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Explanations for the 2022 Official Step 3 Practice Questions
11.02.22 // Medicine
Here are my explanations for the August 2022 update of the official practice
materials.

The asterisks (*) signify one of the only two new questions compared with the prior
set.

My explanations for the old 2020 set are here and the 2018/2019 set are here. There
were 71 new questions in 2020 vs 2019, so going through that older set may still be
worth your time. The one before that, which I explained here, was revised in
November 2017.

You can find my thoughts on preparing for Step 3 here. Since writing that post, the
main substantive change in the exam has been the ability to schedule CCS on a
nonconsecutive day. In short, I think the free materials and UWorld should be enough
for most folks. If you want book recs, they’re in that post. If you need another
question source, I haven’t tried any of them, but you can get 10% off the popular
BoardVitals if you’re interested by using code BW10.

As for this free 137-question practice exam, Blocks 1 and 2 are “Foundations of
Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are
“Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each.
Total practice time should be no more than 3:30 if taken under test-day conditions.

Block 1

1. E – Rash and arthritis after exposure to a sick kid with a “facial rash”
and fever. The kid’s vague description is a perfectly good fit for the slapped
cheek of Parvovirus B19. Adults most commonly get polyarthralgia (and
sometimes, dangerously, aplastic anemia).
2. A – Of the choices, the best explanation for a liver mass in an
otherwise healthy female is a hepatic adenoma, a benign lesion for which the
patient’s OCPs are a common modifiable risk factor. These do have a
tendency to bleed, especially when large, which is an indication to stop her
hormonal contraceptive.
3. C – She has glomerulonephritis in the setting of what looks like strep
throat. Post-strep glomerulonephritis is a type III hypersensitivity, an
immune-complex deposition disease that consumes complement (C3).
4. D – That’s a lot of hyperthyroidism symptoms. Onycholysis
(Plummer’s nails) is one of them, but as long as you didn’t somehow let it
distract you, the rest of the question info (cold intolerance, anxiety, low BMI)
points you in the right direction as well.
5. C – Retinitis pigmentosa most commonly has an autosomal dominant
inheritance pattern, but the tree we have shows clear X-linked inheritance. In
this case, her husband has the disease, meaning his one X copy carries the
mutation. However, her son’s X-chromosome must come from her, so her
male children have no chance of being affected. Her daughters, however,
would be obligate carriers.
6. E – First-line therapy for OCD is SSRIs.
7. E – Stratification is the partitioning of subjects by a non-treatment
factor and should be your knee-jerk response as a method to control for
confounding variables (i.e. potentially important variables nonetheless not
being directly studied). By stratifying people into groups by the variable in
question, you remove its possible confounding influence.*
8. E – I think the answer here is probably intuitive even if you don’t
actually know why. But anyway, recall that sickle cell RBCs have a
decreased lifespan, so they don’t stick around as long to accumulate glucose
as normal RBCs do, which artificially lowers the A1C value.
9. A – You can’t hold records hostage.
10. A – Bleeding in cirrhosis is more complicated and multifactorial than
you’d think, but the elevated INR in cirrhosis is primarily secondary to
synthetic dysfunction. Recall that elevated PT/INR is related to decreases in
Factors II, VII, IX, and X, and the liver makes fibrinogen and factors II, V,
VII, IX, X, XI, and XII. Of the choices, Factor VII deficiency is the biggest
bleeding risk.
11. E – Classic features of scleroderma. Skin-tightening about the mouth
can complicate airway management.
12. C –Number needed to treat (NNT) is 1/(ARR = difference in outcome).
There was a 20% difference (35% vs 15%) of recurrent encephalopathy. 1/.2
= 5.
13. B – This is a well-designed study. The main problem is that EPCS is
technically challenging to perform and sclerotherapy is available basically
everywhere.
14. B – B is true (it’s in the table and has an itty-bitty p-value). A
confidence interval including 0 (choice A) means the two options
are not significantly different.
15. E – Signs and symptoms of secondary syphilis. It’s usually prudent to
keep STIs as a differential for most cases of young-healthy-person-suddenly-
develops-a-constellation-of-weird-symptoms.
16. C – While there’s overlap between exposure-related/allergic-type
symptoms and viral URIs, in this case, RSV is the only virus they gave you,
and that’s not going to pan out for this combination cough/coryza/itchy eyes
in older kids. As we’ve learned with COVID, viruses travel between people
and don’t stay localized to a single physical environment like mold from
poorly mitigated water damage.
17. A – When someone seems like a truly awful adult, antisocial
personality disorder (apparent “charm” is a test-favorite). When under the age
of 18, conduct disorder.
18. B – You want to nonjudgmentally hear about what happened from the
patient in his own words in order to evaluate. I do love that they included
truth serum though.
19. B – Irregular tachycardia? Could she have symptomatic a-fib? Would
an ECG provide the diagnosis immediately? Yes and yes and yes.
20. B – He is sick leading to decreased PO intake leading to prerenal
physiology and hypovolemic hyponatremia. This is very common and the
cause of the majority of AKI we see in the hospital when literally anyone is
sick. Treat with fluids.
21. E – Posterior knee dislocation often results in vascular injury (there is
no discrete fracture on the radiographs).
22. A – His party foul was cataplexy (the awkward passing out at moments
of excitation), which is common in narcolepsy. Decreased sleep latency and
the need for frequent (but restorative) naps are also characteristic. See this
adorable video.
23. C – The control group needs to have radiographs in order to prevent a
systemic ascertainment bias from unintended differences in the composition
of the two groups.
24. D – We have no reason to doubt the patient’s decision-making
capacity, and he doesn’t want treatment. He does, however, have metastatic
cancer. Hospice is a very underutilized program that can help patients with
terminal illnesses navigate the end of life by prioritizing their care goals and
comfort.
25. A – Infectious bloody diarrhea is dysentery. Of the choices, only
Campylobacter jejuni causes dysentery.
26. C – Reactive arthritis is associated with HLA-B27. You probably
remember this most as the young man with arthritis after an STI (most often
chlamydia trachomatis), but bowel infections also do the trick (typically
Campylobacter, Salmonella, Shigella, or Yersinia).
27. A – The most common cause of bloody/black nipple discharge is an
intraductal papilloma, which can be diagnosed via ductography. That said, in
real life, ultrasound is highly user-dependent and most people would probably
at least do another targeted ultrasound to try to find the lesion now that
there’s new discharge. For one thing, it’s easiest to biopsy a lesion that is seen
on ultrasound.
28. D – Math.
29. B – Toxic shock syndrome, caused by exotoxin-producing Staph and
Strep. They don’t have to mention the word tampon.
30. A – Old man with shoulder girdle pain and/or stiffness, nonspecific
somatic complaints, and an elevated ESR? Polymyalgia rheumatica, a disease
of exclusively old people.
31. C – Benzos, like alcohol, suppress respiratory drive. That’s why
they’re potentially lethal.
32. A – Looks like a combination of chemo-related side effects and
pancytopenia.
33. E – Isolated elevated respiratory rate in an otherwise healthy and well-
oxygenated baby after a C-section is typically TTN, felt to be a result of
retained lung fluid that would normally be squeezed out/resorbed during the
normal birthing process.
 34. D – The ulna is fractured, and the radial head is dislocated (way too
high). The eponym for this pattern is called a Monteggia fracture-dislocation.
35. A – The diagnosis of inflammatory bowel disease can be made with
colonoscopy.
36. A – She might be doing drugs, but a little coke and MJ don’t cause
papilledema (a sign of increased intracranial pressure) and cerebellar signs. A
cerebellar tumor could, commonly a medulloblastoma in a patient of this age.
37. C – It’s cholangitis because of the stone lodged in and obstructing the
common bile duct, which is why the CBD is dilated; you would suspect this
clinically before the ultrasound essentially confirmed it due to the
combination of upstream liver and pancreatic issues. Only a stone in the distal
CBD will affect both organs.
38. A – Intention tremor that’s improved with alcohol is classic for
essential tremor, which can be exacerbated by SSRI therapy.

Block 2

1. D – A-fib isn’t ideal, but it’s the giant pleural effusion that’s causing
her SOB and hypoxia. Thoracentesis will be diagnostic and therapeutic.
2. D – Very long question, but we have a combination of post-op severe
abdominal pain, fever, and leukocytosis. Of the choices, an ultrasound can
(more or less) evaluate the aortic repair and look for free fluid. It would also
evaluate for the possibility of acalculous cholecystitis in this old sick patient,
which is likely the thrust of this question. In real life, this patient would
definitely get a CT scan, but that’s not a choice here.
3. E – An ultrasound is used to assess for a tappable joint effusion,
particularly in order to exclude septic arthritis. Transient synovitis (aka “toxic
synovitis”) is the most common cause of acute hip pain in children aged 3-10
years and is what this child likely has. It frequently occurs after a URI, and a
low-grade fever is typical.
4. E – She has a-fib with rapid ventricular response based on the
irregularly irregular rhythm and tachycardia. You don’t really need to know
the murmur part to get this question correct, but remember that mitral stenosis
results in a diastolic fill murmur loudest at the apex (the snap is the stenotic
valve finally and dramatically opening thanks to the increased pressure).
Chronic MS predisposes to a-fib due to left atrial enlargement, which
stretches and deforms the conduction pathways.
5. B – Diabetic gastroparesis in a long-standing diabetic.
6. E – Vitamin D deficiency is rampant with symptoms including fatigue,
muscle aches, and depression, among others. Checking a vitamin D level is
also just helpful to make sure we’re treating osteoporosis sufficiently.
7. D – Gas exchange requires both the ventilation of alveoli and the
circulation of blood through the capillary bed. Hypoxygenation with a lung
infection is usually due to a VQ mismatch and shunting as blood still travels
through lung tissue that is poorly ventilated. This is the opposite of a
pulmonary embolism, where the perfusion is low to the normally ventilated
lung.
8. C – An intoxicated physician can’t work due to patient safety,
obviously, but you also can’t cover for them and try to hide the event.
9. D – The first imaging study for any musculoskeletal complaint outside
of spine trauma is a radiograph.
10. B – You want the first test to be highly sensitive in order to catch most
cases of the disease. You want the confirmatory test to be highly specific so
that only true positive cases make it through.
11. C – You want to make sure she is taking the prescribed medication and
confirm she’s not taking anything else on the side.
12. A – That isn’t the “opening remark” you might want to use, but it is
absolutely the only one that’s appropriate from the list.
13. C – Tubal injuries/scarring like those resulting in hydrosalpinx are
often secondary to STIs, particularly Chlamydia, and are a common cause of
infertility.
14. A – Leg claudication in a heavy smoker is concerning for the PAD.
The initial test is an ABI.
15. D – From the data provided, no one with a negative D-dimer had a PE
(high negative predictive value, D), but a positive D-dimer was seen in tons
of normal people (low positive predictive value).
16. D – Lying is bad.*
17. C – The p-value column only demonstrates one significant value: HIV
co-infection.
18. C – Ah, the halcyon days before Covid. You’re not done with him yet.
But, he could have TB, so mask up.
19. E – Clear alcohol withdrawal seizures. What else were you hoping to
find? If “no further evaluation” is an option, be extra sure you don’t want to
pick it.
20. A – Only A is true. B is the opposite (hypoxemia was less impactful).
As for C, the CI for the odds ratio of lung infiltrates includes 1, meaning that
it was not statistically significant (which also means that D is wrong).
21. C – Spontaneous panic-like sympathetic overload episodes in a person
with a family history suggesting MEN2A (comprised of medullary thyroid
carcinoma, pheochromocytoma, and parathyroid hyperplasia or adenomas).
We need to work up a pheo, which we can do laboratorily by measuring
serum metanephrines.
22. B – You can gently correct incorrect statements, catastrophizing, etc.
Denying someone’s feelings (D) is unhelpful, blowing someone off from
their story in the middle of evaluation is absurd (C), and just giving advice
(A) like an over-credentialed coach isn’t going to work.
23. A – Acute-onset LBP and radiculopathy are typically related to a
herniated disc.
24. E – Dementia in the setting of multiple strokes sounds great for
vascular dementia. This is especially likely given the rapid course and
association with focal neuro deficits, but be aware in real life that dementing
processes are not mutually exclusive.
25. A – Lots of lymph nodes and splenomegaly with weight loss and
fevers is concerning for lymphoma. In this case, mediastinal nodes are also
causing airway compression.
26. D – An uncontrolled seizure disorder and driving don’t mix.
27. D – Power is 1 minus the type II error (aka the false-negative
threshold).
28. D – Liver disease was a contraindication in the drug ad (red box at the
end), and the patient has cirrhosis.
29. D – The ad shows that all three doses were similar vs placebo.
Remember, when in doubt, the exam loves to test the difference between
measurable differences (or even statistical significance) and clinical
significance.
30. B – Most cases of sinusitis are viral and result in mucosal
swelling/edema.
31. C – Middle-aged female with muscle aches, proximal muscle
weakness, and an elevated CK indicating muscle breakdown. The skin
cracking is a description of “mechanic’s hands.”
32. C – Likelihood ratios are often used to judge the performance of a
diagnostic test by determining the likelihood that a test result changes the
probability of the underlying condition being present. LR = sensitivity / (1 –
specificity). In this case, that’s (120/336) / (1 – [365/375]). Note that we use
365 because we’re calculating the true negative rate and they provided us
with 10 false positives out of the 375 individuals negative for HIV.
33. B – This question is actually straight-up bad. There are multiple
societal players and guidelines, which complicates things, but the move over
the past decade has been to try to biopsy fewer lesions because we’re
dramatically overdiagnosing and overtreating thyroid cancer. Basically, a 1
cm nodule should really only be biopsied if it has concerning ultrasound
characteristics like microcalcifications. Just saying it’s solid doesn’t really
count. The alternative to FNA is observation though, so at least A, C, and D
are unworkable.
34. D – Working outside in the “southwest United States” with
nonbacterial pneumonia (no improvement on antibiotics, eosinophilia) is a
great setup for coccidiosis.
35. D – Sounds like the patient is behaving like a prototypical American.
A family meeting would be appropriate because family meetings are basically
always appropriate. Legal guardianship for liking fast food and cigarettes is
absurd, Down syndrome or not.
36. E – OTC cold medications often contain decongestants that cause
vasoconstriction.
37. E – Fever + flank pain + UTI = pyelonephritis. No further workup is
needed for a woman’s first episode of pyelo, despite common ER practice. If
she fails treatment, then she’ll need imaging.
38. F – Lateral medullary syndrome from vertebral dissection taking out
PICA. This causes a Horner’s-like syndrome due to loss of descending
sympathetic fibers in addition to vertigo, nystagmus, and crossed findings of
ipsilateral facial sensory/cranial nerve deficits and contralateral pain and
temperature loss.
39. E – Analgesia abuse nephropathy. That’s a lot of Advil.
Block 3

1. A – Trigeminal neuralgia is classically treated with carbamazepine.

2. C – Pain with passive flexion is a classic exam finding of compartment
syndrome. In this case, muscle breakdown (evidenced by the elevated CK) is
the source of the swelling that is poised to threaten the limb.
3. C – Radiofemoral delay and pulse/BP differentials between upper and
lower extremities are physical exam findings of aortic coarctation. The
stiff/noncompliant narrowed aorta increases afterload and results in
hypertension.
4. E – Pregnancy of unknown location. She doesn’t have a tubal mass to
suggest an ectopic pregnancy, so we perform serial HCGs to see if this is an
early intrauterine pregnancy, an early ectopic pregnancy, or a failed
pregnancy.
5. C – Postpartum psychosis is an even bigger risk factor for future
peripartum psychiatric issues including depression than run-of-the-mill
postpartum depression.
6. C – LDL is just above the normal range. In an otherwise healthy adult,
the statin treatment threshold is 190. Everyone should have a “heart-healthy
diet” and exercise.
7. C – ABCs.
8. C – He’s in as good of shape as he can be. But no one feels
comfortable after getting stabbed, receiving a chest tube, getting a
thoracotomy, and then keeping a chest tube or two. The tachycardia may or
may not be an objective sign of pain here as well.
9. E – It would seem he has developed decompensated acute right heart
failure in the setting of constrictive pericarditis. An effusion with tamponade
is theoretically possible as well, especially keeping in mind that acute
effusions often don’t result in the water bottle heart on x-ray that you learned
about because it takes some time for the pericardium to stretch, but the X-ray
showing a normal size heart is a tip-off here that the pericardium has
thickened and hardened, preventing normal heart-filling (and therefore no
cardiomegaly as we so often see in heart failure from most causes). Even if
the new heart failure was from another cause, an echo would still be the right
choice to see what’s going on.
10. A – Clear-cut varicose veins. The initial treatment of choice is
compression stockings. Venous imaging is really only indicated if there are
signs to suggest DVT or pre-procedurally prior to an ablative procedure.
11. A – Cat bites on Step exams classically result in infection by
Pasteurella multocida. Beta-lactams work just fine, so Ampicillin would be a
great choice. Amp has the benefit (unlike a fluoroquinolone) of also covering
anaerobes since most bite injuries are actually polymicrobial.
12. E – Initial cervical cancer treatment is all about staging. Low-stage
localized disease gets surgery and higher stages get chemoradiation.
13. D – He has hypertension.
14. D – Trich is often asymptomatic. (Rapid) reinfection is common, and
he (and any other occult partners) should be treated empirically even if
asymptomatic to prevent reinfecting the girlfriend.
15. A – HIV+ with CD4 < 200 means full-blown AIDS, hence the oral
hairy leukoplakia (painless, un-scrapable unlike thrush). He needs
antiretroviral therapy, which addresses the root cause of his current
complaints. He does also need opportunistic infection prophylaxis/treatment,
but that’s not an option and would be in addition to antiretroviral therapy.
16. A – She has somatic manifestations of a targeted anxiety
disorder/phobia. This would best be treated with CBT.
17. A – Not just pharyngitis or even tonsillitis, the swollen oozing tonsil
displacing the palate and uvula and resulting in trismus suggests a
peritonsillar abscess, which requires drainage.
18. C – It would seem he’s a hemophiliac given the bleeding diathesis with
an X-linked inheritance. With that inheritance pattern, his daughters will be
obligate carriers and his sons will be totally fine. Therefore, the sons of his
daughters will have a 50% chance of having the disease.
19. E – Smooth small objects like dimes should pass. A rule of thumb is
that anything around 1 inch or larger (i.e. quarter or larger) is a problem and
should be retrieved if accessible, as well as coin batteries (if still in the
esophagus), multiple magnets (which can bind bowel loops together and
cause obstruction/perforation), and probably most things with super pointy
edges. Once a single smooth object makes it to the stomach, it’ll usually be
fine. Some recommend a radiograph if the object hasn’t passed by three days.
20. D – Back pain is a way of life for the morbidly obese.
21. C – Abnormal uterine bleeding in a woman over 45 requires an
endometrial biopsy to rule out endometrial cancer. For patients younger than
45, EMB is also recommended for those not responding to medical therapy or
who have prolonged periods of unopposed estrogen stimulation.
22. C – Smoking is by far the worst modifiable risk factor of all time.
23. A – You know you want more PEEP, but PEEP isn’t always like
cowbell. Sometimes you can have too much. Forcing all that air into
noncompliant lungs can raise intrathoracic pressure, which reduces right heart
venous return, hence the JVD and systemic hypotension (the latter secondary
to the Starling mechanism). Tidal volume and respiratory rate might also be
reduced, but the bottom line is that we need to tweak the ventilation settings.
24. D – Small anal fissures are treated with a bowel regiment/stool
softening. This isn’t a hemorrhoid or perirectal abscess.
25. A – Intravenous calcium is used to prevent bad-news cardiac effects of
hyperkalemia. Not sure the peaked T-wave on the ECG are really necessary
for this question when they give you a serum potassium of 6.4.
26. D – Rifampin is meningococcal prophylaxis used for close contacts.
You do not want to get meningococcal meningitis.
27. E – She is severely anemic, which can certainly cause chest pain by
itself irrespective of her underlying sickle cell disease, and she needs a blood
transfusion. Analgesia is also critical in any potential sickle cell crisis, but
that isn’t an option here.
28. B – Patients with Parkison’s and other old, weak, and/or demented
folks are at high-risk for aspiration. PNA in this population, particularly
involving the RLL, could be aspiration pneumonia, and steps should be taken
to make sure an appropriate diet plan is in place.
29. E – IV metoprolol is great for rate-control. It even worked already
during this admission; it just doesn’t last very long. Rapid onset, short
 duration. He’ll need continued IV rate control until oral meds (or other
therapy) can treat his RVR or it resolves on its own.
30. C – Anthracycline-induced (e.g. doxorubicin) cardiomyopathy can
occur years after treatment and warrants screening echocardiography.

Block 4

1. D – He has toxo from eating cat feces in the dirt (oops). That doesn’t
address the why of his pica (geophagia, in his case). I don’t know about you,
but I don’t think managing dirt-eating in five-year-olds is part of most
people’s practice, even in “Advanced Clinical Medicine.”
2. D – We should be worried about a spinal cord lesion or cord
compression, possibly from spinal metastasis in the setting of breast cancer.
Recall that the spinothalamic tract crosses in the spinal cord unlike the main
sensory and motor tracts, which cross in the brainstem, which is why a right-
sided lesion would affect right-sided strength, sensation, and reflexes but left-
sided pain/temperature. The inguinal ligament is the T12 sensory level, but
you might remember that the fibers travel 1-2 segments before crossing, so
the sensory level will often be below the lesion level (i.e. our lesion could be
at T10).
3. C – The combination of fever and back pain is concerning for
osteomyelitis. MRI is the test of choice.
4. E – You might recall that children with sickle cell disease are at risk
for salmonella osteomyelitis in addition to the more common bugs like
MRSA. Empiric treatment should cover both: vanc for MRSA and a third-gen
cephalosporin like cefotaxime for the salmonella.
5. D – Pain control is always a priority. Obviously, you’re going to get an
imaging study and give antibiotics, but the question here is getting at how to
address his symptomatic misery.
6. C – Lactic acid lotions are used for exfoliating and moisturizing super
dry skin. There is no evidence for an infection or inflammatory condition.
7. D – It’s all from outlet obstruction. We need to drain that bladder, so if
a foley can’t be passed, then it’s time for a suprapubic catheter.
8. A – Abscesses get drained.
9. E – She has cerebral edema, which is the leading cause of death in
DKA. Signs, in this case, were somnolence, lethargy, headache, n/v, and
incontinence. Seizures, bradycardia, and eventually respiratory arrest are also
bad news. Mannitol decreases ICP.
10. B – Hormonal therapy with estrogen is the most effective treatment for
the symptoms of menopause like hot flashes. Nonhormonal therapies like
gabapentin and certain antidepressants carry lower risks but are not as
effective and therefore not “most likely to alleviate” her symptoms. She has
evidence of prior TB, but that’s a distractor.
11. E – Thinking psoriasis with the raised red, scaly plaques, and even
some nail involvement, but every rash can be treated with steroids right?
(kidding not kidding.) I presume the episode of joint pain is a toss-out to
suggest psoriatic arthritis.
12. D – Try not to fight “normal patient just needs a high five” questions.
13. D – Cocaine can cause chest pain and even MI due to alpha-mediated
coronary artery vasoconstriction and spasm. He hasn’t responded to the first-
line treatments of ASA, NTG, and BZD, so next up is phentolamine, an
alpha-blocker that can loosen things up.
14. D – He has the four-liner description of hypovolemia. You treat
hypovolemia with saline. Remember your ABCs.
15. C – Thrush is common in newborns and young infants and is almost
always initially treated with topical nystatin. Difficult cases can be treated
with oral (systemic) fluconazole. In a newborn, the two most common
sources of a white tongue are milk residue and thrush. Milk residue comes off
easily. You of course can scrape thrush off, but not necessarily with “gentle”
scraping, and doing so will often leave red, inflamed areas underneath.
16. B – MDD is treated first-line with SSRIs. He has complicated
depression (with hallucinations), not bipolar disorder.
17. D – That late systolic murmur is concerning for aortic stenosis.
Untreated aortic stenosis is a rapid killer of old people, especially if it’s
already symptomatic.
18. E – Super common safe combination.
19. C – Most patients with Bell’s palsy have a complete recovery.
20. E – Asthma exacerbations are treated with steroids. Even though her
flow rates aren’t that bad, she is not getting relief with her rescue inhaler.
21. A – Gestational diabetes is pretty likely in this overweight patient with
a history of a large baby delivery and now measuring greater than dates.
22. E – Immediate and most effective pharmacotherapy to help firm up the
uterus and stop postpartum hemorrhage is oxytocin.
23. A – This is an example of cold urticaria, a rash that forms on cold-
exposed skin and typically worsens as the skin warms (hence why it
happened after she returned home). Mild reactions don’t require treatment
(such as antihistamines or an EpiPen), but avoiding cold exposure will allow
the reaction to fade and prevent future occurrences. Anaphylaxis can occur.
24. B – Community-acquired pneumonia (possibly with an atypical
pathogen suggested by the addition of diarrhea) in a pregnant patient. Patients
with comorbidities (e.g. COPD, alcoholism, diabetes) should get levoflox,
moxiflox, or a combination of a beta-lactam like amoxicillin or third-gen
cephalosporin like ceftriaxone PLUS a macrolide (e.g. azithromycin).
Fluoroquinolones are generally avoided in pregnancy when effective
alternatives are available, making B a better answer than C.
25. D – Lovenox is the DVT prophylaxis of choice in patients with
reasonable renal function. Recent knee surgery isn’t a contraindication;
orthopedic surgery is a huge risk factor!
26. C – Addison’s disease presenting with Addisonian crisis–indicated by
the combination of skin bronzing, generalized weakness/failure to thrive, and
salt wasting with hyponatremia and hypotension–will immediately need
fluids and steroids. This is a commonly fatal condition when insufficiently
untreated.
 27. D – Super duper classic gout. Big angry MTP joint full of white cells
but no organism (Podagra). Treatment of an acute attack would be
indomethacin. Prophylaxis is allopurinol.
28. D – The AAFP actually recommends a single dose of oral steroid
(usually dexamethasone) in all (even mild) cases of croup to help with airway
edema. Croup is viral, so no antibiotics.
29. B – The diagnosis of shingles here is clinical and does not require any
further testing itself. However, given multiple sexual partners and a case of
shingles way younger than typical, HIV testing is prudent. HIV significantly
increases the risk of reactivation diseases like shingles.
30. B – Condyloma acuminatum (genital warts) can be treated with
imiquimod, a topic immune-response modifier.
I’m a fallible human being. Questions/thoughts are welcome in the comments as
always.
113 is an example of ichthyosis vulgaris

Marcus 02.04.23 ReplyThanks so much for making this! 76 is lateral medullary

(Wallenberg) syndrome, likely due to vertebral artery dissection from the neck
manipulation resulting in blocking the PICA. So it’s the descending sympathetic
fibers in the medulla rather than the cervical ganglia that are
damaged.Cassie 02.07.23 ReplyFor question 95, my first answer was Hemophilia, but
the uncle threw me off. I may have overthought it, but XR disorders should skip
generations. AD and AR don’t fit, but the uncle really shouldn’t be affected

– 7.e: why not “matching”. First Aid says that matching helps in reducing
confounding vs. stratification helps in reducing effect modification.
– 118. E: why not MTX if the patient also has joint pain?

-16.C : Did you pick Mold over Asbestos just because they mention water pipes?
Because I think that Asbestos can also happen from Fire and present with similar
symptoms.

7 e = Matching is good choice for prospective cohort or RCT. here they were given
case control. so After result, stratification is feasible choice to rule out confounder.

118 e = Read carefully. Patient had transient joint pain but no recurrence. that means
treat only rash.
16. TBH I am just gonna mug that up. Too strange to remember logically.

Q. 109. Explanation is incorrect. Diagnosis is Transverse Myelitis. Patient has fever.

Cord Compression will not result in fever

This a specifically a work up question, not a diagnosis question. It’s about

knowing how to evaluate a clinical scenario (new spinal cord level) and, to
an extent, what the differential considerations include. If you knew with
certainty the spinal cord lesion was TM, what value would an MRI really
have?

Q15 is HIV not syphilis.

I don’t believe that’s true, no. Just for fun, I just asked ChatGPT, which after totally
botching it by thinking of Parvovirus B19/Fifth Disease, had this to say after I
narrowed it down to an STI:The symptoms described in the medical exam
question, particularly the history of a flu-like illness followed by a rash, are
suggestive of secondary syphilis, which is a sexually transmitted infection (STI).
Syphilis is caused by the bacterium Treponema pallidum.