NBME Answers : fulminant

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submitted by brethren_md(105), visit this page

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Requires knowing how to calculate an anion gap - look it up. In this case, it is a normal anion gap metabolic acidosis. Know the mneumonics MUDPILES and HARDASS. Renal Tubular acidosis is the only answer choice that is an example of a normal anion metabolic acidosis.

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mousie Anion Gap: Na - (Cl + HCO3) = normally around 10-12 +5

seagull good to know. I keep looking up the urine values but all it said was "varies", then I threw my computer and yelled "does that vary Mother F****ers. I do feel better now. +80

_yeetmasterflex glad I wasn't the only one who got very pissed off at the urine values +4

fulminant_life Usually the first thing I look at is whether or not the Cl- is high. Generally if the Cl- is high its going to be a normal gap +9

henoch schonlein i think they gave you the urine values bc you can calculate the URINE anion gap which is (Na + K - Cl). In this case the Urine Anion Gap is positive (5). Boards and Beyond mentions that a positive UAG is due to Renal Tubular Acidosis Type 1 (inability of alpha intercalated cells to secrete hydrogen ions). just another approach to answer this q +23

270onstep1 Actually diarrhea is the "D" in "HARDASS"(reason why I was stuck between Chron's and RTA). Ended up getting it right with RTA.. +1

talha_s So the reason this is not Crohn's disease is actually what BnB explains in Renal Tubular acidosis video. Anytime there is a Metabolic Acidosis with intact kidney secretion of H+, the URINARY Anion gap (Na+K-Cl) is NEGATIVE. This is because the excess NH4 that is secreted into urine is combined with Cl-. Therefore, in Crohn's disease and Type 2 Renal Tubular Acidosis, the urinary anion gap is NEGATIVE. In this question, the urinary anion gap is POSITIVE so this would be an example of Type 1 RTA because the kidney can not excrete H+. I got it right by chance, definitely did not understand it in this much detail when I was answering it lol +11

ih8payingfordis FA 2019 pg 580 - 581 +

submitted by m-ice(370), visit this page

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This woman has a lot of signs that point toward an intestinal parasitic infection: recent travel to Papua New Guinea, cough and alveolar infiltrates, high eosinophil count, and a stool sample that has a worm in it. Most likely the patient has a Strongyloides infection, as this is the intestinal parasite that shows larva on stool sample. Basically all intestinal parasites can be treated with Bendazole drugs, such as Thiabendazole. Praziquantel would be more appropriate for a worm or liver fluke infection.

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fulminant_life just to add to the explanation above," cutaneous larva currens" is a specific finding for strongyloides. Also the picture they used is the exact same one on wikipedia lol +10

yb_26 they really should add Wikipedia in the list of top-rated review resources with A+ level of recommendation in FA2020))) +12

usmile1 also a side note: cutaneous larva CURRENS is pathognomonic for strongyloides whereas Cutaneous larva MIGRANS is for ancylostoma braziliense or nectar Americanus +7

solgabrielamoreno FA 2019 pg 159 . Bendazoles because worms are bendy. (Treatment for roundworms) Praziquantel is for Cysticercosis (Taenia Solium) and Diphyllobothrium Latum Mefloquine : treats malaria Hydroxycloroquine: treats Malaraia, also RA & Lupus (immunisuppresive & anti-parasite) Dexamethasone: Steroid for inflammation +2

abhishek021196 FA20 says Ivermectin OR Bendazoles for Strogyloides, so in a future question, if Ivermectin is listed, that could be the right answer for this as well. +3

jurrutia When in doubt, pick a bendazole +

submitted by medstruggle(21), visit this page

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Can someone explain why does this patient have hypokalemia?

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colonelred_ Catecholamines activate the Na/K pump, which will drive K inside. +11

trazabone Read online that catachelamines are released following tonic clonic seizures. Besides that, BP of 180/100 could indicate that catecholamines are circulating. +1

fulminant_life This mechanism is why giving albuterol for hyperkalemia works +10

nbmehelp Why does this guy have increased catecholamines tho +

johnson His SNS activity is seriously increased --> increased catecholamines. +1

nbmehelp Why is his SNS activity increased? Is the BP literally the only hint? +

youssefa Alcohol withdrawal creates a hyper- catecholaminergic state + Seizures do that as well. +5

water My best guess is that withdrawal puts the body in a state of stress (same for seizures) and with stress you have release of catecholamine which we'll see in the BP and the hypokalemia. +3

submitted by vshummy(184), visit this page

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So the best i could find was in First Aid 2019 pg 346 under Diabetic Ketoacidosis. The hyperglycemia and hyperkalemia cause an osmotic diuresis so the entire body gets depleted of fluids. Hence why part of the treatment for DKA is IV fluids. You might even rely on that piece of information alone to answer this question, that DKA is treated with IV fluids.

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kbland https://step1.medbullets.com/endocrine/109032/diabetic-ketoacidosis-dka +3

fulminant_life I just dont understand how that is the cause of his altered state of consciousness. Why wouldnt altered affinity of oxygen from HbA1c be correct? A1C has a higher affinity for oxygen so wouldnt that be a better reason for him being unconscious? +8

toupvote HbA1c is more of a chronic process. It is a snapshot of three months. Also, people can have elevated A1c without much impact on their mental status. Other organs are affected sooner and to a greater degree than the brain. DKA is an acute issue. +10

snafull Can somebody please explain why 'Inability of neurons to perform glycolysis' is wrong? +5

johnson Probably because they're sustained on ketones. +6

doodimoodi @snafull glucose is very high in the blood, why would neurons not be able to use it? +3

soph @snafull maybe u are confusing bc DK tissues are unable to use the high glucose as it is unable to enter cells but I dont think thats the case in the neurons? +2

drmomo https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909073/ states its primarily due to acidosis along wth hyperosmolarity. so most relevant answer here would be dehydration +3

drmohandes I thought the high amount of glucose in the blood (osmotic pressure), sucks out the water from the cells. But you also pee out all that glucose and water goes with it. That's why you have to drink and pee a lot.. +10

titanesxvi Neurons are not dependent on insulin, so they are not affected by utilization of glucose (only GLUT4 receptors in the muscle and adipose tissue are insulin dependent) +33

drpatinoire @titanesxvi You really enlightened me! +2

mutteringly I don't make the connection of what titanesxvi said to the question - can someone explain? +1

motherhen @mutteringly it explains why the answer choice "inability of neurons to perform glycolysis" is wrong +2

jbrito718 The real question is does HbA1C even alter O2 affinity? +

submitted by m-ice(370), visit this page

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This question only concerns women in the 50-54 age group. The group has a mean of 246 and standard deviation of 50. Therefore, all those with values greater than 296 are all those above one standard deviation. 2/3 of all values on a normal distribution are within one standard deviation in either direction. Therefore, 1/3 are outside of this in either direction, meaning 1/3 of women have a value less than 196 or greater than 296. If we split that in half to only choose those greater than 296, we get 1/6 women, which is about 16%.

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guillo12 Sorry, but there is not other way that I can understand this? +2

fulminant_life @guillo12 basically 67% fall within 1 sd. That means that 33% are +/- >1sd. So taking only those with above 296, you only look at those >1sd above the mean which is 16.5% . The other 16.5% are those >1sd below the mean. +12

guillo12 Thank you!!! @fulminant_life +

submitted by tea-cats-biscuits(273), visit this page

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You know it’s an enveloped virus since it doesn’t hold up to acid or being dried. You know it causes a fever and a cough, while affecting the larynx. Only virus category that fits all that info is the coronavirus (causes SARS) from that list.

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zelderonmorningstar EBV doesn’t cause fever and cough? +1

zelderonmorningstar Wow, just checked First Aid and it doesn’t list “cough” as a symptom of EBV. +4

drdoom EBV is not a “respiratory virus”; it’s a *B cell virus*. Even though you might associate it with the “upper respiratory tract” (=kissing disease), it doesn’t cause respiratory inflammation since that’s not its trope. B cells are its trope! That’s why EBV is implicated in Burkitt Lymphoma, hairy leukoplakia and other blood cancers. (EBV is also known as “lymphocryptovirus” -- it was originally discovered “hiding” in *lymphocytes* of monkeys.) So, EBV = think B cells. +30

fulminant_life EBV does cause pharyngeal and laryngeal inflammation along with fever, malaise, and cough and LAD. The only thing that pointed me away from mono and towards coronavirus was the patients age. +8

nbmehelp Can someone explain what not holding up to acid or being dried has to do with being enveloped? +

yb_26 @nbmehelp, the envelope consists of phospholipids and glycoproteins => heat, acid, detergents, drying - all of that can dissolve the lipid bilayer membranes => viruses will loss their infectivity (because they need an envelope for two reasons - to protect them against host immune system, and to attach to host cells surface in order to infect them) +12

lowyield @yb_26 does that mean that non-enveloped viruses hold up better to acid/dryness? +2

rina yes enveloped viruses are easier to kill (see post from drsquarepants: https://www.nbmeanswers.com/exam/nbme23/1161). also i think the "when dried" might refer to the fact that coronavirus is spread by respiratory droplets (don't even need to read first aid can just read the news at this point!) +4

submitted by m-ice(370), visit this page

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The patient needs medical attention immediately, which eliminates obtaining a court order, or transferring her. A nurse does not have the same training and qualifications as a physician, so it would be inappropriate to ask them to examine the patient. Asking the hospital chaplain again could be inappropriate, and would take more time. Therefore, the best option among those given is to ask the patient if she will allow with her husband present.

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sympathetikey Garbage question. +71

masonkingcobra So two men is better than one apparently +33

zoggybiscuits GarBAGE! ? +2

bigjimbo gárbágé +5

fulminant_life this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +17

dr.xx I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39 +11

medpsychosis The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +21

sahusema I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +29

sherry I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +1

niboonsh This question is a3othobillah +11

sunshinesweetheart this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +9

drmohandes I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +15

myoclonictonicbionic @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +16

korahelqadam All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +3

sars This is a very fair question. I agree with sunshinesweetheart above. That is all. +2

wrongcareer69 Garbage question +1

alimd well we should wait for the question "if a man shouts I CANT BREATHE with a police knee on his neck, what is your next step? Ans- wait 8 minutes." +3

beto okay, touch me when my husband looks. are they preparing for threesome?? fckn question +

fatboyslim I'm a Muslim man and I got it wrong. I chose B lol. I thought by her saying I don't want to be examined by a man stays true regardless of whether her husband is there to not. I guess it doesn't hurt to ask her what would make her feel more comfortable if it allows a male doc to examine her. +

submitted by mousie(272), visit this page

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Why no sweating? I mean I get Ecstasy is probably the drug of choice before an all night dance party (lol) but don't understand why there would be cold extremities and no sweating when is FA it says hyperthermia and rhabdo????

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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. +13

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. +13

yotsubato Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +22

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 +10

monkd Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +6

usmleuser007 Why not LSD? +1

d_holles @usmleuser007 LSD doesn't cause HTN and ↑ HR. +2

sbryant6 @fulminant_life FALSE. KETAMINE CAUSES CARDIOVASCULAR STIMULATION. +12

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." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008716/ +5

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. +1

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" +1

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. +2

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."(https://www.openanesthesia.org/systemic_effects_of_ketamine/) +1

brise LSD does cause HTN and tachycardia according to uworld! @d_holles +2

submitted by thomasalterman(181), visit this page

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Trihexphenidyl and Benztropine are antimuscarinics that can treat the resting tremor and rigidity of parkinsonism.

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mousie haloperidol induced Parkinson's... ? adding a anticholinergic can counter these adverse effects of the antipsychotic .. ? +3

fulminant_life @mousie yeah it balances the dopamine-cholinergic imbalance caused by the antipsychotics +

kai +So antipsychotics induce Extrapyramidal side effects which is drug induced Parkinson = low Dopamine High Ach, and you would treat this with anticholinergic (Benztropine).This is neurologic. +Antipsychotics also produce non-neurologic, systemic anti-cholinergic effects like dry mouth, sedation, hypotension etc +

an1 UW asked this too, benztropine is the drug of choice +

submitted by yotsubato(1208), visit this page

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Was it just me, or did "age at onset in years" appear RIGHT above the number of patients, rather than the mean. Which confused me for a good 3 minutes.

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fulminant_life Definitely was the same for me. I was so confused for like 5 mins +21

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) +9

mellowpenguins Are you serious. NBME strikes again with shitty formatting. +10

yex OMG!! Now I just realized that. Super confused and also thought onset of age was 36. :-/ +8

monkey what is 36 supposed to be? +1

thomasburton Think the number of people in that group +5

paulkarr Yup...was looking at it for a good 3 min before just doing the "fuck it..it's gotta be 99" +6

arcanumm Age of Onset is the Title of the table, which I didn't figure out until after exam was over. What terrible formatting. +4

veryhungrycaterpillar This is straight up tatti. I was like what muscular dystrophy is showing up with an almost biphasic age of onset between adolescence and 30s? Fucked it up. +

handsome how did you get the 99 what is your solution ? hehe +