welcome redditors!to snoo-finity ... and beyond!

“Arrggg, here be fellow mateys seeking an explanation!”




... neovanilla is asking for clarification on nbme20/block4/q#41 (A 56-year-old man with a 20-year history of chronic...)
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submitted by neovanilla(0)

The crux of the question is asking, if the patient feels decreased pain (which is driven by opioid molecules; that's why opioids are administered as painkillers), then how do you stop the inhibition? An opioid antagonist (naloxone is the only one that is an antagonist)

neovanilla  wrong answers: b-endorphin - an endorphin and ACTH hormone (similar to ACTH, POMC) that can bind to the µ-opioid receptor Enkephalin - a neurotransmitter involved in the indirect basal ganglia pathway (along with GABA); it can also bind to delta-opioid receptors Morphine - an opioid agonist (used for pain relief) Oxycodone - Another opioid agonist (~same potency as morphine)
... dartosfascia is asking for clarification on nbme24/block1/q#42 (A 68-year-old woman with acute myelogenous leukemia...)
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submitted by dartosfascia(0)

Why would you give GMCSF to someone with AML?? Isn't the whole goal of treatment to knock out the granulocytes? I feel like giving someone GMCSF after they were JUST treated for AML is asking for a relapse but what the hell do I know.

drdoom  The problem in AML (acute myeloid leukemia) is that precursor cells “get stuck” on their way to becoming (mature) granulocytes. Giving GM–CSF “pushes” them toward a more differentiated state and, because they divide as they mature, the cells become vulnerable to drugs that disrupt cell division (replication): “Granulocyte–macrophage colony-stimulating factor (GM–CSF) can stimulate proliferation of leukemic blasts and sensitize these cells to the cytotoxic effects of S-phase–specific drugs.” https://www.nature.com/articles/2402368
... sammyj98 is asking for clarification on nbme20/block2/q#35 (A 36-year-old woman comes to the office because of a...)
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submitted by sammyj98(4)

maybe I overthought this one, but doesn't she have free air in the bottom left? Or is that the bottom of the pleural space...

ibestalkinyo  That's probably the most inferior portion of the right lung
... pg32 is asking for clarification on nbme20/block4/q#48 (A 24-year-old man comes to the emergency department...)
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submitted by pg32(5)

Can anyone explain why the lipase concentration is so high if there is an issue with LPL in hyperchylomicronemia?

garima  due to pancreatitis
neovanilla  ELI5?
... jinzo is asking for clarification on nbme20/block3/q#19 (A 23-year-old man comes to the physician because of...)
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submitted by jinzo(5)

A - nucleus ( with nucleolus inside ) B - mitochondria C - RER ( you can see attached ribosomes ) D - ?? may be lysosomes E - glycogen granules

... rainlad is asking for clarification on nbme21/block3/q#12 (A 55-year-old man with hypertension comes to the...)
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submitted by rainlad(1)

How do we explain the bruit in this case? Also why isn't it left artery aneurysm? That seems like it would better explain the bruit

gdupgrant  The bruit is basically just turbulent flow, which is most commonly caused by artery narrowing. I was just reading https://emedicine.medscape.com/article/463015-clinical on renal artery aneurysm and it looks like most of the hypertension is actually related to a pre aneurysm stenosis, so i think stenosis is the "better" answer, esp. since the pt has like every risk factor for stenosis. To be honest I had not ever really thought about RAA for this case because bruit over RA has been drilled into my head as renal artery stenosis, but i apprecaite seeing how this is a super reasonable answer - just the stenosis is "more likely"
... rainlad is asking for clarification on nbme21/block3/q#38 (A 28-year-old man develops a temperature of 39.9°C...)
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submitted by rainlad(1)

would we be worried about using G-CSF given that he has acute leukemia? would it stimulate growth of his cancer cells?

suckitnbme  I think we're assuming that we eradicated the leukemia with the chemo. However at the same time a lot of normal stem cells were also killed off so we give GCSF to help recovery especially since they have an infection.
... drbravojose is asking for clarification on nbme22/block2/q#23 (A 32-year-old woman comes to the physician because...)
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submitted by drbravojose(1)

FA 2019 p156 Does anyone know how to differentiate the picture labeled Trypanosoma brucei and cruzi?

footballa  This question is likely not important for two reason: They're both Trypansomastigotes, so of course they look almost the same. You can differentiate these two species clinically as they have very little clinical similarity in patient presentation. For these reasons there's little to no reason you would be expected to differentiate these two species by histology alone
... readit is asking for clarification on nbme21/block1/q#25 (A 28-year-old man is brought to the emergency...)
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submitted by readit(3)

Why is is not pseudo aneurysm?

"Aortic pseudoaneurysms typically occur as a result of trauma +/- intervention, a considered subset of traumatic aortic injury in the majority of cases. They can be acute or chronic."

https://radiopaedia.org/articles/aortic-pseudoaneurysm?lang=us

readit  *same goes for saccular aneurysm, which also is usually 2/2 trauma
samsam3711  In the question stem there is no indication of trauma so it would be hard to just assume that
almondbreeze  see my comment above for marfan syndrome. might help
... ilovemypuppies2295 is asking for clarification on nbme20/block2/q#29 (A 25-year-old woman has a flu-like illness (fever,...)
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submitted by ilovemypuppies2295(1)

What makes this coxsackie virus over Adenovirus? Both cause myocarditis which would be seen on autopsy? Is it just more common to get coxsackie?

drdoom  the general consensus appears to be that Coxsackie is more common than Adenovirus, but i haven’t come across any papers or textbooks that would agree (they only mention “Coxsackie” and “Adenovirus” as associations with myocarditis)
bharatpillai  there specifically is a question on uworld in which a young woman gets viral myocarditis with sore throat and the answer to that is adenovirus. i think thats why many people (including me) got it wrong :(
... qfever is asking for clarification on nbme20/block3/q#19 (A 23-year-old man comes to the physician because of...)
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submitted by qfever(5)

Does anyone know what are A, C, D? For C not sure if it's pointing to the ribosomes on RER.

(I'm assuming E is glycogen granules based on a comment below!)

... lilyo is asking for clarification on nbme18/block4/q#29 (65 yo man, cancer of the cecum)
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submitted by lilyo(5)

Anyone have an idea on how to approach this question?

gdupgrant  So the thing i think they tried to catch people on was that the SMV Joins with the splenic to become the portal vein and the IMV feeds into the splenic vein. And they want you to know that cecum is midgut, so drained by the SMV. so my approach was automatically eliminate any answer that included IMV or Splenic vein and that left me with only Ileocolic → superior mesenteric → portal → right hepatic branch of the portal
... poisonivy is asking for clarification on nbme24/block4/q#12 (A 25-year-old woman takes an overdose of...)
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submitted by poisonivy(10)

can we consider the overdose as a suicidal attempt? if so... wouldn't she be considered as without decision-making capacity?

em_goldman  People who are suicidal still have decision-making capacity; it's not equivalent to advanced dementia or other situations where decision making is impaired. Laws vary by state; I know in my state that the maximum time for holding someone against their will is 48 hours unless a court has deemed them incompetent and designated another person as their legal decision maker, including people who are actively suicidal. My understanding of the law as a layperson is that her living will was signed along with people bearing witness to the fact that she was the one who signed it, and it was what she wanted. Ethics aside, it would be almost impossible to prove that she legally initiated a DNR in a state of suicidality that was intense enough to interfere with her decision-making capacity in that moment.
... mahitha is asking for clarification on nbme19/block2/q#5 (38 yo woman, 6 months depressed mood, joint pain, weakness, memory problems + erythema migrans)
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submitted by mahitha(0)

Can anyone PLZZ explain how lymes disesa has memory problems and depressed mood?

drdoom  Chronic inflammation, and the persistent elaboration of cytokines that go along with it, can cause all sorts of unusual and nonspecific problems, including cognitive compromise. (Just imagine how you might feel if you had low-grade fever for, say, a decade.) Patients who have suffered significant cardio- or cerebrovascular “events” report depressed mood following the event. My guess is that the memory problems can be from chronic inflammation or as a result of spirochete vasculitis which, over time, results in a kind of vascular dementia (“multi-infarct”). You see spirochete vasculitis (of the thoracic aorta), as well as vascular dementia, in another famous spirochete, Treponema pallidum, the culprit behind Syphilis.
... mrglass is asking for clarification on nbme20/block3/q#35 (A 51-year-old man has the acute onset of fever and...)
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submitted by mrglass(3)

Why would this not be acute transplant rejection leading to ARDS? The creatinine is elevated, and I see any reason why it would be elevated beyond rejection

sammyj98  I selected the same. I think part of the question wanted us to recognize that the pt was not receiving CMV prophylaxis (hinted that they are getting TMP-SMX but no Gancyclovir) so they're at really high risk for CMV specifically. UpToDate: •Universal prophylaxis with valganciclovir or ganciclovir is typically given to patients at risk for cytomegalovirus (CMV) reactivation (eg, seropositive recipients and those with seropositive donors). The duration of therapy often depends on the type of organ transplanted, the risk status of the patient, and individual institutional practice. Some transplant centers prefer to use a pre-emptive approach (eg, routine CMV viral load monitoring within initiation of treatment when reactivation becomes evident) for specific patient populations. (See 'Cytomegalovirus' above.)
... brookly_ is asking for clarification on nbme23/block4/q#33 (A 16-year-old girl with bulimia nervosa is brought...)
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submitted by brookly_(0)

I thought bulimia give rise to metabolic alkalosis ...can someone elaborate ?

drdoom  Remember, bulimia itself does not mean “purging”; it means “ox-hunger”. It is purging (e.g., intentional vomiting, laxative abuse, diuretic abuse, excessive exercise, or extreme fasting) which creates metabolic disturbance. The type of disturbance depends on your preferred route of “exit”.
... divya is asking for clarification on nbme23/block2/q#3 (A prospective study is done to assess the relative...)
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submitted by divya(10)

okay but where in the question is it asking whether it's intention to treat or per protocol or as treated???

are we to assume its ITT if they don't mention anything or the part of the question that says "primary analysis" the giveway to ITT??

kpjk  I had the same doubt. I think if we were to consider "per protocol" then answer would have to be a mash of options A and B. There is no option that would be right for per protocol
... mikay92 is asking for clarification on nbme24/block1/q#42 (A 68-year-old woman with acute myelogenous leukemia...)
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submitted by mikay92(0)

Did anyone else find this question painfully poorly written? I spent so long just trying to figure out what the heck they were asking.

It's as if they don't want us to do well...

drdoom  I don’t think the NBME ever “intends” to write an ambiguous or poorly worded stem. What they want to do is write questions whose response choices are not “blatantly obvious” but which do have a single, “most correct” choice. That’s actually surprisingly difficult! If the correct choice were “obvious”, the test would not be doing a good job assessing anyone’s ability to make subtle judgment calls (an important skill, one might argue, in the morass that is the real world); this is also the reason they eschew “buzzwords”, generally. If a stem has two or more choices that are “equally correct”, the same lapse has occurred: they would be failing to assess the capacity to make subtle judgment calls.
drdoom  All that said, please see this perfect metaphorical description of all Step 1 questions: reddit.com/r/step1/comments/4jegfu/took_step_1_wanted_to_share
... blueberrymuffinbabey is asking for clarification on nbme23/block2/q#3 (A prospective study is done to assess the relative...)
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submitted by blueberrymuffinbabey(0)

I got this one wrong, but based on the ITT perspective others mentioned, maybe the "in their primary analysis" part of the question is a tip off. They'd start with including them in the original groups and then do additional analysis to try and tease out the impact? IDK

... diabetes is asking for clarification on nbme23/block3/q#49 (Genetic analyses of cells obtained on amniocentesis...)
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submitted by diabetes(4)

how is adrenal medulla has ACH nicotinic receptor which are ligand-gated Na/k channeles ? muscarinic ACH receptors are G-protein-coupled receptors.

gdupgrant  epinephrine acts on alpha or beta adrenergic receptors which are all G protien receptors. muscarinic receptors are also G coupled but Acetyl choline wasnt an answer choice. In the adrenal medulla the chromaffin cells are kinda like modified post ganglionic neurons and have nicotinic receptors.
... diabetes is asking for clarification on nbme23/block2/q#4 (An 18-year-old woman comes to the physician because...)
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submitted by diabetes(4)

can somebody explain how energy production by glycolysis increased, since aerobic glycolysis produce 32 net ATP,compare to 2 net ATP through anaerobic glycolysis ?

diabetes  i think the stem should be "energy production by an anaerobic glycolysis "
blueberrymuffinbabey  yeah that's the bit that tripped me up too. i get that there would be increased glycolysis in general to compensate for lack of TCA function but...the fact that it says "energy production by glycolysis" is kind of misleading/confusing.
... medninja is asking for clarification on nbme15/block2/q#29 (2-month-old male infarct, brought to ER, 2 days generalized tonic-clonic seizures)
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submitted by medninja(2)

This question sounded like botulism, anybody knows why is tetanus?

... hello36654 is asking for clarification on nbme23/block2/q#16 (Which of the following best explains impaired action...)
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submitted by hello36654(0)

so why is "cessation of fast axonal transport" wrong? Don't myelinated axons, by definition, have fast conductance? So demyelinated axons would have "cessation of fast axonal transport", which is the answer A, right?

diabetes  i think it slows down ,no cessation .
gdupgrant  Because fast axonal transport refers to the transport of vesicles containing neurotransmitters or some kind of cell product up and down microtubules in the axon. It isn't related to actual electrical signal transduction.
... hello36654 is asking for clarification on nbme23/block2/q#9 (A 60-year-old man has had easy fatigability, loss of...)
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submitted by hello36654(0)

I understand why it's lung now, but I picked thyroid gland because often times thyroid tumors press on the parathyroid sitting above, which causes the parathyroids to secrete more Ca...can someone comment if they've read this too?

paulkarr  I personally have not read that, but I wouldn't be surprised by that fact. I think with these NBME problems though, if you can get the answer within one "step" that should be your choice. Here you can just go Squamous Cell Carcinoma with a direct action on serum calcium levels (via PTHrP). Thyroid requires a few more steps, (assuming your statement is true) so in the eyes of NBME, it ain't gonna be the right choice. Always follow the "KISS" logic!
... yobo13 is asking for clarification on nbme24/block4/q#3 (A 23-year-old woman is brought to the emergency...)
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submitted by yobo13(1)

Can someone explain why it can't be Crohn's since that would also cause a non AGMA?

drpatinoire  If she has Crohn, she has already lost a lot of K, HCO3-, then the compensatory system wouldn't let her keep losing electrolytes in her urine.
... elf16 is asking for clarification on nbme22/block2/q#7 (A 66-year-old man comes to the physician because of...)
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submitted by elf16(2)

How is this different from the question on NBME 21 in which a 68-year old man also had psychogenic ED? But the answer was normal libido and nocturnal erections.

toxoplasmabartonella  In that case, his testosterone was normal and he had no signs of depression. The stem did say his wife passed away few months ago, so i personally chose low libido, but whatever.
... cat5280 is asking for clarification on nbme23/block1/q#37 (A 47-year-old woman with multiple sclerosis is...)
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submitted by cat5280(1)

Could someone please explain why you were able to eliminate the spinocerebellar tracts?

ergogenic22  Spinocerebellar is only responsible for Proprioception (unconscious). This patient also has reduced vibration sensation, which the dorsal column tracts are responsible for.
... krewfoo99 is asking for clarification on nbme24/block4/q#17 (A 63-year-old woman undergoes operative repair of a...)
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submitted by krewfoo99(17)

Why would decreased movement through the cerebreal aquaduct be wrong? With all the build of blood in the CSF tract without absorption, wouldnt movement also be decreased through the aqueduct?

ergogenic22  this would cause a non-communicating hydrocephalus with enlarging of the lateral and 3rd ventricles but normal 4th ventricle and subarachnoid space
... defalty98 is asking for clarification on nbme23/block1/q#16 (Physical analysis of the isolated genomic DNA from a...)
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submitted by defalty98(2)

Why are we complicating things? Change in the bases will destroy the palindromic sequence required for any restriction endonuclease to work. Methylation is the only option that makes sense.

arcanumm  This makes sense have reading what your comment. I overlooked this and just assumed the GATC was a mutation that allowed the restriction enzyme to work on the mutant only.
arcanumm  it makes even more sense when looking at "numerous small fragments." Methylation is truly the obvious answer here in retrospect.
bgiri  DNAse can also cause a change in base by breaking down dna at the GATC sequence?
... jigyasa is asking for clarification on nbme23/block1/q#13 (A researcher is asked to prospectively investigate...)
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submitted by jigyasa(0)

Why have you taken 180 as patient years? Isn't patient years calculated as no of patients multiplied by the number of years they suffer?

... titanesxvi is asking for clarification on nbme23/block4/q#28 (An 18-month-old girl is brought to the physician...)
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submitted by titanesxvi(15)

why not decrease CA activity in the proximal tubule? this also could lead to metabolic acidosis.

ergogenic22  carbonic anhydrase inhibitors can cause Type 2 RTA but it is not the cause here (cystinosis)
... krewfoo99 is asking for clarification on nbme23/block1/q#22 (An investigator is studying the adverse effects of a...)
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submitted by krewfoo99(17)

Why would perforins be the wrong answer? Wouldnt accumulation of toxic proteins cause the cell to undergo apoptosis ?

ergogenic22  Bortezomib does not directly activate perforin. It directly inhibits the proteasome which → enables CD8+ T cells to initiate apoptosis → via perforin release (in essence a downstream effect).
... krewfoo99 is asking for clarification on nbme23/block1/q#33 (A 25-year-old woman and her 25-year-old husband come...)
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submitted by krewfoo99(17)

In what situations will HbH be formed (3 alpha chain deletions)?

ergogenic22  one parent has 2 deletions on the same gene, the other parent has 1 deletion, and the offspring receives all three. In this question, both parents have alpha 1 deletion
ergogenic22  actually its possible that they both have 2 gene deletions, but regardless, a-thalassemia trait is more likely
ergogenic22  and someone above said Asian people are cis-2 deletion so the offspring will not receive two deletion from one parent
ergogenic22  ↑↑ I made a mistake by confusing trans and cis cis has deletions on the same chromosome and can pass two deletions to off spring, therefore a chance of allowing HbH
... krewfoo99 is asking for clarification on nbme23/block1/q#28 (An otherwise healthy 82-year-old man is brought to...)
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submitted by krewfoo99(17)

Can someone explain what the picture is supposed to show? Is it supposed to be segmented neutrophils?

titanesxvi  yes do to B12 deficiency
... krewfoo99 is asking for clarification on nbme23/block3/q#12 (A 39-year-old man comes to the physician for a...)
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submitted by krewfoo99(17)

Wouldnt the HCOM murmur be best heard in the aortic area?

krewfoo99  Correction: Shouldnt it be heard best in the left upper sternal border?
... krewfoo99 is asking for clarification on nbme23/block4/q#23 (A 74-year-old woman comes to the physician because...)
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submitted by krewfoo99(17)

Anyone know why heart sounds would be distant in COPD exacerbation?

yng  Patient is usually obese (blue bloater) --> diaphragm movement is limited --> can't take deep breaths, and in extreme cases, the chest size increased and causing distant heart sound.
... krewfoo99 is asking for clarification on nbme23/block4/q#23 (A 74-year-old woman comes to the physician because...)
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submitted by krewfoo99(17)

Anyone know why heart sounds would be distant in COPD exacerbation?

marat  Cause lungs are overextended
marat  overexpanded
... krewfoo99 is asking for clarification on nbme23/block4/q#41 (Electrophysiology of the heart is studied in an...)
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submitted by krewfoo99(17)

In boards and beyond, It is said that third degree heart block is due to block in the HIS Purkinjee system. So why would ablation of AV node cause this disease?

Wouldnt destruction of part of left ventricle be a better answer ?

... amirmullick3 is asking for clarification on nbme18/block3/q#41 (24 yo man, 3 days of progressive numbness of both feet)
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submitted by amirmullick3(23)

Is this Guillain barre though? I felt it was Acute inflammatory demyelinating polyradiculopathy, discussed on page 512 FA 2019.

There is no relation to C jejuni here nor does the patient have any other relations to infection such as eating something or etc.

wishmewell  Acute inflammatory demyelinating polyradiculopathy is a subtype of GBS.
... niboonsh is asking for clarification on free120/block2/q#24 (A 33-year-old man undergoes a radical thyroidectomy...)
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submitted by niboonsh(111)

external carotid branch supplies the superior parathyroid glands as well........?

yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch.
... divya is asking for clarification on nbme21/block4/q#26 (The immunosuppressive agent cyclosporin A (CsA) is a...)
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submitted by divya(10)

Can anyone discuss what's responsible for inhibiting the processes given as other options?

... divya is asking for clarification on nbme21/block4/q#12 (A 24-year-old man with a history of drug abuse has...)
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submitted by divya(10)

Why is there rhinorrhea in opioid withdrawal? And also, if stimulants like cocaine cause nasal vasoconstriction, shouldn't opioid withdrawal do the same?

... sunshinesweetheart is asking for clarification on nbme24/block3/q#3 (A 37-year-old woman with HIV infection is brought to...)
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submitted by sunshinesweetheart(15)

out of curiosity, why are AST and ALT high? is that saying the NRTI used was diadenosine which led to pancreatitis also?

krewfoo99  AST and ALT will not be elevated in pancreatitis, they will only be increased during liver damage. NRTI causes hepatoxicity (although FA 2018 states NNRTI causes hepatotoxicity, NRTI could also be an option considering the two classes are similar. The hepatoxicity will cause an increase in ALT and AST
... paloma is asking for clarification on nbme21/block1/q#28 (A 47-year-old man is brought to the emergency...)
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submitted by paloma(5)

What about pulmonary vascular resistance? It follows the systemic vascular resistance?

cooldudeboy1  crackles are heard bilaterally so there is pulm patho which leads to increased pulm vascular resistance, since systemic blood flows into the lungs. any block in the flow ahead (lungs) will increase resistance in flow behind ( systemic )
mrglass  This patient is hypoxic increased diffusion distance. This causes pulmonary vasoconstriction. Ordinarily this response is designed to shunt blood to parts of the lungs that are well ventilated, but the response is maladaptive in global hypoxia
... bronchophony is asking for clarification on nbme24/block3/q#50 (A group of physicians submits a report to a medical...)
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submitted by bronchophony(0)

Why not clinical trial? They could report a rare adverse effect in phase 4 clinical trial right?

sunshinesweetheart  there's no control group. it's just a case study. x3
sunshinesweetheart  plus clinical trials at that stage would have had tons and tons of participants (and, most importantly to rule out all the answers, control group)
... md_caffeiner is asking for clarification on nbme20/block4/q#12 (An investigator is conducting a randomized,...)
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submitted by md_caffeiner(4)

what to do with the NONADHERIANT BADDIES???

Intention to treat, "i had the intention to treat so i am gonna leave in this group no matter what"

as treated , "he is not treated as it is so im gonna change his group to control"

per protocol, "you are fired from all of it, protocols bitch"

... houseppary is asking for clarification on free120/block2/q#30 (An otherwise healthy 45-year-old man comes to the...)
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submitted by houseppary(2)

but what is wrong with "Spirochete invasion of gastric cells"? It seems like H pylori is sometimes described as curved and sometimes as a spirochete. And "gastric cells" is general enough that I don't see why it can be wrong. There is H pylori in the gastric cells.

em_goldman  H pylori is sometimes described as helical but more often as curved, but is (confusingly) not a spirochete. Spirochete refers to a particular family, Spirochaete, and are markedly corkscrew. The three important spirochete bugs for Step 1 are Leptospira, Borrelia spp., and Treponema pallidum; Brachyspira spp. get an honorable mention but idk they're high yield for Step 1. Anything other kind of bug is not going to be a spirochete. Additionally, H. pylori is not invasive, and instead resides on the surface of the gastric mucosa. The picture showed some bacteria inside the lumen of glands, not intracellulary.
em_goldman  *idk if they're high yield
em_goldman  *any other kind of bug gosh dang it, lol, definitely in dedicated rn
... amphotericin is asking for clarification on nbme21/block2/q#6 (A 38-year-old woman comes to the physician because...)
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submitted by amphotericin(0)

Why would you not check cortisol, if you're worried for MEN1? I assumed high calcium was implied based on the renal stones

... fallot4logy is asking for clarification on nbme24/block2/q#26 (A 35-year-old man is brought to the emergency...)
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submitted by fallot4logy(5)

in the other hand , urine potassium is high enough , so if seizures =>rhabdomyolysis => myoglobinuria => ATN => high potassium excretion , why not?

krewfoo99  True but hypokalemia would occur in the recovery phase. So weeks after the inciting phase.
... inmyblood is asking for clarification on nbme22/block2/q#46 (A 62-year-old man is being evaluated for rectal...)
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submitted by inmyblood(0)

What is the letter Y indicating in the picture? is it the large intestine?

humble_station  For this answer to make sense to me, Y should be the beginning of the large intestine like the terminal ileum/cecum leading up to the ascending colon
... sunny is asking for clarification on nbme18/block2/q#18 (Researcher testing new cancer drug)
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submitted by sunny(2)

why is this so //i know its basic but still...??

krewfoo99  I think its neutrophils because they mention myelosupression and rapidly dividing cells.
wishmewell  Ya, Neutrophils, basophils, macrophages, eosinophils are considered Myeloid cells. While the rest of the T cells are from the Lymphoid lineage, The Immunoglobulins come from B cells ( lymphoid lineage).
... ssc505684708 is asking for clarification on nbme20/block2/q#42 (A previously healthy 32-year-old woman is brought to...)
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submitted by ssc505684708(0)

What happened to this "previously healthy" young female? Why is she vomiting blood? Drinking too much alcohol?

hungrybox  Completely haram. Inshallah she will receive her due punishment
... amphotericin is asking for clarification on nbme22/block3/q#39 (A 52-year-old man with stable angina pectoris begins...)
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submitted by amphotericin(0)

I put constipation because I thought the medication being described might be CCB: can someone explain why nitrates over CCB?

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance.
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload.
... amphotericin is asking for clarification on nbme22/block3/q#16 (A 27-year-old woman comes to the physician because...)
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submitted by amphotericin(0)

how would you rule out C) dysfibrinogenemia? I first guessed APS but switched it because of the PT/PTT thing

suckitnbme  You should be able to rule it out by the normal Thrombin time. Abnormal fibrinogen would have increased PT/PTT but also increased Thrombin time because the entire pathway is compromised by the inability of fibrinogen to be cleaved to functioning fibrin.
... jean_young2019 is asking for clarification on nbme18/block1/q#30 (29 yo woman irregular menstrual periods)
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submitted by jean_young2019(3)

Could someone explain why this choice is the best answer? I struggled between A and D, and picked A finally, which is "ascertain educational level and provide publications".

donttrustmyanswers  It isn't A, because research shows that understanding of information (i.e. eating good and exercising) isn't enough to cause change. Why it is Provide F/U, over support group, IDK.
... hhsuperhigh is asking for clarification on nbme24/block4/q#24 (A 13-year-old girl who has a 6-year history of type...)
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submitted by hhsuperhigh(5)

The diet is prescribed, so no need to refer to dietician anymore. It is a case of the patient non-compliance of diet. But why can't advise the parents to stop bickering?

... niboonsh is asking for clarification on nbme24/block1/q#8 (A 24-year-old woman at 28 weeks' gestation is...)
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submitted by niboonsh(111)

is no one else concerned about the fact that theyre giving a beta 2 agonist to a woman whos 28 weeks pregnant.......?

yobo13  Beta 2 agonists relax the uterus so this would be okay, right?
med4fun  inhaled drugs do not have as much of systemic affect and B-agonists are used often in pregnancy for asthma control. SABAS are deemed safe but there are increased birth defects with long acting B-agonists.
... lilyo is asking for clarification on nbme22/block1/q#44 (A 52-year-old man with a history of alcoholic...)
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submitted by lilyo(5)

I had the same question regarding this. I know that external hemorrhoids rarely bleed and internal hemorrhoids present as painless bleeding so in my mind I knew I was being asked about internal hemorrhoids. However, superior rectal--> inferior mesenteric vein--> portal vein, can anyone tell me why the answer was superior rectal and not inferior mesenteric?

dubywow  Because the wording sucks. It's a confusing way to word the question. I too was confused what direct tributaries was referring to and chose Inferior mesenteric because I suck and also because this question sucks. Really its asking where are the hemorrhoids? They are on/from the superior rectals even though those veins feed to Inferior mesenteric.
drdoom  Defining tributary: https://i.imgur.com/2zDxPbW.png Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them).
... humble_station is asking for clarification on nbme20/block4/q#18 (A 35-year-old man comes to the physician because of...)
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submitted by humble_station(19)

The question is asking if you did an immunohistochemical labeling of the neoplasm what are you going to target with the use of antibodies. Basically you want the antibodies you have labeled binding to what?

Since this is ZES -- a gastrin secreting tumor -- you want antibodies to gastrin to see where exactly this tumor is coming from

... amphotericin is asking for clarification on nbme24/block2/q#2 (A 45-year-old man comes to the physician because of...)
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submitted by amphotericin(0)

How does OSA lead to peripheral edema and loud S2?

futuredoc  Hypoxia leads to pulmonary vasoconstriction and therefore pulmonary HTN. This can lead to the peripheral edema. Furthermore pulmonary HTN can present with a loud S2.
... happysingh is asking for clarification on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
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submitted by happysingh(15)

i kinda of feel "odd" asking this question : but the patient had an MI 6 months ago, so why would it be unlikely that he was told to "restrict salt, restrict fluids (water) " ??

Guess what i'm asking is : what makes choice E such an unlikely choice (JVD, bi-basilar crackles, peripheral edema) ?

& @meningitis : his bp is 135/82 mmHg ... why is that "HIGH" ??

... hhsuperhigh is asking for clarification on nbme20/block2/q#26 (A male newborn is found to have a decreased blood...)
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submitted by hhsuperhigh(5)

This is how my brain farted while I was doing this question.... I wanted to choose TBG deficiency, but I kept thinking that if TBG is deficient, that means there are less or no binding proteins in the blood. And how can the free T4 be normal? Shouldn't free T4 increase if there were less T4 binding protein? ...

adong  free T4 wouldn't increase because it would be sensed by the pituitary and TSH would drop until free T4 normalizes
... cathartic_medstu is asking for clarification on nbme23/block3/q#8 (A 62-year-old man with a blood pressure of 220/160...)
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submitted by cathartic_medstu(7)

Labetalol = "alpha"-"beta"-lol

From Sketchy

Andrew Yang for president. is it 50 characters yet?

... hello is asking for clarification on nbme23/block4/q#2 (A 60-year-old woman with type 2 diabetes mellitus...)
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submitted by hello(108)

Why are "rotator cuff tear" and "rotator cuff tendnitis" wrong? is it bc both of these would show impingement sign? is there a way to DDx one from the other?

... hello is asking for clarification on nbme23/block4/q#45 (A 32-year-old man has a diastolic blood pressure...)
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submitted by hello(108)

why is plasma oncotic pressure wrong?

rainlad  I think it's because we would expect to see some more proteinuria/albuminuria if the plasma oncotic pressure had increased to compensate
... hello is asking for clarification on nbme23/block4/q#50 (A 48-year-old man has complete loss of hearing in...)
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submitted by hello(108)

which letter is CN IX in this diagram?

titanesxvi  A think is D, but it is not very clear
usmlecharserssss  A WHAT anatomical structure is this ????????
... hello is asking for clarification on nbme23/block3/q#33 (A 78-year-old man has had progressive loss of...)
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submitted by hello(108)

can someone please explain this?

thomasburton  My reasoning was BC>AC so this must be a conductive problem (which to me means something middle ear or out) so usually I think something blocking air flow or impeding the ossicles. You can rule out all other answers as they are all causes of sensorineural (AC>BC).
madojo  Meniere's disease is sensorineural hearing loss with peripheral vertigo due to increased endolymph within the ear.
... hello is asking for clarification on nbme23/block2/q#7 (A 45-year-old man is brought to the emergency...)
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submitted by hello(108)

What's the echymoses supposed to be a clue about? Does this patient have DIC? Does DIC always cause hypovolemic shock?

drdoom  Disseminated intravascular coagulation (DIC) is a syndromic definition. (See tangent.) It does not “always” lead to shock but shock is definitely a possible sequela (since, by definition, DIC = “systemic thrombotic process”; anything systemic should get you a little worried), and so a patient with DIC should be monitored closely!
... cathartic_medstu is asking for clarification on nbme22/block3/q#38 (A 73-year-old man comes to the physician with his...)
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submitted by cathartic_medstu(7)

Can someone correct my reasoning here:

I was thinking positive airway pressure will increase alveolar ventilation and decrease hypoxia induced pulmonary vasoconstriction. Thus, RV after load would decrease => more preload to LV and more cardiac output. Then wouldn't BP decrease?

Any help is appreciated. Thanks.

... dai89 is asking for clarification on nbme23/block3/q#48 (A 20-year-old woman comes to the physician because...)
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submitted by dai89(0)

isn't candida yeast form under body temperature? why the picture shows a mold form?

... drmomo is asking for clarification on nbme24/block4/q#9 (A 10-year-old boy who was adopted from the...)
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submitted by drmomo(2)

why can't it be culex mosquito? maybe wuchereria bancrofti filariasis?

sunshinesweetheart  diff presentation - that's elephentiasis
sunshinesweetheart  plus filariasis isn't the same as microfilariae
... anu is asking for clarification on free120/block2/q#22 (A placebo-controlled clinical trial is conducted to...)
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submitted by anu(2)

why is option D ) there is an increased likelihood of statistically significant findings... wrong ?

micray  There is a decreased likelihood of statistically significant findings due to the much higher threshold (lower p-value).
... anu is asking for clarification on free120/block1/q#11 (A 26-year-old man is brought to the emergency...)
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submitted by anu(2)

what about the increase in pulmonary vascular resistance ? doesnt PCWP fall in hemorraghic shock

... whoissaad is asking for clarification on nbme24/block4/q#18 (A 64-year-old man undergoes surgical repair of an...)
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submitted by whoissaad(24)

Artery of ductus deferens is a branch of infeior vesical artery. So why is B wrong?

happysingh  the question is asking about "adequate arterial supply"
... whoissaad is asking for clarification on nbme24/block3/q#49 (A 20-year-old woman with asthma comes to the...)
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submitted by whoissaad(24)

What guarantee do we have that the roommate is going to stop smoking in the apartment by "asking" him to do so..?

krewfoo99  There is no guarentee. They are basically asking what a trigger is for her asthma recurrence. Smoking in this scenario can be the cause of this patients symptoms. Dont dwell to deep into the question.
... kimcharito is asking for clarification on nbme23/block3/q#22 (A 54-year-old woman with rheumatic heart disease is...)
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submitted by kimcharito(4)

it is normal irradiation to the RIGHT neck? what does it mean?

krewfoo99  @kimcharito Aortic stenosis radiates to the carotids FA pg. 285 (2018)
... soph is asking for clarification on nbme21/block3/q#25 (A 32-year-old woman comes to the physician because...)
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submitted by soph(22)

ok but why is blue nevi wrong? i thought q asks lession in both exposed and unexposed areas.

... yex is asking for clarification on nbme24/block1/q#3 (A 52-year-old woman comes to the physician because...)
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submitted by yex(22)

This was on a previous NBME. How I got it? Intercostal (posterior) is how you get to the vertebral bodies; the other vessels are anterior.

... ap88 is asking for clarification on nbme24/block1/q#13 (A 4-year-old boy is brought to the emergency...)
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submitted by ap88(0)

Why can this not be papillary necrosis? Given the gross Hematuria and proteinuria with a history of analgesic use... I thought that was what this was getting at?

biaancadb  I was confused about this too. Only thing I had to go on is that I wrote down from somewhere that you see papillary necrosis in middle-aged adults and that it's uncommon in children (except those with sickle cell). Also I'm assuming PSGN is technically a proliferative glomerulonephritis since on FA pg. 578 the definition of proliferative is "hypercellular glomeruli", and for PSGN, you see hypercellular glomeruli on LM (due to leukocyte infiltration).
... t0pcheese is asking for clarification on nbme18/block1/q#17 (4 day old boy, vomited throughout night after breastfeeding)
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submitted by t0pcheese(0)

why is the Na normal in this patient? Everything else made sense, the high K and 17 hydroxyprogesterone.

... hyperfukus is asking for clarification on nbme23/block2/q#15 (A child with septicemia has an antibiotic clearance...)
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submitted by hyperfukus(21)

so should we just skip these? cuz there's prob 10 more i couldve gotten write wasting my life on this one

... hello is asking for clarification on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
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submitted by hello(108)

Please help - how are you able to tell that the CT image is not at the level of duodenum?

I don't know what I'm looking for to compare and contrast a CT at the level of the duodenum vs the CT given in this Q.

... hello is asking for clarification on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
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submitted by hello(108)

There has to be a better explanation for why ANP is wrong?

... cr is asking for clarification on nbme24/block3/q#37 (A man accidentally touches the surface of a hot...)
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submitted by cr(1)

Which type of cell we r going to find in blisters?, neutrophils?

... hello is asking for clarification on nbme22/block1/q#48 (A 1-year-old boy is found to have an impairment of...)
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submitted by hello(108)

please help -- If catalase-positive bacteria neutralize their own superoxide, why isn't it the case for catalase-positive bacteria to infections in everyone?

I'm not understanding the connection to NADPH oxidase deficiency.

hello  to cause** infections in everyone
... hello is asking for clarification on nbme22/block4/q#20 (During a study of symptomatic proximal deep venous...)
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submitted by hello(108)

Why isn't this a cohort study?

drdoom  This is a cohort study! (Since it involves splitting people into "groups"; group = cohort.) But the stem asks what "best describes" the design. So, yes, it's a cohort study but a more precise ("more specific") description is Open-label. In other words, "Open-label clinical trial" is a type of cohort study, and, in this case, "Open-label" is a more precise description of what is described in the stem.
drdoom  For a more technical explanation of "Cohort studies", see the definition from the National Library of Medicine: https://meshb.nlm.nih.gov/record/ui?ui=D015331
angelaq11  It is a cohort, just as @drdoom said, but it isn't an "Observational" one.
... hyperfukus is asking for clarification on nbme22/block1/q#37 (A 28-year-old woman is brought to the physician...)
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submitted by hyperfukus(21)

so the lesion is in the Right MLF right? If so I'm just about to memorize the eye see SAME MiLF lol its the MLF on the same side of the eye keep it simple i hope that's what yall are saying lol

... usmile1 is asking for clarification on nbme20/block3/q#19 (A 23-year-old man comes to the physician because of...)
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submitted by usmile1(26)

does anyone know what the structure E is pointing to?

thomasburton  Not sure looks like it might be free ribosomes or other such small cytosolic structure (I picked E too, thought B looked way too big!)
targetusmle  same here!! marked e thinking of it as a mitochondria
msyrett  Glycogen Granules! They are not membrane bound and float freely in the cytoplasm.
... lauri is asking for clarification on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
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submitted by lauri(0)

I CANNOT VIEW THE ENTIRE QUESTION. IS THIS NORMAL?

trichotillomaniac  Hi Lauri, this is normal. We can't post the whole question due to copy right laws but you can almost always find the question you are looking for and the answer to by going to the form and then Ctrl + find -ing the age of the patient and other key words or the answer!
drdoom  HI LAURI. THANK YOU FOR DEMONSTRATING YOUR PROFICIENCY WITH ALL-CAP COMPOSITION!
... maxillarythirdmolar is asking for clarification on nbme20/block4/q#25 (A 52-year-old man is brought to the emergency...)
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submitted by maxillarythirdmolar(10)

Where does the role of B1 stimulation of RAAS come into this? Wouldn't the B1 action cause decrease RAAS? That being said, I can also understand if that's a long term thing and this is a question about the immediate effects...?

... hello is asking for clarification on nbme21/block2/q#29 (A healthy 25-year-old man is participating in a...)
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submitted by hello(108)

Please help

Why is valine incorrect?

An explanation below says that valine would be converted to glucose during regular metabolism?

Regular metabolism = fed state, so why would valine even be converted to glucose?

... burak is asking for clarification on nbme21/block2/q#12 (A 66-year-old woman comes to the physician because...)
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submitted by burak(11)

What does 3 narrowin means? Is that a cause of diverticulary diseases or the result?? And what is that photo means :/

... burak is asking for clarification on nbme21/block2/q#16 (A 34-year-old woman comes to the physician because...)
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submitted by burak(11)

Isn't it dependent on the location? I answered it coronary sinus because av node is located in Koch triangle; which composed of CSinus, Tendon of Todaro, Tricuspid annulus?

hello  The correct answer was atrioventricular BUNDLE-- it's also known as the Bundle of His. AV Bundle ≠ AV Node.
burak  Now it's more confusing to me:) because av bundle is more inferior to the av node.
hello  Patient has ASD --> need to repair interatrial septum. AV bundle aka bundle of His is located neart interatrial septum. Coronary sinus opens into atria but is not located near the interatrial septum
... hello is asking for clarification on nbme21/block2/q#16 (A 34-year-old woman comes to the physician because...)
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submitted by hello(108)

Please help

Mid-systolic ejection click = pulmonic stenosis

How is pulmonic stenosis related to the patient's ASD -- does ASD cause pulmonic stenosis??

burak  ASD has typically 3 associated sounds according to UW, they are all about increased blood in RA. Increased blood in RA causes more blood do ejected from tricuspid (dşastolic rumble), and more blood to be ejected to pulmonary circulation which cause pulmonary flow murmur (midsystolic murmur in pulmonary region). It even can cause pulmonary regurgitaion like murmur, but most important murmur in ASD is typically midsystolic murmur. You can check it out on FA 2018 page 284
hello  Ok, what I learned: Extra blood in the right heart (due to ASD) doesn't lead to pulmonic stenosis? Instead, it's that pulmonic stenosis = most common comorbid heart association with ASD
burak  No it's not pulmonic stenosis, it doesn't lead. Murmur associated with ASD is pulmonic stenosis-like murmur, because it's caused by excess RA and RV volume ejecting to the pulmonary arteries. So it's same location with pulmonic stenosis, and it's systolic. You get it?
hello  @burak Yep!
... ls3076 is asking for clarification on nbme22/block2/q#7 (A 66-year-old man comes to the physician because of...)
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submitted by ls3076(23)

Is decreased nocturnal erections not possible due to the incongruity between onset of symptoms and stroke (2 mos versus 3)? Agree that these questions are very vague and frustrating. Not sure where to get a good grasp on this material.

... ls3076 is asking for clarification on nbme22/block4/q#47 (A 56-year-old woman comes to the physician for a...)
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submitted by ls3076(23)

can anyone explain why (D) metaplasia is incorrect?

angelaq11  because metaplasia would be a transformation of the normal architecture of the respiratory epithelium to one that does not belong there, in response to chronic irritation. This woman had pneumococcal pneumonia that was correctly (and I dare say promptly) treated, so she suffered an acute rather than a chronic insult.
blueberrymuffinbabey  because metaplasia isn't how the normal healing/regeneration response happens in the alveoli. the type 2 pneumocytes serve as stem cells/precursors to both type 1 and 2 pneumocytes so the regeneration is not metaplasia.
... dorsomedial_nucleus is asking for clarification on nbme21/block1/q#43 (A 52-year-old man is brought to the emergency...)
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submitted by dorsomedial_nucleus(0)

Is this just red-man syndrome? Direct mast-cell degranulation caused by vancomycin....and also morphine?

... sam1 is asking for clarification on nbme23/block1/q#50 (A 45-year-old woman with coronary artery disease and...)
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submitted by sam1(7)

What about the additional flow through the circumflex?

maddy1994  exactly man i got 4.5 and i thought he asked ventricle and left circumflex should be there so i put 5 ...glad someone thought like me.i was just cursing myself for over thinking.
djtallahassee  Yea put 5 here too. they are essentially saying the myocardial oxygen supply to the left ventricle comes from the LAD. Not sure if true or not but figured that the LCX would at least contribute 20% of the blood
... varunmehru is asking for clarification on nbme21/block2/q#14 (A 30-year-old woman comes to the office because she...)
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submitted by varunmehru(0)

The mother has autoimmune thyroiditis and treatment is given for hypothyroidism only. why does it matter if the mother's TSH is high or low? Autoantibodies would still be present and they would always cause cretinism irrespective of mother hormones level. Isn't it?

... wolvarien is asking for clarification on nbme22/block3/q#20 (A 43-year-old man is brought to the emergency...)
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submitted by wolvarien(0)

I am trying to figure this out from the links provided. Can someone please explain the rational behind this question ?

p4p4y4  I believe it's that this muscle everts the foot + runs over the lateral malleolus .. But the phrasing on the question is odd
angelaq11  I didn't actually know this one. I just ruled out everything except the fibularis muscles, and then to be quite honest, I think I had never heard before of the tertius one, so...I chose brevis.