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
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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 contri-
bution, 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 upcom-
ing edition.
PUZZLES

1. Loosen Up with Some Medical Eponyms 2

2. Cross My Heart 4
3. Put Some Skin in the Game 6
4. Lytes Out! 8
5. Immune to Myself? 10
6. I’m “Gland” You’re Doing This Puzzle 12
7. Abdominal Pains 14
8. Clinical Scramble 16
9. This Confounded Puzzle! 18
10. GI Feel Terrible 20
11. Nerve-racking Puzzle 22
12. One More . . . For Old Timer’s Sake 24
13. This Puzzle May Cause Petechiae 26
14. A Borderline Puzzle 28
15. This Puzzle is Infectious 30
16. The Heart of Pharmacology 32
17. An Ounce of Prevention 34
18. Puz-culoskeletal 36
19. Catching My Breath 38
20. Are You Smarter than a First-year? 40
21. Not Just Little Adults 42
22. Renal & Lytes 44
23. Surgery Rounds 46

iv
24. Just for Fun—Movie Docs 48
25. I Got Rhythm . . . 50
26. Clinical Scramble 52
27. Birth of a Puzzle 54
28. Labor Pains 56
29. A pHuzzle 58
30. Onco-Logical 60
31. Clear to Auscultation? 62
32. Some Lovers Try . . . This Puzzle 64
33. Doc, I Think It’s My Hormones 66
34. This Puzzle is Giving Me Gas 68
35. BuzzWards 70
36. A Trich Puzzle 72
37. Widow Maker 74
38. Don’t Mess Around with the Pancreas 76
39. Most Common . . . 78
40. Clinical Scramble 80
41. BrainTeaser 82
42. This Puzzle is Kidstuff 84
43. This Puzzle Might Cause Extrapyramidal Symptoms 86
44. Claiming the Inheritance 88
45. CN 2-12 Intact? 90
46. This Puzzle DeLivers 92
47. I Need a Puzzle—Stat! 94
48. Shock and Awe 96
49. Doc Says “I’ve got good news and bad news” 98
50. Step 2 Potpourri 100

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

v
CrossWards™

Loosen Up with Some

1 Medical Eponyms

2 3

5 6

9 10 11

12 13

14

15 16 17

18 19

20

21

22

2
Across: Down:
3 - Nodules or macules on palms or soles 1 - People being watched (studied)
seen in endocarditis: behave differently:
lesions effect
5 - When standing on one leg unable 2 - Dermatology lines
to lift opposite side of pelvis: 4- body dementia
sign 6 - Free Ig light chains seen in plasma
7 - To detect eosinophils in urine, ask for cell dyscrasias: -
a stain proteins
9 - One of the tests for meniscal tear 8 - Flexing the neck causes flexion
13 - Failure of third and fourth pha- of the hips/knees in meningitis:
ryngeal pouches to differentiate: sign
syndrome 10 - Primary adrenal insufficiency:
15 - score: Five parameters disease
assessed at birth 11 - For distinguishing transudative
17 - When rubbing sole of foot in upper from exudative pleural effusion:
motor neuron lesion, great toe criteria
goes up and other toes fan out: 12 - Carpal tunnel test in which wrists are
sign flexed for a minute
18 - BPV treatment maneuver 14 - Vascular tumor associated with HHV-
19 - Deep palpation of LLQ provokes pain 8: sarcoma
in RLQ in appendicitis: 16 - Most common cause of mild
sign unconjugated hyperbilirubinemia:
21 - Necrotizing infection of genital fascia: syndrome
gangrene 20 - Distended neck veins, distant heart
22 - In hypocalcemia, tapping over sounds, low BP: triad
facial nerve causes facial twitch:
sign

Solutions on page 103. 3

CrossWards™

2 Cross My Heart

1 2 3 4

5 6

7 8

10

11 12

13 14

15

16

17 18 19

20

21 22

23 24

25 26 27

28 29 30

31 32

33 34

35

36

37

4
Across: Down:
2 - Harsh systolic murmur radiating to 1 - A sign of #10 across is a systolic
carotids: stenosis murmur that in
5 - Medical term for “done fell out” (sud- intensity with standing
den, temporary loss of consciousness) 3 - Breathlessness with lying flat
7 - Heart rate less than 60 bpm 4 - Most common cause of myocarditis
10 - Most common cause of sudden cardiac in the world: disease
death in athletes (acronym) 6 - Protein that is elevated for several
11 - ACE inhibitors are the referred antihy- days after a myocardial infarction
pertensive drug class in patients with 8 - If you hear a gallop when listening
and proteinuria to the heart, do not think horses, but
12 - ACE inhibitors can cause this nagging think this (acronym)
adverse effect, which would be a 9 - Screen men aged 65 to 75 who have
reason to change to an ARB ever smoked for abdominal aortic
13 - Most common cause of second-
ary hypertension in children: 13 - Most common cause of mitral valve
parenchymal disease stenosis: fever
16 - Cause of secondary hypertension 14 - Patients with atrial fibrillation can
characterized by unprovoked be treated with to
hypokalemia: Hyper reduce risk of stroke
17 - A mobile, pedunculated mass in 15 - ST segment depression suggests this
the left atrium is likely an atrial 19 - Part of the postmyocardial infarction
“recipe”
18 - JVD, low BP, and distant heart sounds 20 - Diffuse ST segment elevation on an
is acute cardiac until EKG of a patient with chest pain that
proven otherwise is worse with lying down suggests
23 - Stasis, hypercoagulability, and injury acute
set a person up for a deep venous 21 - Aortic is one of the
cardiac causes of #5 across, mostly
24 - Drug that inhibits Na+/K+−ATPase and in the elderly
increases cardiac contractility 22 - Treat symptomatic heart failure with
25 - On EKG: Left axis deviation has a diuretic
QRS in lead II 26 - Q waves, that are two small boxes
30 - Severe stenosis of the left main wide or more than one-third the
coronary artery is an indication for this QRS amplitude suggest myocardial
surgery (acronym)
31 - First-line antihypertensive medication 27 - Evaluate heart failure with an
class: diuretics echocardiogram to estimate left
34 - A hypertensive emergency with ventricular fraction
sudden chest pain radiating to the 28 - Most common type of
back suggests aortic cardiomyopathy
35 - Chest pain that is new onset or 29 - A chest x-ray of the patient in #9
that is getting worse is deemed down may show a
angina mediastinum
36 - On examination of the patient in #20 32 - Midsystolic murmur with a “click”:
down you might hear a pericardial valve prolapse
(two 33 - When the QRS is widened, there is
words) some sort of branch
37 - Aortic regurgitation has a block
murmur

Solutions on page 105. 5

CrossWards™

3 Put Some Skin in the Game

1 2

5 6

7 8

10

11 12 13

14

15

16 17

18

19

20 21

22

6
Across: Down:
1 - These “stuck-on” brownish wart-like 2 - Bleeding when a skin scale is
lesions are very common and are scraped: sign
benign: Seborrheic 3 - If you see an older gentleman with
4 - Herald patch heralds this dermatitis: rhinophyma, think this condition
rosea 6 - Type 1 hypersensitivity might be
5 - Flat skin lesion >1 cm this serious reaction
9 - Another name for atopic dermatitis 7 - Pityrosporum ovale is implicated in
10 - Tender, erythematous nodules on this dermatitis
lower legs usually triggered by 8 - Caused by Malassezia furfur:
an illness or drug reaction: Tinea
Erythema 11 - Flat skin lesion <1 cm
13 - Medical term for hives 12 - Group A streptococcal secondary
14 - Elevated skin lesion <5 mm skin infection characterized by
17 - Melanoma is staged by TNM and this honey-colored crusted lesions,
level mostly in children
18 - Small, fluid-filled lesion 15 - #2 down is seen with this inflamma-
19 - This medicine used to treat serious tory skin disease
acne is also a serious teratogen 16 - HSV-2 causes lesions here
20 - contagiosum: Caused 21 - A patient who thinks he has a spider
by poxvirus, tiny lesions with central bite more likely has a skin infection
umbilication, more common in with community-acquired form of
children this (acronym)
22 - Vesicular rash in dermatomal
distribution, common term for the
diagnosis

Solutions on page 107. 7

CrossWards™

4 Lytes Out!

1 2 3 4

8 9

10 11

12

13 14 15

16

17

18

19

20 21 22

23

24

25 26

8
Across: Down:
1 - Psychogenic polydipsia might be a 2 - Correcting #1 across too quickly
cool name for a rock band, but it can can result in central
cause this electrolyte problem myelinolysis
5 - This hormone from the C cells of 3 - Sodium minus (chloride +
the thyroid gland decreases calcium bicarbonate) =
concentration (two words)
6 - Low sodium should be corrected for 4 - “Stones, bones, moans, and groans,”
high this think this
7 - Overdose of this may cause a meta- 7 - A common cause of hyponatremia
bolic acidosis and respiratory alkalosis is a syndrome of too much of this
8 - Loss of deep tendon reflexes is an (initials)
early manifestation of this 9 - Fractional excretion of this is helpful
12 - Before jumping to conclusions on low in figuring out acute kidney injury
calcium, be sure you correct for low 10 - pH <7.4 with PCO2 <40 mm Hg
amount of this (two words)
13 - One other reason not to sniff glue is 11 - It is the P in MUDPILES
that it can cause a metabolic acidosis 14 - Hypokalemia and hypernatremia
with a anion gap found when working up the newly
15 - In severe hyperkalemia, give this first diagnosed hypertensive patient
to protect the heart suggests hyper
18 - Facial spasm brought on by tapping 16 - Diabetes is due to not
by the ear over the facial nerve when enough ADH
calcium is low: sign 17 - Twice the sodium concentration +
20 - Angiotensin-converting enzyme (glucose concentration)/18 + blood
inhibitors can cause this electrolyte urea nitrogen/2.8 gives the calculated
problem serum
23 - The concentration of this determines 19 - T waves may be flat in this electrolyte
tonicity abnormality
24 - Not enough of this in the blood can 20 - If this happens to the blood sample,
lead to Torsade de pointes the potassium may measure elevated
25 - In severe hypercalcemia, give intra- but it really is not
venous hydration and this drug to 21 - Insulin drives this electrolyte
promote calcium excretion intracellularly
26 - Parathyroid hormone (PTH) decreases 22 - Hyperventilation leads to
the resorption of this by the kidney respiratory

Solutions on page 109. 9

CrossWards™

5 Immune to Myself?

3 4

5 6

10

11

12 13 14

15

16

17

18

19

20

10
Across: Down:
5 - Anti-citrullinated protein (CCP): 1 - Anti-basement membrane:
arthritis syndrome
7 - Drug-induced lupus may have 2 - Anti-ro: syndrome
anti- antibodies 3 - Anti-ds DNA
9 - Anti-Jo 1 may point to poly- or 4 - Rheumatoid in RA
myositis 6 - Thyroid peroxidase antibodies:
10 - Anti-centromere (syndrome, disease
acronym) 8 - c-ANCA vasculitis
11 - Antibodies activating thyroid- 12 - Anti-Scl-70
stimulating hormone receptor: 14 - U1 (acronym) in
disease mixed connective tissue disease
13 - IgA 15 - Anti-nuclear antibody
15 - Anti-Sm 17 - Anti-transglutaminase:
16 - p-ANCA: Microscopic disease
18 - Islet cell antibodies:
Type 1
19 - Anti-mitochondrial antibody: Primary

20 - Anti-endomysial:
disease

Solutions on page 111. 11

CrossWards™

I’m “Gland” You’re Doing

6 This Puzzle

2 3

5 6

9 10 11

12 13

14

15 16

17

18

19

20

12
Across: Down:
1 - Useful beta-blocker to treat symp- 1 - Most common type of thyroid cancer
toms of hyperthyroidism 3 - In Type 1 diabetic patient, hyperglyce-
2 - If tapping on facial nerve elicits twitch mia early in the morning in response
of facial muscles, think low levels of to hormones counteracting overnight
this hypoglycemia: effect
5 - A classic sign of #19 across: 4 - Most common cause of #11 down:
“ hump” disease
7 - Antithyroid antibodies 6 - Hyperglycemic crisis in Type 1 diabe-
are seen in #15 across: tes mellitus: Diabetic
8 - Most causes of #14 down are due to 10 - In Type 1 diabetic patient, hyper-
the deficiency of 21- glycemia early in the morning
9 - Very common cause of euvolemic due to insulin being counteracted
hyponatremia (acronym) (by growth hormone) overnight:
12 - Autoimmune adrenal insufficiency: phenomenon
disease 11 - Low TSH with elevated free T4:
15 - Most common cause of elevated Primary
TSH with low free T4: 12 - Low K+ and high Na+ in a newly diag-
disease or thyroiditis nosed hypertensive patients suggests
17 - MEN 1: Pancreatic tumor, parathy- hyper
roid hyperplasia, and 13 - A key clinical issue in hyperosmolar
adenoma hyperglycemic state is
18 - “Stones, bones, moans, and groans,” , which is why aggressive fluid
think this: Hyper replacement (along with insulin) is
19 - Too much ACTH will lead needed
to syndrome 14 - Congenital adrenal hyperplasia leads
20 - Catecholamine-secreting tumor that to the deficiency of this
is a very rare cause of secondary 16 - Part of the treatment of nephrogenic
hypertension diabetes insipidus is
restriction

Solutions on page 113. 13

CrossWards™

7 Abdominal Pains

5 6

7 8

9 10

11

12 13

14 15

16 17

18

19

20

14
Across: Down:
3 - Most gallstones are composed 1 - Deep palpation in RUQ causes
of inspiratory halt in cholecystitis:
4 - In any patient with GI bleed, be sure sign
to have two large IV’s 2 - Free air under the diaphragm on plain
in place film: viscus
7 - Common cause of small bowel 3 - RUQ pain, jaundice, and fever
obstruction suggests this diagnosis
8 - Esophagus looks like a bird beak on 5 - Superficial tear of esophagus often
barium swallow due to excessive vomiting (two
9 - Elevated in acute pancreatitis words)
10 - One of top two causes of pancreatitis 6 - “Female, fat, forty, and fertile” are
14 - Diagnosis for patient with periumbili- classic risk factors for this
cal pain that moves to RLQ associ- 11 - #18 across seen in hemorrhagic
ated with anorexia
18 - Ecchymosis around the umbilicus: 12 - Metaplasia in distal esophagus
sign 13 - Metastasis above the left clavicle:
19 - This kind of hernia requires urgent node
surgery 15 - Abdominal pain on extension of hip
20 - Pain in RLQ on palpation of LLQ: with knee flexed: sign
sign 16 - Acute stomach ulcer in trauma and
burn victims: ulcer
17 - diverticulum is a cause
of oropharyngeal dysphagia

Solutions on page 115. 15

CrossWards™

8 Clinical Scramble

ICATHALLUNIONS

OLDEDCU DIMN

PIADRIME TONEANITT

TUACE STONE

BEERVESILR

ANSWER:

16 Solutions on page 116.

Notes

17
CrossWards™

9 This Confounded Puzzle!

3 4

6 7

8 9

10 11

12

13

14

15 16

17 18

19

18
Across: Down:
3 - 1 divided by the risk 1 - A new blood test is developed to
reduction is the NNT detect S2SFS; among 100 students
6 - Step 2 study fatigue syndrome, or with definite S2SFS by gold standard
S2SFS, occurs in 20% of medical brain scan, the new blood test is
students; a new drug reduces the positive in 80; among 100 students
incidence of S2SFS to 15%; 25% is without S2SFS by brain scan, the
the risk reduction blood test is negative in 90; 89% is
8 - Subtract the predictive the predictive value
value from 1 to get the probability a 2 - Case-control studies are particularly
patient with a negative test has the valuable when studying outcomes
disease that are
10 - A study in which we find a sample 4 - Probability that a patient without the
of students who scored really high disease has a negative test
on Step 2 examination and a sample 5 - The name for the bias in #6 down
who scored really low from a similar 6 - Students who study hard are more
population and then call them up and likely to score high on Step 2 exami-
ask if they used CrossWardsTM is a nation and may also be more likely
- study to use CrossWardsTM, a relationship
12 - A positive ratio is the that may not be random; the best
probability of a positive test result in way to eliminate this potential bias
those with the disease divided by the from a study is to the
probability of a positive test result in students who use CrossWardsTM or
those without the disease not
14 - The NNT in #6 across to prevent one 7 - In studies of screening, the bias intro-
case of S2SFS duced because a screened population
15 - Students in the study in #10 across appears to have longer survival than
who scored high on Step 2 examina- an unscreened population but really
tion may be more likely to remem- does not is called -
ber using CrossWardsTM than those bias
who scored poorly; this is a kind of 9 - A highly test when
bias negative, helps rule out a disease
17 - Proportion in a population who 11 - Proportion in a population who have
develop a disease or outcome over a disease or outcome at a specific
a period of time (e.g., over the next time (e.g., now)
year) 13 - Participants in a study may drop out
19 - Probability that a patient positive for of one group more than the compari-
the disease has a positive test son group; this introduces possible
bias
16 - False positive rate is the same as
1 minus the
18 - A study in which we follow medical
students who use CrossWardsTM and
those who do not and later assess
their board scores is a
study design

Solutions on page 119. 19

CrossWards™

10 GI Feel Terrible

1 2 3 4

5 6 7

8 9

10

11

12

13

14 15

16

17 18 19

20 21

22 23 24

25

26

27

28 29 30 31

32 33

34

35

36 37

20
Across: Down:
3 - Type of inguinal hernia that protrudes 1 - Your patient with epigastric pain
medial to the epigastric artery and elevated lipase has
5 - Hepatic encephalopathy is due to acute
failure to clear this 2 - Autoimmune disorder with positive
8 - Repeated vomiting can lead to this antimitochondrial antibody: Primary
tear that causes upper GI bleeding cirrhosis
(two words) 4 - RUQ pain, jaundice, and fever suggest
12 - If you see this under the diaphragm ascending
on an x-ray, think perforation (two 6 - Inflammatory bowel disease with skip
words) lesions
13 - Eventual fibrosis, scarring, and regen- 7 - Treat this cause of cirrhosis with
erative nodules in the liver that can phlebotomy
result from a wide variety of insults 9 - The cause of this condition (acronym)
14 - Loss of peristalsis without mechanical is adhesions from a prior surgery in
obstruction about two-thirds of patients
17 - Rings and webs in the lower esopha- 10 - Kind of hypertension that results
gus, not to be confused with the from #13 across
name of a deli 11 - Treat #5 across with this
18 - Chronic GERD can lead to metaplasia 15 - Rare syndrome of gastrin being
called esophagus produced by a tumor in the pancreas
23 - One of the organisms that causes that can lead to ulcers (acronym/
bloody diarrhea initials)
25 - Germ that causes ulcers, common 16 - A worrisome source of upper GI
short form bleeding in patients with cirrhosis:
26 - You see Kayser-Fleischer rings not Esophageal
around Saturn, but in this disease 19 - Amylase is NOT one of these criteria
29 - Complication of inflammatory bowel that include elevated glucose, age
disease with dilation of the colon and >55 years, elevated LDH, elevated
systemic toxicity: Toxic ASH, and elevated white blood cell
33 - “Liver flap” count on admission
34 - Most common cause of diarrhea in 20 - High levels of 5-HIAA define this
infants syndrome; patients may have flushing
35 - It is difficulty swallowing and diarrhea
36 - Serologic marker reflecting high 21 - Gluten-free diet is the treatment for
transmissibility of hepatitis B infec- this disease
tion (acronym) 22 - This description of emesis suggests
37 - Most common type of esophageal upper GI bleeding (two words)
cancer in the world (two words) 24 - “Bird’s beak” esophagus
27 - One of the top two causes of
#1 down
28 - The three signs in #4 down are
called triad
30 - These drugs are a common cause of
gastritis and peptic ulcer (acronym)
31 - This sign is inspiratory arrest when
palpating in the right upper quadrant
32 - This lab can be helpful in evaluating
possible mesenteric ischemia

Solutions on page 121. 21

CrossWards™

11 Nerve-racking Puzzle

4 5 6

8 9

10 11

12

13 14 15

16

17

18

19

22
Across: Down:
2 - #19 across usually requires this 1- sign: Dorsiflexion of
procedure great toe with fanning of other toes
3 - Aphasia, contralateral paralysis and 4 - Acute treatment for #12 down
sensory loss, gaze toward the side: 6 - S1 nerve root reflex location:
Where is the lesion? tendon
cerebral artery 7 - This yellowish coloration of CSF from
5 - Sudden onset “worst headache of my lumbar puncture suggests #5 across
life” think this (acronym) 9 - Tear of the middle meningeal
8 - Myasthenia gravis is due to antibodies artery: hematoma
against these receptors 10 - Triad of hearing loss, tinnitus, and
10 - MRI shows white matter lesions vertigo
and CSF has oligoclonal bands (two 11 - Double-vision, dysphagia, and slurred
words) speech seen in
14 - Older patient hits head and ruptures circulation stroke
bridging veins: 12 - Excruciating, one-sided headaches
hematoma associated with nasal stuffiness and
16 - #1 down seen in tearing of the eye
motor neuron lesion 13 - Common cause of vertigo due to
18 - Most common disabling headache malpositioned otolith (acronym)
19 - Seizure lasting more than 15 - Idiopathic CN7 palsy:
10 minutes: epilepticus palsy
17 - Infantile spasms:
syndrome

Solutions on page 123. 23

CrossWards™

One More . . . For Old

12 Timer’s Sake
Meredith Gilliam*

1 2

3 4

5 6 7 8

9 10

11 12 13 14

15 16

17

18 19 20 21 22

23 24

25

26 27

28

29

*Meredith Gilliam was a fourth-year medical student at the University of North Carolina
at Chapel Hill at the time of this contribution.
24
Across: Down:
1 - The most common cause of 2 - Cardiac marker that is one of the first to
right heart failure: rise in an acute myocardial infarction
heart failure 3 - This organism is a leading cause of noso-
5 - Likely diagnosis in an elderly comial infection due to the prevalence of
smoker with hypoxemia, urinary catheters (short form)
polycythemia, and hypercapnia 4 - The valve most commonly affected by
(two words) rheumatic heart disease
9 - These are indiscernible on EKG 5 - The initial test in an elderly patient
tracings of atrial fibrillation, a presenting with acute-onset hemiparesis
common arrhythmia in the elderly (two words—first word acronym)
11 - The most likely diagnosis 6 - An elderly man who sees halos around lights
in an elderly smoker with a at night, has myopia, and denies eye pain
pulsatile abdominal mass should be evaluated for this type of glaucoma
is (acronym) 7 - When your elderly patient needs three pillows
13 - Most common primary brain to breathe comfortably at night, the most
tumor in an elderly patient likely diagnosis is (acronym)
(acronym) 8 - Infection with , when untreated,
17 - In a joint aspirate, positively may lead to rheumatic heart disease later in life
birefringent crystals that appear (shorten the genus to an initial)
blue when parallel to polarized 9 - Most likely diagnosis in an elderly patient with
light suggest this diagnosis proximal joint pain, malaise, elevated ESR, and
18 - This common laboratory value normal CK: rheumatica
may be elevated in an elderly 10 - Common arrhythmia in the elderly causing
man with multiple myeloma an irregularly irregular pulse (two words)
20 - Donepezil, rivastigmine, and 12 - Most likely diagnosis in an elderly patient
galantamine (drugs sometimes with a diastolic murmur, wide pulse pres-
used in Alzheimer disease) sure, and bounding pulses:
are acetylcholinesterase regurgitation
14 - Your patient transferred from a nursing
23 - An elderly man with longstand- home for delirium is found to have a UTI;
ing HTN and a CT showing when you see large mucoid capsules on
ischemia of the internal capsule urine microscopy, your diagnosis
may have a blockage in these (of organism) is
small vessels 15 - Important diagnosis to rule out in your
25 - Painful first MTP joint associ- elderly patient with longstanding HTN and
ated with gout chest pain radiating to the back (two words)
26 - Adults should generally begin 16 - Most likely diagnosis in an elderly
screening for colorectal cancer patient presenting with syncope and a
at age (excep- murmur at the right upper sternal border:
tions for high-risk groups) Aortic
27 - Unlike the pain of rheumatoid 19 - This class of antibiotics should be in
arthritis, that of osteoarthritis your treatment regimen for community-
with use acquired pneumonia to cover atypicals
28 - In rheumatic heart disease, 21 - LVH in your older patient is most com-
heart damage is caused by monly due to longstanding
antibodies against 22 - This treatment should not be delayed in
29 - Name of an NMDA receptor suspected cases of temporal arteritis
antagonist that may have some 24 - The appropriate next test in your elderly
neuroprotective effect in severe patient with back pain and mediastinal
Alzheimer disease widening on chest x-ray: CT

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This Puzzle May Cause

13 Petechiae

1 2 3

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19

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2 - When urine is pink, this is what you 1 - Iron deficiency anemia and thalas-
should think semia are two of the
4 - Test used to detect autoimmune anemias
hemolysis 3 - Petechiae suggest bleeding disorder
8 - Classic abnormal cell of Hodgkin due to dysfunction
disease 5 - Most common inherited bleeding
10 - #15 down may be associated with disorder (acronym)
this inflammation of the tongue 6 - Antidote for heparin
11 - Abnormally elevated hematocrit 7 - Factor VIII deficiency: A
12 - Procedure used to remove excess 9 - Can be used to treat mild hemophilia
immunoglobulin or vWD
14 - MCV > 100 = anemia 13 - Anemia associated with autosplenec-
16 - These malignancies are mostly of tomy (two words)
B-cell origin 15 - Lack of intrinsic factor:
19 - Heparin inhibits the anemia
pathway 17 - Chemotherapeutic drug used to
21 - Oncologic emergency in which blasts prevent frequency of sickle cell crises
occlude the microcirculation leading 18 - Most common childhood malignancy
to CNS symptoms or pulmonary (acronym)
edema 20 - Renal failure, low platelets, hemolytic
24 - Philadelphia chromosome t(9,22) in anemia (acronym)
90% of patients with this (acronym) 22 - BCR-ABL tyrosine kinase inhibitor
25 - Lytic bone lesions and elevated 23 - Primary site of iron absorption
monoclonal proteins
26 - #1 down cause of microcytic anemia
worldwide, common name (Hint: It
really sucks!)
27 - Common cause of iron deficiency in
younger women
28 - Fluctuating fevers in Hodgkin disease
29 - Vitamin K inhibitor (and rat poison)
30 - Deficiency of this enzyme can cause
hemolytic anemia:
kinase

Solutions on page 127. 27

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14 A Borderline Puzzle

1 2

5 6

9 10

11

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Across: Down:
3 - Cluster B: Unstable, impulsive, 1 - Cluster C: The stubborn perfectionist
vulnerable to abandonment, splitter who likes all the soup cans lined up
5 - Cluster C: Noncompliant, perfectly (two words)
procrastinator (two words) 2 - Cluster B: Cannot conform to societal
7 - Cluster B: Overemotional and rules; criminal behavior
dramatic 4 - Cluster C: Insecure, uncomfortable
9 - Cluster A: Mistrustful, hostile, suspi- with decision making or authority
cious, conspiracy theorist 6 - Cluster A: Odd behaviors and
11 - Cluster A: Purposefully socially with- thoughts but no psychosis
drawn, content living alone with no 8 - Cluster B: Grandiose, overly sensitive
friends to criticism, shows little empathy
10 - Cluster C: Involuntarily withdrawn
and shy because fears rejection

Solutions on page 129. 29

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15 This Puzzle is Infectious

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2 - Cholera toxin causes severe watery 1 - A board question about cat bites
diarrhea by overactivating this should make you think this organism
enzyme (two words) (genus)
6 - Its toxin leads to gas gangrene: 3 - Responsible for classic mononucleosis
Clostridium (species) (initials)
8 - Major cause of viral pneumonia in 4 - If your febrile patient returning from
infants (initials) South America has “black vomit” and
9 - Fluke associated with bladder cancer jaundice, think this virus (two words)
(genus) 5 - Group A streptococcus
14 - Group B streptococcus is also known are -sensitive
as streptococcus 7 - Human herpesvirus (HHV)-6 causes
(species) this infantile illness
15 - Use this smear of a sample from an 10 - Group A streptococcus are
unroofed vesicle to test for herpes -hemolytic
17 - A person with cough, fevers, night 11 - Primary syphilis presents with a
sweats, and weight loss due to tuber- painless
culosis has this form 12 - B19 causes erythema
18 - Hand-foot-and-mouth disease is infectiosum (fifth disease)
caused by virus type A 13 - The organism that causes plague
21 - Protozoan genus that causes watery (two words)
diarrhea 16 - Gram-positive rods in branching
23 - Double-stranded circular DNA virus filaments that resemble fungi and
that causes warts form sulfur granules (genus)
24 – Antibiotic-associated diarrhea is 17 - Gram-positive cocci in chains (genus)
usually caused by the toxin from this 19 - Catalase positive gram-positive cocci
organism (genus first letter and species) (genus)
25 – Gram-positive and acid-fast (genus, 20 - If you see trophozoites and schiz-
plural) onts on a patient’s blood smear,
26 - Bats, raccoons, and skunks, oh my! think
This CNS infection has high fatality 22 - A spore forming gram-positive rod
rate genus (think bad fried rice)
27 - Major cause of infant diarrhea around
the world and winter daycare diarrhea
in US

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16 The Heart of Pharmacology

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Across: Down:
1 - Most common side effect of 1 - Direct arteriolar vasodilator that can
nitroglycerin cause drug-induced lupus
6 - Binds to antithrombin III 2 - Lisinopril (and other “-prils”) inhibit
7 - Type of diuretics most useful for this (acronym)
relief of symptoms in CHF patients 3 - Raises BP, increases renal blood flow
8 - Nuisance side effect of ACEIs but not (at lower doses), and increases
ARBs contractility
9 - A nondihydropyridine calcium channel 4 - Dabigatran directly inhibits this
blocker 5 - For torsades de pointes, give this
10 - ACEIs and ARBs can cause this reac- 7 - A class IB antiarrhythmic
tion characterized by swelling of the 8 - Irreversibly binds P2Y12 ADP recep-
lips and tongue tors thereby inhibiting platelets
12 - Centrally acting alpha2-agonist 11 - Slows AV node conduction time by
13 - Type of diuretics that are first-line interrupting AV nodal re-entry
option for hypertension pathways
14 - Mechanism of metoprolol: 15 - Inhibits vitamin K-dependent
blocker coagulation factor synthesis
17 - Drug for hypertension emergency 16 - Irreversibly inhibits cyclooxygenase
that is metabolized to cyanide resulting in decreased thromboxane
19 - These inhibit HMG-CoA reductase A2 synthesis
21 - Losartan (and other “-sartans”) block 17 - Major class of antianginal drugs
this receptor 18 - Epinephrine has (positive/negative)
23 - Spironolactone is a - inotropic effects on the heart
sparing diuretic 20 - Antagonizes acetylcholine receptors
24 - Inhibits Na+/K+-ATPase resulting in 22 - Increases HDL; side effect is flushing
increased contractility

Solutions on page 133. 33

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17 An Ounce of Prevention

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11 12

13 14

15 16

17 18 19

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Across: Down:
2 - One of the screening tests for colon 1 - Bias in observational studies of
cancer (acronym) screening when the screened group
4 - Virus implicated in cervical cancer appears to live longer because sur-
(acronym) vival time starts with diagnosis based
5 - Diet that may help lower BP or on screening test in one group and
prevent hypertension (acronym) diagnosis based on symptoms in the
8 - One of the medications that may unscreened group (two words)
help smokers quit 3 - Screening is beneficial only
10 - Screening test for cervical cancer when given in the
13 - Immunization offered in the neonatal earlier, asymptomatic stage is more
period helpful than waiting until after dis-
15 - Men who have ever smoked 100 ease is detected following symptoms
cigarettes should be screened once at 4 - Screen patients with this diagnosis
the age of 65 for this (acronym) for diabetes according to USPSTF
16 - Screening test for breast cancer 6 - A medication used to prevent altitude
17 - Recommend this to men for primary sickness
prevention when global risk of coro- 7 - A medication used to prevent malaria
nary heart disease exceeds potential when traveling to endemic areas
harms of GI bleeding 9 - This drug can be offered to house-
18 - Secondary prevention hold members or other contacts of
patients who have influenza to try to
prevent spread
11 - Bias in observational studies of
screening when the screened group
appears to live longer because disease
found by screening has a better
prognosis (two words)
12 - Younger, sexually active women
should be screened routinely for this
STI
14 - This test commonly used to screen
for prostate cancer is not recom-
mended by the USPSTF (acronym)
19 - When counseling a patient about
upcoming travel, this organization’s
website is very helpful

Solutions on page 135. 35

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18 Puz-culoskeletal

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14 15

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Across: Down:
3 - Most common peripheral neuropathy: 1 - Common, noninflammatory,
syndrome degenerative wearing out of articular
5 - Class of drugs for rheumatoid arthritis cartilage
(acronym) 2 - Proximal femoral epiphysis separates
7 - HLA-B27 found in majority of from the growth plate leading to
patients with this (two words) displacement of the femur (acronym)
8- dislocation of the hip 4 - Deposition of calcium pyrophosphate
may be detected by Barlow or crystals in joints
Ortolani maneuvers 6 - Initial conservative treatment for
12 - Defect of the pars interarticularis of #3 across is a wrist
the vertebra 7 - Drug of choice for joint pain caused
14 - HLA-DR4 arthritis by #1 down
15 - A test for #3 across asking the 8 - Back pain along with new onset
patient to push flexed wrists together urinary incontinence suggests
to see if it produces numbness and
tingling syndrome
16 - Positive anterior drawer of the knee 9 - Subluxation of radial head in a child
suggests an anterior usually as a result of pulling up by the
ligament tear hand: elbow
17 - Positive McMurray’s test suggests a 10 - Deposition of uric acid crystals in
tear joints
18 - Fracture of fifth metacarpal neck is 11 - Needs immediate fasciotomy:
also known as a syndrome
fracture 13 - Fracture of the growth plate:
19 - Low back pain with radiation down to –Harris
the foot

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19 Catching My Breath

2 3

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Across: Down:
2 - Caused by abnormal sodium chloride 1 - pH 7.25 with pCO2 that is elevated:
transport, most common due to acidosis
mutation at delta-F508 (two words) 2 - Suspect in your
5 - FEV1 70% with residual volume dyspneic patient with bilateral lower
of 130% of predicted indicates leg edema and an S3 gallop (acronym)
lung disease 3 - One of the inhaled anticholinergic
8 - Medication used to relax the airways drugs used mainly for COPD
during acute bronchoconstriction 4 - Lungs are stiff with poor expansion
9 - Infiltrate in the right middle lobe in in patients with lung
an elderly patient with swallowing diseases
difficulty suggests 6 - Procedure for draining pleural effusion
pneumonitis 7 - Pus in the pleural space
13 - A 12-year-old boy who wheezes three 10 - Only treatment besides smoking
times per week and has an FEV1 of cessation that lowers mortality in
84% has mild asthma COPD
15 - Your dyspneic patient with absent 11 - In addition to prn albuterol, the child
breath sounds and deviated trachea in #13 across should be on daily
has a pneumothorax inhaled
16 - Cycles of infection and inflammation 12 - Asbestosis increases risk for this
in the bronchi can lead to this perma- malignancy
nent fibrosis, remodeling, and dilation 14 - Gram-positive cocci in chains (genus)
20 - Pulmonary fungal infection endemic 15 - In patients actively infected, see “red
to the Southwestern US; your typical snappers” on acid-fast staining of
board examination patient with this sputum
will hail from the San Joaquin Valley: 17 - Suspect pulmonary in
mycosis your dyspneic patient with pleuritic
21 - PaO2/FiO2 ratio <200 mm Hg with chest pain and a recently swollen calf
bilateral pulmonary infiltrates 18 - Type of pleural effusion seen in CHF
(acronym) 19 - Cold agglutinins may be seen in
23 - Destroyed airways with obstruction patient with pneumonia caused by
(acronym) (genus only)
25 - Reversible airways obstruction 22 - Nonresectable lung cancer type
26 - This enzyme (acronym) may be (two words)
elevated in patients with sarcoidosis 24 - Palpable vibration of the chest while
27 - Your dyspneic patient with hypoxia the patient says “blue balloons”:
and hypercapnea and worsening Tactile
mental status has acute respiratory

28 - Alpha-1-antitrypsin deficiency is
another cause of

Solutions on page 139. 39

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Are You Smarter than

20 a First-year?

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9 10 11

12 13

14 15

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Across: Down:
2 - Type II pneumocytes produce this 1 - These cells secrete gastric acid
important stuff 3 - Enlargement of the left atrium can
4 - This “ligament” connects the uterus, produce hoarseness, due to compres-
uterine tubes, and ovaries to the sion of a nerve that is a branch of
pelvic side wall the nerve
6 - Ligament that connects liver to the 5 - Nonnucleated immature RBC formed
anterior abdominal wall in bone marrow
9 - Catalase-positive, gram-positive cocci 7 - Cellular site of oxidative phosphoryla-
(genus) tion (plural)
12 - First class of immunoglobulin 8 - Long-chain fatty acids form these
produced upon antigenic exposure prior to passive diffusion
13 - Microtubules are made up of dimers 9 - Pork tapeworm species
of alpha-and beta- 10 - Enzyme that catalyzes testosterone
14 - Pathologic finding in the hippo- to estrogen
campus of patients with Alzheimer 11 - Small molecule that can be antigenic
disease: Neurofibrillary when attached to a carrier
16 - What is the approximate pulse 15 - The receptor for insulin is part of a
pressure of a patient with a diastolic large family of kinase
BP of 60 and MAP of 90? receptors
17 - Depolarization occurs when there is
an influx of this into the myocardial
cells
18 - Inhibits sodium—potassium ATPase
19 - For a diagnostic test, true negatives
divided by true negatives plus false
positives

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21 Not Just Little Adults

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Across: Down:
2 - Most common cause of bronchiolitis 1 - Check for congenital dislocation of
(acronym) the hip using and
3 - Overriding aorta, pulmonary stenosis, Barlow tests
RVH, and #8 across: Tetralogy of 4 - High fever with no other symptoms
for a few days, then a rash maculo-
5 - Drooling, “sniffing” position, high papular rash appears:
fever, muffled voice infantum
8 - Most common congenital heart 6 - Medication given to neonate to
disease (acronym) try to close a PDA (patent ductus
9 - Severe intestinal problem mostly of arteriosus, not a personal digital
premature infants (acronym) assistant!)
11 - Painless rectal bleeding in child under 7 - Sexual development staging
2 years old, two times as common 10 - Caused by mutation in chloride
in boys, 2 inches long, 2 feet from channel gene (two words)
ileocecal valve: 12 - Neonatal jaundice due to
diverticulum bilirubin is always
14 - Steeple sign pathologic
15 - High fever, fingertips swollen/peeling, 13 - Cause of whooping cough (species)
tender cervical nodes, conjunctivitis: 16 - Usual drug of choice for acute otitis
disease media
17 - When an injury does not seem to 19 - Treatment of #15 across includes
make sense based on the history IVIG and high-dose
given by a child’s caregiver, think of
this possibility
18 - Cause of hand-foot-and-mouth
disease
20 - Nonbilious vomiting in a 2-week-old
baby boy (ok, and an olive-shaped
epigastric mass) suggest this (two
words)

Solutions on page 143. 43

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22 Renal & Lytes

Meredith Gilliam*

1 2

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12 13 14

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20

21

22

*Meredith Gilliam was a fourth-year medical student at the University of North Carolina
at Chapel Hill at the time of this contribution.
44
Across: Down:
1 - A child with a syndrome causing 2 - An anion gap is calculated as sodium
decreased reabsorption of phosphorus minus the sum of bicarbonate
in the kidney may develop this and
condition 3 - Likely diagnosis in a thirsty patient
5 - A low pH, low PCO2, and low bicar- with hypernatremia and dilute urine
bonate are consistent with this type (two words)
of acidosis 4 - Renal stones, abdominal pain, and
7 - This small molecule used in the psychiatric changes are associated
estimation of GFR is freely filtered with this electrolyte abnormality
at glomeruli and only moderately 6 - The diagnosis of diabetes insipidus is
secreted by renal tubules confirmed by a
9 - A patient being treated for diabetic deprivation test
ketoacidosis with insulin should be 8 - Toxicity from this tuberculosis drug
monitored for intracellular shift of may result in an increased anion gap
this electrolyte metabolic acidosis
10 - Patients with malignant hypertension 9- are responsible for
may have this type of casts on urine dilating the afferent arterioles of
microscopy (acronym) glomeruli
12 - Elevated levels of this hormone lead 11 - In healthy individuals, glucose is
to hypercalcemia and hypophospha- completely reabsorbed into the
temia (acronym) circulation by this part of the nephron
14 - Secretion of atrial natriuretic peptide (two words)
in response to increased atrial pres- 12 - A much feared complication of
sure results in increased filtration of rapidly correcting hyponatremia is
this ion in the kidney myelinolysis in this region of the
16 - Likely diagnosis in a young woman brain
with dysuria, fever, and WBC casts in 13 - Peaked T waves on an EKG are indic-
her urine ative of this electrolyte disturbance
18 - Low levels of this hormone results in 15 - A high pH, low PCO2, and low bicar-
the excretion of free water (acronym) bonate are consistent with this type
20 - A patient with hypertension, hypoka- of alkalosis
lemia, and metabolic alkalosis should 17 - In Type 1 renal tubular acidosis, the
be evaluated for elevated levels of collecting tubule’s inability to excrete
this hormone this ion may result in hypokalemia
21 - The upper limit of the normal range and calcium-containing renal stones
of an anion gap (spelled out) 19 - This enzyme important to the main-
22 - Decreased deep tendon reflexes and tenance of blood pressure is secreted
decreased respirations are signs of by juxtaglomerular cells in the kidney
this electrolyte abnormality

Solutions on page 145. 45

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23 Surgery Rounds

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Across: Down:
3 - Most common type of breast cancer 1 - One of the “P’s” of acute arterial
7 - Major postsplenectomy complication occlusion
9 - Diagnosis for young man who has 2 - Superficial infection of the breast
sudden onset of pain in scrotum with 3 - Elderly man with LLQ pain, nausea,
swelling and a “high-riding” testicle low-grade fever, mildly elevated
14 - Major risk factor for SBO: Previous white blood cell count likely has
abdominal
15 - Bloody nipple discharge suggests 4 - Marker used to follow colon cancer
intraductal after treatment (acronym)
17 - Pleural cancer linked to asbestos 5 - Calf muscle pain brought on by
exposure walking
18 - Point of tenderness in appendicitis 6 - The “R” in ERCP
19 - “Bag of worms” on testicular 8 - Most common cause of breast lump
examination in young women
10 - Criteria for estimating prognosis in
acute pancreatitis
11 - Young woman presenting with
abdominal/pelvic pain, always rule
out this
12 - Elderly man with history of atrial
fibrillation with acute onset abdomi-
nal pain out of proportion to exami-
nation: Acute ischemia
13 - Trauma patient has tachypnea,
decreased breath sounds on one side
and deviated trachea:
pneumothorax
16 - Large bowel obstruction is due to
colon until proven
otherwise

Solutions on page 147. 47

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24 Just for Fun—Movie Docs

1 2

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12

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Across: Down:
1 - Robin Williams played 2 - Robert De Niro’s character was
Adams brought out of catatonia by L-dopa in
3 - Austin Powers’ nemesis: this 1990 movie
Dr. 3 - Played Dr. Dolittle
5 - Silence of the Lambs: 4 - In this movie, five medical students
Dr. Lecter (one played by Kevin Bacon) conduct
6 - Plays a plastic surgeon turned morti- secret experiments to try to explore
cian in Death Becomes Her the afterlife
7 - Dr. Carlisle Cullen is featured in this 5 - Michael J. Fox: Doc
saga 10 - Played a psychiatrist in Analyze This:
8 - Harrison Ford played Dr. Richard Billy
in The Fugitive 11 - Classic Halloween movie doctor:
9 - William Hurt plays an arrogant Dr. Sam
surgeon who becomes a patient when
he is diagnosed with throat cancer in
this movie: The
12 - Jurassic Park was written by the late
Dr. Michael
13 - The town cared for by a doctor played
by Jeff Daniels becomes infested in
this movie

Solutions on page 149. 49

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25 I Got Rhythm . . .

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Across: Down:
1 - Wide P wave in II (acronym) 2 - Inventor of the EKG
5 - II, III, aVF wall 3 - Interval normally <0.10 s
6 - Conduction abnormality character- 4 - This kind of AV block
ized by wide QRS and RSR’ in V5–V6
(acronym)
8 - This tracing (short form)

6 - I, aVL, V5, V6 wall

7 - QRS 0.10 to 0.12 and left axis
deviation (acronym)
8 - Fatal arrhythmia characterized by
9- degree block: chaotic ventricular activity (short
Prolonged PR interval form)
11 - Large P wave amplitude in II or V1 10 - Steadily prolonging PR intervals
may suggest this (acronym) followed by a dropped beat
12 - This tracing (short form) 12 - This tracing (short form)

14 - Ventricular repolarization
15 - “Wandering pacemaker” tachycardia
13 - The presence of this wave in the (acronym)
setting of a short PR is characteristic 17 - Prolonging the QT interval may be
of Wolff–Parkinson–White “dangereux”
16 - “Saw tooth” waves (short form) 18 - Elevation of this may be difficult to
19 - Firing of the sinus node differentiate from ST elevation
20 - Narrow complex regular tachycardia 19 - Interval normally 0.12 to 0.20 s
without P waves (short form) 21 - Interval normally <0.44 s
22 - Irregularly irregular rhythm with 24 - Conduction abnormality character-
narrow QRS and no P waves ized by wide QRS and RSR’ in V1
(short form) (acronym)
23 - V1, V2 wall 27 - First sign of hyperkalemia (plural)
25 - Ventricular depolarization 28 - QRS 0.10 to 0.12 and right axis
26 - V3, V4 wall deviation (acronym)
29 - This tracing (short form) 31 - Wide complex regular tachycardia
(short form)

30 - Extra wave seen with low K

32 - This tracing (short form)

Solutions on page 151. 51

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26 Clinical Scramble

DESPIR VINE

MOCHASILLO

ICANJUDE

CATSIES

RIBSOFIS

ANSWER:

52 Solutions on page 152.

Notes

53
CrossWards™

27 Birth of a Puzzle

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2- age: Time since the 1 - This term for maternal awareness
LMP of fetal movements, usually occurs
4 - The number of deliveries after 20 weeks around 18 weeks
5 - At 12 weeks of gestation, this organ is 3 - Fetal : Description of
palpable above the pubic symphysis the long axis of the fetus
7 - Stages of labor: Onset of contractions 4 - Fetal : Description of
to complete cervical dilation the orientation of the presenting part
10 - rule: A method for relative to maternal pelvis
determining the due date 6 - The number of pregnancies
11 - This hormone should double every 8 - Stages of labor: Second stage is
48 hours during the early stages of from complete dilation to delivery
pregnancy (acronym) of the
13 - #13 down is made by this organ 9 - Hyperpigmentation of the face
15 - Stages of labor: Delivery of infant to 12 - levels decrease by
delivery of placenta about 25% due to increase in GFR
16 - #13 down causes relaxation 13 - Many of the physiologic changes
of muscle, which of pregnancy are mediated by this
results in lower blood pressure, and hormone
GERD 14 - Increases in tidal volume are
17 - #11 across is analogous to responsible for the respiratory
, causing levels to of pregnancy
decrease during pregnancy (acronym) 19 - Hyperpigmentation in the midline of
18 - A physiologic results the abdomen (two words)
from the dilutional effect of increased 22 - This test of fetal well-being may be
plasma volume deemed “reactive” if there are at
20 - Decreased AFP, estriol, and increased least two 15 × 15 accelerations in a
HCG and inhibin A is the pattern seen 20-minute period (acronym)
in syndrome 24 - deceleration: Caused
21 - Fetal : Description of by fetal hypoxia or placental
the fetal part at the cervix insufficiency
23 - Supplementation with this vitamin
PRIOR to conception is needed to
prevent neural tube defects
25 - deceleration: Caused
by cord compression
26 - deceleration: Caused
by fetal head compression

Solutions on page 155. 55

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28 Labor Pains

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3 - Avoidance of cat feces is advised 1 - The most common cause of fever in
to pregnant women to prevent this the postpartum period
congenital infection (short form) 2-A pregnancy may be
5 - Uterine is the most diagnosed by a “snowstorm” appear-
common cause of postpartum ance on ultrasound
hemorrhage 4 - Preeclampsia is defined as elevated
7 - A woman who develops mastitis blood pressure plus
should keep/stop breast-feeding 6 - The presence of on
9 - In utero exposure is associated with microscopic examination of dried
clear cell carcinoma of the cervix amniotic fluid suggests rupture of the
(acronym) membranes
10 - Screening and treatment for this 8 - Painless vaginal bleeding in the third
organism has significantly reduced trimester should make you suspect a
the rates of neonatal sepsis placenta
(acronym) 11 - A woman in preterm labor at 30 weeks
14 - Premature separation of the placenta should receive to
is known as promote fetal lung maturity
16 - Eclampsia is defined as a 12 - Use of an insulin drip during labor
in a woman with preeclampsia may be necessary to prevent this
19 - The definitive therapy for preeclampsia neonatal complication
22 - dystocia: A feared 13 - This drug has been shown to reduce
complication that is more likely in progression to eclampsia in women
macrosomic infants of diabetic with severe preeclampsia (short form)
mothers 15 - A woman at 12 weeks’ gestation with
23 - A woman recovering from a postpar- vaginal bleeding and an open os has
tum hemorrhage who fails to lactate a/an abortion
may have syndrome 17 - A child with congenital deafness,
25 - Exposure to this drug may cause a cataracts, and a patent ductus should
growth-restricted fetus with mental raise suspicion for this congenital
retardation and characteristic facial infection
features 18 - gravidarum: A severe
26 - This class of blood pressure medica- form of “morning sickness”
tion must be avoided in pregnancy 20 - The most common malpresentation
(acronym) 21 - Treatment with this immunoglobulin
27 - A 1-hour glucose tolerance test may is indicated for Rh-mothers
be used to screen for this pregnancy 24 - A syndrome of severe preeclampsia
complication (acronym) characterized by hemolysis, elevated
28 - This diagnosis must be ruled out in LFTs, and thrombocytopenia
any woman of childbearing age with (acronym)
abdominal pain and/or vaginal bleeding

Solutions on page 157. 57

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29 A pHuzzle

1 2

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12 13

14

15

16 17 18 19

20

21

22

23 24

25 26

27

58
Across: Down:
1 - The major measured anion in the 2 - The ultimate process responsible for
serum all forms of respiratory alkalosis
3 - This number tells you whether you 5 - One of the causes of anion gap
have an acidosis or alkalosis acidosis, in a patient being treated for
4 - pH < 7.35 tuberculosis
6 - One of the causes of anion gap 9 - One of the causes of anion gap
acidosis, in a patient with end-stage acidosis, somewhat antiquated as the
renal disease drug is no longer in use
7 - The most common cause of meta- 10 - Assessment of this value is key to
bolic alkalosis detect the presence of a combined
8 - Byproduct of lipid metabolism, metabolic acid–base disturbance
excreted in the urine (Hint: It might sound like you are
10 - One of the causes of anion gap repeating yourself)
acidosis, in a patient with Type I DM 13 - One of the causes of anion gap
(acronym) acidosis, in an overdose patient
11 - A decrease in the anion gap may 15 - The amount of unmeasured nega-
be observed in the presence of tively charged molecules in the serum
unmeasured cations such as this one 16 - Type of disorder present when the
possibly encountered on a patient in pCO2 is the primary abnormality
the labor ward (short form) 18 - A physiologic respiratory alkalosis
12 - One of the causes of anion gap may be encountered in this state
acidosis, in a patient who has been 19 - Order this to find out the patient’s
NPO in the hospital for several days pH (acronym)
(acronym) 22 - The most common cause of nongap
14 - Another cause of nongap acidosis, acidosis
a group of disorders rather oddly 23 - The first electrolyte in the anion gap
numbered (acronym) calculation
17 - The ultimate process responsible for 24 - One of the causes of anion gap
all forms of respiratory acidosis acidosis, in a septic patient
20 - One of the causes of anion gap
acidosis, in an accidental ingestion of
antifreeze (two words)
21 - Buffer anion primarily responsible for
acid/base regulation
25 - Type of disorder present when the
bicarbonate is the primary abnormality
26 - pH > 7.45
27 - One of the causes of anion gap aci-
dosis, perhaps in a desperate alcoholic

Solutions on page 159. 59

CrossWards™

30 Onco-Logical

2 3

5 6 7

9 10 11

12 13 14

15

16

17 18 19

20

21

22 23

24

25

60
Across: Down:
2 - ALL is seen with greater frequency 1 - Dysplastic nevus syndrome is
in this chromosomal disorder associated with increased risk
( syndrome) of
5 - Eosinophilic rods inside malignant 3 - This lab abnormality commonly
cells are seen in this leukemia occurs in patients on chemotherapy
(acronym) and places them at risk of severe
7 - Actinic keratosis is a precursor lesion infection
to cell carcinoma 4 - Abnormal B-cells in Hodgkin
8 - Co-administration of this drug disease may have a large bilobed
prevents hyperuricemia while on
chemotherapy 6 - Elevation of this electrolyte may
9 - Hodgkin disease may be suspected be the first clue in the diagnosis of
in patients who have pain in lymph multiple myeloma
nodes after drinking 8 - Treatment with all-trans retinoic acid
11 - This tumor marker may be useful for may be curative in the M3 type of
screening for and following hepato- this leukemia (acronym)
cellular carcinoma (acronym) 10 - This tumor marker may be useful for
12 - This anatomic structure defines stag- following colon cancer (acronym)
ing in Hodgkin disease 11 - Most common leukemia in children
15 - Biopsy of this tissue is often needed (acronym)
for the diagnosis of leukemia (two 13 - A patient with multiple purplish
words) vascular papules and plaques in the
16 - The gene product of #21 down lower extremities is likely immuno-
suppresses this cellular process compromised from
17 - Myasthenia gravis may be associated (acronym)
with malignancy of this organ 14 - A patient with a 1.5-cm cervical
20 - This common virus is thought to play lymph node that does not go down
a role in certain forms of non-Hodgkin after 4 weeks should have
lymphoma (acronym) a
22 - This drug inhibits the BCR–ABL gene 15 - Patients with CML in this phase have
product markedly shortened survival
24 - This tumor marker may be useful for 18 - The presence of distant
screening for and following prostate defines Stage IV malignancy in
cancer (acronym) virtually all cancers
25 - A 70-year-old is incidentally found 19 - Enlargement of this organ is a
to have a WBC count of 110,000 and common finding in many leukemias
“smudge cells” on the smear 21 - The Philadelphia chromosome t(9,22)
(acronym) is most associated with this malig-
nancy (acronym)
23 - This cell type is responsible for the
majority of non-Hodgkin lymphomas

Solutions on page 161. 61

CrossWards™

31 Clear to Auscultation?

6 7 8 9

10

11 12

13

14

15

16 17

18

19

20

21

22 23

24

62
Across: Down:
1 - The usual EKG finding in a PE (short 1 - A patient recovering from influenza
form of second word) who suddenly worsens with high
2 - Most pneumonia in children is due fevers and purulent sputum may be
to infected with this bug (initial the
4 - Chronic productive cough may genus)
clue you into a diagnosis of 3 - A tall 18-year-old male who presents
chronic with acute onset chest pain and
6 - In addition to the usual causes of shortness of breath
neonatal sepsis, (bug) 5 - Bilateral adenopathy is
should be considered in a neonate the hallmark of sarcoidosis
with pneumonia 6 - Poisoning with this gas will cause a
8 - Your patient with urosepsis who sud- falsely elevated pulse oximetry
denly develops dyspnea and becomes reading (acronym)
hypoxic despite oxygen administra- 7 - A patient with a pleural effusion from
tion may have this complication pneumonia would be expected to have
(acronym) relatively high levels of
10 - A DVT or PE buys you at least 3 months compared to serum (acronym)
of therapy with 8 - Unlike garden variety community-
13 - A patient with COPD may create acquired pneumonia, coverage of this
their own PEEP by exhaling against class of bugs should be considered
lips when treating aspiration pneumonia
15 - Your patient with calf pain on passive 9 - A normal may rule out
dorsiflexion of the ankle has a DVT/PE if your clinical suspicion is
positive sign low
16 - Be sure to treat your patient with 11 - Your patient with unilateral upper
hospital-acquired pneumonia with extremity weakness and Horner
antibiotics to cover syndrome may have a
19 - Aspiration pneumonia typically tumor
develops in this lobe (two words) 12 - A challenge may be
21 - Churg-Strauss syndrome might be administered to the suspected asth-
suspected in an asthmatic patient matic with normal PFTs
with high levels of this cell line 13 - In addition to increasing the fraction
22 - For a patient who is wheezing more of inspired oxygen, this ventila-
than twice a week, addition of an tor parameter may be increased to
inhaled is recom- improve oxygenation (acronym)
mended 14 - “All that wheezes is not
23 - Hypoxemia that is due to intrapul- ”
monary shunting will not respond to 17 - This first line therapy for #3 down
therapy with speeds resolution
24 - Lung cancer that is the least associated 18 - Occurring in outbreaks, this pulmo-
with smoking nary infection is making a comeback
in part due to decreasing rates of
immunization
20 - A solitary pulmonary nodule that
is unchanged for over 2 years is
likely

Solutions on page 163. 63

CrossWards™

Some Lovers Try* . . .

32 This Puzzle

1 2

6 7

9 10

11 12

13 14

15 16

17 18 19

20 21 22 23

24

25

26

*Some Lovers Try Positions That They Can’t Handle is a mnemonic for the wrist bones.
64
Across: Down:
1 - In addition to #23 across and the 2 - Most commonly fractured long bone
medial meniscus, this structure 3 - Radiographic new bone formation in
is often coinjured as part of the a sunburst pattern is a sign of this
“unhappy triad” (acronym) devastating tumor
3 - Antibiotics are always indicated in 4 - An obese adolescent male with knee
this type of fracture pain and limp may have epiphyseal
6 - This gruesome intervention may be displacement on this bone
limb saving in patients with a painful 5 - A patient with a femur fracture sud-
swollen limb and paresthesias, pulse- denly develops SOB, rash, DIC, and
lessness, paralysis, and poikilothermia cardiovascular collapse (two words)
8 - A patient who develops hand pain 7 - Most common type of shoulder
and numbness after holding the wrist dislocation
in forced flexion for 60 seconds may 9 - Mike Tyson presents with hand pain
have this (acronym) after a match. He has fractured
10 - Atrophy of this group of muscles is a his metacarpal
late sign of #8 across 12 - A 15-year-old track athlete ruptures
11 - What study should be ordered in a her Achilles tendon while being
patient with new onset back pain and treated for a UTI with
urinary incontinence? (acronym) 14 - A first born, female, newborn deliv-
13 - Fracture of this bone should be ered in breech presentation is at high
suspected in a patient with snuff box risk for dysplasia of this joint
tenderness 16 - Falling on outstretched hand most
15 - Most common type of hip dislocation likely results in fracture of this bone
17 - An old man with leg pain that gets 18 - Hormone level that should be
better when leaned forward or walk- checked in #4 down
ing uphill: Spinal 20 - The artery and nerve
19 - Your roommate was out drinking on may be injured in #7 down
Saturday night and awoke on Sunday 21 - arthritis: Must be ruled
with a wrist drop. He has injured out in any patient with a red, hot
the nerve joint
20 - Your patient with an L5–S1 disc 23 - What ligament is injured in a patient
herniation may have a diminished with excess laxity on anterior transla-
reflex tion of the tibia? (acronym)
22 - A person defending himself from an 25 - The finger joint most commonly
attack may end up with a fracture of involved in osteoarthritis (acronym)
this bone
24 - The tubercle of this long bone may be
painful in growing boys
26 - Your patient with a large painful
swollen mass on their elbow may
have olecranon

Solutions on page 165. 65

CrossWards™

33 Doc, I Think It’s My Hormones

3
4 5 6
7 8

9 10
11 12
13 14
15
16

17
18

19
20 21 22
23 24
25 26

27

28

29

30

66
Across: Down:
1 - Most common type of thyroid carci- 1 - Antithyroid drug preferred for treat-
noma ing hyperthyroidism in pregnancy
2 - A patient in diabetic ketoacidosis is 4 - This treatment is by far and away the
always total body deficient in this most important initial treatment for
electrolyte (regardless of serum level) hypercalcemia
3 - Osteoporosis is defined by a 5 - This test along with a thyroid scan
of –2.5 or lower on can help differentiate Graves disease
DEXA scanning from thyroiditis (acronym)
7 - Hyponatremia and hyperkalemia 6 - Hemorrhagic necrosis of the adrenal
should always prompt consideration gland may occur after infection with
of this life-threatening problem this bacteria
9 - Intermediate-acting insulin, usually 8 - This syndrome should always be sus-
dosed twice daily pected in a patient with hypertension
11 - Rarely checked, but often elevated and hypokalemia
antibody in Hashimoto thyroiditis 10 - Adverse effect of nearly all antiglyc-
13 - Agonists to this neurotransmitter are emic agents except metformin
first-line therapy for prolactinoma 12 - Antithyroid drug preferred in absence
16 - Long-acting insulin without a peak of pregnancy
18 - Classically, only Type 1 diabetes mel- 14 - In the absence of contraindications,
litus presents with this life-threaten- this drug is the absolute first-line
ing disorder therapy for Type 2 diabetes
20 - Most aggressive and rapidly fatal 15 - The clinical finding of bitemporal
thyroid carcinoma hemianopsia would prompt one to
25 - “Stones, bones, groans, and psychi- order MRI of this structure
atric overtones” may represent this 17 - Presence of this antibody is highly
electrolyte disturbance specific for Graves disease (acronym)
27 - The first step in evaluation of sus- 19 - Rare but serious side effect of
pected hyperaldosteronism is meas- metformin
urement of the plasma : 21 - Fastest acting insulin
aldosterone ratio 22 - Best screening test for assessing
28 - Type 1 diabetics will always require thyroid function (acronym)
therapy with this at all stages of their 23 - Insulin therapy in diabetic ketoacido-
disease sis is directed at lowering (glucose/
29 - This drug, more commonly used in ketones)
variceal upper GI bleeding, is also 24 - A patient with positive urinary
used to treat acromegaly metanephrines should never be given
30 - Use of this drug class in diabetes has a drug from this class alone
been shown to decrease progression 26 - Psychotropic drug often implicated in
of nephropathy nephrogenic diabetes insipidus

Solutions on page 167. 67

CrossWards™

34 This Puzzle is Giving Me Gas

Meredith Gilliam

2 3

4 5

9 10

11

12

13

14

15

16

17 18 19

20

21

22

23

24

68
Across: Down:
2 - Hirschsprung disease is caused by 1 - An immunocompromised patient
failure of this embryologic popula- with odynophagia and “volcano-
tion of cells to migrate to the rectum like” ulcers in his esophagus may be
(two words) infected with this pathogen (acronym)
4 - This class of drugs works by irrevers- 3 - Patients with severe liver failure may
ibly inhibiting H+/K+-ATPase in present with this coarse hand tremor
stomach cells (acronym) 5 - Autoimmune destruction of the
10 - Most likely diagnosis in an older stomach’s parietal cells may result in
patient with LLQ pain, fever, and this type of anemia
leukocytosis 6 - Nearly all patients with duodenal
11 - Most likely cause of an acute bowel ulcers are infected with this organism
obstruction in a patient who has had (shorten the genus to an initial)
multiple abdominal surgeries 7 - This prokinetic agent may relieve
12 - This ligament attaching the liver the symptoms of gastroparesis by
to the anterior abdominal wall is a antagonizing dopamine receptors
derivative of the fetal umbilical vein 8 - A surgeon may insert a finger through
13 - Autoantibodies against this glyco- the epiploic foramen to compress the
protein found in wheat are present in contents of this ligament to control
80% of patients with celiac disease bleeding
14 - The flushing, diarrhea, and right-sided 9 - This GI hormone secreted by I cells is
heart murmurs associated with car- responsible for the pain that patients
cinoid tumors result from abnormal with cholelithiasis may feel after eat-
production of ing a fatty meal
15 - This liver enzyme may be dispro- 16 - An infant with painless rectal bleed-
portionately increased (relative to ing may have a congenital anomaly
others) in patients with alcoholic resulting from the persistence of this
hepatitis (acronym) embryological duct
17 - Glandular metaplasia in the distal 18 - This type of hemorrhoids are not
esophagus may transform into this painful because they receive visceral
histological type of carcinoma innervation
20 - Bilious vomiting in a neonate and a 19 - A patient with progressive dysphagia
“double bubble” on abdominal imag- and a dilated esophagus with distal
ing is concerning for this congenital stenosis on barium swallow most
abnormality (two words) likely has this condition
21 - Of the histological types of adeno- 22 - This GI hormone is oversecreted in
matous colon polyps, Zollinger-Ellison syndrome
adenomas most likely to become
malignant
23 - Check the level of this protein in
patients with cirrhosis, corneal
deposits, and parkinsonian symptoms
24 - Pathology in this part of the gut may
limit the body’s absorption of folate

Solutions on page 169. 69

CrossWards™

35 BuzzWards

1 2 3

5 6

7 8

9 10 11

12

13 14

15 16

17 18 19

20

21 22

23 24

25

26

70
Across: Down:
1 - Currant jelly stools 2 - Doughy skin (electrolyte abnormality,
7 - Blueberry muffin rash hyper )
9 - Barking cough 3 - Silvery scale
11 - Reed-Sternberg cells 4 - Currant jelly sputum
12 - Bird’s beak on swallow study 5 - Punched-out lesion on skull film
13 - Leftover rice (multiple )
16 - Machine-like murmur (acronym) 6 - Cold agglutinins
18 - Dewdrop on a rose petal 8 - Sawtooth wave (acronym)
20 - Honey-crusted lesion 10 - Christmas tree rash (pityriasis
21 - Café-au-lait spots )
23 - Maltese cross casts in urine 14 - Rose gardener
( syndrome) 15 - Spaghetti and meatballs on KOH
25 - Honeycomb lung (acronym) preparation (pityriasis )
26 - Target lesions (erythema 16 - Cogwheel rigidity
) 17 - Powder burns on laparoscopy
18 - Clue cell (bacterial )
19 - Shipyard worker
22 - Stuck on appearance (
keratosis)
24 - Bat-wing appearance on chest x-ray
(pulmonary )

Solutions on page 171. 71

CrossWards™

36 A Trich Puzzle

3 4

8 9

10

11 12

13 14

15

16

17 18

19 20

21 22

23

24 25

26

72
Across: Down:
2 - Gray discharge, high pH, clue cells 1 - Common uterine tumor that is
(acronym) hormonally responsive
3 - This virus is responsible for the vast 4 - Most common cause of secondary
majority of cervical cancer (acronym) amenorrhea
6 - Motile organism seen on saline 5 - A woman who leaks urine when
wet mount of vaginal secretions is she coughs, laughs, or sneezes has
pathognomonic for incontinence
(short form) 7 - The only way to definitely diagnose
8 - What is the diagnosis in a woman #19 across
who presents with amenorrhea, acne, 9 - You might find a “ cyst”
hirsutism, and insulin resistance? on the ovary of the patient in #19
(acronym) across
9 - Budding yeast on a KOH preparation 10 - Crops of vesicles that progress to
are diagnostic for this organism painful ulcerations
11 - Treatment with this drug may restore 12 - Menstrual bleeding that is irregular in
fertility to the patient in #8 across frequency
13 - Toxic shock syndrome commonly 14 - This prophylactic intervention is an
occurs in women with a retained option for women with the BRCA-1
mutation
15 - The most common breast quadrant 16 - Absence of menses for at least
to encounter breast cancer (two 12 months
words) 19 - Excess of this hormone is a risk factor
17 - Hormonal contraceptive methods for endometrial cancer
which contain increase 20 - OCP use is protective against
the risk of thromboembolic disease cancer
18 - Treatment with this drug is indicated 22 - A cause of increased abdominal girth
in estrogen receptor-positive breast in patient with ovarian cancer
cancers 25 - Purulent cervical discharge and cervi-
19 - Your patient with cyclic abdominal cal motion tenderness (acronym)
pain and nodularity on her uterosac-
ral ligaments has
21 - Woman with a history of migraine
with should be advised
against estrogen-containing contra-
ceptives
23 - This test should be offered to woman
over the age of 50 for breast cancer
screening
24 - A painless chancre followed in several
weeks by a maculopapular rash
26 - A patient with PID who develops
RUQ pain should make you suspect
involvement of this organ

Solutions on page 173. 73

CrossWards™

37 Widow Maker

1 2

3 4

5 6

7 8 9

10

11

12 13

14 15

16 17 18

19 20

21

22

23

24

25

74
Across: Down:
1 - The genus most commonly impli- 1 - Most useful intervention in the
cated in subacute endocarditis (short treatment of PVD is the cessation of
form)
2 - Levels of this peptide are virtually 2 - Duke major criteria (1 of 2)
always elevated in decompensated 4 - Cardiac risk factor: Most easily
CHF (acronym) treated (acronym)
3 - A hypotensive patient with severe 5 - The finding of a delta wave on EKG
burns may be in shock is suggestive of this syndrome
7 - Chest pain relieved by leaning for- (acronym)
ward may be a clue to this diagnosis 6 - The triad of butt claudication, impo-
10 - Prior myocardial infarct may be sug- tence, and decreased femoral pulses
gested by the finding of this on EKG may be due to occlusion of the aorta
11 - A widened pulse pressure may sug- near the
gest this valvular disease (acronym 8 - Harsh systolic murmur that radiates
12 - Cardiac risk factor: Most prevalent of to the carotids (acronym)
all (acronym) 9 - Turner syndrome may be associated
13 - Perform this test to diagnose periph- with this disease of the aorta
eral vascular disease (acronym) 13 - Cardiac risk factor: It is lower in men
16 - Cardiac risk factor: Most potent of all 14 - A low-pitch diastolic murmur, loudest
17 - Occlusion of this coronary artery is at the apex, with an opening snap
often fatal (two words) (two words)
19 - Electrical alternans, a phenomenon 15 - Duke major criteria (2 of 2)
where every other QRS has a differ- 16 - A hypotensive patient with fever,
ent morphology and direction, may elevated WBC with a left shift may
be a clue to this diagnosis be in shock
22 - A hypotensive patient with elevated 18 - A young woman with palpitations
JVP and pulmonary rales may be in and atypical chest pain may have this
shock valvular condition (acronym)
23 - A hypotensive patient who is brady- 20 - The single most powerful drug you
cardic with head trauma may be in can administer in acute coronary
shock syndrome
24 - The organism most commonly impli- 21 - The valve most frequently infected in
cated in acute endocarditis (initial the IV drug abusers
genus)
25 - Cardiac risk factor: Some consider it a
“disease equivalent”

Solutions on page 175. 75

CrossWards™

Don’t Mess Around

38 with the Pancreas

1 2 3

9 10

11 12 13

14

15

16 17

18

19

20

21 22

23 24 25

26

27

76
Across: Down:
1 - The presentation of painless jaundice 2 - Plummer-Vinson syndrome is the
should always worry you for cancer of association of esophageal webs
this organ and
5-A scan may be helpful 3 - Most common form of hiatal hernia
for diagnosis of gallstone disease when 4 - Most common type of gallstone
ultrasound is nondiagnostic (acronym) 6 - Use of this class of over-the-counter
8 - Dark sticky tarry stool medication is a leading cause of
9 - Iron deficiency anemia in an older peptic ulcer disease (acronym)
man or postmenopausal woman is 7 - Tumor marker associated with colon
cancer until proven cancer (acronym)
otherwise 9 - “Skip lesions” are characteristic of this
11 - Relatively common GI cause of form of IBD
chronic cough 10 - The more specific test for acute
12 - A sting from this arachnid may cause pancreatitis
pancreatitis 13 - Pain with swallowing
16 - This unusual form of cholecystitis 14 - Most common location of pancreatic
may occur in debilitated patients or cancer
critically ill patients 15 - sign: Arrest of inspira-
19 - Most common cause of small bowel tion during deep palpation of the
obstruction in children RUQ
20 - A test performed on this bodily sub- 17 - Treatment with this drug may help
stance is the best way to determine the symptoms of carcinoid syndrome
the presence of current H. pylori 18 - This type of adenoma has the highest
infection risk of malignancy
23 - Most common cause of lower GI 21 - Common cause of antibiotic-
bleeding in older adults associated diarrhea (short form)
26 - This test should be ordered in any 22 - A Krukenberg tumor is a metastasis
patient diagnosed with esophageal of gastric carcinoma to this organ
candidiasis 24 - This part of the colon is always
27 - This operation may be curative for involved in ulcerative colitis
ulcerative colitis 25 - The clinical presentation of esopha-
geal spasm is often indistinguishable
from

Solutions on page 177. 77

CrossWards™

39 Most Common . . .

3 4

5 6

7 8

10 11

12

13

14 15

16

17 18

19 20

21 22

23 24

25

78
Across: Down:
2 - Cancer in women 1 - Cause of small bowel obstruction in
3 - Benign breast mass in younger adults
women 3 - Benign tumor of female reproductive
5 - Cause of chronic kidney disease in system
the United States 4 - Primary malignant bone tumor
7 - Cancer in men (acronym)
9 - Cause of osteomyelitis in a sickle cell 6 - Cause of death in diabetics (organ)
patient 7 - Cause of abnormal nipple discharge
10 - Form of thyroid cancer 8 - Childhood malignancy (acronym)
14 - Bacterial cause of infectious diarrhea 9 - EKG finding in pulmonary embolism
16 - Type of shoulder dislocation (acronym)
17 - Cause of maternal mortality 11 - Pituitary tumor
21 - Cause of hypothyroidism 12 - Cause of infection in burn patients
23 - Form of stroke 13 - Skin cancer (acronym)
25 - Cause of acute lower GI bleeding in 15 - Cause of secondary amenorrhea
adults 18 - Cause of bronchiolitis (acronym)
19 - Congenital heart defect (acronym)
20 - Fracture of a carpal bone
22 - Cause of peptic ulcer disease (short
form)
24 - Organism causing UTI (short form)

Solutions on page 179. 79

CrossWards™

40 Clinical Scramble

HOGCU

MUSTPU

YESSTOPHIM

VREEF

DICA FATS AILBILC

ANSWER:

80 Solutions on page 180.

Notes

81
CrossWards™

41 BrainTeaser

1 2

6 7

8 9 10

11 12 13 14

15

16

17

18 19

82
Across: Down:
1- agonists are treatment 2 - Most brain tumors are
for #3 down 3 - Pill-rolling tremor and rigidity: Two
4 - Problem in standing or walking classic signs of this disease
5 - Bitemporal hemianopia suggests a 6 - Treatment for #8 across includes IVIG
lesion here (two words) and possibly this procedure
8 - Acute demyelinating autoimmune 7 - Cannot understand
disorder causing ascending paralysis language: aphasia
(acronym) 8 - Most common primary brain tumor
9 - Loss of upper and lower motor in adults
neuron functions: 10 - Patient who is “weird, wobbly,
lateral sclerosis and wet,” think normal
11 - Axillary freckling, café-au-lait pressure
spots, and iris hamartomas: 12 - Give this to alcoholics to prevent
Neuro Wernicke encephalopathy
15 - Cannot express language: 13 - Painless loss of central vision mostly
aphasia in the elderly:
16 - Cholinesterase inhibitors are used to degeneration
try to slow progression of this disease 14 - Class of drugs used to treat acute
17 - Creutzfeldt-Jakob disease is due to migraines
infection with a
18 - Schwann cell tumor:
neuroma
19 - “Ash-leaf” hypopigmented lesions are
classic for sclerosis

Solutions on page 183. 83

CrossWards™

42 This Puzzle is Kidstuff

1 2

3 4

6 7

9 10

11 12 13

14

15 16 17

18

19 20

21

22

23

24

25 26 27

28 29

30

31

32 33 34

84
Across: Down:
3 - Barking cough and “steeple sign” on 1 - X-linked abnormality affecting the
neck film FMR1 gene: syndrome
5 - Hyperbilirubinemia in the first 2 - Premature infants can develop
24 hours of life is always enterocolitis
6 - Child “tripoding” with high fever, sore 4 - Whooping cough
throat, drooling, muffled voice, and 9 - Hypertonicity, lethargy, and seizures
stridor: Think in a newborn with unconjugated
7 - Atrial defect has a hyperbilirubinemia suggests perma-
fixed, widely split S2 nent deposition in the brain called
8 - High-dose is an 10 - First menstrual period
empiric antibiotic treatment for acute 13 - One of three most common causes
otitis media (if not allergic) of acute otitis media (genus only)
11 - Most common childhood malignancy 14 - Erythema infectiosum (fifth disease)
12 - Hirschsprung disease is suggested by is due to B19
failure to pass within 17 - Newborn has bilious emesis and a
first 2 days of life “double-bubble” sign on abdominal
15 - Most common chromosomal disorder x-ray: Duodenal
and cause of mental retardation: 18 - Looks like a bruise but these “spots”
syndrome are birthmarks
16 - The absence of a red reflex on the eye 19 - First-line therapy for hyperbilirubine-
examination of a newborn suggests mia of the newborn
congenital 20 - One piece of intestine “telescopes”
21 - This drug is given to help close a pat- into another (not to be confused with
ent ductus arteriosus a “dreamy” Leonardo DiCaprio movie)
22 - 45, XO: syndrome 24 - HHV-6 causes this infection that has
23 - Suspect this if the history is discord- prodrome of high fever followed by
ant with physical findings or if there diffuse maculopapular rash
is a delay in parent seeking medical 26 - Most common cause of hypertension
care for a child in children is paren-
25 - Misalignment of the eyes persisting chymal disease
beyond 3 months of age 27 - Advise parents that newborns should
28 - Transient tachypnea of the newborn sleep on their backs (i.e., supine) to
is a diagnosis of decrease risk of this (initials)
31 - Malrotation of the gut 29 - Untreated Kawasaki disease can lead
32 - Congenital herniation of intestine to aneurysms
through abdominal wall near umbili- 30 - Embryonic renal tumor
cus not covered by a sac 32 - Most common cause of meningitis in
newborns (initials)
33 - Most common cause of bronchiolitis
(initials)
34 - Most common immunodeficiency:
deficiency

Solutions on page 185. 85

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This Puzzle Might Cause

43 Extrapyramidal Symptoms

2 3

5 6

8 9

10

11 12

13 14 15

16 17

18

19 20

21

86
Across: Down:
2 - Patient who has had at least one 1 - Apraxia is inability to perform
prior episode of major depression activities
and now is manic: 3 - The “I” in SIGECAPS
disorder 4 - The “G” in the CAGE questionnaire
7 - Syndrome characterized by motor 5 - Abrasions on the knuckles,
and/or vocal tics enlarged parotid glands, erosion
8 - Intense episodes of fear with symp- of teeth enamel: All classic signs
toms such as shortness of breath, of
chest pain, shakiness, and sweating: 6 - GABA-ergic drugs used as anxiolytics
attacks for short-term control
11 - Involuntary muscle spasms from 9 - Fear of being alone in public places:
antipsychotic medication phobia
13 - A side effect of some antipsychotics 10 - A 10-year-old taking methylphenidate
is elevation of this hormone likely has this (acronym)
18 - Patient with auditory hallucinations, 12 - Class of medications used for
disorganized thoughts, and delu- long-term treatment of #8 across
sions likely has (acronym)
19 - Fear of germs leads to repeated 14 - A cause of PTSD in men as well as
hand washing; hand washing is women
the 15 - Amitriptyline is a
20 - Kind of therapy used for #8 across antidepressant
(acronym) 16 - “Caregiver” makes someone else
21 - Procedure reserved for refractory ill (e.g., a child) to get attention:
depression (acronym) Munchausen
17 - Classic mood stabilizer for patients
with #2 across

Solutions on page 187. 87

CrossWards™

44 Claiming the Inheritance

Y UO L K V XWV A C D P G T A U S Z J KH PWC R Q B S S E U
N A N G I S J Y P I N E U R O F I B R OMA T O S I S Z B D G L
L T G Y U H K H A Y Z Z Z B D I G X U Y I S I S C I U N F WW X
K C E Q T D O D R S WW V G B D G L E I X P N X Y S H O B X D Q
J E L U K I F D L U E R Z Y DN T L J B FQ R D C A X NUOH X
I F R I S Z T T Y S J F KH P A A A P R UY BDA C X L O JWC
G R F K C B B D X F R O A T Z G Y I K H N X WG L X W R K U N T
S E Q J B F Y M D D D S Z R E O S C V Y B A AMN C N L U CW B
G P P L WQ Y A C P W B F D Z I A H D W Y L F P N J R M R H M E
T MA T U Y H V X CMMOR E K C K X A A T L P F Q T U B F R W
U I F N K U A C O XW A Z X H U H S B C WB J L C J G M F O N I
L S HW P A C V A V X O K D E M S G T T B B Y B C H U R N Y J C
K I Z I K U J E V U H O X H A P WO J R T F K J L L F H J G F U
L S T L U Y Z U K S E B R G Y A S T O I R E P O T N V O G WQ S
M E C S C I I J V I X A DM A E I U L O C Y Q A J J H O VWZ Z
L N C OM B F NW S B D G A MG T R Z W FW O L A L M T Z S P Q
C E X N Z B F E NOU D G I P X X GU J DR F GG Y J S F O B S
A G F S QG B P S R X J A I QQ J A R N FW B Z X J I Q J S M Z
I OW X K Y A O X B T V J P H A T L V C O K I GW S N U F L G E
C E I Q T I R X A I QO S G E L GOH P B T D KO R CO S P B W
V T T E G I T XW FWN P B J P I A A NO I E R B H T T F E Z T
R S D G X D T W R C U I I M L Z I WN T A N E K C G I M T G O R
J OW Z H Q E S A I F Q S F L R U J D M T L S W L B A U Q Z I M
N B P N NO R A Z T L I WR P Q P T K L C R E F B Y C N P K P C
E D E J K E S G Y S I K V E E MV T S S FQ S E E ONVO L G Q
K QO Y V K Z S K Y P V CN Y H I WS C R C A L X H C E Y Y B V
V A S I I H Z NN CD QOZ OU C U X Y CR Z T B V Z J H X Y P
N HWM J R E P S I B O QM D M O U G A H T M I G D K K C P Y F
C C I D Z M E M Q WN H A U P R A K A D I Y V O F U G P U J T U
U O X N C K Y U F A X J E A E L K R O G WG W U O R F L Y P B P
F L S N W E L S N O M S P B U S Q N F I G K K Q R X R B Z WW G
L T V E AOV S E Y Z C U I HG J HQ A F I X A C Y HVU A I X
I W F T U K M U Y S L T F S B I T J I I N Y O N V NWM M O D W
A N P E V S Z J R X I Z X Q G Y Q O L E A S WH U H O X E X A E
S Z X D P A F T Z R K T D C OQ B K E T S C UO B J V V H Z V N
X E R OD E RMA P I GME N T O S A I YX V L Y L QN S F K P
T I Q Y X U U Z I A F QMR A U I E MMDX MU X S U NM B Y B
N I R F M P E N K T R WH I F H H O Y D L A Z R N U F U N F N T
N Q G R X H C R B N Q OWX S B G H P W Z I WH E P K G K E X N
P AMN D V Y P L I X T E F Q E T MK I RH F U Z V C E T QN U

Hidden in this puzzle are 8 autosomal recessive diseases and 5 autosomal dominant ones.
Can you find them?
88
 Notes

Solutions on page 189. 89

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45 CN 2-12 Intact?

1 2

4 5

7 8

10

11

12

13 14

15

16

17 18

19

20

21

22

90
Across: Down:
1-I 2 - VII
4 - Smell 3 - Eyelid opening (spell out the number)
6 - Eye movement, pupil constriction, 4 - Sight
lens accommodation 5-V
7 - VIII 7-X
11 - XII 8 - Eyelid closing (spell out the number)
13 - Talking and monitoring aortic 9 - Hearing and balance
baroreceptors 10 - IX
16 - III 12 - French kissing
17 - II 14 - Lateral rectus eye muscle
19 - XI 15 - Superior oblique eye muscle
20 - Shoulder shrugging 18 - IV
21 - Chewing, facial sensation (spell out
the number)
22 - VI

Solutions on page 191. 91

CrossWards™

46 This Puzzle DeLivers

2 3

7 8 9

10 11 12

13 14

15

16

17 18 19

20

21

22 23

24 25

92
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4 - Liver injury pattern: High elevation of 1 - This treatment may be indicated for
alkaline phosphatase, bilirubin, incon- severe alcoholic hepatitis
sistent elevation of aminotransferases 2 - Presence of this antibody may be
5 - Antismooth muscle antibody associ- only clue to recent hepatitis B
ated with this form of hepatitis infection during the “window period”
7 - Presence of this antigen is a marker 3 - Anti antibody, associated
for infectivity in chronic hepatitis B with #18 across
8 - Malignancy most commonly caused 6 - Rising cause of cirrhosis, associ-
by chronic hepatitis C (acronym) ated with obesity and diabetes (two
10 - Most common cause of abnormal words)
transaminases 7 - Name the disease: Bronze skin,
13 - Hepatitis virus responsible for diabetes, increase iron saturation
majority of chronic viral hepatitis 9 - Found to be low in patients with
(short form) #24 across
14 - Cause of severe hepatitis (>1,000) 11 - GI disorder often concomitant with
15 - Liver injury pattern: AST:ALT = 2:1 #17 down (two words)
16 - Liver injury pattern: Elevated 12 - The treatment for #7 down
aminotransferases, mild elevation of 15 - Cause of severe hepatitis (>1,000)
bilirubin, alkaline phosphatase 17 - Primary cholangitis:
19 - Serum marker elevated in #8 across Disease affecting mostly young men
(acronym) 18 - Primary cirrhosis:
20 - Cause of severe hepatitis (>1,000) Autoimmune cause of cirrhosis
21 - Cause of severe hepatitis (>1,000) affecting middle-aged women
22 - Presence of this antigen indicates 22 - Presence of this antibody indicates
chronic infection with hepatitis B prior exposure to hepatitis B or
23 - Cause of severe hepatitis (>1,000), vaccination
not enough oxygen to the liver
24 - Name the disease: Young adult with
liver disease and neuropsychiatric
symptoms
25 - A greater than or equal
to 1.1 suggests portal hypertension
(acronym)

Solutions on page 193. 93

CrossWards™

47 I Need a Puzzle–Stat!

2 3

4 5

10

11 12

13

14 15

16

17

18

19 20 21

22 23 24

25 26

27

28

29

94
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1 - Measurement of this value is neces- 2 - A female patient with abdominal
sary to diagnose carbon monoxide pain is until proven
poisoning as the pulse oximeter otherwise
reading will be normal 3 - Name the antidote: Methemoglobin
5 - Use of this drug is indicated for 4 - In addition to antihistamines, this
symptomatic bradycardia drug should be given to all patients
6 - Carotid massage, Valsalva, and cool with anaphylaxis
pack to the face are examples of 6 - Name the antidote: Warfarin
maneuvers 7 - The presence of this finding, often
9 - Name the antidote: Benzodiazepines seen on an upright chest x-ray, is an
11 - The presence of muscle rigidity, immediate indication for exploratory
hyperthermia, and autonomic disabil- laparotomy (two words)
ity may be an adverse effect of this 8 - Name the antidote: Beta-blocker
class of medications 10 - This intervention should be per-
14 - Name the antidote: Methanol formed without delay in patients
15 - Diltiazem slows conduction through with pulseless ventricular tachycardia/
the AV node, which may improve rate fibrillation arrest, once rhythm is
control in a stable patient with this identified
tachyarrhythmia (short form) 12 - For any unstable patient with a
17 - Name the antidote: Anticholinergics brady- or tachyarrhythmia, the first
19 - Name the antidote: Organophos- intervention should be
phate poisoning 13 - The use of epinephrine in a code is
21 - Withdrawal syndrome: Tremor, directed at increasing
tachycardia, hypertension, agitation, perfusion
hallucinations, seizures 15 - The use of this drug may be neces-
24 - Withdrawal syndrome: Anxiety, nau- sary to terminate an episode of
sea, diarrhea, abdominal cramping, supraventricular tachycardia
mydriasis 16 - The most definitive noninvasive
25 - The presence of this lesion differenti- diagnostic test for appendicitis
ates a second-degree from first- 17 - Third-degree burns are characterized
degree burn by full involvement of the dermis and
26 - Name the antidote: Opioids are painless/painful
27 - Use of this antiarrhythmic should be 18 - Name the antidote: Malignant hyper-
considered for patients with refrac- thermia
tory VT/VF arrest 20 - The use of is indicated
28 - In addition to defibrillation, torsades in patients with VT/VF pulseless arrest
de pointes should be rapidly treated who do not respond to defibrillation
with 22 - Name the antidote: Black widow
29 - ACE inhibitors may cause this rare spider
but life-threatening side effect 23 - Name the antidote: Heparin

Solutions on page 195. 95

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48 Shock and Awe

1 2

5 6

7 8

9 10

11

12 13

14

15 16

17

18 19

96
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3 - Peripheral vascular resistance is 1 - The W in PCWP
(increased/decreased) in #2 down 2 - Bacteremia and low BP:
5 - Core body temperature <95°F or shock
35°C 4 - An MI can lead to
7 - A state of inadequate oxygenation to shock
tissues 6 - For patient unresponsive to
11 - Inotropic drug useful if patient is #17 down, use transcutaneous
hypotensive
12 - Second leading cause of death in 8 - Blood loss shock
children 9 - Treat pulseless v-tach same as
14 - Universal blood donor ventricular
15 - Rule of for calculating 10 - First thing for ventricular fibrillation
burn surface area in adults 13 - PCWP is (increased/decreased) in #2
17 - A bee sting may lead to down
shock 16 - PCWP is (increased/decreased) in #4
18 - output is decreased in down
#4 down 17 - A drug to push for symptomatic
19 - One of the drugs useful for atrial bradycardia
fibrillation with rapid ventricular
response

Solutions on page 197. 97

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Doc Says “I’ve got good

49 news and bad news”*

1 2 3

5 6

8 9 10

11

12 13

14 15 16

17 18 19 20

21

22

23 24

25

26 27

28 29 30

31

32

33

34

35

36

*You’re going to have a disease named after you.

98
Across: Down:
1 - Most common dementia associated 2 - Chronic thiamine deficiency in
with Parkinson disease (two words) alcoholics leading to ataxia, confu-
5 - Congenital heart disease with sion, ophthalmoplegia:
downward displacement of the encephalopathy
tricuspid valve into the right ventricle: 3- -Johnson syndrome
anomaly is autosomal recessive condition of
9 - Cruise ship gastroenteritis: conjugated hyperbilirubinemia due to
virus transport defect
14 - Peripheral seventh nerve palsy 4 - Disease classically associated with
15 - Tapping over facial nerve elicits #12 down
ipsilateral facial muscle contraction: 6 - Henoch-Schönlein purpura is due to
sign the deposition of immune complexes
16 - Tonic pupil, larger than contralateral containing this (acronym)
unaffected pupil, with no neurologic 7 - Most common lysosomal storage
significance: pupil disease
17 - Aphthous ulcers, genital ulcerations, 8 - RUQ pain, jaundice, and fever:
ocular inflammation: triad
disease 10 - Child with fever, mucosal inflamma-
21 - Glomerulonephritis and pulmonary tion, cervical lymphadenitis, and des-
disease suggests quamation has disease
syndrome 11 - Autoimmune hyperthyroidism:
22 - Test used to demonstrate that ulnar disease
artery is functional (before doing an 12 - Periodic fever (hyphenated)
arterial line) 13 - VSD, pulmonic stenosis, anteriorly dis-
23 - Pain with forced dorsiflexion of the placed aorta, right ventricular enlarge-
foot supposedly an exam finding in ment: Tetralogy of
patients with DVT: sign 18 - Ptosis, meiosis, anhidrosis:
25 - Forced flexion of the arm to overhead syndrome
position elicits pain in patients with 19 - A lot of vomiting may cause this
shoulder impingement: small tear near the gastroesophageal
sign junction (hyphenated)
26 - Hearing loss, vertigo, tinnitus: 20 - Pericarditis after an acute myocardial
disease infarction: syndrome
30 - People under study behaving 21 - Mild unconjugated hyperbilirubinemia
differently describes the affects up to 7% of the population:
effect syndrome
31 - Stain used to detect eosinophils in 24 - Set of criteria for diagnosing
the urine rheumatic fever
32 - Tumor associated with #18 down, an 27 - Treatment for helping dislodge the
apical lung cancer otoliths in benign positional vertigo:
34 - Hereditary nephritis associated maneuver
with deafness and eye disorders: 28 - For determining cause of B12
syndrome deficiency: test
35 - Allergic angiitis and granuloma- 29 - Nodules or macules in the palms or
tosis in the lungs associated with soles that might be seen in patient with
eosinophilia: Churg- endocarditis: lesions
syndrome 32 - TB in the spine: disease
36 - For distinguishing transudate from 33 - Catheter with a balloon at the tip
exudate in pleural effusion, use these that when inflated helps keep it in
criteria the bladder

Solutions on page 199. 99

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50 Step 2 Potpourri

3 4

6 7 8

10

11 12

13

14 15

16

17

18

19

100
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1 - Blood in urine, pain in the side, 1 - Dermatitis herpetiformis:
and a palpable flank mass: Renal disease
carcinoma 4 - Most common thyroid cancer type
2 - Give for an overdose of diazepam 5 - Your patient in v-fib needs immediate
3 - Painful bleeding in third trimes-
ter with fetal distress: Placental 6 - Red cell casts in urine
8 - “Photographic negative” of pulmo-
7 - Pleural fluid with a pleural:serum nary edema on chest x-ray: Chronic
protein of 0.8 and pleural:serum LDH pneumonia
of 0.75: effusion 9 - Chest pain relieved by leaning for-
10 - A postmenopausal woman with vaginal ward; ECG with diffuse ST elevation
bleeding needs an 12 - Panic disorder treatment (acronym)
biopsy 15 - Back pain worsened by standing
11 - No ganglion cells in the colon: and walking, relieved by sitting:
disease Spinal
13 - B2 agonist for asthma 17 - The “U” in MUDPILES
14 - B12 deficiency anemia is
16 - Treatment for bacterial vaginosis
18 - Pseudomembranous colitis is almost
always from this infection (use the
first letter of genus)
19 - A testicular cancer is most likely
a

Solutions on page 201. 101

CrossWards™

Loosen Up with Some

1 Medical Eponyms

H
A
L J A N E WA Y
A T
N H
L G O
T R E ND E L E NB U R G
W R E N
Y S H A N S E L S
B C
MC MU R R A Y E L
U D J I
P D D I G E OR G E
H K Z I N H
A P G A R B A B I N S K I E T
L I P N O S S
E P L E Y R OV S I NG S
N B S K S
E B I I
F OU R N I E R S
T C
C HV O S T E K S
S

102
Across: Down:
3 - Nodules or macules on palms or 1 - People being watched (studied)
soles seen in endocarditis: JANEWAY behave differently: HAWTHORNE
lesions effect
They are embolic. 2 - Dermatology lines
5 - When standing on one leg unable to LANGER’S. Please use them when
lift opposite side of pelvis: excising a skin lesion!
TRENDELENBURG sign 4 - LEWY body dementia
Signifies weak gluteus. It is like overlapping Alzheimer and
7 - To detect eosinophils in urine, ask for Parkinson diseases.
a HANSEL’S (OR HANSEL) stain 6 - Free Ig light chains seen in plasma cell
Can be acute interstitial nephritis but dyscrasias: BENCE-JONES proteins
not specific. Mostly multiple myeloma but also
9 - One of the tests for meniscal tear Waldenström microglobulinemia.
MCMURRAY 8 - Flexing the neck causes flexion of
13 - Failure of third and fourth pharyngeal the hips/knees in meningitis:
pouches to differentiate: DIGEORGE BRUDZINKSI sign
syndrome Neither this test nor Kernig are useful
22q11.2 deletion, multiple manifesta- since their LRs are close to 1.
tions including partial thymus which 10 - Primary adrenal insufficiency:
causes immunodeficiency. ADDISON’S disease
15 - APGAR score: Five parameters 11 - For distinguishing transudative from
assessed at birth exudative pleural effusion: LIGHT’S
Named after Virginia Apgar, but you criteria
can also remember the components as Dr. Light described these in 1972.
Appearance, Pulse, Grimace, Activity, 12 - Carpal tunnel test in which wrists are
and Respiration. flexed for a minute
17 - When rubbing sole of foot in upper PHALEN. Another classic bedside
motor neuron lesion, great toe test that is not really that useful (and
goes up and other toes fan out: neither is Tinel).
BABINSKI sign 14 - Vascular tumor associated with
It is a primitive reflex in infants, but if HHV-8: KAPOSI’S sarcoma
toe goes up and it is not a newborn, Seen in AIDS.
get a CT or MRI of the brain. 16 - Most common cause of mild uncon-
18 - BPV treatment maneuver jugated hyperbilirubinemia:
EPLEY. Attempts to reposition the GILBERT’S syndrome
free-floating particles. You can see Due to reduced glucuronyltransferase
it demonstrated on some YouTube activity.
videos. 20 - Distended neck veins, distant heart
19 - Deep palpation of LLQ provokes pain sounds, low BP: BECKS triad
in RLQ in appendicitis: ROVSING’S Get a pericardiocentesis tray ready to
sign relieve acute cardiac tamponade!
One of the peritoneal signs.
21 - Necrotizing infection of genital fascia:
FOURNIER’S gangrene
Obviously not a good thing.
22 - In hypocalcemia, tapping over
facial nerve causes facial twitch:
CHVOSTEK’S sign
And do you remember Trousseau’s sign?

103
CrossWards™

2 Cross My Heart

I A O R T I C
S Y NC O P E R H T
C T B R A D Y C A R D I A
R A H G H O
E N H O C M A F P
D I A B E T ES P S C O U G H
S U R E N A L W N
E R H E A I I
S Y E A L D O S T E R ON I S M
S U F C
MY XOMA T A M P ONA D E H
P A S R E
S E L T P I M
T H R OM B OS I S D I G OX I N I
E I O C R A
N C P I
O A N E G A T I V E
S R N J
I D F E
S I D W A C A B G
T H I A Z I D E M R T
B I L D D I S S E C T I ON
U N S T A B L E T T O
N T N F R I C T I ON R U B
D E E A O
L D D I A S T OL I C N
E

104
Across: Down:
2 - Harsh systolic murmur radiating to carot- 1 - A sign of #10 across is a systolic murmur
ids: AORTIC stenosis that INCREASES in intensity with standing
Can cause chest pain, syncope, and heart 3 - Breathlessness with lying flat
failure. ORTHOPNEA. One of the CHF symptoms.
5 - Medical term for “done fell out” (sudden, 4 - Most common cause of myocarditis in the
temporary loss of consciousness) world: CHAGA’S disease
SYNCOPE Caused by T. cruzi transmitted by “kissing
7 - Heart rate less than 60 bpm bugs.”
BRADYCARDIA. Not necessarily pathologic. 6 - Protein that is elevated for several days
10 - Most common cause of sudden cardiac after a myocardial infarction
death in athletes (acronym) TROPONIN
HOCM. Hypertrophic obstructive cardiomy- 8 - If you hear a gallop when listening to the
opathy. heart, do not think horses, but think this
11 - ACE inhibitors are the preferred antihy- (acronym)
pertensive drug class in patients with CHF
DIABETES and proteinuria 9 - Screen men aged 65 to 75 who have ever
12 - ACE inhibitors can cause this nagging smoked for abdominal aortic ANEURYSM
adverse effect, which would be a reason to Screen with ultrasound.
change to an ARB 13 - Most common cause of mitral valve steno-
COUGH sis: RHEUMATIC fever
13 - Most common cause of secondary hyper- 14 - Patients with atrial fibrillation can be
tension in children: RENAL parenchymal treated with WARFARIN to reduce risk of
disease stroke
Get a UA, urine culture, and renal Aspirin can be used in low-risk patient;
ultrasound. newer anticoagulants are available as well.
16 - Cause of secondary hypertension charac- 15 - ST segment depression suggests this
terized by unprovoked hypokalemia: Hyper ISCHEMIA
ALDOSTERONISM 19 - Part of the postmyocardial infarction
17 - A mobile, pedunculated mass in the left “recipe”
atrium is likely an atrial MYXOMA ASPIRIN. Other components are statin,
18 - JVD, low BP, and distant heart sounds is acute beta-blocker and ACE inhibitor.
cardiac TAMPONADE until proven otherwise 20 - Diffuse ST segment elevation on an EKG of
23 - Stasis, hypercoagulability, and injury set a a patient with chest pain that is worse with
person up for a deep venous THROMBOSIS lying down suggests acute PERICARDITIS
Virchow’s triad. 21 - Aortic STENOSIS is one of the cardiac
24 - Drug that inhibits Na+/K+−ATPase and causes of #5 across, mostly in the elderly
increases cardiac contractility 22 - Treat symptomatic heart failure with a
DIGOXIN. Has narrow therapeutic index. LOOP diuretic
25 - On EKG: Left axis deviation has NEGATIVE Like furosemide.
QRS in lead II 26 - Q waves, that are two small boxes wide or
30 - Severe stenosis of the left main coronary more than one-third the QRS amplitude
artery is an indication for this surgery suggest myocardial INFARCTION
(acronym) 27 - Evaluate heart failure with an echocardio-
CABG. Coronary artery bypass grafting. gram to estimate left ventricular EJECTION
31 - First-line antihypertensive medication class: fraction
THIAZIDE diuretics 28 - Most common type of cardiomyopathy
Like chlorthalidone or HCTZ. DILATED
34 - A hypertensive emergency with sudden 29 - A chest x-ray of the patient in #9 down
chest pain radiating to the back suggests may show a WIDENED mediastinum
aortic DISSECTION 32 - Midsystolic murmur with a “click” MITRAL
35 - Chest pain that is new onset or that is get- valve prolapse
ting worse is deemed UNSTABLE angina 33 - When the QRS is widened, there is some
This is an acute coronary syndrome. sort of BUNDLE branch block
36 - On examination of the patient in #20
down you might hear a pericardial
FRICTION RUB (two words)
37 - Aortic regurgitation has a DIASTOLIC murmur

105
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3 Put Some Skin in the Game

K E R A T OS E S
U
S R
P O
P I T Y R I A S I S
T A
Z P A T C H
N E
S V A A
E C Z E MA P
B R H
NOD O S UM Y
R I L
M I U R T I C A R I A
A M H O X
C P A P U L E L I
U E I O P S
L T G C L A R K S
V E S I C L E O
G N R
O I S OT R E T I NO I N
T A
A MOL L U S C UM
L I R
S H I NG L E S S
A

106
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1 - These “stuck-on” brownish wart-like 2 - Bleeding when a skin scale is scraped:
lesions are very common and are AUSPITZ sign
benign: Seborrheic KERATOSES 3 - If you see an older gentleman with
Can be shaved or cryo’d if they bother rhinophyma, think this condition
patient. ROSACEA. Can try topical metronida-
4 - Herald patch heralds this dermatitis: zole to treat.
PITYRIASIS rosea 6 - Type 1 hypersensitivity might be this
5 - Flat skin lesion >1 cm serious reaction
PATCH ANAPHYLAXIS
9 - Another name for atopic dermatitis 7 - Pityrosporum ovale is implicated in
ECZEMA. Very common; treat with this dermatitis
topical steroids. SEBORRHEIC. Flakes in eyebrows,
10 - Tender, erythematous nodules on hairline (dandruff).
lower legs usually triggered by an 8 - Caused by Malassezia furfur: Tinea
illness or drug reaction: Erythema VERSICOLOR
NODOSUM “Spaghetti and meatballs” on slide.
13 - Medical term for hives 11 - Flat skin lesion <1 cm
URTICARIA. Very itchy. MACULE
14 - Elevated skin lesion <5 mm 12 - Group A streptococcal secondary skin
PAPULE infection characterized by honey-
17 - Melanoma is staged by TNM and this colored crusted lesions, mostly in
level children
CLARK’S. And Breslow thickness. IMPETIGO
18 - Small, fluid-filled lesion 15 - #2 down is seen with this inflamma-
VESICLE. Like herpes. tory skin disease
19 - This medicine used to treat serious PSORIASIS
acne is also a serious teratogen 16 - HSV-2 causes lesions here
ISOTRETINOIN GENITALS. HSV-1 causes oral lesions.
20 - MOLLUSCUM contagiosum: Caused 21 - A patient who thinks he has a spider
by poxvirus, tiny lesions with central bite more likely has a skin infection
umbilication, more common in with community-acquired form of
children this (acronym)
22 - Vesicular rash in dermatomal MRSA. Methicillin-resistant staphylo-
distribution, common term for the coccus aureus.
diagnosis
SHINGLES. Caused by reactivation of
varicella zoster virus.

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4 Lytes Out!

H Y P ONA T R E M I A H
O N Y
C A L C I T ON I N I P
T O G L U C OS E
A S P I R I N R
D N G C
H Y P E R MA G N E S E M I A
P O L
M P D C
E A L B U M I N E
T R U M
A NO R MA L C A L C I UM I
I B L L A
N O D O D
S L C HOV S T E K S
I I S M H
P C T O Y H
I A E L D Y
D C H Y P E R K A L E M I
A P
U I E O O L L O
S OD I UM T N I K K
O O A I T A A
S L S S Y L L
I Y S M O E
S S I MA GN ES I UM
I U I I
F U R O S E M I D E P HOS P HA T E

108
Across: Down:
1 - Psychogenic polydipsia might be a cool 2 - Correcting #1 across too quickly can
name for a rock band, but it can cause result in central PONTINE myelinolysis
this electrolyte problem 3 - Sodium minus (chloride + bicarbonate) =
HYPONATREMIA. Always remember ANION GAP (2 words)
Na+ concentration is telling you some- 4 - “Stones, bones, moans, and groans,”
thing about water. think this
5 - This hormone from the C cells of the HYPERCALCEMIA. Which might be due
thyroid gland decreases calcium to hyperparathyroidism.
concentration 7 - A common cause of hyponatremia is a
CALCITONIN. It puts it in the bones. I syndrome of too much of this (initials)
remember “calciBonin.” ADH. Antidiuretic hormone (SIADH).
6 - Low sodium should be correct for high 9 - Fractional excretion of this is helpful in
this figuring out acute kidney injury
GLUCOSE SODIUM. Use urea if on diuretic.
7 - Overdose of this may cause a metabolic 10 - pH <7.4 with PCO2 <40 mm Hg
acidosis and respiratory alkalosis (two words)
ASPIRIN METABOLIC ACIDOSIS
8 - Loss of deep tendon reflexes is an early 11 – It is the P in MUDPILES
manifestation of this PARALDEHYDE
HYPERMAGNESEMIA. Mostly see this 14 - Hypokalemia and hypernatremia found
when monitoring preeclampsia patients when working up the newly diagnosed
on labor ward. hypertensive patient
12 - Before jumping to conclusions on low suggests hyperALDOSTERONISM
calcium, be sure you correct for low 16 - Diabetes INSIPIDUS is due to not
amount of this enough ADH
ALBUMIN 17 - Twice the sodium concentration +
13 - One other reason not to sniff glue is (glucose concentration)/18 + blood urea
that it can cause a metabolic acidosis nitrogen/2.8 gives the calculated serum
with a NORMAL anion gap OSMOLALITY
15 - In severe hyperkalemia, give this first to 19 - T waves may be flat in this electrolyte
protect the heart abnormality
CALCIUM (gluconate) HYPOKALEMIA
18 - Facial spasm brought on by tapping 20 - If this happens to the blood sample, the
by the ear over the facial nerve when potassium may measure elevated but it
calcium is low: CHOVSTEK’S sign really is not
Can you think of an ENT operation when HEMOLYSIS
you might check this? 21 - Insulin drives this electrolyte intracel-
20 - Angiotensin-converting enzyme inhibi- lularly
tors can cause this electrolyte problem POTASSIUM. Remember CBIGKDrop:
HYPERKALEMIA Calcium, bicarbonate, insulin, glucose,
23 - The concentration of this determines kayexalate, dialysis.
tonicity 22 - Hyperventilation leads to respiratory
SODIUM. See #1 across. ALKALOSIS
24 - Not enough of this in the blood can Because of breathing off too much CO2.
lead to Torsade de pointes
MAGNESIUM
25 - In severe hypercalcemia, give intra-
venous hydration and this drug to
promote calcium excretion
FUROSEMIDE
26 - Parathyroid hormone (PTH) decreases
the resorption of this by the kidney
PHOSPHATE

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CrossWards™

5 Immune to Myself?

G
S O
L F J O
R H E U MA T O I D
A P C G P
S U T R A
H I S T ON E S
W I R N T
D E R MA T O S U
G O R
C R E S T E
N O G R A V E S
S B E R G E R S
C N R
L L U P U S
E U
R P O L Y A NG I I T I S
O C U
D I A B E T E S
E L
R B I L I A R Y C I R R HO S I S
M A
A C E L I A C

110
Across: Down:
5 - Anti-citrullinated protein (CCP): 1 - Anti-basement membrane:
RHEUMATOID arthritis GOODPASTURE’S syndrome
See also #4 down. Antibodies attack lungs and kidneys.
7 - Drug-induced lupus may have anti- 2 - Anti-ro: SJOGREN’S syndrome
HISTONE antibodies Also known as sicca syndrome, hall-
Hydralazine is one of the nearly mark symptoms are dry mouth and
40 drugs that can cause this. dry eyes because disease attacks the
9 - Anti-Jo 1 may point to poly- or exocrine glands.
DERMATOmyositis 3 - Anti-ds DNA
Heliotrope rash is classic. LUPUS. See also #15 across and
10 - Anti-centromere (syndrome, acronym) #15 down.
CREST. Calcinosis, Raynaud’s, 4 - Rheumatoid FACTOR in RA
Esophageal dysmotility, Scleroderma, See also #5 across.
Telangiectasias. 6 - Thyroid peroxidase antibodies:
11 - Antibodies activating thyroid- HASHIMOTO’S disease
stimulating hormone receptor: Most common cause of hypothyroidism.
GRAVE’S disease 8 - c-ANCA vasculitis
Most common cause of hyperthy- WEGENER’S
roidism. 12 - Anti-Scl-70
13 - IgA SCLERODERMA
BERGER’S 14 - U1 RNP (acronym) in mixed connec-
15 - Anti-Sm tive tissue disease
LUPUS. See also #15 down and #3 Ribonucleoprotein.
down. 15 - Anti-nuclear antibody
16 - p-ANCA: microscopic POLYANGIITIS LUPUS. See also #15 across and
18 - Islet cell antibodies: Type 1 DIABETES #3 down.
19 - Anti-mitochondrial antibody: Primary 17 - Anti-transglutaminase: CELIAC
BILIARY CIRRHOSIS disease
20 - Anti-endomysial: CELIAC disease See also #20 across.
See also #17 down.

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I’m “Gland” You’re Doing

6 This Puzzle

P R O P R A NOL OL
A
P
C A L C I UM S
L O G
B U F F A L O K M R
A P E R OX I D A S E
R T G V
HY D R OX Y L A S E
A I S
C
S I A D H H
D A Y
O W P
A D D I S ON S E
C L E I R
O D H A S H I MO T OS
R O Y H O
T S D Y D
P I T U I T A R Y R I
S E A O U
O P A R A T HY R O I D I S M
L O I D
N O I
I N C U S H I NG S
S M
P H E O C H R OMO C Y T OM A

112
Across: Down:
1 - Useful beta-blocker to treat symp- 1 - Most common type of thyroid cancer
toms of hyperthyroidism PAPILLARY
PROPRANOLOL. Not only decreases 3 - In Type 1 diabetic patient, hyper-
symptoms but also inhibits conversion glycemia early in the morning in
of thyroid hormone. response to hormones counteracting
2 - If tapping on facial nerve elicits overnight hypoglycemia: SOMOGYI
twitch of facial muscles, think low effect
levels of this 4 - Most common cause of #11 down:
CALCIUM GRAVE’S disease
5 - A classic sign of #19 across: 6 - Hyperglycemic crisis in Type 1 diabetes
“BUFFALO hump” mellitus: Diabetic KETOACIDOSIS
7 - Antithyroid PEROXIDASE antibodies Treat with aggressive IV fluids and
are seen in #15 across insulin while watching potassium
But they are also highly prevalent in carefully.
the general population; not needed to 10 - In Type 1 diabetic patient, hyper-
diagnose hypothyroidism. glycemia early in the morning due
8 - Most causes of #14 down are due to to insulin being counteracted (by
the deficiency of 21-HYDROXYLASE growth hormone) overnight: DAWN
9 - Very common cause of euvolemic phenomenon
hyponatremia (acronym) 11 - Low TSH with elevated free T4:
SIADH. Treat with fluid restriction. Primary HYPERTHYROIDISM
12 - Autoimmune adrenal insufficiency: Order a thyroid uptake scan; treat with
ADDISON’S disease antithyroid drugs or radioactive iodine
15 - Most common cause of elevated TSH ablation, rarely surgery.
with low free T4: HASHIMOTO’S 12 - Low K+ and high Na+ in a newly diag-
disease or thyroiditis nosed hypertensive patients suggests
Treat with thyroid hormone hyperALDOSTERONISM
(levothyroxine) and titrate using 13 - A key clinical issue in hyperosmolar
TSH level. hyperglycemic state is
17 - MEN 1: Pancreatic tumor, parathyroid DEHYDRATION, which is why
hyperplasia, and PITUITARY adenoma aggressive fluid replacement
MEN 1 = 3 P’s. (along with insulin) is needed
18 - “Stones, bones, moans, and groans,” 14 - Congenital adrenal hyperplasia leads
think this: HyperPARATHYROIDISM to the deficiency of this
Which leads to hypercalcemia. CORTISOL
19 - Too much ACTH will lead to 16 - Part of the treatment of nephrogenic
CUSHING’S syndrome diabetes insipidus is SODIUM
20 - Catecholamine-secreting tumor that restriction
is a very rare cause of secondary
hypertension
PHEOCHROMOCYTOMA. If sus-
pected, check urine metanephrines.

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7 Abdominal Pains

M
U
R
P
H P
Y E
C H OL E S T E R OL
H F
O B OR E
M L C R
A D H E S I ON S A C HA L A S I A
L N O T
L I P A S E G A L L S T ON E S
O P I E D
R B A T L V
Y A P P E ND I C I T I S
W C R S C S T R Z
E U R O R H C U L L E N
I NC A R C E R A T E D I H N
S L T S A A O K
S I T T S W E
N S I I R
G T S
R OV S I NG S I
S

114
Across: Down:
3 - Most gallstones are composed of 1 - Deep palpation in RUQ causes
CHOLESTEROL inspiratory halt in cholecystitis:
4 - In any patient with GI bleed, be sure MURPHY’S sign
to have two large BORE IV’s in place 2 - Free air under the diaphragm on plain
7 - Common cause of small bowel film: PERFORATED viscus
obstruction Call the OR.
ADHESIONS 3 - RUQ pain, jaundice, and fever
8 - Esophagus looks like a bird beak on suggests this diagnosis
barium swallow CHOLANGITIS
ACHALASIA 5 - Superficial tear of esophagus often
9 - Elevated in acute pancreatitis due to excessive vomiting (two
LIPASE. So is amylase but less specific. words)
10 - One of top two causes of pancreatitis MALLORY WEISS. Usually heals on its
GALLSTONES. Alcohol is the other. own.
14 - Diagnosis for patient with periumbili- 6 - “Female, fat, forty, and fertile” are
cal pain that moves to RLQ associ- classic risk factors for this
ated with anorexia CHOLELITHIASIS
APPENDICITIS 11 - #18 across seen in hemorrhagic
18 - Ecchymosis around the umbilicus: PANCREATITIS
CULLEN sign 12 - Metaplasia in distal esophagus
Bleeding internally, such as hemor- BARRETT’S
rhagic pancreatitis; Grey Turner sign is 13 - Metastasis above the left clavicle:
at the flank. VIRCHOW node
19 - This kind of hernia requires urgent As from lung or stomach cancer.
surgery 15 - Abdominal pain on extension of hip
INCARCERATED. Or strangulated with knee flexed: PSOAS sign
(and therefore, losing blood supply). Another peritoneal sign.
20 - Pain in RLQ on palpation of LLQ: 16 - Acute stomach ulcer in trauma and
ROVSING’S sign burn victims: CURLING’S ulcer
One of the peritoneal signs. And what is Cushing’s ulcer?
17 - ZENKER diverticulum is a cause of
oropharyngeal dysphagia

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8 Clinical Scramble

HALLUCINATIONS
H A L L U C I N A T I O N S

CLOUDED MIND
C L O U D E D M I N D

IMPAIRED ATTENTION
I M P A I R E D A T T E N T I O N

ACUTE ONSET
A C U T E O N S E T

REVERSIBLE
R E V E R S I B L E

ANSWER: DELIRIUM (When you see

a patient with it, search for the cause!)

116
Notes

117
CrossWards™

9 This Confounded Puzzle!

P
O
S R
I A B S O L U T E
T R P C
R E L A T I V E E O
A E V C N
N A N E GA T I V E S F
D D F E O
C A S E C ONT R O L I P N U
M I C R S N
I M L I K E L I HOOD
Z E S T V T I
E T WE NT Y A I N
L L V G
ME A S U R E ME N T
C P N
T E C
I NC I D E NC E
O I O
N F H
I O
C R
S E N S I T I V I T Y
T
Y

118
Across: Down:
3 - 1 divided by the ABSOLUTE risk reduc- 1 - A new blood test is developed to detect
tion is the NNT S2SFS; among 100 students with
6 - Step 2 study fatigue syndrome, or definite S2SFS by gold standard brain
S2SFS, occurs in 20% of medical stu- scan, the new blood test is positive in 80;
dents; a new drug reduces the incidence among 100 students without S2SFS by
of S2SFS to 15%; 25% is the RELATIVE brain scan, the blood test is negative in
risk reduction 90; 89% is the POSITIVE predictive value
20 –15/20 = 25%. 80/[80 + (100 – 90)].
8 - Subtract the NEGATIVE predictive value 2 - Case-control studies are particularly
from 1 to get the probability a patient valuable when studying outcomes that
with a negative test has the disease are RARE
The NPV itself is the probability that a Think of how long and expensive it would
patient with a negative test does not be to do a cohort study waiting for rare
have the disease. outcomes.
10 - A study in which we find a sample of 4 - Probability that a patient without the
students who scored really high on Step disease has a negative test
2 examination and a sample who scored SPECIFICITY. TN/FP + TN.
really low from a similar population and 5 - The name for the bias in #6 down
then call them up and ask if they used CONFOUNDING
CrossWardsTM is a CASE-CONTROL 6 - Students who study hard are more
study likely to score high on Step 2 examina-
Such a study samples on the outcome tion and may also be more likely to use
and then looks back to measure CrossWardsTM, a relationship that may
exposure. not be random; the best way to elimi-
12 - A positive LIKELIHOOD ratio is the nate this potential bias from a study is
probability of a positive test result in to RANDOMIZE the students who use
those with the disease divided by the CrossWardsTM or not
probability of a positive test result in 7 - In studies of screening, the bias intro-
those without the disease duced because a screened population
14 - The NNT in #6 across to prevent one appears to have longer survival than an
case of S2SFS unscreened population but really does
TWENTY. 1/(0.20 – 0.15) = 20. not is called LEAD-TIME bias
15 - Students in the study in #10 across 9 - A highly SENSITIVE test when negative,
who scored high on Step 2 examination helps rule out a disease
may be more likely to remember using Remember SnNout. Sensitive (Sn) when
CrossWardsTM than those who scored negative (N) rules out.
poorly; this is a kind of MEASUREMENT 11 - Proportion in a population who have a
bias disease or outcome at a specific time
This is classic “recall bias.” (e.g., now)
17 - Proportion in a population who develop PREVALENCE
a disease or outcome over a period of 13 - Participants in a study may drop out of
time (e.g., over the next year) one group more than the comparison
INCIDENCE group; this introduces possible
19 - Probability that a patient positive for SELECTION bias
the disease has a positive test To remember selection bias, think
SENSITIVITY. TP/(TP + FN). problems with “choosing or losing”
participants.
16 - False positive rate is the same as
1 minus the SPECIFICITY
18 - A study in which we follow medical stu-
dents who use CrossWardsTM and those
who do not and later assess their board
scores is a COHORT study design

119
CrossWards™

10 GI Feel Terrible

P B D I R E C T
A MMON I A I C H H
N MA L L OR Y WE I S S O
C P I O M B L
R O L A H O O A
E F R E E A I R N C N
A T C Y S H G
T A T C I R R HO S I S
I L U O T
T I L E U S M Z I
I O V A E S
S C HA T Z K I S B A R R E T T S
E C R A O C
A I N S E
C R C S H I G E L L A
H P Y L OR I C E O S I C
F W I L S ON S A H
F G N S C A
C ME G A C OL ON M L
H E L I S U A
A L G L D A S T E R I X I S
R OT A V I R U S I P I
C C O T D Y S P H A G I A
O T U O S Y
T A N N S
S T D E
H B E A G S QU A MOU S C E L L

120
Across: Down:
3 - Type of inguinal hernia that protrudes 1 - Your patient with epigastric pain and
medial to the epigastric artery elevated lipase has acute PANCREATITIS
DIRECT. An indirect protrudes laterally. Amylase also may be elevated.
5 - Hepatic encephalopathy is due to failure to 2 - Autoimmune disorder with positive anti-
clear this mitochondrial antibody: Primary BILIARY
AMMONIA cirrhosis
8 - Repeated vomiting can lead to this tear that 4 - RUQ pain, jaundice, and fever suggest
causes upper GI bleeding (two words) ascending CHOLANGITIS
MALLORY WEISS 6 - Inflammatory bowel disease with skip lesions
12 - If you see this under the diaphragm on an CROHN’S
x-ray, think perforation (two words) 7 - Treat this cause of cirrhosis with phlebotomy
FREE AIR. Call the surgery team. HEMOCHROMATOSIS. Monitor ferritin and
13 - Eventual fibrosis, scarring, and regenerative CBC.
nodules in the liver that can result from a 9 - The cause of this condition (acronym) is
wide variety of insults adhesions from a prior surgery in about
CIRRHOSIS two-thirds of patients
14 - Loss of peristalsis without mechanical SBO. Small bowel obstruction.
obstruction 10 - Kind of hypertension that results from
ILEUS #13 across
17 - Rings and webs in the lower esophagus, not PORTAL. This can lead to ascites.
to be confused with the name of a deli 11 - Treat #5 across with this
SCHATZKI’S LACTULOSE
18 - Chronic GERD can lead to metaplasia called 15 - Rare syndrome of gastrin being produced
BARRETT’S esophagus by a tumor in the pancreas that can lead to
This can be a precursor to esophageal cancer. ulcers (acronym/initials)
23 - One of the organisms that causes bloody ZES. Zollinger-Ellison syndrome.
diarrhea 16 - A worrisome source of upper GI bleeding in
SHIGELLA. Salmonella, Campylobacter, patients with cirrhosis: Esophageal VARICES
invasive E. coli, and Yersinia are some Never underestimate these.
others. 19 - Amylase is NOT one of these criteria that
25 - Germ that causes ulcers, common short include elevated glucose, age >55 years,
form elevated LDH, elevated ASH, and elevated
HPYLORI white blood cell count on admission
26 - You see Kayser-Fleischer rings not around RANSON’S
Saturn, but in this disease 20 - High levels of 5-HIAA define this syndrome;
WILSON’S. It also affects the liver. patients may have flushing and diarrhea
29 - Complication of inflammatory bowel disease CARCINOID
with dilation of the colon and systemic 21 - Gluten-free diet is the treatment for this
toxicity: Toxic MEGACOLON disease
33 - “Liver flap” CELIAC
ASTERIXIS. Tremor of the hand when the 22 - This description of emesis suggests upper GI
wrist is extended. bleeding (2 words)
34 - Most common cause of diarrhea in infants COFFEE GROUND
ROTAVIRUS 24 - “Bird’s beak” esophagus
35 - It is difficulty swallowing ACHALASIA. Can cause dysphagia for liquids.
DYSPHAGIA. Think obstruction (e.g., mass) 27 - One of the top two causes of #1 down.
if for solids, or scleroderma, achalasia or GALLSTONES. The other is alcohol.
esophageal spasm if for liquids. 28 - The three signs in #4 down are called
36 - Serologic marker reflecting high transmis- CHARCOT’S triad
sibility of hepatitis B infection (acronym) 30 - These drugs are a common cause of gastritis
HBEAG. Hepatitis B e antigen. and peptic ulcer (acronym)
37 - Most common type of esophageal cancer in NSAIDS. Nonsteroidal anti-inflammatory drugs.
the world (two words) 31 - This sign is inspiratory arrest when palpating
SQUAMOUS CELL in the right upper quadrant
MURPHY’S
32 - This lab can be helpful in evaluating possible
mesenteric ischemia
LACTATE

121
CrossWards™

11 Nerve-racking Puzzle

B
I NT U B A T I ON
B
M I D D L E
N
O S A H S
X X C K
A C E T Y L C HOL I N E
N G I P
MU L T I P L E S C L E R OS I S
E H O N L D
N O S E U C
B I C T S U B D U R A L
U P P E R H E E A U
V R R R L L S
E O I L T
S M O W S E
M I G R A I N E R
A S
S T A T U S

122
Across: Down:
2 - #19 across usually requires this 1 - BABINSKI sign: Dorsiflexion of great
procedure toe with fanning of other toes
INTUBATION. To protect the airway. 4 - Acute treatment for #12 down
3 - Aphasia, contralateral paralysis and OXYGEN
sensory loss, gaze toward the side: 6 - S1 nerve root reflex location:
Where is the lesion? MIDDLE cerebral ACHILLES tendon
artery 7 - This yellowish coloration of CSF from
5 - Sudden onset “worst headache of my lumbar puncture suggests #5 across
life” think this (acronym) XANTHOCHROMIA
SAH. Subarachnoid hemorrhage. 9 - Tear of the middle meningeal artery:
8 - Myasthenia gravis is due to antibod- EPIDURAL hematoma
ies against these receptors 10 - Triad of hearing loss, tinnitus, and
ACETYLCHOLINE vertigo
10 - MRI shows white matter lesions MENIERE’S
and CSF has oligoclonal bands (two 11 - Double-vision, dysphagia, and slurred
words) speech seen in POSTERIOR circula-
MULTIPLE SCLEROSIS tion stroke
14 - Older patient hits head and ruptures 12 - Excruciating, one-sided headaches
bridging veins: SUBDURAL hematoma associated with nasal stuffiness and
16 - #1 down seen in UPPER motor tearing of the eye
neuron lesion CLUSTER
18 - Most common disabling headache 13 - Common cause of vertigo due to
MIGRAINE malpositioned otolith (acronym)
19 - Seizure lasting more than 10 minutes: BPV. Benign positional vertigo; some-
STATUS epilepticus times you will see as BPPV, an extra
P for paroxysmal.
15 - Idiopathic CN7 palsy: BELL’S palsy
Peripheral CN7 nerve lesion does not
spare the forehead.
17 - Infantile spasms: WEST syndrome

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CrossWards™

One More . . . For Old

12 Timer’s Sake
Meredith Gilliam

L E F T
R E M
C H R ON I C B R O NC H I T I S
T P H P O T P
P WA V E S E F O L R Y
O T C N N I A O
L R A A I L G
Y I N N N E
M A A A G B M K N
Y L O L L A S E
A F R E P S E UD OGOU T S
L I T B R E
G B I S T N
I R C A L C I UM I NH I B I T OR S
A I A E Y C S T
L A C UNA R C L P D I E
L N R L E I S R
A G P O D A G R A S O
T I L T S I
F I F T Y O I NC R E A S E S D
O G D N C S
N MP R OT E I N S T
A S I I
M O O
M E MA N T I N E

124
Across: Down:
1 - The most common cause of right heart failure: 2 - Cardiac marker, that is, one of the first to rise
LEFT heart failure in an acute myocardial infarction
5 - Likely diagnosis in an elderly smoker with TROPONIN
hypoxemia, polycythemia, and hypercapnia 3 - This organism is a leading cause of nosocomial
(two words) infection due to the prevalence of urinary
CHRONIC BRONCHITIS. COPD is the general catheters (short form)
term for this and emphysema. ECOLI
9 - These are indiscernible on EKG tracings of 4 - The valve most commonly affected by
atrial fibrillation, a common arrhythmia in the rheumatic heart disease
elderly MITRAL
P-WAVES 5 - The initial test in an elderly patient presenting
11 - The most likely diagnosis in an elderly smoker with acute-onset hemiparesis (two words—
with a pulsatile abdominal mass is AAA first word acronym)
(acronym) CT SCAN
Much more common in men. 6 - An elderly man who sees halos around lights
13 - Most common primary brain tumor in an at night, has myopia, and denies eye pain
elderly patient (acronym) should be evaluated for this type of glaucoma
GBM. Glioblastoma multiforme. OPEN ANGLE
17 - In a joint aspirate, positively birefringent 7 - When your elderly patient needs three pillows
crystals that appear blue when parallel to to breathe comfortably at night, the most
polarized light suggest this diagnosis likely diagnosis is CHF (acronym)
PSEUDOGOUT. Caused by deposition of Congestive heart failure; orthopnea is a classic
calcium pyrophosphate dihydrate crystals. symptom.
18 - This common laboratory value may be 8 - Infection with SPYOGENES, when untreated,
elevated in an elderly man with multiple may lead to rheumatic heart disease later in
myeloma life (shorten the genus to an initial)
CALCIUM 9 - Most likely diagnosis in an elderly patient with
20 - Donepezil, rivastigmine, and galantamine proximal joint pain, malaise, elevated ESR, and
(drugs sometimes used in Alzheimer disease) normal CK: POLYMYALGIA rheumatic
are acetylcholinesterase INHIBITORS Treat with corticosteroids.
23 - An elderly man with longstanding HTN and a 10 - Common arrhythmia in the elderly causing an
CT showing ischemia of the internal capsule irregularly irregular pulse (two words)
may have a blockage in these small vessels ATRIAL FIBRILLATION
LACUNAR 12 - Most likely diagnosis in an elderly patient with
25 - Painful first MTP joint associated with gout a diastolic murmur, wide pulse pressure, and
PODAGRA bounding pulses: AORTIC regurgitation
26 - Adults should generally begin screening for 14 - Your patient transferred from a nursing home
colorectal cancer at age FIFTY (exceptions for for delirium is found to have a UTI; when you
high-risk groups) see large mucoid capsules on urine microscopy,
27 - Unlike the pain of rheumatoid arthritis, that of your diagnosis (of organism) is KLEBSIELLA
osteoarthritis INCREASES with use 15 - Important diagnosis to rule out in your elderly
28 - In rheumatic heart disease, heart damage is patient with longstanding HTN and chest pain
caused by antibodies against M-PROTEIN radiating to the back (two words)
29 - Name of an NMDA receptor antagonist that AORTIC DISSECTION
may have some neuroprotective effect in 16 - Most likely diagnosis in an elderly patient
severe Alzheimer disease presenting with syncope and a murmur at the
MEMANTINE right upper sternal border: Aortic STENOSIS
Can lead to chest pain, syncope, or heart failure.
19 - This class of antibiotics should be in your
treatment regimen for community-acquired
pneumonia to cover atypicals
MACROLIDES
21 - LVH in your older patient is most commonly
due to longstanding HYPERTENSION
22 - This treatment should not be delayed in
suspected cases of temporal arteritis
STEROIDS
24 - The appropriate next test in your elderly
patient with back pain and mediastinal
widening on chest x-ray: CT ANGIOGRAM

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This Puzzle May Cause

13 Petechiae

M P OR P H Y R I A
I L
C OOMB S V A
R W T P
H O R E E D S T E R NB E R G
E D C L O
M E Y E T
G L OS S I T I S P OL Y C Y T H E M I A
P M I M
H O C P L A S MA P HA R E S I S
I P I N
L R M A C R OC Y T I C E
I E K
A S P L Y MP HOMA S
S E E Y L
I NT R I NS I C D L
N N E H R
I L E U K OS T A S I S
D C ML L S X M
U I MY E L OMA
HO O K WO R M U T
D U ME NOR R HA G I A
P E L E B S T E I N E N
N WA R F A R I N
P Y R UV A T E B
M

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2 - When urine is pink, this is what you 1 - Iron deficiency anemia and thalas-
should think semia are two of the MICROCYTIC
PORPHYRIA anemias
4 - Test used to detect autoimmune Others are sideroblastosis and anemia
hemolysis of chronic disease (which can also be
COOMBS normocytic).
8 - Classic abnormal cell of Hodgkin 3 - Petechiae suggest bleeding disorder
disease due to PLATELET dysfunction
REED STERNBERG. “Owl’s eyes.” 5 - Most common inherited bleeding
10 - #15 down may be associated with disorder (acronym)
this inflammation of the tongue VWD. von Willebrand disease.
GLOSSITIS 6 - Antidote for heparin
11 - Abnormally elevated hematocrit PROTAMINE
POLYCYTHEMIA. May be a primary 7 - Factor VIII deficiency: HEMOPHILIA A
condition or secondary to some other 9 - Can be used to treat mild hemophilia
process. or vWD
12 - Procedure used to remove excess DESMOPRESSIN. It promotes release
immunoglobulin of vWF (in addition to reducing urine
PLASMAPHARESIS production).
14 - MCV > 100 = MACROCYTIC anemia 13 - Anemia associated with autosplenec-
Common causes are B12 deficiency tomy (two words)
and folate deficiency. SICKLE CELL
16 - These malignancies are mostly of 15 - Lack of intrinsic factor: PERNICIOUS
B-cell origin anemia
LYMPHOMAS 17 - Chemotherapeutic drug used to
19 - Heparin inhibits the INTRINSIC prevent frequency of sickle cell crises
pathway HYDROXYUREA
21 - Oncologic emergency in which blasts 18 - Most common childhood malignancy
occlude the microcirculation leading to (acronym)
CNS symptoms or pulmonary edema ALL. Acute lymphocytic leukemia.
LEUKOSTASIS 20 - Renal failure, low platelets, hemolytic
24 - Philadelphia chromosome t(9,22) in anemia (acronym)
90% of patients with this (acronym) HUS. Hemolytic uremic syndrome;
CML. Chronic myelogenous leukemia. most cases caused by E. coli O157:H7.
25 - Lytic bone lesions and elevated 22 - BCR-ABL tyrosine kinase inhibitor
monoclonal proteins IMATINIB. Treatment for CML.
MYELOMA 23 - Primary site of iron absorption
26 - #1 down cause of microcytic anemia DUODENUM
worldwide, common name (Hint: It
really sucks!)
HOOKWORM
27 - Common cause of iron deficiency in
younger women
MENORRHAGIA
28 - Fluctuating fevers in Hodgkin disease
PEL EBSTEIN
29 - Vitamin K inhibitor (and rat poison)
WARFARIN
30 - Deficiency of this enzyme can cause
hemolytic anemia: PYRUVATE kinase

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14 A Borderline Puzzle

O A
B OR D E R L I N E
S T D
P A S S I V E A G G R E S S I V E
C S S P
H S O E
I H I S T R I ON I C N
Z V I D
O E N A E
T C A L N
Y O R T
P M C
A P A R A N O I D
L U V S
L O S
S C H I Z O I D
I D S
V A T
E N I
T C

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3 - Cluster B: Unstable, impulsive, vulner- 1 - Cluster C: The stubborn perfectionist
able to abandonment, splitter who likes all the soup cans lined up
BORDERLINE perfectly (two words)
5 - Cluster C: Noncompliant, procrastina- OBSESSIVE COMPULSIVE
tor (two words) 2 - Cluster B: Cannot conform to societal
PASSIVE AGGRESSIVE rules; criminal behavior
7 - Cluster B: Overemotional and dramatic ANTISOCIAL
HISTRIONIC 4 - Cluster C: Insecure, uncomfortable
9 - Cluster A: Mistrustful, hostile, suspi- with decision making or authority
cious, conspiracy theorist DEPENDENT
PARANOID 6 - Cluster A: Odd behaviors and
11 - Cluster A: Purposefully socially with- thoughts but no psychosis
drawn, content living alone with no SCHIZOTYPAL
friends 8 - Cluster B: Grandiose, overly sensitive
SCHIZOID to criticism, shows little empathy
NARCISSISTIC
10 - Cluster C: Involuntarily withdrawn
and shy because fears rejection
AVOIDANT

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15 This Puzzle is Infectious

P
A D E N
Y L A T E C Y C L A S E
B S
V Y T
BP E R F R I NG E NS
A L U
C L R R S V
S C H I
S T OS OMA E
T W S L B
C R F E P L E Y
H A E O A GA L A C T I A E
T Z A NC
K V L R A R
N I E A V A S
S E C ON
D A R Y O C OX S A C K I E
T R V T T N
R E M G I A R D I A I I
E A B R P N A
P A P I L L OMA V I R U S H O P
T A C S Y M E
O R I L Y S
C D I F F I C I L E O C T
O A L MY C O B A C T E R I A
C U O S S
C R A B I E S C
I C
R OT A V I R U S
S

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2 - Cholera toxin causes severe watery 1 - A board question about cat bites
diarrhea by overactivating this should make you think this organism
enzyme (two words) (genus)
ADENYLATE CYCLASE PASTEURELLA. Always treat cat bites
6 - Its toxin leads to gas gangrene: Clos- of the hand.
tridium PERFRINGENS (species) 3 - Responsible for classic mononucleosis
8 - Major cause of viral pneumonia in (initials)
infants (initials) EBV. Epstein-Barr virus.
RSV. Respiratory syncytial virus. 4 - If your febrile patient returning from
9 - Fluke associated with bladder cancer South America has “black vomit” and
(genus) jaundice, think this virus (two words)
SCHISTOSOMA YELLOW FEVER. Aedes mosquito
14 - Group B streptococcus is also known transmits the flavivirus.
as streptococcus AGALACTIAE 5 - Group A streptococcus are
(species) BACITRACIN-sensitive
Can cause neonatal meningitis. 7 - Human herpesvirus (HHV)-6 causes
15 - Use this smear of a sample from an this infantile illness
unroofed vesicle to test for herpes ROSEOLA. Exanthema subitum;
TZANCK. Tzanck goodness I do not begins with sudden high fever then
have herpes. rash appears as fever breaks.
17 - A person with cough, fevers, night 10 - Group A streptococcus are
sweats, and weight loss due to tuber- BETA-hemolytic
culosis has this form 11 - Primary syphilis presents with a
SECONDARY painless CHANCRE
18 - Hand-foot-and-mouth disease is 12 - PARVOVIRUS B19 causes erythema
caused by _________ virus type A infectiosum (fifth disease)
COXSACKIE 13 - The organism that causes plague (two
21 - Protozoan genus that causes watery words)
diarrhea YERSINIA PESTIS
GIARDIA. Other symptoms are excess 16 - Gram-positive rods in branching
gas, nausea, and stomach cramps. filaments that resemble fungi and
23 - Double-stranded circular DNA virus form sulfur granules (genus)
that causes warts ACTINOMYCES
PAPILLOMAVIRUS. HPV also has 17 - Gram-positive cocci in chains (genus)
strains that cause cervical cancer. STREPTOCOCCI
24 - Antibiotic-associated diarrhea is 19 - Catalase positive gram-positive cocci
usually caused by the toxin from this (genus)
organism (genus first letter and spe- STAPHYLOCOCCUS
cies) 20 - If you see trophozoites and schizonts
CDIFFICILE on a patient’s blood smear, think
25 - Gram-positive and acid-fast (genus, MALARIA
plural) 22 - A spore forming gram-positive rod
MYCOBACTERIA. Such as TB or MAC. genus (think bad fried rice)
26 - Bats, raccoons, and skunks, oh my! BACILLUS
This CNS infection has high fatality rate
RABIES
27 - Major cause of infant diarrhea around
the world and winter daycare diar-
rhea in US
ROTAVIRUS

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16 The Heart of Pharmacology

H E A D A C H E
D Y C
T O D E M
H E P A R I N A
L OOP R A A C OU GH
I O M L L N
D I L T I A Z E M I A NG I O E D E M A
O B N Z P S D
C C L ON I D I N E I T H I A Z I D E
A N N D U N
I B E T A O M O
N W G S
E A A R I
N I T R OP R U S S I D E N
I F O P L E
T A S T A T I NS
R R I R
A A N G I OT E NS I N
T T N I I N
R E V A
P OT A S S I UM E C
P D I G OX I N
I N
N
E

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1 - Most common side effect of nitro- 1 - Direct arteriolar vasodilator that can
glycerin cause drug-induced lupus
HEADACHE HYDRALAZINE
6 - Binds to antithrombin III 2 - Lisinopril (and other “-prils”) inhibit
HEPARIN this (acronym)
7 - Type of diuretics most useful for relief ACE. Angiotensin-converting enzyme.
of symptoms in CHF patients 3 - Raises BP, increases renal blood flow
LOOP. Such as furosemide. (at lower doses), and increases
8 - Nuisance side effect of ACEIs but not contractility
ARBs DOPAMINE
COUGH. Be aware that both can 4 - Dabigatran directly inhibits this
cause hyperkalemia, and even THROMBIN
angioedema. 5 - For torsades de pointes, give this
9 - A nondihydropyridine calcium MAGNESIUM
channel blocker 7 - A class IB antiarrhythmic
DILTIAZEM. Another is verapamil. LIDOCAINE. No longer given routinely
10 - ACEIs and ARBs can cause this reac- in post-MI patients (only because it
tion characterized by swelling of the killed people!).
lips and tongue 8 - Irreversibly binds P2Y12 ADP recep-
ANGIOEDEMA. See #8 across. tors thereby inhibiting platelets
12 - Centrally acting alpha2-agonist CLOPIDOGREL
CLONIDINE. Side effect is dry mouth 11 - Slows AV node conduction time by
and can cause rebound hypertension. interrupting AV nodal re-entry
13 - Type of diuretics that are first-line pathways
option for hypertension ADENOSINE
THIAZIDE. Hydrochlorothiazide and 15 - Inhibits vitamin K-dependent coagu-
chlorthalidone are examples. lation factor synthesis
14 - Mechanism of metoprolol: BETA WARFARIN. Monitor INR.
blocker 16 - Irreversibly inhibits cyclooxygenase
17 - Drug for hypertension emergency resulting in decreased thromboxane
that is metabolized to cyanide A2 synthesis
NITROPRUSSIDE ASPIRIN. The wonder drug.
19 - These inhibit HMG-CoA reductase 17 - Major class of antianginal drugs
STATINS NITRATES. Men taking nitrates should
21 - Losartan (and other “-sartans”) block avoid sildenafil (Viagra) and similar
this receptor drugs because the combination can
ANGIOTENSIN. Technically cause an unsafe drop in blood pressure
angiotensin-II AT1. (wow, I sound like a TV commercial).
23 - Spironolactone is a POTASSIUM- 18 - Epinephrine has (positive/negative)
sparing diuretic inotropic effects on the heart
24 - Inhibits Na+/K+-ATPase resulting in POSITIVE
increased contractility 20 - Antagonizes acetylcholine receptors
DIGOXIN. Used in heart failure and in ATROPINE
refractory afib. 22 - Increases HDL; side effect is flushing
NIACIN. But just increasing HDL with
niacin does not appear to improve
patient outcomes!

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17 An Ounce of Prevention

L
E
F OB T H P V D A S H
R Y D
E P A T M
V A R E N I C L I N E
O T R E M F
S M T T E L
E E E P A P O
L C L N N Z Q
E H E P A T I T I S B O U
N L S A I L I
G A A A MA MM O G R A M N
T M I N M E
H Y V I
T D I D
A S P I R I N R S C R E E N I NG
M A D
E C

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2 - One of the screening tests for colon 1 - Bias in observational studies of
cancer (acronym) screening when the screened group
FOBT. Fecal occult blood test (yearly appears to live longer because sur-
starting age 50 years); there are RCTs vival time starts with diagnosis based
demonstrating its benefit. on screening test in one group and
4 - Virus implicated in cervical cancer diagnosis based on symptoms in the
(acronym) unscreened group (two words)
HPV. Human papilloma virus; there is LEAD TIME
now a vaccine. 3 - Screening is beneficial only when
5 - Diet that may help lower BP or pre- TREATMENT given in the earlier,
vent hypertension (acronym) asymptomatic stage is more helpful
DASH. Dietary Approach to Stop than waiting until after disease is
Hypertension. detected following symptoms
8 - One of the medications that may 4 - Screen patients with this diagnosis for
help smokers quit diabetes according to USPSTF
VARENICLINE. Getting smokers to HYPERTENSION
quit is one of the most important 6 - A medication used to prevent altitude
things you can achieve as a physician. sickness
10 - Screening test for cervical cancer ACETAZOLAMIDE. It is a carbonic
PAP anhydrase inhibitor.
13 - Immunization offered in the neonatal 7 - A medication used to prevent malaria
period when traveling to endemic areas
HEPATITIS B MEFLOQUINE
15 - Men who have ever smoked 100 9 - This drug can be offered to house-
cigarettes should be screened once at hold members or other contacts of
the age of 65 for this (acronym) patients who have influenza to try to
AAA. Abdominal aortic aneurysm; this prevent spread
population bears 90% of the burden of OSELTAMIVIR. You may know it as
suffering from AAA. Tamiflu.
16 - Screening test for breast cancer 11 - Bias in observational studies of
MAMMOGRAM screening when the screened group
17 - Recommend this to men for primary appears to live longer because disease
prevention when global risk of coro- found by screening has a better prog-
nary heart disease exceeds potential nosis (two words)
harms of GI bleeding LENGTH TIME
ASPIRIN 12 - Younger, sexually active women should
18 - Secondary prevention be screened routinely for this STI
SCREENING. Remember that the CHLAMYDIA. It is commonly asymp-
goal of screening is to help people live tomatic; otherwise of course you
longer or better lives, not just to find would not be screening.
things! See also #3 down. 14 - This test commonly used to screen
for prostate cancer is not recom-
mended by the USPSTF (acronym)
PSA. Prostate-specific antigen.
19 - When counseling a patient about
upcoming travel, this organization’s
website is very helpful
CDC. Centers for Disease Control;
Google it.

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18 Puz-culoskeletal

O
S
S T
C A R P A L T UNN E L
F S O
E E A
U R
DMA R D S T
O P H
G L R
A NK Y L OS I NG S P OND Y L I T I S
C U N T
E C O N G E N I T A L T I
T A U S
A U R G C
M D S P ON D Y L OL Y S I S
I A E U M A
N R H E U M A T O I D P HA L E N
O Q A A T
P C R U C I A T E R E
H I D T R
E ME N I S C A L M
N A B OX E R S
N
S C I A T I C A

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3 - Most common peripheral neuropathy: 1 - Common, noninflammatory, degen-
CARPAL TUNNEL syndrome erative wearing out of articular
5 - Class of drugs for rheumatoid arthritis cartilage
(acronym) OSTEOARTHRITIS
DMARDS. Disease-modifying anti- 2 - Proximal femoral epiphysis separates
rheumatic drugs. from the growth plate leading to
7 - HLA-B27 found in majority of displacement of the femur (acronym)
patients with this (two words) SCFE. Slipped capital femoral
ANKYLOSING SPONDYLITIS epiphysis.
8 - CONGENITAL dislocation of the hip 4 - Deposition of calcium pyrophosphate
may be detected by Barlow or Orto- crystals in joints
lani maneuvers PSEUDOGOUT
12 - Defect of the pars interarticularis of 6 - Initial conservative treatment for
the vertebra #3 across is a wrist
SPONDYLOLYSIS. Break of the “Scot- SPLINT
tie dog’s neck” on x-ray; can lead to Injection is for more serious cases.
spondylolisthesis. 7 - Drug of choice for joint pain caused
14 - HLA-DR4 arthritis by #1 down
RHEUMATOID. Tests that may be ACETAMINOPHEN
positive include RF and anti-CCP. 8 - Back pain along with new onset
15 - A test for #3 across asking the urinary incontinence suggests
patient to push flexed wrists together CAUDA EQUINA syndrome
to see if it produces numbness & 9 - Subluxation of radial head in a child
tingling usually as a result of pulling up by the
PHALEN. It is pretty much worthless. hand: NURSEMAID’S elbow
16 - Positive anterior drawer of the knee 10 - Deposition of uric acid crystals in
suggests an anterior CRUCIATE liga- joints
ment tear GOUT
17 - Positive McMurray’s test suggests a 11 - Needs immediate fasciotomy:
MENISCAL tear COMPARTMENT syndrome
18 - Fracture of fifth metacarpal neck is 13 - Fracture of the growth plate:
also known as a BOXER’S fracture SALTER–Harris
19 - Low back pain with radiation down to
the foot
SCIATICA

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19 Catching My Breath

R
E C Y S T I C F I B R O S I S
S R H P
P E F OB S T R U C T I V E
I E S A H
R M T A L B U T E R O L
A S P I R A T I ON R R
C
T Y I X O A
O
O E C Y M P C
R
R M T G P E R S I S T E
N T
Y A I E S U N
I
S V T E N S I ON M T
C
T E U T E
O
R B R ONC H I E C T A S
I S
E M E E M R I
T
P Y R L B A S
E
T C OC C I D I O I D O N A R D S
O O U O L S O M
C O P D L M I U F I A
O L O A S D R D L
C A A S T HMA M A C E S L
C S I T M C
I M S F A I L U R E I E
A T L
U L
E M P HY S E MA

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2 - Caused by abnormal sodium chloride 1 - pH 7.25 with pCO2 that is elevated:
transport, most common due to muta- RESPIRATORY acidosis
tion at delta-F508 (two words) 2 - Suspect CHF in your dyspneic patient
CYSTIC FIBROSIS with bilateral lower leg edema and an
5 - FEV1 70% with residual volume of S3 gallop (acronym)
130% of predicted indicates _________ 3 - One of the inhaled anticholinergic drugs
lung disease used mainly for COPD
OBSTRUCTIVE. Like asthma (reversible) IPRATROPIUM. Tiotropium is another.
or COPD (irreversible). 4 - Lungs are stiff with poor expansion
8 - Medication used to relax the airways in patients with RESTRICTIVE lung
during acute bronchoconstriction diseases
ALBUTEROL 6 - Procedure for draining pleural effusion
9 - Infiltrate in the right middle lobe in THORACENTESIS. Pneumothorax is a
an elderly patient with swallowing potential complication.
difficulty suggests ASPIRATION 7 - Pus in the pleural space
pneumonitis EMPYEMA. Needs to be drained.
13 - A 12-year-old boy who wheezes three 10 - Only treatment besides smoking cessa-
times per week and has an FEV1 of 84% tion that lowers mortality in COPD
has mild PERSISTENT asthma OXYGEN
15 - Your dyspneic patient with absent 11 - In addition to prn albuterol, the child in
breath sounds and deviated trachea has #13 across should be on daily inhaled
a _________ pneumothorax CORTICOSTEROIDS
TENSION. Get your needle ready! 12 - Asbestosis increases risk for this
16 - Cycles of infection and inflammation in malignancy
the bronchi can lead to this permanent MESOTHELIOMA
fibrosis, remodeling, and dilation 14 - Gram-positive cocci in chains (genus)
BRONCHIECTASIS STREPTOCOCCI. Most common cause
20 - Pulmonary fungal infection endemic of pneumonia.
to the Southwestern US; your typical 15 - In patients actively infected, see “red
board examination patient with this will snappers” on acid-fast staining of
hail from the San Joaquin Valley: sputum
COCCIDIOIDO mycosis TUBERCULOSIS
21 - PaO2/FiO2 ratio <200 mm Hg with 17 - Suspect pulmonary _________ in your
bilateral pulmonary infiltrates dyspneic patient with pleuritic chest
(acronym) pain and a recently swollen calf
ARDS. Acute respiratory distress EMBOLISM. Get a spiral CT or V/Q scan;
syndrome. start heparin.
23 - Destroyed airways with obstruction 18 - Type of pleural effusion seen in CHF
(acronym) TRANSUDATIVE
COPD. Chronic bronchitis and 19 - Cold agglutinins may be seen in
emphysema. patient with pneumonia caused by
25 - Reversible airways obstruction MYCOPLASMA (genus only)
ASTHMA 22 - Nonresectable lung cancer type (two
26 - This enzyme (acronym) may be elevated words)
in patients with sarcoidosis SMALL CELL
ACE. Angiotensin-converting enzyme. 24 - Palpable vibration of the chest while
27 - Your dyspneic patient with hypoxia and the patient says “blue balloons”: Tactile
hypercapnea and worsening mental FREMITUS
status has acute respiratory _________
FAILURE. Needs a ventilator.
28 - Alpha-1-antitrypsin deficiency is
another cause of EMPHYSEMA

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Are You Smarter than

20 a First-year?

P
S U R F A C T A NT V
R B R OA D
F A L C I F OR M E G
E I T U
T M T I S
A I O C
S T A P H Y L OC OC C U S
O R A E H L
L O P L O O
I GM T U B U L I N C
U A E E D Y
M T A NG L E S R T T
A N I N E T Y
P OT A S S I UM A R
E D I GOX I N
S
S P E C I F I C I T Y
N
E

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2 - Type II pneumocytes produce this 1 - These cells secrete gastric acid
important stuff PARIETAL
SURFACTANT 3 - Enlargement of the left atrium can
4 - This “ligament” connects the uterus, produce hoarseness, due to compres-
uterine tubes, and ovaries to the sion of a nerve that is a branch of the
pelvic side wall VAGUS nerve
BROAD 5 - Nonnucleated immature RBC formed
6 - Ligament that connects liver to the in bone marrow
anterior abdominal wall RETICULOCYTE
FALCIFORM 7 - Cellular site of oxidative phosphoryla-
9 - Catalase-positive, gram-positive cocci tion (plural)
(genus) MITOCHONDRIA
STAPHYLOCOCCUS 8 - Long-chain fatty acids form these
12 - First class of immunoglobulin pro- prior to passive diffusion
duced upon antigenic exposure MICELLES
IGM 9 - Pork tapeworm species
13 - Microtubules are made up of dimers SOLIUM
of alpha- and beta-TUBULIN 10 - Enzyme that catalyzes testosterone
14 - Pathologic finding in the hippo- to estrogen
campus of patients with Alzheimer AROMATASE
disease: Neurofibrillary TANGLES 11 - Small molecule that can be antigenic
16 - What is the approximate pulse pres- when attached to a carrier
sure of a patient with a diastolic BP HAPTEN
of 60 and MAP of 90? 15 - The receptor for insulin is part of a
NINETY large family of TYROSINE kinase
17 - Depolarization occurs when there is receptors
an influx of this into the myocardial
cells
POTASSIUM
18 - Inhibits sodium–potassium ATPase
DIGOXIN
19 - For a diagnostic test, true negatives
divided by true negatives plus false
positives
SPECIFICITY

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21 Not Just Little Adults

O
R S V
T
O
F A L L OT
A R
N O
E P I G L O T T I T I S
N A E
V S D N E C O
O N Y L
M E C K E L S A
E O R T
T N I
H J P C R OU P
K A WA S A K I A B U S E F
M C G R I
C OX S A C K I E A T B
X S N T U R
I P E S O
C I D S S
I R I I
P Y L OR I C S T E NO S I S
L N
I
N

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2 - Most common cause of bronchiolitis 1 - Check for congenital dislocation of
(acronym) the hip using ORTOLANI and Barlow
RSV. Respiratory syncytial virus. tests
3 - Overriding aorta, pulmonary stenosis, 4 - High fever with no other symptoms
RVH, and #8 across: Tetralogy of for a few days, then a rash macu-
FALLOT lopapular rash appears: ROSEOLA
5 - Drooling, “sniffing” position, high infantum
fever, muffled voice Also known as sixth disease, caused by
EPIGLOTTITIS human herpesvirus 6.
8 - Most common congenital heart 6 - Medication given to neonate to try to
disease (acronym) close a PDA (patent ductus arteriosus,
VSD. Ventricular septal defect. not a personal digital assistant!)
9 - Severe intestinal problem mostly of INDOMETHACIN
premature infants (acronym) 7 - Sexual development staging
NEC. Necrotizing enterocolitis. TANNER
11 - Painless rectal bleeding in child under 10 - Caused by mutation in chloride
2 years old, two times as common in channel gene (two words)
boys, 2 inches long, 2 feet from ileo- CYSTIC FIBROSIS
cecal valve: MECKEL’S diverticulum 12 - Neonatal jaundice due to
Diagnose with a Meckel’s (nuclear) scan. CONJUGATED bilirubin is always
14 - Steeple sign pathologic
CROUP 13 - Cause of whooping cough (species)
15 - High fever, fingertips swollen/peeling, PERTUSSIS
tender cervical nodes, conjunctivitis: 16 - Usual drug of choice for acute otitis
KAWASAKI disease media
See #19 down. AMOXICILLIN
17 - When an injury does not seem to 19 - Treatment of #15 across includes
make sense based on the history IVIG and high-dose ASPIRIN
given by a child’s caregiver, think of
this possibility
ABUSE
18 - Cause of hand-foot-and-mouth
disease
COXSACKIE A
20 - Nonbilious vomiting in a 2-week-old
baby boy (ok, and an olive-shaped
epigastric mass) suggest this (two
words)
PYLORIC STENOSIS

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22 Renal & Lytes

Meredith Gilliam

R I C K E T S
D H H
I L Y
ME T A B OL I C O W P
B C R E A T I N I N E
E I T S R
P OT A S S I UM D E O C
R E E R B C N A
O S I L
S I P A C
T N R Z E
A S P T H S OD I UM
G I R O Y X D I
L P Y E L ON E P H R I T I S A
A I S S E M
N D P R H A D H
D U I K Y L R
I S R A L D OS T E R ON E
N A L R U N
S T WE L V E O B I
O M G U N
R I E L
H Y P E R MA GN E S E M I A

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1 - A child with a syndrome causing 2 - An anion gap is calculated as sodium
decreased reabsorption of phosphorus minus the sum of bicarbonate and
in the kidney may develop this condition CHLORIDE
RICKETS 3 - Likely diagnosis in a thirsty patient with
5 - A low pH, low PCO2, and low bicarbon- hypernatremia and dilute urine (two
ate are consistent with this type of words)
acidosis DIABETES INSIPIDUS
METABOLIC. Use MUDPILES for the 4 - Renal stones, abdominal pain, and
differential diagnosis. psychiatric changes are associated with
7 - This small molecule used in the estima- this electrolyte abnormality
tion of GFR is freely filtered at glomeruli HYPERCALCEMIA. The famous “stones,
and only moderately secreted by renal bones, moans, and groans.”
tubules 6 - The diagnosis of diabetes insipidus is
CREATININE confirmed by a WATER deprivation test
9 - A patient being treated for diabetic Sounds cruel, doesn’t it?
ketoacidosis with insulin should be 8 - Toxicity from this tuberculosis drug
monitored for intracellular shift of this may result in an increased anion gap
electrolyte metabolic acidosis
POTASSIUM ISONIAZID
10 - Patients with malignant hypertension 9 - PROSTAGLANDINS are responsible
may have this type of casts on urine for dilating the afferent arterioles of
microscopy (acronym) glomeruli
RBC. Red blood cell. Now think why NSAIDs can be
12 - Elevated levels of this hormone lead to nephrotoxic.
hypercalcemia and hypophosphatemia 11 - In healthy individuals, glucose is com-
(acronym) pletely reabsorbed into the circulation
PTH. Parathyroid hormone. by this part of the nephron (two words)
14 - Secretion of atrial natriuretic peptide PROXIMAL TUBULE
in response to increased atrial pressure 12 - A much feared complication of rapidly
results in increased filtration of this ion correcting hyponatremia is myelinolysis
in the kidney in this region of the brain
SODIUM PONS. Central pontine myelinolysis.
16 - Likely diagnosis in a young woman with 13 - Peaked T waves on an EKG are indica-
dysuria, fever, and WBC casts in her tive of this electrolyte disturbance
urine HYPERKALEMIA. Give calcium to pro-
PYELONEPHRITIS tect the heart, then measures to lower
18 - Low levels of this hormone results in potassium.
the excretion of free water (acronym) 15 - A high pH, low PCO2, and low bicarbon-
ADH. Antidiuretic hormone. ate are consistent with this type of
20 - A patient with hypertension, hypoka- alkalosis
lemia, and metabolic alkalosis should RESPIRATORY
be evaluated for elevated levels of this 17 - In Type 1 renal tubular acidosis, the
hormone collecting tubule’s inability to excrete
ALDOSTERONE this ion may result in hypokalemia and
21 - The upper limit of the normal range of calcium-containing renal stones
an anion gap (spelled out) HYDROGEN
TWELVE 19 - This enzyme important to the mainte-
22 - Decreased deep tendon reflexes and nance of blood pressure is secreted by
decreased respirations are signs of this juxtaglomerular cells in the kidney
electrolyte abnormality RENIN
HYPERMAGNESEMIA. One of the things
women on the labor floor being treated
for preeclampsia are monitored for.

145
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23 Surgery Rounds

P
A M
D U C T A L A
I E L S
C V A O R T
L E R S E P S I S
A R F T T
U T OR S I ON R I
P D I A B M O S
R I C N R E G T
E C U S O S U R G E R Y
G P A P I L L O MA E A N
N T I N D N D S C
A I T ME S OT H E L I OM A
N O I N E O N
MC B U R N E Y S O R N C
Y M I E
V A R I C OC E L E R

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3 - Most common type of breast cancer 1 - One of the “P’s” of acute arterial
DUCTAL occlusion
7 - Major postsplenectomy complication PALLOR. Pain, pulselessness,
SEPSIS paresthesias are some others.
9 - Diagnosis for young man who has 2 - Superficial infection of the breast
sudden onset of pain in scrotum with MASTITIS
swelling and a “high-riding” testicle 3 - Elderly man with LLQ pain, nausea,
TORSION. Call the urologist as blood low-grade fever, mildly elevated
supply to the testicle is threatened. white blood cell count likely has
14 - Major risk factor for SBO: Previous DIVERTICULITIS
abdominal SURGERY 4 - Marker used to follow colon cancer
Which causes adhesions. after treatment (acronym)
15 - Bloody nipple discharge suggests CEA. Carcinoembryonic antigen.
intraductal PAPILLOMA 5 - Calf muscle pain brought on by
17 - Pleural cancer linked to asbestos walking
exposure CLAUDICATION
MESOTHELIOMA 6 - The “R” in ERCP
18 - Point of tenderness in appendicitis RETROGRADE. Endoscopic retrograde
MCBURNEY’S cholangiopancreatography; it is a
19 - “Bag of worms” on testicular mouthful.
examination 8 - Most common cause of breast lump
VARICOCELE. Usually needs no in young women
treatment. FIBROADENOMA. It is benign.
10 - Criteria for estimating prognosis in
acute pancreatitis
RANSON. Note that lipase is not one
of the Ranson criteria.
11 - Young woman presenting with
abdominal/pelvic pain, always rule
out this
PREGNANCY
12 - Elderly man with history of atrial
fibrillation with acute onset abdomi-
nal pain out of proportion to exami-
nation: Acute MESENTERIC ischemia
Check a lactate.
13 - Trauma patient has tachypnea,
decreased breath sounds on one
side and deviated trachea: TENSION
pneumothorax
And get your needle ready again!
16 - Large bowel obstruction is due to
colon CANCER until proven otherwise

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24 Just for Fun—Movie Docs

P A T C H
W
A
K
E E V I L
N D
I D F
HA NN I B A L
O G E A
B R U C E W I L L I S M T W I L I GH T
L U L
Y R K I MB L E
W P N
D OC T OR H E L
R O Y C R I C H T ON
Y D S O
S M
T I
A R A C HNOP HOB I A S
L

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1 - Robin Williams played PATCH Adams 2 - Robert De Niro’s character was
3 - Austin Powers’ nemesis: Dr. EVIL brought out of catatonia by L-dopa in
He went to Evil Medical School. this 1990 movie
5 - Silence of the Lambs: Dr. HANNIBAL AWAKENINGS
Lecter 3 - Played Dr. Dolittle
6 - Plays a plastic surgeon turned morti- EDDIE MURPHY
cian in Death Becomes Her 4 - In this movie, five medical students
BRUCE WILLIS. Quite a different (one played by Kevin Bacon) conduct
character from his John McClane. secret experiments to try to explore
7 - Dr. Carlisle Cullen is featured in the afterlife
this saga FLATLINERS. Do not try this at home.
TWILIGHT. (So my daughters tell me.) 5 - Michael J. Fox: Doc HOLLYWOOD
8 - Harrison Ford played Dr. Richard 10 - Played a psychiatrist in Analyze This:
KIMBLE in The Fugitive Billy CRYSTAL
He was a vascular surgeon who had to 11 - Classic Halloween movie doctor:
find the one-armed man who killed Dr. Sam LOOMIS
his wife.
9 - William Hurt plays an arrogant sur-
geon who becomes a patient when
he is diagnosed with throat cancer in
this movie: The DOCTOR
12 - Jurassic Park was written by the late
Dr. Michael CRICHTON
Recently re-released in 3D.
13 - The town cared for by a doctor
played by Jeff Daniels becomes
infested in this movie
ARACHNOPHOBIA

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25 I Got Rhythm . . .

L A E
I Q M
I N F E R I OR L B B B
L T S B A
V T A C H F I R S T
F F O T E W
I B V Z R A E
A F I B D E L T A I A N
M F N W I L C
A F L U T T E R A K J
T U O P WA V E E P
T R R E B O
S V T S Q A F I B
E A N T E R I OR C N
QR S D B H T
E B
S E P T A L B
E P
A V F I B
K B
UWA V E
D
T V
S V T
A
C
H

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1 - Wide P wave in II (acronym) 2 - Inventor of the EKG
LEFT ATRIAL ENLARGEMENT. Often seen in chronic atrial EINTHOVEN. Invented the EKG in 1903.
fibrillation. 3 - Interval normally <0.10 s
5 - II, III, aVF wall QRS. As measured from the beginning of the Q to the end
INFERIOR. Classically due to right coronary artery occlusion. of the S.
6 - Conduction abnormality characterized by wide QRS and 4 - This kind of AV block
RSR’ in V5–V6 (acronym)
LEFT BUNDLE BRANCH BLOCK. A new LBBB is an
ST-elevation MI until proven otherwise.
8 - This tracing (short form)

MOBITZ II. Note how half of the P waves are not

conducted (2:1 block), but the PR interval is constant
(differentiating from Mobitz I/Wenckebach).
6- I, aVL, V5, V6 wall
V(ENTRICULAR) TACH(YCARDIA). Note the wide QRS, LATERAL. Classically due to circumflex artery occlusion.
regular rate, suggesting organized ventricular activity. 7- QRS 0.10 to 0.12 and left axis deviation (acronym)
9 - FIRST-degree block: Prolonged PR interval LEFT ANTERIOR FASCICULAR BLOCK
11 - Large P wave amplitude in II or V1 may suggest this (acronym) 8- Fatal arrhythmia characterized by chaotic ventricular
RIGHT ATRIAL ENLARGEMENT activity (short form)
12 - This tracing (short form) V(ENTRICULAR) FIB(RILLATION). Treated with
defibrillation.
10 - Steadily prolonging PR intervals followed by a dropped
beat
WENCKEBACH. Aka Mobitz type I.
12 - This tracing (short form)
A(TRIAL) FIB(RILLATION). Note the narrow QRS that is
irregularly irregular, with coarse fibrillation waves in the
background.
13 - The presence of this wave in the setting of a short PR is
characteristic of Wolff–Parkinson–White
DELTA. A slurred upstroke into the QRS, indicative of an A(TRIAL) FLUTTER. Note the narrow QRS that is regular, at a
accessory pathway. rate of 150, with the classic “sawtooth” flutter waves at a rate
16 - “Saw tooth” waves (short form) of 300, indicating a 2:1 conduction block.
A(TRIAL) FLUTTER. Atrial rate usually 300 with 2:1 block 14 - Ventricular repolarization
giving a ventricular rate of 150. T WAVE
19 - Firing of the sinus node 15 - “Wandering pacemaker” tachycardia (acronym)
P WAVE MULTIFOCAL ATRIAL TACHYCARDIA. Multiple atrial
20 - Narrow complex regular tachycardia without P waves pacemakers are firing at different times, causing P waves of
(short form) various morphologies.
S(UPRA)V(ENTRICULAR) T(ACHYCARDIA) 17 - Prolonging the QT interval may be “dangereux”
22 - Irregularly irregular rhythm with narrow QRS and no P TORSADES (DE POINTES). French for “twisting around a
waves (short form) point.” A fatal form of ventricular tachycardia, treated with
A(TRIAL) FIB(RILLATION) defibrillation and magnesium.
23 - V1, V2 wall 18 - Elevation of this may be difficult to differentiate from ST
ANTERIOR. Classically due to left anterior descending elevation
artery occlusion. J POINT. It is the exact point where the QRS meets the ST
25 - Ventricular depolarization segment. It may be normally elevated in younger patients.
QRS 19 - Interval normally 0.12 to 0.20 s
26 - V3, V4 wall PR. As measured from the beginning of the P to the begin-
SEPTAL. Classically due to left anterior descending artery ning of the first QRS deflection.
occlusion. 21 - Interval normally <0.44 s
29 - This tracing (short form) QT. As measured from the beginning of the Q to the end of
the T, must be corrected for rate.
24 - Conduction abnormality characterized by wide QRS and
RSR’ in V1 (acronym)
RIGHT BUNDLE BRANCH BLOCK
27 - First sign of hyperkalemia (plural)
PEAKED TS. Although not always seen, tall peaked T waves
V(ENTRICULAR) FIB(RILLATION). Note the coarse,
are an early EKG manifestation of hyperkalemia.
irregular fibrillation waves that denote completely disor-
28 - QRS 0.10 to 0.12 and right axis deviation (acronym)
ganized ventricular activity.
LEFT POSTERIOR FASCICULAR BLOCK
30 - Extra wave seen with low K
31 - Wide complex regular tachycardia (short form)
U WAVE. An upright, usually smaller wave following the T wave.
V(ENTRICULAR) TACH(YCARDIA)
32 - This tracing (short form)

S(UPRA)V(ENTRICULAR) T(ACHYCARDIA). Note the narrow

QRS (which suggests a supraventricular origin) and absence
of P waves (which differentiates this from sinus tachycardia).

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26 Clinical Scramble

SPIDER VEIN
S P I D E R V E I N

ALCOHOLISM
A L C O H O L I S M

JAUNDICE
J A U N D I C E

ASCITES
A S C I T E S

FIBROSIS
F I B R O S I S

ANSWER: CIRRHOSIS

152
Notes

153
CrossWards™

27 Birth of a Puzzle

Q
U
G E S T A T I ONA L L
C P A R I T Y
K O E
E U T E R U S
N I
G I F I R S T
R N M N I
NA E G E L E S F O H C G
V L P L A C E N T A R
T H I R D A R N L E
T S M OOT H K A
Y M G A T S H
A N E M I A L I
L S D OWN S
I T S I
N P R E S E N T A T I ON
E R S S E
A F OL A T E
L N N
V A R I A B L E
T G
E A R L Y
A

154
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2 - GESTATIONAL age: Time since the LMP 1 - This term for maternal awareness of fetal
4 - The number of deliveries after 20 weeks movements, usually occurs around
PARITY 18 weeks
5 - At 12 weeks of gestation, this organ is QUICKENING
palpable above the pubic symphysis 3 - Fetal LIE: Description of the long axis of
UTERUS the fetus
7 - Stages of labor: Onset of contractions to May be longitudinal or transverse.
complete cervical dilation 4 - Fetal POSITION: Description of the ori-
FIRST. Divided into latent and active phases, entation of the presenting part relative to
which are defined by the rate of cervical maternal pelvis
change (1 to 2 cm/hr in the active phase). In the cephalic presentation, the occiput
10 - NAEGELE’S rule: A method for determin- is the landmark, and position may be
ing the due date described as “occiput anterior” for example.
LMP = 3 months + 7 days. 6 - The number of pregnancies
11 - This hormone should double every 48 GRAVITY
hours during the early stages of pregnancy 8 - Stages of labor: Second stage is from com-
(acronym) plete dilation to delivery of the INFANT
HCG. Failure to do so may indicate a failed This is when the pushing happens. Longer in
pregnancy or ectopic pregnancy. primips and in patients with epidurals.
13 - #13 down is made by this organ 9 - Hyperpigmentation of the face
PLACENTA MELASMA
15 - Stages of labor: Delivery of infant to 12 - CREATININE levels decrease by about
delivery of placenta 25% due to increase in GFR
THIRD. Should be less than 30 minutes. A “normal” creatinine in pregnancy may
16 - #13 down causes relaxation of SMOOTH actually be abnormal.
muscle, which results in lower blood pres- 13 - Many of the physiologic changes of preg-
sure, and GERD nancy are mediated by this hormone
17 - #11 across is analogous to TSH, causing PROGESTERONE
levels to decrease during pregnancy 14 - Increases in tidal volume are responsible
(acronym) for the respiratory ALKALOSIS of preg-
Thyroid-stimulating hormone. Though nancy
levels of free T3/T4 remain the same. The respiratory rate remains the same.
18 - A physiologic ANEMIA results from the 19 - Hyperpigmentation in the midline of the
dilutional effect of increased plasma volume abdomen (two words)
The actual red cell mass should remain the LINEA NIGRA
same. 22 - This test of fetal well-being may be
20 - Decreased AFP, estriol, and increased deemed “reactive” if there are at least
HCG and inhibin A is the pattern seen in two 15 × 15 accelerations in a 20-minute
DOWN’S syndrome period (acronym)
These four markers make up the “quad NST. Nonstress test. To be differentiated
screen.” All four are decreased in trisomy from a CST, contraction stress test (rarely
18. Elevated AFP may indicate neural tube performed anymore).
defects. 24 - LATE deceleration: Caused by fetal hypoxia
21 - Fetal PRESENTATION: Description of the or placental insufficiency
fetal part at the cervix An ominous sign.
May be cephalic (vertex) or breech.
23 - Supplementation with this vitamin PRIOR
to conception is needed to prevent neural
tube defects
FOLATE. Usual requirement is 0.4 mg/day.
25 - VARIABLE deceleration: Caused by cord
compression
Have abrupt onset, often “V” shaped.
26 - EARLY deceleration: Caused by fetal head
compression.
Benign.

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28 Labor Pains

E
N
D M
T OX O P
M L R
E A T ONY F
T R T K E E P
R D E S G B S R R
I I T H N E
T N M E Y I V
I U A B R U P T I ON I
S R G O O N G A
S E I Z U R E I G E H
A U D E L I V E R Y
B B S Y I P
R E R C T E
S HOU L D E R S H E E H A N R
O L E E M B E
G A L C OH OL I L M
A H L A C E I E
G DM P S
E C T O P I C
S

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3 - Avoidance of cat feces is advised to pregnant women 1 - The most common cause of fever in the postpar-
to prevent this congenital infection (short form) tum period
TOXO. Toxoplasma gondii may cause hydrocephalus, ENDOMETRITIS. IV antibiotics should be adminis-
chorioretinitis, and intracranial calcifications. tered.
5 - Uterine ATONY is the most common cause of 2 - A MOLAR pregnancy may be diagnosed by a
postpartum hemorrhage “snowstorm” appearance on ultrasound
Bimanual massage, oxytocin, and methylergonovine The women may present with hyperemesis gravi-
are possible treatments. darum, or early onset preeclampsia.
7 - A woman who develops mastitis should keep/stop 4 - Preeclampsia is defined as elevated blood pressure
breast-feeding plus PROTEINURIA
KEEP. There is little risk to the infant, and stopping 6 - The presence of FERNING on microscopic examina-
breast-feeding will only lead to engorgement which tion of dried amniotic fluid suggests rupture of the
will further complicate the infection. membranes
9 - In utero exposure is associated with clear cell 8 - Painless vaginal bleeding in the third trimester
carcinoma of the cervix (acronym) should make you suspect a placenta PREVIA
DES. Diethylstilbestrol. Although it has been off the The placenta covers the cervical os. Do NOT perform
market since 1975, this medication that was once a digital examination unless you know there is no
used to prevent miscarriage continues to show up on previa (i.e., by ultrasound).
board examinations nearly 40 years later. 11 - A woman in preterm labor at 30 weeks should
10 - Screening and treatment for this organism has receive STEROIDS to promote fetal lung maturity
significantly reduced the rates of neonatal sepsis Indicated prior to 32 weeks, and often given in the
(acronym) 32- to 34-week window as well.
GBS. Group B streptococcus. 12 - Use of an insulin drip during labor may be necessary
14 - Premature separation of the placenta is known as to prevent this neonatal complication
ABRUPTION HYPOGLYCEMIA. Usually only required for patients
Risk factors include trauma, hypertension, cocaine who are controlled with insulin during the pregnancy.
use. May result in shock and DIC may occur. 13 - This drug has been shown to reduce progression
16 - Eclampsia is defined as a SEIZURE in a woman with to eclampsia in women with severe preeclampsia
preeclampsia (short form)
19 - The definitive therapy for preeclampsia MAG. Magnesium sulfate. Must monitor for toxicity
DELIVERY as high doses are required by continuous infusion.
22 - SHOULDER dystocia: A feared complication that is 15 - A woman at 12 weeks’ gestation with vaginal
more likely in macrosomic infants of diabetic mothers bleeding and an open os has a/an INEVITABLE
23 - A woman recovering from a postpartum hemor- abortion
rhage who fails to lactate may have SHEEHAN If the os were closed, it would be “threatened.”
syndrome 17 - A child with congenital deafness, cataracts, and
Ischemia and necrosis of the pituitary. a patent ductus should raise suspicion for this
25 - Exposure to this drug may cause a growth- congenital infection
restricted fetus with mental retardation and RUBELLA. Rubella immunity is assessed prenatally,
characteristic facial features but nonimmune women should not receive MMR
ALCOHOL. The facial features are smooth philtrum, until after delivery (it is a live vaccine).
short palpebral fissures, short nose, and thin upper lip. 18 - HYPEREMESIS gravidarum: A severe form of
26 - This class of blood pressure medication must be “morning sickness”
avoided in pregnancy (acronym) And it can happen any time of day. Related to HCG
ACEI. ACE inhibitors. May cause fetal renal defects levels, it is more common in multiple gestations and
and IUGR. molar pregnancies.
27 - A 1-hour glucose tolerance test may be used to 20 - The most common malpresentation
screen for this pregnancy complication (acronym) BREECH
GDM. A 50-gram glucose load is administered and 21 - Treatment with this immunoglobulin is indicated
blood sugar checked in 1 hour. A 3-hour GTT is for Rh-mothers
needed to confirm the diagnosis. RHOGAM. Rh immunoglobulin. Given at 28 weeks
28 - This diagnosis must be ruled out in any woman and at delivery to prevent isoimmunization, and any
of childbearing age with abdominal pain and/or other time there is significant bleeding in pregnancy
vaginal bleeding (i.e., miscarriage).
ECTOPIC. A negative pregnancy test rules it out. 24 - A syndrome of severe preeclampsia characterized
If the patient is pregnant and the location of the by hemolysis, elevated LFTs, and thrombocytopenia
pregnancy has not previously been determined, she (acronym)
needs an ultrasound. HELLP

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29 A pHuzzle

C H L OR I D E
Y
P H
A C I D O S I S E
S U R E M I A
V OM I T I NG V
N K E T ON E S
I P N
D K A M A G T
E Z R I
L I S K A L S
T D L A R T A
A D T L A
R D HY
P OV E N T I L A T I ON
E E R H O B C I
S L E T H Y L E N E G L Y C OL
P T G D L N
B I C A R B O
NA T E A G
R A D T A
A S N L I E P
ME T A B OL I C A L K A L O S I S
O D Y C R
R I T R
Y U A H
M T E
ME T HA N OL

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1 - The major measured anion in the serum 2 - The ultimate process responsible for all forms of
CHLORIDE respiratory alkalosis
3 - This number tells you whether you have an HYPERVENTILATION. May be induced by hypoxia
acidosis or alkalosis from lung disease, anxiety, pain.
PH 5 - One of the causes of anion gap acidosis, in a
4 - pH < 7.35 patient being treated for tuberculosis
ACIDOSIS ISONIAZID
6 - One of the causes of anion gap acidosis, in a 9 - One of the causes of anion gap acidosis, some-
patient with end-stage renal disease what antiquated as the drug is no longer in use
UREMIA PARALDEHYDE. No longer in use in the United
7 - The most common cause of metabolic alkalosis States, previously used as a hypnotic/sedative and
VOMITING. Caused by loss of H+ from the stomach. anticonvulsant. Another “P” for anion gap acidosis is
8 - Byproduct of lipid metabolism, excreted in the propylene glycol.
urine 10 - Assessment of this value is key to detect the
KETONES presence of a combined metabolic acid–base
10 - One of the causes of anion gap acidosis, in a disturbance (Hint: It might sound like you are
patient with Type I DM (acronym) repeating yourself)
DKA. Diabetic ketoacidosis. Insufficient insulin DELTA-DELTA. Only to be done in the presence
causes cells to switch to fat as energy source, of an anion gap acidosis, to detect an additional
producing ketoacids as a byproduct. nongap acidosis or alkalosis. There are confusing
11 - A decrease in the anion gap may be observed in formulae for this, but essentially if you have a pure
the presence of unmeasured cations such as this AG acidosis, the bicarbonate should decrease
one possibly encountered on a patient in the by however much elevated the AG is (normal
labor ward (short form) bicarbonate = 24, normal AG = 12). So if the AG is
MAG(NESIUM). Magnesium is often used at high 16 (up by 4), the bicarbonate should be 20 (down
doses on labor and delivery to treat preeclampsia by 4). If instead the bicarbonate is 18, then there
and related conditions. It is a usually unmeasured is more acidosis that you would predict based on
(though easily can be measured) cation that may the AG alone (nongap metabolic acidosis). If the
cause a false lowering of the anion gap. bicarbonate is 22, then something is counteracting
12 - One of the causes of anion gap acidosis, in a the AG acidosis (i.e., a metabolic alkalosis).
patient who has been NPO in the hospital for 13 - One of the causes of anion gap acidosis, in an
several days (acronym) overdose patient
SKA. Starvation ketoacidosis. A ketoacidosis SALICYLATES
occurring by similar mechanism to diabetic keto- 15 - The amount of unmeasured negatively charged
acidosis. However, in this case, there is insulin, but molecules in the serum
no glucose (patient is starving). ANION GAP. These unmeasured anions, typically
14 - Another cause of nongap acidosis, a group of organic acids, live in “the gap” and cause metabolic
disorders rather oddly numbered (acronym) acidosis.
RTA. Renal tubular acidosis. There are three types: 16 - Type of disorder present when the pCO2 is the
Type 1, Type 2, and Type 4. Remember Type 4 is asso- primary abnormality
ciated with hypoaldosteronism and hyperkalemia. RESPIRATORY. pCO2 will be increased in
17 - The ultimate process responsible for all forms of respiratory acidosis (CO2 is an acid after all), and
respiratory acidosis decreased in respiratory alkalosis.
HYPOVENTILATION. May be due to respiratory 18 - A physiologic respiratory alkalosis may be encoun-
failure from a primary cardiopulmonary process, tered in this state
or due to CNS injury, drugs, neuromuscular PREGNANCY. Due to the mild tachypnea of
disease. pregnancy, likely mediated by progesterone.
20 - One of the causes of anion gap acidosis, in an 19 - Order this to find out the patient’s pH (acronym)
accidental ingestion of antifreeze (two words) ABG. Arterial blood gas.
ETHYLENE GLYCOL 22 - The most common cause of nongap acidosis
21 - Buffer anion primarily responsible for acid/base DIARRHEA. Bicarbonate is lost via the gut at a rate
regulation that exceeds the kidney’s ability to resorb.
BICARBONATE 23 - The first electrolyte in the anion gap calculation
25 - Type of disorder present when the bicarbonate is SODIUM. Na – (Cl + HCO3) = anion gap
the primary abnormality 24 - One of the causes of anion gap acidosis, in a
METABOLIC. Bicarbonate will be decreased septic patient
in metabolic acidosis, increased in metabolic LACTATE. Lactic acidosis is seen in a large number
alkalosis. of clinical situations, including sepsis. Sometimes
26 - pH > 7.45 categorized as Type A (due to impaired tissue oxy-
ALKALOSIS gen delivery and ischemia) and Type B (in patients
27 - One of the causes of anion gap acidosis, perhaps with normal O2 delivery, such as due to metformin,
in a desperate alcoholic malignancy, ethanol).
METHANOL

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30 Onco-Logical

M
E D OWN S
L E N
A ML C S QU A MOU S
N A T C
O A L L O P U R I NOL
M M C O E
A L C OHOL I A F P U
E U L E S
D I A P H R A GM L N B
I I I
V B ON E MA R R OW
L P
A P O P T O S I S
S Y
T HY MU S
E P
T L
A E B V
C S E
I MA T I N I B
L A C
P S A E
I C L L
S L

160
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2 - ALL is seen with greater frequency in 1 - Dysplastic nevus syndrome is associated
this chromosomal disorder (DOWN’S with increased risk of MELANOMA
syndrome) 3 - This lab abnormality commonly occurs
5 - Eosinophilic rods inside malignant cells are in patients on chemotherapy and places
seen in this leukemia (acronym) them at risk of severe infection
AML. Acute myelogenous leukemia. These NEUTROPENIA. Neutropenic fever is
are called “Auer rods.” a medical emergency. Broad-spectrum
7 - Actinic keratosis is a precursor lesion to antibiotics should be hung without delay.
SQUAMOUS cell carcinoma 4 - Abnormal B-cells in Hodgkin disease may
8 - Co-administration of this drug prevents have a large bilobed NUCLEUS
hyperuricemia while on chemotherapy This is the Reed-Sternberg cell with a
ALLOPURINOL. Hyperuricemia may result so-called “owl’s eye” appearance.
from tumor lysis syndrome. 6 - Elevation of this electrolyte may be the
9 - Hodgkin disease may be suspected in first clue in the diagnosis of multiple
patients who have pain in lymph nodes myeloma
after drinking ALCOHOL CALCIUM. Due to increased bone turnover.
This is a rare sign. 8 - Treatment with all-trans retinoic acid may
11 - This tumor marker may be useful for be curative in the M3 type of this leukemia
screening for and following hepatocellular (acronym)
carcinoma (acronym) AML. This type is also called acute promy-
AFP. Alpha fetoprotein. May also be elocytic leukemia.
elevated in certain germ cell tumors. 10 - This tumor marker may be useful for
12 - This anatomic structure defines staging in following colon cancer (acronym)
Hodgkin disease CEA. Carcinoembyronic antigen. It is not a
DIAPHRAGM screening test.
15 - Biopsy of this tissue is often needed for 11 - Most common leukemia in children
the diagnosis of leukemia (two words) (acronym)
BONE MARROW. The procedure usually ALL. Acute lymphocytic leukemia. Vast
involves insertion of a large needle into the majority achieve complete remission.
marrow cavity of the iliac crest. 13 - A patient with multiple purplish vascular
16 - The gene product of #21 down suppresses papules and plaques in the lower extremi-
this cellular process ties is likely immunocompromised from
APOPTOSIS. The gene is called BCR–ABL HIV (acronym)
and expresses an abnormal tyrosine kinase. Kaposi sarcoma is an AIDS-defining illness.
17 - Myasthenia gravis may be associated with 14 - A patient with a 1.5-cm cervical lymph
malignancy of this organ node that does not go down after 4 weeks
THYMUS. 10% to 15% of myasthenia should have a BIOPSY
patients have an underlying thymoma. Any node >1 cm for more than 4 weeks
20 - This common virus is thought to play should be biopsied, though the vast major-
a role in certain forms of non-Hodgkin ity will be benign.
lymphoma (acronym) 15 - Patients with CML in this phase have
EBV. Epstein-Barr virus, most known for the markedly shortened survival
infectious mononucleosis syndrome. Burkitt BLAST. In this phase, the disease is more
lymphoma is closely associated. similar to AML.
22 - This drug inhibits the BCR–ABL gene 18 - The presence of distant METASTASIS defines
product Stage IV malignancy in virtually all cancers
IMATINIB. Brand name is Gleevec. 19 - Enlargement of this organ is a common
24 - This tumor marker may be useful for finding in many leukemias
screening for and following prostate cancer SPLEEN
(acronym) 21 - The Philadelphia chromosome t(9,22) is most
PSA. Prostate-specific antigen. While specific associated with this malignancy (acronym)
for the prostate, it is not specific for cancer. CML. Chronic myelogenous leukemia. Cases
25 - A 70-year-old is incidentally found to have that are positive have better prognosis.
a WBC count of 110,000 and “smudge 23 - This cell type is responsible for the major-
cells” on the smear (acronym) ity of non-Hodgkin lymphomas
CLL. Chronic lymphocytic leukemia. B CELL

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31 Clear to Auscultation?

S I NU S T A C H
A
U
V I R U S E S
E
P U
B R ONC H I T I S
E
U H
C H L A MY D I A A R D S
O D O L N D
H T WA R F A R I N
H R E M P M
O P U R S E D A E
R A E O R N T
H OM A N S E B C H
X T P S E U D OM ON A S
H S X A C
P M Y S H
E A R I G H T L OWE R
R B E L
T E O S I NO P H I L S
U N N
S T E R O I D OX Y G E N
S G
I A D E N O C A R C I N OM A
S

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1 - The usual EKG finding in a PE (short form of 1 - A patient recovering from influenza who
second word) suddenly worsens with high fevers and puru-
SINUS TACH. The “classic” S1Q3T3 pattern is rare. lent sputum may be infected with this bug
2 - Most pneumonia in children is due to VIRUSES (initial the genus)
RSV and influenza are exceedingly common. S. AUREUS. Common in postviral pneumonias.
4 - Chronic productive cough may clue you into a 3 - A tall 18-year-old male who presents with
diagnosis of chronic BRONCHITIS acute onset chest pain and shortness of
Technically defined as >3 months per year for breath
more than 2 years. PNEUMOTHORAX. Caused by spontaneous
6 - In addition to the usual causes of neonatal bleb rupture.
sepsis, CHLAMYDIA (bug) should be consid- 5 - Bilateral HILAR adenopathy is the hallmark of
ered in a neonate with pneumonia sarcoidosis
8 - Your patient with urosepsis who suddenly 6 - Poisoning with this gas will cause a falsely
develops dyspnea and becomes hypoxic elevated pulse oximetry reading (acronym)
despite oxygen administration may have this CO. Carbon monoxide.
complication (acronym) 7 - A patient with a pleural effusion from pneu-
ARDS. Adult respiratory distress syndrome. monia would be expected to have relatively
Capillary leak causes widespread noncardio- high levels of LDH compared to serum
genic pulmonary edema. (acronym)
10 - A DVT or PE buys you at least 3 months of Effusion will be an exudate and the ratio should
therapy with WARFARIN be either >0.6 or >two-thirds the upper limit of
Goal INR 2 to 3. Newer oral anticoagulants are normal serum LDH (Light’s criteria).
likely to come into widespread clinical use. 8 - Unlike garden variety community-acquired
13 - A patient with COPD may create their own pneumonia, coverage of this class of bugs
PEEP by exhaling against PURSED lips should be considered when treating aspiration
This effectively narrows the airway, creating back pneumonia
pressure (PEEP) which helps keep alveoli open. ANAEROBES. Addition of clindamycin or
15 - Your patient with calf pain on passive dorsiflex- metronidazole may be appropriate.
ion of the ankle has a positive HOMAN’S sign 9 - A normal D-DIMER may rule out DVT/PE if
May suggest a DVT, though the usefulness of your clinical suspicion is low
this sign is debatable. 11 - Your patient with unilateral upper extremity
16 - Be sure to treat your patient with hospital- weakness and Horner syndrome may have a
acquired pneumonia with antibiotics to cover PANCOAST tumor
PSEUDOMONAS (bug) Apical lung cancer that may invade the brachial
Choices are aminoglycoside (gentamicin), plexus and sympathetic chain.
extended-spectrum cephalosporin or b-lactam 12 - A METHACHOLINE challenge may be
(e.g., cefixime, pip/tazo), or fluoroquinolone administered to the suspected asthmatic with
(e.g., ciprofloxacin). Resistance rates are high normal PFTs
so may need double coverage. Promotes bronchospasm in the susceptible
19 - Aspiration pneumonia typically develops in patient. Many asthmatics have normal PFTs
this lobe (two words) when not in an exacerbation, unlike COPD.
RIGHT LOWER. Right middle is also common site. 13 - In addition to increasing the fraction of
21 - Churg-Strauss syndrome might be suspected inspired oxygen, this ventilator parameter
in an asthmatic patient with high levels of may be increased to improve oxygenation
this cell line (acronym)
EOSINOPHILS. A granulomatous vasculitis PEEP. Positive end-expiratory pressure.
characterized by pulmonary symptoms, Prevents collapse of alveoli at the end of
eosinophilia, and rash. exhalation improving gas exchange.
22 - For a patient who is wheezing more than 14 - “All that wheezes is not ASTHMA”
twice a week, addition of an inhaled STEROID A useful axiom, though most of what wheezes
is recommended is asthma.
23 - Hypoxemia that is due to intrapulmonary 17 - This first line therapy for #3 down speeds
shunting will not respond to therapy with resolution
OXYGEN OXYGEN
The perfused areas are not ventilated; there- 18 - Occurring in outbreaks, this pulmonary
fore, the supplemental O2 does not reach the infection is making a comeback in part due to
capillaries. decreasing rates of immunization
24 - Lung cancer that is the least associated with PERTUSSIS
smoking 20 - A solitary pulmonary nodule that is
ADENOCARCINOMA unchanged for over 2 years is likely BENIGN

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Some Lovers Try . . .

32 This Puzzle

MC L
L O P E N
A S
V T F
F I E E
A F A S C I O T OM Y
C T S N L S U
E F T H E NA R R
MR I E R C
B F R S C A P HO I D
P O S T E R I OR O I P
L H O A M P R
S T E NO S I S R A D I A L O
S I F
A C H I L L E S U L NA L
X E S C O
I P L X
L T I B I A A
L I D C
A C B U R S I T I S
R P N
Y

164
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1 - In addition to #23 across and the medial menis- 2 - Most commonly fractured long bone
cus, this structure is often coinjured as part of the CLAVICLE
“unhappy triad” (acronym) 3 - Radiographic new bone formation in a sunburst
MCL. Medial collateral ligament. pattern is a sign of this devastating tumor
3 - Antibiotics are always indicated in this type of OSTEOSARCOMA
fracture 4 - An obese adolescent male with knee pain and
OPEN. Infection risk is high. limp may have epiphyseal displacement on this
6 - This gruesome intervention may be limb saving in bone
patients with a painful swollen limb and paresthe- FEMUR. Slipped capital femoral epiphysis is
sias, pulselessness, paralysis, and poikilothermia separation of the femoral head along the growth
FASCIOTOMY. The “P’s” of compartment plate. Often the pain is referred to the knee.
syndrome are well known. Poikilothermia is loss of 5 - A patient with a femur fracture suddenly devel-
normal temperature regulation. ops SOB, rash, DIC, and cardiovascular collapse
8 - A patient who develops hand pain and numbness (two words)
after holding the wrist in forced flexion for FAT EMBOLI
60 seconds may have this (acronym) 7 - Most common type of shoulder dislocation
CTS. Carpal tunnel syndrome. Compression of the ANTERIOR
median nerve as it travels through the wrist. The 9 - Mike Tyson presents with hand pain after a
sign described is called Phalen sign. match. He has fractured his FIFTH metacarpal
10 - Atrophy of this group of muscles is a late sign of 12 - A 15-year-old track athlete ruptures her Achil-
#8 across les tendon while being treated for a UTI with
THENAR. The thenar muscles are innervated by the CIPROFLOXACIN
median nerve. The hypothenars by the ulnar. Fluoroquinolones are known to cause tendon
11 - What study should be ordered in a patient with rupture.
new onset back pain and urinary incontinence? 14 - A first born, female, newborn delivered in breech
(acronym) presentation is at high risk for dysplasia of this
MRI. This may be a case of cauda equina syn- joint
drome, a neurosurgical emergency. HIP. Disease is known as developmental dysplasia
13 - Fracture of this bone should be suspected in a of the hip or congenital hip dysplasia. All newborns
patient with snuff box tenderness are screened by physical examination maneuvers
SCAPHOID. Even if the x-ray is negative, treat pre- at every well visit in the first year of life. Failure
sumptively for fracture. X-ray may take 2 weeks to to diagnose and treat results in early onset of
show fracture. Avascular necrosis is a complication. osteoarthritis and early disability.
15 - Most common type of hip dislocation 16 - Falling on outstretched hand most likely results
POSTERIOR. May occur when a knee hits the in fracture of this bone
dashboard. RADIUS
17 - An old man with leg pain that gets better when 18 - Hormone level that should be checked in
leaned forward or walking uphill: Spinal STENOSIS #4 down
This is called neurogenic claudication. Flexion of TSH. Thyroid-stimulating hormone. Hypothyroid-
the spine opens the spinal canal and relieves nerve ism is an associated condition.
root compression. 20 - The AXILLARY artery and nerve may be injured in
19 - Your roommate was out drinking on Saturday #7 down
night and awoke on Sunday with a wrist drop. He 21 - SEPTIC arthritis: Must be ruled out in any patient
has injured the RADIAL nerve with a red, hot joint
Aka “Saturday night palsy.” The mechanism usually 23 - What ligament is injured in a patient with excess
involves passing out with the humerus in an awk- laxity on anterior translation of the tibia?
ward position compressing the radial nerve. Most (acronym)
cases resolve in time. ACL. Anterior cruciate ligament. A positive anterior
20 - Your patient with an L5–S1 disc herniation may drawer test is described.
have a diminished ACHILLES reflex 25 - The finger joint most commonly involved in
Herniation at that level typically affects the spinal osteoarthritis (acronym)
nerve root one level below. DIP. The PIP is more commonly affected in rheu-
22 - A person defending himself from an attack may matoid arthritis.
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.

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33 Doc, I Think It’s My Hormones

P A P I L L A R Y
R
O
P OT A S S I UM
Y
L
T S C OR E
S R H M
A D R E NA L I NS U F F I C I E NC Y
L I O O N
I U U N I
N P H R N N
E Y A NT I T P O G M
P C D OP AM I NE
O I S C E T
G G L A R G I NE O T H
L L C F I
Y L C O M
C T A U R A
K E T OA C I D OS I S S M Z
M I I O
I L N L
A NA P L A S T I C E
C I S K B
T S HY P E R C A L C E M I A
I P T I T
C R E N I N O T A
A O N H B
C E I L
I NS U L I N S U O
D M C
OC T R E OT I D E K
S E
A C E I NH I B I T OR S R
S
166
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1 - Most common type of thyroid carcinoma 1 - Antithyroid drug preferred for treating hyperthy-
PAPILLARY. And a highly favorable prognosis. roidism in pregnancy
Five-year survival >95%. PROPYLTHIOURACIL
2 - A patient in diabetic ketoacidosis is always total 4 - This treatment is by far and away the most
body deficient in this electrolyte (regardless of important initial treatment for hypercalcemia
serum level) SALINE. By IV infusion.
POTASSIUM. In fact these patients are usually 5 - This test along with a thyroid scan can help differ-
hyperkalemic due to intracellular shifts due to lack entiate Graves disease from thyroiditis (acronym)
of insulin and acidosis. RAIU. Radioactive iodine uptake. Elevated uptake
3 - Osteoporosis is defined by a T-SCORE of –2.5 or is indicative of a hypermetabolic gland (Graves)
lower on DEXA scanning whereas decreased uptake indicates gland
The T-score is the number of standard deviations destruction (thyroiditis).
below the mean for a healthy young adult. 6 - Hemorrhagic necrosis of the adrenal gland may
7 - Hyponatremia and hyperkalemia should always occur after infection with this bacteria
prompt consideration of this life-threatening MENINGOCOCCUS. Aka, Neisseria meningitidis.
problem 8 - This syndrome should always be suspected in a
ADRENAL INSUFFICIENCY. Especially in a patient patient with hypertension and hypokalemia
on chronic exogenous steroids. CONN. Primary hyperaldosteronism.
9 - Intermediate-acting insulin, usually dosed twice 10 - Adverse effect of nearly all antiglycemic agents
daily except metformin
NPH. May also provide basal coverage, though not HYPOGLYCEMIA
technically peakless. 12 - Antithyroid drug preferred in absence of pregnancy
11 - Rarely checked, but often elevated antibody in METHIMAZOLE
Hashimoto thyroiditis 14 - In the absence of contraindications, this drug is
ANTI-TPO. Thyroid peroxidase. the absolute first-line therapy for Type 2 diabetes
13 - Agonists to this neurotransmitter are first-line METFORMIN
therapy for prolactinoma 15 - The clinical finding of bitemporal hemianopsia
DOPAMINE. Bromocriptine for example. would prompt one to order MRI of this structure
16 - Long-acting insulin without a peak SELLA. Tumors of the pituitary gland may encroach
GLARGINE. Used to provide basal insulin. upon the optic chiasm and cause this clinical
18 - Classically, only Type 1 diabetes mellitus presents presentation.
with this life-threatening disorder 17 - Presence of this antibody is highly specific for
KETOACIDOSIS. Insufficient insulin causes cells to Graves disease (acronym)
switch to fat as energy source, producing ketoacids TSI. Thyroid-stimulating immunoglobulin.
as a byproduct. Antibody binds to the TSH receptor, causing
20 - Most aggressive and rapidly fatal thyroid carci- unregulated production of thyroid hormone.
noma 19 - Rare but serious side effect of metformin
ANAPLASTIC. Five-year survival rate is 5% to LACTIC ACIDOSIS. A Type B lactic acidosis, where
10%. there is no tissue ischemia.
25 - “Stones, bones, groans, and psychiatric over- 21 - Fastest acting insulin
tones” may represent this electrolyte disturbance LISPRO. Used for prandial coverage.
HYPERCALCEMIA 22 - Best screening test for assessing thyroid function
27 - The first step in evaluation of suspected hyper- (acronym)
aldosteronism is measurement of the plasma TSH. Thyroid-stimulating hormone. A normal TSH
RENIN: Aldosterone ratio excludes thyroid dysfunction, regardless of T3 or
28 - Type 1 diabetics will always require therapy with T4 levels.
this at all stages of their disease 23 - Insulin therapy in diabetic ketoacidosis is directed
INSULIN. Unlike Type 2 diabetics who may remain at lowering (glucose/ketones)
insulin independent for many years/life. KETONES. The primary problem in DKA is insulin
29 - This drug, more commonly used in variceal upper deficiency and the resultant acidosis that results
GI bleeding, is also used to treat acromegaly from using fats rather than glucose as an energy
OCTREOTIDE. A somatostatin analog that lowers source. Hyperglycemia is merely a sign of the
portal venous pressure. problem, but not the problem itself.
30 - Use of this drug class in diabetes has been shown 24 - A patient with positive urinary metanephrines
to decrease progression of nephropathy should never been given a drug from this class
ACE INHIBITORS. And is generally recommended alone
for secondary prevention of renal disease in BETA-BLOCKER. Blockade of the beta receptors
diabetics. 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 nephro-
genic diabetes insipidus
LITHIUM

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34 This Puzzle is Giving Me Gas

Meredith Gilliam

H
N E U R A L C R E S T
S V
T
E P P I
R H E
I M P R
X H E Y N
C D I V E R T I C U L I T I S
A D H E S I ON S P O O C
O F A L C I F OR M I
G L I A D I N T L I O
E S E R OT ON I N U
C D P A S T
Y V U R
S I A D E NOC A R C I NOMA
T T D M N C
D U O D E NA L A T R E S I A T H
K L N D E A
V I L L OU S A E R L
N I L N G A
I N A A S
N E C E R U L OP L A S M I N
T A
R
I
J E J UNUM

168
Across: Down:
2 - Hirschsprung disease is caused by failure 1 - An immunocompromised patient with
of this embryologic population of cells to odynophagia and “volcano-like” ulcers in
migrate to the rectum (two words) his esophagus may be infected with this
NEURAL CREST pathogen (acronym)
4 - This class of drugs works by irreversibly HSV. Herpes simplex virus.
inhibiting H+/K+-ATPase in stomach cells 3 - Patients with severe liver failure may
(acronym) present with this coarse hand tremor
PPI. Proton pump inhibitor(s). ASTERIXIS. “Liver flap.”
10 - Most likely diagnosis in an older patient 5 - Autoimmune destruction of the stomach’s
with LLQ pain, fever, and leukocytosis parietal cells may result in this type of
DIVERTICULITIS anemia
11 - Most likely cause of an acute bowel PERNICIOUS
obstruction in a patient who has had 6 - Nearly all patients with duodenal ulcers
multiple abdominal surgeries are infected with this organism (shorten
ADHESION(S) the genus to an initial)
12 - This ligament attaching the liver to the H. PYLORI
anterior abdominal wall is a derivative of 7 - This prokinetic agent may relieve the
the fetal umbilical vein symptoms of gastroparesis by antagoniz-
FALCIFORM ing dopamine receptors
13 - Autoantibodies against this glycoprotein METOCLOPRAMIDE
found in wheat are present in 80% of 8 - A surgeon may insert a finger through the
patients with celiac disease epiploic foramen to compress the contents
GLIADIN. Treatment is a gluten-free diet. of this ligament to control bleeding
14 - The flushing, diarrhea, and right-sided HEPATODUODENAL
heart murmurs associated with carcinoid 9 - This GI hormone secreted by I cells is
tumors result from abnormal production responsible for the pain that patients with
of SEROTONIN cholelithiasis may feel after eating a fatty
Carcinoid tumors originate from endocrine meal
cells and are mostly found in the small CHOLECYSTOKININ. It causes gallbladder
intestine. contraction.
15 - This liver enzyme may be disproportion- 16 - An infant with painless rectal bleeding
ately increased (relative to others) in may have a congenital anomaly resulting
patients with alcoholic hepatitis (acronym) from the persistence of this embryological
AST. Aspartate transaminase. In alcoholic duct
hepatitis the ratio of AST to ALT is often >1.5. VITELLINE
17 - Glandular metaplasia in the distal esopha- 18 - This type of hemorrhoids are not painful
gus may transform into this histological because they receive visceral innervation
type of carcinoma INTERNAL
ADENOCARCINOMA. This precursor 19 - A patient with progressive dysphagia and
condition is Barrett esophagus. a dilated esophagus with distal stenosis on
20 - Bilious vomiting in a neonate and a “double barium swallow most likely has this
bubble” on abdominal imaging is concerning condition
for this congenital abnormality (two words) ACHALASIA. Lower esophageal sphincter
DUODENAL ATRESIA. About a fourth fails to relax due to loss of myenteric plexus.
of infants with this or stenosis have Down 22 - This GI hormone is oversecreted in
syndrome. Zollinger-Ellison syndrome
21 - Of the histological types of adenomatous GASTRIN
colon polyps, VILLOUS adenomas most
likely to become malignant
23 - Check the level of this protein in patients
with cirrhosis, corneal deposits, and par-
kinsonian symptoms
CERULOPLASMIN. Wilson disease.
24 - Pathology in this part of the gut may limit
the body’s absorption of folate
JEJUNUM

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35 BuzzWards

I NT U S S U S C E P T I ON P
A K S
T M L O M
R U B E L L A Y E R Y
E F E B I C
M L L S A O
I C R OU P HOD GK I NS P
A O T M E I L
S T A C HA L A S I A
B C E R E U S L S
A R P A M
O V P D A
E V A R I C E L L A A
N A O R S R
D G T S B K
O I H I MP E T I GO
M N R C S N
NE U R O F I B R O MA T O S I S
T S X L O O E
N E P H R OT I C O S N B
D I S R I S O
E O S R
M S R
A I P F H
S MU L T I F OR ME
I
C

170
Across: Down:
1 - Currant jelly stools 2 - Doughy skin (electrolyte abnormality,
INTUSSUSCEPTION. May be seen in hyperNATREMIA)
association with Henoch-Schönlein 3 - Silvery scale
purpura. PSORIASIS
7 - Blueberry muffin rash 4 - Currant jelly sputum
RUBELLA. Congenital rubella KLEBSIELLA. Often seen in alcoholics
specifically. who aspirate.
9 - Barking cough 5 - Punched-out lesion on skull film
CROUP. Caused by parainfluenza virus (multiple MYELOMA)
very frequently (and many others). Monoclonal gammopathy and Bence
Inspiratory stridor. Treat with steroids. Jones protein in the urine.
11 - Reed-Sternberg cells. 6 - Cold agglutinins
HODGKIN’S (lymphoma). MYCOPLASMA
12 - Bird’s beak on swallow study 8 - Sawtooth wave (acronym)
ACHALASIA. The esophageal stricture AFLUTTER. Atrial rate is 300, ventricu-
may resemble a bird’s beak. lar rate 150.
13 - Leftover rice 10 - Christmas tree rash (pityriasis
B. CEREUS. “Food poisoning from ROSEA)
rice?! You can’t B. cereus!” Cause unknown, but probably viral.
16 - Machine-like murmur (acronym) Initial lesion is another buzzword, the
PDA. Patent ductus arteriosus. Closes “herald patch.”
with NSAIDs. 14 - Rose gardener
18 - Dewdrop on a rose petal SPOROTHRIX. Caused by a rose thorn
VARICELLA puncture.
20 - Honey-crusted lesion 15 - Spaghetti and meatballs on KOH
IMPETIGO. Caused by streptococcus preparation (pityriasis VERSICOLOR)
or staphylococcus most commonly. Due to Malassezia fungi.
Treat with topical agents first. 16 - Cogwheel rigidity
21 - Café-au-lait spots PARKINSON’S
NEUROFIBROMATOSIS. Type 1. 17 - Powder burns on laparoscopy
23 - Maltese cross casts in urine ENDOMETRIOSIS. May also see
(NEPHROTIC syndrome) “chocolate cysts.”
Due to the presence of cholesterol 18 - Clue cell (bacterial VAGINOSIS)
esters. Epithelial cells studded with bacteria.
25 - Honeycomb lung (acronym) 19 - Shipyard worker
IPF. Idiopathic pulmonary fibrosis. ASBESTOSIS
26 - Target lesions (erythema 22 - Stuck on appearance (SEBORRHEIC
MULTIFORME) keratosis)
Often due to drugs, viruses. 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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36 A Trich Puzzle

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

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2 - Gray discharge, high pH, clue cells (acronym) 1 - Common uterine tumor that is hormonally
BV. Bacterial vaginosis. Overgrowth of responsive
Gardnerella vaginalis. FIBROID. Aka leiomyoma. Almost always
3 - This virus is responsible for the vast majority of benign, and may decrease in size after
cervical cancer (acronym) menopause.
HPV. Human papillomavirus. Subtypes 16 and 4 - Most common cause of secondary amenorrhea
18 are particularly high risk and account for 70% PREGNANCY
of cervical cancers. 5 - A woman who leaks urine when she coughs,
6 - Motile organism seen on saline wet mount of laughs, or sneezes has STRESS incontinence
vaginal secretions is pathognomonic for TRICH Due to weak pelvic floor muscles. Kegel exer-
(short form) cises often help and are first-line intervention.
Trichomonas vaginalis, a flagellated protozoan. 7 - The only way to definitely diagnose #19 across
8 - What is the diagnosis in a woman who LAPAROSCOPY
presents with amenorrhea, acne, hirsutism, and 9 - You might find a “CHOCOLATE cyst” on the
insulin resistance? (acronym) ovary of the patient in #19 across
PCOS. Polycystic ovarian syndrome. The diag- Endometriomas, hemorrhagic endometrial
nosis can be made clinically without ultrasound implants.
or lab findings, though they may be obtained to 10 - Crops of vesicles that progress to painful
support the diagnosis. ulcerations
9 - Budding yeast on a KOH preparation are HERPES. HSV-2 causes most genital infections.
diagnostic for this organism 12 - Menstrual bleeding that is irregular in frequency
CANDIDA METRORRHAGIA. Menorrhagia is heavy or
11 - Treatment with this drug may restore fertility prolonged bleeding.
to the patient in #8 across 14 - This prophylactic intervention is an option for
METFORMIN. In addition to treating the insulin women with the BRCA-1 mutation
resistance. MASTECTOMY. If they are done with childbear-
13 - Toxic shock syndrome commonly occurs in ing, may opt for bilateral oophorectomy as well.
women with a retained TAMPON 16 - Absence of menses for at least 12 months
The syndrome is caused by preformed Staphylo- MENOPAUSE. Average age of onset is 51.
coccus aureus toxin. Patients appear septic, but 19 - Excess of this hormone is a risk factor for endo-
blood cultures are negative. metrial cancer
15 - The most common breast quadrant to encoun- ESTROGEN. And thus women who are obese,
ter breast cancer (two words) who had early menarche/late menopause, few
UPPER OUTER or no children are at increased risk.
17 - Hormonal contraceptive methods which 20 - OCP use is protective against OVARIAN cancer
contain ESTROGEN increase the risk of throm- Suppression of ovulation is thought to be the
boembolic disease mechanism.
This includes combination OCPs, vaginal ring, 22 - A cause of increased abdominal girth in patient
contraceptive patch. with ovarian cancer
18 - Treatment with this drug is indicated in estro- ASCITES. Usually indicates peritoneal
gen receptor–positive breast cancers metastasis.
TAMOXIFEN 25 - Purulent cervical discharge and cervical motion
19 - Your patient with cyclic abdominal pain and tenderness (acronym)
nodularity on her uterosacral ligaments has PID. Pelvic inflammatory disease. Often polymi-
ENDOMETRIOSIS crobial, gonorrhea or chlamydia, is implicated in
21 - Woman with a history of migraine with AURA 2/3 of cases.
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.
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37 Widow Maker

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

174
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1 - The genus most commonly implicated in 1 - Most useful intervention in the treatment of
subacute endocarditis (short form) PVD is the cessation of SMOKING
STREP. Usually viridans streptococci, 2 - Duke major criteria (1 of 2)
enterococci. BACTEREMIA. Must be sustained, and with an
2 - Levels of this peptide are virtually always organism known to cause endocarditis.
elevated in decompensated CHF (acronym) 4 - Cardiac risk factor: Most easily treated
BNP. B-type natriuretic peptide. And, thus, a (acronym)
normal BNP value has a high negative predic- LDL. Elevations in LDL are associated with
tive value. increased cardiovascular risk and respond
3 - A hypotensive patient severe burns may be in extremely well to therapy with statins.
HYPOVOLEMIC shock 5 - The finding of a delta wave on EKG is sugges-
7 - Chest pain relieved by leaning forward may be tive of this syndrome (acronym)
a clue to this diagnosis WPW. Wolff-Parkinson-White. Accessory path-
PERICARDITIS. EKG will show diffuse ST eleva- way that may cause paroxysmal tachycardia.
tions and PR depression. The delta wave is a “slurred upstroke” going
10 - Prior myocardial infarct may be suggested by into the QRS.
the finding of this on EKG 6 - The triad of butt claudication, impotence,
Q WAVE. Acute and subacute MIs may have and decreased femoral pulses may be due
Q waves as well, but often with concomitant to occlusion of the aorta near the
ST segment and T wave changes, that often BIFURCATION
resolve over time. This is called Leriche syndrome.
11 - A widened pulse pressure may suggest this 8 - Harsh systolic murmur that radiates to the
valvular disease (acronym) carotids (acronym)
AI. Aortic insufficiency. A regurgitant aortic AS. Aortic stenosis. Often described as having a
valve causes a low diastolic blood pressure. crescendo–decrescendo quality.
12 - Cardiac risk factor: Most prevalent of all 9 - Turner syndrome may be associated with this
(acronym) disease of the aorta
HTN. Hypertension is the most common COARCTATION
chronic disease in the United States. 13 - Cardiac risk factor: It is lower in men
13 - Perform this test to diagnose peripheral AGE. Age over 45 in men, over 55 in women.
vascular disease (acronym) 14 - A low-pitch diastolic murmur, loudest at the
ABI. Ankle-brachial index. Performed by mea- apex, with an opening snap (two words)
suring the ratio of systolic blood pressure at the MITRAL STENOSIS. Rheumatic fever is the
ankle to the arm. most common cause.
16 - Cardiac risk factor: Most potent of all 15 - Duke major criteria (2 of 2)
SMOKING. Smoking is the single greatest risk VEGETATION. Often must be visualized on
factor for coronary disease. Quitting smoking transesophageal echo.
halves your risk. 16 - A hypotensive patient with fever, elevated
17 - Occlusion of this coronary artery is often WBC with a left shift may be in SEPTIC shock
fatal (two words) 18 - A young woman with palpitations and
LEFT MAIN. Earning its nickname, “the widow atypical chest pain may have this valvular
maker.” condition (acronym)
19 - Electrical alternans, a phenomenon where MVP. Mitral valve prolapse. Beta-blockers may
every other QRS has a different morphology improve symptoms.
and direction, may be a clue to this diagnosis 20 - The single most powerful drug you can
TAMPONADE. The finding is not sensitive, as administer in acute coronary syndrome
many cases of tamponade have normal EKGs. ASPIRIN. Provides a 50% to 70% decrease in
22 - A hypotensive patient with elevated JVP and death from MI.
pulmonary rales may be in CARDIOGENIC 21 - The valve most frequently infected in IV drug
shock abusers
23 - A hypotensive patient who is bradycardic with TRICUSPID. Pulmonic valve involvement may
head trauma may be in NEUROGENIC shock occur as well.
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.

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Don’t Mess Around

38 with the Pancreas

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

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Across: Down:
1 - The presentation of painless jaundice should 2 - Plummer-Vinson syndrome is the association
always worry you for cancer of this organ of esophageal webs and ANEMIA
PANCREAS Specifically, iron deficiency.
5 - A HIDA scan may be helpful for diagnosis 3 - Most common form of hiatal hernia
gallstone disease when ultrasound is nondiag- SLIDING. Symptomatic treatment is the only
nostic (acronym) intervention. The other type called a
Hepatobiliary Iminodiacetic Acid scan. Radio- paraesophageal hernia requires surgical
active tracer is taken up in the hepatocytes correction to prevent volvulus.
and excreted in the bile, outlining the biliary 4 - Most common type of gallstone
tree and gallbadder. Nonvisualization of the CHOLESTEROL. The other type is a pigment
gallbladder suggests an obstruction of the stone, usually associated with hemolytic
cystic duct and acute cholecystitis. conditions.
8 - Dark sticky tarry stool 6 - Use of this class of over-the-counter medica-
MELENA. Suggests bleeding proximal to the tion is a leading cause of peptic ulcer disease
ligament of Treitz. (acronym)
9 - Iron deficiency anemia in an older man or NSAIDS. Nonsteroidal anti-inflammatory
postmenopausal woman is COLON cancer drugs.
until proven otherwise 7 - Tumor marker associated with colon cancer
Screen with colonoscopy. (acronym)
11 - Relatively common GI cause of chronic cough CEA. Carcinoembryonic antigen. Not useful
(acronym) as a screening test, but may be used in disease
GERD. Some patients may completely lack surveillance.
typical heartburn symptoms. 9 - “Skip lesions” are characteristic of this form of
12 - A sting from this arachnid may cause pancre- IBD
atitis CROHN’S. Lesions may occur in any portion of
SCORPION. Classic pimp question. You will the GI tract, but are often not continuous.
never see this. 10 - The more specific test for acute pancreatitis
16 - This unusual form of cholecystitis may occur LIPASE. Amylase is sensitive, but not specific,
in debilitated patients or critically ill patients as many other conditions may elevate amylase.
ACALCULOUS. That is, there is no stone. 13 - Pain with swallowing
Occurs particularly in burn victims and patients ODYNOPHAGIA
receiving parenteral nutrition. 14 - Most common location of pancreatic cancer
19 - Most common cause of small bowel obstruc- HEAD. Followed by body, and then tail.
tion in children 15 - MURPHY’S sign: Arrest of inspiration during
HERNIA deep palpation of the RUQ
20 - A test performed on this bodily substance is High specificity for acute cholecystitis.
the best way to determine the presence of 17 - Treatment with this drug may help the
current H. pylori infection symptoms of carcinoid syndrome
STOOL. Serum testing detects antibodies OCTREOTIDE
which only indicates exposure. 18 - This type of adenoma has the highest risk of
23 - Most common cause of lower GI bleeding in malignancy
older adults VILLOUS
DIVERTICULA. Usually sudden and painless 21 - Common cause of antibiotic-associated
bright red bleeding. Can be life-threatening. diarrhea (short form)
26 - This test should be ordered in any patient C. DIFF. Clostridium difficile. Virtually any
diagnosed with esophageal candidiasis antibiotic can cause it, but generally associated
HIV. The disease is rare in immunocompetent with broad spectrum beta-lactams, clindamycin.
patients. 22 - A Krukenberg tumor is a metastasis of gastric
27 - This operation may be curative for ulcerative carcinoma to this organ
colitis OVARY
COLECTOMY. Crohn disease, on the other 24 - This part of the colon is always involved in
hand, may recur after resection. 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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39 Most Common . . .

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

178
Across: Down:
2 - Cancer in women 1 - Cause of small bowel obstruction in
BREAST adults
3 - Benign breast mass in younger ADHESIONS. Scarring from prior
women surgeries usually.
FIBROADENOMA. Frequently recur 3 - Benign tumor of female reproductive
even after excision. system
5 - Cause of chronic kidney disease in FIBROID. Aka, leiomyoma. Often
the United States decrease after menopause.
DIABETES 4 - Primary malignant bone tumor
7 - Cancer in men (acronym)
PROSTATE MM. Multiple myeloma. Monoclonal
9 - Cause of osteomyelitis in a sickle cell gammopathy, Bence Jones protein,
patient “punched-out” lesions on x-ray.
SALMONELLA 6 - Cause of death in diabetics (organ)
10 - Form of thyroid cancer HEART
PAPILLARY. Excellent prognosis. 7 - Cause of abnormal nipple discharge
14 - Bacterial cause of infectious diarrhea PAPILLOMA. Usually bloody
CAMPYLOBACTER. Though rarely discharge.
identified. 8 - Childhood malignancy (acronym)
16 - Type of shoulder dislocation ALL. Acute lymphoblastic leukemia.
ANTERIOR. Injury to axillary nerve Overall, has a generally good prognosis.
and artery is possible. 9 - EKG finding in pulmonary embolism
17 - Cause of maternal mortality (acronym)
HEMORRHAGE (POSTPARTUM). SINUS TACH(YCARDIA). The S1Q3T3
21 - Cause of hypothyroidism pattern is actually rather uncommon.
HASHIMOTO’S. And probably the 11 - Pituitary tumor
most common autoimmune disease PROLACTINOMA
overall. 12 - Cause of infection in burn patients
23 - Form of stroke PSEUDOMONAS
ISCHEMIC 13 - Skin cancer (acronym)
25 - Cause of acute lower GI bleeding in BCC. Basal cell carcinoma. Rarely
adults metastatic (<1%).
DIVERTICULOSIS. Usually painless 15 - Cause of secondary amenorrhea
bleeding, large volume, bright red or PREGNANCY. Always obtain pregnancy
maroon blood. testing as a first step in the workup.
18 - Cause of bronchiolitis (acronym)
RSV. Respiratory syncytial virus.
Outbreaks in winter and spring.
19 - Congenital heart defect (acronym)
VSD. Ventricular septal defect. Most
close spontaneously.
20 - Fracture of a carpal bone
SCAPHOID. Tenderness at the ana-
tomic snuffbox.
22 - Cause of peptic ulcer disease (short
form)
H. PYLORI. Along with NSAIDs,
alcohol, steroids, smoking.
24 - Organism causing UTI (short form)
E. COLI

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40 Clinical Scramble

COUGH
C O U G H

SPUTUM
S P U T U M

HEMOPTYSIS
H E M O P T Y S I S

FEVER
F E V E R

ACID FAST BACILLI

A C I D F A S T B A C I L L I

ANSWER: TUBERCULOSIS

180
Notes

181
CrossWards™

41 BrainTeaser

D O P A M I N E
E
P T
A T A X I A
R S
K T
O P T I C C H I A S M
N T
S I
O P C W
N L E
G B S A MY O T R O P H I C
L S N Y
F I B R OM A T O S I S D M T
O A H C B R O C A S R
B P I K O C I
L H A E C U P
A L Z H E I M E R S E L T
S R I P A A
T E N H P R I O N
O S E A S
M I L
A C O U S T I C T U B E R OU S
S

182
Across: Down:
1 - DOPAMINE agonists are treatment 2 - Most brain tumors are METASTATIC
for #3 down 3 - Pill-rolling tremor and rigidity: Two
4 - Problem in standing or walking classic signs of this disease
ATAXIA. You might have this if you PARKINSON’S
drink too much the night after your 6 - Treatment for #8 across includes IVIG
Step 2 examination. and possibly this procedure
5 - Bitemporal hemianopia suggests a PLASMAPHERESIS
lesion here (two words) 7 - Cannot understand language:
OPTIC CHIASM WERNICKE’S aphasia
8 - Acute demyelinating autoimmune 8 - Most common primary brain tumor
disorder causing ascending paralysis in adults
(acronym) GLIOBLASTOMA
GBS. Guillain-Barré syndrome; treat 10 - Patient who is “weird, wobbly, and
with IVIG, plasmapheresis, and wet,” think normal pressure
supportive care. HYDROCEPHALUS
9 - Loss of upper and lower motor neuron Too much CSF.
functions: AMYOTROPHIC lateral 12 - Give this to alcoholics to prevent
sclerosis Wernicke encephalopathy
This is also known as Lou Gehrig THIAMINE
disease; cognitive function is usually 13 - Painless loss of central vision mostly in
spared. the elderly: MACULAR degeneration
11 - Axillary freckling, café-au-lait Can be “dry” or “wet.”
spots, and iris hamartomas: 14 - Class of drugs used to treat acute
NeuroFIBROMATOSIS migraines
It is an autosomal dominant. TRIPTANS
15 - Cannot express language: BROCA’S
aphasia
16 - Cholinesterase inhibitors are used to
try to slow progression of this disease
ALZHEIMER’S. We all know how sad
this disease can be for family members.
17 - Creutzfeldt-Jakob disease is due to
infection with a PRION
Watch out zombie apocalypse.
18 - Schwann cell tumor: ACOUSTIC
neuroma
Sometimes called a Schwannoma, a
rare cause of sensorineural hearing
loss.
19 - “Ash-leaf” hypopigmented lesions are
classic for TUBEROUS sclerosis

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42 This Puzzle is Kidstuff

F N
R E C R OU P
P A T HO L OG I C E
G R R
I E P I G L OT T I T I S S E P T A L
L T U
E A MOX I C I L L I N S
X K Z M S
L E U K E M I A ME C ON I UM
R N P N S O
D OWN G C A T A R A C T R
I M R T R A
P C O V R C I X
H T I ND OM E T HA C I N E
O E G V S E T L
T U R N E R S O I I U L
O U L R A B U S E S A
T S R I U S
H O A S T R A B I S MU S
E X C L U S I ON E I S
R O E W N D C
A R O I A S E
P O L V OL V U L U S P
Y N A M T
A GA S T R O S C H I S I S
R B S G O
Y S V A N

184
Across: Down:
3 - Barking cough and “steeple sign” on neck film 1 - X-linked abnormality affecting the FMR1
CROUP gene: FRAGILE X syndrome
5 - Hyperbilirubinemia in the first 24 hours of Another cause of mental retardation.
life is always PATHOLOGIC 2 - Premature infants can develop
6 - Child “tripoding” with high fever, sore NECROTIZING enterocolitis
throat, drooling, muffled voice, and stridor: 4 - Whooping cough
Think EPIGLOTTITIS PERTUSSIS. It is making a comeback.
Do not upset the child and be prepared to 9 - Hypertonicity, lethargy, and seizures in a
intubate. newborn with unconjugated hyperbilirubi-
7 - Atrial SEPTAL defect has a fixed, widely nemia suggests permanent deposition in
split S2 the brain called
8 - High-dose AMOXICILLIN is an empiric KERNICTERUS. Preventing this is the whole
antibiotic treatment for acute otitis media reason we care about jaundice in newborns.
(if not allergic) 10 - First menstrual period
Can use azithromycin if allergic. MENARCHE
11 - Most common childhood malignancy 13 - One of three most common causes of acute
LEUKEMIA otitis media (genus only)
12 - Hirschsprung disease is suggested by failure MORAXELLA
to pass MECONIUM within first 2 days of life 14 - Erythema infectiosum (fifth disease) is due
Baby’s first poop. to PARVOVIRUS B19
15 - Most common chromosomal disorder 17 - Newborn has bilious emesis and a “double-
and cause of mental retardation: DOWN bubble” sign on abdominal x-ray: Duodenal
syndrome ATRESIA
Trisomy 21. 18 - Looks like a bruise but these “spots” are
16 - The absence of a red reflex on the eye birthmarks
examination of a newborn suggests con- MONGOLIAN. Important to document.
genital CATARACT 19 - First-line therapy for hyperbilirubinemia of
It can be tricky getting neonates to open the newborn
their eyes; try talking to them in your sweet PHOTOTHERAPY. Light them up.
baby-talk voice and putting a gloved-pinky 20 - One piece of intestine “telescopes” into
finger in their mouth (which also allows you another (not to be confused with a
to check the palate). “dreamy” Leonardo DiCaprio movie)
21 - This drug is given to help close a patent INTUSSUSCEPTION. Hardest thing about
ductus arteriosus this is spelling it.
INDOMETHACIN. And if your baby patient 24 - HHV-6 causes this infection that has
also happens to have gout, might help that prodrome of high fever followed by diffuse
too! maculopapular rash
22 - 45, XO: TURNER’S syndrome ROSEOLA
23 - Suspect this if the history is discordant with 26 - Most common cause of hypertension in
physical findings or if there is a delay in par- children is RENAL parenchymal disease
ent seeking medical care for a child 27 - Advise parents that newborns should sleep
ABUSE. Remember that shaken baby on their backs (i.e., supine) to decrease risk
syndrome may present without any other of this (initials)
physical findings but baby can have subdural SIDS. Sudden infant death syndrome.
hematoma and retinal hemorrhages; can 29 - Untreated Kawasaki disease can lead to
lead to brain damage. CORONARY aneurysms
25 - Misalignment of the eyes persisting beyond 30 - Embryonic renal tumor
3 months of age WILM’S
STRABISMUS. Important to detect so inter- 32 - Most common cause of meningitis in new-
vention can prevent amblyopia. borns (initials)
28 - Transient tachypnea of the newborn is a GBS. Group B streptococcus.
diagnosis of EXCLUSION 33 - Most common cause of bronchiolitis
31 - Malrotation of the gut (initials)
VOLVULUS RSV. Respiratory syncytial virus.
32 - Congenital herniation of intestine through 34 - Most common immunodeficiency: IGA
abdominal wall near umbilicus not covered deficiency
by a sac
GASTROSCHISIS
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This Puzzle Might Cause

43 Extrapyramidal Symptoms

M
B I P O L A R
N T
T O
E R G
R U
E I
S B L B
T OU R E T T E S
L Y N
P A N I C Z
A G M O
D Y S T ON I A D
H S R A I
D R A P R O L A C T I N
B I L A Z R
Y S C H I Z O P H R E N I A
P T E P C
R H I Y
C OMP U L S I ON N C B T
X U E L
Y M S I
E C T

186
Across: Down:
2 - Patient who has had at least one 1 - Apraxia is inability to perform
prior episode of major depression and MOTOR activities
now is manic: BIPOLAR disorder 3 - The “I” in SIGECAPS
7 - Syndrome characterized by motor INTEREST. Anhedonia is our fancy
and/or vocal tics medical term.
TOURETTE’S. The vocal tics may be 4 - The “G” in the CAGE questionnaire
coprolalia. GUILTY. Have you ever felt guilty
8 - Intense episodes of fear with symp- about your drinking?
toms such as shortness of breath, 5 - Abrasions on the knuckles, enlarged
chest pain, shakiness, and sweating: parotid glands, erosion of teeth
PANIC attacks enamel: All classic signs of BULIMIA
11 - Involuntary muscle spasms from These signs result from using fist to
antipsychotic medication induce vomiting and the vomiting itself.
DYSTONIA 6 - GABA-ergic drugs used as anxiolytics
13 - A side effect of some antipsychotics for short-term control
is elevation of this hormone BENZODIAZEPINES. Such as loraz-
PROLACTIN. Which can cause epam or clonazepam.
galactorrhea. 9 - Fear of being alone in public places:
18 - Patient with auditory hallucinations, AGORAphobia
disorganized thoughts, and delusions Can result from panic disorder.
likely has SCHIZOPHRENIA 10 - A 10-year-old taking methylpheni-
19 - Fear of germs leads to repeated date likely has this (acronym)
hand washing; hand washing is the ADHD. Attention deficit hyperactivity
COMPULSION disorder.
The fear of germs is the obsession, 12 - Class of medications used for long-
which is relieved (temporarily) by term treatment of #8 across
hand washing. (acronym)
20 - Kind of therapy used for #8 across SSRIS. Selective serotonin reuptake
(acronym) inhibitors.
CBT. Cognitive behavioral therapy. 14 - A cause of PTSD in men as well as
21 - Procedure reserved for refractory women
depression (acronym) RAPE
ECT. Electroconvulsive therapy. 15 - Amitriptyline is a TRICYCLIC
antidepressant
Not used much anymore for treating
depression.
16 - “Caregiver” makes someone else
ill (e.g., a child) to get attention:
Munchausen BY PROXY
17 - Classic mood stabilizer for patients
with #2 across
LITHIUM

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CrossWards™

44 Claiming the Inheritance

Y UO L K V XWV A C D P G T A U S Z J KH PWC R Q B S S E U
N A N G I S J Y P I N E U R O F I B R OMA T O S I S Z B D G L
L T G Y U H K H A Y Z Z Z B D I G X U Y I S I S C I U N F WW X
K C E Q T D O D R S WW V G B D G L E I X P N X Y S H O B X D Q
J E L U K I F D L U E R Z Y DN T L J B FQ R D C A X NUOH X
I F R I S Z T T Y S J F KH P A A A P R UY BDA C X L O JWC
G R F K C B B D X F R O A T Z G Y I K H N X WG L X W R K U N T
S E Q J B F Y M D D D S Z R E O S C V Y B A AMN C N L U CW B
G P P L WQ Y A C P W B F D Z I A H D W Y L F P N J R M R H M E
T MA T U Y H V X CMMOR E K C K X A A T L P F Q T U B F R W
U I F N K U A C O XW A Z X H U H S B C WB J L C J G M F O N I
L S HW P A C V A V X O K D E M S G T T B B Y B C H U R N Y J C
K I Z I K U J E V U H O X H A P WO J R T F K J L L F H J G F U
L S T L U Y Z U K S E B R G Y A S T O I R E P O T N V O G WQ S
M E C S C I I J V I X A DM A E I U L O C Y Q A J J H O VWZ Z
L N C OM B F NW S B D G A MG T R Z W FW O L A L M T Z S P Q
C E X N Z B F E NOU D G I P X X GU J DR F GG Y J S F O B S
A G F S QG B P S R X J A I QQ J A R N FW B Z X J I Q J S M Z
I OW X K Y A O X B T V J P H A T L V C O K I GW S N U F L G E
C E I Q T I R X A I QO S G E L GOH P B T D KO R CO S P B W
V T T E G I T XW FWN P B J P I A A NO I E R B H T T F E Z T
R S D G X D T W R C U I I M L Z I WN T A N E K C G I M T G O R
J OW Z H Q E S A I F Q S F L R U J D M T L S W L B A U Q Z I M
N B P N NO R A Z T L I WR P Q P T K L C R E F B Y C N P K P C
E D E J K E S G Y S I K V E E MV T S S FQ S E E ONVO L G Q
K QO Y V K Z S K Y P V CN Y H I WS C R C A L X H C E Y Y B V
V A S I I H Z NN CD QOZ OU C U X Y CR Z T B V Z J H X Y P
N HWM J R E P S I B O QM D M O U G A H T M I G D K K C P Y F
C C I D Z M E M Q WN H A U P R A K A D I Y V O F U G P U J T U
U O X N C K Y U F A X J E A E L K R O G WG W U O R F L Y P B P
F L S N W E L S N O M S P B U S Q N F I G K K Q R X R B Z WW G
L T V E AOV S E Y Z C U I HG J HQ A F I X A C Y HVU A I X
I W F T U K M U Y S L T F S B I T J I I N Y O N V NWM M O D W
A N P E V S Z J R X I Z X Q G Y Q O L E A S WH U H O X E X A E
S Z X D P A F T Z R K T D C OQ B K E T S C UO B J V V H Z V N
X E R OD E RMA P I GME N T O S A I YX V L Y L QN S F K P
T I Q Y X U U Z I A F QMR A U I E MMDX MU X S U NM B Y B
N I R F M P E N K T R WH I F H H O Y D L A Z R N U F U N F N T
N Q G R X H C R B N Q OWX S B G H P W Z I WH E P K G K E X N
P AMN D V Y P L I X T E F Q E T MK I RH F U Z V C E T QN U
188
Autosomal dominant Autosomal recessive
Osteogenesis imperfecta Bartter(’s)
Marfan’s Cystic fibrosis
Neurofibromatosis Gaucher’s
Noonan’s Wilson’s
Tuberous sclerosis Tay-Sachs
Xeroderma pigmentosa
Phenylketonuria
Galactosemia

189
CrossWards™

45 CN 2-12 Intact?

OL F A C T OR Y
A
C T
I H
OL F A C T O R Y
P L R E
OC U L OM OT OR I E
I G
V E S T I B U L OC OC H L E A R
A E M
G V V I
U E G E N
S N H Y P OG L OS S A L
O T L H
V A GU S I Y
T B S B P
R D OC U L OM OT OR
O U P L G
OP T I C C H O L
R H E A C C E S S OR Y
O L N R O S
A C C E S S OR Y C S
H A N H A
L R G L L
F I V E E E
A A A B D U C E NS
R L R

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1-I 2 - VII
OLFACTORY FACIAL
4 - Smell 3 - Eyelid opening (spell out the number)
OLFACTORY THREE
6 - Eye movement, pupil constriction, 4 - Sight
lens accommodation OPTIC
OCULOMOTOR 5-V
7 - VIII TRIGEMINAL
VESTIBULOCOCHLEAR 7-X
11 - XII VAGUS
HYPOGLOSSAL 8 - Eyelid closing (spell out the number)
13 - Talking and monitoring aortic barore- SEVEN
ceptors 9 - Hearing and balance
VAGUS VESTIBULOCOCHLEAR
16 - III 10 - IX
OCULOMOTOR GLOSSOPHARYNGEAL
17 - II 12 - French kissing
OPTIC HYPOGLOSSAL
19 - XI 14 - Lateral rectus eye muscle
ACCESSORY ABDUCENS
20 - Shoulder shrugging 15 - Superior oblique eye muscle
ACCESSORY TROCHLEAR
21 - Chewing, facial sensation (spell out 18 - IV
number) TROCHLEAR
FIVE
22 - VI
ABDUCENS

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CrossWards™

46 This Puzzle DeLivers

S
T H M
E B I
R C H O L E S T A T I C
A U T O I MMU N E A O
I B F C
D H B E A G H C C
D R U G S P E T O E
L H E P C M T OX I N R
A L C OH OL L O Y D U
U E H E P A T OC E L L U L A R L
T R B H I I O
O A S O B R V A F P
I T A C E T A M I NO P H E N L L
M I L O L M R A
M V E M V I R A L S
U E R Y A T M
N C O R O I
E O H B S A G Y S H OC K N
L B I I
W I L S ON S A A G
T A G
I B
S

192
Across: Down:
4 - Liver injury pattern: High elevation of alkaline 1 - This treatment may be indicated for severe
phosphatase, bilirubin, inconsistent elevation alcoholic hepatitis
of aminotransferases STEROIDS. When the Maddrey’s discriminant
CHOLESTATIC. Suggestive of obstruction of function is higher than 32.
biliary flow. 2 - Presence of this antibody may be only clue
5 - Antismooth muscle antibody associated with to recent hepatitis B infection during the
this form of hepatitis “window period”
AUTOIMMUNE HBCAB. Hepatitis B core antibody. HBsAg
7 - Presence of this antigen is a marker for infec- peaks and becomes undetectable before
tivity in chronic hepatitis B HBsAb is detectable. Thus, in this period, only
HBEAG. Hepatitis B “e” antigen. the HBcAb is detectable.
8 - Malignancy most commonly caused by 3 - AntiMITOCHONDRIAL antibody, associated
chronic hepatitis C (acronym) with #18 across
HCC. Hepatocellular carcinoma. 6 - Rising cause of cirrhosis, associated with
10 - Most common cause of abnormal transami- obesity and diabetes (two words)
nases FATTY LIVER. Nonalcoholic fatty liver disease
DRUGS (NAFLD) may progress to nonalcoholic steato-
13 - Hepatitis virus responsible for majority of hepatitis (NASH).
chronic viral hepatitis (short form) 7 - Name the disease: Bronze skin, diabetes,
HEP C increase iron saturation
14 - Cause of severe hepatitis (>1,000) HEMOCHROMATOSIS. Most common genetic
TOXIN. Aside from acetaminophen, numerous disorder in people of European descent.
other drugs and toxins may cause fulminant 9 - Found to be low in patients with #24 across
liver failure. CERULOPLASMIN. The major copper-carrying
15 - Liver injury pattern: AST:ALT = 2:1 protein. Patients with Wilson disease have a
ALCOHOL defect in copper metabolism which causes
16 - Liver injury pattern: Elevated aminotrans- copper to circulate free, unbound to cerulo-
ferases, mild elevation of bilirubin, alkaline plasmin. Unbound ceruloplasmin degrades
phosphatase rapidly.
HEPATOCELLULAR 11 - GI disorder often concomitant with #17
19 - Serum marker elevated in #8 across (acronym) down (two words)
AFP. Alpha fetoprotein. Elevation of this ULCERATIVE COLITIS
marker in the setting of a liver mass and known 12 - The treatment for #7 down
risk factors for HCC is virtually diagnostic. PHLEBOTOMY
Unlike most all other cancers, tissue diagnosis 15 - Cause of severe hepatitis (>1,000)
is not pursued, partially owing to the high AUTOIMMUNE. Rare, but possible cause of
bleeding risk. fulminant hepatitis.
20 - Cause of severe hepatitis (>1,000) 17 - Primary SCLEROSING cholangitis: Disease
ACETAMINOPHEN. A common overdose, affecting mostly young men
treated with N-acetylcysteine. “Beads on a string” appearance on ERCP.
21 - Cause of severe hepatitis (>1,000) 18 - Primary BILIARY cirrhosis: Autoimmune cause
VIRAL. Usually hepatitis A, but also B or C, other of cirrhosis affecting middle-aged women
non-“hepatitis” viruses including EBV, CMV. 22 - Presence of this antibody indicates prior
22 - Presence of this antigen indicates chronic exposure to hepatitis B or vaccination
infection with hepatitis B HBSAB. Hepatitis B surface antibody.
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.

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47 I Need a Puzzle—Stat!

C A R B OX Y H E MOG L OB I N
P M
E A T R O P I N E
P V A G A L E T
I F I G H
N R T G N Y
E E A F L UMA Z E N I L
D P E M U N E
E H A N T I P S Y C HOT I C S N
F R I N A A E
I I R K G R B
B N C O D L
R E T H A NOL N A F I B U
I R C D O E
L P H Y S O S T I GM I N E V
L A N S N E D
A T R O P I N E A L C OHO L O R A
T N P R A S S N
I C L I Y N P OP I O I D T
O A E N R N O R
N B L I S T E R N A L OX ON E N O
C S P T L
I H A M I OD A R ON E
U R M N
M I I E
N M A G N E S I UM
A NG I OE D E MA E

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1 - Measurement of this value is necessary to 2 - A female patient with abdominal pain is
diagnose carbon monoxide poisoning as the PREGNANT until proven otherwise
pulse oximeter reading will be normal 3 - Name the antidote: Methemoglobin
CARBOXYHEMOGLOBIN. The pulse oximeter METHYLENE BLUE
cannot distinguish oxyhemoglobin from car- 4 - In addition to antihistamines, this drug should
boxyhemoglobin. Hence the oximeter will often be given to all patients with anaphylaxis
read 99% to 100%. EPINEPHRINE
5 - Use of this drug is indicated for symptomatic 6 - Name the antidote: Warfarin
bradycardia VITAMIN K
ATROPINE. Increases adrenergic tone to the 7 - The presence of this finding, often seen on an
heart. upright chest x-ray, is an immediate indication
6 - Carotid massage, Valsalva, and cool pack to the for exploratory laparotomy
face are examples of VAGAL maneuvers FREE AIR. An indication of a perforated viscus.
These may be useful to terminate an episode of 8 - Name the antidote: Beta-blocker
SVT. GLUCAGON. Increases cAMP in the myocar-
9 - Name the antidote: Benzodiazepines dium.
FLUMAZENIL 10 - This intervention should be performed without
11 - The presence of muscle rigidity, hyperthermia, delay in patients with pulseless ventricular
and autonomic disability may be an adverse tachycardia/fibrillation arrest, once rhythm is
effect of this class of medications identified
ANTIPSYCHOTICS. Known as neuroleptic DEFIBRILLATION. Unsynchronized shock.
malignant syndrome, similar to malignant 12 - For any unstable patient with a brady- or
hyperthermia. Dantrolene may be an effective tachyarrhythmia, the first intervention should
treatment for muscle rigidity. be CARDIOVERSION
14 - Name the antidote: Methanol Synchronized cardioversion for unstable patients
ETHANOL. Ethanol outcompetes methanol for (i.e., hypotension, altered mental status).
the alcohol dehydrogenase enzyme, preventing 13 - The use of epinephrine in a code is directed at
further degradation of methanol to formalde- increasing CORONARY perfusion
hyde. 15 - The use of this drug may be necessary to
15 - Diltiazem slows conduction through the AV terminate an episode of supraventricular
node, which may improve rate control in a tachycardia
stable patient with this tachyarrhythmia (short ADENOSINE. A complete nodal-blocking
form) agent. Resets the AV node, abating a nodal
AFIB. Atrial fibrillation, with rapid ventricular re-entrant tachycardia.
response. 16 - The most definitive noninvasive diagnostic test
17 - Name the antidote: Anticholinergics for appendicitis
PHYSOSTIGMINE. A cholinesterase inhibitor. CT SCAN. With oral/IV contrast. Ultrasound may
19 - Name the antidote: Organophosphate poisoning be preferred in children due to concerns over
ATROPINE. Organophosphates inhibit acetyl- radiation exposure, but cannot always reliably
cholinesterase, leading to unfettered acetylcho- rule-out appendicitis.
line buildup and a hyperparasympathetic state. 17 - Third-degree burns are characterized by full
Atropine is an acetylcholine antagonist. involvement of the dermis and are painless/
21 - Withdrawal syndrome: Tremor, tachycardia, painful
hypertension, agitation, hallucinations, seizures PAINLESS. Destruction of nerve tissue leads to
ALCOHOL painless burns.
24 - Withdrawal syndrome: Anxiety, nausea, diar- 18 - Name the antidote: Malignant hyperthermia
rhea, abdominal cramping, mydriasis DANTROLENE
OPIOID 20 - The use of EPINEPHRINE is indicated in
25 - The presence of this lesion differentiates a patients with VT/VF pulseless arrest who do
second-degree from first-degree burn not respond to defibrillation
BLISTER 22 - Name the antidote: Black widow spider
26 - Name the antidote: Opioids CALCIUM
NALOXONE 23 - Name the antidote: Heparin
27 - Use of this antiarrhythmic should be consid- PROTAMINE
ered 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 life-
threatening side effect
ANGIOEDEMA. Mediated by bradykinin.

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48 Shock and Awe

W S
DE C R E A S E D
C D P
A G T
R HY P OT H E R M I A
D A C
I S HOC K
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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3 - Peripheral vascular resistance is 1 - The W in PCWP
(increased/decreased) in #2 down WEDGE. Pulmonary capillary wedge
DECREASED pressure.
5 - Core body temperature <95°F or 2 - Bacteremia and low BP: SEPTIC shock
35°C 4 - An MI can lead to CARDIOGENIC
HYPOTHERMIA shock
7 - A state of inadequate oxygenation to 6 - For patient unresponsive to
tissues #17 down, use transcutaneous
SHOCK PACEMAKER
11 - Inotropic drug useful if patient is 8 - Blood loss shock
hypotensive HYPOVOLEMIC
DOPAMINE 9 - Treat pulseless v-tach same as ven-
12 - Second leading cause of death in tricular FIBRILLATION
children Shock, shock, shock (i.e., defibrillate).
BURNS 10 - First thing for ventricular fibrillation
14 - Universal blood donor DEFIBRILLATION. Shock, shock,
O-NEGATIVE shock.
15 - Rule of NINES for calculating burn 13 - PCWP is (increased/decreased) in
surface area in adults #2 down
17 - A bee sting may lead to DECREASED. Also decreased in hypo-
ANAPHYLACTIC shock volemic shock.
Epinephrine is key part of treatment. 16 - PCWP is (increased/decreased) in
18 - CARDIAC output is decreased in #4 #4 down
down INCREASED
19 - One of the drugs useful for atrial 17 - A drug to push for symptomatic
fibrillation with rapid ventricular bradycardia
response ATROPINE
DILTIAZEM

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Doc Says “I’ve got good

49 news and bad news”

L E WY B OD Y
H E U
O R E B S T E I N S
D N G I G
G C I A NO R WA L K
K H G C U A
I A R K C W
P N R A E H F A
B E L L S C H V O S T E K S A D I E S
L O E R L A
E T S S L K
B E H C E T S H M O D I
S G OO D P A S T U R E S
T I R L E
E A L L E N S L S
I B E H OM A N S J
N E E R E R R L O
M E N I E R E S Y E N
S J P T H AWT HOR N E
C A L S E S S
HA N S E L S I
I E Y P A NC OA S T
L W F O S
L A L P OR T S
I Y L T
N E S T R A U S S
L I G H T S Y

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1 - Most common dementia associated with 2 - Chronic thiamine deficiency in alcoholics
Parkinson disease (two words) leading to ataxia, confusion, ophthalmo-
LEWY BODY plegia: WERNICKE’S encephalopathy
5 - Congenital heart disease with downward 3 - DUBIN-Johnson syndrome is autosomal
displacement of the tricuspid valve into recessive condition of conjugated hyper-
the right ventricle: EBSTEIN’S anomaly bilirubinemia due to transport defect
Possible association with lithium in first 4 - Disease classically associated with #12
trimester. down
9 - Cruise ship gastroenteritis: NORWALK HODGKIN’S
virus 6 - Henoch-Schönlein purpura is due to the
Would ruin a vacation. deposition of immune complexes contain-
14 - Peripheral seventh nerve palsy ing this (acronym)
BELL’S IGA
15 - Tapping over facial nerve elicits ipsilateral 7 - Most common lysosomal storage disease
facial muscle contraction: CHVOSTEK’S GAUCHER’S. It is autosomal recessive.
sign 8 - RUQ pain, jaundice, and fever:
16 - Tonic pupil, larger than contralateral CHARCOT’S triad
unaffected pupil, with no neurologic 10 - Child with fever, mucosal inflammation,
significance: ADIE’S pupil cervical lymphadenitis, and desquamation
17 - Aphthous ulcers, genital ulcerations, ocular has KAWASAKI’S disease
inflammation: BEHCET’S disease 11 - Autoimmune hyperthyroidism: GRAVE’S
21 - Glomerulonephritis and pulmonary disease disease
suggests GOODPASTURE’S syndrome Very common.
22 - Test used to demonstrate that ulnar artery 12 - Periodic fever (hyphenated)
is functional (before doing an arterial line) PEL-EBSTEIN
ALLEN’S 13 - VSD, pulmonic stenosis, anteriorly dis-
23 - Pain with forced dorsiflexion of the foot placed aorta, right ventricular enlargement:
supposedly an exam finding in patients Tetralogy of FALLOT
with DVT: HOMAN’S sign 18 - Ptosis, meiosis, anhidrosis: HORNER’S
But it is pretty much worthless. syndrome
25 - Forced flexion of the arm to overhead 19 - A lot of vomiting may cause this small
position elicits pain in patients with shoul- tear near the gastroesophageal junction
der impingement: NEER sign (hyphenated)
26 - Hearing loss, vertigo, tinnitus: MENIERE’S MALLORY-WEISS
disease 20 - Pericarditis after an acute myocardial
May respond to diuretic. infarction: DRESSLER’S syndrome
30 - People under study behaving differently 21 - Mild unconjugated hyperbilirubinemia
describes the HAWTHORNE effect affects up to 7% of the population:
31 - Stain used to detect eosinophils in the GILBERT’S syndrome
urine 24 - Set of criteria for diagnosing rheumatic
HANSEL’S fever
32 - Tumor associated with #18 down, an JONES
apical lung cancer 27 - Treatment for helping dislodge the
PANCOAST otoliths in benign positional vertigo:
34 - Hereditary nephritis associated with EPLEY maneuver
deafness and eye disorders: ALPORT’S You can find videos of it on the internet.
syndrome 28 - For determining cause of B12 deficiency:
35 - Allergic angiitis and granulomatosis in the SCHILLING test
lungs associated with eosinophilia: 29 - Nodules or macules in the palms or soles
Churg-STRAUSS syndrome that might be seen in patient with endo-
36 - For distinguishing transudate from exudate carditis: JANEWAY lesions
in pleural effusion, use these criteria 32 - TB in the spine: POTT’S disease
LIGHT’S. Published in 1972. 33 - Catheter with a balloon at the tip that
when inflated helps keep it in the bladder
FOLEY

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50 Step 2 Potpourri

C E L L
E
F L UMA Z E N I L
I
A B R U P T I ON
C A
D P
G EX U D A T I V E
P L F L O
E N D OM E T R IA L L S
R M B A I
I E H I RS C H S P R U NG S
C R I B Y O
A L B U T E R O L T P
R L L H
D O M E G A L OB L A S T I C
I N T T L
T M E T R ON I D A Z OL E I
I P O N C
S H N U O
R R S
C D I F F I C I L E I
T M S
I I
S E M I N OM A

200
Across: Down:
1 - Blood in urine, pain in the side, and 1 - Dermatitis herpetiformis: CELIAC
a palpable flank mass: Renal CELL disease
carcinoma 4 - Most common thyroid cancer type
2 - Give for an overdose of diazepam PAPILLARY
FLUMAZENIL 5 - Your patient in v-fib needs immediate
3 - Painful bleeding in third trimester DEFIBRILLATION
with fetal distress: Placental Shock, shock, shock.
ABRUPTION 6 - Red cell casts in urine
7 - Pleural fluid with a pleural: serum GLOMERULONEPHRITIS
protein of 0.8 and pleural: serum LDH 8 - “Photographic negative” of pulmo-
of 0.75: EXUDATIVE effusion nary edema on chest x-ray: Chronic
10 - A postmenopausal woman with EOSINOPHILIC pneumonia
vaginal bleeding needs an 9 - Chest pain relieved by leaning for-
ENDOMETRIAL biopsy ward; ECG with diffuse ST elevation
11 - No ganglion cells in the colon: PERICARDITIS
HIRSCHSPRUNG’S disease 12 - Panic disorder treatment (acronym)
13 - B2 agonist for asthma CBT. Cognitive behavior therapy.
ALBUTEROL 15 - Back pain worsened by standing and
14 - B12 deficiency anemia is walking, relieved by sitting: Spinal
MEGALOBLASTIC STENOSIS
16 - Treatment for bacterial vaginosis 17 - The “U” in MUDPILES
METRONIDAZOLE UREMIA
18 - Pseudomembranous colitis is almost
always from this infection (use the
first letter of genus)
C. DIFFICILE
19 - A testicular cancer is most likely a
SEMINOMA

201