This patient has a testicular mass. Let's examine a few differentials as we go through the answer choices.

Germinal Cell Tumor (Testicular Tumor)

• Usually painless but dull/achy/heavy sensation; palpation of SOLID mass
• No change in size when supine
• No transillumination

Dilated pampiniform venous plexus (Varicocele)

• Usually painless; "Bag of worms"
• Reduced swelling when supine
• No transillumination

Cystic Dilation of the effect ductules (Spermatocele)

• Typically painless; fluctuant swelling of upper testicular pole
• No change in size when supine
• Does transilluminate

Fluid accumulation within the tunica vaginalis testis (Hydrocele)

• Often painless; fluctuant swelling of scrotum
• May/May not change in size wrt position
• Does transilluminate

Vascular Trauma (Hematocele/Ruptured Testis)

• Extremely painful & tender; visible hematoma
• May/May not change in size wrt position
• No transillumination

This question is tricky. I used to always miss this presentation. This is laterally medullary syndrome- which most of us have memorizes is a PICA infarct. Fun fact, PICA comes off the vertebral artery.

This is how I remember the sx. If this helps at least one person I will be glad I am exposing my twisted brain.

3+5=8 & 9-11 & B-P.

3: Horner's syndrome 5:spinal trigeminal- ipsi face pain and temp loss 8: vestibular signs, vertigo diplopia

9-11: Nucleus ambiguous, diminshed gag, dysphagia B: Cerebellar - inferior cerebellar peduncle, ipsi ataxia P: Contra pain and temp, cuz this shit was so painful to memorize I throw it to the other side.

sclera injection and munchies

In the words of afroman. I was gonnna go to work....but then I got high...

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

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

Hyperactive bowel sounds + pneumobilia = gallstone ileus

Very few things put air in the liver

ABI<0.9 is diagnostic of peripheral artery disease. First-line treatment is graded exercise program. Revascularization is only indicated for critical limb ischemia (rest pain, non-healing ulcers)

since she has total blindness just in one eye, right optic nerve lesion makes sense. The poor reactivity to light supports this because eyes receive light through optic nerve (CN2)

Widened pulse pressure in an adult is regurg. Widened pulse pressure in a new born is PDA. because the blood is swishing back and forth

Elimination

(a) ARDS is bilateral

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

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

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

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

I think we've all been pimped on demargination reaction at some point...

Criteria for weaning from ventilator:

1. O2 sat >= 90% with FiO2<=40% and PEEP<=8
2. pH>7.25
3. Initiating breaths (SIMV allows patient to initiate breaths)

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

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

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

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

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

Google bullous poison ivy

These people always have extreme unstable relationships. And do things to gain attention. Self harm, suicidal behavior, splitting. The buzz word for treatment is dialectaial behavioral therapy

I think of these as the people who seemed very cool in middle school because they could get a new boy friend every week

Androgens are responsible for libido in both sexes!

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

Warmest welcome back to Step 1 by NBME lol

Mildly interesting question but worth taking the time to explore the differentials in this vignette.

Fibromyalgia. Prevalent in young - middle-aged & ♀ > ♂. Chronic widespread pain with tender points. Symptoms of pain & stiffness prevalent but Pain > Stiffness. Associated with IBS, urge incontinence & palpitations. Labs tend to be normal. NSAID won't provide relief. This fits!

Polymyalgia Rheumatica. Just like Fibromyalgia, there are symptoms of both pain and stiffness. However, in polymyalgia rheumatica, Stiffness > Pain. The patients tend to be older (>50yr.) and systemic symptoms (fever, weight loss, night sweats, fatigue) tend to be more prevalent. Not seen in this vignette.

Polymyositis. In this diagnosis, proximal muscle weakness is often the chief complaint +/-- mild pain. Serology would show (+) antinuclear antibodies (ANA). The patient does not complain of weakness in this vignette.

Ankylosing Spondylitis. This is seen in ♂ > ♀ (3:1) so it becomes less likely. While pain/stiffness is seen in the back, neck, shoulders of these patients, tenderness is primarily seen at the sacroiliac joints. Furthermore, activity tends to improve symptoms (of stiffness) & NSAIDS would provide some relief. We don't see that in this case.

Seronegative RA. In this vignette, Labs show (--)ANA & RF but patients with this disease would present with joint pain & stiffness particularly in the hands, elbows, knees, feet and ankles. NSAIDS would also provide some relief.

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

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

Mithramycin is evidently an antitumor drug used in testicular cancer

Tamoxifen therapy - treat her immediate neurological issues

Cystourethrocele (herniation of bladder neck) indicates urethral hypermobility -> stress incontinence. Vaginal delivery is a risk factor.

Myelomeningocele is associated with Chiari II malformation -> obstructive hydrocephalus

Gonna write another answer to this since the other answer is so long.

Basically, holosystolic murmur over lower left sternal border in a newborn is most likely a VSD. The murmur from a VSD is due to left-to-right shunt from LV to RV.

In utero and early after birth, pulmonary arterial pressure is high, so the pressure gradient between LV and RV is low. The left-to-right shunt is therefore not that substantial.

As pulmonary growth progresses, the pulmonary arterial pressure decreases, which increases left-to-right shunting and increases the murmur.

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

Sjogren syndrome destruction of the salivary glands, dental caries. I looked at UTD and there isn't anything about the vagina being involved, but there is probably some article out there that links it.

The other answer choices didn't make sense

This kid has signs and sx of dehydration Hyaline casts due to hypovolemia resulting in concentrated urine

AS is strongly associated with HLA-B27 (however, not all patients with HLA-B27 serotype will develop AS)

This kid has nursemaids elbow. Apparently a very simple fix

This patient has signs of internal bleeding Decreased breath sounds--> abdomen filling with fluid, so the diaphragm has to push against increased pressure to get a breath in. Abdominal distension, tachycardic, hypotensive.

hematocrit drop by 12%. think about this. 1% change in hematocrit is 3 units of blood. 1 unit is 500mL. So based on her calculated blood loss, she should have only dropped hct by (1%-2). So I mean it could be underestimated blood loss, but her PE signs point to hemorrage

Threatened (eg, vision change) or confirmed vision loss in GCA requires high-dose intravenous glucocorticoids (eg, methylprednisolone 500-1,000 mg daily), followed by oral therapy with a slow taper over several months to prevent worsening or contralateral vision loss.  Temporal artery biopsy can confirm the diagnosis of GCA; however, therapy should be started immediately when the diagnosis is suspected and should not be withheld while awaiting confirmation. UWorld qid: 3164

This is a capillary hemangioma aka strawberry birth mark. They go away eventually, we dont really mess with them unless they are obstructing the kids vision or breathing somehow.

Ca Gluconate must be given immediately if K > 6.5; think of it as "no point in hydrating or pushing K into cells with insulin if they will die rn of an arrhythmia"

Ca will stabilize immediately, which is why its initial tx.

This is tricky because of the normal hormone levels

Usually PCOS has LH:FSH > 3:1

But, both can still be within the reference ranges!

Normal for females

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

Also, testosterone often, but not always, elevated

These are symptoms of acute benzo withdrawl

A precipitous drop in Hgb effectively rules out malrotation. Overaggressive anticoagulation is associated with intramural hematoma.

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

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

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

this is intusseption, with current jelly stools and episodic abdominal pain. Treat with barium enema

2 months can just get their chest up and recognize moms voice. Apparently they can't grab things until 5 months.....glasses off your face

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

Must've been really fucking stoned to end up in the ED 😂

First-line treatment of any mild acne is topical retinoids and benzoyl peroxide.

Breast engorgement is normal while a woman is breastfeeding. Mild tenderness is normal for several weeks following low-transverse C-section, a notoriously painful incision. This patient has resumed sexual activity and would benefit from contraception, but this is not an answer choice.

The pulling feeling weeks after incision is just scar tissue remodelling.

She only has mild tenderness w/ deep palpation , no pain, no fever, no redness, etc.

This patient with homophobia has some functional impairment (2-week leave of absence) within 2 months following a stressor, with anxiety surrounding a single 'issue'. I approach adjustment disorder by ruling out other answer choices:

PTSD/Acute stress are only diagnosed following life-threatening events.

GAD requires >6mo of symptoms and worry about multiple issues.

Panic disorder requires patient to actively avoid scenarios that may trigger panic attack.

Calcifications in anterior lumbar spine = atherosclerosis in abdominal aorta, a risk factor for AAA. Acute onset pain indicates rupture or impending rupture. BP can be low-normal due to tamponade by retroperitoneal location of abdominal aorta.

note: calcifications in anterior lower thoracic spine = chronic pancreatitis

Congenital cardiomegaly (point of maximal impulse is deviated to the left) and hypotonia are both classic features of Pompe disease.

Although GM1 gangliosidosis can present with hepatomegaly and hypotonia, it is not associated with cardiomegaly.

This patient with anemia and extreme hypotension following MVA is bleeding into her pelvis/thighs. She urgently needs isotonic fluids and blood products prior to further workup.

Radiation therapy is the second most common cause of constrictive pericarditis in the US (after viral/idiopathic)

This question is a rather interesting one. While pharyngitis with viral or bacterial etiologies have very similar clinical presentations, there are a few subtle hints that make Throat Culture the more likely answer regardless of the CENTOR score in this Vignette.

September. The seasonality of Group A Strep (GAS) pharyngitis is usually between winter & early spring. Viral pharyngitis, although all year round, is more common in the colder months.

The main objective of a primary care physician is distinguishing which patients have a higher likelihood of GAS infection vs. viral and because there is a significant overlap between the 2 etiologies, clinical judgment alone is not accurate in diagnosing GAS infections often leading to overtreatment with antimicrobial therapy.

Throat culture is the gold standard in diagnosing GAS. This is done in this scenario, despite the negative rapid test (Sensitivity 70% - 90%), because of the suspicion of viral etiology as well as the avoidance of overtreatment. Throat culture is the most appropriate next step in this case.

Most institutions require adequate titers of HBsAb prior to patient contact.

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

This person has borderline high cholesterol

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

The formula for total cholesterol:

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

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

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

Since this patient is 1 day out of surgery, PO medications are not recommended, since this patient is very likely to have decreased bowel movements from abdominal surgery.

Moderate/severe postoperative pain is usually managed with short-acting opioids, since long-acting opioids have a higher risk of overdose and misuse. Based on the answer choices, patient-controlled IV morphine fits this criteria.