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im confused...doesnt the IR make the eye look down so if its trapped then why is upward gaze affected and not downward?
@cjdinurdreamz it does make your eye look down, so since it's trapped in a functionally shorter position you're trapped looking down, not up.
European implies northern european (they even specified the patient was a person of pallor), mediterranean descent is usually implied by country of origin or by straight-out writing 'mediterranean'.
The MCV is normal, thalassemias are microcytic anemias, that hint helps to rule out the thalassemias. However, I got it wrong, not sure why it cannot be a homozygous mutation in the ankyrin gene
@poisonivy, other commenter pointed out it's autosomal dominant so best answer would be heterozygous
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.
At least, that's the way I saw it.
"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
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?
It also says there are no signs of depression, which would cause the low libido after his wife died.
two years is a enough time to mourn...just saying
thisisfine, it makes absolute sense. That is the same way i saw it
He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat)
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
Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :(
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.
bam! dr_jan_itor just cleaned up that confusion
Yeah the negative EtOH screen threw me off
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.
it said broad based gait and nystagmus
She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment.
@ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus."
NBME questions also stereotype the shit out of their patients
Also, the yeast form of Candida is gram (+)
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.
I chose S. aureus before reading the question (looks like b-hemolysis). Then I saw "budding organisms" and picked the correct one.
I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_-
I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_-
cryptococcus also doesn't take up gram stain because the shell is too thiqq
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.
I'm shocked that I found a fellow puerto rican on this site! Good luck on your test!
dont be shocked! me too! exito!
I was thinking that its Murine typhus transmitted by fleas
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.
Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience.
UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika
FA2019, page 167 RNA virusesy.
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. )
it is chikungunya->fever, polyarthralgia, diffuse macular rash, dengue has retro-orbital pain mostly
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?
Yeah, I got this one wrong with the same logic as you, aesalmon.
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!
@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
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.
I can swear that I saw this exact same question in UWORLD before. The only reason I got it right this time.
@lilmonkey can you please give the QID for the UWorld question?
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.
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. P.s:it struck me as a romantic relationship as well, but it doesn't clear my doubt😓😭
@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?
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.
rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018
what if the alcoholic just has a concurrent rhinovirus infection ;)
and FA2019 page 538.
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.
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?
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.
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
so the bone marrow does not take the role of the thymus?
@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?
@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.
@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."
Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods.
such a BS question IMO
such a BS question IMO
I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption..
This isn't right because the bariatric surgery will cure the prediabetes. It's dumping.
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.
yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time?
^ 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.
so why tf do we give beta blockers for hypertension -.-
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
@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.
@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)
Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245
@dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor