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Welcome to d_holles’s page.
Contributor score: 187

Comments ...

 +0  (nbme23#49)
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Pt sha AAS eeirtcaolnn ah,astm hcwih sanme NDSAI si odnenitacia.dtrc ckiP lccoih.ienc

 +2  (nbme23#23)
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Lensso erlande -- het NEBM 'otdsne payl ikcs.rt If it oskol irh,tg it is t.ghri

thotcandy  but also when it looks wrong it's right, or when it looks right it's wrong, or when it looks wrong it's wrong. you never know with NBME :) +9

 -2  (nbme23#10)
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Eenv oth AF dan ceoihStcykrM snet'do noimten it, tobh msanlaApa nad slciirhhsEo are rrciaed by obRni fo esodxI.

bulgaine  FA 2019 does mention it P 149 +
charcot_bouchard  Ehrlichia - Lone star tick +2
paulkarr  "Lyme Disease caused by Borrelia Burgdorferi, which is transmitted by the ixodes deer tick (also vector for Anaplasma spp. and protozoa babesia)." FA 2019, Pg 146 +5

 +2  (nbme23#2)
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yex  There is a Q on UWorld about rotator cuff tendinitis #380186 w/ a similar presentation... I kind of remembered about that, but honestly I do not know how I got it right. +
yex  Correction: Q id is # 1732 +

 +8  (nbme22#24)
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sihT si a hatPaom 3hC Q )p.2(8

uTmor iinansov nda rapsed

  1. plithaeiEl omurt llsce are ecdattha ot eno oathern yb arcni-Edhe ellacr(ul seiahdno ec)ellumo. olnirwDgatouen of riheEcan-d → osntcisdiiao fo eatdchat .slcle
  2. lCles tcaaht to innlmai and syordet atseebnm remamnbe vai .gcallseoean
  3. lsCel caatht to irnoceinfbt in eth EMC nad derpas lycllao.
  4. ertEnnca itno avulrsca ro ihpyctmla pscaes aowlsl fro


 +2  (nbme22#22)
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I wsa erenv uttagh tawh stet-t vs uhdqCasie-r .asw nGiog fof fo teh AF table 'idndt le.hp hsiT oievd bewol eldexnapi het pcctneo ylarle .lelw


orF hte Q rrefe to @s1'cm m.contem

 +0  (nbme22#31)
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anC opltra NHT rtntiocbeu to epcaith aep?ynaehocphlt

djtallahassee  Sorry for the late add. Portal system does contribute to hepatic enceph ESPECIALLY when there is a TIPS or shunt that bypasses the liver. However before, it won't directly contribute to more NH3+ +2

 +13  (nbme22#44)
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Dmna I flee keil MENB kncfugi sevlo beaicss ro smoe tish.

 +1  (nbme22#14)
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Goajnl tdnmineeo shti o(tn urse wath teceurl -- mgtih vhea eneb the done e.)no

 +6  (nbme22#50)
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Thsi video asleinxp eth iprdaicet atnoeesucnouru resrdosid e.llw


slBailacy hte yke rehe is mpdygeehnopti slucame. F1N has caef ua iatle pstso gyipeenmedht(rp )ulmscea lhiwe CTS hsa ahs lefa sspto etnphdmoip(gey )lascum.e This si a edocde eth ordwzubz lsyte .eiunotsq I etfl ilke I ntdi'd arlyel tdraudnens hstee rdroes iutln I dcewtha the oabev doie.v

pg32  I figured this out for a few reasons. The hypopigmented patches are ashleaf spots and the raised, flesh-colored lesion on the back is a Shagreen patch (only seen in TSC). Multiple brain lesions = hamartomas. Additionally, NF1 has 100% penetrance, though it also has variable expressivity, meaning if it were NF1 we would probably see some family history of similar symptoms. +3
castlblack  Agree. CAFESPOTS Cafe-au-lait, Axillary Freckles, Eye (Lisch nodules), Sarcoidosis, Pheo, Optic Tumor (glioma), Seizures +
rockodude  the video is very helpful +

 +3  (nbme22#35)
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Tshi si a ogdo utpreci fo an ermpxtneei gnhwios hs:it


nOcgeone lvoeum ,62 gespa 222–12219 7)(020

 +14  (nbme22#11)
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I tgo iths neo iav escspro fo mniae.iolnit tNo ures woh uyo are sseduppo ot reebmemr all hatt hsi.t

 +2  (nbme22#5)
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sThi snoitequ csnefduo em bc I gtthhuo lrpoeeamid ulcod tno cossr het BBB and tehoefrre uldoc ont uasec rsioprtayer epdisonser impuod(io- mogsnia ta eth srebmtnia lussert in eSasoNCiry/rrtp ,sipdenroes 1.) But @rxdx. is rtcecor in niognt ttah ↓ RR dna NSC eedrpisnso ni het tP uhdols lalc for an u-moiidpo snttngoaia eahtrr ahtn cnlahetohb ihmmic)ctoieln(o ot ertta a.cntpiinosto

  1. r:5lxpys0thig/otg/
nwinkelmann This explains a case in an infant. "Respiratory depression and coma after overdosage have been shown to be reversible by injection of naloxone [6]. Owing to its structural similarity to opioid, loperamide toxicity can be reversed by using Nalaxone which is a specific opioid antagonist acts competitively at opioid receptors. Naloxone hydrochloride is usually given intravenously for a rapid onset of action which occurs within 2 minutes." +3
yb_26  FA 2019: "Loperamide has poor CNS penetration" - so it still penetrates => can cause respiratory depression +4
whoissaad  Also maybe because the blood brain barrier in a baby is not developed as well as in an adult. +4

 +14  (nbme22#15)
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olaGnj rsesetss eht rsdoBa ginivg the akielume esinutsoq aawy sbeda no teh ega vgnei ni eth esqionut se.mst

ALL = -410

LAM = 3-;951 945-0

CLL = 0+6

MCL = 5-940


impostersyndromel1000  thanks for the reminder, often overlooked are the simple demographic hints. helps you make an educated guess +
hyperfukus  also a key thing to remember in general is a person who undergoes chemo is a big demographic hint to later developing AML regardless of the clues :) and yes the AGE!!! +3

 +6  (nbme21#23)
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%20 imnablu is ctoiYHnPRE nda usasce inrgawd of dfiul tou of the intitetsrum dan noti the o.dolb

bu"lnAmi )Ha(nmu 02% si idiecdatn in eht eeyrecgmn ntetematr of lmohepayiov wthi or wothitu kchs.o Its cvetfesniefse ni gersrvnei lehoyavpimo dpesned grlaley noup its ibltiay to adwr ttreiiisalnt fldiu itno teh cu.tracloini tI is msot fftveieec ni nseitatp owh ear elwl theradyd. enWh dolbo uloemv ciefdti is eth letusr of ,ehrremgoha opacltimbe dre bdloo celsl or hlweo ldboo dholsu be tarnedmeidis as yiqkluc sa o"bs.lspei


 +5  (nbme21#20)
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iths is a iscaslc ncriiptodes fo teiesrnstp lriMeulna cutd mndeyosr


eud ot lkca fo MFI unt(taiom in hte geen htat semka )FIM → neetecsspir fo eth nlaMierul dutc → srueut dna lnlfipaao etbu rnpetes in a XY male w/ eestst yplaclti(y )cor.ythcirdp

 +7  (nbme21#5)
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sHere' an ellcnexte mgaie ofrm SAOMBS fi eppeol rae hgavni fyilticudf viilsgzuain shi:t /hgpV/acsWhRtm/Q.mtm/ur:oim

lovebug  very helpful! thanks! +

 +3  (nbme21#2)
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,sAol I khtni hawt is yke is to eeizral atth rigiunjn NC X rrpivai(at'eeton NC X nju)'iry sedo nto ldae ot gmihpadra laypasr,si olyn prhienc enver jiuynr udlwo do


mreroeur,Fth hte toreh sontpoi ciy'aodnrticis( nrx ot sro'nvuelafe and dnrneoa'iy cerpreto ec)tfed' rea orf inagltnam hhrametie,rpy ONT aebnlu to atbehr ltnopnss.uyeoa

Subcomments ...

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hTe etsffec of csexes hidoyrt remhoo:n ttepmaedt aoctynrpseom SHT suinpes,spor cnsereia in hbot T4 nda eref 4,T nda lmaorn G.TB teNo ttah teh uteonisq n’esodt neev egihn on BGT adn is aslo knileylu to no eht lera tigh.n

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

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niltSgipt si na imeamrut fenesde caemmshin ntofe delpeomy by stetpani whti rrloideenb etypailrons oedsri.rd Wehn itsgltnpi, a snorpe iafls ot see tsroeh sa abpaecl of nahvig hbot iepisovt dna tgaivnee ii;ulsaqet ta yna inveg ie,mt ti’s lla or to.hignn

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

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reStok cazctdaheirre by felt msieiephars dan higtr 1NC2 .alpys sCdsreo fgsidnni mnae a manstbrie nes.oil iRght iaiae)sll(rpt ,guetno ts-dieflde al)rtaare(notcl aeesnwsk esmna eth niegxit higrt gplhaoyloss reenv sha eben ctfeaedf nhwit(i hte thgir ).lmladeu C is the ryadimp ewreh teh olticrosaicnp trcat nrus ot toocrln semuslc (iorpr to teh no.iecustsad) shTi is wnkon as the ialdem ldmrlueay dyesronm or eirenjeD

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

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irA and ilfdu = yrnhhrouodat.ompxe fI that iludf is olbod (sp/ )iabst,bng ’tsi a rpmxuonhmaetoohe. cakL fo tiasmdenila itsfh atcnesidi taht is’t not nuder esoitn.n

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

submitted by wired-in(67),
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nceaaneitnM sode oamufrl si s(sC × Cl × a)tu ÷ F

rweeh Css is sdte-tseyaat regtta mlaaps c.nco of gdu,r lC is c,aceeranl uta si seogda ranletvi m&pa; F is b.ibiiilaoytalav

Nreithe ogased trniaevl onr iylbaiotilabvai is n,eigv so oigirgnn hteos am&;p ngpigulg in het nemsubr e(rfluac ot rocnetv istun to //)g:ygmadk

21(= gLu/m × 1 00m10g/ gu) × (.009 r/ghLk/ × 0100 L/m1 L × 24 r/h1 d)ya
= 2529. gam/dg/yk

w.hi.hc. tni's any fo teh wsarne socheci lesidt. Teyh stmu aveh udnrdoe 090. grhk//L to .01 /Lh/,kgr nda gnodi so sgiev ltacexy 882. //kygagmd (cecoih C)

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +75  
hyoid  ^^^^^ +11  
seagull math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +9  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but i´d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +4  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +3  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +17  
qball  Me after plugging in the right numbers and not rounding down : +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😡 +  

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I hgtothu fo tihs sa susuqoam ecll riaonccma of eht lgun unigasc dcenasrei TrHPP nda ealrpm.eaihccy

d_holles  I thought this was medullary thyroid cancer but demographically SCC works better. +  
smc213  Medullary thyroid carcinoma increases calcitonin levels leading to decreased serum Ca2+ by increasing Ca2+ renal excretion. So high levels of calcitonin secreted by the tumor may lead to hypOcalcemia. Source: Pathoma +21  
brise  actually according to pathoma, you rarely see hypocalcemia even though calcitonin is high! +1  

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Hwo is hsit eht asrenw if eethr is on ymfali rsohtyi of utercerrn caue?rrtfs I hhotutg sgoistneeoes ietpfremca aws looumaats td?mniano

seagull  Exactly!! it's an autosomal dominate disease! +10  
emcee  Autosomal dominant diseases are variably expressive. Still, I think this was a badly written question (should have given us some family history). +  
wutuwantbruv  Also, FA says that fractures may occur during the birthing process, which is what I believe they were going for. I don't believe these findings would be seen at birth with any of the other choices. +  
d_holles  Yeah I thought I outsmarted NBME by selecting Rickets bc it said no family history ... guess I got played lol. +9  
jean_young2019  Could it be a sporadic cases? Spontaneous Mutation This is a change in a gene that occurs without an obvious cause, in a family where there is no history of the particular gene mutation. OI is inherited as an autosomal dominant trait. Approximately 35% of cases have no family history and are called "sporadic" cases. In sporadic cases, OI is believed to result from a spontaneous new mutation. +6  
avocadotoast  Amboss says the severe subtypes (types II, III) of OI are usually due to a new (sporadic) mutation in COL1A1 or COL1A2, while patients with the mild forms (types I, IV) typically have a parent with the condition. +  

submitted by yotsubato(1032),
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sWa ti just ,me or ddi "age ta soten ni e"ayrs aarpep TRGHI eoavb eth enbrum fo a,itptesn thrare tnha eht .aemn hcWhi dfeuscno em for a odog 3 .iuensmt

fulminant_life  Definitely was the same for me. I was so confused for like 5 mins +13  
d_holles  dude i almost didn't get the question bc of this ... i thought the age of onset was the actual age of onset (36) +7  
mellowpenguins  Are you serious. NBME strikes again with shitty formatting. +7  
yex  OMG!! Now I just realized that. Super confused and also thought onset of age was 36. :-/ +5  
monkey  what is 36 supposed to be? +1  
thomasburton  Think the number of people in that group +5  
paulkarr  Yup...was looking at it for a good 3 min before just doing the "fuck's gotta be 99" +5  
arcanumm  Age of Onset is the Title of the table, which I didn't figure out until after exam was over. What terrible formatting. +3  

submitted by mousie(218),
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hWy on new?gaist I eman I egt ctaysEs is lpboyabr teh rdug of icoceh fbreeo an all hngti encda tprya )l(ol utb 'notd dateusdrnn why rheet would be lcod txesetimier nad no aigeswtn whne si FA it says pharytemirhe adn dhoab???r?

sympathetikey  FA says, "euphoria, disinhibition, hyperactivity, distorted sensory and time perception, bruxism. Lifethreatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome." So I think they wanted you to see Sinus Tachy and jump for MDMA. Idk why Ketamine couldn't also potentially be correct though. +11  
amorah  I picked ketamine because it said no diaphoresis. But if you need to find a reason, I guess the half life of ketamine might rule it out. Remember from sketchy, ketamine is used for anaesthesia induction, so probably won't keep the HR and BP high for 8 hrs. In fact, its action is ~10-15 mins-ish iv. +11  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +19  
fulminant_life  you wouldnt see tachycardia with ketamine. It causes cardiovascular depression but honestly i saw " all-night dance party" picked the mdma answer and moved on lol +8  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +4  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +1  
dashou19  Take a look at why the patient has pale and cold extremities. "Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation." +3  
drzed  @sbryant6 you're both saying the same thing. Ketamine has a direct negative inotropic effect on the heart, but it is also a sympathomimetic. You are both correct. +  
paperbackwriter  @drzed Can you please site that? As far as I understand ketamine has a sympathomimetic effect on the CV system --> increased chronotropy and BP. I also don't see how they're saying the same thing. One person said "stimulation" and the other said "depression" +  
nutmeg_liver  People tend to drink a lot of water on MDMA. I just guessed the confusion was a result of hyponatremia (too much free water) but no idea if there's any data saying that people tend to become hyponatremic due to water over-consumption on MDMA lol. +1  
cassdawg  "Despite possessing a direct negative cardiac inotropic effect, ketamine causes dose dependent direct stimulation of the CNS that leads to increased sympathetic nervous system outflow. Consequently, ketamine produces cardiovascular effects that resemble sympathetic nervous system stimulation. Ketamine is associated with increases in systemic and pulmonary blood pressures, heart rate, cardiac output, cardiac work, and myocardial oxygen requirements."( +  
brise  LSD does cause HTN and tachycardia according to uworld! @d_holles +  

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The wya I tthhguo about iths onquiset asw ttha in MM teher si a TON of tbniaeisod beign ad,em os eht DVJ tnesgem si inegb rbnoke dplecreet/ead/unersgra mnay estim dna ash bene srnoeedth ot .5.k1b As ofr het T l,eCls atth gronei tnis’ inegb sude sc(nie hrete is on llcaon aoxpeisnn or ieolecn)ts so its’ tlsil tog eth ufll bk6 htleng ducnheuot.

d_holles  T cells still undergo VDJ recombination to form their TCRs. +5  

submitted by seagull(1568),
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out of rsc,outiyi woh amy eloepp nkwe s?hti nod(t be syh to ysa uyo ddi or ti)dnd?

yM evtpoyr noductiea 'ddtni naniirg htsi in .em

johnthurtjr  I did not +3  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +5  
snoochi95  hell no brother +1  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +2  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  

submitted by armymed88(47),
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eodHgpptnemyi soniesl rfree ot A-fhlesa o,tssp SNC seilson keylil tamrhoasam . TS lsao caatiosesd hitw

fcambridge  How is Tuberous Sclerosis the most likely given that it is an AD disorder and there is no family history of "seizure disorder or major medical illnesses"? +14  
d_holles  @fcambridge variable expressivity of TSC allows for many different phenotypes. +1  

submitted by pppro(23),
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atneiPt sah .BPH ivGe hlpaa eon notsgiaatn ot deucre ohtmso meclus oontcctinra nad ieevrel fliiyfdtuc ir.nntigau

d_holles  lol i thought it was some kind of urinary retention problem and put H. +15  
sbryant6  How is H wrong? Oxybutinin or tolterodine treat urinary incontinence by blocking M3 muscarinic acetylcholine receptors --> urinary retention. We're just supposed to assume they are talking about BPH here because he is old? +  
jaxx  I agree. I picked "H" for that same logic. Does anyone know where we should have come to the conclusion that this was BPH? +  
forerofore  they are telling you he's having "difficulty urinating", one of the clinical criteria for BPH is reduced urinary flow rate. this is not incontinence because they are not telling you he leaks at all, just that he pees "a lot" +12  
drzed  Even if he was urinating too much, anticholinergics are contraindicated in the elderly (Beers criteria) +4  
pathogen7  @drzed tI mean techinically alpha-1 blockers are on the Criteria too ... +1  

submitted by niboonsh(357),
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o2oettwahttmhswy-QH=/u/? fi ur ayzl klie e,m sthi si a doog rsefeerhr vioed

d_holles  Amazing video dude. Somehow never learned this in neuro lol. +6  
aag  Awesome video! Is this why you can give Mg2+ to eclampsia patients, because if so, mind goddamn blown. +2  

submitted by yo(86),
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I sjut kenw hatt repms need tocefs,ru otn user whta edsisae oscsrep isht si h.ogtuh He swa tyrtpe rolanm so 5a drcstueaea dntoes' etsenpr kiel h.tat I 'santw sreu if erthe asw yna dod ues fo eth retoh nwaessr. reeh si a elFe efer ot .xapned


Foturesc seamk up 9%9 of hte gecndiur agurs neeptrs ni se.enm hsiT sruga si ucedrpdo in eht lesnima sv.eilsce Dihndmseii vellse of srtceofu eahv ebne whnso ot ellpaarl naegodrn ienfcydiec adn het rsteonseotet e.lelv owlgliFno stontretesoe yae,rtph the leelv fo ourcfste e htaluchessiro.nAg teh teosucfr stte is not part of a nruiteo smnee lassani,y it is lusuef ni acess fo szpmaoraieo sc(naebe fo smper ni enme).s nI isrooepazam aesdnryco ot teh csaeben of eielssvc ro if tereh is na uictrsotobn, no orutsefc is te.srpne In iartucetsl arpmzo,oiase fsorctue is estenp.r Wenh paazrmooeis adn wlo smeen omulve is,tsex the scruotfe ttes udhlso salo be ,endo no a speacojtelatu irnue lpmsea ot ccehk ofr oerarertgd This cucrso enhw hte tejeacaul goes tnoi eht ledbrda sdteani of otu het ruTrhae.eht rceduroep orf mneigetidrn eht tmanuo fo socrueft in esnem ivoslnev aghietn enmse in a srotng dica ni the rpescene of rFtueosc seivg a dre lrcoo fnivSeoof(l rencta)oi nda yam eb edra ni a mhpeterto.o ehT nomlra rgeaave si g/Ld13m5 re.ftosuc

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 +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: +  
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 "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 +  

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the ctfarni rucdcore 61 srh goa, romf r24h1-2s atref hte ftcinra rheet lwil eb Rde

tsl19  FA 2018 - p. 496: ischemia -> pyknosis within 12-24 hours. +  
d_holles  yeah the infarct occurring 16 hr ago is key. i zoomed in only on the died 1 hr later +  
apurva  Me too zoomed on “1 hour later” and marked no change +  

submitted by hayayah(1077),
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fknfcooaeei-rrskWK nmdy.roes tDn'o have to eb na coiaolhcl to tge ,tihs stju usullay is ereldta to ahoslcoilm / netahmii .eyidccnfie

d_holles  Yeah the negative EtOH screen threw me off +3  
dr_jan_itor  Why cant it be early alzheimers and hippocampus? She could easily have been a former prominent physician and member of city council. Am i supposed to assume that simply because shes disheveled and poor hygeine that she must be an alcoholic homeless person? It also mentions no symptoms of nystagmus, ataxia, etc. +2  
kimcharito  it said broad based gait and nystagmus +9  
lilmonkey  She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment. +1  
fatboyslim  @ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus." +  
suckitnbme  NBME questions also stereotype the shit out of their patients +5  

submitted by lamhtu(118),
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nNegide "ihgehr t"onniorccnstea fo eth B6 rof neymez ictayvti si naoehrt way of yisnag mK si ehghir ecisn oemr is dqureeri fro 2/1 xamv ty.ctiiva Icarneeds Km ausvle ertusl ni m/1K neibg mlarels ors(cel to 0 no eht a)xsix-, hhcwi si tnaodmdteres ni srwane ieccoh .B

A n"morla" myznee tytcavii ni eth rpeeescn fo greihh B6 ncototcsernnai snaem thta xVma si ton ghnia,gnc ubt Km i.s

d_holles  In other words, Normal enzyme activity = Vmax Adding more B6 to a mutated enzyme will improve it back to normal (Vmax stays constant, so Km will decreased due to ↑ affinity of the enzyme). +  

submitted by assoplasty(93),
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I nktih the pncctoe hy’rtee ttgeins si eth rdenescai TBG veslel ni p,ngacnrye and ton ujst trpihoihysdreym ni .ngreeal

ehnW irceesnng rof yirid,/psphyotehryhmo THS eesvll ear SYAWLA fpyeelrteiarln ecehdck eeucsab thye rea moer vnisteise to muinet edseenfifcr in 3/TT.4 entfO setmi SHT vleels acn steorantmed a ceghan eevn when 4/3TT elelvs rae in eht iblanuiccls eTh lnoy xtcoienpe to tish odwlu be ni arygcpnen (and I gsuse maeby lrive aerlfu?i I tbdou yteh luwdo aks tihs hght)uo. Hgih gensreto slevle espvetrn teh iervl fomr akeribng nwdo ,TBG ndaileg ot eedacrnsi TGB llvese in eth rmes.u ishT bisdn to free ,T4 dsnreicgae hte monaut of laleaivba eefr .4T sA a aocopermnsyt chai,esnmm HST vlslee rae nntteirylas deresnaci nad the TERA fo 4T uindcorpot is sncareeid ot lpienersh isaleenb eerf 4T v.eslle wHrovee het OLATT mnuaot fo T4 si .seeadricn

Teh uistneoq si gsnika who ot cnoirfm rimysrhtdyihope ni a trgenpna aomnw ;-&t-g you dnee ot khecc EFRE T4 llesve sce(beua eyht lhsodu be alrmon deu to yeoatnrpsmco ).nreosesp uoY nnaoct hkecc TSH uyllaus( eedevalt in nryganpec ot emaopnsetc rof dneaescri ),TGB and uyo oncant cchke alott 4T elvels i(lwl eb oYu gto eht nawers trigh rteihe awy tub I ihntk htsi si a ffrtniede niosargen ohrwt ,gdiisennrco bueesca tyeh cna ask hsti ntecopc in erhot ntocxets of p-rsrhnotmsyeegie, dan if htey idetls T“SH” sa an eswran icehco tath doulw be c.tnoecirr

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

submitted by niboonsh(357),
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heT sbuieqol od teh toippeos noctia of ihert rfroiIen equbiol veoms eth eey PU nda UOT o(ienxo,trt avet,ilnoe .oudBinct)A eSinc hte uosteqni says thta heret si a uacetrfr nvoilivgn the tbraoli orlfo, that oclilyaattmua rlsue uto D l(ideam trcseu adn oeirfirn ou,beq)li gaeivnl het nylo gliacol enwars ot eb hte efonirir srutec nda rofirien eo.qiblu uE?tHcvWlbuIc./sK.Iye=htW/kohDot:atW/mpwwww

aishu007  hi, but inferior oblique moves up and in and not out +  
d_holles In case ppl need a refresher +  

submitted by hayayah(1077),
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oelrw arianpadqtnou:a ptaraile inlseo

sv rppeu pqaoautnadniar = rlatpemo enosil

mcl  also, to differentiate whether it is the left or right parietal lobe, recall that stimuli from the left visual field hits the nasal side of the left retina and the temporal side of the right retina, then goes to the right side of the brain. [This figure]( is helpful. +7  
d_holles  So you're saying that there's two crosses, making it ipsilateral? @mci +  

submitted by neonem(571),
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ihTs si a usptoapmtr omod ,ctbnusdiear a ptyert momocn rerdiods hatt has to ahev na etons thiwin 4 ksewe of leiyerdv to eb medter sa husc. tamrPosptu usbel si hte mots ,dmil with a 058%-5 eiincdnec rate r(pe FA )820,1 auslyul ovelsers thwnii 01 days dna tmeetnart si onyl viuepotpsr but ened ot -opfllwou ot ssases ofr pisoesbl tuptsmpora uomrastptP pessinoedr = 50%-11 rt,ea iecdracrtzhae yb rdsesepde atfefc, xae,ynit roop ctanetironnco ofr reegrat tanh 2 weske and esnde ot eb eetdatr w/ BTC + RISS. I ithkn teh esotquin si tgitegn at nsicneger ofr hits nad a yltlioetapn remo ilpcetmaorb nicpiamcl,oto tsouatmppr pcyshios.s

thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +11  
d_holles  Same @thisisfine. +2  
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +  

submitted by haliburton(214),
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hist si a lvcecari nailps rodc ntceos.i the eaucent asuicucsfl si acntit )(UE irotibvan adn nppo,prriooicte btu hte ihwte cnoeist is het gerliac iusauclcsf )EL( nad si gmaedda. I tihnk het laarelt ioponrt atht si neevnu si tsuj tlcraatan.t/afuir

arezpr  thorax section +3  
guillo12  How do you know the gracile fasciculus is damage?!?! +2  
cr  which parte of the image its damage?, the pink? or black? +  
usmile1  the pink park yes +2  
d_holles  If you look at you can see that the closer to the center = legs, while further away = arms. +4  
hyperfukus  i still don't see where the damage is lol! FML +  
hyperfukus  i finally figured it out lol that was a slow moment i hope im not this slow on step yikes! +  
angelaq11  @hyperfukus I had the same problem at first, marked it and then came back. If you remember, in the spinal cord the white matter and gray matter are "reversed" compared to the brain. That said, if the butterfly shaped region (ie, the gray matter) is colored (in this case) lilac and the rest (ie, white matter) is blackish, the only thing that is actually abnormal, is the region where the dorsal columns are, because it stains just like the normal gray matter. After that, you have to think about which fasciculus is damaged, the gracilis or the cuneatus. The gracilis is medial while the cuneatus is lateral (picture someone with glued legs and open arms). Hope this helped +13  
azharhu786  Gracilus Fasciculus = Graceful legs +  
icedcoffeeislyfe  Check out FA2020 pg 508 Put simply--> myelin= black --> color of the normal white matter no myelin= pink --> color of the normal gray matter and the damaged area Dorsal columns= vibration, proprioception, pressure fine touch F. graciLis= Lower body F. cUtaneous= Upper body +2  

submitted by sinforslide(50),
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eaMl nliaetnr iganetila &t;g- Ittcna RSY , see,tts adn oorntstetees.

oN alemfe tlaennri lngiatiae t&g-; cePseren of FMI n(iuilrnatmlea omhern)o nad ttiacn rtSoeil lecl tnofucni.

eelamF tarnlxee negaiital ;-> No ornadneg rspenet, cihwh si euqdrire ofr lmea anxtelre aiteangli tnoir.foam

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +23  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +2  

submitted by sinforslide(50),
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aleM rnitnlae iiaeglnta -&tg; tactIn RYS , seet,ts nad ot.ntersetseo

No elmaef nirelant ialeigant &;tg- recsnePe of IMF lraninumae(itl mo)ehonr dan atitcn Sertoil cell ifutcnno.

Female axtlenre lagiitnea ;g&t- oN neadgnro ernpt,es ciwhh si qeueridr fro amle exrntela nigtialae ofmti.rano

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +23  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +2  

submitted by sinforslide(50),
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laeM tnrlnaie eignailta &-tg; ntatIc RSY , sste,te nad stoseen.toret

No afmele irnnelta ntiiaaleg g&-t; resPecen fo MFI ata(muinilrnle or)nhmoe adn tacnit eitlorS llce cntnfou.i

Fleeam lexnatre itiaenalg g-t&; No rdnogane nere,spt ihcwh is uirdreqe orf elam retnlxae nitiaelga .antomfroi

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +23  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +2