NBME Answers : dr_jan

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submitted by yotsubato(1030),

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yhW si ish oiibdL ?alormn 'tsI totllya epdcxtee htat eh mya vahe deucdre idlboi rtfae ihs ewfi iedd 2 yaers aog morf moes ohleirrb glnroedop lsn.slei

nala_ula perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +

nala_ula At least, that's the way I saw it. +

home_run_ball "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +

thisisfine The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1

btl_nyc It also says there are no signs of depression, which would cause the low libido after his wife died. +

temmy two years is a enough time to mourn...just saying +

temmy thisisfine, it makes absolute sense. That is the same way i saw it +

dr_jan_itor He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +

submitted by sympathetikey(1354),

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Ieiorrnf quoeibl = pslhe oyu ookl pu ;& n.i

soAl, hyte adsi oorfl of het ,otrib os it maesk esens htat hte einrirfo eusmslc dwluo gdadema.

sahusema I know you're right. I was just so uncomfortable picking an answer with "inferior rectus" because damage to the inferior rectus does nothing to explain the clinical findings of impaired upward gaze. Unless the muscle is physically stuck and can't relax or something +6

emmy2k21 Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :( +2

dr_jan_itor in the last sentence it asks you to assume an "entrapment", so it is actually the inferior rectus which is the cause of the upward gaze palsy. The entrapped muscle is functionally trapped in it's shortened position, thereby not allowing the orbit to gaze upward. +14

chandlerbas bam! dr_jan_itor just cleaned up that confusion +1

submitted by hayayah(1076),

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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. +

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 g.liller@yahoo.com(28),

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hungrybox Also, the yeast form of Candida is gram (+) +30

dr_jan_itor I got thrown off by the part where they said "ovoid" and thought they were implying a cigar shape. I chose sporothrix for the morphology in spite of knowing that it clincally made no sense. +1

lilmonkey I chose S. aureus before reading the question (looks like b-hemolysis). Then I saw "budding organisms" and picked the correct one. +

the_enigma28 I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +

lowyield cryptococcus also doesn't take up gram stain because the shell is too thiqq +2

submitted by tissue creep(113),

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meningitis More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12

nala_ula I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +2

namira dont be shocked! me too! exito! +2

niboonsh Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +21

dr_jan_itor I was thinking that its Murine typhus transmitted by fleas +

monique I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2

jakeperalta Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +

almondbreeze UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +

lovebug FA2019, page 167 RNA virusesy. +

lovebug Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1

beto it is chikungunya->fever, polyarthralgia, diffuse macular rash, dengue has retro-orbital pain mostly +1

submitted by imaginarybanana(29),

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aesalmon Questions like this usually hinge on asking if you're going to follow the rules or not though, obviously the one asking her to lie and say she was her sister is wrong, but the correct answer is obviously breaking the hospice center's "policy" - presumably if the physician is sending her to hospice then they don't work there so why would the Dr. be able to just tell her its fine? +5

hungrybox Yeah, I got this one wrong with the same logic as you, aesalmon. +1

emmy2k21 I genuinely interpreted this question as though the two women were in a relationship because of the quotes "my close friend". I figured significant others would be allowed to visit simply. Ha seems like I'm the only one who read too far in between the lines! +8

dr_jan_itor @emmy2k21 I also thought the quotes implied a lesbian relationship and that the patient was afraid to share this (they grew up at a time when it was heavily stigmatized). So i was thinking, of course you and your "special friend" can stay together. I know this is not just a phase +8

et-tu-bromocriptine Anything particularly wrong with A (Don't worry. I'll call you right away...")? It seemed like the most professional yet considerate answer choice. Are we supposed to imply that they're partners based on those quotation marks around "close friend"? Because otherwise it seems like too casual and less professional than A, almost as if it's breaking policy. +5

lilmonkey I can swear that I saw this exact same question in UWORLD before. The only reason I got it right this time. +1

docshrek @lilmonkey can you please give the QID for the UWorld question? +2

jakeperalta Can someone explain to me why following hospital policy is the wrong answer? I'm so lost.And essentially how is this option any different from the last option where he asks her to say its her sister? Both go against hospital policy. Would greatly appreciate some insight yall. +

drschmoctor @jakeperalta Following the hospital policy is wrong because it would be cruel and unnecessarily rigid to deny a dying woman the comfort of her closest companion. Also, It would be inappropriate to ask the Pt to lie. What's the point of becoming a doctor if you have to follow some BS corporate policy instead of calling the shots and doing right by your patients? +1

peridot Ya kinda dumb that usually NBME usually tells us to never break the rules, yet here it's suddenly ok. But here the reason for this exception is that while only "family" is allowed, a lesbian relationship qualifies the "friend" as family (they just were never officially acknowledged as family/married due to stigma or state laws, which society recognizes today is dumb and outdated). It's a stupid technicality that her significant other isn't allowed to visit as a family member, so while we usually never want to break rules, this scenario follows the "spirit" of the rule. Plus it's a really extreme scenario where the woman is dying and just wants to spend her last moments with her loved one and it would be too cruel to deny someone that. There is no lie involved, which kinda leaves open the chance for the situation to be cleared up if worse comes to worst. This is different from E which is a straight up lie. Hope that helped. +

submitted by usmleuser007(396),

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nCa osenome pseeal naipexl wyh 'atnc cololha eb cotrecr ni hits enttisg?

niboonsh rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018 +12

dr_jan_itor what if the alcoholic just has a concurrent rhinovirus infection ;) +6

lovebug and FA2019 page 538. +

submitted by whossayin(24),

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niboonsh yea it was a dumbass question, whoever is writing these questions is undoubtedly a crazy genius but homeboy (or homegirl...homeperson?) needs a few grammar lessons. +4

yex I agree. We know that it is a teratogen, but how does that question directs you to think about teratogenic effects instead of something physiologic? +5

dr_jan_itor The questions in the NBMEs by default are reject questions. So highly selective to be awful questsions. I am recieving regular heads up that the stems on the real thing lately are like 10-12 lines long. So these questions are not anywhere near like the test. NBME has f'd us good for this particular round of practice forms. +

submitted by hayayah(1076),

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sweetmed Memory T cells live for six months or less in healthy humans (Westera et al., 2013), whereas naive T cells can live for up to nine years +8

whossayin so the bone marrow does not take the role of the thymus? +1

dr_jan_itor @sweetmed, does that mean that if someone loses their thymus, they would develop imunodeficiencies appx 9 years later as the naive T cells have died off? +8

hpsbwz @dr_jan_itor no, because once all of the thymocytes become T-lymphocytes, they are stored in lymphoid organs until they're needed. this is why removal of the thymus in MG does not cause any immune system deficiency. +6

peridot @dr_jan_itor From wiki: "Thymic involution results in a decreased output of naïve T lymphocytes – mature T cells that are tolerant to self antigens, responsive to foreign antigens, but have not yet been stimulated by a foreign substance. In adults, naïve T-cells are hypothesized to be primarily maintained through homeostatic proliferation, or cell division of existing naïve T cells. Though homeostatic proliferation helps sustain TCR even with minimal to nearly absent thymic activity, it does not increase the receptor diversity." +3

submitted by beeip(124),

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hello Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +

yotsubato such a BS question IMO +6

yotsubato such a BS question IMO +

breis I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +5

teetime This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +2

dr_jan_itor Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1

dhkahat yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +

submitted by strugglebus(165),

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home_run_ball ^ Above is partially right: Propranolol is non-selective Beta blocker: Beta1 stimulation causes inc HR, therefore blocking it will dec HR and dec Cardiac output Beta 2 stimulation causes vasodilation, therefore blocking it will CAUSE UNOPPOSED alpha1 activation --> therefore increasing total peripheral resistance. +42

amarousis so why tf do we give beta blockers for hypertension -.- +6

dr_jan_itor I would also add that the patient was previously on an a2 inhibitor (clonidine), which he ran out of. So he is rebounding on that with upregulated a1 receptor activity. Adding labetalol would cause a greater degree of unopposed alpha, increasing tpr +1

llamastep1 @amarousis They are used for hypertension because the hypotensive effect of the reduced CO is greater than that of the effect of the increase of TPR. Cheers. +7

hungrybox @dr_jan_itor Adding labetalol would not cause unopposed α1 because labetalol and carvedilol are α1 blockers in addition to being nonspecific β blockers (great name btw, I love scrubs haha) +2

mw126 Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +

rockodude @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +