Usmle step 1 Crosswords

CrossWards

USMLE Step 2 Board Review

Anthony J. Viera, MD, MPH Associate Professor Department of Family Medicine University of North Carolina at Chapel Hill Chapel Hill, North Carolina

Matthew A. Sutton, MD Family Medicine Physician Winslow Indian Health Care Center Winslow, Arizona

Acquisitions Editor: Susan Rhyner Product Manager: Catherine Noonan Production Project Manager: Alicia Jackson Marketing Manager: Joy Fisher-Williams Designer: Stephen Druding Compositor: Aptara, Inc.

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DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the healthcare provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.

Puzzled by USMLE preparation or your latest rotation? Tired of the same old boring review? Welcome to CrossWardsTM! We hope you will find these puzzles a more engaging way to review your medical knowledge as you prepare for examinations, ward rotations, or just want to have a fun way to study. Contributors to this edition of CrossWardsTM Step 2: Meredith Gilliam was a medical student at the University of North Carolina at Chapel Hill School of Medicine at the time of contribution, now a resident in internal medicine at the University of Michigan. Look for CrossWardsTM Step 1 and other future editions of CrossWardsTM. Do YOU want to contribute to an upcoming edition of CrossWardsTM? Send your puzzle clues, solutions, and “extra info” in an Excel or Word table (or a Clinical Scramble as a Word file) to: crosswards.submit@ gmail.com. We’d also love to receive your other ideas for puzzles! Include your name, address, and current position/medical school. We will let you know if your puzzle is selected for inclusion in an upcoming edition.

PUZZLES 1.

Loosen Up with Some Medical Eponyms

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Cross My Heart

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Put Some Skin in the Game

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Lytes Out!

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Immune to Myself?

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I’m “Gland” You’re Doing This Puzzle

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Abdominal Pains

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Clinical Scramble

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This Confounded Puzzle!

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GI Feel Terrible

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Nerve-racking Puzzle

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One More . . . For Old Timer’s Sake

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This Puzzle May Cause Petechiae

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A Borderline Puzzle

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This Puzzle is Infectious

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The Heart of Pharmacology

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17.

An Ounce of Prevention

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Puz-culoskeletal

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Catching My Breath

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Are You Smarter than a First-year?

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Not Just Little Adults

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Renal & Lytes

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Surgery Rounds

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iv

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Just for Fun—Movie Docs

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I Got Rhythm . . .

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Clinical Scramble

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Birth of a Puzzle

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Labor Pains

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A pHuzzle

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Onco-Logical

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Clear to Auscultation?

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Some Lovers Try . . . This Puzzle

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Doc, I Think It’s My Hormones

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This Puzzle is Giving Me Gas

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BuzzWards

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A Trich Puzzle

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Widow Maker

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Don’t Mess Around with the Pancreas

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Most Common . . .

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Clinical Scramble

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BrainTeaser

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This Puzzle is Kidstuff

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This Puzzle Might Cause Extrapyramidal Symptoms

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Claiming the Inheritance

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CN 2-12 Intact?

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This Puzzle DeLivers

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I Need a Puzzle—Stat!

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Shock and Awe

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Doc Says “I’ve got good news and bad news”

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Step 2 Potpourri

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CrossWard Solutions (with a little extra info!) begin on page 102. v

CrossWards™

Loosen Up with Some Medical Eponyms

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3 - Nodules or macules on palms or soles seen in endocarditis: lesions 5 - When standing on one leg unable to lift opposite side of pelvis: sign 7 - To detect eosinophils in urine, ask for stain a 9 - One of the tests for meniscal tear 13 - Failure of third and fourth pharyngeal pouches to differentiate: syndrome score: Five parameters 15 assessed at birth 17 - When rubbing sole of foot in upper motor neuron lesion, great toe goes up and other toes fan out: sign 18 - BPV treatment maneuver 19 - Deep palpation of LLQ provokes pain in RLQ in appendicitis: sign 21 - Necrotizing infection of genital fascia: gangrene 22 - In hypocalcemia, tapping over facial nerve causes facial twitch: sign

1 - People being watched (studied) behave differently: effect 2 - Dermatology lines body dementia 46 - Free Ig light chains seen in plasma cell dyscrasias: proteins 8 - Flexing the neck causes flexion of the hips/knees in meningitis: sign 10 - Primary adrenal insufficiency: disease 11 - For distinguishing transudative from exudative pleural effusion: criteria 12 - Carpal tunnel test in which wrists are flexed for a minute 14 - Vascular tumor associated with HHVsarcoma 8: 16 - Most common cause of mild unconjugated hyperbilirubinemia: syndrome 20 - Distended neck veins, distant heart triad sounds, low BP:

Solutions on page 103.

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Cross My Heart

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Across: 2 - Harsh systolic murmur radiating to stenosis carotids: 5 - Medical term for “done fell out” (sudden, temporary loss of consciousness) 7 - Heart rate less than 60 bpm 10 - Most common cause of sudden cardiac death in athletes (acronym) 11 - ACE inhibitors are the referred antihypertensive drug class in patients with and proteinuria 12 - ACE inhibitors can cause this nagging adverse effect, which would be a reason to change to an ARB 13 - Most common cause of secondary hypertension in children: parenchymal disease 16 - Cause of secondary hypertension characterized by unprovoked hypokalemia: Hyper 17 - A mobile, pedunculated mass in the left atrium is likely an atrial 18 - JVD, low BP, and distant heart sounds until is acute cardiac proven otherwise 23 - Stasis, hypercoagulability, and injury set a person up for a deep venous 24 - Drug that inhibits Na+/K+−ATPase and increases cardiac contractility 25 - On EKG: Left axis deviation has QRS in lead II 30 - Severe stenosis of the left main coronary artery is an indication for this surgery (acronym) 31 - First-line antihypertensive medication diuretics class: 34 - A hypertensive emergency with sudden chest pain radiating to the back suggests aortic 35 - Chest pain that is new onset or that is getting worse is deemed angina 36 - On examination of the patient in #20 down you might hear a pericardial (two words) 37 - Aortic regurgitation has a murmur

Solutions on page 105.

Down: 1 - A sign of #10 across is a systolic in murmur that intensity with standing 3 - Breathlessness with lying flat 4 - Most common cause of myocarditis disease in the world: 6 - Protein that is elevated for several days after a myocardial infarction 8 - If you hear a gallop when listening to the heart, do not think horses, but think this (acronym) 9 - Screen men aged 65 to 75 who have ever smoked for abdominal aortic 13 - Most common cause of mitral valve fever stenosis: 14 - Patients with atrial fibrillation can to be treated with reduce risk of stroke 15 - ST segment depression suggests this 19 - Part of the postmyocardial infarction “recipe” 20 - Diffuse ST segment elevation on an EKG of a patient with chest pain that is worse with lying down suggests acute is one of the 21 - Aortic cardiac causes of #5 across, mostly in the elderly 22 - Treat symptomatic heart failure with diuretic a 26 - Q waves, that are two small boxes wide or more than one-third the QRS amplitude suggest myocardial 27 - Evaluate heart failure with an echocardiogram to estimate left fraction ventricular 28 - Most common type of cardiomyopathy 29 - A chest x-ray of the patient in #9 down may show a mediastinum 32 - Midsystolic murmur with a “click”: valve prolapse 33 - When the QRS is widened, there is branch some sort of block

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Put Some Skin in the Game

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1 - These “stuck-on” brownish wart-like lesions are very common and are benign: Seborrheic 4 - Herald patch heralds this dermatitis: rosea 5 - Flat skin lesion >1 cm 9 - Another name for atopic dermatitis 10 - Tender, erythematous nodules on lower legs usually triggered by an illness or drug reaction: Erythema 13 - Medical term for hives 14 - Elevated skin lesion 1,000), not enough oxygen to the liver 24 - Name the disease: Young adult with liver disease and neuropsychiatric symptoms greater than or equal 25 - A to 1.1 suggests portal hypertension (acronym)

1 - This treatment may be indicated for severe alcoholic hepatitis 2 - Presence of this antibody may be only clue to recent hepatitis B infection during the “window period” antibody, associated 3 - Anti with #18 across 6 - Rising cause of cirrhosis, associated with obesity and diabetes (two words) 7 - Name the disease: Bronze skin, diabetes, increase iron saturation 9 - Found to be low in patients with #24 across 11 - GI disorder often concomitant with #17 down (two words) 12 - The treatment for #7 down 15 - Cause of severe hepatitis (>1,000) cholangitis: 17 - Primary Disease affecting mostly young men cirrhosis: 18 - Primary Autoimmune cause of cirrhosis affecting middle-aged women 22 - Presence of this antibody indicates prior exposure to hepatitis B or vaccination

Solutions on page 193.

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I Need a Puzzle–Stat!

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1 - Measurement of this value is necessary to diagnose carbon monoxide poisoning as the pulse oximeter reading will be normal 5 - Use of this drug is indicated for symptomatic bradycardia 6 - Carotid massage, Valsalva, and cool pack to the face are examples of maneuvers 9 - Name the antidote: Benzodiazepines 11 - The presence of muscle rigidity, hyperthermia, and autonomic disability may be an adverse effect of this class of medications 14 - Name the antidote: Methanol 15 - Diltiazem slows conduction through the AV node, which may improve rate control in a stable patient with this tachyarrhythmia (short form) 17 - Name the antidote: Anticholinergics 19 - Name the antidote: Organophosphate poisoning 21 - Withdrawal syndrome: Tremor, tachycardia, hypertension, agitation, hallucinations, seizures 24 - Withdrawal syndrome: Anxiety, nausea, diarrhea, abdominal cramping, mydriasis 25 - The presence of this lesion differentiates a second-degree from firstdegree burn 26 - Name the antidote: Opioids 27 - Use of this antiarrhythmic should be considered for patients with refractory VT/VF arrest 28 - In addition to defibrillation, torsades de pointes should be rapidly treated with 29 - ACE inhibitors may cause this rare but life-threatening side effect

2 - A female patient with abdominal until proven pain is otherwise 3 - Name the antidote: Methemoglobin 4 - In addition to antihistamines, this drug should be given to all patients with anaphylaxis 6 - Name the antidote: Warfarin 7 - The presence of this finding, often seen on an upright chest x-ray, is an immediate indication for exploratory laparotomy (two words) 8 - Name the antidote: Beta-blocker 10 - This intervention should be performed without delay in patients with pulseless ventricular tachycardia/ fibrillation arrest, once rhythm is identified 12 - For any unstable patient with a brady- or tachyarrhythmia, the first intervention should be 13 - The use of epinephrine in a code is directed at increasing perfusion 15 - The use of this drug may be necessary to terminate an episode of supraventricular tachycardia 16 - The most definitive noninvasive diagnostic test for appendicitis 17 - Third-degree burns are characterized by full involvement of the dermis and are painless/painful 18 - Name the antidote: Malignant hyperthermia is indicated 20 - The use of in patients with VT/VF pulseless arrest who do not respond to defibrillation 22 - Name the antidote: Black widow spider 23 - Name the antidote: Heparin

Solutions on page 195.

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Shock and Awe

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Across: 3 - Peripheral vascular resistance is (increased/decreased) in #2 down 5 - Core body temperature 1 cm PATCH 9 - Another name for atopic dermatitis ECZEMA. Very common; treat with topical steroids. 10 - Tender, erythematous nodules on lower legs usually triggered by an illness or drug reaction: Erythema NODOSUM 13 - Medical term for hives URTICARIA. Very itchy. 14 - Elevated skin lesion two-thirds the upper limit of normal serum LDH (Light’s criteria). 8 - Unlike garden variety community-acquired pneumonia, coverage of this class of bugs should be considered when treating aspiration pneumonia ANAEROBES. Addition of clindamycin or metronidazole may be appropriate. 9 - A normal D-DIMER may rule out DVT/PE if your clinical suspicion is low 11 - Your patient with unilateral upper extremity weakness and Horner syndrome may have a PANCOAST tumor Apical lung cancer that may invade the brachial plexus and sympathetic chain. 12 - A METHACHOLINE challenge may be administered to the suspected asthmatic with normal PFTs Promotes bronchospasm in the susceptible patient. Many asthmatics have normal PFTs when not in an exacerbation, unlike COPD. 13 - In addition to increasing the fraction of inspired oxygen, this ventilator parameter may be increased to improve oxygenation (acronym) PEEP. Positive end-expiratory pressure. Prevents collapse of alveoli at the end of exhalation improving gas exchange. 14 - “All that wheezes is not ASTHMA” A useful axiom, though most of what wheezes is asthma. 17 - This first line therapy for #3 down speeds resolution OXYGEN 18 - Occurring in outbreaks, this pulmonary infection is making a comeback in part due to decreasing rates of immunization PERTUSSIS 20 - A solitary pulmonary nodule that is unchanged for over 2 years is likely BENIGN

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Some Lovers Try . . . This Puzzle

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P S T E NO S S A C H I L L E X I L L A R Y

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MC L A V F I A F A S C T S N L E F T H E MR I E B F R O S T E R I OR L H O A I S R A D I S U E S P T I B I A I C

L O S T E I O S NA R S C O M I A

P E N F E T OM Y U R R

C A P HO I D I P P R L O F L NA L C O L X A D C B U R S I T I S P N

Across: 1 - In addition to #23 across and the medial meniscus, this structure is often coinjured as part of the “unhappy triad” (acronym) MCL. Medial collateral ligament. 3 - Antibiotics are always indicated in this type of fracture OPEN. Infection risk is high. 6 - This gruesome intervention may be limb saving in patients with a painful swollen limb and paresthesias, pulselessness, paralysis, and poikilothermia FASCIOTOMY. The “P’s” of compartment syndrome are well known. Poikilothermia is loss of normal temperature regulation. 8 - A patient who develops hand pain and numbness after holding the wrist in forced flexion for 60 seconds may have this (acronym) CTS. Carpal tunnel syndrome. Compression of the median nerve as it travels through the wrist. The sign described is called Phalen sign. 10 - Atrophy of this group of muscles is a late sign of #8 across THENAR. The thenar muscles are innervated by the median nerve. The hypothenars by the ulnar. 11 - What study should be ordered in a patient with new onset back pain and urinary incontinence? (acronym) MRI. This may be a case of cauda equina syndrome, a neurosurgical emergency. 13 - Fracture of this bone should be suspected in a patient with snuff box tenderness SCAPHOID. Even if the x-ray is negative, treat presumptively for fracture. X-ray may take 2 weeks to show fracture. Avascular necrosis is a complication. 15 - Most common type of hip dislocation POSTERIOR. May occur when a knee hits the dashboard. 17 - An old man with leg pain that gets better when leaned forward or walking uphill: Spinal STENOSIS This is called neurogenic claudication. Flexion of the spine opens the spinal canal and relieves nerve root compression. 19 - Your roommate was out drinking on Saturday night and awoke on Sunday with a wrist drop. He has injured the RADIAL nerve Aka “Saturday night palsy.” The mechanism usually involves passing out with the humerus in an awkward position compressing the radial nerve. Most cases resolve in time. 20 - Your patient with an L5–S1 disc herniation may have a diminished ACHILLES reflex Herniation at that level typically affects the spinal nerve root one level below. 22 - A person defending himself from an attack may end up with a fracture of this bone ULNA. A “nightstick” fracture, which may occur when placing one’s arm in the path of a swung blunt object. 24 - The tubercle of this long bone may be painful in growing boys TIBIA. Known as Osgood–Schlatter syndrome. This is benign and resolves spontaneously. 26 - Your patient with a large painful swollen mass on their elbow may have olecranon BURSITIS Often occurs with repetitive trauma. May be infected, or not.

Down: 2 - Most commonly fractured long bone CLAVICLE 3 - Radiographic new bone formation in a sunburst pattern is a sign of this devastating tumor OSTEOSARCOMA 4 - An obese adolescent male with knee pain and limp may have epiphyseal displacement on this bone FEMUR. Slipped capital femoral epiphysis is separation of the femoral head along the growth plate. Often the pain is referred to the knee. 5 - A patient with a femur fracture suddenly develops SOB, rash, DIC, and cardiovascular collapse (two words) FAT EMBOLI 7 - Most common type of shoulder dislocation ANTERIOR 9 - Mike Tyson presents with hand pain after a match. He has fractured his FIFTH metacarpal 12 - A 15-year-old track athlete ruptures her Achilles tendon while being treated for a UTI with CIPROFLOXACIN Fluoroquinolones are known to cause tendon rupture. 14 - A first born, female, newborn delivered in breech presentation is at high risk for dysplasia of this joint HIP. Disease is known as developmental dysplasia of the hip or congenital hip dysplasia. All newborns are screened by physical examination maneuvers at every well visit in the first year of life. Failure to diagnose and treat results in early onset of osteoarthritis and early disability. 16 - Falling on outstretched hand most likely results in fracture of this bone RADIUS 18 - Hormone level that should be checked in #4 down TSH. Thyroid-stimulating hormone. Hypothyroidism is an associated condition. 20 - The AXILLARY artery and nerve may be injured in #7 down 21 - SEPTIC arthritis: Must be ruled out in any patient with a red, hot joint 23 - What ligament is injured in a patient with excess laxity on anterior translation of the tibia? (acronym) ACL. Anterior cruciate ligament. A positive anterior drawer test is described. 25 - The finger joint most commonly involved in osteoarthritis (acronym) DIP. The PIP is more commonly affected in rheumatoid arthritis.

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Doc, I Think It’s My Hormones

P R O P Y L T R H R E NA L I I O U U H R Y A P C O I G G L L Y C E T OA C I M I L A NA P L A C I T S I P C R E A O C I NS U D OC T R S C E I NH I S

A P I L L A R Y OT A S S I UM S C OR E M NS U F F I C I E NC Y O N N I N N NT I T P O G M D OP AM I NE S C E T A R G I NE O T H L C F I L C O M T A U R A D OS I S S M Z I I O N L S T I C E S K B HY P E R C A L C E M I A T I T N I N O T A N H B E I L L I N S U O M C E OT I D E K E B I T OR S R

Across: 1 - Most common type of thyroid carcinoma PAPILLARY. And a highly favorable prognosis. Five-year survival >95%. 2 - A patient in diabetic ketoacidosis is always total body deficient in this electrolyte (regardless of serum level) POTASSIUM. In fact these patients are usually hyperkalemic due to intracellular shifts due to lack of insulin and acidosis. 3 - Osteoporosis is defined by a T-SCORE of –2.5 or lower on DEXA scanning The T-score is the number of standard deviations below the mean for a healthy young adult. 7 - Hyponatremia and hyperkalemia should always prompt consideration of this life-threatening problem ADRENAL INSUFFICIENCY. Especially in a patient on chronic exogenous steroids. 9 - Intermediate-acting insulin, usually dosed twice daily NPH. May also provide basal coverage, though not technically peakless. 11 - Rarely checked, but often elevated antibody in Hashimoto thyroiditis ANTI-TPO. Thyroid peroxidase. 13 - Agonists to this neurotransmitter are first-line therapy for prolactinoma DOPAMINE. Bromocriptine for example. 16 - Long-acting insulin without a peak GLARGINE. Used to provide basal insulin. 18 - Classically, only Type 1 diabetes mellitus presents with this life-threatening disorder KETOACIDOSIS. Insufficient insulin causes cells to switch to fat as energy source, producing ketoacids as a byproduct. 20 - Most aggressive and rapidly fatal thyroid carcinoma ANAPLASTIC. Five-year survival rate is 5% to 10%. 25 - “Stones, bones, groans, and psychiatric overtones” may represent this electrolyte disturbance HYPERCALCEMIA 27 - The first step in evaluation of suspected hyperaldosteronism is measurement of the plasma RENIN: Aldosterone ratio 28 - Type 1 diabetics will always require therapy with this at all stages of their disease INSULIN. Unlike Type 2 diabetics who may remain insulin independent for many years/life. 29 - This drug, more commonly used in variceal upper GI bleeding, is also used to treat acromegaly OCTREOTIDE. A somatostatin analog that lowers portal venous pressure. 30 - Use of this drug class in diabetes has been shown to decrease progression of nephropathy ACE INHIBITORS. And is generally recommended for secondary prevention of renal disease in diabetics.

Down: 1 - Antithyroid drug preferred for treating hyperthyroidism in pregnancy PROPYLTHIOURACIL 4 - This treatment is by far and away the most important initial treatment for hypercalcemia SALINE. By IV infusion. 5 - This test along with a thyroid scan can help differentiate Graves disease from thyroiditis (acronym) RAIU. Radioactive iodine uptake. Elevated uptake is indicative of a hypermetabolic gland (Graves) whereas decreased uptake indicates gland destruction (thyroiditis). 6 - Hemorrhagic necrosis of the adrenal gland may occur after infection with this bacteria MENINGOCOCCUS. Aka, Neisseria meningitidis. 8 - This syndrome should always be suspected in a patient with hypertension and hypokalemia CONN. Primary hyperaldosteronism. 10 - Adverse effect of nearly all antiglycemic agents except metformin HYPOGLYCEMIA 12 - Antithyroid drug preferred in absence of pregnancy METHIMAZOLE 14 - In the absence of contraindications, this drug is the absolute first-line therapy for Type 2 diabetes METFORMIN 15 - The clinical finding of bitemporal hemianopsia would prompt one to order MRI of this structure SELLA. Tumors of the pituitary gland may encroach upon the optic chiasm and cause this clinical presentation. 17 - Presence of this antibody is highly specific for Graves disease (acronym) TSI. Thyroid-stimulating immunoglobulin. Antibody binds to the TSH receptor, causing unregulated production of thyroid hormone. 19 - Rare but serious side effect of metformin LACTIC ACIDOSIS. A Type B lactic acidosis, where there is no tissue ischemia. 21 - Fastest acting insulin LISPRO. Used for prandial coverage. 22 - Best screening test for assessing thyroid function (acronym) TSH. Thyroid-stimulating hormone. A normal TSH excludes thyroid dysfunction, regardless of T3 or T4 levels. 23 - Insulin therapy in diabetic ketoacidosis is directed at lowering (glucose/ketones) KETONES. The primary problem in DKA is insulin deficiency and the resultant acidosis that results from using fats rather than glucose as an energy source. Hyperglycemia is merely a sign of the problem, but not the problem itself. 24 - A patient with positive urinary metanephrines should never been given a drug from this class alone BETA-BLOCKER. Blockade of the beta receptors in the periphery may lead to unopposed alpha adrenergic activity and severe vasoconstriction and hypertension. A similar effect may occur in a patient with cocaine on board. 26 - Psychotropic drug often implicated in nephrogenic diabetes insipidus LITHIUM

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This Puzzle is Giving Me Gas Meredith Gilliam

N E U R

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C H O L E C Y S T O K I N I N

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H A L C R E S T S V T E R I M X H E I V E R T I C S P O F A L C I F T L E R OT ON I D P U R E NOC A R C D M T R E S I A N D A E L

V I A D T D E NA L A L L L OU S I N E C E R U L OP

P P I H E P R Y N U L I T I S O C OR M I I O N U A S T

I NOMA N C T H E A R L N G A A A S L A S M I N T A R I J E J UNUM

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2 - Hirschsprung disease is caused by failure of this embryologic population of cells to migrate to the rectum (two words) NEURAL CREST 4 - This class of drugs works by irreversibly inhibiting H+/K+-ATPase in stomach cells (acronym) PPI. Proton pump inhibitor(s). 10 - Most likely diagnosis in an older patient with LLQ pain, fever, and leukocytosis DIVERTICULITIS 11 - Most likely cause of an acute bowel obstruction in a patient who has had multiple abdominal surgeries ADHESION(S) 12 - This ligament attaching the liver to the anterior abdominal wall is a derivative of the fetal umbilical vein FALCIFORM 13 - Autoantibodies against this glycoprotein found in wheat are present in 80% of patients with celiac disease GLIADIN. Treatment is a gluten-free diet. 14 - The flushing, diarrhea, and right-sided heart murmurs associated with carcinoid tumors result from abnormal production of SEROTONIN Carcinoid tumors originate from endocrine cells and are mostly found in the small intestine. 15 - This liver enzyme may be disproportionately increased (relative to others) in patients with alcoholic hepatitis (acronym) AST. Aspartate transaminase. In alcoholic hepatitis the ratio of AST to ALT is often >1.5. 17 - Glandular metaplasia in the distal esophagus may transform into this histological type of carcinoma ADENOCARCINOMA. This precursor condition is Barrett esophagus. 20 - Bilious vomiting in a neonate and a “double bubble” on abdominal imaging is concerning for this congenital abnormality (two words) DUODENAL ATRESIA. About a fourth of infants with this or stenosis have Down syndrome. 21 - Of the histological types of adenomatous colon polyps, VILLOUS adenomas most likely to become malignant 23 - Check the level of this protein in patients with cirrhosis, corneal deposits, and parkinsonian symptoms CERULOPLASMIN. Wilson disease. 24 - Pathology in this part of the gut may limit the body’s absorption of folate JEJUNUM

1 - An immunocompromised patient with odynophagia and “volcano-like” ulcers in his esophagus may be infected with this pathogen (acronym) HSV. Herpes simplex virus. 3 - Patients with severe liver failure may present with this coarse hand tremor ASTERIXIS. “Liver flap.” 5 - Autoimmune destruction of the stomach’s parietal cells may result in this type of anemia PERNICIOUS 6 - Nearly all patients with duodenal ulcers are infected with this organism (shorten the genus to an initial) H. PYLORI 7 - This prokinetic agent may relieve the symptoms of gastroparesis by antagonizing dopamine receptors METOCLOPRAMIDE 8 - A surgeon may insert a finger through the epiploic foramen to compress the contents of this ligament to control bleeding HEPATODUODENAL 9 - This GI hormone secreted by I cells is responsible for the pain that patients with cholelithiasis may feel after eating a fatty meal CHOLECYSTOKININ. It causes gallbladder contraction. 16 - An infant with painless rectal bleeding may have a congenital anomaly resulting from the persistence of this embryological duct VITELLINE 18 - This type of hemorrhoids are not painful because they receive visceral innervation INTERNAL 19 - A patient with progressive dysphagia and a dilated esophagus with distal stenosis on barium swallow most likely has this condition ACHALASIA. Lower esophageal sphincter fails to relax due to loss of myenteric plexus. 22 - This GI hormone is oversecreted in Zollinger-Ellison syndrome GASTRIN

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BuzzWards

I NT U S S A T R U B E L E M I C R A O S B C E A

U S C E P T I ON

M L A Y F E L L OU P HOD T M T A C R E U S R P O V E V A R I C E N A O R D G T S O I H I M N R C NE U R O F I B R O T S X L N E P H R OT I C O D I S R E O M S A I P F S MU L

170

P K S L O M E R Y B I C S A O GK I NS P E I L HA L A S I A L S A M P D A L L A A S R B K MP E T I GO S N MA T O S I S O O E S N B I S O S R R H T I F OR ME I C

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1 - Currant jelly stools INTUSSUSCEPTION. May be seen in association with Henoch-Schönlein purpura. 7 - Blueberry muffin rash RUBELLA. Congenital rubella specifically. 9 - Barking cough CROUP. Caused by parainfluenza virus very frequently (and many others). Inspiratory stridor. Treat with steroids. 11 - Reed-Sternberg cells. HODGKIN’S (lymphoma). 12 - Bird’s beak on swallow study ACHALASIA. The esophageal stricture may resemble a bird’s beak. 13 - Leftover rice B. CEREUS. “Food poisoning from rice?! You can’t B. cereus!” 16 - Machine-like murmur (acronym) PDA. Patent ductus arteriosus. Closes with NSAIDs. 18 - Dewdrop on a rose petal VARICELLA 20 - Honey-crusted lesion IMPETIGO. Caused by streptococcus or staphylococcus most commonly. Treat with topical agents first. 21 - Café-au-lait spots NEUROFIBROMATOSIS. Type 1. 23 - Maltese cross casts in urine (NEPHROTIC syndrome) Due to the presence of cholesterol esters. 25 - Honeycomb lung (acronym) IPF. Idiopathic pulmonary fibrosis. 26 - Target lesions (erythema MULTIFORME) Often due to drugs, viruses.

2 - Doughy skin (electrolyte abnormality, hyperNATREMIA) 3 - Silvery scale PSORIASIS 4 - Currant jelly sputum KLEBSIELLA. Often seen in alcoholics who aspirate. 5 - Punched-out lesion on skull film (multiple MYELOMA) Monoclonal gammopathy and Bence Jones protein in the urine. 6 - Cold agglutinins MYCOPLASMA 8 - Sawtooth wave (acronym) AFLUTTER. Atrial rate is 300, ventricular rate 150. 10 - Christmas tree rash (pityriasis ROSEA) Cause unknown, but probably viral. Initial lesion is another buzzword, the “herald patch.” 14 - Rose gardener SPOROTHRIX. Caused by a rose thorn puncture. 15 - Spaghetti and meatballs on KOH preparation (pityriasis VERSICOLOR) Due to Malassezia fungi. 16 - Cogwheel rigidity PARKINSON’S 17 - Powder burns on laparoscopy ENDOMETRIOSIS. May also see “chocolate cysts.” 18 - Clue cell (bacterial VAGINOSIS) Epithelial cells studded with bacteria. 19 - Shipyard worker ASBESTOSIS 22 - Stuck on appearance (SEBORRHEIC keratosis) A benign papule common in older age. May have “waxy” surface. 24 - Bat-wing appearance on chest x-ray (pulmonary EDEMA) Caused by the prominence of the pulmonary vasculature.

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T A M A M S E S T N E O C P T A O U M S Y E

172

A Trich Puzzle

F I B V R S O T R I C H L R D A E P C OS C A ND A S H H R ME T F O R M I P ON R C E S U P P E R OU T E C E L R R OG E N S T A MO X P T R Y E ND OME T R I S H T A A MMO G R A M G O S Y P H I L G I A L I V E R D N

H P V R E G N I D A N N C Y R I F E N OS I S V A U R A R S I S C A I N T E S

Across: 2 - Gray discharge, high pH, clue cells (acronym) BV. Bacterial vaginosis. Overgrowth of Gardnerella vaginalis. 3 - This virus is responsible for the vast majority of cervical cancer (acronym) HPV. Human papillomavirus. Subtypes 16 and 18 are particularly high risk and account for 70% of cervical cancers. 6 - Motile organism seen on saline wet mount of vaginal secretions is pathognomonic for TRICH (short form) Trichomonas vaginalis, a flagellated protozoan. 8 - What is the diagnosis in a woman who presents with amenorrhea, acne, hirsutism, and insulin resistance? (acronym) PCOS. Polycystic ovarian syndrome. The diagnosis can be made clinically without ultrasound or lab findings, though they may be obtained to support the diagnosis. 9 - Budding yeast on a KOH preparation are diagnostic for this organism CANDIDA 11 - Treatment with this drug may restore fertility to the patient in #8 across METFORMIN. In addition to treating the insulin resistance. 13 - Toxic shock syndrome commonly occurs in women with a retained TAMPON The syndrome is caused by preformed Staphylococcus aureus toxin. Patients appear septic, but blood cultures are negative. 15 - The most common breast quadrant to encounter breast cancer (two words) UPPER OUTER 17 - Hormonal contraceptive methods which contain ESTROGEN increase the risk of thromboembolic disease This includes combination OCPs, vaginal ring, contraceptive patch. 18 - Treatment with this drug is indicated in estrogen receptor–positive breast cancers TAMOXIFEN 19 - Your patient with cyclic abdominal pain and nodularity on her uterosacral ligaments has ENDOMETRIOSIS 21 - Woman with a history of migraine with AURA should be advised against estrogen-containing contraceptives They are at increased risk of stroke. 23 - This test should be offered to woman over the age of 50 for breast cancer screening MAMMOGRAM. Some authorities recommend age 40. Screening interval is every 1 to 2 years. 24 - A painless chancre followed in several weeks by a maculopapular rash SYPHILIS 26 - A patient with PID who develops RUQ pain should make you suspect involvement of this organ LIVER. PID can cause a perihepatitis with elevated LFTs. This is called Fitz–Hugh–Curtis syndrome.

Down: 1 - Common uterine tumor that is hormonally responsive FIBROID. Aka leiomyoma. Almost always benign, and may decrease in size after menopause. 4 - Most common cause of secondary amenorrhea PREGNANCY 5 - A woman who leaks urine when she coughs, laughs, or sneezes has STRESS incontinence Due to weak pelvic floor muscles. Kegel exercises often help and are first-line intervention. 7 - The only way to definitely diagnose #19 across LAPAROSCOPY 9 - You might find a “CHOCOLATE cyst” on the ovary of the patient in #19 across Endometriomas, hemorrhagic endometrial implants. 10 - Crops of vesicles that progress to painful ulcerations HERPES. HSV-2 causes most genital infections. 12 - Menstrual bleeding that is irregular in frequency METRORRHAGIA. Menorrhagia is heavy or prolonged bleeding. 14 - This prophylactic intervention is an option for women with the BRCA-1 mutation MASTECTOMY. If they are done with childbearing, may opt for bilateral oophorectomy as well. 16 - Absence of menses for at least 12 months MENOPAUSE. Average age of onset is 51. 19 - Excess of this hormone is a risk factor for endometrial cancer ESTROGEN. And thus women who are obese, who had early menarche/late menopause, few or no children are at increased risk. 20 - OCP use is protective against OVARIAN cancer Suppression of ovulation is thought to be the mechanism. 22 - A cause of increased abdominal girth in patient with ovarian cancer ASCITES. Usually indicates peritoneal metastasis. 25 - Purulent cervical discharge and cervical motion tenderness (acronym) PID. Pelvic inflammatory disease. Often polymicrobial, gonorrhea or chlamydia, is implicated in 2/3 of cases.

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Widow Maker

H W B P E R I C A R D W F S U R C A H T N I M S MOK I NG E N T P R T A I L C S T E N O S A U I S

174

S T R E P M Y P OV OL E M K D I T I S L C N O G QWA R C T A B I A G T L E F T MA I V O T A MP ON S P T I R C A R D I OG I C N E U R O S R E U S P I D M

B N P A I C T E R V E M I A I V E G A D E T A T E N I C O G E N I C N

Across: 1 - The genus most commonly implicated in subacute endocarditis (short form) STREP. Usually viridans streptococci, enterococci. 2 - Levels of this peptide are virtually always elevated in decompensated CHF (acronym) BNP. B-type natriuretic peptide. And, thus, a normal BNP value has a high negative predictive value. 3 - A hypotensive patient severe burns may be in HYPOVOLEMIC shock 7 - Chest pain relieved by leaning forward may be a clue to this diagnosis PERICARDITIS. EKG will show diffuse ST elevations and PR depression. 10 - Prior myocardial infarct may be suggested by the finding of this on EKG Q WAVE. Acute and subacute MIs may have Q waves as well, but often with concomitant ST segment and T wave changes, that often resolve over time. 11 - A widened pulse pressure may suggest this valvular disease (acronym) AI. Aortic insufficiency. A regurgitant aortic valve causes a low diastolic blood pressure. 12 - Cardiac risk factor: Most prevalent of all (acronym) HTN. Hypertension is the most common chronic disease in the United States. 13 - Perform this test to diagnose peripheral vascular disease (acronym) ABI. Ankle-brachial index. Performed by measuring the ratio of systolic blood pressure at the ankle to the arm. 16 - Cardiac risk factor: Most potent of all SMOKING. Smoking is the single greatest risk factor for coronary disease. Quitting smoking halves your risk. 17 - Occlusion of this coronary artery is often fatal (two words) LEFT MAIN. Earning its nickname, “the widow maker.” 19 - Electrical alternans, a phenomenon where every other QRS has a different morphology and direction, may be a clue to this diagnosis TAMPONADE. The finding is not sensitive, as many cases of tamponade have normal EKGs. 22 - A hypotensive patient with elevated JVP and pulmonary rales may be in CARDIOGENIC shock 23 - A hypotensive patient who is bradycardic with head trauma may be in NEUROGENIC shock 24 - The organism most commonly implicated in acute endocarditis (initial the genus) S. AUREUS 25 - Cardiac risk factor: Some consider it a “disease equivalent” DM. Diabetes mellitus (type I and II) is a potent risk factor, and some consider it to be the equivalent of having coronary artery disease.

Down: 1 - Most useful intervention in the treatment of PVD is the cessation of SMOKING 2 - Duke major criteria (1 of 2) BACTEREMIA. Must be sustained, and with an organism known to cause endocarditis. 4 - Cardiac risk factor: Most easily treated (acronym) LDL. Elevations in LDL are associated with increased cardiovascular risk and respond extremely well to therapy with statins. 5 - The finding of a delta wave on EKG is suggestive of this syndrome (acronym) WPW. Wolff-Parkinson-White. Accessory pathway that may cause paroxysmal tachycardia. The delta wave is a “slurred upstroke” going into the QRS. 6 - The triad of butt claudication, impotence, and decreased femoral pulses may be due to occlusion of the aorta near the BIFURCATION This is called Leriche syndrome. 8 - Harsh systolic murmur that radiates to the carotids (acronym) AS. Aortic stenosis. Often described as having a crescendo–decrescendo quality. 9 - Turner syndrome may be associated with this disease of the aorta COARCTATION 13 - Cardiac risk factor: It is lower in men AGE. Age over 45 in men, over 55 in women. 14 - A low-pitch diastolic murmur, loudest at the apex, with an opening snap (two words) MITRAL STENOSIS. Rheumatic fever is the most common cause. 15 - Duke major criteria (2 of 2) VEGETATION. Often must be visualized on transesophageal echo. 16 - A hypotensive patient with fever, elevated WBC with a left shift may be in SEPTIC shock 18 - A young woman with palpitations and atypical chest pain may have this valvular condition (acronym) MVP. Mitral valve prolapse. Beta-blockers may improve symptoms. 20 - The single most powerful drug you can administer in acute coronary syndrome ASPIRIN. Provides a 50% to 70% decrease in death from MI. 21 - The valve most frequently infected in IV drug abusers TRICUSPID. Pulmonic valve involvement may occur as well.

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Don’t Mess Around with the Pancreas

C H O L ME S T G E H R E O A C A L D

C O D I V I A F R F Y C O L E C T 176

P A NC R E N E M I I D A N C S L E NA A I C O D R R D S C O R H M N C U L OU S R C P T V H E R N I A Y E L S T OOL T O E R T I C U L E D S C E T H U OMY

A S L I D I N G L ON I P I ON A D S Y E N O P H A G I A A N G I V N A

Across: 1 - The presentation of painless jaundice should always worry you for cancer of this organ PANCREAS 5 - A HIDA scan may be helpful for diagnosis gallstone disease when ultrasound is nondiagnostic (acronym) Hepatobiliary Iminodiacetic Acid scan. Radioactive tracer is taken up in the hepatocytes and excreted in the bile, outlining the biliary tree and gallbadder. Nonvisualization of the gallbladder suggests an obstruction of the cystic duct and acute cholecystitis. 8 - Dark sticky tarry stool MELENA. Suggests bleeding proximal to the ligament of Treitz. 9 - Iron deficiency anemia in an older man or postmenopausal woman is COLON cancer until proven otherwise Screen with colonoscopy. 11 - Relatively common GI cause of chronic cough (acronym) GERD. Some patients may completely lack typical heartburn symptoms. 12 - A sting from this arachnid may cause pancreatitis SCORPION. Classic pimp question. You will never see this. 16 - This unusual form of cholecystitis may occur in debilitated patients or critically ill patients ACALCULOUS. That is, there is no stone. Occurs particularly in burn victims and patients receiving parenteral nutrition. 19 - Most common cause of small bowel obstruction in children HERNIA 20 - A test performed on this bodily substance is the best way to determine the presence of current H. pylori infection STOOL. Serum testing detects antibodies which only indicates exposure. 23 - Most common cause of lower GI bleeding in older adults DIVERTICULA. Usually sudden and painless bright red bleeding. Can be life-threatening. 26 - This test should be ordered in any patient diagnosed with esophageal candidiasis HIV. The disease is rare in immunocompetent patients. 27 - This operation may be curative for ulcerative colitis COLECTOMY. Crohn disease, on the other hand, may recur after resection.

Down: 2 - Plummer-Vinson syndrome is the association of esophageal webs and ANEMIA Specifically, iron deficiency. 3 - Most common form of hiatal hernia SLIDING. Symptomatic treatment is the only intervention. The other type called a paraesophageal hernia requires surgical correction to prevent volvulus. 4 - Most common type of gallstone CHOLESTEROL. The other type is a pigment stone, usually associated with hemolytic conditions. 6 - Use of this class of over-the-counter medication is a leading cause of peptic ulcer disease (acronym) NSAIDS. Nonsteroidal anti-inflammatory drugs. 7 - Tumor marker associated with colon cancer (acronym) CEA. Carcinoembryonic antigen. Not useful as a screening test, but may be used in disease surveillance. 9 - “Skip lesions” are characteristic of this form of IBD CROHN’S. Lesions may occur in any portion of the GI tract, but are often not continuous. 10 - The more specific test for acute pancreatitis LIPASE. Amylase is sensitive, but not specific, as many other conditions may elevate amylase. 13 - Pain with swallowing ODYNOPHAGIA 14 - Most common location of pancreatic cancer HEAD. Followed by body, and then tail. 15 - MURPHY’S sign: Arrest of inspiration during deep palpation of the RUQ High specificity for acute cholecystitis. 17 - Treatment with this drug may help the symptoms of carcinoid syndrome OCTREOTIDE 18 - This type of adenoma has the highest risk of malignancy VILLOUS 21 - Common cause of antibiotic-associated diarrhea (short form) C. DIFF. Clostridium difficile. Virtually any antibiotic can cause it, but generally associated with broad spectrum beta-lactams, clindamycin. 22 - A Krukenberg tumor is a metastasis of gastric carcinoma to this organ OVARY 24 - This part of the colon is always involved in ulcerative colitis RECTUM. May or may not be involved in Crohn disease. 25 - The clinical presentation of esophageal spasm is often indistinguishable from ANGINA Diagnosis of esophageal spasm should generally not be considered before a thorough cardiac evaluation.

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D S A I N U S T A C H E

I

178

Most Common . . .

A D H B R E A S T S I F I B R OA D E NOM I N M I A B E T E S R P R OS L MON E L L A A I P A P I P D I R S L O E B L L U C A MP Y L OB A C D C R M C O E A NT E MOR R HA G E I O S N N N V HA S H I MOT A N P M S C H E M I C Y A Y L O D I V E R T I C U I

A H T A T E L A L L A R Y T T E R R I O R V S OS C D A E P C H O O L OS I S I D

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2 - Cancer in women BREAST 3 - Benign breast mass in younger women FIBROADENOMA. Frequently recur even after excision. 5 - Cause of chronic kidney disease in the United States DIABETES 7 - Cancer in men PROSTATE 9 - Cause of osteomyelitis in a sickle cell patient SALMONELLA 10 - Form of thyroid cancer PAPILLARY. Excellent prognosis. 14 - Bacterial cause of infectious diarrhea CAMPYLOBACTER. Though rarely identified. 16 - Type of shoulder dislocation ANTERIOR. Injury to axillary nerve and artery is possible. 17 - Cause of maternal mortality HEMORRHAGE (POSTPARTUM). 21 - Cause of hypothyroidism HASHIMOTO’S. And probably the most common autoimmune disease overall. 23 - Form of stroke ISCHEMIC 25 - Cause of acute lower GI bleeding in adults DIVERTICULOSIS. Usually painless bleeding, large volume, bright red or maroon blood.

1 - Cause of small bowel obstruction in adults ADHESIONS. Scarring from prior surgeries usually. 3 - Benign tumor of female reproductive system FIBROID. Aka, leiomyoma. Often decrease after menopause. 4 - Primary malignant bone tumor (acronym) MM. Multiple myeloma. Monoclonal gammopathy, Bence Jones protein, “punched-out” lesions on x-ray. 6 - Cause of death in diabetics (organ) HEART 7 - Cause of abnormal nipple discharge PAPILLOMA. Usually bloody discharge. 8 - Childhood malignancy (acronym) ALL. Acute lymphoblastic leukemia. Overall, has a generally good prognosis. 9 - EKG finding in pulmonary embolism (acronym) SINUS TACH(YCARDIA). The S1Q3T3 pattern is actually rather uncommon. 11 - Pituitary tumor PROLACTINOMA 12 - Cause of infection in burn patients PSEUDOMONAS 13 - Skin cancer (acronym) BCC. Basal cell carcinoma. Rarely metastatic (1,000) TOXIN. Aside from acetaminophen, numerous other drugs and toxins may cause fulminant liver failure. 15 - Liver injury pattern: AST:ALT = 2:1 ALCOHOL 16 - Liver injury pattern: Elevated aminotransferases, mild elevation of bilirubin, alkaline phosphatase HEPATOCELLULAR 19 - Serum marker elevated in #8 across (acronym) AFP. Alpha fetoprotein. Elevation of this marker in the setting of a liver mass and known risk factors for HCC is virtually diagnostic. Unlike most all other cancers, tissue diagnosis is not pursued, partially owing to the high bleeding risk. 20 - Cause of severe hepatitis (>1,000) ACETAMINOPHEN. A common overdose, treated with N-acetylcysteine. 21 - Cause of severe hepatitis (>1,000) VIRAL. Usually hepatitis A, but also B or C, other non-“hepatitis” viruses including EBV, CMV. 22 - Presence of this antigen indicates chronic infection with hepatitis B HBSAG. Hepatitis B surface antigen. 23 - Cause of severe hepatitis (>1,000), not enough oxygen to the liver SHOCK. Hypotension leading to hepatic ischemia and infarct. Almost always seen in the presence of other organ hypoperfusion (i.e., kidney). 24 - Name the disease: Young adult with liver disease and neuropsychiatric symptoms WILSON(’S) 25 - A SAAG greater than or equal to 1.1 suggests portal hypertension (acronym) Serum-ascites albumin gradient. Calculated by subtracting the ascites albumin level from the serum albumin level.

Down: 1 - This treatment may be indicated for severe alcoholic hepatitis STEROIDS. When the Maddrey’s discriminant function is higher than 32. 2 - Presence of this antibody may be only clue to recent hepatitis B infection during the “window period” HBCAB. Hepatitis B core antibody. HBsAg peaks and becomes undetectable before HBsAb is detectable. Thus, in this period, only the HBcAb is detectable. 3 - AntiMITOCHONDRIAL antibody, associated with #18 across 6 - Rising cause of cirrhosis, associated with obesity and diabetes (two words) FATTY LIVER. Nonalcoholic fatty liver disease (NAFLD) may progress to nonalcoholic steatohepatitis (NASH). 7 - Name the disease: Bronze skin, diabetes, increase iron saturation HEMOCHROMATOSIS. Most common genetic disorder in people of European descent. 9 - Found to be low in patients with #24 across CERULOPLASMIN. The major copper-carrying protein. Patients with Wilson disease have a defect in copper metabolism which causes copper to circulate free, unbound to ceruloplasmin. Unbound ceruloplasmin degrades rapidly. 11 - GI disorder often concomitant with #17 down (two words) ULCERATIVE COLITIS 12 - The treatment for #7 down PHLEBOTOMY 15 - Cause of severe hepatitis (>1,000) AUTOIMMUNE. Rare, but possible cause of fulminant hepatitis. 17 - Primary SCLEROSING cholangitis: Disease affecting mostly young men “Beads on a string” appearance on ERCP. 18 - Primary BILIARY cirrhosis: Autoimmune cause of cirrhosis affecting middle-aged women 22 - Presence of this antibody indicates prior exposure to hepatitis B or vaccination HBSAB. Hepatitis B surface antibody.

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I Need a Puzzle—Stat!

C A R B OX Y H E MOG L OB I N

D E F I B R I L L A T R T I O N B

E P I N E P H R I N E T H P H A O P I N N C L A E L I S T C S I U M

A NG I OE D 194

V F I R T E A E M A N T I I N R K C A NOL R Y S O S N E A L P R I Y N E R N P H R I N M E MA

A G A L G F L U P S Y C A G O N C T I GM S C OHO A N P R A L OX T A M M I A G N E E

P M A T R O P I N E E T G H N Y UMA Z E N I L N E HOT I C S N A E R B D L A F I B U D O E I N E V N E D L O R A S S N OP I O I D T N O R ON E N O L I OD A R ON E N E S I UM

Across: 1 - Measurement of this value is necessary to diagnose carbon monoxide poisoning as the pulse oximeter reading will be normal CARBOXYHEMOGLOBIN. The pulse oximeter cannot distinguish oxyhemoglobin from carboxyhemoglobin. Hence the oximeter will often read 99% to 100%. 5 - Use of this drug is indicated for symptomatic bradycardia ATROPINE. Increases adrenergic tone to the heart. 6 - Carotid massage, Valsalva, and cool pack to the face are examples of VAGAL maneuvers These may be useful to terminate an episode of SVT. 9 - Name the antidote: Benzodiazepines FLUMAZENIL 11 - The presence of muscle rigidity, hyperthermia, and autonomic disability may be an adverse effect of this class of medications ANTIPSYCHOTICS. Known as neuroleptic malignant syndrome, similar to malignant hyperthermia. Dantrolene may be an effective treatment for muscle rigidity. 14 - Name the antidote: Methanol ETHANOL. Ethanol outcompetes methanol for the alcohol dehydrogenase enzyme, preventing further degradation of methanol to formaldehyde. 15 - Diltiazem slows conduction through the AV node, which may improve rate control in a stable patient with this tachyarrhythmia (short form) AFIB. Atrial fibrillation, with rapid ventricular response. 17 - Name the antidote: Anticholinergics PHYSOSTIGMINE. A cholinesterase inhibitor. 19 - Name the antidote: Organophosphate poisoning ATROPINE. Organophosphates inhibit acetylcholinesterase, leading to unfettered acetylcholine buildup and a hyperparasympathetic state. Atropine is an acetylcholine antagonist. 21 - Withdrawal syndrome: Tremor, tachycardia, hypertension, agitation, hallucinations, seizures ALCOHOL 24 - Withdrawal syndrome: Anxiety, nausea, diarrhea, abdominal cramping, mydriasis OPIOID 25 - The presence of this lesion differentiates a second-degree from first-degree burn BLISTER 26 - Name the antidote: Opioids NALOXONE 27 - Use of this antiarrhythmic should be considered for patients with refractory VT/VF arrest AMIODARONE 28 - In addition to defibrillation, torsades de pointes should be rapidly treated with MAGNESIUM 29 - ACE inhibitors may cause this rare but lifethreatening side effect ANGIOEDEMA. Mediated by bradykinin.

Down: 2 - A female patient with abdominal pain is PREGNANT until proven otherwise 3 - Name the antidote: Methemoglobin METHYLENE BLUE 4 - In addition to antihistamines, this drug should be given to all patients with anaphylaxis EPINEPHRINE 6 - Name the antidote: Warfarin VITAMIN K 7 - The presence of this finding, often seen on an upright chest x-ray, is an immediate indication for exploratory laparotomy FREE AIR. An indication of a perforated viscus. 8 - Name the antidote: Beta-blocker GLUCAGON. Increases cAMP in the myocardium. 10 - This intervention should be performed without delay in patients with pulseless ventricular tachycardia/fibrillation arrest, once rhythm is identified DEFIBRILLATION. Unsynchronized shock. 12 - For any unstable patient with a brady- or tachyarrhythmia, the first intervention should be CARDIOVERSION Synchronized cardioversion for unstable patients (i.e., hypotension, altered mental status). 13 - The use of epinephrine in a code is directed at increasing CORONARY perfusion 15 - The use of this drug may be necessary to terminate an episode of supraventricular tachycardia ADENOSINE. A complete nodal-blocking agent. Resets the AV node, abating a nodal re-entrant tachycardia. 16 - The most definitive noninvasive diagnostic test for appendicitis CT SCAN. With oral/IV contrast. Ultrasound may be preferred in children due to concerns over radiation exposure, but cannot always reliably rule-out appendicitis. 17 - Third-degree burns are characterized by full involvement of the dermis and are painless/ painful PAINLESS. Destruction of nerve tissue leads to painless burns. 18 - Name the antidote: Malignant hyperthermia DANTROLENE 20 - The use of EPINEPHRINE is indicated in patients with VT/VF pulseless arrest who do not respond to defibrillation 22 - Name the antidote: Black widow spider CALCIUM 23 - Name the antidote: Heparin PROTAMINE

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Shock and Awe

W S E C R E A S E D D P G T OT H E R M I A C K

D C A R HY P D A I S HOC O Y E F G P M D I E D O P A M I N E B U R N S V K F D R I ON E GA T I V E I C L R B C L N I N E S R R L N M I E A NA P HY L A C T I C L A T T R C L S C A R D I A C E D I L T I A Z E M O O A T D P N S I I E O N D N E

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Down:

3 - Peripheral vascular resistance is (increased/decreased) in #2 down DECREASED 5 - Core body temperature