CrossWards
USMLE Step 2 Board Review
Anthony J. Viera, MD, MPH
Associate Professor
Department of Family Medicine
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Matthew A. Sutton, MD
Family Medicine Physician
Winslow Indian Health Care Center
Winslow, Arizona
Acquisitions Editor: Susan Rhyner
Product Manager: Catherine Noonan
Production Project Manager: Alicia Jackson
Marketing Manager: Joy Fisher-Williams
Designer: Stephen Druding
Compositor: Aptara, Inc.
Copyright © 2014 Lippincott Williams & Wilkins, a Wolters Kluwer business.
351 West Camden Street
Baltimore, MD 21201
Two Commerce Square
2001 Market Street
Philadelphia, PA 19103
Printed in China
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or
transmitted in any form or by any means, including as photocopies or scanned-in or other electronic
copies, or utilized by any information storage and retrieval system without written permission from the
copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright. To request permission, please contact Lippincott
Williams & Wilkins at 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com,
or via website at lww.com (products and services).
9 8 7 6 5 4 3 2 1
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally
accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty,
expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the
publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered
absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with the current recommendations and practice at the
time of publication. However, in view of ongoing research, changes in government regulations, and the
constant flow of information relating to drug therapy and drug reactions, the reader is urged to check
the package insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new or infrequently
employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the healthcare
provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
To purchase additional copies of this book, call our customer service department at (800) 638-3030 or
fax orders to (301) 223-2320. International customers should call (301) 223-2300.
Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins
customer service representatives are available from 8:30 am to 6:00 pm, EST.
Puzzled by USMLE preparation or your latest rotation? Tired of the
same old boring review? Welcome to CrossWardsTM! We hope you
will find these puzzles a more engaging way to review your medical
knowledge as you prepare for examinations, ward rotations, or just
want to have a fun way to study.
Contributors to this edition of CrossWardsTM Step 2:
Meredith Gilliam was a medical student at the University of North
Carolina at Chapel Hill School of Medicine at the time of contribution, now a resident in internal medicine at the University of
Michigan.
Look for CrossWardsTM Step 1 and other future editions of CrossWardsTM.
Do YOU want to contribute to an upcoming edition of CrossWardsTM?
Send your puzzle clues, solutions, and “extra info” in an Excel or Word
table (or a Clinical Scramble as a Word file) to: crosswards.submit@
gmail.com. We’d also love to receive your other ideas for puzzles!
Include your name, address, and current position/medical school. We
will let you know if your puzzle is selected for inclusion in an upcoming edition.
PUZZLES
1.
Loosen Up with Some Medical Eponyms
2
2.
Cross My Heart
4
3.
Put Some Skin in the Game
6
4.
Lytes Out!
8
5.
Immune to Myself?
10
6.
I’m “Gland” You’re Doing This Puzzle
12
7.
Abdominal Pains
14
8.
Clinical Scramble
16
9.
This Confounded Puzzle!
18
10.
GI Feel Terrible
20
11.
Nerve-racking Puzzle
22
12.
One More . . . For Old Timer’s Sake
24
13.
This Puzzle May Cause Petechiae
26
14.
A Borderline Puzzle
28
15.
This Puzzle is Infectious
30
16.
The Heart of Pharmacology
32
17.
An Ounce of Prevention
34
18.
Puz-culoskeletal
36
19.
Catching My Breath
38
20.
Are You Smarter than a First-year?
40
21.
Not Just Little Adults
42
22.
Renal & Lytes
44
23.
Surgery Rounds
46
iv
24.
Just for Fun—Movie Docs
48
25.
I Got Rhythm . . .
50
26.
Clinical Scramble
52
27.
Birth of a Puzzle
54
28.
Labor Pains
56
29.
A pHuzzle
58
30.
Onco-Logical
60
31.
Clear to Auscultation?
62
32.
Some Lovers Try . . . This Puzzle
64
33.
Doc, I Think It’s My Hormones
66
34.
This Puzzle is Giving Me Gas
68
35.
BuzzWards
70
36.
A Trich Puzzle
72
37.
Widow Maker
74
38.
Don’t Mess Around with the Pancreas
76
39.
Most Common . . .
78
40.
Clinical Scramble
80
41.
BrainTeaser
82
42.
This Puzzle is Kidstuff
84
43.
This Puzzle Might Cause Extrapyramidal Symptoms
86
44.
Claiming the Inheritance
88
45.
CN 2-12 Intact?
90
46.
This Puzzle DeLivers
92
47.
I Need a Puzzle—Stat!
94
48.
Shock and Awe
96
49.
Doc Says “I’ve got good news and bad news”
98
50.
Step 2 Potpourri
100
CrossWard Solutions (with a little extra info!) begin on page 102.
v
CrossWards™
Loosen Up with Some
Medical Eponyms
1
1
2
3
4
5
6
7
8
9
10
12
13
14
15
16
17
18
19
20
21
22
2
11
Across:
Down:
3 - Nodules or macules on palms or soles
seen in endocarditis:
lesions
5 - When standing on one leg unable
to lift opposite side of pelvis:
sign
7 - To detect eosinophils in urine, ask for
stain
a
9 - One of the tests for meniscal tear
13 - Failure of third and fourth pharyngeal pouches to differentiate:
syndrome
score: Five parameters
15 assessed at birth
17 - When rubbing sole of foot in upper
motor neuron lesion, great toe
goes up and other toes fan out:
sign
18 - BPV treatment maneuver
19 - Deep palpation of LLQ provokes pain
in RLQ in appendicitis:
sign
21 - Necrotizing infection of genital fascia:
gangrene
22 - In hypocalcemia, tapping over
facial nerve causes facial twitch:
sign
1 - People being watched (studied)
behave differently:
effect
2 - Dermatology lines
body dementia
46 - Free Ig light chains seen in plasma
cell dyscrasias:
proteins
8 - Flexing the neck causes flexion
of the hips/knees in meningitis:
sign
10 - Primary adrenal insufficiency:
disease
11 - For distinguishing transudative
from exudative pleural effusion:
criteria
12 - Carpal tunnel test in which wrists are
flexed for a minute
14 - Vascular tumor associated with HHVsarcoma
8:
16 - Most common cause of mild
unconjugated hyperbilirubinemia:
syndrome
20 - Distended neck veins, distant heart
triad
sounds, low BP:
Solutions on page 103.
3
CrossWards™
2
Cross My Heart
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
28
29
32
33
34
35
36
37
27
30
31
4
26
Across:
2 - Harsh systolic murmur radiating to
stenosis
carotids:
5 - Medical term for “done fell out” (sudden, temporary loss of consciousness)
7 - Heart rate less than 60 bpm
10 - Most common cause of sudden cardiac
death in athletes (acronym)
11 - ACE inhibitors are the referred antihypertensive drug class in patients with
and proteinuria
12 - ACE inhibitors can cause this nagging
adverse effect, which would be a
reason to change to an ARB
13 - Most common cause of secondary hypertension in children:
parenchymal disease
16 - Cause of secondary hypertension
characterized by unprovoked
hypokalemia: Hyper
17 - A mobile, pedunculated mass in
the left atrium is likely an atrial
18 - JVD, low BP, and distant heart sounds
until
is acute cardiac
proven otherwise
23 - Stasis, hypercoagulability, and injury
set a person up for a deep venous
24 - Drug that inhibits Na+/K+−ATPase and
increases cardiac contractility
25 - On EKG: Left axis deviation has
QRS in lead II
30 - Severe stenosis of the left main
coronary artery is an indication for this
surgery (acronym)
31 - First-line antihypertensive medication
diuretics
class:
34 - A hypertensive emergency with
sudden chest pain radiating to the
back suggests aortic
35 - Chest pain that is new onset or
that is getting worse is deemed
angina
36 - On examination of the patient in #20
down you might hear a pericardial
(two
words)
37 - Aortic regurgitation has a
murmur
Solutions on page 105.
Down:
1 - A sign of #10 across is a systolic
in
murmur that
intensity with standing
3 - Breathlessness with lying flat
4 - Most common cause of myocarditis
disease
in the world:
6 - Protein that is elevated for several
days after a myocardial infarction
8 - If you hear a gallop when listening
to the heart, do not think horses, but
think this (acronym)
9 - Screen men aged 65 to 75 who have
ever smoked for abdominal aortic
13 - Most common cause of mitral valve
fever
stenosis:
14 - Patients with atrial fibrillation can
to
be treated with
reduce risk of stroke
15 - ST segment depression suggests this
19 - Part of the postmyocardial infarction
“recipe”
20 - Diffuse ST segment elevation on an
EKG of a patient with chest pain that
is worse with lying down suggests
acute
is one of the
21 - Aortic
cardiac causes of #5 across, mostly
in the elderly
22 - Treat symptomatic heart failure with
diuretic
a
26 - Q waves, that are two small boxes
wide or more than one-third the
QRS amplitude suggest myocardial
27 - Evaluate heart failure with an
echocardiogram to estimate left
fraction
ventricular
28 - Most common type of
cardiomyopathy
29 - A chest x-ray of the patient in #9
down may show a
mediastinum
32 - Midsystolic murmur with a “click”:
valve prolapse
33 - When the QRS is widened, there is
branch
some sort of
block
5
CrossWards™
3
Put Some Skin in the Game
1
2
3
4
5
7
6
8
9
10
11
12
13
14
15
16
17
18
19
20
22
6
21
Across:
Down:
1 - These “stuck-on” brownish wart-like
lesions are very common and are
benign: Seborrheic
4 - Herald patch heralds this dermatitis:
rosea
5 - Flat skin lesion >1 cm
9 - Another name for atopic dermatitis
10 - Tender, erythematous nodules on
lower legs usually triggered by
an illness or drug reaction:
Erythema
13 - Medical term for hives
14 - Elevated skin lesion <5 mm
17 - Melanoma is staged by TNM and this
level
18 - Small, fluid-filled lesion
19 - This medicine used to treat serious
acne is also a serious teratogen
contagiosum: Caused
20 by poxvirus, tiny lesions with central
umbilication, more common in
children
22 - Vesicular rash in dermatomal
distribution, common term for the
diagnosis
2 - Bleeding when a skin scale is
sign
scraped:
3 - If you see an older gentleman with
rhinophyma, think this condition
6 - Type 1 hypersensitivity might be
this serious reaction
7 - Pityrosporum ovale is implicated in
this dermatitis
8 - Caused by Malassezia furfur:
Tinea
11 - Flat skin lesion <1 cm
12 - Group A streptococcal secondary
skin infection characterized by
honey-colored crusted lesions,
mostly in children
15 - #2 down is seen with this inflammatory skin disease
16 - HSV-2 causes lesions here
21 - A patient who thinks he has a spider
bite more likely has a skin infection
with community-acquired form of
this (acronym)
Solutions on page 107.
7
CrossWards™
4
Lytes Out!
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
8
26
Across:
Down:
1 - Psychogenic polydipsia might be a
cool name for a rock band, but it can
cause this electrolyte problem
5 - This hormone from the C cells of
the thyroid gland decreases calcium
concentration
6 - Low sodium should be corrected for
high this
7 - Overdose of this may cause a metabolic acidosis and respiratory alkalosis
8 - Loss of deep tendon reflexes is an
early manifestation of this
12 - Before jumping to conclusions on low
calcium, be sure you correct for low
amount of this
13 - One other reason not to sniff glue is
that it can cause a metabolic acidosis
anion gap
with a
15 - In severe hyperkalemia, give this first
to protect the heart
18 - Facial spasm brought on by tapping
by the ear over the facial nerve when
sign
calcium is low:
20 - Angiotensin-converting enzyme
inhibitors can cause this electrolyte
problem
23 - The concentration of this determines
tonicity
24 - Not enough of this in the blood can
lead to Torsade de pointes
25 - In severe hypercalcemia, give intravenous hydration and this drug to
promote calcium excretion
26 - Parathyroid hormone (PTH) decreases
the resorption of this by the kidney
2 - Correcting #1 across too quickly
can result in central
myelinolysis
3 - Sodium minus (chloride +
bicarbonate) =
(two words)
4 - “Stones, bones, moans, and groans,”
think this
7 - A common cause of hyponatremia
is a syndrome of too much of this
(initials)
9 - Fractional excretion of this is helpful
in figuring out acute kidney injury
10 - pH <7.4 with PCO2 <40 mm Hg
(two words)
11 - It is the P in MUDPILES
14 - Hypokalemia and hypernatremia
found when working up the newly
diagnosed hypertensive patient
suggests hyper
is due to not
16 - Diabetes
enough ADH
17 - Twice the sodium concentration +
(glucose concentration)/18 + blood
urea nitrogen/2.8 gives the calculated
serum
19 - T waves may be flat in this electrolyte
abnormality
20 - If this happens to the blood sample,
the potassium may measure elevated
but it really is not
21 - Insulin drives this electrolyte
intracellularly
22 - Hyperventilation leads to
respiratory
Solutions on page 109.
9
CrossWards™
5
Immune to Myself?
1
2
3
5
4
6
7
8
9
10
11
12
13
15
16
17
18
19
20
10
14
Across:
Down:
5 - Anti-citrullinated protein (CCP):
arthritis
7 - Drug-induced lupus may have
antibodies
anti9 - Anti-Jo 1 may point to poly- or
myositis
10 - Anti-centromere (syndrome,
acronym)
11 - Antibodies activating thyroidstimulating hormone receptor:
disease
13 - IgA
15 - Anti-Sm
16 - p-ANCA: Microscopic
18 - Islet cell antibodies:
Type 1
19 - Anti-mitochondrial antibody: Primary
1 - Anti-basement membrane:
syndrome
syndrome
2 - Anti-ro:
3 - Anti-ds DNA
in RA
4 - Rheumatoid
6 - Thyroid peroxidase antibodies:
disease
8 - c-ANCA vasculitis
12 - Anti-Scl-70
(acronym) in
14 - U1
mixed connective tissue disease
15 - Anti-nuclear antibody
17 - Anti-transglutaminase:
disease
20 - Anti-endomysial:
disease
Solutions on page 111.
11
CrossWards™
I’m “Gland” You’re Doing
This Puzzle
6
1
2
3
4
5
6
7
8
9
12
10
11
13
14
15
16
17
18
19
20
12
Across:
Down:
1 - Useful beta-blocker to treat symptoms of hyperthyroidism
2 - If tapping on facial nerve elicits twitch
of facial muscles, think low levels of
this
5 - A classic sign of #19 across:
hump”
“
antibodies
7 - Antithyroid
are seen in #15 across:
8 - Most causes of #14 down are due to
the deficiency of 219 - Very common cause of euvolemic
hyponatremia (acronym)
12 - Autoimmune adrenal insufficiency:
disease
15 - Most common cause of elevated
TSH with low free T4:
disease or thyroiditis
17 - MEN 1: Pancreatic tumor, parathyroid hyperplasia, and
adenoma
18 - “Stones, bones, moans, and groans,”
think this: Hyper
19 - Too much ACTH will lead
syndrome
to
20 - Catecholamine-secreting tumor that
is a very rare cause of secondary
hypertension
1 - Most common type of thyroid cancer
3 - In Type 1 diabetic patient, hyperglycemia early in the morning in response
to hormones counteracting overnight
effect
hypoglycemia:
4 - Most common cause of #11 down:
disease
6 - Hyperglycemic crisis in Type 1 diabetes mellitus: Diabetic
10 - In Type 1 diabetic patient, hyperglycemia early in the morning
due to insulin being counteracted
(by growth hormone) overnight:
phenomenon
11 - Low TSH with elevated free T4:
Primary
12 - Low K+ and high Na+ in a newly diagnosed hypertensive patients suggests
hyper
13 - A key clinical issue in hyperosmolar
hyperglycemic state is
, which is why aggressive fluid
replacement (along with insulin) is
needed
14 - Congenital adrenal hyperplasia leads
to the deficiency of this
16 - Part of the treatment of nephrogenic
diabetes insipidus is
restriction
Solutions on page 113.
13
CrossWards™
7
Abdominal Pains
1
2
3
4
5
6
7
8
9
10
11
12
14
13
15
16
17
18
19
20
14
Across:
Down:
3 - Most gallstones are composed
of
4 - In any patient with GI bleed, be sure
IV’s
to have two large
in place
7 - Common cause of small bowel
obstruction
8 - Esophagus looks like a bird beak on
barium swallow
9 - Elevated in acute pancreatitis
10 - One of top two causes of pancreatitis
14 - Diagnosis for patient with periumbilical pain that moves to RLQ associated with anorexia
18 - Ecchymosis around the umbilicus:
sign
19 - This kind of hernia requires urgent
surgery
20 - Pain in RLQ on palpation of LLQ:
sign
1 - Deep palpation in RUQ causes
inspiratory halt in cholecystitis:
sign
2 - Free air under the diaphragm on plain
viscus
film:
3 - RUQ pain, jaundice, and fever
suggests this diagnosis
5 - Superficial tear of esophagus often
due to excessive vomiting (two
words)
6 - “Female, fat, forty, and fertile” are
classic risk factors for this
11 - #18 across seen in hemorrhagic
Solutions on page 115.
12 - Metaplasia in distal esophagus
13 - Metastasis above the left clavicle:
node
15 - Abdominal pain on extension of hip
sign
with knee flexed:
16 - Acute stomach ulcer in trauma and
ulcer
burn victims:
diverticulum is a cause
17 of oropharyngeal dysphagia
15
CrossWards™
8
Clinical Scramble
ICATHALLUNIONS
DIMN
OLDEDCU
TONEANITT
PIADRIME
TUACE
BEERVESILR
ANSWER:
16
Solutions on page 116.
STONE
Notes
17
CrossWards™
9
This Confounded Puzzle!
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
19
18
18
Across:
Down:
3 - 1 divided by the
risk
reduction is the NNT
6 - Step 2 study fatigue syndrome, or
S2SFS, occurs in 20% of medical
students; a new drug reduces the
incidence of S2SFS to 15%; 25% is
risk reduction
the
predictive
8 - Subtract the
value from 1 to get the probability a
patient with a negative test has the
disease
10 - A study in which we find a sample
of students who scored really high
on Step 2 examination and a sample
who scored really low from a similar
population and then call them up and
ask if they used CrossWardsTM is a
study
ratio is the
12 - A positive
probability of a positive test result in
those with the disease divided by the
probability of a positive test result in
those without the disease
14 - The NNT in #6 across to prevent one
case of S2SFS
15 - Students in the study in #10 across
who scored high on Step 2 examination may be more likely to remember using CrossWardsTM than those
who scored poorly; this is a kind of
bias
17 - Proportion in a population who
develop a disease or outcome over
a period of time (e.g., over the next
year)
19 - Probability that a patient positive for
the disease has a positive test
1 - A new blood test is developed to
detect S2SFS; among 100 students
with definite S2SFS by gold standard
brain scan, the new blood test is
positive in 80; among 100 students
without S2SFS by brain scan, the
blood test is negative in 90; 89% is
predictive value
the
2 - Case-control studies are particularly
valuable when studying outcomes
that are
4 - Probability that a patient without the
disease has a negative test
5 - The name for the bias in #6 down
6 - Students who study hard are more
likely to score high on Step 2 examination and may also be more likely
to use CrossWardsTM, a relationship
that may not be random; the best
way to eliminate this potential bias
the
from a study is to
students who use CrossWardsTM or
not
7 - In studies of screening, the bias introduced because a screened population
appears to have longer survival than
an unscreened population but really
does not is called
bias
test when
9 - A highly
negative, helps rule out a disease
11 - Proportion in a population who have
a disease or outcome at a specific
time (e.g., now)
13 - Participants in a study may drop out
of one group more than the comparison group; this introduces possible
bias
16 - False positive rate is the same as
1 minus the
18 - A study in which we follow medical
students who use CrossWardsTM and
those who do not and later assess
their board scores is a
study design
Solutions on page 119.
19
CrossWards™
10
GI Feel Terrible
1
2
3
5
6
4
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
32
33
34
35
36
20
37
31
Across:
Down:
3 - Type of inguinal hernia that protrudes
medial to the epigastric artery
5 - Hepatic encephalopathy is due to
failure to clear this
8 - Repeated vomiting can lead to this
tear that causes upper GI bleeding
(two words)
12 - If you see this under the diaphragm
on an x-ray, think perforation (two
words)
13 - Eventual fibrosis, scarring, and regenerative nodules in the liver that can
result from a wide variety of insults
14 - Loss of peristalsis without mechanical
obstruction
17 - Rings and webs in the lower esophagus, not to be confused with the
name of a deli
18 - Chronic GERD can lead to metaplasia
esophagus
called
23 - One of the organisms that causes
bloody diarrhea
25 - Germ that causes ulcers, common
short form
26 - You see Kayser-Fleischer rings not
around Saturn, but in this disease
29 - Complication of inflammatory bowel
disease with dilation of the colon and
systemic toxicity: Toxic
33 - “Liver flap”
34 - Most common cause of diarrhea in
infants
35 - It is difficulty swallowing
36 - Serologic marker reflecting high
transmissibility of hepatitis B infection (acronym)
37 - Most common type of esophageal
cancer in the world (two words)
1 - Your patient with epigastric pain
and elevated lipase has
acute
2 - Autoimmune disorder with positive
antimitochondrial antibody: Primary
cirrhosis
4 - RUQ pain, jaundice, and fever suggest
ascending
6 - Inflammatory bowel disease with skip
lesions
7 - Treat this cause of cirrhosis with
phlebotomy
9 - The cause of this condition (acronym)
is adhesions from a prior surgery in
about two-thirds of patients
10 - Kind of hypertension that results
from #13 across
11 - Treat #5 across with this
15 - Rare syndrome of gastrin being
produced by a tumor in the pancreas
that can lead to ulcers (acronym/
initials)
16 - A worrisome source of upper GI
bleeding in patients with cirrhosis:
Esophageal
19 - Amylase is NOT one of these criteria
that include elevated glucose, age
>55 years, elevated LDH, elevated
ASH, and elevated white blood cell
count on admission
20 - High levels of 5-HIAA define this
syndrome; patients may have flushing
and diarrhea
21 - Gluten-free diet is the treatment for
this disease
22 - This description of emesis suggests
upper GI bleeding (two words)
24 - “Bird’s beak” esophagus
27 - One of the top two causes of
#1 down
28 - The three signs in #4 down are
triad
called
30 - These drugs are a common cause of
gastritis and peptic ulcer (acronym)
31 - This sign is inspiratory arrest when
palpating in the right upper quadrant
32 - This lab can be helpful in evaluating
possible mesenteric ischemia
Solutions on page 121.
21
CrossWards™
11
Nerve-racking Puzzle
1
2
3
4
5
6
7
8
10
9
11
12
13
14
16
17
18
19
22
15
Across:
2 - #19 across usually requires this
procedure
3 - Aphasia, contralateral paralysis and
sensory loss, gaze toward the side:
Where is the lesion?
cerebral artery
5 - Sudden onset “worst headache of my
life” think this (acronym)
8 - Myasthenia gravis is due to antibodies
against these receptors
10 - MRI shows white matter lesions
and CSF has oligoclonal bands (two
words)
14 - Older patient hits head and ruptures
bridging veins:
hematoma
16 - #1 down seen in
motor neuron lesion
18 - Most common disabling headache
19 - Seizure lasting more than
epilepticus
10 minutes:
Solutions on page 123.
Down:
1-
sign: Dorsiflexion of
great toe with fanning of other toes
4 - Acute treatment for #12 down
6 - S1 nerve root reflex location:
tendon
7 - This yellowish coloration of CSF from
lumbar puncture suggests #5 across
9 - Tear of the middle meningeal
hematoma
artery:
10 - Triad of hearing loss, tinnitus, and
vertigo
11 - Double-vision, dysphagia, and slurred
speech seen in
circulation stroke
12 - Excruciating, one-sided headaches
associated with nasal stuffiness and
tearing of the eye
13 - Common cause of vertigo due to
malpositioned otolith (acronym)
15 - Idiopathic CN7 palsy:
palsy
17 - Infantile spasms:
syndrome
23
CrossWards™
12
One More . . . For Old
Timer’s Sake
Meredith Gilliam*
1
2
3
5
9
6
4
7
8
10
11
12
13
14
15
16
17
18
19
23
20
21
22
24
25
26
27
28
29
*Meredith Gilliam was a fourth-year medical student at the University of North Carolina
at Chapel Hill at the time of this contribution.
24
Across:
Down:
1 - The most common cause of
right heart failure:
heart failure
5 - Likely diagnosis in an elderly
smoker with hypoxemia,
polycythemia, and hypercapnia
(two words)
9 - These are indiscernible on EKG
tracings of atrial fibrillation, a
common arrhythmia in the elderly
11 - The most likely diagnosis
in an elderly smoker with a
pulsatile abdominal mass
(acronym)
is
13 - Most common primary brain
tumor in an elderly patient
(acronym)
17 - In a joint aspirate, positively
birefringent crystals that appear
blue when parallel to polarized
light suggest this diagnosis
18 - This common laboratory value
may be elevated in an elderly
man with multiple myeloma
20 - Donepezil, rivastigmine, and
galantamine (drugs sometimes
used in Alzheimer disease)
are acetylcholinesterase
2 - Cardiac marker that is one of the first to
rise in an acute myocardial infarction
3 - This organism is a leading cause of nosocomial infection due to the prevalence of
urinary catheters (short form)
4 - The valve most commonly affected by
rheumatic heart disease
5 - The initial test in an elderly patient
presenting with acute-onset hemiparesis
(two words—first word acronym)
6 - An elderly man who sees halos around lights
at night, has myopia, and denies eye pain
should be evaluated for this type of glaucoma
7 - When your elderly patient needs three pillows
to breathe comfortably at night, the most
(acronym)
likely diagnosis is
, when untreated,
8 - Infection with
may lead to rheumatic heart disease later in life
(shorten the genus to an initial)
9 - Most likely diagnosis in an elderly patient with
proximal joint pain, malaise, elevated ESR, and
rheumatica
normal CK:
10 - Common arrhythmia in the elderly causing
an irregularly irregular pulse (two words)
12 - Most likely diagnosis in an elderly patient
with a diastolic murmur, wide pulse pressure, and bounding pulses:
regurgitation
14 - Your patient transferred from a nursing
home for delirium is found to have a UTI;
when you see large mucoid capsules on
urine microscopy, your diagnosis
(of organism) is
15 - Important diagnosis to rule out in your
elderly patient with longstanding HTN and
chest pain radiating to the back (two words)
16 - Most likely diagnosis in an elderly
patient presenting with syncope and a
murmur at the right upper sternal border:
Aortic
19 - This class of antibiotics should be in
your treatment regimen for communityacquired pneumonia to cover atypicals
21 - LVH in your older patient is most commonly due to longstanding
22 - This treatment should not be delayed in
suspected cases of temporal arteritis
24 - The appropriate next test in your elderly
patient with back pain and mediastinal
widening on chest x-ray: CT
23 - An elderly man with longstanding HTN and a CT showing
ischemia of the internal capsule
may have a blockage in these
small vessels
25 - Painful first MTP joint associated with gout
26 - Adults should generally begin
screening for colorectal cancer
(excepat age
tions for high-risk groups)
27 - Unlike the pain of rheumatoid
arthritis, that of osteoarthritis
with use
28 - In rheumatic heart disease,
heart damage is caused by
antibodies against
29 - Name of an NMDA receptor
antagonist that may have some
neuroprotective effect in severe
Alzheimer disease
Solutions on page 125.
25
CrossWards™
This Puzzle May Cause
Petechiae
13
1
2
4
5
3
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
23
22
24
25
26
27
28
29
30
26
Across:
Down:
2 - When urine is pink, this is what you
should think
4 - Test used to detect autoimmune
hemolysis
8 - Classic abnormal cell of Hodgkin
disease
10 - #15 down may be associated with
this inflammation of the tongue
11 - Abnormally elevated hematocrit
12 - Procedure used to remove excess
immunoglobulin
anemia
14 - MCV > 100 =
16 - These malignancies are mostly of
B-cell origin
19 - Heparin inhibits the
pathway
21 - Oncologic emergency in which blasts
occlude the microcirculation leading
to CNS symptoms or pulmonary
edema
24 - Philadelphia chromosome t(9,22) in
90% of patients with this (acronym)
25 - Lytic bone lesions and elevated
monoclonal proteins
26 - #1 down cause of microcytic anemia
worldwide, common name (Hint: It
really sucks!)
27 - Common cause of iron deficiency in
younger women
28 - Fluctuating fevers in Hodgkin disease
29 - Vitamin K inhibitor (and rat poison)
30 - Deficiency of this enzyme can cause
hemolytic anemia:
kinase
1 - Iron deficiency anemia and thalassemia are two of the
anemias
3 - Petechiae suggest bleeding disorder
dysfunction
due to
5 - Most common inherited bleeding
disorder (acronym)
6 - Antidote for heparin
A
7 - Factor VIII deficiency:
9 - Can be used to treat mild hemophilia
or vWD
13 - Anemia associated with autosplenectomy (two words)
15 - Lack of intrinsic factor:
anemia
17 - Chemotherapeutic drug used to
prevent frequency of sickle cell crises
18 - Most common childhood malignancy
(acronym)
20 - Renal failure, low platelets, hemolytic
anemia (acronym)
22 - BCR-ABL tyrosine kinase inhibitor
23 - Primary site of iron absorption
Solutions on page 127.
27
CrossWards™
14
A Borderline Puzzle
1
2
3
4
5
6
7
8
9
11
28
10
Across:
Down:
3 - Cluster B: Unstable, impulsive,
vulnerable to abandonment, splitter
5 - Cluster C: Noncompliant,
procrastinator (two words)
7 - Cluster B: Overemotional and
dramatic
9 - Cluster A: Mistrustful, hostile, suspicious, conspiracy theorist
11 - Cluster A: Purposefully socially withdrawn, content living alone with no
friends
1 - Cluster C: The stubborn perfectionist
who likes all the soup cans lined up
perfectly (two words)
2 - Cluster B: Cannot conform to societal
rules; criminal behavior
4 - Cluster C: Insecure, uncomfortable
with decision making or authority
6 - Cluster A: Odd behaviors and
thoughts but no psychosis
8 - Cluster B: Grandiose, overly sensitive
to criticism, shows little empathy
10 - Cluster C: Involuntarily withdrawn
and shy because fears rejection
Solutions on page 129.
29
CrossWards™
15
This Puzzle is Infectious
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
20
21
22
23
24
25
26
27
30
19
Across:
Down:
2 - Cholera toxin causes severe watery
diarrhea by overactivating this
enzyme (two words)
6 - Its toxin leads to gas gangrene:
(species)
Clostridium
8 - Major cause of viral pneumonia in
infants (initials)
9 - Fluke associated with bladder cancer
(genus)
14 - Group B streptococcus is also known
as streptococcus
(species)
15 - Use this smear of a sample from an
unroofed vesicle to test for herpes
17 - A person with cough, fevers, night
sweats, and weight loss due to tuberculosis has this form
18 - Hand-foot-and-mouth disease is
virus type A
caused by
21 - Protozoan genus that causes watery
diarrhea
23 - Double-stranded circular DNA virus
that causes warts
24 – Antibiotic-associated diarrhea is
usually caused by the toxin from this
organism (genus first letter and species)
25 – Gram-positive and acid-fast (genus,
plural)
26 - Bats, raccoons, and skunks, oh my!
This CNS infection has high fatality
rate
27 - Major cause of infant diarrhea around
the world and winter daycare diarrhea
in US
1 - A board question about cat bites
should make you think this organism
(genus)
3 - Responsible for classic mononucleosis
(initials)
4 - If your febrile patient returning from
South America has “black vomit” and
jaundice, think this virus (two words)
5 - Group A streptococcus
-sensitive
are
7 - Human herpesvirus (HHV)-6 causes
this infantile illness
10 - Group A streptococcus are
-hemolytic
11 - Primary syphilis presents with a
painless
B19 causes erythema
12 infectiosum (fifth disease)
13 - The organism that causes plague
(two words)
16 - Gram-positive rods in branching
filaments that resemble fungi and
form sulfur granules (genus)
17 - Gram-positive cocci in chains (genus)
19 - Catalase positive gram-positive cocci
(genus)
20 - If you see trophozoites and schizonts on a patient’s blood smear,
think
22 - A spore forming gram-positive rod
genus (think bad fried rice)
Solutions on page 131.
31
CrossWards™
16
The Heart of Pharmacology
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
32
Across:
Down:
1 - Most common side effect of
nitroglycerin
6 - Binds to antithrombin III
7 - Type of diuretics most useful for
relief of symptoms in CHF patients
8 - Nuisance side effect of ACEIs but not
ARBs
9 - A nondihydropyridine calcium channel
blocker
10 - ACEIs and ARBs can cause this reaction characterized by swelling of the
lips and tongue
12 - Centrally acting alpha2-agonist
13 - Type of diuretics that are first-line
option for hypertension
14 - Mechanism of metoprolol:
blocker
17 - Drug for hypertension emergency
that is metabolized to cyanide
19 - These inhibit HMG-CoA reductase
21 - Losartan (and other “-sartans”) block
this receptor
23 - Spironolactone is a
sparing diuretic
24 - Inhibits Na+/K+-ATPase resulting in
increased contractility
1 - Direct arteriolar vasodilator that can
cause drug-induced lupus
2 - Lisinopril (and other “-prils”) inhibit
this (acronym)
3 - Raises BP, increases renal blood flow
(at lower doses), and increases
contractility
4 - Dabigatran directly inhibits this
5 - For torsades de pointes, give this
7 - A class IB antiarrhythmic
8 - Irreversibly binds P2Y12 ADP receptors thereby inhibiting platelets
11 - Slows AV node conduction time by
interrupting AV nodal re-entry
pathways
15 - Inhibits vitamin K-dependent
coagulation factor synthesis
16 - Irreversibly inhibits cyclooxygenase
resulting in decreased thromboxane
A2 synthesis
17 - Major class of antianginal drugs
18 - Epinephrine has (positive/negative)
inotropic effects on the heart
20 - Antagonizes acetylcholine receptors
22 - Increases HDL; side effect is flushing
Solutions on page 133.
33
CrossWards™
17
An Ounce of Prevention
1
2
3
4
5
6
8
9
10
11
12
13
15
17
34
14
16
18
19
7
Across:
Down:
2 - One of the screening tests for colon
cancer (acronym)
4 - Virus implicated in cervical cancer
(acronym)
5 - Diet that may help lower BP or
prevent hypertension (acronym)
8 - One of the medications that may
help smokers quit
10 - Screening test for cervical cancer
13 - Immunization offered in the neonatal
period
15 - Men who have ever smoked 100
cigarettes should be screened once at
the age of 65 for this (acronym)
16 - Screening test for breast cancer
17 - Recommend this to men for primary
prevention when global risk of coronary heart disease exceeds potential
harms of GI bleeding
18 - Secondary prevention
1 - Bias in observational studies of
screening when the screened group
appears to live longer because survival time starts with diagnosis based
on screening test in one group and
diagnosis based on symptoms in the
unscreened group (two words)
3 - Screening is beneficial only
given in the
when
earlier, asymptomatic stage is more
helpful than waiting until after disease is detected following symptoms
4 - Screen patients with this diagnosis
for diabetes according to USPSTF
6 - A medication used to prevent altitude
sickness
7 - A medication used to prevent malaria
when traveling to endemic areas
9 - This drug can be offered to household members or other contacts of
patients who have influenza to try to
prevent spread
11 - Bias in observational studies of
screening when the screened group
appears to live longer because disease
found by screening has a better
prognosis (two words)
12 - Younger, sexually active women
should be screened routinely for this
STI
14 - This test commonly used to screen
for prostate cancer is not recommended by the USPSTF (acronym)
19 - When counseling a patient about
upcoming travel, this organization’s
website is very helpful
Solutions on page 135.
35
CrossWards™
18
Puz-culoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
36
Across:
3 - Most common peripheral neuropathy:
syndrome
5 - Class of drugs for rheumatoid arthritis
(acronym)
7 - HLA-B27 found in majority of
patients with this (two words)
dislocation of the hip
8may be detected by Barlow or
Ortolani maneuvers
12 - Defect of the pars interarticularis of
the vertebra
14 - HLA-DR4 arthritis
15 - A test for #3 across asking the
patient to push flexed wrists together
to see if it produces numbness and
tingling
16 - Positive anterior drawer of the knee
suggests an anterior
ligament tear
17 - Positive McMurray’s test suggests a
tear
18 - Fracture of fifth metacarpal neck is
also known as a
fracture
19 - Low back pain with radiation down to
the foot
Solutions on page 137.
Down:
1 - Common, noninflammatory,
degenerative wearing out of articular
cartilage
2 - Proximal femoral epiphysis separates
from the growth plate leading to
displacement of the femur (acronym)
4 - Deposition of calcium pyrophosphate
crystals in joints
6 - Initial conservative treatment for
#3 across is a wrist
7 - Drug of choice for joint pain caused
by #1 down
8 - Back pain along with new onset
urinary incontinence suggests
syndrome
9 - Subluxation of radial head in a child
usually as a result of pulling up by the
elbow
hand:
10 - Deposition of uric acid crystals in
joints
11 - Needs immediate fasciotomy:
syndrome
13 - Fracture of the growth plate:
–Harris
37
CrossWards™
19
Catching My Breath
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
23
24
25
26
27
28
38
22
Across:
Down:
2 - Caused by abnormal sodium chloride
transport, most common due to
mutation at delta-F508 (two words)
5 - FEV1 70% with residual volume
of 130% of predicted indicates
lung disease
8 - Medication used to relax the airways
during acute bronchoconstriction
9 - Infiltrate in the right middle lobe in
an elderly patient with swallowing
difficulty suggests
pneumonitis
13 - A 12-year-old boy who wheezes three
times per week and has an FEV1 of
asthma
84% has mild
15 - Your dyspneic patient with absent
breath sounds and deviated trachea
pneumothorax
has a
16 - Cycles of infection and inflammation
in the bronchi can lead to this permanent fibrosis, remodeling, and dilation
20 - Pulmonary fungal infection endemic
to the Southwestern US; your typical
board examination patient with this
will hail from the San Joaquin Valley:
mycosis
21 - PaO2/FiO2 ratio <200 mm Hg with
bilateral pulmonary infiltrates
(acronym)
23 - Destroyed airways with obstruction
(acronym)
25 - Reversible airways obstruction
26 - This enzyme (acronym) may be
elevated in patients with sarcoidosis
27 - Your dyspneic patient with hypoxia
and hypercapnea and worsening
mental status has acute respiratory
1 - pH 7.25 with pCO2 that is elevated:
acidosis
in your
2 - Suspect
dyspneic patient with bilateral lower
leg edema and an S3 gallop (acronym)
3 - One of the inhaled anticholinergic
drugs used mainly for COPD
4 - Lungs are stiff with poor expansion
lung
in patients with
diseases
6 - Procedure for draining pleural effusion
7 - Pus in the pleural space
10 - Only treatment besides smoking
cessation that lowers mortality in
COPD
11 - In addition to prn albuterol, the child
in #13 across should be on daily
inhaled
12 - Asbestosis increases risk for this
malignancy
14 - Gram-positive cocci in chains (genus)
15 - In patients actively infected, see “red
snappers” on acid-fast staining of
sputum
in
17 - Suspect pulmonary
your dyspneic patient with pleuritic
chest pain and a recently swollen calf
18 - Type of pleural effusion seen in CHF
19 - Cold agglutinins may be seen in
patient with pneumonia caused by
(genus only)
22 - Nonresectable lung cancer type
(two words)
24 - Palpable vibration of the chest while
the patient says “blue balloons”:
Tactile
28 - Alpha-1-antitrypsin deficiency is
another cause of
Solutions on page 139.
39
CrossWards™
Are You Smarter than
a First-year?
20
1
2
3
4
6
5
7
8
9
10
12
11
13
14
15
16
17
18
19
40
Across:
Down:
2 - Type II pneumocytes produce this
important stuff
4 - This “ligament” connects the uterus,
uterine tubes, and ovaries to the
pelvic side wall
6 - Ligament that connects liver to the
anterior abdominal wall
9 - Catalase-positive, gram-positive cocci
(genus)
12 - First class of immunoglobulin
produced upon antigenic exposure
13 - Microtubules are made up of dimers
of alpha-and beta14 - Pathologic finding in the hippocampus of patients with Alzheimer
disease: Neurofibrillary
16 - What is the approximate pulse
pressure of a patient with a diastolic
BP of 60 and MAP of 90?
17 - Depolarization occurs when there is
an influx of this into the myocardial
cells
18 - Inhibits sodium—potassium ATPase
19 - For a diagnostic test, true negatives
divided by true negatives plus false
positives
1 - These cells secrete gastric acid
3 - Enlargement of the left atrium can
produce hoarseness, due to compression of a nerve that is a branch of
nerve
the
5 - Nonnucleated immature RBC formed
in bone marrow
7 - Cellular site of oxidative phosphorylation (plural)
8 - Long-chain fatty acids form these
prior to passive diffusion
9 - Pork tapeworm species
10 - Enzyme that catalyzes testosterone
to estrogen
11 - Small molecule that can be antigenic
when attached to a carrier
15 - The receptor for insulin is part of a
kinase
large family of
receptors
Solutions on page 141.
41
CrossWards™
21
Not Just Little Adults
1
2
3
4
5
6
7
8
11
15
16
18
20
42
17
19
9
10
13
14
12
Across:
2 - Most common cause of bronchiolitis
(acronym)
3 - Overriding aorta, pulmonary stenosis,
RVH, and #8 across: Tetralogy of
5 - Drooling, “sniffing” position, high
fever, muffled voice
8 - Most common congenital heart
disease (acronym)
9 - Severe intestinal problem mostly of
premature infants (acronym)
11 - Painless rectal bleeding in child under
2 years old, two times as common
in boys, 2 inches long, 2 feet from
ileocecal valve:
diverticulum
14 - Steeple sign
15 - High fever, fingertips swollen/peeling,
tender cervical nodes, conjunctivitis:
disease
17 - When an injury does not seem to
make sense based on the history
given by a child’s caregiver, think of
this possibility
18 - Cause of hand-foot-and-mouth
disease
20 - Nonbilious vomiting in a 2-week-old
baby boy (ok, and an olive-shaped
epigastric mass) suggest this (two
words)
Solutions on page 143.
Down:
1 - Check for congenital dislocation of
and
the hip using
Barlow tests
4 - High fever with no other symptoms
for a few days, then a rash maculopapular rash appears:
infantum
6 - Medication given to neonate to
try to close a PDA (patent ductus
arteriosus, not a personal digital
assistant!)
7 - Sexual development staging
10 - Caused by mutation in chloride
channel gene (two words)
12 - Neonatal jaundice due to
bilirubin is always
pathologic
13 - Cause of whooping cough (species)
16 - Usual drug of choice for acute otitis
media
19 - Treatment of #15 across includes
IVIG and high-dose
43
CrossWards™
22
Renal & Lytes
Meredith Gilliam*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
*Meredith Gilliam was a fourth-year medical student at the University of North Carolina
at Chapel Hill at the time of this contribution.
44
Across:
Down:
1 - A child with a syndrome causing
decreased reabsorption of phosphorus
in the kidney may develop this
condition
5 - A low pH, low PCO2, and low bicarbonate are consistent with this type
of acidosis
7 - This small molecule used in the
estimation of GFR is freely filtered
at glomeruli and only moderately
secreted by renal tubules
9 - A patient being treated for diabetic
ketoacidosis with insulin should be
monitored for intracellular shift of
this electrolyte
10 - Patients with malignant hypertension
may have this type of casts on urine
microscopy (acronym)
12 - Elevated levels of this hormone lead
to hypercalcemia and hypophosphatemia (acronym)
14 - Secretion of atrial natriuretic peptide
in response to increased atrial pressure results in increased filtration of
this ion in the kidney
16 - Likely diagnosis in a young woman
with dysuria, fever, and WBC casts in
her urine
18 - Low levels of this hormone results in
the excretion of free water (acronym)
20 - A patient with hypertension, hypokalemia, and metabolic alkalosis should
be evaluated for elevated levels of
this hormone
21 - The upper limit of the normal range
of an anion gap (spelled out)
22 - Decreased deep tendon reflexes and
decreased respirations are signs of
this electrolyte abnormality
2 - An anion gap is calculated as sodium
minus the sum of bicarbonate
and
3 - Likely diagnosis in a thirsty patient
with hypernatremia and dilute urine
(two words)
4 - Renal stones, abdominal pain, and
psychiatric changes are associated
with this electrolyte abnormality
6 - The diagnosis of diabetes insipidus is
confirmed by a
deprivation test
8 - Toxicity from this tuberculosis drug
may result in an increased anion gap
metabolic acidosis
are responsible for
9dilating the afferent arterioles of
glomeruli
11 - In healthy individuals, glucose is
completely reabsorbed into the
circulation by this part of the nephron
(two words)
12 - A much feared complication of
rapidly correcting hyponatremia is
myelinolysis in this region of the
brain
13 - Peaked T waves on an EKG are indicative of this electrolyte disturbance
15 - A high pH, low PCO2, and low bicarbonate are consistent with this type
of alkalosis
17 - In Type 1 renal tubular acidosis, the
collecting tubule’s inability to excrete
this ion may result in hypokalemia
and calcium-containing renal stones
19 - This enzyme important to the maintenance of blood pressure is secreted
by juxtaglomerular cells in the kidney
Solutions on page 145.
45
CrossWards™
23
Surgery Rounds
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
46
Across:
3 - Most common type of breast cancer
7 - Major postsplenectomy complication
9 - Diagnosis for young man who has
sudden onset of pain in scrotum with
swelling and a “high-riding” testicle
14 - Major risk factor for SBO: Previous
abdominal
15 - Bloody nipple discharge suggests
intraductal
17 - Pleural cancer linked to asbestos
exposure
18 - Point of tenderness in appendicitis
19 - “Bag of worms” on testicular
examination
Solutions on page 147.
Down:
1 - One of the “P’s” of acute arterial
occlusion
2 - Superficial infection of the breast
3 - Elderly man with LLQ pain, nausea,
low-grade fever, mildly elevated
white blood cell count likely has
4 - Marker used to follow colon cancer
after treatment (acronym)
5 - Calf muscle pain brought on by
walking
6 - The “R” in ERCP
8 - Most common cause of breast lump
in young women
10 - Criteria for estimating prognosis in
acute pancreatitis
11 - Young woman presenting with
abdominal/pelvic pain, always rule
out this
12 - Elderly man with history of atrial
fibrillation with acute onset abdominal pain out of proportion to examiischemia
nation: Acute
13 - Trauma patient has tachypnea,
decreased breath sounds on one side
and deviated trachea:
pneumothorax
16 - Large bowel obstruction is due to
until proven
colon
otherwise
47
CrossWards™
24
Just for Fun—Movie Docs
1
2
3
4
5
6
7
8
9
10
11
12
13
48
Across:
Down:
1 - Robin Williams played
Adams
3 - Austin Powers’ nemesis:
Dr.
5 - Silence of the Lambs:
Lecter
Dr.
6 - Plays a plastic surgeon turned mortician in Death Becomes Her
7 - Dr. Carlisle Cullen is featured in this
saga
8 - Harrison Ford played Dr. Richard
in The Fugitive
9 - William Hurt plays an arrogant
surgeon who becomes a patient when
he is diagnosed with throat cancer in
this movie: The
12 - Jurassic Park was written by the late
Dr. Michael
13 - The town cared for by a doctor played
by Jeff Daniels becomes infested in
this movie
2 - Robert De Niro’s character was
brought out of catatonia by L-dopa in
this 1990 movie
3 - Played Dr. Dolittle
4 - In this movie, five medical students
(one played by Kevin Bacon) conduct
secret experiments to try to explore
the afterlife
5 - Michael J. Fox: Doc
10 - Played a psychiatrist in Analyze This:
Billy
11 - Classic Halloween movie doctor:
Dr. Sam
Solutions on page 149.
49
CrossWards™
25
I Got Rhythm . . .
2
1
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
50
Across:
1 - Wide P wave in II (acronym)
5 - II, III, aVF wall
6 - Conduction abnormality characterized by wide QRS and RSR’ in V5–V6
(acronym)
8 - This tracing (short form)
9-
degree block:
Prolonged PR interval
11 - Large P wave amplitude in II or V1
may suggest this (acronym)
12 - This tracing (short form)
13 - The presence of this wave in the
setting of a short PR is characteristic
of Wolff–Parkinson–White
16 - “Saw tooth” waves (short form)
19 - Firing of the sinus node
20 - Narrow complex regular tachycardia
without P waves (short form)
22 - Irregularly irregular rhythm with
narrow QRS and no P waves
(short form)
23 - V1, V2 wall
25 - Ventricular depolarization
26 - V3, V4 wall
29 - This tracing (short form)
Down:
2 - Inventor of the EKG
3 - Interval normally <0.10 s
4 - This kind of AV block
6 - I, aVL, V5, V6 wall
7 - QRS 0.10 to 0.12 and left axis
deviation (acronym)
8 - Fatal arrhythmia characterized by
chaotic ventricular activity (short
form)
10 - Steadily prolonging PR intervals
followed by a dropped beat
12 - This tracing (short form)
14 - Ventricular repolarization
15 - “Wandering pacemaker” tachycardia
(acronym)
17 - Prolonging the QT interval may be
“dangereux”
18 - Elevation of this may be difficult to
differentiate from ST elevation
19 - Interval normally 0.12 to 0.20 s
21 - Interval normally <0.44 s
24 - Conduction abnormality characterized by wide QRS and RSR’ in V1
(acronym)
27 - First sign of hyperkalemia (plural)
28 - QRS 0.10 to 0.12 and right axis
deviation (acronym)
31 - Wide complex regular tachycardia
(short form)
30 - Extra wave seen with low K
32 - This tracing (short form)
Solutions on page 151.
51
CrossWards™
26
Clinical Scramble
DESPIR
MOCHASILLO
ICANJUDE
CATSIES
RIBSOFIS
ANSWER:
52
Solutions on page 152.
VINE
Notes
53
CrossWards™
27
Birth of a Puzzle
1
2
3
4
5
6
7
8
9
10
11
13
12
14
15
16
17
18
19
20
21
22
23
24
25
26
54
Across:
2-
Down:
age: Time since the
LMP
4 - The number of deliveries after 20 weeks
5 - At 12 weeks of gestation, this organ is
palpable above the pubic symphysis
7 - Stages of labor: Onset of contractions
to complete cervical dilation
rule: A method for
10 determining the due date
11 - This hormone should double every
48 hours during the early stages of
pregnancy (acronym)
13 - #13 down is made by this organ
15 - Stages of labor: Delivery of infant to
delivery of placenta
16 - #13 down causes relaxation
muscle, which
of
results in lower blood pressure, and
GERD
17 - #11 across is analogous to
, causing levels to
decrease during pregnancy (acronym)
results
18 - A physiologic
from the dilutional effect of increased
plasma volume
20 - Decreased AFP, estriol, and increased
HCG and inhibin A is the pattern seen
syndrome
in
: Description of
21 - Fetal
the fetal part at the cervix
23 - Supplementation with this vitamin
PRIOR to conception is needed to
prevent neural tube defects
deceleration: Caused
25 by cord compression
deceleration: Caused
26 by fetal head compression
Solutions on page 155.
1 - This term for maternal awareness
of fetal movements, usually occurs
around 18 weeks
: Description of
3 - Fetal
the long axis of the fetus
: Description of
4 - Fetal
the orientation of the presenting part
relative to maternal pelvis
6 - The number of pregnancies
8 - Stages of labor: Second stage is
from complete dilation to delivery
of the
9 - Hyperpigmentation of the face
levels decrease by
12 about 25% due to increase in GFR
13 - Many of the physiologic changes
of pregnancy are mediated by this
hormone
14 - Increases in tidal volume are
responsible for the respiratory
of pregnancy
19 - Hyperpigmentation in the midline of
the abdomen (two words)
22 - This test of fetal well-being may be
deemed “reactive” if there are at
least two 15 × 15 accelerations in a
20-minute period (acronym)
deceleration: Caused
24 by fetal hypoxia or placental
insufficiency
55
CrossWards™
28
Labor Pains
1
2
3
4
5
6
7
9
10
8
11
12
13
14
16
15
17
18
19
20
21
22
23
24
25
26
27
28
56
Across:
Down:
3 - Avoidance of cat feces is advised
to pregnant women to prevent this
congenital infection (short form)
is the most
5 - Uterine
common cause of postpartum
hemorrhage
7 - A woman who develops mastitis
should keep/stop breast-feeding
9 - In utero exposure is associated with
clear cell carcinoma of the cervix
(acronym)
10 - Screening and treatment for this
organism has significantly reduced
the rates of neonatal sepsis
(acronym)
14 - Premature separation of the placenta
is known as
16 - Eclampsia is defined as a
in a woman with preeclampsia
19 - The definitive therapy for preeclampsia
dystocia: A feared
22 complication that is more likely in
macrosomic infants of diabetic
mothers
23 - A woman recovering from a postpartum hemorrhage who fails to lactate
syndrome
may have
25 - Exposure to this drug may cause a
growth-restricted fetus with mental
retardation and characteristic facial
features
26 - This class of blood pressure medication must be avoided in pregnancy
(acronym)
27 - A 1-hour glucose tolerance test may
be used to screen for this pregnancy
complication (acronym)
28 - This diagnosis must be ruled out in
any woman of childbearing age with
abdominal pain and/or vaginal bleeding
1 - The most common cause of fever in
the postpartum period
pregnancy may be
2-A
diagnosed by a “snowstorm” appearance on ultrasound
4 - Preeclampsia is defined as elevated
blood pressure plus
on
6 - The presence of
microscopic examination of dried
amniotic fluid suggests rupture of the
membranes
8 - Painless vaginal bleeding in the third
trimester should make you suspect a
placenta
11 - A woman in preterm labor at 30 weeks
to
should receive
promote fetal lung maturity
12 - Use of an insulin drip during labor
may be necessary to prevent this
neonatal complication
13 - This drug has been shown to reduce
progression to eclampsia in women
with severe preeclampsia (short form)
15 - A woman at 12 weeks’ gestation with
vaginal bleeding and an open os has
abortion
a/an
17 - A child with congenital deafness,
cataracts, and a patent ductus should
raise suspicion for this congenital
infection
gravidarum: A severe
18 form of “morning sickness”
20 - The most common malpresentation
21 - Treatment with this immunoglobulin
is indicated for Rh-mothers
24 - A syndrome of severe preeclampsia
characterized by hemolysis, elevated
LFTs, and thrombocytopenia
(acronym)
Solutions on page 157.
57
CrossWards™
29
A pHuzzle
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
58
Across:
Down:
1 - The major measured anion in the
serum
3 - This number tells you whether you
have an acidosis or alkalosis
4 - pH < 7.35
6 - One of the causes of anion gap
acidosis, in a patient with end-stage
renal disease
7 - The most common cause of metabolic alkalosis
8 - Byproduct of lipid metabolism,
excreted in the urine
10 - One of the causes of anion gap
acidosis, in a patient with Type I DM
(acronym)
11 - A decrease in the anion gap may
be observed in the presence of
unmeasured cations such as this one
possibly encountered on a patient in
the labor ward (short form)
12 - One of the causes of anion gap
acidosis, in a patient who has been
NPO in the hospital for several days
(acronym)
14 - Another cause of nongap acidosis,
a group of disorders rather oddly
numbered (acronym)
17 - The ultimate process responsible for
all forms of respiratory acidosis
20 - One of the causes of anion gap
acidosis, in an accidental ingestion of
antifreeze (two words)
21 - Buffer anion primarily responsible for
acid/base regulation
25 - Type of disorder present when the
bicarbonate is the primary abnormality
26 - pH > 7.45
27 - One of the causes of anion gap acidosis, perhaps in a desperate alcoholic
2 - The ultimate process responsible for
all forms of respiratory alkalosis
5 - One of the causes of anion gap
acidosis, in a patient being treated for
tuberculosis
9 - One of the causes of anion gap
acidosis, somewhat antiquated as the
drug is no longer in use
10 - Assessment of this value is key to
detect the presence of a combined
metabolic acid–base disturbance
(Hint: It might sound like you are
repeating yourself)
13 - One of the causes of anion gap
acidosis, in an overdose patient
15 - The amount of unmeasured negatively charged molecules in the serum
16 - Type of disorder present when the
pCO2 is the primary abnormality
18 - A physiologic respiratory alkalosis
may be encountered in this state
19 - Order this to find out the patient’s
pH (acronym)
22 - The most common cause of nongap
acidosis
23 - The first electrolyte in the anion gap
calculation
24 - One of the causes of anion gap
acidosis, in a septic patient
Solutions on page 159.
59
CrossWards™
30
Onco-Logical
1
2
3
4
5
6
7
8
9
12
10
11
13
14
15
16
17
18
19
20
21
22
23
24
25
60
Across:
2 - ALL is seen with greater frequency
in this chromosomal disorder
syndrome)
(
5 - Eosinophilic rods inside malignant
cells are seen in this leukemia
(acronym)
7 - Actinic keratosis is a precursor lesion
cell carcinoma
to
8 - Co-administration of this drug
prevents hyperuricemia while on
chemotherapy
9 - Hodgkin disease may be suspected
in patients who have pain in lymph
nodes after drinking
11 - This tumor marker may be useful for
screening for and following hepatocellular carcinoma (acronym)
12 - This anatomic structure defines staging in Hodgkin disease
15 - Biopsy of this tissue is often needed
for the diagnosis of leukemia (two
words)
16 - The gene product of #21 down
suppresses this cellular process
17 - Myasthenia gravis may be associated
with malignancy of this organ
20 - This common virus is thought to play
a role in certain forms of non-Hodgkin
lymphoma (acronym)
22 - This drug inhibits the BCR–ABL gene
product
24 - This tumor marker may be useful for
screening for and following prostate
cancer (acronym)
25 - A 70-year-old is incidentally found
to have a WBC count of 110,000 and
“smudge cells” on the smear
(acronym)
Solutions on page 161.
Down:
1 - Dysplastic nevus syndrome is
associated with increased risk
of
3 - This lab abnormality commonly
occurs in patients on chemotherapy
and places them at risk of severe
infection
4 - Abnormal B-cells in Hodgkin
disease may have a large bilobed
6 - Elevation of this electrolyte may
be the first clue in the diagnosis of
multiple myeloma
8 - Treatment with all-trans retinoic acid
may be curative in the M3 type of
this leukemia (acronym)
10 - This tumor marker may be useful for
following colon cancer (acronym)
11 - Most common leukemia in children
(acronym)
13 - A patient with multiple purplish
vascular papules and plaques in the
lower extremities is likely immunocompromised from
(acronym)
14 - A patient with a 1.5-cm cervical
lymph node that does not go down
after 4 weeks should have
a
15 - Patients with CML in this phase have
markedly shortened survival
18 - The presence of distant
defines Stage IV malignancy in
virtually all cancers
19 - Enlargement of this organ is a
common finding in many leukemias
21 - The Philadelphia chromosome t(9,22)
is most associated with this malignancy (acronym)
23 - This cell type is responsible for the
majority of non-Hodgkin lymphomas
61
CrossWards™
31
Clear to Auscultation?
1
2
3
4
5
6
7
8
9
10
11
13
14
15
16
17
18
19
20
21
22
23
24
62
12
Across:
Down:
1 - The usual EKG finding in a PE (short
form of second word)
2 - Most pneumonia in children is due
to
4 - Chronic productive cough may
clue you into a diagnosis of
chronic
6 - In addition to the usual causes of
(bug)
neonatal sepsis,
should be considered in a neonate
with pneumonia
8 - Your patient with urosepsis who suddenly develops dyspnea and becomes
hypoxic despite oxygen administration may have this complication
(acronym)
10 - A DVT or PE buys you at least 3 months
of therapy with
13 - A patient with COPD may create
their own PEEP by exhaling against
lips
15 - Your patient with calf pain on passive
dorsiflexion of the ankle has a
sign
positive
16 - Be sure to treat your patient with
hospital-acquired pneumonia with
antibiotics to cover
19 - Aspiration pneumonia typically
develops in this lobe (two words)
21 - Churg-Strauss syndrome might be
suspected in an asthmatic patient
with high levels of this cell line
22 - For a patient who is wheezing more
than twice a week, addition of an
is recominhaled
mended
23 - Hypoxemia that is due to intrapulmonary shunting will not respond to
therapy with
24 - Lung cancer that is the least associated
with smoking
1 - A patient recovering from influenza
who suddenly worsens with high
fevers and purulent sputum may be
infected with this bug (initial the
genus)
3 - A tall 18-year-old male who presents
with acute onset chest pain and
shortness of breath
adenopathy is
5 - Bilateral
the hallmark of sarcoidosis
6 - Poisoning with this gas will cause a
falsely elevated pulse oximetry
reading (acronym)
7 - A patient with a pleural effusion from
pneumonia would be expected to have
relatively high levels of
compared to serum (acronym)
8 - Unlike garden variety communityacquired pneumonia, coverage of this
class of bugs should be considered
when treating aspiration pneumonia
may rule out
9 - A normal
DVT/PE if your clinical suspicion is
low
11 - Your patient with unilateral upper
extremity weakness and Horner
syndrome may have a
tumor
challenge may be
12 - A
administered to the suspected asthmatic with normal PFTs
13 - In addition to increasing the fraction
of inspired oxygen, this ventilator parameter may be increased to
improve oxygenation (acronym)
14 - “All that wheezes is not
”
17 - This first line therapy for #3 down
speeds resolution
18 - Occurring in outbreaks, this pulmonary infection is making a comeback
in part due to decreasing rates of
immunization
20 - A solitary pulmonary nodule that
is unchanged for over 2 years is
likely
Solutions on page 163.
63
CrossWards™
32
Some Lovers Try* . . .
This Puzzle
1
2
3
4
5
6
7
8
9
10
11
12
13
15
17
20
14
16
18
19
21
22
23
24
25
26
*Some Lovers Try Positions That They Can’t Handle is a mnemonic for the wrist bones.
64
Across:
Down:
1 - In addition to #23 across and the
medial meniscus, this structure
is often coinjured as part of the
“unhappy triad” (acronym)
3 - Antibiotics are always indicated in
this type of fracture
6 - This gruesome intervention may be
limb saving in patients with a painful
swollen limb and paresthesias, pulselessness, paralysis, and poikilothermia
8 - A patient who develops hand pain
and numbness after holding the wrist
in forced flexion for 60 seconds may
have this (acronym)
10 - Atrophy of this group of muscles is a
late sign of #8 across
11 - What study should be ordered in a
patient with new onset back pain and
urinary incontinence? (acronym)
13 - Fracture of this bone should be
suspected in a patient with snuff box
tenderness
15 - Most common type of hip dislocation
17 - An old man with leg pain that gets
better when leaned forward or walking uphill: Spinal
19 - Your roommate was out drinking on
Saturday night and awoke on Sunday
with a wrist drop. He has injured
nerve
the
20 - Your patient with an L5–S1 disc
herniation may have a diminished
reflex
22 - A person defending himself from an
attack may end up with a fracture of
this bone
24 - The tubercle of this long bone may be
painful in growing boys
26 - Your patient with a large painful
swollen mass on their elbow may
have olecranon
2 - Most commonly fractured long bone
3 - Radiographic new bone formation in
a sunburst pattern is a sign of this
devastating tumor
4 - An obese adolescent male with knee
pain and limp may have epiphyseal
displacement on this bone
5 - A patient with a femur fracture suddenly develops SOB, rash, DIC, and
cardiovascular collapse (two words)
7 - Most common type of shoulder
dislocation
9 - Mike Tyson presents with hand pain
after a match. He has fractured
metacarpal
his
12 - A 15-year-old track athlete ruptures
her Achilles tendon while being
treated for a UTI with
14 - A first born, female, newborn delivered in breech presentation is at high
risk for dysplasia of this joint
16 - Falling on outstretched hand most
likely results in fracture of this bone
18 - Hormone level that should be
checked in #4 down
artery and nerve
20 - The
may be injured in #7 down
arthritis: Must be ruled
21 out in any patient with a red, hot
joint
23 - What ligament is injured in a patient
with excess laxity on anterior translation of the tibia? (acronym)
25 - The finger joint most commonly
involved in osteoarthritis (acronym)
Solutions on page 165.
65
CrossWards™
33
Doc, I Think It’s My Hormones
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
27
28
29
30
66
24
26
Across:
Down:
1 - Most common type of thyroid carcinoma
2 - A patient in diabetic ketoacidosis is
always total body deficient in this
electrolyte (regardless of serum level)
3 - Osteoporosis is defined by a
of –2.5 or lower on
DEXA scanning
7 - Hyponatremia and hyperkalemia
should always prompt consideration
of this life-threatening problem
9 - Intermediate-acting insulin, usually
dosed twice daily
11 - Rarely checked, but often elevated
antibody in Hashimoto thyroiditis
13 - Agonists to this neurotransmitter are
first-line therapy for prolactinoma
16 - Long-acting insulin without a peak
18 - Classically, only Type 1 diabetes mellitus presents with this life-threatening disorder
20 - Most aggressive and rapidly fatal
thyroid carcinoma
25 - “Stones, bones, groans, and psychiatric overtones” may represent this
electrolyte disturbance
27 - The first step in evaluation of suspected hyperaldosteronism is meas:
urement of the plasma
aldosterone ratio
28 - Type 1 diabetics will always require
therapy with this at all stages of their
disease
29 - This drug, more commonly used in
variceal upper GI bleeding, is also
used to treat acromegaly
30 - Use of this drug class in diabetes has
been shown to decrease progression
of nephropathy
1 - Antithyroid drug preferred for treating hyperthyroidism in pregnancy
4 - This treatment is by far and away the
most important initial treatment for
hypercalcemia
5 - This test along with a thyroid scan
can help differentiate Graves disease
from thyroiditis (acronym)
6 - Hemorrhagic necrosis of the adrenal
gland may occur after infection with
this bacteria
8 - This syndrome should always be suspected in a patient with hypertension
and hypokalemia
10 - Adverse effect of nearly all antiglycemic agents except metformin
12 - Antithyroid drug preferred in absence
of pregnancy
14 - In the absence of contraindications,
this drug is the absolute first-line
therapy for Type 2 diabetes
15 - The clinical finding of bitemporal
hemianopsia would prompt one to
order MRI of this structure
17 - Presence of this antibody is highly
specific for Graves disease (acronym)
19 - Rare but serious side effect of
metformin
21 - Fastest acting insulin
22 - Best screening test for assessing
thyroid function (acronym)
23 - Insulin therapy in diabetic ketoacidosis is directed at lowering (glucose/
ketones)
24 - A patient with positive urinary
metanephrines should never be given
a drug from this class alone
26 - Psychotropic drug often implicated in
nephrogenic diabetes insipidus
Solutions on page 167.
67
CrossWards™
34
This Puzzle is Giving Me Gas
Meredith Gilliam
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
68
Across:
Down:
2 - Hirschsprung disease is caused by
failure of this embryologic population of cells to migrate to the rectum
(two words)
4 - This class of drugs works by irreversibly inhibiting H+/K+-ATPase in
stomach cells (acronym)
10 - Most likely diagnosis in an older
patient with LLQ pain, fever, and
leukocytosis
11 - Most likely cause of an acute bowel
obstruction in a patient who has had
multiple abdominal surgeries
12 - This ligament attaching the liver
to the anterior abdominal wall is a
derivative of the fetal umbilical vein
13 - Autoantibodies against this glycoprotein found in wheat are present in
80% of patients with celiac disease
14 - The flushing, diarrhea, and right-sided
heart murmurs associated with carcinoid tumors result from abnormal
production of
15 - This liver enzyme may be disproportionately increased (relative to
others) in patients with alcoholic
hepatitis (acronym)
17 - Glandular metaplasia in the distal
esophagus may transform into this
histological type of carcinoma
20 - Bilious vomiting in a neonate and a
“double bubble” on abdominal imaging is concerning for this congenital
abnormality (two words)
21 - Of the histological types of adenomatous colon polyps,
adenomas most likely to become
malignant
23 - Check the level of this protein in
patients with cirrhosis, corneal
deposits, and parkinsonian symptoms
24 - Pathology in this part of the gut may
limit the body’s absorption of folate
1 - An immunocompromised patient
with odynophagia and “volcanolike” ulcers in his esophagus may be
infected with this pathogen (acronym)
3 - Patients with severe liver failure may
present with this coarse hand tremor
5 - Autoimmune destruction of the
stomach’s parietal cells may result in
this type of anemia
6 - Nearly all patients with duodenal
ulcers are infected with this organism
(shorten the genus to an initial)
7 - This prokinetic agent may relieve
the symptoms of gastroparesis by
antagonizing dopamine receptors
8 - A surgeon may insert a finger through
the epiploic foramen to compress the
contents of this ligament to control
bleeding
9 - This GI hormone secreted by I cells is
responsible for the pain that patients
with cholelithiasis may feel after eating a fatty meal
16 - An infant with painless rectal bleeding may have a congenital anomaly
resulting from the persistence of this
embryological duct
18 - This type of hemorrhoids are not
painful because they receive visceral
innervation
19 - A patient with progressive dysphagia
and a dilated esophagus with distal
stenosis on barium swallow most
likely has this condition
22 - This GI hormone is oversecreted in
Zollinger-Ellison syndrome
Solutions on page 169.
69
CrossWards™
35
1
BuzzWards
2
3
4
5
7
6
8
9
10
11
12
13
14
15
17
18
16
19
20
21
23
22
24
25
26
70
Across:
Down:
1 - Currant jelly stools
7 - Blueberry muffin rash
9 - Barking cough
11 - Reed-Sternberg cells
12 - Bird’s beak on swallow study
13 - Leftover rice
16 - Machine-like murmur (acronym)
18 - Dewdrop on a rose petal
20 - Honey-crusted lesion
21 - Café-au-lait spots
23 - Maltese cross casts in urine
syndrome)
(
25 - Honeycomb lung (acronym)
26 - Target lesions (erythema
)
2 - Doughy skin (electrolyte abnormality,
)
hyper
3 - Silvery scale
4 - Currant jelly sputum
5 - Punched-out lesion on skull film
)
(multiple
6 - Cold agglutinins
8 - Sawtooth wave (acronym)
10 - Christmas tree rash (pityriasis
)
14 - Rose gardener
15 - Spaghetti and meatballs on KOH
)
preparation (pityriasis
16 - Cogwheel rigidity
17 - Powder burns on laparoscopy
)
18 - Clue cell (bacterial
19 - Shipyard worker
22 - Stuck on appearance (
keratosis)
24 - Bat-wing appearance on chest x-ray
)
(pulmonary
Solutions on page 171.
71
CrossWards™
36
A Trich Puzzle
1
2
3
4
5
6
7
8
9
10
11
13
12
14
15
16
17
18
19
20
21
23
24
26
72
25
22
Across:
Down:
2 - Gray discharge, high pH, clue cells
(acronym)
3 - This virus is responsible for the vast
majority of cervical cancer (acronym)
6 - Motile organism seen on saline
wet mount of vaginal secretions is
pathognomonic for
(short form)
8 - What is the diagnosis in a woman
who presents with amenorrhea, acne,
hirsutism, and insulin resistance?
(acronym)
9 - Budding yeast on a KOH preparation
are diagnostic for this organism
11 - Treatment with this drug may restore
fertility to the patient in #8 across
13 - Toxic shock syndrome commonly
occurs in women with a retained
1 - Common uterine tumor that is
hormonally responsive
4 - Most common cause of secondary
amenorrhea
5 - A woman who leaks urine when
she coughs, laughs, or sneezes has
incontinence
7 - The only way to definitely diagnose
#19 across
cyst”
9 - You might find a “
on the ovary of the patient in #19
across
10 - Crops of vesicles that progress to
painful ulcerations
12 - Menstrual bleeding that is irregular in
frequency
14 - This prophylactic intervention is an
option for women with the BRCA-1
mutation
16 - Absence of menses for at least
12 months
19 - Excess of this hormone is a risk factor
for endometrial cancer
20 - OCP use is protective against
cancer
22 - A cause of increased abdominal girth
in patient with ovarian cancer
25 - Purulent cervical discharge and cervical motion tenderness (acronym)
15 - The most common breast quadrant
to encounter breast cancer (two
words)
17 - Hormonal contraceptive methods
increase
which contain
the risk of thromboembolic disease
18 - Treatment with this drug is indicated
in estrogen receptor-positive breast
cancers
19 - Your patient with cyclic abdominal
pain and nodularity on her uterosacral ligaments has
21 - Woman with a history of migraine
should be advised
with
against estrogen-containing contraceptives
23 - This test should be offered to woman
over the age of 50 for breast cancer
screening
24 - A painless chancre followed in several
weeks by a maculopapular rash
26 - A patient with PID who develops
RUQ pain should make you suspect
involvement of this organ
Solutions on page 173.
73
CrossWards™
37
Widow Maker
1
2
3
5
4
6
7
8
9
10
11
12
13
14
16
15
17
18
19
20
21
22
23
24
25
74
Across:
1 - The genus most commonly implicated in subacute endocarditis (short
form)
2 - Levels of this peptide are virtually
always elevated in decompensated
CHF (acronym)
3 - A hypotensive patient with severe
shock
burns may be in
7 - Chest pain relieved by leaning forward may be a clue to this diagnosis
10 - Prior myocardial infarct may be suggested by the finding of this on EKG
11 - A widened pulse pressure may suggest this valvular disease (acronym
12 - Cardiac risk factor: Most prevalent of
all (acronym)
13 - Perform this test to diagnose peripheral vascular disease (acronym)
16 - Cardiac risk factor: Most potent of all
17 - Occlusion of this coronary artery is
often fatal (two words)
19 - Electrical alternans, a phenomenon
where every other QRS has a different morphology and direction, may
be a clue to this diagnosis
22 - A hypotensive patient with elevated
JVP and pulmonary rales may be in
shock
23 - A hypotensive patient who is bradycardic with head trauma may be in
shock
24 - The organism most commonly implicated in acute endocarditis (initial the
genus)
25 - Cardiac risk factor: Some consider it a
“disease equivalent”
Solutions on page 175.
Down:
1 - Most useful intervention in the
treatment of PVD is the cessation of
2 - Duke major criteria (1 of 2)
4 - Cardiac risk factor: Most easily
treated (acronym)
5 - The finding of a delta wave on EKG
is suggestive of this syndrome
(acronym)
6 - The triad of butt claudication, impotence, and decreased femoral pulses
may be due to occlusion of the aorta
near the
8 - Harsh systolic murmur that radiates
to the carotids (acronym)
9 - Turner syndrome may be associated
with this disease of the aorta
13 - Cardiac risk factor: It is lower in men
14 - A low-pitch diastolic murmur, loudest
at the apex, with an opening snap
(two words)
15 - Duke major criteria (2 of 2)
16 - A hypotensive patient with fever,
elevated WBC with a left shift may
shock
be in
18 - A young woman with palpitations
and atypical chest pain may have this
valvular condition (acronym)
20 - The single most powerful drug you
can administer in acute coronary
syndrome
21 - The valve most frequently infected in
IV drug abusers
75
CrossWards™
38
Don’t Mess Around
with the Pancreas
1
2
3
4
5
6
7
8
9
11
10
12
13
14
15
16
17
18
19
20
21
23
22
24
25
26
27
76
Across:
Down:
1 - The presentation of painless jaundice
should always worry you for cancer of
this organ
scan may be helpful
5-A
for diagnosis of gallstone disease when
ultrasound is nondiagnostic (acronym)
8 - Dark sticky tarry stool
9 - Iron deficiency anemia in an older
man or postmenopausal woman is
cancer until proven
otherwise
11 - Relatively common GI cause of
chronic cough
12 - A sting from this arachnid may cause
pancreatitis
16 - This unusual form of cholecystitis
may occur in debilitated patients or
critically ill patients
19 - Most common cause of small bowel
obstruction in children
20 - A test performed on this bodily substance is the best way to determine
the presence of current H. pylori
infection
23 - Most common cause of lower GI
bleeding in older adults
26 - This test should be ordered in any
patient diagnosed with esophageal
candidiasis
27 - This operation may be curative for
ulcerative colitis
2 - Plummer-Vinson syndrome is the
association of esophageal webs
and
3 - Most common form of hiatal hernia
4 - Most common type of gallstone
6 - Use of this class of over-the-counter
medication is a leading cause of
peptic ulcer disease (acronym)
7 - Tumor marker associated with colon
cancer (acronym)
9 - “Skip lesions” are characteristic of this
form of IBD
10 - The more specific test for acute
pancreatitis
13 - Pain with swallowing
14 - Most common location of pancreatic
cancer
sign: Arrest of inspira15 tion during deep palpation of the
RUQ
17 - Treatment with this drug may help
the symptoms of carcinoid syndrome
18 - This type of adenoma has the highest
risk of malignancy
21 - Common cause of antibioticassociated diarrhea (short form)
22 - A Krukenberg tumor is a metastasis
of gastric carcinoma to this organ
24 - This part of the colon is always
involved in ulcerative colitis
25 - The clinical presentation of esophageal spasm is often indistinguishable
from
Solutions on page 177.
77
CrossWards™
39
Most Common . . .
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
21
23
24
25
78
22
20
Across:
Down:
2 - Cancer in women
3 - Benign breast mass in younger
women
5 - Cause of chronic kidney disease in
the United States
7 - Cancer in men
9 - Cause of osteomyelitis in a sickle cell
patient
10 - Form of thyroid cancer
14 - Bacterial cause of infectious diarrhea
16 - Type of shoulder dislocation
17 - Cause of maternal mortality
21 - Cause of hypothyroidism
23 - Form of stroke
25 - Cause of acute lower GI bleeding in
adults
1 - Cause of small bowel obstruction in
adults
3 - Benign tumor of female reproductive
system
4 - Primary malignant bone tumor
(acronym)
6 - Cause of death in diabetics (organ)
7 - Cause of abnormal nipple discharge
8 - Childhood malignancy (acronym)
9 - EKG finding in pulmonary embolism
(acronym)
11 - Pituitary tumor
12 - Cause of infection in burn patients
13 - Skin cancer (acronym)
15 - Cause of secondary amenorrhea
18 - Cause of bronchiolitis (acronym)
19 - Congenital heart defect (acronym)
20 - Fracture of a carpal bone
22 - Cause of peptic ulcer disease (short
form)
24 - Organism causing UTI (short form)
Solutions on page 179.
79
CrossWards™
40
Clinical Scramble
HOGCU
MUSTPU
YESSTOPHIM
VREEF
DICA
FATS
ANSWER:
80
Solutions on page 180.
AILBILC
Notes
81
CrossWards™
41
BrainTeaser
2
1
3
4
5
6
8
11
7
9
10
12
13
15
16
17
18
82
19
14
Across:
1-
Down:
agonists are treatment
for #3 down
4 - Problem in standing or walking
5 - Bitemporal hemianopia suggests a
lesion here (two words)
8 - Acute demyelinating autoimmune
disorder causing ascending paralysis
(acronym)
9 - Loss of upper and lower motor
neuron functions:
lateral sclerosis
11 - Axillary freckling, café-au-lait
spots, and iris hamartomas:
Neuro
15 - Cannot express language:
aphasia
16 - Cholinesterase inhibitors are used to
try to slow progression of this disease
17 - Creutzfeldt-Jakob disease is due to
infection with a
18 - Schwann cell tumor:
neuroma
19 - “Ash-leaf” hypopigmented lesions are
sclerosis
classic for
Solutions on page 183.
2 - Most brain tumors are
3 - Pill-rolling tremor and rigidity: Two
classic signs of this disease
6 - Treatment for #8 across includes IVIG
and possibly this procedure
7 - Cannot understand
aphasia
language:
8 - Most common primary brain tumor
in adults
10 - Patient who is “weird, wobbly,
and wet,” think normal
pressure
12 - Give this to alcoholics to prevent
Wernicke encephalopathy
13 - Painless loss of central vision mostly
in the elderly:
degeneration
14 - Class of drugs used to treat acute
migraines
83
CrossWards™
42
This Puzzle is Kidstuff
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
28
26
27
29
30
31
32
84
33
34
Across:
Down:
3 - Barking cough and “steeple sign” on
neck film
5 - Hyperbilirubinemia in the first
24 hours of life is always
6 - Child “tripoding” with high fever, sore
throat, drooling, muffled voice, and
stridor: Think
7 - Atrial
defect has a
fixed, widely split S2
is an
8 - High-dose
empiric antibiotic treatment for acute
otitis media (if not allergic)
11 - Most common childhood malignancy
12 - Hirschsprung disease is suggested by
within
failure to pass
first 2 days of life
15 - Most common chromosomal disorder
and cause of mental retardation:
syndrome
16 - The absence of a red reflex on the eye
examination of a newborn suggests
congenital
21 - This drug is given to help close a patent ductus arteriosus
syndrome
22 - 45, XO:
23 - Suspect this if the history is discordant with physical findings or if there
is a delay in parent seeking medical
care for a child
25 - Misalignment of the eyes persisting
beyond 3 months of age
28 - Transient tachypnea of the newborn
is a diagnosis of
31 - Malrotation of the gut
32 - Congenital herniation of intestine
through abdominal wall near umbilicus not covered by a sac
1 - X-linked abnormality affecting the
syndrome
FMR1 gene:
2 - Premature infants can develop
enterocolitis
4 - Whooping cough
9 - Hypertonicity, lethargy, and seizures
in a newborn with unconjugated
hyperbilirubinemia suggests permanent deposition in the brain called
10 - First menstrual period
13 - One of three most common causes
of acute otitis media (genus only)
14 - Erythema infectiosum (fifth disease)
B19
is due to
17 - Newborn has bilious emesis and a
“double-bubble” sign on abdominal
x-ray: Duodenal
18 - Looks like a bruise but these “spots”
are birthmarks
19 - First-line therapy for hyperbilirubinemia of the newborn
20 - One piece of intestine “telescopes”
into another (not to be confused with
a “dreamy” Leonardo DiCaprio movie)
24 - HHV-6 causes this infection that has
prodrome of high fever followed by
diffuse maculopapular rash
26 - Most common cause of hypertension
parenin children is
chymal disease
27 - Advise parents that newborns should
sleep on their backs (i.e., supine) to
decrease risk of this (initials)
29 - Untreated Kawasaki disease can lead
aneurysms
to
30 - Embryonic renal tumor
32 - Most common cause of meningitis in
newborns (initials)
33 - Most common cause of bronchiolitis
(initials)
34 - Most common immunodeficiency:
deficiency
Solutions on page 185.
85
CrossWards™
43
This Puzzle Might Cause
Extrapyramidal Symptoms
1
2
3
4
5
6
7
8
9
10
11
12
13
16
14
15
17
18
19
20
21
86
Across:
2 - Patient who has had at least one
prior episode of major depression
and now is manic:
disorder
7 - Syndrome characterized by motor
and/or vocal tics
8 - Intense episodes of fear with symptoms such as shortness of breath,
chest pain, shakiness, and sweating:
attacks
11 - Involuntary muscle spasms from
antipsychotic medication
13 - A side effect of some antipsychotics
is elevation of this hormone
18 - Patient with auditory hallucinations,
disorganized thoughts, and delusions likely has
19 - Fear of germs leads to repeated
hand washing; hand washing is
the
20 - Kind of therapy used for #8 across
(acronym)
21 - Procedure reserved for refractory
depression (acronym)
Solutions on page 187.
Down:
1 - Apraxia is inability to perform
activities
3 - The “I” in SIGECAPS
4 - The “G” in the CAGE questionnaire
5 - Abrasions on the knuckles,
enlarged parotid glands, erosion
of teeth enamel: All classic signs
of
6 - GABA-ergic drugs used as anxiolytics
for short-term control
9 - Fear of being alone in public places:
phobia
10 - A 10-year-old taking methylphenidate
likely has this (acronym)
12 - Class of medications used for
long-term treatment of #8 across
(acronym)
14 - A cause of PTSD in men as well as
women
15 - Amitriptyline is a
antidepressant
16 - “Caregiver” makes someone else
ill (e.g., a child) to get attention:
Munchausen
17 - Classic mood stabilizer for patients
with #2 across
87
CrossWards™
44
Claiming the Inheritance
Y UO L K V XWV A C D P G T A U S Z J KH PWC R Q B S S E U
N A N G I S J Y P I N E U R O F I B R OMA T O S I S Z B D G L
L T G Y U H K H A Y Z Z Z B D I G X U Y I S I S C I U N F WW X
K C E Q T D O D R S WW V G B D G L E I X P N X Y S H O B X D Q
J E L U K I F D L U E R Z Y DN T L J B FQ R D C A X NUOH X
I F R I S Z T T Y S J F KH P A A A P R UY BDA C X L O JWC
G R F K C B B D X F R O A T Z G Y I K H N X WG L X W R K U N T
S E Q J B F Y M D D D S Z R E O S C V Y B A AMN C N L U CW B
G P P L WQ Y A C P W B F D Z I A H D W Y L F P N J R M R H M E
T MA T U Y H V X CMMOR E K C K X A A T L P F Q T U B F R W
U I F N K U A C O XW A Z X H U H S B C WB J L C J G M F O N I
L S HW P A C V A V X O K D E M S G T T B B Y B C H U R N Y J C
K I Z I K U J E V U H O X H A P WO J R T F K J L L F H J G F U
L S T L U Y Z U K S E B R G Y A S T O I R E P O T N V O G WQ S
M E C S C I I J V I X A DM A E I U L O C Y Q A J J H O VWZ Z
L N C OM B F NW S B D G A MG T R Z W FW O L A L M T Z S P Q
C E X N Z B F E NOU D G I P X X GU J DR F GG Y J S F O B S
A G F S QG B P S R X J A I QQ J A R N FW B Z X J I Q J S M Z
I OW X K Y A O X B T V J P H A T L V C O K I GW S N U F L G E
C E I Q T I R X A I QO S G E L GOH P B T D KO R CO S P B W
V T T E G I T XW FWN P B J P I A A NO I E R B H T T F E Z T
R S D G X D T W R C U I I M L Z I WN T A N E K C G I M T G O R
J OW Z H Q E S A I F Q S F L R U J D M T L S W L B A U Q Z I M
N B P N NO R A Z T L I WR P Q P T K L C R E F B Y C N P K P C
E D E J K E S G Y S I K V E E MV T S S FQ S E E ONVO L G Q
K QO Y V K Z S K Y P V CN Y H I WS C R C A L X H C E Y Y B V
V A S I I H Z NN CD QOZ OU C U X Y CR Z T B V Z J H X Y P
N HWM J R E P S I B O QM D M O U G A H T M I G D K K C P Y F
C C I D Z M E M Q WN H A U P R A K A D I Y V O F U G P U J T U
U O X N C K Y U F A X J E A E L K R O G WG W U O R F L Y P B P
F L S N W E L S N O M S P B U S Q N F I G K K Q R X R B Z WW G
L T V E AOV S E Y Z C U I HG J HQ A F I X A C Y HVU A I X
I W F T U K M U Y S L T F S B I T J I I N Y O N V NWM M O D W
A N P E V S Z J R X I Z X Q G Y Q O L E A S WH U H O X E X A E
S Z X D P A F T Z R K T D C OQ B K E T S C UO B J V V H Z V N
X E R OD E RMA P I GME N T O S A I YX V L Y L QN S F K P
T I Q Y X U U Z I A F QMR A U I E MMDX MU X S U NM B Y B
N I R F M P E N K T R WH I F H H O Y D L A Z R N U F U N F N T
N Q G R X H C R B N Q OWX S B G H P W Z I WH E P K G K E X N
P AMN D V Y P L I X T E F Q E T MK I RH F U Z V C E T QN U
Hidden in this puzzle are 8 autosomal recessive diseases and 5 autosomal dominant ones.
Can you find them?
88
Notes
Solutions on page 189.
89
CrossWards™
45
CN 2-12 Intact?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
90
Across:
Down:
1-I
4 - Smell
6 - Eye movement, pupil constriction,
lens accommodation
7 - VIII
11 - XII
13 - Talking and monitoring aortic
baroreceptors
16 - III
17 - II
19 - XI
20 - Shoulder shrugging
21 - Chewing, facial sensation (spell out
the number)
22 - VI
2 - VII
3 - Eyelid opening (spell out the number)
4 - Sight
5-V
7-X
8 - Eyelid closing (spell out the number)
9 - Hearing and balance
10 - IX
12 - French kissing
14 - Lateral rectus eye muscle
15 - Superior oblique eye muscle
18 - IV
Solutions on page 191.
91
CrossWards™
46
This Puzzle DeLivers
1
2
3
4
5
6
7
10
11
8
12
13
14
15
16
17
18
19
20
21
22
24
92
23
25
9
Across:
Down:
4 - Liver injury pattern: High elevation of
alkaline phosphatase, bilirubin, inconsistent elevation of aminotransferases
5 - Antismooth muscle antibody associated with this form of hepatitis
7 - Presence of this antigen is a marker
for infectivity in chronic hepatitis B
8 - Malignancy most commonly caused
by chronic hepatitis C (acronym)
10 - Most common cause of abnormal
transaminases
13 - Hepatitis virus responsible for
majority of chronic viral hepatitis
(short form)
14 - Cause of severe hepatitis (>1,000)
15 - Liver injury pattern: AST:ALT = 2:1
16 - Liver injury pattern: Elevated
aminotransferases, mild elevation of
bilirubin, alkaline phosphatase
19 - Serum marker elevated in #8 across
(acronym)
20 - Cause of severe hepatitis (>1,000)
21 - Cause of severe hepatitis (>1,000)
22 - Presence of this antigen indicates
chronic infection with hepatitis B
23 - Cause of severe hepatitis (>1,000),
not enough oxygen to the liver
24 - Name the disease: Young adult with
liver disease and neuropsychiatric
symptoms
greater than or equal
25 - A
to 1.1 suggests portal hypertension
(acronym)
1 - This treatment may be indicated for
severe alcoholic hepatitis
2 - Presence of this antibody may be
only clue to recent hepatitis B
infection during the “window period”
antibody, associated
3 - Anti
with #18 across
6 - Rising cause of cirrhosis, associated with obesity and diabetes (two
words)
7 - Name the disease: Bronze skin,
diabetes, increase iron saturation
9 - Found to be low in patients with
#24 across
11 - GI disorder often concomitant with
#17 down (two words)
12 - The treatment for #7 down
15 - Cause of severe hepatitis (>1,000)
cholangitis:
17 - Primary
Disease affecting mostly young men
cirrhosis:
18 - Primary
Autoimmune cause of cirrhosis
affecting middle-aged women
22 - Presence of this antibody indicates
prior exposure to hepatitis B or
vaccination
Solutions on page 193.
93
CrossWards™
47
I Need a Puzzle–Stat!
1
2
4
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
25
23
26
27
28
29
94
24
Across:
Down:
1 - Measurement of this value is necessary to diagnose carbon monoxide
poisoning as the pulse oximeter
reading will be normal
5 - Use of this drug is indicated for
symptomatic bradycardia
6 - Carotid massage, Valsalva, and cool
pack to the face are examples of
maneuvers
9 - Name the antidote: Benzodiazepines
11 - The presence of muscle rigidity,
hyperthermia, and autonomic disability may be an adverse effect of this
class of medications
14 - Name the antidote: Methanol
15 - Diltiazem slows conduction through
the AV node, which may improve rate
control in a stable patient with this
tachyarrhythmia (short form)
17 - Name the antidote: Anticholinergics
19 - Name the antidote: Organophosphate poisoning
21 - Withdrawal syndrome: Tremor,
tachycardia, hypertension, agitation,
hallucinations, seizures
24 - Withdrawal syndrome: Anxiety, nausea, diarrhea, abdominal cramping,
mydriasis
25 - The presence of this lesion differentiates a second-degree from firstdegree burn
26 - Name the antidote: Opioids
27 - Use of this antiarrhythmic should be
considered for patients with refractory VT/VF arrest
28 - In addition to defibrillation, torsades
de pointes should be rapidly treated
with
29 - ACE inhibitors may cause this rare
but life-threatening side effect
2 - A female patient with abdominal
until proven
pain is
otherwise
3 - Name the antidote: Methemoglobin
4 - In addition to antihistamines, this
drug should be given to all patients
with anaphylaxis
6 - Name the antidote: Warfarin
7 - The presence of this finding, often
seen on an upright chest x-ray, is an
immediate indication for exploratory
laparotomy (two words)
8 - Name the antidote: Beta-blocker
10 - This intervention should be performed without delay in patients
with pulseless ventricular tachycardia/
fibrillation arrest, once rhythm is
identified
12 - For any unstable patient with a
brady- or tachyarrhythmia, the first
intervention should be
13 - The use of epinephrine in a code is
directed at increasing
perfusion
15 - The use of this drug may be necessary to terminate an episode of
supraventricular tachycardia
16 - The most definitive noninvasive
diagnostic test for appendicitis
17 - Third-degree burns are characterized
by full involvement of the dermis and
are painless/painful
18 - Name the antidote: Malignant hyperthermia
is indicated
20 - The use of
in patients with VT/VF pulseless arrest
who do not respond to defibrillation
22 - Name the antidote: Black widow
spider
23 - Name the antidote: Heparin
Solutions on page 195.
95
CrossWards™
48
Shock and Awe
1
2
3
4
5
7
6
8
9
10
11
12
13
14
15
16
17
18
96
19
Across:
3 - Peripheral vascular resistance is
(increased/decreased) in #2 down
5 - Core body temperature <95°F or
35°C
7 - A state of inadequate oxygenation to
tissues
11 - Inotropic drug useful if patient is
hypotensive
12 - Second leading cause of death in
children
14 - Universal blood donor
for calculating
15 - Rule of
burn surface area in adults
17 - A bee sting may lead to
shock
output is decreased in
18 #4 down
19 - One of the drugs useful for atrial
fibrillation with rapid ventricular
response
Solutions on page 197.
Down:
1 - The W in PCWP
2 - Bacteremia and low BP:
shock
4 - An MI can lead to
shock
6 - For patient unresponsive to
#17 down, use transcutaneous
8 - Blood loss shock
9 - Treat pulseless v-tach same as
ventricular
10 - First thing for ventricular fibrillation
13 - PCWP is (increased/decreased) in #2
down
16 - PCWP is (increased/decreased) in #4
down
17 - A drug to push for symptomatic
bradycardia
97
CrossWards™
49
Doc Says “I’ve got good
news and bad news”*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
26
28
27
29
30
31
32
33
34
35
36
*You’re going to have a disease named after you.
98
24
Across:
Down:
1 - Most common dementia associated
with Parkinson disease (two words)
5 - Congenital heart disease with
downward displacement of the
tricuspid valve into the right ventricle:
anomaly
9 - Cruise ship gastroenteritis:
virus
14 - Peripheral seventh nerve palsy
15 - Tapping over facial nerve elicits
ipsilateral facial muscle contraction:
sign
16 - Tonic pupil, larger than contralateral
unaffected pupil, with no neurologic
pupil
significance:
17 - Aphthous ulcers, genital ulcerations,
ocular inflammation:
disease
21 - Glomerulonephritis and pulmonary
disease suggests
syndrome
22 - Test used to demonstrate that ulnar
artery is functional (before doing an
arterial line)
23 - Pain with forced dorsiflexion of the
foot supposedly an exam finding in
sign
patients with DVT:
25 - Forced flexion of the arm to overhead
position elicits pain in patients with
shoulder impingement:
sign
26 - Hearing loss, vertigo, tinnitus:
disease
30 - People under study behaving
differently describes the
effect
31 - Stain used to detect eosinophils in
the urine
32 - Tumor associated with #18 down, an
apical lung cancer
34 - Hereditary nephritis associated
with deafness and eye disorders:
syndrome
35 - Allergic angiitis and granulomatosis in the lungs associated with
eosinophilia: Churgsyndrome
36 - For distinguishing transudate from
exudate in pleural effusion, use these
criteria
2 - Chronic thiamine deficiency in
alcoholics leading to ataxia, confusion, ophthalmoplegia:
encephalopathy
-Johnson syndrome
3is autosomal recessive condition of
conjugated hyperbilirubinemia due to
transport defect
4 - Disease classically associated with
#12 down
6 - Henoch-Schönlein purpura is due to
the deposition of immune complexes
containing this (acronym)
7 - Most common lysosomal storage
disease
8 - RUQ pain, jaundice, and fever:
triad
10 - Child with fever, mucosal inflammation, cervical lymphadenitis, and desdisease
quamation has
11 - Autoimmune hyperthyroidism:
disease
12 - Periodic fever (hyphenated)
13 - VSD, pulmonic stenosis, anteriorly displaced aorta, right ventricular enlargement: Tetralogy of
18 - Ptosis, meiosis, anhidrosis:
syndrome
19 - A lot of vomiting may cause this
small tear near the gastroesophageal
junction (hyphenated)
20 - Pericarditis after an acute myocardial
syndrome
infarction:
21 - Mild unconjugated hyperbilirubinemia
affects up to 7% of the population:
syndrome
24 - Set of criteria for diagnosing
rheumatic fever
27 - Treatment for helping dislodge the
otoliths in benign positional vertigo:
maneuver
28 - For determining cause of B12
test
deficiency:
29 - Nodules or macules in the palms or
soles that might be seen in patient with
lesions
endocarditis:
disease
32 - TB in the spine:
33 - Catheter with a balloon at the tip
that when inflated helps keep it in
the bladder
Solutions on page 199.
99
CrossWards™
50
Step 2 Potpourri
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
100
Across:
1 - Blood in urine, pain in the side,
and a palpable flank mass: Renal
carcinoma
2 - Give for an overdose of diazepam
3 - Painful bleeding in third trimester with fetal distress: Placental
7 - Pleural fluid with a pleural:serum
protein of 0.8 and pleural:serum LDH
effusion
of 0.75:
10 - A postmenopausal woman with vaginal
bleeding needs an
biopsy
11 - No ganglion cells in the colon:
disease
13 - B2 agonist for asthma
14 - B12 deficiency anemia is
16 - Treatment for bacterial vaginosis
18 - Pseudomembranous colitis is almost
always from this infection (use the
first letter of genus)
19 - A testicular cancer is most likely
a
Solutions on page 201.
Down:
1 - Dermatitis herpetiformis:
disease
4 - Most common thyroid cancer type
5 - Your patient in v-fib needs immediate
6 - Red cell casts in urine
8 - “Photographic negative” of pulmonary edema on chest x-ray: Chronic
pneumonia
9 - Chest pain relieved by leaning forward; ECG with diffuse ST elevation
12 - Panic disorder treatment (acronym)
15 - Back pain worsened by standing
and walking, relieved by sitting:
Spinal
17 - The “U” in MUDPILES
101
CrossWards™
1
Loosen Up with Some
Medical Eponyms
T
MC
P
H
A P G A
L
I
E P L E
N B
E
F OU R N
T
C HV O S T
102
R
B
Y
R
B
I E R
C
E K S
S
L
J
A
N
L
G
R E ND E L E
W
R
Y
S
H
B
MU R R A Y
U D
D
D I G
K
Z
I
A B I N S K I
P
N O
OV S I NG S
S
K
S
I
I
S
H
A
A N E WA Y
T
H
O
NB U R G
E
N
A N S E L S
C
E
L
J
I
E OR G E
N H
E
T
S
S
Across:
Down:
3 - Nodules or macules on palms or
soles seen in endocarditis: JANEWAY
lesions
They are embolic.
5 - When standing on one leg unable to
lift opposite side of pelvis:
TRENDELENBURG sign
Signifies weak gluteus.
7 - To detect eosinophils in urine, ask for
a HANSEL’S (OR HANSEL) stain
Can be acute interstitial nephritis but
not specific.
9 - One of the tests for meniscal tear
MCMURRAY
13 - Failure of third and fourth pharyngeal
pouches to differentiate: DIGEORGE
syndrome
22q11.2 deletion, multiple manifestations including partial thymus which
causes immunodeficiency.
15 - APGAR score: Five parameters
assessed at birth
Named after Virginia Apgar, but you
can also remember the components as
Appearance, Pulse, Grimace, Activity,
and Respiration.
17 - When rubbing sole of foot in upper
motor neuron lesion, great toe
goes up and other toes fan out:
BABINSKI sign
It is a primitive reflex in infants, but if
toe goes up and it is not a newborn,
get a CT or MRI of the brain.
18 - BPV treatment maneuver
EPLEY. Attempts to reposition the
free-floating particles. You can see
it demonstrated on some YouTube
videos.
19 - Deep palpation of LLQ provokes pain
in RLQ in appendicitis: ROVSING’S
sign
One of the peritoneal signs.
21 - Necrotizing infection of genital fascia:
FOURNIER’S gangrene
Obviously not a good thing.
22 - In hypocalcemia, tapping over
facial nerve causes facial twitch:
CHVOSTEK’S sign
And do you remember Trousseau’s sign?
1 - People being watched (studied)
behave differently: HAWTHORNE
effect
2 - Dermatology lines
LANGER’S. Please use them when
excising a skin lesion!
4 - LEWY body dementia
It is like overlapping Alzheimer and
Parkinson diseases.
6 - Free Ig light chains seen in plasma cell
dyscrasias: BENCE-JONES proteins
Mostly multiple myeloma but also
Waldenström microglobulinemia.
8 - Flexing the neck causes flexion of
the hips/knees in meningitis:
BRUDZINKSI sign
Neither this test nor Kernig are useful
since their LRs are close to 1.
10 - Primary adrenal insufficiency:
ADDISON’S disease
11 - For distinguishing transudative from
exudative pleural effusion: LIGHT’S
criteria
Dr. Light described these in 1972.
12 - Carpal tunnel test in which wrists are
flexed for a minute
PHALEN. Another classic bedside
test that is not really that useful (and
neither is Tinel).
14 - Vascular tumor associated with
HHV-8: KAPOSI’S sarcoma
Seen in AIDS.
16 - Most common cause of mild unconjugated hyperbilirubinemia:
GILBERT’S syndrome
Due to reduced glucuronyltransferase
activity.
20 - Distended neck veins, distant heart
sounds, low BP: BECKS triad
Get a pericardiocentesis tray ready to
relieve acute cardiac tamponade!
103
CrossWards™
2
Cross My Heart
I
S Y NC O P
C
R
A
E
N
D I A B E T
S
U
E
R
S
Y
S
MY
P
S
E
T H R OM B
E
I
N C
O A
S
R
I
D
S
I
D
T H I A
B
I
L
U N S T A B
N
T
D
E
L
D
E
104
A O
R
T
H
H O
S
P
R E N
H
E
E
A
U
OMA
A
T
S I S
C
R T I C
E
H
T
B R A D Y C A R
G
H
O
C M A
F
P
E
S
C O
A L
W N
A
I
L D O S T E R ON
F
X
T A M P ONA D E
S
R
L
P
I
O
D I G OX I N
O
R
P
I
N E G A T I V E
N
J
F
E
W
A
C
Z I D E
M
R
T
D
D I S S E C T I
L E
T
T
O
N
F R I C T I ON
E
A
O
D I A S T OL I C
N
D I A
U G H
I
I S M
C
H
E
M
I
A
A B G
ON
R U B
Across:
Down:
2 - Harsh systolic murmur radiating to carotids: AORTIC stenosis
Can cause chest pain, syncope, and heart
failure.
5 - Medical term for “done fell out” (sudden,
temporary loss of consciousness)
SYNCOPE
7 - Heart rate less than 60 bpm
BRADYCARDIA. Not necessarily pathologic.
10 - Most common cause of sudden cardiac
death in athletes (acronym)
HOCM. Hypertrophic obstructive cardiomyopathy.
11 - ACE inhibitors are the preferred antihypertensive drug class in patients with
DIABETES and proteinuria
12 - ACE inhibitors can cause this nagging
adverse effect, which would be a reason to
change to an ARB
COUGH
13 - Most common cause of secondary hypertension in children: RENAL parenchymal
disease
Get a UA, urine culture, and renal
ultrasound.
16 - Cause of secondary hypertension characterized by unprovoked hypokalemia: Hyper
ALDOSTERONISM
17 - A mobile, pedunculated mass in the left
atrium is likely an atrial MYXOMA
18 - JVD, low BP, and distant heart sounds is acute
cardiac TAMPONADE until proven otherwise
23 - Stasis, hypercoagulability, and injury set a
person up for a deep venous THROMBOSIS
Virchow’s triad.
24 - Drug that inhibits Na+/K+−ATPase and
increases cardiac contractility
DIGOXIN. Has narrow therapeutic index.
25 - On EKG: Left axis deviation has NEGATIVE
QRS in lead II
30 - Severe stenosis of the left main coronary
artery is an indication for this surgery
(acronym)
CABG. Coronary artery bypass grafting.
31 - First-line antihypertensive medication class:
THIAZIDE diuretics
Like chlorthalidone or HCTZ.
34 - A hypertensive emergency with sudden
chest pain radiating to the back suggests
aortic DISSECTION
35 - Chest pain that is new onset or that is getting worse is deemed UNSTABLE angina
This is an acute coronary syndrome.
36 - On examination of the patient in #20
down you might hear a pericardial
FRICTION RUB (two words)
37 - Aortic regurgitation has a DIASTOLIC murmur
1 - A sign of #10 across is a systolic murmur
that INCREASES in intensity with standing
3 - Breathlessness with lying flat
ORTHOPNEA. One of the CHF symptoms.
4 - Most common cause of myocarditis in the
world: CHAGA’S disease
Caused by T. cruzi transmitted by “kissing
bugs.”
6 - Protein that is elevated for several days
after a myocardial infarction
TROPONIN
8 - If you hear a gallop when listening to the
heart, do not think horses, but think this
(acronym)
CHF
9 - Screen men aged 65 to 75 who have ever
smoked for abdominal aortic ANEURYSM
Screen with ultrasound.
13 - Most common cause of mitral valve stenosis: RHEUMATIC fever
14 - Patients with atrial fibrillation can be
treated with WARFARIN to reduce risk of
stroke
Aspirin can be used in low-risk patient;
newer anticoagulants are available as well.
15 - ST segment depression suggests this
ISCHEMIA
19 - Part of the postmyocardial infarction
“recipe”
ASPIRIN. Other components are statin,
beta-blocker and ACE inhibitor.
20 - Diffuse ST segment elevation on an EKG of
a patient with chest pain that is worse with
lying down suggests acute PERICARDITIS
21 - Aortic STENOSIS is one of the cardiac
causes of #5 across, mostly in the elderly
22 - Treat symptomatic heart failure with a
LOOP diuretic
Like furosemide.
26 - Q waves, that are two small boxes wide or
more than one-third the QRS amplitude
suggest myocardial INFARCTION
27 - Evaluate heart failure with an echocardiogram to estimate left ventricular EJECTION
fraction
28 - Most common type of cardiomyopathy
DILATED
29 - A chest x-ray of the patient in #9 down
may show a WIDENED mediastinum
32 - Midsystolic murmur with a “click” MITRAL
valve prolapse
33 - When the QRS is widened, there is some
sort of BUNDLE branch block
105
CrossWards™
3
Put Some Skin in the Game
M
A
C
U
L
V E
106
K E R A T OS E S
U
S
P
P I T Y R I A S I
T
Z
P A T
N
S
V
A
E C Z E MA
P
B
R
H
NOD O S UM Y
R
I
L
I
U R T I C A R I A
M
H
O
X
P A P U L E
L
I
E
I
O P
S
T
G
C L A R K S
S I C L E
O
G
N
R
O
I S OT R E T I NO I
T
A
A MOL L U S C UM
L
I
R
S H I NG L E S
S
A
R
O
S
A
C H
E
A
N
Across:
Down:
1 - These “stuck-on” brownish wart-like
lesions are very common and are
benign: Seborrheic KERATOSES
Can be shaved or cryo’d if they bother
patient.
4 - Herald patch heralds this dermatitis:
PITYRIASIS rosea
5 - Flat skin lesion >1 cm
PATCH
9 - Another name for atopic dermatitis
ECZEMA. Very common; treat with
topical steroids.
10 - Tender, erythematous nodules on
lower legs usually triggered by an
illness or drug reaction: Erythema
NODOSUM
13 - Medical term for hives
URTICARIA. Very itchy.
14 - Elevated skin lesion <5 mm
PAPULE
17 - Melanoma is staged by TNM and this
level
CLARK’S. And Breslow thickness.
18 - Small, fluid-filled lesion
VESICLE. Like herpes.
19 - This medicine used to treat serious
acne is also a serious teratogen
ISOTRETINOIN
20 - MOLLUSCUM contagiosum: Caused
by poxvirus, tiny lesions with central
umbilication, more common in
children
22 - Vesicular rash in dermatomal
distribution, common term for the
diagnosis
SHINGLES. Caused by reactivation of
varicella zoster virus.
2 - Bleeding when a skin scale is scraped:
AUSPITZ sign
3 - If you see an older gentleman with
rhinophyma, think this condition
ROSACEA. Can try topical metronidazole to treat.
6 - Type 1 hypersensitivity might be this
serious reaction
ANAPHYLAXIS
7 - Pityrosporum ovale is implicated in
this dermatitis
SEBORRHEIC. Flakes in eyebrows,
hairline (dandruff).
8 - Caused by Malassezia furfur: Tinea
VERSICOLOR
“Spaghetti and meatballs” on slide.
11 - Flat skin lesion <1 cm
MACULE
12 - Group A streptococcal secondary skin
infection characterized by honeycolored crusted lesions, mostly in
children
IMPETIGO
15 - #2 down is seen with this inflammatory skin disease
PSORIASIS
16 - HSV-2 causes lesions here
GENITALS. HSV-1 causes oral lesions.
21 - A patient who thinks he has a spider
bite more likely has a skin infection
with community-acquired form of
this (acronym)
MRSA. Methicillin-resistant staphylococcus aureus.
107
CrossWards™
4
Lytes Out!
C A L C I T
I
N
S
I
P
I
D
U
S
M
E
T
A
NO
B
O
L
I
C
A
C
H Y
I
E
OD I UM
O
O
S
L
I
Y
S
S
I
F U R O S E
108
R
C
H Y P ONA T
O
N
ON I N
I
T
O
A S P I R I N
D
N
G
H Y P E R MA G
P
P
A L B
R
MA L
C A L C
L
L
D
O D
HOV S T E K S
S
M H
T
O Y
E
L
D
E R K A L E M I
O L
N
I
I
T
S
Y
M
MA GN E
P
O
T
A
S
S
I
U
M I D E
R E M I A
G
N
U
I
A
L
K
A
L
O
S
I
P HOS
H
Y
P
L U C OS E
R
C
E S E M I A
O
L
D
C
M I N
E
U
M
UM
I
A
H
Y
P
O
K
A
L
E
I UM
I
P HA T E
Across:
Down:
1 - Psychogenic polydipsia might be a cool
name for a rock band, but it can cause
this electrolyte problem
HYPONATREMIA. Always remember
Na+ concentration is telling you something about water.
5 - This hormone from the C cells of the
thyroid gland decreases calcium
concentration
CALCITONIN. It puts it in the bones. I
remember “calciBonin.”
6 - Low sodium should be correct for high
this
GLUCOSE
7 - Overdose of this may cause a metabolic
acidosis and respiratory alkalosis
ASPIRIN
8 - Loss of deep tendon reflexes is an early
manifestation of this
HYPERMAGNESEMIA. Mostly see this
when monitoring preeclampsia patients
on labor ward.
12 - Before jumping to conclusions on low
calcium, be sure you correct for low
amount of this
ALBUMIN
13 - One other reason not to sniff glue is
that it can cause a metabolic acidosis
with a NORMAL anion gap
15 - In severe hyperkalemia, give this first to
protect the heart
CALCIUM (gluconate)
18 - Facial spasm brought on by tapping
by the ear over the facial nerve when
calcium is low: CHOVSTEK’S sign
Can you think of an ENT operation when
you might check this?
20 - Angiotensin-converting enzyme inhibitors can cause this electrolyte problem
HYPERKALEMIA
23 - The concentration of this determines
tonicity
SODIUM. See #1 across.
24 - Not enough of this in the blood can
lead to Torsade de pointes
MAGNESIUM
25 - In severe hypercalcemia, give intravenous hydration and this drug to
promote calcium excretion
FUROSEMIDE
26 - Parathyroid hormone (PTH) decreases
the resorption of this by the kidney
PHOSPHATE
2 - Correcting #1 across too quickly can
result in central PONTINE myelinolysis
3 - Sodium minus (chloride + bicarbonate) =
ANION GAP (2 words)
4 - “Stones, bones, moans, and groans,”
think this
HYPERCALCEMIA. Which might be due
to hyperparathyroidism.
7 - A common cause of hyponatremia is a
syndrome of too much of this (initials)
ADH. Antidiuretic hormone (SIADH).
9 - Fractional excretion of this is helpful in
figuring out acute kidney injury
SODIUM. Use urea if on diuretic.
10 - pH <7.4 with PCO2 <40 mm Hg
(two words)
METABOLIC ACIDOSIS
11 – It is the P in MUDPILES
PARALDEHYDE
14 - Hypokalemia and hypernatremia found
when working up the newly diagnosed
hypertensive patient
suggests hyperALDOSTERONISM
16 - Diabetes INSIPIDUS is due to not
enough ADH
17 - Twice the sodium concentration +
(glucose concentration)/18 + blood urea
nitrogen/2.8 gives the calculated serum
OSMOLALITY
19 - T waves may be flat in this electrolyte
abnormality
HYPOKALEMIA
20 - If this happens to the blood sample, the
potassium may measure elevated but it
really is not
HEMOLYSIS
21 - Insulin drives this electrolyte intracellularly
POTASSIUM. Remember CBIGKDrop:
Calcium, bicarbonate, insulin, glucose,
kayexalate, dialysis.
22 - Hyperventilation leads to respiratory
ALKALOSIS
Because of breathing off too much CO2.
109
CrossWards™
5
Immune to Myself?
D
C R
S
B E
C
L
L U
E
U
R
P O
O
C
U
D I A B E T E S
E
L
R
B I L I A R
M
A
A
C E L I A
110
R G
N
P U
L
R H E U
A
P
S
U
H I S
W I
E R MA T
G O
E S T
N O
E R S
R
S
G
S
O
F
J
O
MA T O I D
C
G
P
T
R
A
T ON E
S
R
N T
O
S
U
R
E
G R A V E S
L Y A NG I I T I S
Y C I R R HO S I S
C
Across:
Down:
5 - Anti-citrullinated protein (CCP):
RHEUMATOID arthritis
See also #4 down.
7 - Drug-induced lupus may have antiHISTONE antibodies
Hydralazine is one of the nearly
40 drugs that can cause this.
9 - Anti-Jo 1 may point to poly- or
DERMATOmyositis
Heliotrope rash is classic.
10 - Anti-centromere (syndrome, acronym)
CREST. Calcinosis, Raynaud’s,
Esophageal dysmotility, Scleroderma,
Telangiectasias.
11 - Antibodies activating thyroidstimulating hormone receptor:
GRAVE’S disease
Most common cause of hyperthyroidism.
13 - IgA
BERGER’S
15 - Anti-Sm
LUPUS. See also #15 down and #3
down.
16 - p-ANCA: microscopic POLYANGIITIS
18 - Islet cell antibodies: Type 1 DIABETES
19 - Anti-mitochondrial antibody: Primary
BILIARY CIRRHOSIS
20 - Anti-endomysial: CELIAC disease
See also #17 down.
1 - Anti-basement membrane:
GOODPASTURE’S syndrome
Antibodies attack lungs and kidneys.
2 - Anti-ro: SJOGREN’S syndrome
Also known as sicca syndrome, hallmark symptoms are dry mouth and
dry eyes because disease attacks the
exocrine glands.
3 - Anti-ds DNA
LUPUS. See also #15 across and
#15 down.
4 - Rheumatoid FACTOR in RA
See also #5 across.
6 - Thyroid peroxidase antibodies:
HASHIMOTO’S disease
Most common cause of hypothyroidism.
8 - c-ANCA vasculitis
WEGENER’S
12 - Anti-Scl-70
SCLERODERMA
14 - U1 RNP (acronym) in mixed connective tissue disease
Ribonucleoprotein.
15 - Anti-nuclear antibody
LUPUS. See also #15 across and
#3 down.
17 - Anti-transglutaminase: CELIAC
disease
See also #20 across.
111
CrossWards™
6
I’m “Gland” You’re Doing
This Puzzle
P
A
P
C A L C I
L
B U F F A L
A
R
HY
R O P R A NOL OL
UM
O
D
A D D
C
L
E
O
D
H
R
O Y
T
S
D
P I T U I T A R
S
E
A
O P A R A T
L
O
I
N O
I
N
S
P H E O C H R OMO C
112
S
O
K
M
P E R OX I
T
G
R OX Y L A
A
I
C
S I A D H
D
A
O W
I S ON S
I
A S H I MO
G
R
D A S E
V
S E
S
H
Y
P
E
R
T OS
H O
Y
D
Y
R
I
O U
HY R O I D I S M
D
I
C U S H I NG S
M
Y T OM A
Across:
Down:
1 - Useful beta-blocker to treat symptoms of hyperthyroidism
PROPRANOLOL. Not only decreases
symptoms but also inhibits conversion
of thyroid hormone.
2 - If tapping on facial nerve elicits
twitch of facial muscles, think low
levels of this
CALCIUM
5 - A classic sign of #19 across:
“BUFFALO hump”
7 - Antithyroid PEROXIDASE antibodies
are seen in #15 across
But they are also highly prevalent in
the general population; not needed to
diagnose hypothyroidism.
8 - Most causes of #14 down are due to
the deficiency of 21-HYDROXYLASE
9 - Very common cause of euvolemic
hyponatremia (acronym)
SIADH. Treat with fluid restriction.
12 - Autoimmune adrenal insufficiency:
ADDISON’S disease
15 - Most common cause of elevated TSH
with low free T4: HASHIMOTO’S
disease or thyroiditis
Treat with thyroid hormone
(levothyroxine) and titrate using
TSH level.
17 - MEN 1: Pancreatic tumor, parathyroid
hyperplasia, and PITUITARY adenoma
MEN 1 = 3 P’s.
18 - “Stones, bones, moans, and groans,”
think this: HyperPARATHYROIDISM
Which leads to hypercalcemia.
19 - Too much ACTH will lead to
CUSHING’S syndrome
20 - Catecholamine-secreting tumor that
is a very rare cause of secondary
hypertension
PHEOCHROMOCYTOMA. If suspected, check urine metanephrines.
1 - Most common type of thyroid cancer
PAPILLARY
3 - In Type 1 diabetic patient, hyperglycemia early in the morning in
response to hormones counteracting
overnight hypoglycemia: SOMOGYI
effect
4 - Most common cause of #11 down:
GRAVE’S disease
6 - Hyperglycemic crisis in Type 1 diabetes
mellitus: Diabetic KETOACIDOSIS
Treat with aggressive IV fluids and
insulin while watching potassium
carefully.
10 - In Type 1 diabetic patient, hyperglycemia early in the morning due
to insulin being counteracted (by
growth hormone) overnight: DAWN
phenomenon
11 - Low TSH with elevated free T4:
Primary HYPERTHYROIDISM
Order a thyroid uptake scan; treat with
antithyroid drugs or radioactive iodine
ablation, rarely surgery.
12 - Low K+ and high Na+ in a newly diagnosed hypertensive patients suggests
hyperALDOSTERONISM
13 - A key clinical issue in hyperosmolar
hyperglycemic state is
DEHYDRATION, which is why
aggressive fluid replacement
(along with insulin) is needed
14 - Congenital adrenal hyperplasia leads
to the deficiency of this
CORTISOL
16 - Part of the treatment of nephrogenic
diabetes insipidus is SODIUM
restriction
113
CrossWards™
7
Abdominal Pains
M
A D H E S
L
L I P A S
O
R
Y
W
C
E
U
I NC A R
S
L
S
I
N
G
R OV S
114
C
H
O
L
I ON S
A
N
E
G
P
I
B
A
T
A P P E ND I
R
S
C
S
R
O R
C E R A T E D
T
S
A
T
T
S
I
T
I NG S
I
S
H
C
A
C
M
U
R
P
H
P
Y
E
OL E S T E R OL
F
B OR E
C
R
HA L A S I A
O
T
L L S T ON E S
E
D
L
V
I T I S
T
R
Z
H C U L L E N
I
H
N
A
O
K
S
W
E
I
R
S
Across:
Down:
3 - Most gallstones are composed of
CHOLESTEROL
4 - In any patient with GI bleed, be sure
to have two large BORE IV’s in place
7 - Common cause of small bowel
obstruction
ADHESIONS
8 - Esophagus looks like a bird beak on
barium swallow
ACHALASIA
9 - Elevated in acute pancreatitis
LIPASE. So is amylase but less specific.
10 - One of top two causes of pancreatitis
GALLSTONES. Alcohol is the other.
14 - Diagnosis for patient with periumbilical pain that moves to RLQ associated with anorexia
APPENDICITIS
18 - Ecchymosis around the umbilicus:
CULLEN sign
Bleeding internally, such as hemorrhagic pancreatitis; Grey Turner sign is
at the flank.
19 - This kind of hernia requires urgent
surgery
INCARCERATED. Or strangulated
(and therefore, losing blood supply).
20 - Pain in RLQ on palpation of LLQ:
ROVSING’S sign
One of the peritoneal signs.
1 - Deep palpation in RUQ causes
inspiratory halt in cholecystitis:
MURPHY’S sign
2 - Free air under the diaphragm on plain
film: PERFORATED viscus
Call the OR.
3 - RUQ pain, jaundice, and fever
suggests this diagnosis
CHOLANGITIS
5 - Superficial tear of esophagus often
due to excessive vomiting (two
words)
MALLORY WEISS. Usually heals on its
own.
6 - “Female, fat, forty, and fertile” are
classic risk factors for this
CHOLELITHIASIS
11 - #18 across seen in hemorrhagic
PANCREATITIS
12 - Metaplasia in distal esophagus
BARRETT’S
13 - Metastasis above the left clavicle:
VIRCHOW node
As from lung or stomach cancer.
15 - Abdominal pain on extension of hip
with knee flexed: PSOAS sign
Another peritoneal sign.
16 - Acute stomach ulcer in trauma and
burn victims: CURLING’S ulcer
And what is Cushing’s ulcer?
17 - ZENKER diverticulum is a cause of
oropharyngeal dysphagia
115
CrossWards™
8
Clinical Scramble
HALLUCINATIONS
H A L L U C I
N A T
CLOUDED
C L O U D E D
IMPAIRED
I M P A
I
ACUTE
A C U T
E
ANSWER:
O N S
MIND
M I N D
ATTENTION
A T T E N T
R E D
REVERSIBLE
R E V E R S
I
ONSET
O N S
E
I
E
B
L
O N
T
DELIRIUM
a patient with it, search for the cause!)
116
I
(When you see
Notes
117
CrossWards™
9
This Confounded Puzzle!
P
O
S
R
I
A B S O
T
R
P
R E L A T I V E
E
A
E
V
C
N A
N E GA T I V
D
D
F
C A S E C ONT R O L
I
M
I
C
I
M
L I K
Z
E
S
T
E
T WE NT Y
L
ME A S U R
C
P
T
E
I NC I D
O
I
N
F
I
C
S E N S I T I
T
Y
118
L U T E
E
C
O
N
S
F
E
O
N
U
S
N
L I HOOD
T
I
I
N
V
G
ME N T
P
R
E
V
A
L
E
N
C
E NC E
O
H
O
R
V I T Y
Across:
Down:
3 - 1 divided by the ABSOLUTE risk reduction is the NNT
6 - Step 2 study fatigue syndrome, or
S2SFS, occurs in 20% of medical students; a new drug reduces the incidence
of S2SFS to 15%; 25% is the RELATIVE
risk reduction
20 –15/20 = 25%.
8 - Subtract the NEGATIVE predictive value
from 1 to get the probability a patient
with a negative test has the disease
The NPV itself is the probability that a
patient with a negative test does not
have the disease.
10 - A study in which we find a sample of
students who scored really high on Step
2 examination and a sample who scored
really low from a similar population and
then call them up and ask if they used
CrossWardsTM is a CASE-CONTROL
study
Such a study samples on the outcome
and then looks back to measure
exposure.
12 - A positive LIKELIHOOD ratio is the
probability of a positive test result in
those with the disease divided by the
probability of a positive test result in
those without the disease
14 - The NNT in #6 across to prevent one
case of S2SFS
TWENTY. 1/(0.20 – 0.15) = 20.
15 - Students in the study in #10 across
who scored high on Step 2 examination
may be more likely to remember using
CrossWardsTM than those who scored
poorly; this is a kind of MEASUREMENT
bias
This is classic “recall bias.”
17 - Proportion in a population who develop
a disease or outcome over a period of
time (e.g., over the next year)
INCIDENCE
19 - Probability that a patient positive for
the disease has a positive test
SENSITIVITY. TP/(TP + FN).
1 - A new blood test is developed to detect
S2SFS; among 100 students with
definite S2SFS by gold standard brain
scan, the new blood test is positive in 80;
among 100 students without S2SFS by
brain scan, the blood test is negative in
90; 89% is the POSITIVE predictive value
80/[80 + (100 – 90)].
2 - Case-control studies are particularly
valuable when studying outcomes that
are RARE
Think of how long and expensive it would
be to do a cohort study waiting for rare
outcomes.
4 - Probability that a patient without the
disease has a negative test
SPECIFICITY. TN/FP + TN.
5 - The name for the bias in #6 down
CONFOUNDING
6 - Students who study hard are more
likely to score high on Step 2 examination and may also be more likely to use
CrossWardsTM, a relationship that may
not be random; the best way to eliminate this potential bias from a study is
to RANDOMIZE the students who use
CrossWardsTM or not
7 - In studies of screening, the bias introduced because a screened population
appears to have longer survival than an
unscreened population but really does
not is called LEAD-TIME bias
9 - A highly SENSITIVE test when negative,
helps rule out a disease
Remember SnNout. Sensitive (Sn) when
negative (N) rules out.
11 - Proportion in a population who have a
disease or outcome at a specific time
(e.g., now)
PREVALENCE
13 - Participants in a study may drop out of
one group more than the comparison
group; this introduces possible
SELECTION bias
To remember selection bias, think
problems with “choosing or losing”
participants.
16 - False positive rate is the same as
1 minus the SPECIFICITY
18 - A study in which we follow medical students who use CrossWardsTM and those
who do not and later assess their board
scores is a COHORT study design
119
CrossWards™
10
GI Feel Terrible
P
A MMON I A
N
MA
C
P
R
O
L
E
F R E E A I
A
T
C
T
A
T
I
L
U
T
I L E
I
O
S C HA T Z K I S
E
B
D
I
C
H
L L OR Y WE I
I
O
M
A
H
O
R
N
C
Y
S
H
C I R R
O
U S
M
V
A
B A R R E T T
C
R
A
O
A
I
N
S
C
R
C
S H I G
H P Y L OR I
C
E
O S
F
W I L S ON S
F
G N
S
C
ME G A C OL ON
M
H
E
L
I
S
U
A
L
G
L
D
A S T E R
R OT A V I R U S
I
P
C
C
O T
D Y S P H
O
T
U O
S
Y
T
A
N N
S
S
T
D
E
H B E A G
S QU A MOU S C E
120
I R E C T
H
S S
O
B
L
O
A
N
G
HO S I S
T
Z
I
E
S
S
C
E
E L L A
I
C
A
H
C
A
L
A
I X I S
I
A G I A
L L
Across:
3 - Type of inguinal hernia that protrudes
medial to the epigastric artery
DIRECT. An indirect protrudes laterally.
5 - Hepatic encephalopathy is due to failure to
clear this
AMMONIA
8 - Repeated vomiting can lead to this tear that
causes upper GI bleeding (two words)
MALLORY WEISS
12 - If you see this under the diaphragm on an
x-ray, think perforation (two words)
FREE AIR. Call the surgery team.
13 - Eventual fibrosis, scarring, and regenerative
nodules in the liver that can result from a
wide variety of insults
CIRRHOSIS
14 - Loss of peristalsis without mechanical
obstruction
ILEUS
17 - Rings and webs in the lower esophagus, not
to be confused with the name of a deli
SCHATZKI’S
18 - Chronic GERD can lead to metaplasia called
BARRETT’S esophagus
This can be a precursor to esophageal cancer.
23 - One of the organisms that causes bloody
diarrhea
SHIGELLA. Salmonella, Campylobacter,
invasive E. coli, and Yersinia are some
others.
25 - Germ that causes ulcers, common short
form
HPYLORI
26 - You see Kayser-Fleischer rings not around
Saturn, but in this disease
WILSON’S. It also affects the liver.
29 - Complication of inflammatory bowel disease
with dilation of the colon and systemic
toxicity: Toxic MEGACOLON
33 - “Liver flap”
ASTERIXIS. Tremor of the hand when the
wrist is extended.
34 - Most common cause of diarrhea in infants
ROTAVIRUS
35 - It is difficulty swallowing
DYSPHAGIA. Think obstruction (e.g., mass)
if for solids, or scleroderma, achalasia or
esophageal spasm if for liquids.
36 - Serologic marker reflecting high transmissibility of hepatitis B infection (acronym)
HBEAG. Hepatitis B e antigen.
37 - Most common type of esophageal cancer in
the world (two words)
SQUAMOUS CELL
Down:
1 - Your patient with epigastric pain and
elevated lipase has acute PANCREATITIS
Amylase also may be elevated.
2 - Autoimmune disorder with positive antimitochondrial antibody: Primary BILIARY
cirrhosis
4 - RUQ pain, jaundice, and fever suggest
ascending CHOLANGITIS
6 - Inflammatory bowel disease with skip lesions
CROHN’S
7 - Treat this cause of cirrhosis with phlebotomy
HEMOCHROMATOSIS. Monitor ferritin and
CBC.
9 - The cause of this condition (acronym) is
adhesions from a prior surgery in about
two-thirds of patients
SBO. Small bowel obstruction.
10 - Kind of hypertension that results from
#13 across
PORTAL. This can lead to ascites.
11 - Treat #5 across with this
LACTULOSE
15 - Rare syndrome of gastrin being produced
by a tumor in the pancreas that can lead to
ulcers (acronym/initials)
ZES. Zollinger-Ellison syndrome.
16 - A worrisome source of upper GI bleeding in
patients with cirrhosis: Esophageal VARICES
Never underestimate these.
19 - Amylase is NOT one of these criteria that
include elevated glucose, age >55 years,
elevated LDH, elevated ASH, and elevated
white blood cell count on admission
RANSON’S
20 - High levels of 5-HIAA define this syndrome;
patients may have flushing and diarrhea
CARCINOID
21 - Gluten-free diet is the treatment for this
disease
CELIAC
22 - This description of emesis suggests upper GI
bleeding (2 words)
COFFEE GROUND
24 - “Bird’s beak” esophagus
ACHALASIA. Can cause dysphagia for liquids.
27 - One of the top two causes of #1 down.
GALLSTONES. The other is alcohol.
28 - The three signs in #4 down are called
CHARCOT’S triad
30 - These drugs are a common cause of gastritis
and peptic ulcer (acronym)
NSAIDS. Nonsteroidal anti-inflammatory drugs.
31 - This sign is inspiratory arrest when palpating
in the right upper quadrant
MURPHY’S
32 - This lab can be helpful in evaluating possible
mesenteric ischemia
LACTATE
121
CrossWards™
11
Nerve-racking Puzzle
O
X
X
A C E T Y
N
G
MU L T I P L E
E
H O N
N
O S
B
I
C
T
U P P E R
H
E
V
R
R
R
E
O
I
S
M O
M I G R A I
A
122
B
I NT U B A T I
B
M I D D
N
S A H
S
C
K
L C HOL I N E
I
P
S C L E R OS I
L
D
E
U
S U B D U R
E
A
L
L
L
W
S
N E
S
S T A T U S
ON
L E
S
C
A L
U
S
T
E
R
Across:
Down:
2 - #19 across usually requires this
procedure
INTUBATION. To protect the airway.
3 - Aphasia, contralateral paralysis and
sensory loss, gaze toward the side:
Where is the lesion? MIDDLE cerebral
artery
5 - Sudden onset “worst headache of my
life” think this (acronym)
SAH. Subarachnoid hemorrhage.
8 - Myasthenia gravis is due to antibodies against these receptors
ACETYLCHOLINE
10 - MRI shows white matter lesions
and CSF has oligoclonal bands (two
words)
MULTIPLE SCLEROSIS
14 - Older patient hits head and ruptures
bridging veins: SUBDURAL hematoma
16 - #1 down seen in UPPER motor
neuron lesion
18 - Most common disabling headache
MIGRAINE
19 - Seizure lasting more than 10 minutes:
STATUS epilepticus
1 - BABINSKI sign: Dorsiflexion of great
toe with fanning of other toes
4 - Acute treatment for #12 down
OXYGEN
6 - S1 nerve root reflex location:
ACHILLES tendon
7 - This yellowish coloration of CSF from
lumbar puncture suggests #5 across
XANTHOCHROMIA
9 - Tear of the middle meningeal artery:
EPIDURAL hematoma
10 - Triad of hearing loss, tinnitus, and
vertigo
MENIERE’S
11 - Double-vision, dysphagia, and slurred
speech seen in POSTERIOR circulation stroke
12 - Excruciating, one-sided headaches
associated with nasal stuffiness and
tearing of the eye
CLUSTER
13 - Common cause of vertigo due to
malpositioned otolith (acronym)
BPV. Benign positional vertigo; sometimes you will see as BPPV, an extra
P for paroxysmal.
15 - Idiopathic CN7 palsy: BELL’S palsy
Peripheral CN7 nerve lesion does not
spare the forehead.
17 - Infantile spasms: WEST syndrome
123
CrossWards™
12
One More . . . For Old
Timer’s Sake
Meredith Gilliam
C H R ON I
T
P
P WA V E S
E
O T
C
N
L
R
A
A
Y
I
N
N
M A A A
G B M
Y
L
O
L
A
F
R
E
P
L
I
T
G B
I
I
R
C A L C I UM
A
I
A
L A C UNA R
C
L
N
R
A
G
P O
T
I
L
F I F T Y
O
I
O
G
D
N
MP R OT E
A
S
M
M
124
L E F T
R
C B R O
H
P
F
O
N
I
N
K
L
S E UD
B
S
I NH
E
Y
L
P
L
E
D A G R
T
NC R E
N
I N S
I
O
E MA N
E
M
NC H I T I S
O T
P
L
R
Y
I
A
O
L
G
E
N
A
S
E
OGOU T
S
R
E
T
N
I B I T OR S
C
S
T
D
I
E
I
S
R
A
S
O
S
I
A S E S
D
C
S
T
I
O
T I N E
Across:
1 - The most common cause of right heart failure:
LEFT heart failure
5 - Likely diagnosis in an elderly smoker with
hypoxemia, polycythemia, and hypercapnia
(two words)
CHRONIC BRONCHITIS. COPD is the general
term for this and emphysema.
9 - These are indiscernible on EKG tracings of
atrial fibrillation, a common arrhythmia in the
elderly
P-WAVES
11 - The most likely diagnosis in an elderly smoker
with a pulsatile abdominal mass is AAA
(acronym)
Much more common in men.
13 - Most common primary brain tumor in an
elderly patient (acronym)
GBM. Glioblastoma multiforme.
17 - In a joint aspirate, positively birefringent
crystals that appear blue when parallel to
polarized light suggest this diagnosis
PSEUDOGOUT. Caused by deposition of
calcium pyrophosphate dihydrate crystals.
18 - This common laboratory value may be
elevated in an elderly man with multiple
myeloma
CALCIUM
20 - Donepezil, rivastigmine, and galantamine
(drugs sometimes used in Alzheimer disease)
are acetylcholinesterase INHIBITORS
23 - An elderly man with longstanding HTN and a
CT showing ischemia of the internal capsule
may have a blockage in these small vessels
LACUNAR
25 - Painful first MTP joint associated with gout
PODAGRA
26 - Adults should generally begin screening for
colorectal cancer at age FIFTY (exceptions for
high-risk groups)
27 - Unlike the pain of rheumatoid arthritis, that of
osteoarthritis INCREASES with use
28 - In rheumatic heart disease, heart damage is
caused by antibodies against M-PROTEIN
29 - Name of an NMDA receptor antagonist that
may have some neuroprotective effect in
severe Alzheimer disease
MEMANTINE
Down:
2 - Cardiac marker, that is, one of the first to rise
in an acute myocardial infarction
TROPONIN
3 - This organism is a leading cause of nosocomial
infection due to the prevalence of urinary
catheters (short form)
ECOLI
4 - The valve most commonly affected by
rheumatic heart disease
MITRAL
5 - The initial test in an elderly patient presenting
with acute-onset hemiparesis (two words—
first word acronym)
CT SCAN
6 - An elderly man who sees halos around lights
at night, has myopia, and denies eye pain
should be evaluated for this type of glaucoma
OPEN ANGLE
7 - When your elderly patient needs three pillows
to breathe comfortably at night, the most
likely diagnosis is CHF (acronym)
Congestive heart failure; orthopnea is a classic
symptom.
8 - Infection with SPYOGENES, when untreated,
may lead to rheumatic heart disease later in
life (shorten the genus to an initial)
9 - Most likely diagnosis in an elderly patient with
proximal joint pain, malaise, elevated ESR, and
normal CK: POLYMYALGIA rheumatic
Treat with corticosteroids.
10 - Common arrhythmia in the elderly causing an
irregularly irregular pulse (two words)
ATRIAL FIBRILLATION
12 - Most likely diagnosis in an elderly patient with
a diastolic murmur, wide pulse pressure, and
bounding pulses: AORTIC regurgitation
14 - Your patient transferred from a nursing home
for delirium is found to have a UTI; when you
see large mucoid capsules on urine microscopy,
your diagnosis (of organism) is KLEBSIELLA
15 - Important diagnosis to rule out in your elderly
patient with longstanding HTN and chest pain
radiating to the back (two words)
AORTIC DISSECTION
16 - Most likely diagnosis in an elderly patient
presenting with syncope and a murmur at the
right upper sternal border: Aortic STENOSIS
Can lead to chest pain, syncope, or heart failure.
19 - This class of antibiotics should be in your
treatment regimen for community-acquired
pneumonia to cover atypicals
MACROLIDES
21 - LVH in your older patient is most commonly
due to longstanding HYPERTENSION
22 - This treatment should not be delayed in
suspected cases of temporal arteritis
STEROIDS
24 - The appropriate next test in your elderly
patient with back pain and mediastinal
widening on chest x-ray: CT ANGIOGRAM
125
CrossWards™
13
H
E
M
G L OS
P
H
I
L
I
A
This Puzzle May Cause
Petechiae
M
I
C OOMB
R
O
R
D
C
E
Y
S I T I S
P
M
I
O C
P L
P
R
M
E
S
P
S
E
I NT R I NS
N
N
I
C ML
I
O K WO R M
U
L E B S T E I
D
U
HO
D
P E
N
P Y R UV A T E
M
126
P OR P H Y R I A
L
S
V
A
W
T
P
E E D S T E R NB E R G
L
O
E
T
OL Y C Y T H E M I A
M
A S MA P HA R E S I S
I
N
A C R OC Y T I C
E
K
L Y MP HOMA S
E
Y
L
I C
D
L
E
H
R
L E U K OS T A S I S
L
S
X
M
MY E L OMA
U
T
ME NOR R HA G I A
N
E
N
WA R F A R I N
B
Across:
Down:
2 - When urine is pink, this is what you
should think
PORPHYRIA
4 - Test used to detect autoimmune
hemolysis
COOMBS
8 - Classic abnormal cell of Hodgkin
disease
REED STERNBERG. “Owl’s eyes.”
10 - #15 down may be associated with
this inflammation of the tongue
GLOSSITIS
11 - Abnormally elevated hematocrit
POLYCYTHEMIA. May be a primary
condition or secondary to some other
process.
12 - Procedure used to remove excess
immunoglobulin
PLASMAPHARESIS
14 - MCV > 100 = MACROCYTIC anemia
Common causes are B12 deficiency
and folate deficiency.
16 - These malignancies are mostly of
B-cell origin
LYMPHOMAS
19 - Heparin inhibits the INTRINSIC
pathway
21 - Oncologic emergency in which blasts
occlude the microcirculation leading to
CNS symptoms or pulmonary edema
LEUKOSTASIS
24 - Philadelphia chromosome t(9,22) in
90% of patients with this (acronym)
CML. Chronic myelogenous leukemia.
25 - Lytic bone lesions and elevated
monoclonal proteins
MYELOMA
26 - #1 down cause of microcytic anemia
worldwide, common name (Hint: It
really sucks!)
HOOKWORM
27 - Common cause of iron deficiency in
younger women
MENORRHAGIA
28 - Fluctuating fevers in Hodgkin disease
PEL EBSTEIN
29 - Vitamin K inhibitor (and rat poison)
WARFARIN
30 - Deficiency of this enzyme can cause
hemolytic anemia: PYRUVATE kinase
1 - Iron deficiency anemia and thalassemia are two of the MICROCYTIC
anemias
Others are sideroblastosis and anemia
of chronic disease (which can also be
normocytic).
3 - Petechiae suggest bleeding disorder
due to PLATELET dysfunction
5 - Most common inherited bleeding
disorder (acronym)
VWD. von Willebrand disease.
6 - Antidote for heparin
PROTAMINE
7 - Factor VIII deficiency: HEMOPHILIA A
9 - Can be used to treat mild hemophilia
or vWD
DESMOPRESSIN. It promotes release
of vWF (in addition to reducing urine
production).
13 - Anemia associated with autosplenectomy (two words)
SICKLE CELL
15 - Lack of intrinsic factor: PERNICIOUS
anemia
17 - Chemotherapeutic drug used to
prevent frequency of sickle cell crises
HYDROXYUREA
18 - Most common childhood malignancy
(acronym)
ALL. Acute lymphocytic leukemia.
20 - Renal failure, low platelets, hemolytic
anemia (acronym)
HUS. Hemolytic uremic syndrome;
most cases caused by E. coli O157:H7.
22 - BCR-ABL tyrosine kinase inhibitor
IMATINIB. Treatment for CML.
23 - Primary site of iron absorption
DUODENUM
127
CrossWards™
14
A Borderline Puzzle
O
B
S
P A S S I V E
C
S
H
S
I
H I
Z
V
O
E
T
C
Y
O
P
M
A
P
L
U
L
S
I
V
E
128
OR D E
A G G R
S T R I
A R A N
V
O
C H I Z
D
A
N
T
A
R L I N E
T
D
E S S I V E
S
P
O E
ON I C
N
I
D
N A
E
A
L
N
R
T
C
O I D
S
S
O I D
S
T
I
C
Across:
Down:
3 - Cluster B: Unstable, impulsive, vulnerable to abandonment, splitter
BORDERLINE
5 - Cluster C: Noncompliant, procrastinator (two words)
PASSIVE AGGRESSIVE
7 - Cluster B: Overemotional and dramatic
HISTRIONIC
9 - Cluster A: Mistrustful, hostile, suspicious, conspiracy theorist
PARANOID
11 - Cluster A: Purposefully socially withdrawn, content living alone with no
friends
SCHIZOID
1 - Cluster C: The stubborn perfectionist
who likes all the soup cans lined up
perfectly (two words)
OBSESSIVE COMPULSIVE
2 - Cluster B: Cannot conform to societal
rules; criminal behavior
ANTISOCIAL
4 - Cluster C: Insecure, uncomfortable
with decision making or authority
DEPENDENT
6 - Cluster A: Odd behaviors and
thoughts but no psychosis
SCHIZOTYPAL
8 - Cluster B: Grandiose, overly sensitive
to criticism, shows little empathy
NARCISSISTIC
10 - Cluster C: Involuntarily withdrawn
and shy because fears rejection
AVOIDANT
129
CrossWards™
15
This Puzzle is Infectious
P
Y L A T E C Y C L A
S
Y
T
P E R F R I NG E
L
U
L
R
R
S T OS OMA
E
W S
L
F
E
P
L
E
O
A GA
T
K
V
L
R
E
A
V
S
D A R Y
O C
T
V
R
M
G I A R
E
A
B
R
P A P I L L OMA V I R U S
T
A
C
S
O
R
I
C D I F F I C I L E
O
A
L
MY C O
C
U
C
R A B I E S
I
R OT A V
A D E N
B
V
B
A
C
S C H I
T
C
R
H A
Z A NC
N
I
E C ON
R
E
130
S E
NS
S V
L A
OX
D I
B A
I R
B
E
Y
C T I A E
A
R
A
S
S A C K I E
T
T
N
A
I
I
P
N A
H O P
Y
M E
L
Y
S
O C
T
C T E R I A
O S
S
C
C
U S
S
Across:
Down:
2 - Cholera toxin causes severe watery
diarrhea by overactivating this
enzyme (two words)
ADENYLATE CYCLASE
6 - Its toxin leads to gas gangrene: Clostridium PERFRINGENS (species)
8 - Major cause of viral pneumonia in
infants (initials)
RSV. Respiratory syncytial virus.
9 - Fluke associated with bladder cancer
(genus)
SCHISTOSOMA
14 - Group B streptococcus is also known
as streptococcus AGALACTIAE
(species)
Can cause neonatal meningitis.
15 - Use this smear of a sample from an
unroofed vesicle to test for herpes
TZANCK. Tzanck goodness I do not
have herpes.
17 - A person with cough, fevers, night
sweats, and weight loss due to tuberculosis has this form
SECONDARY
18 - Hand-foot-and-mouth disease is
caused by _________ virus type A
COXSACKIE
21 - Protozoan genus that causes watery
diarrhea
GIARDIA. Other symptoms are excess
gas, nausea, and stomach cramps.
23 - Double-stranded circular DNA virus
that causes warts
PAPILLOMAVIRUS. HPV also has
strains that cause cervical cancer.
24 - Antibiotic-associated diarrhea is
usually caused by the toxin from this
organism (genus first letter and species)
CDIFFICILE
25 - Gram-positive and acid-fast (genus,
plural)
MYCOBACTERIA. Such as TB or MAC.
26 - Bats, raccoons, and skunks, oh my!
This CNS infection has high fatality rate
RABIES
27 - Major cause of infant diarrhea around
the world and winter daycare diarrhea in US
ROTAVIRUS
1 - A board question about cat bites
should make you think this organism
(genus)
PASTEURELLA. Always treat cat bites
of the hand.
3 - Responsible for classic mononucleosis
(initials)
EBV. Epstein-Barr virus.
4 - If your febrile patient returning from
South America has “black vomit” and
jaundice, think this virus (two words)
YELLOW FEVER. Aedes mosquito
transmits the flavivirus.
5 - Group A streptococcus are
BACITRACIN-sensitive
7 - Human herpesvirus (HHV)-6 causes
this infantile illness
ROSEOLA. Exanthema subitum;
begins with sudden high fever then
rash appears as fever breaks.
10 - Group A streptococcus are
BETA-hemolytic
11 - Primary syphilis presents with a
painless CHANCRE
12 - PARVOVIRUS B19 causes erythema
infectiosum (fifth disease)
13 - The organism that causes plague (two
words)
YERSINIA PESTIS
16 - Gram-positive rods in branching
filaments that resemble fungi and
form sulfur granules (genus)
ACTINOMYCES
17 - Gram-positive cocci in chains (genus)
STREPTOCOCCI
19 - Catalase positive gram-positive cocci
(genus)
STAPHYLOCOCCUS
20 - If you see trophozoites and schizonts
on a patient’s blood smear, think
MALARIA
22 - A spore forming gram-positive rod
genus (think bad fried rice)
BACILLUS
131
CrossWards™
16
The Heart of Pharmacology
L OOP
I
D I L T I A
O
C
C L ON
A
I
N
E
N I
I
T
R
A
A N
T
T
R
E
P OT A S S I
P
I
N
E
132
H
D
Y
T
O D
H E P A R
R
A
A
O M L
Z E M
I
A
B
N Z
I D I N E
I
N
N
B E
W
A
T R OP R U S
F
O
A
S T A T
R
I
G I OT E NS
N
I
I
V
A
UM E
C
D I G
N
E A D A
C
E
I N
C
L
NG I O
P
T H I
D
T A
O
G
A
R
S I D E
P
L
I NS
R
I N
N
OX I N
C H E
M
A
OU GH
N
E D E M
S
A Z I D
U
M
A
D
E
N
O
S
I
N
E
Across:
Down:
1 - Most common side effect of nitroglycerin
HEADACHE
6 - Binds to antithrombin III
HEPARIN
7 - Type of diuretics most useful for relief
of symptoms in CHF patients
LOOP. Such as furosemide.
8 - Nuisance side effect of ACEIs but not
ARBs
COUGH. Be aware that both can
cause hyperkalemia, and even
angioedema.
9 - A nondihydropyridine calcium
channel blocker
DILTIAZEM. Another is verapamil.
10 - ACEIs and ARBs can cause this reaction characterized by swelling of the
lips and tongue
ANGIOEDEMA. See #8 across.
12 - Centrally acting alpha2-agonist
CLONIDINE. Side effect is dry mouth
and can cause rebound hypertension.
13 - Type of diuretics that are first-line
option for hypertension
THIAZIDE. Hydrochlorothiazide and
chlorthalidone are examples.
14 - Mechanism of metoprolol: BETA
blocker
17 - Drug for hypertension emergency
that is metabolized to cyanide
NITROPRUSSIDE
19 - These inhibit HMG-CoA reductase
STATINS
21 - Losartan (and other “-sartans”) block
this receptor
ANGIOTENSIN. Technically
angiotensin-II AT1.
23 - Spironolactone is a POTASSIUMsparing diuretic
24 - Inhibits Na+/K+-ATPase resulting in
increased contractility
DIGOXIN. Used in heart failure and in
refractory afib.
1 - Direct arteriolar vasodilator that can
cause drug-induced lupus
HYDRALAZINE
2 - Lisinopril (and other “-prils”) inhibit
this (acronym)
ACE. Angiotensin-converting enzyme.
3 - Raises BP, increases renal blood flow
(at lower doses), and increases
contractility
DOPAMINE
4 - Dabigatran directly inhibits this
THROMBIN
5 - For torsades de pointes, give this
MAGNESIUM
7 - A class IB antiarrhythmic
LIDOCAINE. No longer given routinely
in post-MI patients (only because it
killed people!).
8 - Irreversibly binds P2Y12 ADP receptors thereby inhibiting platelets
CLOPIDOGREL
11 - Slows AV node conduction time by
interrupting AV nodal re-entry
pathways
ADENOSINE
15 - Inhibits vitamin K-dependent coagulation factor synthesis
WARFARIN. Monitor INR.
16 - Irreversibly inhibits cyclooxygenase
resulting in decreased thromboxane
A2 synthesis
ASPIRIN. The wonder drug.
17 - Major class of antianginal drugs
NITRATES. Men taking nitrates should
avoid sildenafil (Viagra) and similar
drugs because the combination can
cause an unsafe drop in blood pressure
(wow, I sound like a TV commercial).
18 - Epinephrine has (positive/negative)
inotropic effects on the heart
POSITIVE
20 - Antagonizes acetylcholine receptors
ATROPINE
22 - Increases HDL; side effect is flushing
NIACIN. But just increasing HDL with
niacin does not appear to improve
patient outcomes!
133
CrossWards™
17
L
E
N
G
T
H
T
A S P I
M
E
134
An Ounce of Prevention
F OB T
R
E
V A R
O T
S
M
E
E
C
L
N
H E P A T I T I
L
S
A
A A A
MA MM
M
I
Y
V
D
I
R I N
R
A
H
Y
P
E
R
T
E
N
S
I
O
N
P
N
B
G
S C
D
C
L
E
V
D A S H
D
A
T
M
I C L I N E
E
M F
T
E
L
P A P
O
Z
Q
O
U
L
I
R A M
N
M
E
I
D
R E E N I NG
Across:
Down:
2 - One of the screening tests for colon
cancer (acronym)
FOBT. Fecal occult blood test (yearly
starting age 50 years); there are RCTs
demonstrating its benefit.
4 - Virus implicated in cervical cancer
(acronym)
HPV. Human papilloma virus; there is
now a vaccine.
5 - Diet that may help lower BP or prevent hypertension (acronym)
DASH. Dietary Approach to Stop
Hypertension.
8 - One of the medications that may
help smokers quit
VARENICLINE. Getting smokers to
quit is one of the most important
things you can achieve as a physician.
10 - Screening test for cervical cancer
PAP
13 - Immunization offered in the neonatal
period
HEPATITIS B
15 - Men who have ever smoked 100
cigarettes should be screened once at
the age of 65 for this (acronym)
AAA. Abdominal aortic aneurysm; this
population bears 90% of the burden of
suffering from AAA.
16 - Screening test for breast cancer
MAMMOGRAM
17 - Recommend this to men for primary
prevention when global risk of coronary heart disease exceeds potential
harms of GI bleeding
ASPIRIN
18 - Secondary prevention
SCREENING. Remember that the
goal of screening is to help people live
longer or better lives, not just to find
things! See also #3 down.
1 - Bias in observational studies of
screening when the screened group
appears to live longer because survival time starts with diagnosis based
on screening test in one group and
diagnosis based on symptoms in the
unscreened group (two words)
LEAD TIME
3 - Screening is beneficial only when
TREATMENT given in the earlier,
asymptomatic stage is more helpful
than waiting until after disease is
detected following symptoms
4 - Screen patients with this diagnosis for
diabetes according to USPSTF
HYPERTENSION
6 - A medication used to prevent altitude
sickness
ACETAZOLAMIDE. It is a carbonic
anhydrase inhibitor.
7 - A medication used to prevent malaria
when traveling to endemic areas
MEFLOQUINE
9 - This drug can be offered to household members or other contacts of
patients who have influenza to try to
prevent spread
OSELTAMIVIR. You may know it as
Tamiflu.
11 - Bias in observational studies of
screening when the screened group
appears to live longer because disease
found by screening has a better prognosis (two words)
LENGTH TIME
12 - Younger, sexually active women should
be screened routinely for this STI
CHLAMYDIA. It is commonly asymptomatic; otherwise of course you
would not be screening.
14 - This test commonly used to screen
for prostate cancer is not recommended by the USPSTF (acronym)
PSA. Prostate-specific antigen.
19 - When counseling a patient about
upcoming travel, this organization’s
website is very helpful
CDC. Centers for Disease Control;
Google it.
135
CrossWards™
18
Puz-culoskeletal
S
C A
F
E
A NK Y L OS
C
E
C O
T
A
A
U
M
D
I
A
N
R H E U
O
Q
P
C R U C
H
I
E
ME N I
N
A
I NG S
N
U
R
S
E
M
A
I
D
S
G E N
G
P ON
U
A T O
A T E
C A L
S
136
O
S
T
R P A L T UNN E L
S
O
E
A
U
R
DMA R D S
T
O
P
H
G
L
R
P OND Y L I T I S
U
N T
I T A L
T
I
S
C
D Y L OL Y S I S
M
A
I D
P HA L E N
A
T
R
E
T
R
M
B OX E R S
N
C I A T I C A
Across:
Down:
3 - Most common peripheral neuropathy:
CARPAL TUNNEL syndrome
5 - Class of drugs for rheumatoid arthritis
(acronym)
DMARDS. Disease-modifying antirheumatic drugs.
7 - HLA-B27 found in majority of
patients with this (two words)
ANKYLOSING SPONDYLITIS
8 - CONGENITAL dislocation of the hip
may be detected by Barlow or Ortolani maneuvers
12 - Defect of the pars interarticularis of
the vertebra
SPONDYLOLYSIS. Break of the “Scottie dog’s neck” on x-ray; can lead to
spondylolisthesis.
14 - HLA-DR4 arthritis
RHEUMATOID. Tests that may be
positive include RF and anti-CCP.
15 - A test for #3 across asking the
patient to push flexed wrists together
to see if it produces numbness &
tingling
PHALEN. It is pretty much worthless.
16 - Positive anterior drawer of the knee
suggests an anterior CRUCIATE ligament tear
17 - Positive McMurray’s test suggests a
MENISCAL tear
18 - Fracture of fifth metacarpal neck is
also known as a BOXER’S fracture
19 - Low back pain with radiation down to
the foot
SCIATICA
1 - Common, noninflammatory, degenerative wearing out of articular
cartilage
OSTEOARTHRITIS
2 - Proximal femoral epiphysis separates
from the growth plate leading to
displacement of the femur (acronym)
SCFE. Slipped capital femoral
epiphysis.
4 - Deposition of calcium pyrophosphate
crystals in joints
PSEUDOGOUT
6 - Initial conservative treatment for
#3 across is a wrist
SPLINT
Injection is for more serious cases.
7 - Drug of choice for joint pain caused
by #1 down
ACETAMINOPHEN
8 - Back pain along with new onset
urinary incontinence suggests
CAUDA EQUINA syndrome
9 - Subluxation of radial head in a child
usually as a result of pulling up by the
hand: NURSEMAID’S elbow
10 - Deposition of uric acid crystals in
joints
GOUT
11 - Needs immediate fasciotomy:
COMPARTMENT syndrome
13 - Fracture of the growth plate:
SALTER–Harris
137
CrossWards™
19
R
E
S
P
I
E
R
M
A S P I
T
Y
O E
R
M
Y
A
S
T
R
E
M
P
Y
T
C
O O
C O P
O L
C
A
C
S
I
M
A
138
Catching My Breath
R
E
S
T
R A T
I
C
T
I
V
T
E
U
B
E
R
OC C
U
D
L
O
A S
I
S
C Y S T I C F I B
H
P
F
OB S T R U
A
A L B U T E
I ON
R
X
O
Y
M
P
G
P E R S I S
E
S
U
E N S I ON M
T
R ONC H I E C T
E
M R
L
B
A
I D I O I D O N
O L
S
M
I
U
A
S
D
T HMA
M A
T
F A I L U R E
R O S I S
C T
H
R O
R
A
C
T E
N
T
E
A S
I
S
I V E
L
C
O
R
N T
I
C
O
I S
T
E
A R D S
O M
F
I
A
R
D
L
C E
S
L
M
C
I
E
T
L
U
L
E M P HY S E MA
Across:
Down:
2 - Caused by abnormal sodium chloride
transport, most common due to mutation at delta-F508 (two words)
CYSTIC FIBROSIS
5 - FEV1 70% with residual volume of
130% of predicted indicates _________
lung disease
OBSTRUCTIVE. Like asthma (reversible)
or COPD (irreversible).
8 - Medication used to relax the airways
during acute bronchoconstriction
ALBUTEROL
9 - Infiltrate in the right middle lobe in
an elderly patient with swallowing
difficulty suggests ASPIRATION
pneumonitis
13 - A 12-year-old boy who wheezes three
times per week and has an FEV1 of 84%
has mild PERSISTENT asthma
15 - Your dyspneic patient with absent
breath sounds and deviated trachea has
a _________ pneumothorax
TENSION. Get your needle ready!
16 - Cycles of infection and inflammation in
the bronchi can lead to this permanent
fibrosis, remodeling, and dilation
BRONCHIECTASIS
20 - Pulmonary fungal infection endemic
to the Southwestern US; your typical
board examination patient with this will
hail from the San Joaquin Valley:
COCCIDIOIDO mycosis
21 - PaO2/FiO2 ratio <200 mm Hg with
bilateral pulmonary infiltrates
(acronym)
ARDS. Acute respiratory distress
syndrome.
23 - Destroyed airways with obstruction
(acronym)
COPD. Chronic bronchitis and
emphysema.
25 - Reversible airways obstruction
ASTHMA
26 - This enzyme (acronym) may be elevated
in patients with sarcoidosis
ACE. Angiotensin-converting enzyme.
27 - Your dyspneic patient with hypoxia and
hypercapnea and worsening mental
status has acute respiratory _________
FAILURE. Needs a ventilator.
28 - Alpha-1-antitrypsin deficiency is
another cause of EMPHYSEMA
1 - pH 7.25 with pCO2 that is elevated:
RESPIRATORY acidosis
2 - Suspect CHF in your dyspneic patient
with bilateral lower leg edema and an
S3 gallop (acronym)
3 - One of the inhaled anticholinergic drugs
used mainly for COPD
IPRATROPIUM. Tiotropium is another.
4 - Lungs are stiff with poor expansion
in patients with RESTRICTIVE lung
diseases
6 - Procedure for draining pleural effusion
THORACENTESIS. Pneumothorax is a
potential complication.
7 - Pus in the pleural space
EMPYEMA. Needs to be drained.
10 - Only treatment besides smoking cessation that lowers mortality in COPD
OXYGEN
11 - In addition to prn albuterol, the child in
#13 across should be on daily inhaled
CORTICOSTEROIDS
12 - Asbestosis increases risk for this
malignancy
MESOTHELIOMA
14 - Gram-positive cocci in chains (genus)
STREPTOCOCCI. Most common cause
of pneumonia.
15 - In patients actively infected, see “red
snappers” on acid-fast staining of
sputum
TUBERCULOSIS
17 - Suspect pulmonary _________ in your
dyspneic patient with pleuritic chest
pain and a recently swollen calf
EMBOLISM. Get a spiral CT or V/Q scan;
start heparin.
18 - Type of pleural effusion seen in CHF
TRANSUDATIVE
19 - Cold agglutinins may be seen in
patient with pneumonia caused by
MYCOPLASMA (genus only)
22 - Nonresectable lung cancer type (two
words)
SMALL CELL
24 - Palpable vibration of the chest while
the patient says “blue balloons”: Tactile
FREMITUS
139
CrossWards™
20
Are You Smarter than
a First-year?
P
S U R F A C T A
R
F A L C I
E
T
A
S T A P H Y L
O R
A
L
O P
I GM T U B
U A
E
M T A NG L
A
P OT A S S I UM
E
NT
F OR M
I
M T
I
O
OC OC
E
H
L
O
U L I N
E
D
E S
R
N I
A
S P E C I
140
V
B R OA D
E
G
T
U
I
S
C
C U S
L
O
C
Y
T
T
N E T Y
R
D I GOX I N
S
F I C I T Y
N
E
Across:
Down:
2 - Type II pneumocytes produce this
important stuff
SURFACTANT
4 - This “ligament” connects the uterus,
uterine tubes, and ovaries to the
pelvic side wall
BROAD
6 - Ligament that connects liver to the
anterior abdominal wall
FALCIFORM
9 - Catalase-positive, gram-positive cocci
(genus)
STAPHYLOCOCCUS
12 - First class of immunoglobulin produced upon antigenic exposure
IGM
13 - Microtubules are made up of dimers
of alpha- and beta-TUBULIN
14 - Pathologic finding in the hippocampus of patients with Alzheimer
disease: Neurofibrillary TANGLES
16 - What is the approximate pulse pressure of a patient with a diastolic BP
of 60 and MAP of 90?
NINETY
17 - Depolarization occurs when there is
an influx of this into the myocardial
cells
POTASSIUM
18 - Inhibits sodium–potassium ATPase
DIGOXIN
19 - For a diagnostic test, true negatives
divided by true negatives plus false
positives
SPECIFICITY
1 - These cells secrete gastric acid
PARIETAL
3 - Enlargement of the left atrium can
produce hoarseness, due to compression of a nerve that is a branch of the
VAGUS nerve
5 - Nonnucleated immature RBC formed
in bone marrow
RETICULOCYTE
7 - Cellular site of oxidative phosphorylation (plural)
MITOCHONDRIA
8 - Long-chain fatty acids form these
prior to passive diffusion
MICELLES
9 - Pork tapeworm species
SOLIUM
10 - Enzyme that catalyzes testosterone
to estrogen
AROMATASE
11 - Small molecule that can be antigenic
when attached to a carrier
HAPTEN
15 - The receptor for insulin is part of a
large family of TYROSINE kinase
receptors
141
CrossWards™
21
Not Just Little Adults
F
E P I
N
V S D
O
M
E
T
H
K A WA S A K I
A
M
C
C OX S A C K I
X
S
N
I
P
C
I
I
R
P Y L OR I C S T
L
N
I
N
142
G L O
E C K
O
N
J
B U S
G
E A
T
E
D
E NO
O
R S V
T
O
A L L OT
A
R
N
O
T T I T I S
A
E
N E C
O
N Y
L
E L S
A
R
T
I
P
C R OU P
E
F
R
I
T
B
U
R
S
O
S
S
I
I
S I S
Across:
Down:
2 - Most common cause of bronchiolitis
(acronym)
RSV. Respiratory syncytial virus.
3 - Overriding aorta, pulmonary stenosis,
RVH, and #8 across: Tetralogy of
FALLOT
5 - Drooling, “sniffing” position, high
fever, muffled voice
EPIGLOTTITIS
8 - Most common congenital heart
disease (acronym)
VSD. Ventricular septal defect.
9 - Severe intestinal problem mostly of
premature infants (acronym)
NEC. Necrotizing enterocolitis.
11 - Painless rectal bleeding in child under
2 years old, two times as common in
boys, 2 inches long, 2 feet from ileocecal valve: MECKEL’S diverticulum
Diagnose with a Meckel’s (nuclear) scan.
14 - Steeple sign
CROUP
15 - High fever, fingertips swollen/peeling,
tender cervical nodes, conjunctivitis:
KAWASAKI disease
See #19 down.
17 - When an injury does not seem to
make sense based on the history
given by a child’s caregiver, think of
this possibility
ABUSE
18 - Cause of hand-foot-and-mouth
disease
COXSACKIE A
20 - Nonbilious vomiting in a 2-week-old
baby boy (ok, and an olive-shaped
epigastric mass) suggest this (two
words)
PYLORIC STENOSIS
1 - Check for congenital dislocation of
the hip using ORTOLANI and Barlow
tests
4 - High fever with no other symptoms
for a few days, then a rash maculopapular rash appears: ROSEOLA
infantum
Also known as sixth disease, caused by
human herpesvirus 6.
6 - Medication given to neonate to try to
close a PDA (patent ductus arteriosus,
not a personal digital assistant!)
INDOMETHACIN
7 - Sexual development staging
TANNER
10 - Caused by mutation in chloride
channel gene (two words)
CYSTIC FIBROSIS
12 - Neonatal jaundice due to
CONJUGATED bilirubin is always
pathologic
13 - Cause of whooping cough (species)
PERTUSSIS
16 - Usual drug of choice for acute otitis
media
AMOXICILLIN
19 - Treatment of #15 across includes
IVIG and high-dose ASPIRIN
143
CrossWards™
22
Renal & Lytes
Meredith Gilliam
D
I
ME T A B
B
E
P OT A
R
E
O S
S
I
T
N
A
S
G
I
L
P Y
A
I
N D
D
U
I
S
N
S
H
144
R I C K E T S
H
L
OL I C
O W
C R E A T I N I
I
T
S
S S I UM D
E
O
E
R B C
N
I
P
A
R
Z
P T H
S OD I
R
O Y
X
D
E L ON E P H R I T I S
S
S
E
M
P
R
H
A D H
I
K
Y
L
R
A L D OS T E R
A
L
R
U
T WE L V E
O
B
O
M G
U
R
I
E
L
Y P E R MA GN E S E M I
H
Y
P
N E
R
C
A
L
C
E
UM
I
A
R
ON E
N
I
N
A
Across:
Down:
1 - A child with a syndrome causing
decreased reabsorption of phosphorus
in the kidney may develop this condition
RICKETS
5 - A low pH, low PCO2, and low bicarbonate are consistent with this type of
acidosis
METABOLIC. Use MUDPILES for the
differential diagnosis.
7 - This small molecule used in the estimation of GFR is freely filtered at glomeruli
and only moderately secreted by renal
tubules
CREATININE
9 - A patient being treated for diabetic
ketoacidosis with insulin should be
monitored for intracellular shift of this
electrolyte
POTASSIUM
10 - Patients with malignant hypertension
may have this type of casts on urine
microscopy (acronym)
RBC. Red blood cell.
12 - Elevated levels of this hormone lead to
hypercalcemia and hypophosphatemia
(acronym)
PTH. Parathyroid hormone.
14 - Secretion of atrial natriuretic peptide
in response to increased atrial pressure
results in increased filtration of this ion
in the kidney
SODIUM
16 - Likely diagnosis in a young woman with
dysuria, fever, and WBC casts in her
urine
PYELONEPHRITIS
18 - Low levels of this hormone results in
the excretion of free water (acronym)
ADH. Antidiuretic hormone.
20 - A patient with hypertension, hypokalemia, and metabolic alkalosis should
be evaluated for elevated levels of this
hormone
ALDOSTERONE
21 - The upper limit of the normal range of
an anion gap (spelled out)
TWELVE
22 - Decreased deep tendon reflexes and
decreased respirations are signs of this
electrolyte abnormality
HYPERMAGNESEMIA. One of the things
women on the labor floor being treated
for preeclampsia are monitored for.
2 - An anion gap is calculated as sodium
minus the sum of bicarbonate and
CHLORIDE
3 - Likely diagnosis in a thirsty patient with
hypernatremia and dilute urine (two
words)
DIABETES INSIPIDUS
4 - Renal stones, abdominal pain, and
psychiatric changes are associated with
this electrolyte abnormality
HYPERCALCEMIA. The famous “stones,
bones, moans, and groans.”
6 - The diagnosis of diabetes insipidus is
confirmed by a WATER deprivation test
Sounds cruel, doesn’t it?
8 - Toxicity from this tuberculosis drug
may result in an increased anion gap
metabolic acidosis
ISONIAZID
9 - PROSTAGLANDINS are responsible
for dilating the afferent arterioles of
glomeruli
Now think why NSAIDs can be
nephrotoxic.
11 - In healthy individuals, glucose is completely reabsorbed into the circulation
by this part of the nephron (two words)
PROXIMAL TUBULE
12 - A much feared complication of rapidly
correcting hyponatremia is myelinolysis
in this region of the brain
PONS. Central pontine myelinolysis.
13 - Peaked T waves on an EKG are indicative of this electrolyte disturbance
HYPERKALEMIA. Give calcium to protect the heart, then measures to lower
potassium.
15 - A high pH, low PCO2, and low bicarbonate are consistent with this type of
alkalosis
RESPIRATORY
17 - In Type 1 renal tubular acidosis, the
collecting tubule’s inability to excrete
this ion may result in hypokalemia and
calcium-containing renal stones
HYDROGEN
19 - This enzyme important to the maintenance of blood pressure is secreted by
juxtaglomerular cells in the kidney
RENIN
145
CrossWards™
23
P
R
E
G
N
A
N
MC
Y
146
Surgery Rounds
C
L
A
U
D
I
C
P A
T
I
O
B U R N
D U C
I
E
V
A
E
R
T OR
I
A
C
N
U
S
P I L L O
I
N
T
I
E Y S
P
A
M
T A L
A
L
S
O
R
T
R
S E P S I S
F
T
T
S I ON
R
I
B
M O
S
R
E
G T
O
S U R G E R Y
MA
E
A
N
D
N D
S
ME S OT H E L I OM
N
E
O
O
R
N
M
I
V A R I C OC E L E
C
A
N
C
E
R
Across:
Down:
3 - Most common type of breast cancer
DUCTAL
7 - Major postsplenectomy complication
SEPSIS
9 - Diagnosis for young man who has
sudden onset of pain in scrotum with
swelling and a “high-riding” testicle
TORSION. Call the urologist as blood
supply to the testicle is threatened.
14 - Major risk factor for SBO: Previous
abdominal SURGERY
Which causes adhesions.
15 - Bloody nipple discharge suggests
intraductal PAPILLOMA
17 - Pleural cancer linked to asbestos
exposure
MESOTHELIOMA
18 - Point of tenderness in appendicitis
MCBURNEY’S
19 - “Bag of worms” on testicular
examination
VARICOCELE. Usually needs no
treatment.
1 - One of the “P’s” of acute arterial
occlusion
PALLOR. Pain, pulselessness,
paresthesias are some others.
2 - Superficial infection of the breast
MASTITIS
3 - Elderly man with LLQ pain, nausea,
low-grade fever, mildly elevated
white blood cell count likely has
DIVERTICULITIS
4 - Marker used to follow colon cancer
after treatment (acronym)
CEA. Carcinoembryonic antigen.
5 - Calf muscle pain brought on by
walking
CLAUDICATION
6 - The “R” in ERCP
RETROGRADE. Endoscopic retrograde
cholangiopancreatography; it is a
mouthful.
8 - Most common cause of breast lump
in young women
FIBROADENOMA. It is benign.
10 - Criteria for estimating prognosis in
acute pancreatitis
RANSON. Note that lipase is not one
of the Ranson criteria.
11 - Young woman presenting with
abdominal/pelvic pain, always rule
out this
PREGNANCY
12 - Elderly man with history of atrial
fibrillation with acute onset abdominal pain out of proportion to examination: Acute MESENTERIC ischemia
Check a lactate.
13 - Trauma patient has tachypnea,
decreased breath sounds on one
side and deviated trachea: TENSION
pneumothorax
And get your needle ready again!
16 - Large bowel obstruction is due to
colon CANCER until proven otherwise
147
CrossWards™
24
Just for Fun—Movie Docs
B R U C E W I
D OC
R
Y
S
T
A
L
148
P A T
W
A
K
E
N
I
HA NN
O G
L L I S
L
Y
W
T OR
O
D
C H
E V I L
D
D
F
I B A L
E
A
M
T W I L I GH T
U
L
R
K I MB L E
P
N
H
E
L
Y
C R I C H T ON
S
O
M
I
R A C HNOP HOB I A
S
Across:
Down:
1 - Robin Williams played PATCH Adams
3 - Austin Powers’ nemesis: Dr. EVIL
He went to Evil Medical School.
5 - Silence of the Lambs: Dr. HANNIBAL
Lecter
6 - Plays a plastic surgeon turned mortician in Death Becomes Her
BRUCE WILLIS. Quite a different
character from his John McClane.
7 - Dr. Carlisle Cullen is featured in
this saga
TWILIGHT. (So my daughters tell me.)
8 - Harrison Ford played Dr. Richard
KIMBLE in The Fugitive
He was a vascular surgeon who had to
find the one-armed man who killed
his wife.
9 - William Hurt plays an arrogant surgeon who becomes a patient when
he is diagnosed with throat cancer in
this movie: The DOCTOR
12 - Jurassic Park was written by the late
Dr. Michael CRICHTON
Recently re-released in 3D.
13 - The town cared for by a doctor
played by Jeff Daniels becomes
infested in this movie
ARACHNOPHOBIA
2 - Robert De Niro’s character was
brought out of catatonia by L-dopa in
this 1990 movie
AWAKENINGS
3 - Played Dr. Dolittle
EDDIE MURPHY
4 - In this movie, five medical students
(one played by Kevin Bacon) conduct
secret experiments to try to explore
the afterlife
FLATLINERS. Do not try this at home.
5 - Michael J. Fox: Doc HOLLYWOOD
10 - Played a psychiatrist in Analyze This:
Billy CRYSTAL
11 - Classic Halloween movie doctor:
Dr. Sam LOOMIS
149
CrossWards™
25
M
A
T
S
I Got Rhythm . . .
L A E
I
I N F
L
T
V T A C H
F
F
O
I
B
V
A F I B
D E L
F
N
F L U T T E R
U
O
P WA
T
R
R
V T
S
Q
E
A N T E R I
QR S
D
E
S E P T A L
E
P
A
V F
K
B
UWA V E
D
T
V
S V T
A
C
H
150
Q M
E R I OR
L B B B
S
B
A
F I R S T
T
E
W
Z
R A E
T A
I
A
N
W
I
L
C
A
K
V E
E
E
B
A F
OR
C
B
H
B
B
I B
J
P
O
I B
N
T
Across:
1 - Wide P wave in II (acronym)
LEFT ATRIAL ENLARGEMENT. Often seen in chronic atrial
fibrillation.
5 - II, III, aVF wall
INFERIOR. Classically due to right coronary artery occlusion.
6 - Conduction abnormality characterized by wide QRS and
RSR’ in V5–V6 (acronym)
LEFT BUNDLE BRANCH BLOCK. A new LBBB is an
ST-elevation MI until proven otherwise.
8 - This tracing (short form)
Down:
2 - Inventor of the EKG
EINTHOVEN. Invented the EKG in 1903.
3 - Interval normally <0.10 s
QRS. As measured from the beginning of the Q to the end
of the S.
4 - This kind of AV block
6V(ENTRICULAR) TACH(YCARDIA). Note the wide QRS,
regular rate, suggesting organized ventricular activity.
9 - FIRST-degree block: Prolonged PR interval
11 - Large P wave amplitude in II or V1 may suggest this (acronym)
RIGHT ATRIAL ENLARGEMENT
12 - This tracing (short form)
78-
10 -
13 -
16 19 20 22 23 25 26 29 -
A(TRIAL) FIB(RILLATION). Note the narrow QRS that is
irregularly irregular, with coarse fibrillation waves in the
background.
The presence of this wave in the setting of a short PR is
characteristic of Wolff–Parkinson–White
DELTA. A slurred upstroke into the QRS, indicative of an
accessory pathway.
“Saw tooth” waves (short form)
A(TRIAL) FLUTTER. Atrial rate usually 300 with 2:1 block
giving a ventricular rate of 150.
Firing of the sinus node
P WAVE
Narrow complex regular tachycardia without P waves
(short form)
S(UPRA)V(ENTRICULAR) T(ACHYCARDIA)
Irregularly irregular rhythm with narrow QRS and no P
waves (short form)
A(TRIAL) FIB(RILLATION)
V1, V2 wall
ANTERIOR. Classically due to left anterior descending
artery occlusion.
Ventricular depolarization
QRS
V3, V4 wall
SEPTAL. Classically due to left anterior descending artery
occlusion.
This tracing (short form)
12 -
14 15 -
17 -
18 -
19 21 24 27 -
V(ENTRICULAR) FIB(RILLATION). Note the coarse,
irregular fibrillation waves that denote completely disorganized ventricular activity.
30 - Extra wave seen with low K
U WAVE. An upright, usually smaller wave following the T wave.
32 - This tracing (short form)
28 31 -
MOBITZ II. Note how half of the P waves are not
conducted (2:1 block), but the PR interval is constant
(differentiating from Mobitz I/Wenckebach).
I, aVL, V5, V6 wall
LATERAL. Classically due to circumflex artery occlusion.
QRS 0.10 to 0.12 and left axis deviation (acronym)
LEFT ANTERIOR FASCICULAR BLOCK
Fatal arrhythmia characterized by chaotic ventricular
activity (short form)
V(ENTRICULAR) FIB(RILLATION). Treated with
defibrillation.
Steadily prolonging PR intervals followed by a dropped
beat
WENCKEBACH. Aka Mobitz type I.
This tracing (short form)
A(TRIAL) FLUTTER. Note the narrow QRS that is regular, at a
rate of 150, with the classic “sawtooth” flutter waves at a rate
of 300, indicating a 2:1 conduction block.
Ventricular repolarization
T WAVE
“Wandering pacemaker” tachycardia (acronym)
MULTIFOCAL ATRIAL TACHYCARDIA. Multiple atrial
pacemakers are firing at different times, causing P waves of
various morphologies.
Prolonging the QT interval may be “dangereux”
TORSADES (DE POINTES). French for “twisting around a
point.” A fatal form of ventricular tachycardia, treated with
defibrillation and magnesium.
Elevation of this may be difficult to differentiate from ST
elevation
J POINT. It is the exact point where the QRS meets the ST
segment. It may be normally elevated in younger patients.
Interval normally 0.12 to 0.20 s
PR. As measured from the beginning of the P to the beginning of the first QRS deflection.
Interval normally <0.44 s
QT. As measured from the beginning of the Q to the end of
the T, must be corrected for rate.
Conduction abnormality characterized by wide QRS and
RSR’ in V1 (acronym)
RIGHT BUNDLE BRANCH BLOCK
First sign of hyperkalemia (plural)
PEAKED TS. Although not always seen, tall peaked T waves
are an early EKG manifestation of hyperkalemia.
QRS 0.10 to 0.12 and right axis deviation (acronym)
LEFT POSTERIOR FASCICULAR BLOCK
Wide complex regular tachycardia (short form)
V(ENTRICULAR) TACH(YCARDIA)
S(UPRA)V(ENTRICULAR) T(ACHYCARDIA). Note the narrow
QRS (which suggests a supraventricular origin) and absence
of P waves (which differentiates this from sinus tachycardia).
151
CrossWards™
26
Clinical Scramble
SPIDER
S P I
VEIN
V E I
D E R
ALCOHOLISM
A L C O H O L
JAUNDICE
J A U N D
I
C E
ASCITES
A S C
E
S
FIBROSIS
F I B R O S
I
ANSWER:
152
I
I
T
S
CIRRHOSIS
S M
N
Notes
153
CrossWards™
27
Birth of a Puzzle
Q
U
G E S T A T I ONA L
C
K
E
N
G
I
R
N
M
NA E G E L E S
V
L
T H I R D
A
T
S M
Y
M
A N
L
I
N
P R
E
A
F
L
N
V A R I A B L
T
G
E A R L Y
A
154
L
P A R I T
O
E
U T E R U S
I
F I R S T
N
I
F
O
H C
P L A C E N T A
R
R
N
L
E
OOT H
K
A
G
A
T
E M I A
L
I
S
D OWN
T
S
I
E S E N T A T I ON
R
S
S
E
OL A T E
N
E
Y
G
S H
S
Across:
Down:
2 - GESTATIONAL age: Time since the LMP
4 - The number of deliveries after 20 weeks
PARITY
5 - At 12 weeks of gestation, this organ is
palpable above the pubic symphysis
UTERUS
7 - Stages of labor: Onset of contractions to
complete cervical dilation
FIRST. Divided into latent and active phases,
which are defined by the rate of cervical
change (1 to 2 cm/hr in the active phase).
10 - NAEGELE’S rule: A method for determining the due date
LMP = 3 months + 7 days.
11 - This hormone should double every 48
hours during the early stages of pregnancy
(acronym)
HCG. Failure to do so may indicate a failed
pregnancy or ectopic pregnancy.
13 - #13 down is made by this organ
PLACENTA
15 - Stages of labor: Delivery of infant to
delivery of placenta
THIRD. Should be less than 30 minutes.
16 - #13 down causes relaxation of SMOOTH
muscle, which results in lower blood pressure, and GERD
17 - #11 across is analogous to TSH, causing
levels to decrease during pregnancy
(acronym)
Thyroid-stimulating hormone. Though
levels of free T3/T4 remain the same.
18 - A physiologic ANEMIA results from the
dilutional effect of increased plasma volume
The actual red cell mass should remain the
same.
20 - Decreased AFP, estriol, and increased
HCG and inhibin A is the pattern seen in
DOWN’S syndrome
These four markers make up the “quad
screen.” All four are decreased in trisomy
18. Elevated AFP may indicate neural tube
defects.
21 - Fetal PRESENTATION: Description of the
fetal part at the cervix
May be cephalic (vertex) or breech.
23 - Supplementation with this vitamin PRIOR
to conception is needed to prevent neural
tube defects
FOLATE. Usual requirement is 0.4 mg/day.
25 - VARIABLE deceleration: Caused by cord
compression
Have abrupt onset, often “V” shaped.
26 - EARLY deceleration: Caused by fetal head
compression.
Benign.
1 - This term for maternal awareness of fetal
movements, usually occurs around
18 weeks
QUICKENING
3 - Fetal LIE: Description of the long axis of
the fetus
May be longitudinal or transverse.
4 - Fetal POSITION: Description of the orientation of the presenting part relative to
maternal pelvis
In the cephalic presentation, the occiput
is the landmark, and position may be
described as “occiput anterior” for example.
6 - The number of pregnancies
GRAVITY
8 - Stages of labor: Second stage is from complete dilation to delivery of the INFANT
This is when the pushing happens. Longer in
primips and in patients with epidurals.
9 - Hyperpigmentation of the face
MELASMA
12 - CREATININE levels decrease by about
25% due to increase in GFR
A “normal” creatinine in pregnancy may
actually be abnormal.
13 - Many of the physiologic changes of pregnancy are mediated by this hormone
PROGESTERONE
14 - Increases in tidal volume are responsible
for the respiratory ALKALOSIS of pregnancy
The respiratory rate remains the same.
19 - Hyperpigmentation in the midline of the
abdomen (two words)
LINEA NIGRA
22 - This test of fetal well-being may be
deemed “reactive” if there are at least
two 15 × 15 accelerations in a 20-minute
period (acronym)
NST. Nonstress test. To be differentiated
from a CST, contraction stress test (rarely
performed anymore).
24 - LATE deceleration: Caused by fetal hypoxia
or placental insufficiency
An ominous sign.
155
CrossWards™
28
Labor Pains
E
N
D M
T OX O P
M L
R
E
A T ONY
T
R
T
R
D E S
G
I
I
T
N
M
I
U
A
S
R
G
S E I Z U R E
A
U
B
B
R
E
R
S HOU L D E R
O
L
E
G
A L C OH
A
H
G DM
156
B S
T
H
E
Y
B R U P T
O O
I
G
D E L I
S
Y
C
S H E E H
E
M
OL
I
L
A C
P
E C
F
K E E P
R
R
N E
I
V
I ON
I
N G A
E
H
V E R Y
I
P
T
E
A N R
B
E
L
M
E I
E
S
T O P I C
S
Across:
3 - Avoidance of cat feces is advised to pregnant women
to prevent this congenital infection (short form)
TOXO. Toxoplasma gondii may cause hydrocephalus,
chorioretinitis, and intracranial calcifications.
5 - Uterine ATONY is the most common cause of
postpartum hemorrhage
Bimanual massage, oxytocin, and methylergonovine
are possible treatments.
7 - A woman who develops mastitis should keep/stop
breast-feeding
KEEP. There is little risk to the infant, and stopping
breast-feeding will only lead to engorgement which
will further complicate the infection.
9 - In utero exposure is associated with clear cell
carcinoma of the cervix (acronym)
DES. Diethylstilbestrol. Although it has been off the
market since 1975, this medication that was once
used to prevent miscarriage continues to show up on
board examinations nearly 40 years later.
10 - Screening and treatment for this organism has
significantly reduced the rates of neonatal sepsis
(acronym)
GBS. Group B streptococcus.
14 - Premature separation of the placenta is known as
ABRUPTION
Risk factors include trauma, hypertension, cocaine
use. May result in shock and DIC may occur.
16 - Eclampsia is defined as a SEIZURE in a woman with
preeclampsia
19 - The definitive therapy for preeclampsia
DELIVERY
22 - SHOULDER dystocia: A feared complication that is
more likely in macrosomic infants of diabetic mothers
23 - A woman recovering from a postpartum hemorrhage who fails to lactate may have SHEEHAN
syndrome
Ischemia and necrosis of the pituitary.
25 - Exposure to this drug may cause a growthrestricted fetus with mental retardation and
characteristic facial features
ALCOHOL. The facial features are smooth philtrum,
short palpebral fissures, short nose, and thin upper lip.
26 - This class of blood pressure medication must be
avoided in pregnancy (acronym)
ACEI. ACE inhibitors. May cause fetal renal defects
and IUGR.
27 - A 1-hour glucose tolerance test may be used to
screen for this pregnancy complication (acronym)
GDM. A 50-gram glucose load is administered and
blood sugar checked in 1 hour. A 3-hour GTT is
needed to confirm the diagnosis.
28 - This diagnosis must be ruled out in any woman
of childbearing age with abdominal pain and/or
vaginal bleeding
ECTOPIC. A negative pregnancy test rules it out.
If the patient is pregnant and the location of the
pregnancy has not previously been determined, she
needs an ultrasound.
Down:
1 - The most common cause of fever in the postpartum period
ENDOMETRITIS. IV antibiotics should be administered.
2 - A MOLAR pregnancy may be diagnosed by a
“snowstorm” appearance on ultrasound
The women may present with hyperemesis gravidarum, or early onset preeclampsia.
4 - Preeclampsia is defined as elevated blood pressure
plus PROTEINURIA
6 - The presence of FERNING on microscopic examination of dried amniotic fluid suggests rupture of the
membranes
8 - Painless vaginal bleeding in the third trimester
should make you suspect a placenta PREVIA
The placenta covers the cervical os. Do NOT perform
a digital examination unless you know there is no
previa (i.e., by ultrasound).
11 - A woman in preterm labor at 30 weeks should
receive STEROIDS to promote fetal lung maturity
Indicated prior to 32 weeks, and often given in the
32- to 34-week window as well.
12 - Use of an insulin drip during labor may be necessary
to prevent this neonatal complication
HYPOGLYCEMIA. Usually only required for patients
who are controlled with insulin during the pregnancy.
13 - This drug has been shown to reduce progression
to eclampsia in women with severe preeclampsia
(short form)
MAG. Magnesium sulfate. Must monitor for toxicity
as high doses are required by continuous infusion.
15 - A woman at 12 weeks’ gestation with vaginal
bleeding and an open os has a/an INEVITABLE
abortion
If the os were closed, it would be “threatened.”
17 - A child with congenital deafness, cataracts, and
a patent ductus should raise suspicion for this
congenital infection
RUBELLA. Rubella immunity is assessed prenatally,
but nonimmune women should not receive MMR
until after delivery (it is a live vaccine).
18 - HYPEREMESIS gravidarum: A severe form of
“morning sickness”
And it can happen any time of day. Related to HCG
levels, it is more common in multiple gestations and
molar pregnancies.
20 - The most common malpresentation
BREECH
21 - Treatment with this immunoglobulin is indicated
for Rh-mothers
RHOGAM. Rh immunoglobulin. Given at 28 weeks
and at delivery to prevent isoimmunization, and any
other time there is significant bleeding in pregnancy
(i.e., miscarriage).
24 - A syndrome of severe preeclampsia characterized
by hemolysis, elevated LFTs, and thrombocytopenia
(acronym)
HELLP
157
CrossWards™
29
A pHuzzle
A C I D
S
V OM
N
I
D K A
E
Z
L
I
T
D
A
D
HY
E
L
T
C A R B O
O S I S
I T I NG
M
S K
P
A G
R
A
L
D
E N
H
Y L
D
E
C H
Y
P
E
U R
V
K E
N
T
I
L
A
T
T I
O
E N
R
P OV
E
R
S
E T H
P
G
B I
NA T
R
A
D
A
S
N L
I
ME T A B OL I C
A L K A L
O
D
Y
C
R
R
I
T
R
Y
U
A
H
M
T
E
ME T HA N
158
L OR I D E
H
E M I A
T ON E S
R T
L A T
B
E G L
O S I
OL
S
A
L
A
I ON
C
I
Y C OL
L
N
A
G
T
A
E
P
S
Across:
1 - The major measured anion in the serum
CHLORIDE
3 - This number tells you whether you have an
acidosis or alkalosis
PH
4 - pH < 7.35
ACIDOSIS
6 - One of the causes of anion gap acidosis, in a
patient with end-stage renal disease
UREMIA
7 - The most common cause of metabolic alkalosis
VOMITING. Caused by loss of H+ from the stomach.
8 - Byproduct of lipid metabolism, excreted in the
urine
KETONES
10 - One of the causes of anion gap acidosis, in a
patient with Type I DM (acronym)
DKA. Diabetic ketoacidosis. Insufficient insulin
causes cells to switch to fat as energy source,
producing ketoacids as a byproduct.
11 - A decrease in the anion gap may be observed in
the presence of unmeasured cations such as this
one possibly encountered on a patient in the
labor ward (short form)
MAG(NESIUM). Magnesium is often used at high
doses on labor and delivery to treat preeclampsia
and related conditions. It is a usually unmeasured
(though easily can be measured) cation that may
cause a false lowering of the anion gap.
12 - One of the causes of anion gap acidosis, in a
patient who has been NPO in the hospital for
several days (acronym)
SKA. Starvation ketoacidosis. A ketoacidosis
occurring by similar mechanism to diabetic ketoacidosis. However, in this case, there is insulin, but
no glucose (patient is starving).
14 - Another cause of nongap acidosis, a group of
disorders rather oddly numbered (acronym)
RTA. Renal tubular acidosis. There are three types:
Type 1, Type 2, and Type 4. Remember Type 4 is associated with hypoaldosteronism and hyperkalemia.
17 - The ultimate process responsible for all forms of
respiratory acidosis
HYPOVENTILATION. May be due to respiratory
failure from a primary cardiopulmonary process,
or due to CNS injury, drugs, neuromuscular
disease.
20 - One of the causes of anion gap acidosis, in an
accidental ingestion of antifreeze (two words)
ETHYLENE GLYCOL
21 - Buffer anion primarily responsible for acid/base
regulation
BICARBONATE
25 - Type of disorder present when the bicarbonate is
the primary abnormality
METABOLIC. Bicarbonate will be decreased
in metabolic acidosis, increased in metabolic
alkalosis.
26 - pH > 7.45
ALKALOSIS
27 - One of the causes of anion gap acidosis, perhaps
in a desperate alcoholic
METHANOL
Down:
2 - The ultimate process responsible for all forms of
respiratory alkalosis
HYPERVENTILATION. May be induced by hypoxia
from lung disease, anxiety, pain.
5 - One of the causes of anion gap acidosis, in a
patient being treated for tuberculosis
ISONIAZID
9 - One of the causes of anion gap acidosis, somewhat antiquated as the drug is no longer in use
PARALDEHYDE. No longer in use in the United
States, previously used as a hypnotic/sedative and
anticonvulsant. Another “P” for anion gap acidosis is
propylene glycol.
10 - Assessment of this value is key to detect the
presence of a combined metabolic acid–base
disturbance (Hint: It might sound like you are
repeating yourself)
DELTA-DELTA. Only to be done in the presence
of an anion gap acidosis, to detect an additional
nongap acidosis or alkalosis. There are confusing
formulae for this, but essentially if you have a pure
AG acidosis, the bicarbonate should decrease
by however much elevated the AG is (normal
bicarbonate = 24, normal AG = 12). So if the AG is
16 (up by 4), the bicarbonate should be 20 (down
by 4). If instead the bicarbonate is 18, then there
is more acidosis that you would predict based on
the AG alone (nongap metabolic acidosis). If the
bicarbonate is 22, then something is counteracting
the AG acidosis (i.e., a metabolic alkalosis).
13 - One of the causes of anion gap acidosis, in an
overdose patient
SALICYLATES
15 - The amount of unmeasured negatively charged
molecules in the serum
ANION GAP. These unmeasured anions, typically
organic acids, live in “the gap” and cause metabolic
acidosis.
16 - Type of disorder present when the pCO2 is the
primary abnormality
RESPIRATORY. pCO2 will be increased in
respiratory acidosis (CO2 is an acid after all), and
decreased in respiratory alkalosis.
18 - A physiologic respiratory alkalosis may be encountered in this state
PREGNANCY. Due to the mild tachypnea of
pregnancy, likely mediated by progesterone.
19 - Order this to find out the patient’s pH (acronym)
ABG. Arterial blood gas.
22 - The most common cause of nongap acidosis
DIARRHEA. Bicarbonate is lost via the gut at a rate
that exceeds the kidney’s ability to resorb.
23 - The first electrolyte in the anion gap calculation
SODIUM. Na – (Cl + HCO3) = anion gap
24 - One of the causes of anion gap acidosis, in a
septic patient
LACTATE. Lactic acidosis is seen in a large number
of clinical situations, including sepsis. Sometimes
categorized as Type A (due to impaired tissue oxygen delivery and ischemia) and Type B (in patients
with normal O2 delivery, such as due to metformin,
malignancy, ethanol).
159
CrossWards™
30
Onco-Logical
M
E
D OWN
L
E
A ML
C
S QU
N
A
T
O
A L L O P U R
M
M C
O
A L C OHOL
I
A F P
E
U
L
E
D I A P H R A GM L
N
I
I
V
B ON E MA
L
A P O P T O
S
T HY MU S
E
P
T
L
A
E
C
S
E
I MA T I N
L
A
P S A
I
S
160
S
N
A MOU S
C
I NOL
E
U
S
B
I
R R OW
P
S I S
Y
B V
I B
C
E
C L L
L
Across:
Down:
2 - ALL is seen with greater frequency in
this chromosomal disorder (DOWN’S
syndrome)
5 - Eosinophilic rods inside malignant cells are
seen in this leukemia (acronym)
AML. Acute myelogenous leukemia. These
are called “Auer rods.”
7 - Actinic keratosis is a precursor lesion to
SQUAMOUS cell carcinoma
8 - Co-administration of this drug prevents
hyperuricemia while on chemotherapy
ALLOPURINOL. Hyperuricemia may result
from tumor lysis syndrome.
9 - Hodgkin disease may be suspected in
patients who have pain in lymph nodes
after drinking ALCOHOL
This is a rare sign.
11 - This tumor marker may be useful for
screening for and following hepatocellular
carcinoma (acronym)
AFP. Alpha fetoprotein. May also be
elevated in certain germ cell tumors.
12 - This anatomic structure defines staging in
Hodgkin disease
DIAPHRAGM
15 - Biopsy of this tissue is often needed for
the diagnosis of leukemia (two words)
BONE MARROW. The procedure usually
involves insertion of a large needle into the
marrow cavity of the iliac crest.
16 - The gene product of #21 down suppresses
this cellular process
APOPTOSIS. The gene is called BCR–ABL
and expresses an abnormal tyrosine kinase.
17 - Myasthenia gravis may be associated with
malignancy of this organ
THYMUS. 10% to 15% of myasthenia
patients have an underlying thymoma.
20 - This common virus is thought to play
a role in certain forms of non-Hodgkin
lymphoma (acronym)
EBV. Epstein-Barr virus, most known for the
infectious mononucleosis syndrome. Burkitt
lymphoma is closely associated.
22 - This drug inhibits the BCR–ABL gene
product
IMATINIB. Brand name is Gleevec.
24 - This tumor marker may be useful for
screening for and following prostate cancer
(acronym)
PSA. Prostate-specific antigen. While specific
for the prostate, it is not specific for cancer.
25 - A 70-year-old is incidentally found to have
a WBC count of 110,000 and “smudge
cells” on the smear (acronym)
CLL. Chronic lymphocytic leukemia.
1 - Dysplastic nevus syndrome is associated
with increased risk of MELANOMA
3 - This lab abnormality commonly occurs
in patients on chemotherapy and places
them at risk of severe infection
NEUTROPENIA. Neutropenic fever is
a medical emergency. Broad-spectrum
antibiotics should be hung without delay.
4 - Abnormal B-cells in Hodgkin disease may
have a large bilobed NUCLEUS
This is the Reed-Sternberg cell with a
so-called “owl’s eye” appearance.
6 - Elevation of this electrolyte may be the
first clue in the diagnosis of multiple
myeloma
CALCIUM. Due to increased bone turnover.
8 - Treatment with all-trans retinoic acid may
be curative in the M3 type of this leukemia
(acronym)
AML. This type is also called acute promyelocytic leukemia.
10 - This tumor marker may be useful for
following colon cancer (acronym)
CEA. Carcinoembyronic antigen. It is not a
screening test.
11 - Most common leukemia in children
(acronym)
ALL. Acute lymphocytic leukemia. Vast
majority achieve complete remission.
13 - A patient with multiple purplish vascular
papules and plaques in the lower extremities is likely immunocompromised from
HIV (acronym)
Kaposi sarcoma is an AIDS-defining illness.
14 - A patient with a 1.5-cm cervical lymph
node that does not go down after 4 weeks
should have a BIOPSY
Any node >1 cm for more than 4 weeks
should be biopsied, though the vast majority will be benign.
15 - Patients with CML in this phase have
markedly shortened survival
BLAST. In this phase, the disease is more
similar to AML.
18 - The presence of distant METASTASIS defines
Stage IV malignancy in virtually all cancers
19 - Enlargement of this organ is a common
finding in many leukemias
SPLEEN
21 - The Philadelphia chromosome t(9,22) is most
associated with this malignancy (acronym)
CML. Chronic myelogenous leukemia. Cases
that are positive have better prognosis.
23 - This cell type is responsible for the majority of non-Hodgkin lymphomas
B CELL
161
CrossWards™
31
Clear to Auscultation?
S I NU S T A C H
A
U
V I R U S E S
E
P
U
B R ONC H I T I S
E
U
H
C H L A MY D I A
A R D S
O D
O
L
N D
H
T WA R F A R I N
H
R
E
M
P
M
O
P U R S E D
A
E
R
A
E
O R
N T
H OM A N S
E
B
C
H
X
T
P S E U D OM ON A S
H
S
X
A
C
P
M
Y
S
H
E
A
R I G H T L OWE R
R
B
E
L
T
E O S I NO P H I L S
U
N
N
S T E R O I D
OX Y G E N
S
G
I
A D E N O C A R C I N OM A
S
162
Across:
1 - The usual EKG finding in a PE (short form of
second word)
SINUS TACH. The “classic” S1Q3T3 pattern is rare.
2 - Most pneumonia in children is due to VIRUSES
RSV and influenza are exceedingly common.
4 - Chronic productive cough may clue you into a
diagnosis of chronic BRONCHITIS
Technically defined as >3 months per year for
more than 2 years.
6 - In addition to the usual causes of neonatal
sepsis, CHLAMYDIA (bug) should be considered in a neonate with pneumonia
8 - Your patient with urosepsis who suddenly
develops dyspnea and becomes hypoxic
despite oxygen administration may have this
complication (acronym)
ARDS. Adult respiratory distress syndrome.
Capillary leak causes widespread noncardiogenic pulmonary edema.
10 - A DVT or PE buys you at least 3 months of
therapy with WARFARIN
Goal INR 2 to 3. Newer oral anticoagulants are
likely to come into widespread clinical use.
13 - A patient with COPD may create their own
PEEP by exhaling against PURSED lips
This effectively narrows the airway, creating back
pressure (PEEP) which helps keep alveoli open.
15 - Your patient with calf pain on passive dorsiflexion of the ankle has a positive HOMAN’S sign
May suggest a DVT, though the usefulness of
this sign is debatable.
16 - Be sure to treat your patient with hospitalacquired pneumonia with antibiotics to cover
PSEUDOMONAS (bug)
Choices are aminoglycoside (gentamicin),
extended-spectrum cephalosporin or b-lactam
(e.g., cefixime, pip/tazo), or fluoroquinolone
(e.g., ciprofloxacin). Resistance rates are high
so may need double coverage.
19 - Aspiration pneumonia typically develops in
this lobe (two words)
RIGHT LOWER. Right middle is also common site.
21 - Churg-Strauss syndrome might be suspected
in an asthmatic patient with high levels of
this cell line
EOSINOPHILS. A granulomatous vasculitis
characterized by pulmonary symptoms,
eosinophilia, and rash.
22 - For a patient who is wheezing more than
twice a week, addition of an inhaled STEROID
is recommended
23 - Hypoxemia that is due to intrapulmonary
shunting will not respond to therapy with
OXYGEN
The perfused areas are not ventilated; therefore, the supplemental O2 does not reach the
capillaries.
24 - Lung cancer that is the least associated with
smoking
ADENOCARCINOMA
Down:
1 - A patient recovering from influenza who
suddenly worsens with high fevers and purulent sputum may be infected with this bug
(initial the genus)
S. AUREUS. Common in postviral pneumonias.
3 - A tall 18-year-old male who presents with
acute onset chest pain and shortness of
breath
PNEUMOTHORAX. Caused by spontaneous
bleb rupture.
5 - Bilateral HILAR adenopathy is the hallmark of
sarcoidosis
6 - Poisoning with this gas will cause a falsely
elevated pulse oximetry reading (acronym)
CO. Carbon monoxide.
7 - A patient with a pleural effusion from pneumonia would be expected to have relatively
high levels of LDH compared to serum
(acronym)
Effusion will be an exudate and the ratio should
be either >0.6 or >two-thirds the upper limit of
normal serum LDH (Light’s criteria).
8 - Unlike garden variety community-acquired
pneumonia, coverage of this class of bugs
should be considered when treating aspiration
pneumonia
ANAEROBES. Addition of clindamycin or
metronidazole may be appropriate.
9 - A normal D-DIMER may rule out DVT/PE if
your clinical suspicion is low
11 - Your patient with unilateral upper extremity
weakness and Horner syndrome may have a
PANCOAST tumor
Apical lung cancer that may invade the brachial
plexus and sympathetic chain.
12 - A METHACHOLINE challenge may be
administered to the suspected asthmatic with
normal PFTs
Promotes bronchospasm in the susceptible
patient. Many asthmatics have normal PFTs
when not in an exacerbation, unlike COPD.
13 - In addition to increasing the fraction of
inspired oxygen, this ventilator parameter
may be increased to improve oxygenation
(acronym)
PEEP. Positive end-expiratory pressure.
Prevents collapse of alveoli at the end of
exhalation improving gas exchange.
14 - “All that wheezes is not ASTHMA”
A useful axiom, though most of what wheezes
is asthma.
17 - This first line therapy for #3 down speeds
resolution
OXYGEN
18 - Occurring in outbreaks, this pulmonary
infection is making a comeback in part due to
decreasing rates of immunization
PERTUSSIS
20 - A solitary pulmonary nodule that is
unchanged for over 2 years is likely BENIGN
163
CrossWards™
32
Some Lovers Try . . .
This Puzzle
C
P
S T E NO S
S
A C H I L L E
X
I
L
L
A
R
Y
164
MC
L
A
V
F
I
A
F A S C
T S
N L
E
F
T H E
MR I
E
B
F
R
O S T E R I OR
L
H
O A
I S
R A D
I
S
U
E
S
P
T I B I A
I
C
L
O
S
T
E
I O
S
NA
R
S C
O
M
I A
P E N
F
E
T OM Y
U
R
R
C
A P HO I D
I
P
P
R
L
O
F
L NA
L
C
O
L
X
A
D
C
B U R S I T I S
P
N
Across:
1 - In addition to #23 across and the medial meniscus, this structure is often coinjured as part of the
“unhappy triad” (acronym)
MCL. Medial collateral ligament.
3 - Antibiotics are always indicated in this type of
fracture
OPEN. Infection risk is high.
6 - This gruesome intervention may be limb saving in
patients with a painful swollen limb and paresthesias, pulselessness, paralysis, and poikilothermia
FASCIOTOMY. The “P’s” of compartment
syndrome are well known. Poikilothermia is loss of
normal temperature regulation.
8 - A patient who develops hand pain and numbness
after holding the wrist in forced flexion for
60 seconds may have this (acronym)
CTS. Carpal tunnel syndrome. Compression of the
median nerve as it travels through the wrist. The
sign described is called Phalen sign.
10 - Atrophy of this group of muscles is a late sign of
#8 across
THENAR. The thenar muscles are innervated by the
median nerve. The hypothenars by the ulnar.
11 - What study should be ordered in a patient with
new onset back pain and urinary incontinence?
(acronym)
MRI. This may be a case of cauda equina syndrome, a neurosurgical emergency.
13 - Fracture of this bone should be suspected in a
patient with snuff box tenderness
SCAPHOID. Even if the x-ray is negative, treat presumptively for fracture. X-ray may take 2 weeks to
show fracture. Avascular necrosis is a complication.
15 - Most common type of hip dislocation
POSTERIOR. May occur when a knee hits the
dashboard.
17 - An old man with leg pain that gets better when
leaned forward or walking uphill: Spinal STENOSIS
This is called neurogenic claudication. Flexion of
the spine opens the spinal canal and relieves nerve
root compression.
19 - Your roommate was out drinking on Saturday
night and awoke on Sunday with a wrist drop. He
has injured the RADIAL nerve
Aka “Saturday night palsy.” The mechanism usually
involves passing out with the humerus in an awkward position compressing the radial nerve. Most
cases resolve in time.
20 - Your patient with an L5–S1 disc herniation may
have a diminished ACHILLES reflex
Herniation at that level typically affects the spinal
nerve root one level below.
22 - A person defending himself from an attack may
end up with a fracture of this bone
ULNA. A “nightstick” fracture, which may occur when
placing one’s arm in the path of a swung blunt object.
24 - The tubercle of this long bone may be painful in
growing boys
TIBIA. Known as Osgood–Schlatter syndrome. This
is benign and resolves spontaneously.
26 - Your patient with a large painful swollen mass on
their elbow may have olecranon BURSITIS
Often occurs with repetitive trauma. May be
infected, or not.
Down:
2 - Most commonly fractured long bone
CLAVICLE
3 - Radiographic new bone formation in a sunburst
pattern is a sign of this devastating tumor
OSTEOSARCOMA
4 - An obese adolescent male with knee pain and
limp may have epiphyseal displacement on this
bone
FEMUR. Slipped capital femoral epiphysis is
separation of the femoral head along the growth
plate. Often the pain is referred to the knee.
5 - A patient with a femur fracture suddenly develops SOB, rash, DIC, and cardiovascular collapse
(two words)
FAT EMBOLI
7 - Most common type of shoulder dislocation
ANTERIOR
9 - Mike Tyson presents with hand pain after a
match. He has fractured his FIFTH metacarpal
12 - A 15-year-old track athlete ruptures her Achilles tendon while being treated for a UTI with
CIPROFLOXACIN
Fluoroquinolones are known to cause tendon
rupture.
14 - A first born, female, newborn delivered in breech
presentation is at high risk for dysplasia of this
joint
HIP. Disease is known as developmental dysplasia
of the hip or congenital hip dysplasia. All newborns
are screened by physical examination maneuvers
at every well visit in the first year of life. Failure
to diagnose and treat results in early onset of
osteoarthritis and early disability.
16 - Falling on outstretched hand most likely results
in fracture of this bone
RADIUS
18 - Hormone level that should be checked in
#4 down
TSH. Thyroid-stimulating hormone. Hypothyroidism is an associated condition.
20 - The AXILLARY artery and nerve may be injured in
#7 down
21 - SEPTIC arthritis: Must be ruled out in any patient
with a red, hot joint
23 - What ligament is injured in a patient with excess
laxity on anterior translation of the tibia?
(acronym)
ACL. Anterior cruciate ligament. A positive anterior
drawer test is described.
25 - The finger joint most commonly involved in
osteoarthritis (acronym)
DIP. The PIP is more commonly affected in rheumatoid arthritis.
165
CrossWards™
33
S
A D
L
I
N P
E
K
A
166
Doc, I Think It’s My Hormones
P
R
O
P
Y
L
T
R
H
R E NA L I
I
O
U U
H
R
Y
A
P
C
O
I
G
G L
L
Y
C
E T OA C I
M
I
L
A NA P L A
C
I
T
S
I
P
C R E
A O
C
I NS U
D
OC T R
S
C E I NH I
S
A P I L L A R Y
OT A S S I UM
S C OR E
M
NS U F F I C I E NC Y
O N
N
I
N N
NT I T P O
G
M
D OP AM I NE
S
C
E
T
A R G I NE
O
T
H
L
C
F
I
L
C
O
M
T
A
U
R
A
D OS I S
S
M
Z
I
I
O
N
L
S T I C
E
S
K
B
HY P E R C A L C E M I A
T
I
T
N I N O
T
A
N
H B
E
I
L
L I N S
U O
M C
E OT I D E
K
E
B I T OR S
R
Across:
1 - Most common type of thyroid carcinoma
PAPILLARY. And a highly favorable prognosis.
Five-year survival >95%.
2 - A patient in diabetic ketoacidosis is always total
body deficient in this electrolyte (regardless of
serum level)
POTASSIUM. In fact these patients are usually
hyperkalemic due to intracellular shifts due to lack
of insulin and acidosis.
3 - Osteoporosis is defined by a T-SCORE of –2.5 or
lower on DEXA scanning
The T-score is the number of standard deviations
below the mean for a healthy young adult.
7 - Hyponatremia and hyperkalemia should always
prompt consideration of this life-threatening
problem
ADRENAL INSUFFICIENCY. Especially in a patient
on chronic exogenous steroids.
9 - Intermediate-acting insulin, usually dosed twice
daily
NPH. May also provide basal coverage, though not
technically peakless.
11 - Rarely checked, but often elevated antibody in
Hashimoto thyroiditis
ANTI-TPO. Thyroid peroxidase.
13 - Agonists to this neurotransmitter are first-line
therapy for prolactinoma
DOPAMINE. Bromocriptine for example.
16 - Long-acting insulin without a peak
GLARGINE. Used to provide basal insulin.
18 - Classically, only Type 1 diabetes mellitus presents
with this life-threatening disorder
KETOACIDOSIS. Insufficient insulin causes cells to
switch to fat as energy source, producing ketoacids
as a byproduct.
20 - Most aggressive and rapidly fatal thyroid carcinoma
ANAPLASTIC. Five-year survival rate is 5% to
10%.
25 - “Stones, bones, groans, and psychiatric overtones” may represent this electrolyte disturbance
HYPERCALCEMIA
27 - The first step in evaluation of suspected hyperaldosteronism is measurement of the plasma
RENIN: Aldosterone ratio
28 - Type 1 diabetics will always require therapy with
this at all stages of their disease
INSULIN. Unlike Type 2 diabetics who may remain
insulin independent for many years/life.
29 - This drug, more commonly used in variceal upper
GI bleeding, is also used to treat acromegaly
OCTREOTIDE. A somatostatin analog that lowers
portal venous pressure.
30 - Use of this drug class in diabetes has been shown
to decrease progression of nephropathy
ACE INHIBITORS. And is generally recommended
for secondary prevention of renal disease in
diabetics.
Down:
1 - Antithyroid drug preferred for treating hyperthyroidism in pregnancy
PROPYLTHIOURACIL
4 - This treatment is by far and away the most
important initial treatment for hypercalcemia
SALINE. By IV infusion.
5 - This test along with a thyroid scan can help differentiate Graves disease from thyroiditis (acronym)
RAIU. Radioactive iodine uptake. Elevated uptake
is indicative of a hypermetabolic gland (Graves)
whereas decreased uptake indicates gland
destruction (thyroiditis).
6 - Hemorrhagic necrosis of the adrenal gland may
occur after infection with this bacteria
MENINGOCOCCUS. Aka, Neisseria meningitidis.
8 - This syndrome should always be suspected in a
patient with hypertension and hypokalemia
CONN. Primary hyperaldosteronism.
10 - Adverse effect of nearly all antiglycemic agents
except metformin
HYPOGLYCEMIA
12 - Antithyroid drug preferred in absence of pregnancy
METHIMAZOLE
14 - In the absence of contraindications, this drug is
the absolute first-line therapy for Type 2 diabetes
METFORMIN
15 - The clinical finding of bitemporal hemianopsia
would prompt one to order MRI of this structure
SELLA. Tumors of the pituitary gland may encroach
upon the optic chiasm and cause this clinical
presentation.
17 - Presence of this antibody is highly specific for
Graves disease (acronym)
TSI. Thyroid-stimulating immunoglobulin.
Antibody binds to the TSH receptor, causing
unregulated production of thyroid hormone.
19 - Rare but serious side effect of metformin
LACTIC ACIDOSIS. A Type B lactic acidosis, where
there is no tissue ischemia.
21 - Fastest acting insulin
LISPRO. Used for prandial coverage.
22 - Best screening test for assessing thyroid function
(acronym)
TSH. Thyroid-stimulating hormone. A normal TSH
excludes thyroid dysfunction, regardless of T3 or
T4 levels.
23 - Insulin therapy in diabetic ketoacidosis is directed
at lowering (glucose/ketones)
KETONES. The primary problem in DKA is insulin
deficiency and the resultant acidosis that results
from using fats rather than glucose as an energy
source. Hyperglycemia is merely a sign of the
problem, but not the problem itself.
24 - A patient with positive urinary metanephrines
should never been given a drug from this class
alone
BETA-BLOCKER. Blockade of the beta receptors
in the periphery may lead to unopposed alpha
adrenergic activity and severe vasoconstriction
and hypertension. A similar effect may occur in a
patient with cocaine on board.
26 - Psychotropic drug often implicated in nephrogenic diabetes insipidus
LITHIUM
167
CrossWards™
34
This Puzzle is Giving Me Gas
Meredith Gilliam
N E U R
A D
G
D U
V
168
C
H
O
L
E
C
Y
S
T
O
K
I
N
I
N
D
E S I ON
I A D I N
S
H
A L C R E S T
S
V
T
E
R
I
M
X
H
E
I V E R T I C
S
P
O
F A L C I F
T
L
E R OT ON I
D
P
U
R
E NOC A R C
D M
T R E S I A
N D
A
E
L
V
I
A D
T
D E NA L A
L
L L OU S
I
N
E
C E R U L OP
P P I
H
E
P
R
Y
N
U L I T I S
O
C
OR M
I
I
O
N
U
A S T
I NOMA
N
C
T
H
E
A
R
L
N G A
A
A
S
L A S M I N
T
A
R
I
J E J UNUM
Across:
Down:
2 - Hirschsprung disease is caused by failure
of this embryologic population of cells to
migrate to the rectum (two words)
NEURAL CREST
4 - This class of drugs works by irreversibly
inhibiting H+/K+-ATPase in stomach cells
(acronym)
PPI. Proton pump inhibitor(s).
10 - Most likely diagnosis in an older patient
with LLQ pain, fever, and leukocytosis
DIVERTICULITIS
11 - Most likely cause of an acute bowel
obstruction in a patient who has had
multiple abdominal surgeries
ADHESION(S)
12 - This ligament attaching the liver to the
anterior abdominal wall is a derivative of
the fetal umbilical vein
FALCIFORM
13 - Autoantibodies against this glycoprotein
found in wheat are present in 80% of
patients with celiac disease
GLIADIN. Treatment is a gluten-free diet.
14 - The flushing, diarrhea, and right-sided
heart murmurs associated with carcinoid
tumors result from abnormal production
of SEROTONIN
Carcinoid tumors originate from endocrine
cells and are mostly found in the small
intestine.
15 - This liver enzyme may be disproportionately increased (relative to others) in
patients with alcoholic hepatitis (acronym)
AST. Aspartate transaminase. In alcoholic
hepatitis the ratio of AST to ALT is often >1.5.
17 - Glandular metaplasia in the distal esophagus may transform into this histological
type of carcinoma
ADENOCARCINOMA. This precursor
condition is Barrett esophagus.
20 - Bilious vomiting in a neonate and a “double
bubble” on abdominal imaging is concerning
for this congenital abnormality (two words)
DUODENAL ATRESIA. About a fourth
of infants with this or stenosis have Down
syndrome.
21 - Of the histological types of adenomatous
colon polyps, VILLOUS adenomas most
likely to become malignant
23 - Check the level of this protein in patients
with cirrhosis, corneal deposits, and parkinsonian symptoms
CERULOPLASMIN. Wilson disease.
24 - Pathology in this part of the gut may limit
the body’s absorption of folate
JEJUNUM
1 - An immunocompromised patient with
odynophagia and “volcano-like” ulcers in
his esophagus may be infected with this
pathogen (acronym)
HSV. Herpes simplex virus.
3 - Patients with severe liver failure may
present with this coarse hand tremor
ASTERIXIS. “Liver flap.”
5 - Autoimmune destruction of the stomach’s
parietal cells may result in this type of
anemia
PERNICIOUS
6 - Nearly all patients with duodenal ulcers
are infected with this organism (shorten
the genus to an initial)
H. PYLORI
7 - This prokinetic agent may relieve the
symptoms of gastroparesis by antagonizing dopamine receptors
METOCLOPRAMIDE
8 - A surgeon may insert a finger through the
epiploic foramen to compress the contents
of this ligament to control bleeding
HEPATODUODENAL
9 - This GI hormone secreted by I cells is
responsible for the pain that patients with
cholelithiasis may feel after eating a fatty
meal
CHOLECYSTOKININ. It causes gallbladder
contraction.
16 - An infant with painless rectal bleeding
may have a congenital anomaly resulting
from the persistence of this embryological
duct
VITELLINE
18 - This type of hemorrhoids are not painful
because they receive visceral innervation
INTERNAL
19 - A patient with progressive dysphagia and
a dilated esophagus with distal stenosis on
barium swallow most likely has this
condition
ACHALASIA. Lower esophageal sphincter
fails to relax due to loss of myenteric plexus.
22 - This GI hormone is oversecreted in
Zollinger-Ellison syndrome
GASTRIN
169
CrossWards™
35
BuzzWards
I NT U S S
A
T
R U B E L
E
M
I
C R
A
O
S
B C E
A
U S C E P T I ON
M
L A
Y
F
E
L
L
OU P
HOD
T
M
T
A C
R E U S
R
P
O
V
E
V A R I C E
N
A
O
R
D
G T
S
O
I
H
I
M
N R
C
NE U R O F I B R O
T
S
X
L
N E P H R OT I C
O
D
I
S
R
E
O
M
S
A
I P F
S
MU L
170
P
K
S
L
O M
E
R
Y
B
I
C
S
A
O
GK I NS
P
E
I
L
HA L A S I A
L
S
A
M
P D A
L L A
A
S
R
B
K
MP E T I GO
S
N
MA T O S I S
O O E
S
N B
I
S
O
S
R
R
H
T I F OR ME
I
C
Across:
Down:
1 - Currant jelly stools
INTUSSUSCEPTION. May be seen in
association with Henoch-Schönlein
purpura.
7 - Blueberry muffin rash
RUBELLA. Congenital rubella
specifically.
9 - Barking cough
CROUP. Caused by parainfluenza virus
very frequently (and many others).
Inspiratory stridor. Treat with steroids.
11 - Reed-Sternberg cells.
HODGKIN’S (lymphoma).
12 - Bird’s beak on swallow study
ACHALASIA. The esophageal stricture
may resemble a bird’s beak.
13 - Leftover rice
B. CEREUS. “Food poisoning from
rice?! You can’t B. cereus!”
16 - Machine-like murmur (acronym)
PDA. Patent ductus arteriosus. Closes
with NSAIDs.
18 - Dewdrop on a rose petal
VARICELLA
20 - Honey-crusted lesion
IMPETIGO. Caused by streptococcus
or staphylococcus most commonly.
Treat with topical agents first.
21 - Café-au-lait spots
NEUROFIBROMATOSIS. Type 1.
23 - Maltese cross casts in urine
(NEPHROTIC syndrome)
Due to the presence of cholesterol
esters.
25 - Honeycomb lung (acronym)
IPF. Idiopathic pulmonary fibrosis.
26 - Target lesions (erythema
MULTIFORME)
Often due to drugs, viruses.
2 - Doughy skin (electrolyte abnormality,
hyperNATREMIA)
3 - Silvery scale
PSORIASIS
4 - Currant jelly sputum
KLEBSIELLA. Often seen in alcoholics
who aspirate.
5 - Punched-out lesion on skull film
(multiple MYELOMA)
Monoclonal gammopathy and Bence
Jones protein in the urine.
6 - Cold agglutinins
MYCOPLASMA
8 - Sawtooth wave (acronym)
AFLUTTER. Atrial rate is 300, ventricular rate 150.
10 - Christmas tree rash (pityriasis
ROSEA)
Cause unknown, but probably viral.
Initial lesion is another buzzword, the
“herald patch.”
14 - Rose gardener
SPOROTHRIX. Caused by a rose thorn
puncture.
15 - Spaghetti and meatballs on KOH
preparation (pityriasis VERSICOLOR)
Due to Malassezia fungi.
16 - Cogwheel rigidity
PARKINSON’S
17 - Powder burns on laparoscopy
ENDOMETRIOSIS. May also see
“chocolate cysts.”
18 - Clue cell (bacterial VAGINOSIS)
Epithelial cells studded with bacteria.
19 - Shipyard worker
ASBESTOSIS
22 - Stuck on appearance (SEBORRHEIC
keratosis)
A benign papule common in older age.
May have “waxy” surface.
24 - Bat-wing appearance on chest x-ray
(pulmonary EDEMA)
Caused by the prominence of the
pulmonary vasculature.
171
CrossWards™
36
T A M
A
M S
E S T
N E
O C
P
T
A
O
U M
S
Y
E
172
A Trich Puzzle
F
I
B V
R
S
O
T R I C H
L
R
D
A
E
P C OS
C A ND
A
S
H
H
R
ME T F O R M I
P ON
R
C
E
S
U P P E R OU T E
C
E
L
R
R OG E N
S
T A MO X
P
T
R
Y
E ND OME T R I
S
H
T
A
A MMO G R A M
G
O
S Y P H I L
G
I
A
L I V E R
D
N
H P V
R
E
G
N
I D A
N
N C
Y
R
I F E N
OS I S
V
A U R A
R
S
I S
C
A
I
N
T
E
S
Across:
2 - Gray discharge, high pH, clue cells (acronym)
BV. Bacterial vaginosis. Overgrowth of
Gardnerella vaginalis.
3 - This virus is responsible for the vast majority of
cervical cancer (acronym)
HPV. Human papillomavirus. Subtypes 16 and
18 are particularly high risk and account for 70%
of cervical cancers.
6 - Motile organism seen on saline wet mount of
vaginal secretions is pathognomonic for TRICH
(short form)
Trichomonas vaginalis, a flagellated protozoan.
8 - What is the diagnosis in a woman who
presents with amenorrhea, acne, hirsutism, and
insulin resistance? (acronym)
PCOS. Polycystic ovarian syndrome. The diagnosis can be made clinically without ultrasound
or lab findings, though they may be obtained to
support the diagnosis.
9 - Budding yeast on a KOH preparation are
diagnostic for this organism
CANDIDA
11 - Treatment with this drug may restore fertility
to the patient in #8 across
METFORMIN. In addition to treating the insulin
resistance.
13 - Toxic shock syndrome commonly occurs in
women with a retained TAMPON
The syndrome is caused by preformed Staphylococcus aureus toxin. Patients appear septic, but
blood cultures are negative.
15 - The most common breast quadrant to encounter breast cancer (two words)
UPPER OUTER
17 - Hormonal contraceptive methods which
contain ESTROGEN increase the risk of thromboembolic disease
This includes combination OCPs, vaginal ring,
contraceptive patch.
18 - Treatment with this drug is indicated in estrogen receptor–positive breast cancers
TAMOXIFEN
19 - Your patient with cyclic abdominal pain and
nodularity on her uterosacral ligaments has
ENDOMETRIOSIS
21 - Woman with a history of migraine with AURA
should be advised against estrogen-containing
contraceptives
They are at increased risk of stroke.
23 - This test should be offered to woman over the
age of 50 for breast cancer screening
MAMMOGRAM. Some authorities recommend
age 40. Screening interval is every 1 to 2 years.
24 - A painless chancre followed in several weeks by
a maculopapular rash
SYPHILIS
26 - A patient with PID who develops RUQ pain
should make you suspect involvement of this
organ
LIVER. PID can cause a perihepatitis with
elevated LFTs. This is called Fitz–Hugh–Curtis
syndrome.
Down:
1 - Common uterine tumor that is hormonally
responsive
FIBROID. Aka leiomyoma. Almost always
benign, and may decrease in size after
menopause.
4 - Most common cause of secondary amenorrhea
PREGNANCY
5 - A woman who leaks urine when she coughs,
laughs, or sneezes has STRESS incontinence
Due to weak pelvic floor muscles. Kegel exercises often help and are first-line intervention.
7 - The only way to definitely diagnose #19 across
LAPAROSCOPY
9 - You might find a “CHOCOLATE cyst” on the
ovary of the patient in #19 across
Endometriomas, hemorrhagic endometrial
implants.
10 - Crops of vesicles that progress to painful
ulcerations
HERPES. HSV-2 causes most genital infections.
12 - Menstrual bleeding that is irregular in frequency
METRORRHAGIA. Menorrhagia is heavy or
prolonged bleeding.
14 - This prophylactic intervention is an option for
women with the BRCA-1 mutation
MASTECTOMY. If they are done with childbearing, may opt for bilateral oophorectomy as well.
16 - Absence of menses for at least 12 months
MENOPAUSE. Average age of onset is 51.
19 - Excess of this hormone is a risk factor for endometrial cancer
ESTROGEN. And thus women who are obese,
who had early menarche/late menopause, few
or no children are at increased risk.
20 - OCP use is protective against OVARIAN cancer
Suppression of ovulation is thought to be the
mechanism.
22 - A cause of increased abdominal girth in patient
with ovarian cancer
ASCITES. Usually indicates peritoneal
metastasis.
25 - Purulent cervical discharge and cervical motion
tenderness (acronym)
PID. Pelvic inflammatory disease. Often polymicrobial, gonorrhea or chlamydia, is implicated in
2/3 of cases.
173
CrossWards™
37
Widow Maker
H
W
B
P E R I C A R D
W
F
S
U
R
C
A
H T N
I
M
S MOK I NG
E
N T
P
R
T
A
I
L
C
S
T
E
N
O
S A U
I
S
174
S T R E P
M
Y P OV OL E M
K
D
I T I S
L
C
N
O
G
QWA
R
C
T
A B I
A
G
T
L E F T MA I
V
O
T A MP ON
S
P
T
I
R
C A R D I OG
I
C
N E U R O
S
R E U S
P
I
D M
B N P
A
I C
T
E
R
V E
M
I
A I
V
E
G
A D E
T
A
T
E N I C
O
G E N I C
N
Across:
1 - The genus most commonly implicated in
subacute endocarditis (short form)
STREP. Usually viridans streptococci,
enterococci.
2 - Levels of this peptide are virtually always
elevated in decompensated CHF (acronym)
BNP. B-type natriuretic peptide. And, thus, a
normal BNP value has a high negative predictive value.
3 - A hypotensive patient severe burns may be in
HYPOVOLEMIC shock
7 - Chest pain relieved by leaning forward may be
a clue to this diagnosis
PERICARDITIS. EKG will show diffuse ST elevations and PR depression.
10 - Prior myocardial infarct may be suggested by
the finding of this on EKG
Q WAVE. Acute and subacute MIs may have
Q waves as well, but often with concomitant
ST segment and T wave changes, that often
resolve over time.
11 - A widened pulse pressure may suggest this
valvular disease (acronym)
AI. Aortic insufficiency. A regurgitant aortic
valve causes a low diastolic blood pressure.
12 - Cardiac risk factor: Most prevalent of all
(acronym)
HTN. Hypertension is the most common
chronic disease in the United States.
13 - Perform this test to diagnose peripheral
vascular disease (acronym)
ABI. Ankle-brachial index. Performed by measuring the ratio of systolic blood pressure at the
ankle to the arm.
16 - Cardiac risk factor: Most potent of all
SMOKING. Smoking is the single greatest risk
factor for coronary disease. Quitting smoking
halves your risk.
17 - Occlusion of this coronary artery is often
fatal (two words)
LEFT MAIN. Earning its nickname, “the widow
maker.”
19 - Electrical alternans, a phenomenon where
every other QRS has a different morphology
and direction, may be a clue to this diagnosis
TAMPONADE. The finding is not sensitive, as
many cases of tamponade have normal EKGs.
22 - A hypotensive patient with elevated JVP and
pulmonary rales may be in CARDIOGENIC
shock
23 - A hypotensive patient who is bradycardic with
head trauma may be in NEUROGENIC shock
24 - The organism most commonly implicated in
acute endocarditis (initial the genus)
S. AUREUS
25 - Cardiac risk factor: Some consider it a “disease
equivalent”
DM. Diabetes mellitus (type I and II) is a potent
risk factor, and some consider it to be the
equivalent of having coronary artery disease.
Down:
1 - Most useful intervention in the treatment of
PVD is the cessation of SMOKING
2 - Duke major criteria (1 of 2)
BACTEREMIA. Must be sustained, and with an
organism known to cause endocarditis.
4 - Cardiac risk factor: Most easily treated
(acronym)
LDL. Elevations in LDL are associated with
increased cardiovascular risk and respond
extremely well to therapy with statins.
5 - The finding of a delta wave on EKG is suggestive of this syndrome (acronym)
WPW. Wolff-Parkinson-White. Accessory pathway that may cause paroxysmal tachycardia.
The delta wave is a “slurred upstroke” going
into the QRS.
6 - The triad of butt claudication, impotence,
and decreased femoral pulses may be due
to occlusion of the aorta near the
BIFURCATION
This is called Leriche syndrome.
8 - Harsh systolic murmur that radiates to the
carotids (acronym)
AS. Aortic stenosis. Often described as having a
crescendo–decrescendo quality.
9 - Turner syndrome may be associated with this
disease of the aorta
COARCTATION
13 - Cardiac risk factor: It is lower in men
AGE. Age over 45 in men, over 55 in women.
14 - A low-pitch diastolic murmur, loudest at the
apex, with an opening snap (two words)
MITRAL STENOSIS. Rheumatic fever is the
most common cause.
15 - Duke major criteria (2 of 2)
VEGETATION. Often must be visualized on
transesophageal echo.
16 - A hypotensive patient with fever, elevated
WBC with a left shift may be in SEPTIC shock
18 - A young woman with palpitations and
atypical chest pain may have this valvular
condition (acronym)
MVP. Mitral valve prolapse. Beta-blockers may
improve symptoms.
20 - The single most powerful drug you can
administer in acute coronary syndrome
ASPIRIN. Provides a 50% to 70% decrease in
death from MI.
21 - The valve most frequently infected in IV drug
abusers
TRICUSPID. Pulmonic valve involvement may
occur as well.
175
CrossWards™
38
Don’t Mess Around
with the Pancreas
C
H
O
L
ME
S
T
G E
H
R
E
O
A C A L
D
C
O
D I V
I
A
F
R
F
Y
C O L E C T
176
P A NC R E
N
E
M
I
I D A
N
C
S
L E NA
A
I
C O
D
R
R D
S C O R
H
M
N
C U L OU S
R
C
P
T
V
H E R N I A
Y
E
L
S T OOL
T
O
E R T I C U L
E
D
S
C
E
T
H
U
OMY
A S
L
I
D
I
N
G
L ON
I
P I ON
A
D
S
Y
E
N
O
P
H
A
G
I
A
A
N
G
I V
N
A
Across:
1 - The presentation of painless jaundice should
always worry you for cancer of this organ
PANCREAS
5 - A HIDA scan may be helpful for diagnosis
gallstone disease when ultrasound is nondiagnostic (acronym)
Hepatobiliary Iminodiacetic Acid scan. Radioactive tracer is taken up in the hepatocytes
and excreted in the bile, outlining the biliary
tree and gallbadder. Nonvisualization of the
gallbladder suggests an obstruction of the
cystic duct and acute cholecystitis.
8 - Dark sticky tarry stool
MELENA. Suggests bleeding proximal to the
ligament of Treitz.
9 - Iron deficiency anemia in an older man or
postmenopausal woman is COLON cancer
until proven otherwise
Screen with colonoscopy.
11 - Relatively common GI cause of chronic cough
(acronym)
GERD. Some patients may completely lack
typical heartburn symptoms.
12 - A sting from this arachnid may cause pancreatitis
SCORPION. Classic pimp question. You will
never see this.
16 - This unusual form of cholecystitis may occur
in debilitated patients or critically ill patients
ACALCULOUS. That is, there is no stone.
Occurs particularly in burn victims and patients
receiving parenteral nutrition.
19 - Most common cause of small bowel obstruction in children
HERNIA
20 - A test performed on this bodily substance is
the best way to determine the presence of
current H. pylori infection
STOOL. Serum testing detects antibodies
which only indicates exposure.
23 - Most common cause of lower GI bleeding in
older adults
DIVERTICULA. Usually sudden and painless
bright red bleeding. Can be life-threatening.
26 - This test should be ordered in any patient
diagnosed with esophageal candidiasis
HIV. The disease is rare in immunocompetent
patients.
27 - This operation may be curative for ulcerative
colitis
COLECTOMY. Crohn disease, on the other
hand, may recur after resection.
Down:
2 - Plummer-Vinson syndrome is the association
of esophageal webs and ANEMIA
Specifically, iron deficiency.
3 - Most common form of hiatal hernia
SLIDING. Symptomatic treatment is the only
intervention. The other type called a
paraesophageal hernia requires surgical
correction to prevent volvulus.
4 - Most common type of gallstone
CHOLESTEROL. The other type is a pigment
stone, usually associated with hemolytic
conditions.
6 - Use of this class of over-the-counter medication is a leading cause of peptic ulcer disease
(acronym)
NSAIDS. Nonsteroidal anti-inflammatory
drugs.
7 - Tumor marker associated with colon cancer
(acronym)
CEA. Carcinoembryonic antigen. Not useful
as a screening test, but may be used in disease
surveillance.
9 - “Skip lesions” are characteristic of this form of
IBD
CROHN’S. Lesions may occur in any portion of
the GI tract, but are often not continuous.
10 - The more specific test for acute pancreatitis
LIPASE. Amylase is sensitive, but not specific,
as many other conditions may elevate amylase.
13 - Pain with swallowing
ODYNOPHAGIA
14 - Most common location of pancreatic cancer
HEAD. Followed by body, and then tail.
15 - MURPHY’S sign: Arrest of inspiration during
deep palpation of the RUQ
High specificity for acute cholecystitis.
17 - Treatment with this drug may help the
symptoms of carcinoid syndrome
OCTREOTIDE
18 - This type of adenoma has the highest risk of
malignancy
VILLOUS
21 - Common cause of antibiotic-associated
diarrhea (short form)
C. DIFF. Clostridium difficile. Virtually any
antibiotic can cause it, but generally associated
with broad spectrum beta-lactams, clindamycin.
22 - A Krukenberg tumor is a metastasis of gastric
carcinoma to this organ
OVARY
24 - This part of the colon is always involved in
ulcerative colitis
RECTUM. May or may not be involved in Crohn
disease.
25 - The clinical presentation of esophageal spasm
is often indistinguishable from ANGINA
Diagnosis of esophageal spasm should
generally not be considered before a thorough
cardiac evaluation.
177
CrossWards™
39
D
S A
I
N
U
S
T
A
C
H E
I
178
Most Common . . .
A
D
H
B R E A S T
S
I
F I B R OA D E NOM
I
N
M
I A B E T E S
R
P R OS
L MON E L L A
A
I
P A P I
P
D
I
R
S
L
O
E
B
L
L
U
C A MP Y L OB A C
D
C
R
M C
O
E
A NT E
MOR R HA G E
I
O S
N
N
N V
HA S H I MOT
A
N P
M
S C H E M I C
Y
A
Y
L
O
D I V E R T I C U
I
A
H
T A T E
L
A
L L A R Y
T
T E R
R I O R
V
S
OS
C
D
A
E
P
C
H
O
O
L OS I S
I
D
Across:
Down:
2 - Cancer in women
BREAST
3 - Benign breast mass in younger
women
FIBROADENOMA. Frequently recur
even after excision.
5 - Cause of chronic kidney disease in
the United States
DIABETES
7 - Cancer in men
PROSTATE
9 - Cause of osteomyelitis in a sickle cell
patient
SALMONELLA
10 - Form of thyroid cancer
PAPILLARY. Excellent prognosis.
14 - Bacterial cause of infectious diarrhea
CAMPYLOBACTER. Though rarely
identified.
16 - Type of shoulder dislocation
ANTERIOR. Injury to axillary nerve
and artery is possible.
17 - Cause of maternal mortality
HEMORRHAGE (POSTPARTUM).
21 - Cause of hypothyroidism
HASHIMOTO’S. And probably the
most common autoimmune disease
overall.
23 - Form of stroke
ISCHEMIC
25 - Cause of acute lower GI bleeding in
adults
DIVERTICULOSIS. Usually painless
bleeding, large volume, bright red or
maroon blood.
1 - Cause of small bowel obstruction in
adults
ADHESIONS. Scarring from prior
surgeries usually.
3 - Benign tumor of female reproductive
system
FIBROID. Aka, leiomyoma. Often
decrease after menopause.
4 - Primary malignant bone tumor
(acronym)
MM. Multiple myeloma. Monoclonal
gammopathy, Bence Jones protein,
“punched-out” lesions on x-ray.
6 - Cause of death in diabetics (organ)
HEART
7 - Cause of abnormal nipple discharge
PAPILLOMA. Usually bloody
discharge.
8 - Childhood malignancy (acronym)
ALL. Acute lymphoblastic leukemia.
Overall, has a generally good prognosis.
9 - EKG finding in pulmonary embolism
(acronym)
SINUS TACH(YCARDIA). The S1Q3T3
pattern is actually rather uncommon.
11 - Pituitary tumor
PROLACTINOMA
12 - Cause of infection in burn patients
PSEUDOMONAS
13 - Skin cancer (acronym)
BCC. Basal cell carcinoma. Rarely
metastatic (<1%).
15 - Cause of secondary amenorrhea
PREGNANCY. Always obtain pregnancy
testing as a first step in the workup.
18 - Cause of bronchiolitis (acronym)
RSV. Respiratory syncytial virus.
Outbreaks in winter and spring.
19 - Congenital heart defect (acronym)
VSD. Ventricular septal defect. Most
close spontaneously.
20 - Fracture of a carpal bone
SCAPHOID. Tenderness at the anatomic snuffbox.
22 - Cause of peptic ulcer disease (short
form)
H. PYLORI. Along with NSAIDs,
alcohol, steroids, smoking.
24 - Organism causing UTI (short form)
E. COLI
179
CrossWards™
40
Clinical Scramble
COUGH
C O U G H
SPUTUM
S P U T U M
HEMOPTYSIS
H E M O P T Y S
I
S
FEVER
F E V E R
ACID
A C I
ANSWER:
180
D
FAST
F A S
T
TUBERCULOSIS
BACILLI
B A C
I
L
L
I
Notes
181
CrossWards™
41
BrainTeaser
P
A
R
K
O P T I
N
S
O
N
G B S
L
F I B R
O
B
L
A L Z
S
T
O
M
A C O
182
D O P A M
E
T
T A X I A
S
T
C C H I A
T
I
P
C
L
A MY O
S
OM A T O
A
H
P
I
H A
H E I M E
R
I
E
N
S
E
I
U S T I C
I N E
S M
W
E
T R O P H I
N
Y
S I S
D
C
B R O
K
O
E
C
R S
E
P
H
A
L
T U B
S
C
M
C A S
C
U
L
A
P R I O
T
R
I
P
T
A
N
S
E R OU S
Across:
Down:
1 - DOPAMINE agonists are treatment
for #3 down
4 - Problem in standing or walking
ATAXIA. You might have this if you
drink too much the night after your
Step 2 examination.
5 - Bitemporal hemianopia suggests a
lesion here (two words)
OPTIC CHIASM
8 - Acute demyelinating autoimmune
disorder causing ascending paralysis
(acronym)
GBS. Guillain-Barré syndrome; treat
with IVIG, plasmapheresis, and
supportive care.
9 - Loss of upper and lower motor neuron
functions: AMYOTROPHIC lateral
sclerosis
This is also known as Lou Gehrig
disease; cognitive function is usually
spared.
11 - Axillary freckling, café-au-lait
spots, and iris hamartomas:
NeuroFIBROMATOSIS
It is an autosomal dominant.
15 - Cannot express language: BROCA’S
aphasia
16 - Cholinesterase inhibitors are used to
try to slow progression of this disease
ALZHEIMER’S. We all know how sad
this disease can be for family members.
17 - Creutzfeldt-Jakob disease is due to
infection with a PRION
Watch out zombie apocalypse.
18 - Schwann cell tumor: ACOUSTIC
neuroma
Sometimes called a Schwannoma, a
rare cause of sensorineural hearing
loss.
19 - “Ash-leaf” hypopigmented lesions are
classic for TUBEROUS sclerosis
2 - Most brain tumors are METASTATIC
3 - Pill-rolling tremor and rigidity: Two
classic signs of this disease
PARKINSON’S
6 - Treatment for #8 across includes IVIG
and possibly this procedure
PLASMAPHERESIS
7 - Cannot understand language:
WERNICKE’S aphasia
8 - Most common primary brain tumor
in adults
GLIOBLASTOMA
10 - Patient who is “weird, wobbly, and
wet,” think normal pressure
HYDROCEPHALUS
Too much CSF.
12 - Give this to alcoholics to prevent
Wernicke encephalopathy
THIAMINE
13 - Painless loss of central vision mostly in
the elderly: MACULAR degeneration
Can be “dry” or “wet.”
14 - Class of drugs used to treat acute
migraines
TRIPTANS
183
CrossWards™
42
This Puzzle is Kidstuff
F
R
P A T HO L
G
I
E P
L
E
A
X
K
L E U
R
D OWN
I
P
C
H T
O E
T U R N
O U
T
S
H
E X C L
R
O
A
R
P
O
Y
N
A
R
Y
184
OG I
I G L
MOX
K E M
E R S
R
O
U S I
E
O
L
A
N
E
C
R
OT T I T
T
I C I L L
Z
I A
N
P
G C A T
M R
O V
I ND OM
G V
O
I
L
R
I
U
A
S T
ON
W
I
V OL V U
M
GA S T R
B
S
S
V
I
I
A
T
R
E
S
I
A
R
E
N
A
L
O
C R OU P
E
R
S
S E P T
U
N
S
M
S
ME C ON I
N
S
R A C T
R
C
I
T HA C I N
E
T
U
B U S E
S
S
A B I S MU
I
S
D
C
S
E
U S
P
T
S C H I S I
G O
A
N
A L
UM
O
R
A
X
E
L
L
A
S
S
Across:
Down:
3 - Barking cough and “steeple sign” on neck film
CROUP
5 - Hyperbilirubinemia in the first 24 hours of
life is always PATHOLOGIC
6 - Child “tripoding” with high fever, sore
throat, drooling, muffled voice, and stridor:
Think EPIGLOTTITIS
Do not upset the child and be prepared to
intubate.
7 - Atrial SEPTAL defect has a fixed, widely
split S2
8 - High-dose AMOXICILLIN is an empiric
antibiotic treatment for acute otitis media
(if not allergic)
Can use azithromycin if allergic.
11 - Most common childhood malignancy
LEUKEMIA
12 - Hirschsprung disease is suggested by failure
to pass MECONIUM within first 2 days of life
Baby’s first poop.
15 - Most common chromosomal disorder
and cause of mental retardation: DOWN
syndrome
Trisomy 21.
16 - The absence of a red reflex on the eye
examination of a newborn suggests congenital CATARACT
It can be tricky getting neonates to open
their eyes; try talking to them in your sweet
baby-talk voice and putting a gloved-pinky
finger in their mouth (which also allows you
to check the palate).
21 - This drug is given to help close a patent
ductus arteriosus
INDOMETHACIN. And if your baby patient
also happens to have gout, might help that
too!
22 - 45, XO: TURNER’S syndrome
23 - Suspect this if the history is discordant with
physical findings or if there is a delay in parent seeking medical care for a child
ABUSE. Remember that shaken baby
syndrome may present without any other
physical findings but baby can have subdural
hematoma and retinal hemorrhages; can
lead to brain damage.
25 - Misalignment of the eyes persisting beyond
3 months of age
STRABISMUS. Important to detect so intervention can prevent amblyopia.
28 - Transient tachypnea of the newborn is a
diagnosis of EXCLUSION
31 - Malrotation of the gut
VOLVULUS
32 - Congenital herniation of intestine through
abdominal wall near umbilicus not covered
by a sac
GASTROSCHISIS
1 - X-linked abnormality affecting the FMR1
gene: FRAGILE X syndrome
Another cause of mental retardation.
2 - Premature infants can develop
NECROTIZING enterocolitis
4 - Whooping cough
PERTUSSIS. It is making a comeback.
9 - Hypertonicity, lethargy, and seizures in a
newborn with unconjugated hyperbilirubinemia suggests permanent deposition in
the brain called
KERNICTERUS. Preventing this is the whole
reason we care about jaundice in newborns.
10 - First menstrual period
MENARCHE
13 - One of three most common causes of acute
otitis media (genus only)
MORAXELLA
14 - Erythema infectiosum (fifth disease) is due
to PARVOVIRUS B19
17 - Newborn has bilious emesis and a “doublebubble” sign on abdominal x-ray: Duodenal
ATRESIA
18 - Looks like a bruise but these “spots” are
birthmarks
MONGOLIAN. Important to document.
19 - First-line therapy for hyperbilirubinemia of
the newborn
PHOTOTHERAPY. Light them up.
20 - One piece of intestine “telescopes” into
another (not to be confused with a
“dreamy” Leonardo DiCaprio movie)
INTUSSUSCEPTION. Hardest thing about
this is spelling it.
24 - HHV-6 causes this infection that has
prodrome of high fever followed by diffuse
maculopapular rash
ROSEOLA
26 - Most common cause of hypertension in
children is RENAL parenchymal disease
27 - Advise parents that newborns should sleep
on their backs (i.e., supine) to decrease risk
of this (initials)
SIDS. Sudden infant death syndrome.
29 - Untreated Kawasaki disease can lead to
CORONARY aneurysms
30 - Embryonic renal tumor
WILM’S
32 - Most common cause of meningitis in newborns (initials)
GBS. Group B streptococcus.
33 - Most common cause of bronchiolitis
(initials)
RSV. Respiratory syncytial virus.
34 - Most common immunodeficiency: IGA
deficiency
185
CrossWards™
43
This Puzzle Might Cause
Extrapyramidal Symptoms
B
P
A
D Y S T
H S
D
R
B
I
Y
S C
P
R
C OMP U L
X
Y
186
M
I P O L
N T
T
O
E
R
R
E
S
B
T OU R
L
A N I C
G M
ON I A
R
A
A
P
L
H I Z O
T
H
S I ON
U
M
A R
G
U
I
L
B
E T T E S
Y
N
Z
O
D
I
R O L A C T I N
A
Z
R
P H R E N I A
E
P
C
I
Y
N C B T
E
L
S
I
E C T
Across:
Down:
2 - Patient who has had at least one
prior episode of major depression and
now is manic: BIPOLAR disorder
7 - Syndrome characterized by motor
and/or vocal tics
TOURETTE’S. The vocal tics may be
coprolalia.
8 - Intense episodes of fear with symptoms such as shortness of breath,
chest pain, shakiness, and sweating:
PANIC attacks
11 - Involuntary muscle spasms from
antipsychotic medication
DYSTONIA
13 - A side effect of some antipsychotics
is elevation of this hormone
PROLACTIN. Which can cause
galactorrhea.
18 - Patient with auditory hallucinations,
disorganized thoughts, and delusions
likely has SCHIZOPHRENIA
19 - Fear of germs leads to repeated
hand washing; hand washing is the
COMPULSION
The fear of germs is the obsession,
which is relieved (temporarily) by
hand washing.
20 - Kind of therapy used for #8 across
(acronym)
CBT. Cognitive behavioral therapy.
21 - Procedure reserved for refractory
depression (acronym)
ECT. Electroconvulsive therapy.
1 - Apraxia is inability to perform
MOTOR activities
3 - The “I” in SIGECAPS
INTEREST. Anhedonia is our fancy
medical term.
4 - The “G” in the CAGE questionnaire
GUILTY. Have you ever felt guilty
about your drinking?
5 - Abrasions on the knuckles, enlarged
parotid glands, erosion of teeth
enamel: All classic signs of BULIMIA
These signs result from using fist to
induce vomiting and the vomiting itself.
6 - GABA-ergic drugs used as anxiolytics
for short-term control
BENZODIAZEPINES. Such as lorazepam or clonazepam.
9 - Fear of being alone in public places:
AGORAphobia
Can result from panic disorder.
10 - A 10-year-old taking methylphenidate likely has this (acronym)
ADHD. Attention deficit hyperactivity
disorder.
12 - Class of medications used for longterm treatment of #8 across
(acronym)
SSRIS. Selective serotonin reuptake
inhibitors.
14 - A cause of PTSD in men as well as
women
RAPE
15 - Amitriptyline is a TRICYCLIC
antidepressant
Not used much anymore for treating
depression.
16 - “Caregiver” makes someone else
ill (e.g., a child) to get attention:
Munchausen BY PROXY
17 - Classic mood stabilizer for patients
with #2 across
LITHIUM
187
CrossWards™
44
Claiming the Inheritance
Y UO L K V XWV A C D P G T A U S Z J KH PWC R Q B S S E U
N A N G I S J Y P I N E U R O F I B R OMA T O S I S Z B D G L
L T G Y U H K H A Y Z Z Z B D I G X U Y I S I S C I U N F WW X
K C E Q T D O D R S WW V G B D G L E I X P N X Y S H O B X D Q
J E L U K I F D L U E R Z Y DN T L J B FQ R D C A X NUOH X
I F R I S Z T T Y S J F KH P A A A P R UY BDA C X L O JWC
G R F K C B B D X F R O A T Z G Y I K H N X WG L X W R K U N T
S E Q J B F Y M D D D S Z R E O S C V Y B A AMN C N L U CW B
G P P L WQ Y A C P W B F D Z I A H D W Y L F P N J R M R H M E
T MA T U Y H V X CMMOR E K C K X A A T L P F Q T U B F R W
U I F N K U A C O XW A Z X H U H S B C WB J L C J G M F O N I
L S HW P A C V A V X O K D E M S G T T B B Y B C H U R N Y J C
K I Z I K U J E V U H O X H A P WO J R T F K J L L F H J G F U
L S T L U Y Z U K S E B R G Y A S T O I R E P O T N V O G WQ S
M E C S C I I J V I X A DM A E I U L O C Y Q A J J H O VWZ Z
L N C OM B F NW S B D G A MG T R Z W FW O L A L M T Z S P Q
C E X N Z B F E NOU D G I P X X GU J DR F GG Y J S F O B S
A G F S QG B P S R X J A I QQ J A R N FW B Z X J I Q J S M Z
I OW X K Y A O X B T V J P H A T L V C O K I GW S N U F L G E
C E I Q T I R X A I QO S G E L GOH P B T D KO R CO S P B W
V T T E G I T XW FWN P B J P I A A NO I E R B H T T F E Z T
R S D G X D T W R C U I I M L Z I WN T A N E K C G I M T G O R
J OW Z H Q E S A I F Q S F L R U J D M T L S W L B A U Q Z I M
N B P N NO R A Z T L I WR P Q P T K L C R E F B Y C N P K P C
E D E J K E S G Y S I K V E E MV T S S FQ S E E ONVO L G Q
K QO Y V K Z S K Y P V CN Y H I WS C R C A L X H C E Y Y B V
V A S I I H Z NN CD QOZ OU C U X Y CR Z T B V Z J H X Y P
N HWM J R E P S I B O QM D M O U G A H T M I G D K K C P Y F
C C I D Z M E M Q WN H A U P R A K A D I Y V O F U G P U J T U
U O X N C K Y U F A X J E A E L K R O G WG W U O R F L Y P B P
F L S N W E L S N O M S P B U S Q N F I G K K Q R X R B Z WW G
L T V E AOV S E Y Z C U I HG J HQ A F I X A C Y HVU A I X
I W F T U K M U Y S L T F S B I T J I I N Y O N V NWM M O D W
A N P E V S Z J R X I Z X Q G Y Q O L E A S WH U H O X E X A E
S Z X D P A F T Z R K T D C OQ B K E T S C UO B J V V H Z V N
X E R OD E RMA P I GME N T O S A I YX V L Y L QN S F K P
T I Q Y X U U Z I A F QMR A U I E MMDX MU X S U NM B Y B
N I R F M P E N K T R WH I F H H O Y D L A Z R N U F U N F N T
N Q G R X H C R B N Q OWX S B G H P W Z I WH E P K G K E X N
P AMN D V Y P L I X T E F Q E T MK I RH F U Z V C E T QN U
188
Autosomal dominant
Autosomal recessive
Osteogenesis imperfecta
Bartter(’s)
Marfan’s
Cystic fibrosis
Neurofibromatosis
Gaucher’s
Noonan’s
Wilson’s
Tuberous sclerosis
Tay-Sachs
Xeroderma pigmentosa
Phenylketonuria
Galactosemia
189
CrossWards™
45
CN 2-12 Intact?
OC U L OM
V E S T I B U L
A
E
G V
U
E
S
N
H Y P
T
R
O
OP T I C
R
H
O L
A C C E
H A
L
R
F I V E
A
R
190
V A
B
D
U
C
E
N
S S
OL F A C T
A
C
I
OL F A C T O
P
L
R
OT OR
I
I
G
OC OC H L E A
M
V
I
G
E
N
OG L OS S A L
O T
L
GU S
I
S
B
OC U L OM
P
L
H O
A C C E S S
R
O
OR Y
C
N H
G
L
E
E
A
A B D U
L
R
OR Y
T
H
R Y
E
E
R
H
Y
P
OT OR
G
L
OR Y
S
S
A
L
C E NS
Across:
Down:
1-I
OLFACTORY
4 - Smell
OLFACTORY
6 - Eye movement, pupil constriction,
lens accommodation
OCULOMOTOR
7 - VIII
VESTIBULOCOCHLEAR
11 - XII
HYPOGLOSSAL
13 - Talking and monitoring aortic baroreceptors
VAGUS
16 - III
OCULOMOTOR
17 - II
OPTIC
19 - XI
ACCESSORY
20 - Shoulder shrugging
ACCESSORY
21 - Chewing, facial sensation (spell out
number)
FIVE
22 - VI
ABDUCENS
2 - VII
FACIAL
3 - Eyelid opening (spell out the number)
THREE
4 - Sight
OPTIC
5-V
TRIGEMINAL
7-X
VAGUS
8 - Eyelid closing (spell out the number)
SEVEN
9 - Hearing and balance
VESTIBULOCOCHLEAR
10 - IX
GLOSSOPHARYNGEAL
12 - French kissing
HYPOGLOSSAL
14 - Lateral rectus eye muscle
ABDUCENS
15 - Superior oblique eye muscle
TROCHLEAR
18 - IV
TROCHLEAR
191
CrossWards™
46
A
D R
A L
U
T
O
I
M
M
U
N
E
W
192
This Puzzle DeLivers
S
T
E
R
U T O I MMU
I
D
U G S
P
L
H
C OH OL
L
E
H E
R
B
A
S
O
T
A C E T
I
L
O
V
E
M
E
R
Y
C
O
O H B S A G
L
B
I
I L S ON
T
A
G
I
B
S
N E
E P C
P A T
B
A M I
L
V I
A
R
Y
H
B
C H
A
B
H
E
M
O
OC
H
R
NO
M
R A
T
O
S
I
S
O
B
E
P
L
H
M
I
L E S T A T I C
O
F
C
E A G
H C C
T
O E
T OX I N R
Y
D U
L L U L A R
L
I
I
O
V
A F P
H E N
L
L
R
A
S
M
I
OC K
N
A A G
Across:
4 - Liver injury pattern: High elevation of alkaline
phosphatase, bilirubin, inconsistent elevation
of aminotransferases
CHOLESTATIC. Suggestive of obstruction of
biliary flow.
5 - Antismooth muscle antibody associated with
this form of hepatitis
AUTOIMMUNE
7 - Presence of this antigen is a marker for infectivity in chronic hepatitis B
HBEAG. Hepatitis B “e” antigen.
8 - Malignancy most commonly caused by
chronic hepatitis C (acronym)
HCC. Hepatocellular carcinoma.
10 - Most common cause of abnormal transaminases
DRUGS
13 - Hepatitis virus responsible for majority of
chronic viral hepatitis (short form)
HEP C
14 - Cause of severe hepatitis (>1,000)
TOXIN. Aside from acetaminophen, numerous
other drugs and toxins may cause fulminant
liver failure.
15 - Liver injury pattern: AST:ALT = 2:1
ALCOHOL
16 - Liver injury pattern: Elevated aminotransferases, mild elevation of bilirubin, alkaline
phosphatase
HEPATOCELLULAR
19 - Serum marker elevated in #8 across (acronym)
AFP. Alpha fetoprotein. Elevation of this
marker in the setting of a liver mass and known
risk factors for HCC is virtually diagnostic.
Unlike most all other cancers, tissue diagnosis
is not pursued, partially owing to the high
bleeding risk.
20 - Cause of severe hepatitis (>1,000)
ACETAMINOPHEN. A common overdose,
treated with N-acetylcysteine.
21 - Cause of severe hepatitis (>1,000)
VIRAL. Usually hepatitis A, but also B or C, other
non-“hepatitis” viruses including EBV, CMV.
22 - Presence of this antigen indicates chronic
infection with hepatitis B
HBSAG. Hepatitis B surface antigen.
23 - Cause of severe hepatitis (>1,000), not
enough oxygen to the liver
SHOCK. Hypotension leading to hepatic
ischemia and infarct. Almost always seen in the
presence of other organ hypoperfusion (i.e.,
kidney).
24 - Name the disease: Young adult with liver
disease and neuropsychiatric symptoms
WILSON(’S)
25 - A SAAG greater than or equal to 1.1 suggests
portal hypertension (acronym)
Serum-ascites albumin gradient. Calculated by
subtracting the ascites albumin level from the
serum albumin level.
Down:
1 - This treatment may be indicated for severe
alcoholic hepatitis
STEROIDS. When the Maddrey’s discriminant
function is higher than 32.
2 - Presence of this antibody may be only clue
to recent hepatitis B infection during the
“window period”
HBCAB. Hepatitis B core antibody. HBsAg
peaks and becomes undetectable before
HBsAb is detectable. Thus, in this period, only
the HBcAb is detectable.
3 - AntiMITOCHONDRIAL antibody, associated
with #18 across
6 - Rising cause of cirrhosis, associated with
obesity and diabetes (two words)
FATTY LIVER. Nonalcoholic fatty liver disease
(NAFLD) may progress to nonalcoholic steatohepatitis (NASH).
7 - Name the disease: Bronze skin, diabetes,
increase iron saturation
HEMOCHROMATOSIS. Most common genetic
disorder in people of European descent.
9 - Found to be low in patients with #24 across
CERULOPLASMIN. The major copper-carrying
protein. Patients with Wilson disease have a
defect in copper metabolism which causes
copper to circulate free, unbound to ceruloplasmin. Unbound ceruloplasmin degrades
rapidly.
11 - GI disorder often concomitant with #17
down (two words)
ULCERATIVE COLITIS
12 - The treatment for #7 down
PHLEBOTOMY
15 - Cause of severe hepatitis (>1,000)
AUTOIMMUNE. Rare, but possible cause of
fulminant hepatitis.
17 - Primary SCLEROSING cholangitis: Disease
affecting mostly young men
“Beads on a string” appearance on ERCP.
18 - Primary BILIARY cirrhosis: Autoimmune cause
of cirrhosis affecting middle-aged women
22 - Presence of this antibody indicates prior
exposure to hepatitis B or vaccination
HBSAB. Hepatitis B surface antibody.
193
CrossWards™
47
I Need a Puzzle—Stat!
C A R B OX Y H E MOG L OB I N
D
E
F
I
B
R
I
L
L
A T R
T
I
O
N B
E
P
I
N
E
P
H
R
I
N
E T H
P H
A
O P I N
N
C
L
A
E
L I S T
C
S
I
U
M
A NG I OE D
194
V
F
I
R
T
E
A
E
M
A N T I
I
N
R
K
C
A NOL
R
Y S O S
N
E
A L
P
R
I
Y
N
E R
N
P
H
R
I
N
M
E MA
A G A L
G
F L
U
P S Y C
A
G
O
N
C
T I GM
S
C OHO
A
N
P
R
A L OX
T
A M
M
I
A G N E
E
P
M
A T R O P I N E
E
T
G
H
N
Y
UMA Z E N I L
N
E
HOT I C S
N
A
E
R
B
D
L
A F I B
U
D
O
E
I N E
V
N E
D
L
O R
A
S
S
N
OP I O I D
T
N O
R
ON E
N
O
L
I OD A R ON E
N
E
S I UM
Across:
1 - Measurement of this value is necessary to
diagnose carbon monoxide poisoning as the
pulse oximeter reading will be normal
CARBOXYHEMOGLOBIN. The pulse oximeter
cannot distinguish oxyhemoglobin from carboxyhemoglobin. Hence the oximeter will often
read 99% to 100%.
5 - Use of this drug is indicated for symptomatic
bradycardia
ATROPINE. Increases adrenergic tone to the
heart.
6 - Carotid massage, Valsalva, and cool pack to the
face are examples of VAGAL maneuvers
These may be useful to terminate an episode of
SVT.
9 - Name the antidote: Benzodiazepines
FLUMAZENIL
11 - The presence of muscle rigidity, hyperthermia,
and autonomic disability may be an adverse
effect of this class of medications
ANTIPSYCHOTICS. Known as neuroleptic
malignant syndrome, similar to malignant
hyperthermia. Dantrolene may be an effective
treatment for muscle rigidity.
14 - Name the antidote: Methanol
ETHANOL. Ethanol outcompetes methanol for
the alcohol dehydrogenase enzyme, preventing
further degradation of methanol to formaldehyde.
15 - Diltiazem slows conduction through the AV
node, which may improve rate control in a
stable patient with this tachyarrhythmia (short
form)
AFIB. Atrial fibrillation, with rapid ventricular
response.
17 - Name the antidote: Anticholinergics
PHYSOSTIGMINE. A cholinesterase inhibitor.
19 - Name the antidote: Organophosphate poisoning
ATROPINE. Organophosphates inhibit acetylcholinesterase, leading to unfettered acetylcholine buildup and a hyperparasympathetic state.
Atropine is an acetylcholine antagonist.
21 - Withdrawal syndrome: Tremor, tachycardia,
hypertension, agitation, hallucinations, seizures
ALCOHOL
24 - Withdrawal syndrome: Anxiety, nausea, diarrhea, abdominal cramping, mydriasis
OPIOID
25 - The presence of this lesion differentiates a
second-degree from first-degree burn
BLISTER
26 - Name the antidote: Opioids
NALOXONE
27 - Use of this antiarrhythmic should be considered for patients with refractory VT/VF arrest
AMIODARONE
28 - In addition to defibrillation, torsades de pointes
should be rapidly treated with MAGNESIUM
29 - ACE inhibitors may cause this rare but lifethreatening side effect
ANGIOEDEMA. Mediated by bradykinin.
Down:
2 - A female patient with abdominal pain is
PREGNANT until proven otherwise
3 - Name the antidote: Methemoglobin
METHYLENE BLUE
4 - In addition to antihistamines, this drug should
be given to all patients with anaphylaxis
EPINEPHRINE
6 - Name the antidote: Warfarin
VITAMIN K
7 - The presence of this finding, often seen on an
upright chest x-ray, is an immediate indication
for exploratory laparotomy
FREE AIR. An indication of a perforated viscus.
8 - Name the antidote: Beta-blocker
GLUCAGON. Increases cAMP in the myocardium.
10 - This intervention should be performed without
delay in patients with pulseless ventricular
tachycardia/fibrillation arrest, once rhythm is
identified
DEFIBRILLATION. Unsynchronized shock.
12 - For any unstable patient with a brady- or
tachyarrhythmia, the first intervention should
be CARDIOVERSION
Synchronized cardioversion for unstable patients
(i.e., hypotension, altered mental status).
13 - The use of epinephrine in a code is directed at
increasing CORONARY perfusion
15 - The use of this drug may be necessary to
terminate an episode of supraventricular
tachycardia
ADENOSINE. A complete nodal-blocking
agent. Resets the AV node, abating a nodal
re-entrant tachycardia.
16 - The most definitive noninvasive diagnostic test
for appendicitis
CT SCAN. With oral/IV contrast. Ultrasound may
be preferred in children due to concerns over
radiation exposure, but cannot always reliably
rule-out appendicitis.
17 - Third-degree burns are characterized by full
involvement of the dermis and are painless/
painful
PAINLESS. Destruction of nerve tissue leads to
painless burns.
18 - Name the antidote: Malignant hyperthermia
DANTROLENE
20 - The use of EPINEPHRINE is indicated in
patients with VT/VF pulseless arrest who do
not respond to defibrillation
22 - Name the antidote: Black widow spider
CALCIUM
23 - Name the antidote: Heparin
PROTAMINE
195
CrossWards™
48
Shock and Awe
W
S
E C R E A S E D
D
P
G
T
OT H E R M I A
C
K
D
C
A
R
HY P
D
A
I
S HOC
O
Y
E
F
G
P
M
D
I
E
D O P A M I N E
B U R N S
V
K
F
D
R
I
ON E GA T I V E
I
C
L
R
B
C
L
N I N E S
R
R
L
N M
I
E
A NA P HY L A C T I C
L
A
T
T
R
C
L
S
C A R D I A C
E
D I L T I A Z E M
O O
A
T
D
P
N
S
I
I
E
O
N
D
N
E
196
Across:
Down:
3 - Peripheral vascular resistance is
(increased/decreased) in #2 down
DECREASED
5 - Core body temperature <95°F or
35°C
HYPOTHERMIA
7 - A state of inadequate oxygenation to
tissues
SHOCK
11 - Inotropic drug useful if patient is
hypotensive
DOPAMINE
12 - Second leading cause of death in
children
BURNS
14 - Universal blood donor
O-NEGATIVE
15 - Rule of NINES for calculating burn
surface area in adults
17 - A bee sting may lead to
ANAPHYLACTIC shock
Epinephrine is key part of treatment.
18 - CARDIAC output is decreased in #4
down
19 - One of the drugs useful for atrial
fibrillation with rapid ventricular
response
DILTIAZEM
1 - The W in PCWP
WEDGE. Pulmonary capillary wedge
pressure.
2 - Bacteremia and low BP: SEPTIC shock
4 - An MI can lead to CARDIOGENIC
shock
6 - For patient unresponsive to
#17 down, use transcutaneous
PACEMAKER
8 - Blood loss shock
HYPOVOLEMIC
9 - Treat pulseless v-tach same as ventricular FIBRILLATION
Shock, shock, shock (i.e., defibrillate).
10 - First thing for ventricular fibrillation
DEFIBRILLATION. Shock, shock,
shock.
13 - PCWP is (increased/decreased) in
#2 down
DECREASED. Also decreased in hypovolemic shock.
16 - PCWP is (increased/decreased) in
#4 down
INCREASED
17 - A drug to push for symptomatic
bradycardia
ATROPINE
197
CrossWards™
49
Doc Says “I’ve got good
news and bad news”
H
O
D
G
K
I
P
N
B E L L S
L
E
B E H C E
S
T
E
I
N E E R
M
S
J
C
A
HA N S
I
E
L
W
L
A L
I
Y
N
L I G H T S
198
L E WY
E
R
N
C
I
H G C
A
R
K
R
A
E
C H V O S T
O E
T
S
T S
H
G OO
I
R
A L L E N
B
E
E
R
E N I E R E S
P
T
L
S
E L S
Y
P A NC
F
O
P OR T S
L
T
E
S T R A
Y
B OD Y
U
E B S
G
I
A
NO
U
C
H
E K S
R
S
M
D P A S
L
S
L
H OM
R
Y
H AWT
E
I
OA S T
S
U S S
T E I N S
G
R WA L K
A
W
F
A
A D I E S
L
A
L
K
O D
I
T U R E S
E
S
A N S
J
L
O
E
N
HOR N E
S
S
Across:
Down:
1 - Most common dementia associated with
Parkinson disease (two words)
LEWY BODY
5 - Congenital heart disease with downward
displacement of the tricuspid valve into
the right ventricle: EBSTEIN’S anomaly
Possible association with lithium in first
trimester.
9 - Cruise ship gastroenteritis: NORWALK
virus
Would ruin a vacation.
14 - Peripheral seventh nerve palsy
BELL’S
15 - Tapping over facial nerve elicits ipsilateral
facial muscle contraction: CHVOSTEK’S
sign
16 - Tonic pupil, larger than contralateral
unaffected pupil, with no neurologic
significance: ADIE’S pupil
17 - Aphthous ulcers, genital ulcerations, ocular
inflammation: BEHCET’S disease
21 - Glomerulonephritis and pulmonary disease
suggests GOODPASTURE’S syndrome
22 - Test used to demonstrate that ulnar artery
is functional (before doing an arterial line)
ALLEN’S
23 - Pain with forced dorsiflexion of the foot
supposedly an exam finding in patients
with DVT: HOMAN’S sign
But it is pretty much worthless.
25 - Forced flexion of the arm to overhead
position elicits pain in patients with shoulder impingement: NEER sign
26 - Hearing loss, vertigo, tinnitus: MENIERE’S
disease
May respond to diuretic.
30 - People under study behaving differently
describes the HAWTHORNE effect
31 - Stain used to detect eosinophils in the
urine
HANSEL’S
32 - Tumor associated with #18 down, an
apical lung cancer
PANCOAST
34 - Hereditary nephritis associated with
deafness and eye disorders: ALPORT’S
syndrome
35 - Allergic angiitis and granulomatosis in the
lungs associated with eosinophilia:
Churg-STRAUSS syndrome
36 - For distinguishing transudate from exudate
in pleural effusion, use these criteria
LIGHT’S. Published in 1972.
2 - Chronic thiamine deficiency in alcoholics
leading to ataxia, confusion, ophthalmoplegia: WERNICKE’S encephalopathy
3 - DUBIN-Johnson syndrome is autosomal
recessive condition of conjugated hyperbilirubinemia due to transport defect
4 - Disease classically associated with #12
down
HODGKIN’S
6 - Henoch-Schönlein purpura is due to the
deposition of immune complexes containing this (acronym)
IGA
7 - Most common lysosomal storage disease
GAUCHER’S. It is autosomal recessive.
8 - RUQ pain, jaundice, and fever:
CHARCOT’S triad
10 - Child with fever, mucosal inflammation,
cervical lymphadenitis, and desquamation
has KAWASAKI’S disease
11 - Autoimmune hyperthyroidism: GRAVE’S
disease
Very common.
12 - Periodic fever (hyphenated)
PEL-EBSTEIN
13 - VSD, pulmonic stenosis, anteriorly displaced aorta, right ventricular enlargement:
Tetralogy of FALLOT
18 - Ptosis, meiosis, anhidrosis: HORNER’S
syndrome
19 - A lot of vomiting may cause this small
tear near the gastroesophageal junction
(hyphenated)
MALLORY-WEISS
20 - Pericarditis after an acute myocardial
infarction: DRESSLER’S syndrome
21 - Mild unconjugated hyperbilirubinemia
affects up to 7% of the population:
GILBERT’S syndrome
24 - Set of criteria for diagnosing rheumatic
fever
JONES
27 - Treatment for helping dislodge the
otoliths in benign positional vertigo:
EPLEY maneuver
You can find videos of it on the internet.
28 - For determining cause of B12 deficiency:
SCHILLING test
29 - Nodules or macules in the palms or soles
that might be seen in patient with endocarditis: JANEWAY lesions
32 - TB in the spine: POTT’S disease
33 - Catheter with a balloon at the tip that
when inflated helps keep it in the bladder
FOLEY
199
CrossWards™
50
P
E
R
I
C
A
R
D
I
T
I
S
200
Step 2 Potpourri
G
L
N D OM E
M
E
R
L B U T E
L
O M
N
M E T R
P
H
R
C D I F F
T
I
S E M
T R
H I
R O
E G
ON
I C
I N
C E L L
E
F L UMA Z
I
A B R U P
C
A
P
X U D A T I
L
A L
L
A
S C H S P R
B
Y
T
E N I L
T I ON
D
E
V E
F
O
I
S
B
I
R
U NG S
I
O
L
P
L
H
A L OB L A S T I C
T
T
L
I D A Z OL E
I
O
N C
N U
O
R
S
I L E
I
M
S
I
OM A
Across:
Down:
1 - Blood in urine, pain in the side, and
a palpable flank mass: Renal CELL
carcinoma
2 - Give for an overdose of diazepam
FLUMAZENIL
3 - Painful bleeding in third trimester
with fetal distress: Placental
ABRUPTION
7 - Pleural fluid with a pleural: serum
protein of 0.8 and pleural: serum LDH
of 0.75: EXUDATIVE effusion
10 - A postmenopausal woman with
vaginal bleeding needs an
ENDOMETRIAL biopsy
11 - No ganglion cells in the colon:
HIRSCHSPRUNG’S disease
13 - B2 agonist for asthma
ALBUTEROL
14 - B12 deficiency anemia is
MEGALOBLASTIC
16 - Treatment for bacterial vaginosis
METRONIDAZOLE
18 - Pseudomembranous colitis is almost
always from this infection (use the
first letter of genus)
C. DIFFICILE
19 - A testicular cancer is most likely a
SEMINOMA
1 - Dermatitis herpetiformis: CELIAC
disease
4 - Most common thyroid cancer type
PAPILLARY
5 - Your patient in v-fib needs immediate
DEFIBRILLATION
Shock, shock, shock.
6 - Red cell casts in urine
GLOMERULONEPHRITIS
8 - “Photographic negative” of pulmonary edema on chest x-ray: Chronic
EOSINOPHILIC pneumonia
9 - Chest pain relieved by leaning forward; ECG with diffuse ST elevation
PERICARDITIS
12 - Panic disorder treatment (acronym)
CBT. Cognitive behavior therapy.
15 - Back pain worsened by standing and
walking, relieved by sitting: Spinal
STENOSIS
17 - The “U” in MUDPILES
UREMIA
201