Tommy’s
HY Concepts for the USMLE Step I
(# 1 - 1863)
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
Tommyk posts ( 1-147)
Q. Patient, young, with obesity, hypotonia, mental
retardation, short stature, hypogonadotropic hypogonadism, strabismus, and small
hands and feet. What disease and what is tx?
A. Prader Willi Syndrome. Treat with GH
Q. Pt w/ symptoms include tall stature, ectopia lentis,
mitral valve prolapse, aortic root dilatation, and aortic dissection? What gene
is missing and what is treatment of choice? Don't peek below w/o guessing.
A. Marfan's Syndrome (This WILL be on your test). Defect
in fibrillin gene. Treat the aortic dissection with B-Blockers. Warn them about
pneumothorax and strenous exercise. Tell patients that they are AD inheritance.
Warn them about weird things like an elevator that travel up too fast or an
airplane without decompression.
You have to know that many test takers said it really
"helped" to do the NBME Step 2 questions and the NBME Step 3 questions that they
have on the website. Please do not neglect them. Just ignore the "next step"
questions, and do the diagnosis problems
Q. IF you are given a diagram with an LDL receptor
molecule, and ...
Then if you are asked what ion binds to it, what would
you guess?
Choices: Na, Ca, Fe?
A. The answer is Ca. You should look at the concept of
diagrams of receptors. Remember, many of the writers of the questions are
MD-PhDs and they specialize in their own receptor research.
Q. Uric acid stones (which are transLUCENT on x ray
unlike Ca stones), are common in what three diseases? Bonus: what do uric acid
stones cause symptom wise
A. the three diseases are:
HGPRT deficiency
PRPP synthetase overactivity
Glucose-6-phosphatase deficiency
The stones will present most commonly with hematuria,
then fever/nausea/vomiting, then UTI!!
Q. You HAVE to know this...
Sorry to be patronizing, but you will get this concept
most likely...
What is the primary treatment for the uric acid stones?
2nd treatment if refractory?
A. 1st thing is to alkalinize the urine and hydrate!
Wait for the stone to pass.
If that doesn't work, give allopurinol!
BUT, if the stone is more than .5cm, then use
lithotripsy because the stone will not pass by itself!
Stones are SO common and SO common stuff are all over
the USMLE
Q. A patient who had her gall bladder removed for stones
STILL feels colicky pain, what could be the reason? This is a very HY
concept....
A. loss of inhibitory enteric innervation (motor)
Q. YOU WILL definitely be asked to understand the
concept that a person with an injury to the SURGICAL neck of the humerus/or the
dislocation of anterior shoulder will have which nerve injury?
A. AXILLARY nerve, not the radial nerve.
Q. You HAVE to know this crucial concept tested on most
exams and in clinic!
A woman who diets and cuts out all fats but still eats
carbohydrates. Will she lower her LDL? HDL
A. Everyone will be tested on the concept that
chylomicrons are blood lipoproteins produced from dietary fat.
It is the VLDLs that are produced mainly from dietary
carbohydrate. IDL and LDL are produced from VLDL.
Thus, HER LDL level will still BE HIGH. Crucial
concept!!!
Q. Methinks that every single human taking USMLE had to
know that a man with:
Diffuse demineralization of the bone associated with
hypercalcemia, anemia, hypergammaglobulinemia, proteinuria, and normal serum
alkaline phosphatase is most suggestive of?
A. Multiple Myeloma. I CAN BET MY BOTTOM DOLLAR THAT YOU
WILL SEE MULTIPLE MYELOMA ON YOUR TEST. I definitely did.
Q. A woman with sarcoidosis or with hypercalcemia (there
are a thousand ways to ask this concept) enters your clinic, which is the
diuretic of choice?
A. Furosemide, NOT thiazides or mannitol, or
acetazolamide
Q. A Super high yielder is Hardy Weinberg. If the number
of homozygotes is 1/4900, can you tell me the number of heterozygotes
A. use q2 and then use equation 2pq
Q. Everyone is reporting that they MUST master the
concept of transgenic mice. Here is one concept you must understand:
Transgenic mouse with defect in B2 microglobulin gene.
What is the immuno defect?
A. The B2 microglobin is part of the MHC Class I
molecule. So, a defect here will cause a problem with CD8 + cells so cell
mediated immunity is crushed!
The MHC includes a polymorphic set of genes encoding
cell surface glycoproteins, designated class I and class II molecules, whose
function is to present antigenic peptides to CD8+ and CD4+ T cells,
respectively. Peptides generated in the cytosol from denaturated proteins
fragmented by proteasomes, some components of which are MHC-encoded are
transported into the endoplasmic reticulum (ER) by peptide pumps or transporters
associated with antigen processing (TAP) whose encoding genes are again located
in the MHC. Peptide binding to the class I heavy chain facilitates association
with b2-microglobulin (b2-M) and stabilizes the complex allowing it to migrate
to the cell surface.
B2 microglobin, a component of MHC I molecules,
functions to transport MHC I to cell surface,ditto.
Lack B2 microglobin, no MHC on cell surface. CD8+
cytotoxic T cell needs to bind to MHC I molecules.
result: defect on CD8+ cytotoxic T cells mediated
immunity
Q. A wise man said that you cannot avoid understanding
Biochem thoroughly. So, if I gave you a pic of cbiochem ycles and asked where is
it inhibited by acetyl CoA and enhanced by citrate, would you succeed
A. During fatty acid synthesis in the CYTOSOL, Citrate
will activate aceytl CoA into malonyl CoA, Acyl CoA will block this. (SORRY, in
the question above I meant to say Acyl CoA, not Acetyl CoA)
Nevertheless, this is a crucial biochemical step
underappreciated...by all
Q. Aside from drug abuse and high exercise, which is a
given, what is the next most common cause of lactic acidosis? There are a
thousand poss. ways to ask this concept
A. shock, like septic shock or hypoperfusion.
Q. ubiquitous question in USMLE, clinic, life, and love
is:
A child comes in with meconium ileus, other than
Hirshsprung's, what is the other MAIN common disease you see?
Like on Family Feud, the game show, the best answer is
A..Cystic Fibrosis.
It is too easy to merely ask about salty sweat and fatty
stools, although some will invariably get the easy questions about this disease.
Q. Speaking of my previous question about Meconium ileus,
there is a disease EVERYONE will get on their test, and in clinic...Meconium
ileus is a block of the terminal ileum and is the most common cause of
obstruction and congenital GI anomaly. What is the other name of this that
starts with the letter M?
A. Meckel's diverticulum, persistecne of the vitelline
duct. This is SO HY
You will see this concept everywhere you turn:
Q. A pt. comes in with overdose of scopolamine because
she went on a roller coaster in Disneyland. The doctor in line slips her
physostigmine instead of neostigmine, etc. why?
and now>
A. it is because of the cholinomimetics, physostigmine
crosses the blood brain barrier to CNS.
Neostigmine is better for urinary retention after
plastic surgery (or any surgery).
You will see this concept in your life....soon...
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Q. A med student grabs gentamicin for you to treat
Bacteroides. You will hit him over the head because he is wrong. Why? (What is
MOA of Aminoglycosides)
A. Bacteroides is an anaerobe. Aminoglycosides do not
work on anaerobes b/c they need O2 for uptake, thus blocking formation of 30S
initiation complex!
Q. Young girl has early acne, you give tetracycline,
then years later family comes back at her homecoming and kicks you. Why? (What
is SE of TETRAcycline)
A Tetracycline has the famous concept of discoloring
teeth and blocking bone growth in children, along with photosensitivity.
Q .Anatomical common injuries are super duper HY.
A football player comes in with an injury in the shaft
of his humerus. What nerve is crushed (choices: radial, median, ulnar, axillary)
and what prob. does he have?
Radial nerve is damaged. He is lose his triceps,
brachioradialis, and have wrist drop.
This is a must know...
The aforementioned athlete breaks his supracondyle of
humerus. What nerve is crushed?
(Radial, median, ulnar, or axillary)
(All of you will get a variation of the upper arm
injuries)
A. MEDIAN nerve is blown. He loses his finger flexing
ability and some thumb movements and some loss of sensation over lateral palm
and thumb and radial 2.5 digits
Q. Everyone I hear is asked about brachial plexis
injuries. But they are not easy direct questions. E.g.
A supermodel in a car crash looks at you with a "claw
hand". What two cord segments contribute to the nerve which is damaged?
A. Cord segments are C8 and T1! See, not so easy, right?
Q. Adenosine deaminase def can cause what problem
immunologically?
A. Adenosine deaminase def can cause SCID.
Q. Most I spoke to got this on their test. Distinguish
the Rinne and Weber TEST!?
A. absolutely HY. Weber test- tuning fork in midline of
skull- localizes hearing loss to one side or the other- if it is a conductive
loss, patient hears better on side of defect. If it is sensorineural hearing
loss, hearing is better on opposite side of defect. Rinne test- place tuning
fork on mastoid process until patient can no longer hear vibrations, then place
tuning fork next to external auditory meatus- if patient cannot perceive
vibrations- BC ( bone conduction) is better than AC(air) and patient has a
conductive hearing loss on that side.
If AC is better than BC, then that is the normal ear
Q. Everyone seems to need to understand that:
A Bicornuate uterus, which prevents a woman from
fertility, is caused by what?
A. it is due to the incomplete fusion of the
PARAMESONEPHRIC ducts. Amen
Q. YOU WILL be asked this question:
There will be a person with a history of travel who goes
to Mexico or thereabouts. Then he or she will return with bloody bloating crampy
diarrhea. They will ask you either what is the bug and the disease, and the
treatment. So what are the answers? Look below
A. Ambiasis, dx is dysentery, and you treat with
Metronidiazole and the bug is Entamoeba histolytica.
Q. Since taking the test, I spoke to "a Lot" of people
and the US licensing board wants everyone to know a certain fixed "universe" of
diseases and txs, if you master those, you will at least PASS. That is what I am
trying to help to do for all of us family VALUE MDs!
I "got" this question, my "roommate" got this question,
in 2030 probably, my sons/daughters will get this concept:
What is the MOA of Acyclovir
A. Acyclovir blocks viral DNA polymerase when
phosphorylated by viral thymidine kinase.
Some people will be asked to understand that Acyclovir
is used for the HSV, Varicella, Epstein Barr Virus
The boards LOVE Acyclovir
Q. So common, definitely on everyone's test:
A baby come to your clinic with loud cough that
resembles the barking of a seal, difficulty breathing, and a grunting noise or
wheezing during breathing. What is the dx? And the secondary question they WILL
ask is is it enveloped and what is the structure?
A. Dx is Croup!
Paramyxovirus,
It Has an envelope, has single strand, nonsegmented.
Q. Case: Cilia lack ability to move, so your patient is
sterile, no sperm, and he has ongoing sinus inflammation. What is syndrome and
the protein that is lacking?
A. Kartagener's Syndrome, due to dynein arm defect!
Q. EVERYONE, seriously, EVERYONE I talked to needed to
master this concept for the test:
Case: Child with multiple fractures and BLUE sclera. The
two secondaries are
What is specific defect?
What is the inheritance pattern?
A. Osteogenesis Imperfecta, with abnormal collagen type
I, and inheritance pattern is autosomal dominant! Good Luck!
Q. Hard one, but def. a must!
Here it is..
A child has defect in eustachian tube and middle ear,
which pharyngeal pouch is defective?
A. The first pouch... some of my friends last year got a
whole slew of arches and pouches, a favorite of the NBME, KNOW IT
Q. YOUR SOUL MUST UNDERSTAND that if you have a patient
with probs with his circadian rhythms and autonomic regulation and a DETAILED
diagram with arrows of brain pops up, which nucleus is affected?!
A. The suprachiasmatic nucleus of the hypothalamus!
Peace to Everyone on Earth!
Yoda says rather asks you:
Q. Which one of the following is responsible for
peripheral myelin production?
(Choices: Ependymal cells, Oligodenroglia, Astrocytes,
Microglia, Schwann cells)
A. Schwann cells! Remember that Oligodendroglia are
CENTRAL myelin production
Q.Even my grandmother I think had to understand this for
USMLE:
Case: A patient with a defect in apo C-II and
Lipoprotein Lipase. How will her labs look like? I.E. What is her disease
You WILL get questions PLURAL on the big three:
Diabetes, Hypertension, Hyperlipidemia. so, ...
A.The answer to my question was HYPERLIPIDEMIA
hyperlipidemia type I is associated with :
uncontrolled diabetes mellitus, obesity, and sedentary
habits, all of which are more prevalent in industrialized societies than in
developing nations. In both epidemiologic and interventional studies, hTG is a
risk factor for coronary disease.
Two rare genetic causes of hTG (lipoprotein lipase [LPL]
deficiency and apolipoprotein [apo] C-II deficiency) lead to triglyceride (TG)
elevations
Q. Consequence: cardio disease! They love porphyrias.
Maybe they watched the movie "The Madness of King George" over and over, I dunno,
but in order to pass the test, you have to understand that if you get a patient
with bizarre symptoms like stomach pains with very mild photosensitivity,
delirum, and his urine darkens in the light, you are looking at ACUTE
INTERMITTENT PORPHRIA! So you have to know four things:
What is the deficient enzyme? AND, What substances
accumulate in the urine? AND what two amino acid begin this synthesis of
porphrin molecule? AND what metallic ion cofactor is required. YOU HAVE TO KNOW
THIS TO PASS.
A. Deficient enzyme: uroporphyrinogen 1 synthetase
Porphobilinogen and aminolevulinic acid accumulate in
urine
Glycine and Succinyl CoA are precursors of porphrin
Metallic ion is Fe!
Q. Pt. who drinks his whole life, say the question
describes to you he has Wernicke-Korsakoff syndrome (you know how to spot this
right?), and say the question asks what vitamin is missing AND what DOES THIS
VIT DO. Can you tell me? (It is not enough to know just the vitamin)
A. Vitamine B1 (thiamine), it functions as a cofactor
for OXIDATIVE DECARBOXYLATION OF PYRUVATE and is involved in the crucial HMP
shunt!
REMEMBER...thiamine and the word DECARBOXYLATION RXN
Q. Ahh... the all important Folic Acid def. Everyone
will see this, guaranteed since it is the most common vit deficiency.
YOU HAVE to understand that if you see a slide with
macrocytic megaloblatic anemia, what is missing vitamin (I gave it away, Folic
Acid, but it could also be Vit B12 but without Neuro sym)....anyways, I
digress...What IS the EXACT function of it, and type of reaction?
A. Methylation reactions ...
and it is an enzyme for the all important one carbon
transfers.
Folic acid=METHYLATION reactions
Q. with meowing catlike cry and later is mentally
retarded. But always it is the SECONDARY QUESTION, so what is the disease, the
genetic defect, and the organ that is primarily affected and how? I sound like a
broken record, but EVERY DOCTOR-TO-BE SHOULD KNOW THE CONCEPTS THAT ARE ON THESE
POSTS!
A. Cri-du chat syndrome...BUT did you know that...
chromosome 5's short arm is deleted AND pt has cardiac
defects primarily VSD and ASD!!!!!!!!
Q. Guaranteed you have to know:
Case: A college student comes into your clinic with
fever, hepatosplenomegaly, lymphadenopathy and + heterophil Ab test. What is the
"bug" and most crucial, is it:
SS or DS? (single stand or double strand)
Envelope or no envelope?
linear or circular?
What is the family?
{Believe me, you will see this question}
A. Pt has Mono, and it is Epstein Barr Virus. Most
importantly, the NBME will not stop there!!!! You will have to answer it is a
Herpesvirus family, DS, linear, and it has an envelope. Failure to master this
concept will result in a veil of tears
Q. Older patient comes to you with bone pain, Visual
inspection may reveal bony deformities, such as an enlarged skull, spinal
kyphosis, and bowing of the long bones of the extremities. Localized pain and
tenderness may be elicited with manual palpation. Labs: elevated alk phos.
What is this common disease and drug Rx? You have to
catch this diagnosis b/c it can lead to cancer!!!!!
A. Paget's Disease, treat with bisphosphonates, physical
therapy, could have viral etiology.
Q. Suppose you are a pathologist to be and are shown a
pic of lymph node. Could you point to EXACTLY where the T-cells are housed on a
histo slide? You have to know this
A. Hey, look up on Webpath and pick out the PARACORTEX,
where the T-cells are housed. You have to know this on a pic, not just on
words...
Q. case: skin manifestations include peripheral nerve
involvement with fibromas and plexiform neurofibromas; the iris, with Lisch
nodules; optic nerve gliomas; pheochromocytomas in some patients; skeletal
abnormalities, including craniofacial dysplasia. What is this disease that you
are SURE to have on your USMLE? What is inheritance pattern?
A. Neurofibromatosis, AD (Don't confuse with McCune
Albright which is assoc with girls and precocious puberty) Cheers!!!
Q. Pt appears healthy at birth. Diagnosis is usually
made in infants aged 6-24 months. Inguinal and umbilical hernias are commonly
seen at birth. On physical examination, these patients are observed to have
corneal clouding, hepatosplenomegaly, skeletal deformities (dysostosis
multiplex), coarse facial features, large tongue. You will see this presentation
likely on your test because it is so serious.
They will ask, "What is the missing enzyme?"
A. Hurler's Syndrome and you are having a deficiency of
alpha L iduronidase. Love for everyone!!!
Q EVERYONE I CONSULTED SAID THEY HAD THE UREA CYCLE ON
THEIR TEST AND IT IS SO IMPORTANT IN OUR CLINICS AND LIVES. Know the cycle COLD
until you can draw it out from memory.
For example, we know that an ammonium ion comes in in
the mitochondria with carbamoyl phosphate, BUT urea has TWO nitrogens, which
compound provides the second nitrogen? KNOW THIS. IT is essential for life.
A Answer is aspartate feeds it in!
NOBODY, but NONE of US will give up. We will ALL succeed
and become doctors. Let's let none of us give up and be left behind with their
dreams.
Q. Don't be surprised if you are asked to know this
classic common concept:
Pt with right sided ataxia, loss of pain temp of right
face and left upper and lower extremities, hoarseness, dysphagia, loss of taste
of right tongue, with vertigo and nystagmus. This IS SO CLASSIC FOR WHAT LESION
YOU WILL see in your clinic and a famous test?
A. PICA, posterior inferior cerebellar artery stroke! Be
SURE you can identify it on a brainstem slide.
Q. Invariably, you will be asked:
Pt, older gentleman with visual field defects from a
Circle of Willis (they'll give a pic) hemorrhage. Point to the artery in Webpath.
for now, though, what is the name of this most famous artery?
A This is a case of anterior communicating artery
stroke, the most common circle of Willis aneurysm! Got it? Got Milk?
Q.LIVE to know that:
Niacin, Melatonin and serotonin are derived from what
amino acid? Think hard first before looking!
A. answer is tryptophan! Don't forget....
Q. Sorry to continue to bug you all, but the galaxy
members informed me that all need to know that if:
Given a midsagittal section of the brain, there is an
arrow pointing to the different structures, but the question is:
Case: a child come to your clinic with symptoms of
hypopituitarism. Where is the lesion? POINT TO IT! What is the dx?
A. Pick the answer choice where the arrow is point to
the pituitary (it is next to the hypothalamus, find it on your atlas). This is a
classic question of a craniopharyngioma which is the most common cause of
hypopituitarism in children and it compresses the optic chiasm and hypothalamus.
Q. This is a question that a 99%er told me he knew but
for the rest of us we can be OK if we are clueless:
A man comes in with bilateral and multicentric retinal
angiomas, central nervous system (CNS) hemangioblastomas; renal cell carcinomas;
pheochromocytomas; islet cell tumors of the pancreas; endolymphatic sac tumors;
and renal, pancreatic, and epididymal cysts. CNS hemangioblastoma is the most
commonly recognized manifestation of and occurs in 40% of patients. What is the
dx? No secondary here. Just the diagnosis is Hard enough! BUT common enough for
USMLE CONSIDERATION!
A. Von Hippel Lindau Disease. There will be a MRI of a
brain with a cyst in the cerebellum from a hemangioblastoma. Excellent work my
brothers and sisters
Q. A patient presents with recurrent viral infections
from T-cell deficiency and symptoms pointing to hypocalcemia. Can you tell me
disease (dx) and what failed to develop? A USMLE glorious favorite!!! Kinda hard
though, but popular. You HAVE to know this.
A. Faulty development of 3rd and 4th POUCH caused
DiGeorge's syndrome and thymic hypoplasia and hypocalcemia.
Warning, I heard a lot of students messed this with the
arches, and put 3rd and 4th ARCH (so close and yet so far!)
Q.What is the precursor for heme, which aa? Know this
concept like your mom's birthday
A. glycine. don't forget!
Q. You WILL see a pic and case presentation of a woman
with a picture of an atypical mole (big hint is dysplastic nevus). What is the
associated neoplasm, is it benign or not?
A. It predisposes to malignant melanoma. The NBME wants
you to know the stuff that you CANNOT AFFORD to miss that are COMMON.
Q. Speaking of skin stuff, Suppose you are dreaming and
you see a color photo of a hyperpigmented skin lesion in the axillary area on an
obese person that you have nailed as acanthosis nigricans (as an aside KNOW THAT
THIS LESION IS MORE COMMON WITH DARKER SKINNED INDIVIDUALS). Say they ask you
the most notable associated malignancy, what will you say?
A.Commonly associated with cases with dark skinned obese
individuals, you must be wary that they may get GASTRIC adenocarcinoma! You
cannot miss this and the NBME won't let you off if you don't know this.
Q. Here we go:
There is a young person who comes in with mild tachypnia
because of acidosis, he has enlarged liver, is slightly to moderately icteric;
accompanying hypoglycemia (watch for seizures). What is the MISSING ENZYME?
A.This is a classic presentation of Aldolase B
deficiency. They may want you to know it is autosomal recessive inheritance and
you must terminate BOTH fructose and sucrose in the diet
Q.will faint with disbelief if you don't get this on
your test and also in clinic and in life:
Case: Visual field defect of homonymous hemianopsia,
there will be a series of diagrams of the eye nerves (you guys know with pic I
am talking about right?) with arrows everywhere. Where exactly is the lesion?
A There are at least two dozen questions that can be
asked from this crucial concept with those visual field defects. Master them
all.
an arrow point to the nerves behind the optic chiasm
contralateral.
Q.You WILL see this on your test because in clinic you
will prob see it everywhere:
Case: There is a older man with signs of LOWER (not
upper) GI bleeding. What is the most common disease (hint, neoplasm is not the
answer), secondaries are What area of the bowel is affected and what drug can be
given if surgery is not indicted?
A.This is classic diverticulosis/itis of the lower
descending colon and sigmoid (all proximal to the ligament of Treitz). You can
give vasopressin as a drug.
Watch for distractor answer choices like Meckel's
Diverticulum and Intususception and IBD, these are found in children and
adolescents more often. Always always first consider your age and gender and
ethnicity and travel and meds of your patients!
Q. This USMLE FAVORITE is kinda easy but just in case:
Patient is older gentleman and had a history of lytic
lesions and M protein spike and now present w/ lesion in the kidney, lesion was
stained w/Congo Red? What is the dx and the name of the tissue stained
(condition)?
A. Multiple Myeloma and the stain is amyloidosis. These
two diseases are EVERYWHERE, like Britney Spears pictures on magazines
Q. The NBME declares that you must know your basic
oncogenes, guaranteed. So...
Case: You are given a clinical case where the gene that
is active is c-myc (this is a oncogene, not TSG), what is the related tumor and
specific gene translocation?
A. This is Burkitt's lymphoma, some of you will be asked
that it is a t8;14 gene translocation
Q. Speaking of oncogenes, many will be forced to address
this point (not in Error! Hyperlink reference not valid. but def. in NBME's
brain:
Case: A clinical presentation of MENI and or MENII
(review this quick), then you have to pick the oncogene that is activated. What
will you chose?
we are talking about the ret oncogene. repeat that in
your mind ten times NOW
Again, you are given a blood smear photo (medium
quality) that you know to be follicular lymphomas (review on Webpath). But of
course, the answer is a secondary. So tell me, give a series of answer choices,
what is the oncogene responsible
A. It is bcl-2 which block apoptosis. YES! YOU GOT IT!
Q. So Classic, so repeated, so in vogue, so know it...
A clinical presentation is given where a pupil
constricts with accommodation and is not reactive to light. What is the
treatment? The bug? The name of the syndrome? AND give me the method to
visualize the bug!
A. Penicillin G = Tx
Bug = Syphillis, T. Pallidum
Syndrome = Argyll-Robertson pupil
Visualized by = dark field microscopy
THIS IS A NBME FAVORITE! And you should know it for life
for your patients!
Q. Here is a hard one, but certain to appear:
Case: One of your patients is in childhood with
hepatosplenomegaly, pancytopenia, and crippling skeletal disease. He is Jewish
and a liver biopsy shows glycolipid laden cells. What is the disease name and
the enzyme deficiency given 5 choices that are agonizingly difficult?
A. This is Gaucher's Disease and the enzyme def. is B-glucocerebrosidase!
KNOW that Gaucher's like most other enzyme deficiencies
are AUTOSOMAL RECESSIVE! YES! Go and kick TUSH on this test!
Q. This is an interesting and crucial case seen around
the world in testing centers:
A baby patient of yours has loss of sensation around the
jaw, and suppose the answer choices ask which brachial arch is defective? What
will you answer? (NBME loves those arches)
A. Answer is Brachial arch 1,
cranial nerve V3 is affected along with all the "m"
muscles (e.g. Muscles of mastication, masseter, medial pterygoid), Malleus, and
a couple of others
Q. On test day, you see a question which asks you for
the mechanism of RESISTENCE of bacteria to norfloxacin or ciprofloxacin and then
asks you also the side effects? Will you know?
A. Resistence comes from a mutational change of the
bacterial DNA gyrase. This drug is eliminated renally so don't give to renal
compromised patients. A scary side effect of this is inflammation of tendons and
cartilage damage.
NOTE: These Quinolones have NO EFFECT on anaerobes!
Q. Quickly, you see that oh-so-familiar diagram of th
Cardiac Cycle/EKG. And you are asked what valve corresponds with the END of the
first heart sound (Arrow is pointing there) and is it closing or opening? What
do you say?
A. The Aortic Valve OPENS at the end of the first heart
sound (KNOW THIS)
Q.While we are on the subject, everyone in the world
will face the Cardiac cycle/EKG graphs. So, There is an arrow points to the
place where the S2 STARTS. What valve is opening or closing?
A. The Aortic Valve closes at the beginning of the 2nd
heart sound (KNOW THIS)
Q. Simply, what is the MOA of Cyclosporine
A. inhibits IL-2
Q. Case: You are given a classic presentation of an
older man with Benign Prostatic Hypertrophy (this disease is everywhere). What
is the drug of choice and what is the mech of action
A. You should choose finasteride, a 5 alpha reductase
inhibitor.
Q. You will not get away from Step 1 without seeing a
case of...
An obese woman with infertility, acne, alopecia,
hirsuite. Now, I must ask you what is the hormonal abnormality and the drug of
choice? You could also be asked what cancer is she most at risk of?
(THIS CONCEPT IS A MUST KNOW
A. This is a case of PCOS. There is elevated LH/FSH
ratio, and the LH stimulates testosterone. The lack of progesterone predisposes
the woman to endometrial cancer.
Treat with Oral Contraceptive Pills or an anti androgen
like Spironolactone
Q. EVERY MAN EVERY SINGLE MAN who lives long enough will
get this disease:
Case: Older gentleman with urinary control problems and
complaints include back and hip pain as well as other symptoms such as fatigue,
malaise, and weight loss. There may also be a history of bone fractures. What is
the disease, and the drug of choice (2 NBME favorite choices)?
A. This is sadly prostate cancer with mets to spinal
cord. You need to aim to stop testosterone production. Although castration is
best (seriously), the choice most men opt for is Lupron or generic name
Leuprolide (A LHRH agonist) or Flutamide.
Q. You will get a case of a patient with ptosis and
inability to turn the eye up, down, or inward. At rest, the eye is deviated down
and temporally, and the iris sphincter may be involved or spared. He has a
history of an aneurysm, and his eye does not constrict. Two secondaries: What
nerve is lesioned, AND if you are given a picture of the circle of Willis and a
bunch of arrows, which artery will you pick?!
A. This is an aneurysm of the posterior communicating
artery which is causing CN III to be affected!
Q. Friends, this concept comes up I hear on every exam
and hospital pimp session:
If you get a man with a history of atherosclerosis, and
he dies very suddenly, and he had no thrombus to cause an MI, he died of a
VENTRICULAR ARRYTHMIA
Q. I present you with a patient who has angina at rest
with atherosclerosis, is this:
Prinzmetal angina
Stable angina
or Unstable angina
or MI
UNstable angina,
A. KNOW if you get a version asking Prinzmetal's, you
see ST elevation on stress ECG and ST depression with exertional/stable angina
Q. Here is one that rings through eternity on USMLE
(rhymes!):
Case: A 15 year old soccer player named Goober comes
into your clinic because of acute, serious throbbing pain in the right knee and
is limping. He was "clipped" on his lateral right side of the knee. What three
structures are affected
A. This super HYer is the triad of anterior cruciate
ligament, medical meniscus, and medial collateral ligament. (Think in
abbreviations, ACL, MM, MCL)
Q. If I give you a case with a lumbar puncture (w/ a pic),
and ask with arrows where do I get CSF from, can you tell me?
(Choices: Dural, Subdural, Subarachnoid, Arachnoid)
Also asked is between what two spaces is CSF taken?
A. IT is Subarachnoid, the most common wrong answer is
arachnoid or pia mater.) between L4 and L5
Q. Some patient comes with a history of arrhythmias and
is on a med and she presents with antinuclear antibodies, arthralgias, rash.
What med is she on
Procainamide, KNOW that this and HYDRALAZINE gives SLE
like symptoms (drug induced
You will be given a diagram with the Arachidonic acid
products pathways with arrows everywhere. You have to know which arrow is
pointing to where Zafirlukast acts. (Don't confuse with Zileuton)
Zafirlukast acts on the arrrow pointing at the end step
where Leukotrienes are inhibited. Zileuton acts before and the level of
Lipoxygenase BEFORE HPETE. Don't forget! Review that classic diagram, it is in
BRS and
FA
A pt complains to you about his skin thinning and mild
osteoporosis and saying his esophagus burns. What med is he on that causes this?
(Very popular point)
He is on a Glucocortoicoid, notice that I did not say
"buffalo hump", or central obesity. The boards avoids "clicker" words.
Case: If I present a sideways angiogram of the head,
choose the arrow pointing exactly to the sigmoid sinus AND, can you point to the
cavernous sinus?
The cavernous sinus is right behind the eyes and the
sigmoid floats along the back. LOOK at WEBPATH
Case: What is the proposed mech of action of Lithium,
and does your patient have hyper or hypothyroidism? What about poly- or
oligouria? A MUST KNOW
You bipolar patient has hypothyroidism and polyuria, Li
blocks PIP cascade.
YOU WILL KNOW THIS CONCEPT!:
Case: A 27 yo AID patient has pulmonary complications.
Exam of tissue shows yeast-like with capsules. What does he have? Secondary seen
is how do you treat? Very tricky.
He has Cryptococcus Neoformans, NOT Pnemocystis carinii
due to ID of the capsule. Treat Cryptococcus with Amphotericin B. KNOW
Cryptococcus usually causes meningitis, BUT, it also easily hits the lungs.
While on the SUPER HY topic of AIDS: I remembered I have
to tell you...
Case: 32 yo male has demonstrated AIDS and you see cysts
containing sporozoites can be seen with silver-stained preparations in the
lungs, and he is rather asymptomatic. X-ray shows interstitial infiltrates. What
now are you thinking and what drug will you grab!
He has PCP, the most common disease of the AIDS, treat
with TMP-SMX!!!!!
USMLE LOVES...
Case that you nailed as Influenza...secondaries seen are
where does it replicate? Pick among answer choices does it have envelope? Linear
or NOT?
It along with HIV are the only RNA viruses to replicate
in the NUCLEUS, and.... it has an envelope and is linear single strranded!!!!!!!!!!!!!!!!!
BIGGIE CANDY KWESCHON
A thousand times you will see...
A pt or question defining the subject of DOPAMINE (A
million dollar concept). Which dopamine receptors are excitatory, which are
inhibitory, and is the second messenger cAMP or Ca? This concept alone will let
you answer a thousand questions, seriously...
The oh so important Dopamine has:
D1 and D5 which are excitatory which rev up kidney
perfusion in shock, AND
D2, 3, 4 are inhibitory. Most schizophrenic drugs work
on the D2 receptor which is inhibitory!!!! Wow, I feel great!
Finally, dopamine works on G-protein coupled cAMP second
messengers...
Easily one of the most missed because people THOUGHT
they knew:
PIC: HISTO of muscle fiber. Can you do these if arrows
are everywhere?
1) Point to myosin fibers
2) Point exactly where ATP works/acts in EM.
3) To what does Ca bind to (answer is diff for smooth
and skeletal muscle)
ANSWER ME, PLEEEAASE! (Well, silently, I cannot actually
hear you)
1) Myosin are the middle lines/area (Look up Histo
atlas)
2) ATP is bound to myosin on the Head
3) Ca binds to troponin in skeletal muscle and
CALMODULIN (which activates MLCK)
See, isn't it easy to forget? So DON"T!
HARD ONE:
Patient complain of gradually worsening shortness of
breath, progressive exercise intolerance, and fatigue, and swollen feet. He is
an older man with amyloid deposits everywhere? From 4-6 answer choices of
-myopathies, what does he have? (Hint: Loud diastolic S3 heard)
he has the rather rare but often quizzed Restrictive
Cardiomyopathy (myocardium is stiff)
Case: (VERY COMMON)
Young child with clinical triad of mental retardation,
epilepsy, and facial angiofibromas. What associated cancer is common
CNS hamartomas and cardiac rhabdomyomas You will see
skin lesions so don't pick neurofibromatosis as the answer choice for the pre
cancerous condition or I will cry.
You are given a case and asked to quickly calculate the
ejection fraction. What's the equation?
Stroke vol/ EDV
You will be asked questions about Down Syn. Tell me:
What is the organ most commonly affected (although
Down's hits all systems)?
What cancer is associated?
What hormone do you often treat them with?
Is alpha feto protein low or high at 14 week gest?
Cardiac (e.g. VSD)
Cancer is ALL
Hormone is thyroid hormone
Alpha fetoprotein is low in testing
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
You will know Jedi Knight,
A pic with B1 receptor, which neurotransmitter acts here
(Epi, norepi, Ach, Dopamine)?
Now you see a pic of Lung with B2 receptors. Does same
neurotransmitter act there?
BIG CONCEPT:
Norepinephrine acts on B1 receptors but NOT B2 receptors
(epi does though)
Picture like on Webpath of LOBAR Pneumonia. Histo shows
encapsulated orgs. Then you see myriads of bact/fungi/viruses as possibilities.
What is your first choice
Strep Pneumoniae!
Slide with megaloblastic anemia, pt looks like a B12
def. Intrinsic factor administered. Patient improves. What disease did he have?
(Pick between terminal ileum deficiency and atrophic gastritis) Also, could
there be a bug involved? Which one?
He has atrophic gastritis fr. H. Pylori.
Quick! Can you tell me what is the term for the most
appearing number amongst a given series of number values
it is called the MODE. Came up before
Fast! Tell me the ABCs or name three anaerobes and what
is name of enzyme lacking which makes them vulnerable to oxidative damage?
Actinomyces
Bacteroides
Clostridium
They are missing catalase. Treat with Clinda above the
diaphragm and Metronidazole below the diaphragm!!!
You are given a case with a druggie and he has Hepatitis
C. Choose and tell me if it is RNA/DNA/SS/DS/Helical/Square
RNA, SS, LINEAR (remember that all RNA viruses are
single stranded except Reovirus, AND the letter PCR denote the NON-ENVELOPED
VIRUSES or P-Picorna, C-Calic, R-Reo)
You will see this:
A man comes into your office acting very strange,
sticking out his swollen tongue, and complaining of numbness and prickling. He
is a vegetarian. What two crucial reactions cannot occur because of the missing
diet cofactor
This is classic triad for Vit B12 deficiency.
Homocysteine METHYlation and Methyl malonyl CoA step into TCA cycle is blocked!
Ain't that awesome, I mean the knowledge, I feel sorry for the patient though
valuemd.com
Here is a biggie:
Your patient goes for plastic surgery to look like
Michael Jackson and he is given succinylcholine (muscle relaxant). He suffered
prolonged respiratory paralysis and muscle paralysis afterwards! What enzyme or
mineral is defective? (Hypomagnesium, Hypokalemia, Pseudocholinesterase def)
It is pseudocholinesterase deficiency. Many causes, but
pregnancy, neonates, elderly, burn victims, pesticide poisoning, can be
presented by the Boards
Banana-split question! A patient presents with
epigastric symptoms and melena.. You should pick PUD or peptic ulcer disease
(this disease is everywhere, like air), BUT there is a secondary! Labs rule out
H.Pylori (most common). What is the next HUGE cause?
Chronic NSAID use. Man, I had to do so many anal exams
for this (checking for bleeding with those little Heme cards). They call it the
M-3 student consult.
Wow this a biggie fry with a biggie drink question:
You have a patient with a description of allergic
rhinitis (some 50 million Americans suffer this, you will see this tested), and
he is taking steroids, antihistamines, and pseudoephedrine. He is depressed and
wants anti depressants. You pick one from 5 choices and your attending knocks
you silly. Which one did you pick that is a no-no?
MAO inhibitors cause hypertensive crisis. You deserved
the punch.
Every single person sitting for USMLE gets one of the
Immune def questions, no exception I hear. So, you have a young patient with a
gene defective in making myeloperoxidase, thus the cause of his recurrent
infections. What cells are weakened, what is the MECHANISM LOST, what is the
metal ion in MPO?
(You will see this case, or DiGeorge's, SCID, etc.)
The ability of the immune cells to engage in respiratory
burst is cut off. Myeloperoxidase, MPO, catalyzes the conversion of hydrogen
peroxide and chloride ions (Cl) into hypochlorous acid. Hypochlorous acid is 50
times more potent in microbial killing than hydrogen peroxide.
Neutrophils are weakened which contain Fe
Hey, compare and contrast this oft seen lingering
factoid!
Case: You get another child just like the previous case
with bacterial infections. BUT, this time you discover there is a defect in
microtubules and phagocytics. You see severe gingivitis and oral mucosal
ulceration PLUS albinism on the skin. Secondaries: What is the disease, what two
bugs eat at you, and what is the first drug you reach for?
Here is Chediak-Higashi disease (not too common). But
you get strep and staph infections and you treat with Acyclovir. The KEY to this
diagnosis is the mouth stuff and hypopigmentation! You start with Acyclovir THEN
give the missing globulins through IV because Chediak Higashi is an IMMUNE
DISEASE and Acyclovir boosts the recovery while fighting the viruses. The
globins you transfuse will address the Staph and Strep. OK?
IMPOSSIBLE ODDS, but, look...
Still in your peds rotation, your next patient comes in
with recurrent bronchpulmonary, bacterial, neurologic disease, thymus aplasia,
telangiectasias, growth retardation, and impaired organ mutation, and is walking
funny and waddling. What are you looking at NOW?
HERE,
you are looking at Ataxia telangiectasia, where both the
T and B cells are busted. The alpha fetoprotein levels are always elevated, and
they key finding is ATAXIA!
OOHHMIGOSH!
ANOTHER, would you believe, child, younger this time, 2
years old walks in, again with recurrent bacterial, fungal, infections. His mom
say he suffers often from candida. And you note he has IL-2 def, poss. reticular
or ZAP-70 gene def. Your attending walks in and says he will suffer from PCP and
Herpes. She (attending) asks you to write a prescription for .... ???? What
disease? What med?
This unfortunate child has Severe combined
immunodeficiency or SCID. They usually die by age 2 from PCP. You must
prophylaxis with TMP-Sulfmethoxazole. Consider IV globin transfusion if counts
stay low.
YOU are starting to hear TWILIGHT ZONE MUSIC BECAUSE....
YET ANOTHER CHILD comes into your peds clinic with an
immune def. But this time, the child is hyperreflexic on exam, has abnormal
facies, congenital heart disease, hypocalcemia on labs, and increased
susceptibility to infections. A radiograph shows he has no thymus! What do you
tell your chief? What do you prescribe?
This child has DiGeorge's Disease or thymic aplasia. His
3rd and 4th arch failed to develop. This concept is a favorite of NBME.
Including considering marrow transfusion, you must prescribe Calcium salts and
Vit D!!!!
106. Fiddlesticks, just when you thought you were free,
ANOTHER child walks in with his mom with another immune
deficiency. (I keep on with rhymes, he-he-he). Here he is 4 years old, with
recurrent otitis media, eczema, and thrombocytopenia from Strep pneumoniae. AND,
he bleeds a lot. His IgM is low. Your attending and chief are wondering if you
are able to distinguish all these immune def. diseases. Will you get an honors
grade(Name disease)? What will you treat with? What is mech that is broken?
He has X-LINKED Wiskott-Aldrich syndrome. This is often
confused with the others and Bruton's on exams..hint, hint. But remember the
tendency to get attacks from capule bugs like Strep, with otitis, eczema , and
BLEEDING. The key is LOW IgM, High IgA,and the bleeding. IgM response curtailed.
He is not nearly as bad as SCID case, and you must give him amoxicillin (there
are a lot of options here, like you can give ceftriaxone too) plus globins.
FOR ALL OF THESE IMMUNO CASES STAY AWAY FROM LIVE
VACCINES. The NBME will ask you this, if not now, then later, if not later, then
someone will ask you.......
107. Oh no mate! Another ONE! BUT YOU HAVE TO KEEP
GOING! EVERY TEST WILL HAVE ONE OR MORE OF THESE DISEASES BECAUSE YOU CANNOT
AFFORD TO MISS THEM. IT AIN"T JUST ANOTHER COLD BABY.
This boy has low IgG and presents like WAS syndrome with
continued bacterial infections, diarrhea. And you find out this is X-linked too!
In the absence of functional Btk, mature B cells expressing surface
immunoglobulin and the marker CD19 are few to absent. What disease?
Here is the first immune def. described by Dr. Bruton.
So similar to WAS syndrome, but WAS boys will BLEED. OK? Get them straight in
your head!!! IT IS HARD!
108. This is just a day that won't end! Another child,
this time let's make it a GIRL, comes in with OF COURSE, an immune deficiency
with bacterial and fungal infections. HOWEVER, the NBME has to give up some info
(er...I mean the girl's features do I mean..). {This knowledge is good to know
for life of course, not just a test}.
Soo...you note that all the immune def. choices are
mixing but you see her presenting with lymphadenopathy, hepatosplenomegaly,
growth failure, and stigmata of chronic skin infections. Your fellow med student
(star student) whispers something about def. w/ phagocytes. TWO distinct hints.
AND culture comes back and she has Aspergillus. TELL YOUR ATTENDING WITH CONFID
ENCE......!?????
This is Chronic Granulomatous Disease. This is marked by
the granulomas (skin stuff) and key words phagocyte def. and Aspergillus
infection. Are you getting it all down. YOU HAVE TO IN ORDER TO PASS. All the
immune def. will be among answer choices, they differ so slightly. Master them!
The clock is approaching 5:30, AND the nurse squeezes in
another patient and whaddaknow, he has immune def. with recurrent bacterial
sinopulmonary infections. The NBME, er, I mean attending starts pimping you with
choices...but you note that the patient is OLDER, LESS SYMPTOMATIC (i.e. less
severe disease), and complains of GI symptoms too like diarrhea. What words are
coming out of your mouth?
This is the OH SO COMMON IgAD or Immunoglobulin A def.
Many stay asymptomatic, IgG and Neutrophil levels could be normal. Give
antibiotics....Confused yet? I hope not, I hope I gave you cues to distinguish
the diseases
As an aside, I spoke to 100 people and they all scream
back, KNOW ENDOCRINE!}
Soo...........
Now it is 5:00 pm. You are beat, but happily this time
your patient is not an immune def. case. BUT, you rub your eyes because standing
in front of you are 3 answer choices..errr, i mean fraternal triplets (listen I
am tired, I have not slept yet)...
LISTEN CLOSE, THEY ALL HAVE systemic symptoms such as
weakness, fatigue, malaise, and fever low-grade, two have neck pain, one does
not. Physical exam shows hypothyroidism. But here is the concept that comes
again again again again:
Child A has hypothyroidism, neck pain, and fever chills
and dysphagia
Child B has hypothyroidism, neck pain, and sort of looks
a little like he was hyperthyroid last week from history
Child C is shorter and his neck is NOT tender and gets
constipation a lot
SUPER CONCEPT: Who has what??????????????????? A must
know!!
Child A has ACUTE THYROIDITIS (bacterial) so you must
manage aggressively with antibiotics (penicillin G is DOC)
Child B has SUBACUTE THYROIDITIS (viral) so you just
give aspirin and return visit. (KEY!!, HYPER, then HYPOthyroid features)
Child C has AUTOIMMUNE THYROIDITIS. This is bad because
it is a life-long condition. Treat with levothyroxine.
THIS QUESTION WAS WORDED VERY ODDLY, BUT YOU WILL REGRET
IT IF YOU DON'T TAKE HOME THE CONCEPT!!!!
as to the HY Concept 110, consider that...
someone I knew said they had to distinguish the
hypothyroiders (I did not say it, but you KNOW TSH is high right), and then, he
was given a series
of graphs pointing to thyroid levels. Recall Subacute
thyroiditis can start with HYPER then HYPO thyroidism. The NBME likes to ask
things in a scary way that makes you forget everything, even your own name
during the exam. HOLD YOUR WITS. YOU KNOW MORE THAN YOU THINK
What MAJOR MAJOR drug other than trimethoprim blocks the
loved enzyme dihydrofolate reductase?
Methotrexate:
KNOW you often use it for rheumatoid arthritis,
hydatiform mole, leukemias and it works its magic in the synthesis phase,
stopping thymidine (thymidineless death) and blocks protein synthesis. As I
mentioned, I AM NOT REPEATING "EXAM CONTENT" but know that the NBME will give
you a picture and ask you to POINT to where methotrexate works its magic. They
like doing that. Last year, I wish someone told me just how the NBME likes us to
understand stuff. No one told me. Now I want to lift others up.
AGAIN BEING VAGUE AFTER AZSKEPTIC's warning...
I think that is ridiculous to say that I am
disseminating material with all due respect to AZSKEPTIC. Like I said, there is
a purpose to this very very hard test. There are trillions are pieces of info,
and you HAVE to pick and choose. But the NBME needs to know that you are not
going to come to the US and kill people, soooo..... I relay the concepts like
"Don't give ACE inhibitors to a pregnant woman". This is SURE to be on the USMLE
Step 1,2,3, but am I breaking a RULE to tell people this VITAL piece of info? I
am giving out "exam content" in the sense that I am relaying that IL-5 revs UP
IgA and IL-6 (like IL-1) revs up the acute phase response...BUT THESE ARE the
BASICS that NBME wants US doctors to master. That is why if I recall from my
test a case of a drug overdose and how to treat it, I FEEL COMPELLED to say it
on this board in such a way that does not violate copyright laws or "giving out
answers". Because....every doctor in the world SHOULD know what drug a person
probably took based on his or her symptoms and how to treat them. I encourage
everyone to share the concepts after their exams. The NBME should not mind
unless I tell everyone that "if you get test version KX-115 then the answer to
#1 is B, #2 is A, #3 is E, etc." But to share knowledge that the difference
between ALS and multiple sclerosis is that ALS has no sensory deficits, well
that is just making everyone wiser and better doctors. What do you guys believe?
Anyhow, let truth reign! Let's say a patient comes into
your office at 6:00 pm, my my, and he has vertigo and remarks that he has
difficulty with taste and swallowing. Before you give a prescription for
antivert, is this a dysfunction of the vestibular apparatus of the inner ear? Or
is it a brain stem issue? If it is a brain stem issue, what two nuclei and
nerves are involved
Tricky case. Because vertigo has many causes, note the
DIFFICULTY with taste and swallowing. This pushes up the suspicion of a lesion
to the nucleus solitarius and ambiguus with nerves 7,9, and 10 also lesioned.
AND for the cherry, we see that all the time with a POSTERIOR INFERIOR
CEREBELLAR ARTERY stroke which supplies that area! See?
SO, don't just send them home with antivert and a
reminder slip for a return 3 month visit!! (This IS USMLE MATERIAL, but a MUST
KNOW FOR LIFE!) IF we avoid all discussion and thought of USMLE material, what
is the USE
DRAT! AGAIN...to BE VAGUE....
KEY KEY KEY point. if a patient has no pupillary
reaction to light shined on the right side but there is a reaction to light in
both eyes, when light is shined on the left. The lesion is what? NOW I change
the patient so there is pupil rxn to light on only the right side, when light is
shined in either eye. NOW, where is the lesion?
ABSOLUTELY USMLE BEGS FOR YOU TO UNDERSTAND THIS. IT
WILL BE ON YOUR TEST, IN YOUR LIFE, IN YOUR PRACTICE, IN HUMANITY FOREVER....
For the first patient, the lesion is the right CN2. For
the second, the lesion is left CN3. KNOW IT!
NEURO IS PRIZED LIKE A CHILD FOR THE NBME... so,
Say your pt comes in and you touch both her corneas one
at a time with a q-tip, and you note that ONLY the LEFT eye blinks, then which
cranial nerve is activated?
KEY TO THE CITY point!
Right CN7 (NOT THE LEFT ONE, common mistake)
will try to be vague so I don't anger azskeptic or NBME,
without peeking, what drug blocks out enzyme dihydrofolate reductase!!??? (This
is NBME's 10 ten list of favorite enzymes)
Trimethoprim blocks it. NOW FOR THE NEXT QUESTION...
valuemd.com
Here is a King Kong Koncept!
Two patients walk into your office. Listen close.
Patient A has a stroke in motor cortex that lesions UMN
tract to central facial n.
Patient B went on a camping trip and has a lesion to the
LMN CN VII.
Tell me how each patient will present on physical
exams...
Patient A will have CONTRALATERAL, and LOWER QUADRANT
paralysis.
Patient B will have same side Bell's Palsy features
(can't smile and may drool on affected side)
PROMISE ME that you will know this for LIFE for your
PATIENTS' HEALTH! because tx are distinct! Review neuro pictures, it will be
clear.
Presenting the GODZILLA of concepts:
Now it is 6:30 in your peds clinic (and you are
wondering if you are actually in a surgery rotation), and the nurse brings in a
15 year old boy with "fatty" thick calf muscles. The child trips on a toy and
strangely uses his proximal muscles to assist in standing....
Ahh...you are thinking Duchenne's (gave it away), BUT
WAIT, your attending says NO! What is the disease and what is the defective
protein? And what are the labs? Crucial...crucial... What is the only drug with
known effectiveness for his condition?????
The disease is Becker's, a milder form of progressive
muscular dystrophy.
The defective protein is DYSTROPHIN!
The labs show elevated CPK!
The ONLY drug with current known effectiveness is
prednisolone.
BAD, BAD, disease. Treat well....and be sincere.
To avoid angering AZSKEPTIC, I will make my concepts
less and less sharp and more vague and fuzzy so that I can still feel I am
helping and yet not feel worried that powers greater than me will get
upset...even though I cannot imagine why...but then then again, the world is
MAD...sometimes...
OOOHHH!! What is bigger and stronger than King Kong or
Godzilla. Maybe that new Transformers Robot. This concept is at least that big!
Anemias, SO COMMON, SO TESTED, SO SEEN, SO DIFFICULT ON
EXAMS...SO DON'T NEGLECT...
You see a female with a blood smear with RBCs small
n'round, physical is anemia, hyperbilirubinemia, and abnormal results on the
osmotic fragility test. OK OK she has hereditary spherocytosis (so common in
clinics). But of course, you need to know:
1) What protein is defective?
2) What is the inheritance pattern?
3) What are the main two complications?
4) Surgical treatment?
5) What do you, an intern prescribe to them?
KNOW IT AS YOUR LIFE DEPENDED ON IT!
1) spectrin
2) AD inheritance
3) cholecystitis and aplastic anemia
4) Splenectomy
5) They need folic acid!
What's next, yes, the MECA-Godzilla or maybe Mothra of
Concepts:
Another patient comes in weak with signs pointing to
anemia. You take a blood smear and whoa! cytopenia...blast cells, reticulocytes,
sparse RBCs. And you know this is not autoimmune because it is recent. Hold
it...she mentions she had a gonorrheal infection and is on a med. OH YES! OK, so
what is the disease, name of the med she is on AND what will be the name of the
med you give her as you transfuse bone marrow!?!?!
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
Chloramphenicol is the drug she is on that caused
aplastic anemia. AND you can give cyclosporine or a steroid along with her
transfusion. REMEMBER, aplastic anemia has many causes so be careful. Benzene,
pregnancy, CMV, HIV, EBV, and autoimmune causes are all to be considered
Can we do it over Godzilla? Yes, here is the Pillsbury
Dough Boy of Concepts:
An African American male comes into your office with
signs of very very mild anemia, almost no symptoms, a little jaundice. His main
complaint--a UTI. Your senior hints this is the most common enzyme pathology. A
smear shows Heinz bodies (review please). Now your senior starts a pimping away.
1) What is his disease?
2) Why is it so prevalent?
3) What does the enzyme catalyze? What is the end
product?
4) You grab some sulfamide and nitrofurantoin to treat
his Urinary Tract Infection and your attending smacks you on the other side of
the face that she missed before. Why was she so upset with you?
1) G6PD Deficiency
2) It confers protection against malaria
3) The G6PD enzyme catalyzes the oxidation of
glucose-6-phosphate to 6-phosphogluconate while concomitantly reducing the
oxidized form of nicotinamide adenine dinucleotide phosphate (NADP+) to
nicotinamide adenine dinucleotide phosphate (NADPH). NADPH, a required cofactor
in many biosynthetic reactions, maintains glutathione in its reduced form. RBCs
need NADPH to protect itself against oxidative stresses. (Long winded
explanation, but you have to know it., sorry).
4) You cannot give an oxidizing agent like primaquine,
choroquine, or a sulfa drug, or nitrofurantoin to a patient with G6PD def. Their
RBC will hemolyse and you will lose your license and your attending will lose
her's and your hospital will close and turn into an apartment complex.
Case: an elderly psych patient of yours complains of
arrhymias, what drug is she on? (amitriptyline or thioridazine or lithium or
olanzapine?)
she's on amitrypyline, a tri cyclic antidepressant.
(OTHER tricyclics are imipramine and nortriptyline.
Bad side effect: arrhythmias. Review MOA.
Another elderly psych patient comes to your office with
complaints of colds and a peripheral smear shows low WBCs, what drug caused
this? MOST LIKELY one..Secondaries: which two receptors does it block
Clozapine, blocks 5HT-2 and dopamine. Causes leukopenia.
Yet another elderly psych patient comes into your office
this time with constipation and rigid muscles and (hint other antimuscarinic
sym). He was given a med FOR an ACUTE psych episode where he shouted and hit
others. What is the drug? 2nd: Receptor/MOA? And Name at least two other drugs
in this family
Answer: He is on Haloperidol (used for Positive symp, in
ACUTE cases), the drug blocks D2 receptors, and fluphenazine and thioridazine
are within this family named NEUROLEPTICS,
assoc of course too tardive dyskinesia!
(these are different from the atypicals, make sure you
know the atypicals are risperidone, but also clozapine and olanzapine--neg
symptoms controlled more, diff receptors involved)
An M&M candy question:
Woman walks in with chronically sore right knee. She is
neg. on labs for rheumatoid factor. Under microscope, you see crystals appearing
shorter and often rhomboidal. Under a polarizing filter, crystals do not change
color depending upon their alignment relative to the direction of the red
compensator.
What on earth does she have and what is the name of the
crystals deposited!
Answer IS NOT rheumatoid arthritis or gout, BUT, the
answer is pseudogout, and you see calcium pyrophosphate crystals as ooposede to
birefringent needle crystals in gout! P=Pseudo=Positively birefringent
an M&M peanut candy question:
Next a child enters your clinic with chronic diarrhea
and fatty stools. A younger med student asks you if he has Cystic Fibrosis,
Giardia, or Ulcerative Colitis, or Chron's. But, YOU go further and order labs.
They come back with weird D-xylose test, anti-IgA antibodies, B-cells in the
lamina propia
You go Hoorah because you know:
1) Disease
2) Etiology (viral/immune/etc)
3) is there a specific substance or drug he should take
or avoid?
1) He has Celiac sprue
2) Autoimmune/hereditary/Europe
3) Avoid gliadin wheat in diet
An OVERSIZED CANDY question (BIG FAVORITE)
Next, you have a older African American male who comes
in with chronic CHF and began a new medication. But he suddenly one morning
found his left foot joints swollen and so tender even the weight of the
bedsheets are so painful! (BIG HINT COMING). Labs come back and you see crystals
with needle shapes (shown a pic), (-) birefring...
But NOT SO FAST, THIS IS USMLE!
1) Tell me the likely med he was on and at least two
other meds which could cause this condition.
2) What is the short term and LONG term treatment?
3) MOA (Mech of Action) of disease?
4) What compound builds up?
5) What foods should he avoid?
6) Bonus Biggie: He had a great grandfather who had
similar symptoms but was mildly retarded and scratched himself like crazy! Dx?
) Thiazide diuretics, Cyclosporine, Nicotinic Acid and a
LONG LONG list can do this.
2) Colchicine short term/and Indomethacin and
Allopurinol long term
3) Uric acid precipitates from supersaturated
extracellular (ie, synovial) fluid. The resulting crystals stimulate
phagocytosis by neutrophils and initiation of the inflammatory cascade. OUCH.
4) PRPP
5) (Purine rich foods (especially of anchovies,
sardines, sweetbread, kidney, liver, meat extracts)
6) Lesch-Nyhan syndrome, (a NBME favorite)
NOT IN THE FORM OF A QUESTION BUT THIS IS A LIFE POINT:
People keep missing Goodpasture's and Wegner's, you
know, the diseases with BOTH kidney damage and Lung damage. Can't discern.
POINT IS THAT WITH WEGNER'S GRANULOMATOSIS LOOK FOR
UPPER RESIRATORY SIGNS LIKE SINUSITIS TO DIFFERENTIATE ON THE BOARDS, ER, I MEAN
CLINICS!!!!!
So hard, but the reason so many friends of mine failed
is because they could not differentiate the subtle differences of:
Case; Pt comes in and says she has: Inability to eat dry
food, such as crackers, which sticks on the roof the mouth Tongue sticking to
the roof of the mouth She always has to be putting a glass of water on their bed
stand to drink at night. She has difficulty speaking for long periods of time,
and her eyes are dry and her right wrist is starting to hurt.
HERE'S THE MONEY:
1) Disease?
2) Which HLA is involved?
3) Drug of Choice (DOC)?
4) What dx, is she at increased risk for?
Answers:
1) Sjogren's syndrome (they'll give choices like
Reiter's, PSS, etc.)
2) HLA 3
3) Pilocarpine to stim. secretions! And eye drops!
4) a lymphoproliferative disorder
This one's is KEY:
Next, a male patient comes in with myalgias and low back
pain. He also has reddish (infection like) tinge on his left eye. Your
subordinate med student yells out! "Ankylosing spondylitis!, Rheum. Arthritis!.
But not so fast! You note that labs came back positive for HLA B27, BUT so did
chlamydia culture!!!!!
You scold your med student.
1 Why? Because he had picked the wrong disease, the
right one is?
1.. Reiter's syndrome!
The KEY finding is the Chlamydia or could be Salmonella
and urethral connections. The closing of the triad is the conjunctivitis. Don't
be tricked my brothers and sisters!
YOU COULD BE ASKED BY YOUR ATTENDING/BOARDS WHICH BUG IS
HE MOST SUSCEPTIBLE TO...(they have millions of ways to twist the questions but
the concept remains the same!) MINOR ADDENDUM on hy concept 129, Reiter's= male
Sjogren's=female
This one's is a MAGIC KEY:
Next, another male patient comes in with myalgias and
low back pain! He also has reddish (infection like) tinge on his left eye.
HLA-B27+ Unreal! You are about to say that you have another case of Reiter's,
but you note his labs reveal cardiac anomalies....Your subordinate med student
yells out....What?
(This time your med student is RIGHT!)
This one is ankylosing spondylitis, compare carefully
with Reiter's. One triad has the heart, the other has the urethra!!!! Got It?
Got Milk? Got Love? Got God?
Oh boy..
Another patient comes with lower back pain and the usual
suspects. But she says her arthritis often comes with a fever and is WORSE IN
THE MORNING! You know this dx of course, you know it is NOT osteoarthritis,
which has osteophytes, but what if I presented a pic of the hands with arrows to
all joints. WHICH ONE(S) OF THE THREE JOINTS ARE AFFECTED (DIP, MCP, PIP)? (See,
you HAVE to know pictorially the secondaries.)
Besides NSAIDS, what other three drugs are often tried?
She has rheumatoid arthritis, + rheumatoid factor. This
autoimmune dx has systemic symptoms like her fever and malaise. The answer is:
MCP and PIP joints
OSTEOarthritis has DIP joint inflammation
Q. So depressing...a young girl comes into your office
with a fever and history of weakness, infections, cardiac flow murmur and
petechaie. You order a CBC and find that her smear shows what looks like
immature leukocytes...but you cannot seem to distinguish between ALL and AML
(THIS IS A MAJOR TEACHING POINT, BECAUSE THE SMEARS CAN LOOK VERY VERY SIMILAR
AND THERE WILL BE BOTH ON THE ANSWER CHOICES, SO LOOK IT UP IN A HISTO ATLAS!).
You sud
TOMMYPOSTS 2 ( 149-200)
Q. I present you with a LM image of the thyroid with
arrows everywhere. Tell me the cell and the exact location on the image where
calcitonin is secreted
A. The parafollicular or C-cells secrete calcitonin.
Make sure of it!!!!
Q. The parafollicular or C-cells secrete calcitonin.
Make sure of it!!!!
A. It binds TUBULIN AND BLOCKS POLYMERIZATION OF
MICROTUBULES, THUS BLOCKING MITOSIS.
PARASITE S
Q. NBME wants you to understand all the HELMITHS, one of
my students said he got a whole block of them! (he was prob. exaggerating
though)
So, one by one...
A pt of yours comes in with abd pain after eating raw
fish. He looks lk he has cholecytitis. What drug do you give? What is the bug?
(PIC GIVEN)
A. This is a fluke (looked weird like a worm), Bug is
CLONORCHIS SINENSIS, treat with PRAZIQUANTEL.
Q. A young boy comes to your clinic with diarrhea after
eating "mud pies", what is the bug and the tx?
A. But is the infamous Strongloides stercoralis, tx.
with Thiabendazole
Q. Oh, please note that ALL OF THE CASES YOU WILL SEE ON
THE USMLE WILL LIKELY HAVE A HISTORY OF TRAVEL!
That said, you have a male pt, 30, with epilepsy coming
in after eating "raw pork". What is the helminth and the treatment?
A. the bug is a tapeworm--Taenia solium and you give
Praziquantel and Niclosamide and a steroid to relieve CNS pressure because this
bug swims everywhere, even in the CNS! (Pic given. slide)
THE CASE WILL give travel to Southeast Asia or maybe
Africa.
Q. A traveler comes from Africa (could also be a West
Alaskan Indian), and had told you he ate coyote and dog poop as a college dare!
He is ASYMPTOMATIC but you see cysts in his lungs on X-ray. What's the bug and
TX?
A. Give him Albenza which is trade name for Albendazole
which works by depleting ATP, and the bug if asked is Echinococcus. For this and
the other tapeworm, Taenia, the guy could be scratching his rear end a lot so
wash your hands!
Q. A pt of yours came back from Brazil and has dysuria
and nausea. Plus he told you he ate a bunch of snails at a local exotic
restaurant. What's the bug and tx?
A. He has the famous Schistosoma Haematobium. In US it
is rare because they don't usually eat a lot of snails! But know this fluke has
many subtypes and can clinically present LIKE ANTHING! The NBME will have to be
very specific. One key is it results in granulomas! Treat with Biltricide which
has generic name Praziquantel.
Q. A pt returns to your clinic fr. Latin America with
signs of Asthma. But a stool sample shows a round curved worm (slide is given).
YOUR ATTENDING TELLS YOU THIS IS THE MOST COMMON HELMINTH INFECTION IN THE
WORLD! You are looking at what and will treat with what? AND also seen is what
is MOA of the drugs? BONUS, you must know.
A. YOU are looking at ASCARIASIS. So common. Treat with
Mebendazole (WHICH WORKS BY BLOCKING GLUCOSE UPTAKE). AND pick Pyrantel pamoate
(WHICH IS A NEUROMUSCULAR BLOCKING AGENT WHICH PARALYSIZES THE ROUNDWORM). I
THINK Kaplan AND Error! Hyperlink reference not valid. mentions these bugs but
not ALL THE NECESSARY and tested material is given.
This is FECAL ORAL SPREAD
Q. Don't you dare confuse this with Ascariasis. This
nematode is quite prevalent in the US. That will be the give away and so will
the fact that your peds patient is scratching his behind. Give me bug and drug
A. Watch out, this one I am told is confused with
Ascariasis, but it is Enterobius vermicularis and the case seen is a kid with an
itchy "butt".
Treat with Pyrantel pamoate.
Q. This is a BIGGIE in the US, so you don't need a
history of travel: HERE goes:
A woman patient comes to you after sampling raw spiced
pork sausage links (classic case). She has myalgias and PERIORBITAL EDEMA.
What's the bug and drug and MOA of drug?
A. This helminth is the ubiquitous Trichinella. Very
common the US.
FOR ALL OF THE HELMINTHS QUESTIONS, THE NBME USUALLY
GIVES A EM OR HISTO SLIDE BECAUSE MANY OF THEM PRESENT WITH SIMILAR VAGUE
SYMPTOMS LIKE DIARRHEA, MYALGIA, ETC. SO WATCH CAREFULLY FOR THEIR CLUES WHICH
THEY HAVE TO PROVIDE.
Treat Trichinella with Thiabendazole!
Again, Trichella is assoc. with pigs if all else fails.
Q. This helminth is rather distinct so you likely won't
have trouble!
Hey, you get a patient who came from a trip
photographing wild animals in AFRICA (let's say Ethiopia). He comes to your
clinic and you see hypopigmented (leopard spot like) lesions on his legs. He
photographed from a riverbank (HINT). Give me bug and drug and MOA of drug?
A. HERE we are:
This is "river blindness" or Onchocerca volvulus. BUT
THE MOST COMMON PRESENTATION IS NOT BLINDNESS WHICH IT MAY EVENTUALLY CAUSE, BUT
SKIN LESIONS!
Transmission is by black flies, along riverbeds, mostly
all in Africa. Treat with IVERMECTIN, which works and binds selectively with
glutamate-gated chloride-ion channels in invertebrate nerve and muscle cells.
Q. Here is a MUST KNOW:
A post college grad comes to you who came back from the
PEACE CORPS. She volunteered her time so well, but this is a crisis. She is thin
and athletic, and pretty but sadly one of her legs looks swollen like an
ELEPHANT'S. What's the bug and drug you give?
A. This is too bad, she was trying to do good...This is
a classic NBME example and very common case of Bancroftian Filariasis or
Wuchereria bancrofti where a person is bit by a mosquito and has lymph node
swelling everywhere. Common is a foot and/or leg elephantiasis. Treat FAST with
Ivermectin or Diethylcarbamazine or she will lose her precious leg
Q. While we are on the subject of these parasites, here
Nematodes, we spoke of a drug often used called Mebendazole. What is the MOA?
A. Mebendazole is often used for treatment of
eosinophilic enteritis; inhibits microtubule polymerization by binding to
cytoplasmic b-tubulin; by affecting parasite's intestinal cells, prevents use of
nutrients and essentially starves parasite to death! Sorry parasites...esp. if
you are Buddhist, I guess even a parasite would be sacred!
Q. We are slowly winding down the NBME's list of
parasites...
BUT HERE IS A BIGGIE THAN AFFECTS UP TO ONE BILLION
PEOPLE!
You see one of your dear patient who came back from
Puerto Rico (could be other places too). Now, he complained that a month ago he
started itching, THEN coughing, THEN having diarrhea! Terrible! He is begging
you to diagnose him because he is starting to look anemic!!
What is the bug and drug???????? Oh, also what does his
blood smear show?
A. You are staring at Anclostoma or HOOKworm disease
which is SOOOOO prevalence around the world. You should look for travel history.
Another related hookworm is Necator Americans.
When the bug hatches in the intestine, you get IRON DEF.
ANEMIA, so blood smear will show microcytic RBCs.
You treat with Albendazole or Mebendazole.
Q. This is a mediumee, but you have to know this too:
In your peds clinic, a kids comes in with vision
problems and his mom said he had gotten a couple of new puppies. He also has
wheezing urticaria and he lives in Southeast US. What is the bug and drug?
This is kinda hard because the differential is HUGE, but
the association of:
puppies=southeast US=eye stuff gives it away easy. OK,
so go ahead!
A This is classic for Toxocariasis. You treat with a
drug called Diethylcarbamazine but Thiabendazole can be used too. Puppy poop has
this. You cannot miss this and accidentally treat with antibiotics thinking you
have Pasturella (bacteria).
So how will you KNOW? Well, the NBME will give you a
picture and labs. Remember eosinophilia? It can be as high as 80% with high
IgM!!!!! Oh, I should make that my next CONCEPT!
We have been going over the parasite bugs the NBME WILL
test you on. And they frequently have things that will distinguish them from
bacteria.
1) You may see a clinical history with stages (first
intestines, then lungs, etc. because these guys lay down larvae)
2) You MUST look for the clue for labs and sometimes my
students say they completely skip the lab section because they are in a hurry.
ONE TWO MILLIMETER SPACE has the info HIGH EOSINOPHILIA! If you miss this, you
may treat your patient with antibiotics on your test and get the question wrong.
3) Also, a lot of these bugs are not endemic to the US.
So look for a history of travel.
4) There are only a few drugs here, so please don't
forget them
valuemd.com
Q. Here is one that has been reported POPing up, so you
better know it because it was in a newspaper and...
A Japanese family just came to the US 3 months ago and
then went straight to your clinic. One of the kids has serious pulmonary signs
and was treated for Tuberculosis. HE IS NOT BETTER. Worried parents gave you a
history that he was treated by his older grandma in Japan with raw crayfish for
health. You are glad they came to you because you know you are not looking at TB
but rather....? And you will treat with ???
A finally the drug was what MOA????
A. This is popular with NBME because doctors mistake
this deadly PARASITE with other things like TB or coccidomycosis and then a BIG
lawsuit occurs.
So here you have a big clue about the Japanese ethnicity
and the ingestion of crayfish and the lung findings.
This is pathognomic for....Paragonimiasis.
Please treat with Praziquantel. You must know...
Praziquantel again that it inhibits microtubule
polymerization by binding to cytoplasmic b-tubulin; by affecting parasite's
intestinal cells, prevents use of nutrients and essentially starves parasite to
death. I think I mentioned this before, but I am repeating it because it is very
important.
thought as I finish up the parasites that you really try
to LUMP them somehow. I think of these because they work for me, but you should
use some pneumonic because they are kinda hard to distinguish.
Taenia> Sounds like Tan-in-sol (sun) while Praying
(praziquantel)
[These are weird pneumonics but I think you need some
and personalize them like since I like to pray a lot, I can think of Tanning and
Praying so I associate Taenia with Praziquantel for the drug treatment]
Strongyloides> "strong thighs" (Thighs sounds like)
Thiabendazole
Onchocerca > "On cocaine via IV" (IV for Ivermectin)
Corny, but the parasites need this because their names
are weirder.
Again, try not to confuse the parasites and bacteria.
Look for Travel, look at labs, and look for symptoms that wax and wane over a
month as the parasite goes through larvae stages
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
Let's move on,
I'm quizzing you from before...
Remember my original case of the 2 year old with Chronic
Granulomatous Disease which we discovered is REALLY BAD, what is the name of the
enzyme that was lacking? Do you remember? Were you paying attention? If not,
that is OK, I am not upset at all, but you should keep reviewing my HY posts!
A. Answer is NADPH OXIDASE
Our phagocyte oxidase system is an NADPH oxidase enzyme
complex consisting of 4 component proteins. Membrane-bound gp91 and p22 make up
the b and a subunits of the heterodimer cytochrome b558 portion of phox gene.
But for us, we need to only remember NADPH OXIDASE, not distractors like NADH
OXIDASE or NAD+OXIDASE or NADPH REDUCTASE!
IMMUNO
Q. The NBME wants you to know a simple point about VDJ
recombination. It is a very basic concept which explains antibody diversity. But
if I say it exactly I would be repeating NBME material b/c it is so specific so
instead I'll ask you to read on it for just two seconds. Of course, if I can
think of a way to present it indirectly which I am always doing then I will. But
HERE, let me ask you guys, at the very least, which chain, the H (Heavy) or L
(Light) carries the 3 gene segments? And in CLASS SWITCHING, which antibody,
IgM, IgG, IgA, IgD, or IgE is most "primitive"?
BIG CONCEPT, and some tests had a disproportionate
amount of IMMUNO.
A. While you read up on VDJ, know that the Heavy chain
has the VDJ and there is DNA rearrangement. Know the L and H chains are made
SEPARATELY in the CYTOPLASM by means of DISULFIDE BONDS!!! The LAST step is the
addition of the CARBOHYDRATE moiety. (Look and remember my capital letters...).
Second, at first, all B lymphocytes carry IgM specific
then after undergo class switching to the others (If you were lost here, YOU
REALLY NEED TO KNOW IMMUNO AND REVIEW)
Q. OK, here we go, a patient presents with dyspnea,
endless differential, but here are the secondaries for ARDS:
1) Pretend you already diagnosed ARDS, a deadly illness,
what cell is responsible for the distress?
2) OK, they NBME wants you to understand they will ask
you cases (so what are the main causes?)
3) We know there are a lot of causes of Pulmonary Edema,
but how can you differentiate ARDS edema and Cardiogenic edema?
ARDS carries a 50% death rate. Know it or Die!
A. 1) Neutrophils
2) Ischemic shock/Endotoxic shock/DIC; breathing really
hot air; acute pancreatitis (weird, eh?), drug use
3) It is called Pulmonary Capillary Wedge Pressure test
(LV) LOW in ARDS, HIGH in CARDIOGENIC!
Q. THIS IS A GREAT CONCEPT:
OK, let's dabble in immune just for a change of pace,
for just a second, we will revisit later. We need to know the following..
Whew! I am getting tired again, I need a break so I will
lump a couple of KEY factoids:
1) Could you pick out the right ratio of T to B cells?
2) YOU know the T cells pass through thymus for thymic
education (review if what I just said is foreign), do the B cells pass thru
thymus? If not, where (amongst a series of choices of course)?
3) Which IL type boosts up T helper cells?
A 1) 3:1
2) B cells don't pass thru thymus but the precursors
mature in GALT and Peyer's patches.
3) IL-2
ALL OF THOSE ARE MUST MUST KNOWS, THE CONCEPT ARE IN THE
BRAIN OF THE NBME, BUT I PICKED MY OWN WAYS TO MAKE SURE YOU UNDERSTAND!!! KNOW
THAT NBME WILL ASK THE ABOVE CONCEPTS IN WEIRD WAYS, SO AFTER THE FIRST READING
OF THE QUESTION, YOU WILL BE LIKE "HUH?" THEN FOR EXAMPLE THE ABOVE THREE
CONCEPTS WILL COME TO YOU AND THEN YOU WILL SAY "OH, I KNOW THIS!"
Q. OK, after this I need a few minutes break....
OK, remember that to really learn you need to compare
and contrast so that is why I think I will "LUMP" my HY by subjects if I can at
times. To know what is BLACK, you need to see WHITE, etc.
SOO>>>...
We know IL-1 and TNF-alpha makes your temperature go up,
so
which IL revs up IgA?
A. IL-5
Q. All, the NBME likes to ask things in weird ways:
We just covered helminths. Which IL is most involved?
A. BIGGIE POINT: SAME ANSWER AS BEFORE IL-5. That is how
NBME tricks you. You may "memorize" what I just asked, IgA is stimulated by
IL-5, but then when I bring up the concept that IL-5 revs up both IgA
(intestinal mucosa) and Eosinophils, your brain may hiccup! See, are you
starting to understand????
Q. IMMUNO:
Which mediator is responsible for endotoxin septic shock
and makes you have cachexia (like in cancer)? And then, what is the MECH?
HARD HARD, BUT MAJOR POINTS.
A.
TNF alpha,
1) secreted by MACROPHAGES
2) It causes cachexia by inhibiting lipoprotein lipase
in adipose tissue.
ALSO, FOR ICING ON THE CAKE, KNOW TNF-A also revs up
IL-2 and B-cells.
Q. Here's one more at least:
A patient of yours is predisposed to TYPE I
hypersensitivity. Which IL is mostly responsible. This is a great great
question.... look below after guessing...
A. Surprise, I bet you guessed IL-1 or TNF-a BUT
NNOOOOO!
The answer is IL-4 IL-4 revs up IgE, WHICH THEN is
responsible for anaphylactic shock.
THIS IS AN ULTIMATE CONCEPT. MANY STUDENTS JUST LINK
IL-4 TO IgE, which is fine because some versions of the test will be that
straightforward. BUT SOME OF THE TEST TAKERS WILL BE ASKED JUST LIKE I JUST DID,
INDIRECTLY AND WITH A SECONDARY. It is not a HARD question, but you can GET
EASILY DISTRACTED!
DO YOU GUYS AGREEE????? YOU HAVE TO PONDER AND REALLY
THINK!
Q. Some of you will be asked:
Which IL revs up stem cells?
A. WOW, the answer is IL-3
But some of my students got it wrong because they read
Error! Hyperlink reference not valid. and it said
IL-3 = Bone marrow.
So they Blanked! They KNEW the answer, but they blanked
because they did not stop to recall that stem cells are in the bone marrow.
See, see how easy it is to get tricked? Please let me
know if you agree.
© 2003, 2004 ValueMD Incorporated. All rights reserved.
Q. We MUST BE LUMPERS, (lump info together), it is more
efficient, believe me it is educational theory...
So, which IL is part of the acute phase other than IL-1?
Also, which IL does the same as GM-CSF?
A. IL-6
then IL-3 is like GM-CSF!!!!
Q. You KNOW MHC I = T=cells
AND MHC II =B-cells (these are loose associations), but
tell me,
Mature MONOCYTES secrete which two cytokines?[/b]
A. Mature monocytes are macrophages and they are the
ones that secrete IL-1 and TNF-alpha
Q. Great question:
Give a place where macrophages are fixed in tissues and
name a mediator that activates them to move!!!!!
SUPER DUPER POINT(s)!
A. Kupffer cells of the LIVER and C5a!!!!
YOU MAY THINK I AM BEING TRIVIAL, BUT HINT HINT, I AM
NOT!!! KNOW THESE!!!!!!!! DON"T FORGET!
Q. Differentiate NK T-cells with cytotoxic T-cells!!! It
is things like this which keep students from passing!
A. NK, or natural killer cells specialize in killing
virus infected cells and cancer cells but unlike cytotoxic T cells, THEY ARE
ACTIVE WITHOUT PRIOR EXPOSURE TO THE VIRUS, ARE NOT REVVVEEED UP BY CONTACT, AND
ARE NOT SPECIFIC!
AND, THEY DO NOT HAVE TO PASS THRU THE THYMUS TO MATURE.
(You DO know the cytotoxic T-cells have a receptor, NK's
don't!)
(NK's don't need MHC to act)
Since NKs activated by IL-2 are being used in cancer
research, is there any wonder that what I JUST WROTE WILL BE ON YOUR TEST?!
Q. IT is the WONDER WOMAN of concepts:
Which ILs rev up growth and maturity of B-lymphocytes?
A. The answer is IL-2,4,5!!!
Say it again, 2,4,5
Again, 2,4,5
You "may" be shown a pic.
I KNOW THIS STUFF IS HARD AND BORING AND SO ROTE MEMORY,
BUT IT IS HY, YOU MAY NOT THINK IT IS, BUT IF I CAN HELP EVEN ONE OF YOU GET
THEM ALL STRAIGHT, WE WILL DANCE TOGETHER IN HEAVEN.
Q. This is the KENTUCKY FRIED CHICKEN 20 PACK concept:
You all know CD-8 binds to MHC-1, but if I give you 5
mult choices, which IL revs it UP!!!!!
A. IT is IL-2 !!!!!!!!!!!!!!!!!!!!!!!!!!!! Which also
stimulates itself (Kinky, eh)
NBME LOVES THESE, DRAW A PICTURE UNTIL YOU KNOW IT COLD,
IT IS VERY CONFUSING.
Q. LOOk, you all know all T cells have CD3 (That factoid
alone can help eliminate wrong choices like the leukemia stuff), but, what does
CD3 do?
Is it using the cAMP pathway?
A. This,,,,my friends, is the BATMAN of facts:
CD3 molecules transmit into that the antigen receptor is
OCCUPIED!
This works NOT by cAMP but by the IP3 Ca pathway.
(Music PLaying..) Instead of hearing "This is CNN", you
are hearing "This is the NBME"
WE ARE IN THE NBME MATRIX, where's Keanu?
RE: HY Concept 182,
KNOW COLD that B Cells do not have CD3!!!! AND
B-cells have IgM on the surface BUT T-cells DO NOT!!!
Repeat this over over over over over over over again!
Q. This is the Green Lantern of concepts:
Which 3 cytokines bring neutrophils to the scene
(pretend I show you a histo slide pointing to a neutrophil and THEN ask the same
question)
Secondaries, secondaries...
A. They are
IL-1, IL-6 and TNF-alpha = acute phase response
Are We Getting Anywhere Yet?
Q. FRIENDS, I told you IL-3 revs up bone marrow, now
tell me:
What is different about the T-cells that make IL-3 (vs.
others)?
Now tell me which mediator is used in cancer
chemotherapy to rev up some neutrophils to stave off infection?
A. IL-3, unlike the others are ACTIVATED first
AND WHAT A CONNNECTION:
IL-3 IS SIMILAR TO GM-CSF (colony stim. factor)
KEY: IT IS GM-CSF THAT IS USED IN CHEMOTHERAPY
Q. Oh boy, now we get to complement!!!
This can get really really confusing! If I merely post
my HYers, you will be lost unless you quickly review an IMMUNO book and look at
the COMPLEMENT CASCADE. You WILL be asked which complement factor does what,
NBME is very specific! There are literally 100 questions possible and more just
on the diagram of the complement cascade!
So, I will ask only one or two questions here:
HOPEfully you know for example that C3b opsonizes
bacteria, but which factor (s) neutralize viruses?
A. C1, 2, 3, and 4 neutralizes viruses in the CLASSIC
pathway, and complement:
1) kills GRAM-NEGATIVE BACTERIA
2) IgM and IgG activate complement in the classic
pathway,
3) But, Endotoxin and nonspecifics work in the
alternative pathway!!!
(THE NBME can ask SO many questions on just the words
above, that is why this test is concept based. They could give a list of bugs
and ask which one does C3a work on and you are scratching your head, but then
you notice that all the bugs are gram positive except ONE! And then you will
pick the Gram NEGATIVE bug!) (You may be distracted for 10 minutes trying to
recall what C3a does (anaphylaxis), but YOU WASTED YOUR TIME!
Also, of course, I could ask you what OTHER complement
works like C3a? Then you have to know it is C5a....
And so on , and so on and so on. Do you see how
EVERYTHING IS INTERCONNECTED AND WHY SIMPLE RECALLS DON'T WORK? If you take the
time, you can see into the NBME's mind and KNOW it all.
Q. So after reviewing, which complements are part of the
membrane attack complex (MAC)?
And, which complement do both pathways meet at?
(two questions of candy bars
A. C5b thru C9 = MAC
And both classic and alternative pathways meet at C5.
Tattoo the above facts into your brain!
Q. CANNOT BELIEVE IT, I ALMOST FAINTED BECAUSE I ALMOST
FORGOT TO TELL YOU THAT THE COMPLEMENT SYSTEM MUST BE REGULATED OR..
The system can overreact and destroy our good cells.
So..I told you C1 is an esterase right (no, I didn't, and there is a another
possible question!). OK, what factor blocks C1 and what happens if you lack C1?
Next, give me another case: Human cells have DAF or
(decay accelerating factor) to protect themselves. What factor does DAF work on?
What diseases arise if the above controls are LOST?
A. Your body has C1 inhibitor (rather unoriginal name)
to block C1.
Your DAF blocks C3b thus protecting your cells.
If C1 inhibitor and/or DAF is gone, your capillaries
will weak, you will get PNH (hemoglobin in your urine at night) OUCH!
Q. SPEAKING OF IMMUNO, YOU WILLL SEEEEE..
Interferons, becuase they are DRUG and part your body's
defense..
They are GLYCOPROTEINS (Everything I sort of BOLD is an
unforgettable word/point), and they protect healthy cells and virus
replicaition. KNOW there are alpha, beta, and gamma interferons:
alpha (fr. WBCs) interferons and beta (fr. fibroblasts)
are triggered by viruses and target viral mRNA.
1)NOW, GAMMA interferon are the third interferon, they
are produced by?
2) They active what process?
3) Gammas rev up what cells?
A. 1) Gammas are made by activated CD4 and CD8 T-cells.
2) THEY rev up PHAGOCYTOSIS.
3) This by those NK, macrophages, neutrophils and revs
up MHC I and II antigen presentation, which is like a plate of food that
attracts the phyagocytes. Finally, Gammas revs up B-cell antibody production.
valuemd.com
Q. ok, BIG POINT:
You have to understand the basics of activation. IF say
an antigen presenting cell (Dendrocyte, B-cell, Macrophage) [T-CELL ARE NOT
ANTIGEN PRESENTING!!!!], binds an antigen (virus), then CROSSLINKING occurs and
the cell gobbles up antigen and then PRESENTS IT ON THE SURFACE. A lot of you
know that, but THEN you must follow the storyline. And lovely young helper T
cell comes along and attaches or holds hands with the antigen presenting cell.
THEN, the T-helper cell "blushes red" and is so happy she throws out IL-2, IL-4,
and IL-5 that stimulate both B-cells and T-cells (IL-2 here). Some of the
activated B-cells from what kind of cells in the secondary response and what is
the most common surface Ig?
A. A few activated B-cells turn INTO MEMORY CELLS
(BEFORE, THEY WERE PLASMA CELLS), and they usually have IgG on top of them for
rapid response to reexposure.
IMMUNO IS REALLY TOUGH SO I HOPE YOU GUYS DON'T GET TOO
MANY QUESTIONS, BUT THE GOOD THING IS THAT THE NBME IMMUNO QUESTIONS OFTEN RANGE
FROM SUPER BASIC TO SUPER DUPER HARD.
GET THE EASY ONES RIGHT!
Q. cannot break the copyright rules, but there was a
question where the concept I can describe so you won't miss it.
IT is very very basic. They, many of you will get
variations of the same concept where you are given a pic. of that infamous Y
shaped Antibody and there are like a thousand questions about same concept.
Like, let me make up something original but applicable:
1) Is the Constant Light Chain region part of Fab
fragment or Fc fragment?
2) Is the CARBOXY terminal part of the constant or
variable region?
(There are ways with arrows to address this, so know
this)
3) What kind of bonds KEY PT, holds the chains together?
A. 1) Fab fragment
2) Heavy chain
3) Disulfide bonds, know which drugs can cleave
these....
GET the concepts
Q. 1) Give that famous Y antibody with arrows, where
does complement bind (Fc or Fab portion?)?
2) POINT to where CMV virus attaches.
3) Where can I find sugar side chains?
A. 1) Fc portion
2) Both L and H hypervariable regions
3) Fc fragment
Q. KNOW that LIGHT chains only lie in the AMINO TERMINAL
and are part of only the Fab fragment!!!!
Q. SUPER DUPERS:
MOst know that babies have IgG from Mom until 6 months
of age (a key pt like ..uh on a graph), can the baby defend itself against
syphilis at one month?
A.
YES, the feus can make IgM.
Q. 1)Whoa! you see an EM of an Ig that is a dimer. Where
in the body is it found and MOA? Does this fix complement?
2) Whoa! you see an EM of an Ig pentamer! What's so
special here?
3) The only Ig to cross the placenta, this dude is most
dominant in 2nd response about is what percent of total Ig?
4) You see an Ig in a baby's cord blood that the
IMMUNOLOGIST tells you is rather unknown what it does? what is it?
5) You see an EM of an Ig that binds a basophil on a
smear! Does this one fix complement? What else is special here?
A. 1) IgA (also can be monomer). See in saliva, tears,
gut, vagina, etc.
2) IgM is the PRIMARY response, most efficient in
aggultination
3) IgG of course - 75% of all
4) IgD
5) IgE, anaphylactic allergies DOES NOT FIX COMPLEMENT.
[for example you may be asked a patient has a hookworm
infection, which Ig is reved up? = IgE, right, remember?]
Q. OHHHH! Superkey!
T/F, Delayed hypersenitivity is a function of antibodes,
right, huh?
A. NOOOOO.
Type IV Delayed is CD4 T-cells! Common mistake!
Q. Great question:
A patient of yours tries a new cosmetic cream and then
presents in a couple of days with eczema. Which HYPERSENSITIVITY (I, II, III,
IV) is this?
KEY POINT, I won't bug you with all the possibilities,
but you must MASTER ALL THE FOUR HYPERSENSITIVIES AND THE POSSIBLE OFFENDING
AGENTS, THEY WILL BE ASKED!
A. This is not not not Type I (common mistake), but Type
IV. Often is you see stuff like a case of neomycin or soaps, and then a reaction
a day after after reapplication, you are looking at TYPE IV. Review al of
them...
like Glomerulonephritis is TYPE III (NOT TYPE II)
like Goodpasture's is TYPE II (NOT TYPE III)
(see look above, some student just think kidney
stuff-Type III, and they get stuff wrong!)
like the complement system is activated in TYPE III
like Coombs Test is associated with TYPE II
Q. I heard of 500 questions/ways to address the concept
that:
You know T-cells have CD3,4,and 8 on their surface.
Which CD is a suppressor function?
A. YEAH, CD8 has both cytotoxi and suppressor functions
they suppress B cells and cellular immunity.
Q. Quiz to know if you are reviewing wisely:
1) What cells are involved in AUTOIMMUNITY?
2) Graft rejection?
A. 1) B cells
2) T cells
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
[I CONFESS I CANNOT COVER ALL OF IMMUNO, IT IS SO
CONFUSING AND ENDLESS, BUT I JUST PRESENTED SOME OF THE HIGHEST YIELDING STUFF
Q. There exists out there a diagram of the difference
between:
TH1 and TH2 cells. YOU HAVE TO KNOW THE DIFFERENCES!
1) Which ILs are made by what?
2) IL-12 induces TH1 or TH2
(you have to read these stuff also on your own)
A. Th1 revs up CD8 (T-cells) and macrophages (APCs)
Th2 revs up B-cells via IL-4 and IL-5
Gosh these are ultra high yield but so much I think I
need to SCREEEAAMMM!
TOMMYK POSTS (201-231)
Q. SUPER HYers that have been rounded up in the Wild
West of Usual Suspects in IMMUNO Questions in the MIND OF THE MATRIX NBME!
1) A pt comes in and you see anti-centromere antibodies?
Dx?
A. CREST syndrome
Q. most know Anti ds DNA and anti ANA is Systemic LUPUS,
but give me the one if Drugs induce lupus?
A. anti-histone!!
Think HIS-STONE of COCAINE (drug), so assoc. histone
with drugs
Q. Pt comes in and has skin lesions that are peeling
off, ouch!...pathology lab reports which autoantibody
A. likely pemphigus and anti-epithelial antibody
Q. As I am doing, there are a WHOLE SLEW of
autoantibodies that you must know that I cannot cover all, know them cold
because they are easy points if they are highly specific.
Quickie, can you reverse chronic kidney rejection with
cyclosporin A?
A. NOOOOOOO,
but you can suppress ACUTE REJECTION!
Q. BIGGIE JUICE?
A transplant patient comes to you and cries because
after a year her kidney transplant makes her eyes yellow and her tummy is FAT
(hepatosplenomegaly). What is the MOA? Think.
A. This one was a little tricky,
NOT so much chronic rejection symptoms, but think
Graft vs. host disease!! All the organs are systemically
knocked out!
Q. You see a slide with large cells and hyaline bodies
in the last female kidney transplant patient. What is the virus (HINT) and the
Dx?
A. This is good HYer. She is immunocompromised from
cyclosporine, so she is at risk for CMV, which you see. Give gangclovir (Not
acyclovir), if she is resistant still, give foscarnet.
Q. This connects with my previous concept:
KEY!
Why did you give her Ganciclovir and not Acyclovir? And
if she was resistant, why did Foscarnet work????
A. ganciclovir IS phosphorlyated like acyclovir, but it
LOVES CMV DNA polymerase (MOA). Foscarnet worked because it did not need viral
kinase activation!!!!! (resistence issue)
WOW!
Q. WE JUST TALKED ABOUT acyclovir, gancyclovi,
foscarnet.
Which body organ is at risk of toxicity?
A. all are nephrotoxic and ganciclovir can cause
pancytopenia!
Q
We just mentioned CMV right?
Your door opens. The patient reports decreased visual
acuity, floaters, and loss of visual fields on one side. Ophthalmologic
examination shows yellow-white areas with perivascular exudates. Hemorrhage is
present and is often referred to as having a “cottage cheese and ketchup”
appearance. Lesions may appear at the periphery of the fundus, but they progress
centrally.
OKOKOK, this is CMV, I need you to know CMV retinitis is
common in HIV, but tell me:
The VIRAL FAMILY, and DNA Structure/Envelope
A. CMV is very tested. (As an aside, it is horribly
affecting to unborn babies), IT along with VAV and EBV and HHV are all HERPES
viruses with DS (Double strand), linear envelope
valuemd.com
Q. But wait there is MORE,
our poor CMV patient has HIV, right? Concept is what is
the structure of HIV?????????? be specific.
A. This RNA virus has an envelope, SS+, square, and is
one of the only two RNA viruses to replicate in the NUCLEUS!
Q. A child comes in with pink eye and half his
kindergarten has symptoms of this common virus? Give me structure?
A . Adenovirus is DS linear wihout an envelope! You have
to know the details because one of the answer choices will have DS linear with
envelope. Everyone limits to two choices. Don't be trapped!
Q. NOW, you see a mom with a child coming in with a rash
on his cheeks and is tired a lot. What virus is this for his classic combo? And
give structure!!!!!!!!!
A. Parvovirus B19, 5th disease, shown a picture, no
envelope, SS linear
(This is the only DNA virus that is SS, YOU HAVE TO
START LUMPING IN EVERY WAY YOU CAN UNLESS YOU ARE GOD, AND ONLY GOD DOES NOT
HAVE TO LUMP)
Another LUMP,
Hi (Hepatitis/Herpes) Poxy (Poxvirus) Lady, holding an
ENVELOPE with a Valentine's Day card!
MNEMONIC for the 3 DNA viruses with an envelope, the
others DON'T have an envelope.
OH! INCIDENTALLY, TODAY IS VALENTINE'S DAY. SO HAPPY
VALENTINE'S DAY!
Q. Whew, I am getting tired, but>>>
A child comes in with his face looking like chickenpox
but serology tells you it is Measles. Also his physical reports a grayish spot
on the inside of his mouth before the measles started (Koplick spots). Give me
the structure?
A. This is a NEGATIVE sense, SS, linear, NONSEGMENTED.
UGLY, UGLY. This structure stuff IS ALL OVER THE NBME's
MIND, but it is so hard to master. Click on my posts over and over while
covering the bottom part with the answer until you make NO mistakes...
I am devoting a lot of effort, so DON'T LET ME DOWN,
LET'S WIN!
Q. THEY may give an EM with the previously mentioned
MEASLES VIRUS, what does the capsid look like and what are the 3 other viruses
in this family?
A. The capsule is a HELIX, and RSV, Croup virus, and
Mumps are all part of this Paramyxovirus family.
MAN, this is a PAIN! Right?
Q. HERE IS A CLASSIC, LIKE HAPPY DAYS AND THE FONZ! OR
Laverne and Shirley...
You see a female young sexually active patient with
genital warts you biopsy to be HPV. (SO MANY SECONARIES, like cervical
cancer/cone biopsy needed/CIN grading/colposcopy) EVERYTHING IS CONCEPTS!
Sorry but to the case...the HPV is what structure and
family?
A.
This is a Papovavirus, with NO envelope, DS and circle
shaped! Another secondary is back to your HIV patient, he can get another virus
from his HIV that slams his brain: JC virus...just mentioning...
Are you guys getting these? These are so boring and rote
memory....
Q.
Oh dear, you will see a million of these:
A kid comes in with the common cold and serology says it
is not adenovirus. What is the structure?
Q. OH BOY,
This ain't OLD YELLER, but a raccoon that bit one of
your peds kids and his serology is Rabies!! Quickly, structure! But first you
gotta be quick and give the kid Imogam/Human Rabies Immunoglobulin.
A. this neg stranded virus is SS and HELICAL
Q. Emergency!
Another peds patients came from Africa with serology of
EBOLA! Structure! Please
A. Ebola is neg. sense, enveloped, linear, helical (JUST
LIKE RABIES)! Your poor patient must be isolated because this virus cause
vascular hemorrhages!!!!! And NO DRUG (proven) at least is avaliable! AHHH!
Q.
BIG ONE!
A case of a peds kid comes with a 4 day rash over his
trunk (you need serology so I tell you it is Rubella). What is this Togavirus's
structure?
A. Here is a positive sense, SS, linear, square virus,
with an envelope. You will get a couple of exactly these concept questions which
will make you have diarrhea because it is so hard. Think of mnemonics....
Q. YOU HAVE TO KNOW THIS ONE, because it is EVERYWHERE!
Case: You have a peds kid with serious diarrhea from a
virus. What is this everywhere virus and the structure???????
A. THIS IS ROTAVIRUS, a mainstay in peds offices.
IT IS THE ONLY RNA VIRUS THAT IS DOUBLE STRANDED!
And it is linear, square, with an envelope.
THIS STUFF IS REALLY HARD, I THINK I AM GETTING DIARRHEA
MYSELF!!!!!! KEEP CLICKING MY POSTS TO QUIZ YOURSELF, this part I think is the
hardest because the answer choices will be so hairline similar.
Q. CLASSIC GRANDDADDY QUESTION !
Case: A couple of your newlywed patients go on a cruise
ship. Instead of a good time, they come back to your clinic with the worst
honeymoon ever!! All everyone on the ship did was diarrhea!!!!!!!!!! (You are
walking up a ladder and you are hearing something
spatter..diarrhea..uh..uh...you are walking down the hall and you are hearing
something fall diarrhea...)
What is this classic bug and the structure?
A. This is the FAMOUS NORWALK Virus. IT is SS positive
sense linear and square with NO envelope.
I am hoping that for these last series of posts about
viral structure I see that there are thousands of views becuase that is what it
WILL take to master them and pass them.
IT IS SO BORING RIGHT? AND SO HARD. I mean, gosh!
Oh, a quick personal mnemonic... PCR we know stands for
that DNA amp test. And so remember PCR stands for PICORNA, Calci, Reo viruses.
If you recall the families, then PCR RNA viruses are the only ones without an
envelope.
YOU HAVE TO REPEAT THESE A THOUSAND TIMES, there is no
other way. All the people I spoke to said this was the hardest thing on their
USMLE because they could get the bug right, but they were like pos or neg sense,
whatever?
© 2003, 2004 ValueMD Incorporated. All rights reserved.
Q. HERE IS A MEGA HY and a lumper:
Two patients of yours walk in with antibody specific for
Hepatitis A and E
Another comes in with a tattoo and she has Hep C
A third jumps in your office crying bc she has Hep B
Give me the structures (NBME WILL ASK YOU THIS)
A. Good, we can LUMP Hepatitis A and E wtih SS pos.
sense, linear, square and no envelope. RNA
However, Hep C is also SS pos. sense, linear, square,
but ENVELOPED!RNA
NOW Hep B is a DNA virus curved on EM WITH an ENVELOPE!
You feel you want to avoid this, but the secondaries
will address these..
valuemd.com
Q.
Case: A rocker teen comes in with serology positive for
COXSACKIE B, AN NBME FAVORITE.
Two questions:
What disease and sorry sorry to ask, but give me
structure!!!
A. This bug is part of Picronaviruses and is like Hep A
and E in that it is
!) positive sense, RNA, SS, and square.
2) The disease is MYOCARDITIS
I think this is all so hard you need a mnemonic so let
me give you all one and you make one up yourself or you are dead b/c it is so
much mumbo jumbo: RNA viruses first:
For the POS. SENSE, I think of the viruses that are not
SO BAD because they are:
Rhinovirus, Coxackie, Hepatitis A, E, C, Rubella
(non-congenital one), Coronavirus (common cold), and HIV....(HIV I think is now
not SO BAD because of the new drugs)
(The NEG SENSE are all the other RNA viruses)...(for
example Rabies and Ebola are neg. sense because it is so negative/bad to get
them)
For getting straight the strands, know ALL OF THE RNA
viruses are SS except for Reo/Rotavirus which are DS.
For the Capsule, aside from Corona (common cold) which
is not THAT DEADLY, THE DEADLY VIRUSES ARE HELIX shaped (e.g. INfluenza on an
older man, untreated mumps, rabies, ebola, LCV, Hantavirus (hemorrhagic fever)
The others are all square...
NOW, the DNA viruses you identify because they are
HAPPY!
(H) Hepatitis B
(A) Adenovirus
(P) Poxvirus
(P) Papovavirus
(P) Parvovirus B19
Y
All the DNA viruses are DS except Parvo
You send an ENVELOPE with an p OX to HP (Hewlet Packard
Co) [The p OX stands for poxvirus and the HP stands for Hepatitis B and Herpes]
These mnemonics work for me, but you NEED some otherwise
it is hopeless.... Try to be creative!
I think this is all so hard you need a mnemonic so let
me give you all one and you make one up yourself or you are dead b/c it is so
much mumbo jumbo: RNA viruses first:
For the POS. SENSE, I think of the viruses that are not
SO BAD because they are:
Rhinovirus, Coxackie, Hepatitis A, E, C, Rubella
(non-congenital one), Coronavirus (common cold), and HIV....(HIV I think is now
not SO BAD because of the new drugs)
(The NEG SENSE are all the other RNA viruses)...(for
example Rabies and Ebola are neg. sense because it is so negative/bad to get
them)
For getting straight the strands, know ALL OF THE RNA
viruses are SS except for Reo/Rotavirus which are DS.
For the Capsule, aside from Corona (common cold) which
is not THAT DEADLY, THE DEADLY VIRUSES ARE HELIX shaped (e.g. INfluenza on an
older man, untreated mumps, rabies, ebola, LCV, Hantavirus (hemorrhagic fever)
The others are all square...
NOW, the DNA viruses you identify because they are
HAPPY!
(H) Hepatitis B
(A) Adenovirus
(P) Poxvirus
(P) Papovavirus
(P) Parvovirus B19
Y
All the DNA viruses are DS except Parvo
You send an ENVELOPE with an p OX to HP (Hewlet Packard
Co) [The p OX stands for poxvirus and the HP stands for Hepatitis B and Herpes]
These mnemonics work for me, but you NEED some otherwise
it is hopeless.... Try to be creative!
Q. THE WAY NBME'S VERSIONS OF THE TEST ARE THAT SOMEONE
IN CHINA WILL BE ASK TOXOPLASMA, SOMEONE IN USA WILL BE ASKED TRICHOMONAS,
SOMEONE IN INDIA WILL BE ASKED PLASMODIUM, ETC. SO THE CONCEPT IS THAT TO ANSWER
CONCEPT #47 (E.G.), YOU HAVE TO MASTER SAY 50 FACTS TO GET THAT ONE QUESTION
RIGHT BECAUSE YOU DON'T KNOW WHICH VERSION YOU WILL GET... SO BACK TO THE
CONCEPTS:
You KNOW Trichomonas is SO COMMON in clinics and you
know the drug?
A. metronidazole
Q. You have a patient with a history of travel to
Mexico. Did I ask this? I dunno..
He has bloody diarrhea, that should be enough you know
the bug to treat him with what drug? AND, the next day he comes back after a
cocktail party and said he threw up and had a red rash on his face? What
happened? VERY VERY TESTED AND KEY POINT THAT I THINK IT IS GOOD THAT THE NBME
TESTS THIS.
A. This is classic dysentery from Entamoeba
histolytica/amebiasis. He may present with abd pain like pancreatitis.
The IMPORTANT drug reaction with METRONIDAZOLE (which is
trade name Flagyl) is a Disulfiram like reaction with alcohol!!!!!!!!
Q. This WILL BE ON YOUR TEST (well if not YOU then the
GUY NEXT TO YOU):
A patient with travel to India (a great country with an
exploding GDP), comes back with anemia and he tells you he was bitten by a
mosquito. What bug and drug? Be specific!!!!!
A.
Plasmodium malariae, give him Chloroquine and or
Quinine.
KNOW a side effect of Chloroquine is visual changes and
tell him not to take with Mg antacids because it delays aborption and people
with Plasmodium may take an antacid due to tummy ache
Q. NOW, another traveler, this time from Africa, comes
with bitten by a mosquito and you see the typical malarial signs:
FEVER, VOMITING, MILD SEIZURES, ANEMIA, ENLARGED
SPLEEN/LIVER
Which Palsmodium does he have most likely?
A. NBME wants you to know that Plasmodium falciparum is
more common in Africa while in the previous case Plasmodium Malariae is more
common in India. There is a prodrome and time lag since:
The bite of an infected mosquito introduces asexual
forms of the parasite, called sporozoites, into the bloodstream. Sporozoites
enter the hepatocytes and form schizonts, which are also asexual forms.
Schizonts undergo a process of maturation and multiplication known as
preerythrocytic or hepatic schizogony. In Plasmodium vivax and Plasmodium ovale
infection, some sporozoites convert to dormant forms called hypnozoites, which
can cause disease after months or years. Very important to know the above
mouthful of words I wrote!
OH, you treat Falciparum and Malariae the same way,
Chloroquine
Q. We MUST COMPARE AND CONTRAST FOR THE INFO TO
STICK...so
You get a traveler from India with that mosquito bite
and the aforementioned MALARIAL symptoms, the travel and symptoms will NAIL the
diagnosis for you. But this time she complains the malarial symptoms recur and
relapse over the past two years. What two bugs do this and what drug must you
add to the regimen and WHY?
A. The forms Plasmodium Vivax and Ovale are cyclical and
have dormant stages called hypnozoites in the liver. So, you must ADD
PRIMAQUINE to the regimen.
KNOW THE MOSQUITO'S NAME is Anopheles. Even mosquitos
like the sound of their own NAME!
Q. You are shown a sllide of the horrible Pneumocystis
carinii in an HIV patient.
1) What is the lung X-ray classic finding?
2) Method of infection
3) Drug of choice?
4) When should prophylaxis have BEEN STARTED? KEY POINT,
give T-cell count (hint )
A. 1) Perihilar interstitial infiltrates
2) Inhalation of cysts
3) Trimethoprim-sulfamethoxazole (Bactrim, Septra,
Co-trimoxazole)
4) Probably CD4 count less than 200 and not on PCP
prophylaxis.
Tommyk posts 232-300
Q. We were on the topic of ... hmm... let me first tell
us that the NBME needs you to understand the RECEPTOR AND 2nd MESSENGERS.
HERE is ONE that NBME loves:
The Ryandoine receptor
What are they and what ion triggers them
A. The Ryanodine receptors acts as sentinels for Ca in
the sarcoplasmic reticulum, so remember the receptor type is an Ca channel.
Q. NOW, you KNOW the NBME begs you to study LUNG TISSUE.
So, if I present a clinical case and a histo slide of
the LUNG with arrows of course,
can you point exactly to a
1) Endothelial cell
2) Type I pneumoncytes
3) Type II pnuemoncytes
4) Clara cells?
5) Dust Cells? (What are Dust Cells by the way?)
A. Sorry, but you have to grab your histo atlas, but do
so NOW!
KNOW Dust Cells DC are macrophages
Q. Quick review:
HERE IS AN EMPEROR OF NBME CONCEPTS; YOU GOTTA LOVE IT!
I present a case of a patient named Mr. Wiggles who
comes to you after received Isoniazid tx for TB. He is acting goofy, has
diarrhea, and his skin is inflammed.
1) The secondary/tertiary is What is the function of
compound missing?
2) What is the compound missing?
3) What AA does this come from?
4) What dx does he have?
THIS IS 100% NBME'S THOUGHT PROCESS...
A. 1) Redox Rxs (recall NAD, NADH)
2) Niacin (vit B3)
3) Tryptophan
4) Pellagra
There are like 20 questions from the above concept.
Think hard, and USE THE FORCE, LUKE..or LEA if you female.
Q. While on vitamins,
LOOK, it is common knowledge that Vit A def causes eye
problems, and excess causes hair loss, and muscle pain, AND you have to be
careful to give RETIN-A to your pregnant patients (This will be in NBME's mind),
but
LOOK NOW AT Vit B1 (thiamine). You will face this from
alcoholics:
1) What heart disease is he going to get?
2) What rxn is this a cofactor for (give 2)?
3) 2 main def. diseases please?
A. Again, at least 20 questions from this ONE concept:
1) dILATED Cardiomyopathy
2) This is a cofactor of OXIDATIVE DECARBOXYLATION of
pyruvate and it is a cofactor for TRANSKETOLASE in the HMP SHUNT.
3) of course.... Wernick-Korsakoff syndrome and Beriberi
(I ENCOUNTERED THIS A HUNDRED TIMES IN MY MEDICINE
ROTATION, OBVIOUS THE NBME WANTS ME TO MAKE SURE YOU KNOW IT).
of course, give the alcoholic thiamine before sending
him to AA. Therapy
Q. OHMIGOSH!
A patient of yours named WilliWonka comes in with
cracked lips and difficulty seeing, itcy rash, and the corners of his mouth are
dry. What vitamin? What Reaction? What product?
A.
This is tricky because it looks like Vit A def.
But Vit A, for for muscle and hair stuff...
NOW, we are talking Riboflavin (B2)
2) Oxidation and Reduction
3) FAD
Q. In case they ask, which they WILL, they will ask in a
way like which vit is toxic if overdosed and you will see a bunch of vitamins
and you have to pick the FAT SOLUBLE one. Soo.
On your college campus, unfortunately, the girls from
sorority DEKA are FAT. (Vit D, E, K, A)
ALL THE REST ARE WATER SOLUBLE.
BUT THE NBME TOLD ME YOU SHOULD KNOW THAT:
1) What disease can result in DEKA deficiency?
A. Cystic Fibrosis, and Celiac Sprue are two examples.
KNOW ONE THING I FORGOT ABOUT VIT B12 which is NOT a
member of the DEKA sorority. IT is water solube but is NOT WASHED OUT like the
other water solube vitamins because the liver has a LONG, YEARS LONG, storage of
it.
AND OF COURSE, THE DEKA LADIES ARE JUST AS PRETTY AS THE
OTHERS!
Q. OKO OK OK, This vitamin def. looks painfully like Vit
A def,
so NBME has to ask you this:
If given a PIC of the Biochem. cycles. POINT TO EXACTLY
what reaction and what enzyme is def. if you lack VITAMIN B5?
ONE OF MY STUDENTS GOT A WHOLE BLOCK ON VIT. so he
says...
A.. Acyl CoA rxns are affected, Pantothenate is factor
involved in fatty acid synthase (right after malonyl CoA)!
Q. We addressed this before, but you bought a
multivitamin that is defective in Vit B6 and suppose your diet lack this. What
vital rxn is lost?
A.. This vitamin, which can be def. with girls taking
oral birth control, is used in transamination rxns involving AST and ALT in the
liver e.g.
Q.. SOOOOOOOOOOOOOOOO Classic like a Rolls Royce Silver
Spur:
Case: A patient of yours is an alcoholic who only eats
RAW EGGS. He presents with inflammation of his small intestine.
1) What CLASSIC reactions are knocked out silly?
2) What vitamin is his missing?
A.. 1) ALL reactions involving CARBOXYLATIONS (CAREFUL
HINT HINT, I SAID CARBOXYLATIONS NOT DE-CARBOXYLATIONS, A COMMON MISTAKE) are
wiped out. Look them up.... (e.g. methylmalonyl CoA, Oxaloacetate)
2) Lovely Biotin is missing.
ESSENTIAL POINT:
ON PREVIOUS CONCEPT, KNOW BIOTIN DEF. IS OFTEN ASKED BUT
NOT THAT COMMON. IT IS ALSO SEEN IN PATIENTS WITH
TPN (TOTAL PARENTAL NUTRITION)
AND LONG TERM ADMINISTRATION OF ANTIBIOTICS SINCE
INTESTINAL FLORA MAKE BIOTIN AS WELL AS YOUR EATING IT IN FOOD.
REMEMBER, CONCEPTS CONCEPTS, THIS QUESTION ARE NOT
SHORTCUTS. I HEARD A RUMOR THAT NBME HAS MILLIONS OF QUESTIONS!!!!! COULD THAT
BE TRUE
Q. dunno why, but ALL MY STUDENTS SAY THAT THEY MIX UP
FOLIC ACID AND VIT B12, THINKING THEY ARE THE SAME!
For folic acid (1000 questions here like you have to
give to pregnant females, def. causes neural tube defects, most common vit def
in US, etc. etc. etc. smear is macrocytic anemia, etc etc.)
Here, what two MOA is FOLIC aCid crucial in?
A..
Folic acid is crucial IN:
ONE-CARBON TRANSFER REACTIONS!!!!
THEY are needed for METHYLATION REACTIONS!!!!!
KNOW THAT FOLIC ACID IS NOT STORED IN THE BODY LONG SO
EAT YOUR SPINACH LIKE POPEYE! While Bit 12 is stored for YEARS!
KNOW THAT PABA = FOLIC ACID PRE IN BACTERIA
KNOW DAPSONE AND SULFAMIDES RELATED TO FOLIC ACID
KNOW FOLIC ACID IS CRUCIAL FOR DNA AND RNA SYN VIA THF.
THIS CONCEPT HAS 122 POSSIBLE QUESTIONS (i MADE UP THE
NUMBER 122, BUT IT IS PROBABLY ACCURATE)
Q.. QUICK OFF THE SUBJECT:
valuemd.com
What is the resistence mech of ACYCLOVIR?
A.. Resistant is the mutation of viral thymidine kinase.
Think of the mechanism. LIKE tell me what is the resistence of a quinolone. YOU
CAN FIGURE THE RESISTence questions IF you know the mechanism !!!!!!
YOU CAN DO IT!
Q. Let's finish NBME's wanting you to understand
treatment of protozoa.
Again I feel stupid now, but the NBME wants you to know
Chagas disease. It is so important because the infection rate in South America
is SO prevalent. I feel stupid saying this but YEAH it IS NBME "content" but so
is what I talked about before like rhinovirus and myocardial infarction. I again
just heard someone tell me, "Why are you helping them, YOU did not get the same
help..." I am almost crying because this is against what I believe is the spirit
of humanity and of love and education. Whew...you WILL be given a case of a man
who traveled to someplace like Brazil and he has malaise, arrhythmias, and
mentions he was bitten by a fly. You see these spotty flagellates under a
peripheral smear and suspect Trypanosoma cruzi. What drug will you pick up?
A. The two drugs of choices are:
Benznidazole and Nifurtimox
Q. OK in your peds clinic a patient 17, named MickyMouse
walks in with his mom. She says they came back from abroad Soviet Union and the
kid has very smelly diarrhea that won't stop. His stomach is distended and you
take a stool sample. YOU SEE UNDER THE MICROSCOPE, cysts. Your attending comes
in and hints that this is the MOST common pathogen/parasite to hit children. You
give him the right medicine and know he is going to a wedding where beer is the
drink of choice. What is the drug and the side effect with beer?
A. YOU given him Flagyl (Metronidazole) and you warn him
about a disulfiram like reaction.
OK OK another parasite:
A friend of yours named Willy Wonka just arrived from a
meeting in West Africa where he was bitten by a fly. He has a mild fever and
lymphadenopathy and a chancre on the bite spot.
Need a hint:
The fly is a Tsetse....
What is the disease and the med?
Q.. Ah, another of your patients is only 2 yrs old with
HIV positive. He lives in San Diego in a place where his mom brings him to a day
care. After removal from the day care, the child has voluminous diarrhea, up to
15 liters a day, and you see cyst in the water sample. What is the bug and drug?
A. This one is key because it is so common in the US.
IT is Giardiasis. The ONLY treatment here is Bismuth and
"Kaopectate".
Don't pick Metro as the drug. You will be wrong!
tommyc
all my books say metro is drug of coice against giardia
i dont know the drug you mentioned
can you describe its mao,please?
Sorry, but I made my first REAL BOO BOO error. Yes give
Metro for Giardia.....I was thinking of Cryptosporidum.
Giardia and Cryptosporidum can present so similar on
your test so the USMLE has to provide a PICTURE of Giardia TRophozoites OR
For Cryptosporidiosis they have to give an ACID fast
slide with cysts. IF you quickly look at BOTH ON a Google search with a visual,
you will never mistake them. Thanks..
One of the keys for my passing the test that helped was
that I RIPPED through the tutorial and saved 15 minutes.
NOW, you cannot USE MORE THAN an hour for each block,
BUT, you can ACCUMULATE break and lunch time which is 45 minutes. THUS, if you
can pace yourself fast, you can earn more points I think.
Because a lot of the info is FAST recall, I did NOT take
lunch and RIPPED PAST THE TUTORIAL. So I took these longer breaks where I SUPER
CRAMMED THE HY STUFF, like pharmacology side effects.
That helped a lot because some of my friends did not do
this and they only had enough time for quickie bathroom break and spent lunch
talking it with friends.
But since I used it for CRAMMING, I COULD PROMISE YOU
that it worked because some of the facts WERE IN MY short term 5 minute memory.
Then I would run back into the testing room and go through the 50 questions
really fast for what I could remember quickly off the top of my head so to
speak, then I went back to the "THINKING" problems.
It really worked for me. As I said before, think of what
works for YOU. The day before the test, I SLEPT AT 8:00 pm (I ADMIT I TOOK SOME
OVER THE COUNTER SLEEPING PILLS AND QUIET MUSIC), disconnected the phone and
awoke at 2:00 am. Then I studied like mad because that worked for me since so
much of the test is quick recall and your memory fades fast.
BUT THIS IS WHAT WORKED FOR ME. it may be different for
you. Again, you have to eat a BIG breakfast because my strategy is to skip
lunch. Also, I had a friend drive me to the testing center so I was studying
like mad alll the way til the second my computer turned on. I promise that it
helped me in my case.
Plus, when I signed out and in, I signed out my
signature REALLY MESSY AND FAST to save seconds...some of my friends took like a
MINUTE to sign out.
I maximized everything.....you should too.
And as I mentioned bring TYLENOL or ASPIRIN because it
saved me after the 4th block!!!!!!!
And bring a sweater just in case!!! And hard Candy in
your pocket.
There is a study that says that caffeine helps your
brain...but if you take cafeeine pills you may have to urinate and you can't
leave within a block.
ONE OF MY STUDENTS KNEW THIS AND CONFESSED TO ME THAT HE
ACTUALLY WORE A DIAPER, A DIAPER!!! And he urinated in it so he could save
breaktime for max. cramming.. I am not sure if you want to go that far, but this
test is a LIFE event, so think of everything to gain advantage!
A few of my students, actually just a couple, got in
trouble...
here is why.
Some centers are run like a military zone thru company
Prometric. ONE guy put his hands in his pants. That is all, and his test was
"FLAGGED" and his score delayed. Another took off her SWEATER during a block and
HER TEST WAS FLAGGED! Both cases were dropped, but it delayed your score. SO,
just be careful my brothers and sisters. LOVE, tommyk
ONCE AGAIN, on the PARASITES, the NBME WANTS ME TO TELL
YOU THAT MOST OF THE QUESTION HERE ARE TREATMENT, the BACTERIAL QUESTIONS ARE A
LITTLE HARDER BECAUSE THEY ADDRESS RESISTANCE ETC. BUT YOU NEED MNEMONICS: SO
LET ME OFFER A COUPLE AS AN EXAMPLE AND THEN YOU CAN MAKE YOUR OWN, BUT YOU HAVE
TO MAKE YOUR OWN!
When we think of the PROTOZOANS,
For Trypanosomiasis (African Sleeping) I think of the
evil Apartheid of Africa (Another great EXPLODING GDP nation) and a boy who
"TRIPPED on a White Soldier's PAN, and said "Sorry Sir") [Thus you equate
Trip-PAN-osma with "Sir"amin]
For Pneumocystis carinii, I know the abbreviation is
PCP, and the tx. is TMP so I think of the idea of acronyms and say PCP-TMP,
PCP-TMP PCP-TMP and then it sticks.
For Plasmodiums (Malaria which means "bad" "air") I
think that Ovale and Vivax are the 2nd half of the English alphabet and so is
the tx PRIMAQUINE b/c it starts with a P. Malariae and Falciparum are the first
half of the alphabet (M and F) and the tx is Chloroquine, which has a C which is
also the first half of the alphabet.
For Trichomonas, I had my OB/GYN rotation already and we
used it and the so famous acronym is GET on the metrobus, so G-Giarida,
E-Entamoeba, T-Trichomonas.
For Toxoplasma, I think of TOXic SULFUR gas, so I equate
Toxoplasma with Sulfa drugs.
Finally, with Chagas Disease (T. Cruzi), I recall
reading about the genius of Dr. Chagas and how he isolated the protozoa, it is a
great story and I this he must have been so NICE and smart, so I equate Chagas
with NIfurtimox. (The NI is NICE and the NI is NIfurtimox)
This is cheezy, and I think it is a good example because
you need to make some up or you will forget!!!
MY PERSONAL USMLE SCORE would have been so much higher
if I was better prepared. I did not know what to expect so I sort of lost track
of time and had to bubble in answers at random because:
YOU HAVE TO PERSONALLY KEEP TRACK OF YOUR TIME AND
BREAKS
THEY GIVE YOU A PAD TO WRITE ON, USE IT! AND WEAR THE
EAR PLUGS THEY GIVE YOU.
THE ADVICE I GAVE BEFORE ABOUT THE CRAMMING IN BETWEEN
SAVED ME AND GAVE ME A DECENT SCORE BUT NOT THE SCORE I COULD HAVE EARNED.
THAT IS WHY I AM DOING WHAT I AM DOING NOW.
Before, as I said, when the NBME asks about the parasite
HELMINTHS, you will mostly be asked the tx. Also, you usually will be given TWO
BIG HINTS like the EOSINOPHILIA and a slide of the bug. The HELMINTHS are
notably distinctive b/c like the hookworm looks like it IS HOOKING its fangs of
teeth into Small intestine tissue.
So here we go.
For Onchocerca (river blindness) I think of a person ON
an IV in the hospital. So the IV is IVermectin! ON...IVermectin!
For Filariasis and Toxocariasis, I see the FIL and the
TOXO, and CAR and group them into automobile themes (FIL is fil er up in a gas
station). Then I think that cars are a leading source of death in accidents, and
DIE-thylcarbamazine is the tx.
For Trichinella and Strongyloides, I think of "Tri-ing
to get Strong Thighs" when you exercise. And both need Thi-abendazole
(Thiabendazole).
For the roundworms, HOOKworm, Enterobius and
Ascarius...well I think of a homosexual theme.... listen... Ascaris sounds like
scary and Enter-obius sounds like enter. So I think it is A-SCARY that a guy
would ENTER someone meBEND (ing) azole [Mebendazole]. So then I never forget the
image of Ascariasis and Enterobius treated with MEbendazole. And the hookworm is
easy. A HOOK is BENT, so you treat Hookworm with meBENDazole.
For the tapeworms, I have the PRAYER THEME:
I knew a guy name TAE who PRAYED to the SUN (All the
tapeworms need Praziquantel)
Paragonimus= Paragon means "model" I think of a model
citizen PRAYing
Echinococcus= has words Eck!!! it is AL! (Albendazole)
Schistosoma= sounds like "S-H-I-and another letter that
completes a bad word", then I then I have to PRAY to get forgiveness. Thus
Praziquantel again (Praziquantel sounds like prayer)
The above is very weird but YOU HAVE TO HAVE SOMETHING
or you will forget. I am just sharing my weird stuff to give an example. YOU
must make some yourself
Q.. OK, still LUMPING ALONG..
You see three patients:
Patient A has cystic fibrosis and another Patient B
after bone marrow transplant. Patient C has HIV. The bug I am referring to has
very NONSPECIFIC findings so the question on your test has to give a slide of
the organism. The keys are:
Here, you see 45 degree branching hyphae.
The three above cases are classic cases that are so
common the NBME cannot give an atypical example.
Give me the bug and drug!
A. A three cases are Aspergillosis. Classic cases....
The facts of HIV, cystic fibrosis, marrow transplant are
good, but the ultimate key is 45 degree branching hyphae!
Q. OK, for these groups of FUNGUS, you know most of us
with good immune systems will not see this but...
Case. You have a patient with HIV and presents with
nonspecific findings like fever, etc. but he complains of some mild chest spasms
and a stiff neck. Under the scope, you see little bugs that have a capsule
around them swimming with a stain of India ink.... this is KEY for what yeast
infection?
YES, you know it to be Cryptococus and he has pulmonary
and meningitis. You equate this with pigeon poop, but almost 80% of HIV cases
are correlated with Cryptococcus. The KEY is the slide with the bugs swimming in
halos, and the India INK stain, which is mostly used.
MY goodness, I must be getting tired:
For this bug too you treat with Amphotericin B!
Q. OK, let's keep going with the immune system
dyfunctional diseases:
AGAIN, often the NBME will LIKE HIV and Diabetes cases
with the immunodepressed. During my medicine rounds, these were everywhere, and
it is logical that NBME wants you to know them.
Case: HIV male, 27, presents oddly like Guillain Barre.
He says he has lower back pain and urinary incontinence and lower limb weakness
that is progressing. Hmmm.. you are thinking a huge list including prostate
issues, BUT the NBME must give you some more: So, his CBC comes back with a
bunch of clover leaf shaped lymphocytes. (A lot of this is NOT in Error!
Hyperlink reference not valid. but I know the NBME wants you to know them). OK,
what is the bug and drug? (HARD ONE)
A. This is another common opportunistic infection of
HTLV-1 !!!! or Human T-Cell Lymphotrophic Virus
This is seen with HIV positive patients! There is no
drug for this!!! Maybe some steroids...
This disease was already covered so I won't repeat it,
BUT,
WHILE we are on the subject of immunocompromised people,
KNOW that they are susceptible to all kinds of
LYMPHOMAS, e.g. if they have non Hodgkins, you will get a peripheral smear
instead of like a slide with a yeast or fungus.
Q. NEXT:
You see into your clinic two people:
Bob has had a bone marrow transplant
Bill has HIV.
Both have very distinguishable purpuric skin lesions all
over his trunk and a raised lesion on the inside of their mouths. They have the
constitutional symptoms of fever, weight loss, weakness, diarrhea, flaky skin.
Bill, but not Bob is homosexual fr. history. What is this defining lesion and
treatment?
A. this is pathonmonic for Kaposi's Sarcoma.
It IS the AIDs defining lesion.
1) You will see the skin stuff, and be asked the virus
is HHV-8, (a herpesvirus)
2) I put the other guy in the example because a small
percent of cases follow bone marrow transplantation. Watch for it.
3) Treat with Paclitaxel and Doxorubicin!
Q.. An immunocompromised person on your test, either HIV
or bone marrow transplants, will present similar so you must be a clever
detective:
An HIV positive woman named Jill comes in with a
NON-productive cough, fever, dyspnea. Her CD4 count is under 200 as is with all
these cases. So, the NBME has to give you some clues. For instance, this cases
has no skin lesions so you can rule out Kaposi's, but, labs come back with a
silver stain with yeast like circles that look like CRUSHED PING PONG cojones
(this is fungus, and it is black). What does she have?
A. This is classic as PCP or Pneumocystis carinii is
found in 75% of those without HAART treatment. PCP is very very high on your
differential with HIV patients.
YOU MUST TREAT AND PROPHLYAX with TMP-SMX!!!!!!!!
VERY QUICKLY, NOTE that with all of these
immunosuppressed people they present in a similar way with lung stuff, fever,
diarrhea, etc. So the NBME has to give you a picture...
SO PLEASE GO TO WEBPATH OR ANOTHER SOURCE and quickly
GLANCE at the organism. Some of them are, rather most, are distinctive.
OK?
Oh, usu. their T-cell count is under 200
Q. Another HIV patient comes in with white plaques on
his mouth and she has some mild genital lesions. This organism can hit any organ
but you see a slide of pseudohyphae on a KOH stain; yeast like stuff too. Again,
bug and drug?
A. HERE is the famous CANDIDA ALBICANS!
The pseudohyphae in KOH gives it away plus the genital
involvement. Treat with NYSTATIN!
Q. The NBME say you must recognize this disease which is
often mistaken for Kaposi's Sarcoma. Remember the presentation. But this time,
the NBME tells you the patient is homeless and has cats living with him.
Again, dx and tx?
A. You must catch this subtle difference b/c the drug is
different..
Here you have those CATS and you treat with
Erythromycin.
I forgot to mention this HUGE HIV disease which is
called:
Bacillary Angiomatosis
Q. Here, you have 4 patients come in from different
locations but all have similar symptoms that are SYSTEMIC:
They all have fever, chills, SOB, fatigue, skin stuff.
All let's say are immunocompromised (but not as much as those with HIV).
So...NBME must give clues because otherwise you are helpless. NOW, before we go
further, you must know you have to rule out cancer and TB or LAWSUIT time...
Mr. One lives in the Great Lakes area
Mr. Two lives in Arizona
Mr. Three lives in Ohio
Mr. Four lives in rural Brazil
All the slides show dimorphic fungus. Bugs and Drugs?
A.. OK, I chose the non typical places:
1) Blastomycosis, Great Lakes can also be Mississippi R
eastern US
2) Coccidioidomycosis, Can also see in California, SW
USA, N. Mexico
3) Histoplasmosis, Mississippi and Ohio River valleys
4) Paracoccidioidomycosis Brazil and Latin America, rare
in US
SO, listen up, the presentations are similar and even
the slides all look similar like dimorphic fungi should, but the good thing is
that the lines are deep due to location of patient's travel.
Know you may see a lot of cases with bat, pigeon, bird
poop. Know Histo is by far the most common, and YOU CAN TREAT ALL WITH
AMPHOTERICIN B!
Q.. Now the NBME will definitely want you to master
BACTERIA and the difference between gram pos and neg,/exo vs endotoxin.
NOW I can cover all the Gram postive vs Gram neg bugs
and the classification, but this is BEST DONE BY DIAGRAM, unlike if I ask you a
drug and the MOA. Thus, I must ask you to review the above subjects because they
are easy points.
I WILL ASK ONE QUESTON THOUGH, which, exo or endo toxin
activates the coagulation cascade??????
A. via the Hageman factor, Lipid molecules in endotoxin
activate the cascade to DIC!!!!
© 2003, 2004 ValueMD Incorporated. All rights reserved.
Q. OK, here are some directs:
What bug is Bacitracin sensitve, B hemolytic and has
streptolysin O and an erythrogenic toxin? GOOD POINT
A. This is Strep pyogenes
Q. Now where were we?
Just for a breather, let's move to pharm for a little
while.
Tell me, NBME wants you to be educated about MOA and
esp. side effects of drugs...
We cannot cover everything, but let's have a go:
[First, please know a few basic basic equations on
calculating maintenance dose and loading dose and Vd and Clearance and half
life, they are VERY basic]
BUT FIRST, TELL ME THE DIFF BETWEEN PHASE I AND II
METABOLISM?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Phase I has redox reactions with cyt. 450 and Phase
II inactives the drug via either sulfation, glucuronidation, conjugation, or
acteylation.
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. Case: pt comes with malaria. You prescribe
primaquine. But he tells you he take a H2 blocker starting with the letter "C"
(Hint)
Tell me:
1) Drug
2) What is danger here?
3) The other drugs NBME wants you be aware of that have
a similar effect.
GIANT CUPCAKE QUESTION
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. 1) Cimetidine block the metabolism of drug in the
liver by depressing the P450 system so PRIMAQUINE will be in body longer, more
toxic.
2) same as above
3) Think mnemonic "SICKe"
Sulfa drugs
I soniazid
C imetidine
K etoconazole
e erythromycin
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. CLASSIC like an Indian Motorcyle:
Female pt on oral contraceptives, but she gets pregnant.
Which drugs could have caused this involving P450 system in liver?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A.. Drugs that rev up the P450 system result in the drug
metabolized too quickly:
THIS YOU HAVE TO KNOW:
Think of a "GReasy (Griseofulvin) RIF-raf (An USA slang
term for homeless, Rifampin), jumps into a CAR(bamazapine), with a Queen
(Quinidine) injecting PHenobarbial and PHenytoin." Imagine this case and say it
20 times...
Those are the drugs I need you to know.
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. A young lady comes in asking for oral contraception
with history of stasis. What are you worried about?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Thrombosis
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. African American male comes in with G6PD deficiency
(HUGE CONCEPT).
What drugs lyse his RBCs?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A.. Think of him spinning and dancing..
SPINN
S ulfa drugs
P rimaquine
I soniazid
N SAIDs
N itrofurantoin
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. Pt of yours on a med comes in with a breakout red
rash. What drugs caused this?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A.. Think only of the drug vancomycin, which MOST KNOW
CAUSES RED MAN SYNDROME!
VANComycin, LOOK AT THE FIRST FOUR LETTERS VANC, THEN
Vancomycin
Adenosine
Niacin
Calcium channel blockers
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q.. PRE menopausal woman with Hot flashes. What drug
likely did this, IF she had a family history of breast cancer.
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Tamoxifen
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. Granulocytopenia is seen in a pt whom you gave what
meds? Most common ones?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Think the word granuloCytosis. Say it aloud with the
C, C, C. Think the letter C three times.
Then,
Clozapine
Carbamazepine
Colchicine
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
NBME requires all doctors to know what drugs cause SLE?
Think of a girl with nice HIPPs (SLE is usu. females),
so,
Hydralazine
Isoniazid
Procainamide
Phenytoin
GOOD WORK!
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. An alcoholic pt of yours comes in with hepatic
necrosis. What drugs are commonly seen doing this?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Imagine your alcoholic pt and ask him..
"did you HAVe a drink?" since alcoholics have liver
probs. this relation is strong. Look at letters HAVe, spec. HAV in have...
Halothane
Acetominophen
Valproic acid
Keep Keep remembering by repetition, you have to
remember the MNMENONIC FIRST!
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. A pt of yours has a UTI. You gave him a drug and his
skin is peeling, even the soles and palms. What drug(s) caused this?
You should think..."I must think a SEC!" Look at letters
SEC...
S ulfa drugs
E thosuximide
C arbamzapine
Great. Now YOU MUST REPEAT THIS OVER AND OVER! IMAGINE
THE MNEMONIC FIRST!! This is how your mind works.
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. I agree with the NBME's heavy duty coverage of side
effects. BEFORE you even treat a patient, you should know what it could do to
them if things go wrong! So, in support of the NBME..
Think, over and over, "I SAT in the sun and my eyes hurt
from the glare."
Look at the letters SAT...
S ulfa drugs
A miodarone
T etracyclines
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. sorry the mnemonic with the SAT in the sun causes:
PHOTOSENSITIVITY!
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. After some meds, three patients of your cannot breath
well...and their lungs are fibrotic on exam. What are the three drugs?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Lung Fibrosis
OK, one is Bleomycin (I remember this one because Bleo-
sounds like Blow, and you use your lungs to blow, hence the lung association)
NOW, think I exercise regularly and have strong LUNGS
and ABs (short for abdominal muscles). AB...
A miodarone
B usulfan (a drug for chemo for CML)
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. Pt of yours comes in with aplastic anemia, aa. What
drugs are common for this?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A.. Think Aplastic anemia has the letters abbreviation,
AA for Alcoholics Anonymous. Then associate an Alcoholic CAB driver who hits you
and your blood gushes out!! Yuck! But... look at the word CAB...
Chloramphenicol
Aspirin
Benzene
valuemd.com
See how easy it can be? But you must keep on
repeating...again, again...CAB...CAB, then think of drugs, then think of CAB,
then think of Drugs, IT WILL STICK...
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q.. You gave your patient an antibiotic and she comes
back with neuromuscular damage. What drug caused this?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Know that saying with the Parrot who keeps repeating
"Poly wanna cracker?" You know it... it is so silly and neurotic for the bird to
repeat it.
So....
Poly = NEURO tic
(Poly stands for Polymyxin)
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q.. You gave a patient of your a med for arrthymias but
she presents with Ventricular Tachycardias! (i.e. torsade de pointes meaning
"twisting of the points" in Latin)? What drug has SE?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Think of beautiful QUeen that is SO gorgeous she
makes your heart thump (like ventricular tachycardia)! See the capital letters
QU and SO in the expression?...
Qu inidine
SO talol
Easily associated with ventricular tachycardia now!!!
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. You have a cancer patient on drugs you gave that
presents with Ototoxicity and Nephrotoxicity. What 3 drugs w/ SE?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A. Here is a VERY good mnemonic...
Think of a wild CAlF (CALF, you know those young horses)
that kicks you in the kidney (Nephrotoxicity) and then your head (Ototoxicity).
Recall Ototoxicity is damage to CN VIII so you are dizzy
which makes perfect sense!
Again,
Cisplatin
Aminoglycosides
l (nothing here it is a lower case letter)
F urosemide
MAKE A PICTURE IN YOUR MIND, THEN REPEAT THE MNEMNONIC
THEN SAY THE DRUG. IT DOES WORK!
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
Q. Case: A peds patient of yours comes in from an
antibiotic that you gave him that is giving him joint pain in his tendons. What
drug did you mistakenly give him?
_________________
"All USMLE cases are original and are expressly not from
questions seen, recalled, paraphraphrased from the real USMLE, the material is
for the purpose of the education of future physicians and the safety of their
patients."
A.. There is inflammation of his tendons due to
Fluoroquinolones.
Think "Fluoroquinolones sounds like Floor-oquinolones"
See the word Floor. It is hard material. And so if a kid falls down on the
Floor, he will bust his tendons.
Floor=Tendons
_________________
Q. This is a must know:
An OB/GYN pt of yours has Trichomonas which you treated
with Metronidazole. Tonight she is going to a cocktail party. What do you warn
her about? (THIS IS REALLY ONE OF THE MORE TESTED ONES)
_________________
A. Your patient will have a flushing of the face,
nausea, and vomiting called Disulfiram reaction.
So this is a great mnemonic, think "Female in PMS
(premenstrual syndrome) looks really sick and nauseous, and is vomiting
(Disulfiram reaction).
Procarbazine (a cancer drug)
Metronidazole
Sulfa drugs
(The last two are favorites of NBME)
Q. The boards and hospitals are in LOVE with this one:
A male patient of yours with gastric ulcers on
cimetidine complains of big breasts. Whoa! That ain't good...what other drugs
cause gynecomastia?
A. Think...of a guy with big breasts. Isn't that SICK?
Look at letters SICK..
Spironolactone
Inebriated (This word means drunk with alcohol)
Cimetidine
Ketoconazole
So, Spironolactone, Inebriated w/Alcohol, Cimetidine,
Ketoconazole cause SICK big breasts on a male.
You likely know this, should I give my memory mnemonic?
Penicillin causes anaphylaxis and INH causes
hepatitis....I saw these both in my medicine rotation so it is second nature to
me.....
I just mentioned them to you b/c these are heavily
tested.
Q. This is also a HUGE SE, so you must know cold:
A bipolar patient of yours is on a med and complains of
excessive urination. What drug?
A. This is Lithium. It causes Diabetes Insipidus.
Think this..."IF you Lie, then you should Die-(abetes)"
Li=Di
Q. OK, just in case, did you know the famous one:
ACE inhibitors CAUSE coughing (from bradykinin).
But, let me ask, a patient of yours is depressed and you
medicated him. But he comes back complaining of the inability to read near
vision and a fast heart rate. What drug did you give
A. he is on a tricyclic antidepressant like imipramine
which has anti muscaric side effects, thus mimicking atropine:
This one I remember differently. Let me
explain....Tricyclics cause your eyes to be dry (hallmark sign) so you are not
crying. Since you are not crying, you must be on a drug which keeps you from
getting depressed (hence, antidepression drug).
Tricyclics=antidepression.
Q. This concept is actually a suggestion:
YOU MUST NOT UNDERESTIMATED DRUG SIDE EFFECTS, they are
a MUST KNOW!
SO, YOU ALSO MUST KNOW THEM BOTH WAYS, IN OTHER WORDS,
THEY CAN PRESENT A PATIENT WITH A COUGH AND CHF AND THEN YOU HAVE TO PICK ACE
INHIB. OR THEY COULD TELL YOU A CLASS OF DRUGS LIKE THE TRICYCLICS AND THEN ASK
YOU WHAT SIDE EFFECTS OR DRUG REACTIONS OR EVEN MAKE YOU POINT TO A DIAGRAM
WHERE THE DRUG DOES THE ACTION. THAT IS LIKE 3 OR 4 STEP THINKING, BUT THE NBME
NEEDS YOU TO DO THAT!!!
_________________
Q.. This concept is actually a suggestion:
YOU MUST NOT UNDERESTIMATED DRUG SIDE EFFECTS, they are
a MUST KNOW!
SO, YOU ALSO MUST KNOW THEM BOTH WAYS, IN OTHER WORDS,
THEY CAN PRESENT A PATIENT WITH A COUGH AND CHF AND THEN YOU HAVE TO PICK ACE
INHIB. OR THEY COULD TELL YOU A CLASS OF DRUGS LIKE THE TRICYCLICS AND THEN ASK
YOU WHAT SIDE EFFECTS OR DRUG REACTIONS OR EVEN MAKE YOU POINT TO A DIAGRAM
WHERE THE DRUG DOES THE ACTION. THAT IS LIKE 3 OR 4 STEP THINKING, BUT THE NBME
NEEDS YOU TO DO THAT!!!
_________________
A.
The steroids makes her susceptible to osteoporosis and
heparin can cause the same effect.
_________________
Q.
I SAVED THE BEST FOR LAST:
A mother comes to your clinic in emergency because her
baby looks pale and the baby's heartbeat is slow and barely audible. The baby
was given an antibiotic by an inexperienced med student!
Drug and name of condition please?
A.. The lack of glucoronyl transferase activity in the
newborn will delay the
metabolism of the chloramphenicol to the inactive form.
The result will be an elevated chloramphenicol level which can cause
cardiovascular collapse and death.
Q.. A pt of your overdoses on HEPARIN. What do you do?
A.. protamine sulfate
Q. A hypertensive patient of yours left out the pills
and her young child ate a bunch of them, her heart is very slow on exam. What do
you give?
_________________
A. For B Blockers, you give Glucagon.
Q. A patient of yours swallowed a bottle of weed killer.
What do you give him?
_________________
A.. For organophosphate poisoning, you give either
pralidoxime or Atropine!
_________________
Q. A depressed patient of your tries to kill herself by
swallowing a bottle of imipramine. What do you give her?
_________________
A. you give sodium bicarbonate.
Q. An infant swallowed a bottle of Fe pills. What do you
do?
A. you give her Deferoxamine!
Q. A peds patient of yours comes in having eaten lead
paint chips in his old house. What 2 drugs must you give?
Bonus? What is the difference between the 2 drugs?
A. You could do a gastric lavage, but if lead levels are
high, give both dimercaprol and Calcium EDTA.
The difference between the two is that Dimercaprol (BAL)
crosses the Blood Brain Barrier, and CaEDTA does not!!!
Q. A peds patient of yours presents with choleralike
symptoms with diarrhea massively and there is garlic smell on his breath. What
toxin did he eat and what do you do?
A. this is a perfect presentation of Arsenic poisoning
from a child eating rodenticide. Quickly, give a chelator like Dimercaprol/BAL.
And put him on liquid support due to the diarrhea.
Q. A 37 yo male patient of yours went on a fishing trip
in the Far East and ate a LOT of shark fin soup. He comes to you with headache,
memory loss, ataxia, vision troubles, memory loss, he is in BAD shape. What
happened and what do you do?
A. Whoa!
This is a classic case of methyl mercury poisoning.
People think of thermometers but most cases involve the consumption of fish in
polluted waters. Chelate FAST with Dimercaprol...
Q.. Hey I must ask you guys the mechanism of action of
Dimercaprol!!!!!
A.. This is KEY:
In the last case, mercury binds to the body's ubiquitous
sulfhydryl groups. Thes BAL are thought to compete with sulfhydryl groups in
binding methyl mercury by using its thiol groups.
Watch out, because the newest agent is
2,3-dimercaptosuccinic acid (DMSA) which is proven to be superior to BAL. NOT IN
THE textbooks like
Kaplan and
FA, but may be in NBME's mind.
Q.. Bizarre!
A patient walks into your clinic all giddy and acting
hysterical, has SOB, is dizzy and his job is working at a plastic manufacturing
plant. What did enter his body (HINT: you see this in 007 James Bond movies)?
And what do you give?
A. He has cyanide poisoning, as in the plastics industry
it is part of the solvent. He inhaled the fumes. You must give Sodium Nitrite.,
FAST!
• HY 300- 320
• HY 300: Bizarre!
A patient walks into your clinic all giddy and acting
hysterical, has SOB, is dizzy and his job is working at a plastic manufacturing
plant. What did enter his body (HINT: you see this in 007 James Bond movies)?
And what do you give?
…………………. He has cyanide poisoning, as in the plastics
industry it is part of the solvent. He inhaled the fumes. You must give Sodium
Nitrite., FAST!
• HY 301: NOW, we know that with heavy metal poisoning
we chelate with Dimercaprol, that includes silver, copper, and gold if anyone
actually going to eat such precious metals. BUT, what is the main cause of death
from heavy metal poisoning overall?...................................... it is
encephalopathy of the brain.
• HY 302: I love this case because it involves chemistry
and you MUST be aware of it. Two scenarios:
Patient A is getting a large lidocaine dose for LP:
Patient B is working with aniline dyes in a factory:
Both present to your clinic the same way, with
tachycardia, and symptoms of CYANOSIS like lip/skin discoloration (hint).
1) What is the disease?
2) Mech of disease
3) Treatment
4) Mech of Action of
tx?............................................................A: 1)Both of
these cases are of methemoglobinemia!
2) Any oxidizing agent converts Fe +2 to Fe +3.
3) As such the hemoglobin cannot bind the oxygen in this
ferrous form.
4) Give methylene blue and LATER bicarb and hydration
for the acidosis. Long term tx for chronic cases is Vit C! The methylene blue
acts as a cofactor in the NADPH-dependent metHb reductase system and reduces the
iron to ferric form which can bind the oxygen.
How's that for combining the sciences!
• HY 303: I am almost out of gas. But here goes...
Everyone knows you give acteylcysteine for Tylenol
overdose, but
what if your patient overdoses on Streptokinase that
your inexperienced intern gave him? What do you
do?........................................ Cool.
You treat with aminocaproic acid
• HY 304: Oh no!
A peds patient of yours comes in hyperactive, breathing
heavily and his mom said he ate a bunch of baby aspirin!! What do you
do???..................................... someone told me while I was teaching
that
FA is different, but I stick to my guns:
You perform gastric lavage and give activated charcoal.,
also: just wanted to add that you also alkalinize the urine with some drug like
acetazolamide.
• HY 305: A med student colleague of yours is studying
for USMLE Step 1 and has not sleep for a week. He is dosed on Ritalin,
amphetamines. You bring him to the doctor and your friend is hysterical and
sweating, and his eyes are dilated. What did the doctor do? ……………………..Again,
FA and
Kaplan say different,
but my experience in clinics say:
You administer activated charcoal, give him a
benzodiazepam, and MAYBE haloperidol if he is uncontrollable.
• HY 306: Great concept!
A male 40 yo patient of yours is brought to the clinic
after a suicide attempt by ingesting a bottle of Benadryl (diphenhydramine). He
presents with delirium, hot skin without sweat, he cannot pee and the ECG has
arrhythmias.
1) What mech is going on?
2) What drug do you administer stat for his general
symptoms?
3) What drugs do you give for his restlessness and
cardiac symptoms? ………………………….The diphenhydramine is giving him severe
anticholinergic symptoms.
1) Give Physosotigmine stat (an acetylcholinesterase
inhibitor)
2) After his Ach goes back up, give...
3) Benzos for his restlessness and Sodium bicarbonate
for his arrhythmias. Bingo!
• HY 307: You have patient with non Hodgkin's lymphoma.
He is on high dose methotrexate therapy and the MOPP regimen. What is the MOA of
methotrexate, again (I asked this) and what do I need to give him due to high
dose methotrexate? …………………………Methotrexate is a folate antagonist at
dihydrofolate reductase. You need to give the patient Leucovorin calcium which
is a derivative of folic acid but does not need dihydrofolate reductase.
This is called leucovorin rescue....
Also, give the patient L-asparaginase (produced
naturally by E-coli) which catalyzes L asparagine to aspartic acid!
• HY 308: Now where was I?
Hmmm...LET's roll through more drugs...
What is the SE, Use, and MOA of
acetazolamide?......................................................... ……..SE:
Urolithiasis, Ca most likely.
Use: use if your pt. is alkalotic.
MOA: Blocks enzyme carbonic anhydrase! So bicarb spills
out into the toilet!
• HY 309: You can also use acetazolamide for Glaucoma
because aqueous humor production is decreased!
• HY 310: Hmm.. let's NOT lump all the drugs because
then it will be TOO easy to answer the questions! So, let us drill away
randomly!
We know Buspirone is an anxiolytic, which receptor does
it act on? Be specific!.................................. 5 HT 1A receptor!
© 2003, 2004 ValueMD Incorporated. All rights reserved.
• HY 311: You may know Clonidine (as well as methyldopa)
is an alpha 2 agonist to control HTN, but if I give you a diagram,
Are the receptors PREsynaptic or POSTsynaptic
predominantly?
Second, True or False, is there ANY time clonidine
causes HTN?................................... Clonidine's receptors are mostly
PREsynaptic.
AND, the NBME WILL ASK YOU THAT if given IV push, you
will get momentary HTN from a few postsynaptic alpha 2 receptors on vascular
smooth muscle! The NBME likes you to answer in graph form!!!!!!
• HY 312: HEY,
Simply, you need to be able to eliminate wrong answer
choices! So..
1) wHAT is the SEs of chlorpromazine?
2) Receptor?
3) Major
usage?..................................................... This is an
antipsychotic. Its main SEs are from blockage of cholinergic, adrenergic,
histaminergic, and dopaminergic receptors! all of them! So,
you see the dry eyes, mouth, constipation, can't pee;
The adrenergic block will make you hypotensive when standing suddenly, and you
get impotence. The Histamine effect could make you tired and stop any rashes
from forming. And the D2, again it is the D2 blockade that will give the
extrpyramidal dysfunction: Parkinsonism mostly. After a few months you will get
the rigidity, fever and then Tardive dyskinesia!
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
• HY 313: Case: you are treating a woman with
Parkinson's disease. OK, OK it is an ergot alkaloid called Bromocriptine.
1) SEs?
2) Mech of Action?
3) What other diseases does it
treat?............................................................... 1)
Watchout for first dose cardio failure!
2) This is a D2 agonist and D1 antagonist!
3) Also used to treat hyperprolactinemia, amenorrhea,
galactorrhea.
• HY 314: The readers of this board seem to convey they
understand that B1 blockers are used for HTH, Angina, Arrhythmia. But what is an
important SE in diabetes patients?....................... In diabetes, you can
mask the tachycardia from B1 blockage due to hypoglycemia and you can get
impotent and reflux!
• HY 315: Quicky:
Other than OXYTOCIN, what Ergot alkaloid is used to
contract the uterus in pregnancy?............................................
well, I better say AFTER the delivery b/c if you use it during pregnancy, your
purpose is to abort the fetus.
Here, the answer is ergonovine!
• HY 316: As a group, we already discussed Chloroquine!
But tell me the imp. SEs!............................. Beware of G6PD deficiency
hemolysis, and warn patients about vertigo and itchy skin.
• HY 317: OK, think of cholestyramine...
Give me 1) SEs 2) MOA 3) medical
use…………………………………….Answer: 1) This anti lipid can cause constipation and in
higher doses produce fatty stools, and fat soluble vitamin deficiency!
2) This works by binding bile acids and stops absorption
of cholesterol in the gut. They diverts hepatic cholesterol to make more bile
acids, upregulates LDL receptors and thus lowers plasma LDL
3) it is an antilipid
• HY 318: Which is the only adrenergic receptor to work
by the PIP Ca cascade?................................. alpha 1, the others work
via cAMP!
• HY 319: The anti Parkinson drug Levodopa is used with
Carbidopa. Why?
And what category of rxn is levodopa to
dopamine?........................ carbidopa prevents peripheral utilization by
blocking the enzyme dopa decarboxylase (which is answer #2)
• HY 320: I am sure that the NBME wants you to know
about INSULIN...
1) MOA in Adipose:
2) MOA in Muscle:
3) MOA in Liver:
4) What ion is eliminated when given with glucose as tx?
5) Do you know ALL the enzymes affected by
INSULIN?.................................................answer: 1) Activates
Lipoprotein lipase pulls glucose inside
2) In muscle it stimulates glycogen synthesis, and K and
glucose uptake
3) In liver it makes glycogen by...(tyrosine kinase
activity) and works on all the irreversible steps of glycolysis and glycogen
synthesis.
4) It is used with glucose to get rid of K!
321. ARe we all on DRUGS? Yeah!
OK, NBME wants you to know diabetes drugs COLD like
GLYBURIDE!
you know it is a sulfonylurea that simulates insulin
release from B cells. But what ELSE does it do at what channel?
322. am i getting sloppy, the answer to HY Concept 321
is glyburide acts on K channels hat are ATP sensitive.. watch out it can cause
hypoglycemia.
NOW, with Isoniazid, you give what VITAMIN to min.
toxicity?? HY ultimate!
………………………Vit B6
323. HUGE HUGE HUGE!
What is PHENOTOLAMINE? EXACT, please?
WHAT DRUG IS IT RELATED TO THAT SOUNDS SIMILAR BUT HAS
IRREVERSIBLE EFFECTS?
……………………………..
IT is a NONselective alpha blocker! NONSELECTIVE....
KNOW that PHENOXYBENZAMINE is close but IRREVERSIBLE!
Both are used for pheochromocytoma but cause prominent orthostatic hyPOtension.
324. Tetracyclines...
YOU KNOW the MOA exactly?????
SEs?
What common drink impairs its absorption?
……………………………
hey, these binds to 30S subunit and blocks aminoacyl t
RNA. Now, KNOW the drug uses an energy dependent active transport pump.
SE include fatty liver and brown teeth in kids.
And, milk and antacids block abosrption!
325. We KNOW now that primaquine, you avoid in women
with connective tissue disorders. BUT, in pts. with G6PD def., what other than
hemolysis can it cause?
……………………………….
Dont' give to pregnant women and in G6PD def. we get
methemoglobinemia? REmember?
327. QUICK QUIZ, to learn effectively, you must compare
and contrast!!!!
So, FAST, without hesitation, KNOW and tell me:
1) TWO alpha adrenergics AGONISTS that work only on
alpha 1 receptor (hint, letters M then P)
2) ONE alpha adrenergic BLOCKER selective for alpha 1
only!
3) Does dopamine work on alpha 2 agonism?
4) Quickly, yell out a NON selective B adrenergic
AGONIST!
5) SUPER FAST, scream out a NON selective B adrenergic
BLOCKER (dangerous for asthma patients, see the connection?)
6) SUPER FAST, wail out a B1 selective blocker starting
with letter M!
KNOW THESE UNTIL YOU CAN DO THEM IN YOUR SLEEP!
…………………………………..
1) methoxamine, phenylephrine
2) prazosin
3) NO!
4) Isoproteronol
5) Propanolol
6) Metoprolol
328. Ah, got you!
HERE IS A STRAY CAT QUESTION! BUT exactly the kind of
questoin NBME WILL ASK...
You have to address anemias................iron
deficiency is most common, but two BIGGIES TO KNOW IF YOU KNOW CONCEPTS:
1) Do you give drug Ferrous Sulfate or Ferric Sulfate?
2) and, DO you give the meds to thalassemia or
sideroblastic anemia pts?
………………………………………….
1) MUST give in the form Ferrous Sulfate
2) NO, you don't give iron to these patients with
anemia!! BIG LAWSUIT ISSUE AND A USMLE STEP 1 mustknow.
329. WE addressed methotrexate and its function on DHFR,
but again, if your patient shows signs of toxicity, what drug can you give, and
the name of this process?
……………………………….
Called Leucovorin rescue, give a form of folinic acid.
330. THIS MUCH LOVED DRUG IS used in luekemias,
choricocarcinomas, ectopics, rheumatoid arthritis, etc.
KNOW THESE, and does this drug cross teh CSF barrier?
………………………………
no, not very well!
331. We reviewed that Amrinone is an inotrope. What
enzyme does it work on?
…………………………………………
This CHF drug blocks phosphodiesterase and pumps up
cAMP, just like your coffee!!!!
332. I am thinking of a drug used for Parkinson's...
1) What MOA?
2) What OTHER common drug starting with letters AT... is
similar in that the MOA raises pulse?
3) This alkaloid can result in what psychological
effects?
……………………………………….
Benztropine, works like ATROPINE, but can readily move
into the CNS.
2) It blocks the disinhibited cholinergic neurons and
THUS LOWERS ACh levels. (This is due to the fact that in Parkinson's, you lose
the dopaminergic neurons that block the ACh in the SUBSTANTIA NIGRA)
3) Watch out for SE like atropines AND
DELIRIUM!!!!!!!!!! This is an antimuscarinic!
333. We already reviewed fluoxetine, an antidepressant.
Tell me main commonest side effects???????
…………………………………………
MUST KNOW,
this drug is used by just about half the USA....and the
world...(exaggertion) but...
it causes antimuscarinic side effects....and sometimes
unwanted erections!!!
334. We reviewed Chloramphicol and it binds to 50 S,
but the NBME will likely go a step FURTHER.............
so, give me quickly the ENZYME IT WORKS ON.
two, give me the most feared SE in adults, then
in children...
………………………………………
REMEMBER the concept of all concepts that the NBME wants
you to KNOW SO MUCH about a relatively small universe of things....
HERE, we have chloramphenicol hits PEPTIDYL TRANSFERASE.
MOST WORRISOME is aplastic anemia in adults and the
infamous Grey baby syndrome in babies....
Are you remembering these?????
335. HUGE HUGE HUGE concept.
Your patient is a PREGNANT LADY with SEIZURES! Remember
pregnancy is SO KEY ON USMLE. So, what is DOC?
……………………………..
would you believe, phenobarbital?
336. BIG CUPCAKE question:
What compound does strychine work on?
What is the antidote of choice?
REVIEWING!!!!
…………………………………..
This blocks glycine receptors leading to seizures.
YOU can givce diazepam, among other choices....
337. This question tests your conceptual knowledge of
cancer drugs...
Give me the exact MOA of 6-Mercatopurine?
Used for ALL and Hodgkin's and IBD, what enzyme gets rid
of it?
………………………………………
This cancer drug is acted on by HGPRT, an enzyme in the
purine salvage pathway. It is phophorylated to TIMP which blocks IMP to AMP.
Then, PRPP is blocked from making ribos-5-phophate which regulates purine
synthesis, ending all in the result of lower DNA and RNA
IT IS METABOLIZED BY XANTHINE OXIDASE VIA METHYLATION
AND OXIDATION.
SEE....ALL THE SAME ENZYMES KEEP COMING BACK IN HYers!
338. Big one!
YOU KNOW Amantidine is used in Parkinson's and
Influenza! But give me MOA? Can you point on a diagram which step of viral rep
it works on?
…………………………………
hey, know it works on INfluenza A via blocking assembly
and uncoating.
339. YOU HAVE TO MEMORIZE AND KNOW ALL THE
CEPHALOSPORINS, WHICH ARE FIRST SECOND AND THIRD GEN, UNTIL YOU CAN DO IT FROM
SCRATCH!
But, let me ask, if you know, then I can be happy you
know the concepts:
What is the main notable difference between 1st and 3rd
generation cephs?
………………………………..
Other than affinity for gram negs, 3rd generationers can
cross the BLOOD BRAIN BARRIER!!
340. We previously reviewed MAO inhibitors, but I was
surprised that so many of my students could not recall a single one!!!!!!! Name
at least three..
Second, can you pt to where it will work on a diagram?
…………………………………….
Here's three of them: Selegiline, Tranylcypromine,
Phenelzine
Remember key things like watching out for tyramine
containing foods? Know that MAO-A IS serotonin's affinity and MAO-B is involved
in anti-Parkinson's!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
341. Heres one that is missed a lot:
NITROFURANTOIN is anti UTI med. What grp of people is
this contraindicated in ?
…………………………………..
G6PD def. patients!!!
342. NOTE: NOt a question but KNOW that
when you give ISOPROTERENOL for bradycardia, ask pt if
she is hyperthyroid or diabetic!
343. We previously discussed ATROPINE,
an antimuscarinic,
TELL ME THE THREE RECEPTOR SUBTYPES AND 2ND MESSENGERS
TELL ME ALSO WHEN IS IT USED MOST OFTEN?
WHAT IS THE NAME OF THE DRUG THAT IS RELATED FAMILY TO
TREAT MOTION SICKNESS?
……………………………….
M1 is in the CNS and works via IP3 and Ca
M2 is in heart and works via K and cAMP
M3 is in smooth muscle and works via IP3 and Ca
NBME LOVES THE ABOVE INFO, AND YOU MUST KNOW THE PICS,
You often see atropine for organophosphate poisoning.
And Scopolamine is used for motion sickness.
344. We covered EDROPHONIUM. What is this MOA? What dx
does it work on?
What is the related drug for LONG TERM USES OF SAID dx?
………………………………….
This is an Acetylcholinesterase inhibitor which pumps up
ACh at NMJs. you use this to diagnose myasthenia gravis!!!!!
Pyridostigmine is used for chronic myasthenia gravis!
345. BIGGIE PT:
We spoke of Sulfa drugs, so many of my patients were
allergic to sulfa drugs....
Thus, tell me the enzyme that sulfonamides block?
YOUR ATTENDING WILL SMACK YOU SILLY IF YOU GIVE TO WHAT
4 HUGE GROUP OF HUMANS!!!!??????!!!!!!!?????
………………………………….
This PABA analog, part of TMP-SMX, blocks
dihydropteroate synthetase.
DO NOT... give to
PREGNANT WOMEN
PTS, w/ history of STEVENS JOHNSON SYN
G6PD def patients
PTS with a history of renal stones
IF THE USMLE DOES NOT ASK YOU, YOU WILL BE ASKED DURING
YOUR MEDICINE ROTATION!!!
346. Quicky:
Yohimbine is often presented in as NBME case
everywhere...what's the MOA?
………………………………….
THIS DRUG IS AN ALPHA 2 BLOCKER.
SOME THOUGHT IT WAS AN ALPHA 2 AGONIST.....
remember, DON'T MIX ANTAGONISTS WITH AGONISTS, IT IS AN
EASY COMMON ERROR...
© 2003, 2004 ValueMD Incorporated. All rights reserved.
347. A GIANT:
YOU WILL SEE Glaucoma.
Give me the B-Blocker that is the DOC? What is its MOA?
But what OTHER adrenergic drug can be used and ITS MOA?
BIG SENSITIVE Point!
…………………………………….
Timolol is the DOC via lowering both production and
secretion of aqueous humor.
NOW, an alpha adrenergic AGONIST like epinephrine or
BRIMONIDINE can be used which works similarly but also improves drainage from
the canal of Schlemm!!!!
Surgery is iridotomy....
348. JUST KNOW THIS CONCEPT ASKED A TRILLION WAYS:
Epinephrine is a pure adrenergic agonist: both alpha 1,2
beta 1,2
But NOREPInephrine has NO Beta 2
activity!!!!!!!!!!!!!!!!
AND Phenylephrine is a true alpha activity only drug.
AND Terbutaline is a a true BETA activity only drug.
(like albuterol)
349. To save myself time, I am combining...but you must
must must KNOW
the GLAUCOMA, because in clinics, it can lead to sudden
blindness without symptoms at times. YOU could be sued for one million dollars
easy if you miss this...
KNOW...
As we discussed there is open angle and closed angle
glaucoma...
CLOSED ANGLE is when the canal of Schlemm is blocked and
is an emergency...
OPEN angle is most common...
We talked about the adrenergic meds, but also KNOW that
Prostaglandins like latanoprost are used...
an alpha 2 agonist like Brimonidine can be used...
A carbonic anhydrase inhibitor can be used via MOA of
lowering bicarbonate production and sodium transport and thus aqueous humor
formation...
and finally, a cholinomimetic like pilocarpine can be
used, but a friend of mine who is in ophtho says this is going out of
style...(the miotics)
350. EVERYONE I ever spoke to said CNS pharm is vital
and we just discussed GLAUCOMA. NOW, let's quickly go over BPH, benign prostatic
hypertrophy...
YOU, Dr. ValueMD can use terazosin or prazosin for BPH
(the only diff is that prazosin is shorter acting). (Students think of alpha
blockers only for HTN, but recall that alpha receptors are everywhere, like, in
the bladder?)
[You could use Phenoxybenzamine, but that is a bit too
much, eh]
Second line is FINASTERIDE, which you recall is a 5
alpha reductase inhibitor, MOA please? You remember?
……………………………….
Everywhere I went, I saw BPH (like CHF, Diabetes, etc.).
Finasteride hits 5 alpha reductase and lowers
testosterone production which decrease prostate size.
I did not ask, but for all cases of BPH, YOU HAVE TO DO
A RECTAL EXAM! You must rule out malignancy.
351. REally quick:
IF you see pentamidine on your test/clinics, what BUG
are you treating?
………………………………
PCP or African sleeping sickness...
352. HERE IS a good question that tests your ability to
understand a kEY!
We spoke of methoxamine as an alpha agonist 1. IS IT
inactivated by a MAO?
……………………………..
This drug...which works via PIP and DAG and IP3 and Ca.
all important...used to treat Atrial Tachycardia...is NOT a derivative of
catecholamines!!!
353. HEY, this a a sweetie!
KEY KEY KEY KEY....What drug did I mention BEFORE which
is used ABOVE THE DIAPHRAGM for anaerobes which has the SAME MOA as
ERYTHROMYCIN???? THE NBME IS ALL SECONDARIES, (thus their 350 question STEP 1 is
LIKE a 10,000 question test!!!!!!!)
And what is the mech of RESistance of this drug?
IF YOU KNOW THIS, YOU ARE DOING VERY VERY WELL!!!
…………………………………
We are talking about CLINDAMYCIN! via the 50 S subunit!
And the mech of resistance, do not forget the NBME loves
these resistance questions because they are BIG points in rotations and in
university research in USA...
Bacteria methylate the 50S binding site!!!!! and stop
the drug permeabilty through membranes!!!!
354. Quickly, we discussed this..
What is the MOA of Gemfibrozil? IOW, what enzyme does it
work on? For what disease?
…………………………..
This revs up lipoprotein lipase and breaks down VLDL!!!
355. ORLISTAT IS NOW SEEN ALL OVER ALL USMLE STEPS! HOW
IS THIS ANTILIPID DIFFERENT FROM cholestyramine?
……………………………….
This statin is a HMG CoA red inhib. and cholestryramine
is a bile acid binder that revs up bile acids and thus lowers blood LDL.
Be ready to answer the most common side effect of ALL
statins!!!
THE ANSWER IS MUSCLE PAIN!! IF USMLE STEP 1 does not ask
you, you WILL BE ASKED DURING YOUR MEDICINE ROTATION AS OFTEN AS THEY ASK YOU
YOUR NAME!
356. NOW, another anti lipid is PROBUCOL, what neg.
thing does it do to one of the cholesterol types..? def a must know!
………………………………………..
This antilipid pushes DOWN HDL which is BAD!
357. YOU will have to know ALL the antacids! THEY ARE
EVERYWHERE!
Tell me the three main types, what specific advantage
each one has, the SEs of course, and what PATIENT DO YOU DEF. NOT GIVE THEM
TO????
HUGE GIANT HUMONGOUS CONCEPT! Think first before
answering....this one esp.
4 sep. questions here!!!
…………………………….
Calcium (the famous brand is TUMS) also lowers K
(remember the previous concept somewhere where I told you you give insulin and
Calcium salts to HYPERKALEMICS!! ALL CONCEPTS TIE TOGEHER!)
Aluminum antacids bind phosphate and lower phosphate
levels!!!! (Think Al-phos...sounds like al..batross the bird..worked for me)
Magnesium antacids (famous brand Milk of Magnesia) is
used for constipation too!!
NOW SIDE EFFECTS! (SEs):
Calcium: OVERDOSE can rev up acid secretion!
Aluminum: SE is constipation!
Magnesium: SE is DIARRHEA!
ALL THREE CANNOT BE GIVEN TO RENALLY COMPROMISED
PATIENTS...IF YOU FORGET THIS, YOUR ATTENDING WILL LOSE HER JOB AND YOU WILL BE
DEPORTED BACK TO YOUR HOME COUNTRY!
358. Now, I am thiniing of a famous antifungal we
previously discussed... to treat HIstoplasmosis, Candida, and Cryptococcus!
WHAT FAMOUS DRUG IS THIS (starts with letter A and
rhymes with lamp)?
What is MAJOR SE you watch for?
What organ does it have trouble reaching, thus, what
drug do you co administer???????????????????????
…………………………………………
this is AMPHOTERICIN B!
IT SELECTIIVELY BINDS ERGOSTEROL, which is a fungal type
memb., and you watch for liver and kidney pts, and it can cause FEVER and
CHILLS!
It has some trouble entering the brain, so give with
flucytosine for HIV Cryptococcus Meningitis!!!
359. This POPULAR DRUG is given OFTEN to patients with
SEPTIC SHOCK (my own grandfather died recently of this (starts with letter "N")
NOW, what patient condition is contraindicated????
…………………………
NOREPINEPHRINE, you avoid in hypovolemic patients!
360. Patient of yours named Ben comes in with BP 250/110
!!!
What drug do you grab for IV drip!!!?
What enzyme does this drug act on?
What dangerous SE you watch out for?
……………………………………..
This is DOC for HYPERTENSIVE CRISIS!
It drops PREload and AFTERload via vasodilation via
GUANYLATE CYCLASE!
WATCH OUT FOR CYANIDE TOXICITY!
361. WE MUST KNOW THAT:
Ibuprofen is used for HEADACHES and to close a PDA in a
baby!!!
WHICH EXACT two prostaglandins are blocked downsteam
here that kept the patent ductus open?
…………………………………….
YOU HAVE TO KNOW:
This NSAID indirectly via COase inhibition BLOCKS PGE2
and PGI2
362. THIS WILL ANSWER 1000 QUESTIONS:
BE READY, IN A GIANT PICTURE OF A CELL WITH ARROWS EVERY
PLACE:
WHERE EACH MAJOR ANTI BACTERIAL ACTS...
FOR E.G., WHERE WITH AN ARROW DOES POLYMYXIN WORK?
………………………………………….
POLYMYXIN acts with the arrow pointed at the cell
wall... KNOW EVERYTHING HERE>>>
Sulfas block at step right before DHF on dihydropteroate
synthetase....
Clinda and Erythro block translocase at 50
S.................
Vanco blocks the polymerization step so single
peptidoglycans cannot grow..
ON THIS YOU MUST SEE ON A DIAGRAM!!!
363. Someone asked about Q-Fever...
IT is called Q because its first discovery was a query
or mystery...
It is from bug Coxiella burnetti..
You catch it from ticks in Montana but the bug is
everywhere.
Give DOC Doxycycline..
364. Here is an answer to a Value MD brother/sister but
PLEASE, if I do not get back to your question, I gave my private email on Yahoo!
to a few people and I am WAY behind. I will try to catch up but If i don't, then
I am so sorry.
SOMEONE asked me about PACLITAXEL, which is TAXOL... it
is used for all types of cancers in clinic and blocks microtubule formation.
It causes BAD leukopenia and can be cardiotoxic!
365. Someone asked about MOA of flucortisone and what it
is?
Answer is that it is used for ORTHOSTATIC HYPOTENSION.
It works by sucking back the Na and driving out K. The RENIN is reved up,
restoring BP.
366. Some people said their test is this week and wanted
me to keep em pumped up so I will try my best..pray please for physical strength
so I can push forward. YOUR prayers are working because last hour I felt so
tired but someone's prayer LIT me up and I felt strong again!
Q) Someone asked me about how Praziquantel works since
we talked about it a lot with parasites... again the MOA...
Praziquantel (Biltricide) -- Parasite cyst murderer
agent that destroys approximately 75% of cysts with a single course. Increases
cell membrane permeability in worms, resulting in loss of intracellular calcium,
massive contractions, and paralysis. Causes vacuolization and disintegration of
the schistosome tegument, followed by attachment of phagocytes to the parasite
and then the LAST RITES of the parasite, sorry parasite... bitter tabs though.
367. If I can have time, I will try to correspond with
each of you that asked about personal study schedules. There are SO MANY SAMPLE
schedules out there, but you have to tailor your own. However, you have to make
it so the micro and anatomy are last because they are the most easily forgotten.
Physio should be first. You need breaks of course during the day, BUT short
ones. I told all my SERIOUS students they need to study at least 10-14 hours per
day for a 3 month period. They must have a scientific method to ASSESS their
progress to know if they are being EFFICIENT. One student of mine studied one
year and still she failed...the study plan was not efficient. Everyone is
different though. When I have more time, I will try to answer each one of
you.....
Q) ON MY PREVIOUS POST, I got a WINDOWS MESSAGE to
clarify the name of a disease that causes orthostatic hypertension...
A) There are a lot of them, BUT the common category is
AUTONOMIC FAILURE SYNDROMES like SHY DRAGER synd.
368. Someone asked about URINARY INCONTINENCE,
definitely a HY subject..
YOU will see this all over the place during OB/GYN..
Q) What is MOA of Oxybutynin? What enzyme does it act
on?
A) Oxybutynin (Ditropan) -- Useful for urinary incont.
Inhibits action of ACh on smooth muscle and has direct antispasmodic effect on
smooth muscle which in turn causes increase in bladder capacity and decrease in
contractions.
369. Q) Was, where does Beclomethasone act?
A) It first binds to receptor in cytosol and is carried
to nucleus to a ZINC FINGER DNA BINDING PROTEIN. TRANSACTIVATING STEROID
RESPONSE GENES
GOOD QUESTION AND HUGE HYer!
370. Q) What is the function of Probenecid? What dx and
MOA? SEs?
KNOW THIS ONE!
A) This blocks reabsorption of uric acid and enhances
excretion. DON'T USE IN ACUTE gout but only for chronic gout. ...
This works on the PCT in kidney....
SEs are HY... can cause uric acid stoneS!!!
371. Q) Someone asked about Chorionic villi sampling.
Def. HYer too...during week two, extentions of the cytotrophoblast cells called
chorionic villi formed and projected into the synctiotrophblast cell mass.
During week 3, these villi enlarge and blood vessels grow into them, forming
highly vascularized structures, completely surrounding the chorion. This
intricate network of embryonic vessels is now close to the synctiotrophblast
lacunae which are filled with maternal blood. This forms the placenta!
CHORIONIC VILLI TESTING cannot detect neural tube
defects like the alpha feto protein test done later AT WEEK 16 AROUND....
YOU CAN DO THIS TEST EARLIER THAN AMNIOCENTESIS!
372. Q) Still on drugs...
We know Bleomycin blows out LUNGS (bad SE), what phase
of cell cycle does it act in? Binds to what ion?
A) G2 phase, binds to Fe in oxidase and "cuts" DNA.
373. Here is YOUR answer:
Case: The famous drug Robitussin PM has a cough
suppression agent called DEXTROMETHORPHAN. What is the MOA? What receptor?????
A) Dextromethorphan has shown agonist activity at the
serotonergic transmission, inhibiting the reuptake of serotonin at synapses and
causing potential serotonin syndrome, especially when used concomitantly with
monoamine oxidase inhibitors (MAOIs). In addition, dextromethorphan and its
primary metabolite, dextrorphan, demonstrate anticonvulsant activity by
antagonizing the action of glutamate, wow, an super HYer.
374. Q) What BAD side effect is involved with STATINS if
given with Gemfibrizol?
A) Rhabdomyolysis!! Watch for it!
375. Q) Biggie question: What drug used for Candida
topically works by the same MOA as Amp B?
A) Classic question: answer is Nystatin has same MOA....
376. HARD QUESTION but reviews your fungals...
q) For Cryptococcus meningitis, you used AMP B...what
two other drugs starting with letters, FLU... completes the treatment...MOA too
please??
A) Use Fluconazole and Flucytosine. All the -azoles work
against ergosterol, but Flucytosine is an antimetabolite!!!
377. Q) I know you know that H2 blockers,
antacids, and OMEPRAZOLE are good for GI diseases..
BUT, what drug is also used for peptic ulcer disease
that CANNOT BE COAMINISTERED WITH H2 blockers????
A) SUCRALFATE: this protects peptic ulcer tissue and YOU
CANNOT GIVE WITH ANTACIDS BECAUSE SUCRALFATE NEEDS ACIDIC ENVIRON.
378. I saw a drug called CYTOTEC for stomach ulcers
given out all the time.. This is generic MISOPROSTOL.
Q) What group of people is there you CANNOT give to?
Also give me MOA?
A) This prostaglandin E1 STIMULATES mucus production
and..
YOU CANNOT GIVE TO PREGNANT WOMEN BECAUSE THEY MAY ABORT
FR. CONTRACTIONS TO UTERUS!
379. Q) What two opioid agents are commonly used as an
antidiarrheal? One of these "sounds" like Dextromethorphan, an anticough. MOA?
A) Diphenoxylate and Loperamide are OPIOIDS for diarrhea
control. But stop GI contractions from mu and delta receptor activity!
380. You first learned in college that Vasopressin is
ADH acting on V2 receptors in the COLLECTING DUCT!
Q) But what is MOA on V1 receptors and what is the dx it
treats?
Q) Also, on V2 receptors, it also releases what two coag
factors????
A1) On V1, it vasocontricts the splanchnic bed. So, use
for GI bleeds.
A2) VWF and Factor VIII !!! KNOW THAT!
381. Give me exact MOA of Daunorubicin and Doxorubicin?
SE?
A) This acts on DNA and cuts it hence blocking DNA AND
RNA syn. It works by intercalating and is cell cycle nonspecific!
SE is Cardio damage. "don't let Dawn break your heart"
382. What is MOA of Etoposide???
a) ANti-cancer...Works in S phase and binds DNA
topisomerase II, thus breaking and stopping DNA and RNA production!
383. HEY, I am thinking of antiarrhythmic that works via
blocking Na channels for Class IC and raises depolarization threshold in PHASE
4, (Be able to idenify changes in graphs). It is ONLY USED IN SERIOUS cases of
V-TACH for people with a decent cardio function.
Who am I? (Starts with letter F)
Answer: Flecainide
384. In a famous movie, a doctor used Dopamine to aid a
patient with poor renal perfusion via the...
D1 receptor.
Tell me what other receptors are revved up if I increase
the DOSE of DOPAMINE? very important...
Answer: First, the D1 is activated. Then the B1 is
activated, then if keep increasing, the alpha-1 is activated!! Thus, cardio
function and vasocontriction occur...at higher doses! Can you graph it?
385. WE ALL KNOW WARFARIN IS CRUCIAL HY...
1) WHAT IS MOA, GIVE ME EVEN THE ENZYME!!!
2) WHAT KIND OF RXN (HYDROXY OR CARBOXY) DOES IT DO?
3) GIVE TO PREG WOMEN?
A1) THIS VIT K FACTOR blocks epoxide reductase! The
famous Vit K is a cofactor in CARBOXYLATION REACTIONS!
A2) CARBOXY
A3) NO!!
386. What is MOA of Dipyridamole?
A) This ANTIplatlet works by reving up cAMP and blocking
platlet adenosine uptake...it also decreases vascular tone so OPENS UP blood
vessels?
387. Give me MOA and tx involved with Azathioprine!
A) This blocks purine conversions via IMP dehydrogenase
block...is a purine analog used for KIDNEY TRANSPLANTATION!!!!!!!!!!!!!!!!!!!!
Via immunosuppression!
388. Yeah, you know HYDRALAZINE...but tell me the second
messengers???
Ans: This vasodilator can cause LUPUS but activates
Guanylate cyclase...reving cGMP...causing hyperpolarization!!!!!
WOW!
© 2003, 2004 ValueMD Incorporated. All rights reserved.
389. I am thinking of a class IV antiarrhythmic like
Diltiazem. What channels, exactly,...do they both work on?
A) L type Calcium Channels. Stress the "L". This slows
conduction at the AV node.........oh, the drug is VERAPAMIL....
390. Tamoxifen, a breast cancer ANTIESTROGEN, revs up
which hypothalamic hormone?
ans: GnRH
391. Which cell cycle pt does Vincristine act on? What
dx? What bad SE? What protein does it bind? What is mech of resistance?
A) METAPHASE; for leukemias/lymphomas; peripheral
neuropathy along with the others like hair loss,etc. ; it binds a protein called
TUBULIN. The mech of resistance is tubulin gene amplification!!!
Are you getting all of this????
392. Case: A patient of yours is on
antiretrovirals....AZT is not working,
YOU SHOULD ADD ON ddC or ddl.
Q) What is organ affected in SEs of ddC or ddl?
A) Pancreas...and you may face neuropathies...
393. Case: You have a pt on cancer chemo. She complains
of nausea and you give... name at least two antiemetics for cancer rxns... and
what receptors do they act on?
Answer: Tricky, I am not thinking of the opiod drugs.
The ones usually used are the anti dopaminergic ones...that block the reticular
formation in the medulla brain stem slide. Two egs are Metoclopramide and
Droperidol!!!!
394. OTHER than nitroprusside for HTN emergencies, you
can use DIAZOXIDE, its MOA is thru ATP and K channel activation...which as you
know, when K channel open there is hyperpolarization...etc. relaxation of
vessels...vessels open up....etc. What is this drug's SE?
Ans: Hyperglycemia in Diabetics via B cell inhibition in
pancreas!
395. What is the dx and MOA related to cytarabine?
ans) This ANTIMETABOLITE acts during the S phase and
incorporates ArabineC into DNA. RNA growth continues and leads to IMBALANCE, and
stops growth mostly used for cases of AML.
396. KNOW ALL ABOUT digitalis...it WILL BE ASKED. KNOW
MOA...? What patient condition is contraindicated?
A) Binds Na/K/ATPase pump...Ca revs up...increased
contractility...AV nodal velocity goes down...
DON'T GIVE TO HYPOKALEMICS! AND THOSE ON CLASS I
ANTIARRYTHMICS...
397. SO KEY:
What is MOA of 5-FU?
Answer: 5-Fluorouracil works in S phase and is converted
to 5-FdUMP. This now blocks thymideylate syn, blocking DNA syn, so there is loss
of balance as RNA and protein go up....thymine is LOST.
398. What receptor does IPRATROPIUM work on? What dx?
A) This asthma drug is SO common and blocks ONLY the M3
muscarinic receptors in the lungs (b/c it is inhaled).
399. Everyone needs to know birth control...etc.
What is MOA of progesterones for birth control and what
three conditions is it commonly used for?
answer: In the nucleus, it binds zinc finger binding
protein and lowers GnRH, and the LH and FSH surge.
You give to DUB pts with too much estrogen secretion,
endometriosis, and fibrocystic change, along with the birth control reasons!
400. For the USMLE STEP 1, you must go beyond things
like,"streptokinase is used for tx of thrombosis." SO, what is the exact, and I
mean exact, MOA of streptokinase??? Can you point to where it acts if I show you
a coagulation cascade diagram? These are orignial questions but are EXACTLY the
LEVEL you need to PASS the MONSTER EXAM..
Ans: This streptokinase binds plasminogen, activating
its active site, thus reving up plasmin which then busts up clots and factors V
and factors VIII.
WHEW!!
401
I am so happy Step 1 came in. As I mentioned, I am
tutoring a student who happened to live in my hometown since I gave out my email
to a few people who told me they LIVE IN MY US CITY! So I am tutoring him
because he is panicking. I am NOT CHARGING ANY money so do you guys worry.
Please say a quick prayer that he passes!
Q) What is the Shilling test used for?
A) So KEY!. We use it to identify pernicious anemia by
giving a pt. vit B12 and seeing if intrinsic factor is present!
___________________________________________________
402
This was a concept that someone e-mailed me that I think
I incorrectly responded to:
Q) If you inhibit aldosterone release thru
penicillamine,
a) then you will decrease RENIN levels. (choices she
gave included Ang 1, Ang ii, etc.)
___________________________________________________________
403
The NBME will ask a lot of questions about serum
electrolytes and DIURETICS. This is come up over and over and over again!
LISTEN, for FHA (Acronym Federal Housing Authority).
(which stands for Furosemide, HCTZ, and Acetazolamide), YOU LOSE K (cash) FROM
THE SERUM!!!!!!!!! (Hypokalemia results)
(Think of mnemonic, if the FHA comes, you likely have no
Kash!)
LISTEN, if your patient wants a H (HI)- Fidelity (F)
stereo, he has to BUY IT UP (B=Bi-carbonate) (Hydrochlorothiazide and Furosemide
stands for the H and F), then you must BUY IT UP! ("Buy" sounds like
Bicarbonate, and BUY IT UP means the "Buy"carbonate HCO3 levels in your blood
will increase!) (LINK:metabolic alkalosis)
LISTEN, all Diuretics lower Magnesium, so THINK that if
you sit down to pee (diuretic), you will also have a big MASSIVE GLOB of poop.
The M in Massive and the G in Glob of poop stands for Mg coming out.
(hypomagnesium)
LISTEN, ALL Diuretics raise uric acid in serium,
lowering it in the renal tubules. This mnemonic is easy...DIURETIC SOUNDS LIKE
URIC ACID both have "UR". Say it fast. then you will connect! And Diu"r"etic has
"r" for raise in serum. (This is of clincal importance as Thiazide Diuretics are
used to treat uric acid stones because while serum levels stay high, renal
tubule levels remain low!)
LISTEN, the acronym ASA stands for aspirin, and aspirin
Overdose is acidic. So the A (Amiloride), the S (Spironolactone), and A
(Acetazolamide) . An aspirin Overdose gives you metabolic acidosis!!!!!!!
Also KNOW the connection that the K sparing diuretics
STAys in serum. (S=spironolactone, T-triamterene, A-amiloride) (Usually, I found
it helpful to recall that H and K stay together usually...) HCO3 leaves in the
urine...
LISTEN, for Calcium ions it is tougher. But this works
for me. I think of a S-Ca-fFold falling down a building. (You know, for
painters). So, Calcium administration makes S (Spironolactone) and F
(Furosemide) "fall" out of your urine! See the Ca in word S-Ca-Ffold!!!! (This
is clincially important because LASIX or furosemide is given to CHF patients
every second which predisposes them to Ca stones in kidney!
REPEAT THIS HIGH YIELD CONCEPTs UNTIL IT STICKS!!!!!!
BEcause you will likely be asked this on your test because of the relation to
renal stones....Ca for e.g. causes stones. Hypokalemia, Hyperacidosis...And this
is SO IMPORTANT, you must repeat my mnemnoics over and over.
They worked for a lot of people! And I spent a long time
making up these memory mnemonics. Don't let them go to waste! Someone told me my
mnemonics saved them! Thanks but please they are for everyone and they are
useless unless you repeat them.
Please e-mail me if you like the mnemonics. If they are
bothersome, I will stop submitting them!!!!!
__________________________________________________
404
I am getting so much mail and I love them but my ValueMD
mailbox is not letting me reply.. I just want to say to some of you that I would
LOVE to visit your HOMECOUNTRY if I go overseas! And I am doing fine thanks to
your prayers! And please pray that the student next to me that I am tutoring for
STEP 1 (hence my absence today) will pass this Saturday! He is crying and
desperate. I am serious...
OK, while he is doing one of my exercise drills...
Q) Important point: NBME wants you to know the
difference between procaine and meprivacaine. What is it?????
A) PROCAINE and LIDOCAINE is an ESTER based local
anesthetic like the Novocain your dentist uses!
AND, MEPIVACINE sounds so similar but it is an AMIDE
based local anesthetics.
This is so important because the esters are shorter in
action!!!!
_____________________________________________________
405
Step 1 is right, the NBME WILL WANT YOU TO understand
ALL second messengers because all their questions are secondaries, tertiaries,
tetraaries (spelling is wrong), etc. I cannot stress enough this POST...
SO, LISTEN VERY CAREFULLY:
For the second messengers, you must have ORDER to
remember subtypes and the sub-subtypes which the NBME will definitely ask you:
(1 subtype) Repeat this story, You, say you are a male,
takes out on a date a beautiful girl with an "A1" great BIDI ("Body" which is
stimulating for you) (Receptor A1, B1, and D1 are stim in B1,D1.). Or you can
think acronym one 1 BAD date with a lovely lady. But recall stimulatory.
(2 subype) Then you both are so hungry, hunger
stimulation, so you both order H 2 Hamburgers, so receptor H2 is stimulatory!
BUT, all have exceptions! You open your handheld Palm Pilot to write her phone
number down and note it is powered by an AMD processor (a company that INHIBITS
the dominance of Intel Corp) (The Acronym AMD is A2, M2 (found in the heart), D2
which are all INHIBITORY). OR...think you are 2 M.A.D. because you forgot your
best necktie.
(3 subtype) Now, you take her to see the movie "Matrix
3" (M3 receptor) and you hold her hand during the movies and because you are
nervous, your hand sweat glands are stimulated! M3 receptors in sweat glands are
stimulatory when activated! (MOISTEE..sounds like M3)
NOW THAT WE KNOW WHICH ARE STIMULATORY AND INHIBITORY:
REMEMBER: 1) All the subtype 1s (like alpha 1, M1, V1,
H1, etc.) are STIMULATORY and work via the Phospholipase C, PIP, IP3, DAG, Ca,
Protein Kinase C. Try to link the word ONE-C or say C-ONE. EXCEPT for acronym
BIDI or sounds like BODY. The B1 and D1 (Beta one and Dopamine 1) are stimulate
by ATP, cAMP, Protein Kinase A! (Think all these messengers have the letter "A"
in it for the expression "A" great "BIDI" (body). Recall the letter "A" stands
for Protein Kinase A.
2) NOW, LUMP the subtype 2s: (like alpha 2, muscarinic
2, dopamine 2). Activation, here result in INHIBITORY via adenylcyclase,
PotassiumK, cAMP downreg. and Protein kinase A downreg.. EXCEPTION...here is H2
in the stomach which is stimulatory but STILL involves Protein Kinase A. Think
of eating 2 hamburgers because your hunger is so stimulated! But, do not confuse
that most of the 2s are MAD (M2, A2, D2)!
3) NOW, LUMP the subtype 3s: (which there is only one
you need to worry about which is M3. These attached messengers are PIP, IP3,
DAG, Ca, and Protein Kinase C. Think you did "see" or "C" the movie, right?
BIG HINT: For the 1st and 3rd messengers, think
"generally" the "1" and "3" subtypes like alpha 1 are connected to PIP, IP3, Ca
or Protein Kinase C. "13C"
For the 2nd messenger, which think is in the MIDDLE of
the pack, it is adenylcyclase, ATP, cAMP and Protein kinase A (which ALL have
the letter "A" in them. "2A"
It sounds hard, but if you say them aloud a few times,
you WILL remember. ONE of my students said my originial mnemonic was worth its
weight in gold. I don't know about that, but THANKS TO HIM. Don't worry, I will
ALWAY stay HUMBLE!!!! love, tommyk
© 2003, 2004 ValueMD Incorporated. All rights reserved.
Oh, just so I know, are these mnemonics helping? Please
let me know because if they are not helping, then it is a waste of time for you
to read them!
_________________
406
Case: Another movie with a cousin of Brandon Lee in the
movie "The Crow". He is shot by a fake bullet, but is bleeding heavily. What
drug that is a LYSINE analog do you grab to try to save his life??????? (starts
with letter A)? MOA OF COURSE?
Answer: Aminocaproic Acid which thrombolyzes clots to
stop the bleeding. It binds and inactivates PLASMIN from binding FIBRIN!
407
Case: Two patients of your walks in. Mr. Brown cannot
pee. Mr. White has myasthenia gravis. What drug (starting with letters NEO do
you use and its MOA?
(I really did like the movie Matrix as you can tell)
Answer: You grab Neostigmine!!! An inhibitor of enzyme
cholinesterase! (This of course, boosts ACh is the system!)
_________________
408
Q) What don't aminoglycosides work on anaerobes?
A) Because aminoglycosides need O2 dep. transport and
anaerobes don't have these.
BIG KEY POINT OF RESISTENCE!
_________________
409
Q) For all young women with HTN, you learn in clinic you
always ask if they are on birth control....big point....
NOW, what contrib. does estrogen play to stop ovulation?
A) In the hypothalamus, the estrogen receptors are
overwhelmed, so FSH drops!, thus, helping to stop ovulation!
REMEMBER, DON'T GIVE ESTROGEN TO HTN PATIENTS OR YOU
WILL BE SUED!
_________________
410
IMPORTANT:
What is MOA of Clomiphene citrate?
A) This infertility drug works b/c as a WEAK
antiestrogen, it weakly counteracts GnRH at the hypothalamus, so FSH and LH rev
up and ovulation occurs. Key is it is a WEAK estrogen!
_________________
411
You know that classic pressure curve diagram and the BIG
diagram with EVERYTHING like EKG, Ventricular Volume, Heart Sounds, etc. etc.
I guarantee everyone will face this on their test. But
more important, realize that some mentor told me that at least 10,000 questions
can be asked because it is SO diverse. The concept is not that hard, but see if
you can draw them from scratch (where the S1 is, where isovolumetric contraction
is, where atrial pressure is lowest, etc. IT IS ENDLESS)
_________________
412
Remember, this is a NBME favorite:
Odds ratio is quickly calculated as OR=ad/bc
AND Case Control studies = Odds ratio
AND Cohort Studies = Relative risk
(Think: "This Case is ODD to make the relation that Case
control is Odds Ratio" AND think that a "Cohort" is a grp of people starting
together and people's personalties are all RELATIVE."
_________________
quickly though,
give me the difference and point to a histo slide of:
a) oligodendroglia
b) Schwann cell
ANSWER: Both Myelinate, but Oligos =CNS axons and
Schwann=PNS axons.
BIG POINT that is often asked in relation to tumors....
Think of Schwann or Swans flying off...to the
periphery....
_________________
413
For the embryo arch problems (one of my students got a
whole bunch of them, see you can never tell)...
Just remember that Branchial arch 1= Ms (Masseter,
mandle, etc.) and has nerve CN V3 "IV3 rhymes"
Just recall that Brancial arch 2 has a lot of Ss in it
(Stapedius, Stapes, etc.) and has nerve CN VII "The Roman numeral VII has "two"
II it it"
Just recall that Brancial arch 3 has pharygeal stuff and
CN IX "3P9" rhymes.
Just recall that Branchial arch 4 and 6 have an
"elevator in the larynx" (levator veli palatini and larynx mucles) and CN X.
"Think of the expression, For Sex" (4=sex and "s" is first letter of sex) {But I
personally do not advocate sex before marriage, I just felt I had to put that
point in}
"Another hint for the order are the odd numbers til
ten"= CN V3, VII, IX, X
for arches 1 to 4/6. See CN five has the 3 branch. Just
go in order....
_________________
414
For the imfamous Pharygeal pouches,
just think... you know there are 4 pouches:
1=M iddle ear
2=P alatine tonsil
3=T hymus
4=S uperior parathyroids
"Think the acronym MPTS or Many People Throw Stones,
then work your way down the head anatomy from ear down to parathyroids"
(It gets more complicated of course, but this should
help a lot")
_________________
415
Good one:
BIGGIE:
Case: Pt with infertility and Urinary tract problems.
There was an incompelte fusion of the parameonephric ducts. What is the dx?
Answer: Bicornuate UTERUS
_________________
416
To recall the all important lower injuries,
"Think of actor Johnny DEP falling into a PIT" (I know,
Dep is spelling w/ 2ps, but still" It is easy to remember cause ALL of
girlfriends think he is best looking guy around.
DEP= Dorsiflexion and Eversion is Peroneal (Common
Peroneal)
Then, for the essential levels which they will ask,
"Think, Johnny Dep is
So good 2 Look 4" hence L4-S2 injury. (See, the S in So
and then the 2, then the L in Look then the number 4)
PIT= Plantarfexes, Tibial nerve Inverts. Think, "If I L
ook 4 hiim in the PIT and find him, I will be So 3-illed" (in other words, If I
look for him in the pit and find him, I will be so thrilled) (This completes the
association with L4-S3 nerve roots)
_________________
417
Bold CASE:
A patient of yours named David comes in and cannot move
his hips and there is no knee reflex. What cords are damaged?????
Ans: L2-L4 "Think, you have to link stuff to save memory
brain space so think this: David is in PEDiful (pitiful) shape. Since we linked
PED with Lr and L2 already, the association produces the answer L2-L4 are
lesioned.
_________________
418
YOU MUST KNOW BASIC ANATOMY like the mastication.
So you must associate V3 with the Masseter muscles which
is easily because the mastication muscles all start with letter "M".
HERE, I think always of eating since we are dealing with
mastication....so I say MMM...I'm Very 3-illled to eat (MMM are the masseter
muscles and Very is V and 3 for thrilled) See? If you think it, it will work!!!!
_________________
419
YOU HAVE TO KNOW THE HYPOTHALAMUS COLD!!! Everyone has a
version because the hypothalamus is SO VITAL! HERE goes...
This is from my neuro teacher and myself!
You will be asked to differentiate the anterior and
posterior hypothalamus:
1) "So think A for anterior hypothalams is A for
autonomic regulation"
2) "If you get spanked on your POSTERIOR, you will get
SYMPATHY" [posterior is sympathetic]
3) The SEPTATE nucleus is SEX urges. "They both only
start with "S" "
4) The suprachiasmatic nucleus controls the Circadian
rhythms. "For this, I think of SUPERMAN (suprachiasmatic) CIRCLING (Circadian)
the globe!
5) The ventromedial nucleus controls appetite. So, this
one is easy..I think "I am VeryMuch Hungry" V-Ventro, M-Medial
6) You know Oxytocin and ADH comes from Neurohypophysis
from college biology, so no student ever asked me for a mnemonic but you can
remember the name NOAh for association.
7) The Supraoptic nucleus controls thirst. So I think
that Supra Optic sounds like Super Openorange juice, which makes me thirsty.
_________________
420
YOU HAVE TO PICK IN A DIAGRAM THE LESION IN THE BASAL
GANGLIA
1) OF HUNTINGTON'S
2) Parkinson's
3) Hemiballismus
4) Wilson's
A1) If you HUNT, you must shoot STRIat (straight) =
Striatum
A2) Lesion in compacta nigra (I Parked a Compact Car)
A3) Subthalamas
A4) Wilson's = He Wil (Wilson's) go STRaight (Striatum)
around the Globe (Globus Pallidus)
_________________
421.
Dear Family,
Again, the below is not copyrighted and is original, but
it will seem like an actual USMLE step 1 case you will see because it resembles
the format of what they feel is important for you to know. Please study it
because you will face the same format and "feel" again and again in similar
concepts:
Case: A pediatric patient of yours named Valentine comes
in with vague presentations involving sweating, poor feeding, respiratory
issues, malaise, tantrums, trembling, confusion at times. History shows the
following: Valentine has on your physical hepatomegaly, hyperlipidemia, and
growth retardation, and his sugars are low.
(NOW, NBME USMLE STEP 1 cases can be VERY VERY LONG…do
you know what this child has? If not, I need to give more information….)
More labs come back and you note that there is glycogen
filling up in the body’s cells. Obtain a lipid profile. Modest elevations in
very low-density lipoprotein cholesterol and triglyceride levels sometimes
occur. Evaluate blood and urine for ketones, especially after a brief fast.
Fasting ketosis is prominent.
(NOW, I believe here a well-prepared student should tell
me the diagnosis…but remember, the USMLE is about secondaries to the disease, so
here is the diagnosis and the relevant secondaries that are within the NBME
sphere of focus)
Answers I am looking for:
1) The disease is of course Cori’s disease, a glycogen
storage disease. (Incidentally, the husband and wife team won the Nobel Prize
for their work)
2) If I asked what TYPE it is, you should tell me TYPE
III. Don't confuse it with TYPE I or the others. There ARE clinical
differences....
3) If I asked if gluconeogenesis is impaired, you should
tell me that it is NOT IMPAIRED…a very common student mistake)
4) If I asked you the MOA, you should tell me that the
debranching enzyme is deficient. REPEAT, DEBRANCHING ENZYME DEF.
5) If I asked you the enzyme itself which is a favorite
on the NBME, you should tell me it is alpha 1,6 glucosidase (NOT beta 1,6
glucosidase, NOT alpha 1,4 glucosidase, NOT gamma 1,6 glucosidase, etc. which
can be all in the answer choices)
Again the above is 100% made up by me and is property of
ValueMD and even though it LOOKS like an actual NBME case, it is an original
presentation and not a recall. But, I would not be surprised if it exists
somewhere in the vaults of the NBME’s sphere of focus. This is just what I feel
is a VERY VERY illustrative example of a “model” NBME USMLE Step 1 question. I
feel I need to say this so that you all do not think I am violating copyright
infringment, but rather educating in my own legal way.
Because the NBME also stresses PICTURES and TREATMENT
and or DRUG, you should also know what the patient will present as and how you
will treat them. THEN you may be asked what are the SIDE EFFECTS of the
treatment and the long term consequences.
IT looks impossible, but it is just like remembering
your aunt’s birthday…except of course you have like one million aunts. YOU can
do it, my professional memory studies show most everyone can, but AT DIFFERENT
SPEEDS. And you MUST HAVE THE RIGHT CONDITIONS AS I EXPLAINED BEFORE (NO 2 hour
study days with the TV on, etc.)
I broke my own rule of putting my concepts out of order
by clicking on them via replies, but I HAD to add that this case is almost
exactly the format and content of what NBME wants you to master.
I am writing this because someone asked me if this was
too much detail because it moves past
FA. While I agree
FA is excellent, you must go beyond it...
Love, Tommy
422.
This is not a case like the previous one but I think it
is just as important to say:
1) You must understand how "to study" such vast
material.
2) This is unlike recall only a pretty girl's telephone
number. You must learn the material in LUMPS, so that is why my HYers are
lumped. Again, to know what is purple, you must know what looks close..so you
must know what black, blue, and deep green look like...
3) Repeat the information in GROUP in pre defined
intervals.
4) KNOW the NBME wants you to get the COMPLETE picture.
Anything goes.
© 2003, 2004 ValueMD Incorporated. All rights reserved.
423.
A reader just emailed me something that I MUST INCLUDE:
1) KNOW that the typical words presentations are being
eliminated. For instance, for the dx POLYARTERITIS NODOSA, know that the words
"cotton wool" spots will NOT be given, but the words will be described in detail
in other less obvious or unique words.
2) Thus, buzzwords are becoming LESS AND LESS important.
Ten years ago, when the USMLE STEP1 was a two day 700-750 question test, there
were a lot of ONE LINERS, so BUZZWORDS WERE in vogue and used a lot. NOW, times
have changed.
3) NOW, understand that VARIETY is flowing into the
USMLE STEP 1. That means more diagrams, MRIs, pictures, photographs, CTs,
flowcharts, biochemical pathways, and variable answer choices (not just A-E). My
sources tell me the test is starting to "become alive" in a way.
424.
Sorry, this is not a case question but know this...
And I do not think the NBME will mind me telling you
this...
USMLE STEP 2 materials are appearing in STEP 1!!!!!!!!!!
Many many have told me that they had questions asking what is the best NEXT STEP
in management of the patient. They could be theoretical questions...but really
who knows
425.
I just received another notice..seriously....from a
student who took the STEP 1 and told me to rely this info to you.
Thus, I am making it a "concept" because it is so
important...
The student came in the testing room and she was seated
right next to the door. During one of the sections, there was talking outside by
someone in the waiting area. Since she was SO SO nervous, it really hurt her,
although she could not tell me if it messed up her questions, but she did think
it may be slowed her down so she had to guess on the last question.
Q) So, what can you do about this?
A) Make sure they offer and make sure you wear your
earplugs. I have heard of some students who are seated by the door that asked to
be moved away and were granted their wish, but I am not sure about this because
I have no proof. Don't underestimate this concept because if you are nervous,
HAVE no earplugs, are seated next to the door and freaked out, that could be
VERY BAD.
426.
Someone just keeps telling me test center advice...(I am
going through my emails too).
BUT I AM INCLUDING THIS ONE BECAUSE I FEEL IT NEEDS TO
BE A CONCEPT...
Bring two government IDs which your exact spelling on
it. One of the students was PULLED OVER BY THE POLICE on the way to her testing
center (maybe she did not know the way and made an illegal u turn or maybe she
was speeding). But...listen...if you get caught by the police in your vehicle
for speeding or something...in MANY of the USA states they WILL TAKE YOUR
LICENSE ON THE SPOT, it is policy...the person who told me this lives in USA
Chicago ILLINOIS. BE careful, but bring TWO government picture IDs. NBME centers
will not let you take the test if you don't have pic ID! Then you will wail out
in agony!!!!!!!!!!!!!!!
427.
Quickie case because people often get this confused!
LISTEN...the marker for Wegener's granulomatosis is
C-ANCA. The marker for Polyarteritis nodosa is P-ANCA.
This IS a crucial fact even though it seems so small!!!!
428.
I don't think this is copyright infringement b/c I am
describing what the NBME is asking you to understand, but here it is:
1) KNOW at least the very very simple basics of general
chemistry and physics. Two of my students got these questions.
I cannot repeat the exact ones so I won't break
copyright, but it had to do the delta G Energy stuff and enzymes for General
Chemistry; and the PHYSICS questions had to do with LUNGS, gases kinetics; and
another PHYSICS question had to do with flow equations and BLOOD
VESSELS(remember the liquids and solids equations?)
429.
While we are on the subject, just for completion, I MUST
SAY THIS:
ONE OF MY STUDENT TOLD ME HIS COMPUTER MALFUNCTIONED
DURING HIS TEST! during his personal test day!!!
He said that he came out and the proctor told him that
this never happened before on his watch, and then told him to call a place
called CANDIDATE CARE and gave him a card.
I have NO IDEA what the computer problem was, or even if
the student's problem was legitimate but I left the need to tell you what to do
if such a crazy thing happens.
I was told that he was informed that he may get another
testing day later, of course though he will not be charged as such.
430.
I learned this is VERY CRUCIAL:
Case: You open your door and in comes a guy like Beavis
who asks you, a pathologist, to identify a bug on a slide from a patient with
respiratory symptoms:
YOU see fungi appearing organisms. They have long
branching filaments/rodlike structures under microscope. You are thinking MUCOR,
but Gram stain produces gram positive rods.
Q) What bug is it? But the NBME will likely want you to
tell the difference between it and another related morphological bug that is on
the skin.
A) You are looking at NOCARDIA, an acid fast aerobe you
can catch walking barefooted in soil. You can get respiratory symtpoms.
A2) Now the secondary is the bug ACTINOMYCES, a VERY
common bug growing on your skin. It can infect the sinuses and is a gram
positive anaerobe forming sulfa granules.
WOW, see how interesting this is?
431.
ALL NBME questions are noted by their test takers as
being so VARIED...that is because of the sheer number of questions that they
have and the number of people writing the questions.
SO, some of the questions will be very direct and SHORT.
AND others will be so LONG that you have to SCROLL down
to read the entire QUESTION! Some questions I was told told seconds to answer,
some took almost 6-7 minutes due to 20 different lab results they had to study!
That said, here is one:
ORIGINAL VALUE-MD CASE: A 16 year old patient named
Thelma comes into your clinic with burns all over her body (1st and 2nd degree).
After discussing with the family to rule out abuse (which you are required by
law to do), you must start with what?
Ans1) IV fluids
Q2) Then, you note that her tetanus booster is two years
ago, so what do you do?
A2) You do NOT have to give a booster, the time interval
is 5 years...
Q3) What two main bugs if asked are you worried about
initially?
A3) Pseudomonas of course and also Staphylococcus
Aureus. (You must smell the wound site, if it smells "fruity" like grapes,
Psudomonas is more likely).
Q4) So, the NBME and attending asks you what meds will
you grab?
A4) You must grab 3 types: Morphine, NSAIDS, and an
Antibiotic
Q5) Grab MORPHINE SULFATE FOR THE PAIN. But what do you
be aware of before administering it?
A5) Ask her if she is taking MAOs for depression. Also,
ask her about hypersensitivity and if she is pregnant because the respiratory
DEPRESSION may hurt the baby.
Q6) After NSAIDS (no questions here) what two
antibiotics are recommended typically today in the USA in this case (AND YOU MAY
HAVE OTHER CHOICES ON THE TEST AND IN LIFE--this is ONLY A GUIDE BUT A USEFUL
ONE)?
A6) Grab Silver Sulfadiazine and Neomycin. They should
be good coverage. BUT, they are NOT the ONLY choices...so if on your test or in
life you don't HAVE those choices, just pick the ones with Staph and anaerobic
coverage!
See ya!
432.
This post has both answers to reader questions and a
case:
Q) Why is
FA not good enough for everything? And why is the students' mental processes
in error? And what can be done?
A) Consider a classic case and question I posed to a
group of my students: I asked, "IF YOU ARE ASKED ABOUT LESCH NYHAN DISEASE WHICH
IS A NBME FAVORITE, TELL ME ALL YOU KNOW?" I presented a case with a boy in his
teens with A HISTORY OF OCCASIONALLY FLANK PAIN!
Their response was the EXACT WORDING, "Self mutilation,
Nail biting, Retardation." That was it. Then after waiting, one of them said,
"HGPRT".
OK, but the NBME knows most med students are the best of
the best and will know these 3 bits of info so you will likely NEVER see them. I
remember one student told me that NBME presented the disease with a presentation
that was close but not in those EXACT WORDS, (like nail biting). So, my QUESTION
TO YOU is the following:
Q2) What is causing the flank pain?
A2) Kidney stones from excessive URIC ACID (that can be
another question!)
Q3) You find out that he is on a thiazide diuretic
medication for these kidney stones and a uricosuric called probenecid because
his last doctor thought/heard that thiazide diuretic treat kidney stones and
since uric acid is the problem, he gave him PROBENECID? Do you agree with his
last doctor (hint: he was an inexperienced sub intern)?
A3) NO, he was wrong, the thiazides are contraindicated
from Lesch Nyhan pts. and the uricosuric will only make stone formation WORSE.
Q4) Therefore, what do you change his meds to? And MOA
of new drug please?
A4) He needs Allopurinol.
Q5) What ENZYME does allopurinol inhibit?
A5) It inhibits XANTHINE OXIDASE.
Q6) The NBME and USMLE give all the above in a case and
then ask if anything else you should give him for prophylaxis that is NOT a
prescribed drug? (VERY IMPORTANT)
A6) You MUST give him hydration.
Q7) If I gave you a picture of the brain on MRI with
arrows, which structure is affected in this dx?
A7) Pick the arrow pointing to the basal ganglia.
Q The NBME and Attendings LOVE to asks this in mult
choice form:
What is the genetics behind Lesch Nyhan?
A X linked recessive, so you mostly always see it in
MALES. (although theoretically possibly presented in females which it has been
reported, the NBME will not ask a bizarre EXCEPTION)
PLEASE PLEASE, use this and others as a MODEL for what
you NEED TO KNOW. The one step questions like "What is the capital of New
Jersey, USA?" Answer: "Trenton". They are GONE! (naturally, you won't be asked
USA geography...but you need to get the concepts and THEORY)
Please keep asking me about BUZZWORDS. There are being
slowly ELMINATED. IT does not mean you should forget all of them, because they
may present the buzzword in OTHER COMMON words. But know this fact while you
study!!
Did that answer your questions? (I am addressing my
email question readers)
433.
Q) Key concept: An accident victim comes to your clinic
named Louise. She has a hemoglobin level of 9. Your attending asks you if you
will IMMEDIATELY transfuse. She is alert and oriented times 3.
A) NO, you transfuse usually in clinics (and boards) if
the patient is showing clinical signs. Even if her Hemoglobin is low. BUT, that
said, if her hemoglobin was under 7 (remember that number), then pick
transfusion. I know I would....what do you guys think?
434.
Q) Case: This is a tough tough subject but a HY one: You
have an older patient named Robert who comes to you with mild depression and
dementia. (BE CAREFUL, DISTRACTORS ARE ALZHEIMER'S, etc.). But I tell you that
during PE, I touched his facial nerve and it twitched. And his PE reveals some
muscle spasms (tetany). HE also presents with mild KIDNEY disease....
So if I ask what mineral(mineral, specifically) is
deficient which is specifically related to his tetany and presentation, which
one will you PICK? What dx? (HINT: this is not dementia)
A) Calcium is deficient. Think of the link with the
kidney and its regulation with Vit D which is needed for Ca. I saw this exact
CASE during one of my on call nights!
Q2) What typical sign is found on ECG which confirms
your suspicion?
A2) The QT interval is lengthened. This is CLASSIC..
(Again, CONCENTRATE ON THE FORMAT, of the above case and
secondaries. These are NOT from
Kaplan or NMS or big publishing house. They are from solely my experience as
a teacher which I FIRMLY believe are better suited for you for STEP 1 and the
clinics, because they do not go TOO light or TOO deep into the material...like
the story of Goldilocks and the BEARS, the soup is just right. NOW STUDY STUDY
STUDY STUDY, until you collapse!! Do it NOT for yourself, but for your future
PATIENTS WHO NEED YOU!
435.
BIG POINT:
Case: A female pt of yours named Wilma comes in with
vaginal bleeding with red lumps of cherries that are coming from her vagina. She
believes she is pregnant from high HCG. BUT...I know you are NOT going to choose
"abortion" as a choice because I am telling you that there are weird size and
date assessement problems in history...
BUT, if you need more...the NBME and attendings will
tell you that there is a BUZZWORD...a snow storm pattern on ultrasound and no
fetus.
Q) NOW, you should tell me the dx, (IF you guessed it
before the buzzword then you are doing great!)
Q2) Tell me the karyotype IF the mother's chromosomes
contributed. HARD, but definitely NBME wants you to know.
Q3) What condition does she have PRIOR to her third
trimester involving her BP?
Q4) Treatment Rx?
Q5) What dx can happen if you don't treat?
Q6) What enzyme does the drug I asked you for (which
starts with the letter "M") act on?
A1) Hydatiform MOLE if only the father's genes came on
board. It is called an incomplete mole if the mother contributes her genes and
you will see fetal parts...
A2) 69 XXY, be careful, I asked you about the mom so
this question addressed an INcomplete mole, not a hydatiform mole which is 46
XX...which only involved the father..
A3) Her BP is very high which is called "pre eclampsia".
Which YOU MUST address promptly. If she is of right gestation, you must
deliver...(This is a concept and question by ITSELF!!!!)
A4) Give methotrexate and monitor HCG after delivery
until it goes to zero.
A5) Choriocarcinoma or INVASIVE MOLE!
A6) Methotrexate acts as you recall on my previous posts
acts in the SYNTHESIS PHASE of the cell cycle and block DHFR or dihydrofolate
reductase.
AGAIN, TO ADDRESS A READER QUESTION, PREVIOUS TEACHERS
OR EXAMINEES ARE THE VERY BEST SOURCE OF QUESTIONS OF CONCEPTS FOR THE USMLE
STEP 1. It takes a lot more work (I think I spent about 600-700 hours already),
but YOU EXPERIENCED ONES ARE IN GREAT POSITION TO WRITE THE BEST POSSIBLE
QUESTIONS SINCE YOU KNOW WHAT THE NBME NEEDS YOU TO MASTER, PLUS YOU HAVE CLINIC
EXPERIENCE FROM ROTATIONS, and STEP 1 ADDRESSES A LOT OF 3rd YEAR CLINIC STUFF!
JUST DON'T VIOLATE COPYRIGHT AND REPEAT EXACT QUESTIONS...think of the concepts
and make up your OWN UNIQUE QUESTIONS, then the NBME will be HAPPY with our
attempts!
436.
Copyrighted Original ValueMD Case:
Case: A patient walks into your clinic named Bruce and
is a farmer's helper living in Indiana. He is asymptomatic but has an radiograph
with a coin lesion (1 cm sized) that is calcified on a upper lung lobe. The
lesion has not grown in 18 months (from his chart), and he has no PE symptoms
otherwise. He is otherwise obeying HEALTHY habits (no drug use, smokies)
Q) What is the dx?
A) Because he lives in the Midwest USA, he likely has a
benign granuloma from histoplasmosis since he also works on a farm. Since the
lesion has not grown in 18 months, it is mostly likely NOT LUNG CANCER WHICH
MUST BE RULED OUT AND YOUR ATTENDING WILL KNOCK YOU SILLY IF YOU MISS THIS AND
HE the patient...DIES. The attending will lose his house, his car, and his
friends.
Again, the clues that the lesion is only one cm. Second
he has good health habits. Third, the lesion has not growth in 18 months and he
has no other symptoms which pushes your thinking into a benign HISTO Ca lesion..
437.
Here we go again, today is Sunday, and church and prayer
day. Now that I can take a quick break away from praying, here is a question:'
ValueMD copyright case: You are on a plane bound for Los
Angeles to do a lung transplant. Sitting in the middle seat, you have two
passengers sitting next to you. The man on the left Bob, excited he is sitting
next to a budding doctor, asked you a couple of questions:
Q) "I just took these drug called Edrophonium because my
IM doc wanted to see if I had a disease...I cannot recall the name, what is it?
A1) This short lasting drug is used for diagnosis of
myathenia gravis.
Q2) Then Bob asks, "I ran out of meds and my friend gave
me a drug called Bethanechol." He said it should work the exact same for my dx
MOA. Is that true?
A2) NO! Bechanechol is ALSO a cholinomimetic, but HAS a
different MOA. It is used often in OB patients for urinary retention, and it is
a direct muscarinic agonist. His drug, Edrophonium is a CHOLINESTERASE
INHIBITOR, and thus works indirectly by keeping ACh in the junction longer...
Q3) He pulls out a drug pharmacy box with a drug called
Neostigmine, which his IM doc gave him. He then asked you the MOA exactly?
A3) This, like Edrophium, is a cholinesterase inhibitor.
But it lasts longer so it is used for myasthenia gravis chronically. Its MOA is
that it CARBAMYLATES cholinesterase at the NMJ, and causes the cholinesterase to
stay inactive to HYRATION RXNS.
Q4) Then Bob asks you what would happen to his AV node
in his heart in case he took the entire bottle by mistake?
A4) This class of drugs will have THE PARASYMPATHETIC
EFFECTS at high doses. Remember the M2 receptors in the heart? (THEY WORK VIA a
7 MEMBRANE G COUPLED RECEPTOR that is INHIBITOR in this case. Second messengers
are ADENYLATE CYCLASE WHICH HYPERPOLARIZE WITH POTASSIUM, then lowering cAMP,
then PROTEIN KINASE A is lowered....DO YOU RECALL ALL THIS? Can you label all
the protein enzymes in a blanked out flowchart? THIS IS A VERY VERY VERY
IMPORTANT concept you cannot forget. Do you recall my mnemonic with the chip
company AMD inhibiting dominant chipmaker Intel so letters A, M, D for the 2nd
subtype of receptors as AMD is second to Intel are all working via the same
MOA!)
So, the answer is that the velocity through the AV node
will be reduced!!!
Q5) Next, Bill sitting to your right says that he was a
FORMER PSYCHOTIC who overdosed with a D2 blocker drug and the ER have him
PHYSOSTIGMINE. He asks you why couldn't he use Bob's drug NEOSTIGMINE?
A6) CRITICAL PT I mentioned long ago....PHYSOSTIGMINE
can cross the all important Blood Brain Barrier and so is used for
antimuscarinic cases of D2 antipsychotic drugs in the CNS...NEOSTIGIMINE CANNOT
CROSS.
Q7) Then, he asks you how will he know if he took too
much PHYSOSTIGMINE?
A7) Remember, lump stuff together. This is a
cholinomimetic and will cause the associated symptoms which you MUST KNOW ALL OF
THEM like miosis, it will make people feel like urinating, etc.
Q) Why then is Physostigmine more dangerous than
Neostigmine? Think about it first...
A Because it can cross that Blood Brain Brain, an
overdose will lead to respiratory depression and cardiac depression.
IF YOU REALLY UNDERSTOOD THE ABOVE CASE, YOU ARE DOING
WELL!! Really focus on the words that I capitalize and know that you need to
know EVERYTHING in detail. REREAD the above text over and over. I spent so much
effort to give a NBME-philic case you can model your thinking around...
Tommy
438.
You know all about ATYPICAL PNEUMONIA from MYCOPLASMA
pneumoniae right? But tell me three things quick!
1) Is the cough productive?
A1) NO
Q2) Are the antibody titers WARM OR COLD?
A2) They are positive COLD antibody titers.
Q3) Is the treatment Penicillin G or Penicillin V or
NEITHER?
A4) This one needs a protein blockers like Erythromycin.
439.
You all know the most common primary bone tumor the NBME
will ask is MULTIPLE MYELOMA.
Q) What is the 2nd most common primary bone tumor?
A) Osteogenic Sarcoma...do you know the age, and tx, and
side effects??
440.
YOU all know that Glioblastoma Multiforme is an NMBE
favorite and is the most common primary brain tumor in ADULTS.
Q) But is this the same in children?
A) NO! The most common primary brain tumor in kids is
medulloblastoma. Could you point it out in an MRI? Do you know the Rx?
441.
Q) You know how to spot a clinical case of the CREST
syndrome in a women right? First, think about it...Very important...when the
labs come back, which autoantibody are you looking for?
A) The anti-centromere antibody.
442.
Q) We review a child with Celiac Disease and you KNOW
who diet he must follow. Right now, as a review, tell me what lab antibody type
are you looking for to confirm the diagnosis?
a) Antigliadin antibody
443.
Q) LUPUS in a women can be so devastating...
So tell me the two antibodies for SLE and THEN tell me
the antibodies for SLE that was drug induced, and THEN tell me the drug which
could have caused this crisis!
A) Naturally, you are looking for anti double stranded
DNA and ANA antibodies (single stranded DNA antibodies are a common error) Also,
you KNOW that my mnemonic is "Women have nice HIPPS." So...
H ydralazine
I zoniazid
P Phenytoin
P Procainamide
(Just for your info, know the commonest TRADE names for
some of these drugs. I even heard LASIX is often substituted TOTALLY on the
USMLE TESTS and in clinics for Furosemide. Just like KLEENEX (brand) is known
better than tissue... and BAND AIDS (Brand name) is used more than "adhesive
bandages". But these are exceptions...99% of the time the USMLE sticks to the
generic names.
444.
Original Clinical Case Copyright ValueMD and Family:
We previously discussed cancers. Did you know you could
be presented in clinics and USMLEs with a case addressing cancers and different
organ types? KNOW that the most common cancer in any organ is metastatic and DO
NOT say primary type. Now here it is:
Q) That said, you have an older gentlemen named Crandle
and he comes to you with spiking back pain. On exam, he has loss in his arms and
legs, loss of motor function. You suspect metastatic cancer of the prostate to
the SPINE. What are the classes of drugs you will be asked to master for this
MOST COMMONLY diagnosed cancer in the US (LUNG Cancer is the most common death
from cancer, but PROSTATE is most common in DIAGNOSIS)
A) There are several, and you may be asked all of them,
the MOAs, and their side effects. They may give you like a drug series and asked
the drug class missing. And their MOAs and Side ffects/ SE may be decribed or in
a pictorial form. So know that YOU HAVE to master the below information like
your father’s birthday.
Finasteride, KNOW it is anti androgen, KNOW it acts to
block 5 alpha reductase. KNOW it blocks NOT testosterone directly, but the
conversion of testosterone of testosterone to dihydrotestosterone (A critical
fact). KNOW the SE involves liver failure and loss of libido and impotence.
Flutamide, KNOW it is a NON STEROIDAL, an antiandrogen
confused with Finasteride. It is a MOA involving androgen binding and uptake
(these MOAs sound the same but are drastically different especially on the USMLE
and in “pimping?) All of these will be answer choices, and you will forget
Flutamide from Finasteride!
Leuprolide (Lupron is OH SO COMMON) ?KNOW that its MOA
involves a synthetic nonapeptide analogue of GnRH that acts as a potent
inhibitor of gonadotropin secretion, that is, LH and FSH is decreased.
Bisphosphonates, I told you he had bone pain, right?
KNOW that they stop bone resorption via osteoclasts and NOT reving up
osteoblasts MOA (another common answer pick mistake)
Paclitaxel (Taxol), Prostate cancer is hard to treat
with chemo, but you will have to know that the MOA binds tubulin!
Prednisone ! I betcha you didn’t know that, right? It
helps via MOA of lowering PSA levels.
Hydrocortisone Cream—KNOW positively the MOA--which is
blocking inguinal capillary permeability and inhibiting WBCs leaking and causing
inflammation to the prostate. KNOW that you MUST ASK if the patient has thyroid
issues..
Ketoconazole: EVEN AN ANTIFUNGAL IS GIVEN! KNOW that
this MOA Produces responses similar to that of anti androgens. They block a
variety of cytochrome P-450 enzymes, including 11beta-hydroxylase and
17alpha-hydroxylase, which in turn inhibit steroid synthesis. Could you remember
all of that? If you don’t get a question on this on STEP 1 you WILL be asked at
some other time ALL of the ABOVE INFO.
Q) What is the market that doctors look for to see
Prostate cancer?
A) PSA and alpha feto protein!!!!!
Read the ABOVE POST MANY TIMES, it is confusing! At
least thirty times because there are 444 possible questions in the above post!
Q4) Also, I forgot to mention, what SPECIFICALLY DO YOU
TELL TO a patient you are IDed as risks for PROSTATE CANCER?
Q5) Besides age, due to its genetic linkage, prostate
cancer is more frequent in patients with a strong family history of prostate
cancer. Likewise, people who smoke, African American males, and patients who
consume a diet high in animal fat or high in chromium have increased incidence.
DO NOT FORGET! I SHOULD HAVE BROKEN THIS POST INTO 44 posts, but I WANTED you
guys to lump them together! For better recall!!!
_________________
445.
Regarding PROSTATE CANCER and the previous case:
Q) You suspected prostate cancer in a second patient who
comes in after the first one name Harold. Harold though, has an enlarged
prostate from the famous M3 student consult anal exam, and you start anti
androgen treatment. He does however decribe his bone and sense pain with AN
EXTREME EMPHASIS ON ABRUPT SUDDEN ONSET OF LEG PAIN too. You continue with
prostate cancer tx. Then six months later, your senior attending got sued and
lost his Mercedes and is bicycling to work.
What KEY mistake and dx did YOU MISS? VERY important!
A) You missed the easily and common mistake that the
older guy with a large prostate actually had SPINAL CORD COMPRESSION/SLIPPED
DISK which needed an Emergency surgery with an ORTHOPEDIST. Very common
mistake...
_________________
446.
Q) Still, another guy with another enlarged
prostate...you are running short of surgical gloves...presents with the same
symptoms as the first patient. You start prostate cancer therapy again but CHECK
the CT to rule out spinal cord fracture to not repeat the same error. A new
hematologist comes by and asks if you need her but you say no way...
But then...the replaced attending AGAIN is sued a year
later and you see both of your past attendings losing their Mercedes and riding
on a tandem bicycle to work together. What COMMON dx did you overlook and fail
to rule out?
A) Many, many, leukemias and lymphomas can mimick the
presentation clinically of prostate cancer patients. YOU HAVE BEEN WARNED BY
VALUEMD AND ME! You had to have chosen a different treatment. Say goodbye to a
good residency slot...sorry....
_________________
447.
NOW, you have seen a fourth patient name Jordan who is
an older African American who smokes two packs a day for 40 years, eats only
steak meat, has 6 children and wants no more kids or sexual relations in his
life, and all his male ancestors had prostate cancer....he heard about your past
two attendings and your mistakes...and he refuses all RADIATION THERAPY AND MEDS
FROM YOU because of your common mistakes. But he still likes you and you are
part of his limited HMO plan.
Q) You offer a surgical intervention, and he accepts...
What is the NAME of the intervention and what did you do to him that WAS PROVEN
IN MANY RESPECTED STUDIED TO LIMIT PROSTATE CANCER IMMEDIATELY?
A) You did a radical prostectomy and orchiectomy. That
is, you castrated him. Not too pleasant, but very effective, and VERY ASKED!
_________________
448.
OK, you get a fifth patient in who just saw Jordan your
last pt limping out with pain from the surgery. The fifth guy KNOW everything
now and was refered to your clinic and is only asking advice. His LOCAL PROSTATE
CANCER is being controlled with meds, but his GLEASON score is 6. (KNOW the
Gleason grading since PROSTATE cancer is oh so common)
Q) He asks what are the chances of METASTASIS (which is
often fatal) for him?
Q) Also, what is the MOA the metastasis if he is good
with his meds intake?
A1) After stage Gleason 6, metastatic cancer is
expected. About half of all localized prostatic cancer WILL metastasize even
will full meds tx.
A2) The reason for this--even though aggressive meds are
used--is due to resistance from ANTI ANDROGEN HORMONE REFRACTORY DISEASE FROM
CANCER CLONES.
,
Now, you must remember your readings in PSYCH texts on
how to "break bad news". Really, something like this happened to me. There are a
lot of tears and it is VERY VERY awful. And I am serious.
_________________
449.
MANY MANY USMLE WRITERS want you to understand BASIC
NUTRITION. For real...
So...
Q) A sixth patient a 15 y.o. high schooler, walks into
your clinic named Siegfried. He had a father named Roy who just died of prostate
cancer at 45. He has ALL the risk factors on history. You tell him because he
asked, that IT IS TRUE THAT CASTRATED MALES LIVE LONGER. And he is so afraid
also of meds, but he tells you to "put away the scissors, I am still a young boy
who wants to date girls..and guys". So he asks you about how he can change his
diet? You answer what?
A) Have him eat a lot of tomatoes, broccoli, Asian green
tea, soy products, licorice root, selenium, and antioxidants and the vitamins.
Seriously, the NBME will ask you to answer some basic dietary questions.
_________________
450.
Q) Finishing up, what med can be asked and can be used
if all the mentioned drugs fails? AND give me MOA?
Q) I forgot to ask, what is the difference in MOA of
drugs Leuprolide and Abarelix? (YOU KNOW TO KNOW THIS FOR STEP 1).
A) You can give Suramin for refractory pts w/ MOA of
INHIBITING GROWTH FACTOR for prostate cancer tx.
A2) Leuprolide is a GnRH analog and acts via competition
so lowers LH and FSH.. BUT.... drugs like Abarelix are GnRH receptor
antagonists...so be ready to know that the MOAs are different, but both lower LH
and FSH and thus .... dihydrotestosterone.
_________________
451.
--If you see enzyme disorders, and are asked by your
attending or NBME, what is the mode of inheritance (YOU HAVE TO KNOW ALL OF THEM
COLD), then "usually" this is Autosomal Recessive
--If you see musculoskeletal, structural protein,
endocrine thyroid pancreas, and neurofibromas, then guess Autosomal Dominant.
[Of course there are exceptions, but I am desperately
trying to "lump" because it helps if all else fails]
_________________
452.
Dear Future M.D.s,
I am now flooded with questions in my various mails. I
love them because helping is fun! At least I think so. And the same questions
come again and again..
1) For IMGs, a serious problem that just won't quit is
the language barrier. I think this is the MOST difficult one to handle because
time is a necessity. Please read one of the past posts which addresses this
well.
2) Some of us IMGs are asking what books to study. This
question is definitely one of the top five questions ever asked. I feel you need
to start with
First Aid and choose ONE or TWO of the series:
BRS,
Kaplan Notes, HY series, or
Board Simulator Series or Step-UP.
AND two additions are Goljan's Notes and a GOOD
PATHOLOGY/MRI atlas! (Here you could do Robbins or do Webpath). People do not
realize how visual the test is. They had 99.9999% of their tests in life without
any pictures. But whoa, some of my students get image after image which all look
like a case of pharyngitis.. or they get these abnormal HISTO PATH pics of lung
diseases which all look the same. So, you must must pick a VISUAL source for
your studying.
© 2003, 2004 ValueMD Incorporated. All rights reserved.
Then, you must read and re read the same material. If
you keep switching, I saw students getting confused and lost. Also, the ones who
stuck to JUST ONE SOURCE like
BRS Biochemistry, ended up almost MEMORIZING the words and pictures. It
happens to everyone. You pick up like
FA over and over and then you for example....know that in the Pharm section
the microbiology drugs are discussed first. It helps with memory skills.
3) Many asked about question banks. That IS critical. I
have heard some say they passed with ONLY DOING QUESTIONS. I think this approach
MAY work for some who have the basics DOWN but I do NOT recommend this for most.
But if you lack the fundamentals, then doing
Kaplan
QBank or
BSS is really just wasting your time. You are better off watching a movie or
giving your significant other a backrub/backsctrach. Because you will not retain
the information. I saw students continue doing like QBook over and over and over
and they were getting higher scores because EDUCATIONAL THEORY TELLS US THAT YOU
ARE ONLY MEMORIZING QUESTIONS. It comes up again…you are like driving down the
road to your work and there are vague stuff around that guide you. But you
cannot stop and tell me the name of the road after “USMLE avenue?or the number
of right turns after the gas station. The brain forms these patterns…and they
will not repeat on your real exam. Especially if you are doing questions at
random without linking subject material together in a “SPIDER WEB?like
configuration in your brain.
SO...my advice is?YES, do ValueMD questions first, they
are done by former Step 1ers who are constructing new novel material that will
prepare you for the real exam because they understand the focus and theme and
flavor of the exam to make you a better doctor. Also, when you sit for the real
exam you will be amazed at the sheer VARIETY of the questions. Some are
detailed, some are short answer, some are IMPOSSIBLE, some (just a couple) will
actually just like point an arrow to the nose and ask, “What is this?”…meaning,
a couple of the questions will be very easy. But the sheer variety is what makes
me believe the NBME USMLE Step 1 is like the universe. Of my hundreds of
students, hardly a single exact question repeated when they naturally discussed
them over nights, lunches, etc. BUT, THE SAME CONCEPTS CAME UP IN ALMOST EVERY
TEST. A perfect example of this is the second messenger concept. I tried to give
a mnemonic that works miracles for me…but it may NOT work for you.
Thus, I suggest doing questions (after the ValueMD ones)
by grouping them.
Kaplan is good, but then do
BSS and Princeton Review, and then Board Review Series, then Pathology
Review by Robbins (with pictures), then NMS. Naturally, you will run out of
time, but at least you are using the right method. Again, do questions by system
and subject or you will not retain anything. That is why in the OLD DAYS prior
to the printing press people memorized by LUMPED stories, using rhyming
techniques, timed repetitions, etc. to memorize texts as thick as the BIBLE.
They had to…how do you think you got the present version of Homer’s “The Iliad?
If those same people just picked up the BIBLE at random, read a verse, shuffled
the pages, read another verse, they may someday catch up, but the time for
mastery is unacceptable. Admittedly, there are some, just a few of my students
that blew me away in their capacity. They were only a couple out of thousands,
and many never wanted to use their powers of memory for anything. So again,
doing organized systemized questions in a formalized interval is the solution.
4) Many many questions are coming up about
QBank analogies and the general time frame for preparation that I
recommended for STEP 1. Mastery of
QBank is only a rough measure of how you will score on the real exam.
After taking many polls, I found all sorts of
statistical anomalies. One of my best friends matched in a competitive Radiology
program and blew through 250/99 but was reportedly scoring about 65% on
QBank. NOW, before you get too excited, there were students beating 70%-75%
on
QBank but failing!!!!!!! Also, a close relative of mine was scoring
consistently around 50% and barely passed. After many many statistical points, I
would argue that if you are getting around 50% on
QBank, you are “close?to passing. But what examinees do not realize is the
REAL STEP 1 is HIGHLY VARIABLE IN MATERIAL. Thus, good sources told me that some
had deep emphasis on pharm, others on pathology, others on virology…one girl
said she got mostly all immunology. And through a third party, I heard of a
brilliant US med student who was aceing med school and doing 80% on
QBank but failed his first time because he got a lot of questions on
difficult new research in Molecular Biology. Thus, I recommend what I said
before. I do think
QBank is a VERY good source of questions, but you need varied question
sources but you have to organize them properly.
Also, many asked me for a solution and detailed their
situation where time was a serious problem. Some had to prep for STEP 1 within a
few days only, and some had the time for prep but the situation was too
unwieldly…many, because we are the IMG family have unusual circumstances.
Several desperate mails came because the students had children or sick parents.
My heart breaks…because how will you push a square peg into a circle? YOU MUST
RECEIVE THE TIME YOU NEED. Unlike a few tests that rely on math, or
interpretation skills (LSAT comes to mind), life experience in literature (SAT I
Verbal Section), the USMLE STEP 1 material cannot be gathered by life’s chance
or opportunity. For instance, you will see Xeroderma Pigmentosum because it is a
wonderful concept involving DNA and thymindine dimers and repair defects. But
did you know that maybe if you are lucky you will find only 1000 people in the
entire WORLD of 7 Billion with the disease? That is why THIS TEST NEEDS AND
DEMANDS YOUR 100% ATTENTION and SUITABLE TIME that you need. Again, if you need
maybe six months of 12 hours/day prep, do not feel that you are less smart than
someone who studied in three months. Common society has determined that the
second person is “twice?as smart, but that is NOT TRUE. There can be ONE MILLION
reasons why one needs more time, but what I personally found was a
“VARIABLE?related to reading speed and another “VARIABLE?related to processing
speed. I knew of one of my friends who went to U of MICHIGAN and works at NASA.
He was a super smart guy and blew everyone in my high school away (For you IMGs,
U Michigan like U California, U Virginia, U Miami, U Washington, U Texas are
among an ELITE GROUP OF COLLEGES EQUAL TO THE USA IV LEAGUES LIKE HARVARD.)
Anyhow, my point is that some people are smart enough but I researched there are
about a dozen measurable quantifiable “intelligence?points of reference. It is
like a MACHINE that has many parts. All the machines can finish the work, but
some take longer because maybe one part of the machine is not as efficient. BUT,
that “slower?machine may produce higher quality products. Think of a HP PHOTOJET
and HP LASERJET series #. The PHOTOJET makes BETTER CLEARER pictures, but the
LASERJET is faster. But BOTH make copies and BOTH have value and BOTH are
HELPFUL. So, you need to understand yourself and your limits and what exact time
you need. If you do not approach this properly, then you WILL BE ONE OF FAILURE
STATISTICS.
5) I will need to continue this thread of concepts
because I note that there are additional questions in my mailbox. But please
digest the above information. Oh, by the way, I believe my suggestion of
notecards are effective. Make some up with say Pharm which are easier to
develop. Then start front card #1 and move backwards. If you are getting say
card #26 wrong, then move that card forward so your repetition schedule for that
question/concept will be seen more often. If say you mastered cards 40-46#, then
they will end up toward the back of your index card box. Thus, you can start
scientifically measuring your RETENTION LEVEL and READING SPEED LEVEL. There is
a whole science to this that I feel I should tell you, but I need to go for a
while. So, for the 2 Ross students and 4 East European students, etc. you SHOULD
be worried about the time and scheduling.
6) Quickly, also know that the US students are NOT
smarter than IMGs but they are better at the STEP 1 because of many reasons.
Some include that they JUST FINISHED THE BASIC SCIENCES while some of the IMGS
had them long ago. Also, many of them are “coached?by their schools from Day ONE
with USMLE type questions (pics and all). Plus, the ones that write the test are
mostly the ones that teach and test the US students. So, I believe that ALL IMGs
and USAs are equally smart for the most part…Even if that was not true, it is
NEVER a reason to give in.
LOVE Tommy
453.
Quickly, you are viewing an radiology report and seeing
polyps in the colon--hundreds of them?
Q) What is this disease and the genetics and will this
proceed to cancer?
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
A) After R/U IBD, this is Familial polyposis coli, which
is AD and mostly becomes malignant!
_________________
454.
ON CLINICS, USMLE STEP 1 you have to KNOW lead poisoning
because...about 5% of all children have elevated blood lead and about 25% of all
low income US children living in pre-1950 homes have elevated blood lead which
can cause mental delay, anemic symptoms, bizarre behavior, GI upset. STEP 1
needs you to understand that LEAD POISONING IS SO COMMON BUT SINCE it is easy to
miss (symptoms are non specific), you need to be aware because if you fail to
order a blood lead level test on an at risk pt, you might as well become a city
car ticket handler because you will lose your medical license:
Case: A boy named Donny Dosman comes in with nonspecific
symptoms like hyperactivity, diarrhea, and occasional tired spells. YOU suspect
Lead poisoning.
Q) What is the MOA of the medicine that you will pick as
the DOC?
A) As we mentioned once, BAL or Dimercaprol works via
chelation and is water soluble and rapidly crosses the blood-brain barrier.
Forms a nonpolar compound with lead that is excreted in bile and urine. DOC in
patients with acute lead encephalopathy, in whom first dose is given and then
the second dose is given combined with calcium EDTA after a four hour interval.
Remember that the Ca salts can also treat hyperkalemia! BTW, you found that
Donny ate PAINT CHIPS from his old apartment.
_________________
455.
You Lead intoxicated patient, Donny, then tells you from
his history (he is an African American patient), that he has something called G
6 PD def.
Q) Do you continue with the BAL treatment?
A) NO! BIG legal mess. And you may kill the patient. BAL
in G6PD def pts can hemolyze blood cells.!
_________________
456.
Q) Donny's mother then tells you she has a sister with a
baby who is living with NO LEAD INTOXICATION RISK FACTORS in a new house. You
see the baby named Shazam in your clinic at his one year birthday. Do you need
to do a lead screen?
A) Yes, you still have to do one, and every 2 years
thereafter on this low risk baby.
_________________
457.
Your patient Shazam (recall, he is a baby), is 100%
breast fed. His mommy asks you if she should give IRON supplements b/c she read
it in a magazine.
A) NO, breast milk has enough iron. Give IRON
supplements to formula fed patients unless the Formula can says "supplemented
with IRON".
(This sounds advanced, but I KNOW it IS STEP 1 material)
_________________
458.
Yow! Donny's Father then walks in for a quickie checkup.
In his PE, you ask to see his tongue to test CN 12 but you note that you see
something awful...he has ORAL HAIRY LEUKOPLAKIA. (Review picture) In such a
case, what..
Q1) What two common patient populations will you get
with this devastating dx?
A1) AIDS patients and heavy smokers and drinkers.
Q2) What virus if asked/pimped is involved? (Do you
recall the viral structure and Family?)
A2) This is Epstein Barr Virus, EBV. IT is Double
stranded, enveloped, linear, and part of the HERPES family DNA. It is also a
cause of Burkitt's and mononucleosis!
Please do recall ALL the points here. The USMLE and
attending may trick you and ask if the EBV is an RNA bug, which is wrong. And so
you will have gotten so far but ended up short....
_________________
459.
Your previous bad luck with all those prostate pts is
forgotten, now Donny brings in three relatives with back pain (YOU WILL SEE
THESE EVERY MINUTE DURING ROUNDS AND IT IS A CRITICAL CONCEPT)...
Q1) Donnycousin1 is 20 yo and is lifting heavy boxes for
UPS as a job. You sent him on his way after ruling out deadly causes and
confiming a "pulled deep back muscle". Did you do right by him?
A1) I KNOW I am sounding "picky" but you are mistaken.
The NBME needs you to know that even a young man with a recent pulled back
muscle should be advised to wear a "weight lifter" hip belt.
Q2) Donnycousin2 is 40 and has back pain with NO Hx of
trauma or neoplasm. What may you see on Lumbar Puncture?
A3) In such a presentation, consider a bug that made its
way into his spinal column!
Q3) Donnycousin3 is 65 (older cousin) and oh NO! He has
lower back pain with INCONTINENCE and with CONSTITUTIONAL SYMPTOMS
(Fever/chills/headache). Now what tests do you order, because you are
fearing????
A3) As I said with questions, consider carefully the
age, sex, ethnicity, diet, meds, etc. of the patient. Here is an older gent with
the HINTS of incontinence from tumor pushing a local mass effect on the
sacrococcygeal area and the CONSTITUTIONAL SYMPTOMS!
NOTE: The above cases are so common and tested and asked
and pimped because back pain is so common. I saw more pts coming in with this
than the flu!!!! So you MUST RULE OUT MALIGNANCY, even with younger patients...
_________________
460.
'Case: Donny's cousins have a few second cousins,
weird...all have back pain with same BAD symptoms.....What I and NBME and your
attending NEEDS you to KNOW are the slight differences in the bone producing
tumors of the spine...b/c the tx's are different!!!!!! KNOW....
Osteoid osteoma - Benign and locally self limited
Osteoblastoma - Benign but locally expansile and
aggressive
Osteosarcoma - Malignant spindle cell lesion which
produces osteoid
Q2) Sorry, you must distinguish the bones and cartilage:
KNOW the
cartilage producing tumors of the spine which are...
Osteochondroma - Benign lesion with cartilaginous cap.
Chondrosarcoma - Malignant cartilage producing tumors
that histologically demonstrate round cellular stroma in a chondroid matrix.
Whoa, look at this:
Q3) As I mentioned lymphomas can mimick simple back
pain. It is exactly the kind of question USMLE needs you to KNOW how to
differentiate...AND I KNOW THIS IS A VERY VERY HARD AREA....
Consider the Lymphoproliferative tumors...
Multiple myeloma and plasmacytoma are derived from
plasma cell dyscrasias, which histologically appear as sheets of plasma cells,
and remember lytic lesions and back pain?
Lymphoma - Associated with a large infiltrate of
lymphoid cells
Q4) Sorry, we are NOT done yet!!!! Remember the
Tumors of notochordal origin?
Chordoma - Identified by the characteristic
physaliferous cells.
Round cell tumor - best seen with a Webpath pic
Ewing sarcoma - Malignant tumor of childhood associated
with large sheet of homogenous small, round, blue cells, and you KNOW we talked
about this one.
EVERYONE THOUGHT THIS BACK PAIN AND ALL THESE TUMORS
WERE IMPOSSIBLE TO GET STRAIGHT BECAUSE THE NAMES ALL SOUND THE SAME. I ALSO WAS
SO STRAINED TO MEMORIZE THIS FOR STEP 1.
_________________
461.
Q) YOU MUST KNOW: IF you get a case of a patient with
COPD, ELDERLY, CHF, or sickle disease, you MUST give what specific vaccine that
NBME/clinics will ask?
A) an annual INFLUENZA vaccine.
462.
Q) You have a sickle cell teenager (I SAW SOOO MANY) who
had a splenectomy! WHAT 2 vaccines must they receive!!!? (HINT starts with
letters m and p...)
A) THEY absolutely have to have meninogococcal vaccines
and one for pneumococcus!
463.
Q) All my students say HIV and such buggies are crawling
their way into the TESTS and clinics. When you go into "patients" on the test,
many will have a fever, the most common cause of fever is INFECTION. (Recall
that even SLE can present with fever.) LUMPIN...
You have a patient who is 3 months OLD. Which 2 vaccines
do you reach for?
A) HBV 1 and 2 (fr Birth to 4 months)
464.
LUMPING along..
Q) Your patient Mickey is half a year old. You are asked
by USMLE/ATTENDING what additional three vaccines should have been given? (HINT:
mnemonic..HID) ... I "HID" the candy fr. my 6 month old.
A)
H..Hib!
I...IPV!
D...Diptheria!
(anywhere from 2-6 months of age!)
465.
Q) Your patient Mickey is now grows to 1 1/2 old. Your
USMLE/ATTENDING pimps you and asks which med will you grab next?
A) OPV...and you must be sure he received his THIRD HBV
shot!!! OUCH!
466.
LUMPIN still.
Q) You have another patient named Minnie. She is exactly
1 year old. She is up to date with her immunos. But now, your attending/USMLE
asks what TRIPLE vaccine do you grab? (BIG POINT!)
A) MMR (The first of two) (Remember, Measles, Mumps,
Rubeola)
467.
Q) Oh NO! She comes back in one month. She is 13 months
old. Your attending smacks you and you forgot to give a vaccine!!! (HINT: Starts
with letter V) What is the bug assoc. with vaccine and structure?
A) LISTEN, at between 1 yr to 1 1/2 year, all patients
must have their Varicella Vaccine! It is a HERPES virus family. IT is enveloped,
double stranded, linear!
468.
A lot of people are asking about the "lumping" of some
more MICRO. To answer "Big Concept":
The NBME must demand you understand the common things,
what to do and not to do. Think, you have patients with an infection
(Microbiology):
Case: A patient comes in with signs of a cold, but on
the test and in life, you will be given more. Patient's name is Quentin a 11
year old and he has a fever after a raccoon bite. What vaccine should he have on
his chart GIVEN STARTING IN HIS EXACT AGE that addresses the "bug". What is the
family and structure of the bug?
A) He should have been given Tetanus vaccine that starts
on age 10-11 and gets a "booster" every 10 YEARS. The bug we are worried about
is rabies which is from family RNA Rhabdoviruses, SS, negative sense, square
shaped. If the NBME tests you, know if you get even ONE of these data points
wrong, you will miss the question. (Like thinking it is positive sense and not
neg. sense).
469.
LISTEN, AS A HINT ON THE USMLES AND IN LIFE, THINK VERY
VERY CAREFULLY ABOUT THE PATIENT'S AGE, GENDER, ETHNICITY, TRAVEL, MEDICATIONS.
This is often overlooked.
Q) Listen, a 2 month old named James Joyce comes into
your clinic. He is CURRENTLY ON ANTIBIOTIC THERAPY. Your attending asks if you
are still going to administer his vaccination schedule. Will you?
A) This is one of the most common mistakes. YOU STILL
GIVE HIM HIS VACCINATIONS...usually, (unless he is SO immunodeficient and
deathly ill) and you are holding a syring of live polio vaccine.
470.
Q) If I gave you a list of vaccines, and then told you
the patient is allergic to egg proteins, what common vaccine should you be WARY
of giving?
A) MMR
471.
Q) A patient comes in, he is 4 yo Mexican male with a
POSITIVE PPD test!
Do you continue with his vaccine schedule?
A) YES YOU DO! Seriously!
472.
Q) So NOW YOU START FEELING GOOD ABOUT VACCINES....now a
14 year old pregnant girl named Nancy Voltaire comes in. She is missing her MMR
and OPV (someone just email and asked what is OPV...it is the Oral Polio
Vaccine). Can you give it to her?
A) NO, NO, NO! Including allergic reactions, pregnancy
is contraindicated for Polio and MMR vaccines!
473.
Q) This is VERY important: Tell your attending about the
difference between Sepsis and Bacteremia (most of my students think they are the
same--don't tell your attending that).
A) While you can bacteremia from just flossing your
teeth (it is just bacteria in the blood), sepsis are those buggies crawling into
the intravascular space, possibly causing septic shock, and killing the patient.
474.
Q) A patient named O Henry comes in, is 3 years old with
a fever of 103, PE is normal otherwise. YOU are about to think it is a common
cold virus going around, but there is a blood test that came back with tons of
white cells on the smear! What is the commonest bug? What is the structure and
in fact, tell me all you know here...?
A) Absent a "zebra" this is Strep. pneumoniae. This will
look like "purple circles in chains or lancets (like Middle Age weaponry)" in
stain. It is catalase negative. It is alpha hemolytic, has a POLYSACCARIDE
CAPSULE, is OPTOCHIN SENSTIVE, POS. QUELLUNG SWELLING. Don't confuse this with
Strep. viridans or Strep pyogenes. NOT EVEN ONE CHARACTERISTIC. S. pneumoniae is
SO IMPORTANT that it is like your "tongue" and "tasting". You can't live without
seeing it daily in clinic/tests/etc.
475.
Q) Your subordinate M2 med student says "S. pneumo has
streptolysin O for the alpha hemolysis!!!!" Is he right?
A) Critical point: NO! If you are getting these wrong,
you are NOT RETAINING MAXIMALLY and missing concepts...IT IS STREP PYOGENES, the
bug that causes rheumatic fever, with steptolysin O! S. Pyogenes also has
erythrogenic toxin...WHICH BINDS TO....MHC II as it is a SUPERANTIGEN TOXIN.
476.
EMERGENCY! Someone just emailed and asked a good
question: Then is S. Pneumoniae the most common cause of sepsis?
Q) Can you answer him?
A) NO, as I said, S. Pneumoniae is related to commonly
bacteremia... Sepsis is MUCH MORE SERIOUS, caused by endotoxin from gram neg.
bug like probably E-coli.
477.
Q) So, your trusty med student says, "Let me go get a
good third gen. ceph. for the bacteremic patient..." Is this a good drug of
choice?
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
A) NO! As I said, bacteremia is S. pneumoniae, which is
gram POSITIVE! So, since third gen. cephs. move into gram neg. coverage, pick
PENICILLIN or AMOXICILLIN for the S. pneumoniae!!!!!
Are you getting these right?
478.
Q) Your trusty med student asks, "S. Pneumoniae causes
pneumonia, and you said we can give penicillin, and my friend Jon has "walking
pneumonia" and a non productive cough. Can you write him a prescription for
penicillin?" My question is, will you????????
A) NO, NO, NO!!! The walking pneumonia is from
Mycoplasma pneumoniae, NOT Streptococcus Pneumoniae. Use erythromycin....
Don't miss these!
479.
Q) Hey, now, you get another kid named CS Lewis who
comes in with a fever...but he also has irritibility and right ear pain. What is
the likely dx, bug, and treatment?
A) PLEASE do not tell me you got this wrong. This is
OTITIS MEDIA. (acute middle ear inflammation) This is as common as jokes about
President Bush's grammar mistakes...(sorry Sir!). Most common bug is Strep.
Pneumoniae, and again, the DOC is still Penicillin...
480.
Q) Now, another kid comes in with the same clinical
presentation: irritability, fever pain, right ear pain. But his whole family has
viral colds and HIS culture was NEG for S. pneumoniae. KNOW that Hemophilus
influenzae can cause OTITIS, but due to immunizations, you may also see another
bug...hard question....do you still give the penicillin for coverage?
A) NO! Recall H. Flu is GRAM NEGATIVE! NOT G-+. I am
talking about the next most common bug, Moraxella catarrhalis, also GRAM
NEGATIVE!!!!. This buggie has recently been shown to be both widespread and
pathogenic, (This was ONE OF MY PERSONAL UNKNOWN BUGS IN MY FINAL MICROBIO LAB
TEST!). Several factors have been suggested as virulence factors,
lipopolysaccharide (LPS) being one. Recent studies have shown the LPS to be
without the O-chain, i.e. the polysaccharide part, and to have specific
structural features corresponding to each of the three serogroups, A, B and C.
The structures resemble in many respects those present in other Gram-negative
nonenteric bacteria, with a galabiosyl element as a prominent common
structure....take THAT! So, give GRAM NEG COVERAGE LIKE ceftriaxone. OH, THIS IS
ALSO OXIDASE POSITIVE. Almost all of these buggies are beta lactamase producers,
so penicillin will be cleaved. DO YOU REMEMBER EXACTLY WHERE IF I GAVE A
DIAGRAM? OLDER CONCEPT!
481.
The following question/answer is how your brain will
learn, by comparing/contrasting/analyzing/recalling.... here....
Q) Another child comes in with the same OTITIS MEDIA
symptoms...but NOW, ALL THE USUAL SUSPECTS ARE RULED OUT! But, the recurrent,
chronic suppurative OTITIS MEDIA is cultured and you smell grapes on blood agar.
Plus, your attending says this bug also gave him EXTERNAL OTITIS while he was
swimming. What is the bug? What drug? What structure for this SUPER IMPORTANT
BUG?
A) This is Pseudomonas aeruginosa. For this, you usually
MUST choose two drug combo like Ticarcillin/Gentamycin (A Penicillin and An
Aminoglycoside). You can sub Aztreonam for the penicillin part of the combo.
REMEMBER JEDI KNIGHT, this bug is OXIDASE POSITIVE and is a Gram negative bug.
Review the types of pts. this bug bothers...
482.
Q) Oh, your call night is just NOT ENDING...another kid
comes in presenting like OTITIS MEDIA, but the attending looks inside the ear
and says, NO! This is OTITIS EXTERNA. What did he see?
A) OK, Sir Sherlock Holmes, or Lady Shirleylock
Holmes...you usually see a NORMAL tympanic membrane and just touching the outer
lobe of the ear is painful in OTITIS EXTERNA!
483.
Q) YUP, another patient with OTITIS MEDIA (ascertained
by attending) comes waddling in. He KEEPS GETTING OTITIS MEDIA (MOA is DECREASED
TONE of the EUSTACHIAN TUBE which drains that middle ear and so fluid comes
right back up, I forgot to quiz you on that!) But, now, the mother was told of a
common surgery to correct her son's problem.
What is it?
A) The very common surgery for chronic OTITIS MEDIA is
placement of a tympanostomy tube.
484.
Q) Cont. on with OTITIS MEDIA, there is possible hearing
loss from rupture of the tympanic membrane. But what dx do you immediately worry
about when the bugs move into the INNER EAR...(Hint: Starts with a "L")
A) Labyrinthitis...
485.
Q) CIA...Connections/Imaginations/Associations...let's
look closer at Streptococcus pyogenes. (I won't ask, but do you recall ALL the
structures of this bug?) This bug is the most common cause in clinics/tests for
"strep throat". What is another common term for this dx which involves the
anatomical region most affected? (hint: ans starts with a "p")
A) Pharyngitis. Students mix up Strep pyogenes, which IS
THE SAME AS Group A beta-hemolytic streptococci. The clinics/board exams use
BOTH NAMES...and then students mix this bug with Strep pneumoniae!!!! FATAL TEST
AND CLINIC MISTAKE!
486.
The Group A beta hemolytic strep (Strep pyogenes),
causes Strep pharygitis. [students also mix this up...like thinking Strep
pharyngitis is another different bug entirely instead of the disease that it
IS!...like Strep pneumo is a BUG, not a dx... it is still Strep pyogenes that
CAUSES Strep pharyngitis. ONCE MORE, the dx is Strep pharyngitis, the bug is
Strep pyogenes.] We will come back to this, but think as simple as possible
first...so think that pharyngitis=sore throat. Just start there first....
Q) If this bacterial pharyngitis is suppurative, what
common very bad dx can it lead to? (starts with letters r... a......)
A) Retropharyngeal Abscess!!!! (Remember this closed
space, can you ID it on a side view Radiograph?)
487.
Q) Now, we said S. pyogenes (what is the other name I
JUST mentioned the boards exams uses?) causes the dx Strep pharyngitis. The
suppurative consequence is retropharyngeal abscess. Very bad! But equally bad is
the NON-suppurative consequences!
Give me four VERY IMPORTANT dxs you will see in clinics
and Step 1! This is hard, so look at the mnemonic below:
A) LISTEN UP! CAN YOU IMAGINE "PRetty SCarlet" O'Hara in
the American movie classic Gone With the Wind? Look at the two words "PRetty
SCarlet", NOW look at the first two letters... "PR... SC..." Now connect them
like this:
P oststreptococcal glomerulonephritis (kidney damage)
R heumatic fever (heart damage amongst other stuff)
S carlet fever
C ellulitis
NOTE: The PR involves two organs that are lesioned...the
kidneys and heart. The SC involves the organ called the skin! Link images like
Scarlet O'Hara loving Rhett (Rheumatic) Butler (hero) with all her HEART, and
Rhett replying "I do not give a damn." and urinating over her HEART with with
his KIDNEYS which are emptying. Then SCARLET (heroine) feels terrible at being
ignored and has a fever and faints and injures her skin which causes CELLULITIS
of the skin. Repeat this often used, invented by me, so the copyright is
ValueMD, mnemonic! Remember, the PR>>>SC is Strep pyogenes only. What a nasty
bug!!!
488.
Q) Quickly, is Strep pyogenes Bacitracin sensitive or
Optochin sensitive? Does Strep pyogenes have a capsule?
A) Remember, don't mix up these two bugs which are
ALWAYS mixed up...Strep pneumoniae is sensitive to OPTOCHIN, and Strep pyogenes
is sensitive to BACITRACIN! And Strep pyogenes has NO capsule like Strep
pneumoniae!
489.
Q) Students on clinics and board tests confuse a typical
VIRAL pharyngitis with Strep pharyngitis caused by Strep pyogenes. What is so
UNIQUE and SPECIFIC for making the different diagnosis?
A) For bacterial Strep pyogenes, the pharyngitis pharynx
is tender, and THERE ARE NO URI signs like coughing and rhinorrhea!!!! This is
crucial and HY.
490.
Q) As the previous concept said, VIRUS PHARYNGITIS and
Strep pyogenes pharyngitis is similar. ONE other bug causes similar symptoms. It
is from EBV infection. The SUPER HYer is, "What does a confused intern order as
a test to confirm Strep pyogenes?"
A) I must have ordered this on a thousand kids....you
order a Rapid Strep Test which is an antigen detection test for Strep
pyogenes/group A strep/Beta hemolytic non-group B strep. [HORRIFIC, I heard all
three names interchanged everywhere for this SUPERBUG] This test is awesome...it
comes back in 30 minutes while a throat culture will take days while you wonder
if it is a viral or bacterial cause. This way, you know right away if you need
to administer antibiotics!
491.
Q) What is the tx for this Strep pyogenes pharygitis?
[REMEMBER, THE BUG THAT CAUSES THIS CAUSED THE FAMOUS EUROPEAN STORIES OF
SCARLET FEVER WHICH IN EPIDEMICS KILLED ONE OF FIVE INFECTED PEOPLE. BAD. BAD.
BUG...]
A) Pick up or pick out of answer choices: Penicillin
G!!!
492.
Q) OH NO! For the Strep pyogenes, you found your patient
is allergic to Penicillin G! What do you grab now?
A) Choose Erythromycin for pts. allergic to Penicillin
here.
493.
Q) The Strep pyogenes pharygitis pt comes back five
weeks later with a sudden heart murmur, ECG shows prolonged PR interval,
arthralgias, and blood in the urine. What happened to him/her?
A) For some unlucky ones, you still get the acute
rheumatic fever and acute poststreptococcal glomerulonephritis (presents as
above)! This is an IMMUNOLOGIC REACTION/PROCESS. That is why prophylaxis is
needed. You may need diuretics to control the kidney dx!!!!!!!!!!!!!
494.
Q) After the Strep pyogenes infection, you think you see
scarlet fever from skin abruptions, but this time you get a clue that points in
a different dx. You see RED conjunctiva on PE. What is this?
A) This is the much milder Rubeola/Rubella infection.
Remember, are you retaining while studying? Can you tell me the EXACT structure
of virus?
495.
Q) Another patient steps in for a follow up for Strep
pyogenes pharyngitis follow up (6 weeks ago). She looks like she has scarlet
fever...but a dermatologist attending comes in and says OH NO! We got tests
positive for an exotoxin called SPEA, and her mortality rate for this is up to
70%!!!
What deadly disease is this? What tx?
A) Slightly different clinically presenting from scarlet
fever is TSS or Toxic Shock Syndrome. It will crush multiple organ systems and
is very violent and faster acting then the scarlet fever. There may be DIC,
ARDS, Massive fluid loss, Terrible skin rashes, and so on. The NBME, if they
ask, must describe a test coming back with an EXOTOXIN from the Strep. KNOW that
Staph aureus can also cause TSS from a woman who did not change her tampons
inside her. The TSS from Staph is less deadly, but since you initially do not
know, you must treat TSS for BOTH Strep and Staph with Penicillin and Nafcillin
for the Staph coverage. Consider also giving Clindamycin as well. SErious
disease that you cannot afford to miss.....
496.
Q) OK OK, listen up.. Another patient walks in with the
initial presentation of pharyngitis. But now all bacterial workup is NEGATIVE.
And as I mentioned, you are seeing massive lymphocytosis, lymphadenopathy,
malaise...what OTHER virus IN THE SAME FAMILY OF VIRUSES AS EBV causes this dx
called INFECTIOUS MONO? And please give exact structure?
A) CMV virus may cause MONO, so do the serology with
heterophil antibody tests. CMV and EBV are both from the HERPES virus family.
And they are DNA, Double stranded, linear, WITH an envelope.
497.
Q) Another, I said another case of pharygitis. This
patient is a 12 yo boy named Toby who came in with his mom in the early summer.
There is bad fever and the pharynx is so swollen, Toby does not wish to drink
and has to be placed on IV fluids. Again, all cultures are negative for
bacteria. Serological tests for viruses NOW exclude ALL Herpesvirses. Hmm.. you
wonder as the PE reveals malaise, mild diarrhea, and lesions on the rear end,
feet, and palms of the hand. What is the exact structure of the virus? The dx
name? The virus family? Drug Tx? (This is a great connecting question)
A) The presentation variation of pharyngitis is known as
Hand, Foot, and Mouth disease. Also known as HERPANGINA, this disease is caused
by Coxsackie A virus (not the Coxsackie B=heart). This is part of family
Picornavirus, an RNA virus, which is SQUARE, single strand positive sense,
linear with NO envelope. The treatment is...NOTHING. Unless the airway is
blocked by swelling, this very infective enterovirus comes and goes within a
week. Did you get it???? Please say you did! We are LUMPING ALL THE PHARYNX
inflammation dxs together to catch the subtle but DISTINCT differences...
498.
Q) YOU WILL SEE ON USMLE.....sinusitis (sinus pain,
headaches) because it is so common. In this imaginary patient with sinusitis,
there is NO INVOLVEMENT OF ALLERGENS THUS ELMINATING ALLERGIC RHINITIS FROM THE
CHOICES/Differential. Also, serology is negative for viral etiology. Give me the
usual common bacterial bugs that cause this dx (BIG HINT: We spoke of them
before!) Drug tx?
A) Sinusitis is usually caused by the same bugs as those
which cause OTITIS MEDIA! Use the same drugs.
499.
Continuing with sinusitis,
Q) As a newborn, you have the maxillary and ethmoid
sinuses. What other sinus cavities develop? Do they develop at the same time as
the maxillary and ethmoid sinuses?
A) NO! The frontal and sphenoid sinuses develop later in
childhood. Watch out, you must KNOW that for this young sinus sufferers, you
must be aware of possible orbital cellulitis!
500.
Q) You see coming into your clinic another child with a
sore throat. Could it be again the pharyngitis? NO! Because here, you note the
highly specific stridor (barking like a seal) sound. Three questions. What is a
severe consequence of this dx and what can you give as treatment?
Also, TELL ME THE EXACT STRUCTURE OF THE BUG!??????????
A) This is Classic Croup, from parainfluenza virus. You
may have to inject epinephrine if airway is blocked! And this virus for STEP 1
is...
Family Paramyxovirus, Single stranded, HELIX shaped,
negative sense, linear, WITH an envelope, and this virus is nonsegmented (which
allows for better vaccines since segmentation increases the number of
serotypes)!!!!!!!!! YOU GOT IT! YOU KNOW IT ALL!!!!
501.
Q) HY Concept 500 spoke of croup from parainfluenza.
NOW, there are exactly three other bugs/viruses within the same family. YOU MUST
LUMP. What are they?
A) They are the same family, Paramyxovirus!! Measles,
Mumps, and RSV. On my call last night, there were so many patients with RSV!! We
will discuss the subtle difference between RSV and croup from parainfluenza next
time if I am still alive. I am on call TONIGHT TOO! Coffee, anyone???
502.
To answer Sanaray's Question about the pictures and
diagrams, I found that
BRS Biochemistry,
FA, and
Kaplan all have good diagrams. The key to remembering diagrams..I say it
again..is to stick to one source. I FOUND THAT WRITING OUT MY OWN BIOCHEMISTRY
CHART WAS THE MOST HELPFUL. After referring to BRS, etc. I wrote out this GIANT
BIOCHEMSITRY CYCLE WHERE EVERY SINGLE RELEVANT CYCLE INTERTWINED WITH THE OTHER.
This way, you REALLY remember because you created your own chart. I wonder if
there is a way to paste my own chart onto this site, but THERE ARE MANY biochem
books that have this information. REMEMBER, EVERYTHING FEEDS INTO THE
SUPERHIGHWAY of energy metabolism, that is Glycolysis and the TCA cycle. Know
where every cycle "FEEDS IN". They are NOT isolated, but interconnected. Come to
think of it, Lippincott's Biochem Review has some good "linking" diagrams. If
you really understand how all the pieces fit together, it is SO MUCH EASIER to
remember come test time. Also, people are asking about an atlas, etc...Webpath
is great, but if you really study Netter's Anatomy and understand some of the
basic anatomical relationships (eg. If I ask you to draw a cross section at C8
spinal cord level from a scratch paper, can you draw the MAJOR ARTERIES,
NERVES/GANGLIA/TRACHEA, and the relationship to the other?) Everyone needs to
know this, in the ER, for eg. I needed to know where the retropharyngeal space
was on radiograph. It is stuff like that the NBME will want you to understand.
Tommy..
503.
Q) Again, you will see this on tests and in clinics
every second...patient will come in with signs of a "cold". But what are you
most afraid of? A common coronavirus (Strucure? please? RNA or DNA?), will
resolve without duress in a immunocompetent person. So the NBME/attendings will
"pimp" you on whether the person is immunocompromised (HIV), or has a BAD
Bacterial/Fungal infection and also if the virus could compromise the airway.
So, moving along:
Case: You see a patient named Clarence Day who is a 6
year old female patient who looked like your previous patient with a
"cold"...but you are ALARMED because in addition to tachycardia, she is leaning
forward and slightly gasping for air..PLUS, she is DROOLING (Key!). Dx, and BUG,
and Rx please?
A) Here, the disease is EPIGLOTTITIS, often caused by H.
Flu, (but also S. pneumo and Group A Strep). This is a medical EMERGENCY b/c it
can block the airway, so you call ETN and consider a CRICOTHYROTOMY and
INTUBATE!
504.
Q) Case: You now have a patient named Edgar Poe who is
six months old. His mother brings him in and your med student sees him. He comes
out of the exam room and says that all the family had the "common cold" so he
will send Edgar home with Tylenol only. But when YOU do your exam, you hear
crackles and mild rhonci on lung exam, and the child seems to be gasping for
breath. Your attending comes in and tells you this IS a virus, but in patients
this young, it can cause deadly hypoxic events and infects the bronchioles and
is VERY contagious. The month is December...
Bug and Drug and Structure of Bug please?
A) This is classic RSV virus infection, part of
PARAMYXOVIRUS family with RNA, HELIX shaped, Enveloped, single stranded negative
polarity. The drugs are ONLY given for serious hypoxia. You may be asked to do a
trial of albuterol to rule out asthma (similar presentation), and a rapid
antigen test for RSV. Some like to tx with ribarvirin (MOA please) and a
monoclonal drug called synergin (an RSV antibody)
505.
Case: Similar presentation of a young child, female,
named Edith Wharton. This patient has NOT had her immunization shots. Her mother
is coming to you after her daughter has had fits of coughing that has waxed and
waned for a year now. PE is notable for an extended stridor after taking a deep
breath. Her CBC has marked elevated white count, and your attending tells you
this is a serious NON-viral illness (you can R/O RSV) so that goes though
phases. Bug and drug and dx please?
A) This is the famous "Whooping Cough". The INTERVALS
AND PHASES of strong coughing differentiate it from the other common illnesses.
Since she had no immunization shots, she did not get her Pertussis shot. The bug
is Bordetella pertussis and is a gram neg bacteria. You need a two week course
of ERYTHROMYCIN. (Note, a culture and fluorescent antibody staining can pinpoint
your dx).
506.
Case: Well, I won't put one here except to say know the
most common bugs of pneumonia, a favorite of clinics/boards due to its severity.
But tell me, how can I tell the diff. between say, S. pneumoniae pneumonia and a
viral pneumonia?
A) So key, LISTEN...both viral and bacterial bugs can
cause pneumonia, but understand that a viral (or mycoplasma) source has USUALLY
more BILATERAL, diffuse, crackles, rhonchi, wheezing of this LOWER respiratory
tract infection(s). BUT...a bacterial source points to a more focal or
UNILATERAL source, with dullness to percussion, absent breath sounds.
If you suspect a bacterial origin, treat with Penicillin
or amoxicillin. But if you think you have S. aureus or H. flu, you need a second
or third generation cephalosporin. Recall that "walking pneumoniae" from
Mycoplasma needs different coverage like Erythromycin.
507.
Case: Regarding the pneumonia cases, what outcome are
you most afraid of (don't answer death..)? And what is the treatment?
A) The most common complication of the pneumonias is a
pleural effusion bad enough to compromise respiration. If you "drain" their
lungs with pleurocentesis (you could get out a 1 liter or MORE), you can help
with this outcome.
508.
Case: A female woman, Mrs. Stevenson comes running into
your office with twins with signs and symptoms of meningitis. Both twins are
male and four years old. One male, named Robert, had a prodromal stage that was
not specific and included fever chills nausea. The other male, named Louis, had
a very high fever throughout and missed a prodromal phase. He also has some mild
seizures. Which one has the bacterial origin? And what is the bug most common?
What is the most specific test? What drug will you grab?
A) The bacterial meningitis is life threatening while
the viral is usually not. The bug most common depends on the age of the
patient.. but cover/choose S. pneumoniae as a common cause. The bacterial
etiology usually has an absent prodromal phase. Do a lumbar puncture to pinpoint
bug. Tx with a 3rd gen. ceph. like ceftriaxone which moves into the CSF easily.
509.
Q) Really quick, you see a young patient with diarrhea,
vomiting, and low grade fever. All bacterial cultures come back negative. There
is no history of travel and the patient is taking no medications. The time of
the year is February. What is the most likely VIRAL etiology? Structure?
A) Rotavirus. It is NOT enveloped, is square shaped,
double stranded, and segemented.
510.
Case: You have a young patient who keeps returning to
the clinics after all infectious etiologies for bugs are ruled out! Name a few
NON-infectious causes of diarrhea in your young patient! VERY IMPORTANT!
A) IBD like ulcerative colitis, cystic fibrosis, anti
bacterial meds, and conditions such as celiac sprue or gluten sensitive disease
could do this.
Sincerely, tommy....
511.
Case: You see another young patient in your clinic. This
time, she also has bad diarrhea. So after a history, your medical student grabs
some Immodium (anti-diarrheal). There is blood and yellow sticky "goop" from the
GI, and you see WBCs on wet mount.
1) Is this a good idea to give anti diarrheals?
2) Rapid Rotavirus Antigen Testing is Negative, and so
is Clostridum difficile toxin detection for possible antibiotic use..NEGATIVE.
Other baceterial cultures are negative. Hmm.. you sit there wondering... But
then your attending says she she CYSTS in the stool sample. What bug and drug?
A1) No, do NOT give antidiarrheals here, treat instead
with oral hydration and replace and manage the electrolytes as necessary.
A2) Most commonly, this is Giardia. Treat with
Metronidazole.
512.
Case: A young patient of yours comes in with diarrhea.
All common bacterial and virla tests come back negative. So your attending says
consider a paraiste like Camyplylobacter jejuni. What drug will you reach for?
A) Erythromycin
513.
Case: Still stickin' with diarrhea and stomach
pains...now you see a young patient who was on Clindamycin therapy for a
while...(what are your thoughts?)...your attending says he found Clostridium
difficile TOXIN. DOC, please?
A) Meronidazole, given ORALLY
514.
Case: Now, you are still seeing diarrhea and stomach
pains...but this time your patient is a young African American male who has
associated symptoms of headache, fever, and muscle, and bone pain. What is the
bug now?
A) Consider SALMONELLA.
515.
Case: Still going...another young patient wtih diarrhea
and stomach pains. You get a good history and it does not seem like anything
normally seen...there is some blood in the fecal material...he has isolated
pockets of nerve damage, LOW platlets on a CBC, and hemolytic anemia. Bad, bad
disease. Your attending hints this is caused by a TOXIN spills by a couple of
different bacteria. What is the disease, bugs?
A) This is the infamous HUS, or hemolytic uremic
syndrome. Very deadly. Two bugs..E COLI 0157:H7 and Shigella dysenteriae are
seen to cause this in young patients.
516.
Case: Still diarrhea is facing you....you see another
young male age 10 with fever, some blood in feces, diarrhea. You are thinking
the answer choices/differentials...E coli, Shigella, Salmonella,
Entamoeba...Hmm..hard one but the GI attending stops by and hints this is NOT
parasitic, and the patient has a history of taking H2 blockers and he loves
eating raw pork hot dogs. The labs come back and the bug is oxidase negative,
non lactose fermenting. What is the bug and drug?
A) You are on your way to becoming a doctor if you got
this one right.. this is Yersinia entercolitica (Y. pestis causes the PLAGUE!).
As long as hypovolemic shock is avoided, you are in good shape. Give TMP-SMX as
treatment since this bug is becoming resistant.
517.
Case: We move on briefly to hepatitis...since everyone
in the US receives regular vaccines, you should not encounter HBV for example in
your young patient population too often. But, please understand the HY facts
which address when and where you see the different antigens and antibodies for
each of the Hepatitis viruses...A, B, C, D and E. For Hep B, for example,
understand that about 1 in 10 patients WILL have a chronic carrier state which
IS INFECTIVE. They remain HBsAg (+), so they can infect others. Do you know the
difference between HBV/HDV and HAV/HEV?
KNOW that anti-HB core antibodies are seen after HB
surface antigen has been eradicated, and understand that this may occur before
anti Hep B surface antigen antibodies appears! You must review Hep B core
antigen/antibody detection!
518.
KNOW: That even though the attendings/NBME probably know
that you are familiar that penicillin is the DOC for TREPONEMA PALLIDUM, and
that you need VDRL and RPR for diagnosis, tell me...what is the specific test
that is used for treponemal tests?
A) FTA-ABS test. Just understand that a patient who is
young and has persistent jaundice, heptosplenomegaly and lymadenopathy is a
classic presentation of syphillis obtained through "vertical" transmission, ie,
from mother to child.
519.
Case: You have a young woman, say 21 years of age, which
presents with a positive culture for Chlamydia and Neisseria. She is
sadly...become infertile...
Q) What is the dx? What two bugs are commonly
implicated? And what is the treatment? Can she have another common sequelae?
A) Since one in six or one in five with PID develop
permanent infertility, you must be familiar with this. The two bugs (trick
questions) ARE Chlamydia and Neisseria. The treatment for Chlamydia is
Doxycycline or Azithromycin (Zithromax). For Neisseria, give a single dose of
Ceftriaxone or a quinolone if you wish. The common bug Neisseria causes
accompanied muscle pain in both males and females.
520.
Case: Your poor patient who has PID (pelvic inflammatory
disease) is now coming back to you after two years with the triad of arthritis,
red conjunctiva, and inflammation of the urethra. What is the disease?
A) Untreated PID can progress to Reiter's syndrome.
521.
Case: You see a 23 year old female patient with painless
growths on her vulva. She has a sexual history with multiple partners.
Diagnostic tests demonstrate that this is a VIRAL etiology. What is the bug and
tx?
A) Among the MOST COMMON of the sexually transmitted
diseases, you must know and understand all about HPV or human pap. virus. They
can often cause these painless chancres that you can treat with CO2 laser
ablation, scalpel excision, or laser therapy. MEDICAL pharmacotherapy
consistents of interferon therapy, 5-FU, or Podophyllin (an anti mitotic). You
must make this patient come for ANNUAL pap smears! Why??
522.
KNOW that for a young woman who comes to your clinic
with vaginal itching, there are three USUAL SUSPECTS:
1) Bacterial Vaginosis from Gardnerella vaginitis,
Mycoplasma hominis, and about 20 other vaginal flora. Sexual contact may or may
not contribute... You will see these large "clue cells" on a slide. Tx is METRO.
2) Trichomonas...definitely you will see this, no
question. This is easy to spot because you see these little oval creatures
swimming around in wet mount...sexually transmitted. Treat with METRO.
3) Candida...you KNOW you will see this cottage cheese
looking yeast with pseudohyphae on wet mount. They are often see increasingly
with DIABETICS, PREGNANCY. Treat with NYSTATIN! KNOW this is NOT sexually
transmitted.
523,
Case: ON NO!!! You have a patient with HIV, a young
woman, who is with child!!! What drug will you give her for her baby since about
1/3 of the patients present with transmission eventually to their babies!
A) AZT can reduce the transmission to the fetus to less
than 10%!!!!!
524.
Q) Again, do you know what the most common HIV disease
that progresses to AIDS is? And what is the tx? Do you know what it looks like
under a microscopic slide?
A) This is PCP pneumoniae. TMP-SMX is the tx of choice.
525.
Case: You see a patient named Bram Stoker, who is a
young patient who traveled to the Carolinas in the USA. He comes back with a
tick bite which moves from the ankles and wrists to the PALMS and SOLES. What dx
are you looking at?
A) You are looking at Rocky Mountain Spotted Fever.
Consider the tick bite....tell me, now, how can we distinguish this from
Measles,...a paramyxoirus?
526.
Q) How can you distinguish Measles form Rocky Moutain
Spotted Fever?
A) In Rocky Mountatin spotted Fever, typically the soles
of the feet and the palms are involed . In measles, you will see the main source
which involves to the rash which starts at the head and moves distally from
there. If you are really lucky, you will see Koplick spots in the mouth.
527.
Case: You are seeing a young patient who looks so much
like measles (which is a paramyovius). But your attending notes that instead of
the lesions spreadinly from the head and on downwards, this patient has the
rash/lesions on the truck and spreading to the periphery. She has had an acute
high fever before the developemnt of the rash. What is the bug in question?
A) This is HHV6 or Roseola. NOT MEASLES whch starts at
the HEAD!
528.
Q) Quick review to see if you are getting all the
concepts down. You have a patient say 30 year old female with Lyme Disease from
a camping trip(bitten by a tick and showing physical signs of a bullet lesion on
the leg).. What bug and drug?
A) This is classic from Spirochete Borrelia burgdorferi.
The tick is Ixodes scapularis. here, you can give doxycycline or penicillin and
ceftrizxone.
KNOW that arthritis symptoms may come back again later.
529.
IMMUNOLOGY WILL BE EVERYWHERE IN YOUR TESTS AND CLINICS:
Q) So, you have a patient with a case of a splenectomy
and CLL, HINT: you know his HUMORAL IMMUNE def. is diminished. What type of bugs
is he most suseptible to?
A) Bugs like Neisseria, Strep pneumoniae, and H. flu
which are encapsulated can cause septic shock, osteomyelitis, pneumonia.
530.
Q) Case: Next you see a patient with a diminished
CELLULAR IMMUNE def like HIV, leukemias, steroids. What bugs will attack him?
A) Think about a list including CMV, Candida, PCP,
Toxoplasma, Cryptosporidium, HSV.
531.
Now, you see a patient with Neutropenia (remember this
is different from Leukemia). KNOW that neutropenia has many causes, including
bone marrow suppression, ALL, and chemotherapy. What bugs will you likely see?
A) You will see recurrent UTIs, septic shock, sinus
inflammation and the usual fungus and parasites like Candida and Cryptococci.
532.
Q) Through all your rotations and ALL exams, you must
know the basics of genetics. So please forgive me as I quiz you. You have a
pregnant female with bipolar disorder. She is taking LITHIUM. Is this a good
idea? What effects can happen to the FETUS? (Don't be tricked, I asked about the
fetus, not the mother).
A) The fetus can suffer heart anomalies like the
congenital downward displacement of the tricuspid valve with the septal and
posterior leaflets being attached to the wall of the right ventricle. Bad Bad...
533.
Q) Hard one: A neonate comes to your office with a
deficiency in enamel matrix formation. BESIDES syphillis, critical infections,
what antibiotic is known to affect the teeth in this way if given to the
pregnant mom?
A) Tetracycline
534..
Q) A female patient with chronic anxiety who is also one
month pregnant comes to your office. Your medical student grabs some
thalidomide, which is a anxiolytic and sedative. But....you know better. What
side effect can it cause?
A) To the unborn child this drug can result in seal
flippers where the arms and legs attach to the body. Teratogen!
535.
Q) This is a good case. You have a pregnant woman G2P2,
who comes to your office with recurrent UTIs. Your medical student respectfully
grabs some aminoglycosides to cover the gram negs. You see him hand your patient
a bottle of streptomycin. What is wrong with this picture????
A) All Aminoglycosides, which require Oxygen to be
absorbed, are thus NOT effective on anaerobes like Bacteroides. But, here the
strpetomycin can cause the baby to lose her hearing. If you don't want a HUGE
LAWSUIT, then remember this fact!!!
536.
Case: Regarding the previous two cases, galactosemia and
fructose intolerance, what changes in the diet need to be made? What is the
method of inheritance?
A) For fructose intolerance, eliminate fructose AND
sucrose from the diet.
For galactosemia, eliminate galactose AND lactose from
the diet.
Both the disease are inherited via autosomal recessive
pattern.
537.
Q) What disease am I? I affect the proximal tubule of
the kidney, I am congenital, I exhibit polyuria, polydipsia, and dehydration and
hypokalemia and hypophosphatemia and interrelated manifestations of the
syndrome. The MOA is from solute secretion accompanied by the loss of water.
Despite the dehydration that ensues, the urine is often dilute, reflecting a
concentration defect that is partially caused by hypokalemia. The bouts of
dehydration may be associated with fever, particularly in infants. So, what dx
am I?
A) Fanconi's Syndrome (HINT: Think of a lot of hypos...,
and think of PROXIMAL TUBULE!)
538.
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
539.
Case: A 8 year old female named Virginia Woolfe comes to
you with pain on urination. PE reveals sore throat and no blood in the urine,
parasites on culture, or meds. The rash on the vulva is erysipelas and
cellulitis is present. What two bugs are the likely suspects?
A) Beta hemolytic Group A streptococcus!!!! And maybe
Staph aureus. They cause cellulitis a lot!
540.
A 10 year old girl named Agatha Christie presents with
fever, myalgias, stomach pain, and a rash LIMITED TO THE LOWER EXTREMITIES! (BIG
HINT!) Labs show blood in the stool, RBC casts and mild proteinuria. What
disease? (HINT: Is it Rocky Mountain or SLE or other?)
A) This is NOT Rocky Mountain or SLE. It is Henoch
Schonlein vasculitis! The key words are LOWER EXTREMITIES!
541.
Case: A mother is breast feeding her baby boy Ray
Bradbury. She gets Staph aureus breast feeding, thus...mastitis. Can she
continue breast feeding?
A) Yes.
542.
Case: A child named H.G. Wells comes into your office as
his mother fed him only cow milk from Safeway stores. What effect does it have
on the child?
A) The ultra high protein concentration slams the
kidneys and dehydrates the baby with concomitant malaise.
543.
Case: A 5 y.o. boy named Isaac Asimov presents with
recurrent right upper lobe pneumonia. His development milestones are normal. He
had an ear infection at 1 year of age and rotavirus at 3 years of age according
to the chart. (Is the dx an immunodeficiency disorder or a foreign body
aspiration or Chediak Higashi?)
A) Most common is foreign body aspiration. An IMMUNO
deficiency would have A LOT more infection.
544.
Case: A kid named Frank Herbert comes for a routine
visit. Frank can move an object from hand to hand, sit by himself, imitate
speech, and he can hold an M&M candy easily between his thumb and forefinger.
What age is he? (Pick either 4, 6, 8, 10 months)
A) 10 months
545.
A 5 year old girl named Joyce Carol Oates swallowed a
bottle or her mom's prenatal vitamins. You are the ER attending. What do you do?
A) Prenatal vitamins have high iron. Give deferoxamine!
546
Case: A patient comes with Reye's syndrome. What caused
this? PE is what?
A) Aspirin is responsible, and she has fever, chills and
vomiting. Liver is palpable.A) Prenatal vitamins have high iron. Give
deferoxamine!
547.
Case: You have a young patient named Ernest Hemingway
who comes in with a high fever, rash, and spread downward to the palms and
soles. Before this, Ernest had runny noses, red eyes, and red conjunctiva. He
missed all his immunization shots. What does he have? What is the most common
consequence?
A) He has the measles, and the most common consequence
is otitis media.
548.
A young lady named Ayn Rand is breast feeding her baby.
But she comes to you asking what the difference is between dairy milk and her
own breast milk in terms of vitamins/nutrients? What do you say?
A) As you recall, we said human milk has LESS protein,
BETTER iron absorption, much MORE vitamin C, and much less vitamin K than cow
milk (so this is why many women eat vit K supplements).
549.
Case: You have a 5 day old baby named J.D. Salinger. On
physical exam, you note he has an asymmetric Moro reflex. The biceps carry no
reflex. PE demonstrates his left arm is slightly turned inward. Which 2 cord
segments are affected? AND, what is the dx?
A) C5 and C6 are damaged...this is Erb Duchenne
syndrome.
550.
Case: A young boy named Michael Chrichton comes in with
a hand that appears looking like a "claw". BAM! You know the dx, now tell me
which cord segments are involved?
A) The Klumpke's syndrome is C7, C8 and T1 lesions.
551.
Case: I, Tommy, actually saw and treated this case with
my own hands a couple of days ago...a 10 year old boy came in with recurrent
UTIs. His mother said he had a congenital disease called "Prune Belly Syndrome".
Which organ system does this dx hit often?
A) Not to be confused with Potter's syndrome, PRUNE
Belly Syndrome lesions the kidneys.
552.
Case: A twenty something couple walk into your clinic
with a baby that has cyclical hypoxic events that are not very predictable. But,
the baby is noted to choke and gag when he feeds. Then he stops for a moment,
and breathing continues until the next "event." He otherwise has a normal PE and
history of birth was non traumatic. What is this disease?
A) He has choanal atresia, where his nasal obstruction
may cause death from asphyxia. During attempted inspiration, the tongue is
pulled to the palate, and obstruction of the oral airway results. Especially
during feeding, he must "close" his mouth on the nipple, and he can't breathe!
553.
Case: You see a 14 year old boy named Tom Clancy who is
vigorously itching his scalp and losing tufts of hair. With a clinic fluorescent
lamp, you see patches of blue green areas lighting up in the dark when shined on
his head. What bug is this?
A) This is Tinea capitis. Give an anti fungal.
554.
Case: Let us say that you have a patient and you need to
know the level of reducing sugars in the urine. Do you use the Clinitest or the
methylene blue stain test?
A) The Clinitest. The Methylene blue test helps identify
white cells in the feces.
555.
Case: You are asked which test starting with the letter
"B" can help identify lesions in the LOWER intestinal tract like
intussusception.
A) Barium enema test
556.
Case: A 12 year old boy named John Keats comes into your
office with easy bruising and petechiae all over his body. It came on suddenly
after a cold. There is no hepatosplenomegaly and he has a mild fever, other than
that, his PE is normal. His CBC demonstrates thrombocytopenia. Does this look
like ALL or something else?
Answer: This is ITP, which follows a viral infection
usually. The disease should resolve on its own in two weeks.
557.
Case: For the previous patient, John Keats, if the
symptoms don't resolve in 2 weeks, what can you give him?
A) You may consider giving steroids and gamma globulins.
558.
Case: You see two patients coming in with wheezes and
both look like asthma. But your attending tells you one of the patients has
bronchiolitis. How can you tell the difference?
A) These two diseases present so similiar, but that is
why HISTORY is so important. The family history and PMH should reveal prior
episodes and a family history of asthma. So, make sure you always pay attention
to history and not only the HPI.
559.
Case: You have a worried 30 year old lady named Erich
Maria Remarque who brings her daughter in because the daughter is 3 years old
and she can copy a circle, but NOT an square. Is she behind?
A) No, most 3 year olds cannot copy a square, but can
copy a circle!
560.
Q) Other than HIV infection, which conditions should
make you give a two year old the pneumococcal vaccine?
A) Think and choose steroid use, splenectomy, sickle
cell anemia, kidney failure, and SLE.
561.
Q) A 9 year old male named Stephen King wakes up in the
middle of the night with a facial tick and twich and when he goes to his
parents' bedroom, his attack suddenly stops. Later in the ER, his EEG is normal.
Do you start seizure meds?
A) No, this is benign partial childhood epilepsy, and he
will outgrow it usually. Be careful, he stayed conscious during the attack and
the attack was short in duration.
562.
Two baby children named Anne Tyler and Wallace Stegner
come into your office. The mothers say that during feedings, the baby Anne
drools and gags and coughs! After crying, the coughing does not stop! This
sounds like choanal atresia, but both are NOT. The other baby Wallace has
bilious vomiting....Which kid has a tracheoesophageal fistula and which one has
Duodenal atresia?
A) Wallace, which has bilious vomiting, has duodenal
atresia. Anne, with the gagging and coughing has tracheoesophageal fistula.
563.
Case: Your attending hints the next baby coming in has a
face that is very round and soft. He is not retarded mentally but he is short in
height. His liver and kidneys are slightly large. He has a defect in his
clotting but the hypoglycemia is notable. What is the disease and missing
enzyme?
A) The child has Von Gierke's disease and is missing an
enzyme in gluconeogenesis called glucose 6 phosphatase.
564.
Q) Appearing in 1 in 4000 births, pyloric stenosis
occurs when in childhood and tell me if it has bile in the vomit?
A) Pyloric stenosis occurs a few weeks, NOT HOURS, after
birth. It does NOT have bile in the vomit.
565.
Case: A male name Jeff Wiley who is 32 years old
confesses to you that he lies on his tax returns and embezzles money at work.
Does Federal law say you must inform the federal authorities?
A) No.
566.
Case: A pregnant female comes in with Phenylketonuria.
What exact enzyme is missing?
A) Phenylalanine hydroxylase
567.
Case) You WILL see this case a lot...A 5 year old kid
with a week long fever also comes in with dry cracked lips, shedding of the
skin, and edema and rash all over, and cervical lymphadenopathy. What is the
disease? What body part(s) does it affect?
A) Kawasaki syndrome. This is a vasculitis or medium and
large coronary vessels.
568.
Case: A young patient of your named Thomas Wolfe comes
in before he is entering a US college. Oh, you give him MMR, diphteria, tetanus,
polio vaccines. But, do you HAVE to give him his Hep B shot? What about his H.
flu B shot?
A) No, they are recommended, but NOT required.
569.
Case: Again, you will see BILLIONS of asthma patients.
Other than albuterol, many use steroids. But additional meds include Ipratropium
and Zileuton and Zafirlukast. What is the MOA of these THREE meds:
Iptratropium...antimuscarinic on receptors
Zileuton...blocks lipoxygenase
Zafirlukast...blocks leukotriene receptors
570.
Case: You examine a newborn child who presents with dark
lower extremities but a light pink upper extremities. PE reveals a machine gun
sound over the heart. What is happening?
A) Patent ductus arteriosis and a Coarctation of the
aorta
571.
A 21 year old mother comes in with a question about
breastfeeding since she has a vaginal yeast infection. Can she use the proper
drug safely?
A) Yes, topical administration of nystatin for Candida
is SAFE for breastfeeding.
572.
Case: The previous breastfeeding mother asks you if she
can use benzodiazepines because she is anxious about being a newborn mom and
methylphenidate for her ADD for graduate schooling. She still wishes to
breastfeeding. What do you say?
A) CNS drugs, Steroids, PTU, and alcohol and SOME
antibiotics like ciprofloxacin and tetracyclines should be avoided for
breastfeeding moms.
573.
Case: A young child named Albert Einstein comes in with
cystic fibrosis. He often develops respiratory infections as sequelae. The
radiologist comes back and says the trachea is deviated to the left side and you
had previously heard absent sounds on the right side. What is the pathophys?
A) These patients often develop pulmonary infections
which lead to rupture from cysts caused by S. aureus. Thus, a PNEUMOTHORAX
ensued.
574.
Case: A young boy named Issac Newton was eating a lot of
frozen flavored ice cubes and holding them in his cheeks. Later, his mother
brought him to the ED because his cheeks were slightly swollen, cool, and
erythmatous. What is the name of this condition?
A) Fat injury from the cold is PANNICULITIS.
575.
Case: A young child patient of yours is getting his
immunization shots and reacts poorly to the DTaP shot. Which one component is
likely to have caused the reaction (Choices: Diphtheria/Tetanus/Pertussis)?
A) The Pertussis part is usually culpable if there is an
adverse reaction.
576.
Case: An eight year old boy named Johann Kepler was
playing basketball when he noticed gradual pain, stiffness in the hip area
through the playing season (three months). A radiograph showed femoral head
necrosis. What dx is this?
A) This is Legg-Calve-Perthes disease.
577.
Case: Same clinical case presentation as HY Concept 576,
but this boy basketball player is quite overweight. Other than Legg Calve
Perthes dx, what is likely the problem?
a) Slipped capital femoral epiphysis.
578.
Case: Now, another member of the boys' basketball team
named Ernest Rutherford started playing soccer in field sprayed with
insecticides. He later started the typical cholinergic symptoms of "DUMBELS" or
urination, pooping, sweating, salivating, etc. Other than Atropine, what ELSE
can you often use that starts with the letter, "P"?
A) Pralidoxime, which reactivates acetylcholinesterase.
579.
Case: A neonate born named Alfred Hitchcock suffered
from sepsis due to E-coli. There is a strong correlation between this bug and
galactossemia, which we already studied (recall hepatomegaly, hypoglycemia,
jaundice?). What is the exact enzyme that is missing?
A) Galactose 1 Phosphate Uridyltransferase
580.
KNOW that Fetal Alcohol Syndrome is EVERYWHERE. So
understand exactly how it presents and what organs are involved. Understand it
can "look" like Cerebral Palsy and/or Down's, so watch the demonstration of the
history. You need to present these cases to Child Protective Services.
581.
Case: If I gave you a case of a cyanotic newborn baby
and showed you a RADIOGRAPH with a "boot shaped heart" and slight pulmonary
vascular markings, what common dx is that, and which specific finding is most
important to determine if the baby will survive?
A) This is the Tetralogy of Fallot and the degree of
pulmonary stenosis predicts the outcome of the baby.
582.
Case: When you take tests and go into clinics, you will
see common things commonly. So, say I have six patients with one of the
following:
1-PKU
2-Cleft Palate
3-Clubfoot
4-Hypospadias
5-Phocomelia
6-Myelo-meningocele
Which is the MOST common one you will see?
A) It is hypospadias, one in five hundred....
583.
HARD CASE: Listen, you see a child who is a GIRL in your
clinic and she looks like she is autistic. She is 4 years old. Her mother said
that she seemed fine until 1 1/2 years of age and then there was
neurodevelopmental arrest and then sudden regression. Her PE resembles Cerebral
Palsy with loss of motor functions. Two attendings come in and tell you that it
is NOT cerebral palsy or autism. They say that it only happens to girls, the
gene defect is MECP2, and she has short stature and an enlarged head as a hint
to you. What is this dx that starts with an "R"?
A) Rett's syndrome
584.
Case: You will definitely see this on tests and clinics.
You have a girl who is 12 years old and she is short for her age group at this
time. BUT...labs reveal elevated FSH and LH signaling .... what? And you note a
history of UTIs and hypertension. What is this common dx which occurs in 1 in
2000 women? Can she have children? What meds do you give?
A) You WILL see Turner's syndrome. They have ovarian
failure and FSH and LH will be elevated. The coarctation of the aorta is related
to the HTN. Due to ovarian failure, she sadly cannot have children. You need to
give her GH or somatotropin. And estrogen at the later stages.
585.
Case: You see a woman in your clinic with seizures,
mental retardation, and skin lesions. Your attending TELLS you this is classic
tuberous sclerosis. What is the genetics here? AD, AR, XR, XD?
A) AD, or Autosomal Dominant
586.
Case: "Tyrosine is a precursor for what amino acid?"
asks your attending.
A) Dopamine (VERY CRITICAL) Think "I married a man named
TYler (Tyrosine) who became a DOPe! (Dopamine)."
587.
Case: We covered the fact that PKU is a def. what
enzyme.... ? And in PKU, what primary food group must the patient NOT eat?
A) This AR dx (missing phenylalanine hydroxylase) must
be treated with amino acid bars (among other Rx) and you must tell your patient
to avoid meat, dairy, and nuts. Plus, tell them to be aware of some sodas and
potato chips, which are high in aspartame and phenylalanine.
588.
A five year old boy patient of yours comes in with an
overdose of a common drug used for bed wetting (starts with letter "i"). How do
you think he will present?
A) This is imipramine, a tricyclic. Overdose presents
with lethargy, epilepsy, heart rhythm irregularities.
589.
Case: A 30 month old child presents with small bowel
obstruction seen on x-ray. His PE has bad colicky abdominal pain with bloody
diarrhea and vomiting. You feel a mass in the epigastrium. What is going on?
A) This is intussusception. Very common.
590.
Case: Recall what I said, to REALLY LEARN and RETAIN,
you must study the differential diagnoses TOGETHER. So, the last case was
intussusception. But there is another dx that is similar in presentation and the
most common congenital dx of the ileum that involves the vitelline duct and
ectopic pancreatic and gastic tissue with the GI bleeding. What is this???
A) Meckel's diverticulum (very diff to diagnose at
birth)
591.
Case: HARD, but doable: You are in a city in Israel
where the incidence of this dx is 6 in 1000, very very common. A 5 year old boy
is slowly starting to lose his protective reflexes, and becoming ataxic
(demyelination). He is getting worsening respiratory problems. This disease name
starts with the letter "K" and sounds like the word "Cab". What is the deficient
enzyme here? What is the inheritance?
A) This is Krabbe dx. Krabbe disease is an autosomal
recessive sphingolipidosis caused by deficient activity of the lysosomal
hydrolase galactosylceramide beta-galactosidase (GALC). GALC degrades
galactosylceramide, a major component of myelin. The elevated levels lead to
widespread destruction of oligodendroglia in the CNS and to subsequent
demyelination. Death from respiratory failure often results.
592.
Case: In the same "category" as the previous concept is
this...you see a patient at 6 months of age with hepatosplenomegaly, lung
problems, failure to thrive and psychomotor retardation. Your attending sadly
tells you the patient will likely die by age 3. What is this dx that starts with
the letter N.... and then P...... ? What enzyme is deficient?
A) This is Nieman Pick Disease and results from the
deficient activity of sphingomyelinase, a lysosomal enzyme encoded by a gene
located on chromosome bands 11p15.1-p15.4. The enzymatic defect results in
pathologic accumulation of sphingomyelin (which is a ceramide phospholipid) and
other lipids in the monocyte-macrophage system.
593.
Case: This HYer is so close but so far from the LAST
HYer concept. So, listen up...you have another patient who is an Ashkenazi Jew
with hepatosplenomegaly, pancytopenia, and mild skeletal disease, and you are
thinking Nieman Pick, but this is NOT it...this is Gaucher disease. OK, so what
enzyme is missing?
A) Gaucher disease is a lipid storage disease,
characterized by the deposition of glucocerebroside in cells of the
macrophage-monocyte system. Deficiency of a specific lysosomal hydrolase, acid
beta-glucocerebrosidase leads to the symptoms. Unlike Nieman Pick disease, there
IS a medical treatment! You must get everything right for your patients!
594.
Another similar case! This time you got close enough to
know the ataxia, lost reflexes, slurred speech is Metachromatic leukodystrophy.
So close to Krabbe's and Gaucher's in presentation...what is the enzyme missing?
A) arylsulfatase A!!!
595.
Case: A young patient comes in with a triad of
meningomyelocele, spina bifida, and hydrocephalus. He is 8 months old with a
large head. What is the name of the disease? And what is the Rx?
A) This is Arnold Chiari syndrome and you need to give
acetozolamide.
596.
There are two distinct signs that a baby was shaken
abusively...ie "shaken baby syndrome". What are they? You MUST recognize them
for the child's sake!
A) You may see a floppy baby with retinal hemorrhages
and subdural hematoma.
597.
Case: You are seeing the delivery of a baby from a 18
year old young female with SLE. What is her baby most at risk for (name the
organ system)?
A) SLE is assoc. with complete heart block towards the
child.
598.
Case: An attending nephrologist comes in and explains to
you that he has a patient with a defect in the proximal renal tubular
reabsorption of phosphate. The patient is a young child and is short for his
age. He tells you this is Vitamin D resistant rickets. What is the inheritance
type?
A) X-linked dominant
599.
Case: ANOTHER child comes in with vitamin D resistant
rickets. The most common rickets in the the USA. How will the child walk towards
you?
A) The rickets causes bow leggedness and will result in
a duck waddle.
600.
Case: I sadly saw this one myself....but let's say you
see a deceased newborn infant with a prominent occiput and low set ears. His
hands are clenched with rocker bottom feet. Which trisomy is this? 13, 18, or
21???
A) This is Trisomy 18
601.
Case: Everyone in clinics and from all the USMLE tests
are saying some of the versions heavily quiz physio and graphs and major
homeostasis concepts. So...if you have any patient with V. cholera infection and
they present with dehydration, OR if you have a patient with Diabetes IDDM with
ketoacidosis, what will you initially do? Guess first before peeking at the
answer!
A) Replace fluid and electrolytes first.
602.
Case: For the patients with dehydration, do a careful
history to find out just why they are ill. Give me two classic findings on PE
suggestive of dehydration.
A) Oliguria, (low urine output), and acute weight loss!
603.
Case: Regarding homeostasis and water balance, tell me
some major causes that are CHRONIC which present with dehydration!
A) We already discussed diabetes, but also think of
congenital adrenal hyperplasia, diabetes INSIPIDUS, severe sore throat (which
prevents desire to swallow), cystic fibrosis. Did you get any of these?
604.
Case: As a patient of yours continues to LOSE fluid
balance, he will present first with tachycardia, then his or her respiration
will speed up. Why is this?
A) Often metabolic acidosis ensues, so you have
compensatory respiratory alkalosis!
605.
Case: What is the most common form of dehydration
(hyponatremic, hypernatremic, or isotonic)?
A) ISOtonic!! So this means that water losses roughly
equal sodium losses.
606.
Case: You have a patient with severe fluid loss...what
will the PE present like regarding his skin?
A) When you press his fingertips, capillary refill will
be greater than 3 secs. Also, his or her mucous membranes will be dry (open
their mouths and LOOK). If it is a baby, the fontanelles will be sunken!
607.
Case: Again, your patient is water deprived for a long
time...what will the Urine osmolarity and specific gravity look like?
A) Both values will be severely ELEVATED. think
why...and so will the BUN/Creatine ratio.
608.
Case: Again, lumpin along, what will your water deprived
patient show on his PE for the bicarb level?
A) Secondary to acidosis, his bicarbonate will be
decreased! BUT, KNOW that if he is VOMITING all the time, his body will face
metabolic ALKALOSIS.
609.
Case: This concept is SO CRITICAL...tell me some
differences between INCREASED vs. DECREASED anion gap! Be specific!
A) Increased anion gap includes: Hyperphosphatemia,
HYPOkalemia, HYPOcalcemia, HYPOmagnesemia. Massive diarrhea, lactic acidosis,
DKA, aspirin overdose, chronic kidney failure.
DECREASED anion gap includes: HYPERkalemia,
HYPERcalcemia, HYPERmagnesemia, low albumin, Li overdose.
610.
Case: Say I give you a case study and tell you this is a
prerenal failure. What exact LAB value threshold will you like to see to confirm
this?
A) A BUN/Creatinine ratio over 20.
611.
Case: Lumpin...let's say I present a case to you and the
patient has a capillary finger refill of 1 sec and is very mildly dehydrated
after a tough rugby match. Should I give him IV boluses?
A) No, for mild cases, just do ORT or oral rehydration
therapy. Kinda sorta like giving GATORADE juice, you need to give approx. a
solution with 90 mEq/L Na, 20 mEq/L of K, and 20 g/L of glucose. DO NOT give or
pick just free water to rehydrate!
612.
Case: You have a patient with EDEMA from CHF. You do
recall our discussion of the MOA (Mech. of Action)?
A) The CHF results in decreased renal blood flow. Thus,
you retain Na and water, resulting in EDEMA
613.
Case: Lumpin along....another patient of yours comes in
with EDEMA. He or she has LIVER DISEASE. What is the MOA?
A) Decreased albumin synthesis from liver dx results in
edema here from decreased oncotic pressure.
614.
Case: Lumpin still. Another pt. with edema comes in with
associated protein malabsorption syndromes. What is the MOA?
A) So much protein malabsorption results again in
decreased plasma albumin...thus lower oncotic pressure...and ensuing EDEMA!
615.
Case: Another EDEMATOUS individual. This time he/she has
one of the NEPHROTIC syndromes. What is the MOA of edema?
A) The loss of albumin and protein clotting factors
results in again lowered albumin in the blood, thus lowered oncotic
pressure...and thus EDEMA!
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
616.
Case: A sexually active female walks into your office.
She has a lot of edema. What is the main thing you are thinking of?
A) PREGNANCY or OCPs!
617.
Case: Lumpin still...your physio prof comes in and tells
you your edematous patient has a cardiac origin. HOW will his PE present?
A) SOB, cyanosis, sweating with eating suggest a
congential cardiac origin to the edema.
618.
Case: True or False: Can a severe allergic reaction
mimick other forms of edema?
A) True or Yes...
619.
Case: Speaking of edema, there is a famous often tested
disease that presents as a patient young or old that comes in with a deep rash
that started on the buttocks or lower legs. There is edema on the hands and
feet. About half of the patients initially presented with Upper Respiratory
Infections. What is the pathophys of this disease that we once spoke of? What
meds should you give? (Hint: name starts with H... and is named after someone.)
A) This is Henoch Schonlein Purpura. About half the
cases were preceded by a upper respiratory infection. The etiology of HSP
involves the vascular deposition of IgA immune complexes. More specifically, the
immune complexes are composed of IgA1 and IgA2 and are produced by peripheral B
lymphocytes. The circulating complexes become insoluble, are deposited in the
walls of small vessels (arteries, capillaries, venules), and activate
complement, most likely by the alternative pathway. Thus, group A streptococci,
varicella, hepatitis B, Epstein-Barr virus, parvovirus B19, Mycoplasma,
Campylobacter, and Yersinia are often picked as inciting factors. Treat against
the bug if persistent (after culture), and give prednisone for the inflammation.
They also need pain relief like Tylenol or Ibuprofen for some pain.
© 2003, 2004 ValueMD Inc. All rights reserved
620.
Case: For the previously discussed cases of edema, which
labs will help you differentiate between a liver, cardiac, renal, etc. source?
A) For the liver, do the liver function tests. For the
cardiac, check for cardiomegaly and pulmonary edema on X-ray. Renal sources will
point to inconsistent serum electrolytes and proteinuria.
621.
Case: We discussed patients with water deprivation from
vomiting and diarrhea in a patient. What exact lab value for the Na indicates
Hyponatremia?
A) Serum sodium under 130 mEq/L!
622.
Case: Because you will treat dehydrated patients all day
long in clinics, you need to know what are the most serious consequences of
protracted diarrhea/vomiting? What labs will the USMLE give you to assess the
causes?
A) Beware of Hypovolemic shock as the patient's mental
status worsens with decreased reflexes. The most serious consequence is seizures
and cessation of breathing. Other than BMP, you need blood glucose, liver
function tests, protein and lipid levels.
623.
KNOW every kind of hyponatremia and how the little
arrows will point with respect to Urine Na, Urine specific gravity, etc. Here,
let me ask just ONE question: For hyponatremia due to CHF, what is the value of
the Urine Na and Urine specific gravity?
A) In CHF hyponatremia, urine Na is DOWN, and Urine
specific gravity is UP. Remember the subtle differences...like KNOW that if you
have ADDISON'S dx, the urine Na will be up and the urine specific gravity will
be DOWN! Think why!
624.
Case: Since HYPERkalemia is so dangerous, tell me a few
of the causes of hyperkalemia!
A) Addison's Disease, Acidosis, Dehydration (severe),
Spironolactone drug therapy, and too much K infusion, tubular kidney damage
leading to improper K excretion.
625.
Case: Despite warnings, your patient becomes
Hyperkalemic. What does his/her EKG look like?
A) You will see T wave elevation, then muting of P
waves, then QRS complex widening, and ST segment depression. Deadly V-fib can
result!
626.
Hi brothers and sisters,
I need to address a vital question for everyone because
it continues to be asked.
1) Many are asking about their personal assessments and
how to gauge progress. This is an excellent question. This is SO VALUABLE
because you will then KNOW if you are making progress or not. There is a LOOSE
connection between say
QBankperformance and the actual exam. But, the material does correlate in the sense
that if your
QBankscore is moving higher slowly and steadily, then you KNOW you are at least
retaining some information. But, if you do not have
QBankand/or cannot afford it, you can use Q-Book or another popular source. The most
important issue is not really what you are getting in the absolute percentage,
but whether that number is increasing over a set time. As an aside, I mentioned
what I found to be accurate as to
QBankscores... Most of the students scoring at least a 50% on
QBankpassed the exam. Now, the
QBankleans heavily on Pathology and Pathophysiology, and asks questions with a
slightly different slant than the actual test. So, if you are UNLUCKY and get
say series of questions on Embryology and Immunology and you completely skipped
these two subjects, then you will find that your 50% on
QBankwas not relevant. So, that is what a lot of repeat test takers are saying...that
their second or third etc. test was ENTIRELY different from the initial ones.
Although I am not sure of this since I did not see their tests, I am certain
that the NBME will not allow someone to receive the same or similar questions
from his/her previous test. So much of the computer based testing is CENTERED on
avoiding ANY POSSIBLE shortcuts like this.
Therefore...gauge your progress with weekly question
banks like a
QBank. Then, as I mentioned before, do the USMLE Sample Questions for ALL THREE STEPS
that are found on the NBME website (These are free to download). Then, do the
KaplanSimulated CD that is found EVERYWHERE, your roommate probably has a copy. Also
please complete the two NBME self assessment exams found on their website (There
a cost to this that the NBME charges, but I think it is worth it to gauge your
progress). Also, do the RETIRED NBME Step 1 questions. They can be found
everywhere too for free. I think even ValueMD has a copy of it. You definitely
WILL benefit from doing this to test yourself. For example, if the RETIRED
questions have 100 biochemistry questions, then split them into 4 blocks of 25
questions each. Then do one block every weekend a month before the exam for each
subject topic. Then graph your results to see if you are studying effectively. I
know the question format is different, but the concepts tested were HIGHLY
related to the actual exam in many cases. Also, try to do some of my questions
too as a way to gauge your progress. Maybe you can make notecards of them and
get a filebox. If you get the flashcard question right, then place the notecard
in the end of the file so you will not see it again right away. If you get the
item wrong, then place the notecard towards the front of the pack so you will
see it again sooner. This is a highly effective way to study, and you need to
keep up the repetitions daily. If you start skipping them, you will start
forgetting them.
627. Dear Family,
Many are writing that they are suffering under severe
anxiety and are asking me for advice. This is again a VERY good question.
1) The first thing to know is that this test is very
"coachable" and "doable". Plus, unless you are pushing 50 years of age, you have
time! Even if it takes one or two years to pass Step 1, 30 years from now, this
event will seem like a distant dream.
But there needs to exist the right circumstances or it
just cannot work. Still, many are shouldering the burden of work, family (kids),
AND suffering some personal crisis. Then, they mention their test is in a month.
My heart and everyone else's breaks upon hearing this, but we must ask God for
the right TIME to PASS Step 1. If life events are not going to permit you the
time to study, it is like trying to climb Mt. Everest tomorrow without any
preparation or running the 26.3 mile marathon in a week. Both tasks are doable,
but if you just broke your leg, you cannot run next week. We must all pray to
get that necessary block of time required. Some are trying to lift their anxiety
with serious alcohol and anti-anxiety and then sleeping all day long instead of
studying. Not good. Although a few can use some anti anxiety medication in
MODERATION, this often has the effect of putting you to sleep, which will make
the anxiety 100 times worse after you awaken and lose a day of studying. Better
again to WAIT until the right moment. If you are working and you cannot find
anyone like a family member to live with and feed you while you are studying,
please reconsider taking the test until the right time presents itself. You will
only put more agony onto yourself if you do not pass...
628. Case: Although we glanced over this in Pharm, tell
me what is the Rx for a first time HIV patient of yours and tell me the MOA of
the drugs. Then, we will next quickly go over the MAIN dx of HIV and the Rx.
A) In clinics, we like to give 2 nucleoside analogs like
AZT (Zidovudine) and Lamivudine....PLUS a protease inhibitor like Lopinavir or
Rotinavir (These drugs usually end with suffix -avir). Recall that the
nucleoside analogs are THYMIDINE analogs which blocks virus replication via
REVERSE TRANSCRIPTASE. The protease inhibitors work by blocking the modification
of precursor polyproteins responsible for synthesis of reverse transcriptase and
HIV-1 protease itself.
629.
Case: The next patient comes in with a positive ELISA
and Western Blot for HIV. Do you recall at least TWO VIRAL ANTIGENS in the
peripheral blood to also confirm HIV infection?
A) Look for GP41 and P24 antigen.
630.
Quick, what was the MOST COMMON worry you have with HIV
patients (i.e. main dx)? What is the Rx? (Hint, this bug hits the lungs and can
cause SPONTANEOUS PNEUMOTHORAX!)
A) PCP (Pneumocystis carinii). Give TMP/SMX as the Drug
of choice. This can be LUMPED by thinking all have popular 3 letter
abbreviations (HIV-PCP-TMP/SMX).
631.
Case: Now, the HIV positive person comes in with
headaches and fever. A radiograph is shown that has ring lesions and midline
shift. He was scratched by a cat last month. What COMMON bug starting with the
letter "T" are you thinking of? What is the Rx? What are some side effects?
THINK before you look at the answer below!
A) This is Toxoplasmosis gondii, give a folic acid
antagonist like Pyrimethamine. Watch for his HTN in intracranium and possible
seizure activity!
632.
Case: Now, another HIV positive pt comes with fever, and
MILD headaches and a radiograph with hydrocephalus. What COMMON bug starting
with the letter "C" am I looking at? What drug or Rx?
A) This is highly confused with PCP and Toxoplasma. The
bug I am seeing here is Cryptococcus meningitis. MAKE SURE YOU KNOW THE
DIFFERENCES COLD LIKE YOUR NAME, MOTHER'S NAME, etc. Treat with Amphotericin B.
(Mneumonic: When you think of a "Crypt" (cemetery relation), think of a crazy
band that is obsessed with the DEAD, and likes to play their AMPlified (Amp B)
electric guitars inside the scary Crypt.)
633.
Case: Quick, the NEXT RELATED COMMON bug with HIV
attacks the eyes, leading to loss of vision and retina detachment. What bug and
drug? No hints here...except it starts again with the letter "C". Give
morphology of bug...too.
A) This is CMV retinitis. YOU must give GANCICLOVIR!
This is part of the HERPESVIRUS family. It is double stranded, linear,
enveloped. (My mneumonic....think....CMV stands for California Motorcycle
Vehicle GANG) [Think and imagine a CMV gang riding down the highway getting
flies stuck in their eyes and slowly losing their eyesight!!!]
634.
Case: Now an ENT doctor refers to you a patient with HIV
and oral thrush. What is this super common bug and drug in HIV? Can you identify
IT PRECISELY under a microscope? If not, LOOK for it in a Microbiology
book/atlas!
A) This is Candida. Treat with an "azole" like
Ketoconazole, Clotrimazole or Nystatin.
635.
Case: OK, an HIV patient of yours has really BAD
diarrhea. Your acid-fast staining of stool demonstratess red-stained round
oocysts against a blue-green background. White and red blood cells should not be
seen in the stool. What super common opportunistic bug starting with the letter
"C" is here? Rx?
A) This is Cryptosporidiosis. Drug treatment is
difficult, but the HAART treatment for HIV is helping a lot. Give them
symptomatic treatment with LOPERAMIDE or Kaopectate.
636.
Case: You have a pregnant woman that asks you the
difference if any between taking a teratogen in the first trimester or third
trimester. What do you say?
A) Taking a teratogen in the first trimester usually
damages organogenesis, while taking a teratogen in the third trimester often
slams the CNS development and the growth of the baby!
637.
Case: Some pregnant women come to your office and asks
what is the MOST COMMON maternal disorder that is teratogenic. What do you say?
A) Diabetes mellitus, one in ten diabetic females'
babies have a birth defect.
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638.
Case: A women who is African American with history of
benign fibroids is pregnant. She asks if this could hurt the baby. What do you
answer?
A) Unfortunately, the fibroids can "squeeze" the baby,
and present with abnormal facies, club feet, or abnormal lie/breech
presentation.
639.
Case: What is the inheritance pattern for the most
common blood coagulation disorder named after a doctor with the name "V"?
A) So so common and heavily tested in clinic and exams,
this is Von Willebrand's disease, and is AD or an Autosomal dominant disorder.
Recall, you must tell the pt. she has a 50% chance of passing this to her
children!
640.
Case: You have a patient with the classic triad of low
intelligence, epilepsy, and raised tumorlike angiofibromas on the skin. What is
the inheritance pattern of the dx? What is the name of the dx? What is the
pathology exactly?
A) AD, this is Tuberous Sclerosis (we mentioned it long
ago once), The protein tuberin is dys-regulated, leading to hamartomas and
tumors in all organs of the body, notably on the skin.
641.
Case: This can be both autosomal dominant and recessive
inheritance, but the common-"ness" of it demands a question. A patient comes in
with a history of recurrent episodes of acute pancreatitis and eruptive
xanthomas. He is at increased risk of coronary disease. He lives a sedentary
life and eats only greasy hamburgers. Name SOME common causes of his condition,
both genetic and non-genetic.
A) HyperTRIglyceridemia, this is caused by uncontrolled
Diabetes and obesity. Two genetic causes of high TG are lipoprotein lipase [LPL]
deficiency and apolipoprotein [apo] C-II deficiency leading to triglyceride (TG)
elevations that are exceedingly elevated.
642.
OK, OK, you will be asked a lot of inheritance pattern
questions. That is because you will have to explain to your patients their risks
of passing their dx to their children. So, for all autosomal dominant disorders,
we discussed they are STRUCTURAL PROTEIN disorders. They have 50% inheritance
patterns.
Also, most autosomal recessive disorders are enzyme and
"-emia" (blood stuff) related. Except for three common "-emias", that is:
Hereditary spherocytosis, von Willebrand disease, Protein C deficiency (REMEMBER
AT LEAST THESE THREE EXCEPTIONS), the enzyme and "-emia" diseases are autosomal
recessive. The exceptions to the blood "emia" rule is initials H.P.V. as seen
above. This is an abbreviation "mnemonic". AR is 25% passed on.
643.
Case: Anemia, jaundice, and splenomegaly. This class
triad is seen with a patient who is young and has that classic palpable spleen.
You see a slide which has these round RBCs. What is the disease?
A) We JUST spoke of it. Hereditary spherocytosis
presents in this way. Don't forget this NBME/attending/resident favorite!!! Try
to recall the MOA of the giant spleen.
644.
Q) I may have asked this long long ago, but what is the
problem in Hereditary spherocytosis?
A) Alpha or Beta Spectrin def. (The alpha form is
related to AR inheritance.) But know the Beta form is more common as is AD.
645.
Case: A nonsmoking patient of yours comes in and has
panacinar emphysema. She also had chronic bronchitis. What protease is
malfunctioning? What is the disease and Rx? What is the pathophysiology?
A) This is ALPHA 1 ANTITRYPSIN DEFICIENCY. The genetic
defect of alpha 1 antitrypsin deficiency results in a molecule that cannot be
released from its production site in hepatocytes. Low serum levels of the
protein result in low alveolar concentrations, where the molecule normally would
serve as protection against antiproteases. The resulting protease excess
destroys alveolar walls and causes emphysema. Give a drug branded called
Prolastin to replace the deficiency.
646.
Case: Couple A comes in and you note that the male is
achondroplasic (dwarfism/extremely short stature). The female is pregnant, she
asks what is the chance her baby is going to be have achondroplasia. What do you
say?
A) This is AD, autosomal dominant inheritance, so the
male will transmit the gene to half his offspring.
647.
Case: Couple B comes in and you note that BOTH are
suffer from achondroplasia (dwarfism). They are asking about the inheritance to
their children. What do you say?
A) Again, this is 50% BECAUSE the homozygous form
usually does NOT survive to birth. So the 50% HETEROzygous form will have the
phenotype of dwarfism, but half will be normal.
648.
Q) We are discussing achondroplasia. What is the MOA of
this AD disease?
A) The MOA or pathophys is such that fibroblast growth
factors are structurally related proteins affected...and are associated with
cell growth, migration, wound healing, and angiogenesis. At the cellular level,
their function is mediated by transmembrane tyrosine kinase receptors, known as
fibroblast growth factor receptors (FGFR). Mutation in FGFR3 gene is responsible
for the achondroplasia, or dwarfism.
649.
Case: You research 100 achondroplasia patients and only
10 had any history of the dx in the family... why???
A) Don't forget the mech. of SPONTANEOUS MUTATION. This
disease is noted for 90% new mutations in the lineage.
650.
Case: You see a patient with hypertension, infections,
hemorrhage and renal stones. You feel a large mass on one side of the body. What
mode of inheritance is this dx? What is the dx?
A) AD inheritance, Adult Polycystic Kidney Disease
presents as above with large cysts in the kidneys. Renal failure will usually
result by age 60. Radiographs will show large circles or cysts.
Tommy’s HY 651-700(skip 666,683)
651.
Case: A patient of yours with the previously mentioned
ADPKD dies of a lesion around the vessels in the brain. Given a CT scan, could
you point to the area that is lesioned?
A) Commonly, ADPKD patients die of a berry aneurysm,
even if their renal failure is controlled.
652.
Case: You have a female patient who works in a pet shop
who is 25 years old and sexually active. She just gave birth to a baby boy who
is 7 weeks old. The baby comes in with otitis media, wheezing, and
conjunctivitis. What is the drug you prescribe? What is the bug?
A) So common, this is Chlamydia pneumonia, caught by the
baby through the birth canal. They may be asymptomatic for the first few weeks
of life! Give tetracycline as drug of choice. (Mnemonic: Think and imagine...MY
pet CLAM named RICK who swallowed my pet TETRA fish.) [ My-Mycoplams, CLAM-
ChLAMydia, RICK-Rickettsia...and TETRA-Tetracycline ]
653.
Case: A 4 year old child pt. presents with slowly
progressive difficulty walking. His eyes look like he has telangiectasias or
conjunctivitis. There is some difficulty in respiration, and he is drooling a
little. Histology shows that some Purkinje cells are being lost in his
cerebellum.
1) What is happening to his Immunoglobulin levels?
2) What is the dx?
3) What is the primary pathophys defect?
4) Is this autosomal recessive or dominant?
A) 1) IgA is low, IgG and IgE are elevated.
2) He sadly has ataxia telangiectasia.
3) The primary defect is a problem with a DNA processing
or repair protein.
4) AR
654.
Case: You have a male young patient coming over and over
to your office with pulmonary infections. His stools are reported to be fatty
and foul smelling. The question is, "Which vitamin (B1, C, or D) are you most
concerned about supplementation (you need to give this)?" And the dx name
please. True or false: The disease is X-linked recessive?
A) Due to exocrine pancreas lesions, the CYSTIC FIBROSIS
patient has trouble digesting fat soluble vitamins like Vitamin D. False...the
cystic fibrosis is autosomal recessive! KNOW THIS COLD!!!!!!!
655.
Case: For the previously discussed pt. with CYSTIC
FIBROSIS, what is the most preferred and a specific test for diagnosis?
A) A Sweat Chloride test
656.
Q) Quickly, without pause, tell me the most common bug
to affect our previously talked about CYSTIC FIBROSIS patient's LUNGS (that will
cause pneumonia). What is the Rx? THIS BUG IS SO COMMON, so BE READY TO identify
the morphology (gram stain, etc.) and the appearance on a petri dish.
A) Pseudomonas aeruginosa. Treat is varied and you can
often use a penicillin type- Piperacillin/Tazobactam and combine it often with
Gentamycin. Or you can pick Aztreonam. I have seen Imipenem and cilastatin work
as well. Oh, also know it smells like grapes on a petri dish. Love you all my
brothers and sisters!!!
657.
Case: Another boy enters your clinic with symptoms
mimicking CYSTIC FIBROSIS like fatty stools, fat soluble vitamin deficiency,
failure to thrive. But the boy DOES NOT have any history of respiratory
infections. What is the dx that also starts with the letter "C" that is confused
with cystic fibrosis?
A) Be aware of celiac disease, NO RECURRENT RESPIRATORY
INFECTIONS distinguish it from cystic fibrosis!!!
658.
Case: Yet another patient walks into your clinic with
symptoms mimicking cystic fibrosis like the recurrent respiratory infections,
failure to thrive. BUT, this time you note he has NO MALABSORPTION symptoms.
Name one of a few type of dx that can cause this! (Hint: there is one with three
words, the first letter is "c", second letter is "g")
A) This is Chronic Granulomatous Disease
659.
Q) There was a question on images and how a LOT of
students just omit their studies of them. Some later say that you can answer the
question without the image. BUT BEWARE!!! The NBME carefully and fairly puts in
the images because a panel of experts KNEW the students HAD to have the image to
carefully distinguish it from closely related diseases. SO, be familiar, and
CLOSELY study the image the NBME gives you. It will make a difference over and
over.
660.
Q) YOU HAVE TO understand that congenital syphillis
infection presents in STAGES, so know ALL THE stages! If I gave you a case of
LATE STAGE CONGENITAL SYPHILLIS, could you describe for me all that you know???
A) LATE: Breaks in the skin, saber shins, saddle nose,
neuromuscular paralysis.
661.
Q) NOW, I just asked you late stage symptoms of
congenital syphillis. Tell me the EARLY symptoms of congenital syphillis. You
have to be able to spot this.
A) EARLY: Fever, hepatomegaly, failure to thrive,
anemia, rash
© 2003, 2004 ValueMD Inc. All rights reserved.
662.
Case: This is SO CLASSIC: A young girl comes into your
office lacking her immunization shots. She had a rash that went from the face
then progressed down to the toes. This should ALREADY BE FAMILIAR to you. What
are some associated symptoms?? Tell me also the morphology IF it is a bug.
A) This is Rubella or German measles. Associated
symptoms are fever, lymphadenopathy, and arthritis like symptoms. A TOGAVIRUS,
it is enveloped, square shaped, SINGLE stranded positive sense.
663.
Case: A young girl comes in with a postive serological
test for a bug that is the ONLY double stranded RNA virus you need to worry
about for the Step 1 and in clinics. She is vomiting and has diarrhea. Every
child in her day care has these symptoms. What is the exact morphology of said
bug? What is the bug? What is the most serious sequelae? What is the drug?
A) This is ROTAVIRUS, so common and very contagious.
This is Double stranded, NO envelope, square shaped, with segmentation. WATCH
OUT for dehydration! And there is NO current medication for it. It resolves in
about a week.
664.
Q) If asked, what are the 5 exact categories that
determine the APGAR score?
A) Heart rate (2 max points if over 100), Respiration
(crying?), Muscle tone (Flexion), Reflexes (can she/he cough), and Color (Blue
or Pink)
665.
Q) KEY, when studying, try to keep things simple if
possible...so let me ask you this--If you are trying to distinguish a lumbar
puncture between viral or bacterial meningitis, what is the most easily seen lab
result to differentiate?
A) A viral usually has NORMAL glucose levels.
667.
Case: A young female comes in with her 16 month old
child who just had a tonic clonic seizure after an episode of otitis media and
fever. She is very scared that he will have a lifelong illness. There is no
history of seizures in the family. What do you tell her about the risks?
A) A FEBRILE SEIZURE usually does NOT progress to
chronic epilepic seizure activity, esp. if there is no family history.
668.
Case: YOU will definitely see "skin" stuff in clinics
and the USMLE. So, let's say you see a one year old male with fever and chills
and a RASH. He was OK until an ABRUPT onset of the fever lead straight into a
fine erythematous maculopapular eruption rash that started on this stomach and
waist and spread all over his body. His nose is runny. (His fever suddenly
dropped as the rash started). Picture is given...and the dx starts with letter
"R".
A) This is Roseola infection, a HHV 6 infection (herpes
virus).
669.
Case: HINT: I am thinking of a TOGAVIRUS. Today we have
a 3 year old without immunizations. He has a rash and pain behind the ears. He
also has cervical lymph node enlargement. This picture "looks" like the Roseola
infant but this is NOT the same. The rash started on the patient's face. What is
the morphology? What dx is this?
A) This is clearly Rubella. The lack of immunizations
and the "togavirus" hint should clinch your pick. We are square shaped,
enveloped, single stranded, and linear.
670.
Case: A girl comes in with a rash that is viral in
origin and started on the face bilaterally with a bright red appearance. She had
a low temp for the last day. This virus is associated with fetal hydrops in
utero. What is the bug, dx, and morphology?
A) This "slapped cheek" disease is Parvovirus B19, 5th
Disease, and it is the ONLY Single stranded DNA virus. No envelope.
671.
As I have been doing, every time you see any question,
think of ALL the secondaries of the bug like morphology, Rx, side effects of Rx,
etc., how it looks like under scope, specific stain, etc. Do this automatically
EVERY SINGLE TIME!
672.
Case: Another viral rash, this time you see the rash
start on the face and spread down to the feet. AND you see these gray white dots
on the mucal mucosa that has blue centers and red areolae. The young patient
missed her immune shots. Bug and morphology? Name the OTHER bugs in the virus
family.
A) This is Measles. The KOPLIK's spots are specific. It
is an RNA virus, single stranded, neg. sense, linear. It is a helix shaped bug,
and it is part of PARAMYXOVIRUS family. with Parainfluenza, RSV, and Mumps as
part of the family.
673.
Case: This bug virus is in the same family as the
rhinovirus. This virus causes a rash that unlike measles, starts in the mouth
(oral ulcers) and hands and feet and spreads out. It is common in spring and
summer. What is bug and morphology and dx name?
A) This is Coxsackie A virus causing "Hand foot mouth
disease". It is a PICORNAVIRUS, NO envelope, single stranded, POSitive sense,
square shaped.
674.
Case: A young girl's brother had the same illness that
was a viral rash a month ago. Now, the sister has a similar lesion that is
highly contagious, with pruritic rashes that have several stages of lesions at
the same time. The rashes are "in patches" all around the body. The girl is
considered infectious until all the vesicles are "crusted over", about a week
after the onset. What is the viral culture test? Bug and morphology? Late
sequelae?
A) This is Varicella. The "various stages present at the
same time" is highly specific for the dx. People use a Tzanck prep for culture.
It is a HERPESVIRUS! So, it is a DNA virus, yes to enveloped, double stranded
linear morphology. Herpes zoster/shingles is a late reactivation sequelae that
hits the dorsal root ganglion.
675.
Case: Of the viral rashes/eruptions, what is the Rx?
What should be avoided?
A) Mainly supportive like Tylenol for the fever, and
antihistamines for the itching. Don't give aspirin because you may get Reye's
syndrome.
676.
Case: This is a good one. What are the two most common
bacterial skin rashes? (Give the names of the two bugs and the two common
clinical conditions).
A) Group A Beta hemolytic streptococcus and Staph
aureus. Think of Bullous impetigo and Nonbullous impetigo. Please do an IMAGE
SEARCH on the internet or look in an atlas to view the appearance if you cannot
visualize them.
677.
Q) What is the pathophys of these bacterial infections
of the skin, leading to rashes? Very important.
A) Listen, while intact skin commonly is resistant to
colonization or infection by S aureus or Group A Beta Hemolytic Streptococcus
(GABHS), these bacteria can be introduced from the environment and colonize the
cutaneous surface only transiently. Experimental studies have shown that
inoculation of multiple strains of GABHS onto the surface of volunteer subjects
did not produce cutaneous disease unless skin disruption had occurred. The
teichoic acid adhesins for GABHS and S aureus require the epithelial cell
receptor component, FIBRONECTIN, for colonization. These fibronectin receptors
are unavailable on intact skin; however, skin disruption may reveal fibronectin
receptors and allow for colonization or invasion in these disrupted surfaces.
Factors that can modify the usual skin flora and facilitate transient
colonization by GABHS and S aureus include high temperature or humidity,
preexisting cutaneous disease, young age, or recent antibiotic treatment, so
don't forget the above!
678.
Q) As we recently discussed in a concept, impetigo is
"usually" superficial cutaneous cuts and abrasions while cellulitis often is
WARM and red and moves into deep dermis tissues. What two bugs are responsible
for cellulitis most commonly?
A) Same as impetigo, GABHS bacteria and Staph aureus.
Now a distant third due to good immunizations in the US is H. flu.
679.
Q) What are a couple of Rx choices for cellulitis
infection?
A) Again, treat mainly for the gram positive bugs like
antistaphylococci drugs ox, clox, diclox, and nafcillin (from
Kaplanreview lectures), and cephalexin and or amoxicillin w/clavulanic acid (brand
name augmentin).
680.
Case: Other common rashes are of course..."jock itch",
scalp itch, "ringworm", "athlete's foot". What are the associated bugs? How do
they look like? Rx?
A) These are the "MET" fungi Microsporum,
Epidermophyton, Trichophyton and are part of the Tinea group of infections.
Tinea versicolor, Tinea pedis, Tinea cruris (jockitch), Tinea capitis, Tinea
corporis (body ringworm). These are often HYPOpigmented in color, not as red as
the other rashes. Give the patient one of the azoles, like ketoconazole or
terbinafine (both of which block ergosterol synthesis).
681.
Case: You have a another RASH, lasting at least 5 days,
on a baby. What is the likely bug?
A) This one is CANDIDA ALBICANS. Can you recall EXACTLY
how it looks like under microscope?
valuemd.com
682.
Case: You see a patient who is INTENSELY ITCHING all
over her body and has rashes too. She and her family recently traveled around
the world. Called the "seven year itch" (not after the Marilyn Monroe movie),
this bug shows eosinophilia and is highly contagious. This is NOT the previously
mentioned bugs but is caused by ... ? Rx?
A) This is Scabies caused by Sarcoptes scabei. The
treatment is varied but you can pick an antiparasitic like IVERMECTIN.
683.
684.
Case: Everyone saw this sometime. Can be confused with
impetigo, and other skin rashes that ITCH badly. This...is called LICE, you see
it from a microscopic specimen looking like a little "tick". What is the
pathophys of this?
A) Also called Pediculosis, Lice are buggie parasites
that die of starvation within one and a half weeks of removal from their human
host. Lice feed on human blood after piercing the skin and injecting saliva. A
mature female lays 3-6 eggs, also called nits, per day. Nits are white and less
than 1 mm long. Nits hatch in 8-10 days, reach maturity in 12-15 days. Types of
lice include pediculosis capitis (head lice), pediculosis corporis (body lice),
and pediculosis pubis (pubic lice, sometimes called crabs).
685.
Case: What is the drug of choice for the just talked
about LICE? What is the MOA?
A) Permethrin (Elimite) is preferred. It is very
effective in killing adult lice and nymphs, but not as effective in killing nits
(eggs). Permethrin is a neurotoxin that causes paralysis and death in parasites.
It is available as 5% cream
Copyright © 2003-2005 ValueMD, Inc. All rights reserved.
686.
Case: Here we see another pruritic rash on a female
teenage patient of yours. You attending hints it is a bug that is associated
with sebaceous glands. What is the bug, drugs and what test must you order to
save yourself a possible lawsuit from side effects of the drug
tetracycline?(sorry I gave one of the drugs away)
A) This is COMMON ACNE. It is associated with
folliculitis type lesions and drugs range from benzoyl peroxide to Retin A cream
to tetracycline. Give a pregnancy HCG test for the Retin A and tetracycline
because they are teratogenic.
687.
Q) What is the treatment for diabetes insipidus? What is
the difference between nephrogenic and non nephrogenic DI?
A) Desmopressin acetate (DDAVP) a vasopressin analogue.
NON nephrogenic DI is associated commonly with head trauma, brain tumors, or
craniopharynigomas. Nephrogenic DI is assoc. with collecting ducts not
responding to ADH.
688.
Case: A patient comes in with symptoms of short stature.
Name some causes of this...what are you thinking of? (Mnemonic: GRAPES)
A) Think of GRAPES when you see a short person in your
clinic! Growth hormone, R enal disease (Vit D assoc), A chrondroplasia (could be
spontaneous mutation), P rimary hypthyroidism, E ating/absorption problems
(eating disorders and absorption problems like celiac sprue), "S" for "S"ystic
Fibrosis (actually cystic fibrosis)
689.
Case: Two other short stature young people come into
your clinic. One boy is taking steroids for muscle growth and the other girl has
an XO karyotype. What is the MOA of the short stature here?
A) So many things cause short stature. Here, we see
steroids/hypercortisolism having short stature effect. And also know Turner's
syndrome can cause short stature!!!!
690.
Case: A 22 year old pt named Cressida comes into your
office with bulging eyes and anxiety and tachycardia and anxiety. Does she have
Papillary carcinoma or Graves disease?
A) Graves is the MCC (most common cause) of
hyperthyroidism and the only one that presents with bilateral bulging eyes. The
MOA is IgG binding to TSH, increasing release of TH. Papillary carcinoma is
usually nonsecreting COLD nodules.
691.
Case: Why couldn't the previous case be Hashimoto's
thyroiditis?
A) Because Hashimoto's = HYPOthyroidism. It has a
swollen thyroid and antimicrosomal antibodies.
© 2003, 2004 ValueMD Inc. All rights reserved.
692.
Q) Suppose you are asked by the NBME or an attending
that the MOA of levadopa is the conversion to dopamine. In those neurons, does
dopamine turn into tyrosine or norepinephrine?
A) Norepinephrine.
693.
Case: You are given a case of either a schizophrenic
patient or Parkinson's patient. Tell ME IN GREAT EXACT DETAIL the MOA of
norepinephrine synthesis involving dopamine...
A) First, you have the aa tyrosine. It is converted to
DOPA thru HYDROXYLATION. After, DOPA turns into dopamine via DECARBOXYLATION.
Next, dopamine is transported to the adrenal junction, where it turns into
Norepinephrine via HYDROXYLATION. Finally, in the adrenal medulla in the kidney,
the norepi changes to epinephrine via METHYLATION. REPEAT THE ABOVE LIKE 10,000
times really fast until you can write it from scratch!
694.
Q) The ureter's epithelium is derived from which of the
following: ECTODERM, MESODERM, or ENDODERM?
Ans) Mesoderm
695.
Q) Which arteries supply the urinary bladder? Is it
Internal pudendal?
A) NO! It is the internal iliacs.
696.
Q) T or F: The fasting serum gastrin is abnormal in
patients infected with H. pylori.
A) False!! Duodenal ulcer patients have NORMAL FASTING
serum gastrin. The gastrin moves up after MEALS.
697.
Case: A sickle cell patient has recurrent infections and
a positive Quellung rxn and optochin sensitivity for the bug. What is the most
common bug?
A) The above describes S. pneumo. The encapulated bugs
have a positive Quellung rxn.
698.
Case: A boy named Jack London comes in with recurrent
pneumonia. What enzyme, NADPH oxidase or Glucose 6 phos dehydrogenase is
lacking?
A) NADPH oxidase. He may have CGD.
699.
Case: Nut aspirations are oh so common. So tell us about
the distal blood content of an almond nut lodged in the right lung lobe. Is it
left shifted or does it have a lowered pH? What is the V/Q ratio?
A) The tissue is perfused but not ventilated so the V/Q
hits zero. Thus, it has a LOWERED pH.
700.
Case: You see a patient with POLYCYTHEMIA VERA! You will
see this at some point in your life!!! So, tell me the levels in the blood of
lymphocytes and neutrophils. Which is increased? or are both increased?
A) This is a MYELOPROLIFERATIVE DISORDER, so the myeloid
lines are increased (neutrophils/RBCs/platlets), while the lymphocyte line is
often NORMAL in lab values.
701.
Case: A girl named Catherine came in with a sore throat
which then went away in a week. Then she started urinating RBC casts and "smoky"
urine. What is the bug and histological finding?
A) This is streptococcal infection. First you have the
pharyngitis then the poststrep glomerulonephritis. Commonly, you see
subepithelial bumps on histo section.
702.
Case: A patient of yours has PERIPHERAL nerve
demyelination. Are the oligodendrocytes affected? or is it the Schwann cells?
A) PERIPHERAL nerve demyelination is associated with
SCHWANN cell lesions, oligodendrocytes lesions are associated with the CENTRAL
myelination process.
703.
Case: Are axons preserved in Multiple Sclerosis?
A) Surprisingly, they ARE. The lesion is the
DEMYELINATION.
704.
Case: A female patient has CNS symptoms like difficulty
seeing, weakness and fatigue that present as attacks separated by time. The dx
is progressive and deadly. What is the dx?
A) These ARE the CNS lesions present in MULTIPLE
SCLEROSIS.
705.
Case: Patient of yours has Conn's syndrome and thus
hypertension. Tell us the likely electrolyte problems (is renin up or down,
etc.) and how this is different from SECONDARY hyperaldosteronism.
A) This aldosterone secreting tumor gives high blood Na,
low K, and thus low RENIN. SECONDARY hyperaldosteronism has HIGH RENIN from too
much stimulus by angiotensin II.
706.
Case: A patient of yours named Daige Kurosawa is
Japanese-Korean. He lived in Japan most of his life. He has pain after eating
large meals and coughs sometimes and feels "full" after eating only 2 mini sushi
rolls and Korean dried squid mixed in preservatives. He has stomach cancer.
Which area of the stomach is most likely to have the lesion?
A) the antropyloric region.
707.
Case: After a patient of yours had an MI, your med
student asks if the first diagnostic change is proliferation of fibroblasts. Is
he right?
A) He is wrong. The first change evident is wavy change
of myocytes and intercellular edema. The fibroblasts come weeks afterwards!
708.
Case: After the MI (myocardial infarction) began, when
will you see the infiltration of neutrophils to the site of infarction?
A) Within around 12 hours of the MI onset.
709.
Case: After how long will you see a soft yellow plaque
on the endocardial section after an acute MI?
A) around one week.
710.
Q) If given a histo slide of a glomerulus, could you
point precisely to the exact cells that release RENIN? If you are not sure,
please look it up on a Histology atlas. What about the basement membrane? The
macula densa?
711.
Case: You see a friend bleeding from a knife wound to
the neck. The carotid artery (left) is lesioned. Which vertebrae can you push
the cartoid a. against the anterior tubercle to STOP the bleeding (C2, C3, C4,
C5, C6, C7)?
A) C6
712.
Case: You see a baby having a hard time breast feeding
and breathing. He gags every time he tries to drink milk. You see on X-ray the
most common cause of tracheoeophageal fistula. What is the MOA of the defect?
A) The tracheoesophageal septum failed to fuse in utero
713.
Case: A mother at risk failed to take her folic acid
pills and gave birth to a child with myelomeningocele. Is this due to failure of
spinal bone body or pedicle or what...that failed to form correctly?
A) Neither option given is correct. The correct answer
is failure of fusion of the vertebral arches.
714.
Case: A patient named Aeschylus comes in with loss of
sensation on his medial thigh area and one of his scrotums. What main nerve that
starts with the letter "I" is lesioned?
A) Ilioinguinal n. NOT the Pudendal or Genitofemoral or
Lateral cutaneous nerves.
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715.
Case: A man is lesioned in his brain such that his motor
movements are hypertonic. Movements exhibit rigidity. What area of the brain is
injured that starts with letter "B" and has two words?
A) Basal ganglia
716.
Case: An older man has an aneurysm that lesions the
cerebral cortex at the interhemisphere fissure at the cross section of the
central sulcus (sorry I don't have a picture, but look at an atlas). Is he
having trouble moving what part of his body?
A) His legs. Review the homunculus of the brain.
717.
Case: You medical student says that serologic tests ARE
useful for detection of Mycobacterium leprae and tuberculosis detection. Is she
correct?
A) She is WRONG. You need clincal presentation, skin
tests, and Ziehl Neelsen testing.
718.
Dear Family, As you continue doing the questions here,
make sure to repeat the information and KEEP GOOD TRACK of what you are missing.
If you are missing ALL the anatomy questions, you KNOW you need to review
anatomy. If you are missing all the BIOCHEM questions, you know you need to
review that. Assess the %correct manually so you know if you are RETAINING the
information in these posts. IF one week later you are getting a higher
percentage of questions correct, then you are golden. If not, you need to
schedule shorter repetition schedules. That way, you will know if you are
progressing in your knowledge.
719.
Case: A case of scarlet fever progressed to poststrept.
glomerulonephritis. Tell us about the MOA and the likely pathogen.
A) Likely you are looking and GABHS or Group A beta
hemolytic streptococcus. And the MOA is deposition of immune complexes and the
attraction of complement, C3 and IgG to the site which triggers damage to the
cells of the glomerulus.
720.
Case: What kind of glomerular lesion is caused by HIV
and AIDS?
A) Focal Segmental Glomerulosclerosis, w/ HTN and
proteinuria.
721.
Which two amino acids are ketogenic only? Glucogenic
only?
A) Ketogenic: Leucine and
Lysine.............Gluconeogenic only: Valine and Glutamate
722.
Give us three ways that an oncogenic virus can induce
cancer.
A) Amplification (of proto-oncogenes leading to
overexpression), translocation induction, and inactivation of suppression.
723.
T or F...Retroviruses integrate themselves without
enzymes into the host's DNA.
A) False
724.
Q) Parathyroid cells are derived from WHAT ARCHES, and
what are the main types of cells found?
A) 3rd and 4th arches. Dominant cell is the CHIEF cell.
See it in a histo slide.
725.
Case: You see a forty year old with fatty tissue around
the eyes (look sorta wrinkly and puffy). The LDL levels are ELEVATED. What is
the dx? What is the MOA? What is at least ONE comorbid condition?
A) Xanthelasmas. The LDL is high with foamy macrophages.
Often associated Primarly Biliary Cirrhosis causes inability to excrete
cholesterol.
726.
Case: What is the MOA of gout in alcoholics?
A) The associated ketoacid production and lactic acid
production competitively blocks uric acid secretion, supporting gout with
elevated serum urate.
727.
Case: You have a patient who cannot excrete ammonia.
What happens to the acid and bicarb levels?
A) AMMONIA binds acid H+ and is the major way the body
rids itself of H+. Thus, H+ serum levels increase and bicarb. decreases.
728.
Case: VERY IMPORTANT: What is the difference between
incidence and prevalence EXACTLY in biostatistics?
A) Incidence is the number of NEW cases of a disease
within a given population in a year while prevalence is the number of people
affected in a given number of people within a given year.
729.
Case: Regarding Alzheimer's disease, which of the 3
choices is the most strongly correlated with the MOA of the dx? (pick either
thiamine def. or choline acetyltransferase def or acteylcholinesterase def.)
A) Although many causes are related to Alzheimer's dx,
the lack of Ach from low levels of choline acteyltransferase are correlated
highly.
730.
Case: Quick, what drug starting with the letter "f",
blocks dihydrotestosterone synthesis?
A) Finasteride
731.
Case: Which drug, Tamoxifen or Mifepristone, blocks the
stimulation of estrogen response genes in the nucleus?
A) Tamoxifen
732.
q) Which one, estrogen or mifepristone, blocks
progesterone and causes menstruation? MOA?
A) Mifepristone, its inhibition of pro