The dynamics of the examination questions...

There is a definite reward in mastering the art of exam taking....you will get the question right!
The trick is to "dissect" each question for clues to the correct/best answer, while remembering
this very important rule:

Rule No.1. Every question must contain the answer!

Think about it. How can a question be asked by the examiner without giving ALL the clues
to the correct answer within the framework of the question itself. It is impossible!!!

The exceptions are the one liners...which you must know cold, pure rote memory. But we'll
show you how to skillfully answer them as well, with confidence.

Example: Which organism is the most common cause of Trench Fever?
Answer: Bartonella Quintana.

An example of a complex question, to "dissect":

A 42 year old white male presents to the E.R. with fever, chills, malaise and generalized body
aches and back pain of 3 days duration. Pt. was well prior to the onset of these symptoms.
PMH: Negative. PSH: Appendectomy SH: Smokes 1ppd. ETOH: Socially. FH: Prostate cancer/ HTN/ Ulcerative Colitis. Occupation: Welder. Married with 2 children.
Current medications: None. Allergies: None.

Physical Exam: T: 100.7 HR: 101 BP: 122/66 mm/Hg RR: 18 Pulse Ox: 98% on room air.

Pt. appears prostrated, but non toxic.
Skin: Warm and dry. No petechiae/purpura/jaundice. Nailfolds show faint vertical lines at tips.
HEENT: Essentially unremarakble, except for small prominent blood vessels on conjuntiva.
LUNGS: Clear to auscultation/percusssion
HEART: S1 S2 audible. No murmur/rub/dullness.
ABDOMEN: Soft, non tender, bowel sounds wnl, no organomegaly.
MUSCULOSKELETAL: No CVA tenderness. No joint effusions/synovitis. No needle tract marks.
Noted are small purplish spots on the tip of fingers, that are reportedly painful.
NEUROLOGIC EXAM: Normal.

LABS: CBC with diff. WBC 12.2 Hb/Hct: 14.4/38.6 Platelets: 244K
Electrolytes: Normal
Blood Cultures: Pending
Sed Rate: 48 mm/hr
ASO Titer: Negative
Urinalysis: RBC's 2 + No wbc/trace bacteria. Normal sediment
CXR: Normal
EKG: Sinus rhytm. 98/min. Normal axis. No acute changes.

What is your diagnosis:

A. Acute Viral Syndrome
B. Acute Urinary Tract Infection
C. Acute Bacterial Endocarditis
D. Fever of Unknown Etiology
E. Adult Still's Disease

Correct anwser: C. Acute Bacterial Endocarditis

The question contained all the clues(answers) to pick the correct diagnosis.

Main clues: Fever/malaise/back pain. Of these, back pain is the most important...because
@ 40% of cases of bacterial endocarditis will manifest this symptom.

Vertical lines at nailfolds: Splinter hemorrhages
Conjunctiva: Conjunctival hemorrhages
Purplish spots on fingertips: Osler's nodes (OUCH) on pads of digits.

Missing are two more prominent findings of endocarditis not seen in this patient:
1. Roth spots. White centered retinal hemorrhages are PATHOGNOMONIC.
2. Janeway lesions. Painless purplish hemorrhagic spots on the palmar/soles.

Incidentally, the back back pain occurs, due to microspopic papillary necrosis of the kidneys,
leading to slight HEMATURIA and back pain, of course.

Remember: ALL THE PHYSICAL FINDINGS OF BACTERIAL ENDOCARDITIS ARE FOUND
ON THE HANDS/FEET AND EYES. There are NO other bodily findings!

You have just dissected your first question, succesfully!