• Patient presented with a COPD exacerbation without overt infection (normal WBC with normal neutrophil count, afebrile) and then after receiving IV methylprednisolone (strong systemic steroid) developed a neutrophilic leukocytosis despite clinical improvements
• Key idea: Two common causes of a neutrophilic leukocytosis are infection and systemic steroid use

• Classic presentation of diabetic ketoacidosis in the setting of Type 1 diabetes (polyuria, polydipsia, tachypnea (to compensate for metabolic acidosis), fatigue/weakness, elevated glucose (often 300-500 mg/dL) and elevated ketones)
• Younger patients can also develop type 2 diabetes, but that would more commonly be seen in a patient with elevated BMI and Type 2 diabetes almost never presents as DKA

• Peripartum mood disorders are commonly seen within 4 weeks delivery
• Most common is Postpartum blues (50-75% of pateints) who will have depressed affect and fatigue, but will have resolution within 2 weeks delivery
• The most severe (and least common) peripartum mood disorder is postpartum psychosis, which often leads to delusions, hallucinations and thoughts of suicide or infanticide; these patients require immediate hospitalization due to high risk of injury to self or baby

• Selective IgA deficiency commonly leads to sinopulmonary and GI infections (especially Giardia) and pathognomonically anaphylaxis to blood products (because patient develops anti-IgA antibodies and reacts against IgA in blood products)
• Key idea: Most common immunodeficiency and is most commonly asymptomatic

• Key idea: Peritonitis (rigidity, guarding) + Free air under diaphragm = Emergency laparotomy!!!!!

• Patients who are adequately vaccinated against hepatitis B vaccine will have negative HBsAg, positive HGsAb and negative Hepatitis B core antibody (positive Hep B core antibody = past or current infection)
• Patient is adequately protected against Hepatitis A due to presence of IgG antibodies, which can be the result of vaccination or past infection
• Key idea: Indications for Hep A vaccination are chronic liver disease or increased risk of contracting disease (men who have sex with men, IVDU, travel to country where hepatitis A is prevalent, etc.)

• Patient has signs of a small bowel obstruction (abdominal distention, abdominal pain, vomiting, high-pitched bowel sounds with air-fluid levels on x-ray)
• Most common causes of small bowel obstruction are adhesions, hernia and malignancy, but this patient has air in the liver which is basically pathognomonic for gallstone ileus (can also have air in the biliary tree)

• Patient with blunt thoracic trauma who presents <24 hours later with symptoms (tachypnea, tachycardia, hypoxia) and/or CT/CXR infiltrates over affected area (patchy, alveolar)
• Key idea: Important to differentiate from ARDS, which can have similar presentation but often occurs 24-48 hours after trauma

• Leads to a widened pulse pressure (because blood flows from aorta to pulmonary arteries during diastole, leading to reduced systemic diastolic pressure) with a continuous to-and-fro murmur
• Key idea: PDAs may also predispose to an increased risk of respiratory/lung infections

• Autosomal dominant trinucleotide repeat disease (father also affected) that classically leads to myotonia (difficulty relaxing muscles, most classically gripping) + CTG (Cataracts, Toupee (early balding) and Gonadal atrophy
• Key idea: These patients also commonly have psychosocial symptoms (irritability, tired during day, etc.)

• Differential for dementia in elderly patient includes: Alzheimer’s (chronic neurodegenerative course), Vascular dementia (patient with ASCVD risk factors with stepwise decline), Frontotemporal dementia (early personality changes often around 60 yo), Dementia with Lewy bodies (parkinsonism, visual hallucinations, fluctuating cognition), Normal pressure hydrocephalus (“wet, wacky and wobbly”) and pseudodementias (depression, hypothyroidism, B12 deficiency)
• In this patient with acute/subacute forgetfulness along with components of SIGECAPS (trouble sleeping, decreased appetite, psychomotor retardation) and history of past episodes of forgetfulness that were able to be treated with medication most consistent with a major depressive disorder episode
• Key idea: Alzheimer’s can also lead to signs/symptoms similar to Major depressive disorder, but Alzheimer’s would have a chronic progressive course rather than an episodic course as is seen in this question stem

• Alcohol and benzodiazepine withdrawal lead to similar clinical syndromes with increased autonomic activity (tremors, anxiety, sweating, agitation, etc.) because prolonged use of these medications leads to downregulation of GABA receptors, such that removal of GABA agonists (alcohol, benzo’s) leads to relatively decreased inhibitory activity from ligand binding to GABA receptors
• Key idea: Withdrawal often leads to the opposite effects of intoxication with drug (Example: Opiate use leads to constipation and pinpoint pupils, whereas opiate withdrawal leads to diarrhea and mydriasis)
• https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal

• Patient has missed several days of dialysis and was found down in his house (which can lead to rhabdomyolysis), giving this patient 2 reasons to have metabolic acidosis with hyperkalemia
• Hyperkalemia can lead to abnormal heart rhythms that can lead to patient death, so patients who have hyperkalemia with one of the following three features should first receive calcium gluconate to stabilize the cardiac membrane prior to trying to reduce potassium levels: (1) Potassium > 7.0 (2) ECG changes (Peaked T waves, PR prolongation and QRS widening, disappearance of P wave) (3) Rapidly rising potassium due to tissue breakdown or tumor lysis syndrome

• One of the most common causes of female infertility, especially in overweight women
• Diagnosis requires 2 out of 3 of the following criteria: (1) Clinical and/or biochemical hyperandrogenism (2) Oligomenorrhea (3) Polycystic ovaries on pelvic ultrasound /// Our patient has clinical hyperandrogenism (acne vulgaris) and oligomenorrhea (irregular menses)
• Key idea: Although often associated with insulin resistance and ultimately associated with development of Type 2 diabetes, insulin resistance is not formally included in diagnostic criteria

• All sexually active women 24 and younger should receive STI testing, regardless of whether they have been monogamous with only one partner
• https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/chlamydia-and-gonorrhea-screening

• Another random question that can be approached through process-of-elimination
• Patient doesn’t need any changes to medication regimen because her problem is compliance, cannot ethically refuse to see patient because of compliance, patient has no psychiatric issues, and unethical for parents to punish patient for lack of compliance

• Patient recently started on anticoagulation with a severely elevated INR (therapeutic range is 2-3) and rapidly dropping hemoglobin

• Young woman + eye pain with ipsilateral vision problems = Optic neuritis
• Optic neuritis (as the name implies) is due to inflammation of the associated optic nerve, with further proof that optic nerve is involved being the relative afferent pupillary defect (problem with light getting back to retina in this case)

• Appetite for non-nutritive substances (such as ice, hair, cornstarch on its own) = pica
• Most commonly associated with iron deficiency anemia, with other clues in the stem being the mild pallor on physical exam and leiomyomata uteri (which often lead to heavy menstrual bleeding)

• IBD should always be suspected in a young adult without a clear trigger (international travel, etc.) who presents with increased bowel movements, especially if stools are covered with blood and/or patient has associated abdominal pain
• Diseases associated with erythema nodosum = IBD, tuberculosis, systemic fungal infections (cocci, etc.), sarcoidosis, Behcet’s disease, strep pharyngitis (most common trigger)
• Important to distinguish IBD from IBS because both can present in young adults and both can be described as having increased frequency of mucus-covered stools. Features that point towards IBS include lack of blood in stools, abdominal pain that is relieved with defecation and alternating periods of constipation and diarrhea

• Presentation most consistent with a hemangioma of the skin, which commonly grows during the first year of life but involutes on its own within 5 years

• Patient has persistent history of unstable relationships and self-injurious behaviors
• Delusional disorder and adjustment disorder are transient pathologies
• Major depressive disorder = Depressed mood and SIGECAPS

• Patient’s blood pressure has dropped, pulse has gone up and hematocrit has dropped relative to intraoperative values, pointing to bleeding after surgery

• Patient most likely has poison oak/ivy, which presents >1 day after exposure (Type 4 hypersensitivity) and will lead to a sharp line between rash and unaffected skin
• Patients do not receive prophylaxis against poison oak/ivy
• Cat scratch can lead to cat scratch fever, which leads to lymphadenopathy but will not lead to vesicles/bullae

• Hyaline casts are the most common type of urinary cast and are often seen in setting of dehydration or vigorous exercise; they can be seen in healthy individuals
• Erythrocyte casts = RBC casts = Glomerulonephritis (such as post-strep glomerulonephritis)
• Leukocyte casts = WBC casts = Pyelonephritis and acute interstitial nephritis

• Difficulty of this question is trying to differentiate between normal stresses of being a new mother vs. hypothyroidism
• Features that point to hypothyroidism vs. normal stress include elevated cholesterol levels, memory problems, and lethargy
• Postpartum thyroiditis can present up to 1 year after giving birth and although it is a fairly rare disease in real life, it is often tested on these exams
• Cortisol = Cushing’s (gaining weight, hirsutism, etc.) or Adrenal insufficiency (hypotensive, hyperpigmented skin, craving salt, etc.)

• Patient of Northern European descent with recurrent sinopulmonary infections, poor growth (due to fat malabsorption) and signs of bronchiectasis (streaky lung densities with hyperinflation, mild clubbing)
• Important to distinguish from Kartagener’s syndrome, which would lead to dextrocardia and would be less likely to lead to poor weight gain

• Young patient who presents with acute signs of heart failure (elevated JVP, bilateral basilar crackles, displaced PMI, S3, lower extremity edema, etc.) most likely represents myocarditis, especially in setting of recent viral URI
• Asymmetric septal hypertrophy = HOCM = Sudden cardiac death or exertional syncope in young adult
• Bicuspid aortic valve with stenosis presents as symptomatic AS (syncope, angina, dyspnea) often in a 50-60 year old

https://step-prep.org/tutoring/

• Ovaries not only produce estrogens, but also produce androgens that play a central role in libido (among other things)

https://step-prep.org/tutoring/

• Intussusception often presents in a child 6-36 months old with abdominal pain relieved by drawing knees to the chest +/- bloody diarrhea +/- vomiting. In setting of suspected intussusception, next best step is a contrast/air enema which is both therapeutic and diagnostic.

• X-ray of upper GI tract with contrast indicated in setting of suspected malrotation with volvulus (newborn with abdominal pain + bilious vomiting + distention)

• Corticosteroid enemas sometimes used in ulcerative colitis

https://step-prep.org/tutoring/