Miss List: Final Hammer

Every one of your 518 qbank misses, distilled to the rule that decides it. Forked lines are separate diagnoses — read each arm as its own rule. Repeat misses lead each section. Exam: Tue Aug 25. Companion: Look-Alike Splitter.

Repeat offenders — every fact you missed twice or more

53 rules · hammer these first

CardiovascularAortic dissection: IV beta-blocker FIRST to HR <60, vasodilator second ⟲×4 last 07-15
uncomplicated type B→stays medical
type A→surgery
CardiovascularElevated JVP + Kussmaul + pericardial knock with clear lungs = constrictive pericarditis → pericardiectomy; cirrhosis runs a normal JVP. ⟲×3 last 08-21
Pulmonary / Critical careIncidental solid nodule ⟲×3 last 08-20
<6 mm→none
6-8 mm→CT at 6-12 months
>8 mm→PET/CT
spiculated >2 cm→resect
CardiovascularPost-MI shock day 3-5 ⟲×3 last 08-04
thrill + RA→RV O2 step-up→VSD
soft or absent murmur + high PCWP→papillary rupture
Infectious DiseaseBacterial meningitis = vancomycin + ceftriaxone + ampicillin if >50, plus dexamethasone for all; continue steroid 4 days for pneumococcus. ⟲×2 last 08-20
DermatologyEczema flare ⟲×2 last 08-20
honey crust and pustules→staph → mupirocin
monomorphic punched-out vesicles→eczema herpeticum → valacyclovir, never steroids
Hematology / OncologyAlbumin-only dipstick with grams of total proteinuria, or negative SPEP → light-chain myeloma: send urine immunofixation and serum free light chains. ⟲×2 last 08-19
Pulmonary / Critical careNormal spirometry with isolated low DLCO = pulmonary vascular disease; unexplained PH → V/Q scan for CTEPH. ⟲×2 last 08-18
Pulmonary / Critical careARDS hypoxemia is shunt: raise PEEP before FiO2 while plateau <30; PaO2 <60 means more PEEP. ⟲×2 last 08-18
Infectious DiseaseTick illness with leukopenia + thrombocytopenia + high LFTs and NORMAL hemoglobin = Ehrlichia; treat doxycycline. ⟲×2 last 08-18
GastroenterologyAST:ALT <1 + metabolic syndrome = NAFLD: exclude hep B/C and iron overload first, then weight loss ⟲×2 last 08-17
GastroenterologyCholestatic ALP/GGT ≫ transaminases + pruritus = PBC → AMA, ursodeoxycholic acid (AIH gets steroids) ⟲×2 last 08-17
DermatologyFacial edema + adenopathy + eosinophilia + transaminitis with mucosa SPARED, 2-8 weeks after a drug = DRESS; send CBC diff and LFTs. ⟲×2 last 08-17
CardiovascularWPW ⟲×2 last 08-09
asymptomatic→exercise ECG; delta loss at speed = low risk, observe
preexcited wide irregular AF→procainamide, never nodal blockers
CardiovascularUnexplained high-grade AV block or VT in a young adult (± uveitis) = cardiac sarcoid; a normal biopsy is expected — MRI/PET. ⟲×2 last 08-07
Hematology / OncologyChronic-phase CML (blasts <10%, basophilia) → BCR-ABL TKI first line; hydroxyurea only cytoreduces, transplant only after TKI failure. ⟲×2 last 08-07
RheumatologyChronic symmetric MCP/PIP/wrist synovitis ≥6 weeks = RA even with RF and anti-CCP negative; 20% of RA is seronegative. ⟲×2 last 08-07
RheumatologySuspected sacroiliitis: AP pelvis x-ray first, MRI of SI joints most sensitive early; HLA-B27 is only 75% sensitive. ⟲×2 last 08-07
DermatologyPapulopustular rosacea (pustules, telangiectasias, no comedones) → oral doxycycline; topical steroids on the face cause steroid rosacea. ⟲×2 last 08-07
RheumatologySuspected GCA: high-dose steroids immediately, before biopsy (biopsy stays positive ~2 weeks); amaurosis fugax portends permanent blindness. ⟲×2 last 08-04
RheumatologySynovial WBC ⟲×2 last 08-04
>50,000→septic: cultures, IV antibiotics, drainage
2,000-50,000→merely inflammatory (reactive arthritis → NSAIDs)
NeurologyAscending symmetric weakness with areflexia = GBS → LP shows high protein with normal WBC; IVIG or plasmapheresis, never steroids ⟲×2 last 08-04
RheumatologyIgA vasculitis: palpable purpura (small-vessel, excludes PAN) + abdominal pain + hematuria + normal platelets; skin biopsy establishes it. ⟲×2 last 08-03
EndocrineAndrogen deprivation is the strongest male osteoporosis risk (20% fracture in 5 years); work up male fragility fracture with morning testosterone. ⟲×2 last 08-03
EndocrineLow testosterone with low/normal LH = central: check prolactin, MRI if T<200 under age 65 — never replace first. ⟲×2 last 08-03
NeurologySymptomatic carotid stenosis: a statin is mandatory (read the med list for what is missing) ⟲×2 last 08-03
70-99%→CEA within 2 weeks
50-69% symptomatic→selective
DermatologyPalms and soles SPARED excludes secondary syphilis ⟲×2 last 08-03
herald patch first→pityriasis rosea
post-strep raindrop papules→guttate psoriasis
RheumatologyForefoot pain ⟲×2 last 08-01
web-space "marble" + Mulder click→Morton neuroma
shaft tenderness or axial toe load→stress fracture
CardiovascularEither / or ⟲×2 last 07-29
acute pericarditis→NSAID + colchicine (steroids raise recurrence)
post-MI pericarditis→high-dose aspirin — NSAIDs risk wall rupture
Pulmonary / Critical careClubbing + bibasilar crackles + UIP honeycombing = IPF; sarcoid needs adenopathy, LAM makes cysts not fibrosis. ⟲×2 last 07-29
CardiovascularPAH ⟲×2 last 07-25
positive vasoreactivity→high-dose CCB
negative vasoreactivity→PDE5i/ERA/prostacyclin, and add a drug from a NEW pathway if still symptomatic
Pulmonary / Critical careAECOPD: albuterol + ipratropium + steroids; antibiotics only if sputum purulent, then narrow — broad needs hospitalization within 90 days. ⟲×2 last 07-23
Hematology / OncologyPolycythemia → serum EPO first ⟲×2 last 07-23
low EPO→polycythemia vera (JAK2)
high EPO→secondary — check O2 sats before CT
Pulmonary / Critical careWhich airway test ⟲×2 last 07-22
obstruction already present→post-bronchodilator reversibility (FEV1 +12% and +200 mL)
spirometry is normal→methacholine
Pulmonary / Critical careCOPD survival levers: smoking cessation, LTOT for PaO2 ≤55 or SaO2 ≤88%, pulmonary rehab, select LVRS. ⟲×2 last 07-22
Infectious DiseasePneumonia with hyponatremia, relative bradycardia, high LFTs, failing beta-lactam = Legionella: urine antigen, add azithromycin (elderly) or levofloxacin. ⟲×2 last 07-22
Infectious DiseaseTST: measure INDURATION only, never erythema; use the lowest applicable cutoff (contact ≥5 mm); LTBI → rifapentine+INH 3 months. ⟲×2 last 07-21
Hematology / OncologyOligometastatic disease in a resectable site (liver-only colorectal, solitary brain met) → local therapy with curative intent before chemo. ⟲×2 last 07-17
CardiovascularStatin INTENSITY is the lever — pravastatin and simvastatin never reach high intensity ⟲×2 last 07-15
intermediate 10-yr risk→≥ moderate intensity
ASCVD/PAD→high intensity
CardiovascularMonomorphic VT ⟲×2 last 07-15
stable→IV amiodarone
unstable→SYNCHRONIZED cardioversion
pulseless or polymorphic→unsynchronized shock — the only setting for it
CardiovascularEither / or ⟲×2 last 07-14
aortic-valve endocarditis + new PR prolongation→perivalvular abscess (TEE, surgery)
short soft diastolic murmur + pulmonary edema→acute severe AR
Hematology / OncologyFlushing cannot decide ⟲×2 last 07-13
Darier sign or drug anaphylaxis→serum tryptase
right-sided valve disease + telangiectasias→5-HIAA
Hematology / OncologyHIT: stop ALL heparin including LMWH → argatroban (hepatic clearance if renal failure); no warfarin, no platelet transfusion. ⟲×2 last 07-13
RheumatologyANCA vasculitis with airway disease ⟲×2 last 07-13
asthma + nasal polyps + eosinophils >10%→EGPA (p-ANCA/MPO)
c-ANCA/PR3, destructive sinus, cavitary nodules→GPA
Infectious DiseaseC. difficile: oral vancomycin or fidaxomicin; symptoms back within 8 weeks = recurrence → fidaxomicin, never probiotics. ⟲×2 last 07-02
GastroenterologySAAG ≥1.1 = portal hypertension; then ascitic protein ⟲×2 last 07-02
≥2.5→heart failure
<2.5→cirrhosis
PsychiatryChronic fatigue syndrome: ≥6 months fatigue + post-exertional malaise + unrefreshing sleep → CBT plus graded exercise, not rest ⟲×2 last 07-02
PsychiatrySSRI sexual dysfunction: add bupropion (or sildenafil); venlafaxine carries the same effect, and never cut a working dose ⟲×2 last 07-02
Nephrology / urologyADPKD = bilateral flank masses plus liver cysts and berry aneurysms; abrupt headache with meningismus is SAH, screen the family. ⟲×2 last 07-01
RheumatologyVasculitis with viral hepatitis ⟲×2 last 06-24
HCV + purpura + low C4 + high RF→cryoglobulinemia
HBV + orchitis, ANCA-negative, normal complement→PAN
RheumatologyHip pain ⟲×2 last 06-22
groin with rotation→OA
lateral trochanter tenderness worse lying on side→bursitis
outer-thigh sensory→meralgia
EndocrineAny prolactinoma → cabergoline first, not surgery; untreated microadenoma causes osteoporosis from low estrogen, not mass effect. ⟲×2 last 06-22
PsychiatryEither / or ⟲×2 last 06-21
lead-pipe rigidity, slow onset→NMS → dantrolene + bromocriptine
clonus/hyperreflexia, rapid→serotonin syndrome → cyproheptadine

Cardiovascular

72 rules · 10 repeat misses

Elevated JVP + Kussmaul + pericardial knock with clear lungs = constrictive pericarditis → pericardiectomy; cirrhosis runs a normal JVP. ⟲×3 last 08-21
WPW ⟲×2 last 08-09
asymptomatic→exercise ECG; delta loss at speed = low risk, observe
preexcited wide irregular AF→procainamide, never nodal blockers
Unexplained high-grade AV block or VT in a young adult (± uveitis) = cardiac sarcoid; a normal biopsy is expected — MRI/PET. ⟲×2 last 08-07
Post-MI shock day 3-5 ⟲×3 last 08-04
thrill + RA→RV O2 step-up→VSD
soft or absent murmur + high PCWP→papillary rupture
Either / or ⟲×2 last 07-29
acute pericarditis→NSAID + colchicine (steroids raise recurrence)
post-MI pericarditis→high-dose aspirin — NSAIDs risk wall rupture
PAH ⟲×2 last 07-25
positive vasoreactivity→high-dose CCB
negative vasoreactivity→PDE5i/ERA/prostacyclin, and add a drug from a NEW pathway if still symptomatic
Aortic dissection: IV beta-blocker FIRST to HR <60, vasodilator second ⟲×4 last 07-15
uncomplicated type B→stays medical
type A→surgery
Statin INTENSITY is the lever — pravastatin and simvastatin never reach high intensity ⟲×2 last 07-15
intermediate 10-yr risk→≥ moderate intensity
ASCVD/PAD→high intensity
Monomorphic VT ⟲×2 last 07-15
stable→IV amiodarone
unstable→SYNCHRONIZED cardioversion
pulseless or polymorphic→unsynchronized shock — the only setting for it
Either / or ⟲×2 last 07-14
aortic-valve endocarditis + new PR prolongation→perivalvular abscess (TEE, surgery)
short soft diastolic murmur + pulmonary edema→acute severe AR
HFpEF gets MRA + SGLT2 inhibitor, never the HFrEF pillars; in group 2 PH pulmonary vasodilators cause edema.
Chronic severe AR: replace the valve only for symptoms, EF ≤55%, or LV end-systolic dimension >50 mm.
Class III on all four HFrEF pillars: QRS ≥150 ms with EF ≤35% opens CRT.
WPW's resting QRS is wide, but orthodromic AVRT (80%) runs narrow and regular — the delta disappears.
Syncope while dressing or shaving = carotid sinus hypersensitivity → carotid massage; asystole >3 s or SBP drop >50 → pacemaker.
Atrial flutter after a failed diltiazem trial → cavotricuspid isthmus ablation, now first-line; adenosine only unmasks, never converts.
ESRD does not remove the NSTEMI beta-blocker; it swaps enoxaparin for unfractionated heparin and bans GP IIb/IIIa.
Mediterranean or DASH diet is the intervention with CV mortality evidence; antioxidant supplements have failed every trial.
Persistent EF <50% after peripartum cardiomyopathy → advise against another pregnancy; recovery means normalization.
An ASD itself is silent — the systolic murmur is extra volume crossing the normal pulmonic valve.
BP ≥140/90 before 20 weeks = chronic hypertension → treat with labetalol/nifedipine/methyldopa; ACEi and ARBs are teratogenic.
Previous infective endocarditis is a lifelong prophylaxis indication: educate about amoxicillin 2 g before dental procedures, don't order tests.
A systolic murmur that lengthens or loudens on standing is MVP or HCM; every fixed valve lesion softens.
New AF with RVR in sepsis → IV fluids; rate <150 rarely causes the hypotension, cardioversion won't fix the driver.
BP >20/10 above goal starts two drugs; with gout pick losartan + amlodipine — thiazides and beta-blockers raise urate.
Resistant hypertension: OSA is the common cause — neck >43 cm (men) / >40 cm (women), not coarctation.
Where to listen
right-sided sounds (RV S3, TR)→LSB, supine, louder on inspiration
left-sided sounds→apex, left lateral decubitus, expiration
New AF on a mechanical aortic valve moves the INR target from 2.0-3.0 up to 2.5-3.5.
Deep symmetric T-inversions in V2-V3 = Wellens = critical LAD → cath, never stress; dyspnea is an anginal equivalent.
Regular narrow tachycardia at ~150 = atrial flutter with 2:1 block; MAT and AF are irregularly irregular.
Repair an AAA at ≥5.5 cm in men, ≥5.0 cm in women; intramural thrombus is universal, not an anticoagulation indication.
NSTE-ACS: GRACE >140 → angiography within 24 h; <2 h needs shock, HF, refractory angina, or electrical instability.
Pulmonary hypertension work-up
the stem already names the cause of PH→order echo
the diagnosis is still open→right heart cath
Read the disk margins
indistinct and swollen→papilledema = malignant hypertension
pale with distinct margins→old atrophy
Either / or
hypoxemia that doesn't correct with oxygen→right-to-left shunt
WPW + TR + clubbing in an adult→Ebstein anomaly
LVH on ECG plus S4 and elevated JVP → echo; LVH with strain makes the exercise ECG uninterpretable.
Hypertensive urgency (no end-organ damage) → uptitrate the existing long-acting drug; sublingual nifedipine is never the answer.
Recurrent vasovagal syncope causing injury → tilt-table test; switch answers only for a new stem fact, not personal practice.
Post-cath pulsatile groin mass — confirm with ultrasound
systolic-only bruit→pseudoaneurysm
continuous bruit→AV fistula
Mechanical mitral INR target is 2.5-3.5; EF 41-49 without symptoms is not heart failure — no drug without an indication.
Rheumatic carditis with residual valve disease: benzathine penicillin G monthly for 10 years or until age 40, whichever is longer.
PCWP — the wedge overrules the story
>15→postcapillary = group 2 PH from left heart
≤15→precapillary
Sacubitril blocks neprilysin, so BNP rises on ARNI — follow NT-proBNP; obesity lowers BNP; the med list is data.
Viral myocarditis with reduced EF is HFrEF — give GDMT; steroids only for giant-cell, sarcoid, or eosinophilic; NSAIDs worsen it.
Constitutional symptoms + systemic emboli + apical diastolic murmur with NEGATIVE blood cultures = left atrial myxoma → resect.
Claudication worse DOWNHILL and relieved by leaning forward is neurogenic → MRI lumbar spine; normal pulses kill the ABI.
Balloon mitral valvotomy
moderate-or-severe MR (or LA thrombus)→contraindicated
severe pulmonary hypertension→an indication, not a barrier
Symptomatic bradycardia: stop the rate-slowing drug first — donepezil raises vagal tone and hides in the Alzheimer med list.
VTE within 3 months = very high thrombotic risk → defer elective surgery until anticoagulation finishes; DOACs are never bridged.
IVDU + fever + new murmur → echocardiography; it is the test that drives treatment (vegetation size, abscess, surgery).
Either / or
edema with a NORMAL JVP→not heart failure
low voltage + effusion + bradycardia + hyponatremia→check TSH
Two murmurs: name the primary and its consequence
opening snap + apical rumble→MS, the primary lesion
inspiratory LSB murmur→secondary TR
Buttock/hip claudication + erectile dysfunction = aortoiliac (Leriche) → femoral bruit; statin myopathy is constant, not exertional.
Suspected severe AS before noncardiac surgery → TTE first; stress testing is relatively contraindicated and answers the wrong question.
New uncomplicated hypertension gets a routine panel including HbA1c; papillary thyroid cancer is sporadic — metanephrines need red flags.
Before high-VTE-risk surgery
tamoxifen — procoagulant→hold 2-4 weeks
statins, PPIs and existing beta-blockers→continue
Women: exercise treadmill ECG yields more false positives, but stress imaging performs equally; presentation atypical, risk burden higher.
Superficial thrombophlebitis >5 cm long or within 5 cm of the deep system → duplex ultrasound before treating.
QTc >500 ms = torsades risk: beta-blocker for LQT1/2, ICD after syncope, and stop QT-prolonging drugs like levofloxacin.
Upper-extremity hypertension with weak, delayed femoral pulses = coarctation; look for rib notching, bicuspid aortic valve, Turner syndrome.
Periprocedural warfarin
mechanical MITRAL valve→bridge — the only indication
bileaflet aortic→just hold until INR <1.5
Fixed widely split S2 = ASD → right axis, RBBB, right atrial enlargement — an ASD never causes LVH.
Preoperative cardiac testing
poor functional capacity (<4 METs) + elevated RCRI + high-risk surgery→pharmacologic stress test
≥4 METs→just operate
Either / or
asymmetric wall ≥15 mm + strain/Q waves + family history→HCM; two-thirds have no LVOT gradient
≤12 mm symmetric→athlete's heart
Asymptomatic HCM needs no sports restriction; an ICD only for high-risk features.
Claudication with a normal resting ABI (0.9-1.3) → exercise ABI; a drop >0.15 confirms PAD.
LBBB or a paced rhythm makes the treadmill ECG invalid → pharmacologic nuclear stress (adenosine, regadenoson).
ABI >1.3 = noncompressible calcified vessels → toe-brachial index, not exercise ABI.
Mechanical valve or mitral stenosis = valvular AF = warfarin only; DOACs are contraindicated.
Flank pain + hypotension after femoral access = retroperitoneal hematoma → CT to confirm.
Persistent tachycardia causes a reversible dilated cardiomyopathy; rate control restores the EF.
VSD = harsh holosystolic murmur at the LLSB; the louder the murmur, the smaller the defect.

Pulmonary / Critical care

51 rules · 7 repeat misses

Incidental solid nodule ⟲×3 last 08-20
<6 mm→none
6-8 mm→CT at 6-12 months
>8 mm→PET/CT
spiculated >2 cm→resect
Normal spirometry with isolated low DLCO = pulmonary vascular disease; unexplained PH → V/Q scan for CTEPH. ⟲×2 last 08-18
ARDS hypoxemia is shunt: raise PEEP before FiO2 while plateau <30; PaO2 <60 means more PEEP. ⟲×2 last 08-18
Clubbing + bibasilar crackles + UIP honeycombing = IPF; sarcoid needs adenopathy, LAM makes cysts not fibrosis. ⟲×2 last 07-29
AECOPD: albuterol + ipratropium + steroids; antibiotics only if sputum purulent, then narrow — broad needs hospitalization within 90 days. ⟲×2 last 07-23
Which airway test ⟲×2 last 07-22
obstruction already present→post-bronchodilator reversibility (FEV1 +12% and +200 mL)
spirometry is normal→methacholine
COPD survival levers: smoking cessation, LTOT for PaO2 ≤55 or SaO2 ≤88%, pulmonary rehab, select LVRS. ⟲×2 last 07-22
Jet lag is circadian misalignment → timed melatonin past 4 time zones plus bright light, never a hypnotic.
Malignant effusion with negative cytology → contrast chest CT next; cytology yield is low when pleural pH ≥7.3.
Exudate with eosinophils >50% arriving 10-15 years after asbestos = benign asbestos pleural effusion, self-resolving.
Rock quarry work + upper-zone micronodules <10 mm = silicosis 10-30 years out; screen TB, PPD ≥10 mm positive.
VAP prevention: antiseptic oral care plus semirecumbent 30-45 degrees; supine increases aspiration and VAP.
Asthma + brown mucus plugs + eosinophilia + migrating infiltrates = ABPA → Aspergillus skin testing first.
On an ILD stem HRCT establishes the diagnosis; echo only characterizes the pulmonary hypertension complication.
Near-complete bronchodilator reversibility separates asthma from COPD; 20% of COPD never smoked, so smoking history discriminates nothing.
Infiltrate 4-12 weeks after chest radiation that failed antibiotics = radiation pneumonitis → prednisone 2 weeks, then taper.
Post-viral bronchitis with normal vitals → inhaled beta-2 agonist; no antibiotics, no CXR unless pneumonia suspected.
Refractory anaphylaxis on a beta-blocker → IV glucagon, which raises cAMP past the blocked receptor.
Allergen plus two organ systems = anaphylaxis → IM epinephrine 0.3-0.5 mg immediately, however stable the patient looks.
Daytime somnolence + morning headache + unrefreshing sleep = OSA → polysomnography; Hgb 11.4 is normal in pregnancy.
Fever and infiltrate after aspiration
hours→chemical pneumonitis, supportive only
over days→bacterial pneumonia, antibiotics
COPD in a never-smoker → ask about biomass fuel (wood, dung, crop residue); air pollution is not a cause.
Weight loss and wanting off CPAP → repeat the sleep study first; 90th-percentile pressure above mean means residual OSA.
Bronchiectasis with lifelong recurrent infections → quantitative immunoglobulins for CVID; PFTs grade severity, never find the cause.
Asthma uncontrolled on low-dose ICS → add a LABA; scheduled SABA causes tachyphylaxis and is never a step-up.
Symptomatic COPD on one long-acting bronchodilator → add the other class; ICS only when eosinophils ≥300.
Hemoptysis + falling hematocrit + bilateral opacities = diffuse alveolar hemorrhage → sequential BAL, returns get progressively bloodier.
Surgery-provoked VTE gets exactly 3 months of anticoagulation, then stop — no confirmatory CT needed.
Bloody lymphocytic exudate in a smoker → repeat thoracentesis cytology; TB needs ADA >40, IGRA detects latent only.
Farmer or bird exposure + upper-lobe centrilobular nodules + low DLCO + normal IgE = hypersensitivity pneumonitis → remove antigen.
Hot tub + acute dyspnea + interstitial infiltrates = MAC hot tub lung; Pseudomonas gives folliculitis, not pneumonia.
Auto-PEEP in a ventilated obstructive patient → decrease respiratory rate; increase, never decrease, inspiratory flow to lengthen exhalation.
Exacerbations despite triple therapy + chronic bronchitis + FEV1 <50% → roflumilast or azithromycin; oxygen is a mortality lever.
Asthma + nasal polyps + sinusitis = AERD → every COX-1 NSAID cross-reacts; use salsalate, acetaminophen, or celecoxib.
Hypoxemia + confusion + petechiae 24-72 hours after long-bone fracture = fat embolism → supportive care, clinical diagnosis.
COPD flare without fever, purulence, or albuterol response → CT angiogram for PE; never stress-test acute dyspnea.
Post-extubation respiratory failure → reintubate; NIPPV helps only COPD and increases mortality in ARDS.
Respiratory alkalosis on assist-control → lower VT toward 6 mL/kg; cutting the set rate does nothing if patient-triggered.
Group 3 PH from COPD → oxygen and treat the lung; PAH vasodilators worsen V/Q mismatch.
Bilateral hilar adenopathy needs tissue → EBUS-TBNA of the node; no empiric steroids before excluding TB.
Upper-lobe bronchiectasis + pancreatic insufficiency = cystic fibrosis → sweat chloride >60 mEq/L twice.
Refractory asthma with normal spirometry + inspiratory wheeze = vocal cord dysfunction → flow-volume loop, flat inspiratory limb.
Milky pleural fluid → triglycerides >110 = chylothorax; lymphoma obstructing the thoracic duct is the top cause.
Peripheral pleural-based infiltrates sparing the center + eosinophilia = chronic eosinophilic pneumonia → steroids; PAP is central bat-wing.
Post-intubation unilateral breath sounds with normal ETCO2 = right mainstem intubation → withdraw the tube.
Asthma discharge: oral prednisone 5-10 days plus a stepped-up controller; never LABA without ICS.
Severe kyphoscoliosis with hypercapnia = chest-wall restriction → nocturnal NPPV improves survival.
Single high-dose irritant exposure causing asthma symptoms = RADS → confirm with methacholine challenge.
OSA causes nocturnal bradyarrhythmias and atrial fibrillation → CPAP is the primary treatment.
ARDS ventilation: 6 mL/kg ideal body weight, permissive hypercapnia, prone when P/F <150.
Sudden ETCO2 rise during CPR = ROSC; ETCO2 >10 mm Hg predicts survivability.

Hematology / Oncology

53 rules · 6 repeat misses

Albumin-only dipstick with grams of total proteinuria, or negative SPEP → light-chain myeloma: send urine immunofixation and serum free light chains. ⟲×2 last 08-19
Chronic-phase CML (blasts <10%, basophilia) → BCR-ABL TKI first line; hydroxyurea only cytoreduces, transplant only after TKI failure. ⟲×2 last 08-07
Polycythemia → serum EPO first ⟲×2 last 07-23
low EPO→polycythemia vera (JAK2)
high EPO→secondary — check O2 sats before CT
Oligometastatic disease in a resectable site (liver-only colorectal, solitary brain met) → local therapy with curative intent before chemo. ⟲×2 last 07-17
Flushing cannot decide ⟲×2 last 07-13
Darier sign or drug anaphylaxis→serum tryptase
right-sided valve disease + telangiectasias→5-HIAA
HIT: stop ALL heparin including LMWH → argatroban (hepatic clearance if renal failure); no warfarin, no platelet transfusion. ⟲×2 last 07-13
Life expectancy under 5-10 years (NYHA III post-MI) → stop mammography entirely; USPSTF ends screening at 74.
MDS with del(5q) and platelets >400,000 → lenalidomide first line, not transplant; transplant is for higher-risk fit patients.
Bleeding + isolated long aPTT + non-correcting mixing study = acquired factor VIII inhibitor → recombinant factor VIIa now, steroids later.
ER+ HER2− node-negative with LOW 21-gene recurrence score → lumpectomy + whole-breast radiation + endocrine therapy, no chemotherapy.
High pretest DVT + negative compression ultrasound + high D-dimer, still symptomatic → repeat ultrasound within days, not reassurance.
Coombs C3-positive/IgG-negative with RBC clumping and spurious MCV after mycoplasma = cold agglutinin disease → warming and rituximab, not steroids.
Platelet fall on heparin day 1-4 with nadir >100,000 and no clot = type 1 HIT → continue heparin, observe.
Symptomatic anemia during curative-intent chemotherapy → transfuse (no Hb threshold); ESAs are palliative-only, dose reduction trades cure for comfort.
Blasts + leukoerythroblastic smear 5-10 years after anthracycline = therapy-related AML; a normal MCV kills the nutritional explanation.
Dabigatran before urgent hip surgery
normal thrombin time→no active dabigatran → proceed to urgent hip surgery now
thrombin time prolonged→idarucizumab
Low factor VII with NORMAL factor V = vitamin K deficiency; liver failure drops V and VII together.
Basophils 0% with toxic granulation and Döhle bodies = leukemoid reaction; CML requires basophilia.
Cryoglobulinemic vasculitis
LOW C4→hepatitis C serologies
normal complement→type I → SPEP for myeloma/CLL
CLL + high reticulocytes + indirect hyperbilirubinemia = warm AIHA → SPHEROCYTES on smear, Coombs IgG-positive.
ABVD toxicity: match organ to drug
cardiomegaly + edema + clear lungs→doxorubicin cardiomyopathy
hypoxemia + fibrosis→bleomycin
Lung cancer screening = ANNUAL low-dose CT, ages 50-80, ≥20 pack-years, quit within 15 years; one-time CT saves nobody.
Newly diagnosed metastatic NSCLC: EARLY PALLIATIVE CARE added to chemotherapy prolongs survival; radiate only symptomatic bone lesions.
Tamoxifen's top risk is VTE (2-3×, first 2 years) plus endometrial cancer; postmenopausal bone density RISES (SERM = tissue-selective).
Leukoerythroblastic smear + massive splenomegaly → BONE MARROW CORE BIOPSY (aspirate is a dry tap); flow cytometry cannot show fibrosis.
Thrombophilia testing while anticoagulated
factor V Leiden and prothrombin G20210A DNA tests→accurate on anticoagulation
protein C/S and antithrombin ACTIVITY assays→must wait
Established tumor lysis (uric acid >8, rising creatinine) → RASBURICASE; allopurinol only prevents new urate, calcium gluconate never lowers potassium.
Petechiae, especially on the soft palate, are specific for a LOW PLATELET COUNT; von Willebrand disease bleeds with normal platelets.
Coombs-negative intravascular hemolysis + unusual-site thrombosis (portal vein) + pancytopenia = PNH → flow cytometry CD55/CD59, eculizumab after meningococcal vaccine.
Drug-induced leukopenia with ANC >1000 and no infection → serial CBCs; do not stop a drug that is working.
Anemia of CKD: trial iron first when TSAT ≤20% or ferritin low; never start an ESA at Hb ≥10.
Blisters on sun-exposed hands + HCV + high ferritin = porphyria cutanea tarda → repeated PHLEBOTOMY or low-dose hydroxychloroquine first.
A G6PD level drawn during acute hemolysis is falsely normal (young retics) — recheck in 2-3 months; bite cells decide.
Known PV that stops needing phlebotomy, becomes anemic, and grows a spleen = post-PV MYELOFIBROSIS, not a second malignancy.
INCENTIVE SPIROMETRY on every sickle cell pain-crisis admission prevents acute chest syndrome; antibiotic prophylaxis does not.
Scleroderma-like skin + sicca + CHOLESTATIC liver after allogeneic transplant = chronic GVHD; systemic sclerosis spares the liver.
Anemia + thrombocytopenia + AKI after bloody diarrhea = HUS → peripheral SMEAR for schistocytes; antibiotics and antimotility agents worsen it.
Malabsorption: the site names the deficiency
metformin, at the TERMINAL ILEUM→B12 deficiency
jejunal (celiac) atrophy→iron, folate and vitamin D
Burning red feet relieved by cooling with platelets 540,000 = erythromelalgia of a myeloproliferative neoplasm → LOW-DOSE ASPIRIN.
Sickle cell stroke prevention = chronic SIMPLE transfusion q3-6 weeks to HbS <30%; anticoagulants do nothing against vaso-occlusion.
Recurrent abdominal pain + dark urine + hyponatremia after low-carb diet or OCPs → urinary PBG during the attack, then hemin.
Baseline aPTT already elevated (lupus anticoagulant) → monitor heparin with anti-Xa, target 0.3-0.7 U/mL.
Painless lymphadenopathy persisting after the infection resolves → observe 3-4 weeks then EXCISIONAL biopsy; FNA is inadequate for lymphoma.
Surface marker → the antibody
CD20→rituximab
CD30→brentuximab (Hodgkin)
CD33→gemtuzumab (AML)
CD38→daratumumab (myeloma)
CD52→alemtuzumab (CLL)
APS in pregnancy → LMWH + low-dose aspirin (therapeutic dose if prior thrombosis, prophylactic if morbidity only); warfarin teratogenic, DOACs out.
Carcinoid syndrome requires LIVER METS; flushing + secretory diarrhea + right-sided valve fibrosis → 5-HIAA, treat with octreotide.
Bone metastases: zoledronic acid or denosumab prevent skeletal events; CrCl <35 → denosumab only.
Isolated thrombocytopenia = presumptive ITP, but test HIV and HCV before treating.
Protein gap >4 → SPEP; M-spike >1.5 g/dL, non-IgG type, or abnormal free light chains → bone marrow biopsy.
MAHA + severe thrombocytopenia
NORMAL coags→TTP → plasma exchange; never transfuse platelets in TTP
low fibrinogen→DIC
von Willebrand disease before a procedure
type 1 + minor procedure→DDAVP
type 2B, type 3, or major surgery→VWF concentrate
Extensive-stage SCLC → platinum + etoposide + atezolizumab first; no surgery, no molecular profiling.
Either / or
left-shifted myeloid spectrum with Philadelphia chromosome→CML
mature small lymphocytes with smudge cells→CLL

Infectious Disease

51 rules · 5 repeat misses

Bacterial meningitis = vancomycin + ceftriaxone + ampicillin if >50, plus dexamethasone for all; continue steroid 4 days for pneumococcus. ⟲×2 last 08-20
Tick illness with leukopenia + thrombocytopenia + high LFTs and NORMAL hemoglobin = Ehrlichia; treat doxycycline. ⟲×2 last 08-18
Pneumonia with hyponatremia, relative bradycardia, high LFTs, failing beta-lactam = Legionella: urine antigen, add azithromycin (elderly) or levofloxacin. ⟲×2 last 07-22
TST: measure INDURATION only, never erythema; use the lowest applicable cutoff (contact ≥5 mm); LTBI → rifapentine+INH 3 months. ⟲×2 last 07-21
C. difficile: oral vancomycin or fidaxomicin; symptoms back within 8 weeks = recurrence → fidaxomicin, never probiotics. ⟲×2 last 07-02
Skin and soft tissue infection
purulent (abscess, furuncle, carbuncle)→S. aureus/MRSA
nonpurulent spreading cellulitis→group A strep
Intensely pruritic serpiginous track
migrating 1-2 cm/day→cutaneous larva migrans → ivermectin
moves cm per hour→Strongyloides larva currens
Aspiration risk + dependent cavity with an AIR-FLUID LEVEL = lung abscess → ampicillin-sulbactam; no drainage, no bronchoscopy.
Post-transplant infections
first month→nosocomial (Pseudomonas, line, wound)
1-6+ months of immunosuppression→opportunists
Hemolysis + thrombocytopenia weeks after transfusion = babesiosis → peripheral smear (ring forms, Maltese cross); Babesia never grows in culture.
Mold growing in BLOOD cultures = Fusarium (~40%), never Aspergillus; Nocardia is a bacterium — treat amphotericin B and/or voriconazole.
Doxycycline tick prophylaxis only if Ixodes attached ≥36 hours or engorged, removed <72 hours, local infection rate ≥20%.
Kaposi sarcoma
localized asymptomatic→ART alone
visceral, extensive, or rapidly progressive disease→chemotherapy
Calcified brain lesions = neurocysticercosis → MRI brain with contrast; stool ova finds the gut tapeworm, not the cysts.
Candidemia bundle = echinocandin + catheter removal + DILATED retinal exam; echo is for Staph aureus or persistently positive cultures.
Chronic steatorrhea in a hiker → stool microscopy for Giardia; exclude infection before chasing celiac serology.
Ring-enhancing lesion
CD4 <100→toxoplasmosis
CD4 <50→CNS lymphoma
CD4 above that, with a murmur→septic embolus
Purulence is not a bacterial criterion: sinusitis antibiotics need ≥10 days, severe ≥3 days, or double-sickening.
After I&D add TMP-SMX or doxycycline when abscess ≥2 cm, surrounding cellulitis, systemic signs, or immunocompromise; cephalexin misses MRSA.
Meningococcal meningitis = DROPLET precautions (surgical mask within 6 ft, private room) 24 hours; close contacts get rifampin/cipro/ceftriaxone.
Eosinophilia + GI pain + "asthma" flaring on steroids + endemic origin = Strongyloides SEROLOGY; two negative stools exclude nothing.
Diffuse palm/sole rash + moth-eaten alopecia + lymphadenopathy + high alk phos = secondary syphilis → one IM benzathine penicillin.
High-dose TMP-SMX → HYPERKALEMIA (trimethoprim blocks ENaC) plus a false creatinine rise; its acidosis is non-anion-gap.
Fever + regurgitant murmur + embolic infarcts + negative cultures = endocarditis → ECHO first; culture-negative means Coxiella (livestock)/Bartonella.
Military recruit + bilateral conjunctivitis + pharyngitis + lower respiratory illness ± diarrhea = adenovirus.
Inpatient non-ICU CAP = ceftriaxone + azithromycin (or respiratory fluoroquinolone); add vancomycin only with a stated MRSA risk factor.
Sterile pyuria after a failed appropriate antibiotic course in an endemic-origin patient = GU TB → three morning urine AFB cultures.
Endemic fungus, which test
peripheral eosinophilia + thin-walled cavity + Southwest travel→coccidioidomycosis → SEROLOGY
Histoplasma and Blastomyces→urine antigen
Lymphocytic exudative effusion with negative fluid studies → PLEURAL BIOPSY; sputum and pleural-fluid AFB are low yield.
Disseminated MAC (CD4 <50) = clarithromycin + ethambutol ± rifabutin; azithromycin alone is prophylaxis, and monotherapy breeds resistance.
Untreated Lyme's most likely late complication is ARTHRITIS (~60%, one large joint); carditis is early disseminated and ~5%.
Gram-positive BACILLI in CSF = Listeria → ampicillin alone; Listeria is intrinsically resistant to every cephalosporin.
Traveler's diarrhea self-treatment
most destinations→fluoroquinolone
Southeast Asia (quinolone-resistant Campylobacter)→AZITHROMYCIN
Giardia, not ETEC→metronidazole
Pyrimethamine always pairs with LEUCOVORIN to rescue host marrow; sulfadiazine already covers PCP, so no added TMP-SMX.
Asplenia + purpura fulminans + DIC + shock = meningococcemia → CEFTRIAXONE; asplenia means encapsulated organisms.
A negative TST days after exposure proves nothing → repeat at 8-12 weeks (IGRA 4-6); contact cutoff is 5 mm.
Nocturnal perianal itch with young children at home = pinworm → scotch-tape test, albendazole, treat the whole household.
Rapid influenza is ~65% sensitive: treat clinically with oseltamivir if <48 hours or high-risk (age ≥65, cardiopulmonary disease).
DKA + periorbital swelling + sinus tenderness = rhino-orbital mucormycosis → EMERGENT surgical debridement plus liposomal amphotericin; antibiotics do nothing.
Candida in sputum or BAL of a ventilated patient is colonization → no antifungal; treat only candidemia.
Febrile neutropenia = antipseudomonal beta-lactam MONOTHERAPY (pip-tazo/cefepime/carbapenem); vancomycin only with line, pneumonia, skin source, instability, or MRSA colonization.
Febrile returning traveler
5-7 day fever + retro-orbital pain + RISING hematocrit + falling platelets + bleeding→dengue
fever running weeks with relative bradycardia→typhoid
Candida endocarditis = amphotericin B plus surgery; fluconazole is suppression only (C. krusei/glabrata resistant); pseudohyphae on Gram stain.
Ear pain with bony erosion — ESR splits it
ESR >100→malignant otitis externa
ESR normal/low after failed cipro→squamous carcinoma → biopsy
Tabes dorsalis + Argyll Robertson pupil + ascending aortitis = tertiary syphilis: RPR often negative, diagnose by treponemal EIA, IV penicillin G.
Syphilis cure = 4-fold RPR/VDRL drop; treponemal tests stay positive for life; serofast at 6 months → observe.
Neutropenia or chronic steroids + halo sign + positive galactomannan = invasive aspergillosis → voriconazole; PCP has NEGATIVE galactomannan.
PrEP = daily tenofovir/emtricitabine for any ongoing HIV risk; check HIV status and renal function before starting.
Hepatitis A post-exposure
healthy under 40→vaccine
over 40, immunocompromised, or chronic liver disease→immune globulin within 2 weeks
Suspected prosthetic joint infection: aspirate the joint first; culture-negative does not mean sterile.
Acute HIV (mono-like illness + rash + low CD4) is diagnosed by HIV RNA, not antibody — window period.

Rheumatology

43 rules · 9 repeat misses

Chronic symmetric MCP/PIP/wrist synovitis ≥6 weeks = RA even with RF and anti-CCP negative; 20% of RA is seronegative. ⟲×2 last 08-07
Suspected sacroiliitis: AP pelvis x-ray first, MRI of SI joints most sensitive early; HLA-B27 is only 75% sensitive. ⟲×2 last 08-07
Suspected GCA: high-dose steroids immediately, before biopsy (biopsy stays positive ~2 weeks); amaurosis fugax portends permanent blindness. ⟲×2 last 08-04
Synovial WBC ⟲×2 last 08-04
>50,000→septic: cultures, IV antibiotics, drainage
2,000-50,000→merely inflammatory (reactive arthritis → NSAIDs)
IgA vasculitis: palpable purpura (small-vessel, excludes PAN) + abdominal pain + hematuria + normal platelets; skin biopsy establishes it. ⟲×2 last 08-03
Forefoot pain ⟲×2 last 08-01
web-space "marble" + Mulder click→Morton neuroma
shaft tenderness or axial toe load→stress fracture
ANCA vasculitis with airway disease ⟲×2 last 07-13
asthma + nasal polyps + eosinophils >10%→EGPA (p-ANCA/MPO)
c-ANCA/PR3, destructive sinus, cavitary nodules→GPA
Vasculitis with viral hepatitis ⟲×2 last 06-24
HCV + purpura + low C4 + high RF→cryoglobulinemia
HBV + orchitis, ANCA-negative, normal complement→PAN
Hip pain ⟲×2 last 06-22
groin with rotation→OA
lateral trochanter tenderness worse lying on side→bursitis
outer-thigh sensory→meralgia
Sjögren beyond 6 years with a hard painless parotid + adenopathy + anemia = MALT lymphoma (5% lifetime); excisional node biopsy.
Naming dermatomyositis obligates age-appropriate cancer screening (5-fold risk); treat with prednisone 1 mg/kg, not the PMR dose.
Olecranon bursal fluid >3,000 cells with fever = septic bursitis → drainage plus anti-staph antibiotic; a negative Gram stain excludes nothing.
Finger-flexor plus quadriceps weakness with dysphagia = inclusion-body myositis; distal weakness in a myopathy is never myasthenia.
Prednisone dose
PMR→12.5-25 mg/day
GCA symptoms→40-60 mg
RA with hand swelling and carpal tunnel shows PIP synovitis; an option's "without articular abnormalities" clause disqualifies it.
RA active on maximum methotrexate: continue MTX and add the TNF inhibitor; a tolerated partial responder is the anchor, never swapped out.
Nonradiographic axial spondyloarthritis: scheduled NSAIDs plus physical therapy; systemic steroids do not work in axSpA.
Longstanding RA with nephrotic-range proteinuria and bland sediment = AA amyloidosis; IgA nephropathy is defined by hematuria.
Retiform purpura with earlobe lesions, leukopenia, and both MPO and PR3 positive = levamisole-adulterated cocaine; PAN is always ANCA-negative.
Destructive shoulder, rusty effusion, WBC 630, no crystals under polarized light = hydroxyapatite (Milwaukee shoulder); alizarin red stains it.
First CMC osteoarthritis after NSAIDs fail: thumb spica orthosis is the rung before any injection.
Anti-Ro positive in pregnancy → fetal echocardiography at 18-22 weeks for congenital heart block.
Diffuse scleroderma with anti-Scl-70 and exertional desaturation → HRCT for ILD; a normal chest x-ray never excludes it.
Nodules on DIP joints are tophi, not RA (RA spares DIPs) → allopurinol to urate <6; urate can be normal in tophaceous gout.
Vertebral compression fracture already diagnosed on x-ray: early mobilization, not repeat imaging; symmetric ankle areflexia at 76 is age.
RA with hyperreflexia and ankle clonus = atlantoaxial subluxation → MRI cervical spine before any gait training.
Nail pitting + DIP involvement + pencil-in-cup erosions with normal ESR/RF = psoriatic arthritis; skin psoriasis follows later in 30%.
Worst RA prognosis = anti-CCP AND RF both positive (double seropositivity) plus erosions; ANA carries no RA prognostic weight.
Granulomatous small-vessel vasculitis with sinus and lung disease = GPA; limited GPA is ANCA-negative about 30% of the time.
Scleroderma
abrupt severe hypertension + rising Cr→renal crisis → ACE inhibitor, given even in acute renal failure
Raynaud→CCB
Unilateral burning sole pain with a positive Tinel behind the medial malleolus = tarsal tunnel syndrome; RA is a listed cause.
Longstanding seropositive RA + splenomegaly + ANC <1,000 = Felty syndrome; compute the ANC, then marrow biopsy to exclude LGL leukemia.
Hand OA failing acetaminophen at age ≥65 or with HTN/CKD/CHF → topical diclofenac, not systemic NSAIDs; DIP osteophytes need no serology.
Postmenopausal RA with smoking, low BMI, and prior steroids → DXA; screen before 65 when risk factors stack.
Severe psoriasis with psoriatic arthritis → test for HIV; hepatitis C gives RA-like arthritis with purpura instead.
Sicca + non-gap acidosis with hypokalemia + urine SG 1.001 = Sjögren (distal RTA, nephrogenic DI); lip biopsy establishes it.
2nd-3rd MCP arthropathy with hook osteophytes and chondrocalcinosis = hemochromatosis; check ferritin and transferrin saturation.
Burning pain out of proportion after injury plus autonomic changes = CRPS; treat with early physical therapy and bisphosphonates.
Acute vertebral compression fracture pain: NSAIDs first, calcitonin nasal spray if refractory; no routine vertebroplasty or bracing.
Chondrocalcinosis under age 55 = CPPD → screen hemochromatosis with iron, TIBC, ferritin; uric acid is unreliable during an attack.
Young man with inflammatory back pain, enthesitis, and aortic root dilation with AR = ankylosing spondylitis aortitis, not syphilis.
Isolated cutaneous leukocytoclastic vasculitis
negative workup and no ulceration→symptomatic care
necrosis or chronicity→immunosuppress
Transplant or chronic steroids + groin pain on weight bearing with normal ESR/CRP = avascular necrosis → MRI, never a steroid injection.

Gastroenterology

35 rules · 3 repeat misses

AST:ALT <1 + metabolic syndrome = NAFLD: exclude hep B/C and iron overload first, then weight loss ⟲×2 last 08-17
Cholestatic ALP/GGT ≫ transaminases + pruritus = PBC → AMA, ursodeoxycholic acid (AIH gets steroids) ⟲×2 last 08-17
SAAG ≥1.1 = portal hypertension; then ascitic protein ⟲×2 last 07-02
≥2.5→heart failure
<2.5→cirrhosis
Liver transplant
active sepsis→an absolute contraindication
HCC within Milan criteria→an indication, not a barrier
Cirrhosis + AKI + bland urinalysis = hepatorenal syndrome → stop diuretics, IV albumin 48h; paracentesis worsens it.
Constipation ladder: bulk-forming fiber first, then osmotic PEG, then secretagogues; a slow-transit marker study does not upgrade therapy.
Colicky pain + prior laparotomy + empty rectal vault = SBO → upright chest/abdominal films first, CT only if nondiagnostic.
OCPs + tender hepatomegaly + new high-SAAG ascites with NORMAL albumin = Budd-Chiari → Doppler the hepatic veins.
Either / or
Low IgE with no temporal link to meals→sensitization, not allergy
pain relieved by defecation→IBS
Oral itching after two different melons in a hay-fever patient = pollen-food allergy syndrome (ragweed cross-reactivity).
Bird-beak achalasia with age >60, symptoms <6 months, or weight loss → EGD first to exclude pseudoachalasia.
Any upper GI bleed → EGD; barium coats mucosa and sabotages it; INR 1.3 does not delay.
Gallstone pancreatitis + dilated CBD + cholestatic LFTs = urgent ERCP with sphincterotomy, not HIDA (ALT >150 predicts stones).
Positive urea breath test after triple therapy = failure → bismuth quadruple; PPIs cause false-negatives, never false-positives.
Fever + pain after polypectomy = perforation; negative plain films do not exclude it → CT with water-soluble contrast.
Inadequate bowel prep → repeat colonoscopy within 1 year regardless of findings; exam quality gates the interval.
Liver disease under 40 with negative viral serologies + neuropsychiatric signs = Wilson → slit lamp, then ceruloplasmin.
Oropharyngeal dysphagia + gurgling + halitosis = Zenker → barium esophagram; EGD first can perforate the pouch.
Fistula
Crohn-related→medical first, infliximab
non-IBD fistula, abscess, or medical failure→surgery
Already gluten-free and asked what RULES OUT celiac → HLA-DQ2/DQ8, the only diet-independent test (NPV >99%).
Acute hepatitis B
immunocompetent adult→supportive care (>95% clear)
INR >1.5 or liver failure→antivirals
Partial response to once-daily PPI = escalate to BID before meals; EGD only for alarm features or BID failure.
Sigmoid volvulus
without gangrene, peritonitis, or free air→flexible sigmoidoscopy detorsion + rectal tube
gangrene or recurrence→surgery
Celiac disease causes functional hyposplenism → pneumococcal vaccination at diagnosis regardless of age.
Eosinophilic esophagitis endoscopy = concentric rings (trachealization) + linear furrows; biopsy ≥15 eosinophils/hpf.
Ogilvie: supportive care first; neostigmine only after 24-48h failure or cecum >12 cm, never post-MI or beta-blocked.
Pancreatitis
lipase still elevated 4-6 weeks after acute pancreatitis→pseudocyst
NORMAL lipase→chronic pancreatitis
Thin patient whose T2DM suddenly worsens + weight loss + smoking → CT abdomen for pancreatic cancer.
Diabetic autonomic neuropathy → SIBO: watery nocturnal diarrhea + flatulence → carbohydrate breath test, treat rifaximin.
H. pylori biopsy is falsely negative during active bleeding or on PPI → confirm with urea breath or stool antigen.
Chronic radiation proctitis: sucralfate enemas first-line; argon plasma coagulation only after sucralfate fails.
Esophageal cancer risk
Achalasia→raises esophageal SQUAMOUS cell carcinoma risk
GERD/Barrett→raises adenocarcinoma risk
AST:ALT >2 + fever + jaundice in a heavy drinker = alcoholic hepatitis; Maddrey >32 → steroids.
Cirrhotic ascites: spironolactone 100 mg + furosemide 40 mg, held at the 2.5:1 ratio.
CD4 <100 + odynophagia = candidal esophagitis → empiric fluconazole, no endoscopy needed.

Endocrine

29 rules · 3 repeat misses

Androgen deprivation is the strongest male osteoporosis risk (20% fracture in 5 years); work up male fragility fracture with morning testosterone. ⟲×2 last 08-03
Low testosterone with low/normal LH = central: check prolactin, MRI if T<200 under age 65 — never replace first. ⟲×2 last 08-03
Any prolactinoma → cabergoline first, not surgery; untreated microadenoma causes osteoporosis from low estrogen, not mass effect. ⟲×2 last 06-22
New neck symptom after thyroidectomy plus RAI → thyroglobulin with TSH/free T4 first; ultrasound only if thyroglobulin is detectable.
Screen Cushing with late-night salivary cortisol or 24-h urine free cortisol; estrogen OCP raises CBG and falsely fails dexamethasone suppression.
T2DM needing weight loss → GLP-1 agonist; DPP-4 drops A1c only 0.5% and is weight-neutral; recurrent candidiasis vetoes SGLT2.
Every adrenal incidentaloma gets 1 mg dexamethasone suppression plus fractionated metanephrines; benign 2-HU imaging excludes cancer, never secretion.
Check TSH before any workup of new dyslipidemia; familial hypercholesterolemia never raises triglycerides.
Achilles tendon xanthomas with LDL >190 = familial hypercholesterolemia; a TSH of 5.4 cannot produce LDL 223.
DKA in an obese adult with negative GAD/islet/insulin antibodies = ketosis-prone T2DM → taper the insulin off.
Facial and arm fat LOSS since childhood = acquired partial lipodystrophy; Cushing adds facial fat, never removes it.
LDL 84 on moderate statin with risk enhancers is unfinished: target both a 50% reduction and LDL <70.
Gastroparesis with T2DM → dapagliflozin; pramlintide and GLP-1 agonists work by slowing gastric emptying.
Avoid pioglitazone in osteopenic postmenopausal women — TZDs cause bone loss and fractures.
Monofilament test the distal hallux and metatarsal heads 1, 3, 5; the heel is never a site.
DKA glucose ≤200 → add dextrose and continue insulin until the gap closes; keep KCl unless K >5.3.
New diabetes in a lean adult (BMI 21) with autoimmunity = LADA → GAD65 antibodies, not imaging.
Never uptitrate levothyroxine for residual symptoms when TSH is normal; the TSH is the target — hunt other causes.
No diet beats another for 1-year weight loss; very-low-carb's only reliable difference is more GI symptoms and headache.
Severe hypercalcemia = saline plus calcitonin plus zoledronic acid concurrently; furosemide is not routine, denosumab if CrCl <30.
Thyroid nodule malignancy risk
HIGH TSH→raises it (low TSH = hot = benign)
external head/neck radiation and family history→count
nodule number, smoking, radioiodine isotopes→do not
Hypercalcemia
calcium >13, acute and very symptomatic→PTHrP of malignancy
mild (<11), chronic, asymptomatic→primary hyperparathyroidism
Low TSH with low free T4 = central hypothyroidism → cosyntropin stimulation before levothyroxine, which can precipitate adrenal crisis.
Hypogonadism workup starts with morning total testosterone; LH/FSH only after a confirmed repeat low.
PCOS: lifestyle plus OCP first-line; hirsutism takes 6 months — add spironolactone only if response is inadequate.
Either / or
MEN1→3 Ps (parathyroid, pancreas, pituitary)
MEN2→RET, medullary thyroid cancer, pheo — exclude pheo before surgery
Thyroid nodule with low TSH → scintigraphy; a hot nodule is benign → radioiodine or surgery, not chronic methimazole.
Resistant hypertension with hypokalemia = primary hyperaldosteronism → aldosterone-to-renin ratio first, not OSA.
Triglycerides >1000 with pancreatitis risk → plasmapheresis; an insulin drip lowers triglycerides acutely.

Nephrology / urology

29 rules · 1 repeat miss

ADPKD = bilateral flank masses plus liver cysts and berry aneurysms; abrupt headache with meningismus is SAH, screen the family. ⟲×2 last 07-01
Bleeding in kidney failure with a NORMAL platelet count = uremic platelet dysfunction → desmopressin; transfused platelets fail in uremic plasma.
In dialysis, iron deficiency is TSAT ≤20% and ferritin ≤200 → IV iron; it is the commonest ESA resistance.
Sulfadiazine AKI with urine pH ≤5.5 and volume depletion → urine sediment for crystals; treat with fluids and alkalinization >7.15.
Compute the urine anion gap in non-gap acidosis
negative→GI losses
hyperkalemia→type 4 RTA requires it
pH 7.40 with HCO3 12 and PaCO2 20 = gap acidosis plus respiratory alkalosis = salicylate, not compensation.
Nocturia without increased daytime frequency is volume, not prostate — increase the diuretic before adding an alpha-blocker.
Varicocele (bag of worms, shrinks supine) with no fertility desire → scrotal support and NSAIDs, not surgery.
Any ECG change with hyperkalemia → IV calcium gluconate first; it raises threshold, it does not lower potassium.
Lithium nephrogenic DI (no rise after DDAVP) → amiloride plus low salt; fluid restriction causes hypernatremia.
Nephrotic syndrome with positive anti-PLA2R, normal creatinine, bland sediment = primary membranous — no biopsy, no cancer CT.
An anion gap of 41 names an added organic acid: metformin plus AKI = lactic acidosis; CKD rarely exceeds 20.
Refractory hypokalemia with HCO3 40 and Cl 82 from NG suction: treat the alkalosis with saline, KCl, PPI.
Hypercalciuric stone-former → sodium under 2300 mg/day and >2 L urine; never restrict calcium, never give vitamin D.
Synpharyngitic gross hematuria with dysmorphic RBCs = IgA nephropathy → quantify GFR and proteinuria; biopsy if proteinuria >500 mg/day.
In CKD hypertension the potassium gates RAAS: at K 5.0 uptitrate chlorthalidone — thiazides still work at eGFR 28.
Livedo reticularis with blue toes, eosinophilia and AKI one week post-cath = cholesterol embolism, not AIN.
Atherosclerotic renal artery stenosis → ACE inhibitor plus diuretic first; stent only for refractory HTN or flash pulmonary edema.
Painless gross hematuria in an older adult = CT urography plus cystoscopy; antiplatelets never explain it and DAPT continues.
Stone-former
serum calcium 10.8→repeat calcium and PTH
recurrent stones without a serum cause→24-hour urine
Caliceal dilation WITHOUT ureteral dilation plus DVT and bland urine = retroperitoneal fibrosis, not interstitial nephritis.
Dipstick blood with no RBCs = myoglobinuria → check CK; FENa can be falsely low in rhabdomyolysis.
Sildenafil is first-line for ED even in ESRD; alprostadil only after a PDE5 inhibitor fails.
Dialysis PTH target is 2-9x normal — a "normal" PTH of 26 = adynamic bone → stop calcitriol.
Read pH first to name the primary: compensation never crosses 7.40; expected PaCO2 ≈ the last two pH digits.
Acute (<48 h) hyponatremia with any symptom → 3% saline, raise 4-6 mEq/L, maximum 8 in 24 hours.
AIN = culprit drug plus sterile pyuria, WBC casts, eosinophiluria → stop the drug; steroids only if no improvement.
A prostate nodule on DRE gets biopsy regardless of PSA; a normal PSA does not exclude cancer.
Prevent contrast AKI with IV isotonic saline; if volume overloaded, diurese first, then give the contrast.

Neurology

23 rules · 2 repeat misses

Ascending symmetric weakness with areflexia = GBS → LP shows high protein with normal WBC; IVIG or plasmapheresis, never steroids ⟲×2 last 08-04
Symptomatic carotid stenosis: a statin is mandatory (read the med list for what is missing) ⟲×2 last 08-03
70-99%→CEA within 2 weeks
50-69% symptomatic→selective
Foot drop with weak eversion but intact inversion and plantar flexion = common peroneal at the fibular head.
Painful proximal L2-L4 wasting with areflexia, downgoing plantars, weight loss and orthostasis = diabetic amyotrophy, not compressive myelopathy.
Fever + asymmetric flaccid weakness with absent reflexes and downgoing plantars = West Nile anterior-horn myelitis, not stroke.
Post-gastric-bypass dorsal column loss (vibration, proprioception) + memory change = B12; the bypassed stomach made intrinsic factor.
Subacute cerebellar syndrome + lung mass + NORMAL MRI = paraneoplastic cerebellar degeneration (anti-Yo/Hu/Ri).
New encephalopathy after a valproate dose increase → check serum ammonia; VPA level and LFTs can be normal.
Obese young woman, pulsatile headache worse lying flat, empty sella = IIH → LP opening pressure >250 mm H2O.
Peripheral sensory ataxia + normocytic anemia + hypercalcemia = myeloma → serum immunofixation, not MRI.
Brain death is clinical: the bedside apnea test (PaCO2 >60) is essential; EEG and blood flow are ancillary.
Tinnitus
non-pulsatile continuous→audiometry first
pulsatile or position-dependent→MRA for a vascular cause
MS = lesions disseminated in time and space + periventricular ovoid T2 plaques; oligoclonal bands when MRI is atypical.
Gradual bilateral ataxia + nystagmus on phenytoin = toxicity, not stroke; omeprazole inhibits CYP2C19 and raises the level.
Either / or
>5 attacks/day, 2-30 min→paroxysmal hemicrania — indomethacin response is diagnostic
15-180 min→cluster → oxygen
Abrupt anterograde amnesia with preserved identity, resolving <24 hours = transient global amnesia; no treatment needed.
Tremor
bilateral action/postural, improving with alcohol→essential tremor → propranolol or primidone
rest tremor→Parkinson
Vertigo with normal head impulse, direction-changing nystagmus, or skew = central → MRI/DWI, since CT misses posterior fossa.
Fever + lead-pipe rigidity + AMS + CK >1000 = NMS → stop the antipsychotic, dantrolene + bromocriptine.
Forehead involved = peripheral CN7 Bell palsy → prednisone within 72 hours, no imaging unless atypical.
Subacute multifocal deficits in a cancer patient = leptomeningeal carcinomatosis → gadolinium MRI brain and spine, then LP cytology.
Parkinson, first drug
young patient→dopamine agonist first
elderly or cognitively impaired→levodopa first
Painful monocular vision loss + RAPD + NORMAL or swollen disc = optic neuritis → MRI brain for MS; disc pallor is a late atrophy sign.

Dermatology

22 rules · 4 repeat misses

Eczema flare ⟲×2 last 08-20
honey crust and pustules→staph → mupirocin
monomorphic punched-out vesicles→eczema herpeticum → valacyclovir, never steroids
Facial edema + adenopathy + eosinophilia + transaminitis with mucosa SPARED, 2-8 weeks after a drug = DRESS; send CBC diff and LFTs. ⟲×2 last 08-17
Papulopustular rosacea (pustules, telangiectasias, no comedones) → oral doxycycline; topical steroids on the face cause steroid rosacea. ⟲×2 last 08-07
Palms and soles SPARED excludes secondary syphilis ⟲×2 last 08-03
herald patch first→pityriasis rosea
post-strep raindrop papules→guttate psoriasis
Blistering with milia and scarring on sun-exposed dorsal hands = porphyria cutanea tarda → test for hepatitis C; treat with phlebotomy.
Dusky coalescing bullae with oral and conjunctival erosions weeks after a drug = SJS; fixed drug eruption requires recurrence at the same site.
Chronic urticaria: scheduled daily second-generation H1 antihistamine first line; NSAIDs aggravate it, acetaminophen does not.
Pretibial yellow-brown plaques with atrophic center and telangiectasias = necrobiosis lipoidica; screen for diabetes, lesions can precede it.
Non-pruritic skinfold rash in obesity or diabetes with satellite pustules = candidal intertrigo → topical miconazole; steroids feed the yeast.
Fever, neutrophilia, and dense dermal neutrophils WITHOUT vasculitis on biopsy = Sweet syndrome → corticosteroids, stop the failing antibiotic.
Intensely pruritic grouped vesicles on elbows, knees, buttocks = dermatitis herpetiformis = celiac → iron malabsorption; dapsone plus gluten-free.
Bilateral, afebrile red legs with rust-brown hemosiderin and edema = stasis dermatitis → topical triamcinolone plus compression, never antibiotics.
Painless hyperkeratotic papule in a meat handler = common wart → salicylic acid or cryotherapy; excision scars the face.
Lichen planus (pruritic purple polygonal papules, Wickham striae) → topical steroids; its hepatitis C link is a clue, not a treatment target.
After rewarming frostbite at 37-39°C: nonadherent gauze, elevate, tetanus; occlusive dressings extend damage and hyperbaric oxygen is unproven.
Non-healing ulcerated lesion enlarging over years in sun-damaged or burn-scarred skin = SCC (Marjolin ulcer) → biopsy.
Leukoplakia
not indurated or ulcerated→observe and stop tobacco
induration or ulceration appears→biopsy
Nail pitting with onycholysis after failed antifungals = psoriasis → full skin exam before any labs; pitting is never thyroid.
Hyperkeratotic crusted plaques with LITTLE itch in an immunocompromised patient = crusted scabies → oral ivermectin plus topical permethrin.
Malar rash
spares the nasolabial folds, plus oral ulcers→SLE
involves the folds→rosacea
Target lesions
HSV the top trigger→erythema multiforme
drug plus mucosal involvement→SJS/TEN
Wood lamp
coral-red→erythrasma
yellow-green→tinea versicolor
blue-green→Pseudomonas

Psychiatry

21 rules · 3 repeat misses

Chronic fatigue syndrome: ≥6 months fatigue + post-exertional malaise + unrefreshing sleep → CBT plus graded exercise, not rest ⟲×2 last 07-02
SSRI sexual dysfunction: add bupropion (or sildenafil); venlafaxine carries the same effect, and never cut a working dose ⟲×2 last 07-02
Either / or ⟲×2 last 06-21
lead-pipe rigidity, slow onset→NMS → dantrolene + bromocriptine
clonus/hyperreflexia, rapid→serotonin syndrome → cyproheptadine
Trauma 3 days to 1 month ago with nightmares, avoidance and startle = acute stress disorder → trauma-focused CBT.
Suspected physician impairment after a failed direct approach → report to the state physician health program; telling the supervisor is insufficient.
Either / or
Bilateral painless parotid swelling + hypokalemic hypochloremic ALKALOSIS→self-induced vomiting/bulimia
non-gap acidosis→laxatives
Depression with a weeks-long prognosis → methylphenidate, effective in 1-2 days; antidepressants take weeks. Match onset to prognosis.
Drug-induced parkinsonism plus a weight constraint → aripiprazole (low EPS, weight, QTc); olanzapine's weight gain rivals clozapine.
Antipsychotic monitoring
every second-generation antipsychotic→fasting glucose, lipids, BP, waist at baseline, 3 months, annually
clozapine→CBC/ANC
Lithium levels
ACE inhibitors/ARBs, thiazides, NSAIDs, verapamil→raise the level
amlodipine, hydralazine, carvedilol and clonidine→safe
Either / or
Multi-domain worry about health, money and work→GAD
depressed mood or anhedonia→MDD requires it
Screen for unhealthy alcohol use with the single-item question or AUDIT-C; CAGE and a full history are not first.
Somatic symptom disorder → regularly scheduled visits with one PCP every 2-4 weeks; psychiatry referral comes after the alliance.
Elderly widowed man, hopeless, firearm access, evasive about SI → hospitalize; medication and therapy come after safety.
Either / or
A fixed false belief without insight outranks the rituals→delusional disorder, somatic type
patient knows it is irrational→OCD
Diagnose depression in cancer by non-somatic markers: anhedonia/withdrawal, worthlessness, EXCESSIVE guilt, SI; fatigue and weight loss are unreliable.
Eating disorder, which one
any compensatory behavior (laxatives, exercise, fasting)→bulimia
no compensatory behavior→binge-eating disorder
BMI <18.5→anorexia
Eating disorder pharmacotherapy
bulimia→fluoxetine
anorexia→olanzapine
bupropion→contraindicated in eating disorders (seizure risk)
ED
preserved morning erections→psychogenic → counseling
loses nocturnal tumescence→organic
Recurrent unexpected attacks + anticipatory anxiety = panic disorder → SSRI plus CBT.
Psychotic or severe medication-refractory depression → ECT, the fastest effective treatment.

OB/Gyn

10 rules · 0 repeat misses

Pap interval follows the TEST (start 21, stop 65)
cytology alone→every 3 years
co-testing or primary HPV→every 5 years
FSH 66 with low estradiol = primary ovarian insufficiency (FSH up = ovary failed); normal follicular FSH is single digits, OCPs mask it.
Preeclampsia runs to 6 WEEKS postpartum, most within 48 hours: hypertension + pulmonary edema + proteinuria → BP control plus magnesium.
Friable cervix + mucopurulent discharge = cervicitis → empiric ceftriaxone + doxycycline; NAAT goes alongside, cervical Gram stain is only 50% sensitive.
Unilateral pruritic ulcerated nipple unresponsive to emollients = Paget disease → biopsy + bilateral mammogram; underlying carcinoma common without a mass.
Secondary amenorrhea step 1 is a pregnancy test even after tubal ligation (failure up to 3.6%); adenomyosis causes heavy painful menses.
Breast mass in lactation
multiple tender masses with no fever or erythema→plugged ducts
fever added→mastitis
single painless mobile mass→galactocele
A suspicious palpable breast mass needs core needle biopsy despite normal imaging — mammogram/ultrasound miss up to 30%.
Vaginal pH
≤4.5→candida or physiologic leukorrhea
>4.5→BV (clue cells) or trichomonas (flagellates)
Screen every pregnancy at 24-28 weeks with the 1-hour 50 g GCT; diagnose with the 3-hour 100 g OGTT.

General IM

7 rules · 0 repeat misses

Smoking-related screening
15 years after quitting→stop lung-cancer LDCT
any ever-smoker man aged 65-75→one-time AAA ultrasound
Preop herbs
ginkgo, ginseng, saw palmetto→bleeding herbs → stop 14 days preop
St John's wort→induces CYP and lowers INR
Either / or
HCPOA→grants decision-making, not PHI access
an express confidentiality request→survives anesthesia — wait for the patient to wake
Statin myopathy workup = CK, TSH, vitamin D; hypothyroidism both mimics and worsens it.
Recurrent sinopulmonary infections plus autoimmunity with low IgG/IgA/IgM = CVID → IVIG replacement.
Post-prostatectomy stress incontinence: first-line is pelvic floor exercises plus biofeedback.
Either / or
Sensitivity→rules OUT (SnOUT)
specificity→rules IN (SpIN)
prevalence→shifts PPV and NPV, not either

Geriatrics

5 rules · 0 repeat misses

Stage pressure injuries by the deepest tissue visible
fat→stage 3
bone or tendon→stage 4
Bilateral high-frequency hearing loss with normal drums = presbycusis; otosclerosis is unilateral and conductive.
Frailty determination best predicts 30-day complications and nursing-facility discharge; odds ratio near 20 versus non-frail.
Elderly self-neglect with MCV 102, AST:ALT 2:1, and repeat accidents = alcohol use disorder, not malnutrition.
Involuntary weight loss with preserved appetite and normal labs → detailed social history: cannot shop, cook, or afford food.

Ophthalmology

6 rules · 0 repeat misses

Leukocytes layered in the anterior chamber (hypopyon) + ciliary flush = anterior uveitis; a hordeolum sits on the lid.
Recurrent chalazia with burning gritty eyes → look for CRUSTING AT THE LASH BASE, the finding unique to blepharitis.
Flashes + floaters + a peripheral FIELD DEFECT = retinal detachment; a normal funduscopic exam does not rule it out.
Contact-lens corneal ulcer → topical FLUOROQUINOLONE for Pseudomonas; erythromycin misses it, and never patch or steroid.
Either / or
distance vision loss corrected by MINUS lenses→myopic shift of early nuclear cataract
near vision loss needing PLUS lenses→presbyopia
Sectoral red eye that BLANCHES with phenylephrine = episcleritis → NSAIDs, not vision-threatening.

Biostatistics

3 rules · 0 repeat misses

LR+ = sensitivity ÷ (1 − specificity); likelihood ratios are prevalence-independent, so quoted pretest probability is a decoy.
Randomization's unique benefit is balancing unknown confounders; it facilitates, not prevents, allocation concealment.
Near miss caught before reaching the patient → report to the event-reporting system; patient disclosure is discretionary.