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Welcome to adong’s page.
Contributor score: 84

Comments ...

 +1  (nbme23#3)

By default you should use intention to treat analysis b/c it's the most conservative.

 +0  (nbme23#32)

You can answer by process of elimination. "Competitive interactions" makes you think stimulatory NT. Cross out GABA and glycine. In the cortex so glutamate. Metabotropic would mean there's second messengers involved and the receptor would not transmit calcium. Hence NMDA.

 +3  (nbme23#27)

If you're confused by the systolic murmur look at FA2019 p.288. ASD can cause systolic ejection murmurs in the pulmonic location (can think of it as increase turbulent flow).

Of course the more important thing is fixed splitting so SMASH away.

 +0  (nbme23#45)

In addition to what has already been said I think an important point in the question was regulatory adjustments which points more towards arteriolar regulation.

 +0  (nbme23#44)

tricky image but question is asking more specifically about his visual complaints which is just "double vision" so IR entrapment is the best answer

 +2  (nbme23#10)

I don't think you're supposed to know any complicated niche piece of knowledge. You have to infer that the pt has a skin lesion and is therefore prone to skin infections, most commonly from Staph aureus.

 +2  (nbme22#49)

the patient is pregnant so not doxy. azithro is alternative (see sketchy vid)

 +7  (nbme22#44)

Dicumarol is in the coumarin family which includes warfarin. It helps if you think about warfarin's brand name Coumadin. Coumadin, coumarin, dicumarol...all the other derivatives have COUM it in some fashion

 +6  (nbme22#45)

neuroendocrine cells doesn't always mean neural crest

prolific_pygophilic  you're god damn right.... kms +1

 +15  (nbme22#38)

literally know every single name they can possibly call this

djtallahassee  literally a new name every nbme +7

 +0  (nbme22#2)

from uworld: fibrates activate PPAR-alpha to increase LPL and decrease VLDL production

 +1  (nbme22#46)

uworld says somewhere that testosterone increases hematocrit, increases LDL, and decreases HDL

passplease  Estrogen increases HDL. Testosterone is converted into estrogen. Why doesnt testosterone increase HDL. Why is my logic wrong? +
avocadotoast  The woman in this vignette has an increased androgen:estrogen ratio, so the effects of testosterone on lipid levels will be greater than those of estrogen on lipid levels. Boards and beyond also states that testosterone causes an increase LDL, decreased HDL, and increase in hematocrit, which is why males with primary hypogonadism can present with anemia and the use of anabolic steroids can present with erythrocytosis. +

 +2  (nbme22#43)

got confused by the systolic pulsation of the liver but basically regurgitant blood from RV will go into RA > IVC > hepatic veins

 +1  (nbme22#8)

the question can easily be misinterpreted. it's asking for urinary pH, urinary bicarb, and urinary volume

 +1  (nbme22#30)

hit the kidney so retroperitoneal. leaves only the duodenum and splenic flexure. kidneys are more lateral structures so splenic flexure (at turn of descending colon)

jackie_chan  Basically how I reasoned too; left kidney is close to tail, not body, of pancreas so that was out, duodenum is right side, stomach is not retroperitoneal, supraadrenal gland is superior to kidney, not immediately anterior; thus leaves splenic flexure (and its also left side) +

 +1  (nbme22#7)

Pretty much if they can masturbate or get it up alone in any way their nocturnal tumescence should be normal meaning that their innervation and reflex pathways are all intact. Libido aka sex drive from what I’ve seen so far is altered by depression. So like in the question on NBME 21 the stem stated that screening for depression was negative which is why libido would also be normal in this case. If there’s ever a Q with a depressed guy and normal lab values and physical exam, most likely gonna be decreased libido with normal night erections - courtesy of /u/diffuseaxonalinjury

 +3  (nbme22#30)

you need to add an amine (nitrogen) and most biochem processes from sugar --> amine requires glutamine

 +6  (nbme22#35)

Super annoying they are using the same picture BUT you can answer with process of elimination. No mass in the picture so not nephroblastomatosis or RCC. 4 year old so not amyloidosis. Stem does not really cue you into membranous GN. Instead it talks about UTIs which would have inflammatory processes --> interstitial inflammation.

 +2  (nbme21#26)

Cecum is intraperitoneal even though it's part of the ascending colon

azibird  How were we supposed to know this? Thanks for the clarification. I picked cecum because FA says Crohn is usually the terminal ileum and colon, so I figured cecum would be the most likely vs the descending colon. +4
kevin  Yeah that's what I thought at first too. Figuring it was a tricky question, I went with descending colon because 1) ascending and descending are retroperitoneal, so we know the latter is for sure right, and 2) cecum has it's own name (ie it's different than the ascending colon), so it probably isn't retroperitoneal in that regard. You can remember ascending and descending are retroperitoneal by remembering the greater omentum wraps around the transverse colon and from anatomy lab that there's a mesoappendix, mesocecum, etc (peritoneal) +

 +5  (nbme21#8)

Euthyroid sick syndrome = levels of T3 and/or T4 are abnormal, but the thyroid gland does not appear to be dysfunctional. The classical phenotype of this condition is often seen in starvation, critical illness, or patients in the intensive care unit. The most common hormone pattern is low total and free T3, elevated rT3, and normal T4 and TSH levels.

 +2  (nbme21#39)

FA19 p.233 cortisol has a permissive effect on catecholamines

 +0  (nbme21#25)

unequal BP/pulses in the arms is a big key for aortic dissection

 +5  (nbme18#18)

Increased pressure is in the Bowman space (NOT the glomerular capillaries) so the only pathology listed that would cause backward build up of pressure is BPH

peyerpatchkids6  Does anyone know why its not diabetes? +
michaelshain2  because the NBME said so, obvs! +

Subcomments ...

submitted by sugaplum(241),
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ppnhmnyieapoolrnela si na ahalp tsigano that tlsuiemats rtalreuh oshotm mlecus - mfor utoepdta, hovewre, it salo asys it si not mmneroeddce mattnerte enmayor

ugalaxy  α1 stimulation (via α1 agonist) constricts the bladder sphincter thereby, preventing sudden bouts of micturition during coughing/sneezing (abdominal stress). +5  
sammyj98  I thought that B3 stimulation stopped urination +5  
adong  @sammyj98 B3 would facilitate bladder relaxation +  
hvancampen  @sammyj98- were you thinking of oxybutynin? (thats what I thought of!) According to FA, its used for urge incontinence not stress. +1  
drzed  Nah he/she's talking about Beta-3 receptors which are Gs coupled. Gs increases cAMP thus it would cause smooth muscle relaxation -> bladder relaxation! +1  
donttrustmyanswers  From Mayo: "There are no approved medications to specifically treat stress incontinence in the United States. The antidepressant duloxetine (Cymbalta) is used for the treatment of stress incontinence in Europe, however." +1  
nreid4  @hvancampen oxybutynin is an M3 muscarinic antagonist, not B3. +  
alienfever  I thought about B3 agonist as well and got this wrong. I think maybe B3 agonist can be used for bladder (URGENCY incontinence) where the main issue is detrusor over reactivity. In STRESS incontinence however the problem has nothing to do with detrusor, so we use α1 agonist to constrict the sphincter. +1  

submitted by hayayah(994),
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balComoo si an eye ntaaomyilrb htat uscroc ebreof Te'ryeh snsmiig scepie fo tieuss ni susctrtuer taht frmo eth .eey

  • Cmolobosa nfeafictg eth isri, wihhc rtsuel in a lye""keoh rappeacnea fo het ilpu,p lgnreleay od ont laed ot isoinv o.sls

  • lmosaoboC oinvlvnig hte aneitr tulesr in svioni lsso ni icfipsce rpsta fo het ilsavu elidf.

  • aLger lietran sbomoolac or eosth feifgtnca eth tocip ervne cna scuea low vosi,ni hihwc semna onvsii slos ttah ntocna be peclmeylto ecdrrotec wiht aslgsse or tactnoc ne.lsse

mousie  thanks for this explanation! +  
macrohphage95  can any one explain to me why not lens ? +  
krewfoo99  @macrophage95 Lens are an interal part of the refractive power of the eye. Without the lens the image would not be formed on the retina, thus leading to visual loss +4  
qfever  Do anyone know why not choroid? +1  
adong  @qfever, no choroid would also be more detrimental to vision since it supplies blood to the retina +2  
irgunner  That random zanki card with colobomas associated with a failure of the choroid fissure to close messed me up +7  
mnemonicsfordayz  Seems like the key to this question is in what is omitted from the question stem: there is no mention of vision loss. If we assume there is no vision loss, then we can eliminate things associated with visual acuity (weird to think of in 2 week old but whatever): C, D, E, F. Also, by @hayayah 's reasoning, we eliminate E & F. If you reconsider the "asymmetric left pupil" then the only likely answer between A & B is B, Iris because the iris' central opening forms the pupil. I mistakenly put A because I was thinking of the choroid fissure and I read the question incorrectly - but it's a poorly worded question IMO. +  
mamed  Key here is that it doesn't affect vision- the only thing would be the iris. All others are used in vision. Don't have to know what a coloboma actually is. +1  
azibird  The extra section of that Zanki card specifically says that a coloboma "can be seen in the iris, retina, choroid, or optic disc." Don't you dare talk trash about Zanki! +1  

submitted by alexb(43),
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iSecn eterh ewer lsa"lm nusatom of oniem"cum I ohttugh it utcldn'o eb .rstieaa sTrun out taiaers 'tsin wasayl ensebca fo em,nlu ti acn salo be oamnbral grrannwio of n,uelm iwallnog ujts a sllma utnmao ot pass rto..uhhg.

adong  I don't think that's true, atresia literally means closure/absence of the lumen. I also got tripped up by the meconium but that could be just GI epithelium that was shed while in utero etc. I wouldn't change your definition of atresia. +2  
srdgreen123  one thing i would say is that in the case its due to failure of recanalization and not due to failure of formation like other types of atresia, so its possible that when it was de-canalized, it was not 100% closed allowing for some meconium to pass +  

submitted by pitaziki(-5),
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Wyh si eht eanwsr riulsaifb sveirb and not albiisfur eisuttr? owH od oyu ighitisdsun wnbetee het wot orfm this titegvn?e

gainsgutsglory  tertius is an anterior muscle and overlays the dorsum of foot as it fans out to the toes. Does not relate to the lateral malleolus. +  
adong  wrong question to post on agree with above +  

submitted by gh889(92),
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orFm keSadHrouhyoonenk on etdi:dr

aWht eth sotqeniu si tingtge at si the ctaypmsthei acnhi was .dprsea tI saw a rleebitr ayw of riwngdo ti.

urYo trienora tlhhmosauayp is esisprbelon ofr icolnog ruesafet dna is nrude pymheasttiaarcp ol.rnotc A sneoil dwoul auesc raeihhrmp.tye

Yuro etsooirrp ohsputaalmyh is spleeobnsri rfo ihgtnae ehnw ueory' cdol dna to etaergen the vreeF rssponee nda is reudn ehtycitsamp tnolc.or A ienslo wludo ceusa ymhpira.oteh

nI shit tnosique it si psimly isnagk a soerpn sget is,ck slumaphoayth swa peadsr, twah .snapehp

Aewr:sn thomasapuyhl ilwl tlisl be ealb to tlaeeev est oydb repueatmter to aettlb tnci.ineof

i:nHt FI teyh evig a uetnqois ailrims ot ihst tub drowerde ot idlnuec a iseoln of hte pctyiatesmh siferb ro of het stmao,haulyhp ouy duwlo in turn ONT eb bale ot eeegtnar a revef eosernsp ot ei.cniofnt heT lutmpsyaoahh dowul be reteiyln uernd pyrtthpacaeisma tcronlo

hsTi sadd ermo eonxttc ot eth aftc eth Q tsstea atth teh ytcthasipems was dsaepr

oslerweberrendu  So, this says sympathetic also spared and hypothalamus also spared. Then what was wrong with this clinical case?? +  
adong  i think the sympathetic system is actually impaired b/c it's cut before it can "outflow" least it's the only way this makes sense +3  
suckitnbme  I agree. I think the question stem is saying the sympathetics were lesioned. Not that they were spared. +3  

submitted by sinforslide(41),
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aMle inntelar ngtiiaeal ;g-&t Itantc SRY , e,ttsse nda s.rttoeesnoet

No leaemf nriatenl nigaitael -&;gt rePeencs of MIF (enailluaritnm eh)oronm adn cttani Soirlet clle uncn.foit

Flmeea trxleean etinliaga &-gt; oN ogradenn pen,sret ihchw is eudrqier for ealm lexarten egiatlain o.noarimtf

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +9  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +1  

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fI hbto ZHTC dan opol euidcirst eewr devrpoid as an wsenra ciohce, utfrerh lecu atth zhtc olwdu eb the erwasn ecchoi is teh iortnpnesaet fo teh ntaietp le"gifne .fnu"yn hisT ssesugtg aiemleprhycac ciicr(tyshpa rseovne)ot wihch si a deis efcfte quuein to T.CZH

adong  there wasn't any loop diuretics... +  
the_enigma28  Good explanation!! +  

submitted by hello(258),
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heT Q tmse etssta FXOO is a trsionitnprca tacrfo tath sndpoesr ot usnnili nlnagsigi yb tgraleni teh ropninsrtcait fo tbemoilac snege t&;g-- rreheo,tfe XOOF is a titipnasrcorn aoftrc vlvendio in mesmbl.otia shTi hosdul mkea sesne beuaecs nereri-stlunocpi icvaantoit has a olre ni egarugiltn etom.abisml

shiT Q kass baotu ervribesel ywas htat linnuis teraeusg XOFO tancionrptrs roftca .vitytaic

iet-inumiqebtUidda tpiesosrlyo si ibrslvireere. Emalnitie all hecscoi xcepte fro B, D, adn .H

ulseio-nIpnersrtc otfnincu uhrgtoh I3PK il.gagnsni PKI3 ninigagls vniovesl ppiarhosythnolo fo nersei -&-t;g riesen pptrlioynahoosh si a ireerlevsb po.sercs iitlamEne H. YF:I ia/mrinnopote cadi rtpnahooliyphso si ysawal lrie.ebsevr

You rae tfle twih cihcseo B adn D.

OFOX is a nitisracnotpr oarftc -t&;g- tatronicsirpn ctorasf edmiate eeng tcaivtyi by hungtistl ntebewe teh typsolacm adn egliRtngau teh naicotlo fo OXOF nrocriitstnpa tcafor i..e( olmtycpsa .vs lun)cues wlil fheoreert ebvyrslier edtuamlo eOidXd-OaFmet aloebtmci gene v.citiyta

sThi alevse yuo ihwt teh ocertcr wn:aser coeChi B.

adong  A better way to think about it is insulin acts through MAPK which is a serine/threonine kinase +  

submitted by strugglebus(153),
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nysLie si dseu in esitaln dna olaneclg ossrc gki;nlin ti is cosrs lidken yb ylyls oxiesad ot aekm cgoalenl frsebi

charcot_bouchard  Thats my brother from UFAP mother +2  
smpate  but glycine and proline are used in elastin too. Seems like you'd have to know about desmosine though that's not in first aid. Or maybe you can infer lysine since it's charged and is probably more important in maintaining stability? +  
adong  the only thing we know about cross-linking is with LYSYL oxidase, hence lysine +2  

submitted by aj32803(3),
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dUowrl ypcfilciasle ysas htta saoPs ascesbs nsmae eht tnpiate lilw prrfee fioelnx ot doiav neittcrghs teh eslmu.c thaTs' yhw oasPs ddi otn kmea nesse ot em ncesi teh aepntit rreeefdrp ,tnoixnees ihhcw doulw be hetgrtnics tou het lumecs.

nO the hoetr dhna ts'i irthg no eht rabeevtr nda s'it atescdaiso wtih B.T

adong  it's confusing but i think b/c psoas acts to flex at the hip, staying completely flat would keep the muscle from being contracted. uworld is talking about the psoas test which would end up hyperextending the psoas muscle which would elicit pain (psoas test can also be done with active flexion against pressure which would explain the not wanting to flex). +1  
kamilia20  First ideal to my mind is that:patient is a TB, TB prefer psoas +  

submitted by dr_jan_itor(65),
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naC noyean esrnaw hyw ihts oen ntc'a eb .F Beat atmahelasi rjmoa? I aws hiingtnk aceebus fo sih aienam adn hte uenro"ape ntceesd" hicwh nlidcsue teh mndteaiirnea usraoep.en seUnls BEMN trisrew tnkih htat aeonurep ylno easmn teh seon thwi rxtea thewi eppelo lol

dickass  European implies northern european (they even specified the patient was a person of pallor), mediterranean descent is usually implied by country of origin or by straight-out writing 'mediterranean'. +  
poisonivy  The MCV is normal, thalassemias are microcytic anemias, that hint helps to rule out the thalassemias. However, I got it wrong, not sure why it cannot be a homozygous mutation in the ankyrin gene +2  
adong  @poisonivy, other commenter pointed out it's autosomal dominant so best answer would be heterozygous +  

submitted by ye2019(3),

Physical exams showed tenderness of costophrenic angles, which are the places where the diaphragm (-phrenic) meets the ribs (costo-). Not the Costovertebral angle tenderness that we think to hint renal disease.I got confused with this point.

adong  honestly think this was a typo. hot trash +2  
neovanilla  Assuming it was not a typo, how would the costophrenic angles be tender in this condition? ...From crying...? +1  

submitted by step1soon(43),

Anything upper lip + above → basal cell carcinoma

Anything lower lip → Squamous cell carcinoma

FA 2019 -pg 473

adong  it's saying upper vs lower lip. this pt has it on the nose +1  

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sTih si LELITRYLA eth aesm thoop they esud to resdiebc het e4a-loydr- boy thwi dfsfeui lccitaor srsnoeci rfom MEBN 18. Cna osneeom eanpixl twsha' ggion no reeh

lancestephenson  *Tubular atrophy, not cortical necrosis lol +  
charcot_bouchard  Can u fuckers talk about spoilers +1  
adong  same photo because the end gross pathology is the same. whether it's due to cancer or whatever the 4 year old boy had (some sort of obstruction IIRC) it ends with atrophy of the kidneys +  

submitted by hhsuperhigh(23),
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Tshi si who ym rbina tdfrea ewlhi I wsa gdoni hist .tes..uiq.on I nwadet ot sceoho TGB niciedye,cf utb I etkp niitghnk atht fi GBT si c,netfieid ttha esanm ereth era elss ro no ndiignb rtisoenp ni hte Adn how anc the reef 4T eb oln?mra nu'dlothS efer 4T iecnsear fi reteh erwe sesl 4T ibdinng itp?eonr ...

adong  free T4 wouldn't increase because it would be sensed by the pituitary and TSH would drop until free T4 normalizes +2