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Welcome to ibestalkinyo’s page.
Contributor score: 43


Comments ...

 +1  (nbme21#8)

Anyone find it strange that the NBME loves to write questions where physicians are alcoholics?

athenathefirst  Their job is to find our flaws haha +
tadki38097  this patient isn't actually a physician, they are trying to show that the patient has confabulation (making up stuff but truly believing it) +
sarahs  good point...negative alcohol screening threw me off +

 +1  (free120#21)

This patient presents with signs suggestive of metastatic pancreatic cancer. One multisystemic sign of pancreatic cancer is hypercoagulability.


 +2  (free120#4)

This is an example of a stressor (divorce) inducing the immature defense mechanism "Acting Out" which FA defines as: Expressing unacceptable feelings and thoughts through actions.


 +4  (free120#2)

Injuries to the lateral portion of the knee and fibula often commonly injure the common fibular/common peroneal nerve. Functions of the common fibular nerve include: sensation of the dorsum of the foot, dorsiflexion and eversion of the foot.


 +1  (nbme20#35)

The corticospinal tract runs from the cerebral cortex (Pre-Central Gyrus), through the posterior limb of the internal capsule, and into the posterior portion of the brainstem where they form highly myelinated medullary pyramids. These travel down the spinal cord, decussate and synapse of lower motor neurons in the ventral horn of the spinal cord.

A past history of cerebral infarction must have affected this patient's left middle cerebral artery and through Wallerian degeneration, the left medullary pyramid degenerated.

Destruction of the left corticospinal tract before decussation leads to contralateral spastic hemiparesis (since this is an upper motor neuron lesion.





Subcomments ...

submitted by neonem(570),
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snnTie" wlboe" is edu to driala erven einpeimgmtn nrea eht atellra ncioyelped of teh s.murheu oxsneErt cpira iasildar birsev si a lemusc fo het eetxonsr pammtoncert of hte mfrr,aoe enasitorgi rfmo eht lalatre odiyncepel sa l.lwe

ibestalkinyo  The radial nerve is NOT involved with lateral epicondylitis. The underlying pathophys is inflammation of the tendinous bursa and origin of the extensor tendons. Radial nerve involvement would lead to more neurologic deficits such as loss of sensation and weakness rather than tenderness and pain against resisted extension. +1  


submitted by neonem(570),
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Morja srki rftaco rfo citora sdsoicitne si pnisnt,eyehro nda ni ihts ecsa ihgtm eb ude ot naicoec use, hhwic ssceau mearkd .trenneosiyph ciostnssDei uasce a trea ni eth nitauc ntmaii -- blodo nac wolf swbdkacra iotn het ridrmuaecpi nad suace pe.ndamtao siTh stfenmais as alcckser ni teh ulng ued ot poor tfel trcvralnieu fnoictnu osnlialifl(/dctgii eplmrob edu ot sope)cmosnri.

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9  
temmy  please why is there where a diastolic mumur? +1  
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8  
garibay92  Does anyone know why is this patient's tepmerature elevated? +1  
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1  
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +  
almondbreeze  he's only 28 - another clue for marfan? +  
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2  
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1  
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +1  


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The aorrw is ipntigon to a lpruntioeh tleibol(mud :u)lceuns main thirgfe fo teh unmemi eytmss ni eatuc oaamnfinmtil adn ilcbaraet fctnnoiie shc(u as rtnpoiasai )un.piomaen a5C is a emocichttca ofatcr for sM.PN

ibestalkinyo  Other chemotactic factors include IL-8 and LTB4 +5  
j123  Note: C5a is a chemotactic factor for many immune cells in addition to neutrophils. Also, C3a is a chemotactic factor for just eosinophils and basophils (not neutrophils) +1  
cheesetouch  Q. What's so sexy about C5a? A. It's like Chanel No. 5 for neutrophils: they smell it and come running. +5  


submitted by anu(4),
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awth ubtoa teh ncsraiee in rampuylno sluarvca iereatscsn ? tsdone WPCP afll in ogchmrahire khcos

ibestalkinyo  I think this may have something to do with hypoxic vasoconstriction? +  
medguru2295  PCWP falls because there is less blood going into the Lungs and therefore, less blood coming out (decreased preload). However RESISTANCE is a measure of how difficult it is for blood to flow. That essentially means constriction. As stated above, it is likely hypoxic vasoconstriction as well as just global sympathetic attempt to maintain BP. If it said pressure in pulmonary arteries, it would likely be decreased as the vasoconstriction cannot full compensate the blood loss! +1  
medguru2295  PCWP falls because there is less blood going into the Lungs and therefore, less blood coming out (decreased preload). However RESISTANCE is a measure of how difficult it is for blood to flow. That essentially means constriction. As stated above, it is likely hypoxic vasoconstriction as well as just global sympathetic attempt to maintain BP. If it said pressure in pulmonary arteries, it would likely be decreased as the vasoconstriction cannot full compensate the blood loss! +  
sharpscontainer  Actually I don't think this is due to hypoxic vasoconstriction. The alveolar oxygen content of the lungs remains high, so there's still a good amount of oxygen getting into the pulmonary vessels, even if less of it can bind to Hb. I think instead it's that there's tons of sympathetic stimulation from hypovolemia, so alpha 1 in the pulmonary blood vessels is activated (which is separate from beta 2 bronchodilation which is a smooth muscle thing). https://www.ncbi.nlm.nih.gov/pubmed/10378571 +8  
avocadotoast  PVR = (PAP - PCWP) / CO. There is a decrease in cardiac output in hypovolemic shock. Given its inverse relationship with pulmonary vascular resistance, we should choose an increase in PVR for this question. +2  
topgunber  in hypovolemic/hemorrhagic shock there is a decrease in systemic blood pressure , there is an Increase in TPR (it's a compensation) to maintain flow. I think it's safe to apply the same logic to the pulmonary circulation where there is decreased blood pressure there will be an increase in TPR to maintain flow. (due to the sympathetic activation from the baroreceptor reflex). As someone said, the PCWP will fall, the increase in TPR is a compensation just like in systemic circulation. There will be absorption - we wouldn't want to lose more intravascular volume when you've lost blood. I'm not 100% if its due to hemoconcentration or a severe decrease in hydrostatic pressure in the capillaries, though +  


submitted by vish7287(-1),
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fI tsI oPetgaudos nth wesanr lowdu eb aciucml sh!rayeopppt!ho

ibestalkinyo  If I look at a sheep and think it was a goat does that make the sheep a pseudogoat? +8  


submitted by strugglebus(165),
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ehTer ear eicatnr totsanisui ni ichhw yuo t'ond deen ot itonfy teanrsp uabot ayntihng nwhe agtnerit a -SIdcT-lhis aer eon of me.ht The aoerns ignbe thta ertteanud SIsT lwil seuca erom rapsde sa lewl sa can aedl ot PID

ibestalkinyo  Mnemonic for things not needing parental consent: Sex, Drugs, Rock and Roll (Emergency Trauma)(except HIV) +3  


submitted by johnthurtjr(144),
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FA 1290 gp 4:00

satM s..lle.c nca be iaectvdat yb sseuti armat,u a3C nad ,5aC aeurcsf EIg -olrsicinskng yb intngea gEI( ecotrpre rag)toagiegn g--;&t neudaraolngit -g&-;t eleeasr fo sntmihaei, neihr,pa rtspyat,e and eonlhipios iohaemccctt stc.foar

ibestalkinyo  AKA Anaphylotoxins +2  
dermgirl  FA 2020 pg 408 +  


submitted by hayayah(1076),
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ysiitviSten stets ear seud rfo eencgnsi.r yfSpceiicit sstte rae used ofr itrnnoaoficm ftrea vpstoeii innssrgee.c

sneitiSyivt tsest are sude orf isegen hwo aynm oelepp uyltr ehva eht e.siasde ciSpyfetiic tsste ear rfo ehost hwo od not vahe teh esised.a

A lhyghi isneeitsv estt, enhw gaetnevi, eulrs UTO .seeaids A ighyhl cefiipcs test, ewhn tsievo,pi uesrl IN saisd.ee So, a sett hiwt ithw low stesiivyint acnotn ruel uto a a.dssiee A tset hitw olw citefsciipy 'cnat eurl in edises.a

Teh dtocro nda peattin want ot enecrs rfo ncool ranecc nda urle it ou.t The orodct ulwdo atwn a ttes wthi ghhi siyistneitv to be ebal to do ahtt. eH oskwn tath ittsgen ehr losto ofr odlob illw nto lure uot the tspiilbyosi fo lcnoo CA.

sympathetikey  SeN Out (Snout) --> sensitive test; - test rules out SPec In (Specin) --> specific test; + test rules in +23  
usmlecrasher  can anyone pls explain why it is not << potential false- positive results >> ??? +  
almondbreeze  correct me if I'm wrong, but 'high FP (choice C)=low specificity (choice B)'. Whereas high specificity is required to rule in dz +2  
almondbreeze  picked positive predictive value myself. can anyone explain why not PPV? +  
williamfreakingosler  The principle @hayayah is talking about (a negative test being relied upon to reliably rule out) is negative predictive value ("NPV"). I don't see why "uncertain NPV" isn't the correct answer, particularly because NPV is predicated on the disease having the same base rate in the person(s) being tested as in the population that was characterized for the test statistic. Given that the patient has a strong family history of colon cancer, the NPV of FOBT is uncertain. Said another way, the sensitivity of a test does not change with the population, but the NPV does. The whole reason the doctor is denying FOBT is because of bayesian thinking (a priori information related to family history), and from my point of view bayesian logic is more relevant to PPV/NPV than to sensitivity, hence my confusion over why NPV isn't the right answer. +2  
ibestalkinyo  I thought negative predictive value for the same reasoning +  
raga7  AFTER THE RESULT OF TEST WE CAN USED PPV OR PPN, BUT FOR TEH FIRST TIME LOOKING ANY DESEASE USE SENSITIVITY OR SPECIFICITY. +  


submitted by sciguy(1),
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HS is tsaoomula tandomi,n utb hxtiiebs etiepnlomc ennptaerec. So eh adh no corrde fo aosrnepl ay,flim but ltlis ilkley uhogytzsre.e

(kieW)dpiia eTh lcicilna ietrsyev fo HS srivae omrf epme-rsyomft raercir to eeervs shmoeylis bsuecea eht orddiesr bisxheti toipelemcn ncaprentee ni sit xniep.oesrs

ibestalkinyo  This is what threw me off; I figured with 2 unaffected parents, it's more likely he had an autosomal recessive mutation. +1  


submitted by yotsubato(1030),
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syi"phscnai udslho aslawy ucaneergo ehlyath rmdanuianirgo- uo"aotmin.cmnci

loAs 'ueroy noggi ot od omse siesruo githns ot eurc shit g'irls dsa,esei idlgena up to oaunamtpi.t Yuo atcn heid ahtt romf .her

djjix  Non sense ... you can hide the amputation from her +19  
charcot_bouchard  Just show her one leg twice. +4  
pg32  I picked "request that an oncologist..." because I figured it would be better to have someone with more knowledge of next steps and prognosis discuss the disease with the family as compared to someone working in the ED... why is that wrong? +2  
ibestalkinyo  @pg32: Referring to another physician is almost never an answer for NBME/USMLE questions. Plus, I feel like this would be hiding the patient's problem from her and the patient's parents. +5  
dunkdum  I think the reason that you requesting the oncologist isnt the most correct answer here is because... even if more tests needed to be done... you would still discuss with your patient about that fact and say "Hey these results came back suggesting that you might have this disease, we will need to do more testing to make sure we can get it taken care of if you in fact have this disease." and you'd probably do that before you go and get the oncologist. +4  
peteandplop  @pg32 I was kind of with you, but I went with the correct answer because it says STRONGLY suggestive. If you're giving me a powerful word to really emphasize this is osteosarcoma, there's no need to delay passing that information to patient, and in this case of a minor, her parents. +2  


submitted by hayayah(1076),
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lyboisosmhadyR anc nteersp nkloigo keil a inyedk unrjiy ti( anc eald to uceat arltubu icensros sa )l.wle eTh tleeorlctye nifsgdni are ujst elki rnela rlfeaui nIc.( ,K+ .nci 4,O-P .cde )Ca

oT ffeterniiatde bwentee armysiohbdlsoy and nyekid juy,rni uyo eckhc hte ueinr ot ese fi heter era yna sBCR. In yishldosmyrabo trhee aer no efer CBsR ni hte ir.eun

ergogenic22  "Crush injury" is a buzz word for rhabdo +11  
ibestalkinyo  The mechanism by which AKI occurs after rhabdomyolysis are due to free radical formation. Other urine finding include blood on dipstick, but as hayayah said, no frank RBCs. +2  


submitted by sammyj98(24),

maybe I overthought this one, but doesn't she have free air in the bottom left? Or is that the bottom of the pleural space...

ibestalkinyo  That's probably the most inferior portion of the right lung +1