Patient had ALS. Combination of UMNL + LMNL --> only answer option that had anything to do with these was atrophy (LMNL). Also, remember that their MCC of death is due to respiratory/ diphragmatic failure!
"pink, soft, granular, edematous wound" describes granulation tissue, which appears around day 3 and last several weeks. At this time, there is also an abundance of fibroblasts, endothelial cells (which contribute to angiogenesis with up regulation of VEGF) and macrophages as well as keratinocytes.
I was so lost when I saw this. But I was able to break it down and figure out what's happening.
HOX is transcription from Head (cranial) โ> Toe (caudal)
I think of this as โHBO is Sex from Head to Toeโ: HBO shows have a lot of nudity and what not, the sex helps me think of HbO + seX = HOX; it's for arrangement from the head to the toe.
One of the cervical has become a thoracic looking segment. So we have replaced a cranial segment (cervical) with something closer to the feet/ caudal (thoracic)
So the Hox gene at the top is expressing caudal info when it should be cranial at C7
Common Chelators:
Commonly Chelated Drugs:
These create insoluble complexes and are inhibited from being absorbed!
The cavernous sinus contains CN 3,4,V1,V2, and 6 (right next to the ICA).
A: MCA defect (face and upper limb)
B: olfactory (recall that this is the only sense spared in thalamic strokes)
C: damage to macula, could be an MCA defect?
D: MCA; supplies parental and temporal(total HH, macula NOT spared), PCA; supplies occipital and some of temporal (total HH, macula spared) - mentioned pareital and temporal because of the quadrantonopis; 2 quads = 1 hemianopsia
E: LR (recall LR6, SO4)
Correct me if I'm wrong. But I think both types of Pneumocytes sit in the basement membrane. Damage to Type 2 results in an inability to restore lung tissue (they regenerate 1 and increase surfactant) whereas type 1 is used for gas diffusion. So if the BM with the type 2 pneumocystis is damaged, no restoration. I didn't pay much attention to preclude though lol...
21-OH is the most common def, and it has 3 subtypes.
1) A Classic salt wasting: at birth, dehydrated, low Aldosterone (high K, low H, low water), ambiguous genitalia
2) A classic non salt wasting: at birth, ambiguous genitalia, fluid level normal
3) non classic late subtype which is basically A/S and just has girls with acne, oligomenorrhea and hirsutism.
High 17 indicates that the defect must be 21.
11 defects --> 21 will be high because 11 comes after 21, hypertension will be seen
watch Dr. Randy Neils YouTube video on this, amazing job!
Kaposi Sarcoma --> up regulation of VEGF --> treat with an anti-VEGF eg. bevacizumab (anti-neoplastic)
The kidney on the right side lies slightly lower because the liver pushes it down. So the border is sort of rib #11.5 or 12th between the liver and the right kidney.
On the left side, the border between the spleen and the left kidney is the 11th rib --> 9th and 10th are above this so the injury was to the spleen. Also recall that the MOST commonly damaged organ after trauma is the spleen.
Like another common stated, B,C,D,E are wrong right off the bat. A says DISCUSS treatment and referral. It's not the same as saying refer to etc. Even if referral threw you off, don't you think it's important to ask the patient why he's doing what he is and if he wants to change/ or know the long term effects rather than straight up saying "here, take some methadone. it'll help you quit". what would you want in this patients shoes? someone to help you through the situation step by step (most probabaly)
โBlood solubility: slow speed
โBlood solubility: fast speed
โLipid solubility: very potent
โLipid solubility: not potent
Potency = 1/ MAC
Important to not confuse the equations on this one. Because they asked for women only, we can eliminate the mens information.
RR = ET/ EC =33%
ARR = EC - ET = 8%
RRR = EC - ET / EC = 67% (our answer)
Holosystolic: MR, TR, or VSD
Lower left sternal border (the left border is Erb's point, beneath that is the Tricuspid area) --> TR or VSD
Whats more common? VSD (by far!!)
If they had mentioned the mum having BPD or taking pills for a psych disorder, then TR could be a big contender.
so this patient had a very tender thyroid gland.
first start ruling out. no exop was trying to say its not graves. she also had a LOW TSH (indicating it was hyperthyroid ~ recall that many hypothyroid conditions present with primary hyperthyroidism labs).
there wasn't enough to support A here (should have low iodine uptake and low thyroglobulin).
thyroid abscess needed a fever and is just an odd Dx.
Toxic MNG and subacute left.
subacute or de quervains is VERY painful. if you look in the endo section, subacute is actually the ONLY tender condition
Concentric: in order of most to least common
1) HTN
2) Aortic Stenosis
3) HCOM
Concentric is a Chunky wall (the ventricle is not dilated, on the wall is thicker)
C,D and E were obviously wrong. A and B were left. I opted for B, but then changed it. A nurse may not be able to catch the same things a doctor could. And also, A says to ASK. She has the right to say no, and what happens after that is of no concern to us in this scenario. Theres never any harm in asking.
I use parasympathetic/ sympathetic principles to figure this out. If you're laying down, you're most likely resting and digesting. That rules out E, C (RAAS is due to high Sympathetic tone) and also D (high plasma volume is a result of RAAS). This left A and B. Decreased plasma sodium volume would have been the case if he was drinking a lot of water, or had SIADH possibly. I couldn't really find the connection between this option and his PNS activity. So I went for A, especially because it was directly opposite of one option I KNEW was wrong.
High Alkaline phosphates (bone, GB, liver)--> test the GGT
High GGT indicates gall bladder issue (ALKP >> AST & ALT)
Low GGT is liver disease (ALKP << AST & ALT)
Bilirubin is high in both
Unconjugated is high when there's a def of UDP-glucoronylase. This guy has stones in the CBD; they can't get out. that's going to be increased conjugated bilirubin
I feel like everyone is talking about all these reactions when I just draw out the graph. We wanted to increase the Km (move it on the X axis), that would lead to it crossing on the y axis (Vmax). if we kept the Km at the same spot, it wouldn't overlap the point on the max else they'd have been the exact same lines...
NADPH def: CGD --> infections with catalase + (SNAPS - staph species, nocardia (NOT actinomyces), aspergillus, pseudomonas (esp cepacia), serrate marcescens) ~ Dihydrorhodamine or nitroblue tetrazolium testing MPO def: candida infections, responsible fro green colour of sputum
UW: "gaps between endothelial cells allow blisters to form". this guy has a blister.
Was about to choose decreased transferrin because I couldn't see hyper-segmented neutrophils. But NBME often tries to throw us off with vague images. So I read again. Caught the "Ileal resection". Iron Fist Bro! Ileum is B12 absorption. B12 results in megaloblastic anemia. N5-MTHF is a step in converting DHF into THF. Inhibited in megaloblastic anemia like B12 and B9 def.
"splinting" (pushing the vaginal canal with fingers to defecate) is commonly seen with a rectocele.
+Pelvic organ prolapse includes pelvic pressure ("feeling a bulge or that something is falling out of the vagina")
+Posterior vaginal wall prolapse (rectocele) can cause constipation
+splinting is common but not uterine enlargement
+Premenopausal, nonobese nulliparous women are at lowest risk for pelvic organ prolapse.
https://www.pelvicexercises.com.au/wp-content/uploads/2019/05/Rectocele-prolapse-min.png
Stool seems to go towards the vaginal wall, but doesn't come out. pushing the POSTERIOR vaginal wall towards the bum will help with defecation
Asking about the CAUSE, not the response. The cause for a dilated ureter is increased GFR.
4 values are considered Pc (increases push into ureter direction) Pi (increases push into bowmans) ฯc (increases pull into bowmans) ฯi (increases pull into direction of ureter)
If ureter is dilated, the bowmans capsule is PUSHING out more fluid โ> increased GFR (high Pc) and pulling less (low ฯc)
Got this wrong because I thought they wanted to know what the response would be...
Goljian: Pregnancy/ OCP use: High T4, normal TSH Steroids(anabolic): Low T4, normal TSH
Resistant to digestion: does not break or get deactivated (endonuclease creates a nick in the strand, which means that it BREAKS the strand; even if it is for correction purposes) Deactivation is done by methylation; so if methylase is defective, the sequence will never be muted (digested/ broken down/ cleaved)
the child was in a daycare, sonnei and rotavirus are the ones to keep in mind. sonnei can also be due to unwashed veggies too. and the inflammatory stool (neutrophils) also indicates sonnei. the lack of exposure (undercooked meat for EHEC) helps to rule out E.Coli. dirty water (ETEC and EIEC) aren't possible because of this kids bloody stool. Also for this to be HUS (the only possible E.Coli with bloody diarrhea), we should have seen the triad or at least something about it (anemia + thrombocytpoenia + Acute Renal Insuff.). Also, "mucoid stools" is right from the FA chart for shigella.
I just used common sense to rune out the answers here. Firstly, knowing that cortisol is increased during times of stress (starvation; like this stem). Insulin causes hypoglycaemia so the body wouldn't produce more in a stressful state (expect glycogen to be higher). IGF-1 acts like GH and these states of growth require energy which this man clearly doesn't have. There wasn't enough to support testosterone and T3 changes so those were ruled out pretty quick.
I had this narrowed down to Influenza virus and 23-Valnet Pnuemococcal. I was opting fro 23 but this patient actually has a dry cough, whereas Strep P often has a productive, rust coloured cough. Also, Strep Pneumo often causes pulmonary consolidation and so breath sounds would be increased. But don't forget, influenza can increase the risk of staph aureus pnuemo!
Common Chelators:
Commonly Chelated Drugs:
These create insoluble complexes and are inhibited from being absorbed!
FA 2019 page 308. Most common cause of acute/primary pericarditis is assumed to be viral.
Acute stress disorder involves flashbacks of traumatic event, avoidance of triggers, depressed mood, and nightmares; lasts 3 days - 1 month; can evolve to PTSD if lasts >1 month
Panic Disorder is recurrent and happens unexpectedly without known triggers
Biploar and Histrionic easily ruled out
Alcohol Withdrawal is left as the right answer. Symptoms also match with time course. Delirium tremens 2-4 days after last drink
This question is really testing what the different types of diarrhea show. Key is "stool shows no abnormalities". In malabsorption, exudative, osmotic, and secretory diarrhea, your poop would be weird in some way. A motility disorder is the ONLY type here that would cause normal poop.
Transposition of the vanA gene from vancomycin-resistant Enterococcus is how it transfers resistance. They use transposons which are located on plasmids. If you have plasmid loss, you won't have transposons, and resistance will decrease.
Could someone explain why this choice is the best answer? I struggled between A and D, and picked A finally, which is "ascertain educational level and provide publications".
warfarin inhibits epoxide reductase which prevents gamma carboxylation of NEW vitamin K dependent clotting factors. the therapeutic efficacy of warfarin is delayed until prexisting/OLD factors get consumed, which usu takes at least 3 days.
Therefore, it will not affect the PT for at least three days because the old factors are still around. Since factor II has the longest half life, it takes the longest for the old factor II to go away/get used up and that is why the PT has not increased yet in this patient.
"splinting" (pushing the vaginal canal with fingers to defecate) is commonly seen with a rectocele.
+Pelvic organ prolapse includes pelvic pressure ("feeling a bulge or that something is falling out of the vagina")
+Posterior vaginal wall prolapse (rectocele) can cause constipation
+splinting is common but not uterine enlargement
+Premenopausal, nonobese nulliparous women are at lowest risk for pelvic organ prolapse.
https://www.pelvicexercises.com.au/wp-content/uploads/2019/05/Rectocele-prolapse-min.png
Stool seems to go towards the vaginal wall, but doesn't come out. pushing the POSTERIOR vaginal wall towards the bum will help with defecation
I feel like everyone is talking about all these reactions when I just draw out the graph. We wanted to increase the Km (move it on the X axis), that would lead to it crossing on the y axis (Vmax). if we kept the Km at the same spot, it wouldn't overlap the point on the max else they'd have been the exact same lines...
Was about to choose decreased transferrin because I couldn't see hyper-segmented neutrophils. But NBME often tries to throw us off with vague images. So I read again. Caught the "Ileal resection". Iron Fist Bro! Ileum is B12 absorption. B12 results in megaloblastic anemia. N5-MTHF is a step in converting DHF into THF. Inhibited in megaloblastic anemia like B12 and B9 def.
If patient -only- had hypertension: ACTH more likely than SIADH.
Patient with hypertension AND hypokalemia: 100% ACTH.
Don't feel bad friends, I also had this question wrong :(...
Asking about the CAUSE, not the response. The cause for a dilated ureter is increased GFR.
4 values are considered Pc (increases push into ureter direction) Pi (increases push into bowmans) ฯc (increases pull into bowmans) ฯi (increases pull into direction of ureter)
If ureter is dilated, the bowmans capsule is PUSHING out more fluid โ> increased GFR (high Pc) and pulling less (low ฯc)
Got this wrong because I thought they wanted to know what the response would be...
"Parasternal heave (lift) occurs during right ventricular hypertrophy (i.e. enlargement) or very rarely severe left atrial enlargement." RV hypertrophy can be seen so easily because the RV is at the anterior surface of the chest.
In this patient blood from LA to LV decreases in saturation, so it is going somehwere. From the O2 sat. we can deduce there is probably a VSD (increased RV pressure would cause RVH and parasternal heave). Furthermor, the vignette is likely describing tetralogy of fallot (caused by anterosuperior displacement of the infundibular septum). In Tet spells, RV outflow is too obstructed and patient gets cyanosis and R>L shunting Squats increase SVR, decreasing R>L shunting, putting more blood through pulmonary circuit and relieving cyanosis.
Patient has Spina bifida occulta which is a neural tube defect (failure of fusion of the neuropores). Sclerotomes are the part of each somite in a vertebrate embryo giving rise to bone or other skeletal tissue. Since a part of this patient's spina bifida included "abscense of spinous process" then a sclerotome was involved. Knowing that neural tube defects are an issue with fusion should be enough to get to the right answer.
If the notochord failed to develop then the entire CNS would not develop as the notochord induces formation of neural plate.
If the neural tube failed to develop then the whole CNS would not have developed.
Yolk sac is irrelevant to this patient.
When neural crest cell it has different outcomes in different tissues. Failure of neural crest to migrate in heart can cause Transposition of great vessels, Tetralogy of Fallot, or Persistent truncus arteriosus. Failure of neural crests to migrate in GI can cause Hirschsprung disease (congenital megacolon). Treacher Collins Syndrome can occur when neural crest cells fail to migrate into 1st pharyngeal arch. Neural tube defects has nothing to do with failure of neural crest migration though.
How do you distinguish this from testicular torsion? Is it just because it started in the left flank?
Notice that A) Bronchoconstriction, B) Glandular secretion, D) Peristalsis, E) Vasodilation of skin are all under parasympathetic control.
The only sympathetic control is heart rate, which would increase.
Notice that A) Bronchoconstriction, B) Glandular secretion, D) Peristalsis, E) Vasodilation of skin are all under parasympathetic control.
The only sympathetic control is heart rate, which would increase.
MHC I function is integral to cancer suppression. MHC I displays endogenously synthesized proteins and presents them to CD8+ T cells. The failure to display MHC I, or MHC I display of non-self (and by extension cancerous) proteins triggers a cellular immune response, leading to destruction of the cell.
The proteasome is used for the degradation of worn out, senescent, or malformed proteins. As cancer develops, more mutations lead to increased wrong proteins. Only by expression of the proteasome, or its over-expression, can these mutant proteins be degraded fast enough to not be displayed by MHC I and lead to the cell being killed. Bortezomib blocks the proteasome, so the mutant proteins are displayed on the surface, allowing the immune system to recognize and kill pathological cells.
Could someone explain why "Cardiac catheterization with stent placement" is incorrect?
My thought process was that this guy has an occlusion of his RCA --> knocking out his AV node --> 3rd degree AV block. Also his pulse is 40 which suggest a RCA infarction as well.
The reason I went with this is because he got to the hospital within 30 minutes and they put this information first and made it seem important. If his RCA could be opened up, then the damage could be reversible.
I get the pacemaker, but first I feel like you would attempt to unocclude the vessel and give it some integrity.
Glucose is co-transported into enterocytes of SI via sodium
can anyone please explain why option E which is increased in Urinary pH is not the correct answer. becasue hydrogen wasting is also a form of correcting respiratory acidosis.
can anyone please explain why option E which is increased in Urinary pH is not the correct answer. becasue hydrogen wasting is also a form of correcting respiratory acidosis.
How did anyone get this as T cruzi? That was literally the first answer I ruled out. She has swelling of the eye, but that is the only sx that fits. Chagas presents 10-20 years after initial infection, not two weeks later. It also doesn't present with recurrent fever, muscle aches and joint pain. I mostly ruled it out because of the time course.
This article explains the pathophysiology well: https://www.ncbi.nlm.nih.gov/books/NBK431048/.
The right ventricle is primarily supplied by the RCA which also supplies the SA node and AV node (90% of hearts because they are right dominant), leading to loss of contractility of the right side, and thus fluid buildup causing elevated central venous pressure. Elevated pressures in the liver and portal system would lead to hepatomegaly and free fluid accumulation in the peritoneum.
This is a case of acute transplant rejection. weeks to months after the transplant, recipient cd8 and/or cd4 t cells are activated against the donor (a type 4 HSR) and the donor starts making antibodies against the transplant. This presents as a vasculitis with dense interstitial lymphocytic infiltrates. (FA2018 pg 119)
Lifting head while prone: 1 month Social smile: 2 months Cooing: 2 months
my list of spindle type cells and conditions:
Bronchogenic carcinoma = lung cancer
That being said, lung adenocarcinoma specifically is associated with hypertrophic osteoarthropathy, which is a paraneoplastic syndrome characterized by ๏ปฟdigital clubbing, arthralgia, joint effusions, and periostosis of tubular bones
Weakness with decreased muscle bulk implies problems that include the lower motor neuron system. Decreased DTRs implies a disrupted reflex loop but the absence of sensory loss implies that it is on the motor side of the reflex loop. Of the available choices, B is the best fit. "A" is arguably true because a strictly motor polyneuropathy (such as in lead poisoning) could account for the findings, but a 3-month course could hardly be called "acute."
This is hereditary spherocytosis. The image stinks, but the cells are not super pale in the middle and they're round. Her dad also had a splenectomy (HS is autosomal dominant), which is the definitive treatment for HS.
Pt is also normocytic (90.2 um^3), so a lot of the other answer choices can be eliminated based off this.
In the end, screw this picture because it's not clear and you can't zoom in.
Always be kind! Spending a few extra minutes will make him feel better, solidify your relationship, and not really waste too much of your time. She passed away on this same day, he must be very sad and having someone to talk to can change everything.