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




... benwhite_dotcom is asking for clarification on step2ck_free120
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submitted by benwhite_dotcom(461)

This is a potentially fatal decision. Patients can choose to deny care, but when someone is making the “wrong” choice, it’s important to make sure they have the capacity to do so: do they understand their situation, their options, and the possible consequences of their actions? If so, that’s fine.

... benwhite_dotcom is asking for clarification on step2ck_free120
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submitted by benwhite_dotcom(461)

Source control followed by symptomatic relief. Have you seriously ever heard of anyone doing any of that other crazy stuff?

... trazobone is asking for clarification on nbme13
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submitted by trazobone(4)

SMH it all boiled down to what does tyrosine kinase do? Kinase phosphorylates stuff. So therefore the homodimer would still form but since the key thing thats being messed up here is the kinase, it’s the phosphorylation process that gets disrupted.

trazobone  SMH it all boiled down to what does tyrosine kinase do? Kinase phosphorylates stuff. So therefore the homodimer would still form but since the key thing thats being messed up here is the kinase, it’s the phosphorylation process that gets disrupted. +
... kingfriday is asking for clarification on step2ck_form6
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submitted by kingfriday(3)

This one got me :( i had the right answer but i switched because i kept getting hung up on his PPI treatment (rereading the stem now, it seems he's off treatment)

but can someone explain to me what the answer would be if the guy were on a PPI and had intractible vomiting?

... whoopthereitis is asking for clarification on nbme19
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submitted by whoopthereitis(0)

can anyone elaborate why they chose this answer?

hiroshimi  Even though legally the wife has the right to make the decision first, then the adult children. However, it's still best the wife and children come to a consensus that reflects pt's wish. If there is a disagreement between them that can't be resolved, then the doctor will need to follow what the wife said. In these difficult situations, you are not only treating the patient, but also the whole family so you would try to integrated the family into the process. In short, i feel like the point of this question is don't be an asshole, and don't choose answer that have absolute words in it like "only" +
... misrao is asking for clarification on nbme21
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submitted by misrao(1)

Can someone explain the correlation between 450 mOsmol/day and needing to excrete 1 L of water? Thanks

... llpierso is asking for clarification on nbme22
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submitted by llpierso(0)

I understand why K+ is increased. But why isn't chloride also increased? This is a metabolic acidosis, so bicarb will be low and H+ will be high. You need an ion to balance charges --> increased chloride?

llpierso  Nevermind, thought about this more: DKA causes an anion gap acidosis (hence normal chloride and elevated keto-anions). +
... lickmyass is asking for clarification on nbme20
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submitted by lickmyass(0)

Why not Multiple renal artery aneurysms? I was thrown off by the description of hyperplastic arteriolosclerosis and so I went with this choice. I thought hyperplastic arteriolosclerosis may lead to fibrinoid necrosis of the vessel wall with hemorrhage.

... brise is asking for clarification on nbme23
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submitted by brise(44)

How do you rule out LSD? It also causes tachycardia!

... ht3 is asking for clarification on step2ck_form7
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submitted by ht3(10)

If the chin is deviated to the right, then wouldn't the "mass" (which I assume is the tight SCM muscle) be on the LEFT side of the neck??

... brise is asking for clarification on nbme23
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submitted by brise(44)

I chose anything that would help show a relationship strength: got rid of anything with specificity and sensitivity in it. Leaving only D and F: Temporal relationship sounds more in line with relationship than consistency of other studied. Also how would the consistency of other studies prove anything for the relationship between intervention and child language score in this study?

... benwhite_dotcom is asking for clarification on step2ck_free120
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submitted by benwhite_dotcom(461)

You know that granulomatosis with polyangiitis (née Wegener’s) causes lung disease, but did you know it also causes peripheral neuropathy? Keep in mind that “not all that wheezes is asthma.” Wheezing is a sign of obstructive lung disease, not a diagnostic feature, so consider asthma alternatives in adults. Hemoptysis and fever change the game.

... brise is asking for clarification on nbme23
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submitted by brise(44)

Why is it that you can use acetaminophen in aspirin induced asthma and not here? I literally chose acetaminophen bc in another nbme it said to use it in aspirin induced asthma

brise  Acetaminophen is not an NSAID and therefore it will not treat gout. +1
... carolebaskin is asking for clarification on step2ck_free120
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submitted by carolebaskin(31)

Eeaaasy there, partner. They said they don't want insulin and you're gonna kick them to the curb?

One step at a time, bud.

Offer the insulin, let them refuse (they seem to have capacity), but who ever said anything about discharging them.

Where would they go!?

Haven't they been through enough?

... carolebaskin is asking for clarification on step2ck_free120
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submitted by carolebaskin(31)

Hypercalcemia + lytic spinal lesions = multiple myeloma

What about the fever, leukocytosis, and consolidation?

MM predisposes to infection! It's PNA.

... letsdothis is asking for clarification on step2ck_form8
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submitted by letsdothis(3)

Anyone else get thrown off by the laboratory abnormalities (hyponatremia, hyperkalemia, hyperchloremia, metabolic acidosis)?

... brise is asking for clarification on nbme22
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submitted by brise(44)

Can anyone explain why complement C5-9 is listed?

drdoom  don't have the stem in front of me but the Fc “handle” of antibody allows for opsonization (by macrophages and other APCs) but more immediately it activates circulating complement -> terminating in the formation of the Membrane Attack Complex. MAC is great way to kill nonself intruders without having to wait for macrophages to mature or neutrophils to arrive. FAST ACTIN’ TANACTIN! +1
brise  Thank you so much! +1
... faus305 is asking for clarification on nbme24
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submitted by faus305(6)

You know why I don't get chronic granulomas? Because I've got NADPH Oxidase. It makes OXYGEN FREE RADICALS THAT WIPE AWAY STAINS.

AND THAT'S THE POWER OF OXY-CLEAN.

... kingfriday is asking for clarification on step2ck_form8
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submitted by kingfriday(3)

Why would increasing fluids be incorrect?

kingfriday  nvm, someone whose kidneys dont work means they not able to get rid of fluids anyway so giving them fluids can make things worse +
letsdothis  Yeah, I feel like increasing fluid in any chronic renal conditions is always correct, but I like the steppreps explanation. +
... carolebaskin is asking for clarification on step2ck_form7
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submitted by carolebaskin(31)

Tricky! Yes, fecal occult blood test would pick up hemorrhoid blood and this is a male <50yo, so case closed right?

Wrong! Hematocrit = 35% --> hgb = 35/3 = 11.7 < 13.5 (normal)

Why is he anemic? Do a colonoscopy.

... carolebaskin is asking for clarification on step2ck_form7
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submitted by carolebaskin(31)

thajoker's comment is spot on

And: decreased upward gaze is a normal sign of aging, not always parinaud syndrome

https://pubmed.ncbi.nlm.nih.gov/15114040/

Can dogs look up?

... faus305 is asking for clarification on nbme24
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submitted by faus305(6)

Was I wrong to just pick the only answer with the word nociceptor in it?

... meryen13 is asking for clarification on nbme16
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submitted by meryen13(13)

am i the only one who forgot what was lamellar bodies? :D lamellar bodies (otherwise known as lamellar granules, membrane-coating granules (MCGs), keratinosomes or Odland bodies) are secretory organelles found in type II alveolar cells in the lungs, and in keratinocytes in the skin

... veggievendor is asking for clarification on step2ck_form7
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submitted by veggievendor(1)

Can someone please enlighten me why this is hypothyroidism?

zazzy  depression-like symptoms, bradycardia, 1+ DTRs make hypothyroidism more likely than the other answers! +
... veggievendor is asking for clarification on step2ck_form7
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submitted by veggievendor(1)

Is this because its a patient with SCD and you are worried about osteonecrosis?

... seagull is asking for clarification on step2ck_form8
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submitted by seagull(1392)

Weird question. This is a follow-up - Why would you not have an ultrasound from the previous visit? Perhaps she needs a better doctor.

... mishudishu is asking for clarification on nbme22
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submitted by mishudishu(0)

Who else chose reassurance thinking this was a question about raising the child's self confidence?

... rina is asking for clarification on nbme16
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submitted by rina(6)

why isn't it serum cortisol concentration though. Couldn't that help you identify a pituitary adenoma (i.e. because increased ACTH --> increased cortisol concentration)?

rina  is it because she's showing no symptoms or something? +
... castlblack is asking for clarification on free120
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submitted by castlblack(50)

I picked A, but what is wrong with B? Which type of immunization works faster?

... seagull is asking for clarification on step2ck_form7
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submitted by seagull(1392)

My understanding is that occult blood is commonly due to an upper GI bleed. Wouldn't the colon produce gross blood? I'm hopelessly lost in these matters.

krewfoo99  Yeah I am lost in this one too. Maybe colonoscopy is the right answer to rule out other serious causes of GI Bleeding (Ex: Cancer). +
... seagull is asking for clarification on step2ck_form7
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submitted by seagull(1392)

I literally stared at the word "cul-de-sac" for like 30 seconds and thought to myself - WTF is that? Then promptly missed the question.

P.S. it's the pouch of Douglas (rectouterine pouch).

... aakb is asking for clarification on nbme16
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submitted by aakb(2)

what is the lesion/picture? not really sure what to even google for this.

skilledboyb  I got the feeling that this was some type of a hemorrhoid. The reason why is because they speak about constipation (risk factor for hemorrhoids) and the bigger give away is that this patient is pregnant. The uterus can compress the IVC when it gets large enough and lead to blood stasis behind the obstruction. +3
... geekymle is asking for clarification on nbme18
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submitted by geekymle(9)

what i dont understand of this question is that why is cystic fibrosis causing hyperinflated lungs?

spartanmd  I believe the decreased clearance of respiratory secretion causing difficulty to exhale and air trapping. Chronic air trapping causes hyperinflation of the lungs and clubbing of the hands. +
... geekymle is asking for clarification on nbme18
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submitted by geekymle(9)

okay. i get this question, but what i dont understand is that why cant we inform the patient of the health consequences of not treating her condition?

... seagull is asking for clarification on step2ck_form7
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submitted by seagull(1392)

This is a great example of a poorly written question. Is the infant still sedated from the surgery or ventilated? What is even happening to the surgical site? Why is analgesic therapy not already on-board post surgery? Why is this author such a douche-bag?

Perhaps the world will never know.

... seagull is asking for clarification on step2ck_form7
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submitted by seagull(1392)

Family therapy? Unless her issues are derived from her family in this case she needs behavioral therapy for her assumingly sexual behavior. Why would she open up in front of her dad about the dudes she being inappropriate with?

... athleticmedic is asking for clarification on step2ck_form7
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submitted by athleticmedic(4)

Can anyone help explain to me why he has lower extremity hyperreflexia and upper extremity resting tremor? I can't find anything that associates those symptoms to Schizophrenia.

krewfoo99  I think its because his hypothyroidism is being overtreated with levothyroxine. +
... athleticmedic is asking for clarification on step2ck_form7
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submitted by athleticmedic(4)

"Placenta appears complete but torn" - if it's torn and only appears complete, rather than being confirmed as complete, how can you rule out retained placental tissue? You wouldn't just assume it was complete at a complex delivery, it would require confirmation.

drmohandes  I feel you man, was guessing between the two answers as well. I think torn but complete means the whole placenta is there, but in pieces? Anyway classic scumbag NBME question writing. +
... time2swim is asking for clarification on nbme16
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submitted by time2swim(0)

I understand that damage to the area labeled E would cause issues with the corticospinal tract. However, wouldnt this damage cause UMN findings as it is before the transition to LMN in the anterior horn? In the stem we read that the pnt has LMN finding of "unable to move" So why are we seeing LMN and not UMN findings? thanks in advance

skilledboyb  Paralysis is a finding common both the UMN and LMN. The distinguishing findings are things like: atrophy (LMN): 30 minute onset not long enough to see this reflex changes, spasticity, etc: not mentioned in the stem +
... sphazhang is asking for clarification on free120
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submitted by sphazhang(0)

does anyone understand why the parathyroid hormone concentration is so high when this is supposed to be an iatrogenic hypoparathyroidism question? this really threw me off

drdoom  Inadvertent and abrupt ligation of an artery kills the blood supply to tissue (ISCHEMIA). The tissue (parathyroid gland) will begin to undergo necrosis, releasing its contents, which, in this case, includes a boatload of PTH. +1
... saffronshawty is asking for clarification on step2ck_form7
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submitted by saffronshawty(0)

How is this due to decreased renal blood flow when the BUN/Cr is <20 ?

gh889  ischemia of the kidneys can cause intrinsic renal failure - w/ a BUN/Cr <15 +
... syoung07 is asking for clarification on free120
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submitted by syoung07(20)

Is the correct answer Radon? If so, make sure you associate radon exposure to basements. Radon is in the soil and ya gotta dig up some soil to have a basement.

... schep is asking for clarification on nbme18
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submitted by schep(14)

Why is this Chlamydia? I thought we give erythromycin ointment at birth to prevent conjunctivitis-->blindness from Neisseria gonorrhoeae

schep  In looking through FA, conjunctivitis from gonorrhea occurs 2-5 days after birth while chlamydia occurs 1-2 weeks after birth +1
... isaacyo94 is asking for clarification on nbme22
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submitted by isaacyo94(5)

In systemic infection, wouldn't you get cutaneous vasoDILATION (i.e. distributive shock)? This was my reasoning for choosing B) in this wacky question.

... mannan is asking for clarification on nbme23
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submitted by mannan(7)

Why is medullary thyroid cancer on the lateral side of the neck???

username  I think it is referring to like not in the midline but lateral to it. Not completely lateral but like center lateral +
... juandoe is asking for clarification on nbme19
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submitted by juandoe(-1)

Ok, I don't get this. Since when do we care what the kids think? The spouse is second to an advanced directive, and we have a spouse. And we are going to jump into end-of-life discussions before even discussing what a feeding tube does and why it's beneficial?

... thisquestionsucks is asking for clarification on free120
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submitted by thisquestionsucks(7)

Got this one wrong too. Add it to the count. Decided not to pick gastric mucosa, because I was under the impression that Meckel's diverticulum isn't something you would see in a grown man?

... mannan is asking for clarification on nbme19
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submitted by mannan(7)

Why would it not be answer C) Lutenizing hormone?

My thought process was this:

Leydig cells make testosterone (internal genitalia) that also gets converted to DHT (external genitalia)

Without the leydig cells working you don't have internal genitalia (patient in stem) and you dont have male external (patient in stem)

solidshake  Androgen insensitivity is the better answer because it is more specific for the findings given. A deficiency of LH secretion would point to a problem with Gonadotropic cells in the anterior pituitary which would present with problems with LH and FSH, but the sertoli cells are working here. If you say its because of LH insensitivity, i suppose this is plausible, but Androgen insensitivity is a well known condition that gives this presentation. +
... syoung07 is asking for clarification on nbme23
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submitted by syoung07(20)

How do you pick which malaria species this is? P. vivax and ovale can remain in the liver so I figured hypoglycemia was a result. But I also know that P. falciparum can cause issues with the brain, lungs, and kidneys. I was between adrenal insufficiency and hypoglycemia for that reason.

... syoung07 is asking for clarification on nbme23
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submitted by syoung07(20)

yall seent that episode of scrubs where homie eats carrots, peppers and tomato juice? He's orange from his diet and otherwise healthy.

... cbreland is asking for clarification on nbme18
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submitted by cbreland(59)

Question is asking what increases coronary blood flow? Adenosine and Nitric oxide (NO). Other local metabolites (minor) are CO2 and low O2.

lokotriene  FA2020 p297 +
... isaacyo94 is asking for clarification on nbme23
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submitted by isaacyo94(5)

Ok but seriously, how come the endometrium isn't considered columnar cells in the questions?

rmac  i believe that because it is a pap smear, you could be sampling cells from the cervix is why it is the better answer +
... anechakfspb is asking for clarification on nbme18
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submitted by anechakfspb(27)

I personally picked two groups with similar sample size, can someone explain how they answered this question? Thank you!

tnc  I was very close to picking that as well. However, I ended not going with it because I can just control how many in each groups without picking at random. I would only think about picking at random if I don't want any bias in putting people on one side or another based off certain characteristics. Hence, picking at random would probably by chance put equal similar characteristics on each sides, rather than how many on each side. I hope that makes sense. +2
cbreland  I agree, I feel like randomization is better for balancing characteristics and potential confounders because it would be hard to take in any and all differences in people when hand picking the groups. +1
... chris07 is asking for clarification on step2ck_form7
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submitted by chris07(54)

He's had heat stroke for 2 days???? I get the elevated CK and body temp (all pointing to heatstroke), but the fact that he was a temp of 106 and has been symptomatic for 2 DAYS makes the whole heat stroke diagnosis weird to me.

drmohandes  Exactly my thoughts. -_- +
... meryen13 is asking for clarification on nbme13
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submitted by meryen13(13)

i was so confused by this question. is this because the rest are human antigens, so why would we have antibodies against them? but HPV is antibody toward E6 is foreign...?

topgunber  im going with this explanation. the rest : cd19, her2, Prostate acid phosph, tyrosinase are all endogenous molecules. makes sense that viral protein e6 has the highest immunogenicity. +2
... motherhen is asking for clarification on nbme18
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submitted by motherhen(31)

Are these gottron's papules from dermatomyositis? Pareaneoplastic syndrome from adenocarcinoma, esp ovarian?

j44n  it is not. The pt has a history of being immunocompromised. Also, gottron's are over the hands and dermatomysitis can present with a rash over the eyelid as well! There is also no history muscle weakness at the proximal muscles (shoudler/ hip area) and no mention of an elevated creatine kinase! - hope this helps :) +1
... endochondral1 is asking for clarification on step2ck_form7
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submitted by endochondral1(15)

why not myastehnia for this one? They put some LE weakness in the stem as well so that before respiratory depression made me skeptical of it being a pure descending paralysis and I went with MG instead .

study_dude_guy  I think the history just points more towards Botulism or GBS. Tbh I'm not even entirely sure why this was Botulism and not GBS +
seagull  The nausea, vomiting, and diarrhea are also good cues that this is a foodborne illness. Then the DTR are mildly dulled which won't happen in myasthenia gravis +
... meryen13 is asking for clarification on nbme21
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submitted by meryen13(13)

pt had high indirect bilirubin with high reticulocyte count---> hemolytic anemia. which one in the options is showing hemolytic anemia? pyruvate kinase def.

... yotsubato is asking for clarification on step2ck_form7
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submitted by yotsubato(965)

The indications for blood transfusion for pelvic fracture patients are systolic blood pressure of <90 mmHg, heart frequency >130 bpm and clinical symptoms of shock. In an emergency, combined transfusion of red blood cells, plasma and platelets (6-4-1) is preferred (19).

So...... This question is bullshit?

study_dude_guy  I spent way too long trying to find this paper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394148/ The flow chart is the first figure In major trauma, you give 1-2 L of fluid and check for response, if they are still hypotensive you give blood products. +
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +
... yotsubato is asking for clarification on step2ck_form7
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submitted by yotsubato(965)

Lactose Intolerant I guess? Not Celiac. Kind of a bullshit question.

study_dude_guy  Had the same reaction as you and then I learned that AA is a buzz word for lactose intolerance "African American and Asian ethnicities see a 75% - 95% lactose intolerance rate, while northern Europeans have a lower rate at 18% - 26% lactose intolerance" +
seagull  I also choose Celiac's. "BuT RaCe AnD mEdICiNe DoN't Go ToGeThEr". +
hayayah  I think a key part to differentiate between celiac's and lactose intolerance in this question isn't race, it's because of the part that says "he occasionally had diarrhea after meals since 12 years old and then it got worse since starting college". If he had celiac's he'd have GI symptoms (i.e. diarrhea) any time he ate something containing gluten (which would be every single time he had a meal) since he was 12. You'd also see signs of fat or vitamin malabsorption in celiac's patients and other autoimmune symptoms. Whereas in lactose intolerance, it's much more likely he'd once in a while eat a lot of dairy and have his symptoms triggered, and then he starts college and has even less of a well rounded diet and so his symptoms get worse. +2
... nnasser33 is asking for clarification on nbme15
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submitted by nnasser33(5)

My understanding is that H. pylori actually decreases the risk for esophageal disorders (ex. adenocarcinoma)

How would a chronic H. pylori infection lead to healing ulcer/ stricture formation or adenocarcinoma?

bhavika98  Hey , Basiclly since H.pylori leads to excess acidity in the stomach. over time if irritation persists , intestinal metaplasia can occur to neutralize the acidity and eventually convert to an adenocarcinoma. Hope this helps !! +
... b1ackcoffee is asking for clarification on nbme23
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submitted by b1ackcoffee(34)

I don't know this is weird grammar or I overthought!

They asked 'whose expression is regulated by which of the following hormones?"

I knew defect is in GPCR - adrenergic receptors, whose transcription is regulated by corticosteriods. So chose hydrocortisone.

What was the defect in thought process?

b1ackcoffee  Oh, I get it now. defect in signal transduction by GPCR, not in GPCR itslef +2
... lovebug is asking for clarification on nbme21
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submitted by lovebug(13)

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +4
lovebug  Oh, thank you! +
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +2
csalib2  @drdoom fantastic point. never thought of it that way. +
lovebug  @drdoom THX! very sweet explanation! +
... anechakfspb is asking for clarification on nbme23
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submitted by anechakfspb(27)

Why couldn't it be inhibition of gastric muscarinic (M1) receptors? Wouldn't that be the most effective overall?

... shutch94 is asking for clarification on nbme22
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submitted by shutch94(0)

I get that bleeding time is a measurement of platelet function. Is clotting time a measurement of the coagulation cascade (PTT/PT)?

drdoom  yes, that's correct. +
... rohan225 is asking for clarification on free120
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submitted by rohan225(0)

Why is the answer carrier status unknown? Why can't the mother be homozygous? Duchennes is X linked recessive.

dkhan123  not sure but here is my logic: -Male sibling of patient has died from Duchenne, confirming mother MUST BE either affected or a carrier. -Mother does NOT have the Duchenne phenotype, but has elevated enzymes, suggesting she is a carrier. The Duchenne average life expectancy is 26. Also the question is written such that it implies the mother does not have the Duchenne phenotype and the elevated enzyme level is due to the carrier status of Duchenne and not an unrelated illness. -Lastly, the daughter has normal enzyme levels. This could be due to two possible scenarios, either she inherited the Duchenne gene and has inactivated it, or she never inherited the gene to begin with. +2
... ilikedmyfirstusername is asking for clarification on free120
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submitted by ilikedmyfirstusername(11)

Why not superoxide dismutase? Its the step right in between NADPH (chronic granulomatous disease) and MPO

ilikedmyfirstusername  I guess that could potentially manifest as an even worse phenotype in SCID? +
thekneesofbees  Its because SOD forms H2O2, but H2O2 is broken down by catalase. Since Staph Aureus is catalase positive, it wouldn't be killed by it anyway. +2
... masn8cc is asking for clarification on nbme18
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submitted by masn8cc(2)

Can someone explain how they r/o aortic stenosis? because that could enlarge the LA and give the same sx of hoarseness etc. And the murmur also fits with AS

bmalamet  You would not see a "viable pulsation above the manubrium, which you should not confuse with a "brisk carotid upstroke" associated with aortic stenosis. +2
nbmeanswersownersucks  "brisk carotid upstroke" is the description of a normal carotid pulse. Aortic stenosis has a slowly rising/late peaking upstroke since the stenosis impedes flow out of the LV. +4
overa  AS affects the LV first. it isn't until later in the disease progression that there will be a significant enough enlargement of the LA to cause impingement of the LA. By the time the problem was that bad there would also be pulmonary findings of backed-up pressure (in my not so expert opinion). +
305charlie94  Can anyone explain why the trachea is deviated in an aortic aneurysm? Made me think of a pneumothorax here +1
baja_blast  ^It's basically mass effect. Aortic aneurism takes up space in the thorax, displacing the trachea to the right. Take a look at this CXR: https://radiopaedia.org/cases/thoracic-aortic-aneurysm-3?lang=us +3
... chadgas is asking for clarification on nbme18
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submitted by chadgas(1)

Did anyone have any difficulty deciding between C and E? I knew it was a Vitamin D deficiency, but doesn't calcitriol feedback to decrease PTH production?

nbmeanswersownersucks  I think it is because the question stem asks about the deficiency that "DIRECTLY" affects a process. Vitamin D directly affects calcium reabsorption whereas it is the rise in Calcium (caused by Vitamin D) that then negatively regulates PTH production (so Vitamin D indirectly regulates PTH). The "directly" wording has gotten the best of me more than a few times so now I've become hyper-aware of that wording. +3
nbmeanssux  Also, I just realized it asks about "vitamin deficiency" and calcium is technically a mineral :/ +
... gandon is asking for clarification on nbme23
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submitted by gandon(-1)

what drug acts on C?

... boostcap23 is asking for clarification on nbme24
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submitted by boostcap23(32)

This mentioned anywhere in FA or other board prep resources or just supposed to be common knowledge lol?

... md_caffeiner is asking for clarification on nbme18
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submitted by md_caffeiner(45)

yo sketchy veterans.

do you remember that loping back and forth lop eared rabbit that was increasing the phasic segmentation and therefore icreasing stool transit time?

This is it now.

... peteandplop is asking for clarification on nbme20
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submitted by peteandplop(22)

Can anyone explain why it's not anxiolytic? My logic was this dude has a bum ticker from previous MI, and his HR was 104/min--which can't be good for the old heart. I went w/a anxiolytic to bring his HR and anxiety under control.

Would an antidepressant do the same, thus, is it a better answer, or cover a wider range of symptoms?

underd0g  An SSRI would cover both depression and anxiety. +1
... jessikasanz is asking for clarification on nbme22
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submitted by jessikasanz(4)

What does Zidovudine act on? It is a rev transcriptase inhibitor. Resistance often occurs at site of drug activity.

... baja_blast is asking for clarification on nbme15
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submitted by baja_blast(91)

Anyone know why this was Hydronephrosis and not Staghorn Calculus??

hchairston  There are no calculi in the image. The image shows a dilated ureter, you know it's a ureter because there is an opening into the hilum of the kidney. +2
prosopagnosia  Personally, I couldn't tell that the ureter was dilated without a comparison image. But what I did notice was the dilation of the renal calyces and severe renal atrophy which clued me into some ureteric obstruction --> Hydronephrosis. +1
trazobone  OK so I put ARPKD bc of chronic renal insufficiency and also i thought the dilated parts were cysts +1
shieldmaiden  Remember that for ARPKD both kidneys will be affected and it will involve the cortex as well as the medulla. If you notice, the cortex is intact +1
... anechakfspb is asking for clarification on nbme22
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submitted by anechakfspb(27)

Why couldn't it be retroperitoneal idiopathic fibrosis?

faus305  Idiopathic RPF is a rare fibro-inflammatory disease. It typically does not involve the adrenals, seagull is right in that this answer is just critical thinking, even if IRPF reached the adrenals it would likely harm their "configuration" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926988/). +
... notyasupreme is asking for clarification on nbme16
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submitted by notyasupreme(18)

Just wondering if someone could explain the difference between collagen and elastin for this one? I thought either or could be used for tensile strength. Anyone have clarification, don't know why collagen is the best answer!

notyasupreme  Lol, never mind I realize, it's a scar and that's type III collagen! +2
meryen13  type III is whats usually present but then it gets replaced by collagen I in the scar tissue to add more strength. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4352699/ +
i_hate_it_here  It is also the disulfide bonds that add to tensile strength of collagen, while the inter-chain fibril cross-linking that leads to elastins elasticity FA2020 pg: 51&52 +
xw1984  I think the Q emphasized postoperatiive. Maybe the production of elastin does not increase much comparing to collagen. +
topgunber  i think they would refer to elastin in cases of arteriolar compliance +
... tbarbacc95 is asking for clarification on nbme24
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submitted by tbarbacc95(-1)

Anyone else think that B was on the proximal straight tubule?

boostcap23  Yupp :( +1
... azibird is asking for clarification on free120
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submitted by azibird(158)

How can we differentiate RSV from the common cold? Is it the bilateral, diffuse wheezes and expiratory rhonchi? Along with the intercostal retractions, signifying significant respiratory problems?

nbmeanswersownersucks  I was initially thinking it was rhinovirus too but in retrospect I think the wheezes etc make RSV more likely +2
kevin  The key demographic for RSV is infants (<2yo), so based on age alone RSV is what they're going for imo. +3
lpp06  Signs of respiratory distress = bronchiolitis over rhinovirus +1
... azibird is asking for clarification on free120
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submitted by azibird(158)

This patient has a mixed hyperbilirubinemia. How could Gilbert syndrome, cause direct bilirubin to increase? The syndrome is caused by mildly decreased UDP-glucuronosyltransferase conjugation and impaired bilirubin uptake. So there's absolutely no way it could increase direct bilirubin! I thought this must mean that there was an obstruction or extravascular hemolysis.

... icedcoffeeislyfe is asking for clarification on free120
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submitted by icedcoffeeislyfe(35)

Is the decrease in baroreceptor output due to the body adapting to the hypertension?

azibird  Apparently. "Baroreceptor activity is reset during sustained increases in blood pressure so that in patients with essential hypertension, baroreceptor responsiveness is maintained." "It is a universally accepted phenomenon that vascular baroreceptors reset to operate at higher pressure levels in hypertension." Okay, so they can reset to normal levels, but wouldn't this patient already have undergone their reset? Why would the receptors further decrease? I thought that eventually their LV would hypertrophy and fail, leading to decreased stroke work. https://www.ahajournals.org/doi/full/10.1161/01.HYP.0000160355.93303.72 https://pubmed.ncbi.nlm.nih.gov/3042363/ +3
azibird  From Costanzo Physiology: "The sensitivity of the baroreceptors can be altered by disease. For example, in chronic hypertension (elevated blood pressure), the baroreceptors do not “see” the elevated blood pressure as abnormal. In such cases, the hypertension will be maintained, rather than corrected, by the baroreceptor reflex. The mechanism of this defect is either decreased sensitivity of the baroreceptors to increases in arterial pressure or an increase in the blood pressure set point of the brain stem centers." +11
mangomango  Hypertensive heart disease causes concentric LVH - impaired diastolic function, preserved ejection fraction +
... motherhen is asking for clarification on nbme16
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submitted by motherhen(31)

In other words, what is the active product of the thyroid gland that is needed for normal development? Only thyroxine, iodine and thyroglobulin are in the thyroid gland. Of these, thyroxine is the active hormone produced that would affect development.

... maria_danieli is asking for clarification on nbme24
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submitted by maria_danieli(1)

So does someone know what is phase 0 for? It was an option... somathing like "let me see if i can study this thing?"

cheesetouch  via google - A Phase 0 study gives no data on safety or efficacy, being by definition a dose too low to cause any therapeutic effect. Drug development companies carry out Phase 0 studies to rank drug candidates in order to decide which has the best pharmacokinetic parameters in humans to take forward into further development. +
boostcap23  Phase 0 is an extremely small dose (1% of normal) given to easily rule out any harmful effects. Basically used as a quick way to eliminate further trails/research on drugs that don't work. +1
... barbados is asking for clarification on nbme16
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submitted by barbados(4)

Did anyone else feel like the question should have been more specific as in saying "just before the consumption of a meal"? As in saying she has high ghrelin = high hunger just before she eats so point B?

lee280  I agree, at the start, I got a bit confused because I felt like the question was probably less specific than it would have been, but NBME being NBME this is really expected. When you think about it more closely, once you consume the meal then ghrelin will peak and start dropping. +9
notyasupreme  I agree, I had B at first but then thought too deep into it. I thought if she ATE a meal, she'd be full and low ghrelin. Annoying to get a question wrong on something so simple. +1
radzio1  Also got this question wrong. A really bad explanation what they want from the curve... +1
... diplococci is asking for clarification on nbme24
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submitted by diplococci(1)

I was confused because UW 19280 says pulmonary artery systolic pressure will be increased to maintain forward movement of blood. How does this not lead to pulmonary vascular resistance being increased?

boostcap23  Pressure doesn't necessarily equal increased vascular resistance. Pulmonary resistance regulation mainly increases in areas of hypoxia, and decreases in well-oxygenated area's to send blood to well ventilated areas, nothing to do with an acute MI. In fact in MI there is vasodilation of apical capillaries and the V/Q ratio will approach 1 to accommodate the extra blood. In this patient, you can see his systemic blood pressure is low yet his systemic vascular resistance is high (due to sympathetic constriction of vessels in response to low CO). I just thought of it like how in normal resting state ventilation is wasted at the apex so in a volume overloaded state that extra blood could go up to the apex. +1
... avocadotoast is asking for clarification on nbme23
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submitted by avocadotoast(12)

Boards and Beyond has a good flow chart for ambiguous genitalia. If the patient is XX - do they have mullerian structures? If yes, it's CAH (increased androgens). If they patient is XY - do they have mullerian structures? If yes, gonadal dysgenesis (no MIH). If no, then it could be due to abnormal androgen receptors, CAH, or low DHT.

... azibird is asking for clarification on nbme18
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submitted by azibird(158)

Follow-up vs support group?

The only thing that saved me was the ancient Step 1 adage: "Never refer!"

Especially when the answer to another question in the same exam was "Encourage the patient to participate in a support group for persons with her condition"

I mean REALLY! The only difference is that they used the word "encourage" instead of refer. Exact same answer.

cbreland  Note to self: Never refer, even when that seems like the better answer +
... azibird is asking for clarification on nbme18
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submitted by azibird(158)

Can someone explain the physical findings?

"Cardiac examination shows a grade 2/6 pansystolic murmur heard best at the lower left sternal border, which increaes on inspiration. The point of maximal impulse is palpated in the sub-xiphoid area S1 and S2 sounds are distant"

I don't understand how any of these would correspond to cor pulmonale.

drdoom  Backfilling of blood from the lungs into the R ventricle is stretching out the R side (dilation) and also remodeling the heart via hypertrophy (the heart has to pack on mass to eject the ever greater amount of blood piling up from lungs). Dilation of the R ventricle “pulls apart” the leaves of the tricuspid valve=``lower left sternal border``; when the heart is in systole, the tricuspid valves don’t make good contact and blood rushes from high pressure compartment (RV) to the low pressure (RA) == ``pansystolic murmur`` +
drdoom  The tricuspid murmur gets worse with inspiration because when you ask someone to take a good, deep breath, the diaphragm (a very strong muscle, indeed) pulls the entire thoracic cage down and out (expansion) — including the heart! Because the heart “gets pulled from all directions”, the tricuspid leaflets make even less contact == bigger hole == more pronounced murmur during systole. +3
drdoom  The point of maximal impulse (the heart apex) is way below the xiphoid because this guy’s heart is so big from the years of dilation and hypertrophy — that’s also why the S2 sounds are distant: the great vessels (and their valves) are buried even deeper than usual, so you can’t hear them snapping shut (aortic & pulmonic valves; S2=“dub”). +
cancelstep  Similar to what's been said, but here's how I answered: Agree that a pancystolic murmur at LL Sternal Border is tricuspid regurgitation, increases with inspiration because increased right ventricle preload would increase amount of regurgitation. PMI in sub-xiphoid area means that the strongest contraction is happening sub-xiphoid which has to be due to right ventricular hypertrophy (left ventricular hypertrophy would push PMI towards axilla). Diffuse, scattered wheezes bilaterally are probably indicative of COPD from history of smoking which would cause a secondary pulmonary hypertension due to hypoxemia and vasoconstriction in the lungs (primary is idiopathic, most commonly occurs in younger/middle-aged females). So this explains why you have RVH. Pulmonary edema would be crackles on lung auscultation and would point to Left HF, but not the case here. Also, BP 150/80 in a 68-year old without any medication is definitely high, but not causing AS. Peripheral/liver edema = RHF +2
... azibird is asking for clarification on nbme18
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submitted by azibird(158)

What is going on here? The mother is not the patient, why are we exploring this further when the son is completely normal? I get it that we would say this if the patient were concerned, but he's not and he's normal so why don't we just tell her that everything is normal? Exploring further will probably make the patient feel worse.

drdoom  Another way to read the stem is like this: “Assume you will make a statement that assures mom that boy is fine. What other statement do you want to make?” Since we’re *already* assuring mom, the best next thing is to ask an open-ended question. There’s a reason for this. As a physician, you really don’t want to say more than what you are (1) sure of or (2) obliged to. “Accept him as he is” = judgy. “He’s not going to get any taller” = you don’t know this for sure. +3
cbreland  I had it down between the correct answer and "your son is average". Picked the wrong one. As stated by @drdoom, the stem says you have already reassured that everything is fine. It would be a good time to get extra info from mom instead of say the same thing over again. Really the question gave us the answer (I still picked wrong, but we'll do better on test day!) +1
... hungrybox is asking for clarification on nbme19
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submitted by hungrybox(963)

I put C because I thought that the weakness of the lower 2/3 face meant there was something more going on than just speech problems from Broca's aphasia.

Can anyone tell me why I'm wrong?

drdoom  A: Broca’s +
drdoom  B: Premotor +
drdoom  C: Motor +
drdoom  D: Somatosensory +
drdoom  Damage to C (motor) wouldn’t explain *fluency* problems. Fluency (=Latin ``flow``; the ease with which the brain formulates words). Slurred speech is your brain knowing and formulating the words easy but your mouth muscles not co-operating! +
drdoom  So, dis-fluency ≠ slurred speech. This gentleman is dis-fluent in the same way you’re dis-fluent when you visit Paris: your brain struggles to formulate French words in the first place! The only lesion that explains that in your native tongue is a lesion to the language synthesis center = Broca’s area. +
... usmleboy is asking for clarification on nbme22
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submitted by usmleboy(9)

LOL. I thought they were asking for Urinary pH, but blood bicarb and blood volume.

Who in their right mind would ask for urinary pH, urinary bicarb, and urinary blood volume by saying ".... urinary pH, bicarbonate and volume"

Am I crazy?

... passplease is asking for clarification on nbme16
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submitted by passplease(20)

Why not a tear in the sciatic nerve? especially since it radiates down to the leg

cassdawg  My main thoughts on this is that an actual tear in the sciatic nerve is extremely difficult and further it would present with motor weakness to the muscles innervated by the sciatic nerve as well (the hamsrtings and adductor magnus, FA2020 p452). The sciatica pain that you are referring to is more common with injury to the nerve via herniated disc. +1
azharhu786  I also thought he was too young for the intervertebral disc rupture so picked sciatica tear :( +
... azibird is asking for clarification on nbme24
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submitted by azibird(158)

Who else came here after getting triggered by this answer?

yousif11  This question did not age well +3
... wherearetheanswers is asking for clarification on nbme19
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submitted by wherearetheanswers(10)

The kidneys make glucose too? 6 years of studying science and no one mentions the kidneys.

... euphoria is asking for clarification on nbme21
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submitted by euphoria(1)

i have answered this question right, but why there is mid systolic murmur in the stem?

mittelschmerz  He also has MVP, but asthma is more likely to cause this symptomatology and he has a family hx. +1
euphoria  Thank you very much bro :-) +1
... cuteaf is asking for clarification on nbme23
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submitted by cuteaf(5)

Why is it not answer " Postatic venous plexus to the the internal iliac veins" I thought the route of metastases to the spine is prostate plexus -> internal iliac veins -> vertebral plexus??

mariame  The major metastatic pathway to the vertebral column is via the vertebral venous system, and it appears that prostate cancer cells first metastasize to the vertebral body and then spread secondarily to the processes or other vertebrae. https://pubmed.ncbi.nlm.nih.gov/8065995/ +
... azibird is asking for clarification on nbme24
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submitted by azibird(158)

Why are there lots of RBCs but few RBC casts? That made me think about a post tubule process.

boostcap23  Any amount of RBC casts is an abnormality and indicates tubular pathology. Normally should have none. Just like how even a single neutrophil in CSF is abnormal. +1
... russnels is asking for clarification on step2ck_form7
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submitted by russnels(13)

Why would this not be ABO incompatibility? Is Rh incompatibility just more common?

boostcap23  Yes for newborns specifically Rh incompatibility is more likely and also much more severe (see pg 405 FA 2020). ABO incompatibility would produce only mild jaundice and is actually quite common. +2
mguan1993  in addition i took the description of baby being edematous to mean hydrops fetalis, which Rh incompatability is associated with +
... russnels is asking for clarification on step2ck_form7
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submitted by russnels(13)

Anybody have any good insights as to what is going on here? Does surgery somehow cause hypokalemia? Or does this have to do with digoxin toxicity? I'm not sure how surgery fits in. Thanks in advance!

misscorona  Looking at UpToDate, hypokalemia is listed as one of few postoperative electrolyte abnormalities. Surgical stress releases aldosterone which leads to hypokalemia. Hypokalemia is a known cause of premature ventricular contractions. Digoxin toxicity can cause premature ventricular contractions but it seems like this patient was on these medications prior to surgery and this may be less likely contributor. Side note, digoxin can lead to hyperkalemia. +2
yotsubato  Ah so it is a BS question.... Ugh. +2
krewfoo99  I think surgery/stress will lead to increase in cortisol which acts like aldosterone to cause hypokalemia leading to premature ventricular contractions +
... russnels is asking for clarification on step2ck_form7
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submitted by russnels(13)

My understanding was that both IUDs and OCP can reduce risk of ovarian epithelial cancer. Anybody know why OCPs are better than IUDs?