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Recent comments (see more)

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on acute cystitis caused by Chlamydiae.

Chlamydial cell wall lacks classic peptidoglycan (due to reduced muramic acid), rendering β-lactam antibiotics ineffective.

Labs will demonstrate a (positive) leukocyte esterase. (positive) nitrites (indicates presence of Enterobacteriaceae). Sterile pyuria (pyuria with negative urine cultures) could suggest urethritis by Neisseria gonorrhoeae or Chlamydia trachomatis.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

(FA 2021, Pg. 527)

This question is testing knowledge on the clinical reflexes, specifically the Achilles reflex.

One of the key things to pay attention to in the stem is that the patient has a left Achilles tendon reflex that is absent. The Achilles tendon reflex involves S1, S2 ("buckle my shoe").

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on sarcoidosis.

It is not referenced in First Aid, but this is neurosarcoidosis. You can find a small amount of info on it in AMBOSS:

  • Nervous system (neurosarcoidosis)
  • Cranial nerve palsy (facial nerve palsy is the most common)
  • Diabetes insipidus
  • Meningitis
  • Hypopituitarism
  • Peripheral neuropathy
  • Myopathy

Sarcoidosis can present in many other areas besides the lungs which is the typical question stem we are all used to seeing. One thing to note about it, is that where ever it implants it will cause symptoms in that region (e.g., CSF -> meningitis).

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

(FA 2021, Pg. 416)

This question is testing your knowledge on neutrophils.

In the stem patient has a right hand that is tender, erythematous, and edematous with an intact wooden splinter embedded in the soft tissue. Then the description of "white exudate" is given. This white exudate is pus and is generated by neutrophils. Additionally, neutrophils are the first responders to most insults to the skin.

Another very important thing to know is the neutrophil chemotactic agents: C5a, IL-8, LTB4, 5-HETE (leukotriene precursor), kallikrein, platelet-activating factor, N-formylmethionine (bacterial proteins). Make sure you know this, the test makers love to test this!

... surgerydoctorca_sgu made a comment (nbme19)
 +1  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on gout.

In the question stem the examiners are showing you a picture of a hand with extensive tophus formations (often these appear on the external ear, olecranon bursa, or Achilles tendon).

Strongest risk factor for acquiring gout is hyperuricemia, which can be caused by:

  • Underexcretion of uric acid (90% of patients)—largely idiopathic, potentiated by renal failure; can be exacerbated by certain medications (eg, thiazide diuretics).
  • Overproduction of uric acid (10% of patients)—Lesch-Nyhan syndrome, PRPP excess, 􏰂 cell turnover (eg, tumor lysis syndrome), von Gierke disease.

Treatment:

  • Acute: NSAIDs (eg, indomethacin), glucocorticoids, colchicine.
  • Chronic (preventive): xanthine oxidase inhibitors (eg, allopurinol, febuxostat).
surgerydoctorca_sgu  (FA 2021, Pg. 479) For above referenced information. +1
... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on microtubule inhibitors (all are M-phase specific).

Specifically, this question is asking you about Vinblastine. One important adverse effect to know about vinblastine (blasts the marrow): myelosuppression. Therefore, you would see a significant decrease in the numbers of neutrophils.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on T- and B-cell activation.

My specifically it is asking about B-cell activation and class switching. The following steps occur during this process, and step 4 is what you need to know in order to answer this question correctly:

1) Th-cell activation as above. 2) B-cell receptor–mediated endocytosis. 3) Exogenous antigen is presented on MHC II and recognized by TCR on Th cell. 4) CD40 receptor on B cell binds CD40 ligand (CD40L) on Th cell. 5) Th cells secrete cytokines that determine Ig class switching of B cells. 6) B cells are activated and produce IgM. They undergo class switching and affinity maturation.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on ovulation.

During ovulation there will be increased estrogen, increased GnRH receptors on the anterior pituitary. Estrogen will continue to rise and then eventually this will stimulate LH surge --> ovulation (rupture of follicle). Increased temperature will also occur and this is (progesterone induced).

Also, keep in mind that there are two phases of the ovarian cycle:

  • Follicular phase
  • Luteal phase
... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This is question is testing your knowledge on the pudendal nerve (S2-S4).

Is this patient the the motor component - external urethral and anal spincters. Injury such as stretch during child birth, prolonged cycling, and horseback riding could cause this. Patients will present with decreased sensation in the perineum and genital area; can cause fecal and/or urinary incontinence.

It is also important to know that the pudendal nerve can be blocked with local anesthetic during childbirth using ischial spine as a landmark for injection.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

(FA 2021, Pg. 675)

This question is testing your knowledge on cryptorchidism.

This condition results in descent failure of one or both testes; impaired spermatogenesis (since sperm develop best at temperatures < 37°C); can have normal testosterone levels (Leydig cells are mostly unaffected by temperature); associated with increased risk of germ cell tumors. Prematurity increases risk of cryptorchidism. Decreased inhibin B, increased FSH, increased LH; testosterone decreased in bilateral cryptorchidism, normal in unilateral. Most cases resolve spontaneously; otherwise, orchiopexy performed before 2 years of age.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on Candida albicans. When CD4+ is lower than 100/mm3 then the patient is at risk for a normal flora candida skin infection.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge of being aware that when a patient is experiencing symptoms/pain that it may be due to a depression or a major depressive episode. This patient is experiencing symptoms but there is no apparent medical evidence for those symptoms.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on Lyme disease. The stem describes the patient as having a rash and flu-like illness 2 months ago, and now he is presenting with pain in multiple joints and fatigue. The stem is describing Stage 1 and 2 of Lyme disease.

  • Stage 1—early localized: erythema migrans (typical “bulls-eye” configuration B is pathognomonic but not always present), flu-like symptoms.

  • Stage 2—early disseminated: secondary lesions, carditis, AV block, facial nerve (Bell) palsy, migratory myalgias/transient arthritis.

There us also a Stage 3 which was not described in the stem:

Stage 3—late disseminated: encephalopathy, chronic arthritis, peripheral neuropathy.

Also, when it comes to treatment know that doxycycline is 1st line, and if you have a pregnant patient then you would prescribe amoxicillin or to patients who are under 8 years old. Additionally, IV ceftriaxone is required.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on the respiratory/conducting zone. The bronchioles are comprised of the (bronchioles, terminal bronchioles, and respiratory bronchioles) which all contain smooth muscle, the respiratory bronchioles have the most "sparse" amount of smooth muscle though. Together, these comprise the largest amount of smooth muscle in the respiratory tract and therefore would be most susceptible to flow limitation due to smooth muscle contraction during an asthma attack.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on tetracyclines. The patient in the stem is taking tetracyclines and had spent the day at the beach (a big no no) while on these meds. One adverse effect with tetracyclines is that they cause photosensitivity.

Make sure you know all of the adverse effects of tetracyclines and many of them have very bad outcomes.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is testing you knowledge on skeletal muscle adaptations (specifically atrophy). The patient is described to have cachexia and significant muscle wasting, these are manifestations of atrophy. Atrophy occurs via:

  • Decreased myofibrils (removal via ubiquitin-proteosome system)
  • Decreased myonuclei (selective apoptosis)

It is important to know the molecular mechanisms of atrophy above as these are what the test makers love to test your cellular and molecular knowledge on many concepts.

... surgerydoctorca_sgu made a comment (nbme19)
 +1  submitted by surgerydoctorca_sgu(6)

This question is testing your knowledge on Severe Combined Immunodeficiency (SCID). When considering a SCID diagnosis consider these aspects:

Defect:

  • IL-2R gamma chain (most common, and x-linked recessive).
  • Adenosine deaminase deficiency (Autosomal recessive)..
  • RAG mutation --> VDJ recombination defect.

Presentation:

  • Patients will present with features such as failure to thrive, chronic diarrhea, and thrush.
  • Patients will present with recurrent viral, bacterial, fungal, and protozoal infections.

Findings:

  • Decreased T-cell receptor excision circles (TRECs)
  • Part of newborn screening for SCID
  • Absence of a thymic shadow (CXR), germinal centers (on lymph node biopsy), and T cells (flow cytometry)
... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

I believe this question is just testing your knowledge on type I pneumocytes and is you know that these are what comprise a majority of the alveolar surface area.

To be more specific, type I pneumocytes are of squamous cell origin and they cover 97% of alveolar surfaces. It makes sense that they would be made of thin "squamous" tissue as this is what makes them optimal for gas exchange.

... surgerydoctorca_sgu made a comment (nbme19)
 +0  submitted by surgerydoctorca_sgu(6)

This question is asking you about one very peculiar fact about Hepatitis E, and that is that is can cause fulminant hepatitis in expectant (pregnant) patients. This leads to a high mortality in pregnant patients.

Some other important things to know about Hepatitis E is that it is enteric and epidemic (e.g. in parts of Asia, Africa, Middle East), and that there is no carrier state.

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 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
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: https://healthcare.utah.edu/huntsmancancerinstitute/gynecologic-cancer/images/vulvar-anatomy-image.jpg +
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!

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