1. In-Training Exam
Zebras 2013
Dan Girzadas Jr. MD

2. Financial Disclaimer
 I am not a paid speaker.
 I am not promoting any product.
 Zebras are not commonly used in
medical practice and hence there is no
company willing to pay doctors to
promote their sale.

3. What’s a Zebra?
 When you hear hoof beats, it’s usually
horses not zebras.
 Think of the in-training as a safari
 Zebras are relatively rare clinical entities
 Distraction
 Foils
 Sew doubt

4. What’s a Zebra? Objectives
 The Attendee should be able to recognize
uncommon emergencies known to be used
on board exam questions (Zebras).
 The Attendee will have familiarity with these
uncommon emergencies and rule them in/out
of a board question more quickly and
confidently

5. Zebra Subcategories
 Cardiovascular  Heme-Onc
 Toxicology  GI
 Infectious Disease  Orthopedics
 Neuro/Neurosurgery  Miscellaneous
 OB-Gyne  Environmental

7. Cardiovascular

8.  Torsades
 QTc>500 is high risk
 Romano-Ward (Autosom Dom)
 Jervell and Lang-Nielson (Auto Rec,
Deafness)
 Long QT Syndrome
 Treat with Mag, Pacing, Isoproteronol,
1b’s

9. Murmur increased with
standing/valslava
Murmur decreased with
squatting or leg
elevation
Fluids and beta blockers
decrease obstruction
Decreased preload and
increased inotropy
worsen obstruction
Assymetric LV wall
thickening
HOCM
Betablockers/AICD

10.  Syncope
 Sudden death
 Southeast Asian Men
 Brugada Syndrome
 AICD

12. 1. Hypothermia
2. Osborne
wave

13. 1. Vasculitis
2. Associated with colic,
gi bleed,
intussusception,
abdominal pain (65%)
3. Glomerulonephritis
(25-50%)
4. Arthritis, scrotal
swelling
5. Palpable purpura on
buttocks and lower
extremities
6. TX: Supportive care
7. Henoch-Schonlein
Purpura

15. Pericarditis

16.  Most Common Cause of
Cyanotic Heart Disease
over the age of 4
 RV outflow
obstruction/VSD
 Left sternal border
murmur
 Squatting
 Boot heart with
decreased lung
markings
 Tetrology

17. Terrible T’s: Cyanotic Heart
Lesions
Right to Left Shunt
 Transposition
 Tetrology
 TAVR
 Truncus
 Tricuspid/Pulmonary Atresia
 Hypoplasts
 Ebstein’s, Some Coarcts

18. 1. Hypertension/flushing
2. severe headache
3. Dx test:urine
catecholamines
4. Alpha and beta block
prior to surgery
5. Pheochromocytoma

19.  Sudden painless
vision loss
 Associated with
HTN, vasculitis,
hypercoaguable,and
glaucoma
 Diffuse retinal
hemorrhages;
“Blood and thunder”
Tx:asa
Central Retinal Vein
Occlusion

20. 1. Sudden painless
vision loss
2. Ophth artery first
branch of
IC/embolic event
3. Pale retina and
cherry red macula
4. Tx with ocular
massage, topical
beta blocker,paper
bag,diamox,ant
chamber
paracentesis
5. Central Retinal
Artery Occlusion

21.  3-5 Days following AMI
 Associated with small to
medium inferior MI’s
 Acute CHF with
holosystolic murmur
 Treatment is surgical
 Papillary Muscle
Rupture
 Stabilize with afterload
reduction/nitroprusside

23. Toxicology

24.  Welders/solderers/
 smelters
 Fever/chills/myalgias
 Inhaled zinc oxide
fumes
 Cough and hemoptysis
 Can have abnormal
CXR
 Gets better when away
from the job
 Metal fume fever

25. 1. Agents that cause
SLUDGE + weakness
and seizures
2. All potent
organophosphates
3. Sarin/VX
4. Nerve agents/Chemical
warfare agents
5. Treat with atropine
(muscarinic symptoms)
and 2-PAM (nicotinic
symptoms)

26.  Cause of 95% of deaths
from Mushroom
Poisoning
 Intense Nausea/vomiting
that begins greater than
6 hours post-exposure
 Hepatic toxicity
 AC/Pen g/silibinin/NAC
 Beware hypoglycemia
 Amanita phalloides
 Gyromitra similar
presentation but can also
cause seizures

27.  Antivenin indications
 Local progression
 Coagulopathy
 Systemic effects
 SPREAD/BLED/ALMOST
DEAD
 All coral snake bites
 10 vials for crotalids/3
vials for coral snakes

28. 1. Toxin in paint stripper that may cause
delayed endogenous production of
carbon monoxide
2. Methylene chloride
3. Methylene Chloride=Carbon Monoxide

29. 1. Multi-use antidote
2. Gyromitra poisoning
3. One ancillary treatment for ethylene
glycol poisoning
4. Treat seizures related to isoniazid
poisoning
5. Pyridoxine

30. 1. Blocks cytochrome A3,
2. Doesn’t bind hemoglobin
3. Acidosis/coma/shock/dyspnea
4. Industrial exposure
(plastics/photography/
electroplating), smoke
inhalation
5. Scent of bitter almonds
6. Tx: hydroxocobalamine or
sodium nitrite/sodium
thiosulfate
7. Cyanide poisoning

31. 1. Toxin blocks inhibitory glycine at post-
synapse brainstem and spinal cord
2. Muscle spasms/ conscious
“convulsions”
3. Tx:benzos/ neuro-muscular blockade
4. Pt’s remain conscious
5. Can cause rhabdomyolysis
6. Strychnine poisoning

32. Sour gas leak kills worker: Employee never returned from
changing flow meter at remote gas facility (The Edmonton Journal,
March 8, 2008, Jennifer Fong).[8]
 Blocks cytochromes
 Acts similar to cyanide plus
it is a lung and eye irritant
 Shorter acting so victims
may recover from brief
exposure
 Tx:Sodium
nitrite/hydroxocobalomine?
 Hydrogen sulfide poisoning
 3rd Cytochrome poison=CO

33. 1. Toxin causing crampy abdominal pain
2. Vomit and diarrhea followed by
hypotension
3. Garlic odor to breath
4. Weakness, paresthesias, and rash
(Chronic)
5. Arsenic poisoning
Binds sulfhydryl groups/vasodilation/edema/tx with chelation BAL

34.  Pregnant Mom ingests Amanita
Mushrooms. Should you induce
delivery? Should you advise the mom
that the baby has a high risk of hepatic
damage?
 Neither. Amatoxins don’t cross the
placenta.

36. Infectious Disease

37. EOM weakness/diplopia
Absence of papillary light reflex/blurred vision
Generalized muscle weakness, poor suck in
infants/ constipation
Causes: improperly canned foods, honey
(infants), wounds (rare)
TX: pen in infants?/antitoxin for adults and
immune globulin for infants<1yr
Botulism
 Nerve conduction studies, Blood for botulinum toxin or
positive stool Cx are Dx

38. Botulism

39. Infection following
laceration in fresh
water lake
Most common organism:
aeromonas hydrophilia
FQ/Bactrim/Doxy
Infection following
laceration in sea water
Most common organism:
vibrio species
3rd Gen Ceph and Doxy

40.  Parasitic infection
Taenia saginata, Taenia
solium
 Seizures (#1 cause
adult-onset SZ world-
wide)
 Calcifications or cystic
lesions in brain
 Mexican immigrants
 Undercooked pork
 Cystercircosis

41. 1. Posterior
cervical
adenopathy
2. Macular rash
starting at face
and moving to
trunk and arms
3. Rubella
4. German measles

42.  Palatal Weakness
 Pseudomembrane
 Myocarditis
 Tx: pcn or erythro
and antitoxin
 Diphtheria

43. 1. Dermacentor tick is
vector
2. Rickettsial infection
3. Fever before rash
(ankles and wrists)/ bad
headache
4. Tx:doxy or
chloramphenicol
5. Rocky Mountain Spotted
Fever

44. BIL R DR
 Borellia
 Ixodes
 Lyme
 Ricketsia
 Dermacentor
 RMSF

45. 1. Viral illness
2. Vectors: bats/foxes/
raccoons/skunks/livestock
3. Squirrels, hamsters and rats don’t carry the
disease
4. TX: Irrigate wound with povidone-iodine
solution
5. HRIG 20IU/kg as much as possible around
wound, plus 5 doses of vaccine (in the
deltoid) on days 0,3,7,14,28.
6. Only one survivor in US without pre/post
exposure prophylaxis
7. Rabies

46. Wound Preparation: Buy or
Sell
 Povidone-Iodine or Chlorhexidine in
wound
 Shaving surrounding hair
 Irrigation pressure of 8 psi
 Scrub wound with sponge
 Wound soaking
 Best irrigation fluid

47. Category A Bioterrorism
Agents
USA Beats Extremist Plotters
1. Small Pox  supportive
2. Anthrax  AG/Cipro/Doxy
3. Plague (Y. Pestis)  AG/Cipro/Doxy
4. Botulism  Antitoxin
5. Tularemia  AG/Cipro/Doxy
6. Ebola et al.  Supportive

48. 1. Tick borne illness
2. Like RMSF, but
rash less common
3. Liver dysfunction
4. Leukopenia/
5. encephalitis/renal
failure
6. Tx:doxy
7. Bacteria is
Ehrlichia
8. Erlichiosis

49. 1. Protozoan infection
2. Heart failure
(#1cause in Latin
America)
3. Megaesophogus/
4. megacolon
5. Kissing bug
6. Periorbital swelling
7. Tx: nifurtimox or
benznidazole
8. Chaga’s
Disease/trypanoso
miasis

50.  Worm, most
common parasitic
disease in the world
 Eosinophilia
 Pneumonitis/hemopt
ysis
 Intestinal or biliary
obstruction
 Treat with
mebendazole
 Ascaris lumbricoides

51.  Protozoan parasite
 Malaria like, febrile
illness
 Hemolysis/rings in
rbc’s
 20% also have lyme
disease/ same tick
vector
 Treatment is quinine
and clindamycin
 Babesiosis

52. 1. Parasitic infection
2. Eating pork
3. Affects striated muscle
4. GI symptoms/periorbital
edema/ muscle spasms
5. Myocarditis/gi/pulmonary
edema
6. Eosinophilia
7. Trichinosis

53. 1. Cough, coryza and
conjunctivitis
2. Macular
erythematous rash
starts at hairline
and moves down to
feet
3. Koplick’s spots
4. Supportive care
5. Rubeola
6. Measles

54. 1. Major Jones criteria for
Rheumatic Fever
2. Polyarthrits (Joints)
3. Carditis (echO)
4. Subcutaneous nodules
(Nodules)
5. Erythema marginatum
(Erythema)
6. Chorea
(Sydenham’s)
 Aschoff Body: Damaged collagen

55. 1. Enter through skin
or be ingested
2. Hematuria/
3. hemetemesis/
4. cirrhosis/CNS
symptoms
5. DX confirmed with
eggs in feces and
rectal biopsy/
6. Tx:prazaquantel
7. Schistosomiasis

56. 1. Worm that sucks
blood from
intestinal villi
2. Anemia/ hi output
chf
3. Hand and foot
rash and pruritus
4. Mebendazole for
treatment
5. Hookworm

57.  Toxic
appearing/fever
 Headache
 Coma
 Periorbital edema
 Proptosis
 Cavernous sinus
Thrombosis

58. 1. Tender red nodules on lower
extremities
2. Causes: drugs/UC/strep
3. Tx:bedrest/intralesional
steroids/potassium iodide
4. Erythema nodosum

59.  A form of malaria
 The most lethal form
 Tx:Malarone or quinine and doxy or
mefloquine and doxy
 Falciparum

61. Neurology/Neurosurgery

62. 1. Eye physical exam
finding
2. Interruption of
sympathetics
3. Causes include:
4. Internal carotid
dissection/pancoast
tumor /CVA/herpes
zoster
5. Ptosis/miosis/anhidrosis
6. Horner’s syndrome

63. Lower extremity weakness
Back pain
Band sensation around thorax
Sphincter dysfunction
MRI shows no tumor, abscess
hematoma, or disc problem
LP shows pleocytosis
Some association with MS
Multiple other etiologies
Transverse Myelitis
TX: Steroids or immunoglobulin
but both are controversial

64. 1. Most common cause of optic nerve
related vision loss in 20-40yo’s
2. Painful , especially with eye movement
3. Afferent pupillary defect
4. Associated with MS
5. IV steroids or nothing, prednisone has
worse outcome
6. Optic neuritis

65.  Tumor
 Deafness/ataxia
 Ipsilateral facial
weakness
 Decreased corneal
reflex
 Cerebellar signs
 ACOUSTIC
NEUROMA/CPA
tumor

66.  Loss of motor
function and
pinprick sensation
 Retains position and
vibratory sense
 10-20% recover
some motor function
 Give steroids
 Anterior Cord
Syndrome

67.  Penetrating trauma
to spinal cord
 Ipsilateral
weakness/loss of
proprioception and
vibration
 Contralateral loss of
pain-temp
 Brown- Sequard
Syndrome

68. 1. Treatment of Cyclic Antidepressant
Seizures?
2. NaHCO3
3. Phenytoin
4. Phenobarbital
5. Lorazepam
6. Lorazepam=yes

69.  Hyperextension
cervical spine
trauma in old guy
 Upper extremities
weaker than lower
extremities
 MUD
 Central cord
syndrome

70.  Due to Lung tumor
or liver metastasis
 Serotonin and other
vasoactive
substances
 Right side valvular
heart disease
 Diarrhea
 Facial Flushing
 Carcinoid Syndrome

71. 1. Big ventricles on
brain CT
2. Dementia/ataxia/
incontinence
3. Normal pressure
hydrocephalus

72. 1. Autoimmune disease
2. Post synaptic antibodies causing
weakness
3. Affects young women and old guys
4. Avoid
steroids/aminoglycosides/narcotics
5. Myasthenia gravis

73.  Acute weakness
 Classic patient is a male waking the next day
after a large meal
 Ate carbohydrate rich meals
 Low k/high K/abnormal thyroid function on
lab testing
 TX: cautiously manage hypo/hyperkalemia,
manage hyperthyroidism with propranolol
 Familial periodic paralysis/Thyrotoxic periodic
paralysis

74.  SIADH vs. DI
 Hyponatremia vs. hypernatremia
 concentrated urine dilute urine
 Water restrict NS or vasopressin
 Tumor central or renal

75.  Lung Cancer
 Proximal weakness
 Presynaptic pathophysiology; Antibodies
to calcium channels
 Grip gets stronger over seconds
 Muscarinic insufficency
 Eaton-Lambert syndrome

77. OB-Gyne

78.  Test for greater than
30ml of fetal-maternal
hemorrhage in trauma
 Indicates need for more
than usual
300micrograms of
rhogam in rh- females
greater than 12 weeks
pregnant.
 Kleihauer-Betke test
 Other tests like K-B are
flow cytometry and
rosette test

79.  Upper Abdominal Pain
 Pre-ecclampsia
complication?
 Multiparous/ maternal
age >35
 BP may be normal
 Hemolysis,elevated liver
enzymes, low platelets/
 HELLP syndrome

80. 1. Right sided thoraco-
abdominal pain
2. Adhesions around liver
3. Perihepatitis
4. Secondary to a pelvic
infection
5. Chlamydia or gonorrhea
6. Fitz-Hugh Curtis
syndrome

81. 1. Which of the following vaccines and
immunoglobins are safe in
pregnancy?
2. Rabies=yes
3. Tetanus=yes
4. Hepatitis B=yes
5. Influenza=yes
6. Varicella=no
7. (Shot’s gonna HIRT)

83. Heme-Onc

84. 1. Most common inherited bleeding
disorder
2. Prolonged bleeding time
3. NL PT/PTT
4. Treat with desmopressin, factor
8,cryopercipitate
5. Von Willebrand’s disease

85.  Coombs test direct is
positive :
 Immune mediated
hemolytic anemias/
antibodies on the rbc
 Coombs test indirect is
used for:
 Antibodies in the serum
 Autoimmune hemolytic
anemia
 Hd of newborn, drugs, scd, thalasemia,
mult myeloma, hodgkin/hiv

86.  Hemolytic anemia
 Thrombocytopenia
 Renal vascular
endothelial
injury/platelet thrombi
 Kids
 Ecoli 0157:H7
 HUS
 Supportive Care,
Dialysis, watch for
hyperkalemia

87. 1. Thrombocytopenia
2. Hemolysis/renal
failure/fever/multiple
organ ischemic
damage
3. Similar to HUS but
more neuro signs
4. Tx: plasma exchange,
steroids, supportive
care
5. TTP or TTP-HUS

88. 1. Hemophilia with head injury
:Treatment?
2. 100%, 50u per kg of Factor 8 BEFORE
CT BRAIN
3. Joint pain
4. 50%, 25u per kg of Factor 8

89. 1. Hemolytic anemia
2. Sulfa drugs, pyridium, nitrofurantoin
and fava beans
3. Heinz bodies (precipitated hgb within
RBC)
4. African-Americans higher risk
5. G6PD deficiency

90. 1. Abdominal pain/weakness/psychiatric
symptoms
2. Diminished reflexes
3. DX test:Urine aminolevulonic acid and
porphobilinogen
4. Tx: Supportive care, iv glucose,
hemin, B6, stop offending drug
5. Acute Intermittent Porphyria

91.  Disease due to platelet autoantibodies
 Pupura and bleeding with low platelets
 Tx:steroids and sometimes
splenectomy
 Acute in kids/chronic in adults
 ITP

93. GI

94.  Marathon Runners
 Youngish adults
 Mobile Cecum
 Surgical Tx
 Cecal volvulus

95.  Most common Neonatal
GI Emergency
 Vomiting/poor
feeding/abdominal
distension
 Increased incidence with
prematurity
 Pneumatosis
intestinalis/hepatic portal
air
 NEC
 Vanc/Gent/Clinda
 ICU and Surgery Consults

96. Orthopedics

97. 1. 4-9yo child with a
limp/no fever
2. Avascular necrosis
of the femoral
head
3. Legg-Calve-
Perthes
4. 12-15 yo with
groin/hip/thigh/
5. knee pain
6. SCFE

98. 1. Salter Harris
2. 1-M-E-
(metaphysis)-
epiphysis)-4
3. This is a SH3

99. 1. Autoimmune disease in kids
2. Usually involves a single joint (knee) and not
destructive
3. Associated with iridocyclitis, inflammatory bowel
disease, Reiter’s syndrome
4. Polyarticular version with positive ana titers and
more destructive
5. Systemic version has high
fevers,rash,pericarditis,negative ana,joint
destruction
6. Treat with asa or steroids
7. Juvenile rheumatoid arthritis

101. Environmental

102. 1. How do you
remove jelly fish
Nematocysts?
2. Acetic acid
(vinegar)
3. Supportive care
afterward, pain
relief, wound care,
and for Chironex
envenomnations
antivenin

103. 1. How do you treat pain from sea
urchins?
2. Immerse in hot water as high as 113F

104. 1. Prolonged
exposure can
cause chemical
burn
2. Classic patient is
brick layer or
mason
3. TX: treat with
copious water
irrigation
4. Portland Cement

105. A Few Radiation ?’s
1. Blocked by paper, blocked by clothing,
blocked by concrete
2. Alpha, beta, Gamma
3. The best marker for outcome:
4. 24 hour lymphocyte count
5. Blood 200 rads/gi 600 rads/cns 2000 rads
6. New patient: remove clothing, wash, place
sheet

107. Miscellaneous

108.  More Common left side
 Dilatation of
pampiniform plexus
 Venous drainage in to
left renal vein (caught
between SMA and AO)
 Valsalva makes veins
more prominent
 Men may have
decreased fertility
 Boys may
retroperitoneal mass
 Varicocele

109. 1. Autosomal-dominant disease
2. Mucosal telangiectasias
3. Epistaxis
4. Osler-Weber-Rondu syndrome

110. 1. Complication of hi potency
neuroleptics
2. Idiosyncratic reaction
3. Hyperthermia/rigidity/autonomic
instability/altered mental status
4. Tx:rapid cooling/ fluids/ benzos/
dantrolene/bromocriptine/ECT?
5. Neuroleptic malignant syndrome

111. 1. Elevated liver enzymes/prolonged
pt/increased ammonia level/
2. Nl bilirubin
3. Increased ICP
4. Chicken pox and ASA
5. Reye’s syndrome

112.  Oral-eye-genital lesions
 Erythema nodosum
 Autoimmune
 Cholchicine, prednisone, cyclosporine
 Behcet’s disease

113.  Hocm
 Papillary muscle rupture
ludwigs
Reiter’s
Transverse Myelitis
Glaucoma E=M2C