Tommyk posts 232-300

[mommd]

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!

[Anonymous]

thank you soooo much
you are a great and helpful person
you and tommyc are both alike in that you are spending your time helping people-thanx again..

[Anonymous]

thank u mommd.

do you hv the rest saved as one post?

its taking forever to get each post . i dont hv acess to a computer at home and copying and pasting each one is taking too long.

Fleur

[Anonymous]

God bless you

[kris2c]

from mommy

Hi Tommy ,
It is really nice reading your mails.I took my step last year but failed.I could not take it again as i got depressed& I have some personal problems too.Now I am again registered.But I don't hve confidence in me. Please guide me what to do? I have to take my exam by 12th Dec.My email address is mbbsamritsar@yahoo.com
Thanks

[Faydoc]

Thanks so much for the info. If there are any suggestions you might have to offer would be greatly appreciated.
Thanks Again

[katwal]

helo
thank u for everything!
my exam is in this april.
i have many Q to ask with you and has to clarify withyou
will you please help me out.
u r genius.
yor help is really appreciated.
i wll be greatful if u could do me a favour.
GOD bless you

[husayn]

Thanks
Well Done!
really!