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 +0  (nbme24#3)

Diarrhea in HARDASS can lead to metabolic acidosis as well. On second thought I decided to take crohn disease cuz I figured the clinical picture is more intermittent with potassium disturbances. I guess I just overthink due to the lack of other physical abnormalities.

daddyyikes  other than the patient not haveing any sxs of crohn's i dont see any reason why its not crohn's. we differ crohn's and rta by urine anion gap. in chronic diarrhoea it is negative while in rta its +ve but in question the anion gap was normal

 +0  (nbme20#10)

This is the second best choice I was gonna take during the exam. I thought Age was better since FA indicated decreased estrogen and old age are the reasons for bone resorption. Can somebody explain to me why Age could not possibly be the answer?

kard  I solve it like this: So age is 70 (already, nothing we can do to change it), is asking about a predictor of success in the Rehab process (So basically, what this patient did in matter of activity, life style, etc. to have a Good rehab process). So From all the answers the, Activity level is the most likely choice because of the, increase in Bone density(Specially Weigh bearing) and OsteoBlastic activity.




Subcomments ...

submitted by jejunumjedi(15),

The blood smear depicts Schuffner stippling. Found the exact image on the web with explanation:

http://spot.pcc.edu/~jvolpe/b/bi234/lec/2_parasites/images/P._vivax.htm

doctorboomboom  Hey thanks for finding the image! Do you know why the answer can’t be Chloroquine resistance? I was b/w that and formation of hypnozoites. +1  
jejunumjedi  I think it's just that Schuffner stippling and hypnozoites are both specific to vivax and ovale species. These species could be chloroquine resistant or sensitive, but if you have Schuffner stippling or hypnozoites, you can definitively say that it's either vivax or ovale. +1  
sherry  Species with hypnozoites is not called chloroquine resistant. Chloroquine-resistant species means trophozoite/schizont cant be killed by chloroquine. We dont have enough info to decide whether the spp in the q is resistant/sensitive. But we do know he moved from Honduras to USA 1 year ago. +1  
soph  UW: in africa most malaria species are resistant to chloroquine. he is from hondruas +  
randios  Can anyone explain the 1-week history of fever? Ruled out vivax and ovale due to 48 hr cycles. Or did they just throw that in as an unspecific symptom. +  


submitted by m-ice(123),

The patient shows no sign of cortical activity, but has some brainstem function intact, which implies she is in a form of persistent vegetative state. She has a living will that designates mechanical ventilation should be discontinued if that situation arises, so we must follow it and make not attempt to resuscitate.

lfsuarez  Why would the second part of that be correct when there is not mention of a DNR? +3  
ug123  DNI and DNR are different right? This patient had a DNI. Why would we assume it to be DNR too? +  
sherry  DNI and DNR are indeed different. But it is not the case here. The patient needs to be extubated means she did not sign a DNI or DNR in the first place. I assume her living will is more like terminate supporting treatment in a vegetative state. So there is no need to do resuscitation anyways. But I agree this is not a good question. +  
shayan  "The patient has signed the living will and is consistent with her directives" but the stem doesnt tell has what is in her living will about the extubation? we are extubating on the request of her husband? this is confusing ! +  
criovoly  I believe this question was not well constructed... it's one of those! +  


Why is it aphthous ulcers if there are no GI symptoms? Why can’t it be herpes zoster?

colonelred_  It’s just canker sores, they come and go. I think in herpes the gingivostomatitis really only happens when you first get infected. After that you just get recurrent cold sores. +1  
hyoid  Herpes zoster is not the same as herpes simplex virus. +5  
bigjimbo  you would see dermatome rash in zoster +1  
kateinwonderland  cf) Just in case someone wanted to know the causative organism of aphthous ulcers :The precise cause of canker sores remains unclear, though researchers suspect that a combination of factors contributes to outbreaks, even in the same person. Unlike cold sores, canker sores are not associated with herpes virus infections. +2  
charcot_bouchard  Herpes Zoster doesnt cause gingivostomatitis. Herpengina can cause vesicular lesion in mouth but happens to children in summer season by entero virus +  
drdeeznuts1  I'm wondering if this could be a mild case of Behcet syndrome without genital involvement +  
sherry  It sure can be Behcet or Pemphigus if the q provides us with more info. Canker sores just come and go for years with unclear mechanism. Also herpes zoster is shingles by VZV, not HSV1. +  


submitted by brethren_md(44),

Chronic Mesenteric Ischemia aka intestinal angina. Main clues are postprangial epigastric pain, weight loss. Usually due to Celiac (a), SMA, or IMA atherosclerosis.

neonem  What's tough about these answer choices though is that you have 2 different viable combos. +  
codyluvr95  The ectatic aorta might also mean AAA below the renals, affecting the IMA, +2  
sherry  Also since there is this ectatic aorta, the arteries involved need to be adjacent to one another. If there is a choice as in celiac and SMA, it could also be correct. +  


submitted by ihavenolife(14),

Pg 360 First Aid 2019

Internal Hemorrhoids

-Visceral innervation (no pain felt), Superior rectal a., Superior rectal vein (drains to IMV), Internal iliac lymph nodes

versus

External Hemorrhoids

-Somatic innervation (they hurt), Inferior rectal a., Inferior rectal vein (drains to internal pudendal vein), Superficial inguinal lymph nodes

kateinwonderland  Above pectinate -V:sup. rectal v -> inf. mesenteric v. -> splenic v. -> portal v -internal iliac LN Below pectinate -V:inf. rectal v -> internal pudendal v->internal iliac v->common iliac v->IVC -superficial inguinal LN (FA 2018 p360) +  
sherry  Venous drainage above pectinate, most to the portal vein, some to internal iliac v via middle rectal vein. I think the real solid key here is that the clinical vignette suggests hepatic cirrhosis. +  


submitted by neonem(257),

Just had to know that NRTIs (specifically the nucleosides) cause lactic acidosis

brethren_md  Also NRTIs are hepatotoxic, cause the increased liver enzymes seen in the patient. +2  
sherry  Actually, NNRTIs are more well-known for hepatotoxicity. But I guess NRTIs is the next best option for this one. +2  


submitted by m-ice(123),

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. +17  
masonkingcobra  So two men is better than one apparently +5  
zoggybiscuits  GarBAGE! ? +  
bigjimbo  gárbágé +  
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? +1  
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 +1  
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. +5  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +5  
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 +  
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 +  


submitted by dragon3(4),

I almost picked asking the roommate not to smoke in the apartment, but then I figured that's beyond the scope of the doctor... another person said taking steroids would be too much for now, and I suppose that's because the asthma is well-controlled with her inhaler rn? (that's what I had picked)

sherry  I would say the patient's asthma only got worse after her moving out. So its more allergen-related. Getting rid of the allergen is always better than upgrading medications. +  
et-tu-bromocriptine  Rippp the "don't be a dick" strategy definitely failed me on this one. For some reason, I thought requesting the patient to ask someone else to change their smoking habits would be a tad too much. I can just picture UWorld smacking me with a "Although it is likely that the roommate's cessation of smoking could alleviate the patient's asthma exacerbations, this request would be out of the physician's scope....etc." +6  


submitted by yotsubato(264),

Cold air induces asthma attacks.

Decreasing course load wont help

Taking steroids is too much for now

Moving back to the dorms is not viable

Air cleaners dont work enough

Dont get rid of the Good Boye

Smoking indoors is disgusting

sherry  Stress can actually be a trigger for asthma. I think the problem here is that she has alwasys carried a heavy course, while the disease just started recently. +1  


submitted by catch-22(19),

I woud do a retrospective cohort here. I don't think this question is correct and provides too little information to get the correct answer. "Time efficient" is the operant word here but they simply didn't consider that retrospective cohort would be a better design here as long as the variables are coded.

sherry  I agree. I was hesitating between the two choices. I still think cohort study is better regarding the "risk". I hope this kind of questions wont pop out on the real thing. +1  
soph  I think key here was they were measuring risk though +  
yex  I also chose cohort, since it is comparing a given exposure. +  


submitted by usmleuser007(113),

Salivary secretion 1. At low flow = High concentration of potassium; low concentrations of sodium, bicarb, & chloride 2. at high flow = low concentration of potassium; high concentrations of sodium, bicarb, & chloride

sherry  That's exactly what I was thinking when I was taking the test. But I was sidetracked by same HCO3 level. Can somebody explain this part to me?? +  
charcot_bouchard  Because salivary duct removes Na & Cl while secrete K & Hco3 in lumen. In low flow rate HCO3 & K inc because duct is doing its thing for more time. At high flow rate K slightly dec (as cant be secrted as much) but HCO3 stays almost same. the reason is high flow indicates higher metabolism & higher bicarb production. +  
cienfuegos  Regarding the bicarb (via BRS Physiology, which explains flow rate as coming down to "contact time" where slow flow allows more reabsorption of NaCl): The only ion that does not “fit” this contact time explanation is HCO3−; HCO3− secretion is selectively stimulated when saliva secretion is stimulated. +1