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chicken + bloody diarrhea
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Step 2 Mehlman

Mehlman

TermDefinition
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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