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 +1  (nbme21#3)

APOCRINE vs. ECCRINE

Your skin has two types of sweat glands: eccrine and apocrine. Eccrine glands occur over most of your body and open directly onto the surface of your skin. Apocrine glands open into the hair follicle, leading to the surface of the skin. Apocrine glands develop in areas abundant in hair follicles, such as on your scalp, armpits and groin.

Ref: https://www.mayoclinic.org/diseases-conditions/hyperhidrosis/multimedia/sweat-glands/img-20007980


 +1  (nbme20#3)

Imo, this answer choice is wrong, there is no problem in the process of collagen "synthesis" per se. The issue is with excessive synthesis and disorganized deposition. Not an 'abnormal synthetic process' - as would be in EDS, MF, Menkes, etc.

whoissaad  Exactly my reasoning for not choosing collagen "synthesis"

 +3  (nbme20#49)

BBs work by decreasing cAMP and Ca2+ thereby slowing SAN & AVN activity. This prolongs phase 4 of depolarization. Therefore, they are known to increase the duration of diastole (predominantly) causing both a rise in heart coronary perfusion and reduction in heart rate.


 +0  (nbme24#40)

Did anyone else wonder WHAT "PULMONARY SYMPTOMS" is the question referring to?? There is literally not a single symptom mentioned in the whole vignette. No "crackles heard over both lung fields" are not symptoms. They are signs found by the physician.

Seriously doubting the whole NBME board test writers right now. Do they adequately revise their work? This is not the first technical mistake I realize on the new forms.

nbmehelp  Yup. Looking back its clear what they were trying to get at, but this definitely threw me off when I was taking the test bc I kept rereading the question looking for a specific symptom the pt had that they wanted me to explain.

 +2  (nbme24#23)

WTF is "weakness of plantar dorsiflexion" ????? it's like saying "extension flexion" This is not the only obvious technical mistake in the new NBMEs ...

karthvee  loool
yex  Funny Board!! Yeahhhhh

 +2  (nbme24#40)

Am I the only one who thought, my whole life, that it actually originates from the thyroid but just physically connected to the tongue

nbmehelp  same




Subcomments ...

submitted by neonem(251),

I think metastasis was the best option here because there are multiple malignant neoplasms... primary cancers tend to start as a single mass in the tissue of origin. In the lung, metastases are more common than primary neoplasms.

dbg  I seriously could not figure out whether those white opacities were actual lesions or reflections from the actual picture (flash light) ... mind went all the way maybe this is the shiny pleura so they're going after mesothelioma. smh +1  
dbg  shiny pleura with tiiiiny granulations if you look closely. but obviously was far off +  
et-tu-bromocriptine  "Multiple cannonball lesions" is indicative of a metastatic cancer. I think if they were leaning towards a mesothelioma, they'd show the border/edge of the lung ensheathed by a malignant neoplasm (see image): https://library.med.utah.edu/WebPath/jpeg1/LUNG081.jpg +1  
bullshitusmle  guys something I learned from NBMEs is that if there is a clinical vignette dont even look at the images they give you ,they are all useless and time-consuming +  


submitted by neonem(251),

I think metastasis was the best option here because there are multiple malignant neoplasms... primary cancers tend to start as a single mass in the tissue of origin. In the lung, metastases are more common than primary neoplasms.

dbg  I seriously could not figure out whether those white opacities were actual lesions or reflections from the actual picture (flash light) ... mind went all the way maybe this is the shiny pleura so they're going after mesothelioma. smh +1  
dbg  shiny pleura with tiiiiny granulations if you look closely. but obviously was far off +  
et-tu-bromocriptine  "Multiple cannonball lesions" is indicative of a metastatic cancer. I think if they were leaning towards a mesothelioma, they'd show the border/edge of the lung ensheathed by a malignant neoplasm (see image): https://library.med.utah.edu/WebPath/jpeg1/LUNG081.jpg +1  
bullshitusmle  guys something I learned from NBMEs is that if there is a clinical vignette dont even look at the images they give you ,they are all useless and time-consuming +  


submitted by lnsetick(33),
  • APocrine = your armpits smell like an APE
  • ceRUMen = there’s no ROOM in your ears since they’re full of wax
  • EC-CRYne = when you ECercise, your pores are CRYing
  • SEBaceous = SEBum is SEEPing out of your pores
hungrybox  as an ape i'm offended +9  
dr.xx  stop being an ape. evolutionize! +5  
dbg  as a creationist i'm offended +  
maxillarythirdmolar  Also, Tarsal/Meibomian glands are found along the rims of the eyelid and produce meibum +  


submitted by neonem(251),

Sounds like a case of Li-Fraumeni syndrome - since p53 is a tumor suppressor for a bunch of cell types, mutations in this gene (as in LFS) result in a myriad of familial tumor types.

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 +3  
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. +3  
dbg  ^ this guy cracked the code. nbme ur doomed. +1  
cienfuegos  @privatejoker: I feel the pain. Quick FYI: UW includes brain in the associated tumors. +1  
hyperfukus  we can just make her thing SBBLA and hopefully never get this wrong again +  


submitted by hpsauce(0),

I believe this is Caplan Syndrome (bronchogenic carcinoma + rheumatoid arthritis). Only flaw to that is that the pulmonary findings don't perfectly represent pneumoconioses.

dbg  it's just bronchogenic ca, type of adenoca, which is classically associated with 'hypertrophic osteoarthropathy' +  
woodenspooninmymouth  To get it for the test, remember that lung adenocarcinoma is associated with clubbing. Mechanistically, this woman probably had RA. Then she was exposed to asbestos. The asbestos in the context of RA lead to caplan syndrome. The asbestos also triggered her bronchogenic carcinoma. +  
step1soon  Then why isnt Rheumatoid Arthritis right? what comes first? bronchogenic carcinoma or rheumatoid arthritis? +  


Syringomyelia normally presents with bi-lateral loss of pain/temp in a cape like distribution due to damage of the anterior white commisures of the Spino-Thalamic Tract.

This person also has wasting of the small muscles of her hand, which is due to Syrinx expansion causing damage to LMNs of the anterior horn (from CNS Pathoma)

dbg  you're talented, bball and now this +2  


submitted by youssefa(15),

From Faid 2019 new figure: IGF-1 mainly functions as an anabolic hormone on muscles and bones (pretty much like insulin-> decreases serum glucose). GH acts separately by promoting insulin resistance (increasing serum glucose). Therefore, IGF-1 is not the answer. If GH was among the answers it would have got really confusing.

charcot_bouchard  Can anyone take a little time to curse on that daughter? +1  
dbg  Sure, charcot. Just wished on her to get a couple of charcots (the triad, your aneuryms, marie tooth, etc). +  
noorahsaahir  Charcot_bouchard and dbg best comments .... 🤣🤣🤣🤣🤣 +  


submitted by hayayah(394),

With chronic vomiting, you lose electrolytes and a lot of acid. It triggers metabolic alkalosis which is why all the serum values are low (or on the lower end of the normal range) except for bicarbonate.

ergogenic22  decreased K+ (from increased RAAS due to volume loss) and decreased Cl- (loss of HCl from the stomach), Alkalosis from loss of HCl and thus high bicarb. For this reason high to mid range K is wrong +3  
sbryant6  Wouldn't increased RAAS lead to increased Na+? The answer shows decreased Na+. +1  
sbryant6  Also, remember Bulimia Nervosa is associated with hypokalemia. +  
sugaplum  so the range they gave for K is 3-6? so 3.2 is WNL then? or are we just operating on "it is on the lower end of normal in peds" +1  
dbg  sodium levels in pyloric stenosis vary, nothing really classic, can be high as in this case simply due to hydration, can low in other cases if aldosterone managed to reverse that to the other extreme +  


submitted by strugglebus(69),

Most of the pts values were normal. Drinking wasn't outrageous, LDL was mild, BMI has fine. He did have HTN though. The biggest risk factors are the fact that he had suffered an MI and started suffering severe depression (weight loss/anxiety). Thus, he is more at risk for suicide.

sohaib111  Won't having an MI be a very big risk factor for another one ? And also if they wanted this answer (the anti-depressant), why would they just add that his LDL is inreasing in the last sentence... +3  
dbg  bc they're SOBs and DOBs +2  
doodimoodi  Yeah, recommended LDL in people with previous heart problem is < 100 jeez +  
asingh  It is because of the timeframe of mortality is 2 yrs, everything else will affect later +  


submitted by notadoctor(56),

Analysis of the elastin in the question showed a decreased number of desmosine cross-links. Desmosine is made up of four lysine residues. Therefore abnormal elastin is likely missing lysine necessary for the formation of these desmosine cross-links. Wikipedia article on Desmosine.

dbg  how can i trust you, you aint even a doctor +2  


pKa is pH at which any drug is at its 50% ionized state.

Now we are alk urine i.e inc pH. when pH>pKa it will have two diff path for acidic drug & basic drug.

Acidic drug will inc its elimination (inc ionized form), basic drug will be more absorbed. so we need to know the drug is basic /acidic.

Now if u alk urine its elimination inc. so it have to be acidic. or u can know its a sodi salt of drug with CNS property i.e most like Phenobarbital (Weak acid)

so if pKa of drug is 6---at pH 7 we will start eliminating

but if pKa is 0 we need to raise pH of urine at 11 to start eliminating.at that point prev drug (pKa=6) would be totally out of system.

thats why A is the right ans (pKa = 6)

charcot_bouchard  Correction : Not 0. i means if pKa is 10 +1  
charcot_bouchard  2nd update : cont to learn school grade chem. if pKa > 7 it is base. and if pKa is < 7 it is acid. Since we established the drug have to be a weak acid pKa cant be more than 7. +  
dbg  thanks, but Pka and PH are not at all the same thing +  


submitted by famylife(37),

"Thyroglossal duct cysts most often present with a palpable asymptomatic midline neck mass usually below [65% of the time] the level of the hyoid bone."

"The thyroglossal tract arises from the foramen cecum at the junction of the anterior two-thirds and posterior one-third of the tongue."

https://en.wikipedia.org/wiki/Thyroglossal_cyst

dbg  Am I the only one who thought, my whole life, that it actually originates from the thyroid but just physically connected to the tongue +5  


submitted by lsmarshall(191),

Androgen Insensitivity Syndrome - Defect in androgen receptor resulting in normal-appearing female (46,XY DSD). Functioning testes causes increased testosterone at puberty, which is converted to estrogen peripherally, giving female secondary sexual characteristics (female external genitalia). Lack of androgen receptor function leads to absent or scant axillary and pubic hair. Patients have rudimentary vagina, but uterus and fallopian tubes absent.

Androgen insensitivity syndrome is the answer but you might have considered Müllerian agenesis (Mayer-Rokitansky- Küster-Hauser syndrome).

Mullerian agenesis will have normal hormone levels and may present as 1° amenorrhea (due to a lack of uterine development) in females with fully developed 2° sexual characteristics (functional ovaries). Hair development is normal as well. Patients also have normal height.

Seems like this question did not give us much to distinguish besides height and tanner stage 1 pubic/axillary hair.

dbg  100% agreed. Mullerian agenesis was on my mind too. The full breast development kept me fixed at this dx. Did not think how high testosterone at this age and insensitivity would push towards peripheral conversion to estrogen and hence breast development. Thanks. +