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Recent comments (see more)

... 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.

... 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.

... 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?

... 305charlie94 made a comment (step2ck_form7)
 +0  submitted by 305charlie94(4)

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

... azibird made a comment (step2ck_free120)
 +0  submitted by azibird(256)

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
... azibird made a comment (step2ck_free120)
 +0  submitted by azibird(256)

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 ≥2 or aortic root dissection) and ectopia lentis.

  • Aortic criterion (aortic diameter Z ≥2 or aortic root dissection) and a causal FBN1 mutation.

  • Aortic criterion (aortic diameter Z ≥2 or aortic root dissection) and a systemic score ≥7.

  • 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

... azibird made a comment (step2ck_free120)
 +0  submitted by azibird(256)

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.

... azibird made a comment (step2ck_free120)
 +0  submitted by azibird(256)

Still confused about this one. I guess it depends how you read that last line:

"Which of the following potential flaws is most likely to invalidate this study?"

If you read it as which flaw is most likely to be present, then I guess selection bias is most likely.

If you read it as which flaw, if present, is most likely to invalidate the study, then that type I error would be 100% likely to sink the results, guaranteed. Guess they meant the first one... Because yes p=0.01 so it's not likely they had a type 1 error.

Beef with this q.

... azibird made a comment (step2ck_free120)
 +0  submitted by azibird(256)

Step Prep has the answer on this one: diaphragmatic hernia.

https://step-prep.org/nbme-step-2-free-120/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473789/

... moxomonkey made a comment (step2ck_free120)
 +0  submitted by moxomonkey(20)

this question is funny, considering that post-exposure antibiotic prophylaxis is indicated "regardless of vaccination status", I guess this would be a correct option if the "study partner bad fever" were a confirmed case

... azibird made a comment (step2ck_form8)
 +0  submitted by azibird(256)

"Carotid pulses are decreased. A systolic bruit is heard over the abdomen at midline. The left femoral pulse is absent and the right femoral pulse is decreased. A left femoral bruit is heard." ^What in the hell is going on here? I'm freaking out about her absent femoral pulse meanwhile they just want to ask about ACE inhibitors...

And on that subject, how do ACE inhibitors not decrease intravascular volume? "This class of agents effectively inhibits the conversion of angiotensin I to the active vasoconstrictor angiotensin II, a hormone that also promotes, via aldosterone stimulation, increased sodium and water retention. The ACE inhibitors, therefore, are capable of lowering blood pressure primarily by promoting vasodilatation and reducing intravascular fluid volume." https://pubmed.ncbi.nlm.nih.gov/2188439/

"They work by causing relaxation of blood vessels as well as a decrease in blood volume" https://en.wikipedia.org/wiki/ACE_inhibitor

Obviously angiotensin is the safest answer but I am beyond baffled about how "decreased intravascular volume" is incorrect. Anyone?

... azibird made a comment (step2ck_form8)
 +0  submitted by azibird(256)

Was anyone else torn because you thought the colonic hydrogen travelled backwards up the entire gut to be exhaled via mouth fart? So that the small-bowel must have decreased pH?

Maybe just me...

Well apparently that's not how the test works. Or the human body. "The hydrogen produced by the bacteria is absorbed through the wall of the small or large intestine or both. The hydrogen-containing blood travels to the lungs where the hydrogen is released and exhaled in the breath where it can be measured." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155069/

... azibird made a comment (step2ck_form8)
 +0  submitted by azibird(256)

What does "central hilar opacification bilaterally" on x-ray represent?

... azibird made a comment (step2ck_form8)
 +0  submitted by azibird(256)

What is that black sliver on here retina?

... notyasupreme made a comment (step2ck_free120)
 +0  submitted by notyasupreme(44)

This is hilarious, did anyone else think it could be viral pericarditis, which in another question required prompt evaluation with an echo. I initially thought EKG, then echo, then NSAIDs as the order. Apparently, we just skip the diagnosis and go straight to NSAIDs in these patients now. Unbelievable.

... notyasupreme made a comment (step2ck_free120)
 +0  submitted by notyasupreme(44)

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?

... notyasupreme made a comment (step2ck_free120)
 +0  submitted by notyasupreme(44)

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?

notyasupreme  lol jk, just looked it up and apparently I know shit about the female anatomy! +
... azibird made a comment (step2ck_form8)
 +0  submitted by azibird(256)

Yes, this is Gilbert syndrome. Here's my beef with this question: UDP-glucuronosyltransferase is a liver enzyme. Conjugation takes place in the liver, not the serum.

Here's how you can diagnose Gilbert syndrome according to UTD: "A reduction in hepatic bilirubin-UGT activity, which is approximately 30 percent of normal" https://www.uptodate.com/contents/gilbert-syndrome-and-unconjugated-hyperbilirubinemia-due-to-bilirubin-overproduction

Here's a picture from UTD of the enzyme sitting HAPPILY WITHIN THE HEPATOCYTE: https://www.uptodate.com/contents/image?imageKey=GAST%2F52393&topicKey=GAST%2F3578&search=gilbert%20syndrome&rank=1~53&source=see_link

So how is this a "deficiency of serum glucuronosyltransferase"?

Meanwhile, according to FA2020 p394, Gilbert syndrome also causes "impaired bilirubin uptake." Aka "Impaired hepatic storage of serum bilirubin"

My rage knows no bounds.

azibird  Maybe FA is wrong and Gilbert syndrome does not involve impaired bilirubin uptake. "Disorders of bilirubin uptake and intrahepatic storage are only infrequently described in the literature (19), and the clinical significance of these disorders remains to be confirmed." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821713/ +
... drdoom made a comment (step2ck_form6)
 +0  submitted by drdoom(1174)

via @azbird

The only reliable way to differentiate between PCP and cocaine on these exams:

  • nystagmus (not present here)
  • catatonia/sedation

Weird facts about PCP intoxication:

  • May wax and wane between extreme agitation and sedation
  • Blank stare and flat affect
  • Rigidity
  • May not have hypertension or tachycardia
Some notes
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Help your fellow humans! (see more)

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!
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! +
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!
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!
calvin_and_hobbes asks (nbme20):
Why is the T normal in this patient? I would have predicted underlying infection — ie, fever — before even "early" septic shock. I selected septic shock purely for the intractable low SVR despite fluids but want to understand more about the absence of fever... Thanks! help answer!
drdoom  Elderly (and immunocompromised, generally) do not mount robust fever responses to bacteria and other microorganisms; in elderly, this probably has to do with “declines” of the innate immune system (your macrophages, dendritic cells, monocytes, &c., just don't function as well as they used to). In other words, if you (1) wiped out someone's immune system and then (2) injected bacteria into their bloodstream, you wouldn't observe any fever either. The presence of a “typical” (normal) fever in an elderly or immunocompromised patient can be a super concerning sign: they might have a raging infection on the inside. +
drdoom  ^from the article: “Absent or blunted fever response in the elderly. There is ample evidence that a blunted fever response to a serious bacterial, viral, or fungal infection suggests a poorer prognosis than does a robust fever response [13]. In addition, there is a substantial body of data, mostly from animal models, that fever—through its effects on immune function—may be an important host defense mechanism [14]. Roughly 20%–30% of elderly persons with serious bacterial or viral infections will present with a blunted or entirely absent fever response [2,3,15].” +

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