USMLE Step 2 Review
Tanner stage 2; unilaterally; Thelarche; Thelarche; Pubarche; Growth spurt; Menarche
It is common and normal for girls during puberty to have asynchronous breast development.
This type of breast development (breast bud) often begins __________ (_____________).
Tenderness is also common as glandular tissue grows.
Normal pubertal sequence: __________ → _________ → __________ _________ → ____________.
Asymmetry can persist for months.
menarche; 12.5 years; 1–2 years after menarche; not ovulate
The average age of ____________ in the U.S. is around ____ _______.
Irregular bleeding is physiologic in the first ______ ______________ ________ ______________.
Most adolescent girls do _____ _______ in early cycles.
Wiskott-Aldrich; (Micro)thrombocytopenia, eczema, recurrent infxns, B and T cell dysfunction; X-linked
recessive WAS (defective actin cystoskeleton); low IgM and elevated IgA
Diffuse eczematous rash, otitis media, oral thrush in a 7-month old.
Diagnosis? Findings? Mutation? Ig Findings?
Ataxia telangiectasia; cerebellar ataxia, telangiectasias, and recurrent sinopulmonary infxns; ATM gene
defect (failed DNA repair); elevated AFP, low IgA, low IgG, low IgE; high risk of malignancy.
Child with ataxia, spider angiomas, and recurrent infections. Diagnosis? Mutation? Immunoglobulin
findings? Cancer risk?
Perinatal HIV; failure to thrive, chronic diarrhea, lymphadenopathy, thrush, infxns (e.g., PCP, otitis
media); CD4+ lymphopenia; may have normal IgG early due to maternal transfer; diagnosis by PCR in
infants <18 months
Thrush, lymphadenopathy, FTT, diarrhea in infant. Diagnosis? Labs? Transmission risk factors?
Hyper-IgE (Job) syndrome; coarse facies, retained primary teeth, eczema, recurrent skin abscesses,
pulmonary infections; STAT3 mutation (impaired neutrophil chemotaxis); high IgE, eosinophilia
Eczema + recurrent skin infections + high IgE + retained teeth. Diagnosis? Gene? Immune defect?
X-linked (Bruton's) agammaglobulinemia; recurrent pyogenic bacterial infxns after 6 months (loss of
maternal IgG), no tonsils/lymph nodes, absent B cells, all Igs decreased; BTK gene (tyrosine kinase)
mutation; X-linked recessive
Boy with recurrent bacterial infections (e.g., pneumonia, otitis media), no lymphoid tissue, and no
immunoglobulins. Diagnosis? Signs/Sxms? Mutation? Immunoglobulin findings? Gene? Inheritance?
,CVID; adolescence or adulthood; recurrent sinopulmonary infections, autoimmune disease,
bronchiectasis; low Igs; normal B-cell count but impaired function
Teen/adult with recurrent infections + autoimmune features + low IgG/IgA. Diagnosis? Typical age? Ig
pattern?
Hyper-IgM syndrome; mutation in CD40 ligand (on T cells), can't class-switch; high IgM, low IgG/A/E;
recurrent sinopulmonary and opportunistic infections (e.g., PCP); X-linked
Boy with high IgM, low other Igs, and opportunistic infections. Diagnosis? Mutation? Immunoglobulin
findings?
LAD; defective CD18 integrin; delayed separation of umbilical cord, recurrent infections without pus,
neutrophilia.
Delayed cord separation, no pus, high neutrophil count. Diagnosis? Defect? Cell marker?
Screen for TB, Screen for Hepatitis B, and Update immunizations
Before anti-TNF agents, always:
IV fluids (isotonic), Pain control (opioids often required), O2 (if hypoxic), Abx (only if febrile or
infectious signs), and transfusion (only if severe anemia, acute chest, stroke, or splenic sequestration)
Management of Vaso-Occlusive Crisis:
IV Ceftriaxone (Concern for Encapsulated Organism Sepsis)
Sickle cell patient + Functional Asplenia + Fever
Exchange transfusion (Acute chest syndrome)
Sickle cell patient + Hypoxia + infiltrate + fever
Simple transfusion (Aplastic crisis)
Sickle cell patient + Severe anemia + fatigue + ↓ retic
Exchange transfusion
Sickle cell patient + stroke symptoms
Febrile nonhemolytic transfusion reaction; antipyretics only
Fever + chills + 1–6 hrs after transfusion + due to cytokine accumulation + no hemolysis
Acute hemolytic transfusion reaction; stop transfusion, supportive care, labs
Fever + flank pain + hemoglobinuria + DIC + hypotension <1 hr after transfusion + ABO mismatch
Delayed hemolytic transfusion reaction; supportive only
Low-grade fever + jaundice + anemia + 3-10 days after transfusion + anamnestic response to RBC
antigen
,Anaphylactic transfusion reaction; stop transfusion + give epinephrine
Shock + wheezing + angioedema + urticaria + within minutes of starting transfusion + IgA deficiency
TRALI (transfusion-related acute lung injury); stop transfusion, supportive care
Acute hypoxia + bilateral infiltrates + <6 hrs post-transfusion + normal JVP + donor anti-leukocyte Abs
TACO (transfusion-associated circulatory overload); stop transfusion, give diuretics, O2
Dyspnea + crackles + HTN + JVD + pulm edema after multiple or rapid transfusions (esp. elderly/CHF)
Denial
When a patient refuses to acknowledge a clear truth (e.g., diagnosis, prognosis), especially after hearing
distressing news
Rationalization
Justifying behavior with logical reasons
Suppression
Voluntary decision to postpone emotion; Med student delays grief to study for exam
Sublimation
Redirecting impulses into acceptable behavior; Aggressive person becomes a surgeon
Altruism
Terminal cancer pt volunteers in hospice
Delusional disorder (somatic type); antipsychotics and build trust
Fixed false belief (e.g., skin infestation, body odor) + no other psychotic symptoms + functioning mostly
intact
La belle indifférence; Functional neurological symptom disorder (conversion disorder)
Inappropriately calm attitude toward profound neurologic deficits (e.g., blindness, paralysis). Typically
seen in this disorder.
Idea of Reference; Schizotypal PD, schizophrenia
Belief that random external events (e.g., TV shows, strangers talking) refer specifically to oneself.
Schizotypal PD
Eccentric behavior + magical thinking + odd speech + social anxiety from paranoia (not indifference)
+ wants relationships but is too anxious/weird
Schizoid PD
, Detached, emotionally cold, prefers to be alone + lacks close relationships but not distressed by
it + doesn’t want connection or intimacy
Paranoid PD
Pervasive mistrust of others + interprets benign actions as hostile + holds grudges + hypervigilant but
no fixed delusions
PCP intoxication; benzos + supportive care
Agitation + hallucinations + superhuman strength + vertical nystagmus + seizures + mydriasis + HTN +
NMDA antagonist
LSD intoxication; reassurance + benzodiazepines if severe
Visual hallucinations + synesthesia ("hearing colors") + depersonalization + pupillary dilation + no violent
behavior
Methamphetamine intoxication; benzos for agitation/seizures
Severe agitation + psychosis + diaphoresis + HTN + tooth decay + tactile hallucinations (e.g., “bugs
crawling”)
Benzodiazepine overdose; flumazenil
Sedation + ataxia + slurred speech + normal vital signs + no respiratory depression (unless co-ingestion)
MDMA (ecstasy) intoxication; benzos, cooling, correct Na
Euphoria + increased sociability + bruxism (teeth grinding) + hyperthermia + hyponatremia + serotonin
syndrome (agitation, clonus, AMS)
MOA: Increases serotonin, dopamine, norepinephrine
Can cause SIADH → hyponatremic seizures
Can lead to rhabdomyolysis from hyperthermia
HSV encephalitis; Non-contrast CT, then LP, then IV Acyclovir (DO NOT WAIT FOR PCR RESULTS), then
MRI (T2/FLAIR)
Increased signal intensity (bright area) in the right temporal lobe.
The rest of the brain appears symmetric and without mass effect or midline shift.
B12 deficiency
Tanner stage 2; unilaterally; Thelarche; Thelarche; Pubarche; Growth spurt; Menarche
It is common and normal for girls during puberty to have asynchronous breast development.
This type of breast development (breast bud) often begins __________ (_____________).
Tenderness is also common as glandular tissue grows.
Normal pubertal sequence: __________ → _________ → __________ _________ → ____________.
Asymmetry can persist for months.
menarche; 12.5 years; 1–2 years after menarche; not ovulate
The average age of ____________ in the U.S. is around ____ _______.
Irregular bleeding is physiologic in the first ______ ______________ ________ ______________.
Most adolescent girls do _____ _______ in early cycles.
Wiskott-Aldrich; (Micro)thrombocytopenia, eczema, recurrent infxns, B and T cell dysfunction; X-linked
recessive WAS (defective actin cystoskeleton); low IgM and elevated IgA
Diffuse eczematous rash, otitis media, oral thrush in a 7-month old.
Diagnosis? Findings? Mutation? Ig Findings?
Ataxia telangiectasia; cerebellar ataxia, telangiectasias, and recurrent sinopulmonary infxns; ATM gene
defect (failed DNA repair); elevated AFP, low IgA, low IgG, low IgE; high risk of malignancy.
Child with ataxia, spider angiomas, and recurrent infections. Diagnosis? Mutation? Immunoglobulin
findings? Cancer risk?
Perinatal HIV; failure to thrive, chronic diarrhea, lymphadenopathy, thrush, infxns (e.g., PCP, otitis
media); CD4+ lymphopenia; may have normal IgG early due to maternal transfer; diagnosis by PCR in
infants <18 months
Thrush, lymphadenopathy, FTT, diarrhea in infant. Diagnosis? Labs? Transmission risk factors?
Hyper-IgE (Job) syndrome; coarse facies, retained primary teeth, eczema, recurrent skin abscesses,
pulmonary infections; STAT3 mutation (impaired neutrophil chemotaxis); high IgE, eosinophilia
Eczema + recurrent skin infections + high IgE + retained teeth. Diagnosis? Gene? Immune defect?
X-linked (Bruton's) agammaglobulinemia; recurrent pyogenic bacterial infxns after 6 months (loss of
maternal IgG), no tonsils/lymph nodes, absent B cells, all Igs decreased; BTK gene (tyrosine kinase)
mutation; X-linked recessive
Boy with recurrent bacterial infections (e.g., pneumonia, otitis media), no lymphoid tissue, and no
immunoglobulins. Diagnosis? Signs/Sxms? Mutation? Immunoglobulin findings? Gene? Inheritance?
,CVID; adolescence or adulthood; recurrent sinopulmonary infections, autoimmune disease,
bronchiectasis; low Igs; normal B-cell count but impaired function
Teen/adult with recurrent infections + autoimmune features + low IgG/IgA. Diagnosis? Typical age? Ig
pattern?
Hyper-IgM syndrome; mutation in CD40 ligand (on T cells), can't class-switch; high IgM, low IgG/A/E;
recurrent sinopulmonary and opportunistic infections (e.g., PCP); X-linked
Boy with high IgM, low other Igs, and opportunistic infections. Diagnosis? Mutation? Immunoglobulin
findings?
LAD; defective CD18 integrin; delayed separation of umbilical cord, recurrent infections without pus,
neutrophilia.
Delayed cord separation, no pus, high neutrophil count. Diagnosis? Defect? Cell marker?
Screen for TB, Screen for Hepatitis B, and Update immunizations
Before anti-TNF agents, always:
IV fluids (isotonic), Pain control (opioids often required), O2 (if hypoxic), Abx (only if febrile or
infectious signs), and transfusion (only if severe anemia, acute chest, stroke, or splenic sequestration)
Management of Vaso-Occlusive Crisis:
IV Ceftriaxone (Concern for Encapsulated Organism Sepsis)
Sickle cell patient + Functional Asplenia + Fever
Exchange transfusion (Acute chest syndrome)
Sickle cell patient + Hypoxia + infiltrate + fever
Simple transfusion (Aplastic crisis)
Sickle cell patient + Severe anemia + fatigue + ↓ retic
Exchange transfusion
Sickle cell patient + stroke symptoms
Febrile nonhemolytic transfusion reaction; antipyretics only
Fever + chills + 1–6 hrs after transfusion + due to cytokine accumulation + no hemolysis
Acute hemolytic transfusion reaction; stop transfusion, supportive care, labs
Fever + flank pain + hemoglobinuria + DIC + hypotension <1 hr after transfusion + ABO mismatch
Delayed hemolytic transfusion reaction; supportive only
Low-grade fever + jaundice + anemia + 3-10 days after transfusion + anamnestic response to RBC
antigen
,Anaphylactic transfusion reaction; stop transfusion + give epinephrine
Shock + wheezing + angioedema + urticaria + within minutes of starting transfusion + IgA deficiency
TRALI (transfusion-related acute lung injury); stop transfusion, supportive care
Acute hypoxia + bilateral infiltrates + <6 hrs post-transfusion + normal JVP + donor anti-leukocyte Abs
TACO (transfusion-associated circulatory overload); stop transfusion, give diuretics, O2
Dyspnea + crackles + HTN + JVD + pulm edema after multiple or rapid transfusions (esp. elderly/CHF)
Denial
When a patient refuses to acknowledge a clear truth (e.g., diagnosis, prognosis), especially after hearing
distressing news
Rationalization
Justifying behavior with logical reasons
Suppression
Voluntary decision to postpone emotion; Med student delays grief to study for exam
Sublimation
Redirecting impulses into acceptable behavior; Aggressive person becomes a surgeon
Altruism
Terminal cancer pt volunteers in hospice
Delusional disorder (somatic type); antipsychotics and build trust
Fixed false belief (e.g., skin infestation, body odor) + no other psychotic symptoms + functioning mostly
intact
La belle indifférence; Functional neurological symptom disorder (conversion disorder)
Inappropriately calm attitude toward profound neurologic deficits (e.g., blindness, paralysis). Typically
seen in this disorder.
Idea of Reference; Schizotypal PD, schizophrenia
Belief that random external events (e.g., TV shows, strangers talking) refer specifically to oneself.
Schizotypal PD
Eccentric behavior + magical thinking + odd speech + social anxiety from paranoia (not indifference)
+ wants relationships but is too anxious/weird
Schizoid PD
, Detached, emotionally cold, prefers to be alone + lacks close relationships but not distressed by
it + doesn’t want connection or intimacy
Paranoid PD
Pervasive mistrust of others + interprets benign actions as hostile + holds grudges + hypervigilant but
no fixed delusions
PCP intoxication; benzos + supportive care
Agitation + hallucinations + superhuman strength + vertical nystagmus + seizures + mydriasis + HTN +
NMDA antagonist
LSD intoxication; reassurance + benzodiazepines if severe
Visual hallucinations + synesthesia ("hearing colors") + depersonalization + pupillary dilation + no violent
behavior
Methamphetamine intoxication; benzos for agitation/seizures
Severe agitation + psychosis + diaphoresis + HTN + tooth decay + tactile hallucinations (e.g., “bugs
crawling”)
Benzodiazepine overdose; flumazenil
Sedation + ataxia + slurred speech + normal vital signs + no respiratory depression (unless co-ingestion)
MDMA (ecstasy) intoxication; benzos, cooling, correct Na
Euphoria + increased sociability + bruxism (teeth grinding) + hyperthermia + hyponatremia + serotonin
syndrome (agitation, clonus, AMS)
MOA: Increases serotonin, dopamine, norepinephrine
Can cause SIADH → hyponatremic seizures
Can lead to rhabdomyolysis from hyperthermia
HSV encephalitis; Non-contrast CT, then LP, then IV Acyclovir (DO NOT WAIT FOR PCR RESULTS), then
MRI (T2/FLAIR)
Increased signal intensity (bright area) in the right temporal lobe.
The rest of the brain appears symmetric and without mass effect or midline shift.
B12 deficiency
