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

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.

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

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.

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 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.

• Patient presenting with signs/symptoms concerning for meningitis vs. subarachnoid hemorrhage who also has signs of increased intracranial pressure and should therefore have a CT scan performed before a lumbar puncture
• Key idea: Optic fundi cannot be visualized = Papilledema = Increased intracranial pressure = Contraindication to lumbar puncture due to risk of cerebral herniation
• Key idea: Both meningitis and subarachnoid hemorrhage can lead to fever and signs of meningismus (pain with neck flexion, Kernig sign, etc.)

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

• 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

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

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....

I love these shit pictures. It's like some old angry dude opened a text book from the 1950s and took a picture with his razor phone then uploaded the picture using windows 99.

This was so free I thought I wandered into a Canadian hospital for a minute.

this question would be a lot easier if the answer choice was worded "spinal epidural hematoma"

If you're ever unsure and it seems like it's not cancer. You slam the "Reassure" answer choice with passion.

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

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

• 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

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

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

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%."

im convinced you cannot differentiate this from chancroid

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

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.

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.

TSS: sunburn like rash particularly on the palms and soles and very rare

Meningococemia fits better for a college-age girl who has been living in cabins/dorms and cannot be aroused/altered mental status

https://rarediseases.org/rare-diseases/toxic-shock-syndrome/

• Older patient with multiple myeloma (monoclonal spike on SPEP and bone marrow biopsy showing >50% plasma cells), which leads to impaired production of normal immunoglobulins, leading to increased risk for sinopulmonary infections (due to impaired IgA production) and encapsulated infections (due to impaired IgG –> impaired opsonization –> increased risk of encapsulated infections such as Strep pneumo, H. influenzae and Neisseria)

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

• Category 3 fetal heart tracings (require immediate delivery): (1) Recurrent late decelerations + absent variability (2) Recurrent variable decelerations + absent variability (3) Bradycardia + absent variability (4) Sinusoidal pattern
• Cervical dilation < 10 cm and need for immediate delivery –> C-section
• Cervical dilation of 10 cm and need for immediate delivery –> Operative vaginal delivery (forceps delivery)
• Key idea: Indications for C-section in the active phase (6-10 cm cervix) of labor (1) Active phase arrest with no cervical change for 4 hours with adequate contractions (>200 Montivideo units) or for 6 hours with inadequate contractions (2) Category 3 fetal HR tracing

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

• Older male patient with tearing chest pain radiating to the pack, different upper extremity blood pressures, aortic regurgitation murmur and a widened mediastinum on CXR, all of which are consistent with aortic dissection
• Key idea: Beta-blockers (such as labetalol) 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/tutoring/

pressure (decubitus) ulcers

• over bony prominence
• impaired mobility / abnormal mental status

arterial ulcers

• most distal parts where blood flow is low (tips of toes)

diabetic foot ulcers

• Charcot deformity
• soles of feet under metatarsal heads
• tops of toes

venous stasis ulcers

• edema
• stasis dermatitis
• pretibial or above medial malleolus

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

• Patient engaging in intense physical activity presenting with signs of heat stroke (fever, seizure/encephalopathy, dry hot skin) and rhabdomyolysis (myoglobinuria), who should be treated with IV fluids to decrease the risk of myoglobin pigment stones precipitating kidney damage
• Key idea: The major tenant of rhabdomyolysis management is aggressive IV fluid resuscitation because patients develop decreased effective circulating volume (due to fluid shifts into damaged muscle) and because patients are at risk for acute tubular necrosis secondary to myoglobinuria (with increased fluids helping to dilute these pigments and decrease the risk of tubular obstruction)

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

kids start to take first few independent steps by 12-18mo

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.

• Key idea: ON THE BOARDS, ALCOHOLISM = MALNUTRITION!
• Hypomagnesemia –> Refractory hypokalemia and hypocalcemia
• Key idea: In the setting of hypocalcemia, important to always check a magnesium level and a serum albumin level (low albumin –> low total calcium)

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

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.

SO Pulmonary Angiography has dye that shouldn't be used in CKD.

Why does the question need to be like a book in length. I was balancing like 20 ideas with her F**King diabetes and HTN. WTF

• Did not have access to media player, but the patient’s presentation is consistent with a URI
• CHF: Cyanosis, delayed capillary refill, etc.
• Idiopathic pulmonary hypertension: Lower extremity edema, congestive hepatopathy, loud P2, RV heave
• Pericarditis: Febrile, friction rub, etc.
• VSD: Often asymptomatic until later age, will lead to a systolic ejection murmur in the lower left sternal border

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

• Family therapy is appropriate in this case because the father, mother and daughter could benefit from improved communication and coping strategies
• Note: Family therapy is also effective in the management of a patient with schizophrenia (helps to educate family about symptoms, course, etc.)

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

• Young girl with a history of chronic corticosteroid use and cushingoid appearance who presents with constant back pain with vertebral point tenderness with imaging showing vertebrae with increased lucency, most consistent with a compression fracture in the setting of steroid-induced osteoporosis
• Key idea: Vertebral compression fracture comes in 2 flavors (1) Chronic fracture: Painless with progressive kyphosis and loss of stature (2) Acute fracture: Low back pain with decreased spinal mobility + tenderness at affected level
• Key idea: Causes of point tenderness over vertebral body includes compression vertebral fractures, osteomyelitis and metastatic disease to vertebral bone
• Risk factors for osteoporosis –> compression fracture: Low weight (osteoporosis), increased age, women, chronic corticosteroid use or Cushing syndrome

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

• 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

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

dx of htn in kids requires BP measurements at 3 different visits:

• kids: ≥ 95 percentile

• adolescents (≥ 13y): ≥ 130/80

• 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)