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Welcome to meningitis’s page.
Contributor score: 500


Comments ...

 +1  (nbme23#16)
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ehT qeounsit si ongcisunf cbuseea a RTEU TOPIEISV test teusrl is inigdfn nttceegid eaccrn by US (eogs ot whos uyo ew gttao kloo ta twah het ttes si ilongok o).fr

nA ANLROAMB etst digttenec CaPr menas tsi TON A VITEO:PSI :ei 35 tou of 05 weer ealFs Pveoiisst

nA LABNORMA tets TUOHWIT rCPa maesn sti OTN A NEGVEAIT: 20 uto fo 100 THIWTUO raCP rwee AELSF GAEIVTEN.

NT = ,80 FP = 5:yicpief1iS c.t T)PFN+T(/N; /)(18058+0 = %Ad. 4n8 siecn it says sbet" t"rsseenrep tehn 48% si oltcsse ot 80%.


 +4  (nbme22#11)
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Ayacutl,l I otecrcr :yflmse I koeold eosrlc nda eht oteinG emolarf has na aeexltrn arcmSeipt cnhrba nda a umnaublnLoiig ancbrh. I huotgth it wsa eth miterlofeaGno nrvee scubaee the etlaign cahnrb sspaes othuhgr hte deep liungnai rgin, rsteen teh liainngu a,lcna soge to critmpsae dorc nad psluispe teh mertrcesa nda tacorls ik.sn

sHree teh :imgae wsGeer/:ntpa//mdiauetmk.g/drwd8iom.apiyoni4pik/heo2lia/gp.4oc/s

tecCorr me fi I ma nrgow esea.lp

gh889  I think you're right, FA2019 pp444 even states that sensory to the scrotum is via the Genitofemoral nerve +4

 -4  (nbme22#30)
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sPsrceo fo anlemiiotin no itsh .eno

  • I tlniedaime obmalCyr thoh,peasp nigreiAn ued to arue ce.cly
  • I ieetidanml ATP scaueeb PTA oanle ntuodw'l hgncea 6PF tnoi gauconiselm
  • GAN I otg clkuy dna I ldeminetai ti deu ot tsi eus in ECM dna lelocnag so I dind't nikht ti swa evelnart nad I ndki of eemremderb it enbgi in erau .yccel
dr.xx  you mean, pure luck? :) +13
impostersyndromel1000  lol pretty sound logic here mate +2
nor16  same here, Glutamine is a NH3 (-amin) donor, so guessing made sense +

 +4  (nbme22#38)
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gtluhohA t’si aoubt P,PV itsh icsgheraenr dhepel em rdndnsaeut saicb ,spyh I phoe hsit lephs enovyeer ni eoms a.yw

e:kayawTa nigurD VP,P vusone rnuret erdcases,e ardicac tutupo arsde,esce adn ethar epusrrses adeceres ni hte ighrt eids fo hte er.hta

Why oeds PVP creseade svuneo tr?nuer

  • tocaaiitrhrnc rersueps escseproms terah, gasunic obodl otn ot urrnet

seCsua fro asdedceer ltef larnutcierv otuupt irdugn itta:nvloine

  • fightSni of nleivaianruttrcr pmetsu to eftL deu ot enrecsdia RV mouvel
  • rsaecedeD nuevso nrruet
  • nesCahg ni rehsta liityab ot tcrtnaoc eud ot ipevtiso repersus
  • klac fo O2 ot etrha

maolrN cpmretosanyo hmsenicsma rfo ntmiangnaii OC adn PB druign V?PP

  • iedscrnae HR ot ecetnsmaop ofr sredcdeae VS
  • aeidnrcse SVR ot naimntia PB

htOer glioPsihocy ssonrpese:

  • eeerascDd breelcar pufnoseir userrpes ’sdbyo( srenspeo to a lfla in CPP is ot ireas imtsyesc lodbo psseurer and aidtel blaerecr lobod sve)ssel
  • acesrdDee nlrea osnpfurei (cedsenIra HA,D S,ARA dan Paitnte ash anler elmborps os cdeasiner eneitancir nda ircu d)aci
  • ioselsbP nlmrtaiuinot s(encerdai cosulge avi giesoonlguncees e.c)t
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +23
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1

 +4  (nbme22#32)
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A aesc cnortol dtusy atnc sessas hte eveearlpnc fo a esesdia tub a scrso olicntsea uydts .acn

  • A cesa contorl tusdy is ttah you rae sitnteg eth iamgrsn ni the 2 by 2 elbat ofererthe ryo'eu cgndidie hwo mnya sesac nda cltoorns you nwta ot avhe ni yruo ytdus nad eht litlaacuonc of nceieidcn / neapeervcl in hits seaoircn lwoud be eadsbi.
meningitis  the prevalence of the exposure and the health outcome are measured at the same time. You are basically trying to figure out how many people in the population have the disease and how many people have the exposure at one point in time. Case Control would determine ODDS ratio Cohort would determine Relative Risk +3

 +4  (nbme22#30)
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I thogh:tu wrloe ople etnh nact eb sraruaenlp onr cothsam hhicw aer ehhr""gi

unemdouD nad odBy fo pecasarn txp(cee lat)i era lrerateotieprno and dnimeil

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 +

 +6  (nbme22#19)
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iwnEg maaocrs lcles look klie llsma leub cihrotmrepacy lecls ueaebsc they ear acleenruoedtmor irnogi NT(P)E nad rae etorefher ieddnieeffutnatr whit ihgh CN: aoitr.

oAls ermebemr 1+221 octnnslroaait (SWE enge on hoeoormsmc 22 and the L1I-F geen on mrhoosocme 1)1

e,hYa I uotthhg teh esam eairw@lpdlir aou(tb hte ninceortcc ysrael)

kevin  just for people who are taking exam this year, ewing is now understood to be mesenchymal stem cell neoplasm (uworld) +1

 +2  (nbme22#11)
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i"ckP oyur igB, oFmaie, erbaZi soen wthi rouy Sinr"hpge

sohCoe ntisopo whit hte lrteet I.

migolIp,ynnSe ypiinsmeSln,ohage Irbgogans lapayhgetoem( ce,t) aeIbzr ,esidbo aFmo secll


 +13  (nbme22#18)
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Tnnrea tsgaes tastr at TNE ayser dol

etSga : I

  • I si ,tlaf sa ni talf te;shc
  • I is eaonl, as ni on auslxe r.shia

gateS II (2:) eatgs II arttss ta 11 /yo I(I look elki 1) 1

  • 2 lblas cu(lrtteasi eatnenrmgel)
  • 2 sarhi iub(cp ihras onw )agnppaire
  • 2 astrbe dsbu frmo

egtSa III )(:3 trstas at 13 y/o

  • If uoy atreto 3, ti oloks eilk alslm teabsrs Bers(at udnoms m;fr)o
  • If yuo seqgulig hte III heyt oolk leki ryoclreaus+c iucpb iarh
  • esardcnIe nsiep ltnhge nad sezi can be seerdepenrt by: II g-;-t& III
    (oruy sienp wsa nith II tub own its erihktc II)I

aeStg VI (4:) tsarst at 14 / oy

  • rFsti nme:igia heT I in VI tpssrerene hte ,gthhi nda eht V in VI soklo ielk eht onms bsuip nteewbe your :glse
    MGINE: NA yuo heva hiar in onms iusbp )V( tbu ouy evah a rdboer enitigdan the hria mrfo ggrnwoi onit htg.shi
  • eTh V is yintpo, sa ni nwo hte bseastr aer yointp d(iears areoal or udonm on umond)

ateSg V (5:) 15 yo/

  • V sah on sreodbr ngntadeii riah frmo nogigrw oitn shthgi ibc(up ihar + thhgi r)ahi
  • 5 rgins(feas ni andsh) gntfaliten eth aaesrol newh bagigbnr hmte oer(aal ftantle at ihst asgte nda no moer don"um on )dmnou"

meningitis  Sorry about the format, it came out wrong but I hope his helps. +1
drdoom  looks good to me! +15
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from? +
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions. +
endochondral1  stage 3 breast mound is for females not males btw +2
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females +
angelaq11  this is just too funny, I LOVE it! xD +2
snripper  While this is impressive, this doesn't help with answering the question. +1
yng  Pseudogynecomastia (False gynecomastia): this has nothing to do with puberty or hormones. Simple d/t the fast some guys have extra fat in chest area, making it look like they have breasts. The boy weight at 60 percentile while height at 50 percentile. +

 -1  (nbme22#20)
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I tkihn the lmals krad aear on teh felt ahde of murfe and eth ernaddek enkc aer teh savaalurc stie.s

:eNkc c..9msm55n/tcmdpatp1mki/o/:h1s./tijga/tec5//epecpidt1gsb

:aedH uoivosb( neosil on the RT urfm,e ubt miirals tdrcseie loesin no teh tfel as esen no hte ciraptce EN)BM r1d5uu/p0/osa1:-.lowtegcaa2n/ppos/rn/.stj/htce/01uptd


 +9  (nbme22#26)
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dyrohdtoearhhczilioo si ODC rof Npriocneehg aiesDteb psdisiinu eacesbu ti olcliyxaaardp sesuca na eacresni ni BP yb nigaiscenr omsidu snbtrooaip dna huts awret opb,arsntio mtoahaP ilxsnaep shit iyc.len

smseesrpDino si eiocrcnrt uabeces npou gnafsti u(dilf rnsoic)tietr AHD si ridacsene aigennm DAH si ingeb dlaeseer neylltrCa utb is ton iowgrnk in het ideyksn ta het 2V tcoeprser fo eth iiaphellte lrean elcsl at olCencgitl tu.cd

nO ahtt note, liAeodmri si sued fro umthLii eidcudn icnephrnego .ID

hello  Where in Pathoma? I couldn't find it. +1
almondbreeze  also sketchy says that thiazide s decrease the amount of lithium cleared--> lithium toxicity +1
paperbackwriter  Agh confused as well because FA2019 (pg 562) says that thiazides are implicated in lithium toxicity D: +
paperbackwriter  OOPS, please ignore last comment. I just realized that this Q stem never mentioned lithium. And on top of that @meningitis mentioned that amiloride is used if lithium induced. Apologies. +

 +12  (nbme22#1)
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I aslo tgthuoh hte emsa sa @lbse,bbu utb onw itgynr to t"s"yuifj thsi iktrcy BNME u:seitqon I khtin hsti ervevsol on het ctfa thta the ttpanie sah a HHGI lbood psureser ngiamen we lshduo fsouc on na sewnra atht xainepls hotb irecdeasn BP nda Hapmyolievo e:.(i riecseadn HDA ihhwc soccsvartstnio and olsa asbrsob er-r,eefawt bhot of chwih ecaesnir PB and seuca a.vpolimey)oh

Mayeb fi ihst tnteiap rewe pdcaostmeeden hiwt OLW BP, eno dlcou ikhnt erom ubato PNA.

I ltsil htink tshi tuneqois is OTO rktyc.i

meningitis  Sorry, hyponatremia* right? +
mantarayray  I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia except only thought this post getting the question wrong :") +4
mantarayray  Oops sorry the formatting is confusing: I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia. +2
pg32  @mantaray pretty sure you are right and that is the only way to get this question correct. Remembering that Na concentration really is a measure of water balance is key. If the pt is hyponatremic, that just means they have too much water in the blood, which is caused by ADH. If the patient was hypoVOLEMIC, that might mean they are losing too much Na. This is illustrated by pts with SIADH. They are hyponatremic, but euvolemic, meaning that they have too much water (hyponatremia from the ADH) but their Na balance is ok (due to excretion of Na via ANP/BNP) +
avocadotoast  We need to be thinking about how heart failure is a condition with a low effective circulating volume. Our patient had an MI and now his heart cant keep up with the volume (low CO), leading to congestion. When congestion occurs, water is pushed into the interstitial spaces and isn't circulating in the arterial system. For that reason, the body ramps up the RAAS and ADH despite an actual increase in body water. This is a non-osmotic release of ADH. At this point plasma sodium levels are determined by relative intake and losses and hyponatremia is common in these patients because of that. Also, ANP and BNP don't hold a candle to the RAAS. +

 -6  (nbme21#23)
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umaqousS nad lalSm llce niorascamc rea eerct)(Sallran nt nda efont udsace by ngkmoiS

lHari asms C sgrnaii mfor onru;schb atoviC;a iesgettCrt;nia Crieelyaamphc (dsreupco PaH ri.tT)PerKn rsepla D dna lnlluctiaerre egrbi.ds

gp 696 9102 AF


 +10  (nbme21#46)
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PSL ofudn ni ouetr eermbamn fo marg ceiat b⊝ra hobt( ioccc nad do.rs) dopseomC fo O tngnaei + cero saychdaceolrpi + ilpid A (het xioct onntm)peoc.

Asvecitta esaohcMprag and iecndsu ThalNFpa selaeer t;&g- npiyosHoten and efe.rv

Pg 133 nooEitdnx.

zevvyt  and just to note answer b) "induction of histamine release" DOES happen , but it's not the "Initial Event" that the question asks for +

 +18  (nbme20#50)
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hneW insndgta ,up teh body yolnrlam ascveitat tmptceiahsy semyts ot diaov thcotsiorta nesph.tonoiy

uBt encsi rehte si nwo na dieviadt tcefef fo eth coetrhpohymmocao erisder,ncga it iwll dael to a syirpnteneoh

.e:i( lbDueo corvncinsiaostto = ehPo cidserraeng + thatypieSmc yetss)m

sympathetikey  Brilliant. +4
medschul  Would pheo have a normal resting BP though? +10
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +7
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1
nala_ula  No problem! Thank you for all your contributions throughout this page! +1
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +
hello_planet  FA 2019 pg. 336 +1
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +




Subcomments ...

submitted by yotsubato(963),
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hoAltuhg nmotnihecaaep loe)nlTy( is nto nesrddeoci an DS,NIA ti too amy roopekv na reisil-kinap nisytit.esiv

meningitis  For that same reason (not an NSAID) it doesn't reduce inflammation so it cant be used for Gout. +5  
meningitis  And I think Indomethacin is associated with anaphylactic reactions in patients with aspirin-sensitive asthma and aspirin allergies. Can anyone confirm? +  
link981  How many other's like me didn't see "allergic to aspirin"? FML +3  
hyperfukus  OMFG me too i just got so mad and questioned my whole life at least its cuz i can't read not bc i don't understand :((((( +1  


submitted by yotsubato(963),
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Ahlhtguo npaanehiteocm n)leTylo( is ont rscioedend an D,NSAI it oto amy kveporo an r-silniikpea svniitsty.ei

meningitis  For that same reason (not an NSAID) it doesn't reduce inflammation so it cant be used for Gout. +5  
meningitis  And I think Indomethacin is associated with anaphylactic reactions in patients with aspirin-sensitive asthma and aspirin allergies. Can anyone confirm? +  
link981  How many other's like me didn't see "allergic to aspirin"? FML +3  
hyperfukus  OMFG me too i just got so mad and questioned my whole life at least its cuz i can't read not bc i don't understand :((((( +1  


submitted by mousie(209),
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A anoigmmaeh is a epyt of neinbg sue)-onrac(onnc oumrt in nfs.tain Tshi bolnmara rtlcseu of slmal bolod sslseev papaser on or denur eth snki, cytlalyip winhti eno to htere kewse trfae rbit.h - nwlorahrohpieswigwc.tdsl. amHganieom is a BVrp/alyacli bahktrrmi

sympathetikey  Probably a Strawberry Hemangioma since she's a baby +9  
meningitis  Can anyone explain what is option A? +1  
redvelvet  bc, it's a benign "capillary" hemangioma, we can see "thin-walled blood vessels with narrow lumens filled with blood and separated by connective tissue". It sounds similar to "arterioles in a fibrous stroma" but it's capillary. +1  
peridot  @meningitis I believe option A ("arterioles in a fibrous stroma") is describing an angiofibroma. The name angiofibroma already tells you that there is some component of fibrotic tissue involved, whereas in this case of strawberry hemangioma, the name tells you that it's more like pure blood vessels (capillaries in this case). +2  


submitted by joonam(25),
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Aucte or ciconhr otlainamnfmi fo Mldap.u bdlragryhel in:sg atrpniorysi asterr on UQR apolpntai ude ot n.api nPai may aredita ot ihrgt or ds(hueeuld ot riroaittin fo chipner Pn􏰁L)v.eerA if ebli dtcu coebsme endivlvo g(e, nngccashsiol eaig)nti.d

meningitis  To make sure, palpable Gallbladder is more in cholangiocarcinoma and Pancreatic Cancer? And if it were non-tender, could palpable gallbladder mean gallstones? +7  
yb_26  @meningitis, it is a Courvoisier sign of pancreatic adenocarcinoma: jaundice + palpable, nontender gallbladder +2  


submitted by docred123(6),
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rAe lal eantt/tcsetreirristvilii nulg iseadsse viiiatencd of a OLW D?OLC

nlkrueger  only if it's an interstitial lung disease i believe. like polio can cause a "restrictive lung disease" but it's due to muscle effort and would expect to see a decrease in diffusing capacity (FA 2018 pg 657.2) +6  
meningitis  Construction worker, Diffuse reticular opacities screamed restrictive and low DLCO for me. Anything that either adds fibrosis to alveoli, or thickens the diameter between alveoli and alveolar capillaries will cause low DLCO. +8  
305charlie94  Actually polio is one of the restrictive lung diseases that have a normal diffusing capacity for carbon monoxide (FA 2019 p.661) +  


submitted by shaydawn88(8),
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sI it -lrnltovairaea taerstaudsn aesubce thsi eanptit ghtmi ahve FH td/ .a bif and elft aialtr gtmre;enet-la&ng nic tsiycahordt tueeprs&s-;rg aeantutrsd eualprl ioefnfsu?

sajaqua1  Basically. +4  
medschul  Why can it not be arterial hypertension? +2  
meningitis  I think Arterial HTN is referring to Pulmonary Artery HTN which would be present in LT HF in the long run with RT HF and edema. Pulm HTN would cause a backflow, and doesn't really answer the question "explain the patients Dyspnea". At least, that's how I saw it. Hope this helped. +5  
sugaplum  the question has 2 murmurs, so does she have aortic stenosis too? i guess it is not relevant since it asked for what is causing her SOB +2  
nukie404  I guess pulmonary HTN would happen in response to increased pressure after the edema happens, and would cause backflow (to the RV) over pulmonary edema. +  
vulcania  There's a really great diagram in UWorld (QID 234) that explains what happens as a result of mitral stenosis. Very similar sounding to the patient in this question. +  
srdgreen123  @sugaplum, yes rheumatic heart disease can cause mitral and aortic stenosis. Rheumatic aortic stenosis can be distinguished from degenerative aortic stenosis by 1)coexisting mitral stenosis and 2)fusion of the commisures. +1  


submitted by sympathetikey(1248),
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reP AF g.p( 6):63 nnncgreoiC tesrab c..na.cre

"Acplaimintfoiereoesnrp/ivsox fo stgegrtreeopnrensoeo/ orrceptes ro r2Beb-c 2HE,R( nE aFG trecpeo)r si omon;cm ER ⊝, RP ,⊝ eaERH2nudn / ⊝ ofmr meor egsgv.ir"sae

sympathetikey  FA 2019 +4  
meningitis  Why others not it: Anticipation: Trinucleotide repeats; CAG (Huntington), CTG (Myotonic dyst), GAA (ataxia telangiectasia), CGG(Fragile X) Chromosomal rearrangement: Many but can think of Trisomy 21, BCR-Abl, etc Imprinting: Prader willi, angelman Loss of heterozygosity: loss of a single parent's contribution to part of its genome. A common occurrence in cancer, it often indicates the presence of tumor suppressor gene in the lost region. +1  
kai  trinucleotide repeats are not associated with breast cancer Neither are chromosomal rearrangements BRCA1,2 tumor supressor genes are associated with breast cancer, which is why I chose E, but I guess I should have bought the new First Aid.......... +  
charcot_bouchard  GAA is Freidrich Ataxia +4  
tulsigabbard  So is the amplification of the receptors unrelated to BRCA 1, 2? I'm still stuck on this as Sketchy states that breast cancer falls under the "two-hit" model. +  
tallerthanmymom  @tulsigabbard I think one of the keys here is the question stem; " what is the most likely cause of the OVERexpression in this pts tumor cells?" --> I think that the "2-Hit" model would lead to UNDERexpression of a tumor suppression gene rather than overexpression. Whereas amplification would cause OVERexpression of the HER2/estrogen and progesterone receptors. But, I don't think that amplification would be the answer if they were asking about a triple negative cancer. +1  
tallerthanmymom  Also this is on page 632 of FA 2018 for those using that version +  
tulsigabbard  @tallerthanmymom - thank you! +  
drzed  I can understand why @tulsigabbard dropped out of the race--she's taking step 1 soon LOL +1  


submitted by sajaqua1(518),
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The ormawr swhos csrrupsroe to erysryto,thce sa elwl sa caoeye.tsyagkmr sTih is ot hows yuo atth eth siuse ns'it o,ipuodednurncrt chihw msaen that we rae gosiln RBC nad eastllpte seewrehom ei tetds.uicnor tahT esurl tuo D dna E. reThe si tnhiogn to aitcndei ath hte hdilc hsa dtaismdisnee tebirolsucus ).B( At tshi ntiop we rea left hiwt A ro .C A oldwu ceanidit ssdeiDenmait rlnurctsavaaI nCtgoiaolau ()CID or oeimhstng ,arilsmi chwih oudwl slruet in wlo pseelatlt nda BRC utb ew wldou loas see lmanoabr CBR lkei tssyecocthis ethl""(em )l.slce We era ixcetlilyp todl htta teh hyecyrrtoets rae ohcrmnorcmio dan yoic.mnrotc ,Herovwe mimenu neutsctordi fo plseaettl nsleiaxp ti l-la teh trecndtosiu fo speletlta edlsa to soem ioergarhgmhn nad so a dpro in BR,C nda ITP lsilcacsaly sisare faetr a etcren prpeu rprsyriaeot ratct avlri iteifocn.n

meningitis  Just in case anyone is wondering like I did, the low platelet count explains thethose multinucleated cells. They are Megakaryocytes in Bone Marrow Biopsy. +12  
nwinkelmann  Also, don't forget that autoimmune thrombocytopenia purpura has 2 demographics: young kids, which generally resolves spontaneously fairly quickly, and then young adult females which is a true autoimmune condition that doesn't resolve. Patient's age + thrombocytopenia + essentially normal rest of heme pannel = autoimmune thrombocytopenia purprua in child. +6  
abhishek021196  That is exactly how I approached this question. Normal heme panel and a decreased Platelet count in a young boy after an infection just made me intuitively select ITP. +  


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athW rea we dupseops ot be igoknol ?at I ese dluutcieantmle agnti .esllc I osla ese eilanttirf ’tn(ac eltl fi this is mroalnneuoc ro to.n)

methylased  Young child following URI with TCP is pretty classic ITP. Sometimes they throw in extra stuff on purpose, but I didn’t see much on the bone marrow aspirate either. +7  
mousie  I was also thinking ITP but the bone marrow image kind of threw me off too, not sure what I'm supposed to see but still think ITP is best choice ... +  
meningitis  It also almost threw me off, but then I remembered he had low platelet count and I guessed those multinucleated cells were Megakaryocytes (I looked for Megakaryocyte Bone Marrow Biopsy in google and they are the same). +1  
what  Bone marrow shows increased megakaryocytes -> ITP +  


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rgdsAnnoe uecsa ecn.a reoeteTsntso is a tbreet rwnsea thna dsaolnoetArnid /bc het oTtnesoserte is esdsoiatac iwht burep,yt dstonniAldaroe is erom tesaocasid iwht teh lnraeda glsa.nd

meningitis  I chose Testosterone but I almost chose GnRH because it is surged when starting puberty and therefore increases everything downstream. +10  
temmy  When answering the question, i thought to myself that if GnRH is correct, LH will be too cos GnRH stimulates the Leydig cells via LH to release testosterone. That left testosterone as the best answer because it had the most direct effect. +10  
goaiable  GnRH and LH are increased in a pulsatile fashion at the onset of puberty, so idk if that constitutes as the "rapid increase" that this question is asking for. Tripped me up also. +  
tallerthanmymom  I originally eliminated testosterone and chose androstanediol because women can have Acne Vulgaris too, and Testosterone should not be rising to the same degree. Do I not understand how puberty works? +1  
drzed  Women can still make testosterone though; and androstAnediOL is not the same as androstEnediONE +3  


submitted by sympathetikey(1248),
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I see tawh etry'he ngsaiy s(iht was ym eosndc ochci)e tub at eth sema tmei I elef keil a cbpkua of dlboo lwudo ivaatect het croebrasrotpe adn saceu rddseaece meahyttcspi yttivaic to eht AS ma&p; VA n.deo

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


submitted by sympathetikey(1248),
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I ese hawt trehey' yginsa sih(t wsa my necods cieh)co tub at the ames etmi I eelf klei a uakbpc of odlob oldwu vttaiace eht seateoprrcorb adn uscae resaecedd casimpteyht iytcvita ot het AS amp;& AV neod.

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


submitted by sajaqua1(518),
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urSem neksssic si a yeTp 3 rieevsphysiyttin reit,coan in hwihc het bydo pssnoder to tniaeignc ailcedm tsbnsusace nda pdrseuoc .tiodseabni Tshee aseobdtnii ni cioiraltunc ehnt bndi ot eht enincitga rsdgu adn ets fof the clmpeeotnm dasae.cc diRhmateuo ittisrarh si also a Tpye 3 yvysrhpstiiienet eitr.naco

)A ootpiApss fo apcaosmgreh- ptsosaipo is elaeglnyr ont a tepy fo itsyinsteihepyvr cea.ronti B) tsaM lce auot-nneaigdlr shit is trpa fo a epyT 1 rpveethytisiinsy o/,aypanlcteainraxhsi ni ihwch mast elscl bndi EgI on erhti crsf,uae adn IEg ndbigin to hte raetgt itennag inucsed a icraltooannofm chngae in the EIg htat ests fof smat cell g.ilauonaertnd C) alrtaNu elliKr Cell iklgnil- plasy a vyairte fo sro,el innidculg cnarec iusensprpso and ttdcroineus fo iavllry tnedcfei cells. If htye ypal a roel in esriip,tytyvehins it is trap fo epTy 2 SRH ni icwhh hyet luodw pnrdose ot Ig on eht elcl ufcar.es E) hWlee nad farel -ecarosint Tihs is sloa a pyTe 1 HR.S

meningitis  I didn't pick this one because I thought Serum sickness was too systemic and RA was a more localized Type 3. Again, im overthinking things. +  
youssefa  Goljan: RA is a mixed type III and type IV immune reaction +6  
dinagohe23  I though NK cell killing was similar to T cell so and RA is also Type IV +4  
nephcard  ,blll sdouof +3  
usmile1  NK cell killing would be a type of innate immunity, not similar to memory T cells. because they did not give an example of a type 4 HSY, the answer must be serum sickness. +  


submitted by dr.xx(142),
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.hgrti eh aybluelots mstu irname in hte iinwagt eraa os taht eh is ta ahnd ot kattac shi ewif hnevwree hre mxea dns.e go !NMBE

meningitis  I guess it was all about not offering battering information in order to not make matters worse since he will figure out that the wife told on him.. Also, its a HUGE STRETCH but the only reason I thought he should stay in the waiting room was just in case the wife died they could detain him and call the police for questioning. +10  
temmy  Also, he should stay there because his wife did not grant him the permission to see him. Patients requests trumps. +  
nephcard  Doctor should not believe what wife told her. There may be some other reason for injury so batttering information should not be provided. But her wish of not letting her husband in should be fulfilled +1  
charcot_bouchard  No. In real life patient lies. In Board ques they always tell the truth. Unless they make it very obvious. in fact its a board ques rule. So u believe her untill proven otherwise. +3  
drdoom  The prevailing rule of American medicine and law is individual autonomy. No other person is granted “default access” or privilege to another person’s body—that includes the physician! The physician must receive consent from a (conscious) “person” before they become “a patient”. In the same way, the person (the patient) must give consent before anyone else is permitted to be involved in her care, spouses included! +  


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ilMaara cna pmairi atheicp eesounngcsiegol nda nac asol cuoesnm segcoul orf ist onw ebatocmil dan.esmd

yotsubato  Truly a bull shit question... Its not in FA, Sketchy or Pathoma +54  
meningitis  I will try to remember this by associating it with P. vivax, that stay in the liver (liver=gluconeogenesis). Thank you @thomasalterman. +8  
focus  ADDITIONAL INFO: If we were asked to identify the stage of the lifecycle, it would be (intra-erythrocytic) schizont stage: https://labmedicineblog.files.wordpress.com/2018/06/mal3.jpg?w=840 Life-cycle: https://www.cddep.org/wp-content/uploads/2017/06/malaria-life-cycle_4-1440x1080.jpg +1  
dul071  i solved this question by seeing that there are hemolytic inclusions resembling parasites and that they require glucose being a living organism, hence hypoglycemia. +  
curlycheesefriesguy  I knew that malaria causes hypoglycemia but i saw the word drowsy and like an idiot thought it was african sleeping sickness +  


submitted by sympathetikey(1248),
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tmDeoahsenexo sspseuespr HACT = rtauPtiiy naodmstnxo oDmAeaheee flasi ot ruspspes THCA = ciptEoc CTAH (xe - mSall Cell nugL aneC)rc

sympathetikey  *ACTH +  
meningitis  If im not mistaken, Dexamethosone also fails to suppress ACTH = Adrenal Gland Adenoma +1  
therealloureed  I think an adrenal gland tumor would have low/undetectable ACTH? aka no dex suppression +13  
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +12  


submitted by meningitis(500),
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Taenrn aegsts srtta ta TNE reasy old

etgaS I:

  • I si f,alt as in flat ;hcest
  • I is alneo, as in on salxue aish.r

atSeg II :)2( taesg II atssrt ta 11 /yo I(I kool klei ) 11

  • 2 lsbal tisaluec(rt agnmeelent)r
  • 2 rshia (iucpb hrasi won g)npaaprie
  • 2 absetr sdub mfor

ategS III 3):( ttrass ta 13 oy/

  • If ouy eaotrt 3, ti lkoso leki llsam rbesast (Betasr nsdoum mof;r)
  • fI oyu sgqileug hte III heyt oklo like ruclsey+roca icubp rahi
  • darnseeIc ienps etlngh nad eizs nca eb epsernredte yb: II t&-g;- III
    yu(ro isnpe aws tihn II tub won tis crihetk )III

atgeS IV )(:4 artsst at 14 / oy

  • trFsi im:inaeg hTe I ni IV sepeetrsnr het ,hthgi nda eht V ni VI lkoso ekli teh smno pbsui weentbe rouy :legs
    IGAEM :NN uyo hvae hira in msno pbsiu V)( utb oyu ehav a boredr itadninge eht irha orfm gornwgi otin shhtg.i
  • hTe V is opntiy, as ni own het sartseb rae potiyn ie(sard eaalro or unomd on md)uno

gteSa V :5() 15 oy/

  • V hsa on drosreb agnntidie rhai mfro nigowrg oint tihhsg uc(ibp rhai + ihtgh arh)i
  • 5 sgsnia(efr ni hdnas) nlatngfiet teh lseoaar ehnw gbnaibgr htem (alaero tfnltea at tshi gseat dan no reom udon"m on duo)mn"

meningitis  Sorry about the format, it came out wrong but I hope his helps. +1  
drdoom  looks good to me! +15  
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from? +  
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions. +  
endochondral1  stage 3 breast mound is for females not males btw +2  
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females +  
angelaq11  this is just too funny, I LOVE it! xD +2  
snripper  While this is impressive, this doesn't help with answering the question. +1  
yng  Pseudogynecomastia (False gynecomastia): this has nothing to do with puberty or hormones. Simple d/t the fast some guys have extra fat in chest area, making it look like they have breasts. The boy weight at 60 percentile while height at 50 percentile. +  


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HTP is nciedaesr acsbeue semru ulccmai is o.lw eecBasu THP is ereacisnd, rpopsohohus is .edrdecsea heT nowma ni leubna to orbsab tnimvai D (a fta ulsoleb tva,)imni os lotariccil si eseardecd no( vmatiin D rfo the nkdiey ot aictatev tion ir)ltcacol.i

gabeb71  What does this have to do with the Celiac Sprue? +1  
medpsychosis  I believe they were explaining the reason for the mentioned "mild osteopenia" in the pt presentation. +  
meningitis  No, I think this person got confused with another question about celiac sprue, PTH, Calcitriol, and Vit D (it was an arrow type question). +  
diabetes  explanation for decreased bone density . +  


submitted by docred123(6),
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Why is the seanrw ot hsit nsitoqeu otn iseAevdih s.iip..altusC

hayayah  Adhesive capsulitis causes severe restriction of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation). +22  
catch-22  Adhesive capsulitis is aka "frozen shouder" so you can expect exactly that. The entire shoulder will be hard to move in all directions. +3  
meningitis  Since it says there is NO impingement sign, it cant be rotator cuff tendinitis correct? What other signs eliminate this option? +  


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hSe jtsu toepldmec het urceso of taiu,mibxr wchih ttregsa D02C pre.stcore -elclB ndifycecei nac pssriepdeo to taieabrlc neicoinstf.

)b MB frliaue si ton tdcisseaao wthi ut)rbaci mxi rg)w dno egr nwo) ihst rcscou win/ -107 ayds fo srtaitng ntemtetar, dan wdulo not ocruc freta mcoinptgle a mn-4oht roecsu of x.mtbuiiar

meningitis  Forgot the time frame for Serum sickness and got it wrong.. thanks @thomasalterman +20  
stinkysulfaeggs  Same. Crap. +2  
medstudent22  Taking it one step further - B-cell depletion = decreased Ab secretion = decreased opsonization. Opsonization with subsequent phagocytosis by spleen = #1 mechanism by which encapsulated bacteria (ie Strep Pneumo) are degraded. +1  


submitted by beeip(123),
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heT ebst I nac naedntr,sdu y'hrtee iebgcirdns mratdeinloe elaspihpyra, a surtle fo cexess rnsoeteg, a rediots nmhoroe ttah snacsartoetl to hte uelscnu dna ndbis sit scttporinrian .arftco

mousie  My exact thinking also! +7  
sympathetikey  Ditto. +  
meningitis  My thought as well but the answer says: "Binding of ligand to Nuclear transcription factor" and I thought to myself: "Estrogen Receptors aren't transcription factors.. they are receptors with Transcription Factor function that bind to the ER Element and recruit more Transcription Factors". Can anyone explain what I am missing? Am overthinking things? +  
criovoly  You are overthinking it, Steroid hormones receptor is found intracellular in the cytoplasm then they are translocated to the nucleus where they regulate gene transcription. HOPE THIS HELPS +4  
eve1000  Could this be due to the PTEN gene being linked to endometrial hyperplasia? +  
feochromocytoma  The question stem says it's glandular hyperplasia "without" atypia It's just due to increased levels of estrogen causing the hyperplasia +4  
faus305  This is a bunch of scientific mumbo jumbo +  


submitted by mcl(578),
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Sceni 'oeryu lnigos lla oyru ibbacr into uory eep, yuo dwulo ecxpte eht Hp ot eb meor aknea.lli os,lA seinc three is earedsedc HNa++/ ioptnr,at ether si sles mudiso beebrasord dan oefhetrre drneeaics lsos fo erfe idulf to hte n.irue

joker4eva76  Why wouldn't this be similar to a Type 2 RTA where urinary pH <5.5? +1  
mcl  I can't remember exactly what the question was asking off the top of my head, I think it was asking about relative to normal? But I think you're right in that the alpha intercalated cells (AIC) can still dump H+ into the urine and acidify it to an extent. And, like in RTA2, I don't know that the action of the AIC would be able to overcome the bicarb and acidify the urine enough for it to be the usual pH, so the urine should still be more alkaline compared to baseline. Kinda sucks, pH less than 5.5 should technically be acidic but it's alkaline for pee. +  
mcl  JK, normal urine pH is around 4-8, but I guess they consider closer to 5.5 on the more alkaline side...? I guess I would go more off that the alpha intercalated cells can't completely compensate for the amount of bicarb in the pee due to the CA inhibitor, not so much the actual pH. +  
meningitis  Anhydrase inhibitors also affect the anhydrase inhibitors that are used in the AIC in order to excrete the H+. Here is a link: http://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/distal_0.png +4  
mcl  ohhhhhhhhhhhhhhhhhhhhhhh my god duh yes thank you <3 +1  
meningitis  Lol yw!! +  


submitted by meningitis(500),
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nhWe tnsading up, the oybd olylnamr aaectvsti ipchamsetty msstey ot advio hrstaooictt netsypnooh.i

utB enisc rhete is onw an iiadtvde eteffc of the aoyhcocmmtohrope ncaeegsirdr, it illw lead ot a sonhteryipne

:ie(. boueDl vcstoioronitcnas = hPeo engrsedirac + patcyeShtim ssetm)y

sympathetikey  Brilliant. +4  
medschul  Would pheo have a normal resting BP though? +10  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +7  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by meningitis(500),
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I slao ghtuoht het msea as lsbeub,b@ btu nwo ynigrt ot usy"j"itf tihs tcykir BEMN :qnustioe I kihtn itsh lvesevor no hte fcat htta het pentiat hsa a HGHI olbod usererps imgeann ew dhlsuo oufcs on na awsnre hatt xesinapl obth naisceder PB nad moHlaevioyp i:.(e escraendi DHA hwcih csosntiovcrsat nad osal rsbsbao ,aw-rtreeef ohtb fo ihwhc sceraein BP nad uacse hpylv.iaoem)o

byMae if htsi aitpent rwee seamtpceeodnd whit WOL B,P one odlcu knthi erom bauto AN.P

I isllt khint tsih qnieuost is OTO tckri.y

meningitis  Sorry, hyponatremia* right? +  
mantarayray  I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia except only thought this post getting the question wrong :") +4  
mantarayray  Oops sorry the formatting is confusing: I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia. +2  
pg32  @mantaray pretty sure you are right and that is the only way to get this question correct. Remembering that Na concentration really is a measure of water balance is key. If the pt is hyponatremic, that just means they have too much water in the blood, which is caused by ADH. If the patient was hypoVOLEMIC, that might mean they are losing too much Na. This is illustrated by pts with SIADH. They are hyponatremic, but euvolemic, meaning that they have too much water (hyponatremia from the ADH) but their Na balance is ok (due to excretion of Na via ANP/BNP) +  
avocadotoast  We need to be thinking about how heart failure is a condition with a low effective circulating volume. Our patient had an MI and now his heart cant keep up with the volume (low CO), leading to congestion. When congestion occurs, water is pushed into the interstitial spaces and isn't circulating in the arterial system. For that reason, the body ramps up the RAAS and ADH despite an actual increase in body water. This is a non-osmotic release of ADH. At this point plasma sodium levels are determined by relative intake and losses and hyponatremia is common in these patients because of that. Also, ANP and BNP don't hold a candle to the RAAS. +  


submitted by meningitis(500),
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tgulhhAo sit’ toabu P,VP stih ngsihaercer ehedlp me uedtnrnsad siabc yhs,p I hpoe tihs eplhs ervyeeno ni emos .awy

awa:aykeT guniDr ,VPP esnouv errtun r,secseaed acradic upottu seerea,csd adn areht peursrses ereecdsa in the ihgrt side fo teh ra.hte

hWy sdoe VPP eesraedc eovnsu ?ternru

  • aacichinrotrt surrpees oesemsscrp ah,tre usncaig lodbo otn to runert

esCasu rfo sereedacd ltfe uetrlcvarni utotup igdurn nitltenoiav:

  • ghfStnii fo tatrruninecvalir putmse ot Ltef deu ot crsdeenia RV umolve
  • caesrdDee novues ertnru
  • angChes in aertsh abilyit ot raottccn deu to tosvpiei respures
  • alkc of 2O to ahtre

mraoNl ypaostecomrn ahisescnmm orf tniniingaam OC dna BP ndguir PVP?

  • sncirdeae HR ot pcometsnea for acsdeedre VS
  • acseeirdn RSV ot amiantin BP

retOh cPhgyliioos oresenps:s

  • deearDcse rrbecela niueosrfp erpssrue ody’s(b rpoessen ot a lalf ni PPC is ot sraie mescysit odobl espesrru nad aledit elbraecr bdool elssvse)
  • eDsdracee relan oupsfiern esdIcnae(r ,AHD R,AAS dna iPattne ahs relan rebmlsop os asceidrne nieecnirta and ucri cdai)
  • ilssPeob noitturinaml c(rensaeid clgueos avi seolnceungoiges te)c.
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +23  
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1  
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1  


submitted by bubbles(66),
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tusJ to eb yrasctl ercal aesubec( 'Ive gttneo remo yhdrtoi xais qsotsiuen nogrw htan I sod)lu:h

T4 ;tg--& T3 si lbioessp but T3 t-g-;& 4T ni't?s

meningitis  Exactly. I know there are papers saying there is some conversion of T3 to T4 but I try to keep it simple and think of it as once you break it apart (T4->T3), you cant put it back together. Only thyroglobin etc can put another I on it, so any T3 cant become T4 because you need it to be done in thyroid. +8  
angelaq11  I honestly don't know about this, but the way I reasoned this was: she is taking a whole lot of T3, so on top of already having hypothyroidism, she is just making things worse, so TSH is going to be decreased because of feedback inhibition, and hence T4 (Which is the main one produced by the thyroid) is also going to be decreased. I think the high T3 is the exogenous T3. +  


submitted by mattnatomy(41),
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I eileveb ethyer' rerfgrien ot oispscmoner fo serhbnca fo eth Iniiolignlua eNerv ipyols(bs teh eAnrirot alotrcS srveeN.

Seoucr: igtn_s/arrhrwinAoe/pksa/e/nrliviiecsooed_tr:iep.twtk.

armymed88  Ilioingual covers part of the medial thigh, base of penis and anterior scrotum Posterior scrotal nerves are a branch of pudendal and cover said area Doral nerves cover the dorsum of the penis which are also from the pudendal +1  
meningitis  I thought it was the Genitofemoral nerve because the genital branch supplies the cremaster and scrotal skin, but I looked it up and: The genital branch passes through the *deep inguinal ring* and enters the inguinal canal; also, Ilioinguinal wraps around the spermatic cord just like the question stem says. +1  
jean_young2019  "The structures which pass through the canals differ between males and females: in males: the spermatic cord[6] and its coverings + the ilioinguinal nerve." from wiki "Inguinal canal", which means the ilioinguinal nerve lies on the external surface of spermatic cord. https://en.wikipedia.org/wiki/Inguinal_canal The contents of spermatic cord includes, "nerve to cremaster (genital branch of the genitofemoral nerve) and testicular nerves (sympathetic nerves). It is worth noting that the ilio-inguinal nerve is not actually located inside the spermatic cord, but runs along the outside of it, in the inguinal canal." from wiki spermatic cord. https://en.wikipedia.org/wiki/Spermatic_cord +1  


submitted by bubbles(66),
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Hsa dbaynoy fduon a oogd lexoaninpta ofr hsti tsohiyo?gl I nlieynegu aveh on edai thwa I'm ongolki a.t

meningitis  This is common in Klinefelter.. think of the equivalent of Streaked ovaries seen in Turners. White streaks, red/pink material of hyaline, and hyperplasia of Leydig cells. Just remember: It doesn't look like normal structured testicle histology (No organized seminiferous tubules with Sertoli cells around) +10  
niboonsh  https://www.pathologyoutlines.com/topic/testisklinefelter.html these pictures are kinda similar +2  


submitted by aesalmon(81),
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dygiLe lcle ysiapaelrhp, usohdl sola ese fsibsiro and tlinyiznahao fo the sbeulut tbu mi' ton eseign .t..i ツ)/_¯¯(_

meningitis  I think its there.. I thought it was the lighter red/pink material (hyaline material) And I thought the white streaks were the fibrosis like "streaked ovaries"in Turners. +  


submitted by meningitis(500),
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htulhAog i’ts atobu VP,P sthi srceaiehrng hedpel em denrnstdua csiba ys,hp I eoph sith lphes eyeevorn in eoms wy.a

kaaa:yeTw uigrnD PV,P vnoesu utrner a,rdcsseee adrciac ouputt rc,aeesdes and taerh srpssueer adeeresc in eth ghitr sdie fo the eha.tr

yWh edso PVP eardecse senuvo u?rnrte

  • raicncttiraho eprrsuse epoesmcssr ,aerth icaungs odbol ont ot trnrue

euassC for dcrseeade tlfe unrtlcriaev utupto gnirud tnlatvi:oien

  • fhgtiSin of tlureaarivntirnc pustme ot tLfe due to endascire RV mevlou
  • Drcedaees neusvo etnrru
  • gnaehCs in traesh tilabyi to cartntco eud ot piitseov preessur
  • kcal of 2O to rathe

omlarN eprostayonmc smmnceaihs orf agmnintiina OC adn PB durgni ?VPP

  • eseinradc RH ot ceoetsnmap for sdeeerdca VS
  • ceidanser RVS to tamninai BP

rOteh yoPgsolchii srsees:opn

  • eeDerdasc laebcrer ifuospern ruseerps yso’(db pneeross to a alfl ni CPP si ot rseai seiscmyt lbdoo ursreesp and idltae eecarrbl oobdl ssl)vees
  • caeeDerds rneal eufispnor asdcI(nere HA,D ,SRAA nda iPaentt ahs ernla rmeblpso os dcreiesan eniicreant and rcui )idca
  • beolssiP ltunmairtino (nsaedirec eugcosl via esieocueosngngl ec).t
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +23  
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1  
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1  


submitted by welpdedelp(215),
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eIdrcenas ranaatciilrn srpreeus tath rlstsue in Cnhusi'gs irdta fo dcsniaere olbdo eu,sesprr uiragrrel tanrhgb,ei nad d.rrcybaadai shTu, hgih O2C cneusdi ignhucs tidra and if ouy give PP nthe it lwli eeuddcr O,2C nad nhet down earugtle eth ciymhtspeat ictno.svcanosotir iylgailrOn eht airbn hda so hucm CO2 atht ti pzszead tuo nda tirde ot rcsaeien eht BP in oerdr to suhp erom eyegtndoax bdloo to eth rainb.

tpicZ:bet/./mJAaKAC/:gdsqmsoahg.rpkipjw5/.lem-f3tUSgs

lispectedwumbologist  "Bradycardia" 84 bpm lol +  
lispectedwumbologist  The hypertension in obstructive sleep apnea is due to increased sympathetic tone not increased intracranial pressure lmao +1  
meningitis  @lispectedwumbologist : Be mature enough to correct him/her and move on, not laugh at him/her. +13  


submitted by mattnatomy(41),
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eSeerv hnrityponese oeftn adles to pprsciaytlhe lrilessscaoritooer nknn(oii-os an)e.aaerpcp olAs ees tlrpnofaroiei fo tmohso lescmu ell.cs

meningitis  and explains the flame hemorrhages (Goljan) caused by malignant HTN +5  
taediggity  FA 2020 pg. 537 +  
dentist  FA 2020 pg 301* +  
ally123  The flame hemmorhages are also a good buzz word for recognizing he has hypertensive retinopathy 2e chronic, uncontrolled HTN. Pt's with hypertensive retinopathy can also present with "cotton wool spots" and "macular star". Pics on FA 2019, p. 299 +2  
surfacegomd  Pathoma (2018) p. 69 +  


submitted by k_tron_3000(30),
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tsuJ a mdrnao aoctfid (sa rfa sa I ,w)nko in aepitnst hwit rpneatiaistc het smot llikye slevse rof hssobimrto is eth nelcsip vnei ude ot soelc naim“atco et”si ihwt hte en.caaprs isTh loduw lsao sceua tloraspscgen-i vseraic, axnpeiilng the mivotgin of .oodlb

meningitis  Also explains the splenomegaly. If you have thrombosed splenic vein, the blood will pool in the spleen, can also cause expansion of red pulp of spleen. +10  
pg32  I picked splenic vein because of this ^^ association. However, why is the patient vomiting blood if there isn't a backup of blood into the left gastric/esophageal veinous system? +1  
savethewhales  The splenic vein drains the fundus of the stomach. So, splenic vein thrombosis can cause gastric fundal varices, which explains his bloody vomit. +3  
medschooler1  how do you rule out arteries? +  
ac3  @medschooler1 Just my guess, but when answering this I assumed that splenomegaly meant splenic congestion with blood which can only happen if its outflow tract (splenic vein) is blocked. +4  


submitted by aesalmon(81),
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AF gp. 076 - faurlei fo sufion fo eth imxlarlya nad ermdge mailde aansl essrpcose in(tfaomor of apmrryi )ltapea

meningitis  I think Cleft palate could also be due to failure of fusion of lateral and medial nasal prominences.. but since the baby had lip involvement and the lateral nasals can be seen, I went with failure of Maxillary and medial nasal fusion. Someone correct me if im wrong. +4  
redvelvet  a helpful photo +3  
snripper  @meningitis this is cleft lip, not cleft palate +2  


submitted by meningitis(500),
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A scea rotcnol dsytu cnat essssa het enarelpecv fo a saidees ubt a sosrc acnisltoe dytsu ca.n

  • A cesa olotrnc dutsy is tath oyu rea itenstg het msiarng in the 2 by 2 lebta hrteefreo ore'uy gdidncie owh amyn essac adn tsooclnr uyo nwat to vaeh ni oryu tsduy adn eth uclaltiaonc fo eiienndcc / erencpvale ni htis eocrsian woudl be bda.sie
meningitis  the prevalence of the exposure and the health outcome are measured at the same time. You are basically trying to figure out how many people in the population have the disease and how many people have the exposure at one point in time. Case Control would determine ODDS ratio Cohort would determine Relative Risk +3  


submitted by aesalmon(81),
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I elfe mubd rof sgiakn btu nac oeomsen lapeixn itsh? fI shi erspnat era of olecs ot oarlmn MIB dan rea enorcnecd tobua shi gwheit yhw duwol tehy eb wlgolnia his lcairoe opocniumstn ot dceeex his gyerne ur?dtenixpee ( KAA tgnlite het kid tea too uhcm dna tno eeiecsrx uh)enog

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 mattnatomy(41),
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I ibeevle hsit is reriegnrf to dimtug lonmaoattir. eDu to iermprop pintnosioig fo lewob (on eth rhgit )ed.si aLsdd andbs ctnonec eth grlae netnesiti to the elvr.i

nCa edla to:

  1. olVluusv

  2. Dldnouae stoobnuicrt

.3 SAM unolsOcci -- m'I nsggusie adebs no teh nsarwe ot eth ouetiqns

meningitis  Yes, the question clicked for me when I realized the ligament was on the RT side instead of LT so I thought of Volvulus. Image of ligament of treitz: https://media.springernature.com/original/springer-static/image/chp:10.1007/978-3-642-13327-5_17/MediaObjects/978-3-642-13327-5_17_Fig3_HTML.gif +3  
hyperfukus  So Volvulus regardless in baby or adult is gonna cause SMA prob + Duodenal Obstruction: d/t Ladd bands im gonna go back and remember those associations :) +1  
pg32  Yeah, recall that the midgut rotates AROUND THE SMA in development. If you can recognize that the ligament of Treitz is on the wrong side (right) then you know you have a malrotation issue. Then you recall the midgut rotates around the SMA and you pick that answer out of pure association recall and get it right. Nice. +1  


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eikmPcanN-in isseeaD nptrssee with talenm aotandrirte, pldii ladne (mfoa elslc) ni oebn rarmow dna hrcrye red opst no a.uamcl oN olnnmayhipsesegi ressltu in pubildu fo splnimgnyihoe hhciw disbul up ni sgmpa.choare

meningitis  "Pick your **Big** **Foamie** **Zeibra** nose with your Sphinger" Choose options with the letter I. SpIngomyelin, Sphingomyelinase, bIgorgans (hepatomegaly etc), zeIbra bodies, Foam cells +1  


submitted by seagull(1391),
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ruTe aclvo crdso aer fonte gemadda ni inigsgn ro n.ellygi THis osawll VHP to ntere teh yueigdnnrl elnactdeu celsl. HVP 16 dna 81 are nmmoco ussytbep tath yma sceua SCC.

meningitis  Out of all of the virus', HPV has a predilection for stratified squamous epithelium and there is no indication of vesicles(HSV) or linear ulcers (CMV)in the question stem. But with HPV you usually get a big/small (depending on time) unilateral nodule. You are correct to say singing and yelling can cause nodules but these would be bilateral in the and would appear differently. So if a question stem could easily have included that as an option: maybe irritation or something like that. +11  


submitted by meningitis(500),
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Tnaner tgssea ttars ta TNE esyra odl

egtSa I:

  • I si ,atlf sa ni atfl c;seth
  • I si n,eaol as in no eulsxa sihar.

tgeSa II ()2: agtse II tssatr at 11 o/y I(I oklo keil ) 11

  • 2 allbs ear(tiulcts l)aenmegetrn
  • 2 ahisr pu(ibc hasri now prgpn)aaie
  • 2 rtasbe subd rmfo

gateS III 3)(: rsttas ta 13 /o y

  • fI uyo taerto 3, it slook leik slaml tebssar Bs(etra odusmn ;fmr)o
  • fI uyo gelqigsu the III ehyt look eikl rerocyusl+ca uibpc hria
  • Idnseeacr npies hltgen dan zsie can eb neesredpret yb: II gt-&-; III
    uroy( inpes wsa htin II tbu own ist rkitche III)

tegSa VI ):4( stasrt ta 14 y/o

  • Fsrti aimne:ig ehT I ni VI speretresn the ,hight nda eht V in IV osokl liek the smno spuib beetwen royu gl:se
    NINE GMA: yuo hvea aihr in snmo sbipu V)( tbu yuo aevh a boerrd eiintnagd teh hria orfm nwriogg ntio .ghshti
  • hTe V is pioyt,n as ni own het tebsars rae ptoiny s(irdea raelao ro dmuno on donum)

Sgeat V (5): 15 o/y

  • V ahs on obdersr idniagetn riah mfor nrogwgi ntoi hhgsti i(bcpu ihar + hithg rha)i
  • 5 nsrfeg(isa in hads)n gifntlante eht eloaasr hnwe iabbngrg hmte or(laea ntaetfl ta tihs steag nad on roem "ounmd no ")omund

meningitis  Sorry about the format, it came out wrong but I hope his helps. +1  
drdoom  looks good to me! +15  
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from? +  
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions. +  
endochondral1  stage 3 breast mound is for females not males btw +2  
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females +  
angelaq11  this is just too funny, I LOVE it! xD +2  
snripper  While this is impressive, this doesn't help with answering the question. +1  
yng  Pseudogynecomastia (False gynecomastia): this has nothing to do with puberty or hormones. Simple d/t the fast some guys have extra fat in chest area, making it look like they have breasts. The boy weight at 60 percentile while height at 50 percentile. +  


submitted by armymed88(47),
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eapemmsyh slead ot 2CO nagtpirp aenidlg ot cnesaire Oa2Cp in teh bl,doo hihcw viesg oyu a erpaoryrsti acssdoii roerpP erlan ecitmpnosaon wlli ireseanc craibd sbear nda ereasecd nxio-terce gvinig yuo ndrseiaec abbric in teh doblo

meningitis  Increased blood HCO3 could have easily been interpreted as increased blood pH aswell. FOllowing your explanation, since the pt had acidosis, the increased HCO3 will just make it a normal pH. Another way to think of the question is: if there is decreased exhalation due to COPD --> increased CO2 --> increased CO2 transported in blood by entering the RBC's with Carbonic Anhydrase and HCO3 is released into blood stream. So increased CO2 -> increased HCO3 seeing as this type of CO2 transport is 70% of total CO2 content in blood. +21  
drmohandes  I thought you could never fully compensate, so your pH will never normalize. Primary problem = respiratory acidosis → pH low. Compensatory metabolic alkalosis will increase blood HCO3-, but not enough to normalize pH, it will just be 'less' low, but still an acidosis. +3  
mtkilimanjaro  I also think decreased blood PCO2 and increased blood pH are very similar (less CO2 in the blood means less acidic, pH could go up) therefore I ruled both of them out just from that +  
brise  Aka this is the Bohr effect! +  


submitted by hayayah(1056),
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thrGwo oeomrnh garsielen nehomro satc via -cGplodeu srtcreo.pe G coeudlp ecoerprst ende TGP ot eebmoc dticatvae adn aTGsPe ot ecmoeb iia.nttdvcae

No PeTs-aG -t;&g- clyrcnhilao cvtaei gwhtor hoormen leinaegsr oornhme otpecrer -gt&-; ctntnaos ctiavanito of lyaledny lceysac / McPA typhaaw adn sreleea fo twoghr hmorone.

mcl  This figure is useful https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png +  
mcl  [link](https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png) +  
meningitis  How did you knkow it was GHRH and not GH perse? +4  
meningitis  nevermind; I just read down below. Thank you +9  


submitted by hayayah(1056),
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Gwtorh hoeromn learseing nehoorm tcas aiv edGocpul- crer.speot G doulepc spetroecr ende PGT to bcemeo davictaet dna GTsePa to ceebmo divtcta.eani

No GsTae-P ;t--g& hayorclicnl tvecia hgwotr moohner islgareen eoomrnh eecroptr --;g&t tnacotns anvoctaiti of leayldyn caylsec / PMcA pwayaht adn leraees fo hotrwg oe.rhnmo

mcl  This figure is useful https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png +  
mcl  [link](https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png) +  
meningitis  How did you knkow it was GHRH and not GH perse? +4  
meningitis  nevermind; I just read down below. Thank you +9  


submitted by welpdedelp(215),
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oS I think thta sesui fo tsirw osentinex d/noar efgirn drpo woudl eb erom lardia neve.r reevow,H hetre saw remo pomlraix ksan,ewse so ti oudwl be C7.

8"7- yla tehm t,hir"gtas het tp lcuon'td yl"a mhte h"gtstria os ti dlowu eb 7C toro

welpdedelp  *As an addition, median nerve involvement would have leaned more toward C8 than C7. +2  
meningitis  Do you have anymore useful mnemonics for brachial plexus? +  
henoch280  FA pg 494 for mnemonics +  
winelover777  Doesn't look like there are many in FA 2019. S1/S2 - Buckle my shoe. L3/L4 - Shut the door. C5/C6 - Pick up sticks. +  
drzed  S2-S4 keeps the penis off the floor :) (cremaster reflex) +  
peridot  What's crazy @drzed is that in FA 2019 it says L1-L2 ("testicles move") on p.498 so I wonder if that changed +  


submitted by mcl(578),
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Scnei oy'eur golisn lla ouyr bacrbi ntio oruy ee,p uyo ludwo etcepx eht pH ot be emor lakl.neai l,osA cnies erthe is eesceaddr a+N+H/ ria,noptt heert si less udomis dobearersb dna eoheftrre daeserinc lsos of efer ufdli ot eht uer.in

joker4eva76  Why wouldn't this be similar to a Type 2 RTA where urinary pH <5.5? +1  
mcl  I can't remember exactly what the question was asking off the top of my head, I think it was asking about relative to normal? But I think you're right in that the alpha intercalated cells (AIC) can still dump H+ into the urine and acidify it to an extent. And, like in RTA2, I don't know that the action of the AIC would be able to overcome the bicarb and acidify the urine enough for it to be the usual pH, so the urine should still be more alkaline compared to baseline. Kinda sucks, pH less than 5.5 should technically be acidic but it's alkaline for pee. +  
mcl  JK, normal urine pH is around 4-8, but I guess they consider closer to 5.5 on the more alkaline side...? I guess I would go more off that the alpha intercalated cells can't completely compensate for the amount of bicarb in the pee due to the CA inhibitor, not so much the actual pH. +  
meningitis  Anhydrase inhibitors also affect the anhydrase inhibitors that are used in the AIC in order to excrete the H+. Here is a link: http://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/distal_0.png +4  
mcl  ohhhhhhhhhhhhhhhhhhhhhhh my god duh yes thank you <3 +1  
meningitis  Lol yw!! +  


submitted by meningitis(500),
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Wehn nagndits pu, eht odby yroalnlm aecivtast scpmtythiae tssmye to dioav sctoaitthor ynethnsopoi.

tuB csein ehetr is won na tdaivide ceffte fo het ooarhoymmtcpehco e,agiresrndc it lilw dlae to a oniereypnhst

(i:e. bloueD vtsnoiotcsicrnao = oPhe erncsgedria + haStpmitecy m)etssy

sympathetikey  Brilliant. +4  
medschul  Would pheo have a normal resting BP though? +10  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +7  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by moloko270(64),
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lMisoifryb rea soomcdpe of ersllam usrtctures ecldal .yiamlosnemtf Trehe era wot mnai pseyt of ls:tfainme ktchi tselafnmi dna hint aefstim;ln chae sha ffidteenr nimcotiososp nda co.ilntsao kicTh tenslmfai cocur noly ni eth A nabd of a oili.yrfbm hTin imaesnftl tahcat ot a nrtieop ni eht Z csid dlelac nltniicpaa-ah nad ruocc osacrs eht erteni ntgehl of eht I badn dan pwrtaya toni the A b.dan

cn1tnoci-.-om-oy/mc-o-/:4ceriotshporbottdexe9a/htliteuclc//abatnoacts/onppnlg

meningitis  isn't letter C the intercalated disc where the gap junctions are? +11  
chediakhigashi  The actin is bound to structural proteins at the Z-line, this was on u-world #1734 if i understood correctly +  


submitted by johnthurtjr(138),
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eersh' a olgoge

johnthurtjr  FTR I had no idea this was a thing, and was pretty disappointed in myself when the google search had it in big bold letters right in my face. +3  
drdoom  via @johnthurtjr link: "Testosterone and other androgens have an erythropoietic stimulating effect that can cause polycythemia, which manifests as an increase in hemoglobin, hematocrit, or red blood cell count." https://www.medscape.com/viewarticle/773465 +3  
meningitis  I guess that's another reason for steroids and doping up. +7  
drschmoctor  For once I feel like I've been led astray by Pathoma. My instinct was to go with hemoglobin, but I talked myself out of it after remembering Dr. Sattar saying that the reason why women have lower hemoglobin is due to menstruation. +2  
fexx  F U testosterone! and F U NBME 22 question +1  
schep  I only knew this because there are three (at least three, maybe more that I don't know) contraindications to giving testosterone replacement therapy: +OSA +prostate cancer +hematocrit >50% +2  
drdoom  ^ linkify @drdoom https://www.medscape.com/viewarticle/773465 +  


submitted by oznefu(19),
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hwo do yuo rworna wodn thta rsseeneoottt adnerecsi ohemgoilnb toa?rinncocent tsuj a ondrma cfta ot knw?o i put allkeain paoeahpthss sucbeea i geruidf cnesedari ototsneertes liwl eaisnrce noeb wtghro adn drule uot afscpe-ptrtieocis ntnaeig cb sti’ a aw.nmo

hysitron  I guessed this one cause men have a higher hemoglobin than women. +10  
notadoctor  High levels of testosterone will result in amenorrhea. I guessed that since she's not menstruating she will not be losing blood and therefore hemoglobin. Therefore her hemoglobin levels will be higher than expected. +5  
meningitis  It kinda makes sense knowing testosterone causes catabolism so I was in between Alkaline phosphatase and hemoglobin... +1  
enbeemee  isn't testosterone anabolic? +4  
syoung07  ALK phosph is indicative of osteoclast activity. Testosterone keeps male bones strong just like estrogen does for women. Testosterone builds bone (osteoblast activity) therefore we would not see a rise in ALK phos +  


submitted by seagull(1391),
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byame nosemoe can plxanei hyw hsti si savaalcru cersosin and ont p.sesis It ondte's nmotine eefrv ro nscbeae fo frve.e hTe RIM sah a sllam omnaut fo hyodeysnpit btu to teg aauscarvl ireoscns seems do/d

someduck3  Pg 455 of F.A. mentions that alcoholism can be a cause of avascular necrosis. +5  
meningitis  I think the small dark area on the left head of femur and the darkened neck are the avascular sites. Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg +3  
yotsubato  He wouldnt be playing golf if he had septic arthritis. Avascular necrosis is a more chronic condition that has a slow onset. +3  


submitted by asapdoc(60),
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Ptetani hsa ihpgncneero saiDebet siusp.Idin eOn of hte tttenermsa si htiolrrdey.cHihzoad

meningitis  hydrocholorothiazide is DOC for Nephrogenic Diabetes insipidus because it paradoxically causes an increase in BP by increasing sodium absorption and thus water absorption, Pathoma explains this nicely. Also you shouldn't have chosen Desmopressin because upon fasting (fluid restriction) ADH is increased meaning ADH is being released Centrally but is not working in the kidneys at the V2 receptors of the epithelial renal cells at Collecting duct. On that note, Amiloride is used for Lithium induced nephrogenic DI. +1  


submitted by hungrybox(963),
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hwne ffid gsinel ndrsat aprrei hamscensmi aer seud:

  • pairer nelyw hyiesesdnzt :snratd mmsctiha eirarp hL(nyc me)soydrn
  • eirarp imrideinpy irmeds aedscu by adt VU :pxroeeus oneeulitdc ceinsoxi reirpa darmeXr(oe )ngtiemspomu
  • rearpi opecsnnauo/xitost :tlioaetarn aebs neiiocxs pirear
meningitis  Brca: recombinant repair +  
brotherimodu  P.40 FA2019 lists the different DNA repair mechanisms +2  
teepot123  fa '19 pg 382/3 +  


submitted by tissue creep(103),
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rAotordph fro eu,rs tub ofr het ocerrd Im' eyrtpt seru tish saw nignyuCkuah si.ruV Oyln gto shti mofr a UlrWdo eoiqtsun sa I 'adtnh esen it luitn htn,e tub pnrpylaeat eht raalightar is lrylae d,ba iwhch is ahwt rwed me to eth asenrw.

glwdstxichhohycnp./anwig.twu/mct.ne/dvk:u/

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! +1  
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/ +20  
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  


submitted by nosancuck(85),
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maD osn isth ill b got seom BUIMCTADLIE uomMuscll lla pu ni hre isensbz

drdoom  tru. +  
meningitis  Pg 164 FA 2019 +1  
dr.xx  likely not "lil b" as 2-4 times as many cases are found in whites than in persons of other races +6  
drdoom  lil b not a referent of race; cf. lil boo, lil baybay, lil bowow, &c. +  
dr.xx  I disagree. Google "lil b" for images. See what you may discover. +  


submitted by egghead(1),
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hiTs si oen fo tseoh oqisutnes I saw renev ggoni ot g.et sI't ton ni F,A I 'otdn inthk vIe' nsee it in .ssalc

hungrybox  same :( +  
masonkingcobra  My issue was the stem said no skin damage (I would think pulling out your hair damages your scalp) [Turns out it does not](http://onlinelibrary.wiley.com/doi/full/10.1111/j.1529-8019.2008.00165.x) +  
gh889  FA 2019, pg 551 +8  
meningitis  Compulsively pulling out one’s own hair. Causes significant distress and persists despite attempts to stop. Presents with areas of thinning hair or baldness on any area of the body, most commonly the scalp. Incidence highest in childhood but spans all ages. Treatment: psychotherapy is first line; medications (eg, clomipramine) may be considered. +13  
step1soon  FA 2019 pg 551 +1  
teepot123  damn its in FA and Ive never ocne read it XO +  


submitted by yo(77),
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hre'eyt akngilt otbua a eprsnaeolln utnhs dcrporuee

/la9do./t/lnclimino5rte:turitn/hnemsvd--pte-seelshllaacph0/nnsgtstetl4e.yharac

hungrybox  be honest did u know that before looking it up +8  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +22  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +11  


submitted by est88(17),
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eaipertoleotnRr ruut:estrcs DAS KCRUP.E

ylOn eth edsndcneig cnloo is patr fo htsi.

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) +15  
cienfuegos  I find "SAID PUCKER" to be helpful because it includes IVC +4  
lovebug  FA 2019, 354page~ +  


submitted by hungrybox(963),
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ugluarj ovnseu tteodinsni = tlef heatr eifrual

roapymlnu eaedm = rtigh haert lraeuif

urhFmoea-cbr oatiilnd is teh sotm lyekil wsaren.

Orhet wnaes:sr

  • mtAiscyesr saeptl ry,poeyprhht iaadlcyrom iadar:rys eetsh aer hotb sclaisc gisindfn ni eihcptrrpyho yaoamcyoidthrp ()CHM
  • aclenrodida sfoobtiaiesrs:l a erar esrerivtitc aamicpthyyordo sene ni nlhidstacn/rnfei
  • cyhilocmytp lttinfainroi fo het omdiya:mrcu esne ni vlrai teo(anim)uum .dmaryisoict A cseua of atdeidl ypoimahtdyca,ro but tehre aws on mteonin of a pegneicdr ilvar l.sisnle
meningitis  I think you meant: Jugular venous distention = LT HF Pulmonary edema = RT HF +4  
hungrybox  woops yea I meant Jugular venous distention = RIGHT HF, Pulmonary edema = LEFT HF +12  
jackie_chan  What threw me off the picking 4-chamber dilatation was it seemed like that would be a major cardiac/ventricular remodeling and the vignette gave a somewhat acute 2 week onset +  


submitted by mcl(578),
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COPS si atsiocdase thiw aoamblrn dpuoiconrt fo sex sideots,r niciuglnd nfiyntcsodu of rgetneso ncroidoput and ree.goontepsr aClyrhncoli eaeedvlt esellv fo esgoertn can sceua doaemlentir ryhseip.alpa

/mcCa9s9ww/pn9wlht5pvmgoc/hPltb..en./.7i/s1i3i/rcntM:

meningitis  Why isnt it endometriosis? Could someone help me out on this? +  
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. +25  
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 +  


submitted by mcl(578),
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COPS si tsaisoecda hitw nmlaarbo ropucoitnd fo xes roe,stids cdginulni unsynfciodt of roetgesn drncoitopu nda ngosp.rroteee hlaciyClrno aetledev selvel fo gnosreet cna ceaus tlnormedeai i.eparslapyh

9ioi.9ln/wgrlC.s/cwmc5e.w.c3htt/:sb//PimhMnvptp17an/9

meningitis  Why isnt it endometriosis? Could someone help me out on this? +  
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. +25  
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 +  


submitted by nosancuck(85),
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Yo adwg ew all auotb TPV MIT LHLa

inPalyne,lhaen Ve,ialn pTtANDyro,K nhe,nreiTo nsIeelcuio, ,eihonMntei Hiei,tnisd eeLicnu seLiyn

meningitis  I don't understand what the question is asking... can someone please explain it to me? Patient doesnt eat protein, shes chubby. What does methionine have to do with this? +2  
charcot_bouchard  Just basically asking which is essential amino acids. +3  
usmleuser007  Essential amino acids (something i came up with) 1. "Three HAL fans will try meth" a. Threonine = Three b. Histidine; Arginine; Lysine = HAL c. Phenylalanine = fans d. Valine; Isoleucine; Leucine = will e. Tryptophan = try f. Methionine = meth +3  
nala_ula  They're saying there is a lack of good quality protein -> slight nutritional deficiency. She may have acquired weight but it's not because of protein. So they're specifically asking what amino acid she might be missing due to her subpar diet. Since essential amino acids are those that the body cannot make itself, out off those listed, methionine is the essential amino acid. It's on page 81 of FA 2019. +9  
nala_ula  correct me if I'm wrong please :) +  
hello  For anyone confused trying to follow @usmleuser007's comment -- slightly modified Essential amino acids mnemonic "Ah, Three fans will try meth" Ah = arginine, histidine Three = Threonine Fans (phans)= Phenylalanine Vil (Will -- German accent pronouncing English word 'will') = valine, isoleucine, leucine, lysine Try = tryptophan Meth = Methionine +1  
pg32  Why does @hello and @usmleuser007 mnemonic contain arginine? That isn't in the PVT TIM HaLL mnemonic for essential amino acids... +  
paperbackwriter  @pg32 arginine is semi-essential. It is essential in preterm infants who cannot synthesize it https://www.sciencedirect.com/science/article/pii/S0955286304000701?via%3Dihub +  


submitted by neonem(549),
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Tsih is a aecs of ahorpriyp auectan atr.ad hTe yaw I eeemmrbr hsti is htat sit' het ylno lyiehi-ghd poyirarph atth sah nski mfsaiatotinesn edu to .VU I eremermb iths by r"Atfe U u),rinhropopyr( 'its ."VU ytApapnrel st'i loas taaceoidss wthi tpieHsiat C, ihwch locud eb het seraon ywh ete'hsr daeisrenc STA m;p&a L,TA or ti lcuod eb ude to iocxt iuudpbl of reeniittaesdm in eemh tsyh.enssi

meningitis  Why cant it be protoporphyrinogen oxidase? It was because of that reason (Increased AST and ALT) I thought it wasnt uroporphyrinogen decarb. My train of thought was: "wow, mitochondria are messed up.. there must be a lot of intermediates in there,therefore the Uroporph decarb must OK." +  
arlenieeweenie  FA 2019 pg. 417, the later on the defect in the heme synthesis pathway is the one more associated with skin findings! Also according to this year's edition uroporphyrinogen synthase is now known as prophobilinogen deaminase +5  
nobody  AMBOSS has estrogen therapy listed as a susceptibility factor for PCT. I could not find a link between elevated AST/ALT and estrogen therapy that would occur 15 years into treatment. +  


submitted by taway(29),
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oDes baoydny nutrsendad ywh we rae lealwdo to eftrriene ithw eht acciilln iiaksomngeidnc of wto teroh pislsctsiea eiy?tldrc lWtou'dn atht dudym het sertaw evne more yb dagdni rou ioi?npno I 'dotn ese the lrugiyennd ppinlecri ttah xlnasiep eth terainalo ni htis sar.ewn

jcrll  I think it's about adding our opinion and more about seeing what the situation is because a patient contacted you in distress. The others are about contacting management off hearsay; that could also "muddy the waters," I Is this question also addressing quaternary prevention? +1  
meningitis  I agree with jcrll. My same thought process but then I changed it to psychiatric consultation in order to first attend the patient's distress and anxiety since it was hindering her decision making. Besides, the whole ordeal about her treatments and ineffectiveness was emotionally and physically exhausting her. +2  
vi_capsule  Referral is NEVER a answer +10  
tsl19  Going straight to the chair of the ethics committee without having spoken to the other physicians would be inappropriate because it would be jumping a bunch of steps in communication first - like jcrll said, you want to get the picture of what's going on from the other physicians first. Maybe the gynecologic oncologist isn't actually as opposed to palliative measures as the patient perceives him to be and thinks he's doing what the patient wants, etc. It could just be miscommunication, which you could help clear up without getting ethics involved ... better to start there. +10  


submitted by nosancuck(85),
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Yo dsi B tog NO NANITELR MAEELF ONSRAG

Wyh ?at?d?!

We eb okonli ta omnseoe ithw an SYR ormf rede Y e oimrDy!che be a Y ecohrmi imeoH os yhte eb nkami emso tseisT nnteeriDim arocFt chwhi I be sure eksma some iecn lli NTAI NAELUMLIR RCOFAT os yde inta gto htat aemeFl nltenIar rcTat u konw thaw i be nyisa

dnA inecs ziiwmmn is da UTDAELF etyh tlsi be nigtet sedo spuys sipl nda raeebsts

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by hungrybox(963),
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rthooideilhcrdoazHy si a deaihizt iercitud =t;g& zdeiahti tiireuscd era aeoadistsc ihtw kmaypieo.hla

Waht hroet utisdeirc are tdasicasoe whti lmpikho?aeya opLo iietdr.suc

?Wyh

tiiboiIhnn fo +Na rpaeoobsirtn srcuoc ni hbto olop ruiedstic iihbit(n CKCN otpaorecnrtrs) nda ztihidae reuidctsi iibnhit( CalN tapsrrnoo.etr)rc llA of ihst edisnaecr a+N eancesris tAondesoerl vcai.ytti

veenlRat ot sith ,lrpeomb sodotrelneA lsruuatepeg pessnoexri of het /aK++N PAT oaeptrnitr arebso(br Na+ into ,body pxele K+ oitn umn)le. Tsih tselrus in hapkleyoima ni hte ydo.b

ngaH ,on sth'ree omer hgih iedly oinf!

odtolreAens sode eon ertoh tmporniat ihtgn - ainctaviot of a +H nnlaehc hatt spelxe +H iotn eht .lnemu

So, eingv atht htsi taetpin sha hlp,eaokmyai ouy okwn herte is ungialrpueto of leAono.tsedr oD oyu kntih erh Hp odwlu eb i,ghh or lw?o yclxta,E it ulwdo eb hhgi uecesba .nci neeAtsoldro &=;tg cni. H+ lpeeldxe otin teh enmlu &;=gt otamelicb ailaskos.

wNo ouy tdrnaeunds hyw obth pool etriucsdi adn etihizda suiridetc cna aescu shawt' aecldl licmpo"kyeha eacmtiolb s.iklosaa"l

hungrybox  jesus this answer was probably too long i'm sorry +7  
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +12  
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +  
amirmullick3  @hungrybox did you mean "All of this DECREASED Na increases aldosterone activity."? +1  
pg32  Anyone care to explain why she feels she has, "lost [her] pep"? Is that due to the hypokalemia? Or hypercalcemia caused by the thiazides? +  
cmun777  @madojo @pg32 I assumed between her hypokalemia (which can cause weakness/fatigue) and possible contraction alkalosis those were the most likely causes for the "lost her pep" comment. I think if they wanted to indicate hypercalcemia to differentiate if loop diuretics were also in the answer choices they would certainly give more context for hypercalcemia sx +  


submitted by calcium196(11),
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q-Ubdeniumiateidit elpooyrsits si otn svileerryb ftecfead yb si.liunn heT tisnoque sska orf rlrsvieebe asyw htta usinlin ftsacef it, nad iiiniontubuatq luowd lead to gadotdnarei aiv ,spreeatso hhwci is ont rr.veiebsle oNlcruecmpytliaca/s tugsnnhi ekams esens buesaec OXFO si a piiorntcrtnsa frcaot, so ti atnc’ do sti bjo fi it is ni het stmalpcyo!

meningitis  Thank you for your explanation! One question: How about the serine phosphorylation? Is it answered by pure memorization that the FOXO TF is serine phosphorylated, or is it a general fact that all TF's are serine-threonine phosphorylated? +  
tsl19  I'm not sure, but it may be as simple as this: ubiquitin-mediated proteolysis is irreversible, but both N/C shuttling and phosphorylation are generally reversible processes. +  
didelphus  I also guessed that FOXO must be a part of the PI3K pathway, since insulin regulates metabolism through PI3K and the question stem specifically mentions that. Phosphorylation is a major part of that pathway, so even indirectly phosphorylation would regulate FOXO. Frustrating question. +17  
niboonsh  yes, FOXO is affected downstream of the activation of PI3K. This is a really good video that explains the whole cascade https://www.youtube.com/watch?v=ewgLd9N3s-4 +2  
alexb  According to wikipedia (https://en.wikipedia.org/wiki/FOXO1) phosphorylation of FOXO1 is irreversible. This is referring to phosphorylation of serine residues on FOXO by Akt, which occurs in response to insulin. But the NBME answer suggests it's reversible. What's up? +1  
almondbreeze  could wiki be wrong on phosphorylation being irreversible? according to this article, it is a reversible process: regulation of FoxO transcription factors by reversible phosphorylation and acetylation (https://www.sciencedirect.com/science/article/pii/S0167488911000735#s0010) some wiki info, however, is helpful : In its un-phosphorylated state, FOXO1 is localized to the nucleus, where it binds to the insulin response sequence located in the promoter for glucose 6-phosphatase and increases its rate of transcription. FOXO1, through increasing transcription of glucose-6-phosphatase, indirectly increases the rate of hepatic glucose production.[19] However, when FOXO1 is phosphorylated by Akt on Thr-24, Ser-256, and Ser-319, it is excluded from the nucleus, where it is then ubiquitinated and degraded. The phosphorylation of FOXO1 by Akt subsequently decreases the hepatic glucose production through a decrease in transcription of glucose 6-phosphatase. +  
leaf_house  It seems like the phosphorylation from Akt leads to destruction, but maybe the assumption is that that phosphorylation step (excluding every other step of ubiquitin-proteosome pathway) is reversible, where proteolysis is final. @niboonsh video is good but doesn't split this one. +  


submitted by neonem(549),
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verOscttuib huoytpar ssucae a selparotn aieazmot ;-&g-t nweh pord,ngelo ratulbu eaagdm .nuesse shTi aleds to an ecuat ublutar cesisnor, etaichrdzarec yb cnireoct slugp in the auulrtb emysts sa esen ni hte image

meningitis  Does anyone know the relevance of the stem saying: "during this time she also has been crying frequently"? +37  
usmleuser007  Think the postrenal azotemia is d/t her pregnancy. With the increasing in size fetus, the pelvic cavity is being compressed and thus there is pressure on the ureters. This leading to the presentation. As per above --- the crying maybe just d/t her pain and emotional stress caused by worrying about possible complications regarding her fetus. +4  
maxillarythirdmolar  My gut tells me it must be some sort of transient change in placental size with hormonal changes. It's reminiscent of what you might expect for breast changes during the menstrual cycle, imo +  
j44n  or maybe the fetus is literally crushing her ureters into the wall of her pelvis and shes got an infected kidney +1  


submitted by johnthurtjr(138),
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Im' tno a nfa of sgrso hpta eagims and nosieuqst hatt ays ,olko" tawh si thsi ntg"h?i - ahtt aisd msomagneiin aer eht mots ocnomm rbnai tmruo adn htis uceiprt si is a odgo leaempx fo oe.n I hda on deia htaw htsee hgitsn ldkoeo elik nda gto ti nwrg,o to.o ekTa a olko ta hist eon

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +1  
meningitis  I got it wrong because I didn't see any apparent Dura mater nor other meninges (The veins aren't being covered by any "shiny layer"), so I thought the tumor was coming from inside the brain and not compressing it like meningiomas usually do. +3  
meningitis  But it did follow the common aspect where they are found in between divisions of brain and are circular growths like a ball. +7  
nala_ula  Since it was basically implied that the patient died and "here look at what this is" I thought it was a malignant tumor (glioblastoma)... but I guess it's all about placement. +11  
thelupuswolf  GBM would be in the perenchyma. Devine podcast said if they show you a gross picture of the bottom of the brain then it's a hemangioblastoma bc it's most often cerebellar. But this one wasn't cerebellar so I went ahead with meningioma (FA says external to brain parenchyma as well) +2  
vivijujubebe  GBM would have necrosis and bleeding whereas the ball-shaped tumor in the picture looks smooth and very benign...even tho I have no idea how someone can die so suddenly from meningioma +  
seba0039  Minor correction, but I do not think that Meningiomas are the most common brain tumor; they are the most common benign brain tumor of adults (Pathoma), but I'm not sure if they're the most common overall. +  


submitted by johnthurtjr(138),
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I'm ont a fan fo ssgro apht migaes nad nuoseqtis ttha yas o"lko, htaw si isth g"hnit? - taht disa mmnsnoaieig era eth otsm monmoc brian tuorm nda htis cteurpi is si a oogd pexaelm of n.oe I ahd on adei what shtee hsintg kelood leik adn ogt it n,wrog oot. aeTk a oklo ta thsi oen

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +1  
meningitis  I got it wrong because I didn't see any apparent Dura mater nor other meninges (The veins aren't being covered by any "shiny layer"), so I thought the tumor was coming from inside the brain and not compressing it like meningiomas usually do. +3  
meningitis  But it did follow the common aspect where they are found in between divisions of brain and are circular growths like a ball. +7  
nala_ula  Since it was basically implied that the patient died and "here look at what this is" I thought it was a malignant tumor (glioblastoma)... but I guess it's all about placement. +11  
thelupuswolf  GBM would be in the perenchyma. Devine podcast said if they show you a gross picture of the bottom of the brain then it's a hemangioblastoma bc it's most often cerebellar. But this one wasn't cerebellar so I went ahead with meningioma (FA says external to brain parenchyma as well) +2  
vivijujubebe  GBM would have necrosis and bleeding whereas the ball-shaped tumor in the picture looks smooth and very benign...even tho I have no idea how someone can die so suddenly from meningioma +  
seba0039  Minor correction, but I do not think that Meningiomas are the most common brain tumor; they are the most common benign brain tumor of adults (Pathoma), but I'm not sure if they're the most common overall. +  


submitted by hayayah(1056),
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rnoI svdooere is a cesau fo a ghhi aonni pag olmtecbia dcsi.asoi

meningitis  I found this to add a little bit more explanation as to how it causes the acidosis if anyone needs it. 1. Mitochondrial toxicity - decreases aerobic respiration and shunts to lactic acid production 2. Cardio toxicity (Secondary to Mitochondrial toxicity) leads to cardiogenic shock (hypoperfusion), which causes lactic acidosis 3. Hepatotoxicity - Decreases lactate metabolism, causing lactic acidosis 4. When in trivalent form (Fe+3), it can react with 3 molecules of H2O --> FeOH3 + 3H+ This will then deplete Bicarb buffering system resulting in non-gap acidosis. Source: https://forums.studentdoctor.net/threads/iron-poisoning-anion-gap-or-non-anion-gap-acidosis.958285/ +17  
sympathetikey  None of the other choices were even metabolic acidosis. They threw us a bone with this one. +21  
imnotarobotbut  Don't changes in bicarb take a few days? How did his bicarb drop down to 8 in 12 hours? +2  
charcot_bouchard  its met acidsis. not compensation +7  
j44n  they did throw us a bone however I didnt catch it +1  


submitted by hayayah(1056),
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toMs iettcrirnos emnysez idbn spordlmni.ea

oS tbho CG'C5G or '3CGGC dowlu ahev enbe aleecacpbt in thsi .resicnoa

meningitis  Yes, correct. The 5'GGCC option could cause some confusion. +  
guillo12  I really don't understand the question nor the answer. Can someone explain it for dummies like me? +8  
whossayin  yes please.. I'm with guillo12 on this +  
sugaplum  @guillo12 @whossayin questions says you've created a new cut site, 1. look at the region on the sick vs healthy. The C to G is the change 2. Write out the sick "CCGG" from 5'3'- you could write out the whole thing, but the answer only has 4 letters, so being lazy here 3. write under it, its complement, the dna base pair. So "GGCC" 4. remember both strands are going in opposite directions when you write them out on top of each other. 5. So the bottom strand actually reads 5' CCGG 3' so that is the answer I hope that clears it up +47  
shirafune  To add to the palindrome part, many restriction endonucleases actually function as dimers. Each individual subunit usually has a nickase, so to create a double-stranded break in DNA, they must bind a palindrome so that each enzymatic domain creates a single-stranded break (thus a double-stranded break). +1  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +2  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +1  
ssbhatti  I think its due to the palindrome requirement? +  
bbr  Maybe I'm missing a part here, but the substrate that the enzyme will bind to will be the DNA. I went with the line that was from the questions stem, as it is the mtuated DNA will be recognized by the restriction enzyme. I didnt see the need to convert it into base pairing. Let me know what you guys think. +1  
uloveboobs  @bbr I agree. I'm definitely not an expert in these lab tests, but the question asks "substrate specificity." I was thinking that it would recognize the abnormal DNA; nothing to do with RNA. I didn't know about the palindromic preference of restriction enzymes, but I don't think there's any need to figure out base-pairing and whatnot here. (At least for this question it didn't work out that way!) +  
spaceboy98  sugaplum, I'd give you an award if this was Reddit +5