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 +5  (nbme21#23)
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 +22  (nbme21#29)
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hello  I want to re-emphasize something that @assoplasty has already stated :). The Q-stem states serum glucose = 100, and the Q asks why the patient is able to maintain normoglycemia. Therefore, you can immediately eliminate choices A and C because acetoacetate and beta-hydroxybutyrate are sources of energy during ketogenesis -- ketogenesis does not provide glucose energy sources. +7
chandlerbas  ^ this checks out: valine and isoleucine are broken down in the muscle into branched chain 2 oxo acid via branched chain aminotransferase (reversible) then the valine and isoleucine leave the muscle and swims to the liver to be acted on by branched chain 2 oxo acid DH (irreversible). So bascially the process from taking BCAA valine and isoleucine requires 2 enzymes. the first enzyme is in the muscle, and the second enzyme is in the liver (for simplification purposes --> both organs contain both enzymes but dont have the same affinity for their substrate). source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1147506/?page=4 so you're right to say that the liver +5
toxoplasmabartonella  Thank you for such a great explanation. Isn't it glutamate instead of glutamine that combines with pyruvate in muscle to yield alanine for Cahill cycle? +1
almondbreeze  @ toxoplasmabartonella think you are right +
revanthshanmukh  its given that methionine histidine and valine are glucogenic AA.nso why not these form the glucose in the body first compared to alanine? +

 +66  (nbme21#31)
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I tnihk hte tpocnec erety’h ngsiett is teh idcrnseea TGB eelslv ni pyrengan,c dan tno stuj tpriiysrmdehyho in lengare.

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hTe qoueitsn si ginaks who ot fincorm tyoidhhyirrpesm ni a egnntpar ownam --tg;& you eedn ot hkcec RFEE T4 lleevs seu(ecab etyh hdusol eb arnlmo ude ot rtosneoycpam ro.eess)pn You ntonac kcche HTS layu(uls aeevtled ni agnpercyn ot cmpoeeatns rfo cserdnaei ,G)TB dna ouy tocnan ckhec ltaot T4 eellvs w(lil be sn).caeired uoY tgo the snerwa gthir iehtre ayw tub I khnti sith is a reidfentf oangsrnie othwr dincsei,rong ebacseu yeth acn ask tish noeptcc in troeh xtoentsc fo myreitgserenohps-, adn if etyh slited ”“TSH as an arsnwe cchioe thta owdul be eoriccn.rt

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +8
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +2
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +1
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +1
lovebug  Amazing answer! THX +
an_improved_me  Just to add: Pregnancy is not an exception to using TSH in suspected hyperthyroid pregnant patients (not sure in hypothyroid); you would still get a TSH first, and if its unusually low, you would then proceed to measure T4 (free, total), and so on. https://www.uptodate.com/contents/hyperthyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-causes?search=hyperthyroidism%20in%20pregnancy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H994499 +




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