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Welcome to sugaplum’s page.
Contributor score: 323


Comments ...

 +0  (step2ck_form6#27)

These are symptoms of acute benzo withdrawl

drdoom  holy cow you are crushing it right now. frickin POWER SESSION +1

 +0  (step2ck_form6#21)

These people always have extreme unstable relationships. And do things to gain attention. Self harm, suicidal behavior, splitting. The buzz word for treatment is dialectaial behavioral therapy

I think of these as the people who seemed very cool in middle school because they could get a new boy friend every week


 +1  (step2ck_form6#45)

She has signs of a small bowel obstruction. no hx telling us any other cause. With air in the liver, we think that something has recently passed through to make the bile ducts dilate.


 +0  (step2ck_form6#23)

Spontaenous pneumothorax if you look at the right chest, there is a backwards figure 3 looking line around ribs 6-7. That is the collapsed lung, you need to drain the air out so the lung can reinflate.


 +0  (step2ck_form6#7)

This patient has NAPDH Oxidase deficiency which causes chronic granulation disease. You can trap the bacteria, but you can't make the ROS to kill it. So you just live with a bunch of full trash bags...of bacteria you collected... Most common bugs are catalase positive. S. aureus; Escherichia coli, Candida, Klebsiella, Pseudomonas, Aspergillus;


 +0  (step2ck_form6#17)

They are taking my buzz words away.......:(

Opening SNAP plus a diastolic rumble.. this is mitral stenosis


 +2  (step2ck_form6#36)

This question is tricky. I used to always miss this presentation. This is laterally medullary syndrome- which most of us have memorizes is a PICA infarct. Fun fact, PICA comes off the vertebral artery.

This is how I remember the sx. If this helps at least one person I will be glad I am exposing my twisted brain.

3+5=8 & 9-11 & B-P.

3: Horner's syndrome 5:spinal trigeminal- ipsi face pain and temp loss 8: vestibular signs, vertigo diplopia

9-11: Nucleus ambiguous, diminshed gag, dysphagia B: Cerebellar - inferior cerebellar peduncle, ipsi ataxia P: Contra pain and temp, cuz this shit was so painful to memorize I throw it to the other side.


 +1  (step2ck_form6#34)

She has pica. Do a CBC to check for iron deficiency anemia. Microcytic low hgb hct


 +0  (step2ck_form6#19)

This is a capillary hemangioma aka strawberry birth mark. They go away eventually, we dont really mess with them unless they are obstructing the kids vision or breathing somehow.


 +0  (step2ck_form6#36)

We want to prevent it from happening so we want to measure how much of it is actually happening.


 +0  (step2ck_form6#4)

I got this wrong too. but thinking more we should think about the travel hx, to TB endemic area. This isn't a hemorrage cuz its been happening for 2 weeks, aspergillous usually settles in TB cavities.


 +1  (step2ck_form6#3)

CF, + family hx of norther european. Lungs with lots of gunk it in that is difficult to remove. recurrent infections

kingfriday  adding to this. kid also has poor growth which reflects poor pancreatic function +

 +0  (step2ck_form6#12)

This kid has nursemaids elbow. Apparently a very simple fix


 +0  (step2ck_form6#5)

Sjogren syndrome destruction of the salivary glands, dental caries. I looked at UTD and there isn't anything about the vagina being involved, but there is probably some article out there that links it.

The other answer choices didn't make sense


 +1  (step2ck_form6#35)

this is intusseption, with current jelly stools and episodic abdominal pain. Treat with barium enema


 +0  (step2ck_form6#41)

I missed this the first time because I wasn't thinking about it right. This man has new onset Type 2 diabetes. This is characterized by Insulin resistance, so initially the patient's body will increase insulin production to combat the new diabetes

medicalmike  Does T2DM cause weight loss? I interpreted this older man with weight loss and new-onset T2DM as having pancreatic cancer. +
kingfriday  i guess if you dont get the anabolic benefit of insulin, you can't build up your weight- at least that's how i took it +

 +0  (step2ck_form6#9)

This patient has wernicke's encephalopathy secondary to alcohol abuse. The tx is Thiamine, Vit b1. They also can have damage to their mamilary body


 +0  (step2ck_form6#8)

She is the classic demographic for pulmonary arterial hypertension. Slowly progressive disease. The PE findings support it

medicalmike  This patient's mitral opening snap and diastolic murmur are due to her mitral stenosis. Long-standing MS leads to elevated left atrial pressures which transmit to the pulmonary artery -> secondary pulmonary hypertension (not primary idiopathic PAH) +3

 +2  (step2ck_form6#39)

Widened pulse pressure in an adult is regurg. Widened pulse pressure in a new born is PDA. because the blood is swishing back and forth


 +0  (step2ck_form6#25)

This is a USPTF guideline to screen patients who are sexually active with inconsistent condom use. 18 year olds shouldnt be screened for any of the other stuff


 +0  (step2ck_form6#38)

sounds like she has acute bronchitis; which is like inflammation/irritation of the airway, so there is narrowing Beta agonist will decrease the inflammation and open the airways up

boeboeboe  I think she more likely has asthma. Cough is worse at night and worse with physical activity. Key findings on exam: end-expiratory wheezes bilaterally. Responsive to b2-agonists. +1

 +0  (step2ck_form6#32)

According to UTD there is an increased risk of UC flairs during pregnancy. This is weird because the rule is "pregnancy causes these autoimmune/inflammatory stuff to go down" and they love testing the exceptions....

UTD" Fertility, pregnancy, and nursing in inflammatory bowel disease"


 +0  (step2ck_form6#40)

CTG first aid mneumonic Cataracts Toupee Gonads- hypoplastic


 +0  (step2ck_form6#14)

Giant cell arteritis. These people have inflammation of large and medium vessels, we think carotid arteries mostly, and their branches. The most immedieate concern for these patients is BLINDNESS which can be caused if the retinal artery gets blocked (branch of internal carotid). SO for these people you don't wait for a biopsy you start them on high dose steroids ASAP. mc in >50 white women. But sometimes they like to get interesting with the demographics.


 +0  (step2ck_form6#43)

she has peritonitis, a known complication of peritoneal dialysis. We want to know what the bug is. so gram stain to direct treatment appropriately


 +0  (step2ck_form6#22)

this one is tough but this is what I am thinking. If you loose your Ovaries you loose your major source of estrogen. Once your replace that orally, you will have excess estrogen floating in the body. that will go shut down your HPA axis, so your other androgens will now be decreased --> low libido


 +0  (step2ck_form6#42)

sclera injection and munchies

In the words of afroman. I was gonnna go to work....but then I got high...

drdoom  I was gonna get up and find the broom but then I got high .. +1

 +1  (step2ck_form6#18)

Viral myocarditis can lead to acute decompensated heart failure. can be d/t parvo, coxsackie or bacterial infections


 +1  (step2ck_form6#37)

2 months can just get their chest up and recognize moms voice. Apparently they can't grab things until 5 months.....glasses off your face


 +0  (step2ck_form6#8)

Intrauterine fetal demise (aka stillbirth) is death of the baby after 20 weeks. You should recommend an autopsy to see what caused the death. Can be due to congenital abnormalities or chromosome problems


 +0  (step2ck_form6#11)

According to UTD Postpartum thyroiditis is similar clinically and pathogenetically to painless thyroiditis except that, by definition, it occurs in women within one year after parturition (or after spontaneous or induced abortion).

TSH makes sense because she is bradycardic and has poor concentration


 +0  (step2ck_form6#13)

This patient has signs of internal bleeding Decreased breath sounds--> abdomen filling with fluid, so the diaphragm has to push against increased pressure to get a breath in. Abdominal distension, tachycardic, hypotensive.

hematocrit drop by 12%. think about this. 1% change in hematocrit is 3 units of blood. 1 unit is 500mL. So based on her calculated blood loss, she should have only dropped hct by (1%-2). So I mean it could be underestimated blood loss, but her PE signs point to hemorrage


 +1  (step2ck_form6#26)

Irregular periods, acne, and infertility line up with PCOS. Even though you don't palpate any masses on exam. The ovaries aren't necessarily palpably larger. I think of this like normal ovulation cysts that did not rupture properly, because they didn't get the correct signal (LH Surge)


 +1  (step2ck_form6#31)

since she has total blindness just in one eye, right optic nerve lesion makes sense. The poor reactivity to light supports this because eyes receive light through optic nerve (CN2)


 +1  (step2ck_form6#6)

This kid has signs and sx of dehydration Hyaline casts due to hypovolemia resulting in concentrated urine


 +0  (step2ck_form6#20)

Suspect renal artery stenosis, since he also has htn


 +2  (free120#13)
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oFr fenercree A F 2091 gp 136 sha a dogo imega ot see siht


 +17  (free120#31)
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ensIca noeyna else saw itkinhgn het e:asm
I was utskc teebenw this nad vtnaria fo wonnknu ficna.iiegnsc eHve,row rtanaiv of nnknuow iacgecfniisn is a cusneeqe nto a nilseg dteiuenlco

nbme4unme  Thank you for explaining, I selected the unknown significance answer as well! +3
dhkahat  lol fuck this test +

 +5  (free120#9)
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hTsi qtneiosu si iksgan tbaou VJD anrnmerraetge wchhi enhppsa ni hte oneb marw.ro eTh seneg rea lla pdecpho up eceabus hte B clle is nyirtg ot ngteerea a uuieqn tmniacioobn rof tsi rceeptro
msi elp tp.eoc.n.sc ddo rdnoigw

peraCht 3 of woh" hte mnimeu ssmtey "osrwk - msaeweo ookb

varunmehru  in the question stem, they are asking about a constant region. VDJ rearrangement is for the variable. It doesn't make sense :( +3
sallz  Both the constant (heavy chains) and the light chains undergo gene rearrangement. The heavy chain undergoes V(D)J random recombinations, while the light chain undergo VJ random recombinations. So gene rearrangement could work for both regions. +6
azibird  The constant region does not undergo recombination. That's why it's called constant. It's just right next to the variable region though, so they get expressed together as one protein. That's why the constant-labeled DNA region is variable length here. +1

 +8  (nbme23#45)
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ihTs si urlusiidoc but I oucld vrnee eepk sheet ttahrsgi msoe te my lfy ia:m
Ahc ye adargnp enetrMy
eopD csniuo VT hiwt a side oH* h(sow' snaem rae jsut )liniasit SNc
nU cle dna tuna Rehpa adn raas C unsoi Gbbay walasy ciesrmgan a-a-aNNN
rpio en idnmsre em of hte lorco lube, os oulcs elcseuur

paulkarr  LOL. Achey Granpa Meynert. I'm gonna steal this from you. +
abhishek021196  Achey grandpa Meynert = ACh / Basal Nucleus of Meynert Dope Cousin VT = Dopamine / Ventral tegmentum, SNc Uncle and aunt Raphe and Sara = Serotonin / Raphe nuclei(medulla, pons) Cousin Gabby always screaming NA-NA-NA = GABA / Nucleus Accumbens Norepi = Locus ceruleus. +1
llamastep1  Amazing +
mnemonicsfordayz  ACHey GRANDPA MEYNERT TREMBLES in the BASEment; DOPE cousin VT SNaCks DOWNstairs by the kitchen TAP; NANA GABBY ROCKS and ANXIOUSLY cooes...; "NENENENE... NENENENE...NENENE...NENE" to CRYING BLUE-eyed baby ELSIE; aunt SERO and uncle RAPHE DULLY PARK in the DOWNpour. CAPS = relevant info, lowercase = irrelevant. Includes diseases: DOWN, ANXIOUSLY, CRYING, DOWN = anxiety/depression; TREMBLES, TAP, ROCKS, PARK = movement disorder; GRANDPA = Alzheimer's. Note: ELSIE = LC = Locus ceruleus +
mnemonicsfordayz  The extended "NENE" series is just for humor - shorten if you like ;) Also, ANXIOUSLY applies to both NTs in that sentence: GABA and NE. +
castlblack  I use AChoo meynose +1
faus305  I almost didn't even look at this review but then I thought "maybe someone has a cool mnemonic." and would you look at this. +

 +10  (nbme23#41)
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alwsay mreebmre etmh ni erdro htwi ofurma,l TSEA=ESII
dan het otw no teh NED are OINCUD-DAT

makinallkindzofgainz  The supraspinatus AB-ducts. The Subscapularis ADDucts +
makinallkindzofgainz  disregard my comment, I misread what you meant +
drzed  How are you supposed to remember which S is which? +2
drschmoctor  @drzed "Supra" = on top, so the 1st S is for supraspinatus. +1
usmleaspirant2020  according to Physeo : INFraspinatus--EXternal rotaTION------INF-ECTION +
destinyschild  wow, sugapulm, that mnemonic is gold. you are gold. +1

 +3  (nbme18#44)
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AF 2190 gp 555
uc aes of claebmoti olalsskai igivnonim t emoseno hswo a emuic,bl hmyopaeilak adn oaepcomyhlhri aer onmm.oc
onian pag rfouaml +b-ra()libcCNa ie cnS we vaeh cexeivses bicbra ehetr untlhod's be a erlag g.ap rNloma si -12.8


 +1  (nbme18#25)
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mw4.pdnbgnhiwhvb44u7ipt//1lw.:s7e/.m6tn/.co o nmmco issues ni tepy 1 dan pyet 2 icaestdib

azibird  That article does not once mention the word diarrhea. +2

 +1  (nbme18#15)
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AF 0921 Pg 337
h rcinoc siagtistr cuslaom falmanmiiont andegil ot yorphat

pg32  I would also add that I think they are specifically trying to get us to think of pernicious anemia here, where parietal cells are destroyed/lose their fxn. In that case, ECL cells may hypertrophy to encourage acid secretion because the parietal cells are not responding to their usual signals. All the other answer choices are quite clearly incorrect, and Zollinger-Ellison is a gastrinoma, which causes hypertrophy of the gastric mucosa so that is also wrong. +8

 +3  (nbme18#27)
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AF 0219 Pg 120
reoccsl ypnio usecsa oerthnisenyp dan totxynohreiipc

schep  it can also cause gingival hyperplasia +1

 +5  (nbme18#40)
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the epered het anomemla esog hte swreo eht psgoisnor

wishmewell  isn't the basement membrane the deepest? +
wishmewell  nvm! lol +1
lilyo  I also picked basement membrane but unlike you I haven't had a "nvm" moment. Help please. +2
mcdumbass  @lilyo Basement membrane is between the epidermis and dermis; beneath the dermis is the subcutaneous tissue +5
blah  I think some people might have picked basement membrane because we're taught once cancer goes through the BM it turns from in situ to invasive. This is correct, but subcutaneous as the others pointed out are deeper so the prognosis is worse (BM + deeper tissue). +3

 +0  (nbme18#45)
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nbb evoid - ianeltnivto adn suo.ensrfip
iadvdeern untetl utb lewl ueesrpdf = ornaisp,ait uucsm gl,up ls.ecaattsei hst i eusasc olyhgopisci gnuithns.


 +5  (nbme18#48)
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losCloehter trese sarlohyde is ededen rof eevesrrs llrhcoeetos aopsr,ntrt otn acpcenirat znymse.e
- I dsemsi htis
bit..nm9plb/:ihgnt7u0nm/p8v1we4/csd3.w/oh.w2


 +2  (nbme18#13)
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narHpei nuciedd mtnitcyo:eoaborhp gIG saatngi tleeaptl toarfc 4
AF 9210 gape 472


 +3  (nbme18#3)
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AF 9102 gp 224 ma&;p nbb devio
D A at olw esdso 1d dseiatl rnlae sl,esvse
idmmeu 1b gintaso = onooctirpi adn icoohcornpt
h hig essod a1 giasnot = itocstaoocsnrniv


 +7  (nbme18#33)
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FA 1029 gp 1-695
X ekdnli umsacrlu dhprsyyo.t The enhacc that eth omm II1I- is a ceirrra si 1XY /.2 omnrl(a raadpgn -I)I1 * XaX e(racrri mdgmrona I)I-2 o uY know tath 1I-II is a mel,fea so noyl kool at ah,fl os 12/ na.cceh
Teh aecnch atht IsI1-'I etam si a icrrera is nrae ozre. oS ew amek mih rona.ml XY la(romn da)D * XXa rc(irera mom II)I-1 nScei ew owkn tis a oby uyo lyno olko ta lah,f so eht chanec of hmi gihnav ti is /.12
os /12 * 2=/1 41/
se ehT era owt ineeedpdntn nseetv, eth echacn the mmo is a reacrir * het haeccn eth idk egts het factdfee X.


 +1  (nbme18#47)
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latniiybI to felx at eth PID is eldcla eersyJ" i"nrgef

csudw:chwtuupt7//Xhswvhamm/o.=Nyat.w?oewtb4


 +10  (nbme18#6)
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4th yalgahpren cpuho isveg seir ot psoeruri t.hdroasaiypr
AF 1290 gp 607

riyadh  What he want to know about choice B? +

 +4  (nbme20#21)
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B e-lsenHe tCa cahScrt ni onpo-incmeommtut - chmiccpg.htmral.pacli.sntyeodaowchtw:y/tt/lhwslots/oepmnoo/tptuhaBtloler an eeaenshl ni -Id-rumseooocmpmimn aiiBacyrl asotoamtisngi oo skL klie asopki oaasmrc Di uffs"e pchotuilerni nlteafir"it F A 0291 177

almondbreeze  FA 177 says Kaposi has lymphocytic inflammation whereas Bartonella spp has neutrophilic inflammation. I guess this does not apply when immunocompromised? But doesn't Bartonella usually affect the immunocompromised ppl? +
almondbreeze  Got it after seeing that she's immunocompetent +

 +1  (nbme20#15)
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hntyetSci iecdeon agnao,l ahs mdil iOipod fsfteec hwen esud ni gihh insrnec.nctoato cnHee osiiotntpcna FA 0291 716


 +1  (nbme20#34)
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hesTe slyaaw pierptd em :pu
+ is=liPdpoay onpdesrs ot rtawe ea,nritpiodv lwo sremu Na
+ elC=rtna rdnsopes to s,pnavsresio gihh smreu aN
gche eNnri+po = noeprssd to ig,nonth alornm ermsu Na

lynn  I think serum Na+ only depends on the patient's access to water. FA19 pg 344 says serum osm is high in both and doesn't mention Na specifically. Spent a while double checking for DI, but low serum Na for polydipsia is definitely correct. +
drzed  In general, SIADH or polydipsia will cause HYPOnatremia, and DI (central or nephrogenic) will cause HYPERnatremia, but in the latter--as you stated--water access change the serum Na. +

 +6  (nbme20#26)
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iThs is ptlapyaren lntecaiong dhioryt igibndn louniglb ieyeccdifn

-Tngdib"ixinnyerho ilbglnuo efccnyieid — drgiinynie-Tnoxhb niublolg G)(BT cyiecnedif si icezaactredhr yb low surem oattl 4T tub lorman rfee T4 adn HT;S eht osnigsida si fincodemr yb usmnigear TBG rantiencs.tonco ehTes nnitfsa hvea lrnmao dioyrht niuftnco dna do not rrequie "tneamtret. - pt'etuto*nacda idnf ni A,F mbeay ti is in heert ?sweerehom

hhsuperhigh  The only thing I can relate to this is FA P331 " TBG in pregnancy, OCP use (estrogen increases TBG) increases total T3/T4", so here is the opposite situation, which TBG decreases, and total T3/T4 decreases... +12
jawnmeechell  Goljan talks about this (around 33 mins into his endocrine lecture) in relation to increased androgens causing decreased TBG +2
sarahs  why isnt it maternal antithyroid ABs? +

 +2  (nbme23#41)
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FA 9012 gp 126 isdriepoevlEx -mnc nlrcoamu eiutmpihle

hopsalong  I use barrett's esophagus to remember these questions. Remember barrett's esophagus is squamous to columnar metaplasia -> this happens because of increased acid in the esophagus. What this means is that columnar cells are better for dealing with acid/internal fluids, and are a better cell type. Squamous is a better cell type for dealing with outside irritants. This means the vagina will be lined with squamous cells normally, and the cervical canal will be lined with columnar epithelium. +8

 +6  (nbme23#12)
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nanlinaohormyplppee si na lpaah noisagt ttah siletautsm aehrrltu otmhso ucelsm ono.nricctta - ofmr tpeu,dtoa we,ovehr ti saol sasy ti si tno mncdreeomde tmrtetean anreymo

ugalaxy  α1 stimulation (via α1 agonist) constricts the bladder sphincter thereby, preventing sudden bouts of micturition during coughing/sneezing (abdominal stress). +6
sammyj98  I thought that B3 stimulation stopped urination +5
adong  @sammyj98 B3 would facilitate bladder relaxation +
hvancampen  @sammyj98- were you thinking of oxybutynin? (thats what I thought of!) According to FA, its used for urge incontinence not stress. +1
drzed  Nah he/she's talking about Beta-3 receptors which are Gs coupled. Gs increases cAMP thus it would cause smooth muscle relaxation -> bladder relaxation! +1
donttrustmyanswers  From Mayo: "There are no approved medications to specifically treat stress incontinence in the United States. The antidepressant duloxetine (Cymbalta) is used for the treatment of stress incontinence in Europe, however." +1
nreid4  @hvancampen oxybutynin is an M3 muscarinic antagonist, not B3. +
alienfever  I thought about B3 agonist as well and got this wrong. I think maybe B3 agonist can be used for bladder (URGENCY incontinence) where the main issue is detrusor over reactivity. In STRESS incontinence however the problem has nothing to do with detrusor, so we use α1 agonist to constrict the sphincter. +1




Subcomments ...

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Blowe eht tneaedt inle, aanl acrnec dgariaen is ieicplsfrau inia.nlgu Avboe eth teenatd ilne, iousrrpe aetcrl (etnh li)c.ai

sugaplum  above the dentate line superior rectal drains into inferior mesenteric then goes into the portal system http://www.surgicalcore.org/popup/420229 +  
sugaplum  my mistake, the question is asking lymphatic drainage not venous +1  


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oBwle eht tndetea ,leni anal anrcce ineagadr si ifescarpliu gi.iunlan Above hte etdenat i,enl ousrripe eactrl nh(te .)liaic

sugaplum  above the dentate line superior rectal drains into inferior mesenteric then goes into the portal system http://www.surgicalcore.org/popup/420229 +  
sugaplum  my mistake, the question is asking lymphatic drainage not venous +1  


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icNotrac sue orf aytlceu punilaf snditinooc si btho aearnesolb and tripmta.on rethoSmt-r eus teaymi(ledmi gtrscoulp-sai) sdoe not ldea to gmtleonr- nnedeedecp (or so eeoppl vahe thgot…u.h) ndA sey, sugrd tsaicdd husdlo lsao veercei cotrasnic to ltooncr pnai.

drdoom  prefer “patients with hx of substance abuse” over more conveniently typed but less redemptive “drug addict” +11  
sugaplum  I don't see why switching her to oral pain meds when she is ready would be incorrect. Clearly she is worried about being on the pain meds, I feel making a proclamation that she has a low risk of addiction would be profiling just because she doesn't have a history. The opioid epidemic also affects people who didn't have a previous history of drug abuse. Just a thought, not trying to push any buttons. Maybe I am thinking to hard about this, but I don't see the clear A vs B line for this question. +43  
nbme4unme  @sugaplum I thought the exact same thing as you and chose the acetaminophen answer accordingly. I maintain that I am correct, my score be damned! +6  
sushizuka  I had a similar question on UW and the explanation stated that the correct answer choice was the only one that addressed the patient's concern and answered her question. The rest were just alternative treatments, so they were incorrect. But I too answered with oral pain meds. +5  
angelaq11  couldn't agree more with you all. I chose acetaminophen because opioid abuse is NO joke. The crisis is still going strong because of answers like this... +1  
houseppary  I ruled out oral acetaminophen because they described in great detail the severity of her injuries, and indicated that she wasn't even fully conscious/aware when she asked this question about opioids. Rather than expose her to more pain, and possibly worsen her long-term pain prognosis, by switching to acetaminophen too early, in this case it makes sense to keep her comfortable because she's very seriously injured and not even fully lucid. It's kind to reassure her in this case. +2  
anastomoses  I appreciate all of the passion for the opioid crisis, and the wording of the answer is definitely not ideal. However, PAIN is also very real, and there is no way acetaminophen alone would cut it in a case like this, not "as soon as she can take medications orally." Maybe I'm lucky to have 6 months in clinicals before STEP or had a mom who just went through urgent spine surgery for breast cancer mets, but there is a time and place for opioids and this is clearly one of them. Thank you for coming to my ted talk. +3  
llamastep1  I agree with anastomoses, cmon guys have you ever had serious pain? oral acetaminophen is NOT enough for that type of pain. +2  
sora  I r/o oral acetaminophen b/c she's post-op for major GI surgeries so you might want to avoid PO meds for a while +  
melchior  As argument against the oral acetaminophen answer choice, it says "switch the patient to oral acetaminophen boldas soon as she can take the medication orallybold" This means you're just waiting for her swallowing inability from the facial fracture surgery to come back, which might not have much to do with her pain, and so it seems somewhat arbitrary. +  
drpee  Maybe logically/clinically A is true, but this seems like a "patient communication" question to me and I could NEVER imagine A being a good way to phrase this point IRL. +2  


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toeN that the uqeotisn si not nigask athw cesll tgifh sUR.I eTh nuqsoeit akss tawh bal dfgnini wldou be sienstncto thiw acedredse imneum cttiivya nda( htus eth nylo hceoci ttah chaemts “dceedsea”r ihwt an imuenm llce si hte sbte n.wrs)ae

sugaplum  So I read Lymphocyte as leukocyte (because cortisol probably) so that is what I put. but cortisol does increase levels of neutrophils floating around in the blood right, I was going for stress demarg. Can't tell if i am thinking too hard about this. +  


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Lygide lscle kema etr.oetssento eLgyid lelc usrtom aret’n lyawsa isogoilyclhpa ti,ecva ubt sheto ahtt era acn caues .zinsiamclnautoi Galaunsor lcle struo,m on the htreo an,dh oetimmess pduceor eeosgrnt ihch(w acn aedl ot prcsieuooc epbyrtu ni oguny iglsr tbu ieowtrseh yma be locu.t)c saTrtmaoe rae blsaddlo htta pyllcytia hvea a,tf hira, teeh,t ce.t amhoceTs wlil ont be no royu s.ett Oaranvi acocirdni si lhihgy eiyulnkl ot sohw pu on yuro etts, but fi it idd, it uodwl leilyk tnsepre htwi a csisacl ndccraoii omney.rsd

sugaplum  FA 2019 page 632 +1  
divakhan  because................"Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" NBME 24 -#13 Qs explanations/comments on this website, has led me to choose this answer! :D +15  


submitted by sympathetikey(1244),
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hT'ats a wne e..n..o

korsd.so/iegia:nicepAnrhyewtlcptie/s_pek/swi./

sympathetikey  Makes total sense looking back. Just didn't know that was a thing :) +27  
sugaplum  Fun fact: Meredith from Grey's anatomy got her idea for Mini livers from a patient who presented with an accessory spleen.... and who said watching TV doesn't count as studying +22  
123ojm  have gotten at least 10+ NBME or Uworld questions correct because of grey's anatomy +2  
rongloz  LOL got this right because of Grey's anatomy too +  
chediakhigashi  ...today years old +  


submitted by step420(33),
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Thsi is rmlaleuin ainseegs. raNoml earovsi utb etnabs uruts.e

endochondral   why not androgen insensitivity? +  
shaeking  I was wondering the same thing because doesn't androgen insensitivity also have normal female secondary characteristics. Was it the levels of hormones because she doesn't have abnormally high testosterone? +2  
swb  Androgen insensitivity has the same presentation and symptoms. What's the clue that it is mullerian agenesis instead ? +17  
sugaplum  Testosterone would be high if it was androgen insensitivity FA 2019 Pg 625 +13  
charcot_bouchard  Testo would be high in AIS. in AIS pubic hair, axillary hair doesnt devlop because of androgen insensitivity. both have normal breast dev and primary amenorrhea +1  
dickass  This is not androgen insensitivity because she has perfectly normal Estradiol, which means she has perfectly normal ovaries. She also has regular female levels of testosterone. +4  
rockodude  thank you @dickass +1  
j44n  Also AIS has paradoxically large boobs-> tanner stage 5 and thats not mentioned anywhere +  


submitted by hayayah(1056),
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otMs rittenrsoci ezmsney ibnd armnds.eopli

oS tohb G5CGC' or GC'GC3 louwd evah eebn eteabcalpc ni tshi cna.eiros

meningitis  Yes, correct. The 5'GGCC option could cause some confusion. +  
guillo12  I really don't understand the question nor the answer. Can someone explain it for dummies like me? +8  
whossayin  yes please.. I'm with guillo12 on this +  
sugaplum  @guillo12 @whossayin questions says you've created a new cut site, 1. look at the region on the sick vs healthy. The C to G is the change 2. Write out the sick "CCGG" from 5'3'- you could write out the whole thing, but the answer only has 4 letters, so being lazy here 3. write under it, its complement, the dna base pair. So "GGCC" 4. remember both strands are going in opposite directions when you write them out on top of each other. 5. So the bottom strand actually reads 5' CCGG 3' so that is the answer I hope that clears it up +47  
shirafune  To add to the palindrome part, many restriction endonucleases actually function as dimers. Each individual subunit usually has a nickase, so to create a double-stranded break in DNA, they must bind a palindrome so that each enzymatic domain creates a single-stranded break (thus a double-stranded break). +1  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +2  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +1  
ssbhatti  I think its due to the palindrome requirement? +  
bbr  Maybe I'm missing a part here, but the substrate that the enzyme will bind to will be the DNA. I went with the line that was from the questions stem, as it is the mtuated DNA will be recognized by the restriction enzyme. I didnt see the need to convert it into base pairing. Let me know what you guys think. +1  
uloveboobs  @bbr I agree. I'm definitely not an expert in these lab tests, but the question asks "substrate specificity." I was thinking that it would recognize the abnormal DNA; nothing to do with RNA. I didn't know about the palindromic preference of restriction enzymes, but I don't think there's any need to figure out base-pairing and whatnot here. (At least for this question it didn't work out that way!) +  
spaceboy98  sugaplum, I'd give you an award if this was Reddit +5  


submitted by sympathetikey(1244),
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ecChio A. dlwuo veha bnee crrcteo fi htis pitenat asw moemus.icmnoprdomi rPe tsriF ,idA "If C4D 00;,l1t& s.tedn.nrlailng.FBoia: iroNeuthiclp aoImlatmninf.

eH,vorew as tshi pitetna ahs a etcotmnep muemin etssym, zbzu drsow ear ltleeast tncniiogerz rouaamsngl.

yotsubato  Everyones choice A is different. +  
sugaplum  they mean- Diffuse neutrophil infiltration +1  
macrohphage95  what does stellate necrotizng granuloma means ? +1  
krisgsxr600  always with the details! losing dumb points :( +1  
futuredoc12345  @sympathetikey Doesn't the biopsy finding vary with the biopsy location: Lymph nodes have stellate granulomas and Bacillary Angiomatosis (skin lesion) has neutrophilic inflammation. What do you think? +  
chextra  @sympathetikey Pathoma chapter 2 says cat scratch disease forms non-caseating granulomas +1  
almondbreeze  @ chextra Same with FA 2019 pg. 218 +2  
almondbreeze  Sketchy micro: Immunocompetent: regional LN in axilla in one arm (like our pt here) Immunocompromised: bacillary angiomatsis is transmitted by cat scratches +  


submitted by strugglebus(163),
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,lAos seMkcle lwodu evha ceresidb zicamteehhoa or ilufrae ot sspa cmneuiom

sugaplum  I believe failure to pass meconium is Hischsprung's Meckels don't present within the first few days of life, so meconium wouldn't be a factor FA 2019 378 +1  


submitted by stepbystep(1),
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odes semo dinm nnlxegiapi wyh tsih itns' a erta in eth csiitca nr?vee

sugaplum  It is a very thick nerve, so I think it is hard to tear without physically cutting it. Also if it tore you would have tibial and common fibular nerve symptoms as well. You would see sensory numbness and tingling along the dermatome also the mechanism of injury is focused on spine so a disc rupture is more likely +1  
zevvyt  I got this question wrong but I really like because it helped me get past a confusion I hadon this subject. If it were a tear, you'd see the loss of motor function that sugaplum was taling about(FA 444 2019). But if it's a herniation, like in this case, you see Radiculopathy/Sciatica symptoms that are on 446. +2  


submitted by yotsubato(961),
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This touisenq is stlh.luib The nwaom wdlou sotm ilekly be ntedvaacic to Spret ,mouepn caeypilesl fi hes adh a l.eonysemtpc

E cloi is soal an pscadluaeent auiembtrc taht ceuass nn,ipoemua so atth si eorm lyielk .MOI

sugaplum  I agree with you, only possible logic for their answer: the qualifier asplenic makes the "ShIN" pathogens more likely, even though Ecoli can cause gram negative sepsis and DIC. FA 2019 pg 127 Also it says s pneumo causes sepsis specifically in asplenic patients Pg 136 +1  
lmfaoayeitslit  To be honest, the only reason I got this right (because I really was thinking E.Coli as well), is that I ended up remembering the MOPS part of the Sketchy, and I couldn't remember if he said that it was the number 1 cause of all of them or not, and ended up clicking it. It's pretty shitty they don't offer explanations for these. +  
merpaperple  I thought this too but it seems like Strep pneumo is just more specifically associated with infection in asplenic/sickle cell patients than E. Coli is. Just one of those classic associations. There's a sickle in the Sketchy Strep pneumo sketch, vs. no sickle in the E.Coli sketch. +  
drzed  E. coli causes pneumonia by aspiration, for which this patient had no risk factors. For USMLE, if they don't say the patient is vaccinated, you can assume they are NOT. Just because she has a history of splenectomy following trauma does NOT mean she had to been vaccinated--don't fill in the history for the patient, only use the information they give you. +  
vivijujubebe  also DIC more often seen with G- bacteria right???? That's why I chose E.coli instead of S.pneumonia +1  


submitted by whossayin(20),
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hyw t'nac ci"agoiofnatinr teefcd ni T3 nad T"4 eb teh sra?new

sugaplum  I think if it was organification defect you wouldn't have a normal T4 level in the serum. +16  
divya  because there would be an overall decrease in serum T3, T4 and increase in serum TSH levels. +  


submitted by hayayah(1056),
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Lelitt ferign = alrun .verne

1-8CT ear hte oostr fo eht nalur vern,e cwhhi is a bhncra fo teh dimeal cd.ro ehT arnul nerev is ton uonfd in eth caalrp unteln (het eliamd neerv is.)

arlnU n. gameda cna deal to slos of riswt eiolfxn nda ucti,donad lnxeofi fo mdelia gifnre,s oniuabdtc nda tudoicand of girsnfe s(o,ist)rneei tosinca of mdlaei 2 iullabcrm s.cumlse sosL of nnissteao voer mildae 1 /21 snfg,eri nidcuglni htenpahyro ceminene.

sugaplum  Also to add: since it is a bilateral sx it is more likely to be coming from the spinal cord then from equal compression of ulnar nerve (in guyons canal) on both sides. unless she is a cyclist +25  
thefoggymist  shouldn't the other nerves of the same roots be affected? +  
thefoggymist  shouldn't the other nerves of the same roots be affected? +  
charcot_bouchard  Not really. In klumpeke paralysis ulnar nerve s/s dominates (Almost same cause) +  


submitted by hayayah(1056),
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With chcrino niitmg,vo oyu leos lsoetlcyeter and a tol fo c.iad It egrsritg abmcliote illkssaoa hiwhc is ywh lla eht musre lsveua are wlo (or no eth leowr edn fo eht aronlm )enrag texcpe ofr abbcoetar.in

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 +4  
sbryant6  Wouldn't increased RAAS lead to increased Na+? The answer shows decreased Na+. +3  
sbryant6  Also, remember Bulimia Nervosa is associated with hypokalemia. +1  
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" +2  
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 +1  


submitted by namira(30),
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elosbPis aiap:xelnnot

fI eht pt is gankti a ezadiiht (chwhi is K igedt,eln)p it imgth evha lsao eebn vegni ihwt a K nspgrai durg ucsh as sotenn.ocalirpi

eornnocltSpiai sha ocelonicrgoidn secffet shcu sa nmsacotgyaei adn rotc.elrhaaag

sugaplum  I think you could only make this assumption if they said "patient is on standard htn tx" but since they gave the name hctz, would not be fair to assume they are also taking spirinolactone. I went with process of elimination on this one. Even checked access medicine's drug adverse effect profile...galactorrhea not listed for hctz +2  


submitted by hayayah(1056),
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Maelhnto is tciox by wto esmi:nacmhs

i,srtF tenholam acn be ftala ued ot tis SCN rstenespad eepiptosrr ni eht sema nramen as othalne gio.pnniso

,cnSode in a escrops of noix,tciota it si iezltoabdme ot orcimf cida iav elyamodredhf in a reosscp tadtienii yb eht meyenz oalchlo ehesoneraddgy in teh li.vre latMnheo si ncerdvoet ot modyfadelhre iav oolalch eeoednaydgrhs DH)(A and eaoymrehdfld is oceredvnt to mfoicr cdia etr(om)fa avi ledhdeya ayoedsghdneer LD().AH

mrFtoea si cioxt uaeesbc it tihbinis coimalrtndhoi hormcocyte c ,sdioeax guncsai yoxaiph ta eth aculllre ellve, adn tebomlcia oicai,dss anogm a rivtaye fo ohtre ectlmoiba .siredubtsnac

sugaplum  Good pictograph comparing methanol, alcohol, and ethylene glycol. https://wikem.org/wiki/File:Toxic_alcohol_ingestion.JPG +9  


submitted by thomas(0),
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Aswren si yecA.tstro titPane ash oamaiotblsgl lomf.eimtru hAhtuogl sinomngimae yam uccro at cxitnev,eios mgamesnonii rae nebign dna nfoet ptcsaoymm.ita yeTh amy euasc ha/ is,eezrus btu owuld eb ueliylnk to sauce tdhea n/wi m6 of etnso fo .ah/ ehT zeis of rotum and reusoc fo esilsln si nsniettcso tihw hte oerucs of MBG

masonkingcobra  Above is obviously incorrect because the answer is Meningeal lol. Here is a link to a good picture: http://neuropathology-web.org/chapter7/chapter7fMiscellaneous.html +24  
kernicterusthefrog  Obviously thomas is disagreeing with the presentation of the question, and I agreed with him! This absolutely sounds like GBM, with rapid onset leading to death, and the symptoms. The question stem leads you to GBM, and the gross image to meningioma (I guess). +2  
kernicterusthefrog  Furthermore, where are the meninges on the gross image form which this (meningioma) grew?! It should at least show the tissue from whence it came! +1  
nala_ula  Had the same problem, got confused since it appeared that the growth was malignant :( +  
sugaplum  FA 2019 pg 514, also agree with everyone. weird presentation. Glios are malignant death within 1 year, meningioma are often asymptomatic or have focal signs. just a gross pathology question at this point +  
garima  ı think she died bc of pressure or something guys, its obviously round shaped benign lesion, its also extra axial not like GBM. she had this maybe years before death +2  


submitted by celeste(78),
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iTsh sdosnu keil ocnaniF .yromsned ehT xrimpalo tlurabu liihaeeplt clsel ahev a ardh imte arobirbseng lra,tifte os ul'yol ese a sols of ps,oehptah oimna da,csi baeabiro,nct nad .sglucoe

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +4  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +1  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +1  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +  


submitted by sympathetikey(1244),
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daHr to see ued to ropo uecprti tqlaiuy, but bedsa no htaw I cuold es,e ti esems iekl a nsoetsuonpa motuhaenoxpr to me abde(s no het klca of nugl rakngmi on the felt pcdomear to hte grtih )esd.i

feor,Teher necis het glun is dafet,lde lla ouy loduw ahev ni teh eflt deis of hte enop tvac,iy chwih dwluo aekm eht tfle sdie sntrsh.aepneyor

sugaplum  FA 2019 pg667 +14  


submitted by lfsuarez(141),
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Teh tantepi is ecbdrirpes naliedSlif wihch dceaus rasdeniec cPGM slleev era efrehtroe OMHOST SLECMU i.lneoatxar In tshi cesa oyu dowul antw ot asvtdealoi eht deep yrater ot reniaesc lbdoo folw itno eth poorrca aceaovsr.n

sugaplum  aka cavernous artery, that is what I was looking for. Did not realize it was also called the deep artery +5  


submitted by mcl(577),
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Ptentia htwi rleliatba lenra ayrter tbsuir and rhnsetpnyieo ilwl fro rues hvea tcatiiavno of SAR mssyte nad eorrhftee eearnisc ni nng.ntasieoi

hotuAhgl ompmyochrhcotaoe and soeeqctnun tvleedae tcnhaeacoesilm anc esarneci loodb e,upresrs sompmyst rea ltyiyapcl picdiose and nearl btsiur aer tno ykelil to eb .rdhea teaEledv evlsel fo iosnnoret nca soal auecs eoypnshiern,t btu ew would salo eepctx ot ese gf;unislh ,alos rehte si ohgtnin ni het setm ot iteicnad tieaptn si iakgtn SsRSI or iegmnosht eesl thta oucdl idpresepos ehr to edetveal lvesel fo nso.itrnoe aldvtEee eevlsl fo oritydh reohnmo ocldu aols giev napttie ennpyiores,th utb ew loduw lsao ecexpt oethr ngssi fo roystiyphmdheir e,ot(rmsr tehigw slos, t)e.c.

I asw a llteti ofsuecnd fi EOP wloud eb dtaelvee -- if erteh si stonesis of laern riaretes sa( ietddniac by teh iubsr)t het iksyned odclu oasl etecdt isht as aoxyphi adn rpam pu oirnpdtouc fo P.EO ,oHeverw I ednde up ogngi hwti oitsaeinnng ceins ti msedee eorm "rnctec"oe ot em htta ASR luwdo be pu. Dose eyanon okwn yhw tsi' ton PO?E

brise  Wouldn't that be more long term? +3  
sugaplum  I think Epo would indicate Rcc or renal failure, she seems like she has "just" refractory HTN, and no other sx to indicate anemia. +  
davidw  She has Fibromuscular dysplasia which should be in your differential for a young female with hypertension ( along with Conns syndrome and pheochromocytoma). it typically causes stenosis and aneurism formation of the renal arteries leading to elevated renin. +2  


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hTe nittepa ash ANT nrecsaoyd to rnael emihsi.ac euD ot lruabtu snre,ciso eht tiepnta lilw ehva na veeeatdl .eFaN heT eapsnitt' unrie will soal eb udti,el but tihs lilw be clftrdeee by teh wlo nerui oaily,slomt ont eth NaeF

mousie  Hypotension can also cause pre renal azotemia with a FENa <1%.... How do you know this is ischemic ATN and not hypotension induced Prerenal Azotemia? +11  
sympathetikey  I had the same thought as you @mousie, but I think "azotemia" and low urine output push it more towards ATN (looking back; I got it wrong too). Plus, the initially MVC / muscle damage probably caused some tubule injury by itself. +2  
ajo  This might help clarify why the pt. has ATN rather than pre renal azotemia. The question did mention, though subtly, that the bleeding was controlled. That most likely indicates that his hypovolemia has been corrected. Developing azotemia 24 hrs after correction of hypovolemia is more suggestive of ATN (since he doesn't have hypovolemia anymore). I hope that helps and feel free to correct me, if I am wrong. +37  
ajo  In addition to my earlier comment, I just noticed the question also explicitly mentioned that he was fully volume restored. Which is consistent with my earlier assumption! +14  
gh889  Although initially, hypotension causes prerenal azotemia, the volume correction pushes you away from prerenal azotemia. but they want you to remember that in hypovolemia, the kidneys are also becoming ischemic, and so development of azotemia 24 hours later is more indicative of intrarenal azotemia due to ATN +  
sugaplum  for anyone who wants to see it: FA 2019 pg591 +1  
divya  i'm confused about one thing. if the tubules aren't working like they should, the bun:cr ratio falls right? doesn't that essentially mean azotemia reduces too? +  
osler_weber_rendu  Lets all take a moment to admire how shit this question is "Bp 90/60.""Repeated episodes of hypotension in the OR" and still the answer is ATN +4  
donttrustmyanswers  @osler_wever_rendu ATN can be caused by ischemia. +2  


submitted by shaydawn88(8),
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Is ti vaeliornla-tra dsusetarnat sacbeue hits ntaitpe timgh eahv HF d/t .a fbi nad tfel iratla e-enrgmngtt&;eal cni sdtctarohyi s;pue&rs-gert aedsuantrt earlulp fsinufo?e

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