First Aid Cases for the USMLE Step 2 CK, -McGraw-Hill Medical (2009)

FIRST AID

™

CASES FOR THE
USMLE
STEP 2 CK
Second Edition

TAO LE, MD, MHS
Assistant Clinical Professor of Pediatrics and Medicine
Division of Allergy and Clinical Immunology
Department of Pediatrics
University of Louisville

ELIZABETH EBY HALVORSON, MD
Vanderbilt School of Medicine
Class of 2009
Resident
Department of Pediatrics
Wake Forest University Baptist Medical Center

New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto


Copyright © 2010, 2007 by Tao Le. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
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D E D I C AT I O N
To the contributors to this and future editions, who took time to share their

knowledge, insight, and humor for the benefit of all those who yearn to pass
their boards.
and
To our families, friends, and loved ones, who encouraged and assisted us in
the task of assembling this guide.


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CONTENTS

Contributing Authors

xv

Senior Reviewers

xvii

Preface

xix

Acknowledgments

xxi

How to Contribute

xxiii

Cardiology

1

Case 1: Abdominal Aortic Aneurysm

2

Case 2: Acute Cardiogenic Pulmonary Edema

3

Case 3: Acute Coronary Syndrome

4

Case 4: Aortic Dissection

6

Case 5: Acute Myocardial Infarction—Long-Term Management

8

Case 6: Aortic Regurgitation

9

Case 7: Atrial Fibrillation

10

Case 8: Cardiac Tamponade

12

Case 9: Congestive Heart Failure

14

Case 10: Deep Venous Thrombosis

16

Case 11: Dilated Cardiomyopathy (Alcoholic)

18

Case 12: Diastolic Heart Failure

20

Case 13: Aortic Stenosis

21

Case 14: Hypercholesterolemia

22

Case 15: Hypertension—Essential

23

Case 16: Hypertension—Renal Artery Stenosis

24

Case 17: Hypertrophic Obstructive Cardiomyopathy

26

Case 18: Infective Endocarditis

28

Case 19: Myocardial Infarction

30

Case 20: Papillary Muscle Rupture

32

Case 21: Pericarditis

34

Case 22: Peripheral Vascular Disease

36

Case 23: Mitral Regurgitation

37

Case 24: Second-Degree Heart Block

38

Case 25: Wolff-Parkinson-White Syndrome

40

Dermatology

43

Case 1: Acanthosis Nigricans

44

Case 2: Acne Vulgaris

46

Case 3: Atopic Dermatitis

47

v


Case 4: Basal Cell Carcinoma

48

Case 5: Bullous Pemphigoid

50

Case 6: Herpes Simplex

51

Case 7: Hidradenitis Suppurativa

52

Case 8: Kaposi Sarcoma

53

Case 9: Lichen Planus

54

Case 10: Molluscum Contagiosum

56

Case 11: Pemphigus

58

Case 12: Pityriasis Rosea

60

Case 13: Psoriasis

62

Case 14: Stevens-Johnson Syndrome

64

Case 15: Varicella-Zoster Virus

66

Case 16: Tuberous Sclerosis

68

Case 17: Onychomycosis

69

Case 18: Melanoma

70

Endocrinology
Case 1: Acromegaly

72

Case 2: Cushing’s Syndrome

74

Case 3: Adrenal Insufficiency (Addison’s Disease)

76

Case 4: Diabetes Insipidus

77

Case 5: Diabetes Mellitus, Type 1

78

Case 6: Diabetic Ketoacidosis

79

Case 7: Hyperthyroidism (Graves’ Disease)

80

Case 8: Hypokalemia (Hyperaldosteronism)

82

Case 9: Hyperparathyroidism

84

Case 10: Hypothyroidism (Hashimoto’s Thyroiditis)

85

Case 11: Multiple Endocrine Neoplasia, Type I

86

Case 12: Metabolic Syndrome

88

Case 13: Multiple Endocrine Neoplasia, Type II

89

Case 14: Osteoporosis

90

Case 15: Paget’s Disease of Bone

92

Case 16: Pheochromocytoma

94

Case 17: Syndrome of Inappropriate Antidiuretic Hormone Secretion

96

Case 18: Thyroid Nodule

98

Case 19: Subacute Granulomatous Thyroiditis (de Quervain’s Thyroiditis)
Epidemiology and Preventive Medicine

vi

71

100
101

Case 1: Bias and Confounding

102

Case 2: Bioterrorism

104

Case 3: Breast Cancer Screening

106

Case 4: Cohort Studies

108

Case 5: Health Care Screening

109

Case 6: Incidence and Prevalence

110

Case 7: Influenza Vaccine

112


Case 8: Obesity Effects on Health

114

Case 9: Randomized Clinical Trial

116

Case 10: Sensitivity and Specificity

118

Case 11: Reliability and Validity

120

Case 12: Positive Predictive Value, and Negative Predictive Value

121

Ethics and Legal Issues

123

Case 1: Confidentially and Disclosure

124

Case 2: End-of-Life Issues (Advance Directives and Withdrawal of Care)

125

Case 3: Informed Consent

126

Case 4: Minors

127

Gastrointestinal

129

Case 1: Acute Cholecystitis

130

Case 2: Acute Pancreatitis

132

Case 3: Achalasia

134

Case 4: Carcinoid

135

Case 5: Colorectal Cancer

136

Case 6: Celiac Disease

138

Case 7: Diverticulitis

139

Case 8: Esophageal Carcinoma

140

Case 9: Gastroesophageal Reflux Disease

141

Case 10: Hemochromatosis

142

Case 11: Hiatal Hernia

144

Case 12: Inflammatory Bowel Disease

146

Case 13: Liver Cirrhosis

148

Case 14: Irritable Bowel Syndrome

150

Case 15: Peptic Ulcer Disease

151

Case 16: Primary Sclerosing Cholangitis

152

Case 17: Pseudomembranous Colitis

153

Case 18: Small Bowel Obstruction

154

Case 19: Spontaneous Bacterial Peritonitis

156

Case 20: Viral Hepatitis

157

Case 21: Wilson’s Disease

160

Case 22: Zollinger-Ellison Syndrome

162

Hematology/Oncology

163

Case 1: Acute Myelogenous Leukemia

164

Case 2: Acute Lymphoblastic Leukemia

166

Case 3: Amyloidosis

167

Case 4: Chronic Lymphocytic Leukemia

168

Case 5: Factor V Leiden

170

Case 6: Fanconi’s Anemia

171

Case 7: Glucose-6-Phosphate Dehydrogenase Deficiency

172

Case 8: Hairy Cell Leukemia

174

vii


Case 9: Hemophilia

175

Case 10: Hodgkin’s Lymphoma

176

Case 11: Microcytic Anemia

178

Case 12: Multiple Myeloma

180

Case 13: Idiopathic Thrombocytopenic Purpura

182

Case 14: Neutropenia

183

Case 15: Polycythemia

184

Case 16: Sickle Cell Anemia

186

Case 17: α-Thalassemia

188

Case 18: Hemorrhage, Drug-Induced

190

Case 19: Thrombotic Thrombocytopenic Purpura with Hemolytic Uremic Syndrome

191

Case 20: Porphyria

192

Case 21: Transplant Rejection

193

Case 22: von Willebrand’s Disease

194

Infectious Disease

196

Case 2: Chlamydia

197

Case 3: Gonococcal Infection

198

Case 4: Histoplasmosis

200

Case 5: Infectious Mononucleosis

201

Case 6: Lyme Disease

202

Case 7: Malaria

204

Case 8: Methicillin-Resistant Staphylococcus aureus

206

Case 9: Necrotizing Fasciitis

208

Case 10: Neutropenic Fever

209

Case 11: Osteomyelitis

210

Case 12: Pneumocystosis

212

Case 13: Endocarditis

214

Case 14: Rocky Mountain Spotted Fever

215

Case 15: Septic Arthritis

216

Case 16: Thrombophlebitis

217

Case 17: Urinary Tract Infection

218

Musculoskeletal and Connective Tissue

viii

195

Case 1: AZT-Induced Anemia

219

Case 1: Ankylosing Spondylitis

220

Case 2: Carpal Tunnel Syndrome

222

Case 3: Compartment Syndrome

223

Case 4: Dermatomyositis

224

Case 5: Duchenne Muscular Dystrophy

225

Case 6: Herniated Lumbar Disk

226

Case 7: Gout

228

Case 8: Fibromyalgia

229

Case 9: Juvenile Rheumatic Arthritis

230

Case 10: Legg-Calvé-Perthes Disease

231


Case 11: Osteosarcoma

232

Case 12: Rheumatoid Arthritis

234

Case 13: Scleroderma

236

Case 14: Spinal Stenosis

238

Case 15: Systemic Lupus Erythematosus

240

Case 16: Slipped Capital Femoral Epiphysis

242

Case 17: Osteoarthritis

244

Case 18: Takayasu Arteritis

245

Case 19: Temporal Arteritis

246

Case 20: Polymyalgia Rheumatica

247

Neurology

249

Case 1: Amyotrophic Lateral Sclerosis

250

Case 2: Dementia

252

Case 3: Epidural Abscess

254

Case 4: Epidural Hematoma

256

Case 5: Glaucoma

258

Case 6: Glioblastoma Multiforme

260

Case 7: Guillain-Barré Syndrome

262

Case 8: Headache

264

Case 9: Huntington’s Disease

266

Case 10: Infantile Spasms

267

Case 11: Internuclear Ophthalmoplegia

268

Case 12: Benign Positional Paroxysmal Vertigo

269

Case 13: Meningitis

270

Case 14: Multiple Sclerosis

272

Case 15: Myasthenia Gravis

275

Case 16: Partial Complex Seizures

276

Case 17: Stroke

278

Case 18: Parkinson’s Disease

281

Case 19: Subacute Combined Degeneration

282

Case 20: Subarachnoid Hemorrhage

284

Case 21: Subdural Hematoma

286

Case 22: Tonic-Clonic Seizures

288

Case 23: Tabes Dorsalis

290

Obstetrics

291

Case 1: Abortion

292

Case 2: Contraception

293

Case 3: Deep Venous Thrombosis

294

Case 4: Disseminated Intravascular Coagulation

295

Case 5: Ectopic Pregnancy

296

Case 6: Fetal Monitoring

298

Case 7: Gestational Diabetes

300

Case 8: Hydatidiform Mole

302

ix


Case 9: Hypertension

303

Case 10: Infertility

304

Case 11: Isoimmunization

305

Case 12: Mastitis

306

Case 13: Normal Labor

307

Case 14: Normal Physiology of Pregnancy

308

Case 15: Nutrition in Pregnancy

309

Case 16: Placental Abruption

310

Case 17: Perineal Laceration

312

Case 18: Placenta Previa

313

Case 19: Postpartum Infection

314

Case 20: Postpartum Hemorrhage

316

Case 21: Preeclampsia

317

Case 22: Postterm Pregnancy

318

Case 23: Prenatal Screening

320

Case 24: Preterm Labor

321

Case 25: Preterm Premature Rupture of Membranes

322

Case 26: Pyelonephritis

323

Case 27: TORCH Infections

324

Case 28: Sheehan’s Syndrome

326

Gynecology

x

327

Case 1: Amenorrhea, Primary

328

Case 2: Amenorrhea, Secondary

330

Case 3: Breast Cancer

331

Case 4: Bacterial Vaginosis

332

Case 5: Cervical Cancer

334

Case 6: Chancroid

336

Case 7: Fibrocystic Breast Disease

338

Case 8: Endometriosis

340

Case 9: Fibroids

342

Case 10: Genital Warts

344

Case 11: Menopause

345

Case 12: Ovarian Cancer

346

Case 13: Cervicitis

347

Case 14: Pelvic Inflammatory Disease

348

Case 15: Polycystic Ovarian Syndrome

350

Case 16: Postmenopausal Bleeding

351

Case 17: Primary Syphilis

352

Case 18: Toxic Shock Syndrome

353

Case 19: Trichomonas

354

Case 20: Urinary Incontinence

356

Case 21: Vulvovaginal Candidiasis

357


Pediatrics

359

Case 1: Abuse

360

Case 2: Chronic Granulomatous Disease

362

Case 3: Congenital Adrenal Hyperplasia

364

Case 4: Congenital Infections

365

Case 5: Crohn’s Disease

366

Case 6: Developmental Dysplasia of the Hip

368

Case 7: Croup

370

Case 8: Developmental Milestones

371

Case 9: Down Syndrome

372

Case 10: Duodenal Atresia

374

Case 11: Failure to Thrive

376

Case 12: Febrile Seizure

377

Case 13: Henoch-Schönlein Purpura

378

Case 14: Hirschsprung Disease

380

Case 15: Intussusception

382

Case 16: Kawasaki Disease

384

Case 17: Meningitis

385

Case 18: Necrotizing Enterocolitis

386

Case 19: Omphalocele

387

Case 20: Otitis Media

388

Case 21: Physiologic Jaundice

389

Case 22: Pyloric Stenosis

390

Case 23: Respiratory Distress in the Newborn

391

Case 24: Respiratory Syncytial Virus Infection

392

Case 25: Tay-Sachs Disease

393

Case 26: Tetralogy of Fallot

394

Case 27: Varicella

396

Case 28: Ventricular Septal Defect

398

Case 29: Wilms’ Tumor

399

Psychiatry

401

Case 1: Amphetamine Intoxication

402

Case 2: Alcoholism

404

Case 3: Anorexia Nervosa

405

Case 4: Attention-Deficit/Hyperactivity Disorder

406

Case 5: Autism

407

Case 6: Bulimia

408

Case 7: Cocaine Dependence

410

Case 8: Conduct Disorder

412

Case 9: Delirium

413

Case 10: Dissociative Fugue

414

Case 11: Domestic Violence

415

Case 12: Factitious Disorder

416

Case 13: Generalized Anxiety Disorder

417

xi


Case 14: Major Depression

418

Case 15: Personality Disorder, Cluster A

420

Case 16: Opioid Withdrawal

422

Case 17: Bipolar I Disorder

423

Case 18: Personality Disorder, Cluster B

424

Case 19: Personality Disorder, Cluster C

425

Case 20: Schizophrenia

426

Case 21: Posttraumatic Stress Disorder

428

Case 22: Somatization Disorder

429

Case 23: Tourette’s Syndrome

430

Case 24: Suicidal Ideation

432

Pulmonary
Case 1: Acute Respiratory Distress Syndrome

434

Case 2: Acute Respiratory Failure

436

Case 3: Asthma

438

Case 4: Atypical Pneumonia

440

Case 5: Chronic Obstructive Pulmonary Disease

441

Case 6: Emphysema

442

Case 7: Lung Cancer

443

Case 8: Idiopathic Pulmonary Fibrosis

444

Case 9: Mesothelioma

446

Case 10: Pulmonary Embolus

447

Case 11: Pleural Effusion

448

Case 12: Pneumothorax

450

Case 13: Pulmonary Hypertension

452

Case 14: Sarcoidosis

453

Case 15: Tuberculosis

454

Case 16: Wegener’s Granulomatosis

456

Case 17: Sleep Apnea

458

Renal/Genitourinary
Case 1: Acid-Base Disorders

xii

433

459
460

Case 2: Acute Interstitial Nephritis

461

Case 3: Acute Kidney Injury

462

Case 4: Acute Tubular Injury

464

Case 5: Benign Prostatic Hyperplasia

466

Case 6: Chronic Kidney Disease

468

Case 7: Erectile Dysfunction

470

Case 8: Glomerulonephritis

472

Case 9: Hypercalcemia of Malignancy

474

Case 10: Hyperkalemia

476

Case 11: Hypernatremia

478

Case 12: Hyperosmolar Hyperglycemic State

479

Case 13: Hypocalcemia

480


Case 14: Nephrolithiasis

482

Case 15: Nephrotic Syndrome

483

Case 16: Polycystic Kidney Disease

484

Case 17: Renal Cell Carcinoma

486

Case 18: Renal Tubular Acidosis

487

Case 19: Renovascular Hypertension/Secondary Hypertension

488

Case 20: Testicular Cancer

490

Case 21: Traumatic Urethral Injury

491

Selected Topics in Emergency Medicine

493

Case 1: Acetaminophen Overdose

494

Case 2: Anaphylactic Shock

495

Case 3: Appendicitis, Acute

496

Case 4: Bites, Animal and Human

498

Case 5: Burn, Thermal

500

Case 6: Atrial Fibrillation

502

Case 7: Carbon Monoxide Poisoning

503

Case 8: Cardiac Arrest

504

Case 9: Deep Vein Thrombosis (DVT)

505

Case 10: Drowning

506

Case 11: Organophosphate Poisoning, Acute

508

Case 12: Retinal Detachment

510

Case 13: Supraventricular Tachycardia

512

Case 14: Sepsis

514

Case 15: Syncope

515

Case 16: Testicular Torsion

516

Case 17: Trauma, Fracture, Orbital

517

Case 18: Mesenteric Ischemia, Acute

518

Case 19: Trauma, Fracture, Pelvis

519

Case 20: Trauma, Penetrating, Neck

520

Case 21: Wernicke’s Encephalopathy

522

Case 22: Trauma, Penetrating, Abdomen

524

Appendix

525

Index

533

About the Authors

551

xiii


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CONTRIBUTING AUTHORS
Karl Benedict Bezak

Jackie Landess

Vanderbilt University School of Medicine
Class of 2010

Vanderbilt University School of Medicine
Class of 2010

Yuriy Bronshteyn

Mark Newton, MD

Vanderbilt University School of Medicine
Class of 2010

Vanderbilt University School of Medicine
Class of 2009

Elizabeth Eby Halvorson, MD

John W. Wood, MD

Vanderbilt University School of Medicine
Class of 2009
Resident
Department of Pediatrics
Wake Forest University Baptist Medical Center

Resident
Department of Otolaryngology
Jackson Memorial Hospital
University of Miami

Kim Jiramongkolchai
Vanderbilt University School of Medicine
Class of 2010

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SENIOR REVIEWERS
Ebere Chukwu, MD

Derek Riebau, MD

Clinical Fellow
Department of Medicine
Division of Cardiovascular Medicine
Vanderbilt University School of Medicine

Assistant Professor
Department of Neurology
Stroke Center
Vanderbilt University School of Medicine

Nathaniel Clark, MD

Charles Rush, MD

Assistant Professor
Department of Psychiatry
Vanderbilt University Medical Center

Assistant Professor and Clerkship Director
Department of Obstetrics and Gynecology
Vanderbilt University School of Medicine

Titus Daniels, MD

Heidi Schaefer, MD

Assistant Professor

Department of Medicine
Vanderbilt University School of Medicine

Assistant Professor
Department of Medicine
Vanderbilt University School of Medicine

Agnes Fogo, MD

Richard Stein, MD

John L. Shapiro Professor of Pathology and Professor of Medicine
and Pediatrics
Department of Pathology
Vanderbilt University School of Medicine

Professor
Department of Medicine
Vanderbilt University School of Medicine

G. Waldon Garriss III, MD
Assistant Professor of Internal Medicine and Pediatrics
Associate Chair of Ambulatory Education
Associate Director of Internal Medicine-Pediatrics Residency Program
Associate Director of Internal Medicine Residency Program
Department of Medicine
Vanderbilt University School of Medicine

Joyce Johnson, MD
Professor

Department of Pathology
Vanderbilt University School of Medicine

Greg Plemmons, MD

Thomas Talbot, MD, MPH
Assistant Professor of Preventive Medicine
Department of Medicine
Vanderbilt University School of Medicine

Amy Weeks, MD
Assistant Professor
Department of Obstetrics and Gynecology
Vanderbilt University School of Medicine

John Zic, MD
Assistant Professor
Department of Medicine
Division of Dermatology
Vanderbilt University School of Medicine

Assistant Professor
Department of Pediatrics
Division of Hospital Medicine
Monroe Carell Jr. Children’s Hospital at Vanderbilt

Camiron Pfennig, MD
Assistant Professor
Department of Emergency Medicine
Assistant Director, Undergraduate Medical Education

Vanderbilt University School of Medicine
Department of Medicine
Vanderbilt University School of Medicine

xvii


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PREFACE

With First Aid Cases for the USMLE Step 2 CK, we continue our commitment to providing students with the most useful and up-to-date preparation
guides for the USMLE Step 2 CK. This new edition represents an outstanding effort by a talented group of authors and includes the following:
Ⅲ
Ⅲ
Ⅲ
Ⅲ
Ⅲ

Commonly asked question stems on the USMLE Step 2 CK integrated
into a single USMLE-style case
Concise yet complete explanations
Two-column format for easy self-quizzing
High-yield images, diagrams, and tables complement the questions and
answers
Organized as a perfect supplement to First Aid for the USMLE Step 2 CK

We invite you to share your thoughts and ideas to help us improve First Aid
Cases for the USMLE Step 2 CK. See How to Contribute, p. xxiii.

Louisville, KY
Winston-Salem, NC

Tao Le
Elizabeth Eby Halvorson

xix


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ACKNOWLEDGMENTS

This has been a collaborative project from the start. We gratefully acknowledge
the thoughtful comments and advice of the residents, international medical
graduates, and faculty who have supported the authors in the development of
First Aid Cases for the USMLE Step 2 CK.
Additional thanks to the following for reviewing manuscript: Daniel Birchmore,
MD and Meredith Pugh, MD.
Thanks to our publisher, McGraw-Hill, for the valuable assistance of their
staff. For enthusiasm, support, and commitment to this challenging project,
thanks to our editor, Catherine Johnson. For outstanding editorial work, we
thank Isabel Nogueira. A special thanks to Rainbow Graphics for remarkable
production work. For support and encouragement throughout the process, we
are grateful to Thao Pham, Selina Franklin, and Louise Petersen.
Louisville, KY
Winston-Salem, NC

Tao Le

Elizabeth Eby Halvorson

xxi


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HOW TO CONTRIBUTE

To continue to produce a high-yield review source for the USMLE Step 2 CK exam, you are invited to
submit any suggestions or corrections. The First Aid Team also offers paid internships in medical education and publishing ranging from three months to one year (see below for details). Please send us your
suggestions for:
Ⅲ
Ⅲ
Ⅲ

High-yield USMLE Step 2 CK cases
New facts, mnemonics, diagrams, and illustrations
Low-yield cases to remove

For each entry incorporated into the next edition, you will receive a $10 gift certificate, as well as personal acknowledgment in the next edition. Diagrams, tables, partial entries, updates, corrections, and
study hints are also appreciated, and significant contributions will be compensated at the discretion of
the authors. Also let us know about material in this edition that you feel is low yield and should be deleted.
The preferred way to submit entries, suggestions, or corrections is via our blog:
www.firstaidteam.com.
Otherwise, please send entries, neatly written or typed, or on disk (Microsoft Word), to:
First Aid Team
914 N. Dixie Avenue, Suite 100
Elizabethtown, KY 42701

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All entries become property of the authors and are subject to editing and reviewing. Please verify all data
and spellings carefully. In the event that similar or duplicate entries are received, only the first entry received will be used. Include a reference to a standard textbook to facilitate verification of the fact. Please
follow the style, punctuation, and format of this edition if possible.

I N T E R N S H I P O P P O RT U N I T I E S

The author team is pleased to offer part-time and full-time paid internships in medical education and publishing to motivated medical students and physicians. Internships may range from three months (e.g., a
summer) up to a full year. Participants will have an opportunity to author, edit, and earn academic credit on
a wide variety of projects, including the popular First Aid series. English writing/ editing experience, familiarity with Microsoft Word, and Internet access are required. Go to our blog www.firstaidteam.com to apply for an internship. A sample of your work or a proposal of a specific project is helpful.

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