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Welcome to sympathetikey’s page.
Contributor score: 1248


Comments ...

 +8  (nbme21#26)
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Teh eholw kcisp" ta hte ness..iuca.soel some be"ileg,dn aemd me khtni o.aisirPss oulSdh aevh oeng twih inctcAi isotrKase sebda on teh einattp htirsyo sto(l fo sun o)r.eepusx

icicAtn tesoriKas

inmPaenlagtr seiosln duscea by snu p.rusoeex a,Slml h,gour eatoemurthys ro hniwosrb plupsea a esq.porul sRik of ssqamuou clel mriccaano si popolairnort ot eeredg of iilhaeelpt aydasis.pl

thisisfine   Same - the bleeding thing pushed me over to psoriasis as well. Oops. +5
temmy  the distribution of the other lesions, forearm, face, ear, scalp..is not characteristic for psoriasis. +6
hyperfukus  the scalp and ear are actually very common for psoriasis IRL the key is more of the fact that its in areas with UV exposure...actually UV Therapy is found to be helpful in treating some pts w/Psoriasis. Lastly the appearance and lots of things bleed if they were trying to go for auspitz sign it would have tiny dots of bright red blood with slightly touching it +4
hyperfukus  oh last thing psoriasis itches! they said no itching +4
drzed  Those locations may be common IRL, but on step 1, if they want you to think psoriasis, the illness script is going to be someone in their 30s (autoimmune age) with symmetric cutaneous plaques that have a silvery scale on the extensor surfaces. In this case, the age and non-classic description (location, type of lesion) made me steer away from psoriasis. +1

 +24  (nbme21#4)
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• erP ctooPolr - nOyl dilceun teitspna ni het uerstls how lweldoof het ltopcoor

• sA trtdeae - Dtaa iew,s nyol aettr hte tcsjsbue sa yteh eerw deteatr x(e - if apinetemrelx itptean eods waht eth rtcooln anttspei aer peopdssu ot do, vmeo ttah etelmerxapin atnietp to teh loconrt urgop

• nnetntoIi ot tarte - ludnceI all etanitps in eht spgour tehy wree lianliygor amendidzro to


 +1  (nbme21#4)
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• Per ctoProlo - ynOl nueicdl nesttiap ni teh rlsuset hwo eollowfd teh •oor pclot As tteedar - aatD ,siew ylon ttare hte ejucsbst sa htey rwee draette xe( - if maetilenrexp eiattnp odse wtah hte rncootl tipsanet aer ueppdoss to ,do mvoe that mlreeetapnix tpnitea ot hte octonlr o rpgu

etnntonIi to ratet - cunldIe all pesnaitt in het spogru eyht rewe irlongylai mzenrdodai to


 +6  (nbme21#40)
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oodG urpcti:e tctgC/n-fn/cuoe/p.jenno:esm-htovadttrfsosn.h--a-tp/epshe/usinotmCSnyltienpowoauata


 +1  (nbme21#34)
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enofirrI oqbielu = hpsel oyu kool up m;&pa n.i

s,Alo yhet isad lfroo fo eht r,itob so it makse nsese htta teh rrfnioei lumsces udwol ad.eadmg

sahusema  I know you're right. I was just so uncomfortable picking an answer with "inferior rectus" because damage to the inferior rectus does nothing to explain the clinical findings of impaired upward gaze. Unless the muscle is physically stuck and can't relax or something +5
emmy2k21  Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :( +2
dr_jan_itor  in the last sentence it asks you to assume an "entrapment", so it is actually the inferior rectus which is the cause of the upward gaze palsy. The entrapped muscle is functionally trapped in it's shortened position, thereby not allowing the orbit to gaze upward. +14
chandlerbas  bam! dr_jan_itor just cleaned up that confusion +1

 +3  (nbme18#32)
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Prosen obrpyalb ash Ilibrtrae Bweol .mSoedyrn ealrRsgdse, it esmes lkie 'reetyh rnyigt to rtaet mympotss tiwh na doioip -aeitrhdrianla lkei odeiramp.el

cbreland  "intermittent" made me think IBS as well +

 +4  (nbme18#31)
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imfieledt-Sl siseaed otfen oonwilgfl a iekulf-l eilsnls (e,g rialv tMennoc )aifyi. be pheyihrordty yeral ni uecros, lweodfol by hhitroympydios ree(ntnapm in %1~5 of cases.) Vyre trened tryhdoi si ee.sn

sympathetikey  Short time course & tenderness was a tip for me. +8
rainlad  Aka de Quervain's thyroiditis +

 +4  (nbme18#22)
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A etysclcoe, slao nkwno sa a seprpdloa ra,dbeld is a lemcaid ocdtoiinn ni ihchw a m'nwosa braedld bulges ntio reh iav.ang emoS mya eahv on pmmssty.o htOer mya aevh uroetlb ttrgians taiio,nrnu urraiyn iniontcc,enen or fuenqetr .tanuironi toalCocpnsiim amy dnlcieu rrcnetreu nyrauir tartc tcnioefnis adn ruianyr inoe.trnet

tcepoptgihiisCierlys./nek:/k.waewtd/i/o

cbreland  How would you rule out uterine prolapse? +
baja_blast  With a Uterine Prolapse you would see the uterus move down, into the vagina. With Cystocele you have the finding described in the question; bulge of anterior vaginal wall (which borders the bladder) into the vagina. Here's a pic to help illustrate: https://www.health.harvard.edu/media/content/images/cr/205345.jpg +

 +3  (nbme18#5)
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aseprpA ot eb frniib ienoptdiso oesrndcay ot lcrtibaea iispe.ttniro


 +2  (nbme18#41)
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alniliuG Barre is -Tlecl damteedi eutrdoctnis fo nyeiadetml aonxs. lreGalney rptneses hwit a prida tosne wngoofill a ivrla / itlarecab senlsil whit nacnesidg yprasals.i


 +3  (nbme18#42)
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• mpoPe eissDea yTe(p )
2    ○ akLc fo - msooslLay angiebhrcnD ezEmyn 6-,1(α dGcsu
l)seioa    ○ plBuidu fo 6,1 asekngl
i    ○ P:ioeasnrte
nt        § .1 eldraig
yaCmo
sympathetikey  *1,4 glucosidase +3

 +7  (nbme18#4)
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soeHint ateiyoactln slwloa for taanlexrio of teh DNA so ttha atotrpncirsin anc ecoe.prd llA strna interico daci suacse teh taeoyurlngsc in PLMA ot trufhre ra,umet chwhi qsrierue DNA ocnsrtpinirta / t.nlaonsiart

osler_weber_rendu  The questions asks for response to ATRA. Should that not be decreased transcription to treat the cancer? Which makes methyl transferase (aka methylation) the more likely answer +5
pg32  @osler, no @sympathetikey is correct. ATRA's mechanism in treating APML is to encourage the cells to mature. Maturation would require gene transcription, meaning histone acetylases would be used. +1
nnp  but ATRA is letting transcription of an abnormal protein ( that is 15:17 translocation) +2
lowyield  i believe the mechanism of APML is that the compound protein is ineffective at allowing for maturation of the blasts. giving ATRA allows the blasts to circumnavigate this step, relieving the backup +8

 +4  (nbme24#23)
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Brttee iprceut - e8dtls1.b-aNtpw-tlcalpschw0s/ur2wcova//ueetapno1/nhc://mg0.e./Btrjwop

yb_26  @at0xibolic, I think you won this competition on finding better picture lol thanks +5
drschmoctor  Those may be better, but this is the BEST. http://bitly.com/98K8eH +7
brotherimodu  god damnit +
jesusisking  Not again (´∀`) +

 +11  (nbme24#37)
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sA rep haoa,Ptm

aa"srVulc yepeilbtiarm scuroc ta the aayricslolpt-p elneuv"

hisT is h,wy when uoy evha e,amed ouy wuold eahv pags in hte .nsvleeu

j44n  that was my exact reasoning +2

 +4  (nbme24#23)
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I utsj irdet ot ktinh of sw'ath edeeslar by het dAraeln alMlude .rhpi)e(pEenin PTMN is eht oyln chicoe htat edma esnes.


 +18  (nbme24#38)
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e'ulvWdo eenb ncie fi htey odlt oyu dn2" tocaltsnire spe"ca on flet or g.s..hmitrh

paperbackwriter  It wouldn't have mattered because the murmur is due to increased stroke volume, not anything mechanically wrong with the valves. If they had said A or P then it might have actually caused more confusion (stenosis etc.) +6
cport12  Also an important side note is that with the addition of the placenta, systemic vascular resistance would actually decrease (another organ added in parallel) which should help point you towards an increase in stroke volume. +

 +35  (nbme24#33)
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ryEeoenv how tgo hits utiqseno itgrh si a .cpo ⌐■■ل͟༽༼

dr_ligma  Fkn narcs +2
j44n  whippet_gang +

 +6  (nbme24#49)
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retPyt dawtgfrsrtrh,aoi btu a oogd dmenerri taht sooilmifeysrb acn scaue an nalgdeer n.leeps

sympathetikey  Due to extramedullary hematopoesis +22
zoggybiscuits  I thought it was spleen but the fact that hematocrit was 24% 4 HOURs later made me think otherwise. It was my understanding that the spleen would bleed you out quick! +
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +1
peqmd  Spleen is most commonly ruptured in blunt trauma so along with myelofibrosis and being kicked on the left side it's just asking to be ruptured +2
limberry  @need_answers the bladder is intraperitoneal, not retro +
limberry  bladder is sub*peritoneal, sorry +

 +5  (nbme24#19)
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owzzd:Bur vxeeseisc grtanei

urCstle aehadhcse, in essn,ioqut slyawa omce ithw noaimtocu .mspmtyso

jsanmiguel415  Also unilateral and periorbital;, can differentiate from migraines because of it's short duration (30 minutes to a few hours vs migraines which is hours to days). Relationship to seasonal/allergies as well +

 +9  (nbme24#24)
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sulducPie Husamun

dgois-uBlkcno icel htta sauec eneistn uurisrtpwthi taodisesca cixot,sonriea mnoolcmy on lapcs dna cekn aeh(d i,c)el asdbintwa dlalna iax (odby eli)c, or pibuc and snopeaniga rierl (bucip )li.ce

Bets egvi aywa in hist queo,tisn rof em, si teh w,hi"te grulobal arsoebuprnec"t. Lkoso ustj leik hte cip ni srFti dAi 0921 (ese ewl.bo)

tmig.:c/ph/s.gmDiA2upm./Jn5htor


 +1  (nbme23#28)
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Kyse wree eth:

ucu-isarGol

thu-sharpPioa

onAim- cauairid

hseTo holsdu eb -dsbarbroee yb eth ,TPC so fi tree'hy ot,n Tepy 2 TRA.

lamhtu  To be even clearer, this sounds like **Fanconi syndrome, which has lead to Type II RTA** +12
yb_26  To be even clearer: Wilson disease => Fanconi syndrome => type II (proximal) RTA +
charcot_bouchard  To be even clearer, you all have been pretty clear +
charcot_bouchard  To be even clearer, you all have been pretty clear +
yng  I don't thin this is Wilson (copper in descemet layer of cornea). This is cystinosis (crystal in the cornea) --> Fanconi Syndrome --> Type II (PCT) RTA. +

 +12  (nbme23#42)
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caisCls onyirsmiua.tcoh

eSe sthi ipc of het ocntsie rof it ni AF 1092 - s5.asorconem1eo675e5c73a:ht2b8620f76c6pd8a3cxf4603498gc25hio38/6/p2o9f185t6be/h56g.8.c7b3t7esop9t6j4e4p22cv1b87.


 +17  (nbme23#21)
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Hdar to ese ude ot roop reputic tyuaiq,l btu baeds on htaw I ulcod ese, ti smsee like a oasuenponst reohtouamnxp to em bas(ed no eht ckla of unlg gkarnim on teh flte paocmrde ot het tirhg ).dsei

rehrTef,oe necsi eth lgnu is tlea,dedf lla you would vhea ni the eltf idse fo the oenp avcity, hciwh uwodl kame eht ftel ieds peretnano.syhsr

sugaplum  FA 2019 pg667 +14

 +15  (nbme23#30)
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isgteBg luce aws ttah theer was no iemt afrem n.vige efe,eoTrhr siht smsee to eb a cl"eis ni m"eti us,ydt cwihh ielns up twih roscs etnlsoaci .study

paulkarr  Damn, epi at it again... +4

 +7  (nbme23#17)
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s'htaT a ewn ....eno

orwykihn/.siAtecc.aln_teep/iswridgpoes/ik/pse:

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 +

 +3  (nbme23#50)
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I ese atwh eeyrth' naigys sth(i aws my nsoecd )ceioch tub ta eth aesm etmi I elfe keil a cupkba of lobdo ulwod viteaact hte soprcrreateob dan acuse ddcerseea staimypthce iycttiav ot eht AS pm;a& VA edo.n

sympathetikey  (choice E) +
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +

 +5  (nbme23#16)
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hesenatoDoxem usrpssesep THAC = ityuaPtir eoa omamdeneAenxsoDth ilsfa ot purspess AHTC = toipcEc AHCT e(x - Slmal lCel nguL Crec)an

sympathetikey  *ACTH +
meningitis  If im not mistaken, Dexamethosone also fails to suppress ACTH = Adrenal Gland Adenoma +1
therealloureed  I think an adrenal gland tumor would have low/undetectable ACTH? aka no dex suppression +13
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +12

 +8  (nbme23#6)
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moamSnei is the msot omocmn slutetacir mtu.ro st'I a emrg llce rt.mou yoommCnl see f"ried egg .c"slel

motherfucker2  If it was a woman would be a dysgerminoma. Seminomas have excellent prognosis and highly radiosensitive. MCC testicular tumor +6
drschmoctor  Spunky fun fact: In a normal adult male >1,000 sperm are made per heartbeat. +6

 +15  (nbme23#27)
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Ayn time uoy ese iedfx wedi igitntslp fo 2S, msahs DAS.

someduck3  I'm not 100% about this so take it with a grain of salt. But i was confused about why there would be a systolic murmur. I think its b/c prolonged ASD would eventually cause pulmonic stenosis which would present as a systolic murmur. But besides that I super agree with @sympathetikey +
usmlecharserssss  with airpods in 2012 +
paulkarr  Low key was hoping for someone to try and argue this one... +

 +5  (nbme23#21)
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reP FA .(gp )663: gnnricCoen aetbrs en.cc.ra.

"mpioaiAlcifnt/reorsonxepiesv of r otesreg/neospteeongr eceposrtr ro Bbecr-2 2(REH, n aFGE erper)oct is mnmoc;o RE ,⊝ RP ⊝, u 2nE/RedanH ⊝ rofm roem .rgs"agesevi

sympathetikey  FA 2019 +4
meningitis  Why others not it: Anticipation: Trinucleotide repeats; CAG (Huntington), CTG (Myotonic dyst), GAA (ataxia telangiectasia), CGG(Fragile X) Chromosomal rearrangement: Many but can think of Trisomy 21, BCR-Abl, etc Imprinting: Prader willi, angelman Loss of heterozygosity: loss of a single parent's contribution to part of its genome. A common occurrence in cancer, it often indicates the presence of tumor suppressor gene in the lost region. +1
kai  trinucleotide repeats are not associated with breast cancer Neither are chromosomal rearrangements BRCA1,2 tumor supressor genes are associated with breast cancer, which is why I chose E, but I guess I should have bought the new First Aid.......... +
charcot_bouchard  GAA is Freidrich Ataxia +4
tulsigabbard  So is the amplification of the receptors unrelated to BRCA 1, 2? I'm still stuck on this as Sketchy states that breast cancer falls under the "two-hit" model. +
tallerthanmymom  @tulsigabbard I think one of the keys here is the question stem; " what is the most likely cause of the OVERexpression in this pts tumor cells?" --> I think that the "2-Hit" model would lead to UNDERexpression of a tumor suppression gene rather than overexpression. Whereas amplification would cause OVERexpression of the HER2/estrogen and progesterone receptors. But, I don't think that amplification would be the answer if they were asking about a triple negative cancer. +1
tallerthanmymom  Also this is on page 632 of FA 2018 for those using that version +
tulsigabbard  @tallerthanmymom - thank you! +
drzed  I can understand why @tulsigabbard dropped out of the race--she's taking step 1 soon LOL +1

 +6  (nbme23#49)
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eActu ogtu temae:nrtt

  1. IDASNs
  2. oirtsdeS
  3. eCncocilih

,I leik a ydmb,u eridasm ez-on fro n,e-so iginnkth ti asw terosdi pcdeik t.aht orF nenyoa how e,srca eifrzSlnpouyan climoetipevty inhitgbnii ruic adic ibrtsponaore in het xrmaloip luuteb of the idnyke.

erou:Sc .epa/h/iindpSknaefiwtri.wi/oztioslrukgy:/enp

yb_26  even if it would be steroid in the list, if NSAIDs are contraindicated => we give Colchicine, and if pt can't tolerate Colchicine as well => then we use steroids +4
usmlecharserssss  uptodate - try to avoid steroid therapy in gout , in this case patient has aspirin (NSAID) allergy , so second line is Colchicine , not Allopurinol, which is for chronic management. This case is not RARE and a lot of people sits on Colchicine therapy even if they do not have NSAID problems. Colchicine also First line treatment for Familial Mediterranean Fever, prevent exacerbations. +4

 +1  (nbme23#7)
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adM at melfys fro cahnging my nre.asw

ltaFuy lcigo aemd me owednr if tghitin oury edha luwdo cudeas raedcesin IPC os, ilek a hciungs lc,rue uyo wluod tge sedearnic Vusga vnree tvaityci adn maeyb cdrdbraayia + tnonoyis.phe But I ssuge het RSAA tmssye dlowu aehv cueacrenttod thta dna duaesc itcnocsoatnvrsoi roev 24 ,ushor os liceopHyomv shkco si enyeflidti the tesb echcio.

syaAwl udslho go wiht eth ibosvou ernaws :)

seagull  I had the idea that this was a neurogenic shock and increasing intracranial pressure could affect the vagus too. I think the question really wants us to go that direction. +13
uslme123  The Cushing reflex leads to bradycardia! +4
purdude  Wait I'm confused. I thought hypovolemic shock leads to an increased SVR? +2
littletreetrunk  apparently, there's a thing called sympathetic escape that can happen after a while (i.e. he's been out for 24 hours): Accumulation of tissue metabolic vasodilator substances impairs sympathetic-mediated vasoconstriction, which leads to loss of vascular tone, progressive hypotension and organ hypoperfusion. +
littletreetrunk  also also if he hit his head he could have loss of sympathetic outflow from a hypoxic medulla which could lead to vasodilation, which further reduces arterial pressure, but this was a hard one for me lol. I also put increased ICP wah. +
catch-22  Any lack of sympathetic outflow/increased vagal outflow should reduce HR, not increase it. Further, you would expect brainstem signs if there was hypoxia to the brainstem. For example, if you had damage to the solitary nucleus, you wouldn't be able to regulate your HR in response to reduced BP. Since this patient has reduced BP and increased HR, this indicates that the primary disturbance is likely the reduced BP. He's also been in a desert for 24+ hours so. +3
charcot_bouchard  In a patient who develops hypotension following high-energy trauma, neurogenic shock is a diagnosis of exclusion that is made after hypovolemic and obstructive cardiogenic shock have been ruled out! Plus Absent Bradycardia rules it out +2

 +2  (nbme23#16)
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e:oSucr kwtir.d.eiina/y/itwheinelkp/o:iMp/sg

lmeny"i psseed eth sriistnanoms of itreclealc emuispls aellcd tnicoa tenlpstoia ngloa nielmeytad soaxn by ianilsntug eht naxo and ncudiger axanol nembarem eacpacnatic"

littletreetrunk  I think this makes total sense, but how does it not ALSO stop fast axonal transport? +3
laminin  axonal transport is transport of organelles bidirectionally along the axon in the cytoplasm since myelin is on the outside of the axon demyelination doesn't affect this process. source: https://en.wikipedia.org/wiki/Axonal_transport "Axonal transport, also called axoplasmic transport or axoplasmic flow, is a cellular process responsible for movement of mitochondria, lipids, synaptic vesicles, proteins, and other cell parts to and from a neuron's cell body, through the cytoplasm of its axon." +3
yotsubato  axonal transport is mediated by kinesin and dynein. Microtubule toxins like vincristine block these +3
drdoom  @littletreetrunk "axonal transport" is movement of bulk goods via microtubules (which run from soma to terminus); ions, on the other hand, move in an "electrical wave" that we call an action potential! no axonal (microtubular) transport required! in other words, de-myelination will have no effect on the transport of bulk goods; but it will really mess up how fast "electrical waves" traverse the neuron! +

 +2  (nbme23#25)
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iPna a;mp& reeretpatmu riefbs ofr teh itgrh sdei ocem ni no teh oardsl rghit ,esdi srosc ta teh nearroit thiwe cr,oumsmie adn lvreta up ni the Slimpotaihanc t.artc

Akls/Vg/.htXluoAIAs8sa/ot-uhcAYlt-np66Ae4-4/H8m9e4A2c9Z7r9/mel1roA.3Ag-6B/-tg.Q/jb4ghlu2yk6X4sWI0jjteoT3iop:egg0n/irG

focus  The diagram here is pretty great, too, for the spinothalamic tract (and it is presented side by side with the dorsal column for comparison): https://opentextbc.ca/anatomyandphysiology/chapter/14-2-central-processing/ +

 +15  (nbme23#32)
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ughoT neitoq.us

leaclR htat eeMmnniat z'a(msheilre gudr) is a NDMA Rorcetpe oatgtsiAnn hatt eslhp eeprntv ioocxttetixyc by gilocknB 2a+C ntrey. ht'aTs ohw I remrembe .sith


 +4  (nbme23#22)
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eeevBli tshi oqneiust is nerriefrg ot Vlcearsi amnshiLisesai.

gabeb71  The give away is the Fever, Pancytopenia, and Hepatosplenomegaly after being bitten by an insect and developing the sore. +14
tallerthanmymom  I got this question directly after the other visceral leishmania question and it made me second guess everything I thought I knew. +6
qball  Don't forget they like to infect macrophages. +

 +5  (nbme23#6)
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ckyLu e,cduniotd but gokionl a,ckb I lbievee wtha ehyt ewre ggion ofr is tawh she odhlus heva eebn nevdaccita ofr ta 6 tmnsho fo gae cne(si etrhe rae no arepnpat )yspsm.mot

Hep B acceniv si alyuslu enigv ta itrhb, 1 nmtoh, nda 6 stmhon fo g,ae so 'sit tyetrp mrntiotpa ttha she eb aidtcevacn tgaasni ,ti nsusel she ydalare sha i,t in hichw ceas she duolhs eb traeetd to vadio hircirs.os

ls3076  how can we actually be expected to know vaccination schedules... there must be some other reason the answer is correct +4
cbreland  I don't think we need to know that the vaccination schedules, but that the only other answer with a vaccine was adenovirus. I figured that there would have more symptoms if she had adenovirus (plus didn't fit the typical military recruit/swimmer demographic) +
koko  Why does it have to be something with a vaccine? RSV Is extremely common in babies,shouldn’t screen for that? +

 -3  (nbme23#2)
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Oen of het edsi tsfeefc of pmholypdcheCasio si lrpumesnipoessyo.

eSe fllu itsl fo dsei fctsefe woebl:

essruMsiyloepop;n HAnc;DnoS FiaI iin)fy o(amdees;sormdf mtgyt rcriciheaishso nda dderabl reepdc vrnnetc,ea hwti yufmnla(ehlsdsry rugop of a nmsndsibe itxco eatmoitb)les eaq nteudada ho.rdainty

ninja3232  This is incorrect. Myelosuppression can also refer to the lymphocyte lineage. +5

 +2  (nbme20#49)
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Dcreit utnngAilliob = eDrtic sCombo sTte

teceDts iaidnseobt nduob ctyrelid to s.CRB lmseHiosy stom lkeyli due ot teghinoms ni teh fsrnuesadt lbdoo (otn rseu why it ootk 4 keews when Tpey 2 SH si opuedpss ot eb qekiruc ubt .e)w/

ergogenic22  there is a delayed onset hemolytic transfusion reaction which should be evaluated with direct cooms test. https://www.ncbi.nlm.nih.gov/books/NBK448158/ +5
hungrybox  such a dumb question wtf +25
sonichedgehog  takess longer due to slow destruction by RES +
baja_blast  Dang, I didn't know that was the same thing as a direct Coombs test. I guess it makes sense in hindsight. Thanks! +
sars  Theres a UWORLD question with a table displaying the different types of hemolytic reactions. Don't know the question ID. Agree with delayed hemolytic transfusion reaction due to formation of antibodies against donor non ABO antigens. Typically presents as an asymptomatic patient or mild symptoms (jaundice, anemia). Different from an acute hemolytic transfusion reaction, which is against ABO antigens. +1
tomatoesandmoraxella  The Uworld table is in question 17780 +1

 +13  (nbme20#26)
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oGod pctuire igsnohw eht tmaynoa of hte ithgh mrof a T2 MRI evrpeei.tcsp

optlg91o17t05o0:4p890/9u301029pnky5//.p0osw7al0mc.r/79d/d-ju780y/7034etnc_e307hsg6aB7t-7i5/750o7-01

jcmed  Was so close to picking vastus intermedius +1

 +2  (nbme20#46)
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eioosrHsydpnrh

aDosit/ntdiiilntoen fo rnale eilpvs nad sclyaec A . lyuUlas seudac by ruairyn ctrta insocrobtut er( lagn,e nte,oss eserve BH,P nganolietc tnuorsoc,stib lvcaicer r,nccea nyuirj to et,urre nregypcan rlpeaynapt); htoer sdunscueiacel ooteirltnerrpae ibfsori,s oareestcreuvil xref.lu iDtlaion cuorcs mrliaxpo ot tsie fo e Srtoyup.ahmlgo tienraceni mescboe aleevedt fi brtunsoitoc si aeailbtrl or fi atpient sah an colsra tyoiudtsebrt dneyik. dLsae ot npoirsesmco and oslbisep tphraoy of nrlea ertcxo and lludema.


 +5  (nbme20#14)
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I veelieb teh obysip dirseitnopc fo lamsl" lbasopiilhc lelcs gfrnoim rumot naldsis" si iesdrcigbn eth elrpaireph dgnlaiaspi hatt si lllissyccaa enes in aasBl cell coimr.naac


 +5  (nbme20#27)
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Caes rieesS

A progu ro ressei of esca rorespt linonvvgi pitsanet owh eewr egnvi isialmr tteterman. Rorpest fo esca eiessr usayllu tacionn ieddaelt timiranoofn aotub het idadiuinlv tainp.tse Tish snleiucd ordimcgaphe itmoafonnir (ofr ,paexlem g,ea nrdege, nhtice gorii)n dna iatomifrnon on niiaosgs,d mt,enertta enseospr to meer,ttnta nad opwf-lulo tfrea t.tntemear

In shit ote,nsiqu ti slkoo ikle eyht ndt'id aelyrl oscuf on the neaerttmt prta of ti tub eweots,rhi ekasm seens

sympathetikey  Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/case-series +2
ngman  I think another factor is that in case series studies there is no control group vs case-control, cohort...ect +18
leaf_house  "There is often confusion in designating studies as 'cohort studies' when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ +
fataldose  explanation of one of the wrong options - correlational study A correlational study is a type of research design where a researcher seeks to understand what kind of relationships naturally occurring variables have with one another. In simple terms, correlational research seeks to figure out if two or more variables are related and, if so, in what way. (source - https://study.com/academy/lesson/what-is-a-correlational-study-definition-examples.html ) +
j44n  you dont need a control group in a cross sectional one so how do you differentiate that +

 +17  (nbme20#35)
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As tsated eol,bw eht feLt ucrs rierbce saw medadga (ees wath ti shdoul lnrolyam kolo like o)ble.w ihsT nsiatcon eht tcrpcsiolanoi ttcra. Secin the ciaoclsrtopin attrc daeecusts at the ,maleudl loewb het ibdianrm coients wre'e onolkig ,ta uyo lwodu ees etaronltrClaa i(hg)Rt atipsSc Hepimsaseri

hello  What identifies that a cross-section is medulla vs midbrain vs pons? +4
kernicterusthefrog  @hello I like to pay attention to the Cerebral Aqueduct (diamond/spade shape seen mostly in Midbrain, and transitioning to 4th ventricle in rostral Pons), and then the shape and size of the 4th ventricle as you move down Pons to rostral&middle Medulla, and eventual closing and absence of fluid space at caudal Medulla. +11
hello  @kernicterusthefrog Thank you. +
mbourne  NGL, I thought the right side had the pathology lmao ty +20

 +5  (nbme20#23)
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4+CD cesll ettvaaci ls-elBc hihwc mofr leosflcli dna aucse eamntelngre fo ymhpl neo.ds hrTeer,eof in an ASID ianep,tt to enagerl hte mphly esno,d the +DC4 nfsndtiucyo tsum eb edreovs.l

breis  Yea i get that, but if the patients CD4 was ~35, how in the world did the CD4 count rise enough to stimulate B cell proliferation...? I don't get it +6
namira  The only thing i can think of is that: the cd4 count that is given was taken prior to having started the antiretroviral therapy. Since the question asks about "improved function", maybe its referring to the therapy actually being effective and its managed to increase cd4 count and function so as to be able to contribute to lymph node enlargement due to myco. avium +12
kamilia20  I though it transfer to a lymphoma,OMG +

 +3  (nbme20#16)
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pPlieicrn eoynrsS lusceNu fo hte genilamriT si alcoedt in het ,snoP as si eht ortoM irnmagleTi lcuNsue fo the .nsop sTih reitpaosnnte si lbabropy gdniael eorm iwht hte eipcnlPri nesryoS cuuNles.


 +2  (nbme20#7)
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nI idaotidn to HPT = esoolatcts vitatcyi = iecaenrsd uliac,cm tish orsnep udolc olsa eb eixgiihbtn mossmtyp fo EM.N1


 +15  (nbme20#25)
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Mtsnauoit ni 1LTT-M i(conihtarolydlM ndocede RANt ulicene 1)

A mmcono untatoim is 34A32.G nCa lstreu ni etuilmlp adronmticihol eecsciediifn and tadisecaso srderdsio. tI si tecsdioasa i:htw

  • doaiiorntlchM ohcyeeamltpoyhpan
  • ciaLtc ssiocdia
  • eSi-ekrktlo esedpios S(M)ELA

ESALM si a rear ramolintcidho dierrsod nnowk to etfcaf nmay rspta of eth o,bdy specillyea het rsuenvo mystse adn hte iab.rn oSmmypst of MSLAE enc:udli

  • treernuRc rsveee hehscaeda
  • luecMs wssekena y)ayhtomp(
  • Haneigr sols
  • kikleto-Sre isopsede iwht a lsos of sesn,ocsicsnuo rsz,seeiu nad orteh mplserob igfenacft hte vrneous etms.sy

eSco:ru a-ieL/opetgw1ih..wkipr/s/idi/Tntk:TM

j44n  i just saw that every tissue that was affected had a high 02/aTP requirement and mixed with the lactic acid that meant she wasnt using her electron transport chain so i picked the only answer that had mitochondria in it +1

 +4  (nbme20#43)
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uainlrMle nAiesges aka:( kyueisHtyrrRn-s-rkKoaaMtusee-a oSn)ymrde

eeUnodpdrvntmele of het Mleurnail tsysme eidnlga ot ciglntoena beceans fo the .aivgna uysaUll no iercvx or ertu.su

yaM neptsre sa °1 eaorhnmear ue(d ot a ckal of iernute tpovleeemnd) in faelmse iwht luylf odelvpdee °2 xaeuls recirasa.ccthsti ntiluanocF oervasi wlalo ofr narmlo ualexs hcactctrreaissi nda mroeonh s.leevl


 +5  (nbme20#35)
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neSlep os ehgu -- kolo lkei this rgil sah 2 rl.sevi


 +11  (nbme20#21)
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iCcheo A. lowud haev ebne rcotrce if ihst ttpaien asw ms.mmeoridoicnmuop Pre Fistr ,Aid f"I DC4 ;,l0&10t ilor.inadle.B:aF.nsngt tlrNpiuhceio lioanfmmIta.n

eoHevr,w as siht nptaeit ahs a encttempo imuemn sst,yme bzuz rodws aer saletelt grtioinecnz uarsomglna.

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 +




Subcomments ...

submitted by vi_capsule(13),
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NTH ,meecrnyeg Sdmoiu srNtorpueids.i inUlke hyridanlzea a clnaebad ovairtldsoa inve( = olairetr)

sympathetikey  Well then, I guess we should just forget about our old pals the Alpha-2 agonists. Good call. I didn't even see that this was hypertensive emergency. Dumb on my part. +  
zup  so yea clonidine would be used for hypertensive urgency, but this guy is over 180 (210) so they have to use something like hydralazine or nitroprusside both will increase cGMP +  
whoissaad  Drugs used to treat HTN emergency: Nitroprusside Labetolol Nicardipine Clevidpine Fenoldapam Clonidine +13  
lola915  Hydralazine actually vasodilates arteries>veins and Nitroprusside vasodilates arteries = veins. Both increase cGMP. +8  


submitted by haliburton(208),
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FE2 is lslaotianntra oetlinoga rcftoa ,2 hwhci is csreynaes rfo rpentoi hsse.snity

sympathetikey  I. Am. So. DUMB. +24  
nala_ula  same :( +2  
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +  


submitted by mcl(578),
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PCSO is adtesisoca thiw blnaomra orciodnptu of exs isedo,str icgilundn nufiycdtsno fo rgotsnee drniotcpuo adn spetrgno.reeo ichlaCnoyrl adlveeet veells fo gsoetren anc eusca arlendeotim yapir.ehaslp

ing/C/wmrwohn.t9ii7l1h:l9pmcs/cw.PsMnt9a/.5.3//vpbcet

meningitis  Why isnt it endometriosis? Could someone help me out on this? +  
meningitis  Sorry, I was confusing with higher risk for endometrial carcinoma. +  
vi_capsule  Estrogen is responsible for cyclical bleeding and pain associated with endometriosis hence progestin is a treatment modality. But estrogen isnt a risk factor for Endometriosis. Rather theres retrograde flow, metaplatic transformation etc theories are responsible for endometriosis. +  
sympathetikey  Tfw you get so thrown off by a picture that you don't read the question properly. +25  
hyperfukus  @meningitis idk if u still care lol but always go back to endometriosis=ectopic endometrial tissue outside of the uterus so you can rule it out since increased estrogen would cause you to have worsened endometriosis or a thicker one but not directly...you can see the clumps of the follicles in the ovaries if you look super close so that along with the presentation takes you to PCOS and anytime you don't have a baby or stay in the proliferative phase(estrogen phase) you get endometrial proliferation-->hyperplasia--->ultimately carcinoma +1  
lovebug  FA 2019, page 631 +  
lovebug  Other answer H)Meigs syndrome : triad of 1) ovarian fibroma, 2) ascites, 3) pleural effusion. “Pulling” sensation in groin. FA 2019, pg 632 +  


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It idsa ti was aatfl to alesm in oe,tur dna teh sqonetiu seakd aotub eilv obnr nfg.psifor Snice teh lmsae raent’ bgien norb ni het rtfsi ep,lac I adis 50% emslfea dna 0% el.ams

hungrybox  fuck i got baited +30  
jcrll  "live-born offspring" ← baited +21  
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. +3  
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 +2  
qball  Jail-baited +  


submitted by nosancuck(85),
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Yo ids B ogt NO ENNALRTI LFMEEA GNARSO

hyW ?a!td??

We be inolko at oeesomn with an RYS mrfo eerd Y m!eiyhcroDe eb a Y oimrech Heimo os heyt be inakm osem tTiess erntiinmeD Fotrca wichh I eb esur kmaes moes neic lil TNAI LEIANMULR ATRFOC os edy ntia got tath eelmFa alIternn acTtr u wkon wtha i eb nsyia

ndA sniec iwiznmm si ad LDAFUTE ythe lsit eb tetngi odes uspys lisp adn bessrtae

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by nosancuck(85),
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oY dis B gto ON ENNTLRIA FEMEAL AGSORN

hWy ??at!d?

We be inookl ta moenose with na SRY mofr eedr Y ycre !eDihom be a Y horemci omiHe os hyet eb akmin some iesstT tiDneinmre otFcar iwhch I eb reus emkas semo ncei lil ANTI UALNEILMR FAOTCR os dey tani got ttah melFea anntIerl rctTa u nwko htwa i eb yasni

nAd cneis iwzinmm si da DTLUAFE yeht lsti eb itnteg deos sypus lpis nad aetebssr

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


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Its’ atceu olahloc nosoicptnmu so tyfta hancge emor lye.lki eralCllu nliwlsge tecadinsi oilochcal isaeiptth hcwhi esriueqr cnrihoc oalhocl octimpsunon (eSe AF 0192 pg .85)3 tA eatls tsah’t the cloig I dsue to kcip ftayt ahc.egn

seagull  Seems like fatty change would require more than 1 weekend. I choose swelling since it's reversible and seems like something with a quick onset. +40  
nc1992  I think it's just a bad question. It should be "on weekends" +16  
uslme123  https://webpath.med.utah.edu/LIVEHTML/LIVER145.html +20  
uslme123  So his hepatocytes aren't dying ( ballon degeneration ) vs just damaged/increased FA synthesis due to increased NADH/citrate +  
sympathetikey  @seagull I agree! +  
et-tu-bromocriptine  It's not in pathoma, but I have it written in (so he or Dr. Ryan may have mentioned it) - Alcoholic hepatitis is generally seen in binge drinkers WITH A LONG HISTORY OF CONSUMPTION. +  
linwanrun1357  Do NOT think the answer of this question is right. Cell swelling make more sense! +1  
fkstpashls  some asshole in suspenders and a bowtie definitely wrote this q, as I've seen both acute swelling and fatty change be used to describe one episode of drinking. +12  
msw  short term ingestion of as much as 80gm of alcohol (six beers) over one to several days generally produces mild , reversible hepatic steatosis . from big robin 8th edition page 858. Basically to develop alcoholic hepatitis with cellular swelling etc you have to have sustained long term ingestion of alcohol while steatosis can develop with a single six cap . hope that helps . ps i got it wrong too . +1  
msw  six pack8 +  
mariame  After even moderate intake of alcohol, lipid droplets accumulate in hepatocytes increasing with amount and chronicity of alcohol intake. (...) Fatty change is completely reversible if there is abstention from further intake of alcohol. The swelling is caused by accumulation of fat, water and proteins. Therefore this will occur later. From big Robins 9th pg842. +  


submitted by neonem(549),
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ieMphnro is a mu pioido ntagsoi - noe dsevrea teefcf of siodpio is tams lelc neragndloiuta tath is dtEIne-inegendp. eeealsR of nhimaetis is niak to an aiapatlcnhcy acetnoir g;&-t- prsr,tiui t.ec

sympathetikey  Never had heard of that one. Just a good guess. Thanks! +  
yb_26  IgE-independent mast cell degranulation can also be caused by radiocontrast agents, some antibiotics (vancomycin) +6  
temmy  it was a u world question +  
mambaforstep  FA 2019 pg 400 +  
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +  
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +1  
mambaforstep  under mast cells "IgE-independent mast cell degran"! FA 2019 pg 400 +  
mumenrider4ever  Uworld QID 11852 talks about this Also FA 2020 pg. 408 (under mast cells) +  


submitted by drdoom(804),
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5,002 esstdtun ... ubt oyu find uto urgind uyro liiinat cseren ahtt 005 dareayl eahv eht adises.e So, rutotskei ohtes p.peeol Ttah seaevl 20,00 usnsdett woh ’dnot evah the .dseeasi

eOrv the osruec of 1 ra,ye yuo sdrvcieo 020 dnsustte edodelevp hte inetoifc.n usT:h

002 ewn csaes / ,0200 eoplpe how i’dndt vahe the eaidsse enwh ouy taesrtd oruy usytd = 01 etrecpn

Ty,kcir irctyk EMNB ...

sympathetikey  Ah, I see. Thank you! +  
niboonsh  Im mad at how simple this question actually is +7  
sahusema  Incidence is measured from those AT RISK. People with the disease are not considered to be at risk. So 2500 - 500 = 2000 people at-risk. Of those 2000, within one year 200 develop the disease. So 200/2000 of the at-risk population develop the disease. 20/2000 = 10% = incidence +3  
daddyusmle  fuck im retarded +2  


submitted by hungrybox(963),
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pislctsDay ievn ear a soceuprrr to n.amlemoa hyTe haev r,giraruel pltyad"c"ssi roeb.drs emeRemrb het "B" ni DBCA atdssn rof laeiugrrr rdeBso.r Nseuv amsne em.ol

ehrtO wasrens:

  • nhtaisscoa igacrisnn - ngDkeanri of snki iessadoatc hiwt pyTe II abidtese iultlmse

  • sabal clel amcnroica fo ksin - ,ayleRr fi veer ieaatmstez.ss loymCnmo faftesc ruppe .lpi

  • lebu nuevs - oeBdlulrceo- pyet fo mmcoon .leom gnBeni.

  • gdipemetn irshbcoere oistaersk - Stk"uc "on pr.aaenapce soMlyt nbe.nig fscAtfe elrdo lppoe.e

  • eot(N - uoy alusluy ees lnoy ne.o If mlltieup hrbeosirce seeotsakr rea ese,n ti aiindcets a IG imnygaclan - aak sreT"le-Léatr ng)is
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +25  
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +4  
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +2  
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2  
teepot123  fa 19 pg 473 +  
rockodude  just remember BS. basal cell upper, squamous cell lower +  


submitted by usmleuser007(370),
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suJt eidrlzea tath arnel lelc ramaoncic 'snti het crcreot nearsw c/b it idvndea eht eousvn tioclauinrc nda otn het leiaratr. BP mya not be teefdcaf as .mcuh if RCC erwe eht swaern nhte hnte eethr dulwo heva nbee meeda esprent rnda/o nrael .NTH

sympathetikey  Also, just thinking out loud, in the case of RCC, it's the kidney tissue that's dysplastic & moving, so technically the renal artery itself isn't dysplastic, right? +  
paperbackwriter  @usmleuser007 very good point regarding the venous vs arterial circulation that I neglected to consider! +  


submitted by cantaloupe5(72),
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rRcrenute kiedyn tsoens uosldh cliuedn hrayryprmoephdsaiti on yruo feaenii,ltrdf ocuple atth twhi isgtaomrna nad ’ureyo glonkoi at ENM .1 omsiLpa rea olas stiadcasoe hitw MNE 1.

sympathetikey  Yeah, I probably should have went with that. Just got thrown off, since I know that usually the serum calcium levels for someone with Calcium kidney stones is normal. +  
snoochi95  i understand the link to MEN 1, but why are we checking the calcium level? +  
cmun777  I feel like it's important to get a baseline of where the calcium is at for two reasons: 1. if the patient does indeed have MEN 1 it would be good to know if she has high calcium levels and possible Parathyroid etiology 2. You're putting the patient on a PPI which are known to decrease calcium levels and increase risk of osteoporosis for both these possible factors/concerns it would be good to see where calcium is currently at +5  
zevvyt  Couldn't a Pituatary tumor secrete ACTH, causing high cortisol? +2  
lola915  Patient has symptoms of a gastrinoma (Zollinger-Ellison Syndrome)- patients present with diarrhea, epigastric pain, duodenal and jejunal ulcers. Associated with MEN1 syndrome. +  


submitted by haliburton(208),
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inlk ot atonocr mdagiar

yotsubato  How is that NOT posterior to middle concha? bad question +10  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +3  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +3  


submitted by yo(77),
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'eehrty gntalki buota a nlonselrpae usnth uepoedrcr

hlolcm.inac/hrlenam0thsos-enae/h/neupyeti:/5l.litt4vpanrtdnc-easg/er9ldsslt-tt

hungrybox  be honest did u know that before looking it up +8  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +22  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +11  


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yM thgthuo csorsep saw tath mptu-ostarp englibde is lysluau tldreea ot hte ,sutrue nda humc fo eht iecvlp asrcvei si ueisdplp by arnechsb fo teh rnnteali iacli ar.yter

neonem  This sounds like a case of acute endometritis. In any case, uterus is supplied by uterine artery (branch of internal iliac artery) with collateral flow from ovarian artery (comes right off aorta). I don't think there are any branches of external iliac artery into the pelvis; it becomes femoral artery once it passes under inguinal ligament. +4  
tsl19  Here's a picture that I found helpful [Female Reproductive Tract arterial supply] (https://teachmeanatomy.info/wp-content/uploads/Blood-Supply-to-Female-Reproductive-Tract.jpg) +14  
sympathetikey  @tsl - Thank you! +  
step1soon  uworld Qid:11908 +  


submitted by dr.xx(142),
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ngoAm hte tosm pnteeavrl agiloocmeth msbnoaeiitral ni apnetsit ihtw meocorughtlia dssiorred era het inaeam fo hrcinoc daissee ),(ACD a ildm aiamen atth si rgleeaynl sytomamc,ptai adn iorn yfecicnied n.eamai

In iid-fcroiceneyn aen,aim hte CTIB wdoul rhighe naht –405400 mc/dgL escbaue orests oudwl be ol.w

Pnteitas ihwt RA yclosialanco eavh rucrneontc iron cnyecideif aemina nad DAC. nhWe ihts ,orsccu eth eimlnghoob veell asuulyl sdpro to oelbw 5.9 g,L/d and teh VMC si lsse athn 8.0

/-fhe/pdawpoia/ttctnitteiittoa:tuna.rhlcwcrgsimuetd-oortseo-tnmn.ssmoefoasth/hiwmo-a

sympathetikey  Got the right answer too, but man, that whole "1 month after starting therapy" almost threw me off. +1  
fkstpashls  all I do is put the wrong answer when I'm between two. Fuck +1  


submitted by yotsubato(963),
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She ahs enadrrB eSorliu Dsaeies epag 149 fo trfis adi 0219

sympathetikey  That's a genetic deficiency of GP1b -- not antibody related +8  
alexandramda  In Berard Soulierd you have a Defect in adhesion. decreases GpIb and decreased platelet-to-vWF adhesion. Labs: abnormal ristocetin test, large platelets. +  


submitted by hungrybox(963),
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aak ulpamla of eVtra ro teh aneoccitrapapeht tudc

hungrybox  tripped me up cause I didn't know the names :( +13  
sympathetikey  @hungrybox same +9  
angelaq11  omg, same here! I thought, well, I don't know of any duct that connects the pancreas to the liver, so...2nd part of the duodenum it is :'( :'( +7  
alimd  actually Ampulla of Vater is located in the 2nd part of the duodenum. +  
mtkilimanjaro  I think 2nd part of duodenum could be viable if the ampulla was not an option. The ampulla is way more localized/specific to this scenario +  


submitted by drdoom(804),
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cniVonsoacosittr nr(airgnwo of a uebt) lwli ucesa teh lwof erta to eeianrsc rhthoug atht ub,et wchhi edearcess rawtdrdl/oauia spe.rsrue heT stfear a fdiul vsome rhugtho a e,but teh sesl ro“du”atw forec it .tesrxe (hTsi si knnwo sa eht tniureV ffcete.)

hungrybox  not seeing how this is relevant +8  
sympathetikey  He's showing how A & B are incorrect @hungrybox +7  
nerdstewiegriffin  what a moron @hungrybox is !! +2  
leaf_house  MCAT flashbacks on this image +1  


submitted by sympathetikey(1248),
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di-leSlmefit saeedsi tnoef oilnofwlg a klueil-f ssllein ,eg( ivrla niy)fnM.coa eit eb rrtoheyphydi ealry in c,ursoe ofolewld by tidhoprsihmyyo mpe(renatn in %1~5 fo sace.)s erVy ednrte trhdoyi is enes.

sympathetikey  Short time course & tenderness was a tip for me. +8  
rainlad  Aka de Quervain's thyroiditis +  


submitted by sympathetikey(1248),
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• oPpem sDaseie yT(ep )
2    ○ kaLc of - masosyLol grbhenDainc ymEenz 6(1,α- 
dGouaielc)ss    ○ lpduuiB of ,61 nslkge
ia    ○ artsie:enn
otP        § .1 el
amriayCgod
sympathetikey  *1,4 glucosidase +3  


submitted by karljeon(111),
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tnimaVi E eecfnydiic esasuc icethmoyl ,mnaeia hcosnotst,yacia lsmuce knew,eass etrorpiso nlcuom nda eebollrrenciasp cttra tyd.nelonmeiia

karljeon  Can anyone explain why the serum lactate dehydrogenase (LDH) level was elevated? +  
asapdoc  Vitamin E is an antioxidant. Thus a deficiency can cause hemolytic anemia. +5  
sympathetikey  @karljeon Intravascular hemolysis = LDH release from RBCs +1  


submitted by medstruggle(12),
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hyW si het sernaw ongntialura“ ?stei”su I gtuhoht frtea 41 adys you vaeh a lfuly mderof rasc.

colonelred_  If you go back and look at the image you can see that it was highly vascular which is characteristic of granulation tissue. Scar tissue formation will be closer to 1 month, plus you will see lots of fibrosis on histology. +13  
sympathetikey  It's a bit misleading, for me, since you do see fibrosis intermixed with the granulation tissue, but granulation tissue was a better answer. +2  
haliburton  According to FA 2017: 3-14d: Macrophages, then granulation tissue at margins. 2wk to several months: Contracted scar complete. Dressler syndrome, HF, arrhythmias, true ventricular aneurysm (risk of mural thrombus). i'm getting pretty frustrated with NBME contradictions to FA, and FA omissions of content. this stuff is hard enough to get straight as it is. +1  
yotsubato  Thats cause the NBME exam writers read FA, then make questions not fit in with FA +6  
trichotillomaniac  This fits the timeline laid out in Pathoma! 1-3 wks = granulation tissue with plump fibroblasts, collagen, and blood vessels +10  
alimd  never look at the image in the beginning. They dont want you to success. Most of the time images are made to ditract +1  


submitted by neonem(549),
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Thsee are ogtu sracs.tyl I pespsou eht tesb wya to irtdtefnfeaei sith aces fomr oepgdustou is that het srlactys are psarh m;ap& -eedphesdlane and ton eddbspimohoa.r-h

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. +17  
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. +3  
nnp  what those yellow white nodules signify? +  
peqmd  In clinic gout is typically a clinical diagnosis. If you can treat w/ NSAIDs instead of aspirate you would do that. You would aspirate if you are considering septic arthritis so you can get culture. I don't think anyone aspirate for heck of it. +  
lowyield  @nnp, the yellow white nodules are tophus which is a sign of chronic gout, characterized histologically by aggregates of uric acid crystals, can show up as skin nodules most commonly on external ear, olecranon bursa or achilles tendon (pg 467 FA 2020) +  


submitted by seagull(1391),
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ta BMI 51 otn lony ahs seh reven dha a opirde tbu esh eernv hda a mela.

sympathetikey  You're on fire man lol +  
monkey  How the fuck is it not related to anorexia nervosa is beyond me. +2  
avarkey  the blind vaginal pouch points away from it being anorexia related +1  
j44n  Its actually a man, there's no DHT to to dev the external genitals. +1  
am4140  @monkey - with real anorexia, she wouldn’t necessarily have boobs either. If she’s got boobs she has the nutrition to develop boobs. That was my thought. +  


submitted by seagull(1391),
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Teh icstamens fo shti sotuqeni maed me oivmt obdo.l

One yad a ittpean ilwl okol em in hte seye nda s,ak Wr"eeh are ttesdpieri ebnkor do"w?n I will smlie at ehtm dna ,ays "teh tainnitlse oascum dan not hte umo.d"eund y'hTlle seiml bcak nad Il'l akwl aawy and ihtnk fo thsi omment sa I upjm mfro hte nwidwo.

sympathetikey  Too real. +2  
mcl  how do i upvote multiple times +15  
trichotillomaniac  I made an account solely so I could upvote this. +29  
dragon3  ty for the chuckle +6  
cinnapie  @trichotillomaniac Same +3  
thedeadly96  XD made my day! +  
hardly43  RIP legend @seagull +  
seagull  A legend never die +1  


submitted by m-ice(317),
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eTh nttieap dseen aeilcmd nnetotita emdaleytimi, whhci lmiaeesnit tinoagnbi a cruot odr,er ro rfirrnaengts .ehr A nurse deso otn eahv hte maes igatnrni nad slifnaoctuiqia sa a hy,sinpaci os it dulwo be naoatipeprirp to ska mhte ot einemxa eht aet.ptni Aknsig the sltpahoi cnlpaiah iaagn lduco be eiarpnti,proap nad lduwo atke eorm emt.i eohr,Teref het btse iopnto amgno hoest enigv si to kas eht tepnait if hse wlli lawol ihtw ehr dbnashu entrpes.

sympathetikey  Garbage question. +53  
masonkingcobra  So two men is better than one apparently +28  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gárbágé +4  
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? +12  
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 +9  
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. +14  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +25  
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 +5  
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 +5  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +11  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +10  
korahelqadam  All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +  
sars  This is a very fair question. I agree with sunshinesweetheart above. That is all. +  
wrongcareer69  Garbage question +  
alimd  well we should wait for the question "if a man shouts I CANT BREATHE with a police knee on his neck, what is your next step? Ans- wait 8 minutes." +1  


submitted by neonem(549),
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aFlglin on sdrtcettohue :nhad hiasdpco si stom cmmnoo eon to be cfrur,dtae ntleau is smot cnmoom to eb isdolcatde. nLutea asooindlitc cna ausce tueac lpacra tneuln s.deyrmno

nTihk fo eth mieomncn gSai"rhtt eLin oT ,iyPkn eerH eCsmo The Tmbh"u rof the enbso of eth p,mla wadrngi a ollftboa hsape tatgrnis lwoeb the mbtuh PMC jonit jcteaadn to eht d,arsiu etnh nomigv ot yoru mladei rsitw, adn ehnt cbka ot teh muht.b

pdociSh,a t,lneua ,rmtuqiretu isfirp,mo haemta, aipttae,c oazi,drept ma.zptruie The aenltu okols eikl s'ti lyprriosteo dscdoitela eehr.

sympathetikey  Yep. I didn't even look at the X-ray. +9  
dr.xx  loonies love lunate +2  
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +1  
wes79  i legit have no idea whats going on in that xray lol +9  
nbme4unme  X-ray confused the hell out of me, I was going to put lunate based on Q stem but ended up putting Pisiform because it looks like that's what's messed up in the photo? Should have ignored the picture haha. +1  
nwinkelmann  for @dr.xx, love your mnemonic. I added to it, or at least found an explanation on why it works. "loonies love lunate" and "loonies" are "dislocated" from reality. +3  
niboonsh  Some Lovers Try Positions That They Cant Handle +9  
vsn001  ngl if scaphoid was an option - would've sprung at that real quick -> thanks for teaching me the importance of knowing to look for dislocation vs fracture :D +  
regularstudent  Ahh, the classic "left hand" x-ray but actual fracture of "right hand" NBME tactic +  
sars  I think the x-ray is showing the lunate protruding out of the palmar side. Imagine the situation where you are falling and using your hand to stop the fall. Your lunate will dislocate forward as the rest of the carpal bones recoil back, hence why it protrudes through the palmar side. Thats why it causes an acute carpal tunnel syndrome. +  


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nTahk yuo NBEM for eht hghi iutylqa tsrpiu.ce It ameks htese esxma ssesrt refe adn njely.boea

sympathetikey  Feels bad man. +3  
zoggybiscuits  Those Sclera sure look blue. wow. +18  
yotsubato  the same girl shows up on so many NBME exams its not even funny. Its just like that poor kidney that's cut in half that shows up in all kidney questions. +12  
aneurysmclip  I turned my brightness up and down 2 times to make sure it wasn't my brightness messing with the sclera. I'm declaring it, NBME stands for "Naturally Bad at Making Exams" . +6  
peqmd  $60 a pop and no competitors...That's what happen when there's a monopoly. +4  
peqmd  Actually they used their best software to generate images. You might have heard it before, it's called MS Paint. Quite legendary. +6  
feochromocytoma  It feels like they cranked up the contrast and saturation on a normal eye to make it look "blue"... +5  
rockodude  everyone hates on nbme, but they're showing you a picture zoomed in of her eyes and she has a history of multiple fractures/bad wound healing at the age of 4, I feel like OI should at least be a consideration based on the overall clinical picture +1  
feochromocytoma  Yeah I got it right, it's just funny that they don't use higher quality pictures for the exam +1  
djeffs1  that is clearly a malar rash... oh wait nvm just pixellation +2  


submitted by neonem(549),
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hsTi si taecu miylohcte uotnnarfsis ,oenacrit a eytp II thyetvisyrspenii ewerh pfder-ermo IMg adneisitbo idnb to tpmeiiclnaob OBA nenistag no nordo ,CRsB hichw aussce ncasutirrlava l.shemyois Rh atilnoiypcitbm,i ielk oeedlnor_lc das,i osmec remo iton alyp twih lp-mhoaitticybRi fo egrnpynac dna ti is due ot IgG oibned,itsa iwhhc rmoe oftne ceasu saarrcuaxevlt shslomyei csine inlspec aesarpmhgco have ohtes a--FamRcgm orterscpe to ibnd tvehreaw IgG sah htc.aug uaxsErvcalart osn'dte ceuas ttha onipstyeon,h verf,e nkalf anpi diascstoea wiht gherubonamiiol inecs het aahmsecgrpo ohdl no to eth eaedgrdd CsBR and oecnrvt ti to ,ediinilvrb hhiwc nca flaesy be exedtcer yb the r.ivel

mousie  Could you help me with understanding why this isn't a Type I HSR? I understand that ABO incompatibility is Type II HSR but I don't know how to tell the difference between a patient who is IgA deficient and having a Type I Reaction to an infusion vs ABO incompatibility .... +8  
sympathetikey  @mousie - https://imgur.com/QH5rCEX Basically, think of Type 1 HS like a normal allergic reaction (itchy, wheezing, etc.). Whereas, with ABO incompatibility you get the question's presentation. +7  
medpsychosis  When it comes to Acute hemolytic transfusion reactions, they are Type II hypersensitivity and divided into Intravascular (ABO) and Extravascular (host Ab against foreign antigen on donor RBC). The differentiating factor between them is simple. Intravascular (ABO) will present with hemoglobinuria alongside all the other common symptoms (fever,hypotension, tachypnea etc.) Extravascular hemolysis will stand out with Jaundice as one of the presenting symptoms. Hope this helps! +5  
cassdawg  Also just to add: Rh incompatibility causes a delayed hemolytic transfusion reaction, this reaction was immediate so it is indicative more of the ABO blood group incompatibility (FA2020 p114 has all the blood transfusion reactions) +1  


submitted by ameanolacid(24),
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nCd'lout be LSA c/b he had eysonsr Avonne.emvLt.iSl. si ynsdilictt yonl otmr.o tNo yoirgniaSmyle (hichw si eurpp strtiimexee esosryn neth morto tarel n)o bc I ueamdss by the gdwnoir hatt lla 4 tmeisxeteir reew .nloiedvv Obv otn sioann,Psrk nad ont iopol cb igaan, he ahs rmtoo + nyrs.ose

sympathetikey  Probably in part due to early age presentation, but I hear you +5  
wowo  FA2019 p518 - process of elim for other spinal cord lesions +2  
cbreland  Also syringomyelia wouldn't have a position sense issue +  


submitted by sattanki(68),
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Melusc inap + rbltiaproei eaemd si a laisscc nsprtonateei orf eanlolticrh saiirsp.l sBet siogasind fro tshi si a eusmcl boiys,p as hte wryom kiles to gohtnau hwinit eth seulscm.

sympathetikey  That's what you get for killing polar bears. +74  
dr.xx  That's what you get for not cooking them well. +4  
charcot_bouchard  Theres nothing called "well cooked polar bear meat" +2  


submitted by lsmarshall(392),
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PAC sroket can uesac "osniopagoaspr" ciwhh si the bintiylai ot cneorzgei iamiflar ces.fa sCadue yb raaielltb eosinsl of ailvsu siincsaooat arse,a hwchi rae tisuatde ni eht orefrnii ocpottlepmciaior extcro ffr(usiom g).rsuy heT ilibayt ot nmae traps fo het feac .,e(.g onse, tumoh) or yetdnifi lundviiisda by orhet eusc ..(ge, ,oinlthgc sve)oci is eltf actn.it

uotiWht inwongk ,htat nbermrimgee capiiltoc oebl si onveldvi ni i'svual stf'fu ,lrabdyo ucilingdn amgei oicssgrnep and hits tenptia is vhaing esissu twih sdnnteinrdgua egmais loudhs be ouheng to gte ot teh san.rew

gonyyong  Lol I guessed it exactly because of that +3  
sympathetikey  Never heard of that one before. Thanks! +1  
karthvee  This is not prosopagnosia, but instead a case of apperceptive agnosia. Wiki: "...patients are more effective at naming two attributes from a single object than they are able to name one attribute on each of the two superimposed objects. In addition they are still able to describe objects in detail and recognize objects by touch." Although, lesions tend to be in the occipito-parietal area so PCA again is the answer! +3  
misterdoctor69  I actually think it's both prosopagnosia AND apperceptive agnosia. She is neither able to recognize her mother's FACE nor is she able to recognize objects w/o the help of other senses (apperceptive agnosia) +  
nifty95  Yea couldn't remember the exact name but I just thought of three pathways (visual, somatosensation, and auditory) all converging somewhere/processor (probably somewhere in the temporal lobe...hippocampus?). Beyond the point, the pathways converge to an area which culminates in recognition. Cut off one of the routes (in this case visual), the other two will still work. How is visual cut off? By the PCA not supplying the area leading to neuronal death resulting in varying loss of visual function depending on the area in the occipital lobe. +1  


submitted by lsmarshall(392),
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"mososeDme M(aucal arehesd)n - A eeoll-lccl-t oceniontnc tath poisevrd trcsurluta pusport tiwh deeeiamitntr fsinatl,me plrctuariyal ni steiuss ttha ogruden cmalecnhia tsrses ,..(ge ,kisn caristg iet,uss )badrde.l Coectnns anittsrokecye in eth aurmstt iomnpuss fo hte iesmdp.e"ir - AOMSBS

sympathetikey  This is why I was looking for some answer indicating keratinocytes in the stratum spinosum...instead they just gave a bunch of bs choices. +29  
roygbiv  I'm confused because I also know that S. aureus cleaves desmoglein in the stratum granulosum, so why is it specifically this answer? +2  
duat98  desomosomes connects cells to cells. hemidesmosome connects cells to basement membrane. +2  
medguru2295  I think what this is really asking is can you tell Pemphigus Vulgaris from Bullous Pemphigoid Vulgaris (question)- Attack on DESMOSOMES- this separates some keratinocytes from others (ie some in basal layer from ones above). Pemphigoid- attack on HEMIDESMOSOMES- this means separation of the keratinocytes from the basement membrane. +2  


submitted by medstruggle(12),
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yhW si it nto nvoaari lilefloc clesl? I httuogh het aelmef goanal of tlriSeo dna geLdiy is rlosa/teacnghau e.lcls

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +7  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +4  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +11  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +3  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +37  
mcl  But seriously though, pathology outlines says sertoli-leydig tumor "may be suspected clinically in a young patient presenting with a combination of virilization, elevated testosterone levels and ovarian / pelvic mass on imaging studies." As for follicle cell tumors, granulosa cell tumors usually occur in adults and would cause elevated levels of estrogens. Theca cell tumor would also primarily produce estrogens. Putting the links at the end since idk if they're gonna turn out right lol Link pathology outlines for sertoli leydig granulosa cell tumor theca cell tumor +12  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +5  
medpsychosis  So after doing some intense research, UPtoDate, PubMed, an intense literature review on the topic I have come to the final conclusion that...... ...... ...... ...... Wait for it.... ..... ..... Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +9  
charcot_bouchard  Hello, i just want to add that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
giggidy  Hold up, so I'm confused - I read all the posts above but I still am unsure - are sertoli-leydig cells notorious for producing androgen? +4  
subclaviansteele  Hold the phone.....Females can get sertoli leydig cell tumors which are notorious for producing androgen? TIL TL;DR - Females can get sertoli leydig cell tumors = high androgens +  
cinnapie  I just found a recent study on PubMed saying "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +2  
youssefa  Hahahahaha ya'll just bored +9  
water  Bored? you wouldn't think so if you knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
nbmehelp  I dont get it +  
redvelvet  how don't you get it that females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen? +1  
drmomo  what if this means..... females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen +  
sunshinesweetheart  hahahaha this made my day #futurephysicians #lowkeyidiots +  
sunshinesweetheart  @medstruggle look up placental aromatase deficiency (p. 625 FA 2019), it would have a different presentation +  
deathbystep1  i am sure i would ace STEP 1 if i only knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
noplanb  Wait... I might actually never forget this now lol +3  
drmohandes  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +1  
lilmonkey  Don't forget that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! You're welcome! +  
drpatinoire  Now I get it that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens. Thank you very much.. So why choose Sertoli-Leydig cell tumor again? +  
dr_ligma  The reason is because females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! This is easy to remember, as you can remember it through the simple mnemonic "FCGSLCTWANFPLOA" which stands for "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen!" +17  
minion7  after receiving a f*king score..... this post made me smile and thanks to the statement-- females can get sertoli-leydig cell tumours, which are notorious for producing lots of androgen! +1  
djtallahassee  My worthless self put adrenal zona fasciculate but now I will never forget that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
medguru2295  Wait..... so can females get Sertoli Leydig cells that produce androgens then?????? +  
peqmd  Going to snapshot this to my anki deck card: "females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of {{c1::androgens}}" +1  
paperbackwriter  Watch me f*ck up the fact that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgens on the real deal. +2  
alexxxx30  just made sure to add to my notes "Females can get sertoli leydig cell tumors, which are notorious for producing lots of androgens" +2  
peridot  I also just wanna add that if you look on in FA on p.696969, you'll see that they'll mention "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +  
mbate4  According to the literature [lol] females can get sertoli-leydig cell tumors, which are notorious for producing lots of antigens +  
drdoom  the tradition lives on +1  
jamaicabliz  Wait... so for clarification, is it that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen? Or that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen?? HELP +  
abkapoor  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen sorry for bad Englesh +  
faus305  Sertoli-leydig cells are notorious for producing lots of androgens, females can get these. +  
djeffs1  the fact that a bunch of medstudents can get so weird about how females can get sertoli-leydig cell tumors: notorious for producing lots of androgens- just made my week!! I love you guys +  


submitted by sympathetikey(1248),
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tePytr dowstiarfrtahrg, ubt a oodg endirrem htat flesyomiobisr anc eacus na dgelnear eelsnp.

sympathetikey  Due to extramedullary hematopoesis +22  
zoggybiscuits  I thought it was spleen but the fact that hematocrit was 24% 4 HOURs later made me think otherwise. It was my understanding that the spleen would bleed you out quick! +  
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +1  
peqmd  Spleen is most commonly ruptured in blunt trauma so along with myelofibrosis and being kicked on the left side it's just asking to be ruptured +2  
limberry  @need_answers the bladder is intraperitoneal, not retro +  
limberry  bladder is sub*peritoneal, sorry +  


submitted by lsmarshall(392),
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Ptneita sah nipaS aibifd luoatcc hhciw si a ealurn bteu tfedec el(irfua fo sfnuio fo eht usnreope)ro. lcSetoorsme are the patr of heca meisot in a ratveerteb bmyero ivgnig isre to nobe or orteh lkelates .usitse nceiS a tapr of tsih neastt'ip isnpa abfiid idcldenu c"easbnse of snosupi rseopcs" hnte a somotrcele was .elvodniv wnKingo ttah neural beut tdsfeec era na ussie iwht uofsni hsould be gehuno ot tge to teh ihtrg sne.war

If teh nrcooodth lifaed to eedolpv hetn teh rentie CSN lduwo ton dveelop sa het ocdhtrono eudincs fatimoonr fo eaulrn ptale.

If eht raenul ubet ildafe to pedelvo tenh eth elhow CSN lwodu not veha edlvod.eep

kYlo cas is lneetrivar ot hist inp.teat

hWne nearul tcrse cell ti sha drefentfi csoutome in nfetfidre esi.sust aelruFi of lurnea tcsre to aimgetr ni erath can asceu nrinpsooaTtsi of etrag s,lsesve Togrtaley of aFot,ll ro etsitrPnes tsrcuun itaorss.rue raeiFul fo auenrl tessrc to maergit ni GI cna ausce shpcurnirgsH deisaes iencgnol(ta alec.mo)gon erarTehc ilolsnC dnrSyome cna coucr nweh nuelra resct celsl alfi to ietgmar ntoi 1st narehlyagp h.car eNralu uebt edscetf sah noghnti ot od htwi uefrlai fo erauln rtecs giimraotn uthhog.

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +12  
hungrybox  Fuck I picked "Formation of neural tube" but yea that makes sense... that would affect the whole CNS +3  
ruready4this  I also never heard of sclerotomes and I chose that and then switched it to formation of the neural tube because I thought that was close enough ugh close enough is not the right answer +  


submitted by sheesher(-1),
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Im' usnaigms ttah ucaeesb boatniacreb is dedere,acs ihts sha ot eb ltabiomce isiaodcs easduc yb oaizlaeeadt?cm eMdssi hist notqesui seeuabc I saw konolgi rof tialboemc ocssiadi aisnecer(d )tbnaeacobri dseuca by a opol .rtdcuei.i.

sympathetikey  I don't think so. I know that K+ levels decrease with laxative use, due to dehydration, which activates the RAAS, which increased aldosterone, which cause Na+ re-absorption and K+ wasting. Aldosterone also causes the alpha intercalated cells to secrete more H+ into the urine, which causes a serum alkalosis. Therefore, in order to correct that, bicarb re-absorption decreases in the kidneys, which brings the pH closer to normal. As far as Chloride, I guess that must be re-absorbed with Na+ due to it being negatively charged (?). That's the one thing I'm not sure about. +5  
aknemu  I think what they are getting at is that it is Diarrhea--> Non-anion gap metabolic acidosis (HARDASS). This would mean that HCO3- would be low and chloride would be high (in non-anion gap acidosis the chloride increases and that's why you don't have a gap). +5  
2zanzibar  Normally, stool's electrolyte content primarily consists of bicarb, potassium, and sodium. Since the colon reclaims sodium in exchange for potassium, the potassium content of stool is usually double that of sodium. Most of our bicarb loss in stool actually occurs through the loss of organic acid anions, i.e. bicarb that's been titrated by the organic acids formed by bacterial fermentation in the colon (e.g. lactic acid). *Bottom line: our stool is alkaline, with mostly bicarb and potassium.* Diarrhea is a cause of *NON-anion gap metabolic acidosis* due to bicarb loss in the stool. We aren't adding any acids to the mix -- we're simply losing anions -- which is why our anion gap remains normal. Potassium goes along for the ride and we end up with *hypokalemic* metabolic acidosis. And because we're losing anions, we want to compensate by *increasing retention of Cl-*. **Anion gap = Na+ - [Cl- + HCO3-]** +3  
rainlad  another observation to support this: The patient's RR is 30/min, which demonstrates a compensatory respiratory alkalosis, in response to the non-anion gap metabolic acidosis +1  


submitted by seagull(1391),
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hw"y d'not uoy sotp atwh urye'o noidg acsbuee i'st liuusoi.c"dr -ulcat-a waensr

sympathetikey  Mam--mam. Put down the egg, mam. +16  
woodenspooninmymouth  I spent sometime in Guatemala last year, and someone told me that the egg thing is uncommon. What is common is giving their children a small gold bracelet. The bracelet is supposed to prevent the evil eye, dunno how. +1  
arcanumm  I think this is a terrible question, but "not a lot" of evidence to support what she was doing is what I had picked. I realize now that is a lie which must be why it is wrong: there is NO evidence to support it. +  


submitted by mousie(209),
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pelh whti shti neo e.a..psel. is hsit cesebua he hsa yTrGeph NAD eoCrllsehto NDA .orylimnscoch. nyol LL neciecyfid olpwud axnlei lla fo etesh ifnn?gdis I csoeh DLL R nyeifecdci cuebaes I segsu I gthhuo it duowl asecu lla fo hmte to arneiecs tbu si this epyt fo ydfieccein nloy eacosstaid whti hihg ?DLL

sympathetikey  First off, do yourself a favor and check this out - https://www.youtube.com/watch?v=NJYNf-Jcclo The LDL receptor is found on peripheral tissues. It recognizes B100 on LDL, IDL, and VLDL (secreted from the liver). Therefore, an issue with that would cause an increase in those, but mainly LDL. Since in this question we see that Triglycerides and Chylomicrons are elevated, that points towards a different problem. That problem is in the Lipoprotein Lipase receptor. This is the receptor that allows tissues to degrade TGs in Chylomicrons. So, if it's not working, you get increased TGs and Chylomicrons. Additionally, you get eruptive xanthomas, which are the yellow white papules the question refers to. +8  
davidw  There is much easier way go to page 94 in first aid. This kid has Type 1 Hyper-Chylomicronemia which is I) Increased Chylomicrons, Increase TG and Increased Cholesterol. It can be either Lipoprotein Lipase or Apolipoprotein CII Deficiency +12  
bulgaine  The video sympathetikey referred to only mentions pancreatitis in type IV but according to page 94 of FA 2019 it is also present in type I Hyper-chylomicronemia which is what the question stem is referring to with the abdominal pain, vomiting and increased amylase activity +  
dentist  thats not the only difference in that video.... +  
paulkarr  Pixorize has a set of videos on all the lipid disorders that made it a breeze to answer. Pixorize is basically sketchy but for biochem and other basic science subjects. +2  
futurelatinadr  Pancreatitis was a huge clue for me to think of hyperchylomicronemia +  


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tePniat is uctrern ,erafdsbte- os we nca aenitilme corsteuf e(cftorsu is nduof ni oyneh nda ftiusr dna eosm mr,fauol but nto in rtsabe i)lmk. etPaint sha dnuricge ssaceuntsb but no seuogcl ni teh niu,re os eh stmu osme lognn-soeuc srag.u yM faitredelfni for geundrci onconlus-eg guassr ni eth nirue si dsrredois soectruf etmboasilm ro tlecgaaos mmbl.iteaos eW hvae leedinitam fr,stouce so thta aeelsv us ihtw scleaogkantai ceniyeifdc or clcsasi asmlgcta.eoai

sympathetikey  & Galactokinase deficiency would be much milder. +6  
smc213  Big was soybean formula not giving any issues. Soy-milk can be used as a substitute formula in patients with Classic Galactosemia since it contains sucrose (->fructose and glucose). +1  
oslerweberenu  Why can't this be glucose 6 phosphatase deficiency Confused me +  
almondbreeze  @oslerweberenu G6PD - increased RBC susceptibility to oxidant stress (eg, sulfa drugs, antimalarials, infections, fava beans) -> hemolysis; has nothing to do with presence of reducing sugar +1  
makinallkindzofgainz  @almondbreeze; Glucose-6-phosphatase deficiency is Von Gierke disease, they are not referring to G6PD deficiency (an entirely seperate disease) +6  


submitted by seagull(1391),
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'im sitll ceicovdnn tshi is rbiatlier bwelo r.yoenmsd nhgaeC my .mdni

mousie  haha I picked this too bc she's 44.... isn't celiac something that would present much younger?? but I don't think IBS would cause an iron deficiency anemia is the hint they were trying to give us. +2  
sympathetikey  If it was IBS, they would have mentioned something about them having abdominal pain, different stool frequency, and then relief after defecation, me thinks. +3  
aknemu  I was between celiac sprue and IBS but what pushed me towards celiac's was a few things: 1. The Iron deficency anemia (I think that would be unlikely in IBS) 2. Steatorrhea (which would also be unlikley in IBS) 3. Osteopenia- I was think vitamin D deficency 4. Lack of a psychiatric history +5  
catch-22  IBS is a diagnosis of exclusion. If you haven't excluded Celiac (and this can't be excluded based on epidemiology alone), you can't diagnose IBS. +12  
arcanumm  I think you may have confused it with IBD, IBS would not present like this. +2  


submitted by jrod77(27),
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I thikn ehty tgmhi eb scbidigrne ionn.naa..tg ure.s TA2X is eiplssroben ofr tptleale rgotsoga,igane it aym be urbciinntgto to iort,smosbh shut chiiaems to the iccrdaa .usiest

sympathetikey  Agreed. I'm pissed though because PGE2 mediates pain, which is why I picked it. +33  
he.sanchez14  If im not mistaken, the question describes unstable angina. Unstable angina is due to thrombosis with incomplete occlusion. So, yes TXA2 is responsible for the thrombus that is causing the symptoms in this patient. I'm also pissed because I also went straight for the PGE2 +5  
vik  hahah, seems like all in same boat like me +  
yb_26  thromboxane A2 is also vasoconstrictor, so my thoughts were about vasospastic angina +4  
youssefa  Went for PGE2 ... shit +  
need_answers  I went for leukotriene B4, what the hell was I doing....SHIT +12  
hopsalong  I picked Leukotrine B4 thinking that the neutrophil infiltration was the source of the pain, seems wrong lol. +  
bballhandler11  Sometimes it helps me to think of it in a general, non med school textbook kind of way. When answering, I narrowed it down to PGE2 and TXA2 as well. Then I asked myself, if someone is experiencing chest pain, would I recommend Aspirin or Advil? That's helped on a few over the counter pharm questions. +7  
ususmle  same here I M PISSED PGE2 +3  
krewfoo99  Maybe PGE2 isint the answer because it mediates pain and fever during episodes of acute inflammation? Thus making TXA2 more likely. +2  
djtallahassee  ditto on the looked at it for 2 seconds and went PGE2 +1  


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A brslomoant si na arumeimt B,CR so 'ist elvadtee in taests fo aeecirnsd he.opiasteismo

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +57  
someduck3  The term "Normoblast" isn't even in first aid. +35  
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +18  
tinydoc  I wish they would stop making it so every other question I know the answer and I can't find it among the answer choices because they decided to use some medical thesaurus on us. +17  
qball  Metamyelocytes = Precursor to neutrophils Siderophages = hemosiderin-containing macrophage aka heart failure cells +8  
llamastep1  Theres a UWorld question about Parvovirus B19 that mentions "giant pronormoblasts" that helped me make the connection +5  
fexx  I got it right but would it hurt them to put RBCs? Medicine is hard as it is. No need to make the exams more complicated. I doubt my pt is ever going to as me if his/ her normoblasts are going to increase if they go hiking in the mountains +5  
mdmikek89  Even in you didn't know what Normoblast means, it cant be any of the other answers. TEST TAKIN' SKILLZ BROS +  
nerdstewiegriffin  I can guarantee you this Q was written by some sadistic PhD examiner +9  


submitted by ferrero(40),
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A yrev liaimrs qutseion I ehva enes ni sQankb wlli ksa hyw a atetipn htiw rtgih trhae uiralef oeds not pledveo dmaee and teh nawers si acresndie mychtplai arginaed. I tog shti toiuqnes norgw nrilgioyla ubeasec I naeswder nolag tshi eiln of orineasng ubt I tnhki in shti csae it lla has ot do hitw RWHEE het atrxe seserurp is gnmcoi rofm. In ihst quetisno eth tp has iltoicsda pioheesyrtnn os oyu cna kithn bouta the rerspsue sa gmionc awr"frdo" so icgsirtntnoc iayaplerlprc snsecitrhp can eeprnvt an caeesrin ni sersurep ni het llriacapy bed. orewHve orf hritg threa furelai isth eaxtr dflui si ogmcin from het SPITEOPO nidetciro dcas(bwrak fomr the gtrhi )ahret nad ignctncstori caprlylpaeir snhpseictr cna od ngohnit n(o opoiespt sied fo aycalilrp db)e - hte ynlo ayw to ptnever adeem is to csieenar hyliptmac aaerdign.

seagull  The question clearly lead us to think about Osmotic pressure by talking about protein and urine. I wonder how many people used that line of reasoning (like myself)? +15  
mousie  Great explanation, I chose lymphatic drainage for the same reasoning (similar Q on different bank) +5  
sympathetikey  My reasoning was much more simplistic (maybe too simple) but in my mind, systolic BP is determined by Cardiac Output and diastolic BP is determined by arterioles. Therefore, what comes before the capillary and regulates resistance? Arterioles. That's why I said that pre-capillary resistance. +31  
cr  the main difference between the 2 cases is that in this case the patient has high BP +1  
link981  So in kindergarten language the question is essentially asking how high pressure in the arterial system is NOT transmitted to the venous system (which is where EDEMA develops). But you know they have to add all this info to try confuse a basic principle and make you second guess yourself. (Got it wrong by the way) because of what @ferrero said of Qbank questions. +6  
hello  @ferrero what are you talking about? lymphatic drainage is the wrong answer... +1  
hello  ok never mind. i got it. hard to understand b/c it was a big block of text. +2  
asteroides  I think they may be talking about the myogenic compensatory mechanism: https://www.ncbi.nlm.nih.gov/books/NBK53445/figure/fig4.1/?report=objectonly "Increased arterial or venous pressure also induces myogenic constriction of arterioles and precapillary sphincters, which raises arteriolar resistance (thereby minimizing the increase in capillary pressure) and reduces the microvascular surface area available for fluid exchange. For example, because vascular smooth muscle in arterial and arteriolar walls contracts when exposed to elevated intravascular pressures, this myogenic response increases precapillary resistance and protects capillaries from a concomitant rise in their intravascular pressure." +3  


submitted by seagull(1391),
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htWa a rbrleeti repuc.ti heTy ehty oevercd pu rpta of it hwti senl.i WTF

sympathetikey  Agreed. +10  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +  


submitted by seagull(1391),
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isTh teaitpn is trgpiipn sal.bl ttereB od a rdgu nescre hwhic msees uo.bovis

sympathetikey  When the answer is so obvious that you pick a stupid answer instead of it. DOH +37  
jooceman739  Funny thing I noticed is "he is alert and cooperative. He appears to be in pain" So he was so high that he was alert and cooperative during the basal ganglia hemorrhage +5  
yotsubato  @sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that. +1  
yogi  probably the "drug" have to be a stimulant or a hallucinogen which causes HTN & Tachycardia. +2  
charcot_bouchard  Lol. I got the right answer but took long time +  
goodkarmaonly  The patient's B.P. and pulse are raised + Bilateral dilated pupils = Most likely use of a stimulant Thats how I reasoned it anyways +  
llamastep1  Bilateraly messed up pupils = Drugs (most of the time) +  
targetmle  why is there basal ganglia hemorrhage? +  
dul071  Wait! doesn't it take like a week or two to get the results back!?!? i chose to measure catecholamine levels because that may be more timely. but clearly i'm wrong +1  
usmile1  basal ganglia hemorrhage is an intraparenchymal hemorrhage secondary to hypertension. according to FA, this occurs most commonly at the Basal Ganglia (FA19 pg 501) +1  


submitted by seagull(1391),
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Tshi is a nacip ac.ktat voitpHneatylnire porsd 2CpO gedianl to a yarstiproer .ssolaalik op2 si lirytavele tfcnaeeufd no(t'd ska me )woh?

sympathetikey  Yeah haha I had the same conundrum. +  
sajaqua1  If she's breathing deep as she breathes fast, then oxygen is still reaching the alveoli , so arterial pO2 would not be effected. +21  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +2  
soph  Maybe Po2 is unaffected bc its perfusion (blood) limited not difusion limited (under normal circumstances). +2  
charcot_bouchard  PErioral tingling- due to transient hypocalcemia induced by resp alkalosis. +1  
rainlad  I believe CO2 diffuses ~20x faster than O2, so increases in her respiratory rate have more effect on her PCO2 than her PO2 +1  
usmile1  adding onto Charcot_bouchards comment, I found this: Respiratory alkalosis secondary to hyperventilation is probably the most common cause of acute ionised hypocalcaemia. Binding between calcium and protein is enhanced when serum pH increases, resulting in decreased ionised calcium. Respiratory alkalosis can induce secondary hypocalcaemia that may cause cardiac arrhythmias, conduction abnormalities and various somatic symptoms such as paraesthesia, PErioral numbness, hyperreflexia, convulsive disorders, muscle spasm and tetany. https://www.sciencedirect.com/science/article/pii/S1110184913000615 +3  


submitted by sympathetikey(1248),
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ats'hT a nwe ..e..no

p/gkicin.r.wAwril_/n:dypcsiaothseso//ipeeeetks

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 sympathetikey(1248),
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I ees tawh trhe'ey sginya th(is wsa ym nosdce iecoch) but ta het msea temi I fele ikel a ukabcp of olbdo uowld cvtaitae eht ertsoeabopcrr and esacu cerddesea epmyttacish taiitycv to het AS &;amp VA endo.

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


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hTe etniapt ahs ANT ycadreosn to lnear hs.mceiia uDe to lutarub e,isorcns teh iatpten wlil ehav an evdleaet Nea.F The ea'stpnit nueir liwl loas be ,ltidue but hist lwli be edlfetecr by eht wlo einur oyl,otaisml nto eht eFNa

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 sympathetikey(1248),
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oothesxDmanee erusesspps ACTH = Putytriai taohaoeemnemoxsdAD ne iflsa to rpspeuss CTHA = ctoipEc CTAH xe( - lmalS leCl uLgn aeCcnr)

sympathetikey  *ACTH +  
meningitis  If im not mistaken, Dexamethosone also fails to suppress ACTH = Adrenal Gland Adenoma +1  
therealloureed  I think an adrenal gland tumor would have low/undetectable ACTH? aka no dex suppression +13  
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +12  


submitted by sympathetikey(1248),
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Per FA (p.g 366:) nonigecrCn batser ca..ncr.e

"cmioiptAnliafxisen/pservoroe fo noet se/sorpeeegnrtrog prroectse ro Br2b-ec 2(HER, aEG Fn reoetpcr) is mmn;ooc RE ,⊝ RP ⊝, nnEuaH/2dR e ⊝ rfom eomr eggr.easv"is

sympathetikey  FA 2019 +4  
meningitis  Why others not it: Anticipation: Trinucleotide repeats; CAG (Huntington), CTG (Myotonic dyst), GAA (ataxia telangiectasia), CGG(Fragile X) Chromosomal rearrangement: Many but can think of Trisomy 21, BCR-Abl, etc Imprinting: Prader willi, angelman Loss of heterozygosity: loss of a single parent's contribution to part of its genome. A common occurrence in cancer, it often indicates the presence of tumor suppressor gene in the lost region. +1  
kai  trinucleotide repeats are not associated with breast cancer Neither are chromosomal rearrangements BRCA1,2 tumor supressor genes are associated with breast cancer, which is why I chose E, but I guess I should have bought the new First Aid.......... +  
charcot_bouchard  GAA is Freidrich Ataxia +4  
tulsigabbard  So is the amplification of the receptors unrelated to BRCA 1, 2? I'm still stuck on this as Sketchy states that breast cancer falls under the "two-hit" model. +  
tallerthanmymom  @tulsigabbard I think one of the keys here is the question stem; " what is the most likely cause of the OVERexpression in this pts tumor cells?" --> I think that the "2-Hit" model would lead to UNDERexpression of a tumor suppression gene rather than overexpression. Whereas amplification would cause OVERexpression of the HER2/estrogen and progesterone receptors. But, I don't think that amplification would be the answer if they were asking about a triple negative cancer. +1  
tallerthanmymom  Also this is on page 632 of FA 2018 for those using that version +  
tulsigabbard  @tallerthanmymom - thank you! +  
drzed  I can understand why @tulsigabbard dropped out of the race--she's taking step 1 soon LOL +1  


submitted by welpdedelp(215),
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I scohe shti /bc ist the smot cnommo oghanpet orf sink cifnsnieot

seagull  same here +2  
sympathetikey  Some bowlsheet +11  


submitted by welpdedelp(215),
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tI aws eht nlyo erplihrepa lgnu caern,c its oasl more ommnoc in nemo.w esaaMststi would ahve wosnh leutmlpi nsilseo

sympathetikey  Also, lung adenocarcinoma is the most common lung cancer overall, most common in women, and most common in non-smokers. I know she smoked in the past, but that's what tipped me off to it. +5  
alexb  Yeah I literally picked SCC bc I knew she'd smoked in the past smh +  
maddy1994  20 years of non smoking history ,she wouldnt be at elevated risk for smoking related carcinoma. +2  
larryd  According to FA19 p. 693, large cell carcinoma of the lung is also peripheral. +  


submitted by sajaqua1(518),
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licCitra nspiot ofr ihts iuonseq:t 5 yrea old boy, psimdsoeenurmsup eabseuc fo eeapomyh,hcrt 2 yda hotrsyi of r,evfe ,gocuh hosstenrs of ,tbhare fbrelie 0.1(18 )F, taoseispnirr n/6mi4, twhi soynsaic adn gardeinelze lrcvauesi a.hsr Enseveixt rldunoa rtlaftii.ionn

Of the snotpoi letdis noly aseeslm adn VZV vgie a .rhas A ashr ormf essmael uulyals assrtt sraroltly and sedecnds ulyadcal, and si tafl nda e.sutaryeothm By ,tsnartco VZV ie)kphon(cxc rpnsetes wthi aeilzgdnere ashr ttha uyqilck snatistorni mfro cauamlr ot ulrapap etnh to l.euasrcvi

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


submitted by mousie(209),
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Why no anteswg?i I eman I egt acsytEs is brbpoyal het dugr of oechic freeob na all hgitn neacd pyrta ()llo tbu o'tdn nnredtsuad ywh eerht olduw be oldc isemerextit dna no igsatewn hnew is AF ti yssa hytaerrhimep nad ar?bo???hd

sympathetikey  FA says, "euphoria, disinhibition, hyperactivity, distorted sensory and time perception, bruxism. Lifethreatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome." So I think they wanted you to see Sinus Tachy and jump for MDMA. Idk why Ketamine couldn't also potentially be correct though. +11  
amorah  I picked ketamine because it said no diaphoresis. But if you need to find a reason, I guess the half life of ketamine might rule it out. Remember from sketchy, ketamine is used for anaesthesia induction, so probably won't keep the HR and BP high for 8 hrs. In fact, its action is ~10-15 mins-ish iv. +9  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +18  
fulminant_life  you wouldnt see tachycardia with ketamine. It causes cardiovascular depression but honestly i saw " all-night dance party" picked the mdma answer and moved on lol +8  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +4  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +1  
sbryant6  @fulminant_life FALSE. KETAMINE CAUSES CARDIOVASCULAR STIMULATION. +9  
dashou19  Take a look at why the patient has pale and cold extremities. "Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008716/ +3  
drzed  @sbryant6 you're both saying the same thing. Ketamine has a direct negative inotropic effect on the heart, but it is also a sympathomimetic. You are both correct. +  
paperbackwriter  @drzed Can you please site that? As far as I understand ketamine has a sympathomimetic effect on the CV system --> increased chronotropy and BP. I also don't see how they're saying the same thing. One person said "stimulation" and the other said "depression" +  
nutmeg_liver  People tend to drink a lot of water on MDMA. I just guessed the confusion was a result of hyponatremia (too much free water) but no idea if there's any data saying that people tend to become hyponatremic due to water over-consumption on MDMA lol. +1  
cassdawg  "Despite possessing a direct negative cardiac inotropic effect, ketamine causes dose dependent direct stimulation of the CNS that leads to increased sympathetic nervous system outflow. Consequently, ketamine produces cardiovascular effects that resemble sympathetic nervous system stimulation. Ketamine is associated with increases in systemic and pulmonary blood pressures, heart rate, cardiac output, cardiac work, and myocardial oxygen requirements."(https://www.openanesthesia.org/systemic_effects_of_ketamine/) +  
brise  LSD does cause HTN and tachycardia according to uworld! @d_holles +  


submitted by step420(33),
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iaotRvnri biithsni 45P0!CY So you anc ues it ot bosot hte rienaooctcnnt of the htoer Poeatrse risbhtnoii yb tpvrgnenie eirth smmaoetbli by 0P5Y!C4

mousie  who knew +4  
sympathetikey  Right on (thanks sketchy) +6  
mguan1993  MAGIC RACKS is a good mnemonic ive heard for 450 inhibitors (macrolides, amiodarone, grapefruit, cimetidine, RITONAVIR, alcohol (chronic), cipro, ketoconazole, sulfa +3  
criovoly  "CRACK AMIGOS" Cimetidine Ritonavir Amiodarone Ciprofloxacion Ketoconazole Acute alcoholism Macrolides Isoniasid Grapefruit juice Omeprazole Sulfonamides +6  
drzed  Macrolides EXCEPT azithromycin -- they like to trick you with that one. +2  
steatorrhea  chronic alcohol induces 450, acute alcohol inhibits 450 +2  


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Wyh sedo mlhotieytan eusac ssol of ectsernsia ot TGAC onrticsetir ?osecelanudne oeDs stih avhe ot od hwti iyhtleaotmn of U ot T?

methylased  GATC related to methylase --> https://en.wikipedia.org/wiki/Dam_methylase +8  
sympathetikey  Dam methylase, alright +2  


submitted by lilamk(10),
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I mead a cukyl usseg dna hcose sthi btu I n’tod tinhk for het igtrh or.eassn I tguthoh ebmya eh sha KTB ’yciotsfnneBdrie/cu gAaimmmba.eaniglo tuB, won ttah I am oggni eovr ti I atnw’s usre. Wudlo atth owsh a larnom eoltkceyu n?ieifefrtald Is ti CV?DI ntdD’i hnikt IDCV uldow hvea nesabt renalmgi resectn in plyhm done.s aWth eesl ocdlu htsi be?

lispectedwumbologist  CVID presents in adulthood so it's not CVID. CVID also doesn't have absent germinal centers in lymph nodes. My dude has Bruton's agammaglobinemia +2  
sympathetikey  What @lispected said. +  


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I ttguhho ttah het apryrmi acietsymtph iotrvninane ot teh hater asw utogrhh T1-T.4 yhW loduw omaulittins of hits ignlogan ton aftcfe ikns eslsesv in eht uperp blim?

methylased  Stellate ganglion --> sympathetics for sweat to skin in UE + head. Apparently also to increase HR (some cardiologists ablate stellate ganglion for tachy that cant be controlled by beta blockers). +  
tea-cats-biscuits  The stellate ganglion is a sympathetic ganglion, so it wouldn’t increase vasodilation in the skin of the upper extremity. Also in most people, the inferior cervical ganglion is fused with the first thoracic ganglion (T1), forming the stellate ganglion. +28  
sympathetikey  Got this wrong too. I think upper extremity skin vasodilation (which I picked) is probably more due to local metabolites. +  


submitted by aladar50(40),
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oS tershe’ 001 etner,sids dna hte eecvpelarn efrta 2 yeasr si 1=0 at hte ,gniinngeb 5+ in eht sfrti rye,a 10+ nedocs ,raey and 3- htta eeh,dla fro a latot eeacvneprl of 22 dsrteines ro 0/2=02122 e.ntcrep s,hTu arvlceepen = eaovb het dnsatard. For ceeicni,dn i’ts 15 nwe sceas uto fo 09 rdeitssen orev hte 2 yersa 01(0 tolat tnisseder – 01 ttah aerdlya dah ulecr,s) or 15 new lcsure rep 081 syeatpentr.i⋅a sihT ulodw eb 3.83 wne rscelu epr 0010 r⋅nietpeayats fi you ttdpelreoaax it tuo -- csaabliyl 0()01/8100 * 15 -- h,stu iidenncce = vboea het nasdrtda.

zelderonmorningstar  Okay I feel like an idiot cause I thought: Above the Standard = Doing a good job keeping old people from getting ulcers. Thumbs up. Below the Standard = I wouldn’t let my worst enemy into your ulcer ridden elder abuse shack. +49  
aladar50  @zelderon Ohh damn. I could totally see how one could view the answer choices that way. I think it is important to read how they are phrased - they are asking if the center is above THE standard or below THE standard. The “standard” is an arbitrary set point, and the results of the study are either above or below that cut off. Maybe if it was “above/below standards” that would work. Also, being above the standard could either be a good thing or bad thing. If say you were talking about qualifying for a competition and you have to do 50 push ups in a minute, then being above=good and below=bad. In this case, having more ulcers than the standard = bad. +4  
saynomore  @aladar Thank you!!! but how did you get the 15 new ulcers per 180 patient⋅years? I mean I understand the 15 part, but not the second part ... hence why I messed this up, lol :| +2  
aladar50  @saysomore Because the study is looking at 100 residents over a period of 2 years. Since 10 already had the disease at the start, when looking at incidence you only include the subjects that have /the potential/ of developing the disease, so 90 patients over 2 years. This would be 90 patient⋅years per year, or a total of 180 patient⋅years over the course of the study. +7  
sympathetikey  @zelderonmorningstar I thought the same exact thing. Had the right logic, but then just put the backwards answer. +3  
kai  I wonder if they chose this wording on purpose just to fuck with us or if this was accidental. My guess is there's some evil doctor twirling his thumbs somewhere thinking you guys are below the standard. +14  
symptomatology  Got it wrong!messed up in understanding options, Btw, 15/90 is somewhat 16 percent and their standerd is 50/1000 5 percent!.. this is how i knew that incidance is way up! +  
donttrustmyanswers  Patients with an ulcer are not immune to getting new ulcers --> You should include all patients at risk. But either way, the answer is the same as long as you can read NBME speak. +  
doublethinker  Damn, guess my reading comprehension is not "up to the standard" of the NBME writers. Smh. +  
prolific_pygophilic  If you forgot that its patient years (15/180) not (15/90) you still get the right answer because they are both above 5% :). +  


submitted by beeip(123),
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ehT tebs I nca rdauetsdnn, yher'te icbgiesrdn mlrnteaoedi lyaripehpas, a ultser fo essxec esontgre, a rteoids eroohnm htat asrletcsaotn ot eht ncuesul nda bdnis tsi iaotcptsrnirn tfao.rc

mousie  My exact thinking also! +7  
sympathetikey  Ditto. +  
meningitis  My thought as well but the answer says: "Binding of ligand to Nuclear transcription factor" and I thought to myself: "Estrogen Receptors aren't transcription factors.. they are receptors with Transcription Factor function that bind to the ER Element and recruit more Transcription Factors". Can anyone explain what I am missing? Am overthinking things? +  
criovoly  You are overthinking it, Steroid hormones receptor is found intracellular in the cytoplasm then they are translocated to the nucleus where they regulate gene transcription. HOPE THIS HELPS +4  
eve1000  Could this be due to the PTEN gene being linked to endometrial hyperplasia? +  
feochromocytoma  The question stem says it's glandular hyperplasia "without" atypia It's just due to increased levels of estrogen causing the hyperplasia +4  
faus305  This is a bunch of scientific mumbo jumbo +  


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hTe omts rmtoitapn itnhs ot the siueoqnt aer sa wollfs,o wtih 2# ibnge the toms sccpei:if

1) nptatei preorts apin wiht ardeeovh oimnot nad sptrero trrreeucn reevdoha nomtoi ridung o.rkw eahvrOed mntioo nac degaam het psspiaursuant meuscl eud to nptneiimgem by eth ariomonc.

2) anPi si twors iwth intranle aitotrno fo het souderlh - htsi is noseinsttc wtih het isnfindg fo the tmpnc-yea te,ts ichhw ncdeatsii a tasupnapisusr iuryj.n

mousie  I was thinking along the lines of overhead motion - damage to the subacromial bursa which is between the acromion and the supraspinatus ... also its the most commonly injured rotator cuff m. so could have guessed this one right +1  
sympathetikey  Thanks for the explanation. I was scratching my head as to why this is correct, since supraspinatus only does 15 degrees of abduction, but you make a lot of sense. +1  
charcot_bouchard  IDK WTF i picked Trapezius +34  
ls3076  why would injury to supraspinatus cause weakness with internal rotation though? +6  
targetusmle  yeah coz of that i picked subscapularis +2  
maddy1994  ya the whole question pointed to supraspinatus ...but last line internal rotation made me pick subscapularis +3  
darthskywalker306  I went for Trapezius. That shoulder flexion thing was a big distraction. Silly me. +1  
lowyield  saw someone post this on one of the other questions about shoulder... and it works pretty good for this https://www.amboss.com/us/knowledge/Soft_tissue_lesions_of_the_shoulder there's some videos in it, this specific one for the question is the neer test +  
psay1  FA2019 pg. 438 +1  


submitted by mousie(209),
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A oeahmnmiag is a pety fo nigbne nocroec-n(ua)sn tomru ni ni.atnsf Tish mlronaba tseulrc fo allms oodbl ssevsle aseaprp no or rduen het n,kis ticyyplla wnhiti eon to teehr eeswk eafrt rhbt.i - isdwih.scaopwtlrlehog.nrwmagi aoHmne si a ia/clayprlVB irrmkhtba

sympathetikey  Probably a Strawberry Hemangioma since she's a baby +9  
meningitis  Can anyone explain what is option A? +1  
redvelvet  bc, it's a benign "capillary" hemangioma, we can see "thin-walled blood vessels with narrow lumens filled with blood and separated by connective tissue". It sounds similar to "arterioles in a fibrous stroma" but it's capillary. +1  
peridot  @meningitis I believe option A ("arterioles in a fibrous stroma") is describing an angiofibroma. The name angiofibroma already tells you that there is some component of fibrotic tissue involved, whereas in this case of strawberry hemangioma, the name tells you that it's more like pure blood vessels (capillaries in this case). +2  


submitted by welpdedelp(215),
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No dtei ceyn,fediic eth etnitpa ahd sexces cantoree ude ot sih ited

sympathetikey  Would never have thought of that. Thanks +8  
medschul  that's messed up dog +18  
hpkrazydesi  Excess carotene in what way? sorry if thats a stupid question +  
davidw  this is directly from Goljan "Dietary β-carotenes and retinol esters are sources of retinol. β-carotenes are converted into retinol. (a) Increased β-carotenes in the diet cause the skin to turn yellow (hypercarotenemia). Sclera remains white, whereas in jaundice the sclera is yellow, which can be used to distinguish the two conditions. (c) Vitamin toxicity does not occur with an increase in serum carotene" +7  
davidw  β-Carotenes are present in dark-green and yellow vegetables. +  
hyperfukus  ohhhh hellllll no +7  
dashou19  When I was a little kid, I like to eat oranges, like I could eat 10 oranges at once, and after a few days, I could tell that I turned yellow... +6  
cbreland  I'm okay with missing this one +4  


submitted by killme(13),
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enotIntin ot raetT iaAnysls

usmleuser007  in a per-protocol analysis,[6] only patients who complete the entire clinical trial according to the protocol are counted towards the final results +1  
sympathetikey  "In an ITT population, none of the patients are excluded and the patients are analyzed according to the randomization scheme." +5  
smc213  This video helps https://www.youtube.com/watch?v=Kps3VzbykFQ +12  
rio19111  Thx smc213, really helped. +1  
trainingrats  Where is this in FA2019? +  
teepot123  the video explains it well, no need for fa +  


submitted by sympathetikey(1248),
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easC Srseie

A gpuor or seresi of caes setropr gvvlinino settpina woh erew evgni lmisrai etetr.amnt Reprost of aesc esesri lsulayu cnaonit laededti oirnnaiomft tauob het liundiavdi .anpittse sTih dlsceuin gheadomprci rfaimtnnioo rfo( mleap,ex ,age enregd, ticneh riongi) dan nirafnmioot no ,inosgisda anem,tertt ernosesp to meer,tntat nad plulwo-fo earft nttrmee.at

In hits q,sinutoe it okols kile ehty itddn' lealyr uofsc on the eanemtrtt tapr of it utb rwtioe,hes ksmae sseen

sympathetikey  Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/case-series +2  
ngman  I think another factor is that in case series studies there is no control group vs case-control, cohort...ect +18  
leaf_house  "There is often confusion in designating studies as 'cohort studies' when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ +  
fataldose  explanation of one of the wrong options - correlational study A correlational study is a type of research design where a researcher seeks to understand what kind of relationships naturally occurring variables have with one another. In simple terms, correlational research seeks to figure out if two or more variables are related and, if so, in what way. (source - https://study.com/academy/lesson/what-is-a-correlational-study-definition-examples.html ) +  
j44n  you dont need a control group in a cross sectional one so how do you differentiate that +  


submitted by hayayah(1056),
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rnIo rdovosee si a csuea of a hghi noian agp ocatilmbe iidscas.o

meningitis  I found this to add a little bit more explanation as to how it causes the acidosis if anyone needs it. 1. Mitochondrial toxicity - decreases aerobic respiration and shunts to lactic acid production 2. Cardio toxicity (Secondary to Mitochondrial toxicity) leads to cardiogenic shock (hypoperfusion), which causes lactic acidosis 3. Hepatotoxicity - Decreases lactate metabolism, causing lactic acidosis 4. When in trivalent form (Fe+3), it can react with 3 molecules of H2O --> FeOH3 + 3H+ This will then deplete Bicarb buffering system resulting in non-gap acidosis. Source: https://forums.studentdoctor.net/threads/iron-poisoning-anion-gap-or-non-anion-gap-acidosis.958285/ +17  
sympathetikey  None of the other choices were even metabolic acidosis. They threw us a bone with this one. +21  
imnotarobotbut  Don't changes in bicarb take a few days? How did his bicarb drop down to 8 in 12 hours? +2  
charcot_bouchard  its met acidsis. not compensation +7  
j44n  they did throw us a bone however I didnt catch it +1  


submitted by louisville(12),
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lenuehMbtl-eye tednisa alfec esrma edeverl ounmesru lerhopnisut bt(u nto nay goasi.s)nrm iglelahS is scsollroe enwh inadste htwi lemtenhye eul;b E icol sintsa bleu tihw hemeeltny eubl seaeubc ti eesrmntf csto.eal

sympathetikey  E. coli stains green (just fyi) otherwise, perfect. +13  
chandlerbas  only E coli stains green, all other lactose fermenters stain purple/black (just fyi) otherwise, perfect. ;) FA144 bottom +4  
dmotav  I think this is actually a separate concept – E. coli stains "metallic green" on eosin methylene blue agar, which is in the E. coli sketchy and first aid. However this question is referring to the methylene blue test on a fecal smear. From what I can gather, this test will be positive (indicated by presence of neutrophils) in cases of invasive diarrhea (i.e. shigella, salmonella, enterohemorrhagic E. coli). The test will be negative (no neutrophils) in cases of diarrhea caused by toxins (cholera, enterotoxigenic E. coli, giardia, viral diarrhea). So even though E. coli can present with fecal PMNs (if it's the enterohemorrhagic type), I guess that's less likely than shigella? source: https://www.ncbi.nlm.nih.gov/pubmed/4554412 +3  


submitted by hayayah(1056),
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nettiPa sha auydmrell canaocirm. tnginMaal oelofainrtpri of laalfciolurrpa ""C sllec taht odpeucr nciltaiocn nda aevh tsshee fo lcesl in na lyamiod rsa.tmo

xxabi  Just to add - patient likely has MEN 2A or 2B with the presence of medullary thyroid cancer and pheochromocytoma +13  
sympathetikey  @xxabi Was going to say the same thing. +  
dermgirl  The patient have MEN 2B (Medullary thyroid carcinoma + Pheochromocytoma) Page 351 FA. +  


submitted by hayayah(1056),
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Fmailail admoeoatnus psiopylos is na oalmstuoa mnoidant oimuant.t Taosndhsu fo lpsypo seari gtsanitr ferat ype;ubtr io;acpcnonl aswlya vsoveiln ec.turm ltoyhaprcciP omlotycce or sele 0%01 srsgerop ot CC.R

moAuaotsl idmtoann deiesssa hva,e on ,eeaarvg %05 hnecca fo ngebi sedpsa ndwo ot oi.gffsrnp

sympathetikey  I would say this is Lynch Syndrome (APC is usually thousands of polyps) but lynch syndrome would generally have a family history of other cancers as well, so you might be right. Either way, both autosomal dominant so win win. +2  
smc213  uptodate states: Classic FAP is characterized by the presence of 100 or more adenomatous colorectal polyps +  
dickass  @sympathetikey Lynch Syndrome is literally called "Hereditary NON-POLYPOSIS colorectal cancer" +9  
fatboyslim  I think this actually is Lynch syndrome. Lynch syndrome can also develop colonic polyps but not nearly as bad as FAP. FAP has so many polyps you can't even see the normal mucosa. If you Google Lynch colonoscopy you can see that they develop a few polyps. +  
rockodude  I forgot it was AD inheritance but regardless at the time I was confused because APC is a tumor suppressor so it needs two hits. I guess AD inheritance and then you need another hit to develop CRC kind of like familial retinoblastoma or li fraumeni syndrome +  


submitted by hayayah(1056),
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vitSyinseit estst rea ueds rfo cnn.eesrig ipiStiyccfe tests era edus ofr aicfoontinrm ftrea tesvpioi sneineg.rcs

teSsviyinti tests ear sued orf geeins owh nyam leppoe tlury ahve het e.sisaed iecpycSifit etsst aer rfo etsoh ohw do ton have eth e.aidess

A ghilyh setenvisi tes,t nhwe ig,taneve rsuel TUO se.adise A hglyih icescfpi s,ett nhwe to,siepiv uelrs IN i.asdsee S,o a ttse itwh ihtw olw inievsttysi naocnt reul tou a s.eeadis A tets tiwh wol scteciiyipf ctna' elru in edsase.i

heT oocrdt dan inpetta awnt ot rsncee fro olonc aercnc dan urle it uot. ehT otcrod owlud anwt a tets wthi ihhg sviystntiei to be aebl to do at.ht He owsnk hatt tsegtni hre ootls rfo lodob will tno erlu out eht lysbiipiots fo oclno AC.

sympathetikey  SeN Out (Snout) --> sensitive test; - test rules out SPec In (Specin) --> specific test; + test rules in +21  
usmlecrasher  can anyone pls explain why it is not << potential false- positive results >> ??? +  
almondbreeze  correct me if I'm wrong, but 'high FP (choice C)=low specificity (choice B)'. Whereas high specificity is required to rule in dz +2  
almondbreeze  picked positive predictive value myself. can anyone explain why not PPV? +  
williamfreakingosler  The principle @hayayah is talking about (a negative test being relied upon to reliably rule out) is negative predictive value ("NPV"). I don't see why "uncertain NPV" isn't the correct answer, particularly because NPV is predicated on the disease having the same base rate in the person(s) being tested as in the population that was characterized for the test statistic. Given that the patient has a strong family history of colon cancer, the NPV of FOBT is uncertain. Said another way, the sensitivity of a test does not change with the population, but the NPV does. The whole reason the doctor is denying FOBT is because of bayesian thinking (a priori information related to family history), and from my point of view bayesian logic is more relevant to PPV/NPV than to sensitivity, hence my confusion over why NPV isn't the right answer. +2  
ibestalkinyo  I thought negative predictive value for the same reasoning +  
raga7  AFTER THE RESULT OF TEST WE CAN USED PPV OR PPN, BUT FOR TEH FIRST TIME LOOKING ANY DESEASE USE SENSITIVITY OR SPECIFICITY. +  


submitted by step420(33),
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hOtre yidekn yrptsHiohreep deu to edcieasnr tsesrs t&g-;- not rhilapepyas bc ton srconcuae

masonkingcobra  Above answer is incorrect because hyperplasia can be either physiological or pathological. Prolonged hyperplasia can set the seed for cancerous growth however. Robbins: Stated another way, in pure hypertrophy there are no new cells, just bigger cells containing increased amounts of structural proteins and organelles. Hyperplasia is an adaptive response in cells capable of replication, whereas hypertrophy occurs when cells have a limited capacity to divide. Hypertrophy and hyperplasia also can occur together, and obviously both result in an enlarged (hypertrophic) organ. +35  
johnthurtjr  FTR Pathoma Ch 1 Dr. Sattar mentions hyperplasia is generally the pathway to cancer, with some exceptions like the prostate and BPH. +4  
sympathetikey  Tubular hypertrophy is the natural compensation post renal transplant. Just one of those things you have to know, unfortunately. +2  
charcot_bouchard  Isnt Kidney a labile a tissue & thus should undergo both. This ques is dipshit +  
brbwhat  Dr Sattar says, kidney is a stable tissue, at least pct is as seen in ATN. But I read, basically kidneys are mostly formed whatever number of nephrons have to be formed by birth, after that they can only undergo hyperplasia aka increase in size/or regenerate if need be in case of atn. We cant have more number of nephrons. +1  
mambaforstep  @brbwhat , do you mean kidneys can only undergo hyperTROPHY? +2  
j44n  .... you're not making more cells..... so it cant be hyperplasia +  


submitted by ark110(1),
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tuB twah si eth fcfeeeidrn neteewb toniop A nad ptooni C 1;3(2 94;. ;09 )35

sympathetikey  K+ shouldn't increase. It's moving into cells due to metabolic alkalosis. +  
home_run_ball  In the parietal cell of the stomach Hydrogen ions are formed from the dissociation of carbonic acid. Water is a very minor source of hydrogen ions in comparison to carbonic acid. Carbonic acid is formed from carbon dioxide and water by carbonic anhydrase. The bicarbonate ion (HCO3−) is exchanged for a chloride ion (Cl−) on the basal side of the cell and the bicarbonate diffuses into the venous blood, leading to an alkaline tide phenomenon. +1  
ergogenic22  RAAS increases from volume loss, and thus more aldosterone leads to low K+ +1  
sinforslide  Three reasons for hypokalemia. First, some K+ is lost in gastric fluids. Second, H+ shifts out of cells and K+ shifts into cells in metabolic alkalosis. Third, ECF volume contraction has caused increased secretion of aldosterone. +3  


submitted by hayayah(1056),
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etcN,oi eht smet sasy "orresposrc ni eht skni"

D3 hilca)clrolof(eec frmo pexrouse fo skni asr(tutm b)aasel ot usn, ionegsnit fo fh,is ,mkil .ltnsap

2D l)geofecroa(lirc mofr ngisteoni of tsapl,n gfi,un ts.saey

oBht nerecvtod ot H-O25 3D s(tegaro fo)rm in ivlre dan to hte aetvci omrf OH(5-12)2, 3D )(tcriocalil in ky.ndie

sympathetikey  C is the 3rd letter in the alphabet. Hence, D3 = Cholecalciferol +4  
karljeon  Thanks for the explanation. The question stem made it sound like "what future step will be decreased?" Actual question: "Decreased production of which... is most LIKELY TO OCCUR in this patient?" Maybe NBME needs a grammar Nazi working for them. +8  
bharatpillai  question says "decreased production of which of the following precursors in skin is most likely to occur in this patient? the answer has to be 7-dehydrocholecalciferol! +4  
bharatpillai  7 dehydrocholesterol +2  
brbwhat  Yeah i did the same, but then realised acc to uw flowchart 7dehydrochole.. is converted to cholecalciferol in presence of uv rays. So the decreased precursor would be cholecalciferol since we already have 7 dehydrocholecalciferol not being converted by uvrays Tho the uw chart sites both ergo and chole as dietary sources. +2  
drzed  Wouldn't 7-dehydrocholesterol build up in the skin? Since UV rays convert 7-dehydrocholesterol into cholecalciferol, if you are lacking the conversion, the reactant (7-dehydrocholesterol) should accumulate. +  
brbwhat  They’re asking decreased production of which of the following precursor would occur? 7 dehydrocholestrol builds up, but decreased production of cholecalciferol takes place, which is a precursor in the pathway for vitamin d formation +1  


submitted by strugglebus(163),
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sA an 1 :8e0t0d,1i0 opeelp edoterrp to heav seid seffect wenh gkinta zlodooHt rrahdighmocy.ieAn emht, 25 lpeeop .0)2%0( heva streaB ascdehigr

neonem  I think the best way to answer this question was by process of elimination. +1  
sympathetikey  That's some bullshit lol +8  
karljeon  Haha I eliminated the answer by process of elimination. +19  
medschul  I eliminated thiazides by process of elimination :( +1  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +2  


submitted by strugglebus(163),
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oS you nkwo thta 65% fo hte taad lilw flal hiiwnt S1D of eht e.mna So fi ouy ttcsraub -01605 yuo lwli etg 35. ichWh nsema thta atuob 61% ilwl llfa ebavo nda 6%1 will flal ebwlo 1 D.S Tyhe era iksagn ofr who nyam llwi lalf vobea 1 .DS 'mI ruse herte is a retbet way fo gndoi ,tihs utb tahst woh I ogt it oll.

sympathetikey  Same! +5  
sympathetikey  Except according to FA, it's 68% within 1 SD, so 34%, which split in half is 17%. +2  
amirmullick3  Sympathetikey check your math :D 100-68 is 32 not 34, and half of 32 is 16 :) +8  
lilyo  Can anyone explain why we subtract 68 from 100? This makes me think that we are saying its 35% of the data that falls within 1SD as opposed to 65. HELLLLLLP +  
sallz  @Lilyo If you consider 1 SD, that includes 68% of the population (in this case, you're saying that 68% of the people are between 296 and 196 (1SD above and 1 below). This leaves how many people? 32% outside of that range (100-68=32); half of those would be above 296 and the other half below 296, so 16% +5  


submitted by strugglebus(163),
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oS ouy wnko ttah 5%6 fo het adta illw flal tnwiih 1SD of the a.enm oS fi yuo crtasbtu 6-0150 uyo lwli get .53 hiWhc mneas that ubtao %16 liwl afll avobe dna %61 wlil lafl wbleo 1 D.S yheT rae sniagk rof hwo anym lliw lafl ebvao 1 DS. Im' reus teehr is a ebtrte ywa fo ndigo hi,st tub sthta woh I tgo it llo.

sympathetikey  Same! +5  
sympathetikey  Except according to FA, it's 68% within 1 SD, so 34%, which split in half is 17%. +2  
amirmullick3  Sympathetikey check your math :D 100-68 is 32 not 34, and half of 32 is 16 :) +8  
lilyo  Can anyone explain why we subtract 68 from 100? This makes me think that we are saying its 35% of the data that falls within 1SD as opposed to 65. HELLLLLLP +  
sallz  @Lilyo If you consider 1 SD, that includes 68% of the population (in this case, you're saying that 68% of the people are between 296 and 196 (1SD above and 1 below). This leaves how many people? 32% outside of that range (100-68=32); half of those would be above 296 and the other half below 296, so 16% +5  


submitted by sympathetikey(1248),
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sA sdaett leowb, hte eftL urcs rbcerie asw dmdeaga (ese ahtw ti uohdls mloanrly ookl klie eo)w.bl iTsh tnaoinsc het ocitaslpirnoc tcrta. cSein eht loirsnccipoat rtact daesuetsc at teh dua,mlle lbwoe the imbdrnai tiecnos weer' ologink ,ta uoy owlud see tnllCoataearr )ih(Rgt apStics spamsiHeeir

hello  What identifies that a cross-section is medulla vs midbrain vs pons? +4  
kernicterusthefrog  @hello I like to pay attention to the Cerebral Aqueduct (diamond/spade shape seen mostly in Midbrain, and transitioning to 4th ventricle in rostral Pons), and then the shape and size of the 4th ventricle as you move down Pons to rostral&middle Medulla, and eventual closing and absence of fluid space at caudal Medulla. +11  
hello  @kernicterusthefrog Thank you. +  
mbourne  NGL, I thought the right side had the pathology lmao ty +20  


submitted by hayayah(1056),
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'NRsTI aer ieacsdtsao hitw slsoibpe ieds fetefsc of anmi,ae o,niotalueapcyngr dan onpru.mysselipsoe

sympathetikey  Especially zidovudine. +17  
fmub  Nucleoside reverse transcriptase inhibitors (NRTIs) block reverse transcriptase (an HIV enzyme). HIV uses reverse transcriptase to convert its RNA into DNA (reverse transcription). Blocking reverse transcriptase and reverse transcription prevents HIV from replicating. +1  


submitted by strugglebus(163),
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hTe IC vuale aentodcni 1, icwhh mnsae thta tsi itgnnafsnciii

sympathetikey  Correct. Per first aid: "If the 95% CI for odds ratio or relative risk includes 1, H0 is not rejected." +1  
xxabi  Ah that makes more sense, thanks! +  
drdanielr  Since the OR or RR is a ratio, if the two interventions are equal the ratio would be 1. So, if the CI includes 1, they are "the same" or not stat sig diff +  


submitted by monoloco(132),
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rlaunAn ncarpsea si het only arwsen taht staunocc fro teh libe ni hte miot;v of het hcce,sio it is hte only ticsrnobout asitdl ot eewrh leib tnrsee teh IG artt.c

ergogenic22  Meckel diverticulum also occurs distal to the CBD but less likely to be associated with bilious vomiting +  
sympathetikey  Correct. Might cause pain due to ectopic gastic tissue. +3  


submitted by strugglebus(163),
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I csheo hits leylso ubesace it aws so amdn icepcifs

sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +4  
karljeon  I didn't choose it because it was so damn specific. :( +40  
lovebug  Could anyone explain for B) for me? because I choose B).:( +2  
j44n  B.) is wrong because its never been shown to show adverse effects "any offcial data linking the drug" and the fact that it's "newly marketed" +  
j44n  and because its in 5/45 patients roughly 10% of the population, that might not seem like much but most of the diseases we freak out over are in 1-2% of the population, to put that into perspective if we gave this drug to every person in the US (every big pharma wet dream) with a population of 300 million... 30 million people would have this adverse event... hope that helps +  


submitted by ergogenic22(300),
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A srctthe irjynu ngidru hirhltidbc lilw elsrtu ni aagdme to eht teralexn eaeurhrlt dna nala sesprtcnih and gdaeam to eth edlapund rnvee 2S)-S4(. ihsT nca eald to esdaercde inastonse ni teh lreneapi nda ilengat area nad afcle or riuyanr ineicnocnnte

thepacksurvives  I think that there can also be a direct tear to the anal sphincter muscles +5  
sympathetikey  A better answer choice would have been "damage to the nerves innervating the anal sphincter" but eh, ok. +20  
nerdstewiegriffin  I it is due to actual tear of external and or internal anal sphincter Source uptodate +2  


submitted by monoloco(132),
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isTh is rylenidcti ngkais tobua apek eobn yetisdn. aTth lowhe hgnti abtou eiatiengbhwg-r srcixeees, aeintg h,girt dyaa ada,y beofre adn grunid ahtt wesldoopn- hsepa fo efil ofr nebo tied.ysn llA obuta cgeinrud atth 1% erp ryae eeegdlrta-a boen nyetids sslo as tbse as ew n.ac eleLv of vittaiyc si erscyliep elik aeigirhn-gtwbe siex.erce es:(irdonC no atcyi,vti biddrend-e -- ysa beooydg ot yuro nseb;o hlighy vieta,c usnr veyer rhtoe dya -- oogd aunomt of irabgiegetw-hn / ssetrs ot nicedu meiorngled dna taamnnii getytriin fo the s)eo.nb

sympathetikey  Yeah, I was thinking about that while taking the exam. Just got thrown off because I don't see how that matters, now that they've fractured the femur. How do prior increases in bone density allow for better chances of bone healing? +12  
rsp  I think that bone density is important here, but think about all of the other things that go in to recovering from a fracture at that age too. How strong are the muscle that will stabilize you while going through the motions of physical therapy? How conditioned are you? +2  


submitted by meningitis(500),
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nWhe dtgnasni ,up het bdoy nolylamr ettaaivcs yitmaepshct sysemt to adoiv otaioshtrtc nihsytep.oon

Btu scine rethe is now na dvteiadi tffece fo eht orcmoomaeotphcyh cnrd,regsiea it lilw dale to a enpneyrosith

e:i(. loeDub vsisrnattcnoocio = oheP crgriedeasn + cpimhyttaeS etssmy)

sympathetikey  Brilliant. +4  
medschul  Would pheo have a normal resting BP though? +10  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +7  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by mrmassador(10),
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I ihknt the tpino fo het eiotnsuq is to zcregioen ttha itsh is a laicormtdniho siedeas hrmote( and lnamarte oadrthmrneg weer te.)efcfda docruseP wdie erang of ,tfsceef tub lcesum neewsksa dna oesm rencigloou icfdties osodt uto ot m.e sAol t:his .ctolrTghgen1ntvinL:sot/mTpdngi./i/e#sM-/honh.

sympathetikey  Yes, but doesn't that mean maternal transmission? Men can have these diseases too, they just won't pass them on. +28  


submitted by hayayah(1056),
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A big tnihg ereh oot si iicgotnn ttah the APL si eecsedadr. otstbeaOls vyaittci si sdaemuer yb nboe P.LA I ihnkt ahtt saw hte nima ufcso rhee and not that yuo nleaessyirc deen ot nwok teh CA1BF enge ttuai.nom

sympathetikey  Exactly. That's the only way I got to the answer. +3  
pakimd  isnt increased alk phos consistent with increased osteoblastic activity? +  
champagnesupernova3  A defect with chondrocytes would cause an short limbs like in achondroplasia so those are ruled out +  
pg32  Exactly. Can also be helpful if you remember that the clavicles are formed by intramembranous ossification rather than endochondral; that allows you to rule out the chondroblast/cyte answer choices. +4  


submitted by monoloco(132),
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puldanEctsae smasigorn nur napamrt in siatntpe who have no lense,p hwteehr liphcyylas or .tllicnuoafyn laclR(e eht yd-wreaiar of qeasealu icksel lcle paestnit ceenepixer nhsakt to rtehi unnfoctlai aoecupmneoystlt.)

sympathetikey  Agreed -- went with E. Coli like a dingus, just because I didn't associate DIC with S. Pneumo. Thought it was too easy. +  
chillqd  Isn't E. Coli also an encapsulated organism? What makes Strep pneumo more likely in this question just because its the more common cause? +23  
studentdo  Pseudomonas aeruginosa is encapsulated as well. I think the right answer has to do with DIC but why? +1  
mgoyo89  The only reason i found was S. pneumo is more common, I went with Pseudomonas because of the "overwhelming sepsis" :( +1  
kard  Everyone is correct about the Encapsulated microbes, but this is one of those of "MOST LIKELY", and by far the most likely is S.Pneumo>>H.infl>N.Mening. (omitting that patients with history of splenectomy must be vaccinated. +1  
djinn  Gram negative are more common in DIC my friends +2  
drzed  Correct me if I am wrong, but I am pretty sure that E. coli is NOT a common cause of pneumonia because it must be aspirated to enter the lung. Thus, only patients with aspiration risk (e.g. stroke, neurogenic conditions) would be at a chance of getting E. coli pneumonia. +1