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Comments ...

 +0  (nbme21#25)

This is my second time doing this question TY COVID. The definition of an Osm is the number of osmoles of solute per liter of solvent. The stem tells you the highest she can concentrate her urine is 450 mOsmol/kg H2O, and she takes in 450 mOsmol/day. She also loses 1000 mL from sweat, feces, etc.. The mOsmol variables are NOT related to the 1000 mL. It is going to take 1 liter to concentrate that 450 mOsmol urine, and she also loses a separate unrelated 1 liter. Together, the minimum amount of H2O needed is going to be 2 liters.


 +1  (nbme21#37)

Some of these explanations really doing the most. If the enzyme is able to increase to normal activity with a higher level of the substrate, that means we’re in a competitive inhibitor situation. Competitive always crosses on the graph, so we can eliminate A and D.

Now we analyze Km. We want small Km’s for potent enzymes. Size does not always matter 😉. Except in this case we don’t want that potency, we want to look for a 1/(really big Km), (value that is closer to zero), bc we want a weak big Km to be able to overpower the competitive inhibitor. Comparing the remaining 2 choices, B has a Km value closer to zero so there’s your answer.


 +0  (nbme21#23)

I was so fixated on the fact that in a TB granuloma, macrophages produce IL12 or TNFalpha, not IL1. So I eliminated C and clicked B, even tho it’s not CD4 lymphocytes that produce TNFalpha. But the fact that macrophages produce IL1 still didn’t make any sense.

I couldn’t find any explanation in first aid for this (it doesn’t tell you what cells secrete IL1), but according to my notes from an immuno lecture I half paid attention to, IL1 is a cytokine of innate immunity secreted by monocytes, macrophages, endothelial cells, and epithelial cells; so basically everybody. This goes in conjunction with everything that FA says (FA18 p. 108)

makingstrides  Macrophages secrete Il-1,6,8,12 and TNF - alpha. In this scenario, the patient is Il-12 receptor deficient. When macrophages engulf an object, it releases Il-12 to stimulate T-lymphocytes, that in return, release Ifn-gamma, which would convert the macrophage into an epithiliod histiocyte. +

 +0  (nbme20#24)

Why has no one commented about recurrent branch of median? Recurrent branch of the median nerve innervates all thenar muscles, with the exception of the adductor polis which is innervated by the ulnar.

Also the recurrent branch does not innervate interosseous muscles, that’s ulnar.

Also also Froment’s sign tests thumb adduction.


 +0  (nbme20#32)

What is partial oxidation lmao. Is it beta oxidation? Is it FAs that has been partially oxidized? Is it FAs that have been partially beta oxidized? Please advise.

trazobone  Ok after regrouping with myself, if you ignore the “partial” part of the answer choice, it makes sense. And you can eliminate everything else. +

 +0  (nbme20#26)

You would think the rectus femoris is in the back bc rectum, and biceps is in the front. But no. Okay then.

makingstrides  This is how I remember the biceps, hopefully it helps. Biceps flexes (think of biceps of your arm) - flexion of the leg is raising the leg posteriorly; therefore biceps femoris must be posterior. +1

 +0  (nbme20#1)

For anyone who was like me and clicked Liver Testosterone Metabolism, yes you would see gynecomastia in a liver pathology, but that’s because the liver metabolizes ESTROGEN not testosterone, leading to an overall imbalance of estrogen:testosterone levels.


 +0  (nbme13#7)

Normal hormonal, male sperm study and normal semen: still can’t conceive then give TYR (???) with clomiphene, that is antagonist at GnRH receptor at hypothalamus, block estrogen mediated inhibition of GnRH hence increase release of LH surge Bromocriptine - would be helpful if the pt has infertility due to INCREASE LPEDS CTIRAON (??? I am assuming its PROLACTIN) - is stopped in US due to clear cell carcinoma in young female born to term. Ethinyl estradiol - bind estrogen & GnRH; LH surge: no use. (Inc risk of endometrial carcinoma) Medroxyprogesterone - is progesterin bind progesterone eonis(oeeccn.rprpmot..t. (???) of morning after pill)

trazobone  Clomiphene: a SERM, antagonist at estrogen receptors in hypothalamus (FA18 637) +

 +0  (nbme13#15)

SMH I had it in my head that bromocriptine is used to treat Parkinson so I eliminated the answer. But it’s a dopamine agonist that will also treat a pituitary prolactinoma.

trazobone  SMH I had it in my head that bromocriptine is used to treat Parkinson so I eliminated the answer. But it’s a dopamine agonist that will also treat a pituitary prolactinoma. +

 +0  (nbme13#41)

A) Codeine - common in cough syrup but it’s a weak agonist at mu and delta receptors, so there’s potential for substance abuse.
B) Dextromethorphan - a cough suppressant with low potential for abuse and does not cause constipation; antagonizes NMDA receptors (not mu kappa or delta receptors).
C & D) Hydromorphone & oxycodone -- potent opioids used to treat moderate to severe pain (I am assuming they work at mu receptors but it’s not in FA so 🤷🏻‍♀️)

E) Tramadol - a weak opioid agonist used for neuropathic pain, acts by reuptake of NE and 5HT

trazobone  A) Codeine - common in cough syrup but it’s a weak agonist at mu and delta receptors, so there’s potential for substance abuse. B) Dextromethorphan - a cough suppressant with low potential for abuse and does not cause constipation; antagonizes NMDA receptors (not mu kappa or delta receptors). C & D) Hydromorphone & oxycodone -- potent opioids used to treat moderate to severe pain (I am assuming they work at mu receptors but it’s not in FA so 🤷🏻‍♀️) E) Tramadol - a weak opioid agonist used for neuropathic pain, acts by reuptake of NE and 5HT IN CASE ANYONE TRIES TO SCRAMBLE +

 +1  (nbme13#21)

If anyone else is on the dumdum boat and didn’t know what a paranganglioma was: a neuroendocrine tumor that begins in nerve cells, closely related to a pheochromocytoma

cheesetouch  Mayo clinic says 2 out of 1 million people have a paraganglioma. Talk about a zebra! +1

 +1  (nbme13#41)

SMH I was thinking alcoholic B12 loss of vibratory, so obvious now he has ALS. Hyperreflexia UMN sign, fasciculations LMN sign. And common cause of death is due to aspiration pneumonia because of dysphagia (LMN deficit). FA 2018 p 514

trazobone  Sorry dysphagia (UMN deficit) +
trazobone  SMH I was thinking alcoholic B12 loss of vibratory, so obvious now he has ALS. Hyperreflexia UMN sign, fasciculations LMN sign. And common cause of death is due to aspiration pneumonia because of dysphagia (UMN deficit). FA 2018 p 514 +
cheesetouch  UMN vs LMN is FA18 p 513 also! +

 +0  (nbme13#21)

I answered this via process of elimination.

A) Gliobastoma multiforme - no b/c that would need to show a tumor B) HSV encephalitis - would need to be in the temporal region and also doesn’t quite fit with the 25 year seizure disorder history C) Mesial temporal sclerosis - i have no idea what this is really, but judging from “sclerosis” i assume there needs to be some signs of sclerosis which is not present in the photo D) Neonatal ischemic stroke - no she old E) Vascular malformation - could not think of a vascular disorder that was associated with seizures, but it makes sense b/c the picture shows a bunch of dilated spaces which I assumed are the vessels being malformed

trazobone  I answered this via process of elimination. A) Gliobastoma multiforme - no b/c that would need to show a tumor B) HSV encephalitis - would need to be in the temporal region and also doesn’t quite fit with the 25 year seizure disorder history C) Mesial temporal sclerosis - i have no idea what this is really, but judging from “sclerosis” i assume there needs to be some signs of sclerosis which is not present in the photo D) Neonatal ischemic stroke - no she old E) Vascular malformation - could not think of a vascular disorder that was associated with seizures, but it makes sense b/c the picture shows a bunch of dilated spaces which I assumed are the vessels being malformed +1

 -1  (nbme13#32)

SMH it all boiled down to what does tyrosine kinase do? Kinase phosphorylates stuff. So therefore the homodimer would still form but since the key thing thats being messed up here is the kinase, it’s the phosphorylation process that gets disrupted.

trazobone  SMH it all boiled down to what does tyrosine kinase do? Kinase phosphorylates stuff. So therefore the homodimer would still form but since the key thing thats being messed up here is the kinase, it’s the phosphorylation process that gets disrupted. +1

 +0  (nbme13#29)

This is straight up testing if you knew Ab nomenclature 🙄. -umab designates human origin while -omab designates murine origin. So bevacizumab is a humanized Ab. The other answer choice saying it was a murine Ab directed against VEGF was designed to trick you. Luckily I did not fall for such witchery.

trazobone  This is straight up testing if you knew Ab nomenclature 🙄. -umab designates human origin while -omab designates murine origin. So bevacizumab is a humanized Ab. The other answer choice saying it was a murine Ab directed against VEGF was designed to trick you. Luckily I did not fall for such witchery. IN CASE ANYONE TRIES TO SCRAMBLE +1

 +0  (nbme13#7)

This cells should be stem cell transplant so homing is the environment that accept them and nourish them with growth factors to mature

trazobone  I don’t understand what I unscrambled. This does not apply to the question stem? +
trazobone  Apparently there is something called “hepatic homing” that occurs with mononuclear inflammatory cells I have never heard such a thing +1

 +2  (nbme15#3)

Vitals and need to be treated first, so atropine and then pralidoxime.

RIP I’m not descrambling this link

Important note that organophosphate becomes irreversible at a certain point so pralidoxime does still need to be given early


 +1  (nbme15#43)

Cool and pale extremities rules out distributive causes (neurogenic, anaphylaxis, septic).

Hypovolemia would describe a process of volume loss bleeding (or dehydration) and would not explain the crackles or jugular venous distention.

Don’t be thrown off by the normal heart sounds. I am getting real good at this descrambling thing.

cheesetouch  JSYK, if it shows scrambled to one person doesn't necessarily mean it does to another. And wouldn't this possible show scrambled too to them :P? +
trazobone  No because I’ve seen a trend where they only descramble comments posted more than a year ago. Everything that’s I’ve seen commented last month or within the last couple of months is unscrambled. But this is only a working theory lol +2

 +3  (nbme15#9)

He has a down and out pupil caused by CN III palsy. His gaze is due to opposed action of the lateral rectus and superior oblique; ptosis due to denervation of levator palpebrae superious.

The only injury listed that could cause a CN III palsy is aneurysm of the PCA compressing the occulomotor nucleus.

shieldmaiden  oculomotor nerve* +

 +1  (nbme15#39)

NAPQI is a toxic intermediate is formed by in small amounts by metabolism of acetaminophen. Depletion of hepatic glutathione stores by NAPQI leads to acute APAP(?) toxicity and acute liver injury.


 +5  (nbme15#26)

Acute MI and mitral regurg from the murmur leads to LV failure and backflow of blood into the lungs.

This leads to increased pulmonary hydrostatic capillary pressure. This will lead to excess volume leaking from the pulmonary capillaries into the interstitial and this will manifest as pulmonary edema (crackles).

Pulmonary edema will interfere with gas exchange leading to hypoxemia.


 +1  (nbme15#28)

Classic myasthenia gravis picture. Worsens with use. Sx include diplopia improvement with AChE

Also side note don’t focus on the pregnancy status but women who are in the postpartum period are at particularly high risk of developing myasthenia gravis


 +1  (nbme15#14)

Strep Viridans is oral flora causes subacute endocarditis affecting previously damaged valves, and is often associated with sequelae of dental procedure.

A) Enterococci can also cause subacute endocarditis but they are gamma hemolytic and follow GG/UI procedure B) beta hemolysis causes acute beta hemolysis and i got too lazy to unscramble the rest i dont think it even addresses my question

trazobone  Strep mitis is part of the viridans group of streptococci, most commonly found in throat, nasopharynx, mouth. Gram + facultative anaerobe, catalase (-) and alpha hemolytic +2
whk123  Also, the image gives a clue (also present in FA strep pneumo section) that it belongs to strep family, strep pneumo ruled out because it is beta-hemolytic so strep mitis is left which eventually is alpha-hemolytic +1
trazobone  Wait no strep pneumo is also alpha hemolytic. I think you meant to type staph aureus +
whk123  OMG, where the heck my one line went- EDIT: strep pneumo ruled out because it is not associated with heart issues and dental procedure thing present in the scenario, staph aureus ruled out because it is beta-hemolytic so... Thanks trazobone for bringing this to attention +1




Subcomments ...

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privatejoker  So is the heavily implied step-wise formation of Syphilis symptoms as presented in FA complete BS then? Why break it down into stages and have us learn it as such if this is not the case in real practice? +5  
lilmonkey  Exactly, Goljan mentioned this in one of his audio lectures. All kinds of lesions in syphilis caused by vasculitis. +3  
lovebug  I know it's silly question. but Could anyone give an why answer is lymphocyte and plasma cell not neutorphiles.? bc syphilis is a bacteria, not virus. +  
trazobone  @lovebug my guess is bc its a spirochete, so it doesn’t act like a normal bacteria. One of the screening test for syphilis is FTA Abs, so a proliferation in plasma cells makes sense. Then by deduction, if its able to affect plasma cells, it can do the same with lymphocytes. But this is me trying to logic everything together so. +  


submitted by misrao(2),

Can someone explain the correlation between 450 mOsmol/day and needing to excrete 1 L of water? Thanks

trazobone  This is my second time doing this question TY COVID. The definition of an Osm is the number of osmoles of solute per liter of solvent. The stem tells you the highest she can concentrate her urine is 450 mOsmol/kg H2O, and she takes in 450 mOsmol/day. She also loses 1000 mL from sweat, feces, etc.. The mOsmol variables are NOT related to the 1000 mL. It is going to take 1 liter to concentrate that 450 mOsmol urine, and she also loses a separate unrelated 1 liter. Together, the minimum amount of H2O needed is going to be 2 liters. +  


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erytudhio kcsi mdyrsoen si mtesomeis edalcl lo"w 3T r"yden.som olsA uoy ownk hatt hte tnipeat is uordteihy eaecubs her 4T adn TSH are wthnii hte ecerefner ra.eng heS is .sick

yotsubato  This is not in FA btw. +9  
niboonsh  https://www.ncbi.nlm.nih.gov/books/NBK482219/ probably caused by her recurrent pneumonia +3  
eacv  I though in this one as a sick sinus syndrome hahaha in UW. +  
pg32  Pretty sure boards and beyond teaches this wrong. Dr. Ryan says that in euthyroid sick syndrome T3, T4 and TSH will be low, but rT3 will be elevated. +  
pathogen7  In reality, TSH and T4 levels can be highly variable based on the stage of Euthyroid sick syndrome. One thing that happens for sure, I believe, is that T3 is down and rT3 is up. +1  
trazobone  I think I been in quarantine too long I am really giggling at she is sick LMAO +  


submitted by uslme123(66),
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happyhib_  his bp was something like 130/50; with diastolic around 50 I figured he couldnt have increased SVR because his diastolic would be higher? +1  
trazobone  I had this same reasoning I completely glossed over the BP 🤦🏻‍♀️ +  


submitted by imgdoc(135),
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lovebug  I know it's silly Q. but why not C) Granulomatous colitis? lol. thank you! +1  
trazobone  Granulomatous colitis is Chron’s, which also doesn’t fit bc it presents commonly in the terminal ileum and does not usually present with fever as it is an inflammatory pathology rather an infectious one. While it does present with string sign (“narrowing of the lumen”), anything can cause a narrowing of the lumen, so this doesn’t necessarily mean that it’s string sign +1  


Might be a dumb question but... Can patients normally breathin on their own if givne succinylcholine?

trazobone  Yes! Normal people will have an adequate level of pseudocholinesterase to break down the succinylcholine and eventually cease its effects. But if your question is, will succinylcholine still inhibit breathing in a normal person, yes it will. It will work to paralyze muscles (like your diaphragm) in both a normal person and in someone with the pseudocholinesterase deficiency. The main issue is the ability to eventually break down the succinylcholine and come out of the paralysis +  


submitted by trazobone(35),

What is partial oxidation lmao. Is it beta oxidation? Is it FAs that has been partially oxidized? Is it FAs that have been partially beta oxidized? Please advise.

trazobone  Ok after regrouping with myself, if you ignore the “partial” part of the answer choice, it makes sense. And you can eliminate everything else. +  


submitted by medstudent(14),

I struggled with why this couldn’t be essential HTN for a while. I think what it comes down to is this, and someone help me out if I’m incomplete/wrong.

In bilateral RAS, ACE inhibitors will decrease the GFR from dilation of efferent arteriole and they can’t increase the GFR further because they’re already maxed out on afferent dilation to keep up GFR in the first place.

In essential HTN, yes ACE inhibitors decrease GFR from dilation of efferent arterioles, however they’re able to maintain GFR through autoregulation because they haven’t touched their afferent arteriole. So this means that renin won’t actually increase.

TL;DR: Bilateral RAS is unable to use autoregulation to correct the decrease in GFR where essential is able to.

trazobone  I also put essential HTN. But you would always see an increase in renin activity whenever you give an ACEi bc it’s blocking the downstream pathway (no AgII or aldosterone effects), regardless if the pt had RAS or essential HTN. The same goes for ARBs. So my thought process is, because renin and aldosterone levels were initially high, those are obvious causes of his HTN, therefore it can’t be essential HTN. Essential HTN is related to an increase in CO or TPR, while secondary HTN is due to renal/renovascular diseases & RAS or hyperaldosteronism. FA18 p 296 +  


submitted by hayayah(1079),
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sammyj98  I like you sticking up for the kidneys, thinking they're increasing Renin for the benefit of the whole body, but lets face it, the kidneys are a couple selfish dicks who want the high blood pressure all for themselves. LeftVentricularSolidarity +6  
trazobone  ^ I love reviewing NBMEs for comments like this 😂 +  


submitted by bbr(25),

Another way to think of this: She has a strong family history, so we are thinking she probably does indeed have this mutation (probably a True Positive). Our fear, would be we do the wrong test and aberrantly tell her that she is in the clear (False Negative). Having a high False Negative would be deleterious to this patient, and plugging this into a 2x2 table gives a low sensitivity (TP/ TP +FN).

trazobone  What a beautiful explanation THANK YOU +  


submitted by trazobone(35),

SMH I was thinking alcoholic B12 loss of vibratory, so obvious now he has ALS. Hyperreflexia UMN sign, fasciculations LMN sign. And common cause of death is due to aspiration pneumonia because of dysphagia (LMN deficit). FA 2018 p 514

trazobone  Sorry dysphagia (UMN deficit) +  
trazobone  SMH I was thinking alcoholic B12 loss of vibratory, so obvious now he has ALS. Hyperreflexia UMN sign, fasciculations LMN sign. And common cause of death is due to aspiration pneumonia because of dysphagia (UMN deficit). FA 2018 p 514 +  
cheesetouch  UMN vs LMN is FA18 p 513 also! +  


submitted by trazobone(35),

SMH I had it in my head that bromocriptine is used to treat Parkinson so I eliminated the answer. But it’s a dopamine agonist that will also treat a pituitary prolactinoma.

trazobone  SMH I had it in my head that bromocriptine is used to treat Parkinson so I eliminated the answer. But it’s a dopamine agonist that will also treat a pituitary prolactinoma. +  


submitted by trazobone(35),

SMH it all boiled down to what does tyrosine kinase do? Kinase phosphorylates stuff. So therefore the homodimer would still form but since the key thing thats being messed up here is the kinase, it’s the phosphorylation process that gets disrupted.

trazobone  SMH it all boiled down to what does tyrosine kinase do? Kinase phosphorylates stuff. So therefore the homodimer would still form but since the key thing thats being messed up here is the kinase, it’s the phosphorylation process that gets disrupted. +1  


submitted by trazobone(35),

I answered this via process of elimination.

A) Gliobastoma multiforme - no b/c that would need to show a tumor B) HSV encephalitis - would need to be in the temporal region and also doesn’t quite fit with the 25 year seizure disorder history C) Mesial temporal sclerosis - i have no idea what this is really, but judging from “sclerosis” i assume there needs to be some signs of sclerosis which is not present in the photo D) Neonatal ischemic stroke - no she old E) Vascular malformation - could not think of a vascular disorder that was associated with seizures, but it makes sense b/c the picture shows a bunch of dilated spaces which I assumed are the vessels being malformed

trazobone  I answered this via process of elimination. A) Gliobastoma multiforme - no b/c that would need to show a tumor B) HSV encephalitis - would need to be in the temporal region and also doesn’t quite fit with the 25 year seizure disorder history C) Mesial temporal sclerosis - i have no idea what this is really, but judging from “sclerosis” i assume there needs to be some signs of sclerosis which is not present in the photo D) Neonatal ischemic stroke - no she old E) Vascular malformation - could not think of a vascular disorder that was associated with seizures, but it makes sense b/c the picture shows a bunch of dilated spaces which I assumed are the vessels being malformed +1  


submitted by trazobone(35),

A) Codeine - common in cough syrup but it’s a weak agonist at mu and delta receptors, so there’s potential for substance abuse.
B) Dextromethorphan - a cough suppressant with low potential for abuse and does not cause constipation; antagonizes NMDA receptors (not mu kappa or delta receptors).
C & D) Hydromorphone & oxycodone -- potent opioids used to treat moderate to severe pain (I am assuming they work at mu receptors but it’s not in FA so 🤷🏻‍♀️)

E) Tramadol - a weak opioid agonist used for neuropathic pain, acts by reuptake of NE and 5HT

trazobone  A) Codeine - common in cough syrup but it’s a weak agonist at mu and delta receptors, so there’s potential for substance abuse. B) Dextromethorphan - a cough suppressant with low potential for abuse and does not cause constipation; antagonizes NMDA receptors (not mu kappa or delta receptors). C & D) Hydromorphone & oxycodone -- potent opioids used to treat moderate to severe pain (I am assuming they work at mu receptors but it’s not in FA so 🤷🏻‍♀️) E) Tramadol - a weak opioid agonist used for neuropathic pain, acts by reuptake of NE and 5HT IN CASE ANYONE TRIES TO SCRAMBLE +  


submitted by trazobone(35),

This is straight up testing if you knew Ab nomenclature 🙄. -umab designates human origin while -omab designates murine origin. So bevacizumab is a humanized Ab. The other answer choice saying it was a murine Ab directed against VEGF was designed to trick you. Luckily I did not fall for such witchery.

trazobone  This is straight up testing if you knew Ab nomenclature 🙄. -umab designates human origin while -omab designates murine origin. So bevacizumab is a humanized Ab. The other answer choice saying it was a murine Ab directed against VEGF was designed to trick you. Luckily I did not fall for such witchery. IN CASE ANYONE TRIES TO SCRAMBLE +1  


submitted by trazobone(35),

Normal hormonal, male sperm study and normal semen: still can’t conceive then give TYR (???) with clomiphene, that is antagonist at GnRH receptor at hypothalamus, block estrogen mediated inhibition of GnRH hence increase release of LH surge Bromocriptine - would be helpful if the pt has infertility due to INCREASE LPEDS CTIRAON (??? I am assuming its PROLACTIN) - is stopped in US due to clear cell carcinoma in young female born to term. Ethinyl estradiol - bind estrogen & GnRH; LH surge: no use. (Inc risk of endometrial carcinoma) Medroxyprogesterone - is progesterin bind progesterone eonis(oeeccn.rprpmot..t. (???) of morning after pill)

trazobone  Clomiphene: a SERM, antagonist at estrogen receptors in hypothalamus (FA18 637) +  


submitted by trazobone(35),

Cool and pale extremities rules out distributive causes (neurogenic, anaphylaxis, septic).

Hypovolemia would describe a process of volume loss bleeding (or dehydration) and would not explain the crackles or jugular venous distention.

Don’t be thrown off by the normal heart sounds. I am getting real good at this descrambling thing.

cheesetouch  JSYK, if it shows scrambled to one person doesn't necessarily mean it does to another. And wouldn't this possible show scrambled too to them :P? +  
trazobone  No because I’ve seen a trend where they only descramble comments posted more than a year ago. Everything that’s I’ve seen commented last month or within the last couple of months is unscrambled. But this is only a working theory lol +2  


Patient is obese with a BMI of 30 and a major risk factor for T2DM is obesity and high-calorie diet.

castlblack  what is wrong with low carbohydrate? Carbs raise insulin after all +3  
trazobone  I also have this question ^^^. My guess is the question says which diet is most effective so if he had a low-carb diet but high in everything else, then he won’t lose weight. Versus no loopholes in a low-calorie diet +1  


submitted by trazobone(35),

SMH I was thinking alcoholic B12 loss of vibratory, so obvious now he has ALS. Hyperreflexia UMN sign, fasciculations LMN sign. And common cause of death is due to aspiration pneumonia because of dysphagia (LMN deficit). FA 2018 p 514

trazobone  Sorry dysphagia (UMN deficit) +  
trazobone  SMH I was thinking alcoholic B12 loss of vibratory, so obvious now he has ALS. Hyperreflexia UMN sign, fasciculations LMN sign. And common cause of death is due to aspiration pneumonia because of dysphagia (UMN deficit). FA 2018 p 514 +  
cheesetouch  UMN vs LMN is FA18 p 513 also! +  


submitted by trazobone(35),

This cells should be stem cell transplant so homing is the environment that accept them and nourish them with growth factors to mature

trazobone  I don’t understand what I unscrambled. This does not apply to the question stem? +  
trazobone  Apparently there is something called “hepatic homing” that occurs with mononuclear inflammatory cells I have never heard such a thing +1  


submitted by trazobone(35),

This cells should be stem cell transplant so homing is the environment that accept them and nourish them with growth factors to mature

trazobone  I don’t understand what I unscrambled. This does not apply to the question stem? +  
trazobone  Apparently there is something called “hepatic homing” that occurs with mononuclear inflammatory cells I have never heard such a thing +1  


submitted by cassdawg(1165),

She has > or equal to 2 symptoms including positive (hallucinations) and negative (flat affect, social withdrawal) symptoms which have been present for >6months, supporting the diagnosis of schizophrenia. Thus, she should be started on an atypical antipsychotic (i.e. olanzapine) which is first-line for schizophrenia.

whk123  Plus she is also thin so no as such worry for the Olanzapine side effect Obesity, and olanza is the only antipsychotic agent in the list. +  
trazobone  When you mix up fluoxetine with fluphenazine...... +1  
whk123  Hey, Let's visualize I hope it may help. U gave ur depressed SIR OX a HAPPY drug after its ingestion he starts FLYing with his dear PARROT all over the CITY. So SSRIs(Happy drugs)- SIR (Sertraline), FLYing OX (FLUOXetine and FLUvOXamine), PARROT(Paroxetine), CITY (CITALOPRAM ans esCITALOPRAM) +1  
trazobone  Actually its deSERT for sertraline :) +  
whk123  Yeah. Wonders of Sketchy Pharm ;) +  


submitted by cassdawg(1165),

I definitely did not know this, but apparently smoking can worsen GERD due to tendency of nicotine to cause relaxation of the lower esophageal sphincter. Smoking is also linked to stomach ulcers due to interference with gastric mucosa and acid production. Just don't smoke kids. Don't do drugs. Stay in school forever like med students.

i_hate_it_here  don't tell me what to do +  
trazobone  Don’t you just love it here +  


submitted by andro(189),

The question essentially wants you to make a distinction between Pubertal Gynecomastia and Pathological Gynecomastia

Pubertal gynecomastia

  1. may be unilateral or bilateral
  2. tender or nontender
  3. found in 50 % of adolescents and typically resolves by the age of 17 , and as such patients require little more than reassurance

This Patient however is already above the age of 17( rule out reassurance !) Of the possible causes of pathological gynecomastia , anabolic steroid use is a very likely option based on the description provided

trazobone  See i assumed this was a “how to be a more empathetic physician” question, so i said reassurance. But i guess not putting reassurance makes sense bc it implies everything is normal +4  
cheesetouch  @Trazobone I think it's just one of those "suspect everyone until proven trustworthy/otherwise" questions :P +1  


submitted by cassdawg(1165),

The burnt almond smell and noncyanotic dyspnea is characteristic of cyanid poisoning. Cyanide poisoning is treated with nitrites because nitrites oxidize hemoglobin to form methamoglobin which binds cyanide, allowing less toxicity. Thiosulfate is often added to increase renal excretion as thiocyanate. Cyanide toxicity may also be treated with hydroxycobalmin, which binds cyanide.

FA2020 p667 has differentiation of cyanide from CO poisoning.

drippinranch  is there a circumstance where you would treat cyanide poisoning first with hyperbaric oxygen before hydroxy/nitrates/thiosulfate? +1  
prosopagnosia  If the patient had concomitant carbon monoxide poisoning, then I think the hyperbaric oxygen would help. But in order to reverse cyanide poisoning, hyperbaric oxygen will not help because the cells are unable to use oxygen since the cyanide directly inhibits oxidative phosphorylation. +1  
i_hate_it_here  Another thing to know about this is that unlike with CO poisoning, your O2 saturation of hemoglobin, total O2 content, and oxygen-hemoglobin dissociation curve would all be normal. FA2020 pg: 666 +1  
trazobone  Thank you i love it here +  
cheesetouch  FA18 p 648 +  


submitted by cassdawg(1165),

She has > or equal to 2 symptoms including positive (hallucinations) and negative (flat affect, social withdrawal) symptoms which have been present for >6months, supporting the diagnosis of schizophrenia. Thus, she should be started on an atypical antipsychotic (i.e. olanzapine) which is first-line for schizophrenia.

whk123  Plus she is also thin so no as such worry for the Olanzapine side effect Obesity, and olanza is the only antipsychotic agent in the list. +  
trazobone  When you mix up fluoxetine with fluphenazine...... +1  
whk123  Hey, Let's visualize I hope it may help. U gave ur depressed SIR OX a HAPPY drug after its ingestion he starts FLYing with his dear PARROT all over the CITY. So SSRIs(Happy drugs)- SIR (Sertraline), FLYing OX (FLUOXetine and FLUvOXamine), PARROT(Paroxetine), CITY (CITALOPRAM ans esCITALOPRAM) +1  
trazobone  Actually its deSERT for sertraline :) +  
whk123  Yeah. Wonders of Sketchy Pharm ;) +  


submitted by baja_blast(113),

Anyone know why this was Hydronephrosis and not Staghorn Calculus??

hchairston  There are no calculi in the image. The image shows a dilated ureter, you know it's a ureter because there is an opening into the hilum of the kidney. +2  
prosopagnosia  Personally, I couldn't tell that the ureter was dilated without a comparison image. But what I did notice was the dilation of the renal calyces and severe renal atrophy which clued me into some ureteric obstruction --> Hydronephrosis. +1  
trazobone  OK so I put ARPKD bc of chronic renal insufficiency and also i thought the dilated parts were cysts +2  
shieldmaiden  Remember that for ARPKD both kidneys will be affected and it will involve the cortex as well as the medulla. If you notice, the cortex is intact +3  
taylor5479  Also, it's my understanding that ARPKD typically presents much younger with a lot of really small cysts, kind of with a spongelike appearance. +  


submitted by cassdawg(1165),

My take on this question is that he is about to be diagnosed with advanced stage pancreatic cancer, which has a high mortality rate. On its own, pancreatic adenocarcinoma is not associated with any of the psychological disorders. However, a diagnosis of a terminal condition or advanced cancer of any kind that would require aggressive treatment with poor prognosis would be associated with major depression. Thus, he is at most risk of major depressive disorder.

cheesetouch  Study break journal article about depressive symptoms before pancreatic cancer diagnosis - https://journals.lww.com/pancreasjournal/FullText/2018/04000/Early_Detection_of_Pancreatic_Cancer__The_Role_of.1.aspx +5  
trazobone  Did anyone else think that the mass would considerably extend into the terminal ileum and then cause a deficiency of B12 absorption, thus leading to memory impairment LOL +1  


submitted by cassdawg(1165),

This man likely has diabetic neuropathy and thus would have neuropathic pain. Neuropathic pain is described as a burning pain as compared to the other kinds of pain.

Here are some differences between nocioceptive and neuropathic pain.

Here is a chart of descriptors used for neuropathic v nocioceptive pain.

trazobone  I appreciate u cassdawg +  


submitted by justoil(0),

In ectopic pregnancies, hCG is elevated from baseline, but less than in normal pregnancy and much less than hydatidiform mole.

This stem only says that hCG is elevated from baseline, so it could be ectopic, normal pregnancy or hydatidiform mole.

From those 3 options, it's not normal pregnancy bc of low hCG & presentation, and it's not hydatidiform mole because of low hCG, the presentation & the gross pathology (hydatidiform mole wouldn't have something that looks that much like a fetus). So it's most likely an ectopic pregnancy.

hiroshimi  How do you know that the "increased hCG" is actually lower than what you expect, since the stem did not say anything else??? I was between ectopic pregnancy and hydatidiform mold since the partial mole can have partial fetus as well. But I guess it's just partial, not the full fetus like we see in the picture. Also, hydatidiform associate with irregular bleeding and/or hyperemesis than acute pain. +1  
trazobone  Also to add to the partial vs ectopic, the presence of leukocytosis fits better with ectopic since she’s in pain which means the fallopian tube ruptured and now you need immune system to go work. But FA mentions nothing about leukocytosis associated with ectopic pregnancy so I am conjecturing. +1  


submitted by ergogenic22(321),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

eH sha a dwon nda tuo ,ulppi esduca yb NC III .yplsa Hsi agez si edu ot npudposeo itncoa fo eth ltarela rstuce nda orirupes lqboi;eu isotps edu ot orevntneadi of ravtleo rbeaaplep souprisise.

hTe yoln ynujri ltdeis hatt lcuod ucesa a NC III slpya is seurmnya of het ACP nreiscpgmos the ucalrooomtr lcseuu.n

cheesetouch  Compression of superior cervical ganglion -> Horner's syndrome -> ptosis, miosis, anhidrosis, would NOT have dilated pupil. +2  
jmd2020  Aneurysm of the PCA would compress the oculomotor NERVE, not the nucleus (just fyi) +2  
trazobone  I appreciate u cheesetouch +  


The question stem describes a man with presumed orthostatic hypotension. HCTZ is associated with this condition (by causing a relative hypovolemia), and his symptoms of feeling faint when sitting up too quickly also match nicely.

When he stands, gravity causes a redistribution of blood to his legs, causing decreased venous return.

Orthostatic hypotension is defined by an inadequate baroreceptor response, hence decreased baroreceptor activity.

Lastly, we know his cerebral blood flow is decreased if he is feeling dizzy.

Helpful image: http://calgaryguide.ucalgary.ca/wp-content/uploads/2015/10/Orthostatic-Hypotension-Pathogenesis-and-clinical-findings.png

trazobone  I got stuck between increased vs. decreased baroreceptor activity. So my takeaway from this is that the baroreceptor activity will decrease regardless since there is a decrease in venous return. Key emphasis is in inadequate baroreceptor response. So activity decreases but not enough to compensate because venous return is severely decreased, hence the orthostatic hypotension. +  


submitted by trazobone(35),

Strep Viridans is oral flora causes subacute endocarditis affecting previously damaged valves, and is often associated with sequelae of dental procedure.

A) Enterococci can also cause subacute endocarditis but they are gamma hemolytic and follow GG/UI procedure B) beta hemolysis causes acute beta hemolysis and i got too lazy to unscramble the rest i dont think it even addresses my question

trazobone  Strep mitis is part of the viridans group of streptococci, most commonly found in throat, nasopharynx, mouth. Gram + facultative anaerobe, catalase (-) and alpha hemolytic +2  
whk123  Also, the image gives a clue (also present in FA strep pneumo section) that it belongs to strep family, strep pneumo ruled out because it is beta-hemolytic so strep mitis is left which eventually is alpha-hemolytic +1  
trazobone  Wait no strep pneumo is also alpha hemolytic. I think you meant to type staph aureus +  
whk123  OMG, where the heck my one line went- EDIT: strep pneumo ruled out because it is not associated with heart issues and dental procedure thing present in the scenario, staph aureus ruled out because it is beta-hemolytic so... Thanks trazobone for bringing this to attention +1  


submitted by cassdawg(1165),

The inferior constrictor is innervated by the vagus nerve (all pharyngeal muscles except the stylopharyngeus are innervated by the vagus nerve; the stylopharyngeus is innervated by the glossopharyngeal). It is motor fibers because these muscles are involuntary skeletal muscles.

This individual has Zenker Diverticulum, which leads to an outpouching between the thyropharyngeus and cricopharyngeus and presents with the symptoms described (dysphagia, halitosis, FA2020 p384).

Here is a 2.5 minute video on the pharyngeal constrictors and innervation if you are a more visual learner.

Here is an image of the pharynx and innervation.

radzio1  somehow I got confused because motor and vagus didnt go along. +1  
trazobone  Some say marry money but my brother says big boobs matter most. Vagus boobs +  


submitted by trazobone(35),

Strep Viridans is oral flora causes subacute endocarditis affecting previously damaged valves, and is often associated with sequelae of dental procedure.

A) Enterococci can also cause subacute endocarditis but they are gamma hemolytic and follow GG/UI procedure B) beta hemolysis causes acute beta hemolysis and i got too lazy to unscramble the rest i dont think it even addresses my question

trazobone  Strep mitis is part of the viridans group of streptococci, most commonly found in throat, nasopharynx, mouth. Gram + facultative anaerobe, catalase (-) and alpha hemolytic +2  
whk123  Also, the image gives a clue (also present in FA strep pneumo section) that it belongs to strep family, strep pneumo ruled out because it is beta-hemolytic so strep mitis is left which eventually is alpha-hemolytic +1  
trazobone  Wait no strep pneumo is also alpha hemolytic. I think you meant to type staph aureus +  
whk123  OMG, where the heck my one line went- EDIT: strep pneumo ruled out because it is not associated with heart issues and dental procedure thing present in the scenario, staph aureus ruled out because it is beta-hemolytic so... Thanks trazobone for bringing this to attention +1