- Flashcards V9
    
    **Goal:** Create high-yield Anki cards for missed/challenging Qbank/NBME questions I got wrong (USMLE Step 2 CK) to target weaknesses efficiently.
    
    **Key Principles:**
    
    - Focus on **Dx**, **next step**, **Tx**, or key concepts.
    - Include reasoning ("why") when relevant.
    - Prioritize **high-yield details**: diagnostic criteria, management steps, pathognomonic signs, "if" points, and differentiating principles.
    
    **Flashcard Format:**
    
    **Front:** 
    
    - Concise clinical vignette + **Dx? xyz?**
    - ≤1 line
    - Always ask Dx, and what’s **(xyz)** asked in vignette, which can be either **Next step, Tx, cause, mechanism, pathogenesis, pathogen**
    
    *Example:*
    
    *"65yo M → Sudden R-sided weakness + gaze deviation → Dx? **Next step?**” (Next step can be changed to **Tx, cause, mechanism, pathogenesis, pathogen** depending on the question asked in the vignette)*
    
    **Back 1:** 
    
    **Answer**
    
    (direct, specifically bold the main/actual answer depending on what’s asked in the vignette).
    
    *Example:*
    
    *"Acute ischemic stroke → Next step: **Alteplase (if within 4.5h) + CT/MR angiography."***
    
    **Back 2:**
    
    **Explanation:** 
    
    *[explain/teach the correct answer with two bullets (not more)]*
    
    - *1st bullet:* Core concept (e.g., diagnostic criteria/pathophysiology).
    - *2nd bullet:* Key action (e.g., next step, first-line Tx).
    
    **Buzzword:** 
    
    - *Classic presentation pattern* (e.g., *"Sudden focal deficit + gaze deviation → Anterior circulation stroke"*).
    
    **High-yield:** 
    
    - *2–3 **must-know/high-yield** facts (e.g., risk factors, diagnostic/management algorithm, first step, contraindications, red flags, complications).*
    - *For complex diagnostic & management algorithms, make a comprehensive step-by-step chart to make it easy to grasp.*
    
    **USMLE Traps:** 
    
    *[teach the common pitfalls or tricky/”if” points that the USMLE step 2 CK/NBME exams like to test]*
    
    - 1–2 **exam tricks** (e.g., *"❌ MRI before alteplase delays Tx; CT excludes hemorrhage 1st"*).
    
    **Incorrects:**
    
    - *Mention each wrong answer choice*
    - *However, don’t mention the choice letters in brackets (no need for A, B, C, D)*
    - *For each wrong option, two bullets:*
        1. **First bullet: Why wrong/Rule out?** (e.g., *"Aspirin: Prevents recurrence but doesn’t lyse clot acutely"*).
        2. **Second bullet: When is it correct/Rule in?** (e.g., *"🔍 'TIA → Aspirin + clopidogrel (dual antiplatelets)'"*).
    
    **DDx Table:** 
    
    - *For differential diagnosis purposes, make a table to compare top differentials meticulously*
        - In the upper horizontal row, give different conditions
        - In the vertical columns, compare them comprehensively
        - Table template is shown in the card templates below
    - *For complex management algorithms, make a table/chart*
    
    **Style:**
    
    - Use abbreviations (Tx, Dx, Hx, PE) and symbols (↑, ↓, →).
    - Avoid over-abbreviating uncommon terms.
    - Bold only important parts, not everything.
    - Avoid over-bolding unnecessary portions.
    - Avoid being too wordy (use “less yet clear cut wording method”)
    - Each bullet should be a quick point
    - Strictly adhere to source material; no fluff.
    - Mimic the structure of the provided templates exactly, keeping the same order and sections.
    - Strictly follow UWorld/NBME explanations.
    - Word count per card 150-200 (strictly; not more)
    
    ---
    
    - **Template card 1**
        
        **Front**
        
        54yo F → **intermittent severe R flank pain** (every 30 mins) + nausea/vomiting + **fatigue/bone aches** ×1 month → Dx? **Additional study?**
        
        **Back 1**
        
        **Primary hyperparathyroidism** (due to parathyroid adenoma) → **Serum intact PTH** (confirms Dx).
        
        **Back 2**
        
        ✅ **Explanation:**
        
        - **Pathophysiology**: PTH-secreting adenoma → ↑ **osteoclast activity** + ↓ renal phosphate reabsorption → **hypercalcemia** + **hypophosphatemia**.
        - **Key action**: **PTH level** confirms Dx; **parathyroidectomy** for symptomatic/young patients.
        
        💡 **Buzzword:**
        
        - *"Recurrent nephrolithiasis + fatigue/bone pain + hypercalcemia → Primary hyperparathyroidism."*
        
        📌 **High-yield:**
        
        - **Labs**: ↑ **Calcium**, ↓ **Phosphate**, ↑ **PTH**, normal/low **25-OH vitamin D**.
        - **Complications**: Osteoporosis, nephrolithiasis, peptic ulcers, **neuropsychiatric symptoms** (e.g., difficulty concentrating).
        
        🔍 **USMLE Traps:**
        
        - ❌ **CT/MRI** unnecessary for adenoma Dx (use **sestamibi scan** if localization needed).
        - ❌ **Urine culture** if suspect infection (but this patient has **hypercalcemia**, not UTI).
        
        ❌ **Incorrects:**
        
        - **CT abdomen**
            - ❌ Rules out obstruction but **doesn’t diagnose hyperparathyroidism**.
            - 🔍 *"Use for hydronephrosis or complex stones, not for PTH workup."*
        - **MRI brain/abdomen**
            - ❌ Only for **MEN syndromes** (pituitary/pancreatic tumors), not indicated here.
            - 🔍 *"No family Hx or other endocrine tumors → Low suspicion for MEN."*
        - **Urine culture**
            - ❌ For **struvite stones** (urease-positive bacteria), but this is **calcium stone** from hypercalcemia.
            - 🔍 *"Dysuria suggests irritation from stone, not infection."*
        - **No testing**
            - ❌ Untreated hyperparathyroidism → **osteoporosis, renal failure, CV disease**.
            - 🔍 *"Always evaluate hypercalcemia!"*
        
        ⚕️ **DDx Table: Hypercalcemia Causes**
        
        | **Feature** | **Primary Hyperparathyroidism** | **Malignancy** | **Vitamin D Toxicity** |
        | --- | --- | --- | --- |
        | **PTH Level** | ↑ | ↓ (suppressed) | ↓ |
        | **Phosphate** | ↓ | Normal/↑ | ↑ |
        | **1° Symptom** | Stones/bones/groans/moans | Weight loss, fatigue | Nausea, confusion |
        | **Next Step** | **PTH + calcium** | **PTHrP** | **25-OH vitamin D** |
    
    ---
    
    - **Template card 2**
        
        **Front**
        
        16yo M with T1DM → vomiting, drowsiness, Kussmaul respirations + glucose >600, HCO₃⁻ 10, pH 7.13 → Dx? **First intervention?**
        
        **Back 1**
        
        **Diabetic ketoacidosis (DKA)** → Initial step: **IV 0.9% saline bolus** (volume resuscitation before insulin).
        
        **Back 2**
        
        ✅ **Explanation:**
        
        - **Pathophysiology**: Insulin deficiency → lipolysis → ketogenesis → **anion gap metabolic acidosis** (pH <7.3, HCO₃⁻ <18).
        - **Priority**: **Hypovolemia** from osmotic diuresis → **1L NS bolus first** → then start insulin drip.
        
        💡 **Buzzword:**
        
        - *"Sweet breath odor + Kussmaul breathing + hyperglycemia → DKA."*
        
        📌 **High-yield:**
        
        - **Diagnostic triad**:
            1. Glucose >250 mg/dL
            2. pH <7.3 + HCO₃⁻ <18
            3. Ketones in blood/urine
        - **Management sequence**:
            1. **Fluids** (NS bolus → maintenance)
            2. **Insulin drip** (after fluids) 
            3. **K⁺ repletion** (if K⁺ <5.5)
        
        🔍 **USMLE Traps:**
        
        - ❌ **IV insulin** before fluids → risk of **cardiogenic shock** (↓ BP from intravascular shift).
        - ❌ **Bicarbonate**: Only if pH <6.9 + hemodynamic instability (rare).
        
        ❌ **Incorrects:**
        
        - **Promethazine/ondansetron**
            - ❌ Nausea resolves with DKA treatment; antiemetics delay definitive care.
            - 🔍 *"Never prioritize symptomatic relief over life-saving measures."*
        - **Subcutaneous insulin**
            - ❌ Absorption too slow in hypovolemia; **IV insulin required**.
            - 🔍 *"Only switch to SC when pH normalizes + eating."*
        
        ⚕️ **DKA Management Algorithm**
        
        | **Step** | **Action** | **Rationale** |
        | --- | --- | --- |
        | 1 | **1-2L NS bolus** | Correct hypovolemia |
        | 2 | **Insulin drip** | Stop ketogenesis (after fluids!) |
        | 3 | **Add D5 + insulin** | When glucose <250 → prevent hypoglycemia |
        | 4 | **K⁺ replacement** | Insulin drives K⁺ into cells |
    
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