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Contributor score: 33

Comments ...

 +4  (nbme22#2)

So this patient is essentially in hypovolemic shock because he's hemorrhaging blood from the aorta.

A) You'd have increased ADH to conserve volume B) You'd have increased BUN:Cr ratio b/c due to a decrease in blood flow C) Increased TPR naturally due to less pressure on barorecptors D) Decreased Capillary hydrostatic pressure b/c they have decreased volume E) Decreased Carotid sinus firing rate b/c less pressure F) The Answer: RAAS is activated -

drzed  (B) You get an increased BUN:Cr ratio because increased urea absorption at the proximal tubule (conservation of water), but you lose the same amount of Cr since none of it is reabsorbed; thus the ratio increases. +5
kevin  I may be wrong but I think more of the urea (BUN) would be absorbed in medullary collecting duct in this situation due to ADH; think I saw a question on this in uworld, could pop up +

 +2  (nbme22#31)

2/6 systolic murmur over the left sternal border,an S3 (increased LV filling), low 02 sat, figured this patient had hypertrophic cardiomyopathy and early signs of CHF, so the answer was crackles from the pulmonary edema from fluid back up from the HF as brise pointed out below the 1st comment.

samadmom  I believe this patient actually has dilated cardiomyopathy (as opposed to hypertrophic) due to his age, HTN, presence of S3 (hypertrophic usually has S4), and also his murmur. The murmur indicates mitral regurg, the tip-off was "radiating to the axilla". Because the stem states that the PMI is diffuse this can lead us to think that his heart has enlarged in an unpredictable way (ie. making it acceptable that the placement of the murmur is different from where we expect). Lastly, secondary mitral regurg is an indicator of poor prognosis for HF. Once the ventricle has dilated to such a point, the mitral leaflets are unable to properly close and perpetuate the backward flow of blood. Hope this helps! +

Subcomments ...

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numMoaesrb pGresmeiriotulhnol is hiNpro;cet LONY PTIRORINAEU is ni teh vienettg

tI ca'nt eb NGMP becaues NPMG is Npicrheti twih olbiepss chitrNeop

trOhe iseohcc rae ainiletdme yb anlRe Bopsiy

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +4  
cooldudeboy1  could someone explain why the other choices are ruled out by biopsy? +  
arlenieeweenie  @cooldudeboy1 PSGN does have a granular immunofluorescence, but there is no previous illness or hematuria mentioned so you can rule that out. Goodpasture is classically linear IF since they're antibodies against the GBM. IgA nephropathy is mesangial IF so it would deposit more in the middle. Minimal change wouldn't show anything on IF +2  
qball  I know First Aid states MPGN as a nephritic disease but I think it can present as nephritic or nephrotic syndrome. Of course, the renal biopsy helps give it away but I wouldn't be so quick as to rule out MPGN +1  
taediggity  Totally agree w/ you Qball... I thought MPGN too, but I think Penicillamine makes it Membranous Nephropathy +  

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oNt 100% uers on sith n,oe utb sehre’ who I hpaeacpord :it snimehtia csaseu ireatlar onldtiia s=arec(eded eorraralti n),sreatcies btu lla fo thta oblod hsa ot go reeoheswm senci yuo own hvae emro bodol lonifwg hgrhout het erseriat nad thta eheewrsom si eht iarcilaslep s(eandeicr claaylipr hydroctaist )esupserr. tisanmHie uessac rceedsina riyaieleptmb fo teh lycppoa-lstira svneule eon( of D.r ts’taaSr rtfeivao afsct) so yod’u have nriadcese icrlpalya ntfortaili

taediggity  Totally agree, arterial dilation--> increases blood flow into capillaries/increases capillary hydrostatic pressure + increasing permeability of the post-capillary venules= Increased Capillary Filtration Rate +1  
makinallkindzofgainz  I love you explanation, but I don't think filtration rate is dependent upon permeability of the post-capillary venules. I think the filtration rate is increased simply due to the increased blood flow; this is similar to how increased renal blood flow will increase Glomerular Filtration Rate (GFR). +10  

submitted by drdoom(883),
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Yuo aveh ot thkin uboat sith iguns teh otccnep of OTINCNDIOAL AIBOBIRTYLP. toerhnA ayw ot ksa tshi tyep of qneusiot si ekil ihts: I“ wohs ouy a itpenat iwth onuesospant pohaux.enmtor hiWhc rhteo gtnih is tmos ilylke to be uetr btaou atth n”soep?r rO uoy can searph it ethes :ywsa

  • neGiv a OTCNIONID (nsonaspoute pnoume,) waht torhe nfdigni si tosm llkiey ot be eht ecsa?
  • eGvin a olpo fo pepelo hitw psnaetounso ,tunpohrxoame twah heotr ihtgn is tosm ylkeil to eb eurt utboa mh?te

nI teohr wrods, of lal eppelo ohw nde pu whti opantunoses pouen,m eth tsmo cmnomo ehtor gihnt tboua mhte is hatt they ear AMEL mpa&; HI.NT

If I egav ouy a ekbtuc of ussoaennpot oneupm nitespat -- nda yuo hcedaer oryu nahd in ehtre dan deplul noe tou -- ahwt oirascne uwdlo eb remo mom:noc nI ruoy hdan ouy evha a kemsro or ni yrou adhn oyu ahve a thni me?al ’Ist eth at.rtle

someduck3  Is this the best approach to all of the "strongest predisposing risk factor" type questions? +  
drdoom  There is a town of 1,000 men. Nine hundred of them work as lawyers. The other 100 are engineers. Tom is from this town. He rides his bike to work. In his free time, he likes solving math puzzles. He built his own computer. What is Tom's occupation most likely to be? Answer: Tom is most likely to be a lawyer! Don't let assumptions distract you from the overwhelming force of sheer probability! "Given that Tom is from this town, his most likely occupation (from the available data) = lawyer." +4  
drdoom  There is a town of 1,000 spontaneous pneumo patients. Six hundred are tall, thin and male. The other 400 are something else. Two hundred of the 1,000 smoke cigarettes. The other 800 do not. What risk factor is most strongly associated with spontaneous pneumo? (Answer: Not being a smoker! ... because out of 1,000 people, the most common trait is NOT smoking [800 members].) +4  
impostersyndromel1000  this is WILD! thanks guy +3  
belleng  beautiful! also, i think about odds ratio vs. relative risk...odds ratio is retrospective of case-control studies to find risk factor or exposure that correlates with grater ratio of disease. relative risk is an estimation of incidence in the future when looking at different cohort studies. +  
drdoom  @impostersyndrome I love me some probability and statistics. Glad my rant was useful :P +  
hyperfukus  @drdoom i hate it which is why your rant was extremely useful lol i learned a ton thanks dr.doom! +1  
dubywow  I caught he was thin. The only reason I didn't pick Gender and body habitus is because he was not overly tall (5'10"). I talked myself out of it because I thought the body habitus was too "normal" because he was not both thin AND tall. Got to keep telling myself to not think too hard on these. Thanks for the explanation. +1  
taediggity  It isn't just that this person has Ehlers Danlos and they're more prone to spontaneous pneumo??? +1  

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tlAughoh eethr are on ecfciisp spreeh isconditra, a FSC nleap ihwt losytm lcsotyeuek censiatid a iavlr tofnencii (as elwl as the mnorla c)egousl. oS uoy nac lrue tou ,TB osuodnsaircioers and .ticaarble /ziegdsiunrkkinrB insg are adteler to msgi,niiten utb neve if you tn'od wkon wtha shoet era, the istuenoq assy thta eerht is na yorlminaatb in teh ATEMPOLR lbeo mtnsne(giii = sm.)eegnni aecisEpnlthi ouldw eb hte steb anrsew, lacspiylee uacesbe pseeHr Eiiptnlachse satfecf teh etpmaolr loeb.

taediggity  Also look for Kluver-Bucy like symptoms in the stem +1  
mambaforstep  why? +  
b1ackcoffee  I agree with everything but normal glucose. Glucose here is NOT normal. to quote wiki "The glucose level in CSF is proportional to the blood glucose level and corresponds to 60-70% of the concentration in blood. Therefore, normal CSF glucose levels lie between 2.5 and 4.4 mmol/L (45–80 mg/dL)." +  
baja_blast  NBME reference table gives normal CSF glucose to be 40-70 mg/dL. As far as I'm concerned, for the purposes of the exam the reference table is probably a better source than wiki. +4  

submitted by seagull(1567),
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otu fo tsciuoy,ir how amy eloppe kwen s?hit t(odn be hsy ot ays ouy did or ?tdni)d

My rypotev ounatecdi dti'dn rinanig sthi ni m.e

johnthurtjr  I did not +3  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +5  
snoochi95  hell no brother +1  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +2  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  

submitted by nwinkelmann(294),
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I unfdo sith enhw tinygr to rsnnuetdda wyh siacenedr NO decaus :acshedeha /ttrseittNsniraie era a yrve onmcom eaahedch nda rimeanig ofod rtgsiegr (eM)DWb and irsea icrtni oeixd le.evls ihgH lsvlee of icrnti doxei are seoacdiats twhi girmaine ud.(Syt) esaceadHh adn esinarmig rea losa reyv nmoomc ni ntiaoeismcd ttha btoos nctiri o,xied ushc a agivar s,(ydt)u tbu it si cruelna ywh itsh .anhpsep eTh nrlagoii hotspishey asw atth cinitr eidxo rsniacees bdool lveess isze adn tgsigrer a irneimag, utb eth vaagir sdtuy and thoser odreisvpd sthi. erwNe tdisuse no ircnit oiedx ohsws ahtt it asrcnesei the depepti (PCG)R atth is donecidser binrsspeleo for nigtigregr megiiarsn u)y(dSt tfrea rscseenia in io.fntimnaalm eacuBse incitr eixdo is sscdiataeo ncroenigue mmantofnalii ,siedessa sti' leliyk taht aahcsedeh dna ginmaseir ormf rntiic xoied era a wnraing gisn of sith mominfltinaa )d(.yuSt

eTh arsrhcee si sayalcilb ttgsain tath tirtsane iresa inrcit xdioe sellev nda ghih itrinc ixoed svleel icserane nliamfoiamtn and hsahcdeae nad nmgsaieir. eovHwe,r eth eatcx soanre why ihts enphpas si wnuonnk.


taediggity  Goljan and FA mentioned this as Monday Disease for people who worked in industries that heavily used nitrates, where they would build tolerance during the week and then get a headache when they went back to work on Monday +4  
nootnootpenguinn  Just to add to this- one of the side effect of NG when given to patients with MI is "massive headache"! That's how I the question right! +  
mumenrider4ever  This is similar in how triptans induce vasoconstriction which is used to treat migraines +  

submitted by welpdedelp(227),
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It asw a uogrneiFurs i-togd;-b&se .ssesotasbi uiruFeornsg oesidb rea beeeidlv to eb oermfd by mpchgaoresa atth vaeh hatsecdgpyoo dan ttdeapmet to segidt the e.sifbr

almondbreeze  info about ferruginous bodies being mf can't be found on FA/UW :'( they just say it's 'material' +  
taediggity  FA 2020 677, FA 2019 659... mf?? mofos?? +3  
69_nbme_420  Just to add: The question asks what cell type initiated the Fibrosis → Alveolar macrophages engulf the particles and induce fibrosis (same pathophys for all Pneumoconiosis). Pathoma 2019 Pg 92 +7  

submitted by mattnatomy(43),
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reeeSv nsreeyhitopn ofnte delas to cytprhpiales soercrailrisstooel -inons(inko )eencp.araap osAl see niaploetrfiro fo otsmoh slcuem .ecsll

meningitis  and explains the flame hemorrhages (Goljan) caused by malignant HTN +5  
taediggity  FA 2020 pg. 537 +  
dentist  FA 2020 pg 301* +  
ally123  The flame hemmorhages are also a good buzz word for recognizing he has hypertensive retinopathy 2e chronic, uncontrolled HTN. Pt's with hypertensive retinopathy can also present with "cotton wool spots" and "macular star". Pics on FA 2019, p. 299 +2  
surfacegomd  Pathoma (2018) p. 69 +  

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hsiT eon aws a ltleit crtkiy. orF ihts eno eht eky is the olw oriidoianed .utaepk iTsh tetapin ash hghi 4T nda lwo STH wichh keams neses ni a hdryeyohiprt pti,atne arpephs oyru tfirs hgtotuh si ahtt siht antptei ash Gevrsa’ i.daesse eve,rHow in Gsr’eva yuor idytrho si inbge tesuiltmda to eakm moer itdhryo rhneomo fmor rsthcac dan sa cshu ouldw hvea an iedscaern oedaidniiro ektapu esubcae the ihtoydr is rnigginb in the edireruq (wno ardaoeldb)iel no.eiid ishT is ywh it si ont sveGra el“ersae( fo ihtdryo oeonmrh frmo a itohdyr tdluaietsm yb stnii)ode”.ab

oS if sit ont earvsG’ hwta cudol it e?b oFr hist uo’dy hvae to nwko taht oiHm’sthosa osyrhTiditi (olsa wonkn sa hcinoCr omcitLycpyh iToihtrdsyi dna is tfeno edrerfre to sa hucs on radob exsam ot wthor you ff)o sha etreh apshes - trisf tehy ear tpoiryhdey,hr thne reydui,oth hetn het siclcsa yotdoyhprih ahtt yuo uoldw txeecp whit olw 4T adn gihh H.TS This swa eht key ot isth onsu.etiq Teh sanoer for hsti si htat dnatoyriith proxdsaeie iasbndteio ni soi’hstmaoH ceasu eht rtiodhy ot elearse all fo tis tresod tryodih oheonrm naikgm eth ettinpa preyodthriyh rof a hrsto oprdie fo .tiem ertfA hsit imeavss eelaers fo doirhty onoemrh, eth esnoidbait aekm mhet unbale ot emak nwe HT nad orehfrete tyeh emeocb uyorehtdi fro a rhtso pioder nda enth rpyiodhytho wihhc uoy owlud !extpce ecnSi eyht c’tna make wne T,H hte ridyoht will ont eakt pu eth doiiioandre dna fotherree trehe lliw eb wol iioiadernod tkaepu. H,eenc aerl“ese fo drtoes dryihot renomoh omrf a tiordhy dgnla atlietdrifn yb pyhlotcsm.”ye aak ypytchLcm“io osma(si)hoht itdirh.”iosty

I hnkit lr“seaee of hrotiyd mhernoo form a tlmyoomsphau yodihrt ad”nlg si ferenrgir to eosm kdin fo otrdhiy rnacec ni wichh easc uyo ludwo xtepce etmh ot eb idebgrscin a olnedu no ddariooneii .apkteu

Sma​ymur idove hree dna saol a teagr stie ni :leareng cgdnqtr:eiolmerhn/seid/r./uhn/eatpnd/ea/tdieoosoyrpci

aesalmon  pg 338 of FA lists it under hypothyroidism but it does present as transient hyperthyroidism first +9  
hyperfukus  yep that was the key! Goiter is "HOT" but the remaining answer choices were still kind of bleh D was distracting the hell out of me i spent so long to convince myself to pick C and move on +3  
hello  Pasting nwinkelmann's comment as an addition: Choice "D" is wrong b/c "lymphomatous thyroid gland" = primary thyroid lymphoma (typically NHL, which is very rare) or Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. Both of these present with hypothyroidism with low T4 and high TSH (opposite of this patient). +1  
taediggity  I absolutely love your @liverdietrying, however the pathogenesis of postpartum thyroiditis is similar to Hashimoto's, so I think this person has postpartum thyroiditis and your explanation of transient thyrotoxicosis is spot on, which would also occur in postpartum thyroiditis +11  
pg32  I agree with @taediggity. Also note that women eventually recover from postpartum thyroiditis and typically become euthyroid again, which doesn't happen with Hashimoto's. +  
vulcania  In FA (2019 p. 338) it says that thyroid is usually normal size in postpartum thyroiditis, but the patient in this question had a thyroid "twice the normal size." I guess at the end of the day it doesn't matter which diagnosis is right for this question cause they both seem to lead to the same correct answer :) +2  

submitted by dr.xx(151),
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As rtpa of recoinmyb p,omndveelte eht asernpac frmos sa wto udbs orfm hte g,roetfu an oemiybrcn tueb taht si a seprcurro ot eht tslsgnneoittraia ttca.r tI si reofrthee fo neadldoemr rii.gno


gh889  nice! I reasoned it as that most of the GI system is of endodermal origin +9  
taediggity  FA 2020 pg 613 +1  
mutteringly  FA 2019 pg 599 +  

submitted by bubbles(69),
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stneBmea arenbmem ieytitngr si hte ientatdrmen of lufl ngul ervycero onollfiwg lmonuapyr


()1 ossl of eebmsnta rabmenem nitreygit is ciacitrl ni ermentgniid the tni“op fo no rt”r,nue nad ncsiuobtrte to hte yanbiliit to rseilehbtsa rlamon ngul eruatrccieht wthi omtoinrop fo ifbsoris;

)2( slos fo paiielhelt lc,sle loaeeldnthi e,lcsl nad beeanmts mbernema titgrinye ni ulaus rittanilteis aipneunmo asoitcsead with pthiiicado rupmnlyoa iifbrsso edlsa ot eyrdtseod nglu aurciteetcrh adn erpptaeul biis;sfor

)3( namstrognifr orghtw arctoβ-f si enase,crys utb otn etiynlre iftu,fescni to pomeort rnnpemtea sri;obsfi

(4) einsptstre niiatjrutigr/n/ietnrnya is lcicarit fro hte naioratogpp fo foi;isrsb

5() ocaphtiidi ournmpayl srsbioif is an leapmxe of a rsesocp altrdee to het peensretcis fo an nnet)(“igs,”a crohinc f,oaliinntmma adn ib;fosirs nda

(6) quuein lcesl are irciltac crulelal splraey ni the aglneiuort fo ofs.bsiri

:n toiitca/in/t4mM4.rpw/n2pcP/s.:/5wenh.a/bolsth.lic62miwgt1cCv

kernicterusthefrog  Lovely +  
endochondral1  any FA or pathoma or uworld correlation? +  
endochondral1  or was this a random? +  
taediggity  Type II pneumocytes serve as the stem cell precursors, w/out those you're more or less fucked: FA 2020 pg 661 +4