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Comments ...

 +0  (nbme21#8)

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

 +0  (free120#21)

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

 +0  (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.

 +0  (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.

 +0  (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(371),

"Tennis elbow" is due to radial nerve impingement near the lateral epicondyle of the humerus. Extensor carpi radialis brevis is a muscle of the extensor compartment of the forearm, originates from the lateral epicondyle as well.

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(371),

Major risk factor for aortic dissection is hypertension, and in this case might be due to cocaine use, which causes marked hypertension. Dissections cause a tear in the tunica intima -- blood can flow backwards into the pericardium and cause tamponade. This manifests as crackles in the lung due to poor left ventricular function (filling/diastolic problem due to compression).

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. +5  
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) +6  
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 +1  
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. +  

The arrow is pointing to a neutrophil (multilobed nucleus): main fighter of the immune system in acute inflammation and bacterial infection (such as aspiration pneumonia). C5a is a chemotactic factor for PMNs.

ibestalkinyo  Other chemotactic factors include IL-8 and LTB4 +  

submitted by anu(4),

what about the increase in pulmonary vascular resistance ? doesnt PCWP fall in hemorraghic shock

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! +  
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! +  

submitted by vish7287(1),

If Its Pseudogoat thn answer would be calcium pyrophosphate!!

ibestalkinyo  If I look at a sheep and think it was a goat does that make the sheep a pseudogoat? +3  

submitted by strugglebus(96),

There are certain situations in which you don't need to notify parents about anything when treating a child--STIs are one of them. The reason being that untreated STIs will cause more spread as well as can lead to PID

ibestalkinyo  Mnemonic for things not needing parental consent: Sex, Drugs, Rock and Roll (Emergency Trauma)(except HIV) +1  

submitted by johnthurtjr(81),

FA 2019 pg 400:

Mast cells... can be activated by tissue trauma, C3a and C5a, surface IgE cross-linking by antigen (IgE receptor aggregation) --> degranulation --> release of histamine, heparin, tryptase, and eosinophil chemotactic factors.

ibestalkinyo  AKA Anaphylotoxins +  
dermgirl  FA 2020 pg 408 +  

submitted by hayayah(603),

Sensitivity tests are used for screening. Specificity tests are used for confirmation after positive screenings.

Sensitivity tests are used for seeing how many people truly have the disease. Specificity tests are for those who do not have the disease.

A highly sensitive test, when negative, rules OUT disease. A highly specific test, when positive, rules IN disease. So, a test with with low sensitivity cannot rule out a disease. A test with low specificity can't rule in disease.

The doctor and patient want to screen for colon cancer and rule it out. The doctor would want a test with high sensitivity to be able to do that. He knows that testing her stool for blood will not rule out the possibility of colon CA.

sympathetikey  SeN Out (Snout) --> sensitive test; - test rules out SPec In (Specin) --> specific test; + test rules in +3  
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 +1  
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 +  

submitted by sciguy(0),

HS is autosomal dominant, but exhibits incomplete penetrance. So he had no record of personal family, but still likely heterzygous.

(Wikipedia) The clinical severity of HS varies from symptom-free carrier to severe hemolysis because the disorder exhibits incomplete penetrance in its expression.

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

submitted by yotsubato(520),

"physicians should always encourage healthy minor-guardian communication."

Also you're going to do some serious things to cure this girl's disease, leading up to amputation. You cant hide that from her.

djjix  Non sense ... you can hide the amputation from her +8  
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? +1  
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. +1  
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. +  

submitted by hayayah(603),

Rhabdomyolysis can present looking like a kidney injury (it can lead to acute tubular necrosis as well). The electrolyte findings are just like renal failure (Inc. K+, inc. PO4-, dec. Ca)

To differentiate between rhabdomyolysis and kidney injury, you check the urine to see if there are any RBCs. In rhabdomyolysis there are no free RBCs in the urine.

ergogenic22  "Crush injury" is a buzz word for rhabdo +2  
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. +1  

submitted by sammyj98(6),

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