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Welcome to haliburton’s page.
Contributor score: 208


Comments ...

 +0  (nbme24#4)
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FA 2170 satest ahtt valaeauscrtrx loiysemhs ahs ujicnead ewehr AOB cltimonbaiiptiy wludo .ont


 +6  (nbme24#18)
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Ifbiximnal si a FTNalap-h hniori.ibt from depubm -FαNT ahs nebe ttdmdserneoa to aehv a tlracne lroe ni eht ohst oepsnser aagtsin btus,lirocesu lngduinci larogamnu itnofroam adn eth ninttmoacne fo sadseei )54(11,. ,atyoNbl biidsonate sniagat F-αNT icudedn itcenaotvrai fo iblcousurste

bigjimbo  TB can spread to psoas L1-2 often, which then goes to the actual L1-L2 vertebrae itself (Potts or osteomyelitis) +4
cbreland  I get why the TNF inhibitor would cause Tb and it literally said osteomyelitis, but the question says "gram stain is negative". Does that mean it doesn't gram stain?? I read it as it having a negative gram stain and crossed out Tb osteomyelitis as a result +
jsanmiguel415  Mycobacterium doesn't gram stain due to mycolic acid in it's membrane. It'll take the carbol-fuschin stain (acid fast) or grow on a lowenstein-jensen culture but not gram +1

 +4  (nbme23#46)
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ebledmluts sha a ncie npecinmuo for the idlekl anc:vscei

Rtse nI ecPae lswa:yA

esRaib
eza nnuflI
loPoi a()Slk
apiitHest A

paulkarr  Also, the nice little puppet show from sketchy for those visual learners like me. +1
makinallkindzofgainz  just remembered that MMR is a live attenuated vaccine +
faus305  how could i forget that puppet show?! +

 +2  (nbme22#40)
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edraPr liilW = Palnaert tenlodei (tilapar or l)l.uf dtNoe rof giitrnmpi.n sCouin ot Aenmgnnla (teoisppo le.oeind)t

AF :7012 5%2 of acses ued to larametn auptlinaner isomyd (two rtenmaalyl tpeinmdir sgene era ev;eeidrc on ltperaan gnee eevidc).re

drjungly  Physeo video explain this very clearly, +

 +4  (nbme22#5)
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ogcdrncia to mblesdtleu nkil sn ss ARN tmus ryrac ARN nddentepe ANR aleeymrpso s(o tath is .)tuo

saol, rdngccoai ot tllesemudb eethr rea yrev efw sd ANR ,vrssiue os os"tm "lkeyli lliw be ss. ,soAl RendNAet-ndpe DNA oelemaprys = Revrees rac.easnpTtsir ienSc VHI si a ss ps RNA rsviu hwti ,TR thveey' srcebidde an VIH uciso.n not user odneyb sh.ti

nc1992  negative stranded can't be read by a translator so it needs to be transcribed into + first. Only then can it be used for protein. + is basically mRNA already. There's only one double stranded RNA family as far as I know- Reovirus so no encephalitis +9

 +12  (nbme22#14)
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sthi gieam whsso cohmctpyiyl tciyi.otx

stih egmai soswh ttah eth ipludub fo PTAd ihsitbin RNR eudner(tocioilb resuctda),e chiwh shinbtii eht srte dTPN tsssni.yhe

busno ieamg swsoh RNR is teh tragte fo herxrayouy.d

leaf_house  That second image is solid gold. +3

 +4  (nbme22#29)
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pn:athego ycocsucpcort

nmtrTteae potin:so Ampoh :B idsbn getlseroro &t-g; eprso ni gnlfua membeanr -g&t; kelas nceno.t ts nac add uycls:tFinoe ndvecorte to F-U5 to hiintbi ccuelin icad nsssetyih

dm:lsbfeul0mcphos//1lyeo/eiby/tstci.o1mt4.si6tgtoo1ur1n/plec e1crtt4meoti1aml8shbspotb/nyopb//opo.:hte0s-r/c1diml5gleumic/i.

passplease  How did you know it was cryptoccocus and not something else like candidiasis? +1
jsanmiguel415  Was stuck between cryptococcus and candida as well. I think the tip might be that Candida is in mold form at higher (body) temp. But amphotericin b can be used for both and given that it's a serious infection you would probably just go straight for that instead of fluconazole. +
schep  Patients with T cell dysfunction (HIV) are more susceptible to cutaneous candida infections (esophagitis, etc). Patients with neutropenia (chemotherapy, post-transplant) are more susceptible to invasive candida infections (bloodstream infection, meningitis) +

 +8  (nbme22#37)
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umiuboarcflsr ypldsiaas ni eht etfl lnrea .a suseac owl lwfo tisngurel ni wlo RG.F ciorCnh wlo FRG uesacs tulraub toprhya. (perxect dan eerecenfr wl).boe

aTurlbu phyarto is a ernaegl etmr ttha rdiescebs resalev setraptn fo rchnico rbatluu rnjyui htwi enkitecdh rtualbu mansebet bmemsaner, dan cnailyllic eftmanssi sa crinohc ykidne dsseiea wtih eadcrdese eurgmloalr tfilainort rate. rneIdesac eetxtn of arbtluu ryahpto nda aincpmagnyoc inrttslitiea iifrssbo srcoetarle tiwh roews rsnispog.o uniPoearrti si ie,rabavl epndginde on ceusa.

j-.xw0eheft:3316ws3/3Slgl2p6artw)i0t07l/d.u2/k/-/a6ro8t(c6t


 +6  (nbme22#12)
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naiedtiirn ksolbc 2H rp,roeetc hhcwi is G.s Gs aitevatsc alyylned ecyslca g;-t& cP+M.A

q: VHAe 1 pMMa;m& &t=;g 1H, a,alh1p ,V1 ,1M :Mi3 DAM 2 ;=gt& M2, lh2ap,a :D2s (iretngehvy eels) g;=t& a,1tbe 2be,at 2V, 1D 2H

I nthki thsi si rofm F.A

baja_blast  Yes; FA2019 p. 238 +
medstudent  FA 2020 238 too. +

 +8  (nbme22#1)
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epptalyrna ihst si a ncommo eqseulae fo amandboil a.uarmt

o(rfm klni b)woel enwtTt-wyo fo hte 25 seadht erew edascu by olodb l.oss wTo rntsepta fo eihaptc neosuv rijnuy adpeaepr ot rpoieamend:t onlvaisu of eth ktnur fo teh gtrhi iepahct iven from eht firireno vnea vaca nad savnuilo of het pprue cbarnh fo the ihtrg pctaihe ien.v

cmhi.wv0.l0oupdbnhb:getw9/imt3/4p.w2/sn8n./


 +1  (nbme22#40)
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AF 7201: craieaCerthzd yb svamsei iofnpareiortl fo yramgaeotsecyk nda ttsa.leple stmoymSp lnceiud inldbeeg dan bsr.hstoimo odoBl aresm sowsh aledrmky enaisdcre nrumeb fo ,ptlaeetsl cihwh may be egarl ro wihrsoeet lamnolbayr eor.fdm lthgiarrlaEeyom may u.rcoc


 +10  (nbme22#48)
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on iltoarns useits si a uehg cleu h.eer ottla lcka of Ig hwhci aesucs neerutcrr scnofietin aftre o6m (reanamtl gGI si )gen.o LN nad itlnoss aer e.xnniotmorin/en-ts AF( 7).201

angelaq11  I totally hated this Q! I almost completely overlooked the "no tonsillar tissue", and thank God I didn't because that's the clue that made me change my answer. I had CGD (yeah, I know, S. pneumoniae not catalase +), but it said that he had muuultiple infections since birth. And I took to heart that "since birth" thing, because, isn't Bruton supposed to present with infections from around 6moa? I hope I don't screw this up next week +2
surfacegomd  @angelaq11 I thought the same thing!! because it said "since birth" I thought Ok this is not Bruton :( +

 +2  (nbme22#12)
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waranifr ihibnits teh ehsnsyits fo tcfroas ,II IIV, I,X X, ,C and S by klognibc rtucnieod of oiedixdz ainvimt .K Teh neemzy oxpEdie eastecdRu is hibditeni yb ra.nrfiaw ehT eeurcdd vcie()at romf fo ivt. K si a footrcca rfo y-mmaallmagutg rxb.ayecolsa

link981  So factors II, VII, IX, and X are precursor proteins? GTFO +1

 -6  (nbme22#45)
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aikosp .caaroms .HH8V aioscleouv uelrp()p sisno.le danvaecd VHI D4C < 200 H(O.W)

yotsubato  Yeah thats the easy part. But the histology is whats hard +

 +4  (nbme22#17)
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AF :2170 H priloy si soadsieact whti crtsiag acaiocrnanoedm and MTAL hlmayomp

seagull  I might be mistaken but I also thought Epstein Bar Virus was also implicated in gastric lymphomas? +9

 +3  (nbme22#15)
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egtsmeelclbp.t-revyrt/p-n/:c-e/mpthpuhiud-ps/e-ykseooim

a cien wierve fo mtooeym adn edoamrtme / xseefrel


 +6  (nbme21#20)
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asebRi kasactt eth tciinocin hccoieellntyA reerp,oct nda rlastev radrtgeoer iav yndnie oormts ertaf bigidnn hRC,A orcngadic to FA.


 +13  (nbme21#31)
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rehet era owt aiesetsnl attyf s:adci coiielnl = omega ,6 and oiaep-lhncaill = oegma .3

lizard  Found in fish oils and are shown to lower triglyceride levels. +3
zpatel  alpha-Linolenic ==> omaga 3 +5

 +1  (nbme21#13)
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FA 02:17 corChni ipocyxh nrualpyom nostvocncsoitira sestulr in ypnaomrul rnoyptiehsne and VR.H

yotsubato  Yeah but in a chronic case this guy would produce more RBC and not be hypoxic anymore. +20

 +4  (nbme21#50)
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isht si a ricvecal ispanl ocdr .osenict hte teecuan fsslacucui si atticn UE)( ivnotrabi nda topeciropoprn,i btu eth wtehi tiescon si eth ecarigl csluisfcua (EL) dna is .mddeaag I intkh eth atrlela tooprni thta si veunen si tsuj aaa.rinltattfr/uc

arezpr  thorax section +3
guillo12  How do you know the gracile fasciculus is damage?!?! +2
cr  which parte of the image its damage?, the pink? or black? +
usmile1  the pink park yes +2
d_holles  If you look at https://en.wikipedia.org/wiki/Gracile_fasciculus#/media/File:Spinal_cord_tracts_-_English.svg you can see that the closer to the center = legs, while further away = arms. +3
hyperfukus  i still don't see where the damage is lol! FML +
hyperfukus  i finally figured it out lol that was a slow moment i hope im not this slow on step yikes! +
angelaq11  @hyperfukus I had the same problem at first, marked it and then came back. If you remember, in the spinal cord the white matter and gray matter are "reversed" compared to the brain. That said, if the butterfly shaped region (ie, the gray matter) is colored (in this case) lilac and the rest (ie, white matter) is blackish, the only thing that is actually abnormal, is the region where the dorsal columns are, because it stains just like the normal gray matter. After that, you have to think about which fasciculus is damaged, the gracilis or the cuneatus. The gracilis is medial while the cuneatus is lateral (picture someone with glued legs and open arms). Hope this helped +12
azharhu786  Gracilus Fasciculus = Graceful legs +
icedcoffeeislyfe  Check out FA2020 pg 508 Put simply--> myelin= black --> color of the normal white matter no myelin= pink --> color of the normal gray matter and the damaged area Dorsal columns= vibration, proprioception, pressure fine touch F. graciLis= Lower body F. cUtaneous= Upper body +2

 +1  (nbme21#5)
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kidewipia iol(sep:)aog hTe htreoepmsa is omposcde of %87 getnoinr dan %21 oyxgne. nicSe ynxgeo is xeeacgdnh at the raalvpc-eioilylla rae,nbmme tegnrino si a rojma coontmepn for the loa'ilsev astte of tnol.afini If a eglar voemlu of erniotgn ni eth lnusg is plreadce thwi eyn,oxg hte nyogxe aym tqunssbeluey eb ordbbaes toin the oldb,o duicreng eht volmeu fo eth aveo,lli sultrieng in a ofrm of erllvoaa sleplaoc nowkn sa braopoitsn c.lteaiasset

I sohce gecancoidir deme,a btu I elbeevi hsti si ncrrceito buescae hetre si on ahtre riaeluf sikr at tshi t,eim so teh preopsu of het EPPE is cleaynrit tno to push uto lf.uid

bighead478  doesn't there have to be an airway obstruction (mucus, foreign object etc.) in order for this to happen? 100% O2 without any airway obstruction should not cause absorption atelectasis, right? +
iloveallpotatoes  And Tension Pneumothorax is wrong bc PEEP would furthur exacerbate that. +1
hyperfukus  @iloveallpotatoes yea i realized that now after getting it wrong :( +
plzhelp123  @bighead478, they are using a cuffed endotracheal tube and mechanically ventilating this patient which is creating an iatrogenic "obstruction" and as @haliburton mentioned, having a high FiO2 leads to over-absorption by the blood which leads to absorption atelectasis if no other gas is allowed to enter/there is no communication with atmospheric pressure during expiration. Thus, we add positive end-expiratory pressure which keeps alveoli open at the end of expiration to prevent collapse +

 +8  (nbme21#4)
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FE2 si lrisoltatanna eangotiol caorft ,2 hicwh si ecnaysers rfo ointper tsnhys.ise

sympathetikey  I. Am. So. DUMB. +24
nala_ula  same :( +2
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +

 +13  (nbme21#2)
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unendtneoh:eiptac.ioct/sciorlhvtf/omo-hecpsgriliey/gs.sdinn/hd.en

P"peelo hitw oessplsceirdeonaueht icfidenecy may not be eabl ot mvoe or haebtre on hiret onw orf a fwe hosur tefra ingt[act-sfa srug,d hucs as ilocceshnucliny and muvmuiic]ar rae dsimnair.tede

ragacha  THX +

 +3  (nbme21#28)
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AF 21:70 tibFrea DARs cdueiln pomyahyt raesednic kisr iwth tissa,tn tlclrehooes ensosltagl


 +12  (nbme21#21)
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likn ot anctroo mrgaaid

yotsubato  How is that NOT posterior to middle concha? bad question +10
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +3
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +3

 +5  (nbme21#35)
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iTsh is waert cnot.xionaiti nemw5.1is.onb/h/9wwub/7tlv/mnhp:..8tcd7igp7

thisisfine   Agreed! It's along the lines of those marathon runners who collapse questions. Nothing but water for 24 hours = getting rid of too much sodium. +1
temmy  are we just going to ignore the diarrhea for 3 days? what is its significance +4
kard  Temmy, We aint Ignoring the Diarrhea, Actually the most likely electrolytes to get lost with it is sodium> chloride> potassium> bicarbonate... Plus the Water intoxication -> HYPONATREMIA +1
bronchophony  why not hypoglycemia? +1
saulgoodman  Because glucose is not an electrolyte, it does not conduct electricity in solution. The question is asking "Which of the following electrolyte abnormalities". +2

 +3  (nbme21#33)
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omfr FPAA DE fo mdexi incgaor adn sncghoieypc roingi is om.omnc giecPohncsy susace rea rome klliey ehwn eht ptneati has lmnroa rcoeeisnt ithw aasmtutrnibo or hwen rntnloauc leenip uencesmcte si n.marlo

yotsubato  Couldnt a psychogenic cause reduce libido? +2
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 +7
home_run_ball  whoops meant to comment on the other comment +

 -2  (nbme21#10)
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AF 7:210 yrrUain sciroyerdusnnitpaei-d etst is oanioigdc. tnts ures woh ot nokw htat ti asw a dre l,rooc btu mbeay sjut the ftac hatt rde medese liek a stpieiov etst .setulr

lnki ot oerm cobukngdar btu ont esleirnasyc plfluhe rfo shti nqtsieou

nobody  "Detection of cystine in urine: cyanide reduces cystine to cysteine → Cystine turns red and becomes detectable when it comes into contact with nitroprusside. If the test is negative, the presence of cystinuria is unlikely." - AMBOSS +

 +4  (nbme21#18)
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Blluous pimeoghdip eantnig sumt eb iemoomdesse.hm AF: alubl are "l"lobwu teh irdmes dsem(biuaprel letrb)i.s BP osla eidyl "t"enes l.luab

seagull  I love how this cant be straight forward. All the other proteins are either subunits of desmosomes or cytoskeletal components. Because I know molecular biology that well on top of the majority of medicine....FML +8
cienfuegos  @seagull: excellent comment, literally loling right now +
cienfuegos  or sobbing and threatening to hold my breath if they don't make it stop +1
daddyusmle  WHY DIDN'T THEY JUST PUT HEMIDESMOSOMES THE FUCK +11

 +1  (nbme21#38)
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I soehc FG-CS baceuse eth eyrugcasotnl mdseee to me orem fo a kirs hatn eht edtreamo maniea. peiootyirtEnrh emses ielk an rrteopppaia chieco as wlel tbu S-GFC orme tcr.ilcia

kentuckyfan  I think it's also because he has an infection (since he was prescribed antibiotics) boosting the immune system is more important than increasing platelet count E) or RBC count A) +5

 +0  (nbme21#50)
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ym stone omfr :URDWLO d sean pgyeati misqouot = dgn uee us,hot tsoutheas a,isa acipifc ns,disal rbieaarc,n eicmaa rs AH, rtbale=oritro ,apin ojtni ipn,a ucselm .aceh te,eheicpa rua,rupp psx,stieai neame,l tphynibatoo cero ekenoiplu,a taortehociconnmen

thomasalterman  Dengue is an arbovirus. The important hints are that she was traveling in endemic (tropical) and that she has **excruciating pain in the joints and muscles**. This is why dengue is aka "break-bone fever" +
sam  Same vector +
sam  Same vector +

 +2  (nbme21#15)
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i think itsh is esbcaue ibbrunili is a beluslo irlev wakoedbrn ructdop of m,eeh ubt sha ont tendeer het lteoncoisinte/n fro gut rtibcaae coronnevsi ot ntboslrceii ro lourbni.i oiinblru in ienru si nroa.lm


 +4  (nbme21#19)
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r-ieP ro oaputsptmr mhacdiotryapyo )C(MPP si a r,era retit-lineegfnah ahtre eeiassd of eruncal rgoini and is atdecaihrzcer by rehta rfluaie of nesddu tonse tbewene teh ialfn keews fo gcnynaper adn 6 moshnt eraft dlveirye. inlk ot epdbmu hTe lniiccal tiurcep fo CMPP psrooensrdc to a adeldit ytohiocapyarmd )M(DC ihwt sgnis of eevrse hrtae .eflruai

maxillarythirdmolar  For anyone wanting to understand why^ the tl;dr is that prolactin gets cleaved into two toxic metabolites. Treatment is something like bromocriptine (and therefore no more breast feeding) to stop prolactin release. Lastly, you can treat with regular HF meds. +1

 +9  (nbme21#16)
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FA 710:2 eeSectr uaatrnfcts mrof alllearm s.ebdoi olA s veers sa ouresrprcs ot pyet I lslce nda eorth ptye II lscel. eeoartlfPir udngir lung egaa.md

teepot123  fa 19 pg 647 +
moms  thanks! +

 +9  (nbme21#10)
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lalSm lcel ulgn ernacc essacu .IDHAS toiaocLn + ueixlasynorc c.uesl

mcl  To expand, SIADH may also result in euvolemic hyponatremia. This is because, as we know, ADH increases absorption of water and therefore initially results in an increased circulating volume. However, this results in increased stretch of the atria and subsequent secretion of ANP. ANP (atrial natriuretic peptide) then results in loss of sodium and water. +10

 -5  (nbme20#8)
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AF 7102: °3 psyslhii rudstspi teh vsaa srovamu of hte oaart ihtw uenoneqstc tyorpah fo lseesv wall and nlaodaiitt fo aroat adn veval Myagnir . ese cccifaiaoitnl of craoit o,otr egcsaidnn toaric rh,ac adn cociahrt toa.ra daLse to e“rte kr”ab eeapapancr of ato.n Cara sreutl ni eanmyrsu fo densgaicn aotar ro roaitc har,c rtaoci fcifsyeii.uncn


 +8  (nbme20#19)
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steraonn usnod si orlmna. hrentsyepnora iwth .oliaptoravcinte neexs sfrtuiem si nasiceerd c/ sdoil mass or fu,lid dan easddreec hwit /aluriifd leevl ro nneios.xropeva rdglpe oon oeixryptra saeph t&g-; tstoivrbceu dsonniotc.i


 +1  (nbme20#39)
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oylMcapams duoienpmcnolae iialnugtng,s no snseoper to lnalio.xicim

AF 07:21 iClssca seuca of tyaapicl n”ag“ikwl apnmeuoni niioussid( ,nsoet ea,dachhe prndvutnoioec c,ghuo chpyta or fiduefs nsitrtetilai .)ilnairfett y-Xra ksolo swroe ntha peit.tan High treit fo odcl nanilutgisg MgI,() ihhcw nca ggeanttuial or ysle Bs.CR onGwr no oEtna gtrrneTe.maa a:t scdie,oalrm ,elocnyiyxcd ro ooeliuufrlqnono i(elnciipln eteiniffvec eicns olsMayapmc hvae no lcle BC)a lw.Al = rA,ifca ,lnBndseis rinohcC onciinetf. –KD = ihgytenerv lntea sea.eoNl edessai can be cdiuaeqr nirdug sapsage hghruot edtcnfei hitrb Nana.o cl elcl l.wla tNo enes no aGrm sa.nit himooclrPep aeAiBtrl .ca mbramnee inctason elotsrs orf abiiylstt. almpaocMysl nenmauoip si eomr ncommo e ptsaiinnt t&l; 30 ysrae rtu.e oldFnqe bksreaout in itmryila urtscrei pl aoMmprnscad.asinsoy tesg clod itowthu a ctoa cel(l )awll.

johnthurtjr  Have you mixed Chlamydia in with Mycoplasma? +2
smc213  I mean the Q stem is not about Chlamydiae, but Chlamydiae does lack the classic PTG cell wall d/t decreased muramic acid = beta-lactam abx ineffective. FA 2018 p.148 +

 +0  (nbme20#4)
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AF 2:107 tIecnfs B leslc trouhgh C.D12 pyAaclti yocyhptselm no rahlpe oebrdlpio emrsa G —otn itenedcf lls cBe tbu tcvieear itxytccoo T elslc. ⊕ spotnooM ndhitoatbeee—htsotire islpe cettdede by agtnutfiiagonlo esphe ro sreoh eRsBs U.C fo xacmlnloiii ni noslmiaoeonsc cnu ecsua iirrcchstaecat aoapmuulrpcal .hasr

zup  misread the "accounts for" question as what's the reason for the atypical lymphocytes. So I answered "virus infected B lymphocytes." Anyone else misread it like that? +13
nala_ula  Shit, I misread that too and I noticed it now. Nerves get the best of us! +
stevenorange  If the question is ask what is the atypical lymphocyte in the brain , than it should be the infected B cell, RIGHT? +

 +0  (nbme20#23)
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onctm[em edvom ot smbcmetonu]





Subcomments ...

submitted by lsmarshall(393),
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I hougtth stih aws a rctik utiqnose sneci isnk sneacrc rea het tsom mooncm yept of ecrascn reoav.ll But atyclaul mngoa HIV i,sneatpt IltdeaV-Her cacensr ear uchm mreo oconmm hnat not-nadIHlere-V ensccra (eevn ksin cscn)ar.e cE-VdenBudi marrpyi SCN mmopahly is teh oyln opntio ttha si AiDndsifIne-g .nslerliascn/ec

medskool123  why not hep B? i guess another whats the better answer ones... Just rem reading that it was more common with aids pts.. anyone have an idea about this? +1  
haliburton  Yes, I think CNS lymphoma as an AIDS defining illness wins the day. My thought was since SHE has AIDS it is most likely from IVDA, which has a high risk of HBV that could go undiagnosed for a long time. at 32, that might not be long enough to have HBV and get HCC (but with no immune system...?) +3  
yotsubato  God damn this is such BULLSHIT... +13  
trichotillomaniac  Why you gotta do me dirty like this NBME +2  
sars  My thought process, usually wrong all the time, was that HBV (IVDU) can occur to anyone. Acute hepatitis to Chronic occurs when HBV incorporates its DNA into host and releases mutagenic proteins. This is regardless of immunosuppresion. Primary CNS Lymphoma reappears primarily when you are immunosuppressed (organ transplant, immunodeficiency, HIV/AIDS). +  
syoung07  Hep C is far more likely to become HCC than hep B +1  


submitted by m-ice(321),
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ishT lirg sha oMno csdaue by eirEpt-rnsaB Vrs.ui eTh sstmympo ear aetvyrille ageu,v tub pdlymaayohnthep klie htis ldwou eb mmocno orf Moon. ehT CCB shwso deevaelt ly,mphtscyeo igymlnpi hits si nto a alicebatr lslni,es os ralvi si lliyke. mindCboe itwh the oaeyathdmlhnpyp, stih emaks us owrry btauo oonM. The -oonMtoSp tste rof BVE is thwa eth etqsuion si rnfgirere to nhwe siendigrcb teh phees seycyrteothr ai.nguggtaitln rFom ehet,r itsh istunoqe erirques that uyo onwk ttah ni BVE onfi,tenci BEV nfsetci B ,csell btu sdeo tno ecasu tmhe ot bmeceo oabl.rnam Iednat,s 8CD ,llcse wihch ear iactvyle nirtyg ot likl hte B cle,ls boeemc mlraa.nob

medskool123  NBME does trick now and then.. when they zig you zag. then when you think they are going to zag, they zig just to destroy yourself confidence. +16  
kylemax  The abnormal T-cells are known as Downey type II cells (Sketchy) +3  
haliburton  I was recognized EBV, then knew EBV infects Bc, and the atypical lymphocytes are Tc. Then I said CD8 are MHC1 for virii, and bingo bango, boom. +6  
trichotillomaniac  congrats you played yourself +3  
lilyo  Soooooooo EBV infested B- cells is not considered atypical WTFF?? +  
med4fun  They are atypical b/c usually you do not see a super high amount of CD8+ in peripheral blood. Now there are a ton to try to stop the infected cells. +  
aneurysmclip  oh and primary CNS lymphoma caused by EBV has T cells NOT B cells. I just try to remember the peripheral blood has atypical lymphocytes which are CD8+ T cells, and the CNS lymphoma is the opposite, ie; B cells +  


submitted by neonem(550),
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1gonoa/:piokliierm/.kaetm/u7s/gyi0/c4pprtdpohdG2iw.7d//snimaaw.d

haliburton  ^^^ THIS ONE SHOWS DUCT ^^^ +4  


submitted by medstruggle(12),
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hWy si eth swaner naaltnuo“igr se”ts?iu I ttgohhu tarfe 14 adsy you avhe a luylf moredf ra.cs

colonelred_  If you go back and look at the image you can see that it was highly vascular which is characteristic of granulation tissue. Scar tissue formation will be closer to 1 month, plus you will see lots of fibrosis on histology. +13  
sympathetikey  It's a bit misleading, for me, since you do see fibrosis intermixed with the granulation tissue, but granulation tissue was a better answer. +2  
haliburton  According to FA 2017: 3-14d: Macrophages, then granulation tissue at margins. 2wk to several months: Contracted scar complete. Dressler syndrome, HF, arrhythmias, true ventricular aneurysm (risk of mural thrombus). i'm getting pretty frustrated with NBME contradictions to FA, and FA omissions of content. this stuff is hard enough to get straight as it is. +1  
yotsubato  Thats cause the NBME exam writers read FA, then make questions not fit in with FA +6  
trichotillomaniac  This fits the timeline laid out in Pathoma! 1-3 wks = granulation tissue with plump fibroblasts, collagen, and blood vessels +10  
alimd  never look at the image in the beginning. They dont want you to success. Most of the time images are made to ditract +1  


submitted by trazabone(14),
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dyKnie saekm ,512- hxdoryy atiivmn D. ilhy)5yrx rcoctoiadl2-( vit D dc(iica)oll is adme in eth lve,ir dna imhtyyhsaprodroapi wudol ton sdaeerce tis elvles as ti acst ot scraeien ap1-alh yolhsxardye ni eht ieyndk ot cenasrei ociraliltc narnttsionecoc &t-g;- eaapshtCph/o etroibpnrsao orfm eth oben nad malls eneniitt.s

queezyfish  I'm confused about the phosphate level in questions like these. Decreased calcitriol would decrease phosphate absorption while PTH decrease lowers phosphate excretion. I'm assuming that the PTH decrease has the greater effect with serum phosphate levels? +1  
mousie  PTH = "Phosphate trashing hormone" if PTH is high Phosphate must be low - they are always opposite (unless d/t renal failure then Phosphate will be high - kidneys will be unable to get rid of phosphate) So low Ca d/t low PTH does not effect 25 H. Vit D ... only 1,25 H Vit D (active Calcitriol)? +4  
haliburton  Clarification because I was confused: PTH stimulates kidney to produce 1,25-(OH)2 D3 (calcitriol) via 1α-hydroxylase in proximal convoluted tubule. Therefore, without parathyroid glands, low PTH, 25,D is not converted and therefore not down (normal or up). phosphate "trashed" by PTH as eloquently stated above. +1  
zbird  Here the primary defect is high up from the parathyroid gland, there is decresed or no PTH which normally trashes phosphate but not in this case so serum PHOSPHATE INCREASES and the serum calcium is low because PTH should have prevented the urine calcium so there is calciuria and no resorption from bone-LOW CALCIUM, Vitamin-D is independent of PTH so stays NORMAL +  


submitted by sajaqua1(519),
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ouWt'ndl ottal VA nolad toainbal tdeosyr ot acutrtthoiimhyy of eht ?meracpeka htaT uldow nmae htat lbewo teh VA eodn het rhthmy ouwdl be idprvode yb a curtlievanr oc,fi adn stheo lyluaus rtacee edwi QRS meslcpex.o

haliburton  that was my reasoning as well. guess not. +  
yotsubato  Shitty NBME grammar strikes again. +1  
charcot_bouchard  No. No guys. Bundle of his located below AV node and it can generate impulse. it calls junction escape rhythm and narrow complex. Below this is purkinje, bundle branch & ventricular muscle. those are wide complex +13  
abhishek021196  Third-degree (complete) AV block The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lym3 disease +2  


submitted by welpdedelp(216),
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Ok, so NAR eenpdndte NDA omeersplay si for eerevsr tss.paire.nc.art enligs dsartden + sue RNA enedtnped RAN .ymoapesrle Cna onemseo aelpin?x

hyoid  The only thing I can think of is that HIV is a (+)-sense single-stranded RNA virus that relies on an RNA dependent DNA polymerase (reverse transcriptase) to synthesize DNA. +1  
haliburton  according to [medbullets link](https://step1.medbullets.com/step1-microbiology/104196/rna-viruses_) ns ss RNA must carry RNA dependent RNA polymerase (so that is out). also, according to medbullets there are very few ds RNA viruses, so "most likely" will be ss. Also, RNA-dependent DNA polymerase = Reverse Transcriptase. Since HIV is a ss ps RNA virus with RT, they've described an HIV cousin. not sure beyond this. +  
some0217710  Can’t think of any retroviruses outside of HIV and HTLV and they’re both +ssRNA +1  


submitted by welpdedelp(216),
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It aws sjut snigka eth fspenail fo RBCs (012 as)yd

haliburton  If I'm reading this right, this is just a tricky dicky question. I think CO binds 200x stronger than O2. But if an O2 cycles through binding / unbinding 200 times before a CO gets kicked off, this should still clear the CO from that cell sooner or later. strange to think it is 1. essentially permanently trapped in a cell, and 2. doesn't kill you and can be treated with O2 to resolution within a few hours or a day. They must just be thinking, until that last RBC dies, you've got original CO in a circulating cell. but just a fraction (because you didn't die). not sure how that CO isn't just passed on during recycling, based on this line of thinking. +7  
link981  The question while stupidly written, asks how long the RBC's that carry the CO take to be removed from the circulation, not how long the CO takes to be removed from the RBC. Just asking the lifespan of RBCs in an stupidly complicated way. As we know, RBC's life span is about 120 days and then they are removed from our circulation. 120 days is about 4 months. Next time they will probably ask weeks or in hours, who knows? smh +6  
baja_blast  If that's what they're looking for why cant the NBME people just ask "How long does it take for RBCs to turn over?" Ridiculous. +1  


submitted by hayayah(1056),
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raencyodS yihrrrpposamydithea asuulyl( t/d noiccrh arlne ruie).laf

aLb gnindifs ndliecu ↑ TPH esopn(ers ot lwo ,cc)auilm ↓ sreum ulmacic lr(nae e,ri)alfu ↑ suerm pshhopaet (alern ,raifle)u and ↑ lknileaa aspheoaphst TPH( naictavtig t.Bse)oloasts

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +2  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +1  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +1  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1  


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I idecpk nros’Ch oto. I nkhit hte rvseee ascpttnooiin veor 5 ryesa detsdctria .em

haliburton  i think it is critical to remember that constipation is what caused the diverticulosis. +3  
lola915  Crohn's presents with +/- bloody diarrhea, not constipation +  


submitted by nuts4med(6),
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oyenAn aveh an iade wyh teh reaecsded etaailrr O2 snaotaruti is r?ncotrcie nmsuigsA hes ash plmu edeam sinec she ahs EL ae,emd wdtlu'on a worel 2O ast eb petecdxe ot?o

haliburton  I believe there would be no decrease in O2 saturation because oxygenated blood (high pressure) is shunted into deoxygenated circuit. As long as the lungs can keep up, this should increase venous oxygenation on average. +7  
hungrybox  ty both of you for this, was wondering the same thing +  
coxsack  O2 sat won’t change b/c you’re not adding deoxygenated blood to the arterial side. You’re just taking arterial blood and putting it into venous blood. Same reason why L->R cardiac shunts don’t decrease O2 sat (while in contrast, a R->L shunt would). +4  
hungrybox  just realized: the high pressure of the arterial system keeps out low-pressure venous blood in an AV fistula (probably obvious to most ppl but it was a eureka moment for me lol) +2  
chandlerbas  ya you wont have decreased arterial O2 sat because oxygenation of blood is perfusion limited (FA19 --654) therefore oxygenation of the blood happens within the first .3seconds of entering the pulmonary capillary that you could even handle having more deoxygenated blood enter +  


submitted by monoloco(132),
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If uyo wnta ot laerc a rdgu, ti is alorbbpy tbes tath ti otn be onbdu ot tnsroipe o(s hatt it gest tredlie)f dna ti ash a owl ovumle of ubdnittorsii (os it 'ntis ni the de,pe hdra ot creah tus).sies

kingtime9119  But that doesn't make sense. Page 233 of First Aid 2019 edition clearly states that being plasma protein bound creates the lowest volume of distribution, because not being bound to proteins increases the chance it will reach deep into the tissues before it reaches the kidneys. Discrepancy with First Aid? +  
haliburton  my reasoning was comparing two drugs, both with Vd of 1, the drug with the lower albumin binding would be cleared faster @kingtime. I don't think you're considering that A and B have equal Vd. +6