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 +1  (nbme24#46)

When proteins being made in the ER misfold, they accumulate in the ER, which then triggers them to be spit out into the cytosol and become degraded by proteasomes. Thus, the accumulation of the misfolded protein in the ER is required for them to ultimately be tagged by ubiquitin and be degraded in proteasomes.

Even if you argue that they will be accumulating in the cytosol because proteasomes are in the cytosol, the question is asking where are the proteins accumulating, not being degraded. So they can't accumulate in proteasomes, because they are destroyed in them.

drdoom  nice catch with the “accumulating” remark! qq, when you say “triggers them to be spit out into the cytosol”, do you have a source for that? don't recall learning that anywhere myself. thx!
therealslimshady  I can't remember where I read this but it stuck with me, I think it was a cell bio book

 +1  (nbme24#19)

C and D are never really the right answers on ethics questions. B is out because nurses are not specifically trained to do this), you're left with A and E. Because her blood pressure is 90/60, pulse is 120, she's bleeding out and this is an emergency. The other facility is 2 hours away. Asking the patient if she'd allow the exam wouldn't hurt, wouldn't it? It doesn't say "forcefully examine her", it says ask. If she says no, then you'd have no other choice but to let her bleed out on the 2 hour drive to her family obstetrician.

drdoom  dude you’re on point with these close readings of the stems! Lit(erature) major?

 +0  (nbme24#49)

I honestly don't understand why A is the correct answer. I picked "move back to the dorm" because there are three asthma triggers in her dorm: (1) the smoker, (2) the fact that her roommate doesn't like it when it's too warm (she doesn't want to be cold, and cold is a trigger for asthma), and (3) the stress of people who don't clean their dishes. Stress, cold, and smoke. Those are triggers for asthma that are present in her apartment. Is anyone else not seeing this?

123ojm  Because presumably she's already signed a lease and cannot afford to pay a second rent by moving back into the dorms. I think this goes back to making suggestions for our patients that are reasonable for them to achieve.
123ojm  Also her roommate is the one that makes it warm, so the apartment is not cold

 +0  (nbme24#35)

Here is my personal way how I reasoned to the correct answer, if it helps anyone. First off, I recognized she probably has ALS, as she has purely motor symptoms (no sensory symptoms) that include both UMN (3-week history of muscle cramps) and LMN lesions (fasciculations, atrophy). In ALS, you have damage to anything that is composed of UMNs and LMNs. UMNs are found in (A) cerebral white matter, (B) corticospinal tract, and (C) internal capsule. I picked (D) for two reasons: (1) she has more LMN symptoms than UMN symptoms (the only UMN symptom was muscle cramps), and (2) choices A, B, and C are all UMNs, and so they can't all be right.

That's just what was going on through my brain. Very convoluted I know and might have errors, but if I helped at least 1 person then I did my job.


 +0  (nbme24#2)

Daytime sleepiness, fatigue, frequent nighttime awakening, snoring, and obesity (BMI>30) are all symptoms of obstructive sleep apnea. Frequent cessations of breathing during sleep result in a decreased O2 saturation in his lungs, which causes hypoxic vasoconstriction in the pulmonary vessels, and over time this leads to irreversible pulmonary hypertension (loud S2), and the pulmonary HTN eventually causes right heart failure, which is what's causing his peripheral edema.


 +0  (nbme24#19)

Weird wording on the last sentence "Which of the following pulmonary function tests in this patient will most likely show a result greater than the predicted range?"

I mean, I was like this guy definitely has pulmonary fibrosis, so I'm predicting that his range of FVC, RV, FRC, TV, etc is low. It would be nice if it said 'greater than a normal patient'


 +0  (nbme24#5)

I thought there weren't supposed to be trick questions on these things.


 +0  (nbme24#10)

Given the diagnosis of AAA, why did he have syncope? I was first thinking it was from rupture, but his blood pressure is not hypotensive, so how could he get syncope from that.

Or maybe the AAA was compressing the inferior vena cava, causing syncope?


 +0  (nbme24#24)

You can eliminate C because her diabetes was well controlled in the past. The fact that there is stress in her family and she has poor glucose control tells you that the her poor glucose control is secondary to the stress in her family. So you want to fix the real problem, and to do this, you need more information about it, so pick B, as open-ended questions will always give the physician more insight to what's going on and better be able to decide how to tackle the problem





Subcomments ...

When proteins being made in the ER misfold, they accumulate in the ER, which then triggers them to be spit out into the cytosol and become degraded by proteasomes. Thus, the accumulation of the misfolded protein in the ER is required for them to ultimately be tagged by ubiquitin and be degraded in proteasomes.

Even if you argue that they will be accumulating in the cytosol because proteasomes are in the cytosol, the question is asking where are the proteins accumulating, not being degraded. So they can't accumulate in proteasomes, because they are destroyed in them.

drdoom  nice catch with the “accumulating” remark! qq, when you say “triggers them to be spit out into the cytosol”, do you have a source for that? don't recall learning that anywhere myself. thx! +  
therealslimshady  I can't remember where I read this but it stuck with me, I think it was a cell bio book +  


submitted by drschmoctor(45),

How does one differentiate factitious disorder from being thirsty w poor impulse control?

therealslimshady  If you're asking how to rule out diabetes insipidus, I think it's because: Diabetes insipidus is caused by a lack of ADH effect, so they will be peeing out too much water, thus making them dehydrated and hyperosmolar (thirsty). This CHF patient is presenting with signs of fluid overload +  


For those who were wondering like me, they gave the Beta-hydroxybutyrate (a ketone body) levels in order to rule out DKA (diabetic ketoacidosis) in a type 1 diabetics and which would otherwise not be distinguishable based only on C-peptide and insulin levels

therealslimshady  Regardless of the ketones, DKA is not likely anyway, since you'd see hyperglycemia in it, but this patient has hypoglycemia +  


in the other hand , urine potassium is high enough , so if seizures =>rhabdomyolysis => myoglobinuria => ATN => high potassium excretion , why not?

krewfoo99  True but hypokalemia would occur in the recovery phase. So weeks after the inciting phase. +1  
therealslimshady  Acute rhabdomyolysis would lead to hyperkalemia, not hypokalemia, because cells are packed with K+ +  


submitted by neonem(451),

Small cell carcinoma of the lung may produce paraneoplastic syndromes, of which ACTH and ADH are the more common subtypes. ACTH excess leads to excess stimulation on the adrenal cortex to produce cortisol, resulting Cushing's syndrome. Excess cortisol (normally a stress hormone) causes hypertension via potentiation of sympathetic stimulation on the vasculature. It can also cause hypokalemia by acting as a mineralocorticoid when in excess, saturating the ability of 11-beta-hydroxysteroid dehydrogenase (present in the renal tubules) to convert cortisol to cortisone, which doesn't act as a mineralocorticoid.

therealslimshady  Adding some ways to eliminate the other answer choices for good measure: B) ADH can be secreted by small cell lung cancer (SCLC), and would cause SIADH, but that does not manifest with hypertension or hypokalemia. C) Epinephrine can cause hypertension (a1 effect), and hypokalemia (via stimulation of the Na/K-ATPase), but is secreted by pheochromocytomas rather than SCLC. D) PTHrP does not cause hypertension or hypokalemia, and is secreted by squamous cell carcinoma of the lung, not SCLC. E) VIP can cause hypokalemia through diarrhea (see VIPomas in First Aid), but not hypertension, nor is secreted by SCLC. +2  


submitted by gonyyong(64),

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

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

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +12  
howdywhat  my exact thought, telling him that it will last for somewhere around a year and a half doesnt seem so reassuring +1  
suckitnbme  I thought it was reassuring in that the kid is being told this isn't permanent as well as that this isn't something serious. It's important to inform him about the prognosis. +5  
thotcandy  "don't worry your gynecomastia isn't permanent, but the mental scars from the bullying you will receive in HS definitely will be :) good luck!" +1  
therealslimshady  What is the gynecomastia is from a prolactinoma? +  
misterdoctor69  @therealslimshady the gynecomastia is from the sudden surge of testosterone during puberty being converted into estrogen => more breast tissue. +  


submitted by neonem(451),

This patient has major depressive disorder: loss of interest/anhedonia (need to have this or depressed mood),sleep problems, weight changes, decreased energy, thoughts of death. Meets criteria because > 2 weeks timeframe. SSRIs are first-line; paroxetine is in this category. SSRIs also help with weight gain - might be an added benefit if the patient is underweight.

The cardiac stuff might have just been a distractor, except that you probably wouldn't want to give tricyclics (i.e. amitriptyline) since they have pro-arrhythmic side effects. Patient probably has prolonged PR interval due to beta blockers.

adisdiadochokinetic  Another reason not to use TCAs (or alprazolam or haloperidol for that matter) is that the Beers criteria state to avoid the use of all of those drugs in patients over the age of 65. +2  
t123  The cardiac stuff is not a distractor - MDD is common after an MI, and a very poor prognostic factor (reinfarction) +4  
therealslimshady  Beers criteria also says avoid antidepressants though. +  


submitted by neonem(451),

NRTIs are the main HIV therapy drug that can cause bone marrow suppression (not as common with NNRTIs). This class includes zidovudine, didanosine, emtricitabine, lamivudine, stavudine, abacavir. Zidovudine is most known for this side effect.

Nelfinavir = protease inhibitor azithromycin = aminoglycoside (not really used for HIV) pentamidine = another antimicrobial, mostly used for pneumocystis I think? Lamivudine = another NRTI but less known for bone marrow suppression

adisdiadochokinetic  Azithromycin is a macrolide, not an aminoglycoside FYI, and its use in HIV is primarily as prophylaxis at very low CD4 counts for, among other things, the mycobacterium avium complex. +5  
nbmehelp  How would we have known to choose Zidovudine over Lamivudine tho +5  
mjmejora  @nbmehelp the sketchy with Princess Izolde (Zidovudine) eating bone marrow was my only tip off +6  
niboonsh  you have ero bone marrow if you take idovudine +1  
niboonsh  the z's were supposed to be bold idk what happened. you have Zero bone marrow if you take Zidovudine +4  
t123  Zidovudine is also a very early NRTI developed. As a good rule of thumb, older drugs have worse side effects +2  
therealslimshady  Zidovudine Zaps your bone marrow (sorry) +1  


submitted by haozhier(3),

Can someone please explain to me: If the posterior 1/3 of the tongue is developed from 3rd and 4th pharyngeal arches, why is it wrong to choose pharyngeal arch?

therealslimshady  Welcome to NBME +  


gubernaculum  also just an FYI, her achilles reflex symptom is called Woltman Sign and can be seen in many cases of hypothyroidism +1  
ruready4this  got the right answer but does anyone know why a lingual thyroid would cause hypothyroidism instead of hyperthyroidism? because I know patients who have a lingual thyroid removed are at risk of hypothyroidism +1  
therealslimshady  Probably not scientifically accurate, but the body is like, hey, lingual thyroid, you're in the wrong place, you don't get to grow! Hypothyroidism ensues. Plus I don't think you'd be able to swallow if you had a normal-sized thyroid literally inside your throat. +  
qiss  @ruready4this, she probably has hypothyroidism because her lingual thyroid isn't functioning enough like a normal sized thyroid. The question mentioned no palpable thyroid gland, as in the lingual thyroid is doing all of the work due to an absent thyroid gland in the neck. This is actually the reason why patients who have a lingual thyroid removed are at risk for hypothyroidism- once you remove it, you have zero tissue producing thyroxine. +  


submitted by ap88(-1),

Why can this not be papillary necrosis? Given the gross Hematuria and proteinuria with a history of analgesic use... I thought that was what this was getting at?

biaancadb  I was confused about this too. Only thing I had to go on is that I wrote down from somewhere that you see papillary necrosis in middle-aged adults and that it's uncommon in children (except those with sickle cell). Also I'm assuming PSGN is technically a proliferative glomerulonephritis since on FA pg. 578 the definition of proliferative is "hypercellular glomeruli", and for PSGN, you see hypercellular glomeruli on LM (due to leukocyte infiltration). +1  
gubernaculum  also papillary necrosis tends to be the cause of these 4 (SAAD papa): Sickle cell, Acute pyelonephritis, Analgesics, Diabetes, which the patient does not have +1  
therealslimshady  If you're torn between papillary necrosis and proliferative GN (PSGN) here, note that the patient has three things that are not supposed to be seen in renal papillary necrosis: (1) elevated BUN and creatinine, (2) RBC casts, and (2) peripheral edema. +  


submitted by hhsuperhigh(11),

The diet is prescribed, so no need to refer to dietician anymore. It is a case of the patient non-compliance of diet. But why can't advise the parents to stop bickering?

therealslimshady  I remember Boards and Beyond said that you never want to pick any statements that sound "scolding", plus it couldn't be much help to just say "stop arguing", it's better to find out information on what's causing the arguing so that you can stop it entirely, which choice B will allow you to do. +  


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