{"id":7320,"date":"2025-08-04T00:01:00","date_gmt":"2025-08-04T08:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=7320"},"modified":"2025-10-01T11:38:25","modified_gmt":"2025-10-01T19:38:25","slug":"usmle-step-2-ck-question-of-the-day-nasal-crease","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease","title":{"rendered":"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Nasal crease"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\/#Major_Takeaway\" >Major Takeaway&nbsp;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Today, we\u2019re examining a clinical case of a 35-year-old taxi driver presenting with itchy, watery eyes and excessive sneezing. What&#8217;s the the likely cause?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 35-year-old taxi driver presents to the office because of itchy, watery eyes and excessive sneezing that have become more severe with the change of seasons. The patient has taken an over-the-counter medication in the past with moderate relief of the symptoms, but it made the patient very drowsy. Past medical history is significant for eczema. Family history is non-contributory. Vitals are within normal limits. Physical examination shows a prominent nasal crease. The nasal turbinates are boggy and bluish gray. There is copious watery nasal mucus. The patient asks the physician to switch to a medication that will not impair his ability to drive. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following medications is <em>most appropriate <\/em>for this patient?\u00a0<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Chlorpheniramine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Diphenhydramine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Hydroxyzine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Loratadine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Promethazine<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Osmosis.org at the University College London, UK\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/DIp3u0oTLo4?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Loratadine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Chlorpheniramine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Chlorpheniramine is a first-generation antihistamine. It is more likely to cause sedation and drowsiness in this patient, as it is lipophilic and easily crosses the blood-brain barrier.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Diphenhydramine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Diphenhydramine is a first-generation antihistamine. It is more likely to cause sedation and drowsiness in this patient as it is lipophilic and easily crosses the blood-brain barrier.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Hydroxyzine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Hydroxyzine is a first-generation antihistamine. It is more likely to cause sedation and drowsiness in this patient as it is lipophilic and easily crosses the blood-brain barrier.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Promethazine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Promethazine is a first-generation antihistamine. It is more likely to cause sedation and drowsiness in this patient as it is lipophilic and easily crosses the blood-brain barrier.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with sneezing, rhinorrhea and watery eyes, consistent with allergic rhinitis. The patient should be treated with a second-generation H1 receptor blocker such as cetirizine, loratadine or fexofenadine, to avoid sedation. These drugs have far less lipid solubility than first generation H1 blockers, resulting in less cognitive side effects. In addition, the antimuscarinic side effects also tend to be less severe, so second generation H1 blockers are preferable to first-generation H1 blockers in the treatment of allergic disease.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">On the contrary, first-generation H1 blockers such as diphenhydramine or hydroxyzine, have high lipid solubility and can easily cross the blood-brain barrier to cause cognitive side effects like sedation. Other side effects include increased appetite, and weight gain; antimuscarinic effects (e.g. dilated pupils, blurry vision, and dry mouth); and anti-\u03b1-adrenergic effects (e.g. orthostatic hypotension and dizziness).\u00a0\u00a0<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"875\" height=\"431\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/08\/image_dcdc60.png\" alt=\"H1 BLOCKERS ~ REVERSIBLY --| H1 RECEPTORS\n2nd Generation\nSuffic * &quot;-adine&quot;: \n- Fexofenadine\n- Desloratadine\n- Loratadine \n*Exception: Cetirizine\nLipid Solubility\n* &gt; 1st generation\nTreats\n* Allergic reactions\nSide Effects\n* Less cognitive\n- Antimuscarinic\nPreferable than 1st generation\" class=\"wp-image-7324\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/08\/image_dcdc60.png 875w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/08\/image_dcdc60.png?resize=300,148 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/08\/image_dcdc60.png?resize=768,378 768w\" sizes=\"auto, (max-width: 875px) 100vw, 875px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>When compared to first-generation H1 blockers<\/strong> (e.g. <strong>diphenhydramine or hydroxyzine), second-generation H1 receptor blockers <\/strong>(e.g. <strong>cetirizine, loratadine or fexofenadine) <\/strong>have far less lipid solubility than the first generation, resulting in less cognitive and antimuscarinic side effects.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video:<\/strong> <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Antihistamines_for_allergies\">Antihistamines for allergies<\/a><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Vacchiano, C., Moore, J., Rice, G. M., &amp; Crawley, G. (2008). Fexofenadine effects on cognitive performance in aviators at ground level and simulated altitude. Aviation, space, and environmental medicine, 79(8), 754-760.&nbsp;<\/li>\n\n\n\n<li>Verster, J. C., &amp; Volkerts, E. R. (2004). Antihistamines and driving ability: evidence from on-the-road driving studies during normal traffic. Annals of allergy, asthma &amp; immunology, 92(3), 294-304.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\/md\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_GENERAL3_2023.png\" alt=\"\" class=\"wp-image-4447\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_GENERAL3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_GENERAL3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 2 CK practice questions? Try Osmosis by Elsevier today! Access your\u00a0<em><strong><a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/strong><\/em>\u00a0and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Test your knowledge on treating allergic rhinitis in a patient with drowsiness concerns. Which antihistamine minimizes sedation and maintains alertness?<\/p>\n","protected":false},"author":202,"featured_media":7323,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,45],"tags":[1316,1319,1318,1313,1317,1315,245,1314,1320,671],"class_list":["post-7320","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-2","tag-allergic-rhinitis","tag-allergy-treatment","tag-antihistamines","tag-cetirizine","tag-diphenhydramine","tag-loratadine","tag-nursing-education","tag-second-generation-antihistamines","tag-sedation","tag-usmle-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 CK Question of the Day:\u00a0Nasal crease - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-nasal-crease\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Nasal crease - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Test your knowledge on treating allergic rhinitis in a patient with drowsiness concerns. 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