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Contributor score: 4

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submitted by neonem(514),
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Filgnla on utsrceohdtet a:dhn shadopci is mtos oocnmm eno to eb eur,ctrdfa lnaetu si stom oconmm ot be .eltoisaddc neatLu onsiticolad can cuase aceut acpalr nluent .emrsdnyo

hinkT fo the mmoncein igatShr"t iLen oT i,yknP ereH meosC heT mb"Thu fro eth oesbn of teh ,mapl nwgirda a obtlfola pehsa tarsting ewblo hte mtuhb CPM ijotn cteaandj to eth du,isar tneh gvmnoi ot rouy iadlem ,tisrw and ehnt acbk ot hte btum.h

pd,Shoica utla,ne mutritu,rqe pm,sriifo ethaa,m ieatpcat, ze,riopdat uarpze.mti hTe utenla losok eikl t'is oeprlrsytoi slcodetdia ee.rh

sympathetikey  Yep. I didn't even look at the X-ray. +7  
dr.xx  loonies love lunate +2  
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +  
wes79  i legit have no idea whats going on in that xray lol +8  
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  
doctorevil  She Looks Too Pretty, Try To Catch Her is a mnemonic that works for me. +  
niboonsh  Some Lovers Try Positions That They Cant Handle +7  
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. +  

submitted by drdoom(658),
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hTe ulddenoa mueln nd(a raeactpnci psterosea kile TNM)OYCPISYRH si het ites rheew epciartnca nzyeems oseaepi“d(psen”d)t aeevlc erlga odlteiepspyp toni mrseall btsi ,.psepppsi)ertetdtieidd=(i It si ta eth BSRHU EBDRRO eehwr eth laslmest kisnd of epstpedi e,sdpripeddtstipi()petie ear korbne wdon niot threi aionm adi,sc hhwci flylian can eb dartso-onepcrt tihw a+N otin het nalittnesi .clel

I khitn boaut ti hsit wa:y

  • ohctmsa acid tneeaursd nad seop“n p”u ietspron utw(ohit iipcfsce eaecal;vg)
  • petnrcaiac sneemzy hten evlace dedrtuaen pyotplpseied ntoi mrasell bt;si
  • sbhur eorrdb enmszey ainlylf karbe wndo sinteit epsdteip into eaobrlabsb imnao c.sdia
regularstudent  Isn't the brush border still part of the intestinal lumen? Don't the amino acids enter into the intestinal cell (the "intestinal mucosa")? +  
drdoom  @regularstudent No, the lumen is literally the cavity—the empty space. +  

submitted by drachenx(38),
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These sinkd fo ousetiqns era relyla rdah aceuesb e'vI erven nees emefal creedpvtiuro tcestusrru irl. :c

nbmehelp  Lmao +1  
regularstudent  Lmao +  

submitted by lamhtu(86),
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lPtaetle ceedaerhn nda leeapttl gigogernata are tieffdren hisntg dna iths einrecefdr AERTSTM A L.OT ckFu ,uyo BN.EM heseT ecfifrsdeen psylspdeou mertta no eosm iquoetsns nad nto on .ohster Weehr si eth i?nessoccnyt lel?Ho

hungrybox  Agreed. This is so fucking stupid. +  
hungrybox  "Aspirin inhibits platelet aggregation and produces a mild bleeding defect by inhibiting cyclooxygenase, a platelet enzyme that is required for TXA2 synthesis." literally straight from Big Robbins +1  
susyars  Im gonna upvote this bc i love to be right +2  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +1  

submitted by hungrybox(800),

(D) Portal hypertension: Portal hypertension is a complication of longstanding alcoholism, but it is not the cause of acute or chronic pancreatitis.

In acute pancreatitis, alcohol transiently increases pancreatic exocrine secretion and contraction of the sphincter of Oddi (the muscle regulating the flow of pancreatic juice through papilla of Vater).

This leads to activation of pancreatic enzymes and acute pancreatitis follows soon after.

In chronic pancreatitis (as in this patient), alcohol increases the protein concentration of pancreatic secretions, and this protein-rich pancreatic fluid can form ductal plugs.

Made this explanation in case any of you were dumb enough to think "pancreatitis → alcohol → portal hypertension" like me.

hungrybox  oh my source was big robbins btw +  
regularstudent  I was definitely dumb enough +  

To get such vague questions right:

  1. Consider saying all the statements in the snarkiest tone possible under your breath (translate to mother tongue if IMG for bonus effect).

"Stop Bickering" - while saying, don't you get a hint of paternalism, like the doctor treating the parents as teenagers themselves. They are fully grown-up themselves; they know they shouldn't bicker!

  1. Don't choose the refer option on Step 1 (99% of the time correct).... unless no other option at all fits your case first UWorld has questions going to court as the right answer even! But in all of them, it was evident that no other option could come close to being polite/nice/ethical/legally correct.

  2. Options that say - encourage/endorse/discuss/ask - are always preferred. Communication = Key Questions

regularstudent  I love this lmao. I said stop bickering because I thought it would be fucked up to ask the parents about how their kid's diabetes has impacted their family. Me :"So how has this kid's disease impacted your family?" Parents"Oh! we're about to divorce because of this fucking kid. She's a constant stress, and that's why we constantly fight, even during dinner and at the doctor's office!" +  

submitted by cassdawg(586),

For diabetic nephropathy (as evidenced by her microproteinuria), ACE inhibitors or angiotensin receptor blockers (-sartans, such as irbesartan) are first line for preventing progression of the disease. They also help to further control blood pressure. Thus, an ARB would be the best choice of the answers given.

regularstudent  I was under the impression that African-Americans did not respond well to ACE inhibitors and ARBS. Our school taught us this pretty early on, and made sure we didn't forget. That's why I chose amlodipine. Bummer! +3  
pranspach  ^Yes, I believe African-Americans may respond to other treatments more so than ACEI/ARB (because they are relatively lower renin producers, if I remember correctly) such as calcium blockers and hydralazine (per Sketchy) for simple hypertension; HOWEVER, since the patient also has diabetic nephropathy, ACEI/ARB also decrease intraglomerular pressure in addition to addressing the hypertension. FA2019 pg 596 for ACEI, pg312 for table on hypertension treatments. +