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Looking back, I know it's osteosarcoma but the lung metastases made me think of Ewing's
Ewing sarcoma is common in boys <15 years old. This patient is a 70 year old woman. The stem notes elevated periosteum and a sunburst pattern which are characteristic of osteosarcoma.
Also "sunburst pattern" is a classic description of Osteosarcoma.
just would like to make a small correction
phase 3- not placebo, but a drug already present in market
so to test if there is improvement over standard care
phase 2- would have the placebo, to see if the drug is actually working
thats why i got confused in this question
couldnt phase 2 also have randomized,prospective double blinded study
Sorry! Just saw FA- it says even placebo can be used in phase 3
Ugh I over thought it, I figured if you wanna give your patient a new treatment you wouldn't send her to possibly receive PLACEBO, am I the only who thought this?
for the vast majority of drugs, the FDA / NIH don't allow placebo testing anymore (regardless of FA!)
also just to verify, there is no such thing as phase 0 right?
Not that i know of or is in FA
I've heard animal testing is called phase 0.
Just saw a good summary of nerves/vessels involved saying, "pelvic parasympathetic fibers from S2-S4 can cause cavernous arteriole vasodilation via the cavernous nerve without of central stimulation."
S2-3-4 keeps the penis off the floor
Modifying @seagull into iambic pentameter: “S2, S3, and Number 4 / keeps the big ole penis / off the floor”
I can assure you the validity of answer (speaking from experience)
I've always wondered how quadraplegics got it up. I guess their girls help em lol
Emission, as the first phase of ejaculation, is a sympathetic spinal cord reflex and is defined as the deposition of seminal fluid into the posterior urethra. Ejaculation or expulsion is due to the combined action of sympathetic and somatic pathways.
actually on page 613 FA19 lol
I endorse clicking that link
Hahahahahahaha, that's a must click. Someone please buy it and let me know.
It doesn't explain the sudden death, but I suppose they aren't asking for that!
I hate this type of ques. Here it is. Tell me what it is?
also, a liver infarct is unlikely due to rich dual blood supply.
@divya Rather, if there was an infarct, it will be hemorrhagic, not pale.
Multiple solid lesions on a healthy liver = meta. I assumed breast wouldn't meta to liver (it's usually GI cancers) but it makes sense since all the blood gets filtered by the liver at some point. TIL!
The prevailing rule of American medicine (and law) is individual autonomy. No other person, professional or otherwise, is granted “default access” or privilege to another person’s body—that includes the physician! The physician must receive consent from a (conscious) “person” before they become “a patient”. In the same way, the person (now, the patient) must give consent before anyone else is permitted to be involved in her care—spouses included!
B and C are actually wrong because they put the patient in danger for when she is discharged and has to return home. she probably has things she needs in their home (eg passport, money, etc) and if the husband knows she has told you about the abuse she is at risk of being killed.
Am I the only one who has never heard of C1Q?
I knew SLE is related to low complement but when it talked about a "mutation" it threw me off.
When the answer is so obvious that you pick a stupid answer instead of it. DOH
Funny thing I noticed is "he is alert and cooperative. He appears to be in pain" So he was so high that he was alert and cooperative during the basal ganglia hemorrhage
@sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that.
probably the "drug" have to be a stimulant or a hallucinogen which causes HTN & Tachycardia.
Lol. I got the right answer but took long time
The patient's B.P. and pulse are raised + Bilateral dilated pupils = Most likely use of a stimulant
Thats how I reasoned it anyways
Bilateraly messed up pupils = Drugs (most of the time)
why is there basal ganglia hemorrhage?
Wait! doesn't it take like a week or two to get the results back!?!? i chose to measure catecholamine levels because that may be more timely. but clearly i'm wrong
basal ganglia hemorrhage is an intraparenchymal hemorrhage secondary to hypertension. according to FA, this occurs most commonly at the Basal Ganglia (FA19 pg 501)
Standard lab values are incorrect, way to go NBME.
I think they mean to put mm Hg. Normal CSF pressure is about 100-180 mm H20 which equates to about 8-15 mm Hg.
I lost a bit of time wondering about that ugh lol
I thought there must be an obstruction in the ventricles somewhere preventing csf from getting to the spine. so pressure is low in spinal tap but in the head it must be really high.
Pseudo tumor cerebri can have normal ICP. Who knew
Hi, mjmejora, MRI did not see anything abnormality, couldn't this mean that there was no obstruction in the ventricles?
I thought about that but then I ruled it out as with the NBME ethics questions the answer is almost never to defer to someone else. The question doesn't ever tell you what type of doctor you are for you to be referring to a different more specialized physician. Also I assume that they think if there was something wrong you could handle it.
Out of all the questions (UWorld,NBMEs etc.) I can only think of 1 question where you had to refer.
even i thought pediatrician should be called as after all, every newborn is screened by pediatrician and in this case, he had abnormality! i still wonder why would gynaec comment on that!
so you're not gonna conceal the abnormality and act like its their fault? since they touched it last
How on earth would they expect the parents to conceal a malformed upper extremity from the grandmother and the aunt of the child in a family that is close enough to allow these people to be in the room during the delivery. As always the ethics questions seem to make sense in retrospect, but always seem to have a ludicrous action on your part that you wouldnt do in practice.
It's not just conceal but it's a private and sad moment, gotta give the parents some time to process it.
I think this is standard for restrictive lung diseases. In obstructive the airways collapse during expiration so it's hard to expire, but there's a long drawn out end to epiration as little by little it escapes, leading to a decreased FEV1/FVC. In restrictive pt's just aren't able to move and expand their lungs enough, so when they expire it's of a small volume, but there isn't any collapse involved. It's like a normal expiration just with a restricted volume, making the FEV1/FVC normal.
@usmlecharserssss In restrictive lung diseases, the ratio is either normal or increased.
And the reason why FEV1/FVC is either normal or increased in restrictive lung disease is very simple: the FEV1 and FVC both decrease because you are restricting airflow, but the FVC will decrease MORE than the FEV1, and thus because the denominator is larger, the fraction either stays normal, or increases slightly
Contrast this to obstructive lung disease where you have an obstruction to air FLOW, e.g. the FEV1 will decrease more than the FVC, leading to a low ratio by defition
To add to what @drzed said, fibrosis causes radial traction on the airways therefore increasing FEV1/FVC. Theres a Uworld q on it
LOL. Achey Granpa Meynert. I'm gonna steal this from you.
Achey grandpa Meynert = ACh / Basal Nucleus of Meynert
Dope Cousin VT = Dopamine / Ventral tegmentum, SNc
Uncle and aunt Raphe and Sara = Serotonin / Raphe nuclei(medulla, pons)
Cousin Gabby always screaming NA-NA-NA = GABA / Nucleus Accumbens
Norepi = Locus ceruleus.
ACHey GRANDPA MEYNERT TREMBLES in the BASEment; DOPE cousin VT SNaCks DOWNstairs by the kitchen TAP; NANA GABBY ROCKS and ANXIOUSLY cooes...; "NENENENE... NENENENE...NENENE...NENE" to CRYING BLUE-eyed baby ELSIE; aunt SERO and uncle RAPHE DULLY PARK in the DOWNpour. CAPS = relevant info, lowercase = irrelevant. Includes diseases: DOWN, ANXIOUSLY, CRYING, DOWN = anxiety/depression; TREMBLES, TAP, ROCKS, PARK = movement disorder; GRANDPA = Alzheimer's. Note: ELSIE = LC = Locus ceruleus
The extended "NENE" series is just for humor - shorten if you like ;)
Also, ANXIOUSLY applies to both NTs in that sentence: GABA and NE.
Don't mind me. Just sippin my dumb ass soda over here.
The term "Normoblast" isn't even in first aid.
NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess.
I wish they would stop making it so every other question I know the answer and I can't find it among the answer choices because they decided to use some medical thesaurus on us.
Metamyelocytes = Precursor to neutrophils
Siderophages = hemosiderin-containing macrophage aka heart failure cells
Theres a UWorld question about Parvovirus B19 that mentions "giant pronormoblasts" that helped me make the connection
I got it right but would it hurt them to put RBCs? Medicine is hard as it is. No need to make the exams more complicated. I doubt my pt is ever going to as me if his/ her normoblasts are going to increase if they go hiking in the mountains
I can guarantee you this Q was written by some sadistic PhD examiner
Bulimia comes from Greek "ravenous hunger"; the term is a literal concatenation of the words for ox (bous) + hunger (limos). So, in Greek, bou-limia is literally "ox hunger", which is a nod to how the word is used in medicine = perpetual and insatiable appetite for food (the very "opposite" of vomiting).
I agree with your reasoning but the classic case description of Bulima lists electrolyte disturbance of HypOkalemia, HypOchloremia, and Metabolic Alkalosis, along with other things like parotid hypertrophy and dorsal hand calluses due to the induced vomiting. I tripped up there. :/
FA 20 Pg 567
Take home lesson: reasoning > memorizing
Also, when Meningococcal meningitis is treated ... close contacts are also treated prophylactically whereas the others typically are not. There's also a subunit vaccine for n. meningitis due to high infectivity rate especially in crowded establishments.
So, Cholera is also p2p but Mening is more likely?
in cholera people to water => water to people
Remember the fire sprinklers from Sketchy for M. Meningitis. as respiratory droplets are the easiest to transmit from person to person.
but the poop water comes from people so....
Respiratory dropplets is easier than fecal-oral tho
Can also reason that n. meningitidis is common in college students because they live in close quarters which suggests high rate of transmission even amongst immunocompetent individuals
I can see why fecal-oral can seem like person-to-person transmission. What helped me reason it was that in countries with lots of cases of cholera, the primary reason is lack of water sanitation. Even when you google cholera, you get pictures of people collecting dirty water and how the WHO is aiming to reduce cases of the disease by improving water sources. Therefore it's more of a systemic/environmental problem rather than the fact that one person accidentally touched another person's poopy parts and then transmitted it to their own mouth, making this less of a person-to-person thing, especially when compared to another answer choice such as Meningococcal meningitis.
To add, think of the water in cholera as a reservoir. The bug is going to hang out there between infecting another person. In meningitis it seems we are going from 1 persons saliva to another. Without much of a reservoir inbetween. (might be using the word reservoir incorrectly).
link didn't open for me
prefer “patients with hx of substance abuse” over more conveniently typed but less redemptive “drug addict”
I don't see why switching her to oral pain meds when she is ready would be incorrect. Clearly she is worried about being on the pain meds, I feel making a proclamation that she has a low risk of addiction would be profiling just because she doesn't have a history.
The opioid epidemic also affects people who didn't have a previous history of drug abuse. Just a thought, not trying to push any buttons. Maybe I am thinking to hard about this, but I don't see the clear A vs B line for this question.
@sugaplum I thought the exact same thing as you and chose the acetaminophen answer accordingly. I maintain that I am correct, my score be damned!
I had a similar question on UW and the explanation stated that the correct answer choice was the only one that addressed the patient's concern and answered her question. The rest were just alternative treatments, so they were incorrect.
But I too answered with oral pain meds.
couldn't agree more with you all. I chose acetaminophen because opioid abuse is NO joke. The crisis is still going strong because of answers like this...
I ruled out oral acetaminophen because they described in great detail the severity of her injuries, and indicated that she wasn't even fully conscious/aware when she asked this question about opioids. Rather than expose her to more pain, and possibly worsen her long-term pain prognosis, by switching to acetaminophen too early, in this case it makes sense to keep her comfortable because she's very seriously injured and not even fully lucid. It's kind to reassure her in this case.
I appreciate all of the passion for the opioid crisis, and the wording of the answer is definitely not ideal. However, PAIN is also very real, and there is no way acetaminophen alone would cut it in a case like this, not "as soon as she can take medications orally." Maybe I'm lucky to have 6 months in clinicals before STEP or had a mom who just went through urgent spine surgery for breast cancer mets, but there is a time and place for opioids and this is clearly one of them. Thank you for coming to my ted talk.
I agree with anastomoses, cmon guys have you ever had serious pain? oral acetaminophen is NOT enough for that type of pain.
I r/o oral acetaminophen b/c she's post-op for major GI surgeries so you might want to avoid PO meds for a while
As argument against the oral acetaminophen answer choice, it says "switch the patient to oral acetaminophen boldas soon as she can take the medication orallybold" This means you're just waiting for her swallowing inability from the facial fracture surgery to come back, which might not have much to do with her pain, and so it seems somewhat arbitrary.
Maybe logically/clinically A is true, but this seems like a "patient communication" question to me and I could NEVER imagine A being a good way to phrase this point IRL.
why cant this be hand foot and mouth disease cause of coxsache
Also thought it was Hand-foot-mouth an RNA virus but I did consider Herpes. Changed because I thought Hand foot and mouth would be more common.
Hand foot mouth usualy involves all 3 places (hands, feet and mouth/perioral area) and the lesions on the hand arent localized to just one finger.
Hand foot mouth disease affects palms and soles. ref: FA 2019 - 150
wouldnt the history also be different for coxsakie
I think this image is trying to show the "dew drops on a rose petal" sign on Hermes, the god of Herpes on Sketchy Micro
Google some images of HF&M disease. The small blisters look very different from herpetic whitlow.
It seems to me that the brain stem problems can all be answered using the Rule of 4s rather than memorizing the actual brain stem histology.
Yeah I think so too! With the right CN12 palsy you already know it has to be medial (factor of 12) and that would be enough to answer this question. The hemiparesis just confirms that its a medial lesion (starts with M). I know many of us like to really understand the concepts not just use these "tricks" but hey if it works it works.
Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch.
Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery.
^ 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.
so why tf do we give beta blockers for hypertension -.-
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
@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.
@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)
Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245
@dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor
Would pheo have a normal resting BP though?
I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol
The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up.
Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing.
No problem! Thank you for all your contributions throughout this page!
I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well.
When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers.
UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure.
Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha