test for guillian barre

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Step 2 Mehlman

Mehlman

Term	Definition
chicken + bloody diarrhea	campylobacter or salmonella
tx for entamoeba	metronidazole
bloody + “appendicitis”	yersinia
test for guillian barre	electromyography and nerve conduction
CF patient under 10 type of pneumonia	Staph Staph until 10, then pseudo
CP patient over 10 type of pneumo	pseudomonas
type of incontinence for mid-urethral sling	stress incontinence
2 tx can use for pyelonephritis	cipro or amp/gent
what do you need to check in RA patient before surgery	atlanto instability do CT
empric for endocarditis	Vanc. or amp/sulbactum and gent
anti-cholinergic to stop pee	oxybutinin
cholinergic to help pee	bethanachol
tx for MS flares vs maintanence	steroids for flares, interferon for mainanence
vestibular neuritis vs labyrinthitis	Labyrinthitis has tinnitus and hearing loss
to and fro murmur	PDA
murmur associated with rubella	PDA
heart problem of baby born to mom who has lupus	third degree heart block
heart problem in williams	Supravalvular AS
worse with valsalva	HOCM
late peaking sys murmur with ejection click	AS
Travel + self-limiting watery or brown/green diarrhea	Traveler diarrhea = ETEC HL or HS toxin
Abx (clindamycin, beta-lactam, cephalosporin) + diarrhea	C. difficile
Dx of C. diff	stool AB toxin test, not stool culture
Fever of 104 + abdo distension in C diff	toxic megacolon
Tx of C. diff	vancomycin, not metronidazole (updated guidelines as of Feb 2018)
Bloody diarrhea + travel	Entamoeba histolytica
Tx of E. histolytica	metronidazole + iodoquinol; can give paromomycin
Close quarters or military barracks or cruise ship + watery diarrhea	Norwalk virus
Child <5 years + watery diarrhea	rotavirus
Few organisms causing bloody diarrhea	Shigella
Bloody diarrhea + appendicitis-like pain (pseudoappendicitis) in a child	Yersinia enterocolitica
Bloody diarrhea + reactive arthritis in an adult	Y. enterocolitica, Campylobacter, Shigella, Salmonella
Diarrhea + Guillain-Barre syndrome	Campylobacter
GBSyndrome CSF?	albuminocytologic dissociation (high protein + normal cells)
GBSyndrome Dx?	electromyography + nerve conduction studies (on NBME)
Cardiac ischemia + need to evaluate	ECG stress test first-line
Cardiac ischemia + abnormal baseline ECG (e.g., BBB)	Echo stress test (need normal ECG to do ECG stress test)
Cardiac ischemia + patient can’t exercise	dobutamine + ECG/echo
ECG shows diffuse ST-segment elevations	pericarditis
Pericarditis Tx	NSAID, or steroid, or colchicine
Central chest pain worse when supine; better when leaning forward	pericarditis
Lateral chest pain after viral infection + increased CK	pleurodynia (intercostal muscle spasm)
ST-segment depressions in the anterior ECG leads	posterior MI
Electrical alternans on ECG	pericardial tamponade / pericardial effusion
Pulsus paradoxus (drop in systolic BP >10 mm with inspiration)	cardiac tamponade or severe asthma
Beck triad	hypotension + muffled heart sounds + JVD
Bloody diarrhea + poultry consumption	Campylobacter jejuni or Salmonella spp.
Tx of tamponade	pericardiocentesis or pericardial window
Tamponade	do echo before pericardiocentesis if both listed (even though sounds wrong, on 2CK NBME)
CPP + lobar pattern (right-lower lobe consolidation + dullness to percussion)	Strep pneumo
CPP + lobar pattern, but they say “interstitial” in the vignette description	Mycoplasma, not S. pneumo Empiric Tx for CPP
Tx for CPP is pt on Abx past three months	fluoroquinolone over azithro
Pneumonia in CF patient <10 years	S. aureus exceeds Pseudomonas
Pneumonia in CF patient >10 years	Pseudomonas exceeds S. aureus.
Pneumonia after influenza infection	USMLE wants S. aureus
Pneumonia + rabbits	F. tularensis
Pneumonia + cattle	Coxiella (Q fever)
Pneumonia + birds	Chlamydia psittaci
Leg swelling + pain + shortness of breath	Pulmonary embolism caused by DVT
Tx of PE	Heparin before spiral CT
Tx of PE in pregnant woman	V/Q scan, not CT
Tx of PE in someone already on warfarin	spiral CT to confirm, then IVC filter
Acid-base disturbance in PE	resp. alkalosis (low CO2, high pH, low O2, normal bicarb [too acute to change]) Acid-base disturbance in asthma
Acid-base disturbance in aspirin toxicity first 20 mins	resp. alkalosis (low CO2, high pH, normal O2, normal bicarb [too acute to change])
Acid-base disturbance in aspirin toxicity after 20 mins	mixed metabolic acidosis-respiratory alkalosis (low CO2, low pH, normal O2, low bicarb)
Tx for aspirin toxicity	bicarb (increased excretion through urinary alkalinization)
Tx for TCA toxicity	sodium bicarb
Normal calcium	8.4-10.2 mEq/L
Tx of hypercalcemia	10.2-12 -> normal saline (0.9% NaCl)
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Community-acquired pneumonia (CPP) + bilateral CXR infiltrates	Mycoplasma
Tx of hypercalcemia	12-14 -> normal saline (0.9% NaCl) only if asymptomatic; add bisphosphonate (e.g., pamidronate) if symptomatic
Tx of hypercalcemia	14+ -> normal saline (0.9% NaCl) + bisphosphonate
High calcium + polyuria	nephrogenic diabetes insipidus (weird, but on NBME)
High calcium + confusion	delirium caused by high calcium
Low calcium or potassium not responsive to supplementation	cause is low Mg
Low calcium or potassium in alcoholic	hypomagnesemia is cause
Ataxia, confusion, ophthalmoplegia	Wernicke encephalopathy (B1 deficiency)
Retrograde amnesia + confabulation in alcoholic	Korsakoff psychosis
Wernicke-Korsakoff syndrome	mammillary bodies
Hx of many pregnancies + downward movement of vesicourethral junction	stress incontinence
Tx of stress incontinence	pelvic floor exercises (Kegel); if insufficient
Hyperactive detrusor or detrusor instability	urge incontinence
Need to run to bathroom when sticking key in a door	urge incontinence
Incontinence in multiple sclerosis patient or perimenopausal	urge incontinence
Tx of urge incontinence	oxybutynin (muscarinic cholinergic antagonist) or mirabegron (beta-3 agonist) Incontinence + high post-void volume (usually 3-400 in question; normal is <50 mL)
Tx for overflow incontinence in diabetes	bethanacol (muscarinic cholinergic agonist)
Incontinence in BPH	overflow incontinence due to outlet obstruction
Tx for overflow incontinence in BPH	insert catheter first; then give alpha-1 blocker of 5-alpha-reductase inhibitor; then TURP if necessary
Exquisitely tender prostate on digital rectal exam	prostatitis
Prostatitis Tx	ciprofloxacin (fluoroquinolone
Costovertebral angle tenderness + fever	pyelonephritis
Costovertebral angle tenderness + granular casts	pyelonephritis (correct, super-weird; NOT acute tubular necrosis; this is on 2CK NBME)
Tx for pyelonephritis	ciprofloxacin, OR ampicillin + gentamicin
Saddle anesthesia + urinary retention	cauda equina syndrome
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Perianal anesthesia + urinary retention or incontinence	conus medullaris syndrome
Gradual-onset dementia + no sensory or motor dysfunction	Alzheimer
Mini-mental state exam score low + patient tries to do well	Alzheimer
Mini-mental state exam score low + patient is apathetic / takes long to perform tasks / does poorly on reverse serial 7s	depression (pseudodementia)
Patient complains about memory loss	normal aging, not Alzheimer
First-line Tx for Alzheimer	donepezil (cholinesterase inhibitor also give galantamine or rivastigmine

NMDA receptor (glutamate receptor) antagonist used in Alzheimer Tx	memantine
Step-wise dementia/decline and/or sensory/motor disturbance	vascular dementia
Hx of hypertension + dementia + sensory/motor disturbance	vascular dementia
Visual hallucinations + Parkinsonism + dementia	Lewy body dementia
Apathy + disinhibition + personality change + dementia	frontotemporal dementia (Pick disease)
Urinary incontinence + ataxia + CNS dysfunction (wet, wobbly, wacky)	Normal-pressure hydrocephalus
Wet, wobbly, wacky + Parkinsonism	still NPH
Parkinsonism in young patient	Wilson disease till proven otherwise
Parkinsonism in older patient	Parkinson disease
Parkinsonism + axial dystonia	progressive supranuclear palsy
Tx of UTI	TMP/SMX or nitrofurantoin
Tx of cystitis	nitrofurantoin (need not be pregnant)
Waiter tip position in kid	upper brachial plexus injury
Claw hand	lower brachial plexus
Pronated arm + wrist-drop	radial nerve injury
Midshaft fracture of humerus	Radial nerve injury
Supracondylar fracture of humerus	median nerve injury
Surgical neck of humerus fracture	axillary nerve injury
Medial epicondylar injury	ulnar nerve injury
Weakened biceps + loss of sensation of lateral forearm	musculocutaneous nerve injury
Paresthesias + pain following burn or casting	compartment syndrome
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Compartment syndrome Dx	measure compartment pressure
Compartment syndrome Tx	fasciotomy of uncast
Guy lifts heavy box	severe lower back pain + muscle spasm + no radiculopathy
Lumbosacral strain diagnosis	DO NOT x-ray
Lumbosacral strain Tx	NSAIDs + exercise as tolerated; bedrest is the WRONG answer
Guy lifts heavy box	severe lower back pain + radiculopathy
Point tenderness over a vertebra in older woman	osteoporosis (compression fracture)
Point tenderness over a vertebra in younger patient on steroids	osteoporosis (compression fracture)
Point tenderness over a vertebra in patient with autoimmune disease	recognize patient is on steroids -> osteoporosis (compression fracture)

Point tenderness over a vertebra in IV drug user	epidural abscess
“Step-off” of one vertebra relative to another	spondylolisthesis
Back pain worse in the morning and gets better throughout day in male 20s-40s	ankylosing spondylitis
Bamboo spine	ankylosing spondylitis
Dx of AS	x-ray of sacroiliac joints
Back pain worse when standing or walking for long periods of time	lumbar spinal stenosis
Radiculopathy down an arm	cervical disc herniation
Bilateral paresthesias in the arms in rheumatoid arthritis patient	atlantoaxial subluxation
Bilateral paresthesias in the arms in rheumatoid arthritis patient	MR of spine to Dx atlantoaxial subluxation
Prior to surgery in rheumatoid arthritis patient	cervical CT or flexion/extension x-rays of cervical spine to check for atlantoaxial subluxation

Back pain in elderly patient with hypercalcemia	multiple myeloma or metastases
Back in pain in patient with history of other type of cancer	metastases
Suspected spinal mets	MRI
Metastases to long bones in prostate cancer	osteoblastic (Dx with bone scan); spine do MRI
High hemoglobin +/- pruritis after shower +/- plethora +/- splenomegaly	polycythemia vera
High hemoglobin + low EPO	polycythemia vera
Pruritis after shower	basophilia
High hemoglobin + lung disease / low pO2	secondary polycythemia (high EPO)
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Polycythemia + hypercalcemia + smoker + red urine	RCC (paraneoplasic EPO + PTH-rp)
Blurry vision or Raynaud or pain in fingers or headache	hyperviscosity syndrome Hyperviscosity syndrome
Hereditary spherocytosis	AD, ankyrin or spectrin or band protein deficiency; Tx = splenectomy Treatment for ITP
Tx for hereditary hemochromatosis	serial phlebotomy
Tx for secondary hemochromatosis (transfusional siderosis)	chelation therapy (deferoxamine)
Viral infection + tinnitus + vertigo +/- neurosensory hearing loss	labrynthitis
Viral infection + vertigo	vestibular neuritis
Tx for multiple sclerosis flares	IV steroids (IV methylprednisolone)
Given to MS patients between flares	interferon-beta
Tx for spasticity in MS	baclofen (GABA-B receptor agonist)
Incontinence in MS	urge (hyperactive detrusor, as mentioned earlier)
New-onset murmur + fever	endocarditis till proven otherwise
Empiric Tx for endocarditis	vancomycin or ampicillin/sulbactam, PLUS gentamicin
Beta-lactam (e.g., nafcillin) or cephalosporin + rash + renal issue	interstitial nephritis
Interstitial nephritis	WBCs in the urine (eosinophils)
Fixed splitting of S2	atrial septal defect
Holosystolic murmur at left sternal border PLUS either parasternal heave or palpable thrill	VSD
Holosystolic murmur at left sternal border PLUS diastolic rumble	also VSD
To-and-fro murmur	PDA (on 2CK NBME)
Pan-systolic-pan-diastolic murmur	PDA
Continuous, machinery-like murmur	PDA
Congenital rubella syndrome	PDA
Heart problem in neonate of mom with SLE	congenital third-degree heartblock
Heart problem in William syndrome	supravalvular aortic stenosis
Bicuspid aortic valve	aortic stenosis
Mid-systolic (crescendo-decrescendo) murmur + gets worse with Valsalva	HOCM
Mid-systolic (crescendo-decrescendo) murmur + no change or softens with Valsalva	aortic stenosis MEHLMANMEDICAL.COM 8
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Myxomatous degeneration of mitral valve	mitral valve prolapse
Marfan or Ehlers-Danlos syndrome	MVP or aortic regurg
Rheumatic heart disease acutely (onset of Group A Strep infection)	mitral regurg
Rheumatic heart disease later on (years after infection)	mitral stenosis
Mid-systolic click	MVP
Late-peaking systolic murmur with ejection click	another way they describe aortic stenosis
Bounding pulses + massively wide pulse pressure	aortic regurg
Brisk upstroke + precipitous downstroke of pulse	aortic regurg
Syncope + angina + dyspnea (SAD)	aortic stenosis
Dyspnea in second trimester of pregnancy	mitral stenosis
Dyspnea late in pregnancy	peripartum cardiomyopathy
Screening at age 50	mammogram (every two years) + colonoscopy (every ten years)
Colon cancer in first-degree relative (sibling or parent)	start at age 40 or ten years before diagnosis in relative, whichever is earlier, and do every 5 years.

Breast imaging (if performed)	ultrasound only under age 30; over age 30 do mammogram +/- ultrasound
Anuria (no urine output) after removal of catheter	acute urethral obstruction
Contrast induced nephropathy; how to prevent	saline hydration beforehand
BUN/Cr > 20	prerenal (hypovolemia)
BUN/Cr <20	not prerenal (15-20 for post-renal, and <15 for intra-renal is wrong on 2CK NBMEs)
Blood loss + oliguria	acute tubular necrosis
Blood loss + obstetric catastrophe	diffuse cortical necrosis
Sickle cell + nephrotic syndrome	focal segmental glomerulosclerosus
Sickle cell + red urine	renal papillary necrosis
2+ blood in urine but 0-4 RBCs/HPF on LM	false + blood on dipstick
Pleural / supradiaphragmatic plaques	asbestosis
Preferred antibiotic in sepsis	ceftriaxone
Sepsis Tx in young children	cefotaxime
Tx for spontaneous bacterial peritonitis	ceftriaxone
Cirrhosis or recent peritoneal dialysis or nephrotic syndrome + fever + abdo pain	SBP
Dysphagia to solids and liquids at the same time to start	says neurogenic cause
Dysphagia to solids that progresses to solids and liquids	esophageal cancer
Halitosis +/- gurgling sound when swallowing +/- regurgitation of undigested food	Zenker
Zenker + achalasia initial Dx modality	barium swallow
After barium swallow is done and shows bird’s beak appearance	monometry to confirm Dx of achalasia
Pt with Hx of GERD + dysphagia	straight to endoscopy to rule out cancer
Diabetic pt with new-onset GERD	diabetic gastroparesis
Diabetic pt with new-onset GERD	give metoclopramide, not PPI
Diabetic gastroparesis before giving med	endoscopy first to rule out physical obstruction
Endoscopy negative for diabetic gastroparesis	do gastric-emptying scintigraphy
Bulimia nervosa or anorexia	never give buproprion (seizure risk)
Electrolyte abnormality in anorexia	hypokalemia
Most common cause of death in anorexia	arrhythmia from hypokalemia
Refeeding syndrome	worry about hypophosphatemia
Tx of anorexia + depression	mirtazapine (alpha-2 antagonist); stimulates appetite
Amenorrhea in anorexia	low FSH + low estrogen (hypogonadotropic)
Premature ovarian failure + Turner syndrome + menopause	high FSH (low inhibin) + low estrogen
Cholelithiasis	Dx with abdo ultrasound; fat, forties, female, fertile
Biliary colic + fever	cholecystitis
Tx of cholelithiasis + cholecytitis	cholecystectomy
Pt doesn’t want surgery or is pregnant	ursodeoxycholic acid (ursodiol)
Abdo USS negative in suspected cholecystitis	HIDA scan
Gall bladder doesn’t light up on HIDA scan	confirms cholecystitis
Cholelithiasis in pregnancy	estrogen upregulates HMG-CoA reductase + progesterone slows biliary peristalsis

Trichotillomania (eating one’s hair) + GI symptoms	gastric bezoar (hair ball)
Hx of surgery + high-pitched bowel sounds or acute-onset abdo symptoms	small bowel obstruction (SBO)
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Renal failure + friction rub over chest	uremic pericarditis
High leukocytes + low leukocyte ALP	CML
Metamyelocytes + myelocytes + splenomegaly	CML
Tx of CML	imatinib; causes fluid retention / edema
Smudge cells + autoimmune hemolytic anemia	CLL
Auer rods	AML; composed of myeloperoxidase
Tx of AML	DIC caused by Auer rod release into blood
Kid with high lymphocytes	ALL or pertussis (weird bc bacterial, but lymphocytes often >30k) Dry cough in winter
Young African American woman + dry cough + normal CXR	asthma (activation of mast cells), not sarcoidosis Young African American woman + dry cough + nodularity on CXR
Hypercalcemia in sarcoid, why?	epithelioid (activated) macrophages produce 1-alpha hydroxylase, thereby activating vitamin D3
Increased calcium in sarcoid	means decreased calcium in feces (bc D3 increased small bowel absorption) Tx for sarcoid
Outpatient Tx of asthma	SABA, then low-dose ICS, then maximize dose of ICS, then LABA, then use any number of drugs (e.g., mast cell stabilizers, anti-leukotriene, etc.), then oral steroids last resort
Kid with asthma on SABA inhaler + not effective + next best step?	ICS (fluticasone)
Kid with asthma on SABA inhaler + most effective way to decrease recurrence?	oral steroids (not next best step, but certainly most effective)
40s male + hematuria + hemoptysis	Goodpasture syndrome
Antibodies in Goodpasture	Anti-GBM (anti-collagen IV)
Dx of Goodpasture	antibodies first, but confirmatory is renal biopsy showing linear immunofluorescence Hematuria + hemoptysis + “head-itis” (mastoiditis, sinusitis, otitis, nasal septal perforation)
New name for Wegener	granulomatosis with polyangiitis
Dx of Wegener	c-ANCA (anti-PR3; anti-proteinase 3)
Asthma + eosinophilia	Churg-Strauss
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New name for Churg strauss	eosinophilic granulomatosis with polyangiitis
Dx of CS	p-ANCA (anti-MPO; anti-myeloperoxidase)
Hematuria in isolation + p-ANCA in serum	microscopic polyangiitis (MP)
Severe renal disease in Wegener or Goodpasture or MP	rapidly progressive glomerulonephritis (crescentic) High ALP + high direct bilirubin + high amylase or lipase
High ALP + high direct bilirubin + high amylase or lipase + remote Hx of cholecystectomy	sphincter of Oddi dysfunction (can’t be a stone cuz the gallbladder was removed ages ago)
High ALP + high direct bilirubin + normal amylase or lipase in someone with recent cholecystectomy	choledocholithiasis (retained stone in cystic duct that descended, but not distal to pancreatic duct entry point) Dx and Tx of choledocholithiasis
High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy	pancreatic cancer
Dx of pancreatic cancer	CT abdo with contrast
High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy + CT is negative	cholangiocarcinoma
High ALP + high direct bilirubin + normal amylase or lipase + diffuse pruritis + high cholesterol	primary biliary cirrhosis (PBC)
High ALP + high direct bilirubin + normal amylase or lipase + autoimmune disease (in pt or family)	PBC Dx of PBC
Recent cholecystectomy + fever + abdo pain	post-op bile leak
High ALP + high direct bilirubin + normal amylase or lipase + CT shows cystic lesion in bile duct	choledochal cyst
Imaging to view liver or pancreas	CT with contrast
Imaging to view gallbladder	Ultrasound
Imaging to view gallbladder in suspected cholecystitis only if USS negative	HIDA scan
Imaging to view bile ducts	ERCP or MRCP (choose ERCP > MRCP if both listed)
Teenage girl with Hx of cutaneous candida infections since childhood	chronic mucocutaneous candidiasis MCC
Bacterial + fungal + protozoal + viral infections since birth	SCID
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Bacterial infections since age 6 months	Bruton
Bacterial infections only since birth	Bruton (rare as hell to say from birth, but it’s on new 2CK NBME)
SCID XR variant	common gamma-chain mutation (IL-2 receptor deficiency)
SCID AR variant	adenosine deaminase deficiency
Bruton mechanism	tyrosine kinase mutation
Hyper IgM syndrome	deficiency of CD40 ligand on T cell (can’t activate CD40 on B cell to induce isotype class switching)

Greasy, scaly scalp + itchy + papules + adult	seborrheic dermatitis
Tx for SD	azole or selenium shampoo
Tx for tinea capitis	oral griseofulvin for patient only
How to decrease risk of tinea capitis	avoidance of sharing of hats
Tx of onychomycosis (nailbed fungus)	oral terbinafine
Tx of tinea pedis	topical terbinafine or topical azole
Tx of tinea corporis (ring worm)	topical azole (clotrimazole or miconazole)
Tx of cutaneous candida	oral azole
Tx of oropharyngeal candida	nystatin mouthwash
Tx of esophageal candidiasis	oral azole, not nystatin mouthwash
Tx of vaginal candidiasis	topical nystatin before trying oral azole
Odynophagia (painful swallowing) in immunocompromised pt	esophageal candidiasis till proven otherwise
CNS fungal infection or fungemia (rigors/chills)	amphotericin B
Cryptococcal meningitis	amphotericin B + flucytosine, then do fluconazole taper
Simple fungal pneumonia	fluconazole
Sporothrix schenckii (rose thorn + finger papule)	itraconazole
Hypopigmentation on upper back / trunk	tinea versicolor (Malassezia furfur)
Tx of tinea versicolor	topical selenium
Most common cause of impetigo	S. aureus now exceeds S. pyogenes
Tx of impetigo	topical mupirocin
Beefy red, well-demarcated skin plaque	erysipelas
Most common cause of erysipelas	Group A Strep (S. pyogenes) >>> S. aureus
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More diffuse pink skin lesion + tenderness + fever	cellulitis
Most common cause of cellulitis	S. aureus exceeds S. pyogenes
Tx of erysipelas + cellulitis	oral dicloxacillin or oral cephalexin
Wide-complex tachyardia	ventricular tachycardia (VT)
Narrow-complex tachy	SVT
Tx for SVT	vagal/carotid massage first; if doesn’t work, then adenosine
Tx of VT	anti-arrhythmics, e.g., amiodarone
Tx of SVT or VT in setting of coma / unconsciousness	direct-current countershock
Tx of first-degree heartblock or second-degree Mobitz I (Wenckebach)	observe
Tx of second-degree Mobitz II or third-degree heartblock	pacemaker
First-degree heartblock	PR-interval >200 milliseconds
Mobitz I	gradually prolonging PR-interval before a QRS drops
Mobitz II	no gradual prolongation of PR-interval; QRS randomly drops
Third-degree	HR super slow at 30-40; no relation between p-waves and QRS complexes
Infective causes of third-degree	Lyme disease, congenital lupus, diphtheria
Give killed IM influenza vaccine when?	Every year in fall/winter only; start from 6 months of age
Killed IM Influenza vaccine safe in pregnancy?	Yes, give anytime to pregnant women
Live-attenuated intranasal influenza vaccine guidelines?	Only give age 2-49 to non-pregnant, non- immunocompromised persons
Vaccines at age 2, 4, 6 months: HepB, Polio Salk, Pneumo PCV13, DPT, HiB, rotavirus (also give HepB at birth) HPV vaccine when	age 9-45
Mom’s HepB status unknown	give neonate HepB vaccine; only give immunoglobulin if mom comes back + MMR
Varicella	one dose between 12-18 months
Age 65 or older	give Pneumo PCV13 followed by PPSV23 6-12 months later
Asplenia or sickle cell	PCV13 + PPSV23 + HiB + Meningococcal
Circular lesion in pancreas seen in pancreatitis	pseudoabscess
Centri-acinar emphysema	smokers
Pan-acinar emphysema	alpha-1 anti-trypsin deficiency
Young adult + non-smoker + has emphysema + relative died of hepatic cirrhosis	alpha-1 anti-trypsin deficiency
CREST syndrome lung pathology?	can cause pulmonary fibrosis
Restrictive lung disease	normal or increased FEV1/FVC
Obstructive lung disease	decreased FEV1/FVC
Why is FEV1/FVC normal or high in restrictive?	radial traction on outside of airways is sticky (keeps airways from closing)
Apex to base lung changes when sitting/standing	both ventilation + perfusion increase apex to base
Most common cause of otitis media	Strep pneumo
Tx of otitis media	oral amoxicillin only
Tx of recurrent OM	amoxicillin/clavulanate
When to do tympanostomy tube	three or more OM in 6 months, or 4 or more in a year
Most common cause of otitis externa	Pseudomonas
Tx of otitis externa	topical ciprofloxacin + hydrocortisone drops
Prevention of OE in someone with constant water exposure (e.g., crew team)	alcohol-acetic acid drops
Tx of earwax buildup	carbamide peroxide drops
Low hematocrit chronic disease Low hematocrit anemia
+ low MCV + low transferrin + low TIBC + transferrin saturation normal or low	anemia of
+ low MCV + high transferrin + high TIBC + transferrin saturation super-low	iron deficiency
+ low MCV + increased red cell distribution width (RDW)	iron deficiency anemia + low MCV + low/low-normal RDW
+ low MCV + low iron + low ferritin	iron deficiency
+ low MCV + normal iron + normal or high ferritin	thalassemia
Low hematocrit
Low hematocrit
Low hematocrit
Low hematocrit
Low hematocrit
thalassemia
Microcytic anemia that doesn’t improve with iron supplementation	thalassemia Dx of thalassemia
+ low MCV + normal iron + normal ferritin in pregnant woman on iron supplements
Low hematocrit + normal MCV + low iron + normal or high ferritin	anemia of chronic disease
Tx of anemia of chronic disease if renal failure is cause	answer = EPO
Tx of anemia of chronic disease if renal failure not cause (IBD, RA, SLE, etc.)	CANNOT give EPO; Tx
underlying condition.
High BP + smoker + TIA or stroke or retinal artery occlusion. How to best decrease stroke risk	Answer =
lisinopril, not smoking cessation
Normotensive old pt + TIA or stroke or retinal artery occlusion	atrial fibrillation
Hypertensive pt + stroke	do carotid duplex ultrasound
Normotensive pt + stroke	do ECG; if ECG normal
High BMI female + irregular menstrual cycles	anovulation
Anovulation + hirsutism	PCOS
Anovulation. Cause USMLE wants?	insulin resistance
Why hirsutism in anovulation	abnormal GnRH pulsation causes high LH/FSH ratio
Why high LH/FSH ratio important in anovulation/PCOS	ovulation stimulated when follicle not ready
ovulation (anovulation)	follicle retained as cyst
What’s LH do?	Stimulates theca interna cells (females) and Leydig cells (males) to make androgens
What’s FSH do?	Stimulates granulosa cells (females) and Sertoli cells (males) to make aromatase; also
primes follicles
Tx for PCOS	if high BMI, weight loss first always on USMLE
Tx for PCOS if they ask for meds and/or weight loss already tried	OCPs (if not wanting pregnancy);
clomiphene (if wanting pregnancy)
PCOS increases risk of what	endometrial cancer (unopposed estrogen)
Tx of prostate cancer	flutamide + leuprolide together (if they force a sequence, choose F then L).
Tx of acute gout	indomethacin (NSAID) first on USMLE; then steroids, then colchicine
Tx of acute gout if indomethacin + steroids not listed	colchicine
Tx of acute gout in pt with renal insufficiency or Hx of renal transplant	steroids
Tx of chronic gout (decrease recurrence)	allopurinol or febuxostat (xanthine oxidase inhibitors)
Never give which drug to pt with Hx of uric acid stones or over-producer	probenecid (uricosuric)
What are rasburicase / pegloticase	urate oxidase analogues
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Young kid + self-mutilation + red-orange crystals in diaper	Lesch-Nyhan syndrome (X-linked) Lesch-Nyhan enzyme
Crystal type in pseudogout	calcium pyrophosphate deposition disease
Two main causes of pseudogout	primary hyperparathyroidism + hemochromatosis
Two ways pseudogout presents	monoarthritis of large joint (i.e., knee) or osteoarthritis-like presentation in someone with primary hyperparathyroidism or hemochromatosis
32M + dark skin on forearms + increased fasting glucose; Dx?	hemochromatosis (bronze diabetes)
Same male + painful hands + x-ray shows DIP involvement. Joint pain Dx?	pseudogout
Tx of pseudogout	same as gout acutely; Tx underlying condition for chronic
Biggest risk factor for osteoarthritis	obesity
Tx of osteoarthritis	weight loss; if normal BMI
Patient with OA taking naproxen (NSAID) + peripheral edema	increased renal retention of sodium
Patient taking NSAID + edema; why?	NSAID decreases renal blood flow
compensate for perceived low volume status	water follow sodium
Tx of rheumatoid arthritis	Two-armed: symptom-relief + disease-modifying anti-rheumatic drugs (DMARDs)
Symptom-relief for RA	NSAID first, then steroids (these do symptoms only; do not slow disease progression)
DMARDs for early RA	always methotrexate first; if insufficient, add another DMARD (sulfasalazine or
leflunomide); if insufficient add anti-TNF-alpha agent
Methotrexate MOA	dihydrofolate reductase inhibitor
Methotrexate side-effects	pulmonary fibrosis + hepatotoxicity + mouth ulcers (neutropenia)
Sulfasalazine MOA	metabolized into sulfapyridine + mesalamine in the gut by bacteria
Mesalamine is 5-ASA absorbed as the Tx for RA; only NSAID considered to be DMARD
Leflunomide MOA	dihydroorotate dehydrogenase inhibitor (pyrimidine synthesis)
Most specific Abs in RA	anti-CCP (cyclic citrullinated peptide), not RF (rheumatoid factor)
X-ray of hands in RA vs OA	Only OA has DIPs involved; RA is PIPs + MCPs
Symmetry in RA vs OA	RA is symmetrical; OA is not
Any pt with red, warm, tender knee	joint aspiration (arthrocentesis); septic arthritis till proven otherwise
Biggest risk factor for septic arthritis	abnormal joint architecture
Pt groups most likely to get SA	prosthetic joints, RA/OA, recent intense exercise/joint trauma; peds (JRA) MEHLMANMEDICAL.COM 17
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Pt group most likely to get SA	those with prosthetic joints (can’t be more abnormal than fake joint) Pt with OA or RA has red, warm, tender knee
17F had kickboxing tournament last weekend + knee is red, warm, tender	arthrocentesis (SA)
Kid + recurrent knee redness, warmth, pain + fever	Juvenile rheumatoid arthritis (JRA; Still disease) Kid + recurrent joint pain +/- high ESR +/- rash
Kid + recurrent joint pain + anemia	JRA (anemia of chronic disease)
Kid with suspected JRA has sore knee	must do arthrocentesis to rule out septic arthritis
Most common presentation finding in SLE	arthritis (>90%)
Woman 20s-40s + arthritis + thrombocytopenia	SLE
Woman 20s-40s + arthritis + mouth ulcer + circular skin lesions	SLE
Malar rash + low RBCs + low WBCs + low platelets; mechanism for low cell lines?	increased peripheral destruction (antibodies against hematologic cells lines seen in SLE; isolated thrombocytopenia most common) Tx of SLE flare
SLE + red urine; Dx?	lupus nephritis, more specifically, diffuse proliferative glomerulonephritis (DPGN) Histology of DPGN
Tx of lupus nephritis	mycophenolate mofetil
Tx of discoid lupus	hydroxychloroquine
Most specific Abs for SLE	anti-Smith (RNP), not anti-dsDNA
Which Abs go up in acute SLE flares	anti-dsDNA (and C3 goes down)
Drug-induced lupus Abs	anti-histone
Drugs that cause DIL	Mom is HIPP
Viral infection + all three cell-lines are down	viral-induced aplastic anemia
Viral-induced aplastic anemia; next best step in Dx?	bone marrow aspiration
Viral-induced aplastic anemia; mechanism?	defective bone marrow production (contrast with SLE)
Viral infection + low platelets	ITP (immune thrombocytopenic purpura)
Woman 30s-40s with random bruising at different stages of healing	(also ITP; first rule out abuse) Mechanism of ITP
Dx of ITP	answer = low platelet count; don’t choose increased bleeding time
ITP Tx	steroids first, then IVIG, then splenectomy
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ITP episode	next best step in management
ITP episode	most effective way to decrease recurrence
Family Hx of heme condition treated with splenectomy	hereditary spherocytosis (autosomal dominant)
Bleeding time meaning?	platelet problem
PT and aPTT meaning?	clotting factor problem
Heme findings in ITP	increased BT, normal PT, normal aPTT
Heme findings in hemophilia	increased aPTT; bleeding time and PT are normal
Cause of hemophilia	X-linked recessive; hemophilia A (factor VIII def); hemophilia B (factor IX def)
Tx of hemophilia A	desmopressin for hemophilia A (increases VIII release); then give factor VIII
Tx of hemophilia B	give factor IX
Classic hemophilia presentation	hemarthrosis in school-age boy; bleeding after circumcision in neonate
Inheritance pattern of vWD	AD
Heme findings in vWD	bleeding time always high; PT always normal; aPTT elevated half the time
What is main function of vWF?	bridges platelet GpIb to underlying collagen (adhesion, not aggregation)
What is secondary function of vWF	stabilizes factor VIII in plasma (that’s why aPTT only half time increased)
vWD presentation	always one platelet problem + one clotting factor problem
Platelet problem?	epistaxis, bruising, petechiae
Clotting factor problem	menorrhagia, excessive bleeding with tooth extraction, hemarthrosis (but
hemarthrosis very very rare in vWD; it is seen in hemophilia)
vWD treatment	desmopressin
Vitamin K deficiency heme parameters?	Increased PT + aPTT; bleeding time normal
Cause of vitamin K deficiency in adults	chronic Abx knock out colonic flora
Cause of sickle cell	glutamic acid to valine mutation on beta-chain
Inheritance of sickle cell	AR
Nephrotic syndrome in SS	FSGS
Dark urine in SS	renal papillary necrosis
HY drugs that cause agranulocytosis	clozapine, ganciclovir, propylthiouracil, methimazole, methotrexate,
ticlopidine
How will agranulocytosis (neutropenia) present on USMLE?	mouth ulcers + fever MEHLMANMEDICAL.COM 19
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Tx for febrile neutropenia / neutropenic fever	immediate broad-spectrum IV Abx Broad-spectrum Abx example?
PTU and methimazole are used for what?	Tx of Graves
Ticlopidine is what?	ADP2Y12 blocker anti-platelet agent (clopidogrel, prasugrel, ticagrelor also)
Strongest indication for anti-coagulation	prosthetic material in heart / prosthetic valve (factoid in isolation)
Travel + self-limiting watery or brown/green diarrhea	Traveler diarrhea = ETEC HL or HS toxin
Abx (clindamycin, beta-lactam, cephalosporin) + diarrhea	C. difficile
Dx of C. diff	stool AB toxin test, not stool culture
Fever of 104 + abdo distension in C diff	toxic megacolon
Tx of C. diff	vancomycin, not metronidazole (updated guidelines as of Feb 2018)
Bloody diarrhea + travel	Entamoeba histolytica
Tx of E. histolytica	metronidazole + iodoquinol; can give paromomycin
Close quarters or military barracks or cruise ship + watery diarrhea	Norwalk virus
Child <5 years + watery diarrhea	rotavirus
Few organisms causing bloody diarrhea	Shigella
Bloody diarrhea + appendicitis-like pain (pseudoappendicitis) in a child	Yersinia enterocolitica
Bloody diarrhea + reactive arthritis in an adult	Y. enterocolitica, Campylobacter, Shigella, Salmonella
Diarrhea + Guillain-Barre syndrome	Campylobacter
GBSyndrome CSF?	albuminocytologic dissociation (high protein + normal cells)
GBSyndrome Dx?	electromyography + nerve conduction studies (on NBME)
Cardiac ischemia + need to evaluate	ECG stress test first-line
Cardiac ischemia + abnormal baseline ECG (e.g., BBB)	Echo stress test (need normal ECG to do ECG stress test)
Cardiac ischemia + patient can’t exercise	dobutamine + ECG/echo
ECG shows diffuse ST-segment elevations	pericarditis
Pericarditis Tx	NSAID, or steroid, or colchicine
Central chest pain worse when supine; better when leaning forward	pericarditis
Lateral chest pain after viral infection + increased CK	pleurodynia (intercostal muscle spasm)
ST-segment depressions in the anterior ECG leads	posterior MI
Electrical alternans on ECG	pericardial tamponade / pericardial effusion
Pulsus paradoxus (drop in systolic BP >10 mm with inspiration)	cardiac tamponade or severe asthma
Beck triad	hypotension + muffled heart sounds + JVD
Bloody diarrhea + poultry consumption	Campylobacter jejuni or Salmonella spp.
Tx of tamponade	pericardiocentesis or pericardial window
Tamponade	do echo before pericardiocentesis if both listed (even though sounds wrong, on 2CK NBME)
CPP + lobar pattern (right-lower lobe consolidation + dullness to percussion)	Strep pneumo
CPP + lobar pattern, but they say “interstitial” in the vignette description	Mycoplasma, not S. pneumo Empiric Tx for CPP
Tx for CPP is pt on Abx past three months	fluoroquinolone over azithro
Pneumonia in CF patient <10 years	S. aureus exceeds Pseudomonas
Pneumonia in CF patient >10 years	Pseudomonas exceeds S. aureus.
Pneumonia after influenza infection	USMLE wants S. aureus
Pneumonia + rabbits	F. tularensis
Pneumonia + cattle	Coxiella (Q fever)
Pneumonia + birds	Chlamydia psittaci
Leg swelling + pain + shortness of breath	Pulmonary embolism caused by DVT
Tx of PE	Heparin before spiral CT
Tx of PE in pregnant woman	V/Q scan, not CT
Tx of PE in someone already on warfarin	spiral CT to confirm, then IVC filter
Acid-base disturbance in PE	resp. alkalosis (low CO2, high pH, low O2, normal bicarb [too acute to change]) Acid-base disturbance in asthma
Acid-base disturbance in aspirin toxicity first 20 mins	resp. alkalosis (low CO2, high pH, normal O2, normal bicarb [too acute to change])
Acid-base disturbance in aspirin toxicity after 20 mins	mixed metabolic acidosis-respiratory alkalosis (low CO2, low pH, normal O2, low bicarb)
Tx for aspirin toxicity	bicarb (increased excretion through urinary alkalinization)
Tx for TCA toxicity	sodium bicarb
Normal calcium	8.4-10.2 mEq/L
Tx of hypercalcemia	10.2-12 -> normal saline (0.9% NaCl)
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Community-acquired pneumonia (CPP) + bilateral CXR infiltrates	Mycoplasma
Tx of hypercalcemia	12-14 -> normal saline (0.9% NaCl) only if asymptomatic; add bisphosphonate (e.g., pamidronate) if symptomatic
Tx of hypercalcemia	14+ -> normal saline (0.9% NaCl) + bisphosphonate
High calcium + polyuria	nephrogenic diabetes insipidus (weird, but on NBME)
High calcium + confusion	delirium caused by high calcium
Low calcium or potassium not responsive to supplementation	cause is low Mg
Low calcium or potassium in alcoholic	hypomagnesemia is cause
Ataxia, confusion, ophthalmoplegia	Wernicke encephalopathy (B1 deficiency)
Retrograde amnesia + confabulation in alcoholic	Korsakoff psychosis
Wernicke-Korsakoff syndrome	mammillary bodies
Hx of many pregnancies + downward movement of vesicourethral junction	stress incontinence
Tx of stress incontinence	pelvic floor exercises (Kegel); if insufficient
Hyperactive detrusor or detrusor instability	urge incontinence
Need to run to bathroom when sticking key in a door	urge incontinence
Incontinence in multiple sclerosis patient or perimenopausal	urge incontinence
Tx of urge incontinence	oxybutynin (muscarinic cholinergic antagonist) or mirabegron (beta-3 agonist) Incontinence + high post-void volume (usually 3-400 in question; normal is <50 mL)
Tx for overflow incontinence in diabetes	bethanacol (muscarinic cholinergic agonist)
Incontinence in BPH	overflow incontinence due to outlet obstruction
Tx for overflow incontinence in BPH	insert catheter first; then give alpha-1 blocker of 5-alpha-reductase inhibitor; then TURP if necessary
Exquisitely tender prostate on digital rectal exam	prostatitis
Prostatitis Tx	ciprofloxacin (fluoroquinolone
Costovertebral angle tenderness + fever	pyelonephritis
Costovertebral angle tenderness + granular casts	pyelonephritis (correct, super-weird; NOT acute tubular necrosis; this is on 2CK NBME)
Tx for pyelonephritis	ciprofloxacin, OR ampicillin + gentamicin
Saddle anesthesia + urinary retention	cauda equina syndrome
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Perianal anesthesia + urinary retention or incontinence	conus medullaris syndrome
Gradual-onset dementia + no sensory or motor dysfunction	Alzheimer
Mini-mental state exam score low + patient tries to do well	Alzheimer
Mini-mental state exam score low + patient is apathetic / takes long to perform tasks / does poorly on reverse serial 7s	depression (pseudodementia)
Patient complains about memory loss	normal aging, not Alzheimer
First-line Tx for Alzheimer	donepezil (cholinesterase inhibitor also give galantamine or rivastigmine

NMDA receptor (glutamate receptor) antagonist used in Alzheimer Tx	memantine
Step-wise dementia/decline and/or sensory/motor disturbance	vascular dementia
Hx of hypertension + dementia + sensory/motor disturbance	vascular dementia
Visual hallucinations + Parkinsonism + dementia	Lewy body dementia
Apathy + disinhibition + personality change + dementia	frontotemporal dementia (Pick disease)
Urinary incontinence + ataxia + CNS dysfunction (wet, wobbly, wacky)	Normal-pressure hydrocephalus
Wet, wobbly, wacky + Parkinsonism	still NPH
Parkinsonism in young patient	Wilson disease till proven otherwise
Parkinsonism in older patient	Parkinson disease
Parkinsonism + axial dystonia	progressive supranuclear palsy
Tx of UTI	TMP/SMX or nitrofurantoin
Tx of cystitis	nitrofurantoin (need not be pregnant)
Waiter tip position in kid	upper brachial plexus injury
Claw hand	lower brachial plexus
Pronated arm + wrist-drop	radial nerve injury
Midshaft fracture of humerus	Radial nerve injury
Supracondylar fracture of humerus	median nerve injury
Surgical neck of humerus fracture	axillary nerve injury
Medial epicondylar injury	ulnar nerve injury
Weakened biceps + loss of sensation of lateral forearm	musculocutaneous nerve injury
Paresthesias + pain following burn or casting	compartment syndrome
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Compartment syndrome Dx	measure compartment pressure
Compartment syndrome Tx	fasciotomy of uncast
Guy lifts heavy box	severe lower back pain + muscle spasm + no radiculopathy
Lumbosacral strain diagnosis	DO NOT x-ray
Lumbosacral strain Tx	NSAIDs + exercise as tolerated; bedrest is the WRONG answer
Guy lifts heavy box	severe lower back pain + radiculopathy
Point tenderness over a vertebra in older woman	osteoporosis (compression fracture)
Point tenderness over a vertebra in younger patient on steroids	osteoporosis (compression fracture)
Point tenderness over a vertebra in patient with autoimmune disease	recognize patient is on steroids -> osteoporosis (compression fracture)

Point tenderness over a vertebra in IV drug user	epidural abscess
“Step-off” of one vertebra relative to another	spondylolisthesis
Back pain worse in the morning and gets better throughout day in male 20s-40s	ankylosing spondylitis
Bamboo spine	ankylosing spondylitis
Dx of AS	x-ray of sacroiliac joints
Back pain worse when standing or walking for long periods of time	lumbar spinal stenosis
Radiculopathy down an arm	cervical disc herniation
Bilateral paresthesias in the arms in rheumatoid arthritis patient	atlantoaxial subluxation
Bilateral paresthesias in the arms in rheumatoid arthritis patient	MR of spine to Dx atlantoaxial subluxation
Prior to surgery in rheumatoid arthritis patient	cervical CT or flexion/extension x-rays of cervical spine to check for atlantoaxial subluxation

Back pain in elderly patient with hypercalcemia	multiple myeloma or metastases
Back in pain in patient with history of other type of cancer	metastases
Suspected spinal mets	MRI
Metastases to long bones in prostate cancer	osteoblastic (Dx with bone scan); spine do MRI
High hemoglobin +/- pruritis after shower +/- plethora +/- splenomegaly	polycythemia vera
High hemoglobin + low EPO	polycythemia vera
Pruritis after shower	basophilia
High hemoglobin + lung disease / low pO2	secondary polycythemia (high EPO)
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Polycythemia + hypercalcemia + smoker + red urine	RCC (paraneoplasic EPO + PTH-rp)
Blurry vision or Raynaud or pain in fingers or headache	hyperviscosity syndrome Hyperviscosity syndrome
Hereditary spherocytosis	AD, ankyrin or spectrin or band protein deficiency; Tx = splenectomy Treatment for ITP
Tx for hereditary hemochromatosis	serial phlebotomy
Tx for secondary hemochromatosis (transfusional siderosis)	chelation therapy (deferoxamine)
Viral infection + tinnitus + vertigo +/- neurosensory hearing loss	labrynthitis
Viral infection + vertigo	vestibular neuritis
Tx for multiple sclerosis flares	IV steroids (IV methylprednisolone)
Given to MS patients between flares	interferon-beta
Tx for spasticity in MS	baclofen (GABA-B receptor agonist)
Incontinence in MS	urge (hyperactive detrusor, as mentioned earlier)
New-onset murmur + fever	endocarditis till proven otherwise
Empiric Tx for endocarditis	vancomycin or ampicillin/sulbactam, PLUS gentamicin
Beta-lactam (e.g., nafcillin) or cephalosporin + rash + renal issue	interstitial nephritis
Interstitial nephritis	WBCs in the urine (eosinophils)
Fixed splitting of S2	atrial septal defect
Holosystolic murmur at left sternal border PLUS either parasternal heave or palpable thrill	VSD
Holosystolic murmur at left sternal border PLUS diastolic rumble	also VSD
To-and-fro murmur	PDA (on 2CK NBME)
Pan-systolic-pan-diastolic murmur	PDA
Continuous, machinery-like murmur	PDA
Congenital rubella syndrome	PDA
Heart problem in neonate of mom with SLE	congenital third-degree heartblock
Heart problem in William syndrome	supravalvular aortic stenosis
Bicuspid aortic valve	aortic stenosis
Mid-systolic (crescendo-decrescendo) murmur + gets worse with Valsalva	HOCM
Mid-systolic (crescendo-decrescendo) murmur + no change or softens with Valsalva	aortic stenosis MEHLMANMEDICAL.COM 8
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Myxomatous degeneration of mitral valve	mitral valve prolapse
Marfan or Ehlers-Danlos syndrome	MVP or aortic regurg
Rheumatic heart disease acutely (onset of Group A Strep infection)	mitral regurg
Rheumatic heart disease later on (years after infection)	mitral stenosis
Mid-systolic click	MVP
Late-peaking systolic murmur with ejection click	another way they describe aortic stenosis
Bounding pulses + massively wide pulse pressure	aortic regurg
Brisk upstroke + precipitous downstroke of pulse	aortic regurg
Syncope + angina + dyspnea (SAD)	aortic stenosis
Dyspnea in second trimester of pregnancy	mitral stenosis
Dyspnea late in pregnancy	peripartum cardiomyopathy
Screening at age 50	mammogram (every two years) + colonoscopy (every ten years)
Colon cancer in first-degree relative (sibling or parent)	start at age 40 or ten years before diagnosis in relative, whichever is earlier, and do every 5 years.

Breast imaging (if performed)	ultrasound only under age 30; over age 30 do mammogram +/- ultrasound
Anuria (no urine output) after removal of catheter	acute urethral obstruction
Contrast induced nephropathy; how to prevent	saline hydration beforehand
BUN/Cr > 20	prerenal (hypovolemia)
BUN/Cr <20	not prerenal (15-20 for post-renal, and <15 for intra-renal is wrong on 2CK NBMEs)
Blood loss + oliguria	acute tubular necrosis
Blood loss + obstetric catastrophe	diffuse cortical necrosis
Sickle cell + nephrotic syndrome	focal segmental glomerulosclerosus
Sickle cell + red urine	renal papillary necrosis
2+ blood in urine but 0-4 RBCs/HPF on LM	false + blood on dipstick
Pleural / supradiaphragmatic plaques	asbestosis
Preferred antibiotic in sepsis	ceftriaxone
Sepsis Tx in young children	cefotaxime
Tx for spontaneous bacterial peritonitis	ceftriaxone
Cirrhosis or recent peritoneal dialysis or nephrotic syndrome + fever + abdo pain	SBP
Dysphagia to solids and liquids at the same time to start	says neurogenic cause
Dysphagia to solids that progresses to solids and liquids	esophageal cancer
Halitosis +/- gurgling sound when swallowing +/- regurgitation of undigested food	Zenker
Zenker + achalasia initial Dx modality	barium swallow
After barium swallow is done and shows bird’s beak appearance	monometry to confirm Dx of achalasia
Pt with Hx of GERD + dysphagia	straight to endoscopy to rule out cancer
Diabetic pt with new-onset GERD	diabetic gastroparesis
Diabetic pt with new-onset GERD	give metoclopramide, not PPI
Diabetic gastroparesis before giving med	endoscopy first to rule out physical obstruction
Endoscopy negative for diabetic gastroparesis	do gastric-emptying scintigraphy
Bulimia nervosa or anorexia	never give buproprion (seizure risk)
Electrolyte abnormality in anorexia	hypokalemia
Most common cause of death in anorexia	arrhythmia from hypokalemia
Refeeding syndrome	worry about hypophosphatemia
Tx of anorexia + depression	mirtazapine (alpha-2 antagonist); stimulates appetite
Amenorrhea in anorexia	low FSH + low estrogen (hypogonadotropic)
Premature ovarian failure + Turner syndrome + menopause	high FSH (low inhibin) + low estrogen
Cholelithiasis	Dx with abdo ultrasound; fat, forties, female, fertile
Biliary colic + fever	cholecystitis
Tx of cholelithiasis + cholecytitis	cholecystectomy
Pt doesn’t want surgery or is pregnant	ursodeoxycholic acid (ursodiol)
Abdo USS negative in suspected cholecystitis	HIDA scan
Gall bladder doesn’t light up on HIDA scan	confirms cholecystitis
Cholelithiasis in pregnancy	estrogen upregulates HMG-CoA reductase + progesterone slows biliary peristalsis

Trichotillomania (eating one’s hair) + GI symptoms	gastric bezoar (hair ball)
Hx of surgery + high-pitched bowel sounds or acute-onset abdo symptoms	small bowel obstruction (SBO)
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Renal failure + friction rub over chest	uremic pericarditis
High leukocytes + low leukocyte ALP	CML
Metamyelocytes + myelocytes + splenomegaly	CML
Tx of CML	imatinib; causes fluid retention / edema
Smudge cells + autoimmune hemolytic anemia	CLL
Auer rods	AML; composed of myeloperoxidase
Tx of AML	DIC caused by Auer rod release into blood
Kid with high lymphocytes	ALL or pertussis (weird bc bacterial, but lymphocytes often >30k) Dry cough in winter
Young African American woman + dry cough + normal CXR	asthma (activation of mast cells), not sarcoidosis Young African American woman + dry cough + nodularity on CXR
Hypercalcemia in sarcoid, why?	epithelioid (activated) macrophages produce 1-alpha hydroxylase, thereby activating vitamin D3
Increased calcium in sarcoid	means decreased calcium in feces (bc D3 increased small bowel absorption) Tx for sarcoid
Outpatient Tx of asthma	SABA, then low-dose ICS, then maximize dose of ICS, then LABA, then use any number of drugs (e.g., mast cell stabilizers, anti-leukotriene, etc.), then oral steroids last resort
Kid with asthma on SABA inhaler + not effective + next best step?	ICS (fluticasone)
Kid with asthma on SABA inhaler + most effective way to decrease recurrence?	oral steroids (not next best step, but certainly most effective)
40s male + hematuria + hemoptysis	Goodpasture syndrome
Antibodies in Goodpasture	Anti-GBM (anti-collagen IV)
Dx of Goodpasture	antibodies first, but confirmatory is renal biopsy showing linear immunofluorescence Hematuria + hemoptysis + “head-itis” (mastoiditis, sinusitis, otitis, nasal septal perforation)
New name for Wegener	granulomatosis with polyangiitis
Dx of Wegener	c-ANCA (anti-PR3; anti-proteinase 3)
Asthma + eosinophilia	Churg-Strauss
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New name for Churg strauss	eosinophilic granulomatosis with polyangiitis
Dx of CS	p-ANCA (anti-MPO; anti-myeloperoxidase)
Hematuria in isolation + p-ANCA in serum	microscopic polyangiitis (MP)
Severe renal disease in Wegener or Goodpasture or MP	rapidly progressive glomerulonephritis (crescentic) High ALP + high direct bilirubin + high amylase or lipase
High ALP + high direct bilirubin + high amylase or lipase + remote Hx of cholecystectomy	sphincter of Oddi dysfunction (can’t be a stone cuz the gallbladder was removed ages ago)
High ALP + high direct bilirubin + normal amylase or lipase in someone with recent cholecystectomy	choledocholithiasis (retained stone in cystic duct that descended, but not distal to pancreatic duct entry point) Dx and Tx of choledocholithiasis
High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy	pancreatic cancer
Dx of pancreatic cancer	CT abdo with contrast
High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy + CT is negative	cholangiocarcinoma
High ALP + high direct bilirubin + normal amylase or lipase + diffuse pruritis + high cholesterol	primary biliary cirrhosis (PBC)
High ALP + high direct bilirubin + normal amylase or lipase + autoimmune disease (in pt or family)	PBC Dx of PBC
Recent cholecystectomy + fever + abdo pain	post-op bile leak
High ALP + high direct bilirubin + normal amylase or lipase + CT shows cystic lesion in bile duct	choledochal cyst
Imaging to view liver or pancreas	CT with contrast
Imaging to view gallbladder	Ultrasound
Imaging to view gallbladder in suspected cholecystitis only if USS negative	HIDA scan
Imaging to view bile ducts	ERCP or MRCP (choose ERCP > MRCP if both listed)
Teenage girl with Hx of cutaneous candida infections since childhood	chronic mucocutaneous candidiasis MCC
Bacterial + fungal + protozoal + viral infections since birth	SCID
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Bacterial infections since age 6 months	Bruton
Bacterial infections only since birth	Bruton (rare as hell to say from birth, but it’s on new 2CK NBME)
SCID XR variant	common gamma-chain mutation (IL-2 receptor deficiency)
SCID AR variant	adenosine deaminase deficiency
Bruton mechanism	tyrosine kinase mutation
Hyper IgM syndrome	deficiency of CD40 ligand on T cell (can’t activate CD40 on B cell to induce isotype class switching)

Greasy, scaly scalp + itchy + papules + adult	seborrheic dermatitis
Tx for SD	azole or selenium shampoo
Tx for tinea capitis	oral griseofulvin for patient only
How to decrease risk of tinea capitis	avoidance of sharing of hats
Tx of onychomycosis (nailbed fungus)	oral terbinafine
Tx of tinea pedis	topical terbinafine or topical azole
Tx of tinea corporis (ring worm)	topical azole (clotrimazole or miconazole)
Tx of cutaneous candida	oral azole
Tx of oropharyngeal candida	nystatin mouthwash
Tx of esophageal candidiasis	oral azole, not nystatin mouthwash
Tx of vaginal candidiasis	topical nystatin before trying oral azole
Odynophagia (painful swallowing) in immunocompromised pt	esophageal candidiasis till proven otherwise
CNS fungal infection or fungemia (rigors/chills)	amphotericin B
Cryptococcal meningitis	amphotericin B + flucytosine, then do fluconazole taper
Simple fungal pneumonia	fluconazole
Sporothrix schenckii (rose thorn + finger papule)	itraconazole
Hypopigmentation on upper back / trunk	tinea versicolor (Malassezia furfur)
Tx of tinea versicolor	topical selenium
Most common cause of impetigo	S. aureus now exceeds S. pyogenes
Tx of impetigo	topical mupirocin
Beefy red, well-demarcated skin plaque	erysipelas
Most common cause of erysipelas	Group A Strep (S. pyogenes) >>> S. aureus
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More diffuse pink skin lesion + tenderness + fever	cellulitis
Most common cause of cellulitis	S. aureus exceeds S. pyogenes
Tx of erysipelas + cellulitis	oral dicloxacillin or oral cephalexin
Wide-complex tachyardia	ventricular tachycardia (VT)
Narrow-complex tachy	SVT
Tx for SVT	vagal/carotid massage first; if doesn’t work, then adenosine
Tx of VT	anti-arrhythmics, e.g., amiodarone
Tx of SVT or VT in setting of coma / unconsciousness	direct-current countershock
Tx of first-degree heartblock or second-degree Mobitz I (Wenckebach)	observe
Tx of second-degree Mobitz II or third-degree heartblock	pacemaker
First-degree heartblock	PR-interval >200 milliseconds
Mobitz I	gradually prolonging PR-interval before a QRS drops
Mobitz II	no gradual prolongation of PR-interval; QRS randomly drops
Third-degree	HR super slow at 30-40; no relation between p-waves and QRS complexes
Infective causes of third-degree	Lyme disease, congenital lupus, diphtheria
Give killed IM influenza vaccine when?	Every year in fall/winter only; start from 6 months of age
Killed IM Influenza vaccine safe in pregnancy?	Yes, give anytime to pregnant women
Live-attenuated intranasal influenza vaccine guidelines?	Only give age 2-49 to non-pregnant, non- immunocompromised persons
Vaccines at age 2, 4, 6 months: HepB, Polio Salk, Pneumo PCV13, DPT, HiB, rotavirus (also give HepB at birth) HPV vaccine when	age 9-45
Mom’s HepB status unknown	give neonate HepB vaccine; only give immunoglobulin if mom comes back + MMR
Varicella	one dose between 12-18 months
Age 65 or older	give Pneumo PCV13 followed by PPSV23 6-12 months later
Asplenia or sickle cell	PCV13 + PPSV23 + HiB + Meningococcal
Circular lesion in pancreas seen in pancreatitis	pseudoabscess
Centri-acinar emphysema	smokers
Pan-acinar emphysema	alpha-1 anti-trypsin deficiency
Young adult + non-smoker + has emphysema + relative died of hepatic cirrhosis	alpha-1 anti-trypsin deficiency
CREST syndrome lung pathology?	can cause pulmonary fibrosis
Restrictive lung disease	normal or increased FEV1/FVC
Obstructive lung disease	decreased FEV1/FVC
Why is FEV1/FVC normal or high in restrictive?	radial traction on outside of airways is sticky (keeps airways from closing)
Apex to base lung changes when sitting/standing	both ventilation + perfusion increase apex to base
Most common cause of otitis media	Strep pneumo
Tx of otitis media	oral amoxicillin only
Tx of recurrent OM	amoxicillin/clavulanate
When to do tympanostomy tube	three or more OM in 6 months, or 4 or more in a year
Most common cause of otitis externa	Pseudomonas
Tx of otitis externa	topical ciprofloxacin + hydrocortisone drops
Prevention of OE in someone with constant water exposure (e.g., crew team)	alcohol-acetic acid drops
Tx of earwax buildup	carbamide peroxide drops
Low hematocrit + low MCV + low transferrin + low TIBC + transferrin saturation normal or low	anemia of chronic disease
Low hematocrit + low MCV + high transferrin + high TIBC + transferrin saturation super-low	iron deficiency anemia
Low hematocrit + low MCV + increased red cell distribution width (RDW)	iron deficiency anemia
Low hematocrit + low MCV + low iron + low ferritin	iron deficiency
Low hematocrit + low MCV + normal iron + normal or high ferritin	thalassemia
iron deficiency anemia + low MCV + low/low-normal RDW	thalassemia
Microcytic anemia that doesn’t improve with iron supplementation	thalassemia
Low hematocrit + normal MCV + low iron + normal or high ferritin	anemia of chronic disease
Tx of anemia of chronic disease if renal failure is cause	answer = EPO
Tx of anemia of chronic disease if renal failure not cause (IBD, RA, SLE, etc.)	CANNOT give EPO; Tx underlying condition.
Dx of thalassemia + low MCV + normal iron + normal ferritin in pregnant woman on iron supplements	thalassemia
High BP + smoker + TIA or stroke or retinal artery occlusion. How to best decrease stroke risk	Answer = lisinopril, not smoking cessation
Normotensive old pt + TIA or stroke or retinal artery occlusion	atrial fibrillation
Hypertensive pt + stroke	do carotid duplex ultrasound
Normotensive pt + stroke	do ECG; if ECG normal
High BMI female + irregular menstrual cycles	anovulation
Anovulation + hirsutism	PCOS
Anovulation. Cause USMLE wants?	insulin resistance
Why hirsutism in anovulation	abnormal GnRH pulsation causes high LH/FSH ratio
Why high LH/FSH ratio important in anovulation/PCOS	ovulation stimulated when follicle not ready
ovulation (anovulation)	follicle retained as cyst
What’s LH do?	Stimulates theca interna cells (females) and Leydig cells (males) to make androgens
What’s FSH do?	Stimulates granulosa cells (females) and Sertoli cells (males) to make aromatase; also primes follicles
Tx for PCOS	if high BMI, weight loss first always on USMLE
Tx for PCOS if they ask for meds and/or weight loss already tried	OCPs (if not wanting pregnancy); clomiphene (if wanting pregnancy)
PCOS increases risk of what	endometrial cancer (unopposed estrogen)
Tx of prostate cancer	flutamide + leuprolide together (if they force a sequence, choose F then L).
Tx of acute gout	indomethacin (NSAID) first on USMLE; then steroids, then colchicine
Tx of acute gout if indomethacin + steroids not listed	colchicine
Tx of acute gout in pt with renal insufficiency or Hx of renal transplant	steroids
Tx of chronic gout (decrease recurrence)	allopurinol or febuxostat (xanthine oxidase inhibitors)
Never give which drug to pt with Hx of uric acid stones or over-producer	probenecid (uricosuric)
What are rasburicase / pegloticase	urate oxidase analogues
Young kid + self-mutilation + red-orange crystals in diaper	Lesch-Nyhan syndrome (X-linked) Lesch-Nyhan enzyme
Crystal type in pseudogout	calcium pyrophosphate deposition disease
Two main causes of pseudogout	primary hyperparathyroidism + hemochromatosis
Two ways pseudogout presents	monoarthritis of large joint (i.e., knee) or osteoarthritis-like presentation in someone with primary hyperparathyroidism or hemochromatosis
32M + dark skin on forearms + increased fasting glucose; Dx?	hemochromatosis (bronze diabetes)
Same male + painful hands + x-ray shows DIP involvement. Joint pain Dx?	pseudogout
Tx of pseudogout	same as gout acutely; Tx underlying condition for chronic
Biggest risk factor for osteoarthritis	obesity
Tx of osteoarthritis	weight loss; if normal BMI
Patient with OA taking naproxen (NSAID) + peripheral edema	increased renal retention of sodium
Patient taking NSAID + edema; why?	NSAID decreases renal blood flow
compensate for perceived low volume status	water follow sodium
Tx of rheumatoid arthritis	Two-armed: symptom-relief + disease-modifying anti-rheumatic drugs (DMARDs)
Symptom-relief for RA	NSAID first, then steroids (these do symptoms only; do not slow disease progression)
DMARDs for early RA	always methotrexate first; if insufficient, add another DMARD (sulfasalazine or leflunomide); if insufficient add anti-TNF-alpha agent
Methotrexate MOA	dihydrofolate reductase inhibitor
Methotrexate side-effects	pulmonary fibrosis + hepatotoxicity + mouth ulcers (neutropenia)
Sulfasalazine MOA	metabolized into sulfapyridine + mesalamine in the gut by bacteria
Mesalamine is	5-ASA absorbed as the Tx for RA; only NSAID considered to be DMARD
Leflunomide MOA	dihydroorotate dehydrogenase inhibitor (pyrimidine synthesis)
Most specific Abs in RA	anti-CCP (cyclic citrullinated peptide), not RF (rheumatoid factor)
X-ray of hands in RA vs OA	Only OA has DIPs involved; RA is PIPs + MCPs
Symmetry in RA vs OA	RA is symmetrical; OA is not
Any pt with red, warm, tender knee	joint aspiration (arthrocentesis); septic arthritis till proven otherwise
Biggest risk factor for septic arthritis	abnormal joint architecture
Pt groups most likely to get SA	prosthetic joints, RA/OA, recent intense exercise/joint trauma; peds (JRA)
Pt group most likely to get SA	those with prosthetic joints (can’t be more abnormal than fake joint) Pt with OA or RA has red, warm, tender knee
17F had kickboxing tournament last weekend + knee is red, warm, tender	arthrocentesis (SA)
Kid + recurrent knee redness, warmth, pain + fever	Juvenile rheumatoid arthritis (JRA; Still disease) Kid + recurrent joint pain +/- high ESR +/- rash
Kid + recurrent joint pain + anemia	JRA (anemia of chronic disease)
Kid with suspected JRA has sore knee	must do arthrocentesis to rule out septic arthritis
Most common presentation finding in SLE	arthritis (>90%)
Woman 20s-40s + arthritis + thrombocytopenia	SLE
Woman 20s-40s + arthritis + mouth ulcer + circular skin lesions	SLE
Malar rash + low RBCs + low WBCs + low platelets; mechanism for low cell lines?	increased peripheral destruction (antibodies against hematologic cells lines seen in SLE; isolated thrombocytopenia most common) Tx of SLE flare
SLE + red urine; Dx?	lupus nephritis, more specifically, diffuse proliferative glomerulonephritis (DPGN) Histology of DPGN
Tx of lupus nephritis	mycophenolate mofetil
Tx of discoid lupus	hydroxychloroquine
Most specific Abs for SLE	anti-Smith (RNP), not anti-dsDNA
Which Abs go up in acute SLE flares	anti-dsDNA (and C3 goes down)
Drug-induced lupus Abs	anti-histone
Drugs that cause DIL	Mom is HIPP
Viral infection + all three cell-lines are down	viral-induced aplastic anemia
Viral-induced aplastic anemia; next best step in Dx?	bone marrow aspiration
Viral-induced aplastic anemia; mechanism?	defective bone marrow production (contrast with SLE)
Viral infection + low platelets	ITP (immune thrombocytopenic purpura)
Woman 30s-40s with random bruising at different stages of healing	(also ITP; first rule out abuse) Mechanism of ITP
Dx of ITP	answer = low platelet count; don’t choose increased bleeding time
ITP Tx	steroids first, then IVIG, then splenectomy
ITP episode	next best step in management
ITP episode	most effective way to decrease recurrence
Family Hx of heme condition treated with splenectomy	hereditary spherocytosis (autosomal dominant)
Bleeding time meaning?	platelet problem
PT and aPTT meaning?	clotting factor problem
Heme findings in ITP	increased BT, normal PT, normal aPTT
Heme findings in hemophilia	increased aPTT; bleeding time and PT are normal
Cause of hemophilia	X-linked recessive; hemophilia A (factor VIII def); hemophilia B (factor IX def)
Tx of hemophilia A	desmopressin for hemophilia A (increases VIII release); then give factor VIII
Tx of hemophilia B	give factor IX
Classic hemophilia presentation	hemarthrosis in school-age boy; bleeding after circumcision in neonate
Inheritance pattern of vWD	AD
Heme findings in vWD	bleeding time always high; PT always normal; aPTT elevated half the time
What is main function of vWF?	bridges platelet GpIb to underlying collagen (adhesion, not aggregation)
What is secondary function of vWF	stabilizes factor VIII in plasma (that’s why aPTT only half time increased)
vWD presentation	always one platelet problem + one clotting factor problem
Platelet problem?	epistaxis, bruising, petechiae
Clotting factor problem	menorrhagia, excessive bleeding with tooth extraction, hemarthrosis (but hemarthrosis very very rare in vWD; it is seen in hemophilia)
vWD treatment	desmopressin
Vitamin K deficiency heme parameters?	Increased PT + aPTT; bleeding time normal
Cause of vitamin K deficiency in adults	chronic Abx knock out colonic flora
Cause of sickle cell	glutamic acid to valine mutation on beta-chain
Inheritance of sickle cell	AR
Nephrotic syndrome in SS	FSGS
Dark urine in SS	renal papillary necrosis
HY drugs that cause agranulocytosis	clozapine, ganciclovir, propylthiouracil, methimazole, methotrexate, ticlopidine
How will agranulocytosis (neutropenia) present on USMLE?	mouth ulcers + fever MEHLMANMEDICAL.COM 19
Tx for febrile neutropenia / neutropenic fever	immediate broad-spectrum IV Abx Broad-spectrum Abx example?
PTU and methimazole are used for what?	Tx of Graves
Ticlopidine is what?	ADP2Y12 blocker anti-platelet agent (clopidogrel, prasugrel, ticagrelor also)
Strongest indication for anti-coagulation	prosthetic material in heart / prosthetic valve (factoid in isolation)

Created by: gracey4u

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