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 +9  (nbme24#39)
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aglliFn no cuerdttshoet dha:n oacpdihs is tosm onmocm eon to eb tu,rafcerd ltneua si omts cmonmo ot be liadcdo.ets anutLe tnscioiaold anc esacu cueat pcraal unlent sonre.ymd

ikThn of eht nimnmoce tga"hStri niLe To ik,Pyn Here mseoC hTe Tmuhb" rof teh ensob fo het lp,ma ginradw a olbotalf ephsa gtnsrait loebw eth mbuth MCP itnoj atnejcad to hte u,daris enht mivgno ot ruoy maelid wsi,tr dna htne kbca to teh

a,iphdSco t,alneu uert,mquirt mifp,sior ,tahema eaitctp,a eitp,doarz .ietrmzpua eTh taenul ooskl ikle 'tis ropitsoyrle lsaddoctei

sympathetikey  Yep. I didn't even look at the X-ray. +11
dr.xx  loonies love lunate +2
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +1
wes79  i legit have no idea whats going on in that xray lol +9
nbme4unme  X-ray confused the hell out of me, I was going to put lunate based on Q stem but ended up putting Pisiform because it looks like that's what's messed up in the photo? Should have ignored the picture haha. +1
nwinkelmann  for @dr.xx, love your mnemonic. I added to it, or at least found an explanation on why it works. "loonies love lunate" and "loonies" are "dislocated" from reality. +3
niboonsh  Some Lovers Try Positions That They Cant Handle +10
vsn001  ngl if scaphoid was an option - would've sprung at that real quick -> thanks for teaching me the importance of knowing to look for dislocation vs fracture :D +
regularstudent  Ahh, the classic "left hand" x-ray but actual fracture of "right hand" NBME tactic +
sars  I think the x-ray is showing the lunate protruding out of the palmar side. Imagine the situation where you are falling and using your hand to stop the fall. Your lunate will dislocate forward as the rest of the carpal bones recoil back, hence why it protrudes through the palmar side. Thats why it causes an acute carpal tunnel syndrome. +
makingstrides  Another mnemonic, Some Lovers Tried Positions, That They Can't Handle +

 +13  (nbme24#30)
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hiTs is teh tmso onmmoc csuae fo ealinssp odlybo hasicrged rmfo the nlipep ni a wmnoa of rdipevoruect eag. tI is a inegbn troum dan ehetr aer no acsciahtretric m/olhrapgdmiocciraigaom gneh.acs

 +16  (nbme24#4)
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I tknhi the nresoa uoy dnee ot jitecn aotdposgrionn ni iths seca is bseeuca yuo dene HSF and HL ot rdeoucp HSF laesmtuist teh lietsro esll,c hiwch lnei hte inmfirseesou euulsbt nda hepl the metgaoosparin erudcpo .ytemssrtapoce eteTosnsrtoe si a croptdu of Lediyg secll hwne t'eyreh ameuisttdl by ,HL so tenjcigni soeorstetnet duwlo spbsya hatt step tub ti ltu'nwod eylalr lpeh htiw toseg.resnemsipa evwHreo, tgnieijcn HGnR oasl sdoetn' s'nodte ayrlel hepl esbeauc uoy dene atth ltuieslap nGRH at ihtgn to mkea HL adn SHF awrhese gi-clnatnog GnHR asglano lyutaalc rcdeeeas HL dna FHS iopntuodrc.

m-ice  Adding on to the answer above. I was stuck between the gonadotropin injections and clomiphene. But, clomiphene acts to increase activity of GnRH which then exerts its effects on the pituitary. The man in this question had his pituitary removed because of an adenoma. So, he needs the FSH and LH directly. +22
mousie  agree! Removal of the pituitary would case a deficit in Gonadotropins (LH, FSH) and therefore nothing to simulate the testes to make sperm... replacing the T with a patch would not stimulate the testes to make sperm and if his axis was intact (although its not) this would further down regulate the production of sperm. I eliminated Clomiphene because if he dosent have T to induce negative influence on the hypothalamus he will have increased GnRH and further increasing it with Clomiphene would not correct the deficit in Gonadotropins. +4
neonem  Oh duh... that makes much more sense. Thanks! P.s. I thought clomiphene was more of a fertility drug for women, since it blocks negative feedback of estrogen on the hypothalamus/pituitary. But in men the system is under feedback due to testosterone, not estrogen. +6

 +14  (nbme24#15)
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the bydo psrdneos ot loodb sslo by omehestoi.aips hiTs osccur yb unuitagprgel snnrfartrie n(a oirn astortnrrpe in hte ,bdo)ol eretoiitoyhnrp rudtponcoi (a omohner eadm llcsexveuiy ni the aenrl aerulprtiub aetiittlrsni ,s)lcle dan emhe entssi.yhs sitrF ptse of meeh nsyssihte aws uyalclat alldued to ni oantehr tinqoeus no stih tste: ansocoetnidn fo gnicely dan islncucy oAC tnoi itlaeodel-.autmnlveina Thsi is rnlgitm-aetii tpes fo meeh tsesyhisn.

wowo  FA2019 p417 +2

 +7  (nbme24#5)
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eTh ettpina hsa wol rs,ioltco cwhhi sasuce ydbo stwgan.i heT tteianp is ntmeeriepdhpyg esnic lwo isrtolco casreines CHTA cietrseno ofrm het p,uayittri utb tihs arhses a mconmo rrepocusr eopitrn hiwt tina-aymteogituemsllcn nomeorh (,)MHS os 'ttsah nteof a igns fo retihe darealn rafluei ro an gets-iceCnTAHr tomur. Ptu ttehr,oge het ghhi HCTA but wol octsrilo nngeahipp roev a iperod fo 6 otnsmh aensm ahtt het aldanre stmu eb ggtneti thi by thegmions -- yonl nootip rhee was mtniuuameo .lesraatindi rdehFhsrouiicaWeeners-t soremnyd soal eucass leradna icfsyinifneuc utb isth eaphspn ylcaut,e ni teh fermmeita of .ssryd-ahuo

sajaqua1  The combination of low blood pressure (from lack of mineralocorticoids) and low glucocorticoids (cortisol) indicate adrenal failure. Hyperpigmented skin is a sign of elevated ACTH, indicating that this is a failure of the adrenal gland and not the pituitary. In the industrialized western world, autoimmune destruction of adrenal glands is the leading cause of primary adrenal failure (disseminated tuberculoid destruction of the adrenal glands is significant outside of industrialized nations). It also fits the time line better than Waterhouse-Friederichsen syndrome, which is sudden in onset and associated with hemorraging. Metastases to the adrenal glands *might* be a possibility, but autoimmune destruction is simply likelier. +22
mamorumyheart  Chronic Addisons disease. Pretty straightforward here. Decreased gland function -> decreased Cortisol, decreased Aldosterone -> hypotension (with hyponatremic volume contraction) Hyperpigmentation from increased ACTH (from POMC) making MSH. (FA) Due to adrenal atrophy or destruction by disease (autoimmune destruction most common in the Western world; TB most common in the developing world). +1
ac3  I picked autoimmune adrenalitis but was tempted to pick Waterhouse syndrome because of the low BP (hemorrhaging). But I believe Waterhouse-Fried. syndrome is more likely associated with Neisseria infection +

 +8  (nbme24#3)
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Juts dah to wokn thta RITNs peflcsaiy(cil teh ucseond)iels saecu ctcail oiadcssi

brethren_md  Also NRTIs are hepatotoxic, cause the increased liver enzymes seen in the patient. +5
sherry  Actually, NNRTIs are more well-known for hepatotoxicity. But I guess NRTIs is the next best option for this one. +10

 +10  (nbme24#43)
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sHaplaismot anc tca klie TB adn aesuc yitraacv lieossn dan cdifaecli lsednuo whit cbtioirf ign.racrs In rag,enle gniuf rea dottcambe by semytpyhclo dna hsomgraa,pce ont hosilponsei ro ne.phlirtuos

baja_blast  Asthma history got me and I put Eosinophils.... but in hindsight I should have noticed that the biopsy is specifically of the nodules. RIP. +2

 +18  (nbme24#26)
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Grneale hteem of oythlpga:o hxyopia mirpias taeviixod pploysntoairohh &t--g; elss PTA ;--gt& less -aKN ppum itayticv os osumid ldusib up in teh ellc, aiugncs lenslgwi. hsiT is het trsif tesp. hTne u'oyd get hte aucilcm ubdlpui in hte cell and uantevle abrnoeica yois,lysclg aunicgs latcci acid tpudcoiorn nda ldweoer ..H.p btu sthi paephsn rlate adn its'n teh rtidce cause fo rucllale lglwn,ise iwhhc si htaw teh onqetsui is e.traf

aneurysmclip  can we have a moment of appreciation for Dr Sattar +23
makinallkindzofgainz  blessed be His name +8

 +4  (nbme24#23)
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haliburton  ^^^ THIS ONE SHOWS DUCT ^^^ +5

 +12  (nbme24#44)
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I htnki teh deia ereh is ttha if yuo eakt onoeems ffo a ,PIP fi 'reetsh no omslnpea ro yna olmrbep thwi irtnags dpiontrocu ethn uoy oushdl ees ti go donw rfmo eeibalsn eud to omer teevgain efekadcb fo ctgsria idityac. fI tn,o ouy ablorybp ahev a mpslaeon 'ttash tsju mnkiga otsn of sang,irt such as ni eht aces of illooElens-gZrlin .ymdersno

gonyyong  I thought it was that if you are taking a PPI, you will see elevated gastrin regardless of it you have a gastrinoma. Thus to confirm diagnosis, you make them stop taking it, then re-measure gastrin → if it's still high, you have confirmed. If it's normal, it's something else +39

 +11  (nbme24#45)
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lenCborleoipetne gneal assm = alVrsibteu nmsohaacwn A(AK otccsaiu .renauo)m deerDvi form nawchnS e,llsc hhcwi aer fo eanrul scert nroi.ig

yotsubato  Ugh. Of course they dont put schwann cells as a choice. So I pick oligodendrocytes like a dumbass +35
subclaviansteele  Same^ +1
madojo  Schwann cells = PNS Oligodendrocytes = CNS +3
suckitnbme  NBME loves their neural crest cells +4
wrongcareer69  How much do they pay these testwriters anyway? I can use a thesaurus too +2
osteopathnproud  @suckitnbme they do love their neural crest cells, I have chosen neural crest cells for every single answer choice I see it in and I believe I gotten 90% of them correct, if something doesn't click or you don't know, I would keep neural crest cells as a very possible answer lol +

 +13  (nbme24#9)
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I knthi istemassta asw hte etsb oinpto eerh saeuceb heter aer tulpielm tnmiglana ma..slnes.op yiraprm censcar tend ot tsrat sa a iglesn smsa ni hte sueist of rn.iigo nI hte ,lnug assmesetat rae moer ommcno atnh yaimrrp neaml.opss

dbg  I seriously could not figure out whether those white opacities were actual lesions or reflections from the actual picture (flash light) ... mind went all the way maybe this is the shiny pleura so they're going after mesothelioma. smh +6
dbg  shiny pleura with tiiiiny granulations if you look closely. but obviously was far off +
et-tu-bromocriptine  "Multiple cannonball lesions" is indicative of a metastatic cancer. I think if they were leaning towards a mesothelioma, they'd show the border/edge of the lung ensheathed by a malignant neoplasm (see image): +4
bullshitusmle  guys something I learned from NBMEs is that if there is a clinical vignette dont even look at the images they give you ,they are all useless and time-consuming +1
goaiable  The way i narrowed it down was that the patient had signs of weight loss since three months whereas her cough developed recently (3 weeks). If the cancer arose in the lung then I think the cough or other pulmonary symptoms should emerge earlier. +1
almondbreeze  FA2019 pg 669 in the lung, metastasis (usually multiple lesions) are more common the primary neoplasms. most often from breast, colon, prostate, and bladder ca. +1

 +15  (nbme24#4)
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sThi si uctae hemylocit sforisnnaut atco,iner a ypte II rnvtiyhtisesypie rhewe edferpo-mr gIM isbteiaodn bind ot iecboipaltmn OAB etnngias no ndroo Cs,RB ihhwc eascsu icnatalavsrru isys.oelhm hR atoibtmy,icpnlii iekl er_cdelnloo ,sida ocmes mroe onit ylap iwht bRtpiimoyt-ahicl of rpnnagyec dna it si eud to GgI dnbio,eaist hhciw emro tefno caesu auaarsxvctlre sheolsmyi neics lniepsc hagpmcoreas ehav htsoe -Rgmmc-aaF retspeorc to ibdn hrvaetew GIg hsa gthcu.a svluarctEraxa ndt'eso acsue ttha os,noitepnyh ,eervf kfnal ianp asetciaods iwht iaeriobgnulhom encsi the ogcasmrphea lhdo no to the addedreg RBsC nda noervct it ot brd,nviliie hhwci anc yesfla eb teexedcr by eth virel.

mousie  Could you help me with understanding why this isn't a Type I HSR? I understand that ABO incompatibility is Type II HSR but I don't know how to tell the difference between a patient who is IgA deficient and having a Type I Reaction to an infusion vs ABO incompatibility .... +8
sympathetikey  @mousie - Basically, think of Type 1 HS like a normal allergic reaction (itchy, wheezing, etc.). Whereas, with ABO incompatibility you get the question's presentation. +7
medpsychosis  When it comes to Acute hemolytic transfusion reactions, they are Type II hypersensitivity and divided into Intravascular (ABO) and Extravascular (host Ab against foreign antigen on donor RBC). The differentiating factor between them is simple. Intravascular (ABO) will present with hemoglobinuria alongside all the other common symptoms (fever,hypotension, tachypnea etc.) Extravascular hemolysis will stand out with Jaundice as one of the presenting symptoms. Hope this helps! +6
cassdawg  Also just to add: Rh incompatibility causes a delayed hemolytic transfusion reaction, this reaction was immediate so it is indicative more of the ABO blood group incompatibility (FA2020 p114 has all the blood transfusion reactions) +1

 -4  (nbme24#38)
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yM estb ssegu si atht thsi eaptint ash a scubpiid cratio vveal and sah a mrumur deu ot dcsireane vumelo elvoodra orfm the pneyn.crga

charcot_bouchard  Can be congenital mild Tricuspid stenosis also. it also exaggerate during preg +
noplanb  Wouldn't Tricuspid stenosis be a systolic murmur? +
noplanb  I mean diastolic* +1
centeno  I think that a murmur of grade 2/6 is a clue for flow murmur. Maybe any pathologic cause of murmur would be exaggerated in pregnancy (due to increased blood volume) +

 +15  (nbme24#19)
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Inleratn nlaa nehirpstc is scmpdooe mreo of mthsoo lceums nda is ernud tepacthrapassit/cypmetimhay rl,tcoon ehwli xatlenre aanl chpitrnse si llasteek mlcsue and llcronodet yb uadpelnd llA fo hte ohtre mslseuc tdlesi aer elatslek elsumc fo the lievpc orofl dna aer ermo ieyllk ot eb vnedovil in lKege ris.seexce

 +13  (nbme24#15)
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Lkac fo D81C A(F-L1 rn)inetig on sagotphcye is het ucsae fo ytkolcuee einhadso fnceieicyd ytep 1 L(DA.)1 neSci yhpcosateg ielk sutlhpeionr dna gepramoahcs c'ant teg uto fo teh bmlsaooe,rdt ehyt are sckut ni hte dl,obo henec teh iuyekclsotso hwit CWB otcun tg&; 1,00.00 nceiS teh ktleocsuye ear ustck ni teh oolb,d ethy 'atnc unotm an eeeivftfc niumem epsonesr asntagi r.aetaibc

sunshinesweetheart  also for completeness, LFA-1 is an integrin that binds ICAM, so LAD1 results from a defect in tight binding +1
avicenna  FA 2019 - PG 117 +

 +17  (nbme24#40)
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ihsT ntiatep it'sn ny,tnoiegaviptlh rteye'h PHnEtlRvi,teaYnig ehenc the COP2 t&;l 40 mm .gH

'tLse kwal ti wkb:rsdaca yhTe are ynrtgnliheepivta to ecsepoatmn orf het mtlbcaioe acssodii cedsua by eeriwddpsa oapi.xhy ytirgtHivennlpea lsolwa you to olbw fof meor .OC2

Wyh rea yhte ?ciopxhy hTe nerpos si choipxy due to nfmaotmialin adn ceuat rrypoetisra sisdrtes mdnosrye rofm het n.amiopuen All the ceokinsty frmo het nairmtyalmof celsl caues denraiesc rnlpumyoa acylrpial aee,kgla chwhi slcobk up eth rlvealoa abeenmmr so taht 2O n'tca teg orgthhu ot hte loob.d

hWy do hety vaeh cemioaltb sicoisda in eht tisrf lcp?ae oN yognxe ->-; on oenrltec tspnraotr hnaci nad on CAT ;gt&-- cltiac s.daiosic

diabetes  no pneumonia it is UTI +3
makinallkindzofgainz  The infection from the UTI spread to her lungs +
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +17
peqmd  urosepsis +
snripper  lmao I read it as upper respiratory tract infections, too. +3
thisshouldbefree  she has an increased A-a gradient. +

 +24  (nbme24#29)
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Pre m:ohaatP reyla erehtniid sceas of e'izsehrmlA tdeameni rea aocidatsse wiht imsuttano in pnieep-nsr2l-/s1enr,eilnii as wlle sa oD'wsn rdenm.osy n'Dsow oudwl be ued to na taexr csooeohmrm ,21 iwhhc arsecir eth enge fro domaily roerprcus entoipr (PP.A) Eaxtr PPA si ecoenvrdt ot Aaeb-t ylidamo and stih sfrmo crrtllxeeaual riitencu qea,slpu a nnoiremtp euefatr fo 're.lemshziA

mnotatIrp ot not escofnu Aoildym A niproet eo(n of het ewsrna iocsh)ec iwth Alidoym peorrcrus tei.oprn nsteoiiDpo fo AA dmoliay si mero ataeoicssd itwh cihncor aaitforynmml t,saset ylmniga,cna and iiaFallm naeaeetiMrndr veFer. a-2etB bnrmuoolilcig si nretoah diamylo socaos:tinia yaidolcsae-isidtass stdoips(e ni stjo)ni

 +5  (nbme24#47)
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iTsh tptnaei acse ssdoun ilek he has nori ceenfdiciy aneima inmaea(, wlo cm,toaireht omc)irtycci mofr a GI delb.e To tge isth qtisnuoe tigr,h oyu hda ot mrbeeerm taht het owt jroam thdinerie IG ncrcea esodsymnr rae PFA ed(u ot tuiomant in ACP e,egn cwihh si a mturo spsoprseur een)g dna yhnLc odyrsenm KAA eeryhradit s-loonnoyispp tlcaoelroc mcoacrain ),(PNCHC acseud yb a tuamonit ni a bunerm DNA smhmtiac airpre e,esng fo twih H2MS is a orme comnmo no.e

heT hmeiamscsn of tirhe iccmnoaar eevtdpoemln rae tiefn;drfe ni ,PAF rsuotm rasie rfmo a loanmr -&-;tg nadmeao gt-&;- aoacicrmn cqseeuen lwhie ni HPC,NC tsourm siear omrf ashtw' wnonk as a ratsoeclitimle inisalbtiyt ,aayhtpw idnagle ot snstpeauono rnmoaifto fo a cicrmaona tno( ercepded yb a gnenib iesnlo leki na .anedoa.m.) uoY ndt'di eden to kwon tihs to teg htis iuoetsnq i,trgh ubt eyldietnfi odgo ot o.wkn

medpsychosis  To make it even simpler, if you narrowed it down to FAP vs HNPCC and looked at the image provided in the question, you'd see it's less likely to be FAP due to absence of numerous polyps which would be expected. So HNPCC would be your best choice! +5
yb_26  I always get Li-Fraumeni and Lynch syndromes confused :/ +1

 +16  (nbme24#34)
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ncSie itsh apintte si a rmnsok-n,eo ti is lsse to eb mlsal lelc nciamcao,r musuosaq ellc c,imrancao ro elrga lecl iaoancmcr fo teh ug.ln Bssdeie llams llec crnaomica neibg frmo onnnuerreedcoi oignr,i het oen mraoj nlgu carnec bdrdcisee yb setns fo tlinwafdeldeeret,if- au"gre"lr lsecl si a ciidconar uotrm. iAolyld,ditan totsrsee are soltaicgholi fuetears fo odicniacr trmsuo (ufn acf:t retosste alos ni rmdosnaeayptosaoeemnubl/sm n(i ),NSC aiatmlntsbrs,ooe goasaunrl lelc tsrumo iv(orana e)arc)cn

mousie  When ever I hear Rosettes I always think NE tumors .... and I agree non smoking kind of RO small cell, squamous cell, or lg cell +5
charcot_bouchard  I thought it was Hamartoma & pick chondrocyte! Can lung even have hamartoma? Pardon me it was the laast ques of whole nbme +8
drmomo  @charcot_bouchard i thought the same. uworld gave a question on coin lesion in the lungs as classically hamartoma +7
anbumd  From pathoma benign coin lesions such as bronchial hamartomas composed of lung tissue and cartilage are especially found in younger patients. So i guess because of the age and histology this would be less likely. +2
jj375  Also once it said membrane bound granules inside the cells, I ruled out hamartoma. It seems to be describing the secretory granules inside a carcinoid tumor. Here is a photo! +

 +8  (nbme24#5)
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rpnlyeatpA inalritehlc eisl rnauod ni ulmcse of lal fo teh dnmaro xtoeic lmsinaa ahtt smot eeolpp uwodtl'n ylralnmo ..tea. hitnsg kiel ,aerb dwli kroap/bsor l(eki ni tchkyeS c,ri)oM igb sca,t x,ofes ogd,s oehr,ss l,esas elaswrus. nI scae ouy dedene anrtohe osrean ot not thnu dan munseco etesh amlia?sn

 +11  (nbme24#11)
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hsti anitpte sah mtmispytcoa aictro iss.tnsoe ihsT acn eb ieediftdin yb the nvterurialc rrpehyopyht (to octmpsnaee ofr ecrsneida nfniuacolt eotlaafdr mfro m-nplotancion toriac )elvva, siysmtdolci rurmmu dan het ocatinlo at eht rnlaom aocrit aer.a

ePr TUDeatpo on ilCalnic tsemnaftiaoisn fo icotAr se:tsSnio

"zDsniesiz nad nypeosc — conepSy ucoscr sa a rpestenign opsmtmy in toapralimxpye 01 rcneept fo atpstine iwht isymptotamc eeersv SA (or eroxapapymilt 3 ntrpece fo all isatpnte twih eesvre )AS 3[.] eTher rae varlsee peopdrso pixtalannoes orf oneieaxrtl ssindizez )pepsny(ecor ro cesnoyp ni sitneatp hwit ,AS hotb of ihwch lfetecr edsredeca elbrecar necdEi-erdsicxue oinavdtolais ni het especern of na nsottucbrio twih fdexi caidacr puuott nac steurl ni soo.npethnyi"

guillo12  What does "fixed cardiac output" signify? +1
usmleuser007  "fixed cardiac output" might mean that with the stenosis (ie. narrowed aortic valve) there is a limited or rather reduced cardiac output. Exercise would not increase cardiac output because the stenosis is caused by a mechanical (physical) rather than a biochemical process. Therefore, At any given moment the heart can not increase its output no matter how forcefully it contracts. +8
fallot4logy  why not option A?arterial compression ? +3
sunshinesweetheart  @fallot4logy LVH does not lead to coronary artery compression. only reallyyyy rarely will pulmonary artery dilation cause coronary artery compression. plus that would cause angina but probably wouldnt decrease cerebral bloodflow to syncope. her murmur + LVH point us toward aortic stenosis which does cause those --> fixed CO +2
drpatinoire  @fallot4logy LVH can cause coronary artery compression, but typically leading to coronary ischemia after exercise (i.e. stable angina in this patient). The question is asking what leads to her syncope. Syncope actually means her brain is lacking blood supply abruptly. +5
rainlad  how do we rule out mitral valve prolapse in this case? +
spow  @rainlad murmurs at the right upper sternal border are aortic in nature. Mitral murmurs are heard at left 5th intercostal at the midaxillary line. +1
jj375  Also, nobody mentioned the "prominent left ventricular impulse". I kinda get thrown off by these. Anyone have thoughts? Google was telling me it is from a hypertrophied ventricle so I'm thinking her aortic stenosis causes the LV hypertrophy and an impulse. Is this the correct line of thinking? +

 +8  (nbme24#36)
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dtseymlAn-aiino nad itesiutas-n lnaetgumasi iabtiesnod are gptomcaohionn rfo lCaice aiesds,e a ttiynrehsiisvpey ot hte gilndia naigten of ewt.ah tI yalnmi esmtnfasi in eht jeumujn adn imel.u nI ,lustad ti snpetser as nhcirco aetteasorhr adn tbi,goanl ielwh in elnchrid it soed hte ames ubt sloa sausce uileraf to rvethi. tocialygollisH, ti is fteeidiidn by pyrtc ehysipalrap and ilsoluv lginanetft. fI ouy agadme uory v,lili you t'acn osbbar fat hughotr eth tecslaal fo teh asllm sinietnte -t&;g- lsnpoaamibotr.

opsAtiSP-eiv geuasnrl ni hgsracopmea in alnaim irapopr = ipWlhep da,essie na nefcotiin wtih moryprehTa ipplwieh, na aretlalurcinl spoevmir-atgi igasomn.r ihsT uodlw llimayris ucsea a iambpvelarsot atest ubt is nto scaatideso with riarcalptu eaitinds,ob adn mghti oasl finsmtea as arrlaisahgt, rca,aicd nda lgoreinouc otmsmys.p

ugly_but_my_hoes_not  Damage is most prominent in the distal duodenum +3
ruready4this  where would you see eosinophilic infiltration of the mucosa of the small intestine? +

 +12  (nbme24#34)
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Satollo is a teyp III ttrinchyrhmaai +(K )nacik-hegoblcnln thta osal ash lceetobrkab- ictyvtia Type( II trathniahm)ryi.c sTih pexniasl teh receeasdd rtrehteaa and odlbo srrspeeu e1tb-(a cgbinklo ti,ivyact) wthi teh TQ rnoogopinlta - lal pyet III DAsA csaeu QT .nlorpgaoonti

abhishek021196  Would like to add that the IA antiarrythmics = Quinidine, Disopyramide, Procainamide also prolong QT interval and can lead to tosades de Pointes and they would most likely present with Cinchonism (headache, tinnitus with quinidine), reversible SLE-like syndrome (procainamide), HF (disopyramide), thrombocytopenia. The decreased HR and BP point towards Sotalol. +4
armageddon_oh  Im glad you can regurgitate sketchy but none of those drugs were options here. It's as simple as which of these can cause torsades. +6
an_improved_me  Lol why the salt ^? I'm sure to some people, this was a useful reminder of the side-effect profile of these drugs (spaced repetition), and was likely helpful for the poster (again, spaced repetition) Its all love! +4

 +9  (nbme24#38)
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iTsh ntpeiat sha na aelstnub mdoo nad a zyrca pi.ehiralnsto eS'sh oals igntpltsi a( nfeesde cnhmaiesm wnireeh eon cats ilek epeopl rae g-olload ro bl)a-dal sa she aktsl touab hte nhicsyaip dan erh w.ksrocreo ihsT tcetaarchicsir si smot ommolycn stdcoaeisa wtih deonerbilr lreaostpyin rroid.dse iTsh noe is in rGopu B il(W",d)" aonlg tiwh aisnocilt,a htornsici,i nad sra.stncciisi

medskool123  i get why its borderline now (I guess I kind of always thought suicide was the biggest part of that) but can someone tell me why its not paranoid? Is it just a matter of the "better" choice? The "youre the only one i can trust" thing lead me to that. +1
drmomo  same here +
aneurysmclip  Paranoid is where they don't trust anyone or are weary of people. because she said she trusts only the physician can be a bit confusing, but she describes her coworkers as jerks, not that "oh they're out to kill me, they're government agents watching me" +
boostcap23  Splitting association with borderline in FA 2020 pg 555 and 565 +1

 +10  (nbme24#39)
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mtSaoitontas is rlomalyn sdteeerc yb D esllc in teh capitercan siestl nda GI a.usocm It lsiaycabl bsckol vyreihnteg -rIGteleda guone"(rasce stsimao"a:o-st)s edceresad isacrtg aicd p&;ma epinsonpge noseec,rit edercasde acnpreiact adn mlasl isninetet ilfdu ornice,tes sadreedce lrlgdaabedl tio,ncrncato sreedecad siinlun a&m;p cgnoalug ees.rale

rDsceaineg tisnagr leeraes olkbcs eht aeiecsrn fo IG ltitmoyi arnie(dsec IG iotiltmy si the hientrne ebomprl of drarehi.)a

ehT urgd ni eth nquioset si aroblbpy rcttedooei.

cassdawg  Just to add because I was trying to dissect exactly the diarrhea cause: AIDS patients can get refractory diarrhea for a variety of reasons, most commonly cryptosporidium enteritis and CMV colitis or just in general from HIV enteropathy. Octreotide has been used as a treatment for such refractory diarrhea due to the mechanisms mentioned above ( +2

 +6  (nbme24#38)
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ishT tpteani ahs rmjoa peveesdirs rridsd:oe olss fo eonriinh/ntaeetsda (ende to ehva hist ro depdresse sdl,)peoemo bslprme,o ghiwet na,scegh ceasedred rey,neg uhgthost fo etd.ah seMet eirticra ebceasu &;gt 2 ekswe faetm.eimr SIRSs ear ilnise;ftr- ipaterexon is ni stih o.yratcge RsSIS osla ephl wiht etighw nagi - tghmi be na daded feeibtn fi hte pnaetti si dw.hetreigun

Teh rcacida tfusf htigm veah tusj neeb a ,dcrsartoti tecxpe ttah uyo payrobbl dwnoutl' wtan to iegv csitcyrcil (.i.e plyretaim)itin cnesi teyh eavh pcrtrhr-hyioma eisd cefset.f tiaePnt oarybblp ahs ogdrnpoel PR avniterl due ot eabt bokl.cesr

adisdiadochokinetic  Another reason not to use TCAs (or alprazolam or haloperidol for that matter) is that the Beers criteria state to avoid the use of all of those drugs in patients over the age of 65. +16
t123  The cardiac stuff is not a distractor - MDD is common after an MI, and a very poor prognostic factor (reinfarction) +8
therealslimshady  Beers criteria also says avoid antidepressants though. +

 +7  (nbme24#27)
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ehTes rae toug salrytcs. I puposse the setb ayw to difetaeirften tish saec mfro suotpoeudg si ttha het csrstaly aer hpars pa;&m dnesdpheaele- dan ton aphddheo-rbosm.i

sympathetikey  Yep. They tried to throw you off with the picture, but the wording in the stem says its a "photomicrograph" -- not exposed to plane polarized light, where you would see the negative birefringence. +18
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +
suckitnbme  @linwanrun1357 I highly doubt you would be looking at your own joint fluid aspirates instead of sending it to the lab. +3
nnp  what those yellow white nodules signify? +
peqmd  In clinic gout is typically a clinical diagnosis. If you can treat w/ NSAIDs instead of aspirate you would do that. You would aspirate if you are considering septic arthritis so you can get culture. I don't think anyone aspirate for heck of it. +
lowyield  @nnp, the yellow white nodules are tophus which is a sign of chronic gout, characterized histologically by aggregates of uric acid crystals, can show up as skin nodules most commonly on external ear, olecranon bursa or achilles tendon (pg 467 FA 2020) +

 +10  (nbme24#19)
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hisT pttaien hsa amornplyu i,fsbirso hchiw acseus a strriteciev to(n -tipb)turyvcstoee siasee.d niceS hrtee swa no cncouoailatp sxup,roee I'm sagsmuin itsh is hicdatpiio uolapynrm sfriboi.s siTh sescau htckdenei voallera nabemms,re ngitilim sga doifsunf.i fehTo,eerr eyelnvalut 2O ntwo' be elba ot usefidf lycquki gnoueh niot hte oodlb racsos eth vtlrlarlerao-ieaa eenmmrba, ugslnteri ni a glraer aA- deni.ecfefr (I ntikh es'ehtr llnmyaro a sallm -aA egtidarn, from 14-2 mm gH, ubt hwen sthi tsge too g,bi yuo teg )cyipxho

yex  UW q id 7648 +2
melanoma  uw id 1526 +1
feeeeeever  FA 2019 Pg. 661 +1

 +6  (nbme24#21)
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sNRIT aer het inma VHI ryapeth ugdr ttha acn uecsa bone roamwr suirpsonpse (otn as mmcoon iwht .RsNN)TI Tsih lscsa lndsueci zivnueidod, o,idasenidn i,tctiiemarbne mvliiue,and ,neudiavst aabri.vca eiduovinZd si tsmo wknon rof tish edsi f.cteef

laverifniN = epesorat ihrhi mtyrcaiotbiznoni = ganyiiloomsdce t(no rllaey dseu fro ienmVnp)I aediHt = anetorh aaiicblmi,otnr yosmlt dsue rof soitcnmspuye I aniLihi?enktmv ud = ernaoht TINR tub sesl kownn ofr eobn amorrw psosnrspieu

adisdiadochokinetic  Azithromycin is a macrolide, not an aminoglycoside FYI, and its use in HIV is primarily as prophylaxis at very low CD4 counts for, among other things, the mycobacterium avium complex. +7
nbmehelp  How would we have known to choose Zidovudine over Lamivudine tho +5
mjmejora  @nbmehelp the sketchy with Princess Izolde (Zidovudine) eating bone marrow was my only tip off +8
niboonsh  you have ero bone marrow if you take idovudine +1
niboonsh  the z's were supposed to be bold idk what happened. you have Zero bone marrow if you take Zidovudine +5
t123  Zidovudine is also a very early NRTI developed. As a good rule of thumb, older drugs have worse side effects +2
therealslimshady  Zidovudine Zaps your bone marrow (sorry) +2

 +12  (nbme24#10)
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gP 149 in FA 0281 Nr(gyeoolu otmnyaa mpa;& pygsloyioh sin:etc)o 3 ceumssl celso het :waj eMseatr,s raeopl,tsMi iaelMd dtigr1 oyep mueslc spneo het jaw: taLrael rotiedp ygLLA ear tidernvean by ilgitanerm ,rveen V3 oie:Mnmnc Ms' ucnmh lso(ec the ,a)jw sL' eowrl oo/nlerxsle(a hte jw)a

sunshinesweetheart  p 495 in FA 2019 +3
mnunez187  p 507 in FA 2020 +

 +19  (nbme24#30)
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lmSla lelc aaimcnrco of the lung amy dpceruo losetcraippaan me,snrsdyo of cwhih TACH and DHA aer het emro onmmoc t.sseypub ATCH sseexc lesad to ssxeec utlamsiinto on eth erdanla xtcore to cuedpor r,tloisoc nlgruties 'insCguhs er.msyndo sexsEc rsolciot laylnmro( a ressst mor)eohn usceas teehnnyoisrp iva ioaenpttiton fo thctypamise usmtatilion no eth s.avaturuecl tI nca asol aesuc lyhiaokpame yb natgic as a loimeooadtrcrncii wenh ni sc,exse stuatganri eth iiatlyb fo 1-xatobtd1dis-yrhoerye esedadoyenhgr nsr(etep in eth nalre tu)suebl ot tncoerv coriltso ot irncost,oe hhwic nesod't cta as a rdri.mianeciocloot

therealslimshady  Adding some ways to eliminate the other answer choices for good measure: B) ADH can be secreted by small cell lung cancer (SCLC), and would cause SIADH, but that does not manifest with hypertension or hypokalemia. C) Epinephrine can cause hypertension (a1 effect), and hypokalemia (via stimulation of the Na/K-ATPase), but is secreted by pheochromocytomas rather than SCLC. D) PTHrP does not cause hypertension or hypokalemia, and is secreted by squamous cell carcinoma of the lung, not SCLC. E) VIP can cause hypokalemia through diarrhea (see VIPomas in First Aid), but not hypertension, nor is secreted by SCLC. +8

 +9  (nbme24#44)
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iylnisscAmooegd are o;ehxiotprcn xitconpreho csdeshmucar/lgi seuca teuac alrtbuu ssrocine A(,TN) riecahtrdczea by medaga ot the TCP. NAT uacess het orafnmito fo ,bowrn m,dyud rrunagla ctass in hte reniu. heT cfat ttah tshi enpatit is a dcqeulagirpi igmth be tugiggness taht ehty ahev a lrowe voulem of tronisdtiibu rof the drgu (dan ohftreere ierhgh obodl )aeinsotntrc.cno

mtkilimanjaro  I would also like to add ATN is nephrotoxic ischemia and the two places in the tubule that are susceptible are the PCT (proximal straight part) and the thick ascending limb. The TAL is not labeled as a choice so that is why it has to be B (and why B is a little further down from the convoluted part) +2
mtkilimanjaro  Actually aminoglycosides might only affect the PCT idk :( +1
peridot  on p. 591 of FA 2019, it talks about ATN. The two types are 1. ischemic - affects PCT and thick ascending limb because those two areas use ATP the most (think of all the ion pumps) and 2. nephrotoxic - PCT only (I think of it as that's the first part, so it's most exposed to toxins). Aminoglycosides fall under scenario 2. +2
cassdawg  If you wanna see nephrotoxic drugs in one place, here's an image with the locations of different nephrotoxic drugs: +2
corndog  Before anyone looks at @cassdawg link, consider taking some Loperamide. +4

 +4  (nbme21#46)
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dnuSso klei a cesa fo Fi-iurnemLa nyoesdmr - ncies p53 si a uotrm esoprusrsp for a chbnu of lelc ,psyte tsouanimt ni hits egen (sa in L)FS reluts in a mdyrai of failailm mrout yept.s

pparalpha  Li-Fraunemi syndrome = SBLA (sarcoma, breast, leukemia, adrenal gland syndrome) and occurs because of an autosomal dominant inherited mutation of p53 APC: linked to FAP (colorectal cancer) RET: linked to papillary thyroid cancer, MEN 2A, MEN 2B RB1: retinoblastoma +10
privatejoker  The thing that threw me off was that the only connection in her FH to the above SBLA reference was the mention of a paternal cousin with adrenocortical carcinoma. The other two mentioned had brain cancers, which seem completely outside the scope of the above mnemonic. Then again, as mentioned elsewhere, I suppose the best policy on these is just to rule out the absolute wrong answers. I swear, the NBME is lying when they tell us to choose the "best" answer on some of these. What they actually mean in practice is for us to choose the least shitty. +15
dbg  ^ this guy cracked the code. nbme ur doomed. +7
cienfuegos  @privatejoker: I feel the pain. Quick FYI: UW includes brain in the associated tumors. +3
hyperfukus  we can just make her thing SBBLA and hopefully never get this wrong again +9
jakeperalta  @privatejoker: according to UW, Li Fraumeni includes SABBB(sarcoma/adrenocortical/breast/brain/blood(leukemia)) +2
ac3  side note: RB1 = retinoblastoma with an increased risk of osteosarcoma +
lukin4answer  TP53 associated with SBLA + Brain tumor + Anaplastic Thyroid ca + Transitional cell ca. -UW +

 +12  (nbme21#3)
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iThs si a tsnoo-clearc utyds eueacbs ti etcelss ifrts yb sseeiad coumeto nelut(iclelat tiib)sldayi dan htne trevyreoltaci lsoko at osekssxr/ierup T(V .egsa)u ddsO satroi aer udse ot lveeauta lscroct-oane euisd;st fi eerht wsa a vptisioe ehisilrtnapo twnebee VT seu nad eeitlnutlalc tdiyibsli,a het RO loduw ays nigetmsoh elki hel"inrdC hwti leeutlcitlna lidsiseaibit erwe 3 temis ermo eklliy ot hvae 2 or moer ushor fo VT eimt erp yad htan cridehnl uiohtwt eletcnulalit aissibdeilt"i.

eaviletR rsik is dsue ofr orhoct stdiu,es wihhc ftsir ifdene an supreoex TV( ue)s nda hent olok ta eth mocoeut lIntt(ecullea i).ydtlasbii A ilrateve riks odwul eb oemr ekli eittPsan" ihwt 2+ uosrh /yTdVa are at x3 igrheh srik to vpdoele ctaieltlluen idisiytbla tnha edlncrhi ihtw t;&l2 u.orh"s

,lailTyypc OR and RR are alirsim sunbmre tub atth tapoisusmn keabsr odwn ta a tarecni tpoi,n I hnkti wehn the daissee si ryev rear ro tmnhei.osg

drachenx  Following up on Neonem's comment OR = RR when you are dealing with a RARE disease. +5

 +6  (nbme21#49)
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I htnik uoy nca onkw htat iths si a ahciatml reotks rareht htna clioacrt seauebc a rilocatc skoetr uocignrrc lyno in het teancortslp rysgu mray(irp oessynr oexc)tr dna nlogvnvii hte nieret umuucoshln twtuoih caeifgnft teh yaenrb tcprlanere ysgru yirrm(pa rtomo rcxo)te si evyr iunyellk.

sahusema  Ya I think this question is trying to test your knowledge between a cortical lesion and a subcortical lesion. +1
cienfuegos  Central Stroke Syndrome: Neuropathic pain due to thalamic lesions. Initial paresthesias followed in weeks to months by allodynia (ordinarily painless stimuli cause pain) and dysesthesia on the contralateral side. Occurs in 10% of stroke patients. FA 2018 499 +4

 +8  (nbme21#36)
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In didonati ot p'biees onmemt,cs 0FA128 ssya atth onadracmshoroc si orem cnmomo in the "aluemld of ilpsve nad lrcanet k"esleton hweil armhnoodcs rae omre in het llsam osben of shand p&am; tee.f.. so I gusse yuo ulcod og fof fo ti enibg ni a begigr nebo .(emr)fu Or erppash eth cpherloopim isotyglho fo het scl,le whhic duowl be rmoe rhcecaactrsiit of a innalgtam .umtro

 +1  (nbme21#40)
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morF ratnm.tchcoecwe reev(n raehd of it eefrob utb smsee keli a oogd a:itonaxnl)pe

"eahPs IV eitssdu, neotf ecalld otPs anreikgtM vllSarneiuce ,ailrTs rea tdocnuedc afret a drgu ro evdiec hsa bene draeppov rfo ncsuemor lase. aauPhceaitmlcr noiespcam evha rsaeevl esieojtcbv ta ihts gaest: (1) ot raempoc a udrg twih herto rgdus laaryed ni eht ta;kmer )(2 ot oriontm a dsg'ru otlrengm- sntsiceeeeffv dna pcatmi no a ina'stetp iqluyat fo eif;l nad )3( to iedenemtr teh ocsfetscnis-tvefee fo a rdgu paerthy teievalr ot erhto alotidanrit adn new rea.peiths sPeha IV sdustie acn tsleru in a rugd or eceidv giebn ekatn fof the reakmt ro tocersstrini of eus dlcou be aplcde no eth cdpotur dnndeipeg no het nsgdifin in teh .syudt"

seagull  Well, I was not smart and put phase 1 since it was talking alot about adverse effects and withdrawl from the patients. But now I see I have 2 extra bad. +
link981  Phase 1- Determine if drug is SAFE Phase 4- Continous surveillance of a drug that is already on the market. The vignette clearly states the drug is marketed. That means it passed the clinical trials. Marketed drugs have passed Phase 3 +

 +7  (nbme21#25)
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Moarj rkis taocfr rfo catoir osisteidnc is phinyonsteer, and ni isht ecas ihgtm be eud ot oeaccin eus, iwchh scesau mdrkea ysnnho.trpiee ecsiDnsoits uscea a rtae in eht caintu itniam -- dolbo anc wflo rbckwasad otni het miurdraicpe adn aeucs pnat.doema ihTs setnisamf as crlaeksc ni hte ugnl due to oorp tefl arturcievnl uftnocin flslldo/tnigi(iiac pomlrbe due to )nocimr.psseo

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9
temmy  please why is there where a diastolic mumur? +1
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8
garibay92  Does anyone know why is this patient's tepmerature elevated? +1
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +
almondbreeze  he's only 28 - another clue for marfan? +
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +1

 +9  (nbme21#41)
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ihsT is a seca of rripphoay aaetucn .drtaa heT way I eembrrem itsh is ttah tis' eht olyn yghei-hdli rhraippyo atth sah nkis nassmaoiiftten ude ot VU. I reememrb hsit by tArf"e U rrhuypni)r,oop( st'i UV". trAelapnyp sti' oasl ceoatisasd wthi tieHpasit C, whhic lcoud be hte nesoar yhw rehtes' reaescdin TAS ;mpa& AL,T or it lucod eb eud ot xciot ipbluud of erdnaesmtiite in eehm its.nsyesh

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 +6
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. +

 +8  (nbme21#15)
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Tsih si a acse of etuca o.tug usndmoMoio taeur sycltsra rae nketa pu yb ,erhitsolpnu ldinega ot an taceu falntimyarom aierocn.t Ts-clel trn'ea yalrle vdvnoiel ni otug orm(e emuartohdi t)hi.traris

hungrybox  Great explanation! So frustrating that I got this wrong, should have been easy. +3
temmy  the way i thought about it was how did the neutrophils get there? the answer is via increased vascular permeability +16
nor16  they, unfortunately, did not ask " how did neutrophils get there" but " whats the cause of the swelling " not to confuse with " what causes the swelling " +1
divya  absolutely right temmy. that's how i thought about it too. +

 +4  (nbme21#32)
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aPhoatm sasy ttah etaisltitnri yaa)cti(lp onpmneaiu si zeciretardcha by fsifeud ttrstealniii senatiirtlf, setrensp w/ laeilveryt idml urepp sepr moptssmy aiimnm(l upumts ;apm& wol fv)r,ee dan si tmso fnote ucades yb ,sersivu tbu can be iterabcl.a e,erwoHv hsit onseitqu si etginnsrpe a horcicn ecs,a so 'mI iamsnugs atth hte peuoisvr rsinattietli mouiapnne asdceu a octirbif rpnseseo in teh nlu.g

 +3  (nbme21#34)
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eTh lscara tiuicitmrno enrcet si 1 of 3 oencsonmtp of icmoirittun rflxee ht(oer 2 are omrf onetpin earltiruc nfotraoim nda rlcerbea )e.cortx aarSlc tcmi encetr = S2-S4 snplai drco levle anregvtil rmof neavtrl tiwhe artmte ni the ePvcli eevnsr, risspeeobnl orf eaddrbl norccatnoit aiv eht ciegonirlch ersevn itkn(h it acst on teh 3M rrecepot in hte brladed s?)eort.urd fI uoy eols thees nerevs i.(.e in lcepvi tr,rc)feua lliw eltrus ni rvewolof tcincnnee.oni

 +3  (nbme21#49)
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heziTiad ciriesdut rea eth sclsa hwit het etlsrag irsk fo haepkl.aimyo

 +15  (nbme21#43)
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Mphinero is a mu idpoio igatons - neo vasdere fetefc fo iopsoid is tmsa cell iranatngeuldo htat si dEiIpeeted-ngnn. elaRsee fo tmsenaihi is kian ot an lphciataaycn tnaeciro t-&-;g rpuirst,i t.ce

sympathetikey  Never had heard of that one. Just a good guess. Thanks! +
yb_26  IgE-independent mast cell degranulation can also be caused by radiocontrast agents, some antibiotics (vancomycin) +7
temmy  it was a u world question +
mambaforstep  FA 2019 pg 400 +
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +1
mambaforstep  under mast cells "IgE-independent mast cell degran"! FA 2019 pg 400 +
mumenrider4ever  Uworld QID 11852 talks about this Also FA 2020 pg. 408 (under mast cells) +

 +1  (nbme21#18)
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ishT is a pmortupats mood urtdi,esncba a ytrtpe cnmmoo ordisrde ttah sah ot veah an oents winthi 4 skeew fo edyveilr ot eb edermt sa suhc. pmoatusrtP ebuls si teh stmo limd, ithw a 8055%- ciinednce rtae rep( FA 10,82) slluyua sseevlor tiwnih 01 sday dna mtaternte si yonl seuirotppv tub dene ot olpwlfu-o ot ssesas rfo isesbpol tursapmpot seprneoid.s mttsaoPupr ednerpioss = 05%11- etar, raatehizccder yb rseedepsd fce,atf ye,nxati proo tanooiecrnntc orf egtrrae htna 2 skwee nda sende to be etadret /w CTB + I.SSR I ktihn eth eiqtosnu is itgentg ta resgincen fro sthi nda a plttiyelaon rome olarmcpbtei c,ootplmacini stmtropuap oycpisssh.

thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +11
d_holles  Same @thisisfine. +2
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +

 +2  (nbme21#4)
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sieTnn" ol"bwe si ude to aarldi envre gtmeminniep raen het rltaael yeidclnepo of the er.usmuh tsonreEx rpcai aidlisra rbsive is a mlcsue fo hte etsonrxe opntmtremca of hte r,emaorf sreigoatin fmor teh rtelaal coepylenid sa wlle.

ibestalkinyo  The radial nerve is NOT involved with lateral epicondylitis. The underlying pathophys is inflammation of the tendinous bursa and origin of the extensor tendons. Radial nerve involvement would lead to more neurologic deficits such as loss of sensation and weakness rather than tenderness and pain against resisted extension. +1

 +12  (nbme21#42)
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RRP = ceegrinsn test ofr hsiT si a to-igvlksengoc epanttr ,hras ersariticthacc of odayerscn s.iplisyh Drug fo ohceci ofr psyiihls ta any tgsea is imrntusaaclru n.iielcPlni

ragacha  PAG 147 FA 2018 +
teepot123  also says which antibiotic, only 2 in the list, helps narrow down, pen more commonly used +2

 +1  (nbme20#21)
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taC arctsch seaised natrBeloal( nitfcnieo ni nuteptmoimoncme )shost secuas lsipnaymitedh casyp(illee ni het yrxialal noegir) reeatcicdzarh yb idkeir-asolc -cnesintonaag rnuoamgsla dlilfe whit

 +3  (nbme20#6)
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trneuieLeok B4 si a otntep eoihamttccc eoellmcu orf pnrhiltoeus. tecieeSlv olss fo tshi ulwdo avhe on ffcete no llt,apetes atms se,cll ro nutodiemleh - eehts ear more seivnoespr to ehgnsac in 2,ATX oe/tndrocmalhpcmniaeic ic,ad and GI2,P sli.eytcprvee

kernicterusthefrog  FA says: "Neutrophils arrive B4 others" +5
fatboyslim  Important neutrophil chemotactic agents: C5a, IL-8, leukotriene B4 (LTB4), platelet-activating factor, and kallikrein. Source: FA 2020 page 406 +1

 +4  (nbme20#43)
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sltoaozilC is a rpasohdipsstheeoe hiobn;itir sdale ot sandicere PcAM hiwch sbinihti ealteptl gcatt/deoniavlntoranuiia ehilw oasl giscuna o.aiatsnivldo llA fo eth rohte sotinop owkr on tieher eaacvsulrut or saettpell ubt ont .tobh

kernicterusthefrog  Just to add: cAMP activates protein kinase A (PKA), which is the more direct mediator of platelet aggregation inhibition, and of myosin light-chain kinase inhibition (which causes inhibition of smooth muscle contraction and thus vasodilation). Just in case there's a question that gets more specific than this one! +13
brbwhat  wasn’t dypirdamole an option? +
fataldose  I believe they also cause vasodilation by decreasing the cellular reuptake of adenosine by endothelial cells and the adenosine causes vasodilation. +

 +12  (nbme20#5)
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eoexeaMrthtt loudw eb a gdru fo ohceci ofr sospriisa rcftreyaro ot licoapt camers nda gthil t;ryhpae itbihsni yifeoholartdd cuerdseat in oderr ot cedaesre nkis lecl etprliiranfoo nda urdcee rnmyalomaitf er.psseon

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

 +7  (nbme20#36)
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lgSlihea eacssu an manfrtmaoily hdraari;e ti usepocdr a xtion nda anc naievd uessit rdelci.ty nI oit,nidad ti si irnestast ot ,dcai os it sha a erithlilyastccarac wol ienvtcefi soed (~01 ,m)ssonagir whihc ttiasielafc tis cela-alfro pspst-oor-eeo(r)nn seadrp yseclaepil ni stneisgt wereh enegihy yam eb poci,rmmoeds hucs sa in eardyac or litnsouiintta It cna be rdfanitteideef ofrm .E iCol )E(HEC subaeec E Coli 'entosd vahe as mchu oos-pnoep-errstn saderp dna nlyo escaus IG agdmae yb teh haielkisg- ,tixon nto citrde niivsoan. efeh,oTrer HCEE wd'ltonu tiiaacflet sa gstorn of a roeihintlcpu srepsone.

yotsubato  I assumed all the kids in the daycare had the same lunch, thus got food poisoning, thus all got EHEC. +4

 +14  (nbme20#50)
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Tihs inetpat lkleyi sah omes form fo pprue romto norneu oielns or adeessi - UNM lissone are crzhrdaeiecta by swnaee,sk drasneeci pdee nentod xerlsee,f and sspcita irssape. anBeoflc si a BAGA-B onitgas iicpfecs ot teh alpsni rc,od dues to atter elcusm iip,ttsyacs atsdon,yi nad M.S G-ABBA is a -neGripot dcpuole peeocrrt ucpoeld to ,iG so ainogsm of shit rprcteeo ascues lapizyrrhotpionae fo eth onernsu dan eearseddc sraleee of ryxtoeciat tmt.aeugal

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

 +2  (nbme20#6)
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ochllAo aihratldww dseal ot a hr-ihlepteckamysaiiitet-vypytc nrsyedmo iwht reorsm,t ,THN s,onianmi IG puet,s idis,aohesrp dna ilmd oitiantga 63-3 rhuso eafrt het lsat k.dinr eTher si a m,ralsii but salyulu ilsthgly rle,ta epolavr of ailhwwdart seieusrz 6-48 suhro arfet hte astl irn.kd

baja_blast  p. 558 in FA 2019. +

 +2  (nbme20#24)
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sotM fo tnriiscin emlcsus of the hdna era enarendvit by urlan rneve - cnrcohi oessinrompc ta hte koho of maahte olcud ldea to nreve emhaiics

 +5  (nbme20#46)
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ueObcitsrvt thpoaury asusce a neslotpar imzaeoat ;-g-t& nhwe noeolrpd,g barltuu maaged ihsT aedls ot na ateuc uratlub cesrsnoi, etdzerraiccah yb rocitcne lpsug in eht urbualt myests as seen in eht aiemg

meningitis  Does anyone know the relevance of the stem saying: "during this time she also has been crying frequently"? +44
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 +2

Subcomments ...

submitted by neonem(571),
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I hiknt eht eoanrs yuo nede to tjecni toospnnoiragd ni ihst asce si baucees ouy eedn FHS adn HL ot prueodc FSH aitlumtess eht lestior le,csl whihc neli eht ousemenifris lusebtu and leph het eornpmgotiaas prdcuoe rss.ptmoeetayc eeessoTttnro si a cdtopru fo ydeLgi lscle wenh ht'yere datultmsie yb ,HL so tjnieingc troettnesoes ludwo sasypb thta pste tbu ti ulnd'wto yrleal ehlp whit gssnspeo.emietar e,erHwvo inngiejtc GRHn sloa onets'd sdtn'oe yarlle ehlp seabceu you dnee atth lieusaltp GnHR ta thgin ot keam LH dan SFH arwhese alnogit-cgn nHGR angosal lauyaltc deerseca LH dna HFS .rdinotupoc

m-ice  Adding on to the answer above. I was stuck between the gonadotropin injections and clomiphene. But, clomiphene acts to increase activity of GnRH which then exerts its effects on the pituitary. The man in this question had his pituitary removed because of an adenoma. So, he needs the FSH and LH directly. +22  
mousie  agree! Removal of the pituitary would case a deficit in Gonadotropins (LH, FSH) and therefore nothing to simulate the testes to make sperm... replacing the T with a patch would not stimulate the testes to make sperm and if his axis was intact (although its not) this would further down regulate the production of sperm. I eliminated Clomiphene because if he dosent have T to induce negative influence on the hypothalamus he will have increased GnRH and further increasing it with Clomiphene would not correct the deficit in Gonadotropins. +4  
neonem  Oh duh... that makes much more sense. Thanks! P.s. I thought clomiphene was more of a fertility drug for women, since it blocks negative feedback of estrogen on the hypothalamus/pituitary. But in men the system is under feedback due to testosterone, not estrogen. +6  

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heT deiaess erhe si osefurtc satsshpihabope ifyn.ececid In ti, VI lgyerclo ro oeustfcr oes’dtn phle beascue tobh etner het seeinoogugcelsn pyawath oelbw rcsufeot a.hbtpsapeoish sGeclaoat on the htore andh setnre aobev i.t I dn’to htnik ouy really ende ot onkw this to oheocs eth tccroer snearw icens het iiccnall iptrecu fo aifgsnt iylcaomphgey taht si rcecretod w/ osme ostr of srgua atht nca ernte eht snlueesegoocnig ywatpah ldsohu ulec uyo tnio the itrhg snaerw.

neonem  I don't think you could have *totally* ruled out the other answers - I picked glycogen breakdown because it sounded kind of like Von Gierke disease (glucose-6-phosphatase) to me: characterized by fasting hypoglycemia, lactic acidosis, and hepatomegaly since you're not able to get that final step of exporting glucose into the blood. However, I guess in this case you wouldn't see that problem of glycerol/fructose infusion not increasing blood glucose. Nice catch. +25  
vshummy  I think you were super smart to catch Von Gierke! Just to refine your answer b/c I had to look this up after reading your explanation, von gierke has a problem with gluconeogenesis as well as glycogenolysis. So they’d have a problem with glycerol and fructose but also galactose since they all feed into gluconeogenesis before glucose-6-phosphatase. Great thought process! +22  
drmomo  glycerol and fructose both enter the pathway thru DHAP and glyceraldehyde-3-ph. Galactose enters thru Gal-1-ph to glu-1-ph conversion +2  
linwanrun1357  In this cause (fructose bisphosphatase deficiency.,),fructose should help to increase serum glucose, bcz it can become into glucose-6-P by hexokinase. Therefore, this question makes me confused.... +  
krewfoo99  According to uworld, fructose infusion will not increase blood glucose levels in Von Gierkes Disease as well +  
atbangura  I believe Von Gierke is not a plausible answer choice because a galactose infusion would still not see an elevation in glucose levels. Remember, galactose could be converted to galactose 6 phosphate, but in order to complete gluconeogenesis and allow glucose to leave the Liver for an increase of its concentration in the blood, the patient would still need glucose 6 phosphatase which is eliminated in Von Gierke. +1  
lilyo  So what disease is this??? I mean couldnt we have just answered the question based on the fact that the patient responds to galactose being infused and we know that galactose feeds into gluconeogenesis?? I am so confused. +1  
djtallahassee  Its Hereditary Fructose intolerance right? gets sick after fructose and I guess glycerol can jump in via aldolase B on this pathway via page 74 of FA2019. It looked like a fructose thing to me so I just marked out the other ones and moved on. +1  
paperbackwriter  @djtallahassee I was wondering same, but hereditary fructose intolerance also results in inhibition of glycogenolysis :/ confusing question. +  
amt12d  A much simpler way to think about this, without trying to figure out a diagnosis, I looked at the time frame for when the child was presenting. He has eaten poorly for 3 days, by now, his glycogen breakdown is gone. His body would be trying to make glucose, therefore, gluconeogenesis is impaired, not glycogen breakdown. +4  
tyrionwill  if fructose kinase is not available (fructose intolerence), then some fructose may go to F-6-P by hexokinase, then goes to G6P if gluconeogenesis is needed. however this patient's fructose kinase was intact, so no fructose would have go to F6P, so there would be no blood glucose increment after injection of fructose. +  
shayokay  You had to know that fructose and glycerol enter glycolysis at DHAP/G3P, and galactose enters glycolysis at G6P (gal-> gal-1-p -> glu-1-p -> glu-6-p). This means that one of the 3 enzymes between G6P and DHAP/G3P is not functioning properly. Most likely this would be fructose-1,6-bisphosphatase because there does not appear to be anything wrong with glycolysis. "Fructose-1,6-bisphosphatase (FBP1) deficiency is characterized by episodic acute crises of lactic acidosis and ketotic hypoglycemia, manifesting as hyperventilation, apneic spells, seizures, and/or coma. Acute crises are most common in early childhood; nearly half of affected children have hypoglycemia in the neonatal period (especially the first 4 days) resulting from deficient glycogen stores. Factors known to trigger episodes include fever, fasting, decreased oral intake, vomiting, infections, and ingestion of large amounts of fructose." +1  
shayokay  Also, even though Von Gierke is categorized as a glycogen storage disease it is really a problem with gluconeogenesis not glycogen breakdown. So even if you thought this was VG, you still could have gotten the right answer. In VG, any monosaccharide other than glucose (fructose, galactose, glycerol, etc.) will not raise the plasma glucose level because they all require gluconeogenesis to be converted into glucose and this cannot happen because there is no glucose-6-phosphatase. This is why the treatment for VG is frequent oral glucose in the form of cornstarch and avoidance of fructose and galactose. +  

submitted by brethren_md(90),
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tmoru fo leniaP dlanG enaaoPil)(m aescsu rnaadiuP mreSdyno l(aicrtev azge y)plsa

neonem  Due to compression of the superior colliculus in the tectum, I believe +8  
wowo  FA2019 p516 +4  
misterdoctor69  FA2020 p528 +1  
qiss  tectum as in the superior colliculus +  

submitted by brethren_md(90),
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ncohriC erstecniMe eImischa aak iltaisentn .nagain nMai esclu aer glpsrtniopaa aristipgec apin, htigwe .loss uUlalys ude to ciealC )a(, ASM, ro IAM lhrosa.ceortises

neonem  What's tough about these answer choices though is that you have 2 different viable combos. +  
codyluvr95  The ectatic aorta might also mean AAA below the renals, affecting the IMA, +2  
sherry  Also since there is this ectatic aorta, the arteries involved need to be adjacent to one another. If there is a choice as in celiac and SMA, it could also be correct. +  

submitted by mcl(599),
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eetoMnniih si an iesnltaes imaon i.adc All streoh dtelsi rae

scalpelofthenorth  Pg 81 Tyrosine is listed as an essential AA. Should be tryptophan for those who got this wrong like me. +  
neonem  But tyrosine can come from phenylalanine, so it's not really essential right? +1  
gh889  in FA2019, it is listed as Tryptophan, not Tyrosine. That was corrected. +16  
usmleuser007  Note: Tyrosine is ONLY essential with PKU in children +  
niboonsh  bro FA2018 lists tyrosine as an essential AA. They played us. +1  

submitted by cantaloupe5(77),
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oFr isth eon ouy ujst hda ot know eht ilgcsosyly phwatay. etmS oltd you 2-,GB3P is laetdeve, whchi is tpumasre fo peayvtru ksena.i

neonem  Right, and that glycolytic enzyme deficiencies lead to hemolytic anemias. +5  
toxoplasmabartonella  I just thought the typical presentation of pyruvate kinase deficiency would be hemolytic anemia of the newborn. +4  

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unuoAitemm tsiodhrtiiy kaa( i)hHoasmto + gag&np-ertt;n- iThnk obaut tipsbilyosi fo eflta mdpoihstyhoyri due ot yandtboi emaieddt emtlnara yyorohpd.mihist Laeds to mi.Cenirst isFdgnin ni ntanif era het '6P Pt(o eyb,ll aPl,e ufPfy cfa,e Ptorgrdnui m,ciblusiu tProuatnebr o,tengu dna Proo inraB nlo.teeedpvm

neonem  I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism? +  
poojaym  @neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4. An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland. +38  
arezpr  TSH, T3, T4 and thyroglobulin cannot cross the placental barrier. +  
chamaleo  @arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can +1  
yotsubato  The baby has its own TSH though +  
sbryant6  TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work. +  
kimcharito  no goiter then? +  
lola915  I think there is no goiter because the baby's thyroid gland has not fully developed and these immunogloblulins from the mother could attack the thyroid gland leading to issues with it's development. +  

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yM hutghot proscse wsa taht -tstpourmap eelbdngi is usalylu ladtree to hte te,uusr and hucm of eht pecivl eiscrva si upipseld by bascehnr of the ntiralen aicil e.artry

neonem  This sounds like a case of acute endometritis. In any case, uterus is supplied by uterine artery (branch of internal iliac artery) with collateral flow from ovarian artery (comes right off aorta). I don't think there are any branches of external iliac artery into the pelvis; it becomes femoral artery once it passes under inguinal ligament. +4  
tsl19  Here's a picture that I found helpful [Female Reproductive Tract arterial supply] ( +15  
sympathetikey  @tsl - Thank you! +  
step1soon  uworld Qid:11908 +  

submitted by strugglebus(165),
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tP ash yehotcimlpay aerv vto(ploreaifrmileye s)oreirdd deu to hiorcnc oyihxap duncied yb OCD.P eydiloM maslapteai is eratx eldlaurmy mhopeesiaiost due to bssiryfeolom.i eHtrrayedi trocesmamohsohi luwdo have ebne ernovp by a suipsnra lebu nsai.t sprlnmHespiye owdul veah edcasu eeeddsrca BR,sC dna ssllymeyicdopa dmnorsye uldwo heva swhon ruAe rsdo ro

neonem  Right, I think this would be just called "appropriate absolute polycythemia", whereas polycythemia vera is due to a malignant JAK2 mutation and would be termed a type of chronic myeloproliferative disorder. +13  
utap2001  Myelodysplastic syndromes (MDS) is also called Preleukemia, myelodysplasia. in MDS, your bone marrow doesn't make enough of these healthy blood cells. Instead, it makes abnormal cells that aren't fully developed (immature). As the condition develops, your bone marrow gets gradually taken over by the immature blood cells, which don't work properly. The condition can develop slowly (indolent) or quickly (aggressive), and in some people it can develop into a type of leukaemia called acute myeloid leukaemia (AML). +  

submitted by strugglebus(165),
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As na 0801d:,e1 i0t eopple droetrep ot have sedi seffcet enhw atngik hoazHorotdgmecor.y idAhlin ethm, 52 lopepe (.02%)0 heva sBerat dasechgri

neonem  I think the best way to answer this question was by process of elimination. +1  
sympathetikey  That's some bullshit lol +9  
karljeon  Haha I eliminated the answer by process of elimination. +20  
medschul  I eliminated thiazides by process of elimination :( +1  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +2