Think Like the Test Maker
USMLE Step 1
Pass/Fail
Course
Rahul Damania, MD
Integrated Microbiology |
Respiratory
USMLE Step 1
Respiratory Respiratory Microbiology
A 28 yo M presents with fever, cough, and rhinorrhea. He is noted to
undergo nasopharyngeal swab testing. Non-enveloped, naked virus
particles are extracted. They contain RNA molecules which subsequently
undergo translation to create virulence in the upper respiratory tract. Which
NBME STYLE of the following is the most likely pathogen behind this patient’s
QUESTION symptoms?
A. Influenza A
1373 B. HSV-1
C. Rhinovirus
D. RSV
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A research study is focused on virulence factors for human influenza A
virus. The patients in study undergo respiratory tract epithelium biopsy.
Which of the following proteins if isolated in the respiratory tract
epithelium would confer primary infection in patients?
NBME STYLE A. Antigenic glycoprotein
B. Cholesterol capsule
QUESTION
C. Polysaccharide capsule
D. I-CAM-1
E. RNA polymerase
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A 30 yo M presents with fever and shortness of breath. He was seen at the
urgent care a week ago as he was having runny nose, cough, congestion,
fevers, and myalgias. The patient endorses headache. Physical exam is
notable for no neck stiffness; respiratory exam shows L crackles. A CXR is
notable for two lobar opacities in the L chest. Which of the following
NBME STYLE
pathogens is most likely the cause of the patient’s symptoms?
QUESTION A. S pneumoniae
B. M Catarrhalis
C. S aureus
D. Non-typeable H flu
E. K pneumoniae
A patient presents with runny nose and fever. He had a URI for the past 7
days and seems to ‘not go away.’ The patient now has pain in his maxilla.
USMLE STYLE VS 103℉. Lung sounds are clear. What is the likely diagnosis?
Sinusitis
QUESTIONS
What is a severe CNS complication?
Frontal lobe abscess (extension via ethmoid & cribriform plate).
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A 5 yo F presents with decreased oral intake. She returned from her
grandmother’s summer vacation home two days prior. Examination notes
ulcers in the posterior oropharynx. There are no exudates. Skin
examinations notes tender non-vesicular lesions on the palms and soles.
NBME STYLE Which of the following co-morbid conditions may occur as a result of this
infection?
QUESTION
A. Bacterial meningitis
B. Super-imposed HSV infection
C. Coronary artery aneurysms
D. Myocarditis
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A child undergoes evaluation at a school summer camp. The child was not
feeling well yesterday at home, and this morning was noted to have a
temperature of 101.3 ℉. He is complaining his throat is sore. On
examination, posterior oropharynx is erythematous. There is conjunctival
hyperemia. Which of the following describes the morphology of the likely
NBME STYLE
etiology?
QUESTION A. single stranded DNA virus
⊕
B. gram diplococcus
C. double stranded DNA virus
⊕
D. mRNA linear, segmented virus
A 1 yo M presents in November with cough. His mother was concerned as
his voice sounded hoarse and at night he had ‘loud noises’ on inspiration.
He presented via ambulance due to intercostal retractions and audible
USMLE STYLE stridor. What is the likely morphology of the virus behind this patient’s
symptoms?
QUESTIONS
→
Laryngotracheobronchitis Parainfluenza
Paramyxovirus is a SS (--) linear RNA virus.
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A 5 mo M presents to the pediatric intensive care unit. The patient was
born at 35 weeks gestation. He has been otherwise healthy. He has an
older brother who had a cold few days before presentation. The patient is
noted to have tachypnea, intercostal retractions, and flaring of the nasal
alae. There are bilateral wheezes and basilar crackles. CXR shows
interstitial opacities and no cardiomegaly. Which of the following
NBME STYLE
pathogens is the most likely cause of the patient’s symptoms?
QUESTION A. M pneumoniae
B. S pneumoniae
C. Respiratory syncytial virus
D. Coronavirus
E. Parainfluenza virus
3 yo male presents with acute onset fever and tachypnea. On exam he has
stridor, drooling , and RR 24. A translator is used during the exam as the
patient and his family have recently immigrated from overseas. Patient is
unimmunized. A lateral X-Ray is done. What would be the likely finding?
→
Thumb sign Epiglottitis
USMLE STYLE Typeable H. Influenza (gm – coccobacilis).
Most specific physical exam sign for epiglottitis & impending respiratory
QUESTION
failure?
Drooling in a “tripod position”
What may have prevented this pathology?
→
HiB vaccination vaccine contains type-B capsular polysaccharide
and PRP conjugated to diptheria toxoid.
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A 3 week old male presents to the international health clinic. His mother
has noted pauses in his breathing over the past week. He has had
decreased oral intake as he keeps coughing. After a coughing fit, he
typically has a choking sensation and has emesis. Which of the following
NBME STYLE cell lines may be elevated in this patient?
A. Lymphocytes
QUESTION
B. Basophils
C. Neutrophils
D. Mast cells
E. Eosinophils
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
77 yo male brought in by EMS after awakening with fever, chills, and chest
LOWER pain worse on inspiration. He has copious sputum production. On
auscultation, the patient has decreased breath sounds in the right lower
RESPIRATORY lung field. What are other physical exam features which may be present?
Crackles
TRACT
Dullness to percussion
DISEASE Bronchial breath sounds
Increased tactile fremitus.
Ivan Damjanov, MD, PhD: Pathophysiology, Philadelphia, Saunders Elsevier, 2009, p 171, Fig. 5-23.
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
Walker BR, Colledge NR, Ralston SH, Penman ID: Davidson’s Principles and Practice of Medicine, 22nd ed, St. Louis, Churchill
Livingstone Elsevier, 2014, p 136, Fig. 6.3.
Big Picture:
Fever, SOB, pleuritic chest pain, and sputum + focal lung exam
USMLE loves to test the microbiology:
Neonate + pneumonia =
GBS and EColi
College kid + pneumonia =
Mycoplasma
THINK LIKE Alcoholic + pneumonia =
Anaerobic (Peptostreptococcus, Fusobacterium, Prevotella,
THE TEST Bacteroides)
MAKER Hereditary disorder + pancreatic insufficiency + recurrent pneumonia =
→
Cystic Fibrosis Staph-Aureus (young), Pseudomonas, and B.
Cepacia.
HIV + pneumonia =
Pneumocystis Pneumonia (“ground glass”, “silver stain”, “TMP-
SMX”)
Smoker + COPD + pneumonia =
Legionella (“silver stain”), H. Influenzae, M. Catarrhalis
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
•Big Picture:
→
Acute bronchitis subsequent extension of the infection into
surrounding alveoli
BRONCHOPNEUMONIA
An 18 yo M presents to the urgent care with fever, headache, shortness of
breath and fatigue. The patient is noted to have increased respiratory rate.
Hemoglobin is low. CXR is notable for interstitial opacities bilaterally.
Which of the following pathophysiological mechanisms is behind this
NBME STYLE
patient’s symptoms?
QUESTION A. Lymphocytic infiltration of the thyroid
B. Splenic macrophage consumption of RBCs
C. Sickling of cells in the pulmonary microvasculature
D. Cross reacting IgM antibodies binding to I-antigen on erythrocytes
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A 59 yo F presents with fever and productive cough. The patient has a
history of COPD and chronic cough. The patient smokes 3 packs of
cigarettes per day along with 1 pint of vodka. Sputum analysis is notable
for an encapsulated gm negative, oxidase negative bacilli. Which of the
NBME STYLE following virulence factors mediates this patient’s underlying disease?
QUESTIONS A. Mucoid growth
B. IgA protease
C. Biofilm colonization
D. Streptolysin
E. Pyocyanin
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
A 60 yo M presents with watery diarrhea, cough, and shortness of breath.
His wife found him confused on the porch as he was out for his ‘daily
cigarette smoke break.’ He is febrile, normotensive, and tachypneic. HR is
84 bpm. Labs are notable for hyponatremia. Which of the following entities
NBME STYLE may be responsible for his symptoms?
QUESTION A. Gm rod⊖
⊕
B. Gm diplococci
⊖
C. Gm diplococci
D. Spirochetal organism
A 44 yo F presents with sudden onset fever and productive cough. The
patient has shortness of breath. The patient vital signs are notable for
tachypnea and pulse ox 88% on room air. The patient undergoes sputum
analysis that is negative for acid-fast bacilli, however positive for an
NBME STYLE incomplete zone of hemolysis. Which of the following virulence factors is
related to this patient’s presentation?
QUESTION
A. Evasion of phago-lysosomal fusion
B. F protein fusion
C. ADP ribosylation of EF-2
D. Evasion of phagocytosis
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
An elderly patient presents with weight loss, cough, and bloody sputum. He
has a history of type 2 diabetes, poor dentition, and prolonged oral steroid
use for “some inflammation” in his body. He is noted to undergo a chest X-
ray as his sputum culture is notable for acid fast bacilli. What portion of
NBME STYLE
the lung would be the most likely location of airspace disease?
QUESTIONS A. Right Upper Lobe
B. Subpleural Region
C. Right Lower Lobe
D. Right Middle Lobe
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
Respiratory Respiratory Microbiology
Walker BR, Colledge NR, Ralston SH, Penman ID: Davidson’s Principles and Practice of Medicine, 22nd
ed, St. Louis, Churchill Livingstone Elsevier, 2014, p 136, Fig. 6.3.
USMLE Step 1 Pass/Fail Course Respiratory: Respiratory Microbiology
