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Recent comments (see more)

... โˆ—link981 made a comment (step2ck_form8)
 +0  submitted by link981(207)

Lymphangitis is an infection of lymph vessels, while being a complication of some bacterial infections.

-Key words in vignette is "red streak extending to elbow".

Look at this picture: https://www.jpeds.com/article/S0022-3476(13)00037-1/fulltext.

The form is made because the streak follows the shape of the lymph node. Very noticeable once you see the image.

-Superficial thromphlebitis can't be the answer because it is generally caused by clotting in woman over 40 or 6 months post partum.

Remember the question asks "most likely" but many of some of these choices can definitely be in the differential diagnosis.

... โˆ—link981 made a comment (step2ck_form8)
 +0  submitted by link981(207)

SLE like other autoimmune diseases, may improve or worsen, or can present for the first time during pregnancy. Obstretic complications related to SLE: -Maternal (preeclampsia), - -Fetal (neonatal lupus, intrauterine fetal demise)-

-Neonatal lupus occurs due to passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies (30% prevalent in SLE.-

-Fetal findings: -Cardiac (fetal AV block) that occurs due to maternal autoantibodies binding to fetal cardiac cells. Causes irreversible injury to AV nose. The ventricular heart rate will determine the baseline fetal heart rate and will present with fetal bradycardia (less than 110 beats per minute). - -If the heart block is prolonged, hydrops fetalis can occur.

(https://www.jpedhc.org/article/S0891-5245(13)00232-0/fulltext) Uworld Question ID (12531)

... โˆ—link981 made a comment (step2ck_form8)
 +0  submitted by link981(207)

The majority of infants with CF and MI, whether simple or complex, have pancreatic insufficiency (PI). Confirmation of PI is most efficiently and effectively done by obtaining a fecal elastase. However, the fecal elastase sample should be collected from rectally delivered, formed stools and not from an enterostomy. Watery stools from either an enterostomy or rectally delivered can result in falsely low fecal elastase values. Therefore, in infants with MI and an enterostomy, PI should be assumed and fecal elastase collected at a later date after the gastrointestinal tract is back in continuity and stools are at least of a pasty consistency to confirm diagnosis. Once the infant is able to take a minimal amount of formula or breastmilk by mouth or feeding tube, PERT should be initiated at 2000โ€“4000 lipase units per 120โ€…mL of formula [[37]]. PERT contains lipase to digest to lipids, amylase to digest carbohydrates, and protease

https://www.cysticfibrosisjournal.com/article/S1569-1993(17)30809-3/fulltext#secst0030

... โˆ—ak8 made a comment (step2ck_form8)
 +0  submitted by ak8(2)

you dont see a cherry rod spot on fundoscopic exam picture - indication for fluorescein angiography to CONFIRM the diagnosis. they need to ask a different question if they want us to pick doppler. nbme always wins=(

... โˆ—weenathon made a comment (step2ck_form8)
 +1  submitted by weenathon(69)

Decubitus ulcer is a pressure sore that could be anywhere on the body, and in this case is on the head because the baby can't move.

Ecthyma gangrenosum is an infection usually seen in patients who are critically ill and immunocompromised. The characteristic lesions of ecthyma gangrenosum are haemorrhagic (bloody) pustules that evolve into necrotic (black) ulcers, which doesn't really fit the description here.

Kerion is an abscess caused by a fungal infection, and likely wouldn't be ulcerative

Recluse spider bite would have more severe systemic symptoms in a child (weakness, fever, joint pain, hemolytic anemia, thrombocytopenia, organ failure, disseminated intravascular coagulation, seizures, or death) and you would see puncture wounds.

I didn't think atypical TB or scabies made sense so I didn't go into those.

drdoom  very nice! +
... โˆ—weenathon made a comment (step2ck_form8)
 +0  submitted by weenathon(69)

Even though most small cell lung cancer shows up in late stages, and only 2% of people diagnosed are alive after 2 years, people still frequently get treatment. Usually this is both chemo and radiation, but the chemo comes first to shrink the cancer so you don't have to radiate as large an area. Chemo + radiation is also sometimes used as paliation. (https://www.ncbi.nlm.nih.gov/books/NBK482458/)

... โˆ—nicspabi made a comment (step2ck_form6)
 +0  submitted by nicspabi(1)

"Nerve conduction studies (NCS) and needle electromyography (EMG) are valuable for confirming the diagnosis of GBS and for providing some information regarding prognosis. In addition, electrodiagnostic studies are useful in classifying the main variants of GBS as demyelinating (eg, acute inflammatory demyelinating polyneuropathy) or axonal (eg, acute motor axonal neuropathy" UTD

... โˆ—jj375 made a comment (step2ck_form7)
 +0  submitted by jj375(28)

Nobody has mentioned this but I think another thing that helps with this answer is that the boy was infected with all these that he was immunized for. A 12 month old should've had immunizations for H. flu, and Strep pneumo, yet he was still getting sick. This makes me think he isnt making proper antibodies --> therefore a B cell issue

... hemoglobin_ made a comment (step2ck_form8)
 +0  submitted by hemoglobin_(2)

The patient has SCLC (histo description: uniform, small round cells w/darkly staining nuclei). This type is unresectable (only rare cases of small tumors w/o node involvement), responds to chemo and radiation initially, given more so as palliative care.

... โˆ—jj375 made a comment (step2ck_form6)
 +0  submitted by jj375(28)

High Calcium and low phosphorus --> probably has high PTH.

Vitamin D - leads to absorption of both calcium and phosphorus, so you would have high Ca and Ph. PTH - differentiates between Ca and Ph, it increases Calcium in the body and decreases phosphorus in the body.

... โˆ—jj375 made a comment (step2ck_form6)
 +0  submitted by jj375(28)

BMI โ‰ฅ40 --> Gastric Bypass candidate. BMI โ‰ฅ35 + comorbidity --> Gastric Bypass candidate.

She has already tried weight loss without success. Plus she is a compliant patient (diet, insulin regimen, and daily glucose monitoring)

Everyone has a story and a struggle, and weight is not dependent just on our effort or workout regimen. Genetics, microbiome, and many other factors play a role. Let's not judge these patients but help them!

... โˆ—niboonsh made a comment (step2ck_form7)
 -3  submitted by niboonsh(404)

so you just open a bitch up without any other workup whatsoever? stupid question

ak8  watch your mouth! i see why nbme is testing harder on ETHICS now +1
... โˆ—gigantichawk made a comment (step2ck_free120)
 +0  submitted by gigantichawk(1)

I thought I heard in a Divine podcast that if the labs showed pretty clear gallstone pancreatitis you could just skip the US and go right to ERCP. Guess not.

... โˆ—gigantichawk made a comment (step2ck_free120)
 +0  submitted by gigantichawk(1)

NPPV is approved for hospice patients for palliative reasons.

This patient is struggling to breathe, which is probably causing her some degree of suffering.

NPPV is non-invasive, and could alleviate her pain while not being a curative measure.

... โˆ—gigantichawk made a comment (step2ck_free120)
 +0  submitted by gigantichawk(1)

Was anyone thinking calcium pyrophosphate? Inflammatory joint, patient with RA, no organisms seen on FNA, would be treated with steroids?

... โˆ—305charlie94 made a comment (step2ck_form7)
 +0  submitted by 305charlie94(6)

Shouldn't early salicylate OD cause resp alkalosis? I thought only late salicylate OD caused increased anion gap metabolic acidosis. I chose Methanol given her eye sxs and I thought aspirin should be ruled out due to the timing of her OD

... โˆ—azibird made a comment (step2ck_free120)
 +1  submitted by azibird(269)

UTD:

Stabilization - Circulation

A child with exertional heat stroke may require 60 mL/kg or more of normal saline.

Rapid cooling

For children receiving treatment for heat stroke in the hospital, we suggest evaporative cooling rather than cold-water immersion. Evaporative cooling is preferred for hospital treatment of heat stroke in children because it does not interfere with efforts to maintain monitoring and ongoing resuscitation in unstable patients. Cold-water immersion is associated with significant discomfort, shivering, agitation, and combativeness; and is not clearly more efficacious for rapid cooling in the pediatric population. When evaporative cooling is not available, cold immersion is suggested.

https://www.uptodate.com/contents/heat-stroke-in-children

TL;DR

  • Everyone needs fluids (and those should probably be administered ASAP)
  • Cold-water immersion is not preferred
... โˆ—azibird made a comment (step2ck_free120)
 +1  submitted by azibird(269)

Why echo and not angiography?

From UTD:

Aortic disease

As recommended in the 2010 American College of Cardiology/American Heart Association/American Association for Thoracic Surgery thoracic aorta guidelines, echocardiography is recommended at initial diagnosis and at six months to assess the aortic root and ascending aorta in patients with MFS

Approach to diagnosis of MFS

MFS is most commonly diagnosed using the 2010 revised Ghent Criteria. These are based on the presence or absence of family history, physical examination, imaging of the aorta, and genetic testing in some cases.

The revised Ghent nosology puts greater weight on aortic root dilatation/dissection and ectopia lentis as the cardinal clinical features of MFS and on testing for mutations in FBN1. For the aortic criteria, aortic root Z score calculators are available for children and adults.

In the absence of family history of MFS

For individuals without a family history of MFS, the presence of one of any of the following criteria is diagnostic for MFS:

  • Aortic criterion (aortic diameter Z โ‰ฅ2 or aortic root dissection) and ectopia lentis.

  • Aortic criterion (aortic diameter Z โ‰ฅ2 or aortic root dissection) and a causal FBN1 mutation.

  • Aortic criterion (aortic diameter Z โ‰ฅ2 or aortic root dissection) and a systemic score โ‰ฅ7.

  • Ectopia lentis and a causal FBN1 mutation that has been identified in an individual with aortic aneurysm.

https://www.uptodate.com/contents/genetics-clinical-features-and-diagnosis-of-marfan-syndrome-and-related-disorders

https://pubmed.ncbi.nlm.nih.gov/20591885/

TL;DR Echo for aortic diameter

drdoom  incredible. thank you, professor! :^) +
... โˆ—azibird made a comment (step2ck_free120)
 +1  submitted by azibird(269)

What the hell is going on here? Still no answer that makes sense. We have:

  • "Poor air movement, especially on the LEFT"
  • What looks like a RIGHT tension pneumothorax on CXR
  • Shock and stupor ensue...
  • Oh, and also hypovolemic shock and maybe a weirdly shifted PMI

Put it all together: RIGHT tension pneumothorax

But why the hell are breath sounds decreased on the LEFT? That alone made me switch to some crazy heart crushing atelectasis answer. I honestly thing the R/L mixup may be a typo because without that the question is simple.

Some notes
❧ Some comments are scramble-resistant (Scramble-resistant Staphylocomment aureus)
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Help your fellow humans! (see more)

โˆ—niboonsh asks (step2ck_form7):
so you just open a bitch up without any other workup whatsoever? stupid question help answer!
ak8  watch your mouth! i see why nbme is testing harder on ETHICS now +1
โˆ—gigantichawk asks (step2ck_free120):
Was anyone thinking calcium pyrophosphate? Inflammatory joint, patient with RA, no organisms seen on FNA, would be treated with steroids? help answer!
gigantichawk  "Septic arthritis may be definitively established in the setting of positive synovial fluid Gram stain/culture. In patients with purulent synovial fluid (leukocyte count 50,000 - 150,000) but negative synovial fluid cultures, a presumptive diagnosis of septic arthritis can be made." Acute Calcium Pyrophosphate deposition would typically have a leukocyte count of 15,000 - 30,000 on aspiration. +
โˆ—305charlie94 asks (step2ck_form7):
Shouldn't early salicylate OD cause resp alkalosis? I thought only late salicylate OD caused increased anion gap metabolic acidosis. I chose Methanol given her eye sxs and I thought aspirin should be ruled out due to the timing of her OD help answer!
โˆ—azibird asks (step2ck_form8):
What does "central hilar opacification bilaterally" on x-ray represent? help answer!
sorrel1000  @azibird that confused me too. I was thinking sarcoidosis and then put constrictive pericarditis down. But now looking back, there wasn't enough support for sarcoidosis. +1
โˆ—azibird asks (step2ck_form8):
What is that black sliver on here retina? help answer!
โˆ—notyasupreme asks (step2ck_free120):
What a dumb question, there's literally a UWorld question about how a girl with a hx of seizures faked one and how you need to do neuro testing if they have no post-ictal confusion. I'm sorry, why are we even entertaining this if she has NO post-ictal confusion? help answer!
โˆ—notyasupreme asks (step2ck_free120):
I'm sorry but how the hell are you supposed to know it's vulvar when it says nothing about the vulva. I was between that and polyps, but put polyps because it was on the perineum? Like how the hell is that the vulva? help answer!
notyasupreme  lol jk, just looked it up and apparently I know shit about the female anatomy! +
jj375  I was quite confused by this too, especially since it said vulva but then said anal verge, but then also said vaginal bleeding. Here is a photo in case anyone else needs it: https://healthcare.utah.edu/huntsmancancerinstitute/gynecologic-cancer/images/vulvar-anatomy-image.jpg +
โˆ—azibird asks (step2ck_form7):
Agree that this question sucks. Why not go for psychodynamic psychotherapy since the patient specifically says she would like to understand why she does these things? Not a great option but still... help answer!
โˆ—adong asks (step2ck_form8):
they really copied and pasted this sh!t on nbme 6-8 huh? couldn't afford another heart sound smh help answer!
โˆ—adong asks (step2ck_form7):
they really copied and pasted this sh!t on nbme 6-8 huh? couldn't afford another heart sound smh help answer!
โˆ—notyasupreme asks (step2ck_form6):
Cardi B voice: WHAT WAS THE REASON for the goddamn Gram - stain, like whyyyyyyyyy. That's why I put prostatitis, even though the non-tender prostate threw me off. Damn, these questions are really just read the first and last sentence huh? help answer!
โˆ—notyasupreme asks (step2ck_form6):
I think I thought too deep into this, but isn't the cause of post-op fever on days 3-5 UTIs? I just remembered the mnemonic, but I guess I was thinking too deep.. help answer!
abelaia  probably classic overthink. likely to do with the type of blood culture grown. Staph vs. E. coli. +
โˆ—groovygrinch asks (step2ck_form7):
I thought with the whole <6 months or less thing he would qualify for hospice care in a skilled nursing facility? I am the only one who thinks it's a dick move to question this guy's decision making? help answer!
โˆ—joeschmo asks (nbme24):
If the directives state mechanical ventilation be discontinued it's implied that she would rather die. Why would anyone try to resuscitate when a decision has been made to pull the plug? help answer!
โˆ—epiglotitties asks (nbme20):
This isn't the scenario in this question, but I was wondering what would happen if you had told the parents the diagnosis and they didn't want their child to know? help answer!
yogurt-dimple asks (nbme25):
Am I crazy, or does the question stem imply that this was inherited paternally? help answer!
raspberry-muffin  In this question sounds like inherited paternally , but this muscle biopsy confirmed Mitochondrial inheritance. Muscle biopsy: Immunohistochemistry typically shows ragged red fibers, which are caused by sub-sarcolemmal and inter-myofibrillar accumulation of defective mitochondria in muscles (mitochondria stain red). Probably Mother has the same condition too. +
yogurt-dimple  Gotcha. Yeah, the red ragged fibers tipped me off to mitochondrial myopathy, but because the stem implied paternal inheritance, I figured there was just another disease I had forgotten about that presents with them. +
drdoom  @raspberry-muffin I'm not convinced. It is highly unlikely the NBME would write this question and expect you to "assume" mom has condition without making any mention of mom. Plus, it is simply highly improbable that myopathy is present in both mom and dad lineage. That seems off to me. +
drdoom  @yogurt-dimple, I think this a key line in the explanation: โ€œHowever, there are additional mutations that affect mitochondrial RNA translation, trafficking and incorporation of respiratory protein complexes, and maintenance of the inner mitochondrial membrane that can also lead to mitochondrial myopathy.โ€ +
drdoom  Yes, they say, "Mitochondrial diseases are strictly inherited through the mother" but this is not a mitochondrial disease โ€” this is a "non-mitochondrialโ€“derived" mitochondrial myopathy; yes, mitochondria are affected but the mutation is in somatic (nuclear) genes that govern the maintenance of "healthy mitochondria". This is because the mutation affects the function/operation of mitochondria but the mutation itself is in the nuclear DNA (which control something about the "quality" of mitochondria but what exactly is not yet known). +
โˆ—shelbinator94 asks (nbme18):
Why couldn't this be branching enzyme impairment? They both cause cardiac symptoms (according to Amboss at least) help answer!
โˆ—kms123 asks (free120):
can someone explain why it's not degranulation of eosinophils? help answer!
fhegedus  Eosinophils (FA 2020 page 408) are involved in type I hypersensitivity reactions (asthma, allergy, analphylaxis), parasitic infections and other pathologies. They are not involved in edema formation. I hope this helps! :) +
fhegedus  Also, the patient in the question got a laceration, which probably led to a bacterial infection; so neutrophils would be predominant, not eosinophils. +
โˆ—kms123 asks (nbme22):
How would we rule out antithrombin deficiency? help answer!
sd22  PT, PRT, and TT normal in antithrombin deficiency. FA โ€˜20 pg. 428 +
sd22  PTT* lol autocorrect clearly hasnโ€™t been studying +
โˆ—calvin_and_hobbes asks (nbme21):
This Q stem was confusing to me because I thought pain>>itch for shingles. Any thoughts? help answer!
โˆ—calvin_and_hobbes asks (nbme21):
"In addition to slightly decreased platelet count..." โ€” why are plts slightly low in EBV infection/mono? help answer!
โˆ—empem28 asks (nbme22):
totally buy the answer of K+ being increased, but can somebody explain why her extreme dehydration (decreased skin turgor, excess urine output) wouldn't lead to an increase in serum [Na+]? help answer!
โˆ—sd22 asks (nbme21):
Can anyone help explain what the other options would entail? help answer!
โˆ—marcspoop asks (nbme20):
Anyone else jump to phenylephrine as a drug that would clear the sinus congestion and also happens to cause constipation? Just me... cool help answer!
โˆ—ekraymer asks (nbme22):
Was it wrong to see blood tinged sputum, and automatically assume its cancer? since none of the others would have caused blood tinged sputum? help answer!
โˆ—calvin_and_hobbes asks (nbme20):
Due to its pink staining, I thought B was smooth muscle surrounding the corpus cavernosum. But I suppose that the cells composing the CC are contractile by themselves? And my assumption would make the penis a giant muscle โ€” which it most certainly is not... help answer!

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