

This is a normal x-ray!

Like veggievendor said, this is a kid with sickle cell disease and limited hip ROM, so check the hip for osteonecrosis


 +1  (step2ck_form7#11)

TSS: sunburn like rash particularly on the palms and soles and very rare

Meningococemia fits better for a college-age girl who has been living in cabins/dorms and cannot be aroused/altered mental status

https://rarediseases.org/rare-diseases/toxic-shock-syndrome/


 +1  (step2ck_form7#8)

The mother was already treated for GBS -- observation is indicated in the newborn.

AAP: "For well-appearing term newborn infants born to mothers with an indication for intrapartum antibiotic prophylaxis (IAP) to prevent GBS disease and receipt of 4 or more hours of penicillin, ampicillin or cefazolin at the appropriate doses before delivery, routine care, and 48 hours of observation continue to be recommended."

But, this mother was already treated, so they do not even have an indication for IAP

https://pediatrics.aappublications.org/content/128/3/611


 +2  (step2ck_form7#35)

thajoker's comment is spot on

And: decreased upward gaze is a normal sign of aging, not always parinaud syndrome

https://pubmed.ncbi.nlm.nih.gov/15114040/

Can dogs look up?


 +1  (step2ck_form7#28)

That's a bird's beak deformity!

Nerve damage causes increased LES tone and decreased peristalsis

If they show you a picture of a barium swallow, it can only be a few things

  1. achalasia (bird's beak)
  2. Zenker (outpouching)
  3. volvulus/malrotation (corkscrew)
  4. stricture (symmetric narrowing)
  5. cancer (crazy, irregular stricture "hold up" prestricture dilatation; shouldering? whatever that means)

 +4  (step2ck_form7#38)

Male (XY) + Encapsulated organisms = X linked (Bruton) agammaglobulinemia

  • First: S pneumoniae
  • Then: H influenza type B
  • And now... S pneumoniae again!

Remember: S pneumoniae is a gram positive lancet-shaped diplococcus and is the #1 cause of MOPS (meningitis, otitis media, pneumonia, sinusitis)

N meningitidis is a gram negative diploccocus

creamy  Thanks Carole. +2

 +1  (step2ck_form7#44)
  • Unconscious trauma patient? intubate!

  • GCS < 8? intubate!

  • stabbed in the neck, GCS = 15, expanding mass in lateral neck? intubate!

  • Stabbed in neck with crackling to palpation of anterior neck? fiberoptic broncoscope!

  • huge facial trauma, blood obscures oral cavity? cricothyroidotomy/cricothyrotomy!


 +1  (step2ck_form7#45)

Schilling test:

  • oral radiolabeled vit B12 + intramuscular injection of unlabeled vit B12 an hour later
  • urine collection for 24 hours

Normal test: >10% of radiolabeled B12 in the urine

Impaired absorption: <10%

This patient has impaired absorption and it is corrected by oral intrinsic factor

Atrophic gastritis chronic inflammation causing pernicious anemia --> auto Ab against parietal cells or intrinsic factor


 +1  (step2ck_form7#19)

Remember: FAT RN

  • F ever (T = 38.3C/101F)
  • A nemia (hct=11%!!!)
  • T hrombocytopenia (plt=52k/mm3)
  • R enal involvement (Cr = 3.5 mg/dL)
  • N eurological symptoms (fluctuating consciousness)

And the smear shows schistocytes, so you should be thinking MAHA


 +3  (step2ck_form7#15)

OCPs offer significant protection against

  • Ovarian cancer: decreased ovulation --> less damage
  • endometrial cancer: decreased endometrial proliferation
  • iron-deficiency anemia: decreased bleeding
  • reduced risk of benign breast disease

IUDs only act locally


 +3  (step2ck_form7#25)

Patients who complain of persistent RUQ pain after cholecystectomy should be evaluated for post-cholecystectomy syndrome

Evaluated via abdominal imaging (e.g. ultrasound) followed by direct visualization (e.g. ERCP, MRCP) to find and remove the stone.

etiologies include:

  • biliary (e.g. retained cystic duct stone, damage to the duct)
  • extra-biliary (e.g. pancreatitis) causes.




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