Boyfriend is currently studying for Step 2, while I’m studying for “oh god, I’m going to be an M3 in 6 months”. So sometimes we quiz each other.
Boyfriend: Okay. There’s a woman in her 60s – a smoker with a history of COPD and diabetes mellitus who presents to you in the middle of a current stroke. She frequently travels on long, crowded bus rides. What’s the most likely etiology of the stroke?
Me: … Hmm. Any medications?
Boyfriend: Estrogen pills, albuterol, and metformin.
Me: *am stumped* Well, what are her stroke symptoms?
Boyfriend: Doesn’t matter.
Me: Well, why does she travel on buses so much?
Boyfriend: Uh, she’s volunteering at a nursing home in another city, 4 hours away.
Me: What kind of buses are they?
Boyfriend: … they are buses.
Me: Who else rides these buses? Any homeless people?
Boyfriend: … No. They’re, uh, extremely fancy buses for rich people.
Me: Does she have cats?
Boyfriend: No. She has never touched a cat in her life. Or a litter box.
Me: … What about sushi?
Boyfriend: No. She’s never even seen a fish. Or eaten raw meat of any kind. Or touched a rabbit, or a pigeon, or traveled outside of the country –
Me: Ah, but what about-
Boyfriend: Or Florida. Nowhere sub-tropical.
Me: Damn. Well, what were the lung and heart exams like?
Boyfriend: Lungs were surprisingly clear, though there was a mild diastolic murmur in the heart.
Me: AHA. Can I get a chest x-ray? And a brain CT without contrast?
Boyfriend: CT comes back normal. CXR shows clear lungs, slightly hyperinflated, and some mild cardiomegaly.
Me: Aha! Cardiac… stuff. So.
Me: So… any claudication?
Boyfriend: You don’t know. She can’t tell you. She’s currently stroking out.
Me: See, it does matter what her stroke symptoms are! I didn’t know she couldn’t talk.
Boyfriend: Okay, fine – we’ll say she had a PCA stroke. So she only has ocular deficits and can still talk to you. And her thighs are red and swollen, which she’s unhappy about.
Me: INFECTION. I demand a CBC.
Boyfriend: It’s normal.
Me: Damn. Thyroid? Crepitus?
Boyfriend: Healthy. And no crepitus. I promise she doesn’t have necrotizing fasciitis.
Me: Well then, what the –
Boyfriend: Soooo.. the thigh symptoms are..?
Me: Oh. OH! So she had a DVT! A DVT that embolized to her brain! But why did she have a clot to throw in the first place?
Me: – you know, I still think that TB might have something to do with it. I don’t know how, but the buses were “crowded”…
Boyfriend: … But how can a DVT embolize to the brain?
Me: Because she has a patent foramen ovale, just like 25% of the population.
Boyfriend: HIGH FIVE! See, you know your stuff!
Me: Oh. Wait, that was – that was it? That’s the answer? But… why did she throw a clot?
Boyfriend: … because smoking, estrogen, and long travel are all risk factors for DVT.
Me: Damnit! I thought it had something to do with the bus exhaust fumes.
Boyfriend: Yeah, it didn’t.
Me: But the good news is, in two years, I’m gonna rock Step 2.
Boyfriend: … Just so you know, on Step 2 you only get 72 seconds per question.
Haha, that was a funny and beneficial exchange. Lesson learned : your boy/girlfriend must be a med student.
Hah, people will try to dissuade you from dating within your school – but it totally has advantages! (Especially if you find someone who’s ahead of you. Free books!)
May I politely disagree? I see a lot of stroke patients. The DVT/PFO thing in a woman who’s a smoker and on OCP is something I’ve seen from time to time with younger women, but in a diabetic lady in her sixties who’s also a smoker, I’d bet she’s got tons of atherosclerotic disease and she’s probably hypertensive. Or maybe she’s got undiagnosed a-fib.
Yeah agreed – the context was that he remembered that specific question because he thought it was such classic “only in standardized testing, not in real life” trivia. (I mercilessly cut that part because the entry was getting too long.)
So I could’ve made an argument for hypertension… if I had been thinking of “things that make sense” instead of “TB involves crowded places!” 😉