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Comments ...

 +0  (step2ck_form8#42)
  • Obese middle-aged patient with daytime fatigue and a likely reactive polycythemia (chronic hypoxia –> increased EPO production –> increased Hgb/Hct) in the setting of obstructive sleep apnea +/- obesity hypoventilation syndrome
  • Obstructive sleep apnea requires polysomnography for formal evaluation

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


 +1  (step2ck_form8#41)
  • Young woman with a nontender thyroid mass/nodule that is 2 cm in size, requiring fine needle aspiration biopsy
  • Key idea: All thyroid nodules should be worked up with a TSH and thyroid ultrasound, with thyroid nodules greater than 2 cm in diameter or thyroid nodules greater than 1 cm with high-risk sonographic features (irregular markings, microcalcifications, etc.) should undergo fine needle aspiration biopsy
  • Key idea: The thyroid gland is highly vascular, which is why you would always use a fine-needle aspiration biopsy for evaluation
  • Key idea: Mass in the neck that moves with swallowing = Thyroid or thyroglossal duct cyst
  • Key idea: Hypofunctional or “cold” thyroid nodule has a higher risk of malignancy as compared to a hyperfunctional “hot” thyroid nodule

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

ht3  sooo you're saying to get TSH first...so why would the answer not be thyroid function tests..? +2
nbmesuxugh  I thought that too but the question is asking to establish the diagnosis not the next best step! just be careful on test because I have seen tricky questions like that +2

 +0  (step2ck_form8#40)
  • A previously healthy young man with recent life stressors who presents with sudden onset of blindness in one eye with a completely normal physical exam (including tests demonstrating that he can in fact see out of that eye), most consistent with conversion disorder
  • Testing will often involve a neurologist and psychiatrist

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


 +0  (step2ck_form8#39)
  • Middle-aged man found to have elevated blood pressure for the first time, and therefore should be initially managed with a trial of lifestyle modifications

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 +0  (step2ck_form8#38)
  • Previously healthy young woman who presents with heavy menstrual bleeding and easy bruisability found to have thrombocytopenia with bone marrow aspirate showing increased number of megakaryocytes, with platelet count responsive to prednisone, most consistent with idiopathic thrombocytopenia
  • Key idea: Immune thrombocytopenia caused by platelet antibodies and is often associated with a preceding viral infection
  • Impaired platelet production = Aplastic anemia = Pancytopenia

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


 +0  (step2ck_form8#37)
  • Thymus is normal in children < 3 years of age and commonly leads to “sail sign” due to triangular shape

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


 +2  (step2ck_form8#36)
  • Key idea: Ingestion of household bleach is often considered a benign ingestion, whereas ingestion of industrial-grade bleach is very severe/morbid

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


 +0  (step2ck_form8#35)
  • Key idea: Most common causes of elevated AFP in a pregnant patient are under-estimation of gestational age, fetal demise, multiple gestations, ventral wall defects, neural tube defects and liver disease
  • Key idea: Next step in management of elevated AFP is ultrasound to assess gestational age, viability, number of pregnancies, and assess for defects

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


 +0  (step2ck_form8#34)
  • Newborn who has trouble swallowing and handling secretions, most consistent with a suspected tracheoesophageal fistula which can be tested by passing an NG tube

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 +0  (step2ck_form8#33)
  • Signs of zinc deficiency: Alopecia, dermatitis, scaly skin around mouth/eyes, abnormal taste, impaired wound healing
  • Signs of copper deficiency: Hematologic abnormalities (microcytic anemia, leukopenia) and myeloneuropathy
  • Iron deficiency: Microcytic anemia

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

bobson150  Not to mention this is Wilson's disease... this guy should have tons of copper lying around +1

 +0  (step2ck_form8#32)
  • Modifiable risk factors for osteoporosis: Excessive alcohol intake, sedentary lifestyle, smoking
  • Non-modifiable risk factors for osteoporosis: Advanced age, postmenopausal woman, low body weight

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


 +0  (step2ck_form8#31)
  • Elderly nursing home patient presents with altered mental status, fever, hypotension, warm extremities and a positive urinalysis (pyuria if >10 WBC/hpf), most consistent with urosepsis (infection leading to peripheral vasodilation and distributive shock)
  • Key idea: Distributive shock (anaphylaxis, sepsis, CNS injury) is the only type that will lead to warm and dry skin
  • Key idea: Patient needs to have symptoms in order to be diagnosed with UTI > Asymptomatic bacteriuria in the setting of a positive urinalysis, but in addition to dysuria and suprapubic tenderness, altered mental status is often attributed to UTI and considered a symptom

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


 +0  (step2ck_form8#30)
  • Pain in the hips/thighs that is exacerbated by walking and improves with leaning forward with normal posterior tibial pulses, most consistent with pseudoclaudication due to spinal stenosis
  • 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

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

seagull  Cannot a herniated lumbar disk lead to spinal stenosis? asking for a friend. +

 +0  (step2ck_form8#29)
  • Key idea: Diverticulitis classically leads to dull LLQ pain, nausea/vomiting, alteration in bowel habits and bladder symptoms (sterile pyuria, dysuria, etc.) +/- tender LLQ mass
  • Key idea: Diverticulitis treated with bowel rest and antibiotics (ciprofloxacin + metronidazole) and followed up 4-8 weeks later with colonoscopy (colonic malignancy can mimic the presentation and CT findings seen in diverticulitis)
  • Key idea: Indications for surgery in setting of acute diverticulitis (1) Emergency operation (peritonitis, abscess, etc.) (2) Any patient who has survived 2 episodes of acute diverticulitis should have elective removal of affected area to prevent recurrence

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

danielle359x  Pneumaturia=fistula=probably diverticulitis +

 +0  (step2ck_form8#28)
  • Blighted ovum = Anembryonic pregnancy = fertilized egg attaches to uterine wall but the embryo does not develop during the first trimester

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


 +1  (step2ck_form8#27)
  • Pregnant patient with type 2 diabetes with signs of poorly controlled blood glucose while on metformin, therefore requiring step-up in therapy to include insulin
  • Target blood glucose levels in gestational diabetes mellitus are fasting glucose < 95, 1-hour postprandial glucose < 140 and 2-hour postprandial glucose < 120
  • Key idea: Treatment options in gestational diabetes are (1st-line) Dietary modification (2nd-line) Insulin, metformin

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


 +0  (step2ck_form8#26)
  • Young woman with hypertension, headaches and a renal arteriography showing an 80% obstructive lesion, most consistent with fibromuscular dysplasia leading to renal artery stenosis
  • Key idea: Although fibromuscular dysplasia most commonly leads to resistant hypertension due to renal artery involvement, cerebrovascular fibromuscular dysplasia also a common presentation (headache, tinnitus, dizziness, TIA, amaurosis fugax, etc.)

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


 +0  (step2ck_form8#25)
  • Young woman with suspected UTI who has symptoms that are refractory to 2 courses of antibiotics and urethral tenderness on physicial exam, most consistent with urethritis which is most commonly caused by N. Gonorrhea or Chlamydia trachomatis
  • Key idea: On the NBME, when it says that a woman is sexually active and uses oral contraception, that means that they do not need condoms and are at increased risk for STIs
  • Key idea: Empiric urethritis treated with azithromycin + ceftriaxone, gonorrhea positive only treated with azithromycin + ceftriaxone and chlamydia positive only treated with azithromycin only

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


 +0  (step2ck_form8#24)
  • Elderly man with imaging showing metastatic pancreatic cancer also found to have a stable abdominal aortic aneurysm
  • Median survival of metastatic pancreatic cancer is 3-6 months, so the patient would most likely die from cancer before having any negative effects from the aneurysm, so repair of aneurysm has risks > benefits for this specific patient
  • Indications for abdominal aorta aneurysm repair in healthy patient: (1) > 5.5 cm in diameter (2) expansion of at least 0.5 cm in 6 months and/or 1 cm per year (3) symptomatic (abdominal pain, flank pain, limb ischemia)

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

bobson150  It's frustrating that they'd expect us to know prognosis at this level. I know metastatic pancreatic cancer is bad news bears, but the AAA fits criteria for repair (in a healthy person) +5

 +0  (step2ck_form8#23)
  • Causes of rapid-onset food poison (< 6 hours) are due to ingestion of pre-formed toxin and are most commonly caused by Staph aureus (cream-based food such as egg salad) or Bacillus cereus (reheated rice syndrome)
  • Clostridium perfringens (improperly cooked/stored meat) is another cause of food poisoning, but often occurs 6-24 hours after ingestion because patients ingest spores which need germinate in digestive tract to secrete toxin

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


 +0  (step2ck_form8#22)
  • Teenage wrestler (wrestler should always make you think of tinea infection!) who has an erythematous, scaly, pruritic, annular rash with raised-edges most consistent with tinea corporis
  • The most common dermatophyte organisms include Trichophyton, Microsporum, and Epidermophyton

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


 +0  (step2ck_form8#21)
  • Young patient with concern for IBD (increased stool frequency, signs of inflammation [fatigue, weight loss], bloody stools) who presents with ill-appearance, fever, hypotension, abdominal distention and an X-ray showing dilated transverse colon, consistent with toxic megacolon in setting of ulcerative colitis
  • Key idea: Toxic megacolon associated with ulcerative colitis and C. diff colitis
  • Colonic pseudo-obstruction often seen in elderly patient who is post-op and/or received opiates, diverticulitis leads to LLQ pain in an elderly patient, and ischemic colitis leads to “pain out of proportion” in a patient with risk factors (atrial fibrillation, endocarditis, etc.)

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

killuashi  Would toxic megacolon only show up in one part of the bowel? Shouldn't the whole bowel be dilated in toxic megacolon and not just the transverse colon? +
ht3  ^I thought that too but also isn't toxic megacolon painful...? or nah? +
danielle359x  Toxic megacolon is typically most prominent in the transverse colon. According to UpToDate, 82% of cases present with pain. I feel like they didn't need to emphasize twice that the patient had no pain, but that's NBME for you... +

 +0  (step2ck_form8#20)
  • Patient with Cushing’s triad (bradycardia, hypertension and irregular respirations) which is a sign of elevated intracranial pressure with a CT scan showing a high-density peri-ventricular hemorrhage, most consistent with a hypertensive bleed
  • Key idea: Common causes of brain bleeds include trauma, hypertension and cerebral amyloid angiography

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

seagull  Bathrooms are very common areas of falling for the elderly/everyone. However, those tend to result in intracranial hematomas. This is a very significant brain bleed. HTN is classically associated with lacunar infarcts which honestly are not as massive as shown. THis might be a ruptured berry aneurysm from HTN but we couldn't know for sure. Not a great question but he has pre-existing HTN so I guess we'll go with it. +4
saffronshawty  bruh, i straight up thought that was a tumor lol +2

 +1  (step2ck_form8#19)
  • 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
welpdedelp  Following ABCs, why wouldn't you intubate first? I understand shunt doesn't get corrected, but it would seem you would still take control of airway since kid seems to be crashing. +
quaranqueen  I think that intubation wouldn't make a difference if it's transposition of the great arteries because the oxygenated blood would just end up going back to the right heart and back through its closed circuit +

 +0  (step2ck_form8#18)
  • Lisinopril is an ACE inhibitor that leads to decreased angiotensin 2, and therefore leads to decreased vasoconstriction, decreased Na/H20 reabsorption in the kidney, decreased aldosterone and decreased ADH, all of which can lead to decreased blood pressure

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


 +0  (step2ck_form8#17)
  • Elderly patient with vasculopathic risk factors (hypertension, diabetes, smoking) presenting with acute shortness of breath, diaphoresis and pallor found to have hypotension and pulmonary edema with ECG findings of ST elevation in the anterolateral leads (I, avL, V2-V6), most consistent with myocardial infarction complicated by cardiogenic shock
  • Aortic dissection would lead to pain radiating to the back and X-ray would show widening of the mediastinum

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





Subcomments ...

submitted by step_prep3(11),
  • Thymus is normal in children < 3 years of age and commonly leads to “sail sign” due to triangular shape

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