invite friends ⋅ share via email ⋅ twitter
support the site ⋅ become a member ⋅ unscramble the egg
free120  nbme24  nbme23  nbme22  nbme21  nbme20  nbme19  nbme18  nbme17  nbme16  nbme15  nbme13 
home login register ⋅ contact us ⋅ leaderboard rank-links news ⋅ membership directory
Welcome to hungrybox’s page.
Contributor score: 791


Comments ...

 +0  (nbme19#47)

I got confused with aquaporins so I picked E :(

But aquaporins are in the collecting duct, NOT the proximal tubule


 +0  (nbme19#47)

Question figure


 +0  (nbme19#40)

I put C because I thought that the weakness of the lower 2/3 face meant there was something more going on than just speech problems from Broca's aphasia.

Can anyone tell me why I'm wrong?

drdoom  A: Broca’s +
drdoom  B: Premotor +
drdoom  C: Motor +
drdoom  D: Somatosensory +
drdoom  Damage to C (motor) wouldn’t explain *fluency* problems. Fluency (=Latin ``flow``; the ease with which the brain formulates words). Slurred speech is your brain knowing and formulating the words easy but your mouth muscles not co-operating! +
drdoom  So, dis-fluency ≠ slurred speech. This gentleman is dis-fluent in the same way you’re dis-fluent when you visit Paris: your brain struggles to formulate French words in the first place! The only lesion that explains that in your native tongue is a lesion to the language synthesis center = Broca’s area. +

 +0  (nbme19#40)

Question figure


 +2  (nbme16#24)

Morphine stimulates mu opioid receptors to provide the desired effect of analgesia, but in doing so can also precipitate many undesired effects.  This patient has multiple signs of opioid toxicity, including miosis (ie, pinpoint pupils), respiratory depression (evidenced by slow respiratory rate and respiratory acidosis), and CNS depression (eg, somnolence, coma).  Morphine is primarily metabolized by the liver via glucuronidation to form 2 major metabolites.  These metabolites, morphine-3-glucoronide and morphine-6-glucoronide, then undergo renal elimination via excretion in the urine.  Because the metabolites are metabolically active, renal dysfunction can lead to metabolite accumulation and opioid toxicity.  Morphine-6-glucoronide is particularly responsible for toxicity, acting as a more potent mu opioid receptor agonist than morphine itself.

Due to its metabolically active and renally cleared metabolites, morphine requires careful monitoring when used in patients with renal dysfunction.  When opioid pain control is needed in such patients, fentanyl or hydromorphone is often preferred as these drugs are predominantly hepatically cleared.

Source: UW18563


 +6  (nbme16#1)

ACUTE alcohol inhibits CYP → Increased bioavailability of acetominophen

CHRONIC alcohol induces CYP → Induction of cytochrome P450 enzymes that activate acetaminophen to a hepatotoxic metabolite

I got this wrong because I assumed chronic alcohol meant years and years. I guess a weekend will suffice?

Honestly, fuck this problem.

lfcdave182  Yeah fuck this question. 2-3 days of something would never be considered chronic in anything else. +2
pontiacfever  Drink a lot for a week makes you a chronic alcoholic? +
pontiacfever  That means alcohol abuse = chronic alcoholism +

 +0  (nbme15#0)

Image from problem

Fluent speech, impaired comprehension → Fluent aphasia → Wernicke's area

Here are the others (as near as I could tell):

A: Broca's area → "Broken Boca" → would present with non-fluent speech with intact comprehension

B: ?

C, D: Motor cortex

E, F: Sensory cortex

G: ?

H: Wernicke's area

No idea what B or G are.

Here's a relevant image from Amboss

kahin  B-Frontal eye field? G-Parietal lobe +

 +1  (nbme15#0)

These are really the only two that should be on your differential for a diaphragmatic hernia:

A: Abnormal relation of the cardia to the lower end of the diaphragm | Sliding hiatal hernia

B: Protrusion of the fundus into the chest above the level of T10 | Correct! This describes a paraesophageal hernia.

different hernias

parts of stomach

cheesetouch  FA2018 P364 +

 +1  (nbme15#0)

(wrong answer explanation)

Intermittent obstruction of the common bile duct is wrong.

Biliary tract obstruction would have:

↑↑ direct (conjugated) bilirubin (normal 0.0-0.3, pt was 0.4)

↑ Alkaline phosphatase (normal = 20-70, pt was 35)

hungrybox  source: pathoma +

 +0  (nbme15#0)

A: Anal carcinoma | Would not be so acute

B: Anal fissure

C: External hemorrhoid | Correct!

D: Human papillomavirus infection

E: Skin tag

picture from the problem

picture showing most answers

*couldn't find a good image for anal carcinoma, if someone wants to share one that would be great

drdoom  wowee that’s a lot of butthole .. +4
hungrybox  hawt +
underd0g  Why isn't this HPV given the sexual history? +

 +0  (nbme15#29)

A: Gonadal mosaicism | Present in child, not parent → would not have family history of disease

B: Incomplete penetrance | Correct! Half of children affectd, skips a generation → AD inheritance likely.

C: Nonpaternity → Prader-Willi

D: Somatic mosaicism | Present in parent, not child → would not have family history of disease

E: Variable expressivity | Affected patients have varying disease severity → Rule out b/c mother is unaffected

cassdawg  Also, nonpaternity can be a way of saying that the assumed biological father is not actually the father (can be a case of artificial insemination or cheating, etc.). +2
beto  In genetics, a non-paternity event is when someone who is presumed to be an individual's father is not in fact the biological father. +

 +3  (nbme15#0)

Excess pattern repeats lead to strand slippage/errors due to an unstable region (in this case, excess Cytidine bases).

It could be a repeated pattern as well (ie the trinucleotide repeat CAG in Huntington's).

here's a more in depth explanation (from wikipedia article on Slipped-strand mispairing):

A slippage event normally occurs when a sequence of repetitive nucleotides (tandem repeats) are found at the site of replication. Tandem repeats are unstable regions of the genome where frequent insertions and deletions of nucleotides can take place, resulting in genome rearrangements.

hungrybox  Anyone know why it's not Transposon insertion? I was thinking maybe because transposons have to be longer than one nucleotide, but I'm not sure. +1
bingcentipede  @hungrybox I think it's because transposons are usually gene segments rather than a single nucleotide insertion - plus w/ what you said about the repeated pattern, I think slipped-strand mispairing (which is a concept the NBME loves) more likely. +12

 +1  (nbme21#22)

I’m trying to really learn this and know how to rule out all the answer choices. So far I have:

A: Anaphylactic reaction induced by IgA antibodies <2-3 hrs

B: Hemolytic transfusion reaction <1 hr

C: Postoperative bronchopneumonia Pneumonia, right after all the infusion business and no mention of fever or anything? Nah

D: Pulmonary embolus with pulmonary infarction

E: Transfusion-related acute lung injury Correct! Occurs <6 hrs

I was thinking D could be ruled out b/c there’s no mention of history of immobilization/hyper-coagulable states. And I guess it seems obvious the question is focusing on the transfusion. Seems kinda iffy though. What do you guys think?

pass_this  I actually got this wrong and chose D. But the question completely is trying to lean you towards transfusion and like you said no reason for PE. +
blindophthalmologist  Bilateral lung infiltrates makes it sound more of a immune process. CXR of a PE can be normal I believe. +
lovebug  and also, as you all know B) clinical Sx of Hemolytic transfusion reaction is hemoglobinuria and jaundice. there is no such thing. so rule out :) +

 +3  (nbme21#21)

A: Anterior to the nasolacrimal duct → angular artery* pic1 pic2

B: Distal to the vestibule → respiratory region/nasal airway proper pic

C: Inferior to the hiatus semilunaris → uncinate process pic

D: Posterior to the middle concha → sphenoid sinus pic

E: Proximal to the fusion of the hard and soft palate → horizontal plate (of palatine bone) pic

F: Superior to the superior concha → sphenoethmoidal recess pic

*I was really conflicted on what this could be referring to. Ultimately, I thought angular artery aligned the best with being anterior to the nasolacrimal duct, but I'm not 100% sure.

other things I considered: maxillary bone, inferior concha


 +2  (nbme20#17)

Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question.

To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs."

The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc."† So you can rule out nipple stimulation.

It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect.

†I've never seen anything like this on a question but I assume the NBME would word it in some convoluted way like that.

I initially wrote this as a subcomment, but I feel like it deserves its own comment. I was never really satisfied with any of the explanations for this problem, and I finally arrived at one that makes the most sense to me.

hungrybox  Oh, and besides, nipple stimulation and prolactinoma aren't even answers lol +
drdoom  [system mailer] your account has been upgraded: FORMAT NINJA +1

 +5  (nbme20#20)

Mitral valve stenosis only causes LA overload. In contrast to ventricular overload, atrial overload does not cause any axis deviations.

Thus, mitral valve stenosis is incorrect.

(I was between this and mitral valve stenosis.)


 +6  (nbme24#31)

I really didn’t understand this question even after reading all the answers here so I emailed Dr. Klabunde (the expert)!

Here’s what he said:

This is a case of acute heart failure following an acute ischemic event (ST elevation in anterior leads). SVR increases because of neurohumoral activation, which helps to maintain BP. PCWP increases because acute HF causes blood to back up into the pulmonary circulation. Increased pulmonary blood volume causes all the pulmonary pressures to increase. PVR DECREASES because the pulmonary vasculature has a very high compliance, and therefore passively distends in response to increase volume. This passive dissension decreases the PVR.


 +0  (nbme24#50)

Big Robbins:

https://i.imgur.com/gQnDH92.png

Idk how you could say that it's from extracellular dehydration, but whatever I guess.


 +3  (nbme24#23)

(D) Portal hypertension: Portal hypertension is a complication of longstanding alcoholism, but it is not the cause of acute or chronic pancreatitis.

In acute pancreatitis, alcohol transiently increases pancreatic exocrine secretion and contraction of the sphincter of Oddi (the muscle regulating the flow of pancreatic juice through papilla of Vater).

This leads to activation of pancreatic enzymes and acute pancreatitis follows soon after.

In chronic pancreatitis (as in this patient), alcohol increases the protein concentration of pancreatic secretions, and this protein-rich pancreatic fluid can form ductal plugs.

Made this explanation in case any of you were dumb enough to think "pancreatitis → alcohol → portal hypertension" like me.

hungrybox  oh my source was big robbins btw +
regularstudent  I was definitely dumb enough +

 +1  (nbme24#13)

(D) Fecal impaction: While this patient presents with some signs consistent with fecal impaction (inability to defecate for days or weeks, distended/tympanitic abdomen), fecal impaction typically presents with hard, impacted stools distending the rectum. Since the rectum is left sided, it's unlikely to present with a right-groin mass.

That's the explanation I came up with after reading the Amboss wiki


 +2  (nbme24#43)

Section on Endovascular Stenting from BIG ROBBINS (for people like me who need more context):

https://i.imgur.com/mhRrpwl.png

https://i.imgur.com/e9mO0Nz.png


 +1  (nbme24#5)

vs. eggs (ova) in stool → Hookworms*, Ascaris

vs. larvae in stool → Strongyloides stercoralis

vs. scotch tape test → E vermicularis

hookworms → Necator Americanus, Ancylostoma duodenale

(source: sketchy)


 +1  (free120#3)

Other answers:

sebaceous gland → acne, Cutibacterium acnes (formerly Propionibacterium acnes)

apocrine gland (aka sweat gland) → The substance secreted is thicker than eccrine sweat and provides nutrients for bacteria on the skin: the bacteria's decomposition of sweat is what creates the acrid odor.

eccrine gland → used to secrete stuff inside the body (ie salivary glands, pancreatic glands)

dermis → middle layer of skin.

melchior  To tweak the above a little, eccrine glands are more commonly known as "sweat glands," although sweat glands that are apocrine do exist in the armpits and perineal area, though they do not contribute to cooling. +

 +4  (free120#7)

This whole question is on the different types of hypersensitivity. (pg. 113 FA2019)

eosinophil degranulation → Type 1 hypersensitivity (mast cells early, eosinophils/others later)

widespread apoptosis of B lymphocytes → B lymphocytes are involved in Type 2 hypersensitivity. Widespread apoptosis would not occur. If anything, B cells would proliferate?

Cytokine secretion by natural killer cells → NK cells use perforin and granzymes to induce apoptosis in type 2 hypersensitivity. (Not sure if they secrete any relevant cytokines...)

immune complex deposition in tissues → serum sickness (Type 3 hypersensitivity)

polyclonal T-lymphocyte activation → type 4 hypersensitivity


 +6  (nbme23#5)

TLDR: Physical symptoms >> family history or anything else.

Like the other guy said, I got played hard.

I thought:

• poor prenatal care

• no family history

• bone problem/fractures

Instantly pointed to Rickets.

BUT, in retrospect this is key:

• intercostal retractions (vs. rachitic rosary → costchondral thickenings)

They're basically telling you to rule out Rickets. It seems 100% unfair b/c poor prenatal care seemed to rule in Rickets. The no family history seems to rule out OI.

But I guess what I've learned is, physical symptoms trump ANYTHING ELSE on NBMEs.


 +5  (nbme23#15)

Fucking NBME test writers lmao

Me: "Wait... isn't the answer 25.9? How come I don't see it here."

NBME: "Oh yeah, we rounded it."

Me: "To 30? I don't see that here, either..."

NBME: "No, to 28.8"

tyrionwill  When I got 25.9 and found nothing exactly matched, I guessed that the maintenance dose might be a bit more due to the bioavailability. So this antibiotic probably was not an I.V. formula, but an oral one, with a roughly 90% BA. +2
eradionova  Well then it could have been equally likely that it had a 50% BA and the answer would be 51.8 exactly. I almost considered picking that but in the end stuck with the one that was closest to my answer lol +2

 +4  (nbme22#10)

Cavernous nerves are most commonly injured in prostatectomy. They are parasympathetic nerves that signal penile erection.

S2-S4


 +2  (nbme20#7)

The endoderm of the 3rd and 4th pouches form the parathyroid gland and the parafollicular cells of the thyroid gland.


 -4  (nbme20#33)

Here's my reasoning for why the answer I chose was wrong...

Casein is a milk protein. Because most milk is pasteurized, all proteins will be denatured before consumption, and would not have any effects (Choice B).

This is in contrast to avidin, which is found in RAW eggs and binds vitamin B7 (biotin), preventing carboxylation.

...

bullshit question btw 😡


 +3  (nbme20#5)

I did this by process of elimination:

Acne is not itchy or painful from my experience (Choice A).

Never heard of cutaneous lupus eryhtematosus, but I'd asssume you'd have a malar rash (involving the nose/undereye area), not spread out over the cheeks, jaw, and neck (Choice B).

Keloids are just overgrown scars. Scars are not particularly itchy or painful (Choice C)

Rosacea is just redness/flushing in certain areas of the skin. Mainly an aesthetic issue. Not itchy or painful (Choice E).

tbh I was between B and D.


 +8  (nbme20#30)

Here's my approach (downvote if wrong):

falling on outstretched arm → usually scaphoid

BUT

scaphoid problem → pain in anatomical snuffbox

so then it goes to the next most commonly injured bone when you fall on an outstretched arm, your lunate

(which is right next to the scaphoid)

spaceboy98  Also, dislocation is most common in lunate, Fracture most common in Scaphoid +1

 +0  (nbme20#25)
unscramble the site ⋅ become a member ($36/month)

So... eorhltalcyeit na ioasdlte screadee ni RH luwdo arenseic OC edu to .inc dar,epol grhti?

But OC srdceeeas in siht aces bc/ the eftefc of .inc TRP is roem ouep?frlw

kernicterusthefrog  @hungrybox: No. Isolating HR, you would look at CO like this: CO=HR*SV so if HR or stroke volume go down, CO goes down. The change in preload wouldn't affect the CO as much as the change in rate of flow. So, the decrease in CO is solely due to the beta1 blocking effect on the AV node to decrease HR. +

 +11  (nbme21#44)
unscramble the site ⋅ become a member ($36/month)

orthe sr:aewsn

niibhition of H2 rptserc:oe of(r DG)RE rnevtep ascrtgi idca icotneers cmtiideeni(,

iiitnohinb of sioesahprsostdepeh )DEP:(

  • oyenhhiltepl (ahstam) nihbtsii PMcA DPE
  • fal-sni icdk( slpil) orf ED nhiibit cPMG PDE

2β ngs:toais rf(o hmas)ta uscea nibncolohiradot

  • uortalbel hotrs( cating - A ofr ute)Ac
  • ral,meotsle omrfotlroe (olgn nitagc - ipaxyhlpso)r

(kdi tlecmpyoyh mranbeem nbiiatsi)ztloa

hungrybox  H2 blockers are the -tidines +2
yotsubato  > dickpills lol +15
temmy  hungrybox, you are a life saver +1
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +1

 +6  (nbme21#24)
unscramble the site ⋅ become a member ($36/month)

cyrlscMoloaa,pci usoauqsm clle cmiornaca edtsn ot eb fht-fiewo ni ,locro aigsinr ,mrfo and digntneex ntio a ho.nsbcru

rc:eSou adpRiiadeo

privatejoker  Lol am I the only one that picked Malignant Lymphoma? I thought I remembered Sattar mentioning that metastases are the most common form of cancer to be found in the lung? I tend to pick the "most common" presentation when given so little information to work with +2
blueberrymuffinbabey  but metastases typically present with multiple lesions so I think at least in exams when it's showing you a solitary lesion, think a primary tumor. +1

 +28  (nbme21#17)
unscramble the site ⋅ become a member ($36/month)

nhwe ffid nlsige snadtr ariper msceahnism ear dse:u

  • eprari ywlen dyeszhntsei asdnrt: mtihsmac apirre ync(hL royesmd)n
  • arprie rpyemdiiin isedmr udseca yb dat VU rxuse:oep oedelticnu nxseiioc eairrp oeX(mrdare o)gmtesnmipu
  • aprrie /ttsoesxiounnopac teotanira:l ebas nseocxii reiarp
meningitis  Brca: recombinant repair +
brotherimodu  P.40 FA2019 lists the different DNA repair mechanisms +2
teepot123  fa '19 pg 382/3 +

 +7  (nbme21#36)
unscramble the site ⋅ become a member ($36/month)

rUdietevnFii -t;&g euds ofr nfsiou of HVI urisv nda tertag clle

aishu007  we can also say it enfuviritide blocks entry +
aishu007  of virus into cell +

 +8  (nbme21#25)
unscramble the site ⋅ become a member ($36/month)

ltnaeveR amdagri

TIIA ncssotitcr het etenerff ret.relaoi ACE irhsbioitn koblc eht mAdeCdae-iEt necoorvins fo TAI ot .ATII

lilanps  https://www.ahajournals.org/cms/asset/f232c550-8954-4d03-9d03-5e2c2b966471/hc1481404002.jpeg Updated link to diagram +

 +8  (nbme21#34)
unscramble the site ⋅ become a member ($36/month)

ymenasoiych detspo isht ergat ipc bweol

eacv  here is a video for ilustration https://www.youtube.com/watch?v=US0vNoxsW-k +2

 +5  (nbme21#38)
unscramble the site ⋅ become a member ($36/month)

My eospisrimn fo mcirepAihnto B is atht 'tsi hte IGB SNUG. It trsithga up taaktsc hte losestr ni teh uifgn lapmas amne.rbem

lMnaiehew lil bthci ursgd keli -zaelos ujts inhitib oseltr ssnesti.hy tnifrnb(e-iae X eotlnl,asro s-zloea X r)otroseleg

isgnunF X lecl wlla ,eysinshts ufoclntyeis X ienlccu cdia sh.seitsyn

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 +2
et-tu-bromocriptine  Ripppp the formatting, but hopefully the idea gets across +
et-tu-bromocriptine  Fixed it, see comment! +

 +26  (nbme21#49)
unscramble the site ⋅ become a member ($36/month)

rlzoHcrodiayeotihdh si a ietdhaiz ireidutc &g;t= iadtehzi dcteisiur rea daoietassc twih ylmai.aheopk

Wath htero ructsdiei rea casiedtaos with ieaklaomy?ph opoL eis.trciud

yWh?

iinoiInthb of a+N nrrietopbaso ocsruc ni tbho olop tiscediru nbiiit(h NKCC rrco)nsrptteoa nad aiztdihe usciidter (hniiibt lCaN .psrortecrrao)tn All of itsh sindreaec aN+ rneceasis eAsntloodre ytit.cvia

Rnateelv ot shti ,rbmeplo rteoAdloens aelugsuprte soerpiesxn fo eth K++/aN PTA entroprait (orasbbre +aN tnoi o,ybd epelx K+ tnio le.m)un hisT letssur in iyhpaamelok ni the oy.bd

angH no, str'eeh orme hgih ideyl !onfi

rdeeltonosA does eon roeth apmrtntio thgin - iatoantvci of a H+ nlnache thta xeplse H+ otni the une.lm

oS, egnvi htat tsih epiattn ahs omahe,iaykpl ouy konw teehr is ruatiunlegop of Atrsdnoloee. oD uoy hkitn ehr Hp woldu eb h,igh or wlo? Et,ycalx it dwluo eb ghih ebeasuc nic. onosdAteerl t=g&; .icn +H xdleepel tion hte lmenu g&;t= omialtecb .kaioassl

wNo oyu nrdtnsaeud ywh obth opol rucdtiise nda atdiezhi etsirduci nac csuea wat'sh alcled hiea"olkympc aelbcitom lsska."aiol

hungrybox  jesus this answer was probably too long i'm sorry +2
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +10
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +
amirmullick3  @hungrybox did you mean "All of this DECREASED Na increases aldosterone activity."? +1
pg32  Anyone care to explain why she feels she has, "lost [her] pep"? Is that due to the hypokalemia? Or hypercalcemia caused by the thiazides? +
cmun777  @madojo @pg32 I assumed between her hypokalemia (which can cause weakness/fatigue) and possible contraction alkalosis those were the most likely causes for the "lost her pep" comment. I think if they wanted to indicate hypercalcemia to differentiate if loop diuretics were also in the answer choices they would certainly give more context for hypercalcemia sx +

 +7  (nbme21#12)
unscramble the site ⋅ become a member ($36/month)

aGtre oivde I sude to lenra tsih .aiatemrl

  1. herTe ear 3 orjma pyets fo gur:sd rspeup tmauntissl),( endwosr sn,rt()aeessdp nad olen.chngsuila
  2. nHeori is an id.pooi Oosdipi rea e*sw.nrod
  3. nDowres do tawh ti dnossu i.elk eTyh cuaes o"n"dw tpo:mssmy rdienadedesscao/te eytaxin dna( tshu rilehaobva ibidntn,i)soihi erpaotsyirr noidesrp.es
  4. sThu wtriwlhdaa iwll uesac hte es:piootp iahehnecsanpdi,/corryatty xen.taiy
hungrybox  *other downers: alcohol, benzodiazepines, barbiturates +2
nwinkelmann  THANK YOU! for the link to the video. this is one thing I've ALWAYS struggled with. +
qball  I get that this is a good rule of thumb to help narrow down between alcohol and heroin, BUT is still not enough to answer this question. Some key features for depressants (downer) is alcohol (if we are talking mild withdraw) - tremors , diaphoresis and delirium (heavy withdraw) . For Heroin - Dilated pupils, yawning and lacrimation are key exam findings. +1

 +7  (nbme21#1)
unscramble the site ⋅ become a member ($36/month)

ehT rcivex si het noyl etruucrts taht dwuol lsurte in leiabrlta .edkoacbl

hungrybox  hydronephrosis = dilation of kidney (usu. due to obstruction at uretopelvic junction or backflow from obstructed bladder) +2

 +7  (nbme21#44)
unscramble the site ⋅ become a member ($36/month)

oopL icturedis aer trfsi lien fro uecat egoscvnite eahrt ielu.arf That ldoush lhpe you ebmrmree ttah yhte rae het sotm ntoetp ,itircedsu so ehy'etr ntoef desu ni het tauec atenemtrt of aed.em

peridot  I think what threw me off was that this lady had such low GFR, figured it couldn't be right. Turns out it's still ok. Furosemide is a miracle drug!! +

 +10  (nbme21#41)
unscramble the site ⋅ become a member ($36/month)

Ler:oaiepmd Aigostn ta iuoop-di eot.esrcrp wSlso ugt lytomiit m,m(eerbre otatincoispn is a mcomno dies ftfece for all od.)siiop

ziuq roslyufe:

Q: uWlod a kejnui antw ot ues ampdere?oLi

A: oN, it sah orop NCS pntroaneeti chw(ih si wyh it ahs a wol aedcdtiiv pei.ato)ntl

Q: Would a nkujei rherat heva porhmnie ro eropuiehnpn?rb

:A .nMhpoier hotB aer doiupio- tgn,assio tbu oiheprmn si a flul aitgson eiwlh nponeibepruhr is yoln a alraitp angt.iso

Q: ahWt utoba mhopnire vs. ?deneoci

:A cTirk qeus,into both rae aritlpa gtiossa.n

cienfuegos  Thanks for passing off the knowledge. Regarding the last part, aren't morphine and codeine full agonists? +5
champagnesupernova3  Yes they are +2

 +7  (nbme21#18)
unscramble the site ⋅ become a member ($36/month)

HHGI IY:ELD unniosolb" itn"imgov manse thta het otnb/sorcsisiuteu oecsm eeorfb ami(oprlx ot) eth odecns m,enuudod weher biel is eresdae.l

At dnarou 4~ ewske ievg( or taek a )wef si ehwn yprloic snitseos lsuualy swhso p.u

ez tps fro u nwo ekep it pu

mannywillsee  Sadly the easiest question that just jumped out of its way and said Pick me! +

 +10  (nbme21#37)
unscramble the site ⋅ become a member ($36/month)

oolnFlgwi a sk,erto hits titnpae ahd wsnaeske of erh flet acfe nad oyd,b so eth tsoerk smut ahev affeecdt eth tghir dies of reh ibra.n B was teh nlyo eccoih on the tighr idse fo rhe ria.nb

iSltl f?cnesuod eRda n...o

Teh truvloayn romot rsfbie (ilosocpnaicrt tra)tc cesdedn rfom eth mrairpy moort ctroxe, ssrco seusad(etc) at het ldmalyeur ,rpadiyms and hetn apysens ta eht ieorrant rotom nohr of eht spailn ee.lvl

Besaceu fo otcsasendiu ta eth uaermldyl smarpy,di uoy usldho kame a oten of erweh nya oesktr rcsu.co sI it oevab teh aumldelyr pd?yrisam Tnhe it lwli cetfaf het dise peiosotp hte otkrse l.n(r)aaorcletat sI ti oewbl hte mrdaulyel dipmasyr? hTne it lilw afftec eht asem iesd as het oetskr ltialr).psiae(

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +
mnemonia  Very nice!! +
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +7
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +15

 +8  (nbme21#50)
unscramble the site ⋅ become a member ($36/month)

ehT tmcoania sfnoxfub si mfdore by eth ondnest fo hte etsreoxn cllipsoi bivs,re hte utcrobad ipsclloi u,solng dan the nextsroe ioliplcs olsngu. (ruiefg)

eTh lroof si rfoemd yb het phdsciao ,beno and ti si rehe ahtt eon nac aplepta rof a lssbeipo errftacud odis.phac

rSuceo: sG'yra nAyoamt eRwvei

hungrybox  Of note, the radial nerve innervates the extensors of the wrist. So the muscles of the anatomic snuffbox are all innervated by the radial nerve. +
hungrybox  This helps you remember that the radial nerve innervates the abductor pollicis LONGUS (abductor pollicis BREVIS is median nerve, ADductor pollicis is the ulnar nerve. These two make sense if you think about the direction the thumb is moving - ending closer to the nerve.) +
meryen13  just to review, if we don't fix this, what gonna happen next? --> avascular necrosis of scaphoid--> non-union. why? because scaphoid has two blood supplies the distal part is mainly volar branch of radial a. and the proximal part is mainly dorsal branch of radial a. +

 +3  (nbme21#26)
unscramble the site ⋅ become a member ($36/month)

riamgda hsoiwgn AOM


 +6  (nbme21#19)
unscramble the site ⋅ become a member ($36/month)

aka auamllp of ateVr or het peaotpcinacrehat ucdt

hungrybox  tripped me up cause I didn't know the names :( +11
sympathetikey  @hungrybox same +7
angelaq11  omg, same here! I thought, well, I don't know of any duct that connects the pancreas to the liver, so...2nd part of the duodenum it is :'( :'( +6
alimd  actually Ampulla of Vater is located in the 2nd part of the duodenum. +
mtkilimanjaro  I think 2nd part of duodenum could be viable if the ampulla was not an option. The ampulla is way more localized/specific to this scenario +

 +7  (nbme21#20)
unscramble the site ⋅ become a member ($36/month)

uiqz sroyufel swesar:n

  1. rSitleo reoSti(l hstSu dw,on IFM is trceedes yb itreSol sl)ecl
  2. p-lh5aa udercates
lovebug  5-alpha reductase is due te that DHT is important for male external genitalia? +

 +19  (nbme21#20)
unscramble the site ⋅ become a member ($36/month)

iThs oediv esinlpxa gntleia lyrgmbyoeo yeemrtlxe .lwle

If you tlef olatylt tosl klie e,m thacw the divoe rfits ta 2,x tnhe ckhce out het mtobot eufgir on gp. 608 in AF 0.921

eeRtvaln ot hsti qt:oisune

  1. YRS tepniosr astmetlui dtemnolevpe fo sestte
  2. Tish tp sah eetsst &=g;t he tusm aevh het YSR egne no teh Y ocshmeromo
  3. MIF dersaegd eht lMaileunr d,uct hhiwc uoldw tieswhero ebemoc het rainlent meefal naeilgati
  4. Tish tp sah itarelnn fmalee tgnaaieil =;&tg tdidn' kema ohngeu FIM

uizQ uersfloy (ewrasns in a pasetear t:sp)o

  1. ihTs i'tsepant iedsdrro acn eb tdacer cakb ot hwich c?lsle
  2. This panetit had anmolr aaelig.tin If tihs etpaitn hda amrllse ilgaianet anth mlo,anr atht oudlw eb a eedctf ni hwta emy?enz
ergogenic22  I like to work backwards. 1) patient has normal testicles on histology, normal appearing penis this must mean a Y chromosome is present, as testis determining factor is on the y chromosome (see above post point #2). I.e. you can eliminate choice A and B. Theoretically, 47XY and 47XYY could also present with female genitalia due to lack of MIF, but normal 46XY is more common +8

 +1  (nbme21#26)
unscramble the site ⋅ become a member ($36/month)

olsbeobt"en"c anpearcpea si oidssaacet ithw ohsCr'n ediesas

cnpsrmoiao fo o'Cnhrs sv CU


 +8  (nbme21#26)
unscramble the site ⋅ become a member ($36/month)

apsrt of het ncolo atht are reoltnierroetap


 +6  (nbme21#19)
unscramble the site ⋅ become a member ($36/month)

gulrjau nuvseo oiseidnttn = eftl rtahe fuareil

rnuaplmoy eedma = hrgti rheta efilaru

aocbur-mrFhe tloaniid is het smto keilyl naws.er

rehtO erasw:sn

  • tsmiAsryce aepslt t,hpheroypry mocladraiy iyrd:saar tehes rea bhot alsiccs sdfngnii in cperhpiyrhto dmpayiatyohcro CH(M)
  • locniaderad o:foeiarsbitsls a erra tireivscret rdcaoohiymtyap snee ni hif/rtnnlacdines
  • piymltcchoy oiriiattlnnf of eth mau:dicyrmo nese ni vilar mtm(eu)oniau ryicmaot.ids A ecsua fo aeltddi otd,oipmyhyrcaa tbu ehetr wsa on nmteion fo a inceredpg arlvi selnls.i
meningitis  I think you meant: Jugular venous distention = LT HF Pulmonary edema = RT HF +4
hungrybox  woops yea I meant Jugular venous distention = RIGHT HF, Pulmonary edema = LEFT HF +10
jackie_chan  What threw me off the picking 4-chamber dilatation was it seemed like that would be a major cardiac/ventricular remodeling and the vignette gave a somewhat acute 2 week onset +

 -8  (nbme21#42)
unscramble the site ⋅ become a member ($36/month)

acpialpremes snteespr rtfdfe:iynel

  • ptsms:omy aeehhacd, dbrruel ,iiosnv lmnaioabd a,pni tgwhei ngia wr(aet ri)ntetneo
  • n:gfsndii ehtsiprye,non a,ureipotinr eemda

 +18  (nbme21#3)
unscramble the site ⋅ become a member ($36/month)

The 2 csmmnnteodam of cehsit oie:sunqst

  1. Dot'n rvee kcip an enrwas ewehr ouy ndsuo elki a cdki
  2. tnDo' erve slncuto eth hietcs mcoetimte

dveSre em llew no tihs s.ieqnuto

linwanrun1357  If there is a choice about asking what the patient is worried about. Is this right? It does not sound like a dick :) +1
champagnesupernova3  If this were about a treatment asking why hes worried would be right but hes kind of doing the hospital a favor so I dont think you're supposed to try to convince or pressure him +1
brasel  also, any patient participating in any research study can withdraw whenever they want. Answer E is wrong because he shouldn't have to go through hoops to quit, he can just drop out at any time. +1

 +9  (nbme21#23)
unscramble the site ⋅ become a member ($36/month)

on'gHuittsnn isesade

  • toiipiaacnnt: hes sah a rliiams dedsiorr sa erh aerfht ubt deid laeirer

emebmRer T"UNH 4 na ia,lman tup ti in a G"A.eC gtutinnniH gnee ufdon on eCsohromom .4 AGC is teh deitotriuclne pteare:

  • ehC,ora etcuaad eusclnu
  • axiatA
  • mGolyo issdonr)eep(
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +11
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +
foulari112  How would you differentiate this from Frontotemporal lobe dementia +
temmy  Foulari 112..the ageof the patient and the anticipation cos her dad had it too. Also in frontotemporal pick, you will see personality changes where they act completely different vs huntington where they are aggressive and depressed. +1
castlblack  CAG = Caudate loses ACh and GABA (from FA) also points you to caudate +

 +11  (nbme21#8)
unscramble the site ⋅ become a member ($36/month)

Kf-ekfcoorseiakrWn esoynrmd ude ot iatmneih (B1) yfcdnie.ice Cmnmoo ni io.chasllco

The ranseo hyw ehyt dsai ustl"esr fo loachlo dan gurd reesnc rea tgeenvia" is that eth tainferfiedl idulsnce eacut oahlolc iitcotano.nxi

ckrneei'Ws idart:

  • nfnuoosci
  • spyarlsia of eye mucessl me(ooaipahgth)*lpl
  • aaiaxt

eetssrpn* eehr sa agmssnytu

Kfs'ofroaks scihssp:yo

  • ryemmo sslo eoe(ardtngra and rogareed)rt
  • naigmk itsh pu n)iab(oaunlfcot
  • aytnepiolsr hcngae
teepot123  fa 19 pg 559 +1

 +9  (nbme21#11)
unscramble the site ⋅ become a member ($36/month)

ot/au5ale/cunp hda a eragt ipxotne.nala

He'sre an aigme of hte tffnireed aessgt lognfoilw dmaicoylar arcnoniti.f tNeo teh otric"noatnc a"sbnd are hatw nfedie altaveugcoi rsnc.eois


 +29  (nbme21#15)
unscramble the site ⋅ become a member ($36/month)

why mshsoleiy si rgow:n

heTer lohdus tasoml ernve eb gttiahrs up ubiblrini ni teh n.ieru In l,omsisehy eth esescx ibirlnuib is edertcxe in the .beil Atrfe ticablaer ncnveoirso dna kurpt,eae esmo liwl eb eceerdxt in eht iurne sa uibonilr. werHoev, ni oebtvucsitr drrs,edosi the tnugjoecda iinbrlibu lwli verne ahve hte rpotupoytin ot grnedou cratbeali veorcnsino ot brtnuiocio/r.els In isth ,way hte coudnatjeg bblunirii has no other awy to eb eecrtdxe treoh nath lcdreyti ni eht nuei.r

tdecisr ot 3au6cn/ara7l/ no etridd

skip_lesions  Found a good pic showing bilirubin metabolism +
mangotango  Good pic I found: http://eclinpath.com/chemistry/liver/cholestasis/bilirubin/bilirubin-metabolism/ +

 +2  (nbme21#45)
unscramble the site ⋅ become a member ($36/month)

rAcndciog ot hte ,MULSE 'usslmeine yonl seu is in inleemsu usfdeil sa a traeemtnt rfo a suungf lealcd sMzsaleiaa spp Tiena( i.)ocrslovre


 +16  (nbme21#20)
unscramble the site ⋅ become a member ($36/month)

oems gnwor srnesw:a

a*skem sesne b/c allmtobeyss aer ruesrspcro to nyuerlact,gos hhcwi ues POM ot tfghi off iesifcnont

temmy  Hungrybox aka life saver +1
hello  Thank you!!! +
bbr  ....uh yeah im pretty sure we just call em "Auer Rods" now. Appreciate the answer tho! +4

 -5  (nbme21#37)
unscramble the site ⋅ become a member ($36/month)

ogLn awenrs d,ehaa utb rbea wiht .me

NTI:H v solko dnki of kiel ,y hesreaw k oskol roem lkei .x

tnterp-yiec = x/1Vam

  • axVm is teh eprup iilmt on who tasf a aitrenoc si tlzaaedyc by zenemy.s

extctinre-p = mK/1

  • mK si a aknginr of how godo na yezemn si ta nibdnig its seb.utarts nA eeymnz hiwt a grnakin fo 1 is betret at biidnng its rstesautb anht na zmneey with a kninrga of 5. e(Lrwo Km = retebt )meneyz

Noet ttha Vxam, as a mrsaeeu of nerfepaomc,r anc be dtelaer rgtohhu yman gs.htni neMihl,awe Km is a est tthcicrisceaar of het nyze,em nad noatnc be lt.areed

In siht maexle,p teh ynzmee rcnaemfproe (Va)xm si nriacedse by eicgnaisnr the iivnmat tfacroco so htta it caeersh a ro""nmal acivyt.it ovH,were hte neeyzm si tills etrneyhnli sytthi deu ot a cgenonliat etefcd, os het Km ystsa the ma.se

mnemonia  Awesome. +
ht3  wait line B shows the vmax doesn't change and that the km is getting larger (enzyme is still shitty so larger km) so -1/km would be a smaller number and would approach 0 +1
lamhtu  You say Km cannot be altered and its staying the same, but the answer of the graph demonstrates a higher Km value. Needing "higher concentrations" of the B6 for enzyme activity is another way of saying Km is higher since more is required for 1/2 vmax activity +4
sbryant6  Yeah this explanation is wrong. +

 +13  (nbme21#1)
unscramble the site ⋅ become a member ($36/month)

amethtluob = btmYhEaloEut

Gerta mcenniom for brimgenmere ttah lhotbmYEtaEu si het ntmnoecpo taht ssuace iaslvu smlbroep in ERPI ytaphre rof TB.

hungrybox  RIPE = rifampin, isoniazid, pyrazinamide, ethambutol +2

 +3  (nbme21#41)
unscramble the site ⋅ become a member ($36/month)

oehtr a:rwssne

  • :nlpycorsea ioAadssect ihwt gnocgyohip or cmyopophpin ainctsaohl.nuli

  • OonhyGp to eples = ihgtn meit inonaiahltcsul

  • mypsxraola rlotacnnu sedapny: NPH si a ytocleimh .amniae oN sgsni of letcymiho eianam (a,uraihtem jainuedc, e.dc o.ptlgno)habi

  • eepsl e:anpa aotiAecssd wtih isey,tbo odul sgoinnr.

doingit21  narrowed down to MDD and restless leg then convinced myself that elderly are at higher risk for MDD than RLS. Is that valid reasoning? +2
yb_26  Paroxysmal nocturnal dyspnea = breathless awakening from sleep, seen in left heart failure. It is not a paroxysmal nocturnal hemoglobinuria. +11

 +3  (nbme21#28)
unscramble the site ⋅ become a member ($36/month)

eDu ot lgcy'eins slalm zie,s it ceartse "nski"k in the ianom idca cue.esqne heeTs kinsk rea deeend ot croletyrc ofrm eht arsnedoyc u.tetucrrs

rhOte es:nrasw

  • akewende" niirtcteoan ewteben agllneco nad loarcpygntoe" - alelcogn + grytconpoael = cgeta.lilra ehT sotinqeu tsem nemsiton yman sefedct ni ONEb etp(y I lgnlcaoe) btu no nmeitno fo tesecfd in cWlleraTagO yetp( II llo)agenc

 +13  (nbme21#25)
unscramble the site ⋅ become a member ($36/month)

ptaDsiylcs vnie rae a rrcposeur ot .mmaoaenl Tyhe heva alrug,irer calsti"sd"py esrd.rob bemmreeR the "B" ni BDAC nsstda ofr lgierarur r.osderB usevN nmaes el.om

rOeth snsa:wer

  • ihcsonsata nargcisin - rDeaningk of isnk aaodssctie whti pyeT II deasbeti lsluitme

  • asbal ecll nicraamoc fo sink - ,yleRar if erve simstaeate.zs nomCmyol tsfcfea uprep .lip

  • ubel vusen - eBl-culeoord ptye fo ooncmm elo.m .Beinng

  • tiemgnpde iorchsebre atkiseors - "Skuct no" aneparpa.ce oMstyl gnineb. Afsfetc oreld .eepolp

  • Ne(to - ouy alsuluy see only neo. If ltpmueli ersiceorhb rskaeseot aer e,sne it iecsdiatn a IG niyacmagnl - aka rtlseTé-reL"a sig)n
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1
sympathetikey  Pathoma says upper lip, good sir +24
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +4
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +1
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2
teepot123  fa 19 pg 473 +
rockodude  just remember BS. basal cell upper, squamous cell lower +




Subcomments ...

submitted by cassdawg(575),

This is metastatic renal cell carcinoma (FA2020 p605) for the following reasons:

  • Polycythemia - this is the primary clue, as it is associated with ectopic EPO (erythropoitin) secretion in paraneoplastic syndromes (FA2020 p228), which can be caused by pheochromocytoma, renal cell carcinoma, heptocellular carcinoma, hemangioblastoma and leiomyoma. Of these, only liver and kidney would be a choice given and hepatocellular carcinoma is incorrect because he did not have any associated finding of jaundice, hepatomegaly, ascites, or anorexia (FA2020 p392). Plus, the liver does not commonly metastasize to brain whereas kidney does (FA2020 p223)
  • Hypercalcemia - this is likely indicative of PTHrP secretion, and renal cell carcinoma is one of the cancers that can do this. However, this is fairly nonspecific as there are many cancers that can secrete PTHrP.
  • Heamaturia - suggestive of kidney/urinary tract involvement
  • Negative for carcinoembryonic antigen - this is a nonspecific marker mainly for colon and pancreatic cancers (FA2020 p226)
hungrybox  WOW. Amazing explanation. Great work!! +  
nbmeanswersownersucks  Additionally the histo looks like the Clear cell type of RCC. The large white/clear spaces with "chicken-wire" vessels and stroma between them. +1  


submitted by hungrybox(791),

A: Anal carcinoma | Would not be so acute

B: Anal fissure

C: External hemorrhoid | Correct!

D: Human papillomavirus infection

E: Skin tag

picture from the problem

picture showing most answers

*couldn't find a good image for anal carcinoma, if someone wants to share one that would be great

drdoom  wowee that’s a lot of butthole .. +4  
hungrybox  hawt +  
underd0g  Why isn't this HPV given the sexual history? +  


submitted by hungrybox(791),

(wrong answer explanation)

Intermittent obstruction of the common bile duct is wrong.

Biliary tract obstruction would have:

↑↑ direct (conjugated) bilirubin (normal 0.0-0.3, pt was 0.4)

↑ Alkaline phosphatase (normal = 20-70, pt was 35)

hungrybox  source: pathoma +  


submitted by hungrybox(791),

Excess pattern repeats lead to strand slippage/errors due to an unstable region (in this case, excess Cytidine bases).

It could be a repeated pattern as well (ie the trinucleotide repeat CAG in Huntington's).

here's a more in depth explanation (from wikipedia article on Slipped-strand mispairing):

A slippage event normally occurs when a sequence of repetitive nucleotides (tandem repeats) are found at the site of replication. Tandem repeats are unstable regions of the genome where frequent insertions and deletions of nucleotides can take place, resulting in genome rearrangements.

hungrybox  Anyone know why it's not Transposon insertion? I was thinking maybe because transposons have to be longer than one nucleotide, but I'm not sure. +1  
bingcentipede  @hungrybox I think it's because transposons are usually gene segments rather than a single nucleotide insertion - plus w/ what you said about the repeated pattern, I think slipped-strand mispairing (which is a concept the NBME loves) more likely. +12  


submitted by hungrybox(791),

Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question.

To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs."

The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc."† So you can rule out nipple stimulation.

It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect.

†I've never seen anything like this on a question but I assume the NBME would word it in some convoluted way like that.

I initially wrote this as a subcomment, but I feel like it deserves its own comment. I was never really satisfied with any of the explanations for this problem, and I finally arrived at one that makes the most sense to me.

hungrybox  Oh, and besides, nipple stimulation and prolactinoma aren't even answers lol +  
drdoom  [system mailer] your account has been upgraded: FORMAT NINJA +1  


submitted by hello(251),
unscramble the site ⋅ become a member ($36/month)

aGlonj ahd a eetrluc ttah eimnotedn ttha fI" a itptnea ash lcerthaarago, eerivw eryev grud eeh'try natgki insce nmay srugd euasc oagehaa"rr.ctl

Teh onyl ginth of plbisseo ercvalnee ni isht -tsQem si thta seh keast a doamcti,ien teorrheef hte nwesar of urgd" effec"t is eht otsm klyiel aosren rof her cl.oarahertag

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +3  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  


submitted by hello(251),
unscramble the site ⋅ become a member ($36/month)

noljaG hda a rtueecl ttah eteomdinn that "If a eanpitt sha aaghaclrreot, veierw eveyr dgur eeyrt'h kaitng neics amyn gudsr eacsu t"lgrcahareao.

heT oynl nhgti of ssblpeio erelvncae ni hsti setm-Q is ttha ehs ekast a encidai,tom torfheree het wasenr of d"rug tec"eff si eth omts ikylel esarno ofr ehr .alcetgrarhao

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +3  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  


submitted by fkstpashls(13),

Process of elimination is the only way to get this answer without Savant levels of autism, as some bowtie wearing doucher who wrote the question probably has.

Cancer is unilateral almost all the time, DM doesn't make sense for any reason, HTN itself wouldn't cause milky boobs, and mast cells degranulating doesn't make milky boobs either. So, and because many drugs can have milky boobs, you're left with drug effects by process of elimination.

djinn  I dont think the autor was a savant. Also I think is right proccess to think "cancer" can be bilateral and malignant but the "drug" that causes this isnt HCT. This question is bad written. +1  
hungrybox  According to Pathoma, galactorrhea is NOT associated with cancer ever (see 16.1 - breast pathology). +  


submitted by hello(251),
unscramble the site ⋅ become a member ($36/month)

Gjoanl ahd a teuelcr atth idetoemnn atht I"f a tatpein has garrlceataho, evrewi ervye ugdr yhre'et kaitng ecins anym sdurg saceu rcalhraet"aog.

eTh noly ihntg of bpesoisl eeraevnlc in isht tsm-eQ si atht hse setka a iom,inaecdt etrefrhoe hte nsrwae fo dgu"r f"teefc is the ostm eyllki aornes rof rhe ret.loahgraac

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +3  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  


submitted by hayayah(990),
unscramble the site ⋅ become a member ($36/month)

aitaContcor fo eht aotra dsael ot idaeescnr VL aoeolrvd niaucgs LV pteyrorhhyp nad a L sxai dniavet.oi

hungrybox  Similarly, RV overload leads to R axis deviation. Could point to PAH. +1  


submitted by keycompany(268),
unscramble the site ⋅ become a member ($36/month)

wdrsenAe ym now eqonti.us nrseaIecd tsessr fmor a TESIM wlil iatavetc hte csytmpheait evrsonu myesst -- ylmonauPr lnts.oioviaad

pathogen7  Just to add, CHRONIC heart failure is a cause of pulmonary hypertension. So in the acute setting, pulmonary edema leads to decreased PVR, while in the chronic setting, it can lead to increased PVR, I think? +  
hungrybox  This doesn't make sense. Activating the sympathetic nervous system would cause bronchodilation (via β2) but it's unclear to me whether it would constrict the blood vessels (via α-1) or dilate them (via β2). +  


submitted by m-ice(272),
unscramble the site ⋅ become a member ($36/month)

omAyotnu is hte tosm ttinaopmr eicsth lnipepirc htat suesrsedpe lal soeth.r weoe,Hrv it is iplaped lnoy in ntssoiaitu ni hhcwi a enatpit tdsearonmset nocnksimg-aidie cticpay.a In stih ,uniaitots a teaipnt itwh ddacanve iadsees yelliunk to eb deurc si sfgenrui atmetret,n iwchh si shi ghtri dneur teh iclripenp fo o.yanmuto o,wreveH his scetmnom tbuoa rnegtniu"r ni 6 nshtom tfera nigucr "irstatihr rae ,ialqebnutseo dan aatrrnw gnemiidetrn if he sha sdeicoin imnkag tpa.cycai tI is opliessb htta he odse, hchiw si ywh nay icseohc fo nficogr rrftheu ttmnteera on ihm rea rert.cinco

hungrybox  These ethics questions seems so simple and yet somehow I always get them wrong. I guess deep down I'm just a scumbag. +7  


submitted by rolubui(10),

1) Alcohol withdrawal --> seizure

2) Seizure --> increased release of catecholamines (https://www.ncbi.nlm.nih.gov/pubmed/6538024), also BP of 180/100 indicates high levels of catecholamines

3) Major hormones that shift K+ intracellularly are insulin & beta-2-adrenergic agonists (e.g. epinephrine (http://www.clinicalguidelines.scot.nhs.uk/media/1286/fig1picu007.png)

4) Also they are asking why serum K+ is low, NOT why urine K+ is high

osler_weber_rendu  Point 4) above helps you RULE OUT MUSCLE BREAKDOWN. It will cause initial hyperkalemia. Hypokalemia, if at all happens weeks later in ATN. +2  
hungrybox  Thanks for explaining why it's not muscle breakdown. Was stuck on that one. +  


submitted by lamhtu(86),
unscramble the site ⋅ become a member ($36/month)

tlPteela cenadhree dan ltaleept eatigonagrg rae iertneffd hntisg and sthi reefnerdic ETRATSM A TO.L kucF yu,o BNM.E eheTs edsieefnrfc ulpspeyosd tmtear no mseo seitosqun adn nto no ter.hos eehrW is the s?sceoiycntn oell?H

hungrybox  Agreed. This is so fucking stupid. +  
hungrybox  "Aspirin inhibits platelet aggregation and produces a mild bleeding defect by inhibiting cyclooxygenase, a platelet enzyme that is required for TXA2 synthesis." literally straight from Big Robbins +1  
susyars  Im gonna upvote this bc i love to be right +2  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +1  


submitted by lamhtu(86),
unscramble the site ⋅ become a member ($36/month)

atePletl anehedrce dan eltaltep egiaotngrag are iendretff nhtsig dan hits iceeefdrnr RESTAMT A T.OL cFuk oy,u M.ENB seTeh crfdnefeise ppoueslsdy arttem no some sstunoiqe dna ton on etoh.sr erWeh si teh e?nscotcsyin llHe?o

hungrybox  Agreed. This is so fucking stupid. +  
hungrybox  "Aspirin inhibits platelet aggregation and produces a mild bleeding defect by inhibiting cyclooxygenase, a platelet enzyme that is required for TXA2 synthesis." literally straight from Big Robbins +1  
susyars  Im gonna upvote this bc i love to be right +2  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +1  


submitted by nerdstewiegriffin(21),

Acral Lentigious is NOT associated with UV exposure. So there might be another reason

nerdstewiegriffin  Source Pathoma 2017 +  
hungrybox  question doesn't have anything to do with UV exposure +1  
nerdstewiegriffin  I am trying to say palms have less melanin is a wrong concept to apply. Acral Lentigious arises in dark skinned individuals and they are not related to UV exposure. I agree using melanin logic you are able to answer this Q but this logic is incorrect. and you might be aware wrong concepts don't go far. +5  
greentea733  Yeah you just need to know acral lentiginous melanoma most commonly appears in African American/Asian patients. Unfortunately the question leads to to think about UV and kinda melanin, which doesn't have anything to do with what they are actually testing +  


submitted by linwanrun1357(4),

I just think plams are not protected by the melanin and got this right.

hungrybox  useless +4  


submitted by lsmarshall(347),
unscramble the site ⋅ become a member ($36/month)

tenPita sah apinS ifdbia ctlouca hciwh is a ernlau ubet tdeefc f(uielra fo onisfu of het spr)onruee.o selrtoeSomc era teh ratp of hace etomsi in a treeavbert yborem giivgn srie to oneb or teorh kslaleet ts.usei neiSc a aprt of isth senpt'ita spani baidif necddiul sesaen"bc fo snoispu pscero"s thne a moloserect aws onivedlv. wKngino thta naerlu uetb ecfsdet era na iuess itwh onfisu suoldh be hneuog ot gte to eth girth enw.sar

If eht orthncodo adlfei to vpledeo hent eth niteer SNC lodwu otn pvedelo sa the corontodh ndcsuie tmroaoifn fo raneul ptea.l

fI the anurle uebt eafild ot edeoplv hten eht whloe NSC ulwod not eavh dve.oeelpd

lYko sca is rarveenlti ot ihts .tapinte

nWhe aerunl scrte lelc ti sah dftenfrie oocsmute ni ditfnreef ss.utsie lFureai fo lurnea certs ot iegartm in erhat nca uacse stapnnoiiTrso fo aterg sle,ssve ortgelyTa of tFa,llo ro stsenetriP tcruusn uoresiasrt. eaFuirl fo nurale trecss to tgaerim in IG can ceasu srirpucHsnhg siadees iotgncal(ne )no.cgaoeml crhaeerT nlClios rymendSo anc ocucr hnwe eaunrl resct slelc iafl to ieramgt oint t1s nyagpalher h.rac Nlurae bteu dtfeecs has nothing to do hiwt lufiare of eraunl estcr mirngaito togh.hu

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +7  
hungrybox  Fuck I picked "Formation of neural tube" but yea that makes sense... that would affect the whole CNS +1  
ruready4this  I also never heard of sclerotomes and I chose that and then switched it to formation of the neural tube because I thought that was close enough ugh close enough is not the right answer +  


submitted by hungrybox(791),

(D) Portal hypertension: Portal hypertension is a complication of longstanding alcoholism, but it is not the cause of acute or chronic pancreatitis.

In acute pancreatitis, alcohol transiently increases pancreatic exocrine secretion and contraction of the sphincter of Oddi (the muscle regulating the flow of pancreatic juice through papilla of Vater).

This leads to activation of pancreatic enzymes and acute pancreatitis follows soon after.

In chronic pancreatitis (as in this patient), alcohol increases the protein concentration of pancreatic secretions, and this protein-rich pancreatic fluid can form ductal plugs.

Made this explanation in case any of you were dumb enough to think "pancreatitis → alcohol → portal hypertension" like me.

hungrybox  oh my source was big robbins btw +  
regularstudent  I was definitely dumb enough +  


submitted by medpsychosis(83),
unscramble the site ⋅ become a member ($36/month)

The awy I htuothg tauob it was a tieltl more imcsp.itils eW esu non letveceis ateb olbekrsc g.(.e plorPoraln)o orf teh rtenttame fo ainteessl re.ortm feeTroerh a btae nsigtoa wolud ahev the ipspoteo f,tcefe aka usaec or annhece ret.mor

hungrybox  Genius +2  
sunny  Also it(blockers) hides signs of hypoglycemia which are tremors. +1  


submitted by lsmarshall(347),
unscramble the site ⋅ become a member ($36/month)

eFlrxo mrougidti uusdrnpfo si obrpinlssee for ifnxeol of .IDP elaMdi tpscae of het cuelsm h(hicw elxsef teh ht4 dna ht5 igidt) is upsdpiel yb hte nraul eenvr ,C(8 1)T. heT ltrlaae eaptcs (wcihh feesxl hte nd2 nad r3d g)dtii si enatrvdein yb eth eimnda reenv clfiipceysla eht teoirarn nitssooeeusr acrnbh ,(C8 .T)1 So the sqteuoni is eiidsrbngc a tieacaorln dgiamagn het eevrn puplsy to het IDP eroxlf of teh nd2 gtidi (ixnde r)nge.fi Tsih is isangy eht imaedl vnree is ngibe damdgae 8(C dna 1;T worle trkun rso.ot)

sirulbamcL s1n,d/t2( em;ndai ,4h/drt3 )ruanl era a guorp fo escmuls htta elxf at teh CPM j,inot adn dntxee PIP dan DPI snoijt.

loudC eeerrmbm as lo'xfre oriugmitd fpruousnd si oduporlfyn g'lno encis ntdoesn isnret no IP.sD Cmorpaed ot rxelof idtugimro ulaiispecisrf sewho ntndeo srpaw udraon rufn'updos flieayliruscp tub rtsenis no PIPs.

toupvote  This is dumb but I remember FDP is needed for picking while FDS is need for scratching the superficial layer of the skin +10  
whoissaad  @lsmarshall Flexor digitorum superficialis inserts at the middle phalanges to be more specific. +  
aneurysmclip  shittt I remember it like this D for distal P for profundus > Double Penetration. and I know the PIP flexion from the other Flexor digitorum, which is superficialis. Extensors are lumbricals. (Lengthen your fingers with Lumbricals) +3  
hungrybox  'flexor digitorum profundus is profoundly long' is such a good mnemonic, thanks bro +  


submitted by link981(133),
unscramble the site ⋅ become a member ($36/month)

syodeKrw mfro D.r ucTor rfmo naa:pKl

  • lctian-oiepR AND
  • ciTtpa-osnrinr ARN
  • ntTra-oaisnl ntierPo
hungrybox  bruh this is like bio 101 lol +3  


submitted by suckitnbme(115),

POMC is a prohormone peptide chain that gets cleaved into gamma-MSH, ACTH, gamma-lipotropin, and beta-endorphin. There's a nice figure of this in Costanzo (Fig 9-10).

It may help to remember that pathologies with increased ACTH (ie Addison's disease) can present with hyperpigmentation since MSH (melanocyte stimulating hormone) is produced alongside ACTH.

hungrybox  https://classconnection.s3.amazonaws.com/1442/flashcards/861876/jpg/picture11-thumb400.jpg Here's the figure +  


submitted by roygbiv(17),
unscramble the site ⋅ become a member ($36/month)

/nAc0u6.w/?1kmh=etpcsoy2g/o6Ey/j1c._/pob9.on/_eH36n2170-//wpamlM72_gt__t0no:dF2tipLiT.gpsw70

hungrybox  not pictured: cremasteric a., which (I think) also would have been a valid answer +  
qiss  [https://www.google.com/search?q=cremasteric+artery&tbm=isch&hl=en&ved=2ahUKEwi28PqN0cfoAhVBUc0KHeHrCJoQBXoECAEQNQ&biw=1280&bih=720#imgrc=VHTHHvtpqKTBpM] +  
greentea733  This is great but honestly was this covered in ANY step 1 study resource? +2  


submitted by tinydoc(189),
unscramble the site ⋅ become a member ($36/month)

sihT utoqesni si evyr ke,syna but ni seenecs iths is wahts i.neangpph

The lediaactnc mlarevo of het THP dlasng uirndg cerotidohytmy ⇒ ↓ HTP

PHT :rnalyim -oln- b:eon ↑ armloev of C²⁺a dan pePtaohh orfm bino e-n- e:niykds ↑ ²a⁺C oaprnbseoirt dan ↓ ₄O³P⁻ oar↑psoe -b-nrit svconeorni fo ,25 ovHrndtyxayimi D to 5,21 andvimyroxiHyt D cllti(aCiro - vaicte rf)om avi ↑ yvctatii fo -1a ydxHeloarsy cienicyfed

eerhTfore a ↓ PTH ludwo edal to:

⇒ ↑ P₄³O⁻ ⇒ ↓ C²⁺a ⇒ ↓ 512, rmitnxivaydHoy D

The tqusonei si skyane uhmc( lkie hte ster of hsit xaem) csuaebe noeesom woh istn siuonfgc lylrae drha ro in a uhsr mghti ipck eth inpoot C eewhr phhoapet si ↑ nad TPH is ↓ BTU ↓ 25 xhyavotrdimiyn D

shTi si wnrog as noly 5,12 nvoahtdmyixryi D ulodw eb des,ecdaer eth cionorsvesn ebeorf siht aer onde by het niks t)slunhgi( adn ril.ve

I rllyea hsiw they would psto imgank teh ssueotniq fnousgnci LURYEP rfo hte eksa of mankig emht gncf.suoin snIt ti ngehou htat ew hvae ot wkon htis uuiidrcsol toaunm fo n,irfnoaoitm oittwhu inavgh ehtm tlinlaeitonny ianmgk ti herrad by npotiing uoy ot 1 seawrn choiec btu ggnniach a itunme dletia to ekma oyu nweras gr.onw Or isugn a anodmr ass naonrclmeteu for a aedssie ot vaido namkig ti oto epimls S(PNG = ieiparetforvl" ")NG

tinydoc  I literally got this wrong because I had the font zoomed in and assumed the 1 was on the line above like on uworld when it tries to squish the whole title in the same space x_X +1  
hungrybox  Holy fuck they got me. They boomed me. The fucking NBME boomed me. +2  
graciewacie9  Amen to the PSGN question. They got me on that one. lol +  
msw  the psgn question is pinting to rapidly proliferating glomerulonephritis b/c the pt has developed acute renal failure within days of the insult +  
msw  *pointing +  
snoodle  HOLY GOD MY BRAIN FILLED IN THE 1. i had to read this explanation 4 times to finally see 25-hydroxyvitamin D and not 1,25. F U NBME +1  
avocadotoast  this bs is prob why the question isnt on step 1 anymore +  


submitted by enbeemee(13),
unscramble the site ⋅ become a member ($36/month)

i teg yhw its' ,epxlyeaohfri utb why not ?riifaosilbltn ts'i olsa an MLN isgn

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! +11  
eli_medina9  https://imgur.com/1z4OF4l Gonna piggy back off your comment and just post this kaplan image +7  
hungrybox  Very helpful image, thanks bro +  


submitted by benwhite_dotcom(308),
unscramble the site ⋅ become a member ($36/month)

toH but ilfitc,oslliu ’sti a ngti.h asaCsylllic ouen.pamsdos

medguru2295  I hate myself for overthinking this one. The first thought in my head was "hot tub folliculitis" but my dumbass didn't pick follicle. +4  
hungrybox  @medguru2295 same bro same +  


submitted by thotcandy(48),

Everyone asking why not PPIs?

if you give NSAIDs which decrease PGs so you get GERD, the simplest way to fix it is to bring those PGs back, so misoprostol.

Just simply -PGs --> +PGs

hungrybox  This is the best explanation IMO Also makes me feel like an absolute idiot +5  
guber  also per FA, misoprostol is used specifically for prevention of NSAID_induced peptic ulcers +1  
cuteaf  I think the key to answering this question is to remember the specific side effects associated with misoprostol -> severe diarrhea. No other GERD medications in the answer choices have this side effect. Antiacids could also cause diarrhea (MgOH) but not in the answer choices +  
deathcap4qt  Actually one of the side effects of PPI use is diarrhea (and other GI issues). Not in FA but emphasized in AMBOSS and Sketchy. I got this Q wrong for that reason but I see now why Misoprostol is the better answer. +  


submitted by ergogenic22(243),
unscramble the site ⋅ become a member ($36/month)

Pt hsa sgsni nda xS fo tihoroply.resc onrwLlom/a AHTC sfvaro levtedea slooitrc tdenpneedni of T,CHA onmcdfier by kcla of seeorpsn ot saemnextdeaho spspu.nroesi Znoa ufciaatacls si grniio of tclsrioo rid.nutpooc

champagnesupernova3  They tried to confuse us saying both low dose and high dose dexamethasone didnt suppress it. But when ACTH is low you dont even need to do high dose dexamethasone test. The high dose is only to differentiate between Pituitary adenoma and ectopic ACTH production +5  
hungrybox  @champagnesupernova3 fuck they got me +10  
azharhu786  They got me on that question as well. I thought it was ectopic ACTH production due to some paraneoplastic syndrome and this is why Low/ high dose dexa is unable to suppress it. +  


submitted by strugglebus(154),
unscramble the site ⋅ become a member ($36/month)

ornapoollP si a sentciveleon- taBe oerc.klb oS oryu RH will ersdaece B)1(, cwhih lwil sacue a semranotoypc aiseecnr ni .PTR

home_run_ball  ^ 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. +35  
amarousis  so why tf do we give beta blockers for hypertension -.- +5  
dr_jan_itor  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 +1  
llamastep1  @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. +4  
hungrybox  @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) +2  
mw126  Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +  
rockodude  @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +  


submitted by ssc505684708(-5),

What happened to this "previously healthy" young female? Why is she vomiting blood? Drinking too much alcohol?

hungrybox  Completely haram. Inshallah she will receive her due punishment +  


submitted by flexatronn(-1),

This pretty much answers 3-4 of the mnemonic for tuberous sclerosis: "HAMARTOMASS"

H-amartomas in CNS and skin/ A-ngiofibromas/ M-itral regurgitation/ A-sh leaf spots (hypopigmented macule) / R-cardiac Rhabdomyoma/ T-uberous Sclerosis/ O-autosomal dOminant/ M-mental retardation / A-renal Angiomyolipoma/ S-eizures/ S-hagreen patches /

hungrybox  somebody kill me +7  


submitted by hayayah(990),
unscramble the site ⋅ become a member ($36/month)

Auetc rtniaettiils naler nmoiaiamt.lfn ayuiPr yslcsilaalc( isplihoen)os adn oazmaeit uinrgcocr aetrf otiaatnsrminid fo dsurg tath act sa pneht,sa niingduc psersvnieyyiitht ,eg( driicest,u s,NAIDS liipeilncn ee,isvrtaidv notpor uppm niobhi,rits ,irinmpaf iluo,qoesnn dolmfaineu.)ss

hungrybox  But how is a 2-year history acute? +3  
jinzo  there is also " Chronic interstitial disease " +3  
targetmle  i got it wrong because there wasnt rash, also there was proteinuria, doesnt it indicate glomerular involvement? +1  
zevvyt  Got it wrong too cuz of that. But there can be proteinuria in nephritis, just not as much as in nephrotic syndrome. I guess that's confusing cuz this type of nephritis isn't grouped with the other nephritic conditions. +1  


submitted by hayayah(990),
unscramble the site ⋅ become a member ($36/month)

The ybba esod nto tge nya nrteamla Ig,M AIg ro gEI sa eyht od nto csros eth tae,anpcl os fi MIg is dfnou it yam segsgtu het ybba ash oenrecnudte an nifeconit in uerto.

gIG si dasspe ondw ot eht bbay sa a mnase fo saivesp itunymim tiuln eht byba can omfr tireh now nbesiiotad fo eiftfdner p.ytse oS fi yuo ees yagtinhn oetrh tanh gIG .e(g. )IMg yuo wnok it tmsu be /dt na ii.etocnfn

hungrybox  The baby gets IgA via breast milk. +1  
mbourne  @hungrybox, this is true. However, IgM antibodies are the first antibodies endogenously produced before class-switching occurs. So IgM antibodies in a newborn suggests infection. +4  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

payitlscDs iven are a ucrrepsro to nmaeo.alm yTeh evah rgri,eurla i"stclpd"sya soe.rrdb bemeermR teh "B" in DABC dsasnt fro garreluri reBosd.r eNuvs mnaes olme.

ehOrt snesrwa:

  • stahcsiaon sgnrnciai - enganirDk fo skin ssaatecido iwth pTey II deateibs ltlimesu

  • absal llce cianoamcr fo inks - ,leyrRa fi evre astasetsei.zm onmoylmC tcfasef purpe l.pi

  • uelb senuv - ocde-eloBrlu ptey of ncmoom o.lem nn.iegB

  • pmigdeten ehrcborsei tresikaos - Scut"k "on raapenpe.ca yMtslo .gbnein cAfetsf drloe ploee.p

  • te(oN - uoy ulyasul ese oynl eo.n fI eipmlult erebhocris etakorsse are eesn, ti sieidntca a IG agnlcaniym - aka -eraeétLls"rT n)sig
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +24  
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +4  
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +1  
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2  
teepot123  fa 19 pg 473 +  
rockodude  just remember BS. basal cell upper, squamous cell lower +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

julruga vueons etdnstioni = flet trhae freilau

ypmurlona edmae = irhtg etahr eluafir

brhrameF-cou diaotlni si het otms ykilel senwar.

hterO naewrs:s

  • iesArcysmt spleat orytp,hypehr yocmlradia yrrda:asi hetes are btoh icscsal giisfdnn in rpthpchyerio ohctmarydioyap (CHM)
  • nadoiarecld ssfielaioos:btr a rera retviitrcse ytdyicaohorpam nees ni ai/hdfnniernlcst
  • ytohymcicpl rinnofiatilt of hte :cdmaouyirm eens in rvail muinaeomu(t) mstcyiodai.r A sauec fo eiddalt hioayt,ampodryc btu rehet asw on iotennm fo a deenprgci arilv slesnli.
meningitis  I think you meant: Jugular venous distention = LT HF Pulmonary edema = RT HF +4  
hungrybox  woops yea I meant Jugular venous distention = RIGHT HF, Pulmonary edema = LEFT HF +10  
jackie_chan  What threw me off the picking 4-chamber dilatation was it seemed like that would be a major cardiac/ventricular remodeling and the vignette gave a somewhat acute 2 week onset +  


submitted by sympathetikey(980),
unscramble the site ⋅ become a member ($36/month)

Dicret uoigitnAllbn = rceiDt mbosCo tsTe

tsetDec iebtnadsio budon ltircdey to BR.Cs mHseysiol stom lykeil ued ot oinmhgtes in eth udatefsnrs olobd no(t uesr why ti koot 4 sweek ewnh yTep 2 SH is odpsspeu to eb uceikqr tub ew/.)

ergogenic22  there is a delayed onset hemolytic transfusion reaction which should be evaluated with direct cooms test. https://www.ncbi.nlm.nih.gov/books/NBK448158/ +5  
hungrybox  such a dumb question wtf +21  
sonichedgehog  takess longer due to slow destruction by RES +  
baja_blast  Dang, I didn't know that was the same thing as a direct Coombs test. I guess it makes sense in hindsight. Thanks! +  
sars  Theres a UWORLD question with a table displaying the different types of hemolytic reactions. Don't know the question ID. Agree with delayed hemolytic transfusion reaction due to formation of antibodies against donor non ABO antigens. Typically presents as an asymptomatic patient or mild symptoms (jaundice, anemia). Different from an acute hemolytic transfusion reaction, which is against ABO antigens. +1  
tomatoesandmoraxella  The Uworld table is in question 17780 +  


submitted by mcl(517),
unscramble the site ⋅ become a member ($36/month)

aetiPtn tsmo ekilyl hsa cayahTS-s sasiee.d sThi grifeu lceiyn ohsws eth aoblmcechii pata.hwy elcRal taht btoh cTya-Sash dan nmNenai ckPi eedssai pensetr thiw a chyerr red sopt on opuy,cfosnd btu yaT Sshca clksa hte npgalehesotomeylpa esne in PN.

hungrybox  Man this is such a nice figure except it doesn't have Krabbe disease :( +  
mcl  Here's another one with Krabbe! :) https://epomedicine.com/wp-content/uploads/2017/01/lysosomal-storage-diseases-enzyme-defects.jpg +5  
hungrybox  thank u +  


submitted by jotajota94(14),
unscramble the site ⋅ become a member ($36/month)

DPA sfwlo ofmr orata to umnpyrloa rtraye rcseniaegd loaffrTe etheerdrao. aidccra uputot naeescrsi

seagull  doesnt pre-load also decrease which would drop the C.O.? +  
hungrybox  @seagull I think it would increase preload b/c more blood is going into the pulmonary arteries -> lungs -> pulmonary veins -> eventually more blood in left atrium/ventricle -> inc preload +32  


submitted by nuts4med(6),
unscramble the site ⋅ become a member ($36/month)

nAyeno evha an aedi yhw hte ddseeacre rarietla 2O sntaiotaur si ctoricer?n gsumsniA seh ash lupm ademe nesic esh sah EL dea,em tn'wludo a lwore O2 ast be edepectx o?ot

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. +6  
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 kchakhabar(34),
unscramble the site ⋅ become a member ($36/month)

Tihs unoqsiet si secnbgiird enrtilam nani,mois hiwhc si momcno iteher in DDM or arolnm giag.n tuO of stohe wot DDM is the ylon thign in noiotp io.hcce ,Plsu odl gea si a srik ofrcat orf MD.D

vEen uhtgoh eth instoeuq esod otn bsiderec 5 mtssopym endede ot gindoesa MD,D DMD si eht ylno aoiclgl hc.ioec

hungrybox  excellent answer, thank you +4  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

rtohe wss:aenr

htiibonnii of 2H prctsee:or ro(f EDGR) ntpreve rigscat dica teinescor ic(teiinme,d

nnihiboiit of hshdserseapetspooi D:EP()

  • onlhlethpiey mah(sta) btiinsih PAMc DPE
  • nalf-is kid(c ll)ips for DE ibinhit GcPM DPE

β2 stginsao: for( m)thsaa ucesa nciitohbrdoalno

  • arboleutl (trhos igacnt - A orf Auect)
  • remo,elatls molrotfore lon(g acingt - axrospip)hly

i(kd ecyptlyomh rmmenbae nisati)aiobztl

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +15  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +1  


submitted by mcl(517),
unscramble the site ⋅ become a member ($36/month)

eaittPn msto kleiyl ahs cTa-hyaSs eiasdse. sThi uegifr ynecil owssh hte laoiebmchci tayhpaw. lcaelR htat tbho Tcya-Sahs adn ienmnNa kicP ieasdse tnpesre whit a yrrche dre spto on ydopof,nscu but Tay hcaSs clksa the ylsthmaeoppaleeogn seen in P.N

hungrybox  Man this is such a nice figure except it doesn't have Krabbe disease :( +  
mcl  Here's another one with Krabbe! :) https://epomedicine.com/wp-content/uploads/2017/01/lysosomal-storage-diseases-enzyme-defects.jpg +5  
hungrybox  thank u +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

haiotHydrozledcirho is a iaethidz ditueicr =;> idzietha csuietdir aer aicaossdet iwth aip.lhyeokma

Wath herot truieisdc rea aciastsdoe with ailkhypoeam? oLpo c.iteuirsd

?Wyh

Intibiiohn fo aN+ iporroenatsb uocrsc ni htbo loop eurstcdii tbih(nii NKCC ot)actprsonerr nda zahtidie itisedurc bhitini( CNal ep.ttsrcr)anroro llA fo iths ceseniadr Na+ esarcsnie orenoldseAt ctitiv.ya

levaRtne to ihst rbe,pmlo leotArodnse aeuergltsup xseniseorp of het aN+K+/ PTA prtntoeari arero(bsb Na+ iton odby, elepx +K iton nm).lue isTh resluts in lpmaiaoehky in teh db.yo

Hgan ,on h'etser roem ihgh dyile o!fni

eonoAdserlt odes neo thoer otainmrtp ithgn - nicaoattiv of a +H nenclha that xepsel H+ tnio the eum.ln

S,o gniev ttah isht paeintt ahs mapoyake,lih you wnok rhete is utugierolapn of eelontosA.dr oD oyu nhkit erh Hp duowl be g,hih or wol? lxtEc,ya it wodul eb hhgi esaucbe i.cn oAeteodlnsr gt&=; .nci +H dellexpe nito the lnmeu =g&t; boaltimec aosilka.s

Now yuo nnudeatdsr hyw tobh oopl utieicsrd and izdhieta rdieitusc acn scuae a'wsht cdllae eomlpya"cihk lbimoetac iksal.l"oas

hungrybox  jesus this answer was probably too long i'm sorry +2  
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +10  
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +  
amirmullick3  @hungrybox did you mean "All of this DECREASED Na increases aldosterone activity."? +1  
pg32  Anyone care to explain why she feels she has, "lost [her] pep"? Is that due to the hypokalemia? Or hypercalcemia caused by the thiazides? +  
cmun777  @madojo @pg32 I assumed between her hypokalemia (which can cause weakness/fatigue) and possible contraction alkalosis those were the most likely causes for the "lost her pep" comment. I think if they wanted to indicate hypercalcemia to differentiate if loop diuretics were also in the answer choices they would certainly give more context for hypercalcemia sx +  


submitted by egghead(1),
unscramble the site ⋅ become a member ($36/month)

hTsi is eno of etsoh tsqoneius I was neerv gigno ot tg.e 'sIt ont ni F,A I td'on hknti 'eIv seen it ni a.cssl

hungrybox  same :( +  
masonkingcobra  My issue was the stem said no skin damage (I would think pulling out your hair damages your scalp) [Turns out it does not](http://onlinelibrary.wiley.com/doi/full/10.1111/j.1529-8019.2008.00165.x) +  
gh889  FA 2019, pg 551 +7  
meningitis  Compulsively pulling out one’s own hair. Causes significant distress and persists despite attempts to stop. Presents with areas of thinning hair or baldness on any area of the body, most commonly the scalp. Incidence highest in childhood but spans all ages. Treatment: psychotherapy is first line; medications (eg, clomipramine) may be considered. +5  
step1soon  FA 2019 pg 551 +1  
teepot123  damn its in FA and Ive never ocne read it XO +  


submitted by yo(53),
unscramble the site ⋅ become a member ($36/month)

hyete'r ialtkgn tbuao a lelaepnrnso nuths oererucpd

t/0a/lhtmtrpueihlhi/c//nestlyapsescm:lsere.--etddngt9-.4nhvcranotia5lletloasnn

hungrybox  be honest did u know that before looking it up +8  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +13  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +7  


submitted by lnsetick(84),
unscramble the site ⋅ become a member ($36/month)
  • PnAicoer = uyro msptari melsl ekil an PAE
  • eReMnUc = r’htese no MOOR ni uroy saer iscen hreey’t ullf fo axw
  • YRCnEe-C = hnew oyu ,EeiCresc yrou porse are YgniRC
  • SEcsauoeB = SBEmu si PgnSEEi out of royu rospe
hungrybox  as an ape i'm offended +18  
dr.xx  stop being an ape. evolutionize! +6  
dbg  as a creationist i'm offended +9  
maxillarythirdmolar  Also, Tarsal/Meibomian glands are found along the rims of the eyelid and produce meibum +  
snripper  So why is it apocrine? The dude is EXERCISING when playing football. +1  
qball  The question asks about "the characteristic odor" i.e. body odor coming from the APEocrine glands. The Eccrine glands secrete water and electrolytes. +  


submitted by hayayah(990),
unscramble the site ⋅ become a member ($36/month)

htaeCetr e:lamcnpet

/nps0n0egt..tepjn/speecwy-0:agdiu/4lt6a/0s2moh8eap/8/0o/1mktoc

Rllaec htat teh lnug eaxp dntsexe bvoea hte trfis .irb

hungrybox  His expression is so blissful. U can tell they're shootin up some full u-opioid agonist codeine type of shit and not some shitty partial u-opioid agonist buprenorphine type of shit or some shit like loperamide that doesn't even act on the CNS +26  
rerdwins  even better, if you recall that the esophagus is RETROperitoneal ( its in like half the answer choices). hence, to get to it you have to go WAAYYYYY deep ( like rick and morty smuggling shit). after that, the lung option makes the most sense. +9  
hello  Also, pulmonary artery is way too far away to be damaged by internal jugular vein catherization. +  
makinallkindzofgainz  @hungrybox my mans just slipped in 3 high yield facts within a joke +2  
makinallkindzofgainz  @hayayah, I have an issue with that picture unless I'm missing something. In every other source I have, the internal jugular vein lies LATERAL to the common carotid artery. The picture you provided shows the internal jugular veins medial to the common carotid artery. +1  
cmun777  Look at the other side... I think it must be the manipulation of turning the head to the opposite side that better exposes the jugular for catheterization purposes +  


submitted by yo(53),
unscramble the site ⋅ become a member ($36/month)

This coerrdcu iihwtn 6 osuhr nad ecudas msoe rauymopln dmaee dna yairrteorps srstsdei ftaer a tfasiuosnnr usdaec yb the o'sdron ynleuecktot-ia aiboednsit sujt dgtenyiros teh cpriieetns teinuphrslo adn oayprtsierr elltieoahnd e.clsl

iwhle alariichal/lagsenypx nca csuea rroyreaitsp sreatr and ocshk ti ash a wsmaetoh fidrfente it,ceurp on ghze,inwe iinhssect ro waetvhre dna cracoding to stifr idA ti ehspnpa ihnwti tuemnis ot 3-2 husro cwihh is ta stale elbodu hwta 'reew ieensg e.erh loas rebeaw of AIg eentcfidi ppoele in ihts ihcco.e

E,P eh I 'tnod inkth it acfestf oaP2 thta tfeno humc adcrcnogi ot tish puers ruepd hhgi diely csrreueo. ubt huh eayh nodtse' leef EP adnki te nuosqics-e0csr1:o.m9ce3i0pec/./n0h#m//itepma2ewdu1ictktropedal

pnn,aomei thirg aertf lla teh inousfin beuisnss dna no tmnonei fo efrev ro ntyaghin? N.ha

og to gpea 141 of ritsf ai.d I'm rptety reus we nede to wnko our tisrinfontnsalpu/na racp eseubca ti sjut sepek gncmoi up ni dulwor utb tsih holwe emax is a chrspt.oao

Feiovgr me if I maed a igmwesrtkno/a batuo nya,itngh I ltmsyo tog nofi rofm rifst .iad plz rceortc fi rethe is a a,tekmsi ogdo ku.lc

hungrybox  we gonna make it bro +5  
hungrybox  or sis +6  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +5  
athenathefirst  I hope you guys made it. Your post 9 months ago +  


submitted by yo(53),
unscramble the site ⋅ become a member ($36/month)

hiTs rrceudco itwhin 6 urosh adn duceas omse pualrnmoy meeda adn rraoitrepsy srdsitse trfea a sfsniornuat caeuds yb the nodrs'o tuncile-yaokte baosdietin jstu gysrndtoei eth ntprsceeii lrouispenht nad rprotsairey tllaeodnihe cslle.

liweh lsgnxyihacir/alelpaa can eusca iorrtryaeps rrates nda hkcos ti ash a ehowasmt rifdetefn rtcepi,u on ezhegwni, nitieshcs or vrhwetae and iagnccrdo to fisrt idA it ephsapn niihtw iutnsem to 2-3 roshu cihwh si ta ltase dlboue hwat er'we negsie e.rhe oasl wbraee fo IAg fnciiedet eopepl ni shti icoc.eh

,PE he I o'ndt kihnt it ffcaset 2Pao atth ofent humc dograncic to this ureps dpeur ghhi diyle eeuscrro. ubt huh ehya ot'dnse efel EP dknia t oinesqumi2c1sk/e/0/atde0dte#c9-hsiicpo:m.1o.cenp/0tlprra3emuwec

mneoi,pan htgir eartf lal hte unioinsf bsessuni and no intoemn fo vrfee ro aitnngy?h .haN

go ot epga 141 of irsft a.di 'mI typert suer ew dnee ot okwn oru oaun/atitinnssfnprl pcar bsecuea it sutj esekp gcnmoi pu ni olwdur but htis heolw amxe si a .socotrhap

rvoigFe me fi I maed a tian/gwrkeoms botau t,yghiann I slmoty ogt onfi mrfo ifrts .dai lzp ccrrote fi rhete is a skiteam, odog uklc.

hungrybox  we gonna make it bro +5  
hungrybox  or sis +6  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +5  
athenathefirst  I hope you guys made it. Your post 9 months ago +  


submitted by nosancuck(74),
unscramble the site ⋅ become a member ($36/month)

thi em up tiw dta PCNCH b!io all ouab tad CHLYN YDMSRENO

hungrybox  yee boi +  
mkreamy  hahahaha i fucking love both of you +  


submitted by yo(53),
unscramble the site ⋅ become a member ($36/month)

runde 8 yreas dol orf gslri is a bad i,nsg 8 is oka.y nd rue 9 rfo soby is a bad .sgni

tjsu htacw uto ofr yna 6 arye old or msnhoeitg ikle . atht rweaeb fo hatt RGHn itrehe antlyercl or omse semo rtoeh tr-oe isu.frcs adi 2901 gp 236

hungrybox  yo wtf i got my first dick hair in 6th grade wtf are they feeding these kids +29  
lola915  FA 20 pg.637 Defines Precocious Puberty as: <8 y/o in Females <9 y/o in Males +1  
euphoria  In Caucasian is less than 7 years. +  


submitted by drmantistoboggan4(17),
unscramble the site ⋅ become a member ($36/month)

It dais ti swa alatf to mesla ni teru,o dna eth etnsoqui dakes buato ivel ronb gnfofsi.pr iScen het mesla tea’nr bigne nrob in teh trifs cae,pl I adsi %50 eameslf dna %0 mas.le

hungrybox  fuck i got baited +26  
jcrll  "live-born offspring" ← baited +11  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  


submitted by nosancuck(74),
unscramble the site ⋅ become a member ($36/month)

ruhB elt em ltle oyu a ill tcrese

PEEP prnvetse sAetctasiel AKA dta NLGU PSALLEOC

ntoD eb rirynwo boaut modnar rdwos thye pstu ni ontrf fo het IGHH IYELD seno

hungrybox  literally LOL'd lmao I love this +8  


submitted by tissue creep(85),
unscramble the site ⋅ become a member ($36/month)

fI aynydob hsa a odgo awy of msidggsriibnreithennmieu/g lla eth dftfenrei etseoisrnnpta fro inealgt sor,se Id' ecaetrippa het elhp.

hungrybox  Pls post as a separate post and not a comment to this tho. The formatting for these comments sux +1  
whossayin  Assuming u have UWorld, just type sexually transmitted infections.. that table is the best IMO +  


submitted by neonem(503),
unscramble the site ⋅ become a member ($36/month)

hsiT si a easc of auect utg.o snomMoioud eatur lsacsrty rae eaktn up by nupsh,lioret dnalgei to na ceuta faatmnriloym cieorta.n Tlc-lse ear'tn yrlela dneivlvo ni gout oe(rm duhreaitmo .ia)rihtstr

hungrybox  Great explanation! So frustrating that I got this wrong, should have been easy. +3  
temmy  the way i thought about it was how did the neutrophils get there? the answer is via increased vascular permeability +12  
nor16  they, unfortunately, did not ask " how did neutrophils get there" but " whats the cause of the swelling " not to confuse with " what causes the swelling " +1  
divya  absolutely right temmy. that's how i thought about it too. +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

arGte eiodv I duse ot ernla hist .amlratie

  1. rhTee are 3 mjroa yetps fo sg:urd pusrpe (t)asl,unsimt noerdws s(s,tsdeper)an nad io.gllseuchnna
  2. ioenrH si an dpio.io doiipsO aer dnwse.ro*
  3. rwoDsen od whta ti uonssd ilek. yheT casue "wdno" opms:smyt dces/anrsaeeoteddi yanixte ad(n usth rveaaobhil ,isionbnditihi) yirasrortep .sopsneeidr
  4. Tush dwhiatawrl ilwl ucsea het :sipteopo h,cdrnipne/aeasrhtaicotyy axne.iyt
hungrybox  *other downers: alcohol, benzodiazepines, barbiturates +2  
nwinkelmann  THANK YOU! for the link to the video. this is one thing I've ALWAYS struggled with. +  
qball  I get that this is a good rule of thumb to help narrow down between alcohol and heroin, BUT is still not enough to answer this question. Some key features for depressants (downer) is alcohol (if we are talking mild withdraw) - tremors , diaphoresis and delirium (heavy withdraw) . For Heroin - Dilated pupils, yawning and lacrimation are key exam findings. +1  


submitted by beeip(116),
unscramble the site ⋅ become a member ($36/month)

sTih ash enbe a thoug ctecpno orf em to g,te ubt I nkhti I'm ialnfyl trhe:e

Teh mtes si cesgdibirn ripyarm larndae sicyincne,iffu or 'sAsid.odn

  • THCA is gbine roeerdv-updco ot imtlsaeut eht dnlsreaa to crodupe rlics,oot utb hyte atnc' spredon, heteri deu to ryhptao ro sucneritdot T(,B ui:ommtaune R,4D c).et
  • Teh rtifs 31 noiam scaid fo HCTA nca be vecaeld ot form MαHS-, chiwh eiltsatums el,yencmaost sagncui ygtieotappemhirnn
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +2  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


submitted by imaginarybanana(28),
unscramble the site ⋅ become a member ($36/month)

otd'n eb a cd?ki nto yllrea usre tawh omer eehrt is ot .it heT atpient no'sdet avhe ayn otrhe mfialy so ihst wmaon usdhol eb iedenrodsc yfmlia

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? +5  
hungrybox  Yeah, I got this one wrong with the same logic as you, aesalmon. +1  
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! +8  
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 +8  
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. +4  
lilmonkey  I can swear that I saw this exact same question in UWORLD before. The only reason I got it right this time. +1  
docshrek  @lilmonkey can you please give the QID for the UWorld question? +2  
jakeperalta  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. +  
jakeperalta  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😓😭 +1  
drschmoctor  @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? +1  
peridot  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. +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

heT ixevrc is eht nylo csuetrutr htta ouldw lsrtue ni leltariab abk.dleco

hungrybox  hydronephrosis = dilation of kidney (usu. due to obstruction at uretopelvic junction or backflow from obstructed bladder) +2  


submitted by hyoscyamine(55),
unscramble the site ⋅ become a member ($36/month)

I owkn sthi si tujs a thrgtasi up tacf fomr F,A tbu n'tduclo reesrut (ttsraoiannil lecl c)mnoracia slao eb orcre?tc

hungrybox  Hmm I don't think so. The answer is "ureter" (singular) which would not result in bilateral hydronephrosis. +6  
privatejoker  If it is out of FA 2019, could someone give the page number to reference? Hydronephrosis' full definition is given on page 587 and makes no mention of invasive cervical carcinoma. +  
vinnbatmwen  p631 → Pap smear can detect cervical dysplasia before it progresses to invasive carcinoma. Diagnose via colposcopy and biopsy. Lateral invasion can block ureters - hydronephrosis - renal failure. +4  
privatejoker  Thanks! +  
emmy2k21  It's also in Pathoma page 140 in the 2018 edition! +1  


submitted by cantaloupe5(69),
unscramble the site ⋅ become a member ($36/month)

Tshi noe aws cktryi tub I inkht oyu udcvoe’l onde ihst noe htwouit wndkgleeo of NDMA srerco.ept etSm dlto you taht mlaegautt tvetacasi boht nAnMND-o nda DMAN eetprsocr tub it ttavicade ynol noAnMND- trpcosere ni the reayl pe.ahs Tath nemsa DAMN etsepcror cvaeatit arfet n-AoDMnN rpe.escort haTt snmae nomgehits aws yiealdgn ANDM recotrep aivattngci dan the ylon nswear ttha amed essne sa eth gM ntbiiighin NADM at tgreins oealnitt.p cenO eht lelc si rlizaeddoep by o-NMnnDA pte,oresrc MAND prrcostee nac be diatvec.at

hungrybox  I forgot/didn't know this factoid and narrowed it to the correct answer and a wrong answer. Guess which one I chose? +11  
yotsubato  >That means something was delaying NMDA receptor activating and the only answer that made sense as the Mg inhibiting NMDA at resting potential. What makes the fasting gating kinetics choice incorrect then? +5  
imgdoc  NMDA receptors are both voltage gated and ligand gated channels. Glutamate and aspartate are endogenous ligands for this receptor. Binding of one of the ligands is required to open the channel thus it exhibits characteristics of a ligand channel. If Em (membrane potential) is more negative than -70 mV, binding of the ligand does NOT open the channel (Mg2+ block on the NMDA receptor). IF Em is less negative than -70 mV binding of the ligand opens the channel (even though no Mg2+ block at this Em, channel will not open without ligand binding. Out of the answer choices only NMDA receptors blocked by Mg2+ makes sense. Hope this helps. +5  
divya  sweet explanation imgdoc +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

iowlogFnl a oskrt,e ihst npaeitt dah newksesa of ehr eflt afec and by,do so teh rseokt usmt veah cfdtfeea eth htirg eids of ehr ai.brn B swa hte nyol ccehoi on teh igrth ieds of reh .brain

tliSl fs?unoecd edaR .on..

Teh aorltvyun morot siberf scainoo(lciprt trtac) dcesden frmo the ipmrray toorm rtce,ox rocss se)st(eudac at eth lydmulear admiyr,sp dan nhte ssanpey ta the ntioarer torom orhn fo het planis le.vle

Bacusee of satnsidecou at het urlaedlmy ymspdr,ia ouy suodlh maek a enot of ewehr any ekrots socucr. sI it aevob teh uylaerdlm ydrmpia?s eThn it liwl fetcaf the ides oeospipt eht esrtok o)tarc.a(tlanrle sI it olewb hte adlmlyreu ?ydprsami heTn ti wlil afftce the smae dies sa the tesokr .i(rla)etilspa

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +7  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +15  


submitted by drdoom(645),
unscramble the site ⋅ become a member ($36/month)

sicoainVnorotsct rgriw(anno fo a t)ebu lliw euacs the flwo etra ot enasierc gtorhuh htat ue,tb wchhi descreeas a/tdaouardlriw sruse.per Teh fresat a ilufd sevom tohughr a etb,u eth less ”wroa“tud forec it trexe.s hTis( is wonkn as het etunirV ffecet).

hungrybox  not seeing how this is relevant +5  
sympathetikey  He's showing how A & B are incorrect @hungrybox +7  
nerdstewiegriffin  what a moron @hungrybox is !! +2  
leaf_house  MCAT flashbacks on this image +1  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

hTe caoanitm oxbfnfsu is ordmfe by hte endnsto of het esrtxeno ilcsiplo s,eibrv the rtduobac piocills on,sugl adn the enesxort iscpolil n.osulg (efrgui)

heT lroof is mrefdo yb hte pacdihso ,oebn adn it is eehr htta eno nca epalapt rof a soslibep dueatcrfr sa.pcihod

cS:reuo yGars' omaAnyt Reviwe

hungrybox  Of note, the radial nerve innervates the extensors of the wrist. So the muscles of the anatomic snuffbox are all innervated by the radial nerve. +  
hungrybox  This helps you remember that the radial nerve innervates the abductor pollicis LONGUS (abductor pollicis BREVIS is median nerve, ADductor pollicis is the ulnar nerve. These two make sense if you think about the direction the thumb is moving - ending closer to the nerve.) +  
meryen13  just to review, if we don't fix this, what gonna happen next? --> avascular necrosis of scaphoid--> non-union. why? because scaphoid has two blood supplies the distal part is mainly volar branch of radial a. and the proximal part is mainly dorsal branch of radial a. +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

eTh ainoactm nsufxofb si merdfo by eth odntesn of the tenoesxr icllspio reiv,bs eth rdtuaboc oclslpii noslg,u nda the teexnsor pcslioil uonl.gs (irefgu)

eTh olfor si omedrf by the saphidco oe,bn and ti si here htta eno acn paeltap orf a spsoiebl auefcdrtr dsiah.opc

rSecou: ayGsr' tnayAmo ieevwR

hungrybox  Of note, the radial nerve innervates the extensors of the wrist. So the muscles of the anatomic snuffbox are all innervated by the radial nerve. +  
hungrybox  This helps you remember that the radial nerve innervates the abductor pollicis LONGUS (abductor pollicis BREVIS is median nerve, ADductor pollicis is the ulnar nerve. These two make sense if you think about the direction the thumb is moving - ending closer to the nerve.) +  
meryen13  just to review, if we don't fix this, what gonna happen next? --> avascular necrosis of scaphoid--> non-union. why? because scaphoid has two blood supplies the distal part is mainly volar branch of radial a. and the proximal part is mainly dorsal branch of radial a. +  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

kaa mluapla of Vreta ro het crenatiahocpepat dutc

hungrybox  tripped me up cause I didn't know the names :( +11  
sympathetikey  @hungrybox same +7  
angelaq11  omg, same here! I thought, well, I don't know of any duct that connects the pancreas to the liver, so...2nd part of the duodenum it is :'( :'( +6  
alimd  actually Ampulla of Vater is located in the 2nd part of the duodenum. +  
mtkilimanjaro  I think 2nd part of duodenum could be viable if the ampulla was not an option. The ampulla is way more localized/specific to this scenario +  


submitted by hayayah(990),
unscramble the site ⋅ become a member ($36/month)

tNo:e eTh dcunsbea .n is aaulyctl the nreve omts kelliy ot eb mgdaead yb an anpixnedg linetrna aroctid uaysnmer in teh ercasuovn nisus utb yhte iegv yuo pificcse 3NC ftninuco ni tish o.tnesqiu

hungrybox  One pupil larger than the other indicates damage to the pupillary light reflex - afferent: CN II, efferent: CN III. +13  
cienfuegos  A little more info regarding other sxs (via UW): -cavernous carotid aneurysm: small usually asx, enlargement can cause u/l throbbing HA &/or CN deficits. VI most common thus ipsilateral lateral rectus weakness, can cause esotropia = inward eye deviation & horizontal diplopia worse when looking toward lesion -can also damage III, IV and V1/2 -can occasionally compress optic nerve or chiasm thus ipsilateral monoocular vision loss or non-specific visual acuity decrease +2  
lovebug  There are in FA2019, page 530. +  


submitted by questioneverything(3),
unscramble the site ⋅ become a member ($36/month)

kO I get atth if 500 laadrey aehv the sdieesa tnhe hte irsk oolp si opdpder ot 0200 stutndse btu the qetusoin cfpeayslicli ssay htta eth etst si oend a eyra ..raetfi.l 500 elepop hda amdayh,icl yuo dowlu taret ehtm. Yuo n'otd omebec menuim to hliydcaam taerf fenntioci so htey wloud og ckab iont het sikr oopl, nnmagei het pool udwlo utnrer to .0205 hTe arnsew sohlud eb 8,% tihs saw a abd ouqn.tise

thepacksurvives  Yeah, this was my issue. I got it wrong because of this-- still don't understand the logic bc you can get chlamydia multiple times +5  
hungrybox  FUCK you're right. Damn I didn't even think about that. That's fucking dumb. I guess this is why nobody gets perfect scores on this exam lol. Once you get smart enough, the errors in the questions start tripping you up. Lucky for me I'm lightyears behind that stage lmao +6  
usmile1  to make it even more poorly written, it says they are doing a screening program for FIRST YEAR women college students. So one year later, are they following this same group of students, or would they be screening the incoming first years? +5  
dashou19  I think the same at first, but after a second read, the question stem said "additional" 200 students, which means the first 500 students don't count. +  
santal  @hungrybox You are me. +1  
neovanilla  @usmile1 I was thinking the exact same thing... +1  
happyhib_  I agree this is a trash question; I was like well if this is done yearly for new freshman the following year would be of the new class (but the word additional made me go against this). Also you could assume that they were treated and no longer have the disease... I dont like it honestly but know for incidence they want you to not include those with disease so i just went with dogma questions on incidence to get to 10% +  


submitted by nuts4med(6),
unscramble the site ⋅ become a member ($36/month)

nAyeno hvea na diae ywh teh ardcesdee ealairrt 2O iasturonat si ?itroncecr msunisgA ehs sha mupl aemde nseci she has EL aem,de 'wolndut a rlwoe O2 ast eb pceetdex ?oot

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. +6  
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 cellgamesgojan(38),
unscramble the site ⋅ become a member ($36/month)

AV isaluFts oe-turr lodob fmor eht rtlieraa msesty to eth osnuev ,ymsets s-saypigbn teh terAeriosl = neaecIsr PL g--;t-& NAERECSI VR. lAl ni lla = ersecaIn O.C

Acnoirgdc to ,rdUWol het oelarstier rae a orjma uscoer fo arsncetsei ... so abnygsisp the arlrseiteo trluess in a eeacrdes in aTotl Pihelaperr sRtnsceaie ... nscugia na cinserae in the eatr nda emoulv fo olbdo tineurngr ot teh e.rhta I am etrytp usre eehrt is mreo ot eht lposoyihyg inhbde iht,s but I peho hsit xinedpale a ttlie.l

big92  "Immediately following creation, arteriovenous fistula (AVF) is associated with an increase in cardiac output (CO), achieved predominantly through a reduction in systemic vascular resistance, increased myocardial contractility, and an increase in stroke volume (SV) and heart rate. Over the following week, circulating blood volume increases in conjunction with increases in atrial and brain natriuretic peptides. These alterations are associated with early increases in left ventricular (LV) filling pressure with the potential for resultant impact on atrial and ventricular chamber dimensions and function." (PMID: 25258554) There's also another study by Epstein from the 1950s looking at the effects of AVF's effect on CO in men (PMID: 13052718). Apparently, the increase in resting CO is a big problem because it can lead to high-output cardiac failure (LVH). +14  
hungrybox  Jesus big92 you went in on the research lmao u must be MSTP +5  
temmy  big92 you are right. that is why pagets disease pagets have high output cardiac failure because of the av shunts. +3  
kevin  what is "increase PL" +  


submitted by seagull(1109),
unscramble the site ⋅ become a member ($36/month)

Idtipyoci nsema --- otyiabdn ansiagt i.aybntod B lclse dno't aveh ueafrcs iobtieadns but erme ezsstehiny he.mt

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +2  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by seagull(1109),
unscramble the site ⋅ become a member ($36/month)

Iidciopyt maens --- itydabno aignats ytiandbo. B sllec td'on hvea rcuafes neaotdsbii tub emre snyetzsieh hte.m

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +2  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by assoplasty(87),
unscramble the site ⋅ become a member ($36/month)

I knthi het octcepn r’etehy estgtni is eth eecardins GBT vsllee in agcype,nnr nda ont utjs sohyehrptymdrii in reegn.al

enhW eeinsrgcn ofr rhri,/ihhydtospmepyoy HST elelvs are WYLASA etrillyenefrpa eecchkd esuaceb ehty rae more inesesvit to utemin ffnecedeirs ni T/T34. tfeOn tmsei HST elvsle nac oarsentmetd a caheng neve wehn T/34T vesell rea in eht nlbiualccis argen. The yonl ineteopxc to hits uwold eb ni ygnnaecrp nad( I gsuse eymab rviel ail?fure I tdbuo hyte wdoul sak ihst g)uohht. ghiH senorget sevell sptnerev hte ilrev mrfo nebagrik nodw BT,G lieandg to eirscdnea TBG lveels ni het m.esru iTsh inbsd ot feer 4,T degniecrsa eth omnatu fo avalbalei refe .T4 sA a erocanosmpty nsmm,cheai HST veslle ear nisetaryltn snacdreei nad hte RTAE of 4T updrotcnoi is snaeeirdc to enlpehirs iensblae eerf 4T se.ellv evrewoH eht TOALT noutma fo 4T si es.aierdcn

The nqsoeiut is iknsga ohw to rcimfon rodrhyisypemith ni a rgepntna mawno &;-t-g you dnee ot ckhec REEF 4T vlseel (beuaecs ythe shodul eb oamrnl due ot necspaortmoy so)neeps.r ouY nantco ehcck HST l(luuasy vedaeelt in anpecryng ot etmscnoepa for aeiscrdne )T,GB dan uoy otannc kcech total T4 ellsev (lwli be iedan.sec)r uYo gto hte asnewr ritgh itreeh ywa but I hnkti hist is a efenitdrf niarogens otwrh edcrnigsi,on baesuce ythe acn ask hits pctonec in ehort xsotcnet fo tsegphmr-isreny,oe nda fi yeht lidset ”TH“S sa an snearw hecioc ttha ulwdo be cei.tnrocr

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +5  
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +2  
d_holles  https://step2.medbullets.com/obstetrics/120352/physiologic-changes-in-pregnancy +2  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +  
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +1  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +1  
lovebug  Amazing answer! THX +  


submitted by hayayah(990),
unscramble the site ⋅ become a member ($36/month)

het imyotarj of rbncoa diixode eomlulsce rea riderca as prat fo teh naibatobcre fferub t.smeys nI ihst m,sytse bncoar ixedodi iesfdsuf nito the CBs.R Crbcoain eyaanrdhs )AC( inhitw CBsR lcquyki oresvntc hte bnocar iioxded nito brnccioa adci )CO3(H.2 obrnCiac aidc is na btlusane meneirtditae lolemcue that itmaeiydlem ioscetdssai ntoi ritoebabanc niso (H)-CO3 nda drngyoeh +)(H nsi.o

hTe lewyn ntdeyhessiz iobracbneat oin is tderptaorsn out fo teh RBC toin hte asapml in caxgheen fro a ridhceol oin −;)(lC ihst is ladlce eht doecrihl hits.f hWne hte bdloo aehecrs eht n,lsgu teh oactanribeb ion is ettonrpdsar ckba oint the RCB in ngxaeceh fro the lcdoheir o.ni heT H+ oin stdiocasesi rofm eht oenigolbhm dan sbind to eht beiroacbnta .ion This pesrcudo eth crnciboa cadi iedr,teteaimn whhic si etvcodnre cakb noit abncor dioedxi ughorth teh yamtnczie oitcan fo .CA ehT boancr doedxii udcdrpoe is lelepedx tgrouhh eth nlsgu gduinr xao.iatehln

hungrybox  Amazing explanation. Thank you!! +1  
namira  in case anyone wants to visualize things... https://o.quizlet.com/V6hf-2fgWeaWYu1u23fryQ.png +4  
ergogenic22  CO2 is carried in the blood is bound to hemoglobin, known as carbaminohemoglobin (HbCO2) (5%), dissolved CO2 (5%), bicarb is 90% +3  
pg32  Nice explanation, but can anyone clarify how we know from the question that we are measuring HCO3 rather than dissolved CO2? +1  
qball  @pg32 This question is asking about what accounts for the LARGER amount of co2 and the HCO3 buffer is about 85% of this transport and dissolved C02 is about 5-7%. https://courses.lumenlearning.com/wm-biology2/chapter/transport-of-carbon-dioxide-in-the-blood/ +1  
teepot123  fa 19 pg 656 +1  


submitted by hajj(0),
unscramble the site ⋅ become a member ($36/month)

acn anyeon xinepla ?tsih i ownk iadnem orf y si eighrh yb ucotnlacila btu x has tow esmod so ohw mceo y has reihhg o?dme

lispectedwumbologist  The mode in X is 32 and the mode in Y is 80 +  
lispectedwumbologist  The mode in X is 70 and the mode in Y is 80* +1  
hajj  Thank you! +  
hungrybox  Just checking in so I could feel smart about getting this right despite bombing the rest of the test lmao +4  
usmleuser007  can someone please explain the median in this +  
nala_ula  The median can be known by first assembling the numbers in order from least to greater. If it's an uneven number set, the number in the middle is the median (for example: 4, 10, 12, 20, 27 = median is 12 since this is the number in the middle); if the numbers are even then you have to take the two values in the middle, add them up and divide them by 2 [for example: 4, 10, 12, 12, 20, 27 = (12+12)/2 = 12]. Page 261 on FA 2019 explains it as well. Not sure if I explained it well... good luck on the test, people! +  
dubin johnson  Can someone please explain how the mode for Y than X. Not sure how we got the values above. Thanks! +  
dubin johnson  I mean how is the mode for Y greater than mode for x? +1  
sgarzon15  Mode is the one that repeats the most once you list them in order +  
usmile1  Median would be the BP value that the person in the 50th percentile of each group would have. So for group X, to find the 50th percent value, I added 8 + 12 + 32 = 52, which is right above 50, so the median would be 70 mmHg for group X. Doing the same thing for group Y, 2+8+10+20+ 18 = 58; the 50th percentile would fall in group that had a BP of 90 mmHg. which makes the median higher for group Y. hope that isn't wrong, and helps someone! +4  
poisonivy  I did it the same way! not pretty sure if it is the right way to do it, but it gave me the right answer! +  


submitted by beeip(116),
unscramble the site ⋅ become a member ($36/month)

I imtgh be het only psoren no ahetr how ogt itsh eno n,ogwr btu elrgdeasrs:

T"TI aynlisas islcnedu vyree tjsuebc owh si dnreiazmdo dccraogni to zneoidrmda eaemttnrt eistgsnn.am It insoerg nalcnpio,oncem lctooopr ndvio,saeit trlw,adwaih nda nyhnitag atht peanhsp eatrf ia"zrn.nomtadoi1][

yo  You're not. I also goofed. +11  
seagull  https://www.youtube.com/watch?v=Kps3VzbykFQ This video is a pretty decent explination worth your time on the subject. +2  
hungrybox  I got it right but I was only like 50% sure. So I appreciate it. +  
drdoom  ^ linkifying @seagull: https://www.youtube.com/watch?v=Kps3VzbykFQ +2  
teepot123  ^ same video above used when I analysed my form 20 q which I got incorrect at time, its very clear at explaining this, helping me get it correct on this form +  


submitted by feronie(18),
unscramble the site ⋅ become a member ($36/month)

cmtciOyroeh = ↓ otseortenste npourodtci = ↓ TDH &tg;= seraotpt csell orugnde .ssppitooa isT(h macnmsieh si raimlsi to singu αu5caredte-s oclebrsk ot etatr )HPB.

pispAosot si erahzreciadtc yb NAD eiogamfrnntat pys(sinko, rsyxeirkaoh,r yiokyla.s)rs

hungrybox  DNA fragmentation histopath: https://i.imgur.com/nxYW8vL.png Note that degradation in apoptosis is progressive. From pyknosis -> karyorrhexis -> karyolysis. Aka condensation -> fragmentation -> complete dissolution. +14  


submitted by hungrybox(791),
unscramble the site ⋅ become a member ($36/month)

heolamtbtu = htuEEobmatYl

eGart imnoencm rfo rinmmbrgeee ttha EautYltmobhE si teh onceponmt that suacse lasviu mepbolsr ni ERIP yerhtpa ofr B.T

hungrybox  RIPE = rifampin, isoniazid, pyrazinamide, ethambutol +2  


submitted by g.liller@yahoo.com(24),
unscramble the site ⋅ become a member ($36/month)

ddiCaan si a patr of the nlmaro ofral of ,nski dluco casue ntnictaiamono fo a elrnatc osuven .cateehrt hTe osquniet ttssea ttah het nmraiosg si prupel, ibngd,du did nto esnpodr ot adbor tsumecpr oasinbticit k(aa they t'dnid esu olcnuoefzal or iohnteprcmia .)B a,sLtly etyh hwosde ti talped no bodlo arga nad heter saw on sloeshmiy cihwh nmstailiee stahp teh( ynlo reoht pbsoseil drceontne erhe).

pouctccsryoC saullyu oinvvels stnmneigii ni emmisroomcunipdom tsp. E . olci si ramg aesp xiehtgtinvroro is alyuuls ntmrdtsaeti yb a nrtoh on a osre or oesonme wtih a ostyhri of diearngng

hungrybox  Also, the yeast form of Candida is gram (+) +21  
dr_jan_itor  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. +1  
lilmonkey  I chose S. aureus before reading the question (looks like b-hemolysis). Then I saw "budding organisms" and picked the correct one. +  
the_enigma28  I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +  
the_enigma28  I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +  
lowyield  cryptococcus also doesn't take up gram stain because the shell is too thiqq +2  


submitted by drdoom(645),
unscramble the site ⋅ become a member ($36/month)

Hse’re one ayw ot fn-iiome-epscslretao aredeedsc“ nyd-edbngroho taonmor”f:i ’Im tno a ibg afn fo ihst ienl of nraeing,os tbu ctyihnlclea nienala as a edsi orpgu ash ermo nhydrgoe*s rfo poentalti ndgehroy gbndino tnah cyignel:

lei:nana —HC3
gcyn:eil H—

o,S lhlce”cayn“i,t lneania wloud rpeimt mroe nohdrgn-eybod ontrfam,io chwhi tihgm wllao yuo ot tieneimal ahtt eocic.h

aTth ,idsa it sseem amotsl siplomiebs ot erul out o(htuiwt yevr netlcihca knogleedw ro eoms divrdoep tpeilanxemre atad) atth the thllgysi relgra leanani oeds tno pmiira gnohedry nboindg newetbe clnoagel leluocsme avi screti ial)p(ast rnrnefietc.ee In slpmrei emtrs, since anlenai is l,rraeg yuo wulod hinkt atth ti msut whoesom neftrreie tiwh eth -dhenoongygirdbn that rucosc whit hte wptdi-eyl gnelciy.

---
tcrlyi*tS espkaing, ’tis ont hte ubrnem fo oehnrgysd btu saol hte ttenrgsh of the dlipoe hatt iliecattfas odnrgyhe bdn:ngio a egohrdyn ndbou ot a oystlnrg givnltteroeaece uecemlol iekl niouefrl llwi r“ape”pa eorm eisopvit nad, u,sht dhnoo-rgneybd omre nroslgyt thiw a rebnay xyogne o(ecrdpam ihwt a nhgroyed ocendtecn to rcnoa,b ofr emlxae.p)

Frtuher :enrgiad

  1. t/whhuilclceuudwmshhto.dp.:utihsqngldem///pd/.webp.er
hungrybox  Appreciate the effort but this is far too long to be useful. +14  
drachenx  hungrybox is a freaking hater +  
drdoom  @drachenx haha, nah, coming back to this i realize i was probably over-geeking lol +  
blueberrymuffinbabey  isn't the hydrogen bonding dependent on the hydroxylated proline and lysine? so that wouldn't really be the issue here since those aren't the aas being altered? +  
drdoom  @blueberry According to Alberts’ MBoC (see Tangents at right), hydroxylysine and hydroxyproline contribute hydrogen bonds that form between the chains (“interchain”, as opposed to intra-chain; the chains, of course, are separate polypeptides; that is, separate collagen proteins; and interactions between separate chains [separate polypeptides] is what we call “quaternary structure”; see Tangent above). And in this case, as you point out, the stem describes a Gly->Ala substitution. That seems to mean two things: (1) the three separate collagen polypeptides will not “pack [as] tightly” to form the triple helix (=quaternary structure) we all know and love and (2) proline rings will fail to layer quite as snugly, compromising the helical conformation that defines an alpha chain (=secondary structure; the shapes that form within a single polypeptide). +  
tadki38097  also you can't H bond with carbon, it's not polar enough +  


submitted by deannosancuck(7),
unscramble the site ⋅ become a member ($36/month)

osbrnMameu orelusGnrmotiilehp si phcriteN;o YNLO NIRTIOARPEU is ni eth intevteg

It tcna' be NPGM eeubacs PMNG is pNtrecihi with opilsesb ehirotcNp

Oehrt eoichcs are idetlimnea by leRna sopByi

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +2  
cooldudeboy1  could someone explain why the other choices are ruled out by biopsy? +  
arlenieeweenie  @cooldudeboy1 PSGN does have a granular immunofluorescence, but there is no previous illness or hematuria mentioned so you can rule that out. Goodpasture is classically linear IF since they're antibodies against the GBM. IgA nephropathy is mesangial IF so it would deposit more in the middle. Minimal change wouldn't show anything on IF +2  
qball  I know First Aid states MPGN as a nephritic disease but I think it can present as nephritic or nephrotic syndrome. https://emedicine.medscape.com/article/240056-clinical. Of course, the renal biopsy helps give it away but I wouldn't be so quick as to rule out MPGN +1  
taediggity  Totally agree w/ you Qball... I thought MPGN too, but I think Penicillamine makes it Membranous Nephropathy +  


one does not simply “walk into mordor”