This question tripped me up. I chose 'A' because the question said her living will (consistent with the husband's wishes) does not want mechanical ventilation, but it did NOT say anything about DNR...But come to think of it, what is the point of doing CPR if she cannot maintain spontaneous breathing since she seems to be in a vegetative state? That means if you do CPR and actually want to save her life, you must intubate, which goes against her will. Hence, extubate and do not resuscitate...

I think the question stem may have a mistake because according to FA (2021 p. 528), Parinaud causes light-near dissociation wherein the light pupillary reflex is impaired while accommodation is intact. The question said accommodation is impaired...Anyway, pineal gland tumor fits the best.

I got this question right from watching that House episode of the patient with phantom limb pain lol

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.

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)-

-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)

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 2000–4000 lipase units per 120 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

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=(

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.

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/)

"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

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

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.

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.

BMI ≥40 --> Gastric Bypass candidate. BMI ≥35 + 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!

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.

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.