I was desperately looking for cellulitis. I never did see it. Some say I'm still looking for it to this day.

"No bruits are heard over the neck"

I swear I cannot bang my face hard enough against a wall.

I'm relatively sure that most people were 50:50 between bleach and drain cleaner.

• Current guidelines recommend cefazolin or cefuroxime administered within 60 minutes of skin incision as prophylaxis during hip or knee arthroplasty and should be discontinued within 24 hours
• Key idea: Antibiotic prophylaxis to prevent surgical site infections are given in certain procedures, most commonly major/long surgeries

https://www.aafp.org/afp/2011/0301/p585.html

https://step-prep.org

• Tricky, nuanced question because contraindication to patient receiving a lung resection is if their residual FEV1 will be less than 800 mL following the surgery
  
  
• Normal FEV1 in a healthy woman is typically around 3 L, so in this patient is likely close to 750 mL since she has an FEV1 that is 25% of predicted; therefore, this patient would likely not be able to tolerate any sort of lung resection because she is already barely hanging on in terms of her ventilatory capabilities
  
  
• Could also approach this question through process of elimination because ABG shows mild CO2 retention (seen in many COPD patients), ejection fraction cut-off for surgery often <35%, cardiac stress test was normal and patient has had DVTs for a long time

https://step-prep.org/

• Middle-aged man with fever, lymphadenopathy and splenomegaly found to have elevated leukocyte count with increased eosinophils, myeloblasts, metamyelocytes and myelocytes most concerning for chronic myeloid leukemia
• Key idea: Ways to differentiate between chronic myeloid leukemia and a leukemoid reaction include leukocyte alkaline phosphatase (LAP) levels (elevated in leukemoid reaction and decreased in CML), looking for basophilia (present in CML) and looking at the types of neutrophil precursors present (metamyelocytes > myelocytes in leukemoid reaction and metamyelocytes < myelocytes in CML)
• Note: Metamyelocytes are more mature than myelocytes
• Key idea: Can often tell they type of leukemia based on patient demographics with ALL seen in patients 0-14, AML seen in patients 15-60, CLL seen in patients 60+ and CML seen in patients 40-59

https://step-prep.org

• Young patient with high-risk sexual behavior who presents with fever, malaise, maculopapular rash over the palms and soles and diffuse lymphadenopathy, which is most consistent with syphilis
• Key idea: 3 major infectious causes of rash over the palms and soles can be remembered with CaRS (Coxsackie A, Rickettsia Rickettsii (Rocky Mountain Spotted Fever) and Syphilis)
• Important to contrast syphilis and Rocky Mountain Spotted Fever, with syphilis more commonly leading to a maculopapular rash and diffuse lymphadenopathy (with epitrochlear lymphadenopathy basically being pathognomonic) and Rocky Mountain spotted fever commonly leading to a purpuric rash that spreads from the hands/feet to the trunk

https://step-prep.org

• 16 year old girl with primary amenorrhea (girl without secondary sexual changes by 13 or menarche by 15), short stature, and concern for coarctation of the aorta (hypertension, upper extremity pulses > lower extremity pulses, systolic murmur), most consistent with Turner syndrome
• Coarctation of the aorta needs to be worked up with an echocardiography and then operatively repaired

https://step-prep.org

(E) Pneumothorax

Benzo overdose --> intubation --> airway trauma --> pneumothorax

(A) Aspiration PNA is possible with individuals prone to loss of consciousness, but would not be so acute! She was intubated then crashed 20 minutes later.

(B) Kerley B lines are indicative of pulmonary edema

(C) Pericardial effusion is characterized by Beck's Triad of hypotension, distended neck veins, and muffled heart sounds. And would not explain unilateral diminished breath sounds.

(D) pleural-based hump-shaped density probably describes a Hampton hump, which a wedge-shaped opacity in peripheral lung with its base at a thoracic wall. Caused by pulmonary infarction.

• Key idea: History of heel pain that is worst with first steps in morning and pain with passive dorsiflexion of toes is classic for plantar fasciitis; plantar fasciitis also commonly associated with bone spur on plantar surface of foot
• Differential for heel pain: (1) Plantar fasciitis (2) Bone infection or metastasis (constant pain that is worst at night) (3) Calcaneal stress fracture (worse with activity and palpation) (4) Tarsal tunnel syndrome (percussion tenderness and paresthesias over posterior tibial nerve in tarsal tunnel) (5) Achilles tendinopathy (pain/tenderness at posterior heel with palpable thickening of tendon that can be reproduced with foot dorsiflexion)

https://step-prep.org

• 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

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

• 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/

Contraindications to combined contraception includes:

1. Women > 35 yo who smoke (which is case with this patient)
2. Migraines with aura
3. Hypercoagulable risk factors (<3 weeks postpartum, prolonged immobilization, history of DVT/PE, blood disorders [factor V leiden, etc.])
4. Active breast cancer
5. Liver disease (liver involved in metabolizing estrogen)

https://step-prep.org/

• Young man who recently started treatment with haloperidol presents with rigidity, neck rigidity and oculogyric crisis (eyes displaced upwards) most consistent with acute dystonia
• Key idea: Important to contrast with neuroleptic malignant syndrome, which would lead to constellation of symptoms remembered with Malignant FEVER (Myoglobinuria, Fever, Encephalopathy, Vitals unstable, increased CK Enzymes and Rigidity)
• Key idea: 4 main extrapyramidal effects of antipsychotic use, especially with high potency antipsychotics such as haloperidol, are (1) Acute dystonia (2) Akathisia (3) Parkinsonism (4) Tardive dyskinesia

https://step-prep.org

• All patients (HIV or not) should receive an annual influenza vaccine
• Patients with HIV should receive Strep Pneumo PCV13 followed by the 23-valent PPSV23 8 weeks later and again in 5 years and at age 65
• Based on patient’s serologies (negative Hep B surface antibody), he needs to be vaccinated against hepatitis B
• Note: Patients are not given PCP prophylaxis until CD4 < 200 and T. gondii prophylaxis until CD4 < 100

https://step-prep.org

Orthopedic, neurological, cardiac, and vascular cases are all "clean" wounds that require abx prophylaxis with cefazolin first line. Alternatives include vancomycin and clindamycin

• Young woman with a strong family history of cancer compatible with Lynch syndrome (colon cancer, endometrial cancer, ovarian cancer) who has developed irrregular, heavy vaginal bleeding concerning for possible endometrial cancer
• Indications for endometrial biopsy include (1) Woman over 45 years old with abnormal uterine bleeding or postmenopausal bleeding (2) Woman under 45 with abnormal uterine bleeding with unopposed estrogen (PCOS, obesity), failed medical management or Lynch syndrome

https://step-prep.org

• 87 year old man who is independent in ADLs (eating, bathing, toileting, transferring, getting dressed) and iADLs (shopping, using phone, driving, handling finances, etc.), A&O x 3, recalls 2/3 objects after 5 minutes and has no focal neurologic findings most consistent with normal aging or mild cognitive impairment
• Key idea: Patients with mild cognitive impairment will have mild decline in at least 1 cognitive domain, but will have normal functioning in all activities of daily living with compensation (taking a list to the store), whereas patients with dementia will have global cognitive impairment and marked functional impairment
• To differentiate between Alzheimer’s and vascular dementia, look for other neurologic features (pronator drift, weakness, etc.) which is more consistent with vascular dementia

https://step-prep.org

• Most common cause of unilateral, bloody breast discharge is intraductal papilloma
• Key idea: Intraductal papilloma often does not have a mass on physical exam or mammography findings

https://step-prep.org

• Young male with excessive thirst and urination for 6 months who presents with seizures found to have hypo-osmolar hyponatremia, most consistent with psychogenic polydipsia
• Key idea: This demographic is classically when signs/symptoms of schizophrenia develop, and patients with schizophrenia are at increased risk for psychogenic polydipsia
• Key idea: If patient has hypo-osmolar hyponatremia and a urine osmolality < 100, then they almost certainly have psychogenic polydipsia or beer potomania

https://step-prep.org

• Young man with history compatible with migraines (throbbing headaches associated with aura [nausea, vomiting, photophobia]) that are increasing in frequency and are refractory to abortive/acute treatments, making this patient a good candidate for prophylactic migraine medication
• Key idea: Indications for migraine prophylactic medications include (1) Headaches > 4 times per month or long-lasting [>12 hours] (2) Disabling symptoms (missing work) (3) Refractory to abortive medications
• Key idea: Potential prophylactic migraine medications include Topiramate, Valproate, Beta blockers (such as propranolol), calcium channel blockers or amitriptyline (TCA antidepressant)

https://step-prep.org

• Elderly man with significant smoking history and occupational history of being a coal miner who presents with clubbing and hypoxia with bilateral upper lobe masses and areas of consolidation on chest x-ray most consistent with COPD and/or coal workers’ pneumoconiosis
• Key idea: Of the common pneumoconioses, the majority affect the upper lobes (silicosis, coal workers’ lung, berylliosis) except for asbestosis (lower-lobe predominant)
• Tuberculosis can also lead to upper lobe opacities, but it would more commonly lead to acute fever, night sweats and weight loss in a patient with exposure

https://step-prep.org

• Young healthy man who presents with chest pain and ST-elevation in an anterior distribution after using crack cocaine, most consistent with cocaine-induced MI
• Key idea: Cocaine induced MI treated the same way as atherosclerotic MI, except that beta blockers are not used (due to theoretical risk of unopposed alpha-agonism) and benzodiazepines are used
• Key idea: Cocaine use is associated with myocardial infarction (due to spasm of the coronary arteries) and aortic dissection (due to increased blood pressure), but this presentation more consistent with pure MI because patient has normal BP in both arms (although this is commonly seen in aortic dissections in real life, test writers often will say blood pressures are unequal) and no tearing chest pain into the back

https://step-prep.org

• Elderly woman with chronic COPD history presents with weight loss, progressive shortness of breath and light-headedness found to have JVD with RV heave and loud S2 (all components of pulmonary hypertension) and signs of congestive hepatopathy, all consistent with Group 3 pulmonary hypertension
• Key idea: In most capillary beds of the body, decreased oxygen leads to vasodilation in order to facilitate more bloodflow to the area to maintain perfusion, but the lungs are the one exception in which decreased oxygen leads to constriction of blood vessels feeding that area so that blood is preferentially sent to well-oxygenated portions of the lung to minimize V/Q mismatch, but can lead to cor pulmonale in patients with COPD because their entire lungs are poorly oxygenated, leading to diffuse vasoconstriction and increased afterload on right ventricle

https://step-prep.org

• Patient with small cell lung cancer (uniform, small round cells with dark nuclei), which is often initially treated with chemotherapy followed by radiation and/or surgery
• Patient is young and has no signs of metastasis so palliative care isn’t appropriate, hormone therapy most used for breast cancer and prostate cancer, and surgical resection is NOT used in small cell lung cancer specifically (“the cells are too small for the surgeon to see!”)

https://step-prep.org

• Key idea: 2 most important risk factors for Alzheimer’s is (1) Increased age (2) Family history of early-onset dementia (often due to mutation in Amyloid precursor protein or presinilin-1/2)
• Key idea: Early-onset Alzheimer’s defined by symptoms appearing age 65 or younger

https://step-prep.org

• Young man with recent URI presents with sharp substernal chest pain, fever and ECG with diffuse ST elevations and PR depressions most consistent with viral pericarditis which can be diagnosed with echocardiography because it is often complicated by pericardial effusion

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• Young man presents with altered mental status found to have a severe anion-gap metabolic acidosis (142 – 102 – 12 = 28 > 12), with exogenous ingestion of an organic acid being the only answer that corresponds with this acid-base disturbance
• Excessive loss of bicarbonate = Type 2 renal tubular acidosis (non-anion gap metabolic acidosis)

https://step-prep.org

• Patient with a pulsatile hematoma = damage to an arterial structure
• Based on location at the base of the neck, the most likely vessel involved is the subclavian artery
• Note: If the thoracic aorta were damaged, the patient would likely have more severe hemodynamic collapse due to the amount of bleeding that would be produced

https://step-prep.org

• Organophosphates work by inhibiting acetylcholinesterase, thus leading to increased levels of acetylcholine that lead to overstimulation of parasympathetic functions and sweating (DUMBBELSS: Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm, Emesis, Lacrimation, Sweating, Salivation) by binding to Muscarinic receptors and lead to neuromuscular overstimulation and eventual blockade due to binding to nicotinic receptors

https://step-prep.org

• Patient who has never received vaccination against hepatitis B is stuck with a needle by a patient with labs consistent with active hepatitis B infection, so patient should receive both hepatitis B vaccination series and hep B immune globulin
• Infections that need to be treated with immunoglobulin: Dangerous infections To Be Healed Very Rapidly (Diphtheria, Tetanus, Botulism, Hepatitis B, Varicella, Rabies

https://step-prep.org

• Patient with an inflammed area of the distal radius with red streaks extending from the area towards the elbow, most consistent with lymphangitis
• Key idea: Most common pathogens are MSSA and Group A strep, and therefore empiric treatment is cephalexin

https://step-prep.org

I swear this changes on who you ask. I've seen it as either Isoniazid or Isoniazid + rifampin.

EDIT: 2 answers are correct here (thanks NBME!)

Per CDC

"As of 2018, there are four CDC-recommended treatment regimens for latent TB infection that use isoniazid (INH), rifapentine (RPT), and/or rifampin (RIF). All the regimens are effective."

https://www.cdc.gov/tb/topic/treatment/decideltbi.htm#:~:text=As%20of%202018%2C%20there%20are,All%20the%20regimens%20are%20effective.

• Elderly woman with rheumatoid arthritis presents with pallor and is found to have a microcytic anemia with a decreased TIBC (indicative of increased ferritin stores), most consistent with anemia of chronic disease
• Iron deficiency (microcytic anemia): Iron labs show low iron, increased TIBC and decreased ferritin (often seen in young women due to menses and in older patient is colon cancer until proven otherwise)
• Lead poisoning (microcytic anemia): Patient with exposure who has abdominal pain, neurologic symptoms, etc.
• Key idea: While rheumatoid arthritis can be associated with anemia of chronic disease, osteoarthritis is NOT associated with anemia of chronic disease

https://step-prep.org

• 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

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

• 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

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

• 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.)

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

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

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

• 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)

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

• 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

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

• 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

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

• 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

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

• 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/

• 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/

Am I the only one always see conversion disorder of UWORLD as reassure and follow-up. This test is giving me conversion disorder.

• 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/

• Unable to access audio, but patient has classic symptoms of a URI (fever, cough, rhinorrhea) and likely normal heart sounds (or a soft systolic ejection murmur)

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