This one made no sense. Celecoxib is already the strongest NSAID. I would rather give Dexamethasone. Which works along a seperate mechanism of action.

Bone marrow examination is generally not required for the initial evaluation in most cases of unexplained isolated thrombocytopenia in children. This child has pancytopenia and therefore requires a bone marrow aspiration.

To diagnose hypertension, there must be a hypertensive emergency >180/120, evidence of hypertension related end organ disease if greater than 160/100, or measurements in the office showing bp of greater than 130/80 at least three times. The measurements must be spaced over a period of weeks to months.

OCPs offer significant protection against

• Ovarian cancer: decreased ovulation --> less damage
• endometrial cancer: decreased endometrial proliferation
• iron-deficiency anemia: decreased bleeding
• reduced risk of benign breast disease

IUDs only act locally

Breast cancers are one of the most common malignancies to be associated with hypercalcemia. Most often the hypercalcemia is due to osteolytic metastases and hence portends a bad prognosis. A significant number of the patients with breast cancers (up to 15%) show hypercalcemia in the absence of metastasis.

Hypercalcemia is relatively common in patients with cancer, occurring in approximately 20 to 30 percent of cases. It is the most common cause of hypercalcemia in the inpatient setting.

Male (XY) + Encapsulated organisms = X linked (Bruton) agammaglobulinemia

• First: S pneumoniae
• Then: H influenza type B
• And now... S pneumoniae again!

Remember: S pneumoniae is a gram positive lancet-shaped diplococcus and is the #1 cause of MOPS (meningitis, otitis media, pneumonia, sinusitis)

N meningitidis is a gram negative diploccocus

Nystagmus is almost always pathological unless congenital. Especially gaze evoked nystagmus is almost always pathological.

BPPV btw is head movement induced nystagmus, which isn't the same as gaze evoked. Gaze just means moving eyes whereas bppv usually the nystagmus comes from moving the entire head.

The rest are normal findings for age, except e, which could be normal pupil size for any age.

This is a normal x-ray!

Like veggievendor said, this is a kid with sickle cell disease and limited hip ROM, so check the hip for osteonecrosis

Bacterial meningitis... get a CT first due to signs of neurological deficit (R upper extremity + nystagmus). Otherwise lumbar puncture.

Osmotic diuresis caused by glucosuria is one of the most common causes of excessive renal salt and water loss.

Beck's triad: muffled heart sounds, jugular vein distension, and electrical alternans. This patient has cardiac tamponade. The fluid has to be removed.

A pericardial window is a cardiac surgical procedure to create a window from the pericardial space to the pleural cavity. The purpose of the window is to allow a pericardial effusion (usually malignant) to drain from the space surrounding the heart into the chest cavity.

• Adolescent with a polymorphic facial rash with comedones and inflammatory papules, most consistent with acne which is due to pathology within pilosebaceous follicles
• Apocrine glands associated with hidradenitis suppurativa, epidermal-dermal junction associated with bullous pemphigoid and panniculitis associated with erythema nodosum

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Ill be the Cowboy.

Diagnosis: ALS

Multispike and fasciculation potentials Complex, repetitive discharges occur in ALS of long duration, as they do in other chronic neurogenic atrophic conditions. These are regularly discharging multispike potentials that are time-locked. Other than an EMG finding associated with a chronic neurogenic atrophic condition, this finding has no other unique significance.

Fasciculation potentials are seen frequently but not invariably in ALS. Their presence is not specific to ALS; they may occur in other conditions, some completely benign.

Patients who complain of persistent RUQ pain after cholecystectomy should be evaluated for post-cholecystectomy syndrome

Evaluated via abdominal imaging (e.g. ultrasound) followed by direct visualization (e.g. ERCP, MRCP) to find and remove the stone.

etiologies include:

• biliary (e.g. retained cystic duct stone, damage to the duct)
• extra-biliary (e.g. pancreatitis) causes.

priority for AD patients is rate control. After controlling rate you can throw on something extra for pressure control but rate control comes first.

WTF is this x-ray. I would be better off pepper-spraying myself in the eyes and looking at a good x-ray than this shit.

I do not even begin to see spondlolololisthesis here.

Order of treatment for acute hyperthyroid symptoms

Beta Blocker --> PTU---> Radioactive Iodine

Beta blocker wasnt an answer option but would be correct if given.

"I think there's no intervention necessary here. Newborns should have mom's antibodies. Related. Pay attention to the first bullet point, its a testable concept." reddit.com/r/medicalschool/nbme_7step_2_5_questions/

Doxazosin is not given because he has a history of orthostatic hypotension.

This question is actually a lot deeper than it looks. It is not about "when do you treat thrombocytopenia", which you DO treat when they have bleeding like in the question. This question is about management of ALL which has specific guidelines. According to uptodate, as long as platelet levels are about 20,000 in ALL, you are good to go for a bone biopsy.

• Key idea: Systemic steroids are associated with psychosis and this patient is receiving ACTH, which will stimulate the adrenal gland to release increased amounts of glucocorticoids/steroids, likely precipitating her psychosis (delusions, bizarre behaviors, etc.)
• Alprazolam = Benzo (avoided in older patients due to risk of delirium)
• Amitriptyline = TCA antidepressant (refractory depression, neuropathic pain, migraines)
• Lithium = Bipolar disorder
• Sertraline = SSRI (depression, PTSD, panic disorder, etc.)

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Hypoalbuminemia results in apparent hypocalcemia. Free calcium is unchanged and the patients don't have sx of hypocalcemia, but total calcium stores are depleted (which is what the lab measures).

IV contrast dye used for pulmonary angiography worsened the renal insufficiency(inc in serum CR). Adequate hydration before IV contrast in patient with renal insufficiency can prevent this.

I came here to chew bubble gum and F**K this exam. Instead I got ran train on by all these questions.

Also, my media player didnt even work. I spent like 20 minutes trying to make it work. FML

Retinal vein occlusion is the second most common cause of visual loss in older adults throughout the world. The first is diabetic retinopathy. Age, HTN, and diabetes are risk factors. This patient is a diabetic and the retinal veins are dilated (clear giveaway).

• Unilateral vision loss + Dilated retinal veins and widespread retinal hemorrhages on fundoscopy (“blood and thunder” appearance) = Central retinal vein occlusion
• Central retinal artery occlusion = Cherry-red spot on fundoscopy
• Corneal abrasion = Positive Fluorescein staining, sensitivity to light, pain
• Glaucoma = Bilateral lens opacity and glare from lights
• HSV conjunctivitis = Dendritic ulcers
• Optic neuritis = Optic disk pallor

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• Middle-aged woman with potential infectious disease (fever) leading to one week of uncontrolled hyperglycemia who has signs of orthostatic hypotension (drop in systolic BP >20 or diastolic BP >10 when moving from sitting to standing) and is found to have glucosuria, most consistent with intravascular volume depletion due to glucose acting as an osmotic agent and leading to polyuria
• Key idea: Infections often lead to increased insulin requirement by causing a reactionary hyperglycemia

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• Patient involved in a significant motor vehicle accident with acceleration-deceleration forces who develops neck pain and chest pain with bruising over the sternum and a widened mediastinum (almost always associated with aortic dissection or aortic injury), most consistent with blunt thoracic aortic injury leading to incomplete aortic rupture
• Key idea: Involves the thoracic aorta because the aortic isthmus is tethered by the ligamentum arteriosum and is therefore not freely mobile and is prone to developing severe stretching/shearing forces in the setting of an acceleration-deceleration injury
• https://www.nejm.org/doi/full/10.1056/NEJMra0706159

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In 85 percent of patients with latent TB, the chest radiograph is normal.

Latent TB Treatment:

• ≥5mm – HIV; Immunocompromised; Previously healed TB; Recent contacts
• ≥10mm – IV drug; Recent immigrants; High risk work or home; dz states (DM/Leukemia/ESRD); Kids < 4yrs
• ≥15mm – treat everyone

"The response is a classical example of delayed-type hypersensitivity reaction (DTH), a type IV of hypersensitivities. T cells and myeloid cells are attracted to the site of reaction in the timeframe of 1-3 days and generate local inflammation." - Wikipedia

. The immune response to M tuberculosis is T cell dependent. It comprises not only the conventional CD4 and CD8 T cells, but also γδ T cells and CD1 restricted T cells. γδ T cells recognise phospholigands and no presentation molecules are known thus far. CD1 restricted T cells recognise glycolipids, which are highly abundant components of the mycobacterial cell wall. Although different T cells are required for optimum protection, the immune mechanisms known to have a role in acquired resistance can be associated with two major mechanisms: (a) activation of macrophages by cytokines; (b) direct cytolytic activity. In vivo granuloma formation, which is central to protection, is induced and sustained by cytokines. Mycobacteria are contained within granulomas and in this way are prevented from spreading all over the body.

So it looks like we just need to know this. Nevermind the fact the question stem doesnt even hint at any congenital problem in the girl....

• Young child with non-reactive skin testing for multiple antigens (which is a type 4 hypersensitivity process dependent upon T cells), raising concern for T lymphocyte dysfunction
• Key idea: Patients with HIV can have a falsely-negative PPD in the setting of M. tuberculosis because they have low T cell function and impaired Type 4 HS reaction
• Antibody deficiency = Bruton’s agammaglobulinemia = Recurrent infections with encapsulated infections
• Complement deficiency = Recurrent Neisseria infections
• Impaired chemotaxis = Leukocyte adhesion deficiency = Recurrent abscesses without pus, delayed wound healing, delayed umbilical cord separation
• Impaired respiratory burst = chronic granulomatous disease = Recurrent skin abscesses and infections with catalase positive organisms (Staph, Pseudomonas, Aspergillus, Nocardia, Serratia, etc.)
• Splenic dysfunction (sickle cell disease, trauma patient) = Encapsulated infections (Strep pneumo, H. influenzae, Neisseria)

• Severe SBO presents with:

• SBO initially has high pitched bowel sounds but a complete obstruction has ↓ or absent bowel sounds

• Young man presents with fever, erythema nodosum (painful, red, tender nodules on anterior shins) and bilateral hilar fullness, most consistent with sarcoidosis
• Key idea: Sarcoidosis (like other forms of granulomatous disease) is associated with hypercalcemia because of increased activity of 1-alpha hydroxylase leading to increased production of activated vitamin D –> hypercalcemia, hyperphosphatemia
• Ddx for erythema nodosum: Sarcoidosis, Strep infections, tuberculosis, inflammatory bowel disease, Behcet disease, endemic fungal disease (cocci, histo)
• Key idea: If patient has erythema affecting both legs, then cellulitis is virtually ruled out! (bilateral cellulitis very rare)

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Lets take a picture with a potato, JPEG the hell out of it and throw it on an exam .

Can anyone who got this right explain how they ruled out chancroid? This is the definition I have for chancroid which I thought fit the image/text description (multiple increasingly painful sores and lymphadenopathy), but was incorrect:

"Patients present with extremely painful suppurative ulcers that may be single or multiple.Infection begins as a papule, which quickly progresses to a pustule and subsequent ulcer formation. Painful inguinal lymphadenopathy with subsequent ulceration, usually unilateral, develops in approximately 50%."

You know they could throw us a bone or something... Tell us the uterus is boggy at least, or hard, or ANYTHING AT ALL REALLY....

Tumbleweed

Welcome back to Step 1 minutae... Useless crap they make us memorize, hell not even memorize.