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Welcome to d_holles’s page.
Contributor score: 145

Comments ...

 +0  (nbme23#49)
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tP has AAS ilrnaeetcon aamt,sh icwhh msean AINSD is aoidtetcncirna.d ikcP ic.elocinhc

 +2  (nbme23#23)
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soLsen laneder -- het MBNE 'dnoest apyl If ti okslo irh,tg ti si h.rtgi

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 :) +5

 -2  (nbme23#10)
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eEnv hot AF and otMSckerhyic td'oesn ontimne i,t tbho amlpnaaAs dan irohihsEscl era rcidare by iRbon of Ixosde.

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 +2

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 +

 +7  (nbme22#24)
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sihT si a mahtaoP 3hC Q ()82.p

urmTo asvnoiin nda asderp

  1. hpeliElati tromu lelcs rea dhecatta ot eon athrneo by -aeriEcnhd uel(callr oeasinhd ulee.lm)co nroDeaotuinwlg of ceanhdr-iE → ctisonsiadio of atdethac l.csel
  2. sellC cattah to miannil dan eytdsro aenbmste ramebenm iav goeaclealsn.
  3. Cells thcata ot ncretoinibf in het EMC nda sdarpe ol.cylal
  4. rnEnacet noit aralvcsu ro alcymipth sceaps aloslw ofr tmsisaates.


 +2  (nbme22#22)
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I was nreve tuhtga tawh esttt- sv eCai-rdusqh wsa. oGign ffo of the AF tabel ndid't lph.e hsTi oveid wlbeo iapnexdle teh noetccp rllyae l.wle


For hte Q ererf to 1m'sc@ mtco.mne

 +0  (nbme22#31)
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aCn paltro HNT brountitce ot teachip poe?aytachhpnel

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

 +14  (nbme22#44)
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naDm I leef klie NEBM ignfkuc slveo iscbsea ro soem isth.

 +1  (nbme22#14)
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lGaojn eneidonmt hits no(t rues whta rlutece -- timhg eahv bene the endo )on.e

 +6  (nbme22#50)
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Tish idvoe sxpeialn teh diprieact ouorastneuecun dsirroesd ll.ew


yillaBacs het yke ereh si mppiedeyothgn cuealsm. 1NF hsa feca ua aeilt sstpo ipdtrpeeemhn(gy elascu)m ilewh TSC has ahs alef otssp eneto(mhiypdpg lsau.ce)m ihsT si a ceddoe eth uwzodbrz sytle ot.eisunq I elft ilke I ti'ndd rylael dsannteurd eshte rsredo iulnt I cedtawh het eabvo idvo.e

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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Tish si a ogdo ticpreu fo na rpnteieexm inhwosg is:ht


gcnneoOe lveuom ,26 gaesp 922221–21 70)0(2

 +10  (nbme22#11)
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I gto sthi one iav ersopcs of almnitiein.o Nto urse owh uoy aer eosudpps ot reebmmer lal ahtt .sith

 +1  (nbme22#5)
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Tish onetsiqu oscnudfe me cb I tutohhg plaoeiemdr dcuol not cosrs eht BBB adn trfroheee dluco otn seauc raoyipsrter idsosrpnee md-(upoiio gmiosna ta eht mbesartni tsursle in yCrNrstoSpei/ra spdoien,rse ).1 utB rd.xx@ is retrcoc ni ntiong atth ↓ RR and SNC psendoirse in the tP luhsod lcla for an mi-iuodop gnatoatisn earrht tnah lhetbaohcn mnimtiecci(lo)oh to rttae spn.noitictao

  1. h.g0.tetpsi.osiltcuxaobsatgiayqiel.79rp/ret2cond?/ss6laa/5:ae5=hprsh
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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oGjnla tssesrse hte roBdsa gignvi eth lkeaeuim tnueosqsi aawy bdeas no the gae venig ni eth uetoisnq ss.tem

LAL = 40-1

ALM = 935;1- -4905

LLC = 6+0

MCL = 4905-


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!!! +1

 +6  (nbme21#23)
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20% luinbma is PHYotEicnR adn sacues dwangri fo filud otu fo teh smrettitiun dna iotn eth olbd.o

i"lAnumb )Huamn( 2%0 is ntaiiedcd ni eht rycemgeen tnemetart fo eohioyamvpl twih or tuhowit hk.soc sIt itesnecvfsefe ni rveinegsr olmvoheayip nededps glleary ponu tsi bialtiy to rdwa alttetiiisnr fidul tino eth iaorunc.iltc It is omts fcetvefie ni teatpnis woh rae wlle r.teadhyd When oodbl velumo icdefit si the esltur of garho,remhe lptboaeicm der bodol celsl ro ohwle bodol duhols eb draseteidmni as likcyuq sa spie"lsob.


 +5  (nbme21#20)
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tsih is a slccsia tcpinedsori of reptinstes lurMaleni ctdu nremdsoy


due to klac of IFM itamto(nu in het egen ahtt aesmk M)FI → prcesetsnei fo eht iMnelrlau utdc → reuust adn naolifalp utbe preestn ni a YX amel /w estset i(ylyltapc d).yhicorctrp

 +3  (nbme21#5)
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e'erHs na ecltexeln egaim mrfo SBAOMS if elpepo aer ghvnai clityfdiuf uivgsinzali :thsi pcW//R/mVuagm:hQmot.h/tsmri

lovebug  very helpful! thanks! +

 +3  (nbme21#2)
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Asl,o I kinth hawt is yke si ot erlizae htta gijnunir CN X 'eonarevt(ariipt NC X j)y'unri oesd ton ldea ot rhmadapgi ,sslpyraia lnyo neprihc erenv uijnyr ouwdl do th.ta


,rurrohFemte hte reoth noipost (yiiccrsdia'ton xrn to frn'esolvaue nad 'ornadieny octrpree )tfdece' ear for taianlngm pe,tymreriahh TON naubel to hbatre oaotnnusl.yeps

Subcomments ...

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hTe esfeftc of ecsxes hytdrio hemor:on dmeatettp sonracmetopy HST esponrsi,usp csraeeni in bhot T4 dna free ,4T nda lnaomr .GBT Noet ahtt het tieuqosn eontd’s evne ingeh no BGT dna is aosl uknilyel ot on eht lare

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

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gniSttlip si na ummrtaei sfeened mnacimhse etonf oyelpmed by atsnteip ihwt noreirdelb synelotirpa dsie.dror neWh isltntp,gi a porsne laifs ot ees othser sa pacbale fo hignva tboh eospitvi nad tanviege sai;uetqli at yan eigvn emti, tsi’ lal or not.gihn

d_holles  Got this one wrong -- thought it was acting out. +1  

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eortkS ahrrtiaecdzce by felt aihseiremps dna irthg 1C2N spayl. deCsosr fgndsini maen a mieansrbt s.eloin tgihR laarilt(pie)s ten,ogu dd-etelfis tlno(er)ctalara assewnek samen the nietxig rthig aopgyohssll enevr ash eneb eaedfcft thnw(ii the hgrti dleul)am. C is the ridapym ewreh eth cicsnopotarli rttac rnus ot rnctloo csmuesl or(pri ot eth usdeantsi)co. Tihs si kownn as eth ladmei elmyualrd omnysrde or jenDiree eds.ymnro

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. +9  
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. +2  

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rAi nad lfuid = .yooeuaohmtxnrhpdr fI ahtt ilduf si blodo sp(/ )isgtbn,ab ’ist a eau.htohomnxpeorm kcaL fo anlsmiadiet ihtfs ntdsecaii ttha ts’i ton rnued nniest.o

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. +6  
groovygrinch  Also if there was tension, there would be a mediastinal shift. +3  
t123  Also the gastric bubble is elevated, actually suggesting lower pressure. Mediastinum shifts require more pressure, but the gastric bubble confirms it. +  
myoclonictonicbionic  I was overthinking and thought they're implying that the stomach bubble is the air-food level that was seen on the Xray. +  

submitted by wired-in(62),
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enicaeatnMn esod rumfola si Css( × Cl × t)ua ÷ F

eewhr Css si -teataytseds atgter alapsm of ,urgd lC si ccaarle,ne uat si asdgeo itlaernv ;& F is t.liyaibivlobiaa

hitNree egsoad ialtnevr orn yblbiaoilvtaiai is i,gevn so gngiiron ehots m;p&a nuglpigg in eth nebmrsu ce(uarfl to teoncvr untsi to dmk/ga:/yg)

2(=1 umLg/ × 1 m010g/0 u)g × 90.0( h/k/Lgr × 0001 m/1L L × 24 hr/1 )dya
= .5922 /gmygadk/

hch.i.w. 'tsni yan fo teh waerns shcceoi tdl.ies eyhT smut vahe derondu .009 /hLr/gk ot .10 hk//,grL dan odgni so gisev aylxcte 828. /agmy/gdk icoche( C)

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +56  
hyoid  ^^^^^ +11  
seagull math never worked either. I also just chose the closest number. also, screw this question author for doing that. +7  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +15  
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 +1  
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 +2  
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 +1  
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 +12  
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 ghuhtot of sith as omqssuau lcel mainorcca of eth nugl niucags ncrseaide HrTPP dan e.apilhmecyrca

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 +17  

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How si ihst het rwnsea if hetre si no ifalmy risyoht fo creneurtr ectusrfra? I htuthgo noogisseeset eiefcamptr swa uomoltsaa ?nmtodani

seagull  Exactly!! it's an autosomal dominate disease! +7  
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(841),
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asW it tjsu ,em ro did gea" at onste in seyr"a apprea IHGRT oabve het ubrnme fo tepa,isnt atrher tnha hte mne.a ihWhc nfousced em orf a odgo 3 m.isenut

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) +6  
mellowpenguins  Are you serious. NBME strikes again with shitty formatting. +6  
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? +  
thomasburton  Think the number of people in that group +4  
paulkarr  Yup...was looking at it for a good 3 min before just doing the "fuck's gotta be 99" +3  
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(179),
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yWh on tsagnwe?i I eamn I teg sEcasyt is obalrybp eth udrg of chocei eroebf an all ginth ecdan ayrtp )lo(l tub d'ton rdnnsteadu wyh erthe olduw be oldc etesxeimrti nad on witesgan newh is FA ti ssay iymthprerhea adn or??a?dhb?

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. +7  
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. +9  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +17  
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 :) +3  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +  
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."( +  

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The ayw I ghothut btoau hist quonites aws tath ni MM eterh si a TNO fo oanieidbst bgine ,daem so teh DJV getmesn si bnige orebnk e//sgaprearrdcledneetu ynam sitme nad sah bnee eredtnsoh ot bk1..5 As ofr the T ls,eCl that genrio stin’ begin udse isn(ec theer si on lnolca enipnoasx or nsctie)eol so tsi’ lslit ogt het lflu bk6 lhetgn htnc.oeduu

d_holles  T cells still undergo VDJ recombination to form their TCRs. +2  

submitted by seagull(1182),
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otu fo ys,iiocrtu ohw may poepel wekn ?ihst n(tdo be syh to asy yuo did or tn?did)

yM eptroyv ecatoidun tdn'di angirni this ni .em

johnthurtjr  I did not +1  
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 +12  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +19  
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?" +6  
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 +17  
drschmoctor  Is it biochemistry? Then I do not know it. +3  
snoochi95  hell no brother +  
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 +1  
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 +  
surfacegomd  no clue +  

submitted by armymed88(48),
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eoHegtmnpdypi liseosn eferr ot fhaelAs- st,sop NSC nilsoes yeklli saaamhrmto . ST asol tacsaidsoe whti ei.zsseru

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"? +3  
d_holles  @fcambridge variable expressivity of TSC allows for many different phenotypes. +1  

submitted by pppro(22),
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Pantite ash BH.P eGiv pahal neo nsagontati to recdue oothms meulsc oncnoictatr adn ereveil ciityufdfl

d_holles  lol i thought it was some kind of urinary retention problem and put H. +12  
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" +11  
drzed  Even if he was urinating too much, anticholinergics are contraindicated in the elderly (Beers criteria) +2  
pathogen7  @drzed tI mean techinically alpha-1 blockers are on the Criteria too ... +1  

submitted by niboonsh(299),
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t.?ywtwocztc=ups//tDeob4muw-2:vHuhahQ/ww.vo fi ru lyaz elik m,e sith si a oodg rhrsrfeee dveio

d_holles  Amazing video dude. Somehow never learned this in neuro lol. +5  
aag  Awesome video! Is this why you can give Mg2+ to eclampsia patients, because if so, mind goddamn blown. +1  

submitted by yo(60),
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I ujst newk hatt erpms ende ,tfusrceo otn rseu tahw adseeis pcsreos tihs si .ghthuo eH aws tyeptr nlmaor so 5a aretusdcea edton's esretpn ielk t.hta I at'snw usre if tereh saw nay dod sue fo het rohte ras.wsen erhe si a iln.k eFel rfee ot .axdepn


sueFcotr ksmae up 99% of eth ciuerndg asgur epntser ni smeen. shiT usrga is dperoucd ni teh aemlsin .eivslces diiiDshnme levesl fo fescutro hvea bene wnosh ot arlplale andgonre edfnycecii dan hte tsteotsroene e.vlel lFiwoongl otreotstense ,hyptrea hte lvele of etscufor tlgihehaeo eth esfucotr sett si ton aptr fo a iotneru neesm asiynas,l ti is usflue in sasec fo mpaozsraeio enaecs(b of mpsre ni e)ems.n In sarooiezmpa dyasoenrc to teh becensa of cssevlei ro if erthe is an onutr,tbcois on tcrusefo is net.srpe In urlaitcets ioes,aormzpa srutfceo is Wehn rpzoeasioma nad owl sneem loevmu itssxe, eht frtocues tset hsoldu alos be nde,o on a teaoajletpcsu eiurn seamlp to ckehc ofr dgraeetorr auoientc.laj Tshi ourccs newh eht cauetejla geos noit hte ddlreba tidanse of uto het uee.harrt Th rrcdepoeu rfo igneentrdim eht atuomn of rtsocefu ni neems elvsniov hantegi enesm ni a ogrsnt daic in hte rensepce of nc.lorisroe oFrtescu esvig a red olroc ieo(lSfonvf onaiec)tr nda yam eb rade ni a r.oeptomeht ehT lrnoam gareeva is gLd1/53m fstucroe.

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 +2  
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.... +  

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teh anrfict rcecudor 16 rsh ag,o rfom 2sh4r-21 afetr the trfnaic rtehe lwil eb deR euro.snN

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(1000),
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eieofKcrsok-narkWf rmndes.oy o'Dnt evah ot eb an occhlaoil to tge i,hst stju asuluyl is derelta ot slmohacloi / niahetim ydn.eicecif

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 +6  
lilmonkey  She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment. +  
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 +4  

submitted by lamhtu(89),
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endNeig rih"ehg naeont"srctiocn of eht B6 rfo enmyze tiviatyc si eronaht awy fo ysniga mK si greihh ecins emro is edrqirue fro 12/ mavx yitv.iatc rascdnIee Km uelvas tuelsr in /1Km gineb rlslaem orsel(c ot 0 on hte x-xas,)i chwih si tesnrdoedmta ni rewnas ccieoh .B

A oan"l"mr yezmen tviycati in het neeescrp of hhgrie 6B nnocnesctarito msean ttah mVax is ont nncggha,i tbu mK si.

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(90),
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I nthki the conpcet yet’reh gitsten si het sdieecarn GTB lleves in ycrga,npen adn otn sujt soepyhdyrimtrhi ni nel.raeg

hnWe eneicgsrn rfo y,ymhypepd/rshtiohiro STH lvelse are YWAASL typaefnleelrir cdhkece sebacue yeth are remo ievnsiset to minute eicsefderfn ni /4.TT3 nfOte tiesm STH vllees cna smrnodattee a canhge nvee enhw T/3T4 lvlese are in eht iccsulainbl Teh lnyo enexipoct ot siht udlwo eb in regaypnnc (dan I susge emyba levir uri?alfe I obdut hety olwud aks this ghu.ot)h higH eosrngte lsvlee ptsevenr eht lrvie rmof kbarieng odnw GB,T ladgnie ot rdaesenci GTB sllvee ni het merus. shTi dinsb ot efre T,4 idrnesaecg het tmoaun of ileavalab efre .4T sA a cteraypnsomo s,emmnihca TSH vesell era ltnniesatyr esiacernd and hte RTEA fo T4 nudcrtopoi is nicaedsre ot rinhesple anslbeie eref T4 slevl.e vHoerew het LTTOA numtao of 4T is enrdsieca.

Teh oneitusq si singak owh to firnmco erhdisyrythmpio ni a aretgnpn waomn -;t-&g uoy nede ot ckech EREF 4T levels (aebcuse htey shdoul be anlorm edu ot ysoetrapcnom n)s.sropee oYu onnatc ccehk TSH ayllus(u ealedtve in recganpny to mctpesaeno orf deancries TB),G dan oyu cnnota eckhc atotl 4T eslevl l(ilw be uYo otg eth warsne ihrgt hterie way but I nhtik isht si a rednffeti giosennar hrtwo icnngiedsr,o ceeusab heyt can ask isth nteccpo ni roeht ttnscoex of re,yiegr-hesstnopm adn if heyt lstdie S”H“T sa na aserwn oichec atth uwdol eb ntrce.iocr

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +5  
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 +  

submitted by niboonsh(299),
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heT qbsleiou od hte potepiso cionat fo tiehr emn.a ferrInio eqiulbo evsmo het eye UP adn OTU ne(ti,xroot lainov,tee uicoBntA)d. cneiS the siutoeqn ssay atth rehet is a carutfer noivgvlni eth barltio flo,ro tath ltlaayoumicta uelsr otu D d(ailme rtcues and iiefrorn ,qi)oulbe legiavn eth lyon gcallio swnrae to be the rienirfo tsruec nad efirniro lqi.beou HuW/:y/hI.atl/Imwoh=wtkcWettcWbEDKwosvp?uw.

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

submitted by hayayah(1000),
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owelr oaaaa:rnnitpqud alapteri eionls

vs purep atnrnpiuaadqao = proeatml sienol

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. +4  
d_holles  So you're saying that there's two crosses, making it ipsilateral? @mci +  

submitted by neonem(527),
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hiTs si a taoputrpsm mdoo ebatciusn,dr a erytpt mmocon ersidord ttah sah ot evah na noest iitwhn 4 wesek fo vleryied ot be retmde as hucs. usPaompttr eusbl is hte somt dm,il iwth a 5%85-0 eciindecn tera re(p AF 81,2)0 syulaul eevlorss wnthii 10 ysad and rtaettmen si noly peivsoturp tbu ened ot wolp-ulfo ot ssseas rof oslbseip umtoatsppr deis.enrpso pPtosrmuat pneosedris = 5%01-1 er,at rccizeaeratdh by sdsredeep f,atcfe txy,aeni opro cocieatrtnnon fro eterrag athn 2 wskee and sdene to eb areedtt /w BTC + IS.RS I tnhki het oiunestq si eigntgt at ncnegsrie orf siht dan a nlttpaeolyi rome ralpmiocbet opoicnc,tlami otstppumar ch.syiossp

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. +9  
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(198),
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thsi si a lciaecvr anplis dcor eoscnt.i the eenautc lfciucauss si icttan )(UE iratvonib dna nioeopirpcptor, ubt teh ehwti secniot si het earcilg uuisacsflc E)L( dan si I kntih hte taarell pirootn that si envune si usjt tuftrcia.t/aarlna

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. +3  
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 +10  
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 +1  

submitted by sinforslide(41),
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lMae aniltren tanlieagi &-;tg tInatc RSY , t,etses dan setrsnee.otto

No meflae tinearln laneaigti -t;&g sPcneeer fo MIF almrln(itiuaen m)roeonh dan nciatt ireStol lelc

Faemle terlenax ilnagteia -t;&g No ngeanord r,tnsepe hwhci si ereidqur fro aelm netxlera iaglnaeti f.rmotaoni

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. +9  
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 +1  

submitted by sinforslide(41),
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aeMl tinnarel eigntilaa t&g;- nttIac YRS , stts,ee adn trsoeo.ntetse

No mafele lanernit gliaaeint ;&-tg ensPrece of MFI nra(imaeniltlu mhe)noor and tcnati otlrSie llce tn.foucin

emaelF tnrlxeae aliegtian &;-gt No gnradoen prsten,e wihhc is ideureqr for mael nexetlra algitneai tmo.norafi

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. +9  
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 +1  

submitted by sinforslide(41),
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leMa nrtilena gltiaiane g;t-& Inctta YRS , es,etts nad .eerteotsstno

oN leamfe rtnianle aaetilngi -g;&t rsceePne of IFM elrla(nanmuiit )reomnoh nad tntica eiSlrot lcel n.citfoun

eFmeal eexltnar ailintaeg ;gt-& oN rodenang ,eesnrpt ihwch is euirrqed orf meal rneetlxa ntaailegi t.mirofnao

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. +9  
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 +1