Learn. Integrate. Apply. An Integrative Question-Based USMLE Resource USMLE Step 1 NBME Top Concepts Rahul Damania, MD DEDICATION To my students, mentors, and family. Without your support, insight, and guidance, our mission of inspiring the next generation of physicians would not be possible. Designed by: Ray Ann S. Sampil The United States Medical Licensing Examination (USMLE®) is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). None of the trademark holders are affiliated with HyGuru. In this edition, all images used are for the benefit of integrative student learning and for educational purposes only. No copyright claims are intended. The images are collated based on three publicly accessed resources: public domain, Creative common Attribution License (www.creativecommons.org/licenses/by/4.0/legal code), Creative Commons Attribution-Share Alike license, www.creativecommons.org/licenses/by-sa/4.0/legal code. uploaded by medbooksvn TABLE OF CONTENTS CHAPTER 1 | CARDIAC PHYSIOLOGY 1 Cardiac Cycle Isovolumetric Ventricular Contraction Rapid Ventricular Ejection Isovolumetric Ventricular Relaxation Ventricular Filling Atrial Systole Jugular Venous Tracing Pulsus Paradoxes Pressure Volume Loops Cardiac Action Potentials Answer Key 2 4 5 6 7 9 10 11 12 14 17 CHAPTER 2 | NBME TOP CONCEPTS: CARDIOLOGY 18 Digeorge Syndrome Branchial Pouch Derivatives Lipid Lowering Drugs Shock Thermoregulation S3,S4,HOCOM,DCM,Murmurs Vasculitis Post Mi Complications Answer Key 19 20 21 24 27 28 32 33 35 CHAPTER 3 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: INTRODUCTION 37 USMLE Test Taking Strategy Approach to Multimedia Questions Test Taking Strategy for Image Questions Top Images You Will Encounter on the USMLE Answer Key 38 39 40 52 CHAPTER 4 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: CARDIOLOGY 56 Murmurs & Maneuvers Right Heart Failure Vs. Left Heart Failure Transudative Vs. Exudative For The USMLE Mechanism Of Edema Turner Syndrome Rapid Review Genetic Heart Lesions & Cardiac Anomalies Genetic Conditions & Heart Lesions Pathophysiology Of Tetralogy Of Fallout Pathophysiology Of Tet Spells Endocarditis Microbiology Integration Infective Endocarditis On USMLE Rheumatic Fever Erythema Marginatam Answer Key 57 62 63 64 65 66 67 68 70 71 72 73 74 76 77 CHAPTER 5 | NBME TOP CONCEPTS: RESPIRATORY 79 A-A Gradient (Hypoxemia) Regional Circulation For The USMLE Physical Exam Mcqs (Resp) Restrictive Vs. Obstructive Disease Lung Tumors Acute Respiratory Distress Syndrome Answer Key 80 86 90 93 97 100 102 CHAPTER 6 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: RESPIRATORY 106 Overview Pneumothorax Pneumonia For The USMLE Clubbing Acute Respiratory Distress Syndrome Answer Key 107 110 114 120 121 123 CHAPTER 7 | NBME TOP CONCEPTS: ENDOCRINOLOGY 125 Hormone Signaling Thyroid Disorders Hypothyroid Hyperthyroid Pth And Calcium Men Syndromes Islet Cell Tumors Dka Vs. Hhs Diabetes Pharmacology Aldosterone Disorders Answer Key 126 129 131 133 135 138 140 141 144 145 146 CHAPTER 8 | NBME TOP CONCEPTS: GASTROENTEROLOGY 148 Esophageal Issues Acid Secretion In Stomach Approach To Abdominal Pain On The USMLE Hernias Meckel's Diverticulum Hirschsprung's Disease Inflammatory Bowel Disease Bile Acid Metabolism Hepatitis B Vesicular Steatosis Answer Key 149 153 155 157 158 160 161 164 165 166 167 CHAPTER 9 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: GASTROENTEROLOGY 169 Oral Pathology Esophageal Pathology Stomach Pathology Intestinal Pathology Answer Key 170 174 178 182 183 uploaded by medbooksvn CHAPTER 10 | NBME TOP CONCEPTS: HEMATOLOGY 185 Heme Synthesis CYP Inducers Lead Poisoning Approach To The Blood Smear Intro To Anemia Microcytic Anemia Acute Phase Reactants Summary Of Microcytic Macrocytic Anemia B12 Physiology Normocytic Anemia HUS/TTP Polycythemia Platelet Pathology Warfarin Vs. Heparin Multiple Myeloma Summary & Courses Answer Key 186 187 188 189 192 193 195 196 197 199 200 203 205 207 208 209 210 CHAPTER 11 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: HEMATOLOGY 213 Hematology Overview Peripheral Blood Smear RBC Inclusions Sickle Cell Disease Complications Of Asplenia Summary Of RBC Inclusions Mechanisms Of Extravascular RBC Hemolysis Mechanisms Of Intravascular RBC Hemolysis Normocytic Anemia Aplastic Anemia Cold And Warm AIHA Hus/TTP Cells Of The Immune System Causes Of Eosinophilia On USMLE Causes Of Plasma Cells On USMLE Causes Of Mast Cells On USMLE Answer Key 214 215 216 219 222 223 224 225 226 228 230 231 232 233 234 235 236 CHAPTER 12 | NBME TOP CONCEPTS: NEUROLOGY 238 Brain Hematomas Herniation Syndromes & Cerebral Physiology Cranial Nerve Path (1) Bell's Palsy Cranial Nerve Path Multiple Sclerosis Dementia Dopamine Pathways Trinucleotide Repeat Disorders Neurocutaneous Syndromes Brain Tumors Stroke Answer Key 239 243 246 249 250 251 252 254 255 256 259 261 263 CHAPTER 13 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: NEUROLOGY 266 Neuroanatomy Trinucleotide Repeat Disorders Pituitary Masses Thalamic Stroke Central Pontine Myelinolysis Internal Capsule And Lacunar Strokes Intracranial Tumours For The USMLE Multiple Sclerosis Cerebral Edema Intracranial Pressure Cerebral Autoregulation Baroreceptor Reflex Upper Motor Neuron Signs & Posturing Spinal Cord Pathologies Pseudotumor Cerebri Hydrocephalus CNS Infections Answer Key 267 268 269 270 271 272 274 275 276 277 278 279 281 282 285 286 288 289 CHAPTER 14 | NBME TOP CONCEPTS: RENAL 291 Renal Casts Kidney Stones Urea Cycle + Stones (Pt.2) Into To Nephritic/Nephrotic Nephrotic Syndorme Renal Failure Diuretics Answer Key 292 295 298 301 302 311 312 314 CHAPTER 15 | HIGH YIELD IMAGES & PE FOR THE USMLE STEP 1: RENAL 316 Renal Stones Polycystic Kidneys Nephrotic And Nephritic Syndromes Tumors Of The Urinary Tract Answer Key 317 322 328 337 339 CHAPTER 16 | NBME TOP CONCEPTS: REPRODUCTIVE 341 Disorders Of Sexual Development Turner's Syndrome Integration Testosterone Disorders Mullerian Agenesis Vs. Ais Summary Of Disorders Of Sexual Development Polycystic Ovarian Syndrome Ovarian Physiology Ovarian Tumors Repro Ligaments Uterine Disorders Cervical Disorders (HPV) Answer Key 342 345 347 348 350 351 354 356 360 361 366 367 uploaded by medbooksvn CHAPTER 17 | NBME TOP CONCEPTS: MUSCULOSKELETAL & RHEUMATOLOGY 370 NMJ Disorders Bullous Diseases Hemoptysis & Hematuria Skin Cancers (With Neural Crest) RA Vs. OA Seronegative Spondyloarthritis Lupus Anti Body Rapid Fire (USMLE) Answer Key 371 373 375 376 382 385 388 391 393 CHAPTER 18 | NBME TOP CONCEPTS: PSYCHIATRY 397 Mood Disorders Bipolar + Li Pharm Psychotic Disorders Eating Disorders Drugs Of Abuse (Toxicology) Answer Key 398 399 404 408 411 414 CHAPTER 19 | NBME TOP CONCEPTS: ONCOLOGY 418 Cardiac Oncology Endocrine Oncology Gastrointestinal Oncology Lymphoma & Vascular Tumors Renal Oncology Respiratory Oncology Neuro Oncology Breast Oncology Neoplasia (Get Path Integration) Answer Key 419 421 423 428 431 435 437 439 441 442 CHATER 20 | NBME TOP CONCEPTS: DERMATOLOGY 445 Approach To Urticaria Dermatology Nomenclature Plaques Viral & Bacterial Exanthems Rubella Measles Roseola Erythema Infectiosum Systematic Manifestations Of Herpes Varicella Infections On USMLE Erysipelas Vs. Cellulitis Staph And Strep Infections Nikolsky Sign Manifestations For The Usmle Neonatal Rashes Precursor Lesions To Neoplasia Summary Answer Key 446 448 450 451 453 454 455 456 458 459 461 462 463 464 465 466 CHAPTER 1 Cardiac Physiology for the USMLE 1 uploaded by medbooksvn Cardiac Cycle NBME Top Concepts ➤ Cardiac Physiology Dr. Carl Wiggers Dr. Carl Wiggers • Earliest Descriptions published in 1915 • A comprehensive approach on learning the electrical & mechanical activity of the heart. • Forms the basis for understanding Cardiac Physiology for the USMLE. Creative Commons Attribution License 4.0 Mastering the Cardiac Cycle Creative Commons Attribution License 4.0 STRATEGIES ON MASTERING THE CARDIAC CYCLE Active Recall of Events • Ask yourself ‘Where is the blood flow?’ • Isolate each curve in your mind understanding pressure and volume • Electrical activity of the heart precedes mechanical activity of the heart! Cardiac Physiology: Cardiac Cycle 2 NBME Top Concepts ➤ Cardiac Physiology Cardiac Cycle Major Events and Curves of the Cardiac Cycle Creative Commons Attribution License 4.0 Cardiac Physiology: Cardiac Cycle 3 uploaded by medbooksvn NBME Top Concepts ➤ Cardiac Physiology Isovolumetric Ventricular Contraction Isovolumetric Ventricular Contraction • Isovolumetric Ventricular Contraction – What is the heart doing? • Ventricles contracting What does this say about pressure? – Increases – On the EKG, what wave does this correlate to? • QRS complex – What heart sound do you hear clinically at the beginning of this phase? • 1st heart sound Creative Commons Attribution License 4.0 Cardiac Physiology: Isovolumetric Ventricular Contraction 4 NBME Top Concepts ➤ Cardiac Physiology Rapid Ventricular Ejection Rapid Ventricular Ejection • Rapid Ventricular Ejection – What is the heart doing? • Ventricles contract (max pressure) blood is flowing into the aorta • Aortic pressure is increasing • What is happening with ventricular volume? – Decreasing – On the EKG, what wave does this correlate to? • ST Segment – Which valve is open during this time? • Aortic Valve Creative Commons Attribution License 4.0 Review Systolic Events of the Cardiac Cycle Cardiac Physiology: Rapid Ventricular Ejection 5 uploaded by medbooksvn NBME Top Concepts ➤ Cardiac Physiology Isovolumetric Ventricular Relaxation Isovolumetric Ventricular relaxation • Isovolumetric Ventricular Relaxation – What is the heart doing? • Ventricular pressure decreases – What valve just closed during this phase? • QRS complex – What heart sound do you hear clinically? • 2nd heart sound Creative Commons Attribution License 4.0 Cardiac Physiology: Isovolumetric Ventricular Relaxation 6 NBME Top Concepts ➤ Cardiac Physiology Ventricular Filling Rapid Ventricular Filling • Rapid Ventricular Filling – What is the heart doing? • Ventricles are filling passively with blood • Ventricular volume is increasing • Ventricular pressure is low and constant to keep the passive flow going – What valve is open? • Mitral – What heart sound do you hear clinically? • 3rd heart sound Reduced Ventricular Filling • Reduced Ventricular Filling – What is the heart doing? • Ventricles are relaxed – What valve is open? • Mitral • This is the longest phase of the cardiac cycle. • A patient is undergoing an exercise stress test on a treadmill. What effect will this have on this phase of the cardiac cycle? – Decreased time available for ventricular filling. Ventricular Filling Creative Commons Attribution License 4.0 Cardiac Physiology: Ventricular Filling 7 uploaded by medbooksvn Ventricular Filling NBME Top Concepts ➤ Cardiac Physiology NBME Style Question A middle-aged male presents with shortness of breath while lying flat. He is found to have a 3/6 holosystolic murmur heard best at the apex. Dilated cardiomyopathy is suspected. Which of the following physical exam findings would be less likely to be associated with this presentation? A. Apical impulses shifted to the axillary line at the sixth intercostal space. B. S4 gallop. C. Bibasilar crackles. D. Peripheral edema. E. Hepatomegaly. Cardiac Physiology: Ventricular Filling 8 NBME Top Concepts ➤ Cardiac Physiology Atrial Systole Atrial Systole • Atrial Systole – What is the heart doing? • Atria contracting final phase of ventricular filling – On the EKG, what wave does this correlate to? • P wave and PR interval – Clinically, what can you hear on cardiac exam? • 4th heart sound Creative Commons Attribution License 4.0 Review Diastolic Events of the Cardiac Cycle Cardiac Physiology: Atrial Systole 9 uploaded by medbooksvn Jugular Venous Tracing NBME Top Concepts ➤ Cardiac Physiology Jugular Venous Tracing Creative Commons Attribution License 4.0 NBME Style Question A 30 year old male is hit in the chest with a baseball bat. He is tachycardic and he has shallow respirations. On palpation of his abdomen, a prominent jugular vein is appreciated. Bedside echo shows a collapsed atria on diastole. What is the most likely vital sign change which may be present in this patient? A.Decrease in diastolic blood pressure by 6 mmHg during exhalation. B.Increase in diastolic blood pressure by 10 mmHg during inhalation. C.Decrease in systolic blood pressure by 10 mmHg during exhalation. D. Decrease in systolic blood pressure by 10 mmHg during inhalation. Cardiac Physiology: Jugular Venous Tracing 10 Pulsus Paradoxes NBME Top Concepts ➤ Cardiac Physiology Pulsus Paradoxes Decrease in SBP by 10 mmHg during Inspiration Cardiac Tamponade on the USMLE Step 1: Recognize Triads • Physical exam shows a prominent jugular vein. • BP < 90/60 • Heart sounds are in-audible or muffled. Creative Commons Attribution License 4.0 Cardiac Physiology: Pulsus Paradoxes 11 uploaded by medbooksvn Pressure Volume Loops NBME Top Concepts ➤ Cardiac Physiology Pressure Volume Loops A patient has a rumbling diastolic murmur heard at the apex. The snap of this murmur occurs at which point? • D.Mitral valve opening. • Cardiac event: • A. Mitral valve closure. • B. Aortic valve open. • C. Aortic valve close. • D.Mitral valve opening. Creative Commons Attribution License 4.0 Pressure Volume Loops for the USMLE USMLE Vignettes relevant to this change: • β1 mediated activity • [Ca2+] • PO4 phospholamban • “A patient started on a medication for heartfailure and suddenly develops vision changes and increased [K]?” • Digoxin • Inhibits the Na+/K+ ATPase. • Makes Ca2+ more difficult to leave myocyte. • contractility. Changes in the ESPVR Creative Commons Attribution License 4.0 Changes in EDPVR Creative Commons Attribution License 4.0 Cardiac Physiology: Pressure Volume Loops 12 Pressure Volume Loops NBME Top Concepts ➤ Cardiac Physiology Pressure Volume Loops for the USMLE USMLE Vignettes relevant to this change: • Endi Diastolic Volume • Venous Tone: • Exercise • USMLE Vignette: • A patient who recently was placed on hemo-dialysis for CKD. The patient is noted to have hyperdynamic precordium. Bounding pulses. Diagnosis? • A-V fistula = preload • Passive leg raise Creative Commons Attribution License 4.0 Summary of Effects Positive Pressure Ventilation in the Cardiac Intensive Care Unit. J Am Coll Cardiol 2018;72:1532-1553. Pressure Volume Loops for the USMLE USMLE Vignettes relevant to this change: • Afterload is largely dependent upon aortic pressure. • blood pressure (essential hypertension) • “A 50-year-old male who presents with passing out. He has CP non-tender to palpation. Walk test notes dyspnea. A murmur at the R-second intercostal space is noted. What is the likely mechanism? • Age related calcific stenosis • A-V fistula = preload Creative Commons Attribution License 4.0 Cardiac Physiology: Pressure Volume Loops 13 uploaded by medbooksvn Cardiac Action Potentials NBME Top Concepts ➤ Cardiac Physiology Compare and Contrast Two Action Potentials Creative Commons Attribution License 4.0 Cardiac Action Potential In ventricular muscle, what ion determines the phase 4 of the cardiac action potential? • Potassium permeability • K equilibrium potential is -84 mV What ion determines phase 0 of the ventricular action potential? • Na influx What phase of the ventricular action potential defines the difference between skeletal action potential vs. ventricular action potential? • Phase 2 Cardiac action potential has a plateau phase which is due to Ca influx and K efflux. • Other differences: Ca induced Ca release, and gap-junctions Cardiac Physiology: Cardiac Action Potentials 14 NBME Top Concepts ➤ Cardiac Physiology Cardiac Action Potentials Compare and Contrast Two Action Potentials Creative Commons Attribution License 4.0 Cardiac Action Potential A farmer is working in the field and suddenly experiences lacrimation, rhinorrhea, and diarrhea. He begins to have sweating and bronchospasm. In the ED, his HR is found to be 45. • An increase in which NT defines his symptoms? • Ach (due to inhibition of AchE). • What phase of the nodal action potential does his bradycardia affect? • Phase 4 Cardiac Physiology: Cardiac Action Potentials 15 uploaded by medbooksvn NBME Top Concepts ➤ Cardiac Physiology Cardiac Action Potentials Regional Circulation for the USMLE Cardiac Physiology: Cardiac Action Potentials 16 Answer Key NBME Top Concepts ➤ Cardiac Physiology Ventricular Filling A middle-aged male presents with shortness of breath while lying flat. He is found to have a 3/6 holosystolic murmur heard best at the apex. Dilated cardiomyopathy is suspected. Which of the following physical exam findings would be less likely to be associated with this presentation? A. Apical impulses shifted to the axillary line at the sixth intercostal space B. S4 gallop C. Bibasilar crackles D. Peripheral edema E. Hepatomegaly Jugular Venous Tracing A 30-year-old male is hit in the chest with a baseball bat. He is tachycardic and he has shallow respirations. On palpation of his abdomen, a prominent jugular vein is appreciated. Bedside echo shows a collapsed atria on diastole. What is the most likely vital sign change which may be present in this patient? A.Decrease in diastolic blood pressure by 6 mmHg during exhalation. B.Increase in diastolic blood pressure by 10 mmHg during inhalation. C.Decrease in systolic blood pressure by 10 mmHg during exhalation. D.Decrease in systolic blood pressure by 10 mmHg during inhalation. Cardiac Physiology: Answer Key 17 uploaded by medbooksvn CHAPTER 2 NBME Top Concepts: Cardiology 18 DiGeorge Syndrome NBME Top Concepts ➤ Cardiology NBME Style Question A 2-months-old female presents with seizures. She is lethargic and hypertonic. The patient is also found to have respiratory distress. The exam is notable for a cleft palate, and a murmur is heard on the clinical exam. What is the likely embryological mechanism? A. Defective neural crest migration. B. Neural crest defect. C. Failure of the 3rd and 4th arch to develop. D. Failure of 3rd and 4th pouch to develop. E. Failure of 3rd and 4th cleft to develop. HyGuru Test-Taking Tip RECOGNIZING MULTI-SYSTEM INVOLVEMENT Whenever you see multiple organ systems involved in exam questions, think about a: • Syndrome • Systemic Condition DiGeorge Syndrome: • Recurrent infections Infectious Disease • Hypocalcemia Endocrine. Cardiology: DiGeorge Syndrome 19 uploaded by medbooksvn Branchial Pouch Derivatives NBME Top Concepts ➤ Cardiology Embryology of the Pharyngeal System Creative Commons Attribution License 4.0 Pharyngeal Pouches Creative Commons Attribution License 4.0 Cardiology: Branchial Pouch Derivatives 20 Lipid Lowering Drugs NBME Top Concepts ➤ Cardiology NBME Style Question A 40-year-old female with a history of Grave’s disease is noted to have intermittent chest pain with activity. She has a history of elevated LDL. She takes PTU for hyperthyroidism. She is started on a medication to control her dyslipidemia. Which of the following best explains the mechanism of action of this medication? A. Activation of HMG-CoA Synthase. B. Upregulation of hepatocyte LDL-receptor. C. Downregulation of bile-acid synthesis. D. In-activation of reverse transport in cholesterol metabolism. E. Upregulation of bile-acid metabolism. Relevant Drugs Creative Commons Attribution License 4.0 PPAR integration PPAR-alpha: • Upregulates LPL • Increases TG clearance • Upregulates HDL synthesis Pharm correlate: fibrates • PPAR gamma: • Increases insulin sensitivity • Increases adiponectin levels • Pharm correlate: pioglitazone, rosiglitazone Cardiology: Lipid Lowering Drugs 21 uploaded by medbooksvn Lipid Lowering Drugs NBME Top Concepts ➤ Cardiology Hepatotoxicity Which of the anti-hyperlipidemics can be hepatotoxic? Statins Ezetimibe Niacin What are ways the test maker may as this on the exam? Increases in AST and ALT. Muscle Myopathy Which of the anti-hyperlipidemics can cause myopathy? Statins Fibrates What are ways the test maker may as this on the exam? Increases in CPK. Anti-Hyperlipidemics An experimental trial is studying the modulation of receptor mediated endocytosis via clathrin coated pits as it relates to lipid metabolism. Inhibition of receptor degradation via inactivation of the endo-lysosomal construct is noted to decrease LDL receptors. What is the likely agent studied? PCSK9 Inhibitors: Alirocumab, Evolocumab. PCSK9 Creative Commons Attribution License 4.0 Cardiology: Lipid Lowering Drugs 22 Lipid Lowering Drugs NBME Top Concepts ➤ Cardiology USMLE Test Taking Strategy Experimental Questions Think like the test-maker: Test makers want a student to: • Organize elements of an experiment. • Interpret relevant data. • Relate the experiment to the content you have studied. Strategy: 1. Don’t panic 2. Organize cohorts, groups, or data sets: Ex: Treatment group vs. control Ex: Filling out ‘givens’ 3. Relate to content studied. Cardiology: Lipid Lowering Drugs 23 uploaded by medbooksvn Shock NBME Top Concepts ➤ Cardiology NBME Style Question A 50-year-old male presents with severe chest pain while mowing his lawn. His vital signs: 110/min, 20 breaths/min, 105/70. He is cool and clammy. He is noted to have an elevated PCWP and left-atrial pressure of 20. What are the most likely pressure changes in the pulmonary vasculature seen? Mastering Shock for the USMLE Isolate the primary etiology of each shock. Parameters to watch out for: Cardiac Output: Blood coming out of the heart. TPR: Usually at the level of the pre-capillary arteriole. PCWP: Pressure in the pulmonary artery surrogate for LAP SVO2: Related to oxygen extraction • If tissues are extracting a lot of O2 MVO2 will be low • If tissues are extracting less O2 MVO2 will be high. Understand the monitoring parameters: CO: blood pumping out of the heart SV x HR TPR: resistance of the vessels Usually at the level of the pre-capillary arteriole PCWP: pressure in the pulmonary artery Can be a surrogate for left atrial pressure LVEDV: blood remaining in LV after filling/diastole MVO2: how well are tissues extracting oxygen Measured at the right atrium: If tissues are extracting a lot of O2 -> MVO2 will be low If tissues are extracting less O2 -> MVO2 will be high What is the primary etiology of each shock and extrapolate Cardiology: Shock 24 Shock NBME Top Concepts ➤ Cardiology Mixed Venous Oxygen Saturation Creative Commons Attribution License 4.0 Shock for the USMLE Creative Commons Attribution License 4.0 Cardiology: Shock 25 uploaded by medbooksvn Shock NBME Top Concepts ➤ Cardiology Cardiac Output for the USMLE Cardiology: Shock 26 Thermoregulation NBME Top Concepts ➤ Cardiology Shivering Response to Shivering An athlete is submerged in an ice-bath What is the likely physiologic response? • Shivering posterior hypothalamus regulates this. • ɑ-motor neurons & gamma-motor are activated skeleton muscle contraction and heat production. • Thyroid hormone increases metabolic rate by increasing Na/K-ATPase • Brown fat via beta-3 (Gs) mediated activity. Heat Stroke A football player presents in summer after fainting. He is noted to have temp 104F, tachypnea, and rigid muscles. CPK is elevated. The patient is also noted to have increased Cr. What is the likely mechanism? Abnormal hypothalamic thermoregulatory response. Heat Dissipation Vasodilation. Mechanism? • Hypothalamus mediated peripheral vasodilation • Exposes blood to cooler air Sweating. Mechanism? • Dissipation of heat usually patients in exam questions will have an absence of sweating Pathophysiology: • High body temp proteins denature cell membranes damage multi-organ failure. Cardiology: Thermoregulation 27 uploaded by medbooksvn S3 vs. S4 NBME Top Concepts ➤ Cardiology NBME Style Question A 62-year-old man dies while playing tennis. At autopsy, examination shows cardiac valve defect and concentric left ventricular hypertrophy. Which of the following valve abnormalities is involved in his sudden death? A.Aortic Insufficiency B.Aortic Stenosis C.Mitral insufficiency D.Mitral stenosis E.Pulmonic insufficiency F.Pulmonic stenosis Concentric Hypertrophy Creative Commons Attribution License 4.0 S3-Gallop During what phase of the cardiac cycle will you hear this sound? • Early diastolic sound rapid filling of the left ventricle On USMLE multi-media questions where will be the most likely position to hear this sound? • Apex especially in the left-lateral USMLE Vignettes: • Mitral regurgitation (the best indicator of MR severity) • Dilated Cardiomyopathy. Cardiology: S3 vs. S4 28 S3 vs. S4 NBME Top Concepts ➤ Cardiology Atria rapidly filling into a dilated left-ventricle. Creative Commons Attribution License 4.0 S4 During what phase of the cardiac cycle will you hear this sound? • late diastolic sound atrial contraction USMLE Vignettes: • “Reduced ventricular compliance” • Hypertrophy. Left Ventricular Hypertrophy Questions on the USMLE Creative Commons Attribution License 4.0 Cardiology: S3 vs. S4 29 uploaded by medbooksvn S3 vs. S4 NBME Top Concepts ➤ Cardiology S3 vs. S4 Cardiology: S3 vs. S4 30 Murmurs NBME Top Concepts ➤ Cardiology Murmurs A 15-year-old female has a grade 2/6 holosystolic murmur is heard best over the left fifth intercoastal space adjacent to the sternum. It increases with inspiration, this murmur is most consistent with an abnormality of which of following valves? A.Aortic B.Mitral C.Pulmonary D.Tricuspid Creative Commons Attribution License 4.0 Murmurs for the USMLE Locate the Area of Auscultation Characterize Systolic VS. Diastolic • Systolic: • Aortic Stenosis • Mitral Regurgitation • VSD • HOCOM • MVP • Diastolic: • Mitral stenosis • Aortic Regurgitation Summary of Maneuvers Less Blood in the Heart: • MVP louder (click is earlier) • HOCOM Afterload (high): • Regurgitant murmurs louder Cardiology: Murmurs 31 uploaded by medbooksvn Vasculitis NBME Top Concepts ➤ Cardiology How to Recognize Vasculitis on the USMLE Histology warm-up: what are the three normal layers of an arterial blood vessel? • Intima • Media • Adventitia USMLE presentations: • Fever, fatigue, weight loss, and myalgias non-specific systems full of multi-system involvement. Giant Cell Temporal Arteritis An elderly female presents with muscle pain and difficulty chewing. She states that she had a transient loss of vision during driving. Her ESR is elevated. What is the next best step in management? • Corticosteroids Giant Cell Temporal Arteritis • Granulomas that affect the branches of the carotid (temporal, ophthalmic) This vasculitis is associated with this USMLE vignette/disease: A 70-year-old patient with joint pain. She has a fever and weight loss. Has difficulty climbing stairs and combing hair. Exam shows pain and stiffness in the shoulders and hip. ESR is elevated, and CK is normal. What is the most likely diagnosis? • Polymyalgia rheumatica associate with Temporal Giant Cell arteritis. Hemoptysis and Hematuria Cardiology: Vasculitis 32 NBME Top Concepts ➤ Cardiology Post Myocardial Infarction Complications Myocardial Infarction • A patient presents with substernal chest pain which he noticed after a hike with his grandchildren. He said that the pain stopped after he rested on a bench. He is a smoker, and his exam is normal. What is the likely diagnosis? • Stable angina: • Deep poorly localized pain that relieves with rest or nitroglycerin brought on by activity • Treatment: Vasodilate by increase NO in vascular smooth muscle • What would you see on pathology: Atherosclerosis of the coronary artery lumen > 75% however less than 100% • Plaques can rupture and then usually have super imposed thrombi. If after they rupture and almost occlude the whole lumen of the coronary vessel, what pathology does this refer to: • Unstable angina (negative troponins) • Subendocardial infarction (positive troponins) NSTEMI • Plaques that occlude the whole lumen: transmural infarction. • What is the most common cause of death after myocardial ischemia caused by coronary artery disease? • Arrhythmia VF • A patient presents dead to the ER, autopsy shows complete occlusion of the LAD. What is the likely cause of death? • VF most common prehospital cause of death in MI patients • What is the most common in-hospital death following MI? • Ventricular failure (LV failure/cardiogenic shock) • Remember it takes time (3-7 days) to get structural issues: • Ventricular rupture, mural thrombus, tamponade. • A patient’s heart is studied on autopsy after he myocardial suffered a myocardial infarction. He presented to the hospital within four hours of the acute attack. What would light-microscopy immediately after the event yield? • No visible changes. • First changes occur 4-12 hour range: • Wavy fibers with elongated myocytes • Cell death ensues: • The nucleus shrivels and darkens until there is no more euchromatin (pyknosis) (karyorrhexis) then vanishes (karyolysis) • Mitochondrial vacuolization is a sign of irreversible cell injury fragments Cardiology: Post Myocardial Infarction Complications 33 uploaded by medbooksvn NBME Top Concepts ➤ Cardiology Post Myocardial Infarction Complications Myocardial Infarction • Inflammation ensues and what pathological change occurs one day? • Neutrophillic infilration and coagulation necrosis • At one week macrophages become the prominent cell and at two weeks granulation tissue becomes neovascularized • Structural complications like free wall rupture, septum rupture, or pap muscle rupture occur approx. 1 week after MI • At a month’s time, a patient will have scar formation • What antiarrhythmic is best after MI? • Lidocaine, MexileTine. “I’d Buy Liddy’s Mexican Tacos.” • Class IB Na channel blockers. Timeline of Myocardial Infarction Contraction Bands Creative Commons Attribution License 4.0 Cardiology: Post Myocardial Infarction Complications 34 Answer Key NBME Top Concepts ➤ Cardiology DiGeorge Syndrome A 2-months-old female presents with seizures. She is lethargic and hypertonic. The patient is also found to have respiratory distress. The exam is notable for a cleft palate, and a murmur is heard on the clinical exam. What is the likely embryological mechanism? A. Defective neural crest migration. B. Neural crest defect. C. Failure of the 3rd and 4th arch to develop. D. Failure of 3rd and 4th pouch to develop. E. Failure of 3rd and 4th cleft to develop. Lipid Lowering Drugs A 40-year-old female with a history of Grave’s disease is noted to have intermittent chest pain with activity. She has a history of elevated LDL. She takes PTU for hyperthyroidism. She is started on a medication to control her dyslipidemia. Which of the following best explains the mechanism of action of this medication? A. Activation of HMG-CoA Synthase. B. Upregulation of hepatocyte LDL-receptor. C. Downregulation of bile-acid synthesis. D. In-activation of reverse transport in cholesterol metabolism. E. Upregulation of bile-acid metabolism. Shock A 50-year-old male presents with severe chest pain while mowing his lawn. His vital signs: 110/min, 20 breaths/min, 105/70. He is cool and clammy. He is noted to have an elevated PCWP and left-atrial pressure of 20. What are the most likely pressure changes in the pulmonary vasculature seen? Cardiology: Answer Key 35 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Cardiology S3 vs. S4 A 62-year-old man dies while playing tennis. At autopsy, examination shows cardiac valve defect and concentric left ventricular hypertrophy. Which of the following valve abnormalities is involved in his sudden death? A.Aortic Insufficiency B.Aortic Stenosis C.Mitral insufficiency D.Mitral stenosis E.Pulmonic insufficiency F.Pulmonic stenosis Cardiology: Answer Key 36 CHAPTER 3 High Yield Images & PE for the USMLE Step 1 (Introduction) 37 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction USMLE Test Taking Strategy Approach How multimedia questions are written on the NBME/USMLE? Types of Media: • Static Images • Patient Photographs • Videos • Interactive Media • Sound files Content Areas Conducive to the Use of Media • Dermatologic & MSK findings • Cardiology (heart sounds) • Neurological exam findings • Ethical and Communication Scenarios Creative Commons Attribution License 4.0 Test Taking Approach An image will not be tested in isolation – the vignette matters! Example Item using Media Creative Commons Attribution License 4.0 High Yield Images & PE Findings: USMLE Test Taking Strategy Approach 38 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Test Taking Strategy for Image Questions Test Taking Strategy for Image Questions Application of Test-Taking Strategy A 40-year-old male with AIDS has 6-week history of weakness in his right hand and mild headache. A CT head is shown. What is the likely causal Organism? ▹Define the image: ▹Radiographic ▹Of what: ▹Brain ▹Look for normal, abnormal, asymmetry: ▹Circular, enhancing intraparenchymal mass. be tested in isolation – the vignette matters! Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Test Taking Strategy for Image Questions 39 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Test Taking Strategy for Image Questions Ring Enhancing Brain Lesions for the USMLE Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Test Taking Strategy for Image Questions 40 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE General Layout A 45-year-old male has a MVA and suffers a right femoral shaft fracture. He has a surgery, and 3 days post op he presents with tachycardia, tachypnea and pleuritic chest pain. He is hypoxemic and has a rash shown. CT shows blockage of pulmonary artery flow. What is the most likely cause of the patient’s hypoxemia? A. Fat Embolism B. Acute Contact Dermatitis C. Meningococcemia D. Anesthesia Reaction Creative Commons Attribution License 4.0 NBME Style Question A 60-year-old male with history of alcoholism presents with vomiting bright red blood. The patient is tachycardic and hypotensive. In the ED, despite resuscitation, the patient passes away. An autopsy is performed to identify the cause of death. An image of the esophagus is shown. Which of the following mechanisms most likely contributed to this patient’s hemorrhage? A. Eosinophilic Esophagitis B. Deficiency of Vitamin K dependent clotting factors C. Peptic Ulcer Disease D. Barret’s Esophagus E. Imbalance of pressures in the caval-portal system Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 41 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Imbalance of Two Systems = Portal HTN Creative Commons Attribution License 4.0 Esophageal Varices NBME Style Question A patient is noted to have ten to fifteen 2 cm lesions on her trunk, neck, and lower extremities. The lesions have been present since birth. A lesion on her extremity is shown. Multiple family members are also known to have this lesion. Given this finding, the patient is most likely to have which associated pathology? A. Renal angiomyolipomas B. Hamartomas seen in the iris C. Charcot Leyden crystals in sputum D.Ashleaf spots Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 42 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Neuro-fibromatosis Creative Commons Attribution License 4.0 NBME Style Question A 17 year old boy presents to the emergency department after having a tonic-clonic seizure. He is noted to have a skin exam shown in the photomicrograph. Upon further history, which of the following findings would likely to be found? A. Hearing loss B. Episodic depression C. Individualized learning plan in childhood D. Family history of substance use Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 43 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Tuberous Sclerosis Creative Commons Attribution License 4.0 NBME Style Question A 50-year-old male presents with weakness. He is noted to have hypertension & hypokalemia. An abdominal CT scan reveals an adrenal mass. The patient undergoes biopsy of the mass. An EM image is shown of the adrenal cortex. The patient’s pathology is most closely related to which labeled zone in the photo-micrograph? A. A B. B C. C D. D E. E Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 44 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Hypertension and Hypokalemia Creative Commons Attribution License 4.0 NBME Style Question A 60 -year-old male presents for follow up. The patient has suffered from a myocardial infarction nine-months prior, and since then has been seen as an outpatient for cardiac rehabilitation. His recovery was uneventful. A photomicrograph of the area of infarction is shown. Which of the following macrophage products is primary responsible for the tissue labeled X? A. Fibroblast Growth Factor B. Interferon Gamma C. Leukotrienes D4 D. Nitric oxide Creative Commons Attribution License 4.0 Timeline of Myocardial Infarction Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 45 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE NBME Style Question A 10-year-old female has fever, tiredness, and a petechial skin rash. Her laboratory studies show a low hemoglobin, low leukocyte count, and low platelets. A bone marrow biopsy is performed. What is the most likely diagnosis? A. Immune thrombocytopenic pupura B. Cyanocobalamin deficiency C. Aplastic anemia D. Acute lymphoblastic leukemia (ALL) Creative Commons Attribution License 4.0 Aplastic Anemia NBME Style Question A 12-year-old female recently was treated for pneumonia. The patient was found to have serologies for mycoplasma positive in the blood. A few days into her illness, she presents with multiple itchy targetoid lesions. Exam of the lesions is shown. Which of the following complications may be associated with this patient’s condition? A. Hemoptysis and hematuria B. Superimposed HSV infection C. Anemia with Coombs positivity D. Positive Nikolsky sign Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 46 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Mnemonic (Rash on Palms and Soles) NBME Style Question A 55-year-old man is in the neuro ICU after suffering a stroke. The patient undergoes an MRI of the brain. The imaging is shown. Which of the following symptoms may this patient have? A. Bitemporal Hemianopsia B. L sided weakness of face and dysarthria C. R sided weakness of face and dysarthria D. Pure sensory loss of the contralateral body E. Weakness of the trunk Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 47 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Localizing Strokes NBME Style Question A patient three months post renal transplant has increasing dyspnea. An X-ray shows atypical, interstitial infiltrates. A broncho-alveolar lavage and lung biopsy is performed. Sample is shown in the photomicrograph. What is the likely organism? A. CMV B. EBV C. Hepatitis B D. HTLV-1 E. Papillomavirus F. Reed Sternburg Creative Commons Attribution License 4.0 NBME Style Question A teenage girl is noted to have sore throat, fever, and malaise. She has tender cervical lymphadenopathy. Abdominal exam reveals a LUQ mass. Laboratory studies show normal hemoglobin, slight elevation in leukocyte count with lymphocytic predominance. A peripheral blood smear is shown. What is the most likely diagnosis? A. Acute lymphoblastic Leukemia B. Acute Myelogenous Leukemia C. Infectious mono-nucleosis D. Hemolytic crisis with reticulocytosis Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 48 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE EBV+ NBME Style Question An 86-year-old male presents with this wife for progressive memory loss. Wife states that the patient is unable to balance his checkbooks. A medication is prescribed to improve these patient’s symptoms. The patient on follow up one year dies. Autopsy is performed. A sample brain tissue is shown. Which of the following is the most likely cause of this patient’s demise? A. CJD B. Hypothyroidism C. Fronto-temporal dementia D. Alzheimer's disease Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 49 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Frontotemporal vs. Alzheimers NBME Style Question A patient is found to have the following physical exam finding shown in the image. Which of the following nerve muscle pairs are likely injured? A. Dorsal scapular – rhomboid major B. Thoracodorsal – trapezius C. Thoracodorsal – serratus anterior D. Long thoracic – serratus anterior E. Long thoracic – trapezius F. Dorsal scapular – subscapularis Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 50 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Top Images You Will Encounter on the USMLE Long Thoracic Nerve Creative Commons Attribution License 4.0 NBME Style Question A patient presents with the physical exam finding shown after excision of a right sided neck mass. Which of the following nerve fibers are likely affected? A. Post synaptic parasympathetic fibers of the vagus nerve. B. Post synaptic fibers of the superior cervical ganglion. C. Pre synaptic fibers from the recurrent laryngeal nerve. D. Splanchnic nerve fibers from the cervical sympathetic trunk. Creative Commons Attribution License 4.0 High Yield Images & PE Findings: Top Images You Will Encounter on the USMLE 51 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Answer Key A 60-year-old male with history of alcoholism presents with vomiting bright red blood. The patient is tachycardic and hypotensive. In the ED, despite resuscitation, the patient passes away. An autopsy is performed to identify the cause of death. An image of the esophagus is shown. Which of the following mechanisms most likely contributed to this patient’s hemorrhage? A. Eosinophilic Esophagitis B. Deficiency of Vitamin K dependent clotting factors C. Peptic Ulcer Disease D. Barret’s Esophagus E. Imbalance of pressures in the caval-portal system A patient is noted to have ten to fifteen 2 cm lesions on her trunk, neck, and lower extremities. The lesions have been present since birth. A lesion on her extremity is shown. Multiple family members are also known to have this lesion. Given this finding, the patient is most likely to have which associated pathology? A. Renal angiomyolipomas B. Hamartomas seen in the iris C. Charcot Leyden crystals in sputum D.Ashleaf spots A 17 year old boy presents to the emergency department after having a tonic-clonic seizure. He is noted to have a skin exam shown in the photomicrograph. Upon further history, which of the following findings would likely to be found? A. Hearing loss B. Episodic depression C. Individualized learning plan in childhood D. Family history of substance use A 50-year-old male presents with weakness. He is noted to have hypertension & hypokalemia. An abdominal CT scan reveals an adrenal mass. The patient undergoes biopsy of the mass. An EM image is shown of the adrenal cortex. The patient’s pathology is most closely related to which labeled zone in the photo-micrograph? A. A B. B C. C D. D E. E High Yield Images & PE Findings: Answer Key 52 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Answer Key A 60 -year-old male presents for follow up. The patient has suffered from a myocardial infarction nine-months prior, and since then has been seen as an outpatient for cardiac rehabilitation. His recovery was uneventful. A photomicrograph of the area of infarction is shown. Which of the following macrophage products is primary responsible for the tissue labeled X? A. Fibroblast Growth Factor B. Interferon Gamma C. Leukotrienes D4 D. Nitric oxide A 10-year-old female has fever, tiredness, and a petechial skin rash. Her laboratory studies show a low hemoglobin, low leukocyte count, and low platelets. A bone marrow biopsy is performed. What is the most likely diagnosis? A. Immune thrombocytopenic pupura B. Cyanocobalamin deficiency C. Aplastic anemia D. Acute lymphoblastic leukemia (ALL) A 12-year-old female recently was treated for pneumonia. The patient was found to have serologies for mycoplasma positive in the blood. A few days into her illness, she presents with multiple itchy targetoid lesions. Exam of the lesions is shown. Which of the following complications may be associated with this patient’s condition? A. Hemoptysis and hematuria B. Superimposed HSV infection C. Anemia with Coombs positivity D. Positive Nikolsky sign A 55-year-old man is in the neuro ICU after suffering a stroke. The patient undergoes an MRI of the brain. The imaging is shown. Which of the following symptoms may this patient have? A. Bitemporal Hemianopsia B. L sided weakness of face and dysarthria C. R sided weakness of face and dysarthria D. Pure sensory loss of the contralateral body E. Weakness of the trunk High Yield Images & PE Findings: Answer Key 53 uploaded by medbooksvn High Yield Images & PE for the USMLE Step 1 ➤ Introduction Answer Key A patient three months post renal transplant has increasing dyspnea. An X-ray shows atypical, interstitial infiltrates. A broncho-alveolar lavage and lung biopsy is performed. Sample is shown in the photomicrograph. What is the likely organism? A. CMV B. EBV C. Hepatitis B D. HTLV-1 E. Papillomavirus F. Reed Sternburg A teenage girl is noted to have sore throat, fever, and malaise. She has tender cervical lymphadenopathy. Abdominal exam reveals a LUQ mass. Laboratory studies show normal hemoglobin, slight elevation in leukocyte count with lymphocytic predominance. A peripheral blood smear is shown. What is the most likely diagnosis? A. Acute lymphoblastic Leukemia B. Acute Myelogenous Leukemia C. Infectious mono-nucleosis D. Hemolytic crisis with reticulocytosis An 86-year-old male presents with this wife for progressive memory loss. Wife states that the patient is unable to balance his checkbooks. A medication is prescribed to improve these patient’s symptoms. The patient on follow up one year dies. Autopsy is performed. A sample brain tissue is shown. Which of the following is the most likely cause of this patient’s demise? A. CJD B. Hypothyroidism C. Fronto-temporal dementia D. Alzheimer's disease A patient is found to have the following physical exam finding shown in the image. Which of the following nerve muscle pairs are likely injured? A. Dorsal scapular – rhomboid major B. Thoracodorsal – trapezius C. Thoracodorsal – serratus anterior D. Long thoracic – serratus anterior E. Long thoracic – trapezius F. Dorsal scapular – subscapularis High Yield Images & PE Findings: Answer Key 54 High Yield Images & PE for the USMLE Step 1 ➤ Introduction Answer Key A patient presents with the physical exam finding shown after excision of a right sided neck mass. Which of the following nerve fibers are likely affected? A. Post synaptic parasympathetic fibers of the vagus nerve. B. Post synaptic fibers of the superior cervical ganglion. C. Pre synaptic fibers from the recurrent laryngeal nerve. D. Splanchnic nerve fibers from the cervical sympathetic trunk. High Yield Images & PE Findings: Answer Key 55 uploaded by medbooksvn CHAPTER 4 High Yield USMLE Images & PE Findings: Cardiology 56 High Yield USMLE Images & PE Findings ➤ Cardiology Murmurs & Maneuvers NBME Style Question An 80-year-old male presents with SOB and fatigue. The patient was brought into the emergency department last week due to lightheadedness during activity. The patient is noted to have a harsh ejection-type murmur at the base of the heart radiating to the neck. Given this murmur, which additional finding may be seen in this patient? A. S3 B. S4 C. Recurrent streptococcal infections in PMH D. Myxomatous valve degeneration due to prolapse Murmurs on the USMLE Creative Commons Attribution License 4.0 Test Taking Approach to Murmurs Cardiology: Murmurs & Maneuvers 57 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Murmurs & Maneuvers Systolic vs. Diastolic Murmurs for the USMLE Maneuvers Cardiology: Murmurs & Maneuvers 58 High Yield USMLE Images & PE Findings ➤ Cardiology Murmurs & Maneuvers Murmurs An 80-year-old male with a cresendo-decresendo systolic murmur that increases with expiration. He has a history of chest pain, and SOB; now he presents after passing out. His murmur is heard best at the right second intercostal space with radiation to the carotids. What feature may correlate to increased severity of this murmur? • A longer and later peak of the murmur intensity of murmur also relates to LV-aorta gradient Aortic Stenosis • What if this patient was a middle-aged male with aortic stenosis. What would be the likely pathophysiologic mechanism? • Bicuspid aortic valve. Bicuspid Aortic Valve Creative Commons Attribution License 4.0 NBME Style Question A patient presents due to syncope. He has no history of trauma and is otherwise healthy. The patient has a harsh systolic murmur throughout the precordium. Lungs are clear and there are no signs of JVD or pitting edema. An echo shows interventricular septal enlargement and low EF. What is the likely mechanism behind the patient’s reduced cardiac output? A. Aortic valve cusp increasing size of LVOT B. Aortic valve dilation and blood in intima of aorta C. Calcified fused aortic valve leaflets D. Mitral leaflet obstructing LVOT Cardiology: Murmurs & Maneuvers 59 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Murmurs & Maneuvers NBME Style Question A patient dies of ventricular arrythmia. Post portem autopsy shows an abnormal interventricular septum, three times as thick as the normal interventricular septum. A genetic analysis of this gross pathological finding would likely show which of the following abnormalities? A. Infiltrative disease due to sarcoid. B. Genetically mutated potassium channels. C. Granulomatous inflammation of myocardium. D. Genetically abnormal myocardial muscle proteins. Hypertrophic Obstructive Cardiomyopathy • What is the micro-pathology finding for HOCOM? – Myofiber disarray • What is the likely genetic mutation behind HOCOM? – Cardiac sarcomere proteins • Beta-myosin heavy chain • Causes diastolic dysfunction and mitral valve regurgitation secondary to anterior motion of the anterior leaflet of mitral valve – Characteristic of diastolic heart failure – high LV end diastolic pressures • What PE maneuvers increase intensity of this murmur? – Maneuvers that decrease preload: • Standing • Valsalva High Yield NBME Images | Hypertrophic Cardiomyopathy Cardiology: Murmurs & Maneuvers 60 High Yield USMLE Images & PE Findings ➤ Cardiology Murmurs & Maneuvers PE Features of Congestive Heart Failure A 50-year-old obese male with a history of smoking presents with increased SOB and exam showing rales with pitting edema. The patient is also noted to have the following PE finding. On echo, he is noted to have a low EF on echocardiography. What is the likely murmur heard on a physical exam? • S3 Early Diastolic Murmur • Represents the la filling into a dilated LV. Right Heart Failure vs. Left Heart Failure for the USMLE Cardiology: Murmurs & Maneuvers 61 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Right Heart Failure vs. Left Heart Failure Right Heart Failure NBME Style Question A patient presents to the ICU with heart failure exacerbation he has CKD and hypertension. Despite aggressive resuscitation that patient dies. Autopsy shows alveolar cells containing increased amount of golden brown cytoplasmic granules that stain Fe2+. Which of the following mechanisms is associated with this autopsy finding? A. Pulmonary embolism B. LV ejection fraction of 30% C. Pneumoconiosis D. Airway hyper-reactivity Cardiology: Right Heart Failure vs. Left Heart Failure 62 High Yield USMLE Images & PE Findings ➤ Cardiology Transudative vs. Exudative for the USMLE Transudative vs. Exudative for the USMLE Cardiology: Transudative vs. Exudative for the USMLE 63 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Mechanisms of Edema Mechanisms of Edema Creative Commons Attribution License 4.0 Cardiology: Mechanisms of Edema 64 High Yield USMLE Images & PE Findings ➤ Cardiology Turner Syndrome Turner Syndrome Creative Commons Attribution License 4.0 Cardiology: Turner Syndrome 65 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Genetic Heart Lesions & Cardiac Anomalies Turner Syndrome Cardiology: Genetic Heart Lesions & Cardiac Anomalies 66 Genetic Conditions & Heart Lesions High Yield USMLE Images & PE Findings ➤ Cardiology Genetic Conditions & Heart Lesions Neonate with seizures secondary to hypocalcemia and recurrent fungal infections. A genetic etiology is suspected. What is the likely cardiac lesion associated with this genetic etiology? • Conotruncal Cardiac Defects • Tetralogy of Fallot • Truncus Arteriosus • Interrupted Aortic Arch. Creative Commons Attribution License 4.0 Cardiology: Genetic Conditions & Heart Lesions 67 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Pathophysiology of Tetralogy of Fallot Pathophysiology of Tetralogy of Fallot Shaped Heart Creative Commons Attribution License 4.0 Cardiology: Pathophysiology of Tetralogy of Fallot 68 High Yield USMLE Images & PE Findings ➤ Cardiology Pathophysiology of Tetralogy of Fallot NBME Style Question A child presents with cyanosis. He has a history of 22q11 deletion and an unrepaired heart lesion. The parents notice the cyanosis exacerbated by increased agitation. Which of the following symptoms is the primary driver for repair of this child’s heart lesion? A. VSD size B. Tricuspid insufficiency C. Right ventricular outflow tract obstruction D. Degree of step down of PaO2 due to R L shunting Cardiology: Pathophysiology of Tetralogy of Fallot 69 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Pathophysiology of Tet Spells Pathophysiology of Tet Spells Cardiology: Pathophysiology of Tet Spells 70 High Yield USMLE Images & PE Findings ➤ Cardiology Endocarditis NBME Style Question A 50-year-old male presents with two weeks of fever and fatigue. The patient is noted to have a mitral valve lesion diagnosed on echocardiography at age 35. The patient presents now with increased CRP, increased ESR and a blood culture positive for gram positive cocci that are alpha hemolytic and optichin resistant. Which of the following additional history findings would be present in this patient? A. History of dental procedure B. History of peritoneal dialysis C. History of prostate hyperplasia D. History of IV Drug abuse Mitral Valve Prolapse • What is the most common cause of mitral regurgitation? • Mitral Valve Prolapse • Bulging MVs into LA during LV systole; redundant valve tissue • What disorders may be associated? • Marfan, EDS, Klinefelter caused by defective embryogenesis of mesenchyme • What makes this murmur louder? • Valsalva and standing. Cardiology: Endocarditis 71 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Microbiology Integration Microbiology Integration • Big Picture: • Subacute bacterial endocarditis usually presents as indolent symptoms of fever + murmur (clinical picture) • USMLE puts dental surgery + hx of MVP + clinical picture: • S. viridans • Dextrans adhere to tooth enamel and fibrin-platelet aggregates • USMLE puts abdominal surgery or on hemo-dialysis + clinical picture: • Enterococcus • Nonhemolytic (Group D), catalase-negative, gram-positive cocci in pairs and chains • USMLE puts history of mechanical valve + clinical picture: • S epidermidis • What is the micro lab characteristic of strept viridans and staph epidermidis? • Strept Viridans: catalase negative, alpha-hemolytic • Green zone of hemolysis on blood agar • Staph Epidermidis: catalase positive, coagulase negative. Cardiology: Microbiology Integration 72 High Yield USMLE Images & PE Findings ➤ Cardiology Infective Endocarditis on USMLE Infective Endocarditis on USMLE – watch for fever + murmur Cardiology: Infective Endocarditis on USMLE 73 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Rheumatic Fever NBME Style Question A child who has immigrated from West Bengal presents to the pediatrician with fatigue and joint pain. The patient has not had any immunizations or birth records sent to the physician. On exam, the patient has a rumbling diastolic murmur heard best at the apex. The patient has a normal neurological exam. Which of the following mechanisms may be contributing to this pathology? A. Type 1 HS B. Type 2 HS C. Type 3 HS D. Type 4 HS Rheumatic Fever A patient who recently immigrated to the USA presents with abnormal involuntary jerking movements. He has a history of sore throat 9 months prior. What is the likely area of the brain which may be affected? • Autoimmune destruction of basal ganglia as they cross react with streptococcal antigen (Mprotein) and brain parenchyma molecular mimicry. JONES Criteria for Rheumatic Fever Creative Commons Attribution License 4.0 Cardiology: Rheumatic Fever 74 High Yield USMLE Images & PE Findings ➤ Cardiology Rheumatic Fever JONES Criteria for Rheumatic Fever Cardiology: Rheumatic Fever 75 uploaded by medbooksvn High Yield USMLE Images & PE Findings ➤ Cardiology Erythema Marginatam Erythema Marginatam Cardiology: Erythema Marginatam 76 High Yield USMLE Images & PE Findings➤ Cardiology Answer Key Murmurs & Maneuvers An 80-year-old male presents with SOB and fatigue. The patient was brought into the emergency department last week due to lightheadedness during activity. The patient is noted to have a harsh ejection-type murmur at the base of the heart radiating to the neck. Given this murmur, which additional finding may be seen in this patient? A. S3 B. S4 C. Recurrent streptococcal infections in PMH D. Myxomatous valve degeneration due to prolapse A patient presents due to syncope. He has no history of trauma and is otherwise healthy. The patient has a harsh systolic murmur throughout the precordium. Lungs are clear and there are no signs of JVD or pitting edema. An echo shows interventricular septal enlargement and low EF. What is the likely mechanism behind the patient’s reduced cardiac output? A. Aortic valve cusp increasing size of LVOT B. Aortic valve dilation and blood in intima of aorta C. Calcified fused aortic valve leaflets D. Mitral leaflet obstructing LVOT A patient dies of ventricular arrythmia. Post portem autopsy shows an abnormal interventricular septum, three times as thick as the normal interventricular septum. A genetic analysis of this gross pathological finding would likely show which of the following abnormalities? A. Infiltrative disease due to sarcoid. B. Genetically mutated potassium channels. C. Granulomatous inflammation of myocardium. D. Genetically abnormal myocardial muscle proteins. Right Heart Failure vs. Left Heart Failure A patient presents to the ICU with heart failure exacerbation he has CKD and hypertension. Despite aggressive resuscitation that patient dies. Autopsy shows alveolar cells containing increased amount of golden brown cytoplasmic granules that stain Fe2+. Which of the following mechanisms is associated with this autopsy finding? A. Pulmonary embolism B. LV ejection fraction of 30% C. Pneumoconiosis D. Airway hyper-reactivity Cardiology: Answer Key 77 uploaded by medbooksvn High Yield USMLE Images & PE Findings➤ Cardiology Answer Key Pathophysiology of Tetralogy of Fallot A child presents with cyanosis. He has a history of 22q11 deletion and an unrepaired heart lesion. The parents notice the cyanosis exacerbated by increased agitation. Which of the following symptoms is the primary driver for repair of this child’s heart lesion? A. VSD size B. Tricuspid insufficiency C. Right ventricular outflow tract obstruction D. Degree of step down of PaO2 due to R L shunting Endocarditis A 50-year-old male presents with two weeks of fever and fatigue. The patient is noted to have a mitral valve lesion diagnosed on echocardiography at age 35. The patient presents now with increased CRP, increased ESR and a blood culture positive for gram positive cocci that are alpha hemolytic and optichin resistant. Which of the following additional history findings would be present in this patient? A. History of dental procedure B. History of peritoneal dialysis C. History of prostate hyperplasia D. History of IV Drug abuse Rheumatic Fever A child who has immigrated from West Bengal presents to the pediatrician with fatigue and joint pain. The patient has not had any immunizations or birth records sent to the physician. On exam, the patient has a rumbling diastolic murmur heard best at the apex. The patient has a normal neurological exam. Which of the following mechanisms may be contributing to this pathology? A. Type 1 HS B. Type 2 HS C. Type 3 HS D. Type 4 HS Cardiology: Answer Key 78 CHAPTER 5 Top NBME Concepts: Respiratory 79 uploaded by medbooksvn A-a Gradient (Hypoxemia) NBME Top Concepts ➤ Respiratory Recognition of Hypoxemia USMLE Questions will test hypoxemia by showing low SpO in exam questions (i.e. <90%) or low P O (<60 mmHg). Use this as a pertinent positive as you paraphrase the vignette. Pathophysiology of hypoxemia NBME Style Question A 52-year-old male is found unresponsive. His medical history is unknown. On PE, he is unresponsive despite sternal rub. He is cool. His laboratory studies are notable for low pH, low PaO , low HCO , high CO . Which of the following diagnoses is most likely to be seen in this patient? A. Respiratory Alkalosis B. Metabolic Alkalosis C. Hyperoxia D. High lactate Respiratory: A-a Gradient (Hypoxemia) 80 A-a Gradient (Hypoxemia) NBME Top Concepts ➤ Respiratory Hypoxemia Hypoventilation An obese patient who presents to the ED after being at a party. He is somnolent and has pinpoint pupils. RR = 8. What would be the likely acid base abnormality? Respiratory acidosis • Unique characteristic no change in A-a gradient. High Altitude An athlete who trains in Colorado. On day two of training, he is found to have an RR= 22. He is in training above sea level for 3 weeks. Labs show elevated Hct. What is the likely mechanism? Increased EPO secretion from peritubular capillary cells • Unique characteristic no change in A-a gradient Hypoxemia Increased synthesis of 2,3 BPG Increased RR decreased cerebral perfusion light-headed. Respiratory: A-a Gradient (Hypoxemia) 81 uploaded by medbooksvn A-a Gradient (Hypoxemia) NBME Top Concepts ➤ Respiratory High Altitude Source: BRS Physiology 2019. Costanzo. Physiology Integration Where are peripheral chemoreceptors located? Carotid body and aortic arch. What are the CN? • IX, and X respectively. What are their major stimuli? • pH (carotid body > arch), pCO2, and primary sensitivity PaO2 (<60-80 mm Hg) Why 60-80 mmHg? • It is at this point where the Hb saturation of O2 drops at a fast rate. Hypoxemia leading to Increased HCT Respiratory: A-a Gradient (Hypoxemia) 82 A-a Gradient (Hypoxemia) NBME Top Concepts ➤ Respiratory High Altitude Source: BRS Physiology 2019. Costanzo. Physiology Integration Where are peripheral chemoreceptors located? Carotid body and aortic arch. What are the CN? • IX, and X respectively. What are their major stimuli? • pH (carotid body > arch), pCO2, and primary sensitivity PaO2 (<60-80 mm Hg) Why 60-80 mmHg? • It is at this point where the Hb saturation of O2 drops at a fast rate. Hypoxemia leading to Increased HCT Respiratory: A-a Gradient (Hypoxemia) 83 uploaded by medbooksvn A-a Gradient (Hypoxemia) NBME Top Concepts ➤ Respiratory NBME Style Question A 45-year-old was hospitalized for hypoxemia. The patient has a history of smoking. He is noted to have increased sputum production. His pulse oximetry is noted to be <90%. He has increased work of breathing on the exam and respiratory distress. He breathes with pursed lips and has a copious purulent cough. Which of the following mechanisms is the primary cause of hypoxemia? A. Alveolar hypoventilation B. Decreased oxygen extraction C. Primary diffusion impairment D. V/Q mismatch V/Q Mismatch A 45-year-old male has an MVA and suffers a right femoral shaft fracture. He has surgery, and 3 days post-op he presents with tachycardia, tachypnea, and pleuritic chest pain. He is hypoxemic and has a rash shown. CT shows blockage of pulmonary artery flow. What is the most likely cause of the patient’s hypoxemia? V/Q mismatch Dead Space • A-a gradient is increased • Diagnosis: fat embolism. Creative Commons Attribution License 4.0 Two Extremes of V/Q mismatch Respiratory: A-a Gradient (Hypoxemia) 84 A-a Gradient (Hypoxemia) NBME Top Concepts ➤ Respiratory V/Q Mismatch – Shunt (Concept: Hypoxemic Vasoconstriction) Graphical Representation of Shunt (Concept: Hypoxemic Vasoconstriction) Respiratory: A-a Gradient (Hypoxemia) 85 uploaded by medbooksvn Regional Circulation for the USMLE NBME Top Concepts ➤ Respiratory Regional Circulation for the USMLE Cardiology Integration What would chronic hypoxic vasoconstriction do to right ventricular afterload? Creative Commons Attribution License 4.0 Respiratory: Regional Circulation for the USMLE 86 Regional Circulation for the USMLE NBME Top Concepts ➤ Respiratory Summary of V/Q Mismatch Creative Commons Attribution License 4.0 NBME Style Question A 62-year-old male comes to the clinic due to a 6-month history of progressive exertional dyspnea. He has no environmental exposures. The patient dies of respiratory failure. Autopsy findings is notable for heterogenous lung parenchyma with predominantly subpleural areas of dense collagen deposition, lymphocyte infiltration, and fibroblast proliferation. Which of the following is the most likely diagnosis? A. Alpha-1 anti-trypsin B. Chronic bronchitis C. Asbestosis D. Idiopathic pulmonary fibrosis E. Chronic hypersensitivity pneumonitis Respiratory: Regional Circulation for the USMLE 87 uploaded by medbooksvn Regional Circulation for the USMLE NBME Top Concepts ➤ Respiratory Diffusion Limitation Creative Commons Attribution License 4.0 Hypoxemia Respiratory: Regional Circulation for the USMLE 88 Regional Circulation for the USMLE NBME Top Concepts ➤ Respiratory NBME Style Question A 5-year-old boy is brought to the office due to intermittent episodes of “blue-ness.” He was adopted and his medical records are unknown. The boy assumes a squatting position to mitigate his ”blue episodes.” Physical examination reveals a prominent right ventricular impulse and a harsh systolic murmur. Which of the following embryological events is the most likely mechanism that caused this patient’s condition? A. Anomalous pulmonary venous return B. Aortic arch constriction C. Deviation of the infundibular septum D. Endocardial cushion defect E. Open ductus arteriosus Tetralogy of Fallot Respiratory: Regional Circulation for the USMLE 89 uploaded by medbooksvn Physical Exam MCQs NBME Top Concepts ➤ Respiratory Physical Exam in USMLE Vignettes USMLE Questions will have the physical exam findings after vital signs & before labs. Understanding the USMLE ”anatomy” of a vignette comfort in NBME questions. USMLE Test Taking Strategy: Physical Exam of the Lung Creative Commons Attribution License 4.0 Physical Exam of the Lung Respiratory: Physical Exam MCQs 90 Physical Exam MCQs NBME Top Concepts ➤ Respiratory NBME Style Question A 72-year-old woman comes to the physician because of a 3-day history of fever, shortness of breath, difficulty swallowing, chest pain, and cough. She is frail. Physical examination shows tachypnea and equal pulses bilaterally. Percussion of the chest shows dullness over the right lower lung field. Laboratory studies show arterial hypoxemia and decreased PCO2. A chest x-ray shows an area of opacification in the lower region of the right lung. Which of the following is the most likely cause of this patient's condition? A. Alveolar proteinosis B. Aspiration C. Cigarette smoking D. Emphysema E. Vasculitis Anatomy Integration Think aspiration pneumonia in the following patients on USMLE: • Altered consciousness dementia, drug intoxication • Dysphagia due to neuro deficits stroke • Large stomach volume & reflux. Creative Commons Attribution License 4.0 NBME Style Question An 18-year-old male presents with sudden onset of chest pain. He recently was at a football game with his friends. He has smoked a pack of cigarettes daily. He has pain worse on inspiration. His RR is elevated. Physical examination shows a thin, tall patient in acute distress. SpO2 = 88%. The trachea is midline. There are decreased breath sounds and hyper-resonance to percussion on the R lung field. Which of the following mechanisms explain these patient's symptoms? A. Apical subpleural bleb rupture B. Hyperinflation and air-trapping C. Panacinar emphysema D. Trauma leading to tension pneumothorax Respiratory: Physical Exam MCQs 91 uploaded by medbooksvn Physical Exam MCQs NBME Top Concepts ➤ Respiratory Anatomy Integration Respiratory: Physical Exam MCQs 92 Restrictive vs. Obstructive Disease NBME Top Concepts ➤ Respiratory Concept Differentiation NBME Style Question A 35-year-old was hospitalized for abnormal liver enzymes. He has a history of jaundice as a neonate. His past chart review shows a decreased FEV1 on spirometry. He is a lifetime non-smoker. Which of the following pathophysiologic mechanisms explains this patient’s underlying condition? A. Increase ROS causing breakdown of lung elastin. B. Decrease in lung defense mechanisms. C. Decrease in proteases increasing lung compliance. D. Decrease elastase activity. Emphysema Respiratory: Restrictive vs. Obstructive Disease 93 uploaded by medbooksvn Restrictive vs. Obstructive Disease NBME Top Concepts ➤ Respiratory NBME Style Question A 38-year-old female presents with shortness of breath. She has decreased exercise tolerance. He currently has a BMI of 41 kg/m2. His RR is 22/min. Physical exam is notable for central obesity. Which of the following spirometry changes would be most likely seen in this patient? A. Decreased FRC B. Increased Residual Volume C. Decreased FEV1 : FVC ratio D. High FEV1 E. Increased chest-wall compliance Functional Residual Capacity for the USMLE Creative Commons Attribution License 4.0 Graphs on the USMLE Creative Commons Attribution License 4.0 Respiratory: Restrictive vs. Obstructive Disease 94 Restrictive vs. Obstructive Disease NBME Top Concepts ➤ Respiratory USMLE Vignette Creative Commons Attribution License 4.0 Asthma Respiratory: Restrictive vs. Obstructive Disease 95 uploaded by medbooksvn Restrictive vs. Obstructive Disease NBME Top Concepts ➤ Respiratory USMLE Vignette Respiratory: Restrictive vs. Obstructive Disease 96 Lung Tumors NBME Top Concepts ➤ Respiratory USMLE Test Taking Strategy USMLE Questions will presentations related to: • Constitutional Symptoms • Paraneoplastic Syndromes: • Physiology tie-ins. NBME Style Question A 59-year-old male presents with right scapular pain. He also is feeling numb in his fourth and fifth fingers in his right forearm. He has had cough with no sputum, weight loss, and occasional night sweats. Travel history is insignificant. He is a 2-pack year smoker. Physical exam is notable for orbital puffiness. Which of the following is the most likely etiology of this patient’s symptoms? A. Airway obstruction. B. Superior sulcus tumor. C. Pleural effusion. D. Pericardial effusion. Small Cell Lung Cancer A 73-year-old smoker comes in with a dry cough and weight loss. He is found to have a large lung mass on imaging and a tumor with a high mitotic count and increased nuclear to cytoplasmic ratio. His sodium levels are low. What is the likely stain which will be positive in this patient’s oncological lesion? • Neuroendocrine in origin NCAM, CD56, chromogranin, synaptophysin. Small Round Blue Cell Tumors (Neural Crest or Neuro-Endocrine in Embryology) Creative Commons Attribution License 4.0 Respiratory: Lung Tumors 97 uploaded by medbooksvn Lung Tumors NBME Top Concepts ➤ Respiratory Small Cell Squamous Cell Creative Commons Attribution License 4.0 Respiratory: Lung Tumors 98 Lung Tumors NBME Top Concepts ➤ Respiratory Adenocarcinoma Respiratory: Lung Tumors 99 uploaded by medbooksvn NBME Top Concepts ➤ Respiratory Acute Respiratory Distress Syndrome NBME Style Question A patient is admitted for pancreatitis. He has a history of alcohol use. He is noted to have mild respiratory distress on admission. On day three of hospitalization, he develops hypoxemia and is transferred to the ICU. He is intubated and chest-x-ray reveals new bilateral pulmonary opacities. Which of the following parameters is most likely to be normal in this patient? A. Capillary permeability B. Work of breathing C. V/Q ratio D. Lung compliance E. Pulmonary capillary wedge pressure Acute Respiratory Distress Syndrome Creative Commons Attribution License 4.0 NBME Style Question A 24-hour neonate presents to the neonatal ICU for tachypnea and hypoxia. The patient was born at 32 weeks to a mother who had T2 DM. Prenatal ultrasounds were notable for polyhydramnios. The patient was delivered via C-section. On exam, the patient has peri-oral cyanosis and a mild murmur at the infraclavicular border with a rumbling sound. Which of the following pathophysiologic mechanisms describe this patient's clinical state? A. Uncontrolled pulmonary artery smooth muscle proliferation. B. Increased L to R cardiac shunting. C. Increase alveolar wall surface tension. D. Oligohydramnios leading to low surfactant. Respiratory: Acute Respiratory Distress Syndrome 100 NBME Top Concepts ➤ Respiratory Acute Respiratory Distress Syndrome Neonatal Respiratory Distress Syndrome Creative Commons Attribution License 4.0 Respiratory: Acute Respiratory Distress Syndrome 101 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Respiratory A-a Gradient (Hypoxemia) A 52-year-old male is found unresponsive. His medical history is unknown. On PE, he is unresponsive despite sternal rub. He is cool. His laboratory studies are notable for low pH, low PaO , low HCO , high CO . Which of the following diagnoses is most likely to be seen in this patient? A. Respiratory Alkalosis B. Metabolic Alkalosis C. Hyperoxia D. High lactate A 45-year-old was hospitalized for hypoxemia. The patient has a history of smoking. He is noted to have increased sputum production. His pulse oximetry is noted to be <90%. He has increased work of breathing on the exam and respiratory distress. He breathes with pursed lips and has a copious purulent cough. Which of the following mechanisms is the primary cause of hypoxemia? A. Alveolar hypoventilation B. Decreased oxygen extraction C. Primary diffusion impairment D. V/Q mismatch Regional Circulation for the USMLE A 62-year-old male comes to the clinic due to a 6-month history of progressive exertional dyspnea. He has no environmental exposures. The patient dies of respiratory failure. Autopsy findings is notable for heterogenous lung parenchyma with predominantly subpleural areas of dense collagen deposition, lymphocyte infiltration, and fibroblast proliferation. Which of the following is the most likely diagnosis? A. Alpha-1 anti-trypsin B. Chronic bronchitis C. Asbestosis D. Idiopathic pulmonary fibrosis E. Chronic hypersensitivity pneumonitis A 5-year-old boy is brought to the office due to intermittent episodes of “blue-ness.” He was adopted and his medical records are unknown. The boy assumes a squatting position to mitigate his ”blue episodes.” Physical examination reveals a prominent right ventricular impulse and a harsh systolic murmur. Which of the following embryological events is the most likely mechanism that caused this patient’s condition? A. Anomalous pulmonary venous return B. Aortic arch constriction C. Deviation of the infundibular septum D. Endocardial cushion defect E. Open ductus arteriosus Respiratory: Answer Key 102 Answer Key NBME Top Concepts ➤ Respiratory Physical Exam MCQs A 72-year-old woman comes to the physician because of a 3-day history of fever, shortness of breath, difficulty swallowing, chest pain, and cough. She is frail. Physical examination shows tachypnea and equal pulses bilaterally. Percussion of the chest shows dullness over the right lower lung field. Laboratory studies show arterial hypoxemia and decreased PCO2. A chest x-ray shows an area of opacification in the lower region of the right lung. Which of the following is the most likely cause of this patient's condition? A. Alveolar proteinosis B. Aspiration C. Cigarette smoking D. Emphysema E. Vasculitis An 18-year-old male presents with sudden onset of chest pain. He recently was at a football game with his friends. He has smoked a pack of cigarettes daily. He has pain worse on inspiration. His RR is elevated. Physical examination shows a thin, tall patient in acute distress. SpO2 = 88%. The trachea is midline. There are decreased breath sounds and hyper-resonance to percussion on the R lung field. Which of the following mechanisms explain these patient's symptoms? A. Apical subpleural bleb rupture B. Hyperinflation and air-trapping C. Panacinar emphysema D. Trauma leading to tension pneumothorax Restrictive vs. Obstructive Disease A 35-year-old was hospitalized for abnormal liver enzymes. He has a history of jaundice as a neonate. His past chart review shows a decreased FEV1 on spirometry. He is a lifetime non-smoker. Which of the following pathophysiologic mechanisms explains this patient’s underlying condition? A. Increase ROS causing breakdown of lung elastin. B. Decrease in lung defense mechanisms. C. Decrease in proteases increasing lung compliance. D. Decrease elastase activity. Respiratory: Answer Key 103 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Respiratory Restrictive vs. Obstructive Disease A 38-year-old female presents with shortness of breath. She has decreased exercise tolerance. He currently has a BMI of 41 kg/m2. His RR is 22/min. Physical exam is notable for central obesity. Which of the following spirometry changes would be most likely seen in this patient? A. Decreased FRC B. Increased Residual Volume C. Decreased FEV1 : FVC ratio D. High FEV1 E. Increased chest-wall compliance Lung Tumors A 59-year-old male presents with right scapular pain. He also is feeling numb in his fourth and fifth fingers in his right forearm. He has had cough with no sputum, weight loss, and occasional night sweats. Travel history is insignificant. He is a 2-pack year smoker. Physical exam is notable for orbital puffiness. Which of the following is the most likely etiology of this patient’s symptoms? A. Airway obstruction B. Superior sulcus tumor C. Pleural effusion D. Pericardial effusion Acute Respiratory Distress Syndrome A patient is admitted for pancreatitis. He has a history of alcohol use. He is noted to have mild respiratory distress on admission. On day three of hospitalization, he develops hypoxemia and is transferred to the ICU. He is intubated and chest-x-ray reveals new bilateral pulmonary opacities. Which of the following parameters is most likely to be normal in this patient? A. Capillary permeability B. Work of breathing C. V/Q ratio D. Lung compliance E. Pulmonary capillary wedge pressure Respiratory: Answer Key 104 Answer Key NBME Top Concepts ➤ Respiratory Acute Respiratory Distress Syndrome A 24-hour neonate presents to the neonatal ICU for tachypnea and hypoxia. The patient was born at 32 weeks to a mother who had T2 DM. Prenatal ultrasounds were notable for polyhydramnios. The patient was delivered via C-section. On exam, the patient has peri-oral cyanosis and a mild murmur at the infraclavicular border with a rumbling sound. Which of the following pathophysiologic mechanisms describe this patient's clinical state? A. Uncontrolled pulmonary artery smooth muscle proliferation B. Increased L to R cardiac shunting C. Increase alveolar wall surface tension D. Oligohydramnios leading to low surfactant Respiratory: Answer Key 105 uploaded by medbooksvn CHAPTER 6 High Yield USMLE Images & PE Findings: Respiratory 106 High Yield Images & PE Findings ➤ Respiratory Overview High Yield images & PE Features • Physical Exam Findings in Select Lung Diseases • Pneumonia & Pneumothorax • Clubbing • Acute Respiratory Distress Syndrome NBME Style Question A six week old child presents in winter with cough and congestion for 3 days. He has subcostal retractions and is tachypneic. His oxygen saturation is 91%. PE shows diffuse expiratory wheezes and rales. CXR shows no focality. Which of the following is the most likely pathogen behind his current condition? A. Adenovirus B. Mycoplasma C. CMV D. RSV E. HiB Understanding Lung PE for the USMLE Creative Commons Attribution License 4.0 Respiratory: Overview 107 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Overview USMLE Vignette A 3-year-old male presents with acute onset fever and tachypnea. A translator is used during the exam as the patient and his family have recently immigrated from overseas. On exam he has stridor, drooling , and is laying on his forearms. A lateral X-ray is shown. What is the likely morphology of the organism behind his symptoms? • Gram negative coccobacilli • Encapsulated, requiring Factor V (NAD+) & X (hematin) • What is the characteristic of the vaccine? • Capsular polysaccharide + protein conjugate • T cell activation & class switching. Creative Commons Attribution License 4.0 Epiglottitis: Anatomy integration Creative Commons Attribution License 4.0 Respiratory: Overview 108 High Yield Images & PE Findings ➤ Respiratory Overview Encapsulated Bacteria Vaccines A child with history of multiple admissions due to pain in his extremities presents with fever, tachycardia, and hypotension. He is found to have a blood culture positive for a gram-positive lancet shaped diplococci. What is the likely pathogenesis? • Sickle cell functionally aplenia due to repeat microinfarction of splenic vascular beds • Decreased immunity towards encapsulated bacteria. Respiratory: Overview 109 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Pneumothorax NBME Style Question An 18-year-old male presents with sudden onset chest pain. There is no trauma. He has pleuritic chest pain. He has an uncle who had similar presentations however he passed away three years prior due to aortic dissection. On patient his R chest is hyper-resonant. Which of the following mechanisms contributed to this patient’s presentation? A. Apical subpleural bleb rupture B. Penetrating Trauma C. Hereditary intra-pulmonary fibrosis D. Pan-acinar Emphysema E. Air trapping Pneumothorax Pneumothorax for the USMLE Respiratory: Pneumothorax 110 Pneumothorax High Yield Images & PE Findings ➤ Respiratory Atelectasis Big Picture: Loss of lung volume due to alveolar collapse A 28-year-old female presents with cough and fever. She is found to have chest-pain that is worse on inspiration. She has also had a twoweek history of arthralgias bilaterally. A CXR is performed and findings are shown. An ANA shows a speckled pattern. What is the mostsensitive lab test which may confirm the diagnosis? • Anti-dsDNA antibody or Anti-Sm (non-histone nuclear proteins). Respiratory: Pneumothorax 111 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Pneumothorax Lupus Creative Commons Attribution License 4.0 Lupus Creative Commons Attribution License 4.0 Respiratory: Pneumothorax 112 High Yield Images & PE Findings ➤ Respiratory Pneumothorax Renal Manifestations of Lupus for the USMLE Creative Commons Attribution License 4.0 Respiratory: Pneumothorax 113 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Pneumonia for the USMLE Pneumonia A 77-year-old male brought in by EMS after awakening with fever, chills, and chest pain worse on inspiration. He has copious sputum production. On auscultation, the patient has decreased breath sounds in the right lower lung field. What are other physical exam features which may be present? • Crackles • Dullness to percussion • Bronchial breath sounds • Increased tactile fremitus Anatomic Distributions of Various Forms of PNA Ivan Damjanov, MD, PhD: Pathophysiology, Philadelphia, Saunders Elsevier, 2009, p 171, Fig. 5-23. Lobar Pneumonia Creative Commons Attribution License 4.0 Respiratory: Pneumonia for the USMLE 114 High Yield Images & PE Findings ➤ Respiratory Pneumonia for the USMLE Microbiology Integration Walker BR, Colledge NR, Ralston SH, Penman ID: Davidson’s Principles and Practice of Medicine, 22nd ed, St. Louis, Churchill Livingstone Elsevier, 2014, p 136, Fig. 6.3. Think Like the Test Maker • Big Picture: • Fever, SOB, pleuritic chest pain, and sputum + focal lung exam • USMLE loves to test the microbiology: • Neonate + pneumonia = • GBS and EColi • College kid + pneumonia = • Mycoplasma • Alcoholic + pneumonia = • Anaerobic (Peptostreptococcus, Fusobacterium, Prevotella, Bacteroides) • Hereditary disorder + pancreatic insufficiency + recurrent pneumonia = • Cystic Fibrosis Staph-Aureus (young), Pseudomonas, and B. Cepacia. • HIV + pneumonia = • Pneumocystis Pneumonia (“ground glass”, “silver stain”, “TMP-SMX”) • Smoker + COPD + pneumonia = • Legionella (“silver stain”), H. Influenzae, M. Catarrhalis Respiratory: Pneumonia for the USMLE 115 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Pneumonia for the USMLE Microscopic Pathophysiology of PNA for the USMLE Bronchopneumonia • Big Picture: • Acute bronchitis subsequent extension of the infection into surrounding alveoli Creative Commons Attribution License 4.0 Respiratory: Pneumonia for the USMLE 116 High Yield Images & PE Findings ➤ Respiratory Pneumonia for the USMLE NBME Style Question A 20 year old male presents with twelve days of cough, low grade fever and malaise. Cough is non-productive. His lung examination shows scattered rales. He is also noted to have anemia, and elevated LDH. Scleral icterus is also noted on repeat eye exam. What is the likely mechanism behind this presentation? A. Type 1 HS. B. Type 2 HS. C. Type 3 HS. D. Type 4 HS. Heme Integration: Autoimmune Hemolytic Anemia Creative Commons Attribution License 4.0 Respiratory: Pneumonia for the USMLE 117 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Pneumonia for the USMLE Mycoplasma Pneumoniae on the USMLE Creative Commons Attribution License 4.0 NBME Style Question A 5-year-old male presents with cough at night. He has had this for the past five months. The patient has a history of seasonal allergies and scaly rash on the flexural surfaces. His lung exam shows no wheezing. Spirometry is notable for a decreased FEV1. The patient may likely have which cytokine elevated in the blood? A. IL-1 B. IL-5 C. IL-12 D. IFN – gamma Pathology of Asthma • What characteristic pathological hallmarks may be seen in the sputum? • Curschmann spirals • epithelium shed from mucus plugs • Charcot Leyden crystals • Needle crystalized aggregates of MBP from eosinophil • Hyperplasia of mucosal glands, along with smooth muscle hypertrophy. Creative Commons Attribution License 4.0 Respiratory: Pneumonia for the USMLE 118 High Yield Images & PE Findings ➤ Respiratory Pneumonia for the USMLE Asthma What would microscopic pathology of a bronchus show? • Mucus in lumen • Inflammation and basement • Membrane thickening • Enlarged mucous glands • Smooth muscle hyperplasia. van Damjanov, MD, PhD: Pathology for the Health Professions, 4th ed, Philadelphia, Saunders Elsevier, 2012, p 178, Fig. 8-16. Pulsus Paradoxes Creative Commons Attribution License 4.0 Respiratory: Pneumonia for the USMLE 119 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Clubbing Obstructive Lung Disease Patient with Cystic Fibrosis presents with foul-smelling, green sputum cough. A CT of chest is ordered. What is the likely diagnosis? • Bronchiectasis Creative Commons Attribution License 4.0 Pathophysiology of Pronchiectasis Creative Commons Attribution License 4.0 Respiratory: Clubbing 120 High Yield Images & PE Findings ➤ Respiratory Acute Respiratory Distress Syndrome NBME Style Question A 50-year-old female is admitted for CVA tenderness and fever. On day three of hospitalization she is admitted to the ICU as the patient has increased hypoxemia. The patient has multi-focal airspace disease on X-ray which are new. What additional pathological finding may be found in this patient? A. Exudative air space disease B. Transudative air space disease C. Non-caseating granulomas D. Red infarct of lobar segment of lung ARDS A patient presents with pancreatitis and is suddenly intubated with a prolonged course in the intensive care unit. He requires increased oxygen requirement, and has new infiltrates on CXR. What is the likely pathological finding this patient may have on alveolar analysis? • Hyaline membranes surrounding alveolo-capillary membrane ARDS which decreases lung compliance • What is pulmonary capillary wedge pressure? • Normal • Elevated PCWP more suggestive of left ventricular failure. Pathogenesis of ARDS Ivan Damjanov, MD. PhD: Pathophysiology, Philadelphia, Saunders Elsevier, 2009, p 169, Fig. 5-20. Respiratory: Acute Respiratory Distress Syndrome 121 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Acute Respiratory Distress Syndrome Acute Respiratory Distress Syndrome Physiology Integration: Pulmonary Compliance Respiratory: Acute Respiratory Distress Syndrome 122 High Yield Images & PE Findings ➤ Respiratory Answer Key Pulmonary Physical Exam for the USMLE A six week old child presents in winter with cough and congestion for 3 days. He has subcostal retractions and is tachypneic. His oxygen saturation is 91%. PE shows diffuse expiratory wheezes and rales. CXR shows no focality. Which of the following is the most likely pathogen behind his current condition? A. Adenovirus B. Mycoplasma C. CMV D. RSV E. HiB Pneumothorax An 18-year-old male presents with sudden onset chest pain. There is no trauma. He has pleuritic chest pain. He has an uncle who had similar presentations however he passed away three years prior due to aortic dissection. On patient his R chest is hyper-resonant. Which of the following mechanisms contributed to this patient’s presentation? A. Apical subpleural bleb rupture B. Penetrating Trauma C. Hereditary intra-pulmonary fibrosis D. Pan-acinar Emphysema E. Air trapping Pneumonia for the USMLE A 20 year old male presents with twelve days of cough, low grade fever and malaise. Cough is non-productive. His lung examination shows scattered rales. He is also noted to have anemia, and elevated LDH. Scleral icterus is also noted on repeat eye exam. What is the likely mechanism behind this presentation? A. Type 1 HS. B. Type 2 HS. C. Type 3 HS. D. Type 4 HS. Respiarotory: Answer Key 123 uploaded by medbooksvn High Yield Images & PE Findings ➤ Respiratory Answer Key Pneumonia for the USMLE A 5-year-old male presents with cough at night. He has had this for the past five months. The patient has a history of seasonal allergies and scaly rash on the flexural surfaces. His lung exam shows no wheezing. Spirometry is notable for a decreased FEV1. The patient may likely have which cytokine elevated in the blood? A. IL-1 B. IL-5 C. IL-12 D. IFN – gamma Acute Respiratory Distress Syndrome A 50-year-old female is admitted for CVA tenderness and fever. On day three of hospitalization she is admitted to the ICU as the patient has increased hypoxemia. The patient has multi-focal airspace disease on X-ray which are new. What additional pathological finding may be found in this patient? A. Exudative air space disease B. Transudative air space disease C. Non-caseating granulomas D. Red infarct of lobar segment of lung Respiarotory: Answer Key 124 CHAPTER 7 NBME Top Concepts: Endocrinology 125 uploaded by medbooksvn Hormone Signaling NBME Top Concepts ➤ Endocrinology Test Taking Strategy: Approaching Hormone Signaling Group hormones based on area of release. • Anterior pituitary • Posterior pituitary • Thyroid gland Define the hormone: • Integrate the mechanism of action All Endocrinology questions: • Think about feedback! NBME Style Question A middle-aged male presents with shortness of breath while lying flat. He is found to have a 3/6 holosystolic murmur heard best at the apex. Dilated cardiomyopathy is suspected. Which of the following physical exam findings would be less likely to be associated with this presentation? A. Apical impulses shifted to the axillary line at the sixth intercostal space. B. S4 gallop. C. Bibasilar crackles. D. Peripheral edema. E. Hepatomegaly. GPCR - Gs Endocrinology: Hormone Signaling 126 Hormone Signaling NBME Top Concepts ➤ Endocrinology GPCR - Gq HyGuru Test Taking Tip: Webs of Knowledge Tyrosine MAP Kinase Endocrinology: Hormone Signaling 127 uploaded by medbooksvn Hormone Signaling NBME Top Concepts ➤ Endocrinology Tyrosine Kinase Associated JAK STAT Endocrinology: Hormone Signaling 128 Thyroid Disorders NBME Top Concepts ➤ Endocrinology Test Taking Strategy: Hyper vs. Hypothyroidism If you are rev-ed up… Hyperthyroidism • Graves = exophthalmos • Arrythmias If you are slowed down… Hypothyroidism • Hypercholesterolemia NBME Style Question A 29-year-old woman presents with nervousness, heat intolerance, and weight loss. Laboratory examination reveals elevated serum thyroxine (T4) and triiodothyronine (T3) levels, while the level of serum thyroid-stimulating hormone (TSH) is decreased. Histologic sections from her thyroid gland reveal increased cellularity with scalloping of the colloid at the margins of the follicles. Which of the following types of autoantibodies is most specific for this individual disease? A. Antimicrosomal antibodies B. Antithyroglobulin antibodies C. Antithyroid peroxidase antibodies D. TSH-receptor-blocking antibodies E. TSH-receptor-stimulating antibodies Thyroid Hormone Where is it secreted from? • Follicles in the thyroid. •Remember these are the only steroid like hormones which are pre-synthesized and stored. • What is more secreted form? • T4 What is rate limiting enzyme for thyroid synthesis? • Thyroid peroxidase: • Oxidation • Organification • Coupling What is mechanism behind thyroid hormone increasing the basal metabolic rate? • Increases Na/K ATPase activity • What type of receptor does thyroid bind to? • Intracellular. Endocrinology: Thyroid Disorders 129 uploaded by medbooksvn Thyroid Disorders NBME Top Concepts ➤ Endocrinology Tyrosine Kinase Associated JAK STAT Thyroid & Pregnancy A female on OCP or who is pregnant will have which type of thyroid profile? • High Total T4 and normal free T3 and T4 Key point is that estrogen will increase thyroid binding globulin increasing total T4 however not affecting the free hormone • Free hormone is important for feedback Endocrinology: Thyroid Disorders 130 Hypothyroid NBME Top Concepts ➤ Endocrinology Hypothyroid Pt with weight gain, and fatigue, complaining of weakness, has heavy periods and deepening of the voice. How are their lipid profiles? • High LDL A patient who has not seen a physician in 20 years presents with AMS and dry skin. DTR is delayed and she has cool, yellowed skin. Non-pitting edema in her face and extremities. What is the likely diagnosis? • Myxedema coma • Non-pitting edema due to increase in GAGs and MPS. Pathophysiology of Hypothyroidism USMLE Point: Another thing to keep in mind for hypothyroid questions is a high-yield psychiatry differential. What may be the likely DSM diagnosis that may mimic hypothyroid? • Depression can have fatigue, depressed mood, weight gain How do you tease them out? • Somatic symptoms such as constipation and physical exam signs like decreased reflexes are not necessarily characteristic of depression and point more to hypothyroid. Hashimoto’s What are the antibodies positive on lab testing? • TPO Ab and antimicrosomal Ab What will the FNA of the thyroid show? • Lymphocytic infiltration with germinal centers along with Hurthle cells • Atrophic epithelial cells with eosinophilic metaplasia and prominent nucleoli. Endocrinology: Hypothyroid 131 uploaded by medbooksvn Hypothyroid NBME Top Concepts ➤ Endocrinology Hashimoto Thyroiditis Creative Commons Attribution License 4.0 Endocrinology: Hypothyroid 132 Hyperthyroid NBME Top Concepts ➤ Endocrinology Hyperthyroid Female with weight loss, tremor, and has palpitations and occasional chest pain. What psychiatric disorder may be also considered as a psychiatry differential? • Anxiety • Typically no weight loss with anxiety USMLE Presentations (besides Graves): • Watch for the obese patient who takes thyroid hormone for weight loss • Pt on the test with hyperthyroidism can also present as atrial fibrillation due to thyroid effect on the heart. Delineating Lab Tests in USMLE Thyroid Questions Are patients with hyperthyroid going to be “revved up” or “chilled out”? • Revved up! Endocrinology: Hyperthyroid 133 uploaded by medbooksvn Hyperthyroid NBME Top Concepts ➤ Endocrinology Grave’s Disease USMLE points: • IgG to TSH receptor (TSI antibody) • Stimulatory antibody What physical exam finding may be pathognomonic for Grave’s? • Exophthalmos (pathognomonic). Mechanism? • Proliferation of retro-orbital fibroblasts causing an increase in GAGs What does FNA of the thyroid show? • Scalloped appearance of colloid Scalloped Thyroid Creative Commons Attribution License 4.0 Endocrine Pharmacology What is the mechanism of the pharmacological agents used to decrease thyroid synthesis? • Block thyroid peroxidase • Methimazole & PTU Hyperthyroidism + on methimazole or PTU fever, sore throat. What lab test may allude to the underlying diagnosis? • Low WBC (check CBC). Endocrine Anatomy A patient with a recent history of follicular thyroid cancer presents for post-operative evaluation after thyroidectomy. He is noted to have difficulty in articulation, speaks in a soft, muffled, and hoarse voice. The affected structure is related to which of the following embryological derivatives? A. Pharyngeal arch 6 B. Pharyngeal pouch 4 C. Pharyngeal cleft 6 D. Pharyngeal arch 3 E. Pharyngeal pouch 3 Endocrinology: Hyperthyroid 134 PTH and Calcium NBME Top Concepts ➤ Endocrinology Parathyroid Hormone Where is the hormone released from? • Chief cells of the parathyroid gland • What pouches are they derived from? • 3rd and 4th What effect does it have on the bone? • Increases calcium and phosphate release from bone • What is the mechanism? • PTH is going to bind to PTH receptor on osteoblasts • Induces osteoblasts to make RANK-L • RANK-L then binds to a RANK receptor on premature osteoclasts with help of IL-1 they create an acidic environment to increase PO4 and Ca concentration in the blood. Osteoblast Osteoclast RANK Estrogen increases osteoprogerin inhibits RANK/RANK-L inhibition of osteoclast differentiation protective against osteoporosis Creative Commons Attribution License 4.0 Parathyroid Hormone What effect does it have on the kidney? • Increases Ca2+ reabsorption where? • Distal convoluted tubule • Inhibits phosphate reabsorption where? • Proximal convoluted tubule • Stimulates active vitamin D synthesis. Mechanism? • Stimulation of 1-alpha-hydroxylase • 25 Vit D 1,25 Vit D. Endocrinology: PTH and Calcium 135 uploaded by medbooksvn PTH and Calcium NBME Top Concepts ➤ Endocrinology Parathyroid Review Active Vitamin D Integration What is the difference between D2 and D3? • D2 is found in vegetables and dietary supplements • D3 is the form we sunbathe in: • Mechanism: 7 dehydrocholesterol which is in the skin gets converted to D3 What is the storage form known as: • 25, OH Vitamin D in the liver, goes to the kidney to become 1,25 OH Vitamin D What effect does the active 1,25 Vitamin D have on the gut? • Increases Ca and PO4 reabsorption. Vitamin D Pathophysiology A patient with sarcoidosis on the USMLE may present with hypercalcemia. What is the mechanism? • Granulomas have intrinsic 1-alpha-hydroxylase activity A child presents with poor growth and recurrent respiratory infections. He is found to have low Vitamin D. His most recent admission was for pseudomonal PNA and he also has foul smelling stools. What is the likely etiology behind his low Vitamin D? • Pancreatic insufficiency causing malabsorption Cystic Fibrosis. Endocrinology: PTH and Calcium 136 PTH and Calcium NBME Top Concepts ➤ Endocrinology 1a Hydroxylase Creative Commons Attribution License 4.0 Parathyroid Adenoma Pt presents with increased thirst and constipation. He has a history of peptic ulcer disease and kidney stones. He as increased ALP and urine cAMP are elevated. Why does this patient have increased cAMP in his urine? • cAMP is high because PTH is a Gs mechanism Lab values with primary hyperparathyroidism: • High calcium • Low phosphate What MEN is parathyroid adenoma related to: • MEN-1 Endocrinology: PTH and Calcium 137 uploaded by medbooksvn MEN Syndromes NBME Top Concepts ➤ Endocrinology NBME Style Question A 23-year-old man sees a physician because he was awakened on several occasions by severe headaches, anxiety, and heart palpitations. Vital signs are within normal limits. On physical examination, he has pectus excavatum, a high arched palate, bilateral pes cavus, and scoliosis. He is noted to have oral lesions on the buccal surface. Which of the following laboratory measures would likely be elevated in this patient? A. Calcitonin B. Calcium C. Insulin D. Phosphate E. Thyroglobulin MEN Syndromes Marfan’s Syndrome Integration Marfan’s Syndrome: • Chromosome 15 • Patho: Fibrillin mutation (elastin) • Ophtho: Lens upward dislocation • Cardiac: Aortic dilation/regurgitation • Resp: Apical bleb rupture Marfanoid Habitus: • Homocystinuria (lens downward) • MEN 2b Endocrinology: MEN Syndromes 138 MEN Syndromes NBME Top Concepts ➤ Endocrinology Adrenal Medulla What are the cells that secrete this? • Chrommafin cells. Different from ECL which release? • Histamine • Derived from neural crest What is primarily secreted? • 80% epinepherine and 20% norepinephrine What is the metabolic byproducts made by NE and E? • VMA & HVA. Pheochromocytoma A 30-year-old female presents with intermittent HA and palp. She is sweating profusely on exam. She says this is not the first time she feels like this. What is next best step? • Urine Metanephrines (and drug screen) What amino acids are precursors to catecholamines? • Phenylalanine and tyrosine. Endocrinology: MEN Syndromes 139 uploaded by medbooksvn Islet Cell Tumors NBME Top Concepts ➤ Endocrinology Islet Cell Tumors Biochemistry Integration of Insulin What cell releases insulin? • Beta cells of the pancreas. Remember this is an ANABOLIC hormone. What are your other anabolic hormones? • Insulin, Androgens, and GH. • What biochemical pathways does it increase? • Glycogenesis and Lipogenesis inhibits lipolysis, and ketoacid formation • Upregulate glucokinase, glycogen synthase, Acetyl Co-A Carboxylase. • Increases protein synthesis. • Via uptake of AA. Endocrinology: Islet Cell Tumors 140 DKA vs. HHS NBME Top Concepts ➤ Endocrinology HyGuru Test Taking Tip:Dehydration USMLE Questions: • Vital signs: • Tachycardia • Hypotension • +/- tachypnea (if underlying acidosis) • Physical Exam: • Dry mucous membranes • Delayed capillary refill • Infants: • No tears when crying • Sunken fontanelle. Approach to Diabetes for the USMLE Endocrinology: DKA vs. HHS 141 uploaded by medbooksvn DKA vs. HHS NBME Top Concepts ➤ Endocrinology NBME Style Question A 27-year-old patient with insulin-dependent diabetes mellitus told his roommate that he could not afford to refill his insulin prescription. When the roommate returned from a weekend trip on Sunday evening, he found the patient unresponsive on the couch with deep labored breathing. Which of the following arterial blood gases taken in the Emergency Department would be expected in this patient? A. pH = 7.22; PaCO2 = 60 mmHg, [HCO3–] = 26 mEq/L, Anion Gap = 12 mEq/L B. pH = 7.02; PaCO2 = 60 mmHg, [HCO3–] = 15 mEq/L, Anion Gap = 12 mEq/L C. pH = 7.10; PaCO2 = 20 mmHg, [HCO3–] = 6 mEq/L, Anion Gap = 30 mEq/L D. pH = 7.51; PaCO2 = 49 mmHg, [HCO3–] = 38 mEq/L, Anion Gap = 14 mEq/L E. pH = 7.40; PaCO2 = 20 mmHg, [HCO3–] = 10 mEq/L, Anion Gap = 26 mEq/L Pathophysiology of Diabetic Ketoacidosis Endocrinology: DKA vs. HHS 142 DKA vs. HHS NBME Top Concepts ➤ Endocrinology Microbiology in DKA A patient with DKA now presents with facial pain and purulent nasal discharge. What is the likely diagnosis? Mucormycosis caused by Mucor & Rhizopus. • What is the morphology? • Broad, non-septate hyphae which branch at right angles. Creative Commons Attribution License 4.0 HHS vs. DKA USMLE Step 1 Endocrinology: DKA vs. HHS 143 uploaded by medbooksvn Diabetes Pharmacology NBME Top Concepts ➤ Endocrinology USMLE Test Taking Strategy: Tackling Pharmacology Questions USMLE Questions: When you see a pharmacological agent in a vignette recall the MOA. ≥ 3 medications may indicate a drug interaction question. • This may be related to: • CYP related (i.e. inhibitor vs. inducer) • Delineation of side-effects. NBME Style Question A patient with focal-segmental-glomerulosclerosis presents to the physician for routine check-up. The patient has been having increased weight-gain due to his steroid bursts. He is noted to have an elevated HgbA1c and is diagnosed with diabetes. His most recent Cr 3.1 mg/dL (H). After initiating pharmacotherapy, he is noted to have an anion-gap metabolic acidosis. Which of the following pharmacological agents would explain his current laboratory state? A. Acarbose B. Canagliflozin C. Pioglitazone D. Sulfonylureas E. Metformin F. Exenatide Diabetes Pharmacology for the USMLE Endocrinology: Diabetes Pharmacology 144 Aldosterone Disorders NBME Top Concepts ➤ Endocrinology HyGuru | USMLE Test Taking Strategy: Aldosterone Questions Aldosterone 1.Brings in Na+ 2.Pees out K+ 3.Pees out H+ Aldosterone Disorders Endocrinology: Aldosterone Disorders 145 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Endocrinology Hormone Signalling A 39-year-old man presents with severe writhing back pain, hematuria, and nausea. An intravenous pyelogram (IVP) confirms a diagnosis of renal calculi. The presence of strongly opaque stones on the plain film is suggestive of calcium oxalate stones, which have an increased incidence with hypophosphatemia. The renal clearance of phosphate is increased by which of the following hormones? A. Aldosterone B. Parathyroid hormone C. Norepinephrine D. Vasopressin E. Angiotensin F. Calcitonin Thyroid Disorders A 29-year-old woman presents with nervousness, heat intolerance, and weight loss. Laboratory examination reveals elevated serum thyroxine (T4) and triiodothyronine (T3) levels, while the level of serum thyroid-stimulating hormone (TSH) is decreased. Histologic sections from her thyroid gland reveal increased cellularity with scalloping of the colloid at the margins of the follicles. Which of the following types of autoantibodies is most specific for this individual disease? A. Antimicrosomal antibodies B. Antithyroglobulin antibodies C. Antithyroid peroxidase antibodies D. TSH-receptor-blocking antibodies E. TSH-receptor-stimulating antibodies A patient with a recent history of follicular thyroid cancer presents for post-operative evaluation after thyroidectomy. He is noted to have difficulty in articulation, speaks in a soft, muffled, and hoarse voice. The affected structure is related to which of the following embryological derivatives? A. Pharyngeal arch 6 B. Pharyngeal pouch 4 C. Pharyngeal cleft 6 D. Pharyngeal arch 3 E. Pharyngeal pouch 3 Endocrinology: Answer Key 146 Answer Key NBME Top Concepts ➤ Endocrinology MEN Syndromes A 23-year-old man sees a physician because he was awakened on several occasions by severe headaches, anxiety, and heart palpitations. Vital signs are within normal limits. On physical examination, he has pectus excavatum, a high arched palate, bilateral pes cavus, and scoliosis. He is noted to have oral lesions on the buccal surface. Which of the following laboratory measures would likely be elevated in this patient? A. Calcitonin B. Calcium C. Insulin D. Phosphate E. Thyroglobulin DKA vs. HHS A 27-year-old patient with insulin-dependent diabetes mellitus told his roommate that he could not afford to refill his insulin prescription. When the roommate returned from a weekend trip on Sunday evening, he found the patient unresponsive on the couch with deep labored breathing. Which of the following arterial blood gases taken in the Emergency Department would be expected in this patient? A. pH = 7.22; PaCO2 = 60 mmHg, [HCO3–] = 26 mEq/L, Anion Gap = 12 mEq/L B. pH = 7.02; PaCO2 = 60 mmHg, [HCO3–] = 15 mEq/L, Anion Gap = 12 mEq/L C. pH = 7.10; PaCO2 = 20 mmHg, [HCO3–] = 6 mEq/L, Anion Gap = 30 mEq/L D. pH = 7.51; PaCO2 = 49 mmHg, [HCO3–] = 38 mEq/L, Anion Gap = 14 mEq/L E. pH = 7.40; PaCO2 = 20 mmHg, [HCO3–] = 10 mEq/L, Anion Gap = 26 mEq/L Diabetes Pharmacology A patient with focal-segmental-glomerulosclerosis presents to the physician for routine check-up. The patient has been having increased weight-gain due to his steroid bursts. He is noted to have an elevated HgbA1c and is diagnosed with diabetes. His most recent Cr 3.1 mg/dL (H). After initiating pharmacotherapy, he is noted to have an anion-gap metabolic acidosis. Which of the following pharmacological agents would explain his current laboratory state? A. Acarbose B. Canagliflozin C. Pioglitazone D. Sulfonylureas E. Metformin F. Exenatide Endocrinology: Answer Key 147 uploaded by medbooksvn CHAPTER 8 NBME Top Concepts: Gastroenterology 148 NBME Top Concepts ➤ Gastroenterology Esophageal Issues Approaching Dysphagia in USMLE Questions HyGuru Test Taking Tip:Difficulty Swallowing NBME Style Question A 56-year-old man presents with weight loss, cough, and diffuse chest pain. He has been having difficulty swallowing for one month. He is unable to drink or tolerate solid foods. Manometry shows increased lower esophageal sphincter (LES) pressure. The high LES pressure is consistent even after swallowing food. A radiological study in this patient would most likely be consistent with which of the following findings? a. Double bubble sign on abdominal x-ray. b. Bird’s beak appearance on barium swallow. c. Obstructive tumor on barium swallow. d. Microcolon on abdominal x-ray. e. Upper esophageal stricture in the esophagus on barium swallow. Gastroenteroloy: Esophageal Issues 149 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Esophageal Issues Achalasia – Failure to Relax the LES Creative Commons Attribution License 4.0 Mallory Weiss vs. Boerhaave Syndrome Esophageal Pathologies Slender female with painful coffee-ground emesis. Examination of the vomitus is consistent with occult blood positivity. What metabolic abnormality may this patient develop? • Mallory Weiss Tear metabolic alkalosis. • Pathophysiology: • Increased Intra-abdominal pressure linear lacerations at GE junction. If this pt presents with crepitus near the clavicle region, What is the diagnosis? • Borheave syndrome air in mediastinum subQ emphysema. Gastroenteroloy: Esophageal Issues 150 NBME Top Concepts ➤ Gastroenterology Esophageal Issues Acid Base Integration Air in the Mediastinum Gastroenteroloy: Esophageal Issues 151 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Esophageal Issues Barret’s Esophagus Obese male with 8-week h/o of asthma like symptoms complains of intermittent squeezing chest pain, especially at night. What pathologic term is used to describe the histological change this patient may have on endoscopy and biopsy of the lower-esophageal region? • Metaplasia (reversible). What is the tissue? • Barret’s Esophagus. • NKSE SCC with goblet cells. • Barret’s Esophagus Esophageal adenocarcinoma • Metaplasia Dysplasia Carcinoma. Creative Commons Attribution License 4.0 Precursor Lesions to Cancer for the USMLE Gastroenteroloy: Esophageal Issues 152 Acid Secretion in the GI system NBME Top Concepts ➤ Gastroenterology Gastrointestinal Physiology Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 NBME Style Question A 38-year-old male patient with a duodenal ulcer is treated successfully with cimetidine. Which of the following mechanisms best describes the agent started in this patient? a. Blocks muscarinic receptors on parietal cells b. Blocks Gq receptors on parietal cells c. Decreases intracellular cAMP levels d. Activation of primary-active transport e. Enhances the action of acetylcholine (ACh) on parietal cells Gastroenteroloy: Acid Secretion in the GI system 153 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Acid Secretion in the GI system Studying Pharmacology for the USMLE NBME Style Question The following pairs of hormones are related to parietal cell secretion. Which of the following pairs most correlate to the gastrointestinal physiology of parietal cells? a. HCl and intrinsic factor b. HCl and pepsinogen c. HCl and HCO3− d. HCO3− and intrinsic factor e. Mucus and pepsinogen Gastroenteroloy: Acid Secretion in the GI system 154 NBME Top Concepts ➤ Gastroenterology Approach to Abdominal Pain on the USMLE Localization of Abdominal Pain for the USMLE NBME Style Question An 18 yr old male complains of nausea and lower abdominal pain. He has no vomiting or diarrhea. He has been afebrile and denies sexual activity. Urine-analysis is negative for leukocyte esterase and nitrites. Ultrasound with doppler shows reduced flow to the testes. Which of the following most likely describes the pathophysiology in this patient? A. Inflammation of the epididymis due to gram negative diplococci. B. Colonization of the urethra due to gram negative rods. C. Spermatic cord twisting with vascular pedicle compromise. D. Neoplastic change to the testes with increased ɑ-fetoprotein. Testicular Torsion Gastroenteroloy: Approach to Abdominal Pain on the USMLE 155 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Approach to Abdominal Pain on the USMLE NBME Style Question A 57-year-old male presents with a primary complaint of erectile dysfunction. After proper evaluation, the patient is started on daily administration of sildenafil. This medication directly causes accumulation of which of the following intracellular mediators? A. Ca2+ B. cGMP C. AMP D. Nitrate E. ANP Sildenafil NEJM Gastroenteroloy: Approach to Abdominal Pain on the USMLE 156 NBME Top Concepts ➤ Gastroenterology Hernias USMLE Vignette Gastroenteroloy: Hernias 157 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Meckel’s Diverticulum Congenital Pathologies A 3-year-old presents with abdominal pain, and rectal bleeding. A Tc-99 screen is done which reveals the presence of gastric tissue 2 feet from the ileocecal valve. What is the likely mechanism behind this pathology? • Failure of the vitelline duct to obliterate completely Meckel’s Diverticulum • Vitelline (omphalomesenteric duct) is the connection between the yolk-sak and the mid-gut. • Gastric tissue in the diverticulum ectopic tissue. • What layers of epithelia is this diverticulum composed of? • True diverticulum • Mucosa, submucosa, muscular, serosa layers. Histology Integration Gastroenteroloy: Meckel’s Diverticulum 158 NBME Top Concepts ➤ Gastroenterology Meckel’s Diverticulum Embryology Integration Creative Commons Attribution License 4.0 Gastroenteroloy: Meckel’s Diverticulum 159 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Hirschsprung’s Disease Failure to Pass Meconium Creative Commons Attribution License 4.0 Gastroenteroloy: Hirschsprung’s Disease 160 NBME Top Concepts ➤ Gastroenterology Inflammatory Bowel Disease Inflammatory Bowel Disease A 26-year-old female presents with abdominal pain and diarrhea. She has been having fatty stools chronically. Barium enema shows narrowing at the level of the jejunum. The patient undergoes EGD. What will be the histological findings behind this diagnosis? • Full-thickness inflammation and non-caseating granulomas Crohn’s disease. Chron’s Disease What immunological mechanism contributes to the pathophysiology of Chron’s? • Macrophages secrete IL-12 induces Th1 • Th1 cells secrete IL-2 and IFN gamma • M (activated) in turn secrete TNF-alpha intestinal cell injury What is the dermatological association with this disease? • Pyoderma gangrenosum along with skin tags/fissures in perianal region. Pyoderma Gangrenosum Creative Commons Attribution License 4.0 Gastroenteroloy: Inflammatory Bowel Disease 161 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Inflammatory Bowel Disease Granulomas for the USMLE Creative Commons Attribution License 4.0 Inflammatory Bowel Disease The patient presents with blood-tinged diarrhea. He states that he has been having abdominal pain and mucousy diarrhea. He has a flexible sigmoidoscopy is done which shows friable mucosal pseudopolyps. What will be the histological findings behind this diagnosis? • Ulcerative Colitis mucosal inflammation & crypt abscesses. Ulcerative Colitis This patient now presents with profuse bloody diarrhea, severe abdominal pain/bloating, and shock. What is the likely diagnosis? • Toxic Megacolon complication of UC • What infectious etiology is most related to toxic megacolon? •T. cruzi. Gastroenteroloy: Inflammatory Bowel Disease 162 NBME Top Concepts ➤ Gastroenterology Inflammatory Bowel Disease Crohn's vs. UC Gastroenteroloy: Inflammatory Bowel Disease 163 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Bile Acid Metabolism NBME Style Question A 40-year-old female presents with episodic right shoulder pain. She states her pain is worse after meals. No trauma is noted in history. Her BMI is 35. Exam shows tenderness to palpation in the RUQ. Which of the following best describes the pathophysiology of this patient’s symptoms? A. Secretin stimulation of pancreatic secretion. B. Musculoskeletal strain of the rotator cuff muscles. C. CCK stimulation of gallbladder contraction. D. Gastrin mediated relaxation of sphincter of Oddi. Bile Acid Metabolism Why does our body need this pathway? • To break-down fat in the small intestine Where does this process occur? • Hepatocyte (liver); stored in GB; released in D What is the rate limiting enzyme? • 7-a-hydroxylase When does this process occur? • Increased parasympathetic activity Process in a nutshell: • Primary bile acids made conjugated to glycine and taurine bile salts intestinal brush border reabsorption enterohepatic circulation (terminal ileum). micelles Gastroenteroloy: Bile Acid Metabolism 164 Hepatitis B NBME Top Concepts ➤ Gastroenterology Mastering Serology for Hepatitis B Understand the basic principles: ▹Hepatitis BsAg and Hepatitis BeAg: • You are infected and e-nfectious. ▹As soon as you have HepBsAg • You make HepBcIgM ▹Once you have HepBsAb – you have resolved the infection or have been vaccinated. In USMLE Questions watch for STI trigger + jaundice, etc. acute Hep B. Gastroenteroloy: Hepatitis B 165 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Vesicular Steatosis NBME Style Question A 37-year-old woman presents for evaluation of abnormal liver chemistries. She has long-standing obesity (current BMI 38) and dyslipidemia. She takes no other medications and has a negative social history. On examination, her liver span is 13 cm; she has no splenomegaly. Several sets of liver enzymes have shown transaminases two to three times normal. Bilirubin and alkaline phosphatase are normal. Hepatitis B surface antigen and hepatitis C antibody are normal, as are serum iron and total iron-binding capacity. Which of the following is the likely pathology on liver biopsy? a.Macrovesicular fatty liver b.Microvesicular fatty liver c.Portal triad hemachromatosis with necrosis d.Cirrhosis e.Copper deposition NAFLD NASH What is the pathophysiology? • Insulin Resistance • Low fatty acid oxidation – more fatty acid uptake. • Non-alcoholic fatty liver-disease • More free radical injury • Causes cell death inflammation • Non-alcoholic steatohepatitis • Stellate Cells secrete TGF-β Fibrosis USMLE Questions: • Watch for metabolic syndrome: • High-abdominal circumference • Dyslipidemmia • High blood pressure • Insulin resistance Gastroenteroloy: Vesicular Steatosis 166 NBME Top Concepts ➤ Gastroenterology Answer Key Esophageal Issues A 56-year-old man presents with weight loss, cough, and diffuse chest pain. He has been having difficulty swallowing for one month. He is unable to drink or tolerate solid foods. Manometry shows increased lower esophageal sphincter (LES) pressure. The high LES pressure is consistent even after swallowing food. A radiological study in this patient would most likely be consistent with which of the following findings? a. Double bubble sign on abdominal x-ray. b. Bird’s beak appearance on barium swallow. c. Obstructive tumor on barium swallow. d. Microcolon on abdominal x-ray. e. Upper esophageal stricture in the esophagus on barium swallow. Acid Secretion in Stomach A 38-year-old male patient with a duodenal ulcer is treated successfully with cimetidine. Which of the following mechanisms best describes the agent started in this patient? a. Blocks muscarinic receptors on parietal cells b. Blocks Gq receptors on parietal cells c. Decreases intracellular cAMP levels d. Activation of primary-active transport e. Enhances the action of acetylcholine (ACh) on parietal cells The following pairs of hormones are related to parietal cell secretion. Which of the following pairs most correlate to the gastrointestinal physiology of parietal cells? a. HCl and intrinsic factor b. HCl and pepsinogen c. HCl and HCO3− d. HCO3− and intrinsic factor e. Mucus and pepsinogen Approach to Abdominal Pain on the USMLE An 18 yr old male complains of nausea and lower abdominal pain. He has no vomiting or diarrhea. He has been afebrile and denies sexual activity. Urine-analysis is negative for leukocyte esterase and nitrites. Ultrasound with doppler shows reduced flow to the testes. Which of the following most likely describes the pathophysiology in this patient? A. Inflammation of the epididymis due to gram negative diplococci. B. Colonization of the urethra due to gram negative rods. C. Spermatic cord twisting with vascular pedicle compromise. D. Neoplastic change to the testes with increased ɑ-fetoprotein. Gastroenterology: Answer Key 167 uploaded by medbooksvn NBME Top Concepts ➤ Gastroenterology Answer Key Approach to Abdominal Pain on the USMLE A 57-year-old male presents with a primary complaint of erectile dysfunction. After proper evaluation, the patient is started on daily administration of sildenafil. This medication directly causes accumulation of which of the following intracellular mediators? A. Ca2+ B. cGMP C. AMP D. Nitrate E. ANP Bile Acid Metabolism A 40-year-old female presents with episodic right shoulder pain. She states her pain is worse after meals. No trauma is noted in history. Her BMI is 35. Exam shows tenderness to palpation in the RUQ. Which of the following best describes the pathophysiology of this patient’s symptoms? A. Secretin stimulation of pancreatic secretion. B. Musculoskeletal strain of the rotator cuff muscles. C. CCK stimulation of gallbladder contraction. D. Gastrin mediated relaxation of sphincter of Oddi. Vesicular Steatosis A 37-year-old woman presents for evaluation of abnormal liver chemistries. She has long-standing obesity (current BMI 38) and dyslipidemia. She takes no other medications and has a negative social history. On examination, her liver span is 13 cm; she has no splenomegaly. Several sets of liver enzymes have shown transaminases two to three times normal. Bilirubin and alkaline phosphatase are normal. Hepatitis B surface antigen and hepatitis C antibody are normal, as are serum iron and total iron-binding capacity. Which of the following is the likely pathology on liver biopsy? a.Macrovesicular fatty liver b.Microvesicular fatty liver c.Portal triad hemachromatosis with necrosis d.Cirrhosis e.Copper deposition Gastroenterology: Answer Key 168 CHAPTER 9 High Yield USMLE Images & PE Findings: Gastroenterology 169 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Oral Pathology NBME Style Question A 9-year-old male presents with fever, sore throat and rah. He is noted to have superficial ulcers on the inside of his cheek. The patient has been exposed to other sick children in his after-school day-care. The likely etiology is associated with which of the following conditions? A. Keratitis B. Myocarditis C. Facial Nerve D. Temporal Lobe Epilepsy E. Super-imposed Bacterial Meningitis Oral Pathology for the USMLE Step 1 Swartz MH: Textbook of Physical Diagnosis: History and Examination, 7th ed, Saunders Elsevier, 2014, p 296, Fig. 9-27. NBME Style Question A middle aged male presents with acute shortness of breath and drooling. He has a prodrome of fevers and runny nose symptoms. He is audibly drooling and holding his mouth wide open. He has severe respiratory distress. Patient decompensates in the trauma bay. An emergency airway procedure known as a cricothyrotomy is performed. What is the likely anatomic landmarks for successful airway securement? A. Two cm inferior to the mandible B. Above the cricoid cartilage and below the thyroid cartilage C. Below the thyroid cartilage and above the thyroid cartilage D. Buccopharyngeal fascia Gastroenterology: Oral Pathology 170 High Yield Images & PE Findings ➤ Gastroenterology Oral Pathology Retropharyngeal Abscess Creative Commons Attribution License 4.0 NBME Style Question A 50-year-old male presents with jaw pain. He is noted to have L submandibular swelling. There has been no trauma. He has a history of dental caries and went 2 weeks ago for a dental extraction on the L side. The patient’s exam reveals puss coming from the L submandibular region. The puss contains sand/grain like particles. Upon analyzing the fluid, which of the following morphologies is most likely to be seen? A. Filamentous branching rod B. Partially acid fast rod C. Bi polar staining gram negative bacilli D. Oxidase positive, gram negative bacili Aphthous Ulcer A patient presents with oral pain. They are found to have a superficial painful ulcer in the cheek described as a gray ulcer with a red border. What is the likely diagnosis? • Aphthous ulcer Creative Commons Attribution License 4.0 Gastroenterology: Oral Pathology 171 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Oral Pathology Aphthous Ulcers A patient presents with recurrent oral pain. They have recurrent scrotal pain and ulcerations in the genital area despite abx therapy. Every few months, they have bilateral painful red eye. On exam, the patient has bilateral knee and wrist pain. What is the likely diagnosis? •Behçet’s disease systemic small vessel vasculitis w/ immune complex deposition • Watch for aphthous ulcers, uveitis, and recurrent genital ulcers. Oral Pathology A patient with history of iron deficiency anemia presents with oral pain. The patient is noted to also have trouble swallowing. Upper endoscopy reveals a web-like tissue in the esophagus. What is the likely diagnosis? • Plummer Vinson Syndrome. Creative Commons Attribution License 4.0 Clinical Triad: Plummer Vinson syndrome Creative Commons Attribution License 4.0 Gastroenterology: Oral Pathology 172 High Yield Images & PE Findings ➤ Gastroenterology Oral Pathology Glossitis Creative Commons Attribution License 4.0 Oral Pathology Kliegman, R: Nelson Textbook of Pediatrics, 19th ed, Philadelphia, Elsevier Saunders 2011, p 1080, Fig. 240.3l; from the Centers for Disease Control and Prevention: Public health image library [PHIL] [website]. http://phil.cdc.gov/phil/home. asp. A college student presents with neck pain and fullness. Three weeks prior he had a self-resolving episode of testicular pain. Serum studies show an elevated amylase. A viral etiology is suspected. What is the likely infectious etiology suspected in this patient? • Paramyxovirus mumps • What is the morphology? • Negative sense ss negative RNA virus • Characteristic of the vaccine? • Live attenuated. Gastroenterology: Oral Pathology 173 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Esophageal Pathology Infectious Esophagitis for the USMLE Swartz MH: Textbook of Physical Diagnosis: History and Examination, 7th ed, Saunders Elsevier, 2014, p 296, Fig. 9-27. Esophageal Pathologies Framework Ivan Damjanov, MD, PhD: Pathophysiology, Saunders Elsevier, 2009, p 254, Fig. 7-14. Gastroenterology: Esophageal Pathology 174 High Yield Images & PE Findings ➤ Gastroenterology Esophageal Pathology Esophageal Pathologies A 5-year-old male presents with difficulty in swallowing. The patient has history of asthma and eczema. The patient undergoes upper endoscopy which reveals furrowing in the proximal esophagus. Biopsy shows >15 bilobed cells. Which cytokine is most likely related to this patient’s current condition? • IL-5 eosinophilic esophagitis • Th2 cell-mediated disorder leading to eosinophilic infiltration of the esophageal mucosa. Tracheoesophageal Fistula Ivan Damjanov, MD, PhD: Pathology for the Health Professions, 4th ed, Saunders Elsevier, 2012, p 236, Fig. 10-5. NBME Style Question A patient presents with chest pain. He is noted to have had chest pain for the past 5 weeks. The chest pain has no change with palpation. The chest pain does not have any relation to activity. The pain is primarily worst at night. He has no dysphagia. He has a history of obesity and diet-controlled diabetes. Which of the following is the most likely diagnosis? A. Acute coronary syndrome B. Costochondritis C. GERD D. Diffuse esophageal strictures Gastroenterology: Esophageal Pathology 175 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Esophageal Pathology Metaplasia is Reversible Long Standing GERD can lead to Ulceration & Stricture NBME Style Question A middle age female presents with edema. Over the past three years she has noticed some difficulty swallowing, and in tolerance to the cold. She describes her fingers turning blue, white, and then red. She also is noticing palpable nodules on her hands. Which of the following antibodies is likely positive in this patient? A. Anti-centromere B. Anti-dsDNA C. Anti-Sm D. Anti-SSA & SSB Gastroenterology: Esophageal Pathology 176 High Yield Images & PE Findings ➤ Gastroenterology Esophageal Pathology Gastric Hernias for the USMLE Pulmonary Hypoplasia A full-term female newborn develops respiratory distress shortly after delivery. Physical examination shows cyanosis, markedly decreased breath sounds bilaterally, and an occasional bowel sound over the left hemithorax. A chest xray taken while the patient is supine shows multiple cysticappearing areas on the left and decreased aeration on the right. What is the likely mechanism? • Failure of the pleuroperitoneal membrane to form Congenital Diaphragmatic Hernia. Gastroenterology: Esophageal Pathology 177 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Stomach Pathology Pyloric Stenosis A mother brings a 4 week old child into the clinic. He has been feeding normally, however recently He has developed projectile, nonbillous vomiting. What is the physical exam finding associated with this likely pathology? • Palpable olive-like mass, and peristalsis of abdomen Pyloric Stenosis • Mechanism? • Hypertrophy of the pyloric muscle congenitally normal increases thickness over time. Pyloric Stenosis Gastroenterology: Stomach Pathology 178 High Yield Images & PE Findings ➤ Gastroenterology Stomach Pathology NBME Style Question A 48-year-old male presents with fever and altered mental status. He was noted to have a recent admission to the hospital for SARS-CoV-2 infection. The patient recovered well and was discharged home. He now presents with fever, hypotension, and warm extremities bilaterally. He is found to have progressive hypotension, and elevations in lactate. He is transferred to the ICU. Which of the following complications is most likely in this patient given his presentation? A. Transudative fluid in lungs B. Increased SVR C. Increased Aerobic Metabolism D. Decreased clearance of acid at the level of the stomach Spectrum of Gastritis Acute Gastritis for the USMLE Gastroenterology: Stomach Pathology 179 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Stomach Pathology Peptic Ulcer Disease Microbiology Integration: H Pylori Gastroenterology: Stomach Pathology 180 High Yield Images & PE Findings ➤ Gastroenterology Stomach Pathology Perforated Duodenal Ulcer Patient with history of PUD in the duodenum presents with acute abdominal pain. Abdominal exam shows rigidity, and guarding, with rebound tenderness. What is the likely diagnosis? • Perforated duodenal ulcer • Watch for free air under the diaphragm. Creative Commons Attribution License 4.0 Complications of PUD Causes of Upper GI Bleeding on the USMLE Creative Commons Attribution License 4.0 Gastroenterology: Stomach Pathology 181 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Intestinal Pathology Causes of lower GI Bleeding on the USMLE Mechanisms of Diarrhea on the USMLE NBME Style Question A patient presents with chronic diarrhea. He is found to have blood and mucus in his diarrhea. The patient recently returned from the Middle East. His H Pylori and C diff test are negative. The patient undergoes colonscopy. Two flask-shaped ulcers are found. Which of the following conditions is this patient most at risk for? A. Cystic brain lesions B. Liver Abscess C. Bile duct obstruction D. Granulomatous cystitis Gastroenterology: Intestinal Pathology 182 High Yield Images & PE Findings ➤ Gastroenterology Answer Key Oral Pathology A 9-year-old male presents with fever, sore throat and rah. He is noted to have superficial ulcers on the inside of his cheek. The patient has been exposed to other sick children in his after-school day-care. The likely etiology is associated with which of the following conditions? A. Keratitis B. Myocarditis C. Facial Nerve D. Temporal Lobe Epilepsy E. Super-imposed Bacterial Meningitis A middle aged male presents with acute shortness of breath and drooling. He has a prodrome of fevers and runny nose symptoms. He is audibly drooling and holding his mouth wide open. He has severe respiratory distress. Patient decompensates in the trauma bay. An emergency airway procedure known as a cricothyrotomy is performed. What is the likely anatomic landmarks for successful airway securement? A. Two cm inferior to the mandible B. Above the cricoid cartilage and below the thyroid cartilage C. Below the thyroid cartilage and above the thyroid cartilage D. Buccopharyngeal fascia A 50-year-old male presents with jaw pain. He is noted to have L submandibular swelling. There has been no trauma. He has a history of dental caries and went 2 weeks ago for a dental extraction on the L side. The patient’s exam reveals puss coming from the L submandibular region. The puss contains sand/grain like particles. Upon analyzing the fluid, which of the following morphologies is most likely to be seen? A. Filamentous branching rod B. Partially acid fast rod C. Bi polar staining gram negative bacilli D. Oxidase positive, gram negative bacili Esophageal Pathology A patient presents with chest pain. He is noted to have had chest pain for the past 5 weeks. The chest pain has no change with palpation. The chest pain does not have any relation to activity. The pain is primarily worst at night. He has no dysphagia. He has a history of obesity and diet-controlled diabetes. Which of the following is the most likely diagnosis? A. Acute coronary syndrome B. Costochondritis C. GERD D. Diffuse esophageal strictures Gastroenterology: Answer Key 183 uploaded by medbooksvn High Yield Images & PE Findings ➤ Gastroenterology Answer Key Esophageal Pathology A middle age female presents with edema. Over the past three years she has noticed some difficulty swallowing, and in tolerance to the cold. She describes her fingers turning blue, white, and then red. She also is noticing palpable nodules on her hands. Which of the following antibodies is likely positive in this patient? A. Anti-centromere B. Anti-dsDNA C. Anti-Sm D. Anti-SSA & SSB Stomach Pathology A 48-year-old male presents with fever and altered mental status. He was noted to have a recent admission to the hospital for SARS-CoV-2 infection. The patient recovered well and was discharged home. He now presents with fever, hypotension, and warm extremities bilaterally. He is found to have progressive hypotension, and elevations in lactate. He is transferred to the ICU. Which of the following complications is most likely in this patient given his presentation? A. Transudative fluid in lungs B. Increased SVR C. Increased Aerobic Metabolism D. Decreased clearance of acid at the level of the stomach Intestinal Pathology A patient presents with chronic diarrhea. He is found to have blood and mucus in his diarrhea. The patient recently returned from the Middle East. His H Pylori and C diff test are negative. The patient undergoes colonscopy. Two flask-shaped ulcers are found. Which of the following conditions is this patient most at risk for? A. Cystic brain lesions B. Liver Abscess C. Bile duct obstruction D. Granulomatous cystitis Gastroenterology: Answer Key 184 CHAPTER 10 NBME Top Concepts: Hematology 185 uploaded by medbooksvn Heme Synthesis NBME Top Concepts ➤ Hematology Hemoglobin Acute Intermittent Porphyria Hematology: Heme Synthesis 186 CYP Inducers NBME Top Concepts ➤ Hematology Guinness, Coronas, & PBRs Induce Chronic Alcoholism Hematology: CYP Inducers 187 uploaded by medbooksvn Lead Poisoning NBME Top Concepts ➤ Hematology NBME Style Question A 4-year-old male presents with cramping and abdominal pain. He has had generalized weakness and decreased feeding. His father works as an industrial laborer. Family history is un-remarkable. He has no other siblings. His labs are notable for an anemia with low-MCV and an abnormal blood smear. Which of the following mechanisms may underlie this patient’s condition? A. Excess blast proliferation B. Auto-antibodies to intrinsic factor C. Inhibition of ferrochelatase D. MPO+ rods in immune cells leading to DIC Glycine + Succinyl coA Hematology: Lead Poisoning 188 Approach to the Blood Smear NBME Top Concepts ➤ Hematology USMLE Test Taking Strategy “Image should be correlated to the question, and should confirm the concept being tested in the vignette” Peripheral Blood Smears Creative Commons Attribution License 4.0 ▸ Paraphrase the vignette to isolate the pathology ▸ Use the peripheral blood smear to confirm your paraphrase ▸ Look at cells which are asymmetric from the normal background. NORMAL PERIPHERAL BLOOD SMEAR NBME Style Question A 30-year-old female presents for a follow up. She is status post a splenectomy 1 year ago after a motor-vehicle accident. She currently feels well and physical exam shows no abnormalities. Lab studies are notable for a mild anemia. Her peripheral blood smear is shown. An increase in which of the following best explains the presence of these abnormal cells? A. Aggregated iron deposits. B. Clusters of remnant DNA. C. Denatured hemoglobin. D. High erythrocyte cellular membrane to internal cell volume. Creative Commons Attribution License 4.0 Hematology: Approach to the Blood Smear 189 uploaded by medbooksvn Approach to the Blood Smear NBME Top Concepts ➤ Hematology Target Cells Target Cells: • Hemoglobin C disease: • “A patient with hemolytic anemia, splenomegaly, and Glu Lysine” • Asplenia • “Sickle cell or MVC patient” • Liver Disease • ”Patient with alcoholism” • “Obstructive liver disease” •Thalassemia • “Chipmunk facies, hair-on-end appearance, chronic transfusions,” Creative Commons Attribution License 4.0 Pathophysiology Breakdown Hematology: Approach to the Blood Smear 190 Approach to the Blood Smear NBME Top Concepts ➤ Hematology USMLE Vignette Creative Commons Attribution License 4.0 Hematology: Approach to the Blood Smear 191 uploaded by medbooksvn Intro to Anemia NBME Top Concepts ➤ Hematology Approach to Anemia Creative Commons Attribution License 4.0 Hematology: Intro to Anemia 192 Microcytic Anemia NBME Top Concepts ➤ Hematology NBME Style Question An 18-year-old female presents with fatigue. She has had some weight gain. She is an avid tennis player. Menarche started at 12. She is Tanner stage 3 on physical exam. Pale conjunctivae are also noted on exam. Her TSH is slightly elevated with a low fT4. Which of the following additional laboratory findings are most likely to be noted in this patient? A. Normal MCV. B. Elevated folate. C. Decreased ferritin. D. Hyper-segmented neutrophils on peripheral blood smear. E. Decreased TIBC. Iron Deficiency Anemia Characteristically, patients will have low Hgb, low MCV, and high RDW. ▹ Represents a high-distribution of RBCs. Think Like the Test Maker: ▹ “Female in the premenopausal period” ▹ “Elderly with anemia, fatigue, weight loss” ▹ “Pregnancy causing a dilutional anemia” ▹ “Third world country child” Pathophysiology of Iron Deficiency Anemia Hematology: Microcytic Anemia 193 uploaded by medbooksvn Microcytic Anemia NBME Top Concepts ➤ Hematology Anemia of Chronic Disease A patient with RA is diagnosed with anemia. What may be the likely classification of this anemia? ▹Anemia of Chronic Disease Pathophysiology: ▹Increased trapping of iron in bone -> IL-1 ▹Hepcidin (acute phase reactant) increases which decreases iron absorption Ferritin is high, TIBC is low USMLE Point: look for PMH noting high inflammation states (SLE, RA, chronic infections). Hematology: Microcytic Anemia 194 Acute Phase Reactants NBME Top Concepts ➤ Hematology Positive & Negative Acute Phase Reactants With inflammation what are markers that are abnormal? • Positive acute phase reactants: • CRP: non-specific sign, fixes complement and increases phagocytosis • Ferritin: inhibits microbial iron utilization • Fibrinogen: promotes endothelial repair • Hepcidin: decreases iron absorption • Serum amyloid A: can lead to amyloidosis • Negative acute phase reactants: • Albumin: conservation of AA • Transferrin Hematology: Acute Phase Reactants 195 uploaded by medbooksvn Summary of Microcytic NBME Top Concepts ➤ Hematology Summary of Microcytic Anemia for the USMLE Hematology: Summary of Microcytic 196 Macrocytic Anemia NBME Top Concepts ➤ Hematology Approach to Macrocytic Anemias Characteristically, patients will have low Hgb, high MCV. • Subset of macrocytic anemias megaloblastic anemia: • B12 • Folate Think Like the Test Maker: • Contrast them by physical exam: • B12 neurological deficits • Folate no neurological deficits. Hypersegmented Neutrophils Creative Commons Attribution License 4.0 NBME Style Question A 59-year-old female presents with progressive fatigue. She is noted to have a history of hypothyroidism. Vital signs are 37.2C, 100/min, RR 15/min, BP 100/80. Laboratory studies are notable for a low Hgb and an MCV of 114. Serum sodium is noted to be decreased. Which of the following pathophysiologic mechanisms most likely is noted in this patient? A. Autoimmune destruction of parietal cells. B. Upregulation of renin-angiotensin-aldosterone system. C. Chronic inflammation leading to elevated ferritin and anemia of chronic disease. D. Decreased dietary folate. Hematology: Macrocytic Anemia 197 uploaded by medbooksvn Macrocytic Anemia NBME Top Concepts ➤ Hematology Test TakingTtip for the USMLE B12 Deficiency Think Like the Test Maker: • Who are patients on the USMLE that you may suspect B-12 deficiency, especially if they present with anemia (MCV>100)? • Vegan • Note: Takes years of being a vegan as B12 is stored in the liver • Patient with pernicious anemia • Patient with gastrectomy • Malabsorption: • Crohn’s disease patient who has lesion of terminal ileum • Fish tapeworm: • Diphyllobothrium latum. Hematology: Macrocytic Anemia 198 B12 Physiology NBME Top Concepts ➤ Hematology Increase MMA Causes Neurological Deficits Odd chain fatty acid metabolism does not plug into TCA Hematology: B12 Physiology 199 uploaded by medbooksvn Normocytic Anemia NBME Top Concepts ➤ Hematology Test Taking Strategy: Recognition of Hemolysis on the USMLE NORMOCYTIC ANEMIAS HEMOLYTIC ANEMIAS Where is the hemolysis occurring? Hematology: Normocytic Anemia 200 Normocytic Anemia NBME Top Concepts ➤ Hematology Intrinsic Hemolytic Anemias NBME Style Question A 20-year-old male presents with cough and fever. The cough is non-productive. He has had no sick contacts and attends college. He is noted to be fatigued. Physical exam is notable for jaundice. Laboratory studies are notable for anemia, a normal MCV, and low haptoglobin. CXR is shown. Which of the following additional laboratory tests will be present in this patient? A. Low indirect bilirubin. B. Increased LFTs with low FEV1. C. Increased ASO titers. D. Coombs positivity. Creative Commons Attribution License 4.0 Hematology: Normocytic Anemia 201 uploaded by medbooksvn Normocytic Anemia NBME Top Concepts ➤ Hematology Mycoplasma Pneumoniae on the USMLE Creative Commons Attribution License 4.0 Hematology: Normocytic Anemia 202 HUS/TTP NBME Top Concepts ➤ Hematology Pathophysiology of HUS & TTP Test Taking Strategy: Recognition of TRIADS on the USMLE What do you need to add to make it TTP? ▹ Fever (look for it in vital signs) ▹ Altered mental status (look for it in physical exam) Hematology: HUS/TTP 203 uploaded by medbooksvn Polycythemia NBME Top Concepts ➤ Hematology Polycythemia Definition: • Increased erythrocytes A patient with PMH notable for renal cell carcinoma presents with increased daytime sleepiness. BMI > 30. He is noted to have an elevated Hct. What is the likely mechanism? • Hypoxemia increasing EPO increased erythrocyte production. If left un-treated, would his pulmonary vascular resistance increase or decrease? • Increase RV afterload? • Increased. How to Approach Polycythemia on the USMLE Creative Commons Attribution License 4.0 Hematology: Polycythemia 204 Platelet Pathology NBME Top Concepts ➤ Hematology Organizing NBME Concepts for Hematology NBME Style Question A 12-year-old male presents with prolonged gum bleeding. He recently was at the dentist for a tooth extraction. His father and paternal aunt have similar issues following minor surgical procedures. He is started on desmopressin (DDAVP). Which of the following most likely highlights the therapeutic mechanism of desmopressin in this patient? A. Increases vWF release by vascular endothelial cells. B. Increases release of factor 10 from vascular endothelial cells. C. Decreases factor 8 release from vascular endothelial cells. D. Promotes clotting via release of fibrin. vWF Disease for the USMLE Hematology: Polycythemia 205 uploaded by medbooksvn Platelet Pathology NBME Top Concepts ➤ Hematology Differentiating between Primary and Secondary Hemostatic Disorders Hematology: Polycythemia 206 Warfarin vs. Heparin NBME Top Concepts ➤ Hematology USMLE Pharmacology Organizing NBME Concepts for Hematology Hematology: Warfarin vs. Heparin 207 uploaded by medbooksvn Multiple Myeloma NBME Top Concepts ➤ Hematology USMLE Test Taking Strategy: Back Pain NBME Style Question A 72-year-old male presents with recurrent bacterial PNA. He is also noted to have abnormal urine analysis notable for nitrites. His childhood PMH is normal. On exam, the patient endorses back pain. He is found to have an abnormal peripheral blood smear. Which of the following findings are most likely to be seen in this patient? A. Hypocalcemia B. Low serum free light-chain C. Qualitative immunoglobulin defect D. Normal creatinine Multiple Myeloma • What is the mechanism behind hypercalcemia? • Increased osteoclastic activity • Breaks down bone • Release of calcium • What is the mechanism behind recurrent infections? • MM abnormal proliferation of plasma cells • Monoclonal expansion of light chains non-functional antibodies bad immune system Hematology: Multiple Myeloma 208 Summary & Courses NBME Top Concepts ➤ Hematology Summary of Top NBME Hematology Concepts Hematology: Summary & Courses 209 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Hematology Lead Poisoning A 4-year-old male presents with cramping and abdominal pain. He has had generalized weakness and decreased feeding. His father works as an industrial laborer. Family history is un-remarkable. He has no other siblings. His labs are notable for an anemia with low-MCV and an abnormal blood smear. Which of the following mechanisms may underlie this patient’s condition? A. Excess blast proliferation B. Auto-antibodies to intrinsic factor C. Inhibition of ferrochelatase D. MPO+ rods in immune cells leading to DIC Approach to the Blood Smear A 30-year-old female presents for a follow up. She is status post a splenectomy 1 year ago after a motor-vehicle accident. She currently feels well and physical exam shows no abnormalities. Lab studies are notable for a mild anemia. Her peripheral blood smear is shown. An increase in which of the following best explains the presence of these abnormal cells? A. Aggregated iron deposits. B. Clusters of remnant DNA. C. Denatured hemoglobin. D. High erythrocyte cellular membrane to internal cell volume. Microcytic Anemia An 18-year-old female presents with fatigue. She has had some weight gain. She is an avid tennis player. Menarche started at 12. She is Tanner stage 3 on physical exam. Pale conjunctivae are also noted on exam. Her TSH is slightly elevated with a low fT4. Which of the following additional laboratory findings are most likely to be noted in this patient? A. Normal MCV. B. Elevated folate. C. Decreased ferritin. D. Hyper-segmented neutrophils on peripheral blood smear. E. Decreased TIBC. Hematology: Answer Key 210 Answer Key NBME Top Concepts ➤ Hematology Macrocytic Anemia A 59-year-old female presents with progressive fatigue. She is noted to have a history of hypothyroidism. Vital signs are 37.2C, 100/min, RR 15/min, BP 100/80. Laboratory studies are notable for a low Hgb and an MCV of 114. Serum sodium is noted to be decreased. Which of the following pathophysiologic mechanisms most likely is noted in this patient? A. Autoimmune destruction of parietal cells. B. Upregulation of renin-angiotensin-aldosterone system. C. Chronic inflammation leading to elevated ferritin and anemia of chronic disease. D. Decreased dietary folate. Normocytic Anemia A 20-year-old male presents with cough and fever. The cough is non-productive. He has had no sick contacts and attends college. He is noted to be fatigued. Physical exam is notable for jaundice. Laboratory studies are notable for anemia, a normal MCV, and low haptoglobin. CXR is shown. Which of the following additional laboratory tests will be present in this patient? A. Low indirect bilirubin. B. Increased LFTs with low FEV1. C. Increased ASO titers. D. Coombs positivity. Platelet Pathology A 12-year-old male presents with prolonged gum bleeding. He recently was at the dentist for a tooth extraction. His father and paternal aunt have similar issues following minor surgical procedures. He is started on desmopressin (DDAVP). Which of the following most likely highlights the therapeutic mechanism of desmopressin in this patient? A. Increases vWF release by vascular endothelial cells. B. Increases release of factor 10 from vascular endothelial cells. C. Decreases factor 8 release from vascular endothelial cells. D. Promotes clotting via release of fibrin. Hematology: Answer Key 211 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Hematology Multiple Myeloma A 72-year-old male presents with recurrent bacterial PNA. He is also noted to have abnormal urine analysis notable for nitrites. His childhood PMH is normal. On exam, the patient endorses back pain. He is found to have an abnormal peripheral blood smear. Which of the following findings are most likely to be seen in this patient? A. Hypocalcemia B. Low serum free light-chain C. Qualitative immunoglobulin defect D. Normal creatinine Hematology: Answer Key 212 CHAPTER 11 High Yield Images for the USMLE Step 1 - Hematology 213 uploaded by medbooksvn Peripheral Blood Smears High Yield Images & PE Findings ➤ Hematology NBME Style Question A 4-year-old male presents with developmental delay. Over the past six weeks mother has noted that the patient has had decreased bowel movements and has been feeling weak. His 2 yo sister has had similar symptoms. What is the most likely cause of this patient’s symptoms? A. Acute leukemia B. Heavy metal poisoning C. Nutritional defect D. Immunodeficiency E. Demyelination of CNS F. CO poisoning Understanding Lung PE for the USMLE • Ferrochelatase • Where is the enzyme located? • Mitochondria • Lead poisoning • Inhibits ferrochelatase • Inhibits Delta ALA Dehydratase • What will blood smear show? • Basophilic stippling • Represents remnants of rRNA in RBCs • USMLE Point: • Lead poisoning presents with non-specific symptoms headaches, constipation, developmental delay • Patients in exam questions will usually be children with a microcytic anemia. Basophilic stippling on the usmle When you see basophilic stippling: 1. Lead poisoning • Pediatric patient + constipation + learning disability • Inhibition of ferrochelatase • What do the basophilic remnants represent? • accumulated rRNA lead inhibits the denaturation of rRNA • Lead denatures ribonuclease hence ribosomes accumulate 2. Sideroblastic Anemia • X linked deficiency in delta ALA synthase (B6) • Basophilic granules (Pappenheimer) contain iron in Xlinked disorder. Naeim F: Atlas of Bone Marrow and Blood Pathology, Philadelphia, Saunders, 2001, p 27, Fig. 2-22M Hematology: Peripheral Blood Smears 214 High Yield Images & PE Findings ➤ Hematology Peripheral Blood Smears Summary of Lead Poisoning Creative Commons Attribution License 4.0 Hematology: Peripheral Blood Smears 215 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology RBC Inclusions RBC Inclusions A 23-year-old African American Male presents with jaundice and SOB after he had a common cold. He had been using his mom’s TMP-SMX antibiotic. Hgb low. What is the likely diagnosis? • G6PD Deficiency what would peripheral blood smear show? • Heinz bodies. What do they represent? • Oxidized Hemoglobin within RBCs • Bite Cells. What do they represent? • Result of phagocytic removal of Heinz bodies by splenic MΦ • Test Taking Pearl: always isolate triggers or stressors with lead to pathology in USMLE questions. Hemolysis due to G 6 PD deficiency Creative Commons Attribution License 4.0 Pentose Phosphate Pathway Hematology: RBC Inclusions 216 High Yield Images & PE Findings ➤ Hematology RBC Inclusions Pentose Phosphate Pathway or HMP Shunt Oxidative Portion of Pentose Phosphate Pathway Creative Commons Attribution License 4.0 No G6PD = no reduced glutathione = oxidant stress wins hemolysis Hematology: RBC Inclusions 217 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology RBC Inclusions RBC Inclusions A 5-year-old African American male presents with thrombocytopenia & extreme abdominal pain. He has a history of several such episodes in the past two years. His most recent episode was for extreme pain in his bilateral lower extremities. There is no trauma and patient has no history of fractures. What is the likely mechanism underlying this diagnosis? • Glutamic acid (normal) Valine (AR) at the sixth position in the Beta-change (missense mutation) • 60-90% HgbSS to be present for sickle cell disease • If there is only a small percentage of Hgb SS on electrophoresis think of trait what is the genetic advantage? • Protection against plasmodium falciparum. Hematology: RBC Inclusions 218 High Yield Images & PE Findings ➤ Hematology Sickle Cell Disease Sickle Cell Disease Sickle Cell Disease A Patients with sickle cell are treated with hydroxyurea to decrease frequency and severity of vasoocclusive crisis. What is the direct effect on their hemoglobin physiology? • Increases HbF less right shift of Hgb & O2 dissociation curve • Hydroxyurea inhibits Ribonucleotide Reductase à what biochemistry pathway is affected? • Pyrimidine Base Synthesis. Hypoxemia leads to sickling of Red Blood Cells Hematology: Sickle Cell Disease 219 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Sickle Cell Disease Sickle Cell Disease USMLE Integrations Hematology: Sickle Cell Disease 220 High Yield Images & PE Findings ➤ Hematology Sickle Cell Disease Encapsulated Organisms Sickle Cell & RBC Inclusions • What is the mechanism behind splenic insufficiency in sickle cell disease? • Sickling in spleen consumption & decreased blood flow splenic infarction • Sickle cell patient post splenectomy may have which RBC inclusion on PBS? • Howell Jolly Bodies what do these represent? • Remnants of nuclear chromatin (do not contain iron). Hematology: Sickle Cell Disease 221 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Complications of Asplenia Complications of Asplenia • What types of vaccines are patients with asplenia or post splenectomy in need of: • Polysaccharide • Specific Vaccines: • S. pneumonia: • Post splenectomy PCV 13 PPSV23 • Meningococcus: • Meningococcal ACWY conjugate vaccine • Hib: • Polysaccharide vaccine conjugated to toxoid • What anti-microbial prophylaxis is important for patients without a spleen? • Amoxicillin (up to at least 5 yo) NBME Style Question A 1-year-old male presents with severe swelling in his hands. He has a family history of brother who died of pneumococcal sepsis. Which of the following serum lab values may be most abnormal in this patient? A. Cortisol B. C5-C9 C. Tryptase D. DAF (CD55-59) E. Haptoglobin Hematology: Complications of Asplenia 222 High Yield Images & PE Findings ➤ Hematology Summary of RBC Inclusions Summary of RBC inclusions NBME Style Question A patient presents after cardiac surgery. Pre-operatively he was noted to have a holosystolic murmur heard best at the 2nd right aortic area. Post operatively, Shischtocytes are seen on peripheral blood smear. What is the likely diagnostic test which may be abnormal? A. Decreased reticulocyte count B. Skull X-ray showing hair-on-end C. Increased serum iron due to anemia of chronic disease D. Decreased haptoglobin Hematology: Summary of RBC Inclusions 223 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Mechanisms of Extravascular RBC Hemolysis Mechanisms of RBC Hemolysis | Extravascular Physical Exam Features of Hemolysis Hematology: Mechanisms of Extravascular RBC Hemolysis 224 Mechanisms of Intravascular RBC Hemolysis High Yield Images & PE Findings ➤ Hematology Mechanisms of RBC Hemolysis | Intravascular NBME Style Question A 5-year-old male presents with hepatosplenomegaly. He is diagnosed with beta-thalassemia. He presents two years later and dies of overwhelming sepsis. On autopsy there are clumps of RBC precursors which are found in the gallbladder and spleen. What is the likely mechanism? A. Extravascular hemolysis B. Intravascular hemolysis C. EPO increase D. Portal hypertension Hematology: Mechanisms of Intravascular RBC Hemolysis 225 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Normocytic Anemia Normocytic Anemia Normocytic Anemias with Reticulocytosis (>2%) Hematology: Normocytic Anemia 226 High Yield Images & PE Findings ➤ Hematology Normocytic Anemia Extravascular vs Intravascular Hemolysis NBME Style Question A 7-year-old male presents with PNA. He has been having frequent nose bleeds and fatigue. His labs show pancytopenia. He undergoes bone-marrow biopsy which shows a profoundly hypocellular marrow with increased lipid cells. What PE feature may be seen in this patient? A. Jaundice B. Splenomegaly C. Gallbladder inflammation D. Angiodysplasia of the nasal passages Hematology: Normocytic Anemia 227 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Aplastic Anemia Aplastic Anemia Key Vignettes Creative Commons Attribution License 4.0 Hematology: Aplastic Anemia 228 High Yield Images & PE Findings ➤ Hematology Aplastic Anemia Key Vignettes Hematology: Aplastic Anemia 229 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Cold and Warm AIHA Auto-Immune Hemolytic Anemia Creative Commons Attribution License 4.0 Hematology: Cold and Warm AIHA 230 High Yield Images & PE Findings ➤ Hematology Hemolytic Uremic Syndrome HUS/TTP TTP Hematology: HUS/TTP 231 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Cells of the Immune System NBME Style Question A 50-year-old male presents with asthma exacerbation. He is noted to have chronic sinus infections. PE shows wrist drop. His IgE count is noted to be elevated and peripheral blood smear shows increased proliferation of cells with dumbbell shaped nuclei. What is the likely lab abnormality in this patient? A. Ab to myeloperoxidase B. Ab to anti-proteinease-3 C. Seronegative spondyloarthropathy D. IgM mediated cold agglutinin Hematology: Cells of the Immune System 232 High Yield Images & PE Findings ➤ Hematology Causes of Eosinophilia on the USMLE Causes of Eosinophilia on the USMLE Hematology: Causes of Eosinophilia on the USMLE 233 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Causes of Plasma Cells on the USMLE Causes of Plasma Cells on the USMLE Hematology: Causes of Plasma Cells on the USMLE 234 High Yield Images & PE Findings ➤ Hematology Causes of Mast Cells on the USMLE Causes of Mast Cells on the USMLE Hematology: Causes of Mast Cells on the USMLE 235 uploaded by medbooksvn High Yield Images & PE Findings ➤ Hematology Answer Key Peripheral Blood Smears A 4-year-old male presents with developmental delay. Over the past six weeks mother has noted that the patient has had decreased bowel movements and has been feeling weak. His 2 yo sister has had similar symptoms. What is the most likely cause of this patient’s symptoms? A. Acute leukemia B. Heavy metal poisoning C. Nutritional defect D. Immunodeficiency E. Demyelination of CNS F. CO poisoning Complications of Asplenia A 1-year-old male presents with severe swelling in his hands. He has a family history of brother who died of pneumococcal sepsis. Which of the following serum lab values may be most abnormal in this patient? A. Cortisol B. C5-C9 C. Tryptase D. DAF (CD55-59) E. Haptoglobin Summary of RBC Inclusions A patient presents after cardiac surgery. Pre-operatively he was noted to have a holosystolic murmur heard best at the 2nd right aortic area. Post operatively, Shischtocytes are seen on peripheral blood smear. What is the likely diagnostic test which may be abnormal? A. Decreased reticulocyte count B. Skull X-ray showing hair-on-end C. Increased serum iron due to anemia of chronic disease D. Decreased haptoglobin Hematology: Answer Key 236 High Yield Images & PE Findings ➤ Hematology Answer Key Mechanisms of Intravascular RBC Hemolysis A 5-year-old male presents with hepatosplenomegaly. He is diagnosed with beta-thalassemia. He presents two years later and dies of overwhelming sepsis. On autopsy there are clumps of RBC precursors which are found in the gallbladder and spleen. What is the likely mechanism? A. Extravascular hemolysis B. Intravascular hemolysis C. EPO increase D. Portal hypertension Normocytic Anemia A 7-year-old male presents with PNA. He has been having frequent nose bleeds and fatigue. His labs show pancytopenia. He undergoes bone-marrow biopsy which shows a profoundly hypocellular marrow with increased lipid cells. What PE feature may be seen in this patient? A. Jaundice B. Splenomegaly C. Gallbladder inflammation D. Angiodysplasia of the nasal passages Cells of the Immune System A 50-year-old male presents with asthma exacerbation. He is noted to have chronic sinus infections. PE shows wrist drop. His IgE count is noted to be elevated and peripheral blood smear shows increased proliferation of cells with dumbbell shaped nuclei. What is the likely lab abnormality in this patient? A. Ab to myeloperoxidase B. Ab to anti-proteinease-3 C. Seronegative spondyloarthropathy D. IgM mediated cold agglutinin Hematology: Answer Key 237 uploaded by medbooksvn CHAPTER 12 NBME Top Concepts: Neurology 238 Brain Hematomas NBME Top Concepts ➤ Neurology NBME Style Question A 23-year-old male presents to trauma bay after MVC. He is noted to be awake and alert on primary survey. Two hours later, he is noted to have a loss of consciousness. His vitals are 140/80, pulse 60/min, RR 10. His pupil is mildly dilated, and bruising is noted in his temple. What is the likely diagnosis? A. Middle Cerebral Artery Ischemic Stroke. B. Epidural Hematoma. C. Subdural Hematoma. D. Subarachnoid hemorrhage. E. Rupture of Bouchard aneurysm. Think Like the Test Maker: Epidural Hematoma What would be possible scenarios in the test question for epidural hematomas? • “Patient who got hit on the side of the head” • “Skull fracture” • “Patient after trauma who was AOx3, and then passes away 5 hours later. • “Talk and Die” What is the affected artery? • Middle meningeal • Branch off maxillary artery (one of terminal branches of external carotid). Test Taking Tip for the USMLE While studying anatomical lesions, integrate high-yield pathologies with anatomy. • If there is an affected artery, nerve, lymphatic, vein track it back to a structure you are familiar with! (i.e. aorta) Neurology: Brain Hematomas 239 uploaded by medbooksvn Brain Hematomas NBME Top Concepts ➤ Neurology Foramen Spinosum Creative Commons Attribution License 4.0 Neurology: Brain Hematomas 240 Brain Hematomas NBME Top Concepts ➤ Neurology Think Like the Test Maker: Subdural Hematoma What would be possible scenarios in the test question? • “Baby who has bilateral retinal hemorrhages” • Child abuse • “Nursing home resident who fell” also “alcoholic” • Both have atrophy of brain, and this increases the risk of bleed in subdural hematoma • Slow onset of symptoms What is the affected artery? •Tearing of the bridging veins. Subarachnoid Patient with U/S confirmed cystic kidneys, has a sudden onset of headache, vomiting, and photophobia. Where is the most likely location of this pathology? • Diagnosis: Rupture of berry aneurysm Sub-Arachnoid Hemorrhage • Classic pattern on CT imaging: • Pattern of blood follows sulci and gyri • CSF tap will show yellow-ish CSF consistent with xanthochromia CCB nimodipine is given to reduce risk of vasospasm Circle of Willis Creative Commons Attribution License 4.0 ACA and Anterior communicating artery junction Mechanism: At this junction there is no strong media, so aneurysms prone to occur and rupture Neurology: Brain Hematomas 241 uploaded by medbooksvn Brain Hematomas NBME Top Concepts ➤ Neurology Brain Aneurysms for the USMLE USMLE Vignette Neurology: Brain Hematomas 242 Herniation Syndromes & Cerebral Physiology NBME Top Concepts ➤ Neurology NBME Style Question A 6-year-old male presents to the intensive care unit after diagnosis of subarachnoid hemorrhage. One hour after admission, his vital signs are notable for BP 140/80, HR 60, RR 12. He has a right pupil minimally reactive and 4 mm in diameter, his left pupil is noted to be 2 mm and reactive. Given normal cerebral autoregulation, which of the following interventions may reduce elevated intracranial pressure in this patient? A. Hypoventilation B. No change in respirations C. Increased blood pressure by stimulating alpha-receptors D. Hyperventilation Test Taking Strategy: Recognition of TRIADS on the USMLE What is the pathophysiology of reflex bradycardia? ▹ Activation of baroreceptor (stretch) efferent parasympathetic activity. Neurology: Herniation Syndromes & Cerebral Physiology 243 uploaded by medbooksvn Herniation Syndromes & Cerebral Physiology NBME Top Concepts ➤ Neurology Cerebral Autoregulation Cerebral Autoregulation Neurology: Herniation Syndromes & Cerebral Physiology 244 Herniation Syndromes & Cerebral Physiology NBME Top Concepts ➤ Neurology Uncal Herniation What is the mechanism behind the dilated pupil? • Compression of CN 3 as it exits the midbrain Pathophysiology: Compression of pre-ganglionic parasympathetic fibers If you damage parasympathetic, what pupillary changes will be present? • Dilation of pupils. Creative Commons Attribution License 4.0 Anatomy of Cranial Nerve 3 Creative Commons Attribution License 4.0 Neurology: Herniation Syndromes & Cerebral Physiology 245 uploaded by medbooksvn Cranial Nerve Path (1) NBME Top Concepts ➤ Neurology NBME Style Question A 16-year-old female presents with fever and throat pain. She is noted to have increased fatigue for the past week. Vital signs are notable for fever. The physical exam is notable for exudates on tonsils and left-sided uvular deviation. CT of the neck shows concern for injury to a cranial nerve. Which of the following nerves related to this patient’s exam findings is most likely to be affected? A. Vagus B. Glossopharyngeal C. Hypoglossal D. Trochlear E. Trigeminal Uvular Deviation Uvular deviation away from the side of the lesion. • R CN X involvement will lead to L uvular deviation. Creative Commons Attribution License 4.0 USMLE Vignette Neurology: Cranial Nerve Path (1) 246 Cranial Nerve Path (1) NBME Top Concepts ➤ Neurology Neuroanatomy Integration Creative Commons Attribution License 4.0 USMLE Vignette Neurology: Cranial Nerve Path (1) 247 uploaded by medbooksvn Cranial Nerve Path (1) NBME Top Concepts ➤ Neurology Neuroanatomy Integration Creative Commons Attribution License 4.0 USMLE Vignette Neurology: Cranial Nerve Path (1) 248 Bell’s Palsy NBME Top Concepts ➤ Neurology Bell’s Palsy An avid hiker who presents with an inability to raise her eyebrows. She has dry eyes and is hypersensitive to sound. What cranial nerve may be affected? ▹ Cranial Nerve 7 Bell’s Palsy (LMN). What is the mechanism behind the hyperacusis? • Stapedius weakness more oscillations on oval window and conduction. ▹ What may happen to this patient’s sense of taste? • Decreased. Chorda tympani is a branch of 7. • Taste Anterior 2/3 of tongue. ▹ What pharyngeal arch is related to cranial nerve 7? • 2nd Microbiology Integration What are organisms related to Bell’s Palsy? ▹ HSV • Double stranded, DNA linear virus ▹ Borrelia Burgdorferi • Obligate intracellular spirochete Borrelia Burgdorferi Neurology: Bell’s Palsy 249 uploaded by medbooksvn Cranial Nerve Path (2) NBME Top Concepts ➤ Neurology USMLE Vignette Neurology: Cranial Nerve Path (2) 250 Multiple Sclerosis NBME Top Concepts ➤ Neurology Multiple Sclerosis A 24-year-old woman with MS has an MRI that shows demyelination of the optic nerve on the left side. On physical exam, what will happen to both pupils when light hits the right pupil? • They will constrict optic neuritis • USMLE Point: • Young female with focal neurological deficit think multiple sclerosis. Neuroanatomy Integration Creative Commons Attribution License 4.0 Vignettes for Multiple Sclerosis Neurology: Multiple Sclerosis 251 uploaded by medbooksvn Dementia NBME Top Concepts ➤ Neurology NBME Style Question A 40-year-old woman presents with a skin rash. She is noted by her family members to have increased episodes of disorientation. The exam is notable for a skin rash on the arms along within the buttocks region. Further history notes increased loose stools and BMI 18. The patient has poor performance on the mental status exam. Which of the following is the most likely pathophysiologic mechanism behind the diagnosis? A. Nutritional deficiency. B. Age-related changes. C. Degeneration of the frontal and temporal regions. E. Neurocutaneous syndrome. Test Taking Strategy: Recognition of Triads on the USMLE What is the likely amino acid precursor? ▹ Tryptophan Neurology: Dementia 252 Dementia NBME Top Concepts ➤ Neurology Dementia for the USMLE Neurology: Dementia 253 uploaded by medbooksvn Dopamine Pathways NBME Top Concepts ➤ Neurology USMLE Neuroanatomy Integration Neurology: Dopamine Pathways 254 Trinucleotide Repeat Disorders NBME Top Concepts ➤ Neurology Trinucleotide Repeat Disorders A 48-year-old male is found by law enforcement homeless on the street, he has multiple domestic violence issues. His family is contacted and says that he has been very threatening over the past few months. The patient during the interview is noted to be smiling intermittently and moving his arms and legs in an uncontrollable manner. His paternal uncle had “some neuro issues” and passed away in middle age. What brain structure may be affected in this patient? • Atrophy of caudate (striatum) Huntington’s Disease • What genetic inheritance pattern? • Anticipation and trinucleotide CAG repeats • What chromosome is affected? • Chromosome 4, AD Creative Commons Attribution License 4.0 USMLE Trinucleotide Repeats Neurology: Trinucleotide Repeat Disorders 255 uploaded by medbooksvn Neurocutaneous Syndromes NBME Top Concepts ➤ Neurology NBME Style Question A 2-year-old female presents with episodes concerning for seizures. On exam, her skin is noted to have small flesh-colored, acne-like lesions. Wood lamp exam shows hypo-pigmented lesions on the trunk and extremities. A murmur is heard. Which of the following echocardiographic findings would be most likely seen in this patient? A. Regurgitation of the aortic valve due to abnormal vaso-vasorum. B. Pulmonic valve stenosis due to failed neural crest migration. C. Mitral regurgitation due to intercavitary mass. D. Mitral valve prolapse due to connective tissue defect. Tuberous Sclerosis Creative Commons Attribution License 4.0 Neurology: Neurocutaneous Syndromes 256 Neurocutaneous Syndromes NBME Top Concepts ➤ Neurology Neuro-fibromatosis Creative Commons Attribution License 4.0 Neurology: Neurocutaneous Syndromes 257 uploaded by medbooksvn Neurocutaneous Syndromes NBME Top Concepts ➤ Neurology Neurocutaneous Syndromes Creative Commons Attribution License 4.0 Neurology: Neurocutaneous Syndromes 258 Brain Tumors NBME Top Concepts ➤ Neurology Organization of Brain Tumors for the USMLE Brain Tumor Rapid Review GFAP+ cells + Rosenthal fibers + cystic/solid components + infratentorial mass? • Astrocytoma PNET+ cells + cystic mass at cerebellar vermis + drop metastasis + Homer Wright? • Medulloblastomas Rapidly progressive mass + midline crossing on MRI + pseudo-palisading tumor cells? • Glioblastoma Multiforme Middle aged female + new onset seizure + ER positive brain mass + psammoma bodies? • Meningioma Neurology: Brain Tumors 259 uploaded by medbooksvn Brain Tumors NBME Top Concepts ➤ Neurology Psammoma Bodies for the USMLE Creative Commons Attribution License 4.0 Neurology: Brain Tumors 260 Strokes NBME Top Concepts ➤ Neurology Test Taking Strategy: Approach to Stroke Questions on the USMLE Isolate focal neurological deficit in vignette. ▸ Sensory and motor dysfunction = large vessel stroke. ▸ Innervation is contralateral ▸ Relate to the homunculus: ▹Arms and face lateral brain MCA ▹Trunk and LE medial brain ACA. NBME Style Question An 80-year-old male presents with left sided numbness and weakness. The patient is noted to have prominent left arm weakness more than the leg. Patient has sensory deficits in the left arm. Visual fields are normal. MRI scan is notable for an ischemic stroke. Which of the following vascular structures may be affected in this patient? A. Left Middle Cerebral Artery B. Right Middle Cerebral Artery C. Left Anterior Cerebral Artery D. Right Anterior Cerebral Artery E. Posterior Cerebral Artery F. Lacunar Artery Strokes for the USMLE Neurology: Strokes 261 uploaded by medbooksvn Strokes NBME Top Concepts ➤ Neurology NBME Style Question A 40-year-old male presents with vertebral trauma. He is noted to have R facial numbness. The exam is notable for hoarseness. There is a reduced sensation of pain and temperature on the right side of the face, and the left side of the body. He is noted to have ataxia when asked to walk. Which of the following arteries may be affected in this patient? A. Posterior Inferior Cerebellar Artery B. Anterior Inferior Cerebellar Artery C. Anterior Cerebral Artery D. Posterior Cerebral Artery PICA vs. AICA strokes for the USMLE Neurology: Strokes 262 Answer Key NBME Top Concepts ➤ Neurology Brain Hematomas A 23-year-old male presents to trauma bay after MVC. He is noted to be awake and alert on primary survey. Two hours later, he is noted to have a loss of consciousness. His vitals are 140/80, pulse 60/min, RR 10. His pupil is mildly dilated, and bruising is noted in his temple. What is the likely diagnosis? A. Middle Cerebral Artery Ischemic Stroke. B. Epidural Hematoma. C. Subdural Hematoma. D. Subarachnoid hemorrhage. E. Rupture of Bouchard aneurysm. Herniation Syndromes & Cerebral Physiology A 6-year-old male presents to the intensive care unit after diagnosis of subarachnoid hemorrhage. One hour after admission, his vital signs are notable for BP 140/80, HR 60, RR 12. He has a right pupil minimally reactive and 4 mm in diameter, his left pupil is noted to be 2 mm and reactive. Given normal cerebral autoregulation, which of the following interventions may reduce elevated intracranial pressure in this patient? A. Hypoventilation B. No change in respirations C. Increased blood pressure by stimulating alpha-receptors D. Hyperventilation Cranial Nerve Path (1) A 16-year-old female presents with fever and throat pain. She is noted to have increased fatigue for the past week. Vital signs are notable for fever. The physical exam is notable for exudates on tonsils and left-sided uvular deviation. CT of the neck shows concern for injury to a cranial nerve. Which of the following nerves related to this patient’s exam findings is most likely to be affected? A. Vagus B. Glossopharyngeal C. Hypoglossal D. Trochlear E. Trigeminal Neurology: Answer Key 263 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Neurology Dementia A 40-year-old woman presents with a skin rash. She is noted by her family members to have increased episodes of disorientation. The exam is notable for a skin rash on the arms along within the buttocks region. Further history notes increased loose stools and BMI 18. The patient has poor performance on the mental status exam. Which of the following is the most likely pathophysiologic mechanism behind the diagnosis? A. Nutritional deficiency. B. Age-related changes. C. Degeneration of the frontal and temporal regions. E. Neurocutaneous syndrome. Neurocutaneous Syndromes A 2-year-old female presents with episodes concerning for seizures. On exam, her skin is noted to have small flesh-colored, acne-like lesions. Wood lamp exam shows hypo-pigmented lesions on the trunk and extremities. A murmur is heard. Which of the following echocardiographic findings would be most likely seen in this patient? A. Regurgitation of the aortic valve due to abnormal vaso-vasorum. B. Pulmonic valve stenosis due to failed neural crest migration. C. Mitral regurgitation due to intercavitary mass. D. Mitral valve prolapse due to connective tissue defect. Strokes An 80-year-old male presents with left sided numbness and weakness. The patient is noted to have prominent left arm weakness more than the leg. Patient has sensory deficits in the left arm. Visual fields are normal. MRI scan is notable for an ischemic stroke. Which of the following vascular structures may be affected in this patient? A. Left Middle Cerebral Artery B. Right Middle Cerebral Artery C. Left Anterior Cerebral Artery D. Right Anterior Cerebral Artery E. Posterior Cerebral Artery F. Lacunar Artery Neurology: Answer Key 264 Answer Key NBME Top Concepts ➤ Neurology Strokes A 40-year-old male presents with vertebral trauma. He is noted to have R facial numbness. The exam is notable for hoarseness. There is a reduced sensation of pain and temperature on the right side of the face, and the left side of the body. He is noted to have ataxia when asked to walk. Which of the following arteries may be affected in this patient? A. Posterior Inferior Cerebellar Artery B. Anterior Inferior Cerebellar Artery C. Anterior Cerebral Artery D. Posterior Cerebral Artery Neurology: Answer Key 265 uploaded by medbooksvn CHAPTER 13 High Yield Images & PE Findings: Neurology 266 High Yield Images & PE Findings ➤ Neurology Neuroanatomy NBME Style Question A 40-year-old male presents with uncontrolled jerking movements. He has had gait disturbances in the past 3 weeks. He has a family history of dementia in his father. On exam, he has a grimace on his face. He undergoes MRI and findings show a lesion in the area marked by red. Which of the following neuroanatomical structures may be implicated? A. Red Nucleus B. Caudate C. Thalamus D. Internal Capsule E. Cingulate Gyrus Caudate Nucleus Creative Commons Attribution License 4.0 Neurology: Neuroanatomy 267 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Trinucleotide Repeat Disorders Trinucleotide Repeat Disorders USMLE Vignette Creative Commons Attribution License 4.0 A 6-year-old male has dull headaches. He is noted to have dizziness and blurry vision. He is an avid baseball player and states he has frequent tunnel vision. An MRI is completed and shows a mass (red arrows). Compression of which structure is most likely responsible for the patient’s visual deficits? • Optic Chiasm • What is the likely diagnosis? • Craniopharyngioma • What is the embryological origin of this tumor? • Rathke’s Pouch surface ectoderm • Endocrine integration: patients may present with pituitary hypofunction on the USMLE (i.e. low growth hormone, low ACTH, etc.). Neurology: Trinucleotide Repeat Disorders 268 Pituitary Masses High Yield Images & PE Findings ➤ Neurology Craniopharyngioma Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 Neurology: Pituitary Masses 269 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Thalamic Stroke NBME Style Question A patient presents with sensory deficits. She has a history of diabetes and hypertension. The patient has diminished right side sensation of the face and pain, touch, temperature of the entire side of right body. The patient has muscle strength that is normal. Speech, vision, and hearing are also normal. What is the likely stroke this patient is exhibiting? A. Pons B. Thalamus C. Somatosensory Cortex D. Motor Cortex Thalamus sandwiches the Third Ventricle Creative Commons Attribution License 4.0 Neurology: Thalamic Stroke 270 High Yield Images & PE Findings ➤ Neurology Central Pontine Myelinolysis Central Pontine Myelinolysis A 35-year-old male with history of small cell lung cancer presents with tonic clonic jerking of the extremities. He is diagnosed with a seizure. He continues to seize in the ER. Preliminary labs are notable for a Na of 125. He is administered hypertonic saline & presents to the ICU, where over the next 2 hours he has a normal Na. The patient continues to have CNS dysfunction. Head imaging is underwent and shown. What is the likely diagnosis? • Central Pontine Myelinolysis • What are the cranial nerves which could be affected? • CN 9, 10, and 11. Creative Commons Attribution License 4.0 NBME Style Question Which of the following scenarios would likely show the change in this diagram (solid line original; change in dashed line)? A. Administration of 3% hypertonic saline B. Administration of isotonic saline C. SIADH D. Diarrhea Neurology: Central Pontine Myelinolysis 271 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Internal Capsule and Lacunar Strokes Neuroanatomy for the USMLE A patient with history of DM, dyslipidemia and smoking presents with inability to speak. The patient is noted to have preserved sensation in all of his extremities however it is noted that the musculature of the face, arm and leg on the right side are weak and paralyzed. Which of the following structures may be implicated? • B. Internal Capsule Creative Commons Attribution License 4.0 Lacunar Strokes Neurology: Internal Capsule and Lacunar Strokes 272 High Yield Images & PE Findings ➤ Neurology Internal Capsule and Lacunar Strokes Neuroanatomy for the USMLE A patient presents to the pathologist for autopsy. He was diagnosed with a malignant brain tumor which was from the astrocyte lineage. Gross pathology shows areas of hemorrhage and necrosis in bilateral hemispheres. What is the likely brain tumor? • Glioblastoma multiforme What structure allowed for this patient to have bilateral involvement? • Corpus callosum. Neurology: Internal Capsule and Lacunar Strokes 273 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Intracranial Tumours for the USMLE Intracranial Tumors for the USMLE Neurology: Intracranial Tumours for the USMLE 274 High Yield Images & PE Findings ➤ Neurology Multiple Sclerosis Vignettes for Mutltiple Sclerosis Creative Commons Attribution License 4.0 Neurology:Multiple Sclerosis 275 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Cerebral Edema NBME Style Question A patient presents with head trauma. 48 hours after the trauma the patient is noted to have a clinical decompensation and goes into a coma. Damage to which of the following structures may be implicated in this patient’s coma? A. Thalamus B. Cerebellar vermis C. Reticular Activating System D. Internal Capsule Monroe Kelly Doctrine Creative Commons Attribution License 4.0 Neurology: Cerebral Edema 276 High Yield Images & PE Findings ➤ Neurology Intracranial Pressure Intracranial Pressure Creative Commons Attribution License 4.0 NBME Style Question A 6-year-old male presents to the intensive care unit after diagnosis of subarachnoid hemorrhage. One hour after admission, his vital signs are notable for BP 140/80, HR 60, RR 12. He has a right pupil minimally reactive and 4 mm in diameter, his left pupil is noted to be 2 mm and reactive. Given normal cerebral autoregulation, which of the following interventions may reduce elevated intracranial pressure in this patient? A. Hypoventilation B. No change in respirations C. Increased blood pressure by stimulating alpha-receptors D. Hyperventilation Neurology: Intracranial Pressure 277 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Cerebral Autoregulation Cerebral Autoregulation Creative Commons Attribution License 4.0 Neurology: Cerebral Autoregulation 278 Baroreceptor Reflex High Yield Images & PE Findings ➤ Neurology Baroreceptor Reflex Integration Creative Commons Attribution License 4.0 Increased Intracranial Pressure Neurology: Baroreceptor Reflex 279 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Baroreceptor Reflex Question Which set of changes in plasma concentration would be expected to cause the greatest activation of the chemoreceptor reflex? Cerebral Edema NBME Style Question A patient after TBI has rigid extension of the upper and lower extremities and mid-positioned fixed pupils. The lesion which explains this patient’s posturing is most likely: A. Pons B. Thalamus C. Substantia Nigra D. Cerebral Hemisphere Neurology: Baroreceptor Reflex 280 High Yield Images & PE Findings ➤ Neurology Upper Motor Neuron Signs & Posturing UMN Signs Neurology: Baroreceptor Reflex 281 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Spinal Cord Pathologies High Yield Spinal Cord Anatomy for the USMLE Spinal Cord Pathologies Neurology: Spinal Cord Pathologies 282 High Yield Images & PE Findings ➤ Neurology Spinal Cord Pathologies Methylmalonic Acidemia occurs due to lack of B12 Think Like the Test Maker B12 Deficiency Neurology: Spinal Cord Pathologies 283 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Spinal Cord Pathologies Spinal Cord Pathologies Spinal Cord Pathologies Neurology: Spinal Cord Pathologies 284 High Yield Images & PE Findings ➤ Neurology Pseudotumor Cerebri Pseudotumor Cerebri Swelling of the Optic Disk Key Triggers in USMLE Questions Creative Commons Attribution License 4.0 Neurology: Pseudotumor Cerebri 285 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Hydrocephalus Hydrocephalus for the USMLE Hydrocephalus Neurology: Hydrocephalus 286 High Yield Images & PE Findings ➤ Neurology Hydrocephalus Hydrocephalus A 75-year-old woman who presents with her son who says he has noticed her forgetting things. She has had a history of evacuated sub-dural hematomas, and states she is embarrassed to come to the physician because she “wets herself.” What is the likely diagnosis? • NPH stretching of the corona radiate. • Pathophysiology: • Descending sacral ganglia nerve fibers going to the bladder stretch release of the bladder causes a reflex filling and • Questions will have triad of “wet, wobbly, and wacky” • Incontinence • Gait described as “magnetic” like there is gum on the floor • Look for dilated ventricles on imaging. Neurology: Hydrocephalus 287 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology CNS Infections Meningitis Neurology: CNS Infections 288 High Yield Images & PE Findings ➤ Neurology Answer Key Neuroanatomy A 40-year-old male presents with uncontrolled jerking movements. He has had gait disturbances in the past 3 weeks. He has a family history of dementia in his father. On exam, he has a grimace on his face. He undergoes MRI and findings show a lesion in the area marked by red. Which of the following neuroanatomical structures may be implicated? A. Red Nucleus B. Caudate C. Thalamus D. Internal Capsule E. Cingulate Gyrus Thalamic Stroke A patient presents with sensory deficits. She has a history of diabetes and hypertension. The patient has diminished right side sensation of the face and pain, touch, temperature of the entire side of right body. The patient has muscle strength that is normal. Speech, vision, and hearing are also normal. What is the likely stroke this patient is exhibiting? A. Pons B. Thalamus C. Somatosensory Cortex D. Motor Cortex Central Pontine Myelinolysis Which of the following scenarios would likely show the change in this diagram (solid line original; change in dashed line)? A. Administration of 3% hypertonic saline B. Administration of isotonic saline C. SIADH D. Diarrhea Neurology: Answer Key 289 uploaded by medbooksvn High Yield Images & PE Findings ➤ Neurology Answer Key Cerebral Edema A patient presents with head trauma. 48 hours after the trauma the patient is noted to have a clinical decompensation and goes into a coma. Damage to which of the following structures may be implicated in this patient’s coma? A. Thalamus B. Cerebellar vermis C. Reticular Activating System D. Internal Capsule Intracranial Pressure A 6-year-old male presents to the intensive care unit after diagnosis of subarachnoid hemorrhage. One hour after admission, his vital signs are notable for BP 140/80, HR 60, RR 12. He has a right pupil minimally reactive and 4 mm in diameter, his left pupil is noted to be 2 mm and reactive. Given normal cerebral autoregulation, which of the following interventions may reduce elevated intracranial pressure in this patient? A. Hypoventilation B. No change in respirations C. Increased blood pressure by stimulating alpha-receptors D. Hyperventilation Baroreceptor Reflex A patient after TBI has rigid extension of the upper and lower extremities and mid-positioned fixed pupils. The lesion which explains this patient’s posturing is most likely: A. Pons B. Thalamus C. Substantia Nigra D. Cerebral Hemisphere Neurology: Answer Key 290 CHAPTER 14 Top NBME Concepts: Renal 291 uploaded by medbooksvn Renal Casts NBME Top Concepts ➤ Renal NBME Style Question A 69-year-old male comes in with back-pain, constipation & fatigue. Patient vital signs are stable. On exam, the patient has dry mucous membranes. Hgb: 8.6 (L) MCV: 92 BUN: 68 (H) Cr: 3.8 (H) Renal biopsy is notable for atrophic tubules, waxy casts which stain intensely with eosin. What is the most likely diagnosis? a.Pyelonephritis b.Urate Nephropathy c.Renal Papillary Necrosis d.Plasma cell Neoplasm e.Hypersensitivity interstitial nephritis Approach to Back Pain for the USMLE Renal: Renal Casts 292 Renal Casts NBME Top Concepts ➤ Renal Test-taking Strategy: Urinalysis You will likely see this in the labs portion of your vignette on the USMLE. ▸UA: ▹ Specific gravity (1.005-1.030) • High? • Concentrated pee • Low? • Dilute pee ▹ Leukocyte esterase • WBC in the pee (may indicate UTI) ▹ Nitrites • Indicative of gram negative bacteria ▹ Other • Heme, Protein, Glucose, Ketones. Integrative Vignette A patient presents after being found crushed under a fallen set of bricks. Bruising is noted throughout the body. He is noted to have a UA which shows +heme. On urine microscopy he has no RBCs noted. Creatinine is elevated. What is the likely diagnosis? ▹ Rhabdomyolysis: • Concept: urine dipstick cannot differentiate between hematuria and myoglobinuria. Urinalysis Whenever you see casts on UA think about tubular or glomerular damage. Casts are proteins which take the form of the tubule Creative Commons Attribution License 4.0 Renal: Renal Casts 293 uploaded by medbooksvn Renal Casts NBME Top Concepts ➤ Renal USMLE Vignette Creative Commons Attribution License 4.0 Renal: Renal Casts 294 Kidney Stones NBME Top Concepts ➤ Renal USMLE Test Taking Strategy: Regional Localization for Abdominal Pain USMLE Questions localize pertinent areas of abdominal pain on PE diagnosis better allows you to isolate Use this as a pertinent positive as you paraphrase the vignette. NBME Style Question A 40-year-old male comes in with R flank pain and nausea which radiates to the groin. He is tachycardic and has mild tenderness to percussion on the R side. Testicular US is negative. UA shows dysmorphic RBCs. Which of the following recommendations would prevent this pathology? a.Limit fluid intake. b.High protein diet. c.Increase calcium in diet. d.High sodium diet. e.Use of loop diuretics. Renal: Kidney Stones 295 uploaded by medbooksvn Kidney Stones NBME Top Concepts ➤ Renal Risk Factors for Kidney Stones Hypercalciuria: • Hyperparathyroidism. • Furosemide. Diet: • in sodium and protein • calcium • Dehydration Other stones: • Uric acid stones watch for patients with gout or CML, PV, etc. • Struvite stones watch for Klebsiella or Proteus UTI. Nephrolithiasis A large kidney stone in the distal ureter may cause what ultrasound finding? ▹ Hydronephrosis. In USMLE questions, what may urine microscopy show? ▹Free RBCs disruption of the ureteral epithelium • Ureter blood supply: • Proximal ureter: renal artery • Distal ureter: superior vesicular artery (branch of internal iliac). Renal: Kidney Stones 296 Kidney Stones NBME Top Concepts ➤ Renal Ureteral Blood Supply Creative Commons Attribution License 4.0 NBME Style Question A middle age female presents with flank pain and hematuria. She has a history of UTIs. She has a blood pressure of 150/80. Her prior urine cultures have grown Klebsiella, Proteus. CT is notable for calyceal dilation. Which of the following describes the pathogenesis of this patient’s UTI? a.Small stone in distal ureter. b.Stone composed of Mg Ammonia and Ca2+ c.Hydrolysis of urea precipitating alkaline urinary pH. d.Low urinary specific gravity. Renal: Kidney Stones 297 uploaded by medbooksvn Urea Cycle + Stones (pt. 2) NBME Top Concepts ➤ Renal Urea Cycle for the USMLE Why does our body need this pathway? ▸To take Ammonia (NH3) and convert it to a solubilized form Where in the body does this process occur? ▸Hepatocytes we excrete urea in urine • Key USMLE question: Pt with liver failure + asterixis What is the rate limiting enzyme of the urea cycle? ▸CPS I • Where is CPS II found? • In the cytosol and found in pyrimidine synthesis What is the allosteric or hormonal feedback? • Activated by n-acetylgultamate. Urea USMLE Questions related to the UREA Cycle Renal: Urea Cycle + Stones (pt. 2) 298 Urea Cycle + Stones (pt. 2) NBME Top Concepts ➤ Renal Pathogenesis of AMP Stones A patient presents with stones that are obstructing the renal pelvis. Proteus mirabilis is isolated on urine culture. What is the mechanism behind these calculi? • Proteus is urease+ hydrolyzes urea to NH3 (gives an pH) AMP stones What are other urease+ organisms? • Proteus • Ureaplasma • Nocardia • Cryptococcus • H. pylori Creative Commons Attribution License 4.0 Uric Acid stones What radiologic characteristic is notable with these stones? • Radiolucent. • Along with cystine stones. Uric acid and cysteine stones: • Alkalinize the urine for management. Remember: • CaP04 & AMP stones form in alkaline urine whereas cysteine and uric acid stones form in acidic urine USMLE Question for uric acid stone: • A patient who has recurrent gout presents with dehydration + kidney stone. A urine analysis shows urine pH being low. What would urine microscopy show? • Rhomboid shaped crystals. Creative Commons Attribution License 4.0 Renal: Urea Cycle + Stones (pt. 2) 299 uploaded by medbooksvn Urea Cycle + Stones (pt. 2) NBME Top Concepts ➤ Renal Calcium Oxalate Stones A patient with Chron’s disease presents with flank pain + hematuria. A diagnosis of nephrolithiasis is made. What is the mechanism behind the likely stone? • Malabsorption free lipids calcium binds to free lipids • Oxalate is free gets circulated and deposited in the kidney stones. USMLE Vignette Creative Commons Attribution License 4.0 Renal: Urea Cycle + Stones (pt. 2) 300 Intro to Nephritic/Nephrotic NBME Top Concepts ➤ Renal Broad Overview of Glomerular Disease for the USMLE Renal: Intro to Nephritic/Nephrotic 301 uploaded by medbooksvn Nephrotic Syndrome NBME Top Concepts ➤ Renal Nephrotic Syndrome A child presents with recurrent anasarca. The patient has recurrent infections and varicoceles. Labs are notable for hyperlipidemia. UA shows fatty casts. What is the mechanism behind: ▹Anasara? • Loss of oncotic pressure ▹Hyperlipidemia? • Reactive increase in lipoprotein synthesis (compensatory mechanism) ▹Recurrent infections? • Loss of immunoglobulins ▹Recurrent varicoceles, DVT, renal/mesenteric vein thrombosis? • Loss of ATIII Nephrotic Syndrome A child presents with scrotal edema and eye-puffiness. He had a history of URI one week prior. A diagnosis of minimal change disease is made. What is the most likely light microscopy finding? ▸Normal glomeruli Pathophysiology: ▸Cytokines loss of charge to basement membrane diffuse podocyte effacement on electron microscopy. What is the likely management? ▸Corticosteroids (very steroid responsive). Minimal Change disease Creative Commons Attribution License 4.0 Renal: Nephrotic Syndrome 302 Nephrotic Syndrome NBME Top Concepts ➤ Renal Nephrotic Syndrome A 50-year-old obese AA with PMH of HIV and sickle cell disease states he has been noticing increased fatigue and swelling in his leg. He is non-compliant with his treatment and social history demonstrates long standing heroin abuse. On labs, he has 3+ proteinuria and fatty casts. What is the likely diagnosis? ▸Focal Segmental Glomerulosclerosis ▸What may electron microscopy show? ▹Podocyte effacement like minimal change disease ▹Corticosteroids (poorly steroid responsive). FSGS Creative Commons Attribution License 4.0 NBME Style Question A 40-year-old female with history of lupus presents with proteinuria. She is noted to have ANA+, and anti-dsDNA antibody. Kidney biopsy is determined to be the next best step. Sample is notable for irregular spikes protruding from the GBM. What is the likely diagnosis? a.Minimal change disease b.Diffuse proliferative glomerulonephritis c.Membranous glomerulopathy d.Membranoproliferative glomerulonephritis Renal: Nephrotic Syndrome 303 uploaded by medbooksvn Nephrotic Syndrome NBME Top Concepts ➤ Renal Membranous Glomerulopathy Creative Commons Attribution License 4.0 Membranoproliferative Glomerulonephritis Renal: Nephrotic Syndrome 304 Nephrotic Syndrome NBME Top Concepts ➤ Renal USMLE Vignette Summary of Membranous Diseases Renal: Nephrotic Syndrome 305 uploaded by medbooksvn Nephrotic Syndrome NBME Top Concepts ➤ Renal Nephrotic Syndrome What is the most common cause of ESRD in the United States? ▸Diabetic Glomerulonephropathy. Pathophysiology of Diabetic Nephropathy Renal: Nephrotic Syndrome 306 Nephritic Syndrome NBME Top Concepts ➤ Renal Nephritic syndrome A child presents with recurrent hematuria. The patient is noted to have hypertension, oliguria and peri-orbital edema. ▸What is the mechanism behind: ▹Hypertension? • Salt retention + inflammation ▹Peri-orbital edema? • Salt retention fluid deposition in loose areolar tissue (potential space for fluid). ▸What does UA typically show? ▹Dysmorphic RBCs and RBC casts. Pathophysiology of Inflammation in Nephritic Syndrome Nephritic Syndrome A 6-year-old male presents with blood in his urine after having a URI + sore-throat. He is noted to be hypertensive. UA confirms hematuria + non-nephrotic range proteinuria. What is the most likely diagnosis? ▸ Well.. it is difficult to know as there is no time period… ▸2-3 days after URI and sore-throat? ▸IgA nephropathy ▸2-4 wks after URI and sore-throat? ▸Post-streptococcal glomerulonephritis. Renal: Nephritic Syndrome 307 uploaded by medbooksvn Nephritic Syndrome NBME Top Concepts ➤ Renal IgA Nephropathy USMLE Integration A 6-year-old child has bloody stools and colicky abdominal pain. He is noted to be tachycardic and hypertensive. There are raised, purple red skin lesions along the buttocks and lower extremities. What is the likely diagnosis? ▸Henoch Schoenlein Purpura ▸IgA vasculitis ▸USMLE Presentations: ▸Arthritis ▸Palpable purpura on LE ▸Renal disease ▸Intussusception NBME Style Question A child is noted to have red urine. He has a hx of atopic dermatitis. He was treated for a skin infection few weeks ago. He is noted to have hypertension and a BUN:Cr notable for intrinsic renal damage. What is the likely mechanism behind this patient’s condition? A. CD8+ T Lymphocytes. B. Histamine release. C. Auto-immune IgG antibodies. D. IgG immune complexes. Renal: Nephritic Syndrome 308 Nephritic Syndrome NBME Top Concepts ➤ Renal Post-streptococcal Glomerulonephritis Creative Commons Attribution License 4.0 Lupus Associated Renal Disease Renal: Nephritic Syndrome 309 uploaded by medbooksvn Nephritic Syndrome NBME Top Concepts ➤ Renal Hemoptysis & Hematuria Syndromes for the USMLE How do you tell MPA from Churg Strauss? P-ANCA positive for both. Churg strauss has asthma and eosinophilia, and granuloma. Renal: Nephritic Syndrome 310 Renal Failure NBME Top Concepts ➤ Renal NBME Style Question A 50-year-old male is admitted for heart failure. He is started on furosemide. He is noted to have a baseline BUN of 12 mg/dL, and Cr of 1.2 mg/dL. On day 5 of hospitalization, it is noted his BUN has risen to 40 mg/dL and Cr to 2.1. What is the likely mechanism? A. Increased upregulation of aquaporins. B. Ureteral compression leading to hydronephrosis. C. Tubular necrosis. D. Decreased efferent perfusion. Pathophysiology of Pre-Renal Azotemia USMLE Vignette Renal: Renal Failure 311 uploaded by medbooksvn Diuretics NBME Top Concepts ➤ Renal NBME Style Question A 65-year-old male presents with skin rash and fever. He is noted to have a history of gout and CHF controlled on furosemide and NSAIDs. UA is notable for pyuria and no nitrites. Urine microscopy shows eosinophils. What is the likely mechanism? a. Immune complex deposition. b. Auto-antibody inflammation. c. IgE mediated hypersensitivity reaction. d. CD8+ interstitial damage. USMLE test-taking tip: • Isolate triggers in test-questions NSAIDS + diuretics cause Acute Interstitial Nephritis. Integrative Review of Diuretics for the USMLE Step 1 Renal: Diuretics 312 Diuretics NBME Top Concepts ➤ Renal Pharmacology Compare and Contrast Pathophysiology of Contraction alkalosis Renal: Diuretics 313 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Renal Renal Casts A 69-year-old male comes in with back-pain, constipation & fatigue. Patient vital signs are stable. On exam, the patient has dry mucous membranes. Hgb: 8.6 (L) MCV: 92 BUN: 68 (H) Cr: 3.8 (H) Renal biopsy is notable for atrophic tubules, waxy casts which stain intensely with eosin. What is the most likely diagnosis? a.Pyelonephritis b.Urate Nephropathy c.Renal Papillary Necrosis d.Plasma cell Neoplasm e.Hypersensitivity interstitial nephritis Kidney Stones A 40-year-old male comes in with R flank pain and nausea which radiates to the groin. He is tachycardic and has mild tenderness to percussion on the R side. Testicular US is negative. UA shows dysmorphic RBCs. Which of the following recommendations would prevent this pathology? a.Limit fluid intake. b.High protein diet. c.Increase calcium in diet. d.High sodium diet. e.Use of loop diuretics. A middle age female presents with flank pain and hematuria. She has a history of UTIs. She has a blood pressure of 150/80. Her prior urine cultures have grown Klebsiella, Proteus. CT is notable for calyceal dilation. Which of the following describes the pathogenesis of this patient’s UTI? a.Small stone in distal ureter. b.Stone composed of Mg Ammonia and Ca2+ c.Hydrolysis of urea precipitating alkaline urinary pH. d.Low urinary specific gravity. Renal: Answer Key 314 Answer Key NBME Top Concepts ➤ Renal Nephrotic Syndrome A 40-year-old female with history of lupus presents with proteinuria. She is noted to have ANA+, and anti-dsDNA antibody. Kidney biopsy is determined to be the next best step. Sample is notable for irregular spikes protruding from the GBM. What is the likely diagnosis? a.Minimal change disease b.Diffuse proliferative glomerulonephritis c.Membranous glomerulopathy d.Membranoproliferative glomerulonephritis Nephritic Syndrome A child is noted to have red urine. He has a hx of atopic dermatitis. He was treated for a skin infection few weeks ago. He is noted to have hypertension and a BUN:Cr notable for intrinsic renal damage. What is the likely mechanism behind this patient’s condition? A. CD8+ T Lymphocytes. B. Histamine release. C. Auto-immune IgG antibodies. D. IgG immune complexes. Renal Failure A 50-year-old male is admitted for heart failure. He is started on furosemide. He is noted to have a baseline BUN of 12 mg/dL, and Cr of 1.2 mg/dL. On day 5 of hospitalization, it is noted his BUN has risen to 40 mg/dL and Cr to 2.1. What is the likely mechanism? A. Increased upregulation of aquaporins. B. Ureteral compression leading to hydronephrosis. C. Tubular necrosis. D. Decreased efferent perfusion. Diuretics A 65-year-old male presents with skin rash and fever. He is noted to have a history of gout and CHF controlled on furosemide and NSAIDs. UA is notable for pyuria and no nitrites. Urine microscopy shows eosinophils. What is the likely mechanism? a. Immune complex deposition. b. Auto-antibody inflammation. c. IgE mediated hypersensitivity reaction. d. CD8+ interstitial damage. Renal: Answer Key 315 uploaded by medbooksvn CHAPTER 15 High Yield USMLE Images & PE Findings: Renal 316 Renal Stones High Yield Images & PE Findings ➤ Renal NBME Style Question A patient presents with left groin pain and microscopic hematuria. Bowel sounds are hypoactive. Which of the following recommendations would most likely prevent a representation of this patient’s illness? A. Safe sex B. Avoidance of lactose C. Low Ca diet D. Increased fluid Intake E. Follow high fiber diet Renal Casts What do casts represent? • Entrapped cells, debris, protein which form in tubular lumens as they leak through glomerulus. Creative Commons Attribution License 4.0 Renal: Renal Stones 317 uploaded by medbooksvn Renal Stones High Yield Images & PE Findings ➤ Renal Urine Analysis Interpretation for the USMLE NBME Style Question A child presents unresponsive. He was playing in the garage last with some fluid stored in a Gatorade bottle. Airway measures are undertaken. The patient passes away due to renal failure. An autopsy shows multiple crystals in the tubular lumen. Which of the following substances are these crystals likely composed of? A. Cystine B. Uric Acid C. Ammonia Mag Phos D. Oxalate E. Lactate Endocrine Integration A patient presents with bone pain. She is noted to have an elevated iCa. Serum studies show an elevated PTH level. UA is notable for microscopic hematuria. What is the likely mechanism of disease? • HyperPTH increased serum calcium calciuria. • Calcium stones are the most common in nephrolithiasis. From Goldman L, Schafer A: Goldman’s Cecil Medicine, 25th ed, Philadelphia, Elsevier Saunders, 2016, p 813, Fig. 126-2. Renal: Renal Stones 318 Renal Stones High Yield Images & PE Findings ➤ Renal Microbiology Integration A patient presents with flank pain. The patient is afebrile. An ultrasound of the abdomen is notable for cortical dilation. UA is positive for LE. A gram negative bacili is isolated on urine culture. When plated, the bacteria catalyzes a reaction from NH2 to ammonia. What is the likely diagnosis? • A Struvite Stone 2/2 Proteus Mirabilis UTI • What is the composition of these stones? • Ammonium, Magnesium, Phosphate • Relate to Urease + organisms. Staghorn Calculus Creative Commons Attribution License 4.0 Gastrointestinal Integration A patient with history of weight loss and foul smelling stools presents with flank pain that radiates to the groin. She has had endoscopies which have revealed noncaseating granulomas in duodenum. ESR is elevated. The patient is dx with a kidney stone in the mid ureter. What is the likely mechanism of the nephrolithiasis? • Calcium Oxalate Stones related to Chron’s Disease. Renal: Renal Stones 319 uploaded by medbooksvn Renal Stones High Yield Images & PE Findings ➤ Renal Calcium Oxalate Stones in Inflammatory Bowel Disease NBME Style Question A patient with history of type 2 DM, obesity, and hyperlipidemia presents with vomiting and flank pain. He has no fever. He is found to have hydronephrosis of the left kidney and proximal ureter dilation on renal ultrasound. What is the most likely finding which would be found in this patient’s urine analysis? A. Malignant tumor cells B. RBCs C. Pyuria D. Red cell casts E. Low specific gravity Renal: Renal Stones 320 Renal Stones High Yield Images & PE Findings ➤ Renal Nephrolithiasis Nephrolithiasis Renal: Renal Stones 321 uploaded by medbooksvn Polycystic Kidneys High Yield Images & PE Findings ➤ Renal NBME Style Question A patient is found to have recurrent pyelonephritis. She is noted to have an anatomical abnormality of the kidney centered around a major aortic vessel. Which of the following vessels may be the likely etiology of the pathology? A. Inferior Mesenteric Artery B. Inferior Vena Cava C. Splenic Artery D. Renal vein Horseshoe Kidney Creative Commons Attribution License 4.0 Renal: Polycystic Kidneys 322 Polycystic Kidneys High Yield Images & PE Findings ➤ Renal Gastrointestinal Anatomy Integration What is the degree of rotation of the Midgut? • 270 degrees Counter-CLOCKWISE at week 10 of development Renal Embryology Creative Commons Attribution License 4.0 Renal: Polycystic Kidneys 323 uploaded by medbooksvn Polycystic Kidneys High Yield Images & PE Findings ➤ Renal Amniotic Fluid Abnormalities for the usmle General Pathology Integration Renal: Polycystic Kidneys 324 Polycystic Kidneys High Yield Images & PE Findings ➤ Renal NBME Style Question A 50-year-old male presents with sudden onset headache. Exam shows nuchal rigidity and photophobia. The patient has no cranial nerve deficits or trauma. He is otherwise healthy. Family history is notable for his brother having cystic kidneys. What is the likely diagnosis? A. Cluster headache B. Migraine C. Subarachnoid hemorrhage D. Lobar hemorrhage E. Bacterial meningitis Autosomal Dominant Polycystic Kidney Disease Renal: Polycystic Kidneys 325 uploaded by medbooksvn Polycystic Kidneys High Yield Images & PE Findings ➤ Renal Polycystic Kidney Disease Congenital Renal Tract Disorders A 2-week male presents with oliguria and palpable mass in lower abdomen. Prenatal records reveal oligohydramnios. What is the likely finding seen on ultrasound? •Thick bladder with bilateral hydronephrosis diagnosis: Posterior Urethral Valve Creative Commons Attribution License 4.0 Renal: Polycystic Kidneys 326 Polycystic Kidneys High Yield Images & PE Findings ➤ Renal Azotemia NBME Style Question A child presents with recurrent urinary tract infections. She undergoes renal ultrasound which reveals dilated renal calyces and cortical atrophy of the upper and lower renal poles. There are changes in the ureter anatomy as well. Which of the following mechanisms best explains her clinical complaint? A. Malignant hypertension B. Childhood lupus C. Vesicoureteral Reflux D. AR Polycystic kidney disease Renal: Polycystic Kidneys 327 uploaded by medbooksvn Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Azotemia Approach to Understanding Glomerular Diseases Renal: Nephrotic & Nephritic Syndromes 328 Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Presentation of Glomerular Diseases on the USMLE Normal Glomerular Anatomy Renal: Nephrotic & Nephritic Syndromes 329 uploaded by medbooksvn Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Minimal Change Disease • What will light microscopy show? • Normal glomeruli • What is the mechanism behind the electron microscopy findings? • Loss of charge of basement membrane + effacement of the podocyte. • What causes destruction of the podocyte? • T cells from infection cytokines (IL-5, for Hodgkin's) effacement. Minimal Change Disease Focal Segmental Glomerulosclerosis A 50-year-old obese, AA with PMH of HIV and sickle cell disease states he has been noticing increased fatigue and swelling in his leg. He is non-compliant with his treatment and social history demonstrates long standing heroin abuse. On labs, he has 3+ proteinuria and fatty casts. • What may his Electron Microscopy show? • Effacement of podocytes • How do you tell the difference between this and MCD? • Patient in FSGS do not respond to steroids • MCD FSGS Renal: Nephrotic & Nephritic Syndromes 330 Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Minimal Change Disease • What will light microscopy show? • Normal glomeruli • What is the mechanism behind the electron microscopy findings? • Loss of charge of basement membrane + effacement of the podocyte. • What causes destruction of the podocyte? • T cells from infection cytokines (IL-5, for Hodgkin's) effacement. Minimal Change Disease Membranous Glomerulonephropathy • Most common cause of nephrotic syndrome in a Lupus patient? • Membranous nephropathy • Most common overall renal syndrome associated with Lupus: • Diffuse proliferative glomerulonephritis • Membranous nephropathy can also be due to what autoimmune other phenomena? • Antibodies to PLA2 Type II HS. Renal: Nephrotic & Nephritic Syndromes 331 uploaded by medbooksvn Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Membranous Glomerulonephropathy Nephrotic Syndrome Renal: Nephrotic & Nephritic Syndromes 332 Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Lupus Associated Renal Disease Creative Commons Attribution License 4.0 Mebranoproliferative Glomerulonephritis Renal: Nephrotic & Nephritic Syndromes 333 uploaded by medbooksvn Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Mebranoproliferative Glomerulonephritis Summary of Membranous Disorders Renal: Nephrotic & Nephritic Syndromes 334 Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Nephritic Syndromes A 6-year-old male presents with blood in his urine after having a URI + sore-throat. He is noted to be hypertensive. UA confirms hematuria + non-nephrotic range proteinuria. What is the most likely diagnosis? • Well.. it is difficult to know as there is no time period… • 2-3 days after URI and sore-throat? • IgA nephropathy • 2-4 wks after URI and sore-throat? • Post-streptococcal glomerulonephritis. IgA Nephropathy & Post Streptococcal Glomerulonephritis Renal: Nephrotic & Nephritic Syndromes 335 uploaded by medbooksvn Nephrotic & Nephritic Syndromes High Yield Images & PE Findings ➤ Renal Glomerulonephritis Images Nephritic Syndrome Renal: Nephrotic & Nephritic Syndromes 336 Tumors of the Urinary Tract High Yield Images & PE Findings ➤ Renal NBME Style Question A 15 month old male brought in by mother after she noticed he had decreased appetite and a mass felt while she was bathing him. On CT of the abdomen, the mass does not cross the midline and is confined to the retroperitoneum. What is the likely diagnosis? A. Hepatoblastoma B. Neuroblastoma C. Nephroblastoma D. Hepatorenal syndrome Differentiation of Wilms Tumor vs. Neuroblastoma Renal: Tumors of the Urinary Tract 337 uploaded by medbooksvn Tumors of the Urinary Tract High Yield Images & PE Findings ➤ Renal Summary of Urinary Tumors Renal: Tumors of the Urinary Tract 338 High Yield Images & PE Findings ➤ Renal Answer Key Renal Stones A patient presents with left groin pain and microscopic hematuria. Bowel sounds are hypoactive. Which of the following recommendations would most likely prevent a representation of this patient’s illness? A. Safe sex B. Avoidance of lactose C. Low Ca diet D. Increased fluid Intake E. Follow high fiber diet A child presents unresponsive. He was playing in the garage last with some fluid stored in a Gatorade bottle. Airway measures are undertaken. The patient passes away due to renal failure. An autopsy shows multiple crystals in the tubular lumen. Which of the following substances are these crystals likely composed of? A. Cystine B. Uric Acid C. Ammonia Mag Phos D. Oxalate E. Lactate A patient with history of type 2 DM, obesity, and hyperlipidemia presents with vomiting and flank pain. He has no fever. He is found to have hydronephrosis of the left kidney and proximal ureter dilation on renal ultrasound. What is the most likely finding which would be found in this patient’s urine analysis? A. Malignant tumor cells B. RBCs C. Pyuria D. Red cell casts E. Low specific gravity Renal: Answer Key 339 uploaded by medbooksvn High Yield Images & PE Findings ➤ Renal Answer Key Polycystic Kidneys A patient is found to have recurrent pyelonephritis. She is noted to have an anatomical abnormality of the kidney centered around a major aortic vessel. Which of the following vessels may be the likely etiology of the pathology? A. Inferior Mesenteric Artery B. Inferior Vena Cava C. Splenic Artery D. Renal vein A child presents with recurrent urinary tract infections. She undergoes renal ultrasound which reveals dilated renal calyces and cortical atrophy of the upper and lower renal poles. There are changes in the ureter anatomy as well. Which of the following mechanisms best explains her clinical complaint? A. Malignant hypertension B. Childhood lupus C. Vesicoureteral Reflux D. AR Polycystic kidney disease Tumors of the Urinary Tract A 15 month old male brought in by mother after she noticed he had decreased appetite and a mass felt while she was bathing him. On CT of the abdomen, the mass does not cross the midline and is confined to the retroperitoneum. What is the likely diagnosis? A. Hepatoblastoma B. Neuroblastoma C. Nephroblastoma D. Hepatorenal syndrome Renal: Answer Key 340 CHAPTER 16 Top NBME Concepts: Reproductive 341 uploaded by medbooksvn Disorders of Sexual Development NBME Top Concepts ➤ Reproductive Test Taking Strategy for Embryology Reproductive Questions NBME Style Question A 15-year-old boy presents with delayed growth spurt. He has had decreased hair growth in his pubic region. Intelligence test is normal. Audiometry evaluation is normal. He is unable to distinguish smells. Ophthalmic exam is normal. Which of the following mechanisms may explain this patient’s disease? A. Primary seminiferous tubule absence. B. Genetic X,O Karyotype. C. Absence of GnRH secretory neurons. D. Rathke’s pouch dysfunction. E. Failure of somatotroph development in the pituitary. Reproductive: Disorders of Sexual Development 342 Disorders of Sexual Development NBME Top Concepts ➤ Reproductive Kalman Syndrome An adult with anosmia and failure of pubertal development presents to the physician for evaluation of infertility. What laboratory abnormalities may be expected? Low GnRH, FSH, LH, and testosterone. Failure of GnRH-releasing olfactory bulbs to migrate. What bony structure does the olfactory nerve exit the cranial cavity? • Cribiform plate of the ethmoid bone. Creative Commons Attribution License 4.0 Disorders of Sexual Development A 16-year-old female presents for evaluation of primary amenorrhea. She has on growth chart short stature, and on exam broad spaced nipples. What are the cardiovascular malformations behind the likely diagnosis? Coarctation of the aorta and bicuspid aortic valve. Turner Syndrome Creative Commons Attribution License 4.0 Reproductive: Disorders of Sexual Development 343 uploaded by medbooksvn Disorders of Sexual Development NBME Top Concepts ➤ Reproductive NBME Style Question A medical school anatomy class is undergoing anatomy review in the cadaveric lab. On one of the cadaveric specimen’s, it is noted that the patient has a bicuspid aortic valve. Which of the following murmurs is consistent with this finding’s downstream pathology? A. Diastolic murmur heard at the sternal border. B. A systolic murmur with click heard at the apex. C. Diastolic murmur heard at the R second ICS. D. Systolic murmur heard at the R second ICS. Bicuspid Aortic Valve can lead to Premature Aortic Stenosis (Triad) Reproductive: Disorders of Sexual Development 344 Turner's Syndrome Integration NBME Top Concepts ➤ Reproductive Systemic Manifestations of Turner's for the USMLE Key Chest X-Ray Findings Related To Turner's Syndrome Rib Notching = Engorgement of Intercostal Arteries Creative Commons Attribution License 4.0 Reproductive: Turner's Syndrome Integration 345 uploaded by medbooksvn Turner's Syndrome Integration NBME Top Concepts ➤ Reproductive Cardiology Integration – Genetic defects Turner's Syndrome vs. Klinefelter's Syndrome Reproductive: Turner's Syndrome Integration 346 Testosterone Disorders NBME Top Concepts ➤ Reproductive NBME Style Question A newborn is evaluated in the delivery room. The baby’s delivery course was unremarkable. Mother’s pregnancy was uncomplicated. Ambiguous genitalia and clitoromegaly are notable on baby’s exam. Mother states that during the latter half of her pregnancy she noticed her voice deepen and have dark coarse facial hair. Remaining maternal and baby exam is normal. Which of the following mechanisms accounts for this infant’s pathology? A. Activation of 21-Hydroxylase. B. Deficiency in 17-Hydroxylase. C. Placental Aromatase Deficiency. D. Increased HMG-CoA Reductase Activity. Turner's Syndrome vs. Klinefelter's Syndrome Children with 5-ɑ-reductase deficiency have male internal genital organs at birth At puberty no phallic growth ambiguous genitalia Reproductive: Testosterone Disorders 347 uploaded by medbooksvn Mullerian Agenesis VS. AIS NBME Top Concepts ➤ Reproductive Question A 16-year-old girl comes to her pediatrician with the complaint that she "has never had a menstrual period.” Her exam reveals a short, blind-ending vagina, and normal breast and pubic hair development. A uterus is not visualized on US. What is the likely diagnosis? Mullerian Agenesis • Key to these questions on the USMLE: •Primary amenorrhea (XX) with fully developed secondary sex characteristics. Mullerian Structures NBME Style Question A 16-year-old female presents with primary amenorrhea. She has had breast engorgement however she has not had any pubic hair. On exam, she is noted to have a blind ended vaginal pouch. Inguinal exam is notable for bilateral smooth masses. If genetic testing is obtained, what would be the likely karyotype? A. 46 X,Y B. 46 X,X C. 45 X,O D. 47 XXY Reproductive: Mullerian Agenesis vs. AIS 348 Mullerian Agenesis VS. AIS NBME Top Concepts ➤ Reproductive Mullerian Agenesis vs. Androgen Insensitivity Syndrome Reproductive: Mullerian Agenesis vs. AIS 349 uploaded by medbooksvn NBME Top Concepts ➤ Reproductive Summary of Disorders of Sexual Development Summary of Disorders of Sexual Development Reproductive: Summary of Disorders of Sexual Development 350 Polycystic Ovarian Syndrome NBME Top Concepts ➤ Reproductive Pathophysiology of PCOS Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 Management of PCOS Reproductive: Polycystic Ovarian Syndrome 351 uploaded by medbooksvn Polycystic Ovarian Syndrome NBME Top Concepts ➤ Reproductive High Androgen States for the USMLE Creative Commons Attribution License 4.0 NBME Style Question A 22-year-old female presents to the emergency department with RUQ. She has a history of PCOS controlled on OCPs. Ultrasound rules out cholelithiasis, however is notable for isoechoic, well demarcated, in-homogenous collection of blood in the right lobe of the liver. In the ED, patient has sudden tachycardia and hypotension. Which of the following pathophysiologic mechanisms most likely underlies this patient’s acute symptoms? A. Radio-opaque gallstone obstructing cystic duct B. Benign liver tumor C. Increased portal pressures due to hepatic fibrosis D. Ovarian artery torsion leading to hypovolemic shock Reproductive: Polycystic Ovarian Syndrome 352 Polycystic Ovarian Syndrome NBME Top Concepts ➤ Reproductive Hepatocellular Adenoma OCP + RUQ/Shock Creative Commons Attribution License 4.0 Reproductive: Polycystic Ovarian Syndrome 353 uploaded by medbooksvn Ovarian Physiology NBME Top Concepts ➤ Reproductive Study Tip: Anatomic Organization Creative Commons Attribution License 4.0 Two Cell Hypothesis Reproductive Physiology Integration Reproductive: Ovarian Physiology 354 Ovarian Tumors NBME Top Concepts ➤ Reproductive Introduction to Ovarian Tumors NBME Style Question A 60-year-old female G0P0 presents with increased satiety. She feels that she has decreased her appetite but continues to have increased waist circumference. Lipid panel and thyroid tests are unremarkable. There is adnexal fullness unilaterally. Which of the following markers is most likely elevated? A. CA-125 B. LDH C. Inhibin D. Testosterone E. B-HcG Reproductive: Ovarian Tumors 355 uploaded by medbooksvn Ovarian Tumors NBME Top Concepts ➤ Reproductive Types of Ovarian Tumors: Surface Ovarian Tumors Creative Commons Attribution License 4.0 Types of Ovarian Tumors: Germ Cell Tumors NBME Style Question A 30-year-old female presents with progressive lower abdominal pain. She is noted to have normal menses. Ultrasound shows a heterogenous unilateral mass. Doppler of ovarian vessels are normal. Patient undergoes removal. Mass is notable of tri-laminar germ disc derivatives. What is the likely diagnosis? A. Ectopic Pregnancy B. Endometriosis C. Serous Papillary Ovarian Cancer D. Ovarian Teratoma Creative Commons Attribution License 4.0 Reproductive: Ovarian Tumors 356 Ovarian Tumors NBME Top Concepts ➤ Reproductive Different Types of Germ Cell Tumors Ovarian Germ Cell Tumors Creative Commons Attribution License 4.0 Reproductive: Ovarian Tumors 357 uploaded by medbooksvn Ovarian Tumors NBME Top Concepts ➤ Reproductive Types of Ovarian Tumors: Stromal Tumors NBME Style Question A 49-year-old female presents with menstrual bleeding in-between her periods. She is otherwise healthy. An ovarian mass is found on pelvic ultrasonography. It is also noted that the patient has an increased endometrial stripe on ultrasound. She just completed her menses 3 days prior. Beta-hcg is negative. What is the likely hormone which may be implicated in this pathology? A. Estrogen B. Progesterone C. B-HCG D. Testosterone Different Types of Ovarian Stromal Tumors Reproductive: Ovarian Tumors 358 Ovarian Tumors NBME Top Concepts ➤ Reproductive Metastasis to Ovary Mucinous Cell of Ovary Creative Commons Attribution License 4.0 Reproductive: Ovarian Tumors 359 uploaded by medbooksvn Repro Ligaments NBME Top Concepts ➤ Reproductive NBME Style Question A post-menopausal female is scheduled to undergo a resection of right ovary for a complex ovarian cyst noted on trans-vaginal ultrasound. Prior to oophorectomy, which of the following anatomic structures must be ligated to prevent hemorrhagic shock? A. Utero-ovarian Ligament B. Suspensory ligament of ovary C. Round ligament of uterus D. Cardinal Ligament Anatomy Integration Reproductive: Repro Ligaments 360 Uterine Disorders NBME Top Concepts ➤ Reproductive Uterine Disorders Uterine Pathology A 24-year-old woman presents with pain and bleeding during menstruation. Her last three cycles have had bad cramps and large amounts of blood. She states that her cycle has been irregular for the last 6 months. She has dyspareunia. What is the likely diagnosis? • Endometriosis • Presence of glands & stroma outside of the endometrial lining • USMLE point: • Watch for cyclical abdominal pain in a menstruating female. Creative Commons Attribution License 4.0 Reproductive: Uterine Disorders 361 uploaded by medbooksvn Uterine Disorders NBME Top Concepts ➤ Reproductive Pathophysiology of Endometriosis Endometriosis & Anatomic Locations Creative Commons Attribution License 4.0 Reproductive: Uterine Disorders 362 Uterine Disorders NBME Top Concepts ➤ Reproductive NBME Style Question A 14-year-old girl presents to the emergency department for vaginal bleeding in between her cycles. She is unsure of her menstrual cycles, and her mom states she may have “had a period 2 weeks prior.” There is no trauma. There is no family history of bleeding disorders. Patient is otherwise healthy. What is the likely cause of this patient’s complaints? A. Endometrial atrophy. B. Increased corpus luteum activity. C. Increased spiral artery proliferation. D. Increased FSH. Anovulatory Bleeding Reproductive: Uterine Disorders 363 uploaded by medbooksvn Uterine Disorders NBME Top Concepts ➤ Reproductive Unopposed Estrogen Risk Factors General Pathology Integration Reproductive: Uterine Disorders 364 Uterine Disorders NBME Top Concepts ➤ Reproductive Endometrial Carcinoma Papillary serous type characterized by serous glands with papillary organization has a fibro-vascular core if that core necrosis and calcifies, what is the histopathological finding? • Psammoma Body Creative Commons Attribution License 4.0 General Pathology Integration How is a psammoma body described? • Laminated, concentric spherules with dystrophic calcification Reproductive: Uterine Disorders 365 uploaded by medbooksvn Cervical Disorders (HPV) NBME Top Concepts ➤ Reproductive Pathophysiology of HPV causing Cervical Camcer Creative Commons Attribution License 4.0 High Risk HPV Strains Creative Commons Attribution License 4.0 Reproductive: Cervical disorders (HPV) 366 Answer Key NBME Top Concepts ➤ Reproductive Disorders of Sexual Development A 15-year-old boy presents with delayed growth spurt. He has had decreased hair growth in his pubic region. Intelligence test is normal. Audiometry evaluation is normal. He is unable to distinguish smells. Ophthalmic exam is normal. Which of the following mechanisms may explain this patient’s disease? A. Primary seminiferous tubule absence. B. Genetic X,O Karyotype. C. Absence of GnRH secretory neurons. D. Rathke’s pouch dysfunction. E. Failure of somatotroph development in the pituitary. A medical school anatomy class is undergoing anatomy review in the cadaveric lab. On one of the cadaveric specimen’s, it is noted that the patient has a bicuspid aortic valve. Which of the following murmurs is consistent with this finding’s downstream pathology? A. Diastolic murmur heard at the sternal border. B. A systolic murmur with click heard at the apex. C. Diastolic murmur heard at the R second ICS. D. Systolic murmur heard at the R second ICS. Testosterone Disorders A newborn is evaluated in the delivery room. The baby’s delivery course was unremarkable. Mother’s pregnancy was uncomplicated. Ambiguous genitalia and clitoromegaly are notable on baby’s exam. Mother states that during the latter half of her pregnancy she noticed her voice deepen and have dark coarse facial hair. Remaining maternal and baby exam is normal. Which of the following mechanisms accounts for this infant’s pathology? A. Activation of 21-Hydroxylase. B. Deficiency in 17-Hydroxylase. C. Placental Aromatase Deficiency. D. Increased HMG-CoA Reductase Activity. Mullerian Agenesis VS. AIS A 16-year-old female presents with primary amenorrhea. She has had breast engorgement however she has not had any pubic hair. On exam, she is noted to have a blind ended vaginal pouch. Inguinal exam is notable for bilateral smooth masses. If genetic testing is obtained, what would be the likely karyotype? A. 46 X,Y B. 46 X,X C. 45 X,O D. 47 XXY Reproductive: Answer Key 367 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Reproductive Polycystic Ovarian Syndrome A 22-year-old female presents to the emergency department with RUQ. She has a history of PCOS controlled on OCPs. Ultrasound rules out cholelithiasis, however is notable for isoechoic, well demarcated, in-homogenous collection of blood in the right lobe of the liver. In the ED, patient has sudden tachycardia and hypotension. Which of the following pathophysiologic mechanisms most likely underlies this patient’s acute symptoms? A. Radio-opaque gallstone obstructing cystic duct B. Benign liver tumor C. Increased portal pressures due to hepatic fibrosis D. Ovarian artery torsion leading to hypovolemic shock Ovarian Tumors A 60-year-old female G0P0 presents with increased satiety. She feels that she has decreased her appetite but continues to have increased waist circumference. Lipid panel and thyroid tests are unremarkable. There is adnexal fullness unilaterally. Which of the following markers is most likely elevated? A. CA-125 B. LDH C. Inhibin D. Testosterone E. B-HcG A 30-year-old female presents with progressive lower abdominal pain. She is noted to have normal menses. Ultrasound shows a heterogenous unilateral mass. Doppler of ovarian vessels are normal. Patient undergoes removal. Mass is notable of tri-laminar germ disc derivatives. What is the likely diagnosis? A. Ectopic Pregnancy B. Endometriosis C. Serous Papillary Ovarian Cancer D. Ovarian Teratoma A 49-year-old female presents with menstrual bleeding in-between her periods. She is otherwise healthy. An ovarian mass is found on pelvic ultrasonography. It is also noted that the patient has an increased endometrial stripe on ultrasound. She just completed her menses 3 days prior. Beta-hcg is negative. What is the likely hormone which may be implicated in this pathology? A. Estrogen B. Progesterone C. B-HCG D. Testosterone Reproductive: Answer Key 368 Answer Key NBME Top Concepts ➤ Reproductive Repro Ligaments A post-menopausal female is scheduled to undergo a resection of right ovary for a complex ovarian cyst noted on trans-vaginal ultrasound. Prior to oophorectomy, which of the following anatomic structures must be ligated to prevent hemorrhagic shock? A. Utero-ovarian Ligament B. Suspensory ligament of ovary C. Round ligament of uterus D. Cardinal Ligament Uterine Disorders A 14-year-old girl presents to the emergency department for vaginal bleeding in between her cycles. She is unsure of her menstrual cycles, and her mom states she may have “had a period 2 weeks prior.” There is no trauma. There is no family history of bleeding disorders. Patient is otherwise healthy. What is the likely cause of this patient’s complaints? A. Endometrial atrophy. B. Increased corpus luteum activity. C. Increased spiral artery proliferation. D. Increased FSH. Reproductive: Answer Key 369 uploaded by medbooksvn CHAPTER 17 Top NBME Concepts: Musculoskeletal & Rheumatology 370 NBME Top Concepts ➤ Musculoskeletal & Rheumatology NMJ Disorders NBME Style Question A patient presents with difficulty chewing and dysarthria. She notices that at the end of the day her eyes droop. She attributes this to general tiredness. On exam, she is noted to have blurry vision when asked to look to the left for a few minutes. Administration of AchE inhibitor improves her symptoms. The mechanism of this disease is most like which pathology? A. Atopic Dermatitis B. Good Pasteur Syndrome C. Rapidly Progressive Cresenteric Nephritis D. Contact Dermatitis Neuromuscular Junction Disorders Musculoskeletal & Rheumatology: NMJ Disorders 371 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology NMJ Disorders NBME Style Question A 40-year-old male presents with weakness more prominent in the lower extremities. He also is noted to have issues with incontinence and achieving erections. His muscle myography is notable for an incremental increase in muscle contraction. Given this presentation, which of the following studies may be abnormal in this patient? A. CT scan of chest B. MRI of brain C. X-ray of vertebral spine D. PET scan of lower extremities USMLE Test-taking Strategy Musculoskeletal & Rheumatology: NMJ Disorders 372 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Bullous Diseases Bullous Diseases Immunofluorescence using IgG & C3 Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Bullous Diseases 373 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Bullous Diseases NBME Style Question A 30-year-old male presents with bloody cough. He recently traveled to northern Africa however he states that prior to his trip he had similar symptoms. He undergoes PFT testing which is notable for increased DLCO. His labs are notable for an elevated creatinine and CRP. Which of the following antibodies may also be positive on laboratory testing? A. Topoisomerase I B. Cardiolipin phospholipid C. Double stranded DNA D. Collagen Type IV Hemoptysis & Hematuria for the USMLE NBME Style Question A 40-year-old female presents with new-onset rash. She has a history of diarrhea, gas, and weight loss which she attributed to “irritable bowels.” Exam shows a vesicular rash in the extensor distribution. She is scheduled to undergo endoscopy. Which of the following histopathological findings may be present upon biopsy? A. Anti-Insulin staining Ab B. Crypt abscesses in the colon C. Intra-intestinal epithelial lymphocytes D. Hyperplastic villi with limited atrophy Musculoskeletal & Rheumatology: Bullous Diseases 374 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Hemoptysis & Hematuria Celiac Disease for the USMLE Creative Commons Attribution License 4.0 Hypersensitivities for the USMLE Musculoskeletal & Rheumatology: Hemoptysis & Hematuria 375 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Skin Cancers (with Neural Crest) Test-Taking Strategy In USMLE questions: Look for location of rash (i.e. sun exposed regions) Look for: • Asymmetry • Border irregularities (i.e. uneven) • Color variegation • Diameter (≥6 mm) • Evolving (i.e. lesion is changing in size) Creative Commons Attribution License 4.0 Neoplasia Integration Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Skin Cancers (with Neural Crest) 376 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Skin Cancers (with Neural Crest) Skin Cancers for the USMLE NBME Style Question A farmer presents with several scaly lesions on the forehead. He is noted to have a rough grainy texture on palpation of these lesions. He undergoes biopsy which is consistent with neoplasia as his report reveals “atypical keratinocytes confined to the basement membrane.” The patient is most likely to be at risk for which of the following conditions? A. Kaposi Sarcoma B. Melanoma C. Dermatofibroma D. Psoriasis E. Squamous Cell Carcinoma Actinic Keratoses can be a precursor to SCC Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Skin Cancers (with Neural Crest) 377 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Skin Cancers (with Neural Crest) Squamous Cell Carcinoma of the Skin Creative Commons Attribution License 4.0 Skin Cancer What is the most common malignant skin tumor? • Basal cell carcinoma What anatomical lesion does it preferentially affect? • Upper lip and inner canthus of eye in sun exposed areas A 59-year-old male presents with a raised papule on the upper surface of his lip. The sides of the crater-like lesion has multiple spiraled blood vessels. What may histological biopsy of this lesion reveal? • Cords of basophilic-staining dysplastic basal cells in infiltrating the underlying dermis. Creative Commons Attribution License 4.0 Basal Cell Carcinoma of the Skin Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Skin Cancers (with Neural Crest) 378 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Skin Cancers (with Neural Crest) NBME Style Question A 4-year-old male presents to the dermatology clinic for recurrent skin rash. Despite being inside for majority of the year, the child is noted to have ”a sunburn like rash” consistently that waxes and wanes. Mother recalls that her uncle had similar sun-burn issues & died from melanoma. Physical exam shows skin atrophy. On the neck and hands there are 3 nevi which have been enlarging rapidly. Which of the following is the likely mechanism behind the pathology? A. DNA mismatch repair B. Cyclin dysregulation C. Nucleotide excision repair D. Repair of DNA crosslinks NBME Style Question A patient presents with a skin rash that has been having irregular borders. A biopsy is taken and is notable for BRAF mutation. Which of the following is the most likely diagnosis? A. Melanoma B. Metastatic GBM C. Sezary Syndrome D. HTLV-1 E. Squamous Cell Carcinoma Melanoma Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Skin Cancers (with Neural Crest) 379 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Skin Cancers (with Neural Crest) USMLE Integration A 27-year-old Caucasian female presents with weight loss and weakness. She feels dizzy and lightheaded. Physical exam reveals several areas of her skin including her elbows and knees are more tan than other areas. The cells which are stimulated are derived from which embryological layer? Neural crest melanocytes • Adrenal insufficiency (primary) POMC is a precursor for three hormones: • ACTH, MSH, beta-endorphin. POMC is a precursor for MSH Neural Crest Derivative Musculoskeletal & Rheumatology: Skin Cancers (with Neural Crest) 380 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Skin Cancers (with Neural Crest) Melanin Biochemistry review: What amino acid is the precursor to melanin? • Tyrosine • Phenylalanine is a precursor to tyrosine. • What is the pathology related to the lack of an enzyme which converts phenylalanine to tyrosine? • PKU – patients present pale and fair, blue eyes and characteristic, musty body odor Musculoskeletal & Rheumatology: Skin Cancers (with Neural Crest) 381 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology RA vs OA Integration of Joint Disorders Big-Picture: • Rheumatoid Arthritis “systemic symptoms” • Osteoarthritis “wear & tear” Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 Rheumatoid Arthritis vs. Osteoarthritis Musculoskeletal & Rheumatology: RA vs OA 382 RA vs OA NBME Top Concepts ➤ Musculoskeletal & Rheumatology Rheumatoid Arthritis A 44-year-old woman comes for swollen fingers in the past 6 months. She says that she has some stiffness in the morning of her extremities that takes over an hour to resolve. What physical exam findings may you find on UE exam? • Swelling of the PIP and MCP joints Rheumatoid Arthritis • Systemic symptoms • Associated with which genetic marker? • HLA-DR4. Pathophysiology Synovium lined by infiltrating lymphocytes edema pannus formation granulation tissue General pathology integration: • 3 characteristics of granulation tissue (III): • Blood vessels, fibroblasts, and myofibroblasts This contraction is the mechanism for ulnar deviation. Creative Commons Attribution License 4.0 Rheumatoid Arthritis (Concept: Neutrophil Recruitment in Joint) Musculoskeletal & Rheumatology: RA vs OA 383 uploaded by medbooksvn RA vs OA NBME Top Concepts ➤ Musculoskeletal & Rheumatology Rheumatoid Arthritis:(Systemic Integration) Creative Commons Attribution License 4.0 Rheumatoid Arthritis (Concept: Neutrophil Recruitment in Joint) “RA + blunted costophrenic angles” • Pleural effusions “RA + intubation + spinal cord paralysis?” • Atlantoaxial instability “RA + CP worse with lying down” • Pericarditis “RA + Apple Green BRF” • AA amyloid “RA + growth on back of knee” • Baker’s cyst “RA + anemia” • Anemia of chronic disease hepcidin inhibiting iron utilization. • ADD SPLENOMEGALY and neutropenia? • Felty syndrome. NBME Style Question A 48-year-old female presents for joint pain. She is noted to have an elevated ESR and CRP. X-ray of her joints are notable for joint space narrowing in the MCP. An auto-antibody, IgM, is detected. Which of the following substances is most likely the target of this auto—Ab? A. Fc portion of IgG B. Sheep erythrocytes C. Sphingomyelin D. ds-DNA E. U1-RNP Musculoskeletal & Rheumatology: RA vs OA 384 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Seronegative Spondyloarthritis Seronegative Spondyloarthropathies NBME Style Question A 28-year-old make presents with dull low back pain. He is noted to have this back-pain in the morning. There is no trauma. Physical exam is significant for decreased extension of spine while standing. PFTs are abnormal. Which of the following features is most likely present in this patient’s work-up? A. Class II HLA positivity. B. M-protein molecular mimicry. C. IgM to IgG. D. Vertebral fusion on CXR. E. Peri-vertebral abscesses with lytic lesions. Psoriatic Arthritis Patient presents with a scaly rash that bleeds when disrupted. He has joint pain. What is the classic radiographic finding? • Patient presents with a scaly rash. He has arthritis. What is the classic radiographic finding? • Pencil-in-cup Psoriatic Arthritis Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Seronegative Spondyloarthritis 385 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Seronegative Spondyloarthritis Ankylosing Spondylitis A 22-year-old man presents to office with lower back pain, and stiffness. He has burning in his eyes. X-ray of the hip demonstrates abnormalities in the central skeleton. What is the likely pulmonary complication associated with this condition? • This usually can affect chest wall movement • Pulmonary association: • Restrictive lung disease • Ophthalmologic association? • Anterior uveitis • X-ray finding is a bamboo spine. Creative Commons Attribution License 4.0 Reactive Arthritis A young man who works in a daycare had bloody diarrhea one week prior and now presents with a red eye. He feels pain during urination and says his ankles hurt when he runs after the toddlers. What is the likely diagnosis? • Reactive Arthritis after a Shigella infection • “Can’t See, Can’t Pee, Can’t Climb a Tree.” • Classical presentation: asymmetric joint arthritis • What is the morphology of the most common organisms? • Shigella gram negative rod • Chlamydia gram negative coccobacllis • Skin finding? • Kertoderma blemorrhagicum which affects palms and soles. Creative Commons Attribution License 4.0 Musculoskeletal & Rheumatology: Seronegative Spondyloarthritis 386 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Seronegative Spondyloarthritis Palms & Soles Integration Summary Musculoskeletal & Rheumatology: Seronegative Spondyloarthritis 387 uploaded by medbooksvn Lupus NBME Top Concepts ➤ Musculoskeletal & Rheumatology NBME Style Question A 30-year-old female presents with SOB. She is diagnosed with a unilateral pleural effusion via CXR. Her further laboratory studies are notable for anemia with high ferritin. Her 3 month follow up shows increased Cr and UA positive for blood and protein. Which of the following mechanisms most likely explains her renal dysfunction? A. Auto-immune attack of podocytes B. Light chain amyloid deposition C. Deposition of immune complexes D. Sub-epithelial humps secondary to chronic streptococcal infection Pathophysiology of Lupus Musculoskeletal & Rheumatology: Lupus 388 Lupus NBME Top Concepts ➤ Musculoskeletal & Rheumatology Lupus A 22-year-old woman with Lupus has a f/u exam. She is tachypneic and tachycardic and imaging shows deep venous thrombosis. 2 yrs ago she delivered a female stillborn at 23wks. Platelet: 250K (normal). PT normal, increased PTT. What is the likely mechanism behind this patient’s current presentation? • Antibodies directed against phospholipids APLS • Can also have false positive syphilis • PTT increased however still you are hypercoagulable. Diagnosis: • Sensitive but not specific? • ANA • Specific markers? • Anti-dsDNA, and Anti-Smith antibodies. • Anti-Smith directed towards snRNPs • Anti-dsDNA = flairs, and poor prognosis • Low complement. • Patient on medication for WPW now has lupus like syndrome. Diagnosis? • Drug induced lupus. Lab abnormalities? • Anti-histone Ab. Musculoskeletal & Rheumatology: Lupus 389 uploaded by medbooksvn Lupus NBME Top Concepts ➤ Musculoskeletal & Rheumatology Systemic Manifestations of Lupus CNS: • Fever • Cognitive dysfunction • Seizures Cardiovascular: • Pericarditis • Libman sacks endocarditis Respiratory: • Pleurisy and effusions Renal: • Membranous Glomerulonephropathy (“spike and dome”) • Diffuse Proliferative Glomerulonephritis (“capillary wire loops”) • Hypocomplementemia. Heme: • Anemia of chronic disease • Thrombocytopenia (thrombolic events from anti-phospholipid antibodies) • Leukopenia MSK: • Migratory arthritis Skin: • Butterfly rash and photosensitivity Rheum: • ANA (sensitive) • Anti-dsDNA and anti-Sm (specific). Musculoskeletal & Rheumatology: Lupus 390 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Anti Body Rapid Fire (USMLE) Multi-System Involvement + Ab in Labs NBME Style Question A 31-year-old female presents with general malaise, myalgias, low grade fever. She is noted to have painful extremities especially in the winter-time as she states her fingers “turn blue.” She was recently hospitalized for a myositis flare. On physical exam, patient has a malar rash on the nose. The patient is also noted to have joint tenderness in the MCP and DIP joints. Lab testing is positive for anti-nuclear antibodies. Which of the following anti-bodies may also be present given this clinical presentation? A. C-ANCA B. Rheumatoid Factor Inhibitor C. Anti-U1-RNP Ab D. P-ANCA E. Anti-Smith Ab Musculoskeletal & Rheumatology: Anti Body Rapid Fire (USMLE) 391 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Anti Body Rapid Fire (USMLE) Antibody and USMLE Significance Musculoskeletal & Rheumatology: Anti Body Rapid Fire (USMLE) 392 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Anti Body Rapid Fire (USMLE) Antibody and USMLE Significance Musculoskeletal & Rheumatology: Anti Body Rapid Fire (USMLE) 393 uploaded by medbooksvn NBME Top Concepts ➤ Musculoskeletal & Rheumatology Answer Key NMJ Disorders A patient presents with difficulty chewing and dysarthria. She notices that at the end of the day her eyes droop. She attributes this to general tiredness. On exam, she is noted to have blurry vision when asked to look to the left for a few minutes. Administration of AchE inhibitor improves her symptoms. The mechanism of this disease is most like which pathology? A. Atopic Dermatitis B. Good Pasteur Syndrome C. Rapidly Progressive Cresenteric Nephritis D. Contact Dermatitis A 40-year-old male presents with weakness more prominent in the lower extremities. He also is noted to have issues with incontinence and achieving erections. His muscle myography is notable for an incremental increase in muscle contraction. Given this presentation, which of the following studies may be abnormal in this patient? A. CT scan of chest B. MRI of brain C. X-ray of vertebral spine D. PET scan of lower extremities Bullous Disease A 30-year-old male presents with bloody cough. He recently traveled to northern Africa however he states that prior to his trip he had similar symptoms. He undergoes PFT testing which is notable for increased DLCO. His labs are notable for an elevated creatinine and CRP. Which of the following antibodies may also be positive on laboratory testing? A. Topoisomerase I B. Cardiolipin phospholipid C. Double stranded DNA D. Collagen Type IV A 40-year-old female presents with new-onset rash. She has a history of diarrhea, gas, and weight loss which she attributed to “irritable bowels.” Exam shows a vesicular rash in the extensor distribution. She is scheduled to undergo endoscopy. Which of the following histopathological findings may be present upon biopsy? A. Anti-Insulin staining Ab B. Crypt abscesses in the colon C. Intra-intestinal epithelial lymphocytes D. Hyperplastic villi with limited atrophy Musculoskeletal & Rheumatology: Answer Key 394 NBME Top Concepts ➤ Musculoskeletal & Rheumatology Answer Key Skin Cancers (With Neural Crest) A farmer presents with several scaly lesions on the forehead. He is noted to have a rough grainy texture on palpation of these lesions. He undergoes biopsy which is consistent with neoplasia as his report reveals “atypical keratinocytes confined to the basement membrane.” The patient is most likely to be at risk for which of the following conditions? A. Kaposi Sarcoma B. Melanoma C. Dermatofibroma D. Psoriasis E. Squamous Cell Carcinoma A 4-year-old male presents to the dermatology clinic for recurrent skin rash. Despite being inside for majority of the year, the child is noted to have ”a sunburn like rash” consistently that waxes and wanes. Mother recalls that her uncle had similar sun-burn issues & died from melanoma. Physical exam shows skin atrophy. On the neck and hands there are 3 nevi which have been enlarging rapidly. Which of the following is the likely mechanism behind the pathology? A. DNA mismatch repair B. Cyclin dysregulation C. Nucleotide excision repair D. Repair of DNA crosslinks A patient presents with a skin rash that has been having irregular borders. A biopsy is taken and is notable for BRAF mutation. Which of the following is the most likely diagnosis? A. Melanoma B. Metastatic GBM C. Sezary Syndrome D. HTLV-1 E. Squamous Cell Carcinoma RA vs OA A 48-year-old female presents for joint pain. She is noted to have an elevated ESR and CRP. X-ray of her joints are notable for joint space narrowing in the MCP. An auto-antibody, IgM, is detected. Which of the following substances is most likely the target of this auto—Ab? A. Fc portion of IgG B. Sheep erythrocytes C. Sphingomyelin D. ds-DNA E. U1-RNP Musculoskeletal & Rheumatology: Answer Key 395 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Musculoskeletal & Rheumatology Seronegative Spondyloarthritis A 28-year-old make presents with dull low back pain. He is noted to have this back-pain in the morning. There is no trauma. Physical exam is significant for decreased extension of spine while standing. PFTs are abnormal. Which of the following features is most likely present in this patient’s work-up? A. Class II HLA positivity. B. M-protein molecular mimicry. C. IgM to IgG. D. Vertebral fusion on CXR. E. Peri-vertebral abscesses with lytic lesions. Lupus A 30-year-old female presents with SOB. She is diagnosed with a unilateral pleural effusion via CXR. Her further laboratory studies are notable for anemia with high ferritin. Her 3 month follow up shows increased Cr and UA positive for blood and protein. Which of the following mechanisms most likely explains her renal dysfunction? A. Auto-immune attack of podocytes B. Light chain amyloid deposition C. Deposition of immune complexes D. Sub-epithelial humps secondary to chronic streptococcal infection Anti Body Rapid Fire (USMLE) A 31-year-old female presents with general malaise, myalgias, low grade fever. She is noted to have painful extremities especially in the winter-time as she states her fingers “turn blue.” She was recently hospitalized for a myositis flare. On physical exam, patient has a malar rash on the nose. The patient is also noted to have joint tenderness in the MCP and DIP joints. Lab testing is positive for anti-nuclear antibodies. Which of the following anti-bodies may also be present given this clinical presentation? A. C-ANCA B. Rheumatoid Factor Inhibitor C. Anti-U1-RNP Ab D. P-ANCA E. Anti-Smith Ab Musculoskeletal & Rheumatology: Answer Key 396 CHAPTER 18 Top NBME Concepts: Psychiatry 397 uploaded by medbooksvn Mood Disorders NBME Top Concepts ➤ Psychiatry NBME Style Question A 50-year-old female presents with sad mood. She is irritable and states she feels worthless and helpless for the last 2 weeks. She just broke up with her husband a month ago. She finds that at work it is tough to concentrate. She has lost weight unintentionally. She did not show up to work today because she “doesn’t have the motivation anymore.” Her vital signs are stable. What is the likely diagnosis? A. Major Depressive Disorder B. Dysthmia C. Adjustment Disorder D. Normal Grief Test Taking Strategy For Psychiatry Questions on the USMLE: • Isolate functional impairments in ADLs • Pay attention to time period for dx. • Think medical causes of psychiatry disorders. Mood Disorders Psychiatry: Mood Disorders 398 Bipolar + Li Pharm NBME Top Concepts ➤ Psychiatry NBME Style Question A 17-year-old male presents to the adolescent clinic. He was in a car accident 2 months ago and witnessed his mother pass away. He states that he wakes up really early and thinks about his mother option. He feels very overwhelmed and says “it’s tough to go to school.” When asked about his mom, he tearfully states that she was an amazing woman. What is the most likely diagnosis? A. PTSD B. Complex bereavement disorder C. Normal Grief D. Major Depressive Episode Teasing out Grief from Depression on the USMLE Teasing out Grief from Depression on the USMLE A 60-year-old male presents to the emergency department intoxicated. He was found to be near a bridge and having a firearm pointed to his head before law enforcement stopped him. His hx is notable for MDD and recent hospitalization for a prior attempt at suicide. On exam he says, “my brother died by hanging himself and I feel worthless as well”…”I am alone and life is not worth living.” What is the most important risk factor which poses the highest risk for completion? • Prior attempt • Other risk factors: • Psychiatric disorders • Firearm possession • Family member passing by suicide •M>F • Poor social support Psychiatry: Bipolar + Li Pharm 399 uploaded by medbooksvn Bipolar + Li Pharm NBME Top Concepts ➤ Psychiatry Key Depression Variants for the USMLE NBME Style Question A 40-year-old male presents with feeling unhappy. He says that he has been so burnt-out at work. He left his previous job as he felt like everything was a chore. His fiancé states that he has little energy throughout the day. He has a history of smoking marijuana as a teenager. When asked how long he has felt these symptoms, he states “idk, Dr., it’s been years.” His toxicology screen is negative. What is the likely diagnosis? A. Adjustment Disorder B. Cyclothymia C. Avoidant personality disorder D. Dysthmia Medical Causes of Depression Psychiatry: Bipolar + Li Pharm 400 Bipolar + Li Pharm NBME Top Concepts ➤ Psychiatry NBME Style Question A 30-year-old male presents to the county physician. He is brought in by police for medical examination. He was arrested last week after being found at Walmart assaulting customers. He states that he is ”a knight in shining armor” and says that he does not need sleep. When asked about his mood, he tells a long story about his childhood and fascination with swords. Tox screen is negative What is the likely diagnosis? A. Brief psychotic disorder B. Bipolar 1 with psychotic features C. Schizotypal D. Hypomania Understanding Hypomania A 42-year-old woman presents due to fatigue and weight gain over the past month. She says she has been struggling with depression for a long time, but that it has gotten worse since her husband was diagnosed with cancer. She also says that she previously had an episode of decreased need for sleep, irritability, and increased goal-directed activity which lasted about a week, but it never significantly impaired her work or home life. What is the likely diagnosis? NBME Style Question A 40-year-old female with CHF presents with tremor. She has a wobbly gait on exam. On review of medications, the physician notes a history of bipolar well treated on a mood stabilizer. She was started on diuretic therapy for CHF on her last visit two weeks ago. Which of the following drug interactions likely contributed to her tremor? A. Li & HCTZ B. Li & Amiloride C. Li & Metoprolol D. Li & Clonidine Psychiatry: Bipolar + Li Pharm 401 uploaded by medbooksvn Bipolar + Li Pharm NBME Top Concepts ➤ Psychiatry Lithium has a Narrow Therapeutic Index Pharmacology Integration Psychiatry: Bipolar + Li Pharm 402 Bipolar + Li Pharm NBME Top Concepts ➤ Psychiatry Long Term Bipolar A CEO presents with sleep issues. Over past two years he has felt unmotivated and has filed for bankruptcy twice as he has made poor purchases and investments in the past 2-3 years. He is sad and states that he only has slept 4-5 hours at night for many months to focus on work. What is the likely diagnosis? • Cyclothymia • Symptoms for 2 years and are never absent for two months Long term depression is to dysthymia whereas long term bipolar is to cyclothymia. Psychiatry: Bipolar + Li Pharm 403 uploaded by medbooksvn Psychotic Disorders NBME Top Concepts ➤ Psychiatry Teasing Out Schizo-Diagnoses on the USMLE Personality Disorders: Schizoid and schizotypal Psychiatry: Psychotic Disorders 404 Psychotic Disorders NBME Top Concepts ➤ Psychiatry NBME Style Question A 30-year-old male is found at a park urinating in a fountain. He states that he must hide from the CIA as they know of his radioactive lab. He used to live this his girlfriend but over the past year, he lives on his friends’ couch, broke up with his gf, and quit his job. When questioned he has a flat affect and says “I don’t care.” What is the likely diagnosis? A. Schizophreniform B. Bipolar 1 C. Depression with Psychotic Features D. Schizophrenia Triad of Psychosis for the USMLE Timing for Schizo Disorders Psychiatry: Psychotic Disorders 405 uploaded by medbooksvn Psychotic Disorders NBME Top Concepts ➤ Psychiatry NBME Style Question A patient is newly diagnosed with psychosis. She is started on an anti-psychotic. The patient is at follow-up three weeks later and states that it has been “challenging to have sex…I just don’t feel interested.” Exam is notable for increased glandular nodularity of breast with intermittent bilateral expulsion of white discharge. What is the likely pathway which is affected? A. Arcuate fasciculus B. Nigrostriatal C. Mesolimbic D. Tubuloinfundibular USMLE Neuroanatomy Integration NBME Style Question A 30-year-old male is found at a park urinating in a fountain. He states that he must hide from the CIA as they know of his radioactive lab. He used to live with his girlfriend but over the past year he broke up with her. He is noted to have 10 psych hospital admissions for depression and was discharged 2 weeks ago. He says that since d/c he doesn’t feel depressed and wants to end the interview because the CIA will be here to kidnap him. What is the likely diagnosis? A. Schizoaffective B. Bipolar 1 C. Depression with Psychotic Features D. Schizophrenia Psychiatry: Psychotic Disorders 406 Psychotic Disorders NBME Top Concepts ➤ Psychiatry USMLE Significance Delusional Disorder A 25-year-old woman believes she is an editor of a famous fashion magazine. She is irritated how is unable to get employment as she states she is the best dressed at work. Her sister states that she works as a waitress and otherwise has no abnormalities on exam. • What is the time period for diagnosis? • ≥ 1 month •Isolated delusions no other psychotic symptoms + not marked impairment Psychiatry: Psychotic Disorders 407 uploaded by medbooksvn Eating Disorders NBME Top Concepts ➤ Psychiatry NBME Style Question A 17-year-old female is admitted to the hospital due to weight loss and syncope. NG tube is placed and feeds are initiated. On day two of admission, the patient reports shortness of breath and has recurrent episodes of ventricular tachycardia. She has tachycardia and hypotension. Labs are notable for low phos, low Mg, and low K. Which of the following hormones best explains the patient’s deterioration? A. T4 B. Cortisol C. Aldosterone D. Insulin Re-feeding Syndrome (Concept: Electrolyte Shifts End Organ) Psychiatry: Psychotic Disorders 408 Eating Disorders NBME Top Concepts ➤ Psychiatry Difference between Anorexia Nervosa and Bulemia Acid Base Integration Psychiatry: Psychotic Disorders 409 uploaded by medbooksvn Eating Disorders NBME Top Concepts ➤ Psychiatry NBME Style Question A 40-year-old male was recently started on a medication for depression. Six weeks later, he has been having issues with erectile dysfunction. He is considering stopping the medication due to this and requests alternative treatment. What is the most appropriate selection for this patient? A. Trazodone B. Impipramine C. Citalopram D. Buproprion Medications for the USMLE which decrease seizure threshold Psychiatry: Psychotic Disorders 410 Drugs of Abuse (Toxicology) NBME Top Concepts ➤ Psychiatry NBME Style Question A patient presents after being brought in by his roommate for weird behavior. He was totally fine two days ago in class. His roommate noticed that he was yelling and was constantly locking and unlocking the door last night. He is noted to have hypertension, tachycardia, and dilated pupils. His roommate states the patient has not slept well due to exams. What is the likely dx? A. Substance induced psychosis B. Delusional Disorder C. Brief Psychotic Disorder D. Adjustment disorder with psychotic features Uppers vs. Downers Introduction to Drugs of Abuse UPPERS DOWNERS Psychiatry: Drugs of Abuse (Toxicology) 411 uploaded by medbooksvn Drugs of Abuse (Toxicology) NBME Top Concepts ➤ Psychiatry USMLE Vignettes A patient who is crying, has slurred speech, blacks out, has wrist drop, AST > ALT? • Alcohol intoxication A patient with history of cirrhosis undergoes a gastric bypass surgery. On day two of hospitalization, patient states that he is seeing the nurses have funny hats and sees bugs on the walls. What is most severe complication of this likely diagnosis? • Delirium Tremens Alcohol withdrawal • USMLE: Confusion, agitation, fever, tachycardia give a benzodiazepine. USMLE Vignettes A homeless male with respiratory depression + pupillary constriction + decreased GI motility and constipation. 85% on RA. What is the likely cause of the hypoxemia? • Hypoventilation Opioid intoxication • Violent yawning + increased secretions. • Signs of opioid withdrawal • What is the likely antidote for opioid intoxication? • Naloxone (shorter duration of action). NBME Style Question A 40-year-old female presents to the ED with a fracture. She states that she ran into a car in the parking lot because she has super-human strength. She is hypertensive and tachycardic. Her exam is notable for vertical nystagmus. She refuses to give a urine exam. What is the likely MOA of the drug of abuse seen in this patient? A. Mu agonism B. NMDA antagonism C. GABA activation D. D2 antagonism NBME Style Question At a high-school health fair, a nurse notices strange behavior in a 16 yo male. She notices that he seems “slow” and when she asks his name he giggles and says “where’s the vending machine.” His urine tox is pending. Which of the following exam features may be most seen in this patient? A. Conjunctival injection B. Nasal perforations C. Miosis D. Bradycardia Psychiatry: Drugs of Abuse (Toxicology) 412 Drugs of Abuse (Toxicology) NBME Top Concepts ➤ Psychiatry Understanding Drugs of Abuse Salient Features of Drugs of Abuse Creative Commons Attribution License 4.0 Psychiatry: Drugs of Abuse (Toxicology) 413 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Psychiatry Mood Disorders A 50-year-old female presents with sad mood. She is irritable and states she feels worthless and helpless for the last 2 weeks. She just broke up with her husband a month ago. She finds that at work it is tough to concentrate. She has lost weight unintentionally. She did not show up to work today because she “doesn’t have the motivation anymore.” Her vital signs are stable. What is the likely diagnosis? A. Major Depressive Disorder B. Dysthmia C. Adjustment Disorder D. Normal Grief Bipolar + Li Pharm A 17-year-old male presents to the adolescent clinic. He was in a car accident 2 months ago and witnessed his mother pass away. He states that he wakes up really early and thinks about his mother option. He feels very overwhelmed and says “it’s tough to go to school.” When asked about his mom, he tearfully states that she was an amazing woman. What is the most likely diagnosis? A. PTSD B. Complex bereavement disorder C. Normal Grief D. Major Depressive Episode A 40-year-old male presents with feeling unhappy. He says that he has been so burnt-out at work. He left his previous job as he felt like everything was a chore. His fiancé states that he has little energy throughout the day. He has a history of smoking marijuana as a teenager. When asked how long he has felt these symptoms, he states “idk, Dr., it’s been years.” His toxicology screen is negative. What is the likely diagnosis? A. Adjustment Disorder B. Cyclothymia C. Avoidant personality disorder D. Dysthmia A 30-year-old male presents to the county physician. He is brought in by police for medical examination. He was arrested last week after being found at Walmart assaulting customers. He states that he is ”a knight in shining armor” and says that he does not need sleep. When asked about his mood, he tells a long story about his childhood and fascination with swords. Tox screen is negative What is the likely diagnosis? A. Brief psychotic disorder B. Bipolar 1 with psychotic features C. Schizotypal D. Hypomania Psychiatry: Answer Key 414 Answer Key NBME Top Concepts ➤ Psychiatry Bipolar + Li Pharm A 40-year-old female with CHF presents with tremor. She has a wobbly gait on exam. On review of medications, the physician notes a history of bipolar well treated on a mood stabilizer. She was started on diuretic therapy for CHF on her last visit two weeks ago. Which of the following drug interactions likely contributed to her tremor? A. Li & HCTZ B. Li & Amiloride C. Li & Metoprolol D. Li & Clonidine Psychotic Disorders A 30-year-old male is found at a park urinating in a fountain. He states that he must hide from the CIA as they know of his radioactive lab. He used to live this his girlfriend but over the past year, he lives on his friends’ couch, broke up with his gf, and quit his job. When questioned he has a flat affect and says “I don’t care.” What is the likely diagnosis? A. Schizophreniform B. Bipolar 1 C. Depression with Psychotic Features D. Schizophrenia A patient is newly diagnosed with psychosis. She is started on an anti-psychotic. The patient is at follow-up three weeks later and states that it has been “challenging to have sex…I just don’t feel interested.” Exam is notable for increased glandular nodularity of breast with intermittent bilateral expulsion of white discharge. What is the likely pathway which is affected? A. Arcuate fasciculus B. Nigrostriatal C. Mesolimbic D. Tubuloinfundibular A 30-year-old male is found at a park urinating in a fountain. He states that he must hide from the CIA as they know of his radioactive lab. He used to live with his girlfriend but over the past year he broke up with her. He is noted to have 10 psych hospital admissions for depression and was discharged 2 weeks ago. He says that since d/c he doesn’t feel depressed and wants to end the interview because the CIA will be here to kidnap him. What is the likely diagnosis? A. Schizoaffective B. Bipolar 1 C. Depression with Psychotic Features D. Schizophrenia Psychiatry: Answer Key 415 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Psychiatry Eating Disorders A 17-year-old female is admitted to the hospital due to weight loss and syncope. NG tube is placed and feeds are initiated. On day two of admission, the patient reports shortness of breath and has recurrent episodes of ventricular tachycardia. She has tachycardia and hypotension. Labs are notable for low phos, low Mg, and low K. Which of the following hormones best explains the patient’s deterioration? A. T4 B. Cortisol C. Aldosterone D. Insulin A 40-year-old male was recently started on a medication for depression. Six weeks later, he has been having issues with erectile dysfunction. He is considering stopping the medication due to this and requests alternative treatment. What is the most appropriate selection for this patient? A. Trazodone B. Impipramine C. Citalopram D. Buproprion Drugs of Abuse (Toxicology) A patient presents after being brought in by his roommate for weird behavior. He was totally fine two days ago in class. His roommate noticed that he was yelling and was constantly locking and unlocking the door last night. He is noted to have hypertension, tachycardia, and dilated pupils. His roommate states the patient has not slept well due to exams. What is the likely dx? A. Substance induced psychosis B. Delusional Disorder C. Brief Psychotic Disorder D. Adjustment disorder with psychotic features A 40-year-old female presents to the ED with a fracture. She states that she ran into a car in the parking lot because she has super-human strength. She is hypertensive and tachycardic. Her exam is notable for vertical nystagmus. She refuses to give a urine exam. What is the likely MOA of the drug of abuse seen in this patient? A. Mu agonism B. NMDA antagonism C. GABA activation D. D2 antagonism Psychiatry: Answer Key 416 Answer Key NBME Top Concepts ➤ Psychiatry Drugs of Abuse (Toxicology) At a high-school health fair, a nurse notices strange behavior in a 16 yo male. She notices that he seems “slow” and when she asks his name he giggles and says “where’s the vending machine.” His urine tox is pending. Which of the following exam features may be most seen in this patient? A. Conjunctival injection B. Nasal perforations C. Miosis D. Bradycardia Psychiatry: Answer Key 417 uploaded by medbooksvn CHAPTER 19 Top NBME Concepts: Oncology 418 Cardiac Oncology NBME Top Concepts ➤ Oncology NBME Style Question A high school athlete presents with a 2-week history of shortness of breath on exertion. He has dizziness and vital signs show bradycardia with normal blood pressure. A diastolic murmur is heard that abruptly stops. The echo shows a pedunculated heterogeneous mass in the left atrium. Which of the following accurately describes this diagnosis? A. Myxoma B. Teratoma C. Rhabdomyosarcoma D. Thrombus E. Lipoma F. Astrocytoma Primary Cardiac Tumors Oncology: Cardiac Oncology 419 uploaded by medbooksvn Cardiac Oncology NBME Top Concepts ➤ Oncology Tuberous Sclerosis – Multi-System Involvement Oncology: Cardiac Oncology 420 Endocrine Oncology NBME Top Concepts ➤ Oncology Thyroid Carcinoma Creative Commons Attribution License 4.0 Thyroid Cancer for the USMLE Step 1 Oncology: Endocrine Oncology 421 uploaded by medbooksvn Endocrine Oncology NBME Top Concepts ➤ Oncology Psammoma Bodies for the USMLE How is a psammoma body described? Laminated, concentric spherules with dystrophic calcification Creative Commons Attribution License 4.0 NBME Style Question A 50-year-old male has a lump in his neck. His exam is notable for a mass in the right thyroid lobe. FNA reveals thyroid carcinoma. He undergoes thyroid resection. Three days post-operatively he is found to be “whispering in a raspy voice.” Which of the following complications likely occurred with this patient? A. Injury to the accessory nerve B. Injury to a branch of the vagus nerve C. Injury to the phrenic nerve D. Injury to the hypoglossal nerve. Embryology Integration Oncology: Endocrine Oncology 422 Gastrointestinal Oncology NBME Top Concepts ➤ Oncology Colon Cancer Overview What are risk factors which increase the risk for carcinoma from a polyp? Size ≥2 cm Sessile growth (versus pedunculated) Villous histology (versus tubular) Creative Commons Attribution License 4.0 Adenoma Carcinoma Sequence Oncology: Gastrointestinal Oncology 423 uploaded by medbooksvn Gastrointestinal Oncology NBME Top Concepts ➤ Oncology NBME Style Question A 60-year-old male presents with fatigue and passing out. He is noted to have dark stools and his wife states he has become increasingly “thin” over the past few months. He undergoes stool testing which is positive for heme. Further workup reveals adenocarcinoma. Which of the following gene mutations is likely responsible for the transformation of a colonic adenoma to adenocarcinoma? A. B. C. D. n-MYC c-MYC COX p53 Associated Colonic Conditions Oncology: Gastrointestinal Oncology 424 Gastrointestinal Oncology NBME Top Concepts ➤ Oncology Pathophysiology of Colonic Carcinoma for the USMLE Colonic Carcinoma Most common site of mets? Liver Pt presents with a fever and a new-onset murmur. Blood culture grows S.bovis (gallolyticus). What is the next best step in management? Colonscopy Bovis gram+ cocci chains; grows in bile, not salt A 40-year-old male is seen in clinic for health-maintenance. His brother had colon cancer at age 50. Should patient get colonoscopy? Yes, first degree screen at age 40 or 10 years prior to presentation (whichever comes first) Patient is diagnosed with colonic cancer what tumor marker may be helpful to track progression? CEA (seen also in COPD, pancreatitis) Creative Commons Attribution License 4.0 Oncology: Gastrointestinal Oncology 425 uploaded by medbooksvn Gastrointestinal Oncology NBME Top Concepts ➤ Oncology Esophageal Cancer for the USMLE Step 1 Creative Commons Attribution License 4.0 Neoplasia – Precursor Lesions to Cancer for the USMLE NBME Style Question A 60-year-old male with a history of hypertension and dyslipidemia presents with chest pain. He also has difficulty swallowing. He states that his chest pain is worse when lying down. There is no relation to activity. CXR and abdominal CXR reveal a “heterogenous air-filled collection behind the retrocardiac border on the left side.” What is the likely pathophysiology behind the diagnosis? A. Laxity of the diaphragmatic-lower esophageal region B. Congenital abnormality of the diaphragm C. Acute trauma leading to colonic contents in the thorax D. Lack of abdominal malrotation Oncology: Gastrointestinal Oncology 426 Gastrointestinal Oncology NBME Top Concepts ➤ Oncology Esophageal Carcinoma Oncology: Gastrointestinal Oncology 427 uploaded by medbooksvn Lymphoma & Vascular Tumors NBME Top Concepts ➤ Oncology Lymphomas on the USMLE Compare & Contrast Non-Hodgkin's Lymphoma NBME Style Question A patient was recently diagnosed with HIV. He has been non-compliant with his therapy. He is noted to have headaches. MRI of the brain reveals a “solitary mass with no calcification in the frontotemporal region.” Biopsy reveals a tumor with T-cell lineage. Which of the following genomes may be present in this patient’s biopsy? A. Bartonella hensale B. Ebstein Barr Virus C. HHV-6 D. CMV Oncology: Lymphoma & Vascular Tumors 428 Lymphoma & Vascular Tumors NBME Top Concepts ➤ Oncology Non-Hodgkin's Lymphoma NBME Style Question A patient with Sjogren syndrome has a rapidly enlarging parotid mass. Exam shows a unilateral heterogeneous mass that is not tender to palpation obscuring the R mandibular region. Parotid excision is likely to reveal which of the following tumor derivatives? A. Malignant squamous cells with keratin pearls B. Anaplastic round blue cells surrounding salivary glands C. S-100 neuro-ectodermal cells surrounding salivary glands D. Germinal centers with distorted lymph node architecture Oncology: Lymphoma & Vascular Tumors 429 uploaded by medbooksvn Lymphoma & Vascular Tumors NBME Top Concepts ➤ Oncology Vascular Tumors Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 NBME Style Question A patient is diagnosed with a highly vascularized tumor surrounding normal cellular epithelium. Increased capillary proliferation is seen on microscopic pathology. An increase in which of the following cellular ligands may be expected in this patient? A. EGF B. FGF C. PDRF D. IGF-1 Oncology: Lymphoma & Vascular Tumors 430 Renal Oncology NBME Top Concepts ➤ Oncology Genitourinary Cancer for the USMLE Step 1 Renal Cell Carcinoma The patient presents with hematuria, and flank pain. He has a fever and hyperglycemia. He has had some weight gain and has felt fatigued. Exam shows truncal obesity and atrophy of extremities. What is the likely mechanism? ACTH paraneoplastic syndrome RCC Other USMLE presentations: Oncology: Renal Oncology 431 uploaded by medbooksvn Renal Oncology NBME Top Concepts ➤ Oncology Renal Cell Carcinoma What is the common histopathological presentation of RCC? Polygonal cells with high glycogen clear cell type which is most common Where in the nephron do these “clear cells” arise? Proximal tubule What is the difference between a renal cell carcinoma and renal oncocytoma? Renal Oncocytoma arises from collecting ducts, benign tumor, and has large eosinophilic cells with increased mitochondria. Creative Commons Attribution License 4.0 NBME Style Question A mother brings her son in due to abdominal distension. His mother states that her son has been having normal bowel movements. She noticed while bathing him last night that he had increased abdominal fullness “more on the left side.” CT scan reveals a homogenous mass at the inferior pole of the kidney that does not cross the midline. If this oncological lesion was associated with a genetic syndrome, which of the following additional findings may be present? A. Episcleritis B. Aniridia C. Uveitis D. Glaucoma Oncology: Renal Oncology 432 Renal Oncology NBME Top Concepts ➤ Oncology Nephroblastoma Creative Commons Attribution License 4.0 A 15-month-old male brought in by mother after she noticed he had decreased appetite and a mass felt while she was bathing him. He is evaluated and found to be hypertensive. What is going to be the pathological hallmark of this diagnosis? Blastema primitive cell which makes glomerulus and tubules related to Wilm’s Tumor • Genetic hallmark of Wilm’s Tumor? • Loss of WT1 gene (tumor suppressor) 2-month-old who presents with hepatosplenomegaly and tongue hypertrophy. Exam shows increased bulk on the left side compared to the right. What is the likely diagnosis? Beckwith Weidemen Syndrome (Wilms, hemihypertrophy, organomegaly) Wilm’s Tumor, Aniridia, GU malformations, Retardation. Renal Embryology What pathologies are related to an abnormal interaction between ureteric bud and metanephros? Unilateral renal agenesis (failure of ureteric bud to form no kidney or ureter) Multicystic dysplastic kidney (failure of ureteric bud to induce mesenchyme unilateral, nonfunctional, cystic kidney). Oncology: Renal Oncology 433 uploaded by medbooksvn Respiratory Oncology NBME Top Concepts ➤ Oncology USMLE Test Taking Strategy: Lung Tumors Creative Commons Attribution License 4.0 USMLE Questions will presentations related to: Constitutional Symptoms Paraneoplastic Syndromes: • Physiology tie-ins. Lung Cancer for the USMLE Step 1 Oncology: Respiratory Oncology 434 Respiratory Oncology NBME Top Concepts ➤ Oncology Adenocarcinoma Small Cell Oncology: Respiratory Oncology 435 uploaded by medbooksvn Respiratory Oncology NBME Top Concepts ➤ Oncology Squamous Cell Creative Commons Attribution License 4.0 Oncology: Respiratory Oncology 436 Neuro Oncology NBME Top Concepts ➤ Oncology Neuro-oncology for the USMLE Step 1 Organization of Brain Tumors for the USMLE Oncology: Neuro Oncology 437 uploaded by medbooksvn Neuro Oncology NBME Top Concepts ➤ Oncology Brain Tumors Oncology: Neuro Oncology 438 Breast Oncology NBME Top Concepts ➤ Oncology Risk Factors for Breast Cancer on the USMLE NBME Style Question A 60-year-old female presents concerned about a right breast mass that she felt in the shower. She notes that there is associated dimpling. There is no redness, fluctuance to the breast. There is no family history of breast cancer. There is prominent lymphadenopathy in the right upper quadrant of her breast. She is found to have an irregular immobile mass on palpation. Which of the following affected structures may be most contributing to her nipple dimpling? A. Axillary lymph node B. Suspensory ligament C. Lactiferous ducts D. Mammary artery Oncology: Breast Oncology 439 uploaded by medbooksvn Breast Oncology NBME Top Concepts ➤ Oncology Breast Cancer Summary for the USMLE Step 1 Creative Commons Attribution License 4.0 NBME Style Question A patient presents with unilateral breast redness. She is 3 weeks postpartum and had a breast mass which was being worked up prior to pregnancy. She has completed a course of dicloxicillin with no relief of her breast redness. She is currently not breastfeeding. Ultrasound of breast shows no abscess. There are hard lymph nodes in the axilla. Which of the following pathophysiologic mechanisms may be contributing to the underlying pathology? A. Lymphatic duct obstruction B. Fibrotic suspensory ligament of breast C. Infection of the superficial epidermis by MSSA D. Deep vein thrombosis of the L brachial vein Breast Cancer Staining Questions typically refer to histo-chemical staining ER PR HER2/neu (gene amplification, TK receptor) The patient is found to have an ER/PR+ breast cancer. What is the characteristic of the receptor this cancer expresses? Intra-nuclear receptor. Drug? • Tamoxifen. Patient is started on a chemo-therapy treatment for an immuno-histochemical staining positive breast CA. She is found to have an echo with a low ejection fraction. What is the likely mechanism of the chemo-therapy treatment? Her2Neu receptor inhibitor Trastuzumab Cardiotoxic. Oncology: Breast Oncology 440 Neoplasia (Get Path Integration) NBME Top Concepts ➤ Oncology Grading vs. Staging for the USMLE Metastasis Oncology: Neoplasia (Get Path Integration) 441 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Oncology Cardiac Oncology A high school athlete presents with a 2-week history of shortness of breath on exertion. He has dizziness and vital signs show bradycardia with normal blood pressure. A diastolic murmur is heard that abruptly stops. The echo shows a pedunculated heterogeneous mass in the left atrium. Which of the following accurately describes this diagnosis? A. Myxoma B. Teratoma C. Rhabdomyosarcoma D. Thrombus E. Lipoma F. Astrocytoma Endocrine Oncology A 50-year-old male has a lump in his neck. His exam is notable for a mass in the right thyroid lobe. FNA reveals thyroid carcinoma. He undergoes thyroid resection. Three days post-operatively he is found to be “whispering in a raspy voice.” Which of the following complications likely occurred with this patient? A. Injury to the accessory nerve B. Injury to a branch of the vagus nerve C. Injury to the phrenic nerve D. Injury to the hypoglossal nerve. Gastrointestinal Oncology A 60-year-old male presents with fatigue and passing out. He is noted to have dark stools and his wife states he has become increasingly “thin” over the past few months. He undergoes stool testing which is positive for heme. Further workup reveals adenocarcinoma. Which of the following gene mutations is likely responsible for the transformation of a colonic adenoma to adenocarcinoma? A. B. C. D. n-MYC c-MYC COX p53 A 60-year-old male with a history of hypertension and dyslipidemia presents with chest pain. He also has difficulty swallowing. He states that his chest pain is worse when lying down. There is no relation to activity. CXR and abdominal CXR reveal a “heterogenous air-filled collection behind the retrocardiac border on the left side.” What is the likely pathophysiology behind the diagnosis? A. Laxity of the diaphragmatic-lower esophageal region B. Congenital abnormality of the diaphragm C. Acute trauma leading to colonic contents in the thorax D. Lack of abdominal malrotation Oncology: Answer Key 442 Answer Key NBME Top Concepts ➤ Oncology Lymphomas and Vascular Tumors A patient was recently diagnosed with HIV. He has been non-compliant with his therapy. He is noted to have headaches. MRI of the brain reveals a “solitary mass with no calcification in the frontotemporal region.” Biopsy reveals a tumor with T-cell lineage. Which of the following genomes may be present in this patient’s biopsy? A. Bartonella hensale B. Ebstein Barr Virus C. HHV-6 D. CMV A patient with Sjogren syndrome has a rapidly enlarging parotid mass. Exam shows a unilateral heterogeneous mass that is not tender to palpation obscuring the R mandibular region. Parotid excision is likely to reveal which of the following tumor derivatives? A. Malignant squamous cells with keratin pearls B. Anaplastic round blue cells surrounding salivary glands C. S-100 neuro-ectodermal cells surrounding salivary glands D. Germinal centers with distorted lymph node architecture A patient is diagnosed with a highly vascularized tumor surrounding normal cellular epithelium. Increased capillary proliferation is seen on microscopic pathology. An increase in which of the following cellular ligands may be expected in this patient? A. EGF B. FGF C. PDRF D. IGF-1 Renal Oncology A mother brings her son in due to abdominal distension. His mother states that her son has been having normal bowel movements. She noticed while bathing him last night that he had increased abdominal fullness “more on the left side.” CT scan reveals a homogenous mass at the inferior pole of the kidney that does not cross the midline. If this oncological lesion was associated with a genetic syndrome, which of the following additional findings may be present? A. Episcleritis B. Aniridia C. Uveitis D. Glaucoma Oncology: Answer Key 443 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Oncology Breast Oncology A 60-year-old female presents concerned about a right breast mass that she felt in the shower. She notes that there is associated dimpling. There is no redness, fluctuance to the breast. There is no family history of breast cancer. There is prominent lymphadenopathy in the right upper quadrant of her breast. She is found to have an irregular immobile mass on palpation. Which of the following affected structures may be most contributing to her nipple dimpling? A. Axillary lymph node B. Suspensory ligament C. Lactiferous ducts D. Mammary artery A patient presents with unilateral breast redness. She is 3 weeks postpartum and had a breast mass which was being worked up prior to pregnancy. She has completed a course of dicloxicillin with no relief of her breast redness. She is currently not breastfeeding. Ultrasound of breast shows no abscess. There are hard lymph nodes in the axilla. Which of the following pathophysiologic mechanisms may be contributing to the underlying pathology? A. Lymphatic duct obstruction B. Fibrotic suspensory ligament of breast C. Infection of the superficial epidermis by MSSA D. Deep vein thrombosis of the L brachial vein Oncology: Answer Key 444 CHAPTER 20 Top NBME Concepts: Dermatology 445 uploaded by medbooksvn Approach to Urticaria NBME Top Concepts ➤ Dermatology NBME Style Question A 40-year-old female presents with sore throat and a skin rash. The patient was recently started on oral amoxicillin. The skin rash is pruritic and notable for raised papules which spare the palms and soles. The patient has a remote history of asthma. What is the likely microscopic finding which will be seen on biopsy of this rash? A. Ab to hemidesmosomes B. Dermal transudative edema C. Ab to desmosomes D. Epidermal spongiosis Pathophysiology of Urticaria Approach to Urticaria on the USMLE Step 1 Identify triggers in exam questions: • Drugs, food, recent prodrome of illness • Physical Exam: • Raised, palpable well-circumscribed pruritic papule or plaque • Transient Dermatology: Approach to Urticaria 446 Approach to Urticaria NBME Top Concepts ➤ Dermatology Hives for the USMLE Sstep 1 NBME Style Question A 50-year-old farmer presents with a rough rash on the scalp. The patient noted this rash a few months ago however now the rash has spread and is itchy. The rash is notable for scaly papules with mild erythema at the base. What is the likely diagnosis? A. Atopic dermatitis B. Actinic keratosis C. Pityriasis rosea D. Psoriasis E. Seborrheic Keratosis USMLE Dermatology Test Taking Tip Pay attention to the Physical Exam for dermatology questions terminology of the rash. it will describe the basic Big Picture: • What are flat lesions? • Macules or Patch • What are raised lesions? • Papules or Plaque • What are fluid containing lesions? • Vesicles or Bullae Dermatology: Approach to Urticaria 447 uploaded by medbooksvn Dermatology Nomenclature NBME Top Concepts ➤ Dermatology USMLE Dermatology (Basic Terms) NBME Style Question A 50-year-old female presents with a skin rash after vacation. The patient is noted to have tan skin with multiple hypopigmented patches & macules on the extremities. She undergoes KOH preparation which is notable for short, cigar shaped appearance hyphae. Which of the following is the most likely cause of this lesion? A. Blastomycosis dermatiditis B. Malassezia globosa C. Sporothrix schenckii D. Histoplasmosa capsulatum Dermatology: Dermatology Nomenclature 448 Dermatology Nomenclature NBME Top Concepts ➤ Dermatology Pityriasis Versicolor Creative Commons Attribution License 4.0 Infection of stratum corneum Dermatology: Dermatology Nomenclature 449 uploaded by medbooksvn Plaques NBME Top Concepts ➤ Dermatology Plaques A 34-year-old woman with chronic skin rash. Shows well demarcated coral-colored plaques with silvery scales over the scalp, elbows and knees. You remove the scales and see pinpoint bleeding. What is the clinical physical exam feature just observed? • Auspitz sign • Scaling lesion that has HLA relationship + environmental factors. Creative Commons Attribution License 4.0 Microscopic Pathology of Psoriasis on the USMLE Dermatology: Plaques 450 Viral & Bacterial Exanthems NBME Top Concepts ➤ Dermatology Microbiology & Dermatology Integration for the USMLE Viral Exanthems A child in daycare presents with a rash on the trunk and extremities. Rash is notable for multiple well demarcated, flesh-colored papules with central umbilication. An infectious etiology is suspected. What is the likely morphology of the agent behind this diagnosis? • Pox virus • Enveloped, double stranded DNA virus • Largest DNA virus replicates in the cytoplasm • What is the mechanism of transmission? • Skin to skin • Fomite. Creative Commons Attribution License 4.0 Dermatology: Viral & Bacterial Exanthems 451 uploaded by medbooksvn Viral & Bacterial Exanthems NBME Top Concepts ➤ Dermatology Rubella, Rubeola, Roseola NBME Style Question A newborn baby is in the nursery. The patient is noted to have white pupils and a harsh murmur heard over the L side of precordium. There is no hepatosplenomegaly. Newborn screening indicates a failed hearing exam. What is the likely intervention which may have prevented this pathology? A. Maternal live attenuated vaccine before pregnancy B. Maternal polysaccharide booster before pregnancy C. Maternal screening of glucose at 20 weeks gestation D. Newborn screening of mucopolysaccharidosis Dermatology: Viral & Bacterial Exanthems 452 Rubella NBME Top Concepts ➤ Dermatology Rubella - High Yield Feature Creative Commons Attribution License 4.0 Viral Exanthems An unimmunized child presents with fever to 102 F, runny nose, and eye discharge. Patient on exam has a benign lung exam however is coughing frequently. White spots on oral mucosa are present. What is the likely diagnosis? • Measles also known as rubeola. • What is the morphology of this virus? • RNA virus, orthomyxovirus (ss –, linear, non-segmented RNA virus) • What are the oral lesions on the buccal mucosa? • Koplik spots. Oral Mucosal Lesions (Viral) Creative Commons Attribution License 4.0 Creative Commons Attribution License 4.0 Dermatology: Rubella 453 uploaded by medbooksvn Measles NBME Top Concepts ➤ Dermatology Measles (Rubeola) NBME Style Question A child presents to the PICU with a generalized seizure. During this episode vitals are notable for a temperature of 40.2℃. Acetaminophen is administered. A few days after admission the patient is noted to have a maculopapular rash on her trunk. What is the likely diagnosis? A. HSV-1 B. HSV-2 C. Human Herpes-6 D. Scarlet fever E. Kawasaki Disease Dermatology: Measles 454 Roseola NBME Top Concepts ➤ Dermatology Roseola (HHV-6) Creative Commons Attribution License 4.0 • Febrile seizures: • Vital Signs (>38℃) • Generalized shaking of upper & lower extremities • Fever then rash on trunk which spreads to extremities. Dermatology: Roseola 455 uploaded by medbooksvn Erythema Infectiosum NBME Top Concepts ➤ Dermatology Erythema Infectiosum A pregnant woman presents with joint pain and low-grade fevers. She has joint pain that is transient in upper and lower extremities. History is notable for febrile contacts throughout the child care center which she is employed. What is the likely morphology of the virus behind her symptoms? • Parvo-virus B19 • Single-Stranded DNA virus • Watch for hydrops fetalis on pre-natal ultrasound She now presents for follow-up as she continues to have chronic arthritis. On routine blood work, she is found to be anemic and thrombocytopenic with low reticulocyte count. What is the likely diagnosis? • Aplastic anemia. Erythema Infectiosum Slapped Cheek Rash Creative Commons Attribution License 4.0 NBME Style Question A 22-year-old female presents to the OBGYN clinic with chief complaint of pruritis and vulvar pain. She is noted to have a prodrome of fever and on exam tender vesicle lesions covering the mons pubis and labia. What is the likely sequela of this patient’s disease? A. Resolution with treatment B. Recurrence of genital lesions C. Squamous cell vulvar carcinoma D. Co-infection with HPV 6, 11 E. Inguinal abscesses Dermatology: Erythema Infectiosum 456 Erythema Infectiosum NBME Top Concepts ➤ Dermatology NBME Style Question A patient is noted to be altered, confused and febrile. A continuous EEG is placed to detect seizures. The patient is diagnosed with temporal lobe epilepsy. The patient continues to be febrile throughout admission in the hospital. Which of the following infectious etiologies is most likely related to this patient’s presentation? A. Toxoplasma B. Streptococcus PNA C. Neisseria Meningitis D. Neurocysticercosis E. Herpes Simplex Virus Dermatology: Erythema Infectiosum 457 uploaded by medbooksvn Systemic Manifestations of Herpes NBME Top Concepts ➤ Dermatology Systemic Manifestations of herpes for the USMLE NBME Style Question A patient is noted to have a vesicular rash involving the T10 dermatome. There is crusting near the umbilicus. The rash does not cross the midline. What is the likely complication which may be seen in this patient on 5 month follow up? A. Polyarthralgia B. Persistent pain in the dermatomal region C. Gross hematuria D. Recurrent disseminated pan-sclerosing encephalitis Dermatology: Systemic Manifestations of Herpes 458 Varicella Infections on USMLE NBME Top Concepts ➤ Dermatology Varicella Infections on the USMLE Microbiology & Dermatology Integration for the USMLE Dermatology: Varicella Infections on USMLE 459 uploaded by medbooksvn Erysipelas vs Cellulitis NBME Top Concepts ➤ Dermatology Bacterial Skin Infections for the USMLE Step 1 Dermatology: Erysipelas vs Cellulitis 460 Staph and Strep Infections NBME Top Concepts ➤ Dermatology Staphylococcal & Streptococcal Infections A child presents with URI symptoms and a peri-oral rash. Exam of the face is notable for a rash with crusted secretions and a yellow-tan appearance. What is the likely diagnosis? • Non-bullous impetigo • S. aureus (gm +, catalase & coagulase +) • Group A Streptococcus (gm +, catalase -, β hemolytic) • Watch for superinfection with herpes or cola colored urine (PSGN). Creative Commons Attribution License 4.0 Staphylococcal Infections An infant presents with fever and hypotension diffuse blisters in the inguinal creases are seen which disappear upon slight pressure. What is the likely physical exam sign seen described in this patient? • Nikolsky sign (+) • Pathophysiology of Staph Scalded Skin Syndrome • Epidermolytic toxins A+B bind to desmoglein 1 of desmosomes à skin splits at the stratum granulosum. Creative Commons Attribution License 4.0 Staph Scalded Skin Syndrome Dermatology: Staph and Strep Infections 461 uploaded by medbooksvn Nikolsky Sign Manifestations for the USMLE NBME Top Concepts ➤ Dermatology High Yield PE Feature Creative Commons Attribution License 4.0 Nikolsky Sign for the USMLE Step 1 NBME Style Question A couple is on their honeymoon. Upon return home, the newly wed wife notices a pruritic, papulopustular rash on the trunk. Two days later, the husband notice the same rash. What is the likely organism which may be behind the presentation? A. Staph aureus B. GAS C. Pseudomonas Aeruginosa D. Pasturella Multicoda Dermatology: Nikolsky Sign Manifestations for the USMLE 462 Neonatal Rashes NBME Top Concepts ➤ Dermatology Neonatal Rashes An infant presents for routine examination. Exam is notable for a red 2.5 cm lesion on scalp with fine telangiectasias surrounding the lesion. The patient is afebrile & is painless. What is the next best response to family? • “This is a benign rash; rash will grow before it spontaneously involutes.” Creative Commons Attribution License 4.0 Neonatal Skin Lesions Dermatology: Neonatal Rashes 463 uploaded by medbooksvn Precursor Lesions to Neoplasia NBME Top Concepts ➤ Dermatology NBME Style Question A 50-year-old farmer presents with a rough rash on the scalp. The patient noted this rash a few months ago however now the rash has spread and is itchy. The rash is notable for scaly papules with mild erythema at the base. What is the likely complication of this disease presentation? A. Basal cell carcinoma B. Super-imposed Staph infection C. Kaposi sarcoma D. Squamous cell carcinoma E. Seborrheic Keratosis Actinic Keratosis Squamous Cell Carcinoma Seborrheic Keratosis Gi Adenocarcinoma Dermatology: Precursor Lesions to Neoplasia 464 Summary NBME Top Concepts ➤ Dermatology Rash on Palms and Soles Creative Commons Attribution License 4.0 Erythema Creative Commons Attribution License 4.0 Dermatology: Summary 465 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Dermatology Approach to Urticaria A 40-year-old female presents with sore throat and a skin rash. The patient was recently started on oral amoxicillin. The skin rash is pruritic and notable for raised papules which spare the palms and soles. The patient has a remote history of asthma. What is the likely microscopic finding which will be seen on biopsy of this rash? A. Ab to hemidesmosomes B. Dermal transudative edema C. Ab to desmosomes D. Epidermal spongiosis A 50-year-old farmer presents with a rough rash on the scalp. The patient noted this rash a few months ago however now the rash has spread and is itchy. The rash is notable for scaly papules with mild erythema at the base. What is the likely diagnosis? A. Atopic dermatitis B. Actinic keratosis C. Pityriasis rosea D. Psoriasis E. Seborrheic Keratosis Dermatology Nomenclature A 50-year-old female presents with a skin rash after vacation. The patient is noted to have tan skin with multiple hypopigmented patches & macules on the extremities. She undergoes KOH preparation which is notable for short, cigar shaped appearance hyphae. Which of the following is the most likely cause of this lesion? A. Blastomycosis dermatiditis B. Malassezia globosa C. Sporothrix schenckii D. Histoplasmosa capsulatum Viral & Bacterial Exanthems A newborn baby is in the nursery. The patient is noted to have white pupils and a harsh murmur heard over the L side of precordium. There is no hepatosplenomegaly. Newborn screening indicates a failed hearing exam. What is the likely intervention which may have prevented this pathology? A. Maternal live attenuated vaccine before pregnancy B. Maternal polysaccharide booster before pregnancy C. Maternal screening of glucose at 20 weeks gestation D. Newborn screening of mucopolysaccharidosis Dermatology: Answer Key 466 Answer Key NBME Top Concepts ➤ Dermatology Measles A child presents to the PICU with a generalized seizure. During this episode vitals are notable for a temperature of 40.2℃. Acetaminophen is administered. A few days after admission the patient is noted to have a maculopapular rash on her trunk. What is the likely diagnosis? A. HSV-1 B. HSV-2 C. Human Herpes-6 D. Scarlet fever E. Kawasaki Disease Erythema Infectiosum A 22-year-old female presents to the OBGYN clinic with chief complaint of pruritis and vulvar pain. She is noted to have a prodrome of fever and on exam tender vesicle lesions covering the mons pubis and labia. What is the likely sequela of this patient’s disease? A. Resolution with treatment B. Recurrence of genital lesions C. Squamous cell vulvar carcinoma D. Co-infection with HPV 6, 11 E. Inguinal abscesses A patient is noted to be altered, confused and febrile. A continuous EEG is placed to detect seizures. The patient is diagnosed with temporal lobe epilepsy. The patient continues to be febrile throughout admission in the hospital. Which of the following infectious etiologies is most likely related to this patient’s presentation? A. Toxoplasma B. Streptococcus PNA C. Neisseria Meningitis D. Neurocysticercosis E. Herpes Simplex Virus Systemic Manifestations of Herpes A patient is noted to have a vesicular rash involving the T10 dermatome. There is crusting near the umbilicus. The rash does not cross the midline. What is the likely complication which may be seen in this patient on 5 month follow up? A. Polyarthralgia B. Persistent pain in the dermatomal region C. Gross hematuria D. Recurrent disseminated pan-sclerosing encephalitis Dermatology: Answer Key 467 uploaded by medbooksvn Answer Key NBME Top Concepts ➤ Dermatology Nikolsky Sign Manifestations for the USMLE A couple is on their honeymoon. Upon return home, the newly wed wife notices a pruritic, papulopustular rash on the trunk. Two days later, the husband notice the same rash. What is the likely organism which may be behind the presentation? A. Staph aureus B. GAS C. Pseudomonas Aeruginosa D. Pasturella Multicoda Precursor Lesions to Neoplasia A 50-year-old farmer presents with a rough rash on the scalp. The patient noted this rash a few months ago however now the rash has spread and is itchy. The rash is notable for scaly papules with mild erythema at the base. What is the likely complication of this disease presentation? A. Basal cell carcinoma B. Super-imposed Staph infection C. Kaposi sarcoma D. Squamous cell carcinoma E. Seborrheic Keratosis Dermatology: Answer Key 468
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