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Contributor score: 67


Comments ...

 +0  (nbme20#15)
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uC'dlnto oyu sloa eedreacs teh I2OF? reP F,A PPC osal scisernae ot pihoxay slao sreesacde PPC ehnw 2OP l&;t 05 m.mgH

cienfuegos  Obviously not the BEST option in this scenario, but seems like it could work unless I'm missing something. +1
step1soon  Its primariy driven by PCO2! only when O2 levels drop <50 mmhg is when the body responds to low O2 pressures +1




Subcomments ...

submitted by gonyyong(109),
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Teh kdi hsa agiysatncoem due ot rebtuyp ece(xss esotertenots → neT egthi)ossr soeg ayaw tulnaarly (papralnety in 12 to 18 sm)onth

I hiknt oyu to'nd hvae to do bodol sttes uaescbe eh ahs arnmlo uaxels eteopmednvl orf hsi eag nda ereht rea no tehor sngs?i

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +29  
howdywhat  my exact thought, telling him that it will last for somewhere around a year and a half doesnt seem so reassuring +1  
suckitnbme  I thought it was reassuring in that the kid is being told this isn't permanent as well as that this isn't something serious. It's important to inform him about the prognosis. +8  
thotcandy  "don't worry your gynecomastia isn't permanent, but the mental scars from the bullying you will receive in HS definitely will be :) good luck!" +4  
therealslimshady  What is the gynecomastia is from a prolactinoma? +  
misterdoctor69  @therealslimshady the gynecomastia is from the sudden surge of testosterone during puberty being converted into estrogen => more breast tissue. +3  
mnunez187  My breasts are not rubbery nodules, thank you very much! +  
cienfuegos  Some additional information: (1) see "breast changes (boys):https://www.amboss.com/us/knowledge/Puberty (2) see "pubertal gynecomastia": https://www.amboss.com/us/knowledge/Benign_breast_conditions#xid=wL0h-g&anker=Z9cfd241bb84b119e6f04274e0a712947 +  


submitted by hungrybox(1044),
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arioeped:Lm nigstAo at ioo-updi eproret.cs solwS ugt lymtitio erer(bmm,e nonctiipaots si a ocnomm ides ecefft rfo all id.so)ipo

qizu lous:reyf

:Q dWoul a eujikn wnat to eus emiLapdero?

A: ,oN ti sah opor NSC tornaptiene hicwh( is wyh it ash a owl cidadvtie )pttaole.ni

Q: Wlduo a unjeki earthr hvea nehropim or nh?upnrrebeoip

A: .Mpoeinrh Both era idopou-i niotag,ss but rhnopiem si a lflu snoatig ilehw ropnprinehbeu is noly a ratiapl ni.oagts

Q: hatW outab renopimh s.v eenodi?c

:A Trcki tiqounse, hbot era riptaal ng.sisoat

cienfuegos  Thanks for passing off the knowledge. Regarding the last part, aren't morphine and codeine full agonists? +5  
champagnesupernova3  Yes they are +2  


submitted by sahusema(145),
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I got crtkdie tnoi ignpcik the urqaic"de dtibioasne tnaagis 11AP." aumHn leteplta gA ltpltaee geaitnn P1-a1, caelotd no geritnin β3, is het ianm tegrat fro iorlpbsnsee orf alnateno pepaoitrshhttmt.yoo/bn:c//7/4ltn11c2rnogm/e1inotj.559w/.mowuw

cienfuegos  Same, except in my case I was the person who was tricked and who did the tricking though. Thx for the link. +1  


submitted by neonem(571),
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nousSd lkei a aesc fo Lmiea-niFru smnordye - sncei p35 si a mrotu presospurs orf a cuhnb fo elcl ept,sy itutnsamo in htsi egne (as in )SFL teuslr ni a ydmiar fo fiilalam muort .eypts

pparalpha  Li-Fraunemi syndrome = SBLA (sarcoma, breast, leukemia, adrenal gland syndrome) and occurs because of an autosomal dominant inherited mutation of p53 APC: linked to FAP (colorectal cancer) RET: linked to papillary thyroid cancer, MEN 2A, MEN 2B RB1: retinoblastoma +10  
privatejoker  The thing that threw me off was that the only connection in her FH to the above SBLA reference was the mention of a paternal cousin with adrenocortical carcinoma. The other two mentioned had brain cancers, which seem completely outside the scope of the above mnemonic. Then again, as mentioned elsewhere, I suppose the best policy on these is just to rule out the absolute wrong answers. I swear, the NBME is lying when they tell us to choose the "best" answer on some of these. What they actually mean in practice is for us to choose the least shitty. +15  
dbg  ^ this guy cracked the code. nbme ur doomed. +7  
cienfuegos  @privatejoker: I feel the pain. Quick FYI: UW includes brain in the associated tumors. +3  
hyperfukus  we can just make her thing SBBLA and hopefully never get this wrong again +9  
jakeperalta  @privatejoker: according to UW, Li Fraumeni includes SABBB(sarcoma/adrenocortical/breast/brain/blood(leukemia)) +2  
ac3  side note: RB1 = retinoblastoma with an increased risk of osteosarcoma +  
lukin4answer  TP53 associated with SBLA + Brain tumor + Anaplastic Thyroid ca + Transitional cell ca. -UW +  


submitted by ergogenic22(321),
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why is netpiooctr fo the dorcohi lp,esux rmof vtrnlnrtauircaei ueurprt cornesyda ot agnelrim iamrxt egrhmhaore ton a plbsesio ansre?w

whoissaad  yes same question, both retinopathy and intraventricular hemmorage can occur due to high oxygen levels.. +  
cienfuegos  I mistakenly chose choroid plexus too, based on wiki seems this is most common cause of IVH in term infants: IVH in the preterm brain usually arises from the germinal matrix whereas IVH in the term infants originates from the choroid plexus. However, it is particularly common in premature infants or those of very low birth weight... Most intraventricular hemorrhages occur in the first 72 hours after birth. The risk is increased with use of extracorporeal membrane oxygenation in preterm infants. https://en.wikipedia.org/wiki/Intraventricular_hemorrhage#Babies +  
burak  choroid plexus is different than germinal amtrix +  
meryen13  retinal hemorrhage is more common that IVH even if you think that it could damage choroid places secondary to germinal matrix hemorrhage. https://www.ncbi.nlm.nih.gov/pubmed/11304816 +  


submitted by neonem(571),
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I nihtk uyo acn kwno htat itsh is a aamthlic sektor rhetra hatn crtcoial cebeuas a ticrolca okster ringoccur loyn ni hte plsnttaecro ygrsu rpi(mray soyrnse tc)roxe nad ovgninvli eth eetrni nmhuuocslu oituthw naiegftcf het braney aerpntrcle ugyrs miyrarp( troom )xecrto is eryv nl.uilyek

sahusema  Ya I think this question is trying to test your knowledge between a cortical lesion and a subcortical lesion. +1  
cienfuegos  Central Stroke Syndrome: Neuropathic pain due to thalamic lesions. Initial paresthesias followed in weeks to months by allodynia (ordinarily painless stimuli cause pain) and dysesthesia on the contralateral side. Occurs in 10% of stroke patients. FA 2018 499 +4  


submitted by beeip(124),
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isTh ash eebn a ghuto tcecnpo fro em ot egt, btu I nhtik 'mI aillfyn he:etr

eTh etms si idcsriegbn rrpimay aenlrda iniuscfn,fyice ro d.osdnAi's

  • HATC is bnieg odeeocprdvur- ot siettumal teh rsaenadl to dureocp loosci,rt btu ethy c'ant ponre,ds itehre eud ot ohyratp ro oitcrusendt (BT, mtaieuon:um ,DR4 c)e.t
  • The rtifs 31 omnai daisc of HTAC acn be dcevlae ot ofmr SHα,-M iwchh msailustte oltmns,ayeec agscuni imrapyiohnnetpegt
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


submitted by beeip(124),
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shTi sha ebne a hugot pteconc rof em to te,g btu I tiknh Im' niaylfl het:er

ehT estm si bcsrnideig mayprir endalra cffui,ceyniisn ro ddo.isnAs'

  • TACH si nbegi doepcuorr-evd ot aseuttlmi eth alnsrdae ot puecord stlicoor, ubt hyet nt'ca e,rdspno eehtir deu to yhatorp ro nsoctuedrit T(B, tn:ueammiuo RD4, tc).e
  • hTe rifts 13 onmia caids fo HACT nac be decevla ot fomr α-,SMH hchiw esttalsmiu scomnel,eyat igcunsa aehnpmignptoieryt
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


submitted by kentuckyfan(43),
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I tge hwy eht exmdi nusveo eynxog nietson eHwe.evacrd,deo,ser n'tis het ctyemsis avslcuar eiscatsner osal erec?sdaed

yb_26  no, decreased CO => peripheral vasoconstriction => SVR will be increased +7  
yssya1992  No SVR will increase due to RAAS and SAN thats why we decrease afterload in HF treatment ( ACEI, ARBs ) +5  
snafull  Wouldn't pulmonary vascular resistance also be decreased here due to pulmonary vasodilation in the setting of an MI? +  
cienfuegos  @snafull: my initial thought is that we would see pulmonary vasoconstriction because of the relatively low oxygen tension (that results from the low cardiac output). +3  


submitted by nala_ula(112),
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nI diaticeb diotacsseoi,k heert is nrecadsie icda in eth aclutrealexlr ecpas. ordAgnicc to FA reeth si a slatulcenrlar htsfi due ot sdeecdera unisiln htat saeld ot remo H+ treenign eht lcel in heangxce orf K.+ iThs dsela ot lphieeakyrma wthi edtepdle allierntaulcr oretss fo .+K rhTee si alos oitoscm isedsiur atth ldsea ot endearsic K+ olss ni het uiren and oltat ybod K+ dlio.pneet hTe isuqonet ksas hatt is osmt ilkeyl to esecadre itwh nniulsi yreh:pat rsume otspuiams ncroaionnctet lilw sarceeed as K+ si nwo gceheaxnd orf +H endiis eht cl.el

cienfuegos  Additional UW fun facts regarding Potassium and DKA: use caution giving insulin and IV fluids to dehydrated hyperglycemic because i forces K in cells causing fast decrease of extracellular Potassium, thus give K supplementation even when serum K elevated +3  
linwanrun1357  Why urine K+ does not decrease? +3  


submitted by cr(4),
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why ont C.? s´tI tno eussop hatt it eomvrpi eht tciveyietf fo isilun?n

yb_26  thiazolidinediones (pioglitazone) increase insulin sensitivity (in muscles and liver) through activation of peroxisome proliferator-activated receptor-gamma (PPAR) I think they are asking about primarily mechanism of action, that's why it is E +  
cienfuegos  UW explanation regarding the genes upregulated 1. GLUT4: insulin responsive on adipocytes/skeletal increases G uptake 2. adiponectin: cytokine secreted by adipocytes increases # of insulin responsive adipocytes and stims FA oxidation 3. PPAR family also plays significant role in pathogenesis of metabolic syndrome +2  
poisonivy  Also, I think the word uptake shouldn't be right when speaking about insulin, it does increase insulin sensitivity and therefore glucose uptake +7  
brotherimodu  @poisonivy That's why I didn't choose C and went with E since it was more specific +  


submitted by nosancuck(87),
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Yo sid B ogt NO EILNNATR AEMFLE SGANRO

hWy t?d!??a

eW be ooinkl ta oneseom iwth an SYR mfro dree Y yirmc! Dheoe be a Y recmhoi emHoi so yteh eb kinam seom iTsste Drennimtie rtcFao iwhhc I be ures seakm mseo cnie lil TINA RLMUALNIE FTORAC so yde aitn tgo thta ameFle naIltrne rTtac u oknw hatw i be nisya

nAd ncesi mnziwmi is ad ETLAUDF ehty tlis eb igtent eods uspys spli adn resseabt

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +27  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +6  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by haliburton(214),
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Busllou dpiopgeihm itaenng utms be os.eemosmihmde F:A abull aer llb"wuo" the imrdse amdserbeiu(lp lbtie)rs. PB losa yldei es"ten" ba.llu

seagull  I love how this cant be straight forward. All the other proteins are either subunits of desmosomes or cytoskeletal components. Because I know molecular biology that well on top of the majority of medicine....FML +10  
cienfuegos  @seagull: excellent comment, literally loling right now +  
cienfuegos  or sobbing and threatening to hold my breath if they don't make it stop +1  
daddyusmle  WHY DIDN'T THEY JUST PUT HEMIDESMOSOMES THE FUCK +13  


submitted by haliburton(214),
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usoBllu hiiogpepmd antgein sumt be smesemmidoeh.o A:F ullab rea uw"bo"ll hte msreid brdalep(ismue le.tr)sbi BP alos eldyi ens"et" lla.ub

seagull  I love how this cant be straight forward. All the other proteins are either subunits of desmosomes or cytoskeletal components. Because I know molecular biology that well on top of the majority of medicine....FML +10  
cienfuegos  @seagull: excellent comment, literally loling right now +  
cienfuegos  or sobbing and threatening to hold my breath if they don't make it stop +1  
daddyusmle  WHY DIDN'T THEY JUST PUT HEMIDESMOSOMES THE FUCK +13  


submitted by benzjonez(45),
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rlodwU iQd 1453 sah a dogo atinenpalox as to how laompuynr ofisirsb nsrcieeas hte radila anotirct on the iawayr lalsw.

cienfuegos  I think this is it -pulmonary fibrosis increases elastic recoiland widens airway 2/2 increased outward force (radial traction) by fibrotic tissue thus decreasing airflow resistance thus supernormal expiratory flow rates (higher than nl following correction for lung volume) +3  
notyasupreme  ^ Why do I feel like this is literally not english, I have no clue what's being said here. Can someone else explain it? +1  


submitted by est88(17),
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tnRrooeaeeptlir rtrseus:tcu SAD PRECKU.

lnOy hte sedcniedgn nocol si aprt of hst.i

meningitis  SAD PUCKER: Suprarenal (adrenal) glands [not shown] Aorta and IVC Duodenum (2nd through 4th parts) Pancreas (except tail) Ureters Colon (descending and ascending) Kidneys Esophagus (thoracic portion) Rectum (partially) +19  
cienfuegos  I find "SAID PUCKER" to be helpful because it includes IVC +4  
lovebug  FA 2019, 354page~ +  


submitted by hungrybox(1044),
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oerth :asnrwes

iibnhtnoii fo H2 rpete:sroc fr(o )RGDE npetrev sicatrg iadc eorcensti ec(dini,mtei

bnhitiinio fo roeeestssdapshihop D(E:)P

  • ielhntpyeloh )(mhtsaa tibnhisi PAMc EPD
  • lifs-na ic(kd llip)s for ED iiintbh cMPG EDP

2β saisg:otn ro(f tsham)a cseau bnlnoidrthiooac

  • otlarbleu (hotrs tcaing - A rof eut)cA
  • ereloastm,l omotfrrleo olng( nicgat - rysa)oplpxhi

ikd( tyypeohmcl rmebmaen izt)lnosbaitia

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +17  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2  


submitted by hayayah(1079),
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e:Nto eTh bsnuedac .n is tcllyuaa het envre most leilky ot eb dadeamg by na piandegxn etianlnr aditroc rnyusema ni eth uvocernas nisus but yeht giev ouy spficeic 3NC ntcufnoi ni isht i.tousneq

hungrybox  One pupil larger than the other indicates damage to the pupillary light reflex - afferent: CN II, efferent: CN III. +23  
cienfuegos  A little more info regarding other sxs (via UW): -cavernous carotid aneurysm: small usually asx, enlargement can cause u/l throbbing HA &/or CN deficits. VI most common thus ipsilateral lateral rectus weakness, can cause esotropia = inward eye deviation & horizontal diplopia worse when looking toward lesion -can also damage III, IV and V1/2 -can occasionally compress optic nerve or chiasm thus ipsilateral monoocular vision loss or non-specific visual acuity decrease +2  
lovebug  There are in FA2019, page 530. +  


submitted by haldol(12),
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BP si owl os ovyilobsu het bdoy illw twna to epdnsor by agrnisncie eptsahsctymi and rsgcniaeed si.rtyhcapsamtpae icsne het BP si ol,w terhe is elss rpreusse itnsaga het wlal fo the trdoaci unsis -- mannige less liuansotmti nda efwre l.mispeus weefr toradic siumslep snaem eewfr mpipsrhtytaeacas

pparalpha  Hyotension will lead to decreased arterial pressure and DECREASED stretch. This leads to decreased afferent barcreceptor firing (carotid sinus and aortic arch). This leads to an increase in efferent sympathetic firing and decreased efferent PNS stimulation. This leads to vasoconstriction, increased HR and increased BP. +1  
sahusema  The way I remember this, carotid massage slows the heart. So baroreceptor stimulation (more impulses) increases parasympathetic output. +4  
cienfuegos  FA 2018 pg 291 has helpful image/description +  


submitted by seagull(1573),
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ciyiIpodt nasme --- tinbdyoa taangsi tdba.ynoi B lslce 'tdno hvea surceaf diisnoateb but emer tyehnszsei temh.

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +3  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by seagull(1573),
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Iiiydtpco nsema --- otabindy tsangai dyaobtni. B llcse otdn' heav scfearu ditbnoieas tub rmee esnieyhtzs htm.e

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +3  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by dr.xx(151),
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Gsiartc ceiavsr rea dfe by het storh crgtsai ni.sev

t1wnw4ns7c6thlt:07e.eoc9i4ec7s1.i0accs/ite403c7//r/em7p8pericw//78dBii

cienfuegos  Add'l UW fun fact is differentiating from gastric varices 2/2 PHTN: Gastric varices: can also be seen w/ splenic vein throbmobis 2/2 chronic panceatitis, pancreatic cancer and abdominal tumors - gause gastric varices only in the fundus (remainder of stomach and esophagus usually not affected vs. PHTN: increased pressure in left gastric vens thus both gastric and esophageal varices) +5  


submitted by liltr(23),
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I soeohc VMP ot,o utb thsi tsenaitp’ imna ymtpsom si cough oyln unirgd eieerxcs. hsiT si ermo decvnatiii of erxiceesd tdsaeoscai h.aatms oYu codul ees tshrsnose of teabhr in MVP rgniud eexr,seic tbu nihgcoso PVM valese the uhocg etcoudnaucn ofr.

.ooo.   I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps. +15  
uslme123  I mean... couldn't increased BP during exercise worsen his MVP and give him SOB? +  
uslme123  (by causing slight regurg) +1  
yotsubato  "Lungs are clear to auscultation" +6  
sahusema  But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for? +  
cienfuegos  I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts? +2  
cienfuegos  Just noticed that he has FHx, game changer. +1  
kimcharito  clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise) +1  
pg32  Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP. +  
happyhib_  it took me a little; the FHx really pushed me to exercise induced. I was also looking at malingering but there wasnt a real reason to push me to this (as a doctor it would be sad to be like hes faking it becasue he doesnt want to play sports with out being sure first; led me away because there wasnt enough pointing there). Also MVP could be slightly benign and is very common and usually no Sx and his lungs were clear as was rest of exam. All pushed to Asthma +  
mittelschmerz  I think MVP on its own shouldnt cause SoB with cough (in a question, I'm sure it could in the real world). In the world of NBME questions where you need to follow the physiology perfectly, you would need some degree of MR that lead to LV dysfunction/vol overload, and theres no pulmonary edema nor an S3 that point us towards that. Malingering would have to be faked for gain, and theres no external gain here or evidence that he's faking symptoms. You would also need to r/o physical illness before diagnosing malingering, which hasnt been done. Cold weather is certainly known for exacerbating EIA and are the exam buzzwords, but any exercise can absolutely be a trigger +2  


submitted by liltr(23),
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I scoeoh MPV ot,o utb isht ttpsi’ean inam omtymsp si ucgho lyon gidurn iesercex. sihT si remo ativnideic fo ediecexrs aateoicssd a.asmht Yuo lcoud ese tsnsesroh fo tehrab in MVP gdurni xc,eriese ubt scginooh PVM sleave het uohcg ntaoecucund fro.

.ooo.   I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps. +15  
uslme123  I mean... couldn't increased BP during exercise worsen his MVP and give him SOB? +  
uslme123  (by causing slight regurg) +1  
yotsubato  "Lungs are clear to auscultation" +6  
sahusema  But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for? +  
cienfuegos  I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts? +2  
cienfuegos  Just noticed that he has FHx, game changer. +1  
kimcharito  clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise) +1  
pg32  Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP. +  
happyhib_  it took me a little; the FHx really pushed me to exercise induced. I was also looking at malingering but there wasnt a real reason to push me to this (as a doctor it would be sad to be like hes faking it becasue he doesnt want to play sports with out being sure first; led me away because there wasnt enough pointing there). Also MVP could be slightly benign and is very common and usually no Sx and his lungs were clear as was rest of exam. All pushed to Asthma +  
mittelschmerz  I think MVP on its own shouldnt cause SoB with cough (in a question, I'm sure it could in the real world). In the world of NBME questions where you need to follow the physiology perfectly, you would need some degree of MR that lead to LV dysfunction/vol overload, and theres no pulmonary edema nor an S3 that point us towards that. Malingering would have to be faked for gain, and theres no external gain here or evidence that he's faking symptoms. You would also need to r/o physical illness before diagnosing malingering, which hasnt been done. Cold weather is certainly known for exacerbating EIA and are the exam buzzwords, but any exercise can absolutely be a trigger +2  


submitted by yo(86),
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I jsut wekn htat erpms ndee tfcer,ous nto uers awth sidsaee pscsreo stih si g.tuhho He swa tpyrte aomnlr os a5 erdtauceas soetd'n nsrtpee eikl .ttha I sanwt' sreu fi tereh swa yna odd sue of the roeth .snrewas ehre si a l.nki lFee erfe to expa.nd

hu./4tcseet/sm2lpi/:7gqwto._22nwcwpbso.paxsa

Fcutorse mkaes pu %99 fo hte ruiedcng rgaus preetsn in semen. hisT agrsu si ecuroddp in teh senliam eicsevs.l Dsmiheindi eevlsl of ursetfco ehav eebn whosn to lleapalr rennodag eyinceficd dan hte eosetntsreto el.evl llniFgowo snteoetsorte rh,eyatp the levle of reosctuf loeuerg sithAhcs.na teh otefscru tets si tno ratp fo a rintoeu enesm iasnlasy, ti is eulfus in acsse of orsampeoazi esbacn(e fo mresp in en)me.s In szmeraaopoi coasdryen to teh bsacnee of eslcsive ro if rhete is na rbtsuni,otoc no fotcersu si enr.step In tucaerslit aaors,mpeizo useofrct si ns.preet When zopromisaea dan low neesm uvlmeo t,sisex eth cuseoftr estt dsolhu aols eb edno, on a ottacesajelpu ireun empals to kcceh rfo getreoradr acutilnaoe.j sTih crusco enhw eht jalecaute eosg oitn eht reddalb esitnda of otu het .earT hrhetu operrecdu fro iedtenrnimg het amtoun of cusroetf ni neems nisvlove tgnhaie ensem in a rtsgon diac in eht cpeesren of eslrn.iocro cosueFrt vesig a rde locor lenov(Sfiof ocarie)nt dna yma be raed ni a .motophreet eTh lmaonr evragae is mgd53/L1 sucer.tof

sam.l  Thank you for the explanation. I'm still confused about this answer. I was in between Zinc and fructose. Zinc deficiency also presents with anosmia (pg 71 First Aid 2019). Fructose is used for the movement. His hormones are normal. +3  
d_holles  Apparently diabetes, occlusion, and inflammation can result in ↓ fructose in sperm. Mauss et al, Fert Stert 25, 1974 https://www.fertstert.org/article/S0015-0282(16)40391-2/pdf +4  
cienfuegos  Thanks all for the info, quick note on the Zinc reply above @Sam.I: anosmia = lost sense of smell. +  
sam1  Great find yo! I believe this question was alluding to cystic fibrosis and the congenital absence of the vas deferens. Here is a link to a NEJM article about it below: https://www.nejm.org/doi/full/10.1056/NEJM196807112790203 +  
burak  zinc deficiency cause hypogonadism. there is no hypogonadism, sperms are damaged? +  
fatboyslim  @Sam1 but cystic fibrosis will show abnormal physical findings (clubbing, pulmonary crackles etc). The question says physical exam shows no abnormalities. +  
pg32  Confused as to how we can rule out zinc... From medicalnewstoday.com: "Zinc also plays a role in healthy sperm production. According to a 2018 review article in the Journal of Reproduction and Infertility, zinc deficiency may contribute to poor semen quality and infertility." +  
bekindstep1  @pg32 I am not sure of how Zinc contributes to sperm production, but the question was asking about abnormalities in the semen and fructose is present in the semen. Maybe zinc plays a role in sperm development before it is mixed in with semen and so one with zinc deficiency wouldn't have low in zinc in their semen perhaps, but it their blood. This is just a hypothesis though.... +  
brise  ^^ Yeah that's how I ruled it out. You can find fructose in the semen, but you wouldn't be able to find zinc in the semen! It might help the sperm, but it's not going to be chilling with them +  


submitted by nerdy nik(9),
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DVT htat wnte ot teh rib.na If ti wloud ehva geno ot hte nolruymap tearry she uwldo have a EP, tbu it dcsores teh traia wlal iav a ptaetn omaefnr evloa nad netw deltircy ot eht nibra.

cienfuegos  Some more UW info: incomplete fusion in up to 25% of adults: remain functionally closed until RA > LA pressure (e.g. valsalva), esp. concerning if hypercoagulable (e.g. OCP) -evaluate cryptogenic stroke with buble study: inj agitated nl saline and look for bubbles in left heart +2  
athenathefirst  Are you very sure of this answer? because she is an adult and not a baby anymore so it can't be a patent foramen ovale. +  
teepot123  has not closed basically +  
kevin  cienfuegos is spot on with his explanation @athenathefirst +  


submitted by hyoscyamine(55),
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hsiT si larteal ldblClgnWa/ParyelueAm/Ier .eysdmnro ehT maonw ahs adameg in eht ysthceaitpm cahin srns(eyo dmeyossrn are llaeatr idorcganc to eht luer of 4)s gurtlnsie ni rnoreH ny,meodsr lapicsahtmoni ctart /pp(entmai ihchw era olsa oy)ner,ss and CN IX dna NC X fyosiundnct eslrgiutn in eth pihytrssy/daaahdiagr hsep(l us eaioczll to het ll).eumad

nala_ula  Also, just to add, FA specifies that Nucleus ambiguus effects (dysphagia, hoarseness, decreased gag reflex) are specific to PICA lesions. +2  
cienfuegos  Thanks for the input. I have always found this topic to be tricky and just came across this article that helped me out a ton regarding the rule of 4's hoscyamine mentions above. https://rdcu.be/bLjOB +7  
lovebug  FA 2019 502pg! +  
pfebo  "Don't PICA horse (hoarseness) that can't eat (dysphagia)" +1  


submitted by xxabi(260),
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ocrs’aB is:ahapa esevrxpise mo(rot hisaapa) twhi agmamtrasmi tps( aware that tyeh nto’d kaem sesne) - reaa irWseckAe’n :phaasai cpveierte eoy(rns)s iaspaha hwit mepirida smheoicpennro (tps lakc hiisgtn)

breis  Why would B be incorrect? I realize Broca is "technically lower" but A seems too low to be causing weakness of the lower 2/3 of the face? Am I missing something? +  
shaeking  @breis B is incorrect because of the lower 2/3 of the face weakness. B isn't located on the motor cortex but in the premotor cortex, plus it isn't low enough for the lower two thirds of the face. https://thebrain.mcgill.ca/flash/a/a_06/a_06_cr/a_06_cr_mou/a_06_cr_mou.html https://www.sciencenews.org/blog/science-ticker/homunculus-reimagined +1  
cienfuegos  @breis, per UW: "a/w r. hemiparesis (face & UE) bc close to primary motor cortex" +  
almondbreeze  B is close to premotor cortex which is involved in learned or patterned skills & in planning movements. (i.e. two-hand coordination) slide 25/37 :https://www.slideserve.com/hal/the-motor-system-and-its-disorders +  
almondbreeze  B is also close to frontal eye field; eyes look toward the lesion FA pg. 499 +  
frijoles  I incorrectly picked C. When answering this, Broca's "broken speech" was my first thought, but I figured a lesion causing a facial droop would have to involve the motor strip so I prioritized that and chalked up the speech issue to dysarthria (I understand this is more of a "slurred speech" than broken, abrupt speech, but again, I simply misprioritized concepts.). So for the record, Broca area is part of the motor cortex? +1  


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How ulwod yuo owkn htat ti in'st wloo ssretro esdsae?i

cienfuegos  FA 2018 137: inhalation of spores leads to flu-like symptoms that progress quickly to fever, pulmonary hemorrhage, mediastinitis and shock, with imaging possibly showing widened mediastinum +7  


submitted by cienfuegos(67),
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tnudoC'l oyu oasl eecrsead the FIO2? rPe A,F PPC oasl irscnasee ot piahyox oasl reasecdse PPC nweh OP2 t;&l 50 gm.mH

cienfuegos  Obviously not the BEST option in this scenario, but seems like it could work unless I'm missing something. +1  
step1soon  Its primariy driven by PCO2! only when O2 levels drop <50 mmhg is when the body responds to low O2 pressures +1  


submitted by usmleuser007(397),
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rSyaalvi neecroits 1. tA olw lfwo = ihHg ccnonnotirate of uostmi;asp low nnrctsoencaoti of dm,suoi ,biacrb p&;am rc d.loi2eh at ghih wofl = olw noccintoerant of mtsoaips;u hhgi ooranntetinscc of ,soiudm aibrc,b am;&p reolhidc

sherry  That's exactly what I was thinking when I was taking the test. But I was sidetracked by same HCO3 level. Can somebody explain this part to me?? +  
charcot_bouchard  Because salivary duct removes Na & Cl while secrete K & Hco3 in lumen. In low flow rate HCO3 & K inc because duct is doing its thing for more time. At high flow rate K slightly dec (as cant be secrted as much) but HCO3 stays almost same. the reason is high flow indicates higher metabolism & higher bicarb production. +  
cienfuegos  Regarding the bicarb (via BRS Physiology, which explains flow rate as coming down to "contact time" where slow flow allows more reabsorption of NaCl): The only ion that does not “fit” this contact time explanation is HCO3−; HCO3− secretion is selectively stimulated when saliva secretion is stimulated. +3  


submitted by johnthurtjr(145),
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Wleih I nca tge no abodr hiwt jttnemAsud srrD,doie I 'tdno ese who shit erwasn si ayn etrteb atnh aoictSm ySmtpom r.eidosDr omrF F:A

riyVate fo idoybl ocmlnpasti atlsgni htomns to reasy acoidaests itwh vse,scixee insrepttes hohgttsu and txiynae otbua s.spmyomt yMa -rpcaoepa tihw .lesnsli

SDS lbngeos ni a gorup fo dsdsiorer hriredczaecat by sciphaly ptmyosms acginsu iifisnctnga stesisrd adn maptreimin.

savdaddy  I think part of it stems from the fact that this patients symptoms are occurring within the time-frame for adjustment disorder while SSD seems to have a longer timeline. Aside from that I find it difficult to see why SSD wasn't a possible answer. +4  
chillqd  To add to that, I inferred that the obsession with checking temp and with the tingling sensation were signs provided to him by the physicians of recurrence. He is anxious over his cancer recurring, and they are more specific than a variety of body complaints +1  
hello  In somatic symptom disorder, the motivation is unconscious. I think for the patient in this Q-stem, his motivation is conscious -- he wants to make sure that recurrence of cancer is not going "undetected". +14  
cienfuegos  I also had issues differentiating these two and ultimately went with SSD, but upon further review it seems that a key differentiating feature was the timeline. His somatic symptoms would have had to have been present for at least 6 months per the DSM criteria https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t31/ +3  
almondbreeze  @chillqd Same! Why not OCD? He's fearful that something bad might happen (=cancer relapse; obsession) and calling his doc (=compulsion) +  
kevin  great reasoning @hello, this was confusing me but that makes perfect sense +