25 y/o male bartender. For the past 3 days, he’s had SOB, dry cough, lots of exercise
intolerance. CXR shows complete whiteout of his lungs. He has to be intubated to maintain
oxygenation status. On 100% FiO2, he has PaO2 of 100, which is not great – should be in the
500s. What are you thinking about? ARDS. If they give you a COVID19 question on Step 2 CK,
it’s an ARDS question b/c it’s the final step. Remember that the COVID19 vaccine is an mRNA
vaccine.
ARDS:
- Very low oxygenation
- PaO2/FiO2 will be very low
- Whiteout lungs
- Biggest Risk factor? Sepsis
- Tx: vent, low tidal volumes and high PEEP (which are lung protective strategies). Make
them prone – lie them on bellies in ICU.
- Mortality rate of ARDS is 40% - that’s why so many people are dying of COVID-19.
19 y/o F. Over the last 4 months, she’s lost 10 lbs and has B sx – fever, ns, weight loss. She
has generalized cervical lymphadenopathy. Dx? Hodgkin’s lymphoma.
Hodgkin’s lymphoma:
- High yield biostats fact: bimodal distribution. This distribution is also works for slow vs.
fast drug acetylators and for osteosarcoma, what they would call “osteogenic sarcoma”.
- Good prognostic factors for Hodgkins?
- Young person > older person
- More lymphocytes you find  better prognosis
- Fewer Reed Sternberg cells  better prognosis
- CD15/CD30 positive. Common in young people
72 y/o M w/ urinary dribbling x6 mo. Physician starts pt on medication. What’s the most likely SE
profile of this med? This person has BPH  you can give an alpha1 blocker, which does not
only block receptors on bladder neck but also in blood vessels  vasodilation of BVs 
orthostatic hypotension.
- Most common SE of 1st line tx for BPH = orthostatic hypotension
Female pt was hospitalized 2 weeks ago for IV broad-spectrum abx for pyelonephritis therapy.
Now, she’s had a lot of gum bleeding, epistaxis and they ask what is the biggest risk factor for
this patient’s condition? Think of a Vitamin K deficiency b/c when you take abx, you’re knocking
out your GI flora that’s typically responsible for making Vitamin K.
- Biggest risk factor for Vitamin K deficiency in a hospitalized pt = broad-spectrum
antibiotics b/c you kill off the GI flora. Can make this an ICU question.
- In these questions, they typically give the pt a weird PMH that involves something like
taking warfarin, so it’s like “double dipping” b/c you have warfarin that inhibits Vitamin K
epoxide reductase  start off with a functional Vitamin K deficiency, then you add abx 
double hit  can’t gamma carboxylate factors 2, 7, 9 and 10 and protein C&S  clotting
factors don’t work.
What is the biggest risk factor for DIC? Sepsis. Bleeding time high, platelet count low, PT and
PTT high, and fibrin degredation products will be high as well. FDPs high, fibrinogen LOW.
- Causes of DIC?
- Amniotic fluid embolus for a woman about to deliver a baby, for instance if she’s
in an MVC around the time of delivery.
- Abortion (eg at weird)  somnolent, nonresponsive  DIC
- Intrauterine fetal demise: eg No fetal movements for the past 5 days, woman has
antiphospholipid syndrome, woman is becoming altered, somnolent, bleeding out
of her nose and ears  DIC. They sometimes make this an ethics question 
let’s say there’s intrauterine demise. NBSIM? Let the woman grieve for a couple
hours but not for too long b/c she’s at high risk for DIC  then dilation and
evacuation of fetus b/c otherwise the fetus will start releasing factors that will
trigger the coagulation cascades  lead to DIC.
Biggest risk factor for RCC? Smoking
Biggest risk factor for bladder cancer, aka transitional cell carcinoma of the bladder? Smoking
Pt is from Egypt and found to lose weight over the last 3 months, +ve blood in urine, and you
look at the patient’s bladder and you notice a lot of keratin pearls. What is the biggest risk factor
for this patient’s presentation? Schistosoma haematobium  relatively common cause of
SQUAMOUS CELL CARCINOMA of the bladder, *not* transitional cell carcinoma of the
bladder, b/c transitional cells under stress from S. haematobium will undergo metaplasia from
transitional epithelium  squamous epithelium  dysplasia  SCC with keratin pearls +/hypercalcemia 2/2 SCC production of PTHrP.
Learning point: for risk factors, look at the context of the exposure to figure out what the greatest
risk factor is for a certain patient’s condition. NBME has learned to test patient-specific risk
factors, so look at the chief complaint, PMH, etc for context.
Pt has smoked for 2 years and has RCC. 10 years ago this patient had a tumor extracted from
the cerebellum and it was calcified on imaging. What’s the biggest risk factor for RCC in this
patient? Von Hippel Lindau b/c patient had a hemangioblastoma. If you see calcifications in a
mass in the cerebellum on NBME, especially if the person has a high Hct, you want to think
about a hemangioblastoma b/c those tumors produce EPO  polycythemia. Smoking for 2
years is unlikely to give you cancer if you have a genetic predisposition to cancer.
Pt over the last 2 days has had very bad RUQ pain and massive ascites  acute ascites. I hope
you’re thinking about Budd Chiari syndrome, typically 2/2 a hepatic vein thrombosis.
- What’s the biggest risk factor for Budd Chiari syndrome on NBME exam? Polycythemia
vera
- If you don’t see polycythemia in the question stem, pts can be BCS from other things:
- Paroxysmal nocturnal hemoglobinuria - ____ (couldn’t hear) mutation  can’t
make GPI anchors  CD55 or CD59 aren’t on RBCs  MAC of C5-C9 will open
RBCs and cause a hemolytic anemia
-
-
Woman on OCPs  cause a person to have hypercoagulability, especially in pts
who smoke, so not recommended for F smokers > 35 y/o to take estrogencontaining contraceptives.
Nephrotic syndrome: acquired anti-thrombin III deficiency  pee out a bunch of
protein in the urine, including anti-thrombin III so you won’t be able to inhibit
factors X and II  BCS