share email twitter ⋅ join discord whatsapp(2ck)
free120  nbme24  nbme23  nbme22  nbme21  nbme20  nbme19  nbme18  nbme17  nbme16  nbme15  nbme13 
Welcome to step_prep’s page.
Contributor score: 48


Comments ...

 +1  (step2ck_form8#6)
  • Elderly woman with rheumatoid arthritis presents with pallor and is found to have a microcytic anemia with a decreased TIBC (indicative of increased ferritin stores), most consistent with anemia of chronic disease
  • Iron deficiency (microcytic anemia): Iron labs show low iron, increased TIBC and decreased ferritin (often seen in young women due to menses and in older patient is colon cancer until proven otherwise)
  • Lead poisoning (microcytic anemia): Patient with exposure who has abdominal pain, neurologic symptoms, etc.
  • Key idea: While rheumatoid arthritis can be associated with anemia of chronic disease, osteoarthritis is NOT associated with anemia of chronic disease

https://step-prep.org


 +0  (step2ck_form8#5)
  • Condoms/diaphragms are associated with increased risk of UTIs in young woman because they lead to increased friction
  • Key idea: Two other common methods of decreasing UTI risks are included in question stem (postcoital voiding, increased fluid intake)

https://step-prep.org


 +0  (step2ck_form8#4)
  • Middle-aged woman with dry mouth, dry eyes, parotitis and dental cavities, consistent with Sjogren syndrome (although classically associated with anti-SSA/SSB, patients are also commonly ANA positive)
  • Sjogren syndrome: Onset in middle age, positive ANA, and often systemic manifestations (malaise, weight loss, joint pains, etc.)
  • Age-related sicca syndrome: Onset in elderly patient, especially women with diabetes or thyroid disorders, no systemic symptoms

https://step-prep.org


 +0  (step2ck_form8#3)
  • Patient with a positive PPD (>10 mm in healthcare workers) who is asymptomatic and without CXR changes, most consistent with latent tuberculosis
  • Key idea: 3 treatment options for latent tuberculosis are (1) Isoniazid and rifapentine weekly for 3 months (2) Isoniazid for 6-9 months (3) Rifampin for 4 months
  • Key idea: PPD induration (NOT erythema) required for positivity depends upon patient risk factors with >5 mm being positive in patients with significant immunosuppression (HIV, organ transplant, immunosuppressant meds), recent contact with patient with active TB or patients with CXR findings consistent with TB // >10 mm being positive for patients from Tb endemic countries, IVDU, residents of high-risk settings (prisons, nursing homes, homeless shelters, etc.), children < 4 years old and patients working in mycobacterial labs // >15 mm in all patients

https://step-prep.org


 +0  (step2ck_form8#2)
  • XX newborn with ambiguous genitalia and elevated 17-hydroxyprogesterone levels, most consistent with 21-hydroxylase
  • Key idea: Three main enzymes that can be deficient in adrenal cortex pathway include (1) 21-hydroxylase (increased testosterone, decreased cortisol, decreased mineralocorticoids) (2) 11-hydroxylase (increased testosterone, decreased cortisol, normal/increased mineralocorticoids because 11-deoxycorticosterone has mineralocorticoid activity (3) 17-hydroxylase (decreased testosterone, decreased cortisol, increased mineralocorticoids)

https://step-prep.org


 +0  (step2ck_form8#1)
  • Middle-aged woman experiencing increased abdominal cramps and diarrhea associated with increased milk consumption, consistent with lactose intolerance
  • Key idea: Pathophysiology is that many people lose activity of the lactase enzyme on the brush border of their small bowel as they become adults, such that lactose can no longer be broken down into glucose and galactose and absorbed (remember that small bowel can only accept carbohydrate monomers)
  • Key idea: Lactose hydrogen breath test would be positive because the lactose would not be absorbed in the small bowel and would therefore travel into the large intestine, where there are many bacteria that will break down the lactose via anaerobic glycolysis, leading to release of hydrogen gas (and cause of bloating in patients)

https://step-prep.org


 +0  (step2ck_form8#46)
  • Described study is subject to observer/measurement bias because each individual physician is making a subjective determination of the patient’s respiratory distress without objective measures such as O2 status, O2 need, respiratory rate, etc.

https://step-prep.org


 +0  (step2ck_form8#45)
  • Newborn delivered by a mother with signs of chorioamnionitis (uterine tenderness and fever) has fever, tachypnea, and ill appearance, most consistent with neonatal sepsis
  • Key idea: All neonates with concern for sepsis should be empirically treated with ampicillin and gentamicin
  • Key idea: Mothers with postpartum endometritis are treated with ampicillin + gentamicin + clindamycin (only difference between the two)

https://step-prep.org


 +0  (step2ck_form8#44)
  • Child with an maternal uncle with hemophilia who presents with joint swelling after minor trauma (concerning for hemarthrosis) with increased aPTT that corrects with mixing, concerning for hemophilia A (Factor VIII deficiency)
  • Key idea: Hemophilia A (X-linked, Factor 8 deficiency) > Hemophilia B (X-linked, Factor 9 deficiency) > Hemophilia C (Autosomal recessive, Factor 11 deficiency)
  • Key idea: If the coagulation studies are prolonged and do NOT correct with mixing, that should raise your suspicion for a coagulation factor inhibitor (often acquired in setting of recurrent transfusions, antiphospholipid syndrome, etc.)

https://step-prep.org


 +0  (step2ck_form8#43)
  • Child presents with a rash on her mouth and cheek with honey-colored crust, most consistent with impetigo
  • Key idea: HSV infection can also present as a honey-color crusted rash on face, but it will be limited to the orolabial region (would not involve the cheek)

https://step-prep.org


 +0  (step2ck_form8#42)
  • Young woman with recent total abdominal hysterectomy who is anuric with drain creatinine = serum creatinine, AKI and mild bilateral hydronephrosis consistent with ureteral ligation/damage due to surgery
  • Key idea: Drain fluid creatinine: Serum creatinine ratio > 1 consistent with urine leak
  • Key idea: Hysterectomy and other female GU operations are highly associated with ureteral damage (especially in NBME exams)

https://step-prep.org

seagull  Why does she still have hydronephrosis bilaterally? Why doesn't the drain collect more urine if it's ligation (draining urine into the peritoneum)? Why would both be injured - WTF is this blind surgeon doing? +2

 +0  (step2ck_form8#41)
  • Meconium aspiration is a common cause of persistent pulmonary hypertension of the newborn because it can lead to pulmonary vasoconstriction, which can lead to decreased pulmonary blood flow that leads to a vicious cycle leading to increased right to left shunting and increased PVR
  • To help combat this pulmonary vasoconstriction, the infant should be treated with supplemental oxygen (increased/improved oxygenation leads to dilation of lung capillaries and decreased pulmonary vascular resistance)

https://step-prep.org


 +0  (step2ck_form8#40)
  • Adolescent with type 1 diabetes found to have microalbuminuria on labs, who should therefore receive ACEi/ARB to reduce risk of kidney damage
  • Key idea: ACE inhibitors or ARBs should be initiated at onset of microalbuminuria in all diabetic patients

https://step-prep.org


 +1  (step2ck_form8#39)
  • Patient with an inflammed area of the distal radius with red streaks extending from the area towards the elbow, most consistent with lymphangitis
  • Key idea: Most common pathogens are MSSA and Group A strep, and therefore empiric treatment is cephalexin

https://step-prep.org


 +0  (step2ck_form8#38)
  • This is a classic presentation for a patient with coarctation of the aorta. When they are first born, blood is able to get past the coarctation because blood flow through the ductus arteriosus enters the aorta distal to the coarctation. When the ductus arteriosus closes in the first week of life, the left side of the heart then sees a massive increase in afterload, leading to heart failure

https://step-prep.org


 +1  (step2ck_form8#37)
  • Key idea: History of heel pain that is worst with first steps in morning and pain with passive dorsiflexion of toes is classic for plantar fasciitis; plantar fasciitis also commonly associated with bone spur on plantar surface of foot
  • Differential for heel pain: (1) Plantar fasciitis (2) Bone infection or metastasis (constant pain that is worst at night) (3) Calcaneal stress fracture (worse with activity and palpation) (4) Tarsal tunnel syndrome (percussion tenderness and paresthesias over posterior tibial nerve in tarsal tunnel) (5) Achilles tendinopathy (pain/tenderness at posterior heel with palpable thickening of tendon that can be reproduced with foot dorsiflexion)

https://step-prep.org

seagull  I like this ddx explanation. well done +

 +0  (step2ck_form8#36)
  • Patient with severe retching/vomiting develops severe retrosternal pain and pain in the chest with a new pleural effusion on the left, most consistent with Boerhaave syndrome
  • Key idea: Severe retching can lead to Mallory-Weiss tear (severe hematemesis) and Boerhaave syndrome (severe chest pain with extrapulmonary air)

https://step-prep.org


 +0  (step2ck_form8#35)
  • Specificity = In patients who do NOT have the disease, what proportion will test NEGATIVE

https://step-prep.org


 +0  (step2ck_form8#34)
  • Patient with severe neuromuscular weakness who remains prone without much movement develops an ulcerative lesion on the back of their head, concerning for a decubitus ulcer
  • Note: Atypical mycobacterial infection can lead to ulcerative, violaceous cervical lymphadenopathy in children

https://step-prep.org


 +0  (step2ck_form8#33)
  • Patients should be randomly assigned to each type of graft in order to equally disperse potential confounding variables

https://step-prep.org


 +0  (step2ck_form8#32)
  • Systolic ejection murmur in the left sternal border consistent with pulmonic stenosis (as seen in Tetralogy of Fallot) and history of becoming cyanotic while crying also consistent with Tetralogy of Fallot
  • Key idea: Causes of early cyanosis from primary heart defects can be remembered with mnemonic 1, 2, 3, 4 and 5 because it can be caused by (1) persistent truncus arteriosus (1 vessel) (2) transposition of the great vessels (2 switched vessels) (3) Tricuspid atresia (Tri = 3) (4) Tetralogy of Fallot (Tetra = 4) (5) Total anomalous pulmonary venous return (5 letters in name)
  • Key idea: Early cyanosis does NOT mean that patient needs to have cyanosis at birth

https://step-prep.org


 +0  (step2ck_form8#31)
  • Middle aged patient with significant smoking history who is breathing with pursed lips (“pink puffer” of emphysema) and has diffuse wheezes in all lung fields, concerning for COPD
  • Aspiration of foreign body would only be acute, asthma would be episodic (not chronic progressive), bronchiectasis would be less likely to lead to diffuse lung changes and heart failure would lead to S4, elevated JVP, significant lower extremity edema, etc.

https://step-prep.org


 +1  (step2ck_form8#30)
  • Patient who has never received vaccination against hepatitis B is stuck with a needle by a patient with labs consistent with active hepatitis B infection, so patient should receive both hepatitis B vaccination series and hep B immune globulin
  • Infections that need to be treated with immunoglobulin: Dangerous infections To Be Healed Very Rapidly (Diphtheria, Tetanus, Botulism, Hepatitis B, Varicella, Rabies

https://step-prep.org


 +0  (step2ck_form8#28)
  • Young man who has been camping for 3 weeks who presents with encephalopathy, fever/chills, headache and maculopapular rash involving the palms and soles along with petechiae/purpura of the lower extremities, concerning for RMSF
  • Key idea: RMSF (along with many other tick-borne illnesses such as Ehrlichiosis, Anaplasmosis, etc.) leads to leukopenia and thrombocytopenia
  • Key idea: Infectious rash over the palms and soles can be remembered with mnemonic CaRS: Coxsackie A, Rickettsia Rickettsii, Syphilis

https://step-prep.org


 +0  (step2ck_form8#27)
  • Pregnant woman with no prenatal care presents with painless vaginal bleeding and a friable ulcer on the cervix, concerning for cervical cancer
  • Key idea: For the NBME exam, if a patient has no prenatal care, then they want you to assume that the patient does not consistently engage in care and likely does not get regular pap smears
  • Note: Fundal placenta excludes placenta previa as a cause (important cause to consider in setting of painless 3rd trimester vaginal bleeding)

https://step-prep.org

seagull  When I hear ulcer on the cervix while pregnant. I dont go jumping and claiming cancer. I think more was needed to clarify this question (as I say about all questions I miss - fml). Maybe a hx of abnormal pap smear or non hpv vaccine hx, something else. +1

 +0  (step2ck_form8#26)
  • Young man engaging in unprotected sex who presents with dysuria and scant urethral discharge
  • Key idea: If testing finds only chlamydia, then treat with only azithromycin
  • Key idea: If testing finds gonorrhea or you are treating empirically, then patient needs azithromycin + ceftriaxone

https://step-prep.org


 +0  (step2ck_form8#25)
  • Child with a family history of asthma who has presentation of cough-variant asthma (cough that is worse at night and with exercise), thereby leading to an obstructive pattern on PFTs (FEV1:FVC < 70% predicted, increased TLC)

https://step-prep.org


 +1  (step2ck_form8#24)
  • Organophosphates work by inhibiting acetylcholinesterase, thus leading to increased levels of acetylcholine that lead to overstimulation of parasympathetic functions and sweating (DUMBBELSS: Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm, Emesis, Lacrimation, Sweating, Salivation) by binding to Muscarinic receptors and lead to neuromuscular overstimulation and eventual blockade due to binding to nicotinic receptors

https://step-prep.org


 +0  (step2ck_form8#23)
  • Elderly woman with trouble driving at night due to vision impairments related to bright lights who also has yellowing of the lenses on physical exam, most consistent with cataracts
  • Risk factors for cataracts: Advanced age, diabetes, corticosteroid use, smoking, excessive alcohol use, excessive sunlight exposure, congenital disease (galactosemia, etc.)

https://step-prep.org


 +0  (step2ck_form8#22)
  • Elderly man with joint pain in his knees and DIP joints of the hand that are worsened by use, most consistent with osteoarthritis
  • Key idea: The two main diseases that affect the DIP joints of the hand (at least on NBME exams) are osteoarthritis and psoriatic arthritis

https://step-prep.org


 +0  (step2ck_form8#21)
  • Patient with small cell lung cancer develops hyponatremia = SIADH until proven otherwise (basically confirmed with a urine osmolality > 100 and urine sodium > 40)
  • Mild hyponatremia symptoms (sodium>120, lethargy/forgetfulness): Fluid restriction +/- salt tablets
  • Severe hyponatremia symptoms (sodium<120, seizures, coma): Hypertonic (3%) saline

https://step-prep.org


 +1  (step2ck_form8#20)
  • Patient with a pulsatile hematoma = damage to an arterial structure
  • Based on location at the base of the neck, the most likely vessel involved is the subclavian artery
  • Note: If the thoracic aorta were damaged, the patient would likely have more severe hemodynamic collapse due to the amount of bleeding that would be produced

https://step-prep.org


 +0  (step2ck_form8#19)
  • Adolescent with history of weight loss despite normal appetite presents with acute nausea, vomiting, abdominal pain, mental status changes and is found to be dry on physican exam with labs consistent with an anion-gap metabolic acidosis (135 – 101 – 14 = 20 > 12) with an elevated glucose, most consistent with diabetic ketoacidosis
  • DKA: Glucose 250-500, anion-gap metabolic acidosis, ketones in urine, GI symptoms predominate
  • Hyperosmolar hyperglycemic state: Glucose > 600, relatively normal acid-base status, no ketones in urine, altered mental status predominates

https://step-prep.org


 +0  (step2ck_form8#18)
  • Young patient with high-risk sexual behaviors presents with acute fever, sore throat, fatigue, tender/enlarged cervical lymph nodes, increased lymphocytes, and mildly increased LFTs with a negative rapid strep test, most consistent with infectious mononucleosis, which is caused by EBV > CMV

https://step-prep.org


 +0  (step2ck_form8#17)
  • Key idea: Fat embolism often develops 24 to 72 hours after inciting event (long-bone fracture, orthopedic surgery, etc.)
  • Key idea: Fat embolism is a clinical diagnosis tht leads to triad of (1) Respiratory distress (2) Neurologic dysfunction (3) Petechial rash (or thrombocytopenia)

https://step-prep.org


 +0  (step2ck_form8#16)
  • Positive predictive value: Of the positive test results, how many actually had the disease (dependent on disease prevalence)
  • Sensitivity: Of the patients with disease, how many had a positive test result (independent of disease prevalence)

https://step-prep.org


 +0  (step2ck_form8#15)
  • Young otherwise healthy woman with severe dermatomal (L5) back pain after heavy lifting that increases with Valsalva and straight-leg raising, most consistent with a lumbar radiculopathy
  • Key idea: Two main causes of back pain with a positive straight leg test are disc herniation and osteophyte (same pathophysiology with spinal root compression)

https://step-prep.org


 +0  (step2ck_form8#14)
  • 4 year old with an enlarged head circumference, signs of cerebellar dysfunction (ataxia, clumsiness, nystagmus, dysarthria) and upper motor neuron deficit of the bilateral lower extremities most concerning for medulloblastoma with drop metastases to the spinal cord
  • Key idea: Medulloblastoma arises in the cerebellar vermis and therefore leads to cerebellar dysfunction and can lead to “drop metastases” to the spinal cord through the CSF circulation

https://step-prep.org


 +0  (step2ck_form8#13)
  • Pellagra (niacin deficiency) commonly seen in patients with a corn-predominant diet and leads to Diarrhea, Dermatitis, Dementia and Glossitis

https://step-prep.org


 +0  (step2ck_form8#12)
  • Young man with significant trauma found to have signs of pelvic fracture (pelvic pain with crepitus/tenderness over the pubis, x-ray findings) found to have a large scrotal hematoma, concerning for a urethral injury
  • Key idea: Although classically a pelvic fracture would injure the membranous portion of the urethra (leading to a high-riding prostate and blood at the urethral meatus), it can also damage the bulbar (spongy) urethra and lead to blood accumulation in the scrotum and blood at urethral meatus
  • Key idea: Retrograde urethrogram is the first test to perform in patients with suspected urethral injury

https://step-prep.org


 +0  (step2ck_form8#11)
  • Patient with history of type 2 diabetes who has not been using medications presents with nausea/vomiting and confusion found to have a glucose level of 890 and a serum osmolality of 316, most consistent with Hyperosmolar hyperglycemic state
  • Key idea: Serum osmolality = (Na x 2) + (Glucose/18) + (BUN/2.6) + (Ethanol/4.6)
  • Key idea: The hyponatremia is secondary to the hyperosmolar state, and therefore is not the primary cause of confusion in this patient

https://step-prep.org


 +0  (step2ck_form8#10)
  • Young sexually active woman (high risk of UTI) who presents with systemic signs of inflammation (fever) and is found to have dysuria, unilateral back pain and severe CVA tenderness, most consistent with pyelonephritis
  • Key idea: 2 major causes of WBC casts/clumps include pyelonephritis and Interstitial nephritis (analgesic nephropathy)

https://step-prep.org


 +0  (step2ck_form8#9)
  • Middle-aged man with HIV presents with progressive pain and difficulty with bowel movements with a DRE showing a palpable mass in the anal canal with central ulceration most consistent with a squamous cell carcinoma
  • Key idea: HPV-related squamous cell carcinomas of the cervix, anus and penis are more commonly seen in HIV patients, which is why female patients with HIV should receive annual pap smears (rather than every 3-5 years)

https://step-prep.org


 +0  (step2ck_form8#8)
  • Signs/symptoms of neonatal lupus include congenital heart block, rash and thrombocytopenia
  • Key idea: Only occurs if lupus patient has antibodies against SSA and SSB

https://step-prep.org


 +0  (step2ck_form8#7)
  • Young woman presenting with neurological symptoms separated in time and space, including L’hermitte’s sign (electric-like sensation with neck flexion) and optic neuritis (unilateral painful vision changes/loss) with a brain MRI showing multifocal, ovoid subcortical white matter lesions in a periventricular distribution most consistent with multiple sclerosis
  • Key idea: Multiple sclerosis is treated chronically with immunosuppressants, but an acute MS flare (such as this patient) should be treated with glucocorticoids, interferon beta or plasmapheresis

https://step-prep.org

spiroskeet  This patient is currently asymptomatic, which is why treatment for her should be IFN-β (or glatiramer or natalizumab). If she still had symptoms of an acute MS exacerbation, treatment would consist of corticosteroids (i.e., dexamethasone/methylprednisolone). If symptoms persist in spite of steroids, she should undergo plasmapheresis. +2

 +0  (step2ck_form8#6)
  • Newborn with family history of cystic fibrosis who has presentation consistent with meconium ileus (failure to pass meconium, bilious vomiting, inspissated tar-like meconium, etc.), and therefore should be treated with pancreatic enzyme
  • Key idea: Cystic fibrosis leads to fat malabsorption because pancreatic enzymes have trouble reaching the GI tract, so patients can benefit from pancreatic enzyme

https://step-prep.org


 +0  (step2ck_form8#5)
  • Young patient on an OCP (leads to increased risk of clotting) with recent history of femur fracture and being bed-bound who presents with dyspnea, pleuritic chest pain, hypoxia and a new small pleural effusion most consistent with pulmonary embolism
  • Virchow’s triad for DVT/PE: (1) Hypercoagulability (2) Stasis (3) Endothelial injury

https://step-prep.org


 +0  (step2ck_form8#4)
  • Young man with a chronic history of Crohn disease who presents with symptoms of a small bowel obstruction (distention, abdominal pain, high-pitched bowel sounds, nausea/vomiting, obstipation and air-fluid levels on small intestine), most concerning for a small-bowel stricture
  • Key idea: Crohn disease leads to transmural inflammation, and can therefore lead to strictures, fistulas, etc.

https://step-prep.org


 +0  (step2ck_form8#3)
  • Young woman with unsafe sexual practices and IVDU presents with fever, generalized lymphadenopathy and a diffuse maculopapular rash involving the palms and soles, most consistent with syphilis
  • Key idea: First-line treatment for syphilis is intramuscular penicillin G, with an alternative being doxycycline in patients with severe penicillin allergy
  • Key idea: Pregnant women with penicillin allergy should undergo penicillin desensitization because they are not allowed to use doxycycline (risk of teeth and bone abnormalities in baby)

https://step-prep.org


 +0  (step2ck_form8#2)
  • Young previously healthy man with recent behavioral changes who presents with severe chest pain, signs of autonomic overactivity (tachycardia, hypertension, diaphoresis), rapid and pressured speech and ST-elevations on ECG, most consistent with substance-induced MI (most likely cocaine)
  • Key idea: In contrast to bipolar disorder (which can also lead to pressured speech, increased activity, etc.), substance-induced behavioral changes will also lead to pure physical manifestations of autonomic overactivity (hypertension, tachycardia, mydriasis, etc.)

https://step-prep.org


 +1  (step2ck_form8#1)
  • Young man presents with altered mental status found to have a severe anion-gap metabolic acidosis (142 – 102 – 12 = 28 > 12), with exogenous ingestion of an organic acid being the only answer that corresponds with this acid-base disturbance
  • Excessive loss of bicarbonate = Type 2 renal tubular acidosis (non-anion gap metabolic acidosis)

https://step-prep.org


 +1  (step2ck_form8#46)
  • Young man with recent URI presents with sharp substernal chest pain, fever and ECG with diffuse ST elevations and PR depressions most consistent with viral pericarditis which can be diagnosed with echocardiography because it is often complicated by pericardial effusion

https://step-prep.org


 +0  (step2ck_form8#45)
  • Key idea: Sunscreen not commonly used in infants under 6 months of age with best strategy to keep infants in the shade especially during the middle of the day and to use protective clothing

https://step-prep.org


 +1  (step2ck_form8#44)
  • Key idea: 2 most important risk factors for Alzheimer’s is (1) Increased age (2) Family history of early-onset dementia (often due to mutation in Amyloid precursor protein or presinilin-1/2)
  • Key idea: Early-onset Alzheimer’s defined by symptoms appearing age 65 or younger

https://step-prep.org


 +0  (step2ck_form8#43)
  • Patient with history of breast cancer presents with progressive shortness of breath with elevated JVP, hypotension, pulsus paradoxus (drop in BP by at least 10 mm Hg on inspiration), enlarged heart on CXR and decreased voltage on ECG, most consistent with cardiac tamponade (likely secondary to cancer recurrence and metastasis to the pericardium)

https://step-prep.org


 +0  (step2ck_form8#42)
  • Patient with type 1 diabetes (relative immunosuppression and increased risk of infection from use of needles for insulin administration) who presents with leg weakness and urinary retention in setting of fever, vertebral tenderness and leukocytosis, most consistent with epidural abscess pressing on the spinal cord
  • Key idea: In setting of low back pain, X-ray is indicated in setting of osteoporosis/compression fracture, ankylosing spondylitis or suspected malignancy
  • Key idea: In setting of low back pain, MRI is indicated in setting of sensory/motor deficits, cauda equina syndrome and suspected epidural abscess/infection

https://step-prep.org


 +0  (step2ck_form8#41)
  • Young obese woman with no alcohol history found to have dyslipidemia and mildly elevated LFTs most consistent with non-alcoholic steatohepatitis
  • Patients use of acetaminophen not sufficient to cause liver damage (more commonly leads to fulminant liver failure in patient with overdose), does not have other signs of hemochromatosis (bronze diabetes, cardiomyopathy, etc.), LFTs incompatible with primary biliary cirrhosis (would be cholestatic with direct hyperbilirubinemia and alk phos >> ALT/AST, and no signs of hepatitis on labs (negative HCV antibody and negative HB surface antigen)
  • Key idea: NASH has overtaken alcoholic steatohepatitis as most common cause of chronic liver disease and cirrhosis in certain countries

https://step-prep.org


 +0  (step2ck_form8#40)
  • Patient with risk factors for spastic bladder (MS) has presentation consistent with urgency incontinence (urge to void immediately with loss of urine before reaching the bathroom at times), which is caused by detrusor hyperactivity/instability
  • Stress incontinence: Loss of urine with cough or increased abdominal pressure, caused by urethral hypermobility or sphincter deficiency
  • Overflow incontinence: Incomplete emptying of bladder leading to leak with overfilling; patient would have increased postvoid residual

https://step-prep.org

tinydoc  But why is the answer not MS? Is it just because the way the question was worded asked what is the cause of the patients symptoms as opposed to what is the underlying cause? +1

 +0  (step2ck_form8#39)
  • Young healthy woman presenting with abdominal pain relieved by stools, with stool consistency being abnormal, all features of irritable bowel syndrome
  • Key idea: IBS is a diagnosis of exclusion that can lead to constipation and/or diarrhea and is often associated with (1) pain related to defecation (2) change in stool consistency (3) change in stool frequency

https://step-prep.org


 +0  (step2ck_form8#38)
  • Patient with small cell lung cancer (uniform, small round cells with dark nuclei), which is often initially treated with chemotherapy followed by radiation and/or surgery
  • Patient is young and has no signs of metastasis so palliative care isn’t appropriate, hormone therapy most used for breast cancer and prostate cancer, and surgical resection is NOT used in small cell lung cancer specifically (“the cells are too small for the surgeon to see!”)

https://step-prep.org

killuashi  initially treated with ...... and/or surgery .... surgical resection is NOT used. Very contradicting +

 +0  (step2ck_form8#37)
  • 72 year old patient with lung cancer presents with non-fatigable weakness affecting the eyes and proximal muscles (hip extensors, eyes), autonomic symptoms (dry mouth, constipation) and loss of deep tendon reflexes, most consistent with Lambert-Eaton syndrome (which can be diagnosed with repetitive nerve stimulation)
  • Myasthenia gravis: Associated with thymoma, oculobulbar weakness that worsens with repeated use
  • Lambert-eaton syndrome: Associated with small cell lung cancer, proximal muscle weakness that improves with repetitive use AND autonomic dysfunction and decreased/absent deep tendon reflexes

https://step-prep.org


 +0  (step2ck_form8#36)
  • In order for patient to be diagnosed with Tourette syndrome, they need to have both multiple motor tics (blinking, shoulder shrugging, sniffing, facial grimacing) and at least 1 vocal tic (grunting, snorting, throat clearing, yelling, obscenities) for at least 1 year

https://step-prep.org


 +0  (step2ck_form8#35)
  • Elderly patient with recent stroke leading to residual right hemiparesis presents with frequent urinary dribbling and filled bladder (palpable smooth mass in suprapubic area), most consistent with neurogenic bladder complicated by overflow incontinence
  • Note: Detrusor instability would lead to urgency incontinence and increased vesicourethral angle associated with stress incontinence

https://step-prep.org


 +1  (step2ck_form8#34)
  • Elderly woman with chronic COPD history presents with weight loss, progressive shortness of breath and light-headedness found to have JVD with RV heave and loud S2 (all components of pulmonary hypertension) and signs of congestive hepatopathy, all consistent with Group 3 pulmonary hypertension
  • Key idea: In most capillary beds of the body, decreased oxygen leads to vasodilation in order to facilitate more bloodflow to the area to maintain perfusion, but the lungs are the one exception in which decreased oxygen leads to constriction of blood vessels feeding that area so that blood is preferentially sent to well-oxygenated portions of the lung to minimize V/Q mismatch, but can lead to cor pulmonale in patients with COPD because their entire lungs are poorly oxygenated, leading to diffuse vasoconstriction and increased afterload on right ventricle

https://step-prep.org


 +0  (step2ck_form8#33)
  • 27 year old patient with hepatitis B (which shares many risk factors with HIV infection) presents with chronic weight loss and acute shortness of breath with cervical lymphadenopathy, white plaques in the mouth (most consistent with thrush), relatively low lymphocyte count and bilateral diffuse infiltrates on CXR most consistent with Pneumocystis pneumonia in setting of HIV/AIDs
  • Key idea: Patient with HIV is considered to have progressed to AIDS when their CD4 count drops below 200 or if they develop an AIDS-defining infection (such as PCP pneumonia)

https://step-prep.org


 +1  (step2ck_form8#32)
  • Young healthy man who presents with chest pain and ST-elevation in an anterior distribution after using crack cocaine, most consistent with cocaine-induced MI
  • Key idea: Cocaine induced MI treated the same way as atherosclerotic MI, except that beta blockers are not used (due to theoretical risk of unopposed alpha-agonism) and benzodiazepines are used
  • Key idea: Cocaine use is associated with myocardial infarction (due to spasm of the coronary arteries) and aortic dissection (due to increased blood pressure), but this presentation more consistent with pure MI because patient has normal BP in both arms (although this is commonly seen in aortic dissections in real life, test writers often will say blood pressures are unequal) and no tearing chest pain into the back

https://step-prep.org


 +0  (step2ck_form8#31)

Relative risk reduction = 1 – relative risk

= 1 – (.1/.2)

= 1 – 0.5

= 0.5

= 50%

https://step-prep.org


 +0  (step2ck_form8#30)
  • History of pins and needles in the hand that is especially bothersome at night and improve with shaking the hand are most consistent with carpal tunnel syndrome (compression of median nerve at the wrist)
  • Initially treated with wrist splinting, with patients with refractory patients receiving steroid injections or even surgery

https://step-prep.org


 +0  (step2ck_form8#29)
  • A patient who likely came to ED with altered mental status in the setting of benzodiazepine overdose is intubated and then becomes agitated, hypoxic, tachycardic and hypotensive most concerning for a tension pneumothorax
  • Key idea: Trauma and mechanical ventilation are two major risk factors for tension pneumothorax
  • Key idea: Ventilator would have high-pressure alarms in this setting because the machine is likely trying to push the same amount of air into the lungs even though the volume has been cut in half

https://step-prep.org


 +1  (step2ck_form8#28)
  • Elderly man with significant smoking history and occupational history of being a coal miner who presents with clubbing and hypoxia with bilateral upper lobe masses and areas of consolidation on chest x-ray most consistent with COPD and/or coal workers’ pneumoconiosis
  • Key idea: Of the common pneumoconioses, the majority affect the upper lobes (silicosis, coal workers’ lung, berylliosis) except for asbestosis (lower-lobe predominant)
  • Tuberculosis can also lead to upper lobe opacities, but it would more commonly lead to acute fever, night sweats and weight loss in a patient with exposure

https://step-prep.org


 +0  (step2ck_form8#27)
  • Middle-aged man with tearing back pain unresponsive to nitroglycerin but responsive to morphine and labetalol found to have severe upper extremity blood pressure with diminished lower extremity pulses, most consistent with an aortic dissection
  • Key idea: Aortic dissection can spread to involve the coronary arteries, leading to an MI (i.e. just because a patient has chest pain and ECG changes consistent with an MI does NOT exclude aortic dissection as a diagnosis)
  • Key idea: Beta-blockers are particularly useful in setting of aortic dissection because the force of blood being ejected from the LV and hitting the aorta can further propagate the tear, with beta blockers leading to reduced contractility and reduced force of blood ejection against the aorta

https://step-prep.org


 +0  (step2ck_form8#26)
  • Child with pain/itching of the year with pain upon manipulation of the tinna, most consistent with otitis externa
  • Otitis externa is most commonly treated with a topical antibiotic (ciprofloxacin drops)

https://step-prep.org


 +0  (step2ck_form8#25)
  • 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 +

 +0  (step2ck_form8#24)
  • Presentation consistent with Obsessive-compulsive disorder, with the patient having distressing obsessions (frequent thoughts of dog and parents being hurt) who copes with repeated compulsions (taps foot, turns lights on and off)
  • Key idea: First line treatment in OCD is SSRIs + CBT (exposure and response prevention); second-line treatments include SNRIs and clomipramine

https://step-prep.org


 +0  (step2ck_form8#23)
  • Patient with recent liver transplant presents weeks later with fever, eosinophilia (in a patient taking prednisone where we would otherwise expect low eosinophils), elevated LFTs and a biopsy showing a mononuclear infiltrate with eosinophils in the hepatic triads, consistent with allograft rejection
  • Key idea: Graft eosinophilia is a sensitive and specific marker of acute rejection in liver allografts (https://www.ncbi.nlm.nih.gov/pubmed/9724472)

https://step-prep.org


 +0  (step2ck_form8#22)
  • Atopic child (eczema, allergic rhinitis) who presents with severe respiratory distress, hypotension, edema of the face and hands and subglottic narrowing on AP x-ray, most consistent with anaphylactic shock
  • Although the history of respiratory distress and stridor in a patient without childhood vaccinations should raise concern for epiglottitis (in which case we would treat with intubation + antibiotics), this diagnosis would lead to sore throat, high fever and drooling and would not as commonly lead to hypotension and would not lead to edema of the face/hands or subglottic narrowing

https://step-prep.org


 +0  (step2ck_form8#21)
  • Key idea: The two most common murmurs heard in setting of Marfan syndrome include aortic regurgitation (early decrescendo diastolic murmur heard best at left/right upper sternal border) and mitral valve prolapse (mid-systolic click followed by mid-to-late systolic murmur of mitral regurgitation heard best at the apex)
  • Key idea: HOCM and MVP are the two murmurs that improve with increases in preload (increased preload leads to less obstruction in HOCM and later MVP murmur because the LV will be more stretched and the chordae tendinae will be more taut)

https://step-prep.org


 +0  (step2ck_form8#20)
  • Young otherwise healthy woman with short course of nausea and diarrhea has persistent indirect hyperbilirubinemia on exam with otherwise normal LFTs, most consistent with Gilbert’s syndrome (deficiency of serum glucuronosyltransferase such that you cannot efficiently conjugate bilirubin)
  • Key idea: Prevalence of Gilbert’s syndrome is ~5-10%

https://step-prep.org


 +0  (step2ck_form8#19)
  • 77-year old patient with a positive PPD skin test (>10 mm positive in patient living in a high-risk facility) who is asymptomatic most consistent with latent tuberculosis
  • Key idea: 3 treatment options for latent tuberculosis are (1) Isoniazid and rifapentine weekly for 3 months (2) Isoniazid for 6-9 months (3) Rifampin for 4 months
  • Key idea: Patients with diabetes, uremia, alcoholism, malnutrition, HIV, pregnancy or epilepsy should always be given pyridoxine (vitamin B6) along with isoniazid due to increased risk of B6-deficiency while on isoniazid
  • Key idea: PPD induration (NOT erythema) required for positivity depends upon patient risk factors with >5 mm being positive in patients with significant immunosuppression (HIV, organ transplant, immunosuppressant meds), recent contact with patient with active TB or patients with CXR findings consistent with TB // >10 mm being positive for patients from Tb endemic countries, IVDU, residents of high-risk settings (prisons, nursing homes, homeless shelters, etc.), children < 4 years old and patients working in mycobacterial labs // >15 mm in all patients

https://step-prep.org


 +1  (step2ck_form8#18)
  • Young man with history compatible with migraines (throbbing headaches associated with aura [nausea, vomiting, photophobia]) that are increasing in frequency and are refractory to abortive/acute treatments, making this patient a good candidate for prophylactic migraine medication
  • Key idea: Indications for migraine prophylactic medications include (1) Headaches > 4 times per month or long-lasting [>12 hours] (2) Disabling symptoms (missing work) (3) Refractory to abortive medications
  • Key idea: Potential prophylactic migraine medications include Topiramate, Valproate, Beta blockers (such as propranolol), calcium channel blockers or amitriptyline (TCA antidepressant)

https://step-prep.org


 +2  (step2ck_form8#17)
  • 16 year old girl with primary amenorrhea (girl without secondary sexual changes by 13 or menarche by 15), short stature, and concern for coarctation of the aorta (hypertension, upper extremity pulses > lower extremity pulses, systolic murmur), most consistent with Turner syndrome
  • Coarctation of the aorta needs to be worked up with an echocardiography and then operatively repaired

https://step-prep.org


 +2  (step2ck_form8#16)
  • Young patient with high-risk sexual behavior who presents with fever, malaise, maculopapular rash over the palms and soles and diffuse lymphadenopathy, which is most consistent with syphilis
  • Key idea: 3 major infectious causes of rash over the palms and soles can be remembered with CaRS (Coxsackie A, Rickettsia Rickettsii (Rocky Mountain Spotted Fever) and Syphilis)
  • Important to contrast syphilis and Rocky Mountain Spotted Fever, with syphilis more commonly leading to a maculopapular rash and diffuse lymphadenopathy (with epitrochlear lymphadenopathy basically being pathognomonic) and Rocky Mountain spotted fever commonly leading to a purpuric rash that spreads from the hands/feet to the trunk

https://step-prep.org


 +2  (step2ck_form8#15)
  • Middle-aged man with fever, lymphadenopathy and splenomegaly found to have elevated leukocyte count with increased eosinophils, myeloblasts, metamyelocytes and myelocytes most concerning for chronic myeloid leukemia
  • Key idea: Ways to differentiate between chronic myeloid leukemia and a leukemoid reaction include leukocyte alkaline phosphatase (LAP) levels (elevated in leukemoid reaction and decreased in CML), looking for basophilia (present in CML) and looking at the types of neutrophil precursors present (metamyelocytes > myelocytes in leukemoid reaction and metamyelocytes < myelocytes in CML)
  • Note: Metamyelocytes are more mature than myelocytes
  • Key idea: Can often tell they type of leukemia based on patient demographics with ALL seen in patients 0-14, AML seen in patients 15-60, CLL seen in patients 60+ and CML seen in patients 40-59

https://step-prep.org


 +1  (step2ck_form8#14)
  • Young male with excessive thirst and urination for 6 months who presents with seizures found to have hypo-osmolar hyponatremia, most consistent with psychogenic polydipsia
  • Key idea: This demographic is classically when signs/symptoms of schizophrenia develop, and patients with schizophrenia are at increased risk for psychogenic polydipsia
  • Key idea: If patient has hypo-osmolar hyponatremia and a urine osmolality < 100, then they almost certainly have psychogenic polydipsia or beer potomania

https://step-prep.org


 +0  (step2ck_form8#13)
  • Patient who has recently gone diving (which should be sounding off alarms about decompression sickness (AKA “The bends”)) who presents with weakness and neurologic symptoms concerning for decompression sickness
  • Key idea: Decompression sickness occurs when nitrogen dissolved in blood at high pressures of deep sea diving forms bubbles as pressure decreases due to rapid ascent to the surface and the bubbles lead to obstruction of blood vessels
  • Key idea: Potential symptoms of decompression sickness include signs similar to stroke (due to blood vessel blockage), flu-like symptoms, and swelling/pain in muscles and joints (remember association of decompression sickness with avascular necrosis of bone)

https://step-prep.org


 +0  (step2ck_form8#12)
  • Most common cause of unilateral, bloody breast discharge is intraductal papilloma
  • Key idea: Intraductal papilloma often does not have a mass on physical exam or mammography findings

https://step-prep.org


 +1  (step2ck_form8#11)
  • 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) +

 +0  (step2ck_form8#10)
  • Older man with atrial fibrillation who is not on prophylactic anticoagulation who presents with non-specific lethargy, hypotension, abdominal tenderness with guarding, increased WBC count and surgical findings of dark necrotic bowel, most consistent with an arterial embolus (most likely from the left atrial appendage in setting of atrial fibrillation)
  • Adhesions would lead to small bowel obstruction (pain, distention, obstipation), and C. difficile would lead to pseudomembrane image on NBME

https://step-prep.org


 +1  (step2ck_form8#9)
  • Young woman with a strong family history of cancer compatible with Lynch syndrome (colon cancer, endometrial cancer, ovarian cancer) who has developed irrregular, heavy vaginal bleeding concerning for possible endometrial cancer
  • Indications for endometrial biopsy include (1) Woman over 45 years old with abnormal uterine bleeding or postmenopausal bleeding (2) Woman under 45 with abnormal uterine bleeding with unopposed estrogen (PCOS, obesity), failed medical management or Lynch syndrome

https://step-prep.org


 +2  (step2ck_form8#8)
  • Current guidelines recommend cefazolin or cefuroxime administered within 60 minutes of skin incision as prophylaxis during hip or knee arthroplasty and should be discontinued within 24 hours
  • Key idea: Antibiotic prophylaxis to prevent surgical site infections are given in certain procedures, most commonly major/long surgeries

https://www.aafp.org/afp/2011/0301/p585.html

https://step-prep.org


 +1  (step2ck_form8#7)
  • All patients (HIV or not) should receive an annual influenza vaccine
  • Patients with HIV should receive Strep Pneumo PCV13 followed by the 23-valent PPSV23 8 weeks later and again in 5 years and at age 65
  • Based on patient’s serologies (negative Hep B surface antibody), he needs to be vaccinated against hepatitis B
  • Note: Patients are not given PCP prophylaxis until CD4 < 200 and T. gondii prophylaxis until CD4 < 100

https://step-prep.org


 +1  (step2ck_form8#6)
  • Young man who recently started treatment with haloperidol presents with rigidity, neck rigidity and oculogyric crisis (eyes displaced upwards) most consistent with acute dystonia
  • Key idea: Important to contrast with neuroleptic malignant syndrome, which would lead to constellation of symptoms remembered with Malignant FEVER (Myoglobinuria, Fever, Encephalopathy, Vitals unstable, increased CK Enzymes and Rigidity)
  • Key idea: 4 main extrapyramidal effects of antipsychotic use, especially with high potency antipsychotics such as haloperidol, are (1) Acute dystonia (2) Akathisia (3) Parkinsonism (4) Tardive dyskinesia

https://step-prep.org


 +0  (step2ck_form8#5)
  • Woman in her late 30s with previous pregnancies presents with progressive menstrual pain and a soft, diffusely enlarged uterus most consistent with adenomyosis (abnormal endometrial tissue within the uterine myometrium)
  • Key idea: Adenomyosis can lead to dysmenorrhea, heavy menstrual bleeding and chronic pelvic pain
  • Key idea: Risk factors for adenomyosis includes age > 40, multiparity and/or prior uterine surgery
  • Key idea: For the NBME exams, a diffusely enlarged uterus is either pregnancy or adenomyosis, whereas an enlarged irregular uterus is consistent with fibroids

https://step-prep.org/


 +1  (step2ck_form8#4)
  • Tricky, nuanced question because contraindication to patient receiving a lung resection is if their residual FEV1 will be less than 800 mL following the surgery

  • Normal FEV1 in a healthy woman is typically around 3 L, so in this patient is likely close to 750 mL since she has an FEV1 that is 25% of predicted; therefore, this patient would likely not be able to tolerate any sort of lung resection because she is already barely hanging on in terms of her ventilatory capabilities

  • Could also approach this question through process of elimination because ABG shows mild CO2 retention (seen in many COPD patients), ejection fraction cut-off for surgery often <35%, cardiac stress test was normal and patient has had DVTs for a long time

https://step-prep.org/

drdoom  very nice +

 +0  (step2ck_form8#3)

3 main types of lower extremity ulcers include (1) Neuropathic ulcers: Seen in diabetic patient, occur on the sole of the foot especially where lots of pressure is placed while walking (such as proximal to big toe) (2) Arterial ulcers: Patient with signs of peripheral vascular disease (claudication, shiny hairless legs) who has ulcer with necrosis often at tips of the toes (3) Venous ulcers: Often seen in patient with chronic lower extremity edema and leads to ulceration on the medial aspect of the leg

https://step-prep.org/


 +0  (step2ck_form8#1)
  • Patient with recent antibiotic usage develops severe diarrhea and abdominal pain, which is most consistent with C. difficile infection
  • Key idea: C. difficile leads to diarrhea by producing two main toxins that lead to enterocyte damage
  • Key idea: Toxic megacolon can be seen secondary to C. difficile infection and ulcerative colitis (at least for NBME purposes)

https://step-prep.org/

seagull  I choose sterilization because C-diff is essentially an imbalance of colonic flora due to antibiotic "sterilization" leading to expansion of C. Diff. However, I ca see how toxin- mediated is the true mechanism but the question seems dirty to me. +1
jd1  I think also technically sterilization refers to inactivating spores (as opposed to disinfection which would not), so would imply Cdiff would be killed off too +1

 +1  (step2ck_form8#2)

Contraindications to combined contraception includes:

  1. Women > 35 yo who smoke (which is case with this patient)
  2. Migraines with aura
  3. Hypercoagulable risk factors (<3 weeks postpartum, prolonged immobilization, history of DVT/PE, blood disorders [factor V leiden, etc.])
  4. Active breast cancer
  5. Liver disease (liver involved in metabolizing estrogen)

https://step-prep.org/





Subcomments ...

submitted by step_prep(48),
  • XX newborn with ambiguous genitalia and elevated 17-hydroxyprogesterone levels, most consistent with 21-hydroxylase
  • Key idea: Three main enzymes that can be deficient in adrenal cortex pathway include (1) 21-hydroxylase (increased testosterone, decreased cortisol, decreased mineralocorticoids) (2) 11-hydroxylase (increased testosterone, decreased cortisol, normal/increased mineralocorticoids because 11-deoxycorticosterone has mineralocorticoid activity (3) 17-hydroxylase (decreased testosterone, decreased cortisol, increased mineralocorticoids)

https://step-prep.org



submitted by step_prep(48),
  • Patient with an inflammed area of the distal radius with red streaks extending from the area towards the elbow, most consistent with lymphangitis
  • Key idea: Most common pathogens are MSSA and Group A strep, and therefore empiric treatment is cephalexin

https://step-prep.org



submitted by step_prep(48),
  • Organophosphates work by inhibiting acetylcholinesterase, thus leading to increased levels of acetylcholine that lead to overstimulation of parasympathetic functions and sweating (DUMBBELSS: Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm, Emesis, Lacrimation, Sweating, Salivation) by binding to Muscarinic receptors and lead to neuromuscular overstimulation and eventual blockade due to binding to nicotinic receptors

https://step-prep.org



submitted by step_prep(48),
  • Young male with excessive thirst and urination for 6 months who presents with seizures found to have hypo-osmolar hyponatremia, most consistent with psychogenic polydipsia
  • Key idea: This demographic is classically when signs/symptoms of schizophrenia develop, and patients with schizophrenia are at increased risk for psychogenic polydipsia
  • Key idea: If patient has hypo-osmolar hyponatremia and a urine osmolality < 100, then they almost certainly have psychogenic polydipsia or beer potomania

https://step-prep.org