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Comments ...

 +2  (nbme18#43)

Not very clear, but petrolatum aka petroleum jelly is used as a barrier so stuff doesn't get into the wound when the skin is compromised. This helps with anti-microbial defense and wound repair.


 +0  (nbme18#44)

X-ray shows a fracture of the surgical neck of the humerus. This where the axillary nerve and the posterior circumflex humeral artery travels.

 +3  (nbme24#41)

Even if you can't interpret the blood smear, this patient is presenting with malaria after being in the US for 1-year. It's highly unlikely that he got newly infected while in the US. What is occurring is a reactivation of dormant malaria (hypnozoites in the liver) that this dude got while in Honduras.

As such this is plasmodium vivax/ovale. What probably happened was that this patient was treated with chloroquine when he was initially infected. This would clear the infection in the bloodstream, but does not kill the hypnozoites in the liver. Treatment with primaquine is needed to clear the hypnozoites, which this patient likely did not receive, hence malaria while in the US.

 +1  (nbme24#40)

There are two types of pneumococcal vaccines for Strep pneumoniae.

The pneumococcal conjugate vaccine (PCV13) is given to children under 5. It is also given to adults age >=65 who are immunocompromised (PPSV23 is also given afterwards).

The polysaccharide vaccine PPSV23 is given to adults, the indications for which I won't go into.

Since this patient is 2-years old he should have received the conjugate vaccine per CDC guidelines.

 +0  (nbme24#31)

POMC is a prohormone peptide chain that gets cleaved into gamma-MSH, ACTH, gamma-lipotropin, and beta-endorphin. There's a nice figure of this in Costanzo (Fig 9-10).

It may help to remember that pathologies with increased ACTH (ie Addison's disease) can present with hyperpigmentation since MSH (melanocyte stimulating hormone) is produced alongside ACTH.

 +0  (nbme24#3)

Tfw NBME said there's no repeats on 23 and 24 and then you get a repeat.

 +1  (nbme21#16)

I was stuck between mitral and aortic and went with aortic because the L ventricle looks enlarged, possibly hinting that the patient had aortic stenosis.

drzed  I went with aortic because it looks like the valve has three cusps, while the mitral valve should only have two. Incorrect logic?

Subcomments ...

submitted by niboonsh(175),

external carotid branch supplies the superior parathyroid glands as well........?

yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch. +  
llamastep1  No they do not, parathyroids are supplied by the inferior thyroid arteries. https://teachmeanatomy.info/neck/viscera/parathyroid-glands/ +1  
suckitnbme  Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery. +  

submitted by sinforslide(24),

The patient walked barefoot on the beach and had cirrhosis, which makes him vulnerable for V. vulnificus bacteremia. V. vulnificus bacteremia has a very poor prognosis.

From Uptodate: "[V. vulnificus] is the leading cause of shellfish-associated deaths in the United States. Infections due to V. vulnificus are most common in individuals who have chronic, underlying illness; individuals with liver disease or hemochromatosis are at greatest risk."

sinforslide  Also see UWORLD ID: 15255 +  
suckitnbme  Vibrio species are mostly non-lactose fermenters except Vibrio vulnificus +  

submitted by breis(19),

I am not 100% on this being correct, but I briefly remember a Psychiatrist saying that the patient has to be seizure free for 6 months minimum and preferred to have no seizure within the last 3 years to be asymptomatic. Do with that information what you will. but for Boards: 3 years.

suckitnbme  Question stem also implies that the patient has been driving already. "has not had any collisions while driving his personal motor vehicle". +  

Mild jaundice with increased unconjugated in an older fellow is decreased UDP-glucuronyltransferase activity. Particularly in context of stress (appendectomy)

pg32  Went with hepatitis because of his recent surgery. Seen problems like this before where recent surgery means they were given inhaled anesthetic that can cause hepatotoxicity/hepatitis. That, along with the elevated AST/ALT and unconjugated bilirubinemia (signifying liver losing its ability to conjugate bilirubin due to inflammation) made me pick hepatitis. Why is that wrong? +  
suckitnbme  @pg32 AST/ALT are only slightly elevated. The patient also is not particularly symptomatic. He's really not that sick. Hepatoxicity is also most associated with halothane which is no longer used in the US. It would be a different story if the patient had surgery done in a different country (as is common in Uworld questions on this) +  

submitted by pg32(42),

Can anyone explain why the lipase concentration is so high if there is an issue with LPL in hyperchylomicronemia?

garima  due to pancreatitis +3  
neovanilla  ELI5? +  
suckitnbme  @neovanilla Type 1-hyperchylomicronemia has increased risk of pancreatitis +  

submitted by rainlad(11),

How do you rule out Protein C deficiency in this case? doesn't that also increase risk of thrombosis and miscarriage?

suckitnbme  @rainlad Protein C deficiency doesn't cause elevated PT and aPTT. I believe they're both normal and assays for the disease measure protein C activity. +1  
drzed  Protein C is an anti-coagulant, so if you lack factor C, then you have MORE clotting factors. This means that the PT and PTT would not be prolonged. +  

submitted by majic(3),

THE MOST COMMON route of Toxo transmission in adults in the USA is ingestion of undercooked pork. Even if cat litter is an option, undercooked pork is still more common.

yotsubato  Also another fun fact. Most people in France are infected by Toxo (like 80%) because of how they eat meat. (Very rare) +1  
madojo  To add on might be TMI but most people have Toxo but are asymptomatic because its in its latent form as a pseudocyst and its not untill you are immunocompromised that it strikes +  
suckitnbme  This patient also probably got toxo in Brazil +  
luciana  JFYI people in Brazil love to eat rare meat at barbecues +  

submitted by xxabi(146),

Stent thrombosis vs re-stenosis. Stent thrombosis is an acute occlusion of a coronary artery stent, which often results in acute coronary syndrome. Can be prevented by dual antiplatelet therapy or drug-eluting stents. Re-stenosis is the gradual narrowing of the stent lumen due to neointimal proliferation, resulting in anginal symptoms.

sunshinesweetheart  so just to clarify - it's the "symptom-free for 3 months" that rules out thrombosis? +2  
hpsbwz  It's moreso that at rest there's no changes, but during exercise there is. Like the pathophys of stable angina. +1  
suckitnbme  I think it's more because of the 2-month history of PROGRESSIVE angina sx with exertion. This points to a chronic process rather than an acute event. +  

submitted by m-ice(185),

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? +7  
ug123  DNI and DNR are different right? This patient had a DNI. Why would we assume it to be DNR too? +2  
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 ! +3  
criovoly  I believe this question was not well constructed... it's one of those! +  
suckitnbme  @shayan extubating at request of the husband because he's following what's in her living will. Following that line of thought, the patient probably wanted withdrawal of care if in a vegetative state. +  
luciana  I understood same as @shayan that she wanted to keep intubated... now reading it again I feel extra dumb with my poor reading interpretation skills +  

submitted by charlie(5),

I think there's a typo on that question. MSH2 gene mutation is the culprit for HNPCC. For MHS2 gene, according to what I just searched, causes Malignant Hyperthermia Susceptibility.

noplanb  Yeah I think it should be MSH +  
suckitnbme  Good to know I wasn't tripping out when I did this question +1  

submitted by m-ice(185),

HMG CoA Reductase inhibitors prevent the liver from synthesizing its own cholesterol. In order to maintain its need for cholesterol, the liver has no choice by to increase its LDL receptor expression in order to take cholesterol from the blood.

suckitnbme  Not sure why NBME felt like they needed two questions on statin MOA on this form. +4  
makinallkindzofgainz  because they didn't even realize it because they make insanely low effort practice exams with awful formatting and vague vignettes, yet here we are paying 60 bucks a pop for "high quality" exams, gimme a break. ok i'm done venting +2  

How do you distinguish this from testicular torsion? Is it just because it started in the left flank?

neels11  and there's no mass in the scrotum, whereas testicular torsion will have that "bag of worms" feel (along with a lack of cremaster reflex) testicular torsion usually happens in a younger age group +3  
medpsychosis  @neels11 I would like to clarify a piece of information. I believe you are confusing Varicocele with Testicular Torsion. Varicocele will present with "bag of worms" feeling. While the absence of cremasteric reflex is a sign of testicular torsion. +6  
johnson  This is the classic "loin to groin pain" of nephrolithiasis. +  
suckitnbme  Testicular torsion would also tend to have a unilateral high-riding testicle. +  

submitted by sangeles(4),

To me it sounds more like nevus simplex. The most common capillary malformation is nevus simplex, which affects more than half of infants. Nevus simplex, or “salmon patch,” lesions are pink, ill-defined patches that tend to occur in midline locations, most frequently on the nape of the neck, glabella, eyelids, nose/lips, scalp, and sacral region Historically, colloquial terms such as “stork bite” (nape) and “angel kiss” (forehead/glabella) referred to nevus simplex lesions in particular anatomical regions. Unlike PWS and most other vascular malformations, most nevus simplex lesions regress within the first 2 years of life Clinical differentiation of nevus simplex from PWS, especially on initial presentation, can be difficult. Lesions with lighter pink color, midline location, and indistinct borders favor nevus simplex. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615389/

suckitnbme  I agree that this nevus simplex and not a strawberry hemeangioma. Of note, nevus simplex lesions are flat lesions formed from dilated capillaries. Lesions on the face tend to regress while lesions on the back of the neck typically do not. https://en.wikipedia.org/wiki/Nevus_flammeus_nuchae +1  

submitted by madojo(54),

Cyclosporin is an immunosuppressant that blocks T cell activation by inhibiting IL-2, so we know thats not right. Cyclophosphamide is an alkylating agent. Doxorubicin is an antitumor antibiotic that generates free radicals and causes breaks in DNA. 5'fluorouracil is associate with pyrimidine synthesis. Leaving Vincristine which is a neoplastic drug that works on microtubules (other drugs that do this colchicine, paclitaxel.

As mentioned already, the cell is stuck in metaphase and cannot undergo the seperation anaphase. M cycle arrest is associated with vincristine and which the mitotic spindle which is what separates the chromosomes is not forming.

suckitnbme  The funny thing is that the image seems to show that the spindle did in fact form. +2  

submitted by neonem(373),

These are gout crystals. I suppose the best way to differentiate this case from pseudogout is that the crystals are sharp & needle-shaped and not rhomboid-shaped.

sympathetikey  Yep. They tried to throw you off with the picture, but the wording in the stem says its a "photomicrograph" -- not exposed to plane polarized light, where you would see the negative birefringence. +10  
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +  
suckitnbme  @linwanrun1357 I highly doubt you would be looking at your own joint fluid aspirates instead of sending it to the lab. +2  
nnp  what those yellow white nodules signify? +  

submitted by gonyyong(55),

Wasn't sure about others, but mammography for general population isn't recommended until 40

_yeetmasterflex  Also wouldn't mammography be secondary prevention since you'd look for asymptomatic disease already present? +7  
suckitnbme  USPSTF recommends starting screening at age 50. 40 by patient choice if there's risk factors. +  

submitted by ameanolacid(13),

Atherosclerosis is the MOST common cause of renal artery stenosis...with fibromuscular dysplasia being the SECOND most common cause (even though it is tempting to choose this option considering the patient's demographic).

xxabi  Is there a situation where you would pick fibromuscular dysplasia over atherosclerosis if given both options? Thanks for your help! +4  
baconpies  Atherosclerosis affects PROXIMAL 1/3 of renal artery Fibromuscular dysplasia affects DISTAL 2/3 of renal artery +17  
gonyyong  Why is there ↓ size in both kidneys? This threw me off +2  
kateinwonderland  @gonyyong : Maybe because narrowed renal a. d/t atherosclerosis led to renal hypoperfusion and decrease in size? +  
drdre  Fibromuscular dysplasia occurs in young females according to Sattar Pg 67, 2018. +3  
davidw  Normally you will see Fibromuscular dysplasia in a young female 18-35 with high or resistant hypertension. She is older has a history type II DM predispose you to vascular disease and normal to moderate elevation in BP +3  
suckitnbme  @gonyyong there's bilateral renal artery stenosis. The decrease in size of both kidneys should be from atrophy due to lack of renal blood flow. +  

submitted by gonyyong(55),

The kid has gynecomastia due to puberty (excess testosterone → estrogen) This goes away naturally (apparently in 12 to 18 months)

I think you don't have to do blood tests because he has normal sexual development for his age and there are no other signs?

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +7  
howdywhat  my exact thought, telling him that it will last for somewhere around a year and a half doesnt seem so reassuring +1  
suckitnbme  I thought it was reassuring in that the kid is being told this isn't permanent as well as that this isn't something serious. It's important to inform him about the prognosis. +2  
thotcandy  "don't worry your gynecomastia isn't permanent, but the mental scars from the bullying you will receive in HS definitely will be :) good luck!" +  

submitted by lsmarshall(270),

Metaplasia - A reversible adaptive response in which there is "Reprogramming of stem cellsŽreplacement of one cell type by another that can adapt to a new stress." Both are normal cells. Respiratory tree should not have squamous cells until respiratory bronchioles (before that; cuboidal in term. bron. > columnar in bronch. > pseudostratified columnar in large. bronch.).

shayan  if its a metaplasia, then how it be normal ? I mean Metaplasia is not normal? +1  
artist90  i got it confused bc the question stated that there was a mass in one lobe of lung and i didn't knew that squamous metaplasia also presents as a mass in lung. i missed that on biopsy they were clearly stating squamous metaplasia. +3  
suckitnbme  @shayan The term "normal" in the answer is used to indicate that the cells appear normal (meaning appropriate size/architecture/appearance). Remember that metaplasia is a normal response to stress. +3  

submitted by krewfoo99(42),

This could easily be confused with Squamous Cell Carcinoma as they are describing a mass. But i think the key difference is that they mention METAPLASIA. If it was dysplasia, then it would have been cancer.

usmlecrasherss  metaplasia also can lead to cancer FA p206 2019 +  
suckitnbme  Dysplasia is not cancer since it is, in theory, still reversible. Only when it becomes irreversible is it a carcinoma. +1  

submitted by snafull(4),

Can somebody explain why this is not a foreign body granuloma?

yb_26  because they mention scattered fragments of foreign material (pt presents 2 months after c-section, sutures are either removed in 1 week or dissolve in few weeks (depends on type of suture material) +  
suckitnbme  I think it IS a foreign body granuloma. The sutures are supposed to be removed or dissolve but sometimes one gets left in. The question says foreign material and sutures are often polarizable. +3  

submitted by beeip(93),

Can anyone explain what they're getting at here? How can bethanechol be indicated and contraindicated?

sniperx3  I think it's because Bethanechol acts on M3 receptors which can treat her urinary problems but it might exacerbate her asthma symptoms since there are M3 receptors on the lungs. +20  
suckitnbme  I definitely had to read this question multiple times to understand it. +  
brotherimodu  I read it like 6 times and gave up +1  

submitted by sweetmed(83),

The Ham test is a test used in the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). The test involves placing red blood cells in mild acid; a positive result (increased RBC fragility) indicates PNH

suckitnbme  It's so obscure of a test that wikipedia only has 4 sentences on it. +  
pathogen7  FA2020 added the Ham test to PNH I believe! +  
pathogen7  Whoops no sorry I am wrong. They did add something called the EMA test to spherocytosis though. +  

submitted by neonem(373),

Cerebellopontine angle mass = Vestibular schwannoma (AKA acoustic neuroma). Derived from Schwann cells, which are of neural crest origin.

yotsubato  Ugh. Of course they dont put schwann cells as a choice. So I pick oligodendrocytes like a dumbass +19  
subclaviansteele  Same^ +1  
madojo  Schwann cells = PNS Oligodendrocytes = CNS +1  
suckitnbme  NBME loves their neural crest cells +3  

submitted by urachus(4),

not EPO bc it's asking what's made from the bone marrow. EPO is from kidney

lilyo  Thanks, I was wondering why EPO was not correct. So EPO synthesis would be stimulated in case of blood loss? its just wrong becase they ask specifically what is going to be produced in the bone marrow? +1  
suckitnbme  @lilyo yes because it's specifically asking what the bone marrow is synthesizing. EPO would also be upregulated but this happens in the kidneys. +  

submitted by drdoom(375),

The stem is describing sequelae of posterior inferior cerebellar artery occlusion, resulting in Wallenberg syndrome. Here’s a nice schematic of the affected nuclei and brain stem regions:


... and a 6-minute YouTube video that walks you through it:


nbme4unme  Great video! Very, very solid review of brainstem anatomy. +  
suckitnbme  This image was surprisingly interpretable for NBME standards +4  
aneurysmclip  and the fact that all you needed to know was the side of the lesion to answer tbh lmao, but other than that localizing to medulla wasn't hard. +1  
medguru2295  Actually, they were quite nice. You didn't even have to know what side. There was no option for left medulla. +1  

submitted by soph(43),

I think key here is they are investigating the hypothesis of ammount of arsenicin water increases RISK of cancer.... best way to measure risk is case control.

nbmehelp  If they were measuring risk shouldn't it be a cohort study though? By looking at first aid.. +2  
270onstep1  They both can determine risk. Key here is the time efficiency of case-control studies when compared to cohort. +  
suckitnbme  Case-control only determines odds ratio which is not calculating risk. In rare diseases the odds ratio can be used as an estimate of the risk ratio however. +  

submitted by keycompany(184),

Image shows Crescent Sign, a common finding in Abdominal Aortic Aneurysms due to mural thrombus occlusion.

happysingh  crescent sign is a finding on radiographs that is associated with avascular necrosis, NOT aneurysms !!! what you're seeing is Calcification of wall of the aortic aneurysm +10  
sabistonsurgery  @happysingh - Thank you. You are correct indeed. +  
suckitnbme  Adding on, this patient is a >65 yo Male with a 120 pack year smoking history. Both are significant risk factors for AAA. +  

submitted by krewfoo99(42),

HPV has high affinity for squamous epithelium. True vocal cords have squamous epithelium, thus HPV tends to grow there

suckitnbme  Specifically stratified squamous epithelium I believe. +  

submitted by nlkrueger(24),

.... would we really take the word of a friend who definitely can't be confirmed? I feel like this is misleading

lispectedwumbologist  All the other answer choices make you come across as an asshole. Easy way to ace ethics questions is to just not be an asshole +4  
seagull  I would be a bigger asshole when the family came I'n after I pulled the plug...opps...but the friend said +12  
dr.xx  The patient has no wife, children, or close relatives... +3  
nwinkelmann  @lispectedwumbologist this is going to be my technique, because I've gotten a couple of these wrong, but I completely agree with everyone else's sentiments of suspicion of going off what a friend said without any confirmation about state of advance directives, etc. It's really dumb. +3  
paulkarr  With these questions; you have to take what NBME says at face value. If it says no family, he really does have no family. This friend is also claiming that the 78 y/o said this about himself, so we know it's the patients wishes rather than someone else's wishes for him. (A son saying he can't let go of his father yet despite the patient's DNR type of situation). +  
suckitnbme  I think the point here isn't that we would take the patient off the ventilator because the friend said so. The answer is saying "Thank you for your input, we will take that into consideration." It's completely non-committal. +4  

submitted by hayayah(620),

Wernicke-Korsakoff syndrome. Don't have to be an alcoholic to get this, just usually is related to alcoholism / thiamine deficiency.

d_holles  Yeah the negative EtOH screen threw me off +1  
dr_jan_itor  Why cant it be early alzheimers and hippocampus? She could easily have been a former prominent physician and member of city council. Am i supposed to assume that simply because shes disheveled and poor hygeine that she must be an alcoholic homeless person? It also mentions no symptoms of nystagmus, ataxia, etc. +1  
kimcharito  it said broad based gait and nystagmus +2  
lilmonkey  She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment. +  
fatboyslim  @ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus." +  
suckitnbme  NBME questions also stereotype the shit out of their patients +2  

submitted by rainlad(11),

would we be worried about using G-CSF given that he has acute leukemia? would it stimulate growth of his cancer cells?

suckitnbme  I think we're assuming that we eradicated the leukemia with the chemo. However at the same time a lot of normal stem cells were also killed off so we give GCSF to help recovery especially since they have an infection. +  

submitted by nuts4med(5),

I was thinking Chron’s because of the narrowing of the lumen and the picture seemed like there was creeping fat. Now that I think about it though, the LLQ and constipation should have led towards diverticulitis pretty quickly.

suckitnbme  Also agree the narrowing of the lumen plus the pic is pointing towards Crohn's. The acute systemic sx of fever and chills is what made me go with diverticulitis (along with the hx of increasing constipation). +1  
pg32  Why does the question say there is NARROWING OF THE LUMEN? Does that happen in diverticulitis? I went with Chron's at the last second against my better judgment because Chron's can cause strictures/narrowing of the lumen. +1  

submitted by hayayah(620),

Secondary hyperparathyroidism (usually d/t chronic renal failure).

Lab findings include ↑ PTH (response to low calcium), ↓ serum calcium (renal failure), ↑ serum phosphate (renal failure), and ↑ alkaline phosphatase (PTH activating osteoBlasts).

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +1  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1  

It said it was fatal to males in utero, and the question asked about live born offspring. Since the males aren’t being born in the first place, I said 50% females and 0% males.

hungrybox  fuck i got baited +19  
jcrll  "live-born offspring" ← baited +8  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +1  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +  
qball  Jail-baited +  

submitted by yotsubato(543),

Why is this NOT chancroid? Theres nothing here that rules it out.

drachenx  Chancroid is described as an ulcer.. whilst in this question they mentioned "vesicles". Pretty much only herpes is vesicular +5  
whoissaad  They mentioned ulcers too. I chose chancroid as well, couldn't find a clue to rule it out. Also thought "discharge" was pointing you towards a bacterial infection. But guess I'm wrong :) +  
emmy2k21  I think NBME/USMLE writers make the assumption the patient is in America unless specified otherwise. Chancroid is not common in the US. If the question stem mentions a developing country, then chancroid can make your differential list. +1  
selectuw  for chancroid, there may be a mention of inguinal lymphadenopathy +2  
samsam3711  Also with chancroid questions they want you to differentiate it between chancroid and syphilis, (eg. Painful vs. painless) and is usually described as a much larger ulcer that is painful (not vesicular as in this question) +  
suckitnbme  Also believe that chancroid does not presents with systemic symptoms like in this vignette. +  

submitted by welpdedelp(146),

It was scabies, which is transmitted person-operon.

welpdedelp  **person-person lol +4  
suckitnbme  NBME loves their scabies +5  
dentist  did you get scabies from "burrows" and "night itching" +  
pg32  My question is where do you get scabies originally? I knew it was transmitted person-to-person, but thought it has to originate somewhere (a pet possibly?) so I went with pets. The internet only seems to say that you get scabies from another person with scabies, so the question remains: where do people contract scabies from? +  

submitted by gh889(57),

From ShoryukenHadooken on reddit:

What the question is getting at is the sympathetic chain was spared. It was a terrible way of wording it.

Your anterior hypothalamus is responsible for cooling features and is under parasympathetic control. A lesion would cause hyperthermia.

Your posterior hypothalamus is responsible for heating when you're cold and to generate the Fever response and is under sympathetic control. A lesion would cause hypothermia.

In this question it is simply asking a person gets sick, hypothalamus was spared, what happens.

Answer: hypothalamus will still be able to elevate set body temperature to battle infection.

Hint: IF they give a question similar to this but reworded to include a lesion of the sympathetic fibers or of the hypothalamus, you would in turn NOT be able to generate a fever response to infection. The hypothalamus would be entirely under parasympathetic control

This adds more context to the fact the Q states that the sympathetics was spared

oslerweberrendu  So, this says sympathetic also spared and hypothalamus also spared. Then what was wrong with this clinical case?? +  
adong  i think the sympathetic system is actually impaired b/c it's cut before it can "outflow"...at least it's the only way this makes sense +2  
suckitnbme  I agree. I think the question stem is saying the sympathetics were lesioned. Not that they were spared. +3  

meningiomas count as enhancing lesions? (this comment needs to be more than 50 characters apparently.)

goldenwakosu  I think it’s because meningiomas are able to calcify (aka sometimes they have psamomma bodies). I got this question wrong too but I totally did not completely register that the tumor was in the dura (interhemispheric fissure + central sulcus). Hope that helps! +1  
pipter  the only reason I got this right was because they described the tumour as being near the falx cerebri. +2  
fcambridge  Other hints include being described as round and seen in a female. Both indicative of Meningioma +5  
niboonsh  also meningiomas typically present with seizures or focal neurological signs +  
suckitnbme  I thought enhancing meant it uptakes contrast. Meningiomas are commonly enhancing lesions per Radiopaedia. +  

Our little friend has a Parvovirus infection, which infects erythroid precursors, causing interruption of erythrocyte production. This is the same way it causes hydrops fetalis in unborn babies and aplastic anemia in sickle cell, etc.

gainsgutsglory  I get Parvo has tropism for RBC precursors, but wouldn’t it take 120 days to manifest? +  
keycompany  RBCs don’t just spill out of the bone marrow every 4 months on the dot. Erythropoesis is a constant process. If you get a parvo virus on “Day 1” then the RBCs that were synthesized 120 days before “Day 1” will need to be replaced. They can’t be because of parvovirus. This leads to symptomatic anemia within 5 days because the RBCs that were synthesized 125-120 days before the infection are not being replaced. +7  
drdoom  @gainsgutsglory @keycompany It seems unlikely that “1 week” of illness can explain such a large drop in Hb. It seems more likely that parvo begins to destroy erythroid precursors LONG BEFORE it manifests clinically as “red cheeks, rash, fever,” etc. Might be overkill to do the math, but back-of-the-envelope: 7 days of 120 day lifespan -> represents ~6 percent of RBC mass. Seems unlikely that failure to replenish 6 percent of total RBC mass would result in the Hb drop observed. +  
yotsubato  He can drop from 11 to 10 hgb easily +1  
ls3076  Apologies if this is completely left-field, but I didn't think this was Parvovirus. Parvo would affect face. Notably, patient has fever and THEN rash, which is more indicative of Roseola. Thoughts?? +3  
hyperfukus  @is2076 check my comment to @hello I thought the same thing for a sec too :) +  
hyperfukus  also i think you guys are thinking of hb in adults in this q it says hb is 10g/dL(N=11-15) so it's not relatively insanely low +  
angelaq11  @Is3076 I completely agree with @hyperfukus and I think that thinking of Roseola isn't crazy, but remember that usually with Roseola you get from 3-5 days of high fever, THEN fever is completely gone accompanied by a rash. This question says that the patient has a history of 4 days of rash and 7 days of fever, but never mentioned that the fever subsided before the appearance of the rash. And Roseola is not supposed to present with anemia. +2  
suckitnbme  @Is3076 another point is that malar rash refers to the butterfly rash on the cheeks that is commonly seen in lupus, so the face is NOT spared. +  

submitted by marbledoc(0),

Why would you ask the patient to identify the pros and cons? I don’t get the approach here!

someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +5  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +1  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +2  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +1  

I put constipation because I thought the medication being described might be CCB: can someone explain why nitrates over CCB?

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance. +1  
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload. +  
beto  decrease of cardiac preload is another word of Venodilation, so Nitrates primarly venodilators. CCB dilate arteria more than veins +  

how would you rule out C) dysfibrinogenemia? I first guessed APS but switched it because of the PT/PTT thing

suckitnbme  You should be able to rule it out by the normal Thrombin time. Abnormal fibrinogen would have increased PT/PTT but also increased Thrombin time because the entire pathway is compromised by the inability of fibrinogen to be cleaved to functioning fibrin. +