Reactions to DTaP An 18-month-old boy is brought to the office for a well baby visit. The mother appears concerned because a day after the administration of the previous dose DTaP vaccine, the baby developed a seizure which lasted for about 2 minutes. She took the baby to the emergency department, where the baby was kept under observation and subsequently discharged. The baby has had no recurrences, and has been in good health ever since. The child is due for the fourth dose of DTaP vaccine today. Which of the following is the most appropriate course of action? A. Do not administer the vaccine [16%] B. Administer the routine DTaP [35%] C. Administer the diphtheria and tetanus toxoids, avoid the pertussis component [3196] D. Administer the pertussis and tetanus toxoids, avoid the diphtheria component [6%] E, Administer the diphtheria and pertussis toxoids, avoid the tetanus component [5%] F. Refer to an immunization specialist [6%] Educational Objective: An immediate anaphylactic reaction, an encephalopathy, or any CNS complication within 7 days of administration of the vaccine is a contraindication for further administration of DTaP. In these instances, DT should be substituted for DTaP since the adverse reactions are usually attributed to the pertussis component of the vaccine. *Extremely high yield question for the USMLEII! Extremely HY Questions-CK 1/48 10/7/13Photo-protection An 8-year-old boy is brought to the office by his mother for a routine check-up. He has fair skin, blond hair and blue eyes. His past medical history is insignificant. His mother wants to know what the best possible photo-protection is for her son, because "his skin has always been sensitive to the sun, and he is almost unable to tan." He had two episodes of sunburn recently. Physical examination reveals several junctional nevi. Which of the following is the best response to this patient's mother? A. Reassure and provide routine care [3%] B. Recommend applying sunscreens before sun exposure [40%] ¥ © C. Minimize sun exposure in the middle of the day [49%] D. Rest under trees or umbrellas during the day [5%] E. Emphasize that clothing is typically useless for sun protection [2%] Educational Objective: Appropriate patient education about photo-protection, especially in the high-risk group, is important. Sun avoidance remains as the best method of photo-protection Know this: Sunscreens should be applied 15-60 min prior to sun exposure to allow enough time for protective film development. *Extremely high yield question for the USMLEI!! Extremely HY Questions-CK 2/48 10/7/13Photo-protection, another question! A 10-year-old girl with blue eyes and blonde hair is brought to the office by her mother for a routine check-up. All her immunizations are up to date. Her family history is significant for myocardial infarction in her father and schizophrenia in a maternal uncle. There is no family history of any skin malignancies. Her height is at the 60th percentile, and weight is at the 56th percentile. While you are examining her, the mother says with much concern that she saw a television program that claimed that the incidence of skin cancer is increasing dramatically. She wants to know the best way to prevent skin cancer in her daughter, especially since they live in California. What is the best advice to help prevent malignant melanoma in this child? A. Sun screen lotion with SPF (sun protection factor) 15 [10%] B. Sun screen lotion with SPF 30 [33%] v © C. Protective clothing [49%] D. Tanning beds [3%] E. No action needs to be taken, since there is no family history of melanoma [4%] Educational Objective: One of the most practical methods of primary prevention of melanoma is wearing protective clothing such as tightly woven fabrics, hats, and long sleeved shirts. Currently, the available data shows little to no protection against melanoma with the use of sunscreen lotions with SPF 15 - 30; however, these can protect from non-melanoma skin cancers such as squamous cell carcinoma. Extremely HY Questions-CFriedreich ataxia A 15-year-old Caucasian male is brought to the office by his mother for the evaluation of a six-month history of unstable gait and speech difficulty which are getting worse over time. His past medical history is insignificant. He is not taking any medications, and denies smoking or alcohol consumption. His blood pressure is 120/70 mmHg and pulse is 80/min. Musculoskeletal examination showed scoliosis and feet deformity with hammer toes." The neurologic examination showed dysarthria, dysmetria, nystagmus, and absence of deep plantar reflexes on lower extremities. What is the most common cause of death in this patient population? v © A Cardiomyopathy [68%] B. Renal failure [14%] C. Diabetes-related complications [3%] D. Malignancy [10%] E. Septic: shock [5%] Educational Objective: Friedreich ataxia is the most common type of spinocerebellar ataxias. Remember the combination of neurologic (ataxia, dysarthria), skeletal (scoliosis, feet deformities) and cardiac (concentric hypertrophic cardiomyopathy) manifestations of the disease. The most common causes of death are cardiomyopathy and respiratory complications. "very high-yield topic for USMLE! Extremely HY Questions-CK 4148 10/10/13Avascular necrosis, SCD ‘A 14-year-old black male comes to the office for the evaluation of pain in his right hip that started several weeks ago. The pain has gradually progressed, and now it imits his daily activties. He has sickle cel disease and was hospitalized three months ago due to a painful crisis that was successfully treated with hydration, oxygen, and analgesics. His temperature is 37.2C (99F), blood pressure is 100/70 mmHg, pulse is 80/min, and respirations are 16imin. Physical ‘examination reveals no local tendemess, but there is restriction of abduction and internal rotation of the hhip. What is the most ikely diagnosis? © A Osteomyelitis caused by Saimonelia © B. Osteomyelitis caused by Staphylococcus ‘C. Joint effusion from septic arthritis, E. Femoral fracture Educational Objective: Aseptic necrosis of the femoral head is a common complication of sickle cell disease. It involves occlusion of end arteries supplying the femoral head, bone necrosis, and eventual collapse of the Deriarticular bone and cartilage. "Extremely high yield question for USMLEN!! Extremely HY Questions-CK 5/48 10/22/13Leuckocoria ‘A.2-month-old female infant born at term is brought to the office for a well-baby visit. Her antenatal and birth histories are unremarkable. Her developmental milestones are all normal for her age. Ophthalmoscopic examination reveats a white reflex in the right eye. The rest of the examination is normal, What is the most appropriate next step in the management of this patient? A. Covering the affected eye [2%] B. Covering the normal eye [5%] ¥ © C, Referral to an ophthalmologist [87%] D_ Reassurance [3%] E. Watchful waiting [3%] Educational Objective: Every case of leukocoria is considered a retinoblastoma, until proven otherwise; therefore, such Gases should be promptly referred to an ophthalmologist. "Extremely high yield question!!! Extremely HY Questions-CK 6/48 10/23/13Hemolytic Uremic Syndrome (HUS) ‘A 6-year-old African-American child is brought in by his father for complaints of easy fatigability and pallor. These symptoms occurred after the son was treated with "some medication” for a recent diarthea. Physical examination is normal except for pallor and muttiple petechiae, Laboratory values are as follows: Hb 8.0 g/dL wec 12,000/emm Platelets: 50,000/emm Blood glucose. 148 mg/d ‘Serum Na 135 mEq/L. Serum K 5.3 mEq/L Chloride 110 mEqit. Bicarbonate 18 mEqL BUN 38 mg/dL ‘Serum creatinine 2.5 mg/dL Total bilirubin 3 mg/dL. Direct bilirubin 0.5 mg/d PT 12 seconds APTT 30 seconds LOH 900 IU/L Reticulocyte count 6% ‘A peripheral blood smear reveals giant platelets and multiple schistocytes. What is the most likely underlying pathophysiology for this boy's pallor? A. Sickle cell anemia © B. Thalassemia ©. Vitamin 812 deficiency D. Folate deficiency © E, Microangiopathic hemolytic anemia © F. Lead poisoning G. Disseminated intravascular coagulation H. Idiopathic thrombocytopenic purpura © |Renal failure Educational Objective: Suspect HUS in a child who has recently recovered from a diarrheal ness and presents with acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia and characteristic peripheral smear finding of schistocytes “Extremely high-yield question for the USMLE!! Extremely HY Questions-CK 7148 10/30/13Pubertal Gynecomastia A 14-year-old boy comes to the office because he has been feeling a mass under his right nipple for the last three weeks. The physical examination reveals clinical findings suggestive of right gynecomastia with very mild tenderness. The left breast and the rest of the physical exam is unremarkable. His testis is 2 cm in length and has 3 mL volume. What is the most appropriate next step in the management of this patient? ‘A. Biopsy of breast mass (7%) v © B, Reassurance [65%] C. Karyotyping [14%] D. MRI brain [2%] E. Serum prolactin levels [11%] Educational Objective: Pubertal gynecomastia is seen in approximately one-half of adolescent boys, at an average age of 14 years. Itis often asymmetric or transiently unilateral, and frequently tender. In prepubertal males the testicular size is normally 2 cm in length and 3 mL in volume. The initial management involves reassurance and watchful waiting/observation, “Extremely high yield question for USMLE! Extremely HY Questions-CK 8/48 10/30/13Osteogenesis imperfecta ‘A 3-year-old boy is brought to the office by his 27-year-old white mother for the evaluation of recurrent bone fractures. His first fracture was that of the femur, and occured when he was 6 months old. He had a fracture of the wrist 4 months ago, His mother also has a history of multiple fractures since childhood. She lost all her teeth at a very early age and is complaining of deainess. Her husband has a history of severe alcohol abuse. On examination, both mother and son have blue sclerae. What is the most ikely involved disease process? ¥ © A. Mutations in type 1 collagen [90%] B. Mutations in fibrillint gene [5%] ©. Child abuse [19%] D. Vitamin-D deficiency [19] E. Congenital syphilis [1%] Educational Objective: Osteogenesis imperfecta is caused by mutations in type 1 collagen. Its typical features are blue sclera and recurrent fractures, "Extremely high yield question for USMLE step-1 and step-2 Time Spent: 1 seconds 90% answered correctly Last updated: [7/7/2010] Copyright © USMLEWORLD.LLC. Extremely HY Questions-CK 9/48 1/12/13Choanal atresia You are called to examine a 2-day old male infant due to difficulty in feeding. He becomes: cyanotic and short of breath when he feeds, but turns pink when he cries. His prenatal, birth and family histories are unremarkable. His vital signs are normal. Chest auscultation is normal. His peripheral pulses are full and symmetric. What is the most likely diagnosis? A. Cyanotic heart disease [9%] B. Acyanotic heart disease with left-to-right shunt [8%] v © C, Choanal atresia [65%] D. Transient tachypnea of the newborn [6%] E. Laryngomatacia [12%] Educational Objective: Suspect choanal atresia in an infant who presents with cyanosis that is aggravated by feeding and relieved by crying Extremely high yield question for USMLE!!! Time Spent: 1 seconds 65% answered correctly Last updated: (7/7/2040) Coprright © USMLEWORLD.LLC. Extremely HY Questions-CK 10/48 11/21/13Cystic fibrosis A 6-year-old gitl is brought to the office due to significant steatorrhea and failure to thrive, ‘She has a poor appetite and general malaise. Her past medical history is significant for prolonged neonatal jaundice and numerous respiratory tract infections. On examination, she looks a litle underweight and has a runny nose. Auscultation reveals mild wheezing and diminished air entry in both lungs. Clubbing is visible on both hands. What is the best diagnostic test for this patient? ‘A. Blood cultures [19%] B. Sputum cultures [1%] ©. CT abdomen [19%] ¥ © D. Sweat chloride test [96%] E. Liver function tests [1%] “Cystic fibrosis is an extremely high yield topic for USMLE. You need to have in-depth knowledge about this topic.” Time Spent: 1 seconds 96% answered correctly Last updated: [7/7/ Extremely HY Questions-CK 11/48 11/22/13Thiazides and hyperglycemia A 55-year-old Caucasian male presents to your office for a routine check-up. His past medical history is significant for gout, hypertension, and hypercholesterolemia. His current medications include enalapril and pravastatin. He does not smoke or consume alcohol. His blood pressure is 156/94 mmHg and heart rate is 80/min. Physical examination reveals that the patient is moderately overweight (BMI = 27 kg/m2) with increased waist-to-hip ratio. You consider adding hydrochlorothiazide to the treatment regimen to improve the control of hypertension. Which of the following metabolic effects do you expect to emerge after this correction? ‘A Hypocalcemia [18%] B. Hyperkalemia [14%] ‘C. Decreased LDL cholesterol [4%] D. Decreased plasma triglycerides [4%] E. Hyperglycemia [59%] Educational Objective: Thiazide diuretics have some unfavorable metabolic side effects including hyperglycemia, increased LDL cholesterol, and plasma triglycerides. Electrolyte abnormalities that can be induced by thiazide diuretics include hyponatremia, hypokalemia, and hypercalcemia. *Extremely high yield question for USMLE! Extremely HY Questions-CK 12/48 3/414Rx of Acne A 17-year-old white male presents to your office because the “spots” on his face "got so much worse recently!” He has several months history of acne. He has been treated for acne before but his rash has nat cleared. Inspection reveals multiple papules with several pustules and nodules. Atrophic Scars are seen. What is the best next step in the management of this patient? A. Topical retinoids [16%] B. Topical antibiotic [9%] C. Oral antibiotic [21%] D. Benzoyl peroxide [7%] wv © E. Oral isotretinoin (46%) Educational Objective: Give oral isotretinoin to patients with moderate-to-severe acne that is predominantly nodulocystic form, and to those who have developed scars. "Extremely high yield question for the USMLE!!! Extremely HY Questions-CK 13/48 S/SN4Herpetic whitlow A 45-year-old male comes to you with complaints of throbbing pain over the pulp of his left index finger for the last two days. He has been feeling warm for the last three days. He denies ever having any sexually transmitted disease or cold sores in the past. On examination, he has a ‘swollen, soft, and tender distal pulp space of the left index finger with some non-purulent vesicles. A picture of his hand is shown below. Tzanck smear of the vesicles show multinucleated giant cells. Which of the following is most likely the occupation of this patient? v — A. Adentist [62%] B. Commercial sex worker [17%] C. A gardener [16%] D. A tailor (5%) Herpetic whitlow is a common viral infection of the hand. It is caused by either type 1 or 2 herpes simplex virus, and is self-imiting. Health care workers who come in direct contact with infected orotracheal secretions are at increased risk of developing whitiow. *Extremely high yield question for USMLE!!! Extremely HY Questions-CK 14/48 3/6/14Best intial Rx to control symptoms of hyperthyrodism A 34-year-old Caucasian female comes to the emergency department and complains that her heart is "racing out of control." She began to feel this way only this morning. She denies any chest pain or shortness of breath. Over the past few months, she has unintentionally lost 10 pounds. Her past medical history is significant for panic attacks, but she claims she has not had an attack for over 10 years. She is very concerned because her father died of a heart attack at the age of 40. The EKG reveals sinus tachycardia at a rate of 120/min. The initial labs show: CBC Hb 12.99/dL Ht 39% MCV 88 fl Platelet count 200,000/cmm Leukocyte count 8,500/emm Neutrophils 67% Eosinophils 1% Lymphocytes 24% Monocytes 8% Serum Serum Na 139 mEq/L Serum K 4.2 mEq/L Chloride 100 mEq/L Bicarbonate 25 mEq/L BUN 10 mg/dL Serum Creatinine 1.0 mg/dL Calcium 9.1 mg/dL Blood Glucose 102 mg/dL TSH < 0.1 microU/mL Free T4 4.6 ng/dl (N 0.9-2.4) Which of the following is the best immediate step to control this patient's symptoms? Propyilthiouracil [8%] . Subtotal thyroidectomy [1%] . Alprazolam [2%] Radioactive lodine [4%] . Propranolol [83%] moom> Extremely HY Questions-CK 15/48 3/9/14Best intial Rx to control symptoms of hyperthyrodism, cont. Educational Objective: In the management of patients with hyperthyroidism, propranolol is generally used for symptomatic relief until the underlying cause is identified and definitively treated. *Extremely important question for the USMLE step-2 Extremely HY Questions-CK 16/48 3/9/14Metabolic Syndrome A 55-year-old Caucasian male presents to the office for a routine check-up. He has no present complaints. His past medical history is significant for @ long history of hypertension. He does not smoke or consume alcohol. His current medications are enalapril and hydrochlorothiazide, His blood pressure is 140/90 mm Hg and heart rate is 80/min. Physical examination reveals @ moderately overweight man (BMI = 27 kg/m2) with a waist circumference of 41 inches. The laboratory studies show: Fasting blood glucose 112 mg/dL Total cholesterol 220 mg/dL LDL cholesterol 140 mg/dL Triglycerides 240 mg/dL Which of the following is the most important pathogenic factor for this patient's condition? A. Impaired secretion of insulin (3%) B. Low absolute values of insulin [2%] C. Insulin resistance [86%] D. Sympathetic hyperactivity [7%] E. Insulin-mediated vasodilatation [1%] This vignette describes a patient with the typical clinical presentation of metabolic syndrome, which includes hypertension, impaired fasting glucose, and dyslipidemia. Patients are also characteristically overweight (as seen in this case), with predominantly central (abdominal) fat distribution that is reflected by an increased waist-to-hip ratio. Insulin resistance plays a central role in the pathogenesis of metabolic syndrome. Metabolic syndrome is diagnosed when at least 3 of the 5 following criteria are met: 1, Abdominal obesity (Men: Waist circumference >40 inches, Women: Waist circumference >35 inches) 2. Fasting glucose >100 - 110 mg/dL 3. Blood pressure > 130/80 mm Hg 4. Triglycerides >150 mg/dL. 5. HDL cholesterol (Men: <40 mg/dL; Women: <50 mg/dL) Educational Objective: Insulin resistance typical for patients with central-type obesity is the key pathogenic factor in the development of type-2 diabetes mellitus and associated abnormalities (hypertension, dyslipidemia). “Extremely high yield question for the USMLEI!! Extremely HY Questions-CK 17/48 3/10/14Use of ACEi in patients with DM A 60-year-old asymptomatic man presents to your office for a routine check-up. He has a 10-year history of type 2 DM, and a 12-year history of hypertension. His current medications include low-dose glyburide and a low-dose thiazide diuretic. His blood pressure is 140/90 mm Hg and heart rate is 65/min. Physical examination shows a soft ejection systolic murmur at the base of the heart. Ophthalmoscopic evaluation reveals no abnormalities. ECG recorded 6 months ago showed left ventricular hypertrophy and non-specific ST segment and T-wave abnormalities. His recent fasting glucose level was in the range of 120 to 150 mg/dL, and HbAtc was 7.1 % (normal < 6%). 24-hour urine collection reveals microalbuminuria. Which of the following is the best measure to slaw end-organ damage in this patient? A Increase the dose of glyburide (3%) B. Increase the dose of thiazide diuretic [1%] C. Switch to insulin [3%] ¥ © D. Add ACE inhibitor [89%] E. Add beta-blocker [2%] Educational Objective: ‘Several randomized controlled clinical trials have demonstrated the beneficial effect of ACE inhibitors on slowing the progression of diabetic nephropathy. * The use of ACE inhibitors in patients with DM is a very high-yield topic in the USMLE. Extremely HY Questions-CK 18/48 3/10/14Immonosuppresents actions and toxicities A 47-year-old diabetic woman comes to the physician due to the recent onset of tremors. She has undergone combined pancreatic and kidney transplantation secondary to end stage renal disease and diabetes. She takes multiple medications, including immunosuppressants. Her temperature is 36.1C (97F), blood pressure is 152/90 mm Hg, pulse is 78/min, and respirations are 16/min. Examination shows gum hypertrophy. Laboratory studies show. Hb 13.0 g/dL WBC 8,000/cmm Serum Na 135 mEq/L Serum K 5.3 mEql BUN 26 mg/dL Serum Creatinine 1.7 mg/dl Which of the following immunosuppressants is most likely responsible for her presentation? A Tacrolimus [24%] B. Cyclosporine [51%] C. Azathioprine [13%] D. Mycophenolate [11%] Educational Objective: ‘Cyclosporine and tacrolimus have the same mechanism of action (calcineurin-inhibitors). The major side effects of cyclosporine include nephrotoxicity, hyperkalemia, hypertension, gum hypertrophy, hirsutism, and tremor. Tacrolimus has similar toxicities, except for hirsutism and gum hypertrophy. *The major toxicity of azathioprine is dose-related diarrhea, leukopenia, and hepatotoxicity *The major toxicity of mycophenolate is bone marrow suppression "Extremely high yield question for the USMLEI!! Extremely HY Questions-CK 19/48 314Rx of Hyperkalemia A 45-year-old mate patient comes to the physician's office for a routine check up. He denies any symptoms and says he feels "perfectly healthy." He was diagnosed with hypertension and mixed hypercholesterolemia a year ago, He is currently taking hydrochlarothiazide, amiloride and simvastatin daily. He does not use tobacco, alcohol or drugs. His blood pressure today is 135/85 mm Hg, Physical examination shows no abnormalities, Routine blood results reveal the folowing cBc Hb 14.2g/dL Ht 42% wcv 86 fl Platelet count 260,000/emm Leukocyte count 8,500/emm, Neutrophils 70% Eosinophils 1% Lymphocytes, 24% Monocytes 5% Serum ‘Serum Na 140 mEq/L. Serum K 5.7 mEq/L Chloride 100 mEq/L. Bicarbonate 24 mEq BUN 10 mg/d Serum Creatinine 1.1 mg/dL Calcium 9.0 mg/dL Blood Glucose 118 mg/dL Total cholesterol 220 mg/dL LDL cholesterol 130 mg/dL ‘The blood sample is checked and is not hemolysed. The EKG shows normal sinus rhythm. What is the most appropriate next step in the management of this patient? A Intravenous calcium gluconate [12%] B. Intravenous dextrose + insulin [79%] C. Stop amiloride and recheck lab results in 1 week [549%] D. Stop HCTZ and recheck lab resuits in 1 week [14%] E. Start patient on a low potassium diet [10%] Educational Objective: Several medications can cause hyperkalemia, Examples of these are: ACE-inhibitors, NSAIDS, and potassium-sparing diuretics, such as spironolactone and amiloride. “Extremely important question for the USMLE step-2 Extremely HY Questions-CK 20/48 3/114Fibromuscular Dsyplasia ‘A.30-year-old woman comes to the physician due to the recent onset of occipital headaches She has taken acetaminophen several times, but the pain returns. She has no fever or visual problems. She has not had similar episodes in the past. She has no history of serious illness, Her temperature is 36.1C (98F), blood pressure is 160/90 mm Hg, pulse is 88/min, and respirations are 16/min, Physical examination shows a right-sided renal bruit. Which of the following is the most appropriate treatment for this patient's condition? A. ACE inhibitors [219%] B. Furosemide [5%] © C. Angioplasty with stent placement [62%] D. Surgery [8%] E. Oral prednisone [4%] Educational Objective: The treatment of choice for fibromuscular dysplasia is percutaneous angioplasty with stent placement, “Extremely high yield question for USMLE!! Extremely HY Questions-CK 21/48 3/1114Various Casts 57-year-old woman is admitted to the ICU after being involved in a highway motor vehicle accident. She was hypotensive at the scene and received 7 liters of fluids, which included crystalloids, blood, and fresh frozen plasma. She apparently had significant external blood loss from multiple fractures and skin loss. She undergoes surgery, after which she is transferred to the ICU and receives continuous IV fluids and vasopressors. Her laboratory studies 24 hours after the accident show the following: Hb 9.5 g/dL ‘WBC 15,000/cmm Platelets 130,000/cmm BUN 34 mg/dL Serum Creatinine 2.2 mg/dL Which of the following is the most likely microscopic finding on urinalysis? A Broad cast [5%] od B. Muddy brown cast [69%] C. RBC casts [12%] D. WBC casts [3%] E. Fatty casts [7%] F. Eosinophils [3%] Educational Objective: Muddy brown granular cast - Acute tubular necrosis RBC casts - Glomerulonephritis WEBC casts - Interstitial nephritis and pyelonephritis Fatty casts - Nephrotic syndrome Broad and waxy casts - Chronic renal failure “Extremely high yield question for the USMLE!!! Extremely HY Questions-CK 22/48 B24Various types of graft rejection and how to deal with them A.56-year-old man develops oliguria three days after having a kidney transplantation, His postoperative course was uncomplicated. His blood pressure is 160/100 mm Hg and heart rate is 90/min. Palpation of the transplant reveals mild tenderness. Laboratory studies show: Serum sodium 145 mEq/L Serum potassium 5.5 mEq/L Serum calcium 8.6 mg/dL Serum creatinine 3.2 mg/dL BUN 30 mg/dl His serum cyclosporine level is normal. Renal ultrasonography does not detect dilatation of the calyces. Biopsy of the transplant shows heavy lymphocyte infiltration and vascular involvement with swelling of the intima. Which of the folowing is the most appropriate next step in management? A. Decrease the dose of cyclosporine [3%] v © B. Give IV steroids [75%] C. Order ureterography [2%] D. Administer IV diuretics [2%] E. Prepare for surgery [16%] Educational 73 Renal transplant dysfunction in the early post-operative period can be explained by a variety of causes, including ureteral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, ‘and acute tubular necrosis. Radioisotope scanning, renal ultrasound, MRI, and renal biopsy can be employed in conducting a differential diagnosis. Acute rejection ts best treated with intravenous steroids. “Extremely high yield question for the USMLE!I Extremely HY Questions-CK 23/48 B24Platelets dysfunction secondary to uremia: A 68-year-old Caucasian man is admitted with a diagnosis of left lower lobe pneumonia, and is started on gatifloxacin. He has a long history of diabetes, hypothyroidism, hypercholesterolemia, and hypertension. He also has diabetic retinopathy, peripheral neuropathy, and nephropathy. He has an arterio-venous fistula placed for a possible dialysis. His medications are insulin, furosemide, atorvastatin, metoprolol and levothyroxine. After having his blood drawn for some laboratory studies today, he bleeds persistently. Laboratory studies show: Hb 11.5 g/dL Platelets 160,000/cmm Blood glucose 178 mg/dL BUN 56 mg/dL. Serum creatinine 3.5 mg/dL His baseline creatinine level is between 3.2-3.5 mg/dL. Which of the following is the most likely cause of his bleeding? A Disseminated intravascular coagulation [8%] B. Platelet dysfunction [59%] C. Factor VIII deficiency [10%] D. Consumptive coagulopathy [17%] E. Thrombocytopenia [5%) Educational Objective: Platelet dysfunction is the most common cause of abnormal hemostasis in patients with CRF. PT, PTT, and platelet count are normal. BT is prolonged. DDAVP is usually the treatment of choice, if needed. DDAVP increases the release of factor VIII:von Willebrand factor multimers from endothelial storage sites. Platelet transfusion is not indicated because the transfused platelets quickly become inactive. "Extremely high yield question for USMLE!! Extremely HY Questions-CK 24/48 B24Cystinuria A 17-year-old man comes to the emergency department and complains of intensive left flank pain that radiates to the groin. He refers to his symptom as "stone passage,” which he has experienced "for so many times since childhood.” His uncle has the same problem. Urinalysis shows hexagonal crystals. The urinary cyanide nitroprusside test is positive. Which of the following is the most likely cause of this patient's condition? wv © A Amino acid transport abnormality [54%] B. Parathyroid adenoma [3%] C. Abnormality of uric acid metabolism [20%] D. Excessive intestinal reabsorption of oxalate [18%] E. Infection [3%] Educational Objective: Cystinuria is an inherited disease causing recurrent renal stone formation. Look for @ personal history of recurrent kidney stones from childhood and a positive family history. The characteristic stones are hard and radioopaque. Urinalysis shows typical hexagonal crystals. The urinary cyanide nitroprusside test is widely used as a qualitative screening procedure. “Extremely high yield question for USMLEI!! Extremely HY Questions-CK 25/48 B24Erythropoietin site effects A 64-year-old man is scheduled for hemodialysis due to end stage renal disease. He has a several year history of hypertension, diabetes, coronary artery disease, hypercholesterolemia, peripheral vascular disease, gout, and diverticulosis. Six months ago, he was admitted for urosepsis. Recently, his hemoglobin has ranged between 8.5 to 9.5 g/dL. He has already been on iron therapy, and now you are considering erythropoietin injections twice weekly. Which of the following is most likely to be seen following erythropoietin therapy? © A. Worsening of his hypertension [47%] B. Increase in insulin requirement [119%] C. Increased susceptibility to infections [6%] D. Deterioration in renal function [9%] E. Flare-up of gout (26%) ‘Some of the most common side effects of erythropoietin therapy are: 1. Worsening of hypertension: This is seen in approximately 30% of patients. 20-50% of Patients receiving I.V. erythropoietin will have more than a 10 mmHg rise in diastolic BP. This rise in BP is less common after the S.C. route of erythropoietin, as compared to the IV. route. Even hypertensive encephalopathy can occur when there is @ rapid rise in BP. Exactly how erythropoietin causes hypertension is not well understood. Treatment includes fluid removal (by dialysis) and use of anti-hypertensive drugs (beta blockers and vasodilators are preferred). Prevention involves slowly raising the hematocrit, with a goal hematocrit of 30-35%. 2. Headaches: These are seen in 15% of patients, 3, Flutike syndrome: This is seen in 5% of patients. It is responsive to anti-inflammatory drugs, and is less commonly seen with subcutaneous erythropoietin administration. 4 Red cell aplasia: This 's a rare, but potential side effect. (Choice B, C, D, and E) Erythropoietin use is not associated with an increase in insulin requirement, increased susceptibility to infections, deterioration in renal function, and flare-up of gout. Educational Objective: ‘The major cause of anemia in patients with end stage renal disease is deficiency of erythropoietin. The anemia is normocytic and narmochromic. The treatment of choice is recombinant erythropoietin, which is started if the Hb is <10g/dL. The most common side effects are worsening of hypertension (30% of patients), headaches (15% of patients) and flu-like symptoms (5% of patients). "Extremely high yield question for the USMLE!!! Extremely HY Questions-CK 26/48 B24Mx of renal calculi A ‘50-year-old man comes to the emergency department due to a sudden onset of severe, colicky pain in the right flank. He was admitted twice in the past for similar complaints; he was managed conservatively and sent home on both occasions. He has no other medical problems. He does not use tobacco, alcohol or drugs. His vital signs are stable. He is given IV fluids and narcotics Laboratory studies show Hb 14.5 g/d WBC 13,000/emm; no bands Platelets 300,000/emm BUN 16 mg/dL ‘Serum Creatinine 0.8 mg/dL. CT scan of the abdomen without contrast shows renal calculi. Which of the following is the best advice for the prevention of future stones in this patient? ‘A. Decrease dietary calcium intake [24%] B. Mega doses of Vitamin C [5%] v © C. Decrease dietary protein and oxalate [65%] D. Restrict fluid intake (19%) E. Increase sodium intake [3%] Educational Objective: ‘The dietary recommendations for patients with renal calculi are. 1, Decreased dietary protein and oxalate 2. Decreased sodium intake 3. Increased fluid intake 4. Increased dietary calcium “Extremely high yield question for USMLEII! Extremely HY Questions-CK 27/48 B24Diffuse Esophageal Spasm A 40-year-old female presents with a 12-month history of episodes of chest pain and dysphagia. The episodes last from a few seconds to a few minutes. She has not had weight loss, fevers or chills. Chest-x ray, ECG and barium swallow show no abnormalities. Manometric studies show simultaneous high amplitude contractions with normal relaxation of the lower esophageal sphincter. Which of the following is the most likely diagnosis? A. Zenker's diverticulum [2%] v © B. Diffuse esophageal spasm [88%] C. Achalasia [4%] D. Scleroderma [4%] E. Infectious esophagitis [1%] Educational Objective: Diffuse esophageal spasm is usually seen in young females and can present with intermittent episodes of chest pain and dysphagia. Barium swallow may reveal a "corkscrew" esophagus. The treatment is supportive. *Extremely high yield question for the USMLE. Understand the pathophysiology, presence or absence of peristalsis, and LES tone in all the above conditions. Extremely HY Questions-CK 28/48 3/14/14C. Diff 50-year-old male undergoes vagotomy and pyloroplasty for a peptic ulcer perforation. His early post-operative course is complicated by fever and hypotension, which are treated with broad-spectrum antibiotics and IV fluid support. He then recovers well; however, on post-operative day 6 he develops nausea, vomiting, abdominal pain, and profuse, watery diarrhea. His temperature is 38.9 C (102 F), blood pressure is 110/70 mmHg, pulse is 120/min, and respirations are 18/min. Abdominal examination shows tenderness in the sigmoidal area. Test of the stool for occult blood is negative. Laboratory studies show: Hb 11.59/dL Platelet count 180,000/emm Leukocyte count 17,500/emm Segmented neutrophils 75% Bands 10% Eosinophils 1% Lymphocytes 14% Which of the following is the most appropriate next step in management? A. Blood cultures [9%] B. Colonoscopy [4%] C. Stool cultures [19%] D. Cytotoxin assay in the stool [65%] E. Observation [2%] Educational Objective: Consider Clostridium difficile diarrhea in all patients who have received antibiotics and develop nausea, vomiting, abdominal pain, diarrhea, and elevated white count. Clostridium difficile is the typical cause of antibiotic-associated diarrhea. Cytotoxin assay in the stool is a highly sensitive test to diagnose this condition. *Extremely high yield question for the USMLE!!! Extremely HY Questions-CK 29/48 3/14/14Giardiasis A 34-year-old Caucasian male presents to the office with a 4-week history of diarrhea. He just returned from a trip to South America, where he developed foul-smelling stools, abdominal cramps and bloating. A three-day course of ciprofloxacin did not relieve his symptoms. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management? A. Schedule colonoscopy [6%] B. Obtain CT scan of the abdomen [5%] wv © C. Prescribe oral metronidazole [83%] D. Prescribe another course of ciprofloxacin [3%] E. Prescribe oral ampicillin [2%] Educational Objective: Any patient who returns from a developing country and has symptoms suggestive of malabsorption should be considered for empirical treatment with metronidazole for giardiasis. Remember the pathophysiology (adhesive disks and malabsorption). *You may get a very similar scenario, but the patient went to a different location (e.g., Rocky Mountains). The answer is the same: Giardiasis “Extremely high yield question for the USMLE!!! Extremely HY Questions-CK 30/48 3/14/14Polyps and colon cancer[see the next page for types of polyps] A 52-year-old Caucasian male comes to you for a routine health check-up. You decide to do age-appropriate screening in this patient and order a colonoscopy. The colonoscopy is normal, except for a 15cm polyp in the left descending colon. A colonoscopic polypectomy is done and the biopsy results are pending. The patient is anxious to know the expected biopsy results and the risk of cancer. Which of the following types of polyps is considered to be most premalignant? A. Hamartomatous polyp [2%] B. Hyperplastic polyp [6%] C. Villous adenoma [78%] D. Tubulovillous adenoma [8%] E. Tubular adenoma [5%] Educational Objective: Most colon cancers develop from polyps. The risk factors for a polyp progressing into malignancy are villous adenoma, sessile adenoma, and size >2.5 cm. Only adenomatous polyps are clearly premalignant, but <1% of such lesions progress to malignancy. Hyperplastic polyps are non-neoplastic and do not require further work-up. “Extremely high yield question for the USMLEI!! fo Polyposis [APC] ss Colon cancer pathways: ———=— HNPCC > Cancer Non-polyposis == IBD [and others] _7 Extremely HY Questions-CK 31/48 12/24/13Colonic polyps As veiwed under microscope Adenomatous (70%) Nonadenomatous (30%) Can develop into cancer Very low risk Divided into tubular and villous Hyperplastic and other less common types Colonic polyps display a variety of histologic patterns. Most of them are non-neoplastic and do not increase the risk of colon adenocarcinoma. Non- neoplastic polyps include: 1. Hyperplastic polyps are composed of well-differentiated mucosal cells that form glands and crypts. 2. Hamartomatous polyps consist of mucosal glands, smooth muscle and connective tissue. They may occur sporadically or in Peutz~Jeghers syndrome or juvenile polyposis. 3. Inflammatory polyps are seen in ulcerative colitis and Crohn disease. They are composed of regenerating intestinal mucosa. 4. Lymphoid polyps are found in children. They consist of intestinal mucosa infiltrated with lymphocytes. Unlike non-neoplastic polyps, adenomatous polyps contain dysplastic mucosal cells and can transform into adenocarcinoma. The following criteria determine the malignant potential of adenomatous polyps: 1. Degree of dysplasia. 2. Histologic pattern: villous adenomas are more likely to undergo malignant transformation than tubular adenomas. 3. Size: adenomas >4 cm have 40% risk of becoming malignant; those <1 cm are most likely benign. Extremely HY Questions-CK 32/48 216/13Breaking bad news ‘A 44-year-old man who comes to the office because he has had several episodes of hemoptysis for the past two months. He admits to smoking 2-3 packs of cigarettes daily for the last 24 years. Physical examination and chest x-ray are very suggestive of a lung malignancy. Chest CT and bronchoscopy with biopsy are done, and the patient goes on vacation in Aruba. The patient returns to the office after one week, and you are now holding the biopsy resutt in your hands. It reads, "the tumor has spread to the hilar and mediastinal lymph nodes with bony extension.” Which of the following is the most appropriate opening statement? ‘A."How much would you like to know about your condition?" [219%] B. "lam sorry to tell you that you have lung cancer and it is fairly advanced.” [11%] ¥ © C. "What do you think of your symptoms?” [39%] D. "Unfortunately, the situation is more serious than what I earlier thought.” [14%] . "Would you like to have someone else with you as | don't have good news for you?” [15%] Explanation: Breaking bad news is a very sensitive issue to both patients and physicians. For this reason, many institutions have: created guidelines to assure that such conversations are carried out as smoothly as possible. The following is an example of the recommended step-wise approach to breaking bad news to a patient 1. Make sure the:patient is in a quiet, private and comfortable environment, 2. Ask the patient how much he knows, or what he thinks he might have. This will give you an idea of what his expectations are. "What do you think of your symptoms?" 3. Ask the patient how much he wants to know. "How much would you like to know about your condition?” 4. Give him @ warning shot. "Unfortunately, the situation is more serious than what | earlier thought.” 5. Break the news if he wants you to. "The results show that you have advanced lung cancer.” 6. Give his prognosis, but always keep him aware of all the options available to make his life as comfortable as possible 7 Try to explain everything as clearly and simple as possible. Educational Objective: Know the recommended stepwise approach to breaking bad news to a patient ‘“*High-yield for the USMLE Extremely HY Questions-CK 33/48Risk for sepsis after splenectomy A 16 year-old-girl with hereditary spherocytosis is scheduled for a splenectomy. She was previously managed with folate therapy and occasional blood transfusions, but her anemia became refractory to medical management alone. Before the operation, she is told that she will have an enhanced risk of developing pneumococcal sepsis. She then asks, "How long will this isk last?" What is the best response to her question? | A 2 weeks [4%] B. Up to 6 months [7%] C. Up to 2 years [4%] D. Up to 10 years [4%] v © E. More than 10 years [80%] Educational Objective: Studies have shown that the risk for sepsis is present up to 30 years and probably longer after splenectomy. Current recommendations state that patients should receive anti-pneumococcal, Haemophilus, and meningococcal vaccines several weeks before the operation, and daily oral penicillin prophylaxis for three to five years following splenectomy. *Extremely important question for the USMLE step-2 Extremely HY Questions-CK c= 3/19/14Causes of folic acid deficiency, especially drugs! A 32-year-old Caucasian female presents to your office for a routine check-up. Her past medical history is significant for generalized seizures controlled with chronic phenytoin therapy. The last seizure was six months ago. She does not smoke or consume alcohol. Physical examination is insignificant, except mild pallor. Laboratory values are: Hb 10.8 g/dL MCV 105 fi Platelet count 180,000/cmm Leukocyte count 7,500/emm Segmented neutrophils 68% Bands 1% Eosinophils 1% Lymphocytes 24% Monocytes 6% Which of the following supplementations could have prevented this. patient's anemia? ¥ © A Folic acid [75%] B. Vitamin B12 [16%] C. Iron [1%] D. Vitamin B6 [8%] E. Vitamin B1 [0%] Educational Objective: The most common cause of folic acid deficiency is nutritional due to poor diet and/or alcoholism. Folic acid deficiency can be caused by some drugs; these drugs can impair the absorption of folic acid (e.g., phenytoin) or antagonize its physiologic effects (e.g., methotrexate, trimethoprim). *Extremely high yield question for USMLE!! Extremely HY Questions-CK 35/48 3/19/14Zenker's Diverticulum A 65-year-old Caucasian male presents to your office with a several month history of difficulty swallowing. He has noticed a right-sided neck mass which increases in size while drinking fluids. His past medical history is significant for hypertension, gastroesophageal reflux disease, and osteoarthritis of his right knee. His current medications include hydrochlorothiazide, ranitidine, and occasional naproxene. You order a barium examination of the esophagus to visualize the abnormality. Which of the following is the most important pathogenetic factor in the development of this patient's problem? v © A Motor dysfunction (529) B. Acid reflux [16%] C. Inflammation [8%] D. Abnormal proliferation [21%] E. Metabolic abnormalities [3%] Educational Objective: Pharyngoesophageal (Zenker's) diverticulum develops immediately above the upper esophageal sphincter by herniating posteriorly between the fibers of cricopharyngeal muscle. Motor dysfunction and incoordination are responsible for the problem. *The surgical treatment of the disorder includes excision and frequently cricopharyngeal myotomy. *Extremely hiah vield question for the USMLE!!! Extremely HY Questions-CK 36/48 3/19/14Pregnancy and viral hepatitis A 29-year-old woman in her 25th week of gestation is diagnosed with chronic hepatitis secondary to infection with hepatitis C virus. Her pregnancy has been otherwise uncomplicated to date. She is married and is monogamous with her husband. Her past medical history is significant only for an appendectomy at age 12. She is currently not on any medications, aside from a daily prenatal multivitamin. Which of the following recommendations should be given to this woman? A. Commence treatment with interferon and ribavirin [1496] B. Avoid breast-feeding the baby after birth [17%] C. Use condoms when engaging in sexual activity with her husband [10%] v © D. Obtain vaccination against Hepatitis A and B, if not already immune [43%] E. Schedule an elective caesarean section [16%] Educational Objective: The overall incidence of vertical transmission of HCV is approximately 2-5%. All patients, including pregnant patients, with chronic hepatitis C should receive vaccinations against Hepatitis Aand B if not already immune. “Extremely important question for the USMLE step-2 Extremely HY Questions-CK 37/48 3/20/14Rx of influenza 57-year-old male comes to your office in the middle of January. He complains of a 4-day history of a nonproductive cough and coryza. He also has vague muscle aches and a mild headache. He denies any shortness of breath or chest pain. His past medical history is significant for hyperlipidemia and impaired glucose tolerance. He takes aspirin and simvastatin 40 mg at bedtime. He has no known drug allergies. His medical records show that he did not show up for his scheduled annual influenza vaccine this year. His temperature is 38. 5 C (101.3 F), blood pressure is 135/80 mm Hg, and pulse is 88/min. Physical examination shows conjunctival redness and an erythematous oropharynx. The tympanic membranes are clear. The heart sounds are audible with no added murmurs, rubs or gallops. His breath sounds are vesicular in quality and equal bilaterally. Which of the following is the most appropriate next step in management? A Administer influenza vaccination now [7%] B. Write a prescription for amantidine [4%] C. Write a prescription for oseltamivir [19%] v © D. Advise bed rest and symptomatic treatment with acetaminophen [68%] E. Empiric trial of oral antibiotics [2%] Educational Objective: Many patients with influenza are treated with bed rest and simple analgesia (e.g., acetaminophen). Antiviral medications can reduce the duration of influenza symptoms by 2-3 days; however, these drugs are only effective if administered within 48 hours of the onset of illness. Amantadine and rimantadine are only active against Influenza A. The neuraminidase inhibitors (i.e., zanamivir and oseltamivir) are active against both influenza A and influenza B *Extremely important question for the USMLE step-2 Extremely HY Questions-CK 38/48 3/22/14HTn is the most important risk factor for stroke A 65-year-old Caucasian male presents to your office complaining of an episode of slurred speech and clumsiness of his right hand. The episode lasted 15 minutes and resolved spontaneously. He had a similar episode one week ago. His past medical history is significant for moderate hypertension, diabetes mellitus (DM) type 2 and osteoarthritis of the right knee. He has smoked one pack of cigarettes daily for 35 years, and drinks 1 - 2 glasses of wine daily. His current medications include metoprolol, glyburide and naproxen. His blood pressure is 160/95 mmhg, pulse is 65/min, respirations are 16/min, and temperature is 36.7C (98F). The physical findings are within normal limits. The lab studies show: Fasting blood glucose + 200 mg/dL Total cholesterol 240 mg/dL LDL cholesterol 140 mg/dL HDL cholesterol 76 mg/dL. What is the most important risk factor for a stroke in this patient? v © A. Hypertension [55%] B. Smoking [27%] C. Elevated cholesterol level [7%] D. Alcohol consumption [1%] E. Diabetes mellitus [10%] Educational Objective: Multiple observational studies have demonstrated that patients with hypertension have approximately four times the risk of stroke when compared to non-hypertensive subjects. *Know the concept of multiple risk factors. Know the association between hypertension and strokes. This is a very common scenario for USMLE Steps 2 & 3 Extremely HY Questions-CK S c= 3/23/14Cluster Headache ‘A 35-year-old Caucasian man comes to the emergency department at 2 am because of severe pain ‘behind the left eye’ which woke him up in the middle of the night. The pain is intense and has a stabbing quality. He took ibuprofen at home but didn't get any relief. He denies fever, chills, decreased or blurred vision, cough, nausea or vomiting. He has no other medical problems. He drinks 3-4 bottles of beer daily. He has no known drug allergies. His temperature is 36.7 C (8 F), blood pressure is 120/80 mm Hg, pulse is 88/min and respirations are 14/min. The examination is unremarkable, except for left-sided ptosis and miosis. Which of the following is the most likely diagnosis? A. Migraine headache without aura [5%] 'B. Migraine headache with aura [2%] C. Sinus headache [2%] D. Trigeminal neuralgia [7%] E. Brain tumor [5%] FF. Cluster headache [53%] G. Tension headache [2%] H. Subarachnoid hemorrhage [5%] |. Meningitis [1%] J. Orbital cellulitis [496] IK. Angle closure glaucoma [14%] L. Retinal detachment [2%] M. Benign intracranial hypertension [1%] Educational Objective: Cluster headache usually presents with acute, severe retroorbital pain that wakes the patient from sleep. It may be accompanied by redness of the ipsilateral eye, tearing, stuffed or runny nose, and ipsilateral Horner's syndrome. *Extremely high yield question for the USMLE!!! Extremely HY Questions-CK 40/48 3/23/14Ulnar nerve injury A 35-year-old Caucasian male presents to your office with a three-month history of right hand clumsiness. His past medical history is insignificant. He works as a clerk in a private company and is not physically active. He does not smoke or consume alcohol. Physical examination reveals decreased sensations over the 4th and 5th fingers of the right hand and a weaker grip compared to the left side. Which of the following is the most probable location of the pathologic process? Wrist [24%] . Mid-forearm [6%] Elbow [63%] Mid-arm [2%] E. Shoulder [2%] Axilla [3%] The clinical scenario described suggests ulnar nerve syndrome: decreased sensations over the 4th and 5th fingers and weak grip due to involvement of interosseous muscles of the hand are characteristic. The most common site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar groove. Prolonged, inadvertent compression of the nerve by leaning on the elbows while working at a desk or table is the typical scenario (Choice C). Ulnar nerve compression can occur at the wrist (Choice A), but is less common. The forearm (Choice B) is a rare site for the ulnar nerve involvement; it occurs mostly in diabetic patients. Educational Objective: The most common site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar groove. *Extremely high yield question for USMLE!!! Extremely HY Questions-CK 41/48 3/24/14Monitoring of GBS A 17-year-old girl is brought to the office by her mother due to weakness of her hands and legs. The weakness has been progressively worsening over the past 24 hours, and she now feels that the weakness is affecting her hips. Her mother says she was a bit unwell a couple of weeks ago, but otherwise her past medical history is unremarkable. The physical examination reveals 1/5 power in ankle and knee flexion/extension and 2/5 power in hip flexion. Reflexes are absent in her lower extremities bilaterally. She is admitted to the hospital. Spinal fluid analysis shows albumino-cytologic dissociation. Which of the following tests is the most appropriate for monitoring her respiratory function? A Arterial blood gas [23%] B. Chest expansion [17%] C. FEV1/FVC ratio [13%] D. Peak expiratory flow rate [17%] E. Chest x-ray [2%] v © F. Vital capacity [28%] Educational Objective: GBS can lead to respiratory muscle weakness and may occasionally result in respiratory failure. The best way to monitor respiratory function in such cases is through serial measurements of bedside vital capacity *Extremely important question for the USMLE step-2 {\ Tt ee |) eee | nie \<— = I ae \] \ / /\ Fj [ \ I al fu PVVWVOVV VIS A [eaten vam] Extremely HY Questions-CK 42/48 3/24/14Cluster Headaches A 34-year-old Mexican male comes to the emergency department and complains of severe episodic headache, especially at night, for the past month. He also complains of unilateral, sharp, stabbing pain in the eye, which wakes him from sleep. The pain often starts suddenly just behind the right eye, and spreads to his face and temple region. It is not associated with nausea or visual disturbances, but is associated with watering of the eyes and nose, and with red eye. He had a similar episode one year ago, and it lasted for 2 months. Which of the following is the best treatment regimen for aborting the patient's pain during an acute attack? A. Oral NSAIDs [7%] B. Verapamil [5%] C. Nasal sumatriptan [13%] D. 100 % oxygen [65%] E. Ergotamine [9%] Educational Objective: 100 % oxygen (treatment of choice) is an effective and rapid method used to abort an acute attack of cluster headache. *Extremely high yield question for the USMLEI!! Extremely HY Questions-CK 43/48 3/25/14Gaits! A 73-year-old Caucasian man is brought to the office by his daughter, who is concerned that he might be depressed. He is a retired surgeon, and has lived alone ever since his wife died a year ago. His daughter visits him every 6 months: she feels bad about not being able to visit him more frequently because her job and family keep her very busy. He denies having any feelings of sadness, guilt, weight loss, loss of appetite, suicidal ideation, deafness, vertigo, and decreased or blurred vision. His medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago. His current medications are glyburide, aspirin and enalapril. He denies the use of tobacco, alcohol, or drugs. His vital signs are within normal limits. He appears withdrawn, less energetic than usual, and walks stiffly. He sits with a stooped posture. He has a fixed facial expression, and his voice sounds monotonous. His deep tendon reflexes are 2+. Sensations and motor strength are normal. There is increased resistance to passive flexion. Which of the following types of gait is most likely to be present in this patient? A. Cerebellar ataxia [2%] v © B. Hypokinetic gait [56%] C. Waddling gait [9%] D. Spastic gait [7%] E. Gait disequilibrium [2%] F. Sensory ataxia [1%] G. Vestibular ataxia [1%] H. Wide based gait [17%] |. Dystonic gait [4%] Educational Objective: Parkinsonism is caused by overactivity of cholinergic neurons and underactivity of dopaminergic neurons in the substantia nigra. A shuffling gait (i.e., the patient appears as if he was chasing his center of gravity) is characteristic of the disease. *Extremely high yield question for the USMLE!!! Know the various types of gaits! Extremely HY Questions-CK 44/48 3/25/14Panic Attacks and depression A 25-year-old female college student comes to the office due to episodes of palpitations and sweating. The episodes are sudden in onset and usually last for 5 minutes, after which she feels very embarrassed. During an episode, she is usually overcome with fear, and her friends have noted that she becomes pale and trembles. These symptoms started approximately 2 months ago, and have been occurring more frequently. Which of the following conditions is most commonly associated with this patient's disorder? A. Alcoholism [15%] | B. Obsessive-Compulsive Disorder [34%] v © C. Depression [34%] D. Somatization disorder [14%] E. Bipolar disorder [4%] Educational Objective: Patients suffering from panic disorder have an increased incidence of depression, agoraphobia, generalized anxiety and substance abuse. “Extremely important question for the USMLE step-2 > Tourrette syndrome associated with OCD Extremely HY Questions-CK 45/48 3/27/14Complications of Anorexia Nervosa A 25-year-old Caucasian woman presents as a new patient after having recently moved to the neighborhood. She says that she was diagnosed with anorexia nervosa two years ago, and that her disorder resolved after intensive psychotherapy. Although her eating pattern is normal now, she is still underweight. Her menstrual cycles have been regular for the past year. She recently married and is now interested in starting a family with her husband. She asks whether her history of anorexia nervosa will affect her ability to conceive or carry a healthy child to term. Given this clinical presentation, which of the following complications is most likely? A. Congenital anomalies [2%] B. Macrosomia [1%] C. Small for gestational age baby [57%] D. Infertility [27%] E. Postpartum psychosis [12%] Although this woman has corrected her eating disorder, she remains at increased risk for developing pregnancy complications associated with the chronic deprivation of essential nutrition Patients with a current or previous diagnosis of anorexia nervosa are at higher risk for giving birth to infants that are premature, small for gestational age (secondary to intrauterine growth retardation), or both. Other potential complications include miscarriage, hyperemesis gravidarum, cesarean delivery, and postpartum depression. Children born to anorexic mothers often suffer from poor growth and intellectual impairment. Remember the other common findings seen in anorexic patients (important for USMLE) Osteoporosis” Elevated cholesterol and carotene levels Cardiac arrhythmias (prolonged GT interval) Euthyroid sick syndrome Hypothalamic-pituitary axis dysfunction resulting in anovulation, amenorrhea, and estrogen deficiency Hyponatremia secondary to excess water drinking is often the only electrolyte abnormality, but the presence of other electrolyte abnormalities indicates purging behavior. Educational Objective: Pregnant women with a current or previous diagnosis of anorexia nervosa are at risk for numerous complications, including miscarriage, intrauterine growth retardation, hyperemesis gravidarum, premature birth, cesarean delivery, and postpartum depression. Osteoporosis is also @ common finding in anorexic patients, whether pregnant or not. AEEN= 2 *Extremely high yield question for USMLEII! Extremely HY Questions-CK 46/48 3/28/14Side effects of Olanzapine A 36-year-old male with a known diagnosis of bipolar disorder presents to the emergency department in the midst of an acute manic episode. He has been treated with valproate for the past six months. He is accompanied by his wife, who informs the attending physician that the patient has taken his medication only sporadically. The man is then hospitalized and his valproate restarted after his serum level is checked and found to be low. While the patient is in the psychiatric ward, olanzapine is added to his treatment regimen. He stabilizes over a period of four days and is discharged home. Upon discharge, his wife asks for more information about this new medication. Which of the following significant side effects is most commonly seen with olanzapine? A. Diabetes mellitus [10%] B. Weight gain [679%] C. Dystonic reaction [6%] D. Agranulocytosis [11%] E. Postural hypotension [5%] Educational Objective: Weight gain is a significant adverse effect associated with olanzapine. *Extremely high yield question for USMLE!!! Extremely HY Questions-CK 47/48 3/30/14‘A 60-year-old Caucasian female comes to the physician because of progressive shortness of breath for the past month. She has had a 13.6 kg (30 Ib) weight loss during this period. She has a history of hypertension and hypothyroidism and takes metoprolol and levothyroxine. She has smoked two packs of cigarettes daily for 35 years. Her temperature is 36.7 C (98 F), blood pressure is 130/70 mmHg, pulse is 80/min, and respirations are 20/min. On examination, decreased breath sounds and dullness to percussion are noted on the right, middle and lower lobes of the lung. Her chest x-ray is shown below. Which of the following is the most appropriate next step in the management? Bronchoscopy [23%] Mediastinoscopy [2%] Thoracentesis [59%] Video-assisted thoracoscopy [4%] Open pleural biopsy [4%] Echocardiography (2%] Diuretics [6%] onmoonDs Educational Objective: Undiagnosed pleural effusion is best evaluated with thoracentesis, except in patients with clear-cut evidence of congestive heart failure. *Extremely high yield question for USMLEI!! Extremely HY Questions-CK 48/48 4/5/14