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Welcome to step_prep2’s page.
Contributor score: 17

Comments ...

 +1  (step2ck_form8#16)
  • Middle-aged man with myasthenia gravis presenting with marked bilateral ptosis, progressive lethargy and decreased breath sounds (all of which point to a myasthenic crisis that would lead to respiratory insufficiency and CO2 retention), who has acid-base findings of acidemia with increased PCO2 and normal HCO3, consistent with an uncompensated respiratory acidosis
  • Key idea: If patient had chronic respiratory failure, HCO3 would be elevated because it would have had time to compensate over time

 +0  (step2ck_form8#15)
  • Middle-aged man with diabetes who presents with severe pain in the scrotum, fever, and confusion with bullae and crepitus over the scrotum/perineum and a leukocytosis and elevated glucose concentration, most consistent with Fournier gangrene
  • Key idea: Fournier gangrene is a form of life-threatening necrotizing fasciitis of the perineum/scrotum most commonly seen in patients with obesity or diabetes mellitus who require urgent surgical intervention (should NOT be delayed for imaging)

 +0  (step2ck_form8#14)
  • Child with refusal to bear weight, fever, leukocytosis and increased ESR, consistent with septic arthritis
  • Septic arthritis: Leads to fever, ill-appearance, leukocytosis, failure to bear weight, synovial fluid WBC > 50,000 with positive gram stain and culture, treated with draining joint space + antibiotics
  • Transient synovitis: Patient will be afebrile, well-appearing between 2-6 years old, often had a previous viral URI, ability to bear weight, normal ESR, WBC count and synovial fluid analysis, condition is self-limited

 +0  (step2ck_form8#13)
  • Middle-aged woman who presents with a vesicular, dermatomal rash with severe burning over the area, most consistent with herpes zoster
  • Key idea: Oral and IV acyclovir are equally effective in treating herpes zoster, so in this patient who does is going to be treated as an outpatient we would use oral acyclovir

 +0  (step2ck_form8#12)
  • Patient has classic presentation of a perimenopausal woman (menses become irregular, vaginal dryness, ~52 years of age)
  • Key idea: Perimenopausal woman can sometimes be treated with hormonal contraceptives to manage irregular bleeding, but this patient is over 35 and an active smoker, which is a contraindication to estrogen-containing OCPs
  • Key idea: Patient would be candidate for topical vaginal estrogen therapy (which does not carry same risks as systemic estrogen therapy)
  • Red flags requiring further work-up: Abnormal uterine bleeding (bleeding between periods, prolonged periods, or heavier bleeding during periods), especially in a patient with risk factors (obesity, PCOS, unopposed estrogen, etc.)

 +0  (step2ck_form8#11)
  • Patient with bilateral tubal ligation, which can increase risk of ectopic pregnancy (because if patient does inadvertently become pregnant, very high risk of ectopic pregnancy because tube is blocked)
  • Key idea: An estimated 1 in 200 patients will become pregnant after receiving tubal ligation, and patients who have had a tubal ligation and become pregnant are at increased risk of ectopic pregnancy compared to woman who have not had a tubal ligation and become pregnant

 +0  (step2ck_form8#10)
  • Young child who had strep throat 2 weeks ago who presents with periorbital edema, gross hematuria, proteinuria and RBC casts (consistent with glomerulonephritis), most consistent with post-strep glomerulonephritis
  • Both IgA and PSGN can lead to gross hematuria associated with an upper URI, with differences being (1) Acute PSGN: Seen 2-4 weeks after infection of pharynx or skin, Seen in children (often age 6-10), leads to low complement levels, patient will have subepithelial immune complex humps (2) IgA nephropathy: Seen concurrently with respiratory or GI infection, more common in young adult men (age 20-30), complement levels unaffected, patient will have IgA-based deposits in mesangium
  • Key idea: Treating strep throat will reduce risk of rheumatic fever, but does not reduce risk of post-strep glomerulonephritis

 +0  (step2ck_form8#9)
  • Baby born with excessive skin on back of neck, swelling of hands/feet and heart murmur which are classically seen in patients with Turner syndrome
  • Key idea: Noonan syndrome is basically the male version of Turner syndrome (although Noonan can also be seen in a female patient)

 +0  (step2ck_form8#8)
  • Young man with ulcerative colitis who presents with fatigue, dark urine, mild jaundice, with a cholestatic pattern on LFTs (alk phos > ALT/AST), most consistent with primary sclerosing cholangitis
  • Primary sclerosing cholangitis: Classically seen in middle-aged men with ulcerative colitis, leads to beading of intra and extra-hepatic bile ducts on ERCP/MRCP, who has positive p-ANCA and elevated IgM
  • Primary biliary cholangitis: Classically seen in a middle-aged woman with other autoimmune diseases who has granulomas with lymphocytic infiltrate on biopsy, positive anti-mitochondrial antibody and elevated IgM

 +0  (step2ck_form8#7)
  • Middle aged man recently started on anticoagulation who presents with progressive abdominal pain found to have a tender, mass next to the umbilicus, most consistent with a rectus sheath hematoma
  • Key idea: Often leads to anemia and leukocytosis
  • Key idea: Risk factors in addition to anticoagulation is abdominal trauma or forceful abdominal contractions (coughing, sneezing, etc.)

 +0  (step2ck_form8#6)
  • Pregnant woman with history of 2 C-sections currently in her 3rd trimester presents with painless vaginal bleeding found to have a placenta previa
  • Key idea: Placenta accreta occurs in up to 15% of cases of placenta previa, with both conditions having previous C-section as the major risk factor

 +0  (step2ck_form8#5)
  • Risk factors for placental abruption: Maternal hypertension, Maternal pre-eclampsia/eclampsia, prior placental abruption, cocaine use, tobacco use, abdominal trauma
  • Note: Maternal hypertension and pre-eclampsia also associated with increased risk of gestational diabetes
  • Maternal hypertension more likely to lead to oligohydramnios and small for gestational age baby (due to poor placental perfusion)
  • Risk factor for placenta previa includes previous placenta previa, previous c-section or uterine surgery

 +0  (step2ck_form8#4)
  • Middle-aged man with severe symptomatic hypertension with left abdominal bruit, most concerning for renal artery stenosis
  • Most common causes of renal artery stenosis include atherosclerosis, fibromuscular dysplasia and polyarteritis nodosa
  • Gold standard for renal artery stenosis is invasive angiography, whereas screening typically done with duplex ultrasound

seagull  This test likes renovascular HTN for some reason. This is like the 3rd or 4 question about it. +1

 +0  (step2ck_form8#3)
  • Patient taking lithium (which is known to cause nephrogenic diabetes insipidus) who has developed polydipsia and polyuria who on water deprivation test is found to have very minimal increase in urine osmolality, most consistent with diabetes insipidus
  • Key idea: To formally differentiate between nephrogenic and central diabetes insipidus, you would give patient desmopressin (increased urine osmolality = central DI // No change in urine osmolality = nephrogenic DI), but in this case the history with lithium is suggestive of nephrogenic
  • Nephrogenic diabetes insipidus: Hereditary, hyperkalcemia, hypokalemia, lithium, demeclocycline
  • Central diabetes insipidus: Pituitary damage (tumor, autoimmune, trauma, surgery, ischemic encephalopathy)

 +0  (step2ck_form8#2)
  • Older patient with BPH with signs of an AKI (creatinine increase of at least 0.3) who also has suprapubic distention/tenderness, consistent with post-renal AKI in setting of urinary retention
  • Diabetic nephropathy can lead to chronic kidney disease over time, but it wouldn’t develop as quickly as seen in this patient

 +1  (step2ck_form8#1)
  • Patient with signs of major depressive disorder (too severe of a presentation for simple adjustment disorder), who should be treated with an anti-depressant, with Bupropion being the only antidepressant listed
  • First-line antidepressants: SSRIs, SNRIs, Bupropion, Mirtazapine
  • Benefits of bupropion: Mild stimulant effects, patient with comorbid cigarette use, helps patients with weight loss, favorable sexual side effect profile

 +0  (step2ck_form8#46)
  • Key idea: Increasing the sample size in a research study leads to a higher powered study
  • Other than sample size, the other aspects of the study are sound (randomization, exposure vs. control, etc.)

 +0  (step2ck_form8#45)
  • 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

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? +

 +0  (step2ck_form8#44)
  • Key idea: For the NBME exam communication questions, the most open-ended and patient-centered response is often correct

 +0  (step2ck_form8#43)
  • Child with atraumatic, progressive, bilateral knee pain with elevated ESR and otherwise normal exam/labs, most concerning for initial presentation of systemic juvenile idiopathic arthritis
  • Along with many other causes of autoimmune disease, SJIA is associated with anterior uveitis
  • Key idea: Classic NBME presentation is a patient with daily spiking fevers associated with a transient pink macular rash, along with signs of inflammation of labs (leukocytosis, anemia, thrombocytosis, increased ESR/CRP)

ht3  mannn this bitch had no fever NOR rash smh +

 +0  (step2ck_form8#42)
  • Presentation most consistent with osteoarthritis because the woman is heavy, the stiffness resolves quickly upon waking, the joint pain is asymmetric and, most importantly, it involves the DIP joints of the hand. The only two diseases that will involve the DIP joints are osteoarthritis and psoriatic arthritis. It is weird that it gets better as the day progresses, but the overall picture is most consistent with OA
  • Key idea: Osteoarthritis characterized by osteophytes, joint space narrowing, subchondral sclerosis and cysts

dlw  Also, Q stem specifically states most likely to find on imaging of her KNEES, not her hands. The hands improve with movement but the knees worsen on walking. +

 +0  (step2ck_form8#41)
  • Patient who had normal hearing up until 3 years ago who has had potential barotrauma (snorkeling-related ear pain) and loud noises who has loss of high-frequency noises, most consistent with noise-related hearing loss
  • Key idea: Elderly patients who have had chronic exposure to noise will first lose high-frequency sounds (bilateral, symmetric sensorineural hearing loss), with young patients with increased exposure to loud noises being able to lose the high-frequency sounds due to destruction of hair cells at the cochlear base

 +1  (step2ck_form8#40)
  • 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)

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

 +0  (step2ck_form8#39)
  • Young woman with previously regular menses presents with a late menstrual period, RLQ abdominal pain with adnexal tenderness, and elevated beta-hCG with a complex adnexal mass on ultrasound, most consistent with uncomplicated ectopic pregnancy
  • Uncomplicated ectopic pregnancy (no hemodynamic instability or signs of rupture): Methotrexate
  • Complicated ectopic pregnancy (hemodynamic instability or signs of rupture): Urgent surgical exploration

 +0  (step2ck_form8#38)
  • Patient with type 1 diabetes who presents with fever, headache and facial swelling with mild ketoacidosis and sinus pathology on CT scan, most concerning for Mucor infection
  • Key idea: Mucormycosis is most commonly seen in ketoacidotic diabetic patients and/or neutropenic patients
  • Key idea: Diagnosis requires biopsy and culture of the sinus mucosa because Aspergillus can less commonly lead to a similar presentation

 +0  (step2ck_form8#37)
  • Key idea: All patients should receive an annual flu vaccine
  • Patients should get a Tdap vaccine as an adult and then a Td booster every 10 years
  • All patients should get pneumococcal vaccines (PCV13 + PPSV23) at age 65, with patients under 65 with relative immunodeficiency or increased risk getting a PPSV23 (chronic heart, lung or liver disease; diabetes; current smokers; alcoholics) and patients under 65 with very high risk getting PCV13 + PPSV23 (CSF leak, sickle cell disease, asplenia, cochlear implants, HIV, chronic kidney disease, organ transplant, etc.)

 +0  (step2ck_form8#36)
  • Young man with signs of hyperthyroidism (palpitations, heat intolerance, decreased TSH, increased T3/T4) who has a tender thyroid (consistent with de Quervain thyroiditis) and also has decreased iodine uptake into thyroid gland (consistent with thyroiditis, where preformed thyroid hormone is released but thyroid gland is not over-producing thyroid hormone)
  • The diagnostic algorithm outlined below is high-yield for NBME exams!

 +1  (step2ck_form8#35)
  • Key idea: Risk factors for asthma include (1) Family history of atopy (2) Environmental exposures (second-hand smoke, pollution, etc.)

thajoker  So to be clear, Family history is the number one risk factor, all the other exposures are secondary risk factors? +

 +0  (step2ck_form8#34)
  • Elderly patient with significant sun exposure (landscaper, farmer, etc.) with an ulcerated, shiny lesion on their chest most consistent with a squamous cell carcinoma or basal cell carcinoma
  • Key idea: Concerning skin lesions should be fully excised with ~3 mm margins unless the lesion is very large or in a location where complete excision may be problematic (ear, face, etc.)

 +1  (step2ck_form8#33)
  • Most common cause of post-delivery bleeding is uterine atony (especially in setting of prolonged, difficult delivery), but the uterine fundus would be described as soft and boggy rather than firm; therefore the next most common cause given that the placenta has been delivered would be trauma (especially with difficult delivery)
  • Causes of post-delivery bleeding is 4 T’s: (1) aTony (most common) (2) Trauma (3) Thrombin (coagulopathy) (4) Tissue (retained placenta, etc.)

 +1  (step2ck_form8#32)
  • Normally the kidneys can handle phosphorous, but in setting of renal failure they cannot and it can lead to build-up of phosphorous that can lead to a variety of deleterious effects, such as metastatic calcification (which can increase risk of stroke, heart attack, etc.) and weak bones (because phosphorous pulls calcium out of bones); these complications are particularly important for kids because they progress chronically over time

 +0  (step2ck_form8#31)
  • 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

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. +

 +0  (step2ck_form8#30)
  • Diagnosis requires 2 out of 3 of the following criteria: (1) Clinical and/or biochemical hyperandrogenism (2) Oligomenorrhea (3) Polycystic ovaries on pelvic ultrasound /// Our patient has clinical hyperandrogenism (coarse hair over body) and oligomenorrhea (irregular menses)
  • Key idea: Although often associated with insulin resistance and ultimately associated with development of Type 2 diabetes, insulin resistance is not formally included in diagnostic criteria

 +0  (step2ck_form8#29)
  • Middle-aged man with signs of hypogonadism, diabetes (polydipsia, polyuria, weight loss, elevated glucose, glucosuria), cirrhosis without alcohol use history (spinder angiomata, increased bilirubin, decreased albumin, mildly elevated LFTs), and bronzing of the skin, most consistent with hemochromatosis
  • Mallory bodies is most consistent with alcoholic hepatitis

 +0  (step2ck_form8#28)
  • Elderly patient with history consistent with claudication (cramping pain in calf relieved with rest), which is best worked up with ankle-brachial index (better than arteriography for initial work-up because arteriography is much more invasive)
  • Key idea: ABI < 0.90 is abnormal
  • Claudication: Patient will have risk factors for peripheral vascular disease (diabetes, HTN, smoking, etc.), reduced lower extremity pulses, reduced lower extremity temperature, pain classically in the calves, reduced hair on legs
  • Pseudo-claudication (spinal stenosis): Positional (improves with flexion), classically affects buttocks and thighs, may be associated with back pain

 +0  (step2ck_form8#27)
  • On NBME exams, exophthalmos should always make you think of Graves disease (especially in the right demographic of a young or middle-aged woman)
  • Key idea: All causes of hyperthyroidism can lead to lid lag and lid retraction secondary to sympathetic activation of the superior tarsal muscle, but Graves specifically leads to exophthalmos and impaired extra-ocular motion due to glycosaminoglycan deposition behind the eyes

 +2  (step2ck_form8#26)
  • Middle-aged patient with smoking history who has developed tenderness, induration, erythema and thickening in a linear distribution on the extremities, most consistent with superficial thrombophlebitis in the setting of pancreatic cancer
  • Key idea: Pancreatic cancer patient will almost always be a smoker in NBME question stem and unique signs/symptoms associated with pancreatic cancer include (1) Back pain + weight loss (2) Migratory thrombophlebitis (Trousseau syndrome) (3) Obstructive jaundice with palpable, non-tender gallbladder (Courvoisier sign) (4) Diabetes in a patient without other risk factors (older patient who is losing weight but develops diabetes)
  • Lymphangitis would also lead to streaks, but would be less likely to lead to thickening/induration and more likely to lead to fever/chills
  • Varicose veins can be sensitive, but are not often tender or erythematous

 +0  (step2ck_form8#25)
  • Elderly patient with significant smoking history who presents with cachexia (secondary to decreased appetite), decreased interest in smoking, abnormal mental status examination, slow speech, and cognitive dysfunction concerning for lung cancer vs. major depressive disorder, but patient has a normal chest x-ray which is more consistent with major depressive disorder and therefore patient should have suicide risk assessment (performed in all patients with depression)
  • Key idea: Major depression leads to at least 5 of the depressed mood + SIGECAPS symptoms for at least 2 weeks

 +0  (step2ck_form8#24)
  • Obese adolescent who presents with atraumatic, afebrile groin pain and a limp with decreased range of motion and imaging showing displacement of the femoral head from the growth plate, most consistent with a slipped capital femoral epiphysis (SCFE) which is treated with pin fixation to avoid avascular necrosis
  • Key idea: Hip problems (osteoarthritis, avascular necrosis of the femoral head, etc.) often lead to groin symptoms
  • 2 common causes of avascular necrosis in child: (1) Legg-Calve Perthes disease: Commonly seen in males between 5-7 years old, X-ray often NORMAL, Idiopathic (2) SCFE: Commonly seen in obese ~12 year old child, Diagnosed via abnormal x-ray, Caused by epiphysis displacing relative to femoral neck and needs to be corrected surgically

 +0  (step2ck_form8#23)
  • Infant with sickle cell disease presenting with sepsis (fever, clear rhinorrhea, lymphocytosis), which is most likely caused by Strep pneumo and can be effectively treated with ceftriaxone
  • Key idea: Sickle cell disease leads to functional asplenia, which leads to increased risk of encapsulated infections (SHiN: Strep pneumo, Haemophilus influenzae, Neisseria meningitidus)
  • Key idea: Although daily penicillin prophylaxis decreases the risk of Strep Pneumo infection, it does not completely eliminate the risk

seagull  I would make a different argument. Because the infant is covered by Penicillin the pneumonia is likely gram negative. We don't have imaging to see the lung parenchyma but I would like to cover pseudomonas (ceftriaxone has partial coverage). Lastly, Ciprofloxacin given orally isn't likely to be done for inaptient (it would need to be an IV medication here). Also Cipro isn't a respiratory floroquinolone unlike moxifloxacin, gemifloxacin and levofloxacin. +1
spiroskeet  Also, fluoroquinolones are contraindicated in children (tendinopathy) +

 +0  (step2ck_form8#22)
  • Key idea: When we set alpha value to 5%, we are saying that there is a 5% chance of committing a type 1 error, which is where NO difference exists between the two treatments/groups/etc. but we do detect a difference (basically the chance that we detect a difference when one does not exist)

 +0  (step2ck_form8#21)
  • Young patient with a father who developed a tic and committed suicide in middle-age who presents with progressive facial grimacing and signs of dementia, most consistent with Huntington disease (which is due to atrophy of the caudate nucleus)
  • Key idea: Huntington disease leads to triad of (1) Chorea (2) Dementia (3) Depression (and other psychosocial issues such as psychosis)
  • Atrophy of substantia nigra = Parkinson’s disease

 +0  (step2ck_form8#20)
  • 32 year old man with nasal polyps, chronic cough that is progressive with copious sputum production who has clubbing and obstructive PFT findings (FEV1:FVC ratio < 70%) found to have Pseudomonas aeruginosa colonization most consistent with bronchiectasis in the setting of cystic fibrosis
  • Key idea: Bronchiectasis and chronic bronchitis (type of COPD) are two conditions most known for copious sputum production
  • Potential etiologies of bronchiectasis: (1) Congenital: Cystic fibrosis, Kartagener’s (2) Chronic/prior infection: Aspergillosis, mycobacteria (3) Rheumatic disease: Rheumatoid arthritis, Sjogren’s (4) Immunodeficiency: Hypogammaglobulinemia (5) Airway obstruction: Cancer
  • Key idea: Bronchiectasis should be worked up with CF testing, PFTs, sputum culture, immunoglobulin levels and high-resolution CT of the chest

 +0  (step2ck_form8#19)
  • Key idea: Patient has Tanner Stage 2 genitalia (testicular enlargement) and therefore does not meet criteria for pubertal delay and is within normal limits for pubertal development
  • Pubertal delay in boys: Lack of testicular enlargement (Tanner stage 2) by age 14
  • Pubertal delays in girls: Lack of breast development by 13 or lack of menarche by 15

 +0  (step2ck_form8#18)
  • Key idea: Caves and Ohio are both buzzwords for Histoplasmosis
  • Key idea: Chest x-ray with bilateral lymphadenopathy and calcified nodules can be seen in tuberculosis, endemic mycoses (histo, blasto, cocci) and sarcoidosis

 +0  (step2ck_form8#17)
  • Key idea: Kawasaki disease characterized by fever of at least 5 days with at least 4/5 of the CRASH: Conjunctivitis, Rash, cervical Adenopathy, Strawberry tongue, Hand and foot edema
  • Key idea: Kawasaki disease treated with IVIG + high-dose aspirin (only time aspirin is given to children)

 +0  (step2ck_form8#16)
  • Young otherwise healthy woman with episodic headaches, palpitations, and sweating found to have severely elevated blood pressure, most consistent with a pheochromocytoma (tumor of adrenal medulla leading to increased catecholamine production)
  • Key idea: Classically leads to episodes of the 5 P’s: elevated blood Pressure, Painful headache, Perspiration, Palpitations and Pallor

 +0  (step2ck_form8#15)
  • Young woman with difficulty swallowing and oropharyngeal dysphagia found to have classic “bird-beak” barium swallow finding of achalasia

 +0  (step2ck_form8#14)
  • Elderly woman with history of cerebral infarction who has aphasia and loss of gag reflex who presents with respiratory distress found to have RLL consolidation, most consistent with aspiration pneumonia
  • Key idea: Aspiration pneumonia caused by anaerobic organisms (because our mouth and GI tract has anaerobes), so patient is often treated with clindamycin which has good anaerobic coverage (other potential options are metronidazole or amoxicillin + clavulanate)

 +0  (step2ck_form8#13)
  • Elderly man with known squamous cell carcinoma who presents with elevated calcium and otherwise normal labs, most consistent with PTHrP production
  • Key idea: Squamous cell carcinoma, breast cancer, renal cell carcinoma, ovarian cancer and bladder cancer are known for producing PTH-related peptide, which has the same effects as PTH (increased calcium, decreased phosphate)
  • Key idea: If answer was metastases to bone (commonly seen in breast cancer, multiple myeloma, prostate cancer) then patient would have back pain and/or imaging with osteolytic changes
  • Key idea: Lymphoma leads to hypercalcemia by leading to increased vitamin D levels

 +0  (step2ck_form8#12)
  • Key idea: Anesthetic that is accidentally injected into the blood stream can lead to systemic signs/symptoms (tingling, numbness, tinnitus, metallic taste, tachycardia, hypertension, etc.)

 +0  (step2ck_form8#11)
  • Adolescent in a traumatic accident who presents with severe epigastric tenderness, nausea, vomiting, hypotension and tachycardia, normal abdominal ultrasound and normal LFTs, most consistent with duodenal hematoma > traumatic pancreatitis; in either case, the best next step would be CT scan of the abdomen
  • Key idea: CT scan is better than ultrasound in setting of pancreatitis, especially when etiology is not gallstones
  • Key idea: Morphine and other opioids (except meperidine) can lead to sphincter of Oddi dysfunction, which can further increase risk for pancreatitis

 +1  (step2ck_form8#10)
  • Elderly woman who presents after an episode of amaurosis fugax (painless transient monocular vision loss caused by a small embolus in the ophthalmic artery) with hollenhorst plaques and an area of ischemia in the optic disc
  • Key idea: Amaurosis fugax is highly associated with carotid artery stenosis with resulting embolization, so patients should be worked up with a carotid artery ultrasound

 +0  (step2ck_form8#9)
  • Young woman with type 1 diabetes who has recent recreational water exposure who presents with a severe form of otitis externa (fever, ill-appearing), most consistent with necrotizing otitis externa
  • Key idea: Necrotizing otitis externa often seen in patients with diabetes mellitus and should be treated with intravenous antipseudomonal antibiotics and surgical debridement if antibiotics are unsuccessful
  • Key idea: In an NBME stem, if it says that there is purulent fluid in the ear canal and that the tympanic membrane cannot be visualized, that tells you that the insult is in the ear canal

 +0  (step2ck_form8#8)
  • Patient with chronic history of hallucinations, delusions, agitation most consistent with schizophrenia
  • Key idea: Schizophrenia due to increased dopamine in the mesolimbic and mesocortical tracts, whereas Parkinson’s is due to decreased dopamine in the nigrostriatal pathway

 +0  (step2ck_form8#7)
  • Patient with history of influenza-like illness ~1 month ago who presents with acute dyspnea, fatigue, light-headedness, ECG changes and echo showing hypokinesis with normal valves, most consistent with a postviral myocarditis
  • Key idea: On NBME exams, if a young patient presents with signs of cardiogenic shock without trauma, a common cause is myocarditis
  • Acute constrictive pericarditis would be seen in patient with radiation to the chest, open heart surgery or some other insult that would lead to fibrosis of the pericardium

Subcomments ...

submitted by step_prep2(17),
  • Young man with signs of hyperthyroidism (palpitations, heat intolerance, decreased TSH, increased T3/T4) who has a tender thyroid (consistent with de Quervain thyroiditis) and also has decreased iodine uptake into thyroid gland (consistent with thyroiditis, where preformed thyroid hormone is released but thyroid gland is not over-producing thyroid hormone)
  • The diagnostic algorithm outlined below is high-yield for NBME exams!

submitted by step_prep2(17),
  • Obese adolescent who presents with atraumatic, afebrile groin pain and a limp with decreased range of motion and imaging showing displacement of the femoral head from the growth plate, most consistent with a slipped capital femoral epiphysis (SCFE) which is treated with pin fixation to avoid avascular necrosis
  • Key idea: Hip problems (osteoarthritis, avascular necrosis of the femoral head, etc.) often lead to groin symptoms
  • 2 common causes of avascular necrosis in child: (1) Legg-Calve Perthes disease: Commonly seen in males between 5-7 years old, X-ray often NORMAL, Idiopathic (2) SCFE: Commonly seen in obese ~12 year old child, Diagnosed via abnormal x-ray, Caused by epiphysis displacing relative to femoral neck and needs to be corrected surgically