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1. A previously healthy 27-year-old woman, gravida 2, para 1, at 26 weeks’ gestation comes to the physician for a routine prenatal…
Domestic abuse
- Key idea: Bruises “in various stages of healing” tells you that bruising has occurred chronically, with distribution on forearms particularly concerning for domestic abuse (“defensive wounds”)
- Key idea: Pregnant woman, unfortunately, are at high risk for domestic abuse
- Pre-eclampsia –> 3rd trimester pregnancy with HTN, proteinuria, edema
- HELLP –> Pre-eclampsia with Hemolysis (anemia), Elevated Liver enzymes and Low Platelets
- ITP –> Most common cause of isolated thrombocytopenia
- von Willebrand disease –> Often presents with signs of platelet dysfunction (nose bleeds, heavy periods, petechiae/purpura) along with normal platelet count, normal PT, normal/increased aPTT (because vWF carries factor 8)
2. A 19-year-old college student comes to the physician because of a 3-month history of cough that occurs only in midafternoon…
Asthma
- Young man with cough at night associated with cold weather with normal work-up, most concerning for cough variant asthma
- Common triggers of asthma: Cold weather, exercise, allergens
- Common causes of chronic cough:
- Asthma
- GERD
- Post-nasal drip
- COPD
- ACE inhibitor side effect
- Sarcoidosis –> Bilateral hilar adenopathy, hypercalcemia
- GPA –> Upper respiratory tract (ear infections, nasal symptoms) + Lower respiratory tract (cough, hemoptysis) + Renal (glomerulonephritis)
- Cocaine use –> Nose bleeds, destructive nasal lesions, hypertension, blown pupils, agitated/aggressive behavior
3. A previously healthy 37-year-old woman who works as a prison guard comes to the physician because of a 2-month history of low-grade fever…
Tuberculosis
- Young woman exposed to prisons who presents with subacute fever, fatigue and hemoptysis found to have a right upper lung infiltrate most concerning for tuberculosis
- Key idea: Subacute/chronic presentation with fever, malaise, weight loss, and/or night sweats should always make you think of malignancy vs indolent infection (mycobacterial, fungal) –> In this case malignancy is less likely given the patient’s age (too young) and the tempo of disease (lung CA would be more chronic)
- High-risk settings for Tb transmission:
- Immigrant
- Homeless shelters
- Prisons
- Congregate living facilities
- Tuberculosis almost always involves the upper lobe of the lung because it is a very aerophilic organism and the upper lobe has a higher V/Q ratio
- Environmental irritants –> Hypersensitivity pneumonitis –> Recurrent episodes of pneumonia-like illnesses following exposure with eventual development of interstitial lung disease
4. An 82-year-old man comes to the physician for a follow-up examination. He has a 2-year history of a painful tingling sensation…
Nortriptyline
- Elderly man with chronic history of T2DM who presents with painful lower extremity tingling refractory to gabapentin and carbamazepine –> next best options for neuropathic pain would be TCA (-triptyline) or SNRI (duloxetine)
- Phenelzine –> MAO inhibitor –> Watch out for tyramine-induced hypertensive episode (associated with wine/cheese consumption) and serotonin syndrome (Agitation, increased Activity and Autonomic symptoms)
5. An otherwise healthy 9-year-old girl is brought to the physician by her mother because she noticed a lump in her daughter’s left…
Follow-up examination in 6 months
- Healthy 9-year old girl who is Tanner stage 2 brought to doctor because of unilateral, 2 x 2.5cm, slightly tender mass beneath left areola most consistent with normal development of a breast bud that can be managed with close follow-up
- Key idea: Breast development may proceed asymmetrically and is completely normal
- Key idea: First step in new breast mass in woman over 35 is mammography, whereas in women under 35 best imaging modality would be ultrasound given increased breast density
- Key idea: Typical development of puberty in girls is breast development –> growth spurt –> menarche
6. A previously healthy 30-year-old woman comes to the physician because of fever, nonproductive cough, and left-sided chest pain…
Mycoplasma pneumoniae
- Young woman presents with 5 days of fever, cough and chest pain with mild diffuse crackles most consistent with atypical pneumonia (“walking pneumonia”), which is most often caused by Mycoplasma pneumoniae in young adults
- Key idea: Best treatment would be macrolide (azithromycin)
- Key idea: While Strep pneumo most common cause of bacterial, lobar pneumonia, young people more common to have atypical pneumonia due to Mycoplasma (which is confirmed by diffuse crackles rather than auscultatory findings localized to one lobe)
- Borrelia burgdorferi –> Lyme disease –> Bullseye rash, non-specific symptoms (fatigue, fever), Bell’s palsy, arthritis, neurologic symptoms
- Coxsackievirus –> Pleurisy, myocarditis
- Influenza virus –> Non-specific symptoms (fever, fatigue) + muscle fatigue
7. A healthy 14-year-old girl is brought for a routine health maintenance examination. On questioning, she says that she has…
Inquire about her attitudes toward smoking and health
- Key idea: For communication questions, best answer is often some form of non-judgmental, open-ended response, which will help physician determine next best step in management
8. The mother of a 16-year-old boy telephones the physician to request drug screening during his annual examination…
Do not agree to testing unless her son agrees to the drug testing
- Key idea: Minors often cannot provide consent or have confidentiality regarding their medical care, with the key exceptions being remembered by the mnemonic “sex, drugs and rock n’ roll”:
- Sex: STD testing, pregnancy care, contraception, privacy regarding sexual practices
- Drugs: Privacy regarding drug use, substance use programs
- Rock n’ roll: Emergency situations where parents cannot be contacted quickly enough
9. A 32-year-old man comes to the physician because of painful blisters on his penis for 2 days. During the past 2 years…
Acyclovir
- Young man with unsafe sexual practices presenting with intermittent episodes of painful genital ulcers found to have vesicular penile lesions with bilateral inguinal lymphadenopathy, most concerning for HSV infection that is best treated with acyclovir
- Painful genital ulcers:
- HSV –> Vesicles on erythematous base that can progress to become shallow ulcers, can be recurrent, mild lymphadenopathy
- Chancroid (H. ducreyi infection) –> Large deep ulcers with severe lymphadenopathy that may be suppurative
- Painless genital ulcers:
- Syphilis –> Single ulcer (chancre) with well-defined borders and firm base –> Treatment with penicillin
- Condyloma acuminata –> Verrucous (wart-like), skin-colored papules
- Lymphogranuloma venereum –> Shallow ulcers with predominant painful lymphadenopathy (buboes) –> Treated with ceftriaxone (form of Chlamydia)
10. A 37-year-old woman comes to the physician because of a 3-month history of generalized fatigue. She has noticed a decreased…
Assay for anti-transglutaminase antibodies
- Young woman with chronic history of GI symptoms (bloating, diarrhea) after carb-rich meals along with microcytic anemia most c/f celiac disease c/b iron deficiency anemia
- Key idea: Celiac disease commonly leads to iron deficiency anemia because it leads to inflammation of the duodenum, which is the primary site of iron absorption (Iron Fist Bro –> Iron (duodenum), Folate (jejunum), B12 (ileum)
- Schilling test –> Useful for suspected pernicious anemia (B12 deficiency [Megaloblastic anemia] with chronic atrophic gastritis)
- Chronic pancreatitis can also lead to intermittent diarrhea and particularly post-prandial pain, but is not associated with iron deficiency anemia
11. A 77-year-old woman who is a resident of a skilled nursing care facility is brought to the physician because of a 1-week history…
Drug-induced esophagitis
- Common causes of drug-induced esophagitis:
- Tetracyclines
- NSAIDs
- Bisphosphonates (alendronate)
- Potassium chloride
- Iron
- Infectious causes of esophagitis in immunosuppressed
- CMV –> Deep linear ulcers
- HSV –> Vesicles and round shallow ulcers
- Candida –> White plaques +/- oral thrush
12. A 32-year-old woman is brought to the emergency department by her husband because of the onset of shortness of breath…
Panic disorder
- Panic disorder = At least one untriggered panic attack + at least 1 month of worry and/or avoidance behavior related to fear of having another attack
- Panic attack symptoms:
- Palpitations, pallor, perspiration
- Abdominal pain
- Nausea
- Intense fear of dying or losing control, LIghtheadedness
- Coughing, choking, chest pain
- Key idea: In a young patient without significant cardiac risk factors who presents with severe chest pain and feelings that they are going to die, panic attack should be high on differential
- Key idea: Panic attacks are not specific to panic disorder, and can also be triggered in setting of phobias, anxiety disorders, etc.
- Generalized anxiety disorder –> Symptoms have to be present for at least 6 months
- Hyperthyroidism –> Weight loss, hair/nail changes, brisk reflexes, etc.
13. A 47-year-old woman comes to the physician because of a 6-month history of mild hand pain that occurs primarily over the palmar…
Use of wrist splints
- Middle-aged woman with history of T2DM who presents with chronic history of pain, numbness and tingling in a median nerve distribution that is worsened by prolonged typing and awakens her from sleep found to have positive Tinel sign, most consistent with carpal tunnel syndrome
- Key idea: Carpal tunnel syndrome can often be managed with behavioral modification and splinting, which prevents the wrists from being in a flexed position overnight –> Next step would be steroid injection followed by definitive treatment with surgical release of the carpal tunnel
- Median nerve sensory distribution: Thumb, finger 2, finger 3, half of finger 4
- Risk factors for carpal tunnel syndrome:
- Obesity
- Pregnancy
- Type 2 diabetes
- Hypothyroidism
- Acromegaly
- End-stage renal disease
- Rheumatoid arthritis
- +/- Repetitive activities
14. A 77-year-old man comes to the physician because of a 4-week history of moderately severe aching and morning…
Prednisone therapy
- Elderly man presenting with subacute aching/stiffness of shoulders and hips without muscle weakness found to have an elevated ESR most concerning for polymyalgia rheumatica –> Best treated with corticosteroids
- Key idea: Polymyalgia rheumatica is associated with giant cell (temporal) arteritis, which can lead to blindness –> Remember that patients with suspected giant cell arteritis should IMMEDIATELY be started on steroids, even before temporal artery biopsy is performed
- Amitriptyline –> Neuropathic pain (diabetes)
- Allopurinol –> CHRONIC gout (don’t start during acute flare)
- Colchicine –> Acute gout flare (unilateral arthritis)
15. A 9-month-old girl is brought to the physician for a well-child examination. Two weeks ago, she had viral gastroenteritis…
Lactose intolerance
- Key idea: Viral gastroenteritis can lead to inflammation/damage of the brush border, which can lead to an acquired, transient lactose intolerance
- Important to differentiate from cow milk allergy, which often presents with bloody stools without other systemic or GI symptoms
- Celiac disease –> Steatorrhea after consuming gluten-based foods (cereal, pasta, etc.)
- Patients GI symptoms of vomiting and diarrhea have largely resolved, so bacterial enteritis or persistent viral gastroenteritis don’t fit
16. A previously healthy 22-year-old woman comes to the physician because of a 3-day history of malodorous vaginal discharge…
Metronidazole therapy
- Young woman presents with 3 days of malodorous vaginal discharge found to have gray vaginal discharge without vaginal/cervical inflammation with clue cells on gram stain most consistent with bacterial vaginosis (Gardnerella infection), which is best treated with metronidazole (clindamycin second-line)
- Vaginal discharge differential:
- Bacterial vaginosis
- Gray, fishy smelling discharge
- Absent cervical/vaginal erythema
- Wet mount demonstrates clue cells (vaginal epithelial cells studded with bacteria)
- pH > 4.5
- Tx: Metronidazole or clindamycin
- Candidal vaginosis
- White, cottage-cheese like discharge
- Cervical/vaginal erythema present
- Wet mount demonstrates hyphae
- pH < 4.5
- Tx: Fluconazole
- Trichomonal vaginosis
- Green-yellow discharge
- Cervical/vaginal erythema present
- Wet mount demonstrates motile trichomonads
- pH > 4.5
- Tx: Metronidazole
- Bacterial vaginosis
- Key idea: Most common cause of malodorous vaginal discharge in a child is actually foreign body (i.e. toilet paper)
17. A 16-year-old girl comes to the physician because of a 2-day history of urinary frequency and urgency and pain with…
Postcoital single-dose nitrofurantoin therapy
- Adolescent girl who is sexually active who presents with 3rd UTI in past 2 months, who may benefit from prophylactic antibiotics (daily TMP-SMX or post-coital nitrofurantoin)
- Postcoital urination is often suggested to reduce risk of subsequent UTI
- Depot medroxyprogesterone shot would not put patient at increased risk for UTI and therefore does not need to be stopped; if anything a diaphragm would probably increase risk of UTI (foreign body)
18. An asymptomatic 42-year-old man with polycystic kidney disease comes for a routine follow-up examination. He has hypertension…
Lisinopril therapy
- Young man with polycystic kidney disease on HCTZ who continues to be hypertensive found to have proteinuria, who could benefit from additional antihypertensive treatment with a RAAS inhibitor (ACE inhibitor, ARB)
19. A 27-year-old man comes to the physician because of a 1-week history of yellow eyes and dark urine. He has a history…
Hepatitis C infection
- Young man with history of IVDU and positive HBsAb (consistent with vaccination or prior infection) who presents with acute scleral icterus and jaundice with dark urine and hepatomegaly most consistent with hepatitis C infection
- Key idea: IVDU puts patients at increased risk for both hepatitis B and hepatitis C infection, but in this patient we know he does not have current hepatitis B infection because he has a negative hepatitis B surface antigen
- Key idea: Hepatitis A infection only comes in acute form and cannot be reactivated or chronic; acute hepatitis A infection often presents with nausea/vomiting/diarrhea after shellfish consumption
- Key idea: Hepatitis D infection (delta virus) can ONLY be seen in setting of active hepatitis B and leads to a superinfection of hepatitis B infection
20. A 52-year-old woman comes to the physician because of a 14-month history of generalized muscle pain and difficulty sleeping…
Antidepressant therapy
- Middle-aged woman with >6 month history of anxiety symptoms (difficulty sleeping, fatigue) also found to have muscle point tenderness most consistent with fibromyalgia, which often is associated with anxiety disorders
- Key idea: Fibromyalgia can often be managed with exercise program and mindfulness training, but can sometimes benefit from specific antidepressant medications (TCAs, SSRIs, duloxetine)
- Glucocorticoid therapy would be appropriate for polymyalgia rheumatica, which would occur in elderly patients and predominantly lead to proximal joint stiffness (rather than point tenderness) with signs of systemic inflammation
21. A 42-year-old woman comes to the physician because of recent high blood pressure readings. During the past month…
Beta-Adrenergic blocking agent
- Young woman with poorly controlled hypertension and migraines who could best be managed for both conditions with beta blockers
- Indications to use beta blockers to treat HTN:
- Heart failure
- Post-MI
- Hyperthyroidism
- Migraines
- Atrial fibrillation
- Indications for prophylactic/preventive migraine medications:
- Frequent (>4/month) or long-lasting (>12 hours) migraines
- Disabling symptoms (missing work/school)
- Unable to take or no relief from abortive medications
- Prophylactic migraine medications:
- Beta blockers
- Topiramate
- Valproic acid
- TCAs
22. A 42-year-old man comes to the physician for a routine follow-up examination. He feels well. He has a 2-year history of mild hypertension…
Hypertension
- Key idea: Single most important risk factor for stroke is HTN (strong expulsion of blood from aorta –> Sheer stress of carotids –> Atherosclerosis), whereas most important risk factor for other forms of ASCVD (heart attack, PAD) is often smoking > diabetes
23. A 47-year-old woman comes to the physician to discuss weight loss. She has a 5-year history of hypertension and was recently…
Gastric bypass
- Middle-aged woman with BMI of 38 complicated by HTN and T2DM who has struggled with traditional weight loss methods and would likely benefit from a gastric bypass operation with continued lifestyle interventions
- Indications for gastric bypass:
- BMI > 40
- BMI >35 and one of the following complications:
- Diabetes mellitus
- Obesity hypoventilation syndrome
- Obesity-related cardiomyopathy
- Severe sleep apnea
- Osteoarthritis interfering with daily activity
24. A previously healthy 2-year-old boy is brought to the physician by his mother because of hoarse cough and difficulty breathing…
Laryngotracheobronchitis (croup)
- Previously healthy 2 year old with up-to-date immunizations presents with one day of hoarse cough and difficulty breathing found to have mild fever, hypoxia and inspiratory stridor most consistent with croup infection
- Key idea: Croup classically affects patients 6 months – 3 years of age and leads to inspiratory stridor + seal-like barking cough
- Key idea: Patients with croup without stridor at rest can often be managed with humidified air +/- corticosteroids, whereas patients with stridor at rest often receive corticosteroids and nebulized epinephrine
- Key idea: If patient presenting with croup becomes increasingly more ill-appearing (high fever, biphasic stridor, increased respiratory distress), important to consider whether patient has progressed to have bacterial trachieitis
- Bronchiolitis –> Infants (often <1 year of age) presenting with wheezing and coughing, often without fever
25. Over the past 4 months, a 66-year-old woman has had progressive shortness of breath on exertion. For 2 weeks…
Measurement of left ventricular ejection fraction
- Elderly woman with history of untreated hypertension who presents with progressive shortness of breath, PND, orthopnea found to have borderline JVD, bilateral inspiratory crackles, laterally displaced point of maximal impulse and S3 most consistent with congestive heart failure, which could be confirmed with echocardiography and measurement of LVEF
- Serial measurement of serum cardiac enzymes –> Suspected myocardial infarction (chest pain radiating to left arm, diaphoresis, etc.)
- Stress test and coronary artery angiography –> May be useful to determine etiology of HF (ischemic vs non-ischemic), but more invasive than echocardiography and cannot diagnose HF
26. A healthy 52-year-old woman comes to the physician because she is concerned about her risk for developing thyroid cancer…
Palpation of the thyroid gland
- Key idea: There is no validated screening test for thyroid cancer, so routine follow-up with history and physical directed at evaluating the thyroid gland are your best bet!
- Key idea: In setting of thyroid nodule, ultrasound > CT
27. A 67-year-old woman comes to the physician because of a 1-month history of diffuse abdominal cramps and worsening constipation…
Trial of fiber supplementation
- Elderly woman with psychiatric comorbidities and history of fluctuations between constipation and 2 bowel movements per day who presents with 1 month of abdominal pain and constipation with reassuring exam and work-up most consistent with irritable bowel syndrome –> Conservative management with mindfulness training and increased fiber consumption/supplementation
- Features more consistent with IBS rather than IBD:
- Fluctuations between diarrhea and constipation
- Lack of inflammatory signs (fever, weight loss, bloody stools)
- Abdominal pain/symptoms relieved by defecation
28. An asymptomatic 67-year-old woman comes to the physician for a follow-up visit. She has a 10-year history…
Adverse effect of medication
- Key idea: Very common side effect associated with calcium channel blockers is lower extremity edema
- Key idea: Often lower extremity edema is associated with disease affecting the heart, liver or kidney, but this patient has no signs/symptoms or lab findings compatible with these diseases and is taking a common culprit medication
29. A 56-year-old woman comes to the physician for a routine examination in October. She has type 2 diabetes…
“Patients who are incubating the influenza virus when they receive the vaccine mistakingly attribute their symptoms to the vaccine. You should get the vaccine.”
- Basically this answer is all that is left after eliminating the other answer choices, which either are overly paternalistic, rely upon guilt-tripping patient or insult their intelligence
30. A 62-year-old woman comes to the physician because of a 9-month history of pain and swelling of her finger joints…
Acetaminophen
- Middle-aged woman with chronic history of painful, swollen PIP and DIP joints that worsens with activity most consistent with osteoarthritis which can be managed with acetaminophen or NSAIDs
- Key idea: Arthritis/arthropathy with involvement of DIP joints almost always due to osteoarthritis or psoriatic arthritis on the NBME
- Key idea: Joint pain that worsens with activity most consistent with osteoarthritis, whereas joint pain that improves with activity most consistent with inflammatory arthritis (RA, seronegative spondyloarthritis, etc.)
31. A 57-year-old woman comes to the physician for a routine health maintenance examination. She has no history of serious illness…
Exercise program
- Middle-aged woman with no history of serious illness found to have dyslipidemia (low HDL and high LDL), with first step in management being lifestyle changes; in her case, exercise program > weight loss because she is already of normal weight (BMI < 25)
- Indications for statin therapy:
- History of ASCVD (MI, stroke, etc.)
- LDL > 190
- Diabetic aged 40-75
- 10-year pooled ASCVD risk > 7.5%
- Key idea: In order to be diagnosed with hypertension, need readings >140/90 at >2 office visits; first step in treatment of newly diagnosed hypertension would be lifestyle changes (weight loss, DASH diet, etc.)
32. A 27-year-old man comes to the physician because of sadness, loss of appetite, and difficulty falling asleep since he and his wife…
Cognitive behavioral therapy
- Young man with recent life stressor who presents with >2 weeks of sad mood, appetite changes, sleep changes, low energy, and decreased interest in activities, most consistent with major depressive disorder which can be treated with cognitive behavioral therapy +/- antidepressants
- Test-taking strategy: Cognitive behavioral therapy is often the answer on NBME questions when asked to select the type of therapeutic technique
33. A 37-year-old man comes to the physician because of intermittent chest pain over the past 2 days. Four days ago, he…
Pleurodynia
- Young man with recent viral URI with intermittent stabbing chest pain with elevated creatine kinase but normal ECG and troponin most consistent with pleurodynia 2/2 coxsackievirus infection (“devil’s grip”)
- Key idea: In a young patient with chest pain, pre-test probability of MI is often low and you should prioritize other diagnoses such as costochondritis, panic attack, pericarditis, pleuritis and pulmonary embolism
- Empyema –> Bacterial pneumonia (fever + cough) with significant illness or non-resolving symptoms
- SLE –> Pericarditis and pleuritis
- PE –> Sudden onset pleuritic chest pain in patient with risk factor (long plane flight, OCPs, etc.)
- Pericarditis –> Pleuritic, positional chest pain +/- fever –> Treat with NSAIDs (in most cases)
34. An 82-year-old woman comes to the physician because of a 6-month history of frequent falls. Prior to each fall, she…
Physical therapy
- Elderly woman with history of recurrent falls without loss of consciousness or orthostasis who has lower extremity weakness and is likely having mechanical falls that could be managed with physical therapy to strengthen muscles
- Key idea: Fall without loss of consciousness decreases probability of cardiac or orthostatic cause
- 24-Hr ECG monitoring and duplex ultrasound of carotids would be appropriate work-up in a patient with a TIA or stroke to search for etiologies
- Meclizine is an antihistamine which could be useful for vertigo but should generally be AVOIDED in elderly patients given risk for significant anticholinergic side effects (confusion, urinary retention, etc.)
35. An 18-year-old woman comes to the physician because of a pruritic facial rash for 2 days. The rash began around the lips and then spread…
Atopic dermatitis with eczema herpeticum
- Young woman with personal/family history of atopy with chronic eczematous rash involving the bilateral antecubital fossa, neck and cheeks who presents due to an acute vesicular facial rash of the lips and cheeks concerning for herpes superinfection of underlying atopic dermatitis
- Key idea: Atopic dermatitis leads to disruption of the skin barrier and puts patients at very high risk for bacterial (Strep, Staph) or viral (HSV) skin infections, which should always be suspected in setting of worsening/flaring disease
- Key idea: Classic distribution of atopic dermatitis among adolescents is in flexural areas (antecubital fossa, popliteal fossa) but patients can also have disease affecting the facial area
- Chronic contact dermatitis with superinfection –> Would expect well-defined plaques and the distribution would need to be at sites of contactants
- Dermatitis herpetiformis –> Affects extensor surfaces and buttocks
- Erythema multiforme with bullous formation –> Classically leads to target lesions, with common triggers being HSV infection and Mycoplasma infections
- Psoriasis –> Classically affects extensor surfaces, sacral area, intergluteal crease, scalp, nails
36. An 82-year-old woman comes to the physician because of difficulty sleeping at night for 6 months. She says she watches television…
Begin sertraline therapy
- Elderly woman with multiple life stressors in past few years who reports a 6 month history of sleep changes, decreased energy, appetite changes, and cognitive impairment most consistent with major depressive disorder –> Treat with CBT +/- SSRIs
- Key idea: Complex grief reaction would include longing for the deceased, etc.
- Key idea: MDD requires symptoms for >2 weeks and requires at least 5 of the following 9 symptoms:
- Sleep changes
- Interest decreased
- Guilty feelings
- Energy changes
- Cognitive problems
- Appetite changes
- Psychomotor slowing
- Suicidal ideation/thoughts
- Depressed mood or anhedonia
- Reversible causes of dementia (i.e. “pseudodementia”)
- Depression
- Hypothyroidism
- B12 deficiency
- Normal pressure hydrocephalus
37. A 42-year-old woman comes to the physician because of a 1-day history of severe pain, swelling, and warmth in her left knee…
Arthrocentesis
- Young woman presents with acute arthritis of left knee with limited range of motion, with next best step being arthrocentesis for diagnostic purposes given concern for possible septic arthritis (although she lacks fever)
- Key idea: Most likely has calcium pyrophosphate deposition disease, which can often occur following surgery or a period of intense exertion (i.e. kickboxing class)
- Key idea: Acute asymmetric inflammatory arthritis should make you consider:
- Septic arthritis (fever, history of joint disease, IVDU, young sexually active individual, etc.) –> WBCs > 100,000 with neutrophilic predominance
- Gout –> WBCs ~50,000 with negatively birefringent needle-shaped crystals
- Calcium pyrophosphate disease –> WBCs ~50,000 with weakly positively birefringent rhomboid-shaped crystals
38. An 11-year-old boy is brought to the camp infirmary by his cabinmates 1 hour after collapsing. The boys had been playing…
Cerebral hypoperfusion
- Patient likely had syncopal episode (i.e. period of cerebral hypoperfusion) because he performed multiple maneuvers that each are associated with cerebral hypoperfusion:
- Standing rapidly –> Drop in venous return due to gravity –> Decreased preload –> Decreased CO –> Decrease in cerebral blood flow
- Breathing deeply and rapidly –> Respiratory alkalosis –> Decreased PaCO2 –> Decrease in cerebral blood flow
- Breathing against closed mouth –> Valsalva –> Acute drop in preload –> Decreased CO –> Decrease in cerebral blood flow
- German medical students who used this exact method in study to show that twitching movements after loss of consciousness is not specific for seizure and can also be seen with syncope: https://www.youtube.com/watch?v=SOsNeUg1iGA
39. A 23-year-old woman comes to the physician because of moderate pain and swelling of her right ankle after twisting it yesterday…
Use of a soft protective brace and early range of motion exercises
- Young woman who twisted her ankle and presents with pain/ecchymosis of lateral malleolus who can bear weight and lacks tenderness at posterior margin of lateral malleolus most consistent with ankle sprain –> Does not meet Ottawa rules and therefore does not require imaging to rule out possible fracture; manage conservatively with bracing and early mobilization
- Ottawa ankle rule: X-ray of ankle required if pain at the malleolar zone AND:
- Tender at posterior margin of medial malleolus
- Tender at posterior margin of lateral malleolus
- Unable to bear weight for 2 steps on each foot
40. A 62-year-old man comes to the physician for a routine follow-up examination. He has type 2 diabetes mellitus and peripheral vascular disease…
Lipid lowering therapy to decrease LDL-cholesterol concentration to less than 100 mg/dL
- Middle-aged patient with history of T2DM and PAD who has an elevated LDL on 2 repeat measurements and would likely benefit from cholesterol lowering medication (i.e. statin) with a goal LDL < 100 given his burden of comorbidities
41. A previously healthy 4-year-old girl is brought to the physician because of a sore throat and temperatures to 38.8…
Low sensitivity
- Young girl presents with exudative pharyngitis and fever found to have negative rapid strep antigen test but positive strep throat cultures, likely because of low sensitivity of rapid antigen test
- High false negative rate –> Low sensitivity –> Bad screening test (miss a lot of patients with disease)
- High false positive rate –> Low specificity –> Bad confirmatory test (overdiagnose a lot of patients without disease)
- Key idea: Sensitivity and specificity are characteristics inherent to the test, whereas PPV and NPV are also influenced by prevalence of disease (i.e. pre-test probability)
42. A 42-year-old woman comes to the physician for a follow-up examination. She has had persistent right heel pain…
Impaired renal excretion of sodium
- Young woman with well-controlled T1DM and HTN who has been taking naproxen for 3 weeks for right heel pain and now presents with 4 days of lower extremity edema to the mid-calf, likely in the setting of NSAID-induced AKI
- Key idea: NSAIDs –> Decreased prostaglandins –> Decreased vasodilation of afferent arteriole –> Decreased GFR (i.e. AKI)
- Key idea: Edema often due to dysfunction of the heart, kidneys or liver
- Key idea: A common class of medications known to cause edema is calcium channel blockers
- Key idea: ACE inhibitors and ARBs can also lead to an acute drop in GFR because they decrease levels of angiotensin 2, thereby leading to vasodilation of the efferent arteriole and decreased glomerular filtration pressure
43. A 32-year-old woman is referred to the physician because of anemia noted on routine testing prior to blood donation…
Measurement of serum iron and ferritin concentrations
- Young woman with regular menstrual periods found to have microcytic anemia with blood smear showing hypochromasia (enlarged area of central pallor) which is consistent with iron deficiency anemia and should be worked up with iron panel
- Key idea: Microcytic anemia due to problem with production of hemoglobin, either due to decreased iron availability (IDA, ACD), impaired globin protein (thalassemia) or impaired heme production (sideroblastic anemia)
- Causes of microcytic anemia and iron panel results:
- IDA
- Causes: Blood loss (obvious, overt), celiac disease
- Iron studies: Low iron, Low ferritin, High TIBC, Low % sat
- Increased red cell distribution width (RDW) because some cells get enough iron whereas others get very little, leading to wide distribution of RBC sizes
- Anemia of chronic disease
- Causes: Chronic infection, autoimmune disease or malignancy
- Iron studies: Low/Normal iron, High ferritin, Low TIBC, Normal/High % sat
- Thalassemia
- Causes: Genetic (Alpha: Asian and African American, Beta: Mediterranean)
- Iron studies: Normal/High iron, Normal/High ferritin, Low/Normal TIBC
- Normal/Narrow RDW because all of the cells have dysfunctional globin and will be uniform in size
- Dx test: Hemoglobin electrophoresis (beta), genetic testing (alpha)
- Sideroblastic anemia
- Causes: Lead poisoning, alcohol, genetic, etc.
- Iron studies: Same as thalassemia
- Lead to basophilic stippling on smear and ringed sideroblasts on bone marrow biopsy
- IDA
- Key idea: In a young woman with anemia, pre-test probability highest for iron deficiency anemia 2/2 blood loss from menstruation –> Also most common cause of shortness of breathe in young women
- Folic acid deficiency –> Megaloblastic anemia (MCV > 100 with hypersegmented neutrophils)
44. A previously healthy 32-year-old man comes to the physician because of a 4-month history of constant pain on the outside…
Use of a forearm strap
- Young man with recent increase in lifting/exercise who presents with refractory lateral elbow pain found to have tenderness over lateral elbow with worsened pain with wrist extension most consistent with lateral epicondylitis (“tennis elbow”) –> Conservative management with assistive devices and activity modifications
- B6 deficiency often seen secondary to isoniazid use in a patient with tuberculosis and leads to neuropathy
- Oral steroid therapy would be appropriate for rheumatologic joint disease (other than psoriatic arthritis), but in that case would expect symmetric symptoms affecting multiple joints in a female>male patient
45. An 82-year-old man is brought to the physician by his daughter because of a 6-month history of memory problems and strange behavior…
Add donepezil to the current regimen
- Elderly man with chronic progressive cognitive issues that are impairing daily functioning with an MMSE < 25, concerning for dementia that can be managed (minimally) with acetylcholinesterase inhibitors such as donepezil or rivastigmine
- Key idea: Other option would be the NMDA antagonist memantine
- Diltiazem can lead to hypotension or lower extremity edema
- Simvastatin can (rarely) lead to myopathy or liver damage
- Clopidogrel would be useful if patient had evidence of TIA or stroke (neurologic findings, asymmetric exam findings, etc.)
- Selegiline is a Parkinson’s treatment, would expect patient to have TRAPS symptoms: Tremor (resting), Rigidity, Akinesia, Postural instability, Shuffling gait
- Depression could lead to pseudodementia and would be treated with SSRIs such as sertraline, but patient does not meet SIGECAPS criteria
46. A previously healthy 6-year-old boy comes to the physician because of a 1-week history of an itchy, nonpainful…
Clotrimazole
- Young boy with 1-week history of pruritic erythematous, scaly plaque with raised borders and central clearing most consistent with tinea corporis which can be treated with a topical antifungal
- Key idea: Oral antifungal needed for treatment of tinea capitis and onychomycosis
- Clindamycin –> Infection (cellulitis, folliculitis, impetigo)
- Hydrocortisone would be useful in many conditions, particularly atopic dermatitis in children which leads to poorly demarcated eczematous plaques predominantly of the antecubital fossa, popliteal fossa, and face
- Permethrin –> Scabies –> Significant nighttime pruritis with burrows of the finger webspaces, wrist, umbilicus, waist and genitals
- Selenium sulfide –> Seborrheic dermatitis –> Greasy, scaling plaques of the scalp and T-zone of the face
47. A 16-year-old boy is brought to the physician because of a 1-year history of severe acne that has not responded…
Avoidance of sun exposure
- Key idea: Many acne treatments can lead to increased photosensitivity, including topical retinoids and oral antibiotics such as doxycycline (as were prescribed in this patient)
- Key idea: Some evidence to suggest that decreased dairy and sugar consumption may help acne in some patients, but evidence is not strong
- Key idea: Alcohol is excessively drying and would likely lead to worsening of acne
- Typical progression of acne therapy with worsening severity (note that treatments are often combined): Benzoyl peroxide or salicylic acid –> Topical retinoid –> topical antibiotic –> systemic antibiotic –> systemic retinoid (isotretinoin)
48. A 55-year-old man comes to the physician for a routine health maintenance examination. He is asymptomatic. He has no history of serious…
Serum lipid studies
- Middle-aged man with >50 pack-year smoking history and excessive alcohol consumption who also consumes high-fat diet with increased BMI who should receive serum lipid screening
- USPSTF strongly recommends screening men > 35yo for lipid disorders, which would be particularly important in this patient given his family history and personal history of smoking and obesity
- Stress test is not often used as a screening test but rather in a patient with suspected coronary artery disease
- HgbA1c or fasting glucose levels >>> 5-hour glucose tolerance test for screening for diabetes
- Ultrasound screening for AAA: Men 65-75 years of age with any smoking history
49. Results of serum lipid studies are within the reference ranges. During a follow-up examination 2 weeks later, the patient’s…
Smoking
- Key idea: Smoking is the strongest modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), which is the #1 cause of mortality in the US
50. A 16-year-old girl is brought to the physician by her parents because she has become increasingly withdrawn…
Assessment for suicide risk
- Adolescent girl with 5 months of increased social withdrawal, decreased interest in activities, somatic symptoms, sleep changes, appetite changes, decreased energy, and sad mood most consistent with major depressive disorder –> ALL PATIENTS WITH DEPRESSION SHOULD BE SCREENED FOR SUICIDAL IDEATION/PLAN
- EBV –> Mononucleosis –> Lymphadenopathy, exudative pharyngitis, leukopenia, fatigue
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