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Recent comments (see more)

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Why is it not toxoplasmosis?

They took antibiotics meant for treating toxoplasmosis and they presented with only one lesion in the right cerebral cortex.

Congenital and immunocompromised toxoplasmosis

Chorioretinitis (inflammation of the retina and the choroid or the vascular tissue of the eye), diffuse intracranial calcifications, and hydrocephalus (indicated by ventriculomegaly) in a new born.

Caused by Toxoplasma gondii infection during pregnancy. Consumption of contaminated, undercooked pork. Can also be due to contact with contaminated cat feces.

In an immunocompromised patient, multiple ring-enhancing lesions within the subcortical white matter, basal ganglia, and/or thalamus are highly suggestive of cerebral toxoplasmosis. Toxoplasma gondii is an obligate intracellular parasite, contracted via ingestion of cysts in raw meat or oocysts in cat feces. In immunocompetent patients, the presentation is usually asymptomatic.

Cerebral toxoplasmosis is treated with a combination of sulfadiazine and pyrimethamine.

shak360  See FA 2020 pp 177 on the common diseases of HIV-positive adults. At a CD4+ cell count of less than 100/mm3, EBV (HHV4) can present with B-cell lymphoma (that is, a non-Hodgkin's lymphoma such as a CNS lymphoma). In CNS lymphoma, it is ring-enhancing and most likely solitary. Whereas with Toxoplasma gondii, it would present with MULTIPLE ring-enhancing lesions. +
... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Cryptococcus neoformans is common in patients with immunocompromising conditions. Usually, I have this infectious yeast associated with India Ink staining (wherein it presents with a clear halo) but on mucicarmine stain, it presents with a red inner capsule, and the narrow budding can be more easily appreciated.

It causes cryptococcosis, meningitis, and encephalitis ("soap bubble" lesions in the brain).

The treatment is amphotericin B with flucytosine, followed by fluconazole for cryptococcal meningitis.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Anaphylaxis following blood transfusion is mediated by IgA in the new blood product in the IgA deficient patient. This is a high-yield classic presentation.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Bacillus anthracis is a gram-positive, spore-forming rod that produces anthrax toxin (an exotoxin consisting of protective antigen, lethal factor, and edema factor). Has a polypeptide capsule (poly d-glutamate). Colonies show a halo of projections, sometimes referred to as a “medusa head” appearance.

It presents as a cutaneous anthrax and a pulmonary anthrax:

  • Cutaneous: Painless papule surrounded by vesicles -> ulcer with black eschar (painless, necrotic) -> uncommonly progresses to bacteremia and death.
  • Pulmonary: Inhalation of spores, most commonly from contaminated animals or animal products, although also potential bioweapons -> flu-like symptoms that rapidly progress to fever, pulmonary hemorrhage, mediastinitis (CXR may show widened mediastinum), and shock. Also called woolsorter’s disease.
... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

(A) "Are you having any problems that you may be too embarrassed to talk about? Would you be willing to talk about them today?" is wrong because it implies that the topic is too shameful to openly discuss and discourages the patient from mentioning the issue. Physicians should avoid asking vague questions that do not directly assess for urinary incontinence.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

"Don't TRI drugs" -> Tricuspid valve endocarditis is typically associated with intravenous drug use.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

See this comment and subcomment in NBME 27.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

The posterior communicating artery (PCom) communicates between the posterior cerebral artery and the middle cerebral artery in the Circle of Willis.

PCom aneurysm can lead to compression and ipsilateral CN III palsy leading to mydriasis (classically called a "blown pupil") and ptosis. The clinical finding is a "down and out" eye (eye in an inferior and lateral position). Recall that the oculomotor nerve courses beneath the posterior cerebral and PCom and are vulnerable to aneurysms.

Compare with other lesions

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

If the renal condition has “proliferative” in the name, it has subendothelial deposits. If it doesn’t have “proliferative” in the name, it must not be subendothelial. So for instance, membranoproliferative glomerulonephritis (MPGN) and diffuse proliferative glomerulonephritis (DPGN); what would you see on biopsy? -> USMLE answer = subendothelial deposits. (from Mehlman Medical Renal)

In this question, this person has irregular subepithelial electron-dense deposits so the correct answer CAN NOT contain the word proliferative. Furthermore, she has 3+ protein in the urine but no evidence of blood indicating that it must be membranous nephropathy.

shak360  Another thing to note is that the "diffuse thickening of the glomerular capillary wall" is equivalent to "membranous" in disease nomenclature. +
... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Taking this from UWorld:

Major functions of the hypothalamic nuclei

  • Ventromedial: mediates satiety; destruction leads to hyperphagia
  • Lateral: mediates hunger; destruction leads to anorexia
  • Anterior: mediates heat dissipation; destruction leads to hyperthermia - AC for anterior cooling
  • Posterior: mediates heat mediates heat conservation; destruction leads to hypothermia - HOT POT
  • Arcuate: secretion of dopamine and inhibits prolactin, GHRH
  • Medial preoptic: Secretion of GnRH, regulates sexual behavior - Implicated in Kallmann syndrome a failure of GnRH-producing neurons to migrate from the olfactory pit
  • Paraventricular: Secretion of oxytocin, CRH, TRH, & small amounts of ADH - POX
  • Supraoptic: Secretion of ADH & small amounts of oxytocin - SAD
  • Suprachiasmatic: Circadian rhythm regulation & pineal gland. In particular, it processes light information from the retina and modulates body temperature and the production of hormones such as melatonin and cortisol. This structure also plays an important role in Jet Lag, or insomnia and daytime sleepiness that one experiences when traveling across the world. - SCN - Sun Censing Nucleus
... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Motor neuron signs

This question was testing the ability to know what upper motor and lower motor signs are. A Babinski sign (presence of the plantar reflex which is the dorsiflexion of the large toe and fanning or the other toes with plantar stimulation in an adult) is significant for an Upper motor neuron (UMN) lesion.

Recall that meningiomas can present with seizures or focal neurologic signs. They are malignant arachnoid cells and these tumors can present with psammoma bodies or laminated calcifications of spindle cells concentrically arranged in a whorled pattern.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Types of atelectasis

Consolidation can be ruled out because this happens when the alveoli become filled with material and should be picked if there were signs of pneumonia or pulmonary edema. There would also be a history of proof on a chest X-ray.

Radiation pneumonitis can cause fibrosis and scarring, which is key for contraction atelectasis.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Autoregulation of perfusion pressures

The local metabolites that vasodilate and increase perfusion to skeletal muscle while exercising are CHALK:

  • CO2
  • H+ (Hydrogen ions)
  • Lactate
  • K+ (Potassium ions)

During rest, the sympathetic tone in arteries (alpha and beta receptors).

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

I was confused and thought that ostial had something to do with bone but I guess ostial refers to the opening or the origin of a vessel (like the cervical Os or the coronary Os).

: /

Most hypertension is essential or physiological or primary and is related to increased cardiac output or increased total peripheral resistance.

Secondary hypertension is secondary to renal/renovascular disease such as fibromuscular dysplasia (a question asking for this would have likely given us an image with a "string of beads" appearance and a vignette with a woman of child-bearing age) OR renal artery stenosis (or as written in this question ostial stenosis of one renal artery) possibly due to atherosclerosis.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Lower extremity innervation

The common fibular (peroneal) nerve gives rise to both the deep fibular and superficial fibular nerves.

  • Injury to this nerve would result in LOSS OF BOTH ankle DORSIflexion (for Deep) and EVERSion (for Superficial).
  • The alteration in sensation would include both the first dorsal web space between the hallux and the second toe (for Deep) and the dorsum of the foot (for Superficial).

This person has decreased sensation in the first web space but sensation over the rest of the foot is normal, implying that the Deep fibular (peroneal) nerve is injured.

The superficial fibular (peroneal) nerve supplies the peroneus longus and brevis muscles. These muscles are the main evertors of the foot. Injury to this nerve would cause weakness in eversion as well as a decrease in sensation or paresthesias over the dorsolateral aspect of the foot.

For completeness, the tibial nerve plantarflexes the foot.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Important cytokines

The picture shown in the question is a classical description of a mild compression fracture seen in osteoporosis (see pp462 in FA2020). IL-1 is also known as an osteoclast activating factor and leads to an increase in RANK- ligand (RANK-L) signaling and subsequent osteoclast-mediated bone resorption. Recall that this can be treated by denosumab (a monoclonal antibody against RANKL).

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

Recall that when a question mentions an ulcerated genital lesion, we should be thinking about two things:

  • An nonpainful and indurated lesion: CHANCRE - due to first-degree syphilis by spirochete Treponema pallidum
  • A painful exudative lesion: CHANCROID - Haemophilus ducreyi (FA has a mnemonic: it's so painful, you do cry [ducreyi])

This question was testing first that HIV is a sexually transmitted disease and that of the listed organisms, Haemophilus ducreyi is sexually rtansmitted.

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

See Question 7 in the same block on related paraneoplastic syndromes (especially hypercalcemia due to increased PTHrP).

... shak360 made a comment (nbme25)
 +0  submitted by shak360(7)

In these questions, we should recall the TORCH infections.

Congenital syphilis is caused by the maternal transfer of the spirochete Treponema pallidum through the placenta after the first trimester. It often results in stillbirth, or hydrops fetalis (which is also seen in Parvovirus B19) and presents with facial abnormalities (notches teeth, saddle nose, short maxilla), saber shins, and CN VIII impairment or deafness (which is also seen with Rubella, hearing loss is also seen in CMV).

The main symptoms linking it to Treponema pallidum are rhinitis, periorificial fissures, and dental malformations. Note that hearing loss, seizures, petechial rash, and intracranial calcifications can also be seen in CMV.

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

niboonsh asks (step2ck_form7):
so you just open a b__ 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
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. +
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!
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
azibird asks (step2ck_form8):
What is that black sliver on here retina? help answer!
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!
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: +
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!
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!
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!
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!
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. +
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!
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!
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: “However, 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.” +
drdoom  Yes, they say, "Mitochondrial diseases are strictly inherited through the mother" but this is not a mitochondrial disease — this is a "non-mitochondrial–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). +
shelbinator94 asks (nbme18):
Why couldn't this be branching enzyme impairment? They both cause cardiac symptoms (according to Amboss at least) help answer!
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. +
kms123 asks (nbme22):
How would we rule out antithrombin deficiency? help answer!
sd22  PT, PRT, and TT normal in antithrombin deficiency. FA ‘20 pg. 428 +
sd22  PTT* lol autocorrect clearly hasn’t been studying +
calvin_and_hobbes asks (nbme21):
This Q stem was confusing to me because I thought pain>>itch for shingles. Any thoughts? help answer!
calvin_and_hobbes asks (nbme21):
"In addition to slightly decreased platelet count..." — why are plts slightly low in EBV infection/mono? help answer!
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!
sd22 asks (nbme21):
Can anyone help explain what the other options would entail? help answer!
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!
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!
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 — which it most certainly is not... help answer!

Tag directory (see more)
Yersinia_pestis weird vitamins visualfielddefect visual_field_defect vascular uniparental_disomy tuberculosis TSH transfusion_reactions transfusion toxoplasmosis toxoplasma_gondii Toxicity Tanner syphilis survival_curves surgery stroke skin SIADH shock schizotypal scabies Saline rotator_cuff rituximab ribosomal restriction_enzymes respiratory_alkalosis Respiratory respiratory reproductive Repro repro Renal renal RAPD RAAS pulmonary

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