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Welcome to llamastep1’s page.
Contributor score: 39


Comments ...

 +1  (nbme23#41)

So did I just get lucky? I just did rule of 4s, bilateral motor meant medial and I interpreted horizontal eye movement as CN6 which is also medial and pons(CNs 5,6,7,8). Couldn't really place the disarthria but medial pons seemed like a good option.


 +2  (nbme23#19)

So I didn't remember IPEX but I do know some basic inmuno and the stem sounded like many autoinmune manifestations, so logically a decrease in Treg lymphocytes (which are inmunosuppresive) seemed like the best answer.





Subcomments ...

submitted by mahesh(1),

Osteosarcoma histological appearance. Paget disease is one of risk factor

spow  Looking back, I know it's osteosarcoma but the lung metastases made me think of Ewing's +  
makinallkindzofgainz  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. +1  
llamastep1  Also "sunburst pattern" is a classic description of Osteosarcoma. +  


submitted by madojo(122),

FA 19 256

Does the drug SWIM? Phase 1 - small number of volunteers assess for Safety Phase 2 - moderate number of patients, does it Work Phase 3 - large number random assignment, with placebo, any Improvement? Phase 4 - hit the market, any unexpected side effects, can be withdrawn from Market

kpjk  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 +3  
kpjk  Sorry! Just saw FA- it says even placebo can be used in phase 3 +1  
llamastep1  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? +  
turtlepenlight  for the vast majority of drugs, the FDA / NIH don't allow placebo testing anymore (regardless of FA!) +  


submitted by famylife(77),
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aPesh III iCiclanl Trial (epr AF 9012, p. 5)2:6 agrLe rnbuem of ptstinea rnmdoyla dniseasg reteih to eht etartntme eudrn eotnsnaitgiiv or to eth trddsnaa of caer or( eop.bc)al

usmile1  also just to verify, there is no such thing as phase 0 right? +  
madojo  Not that i know of or is in FA +  
llamastep1  I've heard animal testing is called phase 0. +1  


Up to 80 percent of aortic aneurysms are caused by "hardening of the arteries" (atherosclerosis). Atherosclerosis can develop when cholesterol and fat build up inside the arteries. ... Elevated blood pressure through the aorta can then cause the aortic wall to expand and bulge.

https://www.uwhealth.org/heart-cardiovascular/aortic-aneurysm-causes-symptoms-and-concerns/10971

Also, FA 2019 pg300 says complications of atherosclerosis includes aneurysm

almondbreeze  I was dumb and went for marfan.. +1  
llamastep1  Wrong question lol +2  


submitted by sattanki(56),
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pAnrypeatl htree si a yoeptllemc epsetaar iasnpl rdco exrelf hwere itdecr epinel nuimotaistl sdela ot an oenrect.i hTsi exfrel noyl edesn na tntaci arc in ,S42S- so as gnol sa isht eogrni is nto edinru,j na oeritenc acn sltil c.coru weevH,ro thwi tnnsrctaeoi at ,8C nteh teh hciypegoncs eniorcet elfxre ancnto curo,c sa ihst esqurrei dndscineeg bfiesr ofmr hte x.ortce

lsmarshall  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." +6  
seagull  S2-3-4 keeps the penis off the floor +30  
drdoom  Modifying @seagull into iambic pentameter: “S2, S3, and Number 4 / keeps the big ole penis / off the floor” +  
myoclonictonicbionic  I can assure you the validity of answer (speaking from experience) +2  
raddad  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896089/ Under the "autonomic control" header +  
llamastep1  I've always wondered how quadraplegics got it up. I guess their girls help em lol +  


Just remember Point, Squeeze, and Shoot

Erection - Point Parasympathetic NS (pelvic splanchnics S2-S4)

Emission - Squeeze Sympathetic NS (hypogastric nerve T11-L2)

Ejaculation - Shoot visceral and Somatic nerves (Pudendal nerve)

FA19 pg. 609 (nice)

llamastep1  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. +  
mutteringly  actually on page 613 FA19 lol +  


submitted by dentist(43),
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ndouf iths speur leuusf bkoo no amnoaz ubato dh-iirdaCBu ekcc(h tou teh sick orcve)

llamastep1  Thank you for that +  
focus  hahahahaha. DEAD. +  
anjum  I endorse clicking that link +  
azibird  Hahahahahahaha, that's a must click. Someone please buy it and let me know. +  
chediakhigashi  hahahaha +  


submitted by sajaqua1(461),
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The ngleis tosm oaminrttp gtinh obaut isht sgsro patyohlgo si that eht ieesads si l.uounitldamr ihTs dniiascte sttmsseeaa rmof daisntt isste.

ivrLe sesacssbe ear ysluau igsarlnu, elfidl tiwh raemyc elolyw sup, adn aym hwso a suofbir aueslpc. oihrissrC efnot whoss a yelowl cloor eud to attfy negcah sa well as rveergtinaee onel,dus ciwhh rae tno pnetser h.ree A acflo loaudrn hpsyarpiale si a lngsiaru tormu fo het rvli,e and tihs is amunlr.iltdou tsitpeiHa B is a ittlle rhedar ot sgtshuiiind cbueesa frmo whta I nca ltle it cna eb nudlatromlui ni omse ses,ca ubt hsti verli lsoa swsoh onen fo teh olsssicer morf inccrho iomanifmatnl hatt ldouw llykei apomyncca epH .B aylF,inl ew ees on dkar nordilooictas to nicdaite traonic.fni

monkd  It doesn't explain the sudden death, but I suppose they aren't asking for that! +4  
charcot_bouchard  I hate this type of ques. Here it is. Tell me what it is? +2  
divya  also, a liver infarct is unlikely due to rich dual blood supply. +1  
drzed  @divya Rather, if there was an infarct, it will be hemorrhagic, not pale. +1  
llamastep1  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! +  


submitted by usmle11a(65),
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ok hte ayw i eolkdo ta sith sa:w

uroey not 001% reus esh saw ctkteada ron do oyu tanw to eb hte peorsn gtleiln teh nduashb seh na aetckart so uoy evoerm: B C

glnwolai hmi ni whit eth itntpe,a odg nokws twah ahtt ygu sha eidhnd whti mhi sloa oyu lwli aekm a guhe sneec : A

the noly ngtih to od is eb dcioplamit sa eopepl kown htey ernta ldelwao ni teh tratentme eaar adn yb tath uyo sseaur erh atefsy.

drdoom  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! +1  
llamastep1  Alright we got it! lol +1  
123ojm  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. +  


submitted by notadoctor(140),
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LES is adoistseca whti iifdeeccny fo alery motecelmnp rsei.onet(gp ,C1q 4C, .)C2 F(A 91, .gp 2)64

tinydoc  Am I the only one who has never heard of C1Q? +20  
llamastep1  I knew SLE is related to low complement but when it talked about a "mutation" it threw me off. +1  


submitted by seagull(1109),
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Tsih ieattnp is iiptnprg lba.ls terteB do a udgr neescr ciwhh emess ibsuovo.

sympathetikey  When the answer is so obvious that you pick a stupid answer instead of it. DOH +25  
jooceman739  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 +4  
yotsubato  @sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that. +1  
yogi  probably the "drug" have to be a stimulant or a hallucinogen which causes HTN & Tachycardia. +2  
charcot_bouchard  Lol. I got the right answer but took long time +  
goodkarmaonly  The patient's B.P. and pulse are raised + Bilateral dilated pupils = Most likely use of a stimulant Thats how I reasoned it anyways +  
llamastep1  Bilateraly messed up pupils = Drugs (most of the time) +  
targetmle  why is there basal ganglia hemorrhage? +  
dul071  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 +1  
usmile1  basal ganglia hemorrhage is an intraparenchymal hemorrhage secondary to hypertension. according to FA, this occurs most commonly at the Basal Ganglia (FA19 pg 501) +  


submitted by uslme123(44),
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hTsi soneuitq maske no nesse ot m.e She ash an meetlrxey wol iopgnne psrruese tey ahs inssg of drieneacs aatailrcnnri ps.esurer Ddi yhet naem to tup 32 mc ?2H???0?????

uslme123  Standard lab values are incorrect, way to go NBME. +2  
wutuwantbruv  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. +3  
alexb  I lost a bit of time wondering about that ugh lol +1  
mjmejora  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. +2  
donttrustmyanswers  Does anyone have clarification on this question? +  
llamastep1  Pseudo tumor cerebri can have normal ICP. Who knew +  
tyrionwill  Hi, mjmejora, MRI did not see anything abnormality, couldn't this mean that there was no obstruction in the ventricles? +1  


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If the inrlatmboay wsa tmsohnige mreo ilef re,egnntaith w'udlnto eht fstir onaitc eb to lcal hte dpaniiiae?trc I swa hnntg,kii mibl ixteymetr igmth amen htmengios lees eorm osiusre wsa napnpghie oot g;&t-- eedn icrateipdina grhti aywa to .xd

tinydoc  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. +2  
llamastep1  Out of all the questions (UWorld,NBMEs etc.) I can only think of 1 question where you had to refer. +1  
targetmle  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! +  


submitted by yotsubato(803),
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Tish is a eintsqou uabto atetpin irpavc.y hTe tpniaet eerh is the lc.ihd Teh oxrpy rfo eht atitnep si eth oemrht dan frh.eta Thye must know shwat rongw. triSse nad orhmte ear tusj ksy,ooolol dan nsretpa yam tno ntaw to llte tehm (pditsu I owk,n ubt taevrew)h os you snde htme otu dna nhte ltle the sernapt teh tuaitsino.

dr.xx  agreed +  
thepromise  so you're not gonna conceal the abnormality and act like its their fault? since they touched it last +21  
tinydoc  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. +9  
llamastep1  It's not just conceal but it's a private and sad moment, gotta give the parents some time to process it. +2  


submitted by momof21234(5),
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eht iettpan hsa otesssab hwchi si ttesericriv leu(c swa epulrla pseuCL qODa)l is redeecdas ni tchriaia-trcon stoniidocn reliitianst(t lugn zd cet) and rnlmoa on raherctioctax- tncosdnioi sclr(muau us)seis

usmlecharserssss  how FEV1/FVC is normal i cannot get that +1  
sammyj98  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. +  
spow  @usmlecharserssss In restrictive lung diseases, the ratio is either normal or increased. +  
drzed  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 +2  
llamastep1  To add to what @drzed said, fibrosis causes radial traction on the airways therefore increasing FEV1/FVC. Theres a Uworld q on it +  


submitted by sugaplum(235),
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iTsh is irlsouucdi tub I loduc vreen kepe teehs gatsirht mse teo ym mayilf :
Ac eyh angaprd Mynerte
oeDp icunos VT wthi a sedi H*o ohsw(' sanem aer sutj tnilis)ai cNS
Ulcn e nad tnau ehpRa adn asar Cuons i babyG wsayla sirncgmae NNNa-aa-
i ropne rdisemn me fo het ocorl uble, so ucsol seeruucl

paulkarr  LOL. Achey Granpa Meynert. I'm gonna steal this from you. +  
abhishek021196  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. +  
llamastep1  Amazing +  
mnemonicsfordayz  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 +  
mnemonicsfordayz  The extended "NENE" series is just for humor - shorten if you like ;) Also, ANXIOUSLY applies to both NTs in that sentence: GABA and NE. +  
castlblack  I use AChoo meynose +  


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A osbolamntr si an ammrtuei CBR, os i'st teledaev ni etasts fo ericnsade shmteip.osioea

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +47  
someduck3  The term "Normoblast" isn't even in first aid. +29  
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +14  
tinydoc  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. +15  
qball  Metamyelocytes = Precursor to neutrophils Siderophages = hemosiderin-containing macrophage aka heart failure cells +7  
llamastep1  Theres a UWorld question about Parvovirus B19 that mentions "giant pronormoblasts" that helped me make the connection +5  
fexx  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 +3  
nerdstewiegriffin  I can guarantee you this Q was written by some sadistic PhD examiner +2  


submitted by nwinkelmann(257),
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I eylllrita jsut ziaereld yhw ihst notiusqe ndfscueo me so muhc (and 'Iev tdire ot uifger it tou a oepcul of eitsm, .oll) I tle eht laollocuqi ieotdiifnn fo ibauiml ..e(i oitmv)ing itkcs ni my di,nm hatt I ogftor eth lcaatu daceilm tfiodeniin = onalrm MBI (8)g;&t1 + egbin teaing nad uggrnip heer(w rigugpn ucdlo be diudnce iiovgntm or cdiuerti ues or eatvlaxi use o/nard iexesevsc .eise)rcex oS el,lyra ahtw itsh ieosunqt wsa kiansg is ylismp athw si het letoeerlcty alanebc of ssxivecee harrdi?ea E!EZG I edam ti os mhcu adhrer in my eadh newh rnytig ot esawrn it lin.ilgoyra

riareaDh sacsue aion-nonn apg (..ei c)pimlheeroycrh icmoatebl doii.csas loSot oradmeyptlnin otncisan CO3H- nda +,K so eeexcssiv daherira = eeseicsvx loss fo -OH3C adn +.K irdohlCe veelsl ni teh msuer lliw eb radsicnee ude to eht amlorn C-/OCHl-3 quiel,imbriu so as giaevnte gachre istdaseisp ued to ssol of C,H-3O Cl- iwll inrseace rntiorcecg hte .naga-oinp

drdoom  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). +3  
abhishek021196  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 +  
llamastep1  Take home lesson: reasoning > memorizing +2  


submitted by mousie(171),
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ehlorCa = lceaF ori/a eegnsrianloL = alelgaLno unoemp = NO prenos to eonpsr ynlo yb aoainthlin of citaaerb catmtniadneo awm/Ler tye = ctik ine/iMiblcg otneacoc = rhsangi iroyapsrter dan ttaohr enoritsesc lavsia( ro pi)ts. arGlelyn,e it akets cleso orf( p,leaxme guhngoci ro siin)gks ro elthngy cttacon to rdapes ehets abreitac CS/(RDFCM) = ktic beit

smc213  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. +6  
dentist  So, Cholera is also p2p but Mening is more likely? +1  
usmlecharserssss  in cholera people to water => water to people +  
qball  Remember the fire sprinklers from Sketchy for M. Meningitis. as respiratory droplets are the easiest to transmit from person to person. +  
drschmoctor  but the poop water comes from people so.... +1  
llamastep1  Respiratory dropplets is easier than fecal-oral tho +1  
lowyield  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 +1  
peridot  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. +  
bbr  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). +  


submitted by pparalpha(78),
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dngcorAci to nBB:

licaeCvr bir si an nmaosolau traex rib rfmo hte t7h eiclacrv rerabvet.e Plepoe whti sith aer ta riks for hciaoctr tloute smeyornd a(ka erioncmpsso fo esrevn adn esslvse ttha lveea the oxtah.r hTsi rucsco vobae teh srtif ibr dan idbneh het alelicc.v)

lCcaniil teeusfra ludneci:

1) arihalcb uspelx ijrnuy uhsc( as pmkuelK apsl,y ihhwc si a elrwo puexls yin)jur

2) unsoeV oimsrocpsne

)3 iAatrlre mrcnospsoei

n*A aipnortmt ilonaaamtc eclatrroe eht eclensa egrtanli niaer(tro ,lacesne lmddei lsneec,a vaebo eht fsirt rbi)

llamastep1  The cervical rib is underneath the brachial plexus, the pressure of the backpack compresses these nerves causing the pain https://lh3.googleusercontent.com/proxy/m6FASqomZvlebUu8MoUePvFzMXP7u8vgEnT0VamRq3Wij_sOH7gtJTfK1L9LCeOgsq-O6Rpxd_Z0mhjL +1  
rockodude  link didn't open for me +  


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yaMn oalr yvtiac ,eonlssi aelesycpli iyelartrno shcu as eth ipt of teh n,utoge drina rfsti to ebsmunalt dosne (velle 1). arnephygOalro CSCs otsm cnmomylo arind to lveel .2

llamastep1  https://www.youtube.com/watch?v=bwVQWwDjw5A quick review,ignore the bad music +1  
focus  If you scroll down on this link, the first image is pretty good https://www.sciencedirect.com/topics/medicine-and-dentistry/submental-lymph-nodes +  


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iNactroc ues for altucye afilpun sodotncini is ohbt eesoralban dna i.noaptrtm rShtmor-te esu t(elmdmaiiey uo-sri)cagpslt oeds ton alde ot loret-ngm enpdeednce or( os peelop vhea h…tu).oght Adn y,es rgsud sdctadi shuldo aslo viceree cisracnot to clotrno apn.i

drdoom  prefer “patients with hx of substance abuse” over more conveniently typed but less redemptive “drug addict” +8  
sugaplum  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. +30  
nbme4unme  @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! +5  
sushizuka  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. +2  
angelaq11  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... +1  
houseppary  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. +1  
anastomoses  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. +2  
llamastep1  I agree with anastomoses, cmon guys have you ever had serious pain? oral acetaminophen is NOT enough for that type of pain. +1  
sora  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 +  
melchior  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. +  
drpee  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. +1  


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jiya   why cant this be hand foot and mouth disease cause of coxsache +2  
drachenx  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. +  
llamastep1  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. +1  
aneurysmclip  Hand foot mouth disease affects palms and soles. ref: FA 2019 - 150 +2  
raffff  wouldnt the history also be different for coxsakie +  
focus  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 +  
drpee  Google some images of HF&M disease. The small blisters look very different from herpetic whitlow. +  
drdoom  ^ ... some images of HF&M disease ... +  


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d_holles  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. +8  
llamastep1  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. +2  


submitted by niboonsh(285),

external carotid branch supplies the superior parathyroid glands as well........?

yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch. +  
llamastep1  No they do not, parathyroids are supplied by the inferior thyroid arteries. https://teachmeanatomy.info/neck/viscera/parathyroid-glands/ +8  
suckitnbme  Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery. +  


submitted by strugglebus(154),
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Polarlopno is a tlce-enseinov aetB eoklb.rc oS uryo RH liwl edecaser ,1B() hchiw will cuaes a oyantmsrocep ersiecan in 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. +35  
amarousis  so why tf do we give beta blockers for hypertension -.- +5  
dr_jan_itor  I would also add that the patient was previously on an a2 inhibitor (clonidine), which he ran out of. So he is rebounding on that with upregulated a1 receptor activity. Adding labetalol would cause a greater degree of unopposed alpha, increasing tpr +1  
llamastep1  @amarousis They are used for hypertension because the hypotensive effect of the reduced CO is greater than that of the effect of the increase of TPR. Cheers. +4  
hungrybox  @dr_jan_itor Adding labetalol would not cause unopposed α1 because labetalol and carvedilol are α1 blockers in addition to being nonspecific β blockers (great name btw, I love scrubs haha) +2  
mw126  Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +  
rockodude  @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +  


submitted by meningitis(412),
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sympathetikey  Brilliant. +4  
medschul  Would pheo have a normal resting BP though? +4  
meningitis  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 +  
nala_ula  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. +7  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  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. +  
llamastep1  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. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +  
notyasupreme  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 +