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Comments ...

 +2  (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

 +3  (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)
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the titanep is tpnarneg so ton xyod. zahirto is talrvtneeai ees( kestyhc div)

 +10  (nbme22#44)
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lruioamDc si ni het moriancu fiayml cwhhi ndelusic nwr.airaf It ehspl fi yuo tinhk abtuo riar'fnswa nadbr eanm domiunC.a auon,miCd rcnoiaum, ua.lacd.loi.mlr hte horte ervaviedtsi evah MOCU it ni meso afsonih

 +6  (nbme22#45)
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nnonroeudciree llcse e'sdnto awslay aemn lanuer recst

prolific_pygophilic  you're god damn right.... kms +2

 +17  (nbme22#38)
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litlrylae konw veeyr lsegni name yhte nca obsslipy clal siht

djtallahassee  literally a new name every nbme +9

 +0  (nbme22#2)
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mfor wroud:l bsteraif iavtatec APa-PlRaph ot ienaercs LPL dna edaserce VLDL udctoirnop

 +1  (nbme22#46)
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lroduw ssya horewesem atht etoeernsstto siacesrne rat,oicthme snrceisea LD,L adn sereaedsc LHD

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. +

 +4  (nbme22#43)
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tgo osfncdue yb teh osytilcs npouasilt of teh ilvre utb lcblsaiay rgnitgrauet ldboo mrfo VR illw go tnoi AR g;t& IVC ;gt& hcteaip inevs

 +1  (nbme22#8)
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eht nqstouie nac lieasy be iserr.tmipedent ist' ksiang orf nryuari ,pH uyrnria cir,bab and iuanyrr ulomev

 +1  (nbme22#30)
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ith hte eynkdi os totoiplraeenerr. veelas nylo eth eduodumn and incplse .rlxefue sikydne aer rmeo arltlea setcursurt so plsncei rfeluex (ta tnur fo gsedndinec lcono)

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

 +1  (nbme22#7)
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ePtyrt mhuc if htey nca tusramteba or etg ti up lenao in ayn yaw tirhe traclnonu mecscuneet shlduo eb ormlan annimeg htat terhi inteoiavrnn adn exferl yahtaswp ear lal a.tctin dbLiio aka sxe deivr fomr htaw Ie’v esen os far is edeatlr by ns.opseredi So leki in the tsoiuqen no ENMB 21 eth etsm atesdt ttha inenecsgr for nsdeserpio wsa getnivea cwihh is hwy ibodil dowul asol eb oamlrn ni hits s.cae If esteh’r reve a Q ithw a sdrsdpeee yug and orlnam lba uelsav nad alhpycsi xm,ae tmso illeyk ngoan be caddsreee ldoiib iwth mnlrao tighn i-sotece rn yrcoseut of xj/uinlyuesrdo/nafuafi

 +3  (nbme22#30)
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uyo deen ot add na mneia rgontei)n( dna tsom hiboemc erossespc rofm rsuga &-t;-g aiemn ereqrius ngutlmiea

 +6  (nbme22#35)
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purSe nayinong hyet aer ungis het maes epctuir TBU uyo anc aswren ithw reocssp of tia.mlnioien oN ssam in eht cpruiet os tno thrbesooimtlpnosaas ro .CRC 4 yera ldo so ton lyimoda.siso Stem deso otn llyaer cue yuo niot enrmubmsoa N.G ndtIase it tlask butoa TIsU hcwih wuldo heav otlamrinymaf preeocsss g&-;t- irietatnislt .ltfnnmoiaaim

 +2  (nbme21#26)
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emCcu si tranplentioirea evne hgutoh si't prta fo eth incaedsgn ooncl

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. +10
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)
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rtEodyhui ksic modesrny = elsvel fo 3T ndao/r T4 rea al,anrbmo btu het trdyhio dnagl sdoe not rpeaap to eb fndoua.litncsy heT aalclssci ptpnehyeo of isht ncoinitdo si fnoet enes in ivatans,ort lccriait lls,isen or sattneip in eht seenintiv race nitu. Teh omst omncmo noerohm attpenr is low tlato and refe ,T3 vdtleeea r,T3 nda anrlmo T4 dan TSH .evlsle

 +2  (nbme21#39)
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FA19 33.p2 iclrosto has a pimsvereis eftecf on ocateeaihslmcn

 +0  (nbme21#25)
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uuqelna se/BpPsul in eth amsr si a bgi yke for aicrot iitnsocdse

 +7  (nbme18#18)
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nIeescdar peuserrs si ni eht owBman sacep NTO( het mgaloleurr ilca)islaper os het nlyo oogytaplh istdle ttha dwulo ceusa wrdacbak iubdl pu of ussrepre si HBP

peyerpatchkids6  Does anyone know why its not diabetes? +
michaelshain2  because the NBME said so, obvs! +
cbreland  Diabetes would have non-enzymatic glycosylation causing increased GFR and hyperfiltation. The stem is referring to increased back pressure (Inc hydrostatic at bowmans space) which alludes to decreased GFR +1

Subcomments ...

submitted by sugaplum(376),
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apoylplmnneparhneoi si an hlapa insogat ttha stsaeliumt uhlrtera omstho mscuel ctano.nricto - orfm pt,udoeta ,woreveh it olas syas it si tno rcoeeedndmm etnetrtam yanoerm

ugalaxy  α1 stimulation (via α1 agonist) constricts the bladder sphincter thereby, preventing sudden bouts of micturition during coughing/sneezing (abdominal stress). +7  
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(1077),
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oboCmlao si an eey ioanbmayrlt htat crusoc beerof .ihrbt 'Teryhe nsgisim pecise fo tsiues ni trstcuurse ttha mfro eth .eey

  • osoboaClm gcffaetni hte i,sir whhic trlseu in a lkoeyhe"" pnapereaac of the ppl,iu nlrygeale od ton dale ot vsinoi s.lso

  • aolbsoCom igovvilnn the erinta ltuser ni iosivn slso ni ccipiesf trpsa fo teh vusial .feldi

  • rgLea ilrtnae osmobcalo ro thoes tnfeiagcf het citop eevrn acn sacue wol i,isvon whhci nsmea vniiso lsso ttha oantnc eb tllmeyopec orterdcce wthi gsesals or ocactnt elnses.

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 +11  
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. +3  
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! +2  

submitted by alexb(47),
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icenS erteh eerw msa"ll asuonmt fo cmomin"eu I uohthtg ti 'ulctond be .riatase Tsurn out sareita ni'ts slawya asneebc fo eunlm, it nca salo eb anorlbma oiragwrnn of nlum,e nlliwaog sujt a lamls tmanuo ot pass

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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Why si the earnws ifulirbas irbsve nad not isarilbfu euittsr? owH do ouy ihsntiuidgs bnwteee teh two rfom hsit i?tgnvtee

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(127),
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Frmo krnHodeokyoSuneha on reti:dd

aWth teh ietuonsq is inttgeg at si the htamcstpyei nhcia swa ea.dprs It saw a brilrtee awy fo ingrdow t.i

ruoY eatrnior laphasytmhou is sbeiposnelr rfo ngicool tfsueaer and si nerud icaepampsythrat ctorlo.n A ilneos wdluo esuca .yrarhmitpeeh

uorY ipoesotrr utopahysmahl si nssliorebpe rfo aithgen ewnh yreo'u lodc dan to egratene the Feerv rseeopsn and si durne smeyithcatp A lniseo wdulo sceua pimhtye.ohra

In isth noqistue it is msylip kagnsi a roepsn setg ski,c youhhsptalam asw ,repdsa htwa hn.esppa

n:seAwr hylpashumota iwll ltils eb abel to laeetev tse obyd teeraermtup ot ealbtt tfi.nncoei

:iHtn FI tyhe ievg a ntqiuoes iarmlsi ot shti tbu oewedrrd to cuendil a lionse of het iyceptstahm fbseir ro fo eht yo,uaaphhsmtl ouy duowl in trun OTN be bela ot gnaeeetr a veref epnesrso to .tneoicfni ehT aphhaluotmsy ulwod be ienetylr erndu teptcpayrmahias oncrotl

hsiT dads reom tconetx to the fact hte Q tasste tath the acstsetyhipm saw psreda

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(50),
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leaM triaelnn gentaiila -tg&; catInt YRS , ,steste and strtoeeoe.tsn

No maelef ntnralei inegtiala ;t-&g rePecsne of FIM letu(rianlmnia meonroh) nda cintat tioelSr llce nfoun.tic

aeFelm aerxtlne eianialtg ;gt&- oN noaregdn ,neseptr ihhcw si reiqdure rof alem elrenxat iinlataeg .tforomnai

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. +23  
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 +2  

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If thbo ZCTH nad ploo idetciurs wree rdoepvid as an searwn h,cieco hetfurr ecul that tczh uodwl be teh nrswea cihceo si eth entsrneptaoi fo the nittape nfgiele" nnuyf". shTi ssugtseg liyeccpehaarm cchpais(rtyi snotveroe) ihhwc si a seid efcfet ueqniu ot .CZHT

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

submitted by hello(313),
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ehT Q tems eststa XFOO si a tocnrsiarintp crtfao that esosdprn to snliuni angsginli yb rgealitn teh arnpiocstnitr of ciaoetmlb gense --&tg; erefroteh, XOFO si a arcntrospiint ctfora ndlvveio in ealtso.mibm ishT dhulos emka nsees cbausee irne-csnpiuertol taoiinvtca sha a lore ni ltnuregaig obei.tslmam

This Q kass uatbo resvlerbie awys taht nisnilu uertegas XOOF torsniantrcp trfoca atii.ytcv

Ubimdeatqte-duiiin ioylesortps is eibreerlvirs. eaEmnliti lal occiseh xetecp orf B, D, and H.

seipI-rrnletncosu fcutonin rtouhhg I3PK .aginnlsig IP3K insgiangl vloesniv rpaptonlohohyis of reiens ;&t--g eneris ynpthaphooilros si a brrsveleei sespcro. leinEmati H. I:FY itoenri/nompa adic shyholtponrpoia is wslaay .eslbrirvee

uoY aer felt thiw ccihseo B and D.

FXOO is a ontpracinirst cratof tg-&;- rcinsrpttoain rtocfas tidaeem eeng aiyivtct yb igunhltst newbeet eth stplmyaco and .ecsunul ueRilggtna the oacionlt of FOOX iinparctstron ocfrta i.(.e sptmocyla .sv lu)csune lilw hfetroree slyverbire uleamdot O-dditmFeaXOe oecbamitl egen yvt.atcii

isTh lavees oyu hitw eht trcreoc aswen:r ochCie .B

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

submitted by strugglebus(165),
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Lyeisn si sdeu in natseil nda lgnacleo rscso ik;nngli ti si soscr dnklie yb sylyl exoaids ot ekam enagcoll esribf

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 +3  

submitted by aj32803(4),
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doUrlw yliicfcpslea asys taht saosP ssacebs snema the tatinep lilw rpreef xfeinlo ot aiovd tcngithesr eht em.slcu T'tahs wyh aPsos idd not eakm ensse to me iescn eht antepit rrrpefede s,nentexoi whchi dlouw eb ghrteticsn otu eht

On the rheto ahnd sti' ihtgr on het eavbrtre nda ts'i ascadsetio wthi BT.

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(71),
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naC nyaeon aswnre yhw tsih neo 'cant eb .F taBe laiehsaatm ?ajmor I was niginthk ueecsab of hsi inmaae nda eth pano"eure "setdenc hhwci sledincu teh meianniaredt a.seurepon ssnelU BENM wriesrt think ahtt naerpuoe yoln enmas het soen iwth texra twieh epolpe oll

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),
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iaPhlscy aemsx whesod ndesrentse fo htiepoonccsr g,elans ihcwh ear eth sclape hwree teh aampgrdih r)ecphni(- etmes eht risb (s)-o.toc tNo eht teCraslvboteor algen esdetsernn tath we tnikh to inth rnlea Iideeass. ogt nucsdofe whit tsih .inotp

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(48),
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gAitynhn preup lpi + bevao → asabl clel naccamior

inhtnAgy owrle lip → Sousmqua clel roacicnma

FA 9012 gp- 734

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

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sihT is RLILTAYEL hte sema ohtpo ythe esdu to dersbcei hte rae-doly-4 byo whit defsiuf rlctocia icsernso mrfo NMEB 81. anC eomesno xaienpl t'awhs oggin on eerh

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 +  
j44n  they used the same kidney on NBME 17 for posterior urethral valves lol +  
j44n  this is probably the most famous kidney in medicine +  

submitted by hhsuperhigh(37),
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Thsi si hwo my iarnb fteard eliwh I wsa gidon tshi I eanwdt to ehoosc GBT cce,ifnediy utb I ekpt ktnhgiin atht fi TBG is eteinfd,ic atht samen ether rea esls ro on gnindib optesnri in eht ndA owh nac eht fere 4T be al?nrmo dSout'hln free T4 eniersac if there wree sesl 4T ibnidng trepn?oi ...

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