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Welcome to rockodude’s page.
Contributor score: 18


Comments ...

 +0  (nbme24#25)

eliminate fecal oral viruses then you're down to EBV and corona. corona is a respiratory virus, second most common cause of common cold, and EBV causes mono, not really associated with a cough. thats how I looked at it


 +1  (nbme22#22)

when we were in our derm block our course director said that on boards, burrows=scabies every freaking time


 +1  (nbme20#13)

why can't this be pylori stenosis since the time period for pyloric stenosis is 4-6 weeks

sohadiha  This pt is vomiting a small amount. Pyloric Stenosis has projectile vomiting (so high force). Also would likely mention a small mass palpated or "olive shaped" mass w/ PS. +1
sohadiha  Also, the infant with PS would not being able to hold food or obtain any nutrients without projectile vomiting it out and this pt is nl height & WT and is only spitting up a few times a day and not with every feed. +1
rockodude  tysm! +

 +0  (nbme20#46)

always do no harm ppl, comes up again and again and again


 +1  (nbme20#49)

why couldn't this be platelet dysfunction, option E, like a qualitative platelet disorder even though the quanitative amount of platelets are normal

kevin  She's in her 90s, she would've likely presented with a platelet disorder decades ago. Given the vignette a normal aging process was most likely +2

 +0  (nbme23#38)

not sure if this is right but the way I thought about it was that after family a surrogate decision maker can be a close friend and the neighbor has cooking for him and running errands for the last 5 years since his wife died so I believe that the close friend surrogate designation may apply





Subcomments ...

submitted by drdoom(885),
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etfAr het fcuf is ide,t het llces and issetu tladis ot eht ufcf will ucnnetio nmusngcoi APT (PD;t-gTAA&P), utb on fsrhe oodlb lilw be ldevireed to r“e”cla htaw lwli eb na laumngcicuat tmaonu fo PDA dna htero toemiaesbl.t DAP nAonid()see= is tilefs a xoryp fo ionmutcnpso and reisdv onasloivatid fo eertai!sr unEvt(olio si st!arm) ecnasIrign ens/odiAePDnA ni a alo“lc nvei”onentrm is a lngsai ot the bydo that a lot fo nisootcnpmu is ncircugor et;her su,ht tsaeirer dan reelioastr tanlyluar laidet ot neeasrci dolob lwfo raset and ews“pe wya”a ctmileoba otucdsypb.r

lispectedwumbologist  You're a good man. Thank you. +  
drdoom  So glad it helped! +1  
seagull  very well put, thank you +1  
eosinophil_council  Great! +  
aisel1787  gold. thank you! +  
pediculushumanus  beautiful explanation! +2  
rockodude  this explanation was on par with Dr. Sattar IMO +2  
flvent2120  Just to add on to this: FA2020 pg. 297. CHALK (Calcium, H+, Adenosine, Lactate, K+) is known to vasodilate muscles during exercise as well as regulate sympathetic tone of arteries at rest +1  


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hTnak you NBME fro hte hihg iualytq ucetrs.pi tI asekm ethse xaesm setssr eref dan eonye.bajl

sympathetikey  Feels bad man. +3  
zoggybiscuits  Those Sclera sure look blue. wow. +20  
yotsubato  the same girl shows up on so many NBME exams its not even funny. Its just like that poor kidney that's cut in half that shows up in all kidney questions. +13  
aneurysmclip  I turned my brightness up and down 2 times to make sure it wasn't my brightness messing with the sclera. I'm declaring it, NBME stands for "Naturally Bad at Making Exams" . +6  
peqmd  $60 a pop and no competitors...That's what happen when there's a monopoly. +6  
peqmd  Actually they used their best software to generate images. You might have heard it before, it's called MS Paint. Quite legendary. +7  
feochromocytoma  It feels like they cranked up the contrast and saturation on a normal eye to make it look "blue"... +5  
rockodude  everyone hates on nbme, but they're showing you a picture zoomed in of her eyes and she has a history of multiple fractures/bad wound healing at the age of 4, I feel like OI should at least be a consideration based on the overall clinical picture +1  
feochromocytoma  Yeah I got it right, it's just funny that they don't use higher quality pictures for the exam +1  
djeffs1  that is clearly a malar rash... oh wait nvm just pixellation +3  


submitted by beetbox(1),

Can someone explain more on how to tackle these types of questions? I suck at these questions for real... To me, he sounded pretty sane and reasonable (does not wish to waste other people's money). Sure he might be under slight depression judging how he has a terminal illness and his statement on how nobody cares for him. But unless he is incoherent or displaying magical thinking, signs of loss of memory etc., why should he be evaluated on decision-making capacity?

drdoom  in medical parlance, you can be so depressed that you're actually cognitively impaired. this is known as pseudodementia. thus, you need to figure out: “is this guy so depressed we can deem him incompetent to make decisions?” +  
rockodude  he says he has an invention to cure arthritis in 6 months he'll be back.. not normal imo. at least for this question thats the line that made me think does this person have capacity +  


submitted by ameanolacid(26),
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erlecssAosrihto si the OMST mmocon cusea fo eanlr reyrta .i.isoest.nsthw ofrlmscubiaru ysailpads enbgi the ESDONC smot mocomn eascu e(evn ohught it is ptmgtein to ecohso hits noiopt escodgnniir the ptiest'an aei.gdcpomrh)

xxabi  Is there a situation where you would pick fibromuscular dysplasia over atherosclerosis if given both options? Thanks for your help! +5  
baconpies  Atherosclerosis affects PROXIMAL 1/3 of renal artery Fibromuscular dysplasia affects DISTAL 2/3 of renal artery +52  
gonyyong  Why is there ↓ size in both kidneys? This threw me off +3  
kateinwonderland  @gonyyong : Maybe because narrowed renal a. d/t atherosclerosis led to renal hypoperfusion and decrease in size? +1  
drdre  Fibromuscular dysplasia occurs in young females according to Sattar Pg 67, 2018. +12  
davidw  Normally you will see Fibromuscular dysplasia in a young female 18-35 with high or resistant hypertension. She is older has a history type II DM predispose you to vascular disease and normal to moderate elevation in BP +9  
suckitnbme  @gonyyong there's bilateral renal artery stenosis. The decrease in size of both kidneys should be from atrophy due to lack of renal blood flow. +3  
tyrionwill  1 year ago, she did not present any physical or Lab abnormalities. This means she must not suffer fibromuscular dysplasia, otherwise she must have presented renal abnormalities for a long long time, or even before DM-2. +2  
rockodude  a little surprised that atherosclerosis leading to bilateral renal artery stenosis and shrunken kidneys could happen that quickly after everything was A okay the year prior +1  


submitted by sajaqua1(535),
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ryimrPa eptnreinov is na evatic etps atken ot dahe ffo or mteiatig a deesi-sa nikht of inio.acctsanv nI tshi ca,es ti is ylieletsf odiaoictmfin re(seicxe) ot eplh 43-00 eayr odl onewm iwegh(t rnigeba xieecres anc eiamttig isoetprosoos, ebsietfn fo cebirao ciesexr).e

onydSace vitrepnneo is arley ctitneoed of a ee,sidsa ionropmgt eyarl vei.teintrnno hisT cloud eicunl hgnsit eilk IVH ntetgsi verye 6 stmoh,n or or lnuana mah.yapromgm

raerTtyi nievoenntitr is pahyret magiin at eridugnc tnpc,clsoamoii glawioln rl,eapse ro mpnvorgii tfuconn.i escintenbA frmo haloclo yma eb hree eeacsbu of ecsnbstua aesub esl,bmorp ro euabesc oesm eamdga plsvoeyiru enod yb holaclo atcnno eb .veprneted lryliaiSm rof a owl bhyrertcadao etdi ew may eb gtimtginia the fstcfee on ableitsomm ttha aehv aaeyldr been do.ne

sunshinesweetheart  p 269 FA 2019 +  
motherhen  [P]rimary= [P]revention [S]econdary= [S]creening [T]ertiary= [T]herapy +3  
rockodude  almost picked alcohol because that may lead to fetal alcohol syndrome, relevant to women of childbearing age, but regular exercise made more sense. complete abstinence of alcohol is a little extreme for a general recommendation +  
jurrutia  Abstinence from alcohol is a form of primary prevention, because alcohol causes many bad outcomes. However, exercise is more important. +  


submitted by drachenx(57),
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eeThs isdnk of esiunostq ear llyrea adhr sebeauc ev'I reevn esne eflema vipetocruerd rctsesutur i.rl c:

nbmehelp  Lmao +3  
regularstudent  Lmao +1  
mutteringly  Lmao +  
rockodude  lmao +  
abkapoor  Lmao +  
dang90  LMao +  
noopnoop  Lmfao +  


submitted by drmohandes(100),
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iamyPrr lyarofcto orextc si oadlcet in eth tomeparl .beol

ecrkcheli

rockodude  I feel pretty dumb for not knowing where smell is processed in the brain at this point in my medical education. Glad I learned it now! +1  


submitted by link981(160),
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Heamitnsi scseau arerteoli loaaosdvii,tn iansguc a pldubui of obdol ni teh sllaairei.cp The asdenrcie oldob in eth elaprcaisil lwli auesc teh psesreur rtehe ot se.ir naolFttrii si eeetnddnp no e,eruspsr hte erhihg eht rsspeur,e eth oerm eht f.tialnrtoi

eRmbemre obodl wlof: ivnes to svuenel ot aresalpiicl to tsroleirea to eeirrsta

yb_26  agree in all, except the blood flow - it is right the opposite [https://teachmeanatomy.info/the-basics/ultrastructure/blood-vessels/] +16  
link981  I stand corrected @yb_26. Brainfart moment 🙈 +  
rockodude  lmao including a link to a teachmeanatomy page on basic blood flow +  


submitted by pparalpha(84),
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cigrndcoA ot B:nB

erlavCci bir is an moanluoas tarxe rib ormf eth ht7 iarlvecc raetbere.v eopPle tihw sith ear ta irks orf ithccaro ettlou oyrsmnde (kaa omienrspsco fo evsenr nad ssesevl tath aevle het rxatho. shiT ccosru bevao teh rstfi bri dna bniedh hte i)a.lvlecc

nilcCali eeuratsf :ieundcl

1) caaribhl xlusep jyruni (cuhs sa kmKelpu p,alsy hihwc si a erwlo xespul y)ujrin

2) suoenV oicmespnsro

3) Aealrtir nocserpmiso

An* nottmpria aamilatocn clatereor eth secalen iltnrgea (aotriner cea,nels lidmed ls,encae bevao eth itfrs )rbi

llamastep1  The cervical rib is underneath the brachial plexus, the pressure of the backpack compresses these nerves causing the pain https://lh3.googleusercontent.com/proxy/m6FASqomZvlebUu8MoUePvFzMXP7u8vgEnT0VamRq3Wij_sOH7gtJTfK1L9LCeOgsq-O6Rpxd_Z0mhjL +1  
rockodude  link didn't open for me +1  


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itEaess ayw ot hknti fo this is ttah htsi si raGaetod. uerS roeeyven hisknt ttah tssorp ksnidr vhea usceogl for het neeryg chhi(w is aols tru)e tbu htye aslo aointnc ausrg sbuecae the osGauec/lN tpctnrar-orose ni hte allms nteiisten elshp ridve eerllyctote in.aetk tiuhotW coleu,gs uoy dnt’o lulp ni siduom ynarle as flnyieiftec ni the gtu adn eth fstir aesmrk of het oaeadGrt uarofml at FU onfud that ncoe eyht vgea goclesu dna lsleteyrocte nidatse of sjut artwe ot hte olatfobl atme dnirgu tccer,ipa thye in’ddt teg as dredhedyta dan htrie eeeytllortc leaanbc swa a tol moer sb.elta

usmleboy  Gaaaaaatttoooraaddeeee! Water sucks! It really really sucks! +2  
mumenrider4ever  You're drinking the wrong water https://www.youtube.com/watch?v=7I2-14y6-jM +1  
rockodude  go gators, we made that shit +  
username  go dawgs +  


submitted by d_holles(187),
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Thsi oiedv eixlpnsa the apdiicret useuunatonocre rdiredoss le.wl

Hswt/kewwLtathw?b8.Ctonu.K7=t/mooucc/pmyv:h

allaysBci het yek heer si neeghimdpyopt msecual. 1FN ash afce ua ielta ospst dhmieypp(etgren lcu)amse hweil TSC ash has alfe sospt impt(oehpendyg sm.c)ulae hTsi is a oddece het bzrowuzd eytsl inteouqs. I eltf iekl I idtn'd elaylr rdntsudena sthee rdroes iunlt I wthcead het baveo iv.eod

pg32  I figured this out for a few reasons. The hypopigmented patches are ashleaf spots and the raised, flesh-colored lesion on the back is a Shagreen patch (only seen in TSC). Multiple brain lesions = hamartomas. Additionally, NF1 has 100% penetrance, though it also has variable expressivity, meaning if it were NF1 we would probably see some family history of similar symptoms. +3  
castlblack  Agree. CAFESPOTS Cafe-au-lait, Axillary Freckles, Eye (Lisch nodules), Sarcoidosis, Pheo, Optic Tumor (glioma), Seizures +  
rockodude  the video is very helpful +  


submitted by mcl(599),
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DCC nedmcmodere mrttetane fo ositsaohcms ionsmna is apelunrqt.zai

makinallkindzofgainz  It's also the pretzel in the Sketchy video, which I think most would agree is more reputable than whoever these "CDC" people are +15  
rockodude  ya until step 1 fucks us with some esoteric cdc guideline +  


submitted by hungrybox(1044),
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scityspDla einv rea a ucoprsrre to ae.nomlam heTy veah lurgie,rar dpssil""ayct rdbrs.eo emrbeRem the B"" ni CDAB tasdsn fro riuagerrl seBrdro. Nuvse names e.olm

Orthe :rsasewn

  • htsaocians niicsagnr - nkeainrgD fo kisn aecsidtsoa hitw Type II tdebieas steumlil

  • aasbl llec ciaorcanm of snki - aye,Rrl fi rvee mseztsiteas.a Cmlonmyo fesftca peupr ipl.

  • beul envus - eoeodBul-rlc pyet fo ocmomn elmo. ginBne.

  • gtepinemd riehrsecob sitaeoskr - cSu"tk n"o ea.eppanrca stoylM n.ibgen eAfscft rlode .eplpeo

  • (Ntoe - yuo ulsuyla ees loyn n.eo fI tpueilml ihsrrobece aeksresot rea es,en it nicsdeita a GI ncylgnaaim - aak sélrera"-eLTt sig)n
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +26  
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +5  
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +5  
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2  
teepot123  fa 19 pg 473 +  
rockodude  just remember BS. basal cell upper, squamous cell lower +  


submitted by rockodude(18),

why can't this be pylori stenosis since the time period for pyloric stenosis is 4-6 weeks

sohadiha  This pt is vomiting a small amount. Pyloric Stenosis has projectile vomiting (so high force). Also would likely mention a small mass palpated or "olive shaped" mass w/ PS. +1  
sohadiha  Also, the infant with PS would not being able to hold food or obtain any nutrients without projectile vomiting it out and this pt is nl height & WT and is only spitting up a few times a day and not with every feed. +1  
rockodude  tysm! +  


submitted by strugglebus(165),
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noPrlalpoo si a vl-eiscnteneo aetB krce.lob So oyur RH will daseecer B(,1) chihw wlli uaecs a namycorostpe rsinceae ni .TPR

home_run_ball  ^ Above is partially right: Propranolol is non-selective Beta blocker: Beta1 stimulation causes inc HR, therefore blocking it will dec HR and dec Cardiac output Beta 2 stimulation causes vasodilation, therefore blocking it will CAUSE UNOPPOSED alpha1 activation --> therefore increasing total peripheral resistance. +42  
amarousis  so why tf do we give beta blockers for hypertension -.- +6  
dr_jan_itor  I would also add that the patient was previously on an a2 inhibitor (clonidine), which he ran out of. So he is rebounding on that with upregulated a1 receptor activity. Adding labetalol would cause a greater degree of unopposed alpha, increasing tpr +1  
llamastep1  @amarousis They are used for hypertension because the hypotensive effect of the reduced CO is greater than that of the effect of the increase of TPR. Cheers. +7  
hungrybox  @dr_jan_itor Adding labetalol would not cause unopposed α1 because labetalol and carvedilol are α1 blockers in addition to being nonspecific β blockers (great name btw, I love scrubs haha) +2  
mw126  Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +  
rockodude  @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +  


submitted by dbg(151),
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,Iom htsi snrawe ceohci si gwro,n htere si on poelmbr ni het roecpss of gcnelola istssnhy""e erp .es Teh ussie is hwti esvesixec ssnyishet dan oddgiszerain nioo.ipdest tNo na 'mnarloab tsteichyn osecp'sr - as udwol eb ni ,DSE F,M kenMs,e .tce

whoissaad  Exactly my reasoning for not choosing collagen "synthesis" +3  
rockodude  dont overthink people, whether its an underproduction or overproduction of collagen, overproduction is still abnormal collagen synthesis. its abnormal to make an excessive amount of collagen 3 leading to a keloid +2  


submitted by hayayah(1079),
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sieseMsn onuatmtis nvloiev a eioutcedln tsusotiubnti lunseirgt ni ahendgc imnoa .iascd miSosemte eht sffceet of nessisem aumitonts yma eb oynl rpnapate nrdeu tecrani telenovmirann odontin;csi uhsc eimnssse namtotsiu era ledlac onicioaldnt snam.uitto anMy snmeessi atstoiumn tsuler ni niposetr hatt ear isltl inolt,ucfna at eatsl to mose erde.eg

soA,l all eht ehrto erassnw woldu lbypbrao aeevl ouy whti hrteie a yetalgr etarled or tfononl-cnniua ptnei.or

thefoggymist  I chose nonsense because I thought it'll make the enzyme shorter (since less bonds = more heat liable = can't work at 42 degrees) but yea, probably won't work even at 30 if it's an early nonsense. +9  
joanmadd  A good clinically related example is HbC disease on electrophoresis. HbC disease is due to a missense mutation (glutamic acid (-) for valine (neutral)). The mutated hemoglobin is still fairly functional but when placed on gel electrophoresis the HbC migrates the least far from the negative electrode due to less negative propulsion (lack of wild type glutamic acid). +2  
fatboyslim  @Joanmadd Just to clarify, glutamic acid substitution for valine occurs in sickle cell disease not HbC. HbC is glutamic acid substitution for lysine :) +6  
rockodude  lyCCCCine for HbC +2  


submitted by hayayah(1079),
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e'Hs not gtinae gehou.n

neO fo osrcl'tios uitnosncf si to esnraiec eenlsoesgciogu,n sli,piyosl adn olo.ystrepis

ankirin  Why wouldn't it be T3? Thyroid hormones also ↑blood sugar and break down lipids +1  
waterloo  @ankirin his symptoms aren't really specific for T3. They don't mention tremors, exopthalmos etc. I think just in physiologic terms, you can bet cortisol is more increased. It's not a great question though imo +  
rockodude  can someone comment on why his appetite is down, per first aid 2019, page 329, cortisol increases appetite. thank you +  
lifeisruff  his daughter isnt there to bring him groceries +  
medstudent22  T3 levels decrease in states of starvation in an attempt to preserve energy. T3 is incredibly metabolically potent - even more so than T4. By decreasing peripheral conversion of T4 to T3 (ie decreasing T3 levels), you are decreasing metabolic activity in "unnecessary tissues", decreasing ATP use, and increasing overall energy availability for necessary tissues (brain). On a side note, rT3 levels may increase but this is not metabolically active and will not be measured as an elevation of T3. Dr. Ryan had a great explanation of this in one of his thyroid videos. https://pubmed.ncbi.nlm.nih.gov/12055988/ +  


submitted by neovanilla(39),

The way I approached the question was to consider what happens 1. When you grow from a baby to a child, and 2. when you grow from a teenager to an older adult. Whatever remained true between both of them was the right answer.

Right answer: The resting BP of a newborn is 65/40 (google), while that of a 1-month old is 95/60. The average adult is higher, with the American Heart Association citing (absurdly, IMO) that "normal" is <120/<80. Nevertheless, the trend is that BP increases as we age, whether we are newborns or old people.

Wrong answers: Development of coronary atherosclerosis: Perhaps due to the American diet it can be argued that the development of atherosclerosis is almost inevitable as you become an older adult. Certainly not true as a baby --> child.

Development of mitral stenosis: Similar reasoning as coronary atherosclerosis; you MAY develop it as an adult (not nearly as common as a buildup of atherosclerotic plaques), but sure, let's say that it can happen. Not true as a baby --> child.

Increased basal heart rate: The opposite is actually true. The basal heart rate of a newborn can easily exceed 150, and that's considered normal. As we age, this heart rate goes down.

Increased cardiac muscle mass: This one was the hardest to work through. It is true that as we age from a baby --> child our heart grows in size. But if we tweak our assumption from before with the American diet, and instead put our patient on a more moderate diet, realistically his heart shouldn't increase in size too much, at least to the point of cardiomegaly.

Increased compliance of arteries: As we become older adults, the compliance of arteries decreases and stiffness increases (careful not to confuse arteries with lungs, which actually do increase in compliance as we age!)

rockodude  basically the American diet is... SAD;) +1  


submitted by thomas(2),
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amiapLLsoomsaris/cop rae teh csoetmomn eot-ssftsui motrus ni duslat. hTe hhig mctiiot nidxe ;apm& ettrivialfin uearnt citdiena atht teh smas si aa.imnngtl

rockodude  most common +  


submitted by smpate(15),
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/htep.usts/stpr/rwd/Phomtafl/ptnmhnhStaTnbed/llta.l.t/:dHae

rockodude  wow that was super helpful +  


submitted by step420(34),
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Tihs si nmulliare .sneasige arlmoN overias tub etbnas teus.ru

endochondral   why not androgen insensitivity? +  
shaeking  I was wondering the same thing because doesn't androgen insensitivity also have normal female secondary characteristics. Was it the levels of hormones because she doesn't have abnormally high testosterone? +2  
swb  Androgen insensitivity has the same presentation and symptoms. What's the clue that it is mullerian agenesis instead ? +23  
sugaplum  Testosterone would be high if it was androgen insensitivity FA 2019 Pg 625 +14  
charcot_bouchard  Testo would be high in AIS. in AIS pubic hair, axillary hair doesnt devlop because of androgen insensitivity. both have normal breast dev and primary amenorrhea +2  
dickass  This is not androgen insensitivity because she has perfectly normal Estradiol, which means she has perfectly normal ovaries. She also has regular female levels of testosterone. +5  
rockodude  thank you @dickass +1  
j44n  Also AIS has paradoxically large boobs-> tanner stage 5 and thats not mentioned anywhere +  


submitted by breis(50),
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etintPa ash olMscdytisi ruurmm erdah at eth aidracc apex. rteeh is saol a FTEL RIALTA a.obyitnlmra Ehoc sswoh TEFL TURMIA si .gledraen

diM tcig .y.esradn.lesol tlfe .trua.im.

tsBe cioc:he tilaMr gegRur

hpsbwz  Why is it regurg instead of stenosis? +3  
minhphuongpnt07  Vague question requires a lot clinical reasoning. mitral regurgitation: holosystolic murmur( this cv: midsystolic), enlarged LA, LV Mitral stenosis: diastolic murmur, enlarged LA, normal LV. only best explanation I can think of: early stage Mitral regur, that's why the murmur is not holosystolic but midsystolic and LV still adequately handle the situation +4  
dickass  @hpsbwz it's regurgitation because the murmur is SYSTOLIC, when the mitral valve is not supposed to make any sound. mitral valve leaks in systole, which causes blood to back up, which causes the left atrium to work harder and eventually hypertrophy. Mitral stenosis would be a DIASTOLIC sound, which is when the left atrium normally contracts. +8  
themangobandit  I'm still confused as to why mitral regurg has an enlarged left atrium. Are we supposed to think that it was mitral stenosis for a time, the high LA pressure led to hypertrophy, and then became mitral regurg? That's how it works in rheumatic fever, right? +  
shapeshifter51  I agree that mitral regurgitation is a holosystolic murmur heard best heard over the apex. However, with the murmur being found in the mitral valve area of auscultation it was the only answer choice that could result in LA enlargement and normal LV. Ruled out mitral valve stenosis since it is a diastolic murmur. +1  
weenathon  @themangobandit I believe mitral regurg could cause an enlarged left atrium from the increased amount of blood flooding back into the left atrium with each systole causing increased pressure on the wall. +  
rockodude  why is LV size normal? doesnt cause MR cause increased preload and overload over time leading to enlarged LV? +  


submitted by waterloo(76),

when CMV is involved in post transplant patients that typically causes pneumonia. I think that was a question in this NBME too. For EBV post transplant, it would be lymphadenopathy etc. That's what I've taken away so far from nbme. I thought maybe the monomorphous B lymphocytes was hinting more towards EBV too, but I don't see why CMV wouldn't remain latent in a B lymphocyte?

uloveboobs  CMV definitely could remain latent in a B lymphocyte, but also is latent in T cells and macrophages (i.e., all mononuclear cells). I think the key in this question is the phrase "monomorphous population of B cells." EBV remains latent in B cells ONLY, whereas CMV is latent in all mononuclear (not just B) cells. +6  
rockodude  ^this is the main point of the question. CMV can cause lymphadenopathy and hepatosplenomegaly as well. Key is the monomorphous phrase. +1  


submitted by hayayah(1079),
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iliaalFm adtosnomeua popssyoil si na omtaaouls ninamotd .iuntoamt aushsndTo of lpopys aisre gstrnait efrat uprt;bye icplanoc;no alaswy vnsvioel .eructm cycarhtPlpio mtccoyeol ro eesl 001% gpsrosre ot .RCC

aAoolumts daniomtn asesdsei h,aev on ,gearaev %05 accehn fo eigbn saesdp odwn ot gpiof.frns

sympathetikey  I would say this is Lynch Syndrome (APC is usually thousands of polyps) but lynch syndrome would generally have a family history of other cancers as well, so you might be right. Either way, both autosomal dominant so win win. +2  
smc213  uptodate states: Classic FAP is characterized by the presence of 100 or more adenomatous colorectal polyps +  
dickass  @sympathetikey Lynch Syndrome is literally called "Hereditary NON-POLYPOSIS colorectal cancer" +9  
fatboyslim  I think this actually is Lynch syndrome. Lynch syndrome can also develop colonic polyps but not nearly as bad as FAP. FAP has so many polyps you can't even see the normal mucosa. If you Google Lynch colonoscopy you can see that they develop a few polyps. +  
rockodude  I forgot it was AD inheritance but regardless at the time I was confused because APC is a tumor suppressor so it needs two hits. I guess AD inheritance and then you need another hit to develop CRC kind of like familial retinoblastoma or li fraumeni syndrome +  


submitted by dickass(88),
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Yhae, ,so stunr otu tish si not iopnhgeecrN DI due to ihuitml e,su uoy n'dot gvei liuhmit ot ratte ezcrshiohp.ani

mbourne  If it was Nephrogenic DI, you would have essentially have the effects of too LITTLE ADH. This patient shows severe hyponatremia, essentially the effects of too much water in the serum. This could be from SIADH or polydipsia, and the question stem and answer choices leave us with Psychogenic Polydipsia as the correct response. +1  
rockodude  I was thinking about carbamazepine causing SIADH but that is an anti-epileptic not antipsychotic and also as someone said above, the urine would have high osmolarity due to water reuptake at the collecting duct. just fyi +  


submitted by sajaqua1(535),
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A) Aetrirno dorc -osmenyrd ossl of omrot ,mdoamcn sa elwl sa tbleraail sols of heat adn np,ia the ineptta sah tno tslo omrto iuotcnf,n so ti cntnoa eb .hist B) atnCrel rdco nodeym-rs penrstse sa a tiboacinmno fo rotmo adn eosrsny sl,os yluluas iwht ddbearl fydnso.cntiu siTh nttieap deos ont paysdil troom ssol or dlbdear oft.sdynncui C) Hdcierom -dnorymse Aosl allecd de,waS-Buorrnq tshi si lepmctoe rjyuni ot hreiet hte lfet ro rithg dsei fo eht asnlpi ordc. It pserestn wthi oortm ydnufcitnso adn eferxl sycunfotidn ailpleylriast ta eth llvee of the lseion; olss fo prepu oromt ammnodc eblwo hte oelins ylriptlasaiel ssitcap( ri);ssepa slso of lasodr ducinrlerm-cao tninasose peiylatlaslri ta dna wbleo eth selo;ni and ossl fo aipn dan eurmtpreeat tseoinsna earatnortlcalyl 2 ot 3 vtearebr ebwlo eht .sleoni )E gmaSynrtee oesr-ymnd a alnniegcot rfliaeu to dopeelv tapr of the npslai do.cr eTh wne stoen fo tysosmpm at 82 reasy dlo keams itsh na ullkenyi ssn,iagoid.

yb_26  amazing, thank you! +  
aisel1787  great explanation +  
rockodude  sensation to pinprick is DCML tract. SCD affects spinocerebellar (not spinothalamic), corticospinal, and DCML. otherwise good explanation. +1  
azibird  Sensation to pinprick is not dorsal column-medial lemniscal tract, it's spinothalamic tract. So this patient has a lesion of the dorsal columns, spinothalamic tract hypersegmented neutrophils, and anemia. What the hell is going on? How is this just posterior cord syndrome? Spinothalamic is not posterior cord. +4  


submitted by drschmoctor(95),

Both parents have alpha-thalassemia trait. Given they are Asian, they will have the cis-mutation. That is, each parent will have 1 chromosome 17 with 0 alpha chain genes + another chromosome 17 with 2 alpha chain genes).

Thus, each parent can pass on either 0 or 2 copies of the alpha chain gene. So, the offspring will have a

  • 25% chance of having 0 alpha chains (causing hydrops fetalis & death in utero),
  • 50% chance of having 2 alpha chains (alpha-thal trait, answer choice D), and a
  • 25% chance of having 4 alpha chains (normal).

A) Hemoglobin H is when there is 1 alpha chain, so that is not possible.

B, C, D) Both parents had normal hemoglobin electrophoresis, so Hb S, HbSC, and B-thal are not possible.

rockodude  *alpha chain is on chromosome 16, beta chain is on chromosome 11 +1