Form 14 Review By System

Cardio

• HTN and its many causes: only really investigate the secondary causes when other abnormalities are present; if not, start them with a diuretic/anti-HTN

  • This was an overthink and distortion; the secondary causes will show a lot more symptoms that will prompt further investigation

• In renal artery stenosis, increased ATII is what causes the HTN

  • This was a distortion of knowledge and overthink; we thought ACE activity is increased, and while that is true, that’s not exactly the main reason why BP is elevated; ATII has a greater effect

• JVD, hypotension, decreased heart sounds = pericardial tamponade; after pericardiocentesis, next is sternotomy/thoracotomy

  • We distorted this with tension pneumothorax because of the hemodynamic instability, but they revealed the lung sounds were clear

• In a patient with CAD who had stent placement and is asymptomatic, there’s nothing that needs to be done in terms of surveillance of disease

  • While true you should do echo, not for surveillance; this was a distortion of knowledge

• Acute limb ischemia when INR is low means anticoagulation isn’t sufficient, so add another one

  • It’s likely we may have gotten inside our head with this one; think about thrombus causing acute limb ischemia and the need to bust that clot

• The issues here were overthinking and knowledge distortion

Respiratory

• When an infant with respiratory distress has a markedly scaphoid abdomen, they are at highest risk of death from pulmonary hypoplasia

  • The presentation given was indicative of a pneumothorax of sorts, but they told you scaphoid abdomen; when we see scaphoid abdomen, think about congenital diaphragmatic hernia

• It’s decreased diffusion capacity that causes hypoxemia with P. jirovecii

  • We overthought this one because we actually picked decreased diffusion capacity but then we saw shunt, but that’s AV shunt, which is cardiac; shunt in the respiratory case is inflammation plugging the alveoli so no diffusion can take place

• Alpha-1 antitrypsin deficiency is a genetic disease that is best confirmed with a genetic test

  • We overthought this question because we knew about emphysema but it’s a lot easier to confirm a suspected genetic disease with a genetic test

• When there is shortness of breath sometime after transfusion with bilateral infiltrates, it’s TRALI

  • We overthought this with pulmonary contusion, but the patient had a transfusion, and it was revealed the injury was at the spleen which contributed to the likelihood of transfusion-related acute lung injury (TRALI) rather than a pulmonary contusion. Recognizing the source of the injury helped rule out other diagnoses and focus on appropriate management.

• If a VQ scan already confirms PE, there’s nothing else that needs to be done

  • We knew spiral CT confirms PE, but so does VQ; since PE is already revealed, there’s nothing else that can tell you something you don’t already know; this was an overthink

• Asthma can occur in conjunction with eczema, especially in infants; don’t count on wheezing

  • We confused this with hypersensitivity pneumonitis, but the history of eczema points to asthma

• In hypoxemia with cor pulmonale, home oxygen is better

  • You saw the severe hypoxemia and thought ventilation; that should be considered, but ventilation can make cor pulmonale worse; this was a distortion of knowlege

• Just because there’s no decreased right sided breath sounds in the setting of foreign body obstruction doesn’t mean the condition is ruled out; any acute onset shortness of breath should have foreign body obstruction considered

  • This was an overthink

• The issues here were overthinking, knowledge distortion, and missing one key term

GI

• Hepatitis A will resolve on its own and not lead to any complications

  • We must have thought about Hepatitis E, which leads to fulminant liver failure; there is an association with A and E, but only in the fact that they are transmitted fecal-oral, not in complications

• Incidental annular pancreas that hasn’t caused any symptoms will have a benign course

  • It’s true that annular pancreas can cause pancreatitis, but this is more of a zebra than a horse; this was a distortion of knowledge

• Esophageal spasm is intermittent dysphagia and sensation of food getting stuck in the chest

  • We saw sensation of food sticking and thought Zenker, but that will have halitosis and regurgitation; we overthought this one

• Between percutaneous drainage and ex-lap for appendicitis, check the hemodynamic stability; if stable, do drainage

  • This was a distortion of knowledge and overthinking; because of the stability, drainage is the next step in management

• CT will identify pancreatitis

  • We saw tenderness in all quadrants and thought SBP; we definitely don’t want to miss that, but the other presenting features were consistent with pancreatitis; this was likely overthinking

• Any iron deficiency anemia in the elderly should have us thinking colorectal cancer until proven otherwise

  • It was likely we were fatigued at this point and getting inside our head

• Along with PPI, for H. pylori, clarithromycin and amoxicillin are used

  • The answer we chose was half-right; we knew about clarithromycin, but tetracycline is used with Peptobismol, while amoxicillin is used with PPI; it was a minor knowledge deficiency in that we knew where to go, but not all the way

• The issues here knowledge distortion, overthinking, and minor knowledge gap

MSK/Derm

• Intestinal malabsorption syndrome leads to deficient vitamin D, which is seen through pseudofractures; it is parathyroid hormone that will be elevated

  • We knew it was some sort of vitamin deficiency, but we overthought it and distorted phosphorous levels; in a hypoparathyroid state, phosphorous is high, but when vitamin D is low, the parathyroid gland will be a lot more active

• Tinea cruris is transmissible by contact, so the best recommendation is to limit contact with infected areas and maintain proper hygiene to prevent spread.

  • We correctly identified this was a tinea infection, but we distorted the transmissibility. When we didn’t see dogs, we thought other animals do this as well, but it is primarily humans who can spread the infection through direct contact or by sharing contaminated items such as clothing or towels.

• With a seizure, there’s a risk of posterior shoulder dislocation, especially if range of motion is diminished and external rotation is impaired; better to get X-ray first

  • We saw the diminished external rotation and thought rotator cuff injury, but the history fits shoulder dislocation, so X-ray is always done before MRI; likely was an overthink

• Myotonic dystrophy has wasting of distal muscles and fish-like mouth with high arched palate

  • We knew this was a dystrophic muscular syndrome and distorted it with myasthenia gravis, but myasthenia gravis occurs in adults and these features are more relevant to myotonic dystrophy

• If a meniscal tear is getting increasingly more painful and worse, they should get surgery

  • We saw conservative management and while true, not for this situation

• Craniosynostosis is a condition where one or more of the sutures in an infant's skull closes prematurely, affecting skull shape and brain development.

  • This was a term we were familiar with but didn’t know the best, so we’ll make sure to review it

• Diabetic foot ulcers that lead to signs of infection should have an MRI done to assess the extent of tissue involvement and to guide treatment decisions appropriately.

  • We thought the ulcer was an arterial ulcer, but the presentation talked a lot about diabetic history and diabetic neuropathy; diabetic neuropathy can lead to ulcers that become infected, so this is more about a potential bone infection

• The issues here were overthinking, knowledge distortion, some knowledge gaps

Neuro

• To decrease the recurrence of MS, subcutaneous glatiramer is used

  • We correctly identified MS, and steroids are used to treat MS; the problem was we distorted the question; they wanted to know how to decrease the recurrence, not exactly treat MS in the moment. In the moment, steroids are used, but to decrease the recurrence, glatiramer is used

• In the elderly, cerebral atrophy can cause shearing of the bridging veins, leading to subdural hematoma; even a fall can cause this

  • We saw the acute presentation of 3 weeks and thought this must have been something else acute; there was an element of overthinking but also forgetting how even non-contact subdural hematoma can happen because cerebral atrophy will put pressure on the bridging veins

• Hypertension is the greatest risk factor for stroke; controlled BP will decrease the risk of recurrent stroke

  • We definitely overthought this one; we figured we needed to add warfarin so we thought we needed to check INR but this was about decreasing the risk of stroke rather than managing anticoagulation

• If someone has neurological instability after deep sea diving, it is decompression sickness and is managed with hyperbaric oxygen

  • You do want to get an MRI, but first at least stabilize with hyperbaric oxygen; this was an overthink

• Glaucoma has a severe onset headache with a high cup:disc ratio

  • We distorted this with IIH, which doesn’t have the cup:disc ratio and isn’t acute in onset

• Bell’s palsy takes months to recover from

  • We were correct in the fact that there is recovery, but underestimated how long it takes to achieve that recovery; if it was in the setting of otitis media, then it can take days, but since it was in the setting of some virus that caused inflammation, it will take longer; this was a situation where we were in between 2 but picked the wrong one

• Tinnitus that is isolated doesn’t require further testing

  • We thought about acoustic neuroma but acoustic neuroma will present with a lot more neurological signs; this was likely an overthink

• The issues here were overthinking, knowledge distortion, some knowledge gaps

Psych/Biostats

• If a patient requests an unnecessary treatment despite showing understanding, physicians are not allowed to provide that treatment

  • We may have gotten this a little bit distorted by thinking about financial elements; this really doesn’t have anything to do with finances and insurance, more about the actual medical care

• When a surgeon chooses the treatment for the patient, there’s no matching going on, because factors exist that had the surgeon choose one procedure over the other

  • We thought this had to be double-blind, but single-blind studies are effective too; this is more about how the surgeon’s knowledge acted as a confounding variable because their knowledge of the patient influenced their choice of treatment, which doesn’t match the two experimental groups

• Uncomplicated grief does have sadness, guilt, fatigue, and decreased concentration and appetite, but there’s no anhedonia or loss of functioning

  • It’s very easy to distort this with MDD, which is what we did; the key here though was he still enjoys activities; it was a distortion of knowledge

• If a patient is understanding and declining treatment options, it’s best to make sure you explain the potential benefits and risks associated with each choice clearly, while also considering their emotional state and motivations behind their decisions.

  • Just because a patient understands and declines doesn’t mean their decision will be taken; need to make sure they get the full picture first; this was likely a distortion of knowledge

• To suspect anorexia, pay attention to BMI and preoccupation with body weight

  • We saw this patient was worried about other things and thought GAD, but GAD has a lot more things the patient worries about; this was an overthink

• Lithium is much more effective in decreasing suicide risk than SSRI

  • While taking someone off SSRI can increase the risk of suicide, there is a higher risk of suicide when taking someone off lithium; this was more about what is more common

• Gender dysphoria increases the risk of developing MDD

  • This was one of the few missed questions where we genuinely didn’t know

• Rates are dependent on population and are not standardized based on race

  • There are a lot of other differences, but when dealing with rates, it’s important to think about population size; this was likely a distortion of knowledge

• Stimulant medications for ADHD will benefit patients even into adulthood

  • This was something we did not know, and that’s okay; we will review it

• Gunshot wounds that cause death should be reported to law enforcement

  • While the medical examiner should be involved, violent crimes should have the police notified; this was distorted knowledge

• The issues here were overthinking, knowledge distortion, few knowledge gaps

Endocrine

• It’s normal to have hyperglycemia following surgery, but dexamethasone can cause hyperglycemia that can be profound

  • We were in between 2 answers here; we had the knowledge but were doubtful

Heme/Onc/Immune/ID

• Recognizing Coxsackie HFM disease: the sores will be inside the mouth, and on the hands and feet, which can lead to discomfort and difficulty eating. In this instance, no other testing is required

  • We saw vesicular lesions and thought about herpes; we distorted the location of the sores of the mouth; with herpes, it is on the outside; Coxsackie has their sores on the inside

• Necrotizing fasciitis doesn’t always have to be blackened skin; there will be exquisite tenderness and warmth

  • We must have thought we needed to enact airborne precautions; this would be preferred if dealing with an aerosolized infection, not with necrotizing fasciitis

• Thrombocytosis following splenectomy is treated with aspirin to prevent platelet aggregation

  • We distorted platelet pheresis, which is what you do in cases of essential thrombocytosis; removing the spleen was reactive thrombocytosis; you would also do platelet pheresis when there are symptoms of stroke or thrombi

• The most common complication for CLL is infection because of the immunocompromised state produced by the disease and its treatment.

  • We thought bleeding was the most common, and while true, it isn’t as common as infection; this was more of a misapplied/distortion of knowledge

• With recurrent bacterial infections and GI infections, check for Ig levels because of potential CVID

  • We even took note of the recurrent bacterial infections but got anxious and overthought it

• Viral respiratory infections have low duration

  • When we saw this question, we jumped to whooping cough, but the patient only had this for 2 days; this was an overthink

• If allergic to penicillin, the treatment for PTA is usually clindamycin

  • Cephalosporins are used too, but not if penicillin allergy exists

• HIV with any cell count increases the risk for opportunistic infections, especially if they are around cats

  • We were tripped up by the normal cell count; because the patient has HIV, he is at risk for Toxoplasmosis if around cats

• The issues here were overthinking, knowledge distortion and misapplication

Multisystems

• With Sjogren’s syndrome, for the dry eyes, the best treatment is pilocarpine, a muscarinic agonist

  • We thought about the esophageal issues and jumped to CCB; this was more about the dry mouth and dry eyes; we overread here

Renal

• In hematuria, microscopic examination of urine sediment is done first

  • We jumped to suspected bladder cancer, and you definitely don’t want to miss that, but we need to have a reason for cystoscopy, and that reason comes from the microscopic examination; this was more a distortion of knowledge

OB/GYN/Repro

• Cornual vs ampullar ectopic pregnancy: cornual pregnancy will extend into myometrium

  • Knew this was an ectopic pregnancy of sorts and ampulla is the most common ectopic pregnancy, but the location was what mattered here; when it extends into myometrium, that’s cornual

• With any case of abnormal uterine bleeding, you want to make sure you rule out endometrial cancer through the biopsy

  • We were down to 2 answers, but didn’t recognize the urgency of endometrial biopsy; we definitely don’t want to miss cancer

• Any firm and rubbery mass should be investigated as breast cancer

  • We saw tender and thought about HS, but we never want to miss cancer; we likely overthought

• Hyperglycemia can cause fetal malformation, especially in a poorly controlled type I diabetic; make sure to check HbA1c

  • We saw the other conventional tests for fetal malformation; this was more of a distortion of knowledge; we really needed to look at the patient’s poorly controlled diabetes

• Breast mass in puberty is okay and requires no further imaging

  • We distorted the knowledge about breast mass imaging; however, it is important to emphasize that in the context of puberty, these findings are generally benign and do not necessitate further investigation unless accompanied by other concerning symptoms.

• STIs must be reported to the local government

  • We likely were not fully grounded in our knowledge of reported infections, but STIs are reportable infections

• Lichen sclerosis is a chronic inflammatory skin condition that can cause irritation and discomfort; it is more common in postmenopausal women

  • We saw the pain and pruritis, the image also looked pink, which is characteristic of lichen planus, but we didn’t think about how much more common lichen sclerosis is in this population; this was more about a distortion of knowledge

• Hypertension increases the risk for oligohydramnios

  • They gave the history for no prenatal care and thought neural tube defect, but the main thing they gave here was hypertension; this was an overthink

• If someone is coming in with an existing positive pregnancy test, TVUS is the next confirmatory test

  • We never want to miss pregnancy test, but this patient already had one; this is now about confirming through imaging; this was an overthink

• Smoking is not a contraindication to OCP if under 35

  • This was very easy to distort, but the key thing here was the age of the patient

• Inadequate weight gain, history of procedures are among some of the risk factors for preterm labor

  • We confused this with fetal growth restriction

• If late decelerations persist for an hour, emergency C-section needs to be done

  • We confused this with amnioinfusion for cord compression; late decelerations is placental insufficiency and it can be corrected with positioning but not if it’s been lasting for an hour; this was also an overread

• Vulvovaginitis will have discharge with epithelial cells and few leukocytes

  • We saw this was a young girl and thought foreign body, but that will show bleeding and an actual foreign body seen; this was an overthink

• Someone clearly symptomatic for ovarian masses needs to have the mass removed

  • They gave the family history of these cancers consistent with BRCA, which makes BRCA testing reasonable, but first remove the mass to test it for cancer; this was more about recognizing the urgency

• Remember that gonorrhea and chlamydia are tied at the hip; a gonorrhea infection can likely lead to chlamydia co-infection

  • The answer we chose was half-right; we needed to consider how chlamydia also comes into play here

• The issues here were overthinking, knowledge distortion, some knowledge gaps