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Welcome to sajaqua1’s page.
Contributor score: 518

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 +2  (familymed1#4)
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Pt si an 11 oy ,M 2 ysda fo asaln nscneigtoo dan soer ra.hott Cghiugon dan eisgnzen etoiuvrdpc of green sc.muu Teehr is sptasonla irdgaane fo cosiuop yeg-erelwnlo m,scuu and laeerndg nosstil.

shTi naeitpt sah a adeh olcd, hiwt satalopns dipr ttah si uaisgnc shi gc.uho vrtliinaA ypteahr ()E is not ddriecte ngsatia eth i.suhvornRi The ipetnat sdoe not hswo isngs fo abtceailr ninifcote ihcwh uwdlo qeuirer iatotincbi haeptyr F(), ylneam ancmiytp aemnembr lguinbg nda aer pn.ia erhTe is on vfeer ot dnictiea evrse fnneitcio or sunis ndesertnes to tncidaei an arXy- fo the isssuen is enaawrdrt ,)(D or taht tcurule fo ecasridgh luwdo cahgne urnecrt tmereattn C).( aBueecs tihs tnnoiicfe si ditifmlse-le nda the dilhc nac olwb reiht en,so ssnui gelvaa ni het lnccii si ont yeseas.crn .)(B

 +4  (nbme23#41)
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Wt'londu ttola VA dalno labontia deosytr ot tuhhiarycoytimt of eht arpekme?ca tTah ulodw mean ahtt eblow eth AV node the tmyhrh dulwo be rivoddpe by a enrlvcuiart ,coif and those sulualy areect weid SQR m.xoespelc

haliburton  that was my reasoning as well. guess not. +
yotsubato  Shitty NBME grammar strikes again. +1
charcot_bouchard  No. No guys. Bundle of his located below AV node and it can generate impulse. it calls junction escape rhythm and narrow complex. Below this is purkinje, bundle branch & ventricular muscle. those are wide complex +13
abhishek021196  Third-degree (complete) AV block The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lym3 disease +2

 +7  (nbme23#11)
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aMel tpanrte dsndlgare.aoinnbs/ce aeocplia is esudca yb the efstfec of rrsitsytohteeondode (D)TH no eht insk fo hte lcsp.a Terotnteseso si retdonevc yb eth eymenz p5uaas-hetcadlr-e onti HT.D eaiinsFtsdeir a 5easudet-c-ra triho,inbi dna so klcsob eth conidtupro of HTD nda nca lhta ro nvee eausc osme raslreve of keam nretapt sdsea.lbn rwHvoee sith eams ctivtiay yma lsao lusret ni ancisftnig uleaxs seid fecstef cldunigni tynamasioe,gc erelitce cdtsoy,ninuf tycaroeujla ys,fcniodntu and decsaeerd biilod.

A) n-oaazDl a keaw grnndoae itwh inrsetgoeainct ,esfectf edsu ni eht rtttaenme fo itneeisoosmdr adn tsobrccfiyi tsreab sdeeis.a )C o-eyrttohenttMsslee siecnttyh T, ti is udse to eptnupselm in etotersosent e,fycecindi ro ni hte amettrnet fo meos etrsab .ancrecs )D onrxn-Oeoald an aolbianc ordites edsu ot eriagn i.hwgte E) latolnS-zoo oeahntr laoiabcn toer,isd iwth pntelaiot udse ofr rateyidrhe ndoae.aegim

sajaqua1  I am embarrassed by these typos. +1
drdoom  lol +

 +8  (nbme23#25)
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The ieatntp tixsbeih oremym osls nad itegvoicn reimainptm tiwh rdgluaa n.toes meherizAl's sesiaed si eky.ill coleiAlnytche ttcaiyvi si dwno in e'lmerh,siAz os -resheCesAat inotshiirb rae uesd to meka ChA oerm a,bevlaail poipsgtn smeo fo eht ftfesce of .mzArlishe'e eeDnizlop si an a-AesrCshtee rthi.boini


A) Co--Q a ctoraf ni ihndotalormci hxsO,oP it si aslo an tniadntxi.oa It si dseu as a ariydte pltsmeeunp, dan si nto FDA daeorpp ofr the eatmntter fo aingtnhy. )C Rlli-zeou a matgaeltu tagsintano used to vntreep xtotyoctcxiiei in LSA D) ig-eeSienll tieScelve BM-OA iriitnohb tath mya eb ueds in eht netmttear of sinrksno'aP, hohgluat I lebieev rheto mterttaens ear pefererrd teseh .sayd )E c-niZ irtpontma orafccto in yamn roniacets iglniuncd osattpncniirr otfcsar zn(ci )ignersf nda in nowdu

 +3  (nbme23#2)
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coyaisenta,Gm sdirep ,aoangimat nad yhpigadmsono (as ewll sa arlamp rmae)tehy aer all ignss fo xcesse grnsote.e heT ervil ni enpstita itwh eatcpih ieadess is edpimair nda os actonn acrle rnogstee feit.yliufsnc Six 12 zo bsree dlayi 72( z,o or ahfl a alln)og si oot hcmu, nda is sngtoyrdei his virle.

uslme123  No hepatosplenomegaly, ascites, or edema through me off. We that being said, I shied away from cirrhosis. I thought that he showed signed of depression, so I went with the thyroid. But who's to say he isn't injection anabolic steroids?! +5
catch-22  The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum. +12
notadoctor  He likely has hepatitis B/C given his history of intravenous drug use. I believe both can have liver dysfunction but may or may not have ascites, whereas the type of damage we would expect from alcohol that would match this presentation would also show ascites. +
charcot_bouchard  For Ascities u need to have portal HTN. Thats a must. (unless exudative cause like Malignancy) +2
paulkarr  For anyone who needs it; the FA photo is kinda burned into my mind for these questions. NBME has some weird infatuation with this clinical presentation.. FA (2019) Pg: 383 "Cirrhosis and Portal HTN". +4
snripper  @paulkarr the problem was that the FA image was burned into my mind so without no ascites or edema threw me off of cirrhosis. +
tyrionwill  cirrhosis doesn't present hepatomegaly, instead, the liver could be shrunken. +1
avocadotoast  Cirrhosis (most likely due to alcoholism in this patient) leads to an increase in sex hormone binding globulin, causing a relative increase in estrogen compared to androgens. Cirrhosis doesn't always have to present with ascites and adema. I agree with @catch-22 that liver disease is a spectrum. This patient does not have ascites because his liver is still able to produce enough albumin to maintain oncotic pressure in the blood. +1

 +18  (nbme23#38)
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heT warrom sohws spurrcsore ot yhycoertst,re sa lwel as seycygko.aatrme hiTs is ot wosh uyo ahtt eht uisse tin's drcuontorid,epun iwhch aensm htat we ear isglno CRB nda taetlelps resmheowe ie edti.sntcuro ahTt serlu tuo D dna .E ereTh si onhnigt to tcdniaie hta het lhdci has sdmdsiteaeni eubscioslutr .B)( At thsi onpit we rae letf whit A or C. A udwol etiiancd isDendamiest Ivautrcsrnaal ounaagClito D)(IC or hnmeotisg ,ralsimi whhic uldow seulrt in olw eletpslta nda CBR tbu ew dolwu laso ees anoblarm RBC klie ticeoyschtss (mte"leh" l) We ear lielypxcit tdlo atth teh coyyrtetsehr rea romncmrohcio dan .yccoitormn Hver,woe unmmie otisertudcn fo leesltatp npislexa ti a-ll the etirsnducot fo ttesllpae lsdea to osem rimohrahgneg adn os a dpor ni CB,R nda PIT ciyallaclss ireass afret a neecrt ppeur itroyareprs ttarc vilar enncoifi.t

meningitis  Just in case anyone is wondering like I did, the low platelet count explains thethose multinucleated cells. They are Megakaryocytes in Bone Marrow Biopsy. +12
nwinkelmann  Also, don't forget that autoimmune thrombocytopenia purpura has 2 demographics: young kids, which generally resolves spontaneously fairly quickly, and then young adult females which is a true autoimmune condition that doesn't resolve. Patient's age + thrombocytopenia + essentially normal rest of heme pannel = autoimmune thrombocytopenia purprua in child. +6
abhishek021196  That is exactly how I approached this question. Normal heme panel and a decreased Platelet count in a young boy after an infection just made me intuitively select ITP. +

 +8  (nbme23#37)
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A arasnddt dnoaivtie is a esrmuae fo bpatioliybr in nrbileegms eth v.agerae enO dsrntdaa nvaoetidi on a lble rceuv ruobitdsiint etraecs a 67% ehccan ahtt eth newsar lliw lei ni ereth. Two rddsatan odieanstiv liwl aceert a %59 ch.cane reehT adarsdtn tisdioanev rcetase a %.997

iThs ipttean ash na egvaaer of 311, nad a 5%9 efndnccoei ta 1016-11 neasm tath eht SD is 51. . oS eno dltaoaiind SD wloud igev us a aengr fo 5-71,8.11.05 rddnuoe to 8.11081-

usmleuser007  How did you get the SD to be 1.5? +
usmleuser007  NVM Got it +1
jesusisking  You wouldn't use Standard error with Confidence Interval? (pg. 262 FA 2019) +

 +7  (nbme23#32)
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heT lcauam esdna of teh ornpneh sphel atnmniia aulubtr lwof by igunsdjta litiaodn fo eht eaerfftn ietorlare fo eht roph.enn Wneh satl is lwo, tsi COX myzsnee setyizhnse GP2I hiwhc tedlai hte frneetaf ieltrra.eo AISDsN tihiinb XCO, oigcknbl shstseniy of GPI2 adn so lyeiicdtrn hgtiniiibn frnetfae ieatleorr .aiidntlo wTo kesew gao our etnptai saw utp on ,nfbuierpo a sneeveonlti-c COX ob.itiinrh Tish aedl ot all sehet fteecsf, ugthisnt fof lodob plpsyu ot het pnnhseo,r ierncagt na yliaicltfra didunec rpod in oobld olwf tath looks has eeatelvd BUN nda re,tcaiienn tub miaitnnsa eth :115 a.rito

 +9  (nbme23#14)
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Doundlae iarseat si ruflyneeqt ecstdasiao ithw oDwn o,ydsnemr nda si uasedc nweh het eudoudmn lsfai ot rlczeaiaen gidrnu mnteoe.depvl ehT aftnni tsnrpese whti ilisuob ignmo,vti os ew kwno ahtt oodf si at tlesa mkiagn it owdn ot hte uemdndou ewher eht iraptcneca tcud ipteesm onti eht siTh tlmseiaeni D ldo(uw rtneesp hitw ubolisonin mtniiog,v ailyyctpl a fwe ewesk aetfr bthr)i and E wldo(u etepnrs htwi ngcoihk dan oigitvnm imdyelteami on ng.f)idee

hTe ecsenper of leib sllte us hatt lieb si tgitgen to het dd,uemuno os tiexreahtcpa iylbiar etsarai osed ton mees slepisbo B.)( Three is otinngh to iaceintd taht the hlcid has an lopcmalheeo )C( csnei the ambedno si deddstnie tihw fdoo tath 'isnt gpaisn,s but eht sgut ear tlils enisdi teh aiomdalbn cavit.y

 +8  (nbme23#43)
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In na lyderle enatpti itwh dteilaso aetvleed alkliean aapteoshsph m(loran esmru aumiccl and eptaoh)shp P'sgtae seiedas of beno hlouds be at het otp fo hte ratn.edfiiefl iTsh saesdie is ude ot rdoesyatliung of ielaccsstoot dna eoslisttocba atiiy;tvc sitfr an anltiii oecttsasol vphirttiyecay seh,pa then eecnidsra osostbltae tityviac fro a imtr,uex tenh esotcaotlss ur"o"ntub idelang ot oiaanvizietemlrrno- nda treosccil neob .peaqlus In taidnoi,d hist acn ceeart torovsneuarei nsshut in teh nbsoe hiwhc rdesseaec eticsasr,ne nilgade to ihgh uttoup radiacc afelrui a( ilsrima lrpboem nca erisa in oieosnevrurta utisafsl rmof blood .ds)lsyiai nO shtgyiloo ti lwil avhe a "icasm"o tnte.pra

A)- sauyenAmlr noeb -ytsc ylalerg a durctpo of ceithvitryypa fo sool,ttsseca itsh srucoc remo tefno in teh slbm,i dna owshs a icctys ceaps iwht eaniblk-lloo iinldat.o B) onaasgAro-cim maroaosiganc of eth beno is n motasl uyrepl iytcl o.nseli hyeT ourcc omer fnterlqyeu ni ueyrngo eeo.ppl )C nciiaN ciyci-edenf I can ndfi gihtonn uotab imvbtnia 3B neiceicyfd nvngliovi .ensob B3 dinfceciet sulrtes ni ,aageprll iwth het saclsic ehTer 'D-s tsremdtaii as(rh nlckcaee no 3/CC4 )admmort,ee m,tnediea and r.ahardie E) caom-taOessor odunF laostm vleyxclsuei ni neuogyr p,leeop tish enbo ogwhrt uorccs at hte ghtrow pa,tle liutcalrypra at teh rmpaloix den fo het ,tabii iatsdl ned fo hte um,fre ro rmaxlipo end of eht mhsreuu i(n hte ongl snoeb doranu yruo nekse or at uroy olss).drehu tI ohwss a la,reg iodsl onrwggi sasm ttah yma erais the eiorutepms ni a rstubnsu dnpna'rmtoCste/a lregn.tai )F tartiPcso maa-oincrc erra ofr bineg eon f,o fi nto teh only cettatasmi nobe cenrac atht is lurepy stolb.ioscate

alexb  Great explanation, except that there was a question in NBME 22 in which the prostatic carcinoma was osteolytic. One of the commenters here looked it up and apparently it's like that 30% of the time or something. So I guess you would have to use the high output HF, normal Ca, high ALP, and mosaic pattern to "play odds" as Goljan would say. +1
qball  At least they were nice enough to put Paget disease because I had no idea what osteitis deformans is. +1
drzed  USMLE seems to be moving away from using eponymous names... so it's a good idea to see if there is a descriptive name for diseases. For example, they don't use the word "Wegener" anymore if you have noticed, since it turns out that guy was a nazi. So now they call it by what it is -- granulomatosis with polyangitis. +3

 +4  (nbme23#36)
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mrSue sikscesn is a eypT 3 yiesitnsehtviryp oacrtien, in whhic hte oybd rsopdnes to cgeainitn caelmid estbusncas nad coudersp sdin.bitaoe Tehes niebdostai ni crnoultaici ethn dibn to eht tninaceig dsrgu nad ste off eth memenltpco ac.scdea atohRimued iirathrst si olsa a Tepy 3 sphiiseteniyrytv irte.noac

)A isoosAtpp fo scapaohmeg-r posistpoa is yeelralgn ont a pyte fo ptvyrhisteiseiny rna.oicte B) saMt lec udiornnaaglet- sthi si tapr of a eTpy 1 viisnhystretyeip exs/natnyciraipalaho, in ihchw tasm llesc bnid gEI on eriht sucf,are nad EgI binding ot eth ragtet nnieagt eusnicd a ioanntrfloamco ngcahe in the IEg ttah sset off amst lecl .duoanietnglra )C Ntauarl leKlri Clel llngii-k ylasp a yaervit of le,rso ngludcini acecrn ppssisronue adn unrtdsciteo of ilrvayl dteinecf .slcel fI eyth layp a lero ni hsvtiriytey,eisnp it si trpa fo epTy 2 RSH ni cwihh thye udwol dsornpe to Ig no eht lelc frase.uc E) hWlee adn eralf t-sciaeonr Tshi is osla a epTy 1 H.SR

meningitis  I didn't pick this one because I thought Serum sickness was too systemic and RA was a more localized Type 3. Again, im overthinking things. +
youssefa  Goljan: RA is a mixed type III and type IV immune reaction +6
dinagohe23  I though NK cell killing was similar to T cell so and RA is also Type IV +4
nephcard  ,blll sdouof +3
usmile1  NK cell killing would be a type of innate immunity, not similar to memory T cells. because they did not give an example of a type 4 HSY, the answer must be serum sickness. +

 +8  (nbme24#11)
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ryPmiar tvepoenrin is an evcait ptse kanet ot deah off ro magttiie a esids-ea iknht of acoiannitcv.s In hsti sac,e it si fstlieyle iaimncfoitod s(e)cerexi ot lpeh 040-3 eyra dol eonmw (iwhteg gnrieba eexcirse cna iitmaegt prostes,iosoo ifeenbst of ebocria

encdoyaS vopretnien si yrale tcnoetide fo a aedsies, rtmgoiopn aryle rtoneiein.vtn Thsi doulc lcineu gnhist ikel VIH tgtnsie ryeve 6 ,ohmtns or or anlanu .mmoyhpaargm

earrtTiy nettenvrnioi si pahtyer nigmia at egrdncui piltams,ocnioc iwalnglo lpesrea, or pinogimvr funno.cit eeAnsitncb rofm oloclha yma be hree besaceu of cesantbsu aesub bselopmr, ro auebcse smeo damgea srlioeypvu node by alcoohl anntco eb ve.repdetn alilySrmi fro a olw deothracyrab ietd ew aym eb tnitgiigma eth csfefte on moiblatems atht evha ryedaal bnee nedo.

sunshinesweetheart  p 269 FA 2019 +
motherhen  [P]rimary= [P]revention [S]econdary= [S]creening [T]ertiary= [T]herapy +1
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 +

 +7  (nbme24#22)
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Teh yeks to sith esnwra rae ttah ti si lifyar sduedn ni ntes,o dna teas.mrgi eNno of teh troeh seawnsr udclo aixlnep eht metomvne of ipna orfm flakn to LQL to usm.crto lWhei teh idneyk oents sode otn talyaluc eretn eht tusm,roc eht anip acn be drfreere ot het scsei.etlt

 +16  (nbme24#20)
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riioVb rehocal nda V. cauehmaltaoyirps rea qlneyufert itadasecos ithw nicnmtposou of ckurndoedoe feooads kile eflihls.hs V. invicsfulu si dtcaaossei tihw ckbrsaih watre ro .atswetrla

A) B. euser-c esngtitev tend to ocsastaie sith wiht eehatder ceri at a fb,feut omitngiv si roem omcomn ntha .drheiraa B) C. jein-uj sditaocaes with edrdekocuno oof,d iepceaysll hnk,icce ro acn be oarctdncte yb cnoattc thiw ilsama.n tI csaesu tariyaoml,fmn olbyod adhreai,r nad amy laso deal to aulnlreiGB-ra ensodm.ry C) C. nr-esfgirnpe as a otoas,rurlp hits si caidsostea hitw good atth is ahedeter thne etlf to amgreient ta mroo preuaetmret rof a gnol emit eeborf mctnpu.sinoo momtpsyS ncleiud ongitivm and idreaha.r )D S. us-auer a heat telabs iotxn doepdrcu by S. erausu si assedotcia htwi drapi esnot of i,omvngit mya be cdmpeoaainc yb ha.eraidr tosM etnof adistcoesa hwit rayid dportscu nda meat.

armageddon_oh  Perfringens is also usually a delayed response, can help in vignettes! +

 +12  (nbme24#44)
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hisT aernsw tsers on the nfidcrfeee weneebt aFlteo and oiencuorv.L rhateltIcna atxhtteerome si vgeni to ockbl rddytloheoifa urcdasete )FDR(H ormf aikgmn foicl aidc oint DHF, adn hten gnruint thta HFD oitn T.FH sihT si oned ot npvrete eht ordutopcni fo natrosnwmde dtscuopr scnseerya orf easiblommt ciuidnnlg DNA nsh.sistey uireoLcvon als(o cealld 5lrmoHFyf--T) acn eb udes to tsiepsde hits rputdco yb geibn tpu niot ypal wdotmra.ens See hte ragidma reh:e tleaFo si deislt sa ilFoc Adi,c exohatrtmtee seftrnerie tihw F,HRD and ivLonuorec si 5oFTyrH-f.l-m erhTe si also trruefh tdespinocir rehe: rsp./rt8u0d1g/dDuk/0/t5wBaahn.g:sbcww

Why seod shti nto ismylp uond hte inaotc fo mtxateteeroh? hsiT is escubea ynam ecsncra do ont vahe eth ecdduer eltoaf ce.iarrr So teh nrescac cipk pu elafto dna h,ttmeaertxeo dna hetir NAD sinstsehy is eeddr.uc eaeilwMhn hrtoe ahythle cslel can kicp pu teh orcoLvuien dna teasv ffo osem fo het rtwso t.efecsf rR,ebemem uoovnlrcie tonnac be igven


 +17  (nbme23#3)
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scBuaee eht bb'yas rehmot hsa epyT 1 eeasDitb iult,lems it is apseblliu that yteh hda leeedvta bodol oeugcsl leesvl ngiurd or tsyrohl erefbo r.ibht lsinnIu odse tno srsco eth clneaatp, tub uecgslo eosd, os ugrdin ibtrh eht noetane uwlod hvea neeb iTsh olduw aedl ot the loaatenn scpanare glearseni nilu,ins giirndv cueogsl oitn escll adn riungtn nwdo e;nogesesnguolic tihs is ywh eth bbay si comeyplycgih ithgr n.ow

B) eaedrsecD yenggocl tcnioenntc-oar I 'otdn wokn the noyceglg inntccaetrono dcreamop ot an duatl atieptn, utb a dcareees ni nogeyclg cenatcnooirnt oludw ceiadint oyngcsgoeclule/g are,slee whihc dowul ton eb a yleomhpciycg sett.a )C ceereDads ggnlyoce hnayetss tayctiv-i esddreeca oggyclne haneysst ivtacyit itescadin yergne bli,ctaosam nad ulowd eadl ot gehirh suerm geucosl lel.evs )D adDsceeer mreus isunnil n-ttaecconrion dcaeeerds mesru nisliun luwod alde to ghierh svllee of lcosueg ni seumr. E) eIrcansed rumse sei-iniklunl gohrtw aftr-oc GFI esod not idbn yrlena sa lwel to iisnnlu tseocrerp sa isulinn seod, dan so oudwl eahv ot eb ni lytmxeere hghi tenasicnnctroo ot ehva hits fet.cfe FIG si tscsoiaeda thiw csitoam hgorwt and lcusme tdonempelv.e

yotsubato  His glycogen concentration is high, since he's been hyperglycemic with lots of insulin until birth. +3
alexb  Also explains why he's 12 pounds. +3
krewfoo99  Also, think of it like this: Insulin causes hypoglycemia, thus this baby must have increased insulin. It is also an anaobolic hormone which is clear by the babys weight. Insulin increases glycogen synthase activity, and causes an increase in concentrations of glycogen. Decrease in insulin would do exactly the opposite +1
tyrionwill  fetus of a mom with DM will develop pancreatic beta cell hyperplasia, which leads to insulinemia trying to reduce the blood glucose. after birth, the excessive blood glucose will be automatically withdrawn while the insulin at that moment is still high, which leads to hypoglycemia. +2

 +4  (nbme23#7)
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tA kwee 8 in otilnaeatgs ledntevmeop eth epnevliogd ugt aeeirhtns tou of het eborym dna gsodenreu cinnsatiigf w.rotgh At ekew 01, hsit atesrot dna is dbeobarres iont the ildaabonm vyati.c uerFlai ot mtleelcyop aesobrrb the utg and reoatt ypporerl anc etuslr in a mnrueb fo desc.tef sicGsthrsasoi si euafrli ot lmeeclpoty esbraordbe het ,tgu vaelgni seom eocstiu eth bnm,odae tiwh no vroinec.g /emr:p0ttlmFeoe/oyepamnetofrptedhveectgaRn2.nt/leh.c/o%il

)B Mtidug vlosvluu- rcuocs sa a sltrue fo totlmiranao as the gut si .bdbarseoer ardirOlyni teh cucem si lhed to eht ckab of eht QRL yb rfbusio b.ansd In eht evnet fo dtugmi vl,ousuvl ehtse adsbn asd(Ld' adb)sn rea tllis hatacedt ot het now iseddlacp ueccm ni eth URQ; hte smprcoes on teh tnietesni,s vgenrenpti doof omrf igmovn ohgthur nda nefto asgncui ilbisou onivitgm in w.obennrs )C Ohelca-mlpoe a etdecf ilamrsi ot ash,ssisgctori btu deocevr by het mepeochlola asc. )D Uilibalmc erahin- the gtu is yteinerl bareodbser in eht enadb,mo tbu a cefdet ni the uulmcrsa lwla rynolevgi it laoswl mlnoeat tfa ro tgu ot lips rgtouhh and eglbu uot enar the csmuiliub, illts btnheea het .skin ishT earihn is yulauls cdreeblui whti s.erupsre E) calrhaU tasfi-ul lruafei of het uacrush to oc,les telsugnir ni teh nalgkie fo runie from na ieognpn rnea hte .usiblcuim

 +7  (nbme23#8)
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lLeaoatbl is a scteievonnel palah1- dan eBta nriraecdeg .tniansaotg In the uv,aeuslatrc phala1- seroectpr ear sboesriepnl for alavrucs rtnctniisooc wihhc seseianrc bolod secyitsuesmr/reps vuscarla s.ietcenars omntngAias owdul secrdeae hte .BP At teh eams mei,t a-B1et eteorscrp ni het hrtea ear pssernioleb rof a svipoiet ncoiiotpr dan toiorhorncpc ftc,sfee riainngces htbo areht tare dan attcnrclii.yot smaiotngnA at het Bt-a1e rtesrceop ni hte trahe odluw eederacs ehtra tar.e

A) lebtAor-lu sorht canitg 2ae-Bt gitsoan, dues for obaioncdlohrnti ni hte lguns. eeTrh is ypyaltcli no rlgea eimtscsy ptso.oanibr )C Pmhoteanne-il a ceelstnienv-o a1lp-ha nda haa2-lp reiselebvr cieeopitvtm ntgaa,oinst ti nac be dues in tinrvyesepeh scgmeeeenir or in aRnydau npomhneoe.n It duolw tno fecfte ertah e.tar D) irnasz-oP na h-al1ap osnit,antag it cna be udes ot tater rshpneynetio or to aertt timsernagh idtasacseo twhi TDP.S It wlodu ont tefecf eathr tare E) lopooP-rnal a v-coleientneoir-csad teaB t,nsainogta udes rfo aymn rdcaica us,essi rof xe,nitay and ni scoyroohethcmopme. iTsh udowl otn eftacf mcsestiy cruvaasl creseina.ts

 +7  (nbme23#15)
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tPtinaasvra is teh yoln iatstn gdru ton deabemzltio yb eht 450P sytmse ni hte ecusBea fo s,thi tvitaparnsa is lsao niquue in atth roem of ti si xeedrcte by teh sydkine than yan rhteo ,ntstai nI iiddaotn ot yhspihoidtmryo thsi pitatne hsa imdl arnel riaf.leu ihTs llwi irpmia treioexcn fo tspv,atnraia geiadnl ot nsdceaire stiaarnavtp nda tis oi,metbtelsa igniarnsce ist ntoipalet rof agsuinc mpyo.tayh

B) tsoiesir-lhihaNp welih teh apentit is yccreemiahlcp, vrsapintata edos ont aesncier hte encciiend fo ydniek s.tnseo C) ieinatraPst-c I do otn onwk of yan snciginfiat oeirtnitcnsa weetenb het snaeparc and aaatsrpv.nit D) iTxoc ietpth-ais lwihe stasitn anc acesu lliydm etdvleae elvri tcnnoufi stet es,cros yeth rae eyealrnlg ont eaasisotdc ihtw yiicoehatt.otpx )E Tepy 2 etebasDi -tsiuellm I od otn knwo fo nya efetfc atht ptavnsaatri sha on eibasetd or dsteabei matcieinos.d

motherfucker2  Lucid. Nice +
qfever  But isn't statin associated with hepatotoxicity too? FA 2019 page 320 +3
srdgreen123  @qfever. I think thats why OP said that statins are not metabolized in the liver. +

 +17  (nbme23#5)
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ihsT tpatnie has ereasdpwdi ioctnudster fo hbot rdanale andsl,g hwihc sname tath ehs liwl eosl ohbt reh icnamolorirsdetcio nda rhe toodcsrigcl.icou heT osls of het rsdroitioliemnacoc adn hte ecftfe on the knsyedi si thwa is begin tdtees h.ree enhW aoltednsreo is tfinignconu adn a,nnbatud it sha ealvsre catiicrl snnotifuc no het nnreh.po ir,tFs ti epruegatuls /N+aK+ sAaPeT esxepsnrio no teh toalaelbrsa rb,enaemm libisatengsh a stnorg lctieealecrohmc igatredn atht retbte srasobb aN+, ilehw eht descneira lnaricultreal +K oirnonancttce eskam it resiea ot soel K+ rfom teh elcl itno het nelmu. oertdsleAno oasl egtlpaueusr the nssirxeoep of pilheialte duomis sechnlna (aEN)C no teh tccnolelig ,tdcu obiernrgabs emro .Na+ i,yallFn nsdetoleroa esniesrca iosrepxnes of +H aPseATs no raplan-ltaetdceiha lcsle of eth gcniceoltl dc,tu hwchi rea elrsinespbo fro tneicrgse H+ it(sh si rpat fo tincacronto akall)iss.o

hitW eth ossl fo tn,lsreaoeod we lwli ees a esreecasd +aK/N+ regdinat and edcaerdse N+a r;tnaspoboeri hits aldse ot ceeadrsde reums umsiod nda cendiarse suemr iout.apmss At eth same i,met tno gxisesprne H+ sePTasA wlil aedl to H+ tno ebgin ce,rdetse actenrig a remo acciid nrnnomvteei (pH illw cee.r)dsea

abhishek021196  Very well written explanation. Bravo +2

 +21  (nbme23#28)
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isrPoerot codr msyonred ccorsu edu ot icantnorif of hte oerrsotip ahfl of the ialpns orc,d fmor ccolonsiu fo het eiostporr spnali rart.ey ruO pitaent sspeernt itwh dreedecas niossnaet ot rkcpiinp bowel eth ellve fo het nseek as llew sa nakgliw hitw a widsb-deea ,agti illkye igcidnniat sslo of opipero.cniorpt ehT teapnti si laos nimace htwi eehytred-sgmpne speh.routlni

ydsepgreteemnH tohpnuelirs rae alycptyil suedac yb an bynitlaii ot kmea nouegh A,ND ascedu by a lack fo narecsyse sesucorrrp dan smvintai culdingni 9B aeftlo() nda B21 If het ntiptae is tolfea denci,efti ew see edaeetlv nyhecmosieot fcnycidei.e fI teh ettanpi is B12 eiitn,fdce we ees eeldetav lncthaeyomlmi daic nda ytmshoceoeni e.lslev enriictsyoaohmpHmyee anc nearscei iho.obsstmr rsohToismb ni eht soorrptei linpas yterra nca ucase reootpsri odrc ody.nserm nI tio,addni kacl fo iatmivn 21B psamrii lenymi oonrtifma adn easld to utabSuce Ciodmebn eiDoganetern, hhwic ftacsfe eth paiatnSiohcml cttra (aoicugtnnc rof reacdedse rpnicpik astisnn,e)o oonsciriltpCa ctrT,a dan oDsarl olMmCuinldae- inmcsuLse ctarT c(ionacngtu orf the reduecd inoro.pctoprpei

)A eirtonrA rocd soed-rymn slso fo omotr od,mcanm as ewll as aialerbtl sslo fo hate and pain, the tpeitna hsa otn sotl rmtoo ifconun,t so it notnac eb ihts. )B enaltrC ocdr eyds-onrm tenpessr sa a tonbimnoica of rmtoo and yersnso lsos, yluauls htiw rbddlea fcs.idnuotny ihTs pettian does nto lpyaids toomr slos ro daerdlb dsio.cnfuytn C) micedorH -yrmsendo lAso ldealc aqrwBneudrSo,- itsh si otpeceml yinjru ot hreiet eth letf or tighr edsi of het nlipas tI nprteses hwit rotmo ftdcyonnsiu and xeelfr sintcdnyouf litpllrisaeay ta teh vleel of eht i;sloen lsos of erpup rmtoo cmmdoan welob eth eolnsi aelytiplalris p(cassti s)ei;aprs sosl of ardlos mlncocradiure- santnoeis lepiasitlalyr at dna bweol teh sle;nio nda ssol fo ipan dna mtereertpua saeotinsn ctaetnrylrllaoa 2 ot 3 tbearrve bwoel eht l.eions )E Stgeemyarn s-rydnmoe a itolcnnaeg eluarfi to vedpoel aprt fo hte saipnl dor.c The wne sonet of smmoytps ta 82 aryes old amske tihs an yuelnkli asi.o,gndsi

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

 +11  (nbme23#47)
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ddBiiChra-u reosmydn rcuocs ehnw ehrte is lociuncos fo eth hiactpe vine ro eth tahiepc vein iafsl ot dnair itno het CV.I sThi cna be dcusae yb hotrssimbo of eht ipahtce eniv, ro yb hrigt dsedi eraht uifarel aguis(nc odlob ot abck' 'pu vwrree,hyee ubt tis nsoaietiftanm ugrothh het ehpctai vine aer all eth gssni of Crdiaui-Bhd donre)ysm. hnntygiA htat anc eainercs eht sikr fo hmbroitoss nac hetn eniscaer the skri of h-idBudariC dme.syrno isTh eicdnslu ypylhmoteaci ,aevr a rlolyecbpuaehga e.tsta rOu ipetatn dan PV tub sdmesi ihs tatiepnnpom wto kewes aog. He wno rtenpsse with scelarl i,tsceur na nagerlde ivlre, and esmo igssn fo rloatp orehsyitpne.n hmsrsoioTb fo het nloy cnataaoiml potoni ndpeeters thta covsre lal fo hist is hte ictehpa einv ie oru tneitpa has ihu.CBd-aird rmRemebe atth -rBudCdhiia lilw evha a tumeg"n evl"ri acneaarpep no rssog togophla.y

B) ecaHtip -cohisrirs i'ts nyleteri sbeiopsl oru epttain esod evha itpaceh iirshsroc fro deuratenl or,anses hereovw eth tuaec tenso saekm sith lses .keyill )C ccePtniara iaoracc-mn pratccinae cnracaoim cuorbnoitst fo eht oomcnm ibel tudc coldu scuea a kcba' p'u fo ib,le eyttulialm gasuinc moes rliev degaam nda llrsace srcietu. weeoHrv ncoe angia eht giimtn amske hist .yiunellk D) olaPtr ivne mhortoisb-s aloptr eniv misrtsobho coldu csaeu oesm esplicn rmgtaelenne nad ptoral enysohn.retip vrwe,oeH ist tbnricotuso ulwdo not scuae a d,neret nderelag elirv uesaebc ti is sreap.mtu )E rimaryP s-arooeihmomshct eud ot a fcdete ni hnpicied o,noudicprt shti ionr olodearv ersstnpe wthi nerdaekd skn,i unnslii iodaguilnrt,es tiepahc adaegm ith(w hte eatoniplt for aepulrocletlah inramocac) and atrhe asesied rvt(scieeirt ro dtelaid cidmoy,haporyat edgipendn no your )sreu.oc heT oynl eon of tseeh sgnis hatt ruo ttiaenp hsa si an ngeadelr re.vli

almondbreeze  FA 2019 pg 386 +

 +36  (nbme23#44)
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A dan J resenertp teh eragcil aicfcusul,s wlihe B nda I rrnpseete hte tnaeuec fcluusi.asc otrTheeg hety ekam pu hte rlaods oiem-acldmunl slnlacmie atcr,t eripelnbsos rfo tinpnpio nprcpeeoti, reiocnp,itoporp aitnirvo,b adn p.resures utnIp si lia.trepsail

C and H akem pu eth eltrala scconiriptoal attcr lao(s adlecl the elaaltr lbasrpeiconre )u,cfuslaisc slrisnoebep ofr oomrt mdnoacm of iepiaatlrsl b.mlsi

D dan G erntsrepe teh aerllat nmotlaiihascp crtta. It is bsoeelrnpsi rof pnia and rutremetepa tun.oniodcc Teh pnitu iressa ni a mbil et(lf olwer xtmyeteri ni sith s,aec) nretes grthhou eth aosldr oort ctri(pdeu ebetewn J dna )H, tsecduases nda dsacnes at het nterario euroscimms s(jut ndbihe E dan F,) nad nlailfy syanseps on eth cndsoe rrdeo euonrn in eth tlerlaa locmpntisaiah tcta.r So teh loipaithncams rcatt is rsbeieplnos ofr alrlcaonartet inap nda earuttpeemr ano.itness ueBeasc our ipetnat sha solt tiaenonss on hte tl,fe the oinsle si in eht igrh.t

E nda F era het torernai ncroipciatslo t.catr tI is dnvloive ni otrmo tnorloc of lxrpamoi s,csemul paltlyyci of het tnrk.u

nor16  good job +5
jimdooder  Pretty infuriating that this question has the standard R and L label while the other spinal cord question had it flipped. +3
larry  A and J represent the gracile fasciculus, while B and I represent the cuneate fasciculus. Together they make up the dorsal column-medial lemniscal tract, responsible for pinpoint perception, proprioception, vibration, and pressure. Input is ipsilateral. C and H make up the lateral corticospinal tract (also called the lateral cerebrospinal fasciculus), responsible for motor command of ipsilateral limbs. +1
larry  D and G represent the lateral spinothalamic tract. It is responsible for pain and temperature conduction. The input arises in a limb (left lower extremity in this case), enters through the dorsal root (pictured between J and H), decussates and ascends at the anterior commissure (just behind E and F), and finally synapses on the second order neuron in the lateral spinothalamic tract. So the spinothalamic tract is responsible for contralateral pain and temperature sensation. Because our patient has lost sensation on the left, the lesion is in the right. E and F are the anterior corticospin +1

 +11  (nbme23#39)
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tFir,s ,lylcticari it is not dcredbeis as nio dtorniiaa pahl(a nda beta cisalt)pre ubt as itdaniroa ttha sah na ininzotoai t.ceffe ruO rarefm has eneb out iatgsdnn ni his ,efdli iknsgao up eht sl.utgnih B-VU is avwe niroaitda htat idcnsue hte mnotaroif of refe acasdl.ri heseT reef dsalraic ni rntu od dmaaeg to het le,cl nliugncdi het ioaomftnr fo dreyinimpi .imresd iThs AND aemgad si hte saebs rfo shi qssmouua ellc cnrciam.oa rFo eomr no VUB- nceuddi refe cldiaar daameg of ,DAN nlgw5n.eis/w6twuhv6/ . Fro emro ofaintmionr on UV raidtnoia ofrm het nmcarAei eancCr eiytc,So elsaep stiiv nvamnoapi//ir-u:.woraenoihttaa/sesse-.cnuae/

A) Dcdrseeae conintuf fo eth isnk sa a reriarb to ae-crgcosnni eth eatipnt sha no rtihoys sutgges eexsourp ot icsonegrcan bieessd UV lhgti, dan as ogln sa hte knsi is tcnait dan lateivelyr heylhta it suhlod uinontfc as oems knid of ibr.rrae )C asdeceIrn rsncioonve fo 32-D5 ot ,1-53D2 - itsh vcirooensn asekt lepca in hte eidknsy iva axhpaaod-1l-lsyyre,h sloa eexdssepr in oruganamls na(d so D231,-5 si neoft eetdlvea in iasiodsco)s.r hsiT ouldw ton ainelxp D) sreneIdac tmoicit tviicaty hroguht nitlitusmao of almseeyn-cto uor tetnpai si ngodedias whti sqoaumus lcel coimn,cara not ea.nomlam )E eaIncrsed sletuiitcpysib ot ikns uaatmr- lhewi eht aemadg ofmr VU gthil to gcenoall deso meka iskn ithrenn adn moer layderi agd,dame iths lwoud otn xlpiaen souamqus lelc aomic.rnac

 +10  (nbme23#6)
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elneBriord alyrpetsino i-sddoerr eseflign of penets""s,mi ytal,csidiui toiuiatfl,m-lens lansuteb ,pnssihotaeirl and eomr coommn ni ewnmo anth in .emn A cmonom deenfes enamsimch in ihts rrioddes si sinti"t"gpl in hichw epolep rae seen as erynltei gdoo ro tieeynrl .bad erdiBnerol aposynertli doidrres si sloa aprt fo hte slrueCt B neaoylptsir ssore,ridd ihcwh ear esodcsatai wthi steusnbca .beuas

imnotarobotbut  Suicide attempts are also commonly seen with Borderline +5

 +21  (nbme23#42)
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Teh iptnaet hsa a proir sritohy fo chtsyryeetom tiwh alirblaet ayhseop,gctopn-oooimlr nad edecievr nxtralee abem trdaaoini to the pislev. heT tneiapt wno psasdliy enhdrsyoohsipr dan oee,rhrrdyut twhi lsiatd learetur rgnanoirw lalra.liebyt heT leeitlkis tnopio si that we aer eeigns doensasih rmof irsopevu syeurgr rnisotctc the eeuts,rr csiuagn its.h

E) letUhriaol ncioaacmr aso(l llceda sriatiotannl ecll cn)aacomri si laos a lstyi.pobiis Wtha mskae isht ukynliel is eth lioctano: labr.letia eTh orrip yehotctmsery dan iatlblaer lmooooaoscyppgr-ihtne udlow veael sarc stiuse no hbto issde of het bod,y tub teh dosd fo aoierltluh racmiaocn asnirig abrylailtel aer yerv .slmi

A) heT eaitpnt adh a ectorset,ymyh so hte sodd of ecertnrur vcilrcea amioancrc rae lsoa lenibcrdyi lo.w C) adn D) rltreUah cayomdnlo adn uathlrer laanrsionitt elcl ilalmpoap era in eht onwgr ionctola ot nucoact rfo lbalraiet arrtuhel gnanrwori wtih ho.ryeuertdr

stinkysulfaeggs  Great explanation - just one addition. The retroperitoneal fibrosis could also be a direct consequence of the external beam radiation. It's linked to both causes. Either way, it's a better fit than urothelial carcinoma (in retrospect). +13
spow  Why would the onset be 15 years later though? +3
drzed  I was thinking the same thing @spow. I had put urothelial carcinoma, thinking that a field defect would result in bilateral tumor. +3

 +4  (nbme23#9)
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ormF ristF di-A pyaltohsciz ieepstnaoslri eixithb eiecrtcnc rpencapaae, odd seliefb or liacgma nikgtinh, nad oliernasernpt nswakdswe.ra Tehse diercbse eth revlsae lrysea of cesto,hl blfeie ni yscihcp asbiieilt adn sryctl,as dan poor yee ncto.atc

A) eilrnr-doBe lsbneatu omods hwti t,iilmyiuvsp lniasfoulmt-,iet s,uidtcyaiil dna a esnes of ,pmensesit ongal hwti a arergte ielhdoilko ni wnome B) p-enentdDe etsoh htwi na xceses dene rfo sppuort dna wol lo-seeefifcdncn Crii-c)ontHis leyesicxvse ,amnlioote ksese ai,tottenn ulxaseyl rcvivaeoot,p cerndenco hwti peeaapncra atc'"(sor dasse"i)e )D asNtr-csiciis iia,ygtodnrs it,ldenet claks hpyatem, mdnsdea het' bes't )E ic-Sizohd uvaolynrt aoiscl whdaawlti,r mtdiiel tomiloane srsxopn,iee ntotcen to be on hrtei now

abhishek021196  SCHIZOTYPAL = Included on the schizophrenia spectrum. Pronounce schizO-TYPE-al: Odd-TYPE thoughts. +

 +9  (nbme23#22)
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CMH I ntncuofi si enlgtiar to cncaer srsnusppeoi. MHC I ssdlyaip deueynoglons tssdheenzyi iornteps nad ensepstr meth to C+D8 T .lcesl ehT ailfure to ydalisp HMC I, or HMC I slydiap fo o-lsefnn n(ad yb noientsxe a)ocrucens rnspeoti ggtsierr a erlclual mminue eorsn,pes daniegl to scrteoutndi of teh c.ell

heT prsoemaoet si edsu rof the aanodrtedig fo wrno o,tu nsetscee,n ro ermdlfmao rt.pesino sA cnarce de,lveosp rmoe muastntio dael ot scaenedir rngwo .sitrenpo lynO by noxseesrip of teh rsoeotpa,em or ist reneoi-v,soerpxs acn thees amnttu tpnisero be ddaedrge sfat nguoeh to nto eb adesplidy by HCM I nda eald ot teh ecll eibng ldl.kei eztBomorbi ockslb teh ,oreempstoa so teh tmunta penisrto rae yieplddsa on het sfuc,era alwnilgo hte mnuiem etmssy to ecergznoi dna lkli oactiogallhp el.lsc

catch-22  Another way to approach it is to think about MHC class I processing. Basically, if you inhibit the proteasome, peptides will not be generated and nothing is available to be loaded onto MHC I (remember MHC I has to be loaded before it's transported to the cell surface). Cells that don't express MHC I get killed by the natural killers. +25
kai  "In conclusion, we have demonstrated that the proteasome inhibitor bortezomib down-regulates class I and enhances the sensitivity of myeloma to NK cell–mediated lysis" from the conclusion of the NIH paper +5
maddy1994  another mechanism is by blocking proteosome u even decrease degration of proapoptotic it enchances apoptosis(from uworld) +3
azibird  But CD8+ and NK cells kill via perforin! Why is this answer wrong? Is it because it's not the primary effect? +2
testready  "The proteasome is the major source of proteolytic activity involved in the generation of peptides for presentation by major histocompatibility complex class I molecules. We report the new observation that bortezomib down-regulates HLA class I on MM cells, resulting in increased NK cell–mediated lysis." +

 +6  (nbme23#40)
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msaPal mmbrnease rea a ldiip y,raelib lcyytalip twih tphpshaeo hsdea on heac uescafr nda olgn oacnbr alits no het neii.ds sehTe nacrosb ear etarnul, and nugedro ihrocbophyd iaesttrconni ofr an ntleeilycrega aarbfelov tstea.

Itrgalne nmemaerb osetrnpi sasp ughrtoh shti ipidl raeib,ly and so muts eb clabepa fo icrgitnaent btho hwit teh lrpao levnstos fo ecrailrnulatl nda erlaultelcrax seac,p as wlel as het diophchrboy ocre of hte rla.ey heT emasartmebnrn iptnroo often ahs laelaaplihh-c roanyscde itf,nronomaco wtih hoicrypodbh uesidres ilek egclyni on het iuesdto wordsta eth onbrac lstai wiht prola oimna cdia edsuseri deckut i.n

makinallkindzofgainz  "high school biology" lmao we really out here +6

 +8  (nbme23#14)
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Teh tnpaeti trstaed ecnrgeiiv s-glpstairuco cunsbtsaeouu inaagltioacntuo arepty,h os tsom eyklli tihere fiacduotnreant ehraipn or olw mcelraolu gwhite M()WL toiaUfanrndect piaensh'r rpyaimr oaattlgicuoanin iabtily secmo ofrm kniorwg wthi iarnhnttibom III ot kclbo ucltoaansoig crfotas II nad X.

reovw,He rhaiepn can oasl bind to a lltteeap toiprne laedlc eeatlltP trFaco 4 4P(F), ufndo in lh-asgneaarl.up nhWe ti dsnbi 4F,P eht enw -Fnip4Perha euemlolc si cimmiueo.ngn hTe numiem eepsrosn ot tihs geeentars 4h-pan-PtieinaFr Ig. lteslPeta arlyeda heva gI rretpeosc on etihr sa,rfuecs so nwhe eesth pirt4fnaha-Pi-en gI trgerig teh eesoprtcr no het tpl,tseael eseht eaelstltp uangelrdeat. hTe galuiaenortdn kciks ffo efhrrtu itcltog,n lednagi ot a odpr ftnoe( meor anth 0)%5 ni tlaetlpe cou.nt


 +5  (nbme23#46)
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inTescaletcyr aer iucaclm tiaecgnhl .naesgt secBeau of ht,si ni a geedonilvp sefut or dclhi teyh illw bind ot culicam otp,ssedi yaneml eteht and senbo. hsTi acn cesau -kulcebbla isiolrocadont of e,etht and si oaaiitcddrncetn ni tgnpenar thrmeos for iths osnrea or in nhidrlec ndreu 8 yrase fo ae.g l,iaoyldinAtd tihs saem ehccialm yeotprpr fo gbidnni ot aucimcl is hwy ctrinae ivatlden aiontcs Ca,mluci( ,geiusmman inor +Fe)2][ netpevr otrapsbino of ,stirealcenyt nad so neemicisd itwh eehst oins n,adtcais( ionr npmnptetli)oeuas sludho be etdim ton to nfetrriee wtih r.ptsboiano


 +21  (nbme23#18)
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Eyenmz A dantss ni orf phsiloohePpsa 2A, nitrgnu ispsldhiophpo ni the ecll emanbmer inot iraohdciacn ac.isd From ehet,r nEyzem B natsds ofr xlaooCeyeycsng O,CX() hilew mnEezy C sndast ofr nsg-yeaL5ipxoe 5(OL.-) 5O-L deoupscr EPE5,-TH hwhci is nuterd iton .eisnrktlouee ekstLeenuior alyp a uloebd oelr in evetns keli aht,asm ecubase htey aecus ibcricostrnohconton n(see in shit nta)ipte adn by gictna as clmiheac tsaarntttca ofr aftylmanomri e,lscl sewho tiatiyvc wlil oslce the aiyraw fr.rueth By oblgckin XCO erpab(slyum thwi an S)NDI,A ew eeavl reom of eht erbtusats aichcirando dcia rof 5X-OL ot lmaytlutei vnretco into nrkuelsoe.iet iThs is the bssia rof a-aieamiispnsnr-nltthr,ato hihwc is neuylqetrf dtcasesoia wiht aalns p.opsly rmtae'S(s ai.r)td


D) irnoPtyclasc sytaesnh . )E moeraTnoxhb tnaessyh

 +9  (nbme23#30)
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ehT patenit rnuenedwt mvrleao of a ealrct oumrt chiwh dah inlvveoentm ithw eht ors.ttape Teh aoticsprt slaecup si rhic thiw svenre cdglinnui teh elvipc hcnpslaicn v,eresn a ste of iehaptmcrpsayat rneesv ebsielrospn fro SPN cuanotiom gr.tauoneil etErsionc ear a cspetipamyraaht fnnto.ciu

)A yraG raim orfm teh phtemcaiyts nhca-i snetierco rae a yaaetmsicrtphap ucfnn,tio tno asthep.yimct noiEssmi of rpsme si a acymesthipt i,cntuonf dan is edtecrdi yb het feniiorr caosgrhyitp nvee.r )C -uPnddlea hte pnlddaeu reven is a stamcoi enver ahtt ircseeve aienostns omfr hte ineps, sroeiptro rsoc,utm s,lcrioti adn blia,a sa lwel as enbig norblpsseie fro some emvnmoet of eth viplce o,olfr nda uoactjea.lni )D Surripeo rithsoagcyp nre-ev a mtheascptiy ,verne siht cbitsoetrun ot teh ycragpihsto peulsx dan amy lsao ntcerbtuoi to hyeitmcpast nrltooc fo omisei.ns E) taerlVn rmaei of --SS42 Tsehe iram iuetotncrb ot hte aenudlpd

focus  Diagrams here are pretty good too: "Point, Squeeze, Shoot" Point- erection: pelvic splanchnic nerves (S2-4) Squeeze- emission: superior hypogastric plexus Shoot- ejaculation: pudendal nerve +

 +11  (nbme23#34)
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ehT eglnsi omst tmnitaorp ghtin botau ihst sogsr otlpaghyo is ttha het aeidses si ran.mdulioltu hisT icdtasein tsssmteaae mofr niattds .estsi

Leirv ascseessb ear syulua glaurn,si lfdiel thwi emyrca yeollw sp,u nad may ohsw a iobrfus p.ueslca sihCirsro tnefo howss a yllweo crool due ot ftayt hnegca as ewll sa evieenerrgta lsuen,od chhiw are tno teperns e.hre A afcol aronudl paylasrhpie si a sulagirn outmr fo het i,lvre dan tshi is Haeitipst B si a tiletl aredhr ot ihidsnstugi easeubc form hwta I acn lelt it anc eb nltdmouirlau ni oems csaes, but htis reivl saol wssho neon of teh lcosrsesi ofrm rohncci iofammnltani that wloud lielky ncaymacop Hep .B ilaFyl,n ew ees no radk iclnaooiodsrt ot cineitda .rficotnian

monkd  It doesn't explain the sudden death, but I suppose they aren't asking for that! +4
charcot_bouchard  I hate this type of ques. Here it is. Tell me what it is? +2
divya  also, a liver infarct is unlikely due to rich dual blood supply. +1
drzed  @divya Rather, if there was an infarct, it will be hemorrhagic, not pale. +1
llamastep1  Multiple solid lesions on a healthy liver = meta. I assumed breast wouldn't meta to liver (it's usually GI cancers) but it makes sense since all the blood gets filtered by the liver at some point. TIL! +

 +24  (nbme23#25)
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Ciicalrt nipsot rof stih s:inqtueo 5 erya dlo ,ybo ussmseoeunpmipdr cbaesue fo hmch,yoetrape 2 yad osyhrti fo ,revef uhg,oc rsesntsoh of rh,teab bfireel (.8110 )F, ioressrpnita /64n,im ihwt acynsosi nad lgnizeeread iurcelsva a.hsr teexsiEnv lrnduao n.itltioanifr

fO eht tispono dlties ynol mslease adn ZVV egvi a A rsha morf easlems lulyuas atstrs llrraytos nda deednscs alluyc,da dna is latf and eey.mtsutorha By attr,cnos VZV knhp(xiecoc) ssneertp tihw inedgzelaer sahr htta iluqcky iinstasnrot rmfo aacmlru ot uraplap nteh to rcvesla.iu

sympathetikey  Good call. +6
imnotarobotbut  Also, VZV causes pneumonia (what this patient probably had) and encephalopathy in the immunocompromised. +5
nwinkelmann  What threw me off was that it didn't mention the synchronicity of the rash. I stupidly took failure to mention to mean that the rash was synchronous, which doesn't fit VZV because chickenpox rash is characterized as a dyssynchronous rash (i.e. all stages of the macule to papule to vesicle to ulceration are seen at the same time). MUST REMEMBER: don't add information not given! +5
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +1

Subcomments ...

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ePntati ash a ftucarre ot the reriinof .rtibo ihsT nca mdg V2 or aneptr het RI c.lmuse ylOn IR mnpetnerat lwudo iipram sivio.n

nlkrueger  if this isn't a globe rupture than idk what is tbh +14  
mousie  the air in the center of the globe made me think rupture too ..... +3  
sajaqua1  There may be some global rupture, but impairment of one of the ocular muscles causing diplopia would still be the best explanation for this patient's double vision. +12  
catch-22  Globe rupture leads to entrapment of the IR muscle which causes diplopia. The question is asking what is causing his visual complaints, which is diplopia, not loss of vision. +2  

submitted by sajaqua1(518),
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laeM ernptat nsdi/cgs.delaoaenrbn acaloepi si desuac by teh fctefse fo ohyteeenttdrroodiss ()HDT no the snik fo eth als.pc nrtseotTesoe is edrtocvne by eht eyznem pedlecs5uat-h-ara iotn TH.D iaertniiFedss a e-5uactear-sd ,hbiriotin adn os cbslok eth doiuncotpr of HDT dna nca alht or even eucas smoe asrlvree fo maek atetprn sensb.ald wroeeHv htis msae cvyiitta yma soal tsleru ni aicinsnfgt xleasu seid scfetfe dlgcniniu ,ntogimysceaa rictelee nocnistd,ufy uecylatrjoa ousnicy,ndft adn cdasdeeer .ibdoil

A) lzna-aDo a kewa naroendg htiw ennogaicetrist c,feestf duse in eth emnrtatte fo oessriemnodit nad ciyfrbcotsi bstear ei.asdes )C lheyoonsesrMete-ttt cteythnis T, it si udes ot euppenltms ni oenestorttse ciefdn,ciye ro in teh rneattmet fo some btares resn.cca D) nxnoreado-lO na aolinacb rsidoet usde ot riange eitg.hw )E ol-ntSzaool nthreao calnoiab iedro,ts iwht inealtotp dseu rof artridheey aomd.eienag

sajaqua1  I am embarrassed by these typos. +1  
drdoom  lol +  

submitted by shaydawn88(8),
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sI ti olirtaa-laenvr tadesutrans uaebesc itsh aettpin gitmh veha HF td/ .a fbi and ltfe iraatl greanml;gnt-&ete icn yrctoashidt ue-prt;g&rsse tdnaersuta prlauel n?ffeious

sajaqua1  Basically. +4  
medschul  Why can it not be arterial hypertension? +2  
meningitis  I think Arterial HTN is referring to Pulmonary Artery HTN which would be present in LT HF in the long run with RT HF and edema. Pulm HTN would cause a backflow, and doesn't really answer the question "explain the patients Dyspnea". At least, that's how I saw it. Hope this helped. +5  
sugaplum  the question has 2 murmurs, so does she have aortic stenosis too? i guess it is not relevant since it asked for what is causing her SOB +2  
nukie404  I guess pulmonary HTN would happen in response to increased pressure after the edema happens, and would cause backflow (to the RV) over pulmonary edema. +  
vulcania  There's a really great diagram in UWorld (QID 234) that explains what happens as a result of mitral stenosis. Very similar sounding to the patient in this question. +  
srdgreen123  @sugaplum, yes rheumatic heart disease can cause mitral and aortic stenosis. Rheumatic aortic stenosis can be distinguished from degenerative aortic stenosis by 1)coexisting mitral stenosis and 2)fusion of the commisures. +1  

submitted by seagull(1393),
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hsTi si a ncipa ak.tcat yioHveelnnittarp odpsr 2pOC aenglid to a irrepaystro .kloassila po2 si ivtlelayer aefudcnfte do(nt' aks em ?woh)

sympathetikey  Yeah haha I had the same conundrum. +  
sajaqua1  If she's breathing deep as she breathes fast, then oxygen is still reaching the alveoli , so arterial pO2 would not be effected. +21  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +2  
soph  Maybe Po2 is unaffected bc its perfusion (blood) limited not difusion limited (under normal circumstances). +2  
charcot_bouchard  PErioral tingling- due to transient hypocalcemia induced by resp alkalosis. +1  
rainlad  I believe CO2 diffuses ~20x faster than O2, so increases in her respiratory rate have more effect on her PCO2 than her PO2 +1  
usmile1  adding onto Charcot_bouchards comment, I found this: Respiratory alkalosis secondary to hyperventilation is probably the most common cause of acute ionised hypocalcaemia. Binding between calcium and protein is enhanced when serum pH increases, resulting in decreased ionised calcium. Respiratory alkalosis can induce secondary hypocalcaemia that may cause cardiac arrhythmias, conduction abnormalities and various somatic symptoms such as paraesthesia, PErioral numbness, hyperreflexia, convulsive disorders, muscle spasm and tetany. +3  

submitted by m-ice(320),
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Teh tniapet essem to vhea na otficnien deu ot irhte edteevla mrpaeeutetr adn nrmbaloa tchse -y.aXr ,eewvorH rtihe kuloycete ntouc is .olw nI io,dtdnia het atipetn ash tsptiieah ,C wihch si teonf oaicaessdt iwth irmlias amrnsnisiots oersut ot H,IV ikel atovsieurnn rgdu .eus

sajaqua1  Not only is their WBC count low, it is not uniform. If we assume a minimum normal WBC count of 5000 cells/mL^3, and a regular range of ~60% neutrophils, then normally a person should have ~3,000 neutrophils/mL^3. This patient has a total of 2000 cells/mL^3, with 1,800 neutrophils/mL^3. Their lymphocytes and macrophages have been whiped out. This is best accounted for by HIV. +35  

submitted by keycompany(295),
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nCa omyedosb how neduratsnd why VPR sseaerdec thiw a dfSte-ediL rcnftia aelpse gltneenih .em I wdolu lsao cearptapei ti fi ouy ouldc rteeal ti ot hrtgi dside ehatr iruaefl oto e..(i owh oluwd ti an)

sajaqua1  I believe that keycompany's answer comes the closest. In an MI, consider it as cardiogenic shock. The heart is a pump, and it is failing to move blood out of the heart and into vasculature. This is why PCWP increases. Because of insufficient output, the body has a sympathetic response. The catecholamines then cause vasoconstriction in peripheral vasculature to keep blood pressure up and continue flow, leading to increased SVR. Meanwhile, the sympathetic response causes vasodilation in the lungs; this would be an appropriate autoregulatory response, because the body is trying to keep up the flow of oxygen throughout the system. This decreases PVR. Is a pretty good article on this. Of course the binding of catetcholamines changes depending on saturation and the response is not perfectly understood. +12  
usmleuser007  My understanding is that the pulmonary circulation changes very little in terms of an acute MI. It is b/c pulmonary circulation has a lot more room to fill with blood much like the spleen in terms of blood accumulation. With higher volume of blood in pulmonary circulation, more blood vessels are able to be recruited specially the apex. With more recruited blood vessels = reduced pressure d/t circulation in parallel. +2  

submitted by seagull(1393),
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I heva na ssuei htiw tsih tseonqiu ihhcw salo lctcsnfoi itwh lUrd.Wo In rerod ot eb raedgdde by esmoestoopr teh lieddfmso rtpoine olwdu deen to be tnperse in hte tlosyco rof .uiuitbnano It ti uaaulcmecdt in the ERR tenh hwo does ti gte dgtgae? nHe,lsyot os oce.inf.lcdt.

sajaqua1  So ordinarily a misfolded protein does undergo ubiquitination and proteolysis. It is noteable that CFTR misfolding doesn't even allow it escape the ER, so it accumulates in the ER +9  

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anC yodnaby neaiplx siht ?one I tup apeerdet tsste bcsuaee I dsmusae an 8-3or-dlaey oawnm is na suaunul hecpamgdior orf pshil.yis

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +5  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +4  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +12  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +10  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +13  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see and +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  
imtiredofstudying  the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +  

submitted by neonem(549),
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eTh pteanit ash owl r,cisloto ihwhc cussae bydo ng.atwis heT ineptta si ermpynigtdepeh nisce owl looicsrt neirssaec TCAH tseroncie omrf het r,ttuayiip ubt hits sashre a omcnmo epsurorcr prineto hitw nmaetugsinlc-ylaoemtit enoohrm S,MH)( os tahts' ftone a ngis of hierte aladern efluira ro an TeHnACrieg-cst roumt. tPu retoet,gh eth ghih HCAT utb olw ctrlisoo phnapinge vroe a pedrio of 6 hsontm nmesa thta eht rlndaae sumt be entgtig thi yb onmthsieg -- loyn oitonp reeh wsa muamountei ini.arsdltae ieusF-reaheirodteWhcsnr nrosmeyd laso acesus ndrlaea iceififunncsy btu ihts phnespa lu,cetay ni eht armeifetm of sosyduhr-.a

sajaqua1  The combination of low blood pressure (from lack of mineralocorticoids) and low glucocorticoids (cortisol) indicate adrenal failure. Hyperpigmented skin is a sign of elevated ACTH, indicating that this is a failure of the adrenal gland and not the pituitary. In the industrialized western world, autoimmune destruction of adrenal glands is the leading cause of primary adrenal failure (disseminated tuberculoid destruction of the adrenal glands is significant outside of industrialized nations). It also fits the time line better than Waterhouse-Friederichsen syndrome, which is sudden in onset and associated with hemorraging. Metastases to the adrenal glands *might* be a possibility, but autoimmune destruction is simply likelier. +22  
mamorumyheart  Chronic Addisons disease. Pretty straightforward here. Decreased gland function -> decreased Cortisol, decreased Aldosterone -> hypotension (with hyponatremic volume contraction) Hyperpigmentation from increased ACTH (from POMC) making MSH. (FA) Due to adrenal atrophy or destruction by disease (autoimmune destruction most common in the Western world; TB most common in the developing world). +1  
ac3  I picked autoimmune adrenalitis but was tempted to pick Waterhouse syndrome because of the low BP (hemorrhaging). But I believe Waterhouse-Fried. syndrome is more likely associated with Neisseria infection +  

submitted by hyoid(40),
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anC sneoemo ialpexn hist n–eoI– di'tdn really wonk htaw ot kmae fo teh bal u.svlea leylaCr she wsa ktaing oto cuhm i,nsilnu ubt who acn yuo eaiitdnefertf caoifusitt ersoidrd omrf a pyte 1 tediabci who stake oto mcuh of hetir silnniu s?deo

m-ice  I think the trick here is that they don't mention that the daughter has a history of Type 1 DM, so she has no reason to be taking insulin at all. She's definitely receiving insulin, but we don't have any history implying she's a type 1 diabetic. That, combined with the fact that there have been multiple episodes like this one, favors that the mother is giving the daughter insulin when she doesn't need it. +18  
sajaqua1  C-peptide is produce by endogenous insulin, but is not part of exogenous insulin. She has elevated insulin, with low C-peptide, so she is receiving too much exogenous insulin. A history of recurrent episodes this year implies a behavioral issue; Factitious disorder imposed on another (also called Munchausen syndrome by proxy). +7  

submitted by m-ice(320),
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Tihs man hsa ssuplu ,dxaruaops a sgin ni ciwhh obldo espeurrs cesredeas arcilystlad uirdgn ususPl pduoaaxsr si a iscalsc ings fo pearcriaild aem.aptdno

nehW fudli feotn( blood) sha doopel ruodna the rhate, eht eahrt gegutsslr to pxdane nad ifll ithw lod.ob sihT msbcoee a bgrgei pebrolm rfo the gthri trcilenev ignudr nrntispio,ia bsecaeu hte htirg ieds fo the thear vseereic snidaeerc vseoun truner udrgni nis.otirpani sBecaue etrhe is udifl vinrgetnep eht gihtr ilrevnetc fmor ganepdinx r,auwtod the lyno tehor calep it nca axpden ot eaooccmdatm is by uhnpsgi no het tpes,mu srkiihgnn eth zeis fo the tefl ternelicv. sTih csesau edcareeds BP wneh teh letf elicevrtn rcottacns uidgnr htat ccdaiar ce.lcy

sajaqua1  In addition to causing pulsus paradoxus, we see jugular venous distension, and muffled/distant heart sounds (hard to hear through the cardiac tamponade). +3  
drdoom  ^ linkify +