1
NBME 9 Step 2 Notes
NBME 9 (STEP 2 CK)
1. Constipation
a. Can apply pressure to the bladder, leading to urinary incontinence
b. Sx = daytime enuresis, bedwetting, urinary frequency and urgency, or urinary tract infection.
c. Other causes such as congenital megacolon (Hirschsprung disease), spina bifida, hypothyroidism, cystic fibrosis, or
diabetes insipidus should be excluded
d. Major signs that suggest an organic cause of constipation include onset of constipation prior to 1 month of age, delayed
passage of meconium, failure to thrive, abdominal distension, intermittent diarrhea or explosive stools, an empty rectal
vault or tight anal sphincter, and midline hair or pigmentary changes over the lumbar spine.
e. Tx = osmotic or polyethylene glycol-based laxatives and dietary modification with increased intake of fluids and fiber.
f. Other answers:
i. Desmopressin is used for DI (large volume of dilute urine, dehydration, thirst, inc. serum osmolality)
ii. Bed wetting alarm is used for nocturnal enuresis
iii. Renal US is used for hydronephrosis, VU reflux, congenital urinary tract abnormalities
2. Insomnia problems
a. OTC meds like antihistamines or zolpidem can be used for primary insomnia
b. Modafinil is a CNS stimulant used for daytime sleepiness in narcolepsy, OSA, and shift-work sleep disorder
c. Trazadone can be used also (serotonin modulator)
3. PCV13 & PPSV23
a. PPSV23
i. for all patients 65+ regardless of medical hx
ii. for 19-64 yrs old w/ certain medical conditions
iii.
b. PCV13
i. Given to pts w/ HIV, lymphoma, leukemia, MM, functional or anatomic asplenia, ESRD, cochlear implants, CSF
leaks, hx of solid organ transplant, congenital or acquired immunodeficiencies and others
c. PCV13 given first followed by PPSV23 at least 8 weeks later
d. Revaccination w/ PPSV23 again 5 years after first dose
4. EBV in transplant patients
a. EBV is common in development of post-transplant lymphoproliferative disorder (esp in pts who remain on high doses of
immunosuppressive meds)
b. PP = virus first infects B cells, which have viral antigens on surface, leading to T cell stimulation w/ destruction of
affected B cells; some infected cells evade immune surveillance and persist in host
i. Pts getting immunosuppressive meds or in those whose T cell population has been ablated, allows for
proliferation of B cells that continue to harbor the virus leading to PTLD
c. Tx = reduction of immunosuppressive meds, +/- rituximab
5. Hemolysis
a. Can be intravascular, extravascular (reticuloendothelial system) or both
b. Extravascular commonly results in splenomegaly
c. Labs:
i. Anemia & reticulocytosis
ii. Inc. indirect bilirubin & LDH
iii. Normal direct bilirubin & ALP
6. Acute dystonia
a. Involuntary, painful muscle spasms after D2 antagonists like typical antipsychotics (ex: haloperidol)
b. CF = torticollis, retrocollis (head tilted back), opisthotonos (arched back), deviation of eyes (oculogyric crisis), rarely w/
laryngospasm/stridor
c. PP = imbalance of dopaminergic-cholinergic pathways of basal ganglia
d. RF = male, young, recent cocaine use, hx of it
e. Tx = diphenhydramine or benztropine (both anticholinergic meds)
7. Acute depressive episode in Bipolar
a. Lithium used for acute mania, acute depression and maintenance bipolar tx
b. Other 1st line meds are: lamotrigine, quetiapine, lurasidone
c. Doc should give psychoeducation abt need for med (even when mood is neutral) to improve pt’s adherence and consider
referral for psychotherapy to address barriers to adherence
,2
NBME 9 Step 2 Notes
d. Note: Valproic is used for acute mania or maintenance not acute depression episode
8. Alcohol intoxication
a. Emotional lability, disinhibition, sedation, slurred speech, ataxia, normally reactive pupils
b. Severely intoxicated: dec. consciousness (coma), slow respirations
c. Chronic heavy alcohol use: leads to hypoglycemia, alcoholic ketoacidosis
d. Tx = protect pt and surrounding from harm, manage airway and breathing in event of emesis, oversedation, or coma;
hydration, repleting vitamins & electrolytes in severe cases; may require intubation
e. Other answers:
i. Cocaine intoxication – elevated mood, pressured speech, tachycardia, HTN
ii. Benzo intoxication – CNS depression, slurred speech, ataxia, emotional lability, memory lapses (but alcohol use
is more common in adolescents + benzo does not cause hypoglycemia or ketoacidosis)
iii. Heroin intoxication – stupor, depressed respiratory rate, constricted pupils
iv. Marijuana intoxication – flushed conjunctiva, hyperphagia, mood changes
9. Botulism
a. G+, spore forming, obligate anaerobic bacteria
b. Produces neurotoxin that is absorbed into the end terminal of cholinergic motor neurons, where it cleaves SNARE proteins
preventing release of Ach vesicles into NMJ
c. Raw honey or canned foods
d. Through inhalation of spores or ingestion of spores
e. CF = rapidly progressive, symmetric hypotonia, hyporeflexia begins w/ cranial nerves (ptosis, sluggish pupils, diminished
gag reflex) and descends to lower extremities as well as causes constipation, poor feeding, and respiratory failure
f. Dx = low amplitude response on repetitive nerve stimulation studies (electromyography) that improves w/ repeated
stimulation
g. Tx = immune globulin, supportive care (+/- ventilation)
h. Other answers:
i. LP is useful for dx of meningitis, encephalitis, GBS (which are rapid onset ascending paralysis)
ii. MRI spine is useful for cauda equina & spinal ganglia in GBS
iii. Muscle biopsy is useful for muscular dystrophies
10. Afib & stroke
a. Afib CF = palpitations, fatigue, lightheadedness and mild dyspnea if symptomatic
b. Prolonged Afib leads to left atrial hemostasis and increases risk of thrombosis
c. Thrombus can from LA can embolize through aorta to left subclavian artery then to left vertebral artery
d. Occlusion of vertebral artery affects brain stem, cerebellum, and occipital lobes
i. Vertigo, nystagmus, ataxia, ipsilateral cranial nerve dysfunction, contralateral hemiparesis, and contralateral
impairment in pain & temperature sensation
e. Paroxysmal or chronic afib pts should start anticoagulation (ex: warfarin) to prevent strokes
f. Other answers:
i. Aspirin & clopidogrel are antiplatelet agents used to prevent recurrent strokes in pts w/out afib
ii. CEA are used to tx moderate to severe carotid artery stenosis
1. Internal carotid is for primary motor and sensory cortices (presents as contralateral hemiparesis &
contralateral sensory deficit of face & UE w/out vestibulocerebellar or brainstem signs)
11. Vestibular neuronitis
a. Inflammation of vestibular portion of CN VIII usually d/t virus
b. CF = acute vertigo, N/V, nystagmus, gait instability
c. Absence of visual input, when pt closes his eyes, commonly worsens peripheral vertigo
d. Pts commonly don’t have hearing loss unless there is concomitant involvement of auditory portion of CN VIII
(labyrinthitis)
e. Tx – self-limited, glucocorticoid taper may hasten recovery, antiemetics & vertigo meds may reduce severity of Sx
f. Other answers:
i. Basilar migraine refers to HA that begins w/ brainstem aura (Sx such as vertigo, incoordination, tinnitus, hearing
loss, diplopia, or dysarthria) lasting few mins to hour & followed by occipital HA
ii. Brainstem hemorrhage may cause locked in syndrome (pontine) or Wallenberg syndrome (lateral medullary)
1. Wallenberg presents w/ vertigo, nystagmus and ipsilateral ataxia along w/ ipsilateral Horner syndrome,
facial numbness, taste loss, dysarthria, dysphagia, and/or pain & temp sensation deficits in contralateral
body
iii. Cerebellar infarction may lead to gait ataxia, nystagmus, dizziness, limb dysmetria or dysarthria
1. Pts typically unable to walk unsupported
iv. Meniere disease is vestibular dysfunction & sensorineural hearing loss that results from pressure accumulation in
endolymph of inner ear
1. CF = episodic vertigo, hearing loss, tinnitus
, 3
NBME 9 Step 2 Notes
2. Dx = Clinical, audiometry (sensorineural loss), weber (unilateral loss leads to lateralization of BC of a
midline stimulus to unaffected ear); Rinne (greater AC than BC in affected ear)
3. Tx = lifestyle (avoid salt, nicotine, alcohol, stress); antihistamine meds (meclizine, promethazine);
methylprednisolone (for refractory dz)
4. Sx will be episodic including hearing loss unlike Vestibular neuronitis
12. Acne vulgaris
a. Comedone, hair follicle that has been blocked by keratin debris
b. Inciting even is hyperproliferation of epidermis & abnormal keratinization
c. Topical retinoid (vitamin A analogs) therapy is 1 st line
i. They normalize keratinization
ii. Used as preventative therapy rather than to tx preexisting lesions
d. Other answers:
i. Bactericidal soap is sometimes used as adjuvant to topical retinoid
ii. OCP or IM medroxyprogesterone may help when there is hormonal component (cyclical flaring of acne; more on
lower face, jawline, chin)
iii. Intralesional corticosteroid therapy can be used if inflamed & painful lesion but risk of atrophy &
dyspigmentation
13. Juvenile rheumatoid arthritis
a. <16 yrs. Old
b. Joint pain & inflammation
c. Extraarticular features: uveitis, lymphadenopathy, rash
d. Sub categories:
i. Oligoarticular - <5 joints (large joints like knee) & ANA +ve
ii. Polyarticular - >5 joints (both large & small joints) & ANA -ve
iii. Systemic – aka Juvenile onset Still disease, variable joint involved, rash, quotidian fever, serositis
e. JIA associated uveitis is MC in female kids w/ oligoarthritic
i. w/out typical signs of uveitis so gets detected late
ii. leads to complications such as cataract, glaucoma, amblyopia, and permanent vision loss
iii. Dx – Slit lamp exam
f. Tx: NSAID, DMARD (ex – Methotrexate) & biologic agents
14. Primary bone malignancy vs metastasis
a. In adults, presence of destructive bone lesion is more commonly metastatic
b. Adenocarcinoma of lung is MC primary lung cancer and MC in nonsmokers in periphery
c. Other cancer that metastasize to bone: breast, thyroid, kidney, prostate
15. Osteonecrosis of femoral head
a. From impaired vascular supply to bone w/ painful degeneration & loss of structural integrity over time
b. Can be d/t direct injury to blood vessel, compression by extrinsic structures or inflammation, venous occlusion or
thromboembolism
c. Associated w/ trauma (fractures/dislocations), alcohol use disorder, systemic corticosteroid use, sickle cell disease,
bisphosphonate therapy & Gaucher disease
d. Dx – x ray or MRI (gold standard)
e. Tx – consult Ortho & PT
16. Stable supraventricular tachycardia
a. Regular, narrow-complex w/out evidence of hypotension or impaired systemic perfusion
b. Tx: Vagal maneuvers, IV adenosine, metoprolol, or CCB used first (these are AV nodal blocking agents)
c. Other answers:
i. Amiodarone tx both ventricular, SVTs and may be used for refractory arrhythmias
ii. Digoxin is for chronic mgmt. of some supraventricular tachyarrhythmias esp if there is a component of heart
failure
iii. Electrical cardioversion – indicated if pt is unstable (hypotension, AMS, angina, respiratory distress)
iv. Pacemaker – used for symptomatic bradycardia, sinus node dysfunction, AV nodal blocks
17. Aortic stenosis
a. d/t fibrosis and calcification
b. severe AS – fatigue, SOB, cough, diminished exercise tolerance, angina, syncope w/ exertion
c. PE – crescendo-decrescendo systolic murmur (heard best at upper right sternal border w/ radiation to carotids), pulsus
parvus et tardus (weak & delayed)
d. Leads to LVH & HF
NBME 9 Step 2 Notes
NBME 9 (STEP 2 CK)
1. Constipation
a. Can apply pressure to the bladder, leading to urinary incontinence
b. Sx = daytime enuresis, bedwetting, urinary frequency and urgency, or urinary tract infection.
c. Other causes such as congenital megacolon (Hirschsprung disease), spina bifida, hypothyroidism, cystic fibrosis, or
diabetes insipidus should be excluded
d. Major signs that suggest an organic cause of constipation include onset of constipation prior to 1 month of age, delayed
passage of meconium, failure to thrive, abdominal distension, intermittent diarrhea or explosive stools, an empty rectal
vault or tight anal sphincter, and midline hair or pigmentary changes over the lumbar spine.
e. Tx = osmotic or polyethylene glycol-based laxatives and dietary modification with increased intake of fluids and fiber.
f. Other answers:
i. Desmopressin is used for DI (large volume of dilute urine, dehydration, thirst, inc. serum osmolality)
ii. Bed wetting alarm is used for nocturnal enuresis
iii. Renal US is used for hydronephrosis, VU reflux, congenital urinary tract abnormalities
2. Insomnia problems
a. OTC meds like antihistamines or zolpidem can be used for primary insomnia
b. Modafinil is a CNS stimulant used for daytime sleepiness in narcolepsy, OSA, and shift-work sleep disorder
c. Trazadone can be used also (serotonin modulator)
3. PCV13 & PPSV23
a. PPSV23
i. for all patients 65+ regardless of medical hx
ii. for 19-64 yrs old w/ certain medical conditions
iii.
b. PCV13
i. Given to pts w/ HIV, lymphoma, leukemia, MM, functional or anatomic asplenia, ESRD, cochlear implants, CSF
leaks, hx of solid organ transplant, congenital or acquired immunodeficiencies and others
c. PCV13 given first followed by PPSV23 at least 8 weeks later
d. Revaccination w/ PPSV23 again 5 years after first dose
4. EBV in transplant patients
a. EBV is common in development of post-transplant lymphoproliferative disorder (esp in pts who remain on high doses of
immunosuppressive meds)
b. PP = virus first infects B cells, which have viral antigens on surface, leading to T cell stimulation w/ destruction of
affected B cells; some infected cells evade immune surveillance and persist in host
i. Pts getting immunosuppressive meds or in those whose T cell population has been ablated, allows for
proliferation of B cells that continue to harbor the virus leading to PTLD
c. Tx = reduction of immunosuppressive meds, +/- rituximab
5. Hemolysis
a. Can be intravascular, extravascular (reticuloendothelial system) or both
b. Extravascular commonly results in splenomegaly
c. Labs:
i. Anemia & reticulocytosis
ii. Inc. indirect bilirubin & LDH
iii. Normal direct bilirubin & ALP
6. Acute dystonia
a. Involuntary, painful muscle spasms after D2 antagonists like typical antipsychotics (ex: haloperidol)
b. CF = torticollis, retrocollis (head tilted back), opisthotonos (arched back), deviation of eyes (oculogyric crisis), rarely w/
laryngospasm/stridor
c. PP = imbalance of dopaminergic-cholinergic pathways of basal ganglia
d. RF = male, young, recent cocaine use, hx of it
e. Tx = diphenhydramine or benztropine (both anticholinergic meds)
7. Acute depressive episode in Bipolar
a. Lithium used for acute mania, acute depression and maintenance bipolar tx
b. Other 1st line meds are: lamotrigine, quetiapine, lurasidone
c. Doc should give psychoeducation abt need for med (even when mood is neutral) to improve pt’s adherence and consider
referral for psychotherapy to address barriers to adherence
,2
NBME 9 Step 2 Notes
d. Note: Valproic is used for acute mania or maintenance not acute depression episode
8. Alcohol intoxication
a. Emotional lability, disinhibition, sedation, slurred speech, ataxia, normally reactive pupils
b. Severely intoxicated: dec. consciousness (coma), slow respirations
c. Chronic heavy alcohol use: leads to hypoglycemia, alcoholic ketoacidosis
d. Tx = protect pt and surrounding from harm, manage airway and breathing in event of emesis, oversedation, or coma;
hydration, repleting vitamins & electrolytes in severe cases; may require intubation
e. Other answers:
i. Cocaine intoxication – elevated mood, pressured speech, tachycardia, HTN
ii. Benzo intoxication – CNS depression, slurred speech, ataxia, emotional lability, memory lapses (but alcohol use
is more common in adolescents + benzo does not cause hypoglycemia or ketoacidosis)
iii. Heroin intoxication – stupor, depressed respiratory rate, constricted pupils
iv. Marijuana intoxication – flushed conjunctiva, hyperphagia, mood changes
9. Botulism
a. G+, spore forming, obligate anaerobic bacteria
b. Produces neurotoxin that is absorbed into the end terminal of cholinergic motor neurons, where it cleaves SNARE proteins
preventing release of Ach vesicles into NMJ
c. Raw honey or canned foods
d. Through inhalation of spores or ingestion of spores
e. CF = rapidly progressive, symmetric hypotonia, hyporeflexia begins w/ cranial nerves (ptosis, sluggish pupils, diminished
gag reflex) and descends to lower extremities as well as causes constipation, poor feeding, and respiratory failure
f. Dx = low amplitude response on repetitive nerve stimulation studies (electromyography) that improves w/ repeated
stimulation
g. Tx = immune globulin, supportive care (+/- ventilation)
h. Other answers:
i. LP is useful for dx of meningitis, encephalitis, GBS (which are rapid onset ascending paralysis)
ii. MRI spine is useful for cauda equina & spinal ganglia in GBS
iii. Muscle biopsy is useful for muscular dystrophies
10. Afib & stroke
a. Afib CF = palpitations, fatigue, lightheadedness and mild dyspnea if symptomatic
b. Prolonged Afib leads to left atrial hemostasis and increases risk of thrombosis
c. Thrombus can from LA can embolize through aorta to left subclavian artery then to left vertebral artery
d. Occlusion of vertebral artery affects brain stem, cerebellum, and occipital lobes
i. Vertigo, nystagmus, ataxia, ipsilateral cranial nerve dysfunction, contralateral hemiparesis, and contralateral
impairment in pain & temperature sensation
e. Paroxysmal or chronic afib pts should start anticoagulation (ex: warfarin) to prevent strokes
f. Other answers:
i. Aspirin & clopidogrel are antiplatelet agents used to prevent recurrent strokes in pts w/out afib
ii. CEA are used to tx moderate to severe carotid artery stenosis
1. Internal carotid is for primary motor and sensory cortices (presents as contralateral hemiparesis &
contralateral sensory deficit of face & UE w/out vestibulocerebellar or brainstem signs)
11. Vestibular neuronitis
a. Inflammation of vestibular portion of CN VIII usually d/t virus
b. CF = acute vertigo, N/V, nystagmus, gait instability
c. Absence of visual input, when pt closes his eyes, commonly worsens peripheral vertigo
d. Pts commonly don’t have hearing loss unless there is concomitant involvement of auditory portion of CN VIII
(labyrinthitis)
e. Tx – self-limited, glucocorticoid taper may hasten recovery, antiemetics & vertigo meds may reduce severity of Sx
f. Other answers:
i. Basilar migraine refers to HA that begins w/ brainstem aura (Sx such as vertigo, incoordination, tinnitus, hearing
loss, diplopia, or dysarthria) lasting few mins to hour & followed by occipital HA
ii. Brainstem hemorrhage may cause locked in syndrome (pontine) or Wallenberg syndrome (lateral medullary)
1. Wallenberg presents w/ vertigo, nystagmus and ipsilateral ataxia along w/ ipsilateral Horner syndrome,
facial numbness, taste loss, dysarthria, dysphagia, and/or pain & temp sensation deficits in contralateral
body
iii. Cerebellar infarction may lead to gait ataxia, nystagmus, dizziness, limb dysmetria or dysarthria
1. Pts typically unable to walk unsupported
iv. Meniere disease is vestibular dysfunction & sensorineural hearing loss that results from pressure accumulation in
endolymph of inner ear
1. CF = episodic vertigo, hearing loss, tinnitus
, 3
NBME 9 Step 2 Notes
2. Dx = Clinical, audiometry (sensorineural loss), weber (unilateral loss leads to lateralization of BC of a
midline stimulus to unaffected ear); Rinne (greater AC than BC in affected ear)
3. Tx = lifestyle (avoid salt, nicotine, alcohol, stress); antihistamine meds (meclizine, promethazine);
methylprednisolone (for refractory dz)
4. Sx will be episodic including hearing loss unlike Vestibular neuronitis
12. Acne vulgaris
a. Comedone, hair follicle that has been blocked by keratin debris
b. Inciting even is hyperproliferation of epidermis & abnormal keratinization
c. Topical retinoid (vitamin A analogs) therapy is 1 st line
i. They normalize keratinization
ii. Used as preventative therapy rather than to tx preexisting lesions
d. Other answers:
i. Bactericidal soap is sometimes used as adjuvant to topical retinoid
ii. OCP or IM medroxyprogesterone may help when there is hormonal component (cyclical flaring of acne; more on
lower face, jawline, chin)
iii. Intralesional corticosteroid therapy can be used if inflamed & painful lesion but risk of atrophy &
dyspigmentation
13. Juvenile rheumatoid arthritis
a. <16 yrs. Old
b. Joint pain & inflammation
c. Extraarticular features: uveitis, lymphadenopathy, rash
d. Sub categories:
i. Oligoarticular - <5 joints (large joints like knee) & ANA +ve
ii. Polyarticular - >5 joints (both large & small joints) & ANA -ve
iii. Systemic – aka Juvenile onset Still disease, variable joint involved, rash, quotidian fever, serositis
e. JIA associated uveitis is MC in female kids w/ oligoarthritic
i. w/out typical signs of uveitis so gets detected late
ii. leads to complications such as cataract, glaucoma, amblyopia, and permanent vision loss
iii. Dx – Slit lamp exam
f. Tx: NSAID, DMARD (ex – Methotrexate) & biologic agents
14. Primary bone malignancy vs metastasis
a. In adults, presence of destructive bone lesion is more commonly metastatic
b. Adenocarcinoma of lung is MC primary lung cancer and MC in nonsmokers in periphery
c. Other cancer that metastasize to bone: breast, thyroid, kidney, prostate
15. Osteonecrosis of femoral head
a. From impaired vascular supply to bone w/ painful degeneration & loss of structural integrity over time
b. Can be d/t direct injury to blood vessel, compression by extrinsic structures or inflammation, venous occlusion or
thromboembolism
c. Associated w/ trauma (fractures/dislocations), alcohol use disorder, systemic corticosteroid use, sickle cell disease,
bisphosphonate therapy & Gaucher disease
d. Dx – x ray or MRI (gold standard)
e. Tx – consult Ortho & PT
16. Stable supraventricular tachycardia
a. Regular, narrow-complex w/out evidence of hypotension or impaired systemic perfusion
b. Tx: Vagal maneuvers, IV adenosine, metoprolol, or CCB used first (these are AV nodal blocking agents)
c. Other answers:
i. Amiodarone tx both ventricular, SVTs and may be used for refractory arrhythmias
ii. Digoxin is for chronic mgmt. of some supraventricular tachyarrhythmias esp if there is a component of heart
failure
iii. Electrical cardioversion – indicated if pt is unstable (hypotension, AMS, angina, respiratory distress)
iv. Pacemaker – used for symptomatic bradycardia, sinus node dysfunction, AV nodal blocks
17. Aortic stenosis
a. d/t fibrosis and calcification
b. severe AS – fatigue, SOB, cough, diminished exercise tolerance, angina, syncope w/ exertion
c. PE – crescendo-decrescendo systolic murmur (heard best at upper right sternal border w/ radiation to carotids), pulsus
parvus et tardus (weak & delayed)
d. Leads to LVH & HF
