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Welcome to passplease’s page.
Contributor score: 8

Comments ...

 -1  (nbme16#26)

Why not a tear in the sciatic nerve? especially since it radiates down to the leg

cassdawg  My main thoughts on this is that an actual tear in the sciatic nerve is extremely difficult and further it would present with motor weakness to the muscles innervated by the sciatic nerve as well (the hamsrtings and adductor magnus, FA2020 p452). The sciatica pain that you are referring to is more common with injury to the nerve via herniated disc. +1

Subcomments ...

submitted by adong(84),

uworld says somewhere that testosterone increases hematocrit, increases LDL, and decreases HDL

passplease  Estrogen increases HDL. Testosterone is converted into estrogen. Why doesnt testosterone increase HDL. Why is my logic wrong? +  
avocadotoast  The woman in this vignette has an increased androgen:estrogen ratio, so the effects of testosterone on lipid levels will be greater than those of estrogen on lipid levels. Boards and beyond also states that testosterone causes an increase LDL, decreased HDL, and increase in hematocrit, which is why males with primary hypogonadism can present with anemia and the use of anabolic steroids can present with erythrocytosis. +  

submitted by haliburton(192),
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passplease  How did you know it was cryptoccocus and not something else like candidiasis? +1  
jsanmiguel415  Was stuck between cryptococcus and candida as well. I think the tip might be that Candida is in mold form at higher (body) temp. But amphotericin b can be used for both and given that it's a serious infection you would probably just go straight for that instead of fluconazole. +  

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DKA o(ssi)idca gt;& usiatPmso sfhsit tou of eht clel > kampeikyerha

AF ,9210 pg 875

mumenrider4ever  While you will have a high serum potassium, your total body potassium will be low due to very low intracellular potassium (which is where the majority of the body's potassium is usually). This is why you give potassium to patients with DKA +  
passplease  Why do you not get an increased bicarbonate concentration? +  
briangibbs3  Bicarb acts as a buffer and binds up excess H+ in DKA +  

submitted by rockediny(10),
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forerofore  diphenhydramine and other Gen 1 antihistamines are good choices for chronic cough in allergy and patients with posterior draining and post viral chronic cough (careful with the elderly). That being said, apparently it also causes constipation, so dextro is still the correct answer. +2  
passplease  Could it also be that you would not prescribe diphenyhyrdramine because they are part of the beers criteria and should be avoided in the elderly? +1  

submitted by mcl(522),
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joha961  Same question. How could you determine between the specific nerve roots (C7 vs. C8)? +2  
mcl  Someone I was talking to (and post below) was saying that first aid mentions triceps is C7, so that's what should've been the big thing for us. +2  
joanmadd  you might see some ulnar nerve involvement if C8 was involved her +  
passplease  but he has generalized tingling which is in both ulnar and median regions? +  

submitted by bingcentipede(120),

There are a lot of hints in the stem to suggest ectopic pregnancy:

-Severely increased B-hCG (meaning there is a pregnancy of some type, versus none in normal women) -lower quadrant pain (either side; why appendicitis is on the differential diagnosis if it's right side) (probably the strongest hint here) -Empty uterus on ultrasound -Sudden onset abdominal pain

passplease  ectopic pregnancy presents with a lower-than expected rise in hcg (as seen in this question) +  
passplease  the empty uterus is what helped me differentiate. A molar pregnancy should have an enlarged uterus. +1  

submitted by bingcentipede(120),

There are a lot of hints in the stem to suggest ectopic pregnancy:

-Severely increased B-hCG (meaning there is a pregnancy of some type, versus none in normal women) -lower quadrant pain (either side; why appendicitis is on the differential diagnosis if it's right side) (probably the strongest hint here) -Empty uterus on ultrasound -Sudden onset abdominal pain

passplease  ectopic pregnancy presents with a lower-than expected rise in hcg (as seen in this question) +  
passplease  the empty uterus is what helped me differentiate. A molar pregnancy should have an enlarged uterus. +1  

submitted by cassdawg(586),

This individual has ankylosing spondylitis (FA2020 p469)

Ankylosing spondylitis is a seronegative spondyloarthritis (meaning not associated with rheumatoid factor) more common in men which has symmetric involvement of the spine and sacroiliac joints. Symptoms include inflammatory lower back pain which improves with exercise and is worsened by immobility. X-rays of the sacroiliac joint would help confirm the diagnosis by showing ankylosis (joint fusion) characteristic of this disorder.

passplease  How did you eliminate rheumatoid arthritis? Age, gender and lack of systemic symptoms? +  
gooooose  That^ and RA typically involves the symmetric MCPs and PIPs, there's also no mention of morning stiffness that improves with use. Ankylosing spondylitis is more common in young males too +  

submitted by cassdawg(586),

Hormone sensitive lipase (HSL) is the enzyme which degrades triglycerides stored within adipocytes (FA2020 p93). Thus, it makes sense that it is activated in times of fasting and suppressed in the fed state.

Insulin would inhibit HSL, as insulin is a fed state enzyme secreted by the pancreas and would want to trigger storage of triglycerides.

In contrast glucagon is secreted in response to hypoglycemia by the pancreas and will trigger fasted state activation. In terms of the fed/fast state I always think of glucagon and epinephrine kind of like a superhero and their side kick, because they usually work together in the fasting state on similar targets to ensure the body has enough energy (this helps me remember that epinephrine and glucagon are fasting state hormones). Here though is epinephrine's big action away from glucagon, where glucagon has minimal effect and epinephrine has the big action of activating HSL! Glucagon has a minor role and other catecholamines and ACTH can also serve to activate HSL as well.

Another example of the synergistic work of glucagon and epinephrine is in glycogen breakdown (FA2020 p85). Both will trigger cAMP increase and protein kinase A activation which will phosphorylate glycogen phosphporylase and activate it (FAST PHOSPHORYLATE! Hormone sensitive lipase is actually phsophorylated to activate it as well).

FUN FACT: Hormone sensitive lipase actually got its name because it was sensitive to epinephrine!

flapjacks  In Type 1 DM, the glucagon response to hypoglycemia is not functional and these individuals are reliant on the epinephrine-stimulated hepatic glycogenolysis. I recall this by remembering you can administer glucagon to these patients if they're having a hypoglycemic episode. They can respond to it, but they aren't releasing it. +1  
passplease  How did you eliminate thyroxine? As it also plays a role in lipolysis. I was thrown off my the low blood pressure and therefore did not select epinephrine. Why would they still have a low blood pressure? +  
jackie_chan  ^ they have low blood pressure because DKA causes a lot of dehydration (vomiting, diuresis due to osmotically active glucose in urine) so low BP Thyroxine I eliminated because remember that thyroxine is unique in that it functions similar to a steroid hormone and acts in the nucleus to upregulate expression of many genes. I figured hormone-sensitive lipase needs to be activated, not stimulated to upregulate expression, so I thought about EPI and beta-3 stimulation. fuckPeter +  

submitted by cassdawg(586),

Dermatomes! (YAY!) Also see FA2020 p452 for lower extremity nerves.

T10 dermatome is the level of the umbilicus.

L1/L2 would be upper medial and anterior thigh, not down to the foot. The most common buzzwords for injury (less likely via the mechanism in this question) would be absent cremasteric reflex as this is where the genitofemoral nerve originates. The cremasteric nerve is usually injured in laproscopic surgery.

L3/4 is correct because this cooresponds to the correct dermatome for the shooting pain.

S1/2 is associated with sciatica (sciatic nerve is L4-S3), which would be a shooting pain beginning in the buttocks and shooting down to the heel (see dermatomes). This is not described here. Also this is less likely because the sacral spinal cord is fused and less likely to get bony outgrowths. The most common cause of sciatica is an L5 bulging disc causing S1 compression.

S4/5 injury is associated with perianal numbness and potential fecal incontenence(pudendal nerve is S2-S4). However this injury would not be atypical because the sacral spinal cord is fused and less likely to have bony outgrowths causing compression.

waitingonprometric  I answered this question a little differently, and it might help someone! I thought about the description of the dermatome going over the knee joint in terms of what reflexes the nerves there would be mediating. i.e. this would be the area of the nerves that mediate the patellar reflex, which is L2-L4, hence the answer. The pnemonic I always use for reflexes is: S1-S2 "buckle my shoe" (Achilles reflex) L2-L4 "kick the door" (patellar reflex) C5-C6 "pick up sticks" (biceps reflex) C7-C8 "lay them straight" (triceps reflex) L1-L2 "testicles move" (cremaster reflex) S3-S4 "winks galore" (anal wink reflex) +3  
passplease  @cassdawg thank you for the explanation. Can you please explain (or point me to the source) about the sacral spinal cord being fused and less likely to get bony outgrowths? Thank you!! +2  

submitted by lfcdave182(24),

Cold temperature: Causes peripheral vasoconstriction and central vasodilation

  • Increased central blood volume --> Lower ADH due to increased blood volume through kidneys
  • Increased central blood volme --> leads to atrial stretching, increased preload --> Increased ANP release
passplease  what organs are considered "central"? I initially thought that the kidneys would not be getting more blood with most of the blood flow going to the lungs and heart +  

submitted by bingcentipede(120),

The patient has a brain cancer, which is 50/50 between primary cancer and metastasis (lung most common; also breast, colon).

The answer is small cell carcinoma of the lung versus a primary brain cancer because there are cells staining positive for carcinoma marker (cytokeratin) and neuroendocrine markers (chromogranin and synaptophysin), which is what SCLC is.

cassdawg  Another reason this is small cell lung cancer is the weakness of the proximal upper and lower extremities while also having augmentation (increasing) of strength with repetitive stimulation. This is characteristic of Lambert-Eaton myasthenic syndrome [where strength increases with stimulation; opposite of myasthenia gravis]. Lambert-Eaton can be caused by a paraneoplastic syndrome of small cell lung cancer (FA2020 p228 and 472) +4  
passplease  What about the fact that it is a single well-demarcated mass. Wouldnt metastatic cancer present as multiple masses? This made me think primary brain cancer. +2  
jaeyphf  @passplease I originally thought this way too and it fucked me. I think the easiest way is elimination + staining. Pt is an adult - eliminate neuroblastoma, ependymoma as both are more common in kids Pt is not immunocompromised - eliminate CNS lymphoma GBM does not stain positive for cytokeratin, chromogranin, synaptophysin - eliminate GBM Left with Small cell carcinoma +  

submitted by zincy7(12),
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bingcentipede  Black stool because blood in the GI tract? +1  
passplease  I was tempted to pick insulin, because of the orthostatics and sweating that could resemble hypoglycemic episodes. Why are those present in a gastrinoma? +2  
deberawr  @passplease it's possible that increased gastrin -> peptic ulcers -> perforation -> shock -> sympathetic nervous system overload -> sweating and hypotension +  

submitted by lsp1992(10),

Can someone please explain what we're seeing on the histo slide? I chose the correct answer because I was thinking fungus because of the immunocompromise and neutropenia (and I thought PAS was used for aspergillus), but I don't see anything fungus-related on that slide.

cassdawg  I think this is Blastomyces (broad based buds) where the darker pink are the blastomyces budding. Here are some similar slides: It could also be cryptococcus potentially ( but I think the bud bases are too broad and there is no clearing/visible capsule that cryptococcus is notable for. Either way you treat both systemic mycoses with amphotericin. +3  
passplease  How did you eliminate CMV? +  
cassdawg  For me, CMV would have the characteristic "owl eye intranuclear inclusion" cells on biopsy but would be less likely to show anything in pleural fluid (i.e. thoracocentesis would not be used to diagnose CMV). Further CMV pneumonitis is an atypical/interstitial pneumonitis (diffuse patchy infiltrates on CXR, FA2020 p683) and he has a lower lobe consolidation with pleural effusion (more characteristic of fungal pneumonia). +1