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 +0  (nbme21#30)

Everything has been covered already, but here's to the visual learners - it's easy to see the relationship between DHT and testosterone. https://imgur.com/a/M8Y3Fdm

(ignore the whole black versus blue colors...it complicates things and I'm sure I miscolored somewhere).


 +1  (nbme21#38)

Rule of thumb/shortcut

  • Nonserious fungal infections: treat with _conazole
  • Serious fungal infections (eg, immunocompromised patients with disseminated infection): treat with amphotericin B

Additional info

  • The main classes of antifungal medications for usmle include:
  • Polyenes (eg, amphotericin B, nystatin) - Bind to ergosterol molecules in fungal cell membranes, creating pores and causing cell lysis
  • Triazoles (eg, _conazole) - Prevent the synthesis of ergosterol, a component of fungal cell membranes
  • Echinocandins (eg, capsofungin, micafungin) - Inhibit the synthesis of glucan, a polysaccharide component of fungal cell walls
  • Pyrimidines (eg, Flucytosine) - Converted to 5-fluoruracil, which then inhibits fungal RNA and protein synthesis

 +0  (nbme23#30)

Anyone know how to rule out small intestine on this one? I thought the omentum played a role in healing in the abdomen, but clearly I'm missing something here.

what  Small intestine has smooth muscle in the walls which will fibrose on injury
youssefa  So cutting through the intestine will damage the crypts of Lieberkühn which contain stem cells that replace enterocytes/goblet cells (Faid). This lack of regenerative ability will have platelets and inflammatory cells to be recruited in order to mediate healing (which end result is fibrosis) The intestinal wall lacking crypts of Lieberkühn acts pretty much like stable cells (e.g: cardiomyocytes) which cannot be regenerated and so fibrosis ensues (e.g: Scar is always end product after MI)




Subcomments ...

don't be a dick? not really sure what more there is to it. The patient doesn't have any other family so this woman should be considered family

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? +  
hungrybox  Yeah, I got this one wrong with the same logic as you, aesalmon. +  
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! +1  
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 +1  
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. +1  
lilmonkey  I can swear that I saw this exact same question in UWORLD before. The only reason I got it right this time. +  


submitted by burak(7),

Pleural space: Midcavicular line: 6-8th ribs Midaxillary line: 8-10th ribs Paravertebral line: 10-12nd ribs

So physician must insert a needle in 8-10th ribs in midaxillary line; but insertion below the 9th rib still has a risk to damage abdominal organs such as liver. Upper border of 9th rib is fine.

Uw question ID: 844

et-tu-bromocriptine  Visual aid that may seem familiar: https://imgur.com/a/JRrN8XH +1  
burak  thanks! +  


It’s acute alcohol consumption so fatty change more likely. Cellular swelling indicates alcoholic hepatitis which requires chronic alcohol consumption (See FA 2019 pg 385). At least that’s the logic I used to pick fatty change.

seagull  Seems like fatty change would require more than 1 weekend. I choose swelling since it's reversible and seems like something with a quick onset. +11  
nc1992  I think it's just a bad question. It should be "on weekends" +5  
uslme123  https://webpath.med.utah.edu/LIVEHTML/LIVER145.html +1  
uslme123  So his hepatocytes aren't dying ( ballon degeneration ) vs just damaged/increased FA synthesis due to increased NADH/citrate +  
sympathetikey  @seagull I agree! +  
et-tu-bromocriptine  It's not in pathoma, but I have it written in (so he or Dr. Ryan may have mentioned it) - Alcoholic hepatitis is generally seen in binge drinkers WITH A LONG HISTORY OF CONSUMPTION. +  
linwanrun1357  Do NOT think the answer of this question is right. Cell swelling make more sense! +  


submitted by youssefa(17),

Wouldn't acute alcohol consumption even in moderate amount cause reversible hepatic cellular injury characterized by cellular ballooning? It should be the right answer unless the question stem means "Weekends"

hello  No. The order of liver damage due to alcohol is: fatty changes --> cellular swelling (cellular balooning) --> necrosis. This Q stem states to the patient consumed large amount of alcohol on a weekend -- he has acutely drank a large amount of alcohol on one weekend --> this corresponds with fatty changes +  
et-tu-bromocriptine  It's not in pathoma, but I have it written in (so he or Dr. Ryan may have mentioned it) - Alcoholic hepatitis is generally seen in binge drinkers WITH A LONG HISTORY OF CONSUMPTION. +  
krisgsxr600  Its kind of in pathoma Chapter 1, "free radical Injury", Section 2 "examples of free radical injury" goes over how free radicals (caused by drinking) lead to fat accumulation +  


submitted by aesalmon(35),

Splenectomy = more susceptible to encapsulated organisms

I put E. coli as its encapsulated but that wasn't the most right answer I guess?

pippylongstock  This question is asking about the ‘S’ of FA Mnemonic for S. Pneumonia “MOPS”. Strep pneumo is the most common cause of sepsis in adults. +1  
emmy2k21  MOPS stands for meningitis, otitis, pneumonia, and SINUSITIS. It doesn't stand for sepsis. My guess as well is which is "more correct". It's about being able to identify encapsulated organisms and the spleen's role in immunity. Ha I chose E coli as well. +1  
et-tu-bromocriptine  emmy2k21 is correct, the S is for sinusitis. I was between E.coli & Strep Pneumo, but then recalled Sketchy putting the sickle on the 'encapsulated' knight in the Strep Pneumo video; Strep Pneumo is more associated with infecting sickle cell "functionally asplenic" patients. +  


submitted by enbeemee(4),

what are the other labeled structures? i can discern the parietal and chief cells, but not the others...

hyperfukus  what is A? +  
et-tu-bromocriptine  According to this source, they're mucous neck cells (secrete acidic fluid containing mucin); compare this with mucus produced by surface mucous cells, which is alkaline. http://www.siumed.edu/~dking2/erg/GI082b.htm +1  
hyperfukus  i gosh i see now! thanks so much :) so if it's Pink=Parietal but not granules got it thank you :) +  


submitted by hungrybox(232),

My impression of Amphotericin B is that it's the BIG GUNS. It straight up attacks the sterols in the fungi plasma membrane.

Meanwhile lil bitch drugs like -azoles just inhibit sterol synthesis. (-terbinafine X lanosterol, -azoles X ergosterol)

Fungins X cell wall synthesis, flucytosine X nucleic acid synthesis.

et-tu-bromocriptine  Rule of thumb/shortcut: Nonserious fungal infections: treat with _conazole Serious fungal infection (eg, immunocompromised patients with disseminated infection): treat with amphotericin B Additional info The main classes of antifungal medications for usmle include: Polyenes (eg, amphotericin B, nystatin) - Bind to ergosterol molecules in fungal cell membranes, creating pores and causing cell lysis Triazoles (eg, _conazole) - Prevent the synthesis of ergosterol, a component of fungal cell membranes Echinocandins (eg, capsofungin, micafungin) - Inhibit the synthesis of glucan, a polysaccharide component of fungal cell walls Pyrimidines (eg, Flucytosine) - Converted to 5-fluoruracil, which then inhibits fungal RNA and protein synthesis +1  
et-tu-bromocriptine  Ripppp the formatting, but hopefully the idea gets across +  
et-tu-bromocriptine  Fixed it, see comment! +  


submitted by hungrybox(232),

My impression of Amphotericin B is that it's the BIG GUNS. It straight up attacks the sterols in the fungi plasma membrane.

Meanwhile lil bitch drugs like -azoles just inhibit sterol synthesis. (-terbinafine X lanosterol, -azoles X ergosterol)

Fungins X cell wall synthesis, flucytosine X nucleic acid synthesis.

et-tu-bromocriptine  Rule of thumb/shortcut: Nonserious fungal infections: treat with _conazole Serious fungal infection (eg, immunocompromised patients with disseminated infection): treat with amphotericin B Additional info The main classes of antifungal medications for usmle include: Polyenes (eg, amphotericin B, nystatin) - Bind to ergosterol molecules in fungal cell membranes, creating pores and causing cell lysis Triazoles (eg, _conazole) - Prevent the synthesis of ergosterol, a component of fungal cell membranes Echinocandins (eg, capsofungin, micafungin) - Inhibit the synthesis of glucan, a polysaccharide component of fungal cell walls Pyrimidines (eg, Flucytosine) - Converted to 5-fluoruracil, which then inhibits fungal RNA and protein synthesis +1  
et-tu-bromocriptine  Ripppp the formatting, but hopefully the idea gets across +  
et-tu-bromocriptine  Fixed it, see comment! +  


submitted by hungrybox(232),

My impression of Amphotericin B is that it's the BIG GUNS. It straight up attacks the sterols in the fungi plasma membrane.

Meanwhile lil bitch drugs like -azoles just inhibit sterol synthesis. (-terbinafine X lanosterol, -azoles X ergosterol)

Fungins X cell wall synthesis, flucytosine X nucleic acid synthesis.

et-tu-bromocriptine  Rule of thumb/shortcut: Nonserious fungal infections: treat with _conazole Serious fungal infection (eg, immunocompromised patients with disseminated infection): treat with amphotericin B Additional info The main classes of antifungal medications for usmle include: Polyenes (eg, amphotericin B, nystatin) - Bind to ergosterol molecules in fungal cell membranes, creating pores and causing cell lysis Triazoles (eg, _conazole) - Prevent the synthesis of ergosterol, a component of fungal cell membranes Echinocandins (eg, capsofungin, micafungin) - Inhibit the synthesis of glucan, a polysaccharide component of fungal cell walls Pyrimidines (eg, Flucytosine) - Converted to 5-fluoruracil, which then inhibits fungal RNA and protein synthesis +1  
et-tu-bromocriptine  Ripppp the formatting, but hopefully the idea gets across +  
et-tu-bromocriptine  Fixed it, see comment! +  


submitted by m-ice(123),

This girl has chronic granulomatous disease, in which the immune system cannot properly form reactive oxygen species needed to kill phagocytosed organisms. This is especially bad when dealing with catalase positive organisms (like Staph), because these organisms already use catalase to break down reactive oxygen species. The most common cause of this condition is a mutation in NADPH oxidase, responsible for the generation of the superoxide radical.

et-tu-bromocriptine  To add on: If neutrophils don't have access to NADPH oxidase, they can still use the bacteria's own hydrogen peroxidase to create ROS and kill the bacteria; however, catalase + organisms will not have this hydrogen peroxidase available (because catalase converts hydrogen peroxidase to O2 and water). So then the neutrophils are screwed and have no way of creating ROS. +1  


submitted by neonem(257),

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 dragon3(4),

I almost picked asking the roommate not to smoke in the apartment, but then I figured that's beyond the scope of the doctor... another person said taking steroids would be too much for now, and I suppose that's because the asthma is well-controlled with her inhaler rn? (that's what I had picked)

sherry  I would say the patient's asthma only got worse after her moving out. So its more allergen-related. Getting rid of the allergen is always better than upgrading medications. +  
et-tu-bromocriptine  Rippp the "don't be a dick" strategy definitely failed me on this one. For some reason, I thought requesting the patient to ask someone else to change their smoking habits would be a tad too much. I can just picture UWorld smacking me with a "Although it is likely that the roommate's cessation of smoking could alleviate the patient's asthma exacerbations, this request would be out of the physician's scope....etc." +6  


submitted by enbeemee(4),

i get why it's hyporeflexia, but why not fibrillations? it's also an LMN sign

et-tu-bromocriptine  Imagine a simple reflex arc: you have an afferent neuron, some interneuron shenanigans, and an efferent neuron (aka LMN neuron). If you damage the LMN, you will get hyporeflexia (due to damaged reflex arc) and fibrillations (because your LMN won't be able to effectively contract muscle on command). However, if you damage the afferent part of the arc, you will still get a damaged reflex arc (hyporeflexia), but your motor neuron will still be able to do its stimulating effectively, so your muscles won't show weak contractions when stimulated by a higher pathway. Kinda confusing but I hope I made it a tad simpler! +2  
eli_medina9  https://imgur.com/1z4OF4l Gonna piggy back off your comment and just post this kaplan image +  


submitted by mousie(83),

A Teen with injection of both conjunctiva = weed could also be abusing other drugs Is 12 years old and four months just too old and too long of a time for it to be impetigo? I narrowed it down to these two and guessed but... I wasn't sure I could eliminate it.

medskool123  I picked impetigo because of the gold stippling... I guess I took that as honey crusted lesions. F*ck NBME. +1  
yotsubato  Huffing gold spray paint. A la the chrome huffers in Mad Max +3  
subclaviansteele  LOL I think that might be what they were going for here. Gold spray paint. +1  
et-tu-bromocriptine  Anyone know what may be causing his weight loss and unwillingness to eat? I thought too much into it and put "mercury poisoning", since I thought the heavy metal's abdominal symptoms may have caused him to not want to eat. ¯_(ツ)_/¯ +  


The key is the free air in the abdominal cavity. Ulcers, especially duodenal ulcers, can perforate into the abdominal cavity. This can cause a pneumoperitoneum (free air under the diaphragm). Not a listed symptom in this question, but this can also cause referred pain to the shoulder by irritating the phrenic nerve. FA 2019 pg 374

et-tu-bromocriptine  To add on to this, anterior* duodenal ulcers tend to perforate (makes sense because closest to the abdominal cavity) whereas posterior duodenal ulcers tend to bleed (due to proximity to the gastroduodenal artery). +1  
smc213  Acute pancreatitis can also occur with a posterior duodenal ulcer rupture. Source: Pathoma +1