Typical Sunday night, really.

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.
Boyfriend:  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?
Boyfriend: …
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.