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 +0  (nbme18#32)

I picked E) inhibition of TNF-a because I thought 2 years of diarrhea sounds like IBD (specifically crohns Disease without bloody diarrhea vs uc which must have bloody diarrha). I still don't see any reason why I wouldnt guess that.

tinydoc  Nevermind just saw the "typically relieved with defecation" which is a pretty big indicator of IBS.

 +1  (nbme23#22)

https://youtu.be/HIRz5hJf3mU

MOA of proteosome inhibitors for MM. TLDR: is that they basically block the proteosome from functioning so that myeloma cells can't recycle protiens (they make a ton of them) and when they can't be recycled they build up and thats toxic to the cell and it dies.

beyond that the question is basically asking if the inhibition of proteosomes isnt specific to the Myeloma cells and it inhibited other cells' proteosomes what would be effected?

MHC class I is present on all nucleated cells (all cells in the body except RBC) and function to present endogenous antigens to CD8+ t cells to be destroyed (for example Viral DNA in an infected cell). The way they do this is by taking the protien it needs to present and breaking it down into much smaller peptide chains (so it can fit on the MHCI. If this step was inhibited in other cells then the the Presentation of MHC I wouldnt be able to present their antigens to CD8+ T cells and Natural killer cells. as the question implies.

The question was super tricky because if you don't know how proteosome inhibitors work then you start looking for an answer that would explain how they would kill tumor cells as well. I got it wrong too. It required knowledge of the way MHC I presents peptides.


 +0  (nbme23#38)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116089/#!po=56.2500

I've had a uworld q where the correct response was to remove the life support if the patient is determined not to be an organ donor.even if the family is actively against this decision. In my experience the answer that is most honest (and likely makes you sounds like a tactless asshole) is usually the correct one on NBMEs. I picked E and I don't see how this friends opinion on his advanced care directives are at all relevant if the patient by all acounts medically and legally is considered dead.


 +1  (nbme24#35)

I don't think it matters whether or not this was ALS ( which I still think it is). But theres fasiculations and Weakness and atrophy those are LMNL signs. Theres sooo many sneaky questions in this exam, this isnt one of them.


 +3  (nbme24#16)

This question is very sneaky, but in essence this is whats happening.

The accidental removal of the PTH glands during thyroidectomy ⇒ ↓ PTH

PTH normally: --in bone: ↑ removal of Ca²⁺ and Phophate from bone --in kidneys: ↑ Ca²⁺ reabsorption and ↓ PO₄³⁻ reabsorption --↑ conversion of 25, Hydroxyvitamin D to 1,25 Hydroxyvitamin D (Calcitriol - active form) via ↑ activity of 1-a Hydroxylase deficiency

Therefore a ↓ PTH would lead to:

⇒ ↑ PO₄³⁻ ⇒ ↓ Ca²⁺ ⇒ ↓ 1,25 Hydroxyvitamin D

The question is sneaky (much like the rest of this exam) because someone who isnt focusing really hard or in a rush might pick the option C where phophate is ↑ and PTH is ↓ BUT ↓ 25 hydroxyvitamin D

This is wrong as only 1,25 hydroxyvitamin D would be decreased, the conversions before this are done by the skin (sunlight) and liver.

I really wish they would stop making the questions confusing PURELY for the sake of making them confusing. Isnt it enough that we have to know this ridiculous amount of information, without having them intentionally making it harder by pointing you to 1 answer choice but changing a minute detail to make you answer wrong. Or using a random ass nomenclature for a disease to avoid making it too simple (PSGN = "proliferative GN")

tinydoc  I literally got this wrong because I had the font zoomed in and assumed the 1 was on the line above like on uworld when it tries to squish the whole title in the same space x_X

 +6  (nbme21#24)

infarcts would be a more peripheral wedge shape

abcess wouldnt be invasive to the surrounding area i think.

squamous cell is more centrally located

wasn't 100% sure but thats the best answer slthough stupid to give 0 symptoms and just a picture, nothing like an actual clinical scenario

tsl19  Squamous cell is centrally located and has cavitation, which you can see in the pic. Similar to this one: https://webpath.med.utah.edu/LUNGHTML/LUNG068.html

 +8  (nbme21#30)

Type 1 Familial Dyslipidemia (pg. 94 FA 19 )

increased TG ---> pancreatitis Eruptice / pruritis Xanthomas and HSM

Can be caused by Lipoprotien lipase or Apoprotien CII deficiency

they said that LPL is fine so its APO CII

Heparin seperates LPL from Herparin Sulfate Moeity on Vasc Endothelium allowing us to test its function in the lab.

I got it wrong too - Stupid Rote memorization recall Question.

masonkingcobra  I think you need to know that ApoCII activates LPL not necessarily know the disease
yotsubato  Knowing the disease makes it easier to remember the details though

 +7  (nbme21#31)

Hyperparathyroidism causing bone lesions is via Osteoblasts increasing RANK -L expression to bind to RANK on Osteoclasts and stimulating them ---> inc Bone Resorption


 +5  (nbme21#49)

Neuropathic Pain after stroke is central Post stroke pain Syndrome

caused by contralateral thalamic lesions

Pg. 504 FA19


 +5  (nbme21#10)

Cysteine Urinary Stones:

Hexagonal Crystals

Positive Nitroprusside test

Due to a hereditary inability to reabsorb : Cysteine, Ornithine, Lysine, And Arginine ( COLA ) ----> Only Cysteine percipitates to make renal stones although all can be found in the Urine.

The diagnosis can be made based on the Characteristic test they mentioned, The Hexagonal shape of the stones, and the fact that his brother has a similar condition ( points to hereditary )

Tyrosine and copper dont cause kidney stones

although calcium is very common it has a different shape and isn't gonna be positive for nitroprusside test.


 +0  (nbme21#48)

Ptx appears to have Muscle spasticity as a result of MS. Spasticity is treated with a muscle relaxant like Baclofen which is a GABA agonist. Bethanacol is a Cholinomimentic which can be used to treat Urinary dysfunction in Multiple sclerosis. but the Question asks what would help treat the spasticity.


 +2  (nbme21#48)

Ptx appears to have Muscle spasticity as a result of MS. Spasticity is treated with a muscle relaxant like Baclofen which is a GABA agonist. Bethanacol is a Cholinomimentic which can be used to treat Urinary dysfunction in Multiple sclerosis. but the Question asks what would help treat the spasticity.

sbryant6  To remember Baclofen is a GABA agonist and muscle relaxant, I always think of the "Greek Baklava". Greek for GABA, Baklava for Baclofen.
sahusema  Also, acts on GABA receptors specifically in the spinal cord




Subcomments ...

submitted by tinydoc(54),

I picked E) inhibition of TNF-a because I thought 2 years of diarrhea sounds like IBD (specifically crohns Disease without bloody diarrhea vs uc which must have bloody diarrha). I still don't see any reason why I wouldnt guess that.

tinydoc  Nevermind just saw the "typically relieved with defecation" which is a pretty big indicator of IBS. +  


Did anyone else go down the: she's hypotensive so maybe she'll get waterhouse friderichsen syndrome because nothing else is making sense to me at this point??? route -

Turns out, severe malaria can cause cardiovascular collapse and hypotension.

shriya goyal  yes I answered it like that +1  
redvelvet  me too :( +  
abigail  me three :( +  
yex  Me four :-/ +  
link981  Slowly raising my hand as well +  
tinydoc  Sammmme +  
bullshitusmle  same here!!!:@ +  


submitted by yotsubato(264),

This is a question about patient privacy. The patient here is the child. The proxy for the patient is the mother and father. They must know whats wrong. Sister and mother are just lookyloos, and parents may not want to tell them (stupid I know, but whatever) so you send them out and then tell the parents the situation.

dr.xx  agreed +  
thepromise  so you're not gonna conceal the abnormality and act like its their fault? since they touched it last +1  
tinydoc  How on earth would they expect the parents to conceal a malformed upper extremity from the grandmother and the aunt of the child in a family that is close enough to allow these people to be in the room during the delivery. As always the ethics questions seem to make sense in retrospect, but always seem to have a ludicrous action on your part that you wouldnt do in practice. +  


If the abnormality was something more life threatening, wouldn't the first action be to call the pediatrician? I was thinking, limb extremity might mean something else more serious was happening too --> need pediatrician right away to dx.

tinydoc  I thought about that but then I ruled it out as with the NBME ethics questions the answer is almost never to defer to someone else. The question doesn't ever tell you what type of doctor you are for you to be referring to a different more specialized physician. Also I assume that they think if there was something wrong you could handle it. +  


Skin provides insulation and prevents heat loss. This patient's body will compensate for increased rate of heat loss by increasing metabolic rate.

davidw  This is directly from Goljan I) Hypovolemic shock may occur due to loss of plasma from the burn surface (refer to Chapter 5). • Loss of protein from the plasma loss may result in generalized pitting edema. II) Infection of the wound site and sepsis may occur. (a) Sepsis due to Pseudomonas aeruginosa is the most common cause of infection in burn patients. (b) Other pathogens include methicillin-resistant S. aureus and Candida species. (3) Curling ulcers may occur in the proximal duodenum (refer to Chapter 18). (4) Hypermetabolic syndrome may occur if >40% of the body surface is burned. +1  
yex  Can someone explain why is it not increased ECF? +  
charcot_bouchard  i picked same. Increased ECF but cant remember why. Can you explain WHY it is increased ECF? what was ur reasoning +1  
isotopes  Burns would lead to a decrease in ECF because the protection from fluid loss is absent; it can lead to shock. :) +  
tinydoc  My reasoning behind picking ↑ ECV was that your losing fluid but not electrolytes with the burn ⇒ the ecv would have increased osmolarity, so the fluid from the ICV would be pushed the the ECV. It made sense to me at the time. I guess technically its wrong because the loss of fluids and the gain of fluids would amount to pretty much the same thing. But the insulation and heat loss thing makes sense I guess. +  
yex  Increased ECF, bc I was thinking about the edema formation.... :-/ +  
atbangura  I picked increased ECF because burns increase the capillary permeability coefficient, but now that I am going over it I realized that increasing the permeability would only transfer plasma volume to the interstitial volume, which are both a part of the ECF so therefore ECF would not change. SMH +  


submitted by mousie(83),

Your pituitary lactotrop cells hypertrophy during pregnancy to produce increasing amounts of prolactin - part of the pathophysiology of Sheehan's syndrome... increased blood loss during delivery can cause ischemic necrosis of pituitary

tinydoc  I thought the elevated Estrogen and progesterone depress the function of Prolactin until delivery. I guess you needed to know that it decreases its function by downregulating receptors or something as opposed actually decreasing the prolactin production. I picked gonadotrophs. This was a fair question but I reasoned it out and arrived at the wrong conclusion. +  
maxillarythirdmolar  Specifically, the estrogen is stimulating lactotrophs as progesterone is preventing the prolactin from actually working on the breasts. So it's the estrogen that is stimulating the lactotrophs to grow, and you would see the effects of this growth if it weren't for the progesterone preventing the action of prolactin (their secretory product) on the breasts. +1  


submitted by notadoctor(60),

SLE is associated with deficiency of early complement proteins(eg. C1q, C4, C2). (FA 19, pg. 462)

tinydoc  Am I the only one who has never heard of C1Q? +1  


A normoblast is an immature RBC, so it's elevated in states of increased hematopoiesis.

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +9  
someduck3  The term "Normoblast" isn't even in first aid. +9  
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +  
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. +2  


submitted by usmleuser007(113),

PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium)

imnotarobotbut  That's not the right answer tho, the answer is the binding of PGE to it's receptor +  
tinydoc  Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1  
maxillarythirdmolar  Keep it simple, stupid. +  
roaaaj  @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +  


submitted by welpdedelp(75),

Hemochromatosis, aka "bronze diabetes". Cannot be Addison due to the hyperglycemia and normal BP

alexb  I missed this bc didn't notice it was a middle-aged guy w/ just 3 year hx of Type 1 DM. +  
tinydoc  I got it mixed up with primary adrenal insufficiency and the acth ⇒ hyperpigmentation. +2  
maddy1994  testicular atrophy &hepatomegaly helped me out to eliminate the options..when i was left with ferritin and saw pigmentation it clicked that it is hemochromatosis +  


submitted by brethren_md(44),

Classic sleep apnea in the patient. Cessation of breathing causes nocturnal hypoxia and systemic hypertension/arrhythmic/sudden death can persist. PaO2 is normal during day and decreased during episodes and at night. Classically seen in Obese patients such as the patient in the question stem.

tinydoc  Caused a cessation of breathing rather than a ↓ in lung volume although a patient could develop an obesity related restrictive lung disease thats not whats happening with this question. +  
sunshinesweetheart  p 665 FA 2019 +  


submitted by step420(18),

Question pretty much is asking what type of virus is Measles, which is a Negative ssRNA virus.

dragon3  is the AIDS to indicate that he can't get live vaccinations? +1  
tinydoc  Yep, also his unimmunized cousin points you to the fact that he got it from someone else who was unimmunized. +  


submitted by tinydoc(54),

This question is very sneaky, but in essence this is whats happening.

The accidental removal of the PTH glands during thyroidectomy ⇒ ↓ PTH

PTH normally: --in bone: ↑ removal of Ca²⁺ and Phophate from bone --in kidneys: ↑ Ca²⁺ reabsorption and ↓ PO₄³⁻ reabsorption --↑ conversion of 25, Hydroxyvitamin D to 1,25 Hydroxyvitamin D (Calcitriol - active form) via ↑ activity of 1-a Hydroxylase deficiency

Therefore a ↓ PTH would lead to:

⇒ ↑ PO₄³⁻ ⇒ ↓ Ca²⁺ ⇒ ↓ 1,25 Hydroxyvitamin D

The question is sneaky (much like the rest of this exam) because someone who isnt focusing really hard or in a rush might pick the option C where phophate is ↑ and PTH is ↓ BUT ↓ 25 hydroxyvitamin D

This is wrong as only 1,25 hydroxyvitamin D would be decreased, the conversions before this are done by the skin (sunlight) and liver.

I really wish they would stop making the questions confusing PURELY for the sake of making them confusing. Isnt it enough that we have to know this ridiculous amount of information, without having them intentionally making it harder by pointing you to 1 answer choice but changing a minute detail to make you answer wrong. Or using a random ass nomenclature for a disease to avoid making it too simple (PSGN = "proliferative GN")

tinydoc  I literally got this wrong because I had the font zoomed in and assumed the 1 was on the line above like on uworld when it tries to squish the whole title in the same space x_X +  


submitted by jambo2222(12),

It’s an osteosarcoma. Sarcoma = hematogenous mets. It’s in the legs so think how a DVT goes to lung. Same idea.

tinydoc  Perfect way to remember it. Thank you! +  


submitted by beeip(63),

This has been a tough concept for me to get, but I think I'm finally there:

The stem is describing primary adrenal insufficiency, or Addison's.

  • ACTH is being over-produced to stimulate the adrenals to produce cortisol, but they can't respond, either due to atrophy or destruction (TB, autoimmune: DR4, etc.)
  • The first 13 amino acids of ACTH can be cleaved to form α-MSH, which stimulates melanocytes, causing hyperpigmentation
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +3  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +5  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +  


submitted by jotajota94(10),

High glucose leads to more insulin production in the fetus (recall that the hormone insulin is anabolic) ---> large fetus (9lb,1oz)---> problems in labor.

tinydoc  I thought that was technically a problem with the fetus and wasnt considered an obstetric complication. +  


submitted by celeste(32),

The constellation of symptoms sounds like tuberous sclerosis. Cardiac rhabdomyoma is a rare benign tumor that is frequently associated with tuberous sclerosis.

tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +3  
tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +2  


submitted by celeste(32),

The constellation of symptoms sounds like tuberous sclerosis. Cardiac rhabdomyoma is a rare benign tumor that is frequently associated with tuberous sclerosis.

tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +3  
tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +2