Block 01 SIM 1 SIM 2 NBME 5

 In a normal distribution, mean ≈ median ≈ mode. Negatively skewed (looks like left hand pushed curve)
has a mode > median > mean and positively skewed (right hand pushes curve) has mean > median >
mode. In these skewed distributions, median is the best measure of central tendency.
 Low hemoglobin, MCV normal, haptoglobin normal, retics up, Coombs negative. RBC fragments and
intracellular deposits of denatured hemoglobin. Dx: G6PD, get a G6PD assay for NADPH formation. It’s
normal while acute attack is occuring but 1-2 weeks later repeat.
 Even in intellectually disabled patients with legal guardians asking for it, forced sterilization is unethical
and women must freely consent to own sterilization.
 Alcohol use disorder, cravings: naltrexone and acamprosate (glutamate modulator). Naltrexone
contraindicated in acute hepatitis/liver failure.
 Homeless person with poor PO intake, labs relatively WNL. Treated with dextrose and thiamine,
following day has severe muscle fatigue. Diagnosis: refeeding syndrome and hypophospatemia. This is
likely due to reduced Vit D and phos intake combined with extracellular shift to maintain homeostasis.
When glucose given, insulin secreted, shifts PO4 intracellularly and unmasks hypoPO4. Concern for
rhabdo secondary to hypoPO4 so check CK levels. Alcoholics frequently have underlying myopathy.
 Left DVT, started on heparin. Next day develops left sided facial symptoms. Non-con CT R MCA
ischemic infarct. Best test to determine mechanism: bubble echo (TEE) for paradoxical embolism
through PFO or ASD intracardiac shunt.
 8 yo M. 3 days of high fever, N/V/D, hypotensive. A1c 5.2%, ketones in urine, Glu 290, Na 128.
Mechanism of hyperglycemia: stress hyperglycemia, NOT T1DM. hyperglycemia + ketoacidosis +
sepsis picture without A1c indicating T1DM is likely stress. Maintain glu 140-180 in ICU.
 3 yo M. 5 day 40C fever, conjunctivitis, peeling and rash of skin, red tongue, normotensive, pulse 120.
Next best step: CRP, ibuprofen for suspected Kawasaki vs. viral illness. Can’t follow up in 3-4 days, has
to be next day because of coronary artery aneurysm risks (peaks at 10 days). Lymphadenopathy least
observed Kawa sx. IVIG and ASA reduces cardiac risks, morb/mort. After getting IVIG have to delay
live vaccines for 11 months. Get echo 2 and 6 weeks after.
 Headaches, rhythmic pulsating when bending over, on Accutane. Ophtho exam peripapillary flame
hemorrhages, venous engorgement, hard exudates, inferior nasal field constriction. Dx: pseudotumor
cerebrii (idiopathic intracranial HTN) that can lead to optic atrophy and blindness.
 58 yo obese male, car accident. Vitally stable. Absent cremasteric, bilateral UE+LE neuropathy.
Etiology: diabetic neuropathy, not spinal cord accident. L1+L2 cremasteric level.
 Cardiac cath performed. Third night chest pain, tachycardia, worse with deep breathing. scratchy sound
on systole left sternal border. Q waves, T wave inversion V2-V5. Dx: peri-infarction pericarditis, typically
within 4 days of MI. pleuritic chest pain worse with inspiration, pericardial friction rub. Diffuse PR

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 deprn/ST elevation can be masked by recent MI. low-grade fever may be present. High dose ASA >
NSAIDs and steroids b/c those will reduce scar formation and cardiac healing.
 2 days of burning with urination. Urine gram stain many neutrophils, no organisms. While NAAT is
pending, best antibiotic treatment: azithro for chlamydia (this is non-gono urethritis), as gono would be
G- diplococci seen. If patient returns possible for reinfection or resistance so repeat swab, possible M
genitalium which req moxifloxacin.
 7 yo F with purulent vaginal discharge, small streak of blood. No signs of trauma/abuse. Dx: vaginal
foreign body. Will lack vulvar symptoms. Likely toilet paper. Saline irrigation or cotton swab removal.
 Lap chole, 2 months later has daily diarrhea. Dx: postcholecystectomy diarrhea, which is bile salt
driven. Also seen with ileal resection, short bowel syndrome. Use cholestyramine to bind excess.
 Antifreeze ingestion vital sign abnormality: deep breathing. AGMA -> compensatory respiratory
alkalosis via Kussmaul. Also look for kidney, pulm edema. Best treatment: fomepizole, don’t give
ethanol at same time.
 4 yo F with fever, passive resistance to neck flexion. Family has pet cat, grandpa visiting from Asia.
Ophtho shows ill-defined, raised, yellow-white nodules near disks, CT basilar meningeal enhancement.
LP low glucose, high protein, 90% lymphocytes. Dx: tuberculosis, not cat scratch. Eye is choroidal
tubercules and classic TB meningitis is basilar meningeal enhancement with lympho pleocytosis of LP.
CSF for AFB. 2 months of RIPE + 8 wk of steroid -> 9 months of RIF+INH.
 Jehovah witness male, car accident. HOTN, Hb 5.5, refusing blood, understands situation. Next step:
don’t give blood, just fluid bolus and pressors. But for his underage daughter, cannot refuse life-
sustaining/threatening treatment, give blood. obv if mother there ask permission but give blood anyway.
 Pulm disaster patient is intubated, Sa88%, rales on right, reduced breath sounds on left. X-ray not
possible. Next step: likely R mainstem intubation so pull back on the tube.
 Bedside ultrasound now test of choice for suspected pneumothorax in crit care, but can still get x-ray.
Chest tube even if on mechanical ventilation.
 Axillary skin tags highly associated with insulin resistance (T2DM) >> Crohn disease perianal skin tags.
 Heavy vaginal bleeding, coag tests negative, vitally stable. Next step: high-dose estrogen OCP first, if
continue to bleed or can’t tolerate THEN IV estrogens. For abn uterine bleeding think PALM COEIN.
 Backpacking in South America, hx of BCG, hired at hospital. Test of choice: IGRA. PPD will be false +.
PPD req a 2-step confirmation because first can be negative (anamnestic), not so with IGRA. If IGRA+
and CXR negative, get INH x 9m for latent TB.
 T1DM, weight loss, fatigued. K 5.6, eosino 7%, lympho 40%, mildly HOTN, TSH 4, A1c 5.5. Dx:
Addison disease! (NAACP for eosinophilia) diagnose with Cosyntropin test. T1DM increases
autoimmune risks and Addisons will lower insulin requirements.
 H pylori serology positive, triple therapy treated. Best test for confirmation of eradication: fecal antigen 4
week post therapy completion. H pylori associated with duodenal ulcers, can do either urea breath test
(more accurate, less available) or fecal test 4 weeks after. Serology can be + 1 yr after.

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  Single episode of depression, responds to therapy. Continue for minimum of: 6 months. If multiple
episodes or suicidal attempt, 1-3 years or forever.
 IVDU hx, now has sudden severe headache, BP 200/100, fever, diaphoretic. Next test: non-con CT r/o
SAH but also meningitis so if CT negative get the LP (xanthochromia). After this resolves, patient has
diarrhea, body aches, persistent HTN. Next step: clonidine to blunt sympathetic opioid withdrawal sx.
 65 yo F with acute back pain after falling in driveway, used PO steroids occ for COPD, XR shows
compression frax. Next imaging/lab management: DEXA hip/spine. This is likely a fragility fracture. T-
score of < -2.5 will be dx osteoporosis (z-score is for same age group). Ca + Vit D + alendronate.
Initiate alendronate FRAX >20% for major fractures or >3% hip fracture.

Block 02
 81 yo M stumbled and fell. No LOC, no head injury. HTN, stroke 10 years ago. Physical exam WNL.
Test to perform: Get Up and Go, postural stability assessment of gait and balance.
 Right anterior knee pain worse by climbing, descending stairs, prolonged sitting. Ibu not helpful.
Crepitus, pain on extension with patellar compression. Dx: Patellofemoral pain. Stretches, thigh
strengthening. Pain typically reproduces on squatting, imaging not required.
 AM headaches, SOB lying flat. Lower muscle atrophy, tongue fasciculations. Mechanism of SOB:
diaphgramatic paralysis from ALS. FVC will be lower supine than upright. Sniff test w/ fluoroscopy.
 Kidney transplant, on cyclosporine, BP 180 K 3.5 SCr 1.1, started on amlodipine, enalapril. now BP 130
SCr 2.4. mechanism of HTN: RAAS due to transplant renal artery stenosis, injury exacerbated by
enalapril. Typically reduces GFR by 30% and a spike of SCr (basically an AKI).
 Diabetic mother, newborn has mild pulmonary congestion and a heart murmur, pulse ox normal. Dx:
transient hypertrophic cardiomyopathy?? Fetal hyperinsulinemia 2nd/3rd trimester, glycogen in IV
septum causing CHF, Echo to diagnose. Spont recovery without surgery. Ebstein with tricuspid regurg,
pulm valve stenosis with Noonan.
 Neck stiffness, fever, 5 yo M. parents refuse all treatment. Next step: treat, meningitis life threatning.
 Best way to study interaction of 2 factors while adjusting for others: multiple linear regression. Multiple
logistic takes dichotomous and other factors.
 Smoke 2 PPD, difficulty swallowing foods and liquids, aspirates. No alarm symptoms. Next best step:
nasopharyngeal laryngoscopy. Dysphagia with both solids and liq = neuromuscular; initial solid and
then liq is mechanical. Prob SCC.
 Pneumonia with urine Osm 500, urine Na 60. Dx: SIADH.
 Methimazole for Graves, now has positive preg test. Next best step: change to PTU since MTZ is
teratogenic in first trimester (aplasia cutis, TE fistula, choanal atresia) -> switch back to MTZ in 2nd and
3rd tri because PTU can cause liver damage.
 Dog bite yesterday, what to do with wound? Leave open to drain. Cats, humans, bites >12 h left open
to heal by secondary intention (except on face).

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  Drunk and endorses passive SI was a mistake. Next step: keep in ED and reeval when sober.
 MI 2 years ago. Chol 240, LDL 140, Trigs 400. Med of choice: statin. Established ASCVD, LDL >190,
DM >40, 10-year >7.5-10% gets a statin. Fibrate when trigs > 1000.
 Screening tests for Turner syndrome: 4-extremity BP, cardiac echo and abd for horseshoe kidney,
hypothyroid, celiac. Learning disabilities but also normal intelligence. Sporadic mutation.
 RA testing: RF, anti-CCP, ESR, CRP. Can start on NSAID while tests waiting for acute relief. All
markers can be negative (seronegative RA, less aggressive) but start on MTX either way.
 Odds Ratio = 2x2 table AD/BC
 Smoking crack cocaine and symptoms of MI, next best step: lorazepam. If still persistent cardiac pain
without EKG or trops, cath anyway because can be aortic dissection or carotid artery involvement.
 Borderline = Dialetical behavior therapy.
 Hypothyroidism on Synthroid, osteoporosis, takes Ca + Vit D with breakfast. Problem: Synthroid on
empty stomach, take supplements with lunch instead.
 MI 2 years ago, diabetes. CXR shows signs of CHF. Which diabetic drug can do this: pioglitazone.
 Gestational DM on insulin drip gives birth. What to do regarding GDM? D/C insulin drip, OGTT
postpartum and screen Q3 years.
 Spider angiomata, bilateral gynecomastia, unresponsive. Vomits bright red blood, BP 100/50 pulse 110.
IVF going. Next best step: ET intubation since cannot protect airway. Likely a variceal bleed. If Hb > 7
and INR is < 2 no need for FFP, go for the octreotide. After band ligation and at discharge, nadolol.
 Short term steroids (< 3 weeks) can be stopped abruptly without HPA insufficiency.
 In DKA add K if < 5.2. keep insulin until gap normalizes. Can switch to SQ if able to eat, glucose < 200,
anion gap resolved, bicarb > 15-20 (keep drip for 1 hr after SQ admin).
 Dx: small bowel obstruction with some air in distant colon. Next step: stabilize. This is not a complete
SBO so no need for immediate surgical intervention. Will often resolve with supportive tx, if not
improving within 24 h, then surgery.
 Syphilitic meningitis can have prodrome for days and not as sick as regular bacterial meningitis. CSF-
VDRL positive. Can have uveitis and other cranial neuropathies.

Block 03
 In regards to complementary/alt medicine, as long as it doesn’t interfere with real care its OK.
 Forceful vomiting, now has epigastric and retrosternal chest pain. Small amount of bright red blood. has
fever, neck veins flat, reduced breath sounds, stool positive. Dx: esophageal perforation. This is
Booerhave syndrome and acute mediastinitis; distal third of esophagus with left pleural effusion.
Mallory Weiss would not present with fever or chest pain or vital instability. Best test for esoph perf is a
water-soluble esophagogram (gastrografin?)
 Dizziness w/ unilateral reduced hearing + tinnitus, taking ASA 2-3 times a day. Dx: Meniere disease.
ASA would not have unilateral sx.
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 OCD: persistent, unwanted, intrusive thoughts.
 17 yo M ran 12 miles 2 days ago, cola urine with 100+ RBC/hpf. Next step: repeat in 1 week.
 CAD, T2DM, HTN, 1 hour of sudden vision loss in right eye. Cherry red macula. Dx: CRAO.
 3 months of tiredness, on Topamax. Nephrolith hx. TSH 5.7 x2, FT4 WNL. Next best step: anti-TPO
antibodies for subclinical hypothyroidism, likely Hashimoto. Anti-TPO assoc with miscarriages.
 Just get a pregnancy test and ask if planning to get pregnant for any woman under 50.
 Sudden-onset L chest pain, worse with inspiration and movement. Pleural friction rub. Sinus tachy, L
costophrenic angle blunting. V/Q scan low probability of PE. Dx: PE. Only a normal V/Q scan rules out
PE, low/mod does not rule out PE.
 Melasma: hyperpigment macules on malar and centrofacial/jaw distribution. Pregnancy, UV exposure.
Minimize sun and use sunscreen. ?hydroquinone, finacea, retinoids (obv not when preg).
 Delivery via vaccum-assistance, soft uterine fundus, heavy vaginal bleeding with clots, vital stable. Next
best step: uterine massage and oxytocin for uterine atony, MCC of postpartum hemorrhage. PPH >500
vaginal >1000 csection, first massage+oxy then methergine/hemabate.
 Swallow button battery, next best step: stat endoscopic removal, it’s battery + stomach acid = burns.
 s/p chlamydia treatment with azithro+ceftriax. Knee, ankle joint swollen. Aspirate 80% neutros, no
organisms. Next step: NAAT for chlamydia, this is reactive arthritis. ABX+NSAIDS.
 Acute cystitis in pregnants abx: 1st UA+urine culture, then Keflex, nitro, augmentin. Always get UA/UC 1
week after for test of cure.
 Acute pyelo in preg treated with daily suppressive therapy until 6 weeks postpartum.
 PRLoma -> low FSH, LH -> low E -> osteoporosis. In most cases PRLoma respond to DA agonists.
 URTI 2 weeks ago, hypercalcemic, PTH elevated. PTH adenoma removed. 2 hrs post op, facial
asymmetry. Dx: Bell palsy? Elyte changes would be bilateral, not unilateral…
 Asymptomatic kid, venous lead 60. Next best step; PO succimer; no treatment < 45.
 Normal newborn has heel prick hematocrit 70%. Next step: recheck via peripheral blood draw.
Neonatal polycythemia (Hct >65%) always rechecked. If still elevated and symptomatic, do partial
exchange (asympto can be observed 24 h)
 On Cipro, stool C diff +. Next step: PO vanco (or PO dificid). If recurrent, do a very slow PO vanco
taper or dificid.
 Pooled analysis shows p <0.05. Stratifying w/factor shows p > 0.05. this is due to: effect modification.
Report separate p values for with and without stratifying factor.
 6 yo F has acne and body odor. Areola enlarged, bone age 9 years, pubic hair. FSH, LH elevated, 17-
OHP WNL. Dx: central precocious. GnRH agonist.
 Marfans get an echo for aortic problems prior to sports.
 Cleft lip/palate is multifactorial. Rule of 10: 10 lb, 10 weeks old, Hb 10.0 for surgery.
 Episodic headaches pts should keep a headache diary.
 Widespread pruritus, occasional urticarial, tense bullae: could be BP so get a bx from skin EDGE.
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Block 04
 Progressive forgetfulness, difficulty walking, reduced vibration sensation, spasticity, hyperreflexitivity.
Likely to be B12 deficiency. Subacute combined degeneration (SACD) which is DCML + LCST. Will
show mild indirect hyperbili (also low hapto, high LDH) because of insufficient hematopoiesis ->
intramedullary hemolysis. No reticulocyte response.
 High sensitivity: negative rules out (SNOUT). High specificity rules in (SPIN).
 Previous pregnancy GBS+ culture 36 week gestation. Now pregnant 39 weeks, fetal status OK, not
tested for GBS this time. Next step: ABX at 18+ hrs for PROM, apparently not for previous GBS+.
Intrapartum ABX for: GBS UTI/bacteriuria in current, GBS+ rectovaginal culture in current, unknown
GBS AND <37 wks or fever or ROM >18h in current, or neonatal GBS in prior…
 Suspect HIV with mucocutaneous ulcers or generalized rash.
 Tons of C/I to estrogen but: thromboembolism, isch stroke, hypertension, smokers > 35, migraines with
aura, DM with end-organ damage.
 Ginko, ginseng, garlic, saw palmetto all increase bleeding.
 In order to overcome observer bias (physicians aware of participant allocation) use randomization to
blind.
 Asymptomatic male has bicuspid aortic valve with no dilation of root and mild gradient. Next best step:
echo of first degree relative?
 Camping in North Carolina, rash and petechiae on wrists. Fever, TCP, no leukocytosis. Dx: RMSF,
doxy for ALL patients including children and pregnants.
 Woman has a right femoral hernia that is reducible. Next step: refer to surgery because can become
incarcerated/strangulated.
 Renal cell carcinoma through renal capsule -> radical nephrectomy.
 Recurrent pressure chest pain, EKG T inversion V5 V6, trop negative. Next step: exercise stress test.
This is unstable angina (ACS without biomarkers). TIMI 0 = stress test.
 Intracavernosal alprostadil needs reversal, drug: intracavernosal phenylephrine.
 Patient on doxorubicin. How to monitor heart? Radionucleotide ventriculography (MUGA).
 Paget disease of skull shows “cotton wool” / nonhomogenous density, get Ca + AlkPhos levels. Once
confirmed Paget get a nuclear bone scan for other involved sites. Tx bisphosphonates which may slow
down hearing loss, doesn’t reverse already damaged.
 20 wk pregnant, normal labs, 1 cm gallstone without wall thickening or perichole fluid. Best intervention:
reassurance. Most preg gallstones resolve spont within 2 months of delivery.
 Wearing seatbelt, car accident. Open femur fracture, ORIF. Next morning has tenderness to seatbelt
area, rales over lung, murmur. CXR irregular opacification of LUL. Dx: pulmonary contusion. Resp sx
delayed ~24h, CT better detecting but not as worrisome as those detected on CXR (worse clinically).
Control pain, O2, vent, will resolve within 1 week.

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  On chemotherapy and TPN. Now has fever, R eye pain, fundo shows white lesions extending from
chorioretinal into vitreous with haze. Dx: candidiasis, not aspergillosis. TPN = candida ->
endophthalmitis. Aspergillus endoph is hemorrhagic. Tx: systemic ampho B, intravitreal, vitrectomy.
 Rosacea often have ocular symptoms including recurrent chalazion (granulo inflame of Meibomian
gland, pea-sized nodule within eyelid).
 Recent otitis media, now has retracted tympanic membrane with yellow fluid and reduced mobility. Dx:
serous otitis media/OME. Common to occur, can last ~3 months. Watchful waiting.
 Power is dependent on sample size. in order to detect rare effect, have to have a ton of n=.
 Severe sudden back pain, on Synthroid, no calcium products. Total protein 8.1, albumin 3.5. next best
step: SPEP and UPEP, this is multiple myeloma. Look for CRAB but I honestly just looked for a gamma
gap (total protein – alb > 4) and that’s MM.
 Amiodarone can cause any effect with thyroid. Hypothyroid (Wolf-Chaikoff) or hyperthyroid (Jod-
Basedow) but it definitely like steroids reduces peripheral T4 to T3. Repeat TFT in a month.

Block 05
 Everyone 13-65 gets HIV screening (p24 antigen, HIV antibodies).
 Thelarche first sign of puberty -> menarche 2.5 years later.
 Relative Risk, RR = risk exposed/unexposed.
 Marked change in behavior in child after moving into new house, think child abuse.
 LP shows 75,000 RBC but no xanthochromia, normal otherwise. Dx: traumatic tap. WBC/RBC ratio
≤ 0.01 is not meningitis.
 Chest pain. EKG NSR, 2x troponin normal, severe osteoarthritis. Get pharmacologic stress testing
(adenosine, dobutamine).
 If you want to detect a very small change, you will need a larger n=.
 Low Hb, MCV <80, RDW 14%. Since RDW is normal, this is actually a genetic cause, so thalassemia,
get an electrophoresis to distinguish α from ß. ß will have high Hb A2 levels.
 With chronic diseases, some patients can have slow course, others more rapid. Slow course will be
less fatal and diagnosed with screening, falsely equating screening with improved survival: length-time
bias. LEAD-time bias diagnoses disease earlier without improvement in survival either.
 Dermatitis, tenosynovitis, polyarthralgia: triad of disseminated gonococcal infection. Give combo
Ceftriaxone + Azithro not just for double coverage but increasing gono resistance.
 Complete, smooth, circular hair loss with distinct margins: alopecia areata. High chance of recurrence
even with successful treatments.
 New mom breastfeeding. Upper outer quadrant of breast is erythematous, tender, no fluctuance. Dx:
lactational mastitis, Tx: dicloxacillin/Keflex and continue to breastfeed. This is clogged pores. If
becomes indurated and fluctuant, get ultrasound before I&D.

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  Acute diarrhea with blood and mucus, dx: dystentery, get stool culture, Shiga toxin assay, fecal
leukocyte count.
 Man has erectile dysfunction with wife but has nocturnal erections. Dx: psychogenic.
 Mono and prescribed amoxicillin, now has rash. Next best step: observation. Will have fatigue.
 Transfusion parameters: <7 or ≤8 in ACS/major surgery patients.
 Remember FRAX > 20% or >3% at hip -> bisphosphonates.
 ITP is due to autoantibody against GP2B/3A. 1st steroids//IVIG, 2nd rituxan, 3rd splenectomy.
 Weakness for 2 months, 3/5 deltoids and hip flexors, normal DTRs. On statin. AST ALT in hundreds,
CK thousands. Dx: inflammatory myopathy, likely poly (if no derm sx). Get antibodies, definitive is
biopsy and CANCER screening. Polymyositis develops interstitial lung disease with anti-Jo-1.
 Fight bite = Eikenella, I think part of HACEK endocarditis bugs. Augmentin and TDaP.
 2 week old girl with Tbili 10, Dbili 0.6, eating and pooping. Dx: breast milk jaundice. Continue feeding.

Block 06
 40 week gestation, pushing. Gets oxytocin. After 3 more hours, still not descending. All vital stable.
Next step: c-section for arrest of labor (no change fetal station w/3 hrs of pushing). Commonly due to
fetal malposition and cephalopelvic disproportion.
 Loss of pain and temperature on right side of face, left trunk and limbs: Wallenberg (lateral medullary).
 Postop hypercapnia and hypoxic respiratory failure, think residual anesthesia. Normal A-a gradient, just
give suppl O2.
 Sensitivity analysis repeats primary analysis after removal of criteria or variables (how is this not effect
modification?)
 4 year old girl has pear-shaped motile organisms and pH 6 vaginal discharge: sexual child abuse.
 Questionnaires are rife with recall bias in case controls, over-estimates exposure risk.
 Likelihood ratio: prob of a test result occurring in a patient with disorder compared to w/o disorder.
 Antimuscarinic toxicity won’t have diaphoresis, but otherwise very similar to amphetamine tox.
 21-OHase CAH will have salt wasting, hypoNa, hyperK. High lab 17-OHP. hydrocortisone
 Women who have sex with women higher chance of developing BV (metro/clinda).
 Initially clear vomit, now tinged with blood. vitally stable. No esoph varices, stomach fundus varices. Dx:
splenic vein thrombosis (short gastric and gastroepiploic vein) esp in pancreatitis.
 Primary dysmenorrhea tx: prostaglandin mediated so NSAIDs > OCP (if sexually active OCP 1st?)
 Sickle cell, now has left leg tender to palpation, no response to oxy. Next step: IV morphine for VOC.
Make sure to rehydrate and oxygenate. Sickle acute chest syndrome treated the same as CAP and
gonorrhea: azithro + ceftriaxone.
 8 mm ureteral stone, no hydronephrosis. Next step: Flomax and d/c.
 High MCV, low B12, test for: intrinsic factor antibodies. EGD will show atrophic gastritis in fundus.
 Ecologic correlational studies can’t always be applied to individual (eco fallacy).
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  Thoracentesis shows lymphocyte predominant, adenosine deaminase exudate. Dx: Tuberculous
pleural effusion, work up for HIV. This is a hypersensitivity to TB/antigens, fluid smear is negative unlike
tuberculous empyema, requires pleural biopsy. Could also be malignancy?
 All unexplained new onset heart failure should be evaluated for CAD with stress testing / angiography.
 Airway inflammation in acute bronchitis can cause small-volume hemoptysis, do a CXR.
 Adjustment disorder begins within 3 months of identifiable stressor.
 STEMI EKG: new ST elevation at J-point >1 mm, new LBBB -> PCI
 SSRI sex dysfunction, switch to Wellbutrin
 Asthma exacerbation during pregnancy: SABA + steroids OK, avoid epi (↓ blood flow to fetus)

Block 07
 Food stuck in chest, iron deficiency anemia, LES relaxation normal. Dx: diffuse esophageal spasm,
barium swallow will show corkscrew. Standard dx is manometry. CCB therapy.
 No leakage of urine with coughing, has strong sensation and can’t make it to the bathroom. PVR 30
mL. next step: bladder training with timed voids for urge incontinence. Then Detrol.
 Irrigation of right auditory canal with cold water: transient conjugate slow deviation of gaze to right,
saccadic correction to midline = psychogenic coma.
 Patients can leave hospice to get life prolonging tx, can return as long as prognosis < 6 mo.
 Acute stress disorder = PTSD but 3 days – 1 month; after 1 month = PTSD.
 BRBPR and got chemoradiation, this is radiation proctitis. Typically within 6 weeks of radn.
 Within 3 days of zoster symptoms, just start on Valtrex, no need for PCR this is a clinical dx. Place pt
on contact and airborne precautions.
 Pregnants with HIV: triple therapy throughout preg, do not breastfeed.
 Snapshot in time = cross-sectional study, observational. Infer, cannot prove causation.
 Sexually active 17 year old girl, when to perform PAP? At 21.
 Likelihood ratio + = SN/(1-SP); LR- = (1-SN)/SP.
 MS pregnants have a higher increase in assisted delivery and csections. Tx acute with steroids,
spasticity with baclofen.
 Fetal head at 0 station, then at -3 station w/late decels. Next step: prob uterine rupture so c-section.
 Intensive glycemic control in T2DM reduces microvascular (nephro/retino/neuropathy) but NOT
macrovascular (MI, stroke), can even increase mortality.
 Cirrhotic patients in hospitals higher risk of developing SBP. Cipro prophylaxis?
 GCS ≤ 8 = INTUB8.
 Persistent nosebleed -> pinching nostril, topical vasoconstriction. Not > 3 days because of rebound.

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Block 08
 Anabolic steroids will increase Hb and Hct.
 Point of starting a statin prior to MI: primary prevention.
 Home-canned fish. Bilateral ptosis, facial weakness, pupil dilation, no lower extremity stuff. This is
botulinism, opposite of Guillain-Barre.
 Infantile hemangiomas grow within first year of life. If on eyelid or airway, require propranolol or surg.
 Gallstone pancreatitis: cholecystectomy within 7 days of improvement in same hospitalization.
 SSRI ok with breastfeeding.
 HIV has more diarrhea and rash, not exudative pharyngitis (mono). If airway obstruction, steroids.
 Multiple Myeloma can cause hyperviscosity syndrome (Waldenstrom).
 Suspecting tuberous sclerosis: brain MRI for hamartomas, EEG for seizures, fundoscopy, skin exam.
Epilepsy MCC death.
 3rd trimester w/ painful vaginal bleeding, tender uterus, late decels = placental abruption.
 Postpartum endometritis ABX = clinda/gent. Or cefox/doxy is for PID…I guess avoid bc breastfeed.
Highest risk factor is csection.
 Old person with delirium: start thinking infx, get a CMP and urinalysis. If tearing out IV and violent,
Haldol.
 Meningococcal meningitis contact prophylaxis: ciprofloxacin, also maybe rifampin.
 Multiple UTIs related to intercourse: postcoital ABX prophylaxis.

Block 09
 ADHD -> parent-child behavioral therapy. Prior to starting stimulants get a cardiac H&P, routine EKGs
are not indicated.
 Kidney transplant, A+. sister is A+, suicide attempt in psych facility. Mother has asthma, A+. Get it from
mother, untreated psych disease C/I.
 Blood transfusion, then severe BIL flank pain, fever, urine dark. This is ABO mismatch, stop and
hydrate with SALINE.
 Older patients get apathetic thyrotoxicosis that can present as dementia.
 Ask all postmenopausal women about vaginal dryness and dyspareunia.
 Concussion. Monitor for 24 hrs, graduated return to play no sooner than 1 week. Must be asymptomatic
for 24 h prior to returning.
 AOM, now has high fever, swelling and tenderness posterior to ear. This is: mastoiditis due to mastoid
air cells. Tympanostomy to drain material along with IV ABX (esp for pseudomonas).
 Sputum reveals squamous cell carcinoma. Next step: you named it, now you have to stage it: chest CT.
 36 week preg. Cervix 4 cm, 50% effaced, OP position, neg GBS. Next step: steroids.
 Narrow QRS tachycardia think PSVT -> vagal, adenosine

r/Step3 | 10
  Tabes dorsalis – syphilitic involvement of DC/ML, don’t forget the pupils too.
 Ruddy complexion, Hb 18, smoked, hematuria. Next step: CT abdomen for RCC.
 Newborn with jaundice, direct antibody test +, TBili 25. Next step: exchange transfusion for severe
hyperbili (>20).
 All children with febrile UTI age < 2 should have a renal/bladder ultrasound to eval for hydro and
ureteral dilation (anatomic abn).
 17 yo F clicking in R hip. Left pelvis drops when right weight bearing, right toe tips while left foot flat.
This is hip dysplasia, abn acetabular development.
 Stress EKG shows no abnormal ST changes which means a low risk for cardio events in future.
 Breast cyst fine needle aspiration of thin green fluid, mass resolves without symptoms. Next step:
ultrasound in 4-6 weeks.
 No further workup for chronic urticarial? Intense pruritus esp at night. Testing for systemic sx. Treat with
2nd gen (Zyrtec, Claritin) > 1st gen (Benadryl, Atarax). Will spont resolve.
 Pravachol in HIV patients because of little CYP interactions.
 4.6 kg infant has cephalohematoma, arm pathology -> macrosomia.
 Suspecting scoliosis -> forward bend test, xray. If Cobb angle < 10 it’s a normal variant. >40 surgery.
 Protrusion of cervix through vaginal introitus -> pessary placement for pelvic organ prolapse.
 Don’t forget DM is a CAD equivalent so if ≥ 40 with DM, automatically get statin.

Block 10
 T1DM and black eschar in nose with bloody drainage. Tx: lipo Ampho B for mucormycosis.
 Hawthorne effect – observing subjects changes their behavior.
 Lewy body dementia – fluctuating cognition, PKSN, REM, visual hallucinations. Very sensitive to
antipsychotics which can cause autonomic dysfunction, cognition, PKSN.
 Arthritis + Fever + Dermatitis = serum sickness. Can occur with acute Hep B.
 Sickle splenic sequestration would have anemia, reticulocytosis.
 Spondyloarthropathy will have leukocytosis but no pathogen isolated; only ~50% are HLA-B27+.
 ADHD stimulant use not associated with incr risk of substance use.
 Suspecting Duchenne -> get CK level, genetic analysis for dx.
 Not returning to baseline between seizures = status epilepticus.
 Warts take 2-3 weeks to clinically resolve, continue tx for 1-2 weeks after.
 TDaP contraindicates: anaphylaxis or encephalopathy within 7 days (give Td instead).
 Painful during ejaculation, mildly tender prostate, aseptic = chronic prostatitis. Alpha blockers, ABX.
 Capillary lead level 35. Next step: venous lead level. Treat if > 45.
 MELD score composites: bilirubin, INR, SCr, sodium.
 Sclerosis often has interstitial lung disease, get PFTs.

r/Step3 | 11
  After PE, patient develops HIT, switched to argatroban. Start warfarin when -> plt count recovers.
 In absence of trauma or nephrolith, first step in hematuria is -> urinalysis.
 Initial lab workup for dermatomyositis – ANA and Ro, La, Sm, RNP, Jo-1, CXR for lung disease.
 Even after orchiopexy for undescended testis, malignancy risk remains.
 Euthyroid sick: low T3, repeat in 8 weeks.
 Infertility is after 12 months (women >35 = >6 months). First step is semen analysis.
 Asymptomatic LVEF ≤ 40% -> start ACEi.

Block 11
 Mitral valve prolapse sound: non-ejection click with mitral regurgitation (systolic, as the valve cusps
extend into the atrium during systole). With squatting the click can disappear, with Valsalva earlier.
 EF 30%, on lots of cardiac meds, EKG Afib RVR. Long-term med management: Amiodarone.
 Horizontal laceration of right upper eyelid, which structure damaged? Levator muscle. Or septum?
 Adolescent pregnancy is a risk factor for preterm delivery, gastro/omphalo, low birth weight, mortality.
 Hyperpigmented spots on chin, shoulder, chest, back. Aunt has BIL deafness. Dx: NF2.
 Risk factors for spont abortion: age >35, hx prior spont abortion, high BMI, substance abuse. MCC of
spont abortion is chromosomal abnormality, uterine anom, infx, DM, HTN, teratogens.
 Critically ill patients who are NPO and then started on feeds, always remember refeeding syndrome
and monitor PO4.
 Transplanted organ viability – fluids, pressors, slight hypothermia.
 Right hand shaking that diminishes with movement, passive resistance to flexion. Best tool for
diagnosis: it’s psych obv no biochemical tools, just physical exam and clinical presentation. Often has
asymmetry and unilateral onset. DATSCAN possible but $$. MRI limited.
 Lupus: anti-dsDNA very specific and correlate with disease activity, nephritis. ANA sensitive (first test).
 Lupus pleurisy (pleural effusion) tx with Pred and Plaquenil?
 Bad prognosis for CLL: organomegaly, lymphadenopathy, anemia, TCP.
 OCP, Hep C, hyperpigmentation of face and blisters on back of hand. Dx: PCT.
 1st step in chronic diarrhea is stool analysis (even if weight loss and alarm sx, no EGD?)
 Celiac disease due to malabsorption will have microcytic anemia and osmotic diarrhea (gap > 125)
 In acute decomp HF if inadequate response to diuretics give a vasodilator to reduce preload (nitro).
 If suspecting scaphoid frax and Xray negative, always splint wrist and repeat in 1 week. MRI best. If left
alone can have nonunion and avascular necrosis.
 38 week gestation, has outbreak of genital warts. What to do for delivery? Expectant management.
Even though HPV can be vertically transmitted most common is juvenile respiratory papillomatosis.
Csection doesn’t prevent vertical transmission therefore just go vaginal.
 16 yo F with rubbery 4 cm mass in superior outer quadrant, will reduce in size after period.

r/Step3 | 12
  IVDU 20 years ago, now has nausea and skin rash, BIL absent ankle reflexes, rash on legs, 2+ blood
on urinalysis, low complement, positive RF. Diagnosis: cryoglobulinemia from Hep C. typical triad is
palpable purpura, weakness, arthralgia. Tx cryo with antiviral therapy and immunosuppressive (ritux
pred)
 High grade villous adenoma, next cscope = 3 years.
 Brother diagnosed with colo cancer age 52. When should 40 year old male get screened? 40. Risk
higher if first degree relative diagnosed prior to age 60.
 High PTH level, DEXA of -2.6 at L spine, next management: not bisphosphonates but PTHectomy.

Block 12
 Person from South America has diskinetic thin LV with apical aneurysm. Dx: Chagas infection, dilated
cardiomyopathy from Trypanosoma cruzi. Can also develop GI disease (megacolon).
 Old man with back pain that is better bending forward, worse when extending back. Dx: spinal stenosis,
confirm diagnosis with MRI not Xray.
 Osteomyelitis initial exam screening: probe-to-bone. Xray often not good until advanced disease. Gold
standard test is MRI very high sensitivity. Bone biopsy with culture for testing.
 Intention to treat compares two interventions with all participants no matter what happened, as if the
reason pt dropped out was because of the intervention. Avoids crossover and attrition, and is very
conservative for intervention’s effect and reduces false + (imagine someone dying 1 week into therapy).
 After 28 day tx with Doxy most Lyme arthritis will be fully cured.
 Just screen all teenagers for depression and suicidal ideation.
 Cant use podophyllin for internal genital warts esp not in preg.
 Left eye swelling, fever, what is the most dangerous physical exam finding? Painful extraocular
movements, upgraded from preseptal cellulitis to orbital cellulites. Get a CT scan.
 Firm testicular mass that does not transilluminate -> get BIL scrotal ultrasound, and if solid, serum
tumor markers.
 Lithium toxicity: try hydration then dialysis.
 Presenting with Lichen Planus, test blood for -> hep C
 Best therapy for OCD is exposure and response therapy.
 EGD shows Barret esophagus without dysplasia, no H pylori. Started on PPI, next step: repeat EGD 3-
5 years later.
 27 yo F with 1 year of anger that begin a week before periods and resolve with bleeding: this is
PMS/PMDD so Rx SSRI, will increase risk for depression.
 Urgent or emergent surgeries can be done in hypothyroid patients as long as myxedema coma not
present. Loading with synthroid can cause ischemia or arrhythmia.
 Cellulitis that is more painful to palpation than expected -> think S pyogenes nec fasc. If crepitus think
C perfringens or B fragilis.
r/Step3 | 13
  Most cases of asymptomatic bacteriuria resolve within 2 weeks. Tx in: pregnant, urology procedures,
within 3 months of renal transplant.
 In ALL pts suspected dementia always get: B12, folate, TSH, screen for depression.

Block 13
 Multiple sexual partners associated with highest risk for PID.
 Within 1-2 weeks of starting iron therapy, reticulocyte count increases, and a month later Hb/HCT.
 Teenagers have postural kyphosis due to slouching. If no neurologic abnormalities, no treatment.
 Young woman, anemia, back pain, low Ca + Vit D = celiac disease.
 Vulvodynia has a positive Q-tip test. Tx is CBT, pelvic floor physiotherapy.
 Hematochezia + hemodynamic instability -> EGD.
 CXR: pulm edema, prominent pulm arteries, elevation of left mainstem bronchus, left atrial
enlargement. Diagnosis: mitral stenosis, possibly from rheum heart dz.
 PMR and temporal arteritis are clinical dx but get an ESR. High ESR is very sensitive.
 tPA blood pressure must be <185/105 and >140/90.
 Early immobilization and operative fracture fixture reduces fat embolism; supportive care tx.
 If responding to Prozac but too jittery/insomnia just try another SSRI.
 Cat scratch tx = azithromycin
 Placenta previa workup: transvaginal ultrasound, NOT digital cervical examination. Requires csection.
 Amniotic fluid embolism occurs during labor/immediately postpartum and can cause DIC. Supportive tx.
 Congenital hypothyroidism likely to thyroid dysgenesis, start hormone supplementation ASAP.
 Pemberton test – facial plethora or engorgement of neck veins concerning for thyroid lymphoma.
 ABPA can cause bronchiectasis, bronchial wall thickening. PO prednisone, itra/vori.
 Scabies uncommon above neck except in children. 5% permethrin for 14+ hours.
 Massive PE can present with new RBBB and tricuspid valve regurg.
 Stress ulcer prophylaxis: mech vent, head trauma, GI bleed, coagulopathy; steroids, sepsis.
 Intussusception due to Peyer patch / Meckel diverticulum, dx air or water sol enema. Intussusception is
apparently a medical emergency so just do it even if guardians not there. Since it can cause
perforations get a AXR afterwards.

Block 14
 15 mo F, 4 days of fever. Rhinorrhea, cough, conjunctivitis, rash on cheeks, anterior cervical lymph
nodes. Dx: Measles (cough, conjunctivitis, coryza).
 In compartment syndrome, edema in that area results in myonecrosis and myoglobinuria, renal failure.
 Cardiogenic shock: ↑ SVR, ↑ PCWP, ↓ Cardiac Index, ↓ BP.
 Pallor and fatigue following syncope, think vasovagal etiology.

r/Step3 | 14
  Standard caloric intake is 30 kcal/kg/day with 1 g/kg of protein.
 Lateral wall of ventricle is left circumflex artery.
 Early AM cough, wheezing, sputum, nothing throughout day. This is likely: GERD, try a PPI.
 Hepatic encephalopathy can be precipitated by diuretics, causing hypovolemia, hypokalemia, metabolic
alkalosis – resuscitate and replete with temporary d/c of diuretics.
 CENTOR < 3 managed symptomatically, ≥ 3 get a RAST prior to ABX.
 Thinking Dilantin supratherapeutic, rather than D/C just reduce the dose.
 Patient with a confirmed ischemic stroke, next best test: bedside swallow evaluation.
 Q6394 is bullshit, no one would let a stroke BP ride that high for 24 h
 Down syndrome infant, SOB with blue face during feeding. Next step: Echo for endocardial cushion
defects.
 Obstructive dysphagia triad: difficulty swallowing solid food, prolonged chewing, swallowing small
portions.
 EKG shows narrow complex tachy with afib, no palpable pulses. Next step: this is PEA so
compressions.
 1 month after triple therapy for H. Pylori, no symptoms. Next step: stool antigen test.
 Nonfrontal scalp hematoma very concerning for skull fracture esp if parietal area.
 Biochemical confirmation of pheochromocytoma, next step -> MRI of abdomen; MIBG if negative. After
surgery most commonly hypotensive (since removal of adrenergics)
 Guillain-Barre syndrome, check vital capacity at bedside because 1/3 req mechanical ventilation.
Treatment includes PLEX and IVIG, do NOT give steroids. If ambulatory, no tx req; tx shortens
recovery time.
 Symptomatic hyperthyroidism -> ß-blocker and probably methimazole to induce euthyroid state prior to
surgery (if preg, PTU 1st tri and MTZ rest). Check labs 2 months afterwards, esp. TT3 and FT4.
 WPW syndrome requires catheter ablation.

Block 15
 Car accident, leg pain. Knees hit dashboard. Knee has mild swelling, stiffness. Likely: posterior cruciate
ligament, force applied directly to anterior knee (contre-coup I guess)
 Blood transfusion and has hyperactive DTR. Mechanism: hypocalcemia due to citrate in blood.
 Urine calcium:creatinine ratio < 0.01 = familial hypocalciuric hypercalcemia syndrome. Reassurance.
 When to give ABX for endocarditis prophylaxis: prosthetic heart valve, previous IE, unrepaired CHD.
 Oropharyngeal thrush, multiple small papules with central umbilication, hemorrhagic crust. This is: HIV+
cutaneous Crypto, get a biopsy. Typically CD4 <100.
 Recall bias == misclassification of exposure, case-control design.
 MCC decreased vision in elderly = cataracts and macular degeneration.
 Risk fx for dental caries: diet, sugary beverages, nighttime bottle feeding, ↓ fluoride.
r/Step3 | 15
  Well-demarcated bright-red, tense, warm skin = erysipelas, due to GAßHS.
 Heat stroke mechanism: cannot sweat enough to lower body temperature.
 Pituitary incidentaloma, asymptomatic -> periodic MRIs.
 If pregnancy test is an answer just get the fucking test
 46 yo F with serous discharge from breast, next step: mammogram + ultrasound. Breast discharge is
pathologic if unilateral, persistent, spontaneous. ≥ 30 = XR+US.
 GERD + severe abdominal pain, hemo stable, next step: upright AXR to R/O perforation. If peptic ulcer
perforation ABX+Fluids. If operated on obv adhesions and bowel obstruction can develop.
 Age is the most important risk factor for osteoporosis and bone frax.
 Thick, protruding rectal mass with bluish discoloration, concentric rings: not hemorrhoids but
PROLAPSE.
 Low-dose CT for lung cancer: 55-80 yo, ≥30 pk and current/quit within 15 yrs. Earlier to quit means
better lung functioning which includes COPD exacerbation.
 Window period for HIV is 1-4 weeks, always repeat. New HIV requires HBV testing (tenofovir?)
 Renal transplant on tacrolimus and steroids, will develop T2DM later on, screen for it.
 DM dx: A1c ≥6.5%, FPG >126, RPG >200 + SX
 Breast implant post-op complications include capsular contracture, shape distortion, rupture. No
problems to fetus. Can breast feed. Get regular mammograms (MRI because scarring?).

Block 16
 Palliative care can be offered at any time even with disease-modifying therapy, unlike hospice.
 Angiodysplasia associated with aortic stenosis, vWD
 Apical diastolic murmur and acute arterial occlusion. Possible dx: atrial myxoma.
 In emergency situations patients lacking DMC can be treated under implied consent.
 Intention to treat preserves randomization.
 6 mo M poor feeding, eyelids droopy, hypotonic, dx: botulinum. Early constipation, descending
paralysis, reduced DTR. IV botulism immune globulin, full recovery expected.
 Lead level between 5 and 44, repeat venous level in 1 month.
 Peripartum cardiomyopathy typically resolves, some can have persistent. Serial echo to evaluate. If
persistent, future pregnancies inadvisable.
 5 week old boy, rhinorrhea, nasal congestion. Bilateral crackles, intermittent apnea. Father and older
sibling have same sx, no cough. Dx: RSV bronchiolitis. If premature or CHD -> can develop apnea.
 Croup = hoarseness, barky cough, inspiratory stridor from parainfluenzae.
 Patient is HIV+ and lab tech splashes urine sample in eye. Urine, feces, tears, emesis are
noninfectious unless blood is in them…no PEP so just irrigate eye and counseling? BS.
 ß-hCG discriminatory zone is >1500. Ectopic location ampulla

r/Step3 | 16
  poor prognosis in low back pain: advanced age, psych comorbidity, prolonged bed rest, use of opioids,
catastrophizing, poor recovery expectation (prob most telling).
 OGTT at 24-28 weeks, if <140 1 hr later good to go. If not, 100 g load and check 3 hrs later. If ≥2 are
elevated you have dx GDM.
 Can resume sexual activity post-MI if successful revasc without ischemic symptoms within 1 month
 Nitrofurantoin contraindicated at term pregnancy due to hemolytic anemia risk
 Apparently if tunneled catheter in place and suspecting infection, can leave in place while ABX??
 If S aureus bacteremia, think -> heart valves, lungs, spine. Vertebral osteo can have XR normal for 2
weeks so MRI spine best.
 Contact lenses, now has purulent drainage and eye matted shut. Dx: bacterial conjunctivitis, usual
SHiM bugs tx w/polytrim but with contact lenses also think Pseudomonas -> topical Cipro . bacterial
conjunct can progress to bacterial keratitis (inflammation of cornea; will show corneal ulceration w/
fluorescein).
 25% of C Diff will recur, restart PO Vanco and slowly taper it. Or Dificid.
 BP 80/50, HR 34, crackles at lungs, II, III, AVF elevation. Therapy: atropine for sinus bradycardia as a
result from inferior MI…not saline for R MI (bc crackles = pulm edema)
 Lupus, on prednisone for months, now has new limp and groin pain. Imaging modality = MRI for avasc
necr // osteonecrosis of hip from steroids.
 Most strep pharyngitis will not have cough, rhinorrhea, or congestion. If RAST + and no C/I -> amox to
prevent rheum fever. RAST is not sensitive so gotta obtain throat culture after -.
 Previous MI -> Q waves -> vtach -> syncope without warning, rapid recovery. Even if asymptomatic
have to admit and get telemetry and echo, prob amio too.
 Difficulty staying awake despite 7+ hrs of sleep, wakes up frequently, hears stuff when falling asleep,
no other problems. Not residency, it’s narcolepsy – get sleep study, sleep diary better for circadian
rhythm disorders. Rx is Provigil. Cataplexy is treated with SSRI/SNRI or apparently GHB
 On valproate and now randomly pregnant. Very well controlled seizures. Next step: continue valproate,
up the folic intake, afp screening. Its okay to change AEDs PRIOR to conception but once pregnant due
to incr seizure risks can’t change them and switching just means more fetal AED exposure. OK to
breastfeed.
 Wernicke triad: encephalo, ocular (lateral rectus palsy), gait (wide) -> give IV thiamine. If progresses to
Korsakoff, that’s mammillary body atrophy and basically permanent. Confabulation.

Block 17
 52 year old with irregular vaginal bleeding, exam is normal. Dx: probably perimenopause but have to do
EMB since >45 years old. If <45 think unopposed estrogen (PCOS, obesity).
 Positively shifted graph (right hand shifts) mode < median < mean

r/Step3 | 17
 Nurse gets needlestick and patient refuses to be tested for HIV. Next step: don’t test HIV, just put nurse
on PEP (prob test her first).
 20 yo M chest pain and syncope while playing soccer. Hasepisodes before. VSS. QT 410, TTE normal.
D/C, 2 days later dies jogging. Dx: anomalous coronary artery, NOT HCM. Sudden cardiac death in
young is likely ventricular tachyarrhythmia associated with coronary artery pathology.
 Responds to psych meds inpt, poor compliance outpt -> long acting injectable.
 Infant lumbar spine has red sac and overlying membrane. Complication: neurogenic bladder ± bowel.
Meningomyelocele from spina bifida
 Hx of multiple transfusions, difficulty finding cross-matched blood. problem is -> alloantibodies, E L K.
RBC do not display HLA antigens
 Confounding bias – exposure-disease relationship obscured by factor associated with both (obesity and
stroke, confounder could be diabetes)
 Exercise in pregnancy not allowed in: cerclage, placenta previa, pre-eclampsia
 9 yo M has trauma to right elbow, neurovascularly compromised. Cant reach parents for consent. Next
step – this is trauma with complications so treat it
 Low-pitched rumbling diastolic murmur w/ opening snap is mitral stenosis, best heard between 5th + 6th
ribs at left mid-clavicular line
 Pregnant, positive syphilis tests, allergic to PCN -> desensitize and give PCN, repeat serology 3rd tri
 Febrile seizure commonly recur and can increase risk of epilepsy
 Amputated digit – wrap in gauze, iced saline, place in sterile bag
 Asympto 2.1 cm thyroid nodule, normal TFT. Next step: FNA due to normal TSH and size ≥ 1 cm
 Dx medullary thyroid cancer, calcitonin elevated, RET mutation. Next step – measure plasma-free
metanephrines because pheo during thyroidectomy would be bad.
 1 week ago elective abortion, now has purulent vaginal discharge, fever, HOTN, tachy, UPT+. After
stabilizing with ABX, next best step -> suction curettage septic abortion (retained products)
 21 yo M athlete has HR 46, PR 250, QT 400, normal else. Next step: reassurance for 1st degree HB
 Keloid tx -> intralesional steroids; high chance of recur
 If suspicious for ACS and initial EKG + trop normal, get serials. EKG 30 min apart, trop 6 hrs apart x3.
 Linear vesicles is synonymous with contact derm
 Lumbar lordosis, right midlumbar paraspinal tenderness, straight leg test at 60 achy pain. Dx:
uncomplicated back pain (lumbosacral strain), try NSAID and PT
 Allergic or nonallergic rhinitis 1st line is intranasal steroids
 Diverticulitis, not improving much after 2-3 days but stable, next step -> re-CT abdomen for ?abscess. if
abscess, requires drainage, IV ABX, partial colectomy weeks later.
 COPD exacerbation with narrow QRS, distinct P wave morphologies, variable PR/R-R. how to treat this
arrhythmia? MAT managed by adequate ventilation not meds. Elyte (↓Mg, K) repleted as well.

r/Step3 | 18
  60 yo F with urinary incontinence, irregularly shaped uterus. Not fibroids – uterine sarcoma!
hysterectomy
 TSH 0.2, asymptomatic, DEXA WNL, FT3+FT4 WNL. Dx: subclinical thyrotoxicosis, monitor TFT
 Lichen sclerosus -> persistent inflammation -> vulvar carcinoma
 Reynaud, now has BP 200/110, headache, papilledema, SCr 2.0. Dx: scleroderma renal crisis. Tx is
with ACEi and nitroprusside, monitor SCr as it will go up due to ACEi. Return to baseline after 72 h.
 Parvo can cause symmetric arthritis in esp young females, no long term effects

Block 18
 A dose-response relationship highly implies a causal relationship
 TIA with tongue now deviating to left. Nerve damaged = left hypoglossal “tongue licks wound”
 Herbal tea, now has mild HTN and low K. this is due to licorice
 Non-Hodgkins, chemoradiation, now has band-like abdominal pain, weakness in LE, Babinski. Next
step -> MRI and steroids for spinal compression
 Provoked DVTs treated for 3-6 months but that’s it
 Brain death dx by: absent cough with tracheal suctioning, no corneal reflex, no gag reflex, no ventilator
response, hypothermia. Remember they can have spont movements.
 Obese female found to have large PE. Started on anticoags, then has bloody emesis and EGD shows
gastric ulcers. Needs anticoag but actively bleeding, next step -> IVC filter
 Severe aortic stenosis heart sound: single S2 during inspiration (nearly simultaneous closure of A and
P valves as split is closed or even paradoxical)
 Knee pops, rapid swelling, grossly bloody fluid aspiration. Dx: ACL. Meniscal effusions are slow and
hemarthrosis rare.
 Positive predictive value wants biggest true positives, lowest false positives (very high specificity)
 Negative predictive value wants biggest true negatives, lowest false negatives (very high sensitivity)
 OCP s/e are HNBB (headache nausea breast breakthrough)
 Testing for multiple hypothesis increases Type 1 error
 Prostate mets to bone -> focal external beam radiation therapy
 Newborn with jaundice, normal activity. Tbili 17, photo initiated. 6 hrs later Tbili 17. Next step – just
continue and repeat level in 6 hrs. Tbili >20 requires exchange, below its OK.
 Coronary cath, stent placed. 2 days later has right groin pain, accented pulsation, dorsalis palpable.
Next step -> ultrasound for ?pseudoaneurysm (contained hematoma)
 Acute paronychia can be due to oral flora -> soaks and topical ABX
 Alcoholic with abd pain relieved sitting upright, loose stools, AST ALT WNL. Test for Dx: CT or MRCP
for chronic pancreatitis. Lipase not always elevated in CP.
 College student with schizo symptoms, get a urine tox first.

r/Step3 | 19
  33 yo F wants contraception. Gained weight, 5-6 days of heavy bleeding, bad memory. Best choice:
mirena
 1 week of gross hematuria, smoking hx. Microscopy normal RBC, CT abdomen negative. Next step ->
cystoscopy for ?bladder cancer
 Nurse needlestick with HIV patient with undetectable viral load. Next step -> triple therapy x 4 weeks.
 Immigrant from Guatemala, blood in stool, eos 13%. Drug of choice -> albendazole.
 Shingles within 72 hrs get a week of Valtrex. If gotten 2-dose varicella or chickenpox no PEP required.
If being treated, cover rash and avoid contact but can live life. Can transmit until crusted over.
 If hypothermic and bradycardic first correct temperature.

Block 19
 Pancreatitis can be diagnosed with physical exam (epig pain) and amy/lipase, CT is not always
required. Get ultrasound of RUQ for gallstone. If alcohol and gallstone negative consider calcium and
lipids.
 In acute pancreatitis with complications >72 h later get a CT for possible pancreatic necrosis/infx
 Just returned from india, has fever, intense muscle and joint pain, TCP. Dx: dengue fever, risk for
circulatory collapse. “positive tourniquet test”
 When to give RhoGAM -> 28 weeks and peripartum within 72 h. obv also with any bleeding episodes.
 Hydroxyurea not used in acute sickle episode
 Unilateral middle ear effusion persistent – could be obstruction due to nasopharyngeal mass, get a
nasal endoscopy r/o cancer
 First step in hypercalcemia is get a PTH level.
 Keratosis pilaris treated with emollients and topical keratolytics (urea)
 Initial workup for urinary incontinence = H&P and urinalysis. Frequency, pattern, volume; pelvic exam
and cough test.
 Subchorionic hematoma -> expectant management; increased risk of spont abortion and other 3rd tri
 Lobular carcinoma in situ has no malignant potential but can cause BIL pathology, excise it
 Preeclampsia can occur up to 12 weeks postpartum, vascular endothelial injury, give Mg
 SGLT2 can cause euglycemic DKA
 Diabetes associated with Duputryen contracture
 Viral URTI with worsening fever and cough – think secondary pneumonia (CURB-65)
 Renal transplant patient develops gout. Treatment: intra-articular steroids.
 IVDU -> has fever, systolic murmur at apex, stiff neck. Dx: mycotic aneurysm and SAH?
 All infants of GBS+ mothers observed in nursery for 48 h.
 Since ceftriaxone can displace bilirubin in neonates (kernicterus) use cefotaxime instead.
 Posterior vaginal mass that increases with Valsalva maneuver -> rectocele; pessary
 Even if induced sputum negative for PCP, if suspecting treat it. If PaO2 < 70 or Aa >35 -> steroids
r/Step3 | 20
  PEP within 72 hrs of exposure with tenofovir-emtricitabine-raltegravir

Block 20
 Hep C antibody +, next step – just like HIV get a viral load.
 16 yo M with arm jerking in AM, drowsy, EEG bilateral polyspike and slow wave discharges. Drug of
choice -> valproate for JME
 Normocytic anemia -> get reticulocyte count for compensation.
 Suspected dementia, always get: CBC, CMP, TSH, B12.
 Vascular vaginal lesion, UPT+, 4 weeks after delivery -> choriocarcinoma
 Patients with aspiration pneumonia must have speech and swallow eval prior to D/C
 Lymphadenopathy can be normal up to 1 month, afterwards refer for biopsy
 Majority of sarcoid dx resolve over time and do not recur
 Treatment of B12 anemia can cause hypokalemia, must replete potassium and monitor x48 h
 Choledocholithiasis best test is not US but ERCP (dx and treats).
 Pregnancy BV treated for symptoms rather than outcomes?
 In CKD patient with anemia, check iron stores before giving EPO
 Sickle acute chest = ceftriax/azithro, sickle bone is ceftriax/clinda?

Block 21
 If on lithium, best antihypertensives are CCB (amlodipine)
 Apparently upright PA CXR is not best test for pneumothorax anymore, its bedside US
 No prenatal care infant has continuous murmur and fails hearing test -> rubella (PDA, hearing,
cataracts)
 Standardized incidence ratio = observed cases/expected cases
 Hepatomegaly + arthropathy + DM -> hemochromatosis, can cause pseudogout CPPD and HCC
 Painless cervical dilation and second semester losses -> cervical insufficiency
 Radicava and Rilutek only approved ALS drugs
 Most cases of acute Hep B resolve spont and can follow up outpt
 If a preg in active labor wants epidural just give it assuming plt > 70k
 C diff diarrhea requires at least 3 loose stools in 24 h
 Ankylosing spondylitis can lead to restrictive lung disease due to limited joint mobility and apical fibrosis
 No cervical change ≥ 2 hours with inadequate contraction times (q2-3m) in active labor = give oxytocin
 Headache and papilledema (increased ICP) get MRI before LP.

Block 22
 Isolated anti-HbC -> do serology and make sure its not window period.

r/Step3 | 21
  In children viral meningoenceph likely coxsackie, HSV, arbo
 Pelvic pain with tender adnexal mass can be torsion -> get ß-hCG r/o ectopic and ultrasound
 Born to HBV+ mother -> infant gets HBIG and vaccine at birth with normal 0-2-6 schedule
 Child needs VZV vaccine with family member recent organ transplant – give vaccine and monitor for a
rash, if develops will need to be isolated until all crusted over.
 Bicuspid aortic valve can -> thoracic aortic aneurysm
 Get a psych history prior to Chantix (varenicline) therapy
 Post-CT can develop iodine hyperthyroidism, may have to give ß blocker and MTZ
 Infants with macrocephaly can get ultrasound because fontanelles open.
 Apparently INR 2.5-3.5 only for mechanical MITRAL valves and aortic + risk factors??
 Newly diagnosed HIV get a pap test immediately because cervical cancer = AIDS defining illness
 No CXR necessary in acute asthma exacerbation, can just give albuterol and steroids
 Isoniazid can cause LFT↑ but until ≥5x or 3x w/symptoms no need to hold or dc
 Nonfunctioning pituitary adenoma -> transsphenoidal resection not dopamine
 Ghana immigrant, smoking, terminal hematuria, peripheral eosinophilia – think schisto, get urine
microscopy not CT cystography
 primary ovarian insufficiency -> get E+P therapy to relieve hot flashes and ↓ bone loss, d/c at age 50
 upper airway cough syndrome has postnasal drip, rhinorrhea, cobblestoning

Block 23
 Smoking cessation at least 4 weeks prior to OR reduces postop pulm risks.
 < 30 yo breast lump gets ultrasound, >30 gets mammo
 Anemia above 50 gets cscope rule out
 8 hour old boy, bladder palpable, low UO. Dx: posterior urethral valves, image with VCUG
 Hepatorenal syndrome – fluid challenge, octreotide, midodrine, albumin
 Thompson test for Achilles rupture – no plantar flexion on calf squeeze
 Tick paralysis suspected – meticulous skin exam and pull tick off, will have great improvement quickly
 On chemotherapy, develops hemorrhagic bulla with erythematous skin. This is ecthyma, Pseudomonas
 In elderly pts who are stable and ambulatory prior to frax, surgery within 48 h to reduce mortality and
pressure ulcers and pneumonia
 Two top predictors of survival with COPD are FEV1 >> age.
 Long QT syndrome – prolonged QT -> VT, short-long RR intervals. Mag for TdP
 38 yo F with 94% sat room air, prominent S2, right axis deviation. Next step: Echo for PAH.
 Steroids don’t do much for toxic shock syndrome – fluids + pen/clinda
 Smoke-filled room, ABG ordered normal. At risk of developing -> supraglottic edema, inhalation injury.
 High risk stress features like ST depression at rest -> PCI

r/Step3 | 22
  Preg Bipolar depression -> ECT
 Ulcerative colitis attack -> get a AXR to evaluate for perf and toxic megacolon dilation
 HELLP at risk for seizures, give mag

Block 24
 3 hour old girl with PROM and clavicular fracture, next step -> reassurance, heals spont without effects
 Toxic adenoma prior to surgery will need to be euthyroid
 IVDU with RUQ tenderness and elevated LFTs. I thought abscess but apparently its Hep C
 Impaired upward gaze – Parinaud syndrome, prob pineal tumor. Can secrete HCG -> precocious
puberty.
 Father with hemophilia, mother not. Boy will never be a hemophiliac but girl will always be carrier
 Organism commonly cultured from corneal foreign bodies – staph
 Hodgkin lymphoma s/p chemoradn. Has enlarged left atrium, aortic regurgitation. Dx: radiation
cardiotoxicity, fibrosis of pericardium and leaflets (restrictive CM). anthracyclines cause dilated CM.
 TURP side effects – retrograde ejaculation >> urinary incont and ED
 CABG -> on amio and anticoag, smoker. CXR shows spotty calcifications along left heart border,
normal LV thickness, enlarged atria. Dx: constrictive pericarditis, complication of CABG.
 If on amiodarone, reduce warfarin dose
 Bilateral linear densities of the lower lobe 2-5 days post-op – this is atelectasis??
 Herceptin cardiotoxicity reversed after D/C
 In pooled analysis watch out for positive publication bias, will bias population
 ITP, bleeding risk or plt < 30k -> IVIG
 Decreased sensation over anterolateral thigh -> lat fem cut nerve entrapment, lose weight loose clothes
 Newly diagnosed HIV, started on HAART -> can develop IRIS (worsening of infx symptoms as body
starts to fight infection)
 Crypto meningitis tx with ampho B + fluocytosine -> fluconazole w/ serial LP to remove pressure
 Somatic symptom disorder – excessive preoccupation ≥6 months w/functional impairment. Schedule
regular same-physician appointments.
 Back pain with nighttime awakening could be tumor
 Pregnant woman, chlamydia negative 1st tri, now positive in 3rd tri. Dx: new STD. NAAT highly sensitive
and specific. Chlamydia can -> PPROM
 Neck mass moves upward when swallowing. Next step -> thyroid imaging and surgical resection bc
thyroglossal duct cyst will get infected
 Carpal tunnel – nighttime wrist splinting, nsaids not useful. If ?dx then do EMG/nerve conduction
studies, median nerve will be demyelinated from compression.

r/Step3 | 23
Block 25
 Asthma has an obstructive pattern with the methacholine challenge
 RBBB with high RV O2 sat. dx: VSD, sound will be holosystolic murmur at LSB
 JVD, lung crackles, diffuse ST depressions. Avoid -> metoprolol in acute decomp HF episode
 Double vision, difficulty swallowing, ptosis. Likely -> myasthenia gravis.
 Positive straight leg test ≤ 60 degrees -> nerve root issues; opposite to spinal stenosis presentation
 Pain on penetrative sex, urine dribbling, multiple UTI, fullness at anterior vaginal wall. Dx: urethral
diverticulum. Diagnosed with MRI of pelvis.
 Easy testing for NF1 is looking at eyes for Lisch nodules
 Benign pulmonary nodule imaging – popcorn, concentric, central, diffusely homogenous calcifications
 Sarcoid eye = uveitis
 16 yo F tired, lost 10 lb in 3 months, LMP 3 months ago, multiple brown freckles everywhere. Lips have
brown spots. I was thinking Peutz-Jeghers but it’s Addisons, look at elyte panel.
 Pain on valgus testing of knee, no effusion -> MCL injury
 Radial head subluxation -> reduction by hyperpronation.
 VSD is the most common CHD, spont closures early in childhood. Small = loud.
 Older woman, tired. Xanthelasma. Antibody -> antimitochondrial for PBC. Ursodiol, ↑ osteoporosis risk
 Ped septic arthritis bugs: Staph aureus, S pneumo, S pyogenes (Vanco). If <3 months think GBS.
 Abdominal pain out of proportion – mesenteric ischemia (will have lactate AGMA) -> get CT angio
 4 T’s for HIT: TCP (30-50% decline), Timing (5-10 days), Thrombosis, alTernatives. D/C and start
argatroban / bival / fonda. Avoid all heparin products forever including flushes, this is an allergy.
 Funnel plots help in assessing publication bias. Data points should be symmetric, left side is
improvement right side is no improvement. If all on left, publication bias.
 Positive for syphilis serology with neurologic symptoms → LP for neurosyphiilis. IV PCN x 3 weeks.
Jarisch Herxheimer with supportive treatment.
 Mobitz 2 gets a pacemaker because it can turn to complete heart block.
 Concurrent otitis media and purulent conjunct is caused by nontypeable H influ → augmentin

Block 26
 10 month old boy primarily breastfed with low Hb, low MCV, low RBC anemia. Dx: breast milk without
iron supplementation. Mentzner index MCV/RBC > 13 = Fe. Im pretty sure thal have ↑ RBC to
compensate.
 House dust mite have highest risk for asthma.
 Prozac discontinued a month ago, started on phelzine. Dx: serotonin syndrome
 DM with early satiety and constipation. Dx: gastroparesis, get an emptying study.

r/Step3 | 24
  Labia minora fused over urethra, excoriations → lichen sclerosis → high potency steroids
 In old people inattentiveness could be dementia, depression, or presbycusis
 2 yo F with persistent watery diarrhea, diet of fruit juice. This is osmotic diarrhea
 If 3+ BP meds and all maxed think about kidney issues -> get abdominal ultrasound for RAS
 2 day old male with BIL white nipple discharge -> reassurance, this is estrogen withdrawal
 2 yo M with baseball-sized nontender fixed palpable mass in right mid-abdomen, dx: neuroblastoma
which is basically a childhood pheo. Wilm similar but no pheo sx, just hematuria
 Sensory loss over anterior, medial thigh, medial shin, arch of foot = femoral nerve injury
 Teenager with blue mass between labia majora = imperforate hymen, can cause constipation
 Cone procedure with spont abortions 20, 21 weeks -> cerclage for cerv insuff. Can develop pelvic
prolapse later in life.
 Flu-like 3 days ago now has dysmorphic RBC hematuria. Dx: IgA nephropathy
 Don’t go skydiving or scuba when pregnant
 34 weeks gestation with severe pruritus on abdomen with striae and excoriations, bile acids normal. Dx:
regular pregnancy?
 Truncal rash on periumbilical area is probably pemphigoid gestationis → topical triamcinolone
 Acute cholangitis → ERCP drainage + stent; labs will have high AlkPhos > AST, ALT
 Cocaine use, persistent ST elevation → PCI
 Gallstone pancreatitis and acute cholangitis → obv ERCP
 Thyroid nodule workup first steps -> TSH, ultrasound. Once you name it, you stage it with CT or US.
 For surgeries d/c metformin day of and start 2 days after
 31 year old man has epigastric fullness and some nausea, no heartburn or alarm symptoms. Next step
is apparently H pylori testing and not dietary modification?? In people < 60 years old dyspepsia gets
worked up for H pylori, > 60 just get go straight to scope…
 Got 6 units of PRBC now has tingling and numbness – citrate chelates calcium
 If suspecting cholecystitis and RUQ negative try a HIDA

Block 27
 Breastfeeding mom has trichomonas, what to do with milk? Give 2g x1 metro and discard milk x 24 h
 Patient had abd pain and tenesmus, then bloody bowel movement. Hx of diverticulosis and ESRD on
dialysis. AXR shows dilated transverse colon without free air. Dx: acute colonic ischemia
 Muscle pain in shoulders and pelvis, normal CK – think PMR, get an ESR and CRP. Low dose pred
 Erysipelas caused by GAS
 Bilateral nipple charge, yellow, 51 year old taking soy and Vit E, normal labs. Dx: physiologic discharge,
reassurance
 Firm abdominal mass with history of similar taken out before – desmoid tumor

r/Step3 | 25
  Genu Valgum (knock knees) normal until age 7. Reassurance, will self-correct.
 Fetus can be breech until 37 weeks, can try external cephalic version
 Liver lesion – peripheral enhancement with IV contrast = hepatic adenoma; FNH uniform enhancement
 Granulation tissue at ear bone-cartilage margin = malignant otitis externa → IV Cipro
 Persistent calcitonin elevation after thyroidectomy for med thyroid cancer → CT scan neck and chest
 If suspecting SAH and CT negative, gotta do LP
 Newborn with good APGAR now with resp distress, horizontal fissure in lung, fluid, mild cardiomegaly =
TTN, will spont resolve, observe w/supportive care and O2
 6 year old boy with persistent bedwetting. Next step – urinalysis for reversible causes. >5 its no longer
acceptable to have enuresis, make sure its not due to UTI or something
 Start steroids within 3 days for Bell palsy, make sure artificial tears and eyepatch. Recovery 1-6 mo.
 50 hour old boy multiple bilious emesis episodes. Not passed meconium. No stool in rectal vault, anus
open. AXR multiple dilated bowel loops, contrast enema shows dilated descending colon. Dx:
Hirschsprung, get a rectal suction biopsy. Maybe Down syndrome
 Shaken baby syndrome – CT head will show retinal hemorrhages, subdural hematomas (bridging vein
shearing)
 Anti-smith antibodies remain high when lupus controlled, monitor complement and ds-DNA.
 Renovascular HTN imaging – CTA/MRI/US of abdomen
 If old person acutely delirious and becoming violent can give Haldol

Block 28
 Superior pulmonary sulcus tumor urgent intervention required if finding lower extremity hyperreflexia
indicating spinal cord compression from tumor invasion.
 Amlodipine causes edema
 If patient has Afib always do CHADS-VASC for anticoag, some patients can be 0
 T2DM, HTN, remote MI. eye has neovascularization, has neuropathy and dizziness. Dx: vertebrobasilar
insufficiency.
 EKG sinus bradycardia, has no pulse. Next step: CPR and epinephrine for PEA.
 Soot around mouth, flushed cheeks, pink palms. Next step in dx: carboxyhb levels. O2 sat will always
be high.
 Pancreatitis severity: elevated HCT (hemoconcentration from third spacing) and BUN are bad.
 Travel to Caribbean + joint pain → think chikungunya fever
 Suicidal thoughts without plan or intent can be treated outpatient
 Global restriction with active and passive range of motion -> adhesive capsulitis, may be due to
underlying rot cuff tendinopathy. Pain worse at night. Try ROM exercises before surgery.
 hCG injection and now bilateral ovarian enlargement with cysts – ovarian hyperstim syndrome

r/Step3 | 26
  HPV vaccine can reduce risk of penile cancer in males; both gender 11-26 yo
 Neonatal gono conjunct can be prevented with topical erythro
 Epigastric discomfort worse after meals, taking Zantac for 2 wks no relief. Next step is not a PPI but just
H pylori testing for dyspepsia??
 Hydatidiform mole – get ß-hCG levels and monitor for 6 months after suction curettage
 Kappa is a quantitative measure of inter-rater reliability
 Confirm diagnosis of sarcoid with biopsy for noncase granulomas
 Bats and raccoons carriers for rabies
 Right ureteral stone with dilated renal calyces – this is hydronephrosis so you have to drain via ureteral
stent or percutaneous nephrostomy.
 Akathisia tx with propranolol

Block 29
 Dog bite, up to date on immunizations – doesn’t need a TDaP.
 Cutting behavior, work up for suicide, hosp not always needed
 BRCA2 male breast cancer gene
 Tick needs to be attached for ≥36 h in order to spread lyme disease
 Pregnant with TB+ get full treatment with monitoring.
 ↑ RDW = iron deficiency anemia
 Rotator cuff tendonitis is lateral shoulder pain
 No tenderness on ear manipulation with lots of drainage in canal = suppurative otitis media
 Systolic anterior motion of mitral valve leaflets == HCM, try a ß blocker
 Ocular melanoma → radiation therapy
 Always stop smoking for at least 1 month prior to surgery
 Rigorous control of BP in ADPKD with ACEi reduces renal decline rate. can screen for ADPKD with US
 ≥70% stenosis of carotid artery + symptoms = CEA
 Acoustic neuromas due to Schwann cells
 10% reduction in weight has more of an impact on BP than smoking…

Block 30
 35 week gestation, fundal height 31, vertex with oligo, reversed end umb artery diastolic flow, no
accelerations, no GBS. Next step → induction of labor, this is fetal growth restriction possibly hypoxia.
 Diaper dermatitis doesn’t effect the inguinal folds or thigh crease → desitin barrier paste
 Lupus die of coronary artery disease, MI from premature atherosclerosis
 15 year old boy, small testes, bone age 13. Next step → FSH, LH, T level for delayed puberty

r/Step3 | 27
  Chronic hypocalcemia → bilateral cataracts, basal ganglia calcifications. Pseudohypoparathyroidism is
high PO4 and PTH levels causing end resistance to PTH.
 Recurrent otitis media, sinusitis – ask about environmental stuff like smoking before jumping to actual
medical stuff
 Hypothyroid, now pregnant. What to do with synthroid dosing? OCP and preg increase TBG so have to
increase synthroid too like 30% and measure TSH monthly
 Elevated alpha feto protein levels → detailed anatomy ultrasound
 Bilateral adrenalectomy -> bitemporal hemianopsia and hyperpigmentation = Nelson syndrome
 Acromegaly die of cardiovascular disease but this is reversible if acro is treated
 CT gallbladder with calcifications in wall. Dx: porcelain gallbladder, must remove for cancer risks
 Sustained clonus and scissoring posture = cerebral palsy, get MRI brain
 Smoking highest risk factor for AAA expansion
 Father diagnosed with colo cancer at 53. When should kid get cscope? 40
 Which test for urine leakage with cough? Q-tip test, >30 degrees confirms stress
 Headaches, BMI 42, Hb 19.2, next step -> get EPO, could be high from OSA -> sleep test
 Ureteral injury can present as gas in foley bag?
 Ulipristal is the most effective emergency contraceptive if taken within 5 days. Copper IUD
contraindicated in setting of acute cervicitis
 Smoker, 2 cm peripheral nodule in lower left lobe. Next step -> prior images or CT for better resolution.
Nodules > 0.8 cm need more workup
 Tibial stress frax rarely show up right away on xray
 Turner get cardiac echo and renal echo on dx
 Fecal impaction -> fecal incontinence.

Block 31
 If two studies have similar stats but one has a larger CI, it means they need to increase sample size
 Late life depression risk factor for dementia
 Biventricular pace device for: LVEF <35%, HF symptoms, LBBB w/QRS >150 msec
 If patient says “I understand the risks involved and concerns but I’m leaving” they leave AMA
 Untreated depression -> CV disease morbidity and mortality
 Frontotemporal has early personality changes
 Plasma ACTH undetectable, high dose DST no suppress cortisol. Next step -> CT adrenals
 Psych + nystagmus likely PCP -> Ativan
 Autoimmune hepatitis is anti-smooth muscle antibody
 28 yo M with polyuria, polydipsia, HTN, hypokalemia. Next step -> PARR for Conn syndrome.
Apparently urination can be caused by hypokalemia

r/Step3 | 28
  6 month hx of involuntary eye closure provoked by bright light, cigarette smoke. Dx: blepharospasm, tx:
botox injections
 COPD -> uses accessory muscles -> weight loss
 Flu 2 weeks ago and now hyperthyroid, dx: subacute thyroiditis, uptake will be diffusely low because of
stored release. No use with methimazole, just beta blocker and NSAID.
 “how many times >5 drinks per day” best one line screener for alcohol
 Eyes crusted shut, watery discharge, mild rhinorrhea -> viral conjunctivitis. No longer infectious once
eye discharge resolves.
 Night terrors resolve over 1-2 years
 Once brain dead diagnosed and organ donor -> hypothermia, volume resusc, pressors.
 S aureus most common cause of impetigo > S pyogenes
 Kidney donation can cause fertility complications
 Blood transfused, 2 hrs later has fevers, tachy. Antibody negative, no free hemoglobin, resolves 6
hours later. Mechanism: febrile nonhemolytic; reduced by: leukoreduction (no cytokines).
 Teenager with asymptomatic proteinuria, best step: split 24-hr collection. If elevated this is orthostatic
proteinuria, will resolve, benign.
 Roux-en-Y bypass, now osteoporosis and hyper PTH. Next step -> 25-OH-D levels from malabsorption
 Hemophilia A patient has frontal hematoma, asymptomatic otherwise. Next step -> non-con CT head
 Unilateral adenitis in children >2 weeks is probably cat scratch disease
 Incidentaloma 2 cm adrenal, next step -> 24 hr urine catechol levels, dexa suppression, 17-ketosteroid
 Rapid reversal of warfarin = PCC, FFP can take a lot of volume to work and its slower

Block 32
 Shoulder dystocia, first maneuver: McRoberts (elevate legs, flex hips)
 Incarcerated can participate in trials but must have IRB oversight approved
 Pregnancy associated with ADAMTS13 deficiency, can exist in postpartum period and cause TTP
 IVC filters can cause recurrent DVTs
 Adolescent girl absent pubic and axillary hair, start thinking mullerian agenesis vs. androgen
insensitivity syndrome, look at T level, uterus presence, and karyotype
 Up to 10% weight loss in first week after birth, regained by 2nd week of life
 Clozaril gets ANC measured
 Confirm tracheal intubation via – capnographic waveform with ventilation
 6 mo M with 93% sat room air, subcostal retractions, coarse breath sounds, expiratory wheezing
bilaterally. Dx: RSV bronchiolitis, supportive care. Can lead to recurrent wheezing, apnea
 Lead-time diagnoses disease earlier and incorrectly says it increases survival
 Endometriosis -> infertility
 If developed statin myopathy, recheck and if normalized, can restart
r/Step3 | 29
  Always get a 2-step PPD but IGRA is better
 Cat bite gets Augmentin, secondary intention closure
 Harsh brassy cough with inspiratory stridor -> this is croup, racemic epi and IM/PO dexa. Xray steeple
 Swelling and tenderness of anterior knee, cannot extend against resistance or lift leg off table. Dx:
patellar tendon tear -> surgery for repair
 Flex sig shows villous adenoma in descending colon, next step -> colonoscopy ASAP

Block 33
 Discontinue raloxifene 4 weeks prior to OR because thrombosis risks
 Vesicles on posterior soft palate -> herpangina from coxsackie
 4 year old boy snoring, gasps for air. Next step -> tonsillectomy, adenoidectomy.
 Motorcycle, hit car. Anterior chest bruises and cyanosis. Breath sounds both lungs. Dx: flail chest?
Despite seeming to have good breaths he’s cyanotic so…
 11 week gestation and right adnexal mass suspicious for carcinoma. When to do surgery? Beginning of
2nd trimester
 History of UTI – behavioral intake and then ABX prophylaxis
 Pharyngeal erythema with spots of grey exudate forming a membrane, complications include ->
myocarditis from diphtheria toxin
 Sudden severe vision loss with temporal sparing = CRAO
 If cirrhosis develops ALWAYS do a SAAG for 1.1
 Hemodialysis, given EPO. No real resolution, what to check next? Iron
 15 year old boy without axillary or pubic hair, small testes. Bone age is 13. Dx: pubertal delay, familial
short would just be short and normal bone age. Kallman would have anosmia.
 EF 25% and now pregnant. Next step – this is too risky, terminate pregnancy.
 Fallen tree branch scraped face, has lymphatic distribution of nodules. Dx: sporotrichosis.
 Low-risk surgeries (breast, cataract) -> no other eval needed.
 B12 anemia can present as megalo anemia, ataxia, dementia, delirium
 SIADH – water intake restriction for hyponatremia with CHF
 Psoriatic arthritis – methotrexate not just topical steroids or UVB
 Varicose vein treatment – leg elevation + stockings, same for stasis dermatitis
 Severe aortic stenosis = <1 cm valve, >40 mm gradient. Replacement to improve survival
 SVC syndrome diagnostic test is CT chest/neck
 81 year old with midshaft spiral humerus fracture -> elder abuse
 Bicarb in TCA overdose to prevent arrhythmias
 “uniformly enlarged, mobile uterus” – adenomyosis, regular heavy menses

r/Step3 | 30
Block 34
 Bedbound for 3 weeks with hypercalcemia, low PTH, low Vit D. Mechanism: immobility
 Sudden confusion and clumsiness. Can converse, cannot copy picture – this is nondominant parietal
lobe (R parietal) injury construction apraxia.
 Concussion, three days has a little dizziness when exercising. Next step – 24 h rest
 Rash on palms and soles with thrombocytopenia – always think HIV
 Weber tuning fork lateralizes to left, AC>BC BIL. This is – right sensineural loss, get ENT eval
 Most significant risk for developing colon cancer is alcohol NOT smoking
 Tourettes -> ADHD and OCD risks
 Carbamazepine -> agranulocytosis, SIADH
 Protective factors against suicide – family connection, religion, pregnancy
 MTX – macro anemia, folinic acid
 Constipated child, small fissure, firm stool. Therapy = oral osmotic laxative therapy
 Spine xray reveals Cobb angle of 17, mild scoliosis – no follow up?
 Laparotomy 2 weeks ago for appendix, now has fever and tenderness over 8th-11th ribs. Dx: subphrenic
abscess, get ultrasound
 Study shows reduction in pain. When separated, nonobese did better than obese. This is – effect
modification, stratification revealed a variable that changed outcome
 Chronic cough in kids is > 4 weeks, do spirometry
 If being brought inpatient and NPO drop basal insulin at least 20%
 Salmonella isolated from stool, immunocompetent. next – supportive therapy
 On OCP, had seizures, started on Dilantin, missed period – this is pregnancy
 Different pupil size, think intracranial hypertension or mass effect, Cushing triad
 Hepatic sarcoidosis – elevations of AlkPhos and GGT along with hyperCa
 Always wear seat belts
 3 year old boy choking -> lean child forward, abdominal thrusts
 Normal LV, dilation of RA and RV. Diagnosis: ASD.

Block 35
 Acute uncomplicated cystitis does NOT need a urinalysis, can rx ABX on symptoms alone, even over
the phone…
 3 day old boy, nonprojectile vomiting, abdomen distended. AXR dilated gas-filled loops of small bowel,
no air-fluid levels, “ground glass” mass on right side. This is – cystic fibrosis? Meconium ileus.
 Playing in farm, now sweating and drooling, bradycardia. Next step – atropine for organophos tox.
 RLS, lab to order – ferritin for ?iron deficiency anemia. If neg and no C/I Mirapex.
 Postictal with sodium of 114, next step -> hypertonic sale for symptomatic hypoNa.

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  Polyhydramnios is amn fluid index > 24
 NPH higher risk of hypoglycemia compared to Lantus
 Smaller studies have higher Type 2 error (lower power = higher ß since power = 1-ß)
 Haldol is safe for pregnants with bipolar mania
 Sjogren like celiac can -> ↑ lymphoma risks
 Tamponade with early diastolic RV collapse req invasive management
 If constipation -> UTI just treat the constipation
 14 year old boy with 3 cm firm mass under areola…do nothing??
 On chemo, now has cavitary chest nodule -> aspergillus
 67 year old with 4 weeks of abdominal pain, no alarm sx. Next best step -> H pylor for dyspepsia?
 Enuresis alarm therapy best long-term success, then desmopressin
 TSH 0.12, TT4 15, pregnancy. Dx: normal pregnancy, reassurance. E+P ↑ TBG
 Anal abscesses can develop -> fistulas
 Smoking history, low back pain worsens at night, paravertebral tenderness. Imaging test: X-ray NOT
MRI?

Block 36
 Velvety skin with atrophic scars, soft early systolic decrescendo murmur, bilateral alveolar infiltrates,
hilar prominence. Dx: Ehlers-Danlos acute mitral regurgitation due to chordae rupture from MVP.
 CN3 palsy associated with PCOM aneurysm
 Remember to treat tricho treat patient and partner(s) otherwise reinfx
 Preconception counseling, had pre-E last time. ASA starting in 2nd tri will lower risks.
 Suspecting TB? Get XR, maybe sputum sampling for AFP and culture, also PCR I guess
 WPW on EKG: short PR, delta wide QRS. Ablate the pathway
 Pregnant with suspected appendicitis – graded compression abd ultrasound -> MRI. If not treated will
develop pylephlebitis (suppurative infx of portal vein).
 Visual sx. 2.5 cm PRLoma and PRL level 5000. Next step – dopamine, NOT surgery??
 Hypoparathyroidism treated with Vit D, if still have high urinary calcium try thiazide
 Tan body, can’t get erections anymore, low FSH/LH. Dx: hemochromatosis, phlebotomy
 Catatonia -> benzos
 Latent TB is noninfectious, can start work without restrictions even if not treating
 Don’t forget vent associated pneumonia is after 48h on a vent, get an aspirate for culture while treating
for staph and pseudomonas
 Seizure disorder and wants to quit smoking – no bupropion, just NRT and counseling
 Cruise diarrhea = norovirus
 On chemo, gets antiemetic therapy, now has stiff muscles. Prob – reglan dystonia

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  Good factors for schizo: later onset, females, acute onset, pos symptoms (psychosis), short duration
 2 weeks of purulent nasal discharge, headache, facial pain, fever. Rx: Augmentin
 Even if treatment is basically futile, if patient wants everything, gotta do it

Block 38
 STEMI dx: new ST elevation in >2 contiguous leads >1 mm at all but V2 V3 (1.5 mm), new LBBB. They
can get tenecteplase
 Baby has diffuse intracranial calcifications, hydrocephalus. Dx: toxoplasma, uncooked meat / cats
 In twin pregnancy, after first twin delivered cervix constricts. As long as other twin is vertex and good
heart tracing, expectant mgmt.
 Car accident, steering wheel broken. Chest damage: aortic rupture @ lig arteriosum / aort root.
 Afib and sudden abdominal pain. Likely: mesenteric ischemia
 New onset seb derm in 25 year old -> HIV test
 5 weeks postpartum. TSH < 0.01, TPO antibodies ↑, thyroglob ↑. This is – postpartum thyroiditis. Will
be euthyroid eventually.
 Scrotal pain, elevation exacerbates pain. This is – torsion, orchiopexy within 6 hours.
 NPH – LP first, then VP shunt.
 Continuous murmur over left interscapular area, physical exam finding: aortic coarctation so low
extremity hypotension and delayed pulses, Figure 3 aorta, rib notching, confirm with echo.
 Placental abruption can be concealed. K-B test for amount of RhoGAM to give
 Urinary retention can cause high PSA, so repeat after resolved
 Asymptomatic hypercalcemia think FHH, measure urinary calcium excretion.
 Hypokalemia can cause paralytic ileus
 33 weeks preg with contractions. Next step -> betamethasone
 R shoulder pain, smoker, reduced vibration at ankles, large prostate. Next step -> bone scan
 Cant get erections anymore, has exertional thigh pain. Next step -> ABI for periph artery disease.
 Pap indicates HSIL, next step -> colposcopy

Block 39
 Multiple 1st tri spontaneous abortions, hysterosalpingogram shows filling defect of middle uterine cavity.
Dx: septum vs. intracavitary leiomyoma, has to be surgically removed to allow pregnancy.
 T2DM, leakage of urine after sneezing, pale vagina, reduced pinprick sensation at perineum. Dx:
overflow incontinence due to neuropathy.
 Someone taking energy pills, TSH very low. 24 hr uptake and thyroglobulin will be – both low
 After bariatric surgery body has to recover nutritionally, delay pregnancy by a year if possible

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  1 month infant born at 36 weeks has apneic episodes for few seconds. Normal else. Dx: periodic
breathing. apnea of prematurity is for >20 seconds at a time.
 Upward lens dislocation = Marfans
 Facial flushing, angular cheilosis, erythematous itchy rash with new DM. Dx: glucagonoma, NME
 Cryptorchidism – can wait 6 months, then orchiopexy by 1 year old
 Inferior MI with bradycardia. Dx: AV block which is not responsive to atropine, have to do pacing.
 TTP treated with PLEX
 Remember that DM is a coronary equivalent
 Coombs is negative, Tbili 16, anemia. Likely – G6PD
 Giardia – refrain from water parks
 T1DM running on Lantus and Humalog. How to dose? Give normal lantus and reduce Humalog after
breakfast, increased blood flow will increase insulin absorption.
 Quitting smoking reduces mortality within 5 years.
 PCP -> rhabdo, give saline and Ativan
 Gastrectomy, now has diarrhea, dizziness, increased bowel sounds. Dx: dumping syndrome, reduce
carbs and increase proteins
 Antiphospholipid antibody w/ heavy periods wants birth control. Best – Mirena, regular OCPs c/i

Block 40+41
 Aortic dissection with extension into L subclavian artery, best treatment -> ß blocker even though it’s
Type A? cant use nitroprusside alone
 Retiled bathrooms, frontal headache, no neck rigidity. Next step -> somehow monoxide poisoning so
rebreather mask
 Grabbing a knife more likely to injure tendons than vessels
 Hormone treatment postmenopause increases risk of stroke even if BP controlled
 Hypertrophic cardiomyopathy + family history of sudden cardiac death + exertional dyspnea -> ICD
 If gout in one joint try a monoarticular steroid injection
 Acute pancreatitis -> 8 wks later has residual abd pain and ↑ lipase. Likely dx = pseudocyst
 14 week gestation GBS bacteriuria. Next steps: amox treatment now and PCN during labor
 Snoring – first eliminate smoking and alcohol consumption before sleep study
 Gastroenteritis pediatric diet – normal diet, less on fruit juice. BRAT outdated now.
 Swallow a coin, next step – repeat x-ray in a week
 3.6 cm loculated cystic lesion in pancreas head. Next step – endo ultrasound + aspiration
 IJ attempted, trachea now deviating to left, hoarse voice. Next step -> intubation
 Passive rabies immunoglobulin + vaccine not recommended in previously vaccinated adults
 s/p papillary thyroid cancer, keep the TSH very low-normal.

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  Recurrent pneumonia, get a swallowing study
 Pediatric fever, CXR shows mild alveolar consolidation and air bronchograms on left -> S pneumo
 HTN is stroke largest risk factor
 Eating fish -> histamine -> scombroidosis
 Swelling around injury site, sweating, increased temp, bluish discoloration. Dx: complex regional pain
syndrome, reflex sympathetic dystrophy – pain out of proportion and allodynia. Nerve block
 If lyme treated no residual risk to pregnancy
 Chronic pancreatitis and DM treatment -> insulin. Glips and GLP c/i in pancreatitis
 Look at PDMP to reduce controlled substance misuse
 Tension headaches have normal exam but trigger points at base of skull
 CD4 190, SQ mass in right antecubital, systolic murmur, BIL nodular lung opacities. Diagnostic step ->
TTE for tricuspid valve endocarditis and septic pulmonary embolisms

SIM 1 Block 1
 Scabies itching typically worse at night. Dx by H&P or scraping.
 BPPV triggered by head movements: rolling over, looking up while standing. Dx Dix-Hallpike, tx
Epley to reposition otoliths.
 Old male, tons of comorbids, unable to really walk after hospital stay. Dx: deconditioning.
 Dx of Hirschsprung via suction biopsy.
 Febrile, chronic Hep C, recent South America, was on Cipro. 6 cm lesion in right lobe. Aspiration
negative for organisms. Dx: E histolytica
 Coin in esophagus. Endoscopy if: unknown time or symptomatic. Asymptomatic within 24 hrs can
be observed with xrays in 12-24 h.
 Surgery for AAA when >5.5 cm or 0.5cm/6 months. If less just screen Q6M.
 High pitched bowel sounds and tender mass in right groin: incarcerated SBO -> surgery
 PTH 700, 24 hr Ur Ca 300, Vit D 25, Ca 10.7, 58 yo, SCr 0.9. Next step: watch with Dexa, SCr, Ca.
This is primary hyperparathyroidism, asymptomatic. PTHectomy when age < 50, Ca > 11, Ur Ca >
400, Osteoporosis.
 Ulcer over base of right second toe is -> DM
 43 year old with 2 cm mobile breast mass. mammo shows no abnormalities. Next step -> US
 Low back pain worse with bending, lumbar paraspinal, reduced ankle reflex bilaterally. Xray shows
L4-L5, L5-S1 narrowing, osteophytes. Next step -> NSAIDs and NOT MRI?
 Post partum hemorrhage, placenta removed in pieces, second degree perineal lac, boggy uterus.
Dx: uterine atony and placenta accrete.
 Sleep hygiene involves avoiding alcohol at night
 Newly dx HTN without end-organ damage -> try lifestyle first

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  Hx prostate cancer, s/p bleomycin. Acutely febrile, tachy, reduced breath sounds and dullness at
left lower base, 72% neutrophils, no cough. CT shows peripheral collection. Dx: wedge infarct PE.
Pneumonia more central, PE more peripheral.
 HCC is often αFP negative, liver parenchyma
 Apparently can only approach for organ donation if specifically trained
 Initial PSA 7, biopsy shows adenoca less than 50% involvement, asymptomatic. This should be
actively surveilled – PSA Q 3-6m and yearly DRE
 Inhalant abuse is transient loss of consciousness, poor coordination, euphoria.
 Infant with reducible mass in right inguinal region. Tx: schedule surgery ASAP
 Long DM hx now has leakage of urine. Mechanism: overflow, incomplete voiding, tx intermit cath
 E+P can be used for a short period in younger <60 women
 Patient tells you orally he doesn’t want life sustaining treatment, not documented. Now
unconscious, mom wants everything done. Since not documented -> do it all.
 New afib / aflut > 48 h must do 3 weeks of anticoag before cardioversion/ablation.

SIM 1 Block 2
 Joint pain, GERD, angiectasias -> CREST anti-centromere
 2 bloody stools, VSS, NG yellow, no longer bleeding. Next step -> cscope. If VS unstable would do an
EGD first for brisk UGIB. If still negative, video capsule endoscopy.
 Antifungal therapy will reduce bacterial cellulitis risks
 Young female has UTI with B fragilis and E coli. Dx: fistula
 43 yo F, BMI 35, pelvic bleeding. US shows fibroids. Next step -> still get an EMB
 Warfarin and aspirin. Suddenly severe pain on right side. Painful RLQ pain on hip flexion, HOTN, and
afib. Dx: not mesenteric ischemia but retro hematoma, imaging not with FAST, a CT??? more
specific…just give Vit K and FFP. Or PCC I guess.
 Shortening of QT is hypercalcemia; hyperK will have peaked T as well.
 Before pneumatic enema for intussusception have to replete fluids! (I thought HSP but gave IVF)
 BP in office repeated high, patient says at home is low. Next step -> 24 hr monitoring.
 Chest radiation -> high JVP and syncope. Mechanism: tamponade, EKG shows pulsus alternans
 Acute urinary retention from nasal decongestants
 CKD with GFR < 30 should be told about renal replacement therapy.
 Mult Myeloma = CRAB -> SPEP + UPEP
 Varicocele -> shrunken testes and infertility
 Infant turns blue feeding, pink crying -> insert NG tube r/o choanal atresia
 Malignant pleural effusion = Stage 4, palliative care at that point. Chemical pleurodesis, not lobectomy.
 On Levaquin, randomly blacked out while driving. EKG will show -> long QT. also with HypoMg, HypoK
 Prostatectomy -> monitor with serial PSAs
r/Step3 | 36
  Limited internal rotation of hip and flexion -> xray for osteoarthritis
 IVDU with patchy BIL chest xray, how to get dx? 1. Sputum induction -> 2. Bronchoscopy BAL. if it is
PCP get an ABG as A-a > 35 or PaO2 < 70 -> steroids
 Candiduria not treated unless urinary symptoms, neutropenia, systemic infx signs. Change Foley.
 Hodgkin lymphoma -> secondary malignancy
 Endocarditis PPX: 1. Previous IE, 2. Unrepaired CHD, 3. Mech valves
 APAP overdose – within 4 hrs get charcoal, otherwise NAC

SIM 1 Block 3
 LVEF < 35% or MI+30% get an AICD
 Initial treatment of PRLoma is DA which shrinks size and reduces mass effect
 MCC thrombophilia is FVL which induces Protein C resistance
 Initial assessment of obesity – TSH, A1c, LFT (NASH), lipid panel. Surgery BMI >35+effects or >40.
 EHEC occurs after undercooked beef OR petting zoos?
 Microcytosis -> iron, chronic disease, thalassemia. Get iron panel, think electrophoresis next.
 BK virus in renal transplant – basophilic inclusion, PCR. Antiviral or reduce immunotherapy.
 DM deliver at 39 weeks, ≥4.5 kg get a c-section
 Muscle weakness – get TSH first?
 ARDS – hypoxemia, BIL infiltrates. Tx - low tidal volume mechanical ventilation.
 Mucous membranes dry and febrile. Mech vented, becomes hypotensive. Next step -> fluids.
Intrathoracic pressure ↑ == tension pneumothorax effects of ↓ venous return.
 11.5 g protein/day lost in urine = nephrotic syndrome, high risk for thrombosis, infection (typical bugs)
 Hemochromatosis eval: 1st iron, 2nd genetics
 Pregnant. Thick yellow discharge, pH 4, vulvar pruritus -> candida
 Na 130, K 2.8, CL 90, HCO3 36. Next step -> urine chloride, met alk. <20 = GI, >20 = diuretics/kidney
 Biceps tendon rupture -> surgical eval, if older can observe
 Headaches awakening from sleep -> MRI. Focal seizure = unilateral and automatisms.
 If bacteremic ALWAYS get a TTE/TEE.
 Wegner can die of diffuse alveolar hemorrhage
 PSC diagnosis with -> endoscopic cholangiography

SIM 1 Block 4
 Hypoplastic LH syndrome – ductal dependent, single S2? TA has syst eject murmur
 2 days of infx sx in etanercept use, CXR shows RLL opacity with cavitation. Dx: S aureus
 If Rh(D)neg and titers 1:2 already sensitized, no need to give rhogam
 Exertional dyspnea, enlarged hilum without lung pathology -> think pulm HTN

r/Step3 | 37
  OSA neck >43 inches male, 41 inches women
 Reducible umbilical hernia not worrisome unless > 1.5 cm or age > 5
 PCOS 2/3 – oligomenorrhea hyperandrogen PCO, get an OGTT. ↑ endometrial ca risks
 MVP with severe MR and LVEF <60 -> get surgery
 Osteoarthritis arthrocentesis <2000 cells is noninflammatory
 Early shingles tx with Valtrex ↓ postherp neuralgia, rapid healing
 Femoral hernias pass below inguinal ligament medial to vein
 Infertility assessment in <35 begins with >12 months of no preg (>35 = 6 mo)
 GBS have autonomic dysfunction (ortho hypo), symmetric motor weakness, hyporeflexias
 Rapidly alternating supraventricular tachy – brady = sinus sick syndrome; pacemaker
 PKSN can start with UNILateral onset and asymmetry
 Cardiac cath can cause eosinophiluria
 Renal carcinoma is unilateral, mass moves on inspiration
 Acute pancreatitis can eat as soon as return of appetite, NG or NJ tube if not eating in 5-7 days
 Fight bite = augmentin
 Most ACCURATE test for polycythemia is genetic JAK2 analysis
 Postpartum thyroiditis can develop recurrent hypothyroidism like hashimoto

SIM 2 Block 1
 Giardia: foul smelling greasy stools, flatus and belching. Cysts resist chlorination, iodine instead.
 Meta analysis RR 0.98 (0.95, 0.99) – this is statistically significant but clinically insignificant. Very close
to null.
 CABG 2 weeks earlier, now has chest soreness, ↓ breath sounds at L base, dullness to percussion,
new pleural effusion <25% of hemithorax height. Next step -> reassurance and monitoring, commonly
seen in CABG. If small (<25%) and asympto, will resolve spont.
 Children can explore their bodies or others bodies but sexual depictions are == abuse
 Vacuum assistance, well-demarcated scalp swelling with ecchymosis. Dx: cephalohematoma. Wont
cross suture lines, can lead to jauncide, calcify/ossify and deform skull.
 Breech, asymmetric gluteal skinfolds and ↑ thigh crease #. Dx: DDH, leg-lenth discrepancy, req ortho
consult and Pavlik harness x 3 months, should monitor until skeletal maturity, have no sequelae
 URTI -> dizziness, no hearing. Dx: vestib neuritis; if + hearing loss -> labyrinthitis. Head-Thrust test+
 Elderly, major depressive disorder, losing weight. Tx: ECT (resistant deprn, preg, suicide risk)
 Intranasal steroids can -> epistaxis, saline nasal sprays
 Pertussis can resemble croup but has a longer prodrome, not much stridor
 Independent variables are investigator controlled. Dependent variables are the affected
 RR 1.35 (1.00-1.61), interpretation: since it INCLUDES 1.0 it is not stat signif

r/Step3 | 38
  Young F 6 months of depression, suprapubic tenderness, pain relieved by urination. Dx: interstitial
cystitis. Bladder training, analgesics, avoid caffeine/alcohol/artif sweeteners
 Any and all changes to IRB requires resubmission and approval no matter the risk
 Old man, tons of cormorbids, A1c 6.5%. next step -> ↓ glycemic control, can be 7.0-8.0%
 36 wk preg, LVEF 20%, mitral regurg, some response to Lasix. Next step -> nitrate, vasodilator. Either
peripartum CM or acute HF that incompletely responds to Lasix -> nitrate/afterload reducer [Block 11].
Cannot give ACEi/ARB in preg
 EGD reveals proximal migration of GEJ above diaphragm, single longitudinal mucosal tear not
bleeding. Next step -> supportive mgmt. hiatal hernia + Mallory-Weiss = PPI, self-limited.
Sclero/ligation only if actively bleeding.
 Blinding reduces ascertainment bias, randomization reduces selection bias. Allocation bias is when
physicians put sicker patients in more intense tx groups.
 ß lactams associated with precipitating HUS from EHEC
 if p<0.05 reject null and accept clinical hypothesis
 nonspecific prodrome -> resolves -> erythematous rash on cheeks, spares nasolabial folds -> lacy,
reticular rash sparing palms and soles = parvo; self-limiting. Arthritis / aplastic sickle crisis
 primary dysmenorrhea in sexually active -> OCP > nsaids
 control groups always maximize estimate of actual impact and reduce confounding/placebo bias and
improve internal validity
 abdominal chemoradiation and now thin, brown discharge at vaginal introitus. Dx: rectovaginal fistula.
Can occur with pelvic radiation, perineal lac, colo cancer, Crohn.
 tTG IgA for Celiac, but can be negative in IgA deficiency. If tTG elevated -> duodenal bx villous atrophy
 pregnant Lupus -> SSA (Ro) SSB (La) antibodies -> fetal AV block. HCQ is OK to take in preg.
 Young thin man has coughing, now pneumomediastinum. Next step -> analgesics, oxygen. This is
primary spont pneumothorax, as long as VSS can resolve spont, supportive tx. No Valsalva.
 ADHD resembles bipolar except bipolar has discrete “episodes”, not chronic similar sx.
 Stress incontinence tx: lose weight, ↓ caffeine/alcohol/tobacco, Kegel, pessary. -> ureth sling surgery
 Bodybuilder taking supplements. Small testes, delayed muscle relaxation. Normal TSH, ↓ FT4, T, LH, ↑
PRL. Next step -> pituitary MRI for central hypothyroidism (normal TSH, ↓ T4).
 CKD strongest risk factor is proteinuria, DM, HTN.

SIM 2 Block 2
 Multiple small round opacities in upper lungs BIL, think silicosis, can ↑ TB risks via cavitations
 Kidney stone, K 3.1, HCO3 18, urine pH 6.1. dx: RTA 1, hypercalciuria.
 Tender ulcer on penis with smaller similar ulcers, painful, tender lymph nodes. Dx: chancroid.
 Strongyloides dx with serology, repeat 3-6 months for cure

r/Step3 | 39
  Case control layout: initially all patients with and without outcomes are selected, THEN risk factors
 External validity = generalizability = application of study results outside of study population
 Risk = exposed / unexposed (divided, ratio will give you % increase or decrease)
 Pragmatic trial evaluate effectiveness IRL; explanatory are efficacy (optimal, controlled)
 Suspecting abuse, don’t ask why in relationship, ask if safe and plan
 In anorexia, CBT 1st obv, if not gaining weight even after nutrition rehab -> Zyprexa
 52 yo F with hot flashes, had a TAH complicated by DVT. Manage sx with -> SSRI; DVT r/o estrogen
 Unilateral purulent bloody foul-smelling nasal discharge in young child == foreign object. Immobilize
child and instrumentation removal, prophylaxis w/ Amox or Clinda
 Widespread molloscum -> HIV test
 16 week preg, gums bleed when brushes, vomiting daily. Hb 10.8, plt 155. Dx: anemia of pregnancy?
 7 yo M 6 days of fever, pharyngitis last week. Now 39C, tenderness over calves, weak dorsiflex, CK
2000, walking on toes. Dx: viral myositis likely from influenza. No hematuria, will resolve spont.
 Infx 2 weeks ago, now urination ↓, on omeprazole and Lisinopril, T2DM, SCr 2.4. UA shows mild
protein, WBC and casts. Dx: omeprazole-induced AIN. AIN by NSAIDS, PCN, diuretics, PPIs.
 Panic disorder have some attacks untriggered, unexpected.
 Primary dysmenorrhea pain starts just prior to, lasts 2-3 into menses
 Any smoking + man age > 65 → AAA ultrasound screen
 Hyperestrogen increases glycogen in vag epith cells = thin clear fluid, physio leukorrhea
 Help Dx ADHD by teacher and parent behavior rating scales, no real psychometric testing

SIM 2 Block 3
 ST slevations in II, III, aVF. Right coronary calcification, aneurysm, child. Previous Hx of: Kawasaki.
 Subtle manifestation of hepatic encephalo include insomnia, mood changes, difficulty completing
tasks. d/c sedatives, start lactulose.
 SSRI abrupt withdrawal = anxiety, dysphoria, tremor, shock. r/o mania
 Hypercalcemia with >14 get saline and bisphosphonates, will take 2 days for ↓ Ca
 Most spont abortions are chromosomal abn, autosomal trisomies
 Chemotherapy long time ago, now has dull to percuss over R lung base. Serosang fluid with LDH 200,
protein 4.2, glucose 30, 60% lymphos. Dx: malignancy. Light criteria is ONE of THREE: PSR protein
>0.5, LDH 0.6, 2/3 ULN LDH. Malig have <0.5 of glucose too.
 FEV1/FVC < 0.7 = COPD, flow loop = “scalloped” on expiration. DLCO normal = mild emphysema
 Sinus sick = alternating brady-tchy from degeneration of cardiac conduction system. pacemaker
 Aspiration of olecranon bursa in bursitis first
 BIL patchy infiltrates in immunosuppressed person can think of PCP, should have ppx with Bactrim
 History of HSV, now preg: Valtrex 36 weeks to delivery, csection if symptoms felt other wise vag

r/Step3 | 40
  Newborn with ventral meatus -> hypospadias, no circ until urology at 6 months
 Nonspecific infectious symptoms in infants, think of AOM
 ITP not tx unless plt < 30k, surgery, hemorrhage. Steroids / IVIG
 Rotavirus common in winter under age 2
 Cough and wheeze starting with new job, relief not at work -> occupational asthma, do spirometry
 Open angle glaucoma can have normal pressures
 Pregnants with exposure to parvo get serology, if active then US for anemia, hydrops
 Prevent ventilator aspiration by -> elevate HOB, minimize sedation with daily holidays and spont
breathing trials, ET tube with subglottic drainage.
 Hx of kidney stones -> increase fluids, limit oxalate (spinach, tomatoes, nuts), limit sodium and protein
while INCREASING calcium to bind excess oxalate
 Transcranial Doppler for all kids with sickle cells, high velocity = stroke risk -> transfusions
 Monochorionic diamniotic with single placenta at risk for -> twin twin transfusion syndrome
 High dose of chlorthalidone, Lisinopril, amlodipine, BP still elevated. K is 4.1. evaluate for -> OSA??
 ≥65 with mild head trauma, asymptomatic -> get a CT head

SIM 2 Block 4
 Bilateral patchy CXR with low O2 sat, think ARDS PaO2/FiO2 < 300. Mechanism is capillary
permeability (endotoxins?)
 Goals of RDS is maintain PaO2 55-80 with TV 6-8 mL/kg, RR < 35, Plateau <30, FiO2 < 60.
 Upper lobe fibronodular, calcified granuloma == latent TB -> 9 mo INH
 Gets heparin, 2 days later plt drops 60%. This is HIT 1, nonallergic reaction so can continue heparin.
 AML on chemo, gets right periorbital swelling and CT shows opacification and bony erosions of
maxillary sinus. Next step -> endoscopic sinus debridement surgery for mucor, ampho B
 Sickle cell, splenic tenderness, Hb 5.3, retics 12%. Dx: sequestration, tx: saline. Transfuse but watch
out as sequestered blood will reenter circulation and -> hyperviscocity, heart failure.
 Postpartum depression wont enjoy their kid
 Acute angle closure glaucoma -> watch out for OTC cough/decongestants
 Lyme carditis -> ceftriaxone
 End of life air hunger -> opioids
 Acalculous cholecystitis -> blood culture, ABX, percutaneous drainage, improves within 24h
 Nonreactive nonstress test can be fetal academia or sleep cycle, do a BPP
 Joint pains. ANA+, RF-, CCP+ -> bad course of RA (not seronegative RA??)
 Delivers child, now smooth round mass at introitus. Dx: uterine prolapse, dc oxytocin and manually
replace it.
 Neonatal HCT 66%, asymptomatic. Next step -> watch glucose and bili.

r/Step3 | 41
  4 year old boy with hard stool palpated in vault, encopresis, recurrent infections and normal growth.
Mechanism: chronic rectal dilation. Could be CF but normal growth.
 Sickle trait can have rhabdo, so breaks and fluids
 Hydatidiform mole ß hCG alpha subunit resembles TSH -> hyperthyroid sx.
 OCP reduces ovulatory cycles thus reduce risk of ovarian cancer
 Intrauterine fetal demise retention can -> DIC via thromboplastin in circulation
 Athlete, increasing dyspnea, EKG with high voltage QRS and T inversions -> TTE
 Otitis externa bugs – pseudomonas, s aureus
 Acute bipolar depression – Lamictal, 2nd gen antipsychs
 COPD exacerbation, gets NIPPV, better and transitioned to nasal cannula. Now has bilateral face and
neck swelling with crepitus. Next step -> CXR for pneumomediastinum, can be self limited and resolve

NBME 5
 2 month infant, conjunctivitis treated with erythromycin. Pulmonary interstitial infiltrates. Diagnosis:
chlamydia or gonorrhea, transcervical.
 Young female with R tension pneumothorax, ask for: illicit substance use?
 High calcium levels, get a regular PTH
 Asthma attack and altered mental status -> intubate
 Patient has DNR/DNI status, comes in with acute cholecystitis. Guardian agrees to surgery. Next step:
suspend order and proceed with operation.
 What does a 95% confidence interval mean? Probability of landing outside of CI range is 5%
 2-hr old newborn spits up formula, unable to swallow. No abdominal mass. NG tube passed until
marking shows 12 cm. next step for diagnosis: not sure what it is, not choanal atresia, possible TEF so
answer is esophagography with contrast.
 20 year old with pulsus alternans was a congenital defect??
 Woman with acne that worsens week prior to period, distribution will be on face and upper chest
 New onset varicocele, think renal cell cancer
 Don’t forget ROC you want closest to Y axis and highest
 “lancinating midthoracic tenderness”, back pain for 4 weeks, twisting and turning. Possible DX:
compression vertebral fracture
 Why bother with any study when ecological fallacy
 Roux-en-Y, now has B12 anemia and diarrhea. Dx: bacterial overgrowth
 Delusions about operation can question competence
 Apparently between coal mine and shipyard, shipyard more NSCLC risk
 Must D/C PPI if you’re going to test gastrin
 No condom use, woman has perihepatic fluid and liver capsule thickening. Dx: fizhugh Curtis
 Strongest risk factor for cerebral palsy is premature delivery
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 Female child with hypertension, 10% height -> I thought turner, but apparently dx is abdominal bruit??
 12 year old girl with septic picture brought in by 17 year old sister, parents not around. Next step ->
examine without parental permission possible life-threatening condition
 Low transverse c section 2 weeks ago, clotty bleeding daily, uterus OK -> observe
 Mother smked and drank, baby has hepatomegaly, periventricular calcifications. Will also have -> deaf
 Total knee replacement, best perioperative prophylaxis is not UFH but LMWH?
 Head and neck radiation -> risk for thyroid neoplasm
 WBC 54000, multiple 2 cm supraclavicular lymph nodes. Asking for elective surgery -> just do it?
 Asymptomatic child, stool culture grows salmonella. Abx: NONE, symptomatic treatment only
 Leukodepleted RBC for delayed nonhemolytic transfusion reaction
 Trigs 1500 -> give a fibrate
 If you’re thinking sarcoid get a CXR
 Ingestion of Vit C chelates iron thus false negative stool test
 FEV1 best predictor for tolerance to pulm resection
 Most children have between 7 to 9 respiratory tract ifnections per year

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