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Recent comments (see more)

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

Proteoglycans are extracellular matrix molecules that have a central protein core or backbone structure with covalently attached glycosaminoglycans. Proteoglycans, cartilage, and water are the main constituents of human cartilage.

In osteoarthritis, the breakdown of articular cartilage caused by chronic repetitive use and inflammation results in the decreased synthesis of proteoglycans by the chondrocytes. The loss of this component of cartilage is reflected at the macroscopic level by cartilage degradation and bone-bone contact osteoarthritic degenerative joint disease. Decreased proteoglycan secretion is expected on arthrocentesis, synovial fluid may show few leukocytes, but otherwise will be without evidence of acute inflammation or infection.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

The patient's enzyme needs more substrate to achieve the same effect as the normal enzyme.

The Km is the substrate concentration at which the enzyme achieves 50% maximal concentration.

More substrate is needed in the patient to reach the 50% maximal velocity than is needed in the normal patient so it must be that there is a mutation in the enzyme that increases Km.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

The Bartholin glands, or the greater vestibular glands, are a pair of glands on either side of the posterior vaginal orifice that secretes a lubricating fluid through two small ducts into the vestibule. When one of these glands becomes blocked, a cyst may occur.

The infection is generally polymicrobial, but anaerobes such as Bacteriodes fragilis, Clostridium perfringens, Peptostreptococcus, and Fusobacterium are key pathogens.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

Cryptosporidiosis presents with severe watery diarrhea in immunocompromised patients; it is diagnosed by microscopy of the stool showing red-pink oocysts on the acid-fast stain.

The patient with HIV infection and 10 days of watery diarrhea and abdominal cramps has been infected with Cryptosporidium, an intracellular parasite that causes a severe GI illness in an immunocompromised patient.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

See this question in NBME 27

... โˆ—shak360 made a comment (nbme18)
 +0  submitted by shak360(14)

See this question from NBME 25.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

The peripheral blood smear shows a schizont form of the parasite, although any malarial stage (gametocyte, schizont, trophozoite, or ring) can be seen on a smear and is diagnostic of infection. CHLOROQUINE effectively eradicates circulating forms if there is no resistance but has NO EFFECT ON THE HYPNOZOITE EXOERYTHROCYTIC forms of P Vivax and P ovale. Addition of PRIMAQUINE effectively treats these liver forms and prevents relapsing infection.

shak360  See this question in NBME 18. +
... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

Pulsus paradoxus refers to the abnormal variation of systolic blood pressure between inspiration and expiration (greater than 100 mm Hg). This presents as jugular venous distension sometimes and is often seen in conditions that restrict expansion of the heart, such as cardiac tamponade.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

Maternal glucose crosses the placenta while insulin does not (remember that HPL services the baby by shunting the mother's glucose to the baby by conferring insulin resistance to the mom). In response to hyperglycemia in the mom, the fetal pancreatic islet cells increase the production of insulin. If the source of glucose is quickly removed, such as after delivery, the infant has a high risk of developing hypoglycemia, which can lead to convulsions and death.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

See this question in NBME 27 asking about what a 5-alpha-reductase deficiency would look like.

The SRY gene is located on the Y chromosome and is responsible for producing the testis-determining factors, which results in male gonadal differentiation. In testis development, hormones secreted by Sertoli cells (MIF Macrophage Inhibiting Factor) and Leydig cells (testosterone and DHT) promote the development of male internal and external genitalia and suppress the development of female structures. SRY gene translocation can occur during recombination in which the SRY gene on the Y chromosome becomes part of the X chromosome, leading to an XX embryo developing male characteristics.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

An intensely eosinophilic globule in the liver is a Councilman body that is indicative of an underlying hepatic disease, viral Hepatitis (usually Hepatitis A), or Yellow fever. This represents a hepatocyte undergoing APOPTOSIS.

Recall that Yello Fever is caused by flavivirus/arbovirus transmitted by the Aedes mosquito causing black vomitus, jaundiced eyes, and the Councilman bodies (intensely eosinophilic apoptotic globules in the liver).

To also answer this question, one had to know that apoptosis caused by activation of the mitochondrial intrinsic pathway is triggered by cellular damage such as radiation, oxidative damage, ischemia, or toxin exposure and leads to release of cytochrome C from mitochondria. Cytochrome C in turn leads to the activation of caspase enzymes. Viral hepatitis primarily leads to apoptosis through the extrinsic rather than the intrinsic pathway.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

Morbilliform skin rash is HIGH-YIELD for a drug reaction, the most severe being Drug reaction with eosinophilia and system symptoms (DRESS). It is associated with the use of allopurinol, anticonvulsants, antibiotics like TMP-SMX, and sulfa drugs. This is a potentially fatal delayed hypersensitivity reaction.

It is also related to a severe rash Stevens-Johnson syndrome or Toxic epidermal necrolysis which is also caused by anti-epileptic drugs (especially lamotrigine), allopurinol, sulfa drugs, and penicillin.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

See here in FA 2020 for a list of extrahepatic manifestations in HepC and HepB. Importantly HepC can induce essential mixed cryoglobulinemia. It presents with palpable purpura in association with arthralgia and peripheral neuropathies caused by immune-complex type III hypersensitivity mediated vasculitis.

The triad is weakness, arthralgia, and palpable purpura. Keep in mind peripheral neuropathy, hematuria, and hepatosplenomegaly and most importantly, Hepatitis C.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

This image is clinically extremely similar to the image for Fibromuscular dysplasia in FA 2020 on pp300.

90% of hypertension is 1ยฐ (essential) and related toยCO orยTPR. The remaining 10% is mostly 2ยฐ to renal/renovascular diseases such as fibromuscular dysplasia (characteristic โ€œstring of beadsโ€ appearance of the renal artery, usually seen in women of child-bearing age) and atherosclerotic renal artery stenosis or to 1ยฐ hyperaldosteronism.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

This question should be easy but if you didn't go through all the options, or if you're like me and tunnel-vision on seemingly right options, then you can miss "gimme" points on a question like this. We know that DNA plasmids in bacterial are circular and don't really have a terminal end or beginning but rather have DNA synthesis sites where DNA polymerases can attach to begin replication.

... โˆ—shak360 made a comment (nbme25)
 +1  submitted by shak360(14)

See this question in block 1 about GVHD.

See also these tables on transplant rejection pathologies from FA 2020.

Chronic allograft rejection of a transplanted organ occurs over months to years (the question was in the timeline of weeks). It is secondary to a CD4+ T lymphocyte response against donor peptides such as MHC. T cell activation leads to cytokine production and humoral and cellular hypersensitivity reactions (type II and IV). When you think Chronic rejection, you should be thinking VESSELS because this often leads to vascular arteriosclerosis and smooth muscle proliferation with parenchymal fibrosis and atrophy.

With acute rejection, you should be thinking of INFILTRATION, that is T-lymphocytes in the vasculature of the tubules and arterial walls leading to endothelitis. The primary histologic changes include interstitial infiltration with lymphocytic cells, in addition to the obliteration of the tubular basement membranes (as in this question with a kidney transplant).

csalib2  awesome. thank you. +1
... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

See pages from FA 2020 and other resources.

The moment we see HepB seropositivity, cutaneous eruptions, and different stages of TRANSMURAL INFLAMMATION WITH FIBRINOID NECROSIS, we should be thinking Polyarteritis nodosa (PAN). It is treated with corticosteroids and cyclophosphamide.

This patient had segmental transmural necrotizing arteritis making PAN the best answer.

Recall that for Giant cell arteritis or temporal arteritis, one would see a headache, temporal tenderness, jaw claudication, and fever.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

See this question in NBME 27.

... โˆ—shak360 made a comment (nbme25)
 +0  submitted by shak360(14)

Antiphospholipid syndrome is diagnosed based on recurrent venous thromboses (hypercoagulability), frequent miscarriages, thrombocytopenia, and a false-positive rapid plasma reagin test. It is associated with clinical criteria including a history of thrombosis (arterial or venous) or spontaneous abortion along with laboratory findings of lupus anticoagulant, anticardiolipin, anti-ฮฒ2 glycoprotein I antibodies.

Help your fellow humans! (see more)

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: +
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—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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