welcome redditors!to snoo-finity ... and beyond!
Welcome to sbryant6's page.
Contributor score: 22
School:


Comments ...

 +0  (nbme23#41)

Pontine arteries are small branches of the basilar artery that can rupture in the setting of poorly controlled hypertension.

nor16  vertical gaze intact = mesencephalon intact horizontal gaze damaged = pons damaged (RPRF) Pons damaged = no access of corticobulbar tracts to motor nuclei in brain stem -> speech impaired



 -2  (nbme22#6)

If you know the MOA of digoxin you should be able to get this question right.


 +2  (nbme21#48)

This question is two-fold. You must know the decision-making hierarchy and also consider autonomy. Making "recommendations" for certain treatments is wrong, because it violates autonomy and informed consent. Physicians should simply explain the RBA's of all treatment options, and allow the family to decide what is best based on informed consent and "their perceptions of the PATIENT'S wishes". If there is no advanced directive, then the decision should be appealed to a surrogate decision-maker. Priority of surrogates is spouse-->adult children-->parents-->siblings. Yes, the spouse would have higher priority, but the family should at least try to reach a consensus first before appealing to "only" the wife. If a consensus, cannot be made, then the wife would have first say in the decision. Therefore, encouraging the family to decide according to the wishes of the PATIENT would be a better first step, especially if the wishes of the wife is contrary to that of the patient. Also, just as a general rule, I typically avoid picking answer options with "absolutes" such as "never, always, only". The purpose of a surrogate is to act in the best interest of the patient.

sbryant6  Correction. According to UWorld Social Sciences (Ethics/Legal/Professional): Advance Directives... "situations in which family members disagree and there is no proxy can be referred to the ethics committee or, as a last resort, to the courts".

 +3  (nbme21#37)

Craniopharyngioma with Calcifications and Cholesterol Crystals (motor-oil fluid). Remnant of Rathke's pouch. Not to be confused with pituitary adenoma.

dubywow  Also, craniopharyngioma is most common supratentorial childhood tumor. That was the big clue for me.

 +1  (nbme21#48)

To remember Baclofen is a GABA agaonist and muscle relaxant, I always think of "Greek Baklava". Greek for GABA, and Baklava for Baclofen.





Subcomments ...

submitted by mousie(83),

Why no sweating? I mean I get Ecstasy is probably the drug of choice before an all night dance party (lol) but don't understand why there would be cold extremities and no sweating when is FA it says hyperthermia and rhabdo????

sympathetikey  FA says, "euphoria, disinhibition, hyperactivity, distorted sensory and time perception, bruxism. Lifethreatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome." So I think they wanted you to see Sinus Tachy and jump for MDMA. Idk why Ketamine couldn't also potentially be correct though. +1  
amorah  I picked ketamine because it said no diaphoresis. But if you need to find a reason, I guess the half life of ketamine might rule it out. Remember from sketchy, ketamine is used for anaesthesia induction, so probably won't keep the HR and BP high for 8 hrs. In fact, its action is ~10-15 mins-ish iv. +2  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +1  
fulminant_life  you wouldnt see tachycardia with ketamine. It causes cardiovascular depression but honestly i saw " all-night dance party" picked the mdma answer and moved on lol +3  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +  
sbryant6  @fulminant_life FALSE. KETAMINE CAUSES CARDIOVASCULAR STIMULATION. +1  
dashou19  Take a look at why the patient has pale and cold extremities. "Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008716/ +  


submitted by link981(33),

Page 36 of FA 2018. Purine antagonist drugs are:

6-MP(Azathioprine is a prodrug of 6-MP), Mycophenolate, ribavirin.

sbryant6  I forgot what the MP stood for in 6-MP, so I chose methylprednisolone. Silly mistake. +  


Good fact to commit to memory: you lose bicarb in the stool (hence why diarrhea causes nonanion gap metabolic acidosis), and especially lose potassium with laxative abuse (as mentioned in the question stem). https://www.uptodate.com/contents/acid-base-and-electrolyte-abnormalities-with-diarrhea

sbryant6  I'm going to go take a big bicarbonate poop now. +4  
happysingh  i would suggest that you look into it a bit more. Why ? Had an nbme question (which confused the shit out of me) cuz, Bluemic Pt. who was abusing Laxatives (had the up & down arrows) and this is what it gave : Laxative Abuse — Metabolic Alkalosis :   ↓K+     ↑Cl-                   ↑pH    ↓HCO3- so one of the points of distinction IS the increase in Cl- with laxative abuse (vs. vomiting, which was a knee-jerk reaction when i hear bulimia) +  


submitted by pppro(5),

Patient has BPH. Give alpha one antagonist to reduce smooth muscle contraction and relieve difficulty urinating.

d_holles  lol i thought it was some kind of urinary retention problem and put H. +4  
sbryant6  How is H wrong? Oxybutinin or tolterodine treat urinary incontinence by blocking M3 muscarinic acetylcholine receptors --> urinary retention. We're just supposed to assume they are talking about BPH here because he is old? +  
jaxx  I agree. I picked "H" for that same logic. Does anyone know where we should have come to the conclusion that this was BPH? +  
forerofore  they are telling you he's having "difficulty urinating", one of the clinical criteria for BPH is reduced urinary flow rate. this is not incontinence because they are not telling you he leaks at all, just that he pees "a lot" +1  


submitted by welpdedelp(75),

This is Lambert-Eaton, which improves with movement as compared to Myesthenia gracias whichh worsens with movement

sbryant6  Lambert-Eaton is typically associated with Small Cell Lung Cancer. Since there was no mentino of that, I was thrown off. Such is the difference between UWorld and NBME I guess. +  


submitted by seagull(423),

The authors went out of their way to find thew worst photo of a granuloma they could. The threw on a stem that suggests that it would be granulation tisue. But little did we know...

amorah  I was between granulation tissue and granuloma. Then ruled out granulation tissue because this is a 10 week old wound. Assuming normal wound healing, granulation tissue would be replaced by type III collagen/resolution by 10 weeks. +4  
sbryant6  Got this right because the exact same question is in Uworld. +  
dubywow  Got baited... took my eye off the ball (and onto that worst photo ever) and missed the Ten week part. Granulation for the "L". +  


submitted by seagull(423),

Im also convinced blocking IL-2 is also a treatment? WHy is TNF-alpha the better answer here?

amorah  FA P120-122. Immunosuppressants for RA are calcineurin inhibitor (cyclosporine and tacrolimus), 6MP, and TNFa inhibitors (adalimumab,infliximab, etanercept). It is important to distinguish that calcineurin inhibitors block t cell activation by preventing IL-2 transcription, not necessarily block IL-2 action. Sirolimus(rapamycin) blocks IL-2 action but it is used for kidney transplant rejection prophylaxis specifically. +3  
sbryant6  Spot on. This image explains how Sirolimus blocks the effects of IL-2: https://image.slidesharecdn.com/11-150813013011-lva1-app6892/95/11immunosuppressants-30-638.jpg?cb=1439429471 +  


submitted by yotsubato(264),

"MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) is a prodrug to the neurotoxin MPP+, which causes permanent symptoms of Parkinson's disease by destroying dopaminergic neurons in the substantia nigra of the brain. It has been used to study disease models in various animal studies." Wiki

ilikecheese  pg 508 FA 2019 +1  
sbryant6  I thought this was testing "lead pipe rigidity" aka Neuroleptic Malignant Syndrome and its connection to dopamine. Had no clue what MPTP was and got it right still. Probably wrong train of thought though. +  


submitted by brise(18),

The question is asking what point would be the most likely to rule in cancer, and high specificity when positive rules in cancer. The highest specificity value is A, bc the the X axis shows (1-specificity)!

sbryant6  SPin and SNout. Specificity in, sensitivity out. +  


submitted by sbryant6(22),

If you know the MOA of digoxin you should be able to get this question right.



submitted by sbryant6(22),

This question is two-fold. You must know the decision-making hierarchy and also consider autonomy. Making "recommendations" for certain treatments is wrong, because it violates autonomy and informed consent. Physicians should simply explain the RBA's of all treatment options, and allow the family to decide what is best based on informed consent and "their perceptions of the PATIENT'S wishes". If there is no advanced directive, then the decision should be appealed to a surrogate decision-maker. Priority of surrogates is spouse-->adult children-->parents-->siblings. Yes, the spouse would have higher priority, but the family should at least try to reach a consensus first before appealing to "only" the wife. If a consensus, cannot be made, then the wife would have first say in the decision. Therefore, encouraging the family to decide according to the wishes of the PATIENT would be a better first step, especially if the wishes of the wife is contrary to that of the patient. Also, just as a general rule, I typically avoid picking answer options with "absolutes" such as "never, always, only". The purpose of a surrogate is to act in the best interest of the patient.

sbryant6  Correction. According to UWorld Social Sciences (Ethics/Legal/Professional): Advance Directives... "situations in which family members disagree and there is no proxy can be referred to the ethics committee or, as a last resort, to the courts". +1  


submitted by hayayah(399),

Cysteine-cysteine chemokine receptor 5 (CCR5) is a protein found on the surface of CD4 cells.

yotsubato  Note, this is NOT in FA +  
sbryant6  It is in UWorld. +  


submitted by mcl(204),

Gait problems raises suspicion for alcohol abuse or inhaled glue. However, onset of gait problems is relatively rapid (couple of months) and gait disturbance with regards to alcohol is either due to intoxication or chronic abuse. Alternative explanation available on SDN. Also see toluene toxicity on medscape.

sbryant6  I got this correct solely based on the patients demographic. Glue is cheap and easily accessible to underage populations. +  
whossayin  Kinda racist of us but that’s how I reasoned my answer too lol @sbryant6 +  
hpsbwz  how is it racist if the only thing thats given is his age lol @whossayin +2  


submitted by dr.xx(42),

Henderson-Hasselbach Equation: pH = 6.1 + log(HCO3 / (0.03 * PaCO2)); so here, pH = 6.92 => Acute (uncompensated) primary respiratory acidosis, with metabolic acidosis

sbryant6  calculator can't do logs yo. +  


submitted by yo(25),

they're talking about a splenorenal shunt procedure

https://my.clevelandclinic.org/health/treatments/4950-distal-splenorenal-shunt

hungrybox  be honest did u know that before looking it up +2  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +1  
sympathetikey  Relax @meningitis. Hungry's just messin :) +1  
sbryant6  Looks like somebody needs an enema to get that stick out. +  


Autoimmune thyroiditis (aka Hashimoto) + pregnant--> Think about possibility of fetal hypothyroidism due to antibody mediated maternal hypothyroidism. Leads to Cretinism. Findings in infant are the 6'P (Pot belly, Pale, Puffy face, Protruding umbilicus, Protuberant tongue, and Poor Brain development.

neonem  I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism? +  
poojaym  @neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4. An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland. +3  
arezpr  TSH, T3, T4 and thyroglobulin cannot cross the placental barrier. +  
chamaleo  @arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can +  
yotsubato  The baby has its own TSH though +  
sbryant6  TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work. +  
kimcharito  no goiter then? +  


submitted by pparalpha(18),

EBV (HHV-4) infects B cell through CD21.

Atypical lymphocytes on peripheral blood smear (not infected B cells, but reactive cytotoxic T cells).

"Mononucleosis": + monospot test (antibodies detected by agglutination of sheep or horse RBCs)

sbryant6  Atypical lymphocytes are CD8+ T cells, not CD4+. Remember that. +3  


submitted by hungrybox(232),

Long answer ahead, but bear with me.

HINT: v looks kind of like y, whereas k looks more like x.

y-intercept = 1/Vmax

  • Vmax is the upper limit on how fast a reaction is catalyzed by enzymes.

x-intercept = 1/Km

  • Km is a ranking of how good an enzyme is at binding its substrate. An enzyme with a ranking of 1 is better at binding its substrate than an enzyme with a ranking of 5. (Lower Km = better enzyme)

Note that Vmax, as a measure of performance, can be altered through many things. Meanwhile, Km is a set characteristic of the enzyme, and cannot be altered.

In this example, the enzyme performance (Vmax) is increased by increasing the vitamin cofactor so that it reaches a "normal" activity. However, the enzyme is still inherently shitty due to a congenital defect, so the Km stays the same.

mnemonia  Awesome. +  
ht3  wait line B shows the vmax doesn't change and that the km is getting larger (enzyme is still shitty so larger km) so -1/km would be a smaller number and would approach 0 +1  
lamhtu  You say Km cannot be altered and its staying the same, but the answer of the graph demonstrates a higher Km value. Needing "higher concentrations" of the B6 for enzyme activity is another way of saying Km is higher since more is required for 1/2 vmax activity +1  
sbryant6  Yeah this explanation is wrong. +  


submitted by nosancuck(37),

This b has Sarcoidosis so her granulomas be activatin dat VitD

sbryant6  Your mom activates my VitD. +  


submitted by tinydoc(54),

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. +2  
sahusema  Also, acts on GABA receptors specifically in the spinal cord +  


@infundibidum6 So, I got to bleomycin due to SketchyMicro. Bleomycin can cause hyperpigmentation and pulmonary fibrosis, and I didn’t have any connections to chlorambucil. Anthracyclines can be used for all sorts of malignancies (free radicals kill lots of stuff), so the exact indications did less for me to get to the answer than it might have with another category. n=1, but it’s not a magic memorization answer at least.

sbryant6  Correction: SketchyPharm ;) +  


submitted by cantaloupe5(35),

Histology showed coagulative necrosis (preserved architecture of myocardial fibers) with neutrophil infiltration which hinted that the MI was within 24 hours. Most likely cause of death within first 24 hours of MI is arrhythmia. Myocardial rupture would also be visible on gross appearance of the heart, which they described in the stem.

bighead478  in FA it shows softening of the myocardium to happen at 3-14 days. Do you think this was overly misleading people (like me) into choosing myocardial rupture? I understand the histo features are consistent with < 24 hours, but the stem should also match this in every detail +3  
sbryant6  Myocardial rupture would not happen until 3-14 days. Since this shows signs of <24 hrs, the answer is arrythmia. +1  
hello  @bighead478 You have to look at the whole picture. Histo shows preserved architecture, which indicates coagulative necrosis -- coagulative necrosis is a histo finding only in the first 24h. The most common causes of MI-related sudden death are: arrythmia > cardiogenic shock (heart pump problem) > rupture. +  


submitted by mcl(204),

Niacin (vitamin B3) antagonizes VLDL cholesterol secretion

sbryant6  Fibrates stimulate PPAR-alpha --> LPL upregulation --> decreased triglycerides. However, this question asked about a vitamin. Vitamin B3=niacin. +  


submitted by hungrybox(232),

Huntington's disease

  • anticipation: she has a similar disorder as her father but died earlier

Remember "HUNT 4 an animal, put it in a CAGe". Huntingtin gene found on Chromosome 4. CAG is the trinucleotide repeat:

  • Chorea, caudate nucleus
  • Ataxia
  • Gloomy (depression)
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +4  
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +  
foulari112  How would you differentiate this from Frontotemporal lobe dementia +  
temmy  Foulari 112..the ageof the patient and the anticipation cos her dad had it too. Also in frontotemporal pick, you will see personality changes where they act completely different vs huntington where they are aggressive and depressed. +  


submitted by hungrybox(232),

Huntington's disease

  • anticipation: she has a similar disorder as her father but died earlier

Remember "HUNT 4 an animal, put it in a CAGe". Huntingtin gene found on Chromosome 4. CAG is the trinucleotide repeat:

  • Chorea, caudate nucleus
  • Ataxia
  • Gloomy (depression)
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +4  
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +  
foulari112  How would you differentiate this from Frontotemporal lobe dementia +  
temmy  Foulari 112..the ageof the patient and the anticipation cos her dad had it too. Also in frontotemporal pick, you will see personality changes where they act completely different vs huntington where they are aggressive and depressed. +  


submitted by usmleuser007(113),

Norovirus (Sketchy) = Affects where a lot of people are in close quarters - especially common on cruises - 90% of all diarrheal outbreaks on cruises

sbryant6  Rotavirus occurs in unvaccinated children. In order for it to spread, all those kids would have to be unvaxxed. +  


submitted by hayayah(399),

Inguinal hernias are usually reducible, femoral hernias are not.

This is an indirect inguinal hernia. It enters internal inguinal ring lateral to inferior epigastric vessels and is superior to the inguinal ligament.

Caused by failure of processus vaginalis to close (can form hydrocele). May be noticed in infants or discovered in adulthood. Much more common in males.

yotsubato  Heres a good picture to help with the concept. https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwjVkIi0yN7iAhWLjqQKHbeXCTUQjRx6BAgBEAU&url=https%3A%2F%2Fwww.herniaclinic.co.nz%2Finformation%2Ftypes-of-hernias%2F&psig=AOvVaw2BzGtQLvSmUN8ymhdvETG5&ust=1560244112252834 +2  
sbryant6  Note that direct inguinal hernias typically happen in older adults. This question presents a younger baby, so it is more like to be indirect. +1  


submitted by hayayah(399),

With chronic vomiting, you lose electrolytes and a lot of acid. It triggers metabolic alkalosis which is why all the serum values are low (or on the lower end of the normal range) except for bicarbonate.

ergogenic22  decreased K+ (from increased RAAS due to volume loss) and decreased Cl- (loss of HCl from the stomach), Alkalosis from loss of HCl and thus high bicarb. For this reason high to mid range K is wrong +3  
sbryant6  Wouldn't increased RAAS lead to increased Na+? The answer shows decreased Na+. +1  
sbryant6  Also, remember Bulimia Nervosa is associated with hypokalemia. +  
sugaplum  so the range they gave for K is 3-6? so 3.2 is WNL then? or are we just operating on "it is on the lower end of normal in peds" +1  
dbg  sodium levels in pyloric stenosis vary, nothing really classic, can be high as in this case simply due to hydration, can low in other cases if aldosterone managed to reverse that to the other extreme +  


submitted by hayayah(399),

With chronic vomiting, you lose electrolytes and a lot of acid. It triggers metabolic alkalosis which is why all the serum values are low (or on the lower end of the normal range) except for bicarbonate.

ergogenic22  decreased K+ (from increased RAAS due to volume loss) and decreased Cl- (loss of HCl from the stomach), Alkalosis from loss of HCl and thus high bicarb. For this reason high to mid range K is wrong +3  
sbryant6  Wouldn't increased RAAS lead to increased Na+? The answer shows decreased Na+. +1  
sbryant6  Also, remember Bulimia Nervosa is associated with hypokalemia. +  
sugaplum  so the range they gave for K is 3-6? so 3.2 is WNL then? or are we just operating on "it is on the lower end of normal in peds" +1  
dbg  sodium levels in pyloric stenosis vary, nothing really classic, can be high as in this case simply due to hydration, can low in other cases if aldosterone managed to reverse that to the other extreme +