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Contributor score: 1032


Comments ...

 +0  (nbme19#47)

I got confused with aquaporins so I picked E :(

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

j44n  there are AQP's in the PCT but they're not that abundant. Look at it this way, AQP's are by definition a transporter and therefore they can be saturated. The PCT is the king of all resorption and a big reason for that is paracellular transport, which can't be saturated. This also makes sense as to why we can treat nephrogenic DI witha thiazide, it causes INCREASED resorb at the PCT which can over power the rest of the nephron. The PCT does everything and the rest of the nephron gets the left overs +1


 +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. +


 +4  (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

caramel  I got this answer through the process of elimination. I figured that A/C/D would NOT cause the pt to have an overdose. And with B, she wasn't using it chronically (3 days..) +
helppls  What drugs inhibit their own metabolism? +

 +9  (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. +4
pontiacfever  Drink a lot for a week makes you a chronic alcoholic? +
pontiacfever  That means alcohol abuse = chronic alcoholism +1
skilledboyb  Why would increased bioavailability of acetaminophen place the patient at increased risk of liver injury? What's dangerous about that? +
i_hate_it_here  Metabolism of acetaminophen turns it into toxic metabolites (NAPQI) that inhibit glutathione in the liver forming toxic tissue products. FA2020 pg: 485 +1

 +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 +
specialist_jello  G : Gerstmann syndome? angular gyrus? not sure +
pakimd  G does look like angular gyrus since it is right above the wernicke area +

 +3  (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 +

 +3  (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 +

 +1  (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 .. +8
hungrybox  hawt +1
underd0g  Why isn't this HPV given the sexual history? +1
prosopagnosia  Anal fissure and Anal carcinoma - would present with rectal bleeding which our patient denies. HPV could lead to anal carcinoma and the image isn't similar to the morphology of condylomata acuminata. External hemorrhoid is the only one that presents with rectal pain (due to somatic innervation from the pudendal nerve) and no bleeding. +1

 +2  (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. +3
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. +22
i_hate_it_here  cool so why do I need to know this +2

 +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

 +8  (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.)


 +16  (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.

motherhen  I thought in cardiogenic shock, PWCP can be increased or decreased depending on if the blood is backing up in the lungs (LHF) or body (RHF). Can someone clarify how we know which is happening here? +1
motherhen  *PCWP +
jsanmiguel415  They say it's an "anterior STEMI" which to me meant V3, V4 aka LAD, which supplies the left ventricle so increased PCWP. If PCWP was decreased it would mean right ventricle is disrupted which is more RCA and would be II, II, AVF or an inferior leads +2

 +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.


 +7  (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 +3

 +2  (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


 +3  (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)


 +4  (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. +2
acidfastboi  Per what @melchior said: "Eccrine glands are the major sweat glands of the human body, found in virtually all skin, with the highest density in palm and soles, then on the head, but much less on the trunk and the extremities" - Wiki +1

 +7  (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.


 +9  (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.


 -6  (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 😡


 +4  (nbme20#5)
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I idd sthi by ecssrpo fo iemioilnta:n

cnAe is not ihcyt or nfiuapl fomr ym eexprienec ei(coCh .)A

Neerv dreha fo ucnatseuo sulup rueaomht,syets tub d'I mssesua yu'od vaeh a alarm hasr ivglno(vin hte dn/eneueoyrse )ara,e otn eradsp tuo vero eth hskcee, waj, and ekcn ie(cCoh .)B

Kediols ear usjt oowgervrn a.cssr rcsSa era ton rriapayltluc chyit or pnufali c(eoihC C)

esRacoa si tsju sfglihne/reunssd ni eicantr eraas fo teh .nksi ilMayn na tcieeasth s.eius Not hitcy ro npiufal cheoCi( E).

htb I asw tnweebe B nda .D


 +11  (nbme20#30)
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sr'eHe ym pcrahaop tdovwen(o if wgnr:)o

afnllgi on oedsrttetuhc mar → yauulsl ispchoad

UTB

ahopdsic rpmloeb → pani in mnlacaoait bnouffxs

so nteh ti geso to eht xent mtos loymcmno eujdnri enbo hnew oyu flla no an uhsertctotde a,mr ouyr ealtnu

hhicw( is irght nxte ot het )poisdach

spaceboy98  Also, dislocation is most common in lunate, Fracture most common in Scaphoid +4

 +0  (nbme20#25)
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...So hletoiyalcetr an tdloesia esredeac in RH wlduo easrecni OC ude to c.ni rop,dlea tr?ghi

uBt CO rsadeeces in ihst seac /bc eth tecffe fo nci. TRP si emro lro?fupwe

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)
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orteh eransws:

iiinhtbnoi fo 2H :oetpresrc rfo( ERDG) epternv sagtric icda etocnires idetci(imne,

ihitiiobnn of eresspodtsaishepoh :P(DE)

  • iyoenthellph smath)a( htisbini cMPA EPD
  • fn-ilas (dick lpl)si for DE inibthi cPMG EPD

2β nais:gsto f(ro ahmas)t sauce tohnnbaioidoclr

  • oltrbleau orht(s inagct - A orf eAutc)
  • lsomlertae, ftolemoorr glon( ncitag - phiorypxsal)

kd(i etcyphylmo nemebram zsbalitantio)i

hungrybox  H2 blockers are the -tidines +2
yotsubato  > dickpills lol +17
temmy  hungrybox, you are a life saver +1
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2

 +6  (nbme21#24)
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iya,coalpslcrMco ouasqusm ellc cmacaorni dtnse to be i-wtefofh in clor,o agsnrii romf, nda nnedtxgie ntoi a .csorunbh

r:Scoue poadiRaied

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. +4

 +30  (nbme21#17)
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wnhe dfif seilgn tdsanr aeirrp hmmaiscsne aer :sdeu

  • aierpr nyewl ysztihensde dnrs:ta smacitmh iarrep (nLchy e)onydrms
  • pearri irimypdien misedr ucdsae yb tda UV sex:rupoe dolteinceu ecosixin arirpe de(aerXorm gs)toemmpinu
  • rpriae epunxoci/tonaotss t:oelitaarn bsae noicxesi iprare
meningitis  Brca: recombinant repair +
brotherimodu  P.40 FA2019 lists the different DNA repair mechanisms +2
teepot123  fa '19 pg 382/3 +

 +7  (nbme21#36)
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ietiFnerUvdi ;-&tg uesd orf nioufs fo HVI vrsiu dan artegt lecl

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

 +8  (nbme21#25)
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eetvRnla maigard

AITI ssttrincoc hte eefrften .reeorliat CEA roitiinbsh olkcb eth C-tdeameiAEd seincnorvo fo ATI to IITA.


 +9  (nbme21#34)
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miacoysynhe dotpes sith etgar ipc wbeol

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

 +5  (nbme21#38)
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yM eiionpssmr fo meichtpAirno B si htat s'it eht IGB SUNG. It thgastir pu skctaat hte ssotlre in hte gniuf saapml rmn.meeab

lnwieMahe ill hbict rugsd liek aolze-s tjus nibhiti toselr ys.sesithn fni(-reetnbai X rteslanol,o s-eazlo X lrgstoo)ere

gnsFniu X ellc lawl stsy,snieh netsyliufco X ciuelnc cida yt.sensshi

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! +

 +27  (nbme21#49)
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oHdzatyhlooiecrdhir is a iedaihtz diiuetcr &=gt; ihzietad srecduiti aer sdoscatiae hiwt mopylhaik.ae

aWth hreto resiitcud aer secadoista thwi hamalpykeio? pLoo i.usrdcite

y?Wh

Ioiibtnhni of Na+ riooanetpbrs cocusr in btoh olpo ieurditcs (tiibnih NCCK npc)ostoterrra dan etzhdiai eicuitsdr (itnibih aCNl ertsncorro.)trpa lAl fo hsti ndciseare aN+ scaienser torolsndAee tciitva.y

Rneaevlt ot tish er,polmb tnoeorAslde ulpegesrtau nepxoseirs of hte NK+/a+ TAP riteatopnr rbsrobea( N+a tion y,bod xlpee K+ toni ln.eum) This lsrutse ni pmiahyaokle in the do.yb

aHgn n,o tesh'er eomr hghi ildey fi!no

oreelotnAsd esdo eno rtheo ptotmainr hitng - cantavitio fo a H+ nncaelh atth esxpel H+ tion eth nemlu.

,oS niveg atht htis ttapine ahs iaaep,mohkly yuo wnko heetr is gptiolrnueua of .doneArtselo oD uyo ktnih her Hp wodul eb ighh, or ow?l ,yactxEl ti dowlu eb ghih eusbcae n.ci roeesnlAtod t;g=& c.in H+ eplxlede toin eth numle =;> aoctemlbi asos.kial

Now uyo dduartnesn wyh hbto oplo ecudsirit nad ihzetdai ruidistce nac acseu wts'ah aeldcl amylhoeikp"c otcmbiale .i"lksaaosl

hungrybox  jesus this answer was probably too long i'm sorry +9
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +14
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +1
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 +

 +8  (nbme21#12)
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eraGt evodi I usde to renal sith am.ealrit

  1. hreeT are 3 orajm pesyt fo urgd:s sppeur mist)snlu(ta, densrwo (dan,seep)srst dan lgihoaelu.snnc
  2. eonHir is na idop.oi posidOi rea s.rwo*end
  3. rwnDoes od waht ti sousdn kle.i yheT ucesa "nwod" mpsomty:s enatcrsdddiee/osea xanieyt (nad usth haevoirlab iioiintdsbih)n, irpytorraes esireos.pdn
  4. Thus alritwhadw ilwl cseua teh ioeop:tsp hpeycyncaite,rraoid/snhat tyai.nex
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)
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Teh crixve si hte ynol cttsreruu ttah uwodl sertul ni rablielta d.lckeaob

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

 +8  (nbme21#44)
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oLpo scderiuti rae tirsf line rfo actue itcevngsoe hetra elif.rau ahTt dulsho elhp uyo bmmeeerr atht yteh rae the msot etoptn truicedi,s so e'hteyr tofne udes in het tcaeu nemtttrea fo eadem.

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)
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Lrp:dimoaee gtinAos at ouopii-d .resoecptr woslS tug milityot mme(erbe,r snonopicatit is a onmomc eids eecfft rfo lla s.)ipiood

zuqi yos:relfu

Q: lWoud a einkju nawt to sue meepir?daLo

:A ,No it has orop NCS etripnotena hcwhi( si hyw it ash a low iddaevcit al)itpon.et

Q: doulW a ijneuk rrtaeh ehav moerihpn or ruhoe?pribpnne

A: e.Mrihnop tohB rea uooid-ip tgas,nsio tub mponierh is a lufl gtnosia ewihl riepnebpuronh si olyn a iaptlra asg.onti

Q: htWa batuo eirhnpmo .sv oceidne?

:A kTirc inseuotq, otbh rae rlpiata sistg.ano

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)
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GIHH ILEDY: lsounbion" otmig"vin aemns ttha hte netsibsicuoso/rut ceoms oeebrf xr(lpamio )ot the scoend uoenm,dud reewh eilb is a.eredles

At oudrna ~4 eekws evg(i or ktae a wef) si wneh crliypo nsioesst syuallu swosh up.

ze tps ofr u now eekp ti up

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

 +11  (nbme21#37)
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olgiloFnw a stk,eor isht tnpiaet ahd seakwnse fo ehr tlfe feac and bdy,o os eth rskeot muts eavh decateff eth irtgh sied of erh iar.nb B swa eth noyl iechco on teh htrig eisd of hre an.bri

lSlti oudnsfce? eRad n...o

hTe vralytuno mootr ibersf asolcip(itcnor cartt) cnsedde rfmo het prairym omrot torce,x sorsc tc)(edeasus ta eht ldeumayrl ,dmrasiyp dan hnte saepysn ta the tirreona rtoom nhro fo eth lspnai le.lve

aBeuecs fo oectnsaudsi ta teh lmraueydl asypridm, yuo lsudho eakm a ento of rwehe yna rkeost rccsuo. Is it obvae the eyallurmd sayidprm? ehTn ti liwl cfaetf hte sied potseipo teh reksto rea.lato)l(nacrt Is ti bweol eth lyrmdaeul yrp?amisd nTeh ti wlil tecfaf the smea dsie sa eht eksrot ali)eltp(arsi.

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 +8
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 +22

 +11  (nbme21#50)
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ehT iacmtnao snfoubfx is drmefo by het nsdnote of eht etnoserx iiocllsp i,vrbse eth tarobucd ioiclspl olugsn, nda het texoresn csiliplo nuog.ls (uigefr)

Teh lofor si eordfm yb the chipaods obne, adn ti si eehr hatt eon anc ppaleta orf a pissbleo ucredtafr .hsoacdip

:Sercuo yGrsa' taymAon Reievw

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)
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aadgrmi niwsogh MOA


 +7  (nbme21#19)
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kaa plauaml of aeVtr ro het ccetioapntarpeha udtc

hungrybox  tripped me up cause I didn't know the names :( +14
sympathetikey  @hungrybox same +13
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 :'( :'( +7
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 +1

 +7  (nbme21#20)
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uzqi suyfolre swrae:ns

  1. eiSltor Sreit(ol suSht ,wodn FIM si eeedstcr by Sloietr )sllce
  2. aahpl-5 treecausd
lovebug  5-alpha reductase is due te that DHT is important for male external genitalia? +

 +19  (nbme21#20)
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Tish dvoie iapeslxn iagetln yoyogrlmbe lrteymexe .well

fI ouy fetl lylatot olts iekl ,me htacw hte eidvo strfi ta 2x, then ckhce uto the otbomt grfeui on g.p 086 ni FA 2901.

tRlnvaee to siht otiusen:q

  1. RYS srpointe tisaelumt vpdeomeeltn of setset
  2. ishT pt sah tseest gt=&; he utms evha het YRS ngee no het Y eohmoscmro
  3. FMI esrdgade eht nrlaMliue d,cut wchih uldow itsehwoer moebec eht aneitrnl faelme lanaegiti
  4. ihsT tp sha rielnnat amelef anleitgia =gt&; 'ddtni emka neough IMF

Qiuz seoyflur ranwss(e ni a asaerept o:p)st

  1. ishT itanep'ts reoiddsr anc be detcra kbca to iwchh cl?lse
  2. hsiT ttapien hda mranlo eigaain.tl If sthi enapitt had raemsll altieniag than ,roanml atth dolwu be a tcedef in ahtw eyzenm?
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 +11

 +1  (nbme21#26)
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bbnosloecet"" peanaercap is ieasatcosd whti rohsCn' aiedess

orcimospan of nhrs'Co sv UC


 +9  (nbme21#26)
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spart fo teh olcon that aer trepnlroeeairot


 +8  (nbme21#19)
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jlguaru vsuneo ietdisonnt = eflt rhaet elaurif

ymoaplurn edaem = gtrhi hrate erauilf

-ubFercmhoar iiltanod is teh tsmo yeillk esr.nwa

eOtrh wsa:ners

  • smsAyecirt stelap yhreytr,poph cyrldoamai aiyrrs:da sthee are bhto ssaclci dnnfigsi ni ryocehiprthp aodymitapoycrh )(CHM
  • didnecaoral fb:seriaooslsit a earr tvreciteisr iamcothrdypyoa eens ni nnhinilsa/ctfrde
  • cimcolytyhp ttinnraflioi of eht uyam:mrcido esen ni ivlra onamemu)iut( tyrod.aicmsi A ausce fo tdedail ,iahcpoyrtaymdo but terhe wsa no nionemt fo a pgcirdene lavir l.niesls
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 +12
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 +

 -11  (nbme21#42)
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lcsmeraieapp ersestnp rf:tdylnieef

  • soyt:mmps edacah,he rulberd ,niovis dbaoinlma pa,in gtheiw gian wer(at oettirenn)
  • nfnigdis: rhnseineytp,o rneitiao,upr eadme

 +20  (nbme21#3)
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eTh 2 mdmnsmonacte of icshte eio:nstuqs

  1. nD'ot eerv pkic an nsrwea where ouy uosdn lkie a kdic
  2. tno'D eevr lcuston hte sceiht eomctmite

rvSdee me lelw on sith tneqiu.so

linwanrun1357  If there is a choice about asking what the patient is worried about. Is this right? It does not sound like a dick :) +3
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)
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nutit'nnsoHg ideases

  • iiittapnonca: she sah a mrisial rosddier as her rhetfa but died arelire

emrRebme THNU" 4 na limn,aa tup ti ni a CA.Ge" iniutngntH eneg doufn no momohroCes .4 CAG is hte dtlireenutcio terpae:

  • hoCar,e adecuat euucnls
  • ixAtaa
  • yGmolo dsrenep)(soi
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. +21
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)
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karff-iocoeKrsnkeW ysmeonrd due to aiteihnm )(1B in.fyiedcce nmoCom in l.cslaocohi

The oasnre hyw ehyt adis etlsusr" fo ollohac nad grud srceen era "eietnvga is hatt teh finlifaedter dneiucls tuaec oclahlo ai.cooiixnttn

nceri'sWke i:adrt

  • nfiocsnuo
  • ilspyrsaa of yee smsleuc ahloth*o)plgaem(ip
  • xataia

te*pssrne erhe sa samtgsnuy

safofkK'osr hcpiosy:ss

  • eyommr sslo (tdnarragoee nad adotrrerg)e
  • ikmang htsi up abitluc)anno(of
  • iserltpyoan neacgh
teepot123  fa 19 pg 559 +1

 +10  (nbme21#11)
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auuecn/tolp/a5 dah a gtrea l.atepnixaon

esH'er an meiag fo eth enftiefdr ssagte iwllofnog yiadaolrmc tf.ncinaroi eoNt the noicaontcr"t n"sbda era awht nfeide iegoctlaavu cios.senr


 +31  (nbme21#15)
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yhw oylsemhsi is or:ngw

Trehe oduhls almtso nreve eb aghirtts pu ilbibnriu in eth r.euin In hiyolsmse, teh sesexc builnirib is dtrxceee in eht ble.i rtAfe ecatbrial soerconivn dna ktr,eaeup semo lilw eb cetrdeex in hte reuin sa i.nirubol oHv,rwee ni eicbsortvut or,serddis het tdoaunjceg uibiblnir wlli eenvr aevh teh oiotnprupty to urodgne latreibca ncnoeirvos ot oncrteluoirs/b.i nI tsih ,yaw hte cgadeujotn bbiurinli sha on otreh ayw ot eb drteceex torhe nhta etdclyir in eth irn.eu

trisdec to /63nu/l7raaca no deirtd

skip_lesions  Found a good pic showing bilirubin metabolism +

 +3  (nbme21#45)
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ccroniAdg ot het ULEM,S mneiuse'sl lnoy seu si ni lnuiemse dfuiels sa a aetnetrtm orf a usngfu clldae aeassilzaM pps ie(naT rosirlv)oc.e


 +19  (nbme21#20)
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emos wngro s:warsen

k*sema essen /cb lsmtaysolbe rea eocrsurrps ot s,acnetgolryu wihch ues OMP ot hgitf off finetsncoi

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! +7

 -5  (nbme21#37)
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onLg enwrsa ah,eda but abre twih m.e

NT:HI v osolk dkin fo leik ,y arewhes k solko remo leik .x

tecentpr-yi = V/mx1a

  • mxVa is het upepr tiiml on woh ftsa a itaeocnr is ctelaayzd yb mzn.eyes

peirtncet-x = K1/m

  • Km si a arnkgin of woh ogdo an eeznym si ta dinnbig ist utbtras.se An ezemyn hwit a gnakrin of 1 si reebtt ta nnbidgi sti stbtuaers hant na zmyene hwit a ngkiran fo 5. owe(rL Km = ettebr my)ezne

otNe tath maxV, as a eaemsur of ee,mpfoncrar anc eb daterle huotgrh namy ght.nsi enleMa,hwi Km is a set ritrasectihcca fo hte en,emyz nad cntnao be tadlr.ee

In hist eel,mpax hte eneyzm erorefcnpam aV(m)x is nsieacred by nsagcirein the mantiiv rtfacooc so thta it eehcars a ""molanr iat.yvtic rvo,eHew eth eyenzm is lstli lnenrhiety sthyit ued to a icgelnnota tcefe,d os eht Km atssy the msae.

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 +13
sbryant6  Yeah this explanation is wrong. +

 +13  (nbme21#1)
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tehltoubam = hatmEYolEutb

Gtear onmicmen ofr eernbrimgme hatt mbhEtutlEoaY si the ncemtnoop that seausc uslvia srblepmo in REPI htarepy orf .TB

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

 +3  (nbme21#41)
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trhoe waens:rs

  • ycransop:el docsaieAst wthi phoyogncgi or nppcmoyipoh acsntiloni.lahu
  • GyhnopO ot sleep = hgnit tiem locahlnusntiai

  • lmaxrospay anolnrctu nyad:eps NPH si a tmoehlciy iaea.mn oN isngs of cmlyetiho aieanm hmaa,ureit( eundjc,ia cd.e go)nbplaoh.it

  • elsep eaanp: Aadtescsio wtih so,tebyi ludo ginos.nr

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. +12

 +3  (nbme21#28)
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eDu to lyesicg'n almls i,zes it tecresa "knksi" ni het moain acid .ueqcseen Teehs knsik era eddnee ot olycetrrc frmo eth encydarso rs.uecttur

rOthe wassr:en

  • a"deweken atconintire wtnbeee naelcgol adn lpanc"egtryoo - oegllcna + rpotgynaocle = ic.reaalltg heT nsutioqe mste toeninms mayn fectsed in OEbN ytep( I )lncegaol but on nmeinto fo dtfesce in TeOgcrallWa p(yte II oacg)nell

 +13  (nbme21#25)
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cyalsiDpst evin rea a rcpsouerr to aom.nealm They evha ielgar,urr ialyspt"d"cs e.rbsrod Rmbmeere hte "B" in ABDC adtnss for reirurlga srroed.B sveuN nsame .omle

Otreh :srsnaew

  • saicohastn icrasignn - ngDkreian of nksi oiseaactsd hitw peyT II bdiaseet ulltemis

  • sabal lecl arioccman of kisn - ryea,Rl fi rvee sszaeiet.astm onmmCylo esfctaf epupr l.pi

  • eulb snuev - eocllurdoe-B etpy of oocmnm ome.l .ngeBni

  • mieedpgnt rbrischeeo skrtseiao - cS"tuk n"o peeaap.arnc soyltM begn.in Acfsetf eordl pl.oepe

  • (eoNt - ouy ulysalu ees nlyo ne.o If teullpim eresbhiroc tseerskao rae sen,e it idetcsina a IG naygmlnaic - aak "sérert-TLela insg)
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1
sympathetikey  Pathoma says upper lip, good sir +26
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 +5
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. +4
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 m-ice(340),
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ntoyoAmu si the omst orpittman scethi rplinciep tath deurepesss all t.erosh e,rweHvo it is iaedlpp loyn in stoiaunits in wichh a itpneta neeosasmtdtr k-nimeondiacsig cpcitaya. In htsi ituos,inta a apentti hitw ddeaancv seadise ieluynlk to be dceur is grfiesun tnamtt,ree hwihc si shi gitrh duren eht ipniprecl of .yautmnoo vrHwee,o ihs ecmstmon atuob irtre"nugn ni 6 thsnmo efrta rcnugi ashirt"tir rae niasboe,quelt nad anratwr tnrnigdeemi fi eh sah idionsce iangkm aiactp.cy It is blesspio thta he seo,d wchhi si ywh nya ehiocsc fo nigfcro rrtfehu tteermtan no ihm aer noretr.cci

hungrybox  These ethics questions seems so simple and yet somehow I always get them wrong. I guess deep down I'm just a scumbag. +14  
mutteringly  Hey there's always dental school +1  
hungrybox  legit made me lol, thanks for that +  
jurrutia  Also, the patient is delusional! He thinks he's going to cure arthritis. You don't have decision making capacity when you're crazy. +  


submitted by cassdawg(1120),

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. +5  


submitted by hungrybox(1032),

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 .. +8  
hungrybox  hawt +1  
underd0g  Why isn't this HPV given the sexual history? +1  
prosopagnosia  Anal fissure and Anal carcinoma - would present with rectal bleeding which our patient denies. HPV could lead to anal carcinoma and the image isn't similar to the morphology of condylomata acuminata. External hemorrhoid is the only one that presents with rectal pain (due to somatic innervation from the pudendal nerve) and no bleeding. +1  


submitted by hungrybox(1032),

(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(1032),

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. +3  
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. +22  
i_hate_it_here  cool so why do I need to know this +2  


submitted by hungrybox(1032),

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(311),
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jnolGa hda a celrute htat emtndoeni ahtt If" a itnepat has arthleagcor,a vriwee eveyr dgru y'ehetr kitnga nesci amny dugsr ausce laht"ocaa.ergr

heT yonl ntihg fo bsiplsoe nceaevrle ni sthi -tsQme is that esh sktea a tc,oadneiim errefetho eth sanewr of dgru" ff"tece is hte stom klyile eosarn rfo reh oeaarhgla.ctr

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. +6  
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(311),
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Gnlaoj hda a teclure htta diennmeto hatt f"I a tentiap sha oagtlacae,rhr ereviw ereyv dgur yeetrh' katngi isnce anmy usgrd sauec e.acogrt"aahrl

heT olny hgtin of bislpeos earevlenc in tshi est-Qm is htat she sketa a toai,cdemin erfetrhoe the nsawer of ugd"r cteef"f si hte toms leilky aerons orf reh areg.rhtaolac

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. +6  
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(18),
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scPoesr fo ieotmilnina is hte ynol yaw ot tge htsi arnswe towihut aatSvn velles of as,mtui as smeo iwobet wiegarn ohcedur hwo twreo het sneqtiuo opyablrb sah.

nareCc is iarnltuael mstlao all eht mi,et DM n'stedo ekam snsee rfo nay ,ernosa TNH fsteil don'utlw ascue klmiy obsob, dan stam cesll tgulaeandignr tse'ndo kmea kiyml sobob eihr.te o,S adn cebseua ymna rgdus anc aveh kyilm ob,sbo r'eyuo etfl hwti rudg estfecf by sspreoc of ilnoinai.mte

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). +  
djeffs1  according to strugglebus's numbers its more likely to be b/l cancer than thiazides... +  


submitted by hello(311),
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lGanoj had a eluerct ahtt tnemeinod htta If" a etnipat ash otae,acghrrla iweevr eeryv urgd ty'erhe kgnait censi myna gsrud eacus tr.hal"agecroa

ehT noly ngiht of obesipls rvlncaeee ni ihts m-Qest is atth hes aktes a eatoiminc,d feotrehre the anewrs of d"gur tffec"e si the tsmo lileyk norsae rof her heratl.ragoac

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. +6  
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(1076),
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raCiaoonttc of teh otara eadls ot ecdranesi VL ooaderlv gincuas LV rhhtppyoeyr dan a L xais .ntoeiavid

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


submitted by keycompany(310),
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erAdsewn my onw esuq.onti sedncerIa srstse orfm a IMSTE llwi cviaaett the cpaithsetym oeunvrs syetsm -- alunroyPm oidivlnoat.as

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). +1  


submitted by m-ice(340),
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nyAuootm is eht omts apnttiomr thcsei ippclrnie tath esdesspreu all seothr. ,oewreHv ti si ialpdep ylon in tnatsoiisu ni chihw a tpaeitn taonsmetsedr sien-dnaciimokg cipaya.tc In isth usn,titiao a teatnpi twih nacveadd eeasids ylikulen to be erudc si efiugsnr neratt,etm whchi is sih rghit nerdu het enpriilpc fo ntoo.ymau ,veoHewr shi mnsmtoec abuto e"nturgnir in 6 hmstno tfera niucgr "hrtasiirt era entualseioq,b and rnaatwr niidntmeger if eh ahs ceidonsi ngimak tpccy.iaa It is ilsbpose atth eh ds,eo hiwch si hwy any ccsheoi of cnoigfr fuehrrt aetnmetrt on ihm aer irnc.croet

hungrybox  These ethics questions seems so simple and yet somehow I always get them wrong. I guess deep down I'm just a scumbag. +14  
mutteringly  Hey there's always dental school +1  
hungrybox  legit made me lol, thanks for that +  
jurrutia  Also, the patient is delusional! He thinks he's going to cure arthritis. You don't have decision making capacity when you're crazy. +  


submitted by rolubui(13),
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1) clholoA adwtilarhw -&g-;t sureiez

)2 ieeurzS t-;-g& isreencda ersleea of aeocaestmclhni (d23:p/n/m65bwiwms4nugit//wvh.cpn0.8elohb.t.,) losa PB fo 01800/1 adnsiceit ghih leevls fo snhetecolamiac

)3 arjoM ehrsonom hatt hsfit +K neyrraluiclllat ear nlinsui ;pma& ibdeg-e-trnrc2aae osiatsng e..g( nprnipiheee (/l.sin/0u/iwuic.1phidhapcenewiit2au810nlw/ite6s7/lomd:n.ts.gkcg.gcpf)

4) olAs they aer igksna hwy ersmu +K is ,lwo NOT wyh reniu +K si gihh

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. +3  
hungrybox  Thanks for explaining why it's not muscle breakdown. Was stuck on that one. +  


submitted by lamhtu(118),
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ePttalle dacerenhe dan teteplal nrigetggaao rea infdteefr gshitn dan tsih rnfecderie STAERMT A OT.L cFuk u,oy NEBM. hsTee screnfeidef edoysplusp aemrtt on eoms stnuisoqe dna otn no teohr.s reeWh is hte ycinecosn?st eH?lol

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 +6  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +4  
j44n  yeah i thought adherence was the GP1B receptor that's already on the platelet +1  
j44n  im also glad we're getting exposed to this horse shit now and now when I'm in a testing center about to put my fist through a screen. +1  
jurrutia  GPiib/iiia receptor is not inhibited by aspirin. Aspirin prevents the upregulation of GPiib/iiia which is not the same as inhibiting the receptor itself. +  
jj375  @jurrutia I think you are thinking of Clopidogrel, prasugrel, and ticlopidine which downregulate GP2b3a expression. Aspirin inhibits COX therefore inhibiting TXA2 and platelet aggregation. +  


submitted by lamhtu(118),
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aPtltlee hcneeedar nda epletlta oegrnggaati ear iedftrfne snhtgi and hist nereecrfdi RTMESAT A .LTO Fkuc o,yu BMNE. hTsee nfderseicef pselodyups ettrma no esom sniseqtou dna otn on ht.sero rWehe is teh neosccny?tsi elo?Hl

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 +6  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +4  
j44n  yeah i thought adherence was the GP1B receptor that's already on the platelet +1  
j44n  im also glad we're getting exposed to this horse shit now and now when I'm in a testing center about to put my fist through a screen. +1  
jurrutia  GPiib/iiia receptor is not inhibited by aspirin. Aspirin prevents the upregulation of GPiib/iiia which is not the same as inhibiting the receptor itself. +  
jj375  @jurrutia I think you are thinking of Clopidogrel, prasugrel, and ticlopidine which downregulate GP2b3a expression. Aspirin inhibits COX therefore inhibiting TXA2 and platelet aggregation. +  


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 +  


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I ujts inkht slmap ear tno pdoteetrc by hte namlnie adn got hsti .hgtir

hungrybox  useless +6  


submitted by lsmarshall(415),
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tetniPa hsa anpSi ibdfai calctou whhci is a raeunl etbu tefdce (ieurfal fo nsofiu of eth er)po.ornuse ltmrecseSoo aer eth tpra of aehc tioems ni a aretebtrve ebomyr invigg reis to onbe or throe allseekt .eutsis icSne a rpat fo ihst pti'tesna ianps iaifdb ndulcdie sabesc"en of piusson cpesso"r neht a omlocesret wsa l.envodiv ngwiKno atht rlunea uetb setdecf ear an ussie ihtw sfionu sdluoh eb eguohn ot tge to het tihgr .eawnsr

fI eth trcohodno ladfei ot elpvdeo nteh the rtenei SCN uldow tno vpledoe as teh rocnhotdo cdsineu rmaioontf of lrnuea .tlpea

If teh rnaleu bute iafeld to eeplovd hnte eht lohew SNC uodwl nto haev ldeepve.do

oYlk cas is rinlrvaeet to iths netai.pt

Wenh urnlae sterc lelc ti hsa defirftne otmcseuo ni iferfentd uitsses. aFulire fo neralu esctr ot giatrme in thrae anc ucsea tiosorTnspain fo treag svs,else gyeraoTlt of ol,lFat ro Ptsnerteis cunrsut arri.stsueo auireFl of lnaure cetssr to mtragie in GI cna eusca nuHcipsrsgrh eaediss nntlcioge(a lc)egmooan. rherTaec lnlosCi dmrnoyeS nca ccrou hnwe unealr trecs esllc ilfa to tgmriea inot t1s lanaphryeg .ahrc Nrlaeu utbe esdfetc ash niognth ot od hitw arluief of reanlu tserc iarngtomi h.gtuoh

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +14  
hungrybox  Fuck I picked "Formation of neural tube" but yea that makes sense... that would affect the whole CNS +4  
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 +1  


submitted by hungrybox(1032),

(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 +3  


submitted by medpsychosis(115),
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hTe ayw I tuothgh obuta it was a tleilt remo cimis.tslip eW esu onn tleecvsei ateb krcloesb g.(e. arPlor)olnop fro hte ttraentme fo tlesansei oet.rrm eTerrehof a eatb stagoin ldouw vhae eth eootppis c,fefet kaa uasce or heceann rmr.toe

hungrybox  Genius +3  
sunny  Also it(blockers) hides signs of hypoglycemia which are tremors. +3  


submitted by lsmarshall(415),
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Flreox iomurtigd nfousprdu is onsbrelseip fro iflonxe fo .PID eiMdla easpct of eht uslecm h(ihcw elxefs the t4h nda th5 igt)id is silppued yb the rauln neevr C8,( 1).T heT ellatra ptasce i(hhcw fselxe teh dn2 nad dr3 iigtd) si ndnvreeati by hte deamni reevn ilyclaescfpi hte oetnrria eentosuossir cnbarh C,(8 )T1. So hte nqutoeis si gsbidnirec a rnaeocital ggimdnaa the evner yuslpp ot hte IPD fexlor fo het 2dn gtdii dxe(in enir.f)g hisT si isaygn eht amlied vneer is enibg agddame C8( nda T;1 eorlw rkunt oo.st)r

uimrbslLca 12t,dn/s( ;nmidea 4d3,rh/t )alnur rea a rgopu of culsmse atht lfxe ta hte CMP ntoj,i adn eetxnd IPP and PID ionjst.

oCdul bmreemer as xo'erfl rduogitim rpodfusnu si opnryudolf lgn'o ensci nsdneto srtnie no DIP.s moepdarC to orflex grmiudito pfrelscsaiuii oshwe notden rpaws rouadn punfds'our sfiycaplleriu tbu irsenst no PsIP.

toupvote  This is dumb but I remember FDP is needed for picking while FDS is need for scratching the superficial layer of the skin +12  
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) +7  
hungrybox  'flexor digitorum profundus is profoundly long' is such a good mnemonic, thanks bro +  


submitted by link981(160),
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yedKsrow form .Dr ruocT fmro Klpnaa:

  • -Roepicitanl AND
  • atnciroprsTin- ANR
  • rot-Tnanslia eoirPtn
hungrybox  bruh this is like bio 101 lol +7  


submitted by suckitnbme(176),

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  not pictured: cremasteric a., which (I think) also would have been a valid answer +2  
greentea733  This is great but honestly was this covered in ANY step 1 study resource? +9  


submitted by tinydoc(233),
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ihTs qtieonsu is vrye ,seanky ubt ni essecne siht is atswh ienpp.aghn

hTe ccltinaeda omlreva fo het THP gdalsn digurn dhceooytytmri ⇒ ↓ HTP

TPH nmoiyl- rn-:al nbe:o ↑ mvaeolr of ²Ca⁺ nad hhtopPea ormf -innoe-b e:nyksdi ↑ ²aC⁺ ropsoetairnb adn ↓ OP⁻³₄ ero aip-r↑o-ntsb snnvooirec fo 25, yxroiHvmtdinay D ot 15,2 yrtmoidxayinvH D olrti(Cical - eticva r)mof aiv ↑ yvaictit fo a-1 yoHelsyxdra fnecyidcei

ohefrreeT a ↓ PHT lwudo dlea to:

⇒ ↑ ₄³PO⁻ ⇒ ↓ a⁺²C ⇒ ↓ ,512 Htdnymiiovyxar D

The eqnsutio si ekynas u(mhc kile hte tesr of this mae)x abesceu eosomen how tnis fuocigsn leyalr rahd or ni a suhr gmhti cipk eht noitop C ewher apphtoeh is ↑ dna TPH si ↓ TBU ↓ 25 xhtadryinviomy D

ishT si norwg as ylno 512, iaximtvohnryyd D uldwo eb edadr,esce het sncsevrnioo robefe ihts era endo yb eht nisk tnh()usgli dna v.lier

I rllaye ihsw ehyt udwol psot kagimn the tsnesquio fsnguconi RELUYP rfo hte skae of gknima htme cf.iugnsno ntIs ti oeugnh atht we evah to wkno htsi srdcuoiilu onmatu of rooniintafm, wituoth anvihg ehtm ainiontyntell ngikam ti rdhear yb ontginip uyo to 1 nesawr cihcoe btu gagnhicn a eintum aieldt to amek uyo wnsrae owrgn. rO nugis a anmodr sas leenuonamtcr ofr a eisaeds ot aviod inkgam ti oot seilpm PSNG( = avilfreoeir"pt GN")

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 +  
zevvyt  so since conversion of 25 --> 1-25 is disrupted , would 25 be high? I know its not an answer choice, just wondering +  


submitted by enbeemee(13),
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i etg hyw 'tsi epyli,ehrxoaf ubt wyh ton lfinirali?tbso 'its oals na NML gisn

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! +14  
eli_medina9  https://imgur.com/1z4OF4l Gonna piggy back off your comment and just post this kaplan image +10  
hungrybox  Very helpful image, thanks bro +  
j44n  its not a efferent motor neuron its the sensory/afferent branch +  


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oHt utb isi,lilltofcu ’its a g.hnti lsyaaiCllcs ond.sopseamu

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. +10  
hungrybox  @medguru2295 same bro same +  


submitted by thotcandy(79),

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 +2  
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 +1  
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. +1  


submitted by ergogenic22(320),
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tP sha sgnis nad xS fo oeoyl.srprcith /aLonorlwm CTAH sorafv aledteve itorcols itnneepdnde fo CH,TA dfnmerioc by lcak fo oeepnsrs ot semnxeaeatdoh risesnpu.osp oanZ stlcaciuaaf is iignor of rstioocl r.pnooutdic

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 +11  
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. +1  


submitted by strugglebus(165),
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rnopaoPllo is a selen-nteoivc aetB cle.obkr So oruy HR iwll ecrsaede ,B)(1 cwhhi lliw aseuc a tocarseynmop esiencar ni P.TR

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. +42  
amarousis  so why tf do we give beta blockers for hypertension -.- +6  
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. +7  
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 +  


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Whta adpeehpn to hsti yiuervop"ls ehtla"yh ngouy ey?Waehm fl is hes inmgvoit dnoDknrgb?ioli too chum ?ohlalco

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


submitted by flexatronn(2),
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This rpteyt cmuh eswrasn 3-4 of eth mnminoce fro uuobster rcsoeis:ls TMAA""RASHOMS

Hsmoaa-mtra in NCS and -M/-mak nsofno sgri/iitiblarA honrtg/atir-Au egis laef stspo htde(niymppeog umlac)e dR/ria- cac bR/asTreoamymubo-o duh SsoioaOl-aos/etmlu csr /n-Om mnttMidalean tetraiodran aA-nl/re u/ShgrneiS lmy-Azsi oaem-aniopeeorg/ teshapc /

hungrybox  somebody kill me +8  


submitted by hayayah(1076),
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Atuce nalseiiitttr earln on.malanifmit uPariy clcys(slalai oisops)leihn dna taaoemzi ongircurc tfrae smitidntnioaar fo urdsg htat tac sa ents,hpa niungicd ynieitehpsviryts g,(e iseu,tidcr INDsAS, ilnliepcin dvvte,iearsi nrootp upmp bsi,tiiorhn inrimp,fa osli,noeuqn )uesomdanf.sil

hungrybox  But how is a 2-year history acute? +4  
jinzo  there is also " Chronic interstitial disease " +4  
targetmle  i got it wrong because there wasnt rash, also there was proteinuria, doesnt it indicate glomerular involvement? +2  
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  
lovebug  FA 2019, Page 591. +  


submitted by hayayah(1076),
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heT bbay does ont etg yna mtrleana gI,M gAI ro gEI as heyt do nto scros hte lnt,aeapc os if MIg is fdonu ti mya usseggt eht abyb ahs ouredenntec an tnceifnoi in oter.u

gIG is sadpes wond to teh bayb as a ansme fo saespvi iymuitnm nulti teh yabb cna mfor ihert nwo dsnaiitboe fo tdrnfeief pe.syt So if ouy ese ghiytnan ethro anth gGI ge..( )MIg you kwon it usmt be dt/ an fcoini.tne

hungrybox  The baby gets IgA via breast milk. +5  
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. +9  


submitted by hungrybox(1032),
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lyisptcaDs neiv ear a esrpcourr ot mneomala. Tyeh ahev ge,rrraiul isys"p"dltac .drroseb mmereebR eth "B" in DBCA adntss orf iarglrreu rord.Bes sNuve sanme .melo

reOth w:nerssa

  • astnhascio gcnrisnai - kangnireD fo skni deaossicat thwi peTy II isateebd slulmeit

  • salba llec aacrconmi fo nisk - raRl,ey if vere tszsiema.ates lnoomymC taesffc ppeur i.lp

  • beul svenu - odBuleolrc-e ypet of onmcmo olem. inB.gen

  • ieepdmngt oehrebicsr troksseai - "Scutk o"n e.apapracne oMylst gn.bnie stcfefA dlroe .poepel

  • eo(Nt - uoy suylaul ees yonl o.en fI eutlimpl oieerchbrs ksoaeerst aer ns,ee it ecnitdais a IG agmacnylni - aak és-ert"TLrlea igsn)
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +26  
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 +5  
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. +4  
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(1032),
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rluajgu nveous ioisentndt = telf earht relafiu

uopynmarl emade = grtih eathr aiulerf

Fmrueabch-ro nidltoai si hte tosm lyleik snr.wae

erthO enasws:r

  • mtrsAeiscy spaetl ytpyheohrr,p loamadriyc sdya:rari thees ear tboh slacsci sgfdiinn in oprthrpyeich oprayiyohtdcma H()CM
  • ralnddiaceo soorftiibl:eass a rrae isvtrriecet mopyytaoadirch esne in scn/dfeirnainlth
  • mciylcotyph liiafnroittn of het mm:rayidouc snee in varil )(uoumeatmin mdyrici.taos A asuec fo ddaltei modt,oiphcaayry btu rethe asw on omitenn of a nigrpcdee vrali leil.sns
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 +12  
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(1354),
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tecDri nlnbiitolguA = trcieD oboCsm steT

ceDetst ioaebndsti noudb rdletiyc to .RCBs emoslsHiy omst ilylke ude to egtmnshio ni teh ratuefsnds oolbd t(no rues hwy ti koto 4 eksew nweh Tyep 2 SH is dpoepuss ot be curkiqe tbu .e/w)

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 +26  
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 +1  


submitted by mcl(598),
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Petinta stmo lyekli ash T-yahsSca isea.dse ihsT feurgi clnyei ohwss eht mileoacicbh aawyp.th Rlcale htat tbho aTsayShc- dna nmainNe cPik eidesas senertp hiwt a yrhrec rde pots on pndo,uyoscf but yaT chsSa lkasc the esoapeloapntmelygh ense ni .NP

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 +7  
hungrybox  thank u +1  


submitted by jotajota94(14),
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PAD lfsow rfmo aorta ot prluaoynm rrtaye cageiedsrn ooah.reflrtedfeeraT aiadrcc tuutpo ecariness

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 +54  


submitted by nuts4med(6),
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Anyneo evha na iead wyh hte ereedadcs teaarril 2O tausnairto is tireronc?c sAsngium seh hsa mpul aemed escin seh ahs EL m,eead woldntu' a owrel O2 sta be ctepdxee oto?

haliburton  I believe there would be no decrease in O2 saturation because oxygenated blood (high pressure) is shunted into deoxygenated circuit. As long as the lungs can keep up, this should increase venous oxygenation on average. +7  
hungrybox  ty both of you for this, was wondering the same thing +  
coxsack  O2 sat won’t change b/c you’re not adding deoxygenated blood to the arterial side. You’re just taking arterial blood and putting it into venous blood. Same reason why L->R cardiac shunts don’t decrease O2 sat (while in contrast, a R->L shunt would). +5  
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(46),
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iTsh qnseuiot si residinbcg nitmrela ,anosinmi chhiw is nocmmo rhitee ni DMD ro rmoaln na.gig Otu fo thoes wto DDM is het olny inthg ni ipoton hec.coi suP,l dol age si a sikr ratofc for DMD.

eEnv houthg hte qusinote sedo otn iscerdbe 5 ssoytpmm ededen to ndasigoe MD,D DMD si hte oyln caillog ce.cioh

hungrybox  excellent answer, thank you +4  


submitted by hungrybox(1032),
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rheto anw:ress

nhiniitoib fo 2H rtecero:ps o(fr )GDER nrtepev gtrasic adic nreescito nitd(ieecmi,

iinbiointh of pphoasrdeoesesthsi E(:PD)

  • ehloehynitlp aas)(mth hiiibtns PcMA EDP
  • -ifnsla cid(k )islpl rfo DE itibhin PGMc DPE

2β anssg:oit ro(f htam)sa eusac liroabinoonchtd

  • uberollat soht(r gnctai - A ofr utcA)e
  • s,emetolarl orflmoerto gnlo( ctgian - sixpolpyhra)

di(k yhleoymcpt beemnrma zioiibtnaaslt)

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +17  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2  


submitted by mcl(598),
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nPietat tsmo eykill ash csSTa-yha eiessda. ihsT rigufe eyilcn swhso eht oabcmciilhe y.ptawha llecRa atth boht -sShycaaT nad naiemNn Pcik esesaid tnrpese with a crrhey edr spto on yc,pfousnod utb aTy hsSac lacsk teh slonyhmleaeetoappg 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 +7  
hungrybox  thank u +1  


submitted by hungrybox(1032),
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Hhdyrehcotidoriaolz si a ditazehi iuitdecr t&;g= iiehzadt rctudiies rae tiessacdao thiw o.hymaipekla

hatW rhtoe tursdieci rae diastaocse twih eaalyhkoimp? opLo i.cteiudrs

hWy?

Ionhbiniit of +aN otirbepnoasr sucocr in ohtb oplo usdrictie (bhintii NCKC ttranoeocrrsp) nad aehiidzt etdsucrii nii(ihtb lNCa ottnreror)ars.pc All of this eescndira a+N enrecsais eerAsnootld viia.tytc

vtaeReln ot htsi b,meporl relesdnAoot artueupsgel ssepeonirx of the K+a/N+ TPA itanpoetrr (rasreobb N+a iton ,dboy lpxee +K toni nu.ml)e Thsi rletsus in haekopmalyi in het yo.db

Hnga n,o 'theres mero hghi yeldi i!onf

elesdnooArt esod eno erhot ampnritto gihnt - ticviaotna fo a +H nnelhac htat sexlep H+ oint eth ulmn.e

oS, nvgie htat thsi apiettn sah pmhealkyio,a yuo wkno ehter is tpunulgieroa of onsdl.oAeret Do you itknh reh Hp doulw eb hhgi, or low? ayExc,lt it lwuod be hhgi eecsbua ic.n sdeoolnrAet ;gt=& .inc +H xldeeepl onit het enlum g=t;& lteoibcam isal.akos

Nwo you sadndrunet hyw boht lopo iesicdtru nda aehizidt itusdrcie nac aeucs haws't ecadll khcl"mpoaiye tbcioemla laiss.l"oka

hungrybox  jesus this answer was probably too long i'm sorry +9  
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +14  
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +1  
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),
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iTsh si eon of sehot noesisqtu I swa rvene gngoi ot egt. stI' tno in ,FA I to'nd inthk v'Ie snee ti ni s.slac

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 +8  
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. +13  
step1soon  FA 2019 pg 551 +1  
teepot123  damn its in FA and Ive never ocne read it XO +  


submitted by yo(85),
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teeyrh' laikngt tbuao a nlonseraepl sthnu cepurreod

9tlm/etsularr/lge-lmcnstlaosepnn0tivt/.haaielndc/hanpnhreysestlc-4ho/-d5eti:t.

hungrybox  be honest did u know that before looking it up +9  
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. +29  
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 +11  


submitted by lnsetick(93),
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  • eonPAcri = oyru atmirps leslm elki na AEP
  • eMecUnR = es’htre on OMRO in ruoy rsae niesc h’yetre lful fo wxa
  • -ReYCCnE = hnew yuo iescEreC, ryuo preso rae CYngRi
  • euSscEaBo = EBumS si inPEgES tou of yuro oepsr
hungrybox  as an ape i'm offended +30  
dr.xx  stop being an ape. evolutionize! +7  
dbg  as a creationist i'm offended +11  
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. +2  
qball  The question asks about "the characteristic odor" i.e. body odor coming from the APEocrine glands. The Eccrine glands secrete water and electrolytes. +1  


submitted by hayayah(1076),
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attreCeh ltnec:aemp

s.op//e-atoaml0s/k/ittm:n84d.ou/pnw8s2etny01/agp0je6hpc00egce/

laeRcl taht eht lgnu exap etsedxn oaevb het tfisr b.ri

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 +30  
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. +12  
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 +5  
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(85),
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iTsh reucrcdo whitin 6 uhrso nad esadcu moes lrpuoanym emaed nda yairorpsetr stdsisre atefr a frsiostnnau scudae by hte nrsoo'd eyttuoecal-nik iantobsdie sutj tgrodsynie het printceesi lteoirhsunp adn rastyrporie etlihaenlod lse.lc

ehlwi y/ciaasexlrlpailngah acn uaecs rsayrtreopi eartrs adn hcoks ti sah a mteoswha fdeenfitr rietc,up no e,whingze heiitnscs ro vahterwe adn occgrdian to itsrf idA ti eaphpns hniiwt iumtens ot -23 srohu hhiwc si ta atles udoleb awth e'rew neegsi erhe. loas areebw of gAI fndicteei lppoee in this chec.io

,EP he I dno't khnti it tfcsaef oa2P htat nfteo uchm incacrodg to sith sprue erpud ghih yeldi oceerrus. but huh hyea dtones' eefl EP ikdan sutqenio2cd0/m-iecw/.31t/trtraemm0son.1#kpp:secelahdic0eopu9i/ec

menpaio,n hrgti freta lal the niunsiof nsessiub dna no eionntm of reevf or iny?nhatg h.aN

og to gaep 114 fo frtsi adi. I'm trteyp ruse ew dnee to nkwo uro paintrfnu/snoaltsni rapc aeucseb ti sjtu speek nomcig up in ldwruo utb tshi ewlho amex is a oaph.otsrc

roevigF me if I dmea a /somgknetrawi abuto aghniny,t I tlmyso tog onfi fomr sfrit d.ia zpl ertrcco if rthee is a tmakesi, gdoo lkcu.

hungrybox  we gonna make it bro +7  
hungrybox  or sis +8  
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 +6  
athenathefirst  I hope you guys made it. Your post 9 months ago +1  


submitted by yo(85),
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This ocdruerc nhtwii 6 hrsou and dceuas osme lyapuormn meead adn parrsotyeri eitdssrs rtaef a nisstnfouar udeacs yb the rdonso' ynklaeuotcte-i disaniotbe tujs retnysodig the ectiseiprn loipthunsre and rioysatrpre lhetnlodaei .selcl

ielwh e/laxcasglrniapiahly nac acuse irtrosapyre rsarte nad hcosk ti hsa a mawotshe eedrtifnf t,prueic on gi,enezwh eicihnsst ro whrteeva dan doricncag ot rtfsi diA it pnaseph thiniw emtsniu ot 32- hrous hhwic is ta eltas eodlub tawh ewe'r iesgne e.her slao bewrea fo AIg tcifneeid plepeo ni tihs o.cihec

E,P he I otnd' thkin ti esafctf 2Poa thta efnto cmuh rdagoiccn to htis espur edrup ghih edyil ecrrseu.o ubt uhh ayhe sdeton' leef EP ankdi sq iotuenpcwtotitm1.eacre9el/upri:d2ieoc.ee0-km/00/pn#ad3/1chsscm

nio,anmpe hgitr raeft lla eht niiuosfn beniusss and on neintmo fo rvefe or niytgnh?a Nah.

og ot epag 411 of siftr ida. Im' eryttp urse ew nede to nwko oru i/anrnpolufnitsatns pcar eebausc it stuj eeksp mongci up in wlduro utb ihst oehwl emxa si a prchtsoao.

eiFrvgo em if I eadm a tskrowage/nim tubao yantgi,hn I mltyso otg oifn rofm ftisr di.a zlp retocrc fi eetrh is a k,amteis ogod cukl.

hungrybox  we gonna make it bro +7  
hungrybox  or sis +8  
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 +6  
athenathefirst  I hope you guys made it. Your post 9 months ago +1  


submitted by nosancuck(87),
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hti em up wit tad NPCCH !boi all bauo adt NYLCH NSRMEYDO

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


submitted by yo(85),
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dnrue 8 rseay odl fro rigls si a dab ig,sn 8 is yk.oa enud r 9 fro bsyo is a dba nsi.g

just hcatw tou orf yan 6 aeyr dlo ro gsthinoem leik .thta erawbe fo htta nGRH ehreit enrltlcya ro some eosm retoh escrf-.osu irt dia 0129 pg 623

hungrybox  yo wtf i got my first dick hair in 6th grade wtf are they feeding these kids +40  
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. +  


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It idsa it saw tafal ot smlea ni roeut, and eth nesitqou askde btuao veil bron i.opfsnrgf incSe hte esmal ’anret inbge bnro ni het irfts cpl,ea I sdai %05 masleef dan 0% emsal.

hungrybox  fuck i got baited +31  
jcrll  "live-born offspring" ← baited +23  
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. +2  
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 +3  
qball  Jail-baited +  


submitted by nosancuck(87),
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uhrB tel me tlle oyu a lil rtscee

EPEP nvtpseer Acelsetsita KAA tda LUNG LLSOCAPE

notD eb ynorwir taubo ormnad rwosd yteh ustp in onrft of hte GHHI YEIDL seon

hungrybox  literally LOL'd lmao I love this +14  


submitted by tissue creep(113),
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If bondayy ash a oogd ayw fo nmbi/eihgesgnsegnudtmrriii lla the ffendteir tnetiprssenao rof ntileag s,rseo 'Id cetiprapea het hple.

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(570),
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sTih si a case of uatce t.guo Misodnmouo uraet cayslrst era ankte up by unlhtris,peo nlgeida ot an atecu yanmlomtiafr rnaetioc. -seclTl art'ne learly evvldoin ni utog r(meo hidmeutaor sa.rtiihtr)

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 +16  
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(1032),
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teGra doevi I esud ot elarn hsit aairmle.t

  1. erheT rea 3 romaj styep fo g:sdur rpueps )t,s(laintsmu dsnwoer (an)sper,stesd and a.neoluisnglch
  2. ieorHn is an io.dpoi sipOiod rae s*deo.wrn
  3. orwsDen do twah ti snsudo i.kel Tyhe seauc "d"wno s:tmospmy snedoretaeciedsa/d anxiyet nd(a thus abhlvierao iiinbs,diotnih) reirrypsota s.redseoipn
  4. shTu arialtwwhd iwll ucesa eth :ptspeioo ,aipo/nyhethaccsandryeirt txny.eia
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(124),
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ishT ahs nebe a thogu tpcnoec fro em to e,tg utb I tinhk 'mI fialnly :teher

Teh tesm is bdiserngci miaprry lradean sfie,infniucyc ro .disAs'nod

  • HCAT si eginb rudvdoo-preec to siutemtal teh nleadrsa to oercpdu ocri,otls ubt htey tnc'a dnposr,e tirhee eud ot atoryph or rsitodeunct ,T(B eutimo:aunm ,R4D .)etc
  • Teh tfisr 31 oiman isadc fo CATH nac be vcledae to frmo -,αMSH ihwhc itsetmulsa ,scmoaleteny iacnsgu yhepreogmipnnttia
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 :( +3  
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. +  


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ndot' eb a cidk? not ayrell seru hawt ermo eterh si to i.t hTe eipttna 'dsnote hvea nay ethro yfmlai os sthi noamw hlsdou be ndsecrdoie maliyf

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. +5  
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(1032),
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heT verxci is eht only tutusrcre ttha duowl slteru ni ltbialear cbledaok.

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


submitted by hyoscyamine(55),
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I wkno tihs si usjt a attrsihg pu ctaf morf A,F tbu to'cudln reeusrt (sotainiltran llce mcncoiraa) sloa be rctcor?e

hungrybox  Hmm I don't think so. The answer is "ureter" (singular) which would not result in bilateral hydronephrosis. +9  
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(76),
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sThi one wsa tickry utb I tkhni oyu cl’oveud doen stih one toutiwh dgwenloek fo MNDA .prcrseoet Stem told uoy htat atltgueam tecavstai tbho MnDnoN-A and ADMN opcetrers tbu ti ivtetacad ynlo NnAMon-D oprertces ni eth alrey es.hap hTat anmse DANM errtscoep vtetiaca ftera -nDoNnMA eoep.rrcts tahT sname inmgoeths aws edganyli DANM ptreecor aviitcagtn adn eht olyn erasnw thta aedm seesn as het gM ngiitiinhb ANDM at ietsrgn .tptoliena ncOe the lcel is oddaeerpzil yb oAND-nMn ree,ctspor NDAM orcreespt anc be eacta.vitd

hungrybox  I forgot/didn't know this factoid and narrowed it to the correct answer and a wrong answer. Guess which one I chose? +14  
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. +6  
divya  sweet explanation imgdoc +  
lovebug  really~~~ sweet. thankyou :) +  


submitted by hungrybox(1032),
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gnlwooliF a esrk,to htis tinpeat hda esnksaew of ehr etfl ceaf nda do,by os teh kseotr ustm haev tffecead het rhigt dsei of ehr n.iarb B wsa teh nylo icecoh on het gihtr seid of reh r.abni

Slitl s?nodfcue edRa ..n.o

eTh arvuoytln ootrm sfiebr (scatpoiniocrl att)rc nsdedce omrf the mraiyrp romot e,coxrt srosc ecs)auts(de at eth rduyelmla ,syrdiapm and hten epnysas ta eht rirotnae ortmo ohnr fo the spnial vle.el

cuBeaes of istadnoceus ta het lryealdmu r,pmidyas you douhsl kame a onet fo ehrew nya oksert sc.coru sI it veoab het llmrdayeu idapymr?s hTne it ilwl teffca eth ised stoipeop teh ktrose aratrlaoecn()lt. sI it elobw teh dmelurlay ?spdiymar Tneh ti ilwl eaffct eth emas desi sa the rtkose ptilie.(rs)aal

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 +8  
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 +22  


submitted by drdoom(880),
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cViiostorcnostna g(arrwonni of a tbue) wlil ausec eht lwof rate to ncreiaes hruohgt tath u,bet hwchi sersecaed talrddiwaaoru/ sprsre.eu The satfer a fludi omsev htuhrog a u,etb eth sles otur”awd“ orefc ti xs.teer hTi(s is konnw as eht tVeruin efefct).

hungrybox  not seeing how this is relevant +8  
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(1032),
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eTh caiotamn ffxubson is mefrod by eht tnensod of eht texrsoen losipicl rbsi,ve the uradboct iopcslil gonusl, dan eth etosrenx iiocplls solnug. (urfieg)

ehT lrofo is eormdf by teh pshacdoi oen,b nda ti is hree atht eno cna tealppa orf a olibesps dftuarcer scodahi.p

orSuce: a'rGsy nyomatA vewRie

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(1032),
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ehT inamctoa uosnffxb si ofmdre by eth netnods of eht rentxeos iollpsci svbie,r the turoabdc silipclo s,gnlou nad hte esrxnteo sloiclip olgnus. (gifeur)

heT lroof si dofmer by het ashcdpoi eno,b nda it is reeh that eno cna paleatp orf a iboslsep tafrdcrue a.ichdops

Srouec: ar'ysG tanmyAo ewRvei

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(1032),
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aka pamulal of tVrae ro het apipeccntraoahet cutd

hungrybox  tripped me up cause I didn't know the names :( +14  
sympathetikey  @hungrybox same +13  
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 :'( :'( +7  
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 +1  


submitted by hayayah(1076),
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o:etN The saedbnuc n. is lcluaayt teh never sotm keylil to eb dedgaam yb an aegnxinpd lanitern tdiaocr yuaensrm in eth serncuvao isnus but tehy eivg ouy siicepfc CN3 icontnuf in itsh tuqeon.is

hungrybox  One pupil larger than the other indicates damage to the pupillary light reflex - afferent: CN II, efferent: CN III. +23  
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. +  


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kO I etg htta fi 050 rlaydea aehv eht iseeads then het kris oolp si porpded to 2000 uetnstds tub teh einqusto plccasiefily asys ttha eht etts si deno a aery arit.lfe.. 050 opepel ahd mdliycha,a yuo uwlod tater mthe. ouY dtno' eebcmo ieummn ot ldhiamcya aertf notfcinie os yhte udowl go akbc tnio hte kris po,ol negnima eth oplo uowld trenru to .0052 hTe rsneaw uhldos be 8,% tsih wsa a adb .qineosut

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 +9  
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. +2  
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),
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noAney vaeh na daie yhw het dearcdsee traeailr 2O ntotsaraui si n?irctroce giumAnss she sah plum eamde iscen esh ahs LE ,dmeae nduo'wlt a owler O2 tas eb eedxctpe 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. +7  
hungrybox  ty both of you for this, was wondering the same thing +  
coxsack  O2 sat won’t change b/c you’re not adding deoxygenated blood to the arterial side. You’re just taking arterial blood and putting it into venous blood. Same reason why L->R cardiac shunts don’t decrease O2 sat (while in contrast, a R->L shunt would). +5  
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 +  


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AV liastFsu erurot- dbool omfr hte rarletai yssmet ot the enousv ,ymsset py-biasngs eht lrreotieAs = enrIseca LP &-gt;-- ARIENCSE R.V All ni lla = secnreaI OC.

gAdnircco to ,rUlodW teh eseolitarr are a jmroa corsue fo eaetinssrc ... os ysgnbpisa eht liaeroesrt sreslut in a dsraceee in lotTa aPehrliper teacseRisn ... gcsianu na csniraee in eth aert dan elvuom fo dlboo rginuernt to the eahtr. I ma rtpyet erus eerth is rome to eht gshyolypoi hiebnd h,tis tub I oehp shit elnedpiax a liltt.e

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). +28  
hungrybox  Jesus big92 you went in on the research lmao u must be MSTP +6  
temmy  big92 you are right. that is why pagets disease pagets have high output cardiac failure because of the av shunts. +4  
kevin  what is "increase PL" +3  


submitted by seagull(1552),
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picyiItod samne --- ndyiabot iagsnat oy.anditb B lelsc d'tno eahv uarsefc adesnoibti ubt erem sytnisehez t.hem

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 +3  
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(1552),
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yIiticodp anems --- oayidbtn istagan ont.yaidb B ecsll d'tno vhae uacsref bnioaiesdt but emer sezihnstye emh.t

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 +3  
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(93),
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I thkni het entcocp ’etyrhe sgintet is eht rdaciseen TGB slleev in ,cyrenpgna dan otn jsut sthdhirmyyoiper ni .aerleng

eWnh igenercsn fro htspodiriyyopye,mhrh/ HST leesvl rae LWSAAY eifeeplytlarnr hcekcde scebaeu eyht are ermo iesevinst ot tuinme feceindserf ni 43T.T/ tnefO tsmie STH elslev nac totdasenmer a ecgnah nvee newh TT3/4 slvlee ear ni teh niscbclauil a.erng The yonl neopcxtei to sith wdolu eb ni yrpacgenn dan( I suseg bymea liver uiera?lf I utbod htey olwud aks hsti hthug)o. iHgh esgeotnr slleev tvsrenpe hte irevl rfmo arkgbeni nowd TGB, alndeig to encariesd BGT lvesle ni eht .usrem hTsi ndbis ot rfee T4, cdngiaesre hte mautno of llavaiabe eref T.4 sA a enrotcyaospm nmscae,mih HTS elselv ear sntelyatrni nicsedaer and teh RATE fo T4 cdprtiooun is ercsndaie to eshrnleip linbease eefr 4T leeslv. reovHwe het ATLOT omatnu fo T4 si eec.raidsn

eTh sointuqe is niagsk how to omcrfin rshtoyyeimhprid ni a pgnatern mnoaw -&-;gt uoy deen to cechk REEF T4 vesell ubas(cee hety hduslo eb rnomal deu ot rpocnsymoaet .)erenspso oYu otcann hkecc HTS ysuulal( aeldetev ni cganpynre to snecpoemat orf earcdines T)GB, dna you ncntao cehck alott T4 elesvl (lilw eb eainds.)erc Yuo got eth rnasew thigr eerhit ayw utb I ktihn tihs si a tfneiderf ngrasneoi hwotr gndc,nirsoei eeubasc hety nca sak itsh tcnpceo ni thero ntcstxoe fo rite-yeomnpgrhes,s dan if teyh litdes HTS“” as na eanwsr iccohe hatt woudl eb rrcite.nco

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +8  
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  
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 +  
an_improved_me  Just to add: Pregnancy is not an exception to using TSH in suspected hyperthyroid pregnant patients (not sure in hypothyroid); you would still get a TSH first, and if its unusually low, you would then proceed to measure T4 (free, total), and so on. https://www.uptodate.com/contents/hyperthyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-causes?search=hyperthyroidism%20in%20pregnancy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H994499 +  


submitted by hayayah(1076),
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het jaryomit fo oancrb ixieodd someelulc ear drieacr as trpa of the bitabraneco ruffbe smet.ys In tsih s,estym racbno xoidide ffsuidse oint eht R.BsC Cbcorian dhaasnrey )(AC tiwnhi BCsR iyucklq rnsteocv eth bcnaor idexdio itno aocncibr acid )(23.OHC Ccrnbaoi iacd si na benlutsa demttieaenri luloceme hatt miyateiemdl adosicsteis toin airctbnaebo onsi C(O-)H3 dna yrodegnh H+)( .nsoi

eTh nwely isezdstheny iabbectrona oin si rprtnadteso uto fo eht BRC nito eth asmpla in eachgexn ofr a hldioerc ion −;()Cl hist si ldacle eth ohecidrl stfhi. heWn eth obdlo hecsare eth gsnul, het oierabtabcn oni si nedtosrptra kbca ntoi hte RBC ni agheexnc fro hte dorchile no.i Teh H+ ion stiiosdesca rofm het gmooinehbl nda sndib to hte bracoetnaib on.i sTih ocpesrud hte icoarcbn caid erd,enemaitti hiwch si ovrnetedc kcba iton bnoarc idedxoi uhoghtr het teymazcin ntcaio fo .AC hTe ncobra eddoxii ddcperuo is plxeeedl throguh teh glnus inrdgu olitxh.eana

hungrybox  Amazing explanation. Thank you!! +1  
namira  in case anyone wants to visualize things... https://o.quizlet.com/V6hf-2fgWeaWYu1u23fryQ.png +5  
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? +3  
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/ +3  
teepot123  fa 19 pg 656 +1  
surfergirl  "majority of blood CO2 is carried as HCO3- in the plasma." I guess that is all they're testing us on, just in a very convoluted way. +  


submitted by hajj(0),
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anc nenoay nxepila ?thsi i konw ediamn rof y si hheirg by aliclncoatu utb x hsa owt desmo os woh coem y sha eigrhh omde?

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(124),
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I imght be eht ylno osrnep no rhaet ohw tog iths oen g,rwno btu gd:reelrssa

TI"T nysasail nldcuies yveer juctbes owh is rdadznimoe cdcarnogi ot zeidnamrod raettetnm .sineantmsg tI osengri capioclne,mnno lotcorpo isovdant,ei ,datwrlhwai nda ntaghyin hatt hapsepn frate ara.iomnt"odzin1[]

yo  You're not. I also goofed. +19  
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),
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Orcoehcytim = ↓ settnsoorete ocrntioupd = ↓ DTH &=g;t reotstap sclle uodnegr otpsio.aps (Tish cmhinsema is alrismi ot ugins αe-c5sdateur bsroekcl ot retat )PB.H

ippsosAot is itrdraeacczeh by AND afngaormitnte kionys(s,p ,srkyihxreaor ksiolar.yy)s

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. +26  


submitted by hungrybox(1032),
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huetotmbla = abhEtlEYmout

areGt icmomnne rof geemimrenbr ahtt lbaEhEYtomtu is het metconnpo htta casseu asuivl pbolesrm ni ERPI hypater fro TB.

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


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dnCaaid si a tapr fo the lnarom olraf fo snk,i uolcd ecsau cotoatimnnina of a ratlecn svneou taceh.tre Teh neouisqt saestt ttha eht ronsgmia si ,rpupel didb,ung ddi not drsnope to dboar cusrmtpe iiobastcint (kaa yeth d'dtni seu zllunfeooca ro ihipmreotnac .B) Ly,tsla yhet owhsde ti aptedl no oldbo arag adn teehr aws no esslohimy hiwch ailisenmte patsh (het lnoy rteho lbposise nceertdno he)e.r

oocprCcutsyc lluayus nsilovev ignimetisn ni mmdoiimnseorpumco s.pt E. lico is gmra ehtotipsnoarrigexv is aluulsy isnmrtedatt yb a otnrh no a esro or eensomo iwht a ohsyitr of nregaidgn

hungrybox  Also, the yeast form of Candida is gram (+) +30  
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(880),
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sHee’r oen way to eemiietsnsr-lca-ofpo “cededasre nhrebydg-oond oamnrt”fio: m’I ton a igb afn fo siht elni fo genin,rsao tbu htycaeclinl eaanlni sa a isde uogpr has remo rhg*eydson rfo etnapilto dyhnorge dobnngi htna eycigln:

leia:nan 3—HC
iln:gyec —H

oS, cel“”ciha,nlyt inaalne luodw rpeimt ermo de-oorhynbndg o,firmatno hciwh himgt loalw ouy ot mateenili taht icc.heo

hTat ai,sd ti esems lomsta mpibsoelsi to luer uot tutowih( rvye icctenahl ekgdlnoew or soem pideordv xlenpmareite atda) atht eht iltglhsy gelarr enaalni oesd ont rmapii ondrehgy onigbdn webetne clgaelon lmeesuloc aiv tirsec isl)at(ap tenei.erecrfn In ripeslm mrets, cisne ienalan is ,rgealr uyo louwd hkitn atth it must moehows neerrieft twih eth noe-goirhgynbndd ttha rsocuc whti teh edp-tiwly ciyelng.

---
rtciySl*t aenk,sipg ist’ ton eht mbruen of odrensyhg utb saol the nsrhtget fo the dleipo taht citistlafea ryehongd dgbi:nno a erondhyg dunbo ot a nltrosgy etaecoltgvieenr meluceol ekli irnulefo lwli rapp”“ea mreo esiopitv nd,a ush,t genhyor-dodbn omer gtnsrlyo hwti a rnbeya noygxe m(apderco tihw a hngerdoy etdnccone to oancb,r orf ele.xp)ma

ruFreht ie:gdnra

  1. hew/d:.upuddchsp/tmtretobci/ueel.duqgnlhhl/..hwspmw/i
hungrybox  Appreciate the effort but this is far too long to be useful. +26  
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 +  


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nMuebmaosr seGinpihtuemroroll si r;Nhpeicot LNOY OPRNURAEIIT is ni hte ettngvei

tI n'atc eb GMNP beesuca MGNP is Nihritcpe twih lbipesso oectpNhri

hrtOe coihces rea aemditneil yb alneR pysBio

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +4  
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 +