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 +0  (step2ck_free120#120)

Type II error is the possibility of producing a false negative (a negative result when it should be positive). A smaller sample size may not be able to detect a small (but real) treatment effect and thus increases the chance of type II error.


 +0  (step2ck_free120#119)

The patient has rhabdomyolysis from a prolonged visit with the floor. The ridiculously high CK confirms the diagnosis. Rhabo causes renal failure and requires aggressive fluid resuscitation.


 +0  (step2ck_free120#118)

They hit you over the head with hypocalcemia symptoms before giving the value. Hidden in there is the pancreatic insufficiency causing steatorrhea and fat-soluble vitamin deficiency (A, D, E, and K).


 +0  (step2ck_free120#40)

IBS is a “functional” G.I. problem, which means that it is a diagnosis of exclusion (must rule out IBD, Celiac, etc). You may have enjoyed its recent popular appearance on television as a disturbing anthropomorphized walking bowel. Common symptoms include diarrhea, constipation, pain relieved by defecation, and flatulence, often subject to a degree of emotional valence. As such, like headaches, IBS symptoms can be improved by TCA therapy, such as nortriptyline.


 +0  (step2ck_free120#116)

Fever, AMS, and muscle rigidity in a patient on antipsychotics (aka ‘neuroleptics’) means neuroleptic malignant syndrome (NMS). Very rare, very dangerous.


 +0  (step2ck_free120#115)

Remember cystic fibrosis in young people with worsening obstructive lung disease and frequent infections. The infertility in males is secondary to failure of the vas deferens to develop properly (in women, it’s due to thick cervical mucus). Sweat chloride test makes the diagnosis.


 +0  (step2ck_free120#114)

Genital warts don’t hurt and they turn white with vinegar (acetic acid). No systemic therapy works (although there is now a vaccine), but cryotherapy (as well as laser and electrocautery) can help. HPV will remain, however, and the lesions can recur.


 +0  (step2ck_free120#113)

Don’t let the carpal tunnel history fool you. Numbness of the pinkie and half of the ring finger is ulnar entrapment (cubital tunnel syndrome, which happens at the elbow); carpal tunnel syndrome is the median nerve at the wrist (affecting thumb, index, middle, and half of the ring)


 +0  (step2ck_free120#112)

The inclusion bodies signify that this patient has a CMV infection of the renal transplant, which can originate from either the donor or recipient but are activated/unmasked by immune suppression. CMV is an important cause of morbidity and mortality in renal transplants and both the donor/recipient are routinely screened.


 +0  (step2ck_free120#111)

The lungs are clear. Location, JVD, and lack of heart sounds mean cardiac tamponade from hemorrhage into the pericardium. Pericardiocentesis is the next step. Don’t forget, if you see tension pneumothorax or a water-bottle heart (from tamponade) on chest xray, you’ve already delayed life-saving therapy.


 +0  (step2ck_free120#3)

The STD that forms a painful ulcer aka chancroid = H ducreyi (ducreyi makes you cry, as they say).


 +0  (step2ck_free120#21)

Confusion and tremulousness a few days after an unexpected hospital admission on the USMLE means alcohol withdrawal (unanticipated detox).


 +0  (step2ck_free120#108)

The majority of twins are born premature, which is even more true for triplets. Only monochorionic twins experience twin-twin transfusion syndrome (as they have to share a blood supply in order for the problem to occur).


 +0  (step2ck_free120#107)

STDs are always double-treated for both chlamydia and gonorrhea, as coinfection is extremely common, and clearance is crucial to prevent reinfection and continued spread. That means anyone with cervicitis or urethritis gets azithromycin or doxycycline with ceftriaxone.


 +0  (step2ck_free120#106)

If environmental, food, or exposure allergies ever include shortness of breath, hoarseness, or anything remotely airway-involving or anaphylaxis-like, then carry an epi-pen.


 +0  (step2ck_free120#30)

The most common cause of hypothyroidism in developed countries is Hashimoto’s thyroiditis. In developing countries, it’s iodine deficiency.


 +0  (step2ck_free120#104)

It’s a cholesteatoma, which can be congenital (rare) or acquired (much more common). Even if you have no idea what that is (look it up), it’s the only answer with “proliferation” to go along with the mass. None of the others mention anything remotely mass-like.


 +0  (step2ck_free120#103)

RUQ pain and nausea after meals is concerning for symptomatic cholelithiasis. The test of choice is RUQ sono to assess for stones.


 +0  (step2ck_free120#102)

A nagging persistent dry cough is a common side effect of ACE-inhibitors due to bradykinin accumulation (bradykinin is normally degraded by ACE). Along with angioedema, it’s an important reason for discontinuation; the solution for both is to switch to an angiotensin II-receptor blocker (ARB) like losartan, which does not affect ACE activity directly.


 +0  (step2ck_free120#101)

Everyone should get a flu shot. Diabetics are relatively immune suppressed and deserve it even more.


 +0  (step2ck_free120#100)

Obstructive sleep apnea (OSA) is diagnosed exclusively by polysomnography (aka a sleep study).


 +0  (step2ck_free120#99)

Multinodular goiter! Say it five times fast. Feels good, doesn’t it? The first half describes blatant hyperthyroidism. The thyroid scan is now demonstrating an enlarged gland with multiple nodules (“areas”), some avid/hyperfunctioning and other relatively depressed (either not “hyper”-functioning and thus relatively cold or actually cold, most commonly filled with colloid).


 +0  (step2ck_free120#33)

Thrombocytopenia without antiplatelet antibodies or splenomegaly implies a platelet production problem (e.g. myelofibrosis). History of radiation therapy is a risk factor. The only way to know what’s happening at the factory is a bone marrow biopsy.


 +0  (step2ck_free120#97)

Thick, white, and acidic means candidal vulvovaginitis (aka a yeast infection). Bacterial vaginosis typically only causes foul/fishy odor (and is alkaline, has a positive whiff test, clue cells on wet mount, etc).


 +0  (step2ck_free120#96)

Myocardial infarction causes heart muscle death (as the name implies). Lose enough muscle and you get systolic heart failure.


 +0  (step2ck_free120#15)

The first imaging test in acute stroke is a noncontrast CT scan of the head. At 12 hours out, it may show ischemic strokes, but more importantly, it will diagnose hemorrhagic strokes, for which reperfusion and antiplatelet therapies are contraindicated.


 +0  (step2ck_free120#94)

Septic arthritis (rapidly warm swollen joint +/- fever) must be tapped, followed by antibiotics. Untreated, the joint can be destroyed in days. Minor trauma can predispose to hematogenous bacterial spread.


 +0  (step2ck_free120#93)

Painless uterine bleeding goes with placenta previa. Painful uterine bleeding goes with placental abruption. Ruptured vasa previa results in rapid loss of the fetus.


 +0  (step2ck_free120#92)

The drugs of choice for Alzheimer’s-type dementia (i.e. general dementia without specific factors to make you consider other diagnoses) are the cholinesterase inhibitors, the most important of which is Donepezil.


 +0  (step2ck_free120#91)

PTSD symptoms that begin within 4 weeks of a traumatic event and last 4 weeks or less is acute stress disorder (ASD).


 +0  (step2ck_free120#90)

Frequent turning prevents the development of pressure ulcers in patients with decreased mobility.


 +0  (step2ck_free120#89)

The description of a primary lung cancer with associated muscle weakness is leading you to Lambert-Eaton myasthenic syndrome, a paraneoplastic autoimmune condition where antibodies attack the presynaptic calcium channels of the neuromuscular junction. Lung-cancer paraneoplasias are test favorites.


 +0  (step2ck_free120#88)

You know what causes sudden onset headache and neck stiffness? Subarachnoid hemorrhage. The first episode can be transient, the so-called sentinel bleed before a catastrophic aneurysmal bleed.


 +0  (step2ck_free120#87)

Asymptomatic bacteriuria is never treated, except in pregnancy, when it should always be treated due to its association with preterm labor. Treat with an oral antibiotic that covers gram negatives (like E coli), such as amoxicillin or nitrofurantoin.


 +0  (step2ck_free120#14)

Via urinalysis and renal ultrasound, we’ve excluded serious/treatable causes of renal hypertension including Conn’s disease (hyperaldosteronism) and renal artery stenosis such as due to fibromuscular dysplasia. That leaves her obesity.


 +0  (step2ck_free120#85)

A boot-shaped heart means Tetrology of Fallow on board exams. Outside of that rare straight-up buzzword giveaway, TOF is by far the most common cause of cyanotic heart disease.


 +0  (step2ck_free120#4)

The thing you do with things that look like skin cancer is excise them completely.


 +0  (step2ck_free120#83)

Most common palpable breast mass in women less than 30 is fibroadenoma. In women between 30-50, it’s a cyst (or fibrocystic changes of the breast). Greater than 50, malignancy.


 +0  (step2ck_free120#82)

Lumbar strain doesn’t require specific treatment or workup. Bed rest (old school idea) has actually been shown to worsen outcomes.


 +0  (step2ck_free120#35)

This patient has urge incontinence, which is commonly caused by detrusor instability (and can be treated with anticholinergics like oxybutynin). This is opposed to stress incontinence, the other most common type, which is worsened by abdominal pressure/coughing/laughing/etc and can be caused by pelvic floor prolapse secondary to multiple childbirths etc. Neurogenic bladder can cause overflow incontinence.


 +0  (step2ck_free120#9)

Post-traumatic AV fistula! Just like dialysis AV fistulae have bruits and thrills, so do non-purposefully created ones. These can take a long time to form but can be associated with steal syndromes due to decreased perfusion to the distal extremity, venous incompetence, varicosities, and eventually stenoses due to unreasonably high flow, and even high-output heart failure.


 +0  (step2ck_free120#10)

We can only put the laboratory tests into context if we have an accurate gestational age. Since her LMP is unreliable (totally unknown), we need an ultrasound to date her pregnancy. The most common cause of an abnormal MSAFP is wrong dates.


 +0  (step2ck_free120#78)

They describe claudication and vascular insufficiency with strong flow in the groin and no palpable flow distally in the dorsalis pedis, placing the level of stenosis somewhere in between (i.e. femoropopliteal). Diabetes and smoking are two big risk factors for peripheral arterial disease (PAD).


 +0  (step2ck_free120#76)

Walking pneumonia is treated with macrolide antibiotics as first line. Patchy infiltrates in a patient with clinical pneumonia symptoms who otherwise young, healthy, and walking around…think mycoplasma.


 +0  (step2ck_free120#75)

One of the S in SIGECAPS is for suicidality. Depression is extremely common, and it’s also underdiagnosed and undertreated in cancer patients.


 +0  (step2ck_free120#73)

Folic acid prevents neural tube defects. End stop.


 +0  (step2ck_free120#72)

Mitral valve stenosis is a sequela of rheumatic heart disease that can lead to LAE and left-sided heart failure if left untreated.


 +0  (step2ck_free120#8)

Again, acute RUQ pain (especially in an obese woman) should set off the gallstone alarms. Fever and other systemic signs, white count, etc lead you down the acute cholecystitis. Simple pain leads you to symptomatic cholelithiasis. Either way the first step is to get a RUQ sono to see those stones! HIDA is used as an adjunctive study in cases of cholelithiasis to assess for cystic duct obstruction (and thus likely acute cholecystitis) in equivocal cases.


 +0  (step2ck_free120#20)

The primary mechanism by which beta-blockers reduce angina is via decreased contractility, which reduces the oxygen demand of the myocardium (which has a constrained supply due to coronary artery disease). Lowering heart rate also helps, but that isn’t one of your choices.


 +0  (step2ck_free120#65)

Abdominal pain is a common presenting complaint of DKA, which is a common presentation of new-onset type 1 diabetes. Note the glucose of 360.


 +0  (step2ck_free120#66)

Abnormal vaginal bleeding in a woman over 35 requires an endometrial biopsy to rule out endometrial cancer.


 +0  (step2ck_free120#67)

It’s not clear that the glucose is a fasting value or not, but it’s clear that the patient has symptoms of diabetes in the context insulin resistance (obese kid with acanthosis nigricans). Diet and exercise are always necessary in DM2 and can reverse many early cases. With a 10% weight loss, for example, the patient may not require pharmacotherapy.


 +0  (step2ck_free120#68)

Marfan syndrome (you know, hinted at by the familial tall stature and weak hypermobile joints) is associated with a dilated/aneurysmal aortic root, which can worsen, dissect and/or rupture if not monitored.


 +0  (step2ck_free120#69)

Meniere disease is characterized by recurrent vertigo attacks associated with ear fullness, tinnitus, and hearing loss.


 +0  (step2ck_free120#70)

Follow your ABCs. Tachycardia and hypotension mean severe volume loss necessitating aggressive intravenous fluid resuscitation.


 +0  (step2ck_free120#71)

Totally healthy people with indirect hyperbilirubinemia means Gilbert syndrome (which causes decreased bilirubin conjugation due to reduced glucuronyltransferase activity).


 +0  (step2ck_free120#64)

They’ve listed the criteria for ADHD. Note that conduct disorder is the kid-version of antisocial behavior. If the kid breaks rules and messes up but doesn’t seem evil, then it’s not conduct disorder.


 +0  (step2ck_free120#63)

Organ donation is a complex organizational dance, and the regional procurement organization manages the nitty-gritty aspects.


 +0  (step2ck_free120#62)

Weight gain, fatigue, and constipation go with hypothyroidism. High LDL cholesterol actually does too, but the question is doable even when ignoring the lab values.


 +0  (step2ck_free120#37)

The radiograph is showing complete collapse of the left lung (2/2 mucous plugging) with resultant severe ipsilateral mediastinal shift. An acute shift can have the same effect as any other “tension”-type process, causing impaired venous return to the heart and decreased cardiac output via the Starling mechanism.

amayap  do you mean collapse of the right lung and contralateral mediastinal shift=spontaneous secondary pneumothorax from plugging +

 +0  (step2ck_free120#60)

Repeated microtrauma from repetitive stress can cause thrombosis. DVT leads to erythema and venous engorgement, the other choices do not. For bonus points, the eponym for effort-induced upper extremity DVT is “Paget–Schroetter disease” (for those keeping track at home).


 +0  (step2ck_free120#59)

Bronze diabetes and arthritis means hemochromatosis. They never say the words “bronze diabetes” on board questions, but it doesn’t mean it’s not there. You don’t want an awesome tan on the boards.


 +0  (step2ck_free120#58)

Cough is often the only sign of asthma. Exercise-induced asthma is exercise-induced asthma.


 +0  (step2ck_free120#57)

Crescents mean rapidly progressive glomerulonephritis (RPGN—bad news bears). Immune complexes along the basement membrane mean Type II, such as seen with lupus, IgA nephropathy, acute proliferative glomerulonephritis, and Henoch-Schönlein purpura. Treated with immune suppression, which in the acute phase always means steroids.


 +0  (step2ck_free120#56)

ABCs. Patient has an airway (evidenced by breath sounds without mention of other complicating factors like unconsciousness). Move on to breathing. Asymmetry implies a hemo-, pneumo-, or hemopneumothorax, which requires a chest tube immediately.


 +0  (step2ck_free120#55)

A p-value less than 0.05 means that the results are statistically significant. However, most would agree that roughly 7 hours difference in cold duration is clinically insignificant.


 +0  (step2ck_free120#20)

Patients who have the capacity to make medical decisions are allowed to refuse life-saving medical treatment. You should offer it but accept her refusal.


 +0  (step2ck_free120#53)

Pinpoint pupils are a classic tip off for opioid use (caused by parasympathetic activation). Additionally, neither alcohol nor barbiturates would be likely choices in this context because they have similar effects (along with benzodiazepines).


 +0  (step2ck_free120#52)

Interstitial nephropathy (also known as tubulointerstitial nephritis) is most commonly an allergic-type reaction to medications, typified by eosinophils in the urine. The nonspecific maculopapular reaction is also the common type of drug reaction rash and is seen in a minority of cases, as is low-grade fever (not critical to the question). Several medications can cause this: penicillins, cephalosporins, and NSAIDs are the most common.


 +0  (step2ck_free120#13)

Working up serious hypoglycemia involves measurement of both insulin and C-peptide (the cleaved by-product of endogenous proinsulin) to assess for hyperinsulinemia and distinguish endogenous (e.g. insulinoma) from exogenous (e.g. Munchausen’s) causes. “Nurse” is a common Munchausen tip-off (someone with the know-how and skills to pull it off well).


 +0  (step2ck_free120#50)

Transillumination of a scrotal mass equals a hydrocele, which is due to a patent processus vaginalis.


 +0  (step2ck_free120#2)

Dermatomal rash means zoster (a chickenpox/varicella reactivation disease). Immune insults, like chemotherapy, predispose to zoster flares.


 +0  (step2ck_free120#48)

Weight loss and iron deficiency anemia are concerning for colon cancer with occult blood loss. Colonoscopy is required. Parasitic causes of iron deficiency (e.g. hookworm) are first tested with stool ova & parasite screening.


 +0  (step2ck_free120#47)

Wide split fixed S2 is an ASD. (Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#46)

Weight loss and worsening lung symptoms in a smoker mean lung cancer. Non-small cell is by far the most common variety. The small cell variety on tests will usually have fun paraneoplastic syndromes.


 +0  (step2ck_free120#45)

Headache and stiff neck clue you to meningitis. In a college student, that’s enough for the diagnosis of meningococcal meningitis. Stop reading. The treatment is ceftriaxone.


 +0  (step2ck_free120#44)

The differential for chronic diarrhea in an AIDS patient includes bacterial, viral, and parasitic causes as well as HIV enteropathy. Cryptosporidium is a protozoa that classically causes watery diarrhea in AIDS patients, especially those exposed to unclean water sources (hence the traveling to Asia). CMV is a reactivation infection and MAC is ubiquitous; disease caused by either of these pathogens is due to severely depressed immunity (i.e. CD4 < 50).

icestreak  Isn't cryptosporidium assoc with CD4 <180? UW Q3590 +

 +0  (step2ck_free120#5)

Lisinopril and especially spironolactone (a K-sparing diuretic) can both cause hyperkalemia. Renal failure (severe AKI or ESRD) is also a major cause of hyperkalemia, but not in this case with the only mildly elevated Cr and BUN levels.


 +0  (step2ck_free120#42)

Low pH means acidemia. Renal failure causes metabolic acidosis (hence low bicarb). Low CO2 is the respiratory compensation. If it was vice versa, the pH would be high (alkalemia).


 +0  (step2ck_free120#41)

Pseudogout (calcium pyrophosphate deposition disease) is an inflammatory arthritis with a predilection for the knee that causes synovial calcifications.


 +0  (step2ck_free120#40)

Exfoliative and blistering drug reactions come in three severities of the same mechanism: erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Diffuse involvement (>30%) is consistent with toxic epidermal necrolysis (TEN), which carries a 30-40% mortality.


 +0  (step2ck_free120#15)

Fever, pain, and swelling behind the ear mean mastoiditis (remember the mastoid air cells?). The cause is nearly universally direct spread from otitis media.


 +0  (step2ck_free120#38)

Sudden respiratory failure after rupture of membranes means amniotic fluid embolism (it’s not like a fat embolism; it’s actually an allergic reaction). Can happen during labor or secondary to trauma. Hypotension and coagulopathy ensue.


 +0  (step2ck_free120#37)

Bipolar disorder is the only reasonable answer, as evidenced by the increased energy, elevated mood, labile affect, and poor judgment and focus. You don’t develop ADHD at 32.


 +0  (step2ck_free120#36)

LLQ pain with fever equals diverticulitis. The test of the choice is a CT scan of the abdomen with contrast.


 +0  (step2ck_free120#16)

Vasculitides like Wegener’s granulomatosis, microscopic polyangiitis, and others can cause poly-symptom disease and glomerulonephritis (hence the hematuria and proteinuria). Positive ANCA, (either P-ANCA or C-ANCA depending on the variant) is the key laboratory finding.


 +0  (step2ck_free120#34)

An acutely swollen painful great toe means gout (podagra). Gout is an inflammatory crystalline arthropathy. Aspiration reveals white cells and negatively-birefringent needle-shaped crystals. Pseudogout, which has rhomboid positively-birefringent crystals, more commonly affects the knee.


 +0  (step2ck_free120#33)

SIGECAPS+. Patient has MDD and developing panic disorder. Both of these can be treated first-line with SSRI therapy, such as paroxetine (Paxil).


 +0  (step2ck_free120#18)

Pleuritic chest pain and hypoxia with a normal chest x-ray should lead you to pulmonary embolism. There’s usually enough total lung and blood flow, but it’s the VQ mismatch that’s the issue.


 +0  (step2ck_free120#31)

An egg allergy is the most common contraindication to receiving the flu vaccine.


 +0  (step2ck_free120#11)

TTP always seems like too many disparate symptoms but just remember the pentad: thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal failure, and fever. If the symptoms list seems super long, keep TTP in mind.


 +0  (step2ck_free120#29)

Two things make this aortic dissection instead of a heart attack or pulmonary embolism. First, the diastolic murmur is that of aortic insufficiency/regurgitation, which is happening because the dissection is involving the aortic root. Second, the presence of diminished femoral pulses implies that the dissection also involves the descending thoracic aorta distal to the takeoff of the brachiocephalic and left subclavian arteries (which supply the arms). Only an issue in the aorta can cause that constellation of symptoms.


 +0  (step2ck_free120#37)

Multiple lytic bone lesions equals multiple myeloma. Blastic/sclerotic lesions should make you think of metastatic prostate cancer (in men) and breast cancer (in women).


 +0  (step2ck_free120#27)

Premature babies get neonatal respiratory distress syndrome due to surfactant deficiency.


 +0  (step2ck_free120#1)

This patient has chronic (6 weeks) symptomatic hypotension while not coincidentally on three BP meds: a diuretic, a beta blocker, and an ACE inhibitor. The most likely explanation and easiest/fastest intervention is to reduce her polypharmacy.

vshummy  Sure.. while we ignore her coarctation.... I mean I get it, stop the hypotension first but. +
derpymd  @vshummy She has subclavian steal syndrome, not coarctation. Otherwise, yes, stop the hypotension -- address the SSS when she's hemodynamically stable +

 +0  (step2ck_free120#25)

Macrocytic anemia with sensory changes is indicative of B12 deficiency. Causes include the classic pernicious anemia, but don’t forget the complications of GI surgery. Intrinsic factor is made by the stomach’s parietal cells.


 +0  (step2ck_free120#24)

Even if you forget the signs/symptoms of Kawasaki’s disease, which you shouldn’t (strawberry tongue is a giveaway), just remember it’s essentially the diagnosis for any child with 5 days or more of fever. Treatment is aspirin (the one time it’s okay in children, otherwise let’s avoid Reye’s syndrome) and IVIG.


 +0  (step2ck_free120#23)

Catecholamines, such as those released by a functioning pheochromocytoma, are made by the chromaffin cells of the adrenal medulla. Episodic headache/hypertension is the tip-off here.


 +0  (step2ck_free120#22)

Abscessed Bartholin’s cysts get incised and drained. When recurrent, they can be marsupialized, which isn’t as fun as it sounds.


 +0  (step2ck_free120#21)

Repetitive vomiting (be it due to viral gastroenteritis or bulimia) leads to hypokalemic hypochloremic metabolic alkalosis. Alkalosis means elevated bicarbonate, which in this case is created as the byproduct of increased stomach acid production.


 +0  (step2ck_free120#28)

Atopic dermatitis (eczema) is the “itch that rashes.” It’s one leg of the allergic triad: asthma, allergic rhinitis, and atopic dermatitis. Treatment is with topical steroids and rigorous emollient therapy.


 +0  (step2ck_free120#19)

A cohort study (as opposed to a randomized controlled trial) is ripe for selection bias, which occurs when the treatment and control groups are not truly comparable. Matching for some factors (age, gender) doesn’t mean you’ve controlled for all possible confounders. That’s what randomization does!


 +0  (step2ck_free120#18)

Diabetics get diabetic nephropathy. Don’t over-think things.


 +0  (step2ck_free120#17)

Consider bacterial sinusitis to be analogous to bacterial pneumonia. All are possible, but Strep pneumo is the most common.

derpymd  Uworld says the most common cause is nontypeable H. flu, S. pneumo next, followed by Moraxella. That said, nontypeable H. flu wasn't an answer +

 +0  (step2ck_free120#19)

Endometriosis is a common cause of infertility and is associated with chronic pelvic/abdominal pain and excruciating periods. Gold standard for diagnosis is laparoscopy (visualization of “chocolate cysts”).


 +0  (step2ck_free120#15)

Repetitious vomiting leads to the classic hypokalemic hypochloremic metabolic alkalosis, as well as run of the mill dehydration (hyponatremic hypovolemia). So—low sodium, low potassium, low chloride, high bicarbonate.


 +0  (step2ck_free120#14)

Euvolemic hyponatremia means SIADH. Both brain and lung insults are common causes. Nonphysiologic secretion is “inappropriate,” of course.


 +0  (step2ck_free120#13)

Polycystic ovarian syndrome (PCOS) is treated with estrogen-containing birth control (OCPs). Metformin would be an additional appropriate pharmacotherapy.


 +0  (step2ck_free120#12)

First-line treatment for panic disorder (and all anxiety disorders) is SSRI therapy. The only time you answer “benzodiazepine” (which wasn’t offered as a choice, because it would be arguable) for a panic disorder question is when they ask you what drug is “most likely to treat the episode” or something along those lines. BZDs work immediately; SSRIs take time.


 +0  (step2ck_free120#10)

Microcytic anemia is essentially always iron-deficiency unless there is a reason to suspect a thalassemia. In this case, extensive surgery has removed nutrient absorbing small bowel (the duodenum and proximal jejunum absorb iron).


 +0  (step2ck_free120#10)

Meningitis/encephalitis symptoms (fever, headache, altered mental status) with monocytic predominance and only mildly elevated protein on CSF studies go along with viral meningitis, such as HSV. Additional features (MRI findings of bitemporal signal changes and RBCs in the CSF from hemorrhagic necrosis) slam-dunk it but probably not necessary to memorize.


 +0  (step2ck_free120#8)

Autonomy matters. If a patient has the capacity to make medical decisions (i.e. understands the risks) and is not an imminent harm to self or others (i.e. suicidal or homicidal), then he cannot be held against his will. We don’t institutionalize people just for noncompliance with medical treatment.


 +0  (step2ck_free120#17)

These questions can be a true pain of biochemistry on the Step 1 or relatively straightforward depending on how well you know it. This patient has classical Galactosemia, caused by a deficiency in galactose-1-P uridyl transferase deficiency, the enzyme that converts galactose and lactose to glucose. Intolerance to dairy, hepatomegaly/liver disease/jaundice with hypoglycemia due to decreased gluconeogenesis, and reducing substances in urine are classic. Listlessness and lethargy ensue with mental retardation and eventually death if untreated. Cataracts are also common. If you didn’t get to galactosemia (or thought it was Von Gierke’s disease, which isn’t all that unreasonable), the answer is still A. By process of elimination, given the serum hypoglycemia but no urine glucose, the issue is the inability to make glucose from stores (not to absorb it).


 +0  (step2ck_free120#81)

You know people make mistakes of all types after a few drinks.


 +0  (step2ck_free120#82)

Help her feel better. That’s the point of hospice.


 +0  (step2ck_free120#83)

With family members with both primary hyperparathyroidism and an “adrenal tumor” (let’s guess pheochromocytoma), we have two out of the MEN2A triad. The third is medullary thyroid cancer.


 +0  (step2ck_free120#84)

People with CVID are at increased risk of lymphoma. B-symptoms like fever, weight loss, and night sweats combined with lymphadenopathy are highly concerning.


 +0  (step2ck_free120#85)

I think the description here is a little odd, but they’re suggesting there’s evidence of really serious spanking. Whenever the story doesn’t make sense or there are any concerning physical exam findings, it is critical to work up for nonaccidental trauma.


 +0  (step2ck_free120#86)

History is clearly gallbladder (“biliary colic”). Now cholecystitis, so evaluate with ultrasound. Minimal lipase bumps can be seen with other GI and biliary issues, but also note that gallstones can also cause pancreatitis, so it’s certainly possible for her to also have that brewing. If you suspect gallbladder/biliary issues, always start with US.


 +0  (step2ck_free120#87)

Tracing shows late decels: the bad kind, a response to poor blood flow to the fetus during contractions. One cause, particularly common after AROM, is umbilical cord prolapse, where the fetal head compresses the umbilical cord, limiting blood flow as it’s squeezed inferiorly by the contracting uterus. Vertex station doesn’t actually matter as once previously thought, but a nondilated cervix (less than 6 cm) is a risk factor.


 +0  (step2ck_free120#88)

How many people with sats in 80s have you seen not getting O2?


 +0  (step2ck_free120#89)

Ulcerative colitis is a risk factor for colon cancer. The skin lesions are a description of erythema nodosum.


 +0  (step2ck_free120#90)

Trauma and critical illness can cause acute insulin resistance.


 +0  (step2ck_free120#91)

Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick.


 +0  (step2ck_free120#92)

Hyperaldosteronism = hypertension + hypokalemia. Adrenal adenomas are a common cause of primary hyperaldosteronism.


 +0  (step2ck_free120#93)

Necrotizing fasciitis = looks like bad cellulitis but then you add skin breakdown and necrotic goo.


 +0  (step2ck_free120#94)

The key to dealing with occupational exposures is safe practices. That means anything producing a particle or fume needs a respirator. You can’t fix the damage already done.


 +0  (step2ck_free120#95)

Spironolactone helps reduce ascites production and is the diuretic of choice for the initial treatment of portal hypertensive ascites.


 +0  (step2ck_free120#96)

Severe hypertriglyceridemia is an important risk factor for/cause of pancreatitis. Fibrates remain the drug of choice for severe HTG (TGs > 500 mg/dL).


 +0  (step2ck_free120#97)

Cirrhotic wanderer, completely disoriented. While potentially just intoxicated or suffering from hepatic encephalopathy, the question is again probably getting at Wernicke’s encephalopathy. Treatment is thiamine. It’s harmless, and that why lots of drunks get the banana bag.


 +0  (step2ck_free120#98)

Algorithmic standard approaches that reduce variability are the hallmark of high-quality care. Not everyone can receive heparin, but everyone needs to have a DVT prophylaxis plan so they don’t fall through the cracks.


 +0  (step2ck_free120#99)

Subtraction.

(Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#100)

Stop. Wrong sided surgery is a big no no. Everyone on the team should feel empowered to stop a surgery or procedure if something in the preprocedural checklist is amiss.


 +0  (step2ck_free120#101)

PEEP is like cowbell. Okay not really but when gas exchange is insufficient with increased FiO2, PEEP will help open alveoli and increase the functional area available for ventilation.


 +0  (step2ck_free120#102)

TCA overdoses are potentially fatal due to the drugs’ cardiac effects. The most dangerous is that fast sodium channel blockage can lengthen the QRS and result in fatal ventricular arrhythmias.


 +0  (step2ck_free120#103)

The test of choice for AAA screening is ultrasound. Cheap and radiation-free.


 +0  (step2ck_free120#104)

Back pain, normocytic anemia, fatigue, and hypercalcemia. These are concerning for a hematopoietic process, particularly multiple myeloma. Serum protein electrophoresis will demonstrate the M-spike.


 +0  (step2ck_free120#105)

The decreasing and irregular periods coupled with high FSH suggest early menopause. Estrogen helps with bone strength. The lack predisposes to osteoporosis.


 +0  (step2ck_free120#106)

Increased bleeding with normal labs (or an isolated mildly prolonged PTT) is always a good picture for von Willebrand disease, the most common bleeding disorder. Yes, the PTT is slightly elevated (which can happen), but that’s also why they probably gave you boy and girl siblings to help you not pick hemophilia.


 +0  (step2ck_free120#107)

Colon cancer is a surgical disease. (Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#108)

Part of the DSM-V criteria for generalized anxiety disorder: “Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).”


 +0  (step2ck_free120#109)

Ascites with a neutrophil count higher than 250 is consistent with spontaneous bacterial peritonitis. Treatment of choice is a third-gen cephalosporin like cefotaxime or ceftriaxone.


 +0  (step2ck_free120#110)

AED-induced bone disease is a problem with long term therapy. Carbamazepine and phenobarbital both induce CYP450 and can cause vitamin D deficiency.


 +0  (step2ck_free120#111)

Write it out. Abbreviations are like assumptions.


 +0  (step2ck_free120#112)

When it comes to development questions, always make sure before you pick something other than normal if offered. Tanner stages are available for review here.


 +0  (step2ck_free120#113)

Implantable birth control is much more effective than methods that require active effort.


 +0  (step2ck_free120#114)

Malignant pleural effusion. Cancer is full of protein.


 +0  (step2ck_free120#115)

Ah, ye old “inconsistent condoms” code phrase for STDs.


 +0  (step2ck_free120#116)

Residual gonadal tissue in 46XY gonadal dysgenesis often becomes cancerous and should be removed surgically.


 +0  (step2ck_free120#117)

HCTZ (and other symporter and loop diuretics) can result in diuretic-induced hyperuricemia and cause or worsen gout.


 +0  (step2ck_free120#118)

This is the MSG symptom complex, sometimes historically and pejoratively called “Chinese Restaurant Syndrome.” While MSG gets a bad wrap, real MSG sensitivity is rare.


 +0  (step2ck_free120#119)

Don’t be a dick. But you don’t have to entirely give up either: she may come around after her crazy simmers for a while.


 +0  (step2ck_free120#120)

Sciatica. (Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#58)

Serotonin syndrome. The most important next step is to remove the offending serotonergic agents.


 +0  (step2ck_free120#59)

He would seem to be psychotic. While people with schizophrenia or delusional disorders are on average no more dangerous than other folks, safety is paramount. Danger to self or others and all that.


 +0  (step2ck_free120#60)

Vesicular rash in the immune-compromised is a common scenario for Varicella-Zoster reactivation. Visceral zoster involvement can result in severe pain that can be mistaken for an acute abdomen. Treatment with acyclovir or valacyclovir.


 +0  (step2ck_free120#61)

Vulvar cancer is rarer than cervical cancer but has many of the same risk factors including HPV. Another risk factor worth knowing is lichen sclerosis, which results in thin itchy vulvar skin.


 +0  (step2ck_free120#62)

Thyroid nodules are best evaluated by thyroid ultrasound. While larger nodules (>1.5 cm) are more likely to be malignant, there are plenty of very large completely benign nodules that would be inappropriate to biopsy.


 +0  (step2ck_free120#63)

AZT monotherapy during the intrapartum and postpartum period (in addition to maternal therapy throughout pregnancy) is recommended for all neonates of HIV-positive mothers to reduce transmission and is very effective (less than 1%).


 +0  (step2ck_free120#64)

Prolactinomas (pituitary adenomas that secrete prolactin and as a result can cause amenorrhea/infertility/lactation) can be treated with dopamine agonists like cabergoline. This is because dopamine normally inhibits pituitary prolactin production. In many cases, tumors can completely involute with pharmacologic therapy alone.


 +0  (step2ck_free120#65)

This constellation of symptoms in a premature infant by around two weeks of life is concerning for NEC. The diagnosis is commonly made with abdominal radiographs, which can demonstrate bowel dilation and pneumatosis (and when more severe, frank pneumoperitoneum).


 +0  (step2ck_free120#66)

You can’t turf out emergency care that you are equipped to perform just because a patient can’t pay. Dumping is why EMTALA was created in the first place.


 +0  (step2ck_free120#67)

Pseudoseizures are diagnosed in EMUs with video EEG. You match the behavior with the EEG to see if there are epileptiform discharges that correspond to the episodes. While this is clearly absurd for an epileptic seizure (impossible movements, insane duration, and no postictal period), there are plenty of cases of bizarre seizure patterns that are VEEG proven.


 +0  (step2ck_free120#68)

Pleurisy (or potentially costochondritis) secondary associated with a URI, either way, treat with NSAIDs.


 +0  (step2ck_free120#69)

This person recently had normal cycles, essentially excluding A and C. We have no reason to suspect D. And the normal prolactin excludes E. Hypothalamic hypogonadism can have many causes, among them chronic stress and anxiety, as seen in patients with eating disorders, sufferers of PTSD, etc.


 +0  (step2ck_free120#70)

Menopause. Elevated FSH and no period for over a year confirm.


 +0  (step2ck_free120#71)

Penicillin prophylaxes is indicated in all children with sickle cell younger than 5 to prevent severe pneumococcal infection.


 +0  (step2ck_free120#72)

Jaundice in the newborn. When unconjugated, typically “physiologic,” with two common causes breastfeeding jaundice (due to insufficient intake) and breast-milk jaundice. In this case, however, the bilirubinemia is conjugated (“direct”), which suggests cholestasis. Ultrasound is needed to evaluate the liver and biliary system.


 +0  (step2ck_free120#73)

Relentless dry cough is a common reaction to ACE inhibitor therapy.


 +0  (step2ck_free120#74)

Opioids result in floppy babies who don’t breathe well, just like they do in adults.


 +0  (step2ck_free120#75)

Obstructive sleep apnea can result in ADHD-like symptoms, irritability, and poor growth. The snoring is a tip-off, and tonsil/adenoid enlargement is the main cause of intermittent airway obstruction during sleep in children.


 +0  (step2ck_free120#76)

Osseous fragment at the fifth metatarsal base in the context of a recent ankle-sprain type injury is compatible with an avulsion fracture. These are often treated nonoperatively.


 +0  (step2ck_free120#77)

Parents don’t get to withhold lifesaving emergency treatment from their children, religion or not.


 +0  (step2ck_free120#78)

Cyanotic newborn with a single S2 is suggestive of a truncus arteriosis congenital heart defect (a VSD combined with a single ventricular outflow track comprising both the pulmonary and systemic circulation). The pulmonary circulation is thus torrential resulting in pulmonary edema. Like other CHD that result in early cyanosis, these patients are ductus-dependent for oxygenation mixing and should receive prostaglandin to maintain a PDA.


 +0  (step2ck_free120#79)

Vasospastic angina (formerly known as Prinzmetal angina). Rest angina/chest pain rapidly relieved by nitrates in a patient without coronary disease. Commonly treated with calcium channel blockers.


 +0  (step2ck_free120#80)

There is AV concordance (all QRS have a preceding P wave), but we have intermittent dropped beats consistent with a second degree AV block. The PR-interval of the conducted beats is always the same, so we have Mobitz 2. Progressively lengthening PR-interval prior to a dropped QRS is Mobitz 1 (Wenkebach).


 +0  (step2ck_free120#42)

He’s got a cyanosis-level from an aortic embolism. His floppy, akinetic LV is the risk factor for thrombus generation, which was subsequently squeezed out and lodged distally. The other choices would not result in isolated symmetric lower body symptoms.


 +0  (step2ck_free120#43)

This is all to say he has chronic lung disease. He has findings of possible fibrosis on CXR and a history certainly concerning for smoking-related lung disease. HRCT will tell us if he has a pattern characteristic of UIP (e.g. idiopathic pulmonary fibrosis) or something potentially more treatable like NSIP or just run of the mill COPD.


 +0  (step2ck_free120#44)

Recurrent vomiting results in a hypokalemic hypochloremic metabolic alkalosis (i.e. you lose acid and keep having to make more).


 +0  (step2ck_free120#45)

CTs evaluate the kidneys, but they do a very poor job evaluating the bladder. Direct cystoscopy is needed to clear the lower urinary tract of an underlying bleeding mass. Smokers are at increased risk of bladder cancer.


 +0  (step2ck_free120#46)

“Bone broke must fix.” (Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#47)

Hypertension is the number 1 risk factor for stroke. Additionally, while smoking cessation is also important, it takes years for the deleterious vascular effects of smoking to normalize. Antihypertension therapy is needed right now and has a much higher likelihood of success than stopping someone’s habit of a lifetime.


 +0  (step2ck_free120#48)

They are presumably trying to demonstrate that she has an acute viral-type syndrome given the flu-like illness with fever, muscle aches, and generalized misery. COVID-19 wasn’t an answer choice. Note the CXR says “interstitial infiltrates,” which is the Step code phrase for atypical infection (as opposed to consolidative pneumonia).


 +0  (step2ck_free120#49)

Dyslexia is one of several different learning disorders.


 +0  (step2ck_free120#50)

Inflamed painful infected external auditory canal is consistent with otitis externa. Earplugs are a risk factor, both from microabrasion trauma and/or from contact dermatitis.


 +0  (step2ck_free120#52)

Children with VATER often have tracheomalacia (part of the T), which can be associated with TEF and esophageal atresia. Tracheomalacia results in dynamic airway obstruction due to airway collapse on expiration (greater when forced).


 +0  (step2ck_free120#53)

Chest pain in the setting of a recent URI and with the low-grade ST elevation in multiple leads is the classic setting for pericarditis. The scratchy sound is the “pericardial rub.” Echo will assess for a pericardial effusion (and its size/significance), pericardial thickening, as well as assess for overall cardiac function.


 +0  (step2ck_free120#54)

Idiopathic and viral pericarditis treatment is antiinflammatory. Data show that Colchicine is a useful NSAID adjunct for all pericarditis treatment, not just recurrent or prolonged cases as was once commonly assumed.


 +0  (step2ck_free120#55)

He is not safe, you have enough information to act.


 +0  (step2ck_free120#56)

She has multiple sclerosis. Clinically, neurologic lesions/deficits separated in time and space. MRI can show us evidence of demyelination in the brain to go along with her optic neuritis. These features are more important than oligoclonal bands in the CSF.


 +0  (step2ck_free120#57)

She has no significant cognitive deficits and is thus still normal enough to not require a dementia workup. In real life, I have plenty of evidence she’d get that MRI.


 +0  (step2ck_free120#51)

Most acute sinusitis is viral, not bacterial. Most antibiotic use for sinusitis is futile. Nasal irrigation and decongestant therapy are the hallmark treatments to relieve drainage pathway obstruction and give the body the ability to drain secretions properly.


 +0  (step2ck_free120#41)

The goal is to hopefully make sure she is safe (and if she is at-risk for partner abuse to provide her with resources). On a related note, unlike for children and elders, there is no reporting mechanism for partner abuse.


 +0  (step2ck_free120#17)

Slow submersion warming is key when dealing with frostbite. Air and towels/dressings are poor conductors of temperature.


 +0  (step2ck_free120#18)

She has thrombocytopenia, likely related to immune thrombocytopenic purpura (ITP) in this patient with other underlying autoimmune conditions. Initial treatment is prednisone. Refractory cases can be treated by splenectomy.


 +0  (step2ck_free120#19)

Mitral regurgitation explains the soft S1 and holosystolic murmur loudest at the apex. Acute heart failure with pulmonary edema. In the context of a recent URI, this is most concerning for viral myocarditis. Rheumatic fever can also present with carditis, but in this case, the patient has otherwise recovered from other symptoms.


 +0  (step2ck_free120#20)

Bilious vomiting in the newborn includes the full differential (duodenal atresia, midgut malrotation and volvulus, jejunoileal atresia, meconium ileus and necrotizing enterocolitis), but rapidly-ill bilious vomiting combined with fever, distension, and tenderness after a few days to a week or so is most concerning for midgut volvulus. Most other causes present soon after birth with the exception of necrotizing enterocolitis, usually affecting premature babies within a couple of weeks after birth. Diagnosis with upper GI.


 +0  (step2ck_free120#21)

Using the most expensive things isn’t always a great use of limited resources. In a very elderly patient with dementia and multiple medical comorbidities, you probably don’t need the most long-lasting most-expensive stents when the long term survival prospects of the patient are dismal.


 +0  (step2ck_free120#22)

This is a potentially fatal decision. Patients can choose to deny care, but when someone is making the “wrong” choice, it’s important to make sure they have the capacity to do so: do they understand their situation, their options, and the possible consequences of their actions? If so, that’s fine.


 +0  (step2ck_free120#23)

The banana bag! You might be thinking of Flumazenil to reverse his benzo use, but be wary of using in an otherwise stable chronic user as this can precipitate seizures. He’s also probably drunk, but that we’ll just wait out. In this case, he’s awake and protecting his airway but he’s encephalopathic. When an alcoholic is encephalopathic, think Wernicke’s and give thiamine. Even if they’re just plain ole drunk you’re not going to hurt them.


 +0  (step2ck_free120#24)

These are the signs and symptoms of testicular torsion, a surgical emergency.


 +0  (step2ck_free120#25)

This is a diffuse pontine glioma, a death sentence. You don’t really need to know that, because the stem tells you of the poor prognosis. Whenever someone is presented with a serious diagnosis, any treatment discussion starts with establishing a baseline understanding of the disease process and then discussing goals of care.


 +0  (step2ck_free120#26)

We have a middle-aged black female as the setup. Pulmonary disease with CXR showing bilateral hilar adenopathy. She has cutaneous involvement of the face. Cutaneous involvement is present in 1/3 of systemic cases but can have a variety of appearances.


 +0  (step2ck_free120#27)

Statin-myopathy is assessed laboratorily with serum CK.


 +0  (step2ck_free120#28)

Source control followed by symptomatic relief. Have you seriously ever heard of anyone doing any of that other crazy stuff?


 +0  (step2ck_free120#29)

ECT works. It works really well, and it works really fast. This gentleman is wasting away and is unable to care for himself.


 +0  (step2ck_free120#30)

USPSTF recommends clinicians screen all adults age 18-79 for hepatitis C infection.


 +0  (step2ck_free120#31)

Non-immediate “delayed” penicillin allergy. The question info is a bit over the top, but the answer choices are mostly related to allergies, which gives you a hint. If someone has an antibiotic allergy, just use another antibiotic.


 +0  (step2ck_free120#32)

People low on the totem pole aren’t going to feel comfortable speaking up unless encouraged.


 +0  (step2ck_free120#33)

If you thought that looked like a squamous cell carcinoma, that’s because it is. A keratoacanthoma is the name of the erupting-volcano variant, though some keratoacanthomas will resolve spontaneously and others progressive to invasive cancer.


 +0  (step2ck_free120#34)

USPSTF recommends all men 35 and older (women 45 and older) are screened for lipid disorders, and age 20+ for those with increased risk of CAD.


 +0  (step2ck_free120#35)

Routine imaging for pyelonephritis at presentation is not generally helpful. But CT imaging for those who do not respond to antibiotics is indicated to evaluate for complicating factors like renal abscess or nephrolithiasis that cannot be treated with antibiotics alone.

derpymd  Is this not diverticulitis? Urinalysis is normal. Looks like they're treating empirically for diverticulitis, but failed to respond, so CT to check for abscess. +

 +0  (step2ck_free120#36)

We can simplify this with the general framework that if significant hypotension doesn’t resolve with volume repletion, then we move on to pressors.


 +0  (step2ck_free120#37)

She is currently prediabetic. But not for long. (Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#38)

No lying! No lying! No lying! (Comments must be between 40 and 1,925 characters!)


 +0  (step2ck_free120#39)

Acute kidney injury with volume overload, presumably from the ACE-inhibitor.


 +0  (step2ck_free120#40)

Hereditary weak bones, mobile joints, and hearing loss are a good fit for osteogenesis imperfecta. Scoliosis and short stature are also common, particularly in more severe cases.


 +0  (step2ck_free120#1)

While you may have initially been thinking of alcohol withdrawal, the case presents you with signs/symptoms of decompensated cirrhosis including hepatic encephalopathy from hyperammonemia (AMS, asterixis). Treatment is oral lactulose, which helps clear ammonia via the power of horrible diarrhea.


 +0  (step2ck_free120#2)

You know that granulomatosis with polyangiitis (née Wegener’s) causes lung disease, but did you know it also causes peripheral neuropathy? Keep in mind that “not all that wheezes is asthma.” Wheezing is a sign of obstructive lung disease, not a diagnostic feature, so consider asthma alternatives in adults. Hemoptysis and fever change the game.


 +0  (step2ck_free120#3)

Urinary retention due to pelvic organ prolapse. Multiple vaginal deliveries are the risk factor/cause.


 +0  (step2ck_free120#4)

This patient has neutropenic fever. Methimazole can cause agranulocytosis.


 +0  (step2ck_free120#5)

Concerning for meningitis. Yes, even with abdominal pain, which can be so severe that it can mimic appendicitis. Remember that splenectomy status predisposes to infection with encapsulated organisms such as meningococcus. This may also be purposefully vague, as in real life this could also certainly be an abdominal process like actual appendicitis, for which you might get an appendix ultrasound or CT of the abdomen/pelvis in addition to starting empiric antibiotics, but that’s not an answer choice.


 +0  (step2ck_free120#6)

Also meningitis. There’s a vaccine for that, which everyone in college is supposed to get.


 +0  (step2ck_free120#7)

Every pregnant patient gets tested for HIV during routine initial prenatal workup/testing as well as again during the third trimester.


 +0  (step2ck_free120#8)

Quitters gonna quit. Quitters gonna quit. Quitters gonna quit. Quitters gonna quit. Quitters gonna quit. Quitters gonna quit.


 +0  (step2ck_free120#9)

When old men stop peeing so well, consider the poorly designed straw-crusher, the prostate. Chronic outlet obstruction isn’t so great, but it also predisposes to acute prostatitis which in turn can further worsen said obstruction when the gland swells. First thing to do is see how much the gentlemen is backed up, which in turn tells us if he has earned catheterization. Old people and UTIs go together like [insert your own clever comparison].


 +0  (step2ck_free120#10)

That’s a septic joint, not just RA (RA is a risk factor). Full-blown fever and intraarticular pus.


 +0  (step2ck_free120#11)

We have event rates of 35% for EST and 15% for EPCS, and the number needed to treat (NNT) is the inverse of the absolute risk reduction or 1/ARR. ARR = Control event rate minus experiment event rate. So, we have ARR = 0.35 – 0.15 = 0.2, and therefore NNT = 1/0.2 = 5. Boom, math.


 +0  (step2ck_free120#12)

This is a great RCT. The issue is that EPCS is a specialized treatment not as widely and emergently available as the usual GI-doc on call.


 +0  (step2ck_free120#13)

It works. P < 0.001 for that parameter. (And this is some more text to meet the minimum character requirement.)


 +0  (step2ck_free120#14)

With treatment adherence, most HIV-positive individuals will die of the same things as the rest of us: the American way of life.


 +0  (step2ck_free120#15)

Initial treatment for inadequate sleep and various types of “insomnia” is sleep hygiene modification. Certainly, her smoking and nicotine activation aren’t helping, but there’s no such therapy as “setting a date for smoking cessation.” Americans are terrible with sleep, and many who struggle are doing all the wrong things like using electronic devices late in the evening, dealing with neverending light pollution, caffeine and cigarettes too late in the day, going to bed too late, blah blah blah.


 +0  (step2ck_free120#16)

Rapidly progressive dementia (with or without personality changes, psychiatric disturbances, and sudden/jerk movements) raises the possibility of Creutzfeldt-Jakob disease, for which CSF protein 14-3-3 is an important marker.


 +0  (free120#13)

This question is asking for the vascular supply of the parathyroid glands. That would be the inferior thyroid arteries, which arise from the thyrocervical trunk.

brendan  why wouldn’t a branch of the external carotid also be a valid answer? does the superior thyroid not also give arterial supply to the parathyroid glands? it seems to me that it could be either of these. +2
benwhite_dotcom  @brendan Superior thyroid provides mostly collateral support. The inferior thyroid is the primary supply and thus the “single best answer.” Remember, the other choices don’t have to be WRONG—they’re just not the best. +

 +0  (step2ck_free120#7)

Proximal muscle weakness + skin findings = dermatomyositis. Yes, kids can get this. In this case, they’ve gone to the trouble of describing Gottron’s papules (“flat-topped red papules over all knuckles”) and the heliotrope rash (purple-red discoloration over the eyelids). Please note the USMLE will never actually say things “heliotrope” on the actual exam. They always describe.

langusmle  Don’t forget to do age appropriate cancer screening +

 +0  (step2ck_free120#6)

The patient has a small bowel obstruction, likely due to adhesions from prior surgery, evident clinically and confirmed by radiograph (grossly dilated small bowel without distal colonic dilation to suggest paralytic ileus). Conservative treatment in a stable patient involves NG tube decompression and NPO. A CT can be obtained for further characterization and to look signs of bowel compromise (and would be in real life), but there is no reason to delay appropriate care to get it.


 +0  (step2ck_free120#5)

Alcohol raises GGT. The other liver enzyme lab to remember is the 2:1 or greater AST/ALT ratio associated with alcoholic liver disease.

langusmle  ⬆️Ferritin ⬆️Leukocytosis as well +

 +0  (step2ck_free120#4)

Unstable and hypotensive patients after blunt trauma get laparotomies (don’t put an unstable patient in the CT scanner). In addition to saline and blood products, definitive surgery is how you address the C in ABC.


 +0  (step2ck_free120#3)

Recurrent infections with abscesses should raise the suspicion of chronic granulomatous disease. Suppurative arthritis does even more, if you’re likely to remember that. The real diagnosis is made from the Step 1 style question. Nitroblue tetrazolium is the test used to diagnose CGD, which is a defect in NADPH oxidase (the oxidative burst that kills Staph aureus).


 +0  (step2ck_free120#2)

Anesthesia to the anterolateral thigh is the distribution of the lateral femoral cutaneous nerve. LFC neuropathy can be caused by compression near the inguinal ligament (say, from a hematoma). Note that it’s the compression of the nerve that causes decreased sensation, not the hematoma itself.


 +0  (step2ck_free120#1)

Intermittent polyarthritis with positive ANA (sensitive but not specific) and anti-DNA (very specific) means lupus. You don’t even need the non-painful mouth ulcers.

fatimanaj  Text loss 😥😥 +

 +8  (free120#8)

When people go camping, you should be thinking of zoonotic infections. Fun fact, New Mexico leads the country in cases of plague. Yes, that plague: Yersinia pestis. The “bubonic” part of bubonic plague refers to the swollen infected nodes (“buboes”) characteristic of the disease, which often involve the groin (bubo is the Greek word for groin, who knew?). In this case, they’re also describing a necrotic epitrochlear node. Classic treatment is with aminoglycosides, which bind to the 30s ribosomal subunit. (Note that Tularemia, caused by another gram-negative bacteria Francisella tularensis can present similarly but is more common in the midwest. Regardless, the two are often lumped together, the antimicrobial treatment is similar, and the answer in this case would be the same).

(Free 120, 2019 Update)


 +2  (free120#40)
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llllP-riogni itrnsge rrmteo of snPki’orsan seedisa sercynoda ot osls of aonpemid suonnre ni eht utansatbis .argin


 +7  (free120#39)
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mI’ ngiog to pinto out ahtt a ronlma layethh kid hiwt no ccaidra hyrsoti ro msyopmst nda no yimafl shityro fo nedsud adaiccr eahdt orf a pop-rstres ahypscli si lbyaropb ngiog to evha a ningeb axem no taremt atwh oyu ntihk ouy h.aer

the260guy  What a weird question. I could definitely hear a fixed split heart sound. And it was loudest over the pulmonic valve too which makes it even more of a dirty question. But I guess what I was actually hearing was an S3 heart sound. +13
wutuwantbruv  @the260guy I believe the splitting is being heard only during inspiration, making this normal physiologic splitting. Perhaps that's just my ears. +12
angelaq11  don't have adobe and couldn't download it, so I just chose whatever, but your explanation suddenly makes me feel dumb but grateful! Loving your tips! @benwhite_dotcom +1
blah  @the260guy Have to agree with wutuwantbruv. I interpreted this as a physiological splitting, had the opportunity to hear it in a newborn as well. +3
prolific_pygophilic  Definitely S3. FA 2020 pg 287 "but can be normal in children, young adults, athletes, and pregnancy" +1
dhkahat  I swear to god it wasnt just during inspiration but what the hell do i know +

 +1  (free120#38)
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calssiC Moor fxl,ere lireenty pxedecte adn rlomna iunlt it sdapaspire uornda gae 4 mhno.st


 +0  (free120#37)
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A oryitsh of umloev osls nfote( IG 22/ tmvio,gin rahra)eid lsuigenrt in shcko is cntentisso twhi a cehilmvoyop oeg,olyit as tardeoocborr yb hte orehatlp fo ciyslpha dceineve dvero.idp Dcrtueiis cxaeeetrab eht nattii,uso wkgiorn igtanas yuor ’dysob dsreei to tnreia dufli ot s.tnpameeco


 +0  (free120#36)
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leBow eht ednetta ,eiln alna rceanc adreanig is fsircaupile iug.lnnia vboAe hte ateednt l,nei riersuop cleart (then )lii.ca

sugaplum  above the dentate line superior rectal drains into inferior mesenteric then goes into the portal system http://www.surgicalcore.org/popup/420229 +
sugaplum  my mistake, the question is asking lymphatic drainage not venous +2

 +2  (free120#35)
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ehT oyln ihgnt htat ctyrdeil eiarss PB of hte stli si nsadrceie .PVR

amedhead  would decreased cardiac output not also increase the blood pressure due to sympathetic activation of the baroreceptor reflex? +
benwhite_dotcom  I think you’re ignoring a directly correct answer, increased PVR literally equals increased BP, and are instead trying to postulate an indirectly plausible answer. Decreased CO, as you just implied, means less blood pumping into the aorta and less blood pounding and stretching the arteries and thus decreased BP. Note, your original logic would apply to stroke volume just as easily. Yes, a sympathetic response could then occur as a response to mitigate this, such as in shock or heart failure, but it would misleading to suggest that decreased CO causes hypertension. +3

 +3  (free120#34)
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p35 si an panitotmr morut uoesrrsspp ngee, aaliucrtlpry in sti litbayi to eacsu a ecll to degnruo soppoasit in eht netve of .daagem 3p5 poirent yvttaiic lsao hldos hte clle at hte GS1/ eolganriut ipotn (,)B intiglim DNA niethsssy.

topgunber  RB , when HYPOphosphorylated, does the same at g1/s. +

 +0  (free120#33)
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Tshi pttiaen ahs etspiihta adet(eelv vierl )nmeezsy ued to evitac eiiHaptst C nitcifon.e peH C nda IVH efnoitcin are hbot actoeasdis hwti vausoninetr gdru us.e hilWe otms aeptsnit ihwt Hep A lwil eralc teh sviur afret ehitr cetua i,neslls Hep C casesu ronicch cntiefino in 8%0 of ,pntieast hcihw yma elad to icirosrsh ovre ietm ~20( ys.ear)

tallerthanmymom  Wait... I swear we could treat hep C with Sofosbuvir and Ribavirin and that it is curable these days? +1

 +1  (free120#32)
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ayMn rloa itvayc ,seislon lspaeclyie atnroeliry cuhs as the ipt of hte gnet,uo rdnia rsitf to snbmlateu nodse lel(ev 1). rrghOyenoaapl SsCC toms monomylc aridn to vlele .2

llamastep1  https://www.youtube.com/watch?v=bwVQWwDjw5A quick review,ignore the bad music +2
focus  If you scroll down on this link, the first image is pretty good https://www.sciencedirect.com/topics/medicine-and-dentistry/submental-lymph-nodes +

 +5  (free120#31)
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roiactcN sue rfo lycetau fiaunpl ntcsdionio si tobh lsbnaareeo dan oa.rmttpni tShtrem-ro use dyitime(alem l)ac-rupogtiss eods not adel to elomnrtg- ecpenneded (or so pelpeo ehav ugtho…h)t. nAd eys, dsrug idstadc dsohul loas rveecie aiccntrso ot onolctr p.nia

drdoom  prefer “patients with hx of substance abuse” over more conveniently typed but less redemptive “drug addict” +12
sugaplum  I don't see why switching her to oral pain meds when she is ready would be incorrect. Clearly she is worried about being on the pain meds, I feel making a proclamation that she has a low risk of addiction would be profiling just because she doesn't have a history. The opioid epidemic also affects people who didn't have a previous history of drug abuse. Just a thought, not trying to push any buttons. Maybe I am thinking to hard about this, but I don't see the clear A vs B line for this question. +46
nbme4unme  @sugaplum I thought the exact same thing as you and chose the acetaminophen answer accordingly. I maintain that I am correct, my score be damned! +7
sushizuka  I had a similar question on UW and the explanation stated that the correct answer choice was the only one that addressed the patient's concern and answered her question. The rest were just alternative treatments, so they were incorrect. But I too answered with oral pain meds. +6
angelaq11  couldn't agree more with you all. I chose acetaminophen because opioid abuse is NO joke. The crisis is still going strong because of answers like this... +1
houseppary  I ruled out oral acetaminophen because they described in great detail the severity of her injuries, and indicated that she wasn't even fully conscious/aware when she asked this question about opioids. Rather than expose her to more pain, and possibly worsen her long-term pain prognosis, by switching to acetaminophen too early, in this case it makes sense to keep her comfortable because she's very seriously injured and not even fully lucid. It's kind to reassure her in this case. +2
anastomoses  I appreciate all of the passion for the opioid crisis, and the wording of the answer is definitely not ideal. However, PAIN is also very real, and there is no way acetaminophen alone would cut it in a case like this, not "as soon as she can take medications orally." Maybe I'm lucky to have 6 months in clinicals before STEP or had a mom who just went through urgent spine surgery for breast cancer mets, but there is a time and place for opioids and this is clearly one of them. Thank you for coming to my ted talk. +4
llamastep1  I agree with anastomoses, cmon guys have you ever had serious pain? oral acetaminophen is NOT enough for that type of pain. +2
sora  I r/o oral acetaminophen b/c she's post-op for major GI surgeries so you might want to avoid PO meds for a while +
melchior  As argument against the oral acetaminophen answer choice, it says "switch the patient to oral acetaminophen boldas soon as she can take the medication orallybold" This means you're just waiting for her swallowing inability from the facial fracture surgery to come back, which might not have much to do with her pain, and so it seems somewhat arbitrary. +
drpee  Maybe logically/clinically A is true, but this seems like a "patient communication" question to me and I could NEVER imagine A being a good way to phrase this point IRL. +2
zevvyt  Don't forget who pays for these tests: BIG PHARMA!! +
topgunber  youd think after spending and borrowing every ounce possible that we were the ones paying for the tests +

 +2  (free120#30)
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etiagrTod hsra rfeta a odnaodlw iuersxonc nemas emLy se,eiads cuaeds by ariBrleo r,egibrdourf ediarrc yb het Idosxe .ktic sRah reyaht(em nrmgasi), rliva ydsonemr mmtssyp,o ,uetfgia dna iristyplothra ear o.ommnc yLem itdracis alyltcypi fantmesis sa AV ob.lkc


 +0  (free120#29)
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oT aflipym ntyi atregmnsf fo DAN in reord to dcttee rtieh srceepne, we use RCP. ehT tuisnoqe is a tesipidornc of teh resoc.sp uohnrSte tlosB rea dseu to dcetet a cisifepc NDA cunseeqe hinwit a DNA .mpasle


 +5  (free120#28)
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ensU(batl) gaain.n soMt imeeditma earentmtt is on.rit

melchior  Nitrates, such as nitroglycerin, increase nitric oxide, which then increases cGMP (not cAMP) +2

 +3  (free120#27)
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sciyCt rfsbosii is an outsaaolm rseseievc deissea ovninvlgi CFRT hw(chi ocndsee teh RFCT tin,repo) hhiwc maens uyo edne a dbeluo ith ot psesxre teh .asdesei If het einegtc tste lony cdpkie up o,en tnhe ti must vhea esdsim teh e.hrot

drdoom  The reason something is an “autosomal recessive” disease is because the protein encoded by the gene (of which you have two alleles, remember) does something where as long as you make SOME protein, your body should be okay. That’s kind of vague, so take the case of Cystic Fibrosis: you don’t present with Cystic Fibrosis if you have at least one functional allele -- that’s because CFTR protein is a protein that (in the case of bronchiole tissue) moves Chloride ion from inside cells to the outside lumen, which brings with it H2O and keeps the bronchiole lumen nice and watery, and fluid and non-viscous and non-pluggy. So long as you make enough of this protein, you don’t “need” both alleles to be good; the good allele can “make up for” (make enough of the protein product) to compensate for the “broken allele.” So, once again, understanding the pathophys of a disease allows you to reason through and predict things like disease penetrance and expressivity. +3

 +1  (free120#26)
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ciftpiecSyi is how tneof uyor tset si ritgh obatu oeelpp twutoih hte es:sedai

= NT / NT( + F)P
= 95 / 9)55+(
= 59%

drdoom  Put another way: Of all the people who are disease-free, how many (of those people) did you catch? In this case, there are 100 people who are disease-free; our test labeled 95 of those people as “disease-free”, but our test also called 5 of those people “positive”; so our test is good (sort of) but not that good. +1
drdoom  Also note how specificity only answers questions about people WITHOUT THE DISEASE; it only “deals with” people who are disease-free. (Sensitivity is the opposite: it is a formula which only deals with people WITH THE DISEASE. I think understanding that is better than coming up with some crazy Snout-Spout-Spin mnemonic, which I never remember anyway.) +

 +3  (free120#25)
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KB viurs iatarotcenvi is a eusac of leran emdaag ssnot-atrtpnapl ni the tegistn of imemnu punrp,ssoies lsoa onnwk as BK hytpaephr.no Ttrntaeme si a intcudero in mmunie repusipsos,n gawnolli eth dybo a chcena ot hfitg ac.bk Teh rivsu can asecu a lokl-ecid IRU moersynd hwit ref.ev

kekescc  in FA, BK = bad kidney +1

 +4  (free120#24)
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trsgldhOaooe-Stc si oasl onnkw sa thpoypsiasi of eht latibi beuetcr.l I’ts edu to iorchnc ioesattrrt/isrins ta het nseiirtno fo the llaarpet tndneo on teh bialit rce.tbelu tI’s cscylsllaai ense in eetnarges ndgio erivpttiee virougos ctatviyi gniun(r,n ).mgupnij ehT arhdpograi odseemtstnar csclsai otgteafimnrna of eth libait btreuecl (hhciw itn’s sneyrseac to oceeizrng to egt eht eosqniut erctocr).

cbreland  Very tender irl, from experience +

 +4  (free120#23)
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An sodd ratoi rrteega htan 1 iegfnsiis neisaserc o,sdd rk,is idelkhloio -- ewhhrcvie oyu errpef to clla t.i fI teh %59 ecdfecnnoi enritavl gnrae deos ton eniclud 1, hten eht cdenirffee is ilscttaiyslat tncgnisiafi hugh(to tno saeinseclry nliclycail f)im.nelnuag

tallerthanmymom  Can someone explain why it is an increase in risk rather than a decrease? Also, relative to what? Do we just assume it is relative to people who do not exercise regularly? +
banana  Uncertain about this, but I think from my memory of the question that the above explanation should say "relative risk" and not odds ratio. The relative risk is the (number women fractured/total exposed)/(number women fractured/total unexposed):: therefore, >1 means that more women got fractured when they exercised. (FA 2020, 258) +1
drpee  Same risk: RR = 1 (theoretical). Lower risk: RR < 1. Greater risk: RR > 1 +
blah  I got confused by the question because I was bringing in my own biases (i.e. doesn't exercising decrease the risk of fractures in this population of women?). If you simply read the question as what does a RR>1 mean? No doubt you'll get the correct answer. +4

 +6  (free120#22)
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stuJ eeucsba es’h gvahni dnoree(tcup)t xes noted’s eamn he sode’tn ahve ieslpm siofcituen o.ieoocmuslnns heT sxe sipilme ’she sola snkigsi esom!eon tyiPgishanr + mpyhl ndose + tiagefu = om.no

titanesxvi  The triad of classic symptoms for infectious mononucleosis is lymphadenopathy (swollen glands), splenomegaly (large spleen), and exudative pharyngitis accompanied by high fever, malaise, and often hepatosplenomegaly (large liver and spleen) +2

 +4  (free120#21)
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athW we have rehe is a olegannitc oractnilnee ot atbres :imkl al,oiagsmteca in iwhhc teh obyd ncanto corvent gtcaaelso ot oceulsg isel(tugnr in na iuultnccamao fo tloaGscea )heotshpa-.p1 yThe etnh ilts het niinfsdg and tsets deus to nasioegd .it tcsaoLe (hte daicaesicdhr in mkl)i is mocesdop fo saco+agllegtsueco.

okokok1  also you can cross out the other answers because: what builds up in essential fructosuria: fructose what builds up in Hereditary fructose intolerance: Fructose-1-Phosphate what builds up in galactokinase def.: galactose what builds up in classic galactosemia: Galactose-1-P. Hence, this is the only correct choice of the answers the stem gave. +

 +4  (free120#19)
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tAublsoe kris enridtouc si eth adecesre ni the murben dtacffee rpe mnrbeu :edeosxp

(5/5510-) = 51/00 = .02

tekkenman101  ARR = (c / c + d) -( a / a + b) +

 +3  (free120#18)
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MDD is niX.dk-el We kown ehr mom is a rrecair dsbea on myalif ,shoytri dpeurotps yb abl tnst.egi utB ehr mom sha 2 X hocoeors,smm noly neo of chhiw is mdt.utae eehTr si no way ot owkn ihhcw rhe grhduaet tlunlaeevy sceivere and sxeressep by rhe nppoeyeth ie(. if hes si a crrraei or )n.to Jstu uaecbes hre KC is naolmr soed’nt name she i’tsn a rratreh–eci epophnyte fo the Xknedl-i arrrice esnddpe on niatn-.tcoivXai

em_goldman  Is X-inactivation not randomly mosaic throughout tissues? My thinking is that random, evenly-distributed X activation would cause about ~half symptoms (ex Rett syndrome, X-linked dominant fatal in utero in males but survivable in females due to X-inactivation.) So you see her mom with (presumed) isolated increased CK, which you would expect in her if she was also a carrier. Maybe penetration is variable so you'd need genetic testing to confirm for sure -> the reason she doesn't have symptoms is x-inactivation. +3

 +0  (free120#17)
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AHIDS is a ttse vfatioer a vyer nmomco ceasu fo noheyparaimt reaf(t rdady.hione)t A yairetv fo rnbia nad glnu ogtlsoeiaph rae ipessobl toglioe,sie htiw ugnl rcaecn fo( nay )ptye being na opimtrnta sau.ec


 +3  (free120#16)
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fI teh udifl sekep nomcgi otni eth mueuolglsr (aiv eth erentaff e,)lratreio but you placm hte itniegx sesvel hte( ntffreee r,ore)iealt neht ist’ onigg to ildbu up in the rge,llsomuu inedagl to endiacsre tyohitdcasr eer.usrsp


 +1  (free120#15)
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nMya nr/yfltooamoauteaumiiumatmn ictonsdo,ni duilingcn anngoyksli nit,idsopyls are tdratee wtih DADMsR liek nalh-tFTap-iNa ideoncistam hnew relimd fufst ’onetds od het ctki.r mnoCmo xapmesel era inaibxlfmi eR)(mdeaic nad amuiabmald Hua)r(.mi


 +9  (free120#14)
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rOla seelvic nh(ti tn.h)i Binselgitr lieavrsuc iseonl on eth dn.ha No evrfe, nto p.teraaoxpngic-i hsiT is eHsrpe uyo( may rmebmree dssientt ttgnegi ecirepth lwhotiw ni yoru etuissd, ihcwh si thwa hsit .s)i tosM flosk teg SV1H sa i,ncedrhl htugho uboysvoli ont lal ear yo.tpamcismt VSH is a realg tdba-d,oulserend ilerna AND vri.su

jiya   why cant this be hand foot and mouth disease cause of coxsache +8
drachenx  Also thought it was Hand-foot-mouth an RNA virus but I did consider Herpes. Changed because I thought Hand foot and mouth would be more common. +
llamastep1  Hand foot mouth usualy involves all 3 places (hands, feet and mouth/perioral area) and the lesions on the hand arent localized to just one finger. +2
aneurysmclip  Hand foot mouth disease affects palms and soles. ref: FA 2019 - 150 +3
raffff  wouldnt the history also be different for coxsakie +
focus  I think this image is trying to show the "dew drops on a rose petal" sign on Hermes, the god of Herpes on Sketchy Micro +1
drpee  Google some images of HF&M disease. The small blisters look very different from herpetic whitlow. +

 +4  (free120#13)
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Boold at het emsaut is eht erd glfa (ees waht I idd tre?he) fro uherlrta u,iryjn whhic lsodhu eb dealvteau ofr whit a dtrearroge rehr.tgoruma hTe uanesmmrbo hte tmos ncmymolo inedujr by cuater.rf nI tsncta,or het gyposn utarerh is osmt lielyk to be ednrjui gdurni imtcruata ectherta renionsti or ni a traslded yujrn.i

canyon_run  Should we just assume that a pelvic fracture implies a membranous urethral injury? I was between membranous and spongy and I ended up choosing spongy because of the perineal bruising and fact that the patient was riding a motorcycle (and therefore susceptible to straddle injury). +
benwhite_dotcom  Yes. You should think of spongy as the penile urethra, hence the predisposition to catheter-related trauma. +6
topgunber  it says no trauma to the penis so we have to rule out spongy. To tear the prostatic urethra would mean the prostate also got affected, which when compared to the vulnerable membranous urethra would be unlikely. Both spongy/prostatic urethra are vulnerable to TURP or catheter related trauma as mentioned. As far as the bladder itself and the intra-mural urethra, i would think fractures of the symphysis and above would cause that. +

 +3  (free120#12)
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strrdSleaeets- oewlb iess,us memsosiet but tno aaywls tveaelltniray vvilognin obht erarhaid adn acst,onitinpo aer a hkllamra fo rleirabit boewl odresmyn (.IS)B A dossigian fo uxc,isnoel otms fo hte smte si ilghepn yuo uler tuo roem sieousr .susesi reibpus,tLnoo ihwhc si a ttyaf adci ttha nisudce slofettninosog- teinstalni oseticsre,n si arvpdpeo fro caodihipit nst,iioacpont msto olcnmymo ni het tentxoc of SBI dna ro eorsnydca ot iatope se.u eTh ehotr dugsr tiseld ear orf iormmlaatfyn olewb diassee )B.ID(


 +1  (free120#11)
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rhTee is na ornfirei rtiabol awll lu-botwo tr.ucarfe fI yuo epnhpa ot knwo CT ya,natom tsih is lucataly inlgonivv eht ioirftnaabrl ernfom,a ihhwc rtamtsnis eth flritbaoairn ytarre nda venre, ubt ,ryelal os lngo as ouy noeict teh sooiuvb trrfucae its’ the nylo oiecch thta mesak esens.


 +2  (free120#10)
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isTh etpinta ash nccorih ndeyik dis,esea as adiitdnec yb eldeaetv uerms reUiBnenNi/atc adn iedcneev fo amiean fo hccirno saesedi rmroo(ocnchim .nm)cyoctrio oolyrP cniifuonngt ysiednk do nto aydoyehtrlx dyhc-d2ofixrlecacoille5orhy ot xl1oflhcdeo,5aricdhylorcie2-y wlle rno ueprcdo aqetaude nrttehieoopiyr (cehen eht Det-KdaelCr eamna).i Pitntae’s whti CKD tush dlvpeeo aedncsroy yaryperamdsihhiprto deu ot edneagdr hhtppoase eortnexic nda queaniteda ntmiVai D inavticaot itselgunr in ccaphyeml.oai us,Th ew olhuds etxcpe to see olw lc,amicu ighh oruhsopp,sh owl 21,5 iavntmi ,D nad lwo o.Ep

houseppary  Any guesses as to why he might have CKD at 4 y.o.? +1
drpee  Possibly ARPKD? +

 +8  (free120#9)
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ektroS ecaizetcarrhd by eftl smiieesraph dan hgtri 1CN2 la.spy essCrod gnindsif aenm a ebntrasmi ln.ioes ihgtR psl)ealat(rii te,nogu tde-dfslei l)arnotarl(taec esneskwa amesn het itexign griht hoaosylgspl evnre sah bnee ftefadec iwn(iht het ghrti l.edlaum) C is teh yrmpiad erweh teh oinotscaicplr rtcta nsur ot nlrcoto emcsuls rpr(oi to eth sais).encodut sThi is kwnno as the ailedm dmeylrula meyodnrs ro ejrDiene .sonerymd

d_holles  It seems to me that the brain stem problems can all be answered using the Rule of 4s rather than memorizing the actual brain stem histology. +13
llamastep1  Yeah I think so too! With the right CN12 palsy you already know it has to be medial (factor of 12) and that would be enough to answer this question. The hemiparesis just confirms that its a medial lesion (starts with M). I know many of us like to really understand the concepts not just use these "tricks" but hey if it works it works. +4
tekkenman101  Except how do you rule out E? The hypoglossal nerve is damaged too and E is medial... +

 +7  (free120#8)
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Teh vrpireaeolfti sepah fo het tlenarsmu cycel si lrdontloec yb nnncipe-teddecyl iase.skn shiT( emask eesns sa edclcentyni-pnde skansei vgerno tliayurvl lla elulalrc diovnsii in itrkcyueao cls.)le

thelongshoreman24  Answer A shouldn't be confused with cAMP-dependent kinases https://www.wikiwand.com/en/Protein_kinase_A +1

 +13  (free120#7)
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hTey ehav rbideecds wtha yuo usaems si a cssicla cesa fo naunoiem.p u,tB APN i’nts na srwean .hceico ahtW eht tenx tsbe ?ihtgn heT aeucs! dlO iarlf pleoep (nda lci)holasco eolv to etg apitosnira mnanp.eoiu LLR si the tmso mmoonc ,siet ichwh yteh hvea pvedrido kntah( y,uo bgi catelvri uc.srhbo)n heTy vene vega ouy teh tnhi ttha teh ntteipa ahs dic“tlyffiu lionasg,”wwl hicwh si eodc ofr risas“peat wnhe lwwsigol.n”a

mannan  wrong answers: Smoking and emphysema are obstructive and more importantly air trapping disease processes and wouldn't really cause the dysphagia. The main vasculitis with lung involvement is We-C-ner granulomatosis that would also have nose and kidney problems - from SATTAR +

 +3  (free120#6)
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hTe aimn woedisdn of ivle siecvnca is taht eyht anc b(ut rylare d)o sueac teh eidesas ’eyetrh eisddgne ot et,nvrep ylctiaypl in seuommcidnmeiomrp- u,idvisindla who tehrie eiveecr the acvncei or ear a colse ctnotac of oonemes owh id.d

em_goldman  Also in the case of the live oral polio vaccine, there's concern of viral reactivation in the feces of people who took the vaccine causing infection of others, even if the original person is protected. I would guess rotavirus is similar but I think the population risk:benefit favors live rotavirus vaccination in lieu of no vaccination, whereas the option of a killed polio virus vaccination is way more worth it than the risk of a polio virus outbreak. +4

 +3  (free120#5)
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lacFonutni drrhapotiya oaamsden nac auecs eldetaev ohidparatyr nmooreh ,TH()P hwhic sslrtue in lmieyeachacpr adn .hpophoaieamsyhtp arpailymecHec si adtzhrerceica by the hrignmy oymtsm:sp sotsne nra,e(l biila,)ry oensb inglcu(ndi nobe niap ot settisio siboafr ,t)cyiacs arsogn onbamil(da ip,na vn/), serhotn p(ryaol,iu i,incopo)nastt nad arptcshiicy trosenoev r(fom podeisrsne ot .)omac

drmohandes  Great explanation, thanks. Does anyone know why this patient is anemic though? Is there some link between hyperparathyroidism and anemia I am missing? +2
drmohandes  *Patient erythryocytes = 3million/mm3 (normal 3.5 - 5.5) +
melchior  From googling, it looks like it just happens. One author says that high concentrations of parathyroid hormone downregulate erythropoietin receptors. Regardless, it corrects after parathyroidectomy, showing that parathyroid hormone likely causes it, somehow. https://www.ncbi.nlm.nih.gov/pubmed/10790758 https://academic.oup.com/jcem/article/97/5/1420/2536309 +
flvent2120  So I understand why parathyroid can be the right answer, but why couldn't kidney be correct? This is just my overthinking things, but renal cell carcinoma can present with PTHrp leading to hypercalcemia +

 +8  (free120#4)
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NCS boiiasasme si stom norolytuios dcesua yb ragNieela ewr,filo iwhhc I ogceeranu yuo to rmomieze sa eht ngntiieaa-“rb maebo”.a onuFd ni aer-whsretf oedsib of aterw lkei pndos nad lakes, it ahs hreet m:rsfo a scyt, a poiootthezr oimbd,)a(e and a lltbieagefal i(e.. sah otw l.a)llagfe fntoneIci is iva alytfcroo lcel osxna ohtrhgu teh bmroriicfr tleap ot het ban.ir

mullerplouis  To add to this it causes Meningoencephalitis. Look out for confusion and brain signs mixed with signs of meningitis. Only a handful of organisms that cause both. +3
osler_weber_rendu  Am I the only one who thought portal of entry cant be through a nerve and just ignored all the nerves? +37
luciana  @osler_weber_rendu I thought the same... I knew it was through cribriform plate, but not that was actually through the nerve +10
paperbackwriter  @osler_weber_rendu yeah same here, otherwise would have been a much simpler question +
melchior  In line with the thinking above, SketchyMicro teaches it as if it just passes through the cribriform plate, ignoring the nerves. Wikipedia says that it actually enters the nerves, then passes through the plate. +5
j44n  this is such an AWFUL disease, I worked in a hospital in south carolina where it happens A LOT and there's nothing at all you can do for them. When your cells go to phagocytose it it has an outer layer it sheds off like how a lizzard will sacrifice its tail when attacked by a predator. +1

 +6  (free120#3)
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No olearnti bteeenw teh ruiatm )(P eawvs and teh SQR epmcxol emnsa -derihdtreeg AV obckl (aak leo”mcet“p eahrt )lcbok. tSmmayctoip enve( )atafl criaarybadd can .etuslr C“a”nnon riatla vwesa ear orminnept uaurgjl nsevou ltsuiaonsp ahtt rccou newh the arait and lnrtcevei crntcota eitulumosslnay chh(i,w of sceuor, dne’tso ylrnoalm hnp.a)ep


 +1  (free120#2)
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olmlToi si a -lbtrke.coeba eatB ekosbcrl nac earbeeacxt /a/rvhcaOiaCetPtsDme wriaya a.ssieed


 +5  (free120#1)
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a-nyAlloMoC siinthbi eht ttaginirmeli- pset in het oiettba-xdnaio fo ftyta dca.i cllgoy,iLa nsirgte lcemus rirquese sles gernye (nda huts sles ened ofr aftyt adic warnekob)d tanh vaeitc cesmlu.

zpatel  it inhibits Carnitine acyltransferase-1 in beta-oxidation. +5
melchior  FA 2020 pg 89 +

 +5  (free120#40)
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heT esnitp’ta hicconr framotlmiayn mtipseniuon si nilkigl off ihs lngu caamephnyr c(omedops rrimalypi fo tyep I .em)cpeusotyn Tyep II eec,ynomsupt in ndtodaii ot mgknai snf,tcautra cna altceprie ni doerr to cepalre tpey I nomeuspyc,te os hyet wlil eb rsaeiec.nd ohcCrin tinratesltii tmamlioiafnn strseul ni rsoi,ifbs hence na cnareeis ni rlfibbas.tso

len49  UW ID 666 has a great explanation. +2
melchior  From the UW ID 666 explanation, although type II pneumocytes normally differentiate into type I pneumocytes after proliferation, they do not differentiate in idiopathic pulmonary fibrosis due to altered cell signals and altered basement membrane, which is why type II pneumocytes are increased. +5

 +0  (free120#39)
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ciClmau xataeol setons are eth stmo cmmnoo iaeyrvt of yeiknd tensos, tub icru acdi oestns eakm up %01-5 sa .llew neNo of het treoh hioeccs are tiasdscaoe itwh arnle uclacli fo ayn e.ytviar

wes79  Also, the fact that hydroureter/hydronephrosis was seen in the absence of a stone on ultrasound supports that the stone was composed of UA +1

 +3  (free120#38)
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ihTs si a tcoipepvsre() ecas re.sies hereT si on tcoroln rpoug d(an arincteyl on lidng.ibn)


 +4  (free120#37)
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eTh oradwer fiudl si dietoacnn ni a speac bdineh het sohtmca but in nfotr of teh noopeeatiltrrer secrsuurtt ..eg( hte ncra)apes, e.i. hte esrsel ac.s


 +2  (free120#36)
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Teh uulsa il-dekclo tyompmss fo runyn ysee dan a eors ahttro are cmomno of reeasvl nssriat of raeviuosdn hatt ear draieyl ametdomcniuc montsga mhnsau in scloe t.noctac


 +2  (free120#35)
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nA laurnna raacesnp nsorurdus eht nduuemod nad acn eascu emretitnintt enaluodd tnt.brciouos Wlhie thsi ntqseuio retilhtaoyecl uqesrier het imggnai to rweasn rcrely,otc the ylno tohre cehoic htta si isealbfe si ceohCi ,D ihwch is wkonn sa SMA d.ymorsne ASM oemydnrs is iuetq raer nad pylaytcil nese ni eelopp ohw aehv eerlctyn ahd nigicanifts heigwt olss. nO het gimani,g it uoldw be mnsoisohg fo teh ddnuemuo by a ibrhgt tancsort elfldi tyarer as oppdsoe to nrsguunriod by stof seitus. I aosl htnik ’its hliygh yilkunle to be te.dtes

houseppary  I agree except that on the imaging, if this was SMA, the artery would not be bright and filled with contrast because the problem states that these studies were taken with oral contrast. So that's not a feasible way to eliminate SMA as the correct answer. I to think the quality of the obstruction seen in the UGI series show an annular-looking obstruction rather than a focal compression as you'd see in SMA. +2

 +2  (free120#34)
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eninIttttrme nuirrcbejhdiii/liepeynbumaa ni an owisheetr tlehhya lidvinaidu is ctiplya of t’rGiselb yesd,morn chwih is duaesc by eht deceaedsr aicttiyv fo PUD oeysnrlarns.ofslguacteru


 +7  (free120#33)
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ernAodgn vinisesnittiy is suaecd yb a iftedeecv ednnogar .eceprrot TDH is ipbslnrosee fro ictrange amel enitlgaia dgrniu talfe luxaes odnmetp.lvee heT aelutdf amuhn rnedeg si aml.efe oS a legyltneica mlae pnateti ihtw cleptmeo rnegodna svietisntniiy si rylxetelna yyictolhpnlepa mele.fa Lack fo seoenrps to renaald sanneodrg ervptnes hira iaofortnm uignrd utpryeb cdrh(.eena)ar


 +4  (free120#32)
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PTT sah a scialsc d:ntpea hcgaaonicmirotpi mchlieoyt maa,ine ocotrtimbh pu,urpar evf,re ralen efial,ru oirnoceulg nsotbemiarial .)AS(M ereWvnhe oyu ese a oinestuq ewerh hte ettapni yudnldse sha a lto ggnoi o,n icsoerdn TT.P

mgemge  Why is TSS wrong? +1
aejinkim  @mgemge: the patient's BP is still up there, and for me, she doesn't have a crazy fever that i associated with when i think of TSS +
cheesetouch  also TSS they would have to give you tampon use or nasal packing left in for a day. And it wouldn't cause schistocytes. +
beltorres23  TTP pentad FAT RN: Fever, Anemia, Thrombocytopenia, Renal, Neuro symptoms +
aakb  The big hint for me was schistocyte formation +

 +4  (free120#31)
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A cngieet aiovntiar in a plutiacarr tdeeoluicn si yb dnniieofit a yp.moplirshmo eoNt hatt het inotsequ yifsalcepicl ststea taht the ntiepor sameirn .cgnunhead


 +22  (free120#30)
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sA ws,ayla t’si amlost trbete ot rnegio eht ceisrtpu nwhe b.plossie ishT mntgenlea sah a eitpcp uler,c hiwch we onwk si daseuc yeaemidlpornt yb H. lpyiro nc.efioint H. iopyrl rdeuoscp pateersos and auralltyrpci s,eaure cwihh wlola it to aeneicsr eht pH of sti oacll envonmrniet by avncegli areu tion aoimnma, chihw si ctxoi to istagcr os.acmu ehT eciprtu eotaetsmsrnd H yp,olir cihwh ear ievtdne iwth vesilr ninasi.gt

joonam  Hey bro, thank you so much for your contributions on these free 120 questions. Your advice on test taking strategies for step 1 have been very helpful. +21
luciana  "Elaborated enzymes by H. pylori may also contribute directly to epithelial cell injury. Ammonia produced through urease activity may be toxic to gastric epithelial cells. H. pylori protease and lipase degrade gastric mucus and disrupt the phospholipid-rich layer at the apical epithelial cell surface, allowing for cell injury from back diffusion of gastric acid." https://www.ncbi.nlm.nih.gov/pubmed/9394757 +2
luciana  I got tricked :( Thought the damage was due to destruction of local somatostatin cells with increased gastrin and acid production... but this is actually the mechanism of duodenal ulcers development related to H. pylori But makes sense, so thats how the somatostatin producing cells are destroyed lol +4
drpee  "Hyperacidity and gastric ulcer development" is also sort of true, but this is hinting at the mechanism for DUODENAL ulcer development from H Pylori. Irritation in the stomach leads to G Cell hyperplasia, increasing acid secrection which causes downstream ulceration. +5
itsalwayslupus  Did anyone else pick the hyperacidity answer just because the correct answer had "local tissue destruction" in it? I figured that H. Pylori was non-invasive, so would not directly damage the tissue it is localized too +5
cbreland  @itsalwayslupus exact same thoughts over here +

 +2  (free120#29)
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Ctaelsaa nad aocgeesvsouta-liip sptgm-irieaov oiccc = hsapt saeuu.r cemA ittsiyivpo eamns eht aacetbri crary eht nege ttah nceofrs seei-nncchlitiaisl,trem hence RSM.A Of the ce,isoch RMAS si radette tiwh maoyvncnci.


 +6  (free120#28)
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gitSitpln si na ummtiear ednsfee smhaecnmi ntoef mlydepeo yb inttesap iwht rnliebodre rpylaetnois rd.idroes hWne pis,lgittn a rsnope iflsa ot ees seorth sa paleabc of hivagn tboh etiopivs nda gevtiena ailqiuts;e at ayn evign miet, ts’i lla or h.nnotgi

d_holles  Got this one wrong -- thought it was acting out. +1
cheesetouch  FA 2018 p539 the 'nurses are cold, doctors are friendly' example is what first aid uses too haha +

 +0  (free120#27)
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The sl’cionLn abder stdoitirnuib dsceiebrd is that of hte 3V anrchb of the lerngamiti ven,er ihcwh sxite hte uklls bsae aiv noaefrm .voela V2 sxiet avi neamfro ro.nduutm 1V sexti iva het ueriospr aitolbr r.sefius


 +11  (free120#26)
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A enw setlbiirng asdiees in na lored epnsor si lityyaclp giogn ot be a muipghesp einqoust. hnTe uoy sujt hvea ot emrmbree het rnefeedifc wtbneee ullsobu odipmphgei vs phgspmeiu grsau.vli luulsoB mgdohppiie is cizraeadtehcr yb hte ssol of smiedohsmemseo htat ndib aentsioerykct ot eth eetansmb meanebrm, eruigtsnl ni ulbal ib(g lsrbi)est ni esara of cfitonir eiCc(ho .A) satntPie ihwt iphmusepg vaiurlgs oesl etrhi edsessommo chwh(i dnib oteiractkyesn ot echa hoer),t os atht hiert kins is ruspe lbera,if ihchw surstel in auitr.ncelo otuMh seclur rea more mcnmoo ni VP.

drpee  Also question suggests a negative Nikolsky sign ("The blisters do not easily break"). This suggests BP over PV. +3

 +1  (free120#25)
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hisdaTize y(yalciltp udse as iipt)esnevsyethran laso cenarise cmaulic nrepotsior in eth asdlti bultue nad are eorheefrt selfuu in ignptnreve cmlcuai taeoalx nesto imanfoort ni sniatpte hitw iplcrcruyaieah e(th aheicmmsn si ont reayll trhow ila)nen.rg aTehidzsi kcolb hte aNCl- ,rstypoemr as epsoopd to olop ctudrieis, hcihw ockbl the tirperro,t nad ,olzeecaadmita hcwih obklcs cnbriaco edayhsrna ni eth oimxrapl ublt.eu


 +3  (free120#24)
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ishT tnioqesu is kasing orf eht aruvacsl pypsul of teh rropadhayit asgnld. thTa ulwod be eth frioienr itryhdo i,eraetrs hichw raise fomr hte vcceyhralorit ktnur.

weenathon  I originally chose vein because I was thinking maybe the hormone release couldn't be carried to the body anymore, but looking back the working of "moderate hemorrhaging" and vessels requiring ligation is what implies it's an artery. Just throwing that out there in case you thought like I did. +4
cheesetouch  if you were clueless like me (well I knew artery but..), picking one with 'thyro' in the name when discussing a thyroid surgery is a good guess :) +6
cbreland  I'm really out here picking one of the answers with vein +

 +7  (free120#23)
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lSwnalwoig octinaim fudil is a icrcalti toonmcnpe of lngu tlvne.oemdep Fustsee twhi ersvee myroshnlgiiodoa era ualpdeg by ypmurolan ,yaaiphplso hihcw is hte asecu of teahd ni stusfee bonr whit erPtto emdonrsy rnlae( ieases)g.n

mambaforstep  this is the second explanation that makes sense to me that I see downvoted. if you see something wrong and downvote, please explain! I want to know what im missing +3
abhishek021196  Maybe someone downvoted because in this question, there wasnt a mention of renal agenesis but rather urethral obstruction although that would lead to Potter sequence as well. +

 +2  (free120#22)
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The p-eulhaalva eprnsocdros ot eth vpla-ue ew lliw pacetc as afcnntsiigi nda ctseelrf het eklihoodli of a eypt I orrre (a felsa )sei.ptiov A reowl -evupaalahl aemns a rewol elbacteacp idhokilelo fo agonitnbi eth mesa eslrstu yb ,nahcec dna hus,t iistafgicnn slrtsue nca eb ropetedr mero coefdltniny (a 1% sfael isteviop erta tnieasd fo a 5% r).ate


 +10  (free120#21)
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eaFr = ygaaamdl

ahtT si lla I adtnwe ot ysa btu I gessu hatt is oto tsohr to eb ctaeedcp by teh mo.wbefr


 +3  (free120#20)
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The sapsifrutnani and erste oimnr rea spnsorleeib fro nrlxeeat traioo.tn hoBt eht iuranfpstsnia nda puisstnsaraup cssemul rae aevntrdien yb a ularsuarappcs .nreev

cbreland  Rotator cuff muscles: Supraspinatus, infraspinatus, teres minor, subscapularis (SITS), their movement is AEEI --> Abduction (first 15), external rotation, external rotation, and internal rotation, respectively. Someone threw out SITS AEEI on another nbmeanswers thread so I'm using it here. Hope this helps +1

 +4  (free120#19)
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eSutaucb bicomnde negraiedtneo srogep(esriv eilehpprar yorenss dan rmtoo os)sl si a tlae gins fo B21 yiediccnfe, hcihw si nmcmoo in dlo eppel.o nO e,msax a airtrigec aitenpt owh sevil oaenl dan yma vahe a t“ae dna ast”to ietd si eliylk to have vinatmi inecsfdiiec,e cpulraairtly fo olfaet nad 21.B


 +3  (free120#18)
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ioipRentlahs whit omerfr patetisn aer gllnreaey frdnweo ,no tub ryh’tee liesecpaly lcbortpmaie if teh neittap wsa a ichparscity i,aettpn as teh perwo cemaianbl of eht etaipaircporit-tnent inharlteoisp dna ofaontirinm het preriodv is iypvr ot aebsuce fo hirte tiatpen cear ovteinemvnl dplreuce a tehayhl nlbaedca hneiastrpoil fo qu.lase

osler_weber_rendu  But what if she hot? +2

 +1  (free120#17)
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pMlteuli tfsinnco.ie s.ebssceAs ehTn yuo earh daeecsedr iidxavote tubsr nad italmideemy hkitn NAPDH ixeaods eciiyfnecd aak hrcinCo loomnagsrautu adise,es hchwi ssueac rrentruce srobgscnfemas-i nitecnsoif ude to eth itabyilni ot llik dtgnseei sinmagrso bcsueea fo het ibniaylti to egnaeert eisdoxurpe daar.icsl

jean_young2019  Then why the choice D, “Inability of leukocytes to ingest microorganisms“, is incorrect?Moreover, Staphylococcus aureus is not an intracellular microorganism. Thank you for your help! +
houseppary  Because in CGD, the macrophages are capable of taking in bacteria but aren't able to do the oxidative burst required to actually kill them. So the macrophages just house live bacteria which leads to granulomas full of walled-off but not dead bacteria. And S. aureus isn't intracellular as part of its normal life cycle, but being eaten by a macrophage isn't part of its normal life cycle. Whether an organism gets eaten by a macrophage isn't part of the consideration of whether it's intracellular. +6

 +3  (free120#16)
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Pebrualt goemysatainc ni selam is nlrmoa nda lleaeygnr gsoe aywa no sti n.ow If mlrnoa“” si na rsnawe ich,oec kaem llayer reus you ’dnto antw ot cpki t.i

scubasteve  3 point in time when gynecomastia is normal... - at birth: placental transfer of maternal estrogens - puberty = increased testosterone results in transient increase in estrogens (aromatase conversion) - men > 50yo = loss of testosterone + more fatty tissue (relative increase in estrogens) +2

 +1  (free120#15)
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heT earsinco brcdiesed si retha rielauf /22 ratlmi evval igntre.oruiagt If we ntwa to rovep het egrgur, ew nac romfnic dna egdar it gnius an h.ceo

pg32  Why isn't catheterization also correct? Via catheterization we would be able to see elevated PCWP, which is a measure of left atrial pressure. +2

 +4  (free120#14)
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hiTs snioetuq is a ttelli ibt S,B in ttah hreet is oingtnh in eht stem ta lla to akem yuo enrif tsih icyeisf.cplal thWa eth istuoqen is yngtri ot ksa is ahtw ftoscar ucase aeicptarclm sisut ni agrenl.e heWli isansolrepfo enceomeictnp is a usc,ae opelpe ovle to ssudisc dn(a eth dsabor loev ot )test opro inhscyipa amiotimonucnc dna kcal of metapyh sa rtoo susace.

angelaq11  THANK YOU! here I was thinking I was the only one. I chose the incompetent physician xD +6
arcanumm  I was on the fence here, but what led me to the correct answer is simply that a question based on an incompetent physician has really no teaching point for our purposes. +
sharpscontainer  Though let's everyone be real, if the patient is poor, they are muuuuch less likely to have access to legal means for a malpractice suit. If only the USMLE cared enough to test us on social determinants of health... +1

 +3  (free120#13)
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lAylcnhtcieeo siancesre rfeat rdgu X, hcihw is the esam ’dew cxpete fi rdug X were a srasnhoeetielc .btrihinoi


 +2  (free120#12)
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nsVctreiiin (a siomsti b)hontriii nulqfreety sucase irlreppaeh ohen,prytau hwhic nca be erseev nda sebrvirrle.ie reOht fnu aiooscitnsas rea imnlecBoy whit mopuaylnr iof,bsirs oaCdhpcpilemosyh and ldebrda ccaer,n nda ixuDoonbcri wthi diletda ihypom.datyaorc


 +2  (free120#11)
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hTis si yilsovbou a anliccli tair.l If ouy konw yuo rae tnggite a du,gr hent ouy rae tno :nblddei s’it an pl-eeanbol .lriat rheTe is on oniarmdozitan as reteh is yonl a ilgsne reattetnm go.pru

charcot_bouchard  But they grouped them based on dosaged? +
keyseph  I think the key thing here is that the participants were told what treatment they would be receiving. This is in line with an open-labeled clinical trial. Open-labeled clinical trials can still be randomized and do not need a control (as in this case). +6
drpee  Yeah, bad question IMO. Open-labeled trial can also be randomized... Since they didn't tell us how participants were selected for each group perhaps that's why C is better than D? +1

 +11  (free120#10)
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pbmzCaareiane is a troiuosno 0P54CY eui,ndcr so oyu hdsuol be usigsneg btlmmieoas no tteram .twha C0YP45 palsy na inomtrtap lreo in thbo tvnmaii D iaoicnttvabio dan tiaeongrdad in het erliv.

mambaforstep  ahhhh i didnt know CYP450 played a role in vit D bioactivation/degradation. thanks! +5

 +1  (free120#9)
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eTh cftfees of exsesc yhordit e:rhmoon metadeptt rtmapsneyoco THS sosunsr,piep iaecsrne ni htbo T4 dna free 4T, and lmoarn G.TB etoN ttha het noiseuqt toe’dns neve gihne no BGT dna si also neilyklu to on the earl h.ting

d_holles  When do we care about TBG? +
zpatel  @d_holles in pregnancy. +

 -11  (free120#8)
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oYu llwi mereberm htta GPD6 fiycecdien sesauc erd olbdo ellsc ot kbrea wdno in ernseops ot aecnirt rroetss,ss snifceiotn, nad .udgsr hTe tiptes’an tyomsmsp rea a ninetfstaoami fo idintrec iuepaiyibenlmrrbih edu to hleossimy C(BR bra.e)ndwok Sa,ful vfaa aesn,b nrouni,tainrfot sizno,adii adn raatmlaaiilsn .(eg. iepamqrni)u era eht onmocm stte vatfori.se

benwhite_dotcom  This question was updated. It is a now a case of bubonic plague (or possibly ulceroglandular Tularemia), both which are treated by aminoglycosides, which target the 30S ribosomal subunit. +27
wes79  do you happen to remmeber what the original question was? thx! +
notachiropractor  treatment would be amino glycoside + tetracycline, double whammy on that 30s ribosomal subunit +2

 +2  (free120#7)
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sThi is rmsue iesskncs, a pety III ne(mimu )pxmocle tiiyths.epysnirve


 +0  (free120#6)
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mebReerm atth tseennfaerrc is ewnh het ntiptae si teanrfrgrsin idcgteier)rn( fenilges about noemoes no to ouy oyu( dmrein tmhe fo eihtr dd.a) erfunnteCtacsrornee is hnwe you od it tbuao htme (yhet dimner uyo fo ruoy ).son Procotinje is wnhe you iassgn oruy own eislfegn to ethm o(yu aer ngay,r os uoy nhitk uoy hyet rea ny.r)ga


 +2  (free120#5)
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ineCdoe is a dprurgo hwit ybisllaca no iagcenlas tesceff by efli.ts It idseatn umst eb oezmeidablt lmyto(s yb the erivl avi D)YP26C otni rmpneioh ni orerd to eprdoiv ilsaang.ea mSeo ofksl cervont erm,o moes .essl

abhishek021196  Just a side note, CYP2D6 is responsible for metabolism of cardiovascular drugs. The dirty mnemonic is that since a 2D Echo is used to image the heart, CYP2D6 metabolizes CV drugs. +1

 +3  (free120#4)
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lcrEtiecal aestarnln no rdbosa samen a ibg iraacilrdep fnufoesi (nad lysuaul caicrda todnapmae ihyylg.pos)o eTh htear noncta llif pyrerpol, roplade aerseescd, iposnyehtno and ytircaahcad s,ueen lidfu pbcauk selad ot aeetdelv JV.P enrgnildyU goloiety ni hsti aitntpe si elanr ifaurl.e

zpatel  Cardiac temponade. +
melchior  Hypotension and jugular venous distension are two components of Beck's triad, which is associated with acute cardiac tamponade. The third component is muffled heart sounds, which is not addressed in this question. +2

 +1  (free120#3)
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sfeufiD vellew-lo TS tleneaovi amens risiaeidrtc.p seeTh tapitsen oeftn ipamclno fo elucitpri thecs pani atth si estoawhm tvealadiel yb tngiist up nda anelgni rfdrawo and evah ittnsad rateh sdo.snu Common tets secuas eduicnl svuir,se iemur,a and 23- wksee etfra rmaoyldaci aniconiftr ersDlrse( roms)nyde.


 +2  (free120#2)
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esnrngAod tilaemust eosbcsuae lasndg dna eusca aen.c In gs,rli siht si irrmyiapl eud to aneecrrdha DDEAA(SHEH/ rneaognd otduoripcn daem yb eth eldrnaa ldang teh aonz t.)rieclusrai sByo nca losa abmle eestoertnots mrfo anaodgl ytrbpeu heubc.r(a)p


 +3  (free120#1)
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ttSnasi aeris LDH and scaedree LLD nad .GsT Trihe tefcfe on LDL si yb arf eth stom ,oeptnt utb teyh od a ltetli ogod no yvg.eirehnt

shieldmaiden  Statins increase HDL and decrease LDL/Cholesterol and TG (less of an effect than with chol) +

 +9  (free120#40)
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naiexrAo aldes to hagondtiopoyoprc gsaoiomhp,dny sa het body seleriaz taht eht tilbyiosspi of hnonuirisg a festu si rzeo dan ivgse up hte n.ersptee eTehr’s a olt of nprpoitgus atad, utb eon ludhos esusg iths nrswae noec yuo rdae the rowd gtmyasn”“ ro( “”dca)nre.


 +2  (free120#39)
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N. roangrohe can gechna sti ,siplu ichhw is leirnebopss fro oniaesdh ot hots llcse and the inma tninega to hhwci the ohts nstmou na muemni orep.esns seseNaiir anooeorgrhe si ebla to stihwc tou rifnefdet iinlp eseg,n dan ofr isth aneos,r irpro fontcinei esod ton cnrfeo go-gnsitlanl miim.tuyn

t123  to emphasize, N. gonorrhea commonly uses phase variation as opposed to genetic changes. +2

 +3  (free120#38)
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imfnroeMt si w.oaeems tI eecasserd phciaet cogusel odr,oupitcn cdeseesar taniensilt spotbrnioa of gucols,e and osrmeivp niiluns nityesivtsi by gscieirann lehrpirepa oelcugs epkaut nad oit.niuitlaz

drschmoctor  And it dramatically increases lifespan in experimental animals! Human trials in progress! +3

 +3  (free120#37)
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Teh rsuopep of amoghR is ot bdni to adn moveer teh hDR nsnatige os tath teh oethrm sedo ont omfr an uenmim ernoesps ingasat hte nnigeta in e’tfsu dboo.l s’tI gveni ot saritk- Rh ieteavng smom ta 82 ewesk and at yevredi.l

weenathon  This question confused me because wouldn't she have already formed antibodies in her previous pregnancy? +4
nbmeanssux  Pregnant mothers don't form anti-RhD antibodies until around 28 weeks (that's why we administer it then) so she shouldn't have formed any from the 12wk aborted first pregnancy +5

 +1  (free120#36)
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A 2b agsotni eilk eht nrcraltodohoib utarbloel dlwou usre pelh atht wiz.gehne oetN thta eienrehnppi (hcsu sa ni an -ppen)ei owdlu olsa hecavie iths but si eenoeisvl;ctn in htsi ae,cs eth psintta’e opmstmsy owdlu be pelhde tosm yb eht t2bea- n.mcopento


 +5  (free120#35)
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He ahs rua(mblpyes )SVR iit.ncslrohbio VRS si na ARN rivsu atht eenstr hte llec avi a sionfu tpinoer hhw(ci is teh rettga fo eht otraicppylhc omnollncoa aobidnyt udgr abimlvz.Pa)iu

aakb  I thought the fusion protein produces multinucleated giant cells. I thought RSV enters using the epithelial G protein? First aid literally says "All contain surface F (fusion) protein, which causes respiratory epithelial cells to fuse and form multinucleated cells." +

 +2  (free120#34)
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or-tviGeasmpi orsd ni a bteaidci ofto noudw (or a lrWod War I lodrsei fhggiint ni a )tenhrc anmes dCtmsiuoilr reprnnefgsi e(th etvuciaas irmgnaso fo asg gr)ang.nee pCesturi ansme ags ni teh iest,ssu hchwi si prucedod as a ruptdcybo of sti ylhghi lrnvutei paahl inxt.o


 +13  (free120#33)
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irlgeaF X si a GGC neioulrdtteic teaepr exionsnap dridrseo hc(iwh iekl utni’soHnntg is a ttse o)re.vaift The ataemrnl neulc si hte itnh to the Xkl-ndei trinhai.ence -itseuAlimk vbrihaeso adn ytaiveelrl glrea dhae rea oocm;mn elagr iettclsse ylno eappar earft tubr.pey

cbreland  Also repeat expansions will get worse with each generation. I went with the learning difficulties and then uncle having issues that were not as severe to a child with issues within the first 2 years of life as being a signal of a triplet expansion +
osteopathnproud  Fragile X syndrome is the most common inherited cause of intellectual disability FA20 pg 62. I just saw intellectual disability plus heritable = fragile X syndrome. +1

 +6  (free120#32)
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ovn drnbielWal seedisa is yb rfa teh mtos mconom ihneitdre endgileb hesa.tsidi qteelFu,ynr the lony raaolortyb naalbirmtyo si eniedrsac gebedlin teim illr(yealt oyu ricpk the itteapn dan ees hwo onlg it satke tmeh to psto egl.d)neib On etp,S ngiebedl omenw ehav VDW. gdeniBel oybs avhe ahemioph.il

winelover777  Agree. PTT does not have to be elevated to be VWD. +5
tulsigabbard  Welp. +
tekkenman101  Except there's no laboratory verified bleeding time given, only aggregation which has to do with platelet-platelet interaction. +

 +2  (free120#31)
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Ari and ldfui = aoxtuerpyomhno.dhr fI ahtt uidfl is ooldb /(ps bni,)tbsag tis’ a emhnxur.othomapoe Lakc of inisadletam fthis itaencdis ahtt i’ts tno undre tio.nsne

d_holles  @benwhite_dotcom how can it not be under tension if air is entering the pleural cavity? +1
nwinkelmann  Because the stab wound isn't functioning like a flap, meaning the air can escape. The reason a tension pneumothorax occurs is because the wound acts as a flap, where on inspiration it is open and air enters, but on expiration is closes and traps the air. +10
groovygrinch  Also if there was tension, there would be a mediastinal shift. +11
t123  Also the gastric bubble is elevated, actually suggesting lower pressure. Mediastinum shifts require more pressure, but the gastric bubble confirms it. +1
myoclonictonicbionic  I was overthinking and thought they're implying that the stomach bubble is the air-food level that was seen on the Xray. +3
cheesetouch  umm air-fluid*^ lol +1

 +3  (free120#30)
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ihWle E ilco is omnlar tug rofla, yrou doyb dwulo errepf it ysat rniilutana.ml

tallerthanmymom  Just remember that E.Coli and Bacteriodes Fragilis (sp?) are the 2 main gutys that cause intraperitoneal infections from the gut. +6
bharatpillai  Why not citrobacter though? +7
mamed  Common organisms involved in gangrenous and perforated appendicitis include Escherichia coli, Peptostreptococcus, Bacteroides fragilis, and Pseudomonas species (UpToDate) +6

 +7  (free120#29)
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hTe rwaro is iotnignp to a tlhuoinepr edmlob(itlu el:unsu)c main efrigth fo eht numiem meysst in etuca iaioanmtfnml nad abcetiral teinioncf s(chu as saarionpti opimae).unn Ca5 si a iachtcemtco raoftc rof .MPNs

ibestalkinyo  Other chemotactic factors include IL-8 and LTB4 +5
j123  Note: C5a is a chemotactic factor for many immune cells in addition to neutrophils. Also, C3a is a chemotactic factor for just eosinophils and basophils (not neutrophils) +1
cheesetouch  Q. What's so sexy about C5a? A. It's like Chanel No. 5 for neutrophils: they smell it and come running. +5

 +7  (free120#28)
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exAtipmroap igtfans oyglisyhpo tiig:nm het obotpaserpst-vi pahes 246(- ohsur afetr a em)la si aetndomdi yb isl.noygsloeycg nGlueeoiosecgsn ofrm 24 uhros ot 2 aysd. eThn sikose.t


 +3  (free120#27)
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Teh mmo liwl spsa no her dnteloie in 0%5. eTh hefrat lliw sasp it no ni 00%1 eucaseb( both fo sih opiesc rea fftd).aece eeer,hroTf teh ldich will yloaiamluctta hvae at eslat one leneiodt adn will vhea het dbleou nldteeoi ni .0%5


 +2  (free120#26)
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r:sC’noh skip ,oilessn ,itelafus rutsicster dn(a the cneynreuass mrrtlusana ivotmelvenn no holot)igs.y

mullerplouis  I think the histology was hinting at the granulomas.. +10
medguru2295  Yes the histo was a granuloma.They also gave fat streaks, and mentioned ileum, and adhesions. LAY-UP! +1

 +2  (free120#25)
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ID si na rponttami iooacptmincl fo oesm ulkls aesb tsrrufeac and cna eb tateder tiwh PA.DDV Yuo borpaylb emmreebr htta sith wskro avi eht notcvaiiat of proaiquna shlnecna, tbu teshe ear doemv rfmo lraicturlanle svcsleie to eth acplai arebmmne ceurfas sa a ruselt of a daeeDVi-DPAdtm ceeasnir nedtalaye cacyels via a yosltmatiur G pertion ahtt ascrisene etanlrullrcai A.cMP

aneurysmclip  Page 332 FA 2019; cAMP signaling pathway, thus increase adenylyl cyclase was best option imo +1
melchior  Page 337 FA 2020; This is working via V2 receptor, which uses the Gs pathway to generate cAMP. Reminder: V1 works via Gq. V1 is present on the blood vessel smooth muscle +10
aakb  also according to sketchy V1 is the vasoconstriction Gq (q shaped raised hole/stand in mini golf) and V2 is in the collecting duct Gs (s shaped mini golf pattern on the grass) +

 +3  (free120#24)
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53p nperoit is teh leattiuiessnnq romut rrsusespop (it ctvitaesa pstio)ps.ao PVH eesnancircsogi si cusdae yb ieonirtns fo het sruiv otni ohts NAD ahtt rdoecpsu a nreopit whchi bsdni to an elnssatie 53p u,asrtestb ytliaflnconu tgciinitnaav 35p nda ringptevne tis opcpitato aadc.esc onTtar/AaatnivscTXi is hwo IHV adn VTHL cuesa acrc.en y-mcc anlatcnooitsr aessuc trtBkui m.ohpalmy

claptain  Just to add to this, HPV can also inactivate Rb via E7 viral protein. +2
mamorumyheart  E6: p53 E7: RB (from FA: 6 before 7, p before R) +2

 +5  (free120#23)
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dnEicem ttkuBir pmloymha anc pphane ni laBirz sa llew as arfiAc waj( so,nlei pfyfu ec.)af ehT mtihaoroprghpoc si ngmtaostnrdei ieigbltn doyb srghemaapoc, a ypet fo rgmpcaehoa nningcioat nyam ygtz,cihaeopd pcpiotota selcl ni iuosvra etssta of girndtoaae.d

weenathon  For anyone else who was wondering why a cancer was undergoing apoptosis (classically we think of cancer EVADING apoptosis), apparently it's due to the myc mutation classic in Burkitt Lymphoma. While myc causes the cell to proliferate, it also induces apoptosis - hence the tingible bodies containing apoptotic cells. (https://www.ncbi.nlm.nih.gov/pubmed/8247541) +1
itsalwayslupus  Also just for people who watch boards and beyond or pathoma (I don't remember which exactly it is from), the "stars" in the "starry night" appearance of Burkitt's (what is being shown here) are lighter because the the cells are dying/gone via apoptosis (supposed to be the "holes" in the "night sky" lol). +4

 +5  (free120#22)
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dnllaetiohE gtith ot’unjicns bitrlimapeye si edcneisar ni spnresoe to rjnyui and lota,nmaiinfm ilnawogl mgoatniri fo white dlboo eslcl dna enisrfd ot hte siet fo jniyru.

jesusisking  Thank you! +
focus  Ugh I was thrown off by "disruption of vascular basement membranes" since it seemed similar to the correct answer but I can see how "separation" would be a normal, expected response of the body that is needed vs. "disruption" would be traumatic and abnormal... please correct me if I am wrong! +1
blah  @focus reasoning sounds right. I nearly picked that but the other choice sounded better. Just semantics. +2
aakb  um just to clarify I don't think the differentiating factor is the wording of separation vs disruption. but rather that the correct answer is separation of ENDOTHELIAL junctions meaning that the spaces between the endothelial cells get wider. vs the answer youre thinking of says the disruption of the vascular BASEMENT MEMBRANE (which is under the endothelial cells) gets disrupted. so meaning something literally broken through the blood vessel and made a cut in the layer beneath the endothelial cells that line the blood vessel Dr. Sattar from pathoma usually draws a basement membrane and a layer of endothelial cells sitting on top +

 +12  (free120#21)
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D’otn let mteh indbl you htwi tsih aiptetns’ yme.isr eTh sesiu of the yda is tath he has a .TDV Tash’t hyw eh amec to het ER ni teh ftisr cesntnee and awht eth udontuasrl swhso ta het nd.e anPtties hitw reccan rea bhgl.aolaueepcry

focus  LOL best explanation possible. +1

 +0  (free120#20)
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oteN htta teh qtsoneiu is ton iasgkn hawt lslec gitfh .IsUR ehT tosnqieu skas twah bal dingfin owudl eb tncnoesits htwi ecdseerad uinemm iacvitty nad( tush the only oichce that hsatcem ”srd“aeceed twih an neimum ecll is the ebts w).neras

sugaplum  So I read Lymphocyte as leukocyte (because cortisol probably) so that is what I put. but cortisol does increase levels of neutrophils floating around in the blood right, I was going for stress demarg. Can't tell if i am thinking too hard about this. +

 -3  (free120#19)
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eMemoirz rp’iinssa nequiu ibdseac-a f:tfecse lmbeotcia ssoicdia nad eirrarytpso oaklslia.s ,oteN tshi is leilyk aalctu areotsriyrp alosi,salk ton lmpiys anlrmo tioarpyrrse ctoioeannmps orf eimtcobal i.ssicaod

mikerite  Based on the correct answer choice, the person is now in metabolic acidosis with respiratory compensation. +4
benwhite_dotcom  The correct answer choice is as listed above (all decreased). Note that whether metabolic acidosis is combined with primary respiratory alkalosis, which is an important teaching point I’ve argued the question writers are probably getting at, or even if just simple respiratory compensation for metabolic acidosis–both can have the same arrows. In this case, it’s not respiratory compensation. In ASA overdose, the respiratory alkalosis actually happens first. Ultimately, the metabolic acidosis dominates and the pH is almost always low. This mixed primary acid/base response to ASA toxicity is highly testable. +1
ali  How long till the respiratory alkalosis turns into a metabolic/mixed picture? +2
benwhite_dotcom  @ali 12 hours is a good number to memorize but it can definitely happen much earlier. +
yoav  From what I understand, the metabolic acidosis only presents 12h post ingestion, while she is only 3h. What do you think? +1
benwhite_dotcom  @yoav, It can definitely happen earlier. It’s more of a by 12 hours (not only beginning then). +
angelaq11  I'm beginning to think that they don't actually care about how many hours lapse after the ingestion, but if we actually know the unique acid-base disturbance. I chose the wrong one, again because I was foolishly thinking about those 12 hours postintoxication +5
charcot_bouchard  I think this is good rule of thmb in USMLE "a Right answer may or may not tick all the correct things but will NEVER have a wrong thing in it". So the ans choice we all chose has Bicarb inc. But this will never happen. at 3 hour we should have pure resp alkalosis with normal bicarb (as per uw). Or in this case decreased due to neutralization by organic salicylic acid. In Aspirin poisoning bicarb will nver increase. +6
elasaf@post.bgu.ac.il  Another important point- they probably gave her RR (30) to indicate that she is hyperventilating==> LOW CO2 +2

 +2  (free120#18)
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poasshetihnpBos kwor yb eedircangs asoecottls vtiyacti ybt(ereh drugniec oenb s)enpooirtr. c“areIedns rtecrpeo aiittncaov of FNkB nilagd RAN)L(K uiocotnrpd” si eht seooiptp fo owh ertnoseg heapyrt rwkso LAKNR( si dfonu no aesoottssl,b adn sit tniviaoatc rgsegitr sscosaotetl nad auselsttmi boen nei.orprost)


 +1  (free120#17)
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syintvietSi urles stingh uot. s’tI TP / (TP + F)N. So ni drore ot uclaetlca het stvtisyneii of this es,tt we dnee hte retu soiptsvei t(he 90 thwi recnca) dan teh fasle gevtaeni:s het npsieatt rfo howm teh ttes si vaeietgn tbu lactlayu do vahe pattsreo ceca.nr


 +1  (free120#16)
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oryaPnulm ofrisisb (a cerrivtstei etaptrn se)eisda is a ojmar uaecs of tiryloamt fro neittpsa ihtw dso.arerclme Lallyocg,i fi teh desesai cesaus iirfossb ewe,seelhr its’ iongg ot aseuc rbiiofss in eth su.gln


 +7  (free120#15)
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idLyeg selcl emak rostsenoe.tte igLyed clel rtmosu reatn’ wlaasy yiisopahclglo ,tecaiv tub ohtes atht ear acn aeucs nlnazcmtoiis.uia nlsaraGuo clle mruos,t no eht treho hdan, msimseeto epcrudo greoents (ichwh acn aeld ot ccoipeosru buteyrp in gyuno irlgs tbu osewhrtie aym be cto)cul. amoasreTt are oaddslbl ttah yllticpay aveh tf,a hrai, hte,te .etc saoheTmc iwll nto be no yrou tse.t raOainv dcicarnoi is yihlhg leuynikl to whos pu no ryuo t,tes but fi ti dd,i ti ouwld lielky pretens hitw a cilascs dciriacon en.dosymr

sugaplum  FA 2019 page 632 +1
divakhan  because................"Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" NBME 24 -#13 Qs explanations/comments on this website, has led me to choose this answer! :D +17
zevvyt  divakhan, thANK you i was hoping praying that someone would have written that +

 +3  (free120#14)
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hTe ariyomgt“r uiopirngsse anpraiel ”srah ck)(i is ilcscas rfo eyro,slgotdsin a spitaicar nmdorurwo qricuade omfr d-vntieaanalcmoetra ls.oi etioSnyrsdogl eaavlr acn worobr (eehnc the a)hrs adn can raemtig ot eht GI tatrc dan ayl hiret ,segg hhwic htne hcaht in eth etnnitesi dna sucae ar.ihaedr tteaTrmne is itrmvcIene n(da if ,ton aamb.zdllnendebeae)zelo/o hcCgkine eth sotlos ofr aevlra is teh omts esnsvtiei ett.s rPsetaia leif secylc rea sorgs.

benwhite_dotcom  As an addendum, I believe this is larva currens (https://en.wikipedia.org/wiki/Larva_currens) in the setting of strongyloides infection and not Cutaneous larva migrans. Strongyloides, unlike CLM, explains the diarrhea, weight loss, and not just the eosinophilia. CLM is generally limited to the skin and typically appears first in hands or feet (whatever touches soil) with perianal involvement being significantly less common. Stool studies are unnecessary in CLM, which is primarily a clinical diagnosis. The other information in the stem is there for a reason. See this nice comparison page: https://www.derm101.com/therapeutic/cutaneous-larva-migrans-larva-currens/introduction/ +2

 +4  (free120#13)
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The ucohP of logsuaD is het capes bweente the ruuset nda teh umetcr ei.(. eth pclea hwree peivlc eref udfil )ge.os


 +4  (free120#12)
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PPC is a ciedh-vnptsoeiyat nad osiatvceiids hecitnsaet ahtt llyegenar tacs sa a ronedw btu cna oals saceu dcelenibri esnrsaiogg pedoulc tihw pain tnivnyesiisit eth( uaepnrms ).grdu aicerVtl yugnmstas si a omlycomn eteonmind sipclyah mxae nngidfi.

azibird  FA specifically mentions hypertension and tachycardia, so I ruled it out immediately. But you're right, it's a hallucinogen, I thought it was a stimulant. +1
azibird  "PCP (10mg/kg, s.c.) causes hypertension that is associated with decrease or tendency to decrease the levels of epinephrine and norpinephrine in the hypothalamus and the brainstem regions." https://www.sciencedirect.com/science/article/abs/pii/0006899384901847 "Over 50% of adult patients present with the classic toxidrome of PCP intoxication: violent behavior, nystagmus, tachycardia, hypertension, anesthesia, and analgesia." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859735/ +
schep  I spent so much time on this question. I also ruled out cocaine, methamphetamine and PCP because (I thought) his vitals didn't match. Then I was forced to convince myself that someone on oxy or a benzo would suddenly get violent... +

 +5  (free120#11)
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heT apbreesotorrc aer tchesrt rroespect the( eorm ifudl in hte el,vses het moer etyh ief)r. So a ttienpa twih heorgcimarh kocsh illw ese a eacedser ni eht acrorebtrpoe niirgf a.ret atciovitnA of ASRA ilwl turels ni esndcerai alcrvsua eessinract voit)sr(nstacconio in reord to aniaintm dlboo eurr.ssep ndA clprisaeai,l cush as oeths in eth ndiyek, lilw eb mdirep rfo tsrnpoiero dna not nrotatiilf no( neo twsna ot eep out odgo iedltu uinre enhw etyh’re dhe.ty)redad iwkeiLs,e yiscesmt rieacliapls liwl refper ot ldoh toon saplma dan not let ti alke iont het nsiuittritme hsad-gicpir.)(tn

tallerthanmymom  Another thing contributing to the increased SVR is increased SNS tone and decreased PNS tone. When BP is low --> Afferent BR firing decreased ---> Efferent SNS firing increases, and PNS decreases --> the inc in SNS tone stimulates a1 receptors ---> Inc SVR BUT, I don't understand what is causing the increase in the PVR because I always thought that inc SNS tone should be causing vasodilation in the lungs and that is why PCWP is decreased. +6

 +5  (free120#10)
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otalT reialphper snesetraic sgeo nowd gdniur ereeicxs as het riesoatler usglpinyp umlecs dan sikn alitde.


 +0  (free120#9)
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uSrtoneh tlsbo era mocylnom sdeu ni imuncloolagim ,utiedss as the hteruson bolt olsawl ofr the dtsuy fo AND lns.itoaaetr tWha is moallnyr one ngee ociogrnauifnt eetdrla ot imeunm llgonibus ni somt stieuss stdsenaemtor pmtelilu iredfetfn sdbna ni eth oneb ow,rram ianveciitd fo egen ermnnereragta. hsTi is aciabslly owh we acrtee new dsioa.binte vacReeti rpcessoes rae clalnlopoy mltipu(le )dbs;an ilemkeua, ni rstncoa,t is mlaonolcon enlig(s .b)adn

ali  I still don’t understand this one. Could you provide a better explanation? +
benwhite_dotcom  The cDNA tag is tagging a constant region common to immunoglobulins, so it normally only finds the one band corresponding to that particular gene (the bands travel different amounts due to their differing size/weight). In the bone marrow sample, that gene has rearranged itself, so the cDNA clone instead tags multiple different genes that are of different sizes on the gel (each one has that same constant region the cDNA is tagging, but with different stuff around it such that the restriction enzyme has cut it up differently). I’d be happy for someone to step in and do a better job on that explanation. +14
em_goldman  A Southern blot starts by cutting DNA strands at a particular (short) site and running them through gel electrophoresis, so identical DNA sequences get cut at the same site and thus are the same length, so they are at the same place on the gel. If there's lots of different sequences, the restriction endonuclease (the scissors) cut the DNA at different places, leading to strands that were the same length originally but are now lots of different lengths -> different places on the gel. But how do you know this is the same gene, just with different mutations? The Southern blot uses a probe to look for a more specific (long) region of DNA that you know is in the target gene. So even though there are mutations causing the less-specific endonuclease to cut the DNA at different parts, the overall architecture of the gene is similar enough that the probe can bind, thus we know it's the same gene. (And in bone marrow WBCs, the mechanism here is genetic rearrangement.) +1

 +4  (free120#8)
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eTh die-sfdlet mseyts is chum rihheg peusrres athn teh gihrt ,eisd ehenc eht ocrita vvale ocngsil is yuulsal ruodel nath hte oinumplc ev.lva A 2P ldorue tahn A2 smean atth teh ropnymual ratreali eserpsru is tfinansiyilcg evalt.eed

topgunber  other answers choices such as peripheral edema and elevated JVP are nonspecific to right heart failure. Loud s3 (ken-tuck- EYYY) are more indicative of volume overload and pulmonary crackles/edema is usually due to a left sided heart defecT with backup of fluid into the lungs. +

 +0  (free120#7)
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iFlarimtgs is a gatuncoleyr nloocy niuttisalgm ortcfa S)G,(CF hcwhi rea sgurd uesd to arsieecn hiwet lobdo llce nctou ni nietsatp wiht iapeknuoel. noLcvuoire cflin(oi idca) nosusd liek ti odwul sola be ,itrhg tub its’ desu to rpneetv obne mrorwa nsueosirpps ni ntetasip ntgaik teaeexhtt.mor aenbpDiteor (like ntyoerih)ietrop si ueds to umteslait dre lodbo lecl dircuonop.t

em_goldman  were we supposed to know that she wasn't taking methotrexate (or did I miss that in the question stem)? +
tallerthanmymom  I don't think Methotrexate is used to treat small cell lung CA; per first aid (2018) the cancers Methotrexate is used to treat include "Leukemias (ALL), lymphomas, choriocarcinoma, sarcoma". It also has some non-cancer uses in rhuematologic ds, ectopic pregnany and medical abortions. +2

 +1  (free120#6)
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ostuugPedo si dcsaeu by feeytoir-binivsngerilpt dorbhomi muicacl peyahophptosr lstryac epi.sndoito Mots olnmmocy cffdaeet cooinalt is het knee. attsorCn itwh tugo, yveeaglint nnftirregieb, big ote. A dalieeffritn for tbho to kpee in indm si tcspei r.strihait


 +0  (free120#5)
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VGEF is a amrjo seistu gtowrh tfcaro titvecaad by uijry,n iokcynte eeselra nnoific,t(e tiaai)lonfnmm dna aiyhxop thta rmotespo ogegssnniiea nad salo asnieserc svuraalc tbelpiamyrei ehnc(e hte eam.e)d This dcereians lyeimrtaeipb asdi ni eth toevnmme of rtinopes nda hiwte dloob lcesl ot the etsi of jin.ruy


 -2  (free120#4)
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dAn eht rwneas i,s iagtnc out aka e“ngbi a tne.g”reea


 +4  (free120#3)
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oHt tbu licuilfi,solt ’ist a htgn.i aclCllissay snumdpoa.seo

medguru2295  I hate myself for overthinking this one. The first thought in my head was "hot tub folliculitis" but my dumbass didn't pick follicle. +10
hungrybox  @medguru2295 same bro same +

 +3  (free120#1)
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smSihicotssoasi si a pciisaart wrmo tlrcurlaapyi enimedc in fcArai t(,gpEy in prtaalic,ur seocm up hte omts no et)snqisou ahtt is mots ieaasctdso whit rihccno sii.tystc itiCsnaoalccif of hte dbldear lawl era tislelsaeyn pntmingoo.ahco nCiroch fcniinote si aceoitassd ithw an iaesdnrec rsik fo qasoumsu elcl acminaroc fo hte eladdbr (sa epspood ot the usula aolorn/ttiltsraiuenihal lcle).

takayasuarteritis  Why does his cell differential show no eosinophilia? Schistosoma is a worm..? +
takayasuarteritis  It also says in FA that SCC of bladder is associated with painless hematuria. My dude in the question stem is having "pain with urination that has increased in severity during the past month." +4
melchior  @Takayasuarteritis, technically he does have eosinophilia. Reference range is 1 - 3%. His is 5%. Also, although SCC of bladder presents with painless hematuria, schistosomiasis itself can have hematuria, and that hematuria can be painful. +1
bekindstep1  FA (2019 pg 160) does say it would be painless specifically which is what made me lean against schistosomiasis +
itsalwayslupus  I think the calcifications, immigration from Africa, eosinophilia, chronic inflammation, and granuloma formation (which can occur with a schistomiasis infection) all together (+ a very slight fever) would all lead to Schistosomiasis, and you would just have to ignore that urination is painful, because many other factors could be causing that too outside of the traditional acute schistosomiasis infection. The pain here is just not the most important factor I don't think. +6




Subcomments ...

When it comes to development questions, always make sure before you pick something other than normal if offered. Tanner stages are available for review here.



This question is asking for the vascular supply of the parathyroid glands. That would be the inferior thyroid arteries, which arise from the thyrocervical trunk.

brendan  why wouldn’t a branch of the external carotid also be a valid answer? does the superior thyroid not also give arterial supply to the parathyroid glands? it seems to me that it could be either of these. +2  
benwhite_dotcom  @brendan Superior thyroid provides mostly collateral support. The inferior thyroid is the primary supply and thus the “single best answer.” Remember, the other choices don’t have to be WRONG—they’re just not the best. +  


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heT oaimrrtg“y rpnsisugoie aaeniplr ha”sr c(k)i is ccslsia ofr dngossoiytlre, a iaricatsp odwroumrn qudciera fomr viam-eecalndanartot ol.si irodeSygolnts ealrva anc oobrwr (nceeh the a)rsh adn nca taegmir ot het IG atrtc dan ayl etrih ,sgeg whhic tneh tahhc ni the iisntnete nad caseu drra.ehia amTetnetr is ciemeIntrv (dna if nt,o dolnebn.eeo/ameldzzb)aale hekngcCi hte soostl orf elarav is teh ostm seiiesnvt etst. saPirtae feil clescy rae rsso.g

benwhite_dotcom  As an addendum, I believe this is larva currens (https://en.wikipedia.org/wiki/Larva_currens) in the setting of strongyloides infection and not Cutaneous larva migrans. Strongyloides, unlike CLM, explains the diarrhea, weight loss, and not just the eosinophilia. CLM is generally limited to the skin and typically appears first in hands or feet (whatever touches soil) with perianal involvement being significantly less common. Stool studies are unnecessary in CLM, which is primarily a clinical diagnosis. The other information in the stem is there for a reason. See this nice comparison page: https://www.derm101.com/therapeutic/cutaneous-larva-migrans-larva-currens/introduction/ +2  


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ldoBo ta eth astmeu is hte red fgal (ese htaw I idd rhe?te) rof aertlruh in,yujr chwhi dusloh be daveeltau fro tiwh a grreartode rmrotgarue.h The aumonmsber eth tmso moyolmnc unrdeji by feac.rtur In totcarsn, hte spynog etauhrr si otsm lyklie ot be rieudjn dginru aitucrtma echatter snernitoi ro ni a sldeatrd i.yjunr

canyon_run  Should we just assume that a pelvic fracture implies a membranous urethral injury? I was between membranous and spongy and I ended up choosing spongy because of the perineal bruising and fact that the patient was riding a motorcycle (and therefore susceptible to straddle injury). +  
benwhite_dotcom  Yes. You should think of spongy as the penile urethra, hence the predisposition to catheter-related trauma. +6  
focus  Diagram: https://www.earthslab.com/anatomy/urethra/ +  
topgunber  it says no trauma to the penis so we have to rule out spongy. To tear the prostatic urethra would mean the prostate also got affected, which when compared to the vulnerable membranous urethra would be unlikely. Both spongy/prostatic urethra are vulnerable to TURP or catheter related trauma as mentioned. As far as the bladder itself and the intra-mural urethra, i would think fractures of the symphysis and above would cause that. +  


submitted by canyon_run(4),
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I tnca’ mese ot fnid a amilirs gaiem nnoeil htta sicbesedr etcyaxl awth the ertho ersaa ear r.ivnegco Ayn ?hlep

benwhite_dotcom  See this image (Fig.6) from https://teachmeanatomy.info/neuro/brainstem/medulla-oblongata/ A and D, for example, would reflect lesions that cause what is called lateral medullary syndrome (Wallenberg syndrome). +1  
canyon_run  Thank you! Would E then be the inferior vestibular nucleus based on that linked image? Also, is hypoglossal involved in the stem because of damage to the nerve fibers themselves rather than the nucleus? +1  
benwhite_dotcom  I think the level in the teachmeanatomy link is a bit off from the NBME image. I assume the NBME is showing E as the hypoglossal nucleus (https://en.wikipedia.org/wiki/Hypoglossal_nucleus). Yes, it’s the fibers. The nucleus is ventral. +  


submitted by canyon_run(4),
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I n’tac mees ot ndfi a iarmisl aeimg noieln htta cbersdies atylxce awht het retoh asrea rae g.nrioevc Ayn ?phel

benwhite_dotcom  See this image (Fig.6) from https://teachmeanatomy.info/neuro/brainstem/medulla-oblongata/ A and D, for example, would reflect lesions that cause what is called lateral medullary syndrome (Wallenberg syndrome). +1  
canyon_run  Thank you! Would E then be the inferior vestibular nucleus based on that linked image? Also, is hypoglossal involved in the stem because of damage to the nerve fibers themselves rather than the nucleus? +1  
benwhite_dotcom  I think the level in the teachmeanatomy link is a bit off from the NBME image. I assume the NBME is showing E as the hypoglossal nucleus (https://en.wikipedia.org/wiki/Hypoglossal_nucleus). Yes, it’s the fibers. The nucleus is ventral. +  


submitted by canyon_run(4),
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hwy si hte tepaltel iegratganog stet is arolmn in VWD? ym eblormp is hatt 1pbG dna rcWVotfa haev to aecttnri ot ndiceu a roicilfnotmaan nhcage in alptseelt ot seleear ADP t&g–; APD sibdn ot pcratod-eepr dna nscuied ab2G/p3 ichhw ealbsen ngaogatrgie iav gnri.bofein hcwhi oduwl lade ot nalaombr iagtgngroa?e dan is het sitintocer aayss tno a epetlatl gnegtgioraa t?est ro nac it eitomsmse eb onlmra nda smimtesoe n?to

benwhite_dotcom  It can be abnormal as well, depends on the subtype and severity (the wikipedia page does a decent job explaining). The most common subtype of VWD is a quantitative defect, which is often mild/nearly clinically occult and can have essentially normal laboratory testing. This is one of those questions where the labs are really there to exclude the other choices. +4  


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Teh oynl thngi ahtt ertdlyci irsesa BP fo het tsil si aecrsenid .RPV

amedhead  would decreased cardiac output not also increase the blood pressure due to sympathetic activation of the baroreceptor reflex? +  
benwhite_dotcom  I think you’re ignoring a directly correct answer, increased PVR literally equals increased BP, and are instead trying to postulate an indirectly plausible answer. Decreased CO, as you just implied, means less blood pumping into the aorta and less blood pounding and stretching the arteries and thus decreased BP. Note, your original logic would apply to stroke volume just as easily. Yes, a sympathetic response could then occur as a response to mitigate this, such as in shock or heart failure, but it would misleading to suggest that decreased CO causes hypertension. +3  


submitted by ashmash(3),
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hyW t’anc we esmasu that the pntatie hiwt na ealeevdt tirced riublnibi edos otn haev esom srot of consrbtuito ehewr hte aaielkln pesphsthaao luwdo eb eeldtaev o(r even nidbu ojshnon d)sneor?my I idntd’ htnik fo lrtGibe easieds speedti het tneitriemtnt sorceu ecauebs I dnet ot kolo at riecdt dan total biiubrlin vselle stfir to ese if teh ricted buriiinlb si evdealet cihhw in ihts ecsa asw detevale.

benwhite_dotcom  Few things. History always comes first. She also has even more indirect bili than direct. There’s also no other indication of obstruction clinically (such as pruritis), and you can’t infer an elevated lab value (alk phos) and rely on that in order to have everything come together. They have to give it to you. +8  
morelife  I saw this question on Gilbert’s and also put down increased ALP. I noticed the relapsing-remitting history. However, my thoughts were that a direct bilirubinemia is a false finding in Gilberts (since it is due to lower UDP enzyme activity), and would more likely indicate obstruction. As you said, you would consciously neglect this finding in favor of the history? For these specific NBME style questions -- you know, the wishy/washy ones -- would you follow the principle of “history first”? +  
benwhite_dotcom  @morelife, Plethora of evidence first. Here everything points in one direction except one small detail. If you were to make a list of pro/cons for each diagnosis using history, physical and objective data (labs, imaging, etc), the scales usually tip firmly in one direction. +2  
wowo  also, unless I'm mistaken, it's not a direct bilirubinemia - tbili is 3 and direct is 1, so unconjugated is 2. They're both elevated. Even with a decrease in function of the enzyme, it still works, so if unconj bili increases, you'll get somewhat of an increase of conjugated bili +1  
kindcomet  @wowo, that makes sense if the unconj bili is due to hemolysis but it doesn't make sense if pathophys is literally the conjugation step. I would have expected DECREASED conjugated bili, if anything. +1  


submitted by ashmash(3),
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hyW nc’ta ew ssmeua ttha het ittnaep twih an eeedtavl rcietd bibinluri odse not veah mose rtos of tcrbotnusio rwehe teh likneala atesopsaphh owuld eb eeleavtd or( neve dnuib sjhonon rs?dnyome) I ddi’nt itknh of briGtel asiesed peeistd teh inrttemttnie socuer aubesce I ndet ot okol ta iecdtr nad oattl nbiiurbli velels trfsi to see if eht ericdt iinrbiulb is aveeeltd iwhch ni tsih easc swa eevdl.tea

benwhite_dotcom  Few things. History always comes first. She also has even more indirect bili than direct. There’s also no other indication of obstruction clinically (such as pruritis), and you can’t infer an elevated lab value (alk phos) and rely on that in order to have everything come together. They have to give it to you. +8  
morelife  I saw this question on Gilbert’s and also put down increased ALP. I noticed the relapsing-remitting history. However, my thoughts were that a direct bilirubinemia is a false finding in Gilberts (since it is due to lower UDP enzyme activity), and would more likely indicate obstruction. As you said, you would consciously neglect this finding in favor of the history? For these specific NBME style questions -- you know, the wishy/washy ones -- would you follow the principle of “history first”? +  
benwhite_dotcom  @morelife, Plethora of evidence first. Here everything points in one direction except one small detail. If you were to make a list of pro/cons for each diagnosis using history, physical and objective data (labs, imaging, etc), the scales usually tip firmly in one direction. +2  
wowo  also, unless I'm mistaken, it's not a direct bilirubinemia - tbili is 3 and direct is 1, so unconjugated is 2. They're both elevated. Even with a decrease in function of the enzyme, it still works, so if unconj bili increases, you'll get somewhat of an increase of conjugated bili +1  
kindcomet  @wowo, that makes sense if the unconj bili is due to hemolysis but it doesn't make sense if pathophys is literally the conjugation step. I would have expected DECREASED conjugated bili, if anything. +1  


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eimoerMz na’isrips eiquun acaseib-d escf:eft alemticbo cioisasd dan sierytorrap ka.ossilal teoN, sith si ekyill laucat eorstrypair ol,lssaiak ton myslip olarmn ioptyearsrr eisonctoanmp ofr tieblmcao csi.odasi

mikerite  Based on the correct answer choice, the person is now in metabolic acidosis with respiratory compensation. +4  
benwhite_dotcom  The correct answer choice is as listed above (all decreased). Note that whether metabolic acidosis is combined with primary respiratory alkalosis, which is an important teaching point I’ve argued the question writers are probably getting at, or even if just simple respiratory compensation for metabolic acidosis–both can have the same arrows. In this case, it’s not respiratory compensation. In ASA overdose, the respiratory alkalosis actually happens first. Ultimately, the metabolic acidosis dominates and the pH is almost always low. This mixed primary acid/base response to ASA toxicity is highly testable. +1  
ali  How long till the respiratory alkalosis turns into a metabolic/mixed picture? +2  
benwhite_dotcom  @ali 12 hours is a good number to memorize but it can definitely happen much earlier. +  
yoav  From what I understand, the metabolic acidosis only presents 12h post ingestion, while she is only 3h. What do you think? +1  
benwhite_dotcom  @yoav, It can definitely happen earlier. It’s more of a by 12 hours (not only beginning then). +  
angelaq11  I'm beginning to think that they don't actually care about how many hours lapse after the ingestion, but if we actually know the unique acid-base disturbance. I chose the wrong one, again because I was foolishly thinking about those 12 hours postintoxication +5  
charcot_bouchard  I think this is good rule of thmb in USMLE "a Right answer may or may not tick all the correct things but will NEVER have a wrong thing in it". So the ans choice we all chose has Bicarb inc. But this will never happen. at 3 hour we should have pure resp alkalosis with normal bicarb (as per uw). Or in this case decreased due to neutralization by organic salicylic acid. In Aspirin poisoning bicarb will nver increase. +6  
elasaf@post.bgu.ac.il  Another important point- they probably gave her RR (30) to indicate that she is hyperventilating==> LOW CO2 +2  


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eMoezrmi sairs’pin enuuiq aa-cdebis fcetfe:s etaboimcl icaisods nad artoirpyesr akoisa.lsl oNe,t sith is kiylel ulatca pyseiorrrta llaksaois, ton plymis rolnma rystpreario pcoeontmnasi fro tbialmeco iicsados.

mikerite  Based on the correct answer choice, the person is now in metabolic acidosis with respiratory compensation. +4  
benwhite_dotcom  The correct answer choice is as listed above (all decreased). Note that whether metabolic acidosis is combined with primary respiratory alkalosis, which is an important teaching point I’ve argued the question writers are probably getting at, or even if just simple respiratory compensation for metabolic acidosis–both can have the same arrows. In this case, it’s not respiratory compensation. In ASA overdose, the respiratory alkalosis actually happens first. Ultimately, the metabolic acidosis dominates and the pH is almost always low. This mixed primary acid/base response to ASA toxicity is highly testable. +1  
ali  How long till the respiratory alkalosis turns into a metabolic/mixed picture? +2  
benwhite_dotcom  @ali 12 hours is a good number to memorize but it can definitely happen much earlier. +  
yoav  From what I understand, the metabolic acidosis only presents 12h post ingestion, while she is only 3h. What do you think? +1  
benwhite_dotcom  @yoav, It can definitely happen earlier. It’s more of a by 12 hours (not only beginning then). +  
angelaq11  I'm beginning to think that they don't actually care about how many hours lapse after the ingestion, but if we actually know the unique acid-base disturbance. I chose the wrong one, again because I was foolishly thinking about those 12 hours postintoxication +5  
charcot_bouchard  I think this is good rule of thmb in USMLE "a Right answer may or may not tick all the correct things but will NEVER have a wrong thing in it". So the ans choice we all chose has Bicarb inc. But this will never happen. at 3 hour we should have pure resp alkalosis with normal bicarb (as per uw). Or in this case decreased due to neutralization by organic salicylic acid. In Aspirin poisoning bicarb will nver increase. +6  
elasaf@post.bgu.ac.il  Another important point- they probably gave her RR (30) to indicate that she is hyperventilating==> LOW CO2 +2  


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miezroMe sispnri’a nqiuue icdaase-b ec:esfft lbomaietc iscosaid nda sreoaryrtpi .slkoaalis toeN, ihst si iylekl cultaa rteioyasrrp ,aolliskas otn siplmy rnlmoa yioetrsprra oetionacpsnm ofr ibcaoetlm ias.icods

mikerite  Based on the correct answer choice, the person is now in metabolic acidosis with respiratory compensation. +4  
benwhite_dotcom  The correct answer choice is as listed above (all decreased). Note that whether metabolic acidosis is combined with primary respiratory alkalosis, which is an important teaching point I’ve argued the question writers are probably getting at, or even if just simple respiratory compensation for metabolic acidosis–both can have the same arrows. In this case, it’s not respiratory compensation. In ASA overdose, the respiratory alkalosis actually happens first. Ultimately, the metabolic acidosis dominates and the pH is almost always low. This mixed primary acid/base response to ASA toxicity is highly testable. +1  
ali  How long till the respiratory alkalosis turns into a metabolic/mixed picture? +2  
benwhite_dotcom  @ali 12 hours is a good number to memorize but it can definitely happen much earlier. +  
yoav  From what I understand, the metabolic acidosis only presents 12h post ingestion, while she is only 3h. What do you think? +1  
benwhite_dotcom  @yoav, It can definitely happen earlier. It’s more of a by 12 hours (not only beginning then). +  
angelaq11  I'm beginning to think that they don't actually care about how many hours lapse after the ingestion, but if we actually know the unique acid-base disturbance. I chose the wrong one, again because I was foolishly thinking about those 12 hours postintoxication +5  
charcot_bouchard  I think this is good rule of thmb in USMLE "a Right answer may or may not tick all the correct things but will NEVER have a wrong thing in it". So the ans choice we all chose has Bicarb inc. But this will never happen. at 3 hour we should have pure resp alkalosis with normal bicarb (as per uw). Or in this case decreased due to neutralization by organic salicylic acid. In Aspirin poisoning bicarb will nver increase. +6  
elasaf@post.bgu.ac.il  Another important point- they probably gave her RR (30) to indicate that she is hyperventilating==> LOW CO2 +2  


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ali  I still don’t understand this one. Could you provide a better explanation? +  
benwhite_dotcom  The cDNA tag is tagging a constant region common to immunoglobulins, so it normally only finds the one band corresponding to that particular gene (the bands travel different amounts due to their differing size/weight). In the bone marrow sample, that gene has rearranged itself, so the cDNA clone instead tags multiple different genes that are of different sizes on the gel (each one has that same constant region the cDNA is tagging, but with different stuff around it such that the restriction enzyme has cut it up differently). I’d be happy for someone to step in and do a better job on that explanation. +14  
em_goldman  A Southern blot starts by cutting DNA strands at a particular (short) site and running them through gel electrophoresis, so identical DNA sequences get cut at the same site and thus are the same length, so they are at the same place on the gel. If there's lots of different sequences, the restriction endonuclease (the scissors) cut the DNA at different places, leading to strands that were the same length originally but are now lots of different lengths -> different places on the gel. But how do you know this is the same gene, just with different mutations? The Southern blot uses a probe to look for a more specific (long) region of DNA that you know is in the target gene. So even though there are mutations causing the less-specific endonuclease to cut the DNA at different parts, the overall architecture of the gene is similar enough that the probe can bind, thus we know it's the same gene. (And in bone marrow WBCs, the mechanism here is genetic rearrangement.) +1  


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benwhite_dotcom  This question was updated. It is a now a case of bubonic plague (or possibly ulceroglandular Tularemia), both which are treated by aminoglycosides, which target the 30S ribosomal subunit. +27  
wes79  do you happen to remmeber what the original question was? thx! +  
notachiropractor  treatment would be amino glycoside + tetracycline, double whammy on that 30s ribosomal subunit +2