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Welcome to charcot_bouchard’s page.
Contributor score: 574


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 +1  visit this page (step2ck_form8#32)
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jesus said "Protec thy heart"

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frijoles  *protecc +

 +1  visit this page (step2ck_form7#13)
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If its intrinsic defect HTF urinalysis is normal with no casts?

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 +1  visit this page (step2ck_form7#22)
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Its not Fire ant. because if it was he would notice instantly. Intense pain followed by intense pruritus.

Hypereosinophilic syndrome is a disease characterized by a persistently elevated eosinophil count (≥ 1500 eosinophils/mm³) in the blood for at least six months without any recognizable cause, with involvement of either the heart, nervous system, or bone marrow.[2]

HES is a diagnosis of exclusion

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 -1  visit this page (step2ck_form7#36)
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Adrenal Insuff - No. Normal K & HCO3. Also normal BP.

Adverser effect of FQ - It doesn't cause anything like this. SIADH causing drugs are SSRI, Cabamazepam, Cyclophosphamide

DI - Would cause mild hypernatremia

SIADH - (the one I chose,,,dk what kind of drug I was on) is also ruled out for one there's no indication of that duh. second the Uosm < Sosm here. 200 vs (2x122 i.e 244+ )

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 +0  visit this page (step2ck_form7#38)
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Ascites & adnexal mass >> Follow adnexal mass workup Even if you follow ascites protocol - ans is diagnostic paracentesis, not therapeutic.

So here you do USG + CA 125 There can be 4 combination -

High Risk USG + Elevated CA125. Worst scene >>Imaging with CT/MRI Exploratory LAP

High Risk USG + Normal CA125. intermediate scene. Also do same as prev. We trust USG more.

Low Risk USG + Elevated CA125. Intermediate scene. But here do only imaging. CA 125 is less trustable.

Low Risk USG feature + Normal CA 125. Best scene. U do further imaging and CA 125 serially to monitor.

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azibird  Agree with this workup. But since US and CA-125 aren't offered, how is ex-lap the most appropriate next step? Seems incredibly wrong to do surgery without the ultrasound, wouldn't the surgeon slap you? I thought you would need something diagnostic so chose paracentesis. Perhaps it should be called diagnostic instead of therapeutic but isn't that still better than rushing into the OR? +1

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Cricothyrotomy -

Indications: 'cannot-intubate-cannot-ventilate' (CICV) scenario (if orotracheal intubation has failed or is contraindicated)

Angioedema

Foreign body in upper airway

Severe oropharyngeal/nasal bleeding

Severe maxillofacial trauma

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 +0  visit this page (step2ck_form6#9)
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First, I guess everyone was correct to diagnose it was a TOF case with VSD.

All murmur follows V shape relation to flow and intensity. TOo much flow (for eg, Such a big VSD that equalize pressure) - Weak murmur.

Too little flow (like severe stenosis, right after birth hish pulmonary resistance) - Weak murmur.

If you decide ur murmur is VSD ans option comes down to A & C. C is not realistic.

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 +1  visit this page (step2ck_form6#46)
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They mentioned costophrenic angle to tip you over to empyema rather than abscess. Also abscess would cause productive cough. this kid has nonproductive one

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 -1  visit this page (step2ck_form6#15)
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Related note - If this was a post mens woman she would need a USG & CA-125 measurement next.

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 +0  visit this page (step2ck_form6#39)
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Indication for bariatric surgery:

BMI ≥40 kg/m2. BMI ≥35 kg/m2 with serious comorbidity (eg, T2DM, hypertension, OSA). BMI ≥30 kg/m2 with resistant T2DM or metabolic syndrome.

This lady needs to cut her stomach as well as all the friends and family around her

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 +0  visit this page (step2ck_form6#44)
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It never occured to me this guy can have HTN. All i thought we have a Marshal Eriksen in stem

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 +0  visit this page (step2ck_form6#1)
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This one was also confusing...i choose Influ because i guess no matter what in the history (untold) this one must be taken in future. And as said in prev comment Yes maintainance is the key...bcz only this one is need to be repeated year after year

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 +0  visit this page (step2ck_form6#10)
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She is obese. No 1 risk factor for OA which affects hip joint. So lose some weight

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notyasupreme  I wish they would just give the BMIs, nobody got time to be deciding if she's obese +1

 +2  visit this page (step2ck_form6#15)
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Deficiency - Stimulation test Excess - Supresssion Test

Basis of these are to inc sensitivity as they are screening test.

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 +0  visit this page (step2ck_form6#3)
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BDX, Naloxene all are self explanatory.

Aspirin cant be given due to bleeding risk.

Pain is moderate to severe. there goes ibuprofen...they are for mild to mod.

Fentanyl to dangerous. transcutaneous patch means long duration of action which is needed for cancer pain that wont go away ever.

so u give morphine....patient controlled.

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 +0  visit this page (step2ck_form6#26)
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I want to know how everyone exclude cocaine....i ruled it out because of 6 hours mark...any other clue?

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 +0  visit this page (step2ck_form6#26)
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If you want to know about the unknown - Methaqualone is a sedative that increases the activity of the GABA receptors in the brain and nervous system, similarly to benzodiazepines and barbiturates. When GABA activity is increased, blood pressure drops and breathing and pulse rates slow, leading to a state of deep relaxation. These properties explain why methaqualone was originally mainly prescribed for insomnia An overdose can lead to nervous system shutdown, coma and death.[4] Additional effects are delirium, convulsions, hypertonia, hyperreflexia, vomiting, kidney failure, coma, and death through cardiac or respiratory arrest. It resembles barbiturate poisoning, but with increased motor difficulties and a lower incidence of cardiac or respiratory depression. The standard single tablet adult dose of Quaalude brand of methaqualone was 300 mg when made by Lemmon. A dose of 8000 mg is lethal and a dose as little as 2000 mg could induce a coma if taken with an alcoholic beverage.

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djtallahassee  Watch wolf of wallstreet to see quaaludes in action +1

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i also spent a lot thinking due to foul smelling stool. But at the end went with IBS because take that out and it's a perfect IBS scenario. Anyone can have a occasional foul smelling stool. Don't lie...You had it in last 6 months

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 +0  visit this page (step2ck_form6#14)
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Think of it as spectrum PMR >> GCA >> GCA with Vision loss

In PMR you treat with low dose steroid only. If improve great. No need for a biopsy.

Temporal artery biopsy is indicated only in GCA with or without PMR.

But when things get dark you don;t wait for a biopsy and start pulse dose steroids.

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 +1  visit this page (step2ck_form6#25)
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All sexually active women age <25 are screened for chlamydia annually.

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 +1  visit this page (step2ck_form6#23)
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If you look at the penetrating abdominal trauma algorithm it has no place for DPL. Indication of lap in PAT - evisceration, HD instability, peritonitis, impalement

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 +0  visit this page (step2ck_form6#2)
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Medical mx is preferred bcz surgical ones carry risk for incondinence

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 +1  visit this page (step2ck_form6#17)
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This pt has dysthymia... MDD and all it;s subtype needs an suicidal risk assessment

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notyasupreme  Tbh, I don't think he has dysthymia lol. I think he has some form of somatic symptom disorder or some Munchausen ass shit. First of all, why does he have a massive binder full of records about vague medical complaints? Sorry I curse so much, I'm from NY +

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It's not asthma. Asthma would have longer history..subacute to chronic i.e >3 weeks. Its AB. mild wheezing no added lung sounds. AB lasting >5days to 3 weeks

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 -9  visit this page (nbme23#22)
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Old dudette have Aortic stenosis. Atrial contraction become essential for this patient. so AS + AFIb is dangerous because this reduces the LV preload significantly and this patient develops HF. So AFib in AS patient need to correct immediately

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aisel1787  she's not so old! stupid comment +1

 +0  visit this page (nbme23#28)
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A case of Fanconi syndrome. If it was isolated Type 2 RTA option B would be the answer.

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 -11  visit this page (nbme23#1)
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After everything its jjust an epidem ques. Below 55 vs Above 55 years

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ls3076  can you elaborate please? +1
charcot_bouchard  I am sorry for this vague answer and here comes to make up after a year lol> So above 55 years old most common cause of adnexal mass is a neoplasm, source FA. Repro That means this patient falls under 55 and since she is menstruating most likely scenario here is a ovarian follicular cyst. +1

 +1  visit this page (nbme24#49)
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Apparently theres role of sympathetic system in psychogenic erection and its comes from T11-L2. So if patient have transaction at L5 they lose reflex erection but still retain psychogenic one.

ABove T9 transaction cause loss of psychogenic erection

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charcot_bouchard  Below L5* (Not at) +

 +1  visit this page (nbme20#6)
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Narcolepsy has one of the following 3 chraracter - 1. Cataplexy 2. dec orexin in csf 3. REM latency <15 min

its ass with (not dx criteria( Hypnagogin/pompic hallcination. Sleep paralysis

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charcot_bouchard  oh dx criteria must also include excessive daytime slepeiness for 3 time per week over 3 month +

 +2  visit this page (nbme24#18)
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I get why its lateral but dont all cranial nerve except 4 arise Ventrally? WTF they add this Dorso before lateral?

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qfever  I think it's the nucleus affected in lateral medullary syndrome (instead of the nerve axons) +
nerdstewiegriffin  Because in the medulla section the nucleus is dorsal motor nucleus of X +
doctordave  They all exit the brainstem ventrally, but the nuclei can be located deep within the brainstem +




Subcomments ...

submitted by bwdc(697), visit this page
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Pleurisy (or potentially costochondritis) secondary associated with a URI, either way, treat with NSAIDs.

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tinylilron  so PE was on my differential... why do we immediately jump to pleurisy??? +
etherbunny  ...and if aspirin doesn't work, what are the chances of ibuprofen doing much better? +
len49  Stone cold normal vital signs and recent viral infxn symptoms points significantly towards viral pleurisy. Aspirin did relieve the symptoms a bit as well. She gets zero points on the Well's criteria, not sure why PE would be super high on someone's differential. +
dnazmzm  What is "splinting"....? +1
lilmonkey  Respiratory splinting is defined as reduced inspiratory effort as a result of sharp pain upon inspiration (severe pleuritic chest pain). +
charcot_bouchard  Post viral pericardial effusion should be on someone differential!! I pick EKG. +1
charcot_bouchard  even in amboss says do a EKG to rule out other cause like peri effusion +
charcot_bouchard  Replace all pericardial effusion with Pericarditis. Thats what was in my head +
charcot_bouchard  Ok. i got my answer. sx is unilateral. if it was pericardial shit would be in middle on cardiac exam no abnormalities. pericarditis would have scracthing sounds chest xray showed no abnormalities than means no pleural effusion either if it was in someones mind. +1
notyasupreme  ^^ i guess that makes sense but this q makes me mad +


submitted by bwdc(697), visit this page
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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.

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tinylilron  Is there somewhere in the article that mentions this? I feel like this is an unfair question because are we just supposed to know that EPCS is a specialized treatment +
etherbunny  I got it only by exclusion- the other answers are all clearly incorrect. Crappy question though. +
lindasmith462  this also isn't what generalization ACTUALLY means. (its the right answer on the test bc I've seen similar Qs several times where problems in generalization = ThE sTuDy DoEsNt ApPlY tO eVeRyOnE. Problems in generalizability is about when you cant apply the findings based on the study population to the target population - not that the target population isn't broad enough. For example a study focused at treating cancer pain in women 40-70 Y.O. w/ breast cancer doesn't have a generalizability problem because you can't apply it to a 30 Y.O. M with testicular cancer. It would be a problem if for example, if there were super strict inclusion criteria (ie no comorbidities and had to come to clinic every week for tx) - that limited how the study would apply to the target pop that likely has many comorbidities/limited health care access. This bastardization of how "generalizability" is a recent trend by salty editors, I cant believe the NBME is hopping on this shit bandwagon +4
charcot_bouchard  IKR! This totally misidentify what ext validity/generalizability means. Like this study is good and generalizable to ALL PEOPLE WHO GETS EPCS AT SPECIALIZED CENTRE.... i mean we are comparing EPCS itself...so why absence of it in other areas hamper its generalizability...those who wont get it, will not be come into equation first place. +2


submitted by seagull(1933), visit this page
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Am I the only one always see conversion disorder of UWORLD as reassure and follow-up. This test is giving me conversion disorder.

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seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +
seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +
bobson150  Gotta get a formal assessment before you treat I guess +5
lindasmith462  you dont need a formal assessment though. its something that can totally be diagnosed and managed by a primary care physician and only needs psych intervention if primary methods dont work. if anything you avoid early psych intervention because being labeled as a "psych" thing makes most patients resistant. +1
osler_weber_rendu  "ReFfeRaL tO a SpEcIaLiSt iS AlWaYs WrOnG" +2
charcot_bouchard  YOU DO THE PSYCH ASSESSMENT (boaard strikes back) +1


submitted by jesusisking(31), visit this page
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Did anyone else think autonomic insufficiency given the diabetes? I know it was previously well controlled but still a 10 year history

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seagull  ya dude. +
charcot_bouchard  You wouldn't expect baseline low BP at that case. Also other features like fever suggest alt dx +


submitted by charcot_bouchard(574), visit this page
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Everything you need to know about Ca, Mg, K And Alcoholics

Dec serum Ca2+ >> Inc PTH secretion

Inc serum PO4− >> Inc PTH secretion

Dec serum Mg2+ >> Inc PTH secretion

Vert low serum Mg2+ >> Dec PTH secretion

3rd point from step 1 knowledge made me choose inc PTH but it shouldn't. This guy has mg of 0.4 which is very low and remember dr ryan “some Mg is needed to release PTH hormone”.

In alcoholics,

Low Mg (Decreased intake) >> PTH resistance + Inhibit PTH release >> Low Ca, Normal to Low Phosphate (can be normal due to low PTH, tends to be low due to nutrition and urinary loss in alcoholics).

Hypomagnesemia is Common in alcoholics due to ↑ urinary loss, malnutrition, acute pancreatitis and diarrhea. Does not respond to calcium. Magnesium Repletion quick PTH recovery, calcium takes time to reach normal level.

Alcoholics also have low K+ refractory to supplementation. This is also due to low Mg. Basically Mg prevents urinary loss via ROMK channel. Mg supplementation is needed to reach normal K level.

Bottom line, Alcoholics are very likely to have low K, Ca, Mg. This can accompany low to normal PO4. This is independent to whether or not CLD is present.

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charcot_bouchard  The hypomagnesemia is special because it makes hypocalcemia and hypokalemia refractory. +1


submitted by charcot_bouchard(574), visit this page
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After everything its jjust an epidem ques. Below 55 vs Above 55 years

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ls3076  can you elaborate please? +1
charcot_bouchard  I am sorry for this vague answer and here comes to make up after a year lol> So above 55 years old most common cause of adnexal mass is a neoplasm, source FA. Repro That means this patient falls under 55 and since she is menstruating most likely scenario here is a ovarian follicular cyst. +1


submitted by jlbae(159), visit this page
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I didn't think it could get any more low yield after that Pompe dz question... I was wrong

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charcot_bouchard  Ha Ha....Biochem is like Terminator. Always comes back +4


submitted by medicalmike(82), visit this page
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Criteria for weaning from ventilator:

  1. O2 sat >= 90% with FiO2<=40% and PEEP<=8
  2. pH>7.25
  3. Initiating breaths (SIMV allows patient to initiate breaths)
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tinylilron  Where can I find this information? I have not had my ICU rotation yet. I see in First Aid Step 2CK there is some information in the Pulmonary chapter but it is a long list and what is the high yield to remember? +
charcot_bouchard  Initial criteria for extubation readiness include - pH >7.25 Adequate oxygenation on minimal support (i.e FiO2 <40% and PEEP <5cm H2O) Intact inspiratory effort and sufficient mental alertness to protect the airway. Those who meet the criteria should undergo spontaneous breathing trial (Turn off ventilatory function while intubated). +


submitted by sassy_vulpix(23), visit this page
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BMI is 75 Kg/m2!!! GAHHH how does it get to that x_x

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lubdub  a flawed system. +2
charcot_bouchard  I can't imagine +


submitted by sassy_vulpix(23), visit this page
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What about acute intermittent porphyria 2/2 alcohol? It also has painful abdomen, polyneuropathy

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jmorga75  Most of the time AIP questions mention a positive family history for it, and symptoms that worsen with fasting. +
satanicdo  they have similar symptoms because lead can disrupt heme synthesis (similar pathophysiology), but AIP causes discrete attacks of pain rather than continuous symptoms. also, lead poisoning can lead to microcytic anemia and hypertension +1
charcot_bouchard  Both shares neuropathy, abdominal pain and neuropsych symptoms. But AIP pains are intermittent and can be very severe. Anemia push towards lead poisoning. Absent of urine color change also push towards lead. And make ur booze in your garage/celler Heck Ya Lead poisoning +1


submitted by bwdc(697), visit this page
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This is obviously a clinical trial. If you know you are getting a drug, then you are not blinded: it’s an open-label trial. There is no randomization as there is only a single treatment group.

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charcot_bouchard  But they grouped them based on dosaged? +3
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). +9
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? +3
cintia05  yes, we cannot infer that they were randomized +


submitted by bwdc(697), visit this page
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Memorize aspirin’s unique acid-base effects: metabolic acidosis and respiratory alkalosis. Note, this is likely actual respiratory alkalosis, not simply normal respiratory compensation for metabolic acidosis.

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mikerite  Based on the correct answer choice, the person is now in metabolic acidosis with respiratory compensation. +5
bwdc  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. +2
ali  How long till the respiratory alkalosis turns into a metabolic/mixed picture? +3
bwdc  @ali 12 hours is a good number to memorize but it can definitely happen much earlier. +1
yoav  From what I understand, the metabolic acidosis only presents 12h post ingestion, while she is only 3h. What do you think? +2
bwdc  @yoav, It can definitely happen earlier. It’s more of a by 12 hours (not only beginning then). +1
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 +7
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. +7
elasaf@post.bgu.ac.il  Another important point- they probably gave her RR (30) to indicate that she is hyperventilating==> LOW CO2 +3


submitted by aladar50(41), visit this page
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The important thing for most of the ethics questions are to look for the answer where you are being the nicest/most professional while respecting the patient’s autonomy, beneficence, non-maleficence, etc. Most of the choices here were either accusatory or basically being mean to the patient. The correct choice is to help the patient but also motivate them to continue physical therapy and to only use the permit as little as necessary. A similar question (which I think was on NBME 23 -- they are kind of blending together) was the one where the patient had test results that indicated he had cancer but the resident said not to (voluntarily) tell him until the oncologist came in later that day, and the patient asked you about the results. You don’t want to the lie to the patient and say you don’t know or that he doesn’t have cancer, but you also don’t want to be insubordinate to the resident’s (reasonable) request.

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drdoom  @aladar Your response is good but it’s actually mistaken: You *never* lie to patients. Period. In medicine, it’s our inclination not to be insubordinate to a “superior” (even if the request sounds reasonable -- “let’s not inform the patient until the oncologist comes”) but *your* relationship with *your* patient takes precedence over your relationship with a colleague or a supervisor. So, when a patient asks you a question directly, (1) you must not lie and (2) for the purposes of Step 1, you mustn’t avoid providing an answer to the question (either by deferring to someone else or by “pulling a politician” [providing a response which does not address the original question]). +3
drdoom  As an addendum, legally speaking, you have a contractual relationship with your patient, *not with another employee of the hospital* or even another “well-respected” colleague. This is why, from a legal as well as moral standpoint, your relationship with someone for whom you provide medical care takes precedence over “collegial relationships” (i.e., relationships with colleagues, other providers, or employers). +
imnotarobotbut  @drdoom, it's not about lying to the patient but it would be wrong for an inexperienced medical student to give the patient their cancer diagnosis, or for a doctor to give a cancer diagnosis if they feel that the patient should be seen by oncology. In fact, the correct answer that the question that was referred to by aladar50 says that you do NOT give the patient their cancer diagnosis even if they asked you directly about it. +2
charcot_bouchard  Dont give it to him. DOnt lie to him that yyou dont know. Tell him let me get the resident rn so we can discuss together Best of both world +5


submitted by cbrodo(77), visit this page
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The posterior columns (Fasciculus cuneatus/Fasciculus gracilis) carry information to the brain regarding proprioception, vibration, discriminative touch and pressure. Physical exam findings suggest a lesion here (the spinothalamic tract carries pinprick/pain and temperature, and these were normal). Since the patient has abnormal findings in the lower extremities, and normal findings in the upper extremities, the answer is Fasciculus gracilis. This is because information from body areas below the level of T6 is carried by gracilis and information from body areas above the level of T6 is carried by cuneatus.

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kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +4
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +4
jess123  I remember it as gracilis = grass so feet haha +5
link981  Just to add found on page 492 on FA 2018. +
charcot_bouchard  Hey Temmy, I can spread my legs too :) +
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +4
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +3
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +1
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +2


submitted by sajaqua1(607), visit this page
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The single most important thing about this gross pathology is that the disease is multinodular. This indicates metastases from distant sites.

Liver abscesses are usualy singular, filled with creamy yellow pus, and may show a fibrous capsule. Cirrhosis often shows a yellow color due to fatty change as well as regenerative nodules, which are not present here. A focal nodular hyperplasia is a singular tumor of the liver, and this is multinodular. Hepatitis B is a little harder to distinguish because from what I can tell it can be multinodular in some cases, but this liver also shows none of the sclerosis from chronic inflammation that would likely accompany Hep B. Finally, we see no dark discoloration to indicate infarction.

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monkd  It doesn't explain the sudden death, but I suppose they aren't asking for that! +5
charcot_bouchard  I hate this type of ques. Here it is. Tell me what it is? +2
divya  also, a liver infarct is unlikely due to rich dual blood supply. +1
drzed  @divya Rather, if there was an infarct, it will be hemorrhagic, not pale. +1
llamastep1  Multiple solid lesions on a healthy liver = meta. I assumed breast wouldn't meta to liver (it's usually GI cancers) but it makes sense since all the blood gets filtered by the liver at some point. TIL! +
sophia  UW QId: 59 +1


submitted by colonelred_(124), visit this page
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Attributable risk = incidence in exposed – incidence in unexposed

= 30/1,000 (smokers) - 30/3,000 (nonsmokers)
= 0.03 - 0.01
= 0.02 (so the attributable risk is about 2%)

Applying it to a population of 10,000:

= 0.02 * 10,000
= 200

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charcot_bouchard  What if i tell you this is a ques of Attributable risk % in exposed? AR= 0.02 / IR in exposed (30/1000) = 0.6667 30 case in 1000. So 300 case in 10,000 0.6667 x 300 = 200 or in another word 66% cases of 100 lung cancer cases in smokers is actually due to smoking. so in 300 cases of smokers 200 is actually due to smoking +5
charcot_bouchard  This is a mind fuck. Lemme tell u guys if any consolation while doing the ques during test i did it with AR = 0.02; NNH = 1/0.02 = 50. 50 persons smoke to cause 1 cancer. 10K smoke to cause 200 cancer. +4
ls3076  Sorry if this is a stupid question. Why is it incorrect to simply apply the same proportion (30 cancer per 1000 smokers) to 10,000 smokers? +2
krewfoo99  @is3076 Thats exactly what is did. I still dont understand how that is wrong. But i guess they want us to think about it in terms of AR +1
hhsuperhigh  @Is3076 and @Krewfoo99, If a person doesn't smoke, the natural risk of getting lung cancer is 30/3000=1%. The smoker's risk is 30/1000=3%. This 3% is not purely contributed by smoking, but mixed with the natural risk. So for calculating the pure contribution made by smoking, you should use 3%-1% which is 2%. And this 2% is the pure contribution of smoking. Not all smokers get lung cancer, the same thing, not all lung cancer among smokers are attributed by smoking. They may get lung cancer anyway despite smoking or not. +21


submitted by colonelred_(124), visit this page
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Attributable risk = incidence in exposed – incidence in unexposed

= 30/1,000 (smokers) - 30/3,000 (nonsmokers)
= 0.03 - 0.01
= 0.02 (so the attributable risk is about 2%)

Applying it to a population of 10,000:

= 0.02 * 10,000
= 200

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charcot_bouchard  What if i tell you this is a ques of Attributable risk % in exposed? AR= 0.02 / IR in exposed (30/1000) = 0.6667 30 case in 1000. So 300 case in 10,000 0.6667 x 300 = 200 or in another word 66% cases of 100 lung cancer cases in smokers is actually due to smoking. so in 300 cases of smokers 200 is actually due to smoking +5
charcot_bouchard  This is a mind fuck. Lemme tell u guys if any consolation while doing the ques during test i did it with AR = 0.02; NNH = 1/0.02 = 50. 50 persons smoke to cause 1 cancer. 10K smoke to cause 200 cancer. +4
ls3076  Sorry if this is a stupid question. Why is it incorrect to simply apply the same proportion (30 cancer per 1000 smokers) to 10,000 smokers? +2
krewfoo99  @is3076 Thats exactly what is did. I still dont understand how that is wrong. But i guess they want us to think about it in terms of AR +1
hhsuperhigh  @Is3076 and @Krewfoo99, If a person doesn't smoke, the natural risk of getting lung cancer is 30/3000=1%. The smoker's risk is 30/1000=3%. This 3% is not purely contributed by smoking, but mixed with the natural risk. So for calculating the pure contribution made by smoking, you should use 3%-1% which is 2%. And this 2% is the pure contribution of smoking. Not all smokers get lung cancer, the same thing, not all lung cancer among smokers are attributed by smoking. They may get lung cancer anyway despite smoking or not. +21


submitted by sympathetikey(1600), visit this page
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Mad at myself for changing my answer.

Faulty logic made me wonder if hitting your head would caused increased ICP so, like a cushing ulcer, you would get increased Vagus nerve activity and maybe bradycardia + hypotension. But I guess the RAAS system would have counteracted that and caused vasoconstriction over 24 hours, so Hypovolemic shock is definitely the best choice.

Always should go with the obvious answer :)

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seagull  I had the idea that this was a neurogenic shock and increasing intracranial pressure could affect the vagus too. I think the question really wants us to go that direction. +17
uslme123  The Cushing reflex leads to bradycardia! +7
purdude  Wait I'm confused. I thought hypovolemic shock leads to an increased SVR? +2
littletreetrunk  apparently, there's a thing called sympathetic escape that can happen after a while (i.e. he's been out for 24 hours): Accumulation of tissue metabolic vasodilator substances impairs sympathetic-mediated vasoconstriction, which leads to loss of vascular tone, progressive hypotension and organ hypoperfusion. +1
littletreetrunk  also also if he hit his head he could have loss of sympathetic outflow from a hypoxic medulla which could lead to vasodilation, which further reduces arterial pressure, but this was a hard one for me lol. I also put increased ICP wah. +1
catch-22  Any lack of sympathetic outflow/increased vagal outflow should reduce HR, not increase it. Further, you would expect brainstem signs if there was hypoxia to the brainstem. For example, if you had damage to the solitary nucleus, you wouldn't be able to regulate your HR in response to reduced BP. Since this patient has reduced BP and increased HR, this indicates that the primary disturbance is likely the reduced BP. He's also been in a desert for 24+ hours so. +5
charcot_bouchard  In a patient who develops hypotension following high-energy trauma, neurogenic shock is a diagnosis of exclusion that is made after hypovolemic and obstructive cardiogenic shock have been ruled out! Plus Absent Bradycardia rules it out +2


submitted by link981(208), visit this page
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However weird, you have to respect the patient's beliefs as long as they aren't putting the newborn at harm. In these types of questions you have to build patient-physician relationships because the patient might become offended if you disregard their beliefs. So while the newborn most likely has gas and not "the evil eye", choice E is the least "offending" answer that suggests treatment.

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charcot_bouchard  Exactly. If she was cracking the egg on Baby's head u stop her lol (i am cracking up on my own jokes) +6
jesusisking  I feel it but dang, she lowkey drizzlin salmonella all over that baby +2
thrawn  But what if the next step of this tradition is feeding the raw egg to the child. It happens in some cultures... I think telling her to continue is wrong - catious indifference seems prudent +
kavarthapuanusha  I knew this would be the answer , but i dint put this coz i am not crazy !!! Tbh no one asked the physician if she should continue or not ! Thats like an unnecessary addition , may be " i understand your concern , but why dont we try to change the formula" Would have made more sense!! +


submitted by hayayah(1212), visit this page
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Case of arteriolosclerosis.

Hyperplastic arteriolosclerosis involves thickening of vessel wall by hyperplasia of smooth muscle ('onion-skin appearance')

  • Consequence of malignant hypertension (>180/120 w/ acute end-organ damage)
  • Results in reduced vessel caliber with end-organ ischemia
  • May lead to fibrinoid necrosis of the vessel wall with hemorrhage; classically causes acute renal failure (ARF) with a characteristic 'flea-bitten' appearance
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masonkingcobra  From Robbin's: Fibromuscular dysplasia is a focal irregular thickening of the walls of medium-sized and large muscular arteries due to a combination of medial and intimal hyperplasia and fibrosis. It can manifest at any age but occurs most frequently in young women. The focal wall thickening results in luminal stenosis or can be associated with abnormal vessel spasm that reduces vascular flow; in the renal arteries, it can lead to renovascular hypertension. Between the focal segments of thickened wall, the artery often also exhibits medial attenuation; vascular outpouchings can develop in these portions of the vessel and sometimes rupture. +1
asapdoc  I thought this was a weirdly worded answer. I immediately ( stupidly) crossed of fibromuscular dysplasia since it wasnt a younger women =/ +26
uslme123  I was thinking malignant nephrosclerosis ... but I guess you'd get hyperplastic arteries first -_- +1
hello  The answer choice is fibromuscular HYPERplasia - I think this is different from fibromuscular DYSplasia (seen in young women); +36
yotsubato  hello is right. Fibromuscular hyperplasia is thickening of the muscular layer of the arteriole in response to chronic hypertension (as the question stem implies) +10
smc213  Fibromuscular Hyperplasia vs Dysplasia...... are supposedly the SAME thing with multiple names. Fibromuscular dysplasia, also known as fibromuscular hyperplasia, medial hyperplasia, or arterial dysplasia, is a relatively uncommon multifocal arterial disease of unknown cause, characterized by nonatherosclerotic abnormalities involving the smooth muscle, fibrous and elastic tissue, of small- to medium-sized arterial walls. http://www.medlink.com/article/fibromuscular_dysplasia +3
smc213  *sorry I had to post this because it was confusing!!!*Fibromuscular dysplasia is most common in women between the ages of 40 of and 60, but the condition can also occur in children and the elderly. The majority (more than 90%) of patients with FMD are women. However, men can also have FMD, and those who do have a higher risk of complications such as aneurysms (bulging) or dissections (tears) in the arteries. https://my.clevelandclinic.org/health/diseases/17001-fibromuscular-dysplasia-fmd +2
momina_amjad  These questions are driving me crazy- fibromuscular dysplasia/hyperplasia is the same thing, and it is NOT this presentation and it doesn't refer to arteriolosclerosis seen in malignant HTN! Is the HTN a cause, or a consequence? I read it as being the cause (uncontrolled HTN for many years) If it was the consequence, the presentation is still not classical! -_- +2
charcot_bouchard  Poor controlled HTN is the cause here +1
charcot_bouchard  Also guys if u take it as Fibromuscular dysplasia resulting in RAS none of the answer choice matches +1


submitted by charcot_bouchard(574), visit this page
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Narcolepsy has one of the following 3 chraracter - 1. Cataplexy 2. dec orexin in csf 3. REM latency <15 min

its ass with (not dx criteria( Hypnagogin/pompic hallcination. Sleep paralysis

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charcot_bouchard  oh dx criteria must also include excessive daytime slepeiness for 3 time per week over 3 month +


submitted by kentuckyfan(47), visit this page
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Since the pain is radicular, a disc herniation is most likely.

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charcot_bouchard  Why it cant be a lumbar vertebra fracture +1
whoissaad  @charcot The patient is young and doesn't have any risk factors for weak bones. Also, disc herniation is a common problem in the young. The disc gets fibrosed and stiff in the elderly so they have less chance for disc herniation. So basically age was the key to answering this question. +4
lovebug  you are genius! thank you! :) +


submitted by step420(32), visit this page
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This is mullerian agenesis. Normal ovaries but absent uterus.

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endochondral   why not androgen insensitivity? +
shaeking  I was wondering the same thing because doesn't androgen insensitivity also have normal female secondary characteristics. Was it the levels of hormones because she doesn't have abnormally high testosterone? +3
swb  Androgen insensitivity has the same presentation and symptoms. What's the clue that it is mullerian agenesis instead ? +27
sugaplum  Testosterone would be high if it was androgen insensitivity FA 2019 Pg 625 +22
charcot_bouchard  Testo would be high in AIS. in AIS pubic hair, axillary hair doesnt devlop because of androgen insensitivity. both have normal breast dev and primary amenorrhea +2
dickass  This is not androgen insensitivity because she has perfectly normal Estradiol, which means she has perfectly normal ovaries. She also has regular female levels of testosterone. +5
rockodude  thank you @dickass +1
j44n  Also AIS has paradoxically large boobs-> tanner stage 5 and thats not mentioned anywhere +
fatboyslim  Androgen insensitivity syndrome will have high testosterone because the testosterone receptor isn't functional, therefore the body is like what the heck and starts dumping more testosterone trying to make them a male but it doesn't work unfortunately +


submitted by hayayah(1212), visit this page
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Add on to the other comment: SICKFACES.COM (when I Am drinking Grapefruit juice) is the mnemonic for remembering the CYP450 Inhibitors:

  • S odium valproate
  • I soniazid
  • C imetidine
  • K etoconazole
  • F luconazole
  • A cute alcohol abuse
  • C hloramphenicol
  • E rythromycin/clarithromycin
  • S ulfonamides
  • C iprofloxacin
  • O meprazole
  • M etronidazole

  • A miodarone

  • Grapefruit juice
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charcot_bouchard  Its not a cytochrome question. IK because i go t it wrong +1
waterloo  both azoles and PPI inhibit cytochrome P450. So one isn't causing the other's lack of effect. +9
stepwarrior  Nope. Inhibiting CYP450 would enhance the effect of itraconazole, so that can't be the mechanism. +2


submitted by mousie(272), visit this page
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Is 45 minutes too long to be anaphylactic and would the absence of rash (urticaria, pruritus) RO anaphylactic?

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hayayah  Yes! Allergic/anaphylactic blood transfusion reaction is within minutes to 2-3 hours. (pg 114 of the 2019 FA has a list of them ordered by time) +10
hayayah  (also allergy / anaphylactic presents with more skin findings (urticaria, pruritus) +9
seagull  The time through me off too. I though ABO mismatch since it occured around an hour. I thought TRALI would take a little longer. +10
charcot_bouchard  Guys anaphylactic reaction to whole blood doesnt occur much except for selective IgA defi. so look out for prev history of mucosal infection. And it can have all feature of type 1 HS inclding bronchospasm. +8
soph  I saw hypotension and though anaphylaxis........ -.- +2
usmile1  Chest Xray showed "bilateral diffuse airspace disease". This is much more indicative of TRALI than anaphylaxis which would have wheezing and possibly respiratory arrest but no actual damage to the lungs. Additionally there was no urticaria or pruritus one would expect to see with anaphylaxis. +9
leemax  you have to look out for- immediate(time is impt)reaction is Anaphylactic/allergic- you see type 1 symptoms(wheezing,urticaria). but if the reaction takes place with an hour(1)-think of type two (AntiBody mediated)-two types here , intravascular (ABO incomtability-you see hemoglobinuria and jaundine) or extravascular(DIC and + coombs). also don't forget -febrile hemolytic where cytokines that are accumulated during storage cause the reaction, here you see fever and chills. but in this question, they are asking about transfusion-related acute lung injury as seen in x-ray description, and this is due to the donor anti-leukocyte Ab acts against host neutrophils and pulmonary endothelial cells. +


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The answer is hyporeflexia because the afferent arc of the muscle stretch reflex has to go through the dorsal rami and dorsal root ganglia. Dumb question, I know, but it’s the only answer that made sense. If you hurt the DRG, you not only lose afferent somatic sensory fibers, you also lose the sensory bodies involved in the various reflexes.

You can also get hyporeflexia from damaging the efferent neurons that innervate the muscle (like a LMN), but as you know these are in the anterior horn and ventral rami.

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ankistruggles  Thanks! I agree with you. +1
brethren_md  Great explanation. +1
gonyyong  Agreed - I think I got this by thinking about tabes dorsalis (syphillis) and why it has hyporeflexia is due to dorsal root damage +10
duat98  I'm confused about why it wouldn't cause muscle atrophy. Isn't that a fever of LMN damage? +8
charcot_bouchard  Muscle atrophy wont occur because alpha motor neuron is intact. Motor control of Corticospinal tract on this is intact. so no atrophy. u can move shiti/ But remeber muscle spindle that is responsible for INITIATING stretach reflex send Ia fibre to DRG from where it synapse with Alpha motor neuron. if DRG is damage ur muscle is fine but u cant initiate strech reflex. areflexia +5
zevvyt  DRG you lose DTR +2


submitted by leny123(7), visit this page
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General rule - Chloroquine sensitive if from Caribbean or Central America west of Panama Canal, this patient immigrated from Honduras so you can eliminate chloroquine resistance as an answer choice (in addition to the vivax/ovale info above).

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charcot_bouchard  Guys along with all intelligent discussion also keep in mind he immigrated 1 year back. So it must be hypnozoites which is causing this because Murica is Malaria free. +28


submitted by colonelred_(124), visit this page
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The analysis only showed a mutation in one allele. CF is an autosomal recessive disease: the disease only manifests if there are mutations in both alleles of the CFTR gene.

If you still have 1 functional copy of the CFTR gene, you can still make the CFTR protein (the chloride channel/transporter), hence your body won’t have any issues.

This is analogous to tumor suppressor genes like Rb: so long as one of the alleles you have is functional, you can make enough of the protein to “make up” for the defective allele. If both get knocked out (Rb-/-), you lose the protection provided by the gene because now you make no protein at all.

The only thing that made sense for this question was the fact that the other allele was not included in the analysis.

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charcot_bouchard  OR another allele has a diff type of mutation because CF is done by like hundreds of diff type of mutation. SO the 70 types that we screened covered one type from one parent but not another that was inherited from other parent. +46
soph  I put D thinking there was a mutation in another protein that interacts with CFTR....thus u dont have CF but some disease with similar phenotype. Is this wrong bc its simply not the case ?? +14
nbmehelp  @charcot_bouchard I think that makes more sense if I understand what you're saying- Probably had a mutation only in 1 of 2 of the same alleles in the analysis but had another mutation in 2 of 2 alleles at a different location not included in the analysis, right? +
fallot4logy  CF is a rare disease , and the possibility to have a mutated gene plus a gene that its not belong to 70 most common cf mutations is extremely rare +5
gubernaculum  @soph i picked D too but now looking back, the panel had 70 of the most common CFTR gene mutations so it is unlikely that they didn't already check a gene that codes for a protein that interacts with CFTR? that's the only way i can rationalize it. its bad writing ultimately +
peridot  I also picked D, but there are over 1700 different mutations for CF and it's too hard to test for them all - the panel in the question tested for the 70 most common. As others mentioned, CF is an autosomal recessive disease, so there must be another mutated allele here for the child to present with the disease. It's more likely, and I imagine not uncommon, that the mutation is not in the panel. As for D, I suppose the best reasoning I can come up for it is that nothing like that exists - what protein interacts with ONE mutated CFTR allele in that it results in the same phenotype as CF, a disorder that requires TWO mutated alleles? I have never heard of such a thing, whereas I have definitely heard of A being the case. +2
weirdmed51  @peridot , ‘B’ being the cause you mean +


submitted by yotsubato(1208), visit this page
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Cool another question taken from the list of things not in FA

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charcot_bouchard  Actually it is in FA. FA 19 Page 100 - Antigen loaded onto MHC1 in RER after delivery via TAP transporter.... Remember FA is that friend who always say I told you so. +32
yotsubato  But not in this context +5


submitted by didelphus(70), visit this page
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Any idea why hyperchloremia isn't an answer? The diarrhea would cause an normal anion gap (hyperchloremic) metabolic acidosis.

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charcot_bouchard  this is the problem bet uw and nbme. in uw it would be for sure a gotcha ques. but in nbme they are usually looking for most obvious. also look what they are asking "most likely". baby would dev low Na before acidosis. Thats my 2 cents +29
temmy  hyperchloremia will not account for the seizure that brought the patient to the hospital. seizures according to first aid is caused by hypocalcemia and hyponatremia +1
cry2mucheveryday  Children with diarrhoea who drink large amounts of water or other hypotonic fluids containing very low concentrations of salt and other solutes, or who receive intravenous infusions of 50% glucose in water, may develop hyponatraemia. This occurs because water is absorbed from the gut while the loss of salt (NaCl) continues, causing net losses of sodium in excess of water. The principal features of hyponatraemic dehydration are: there is a deficit of water and sodium, but the deficit of sodium is greater; serum sodium concentration is low (<130 mmol/l); serum osmolality is low (<275 mOsmol/l); the child is lethargic; infrequently, there are seizures. https://rehydrate.org/diarrhoea/tmsdd/2med.htm#CONSEQUENCES%20OF%20WATERY%20DIARRHOEA +
cry2mucheveryday  Also, why is this being given formula...? May be lactase deficiency...which leads to osmotic diarrhea...leads to hyponatremia(goljan) Aren't newborns supposed to be kept on exclusive breast milk till 6 months?? +
hello  @cry2mucheveryday Don't read too much into it. The fact that the baby is receiving formula isn't relevant to answering the Q. Btw, not everyone breast feeds. Additionally, the Q wouldn't make much sense if it said "they ran out of breastmilk"... +1
hello  @cry2mucheveryday Being on formula then the parents running out of formula is more of a clue for water intoxication. This is typically the scenario that water intoxication presents. However, I suppose if for some reason the baby was being breastfed and the parents switched to exclusively waterfeeding (and no other foods), then water intoxication would also result. +


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