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Comments ...

 +0  (free120#30)

but what is wrong with "Spirochete invasion of gastric cells"? It seems like H pylori is sometimes described as curved and sometimes as a spirochete. And "gastric cells" is general enough that I don't see why it can be wrong. There is H pylori in the gastric cells.

em_goldman  H pylori is sometimes described as helical but more often as curved, but is (confusingly) not a spirochete. Spirochete refers to a particular family, Spirochaete, and are markedly corkscrew. The three important spirochete bugs for Step 1 are Leptospira, Borrelia spp., and Treponema pallidum; Brachyspira spp. get an honorable mention but idk they're high yield for Step 1. Anything other kind of bug is not going to be a spirochete. Additionally, H. pylori is not invasive, and instead resides on the surface of the gastric mucosa. The picture showed some bacteria inside the lumen of glands, not intracellulary.
em_goldman  *idk if they're high yield
em_goldman  *any other kind of bug gosh dang it, lol, definitely in dedicated rn

 +0  (free120#28)

I see how it's splitting, but I also think an argument could be made for reaction formation. He acts as though he hates the one child who didn't come with him to the hospital - maybe he feels hurt and wishes the child had come. Reaction formation would be showing resentment and negativity towards the child to compensate for the fact that he actually wishes the child was there.

Or maybe I just overthink psych questions.





Subcomments ...

Narcotic use for acutely painful conditions is both reasonable and important. Short-term use (immediately post-surgical) does not lead to long-term dependence (or so people have thought…). And yes, drugs addicts should also receive narcotics to control pain.

drdoom  prefer “patients with hx of substance abuse” over more conveniently typed but less redemptive “drug addict” +4  
sugaplum  I don't see why switching her to oral pain meds when she is ready would be incorrect. Clearly she is worried about being on the pain meds, I feel making a proclamation that she has a low risk of addiction would be profiling just because she doesn't have a history. The opioid epidemic also affects people who didn't have a previous history of drug abuse. Just a thought, not trying to push any buttons. Maybe I am thinking to hard about this, but I don't see the clear A vs B line for this question. +13  
nbme4unme  @sugaplum I thought the exact same thing as you and chose the acetaminophen answer accordingly. I maintain that I am correct, my score be damned! +5  
sushizuka  I had a similar question on UW and the explanation stated that the correct answer choice was the only one that addressed the patient's concern and answered her question. The rest were just alternative treatments, so they were incorrect. But I too answered with oral pain meds. +2  
angelaq11  couldn't agree more with you all. I chose acetaminophen because opioid abuse is NO joke. The crisis is still going strong because of answers like this... +  
houseppary  I ruled out oral acetaminophen because they described in great detail the severity of her injuries, and indicated that she wasn't even fully conscious/aware when she asked this question about opioids. Rather than expose her to more pain, and possibly worsen her long-term pain prognosis, by switching to acetaminophen too early, in this case it makes sense to keep her comfortable because she's very seriously injured and not even fully lucid. It's kind to reassure her in this case. +  
anastomoses  I appreciate all of the passion for the opioid crisis, and the wording of the answer is definitely not ideal. However, PAIN is also very real, and there is no way acetaminophen alone would cut it in a case like this, not "as soon as she can take medications orally." Maybe I'm lucky to have 6 months in clinicals before STEP or had a mom who just went through urgent spine surgery for breast cancer mets, but there is a time and place for opioids and this is clearly one of them. Thank you for coming to my ted talk. +  


This patient has chronic kidney disease, as indicated by elevated serum creatinine/BUN and evidence of anemia of chronic disease (normochromic normocytic). Poorly functioning kidneys do not hydroxylate 25-dihydroxycholecalciferol to 1,25-dihydroxycholecalciferol well nor produce adequate erythropoietin (hence the CKD-related anemia). Patient’s with CKD thus develop secondary hyperparathyroidism due to deranged phosphate excretion and inadequate Vitamin D activation resulting in hypocalcemia. Thus, we should expect to see low calcium, high phosphorus, low 1,25 vitamin D, and low Epo.

houseppary  Any guesses as to why he might have CKD at 4 y.o.? +  


An annular pancreas surrounds the duodenum and can cause intermittent duodenal obstruction. While this question theoretically requires the imaging to answer correctly, the only other choice that is feasible is Choice D, which is known as SMA syndrome. SMA syndrome is quite rare and typically seen in people who have recently had significant weight loss. On the imaging, it would be smooshing of the duodenum by a bright contrast filled artery as opposed to surrounding by soft tissue. I also think it’s highly unlikely to be tested.

houseppary  I agree except that on the imaging, if this was SMA, the artery would not be bright and filled with contrast because the problem states that these studies were taken with oral contrast. So that's not a feasible way to eliminate SMA as the correct answer. I to think the quality of the obstruction seen in the UGI series show an annular-looking obstruction rather than a focal compression as you'd see in SMA. +  


Multiple infections. Abscesses. Then you hear decreased oxidative burst and immediately think NADPH oxidase deficiency aka Chronic granulomatous disease, which causes recurrent abscess-forming infections due to the inability to kill ingested organisms because of the inability to generate superoxide radicals.

jean_young2019  Then why the choice D, “Inability of leukocytes to ingest microorganisms“, is incorrect?Moreover, Staphylococcus aureus is not an intracellular microorganism. Thank you for your help! +  
houseppary  Because in CGD, the macrophages are capable of taking in bacteria but aren't able to do the oxidative burst required to actually kill them. So the macrophages just house live bacteria which leads to granulomas full of walled-off but not dead bacteria. And S. aureus isn't intracellular as part of its normal life cycle, but being eaten by a macrophage isn't part of its normal life cycle. Whether an organism gets eaten by a macrophage isn't part of the consideration of whether it's intracellular. +2