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.