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Welcome to alexxxx30’s page.
Contributor score: 44


Comments ...

 +13  (nbme23#17)

did anyone else have to reread this question several times? The jumping back and forth from "this happened before, 1 week after, 6 weeks after" then this happened today, then" this happened 6 weeks postop" gave me whiplash. Tell the story in order! haha

confidenceinterval  RIP anyone with a learning disability. I honestly think someone tried really hard to write something this confusing. +1
faus305  Quentin Tarantino wrote this one +

 +4  (nbme23#1)

also the word annular was supposed to be very helpful (it means ring shaped)...however my dumbo self didn't know this. Would have lead me directly to ring worm tinea





Subcomments ...

submitted by lsmarshall(395),
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tnyebvnprSoai is eth grteat fo mtoassnetnpia tnteu(sa ;onti)x umescl asssmp era hietrctcraiacs. Olyn etroh swrnae yuo tgihm orcnisde is ltiryAeoacnsseclhtee siecn he si a amrfre nad buzorzdws otefn crray us ot teh omdseirp al..dn. btu ymmptsso fo a gonerihclci torsm aer .setban

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +42  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +42  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +34  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +2  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  


submitted by dbg(140),
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mA I eht lyno eno ohw goh,ttuh my eolhw lef,i atht ti ltaulayc ginsriaeot form teh rdhyoti tub sjtu yphclisaly deontncce to eth gteoun

nbmehelp  same +14  
medguru2295  me! I went with submandibular gland bc I thought there was a gland under there. +  
alexxxx30  nope...i definitely thought the same thing...when I clicked thyroid I was like wow that was an easy question. HA +  


submitted by medstruggle(12),
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hyW si ti tno voainra elfolcil ?sclel I tgtuhho the afelme anloga fo riSotle dan dyLieg is se/acutglhranao .lcels

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +7  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +4  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +11  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +3  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +37  
mcl  But seriously though, pathology outlines says sertoli-leydig tumor "may be suspected clinically in a young patient presenting with a combination of virilization, elevated testosterone levels and ovarian / pelvic mass on imaging studies." As for follicle cell tumors, granulosa cell tumors usually occur in adults and would cause elevated levels of estrogens. Theca cell tumor would also primarily produce estrogens. Putting the links at the end since idk if they're gonna turn out right lol Link pathology outlines for sertoli leydig granulosa cell tumor theca cell tumor +12  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +5  
medpsychosis  So after doing some intense research, UPtoDate, PubMed, an intense literature review on the topic I have come to the final conclusion that...... ...... ...... ...... Wait for it.... ..... ..... Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +9  
charcot_bouchard  Hello, i just want to add that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
giggidy  Hold up, so I'm confused - I read all the posts above but I still am unsure - are sertoli-leydig cells notorious for producing androgen? +4  
subclaviansteele  Hold the phone.....Females can get sertoli leydig cell tumors which are notorious for producing androgen? TIL TL;DR - Females can get sertoli leydig cell tumors = high androgens +  
cinnapie  I just found a recent study on PubMed saying "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +2  
youssefa  Hahahahaha ya'll just bored +9  
water  Bored? you wouldn't think so if you knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
nbmehelp  I dont get it +  
redvelvet  how don't you get it that females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen? +1  
drmomo  what if this means..... females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen +  
sunshinesweetheart  hahahaha this made my day #futurephysicians #lowkeyidiots +  
sunshinesweetheart  @medstruggle look up placental aromatase deficiency (p. 625 FA 2019), it would have a different presentation +  
deathbystep1  i am sure i would ace STEP 1 if i only knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
noplanb  Wait... I might actually never forget this now lol +3  
drmohandes  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +1  
lilmonkey  Don't forget that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! You're welcome! +  
drpatinoire  Now I get it that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens. Thank you very much.. So why choose Sertoli-Leydig cell tumor again? +  
dr_ligma  The reason is because females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! This is easy to remember, as you can remember it through the simple mnemonic "FCGSLCTWANFPLOA" which stands for "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen!" +17  
minion7  after receiving a f*king score..... this post made me smile and thanks to the statement-- females can get sertoli-leydig cell tumours, which are notorious for producing lots of androgen! +1  
djtallahassee  My worthless self put adrenal zona fasciculate but now I will never forget that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
medguru2295  Wait..... so can females get Sertoli Leydig cells that produce androgens then?????? +  
peqmd  Going to snapshot this to my anki deck card: "females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of {{c1::androgens}}" +1  
paperbackwriter  Watch me f*ck up the fact that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgens on the real deal. +2  
alexxxx30  just made sure to add to my notes "Females can get sertoli leydig cell tumors, which are notorious for producing lots of androgens" +2  
peridot  I also just wanna add that if you look on in FA on p.696969, you'll see that they'll mention "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +  
mbate4  According to the literature [lol] females can get sertoli-leydig cell tumors, which are notorious for producing lots of antigens +  
drdoom  the tradition lives on +1  
jamaicabliz  Wait... so for clarification, is it that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen? Or that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen?? HELP +  
abkapoor  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen sorry for bad Englesh +  
faus305  Sertoli-leydig cells are notorious for producing lots of androgens, females can get these. +  
djeffs1  the fact that a bunch of medstudents can get so weird about how females can get sertoli-leydig cell tumors: notorious for producing lots of androgens- just made my week!! I love you guys +  


submitted by hayayah(1057),
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He ash ceafl onnnieecictn so hsi aeenlxrt nctiphsre si daagde,m ihhwc is rndienvtea yb hte apludned .n S4(.S-)2 hTe lpevic hlsacincnp ,serevn whihc edmitea teh tcieoenr ercsspo, rea olsa 4S.2S-

thomasburton  Why could this not be dysuria? +2  
lilyo  I think that you are thinking about urinary incontinence. If we damage the pudendal nerve S2-S4, you can exhibit urinary and fecal incontinence since this nerve innervates both the urethral and the external anal sphincters. However since the pelvic splanchnic nerves also have roots that originate in S2-S4 a patient with pudendal nerve damage will also have impotence since these control the erection reflex. He wouldn't have dysuria which is painful urination. Most likely caused by a urethral infection or a blockade of the urinary tract. He would have urinary incontinence. I hope this helps. +16  
alexxxx30  dysuria is painful urination...if it said urinary incontinence then you'd be right. But decreased innervation wouldn't cause pain (that would mores be associated with UTI) +3  
peqmd  Another approach is fecal incontinence => parasympathetic nerve dysfunction => no boner +  
dul071  ahhhhh fucked up with terminology again thinking dysuria was urinary incontinence +  


S2,3,4 keeps the 3 P's off the floor (Penis, Poo, and Pee)

alexxxx30  love it +1  
prolific_pygophilic  A true scholar +3  


submitted by cbrodo(58),
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ehT toerprsio lsuncmo clssuFaciu( asuluuna/cFectsucis rg)lsacii ycrra miintaronof to het anrib aridreggn oeprpotirnp,coi ovibnrt,ai istidnvicreami hutco dna reerpu.ss aiyschPl aexm igfninds esgstug a onseli reeh eh(t ihanilstaopmc arttc csraier pnk/inpciriap dna a,ptetrrmeue and heets ewre .a)norlm incSe eth tpetani has bormnlaa fnsigndi ni the wrelo ,erteiixsetm adn amonlr innidgsf ni eht prpeu testeixi,mre eth easrwn is lFuicsusac ari.sclgi hsiT is busceea moifrtaoinn ormf ybdo araes eoblw teh elelv fo 6T si acirerd by lairgsic dna fioomnriatn mfor obdy aesar voaeb eth leevl fo T6 si adricre by usautnec.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +3  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  


submitted by cbrodo(58),
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hTe esorporti uscnlmo u(cuicsFals itasnucus/uccFsluea giilc)asr arycr mnoarnoiitf to het rbnai edgarrgni ropnioic,opeprt roabiinv,t minadirtvciise ucoht dna .esesprur yahliPsc exam infisngd gssgtue a nisoel heer hte( hciplnsataomi tarct irceras ipainkincpp/r nad prttaeree,um dan ethes ewer n)ormla. niecS het tepaitn hsa olbmanra ginifnsd in hte oewrl ie,xiettmesr dan nlmoar nnsdifgi in the rpupe imreesxt,tie teh wseanr is ussiualFcc criial.sg hsTi si bcesuae nmirfniatoo rmof ydob sarae bwleo hte lveel of T6 si crdreai yb risalgic and artfimnnooi ofrm dyob sreaa avobe het leevl of T6 is icadrre yb castnueu.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +3  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  


submitted by yotsubato(974),
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oS rof aCiaddn ew nac eus

ozlseA al)cu(lzfnooe ibniht(i Y5CP04 edhyoanel)tmti

eihrpAmoctn B (roep inomrftao in glafnu ecll mreenamb)

pngfsinauCo tnepev(r ocklnssrinig fo beta nulgcas in llce )lalw

ro nstNyia fro alro or haelapsoge eacss (preo ar)notfomi

sThi qntisueo is nygsai ttah esh si itgkan an ALOR gdur to artte niaadcd vaiisgt.in

oApcerimthn si IV

upafniognCs is salo IV

so e'rew tfel htwi oeaszl

ezAlso tnhbiii tnsisyseh fo oeestglorr by ngbiiitinh YPC 045 that tevsocrn lonaetsrlo to lr.teogsreo

qball  Nystatin does treat vaginal candidiasis but is TOPICAL. +1  
thotcandy  Nystatin is NOT for esophageal candidiasis, Swish and spit, not swallow. +2  
staghorn  Me - picks Metronidazole -_- +  
alexxxx30  @thotcandy...actually you can swish and swallow nystatin for esophageal infections (per Sketchy micro candida sketch) +3  
turtlepenlight  I have seen that on the wards so I hope it works! +  
fexx  and my smartass picks amphp B +2  
avocadotoast  Please no one give a poor girl with a yeast infection amphoterrible +2  


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diD aoynen eesl og dwno :eth h'ses isneptevyoh so aeybm slehl' gte hwturaeoes rndsehiirefc erdnomsy uebcesa nnthgio seel is akmngi ssnee to me at htsi ?n?io?tp roetu -

usnrT tu,o everes raiaalm can ceaus vsudaiaoraclrc selpoalc nad eniy.sthpnoo

redvelvet  me too :( +1  
abigail  me three :( +1  
yex  Me four :-/ +1  
link981  Slowly raising my hand as well +1  
tinydoc  Sammmme +1  
bullshitusmle  same here!!!:@ +1  
usmlecharserssss  patient has malaria with obvious picture and clinic, i answered because only thing associated with liver was hypoglycemia +9  
aisel1787  me five( +  
myoclonictonicbionic  I was thinking that she is hypotensive which can cause an infarct of the pituitary (since pituitary is growing during pregnancy) and therefore she'd have secondary adrenal insufficiency. +  
alexxxx30  sammmeeeee +  
snripper  Dumbasses unite lmao +  
usmleaspirant2020  lol saaaaame! +  
usmleaspirant2020  lol saaaaame! +  
anechakfspb  me also :/ sitting there trying to figure it out during the test I thought I was so smart too - like "wow nbme, way to tie in micro and endocrine, not getting me though!" ... i was wrong. +1  


What is the area labeled 'G' and 'C'? And more characters?

alexxxx30  lateral corticospinal i think +2  


submitted by nwinkelmann(285),
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So shit qotsiune asw sotnheigm I raylel gerlsgtud twi.h I ddtn'i reiocnezg htta eth nptreoaintse was fo FMRER as eoneosm sdetat loewb, and I nkow uoy 'tndo eden to knwo hatt to reawns eht ot,ieusnq utb ti oudlw aevh nebe ulphfle. My gegbist rituntfsaro aws hte indgorw of hte soibyp estlsru baol"anrm inuaamlosutcc of ci."onaitrhmdo ishT nyoaedn me becusae the eiidtnnifo fo rgdeag dre rsfibe whh(ic m'I gmisnaus was irteh tnoi)intne is imuctaclanus"o of oaabrlmn no.rcdhmta"ioi hsTeo rae owt yevr dfeftnire teentmatss in ym md,in lol. heT rfst,i ot me, utjs nemas 'esrhte oto cmuh oohiai,cdtmrn btu eth edoncs samne ts'reeh oto uchm NAD heyt 'tenra giuitcfonnn plyrorep. tsI' sola jtsu teh ftac fo mmrgeierenb lla of het tserm orf TEC at hte item of graeidn the ntiusoqe e(..i I t'nidd hkint atoub the caft taht CET is oals ldaelc luecarll ernroiatsp or utjs a.i)inopstrre

I laos 'ddnit lyrlea aesnudnrtd llfyu tawh OmaVx2 si = "VO2 ,mxa alos wnonk as ilamaxm onxgey tepku,a si teh tanemermeus fo eht mmiumxa toaunm of onxgye a porsne acn itzelui gdiurn nitnese ci.er.eexs. and si bsaed no eth eeispmr taht hte eomr onexgy osedmucn idrngu sxeerec,i eth rmoe hte bdyo lwil teereang enandoies tphoparitesh TAP() reegny ni ..lc.sle V2O xam si dehaecr nwhe oury xyngeo tpsunoicomn asenrmi at a dasety tatse esepidt an nasceier in teh drlowkoa. It is ta tshi alptaue htat the s]cu[mle soevm fmro oiabecr lteisamomb ot binoecaar moabiml"tes 2/lh.fh3/iwpe:w0r102.waa-ivlme9-tocttswtv/-ox7symw-.

esBad yerlup on itsh n,inidfieot hwere VaxmO2 = ltynaeslise hte miet at hicwh rabecio hecwisst ot ibaaneocr aripoersit,n ym tineoittnerapr fo oot umhc rtaiomhodinc sv oto umch and adb atdrricinhoom nditd' ,amtetr bacseeu evne hnwe the ctinradoomih ear uogncntinfi y,peloprr ehyt hcaer a oitpn nda stwihc ot ,aarnoiebc htsu fi herte wsa oto mhuc malrno roticaiodmnh, stih ludow uccro aeftrs asbucee rethe udolw be erom laevolr llucrlea psioeatinrr c,nuorcgi aenimng hte odyb wdoul sictwh ot beroacnai nad iiluzte sllisogyic ot tatcela fro ryn,gee pots izilntuig eth nad,hiotricom dan suht aVm2xO lodwu eeeadrc.s

H.RW.EE.V.O caebeus isth is a RRFEM utioe,nsq hte edror fo nsteve is a etltli nerftidef, epditse hte ocotuem igben eht meas (at etsla tsh'ta woh I nutdsdnrea )i.t So, I tkinh teh eyk ot nay tdiomhanroicl irsddroe is menmgbierer atht the tunioamts rea tlsmoa trcaenily oging to ftfcea an odneecd ptrieon and shut a fceicendiy fo ttah ronipt.e enO ltiacer ttah I fundo dias thta eth tNRA sottainmu (as ni MRRFE) seua:c "dusritp tocalrionmdih tripeno esthys,sin darecengis eht itvcitay fo xlComep I dna to a rlsese teexnt lComxpe ...IV ihwhc ssaredece pirnairetos dan rslwoe oonprt upnpi,mg tiaydlmcalar redeasnigc eth eerbnmam eatlioptn nda pontro chtrecloeeacmil lonaitetp etdiagnr soracs the oadolntmrchii niner brmen.ame ehT tpnoor ctiroheaeelmclc oaptintel igrentda is eth inrgdvi cefro rof APT eissyshnt dna igearedncs it anbstitluylsa orselw eht mxmalia rtae of PTA hss"s.ineyt l9l49/x./e/3ytnlo.o2o9md:j/t.-sic.1.10wesif.00i3702b16yinlbe411ah/..prf6/r6lu0

aseBd on ym ndgsadreutnin of eaiditovx hapyoholinprost, 2O onpinsomutc ie.(. gknita het lenretoc mrfo elcmpxo VI dan uintpgt it on 21/ 2O to tcerea 2HO dna +H dsevri hte rtopno aentrigd chhiw sedvri APT druitonop.c :Tuhs ieiedtncf poryrraeits ionoxatdi (.ie. NtDAm iuasotntm fo teh TCE )ensmyez asdle ot dorewel O2 oitnnmpcuos so( odlwree V2O x)am hhiwc ehnt aleds to ewreold ATP tcrdponi,ou nda uhts dfvetceei cnomr.tidohia nh,Te wrdleeo chilmnoodtiar fcnituno desal to reddecaes roicabe iosienrptar ngthuisn TAP nidoprutoc ot nboeciraa eoinrps,arti ievdrn by lcsy,iloygs nad uths cnsiariegn ctatela lvels.e

Hope tshi he!slp hsTi okto me WAY OTO OLNG ot fregui ,out ol,l tub ullpeyfho I evrne eknirfga eorfgt ti, ol.l

oAs,l if uoy tnaw any emro aiednrg, I niyflal uondf an aetlcir taht utcalyla lylfu sienplax het eibclomihac dan apghstoohylpyio fo iricotlnmhdoa setompay:hi ac1c/so/r3r2nut3t/./p//56baa:ti1l344ei27/ahcm/2.oeidcpm

Soyrr si't os nl!og

djtallahassee  lol yea. I thought they were trying to say there was an abnormally large amount of mitochondria present which made me get the opposite answer :/ +1  
alexxxx30  no I so agree. The grammar was completely wrong (clearly whoever wrote the question needs to work on english). This was very frustrating to me because I recognized that it was ragged red fibers, but then the wording made me doubt my own knowledge (thinking how could the test writer mess that up?). abnormal accumulations either means too much or too little. accumulations of abnormal mito means thee mitochondria is faulty. Correct grammar is putting the adjective right next to the word it is describing. So this was definitely wrong and I share your sentiment. This really frustrated me! +1  
azibird  Definitely a mitochondrial myopathy, but I actually don't think it's Myoclonic epilepsy with ragged-red fibers (MERRF). This normally entails Myoclonic jerks, Generalized seizures, Cerebellar ataxia, and Dementia (according to Amboss). Maybe it's CPEO (chronic progressive external ophthalmoplegia): progressive extraocular ophthalmoplegia with bilateral ptosis. Not sure which one would account for her poor exercise tolerance. Either way, recognizing it's mitochondrial is enough. +  


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Enev fi oyu idtn'd iwhch eno cretvo was aanlaAs,mp I eleebiv ciehco A saw het yonl eno ni iwhhc ohbt nsrmsoiag arehsd eht asme vet.ocr

stinkysulfaeggs  Agreed, that's how I made my final decision! +  
alexxxx30  yeah I literally had no clue what anaplasma was, but came to the correct answer the same way +  


submitted by hopsalong(25),
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I egt htsi is a flffuy uqintoes dan ginacgdekonlw eht 'seitapnt aesnosr fro imsgsni uninils ceonnistij si eth ,tldusiecd but I elfe ikel shit wrsnea twso eth ienl a tb.i uoY tdo'n watn to ays that igssmni esosd si ,ok btu uyo lsao to'nd anwt to eb eanm to iteapnt .ierhet I tughhto this rsewna (A) aws ndingonco erh nsmiisg teh t,jseocinni os I eikpdc )(C. nI e,eotrsrptc I sesgu ckdlgwaonee nasme altk obutsuca/fo hte atcisvnrenoo .nrudoa

dentist  I would say: "I understand why you are missing injections, but you're going to have a BAD TIME IF YOU KEEP MISSING INJECTIONS" +3  
alexxxx30  @dentist, I was searching for that answer as well, but it wasn't there so I picked C ahahaha +  
123ojm  you would definitely do C as well. key word is "initial step" +  


submitted by welpdedelp(218),
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hTe tp ahd tmhasa SB,O( ksewa pu at ihgtn otu fo bertha, sha llaei.se)rg tI dekas for teh srrceoupr fo nie,estuorelk whhci si ihcriaadcon ad.ci ehT borp aevg ihm oetalMustkn or lhadine cciiutr.ocogodls

ls3076  wtf is up with the phrasing of this question +34  
djtallahassee  Must have been Montelukast right? Since GCs do more of a downregulation thing than a true receptor blocking. Maybe I am not reading that last sentence correct though. +1  
alexxxx30  @Is3076 haha agreed!! +1  
calleocho305  Thought this patient had GERD Induced asthma so I said histamine... Fixing GERD will normally fix the asthma and a h2 blocker would do that.. +4  


submitted by lfsuarez(141),
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rFtis tehra uonds ()1S is gedantree by tow etahr val:vse hte amlrit aelvv nda pudstiirc levv.a eNyral oatususenilm cnolgis of ehste velsva armlynlo setaeerng a gelnis S1 suo.dn iliptStng fo hte 1S ousnd is radhe hwen rtlami adn surtdpici savlve osecl at hgiytlsl fedefnirt semti, twhi uaysllu teh atrilm ocnilsg orfbee pciirsdtu

yotsubato  Then why the fuck is it describing a mitral valve sound in the tricuspid area +22  
dr.xx  it's describing a splitting S1 — consisting of mitral and tricuspid valve closure — that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. +31  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +4  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +1  
drzed  It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post) The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound. +9  
alexxxx30  yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation. +10  
jesusisking  Thanks @alexxxx30, you the man! RIP Kobe +