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Welcome to kingfriday’s page.
Contributor score: 3


Comments ...

 +0  (step2ck_form6#2)

i think this was tested in a similar way in another question in this form. the patients have a right to know or not know their resuts.


 +0  (step2ck_form6#43)

Draw out your 4/4 box.

Note that prevalence does not change specificity or sensitivity and that's why you can eliminate C and D right off the bat.

so with low prevalence, you decrease the amount of people with the disease and if you write out for formulas for PPV and NPV you can see that PPV has its variable in the numerator and denominator decrease (decrease overall) while the NPV only has its numerator in the denominator decrease. i wish I could draw it out i hate typing out math


 +0  (step2ck_form6#20)

honestly someone explain this one to me other than the memory loss is her newest thing and needs to be evaluated. pls


 +0  (step2ck_form6#24)
  • Catecholamine producing tumor -> not likely since the presentation would be more of an intemittent episode of HTN and other sympathetic symptoms
  • Decreased distensibility caused by atherosclerosis: could be describing RAS which is discounted by the lack of abdominal bruits
  • Execess production of ANP -> can be seen in volume overload states and would also result in a reduction of Na+ in the serum due to the actions of ANP- maximal point of impulse not displaced, no edema, low-normal resp.
  • Juxtaglomeular cell hypertrophy and sclerosis -> this would suggest findings of diabetic nephropathy. Patient doesnt have hx or HTN.
  • along with patients labs suggesting high aldosterone state - answer is most likely pointing toward autonomous production of aldosterone.

 +0  (step2ck_form6#10)

Patient does NOT currently have back pain- asking for how to prevent her back pain from occuring.

Being obese is the most important risk factor in back pain and osteoarthritis (step-prep)

USMLE

  • Acute pain (< 4 weeks)
  • treat with NSAID/acetaminophen, maintain activity, consider muscle relaxants or spinal manipulation
  • Subacute (4-12) or Chronic (>12 weeks)
  • Intermittent use of NSAIDs or acetaminophen (decreased freq. in comparison to acute pain), Exercise therapy (stretching/strengthening - which is what i put because i thought the patient was currently in pain), and tricyclics or duloxetine

Secondary prevention also includes exercise therapy and education, and according to this NBME weight loss as well.


 +0  (step2ck_form6#36)

HBsAb = HBs Antibody = negative... so give the vaccine

.___. wow


 +0  (step2ck_form6#45)

The only variable that changes with diet is the triglycerides (goljan)

The formula for total cholesterol:

  • Total = HDL + LDL + VLDL
  • VLDL = TG/5
  • Total = HDL + LDL + TG/5

We need this patient to be fasting to get an appropriate Total cholesterol level.

  • need to do step 1 diet (decrease fats, calories, cholesterol etc.) before moving to step 2 diet (more aggressive diet than step 1)

 +0  (step2ck_form6#18)

This one got me :( i had the right answer but i switched because i kept getting hung up on his PPI treatment (rereading the stem now, it seems he's off treatment)

but can someone explain to me what the answer would be if the guy were on a PPI and had intractible vomiting?


 +0  (step2ck_form6#26)

This was identical to the question in NBME8 - physiological splitting with inhalation - really did not even need the media for this.


 +0  (step2ck_form6#39)

Lady with mets and increased ca2+ (hypercalcemia of malignancy) at risk for cervical spine compression. She also has neurological impairment which makes her a candidate for surgery - decompress spinal cord and cervical stabilization.

I think this lady needs way more than a soft tissue collar and PT - more conservative therapy.

Mithramycin is evidently an antitumor drug used in testicular cancer

Tamoxifen therapy - treat her immediate neurological issues


 +0  (step2ck_form6#37)
  • Format; age: mneumonic (Gross Motor, Fine Motor, Language, Social/Cognitive)
  • 3 months + 3 is before anything else (Roll, x (no fine motor), Laugh, Smile)
  • 6 months: SIX's = 6's - focus on the letter S (Sit, Switch, Schmooze, Stranger Anxiety (lasts until 18-24 months))
  • 9 months: 9 inch PENIS = P's (Pull to stand, Pincer, Papa/mama, Play)
  • 12 months: Twelves = T's *(Two legs (first steps), Track, Two Words (other than papa/mama), Two-of-us (sepration anciety))

ok i think i got it hmmhmm credit to old dirtyusmle video that got deleted. his mneumonic only went up to 12 months


 +0  (step2ck_form6#37)

people don't put up mneumonics anymore- here's one from the dirtyusmle video before he took it down and never put it back up - ill put it down as a subcomment to this comment

kingfriday  Format; age: mneumonic (Gross Motor, Fine Motor, Language, Social/Cognitive) + 3 months: 3 is before anything else (Roll, x (no fine motor), Laugh, Smile) + 6 months: SIX's = 6's - focus on the letter S (Sit, Switch, Schmooze, Stranger Anxiety (lasts until 18-24 months)) + 9 months: 9 inch PENIS = P's (Pull to stand, Pincer, Papa/mama, Play) + 12 months: Twelves = T's *(Two legs (first steps), Track, Two Words (other than papa/mama), Two-of-us (sepration anciety)) +
kingfriday  Damn i tired to format but it doesn't work... +

 +0  (step2ck_form6#26)

This one got me :[ i was looking for the LH>FSH and the ovarian masses - but other than that i agree this pretty much matches up.


 +0  (step2ck_form6#41)

Man I don't know what I was thinkin - i was between glucagon and insulin and then the panic set in. If you have high glucose (in the setting of diabetes) then you're going to suppress the hormone that releases more sugar and increase the hormone that will store more sugar.

kingfriday  DDX- bicarb will be normal[ish] in HHS and decreased in DKA, HDL-cholesterol? i dont know why that would play a role here, Ketones would be increased in DKA in type 1; i think it went something like people with Type 1 can't make insulin so glucagon is unopposed which breaks down fats -> ketones. In Type 2, you still have insulin around so it can suppress glucagon and thus no ketones. +

 +1  (step2ck_form8#32)

Why would increasing fluids be incorrect?

kingfriday  nvm, someone whose kidneys dont work means they not able to get rid of fluids anyway so giving them fluids can make things worse +
letsdothis  Yeah, I feel like increasing fluid in any chronic renal conditions is always correct, but I like the steppreps explanation. +




Subcomments ...

submitted by medgirl11(1),

I believe that this is an ovarian cyst...recheck at different point in cycle

kingfriday  particularly in the follicular phase (first 14 days) of the cycle before ovulation! +  


can someone please explain this answer :D

szsnikaa  Brain abscesses are secondary to septic emboli via hematogenous spread. Edema often forms around these abscesses leading to a mass effect (+ Babinski & Mild Hemiparesis on the left). +2  
kingfriday  Guy has a valve replacement -> he then has a new murmur, fever, and FND - he probably has endocarditis due to staph epidermidis. Carotid artery occlusion wouldn't cause more issues (i think vision in particular would be included) in addition to more severe deficits. There would also be no fever. Venous sinus thrombosis would also not present with fever and also probably include vision problems Encephalitis would probably present with AMS and seizures - may or may not be nuchal rigidity Hydrocephalus: wet wacky wobbly- not seen here +  


submitted by kingfriday(3),

people don't put up mneumonics anymore- here's one from the dirtyusmle video before he took it down and never put it back up - ill put it down as a subcomment to this comment

kingfriday  Format; age: mneumonic (Gross Motor, Fine Motor, Language, Social/Cognitive) + 3 months: 3 is before anything else (Roll, x (no fine motor), Laugh, Smile) + 6 months: SIX's = 6's - focus on the letter S (Sit, Switch, Schmooze, Stranger Anxiety (lasts until 18-24 months)) + 9 months: 9 inch PENIS = P's (Pull to stand, Pincer, Papa/mama, Play) + 12 months: Twelves = T's *(Two legs (first steps), Track, Two Words (other than papa/mama), Two-of-us (sepration anciety)) +  
kingfriday  Damn i tired to format but it doesn't work... +  


submitted by kingfriday(3),

people don't put up mneumonics anymore- here's one from the dirtyusmle video before he took it down and never put it back up - ill put it down as a subcomment to this comment

kingfriday  Format; age: mneumonic (Gross Motor, Fine Motor, Language, Social/Cognitive) + 3 months: 3 is before anything else (Roll, x (no fine motor), Laugh, Smile) + 6 months: SIX's = 6's - focus on the letter S (Sit, Switch, Schmooze, Stranger Anxiety (lasts until 18-24 months)) + 9 months: 9 inch PENIS = P's (Pull to stand, Pincer, Papa/mama, Play) + 12 months: Twelves = T's *(Two legs (first steps), Track, Two Words (other than papa/mama), Two-of-us (sepration anciety)) +  
kingfriday  Damn i tired to format but it doesn't work... +  


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) +  


submitted by kingfriday(3),

Man I don't know what I was thinkin - i was between glucagon and insulin and then the panic set in. If you have high glucose (in the setting of diabetes) then you're going to suppress the hormone that releases more sugar and increase the hormone that will store more sugar.

kingfriday  DDX- bicarb will be normal[ish] in HHS and decreased in DKA, HDL-cholesterol? i dont know why that would play a role here, Ketones would be increased in DKA in type 1; i think it went something like people with Type 1 can't make insulin so glucagon is unopposed which breaks down fats -> ketones. In Type 2, you still have insulin around so it can suppress glucagon and thus no ketones. +  


submitted by sugaplum(324),

I missed this the first time because I wasn't thinking about it right. This man has new onset Type 2 diabetes. This is characterized by Insulin resistance, so initially the patient's body will increase insulin production to combat the new diabetes

medicalmike  Does T2DM cause weight loss? I interpreted this older man with weight loss and new-onset T2DM as having pancreatic cancer. +  
kingfriday  i guess if you dont get the anabolic benefit of insulin, you can't build up your weight- at least that's how i took it +  


submitted by beeip(123),

Guess one needs to bank on "hilar lymphadenopathy with fever" here.

Lacking upper lobe findings, I got this one wrong.

boeboeboe  Patient likely has primary TB presenting with fever, chest pain. Lower lung fields are affected, but usually nothing seen on CXR. Secondary TB affects upper lobes, and is when cavitary lesions will be seen on CXR +  
kingfriday  There's a uworld question that mirrors this presentation, it got me then- the adenopathy is huge +  


submitted by sugaplum(324),

CF, + family hx of norther european. Lungs with lots of gunk it in that is difficult to remove. recurrent infections

kingfriday  adding to this. kid also has poor growth which reflects poor pancreatic function +  


submitted by step_prep4(4),
  • Unable to access audio, but patient has classic symptoms of a URI (fever, cough, rhinorrhea) and likely normal heart sounds (or a soft systolic ejection murmur)

https://step-prep.org/tutoring/

seagull  I also could not access the audio. I expect my refund in the mail since my assessment is compromised. ThAnKs NbMe +1  
kingfriday  I got to the audio, it was just physiologic splitting of heart sounds with breathing (inspiration). Made no impact to the answer. +  


submitted by step_prep2(17),
  • An elderly woman with atrial fibrillation who is not on anticoagulation presents with an acutely cold, painful foot with absent pulses, most consistent with critical limb ischemia secondary to an embolus from the left atrial appendage in setting of afib
  • Key idea: Patients with suspected acute limb ischemia should be treated with immediate initiation of anticoagulation, most often IV heparin

https://step-prep.org/tutoring/

kingfriday  Aye i coulda sworn i got a uworld question that told me to do an exercise program. I guess since this person has ABSENT pulses and cold extremities those are red flag features for us to just jump straight to treatment. +  


submitted by step_prep2(17),
  • Child with resection of ileum (which is responsible for absorption of the ) who presents with macrocytic anemia, most consistent with vitamin B12 deficiency
  • Key idea: To remember the sections of small intestine and pertinent nutrient absorbed in each, use mnemonic Iron Fist Bro for Iron (duodenum), Folate (jejunum) and B12 (ileum)
  • Key idea: Ileum also responsible for absorption of bile salts, which are responsible for fat absorption and absorption of fat-soluble vitamins (A, D, E and K)

https://step-prep.org/tutoring/

kingfriday  I personally like the "I fu*ked brittany" mneumonic +1  


submitted by step_prep2(17),
  • Young man who presents with inflammatory back pain (worse in the morning but improves over course of the day) who has limited range of motion of the back (consistent with “bamboo spine” physiology), all of which is most consistent with ankylosing spondylitis that can be diagnosed with x-ray or MRI of the sacroiliac joints
  • Key idea: Indications for x-ray in setting of low back pain is (1) Osteoporosis or compression fracture (2) Suspected malignancy (3) Ankylosing spondylitis
  • Key idea: Indications for MRI in setting of low back pain is (1) Sensory/motor deficits (2) Cauda equina syndrome (3) Suspected epidural abscess or infection

https://step-prep.org/tutoring/

seagull  THe question said initial step. I thought this was a clinical dx that required elevated ESR, CRP. In reality we would order these and have him get an x-ray. I'm not sure if we can reliably dx Ankylosing Spondylitis unless we have the ESR unless the x-ray clearly shows that bones are fusing. THis is a younger guy too. +  
kingfriday  There was a uworld question that mirrors this if you use the search function you can probably find it. The reasoning they had there said that acute phase markers are usually elevated in AS but they have low specificity for establishing the dx. BONE SCAN - not good for AS, but it is good for osteomyelitis, suspected fractures, and neoplasms > MRI indicated for neurological s/sx +  
spiroskeet  Just found that UWorld question – it asked which would be most likely to establish a diagnosis in the patient. In that case, X-ray of SI joints is the right answer. However, the NBME question asked for initial step. My first step would probably be to order an ESR. It's nonspecific, but ESR is pretty much always nonspecific, so why would you ever order it? +  


submitted by step_prep(48),
  • 87 year old man who is independent in ADLs (eating, bathing, toileting, transferring, getting dressed) and iADLs (shopping, using phone, driving, handling finances, etc.), A&O x 3, recalls 2/3 objects after 5 minutes and has no focal neurologic findings most consistent with normal aging or mild cognitive impairment
  • Key idea: Patients with mild cognitive impairment will have mild decline in at least 1 cognitive domain, but will have normal functioning in all activities of daily living with compensation (taking a list to the store), whereas patients with dementia will have global cognitive impairment and marked functional impairment
  • To differentiate between Alzheimer’s and vascular dementia, look for other neurologic features (pronator drift, weakness, etc.) which is more consistent with vascular dementia

https://step-prep.org

kingfriday  DDx: - Capgras syndrome: someone close to them or a loved one has been replaced by an imposter. Not what's going on here - Dimentia with Lewy Bodys -> would have hallucinations and features of parkinsonism also not seen here (mneumonic: ha-lewy-cinations) - Dimentia, Alzheimers type -> question stem would almost always mention something about the person getting lost in neighborhoods or unable to find their way as part of the pathology - MDD: doesn't meet the criteria of SIGECAPS - Metastatic prostate cancer -> typically presents with back pain which is not seen here Multi infart vascular dimentia -> often a stepwise decline (at 6 months x happened, then at 4 months y happened, and at 2 months z started happening) +  


submitted by step_prep(48),
  • Rhythm strip shows progressively prolonged PR interval until a QRS complex is dropped
  • First-degree AV block = Prolonged PR interval (>200 ms or one big box) but every p wave is followed by a QRS
  • Second-degree type 1 block = PR interval becomes increasingly prolonged until a QRS complex is dropped (p wave not followed by QRS)
  • Second-degree type 2 block = PR interval prolonged with random QRS complexes that are dropped
  • Third-degree block = Atria and ventricles beat independently of one another, with QRS complexes occurring at rates ~40 beats/min and p waves occurring at rates ~80 beats/min

https://step-prep.org

kingfriday  aye OME and UW say that type 2 AV block have normal PR interval but the QRS drops randomly Mobitz Type I - due to delay or break of cardiac electrical signal pathway from atria to ventricles - epidemiology: associated with drugs that block the AV nodes (digioxin, CCB, BB) Benign rhythm -> low risk for complete heart block thus treatment is observation in an asymptomatic pt and attempt to correct reversible causes (holding meds that would impact the AV node) Mobitz type II due to his-purkinje system below AV node - can progress to third degree AV block which requires a pacemaker - QRS in type II can be wider than Mobitz Type I +  


submitted by step_prep3(8),
  • Newborn with cyanosis found to have a heart murmur and hypoxia unresponsive to supplemental oxygen, which is consistent with a severe intracardiac shunt)
  • Patient should be treated with alprostadil (or another prostaglandin analog) in order to keep the PDA open until the heart defect can be operatively managed

https://step-prep.org/tutoring/

seagull  Doesn't it take like 2-7 days for the duct to close? Why is this hour old newborn already cyanotic? +  
kingfriday  early cyanosis might be consistent with transposition of the great vessels and those can be associated with ejection murmurs and a loud S2 +1  


submitted by kingfriday(3),

Why would increasing fluids be incorrect?

kingfriday  nvm, someone whose kidneys dont work means they not able to get rid of fluids anyway so giving them fluids can make things worse +  
letsdothis  Yeah, I feel like increasing fluid in any chronic renal conditions is always correct, but I like the steppreps explanation. +