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Comments ...

 +0  (nbme18#45)

First order kinetics is constant fraction of the drug getting metabolized. So with the values given in the question stem, 16/32=.5 aka 50% of the drug gets metabolized every 6 hours. Then if you write out the decreasing doses (multiplying each value by .5) for until you get close to 1.1, it'll look like the following:

32->16->8->4->2->1

So it took 5 half lives to get to 1 (closest to 1.1). So since each half life is occurring at every 6 hours, you then multiple 5x6=30.


 +0  (nbme18#23)

I think specifically they are referring to the ureteropelvic junction, which is the LAST to canalize and can lead to congenital obstruction. Also, it is the MC cause of prenatal hydronephrosis. This is detected by ultrasound.

Also important, the 3 MC points of ureteral obstruction: ureteropelvic junction, pelvic inlet, and ureterovesical junction.

FA 2020: 578 and 581.


 +0  (nbme18#32)

basically, instead of memorizing every small detail when it comes to anatomy q's, just keep in mind basic principles. Since the question said right lobe of the liver, automatically know it can only involve any of the colics (ex ileocolic, right colic, middle colic) EXCEPT the LEFT! From there know that they all drain into the Superior Mesenteric Vein.

Whereas all the left sided structures drain into the Inferior Mesenteric Vein. The spleen is also on the left so you can cross out any answer choice that includes that.

That leaves you with A, the correct answer.

If you need a visual heres a great link. https://radiologykey.com/venous-anatomy-of-the-abdomen-and-pelvis/


 +1  (nbme18#7)

dont get tripped up on the wording. the answer is "inhibits microtubule disassembly". just remember, "taxes STABILIZE the economy" to remember the moa of paclitaxel and other taxanes.

the other answer choice of "prevents microtubule polymerization" is the MOA of vincristine and vinblastine.


 +1  (nbme16#40)

Why it's not the other choices:

Cystic hygroma: if you see this, associate it with Turners.

Thyroglossal duct cyst: moves up and down with swallowing and doesnt cause the sx presented in this stem.

Tracheomalacia: In tracheomalacia, the cartilage of the windpipe does not develop properly in utero, leaving them weak and flaccid. The weakened walls are likely to collapse and cause an obstruction of the airway. Yes it can cause stridor but has no relation or association with maternal Graves as the cause and also doesnt present as a neck mass.

Vascular ring: occurs when the aorta or its branches form a complete ring around the trachea and the esophagus. This happens when certain parts of the aorta that normally disappear during fetal development persist abnormally. Sx are dysphagia and cough. Most sx are so mild that children who have it often go years without diagnosis. Also doesnt present as a neck mass.


 +0  (nbme16#5)

A way to differentiate between a leukemoid reaction vs CML is that CML has a very low leukocyte alkaline phosphatase (LAP) as a result of low activity in malignant neutrophils, vs benign neutrophilia (leukemoid reaction) in which LAP is  due to  leukocyte count with neutrophilia in response to stressors (eg, infections, medications, severe hemorrhage).

Also some helpful hints is that his temperature is raised as well as his leukocyte count. So an infection from his cut.

I think "leukoclastic response" was just there to trip you up. The closest thing I could find to that term online was: Leukocytoclastic vasculitis (LCV), which refers to small blood vessel inflammation.

Leukopenia is LOW leukocyte count.

Leukoplakia is that "white plaque" you see with Bowens disease (squamous cell CA of penis) and can also be seen in vulvar CA.

Leukotrienes deal with your immune system and are synthesized and released on demand from basophils.

okokok1  *leukemoid reaction will have elevated LAP due to elevated leukocyte count +

 +2  (nbme16#41)

γ-aminobutyric acid =GABA, so not a neurotransmitter dealing with pain. deals with excitability and movement.

dopamine: think of parkinson's (too little of it) and schizophrenia (too much of it), either way doesn't deal with pain reception.

Enkephalin: related to a type of opioid receptor. It closes presynaptic Ca2+ channels, open postsynaptic K+channels and thus decreases synaptic transmission. It actually inhibits the release of ACh, norepinephrine, 5-HT, glutamate, substance P.

Serotonin: think of depression. again, doesnt deal with pain reception.

Substance P: even if you didn't know exactly what it did, you could rule out the others. you could also remember the pathophysiology of migraines: "Due to irritation of CN V, meninges, or blood vessels (release of vasoactive neuropeptides [eg, substance P, calcitonin gene-related peptide]) causing the immense pain of migraines."

For completeness sake: "Muscle nociceptors contain neuropeptides, including substance P (SP) and calcitonin-gene-related peptide (CGRP). These peptides are released when nerve endings are activated and induce local edema by dilating the local blood vessels and increasing their permeability." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696782/

also, good to know aprepitant is an anti-emetic that is Substance P antagonist. Blocks NK1(neurokinin-1) receptors in brain. yes, theres no mention of "pain" in that FA definition but Substance P got its hands in a lot of cookie jars ok


 +1  (nbme16#25)

Albinism: Normal melanocyte number with DECREASED melanin production due to decreased tyrosinase activity or defective tyrosine transport. risk of skin cancer.

okokok1  the choice "decreased number of epidermal melanocytes" is vitiligo. +2

 +0  (nbme19#27)

although each answer choice can be used to treat Nausea and vomiting, only ondansetron is specifically used for chemo-induced nausea and vomiting.

an_improved_me  Actually, metoclosepramide can also be used (inhibits D2? receptors), but i think the important thing is that the initial N/V caused in chemo is d/t an increase in 5-HT3. Therefore, you first give a serotonin antagonist +

 +0  (nbme19#46)

The pt has Paget's disease of the bone aka Osteitis deformans. ISOLATED INCREASE IN ALK PHOS = PAGETS!!! always.


 +0  (nbme19#27)

With the question stem saying "bruit over right posterior flank" that was the clue I used to pick renal artery stenosis. First Aid defines it as the following:

"Renal Artery Stenosis: Clinically, patients can have refractory HTN with negative family history of HTN, asymmetric renal size, epigastric/flank bruits."


 +0  (nbme19#41)

Simple way to think about it: remember a disease that presents in the same way aka Follicular Lymphoma which has constitutively active bcl-2. aka follicular lymphoma promotes it nasty cancerous ways via decreasing cell death.


 +0  (nbme19#8)

I think this is another prime example of NBME not expecting you to know every small detail but instead just answer their question straightforwardly. The question said "...involved in reproducible changes in HOX gene expression" and the only answer choice that deals with modifying gene expression is: transcription factors.


 +0  (nbme22#37)

The question stem is describing a pt with Multiple Sclerosis. INO is HIGHLY associated with that. Then if you follow the rule of 4's, you know that the MLF is medial and ipsilateral to the affected side. Thus, it must be the medial right structure.


 +0  (nbme21#19)

Gallstones that reach the confluence of the common bile and pancreatic ducts at the ampulla of Vater can block both the common bile and pancreatic ducts (double duct sign), causing both cholangitis and pancreatitis, respectively.

FA 2020; pg 386

hannah  It's actually pg 368! +

 +0  (nbme21#45)

An important related clinical application is remembering: Ovarian teratoma and their associations with: Anti-NMDA receptor encephalitis. This presents as: Psychiatric disturbance, memory deficits, seizures, dyskinesias, autonomic instability, language dysfunction.

FA: 2020; pg 228


 +0  (nbme20#19)

this image helps make COPD among other lung disorders clear with various sounds in a table. https://images.search.yahoo.com/yhs/search;_ylt=AwrEZ7mf9MZeFVUA4Dg





Subcomments ...

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okokok1  also you can cross out the other answers because: what builds up in essential fructosuria: fructose what builds up in Hereditary fructose intolerance: Fructose-1-Phosphate what builds up in galactokinase def.: galactose what builds up in classic galactosemia: Galactose-1-P. Hence, this is the only correct choice of the answers the stem gave. +1  


submitted by niboonsh(359),
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yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch. +  
llamastep1  No they do not, parathyroids are supplied by the inferior thyroid arteries. https://teachmeanatomy.info/neck/viscera/parathyroid-glands/ +11  
suckitnbme  Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery. +1  
okokok1  https://www.earthslab.com/wp-content/uploads/2017/07/070417_1014_Parathyroid1-1.jpg this shows a great visual of how inferior thyroid artery does most of the supplying. +  


submitted by username(1),

prolonged bleeding time + prolonged PT = von willebrand disease.

Extra evidence = Autosomal dominant (as we know father also had the same problems. Thus, it's not the hemophilias, as those are X-recessive, and usually daughters are just carriers in those cases)

okokok1  The PT isn't prolonged, it is the PTT. The PTT is prolonged because vWF carries/protects factor VIII which is part of the PTT pathway. +2  


This lady had preterm premature rupture of membranes. She had a genital tract infection, which is a risk factor for PPROM.

From Uptodate: Many of the microorganisms that colonize the lower genital tract have the capacity to produce phospholipases, which can stimulate the production of prostaglandins and thereby lead to the onset of uterine contractions. In addition, the host's immune response to bacterial invasion of the endocervix and/or fetal membranes leads to the production of multiple inflammatory mediators that can cause localized weakening of the fetal membranes and result in PPROM.

alimd  did you pay fucking $30? +1  
cheesetouch  some institutions give students UpToDate access +3  
cbreland  I knew that misoprostol (PGE1) can be used for abortions by forcing uterine contractions, so I figured the answer had something to do with prostaglandins +5  
rthavranek  I knew prostaglandins increased uterine contraction, but I also thought PGE2 caused cervical ripening and since there was a closed cervix, I eliminated that choice. I had no idea what was going on so I just picked oxytocin since that would increase uterine tone without dilation, though my reasoning seems to be incorrect +2  
utap2001  Great, the above message deserve $30. +  
notyasupreme  I think also it said that the fetus releases oxytocin and steroids, which I guess is stupid wording that makes it not right. Anyways, fuck the curve on NBME 18 :) +3  
okokok1  if anyone didn't know what "PPROM" stood for it is: Preterm Premature Rupture Of Membranes" +2  
aakb  I was between the prostaglandin answer and stressed fetal production and release of oxytocin and the reason I didn't pick oxytocin was if the cervical os is closed (membranes ruptured 32 hrs ago and contractions been going on for 12) and there's no effacement, it didn't seem like that baby actually wanted to come out so I thought that's not what's happening here. Plus mom has a fever so inflamed maternal decidua seemed to fit. +  
helppls  If there was an increase in Pgs why did she not have a ripened cervix? +  


submitted by regents(2),

First, I reasoned that HOX genes code for transcription factors needed during embryogenesis (FA2019, p.598).

Next, cervical ribs are abnormal. The ribs are supposed to start at the thorax. So, HOX (needed for growing things during embryogenesis) should be expressed at the thoracic level (ie caudal to cervical level).

okokok1  to add onto cervical ribs being abnormal, they are found to be one of the causes of thoracic outlet syndrome. +  


submitted by bingcentipede(262),

In congenital diaphragmatic hernia, there is a herniation of the intestines through the diaphragm (usually on the LEFT SIDE - more common side). You'll hear bowel sounds in the thorax and the "cystic-appearing areas" are the bowels.

okokok1  yes. and the the reason you most often wont see it on the right is from the protection of the liver. +1  
dermgirl  Diaphragmatic hernia - FA 2020, Pg.370 +  


submitted by okokok1(13),

A way to differentiate between a leukemoid reaction vs CML is that CML has a very low leukocyte alkaline phosphatase (LAP) as a result of low activity in malignant neutrophils, vs benign neutrophilia (leukemoid reaction) in which LAP is  due to  leukocyte count with neutrophilia in response to stressors (eg, infections, medications, severe hemorrhage).

Also some helpful hints is that his temperature is raised as well as his leukocyte count. So an infection from his cut.

I think "leukoclastic response" was just there to trip you up. The closest thing I could find to that term online was: Leukocytoclastic vasculitis (LCV), which refers to small blood vessel inflammation.

Leukopenia is LOW leukocyte count.

Leukoplakia is that "white plaque" you see with Bowens disease (squamous cell CA of penis) and can also be seen in vulvar CA.

Leukotrienes deal with your immune system and are synthesized and released on demand from basophils.

okokok1  *leukemoid reaction will have elevated LAP due to elevated leukocyte count +  


submitted by okokok1(13),

Albinism: Normal melanocyte number with DECREASED melanin production due to decreased tyrosinase activity or defective tyrosine transport. risk of skin cancer.

okokok1  the choice "decreased number of epidermal melanocytes" is vitiligo. +2