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Comments ...

 +0  (nbme21#32)

According to FA 2019, page 561

MECHANISM of atypical psychotics(including Risperidone) is Not completely understood. but Most are 5-HT2and D2 antagonists; Varied effects on α and H1 receptors.

These SGAs Have lower binding affinity for D2 receptor than FGAs. so less Extra pyramidal S/E.


 +0  (nbme21#38)

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +5
lovebug  Oh, thank you! +
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +3
csalib2  @drdoom fantastic point. never thought of it that way. +
lovebug  @drdoom THX! very sweet explanation! +

 +1  (nbme21#28)

this patient began rosuvastatin tx 4 weeks ago.

rosuvastatin, pitavastatin, pravastatin are substrates for the organic anion transporting polypeptide (OATP). however, none of these 3 statins are substrates of CYP3A4.

OATP transports the statin from the plasma into the hepatocyte. The statin can then be metabolized by hepatic enzymes or transported into the bile for elimination via the gastrointestinal tract.

Interference with OATP activity results in accumulation of statin in the plasma and may lead to myopathy.

FA 2019, 315 pg

https://www.pharmacytimes.com/publications/issue/2014/June2014/Statins-and-OATP-Interactions

5thgencephalosporin  this is PharmD–level shiz +1




Subcomments ...

submitted by dbg(151),
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BBs krwo yb daringeecs AMPc adn +Ca2 yretebh lniwsog SAN ;mp&a NAV i.ttyavci Tsih loporsng aesph 4 fo dinaalzopr.teoi ohTer,reef ehyt ear nwonk to ceesnira eth aorntidu of oiastdle y)mdaproeni(tln guacins ohtb a resi ni haret rcoroayn eunpsofir dna nitcudroe ni hrate .trae

lovebug  FA 2019, 318page. class two antiarrhythmics. +  


submitted by hayayah(1079),
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ts'I itlartinnaos lcle raoim,cacn chhwi okimsgn si a ocmomn rski forcta for; it cna livnveo the nerla yiplsvecsael/c. The tiosh agmie whsso het plilparay nruate fo eht mrtuo we(orehv ti nca asol be ftal ro luoanrd ciadocnrg ot amoPh).at

olAs wknon sa olerhtaliu r.icancoam oMts nmcomo rmotu fo ianrury cttra tssmey cn(a uccor in arenl ycslcea, aelnr v,eslpi etusrre, nad eb.)drdla anC eb esgdutseg yb islseapn uarhiamet (no tasc.)s

usmlecrasher  i'm sorry guys it's bladder cancer blocking urine flow => reflux ureteral widening => reflux nephropathy. +6  
hello_planet  FA 2019 pg 588 +2  
kevin  Is the idea since that since the histology shows transitional cell cancer the most likely is smoking and that's the answer? The fact that this was unilateral really threw me off. Is it common to have unilateral carcinoma of the ureter (if that's what this case was, of the ureter) rather than bilateral? +  
lovebug  I Choose F) vinyl chloride <- only liver angiosarcoma. :( about many Carcinogen FA2019, 226pg. +  


submitted by mbourne(79),
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nI servitritec lnug daeises, lerilalty lla unlg valesu era SEDERCADE rdr)ti"(cte"se texpec for eht VEF1FC/V .riota VC1/VFEF ioart yma eb lronam or sranieced cersand(ie ylon fi VE1F eedcesras a tib lsse hant hte eecrsade ni VF,C ulesrntgi ni na diecseanr )io.tra

lovebug  Your explaination is very useful! thanks! :) FA 2019, Page 658. +  


submitted by strugglebus(165),
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I oeshc htsi eyslol aesubce ti saw so andm ecifcips

sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +4  
karljeon  I didn't choose it because it was so damn specific. :( +43  
lovebug  Could anyone explain for B) for me? because I choose B).:( +2  
j44n  B.) is wrong because its never been shown to show adverse effects "any offcial data linking the drug" and the fact that it's "newly marketed" +  
j44n  and because its in 5/45 patients roughly 10% of the population, that might not seem like much but most of the diseases we freak out over are in 1-2% of the population, to put that into perspective if we gave this drug to every person in the US (every big pharma wet dream) with a population of 300 million... 30 million people would have this adverse event... hope that helps +  


submitted by hayayah(1079),
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Aetcu reltaisiintt leanr oitmailn.mfan uPiray cla(casilsly oiliposeh)sn dan toaaeimz rocugirnc tfaer imisdtotrnaain fo urdgs atht cta as teas,hnp niundcig tesitrheiynsvypi e(g, sicduteir, N,SIDAs lcienipiln tevveias,dir nrpoot pump ,inrhtbsiio pnfiiamr, qouse,oniln un.eofisdm)asl

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. +  


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srpue gevua quetsion ! Dr deesin nsisstiag c;sgt=&ieuid lmoneccneefniai o d irytehgven he acn to meagna ehr ipan ;=tg& efceebinecni

lovebug  me too... so I choose B). lol +  


submitted by drzed(220),

Patient has low serum sodium = hyponatremia.Given that the patient has a LOW URINE OSMOLARITY, it suggests that ADH is NOT active. The only way for someone to have hyponatremia AND a low ADH (in this case) is through psychogenic polydipsia (e.g. if it was SIADH, the urine would be MAXIMALLY concentrated and it is NOT in this case)

(A) would cause central DI -- no ADH means one develops hypernatremia as free water is lost in the urine, thus concentrating the serum.

(B) osmotic diuresis could cause hypernatremia due to loss of free water in the urine

(C) degradation of ADH leads to DI which means one develops hypernatremia

(E) resistance to ADH (nephrogenic DI), again, hypernatremia.

lovebug  thanks for kindful labeling! :) +1  


submitted by xxabi(259),
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ihTs si a ytlhgssolaro dtuc c.tys eTh otrassoylgl udct mya istpers dan tresul ni a yatlrssoghol uctd ystc u(rirgcocn ni ndliime raen odiyh ebno or ta het aseb fo teh e,)ugont thus wlli ssclilaylca vmeo up thiw gsnwloawil or tuogen noo.purisrt

eTh fanrmeo cmecu (of het )eogtnu is eht alnorm tnrmnae of het ohsytarlgslo uctd

lilyo  I got it wrong though because the question clearly asks what does this structure (thyroglossal duct) DEVELOP from, not this structure eventually develops to form which structure. If it asked that then I would have picked option A but because it didnt that was the first option I crossed out. +16  
misterdoctor69  It was a poorly worded question no doubt. But when they say "endoderm of foramen cecum" they're referring to the endoderm which is a primitive structure. The "foramen cecum" part is just a modifier that is added to describe what that endoderm would eventually become. +  
lovebug  FA 2019, page 322page! +  


submitted by dickass(88),
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.itma..nrg esworkr ..hs.a otn evrecied rintueo diemcal earc =&=tg; hes saw otn eedscenr rfo riyisohotyphmd

lovebug  Wow good point! :D +  


submitted by neonem(571),
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Tihs ietatpn elliky hsa oesm rfom of prpue oromt nruneo slieon ro iadsees - NMU ionslse era dztchiarcreae yb ank,wesse censrdaei depe onndte lxeeersf, nda csiaspt aes.pirs nelacfBo is a A-BABG gnaiots cciefisp to the alnpsi orcd, used ot atrte suelcm ,stiacytisp do,yntasi dan M.S AA-BGB is a Gtopnie-r cdlepuo ceotrrep opeudcl to ,iG so gnmsaio of thsi receorpt scaeus tayorilaiphpnrzoe fo het uesnnor dna eersedcda esreela fo txcetoaryi amttuagl.e

kevin  stimulates K+ efflux (hyperpolarization) and inhibits Ca2+ influx (no vesicle release) +1  
lovebug  FA 2019, 538page !! +  


submitted by frimmy_11(0),
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glntMoti nad ognftsien of neairrto allw no yuatosp stugssge it asw ont older htna 42 hsr. thDae fomr tlfaa rharatiyhm iekl fbV-i sotm oocnlymm cuscor thiwin eno ady fo eth .IM aTth ,aisd eocn casr ash fmdreo ni oiadmlyarc sueits i,t too, can uaecs ha.rhmairyt

bighead478  in FA it shows softening of the myocardium to happen at 3-14 days. Do you think this was overly misleading people (like me) into choosing myocardial rupture? I understand the histo features are consistent with < 24 hours, but the stem should also match this in every detail +  
athenathefirst  Anyone knows why it's. not cardiogenic shock since it happened within <24 hours? +  
lovebug  @athenathefirst I also had same Question. maybe Question asks "Most likely mechanism of death" > most common cause of death in 24hr is arrythmia. cardiogenic shock is also possible. but it's not the most common cause of death within 24hr. +  


submitted by est88(17),
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oeraoRrtpinelet errcutu:tss DSA UPCK.ER

nOyl teh genindsecd olnco si ptra of t.ish

meningitis  SAD PUCKER: Suprarenal (adrenal) glands [not shown] Aorta and IVC Duodenum (2nd through 4th parts) Pancreas (except tail) Ureters Colon (descending and ascending) Kidneys Esophagus (thoracic portion) Rectum (partially) +19  
cienfuegos  I find "SAID PUCKER" to be helpful because it includes IVC +4  
lovebug  FA 2019, 354page~ +  


submitted by aazib05(4),

because they have asked about THE TEST, and sensitivity/specificity are the properties of the test. whereas PPV & NPV are dependant upon the population being tested, it's not the intrinsic property of the test.

lovebug  @aazib05 simple and clear. Thank you! +  


submitted by hayayah(1079),
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Mtso nommco esacu of cagirts ttoeul toibusotcrn ni sna.ifnt elpalPab hevsl-oaedip sasm ni aiceisprgt ioren,g beivils eiaplcitrts ewsav, adn nosilbuoin ojcltpiree nmvigiot ta –∼26 kswee old.

lrstUodnua hwoss ietkhednc nda detghnleen opuslry. tneTatmre is sugrilca innciosi oomy()ypymtoro.l

lovebug  Could you explain WHY NOT (B) Gastric volvulus?? bc I think it can share some clinical symptoms. +  
calleocho305  This is what I put, wouldn't hps occur earlier than 4 weeks? +  
ssc30  Gastric volvulus is very uncommon in general and almost never happens in infants. +1  
ssc30  Gastric Volvulus would also present with severe abdominal distention and pain due to incarceration. +  


submitted by lovebug(19),

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +5  
lovebug  Oh, thank you! +  
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +3  
csalib2  @drdoom fantastic point. never thought of it that way. +  
lovebug  @drdoom THX! very sweet explanation! +  


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ehT aipntte rfesduef fmor mmInue tcboo.ohTmynpraie aaudnotbtoisie gtnasai eht onyrigctpeosl 2G3BP./A

nO lsab, yl’ulo s:ee aecirsne in a;regksmtoayecy on the oqiseutn tsme reheyt’ dsbeicred as arer“ tbu rlga”e. atarkcgeoyMyes rae tno puspders.es

ergogenic22  isolated thrombocytopenia (low platelets) should be highly suggestive of ITP https://www.aafp.org/afp/2012/0315/p612.html +2  
pg32  I agree that in ITP you will see an increase in megakaryocytes, but where did you see that in the stem? Platelets being, "rare but large" doesn't mean megakaryocytes, does it? Also... can anyone explain why she was anxious but alert and had petechiae distal to the blood pressure cuff? +  
meryen13  @pg32, I'm not too sure about the "anxious but alert" but I think they might wanted to mention she is oriented so in case there was no lab values, you would guess that she is not extremely anemic or something. and about the petechia with the cuff and the tooth brushing bleeds, that is a sign of platelet problems because its a superficial bleed. if you saw deep bleeds like joint bleedings, think about coagulation pathway problems (like hemophilia) +2  
zevvyt  "rare" means thrombocytopenia. "Large" means there are megakaryocytes to make up for the thrombocytopenia +2  
lovebug  FA2019, page419 +1  


submitted by andro(189),

First Point : Lymph forms at the Capillary level of blood vessels ( as this is where fluid moves in and out of vessels along with metabolites and nutrients ) .

The function of lymph is to return excess proteins and interstitial fluid back to the bloodstream ( Recall Lymph eventually drains into the large veins)

Second Point : We may increase lymph either by increasing 1. the rate at which we form it . 2. Decreasing the rate of drainage ( i.e - obstructing lymph vessels )

To increase lymph formation we have to increase the rate at which fluid filters out of the capillaries . This can be done by altering Starlings forces in the capillary

  • Increasing hydrostatic pressure
  • Decreasing Oncotic pressure

Going through the options
Option A : Endothelin will cause vasoconstriction of Pulmonary artery .This is precapillary meaning we will have less blood/ fluid getting to the capillaries - decreased hydrostatic pressure and decreased lymph formation
Option B : Constriction of pulmonary artery again
Option C and D : lead to the physiologic response of hypoxic vasoconstriction
Option E : Increased oncotic pressure decreases the amount of fluid moving out of capillaries

lovebug  now I understand~~!! THX :) +1  
limberry  I believe you mean "Option F: Increased oncotic pressure decreases the amount of fluid moving out of capillaries" instead of Option E, right? +3  


submitted by usmleuser007(397),
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Cna neoomes leeaps anlxpie why anc't lcaoloh be tcrrceo ni isth gisentt?

niboonsh  rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018 +12  
dr_jan_itor  what if the alcoholic just has a concurrent rhinovirus infection ;) +6  
lovebug  and FA2019 page 538. +  


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shSyplii hetseiognspa is het alnftmminaoi nda loetaiirbont of eht sava umosvra l(msla dolbo elsvess) that efdes rbgeig blood lsevses like aoar,t errai,ets iea.rlortse It dose nto tmaret waht hte tagse is, T. lulpdiam sfitnce het vsaa omusvar dan, ni hte s,roespc ratiloeebts hte eesnrv nad obold vlssese. Tihs illks lobdo pyupls to hotse eaars = amshicie tbu on inpa elps(insa )cehcnra. oreM ldoalczei ni raierle stsa,eg and in etarl s,tage eth spsieotrche idtie,easnsm os you ahve the raoat and sainlp rdco evmnvoietnl ubt msea sespnh.egatio :i(Etd jGlano idleepnxa itsh ow.heemse)r

privatejoker  So is the heavily implied step-wise formation of Syphilis symptoms as presented in FA complete BS then? Why break it down into stages and have us learn it as such if this is not the case in real practice? +5  
lilmonkey  Exactly, Goljan mentioned this in one of his audio lectures. All kinds of lesions in syphilis caused by vasculitis. +3  
lovebug  I know it's silly question. but Could anyone give an why answer is lymphocyte and plasma cell not neutorphiles.? bc syphilis is a bacteria, not virus. +  
trazobone  @lovebug my guess is bc its a spirochete, so it doesn’t act like a normal bacteria. One of the screening test for syphilis is FTA Abs, so a proliferation in plasma cells makes sense. Then by deduction, if its able to affect plasma cells, it can do the same with lymphocytes. But this is me trying to logic everything together so. +  


submitted by cantaloupe5(77),
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iThs neo was ryikct ubt I knhti oyu lvcode’u noed hist neo htuwtoi wkleenodg fo AMDN roe.erscpt mteS dolt oyu hatt atmltugea asictvtae tbho on-ANnMD and MNAD prerceots tub it cadiaevtt lnyo oD-nMANn eporctser in het alery sphe.a htTa masen ANDM teprrosec ttcviaae trafe Mon-ANDn stepocr.er Thta seamn igthsnmeo wsa dnyiegal NAMD rroectpe niaiavgctt dan het nloy awrsen htat dmea sense sa hte gM biiingitnh DANM at iegtnsr .leatontpi eOnc het lcle si eepodildzar by -NnDMnAo crte,rpose NADM cerroptse acn eb idavcta.et

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 lovebug(19),

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +5  
lovebug  Oh, thank you! +  
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +3  
csalib2  @drdoom fantastic point. never thought of it that way. +  
lovebug  @drdoom THX! very sweet explanation! +  


submitted by hungrybox(1035),
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uziq serfyluo :seswran

  1. lierotS tSi(lreo tuhsS ,dnow IFM si sdreeetc by tlSroei )sclle
  2. l5aap-h aeesrctud
lovebug  5-alpha reductase is due te that DHT is important for male external genitalia? +  


submitted by beeip(124),
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hTis hsa eben a tough ctpecon for me to ge,t ubt I ktnih Im' lyanlif t:heer

Teh stem is bsidencgir pmariyr nealdar ,cecufsynfniii ro .Ais'oddns

  • TAHC si ngbei eou-peodcrvrd ot ateitslmu eth ndeaasrl to ecudpor cosiltr,o tbu eyht cat'n n,sdepor ierhte ude to yahrpot or oirtedtsunc (,TB oua:emtnmui 4,RD )e.ct
  • eTh tsrif 31 noiam diasc of TCHA nac be valdece to morf HMαS-, hhwci utaismtesl myeeanlcsot, nsugaic onmaihpintgpreyet
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. +  


submitted by mcl(599),
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iirboV caerheol is a ae,em-rvngtagi maomc sedhap cribtaae tath acn saceu yretwa .ediraarh heoCarl xiont tsunnicof yb actvingtia the Gs rensopit &tg-;- cniinesrag tatycivi of yyeadnll ceyslac g;t--& reasecnid cMPA t&;-g- eairencds N+a adn C-l flxfue -g&t;- rahidare.

teepot123  fa 19 pg 146 +  
lovebug  Cholerae's exotoxin does not invade mucosa. but just permanently activates Gs according to FA. +  
lovebug  Same mechanism[Increase cAMP] : 1) Labile toxin of ETEC, 2) Edema factor of B. anthracis, 3) Pertussis toxin of B. pertusssis +1  


submitted by mcl(599),
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briVio chalroee is a n-aeg,ategrmiv mcamo hspaed tbacaeir htat anc acsue eyartw eirrd.haa aCrlhoe onixt nucfstoin by tganivcita het sG speoirnt &--;gt scianngrei cvyittai fo endlylya eysalcc -t;&-g cneedasir APMc ;t&--g eainecdrs +aN dna l-C eufflx g--t&; da.rhreia

teepot123  fa 19 pg 146 +  
lovebug  Cholerae's exotoxin does not invade mucosa. but just permanently activates Gs according to FA. +  
lovebug  Same mechanism[Increase cAMP] : 1) Labile toxin of ETEC, 2) Edema factor of B. anthracis, 3) Pertussis toxin of B. pertusssis +1  


In addition to the more obvious hint of budding organism, candida has fuzzy edges on blood agar which the others don't.

usmlehulk  @paperbackwriter cryptococcus have a narrow budding. +  
lovebug  wow I Didn't know that. THX~! +  


submitted by hayayah(1079),
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Ntoe: heT benudasc n. si tucaally eth vnree msot lyklei to be dadeamg by an digennpax rnlitean torcdai emrysnua in eth sroenavuc suisn btu yeth ivge uoy pscciife 3CN nctnofui ni shit te.squnio

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. +  


submitted by sbryant6(165),
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To embmreer canleBof is a GABA gsonatia and lescum ,xlanaert I alawys htkni of Gk"eer a"aBvlk.a rekeG orf AGAB, and aalvBka rfo Ba.ecolfn

castlblack  Thanks. Baklava is from Armenia though. Go us +1  
athenathefirst  No it's actually Arabic/Turkish. That's why it's called Baklawa. +2  
lovebug  I don't know if this is right. UMN Lesion (In this case, MS) -> Increased DTR, increased muscle spasicity, and dystonia. If Baclofen stimulate GABA B receptor(it's Gi related PTN) -> neuron become hyperpolar -> decreased excitory glutamte -> muscle relax. +  


Key Point: Bilirubin can only be in the urine if it is: (1) conjugated BR, or (2) urobilinogen.

Unconjugated BR is NOT water soluble and therefore CANNOT be in urine. This is why you use phototherapy in Crigler-Najjar. Increased unconjugated BR --> phototherapy isomerizes it so it becomes water soluble.

lovebug  clear and short. good! THX +  
lovebug  as @Basic_pathology said, In Crigler-Najjar synd. Photo TX does not conjugate UCB, but does increase Polarity and Water solubility to allow excreation (FA 2019, 388PG) +1  


Key Point: Bilirubin can only be in the urine if it is: (1) conjugated BR, or (2) urobilinogen.

Unconjugated BR is NOT water soluble and therefore CANNOT be in urine. This is why you use phototherapy in Crigler-Najjar. Increased unconjugated BR --> phototherapy isomerizes it so it becomes water soluble.

lovebug  clear and short. good! THX +  
lovebug  as @Basic_pathology said, In Crigler-Najjar synd. Photo TX does not conjugate UCB, but does increase Polarity and Water solubility to allow excreation (FA 2019, 388PG) +1  


submitted by tissue creep(113),
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rotAdhopr for e,sru but rof teh deorcr Im' yteprt reus sith aws Cungyukhina riV.su Oynl tog iths mrfo a lWordU eisqnuot sa I tdnha' nese ti ntlui e,thn tbu ralpnaepty eth ratahgrial si ayrlle b,da ihwch is athw edwr me ot eht ar.wnse

xe:tciu/otnlnwc/sva/phgtnm.iyw/duk.d.wghhc

meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +2  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +21  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  
beto  it is chikungunya->fever, polyarthralgia, diffuse macular rash, dengue has retro-orbital pain mostly +1  


submitted by tissue creep(113),
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otAporhdr rof ,resu tub for het cerdor Im' perytt eusr thsi saw niCuyanghku uVirs. lOyn tgo ihst ofrm a lodUWr uoqitesn as I dthna' esen it ltuin n,the utb ytneprpaal teh agthiaalrr is ylerla b,ad hiwhc is wtha rdew me ot hte rewn.sa

tiundngc/.wg.pvxma:hhtn/ccwiuw/hlt.k/sydeo

meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +2  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +21  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  
beto  it is chikungunya->fever, polyarthralgia, diffuse macular rash, dengue has retro-orbital pain mostly +1  


submitted by pg32(155),

NBME/Uworld love to test renal artery stenosis in the setting of hypertensive urgency/emergency. Just because this has been done so many times, you can basically get the right answer from the first half of the question. Pt with end organ issues (headache, confusion) and really high BP (I know it isn't 180/120, but it is really high). So this guy basically has hypertensive emergency. I'm already thinking it's renal artery stenosis. Next sentence? A bruit over the left abdomen. Bingo. Renal artery stenosis, most often caused by atherosclerosis in older men (as compared to fibromuscular dysplasia in younger women).

lovebug  He is heavy smoker but, No weight loss, No cachexia -> so can be R/O Left renal cell carcinoma. is it right? +  
lovebug  Renovascular ds. FA2019, pg 592. +  
misrao  and no hematuria so r/o RCC +  


submitted by pg32(155),

NBME/Uworld love to test renal artery stenosis in the setting of hypertensive urgency/emergency. Just because this has been done so many times, you can basically get the right answer from the first half of the question. Pt with end organ issues (headache, confusion) and really high BP (I know it isn't 180/120, but it is really high). So this guy basically has hypertensive emergency. I'm already thinking it's renal artery stenosis. Next sentence? A bruit over the left abdomen. Bingo. Renal artery stenosis, most often caused by atherosclerosis in older men (as compared to fibromuscular dysplasia in younger women).

lovebug  He is heavy smoker but, No weight loss, No cachexia -> so can be R/O Left renal cell carcinoma. is it right? +  
lovebug  Renovascular ds. FA2019, pg 592. +  
misrao  and no hematuria so r/o RCC +  


submitted by medpsychosis(115),
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sihT nttapei ednlyiitfe ahs o lCaridesscoi.Sus in einquost catmfe ni-:rsA cemArain tme amFre-lhayeE sNote-larmBaiud lo aHril Hrpyeoheldtmc-cay aenpiAa ued( to eilhadaeyy-1–dmtαsodrex tmiavin D totaiavcni in .)rohcaampesg

FA 8102 P.( 5)68

icedcoffeeislyfe  FA2020 pg 676 +  
lovebug  and FA2019 pg 662: Vit.D usually activated in Kidney. but They can be also activated by Macrphage like this case. +  


submitted by drdoom(884),
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emSt tlyacual ,staest “nO eniitugqnos, het enaiptt dsoe ton kwno eth eadt eti[]m, eth naem of teh lhtoipas pea[lc], or het eamn fo hre uners who adh usjt uncotdired isehflm ]e[onrps”. ,So pt si risdontieed to item dna lecpa ochC(ie ;)A htta si diiefenlyt onninregcc -- as wloud be ssreeeddp odom Ch(eoic E) dna teh oehrt ichoesc -- btu nltaiii“by ot dsnaenturd everiyst dan ”gnpiosrso is hte omst nigconrcen ciesn htat si teh rvye ieiiontfdn of yciact.pa iytbiIanl to sernudntad = aklc fo tic.pcyaa

lovebug  you explain very clearly. THX!!! +  
drdoom  thanks lovebug! +  


submitted by dr.xx(151),
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iehryderat shetsocomoa.rihm

EFH si aettdum &;=tg teh ssenttneii yeerappltul ttnrpeier a rgsnot trrnnafiser lginsa sa if eht yodb ewre cdineetif ni nroi. ihTs esald to mliamax rion bnprotsioa rfom endgtise fosod adn nori aveordol ni eth s.tsieus

srym.gmtlgtypcorhooyk_np/trieaeaihHadrpiiFohEeie/oo/_#soattwssehaihwdh/.:ikPi

lovebug  Autosomal recessive. C282Y mutation > H63D mutation on HFE gene, located on chromosome 6;associated with HLA-A3 [FA2019, PG.389] +  


submitted by celeste(84),
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ehT onoslctintael of stsmmopy osusnd liek ueobruts oilcsss.er Cacdira dhoymmraboa si a arer inegbn rumto taht is etunqlerfy eiodcsasta twih usretbou crsl.ssioe

tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +15  
tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +2  
arlenieeweenie  He also has seizures and pink-yellow papules, which I think they're trying to describe one of the characteristic ash-leaf or shagreen patches (doesn't sound like either of them to me lol) but that all points to tuberous sclerosis +  
pg32  @arlenieeweenie I think they are actually trying to describe angiofibromas that appear on the face in tuberous sclerosis, though I still think their description is pretty bad haha +5  
lovebug  Tuberous sclerosis. mnemonic : HAMAR(->Rhabdomyoma)TOMASS. FA19 page.513 +  
naarim15  the pink/yellow papules are adenoma sebaceum - "reddish nodules in a butterfly appearance areound the nose and cheeks, acne-like appearance" https://next.amboss.com/us/article/Rk0lnT#Z018f418df303f0090d6f81837408e107 +  


submitted by stefanmil(2),

Why we have deposits in the glomerular membrane. It supposed to be subepithelial - spike and dome - granulations, right?

lovebug  @stefanmil Yap. you're right. I think "Spike and dome" @ EM. and Diffuse capillary and GBM thickening in @ LM. +  


submitted by lilmonkey(19),
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oom-thxeC nma rutiepc form teh AF (satl pgae of hte emh and oonc esnitoc) wrkos lelw orf me in teesh eypts fo tnessuqoi.

lovebug  Bleomycin Induces free radical formation -> breaks in DNA strands.(Anti-tumor effect) FA19, pg431. and other tissues have Bleomycin Hydrolase. but Lung doesn't. So lead to Pulmonary fibrosis. +1  


submitted by mcl(599),
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Niacni vinatim( 3)B stgazaeionn LVDL eleorlthsoc eeictrons

sbryant6  Fibrates stimulate PPAR-alpha --> LPL upregulation --> decreased triglycerides. However, this question asked about a vitamin. Vitamin B3=niacin. +4  
lovebug  FA 19, PG 315. Lipid lowering drug bro. +  
makingstrides  I totally got this question wrong. But I also just realized that it says triglyceride -- VLDL. So VLDL must have been in the answer. Correct me if I'm wrong please. +  


submitted by jejunumjedi(30),
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I hnkit isth si iisgdrnebc a sgainl piepdet ohihcbryopd( ta ei)s.rntm-Nu htWtuoi sgnial epdteip tg=&; nact’ eb dortpsneart iton mnpcldosiae umru.teilc

youssefa  Is this even in FA? Biochem chapter only mentions SRPs. +1  
lovebug  @youssefa FA19, pg 47.[cell trafficking] but not details... +1  


submitted by assoplasty(93),
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I tiknh hte pneccto t’eyher stigtne is the crsdaneie TGB svleel in ,peacnnyrg adn not sjtu ihmpdoyrsehtyri in nal.gree

Wneh eircsnegn fro ihmsye/hppyyodoh,rtir HST lelsve are WYALAS epneilrlatrfye ckdeceh aebsuce yhte era eomr itsnviees to tuemin ifeefsdrnec in 4/T.3T Oneft mesti STH elelsv anc ttedanmesro a acgehn eevn nehw 4/T3T elsvle are in hte cinaiulcslb rne.ga hTe ynol oncteiexp to tish odwul be ni repynngca dn(a I egsus eyamb ilrev flei?ura I obdut yteh dwoul ska this .)ghuhot Hgih erogetns velsel sepntver the evlir omrf nekbgria dwon BG,T ednglia to senicaerd TBG llsvee ni eth umer.s ihsT dnsib ot feer ,4T saidneergc eth utmnao of eliaavlab eefr T.4 sA a nyomoerstcpa sancih,mem STH sevlel ear iystennaltr sadrincee dna hte ATRE fo 4T nuricotpdo si raseidecn ot elsiprneh leainseb eref 4T levle.s oHrewev het TTALO tuoanm of T4 is ciendasre.

eTh qnisuote si ksigna how ot rnfocim derrpythomsyiih in a praengtn onawm g;--t& ouy eedn ot cekch REEF T4 leslev aubse(ec ehyt soldhu be noarlm edu to noeoyscptrma oe).sperns You antocn cckeh THS uslyalu( aleetdve ni ayngnrcep to sneeotmcpa rof adsenerci TG,B) nad oyu actonn ecchk lotta 4T selelv lw(li eb .edecaisr)n You got the rawnes tihrg reeiht wya utb I inhkt sthi is a eefndrfit snnregoia wthro gd,csinorein seuaecb ethy nac aks sthi ccnepto in ohetr noetxstc of rmyesnrpoetes-hg,i nda if yhet eisltd S”“TH as an sweran ciceho atht lduwo be rrnctie.oc

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 cantaloupe5(77),
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apClsrua epaacisdlcoyrh icavcens rae ntefo oadtegncju ot onitrpes ot oipmrev .gucieinmymotin gFieallln si teh olny seawrn ehccio ttas'h a in.opter

mambaforstep  both MHC 1 and 2 are present antigens that are PROTEINS (FA 2019 pg 100). so in order to elicit a T cell response, you need a protein (CANT BE A POLYSACC). that is why vaccines for polysaccaride antigens are often conjugated to PROTEINs--> so that we can elicit a T-cell response (FA 2019 pg 127). +6  
lovebug  Flagellum = Protein, (FA19, pg.124) +  


submitted by haliburton(214),
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FE2 is atrislanlotna gtionloea toarfc 2, cwhih si searncsye orf petrion sesi.htnsy

sympathetikey  I. Am. So. DUMB. +25  
nala_ula  same :( +2  
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +  


submitted by usmleuser007(397),
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laflI seel asi:lf onet thta rhoet easwrn csohiec rae OCDP ptyse

dragon3  (except sarcoidosis) +2  
leaf_house  I got hung up on why this couldn't be sarcoid, and I think no lymphadenopathy is one of the reasons you wouldn't pick it here. (Though it seems like it can cause alveolar septal thickening: https://pubs.rsna.org/doi/full/10.1148/rg.306105512) +  
lovebug  Restrictive VS Obstructive ! very good point! THX! +  
schep  if it were sarcoid, wouldn't the biopsy show noncaseating granulomas? +1  


submitted by hyperfukus(76),
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lAso hoanter kye is ti says rolamn rnepiaapg rgil neo of het gntish aotbu the IAS si that tyhe do teg sydrocaen seulxa nuherracttas.icsi.rcter. rsilg d'not kolo raolmn 'ehtdy eb othrs dan yubbts no bosbo atf ekcn cet

covid2019  I'm confused that they said she appeared "normal". I thought AIS would mean the patient has very scant pubic hair / underarm hair. Wouldn't this be abnormal in a 17 year old? Should have Tanner stage 5 hair.... +  
mumenrider4ever  FA2020 (pg. 639) describes AIS as "Defect in androgen receptor resulting in normal-appearing female (46,XY DSD)" so I assume they're talking about general outwards appearance +1  
lola915  You do get breasts because patient has build up of testosterone that is aromatized into estrogen. No axillary or pubic hair because that requires testosterone. +  
lovebug  THX. SEE AIS (FA19 pg,625) +  


submitted by hyoscyamine(55),
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AF 72gp..3 uumaSqso lcle crinamaco scrcou ni eht purep 23/ of ugaopshse waeehrs nnacceamordiao csrouc ni eth tliasd /13. inSec sith asw in het dmi oupsae,gsh its smqusaou lecl mc.aarnioc eKy fateeur of uqussmoa ellc oaramiccn is iatnekr .elarps

turtlepenlight  can remember it as wearing a pearl necklace (upper 2/3 of throat-ish) +4  
baja_blast  Patient is also a heavy smoker and drinker. In the absence of GERD this should raise suspicion for SCC of esophagus over Adenocarcinoma. +1  
lovebug  Is there anyone who can explain about C)Intra-cytoplasmic pigment? what is this?;; +  
misrao  @lovebug I'm thinking Negri bodies in rabies +  


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rgam +, B lhemi,ctoy glntbmui mltoy,iti mfor cortke tials rmof intca yalpmotezinior cihhw aollw fro meetnmv,o cltri,laarulne rgosw ni lcdo ptsme on ilkm, otfs ecshees, cei re,cma uclhn ate.m

erdisenac eidnnccie in ganrpnet nweom yepiesalcl ni 3dr itetresmr

lovebug  Santa's list! in sketchy. Pregnant women are more likely to get listeria than anyone else. May lead to termination or disease in the newborn (from sketchy.) See FA19, PG139. +  


submitted by niboonsh(357),
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SWMI

sphae noe - is ti Saf?e

aheps 2 - dseo it Wok?r

hpeas 3 - ayn Im?onrsvpemte

hpase 4 - yats on eht Mr?keat

lovebug  Does the drug "SWIM" ? :) FA19, pg256 +  


submitted by divya(59),
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eCutryrnl rhliszmeeA' edaisse netratemt dlnscuei -

nn1hcdaE)e cAh tisrnoasnims ipDzo(eeln, itvR,insiameg teinnalmGaa

2) rtoiueoeNtocrpn via natoaxinitds tmi(naiV )E

)3 MADN peetocrr nsogntimaa tenaine)(mM

lovebug  19FA, 536pg +  


submitted by pparalpha(84),
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eLad Ttixyoci :

sseCu:a itsirunpdo fo hmee istynhess via hboiitinin of ALA amanevlleinut(io adyetahsr)ed

dninFsi:g

A: Aenmia

B: silahpociB iplgsinpt

C: cCilo

D: eahrDiar

E: ahtlpcephEoyan

F: ooFt rdpo

G: Gum i/rodhtseptogsw rtinoaotraut/ged

H: NHT adn yrcapeermeuhi

Orteh awssren:

niZc fiinecdcey:

aC:sesu wol ,eaknti rnoh'sC issadee

isd:nigFn nieumm ncntsouf,yid pmdiiera udown agnlhei r(fo teh igdeolnrme hepsa fo nwodu ahgn,eli znci si eended yb teeimeoanrsopslalt to earkb down tpey III cag,lon)el gp,adysoominh ,rhardiea erma,ttdsii ac,alipeo amoarlbn ttaes nad lelsm

xcEess is .r..are tbu can lead ot //vdn dan mdiobanla ainp

imeguMasn edfnceycii:

Csseua: tng,iocnela ypa,irluo m,tlniauontri evatxali saueb

Fdgnin:is t,eyant eerramupt euitrlcanrv nratioccto,n resaecnid QT niaverlt

1B2 yenfcedici:

usaeC:s vagen idte, nuercsipoi inemaa, aertaincpc u,siess gstacir spsyba er,ysrug islanaprotmbo Cnr(o,h ,ser)up mrilohhiutbyDlop teaulrc/mwopmta iitecfonn

dnF:isngi i,mtyoraccc egtsaomlcalbi aae,imn eounr sspyotmm, necsadrei hscoienetymo dan MMA velsle in esmru

sInearecd iVmatni D:

ssaCe:u anuurtmooslga sseaedi soao(r)cidsis

gdsnnFi:i enbo t,rrsonoeip too much alcumci, osls fo ,pateteip usptor

lovebug  2019 FA, pg 411. +  
lovebug  Nephrotoxicity results from lead exposure because the kidney is the main route by which lead is eliminated. Lead is absorbed by the proximal tubular cells of the renal tubules, where it binds to specific lead-binding proteins. +2  


submitted by pparalpha(84),
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dLae Toxcyiti :

euCs:as trsinoipdu of eemh hsseynsit iav intihnboii fo AAL ovailunamntilee( arehatdd)esy

:gnisidnF

A: ieAnam

B: ahspilocBi pplgstnii

C: ioclC

D: rraeihDa

E: laaepEnhtpohyc

F: Foto prdo

G: mGu sgsotewoi/prthd ogeinaodttautr/r

H: HTN dan ceuypreamrhie

erhOt srweans:

nZic nifecdeciy:

susaeC: wlo aektin, 'srChon sdaeise

inndFi:sg iemnum ftycdus,inno aieimrpd ndwuo ilagenh ofr( hte eidegomlrn shepa of udonw n,glehai icnz si ednede by mstasaeelpiotrnoel ot kebar nowd ypte III nl)g,celao y,odmhgpsanio hdari,rea smt,edrtiai aecop,lia baarolmn tates and smlel

cxEess is rr.a..e but anc laed to vn//d nad aaoidlbmn pnai

sugaMiemn iicceyfdne:

sua:seC eotni,agcnl apryol,ui mittnanrli,ou vxatliea abeus

dis:inngF ty,tane etuemarpr lvitucnarre caoinntto,rc adsirenec TQ aretlvin

21B yecidfinec:

Cuae:ss vnaeg itd,e oipiusnrce a,ienma tapecnicar is,sues sitcagr apsbsy ugsrer,y poamainolbtsr oh(n,Cr ,sup)re lilmyuioDbhhotpr tuaoltmm/wcrpae nfictoine

ninFds:gi ycccmirot,a mclsiaboltgae naieam, reuon mtmyso,ps rdeiensac mityeocsehon adn MMA elsevl in rmseu

nIreaecds Vatiinm D:

:seuasC rlogansautmuo eiessad )id(oassocisr

dsFn:igni noeb s,pooinretr oot chum ul,cimac lsos of patetiep, tuospr

lovebug  2019 FA, pg 411. +  
lovebug  Nephrotoxicity results from lead exposure because the kidney is the main route by which lead is eliminated. Lead is absorbed by the proximal tubular cells of the renal tubules, where it binds to specific lead-binding proteins. +2  


submitted by peridot(68),

Here is my summary of the picture/video that was posted:

There are 3 pathways involved in peeing:

  1. Pelvic n. (aka pelvic splanchnic n.) sends parasympathetic fibers to deltrusor to contract --> squeeze bladder and pee.

  2. Hypogastric n. sends sympathetic fibers to the deltrusor to relax, as well as the internal sphincter to contract --> hold back pee

  3. Pudendal n. sends somatic fibers (under conscious control) to the external sphincter to contract --> hold back pee

In this question, the patient's bladder is filling up so much that it's forced to overflow. That means there is a problem with scenario 1 - damage to pelvic n. so that he can't squeeze his bladder even when it's super full.

peridot  To clarify, this description is meant to go along with @hungrybox's pic link and @eacv's video link +4  
lovebug  thanks a lot! +  


submitted by alexb(47),
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pixoycH rauomylnp ostnicscivtoorna ,PHV)( aosl nonwk as het rEilednautLjrs-le iemmhsanc, is a losygailiochp henmoneonp ni chihw lsmla mlnyurpao tesrriea citorctsn ni hte peresnce fo ollaarve ahoyipx (wol gnxyeo eel.)svl

ihelW hte manitnenaec of ltifn/nuroeiaponeivst ritoa niugrd nalierog ntbioorsctu fo irfolwa si nl,bfceaiei VPH acn eb reelantmitd nguidr bglaol ralvlaeo aoxiphy wchih ruccos twhi oeusxrpe to ghhi tdluteia, hewre PHV saecus a iinsgtniafc enearsci ni altto nompurayl acursval e,scterisan and uynoparlm atreiarl r,ereupss pellitoytna nadglie ot ouyrlnpam ohptiyrnseen adn oauymrnlp mea.de

utaoxvop:esp_klmgrios/ni../Hkrraioicitie_ta//ohdpicypwoinwcntyns

lovebug  2019 FA, Pg 665. PAH +  


submitted by mcl(599),
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OCSP is tsoiedcsaa with aonmrlba cnrtuiopdo fo sxe di,rsteos cnlindigu ytdsicnfuon fo ntregeos ncdtuoopir and eegsort.preno ayinohllrcC edvetlea llevse fo eetngsro nca cuaes datmrelnoie i.epplrsyaha

i79nst9/rthi../MPmwnt/lh1./a9c/3wc/gvlcosbpmiw.:nC5ep

meningitis  Why isnt it endometriosis? Could someone help me out on this? +1  
meningitis  Sorry, I was confusing with higher risk for endometrial carcinoma. +  
vi_capsule  Estrogen is responsible for cyclical bleeding and pain associated with endometriosis hence progestin is a treatment modality. But estrogen isnt a risk factor for Endometriosis. Rather theres retrograde flow, metaplatic transformation etc theories are responsible for endometriosis. +  
sympathetikey  Tfw you get so thrown off by a picture that you don't read the question properly. +29  
hyperfukus  @meningitis idk if u still care lol but always go back to endometriosis=ectopic endometrial tissue outside of the uterus so you can rule it out since increased estrogen would cause you to have worsened endometriosis or a thicker one but not directly...you can see the clumps of the follicles in the ovaries if you look super close so that along with the presentation takes you to PCOS and anytime you don't have a baby or stay in the proliferative phase(estrogen phase) you get endometrial proliferation-->hyperplasia--->ultimately carcinoma +1  
lovebug  FA 2019, page 631 +  
lovebug  Other answer H)Meigs syndrome : triad of 1) ovarian fibroma, 2) ascites, 3) pleural effusion. “Pulling” sensation in groin. FA 2019, pg 632 +  
xw1984  Isn't option G, Leiomyomata uteri, associated with high estrogen level? Per FA 2020, fibroid is estrogen sensitive. +  


submitted by mcl(599),
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PCSO is sdteacaois wiht barlmnoa toupricond fo exs roisste,d lnnducigi odyctnnifsu fo rstogeen nodtoucipr dan reo.spetnegor ralcihnColy devteael slleev fo sngeerot nac scuea eilmrtndeoa railhapy.spe

wn/9aclnr./c5t73ip.cm1hngCb/wvMP./9./hpeiwsi/s9t:mlot

meningitis  Why isnt it endometriosis? Could someone help me out on this? +1  
meningitis  Sorry, I was confusing with higher risk for endometrial carcinoma. +  
vi_capsule  Estrogen is responsible for cyclical bleeding and pain associated with endometriosis hence progestin is a treatment modality. But estrogen isnt a risk factor for Endometriosis. Rather theres retrograde flow, metaplatic transformation etc theories are responsible for endometriosis. +  
sympathetikey  Tfw you get so thrown off by a picture that you don't read the question properly. +29  
hyperfukus  @meningitis idk if u still care lol but always go back to endometriosis=ectopic endometrial tissue outside of the uterus so you can rule it out since increased estrogen would cause you to have worsened endometriosis or a thicker one but not directly...you can see the clumps of the follicles in the ovaries if you look super close so that along with the presentation takes you to PCOS and anytime you don't have a baby or stay in the proliferative phase(estrogen phase) you get endometrial proliferation-->hyperplasia--->ultimately carcinoma +1  
lovebug  FA 2019, page 631 +  
lovebug  Other answer H)Meigs syndrome : triad of 1) ovarian fibroma, 2) ascites, 3) pleural effusion. “Pulling” sensation in groin. FA 2019, pg 632 +  
xw1984  Isn't option G, Leiomyomata uteri, associated with high estrogen level? Per FA 2020, fibroid is estrogen sensitive. +  


submitted by madojo(177),

Know your STD's baby ;-) (going through every other choice on this question):

  • Bacterial vaginosis caused by gardnerella vaginallis. Se a thin, off white discharge and fishy smell (fish in the garden). There's no inflammation Lab findings: pH greater than 4.5 (just like trichomoniasis), and a positive whiff test with KOH. Stem will say something about malodorous discharge and show the infamous CLUE CELLS if we are lucky. Not the answer for this question obviously because we would not expect vesicles with this bacterial disease.

  • Candidiasis is going to be your thick cottage cheese discharge, with inflammation. normal pH see pseudohyphae. Treat with topical nystatin, or oral fluconazole unless you're pregnant than use Clotrimazole. Again not going to see any vesicles.

  • Chancroid per uworld is associated with Haemophilus ducreyi you will have a Deep purulent painful ulcer with suppurative lymphadenitis. Will be told that patient has painful inguinal nodes, there may be multiple deep ulcers with gray-yellow exudate. You do cry with H. duCRYi This wouldn't be true for what our patient has in this question because we aren't told of any inguinal adenopathy. a link to a chancroid VDA

  • Chlamydia trachomatis causes lymphogranuloma venereum which is small shallow ulcers, painless, but then the large painful coalesced inguinal lymph nodes aka BUBOES. Compared with gonnorhea the discharge is more thinner and watery. Again not the case here as its painful and no mention of any BUBOOESS. The discharge in gonorrhea is more thicker. Both lead to PID, treat for both because confection is common. With both patient may have some sort of pain or burning sensation upon urination. Sterile pyuria though for both.

  • Condyloma accuminatum is a manifestation of HPV 6 + 11 (genital warts). They look like big cauliflowers. This is in contrast to Condyloma lata that you see in syphillis which is just a flatter latte brown looking macule.

  • Genital Herpes (the answer to the question) will present with multiple painful superficial vesicles or ulcerations with constitutional symptoms (fever, malaise) Just fits better than all the other choices I ran through.

  • Syphillis is the painless chancre. UW describes it as a single, indurated well circumscribed ulcer, with a clean base. See corkscrew organisms on DF microscopy. Keep in mind other painless ulcers are lymphogranuloma venereum of clamydia (but the buboes are whats painful not the ulcer), and granuloma inguinale (donovanosis - klebsiella granulomatis) but whats hallmark about this one is that its painless without lymphadenopathy

In short, be safe.

drdoom  this write-up is AWESOME ... but it also made me vomit. +  
b1ackcoffee  This is awesome, writeup, not the stds. +  
lovebug  FA 2019 pg 184. I summed up @madojo's comment! this patient have "multiple, tender vesicles and ulcer". and scant vaginal discharge. A) Bacterial vaginosis -> NO vesicle -> r/o B) Candidiasis -> NO vesicle -> r/o C) Chancroid -> should have Inguinal Adenopathy -> r/o D) C. trachomatis -> have Large painful inguinal LN -> r/o E) Condyloma acuminata -> Big Cauliflower -> r/o F) Gental herpes -> YES!!! G) Gonorrhea -> NO Vesicle, creamy prulent discharge -> r/o H) C. trachomatis again (same as D) -> r/o I) Syphilis -> painless chancre -> r/o J) Trichomoniasis -> strawberry cervix, motile in wet prep -> r/o thanks @madojo! +  


submitted by h0odtime(47),
  • Gastrin released by G Cells pyloric antrum, duodenum, stomach stimulates parietal cells to secrete HCl.
  • Parietal Cells (Fundus + Cardia) epithelial cells that secrete HCl and intrinsic factor. They activate gastric chief cells to secrete digestive enzymes.
  • Gastric Chief Cells (Mucosa): releases pepsinogen and chymosin

Labels

  • A Mucous Neck Cell
  • B Nucleus of Parietal Cell
  • C Nucleus of Chief Cell
  • D Nucleus of Endothelial Cell
  • E Nucleus of Fibroblast

Credit to Histo_Man/reddit

lovebug  THX for kindful Lables! +1  


submitted by nor16(58),
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adoGhrtnspoo rae teh /HHSLF dnoicpgru tpityriua elc.ls No vrsa,oei on mersonh,o no ekfcdeba iiiobinnht.

lovebug  THX for great explanation. When I first saw this question, I mistook the gonadotrophs for endometrial cell. so I Choose atrophy. (even that pt undergoes a total hysterectomy) critical mistake... +4  


There was a uworld Q on this. The duration of action of Succinylcholine is determined by its metabolism by plasma cholinesterase. Some people are homozygous for an abnormal plasma cholinesterase, aka "pseudocholinesterase" or "butyrylcholinesterase" (BCHE). People with a homozygous BCHE mutation have delayed metabolism of succinylcholine, mivacurium, heroin, and cocaine.

In these patients, paralysis from succinylcholine can last for hours and you have to maintain them on mechanical ventilation until they can breath on their own

lovebug  2019FA 538pg. +  


submitted by usmle11a(76),
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ok i inthk i heva a ohetyr in rdsrega orf ihst:

teh owlhe rpecrdeuo is ndeo to aeecdrse hte rltpoa N.TH hwhic asmen eth sntuh huosdl be tporla to teysmcsi nidivoga teh evlr.i

a) ecthaip stmce(si)y ot fni enicrph ( ymisscte ) ; n)Bo ccloieoil ltrp(ao ) to nif scnmireet )(aortpl ; on) c ceplins a()rtplo tfle arenl m;)set(cysi sdye ) speriruo tgpiscaeri syt(cs)mei ot feinriro epagiricst )mystesci( ; eo)N ruoireps ctealr ot)a(prl to rpsiueor neeictsrm ( rlpa)ot ; NO

whossayin  You’re a legend. Good theory man, makes memorization a whole lotta easier! +  
lovebug  2019FA, 359pg. +  


submitted by imgdoc(135),
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The acicnlli niresapoentt si ahtt of elwor ilnmaaobd niap, er,vef and icll.hs Thsi laeon dame me tnkih ti aws an ataimrolmnfy ospes.cr lAos het ntoisuqe yssa ehtre era 3 treaespa lopyro ileimtded ongisre fo rnawro .numel As arf sa vaertueilc itolcis is odccn,rene etreh ear on piks lises,no ti si unitcuoosn rerwheve it si. ihsT lopceud itwh eth ohyrtis fo pnciasontito ksema esituivdtcilir the ebst wrnase iceh.co

lovebug  I know it's silly Q. but why not C) Granulomatous colitis? lol. thank you! +1  
trazobone  Granulomatous colitis is Chron’s, which also doesn’t fit bc it presents commonly in the terminal ileum and does not usually present with fever as it is an inflammatory pathology rather an infectious one. While it does present with string sign (“narrowing of the lumen”), anything can cause a narrowing of the lumen, so this doesn’t necessarily mean that it’s string sign +1  


submitted by hayayah(1079),
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This tp sha aelsatciooam / csekitr n(siec sh'e a .k)ddio euCasd by fvetiedce naioiezailtrmn fo sodteio aao)iemtlaos(c or aronlgsiautci rwthog stlaep tke,icrs( lony ni de)inclr.h

ostM loyncmom t/d tViamin D yfeinecc.id

Chdlrien tiwh eirsckt eahv lophacgtoi owb egls (egnu a,)rmuv aedb-liek scotnalrcoodh junnsitco a(iitchcr s)a,oyrr ntrcaseiabo fso(t )lsluk.

  • eD.c mitinaV D lmrona( tfnconiu is to sorbrbae +2aC dna PO)4

  • ce.D semur a2C+

  • ceD.  murse 4PO

  • .nIc PHT

lovebug  FA2019 455pg !!! +1  


submitted by hyoscyamine(55),
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iThs si etllara rrPal/dAu/mWlllgnyebaeIeC mdsyer.on eTh oanmw has dmgaae ni eht mypsiatchet ihcna yso(erns ysrnsmeod rae laetarl carocdnig to teh leur of 4s) ngrisetlu ni roeHrn sdn,erymo alpismitcnaho arctt pmpi(na/et wchih aer slao sy),noesr adn NC IX dan NC X dtyfinocusn lirgnsteu in the yadyatgsrahrsidahi/p p(hsel us clzoilea to hte dleua.lm)

nala_ula  Also, just to add, FA specifies that Nucleus ambiguus effects (dysphagia, hoarseness, decreased gag reflex) are specific to PICA lesions. +2  
cienfuegos  Thanks for the input. I have always found this topic to be tricky and just came across this article that helped me out a ton regarding the rule of 4's hoscyamine mentions above. https://rdcu.be/bLjOB +7  
lovebug  FA 2019 502pg! +  
pfebo  "Don't PICA horse (hoarseness) that can't eat (dysphagia)" +1  


submitted by d_holles(187),
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H'eesr na lxeecltne aemig omrf MBOSSA if loeppe are vahgni dltfcuiify algiuzisniv shti: gp/RmaQosctt:hVr/hmWm//im.u

lovebug  very helpful! thanks! +  


submitted by hungrybox(1035),

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 :) +  


submitted by hayayah(1079),
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Nlioaepsa is new uisste gorwht hatt is uelrdautng,e r,eieibresrlv nda aomncolln.o

lyaltinCo anc eb tneiemdder by hsa-opecthuse-o6glp adgyneerehdso 6D)P(G enmezy misorfo.s D6GP is le-kXdni.

*orF eomr ionofraimtn hkcec uot h.C 3 asNoieapl in aahoPtm

hello  This is great, thank you. +5  
breis  Pathoma ch. 3 pg 23 "Basic Principles" +8  
charcot_bouchard  Shoutout to Imam Satter! Without him this question wasnt possible for me to answer in 10 sec. +13  
fatboyslim  Clonality can also be determined by androgen receptor isoforms, which is also present on the X chromosome (Pathoma Ch. 3 Neoplasia) +1  
lovebug  @fatboyslim thanks for reminding! +  
makingstrides  Just to make sure I got this right, because this is neoplastic and its monoclonal, you want to look at the isozymes to determine its clonality? +  


submitted by thecatguy(17),

This is a very nitpicky question. As I see it, the 3 main concepts tested are:

  • This patient has trigeminal neuralgia (sharp, brief, episodic pain in the face), which is caused by a lesion to primary sensory fibers that carry pain sensation from the face.
  • Multiple sclerosis, which the patient has, is a demyelinating disease (i.e., it affects white matter).
  • The myelinated axons carrying pain sensation from the ipsilateral face enter the brainstem at the level of the pons and then descend (become the spinal tract of the trigeminal). These white matter fibers pass through the pons to synapse on the spinal nucleus of the trigeminal, which is in the medulla (nucleus = gray matter). (picture here). Therefore, a lesion in the white matter (i.e., plaque) in the pons could cause trigeminal neuralgia, and this phenomenon has been observed.

Above the level of the brainstem (thalamus & cerebral cortex), you have second order sensory neurons. Lesions in this part of the circuit are not generally in trigeminal neuralgia. I suppose they also want us to assume that once the spinal tract of the trigeminal enters the medulla, it's not myelinated anymore. I don't think this is completely true, but given the logic described above, pons would still be the better answer.

As people have pointed out, the primary sensory fibers carrying light touch sensation from the face synapse on the chief sensory nucleus in the pons immediately after they enter the pons. This question is not asking about those fibers though.

I got the question wrong too..

mightymito  Wow this is the best explanation yet! Thanks so much for very clearly walking us through a tricky question. +3  
lovebug  @thecatguy Are.... you a professor? thank you very much :) +  


submitted by whossayin(24),
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ehT ecionmmn I ekil orf meniebrgrem hte tnsiocola fo eth aairnlc ensver si hte 2,44,2," erlu"

obvAe ieranmt=sb NC I + anIdMri Ibi= NC I,II s VInP=o NC ,V I,V I,VI IMul=eVlId Ia NC X,I X, I,X IIX

lovebug  @whossayin thanx so much!!! +  


submitted by bbr(25),

damn, the spleen was so big I thought we were looking at the 2 kidneys. Found a new way to get things wrong.

lovebug  @bbr me too. lol +2  


submitted by kentuckyfan(43),
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nSeci hte ipan si aarul,dirc a sicd rntenhioai is stom klei.ly

charcot_bouchard  Why it cant be a lumbar vertebra fracture +  
whoissaad  @charcot The patient is young and doesn't have any risk factors for weak bones. Also, disc herniation is a common problem in the young. The disc gets fibrosed and stiff in the elderly so they have less chance for disc herniation. So basically age was the key to answering this question. +3  
lovebug  you are genius! thank you! :) +  


submitted by hayayah(1079),
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Defceivte suoolgohmo oentcrbaiimon si seen ni raesrvbatiaon/ sanercc hwit eth ACB1R neeg aitmtuo.n

johnthurtjr  Ashkenazi Jews have a higher risk of inheriting the BRCA1 and BRCA 2 gene mutations, just another tip! +2  
lebron james  BRCA1/BRACA2 are involved in the repair of DNA double stranded breaks +6  
samsam3711  Other answers: DNA Mismatch Repair: Lynch Syndrome (MLH1, MSH2) DNA Nucleotide Excision Repair: Xeroderma Pigmentosa +14  
lovebug  not about this question but... Defective "Non"-homologous end joining is seen in Ataxia-telangiectasia. :) +1  
makingstrides  DNA Base excision repair removed damaged, or not correct, bases. +  


submitted by neonem(571),
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reehotatetxM douwl be a rudg of eccoih orf ssiisrpoa eryroftarc to oitpacl scraem and htlgi t;eahpyr tiniibhs itferhdyoolad tcuesarde in oerdr to aserdcee iskn lcle piortiefalorn and deurce fmaoylinmtra e.sensorp

69_nbme_420  Cyclosporine can also be used to treat Psoriasis (NOT cyclophosphamide - ans B) +7  
len49  Drugs that can be used for psoriasis include cyclosporine, MTX, TNF-alpha inhibitors including Etanercept, lnfliximab, adalimumab, certolizumab, golimumab according to FA +2  
medstudent  Kinda summed up in the index - p 791 2nd row halfway down +2  
lovebug  as We all know, 1st line therapy of psoriasis is topical corticosteroid, Vit.D analog (Vit.D inhibits keratinocyte proliferation and stimulates keratinocyte differentiation. +