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 +1  (nbme21#11)

80% chance (power) the study correctly identifies the existence of an association in reality. If an association is determined to exist, >95% chance the study and reality agree with each other (p<.05)

 +1  (nbme21#6)

When you see a pancreatic endocrine tumor in combination with other weird findings, always think MEN 1

 +4  (nbme21#10)

Rosacea. An inflammatory facial skin disorder characterized by erythematous papules and pustule but no comedones. May be associated with facial flushing in response to external stimuli (eg, alcohol, heat).

 +5  (nbme21#37)

GUYS! You really have to look at the axis labels. The question says the pt.'s cystathionine synthase activity (y-axis) is NORMAL with an INCREASED amount of pyridoxal phosphate (x-axis). Y-axis is the same as NORMAL, x-axis shifts to the right showing INCREASED pyridoxal phosphate

 +0  (nbme21#17)

The question says GASTRIC varices, not ESOPHAGEAL varices. My stupid brain. Plus I'm assuming left gastroepiploic would be a correct answer if it was listed.

cmun777  While L gastroepiploic would make more sense than the other answers, considering it has an anastomosis (and therefore an outlet for the increased blood) I think it would have much less risk of varices/bleeding than the short gastric would

 +0  (nbme21#34)

It sounds a lot like PSGN, but PSGN is nephritic and we would see pronounced hematuria with minimal proteinuria.

 +0  (nbme21#37)

Patients with an internal capsule stroke commonly have pure motor weakness affecting the contralateral arm, leg, and lower face. Contralateral spasticity or increased tone with hyperreflexia are also present.

 +1  (nbme21#14)

I got tricked into picking the "acquired antibodies against P1A1". Human platelet Ag platelet antigen P1-1a, located on integrin β3, is the main target for responsible for neonatal thrombocytopenia.https://www.jimmunol.org/content/194/12/5751

cienfuegos  Same, except in my case I was the person who was tricked and who did the tricking though. Thx for the link.

 +6  (nbme21#35)

The Didanosine guy in the NRTI sketch is holding a pancreas sponge.

qball  Sir Dan, my boi.

 +1  (nbme21#15)

I cut open an eyeball once and I was surprised how dense black the material inside was. That plus process of elimination brought me to the right answer

 +1  (nbme21#46)

Associated neoplasms in Li-Fraumeni syndrome. Sarcomas, breast cancer, brain tumors, adrenocortical carcinoma, leukemia

 +1  (nbme21#48)

What a GARBAGE question. He was eating breakfast 2 hours ago just fine and now we are supposed to have the family come to a consensus about a feeding tube like he's on his death bed? BULLSHIT

Subcomments ...

I think it is good to note the demographics. The patient is female and old. That, along with the constipation, made me lean more towards diverticulitis. IBD usually develops in younger persons.

privatejoker  Does the obviously darkened area not point at all towards ischemia of any kind? Maybe I am blind, but I don't see anything that remotely looks like an obstructive diverticulum in this picture. I feel like I would have gotten this question correct if no picture had been provided at all because the symptoms described absolutely pointed towards diverticulitis otherwise. I actually changed my answer because of the image lol +11  
sahusema  Picture is a bullshit distractor +2  

submitted by usmleuser007(220),

just a hunch.... Omeprazole is always the right answer

nala_ula  Famotidine is an H2 blocker which really only stops acid secretion via the stimulation of H+/K+ ATPase by histamine, but it still has vagus and gastrin stimulation. If you use Omeprazole, you get irreversible inhibition of the pump itself which stops the secretion of acid even if there is histamine, gastrin, vagus stimulation. +6  
temmy  what about the healing of her mucosa. Is that not the action of prostaglandin?. That threw me off cos according to FA, misoprostol increases secretion of the gastric mucosa +4  
cry2mucheveryday  same doubt..marked miso +  
sahusema  I guess because misoprostol is more associated with treatment of NSAID related ulcers and PPIs are 1st line DOC for GERD? +1  
makinallkindzofgainz  @temmy, I think that Omeprazole is a better answer because although Misoprostol would promote healing of her esophageal mucosa, it wouldn't do anything to relieve the symptoms of GERD (due to acidic contents in the esophagus) +  

“The combination of a long-acting beta 2 agonist (LABA) and an inhaled corticosteroid is more efficacious in asthma and [COPD] than [...] either alone. Corticosteroids may regulate beta 2 receptor function by increasing expression of the receptor, restoring G-protein/beta 2 receptor coupling, and inhibiting beta 2 receptor downregulation.”


sahusema  In short, cortisol upregulates adrenergic receptors and makes them more sensitive +  

sahusema  that video was sick +  

yotsubato  How is that NOT posterior to middle concha? bad question +4  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +2  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +2  

submitted by hayayah(603),

This pt has an ASD which is a "hole" between the LA and RA. Fixing it could damage the AV bundles.

sahusema  the atrioventricular bundle is also called the bundle of his +1  

submitted by sympathetikey(618),

Inferior oblique = helps you look up & in.

Also, they said floor of the orbit, so it makes sense that the inferior muscles would damaged.

sahusema  I know you're right. I was just so uncomfortable picking an answer with "inferior rectus" because damage to the inferior rectus does nothing to explain the clinical findings of impaired upward gaze. Unless the muscle is physically stuck and can't relax or something +4  
emmy2k21  Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :( +1  
dr_jan_itor  in the last sentence it asks you to assume an "entrapment", so it is actually the inferior rectus which is the cause of the upward gaze palsy. The entrapped muscle is functionally trapped in it's shortened position, thereby not allowing the orbit to gaze upward. +10  
chandlerbas  bam! dr_jan_itor just cleaned up that confusion +  

submitted by mcl(377),

Patient may have hereditary angioedema, which is associated with "recurrent attacks of intense, massive, localized subcutaneous edema involving the extremities, genitalia, face, or trunk, or submucosal edema of upper airway or bowels". The article goes on to say "C1-esterase inhibitor works directly on the complement and contact plasma cascades to reduce bradykinin release" which is also probably good to know.


notadoctor  Thought this was a trick question as C1 esterase deficiency also results in a decrease in C4. However, the second answer choice was not referring to C4 but to C4 binding protein, which I now know is different. I also didn't realize C1 esterase was technically a complement protein. +4  
youssefa  Based on many sources hereditary angioedema does NOT cause a rash (urticaria) which is a main differentiating point between angioedema and allergy. This mislead me in this question. Any clarification? +11  
ergogenic22  +1 on the above because uptodate states that c1 esterase inhibitor deficiency, both acquired and nonhereditary, are both non-urticarial, non-pruritic, and that is confirmed by the above linked article +1  
sahusema  Question writer probably didn't know the difference between cutaneous urticaria and subcutaneous edema. +3  
almondbreeze  same. got it wrong bc the pt didn't have sx of hereditary angioedema - swollen lips and eyelids +1  

submitted by drdoom(369),

2,500 students ... but you find out during your initial screen that 500 already have the disease. So, strikeout those people. That leaves 2,000 students who don’t have the disease.

Over the course of 1 year, you discover 200 students developed the infection. Thus:

200 new cases / 2,000 people who didn’t have the disease when you started your study = 10 percent

Tricky, tricky NBME ...

sympathetikey  Ah, I see. Thank you! +  
niboonsh  Im mad at how simple this question actually is +2  
sahusema  Incidence is measured from those AT RISK. People with the disease are not considered to be at risk. So 2500 - 500 = 2000 people at-risk. Of those 2000, within one year 200 develop the disease. So 200/2000 of the at-risk population develop the disease. 20/2000 = 10% = incidence +2  

submitted by amarousis(15),

so for this one you have to look at the diastolic blood pressure and that's the values you're supposed to read. not the numbers in the columns. Like group X's mode is 70 because it has that value 32 times. group y's mode is 80 because it appears 20 times. for median, you would have to write the diastolic number 50-120 how ever many times it appears and then find the middle. tricky question.

sahusema  Wow. I hate this. I only looked at the number of participants and completely ignored the Diastolic BP readings +3  
ma_rad  Everyone commented how to get the mode right. But there is an easier way to realize that the median in Y is higher without all the calculations. If you see, the last Diastolic BP in group X is 110 (as there are ZERO people with 120). While group Y has 8 people with 120 DBP. This automatically shifts the median to the higher side. I got this wrong though at first I didn't pay attention to the "0" number at group X for 120 DBP +4  

submitted by liltr(15),

I choose MVP too, but this patient’s main symptom is cough only during exercise. This is more indicative of exercised associated asthma. You could see shortness of breath in MVP during exercise, but choosing MVP leaves the cough unaccounted for.

.ooo.   I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps. +10  
uslme123  I mean... couldn't increased BP during exercise worsen his MVP and give him SOB? +  
uslme123  (by causing slight regurg) +1  
yotsubato  "Lungs are clear to auscultation" +6  
sahusema  But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for? +  
cienfuegos  I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts? +1  
cienfuegos  Just noticed that he has FHx, game changer. +1  
kimcharito  clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise) +  
pg32  Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP. +  

submitted by temmy(77),

babies of diabetic moms end up being bigger and that may lead to shoulder dystocia

sahusema  If one of the answer choices was, "that baby gon be big lol" I would have gotten it right +7  

submitted by seagull(722),

Idiotypic means --- antibody against antibody. B cells don't have surface antibodies but mere synthesize them.

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +4  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +1  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  

Pulmonary fibrosis will involve granulation tissue (as it is fibrosis). Granulation tissue includes myofibroblasts, which will "pull" on the airways, thereby increasing radial traction.

sahusema  The fibrosis causes contraction, the airways are pulled open giving less resistance to airflow +1  

submitted by haldol(9),

BP is low so obviously the body will want to respond by increasing sympathetics and decreasing parasympathetics. since the BP is low, there is less pressure against the wall of the carotid sinus -- meaning less stimulation and fewer impulses. fewer carotid impulses means fewer parasympathetics

pparalpha  Hyotension will lead to decreased arterial pressure and DECREASED stretch. This leads to decreased afferent barcreceptor firing (carotid sinus and aortic arch). This leads to an increase in efferent sympathetic firing and decreased efferent PNS stimulation. This leads to vasoconstriction, increased HR and increased BP. +  
sahusema  The way I remember this, carotid massage slows the heart. So baroreceptor stimulation (more impulses) increases parasympathetic output. +1  
cienfuegos  FA 2018 pg 291 has helpful image/description +  

submitted by hayayah(603),

The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery, and the inferior thyroid artery, a branch of the thyrocervical trunk.

sahusema  https://imgur.com/0uBvexe +4  

I obviously thought that the main thing for capacity is to understand the severity and prognosis of her medical condition BUT I thought this was a trick question because they asked "if the mental examination finding showed..." and the stem failed to mention anything about her orientation to place or time. dumb

drdoom  Stem actually states, “On questioning, the patient does not know the date [time], the name of the hospital [place], or the name of her nurse who had just introduced himself [person].” So, pt *is* actually disoriented to time and place (Choice A). That is definitely concerning -- as would be depressed mood (Choice E) and the other choices -- but “inability to understand severity and prognosis” is **the most concerning** since that is the very definition of capacity. Inability to understand = lack of capacity. +  
sahusema  So by the logic of the question, if someone understands the severity of their medical condition AND happens to also be disorientated to place and time. Go ahead and do sx on them, it's fine. +  

submitted by tinydoc(133),

Ptx appears to have Muscle spasticity as a result of MS. Spasticity is treated with a muscle relaxant like Baclofen which is a GABA agonist. Bethanacol is a Cholinomimentic which can be used to treat Urinary dysfunction in Multiple sclerosis. but the Question asks what would help treat the spasticity.

sbryant6  To remember Baclofen is a GABA agonist and muscle relaxant, I always think of the "Greek Baklava". Greek for GABA, Baklava for Baclofen. +3  
sahusema  Also, acts on GABA receptors specifically in the spinal cord +1  

submitted by hyoscyamine(37),

FA pg 217. Too much oxygenation can cause free radical damage leading to retinopathy of prematurity

mmm21  Okay i might be retarded, but why i can’t understand that they r asking about the thing that is damaged ? 😂😂 +2  
sahusema  Seriously! The question says "the goal of treatment is the protection of which of the following structures?" If too much O2 damages the retina, how is this treatment supposed to be protective to the retina? +  
ratadecalle  I think too much oxygen would be with the ventilator having a high FiO2 setting, which they don't mention here but I'm guessing thats the thing they're controlling to avoid oxygen toxicity? +1  
burak  they didn't give the patient fio2 100%, question asks the reason for it. but in a very stupid way +9  
naught  Supplemental O2 may also cause bronchopulmonary dysplasia or intraventricular hemorrhage (germinal matrix, located in subventricular zone NOT choroid plexus) +  
fkstpashls  92-95% isn't high, but it's enough to get everything else oxygenated. Because it's not 100% high flow the retinas don't over-vascularize and lead to damage/hemorrhage, and shit like that. +  

submitted by imgdoc(72),

Basically this question just asks "what is power" and asks you to explain that 80% power. Power is 1 - beta (type 2 error), basically when a difference exists and the null hypothesis is rejected is power. So if the Rx detects a mean difference of 0.4 in asthma in the patients in the treatment group, then that data falls in the 80% power range, and its significance is 95% (p<0.05), P value is just the probability of something happening by chance, so you what this to be less that 5% so whatever you observed isn't bullshit.

I hope this helped, and correct me if I'm wrong.

yssya1992  I have a question : whats the relation then between power and P value ? +  
privatejoker  This one took me a minute and was during the last block so my brain was already fried. But my reasoning was that, as stated above, since it gave you power, it is basically just a long-winded way of asking what Power is, and how this relates to p-value. P-value is the odds that the finding was due to chance alone. Obviously a p-value set to <0.05 implies a greater than 95% chance that the finding is legit. Since the power is said to be 80%, this means that there is an 80% chance that the study finding is legit, at least insomuch that it met the pre-set criteria of being 95% non-chance related. +  
sahusema  80% chance (power) the study correctly identifies the existence of an association in reality. If an association is determined to exist, >95% chance the study and reality agree with each other (p<.05) +  

submitted by neonem(372),

I think you can know that this is a thalamic stroke rather than cortical because a cortical stroke occurring only in the postcentral gyrus (primary sensory cortex) and involving the entire homunculus without affecting the nearby precentral gyrus (primary motor cortex) is very unlikely.

sahusema  Ya I think this question is trying to test your knowledge between a cortical lesion and a subcortical lesion. +  
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 +2  

submitted by beeip(90),

"Excitatory amino acids" refers to glutamate, while "Biogenic" apparently refers to tyrosine, the precursor AA to dopamine and norepi.

sahusema  Amphetamines use the NE transporter (NET) to enter the presynaptic terminal, where they utilize the vesicular monoamine transporter (VMAT) to enter neurosecretory vesicles. This displaces NE from the vesicles. Once NE reaches a concentration threshold within the presynaptic terminal, the action of NET is reversed, and NE is expelled into the synaptic cleft +5  

submitted by whoissaad(40),

Where is this even from? My mind's going hay wire trying to understand this.

sahusema  Hardy Wineberg equilibrium square root 900 = 30 1/2 of all offspring will be carriers so 30*.5 = 15 simple as that +4  
maxillarythirdmolar  this deserves a million upvotes. +  

submitted by m-ice(184),

The patient needs medical attention immediately, which eliminates obtaining a court order, or transferring her. A nurse does not have the same training and qualifications as a physician, so it would be inappropriate to ask them to examine the patient. Asking the hospital chaplain again could be inappropriate, and would take more time. Therefore, the best option among those given is to ask the patient if she will allow with her husband present.

sympathetikey  Garbage question. +29  
masonkingcobra  So two men is better than one apparently +14  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gárbágé +1  
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +3  
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39 +4  
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +9  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +11  
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +  
niboonsh  This question is a3othobillah +4  
sunshinesweetheart  this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +3  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +6  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +4  

Why would it not be anemia of chronic disease with decreased serum transferrin concentration?

lispectedwumbologist  Nevermind I'm stupid as fuck I see my mistake +  
drdoom  be kind to yourself, doc! (it's a long road we're on!) +10  
step1forthewin  Hi, can someone explain the blood smear? isn't it supposed to show hypersegmented neutrophils if it was B12 deficiency? +1  
loftybirdman  I think the blood smear is showing a lone lymphocyte, which should be the same size as a normal RBC. You can see the RBCs in this smear are bigger than that ->macrocytic ->B12 deficiency +13  
seagull  maybe i'm new to the game. but isn't the answer folate deficiency and not B12? Also, i though it was anemia of chronic disease as well. +  
vshummy  Lispectedwumbologist, please explain your mistake? Lol because that seems like a respectible answer to me... +1  
gonyyong  It's a B12 deficiency Ileum is where B12 is reabsorbed, folate is jejunum The blood smear is showing enlarged RBCs Methionine synthase does this conversion, using cofactor B12 +  
uslme123  Anemia of chronic disease is a microcytic anemia -- I believe this is why they put a lymphocyte on the side -- so we could see that it was a macrocytic anemia. +  
yotsubato  Thanks NBME, that really helped me.... +1  
keshvi  the question was relatively easy, but the picture was so misguiding i felt! i thought it looked like microcytic RBCs. I guess the key is, that they clearly mentioned distal ileum. and that is THE site for B12 absorption. +3  
sahusema  I didn't even register that was a lymphocyte. I thought I was seeing target cells so I was confused AF +  
drschmoctor  Leave it to NBME to find the palest macrocytes on the planet. +1