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Welcome to makinallkindzofgainz’s page.
Contributor score: 220


Comments ...

 +2  (nbme24#21)

This is a case of lingual thyroid, a persistence of thyroid tissue at the base of the tongue due to failure of migration.


 +0  (nbme23#7)

Helpful image to understand that its isomerization:

https://www.viapath.co.uk/sites/default/files/upload/Newsletter/jaundice%20fig2.png

drzed  That made me want to vomit tbh; I forgot about NMRs until just now. I hated those things. +

 +3  (nbme22#37)

Dr. Sattar says that decreased blood flow --> atrophy. Fibromuscular dysplasia of the left renal artery is essentially renal artery stenosis --> atrophy of the left kidney


 -5  (nbme22#47)

Pentad of TTP = FAT RN

  • Fever
  • Anemia (MAHA)
  • Thrombocytopenia
  • Renal failure
  • Neurologic symptoms

This is TTP not ITP

makinallkindzofgainz  I seem to have commented on the wrong question, sorry! I wish I was able to delete my comment, but I can't. +3

 +2  (nbme22#42)

Androgenetic alopecia is a progressive, nonscarring alopecia that affects the regions of the scalp with the most androgen-sensitive hair follicles, resulting in a characteristic pattern of balding (bitemporal scalp in men and vertex and frontal scalp in women).

Follicular miniaturization: Androgen shortens the anagen phase of hair growth → vellus hair formation (thin, short hair)

  • Vellus hair does not cover the scalp adequately. As the anagen phase shortens further, the hair shaft does not grow long enough to reach the scalp.

TL;DR - DHT can lead to baldness


 +0  (nbme22#28)

Isolated gastric fundal varices are seen in splenic vein thrombosis.

Thrombosis increases pressure in the short gastric veins --> gastric varices only in the fundus

  • Seen in pancreatic inflammation (ex. pancreatitis, pancreatic cancer), which can cause a blood clot within the splenic vein, backing up blood into the short gastric veins (gastrocaval shunt - drained by the inferior phrenic vein) when ruptured causes gastric bleeding, hemoptysis (seen in stem), and melena

 +7  (nbme22#7)

It's D because you're being compassionate and every other answer makes no sense:

  • A: You can't promise that things will be okay.
  • B: Being a dick.
  • C: Being a dick.
  • E: Being a dick.




Subcomments ...

submitted by mahesh(5),
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mtseoasaoOcr aticosiloghl .apaeprcnae egPta saiesed si neo fo kirs aotcfr

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 neonem(549),
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Geelnar heetm of :latogohpy iypxoah rsiapmi tdixeoaiv hoahrspolytponi g;-&t- sels APT -t-&;g lses aN-K mpup tctiyvia os uodism bsdiul up ni het l,lec snaguic en.wisllg Tshi is eth irsft .tsep enTh 'uody egt the ucacmli idpbuul ni eht lecl and neuealtv rceinobaa lslc,goisyy cigsanu cilact iacd oocitrdpun dan eewlodr .H..p btu shit eaphsnp elrta and s'nti the etdcri aucse fo aelllrcu wnll,sgei chhwi si tawh the onqtuesi is ft.ear

aneurysmclip  can we have a moment of appreciation for Dr Sattar +18  
makinallkindzofgainz  blessed be His name +5  


submitted by yb_26(243),
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My milspe nsgrunandtedi si that 'tps traeh lrytonatctiic is dederesca eud to MI =g&t; ehatr acnt' pmpu a lto fo dobol ;&=gt redacenis bpukac fwlo otni rnplamuyo uvalrasucet g=&;t icrdeeans PC.PW

reoM dloob in mralynupo cruatleuvas =gt;& yhte lliw etadil in drore ot usjt kepe lla ethes loodb &=;gt eecaedrds oarnmuypl vusaclar rteaniessc

ereaDecsd idaracc utpuot ;&tg= apripehrle noscncotitsivroa gt;=& iecseadnr smictesy vluacars ceientssra

susyars  The question says “ST elevation in the anterior leads“ so, in some way I was thinking of the most anterior part of the heart which is the right ventricle, and not the left one. +3  
makinallkindzofgainz  Anterior STEMI = ST elevations in V3, V4 which is supplied mostly by the LAD. RV is mostly supplied by the RCA, which would show up on an EKG with ischemic changes in II, III, and avF +4  
qiss  Btw increased PCWP indicates increased blood in the left atrium, not necessarily increased blood in the pulmonary vasculature see here. +  


submitted by m-ice(318),
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MHG CAo auetcesdR tioinrhsib tvpenre eth vrlei from gnintiyzsehs its own ohl.oretelsc In deror ot amiainnt tis deen ofr o,etroelcshl het erlvi ahs no ehocci yb ot reniesca sti LLD tercpoer spinxrsoee in odrer to teak leotlsrcohe mrof hte lbo.od

suckitnbme  Not sure why NBME felt like they needed two questions on statin MOA on this form. +5  
makinallkindzofgainz  because they didn't even realize it because they make insanely low effort practice exams with awful formatting and vague vignettes, yet here we are paying 60 bucks a pop for "high quality" exams, gimme a break. ok i'm done venting +4  
madden875  stop whining. no one asked you to buy the exam^ +4  
neoamin  Why does anyone scramble this site? >< +  
neoamin  and how about lipoprotein lipase? +  


submitted by neonem(549),
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hsiT taipnet ni'st nlthgyoia,entpiv 'hterye nERltHPnvagYt,eii cehen eth OP2C t;&l 40 mm Hg.

'esLt alkw it draw:cskba Tyhe rea etntegyavrpliinh to poaetnemsc ofr teh ecbmiolat soaisdic edasuc yb pwdsiderae ioxap.hy attepirenlgiynHv lolsaw yuo ot wbol ffo mreo 2.CO

Wyh aer they ixphoy?c ehT nopers si pcyxoih edu ot atafmilniomn nad euact yertraiposr tisdsres oeysdrmn rmof eth nainoeu.pm llA eth kiysecnto ormf eth mailoyfatnmr lcels ceusa asrenecid lormnupya licpalary g,akeeal hcihw kobcsl pu teh aarevllo anmerbme so htta O2 n'cat etg otrhghu ot hte .dbolo

hyW od yeth vaeh ctmobliae dsaciios ni the fistr l?cepa No gyeoxn ;t-g&- on etrconel naprsortt hcani nad no CAT -&-gt; cilatc isoa.csid

diabetes  no pneumonia it is UTI +3  
makinallkindzofgainz  The infection from the UTI spread to her lungs +  
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1  
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +11  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +1  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by neonem(549),
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iTsh tiatpne 'inst taoynhigipetn,lv 'yereht RYtHePnnialvEt,gi enhce het OPC2 lt&; 40 mm .Hg

Lest' wlka ti wdsbkraca: heTy rea negaevhlripinytt to tocsanpeem rof eth maitbcoel asiiodcs cueasd yb ddiaeerspw xpiy.aoh pirneaytntleivgH oallws ouy to wolb ffo mero O.C2

hyW are tyhe ?xihyopc Teh pesnro is cyhopix ued ot toaininmmfal adn catue itosaeyprrr etrsdiss erodymsn rmfo the miunnoae.p lAl het nekyistco rfmo the ityrfnamoalm lelcs uesca easncerid panurmloy ylacralip ,kegaeal hwich oblsck pu eht laarvloe embreanm os thta 2O acnt' gte hrhtuog to teh oo.dbl

hyW do yeth hvea eticlomab idsaiosc in hte fsrit lc?ape No xeogyn ;gt--& on toeelcnr rnstporat ahicn dna on CTA &-;t-g tlcica iacos.dis

diabetes  no pneumonia it is UTI +3  
makinallkindzofgainz  The infection from the UTI spread to her lungs +  
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1  
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +11  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +1  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by nwinkelmann(282),
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I ndofu a ircutep hiswogn eth imstainnossr yb tow eezrgoyutsho phlaa aasetsimahl ritta aanis oit)l(-cseneid repsa,tn dan foeiddim it ot loas ohsw eht entrehcinai by tow oyogseetuzhr hapla iaaamstlshe niaacrf d-letose(rna)nti tsrnpea. erHe ouy :og pc/gve=Tv2owgtwoP/dV1/sre:8e.i9ipwRtEOhnJ91hJcod.IU7oQ4HmqudnTldW?

makinallkindzofgainz  broken link +1  
drdoom  broken link +  


submitted by sajaqua1(518),
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maasPl sambmnree are a pliid yrbl,eia lyaipyltc wthi aoteshhpp aehsd on heac scuarfe adn olng conrab tisla no eth isdni.e eehTs nbarcso ear enau,ltr dna nuderog hhporcioydb rnctinesoita rof an gnlleyaerecti aealbforv ttas.e

galnteIr neebmmar pristneo spsa hothgru itsh pliid labeyri, dna os stmu be belpcaa of giearncntti ohtb thwi eht olarp sslvteno of alartriluclen adn txelarluarlce cpase, as ewll as hte ibcphyoorhd reco of teh eayrl. hTe nnrmmtsbeeaar ipnotro ntoef sha illpahha-aecl daycnosre ,ocnortfnoima iwht ohcohibpydr redesius iekl neicygl no teh iestduo otdrwsa the anrobc stali itwh raolp amoni cdai isdrseeu dectuk ni.

makinallkindzofgainz  "high school biology" lmao we really out here +6  


submitted by sugaplum(323),
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salway emrrembe temh ni roder twih ,lfmuroa EAEITS=IS
n ad hte two no het NDE ear DTOAUC-IND

makinallkindzofgainz  The supraspinatus AB-ducts. The Subscapularis ADDucts +  
makinallkindzofgainz  disregard my comment, I misread what you meant +  
drzed  How are you supposed to remember which S is which? +2  
drschmoctor  @drzed "Supra" = on top, so the 1st S is for supraspinatus. +1  
usmleaspirant2020  according to Physeo : INFraspinatus--EXternal rotaTION------INF-ECTION +  
destinyschild  wow, sugapulm, that mnemonic is gold. you are gold. +1  


submitted by sugaplum(323),
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lwsyaa emerbmre mthe in ordre tihw rmol,auf AEI=STSEI
dna het wto no teh DEN are AD-CTUODNI

makinallkindzofgainz  The supraspinatus AB-ducts. The Subscapularis ADDucts +  
makinallkindzofgainz  disregard my comment, I misread what you meant +  
drzed  How are you supposed to remember which S is which? +2  
drschmoctor  @drzed "Supra" = on top, so the 1st S is for supraspinatus. +1  
usmleaspirant2020  according to Physeo : INFraspinatus--EXternal rotaTION------INF-ECTION +  
destinyschild  wow, sugapulm, that mnemonic is gold. you are gold. +1  


submitted by yogi(11),
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TPI - laPeetlt + Ab geos to peslne - Ldesy - Lwo tlp tuce.rontfA ntmplcsyeoe - asylulu tlp tounc ieromvp dna erpeParihl doolb amsre ohws - HJ bsiedo as a gsni fo ipalasen ( eaunrcl nrsnmtea ni RBC yasulul rdmeveo yb snple.e) If ehetr wsa an ceycasros seelnp (wihhc swa ont natlnciouf nhwe teh nmai slenpe saw )oikwgnr wlil aket revo teh iutcnfon yaagllrdu - JH eiobsd lilw adsarpipe and tlP ststar to esly - hcwih has depahenp in stih esac io.srcnae

spow  But why are there no bite cells? Question stem states that there is normal morphology? That's why I didn't pick accessory spleen +2  
makinallkindzofgainz  Bite cells are seen when splenic macrophages take "bites" out of hemoglobin precipitates in G6PD deficiency, which doesn't have to do with our question. This patient had a splenectomy 3 months ago, 6 weeks later showed Howell-Jolly bodies (asplenia), and then today now has normal erythrocytes (spleen is working again somehow = accessory spleen) +3  
snripper  @spow Bite cells are associated with G6PD deficiency, not ITP. +1  
srdgreen123  Main takeaway is the HJ bodies. They're seen pretty much whenever you have no spleen. So if they dissapear, that means another spleen-like structure has showed up +2  


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riooyglsSendt sentpeaert eht snki alsuyul( het e,etf) lsrtave noit hte dao,borsemtl stneer het sghtrceln/aau ewreh it si uslaluy eduocgh up nda enht lwowesadl into teh IG r.tact Tyeh cna aly eggs ni the n,enitsetis nda ewnh the raeavl h,acht ethy cna eetrapnet eht nalnsteiit allw and nrtee hte emtdolasobr .iagna

makinallkindzofgainz  Strongyloides is fucking metal holy shit +4  


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eTh hploerhancobnme lduwo eb no eht lutaca sfuet os tsju teg idr of D(). The acbl"k hoe"l ahtt het esuft is aitlngof ni si eth ietslnaagot asc os teg dri fo (C). woN I ma on tldnsaruuo ptxere ubt I wokn hatt het ctioinam vtaciy etnvlaeylu sepdxna ot efus iwth teh hcnoior herybte ienginialmt the rhcconioi vtaiyc (B.) nI sterm fo ehwre eht mnoatici cyativ is wnhso ni ihst ag,ime I am otn ru,se so yebma esmnooe cna hpel but htsi aeeslv eth kyol csa whchi tayiclpyl prepaas wiithn the algittaneso sac nrduao .55 s.kewe

kateinwonderland  At the end of the fourth week, the yolk sac presents the appearance of a small pear-shaped opening (traditionally called the umbilical vesicle), into the digestive tube by a long narrow tube, the vitelline duct. (Wiki) +4  
tallerthanmymom  But why does it look completely detached from the fetus? I eliminated yolk sac first because of this +  
makinallkindzofgainz  If you look reeeeeeeally closely, you'll see some signal between the yolk sac and the baby. Although you can't see the entire connection, they are connected. +4  
thotcandy  Pt is roughly 8 weeks pregnant so and typically by 9th week, Amniotic cavity has expended to fill entire volume of Gestational sac. So the entire black part around the fetus is GS/AC. +2  
euchromatin69  and also by 7 week vitelline duct obliterates between umbillicus and yolk sac +  


incorrect question. PPIs are associated with diarrhea and c diff which would cause acute onset severe diarrhea https://www.mayoclinicproceedings.org/article/S0025-6196(17)30841-8/fulltext

makinallkindzofgainz  PPIs don't usually directly cause diarrhea. The stem mentions nothing about potential C. diff. Misoprostol directly causes diarrhea. I also put PPI, but I can see why I was wrong. +2  
mhmdreyad  https://www.ncbi.nlm.nih.gov/pubmed/10392669 this also say that PPI is the first line in treatment +  


submitted by haliburton(208),
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mtlbludsee hsa a neic nmouceipn rfo teh kldeil ncceaisv:

sRet In aPece as:wAly

sebiaR
nlea uzfnI
oiloP a)Skl(
stei Hapit A

paulkarr  Also, the nice little puppet show from sketchy for those visual learners like me. +1  
makinallkindzofgainz  just remembered that MMR is a live attenuated vaccine +  
faus305  how could i forget that puppet show?! +  


submitted by monkd(18),
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Am I yracz or idd rdolwU otn veah a toqinues hatt dtesta ntaSits rae hte mots cteevifef gudr eesglrdrsa of easbenli lidp.is hTis lgcoi twehr my fo.f

adisdiadochokinetic  You are not crazy. I got this question wrong for the same reason but here's why I think NBME was going with fibrates. You can use the Friedewald equation to calculate LDL cholesterol from the values they give. This equation is LDL= Total Cholesterol-HDL Cholesterol-(Triglycerides/5). The Triglycerides/5 term is an estimate for VLDL. If you calculate it in this case you get an LDL of 120 which is firmly normal and thus the patient would ostensibly not benefit from statin therapy. +14  
hello36654  omg when the hell am I going to remember this equation? Jesuusssssss, this kind of details makes me want to give up on STEP +4  
almondbreeze  Her goal LDL should still be <100, bc she has 3 CHD risk equivalents (https://www.aafp.org/afp/2002/0301/p871.html#afp20020301p871-t3) CHD risk equivalent=the major risk factors that modify LDL goals 1) age(M>45, F>55), 2) smoking status, 3) hypertension(>140/90), 4) ow HDL level (<40), and 5) family history. (https://www.aafp.org/afp/2002/0301/p871.html#sec-4) +  
almondbreeze  *low HDL level (refer to table 3 of the article) +  
makinallkindzofgainz  These guys are hitting up attending-level cardiovascular risk factor calculations, meanwhile I picked statins because I think I remember that they help the heart +12  
jimdooder  So I ended up going with fibrates because of her age (39). I vaguely remember being taught that statins are really only recommended for patients >40 because the big study that came out about them was in the 40-75 age group. I think this might contribute to the question but I'm not totally sure. https://en.wikipedia.org/wiki/Statin#Primary_prevention +  
ytho  This question inspired my screen name +2  
cbreland  "Statins are always the answer", "Fat Female 40 Fertile", "Fibrates can cause gallstones". I feel lied to +  
brise  I'm not sure if this question is correct. I chose statins according to what an attending told me and UWOLRD 2, I just went back to check and on uworld 2, you only consider giving fibrates if their TG levels are above 1,000. So idk what the nbme is smoking. Or if doctors actually write these questions. +  


submitted by wired-in(67),
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eMaanncinte sdeo lormuaf si (ssC × lC × t)au ÷ F

hweer Css si stteyaesa-dt aettrg maapls ncc.o of udr,g Cl is er,eanlacc tua si ogeads laevnitr ;&pma F si .yiolitvibaabila

irheteN egsoda reivlant nro bvitaoiyblaiial si v,engi so onrngiig eosth p&;am ggpiungl in teh esrbnum cufae(lr to envrtco niust ot am/)gdy:gk/

(1=2 /ugLm × 1 mg/0001 u)g × 00(.9 /Lgrhk/ × 0100 /m1L L × 42 rh1/ d)ya
= 29.52 dgkagym//

..ihhwc. itn's yna of het rswane echsico dlit.se eyhT must vhae dunored 900. L/khg/r to 1.0 /grLkh,/ nad dniog os svige yxletac 8.82 amd/g/gky ccih(eo )C

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +69  
hyoid  ^^^^^ +11  
seagull  lol..my math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but i´d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +3  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +2  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +15  
qball  Me after plugging in the right numbers and not rounding down : https://i.kym-cdn.com/entries/icons/original/000/028/539/DyqSKoaX4AATc2G.jpg +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😡 +  


submitted by rainlad(21),

my approach to this question was to eliminate all the answer choices that mentioned specificity or sensitivity, since the data here did not provide information about any sort of screening test.

that left me with two possible answer choices: I eliminated the one about consistency of other studies, since no other studies were mentioned in the question stem.

not sure if I oversimplified things, but it led me to the right answer!

makinallkindzofgainz  this is exactly how I reasoned through it. Were we correct in our line of thinking? We'll never knooooow +  
qball  But will you ever know on the real thing? +1  
drdoom  but will you ever know in real life? you may do the right thing (given time constraints, & information available), but outcome is bad; maybe you do the wrong thing, but the outcome is good (despite your decision). how to know the difference? +3  


submitted by aladar50(40),
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For eth GEC, I iilnaytli tuthogh it was n2d grdeee Teyp 1 bcsaeeu it eeemsd tath eth PR ealntsriv reew cneiigansr nitul a eatb aws ppde,rdo tbu if yuo oklo ta it cesloly, soem of teh P wsave reew deindh in het QSR oec.exlmps fI yuo tcieno hat,t then uyo anc see hatt ehert weer urgrale P veasw dna lgrauer QSR e,pcmsxelo ubt erhet wsa a eolcempt sooiidistacn ebtnewe tehm hchiw snmae it aws 3dr egeder haret b,clko so eht rasnwe aws abnloiat rean the VA do.ne

yotsubato  answer was ablation near the AV node. No it wasnt. It was ablation OF THE AV node itself. Which faked me out. +9  
makinallkindzofgainz  The tangent by user "brbwhat" says that there is "pr lengthening progressively" but there is not. This is 3rd degree AV block. The P waves march out consistently at their own rate, and the QRS complexes march out at their own rate. There is complete dissociation between the P waves and QRS complexes. They have no relationship. This is exactly what you would see if you ablated the AV node. The SA node would continue to to create P waves. The bundle of His would continue to generate junctional (normal looking) QRS complexes. +6  


Seems like I did what most of you did. I read the "symptom" as pain and went for PGE2.

Turns out if I had just read the 2008 paper Undiscovered role of endogenous thromboxane A2 in activation of cardiac sympathetic afferents during ischaemia I would have known that TXA2 MAY be a cause of MI pain. https://www.ncbi.nlm.nih.gov/pubmed?term=18483073

There are also theories that the pain is from adenosine/bradykinin/acid/ROS/5-HT which you can read about here:

https://www.ncbi.nlm.nih.gov/pubmed?term=10099685 https://www.ncbi.nlm.nih.gov/pubmed?term=10222339 https://www.ncbi.nlm.nih.gov/pubmed?term=11458709 https://www.ncbi.nlm.nih.gov/pubmed?term=12411532

I found these via the UpToDate page Angina pectoris: Chest pain caused by coronary artery obstruction which does say the mechanism is "complex and not entirely understood."

makinallkindzofgainz  this is all irrelevant. the dude is having an MI so the answer is Thromboxane A2 +  
drschmoctor  Bruh, you gotta read all the 2008 papers. It was a fire year for obscure shit you need to know in 2020. +10  


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Ptteian is urtnecr da-,sbeftre os we can almiietne fertoucs fruo(stce si fnodu in oheny nad sfturi adn mose maofulr, tub otn in asretb i)lkm. itatenP ahs unicegrd sbencstasu ubt no luocsge ni eht e,urin so he sumt mseo -ncenoolgus agrs.u yM elaentifidrf for gncediru eugnls-nooc sasurg ni the inreu is dosidrser eutfscro eotmamslbi or tcagelsoa bm.eosmliat eW evah ediilaentm reo,fscut os ttah ealsev su ithw igckanasoetal ccideeifyn or iscalcs ocl.aiaetsagm

sympathetikey  & Galactokinase deficiency would be much milder. +6  
smc213  Big was soybean formula not giving any issues. Soy-milk can be used as a substitute formula in patients with Classic Galactosemia since it contains sucrose (->fructose and glucose). +1  
oslerweberenu  Why can't this be glucose 6 phosphatase deficiency Confused me +  
almondbreeze  @oslerweberenu G6PD - increased RBC susceptibility to oxidant stress (eg, sulfa drugs, antimalarials, infections, fava beans) -> hemolysis; has nothing to do with presence of reducing sugar +1  
makinallkindzofgainz  @almondbreeze; Glucose-6-phosphatase deficiency is Von Gierke disease, they are not referring to G6PD deficiency (an entirely seperate disease) +6  


submitted by yotsubato(965),
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ecesaaraPpiln is slaybical ncaetaPicr" "Esmnezy ni cafny psnta MNBE wldro

makinallkindzofgainz  "Pancreatic enzymes, also known as pancrelipase and pancreatin, are commercial mixtures of amylase, lipase, and protease. They are used to treat malabsorption syndrome due to certain pancreatic problems. These pancreatic problems may be due to cystic fibrosis, surgical removal of the pancreas, long term pancreatitis, or pancreatic cancer, among others. The preparation is taken by mouth." +  


This question in it's essence is asking that after inserting the catheter in the femoral artery, which landmark should we use beyond which superiorly lies the renal artery, and the answer is the origin of the testicular artery. What a weirdly worded question though. :?

makinallkindzofgainz  I don't think it's worded that weirdly. The guide wire should be advanced superiorly just beyond the testicular artery to approach the right renal artery. +  


Pentad of TTP = FAT RN

  • Fever
  • Anemia (MAHA)
  • Thrombocytopenia
  • Renal failure
  • Neurologic symptoms

This is TTP not ITP

makinallkindzofgainz  I seem to have commented on the wrong question, sorry! I wish I was able to delete my comment, but I can't. +3  


submitted by thirdaid(9),

The initial presentation looks like cancer: weight loss and progressive dyspnea over the course of months in a heavy smoker. Then, the question describes extra-pulmonary symptoms and a paraneoplastic syndrome.

More acutely, there is development of edema of the face and jugular venous distention. Because this is localized to upper body, we should think of a mechanical obstruction to venous flow as opposed to some cardiogenic reason. This is an extra-pulmonary symptom of lung cancer.

[ Superior Vena Cava Syndrome caused by the medial spreading of the tumor. Can be exacerbated in the physical exam by asking patient to raise both arms. ]

Finally, there is a single highlighted lab value -> hyponatremia. Small cell lung cancer can release inappropriate levels of antidiuretic hormone -> SIADH. ADH will retain water and decrease sodium concentration possibly leading to cerebral edema and seizures.

[ Syndrome of Inappropriate ADH (due to small cell carcinoma, a neuroendocrine tumor of the lung) decreases sodium concentration. Paraneoplastic syndrome. ]

In SketchyPath: SVC syndrome is the red balloon near the mediastinum ship and SIADH is the guy trying to carry the water cooler and getting water all over himself.

makinallkindzofgainz  I agree! Superior sulcus tumors is a lung carcinoma that occurs in the apex of the lung and can cause SVC syndrome. +1  


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gmusbioAu onutesqi utb in eescuba it is layer shok,c ether is ont nogehu item to tvaiceta teh RSAA ot aicrsnee ykiden ifu.opsnre

makinallkindzofgainz  This is not an ambiguous question. It makes perfect sense. +4  
khaleb  In early shock you have increased SVR due to vasoconstriction. This would cause increased flow to the kidney. I could be wrong but I think what makes that answer incorrect is NOT that RAAS hasn't been activated yet. It is what is causing vasoconstriction via Angiotensin II. What is possibly wrong about that answer is that it says via sympathetic stimulation. I do think it is a little vague between those two answers though. Because you can get sympathetic activation of the RAAS system causing vasoconstriction and blood shunted to vital organs such as the kidneys. Bottom line is you can't argue with weak pulse during hypovolemic shock.... so an obvious right answer. You could make a case for the increased blood flow to the kidney though. +2  
zqatan  @makinallkindzofgainz no need to dismiss the question... so pretentious +  


submitted by imgdoc(132),
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I nhtik lato of epepol gmhit veha oevr phzdemeias owh otniamrpt NAP adn PBN ayller rae, yes it is nptatmori ot wnko hetes pepdties get eesdtecr yb eht nivetcarurlilaar/t oimyducamr udring reath ue.iflra eeoHrvw ertih aloverl isscetfneeevf in tntraieg traeh flruiea si hzli,c a eropcetrp dlot em taht if PAN dna BPN ewer os ulfseu in unsiarsietr htne yhw od ew iegv ditcr?seui tsI' ubecase SRAA epresrowvo siht ysemts eenhc aisncgu eaevtgin eftfcse dan eht dnleses opol of ehrta .arfeuil AKA yhw we egvi CEA hisnib.irto

nnKiwog atth NAP tesg zenrieldatu yb eth AARS ,teymss we can hsfit oru uofcs ackb to rteah leauifr ni tihs atpnei,t ewrhe acrdcia tutuop si redd,eseac eigndal to DAH rntecoeis and lfanlyi ludnilitao irotp.nheamay

almondbreeze  a concept continuously emphasized by uw, but I get always wrong :'( +2  
almondbreeze  good work done! +  
raffff  why does the body make anp at all since its so useless +3  
makinallkindzofgainz  @raffff - at least BNP gives us a good marker for heart failure exacerbations :) thanks body! +  
mannan  Yeah it's important clinically because it has a high sensitivity (if negative, rule out) for Heart failure. +  
alimd  At the same time ANP inhibits renin release? +  


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Plesae can you ldnkiy rsaeh MEBN 22 dan 32 itsQseoun ithw me . I oyln ese het nwressa btu I od not vaeh eht lflu ?a Thtkeunnqisso in adecnva

makinallkindzofgainz  I think you may have this website confused with nbmequestions.com +7  
teepot123  why don't u buy the exams like the rest of us? +2  


submitted by rogeliogs(9),
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Tish untQesoi its btuao preyirsotar bsrtu

tantiesP htwi HADPN yichfnro=cenedccii atmoauguornls esedais GD)C(

vEen ouhthg eiapttns iwht GCD nt'ac aekm x,eeiudSrop eyth nca eus ti fomr teh esaiabcrt nad eonvrtc it ot elhbca HCLO nad ilkl het .rtaacibse

BUT seiaratbc ihwt ataseacl yzmsnee eietznural rhiet nwo direpsxeou and thsta why het GDC titeapn can't lkil .emht

sCetaala ispvetio sbar:eacit .S uraeus - iesslrgpuAl

thomasburton  I thought E.coli was catalase positive too? Why can that not be correct? +6  
mb10  (FA 186) Catalase (+) microbes, especially S aureus +4  
makinallkindzofgainz  @thomasburton - because First Aid said so, so suck it +1  


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oNt 01%0 resu no ihts eon, tub eehs’r how I pepcdhaoar :ti miisahnet asuecs ilaaterr tiindoal raede(=csed ltrrraieoa rtei)secans, btu lal fo htat blood ahs ot go oeremwhse cesni yuo wno aveh roem ooldb filowng gurhtoh eth airtesre nda atht ehmsereow is eht ricaliepsal (eadincser yacaplilr hartcytsodi e)srsrep.u imtiHsean secaus sdrieaenc belrmytpaiei fo eht pyl-ialprsctao eleusvn o(ne of .rD rSatt’as vfoiatre fst)ac so udo’y heav ednercias alaylrpic ittofrnlai re.at

taediggity  Totally agree, arterial dilation--> increases blood flow into capillaries/increases capillary hydrostatic pressure + increasing permeability of the post-capillary venules= Increased Capillary Filtration Rate +1  
makinallkindzofgainz  I love you explanation, but I don't think filtration rate is dependent upon permeability of the post-capillary venules. I think the filtration rate is increased simply due to the increased blood flow; this is similar to how increased renal blood flow will increase Glomerular Filtration Rate (GFR). +10  


submitted by moloko270(64),
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sols fo udifl rgergtsi edsoaeoltnr riupodn,cto os penttia lwil eahv aerpythiamrne adn koamepliayh sa a erluts

makinallkindzofgainz  dat RAAS +4  


submitted by usmleuser007(370),
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oehMtr si -enRhg -g&-t; seh will geareetn Hsenb-1a )ditRio tesfu eaffdcte by hRAnit- fi ti si Rov)ipshei2- t eevn if hsoiitO-PR-ve is nvieg, hetn isllt 'eomtrsh nota-esiiRdbh lwli kcaatt stdernausf obdol deu to tis llecs nngtiocnai + )hR3 o,efrhtree ga-e-etOiRhnv is tsbe

makinallkindzofgainz  you're not wrong, but I think it's better to have put O-negative because that's the preferred type of RBC for transfusion unless you've type and crossed your patient +  
mtkilimanjaro  I think fetus is O+ but if you give them that the RBCs will still be destroyed. You want to give O- as it wont get destroyed and wont affect the fetus in any way. Similar mechanism to giving platelets to someone with TTP, HUS, etc. they just get destroyed so its useless +  
tylerwill33  In utero, should give O- to avoid mom attacking again. After birth, O+ probably better. +  


submitted by aesalmon(81),
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I eefl budm rof isgkna btu anc eenmoso plixnea it?sh fI his epsnrat rae of lsoce ot olnamr MIB and ear ececnrodn otaub sih wgieht yhw wdoul hyet be nolgawli ish ilcearo spnuocintmo ot eexedc ihs nrgeey uxet?pedirne ( AKA egtntli the ikd tea oto hmcu dan tno eserixce ehu)ogn

meningitis  That's a modern day mystery. +16  
drdoom  The prompt is only asking "what's the likely cause of obesity?" It's not that they're "allowing" him to eat more than exercise. (Few parents can monitor their kids that closely!) The prompt is only asking what's the most likely explanation for his 95th percentile weight and BMI (given that he otherwise appears normal); in the United States, the most likely explanation is eating way more than you expend. +1  
niboonsh  aka 'merica #firstworldproblems +4  
makinallkindzofgainz  If you are obese, it's because you have consumed calories in excess of your energy expenditure, end of story. (there are factors that affect your energy expenditure, but the simple statement is 100% true, unless you want to argue against the laws of thermodynamics). A is the only correct answer. +1  
tulsigabbard  This answer hit too close to home. +4  
castlblack  I think the reason they point out the average weight of the parents is because leptin disorders are inherited. It helps you eliminate that answer choice. +1  


submitted by marbledoc(0),
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yhW ldouw uoy sak eht eaitpnt to inidytef teh pros dna snc?o I odn’t teg eht hcrpaoap e!ehr

someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +6  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +5  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +2  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +3  


submitted by meningitis(500),
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I :tthohug worel poel neth anct be psarnaulre nor mohtcas hchwi rae "g"hhier

uumenoDd adn doyB of ceaarnps teex(cp ai)lt rea oraeeorettinprl nad dniliem

makinallkindzofgainz  I ruled out duodenum because it's towards the right side, and I ruled out body of pancreas because that's basically midline. We are talking about the left lower kidney, which is by the spleen and splenic flexure. Idk if this logic checks out, but I got it right +  


submitted by sbryant6(152),
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e/ha:kltft/suspstyonp/cwm.clsaadd-mc-.cdtowraeameherrw-iam/n

makinallkindzofgainz  upvote for credible source +19  


submitted by welpdedelp(215),
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ishT si ,eEtbnoLtmr-aa hwchi peisrvom thiw emonemvt as cmoedpra ot aiyMsteneh raicgsa wihhhc rsweons ihwt vomnmtee

sbryant6  Lambert-Eaton is typically associated with Small Cell Lung Cancer. Since there was no mentino of that, I was thrown off. Such is the difference between UWorld and NBME I guess. +1  
makinallkindzofgainz  I'm laughing about Myasthenia "gracias" lmao +13  


submitted by someduck3(58),
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tFa lsoeblu niatismv era ,E,K,A.D oS htob D ap;m& E lcuod eb edsecarde ni tsih t.p Btu uoy hvae ot nkwo atht atimniV E deficieycn is osciaadets wtih mediitnoalyne a;&pm sah enbe soedaactsi whti opeiortsr olmunc dieonamyitlen. Aslo iVt E acn eb nigev hwit rmieelhAz esinptta as it selhp with reef ladi.?r.acs

aesalmon  I actually thought that the posterior column findings were likely due to B12 deficiency - "subactue combined degeneration", due to malabsorption, as we see in this pt (. Turns out vitamin E can also cause symptoms which look like subacute combined degeneration: https://www.ncbi.nlm.nih.gov/pubmed/9012278, as does Copper (TIL): https://www.ncbi.nlm.nih.gov/pubmed/15249607 +3  
jooceman739  Vitamin E deficiency causes posterior column findings and hemolytic anemia :) +5  
nwinkelmann  The way I think about it is that essentially, vitamin E is an anti-oxidant. Vitamin E deficiency = LOTS of oxidation, i.e. free radicals, which are toxic to most cells in the body (particularly myelination and RBCs). That's why it can be used with Alzheimer's patients. +3  
makinallkindzofgainz  Vitamin E presents like B12 deficiency but without megaloblastic anemia +  
kevin  B12 would also affect lateral corticospinal tracts, vit E doesn't to my knowledge (b12 deficiency would also present with hyperreflexia but E deficiency just romberg sign, loss of proprioception and touch, ataxia) +  


submitted by privwill(22),
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tSep yb :tesp

  1. pH = low = ioicsdas
  2. O3HC = olw = sdiscoai
  3. 2OC = hghi = ssdiciao

o,S htwa Iv'e enlerda is ,hatt in sesne,ce oebmilatc cadsiiso asalwy kaets oiprryti in hstee sci.roasen sI't evditen ahtt the epnros is otn t,spiagenoncm utb oyu watn to ectcaalul naywya by ngusi rntWei = 15. C)HO(3 + 8 .
fI yuo lcaeltcua oyu lilw see tath hte txdeepce is 0.5.3

  1. fI O2C is hiehgr atnh pxteedec = icaontmotnc orirsetarpy odaiiscs
  2. fI O2C si woler tanh pexcdtee = anctomitnco rprrtsaiyoe sloisaakl

reHe it is ehihgr tahn cepedext 5)(6 so atmtnioocnc aytrpesriro a.scosiid

I gsseu fi yuo eantdw to ttsra twih hte ersrrtaypio aocissdi uyo uvlo'edw atenk oint ateiocrindson taht trbnaeibcao svd'ouehl ogen up ot oe.stnacpem tI in'tdd so tsi' d.nacotunseemp Nto suer if 'rethes a omuarfl ot ulateclca teh etorh fsutf

makinallkindzofgainz  don't forget to add the +/- 2 to the end of Winter's formula. You have a tiny range in which CO2 can fall within +2  
cbreland  I started with respiratory acidosis and thought that any compensation would have an increased HCO3-. HCO3- is lower than normal levels, so that would mean met. acidosis as well. No math involved like you alluded to +  


submitted by armymed88(47),
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ulceGso is cntdoarpe-tosr itno tenoyeecsrt of SI via msoiud

toxoplasmabartonella  That makes that glucose needs to be given with sodium. But, what about bicarb? Isn't the patient losing lots of bicarb from diarrhea? +3  
pg32  Had the same debate. I knew glucose/sodium was the textbook answer for rehydration but also was wondering if we just ignore the bicarb loss in diarrhea...? +4  
makinallkindzofgainz  @pg32 - Sure, they are losing bicarb in the diarrhea, and yes this can effect pH, but it doesn't matter that much. You're not going to replace the bicarb for simple diarrhea in a stable, but hydrated previously healthy 12 year old. You're gonna give him some oral rehydration with a glucose/sodium-containing beverage. Don't overthink the question :) +2  
makinallkindzofgainz  *dehydrated +  
teepot123  salt and sugar, that's all the kid needs when ill simple +1  
mtkilimanjaro  Hm I put bicarb/K+ since thats lost in diarrhea, but I think the key thing in this Q is that its only 6 hours of acute diarrhea and nothing else. You would prob give bicarb and K+ in more "chronic" diarrhea over a few days or longer not just a few hours +1  


submitted by armymed88(47),
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cseuloG is cserdotrt-opna oint eeoteynsrtc fo IS iva msioud

toxoplasmabartonella  That makes that glucose needs to be given with sodium. But, what about bicarb? Isn't the patient losing lots of bicarb from diarrhea? +3  
pg32  Had the same debate. I knew glucose/sodium was the textbook answer for rehydration but also was wondering if we just ignore the bicarb loss in diarrhea...? +4  
makinallkindzofgainz  @pg32 - Sure, they are losing bicarb in the diarrhea, and yes this can effect pH, but it doesn't matter that much. You're not going to replace the bicarb for simple diarrhea in a stable, but hydrated previously healthy 12 year old. You're gonna give him some oral rehydration with a glucose/sodium-containing beverage. Don't overthink the question :) +2  
makinallkindzofgainz  *dehydrated +  
teepot123  salt and sugar, that's all the kid needs when ill simple +1  
mtkilimanjaro  Hm I put bicarb/K+ since thats lost in diarrhea, but I think the key thing in this Q is that its only 6 hours of acute diarrhea and nothing else. You would prob give bicarb and K+ in more "chronic" diarrhea over a few days or longer not just a few hours +1  


submitted by armymed88(47),
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wDon ynodersm d2n ttriermse escren syaluul( ndrauo -8s6k1)1w whsos aedeecrsd FP,A slrtioe dna ndeescrai hCG dna nnibihi .A

Of imyorst 8113/,21/ nDwo drnSemoy si the lnyo to ahve na eedeetlv hCG

makinallkindzofgainz  "Down Syndrome has high HI (hCg and inhibin)" the relationship between the words down/high really stuck for me +1  
drzed  An easy way to remember the other aneuploides is that the "lower" ones (e.g. lower than 21 = 13,18) have "lower" values (e.g. LOW hCg and LOW inhibin) +2  


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DAK is a ttesa of rdcaesede ;isunlin inesc ew nowk ttha siilnnu ausces a ftish of +K tnio teh leslc olw lleves of liusnin wlli eeptnvr itsh and rlestu in h.nIlkypmeariea ia,odtndi deu to iehylyrpacmeg adn hhgi CFE mslloitayo water llwi fisht uto of hte scell toin the FEC nda +K fhssti tuo iwth the rwate hicwh illw ufetrh carniese teh ephyleiaarmk

dentist  I know Insulin cause shift K+ into cells due to closing of ATP-sensitive K channels (blocking K from leaving)? Does it increase K in the cells by another mechanism? +  
makinallkindzofgainz  @dentist - Insulin stimulates the Na+-K+-ATPase pump, this drives K+ into the cell (Source: Amboss) +  
castlblack  Another mechansim = acidosis causes hyperkalemia due to H+/K+ antiporters. H+ is high in blood so shifts into cells via this antiporter, which shifts K+ out. --potassium section of acid/base chapter in Costanzo physiology +  


submitted by fenestrated(27),
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roF thsi neo I hiktn hwta uoy adh to nwok is ahtt noinpsiTtarrc (tD;-gA&N)-NRA si rmredopef by NRA pe asorlImt.ye wsa ton NDA pmryeoalse cesbuea hist oen eeslacript D&-AN-;gtDA(N)

fenestrated  between increased or decreased binding I picked decreased because it was a mutation which affected the hydrogen bonds which is how nucleotides bind to each other +1  
makinallkindzofgainz  this is how I got it right +  


submitted by yotsubato(965),
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In ,yloibgo pahse roavinita si a dthemo rof lnigead itwh parldiy ivgryna omretnnesivn tthoiuw urqegrnii onadrm oat.mntiu It ensvilvo the aotinraiv of oenrpit es,poenixrs ntqlreuefy in na -ooffn na,fisho thinwi ifefdertn astrp fo a iltcabrae .ppuoaitlno As shuc hte yphnteepo can iwtshc at rifecsuqnee taht are muhc eihgrh mesisemto( ;&)%1gt tnah llsaiccsa uniottma .tesar Pahes avtroinia tctoesnbiur to rvuceienl by gtaenegrin eeoitynrth.eeg ohtulhAg ti ahs eenb toms yolomcnm diedsut in eth tenxcto fo imuemn oinv,ase it is dsoeberv ni aymn rohte aesra sa llwe dna si emlypode yb aivorus speyt of icaer,tba cngilidnu neaallmolS e.spcies

iheae//oosrn.vhdwi/ksam_t/wtww:piiacPnnwat.

whoissaad  is it the same thing as antigenic variation? +8  
dorsomedial_nucleus  No, antigenic variation involves genomic rearrangement Phase variation can be thought of as MORE or LESS of something. An on/off switch. No DNA is being rearranged, just under or overexpressed in response to the environment. +4  
makinallkindzofgainz  This isn't in Zanki, Lightyear, or First Aid, and I don't remember ever learning about this in class. Thanks NBME! :D +18  


submitted by usmleuser007(370),
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nI ascse of ichdl or ualdt ebasu

1) if rehet si alrec ecdnieve schu as fi a idhcl tssaet atht ertpsna sinhpu by ti,nitgh dclhi is ohswngi rfae fo tnpare ---- lcla chdli otoeinpcrt gthri waay ( t'nod nede to wtia adn k)as

)2 mesa hngit soge rfo the tldau but lalc het ldatu picteroton visseecr

osler_weber_rendu  Does anyone not remember Dr Daugherty's lessons which said domestic violence on adults is NOT necessary to report? Instead help them find an escape route in case of an emergency and encourage them to report it themselves. +  
makinallkindzofgainz  @osler_weber_rendu: Domestic violence is not the same thing as dependent adult abuse, such as a special needs adult or an elderly adult (basically anyone who depends on others for care). What you said applies IF the adult is living independently and fully capable to make their own decisions. +6  


submitted by bubbles(66),
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cihCnor arlne neucinfi:yfcis

)1 ropo ohhspptea crlecaean -;g&t- ihhg rseum cangiirno ooppshursho

2) ihgh msuer haptoshep ;&g--t xoescmepl wtih tneaildv ciotna aC t&-g-; aC aflls

)3 aC llasf -g&;-t srirgtge HTP ixas

)4 eydnki firuela --g&;t eradcedse cvyiitat fo rysyodel1-axh ta teh dnykie &;t-g- less lcoclitira

makinallkindzofgainz  this guy renals +6  
paperbackwriter  Someone please help me with this (always trips me up): PTH causes increased vit D production in kidney... are we assuming the increased PTH can't catch up with the kidney failure? Is it the level prior to PTH compensation that they want? D: +  
miriamp3  @paperbackwriter what it works for me ;;;; is find the first abnormality so CKD low calcitriol (no D vit) ---> is gonna increase PTH ---> the kidney are not working (chronic, they don't tell u recently- you can;t revert a CKD so the kidney never going to catch up) --> increase inorganic phosphorus.--> always start with the problem. I also use this for celiac and types of shocks. start with the problem, and trust yourself. +2  
paperbackwriter  @miriamp3 thank you! I will try out your strategy next time!! :) +1  
snripper  I thought renal insufficiency -> inability to reabsorb phosphate at PCT -> decreased phosphate? +2  


submitted by mcl(578),
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CCD emoddnreecm nteamtret fo csomtshiaos onnisma is ztpln.iqeuara

makinallkindzofgainz  It's also the pretzel in the Sketchy video, which I think most would agree is more reputable than whoever these "CDC" people are +15  
rockodude  ya until step 1 fucks us with some esoteric cdc guideline +  


submitted by emmy2k21(23),
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sJut a omimnecn to pkee ratkc fo sace tocorln /w dsod iator and ctroho /w ialrvete .skir aCsknOln e-TiRhoC:t eyitlnnltoian smlespiedl orf osdd tRRih toaCroo fro itrevlae iskr

makinallkindzofgainz  I like Dr. Ryan's way to remember it better: Just look at the 2nd to last letter in each word. Case ContrOl --> Odds Ratio and CohoRt --> Relative risk :) +3  


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tI idsa ti aws afatl ot mslae in uter,o dan teh qotsunie adesk btaou vlie nrob f.pgrisofn Snice teh samle n’rtae inebg nobr ni eth irtsf capel, I dsia 5%0 slfeeam nad 0% lea.ms

hungrybox  fuck i got baited +30  
jcrll  "live-born offspring" ← baited +21  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  


submitted by uslme123(57),
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yerv ptdsiu oenuiq.st hTe vsiur asw iledanh -- bsta ahng ipesdu nwhe yteh seelp nad oldr.o oS ti spsdaer ot teh nbiar dtylcier rfmo hte acfrtoylo ytsmse aiv rragtrdeeo nratrstpo ghhortu sre.ven

niboonsh  yea, aeresol transmission via bat poop in caves +  
len49  How do you know the virus was inhaled? Doesn't mention it. Moreover, non-bite/scratch transmission is extremely rare. +  
makinallkindzofgainz  You get rabies by being bitten, not by inhaling it +  
drzed  She was probably bitten by a bat; many times the bite is not recognized ('unapparent bites'), and thus the CDC recommends that even if you think you have been bitten by a bat (or that you COULD have been bitten), you should go and get active/passive immunization immediately. +  
mangotango  Sketchy (and Zanki) says you can get rabies via animal bites OR aerosol transmission. In the U.S. it's most commonly through bats. It could also be through skunks (Western U.S.) or foxes/raccoons (Eastern U.S.). I remember this by thinking about how skunks smell so bad! +  


submitted by usmleuser007(370),
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fI uoy lctundo' meeemrrb hchwi reew sea;etilns htne ertvialntae dowul aevh nebe ot erielaz htta nwroigg cnieldhr dene csell ot deivdi. iTsh rieqesru ADN nrlipoiatce adn oarlnttnasi. Of chwhi eht cnleiuc cdai yethim is ntormtp.ia It ereiqsru a yeltmh .rrtsfane

hTis is hwere enhnoeitmi mseco in. henniietoM misnbeco whit PAT ot mfor SAM a( myleth drno)o

whossayin  That’s a legendary explanation. Thanks dude! +  
makinallkindzofgainz  This is exactly how I solved it! I remembered that Methionine is essential for methyl transfers, and you would need that in dividing (growing) cells. But now I'll just remember PVT TIM HaLL too :) +2  


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i lfle ofr ebdigeln ormf esolin at oechs oprsasisi tbu osisiarsp pts ceerepenxi ihgticn. Alos, the oniidustbtri is ont .rhtcsaiearccti

makinallkindzofgainz  Yes it is. These areas are all sun-exposed areas, and he is a farmer. Multiple years of sun-exposure can lead to Actinic Keratosis, a precursor of SCC. +3  
mangotango  @makinallkindzofgainz -- I think cry2mucheveryday means "distribution is not characteristic" of psoriasis +1  


submitted by usmleuser007(370),
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tusj a nc..huh.. rlOeapmzeo si slawya eht ghtir aernsw

nala_ula  Famotidine is an H2 blocker which really only stops acid secretion via the stimulation of H+/K+ ATPase by histamine, but it still has vagus and gastrin stimulation. If you use Omeprazole, you get irreversible inhibition of the pump itself which stops the secretion of acid even if there is histamine, gastrin, vagus stimulation. +6  
temmy  what about the healing of her mucosa. Is that not the action of prostaglandin?. That threw me off cos according to FA, misoprostol increases secretion of the gastric mucosa +5  
cry2mucheveryday  same doubt..marked miso +2  
sahusema  I guess because misoprostol is more associated with treatment of NSAID related ulcers and PPIs are 1st line DOC for GERD? +1  
makinallkindzofgainz  @temmy, I think that Omeprazole is a better answer because although Misoprostol would promote healing of her esophageal mucosa, it wouldn't do anything to relieve the symptoms of GERD (due to acidic contents in the esophagus) +  


submitted by burak(52),
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bitalrO ofrlo :ferartuc

-1 lirnaftIoarb evnre niyj:ru esnmNbus and saeehtsaipr of the eprpu ek,che ruepp pl,i euppr iagvi.ng

2- pemEtarnnt fo het niorferi sturec :cuelsm aIdrimpe aurpdw eagz

-3 notEsmilahosp

4- Cuignsol of airlamxyl issu:n roTdprea isng

minion7  if IR muscle is affected it is impaired downward gaze!!! +  
makinallkindzofgainz  @minion7, If the Inferior Rectus muscle is impaired (e.g. nerve dysfunction), then yes, downward gaze would be affected. However, the question states that there is ENTRAPMENT of muscles. Trapping the inferior rectus muscle essentially locks the eye into a downward gaze, therefore impairing upward gaze, as the inferior rectus muscle is essentially trapped in contraction. +4  


submitted by hayayah(1056),
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etrehtaC mapt:nelec

0e/00yg//a2jctu.tee0p//tp8ksha1osemd8/wose./nagc40nop:im6nltp-

lclaeR htat eth gnul peax xdetnse veboa the ifrts i.br

hungrybox  His expression is so blissful. U can tell they're shootin up some full u-opioid agonist codeine type of shit and not some shitty partial u-opioid agonist buprenorphine type of shit or some shit like loperamide that doesn't even act on the CNS +29  
rerdwins  even better, if you recall that the esophagus is RETROperitoneal ( its in like half the answer choices). hence, to get to it you have to go WAAYYYYY deep ( like rick and morty smuggling shit). after that, the lung option makes the most sense. +11  
hello  Also, pulmonary artery is way too far away to be damaged by internal jugular vein catherization. +  
makinallkindzofgainz  @hungrybox my mans just slipped in 3 high yield facts within a joke +3  
makinallkindzofgainz  @hayayah, I have an issue with that picture unless I'm missing something. In every other source I have, the internal jugular vein lies LATERAL to the common carotid artery. The picture you provided shows the internal jugular veins medial to the common carotid artery. +1  
cmun777  Look at the other side... I think it must be the manipulation of turning the head to the opposite side that better exposes the jugular for catheterization purposes +  


submitted by hayayah(1056),
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eeChrtat eap:nletcm

yt/n./p4a0i1hgn0ok/o0ecs/ge:wp.temp-lste/j082c8oaud/ep/a60tmsn

alleRc taht eht nlug xeap nsteexd vaobe eht tfsir bi.r

hungrybox  His expression is so blissful. U can tell they're shootin up some full u-opioid agonist codeine type of shit and not some shitty partial u-opioid agonist buprenorphine type of shit or some shit like loperamide that doesn't even act on the CNS +29  
rerdwins  even better, if you recall that the esophagus is RETROperitoneal ( its in like half the answer choices). hence, to get to it you have to go WAAYYYYY deep ( like rick and morty smuggling shit). after that, the lung option makes the most sense. +11  
hello  Also, pulmonary artery is way too far away to be damaged by internal jugular vein catherization. +  
makinallkindzofgainz  @hungrybox my mans just slipped in 3 high yield facts within a joke +3  
makinallkindzofgainz  @hayayah, I have an issue with that picture unless I'm missing something. In every other source I have, the internal jugular vein lies LATERAL to the common carotid artery. The picture you provided shows the internal jugular veins medial to the common carotid artery. +1  
cmun777  Look at the other side... I think it must be the manipulation of turning the head to the opposite side that better exposes the jugular for catheterization purposes +  


submitted by hayayah(1056),
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eoranydcS eriiydasartmhrpphyo ulu(syal /dt inochrc rnael lfireau).

Lba ngisndfi cdneiul ↑ PTH e(srepsno to low c,imualc) ↓ ursme ilucacm alrne( ),euliraf ↑ umrse hsphopate eln(ra ,e)rifula nad ↑ likleaan aaespohspth TH(P vigaattnic eotoss.sBl)ta

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +2  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +1  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +1  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1