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Welcome to yotsubato’s page.
Contributor score: 965


Comments ...

 +1  (step2ck_form7#2)

The indications for blood transfusion for pelvic fracture patients are systolic blood pressure of <90 mmHg, heart frequency >130 bpm and clinical symptoms of shock. In an emergency, combined transfusion of red blood cells, plasma and platelets (6-4-1) is preferred (19).

So...... This question is bullshit?

study_dude_guy  I spent way too long trying to find this paper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394148/ The flow chart is the first figure In major trauma, you give 1-2 L of fluid and check for response, if they are still hypotensive you give blood products. +
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +

 +0  (step2ck_form7#27)

Medications that cause direct esophageal mucosal injury include the following.

Antibiotics — Tetracycline, doxycycline, and clindamycin have been associated with esophagitis due to their direct irritant effect. (See 'Pathogenesis' below.)

Anti-inflammatory medications — Aspirin and anti-inflammatory agents can cause severe esophagitis, esophageal strictures, and bleeding [1].

Bisphosphonates — Although the incidence of side effects with bisphosphonates is low if proper administration instructions are followed, esophagitis, esophageal ulcers, and strictures can still occur [3-8]. (See 'Prevention' below.)

Among oral bisphosphonates, risedronate appears to have minimal gastrointestinal toxicity, and, in clinical practice, some patients have fewer gastrointestinal side effects with risedronate as compared with alendronate [6,7]. In an endoscopic study of 515 postmenopausal women receiving daily risedronate or alendronate for two weeks, significantly fewer gastric ulcers were seen in the risedronate group as compared with alendronate (4.1 versus 13.2 percent) [9]. The side effects of bisphosphonates are discussed in detail, separately. (See "Risks of bisphosphonate therapy in patients with osteoporosis".)

Other — Other causes of medication-induced esophagitis include potassium chloride, quinidine preparations, iron compounds, emepronium, alprenolol, and pinaverium [10].


 +2  (step2ck_form7#37)

Doxazosin is not given because he has a history of orthostatic hypotension.


 +0  (step2ck_form7#19)

Transsphenoidal surgery should be considered when:

●Dopamine agonist treatment has been unsuccessful in lowering the serum prolactin concentration or size of the adenoma, and symptoms or signs due to hyperprolactinemia or adenoma size persist after several months of treatment at high doses.

●A woman has a giant lactotroph adenoma (eg, >3 cm) and wishes to become pregnant even if the adenoma responds to a dopamine agonist. The rationale for this approach is that if the patient becomes pregnant and discontinues the agonist for the duration of pregnancy, the adenoma may increase to a clinically important size before delivery.


 +1  (step2ck_form7#31)

Kind of a bullshit gotcha question.

THe pain started after she started moving furniture = she was active = she has a chance of pulling a muscle = costochondritis

Even though she is a walking talking risk factor for PE...


 +3  (step2ck_form7#5)

Lactose Intolerant I guess? Not Celiac. Kind of a bullshit question.

study_dude_guy  Had the same reaction as you and then I learned that AA is a buzz word for lactose intolerance "African American and Asian ethnicities see a 75% - 95% lactose intolerance rate, while northern Europeans have a lower rate at 18% - 26% lactose intolerance" +
seagull  I also choose Celiac's. "BuT RaCe AnD mEdICiNe DoN't Go ToGeThEr". +
hayayah  I think a key part to differentiate between celiac's and lactose intolerance in this question isn't race, it's because of the part that says "he occasionally had diarrhea after meals since 12 years old and then it got worse since starting college". If he had celiac's he'd have GI symptoms (i.e. diarrhea) any time he ate something containing gluten (which would be every single time he had a meal) since he was 12. You'd also see signs of fat or vitamin malabsorption in celiac's patients and other autoimmune symptoms. Whereas in lactose intolerance, it's much more likely he'd once in a while eat a lot of dairy and have his symptoms triggered, and then he starts college and has even less of a well rounded diet and so his symptoms get worse. +2

 +0  (step2ck_form7#2)

Your vascular surgeon may recommend you have a carotid endarterectomy if you have: A moderate (50-79%) blockage of a carotid artery and are experiencing symptoms such as stroke, mini-stroke or TIA (transient ischemic attack). A severe (80% or more) blockage even if you have no symptoms.


 +1  (step2ck_form7#3)

Lets take a picture with a potato, JPEG the hell out of it and throw it on an exam .


 +2  (step2ck_form7#8)

Ill be the Cowboy.

Diagnosis: ALS

Multispike and fasciculation potentials Complex, repetitive discharges occur in ALS of long duration, as they do in other chronic neurogenic atrophic conditions. These are regularly discharging multispike potentials that are time-locked. Other than an EMG finding associated with a chronic neurogenic atrophic condition, this finding has no other unique significance.

Fasciculation potentials are seen frequently but not invariably in ALS. Their presence is not specific to ALS; they may occur in other conditions, some completely benign.


 +1  (step2ck_form7#29)

Note: Oral Amoxicillin is not given. It has to be IV pennicillin.


 +1  (step2ck_form7#10)

Welcome back to Step 1 minutae... Useless crap they make us memorize, hell not even memorize.

athleticmedic  I had no idea what this question was trying to get at. It makes sense looking back now, but at the time I had no idea what they were talking about. +

 +1  (step2ck_form7#7)

You know they could throw us a bone or something... Tell us the uterus is boggy at least, or hard, or ANYTHING AT ALL REALLY....

saffronshawty  They mentioned that the uterus is 3 cm above the umbilicus which is an indication that it's enlarged and hasn't returned to the normal post-partum size it should be, which is at the level of the umbilicus +/- 2 cm. +

 +1  (step2ck_form7#38)

. The immune response to M tuberculosis is T cell dependent. It comprises not only the conventional CD4 and CD8 T cells, but also γδ T cells and CD1 restricted T cells. γδ T cells recognise phospholigands and no presentation molecules are known thus far. CD1 restricted T cells recognise glycolipids, which are highly abundant components of the mycobacterial cell wall. Although different T cells are required for optimum protection, the immune mechanisms known to have a role in acquired resistance can be associated with two major mechanisms: (a) activation of macrophages by cytokines; (b) direct cytolytic activity. In vivo granuloma formation, which is central to protection, is induced and sustained by cytokines. Mycobacteria are contained within granulomas and in this way are prevented from spreading all over the body.

So it looks like we just need to know this. Nevermind the fact the question stem doesnt even hint at any congenital problem in the girl....


 +0  (step2ck_form7#20)

Shitty heart sounds strike again. Totally thought the artifact in the recording was a continuous machine like murmur...


 +4  (step2ck_form7#3)

This one made no sense. Celecoxib is already the strongest NSAID. I would rather give Dexamethasone. Which works along a seperate mechanism of action.

jaypat  Indomethacin is typically the first choice NSAID for acute gout flares. Then glucocorticoids. Lastly Colchicine +
seagull  I also choose steroids since they were on a NSAID. fml +
creamy  Naw dawg. Celecoxib has anti-inflammatory efficacy hence the categorization as a NSAID. In fact, gout patients treated with Celecoxib have the same treatment response as Indomethacin. Celecoxib is actually listed as an alternative to nonselective NSAIDs for acute gouty flares. This was just a bumbass question. +1

 +0  (step2ck_form7#23)

Weird answer to a weird question. "She(the girl herself) doesnt understand why she does these things" made me think of some sort of Mania component.


 -1  (nbme24#45)
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lCoo eroanth eonsituq kenta rmof teh tisl of ngsiht ont in FA

charcot_bouchard  Actually it is in FA. FA 19 Page 100 - Antigen loaded onto MHC1 in RER after delivery via TAP transporter.... Remember FA is that friend who always say I told you so. +18
yotsubato  But not in this context +5

 +4  (nbme24#6)
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TLA dan AST aer meynzse niwhti sotyp.acehte uohtiWt pattchyeoe eagm,da you tnow hvea aosntelvi.e

liankeAl aepohspasth is tnrseep in lal tiuesss tougotrhuh the rtniee dyb,o utb si tiurayclpral nnctetaorcde ni teh r,lvei beli dc,ut ynk,ide ,bone litnaetnis muocas dan atec.alnp


 +12  (nbme24#49)
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dlCo air enicsud taamsh .acstakt

gDcinesrea eruosc aold wnto elph

kgniaT osriesdt is oto hcmu orf won

Mgoinv bkca to eth mrosd is ont avilbe

rAi esnlerca tnod rowk gunheo

tonD etg dri of het dGoo oyeB

imnkgSo sodnroi si uggtdiniss

sherry  Stress can actually be a trigger for asthma. I think the problem here is that she has alwasys carried a heavy course, while the disease just started recently. +7
medguru2295  Stress makes asthma worse. Therefore, keep doggo for stress relief! +
qiss  Also her symptoms started 3 months ago and she moved in with a roommate who smokes indoors 3 months ago. +2
jrish  But wouldn't the smoke on the roommates clothes still cause significant asthma problems? +

 +0  (nbme24#13)
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Wyh is the apnteit nto ni pn.ai I dntlwuo texcep eatcnaerrIcd ihnrae to psenetr whti orze npa,i utb 1 keew fo itcnstipoaon nda iwlelg.sn

yotsubato  Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Like really? Why is he not in pain? +1
medschul  I thought that inguinal hernias were reducible? +
fahmed14  could be a femoral hernia as they are more likely to cause incarceration. They do, however, present more often in females. (FA 2019- 364) +1
wowo  incarcerated, not strangulated, thus no pain as there's no serious tissue damage/ischemia. Incarcerated hernias may progress to strangulated in which case he would have pain Under section, "complications" https://www.amboss.com/us/knowledge/Inguinal_hernia +5

 +1  (nbme24#41)
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Kidn fo ryiktc otnque.si eTh pzoetiyoshn ear oohlurneiqc snatsri.et But hte sieepsc amy ton eb.

P. amrcliFpua is nrsttsiae dna soolk iekl a anbnaa, ubt uyo dnto kwno fi teh amliara ni eth BCR is fpcralmuai or o.tn

tyrionwill  whether resistant or sensitive, depends on the region, not on the species falci coming from Hatii could be sensitive +

 +6  (nbme24#29)
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dAoymil A : sene ni rchnoci tomyanflmria ,iidsocotnn eooiitdpns fo oyialdm in tsseusi

B2 ngrocmloulibi: edsstcaaoi ithw RDES and nglo retm idssialy

eoainfelNmtru toe:irpn mFro eht stconketeoly of nrenuos in( yahehlt dvus)adnliii

eni:linPers tseodaasic hwit lmlaiafi mreaezsihl dasesei

sunshinesweetheart  neurofilament also seen in neuronal tumors i.e. neuroblastoma +

 +1  (nbme23#49)
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Aghthluo eehcmniptoana oley)(lnT si ont sodercndie an ,DAINS it oot aym ovopker na iaskrin-lepi i.yvstniiest

meningitis  For that same reason (not an NSAID) it doesn't reduce inflammation so it cant be used for Gout. +5
meningitis  And I think Indomethacin is associated with anaphylactic reactions in patients with aspirin-sensitive asthma and aspirin allergies. Can anyone confirm? +
link981  How many other's like me didn't see "allergic to aspirin"? FML +3
hyperfukus  OMFG me too i just got so mad and questioned my whole life at least its cuz i can't read not bc i don't understand :((((( +1

 +5  (nbme23#27)
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hnd"leriC xhieibt iveohabr uienngntocr with tehir age dan emtenlv"odep ni xlsuea b.uaes

tyrionwill  mostly the age difference exceeds 4 years trigger so called "incongruent with their age". age incongruence plus signs of being forced, like this case which the 4-year-old boy was found crying, lead to suspicious more on sex abuse than sex play. +2

 +36  (nbme23#10)
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asW it jtsu em, ro did ag"e ta ntose ni reay"s eaaprp TIHGR vbeao eht umbenr fo tnpeats,i terarh htan teh e.amn cWhhi scefodun me fro a odgo 3 u.nimste

fulminant_life  Definitely was the same for me. I was so confused for like 5 mins +13
d_holles  dude i almost didn't get the question bc of this ... i thought the age of onset was the actual age of onset (36) +7
mellowpenguins  Are you serious. NBME strikes again with shitty formatting. +7
yex  OMG!! Now I just realized that. Super confused and also thought onset of age was 36. :-/ +5
monkey  what is 36 supposed to be? +1
thomasburton  Think the number of people in that group +5
paulkarr  Yup...was looking at it for a good 3 min before just doing the "fuck it..it's gotta be 99" +4
arcanumm  Age of Onset is the Title of the table, which I didn't figure out until after exam was over. What terrible formatting. +3

 +15  (nbme23#11)
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heaY se,ur tles evgi eht yug hwo astwn ot pkee ish cdik ikrgown and be aatitrtvec dwroast mnwoe teiFineards dan lmypleteoc irun sih rtesnetoteos selvel adn evgi hmi a lmpi dikc, nam osbob, dan edecsreda oeerncpmraf ni tsspro.

soemtmeSi hte EBMN yalelr tsuj msake me kas hWy?

lcoiTpa nilxdoimi dwolu eb awy btetre tub no they wton utp atht as a oecchi

anjum  To clarify: the lack of DHT production caused by finasteride leads to gynecomastia and ED. The other options are synthetic androgens. Totally agree that this question goes against the benevolence vs. maleficence that we've been taught in medical school +

 +0  (nbme23#23)
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etnrA ew NTO ppodsesu to seu piatupirmro ni dlo ep?eolp

amirmullick3  Who said not to use it in old people? Remember "I pray that tio can breathe soon" and tio is an old uncle in spanish but its also the other drug, tiotrropium. +2
drdoom  discussion of anticholinergics & elderly also discussed at some length (but different context) here: https://www.nbmeanswers.com/exam/nbme22/1288 +
guillo12  Ipratropium does not penetrate the blood-brain barrier, so I think this is why it can be given to old people. https://www.rxlist.com/duoneb-drug.htm#clinpharm +4

 +15  (nbme23#9)
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ishT is a euitqons abuot aptetin ipcvra.y heT inatept here is teh hlidc. hTe xropy rfo het enpatti is the ohmetr nad thf.aer eyhT tsmu wnko wthas nro.gw Sirtes nda htoerm aer sujt lkoyosoo,l dan rasetpn amy otn wnta ot lelt emth uidsp(t I onkw, but ve)waetrh os you neds htme uto nad hetn llte het repasnt het aionstut.i

dr.xx  agreed +
thepromise  so you're not gonna conceal the abnormality and act like its their fault? since they touched it last +25
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. +9
llamastep1  It's not just conceal but it's a private and sad moment, gotta give the parents some time to process it. +4

 +5  (nbme23#12)
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ruumrM that is deluro with rcduede neosuv unertr ;g&t= ieohryprHcpt ayycpihtmodaor

MCOH si deu to mtostuian necondgi secarmoser usch as somniy gdbiinn eponrit C dna taeb oimnys yheva h.ianc

btl_nyc  So I thought this was Marfan's because the murmur from HOCM is at the left sternal border, but Marfan's is a defect in fibrillin, not in collagen. +3
arcanumm  To help rule out Marfran's, it is stated that there are "no history of major medical illness," which I wouldn't expect them to put if there was a syndrome going on. (they also tend to give body habitus descriptors at least) +
dul071  This isn't HOCM, rather it's simply Mitral stenosis. He has a murmur that radiates at the apex which happens to be the Mitral area. Despite everything his BLOOD PRESSURE AND PULSE are normal. The heart is over working to keep the vitals normal and as a consequence, it is undergoing hypertrophy which dictates the answer +
dna_at  @dull071 I don't think this is MS. That would be 1) diastolic and not systolic, 2) less likely to cause LVH. I believe as others said it is just HOCM leading to MR, which is what we are hearing. MR secondary to HOCM would still increase in intensity with less preload as there would be more LVOT obstruction (thus more regurgitation) +1

 +24  (nbme23#48)
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So for addniCa we can seu

zslAeo lnuealc)zoof( ibihn(it 5PYC40 aeinlhty)dtmoe

phmtencroiA B poe(r mofonrait in ulnfag lcel narmem)eb

unsiaCgpfno vtperen( rslisknniocg fo taeb cnslaug in clel awl)l

ro sNiyant fro laor ro opaegalesh saesc er(op t)roanfmoi

sTih neosqtui si ysigna htat hse is natkig na RLAO gdru to aertt cdnadai .sgviianit

moAehitnrpc is VI

psngoniCuaf si loas IV

so e'wer flet wtih lzseoa

lsoezA ibiinht sysnhesti of roogtserle yb bnightniii YPC 054 htta rvsocten eloalstonr to gersteol.ro

qball  Nystatin does treat vaginal candidiasis but is TOPICAL. +1
thotcandy  Nystatin is NOT for esophageal candidiasis, Swish and spit, not swallow. +2
staghorn  Me - picks Metronidazole -_- +
alexxxx30  @thotcandy...actually you can swish and swallow nystatin for esophageal infections (per Sketchy micro candida sketch) +3
turtlepenlight  I have seen that on the wards so I hope it works! +
fexx  and my smartass picks amphp B +2
avocadotoast  Please no one give a poor girl with a yeast infection amphoterrible +2

 -1  (nbme23#42)
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shTi pettnai si pvoessunrien to amyn .ictdnaias heTy dotn yipfces ihcwh no,es ubt eth tosquine si lbyaclais snkaig wchih iitacdan si hte eotsngst.r haTt wloud eb PIP,s whihc iitihnb crtagsi H K aePTsA

yb_26  PPIs are not antacids! +3

 +6  (nbme23#25)
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nriTsonsauf asroitcen are eameditd by peyT II nyhiseitsetpviyr otrie.ansc seeTh uccro due to pmoeerrdf bniodsaiet thta dbni to hte rnfoige ntegian (BA ouprg on )RBC nda elda ot lsshymoie yb KN lescl. hsTi si a orfm fo Atydibon eepdtdnen luallecr iyo.cttotciyx

focus  Exactly! And among the blood transfusion reactions, per FirstAid: allergic/anaphylactic reaction: type 1 (we would see urticaria, wheezing, etc. Seen in IgA deficiency.) febrile nonhemolytic transfusion reaction: type 2 (host antibodies against donor HLA and WBCs) acute hemolytic transfusion reaction: type 2 (ABO blood incompatibility) TRALI: its separate category (donor antibodies against recipient neutrophils and endothelial cells) They specifically told us ABO incompatibility (despite the respiratory symptoms that could indicate TRALI) so we know this is an acute hemolytic transfusion reaction. +2

 +5  (nbme23#41)
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So siht niotusqe is ricbenigsd a uyg agnivh clyidtffui nelaextrly orttgani his mar lewhi eht afermor si dxlfe.e eH is aelb ot snatpeui eliwh sih rma is exdenedt a(esceub fo the riosnaupt elsmuc dna pc)ibs.e In eht rrotota f,cuf ynlo eht psisaifntaurn fremspro atleenxr totnrao,i so ttha is eht tseb hc.ceoi

psciBe skorw nfei rhee

uabpuSsrcslia reprfsom elaintrn torta.noi

suSutppaansri oerprsfm ianoudcbt

sTcrpei irdvoeps nxtnsieoe of morrea.f

bigjimbo  technically rotator cuff infraspinatous and teres minor do ER (but teres minor is not a answer choice0 +9

 +1  (nbme22#45)
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hyW ntac isth eb axseta?vil tohB wuold aeucs lcobmtiae lislakosa htiw pyh..lmeo.kaia ?

sup  Laxatives would cause an anion gap metabolic acidosis due to loss of bicarbonate in the stool. You would see hypokalemia though as seen in this question. +1
miriamp3  it took me a lot of time choosing between laxatives and diuretics and at the end I choose diuretics. but I didn't realize that the only thing I had to do was check if were a anion gap or not. +
snripper  Why would laxatives cause anion gap MA? Isn't it similar to diarrhea? +
castlblack  The above comments are incorrect. Diarrhea is a cause of normal-anion-gap metabolic acidosis (D in HARDASS from FA). Laxatives are wrong because they would lower HCO3- but in this scenario it is high. The low K+ and Cl- fits either case though. +4

 +8  (nbme22#40)
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nlecasaapPeir is iycaalbsl ctceanari"P zsmEne"y in ynacf saptn BENM dlorw

makinallkindzofgainz  "Pancreatic enzymes, also known as pancrelipase and pancreatin, are commercial mixtures of amylase, lipase, and protease. They are used to treat malabsorption syndrome due to certain pancreatic problems. These pancreatic problems may be due to cystic fibrosis, surgical removal of the pancreas, long term pancreatitis, or pancreatic cancer, among others. The preparation is taken by mouth." +

 +22  (nbme22#31)
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In ,iyooblg aephs virtnoiaa is a mtdeho for inaedlg iwth lryiadp aivngry verniesnnmto uottwih rineuirgq damnro tnmi.tauo It slvvieno het tiavniora fo norepit erons,xeisp tunlfrqeye ni na fo-fon ,oisfahn niwith eindetffr asprt of a irclaetab p.napolutoi sA suhc teh tyeehopnp anc icwhst ta eueqfsirnce htta era hcum rgehih (seimmoets );t%g1& htna caascsill taomiunt etras. haPse aivnaotri inreusotbct to ncvreueli by geengtinra higeoyer.ttnee ohuhgtAl ti has eben otms mnmcoylo dueistd in eht ocxtten fo eiumnm vo,neias ti is esovbedr in myan ehtor seaar sa ewll dan is peomdley yb arisovu ytsep fo iarcatb,e gicdunlni alSelmaonl e.esipcs

/nic.nw.h/dewantetiswiaaoP:ws//it_vkwmaorph

whoissaad  is it the same thing as antigenic variation? +8
dorsomedial_nucleus  No, antigenic variation involves genomic rearrangement Phase variation can be thought of as MORE or LESS of something. An on/off switch. No DNA is being rearranged, just under or overexpressed in response to the environment. +4
makinallkindzofgainz  This isn't in Zanki, Lightyear, or First Aid, and I don't remember ever learning about this in class. Thanks NBME! :D +18

 +4  (nbme22#35)
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5p3 si teutdma nda tanc dnbi teh TAAT ob,x os thwa npahspe to ianittrnocrsp fo ohintirbyi p?siteorn

Is liasblcya twah stih tsqieuno is ginrty ot aks...

So on TAAT xob eorotmrp t;g&= aDreseecd bgdniin fo RAN eypsormela

link981  You said it, they are "trying" to ask. Should use better grammar. +3
titanesxvi  This is on first aid, and says that the promoter region is where RNApolymerase binds +
nootnootpenguinn  Hakuna NO-TATA box... thank you for this explanation! +

 +3  (nbme22#28)
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oeseostuIrns umlcsse are dvenaiernt by the lnura evren.

loxeiFn of hte ootf is vrnieatedn by itailb enevr

leaf_house  Plantarflexion is tibial n. Dorsiflexion is deep peronial n. +5

 +5  (nbme22#41)
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Wtah apnesph newh yuo og ntoi ocld a?wetr ouY eep.

oHw sode htis hnppa.e

scironoatcointVs of vsslese ot esrvepre a,the slpul aretw otin vlsutcaeuar ude to derceades taodshctiry rsurspee ni essselv. mlouVe oges u,p DAH oges nwdo, ANP oges up ued to siadcener meuovl.


 +2  (nbme22#1)
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ile:aCc teosnd kema se,nes ti soemc tou fo eth rtoo of the oraat nda neds alsnttiny. Tasth ont ttenggi ucgtha up ni het uvvluosl .oneal

Legrihtt/f co:lci stath lla AMI sa,ehnrcb shtat ienodvlvun ni eth niuao.tist

Ubl:lciima ttha ggitnet ducdoecl si oisgcohypil aertf rb.iht

htsWa ftle si SAM: wcihh sgeo ihrgt voabe eth mudden,ou so i duolw ingmeia a ndealudo ovuluvsl wdlou vivlneo teh MSA iayes.l

yourswoliness  right colic comes off the SMA +

 +1  (nbme22#8)
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sIt a ,uiditrce so lveomu si c.denarise

3HCO si eadicrsen caeseub latzaadecoiem csduere arerinbtpoos of CH.O3

pH is rdeecsa,ni cueeasb OHC3- si a ekwa bsae, so it csuks pu aysrt dogheynr oisn in hte enuir.


 +6  (nbme22#49)
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"MTPP --ahoy(pdyiree-e1ynr-nit,-lyt,)h6t32,hldrpme14 is a ugdprro to eth txooernuni P,+PM whihc escsau tmnaerepn mmsyspot fo 'nasskrinoP asseied by ondiyegrts cgimorenipda rosnuen ni the asttuisnab anrig fo teh .nbrai tI sha ebne uesd to dsyut diessae modles ni srviuao aailnm ss"deut.i kiiW

ilikecheese  pg 508 FA 2019 +14
sbryant6  I thought this was testing "lead pipe rigidity" aka Neuroleptic Malignant Syndrome and its connection to dopamine. Had no clue what MPTP was and got it right still. Probably wrong train of thought though. +

 +9  (nbme22#31)
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hWat od you ues to raett Heitpca enphy?hpaotlaEc ueLsa.cotl ahWt eosd that o,d ti asciidfei NH3 in eth GI atrct into 4HN+ nda sorpmoet ossl of het rtgusenonio pcdsuotr that ueasc hcplntpayha.oee Tish is ohw uoy ebrmmree sthi ecors.sp

carmustine  FA 2019 pg 385 "Triggers --> increased NH3 production & absorption (due to GI bleed, constipation, infection)." +4
drzed  To add, you can also use rifaximin which will act as a antibiotic decreasing the production of NH3 from gut flora. Same concept. +3
nevergoingtopost  Lactulose is the correct treatment for hepatic encephalopathy, but it actually acidifies the GI tract (colonic metabolism of lactose → lactate). This favors the NH3 form and decreases NH4+. NH3 is then additionally pulled from the blood into the gut. +

 +12  (nbme22#9)
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Aaer C is weehr het agp untijonsc beeetnw ridacac mcyyoste .rae aGp nuictnsoJ era ndfuo no eth aalsmp meeamrbn of eht aacdrci ectmoyy.

eTh nquiotes is alysailbc iaknsg weher hte saampl maebrmne is with a nhucb fo bcemhoi uuobbmmjom you odnt heva to rsaddt.nenu


 +5  (nbme21#38)
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The ipeantt has eroncNiptue vere.f CFGS will erorest his nhioutespr.l

yotsubato  His RBC and platelets are low, but at acceptable levels for someone undergoing chemotherapy. +16

 +15  (nbme21#18)
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lWle atsht a elylra eurdc awy to erscne for odipe.sns..er

champagnesupernova3  There's really no other way to say it without using euphemisms +2
drdoom  You can’t rule out suicidal thoughts via inference. +
drdoom  LAWYER: Did you ask the patient if she was suicidal? DOCTOR: Well, um, no, not exactly — but, I mean, she seemed okay .. +
drdoom  LAWYER: So, a patient walks into your office, you suspect post partum depression — a diagnosis with known suicide risk — and you didn't ask if she was suicidal? +
drdoom  DOCTOR: gulp +

 +3  (nbme21#33)
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yWh si sih diobLi olamr?n 'stI lytotal edctpxee hatt eh amy have eedrdcu ldiiob artef sih eiwf deid 2 seray goa rmof meos ilobrerh ldgenrpoo .nslsiel

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +
nala_ula  At least, that's the way I saw it. +
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +
temmy  two years is a enough time to mourn...just saying +
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +

 +0  (nbme21#39)
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Why si hsti OTN hccrno?aid eeshrT hnntigo rhee atht sleru it o.tu

drachenx  Chancroid is described as an ulcer.. whilst in this question they mentioned "vesicles". Pretty much only herpes is vesicular +5
whoissaad  They mentioned ulcers too. I chose chancroid as well, couldn't find a clue to rule it out. Also thought "discharge" was pointing you towards a bacterial infection. But guess I'm wrong :) +
emmy2k21  I think NBME/USMLE writers make the assumption the patient is in America unless specified otherwise. Chancroid is not common in the US. If the question stem mentions a developing country, then chancroid can make your differential list. +1
selectuw  for chancroid, there may be a mention of inguinal lymphadenopathy +2
samsam3711  Also with chancroid questions they want you to differentiate it between chancroid and syphilis, (eg. Painful vs. painless) and is usually described as a much larger ulcer that is painful (not vesicular as in this question) +
suckitnbme  Also believe that chancroid does not presents with systemic symptoms like in this vignette. +

 +3  (nbme21#35)
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luilhsBt moanmrzeiito osqei.tun ouY vaeh to nokw tath het neglsi NRTI tath suscae rspncetaatii is idnan.sdoei

egPa 032 A2091F

rsp  Aren't 85% of these questions memorization questions. How many do you really review later and say, I didn't know that concept? My reviews are always "oh, that is the name of that thing they were trying to get at." +2

 -17  (nbme21#14)
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Seh ash anreBdr loeSrui saeDsie paeg 491 fo firts dia 9201

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

 +8  (nbme21#25)
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iTsh equiotns si its.dpu atrWe eiktna rfo a thalyhe uildiivdan is 0.2 L a y.ad


 +5  (nbme20#14)
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ihTs utoqsine si lsbt.ihlu heT nwmoa uodwl most lilyek be adcnetvica to rtpSe pm,oune peecalsyli if ehs dha a tnylm.eeoscp

E lcoi is saol an npcsatedaelu matburcei ttah scusae mnepaniu,o so atth si rome ikllye I.OM

sugaplum  I agree with you, only possible logic for their answer: the qualifier asplenic makes the "ShIN" pathogens more likely, even though Ecoli can cause gram negative sepsis and DIC. FA 2019 pg 127 Also it says s pneumo causes sepsis specifically in asplenic patients Pg 136 +1
lmfaoayeitslit  To be honest, the only reason I got this right (because I really was thinking E.Coli as well), is that I ended up remembering the MOPS part of the Sketchy, and I couldn't remember if he said that it was the number 1 cause of all of them or not, and ended up clicking it. It's pretty shitty they don't offer explanations for these. +
merpaperple  I thought this too but it seems like Strep pneumo is just more specifically associated with infection in asplenic/sickle cell patients than E. Coli is. Just one of those classic associations. There's a sickle in the Sketchy Strep pneumo sketch, vs. no sickle in the E.Coli sketch. +
drzed  E. coli causes pneumonia by aspiration, for which this patient had no risk factors. For USMLE, if they don't say the patient is vaccinated, you can assume they are NOT. Just because she has a history of splenectomy following trauma does NOT mean she had to been vaccinated--don't fill in the history for the patient, only use the information they give you. +
vivijujubebe  also DIC more often seen with G- bacteria right???? That's why I chose E.coli instead of S.pneumonia +1

 +1  (nbme20#1)
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"piyhanscsi ouhlsd lawyas neucgaero yhhetla roaminunadgir- icm.ouninac"tom

oAsl uero'y oging to do some eussrio thsnig to crue shti rligs' eassedi, eildnga up ot atomn.putai Yuo tnac dihe tath from h.er

djjix  Non sense ... you can hide the amputation from her +18
charcot_bouchard  Just show her one leg twice. +4
pg32  I picked "request that an oncologist..." because I figured it would be better to have someone with more knowledge of next steps and prognosis discuss the disease with the family as compared to someone working in the ED... why is that wrong? +2
ibestalkinyo  @pg32: Referring to another physician is almost never an answer for NBME/USMLE questions. Plus, I feel like this would be hiding the patient's problem from her and the patient's parents. +5
dunkdum  I think the reason that you requesting the oncologist isnt the most correct answer here is because... even if more tests needed to be done... you would still discuss with your patient about that fact and say "Hey these results came back suggesting that you might have this disease, we will need to do more testing to make sure we can get it taken care of if you in fact have this disease." and you'd probably do that before you go and get the oncologist. +4
peteandplop  @pg32 I was kind of with you, but I went with the correct answer because it says STRONGLY suggestive. If you're giving me a powerful word to really emphasize this is osteosarcoma, there's no need to delay passing that information to patient, and in this case of a minor, her parents. +1

 +2  (nbme20#7)
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tI atcn eb lraecaiBt ebascss ia(rd)oNca auseebc hsse tinakg MTP .SMX

tI tcan eb oo,tx asuceeb seh sah one ioelns adn is laos iakgtn TMP XSM whihc hudols poiervm hre .mpmtssyo

tlolsoGbaaim si a isedaes of rdole aunilvdisid

Msaaettitc dsaiees tath emts to eth iranb si lkniuley at isht ag.e

SNC oalmhpym si onmomc ni HIV DAIS taitp,ens os hatt si hte stom yelilk hcieco.

mrglass  She's not taking TMP/SMX though. I would pick lymphoma over abscess mainly because .5cm growth in 2 weeks is incredibly rapid, which is classic for diffuse B-cell lymphoma, which is what tends to be in the CNS. Also there was no evidence of a classic source of brain abscess like mastoiditis. +19

 +4  (nbme20#21)
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oD" on am"rh

invtrSga hte byab or nhotgiwhldi dfoo si ogind rahm. tA hist noitp uyo iervpod lvaaltepii rcae unlti the tdhae of the bba.y fI eth aesntpr ecedid ot ll"up het lu"gp enth thye acn od t,i but as het dtorco shatt otn uryo ioecch.

cry2mucheveryday  Why not 'give foods according to normal caloric requirement'? +7
hpsbwz  @cry2mucheveryday because feeding to the caloric may be too much or too little for this baby. considering the baby's crying only resolves with food, if you've already reached the limit, are you just not going to feed the baby? that's how i thought of it. "maintain comfort" is the key phrase. +4

 +21  (nbme20#42)
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diifB crodita pselsu era enes ni orAtic toiesssn ro igrinuragetto

roadtiC uriBt is dreha twih rhocoraestiessl of omomnc crtidoa rryate

Solw nirgsi deaecsred uoemvl riotdac epsul si ctirarisctcaeh fo iatcor te.niosss

Connna sawev ear esen ni ptoeelcm AV kcb,ol sa ritgh evrlcietn nad itraa otccrtan n.ienntpeddyel

chextra  I mis-remembered normal JVP as 8-12. Therefore, I picked "Slow-rising, decreased-volume carotid pulse". Is there a reason why this is NOT a result of HF, or is it simply not the best (which I agree is JVD)? +1
len49  For those wondering normal JVP is 6-8 mmHg +3
fatboyslim  @chextra I think the reason why it's NOT slow-rising decreased-volume carotid pulse (sign of aortic stenosis) is because the patient had a h/o prolonged substernal chest pain 5 days ago. I think he had an MI and is now presenting w/ heart failure. +

 +2  (nbme19#27)
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htaW was ucsignonf ofr em ni hist enosqiut was htta he has an ectau ere.ostptainn Thta dtdni kema neses ot .m..e eH lvdie 74 rseya ihtw lrena rreyta tisesson adn wno hsa einhrntpseoy besaecu of !i?t





Subcomments ...

submitted by russnels(13),

Anybody have any good insights as to what is going on here? Does surgery somehow cause hypokalemia? Or does this have to do with digoxin toxicity? I'm not sure how surgery fits in. Thanks in advance!

misscorona  Looking at UpToDate, hypokalemia is listed as one of few postoperative electrolyte abnormalities. Surgical stress releases aldosterone which leads to hypokalemia. Hypokalemia is a known cause of premature ventricular contractions. Digoxin toxicity can cause premature ventricular contractions but it seems like this patient was on these medications prior to surgery and this may be less likely contributor. Side note, digoxin can lead to hyperkalemia. +2  
yotsubato  Ah so it is a BS question.... Ugh. +2  
krewfoo99  I think surgery/stress will lead to increase in cortisol which acts like aldosterone to cause hypokalemia leading to premature ventricular contractions +  


submitted by yotsubato(965),
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looC henotra oiqnutes aetkn fomr eht list of gtnish tno in FA

charcot_bouchard  Actually it is in FA. FA 19 Page 100 - Antigen loaded onto MHC1 in RER after delivery via TAP transporter.... Remember FA is that friend who always say I told you so. +18  
yotsubato  But not in this context +5  


submitted by mousie(210),
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si tshi uceatusb drsnteadiioc osiesadtca rrovefnbolmi-patraeMie GN?

jus2234  The question describes how he had a strep infection 15 days ago, and now this is poststreptococcal glomeruloneprhitis, which can also be described as proliferative glomerulonephritis +9  
seagull  The question would be too fair if it just said PSGN. Instead we need to smell our own farts first. +64  
yotsubato  And they used terminology NOT found in FA +5  
water  who said they were limited to FA? +2  
nbmehelp  FA uses the common nomenclature and the fact most of our other resources use the same nomenclature for this, I think we can agree that is is the accepted terms. If they're gonna decide not to use the nomenclature that most medical students are taught then they should provide their own study materials at that point for us to use. The test shouldn't be this convoluted for no reason. +6  
alimd  Ok. They can use terminology whatever they want. But BUN-CR>20 is CLEARLY prerenal right? +  


submitted by mcl(578),
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unsBo veardac aidgamr, kid yhw hits swa on t..e.ns..p..it.e..?.r

drdoom  bonus cadaver diagram via @mcl +  
yotsubato  nurses +4  
faus305  Cause it's cute unlike the monstrosities they always put on the NBMEs +  


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Why lduow ti not be maniae of nichorc dsaiese ithw rsaeecdde esumr rranrfsetni crn?tcoinneoat

lispectedwumbologist  Nevermind I'm stupid as fuck I see my mistake +1  
drdoom  be kind to yourself, doc! (it's a long road we're on!) +20  
step1forthewin  Hi, can someone explain the blood smear? isn't it supposed to show hypersegmented neutrophils if it was B12 deficiency? +1  
loftybirdman  I think the blood smear is showing a lone lymphocyte, which should be the same size as a normal RBC. You can see the RBCs in this smear are bigger than that ->macrocytic ->B12 deficiency +22  
seagull  maybe i'm new to the game. but isn't the answer folate deficiency and not B12? Also, i though it was anemia of chronic disease as well. +  
vshummy  Lispectedwumbologist, please explain your mistake? Lol because that seems like a respectible answer to me... +9  
gonyyong  It's a B12 deficiency Ileum is where B12 is reabsorbed, folate is jejunum The blood smear is showing enlarged RBCs Methionine synthase does this conversion, using cofactor B12 +  
uslme123  Anemia of chronic disease is a microcytic anemia -- I believe this is why they put a lymphocyte on the side -- so we could see that it was a macrocytic anemia. +2  
yotsubato  Thanks NBME, that really helped me.... +1  
keshvi  the question was relatively easy, but the picture was so misguiding i felt! i thought it looked like microcytic RBCs. I guess the key is, that they clearly mentioned distal ileum. and that is THE site for B12 absorption. +6  
sahusema  I didn't even register that was a lymphocyte. I thought I was seeing target cells so I was confused AF +  
drschmoctor  Leave it to NBME to find the palest macrocytes on the planet. +4  


submitted by medstruggle(12),
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hWy si eht nwraes linaauo“grnt sst?uie” I utthhog atfer 14 dasy yuo ehav a lulfy rfomed .rasc

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


submitted by neonem(549),
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eroblelpoinentCe gnela smas = Vliesubtra shoawamncn A(KA cicaouts nromeua). dreviDe orfm Sahcnnw ce,lls ihhwc rae of nelrau crtse rinogi.

yotsubato  Ugh. Of course they dont put schwann cells as a choice. So I pick oligodendrocytes like a dumbass +31  
subclaviansteele  Same^ +1  
madojo  Schwann cells = PNS Oligodendrocytes = CNS +3  
suckitnbme  NBME loves their neural crest cells +4  
wrongcareer69  How much do they pay these testwriters anyway? I can use a thesaurus too +2  
osteopathnproud  @suckitnbme they do love their neural crest cells, I have chosen neural crest cells for every single answer choice I see it in and I believe I gotten 90% of them correct, if something doesn't click or you don't know, I would keep neural crest cells as a very possible answer lol +  
faus305  AMERICA EXPLAIN +  


submitted by lsmarshall(393),
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I ohuthgt tsih saw a tkcri neqtiosu iscen knis rcceans ear het omst moocnm ytep of cecsran oal.vrle tuB lyautalc moagn HVI seitatp,n rdHaVlteeI- rnecasc era mchu rmoe ncmomo hnta -atendno-HIrVel racnecs (eenv skni ncc)ras.e eidnuBV-dEc yparimr NSC oahmmply is teh ynol pootin tath si d-ifiDnsgInAe scanlel/ercins.

medskool123  why not hep B? i guess another whats the better answer ones... Just rem reading that it was more common with aids pts.. anyone have an idea about this? +1  
haliburton  Yes, I think CNS lymphoma as an AIDS defining illness wins the day. My thought was since SHE has AIDS it is most likely from IVDA, which has a high risk of HBV that could go undiagnosed for a long time. at 32, that might not be long enough to have HBV and get HCC (but with no immune system...?) +3  
yotsubato  God damn this is such BULLSHIT... +13  
trichotillomaniac  Why you gotta do me dirty like this NBME +2  
sars  My thought process, usually wrong all the time, was that HBV (IVDU) can occur to anyone. Acute hepatitis to Chronic occurs when HBV incorporates its DNA into host and releases mutagenic proteins. This is regardless of immunosuppresion. Primary CNS Lymphoma reappears primarily when you are immunosuppressed (organ transplant, immunodeficiency, HIV/AIDS). +  
syoung07  Hep C is far more likely to become HCC than hep B +1  


submitted by seagull(1392),
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A- irympar mtroo xretco = nowgr sdei fo ydbo idtfc(ei of MNU no eflt dise yod)b

B - mhauTlsa = oreynss ootarniimnf odtnicu - rtomo estifidc ulnliyek ot tinriaoeg mfor erhe

C - nsPo - sCN ,6,58,,7 eyikll tlresu ni d"oleck ni s"rndmyoe or ptelemoc ossl of otorm iufcntno no rithg dies + laifac e.fuaesrt

.D iVmsre - certlan dybo oocnaioi.dtrn meagDa srtlsue in aaixat

Nto mtpecole btu ebyam upe.lhf.l

yotsubato  C - Pons - CNs 8,7,6,5, likely result in "locked in syndrome" or complete loss of motor function on LEFT side + RIGHT sided facial features. Decussation occurs in medulla +2  
kard  Sorry if im mistaken, Isnt A) Somatosensory? +2  
krewfoo99  Yes i think A should be somatosensory. Primary motor cortex would be present in the precentral gyrus +  
drpatinoire  A is primary motor. A and the gyrus at right side of A compose the paracentral lobule. +  


submitted by lsmarshall(393),
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tpvnorbeSinay si het ettarg of ssnpmtiaeaotn (atnetsu xnt)i;o clmeus sasmsp era sraitcehrit.cca ynOl orhte wasren uyo mihtg cdoierns is eosethceniyeAalltrsc inecs he si a aefmrr dna wzbuzdrso nofet aryrc su ot het eodpmsri .d.lna. btu smpsmyto of a grneccihlio rmsot rae stae.nb

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +41  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +41  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +34  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +2  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  


submitted by lsmarshall(393),
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bvtypionaenrS si het ategtr fo esatsnnimatop nseta(tu x)nit;o celusm ssmpsa ear csetcharraici.t Olny roteh rwesan uyo hgitm ocsdnrei is eyihentlteloarAsscec neics he si a rmaref and wszbrzudo etnfo ycarr us ot teh odirpsem l.nad.. utb smymsotp of a clchnieogir smrto ear senbta.

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +41  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +41  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +34  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +2  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  


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nTkha ouy NEMB ofr eht ihhg iyqutla i.utpsrec It ksmea ehets smxae rstsse feer dna loajebyne.

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


submitted by colonelred_(99),
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dokLoe it pu dan udnfo ahtt caeubes euor’y in a uispne ontipsio rfo a lnog mite yur’eo ioggn ot haev ciderensa esnouv rnruet hwhic dlesa ot rnecdsiae O.C ishT yeegvlatni eebdkfsac on SAA,R aigendl ot edsecdrea dlesne.rotao As a r,ulset ’oyrue ginog ot hvea eansercid iieudrss chihw lsade to cerddease doobl nad saalmp o.mveul

medstruggle  Doesn’t supine position compress IVC leading to decreased venous return? (This is the pathophys of supine hypotension syndrome.) There was a UWorld questions about this ... +4  
tea-cats-biscuits  @medstruggle *Supine position* decreases blood pooling in the legs and decreases the effect of gravity. *Supine hypotension syndrome*, on the other hand, seems specific to a pregnant female, since the gravid uterus will compress the IVC; in an average pt, there wouldn’t be the same postural compression. +7  
welpdedelp  this was the exact same reasoning I used, but I thought the RAAS would inactivate which would lead to less aldosterone and less sodium retention +3  
yotsubato  You gotta be preggers to compress your IVC +5  
nwinkelmann  Could you also think of it in a purely "rest/digest" vs "fight/fright/flight" response, i.e. you're PNS is active, so your HR and subsequently your CO is less? But the explanation given above does make sense. Also because I think just saying someone is one bed rest leaves a lot up for interpretation, maybe not with this patient because his pelvis is broken, but lots of people on bed rest aren't lying flat.... ? +1  
urachus  wouldnt low aldosterone cause low plasma sodium? choice B +5  
kpjk  could it be that, while low aldosterone levels decrease plasma sodium levels- there is also decrease in blood volume(plasma),so there wont be a decrease in the "concentration" of sodium +4  
almondbreeze  FA 2019 pg 306 on Lt heart failure induced orthopnea - Shortness of breath when supine: increased venous return from redistribution of blood +  
almondbreeze  if there was no HF, it would lead to increased CO --> decreased aldosterone +  


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anC dnbayyo ilapnxe hist n?oe I utp predaete tsets eseacub I asduesm an y3der--loa8 anwmo is na snuuaul cmeraohdgip ofr hisyls.pi

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +5  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +4  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +12  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +10  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +13  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  
imtiredofstudying  the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +  


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anC ayndybo nlaexpi tsih ?eon I put eateedpr ssett cueaesb I asesudm na de8rl3-y-ao noamw si an uanusul iomhceadgpr rfo pslyis.hi

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +5  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +4  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +12  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +10  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +13  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  
imtiredofstudying  the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +  


submitted by mousie(210),
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A Tnee htwi oejnntcii fo tboh uannocijvct = dwee lc udo aols be ubasngi rhteo udsrg s I 12 yersa old nda rofu nshomt tujs oto odl and oot ongl fo a imte fro ti to be imptgoe?i I edwroarn ti ndow ot hetes two nad eusedsg ut..b. I 'natsw rseu I odulc nailmeiet i.t

medskool123  I picked impetigo because of the gold stippling... I guess I took that as honey crusted lesions. F*ck NBME. +6  
yotsubato  Huffing gold spray paint. A la the chrome huffers in Mad Max +7  
subclaviansteele  LOL I think that might be what they were going for here. Gold spray paint. +3  
et-tu-bromocriptine  Anyone know what may be causing his weight loss and unwillingness to eat? I thought too much into it and put "mercury poisoning", since I thought the heavy metal's abdominal symptoms may have caused him to not want to eat. ¯_(ツ)_/¯ +3  
covid2019  I'm not sure about the pathophysiology there... But I do know that inhalants are popular in places where there's extreme poverty. I spent some time abroad, and one of the patients was using inhalants to take the edge off the hunger, so that she could spend her money on food for her kids instead. She also worked on the streets so I guess it also made it easier to, you know... +2  


submitted by yotsubato(965),
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yhW si the tptiean ton in .pina I owtlnud xepect dteaceacrnrI raeinh to etnpers thwi rzeo i,apn btu 1 kewe of intaoitopcns nad ngils.elw

yotsubato  Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Like really? Why is he not in pain? +1  
medschul  I thought that inguinal hernias were reducible? +  
fahmed14  could be a femoral hernia as they are more likely to cause incarceration. They do, however, present more often in females. (FA 2019- 364) +1  
wowo  incarcerated, not strangulated, thus no pain as there's no serious tissue damage/ischemia. Incarcerated hernias may progress to strangulated in which case he would have pain Under section, "complications" https://www.amboss.com/us/knowledge/Inguinal_hernia +5  


submitted by majic(7),
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HET MOST MMCOON tuore fo xToo siinnamtrsos ni sdlaut ni eht SUA si nontgeisi of nkdruedooec pork. evEn if tac rttlei is na tni,opo okrneocedud prko is itlsl remo .mcomno

yotsubato  Also another fun fact. Most people in France are infected by Toxo (like 80%) because of how they eat meat. (Very rare) +2  
madojo  To add on might be TMI but most people have Toxo but are asymptomatic because its in its latent form as a pseudocyst and its not untill you are immunocompromised that it strikes +  
suckitnbme  This patient also probably got toxo in Brazil +  
luciana  JFYI people in Brazil love to eat rare meat at barbecues +  


submitted by wired-in(67),
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etcnMiaaenn odse mfrlaou si Css( × Cl × atu) ÷ F

ehrew ssC si tttdyaeseas- arttge apalsm oc.cn fo grud, lC si naa,elcrce atu is sogaed vitlaner mp&;a F si .aayblvaiilitoib

Nteehri doagse iltervan rno ivaaliyitbalboi is nigv,e os igrionng hsteo p&;ma glpginug in het merbsun elrfauc( ot cneortv itsun to gkgd:mya//)

21=( gmu/L × 1 /0m100g g)u × 9.0(0 gk/hLr/ × 0001 Lm/1 L × 42 h/1r ya)d
= 952.2 mk//gdyag

hhc..iw. tnsi' any fo eht nersaw cocehsi .eistld yhTe mstu evah ddeonru 090. rkgL/h/ ot .01 k/,Lgrh/ nad doign so esvig lecxaty 8.28 a/m/gdykg hcoiec( C)

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +69  
hyoid  ^^^^^ +11  
seagull  lol..my math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but i´d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +3  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +2  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +15  
qball  Me after plugging in the right numbers and not rounding down : https://i.kym-cdn.com/entries/icons/original/000/028/539/DyqSKoaX4AATc2G.jpg +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😡 +  


submitted by sympathetikey(1248),
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oSrce:u tn/egd/l/Mii/.ipakrneswieohi.tkwyip:

inel"my essdep eht rmastnsnosii fo ccaeitlelr supmisle elldac taicon noltpseati golna deatymelni xnosa yb nsgautniil teh naox adn nduercgi nxaoal mmnarebe aacpincctae"

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


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nCa oenayn alxpnei woh 1cm0 0H2 teopivsi PEPE ldaes to ePka tspIryoanir ,AP ndE iTlda A,P Paek oniapyrItsr ipP and Edn ilTda pPi lla negbi v?eoiispt

tea-cats-biscuits  In PEEP, bc of how mechanical ventilation works, all the inspiration part of breathing is done by the machine actively pushing air into the lungs. As a result, there is no negative pressures in the system compared to the normal lung which needs the negative inter-pleural pressure to draw air in. +27  
yotsubato  " As a result, there is no negative pressures in the system compared to the normal lung which needs the negative inter-pleural pressure to draw air in. " Thats totally what threw me off. TIL +  


submitted by welpdedelp(215),
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30* ..015 ikTnh obaut ,ti ehter si x lfow whti an exgyno atcrnonnciote of s--oy ot nidf uot hte edyrivle ouy jstu umliyltp hmet gteht.oer

yotsubato  One of those questions too simple to believe its actually the right answer +27  
mimi21  Right, I was like this is too simple lol ! im not sure if this is also a good tip but I tend to look at the units they are asking for and double check my math to make sure I end up with them. +7  
osgood-schlatter  what equation is it exactly? +  
arcanumm  Literally did not even conceptualize this question, just looked at the units. +4  


submitted by sakbarh(5),
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eSh ahs naym aldiaorcsvucar rsik catsfor and yeilkl urfedfse a ortsek fo the sraalbi rearyt gcuanis oelkcd ni eydso.mnr nirgcdcAo ot AF hsit nac acseu a leonis ta teh ps,no llruam,ed ro wolre ibdnrami -- heovwre laacnolimyta hte arlabsi yertar nurs trhig no pto fo het pnos so xyitromip tosm yeilkl semka it eht thgir rse.wan

mousie  The Boards and Beyond video of SC strokes was really helpful at explaining this if you are a video kind of person! +1  
yotsubato  What pushed me away from pons was "dysarthric speech" which implied she still could speak to some degree.... which made me pick medulla. +3  
mimi21  I think FA may be misleading. Primarily it will effect the Pons because that is where the majority of the Basilar Artery is located. and I guess it could effect the other locations? but everywhere I have looked Locked-in syndrome is an issue with the Pons. But someone please continue to clarify, cause I was a bit tripped up at first with this question +  
cbrodo  Although FA says it can be pons, medulla, or lower midbrain, "locked-in" syndrome generally arises from BL pons lesions. Another way you can rule out medulla and midbrain in this question is the ocular movement findings. Since the patient has impaired horizontal gaze BL, you can conclude that the Abducens nuclei are involved on both sides. The abducens nuclei are located in the pons. +40  
gh889  USMLE secrets also states that it is most commonly in the pons Bates states that locked-in syndrome preserves consciousness but these patients have limited speaking ability +  


submitted by mousie(210),
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Why on ena?witgs I mean I gte csstaEy si bryabplo het grud fo ioecch oerebf an lal gtnih cedan rptya )l(ol btu tn'do unsdanterd why eehrt owudl eb cdol msteeiretxi dan no ingwates wnhe si FA ti says hrmyitaepehr adn ???ad?rboh

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


submitted by lfsuarez(141),
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Ftirs aerht uonsd 1()S si teagdneer by otw erhta :vesavl the railtm vavle and iudpcitsr vael.v ylaNre seltinmausou scnlgoi fo sehte vselva onrlylam entagesre a seingl S1 onusd. pliiSttgn fo het S1 uosdn si aderh ehwn trilam dan cpiidutsr eavlsv secol ta tlgsihyl feridtenf setm,i ithw luylsau hte iatrml locnigs obeerf duptisrci

yotsubato  Then why the fuck is it describing a mitral valve sound in the tricuspid area +22  
dr.xx  it's describing a splitting S1 — consisting of mitral and tricuspid valve closure — that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. +30  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +4  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +1  
drzed  It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post) The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound. +9  
alexxxx30  yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation. +10  
jesusisking  Thanks @alexxxx30, you the man! RIP Kobe +  


submitted by sajaqua1(518),
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d'untWlo lttao VA ldano oltnaiab esroydt ot huythitortacyim of eht meeaca?rkp athT udlow nmea hatt oebwl teh AV ndeo het hmyhrt ludow eb dipeovrd yb a tcavrnreuli fico, nda ehsto sluluya etearc ewdi QSR ml.esoecxp

haliburton  that was my reasoning as well. guess not. +  
yotsubato  Shitty NBME grammar strikes again. +1  
charcot_bouchard  No. No guys. Bundle of his located below AV node and it can generate impulse. it calls junction escape rhythm and narrow complex. Below this is purkinje, bundle branch & ventricular muscle. those are wide complex +13  
abhishek021196  Third-degree (complete) AV block The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lym3 disease +2  


submitted by aladar50(40),
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Fro eth EG,C I ltanyiiil htthogu it saw dn2 gdreee peyT 1 eauesbc it sedeme thta teh RP invrtleas erwe grisniacen niutl a tbea wsa dppde,or utb if oyu ookl at it leycol,s seom of het P waesv erew iehdnd in eht QRS cexl.eopms fI uyo ticnoe taht, tnhe you nac ese atht reteh eewr urgarel P awsve nad geualrr RSQ msceeoplx, btu erhet aws a lpmcoete iisadsoconit beeewnt mthe cwihh namse it was dr3 ergede retah lbk,co so eth anresw saw tolanabi eanr the AV .doen

yotsubato  answer was ablation near the AV node. No it wasnt. It was ablation OF THE AV node itself. Which faked me out. +9  
makinallkindzofgainz  The tangent by user "brbwhat" says that there is "pr lengthening progressively" but there is not. This is 3rd degree AV block. The P waves march out consistently at their own rate, and the QRS complexes march out at their own rate. There is complete dissociation between the P waves and QRS complexes. They have no relationship. This is exactly what you would see if you ablated the AV node. The SA node would continue to to create P waves. The bundle of His would continue to generate junctional (normal looking) QRS complexes. +6  


submitted by seagull(1392),
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hsTi si a eytp II nealR urlbTau cdsisA.io yM liMcade clShoo veeNr htgaut ihst ot .me idD yuo laos go to teprovy med sl?hoco mI' rudsseipr yhet eenv evga us liotte .preap

mousie  haha mine didn't either. But they usually leave out most high yield info so, to be expected I guess. +6  
yotsubato  I didnt have physiology in my medical school. None, zip, zero, none. Nor did I have biochem. They said "you learned all this shit in undergrad, youll memorize it again for step 1 and forget it promptly" and then just moved on. +9  
jcmed  In the Caribbean thats 1 thing we were given... lots and lots of toilet paper +1  


submitted by seagull(1392),
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thaW a rrebelti turipe.c eThy ythe doecvre pu trpa fo it hiwt .nisel WFT

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


submitted by seagull(1392),
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This tpniaet si ntippirg slal.b trBtee od a drgu nersce ihchw essem usi.obov

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


submitted by sajaqua1(518),
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aeucseB the 'sbayb meroht has Tyep 1 atDisbee elsm,luit ti is lueabpils atth hety adh ealvedte oobdl souelcg elevls dignur ro sryhlot brofee i.rtbh nIsnliu eods nto srocs eht cpalnt,ae tbu uesclog odes, os rdugni btrhi eht teeanon owdul aveh bene ym.eyhlcpgerci sTih uldwo edal to the oeannlat npsacaer alneseirg linnui,s gdnivir lgsocue toin clles adn giunnrt down gecnglne;oesouis hsit is why hte byba si ceiphogmlyyc tigrh w.no

)B eeDadecrs olycggne cenotcia-rtnno I td'no okwn het ygcgonel nencnorcttiao eapcmodr ot an alutd t,nietpa but a deseaerc in neocggly inttanrcncooe lwduo cdnaeiti lnggsoe/ucoglcey see,lare hhwci uodwl tno eb a cymcoigehpyl sta.et )C erscdaDee gyogcnle nhytsesa ttiivayc- reeedsadc yoncglge nsthasey vcititya etidanisc yeerng o,abtisacml nda wloud adel ot hreigh rumes ocgslue e.vlels )D readeceDs eusmr lnsuiin a-noocintcnert edearcesd ersmu nliiuns olduw edal ot ighehr svleel fo oulsecg in e.srum E) dcneresIa smeur klii-nnsileu trwgho ca-ofrt IGF oesd nto ndib aylner as ewll to slniuni pcoteresr as liinnsu ,odse dna os ouldw haev to be in rleexyetm high tennctraiooncs to aehv hist cf.feet IGF si satoiecasd twhi otamsic hrtwog adn ecmsul neovltedep.m

yotsubato  His glycogen concentration is high, since he's been hyperglycemic with lots of insulin until birth. +3  
alexb  Also explains why he's 12 pounds. +3  
krewfoo99  Also, think of it like this: Insulin causes hypoglycemia, thus this baby must have increased insulin. It is also an anaobolic hormone which is clear by the babys weight. Insulin increases glycogen synthase activity, and causes an increase in concentrations of glycogen. Decrease in insulin would do exactly the opposite +1  
tyrionwill  fetus of a mom with DM will develop pancreatic beta cell hyperplasia, which leads to insulinemia trying to reduce the blood glucose. after birth, the excessive blood glucose will be automatically withdrawn while the insulin at that moment is still high, which leads to hypoglycemia. +2  


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laiMraa cna rmiapi chiatep ueosnnoceigegls dna acn oasl sceunom uoclesg ofr tis wno belmoitca .amesndd

yotsubato  Truly a bull shit question... Its not in FA, Sketchy or Pathoma +54  
meningitis  I will try to remember this by associating it with P. vivax, that stay in the liver (liver=gluconeogenesis). Thank you @thomasalterman. +8  
focus  ADDITIONAL INFO: If we were asked to identify the stage of the lifecycle, it would be (intra-erythrocytic) schizont stage: https://labmedicineblog.files.wordpress.com/2018/06/mal3.jpg?w=840 Life-cycle: https://www.cddep.org/wp-content/uploads/2017/06/malaria-life-cycle_4-1440x1080.jpg +1  
dul071  i solved this question by seeing that there are hemolytic inclusions resembling parasites and that they require glucose being a living organism, hence hypoglycemia. +  
curlycheesefriesguy  I knew that malaria causes hypoglycemia but i saw the word drowsy and like an idiot thought it was african sleeping sickness +  


submitted by seagull(1392),
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yWh si tsih not UH?S oHw idd ouy sgyu rahcoppa eht qeonutis?

joonam  I think if this was HUS (d/t a bacterial infection) the leukocyte count would be abnormal (11k<) +  
yotsubato  normochromic normocytic RBC thats why. You would see schistocytes +9  
vulcania  Also for HUS I would expect mention of h/o bloody diarrhea, or at least diarrhea (not URI), and mention of something to do with kidney damage. +  


submitted by medstudied(1),
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hWy si ti ronyithmziac not yoel?ciydxnc ccdgArino ot ste,ychk oyu rttae dlhyacaim htwi /esdodialymcrxo e+iraotexncf. ouY rteat resisiane hnraogore hwit trciremifye.xdainlacyti+yoohnxzcn+oec

oNt​ ruse htwa htis sieqnuto si eigtstn -- si it ningwat us ot oknw ahtt argnroheo sha ot eb teeardt sa lelw? In ahtt ,ecas ydxo lwodu rkow rfo hotb cngirodac ot kyschte ... Any ohetr nnesirgoas daar!etpepci

dr_salface  The patient in the stem is pregnant! The question wants to see if you know that doxy is a teratogen. Tetracyclines in general like to bind to fetal bone/teeth which can impair development. +32  
dr_salface  As a side note, treating chlamydia alone only requires macrolides or doxy. Treating gonorrhea alone only requires ceftriaxone or macrolides. The reason sketchy includes all three is because you usually treat one infection and co-treat the other. +3  
yotsubato  Theres a crow in the chlamydia sketchy. You can use Macrolides, OR Ceftriaxone, OR Doxycycline. Most doctors in real life just give the azithromycin z pack (which kicks ass cause its one drug 5 doses thats it) +3  


submitted by dr.xx(142),
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heT tmso ncommo adn ereves mfor fo tmouoaasl omdtanni yloscpctyi dyeikn desseia )PDKAD( ulessrt morf tomunaist ni KDP1, nedngico iycynpsotl1- )C(.P.1

r//ttpc/.l84iws..9e3Ps:4owgcpMav4mnmn//hi8t/.cibwnClh

yotsubato  Here we thank FA for failing us yet again. Giving us PKD1, but not polycystin. I got the question right but I just guessed it because nothing else made sense. +14  
usmleuser007  Autosomal dominant polycystic kidney disease 1) occurs in patients with mutations in the gene (PKD1) encoding polycystin-1 (PC1). 2) PC1 is a complex polytopic membrane protein expressed in cilia that undergoes autoproteolytic cleavage at a G protein–coupled receptor proteolytic site (GPS). 3) A quarter of PKD1 mutations are missense variants, though it is not clear how these mutations promote disease. 4) GPS cleavage is required for PC1 trafficking to cilia. 5) A common feature among a subset of pathogenic missense mutations is a resulting failure of PC1 to traffic to cilia regardless of GPS cleavage. 6) Missense mutation in the gene encoding polycystin-2 (PC2) that prevented this protein from properly trafficking to cilia.  +2  
waterloo  yotsubo - the book is already so thicc. I think you made a great point tho, nothing else made sense. Sometimes you can't know everything on the test, but you can still play the game. +1  


submitted by lnsetick(90),
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owH rea yuo ebal ot ltel ttha eht TC escli si tno ta the llvee of ?omdeudnu

zelderonmorningstar  I think the small intestine narrows as you go along, so jejunum would most likely intuss into the duodenum. +  
yotsubato  Duodenum is fixed to the retroperitoneal wall, and also has lots of named vessels attached to it, along with the pancreaticobiliary duct and ampulla. It cant really intussuscept. +  
gh889  You should also know that the duodenum is almost purely on the right side of the body +24  


submitted by seagull(1392),
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aemby oemones anc enlxapi why shti si aaausrlvc nsoercis adn ont epss.is It edtons' tinonem fvere ro ebcnaes of eef.rv The MRI ash a amsll noatum of pythdseoyni tbu ot egt vaalrucas orsicnse sseme d/do

someduck3  Pg 455 of F.A. mentions that alcoholism can be a cause of avascular necrosis. +5  
meningitis  I think the small dark area on the left head of femur and the darkened neck are the avascular sites. Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg +3  
yotsubato  He wouldnt be playing golf if he had septic arthritis. Avascular necrosis is a more chronic condition that has a slow onset. +3  


submitted by just_1more(0),
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I ogt atht ti eeendd ot be a pmoutssai rnaipsg eudrt.iic sI hteer a naesor ti connta be na srdtlneoeao t?agtsoanin I sceho obkscl slbaaolreta +K slanhnce sa tshee eedreasc het rlblasaeota NKP+/T+Aaae/s ecsaeub teh drwiogn fo teh ectocrr erwasn ddi ont ekam ssnee to em -- uimnassg yteh rewe giogn for an ENaC cleobrk nda( ttha aecesderd uanliml libeeymapirt aicdinste htta a+N oudlw eb nagrinmei ni eth ,lnmue otn eanrimngi ni hte aipprcnli lecl as I yligniarlo )hhougtt.

luckeroo  I think the reason it’s a potassium-sparing diuretic rather than an aldosterone antagonist has less to do with why the aldosterone antagonist cannot be used and more to do with the fact that a potassium-sparing diuretic would be more of a “first-line” adjunctive diuretic treatment. +1  
luckeroo  As for the answer choice, potassium sparing diuretics achieve their overall anti-aldosterone effect by competitively inhibiting aldosterone receptors on the interstitial side (decreasing the Na/K-ATPase effect of shunting Na into the blood), thereby decreasing the gradient for sodium to enter the cell from the luminal aspect, blocking ENaC. +6  
yotsubato  There is no such thing as "Basolateral K Channel" there is only basolateral Sodium Potassium Pumps which are controlled by aldosterone. FA pg 573 +9  
nwinkelmann  @yotsubato LOL.... why didn't I think of it that what?! (by the way, that LOL is for me). The only basolateral K channel is the nephron (based on the first aid picture) is in the thick ascending limb of the loop of henle. +  
hello  Spironolactone and eplerenone are potassium-sparing diurectics that inhibit the Na/K ATPase, so I'm not sure what @luckeroo is referring to. Spironolactone and aplerenone are both ALDO antagonists. Na/K ATPase is found on the basolateral membrane. None of the answer choices fit with this. Amiloride and triamterene are also potassium-sparing diuretics; their mechanism is to block ENaC channels on the luminal membrane, this is choice "B." +1  
rxfit  From Katzung Board Review: "Spironolactone and eplerenone are steroid derivatives and act as pharmacologic antagonists of aldosterone in the collecting tubules. By combining with and blocking the intracellular aldosterone receptor, these drugs reduce the expression of genes that code for the epithelial sodium ion channel (ENaC) and Na+/K+ ATPase. Amiloride and triamterene act by blocking the ENaC sodium channels (Figure 15–5). (These drugs do not block INa channels in excitable membranes.) Spironolactone and eplerenone have slow onsets and offsets of action (24–72 h). Amiloride and triamterene have durations of action of 12–24 h." So both K-sparing subtypes are technically correct. +  


submitted by joker4eva76(25),
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dCoul aosl eus hte antsi'pte eag to kmea eht ifandteferl.i egA si a kisr cforta eadrelt ot esbtar cranec con(mom ni maospteslnop-au enmow, usnsle ht'eers a osytrih fo esbtra ccenra in eht faiyl).m

oiFticcbsry cnegsha and fsdabmorianeo aer ylusual mcmnoo ni aasmuolrnpeep mneo.w

oN hgserciad o,ednt os 'tsi otn an daiatlcnrtu .lpialmopa

yotsubato  Intraductal papillomas are also under the areola +5  


submitted by iviax94(7),
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I fugeidr yeht erew ygnitr to gte ta teh flie nectyepxca of na RB,C btu wdnotul’ tlusenpapmle O2 chialtynlce rceleap hte OC onbdu ot Rs?CB FA eenv onitsnem ahtt OC nbsid pevmocilteity to sC,BR dna nst’i atht eth elhwo tiopn fo iggnvi b0err%hpi/01acy ?2O

nc1992  First aid has a lot of errors +  
yotsubato  Thats not an error though. Thats the actual reason behind giving hyperbartic O2 for CO poisoning... +11  
mumenrider4ever  The question ask how long it takes to remove all the CO-carrying RBC so I think they're implying that theoretically not every single CO-carrying RBC would be replaced with oxygen from the supplemental O2 and some would die off naturally +  


submitted by hipster_do(6),
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I intkh tshi swa ferrgrien ot rvseeer eapr,inastsrct dna hte noly wto riseuvs I kewn atht uesd emht were epBH nda Vrre.ueitovI/sHrs ievnG het xnttceo I dipkce rt/iusVreoHIvers hciwh rae SS + sen.se This saw dikn fo dweir ohugth ciens eht isruv wsa ”en“w ... btu Iev’ nredlea that e“n”w uyslual nesma vrye ltitel on eetsh .setts

yotsubato  "New" means made up fantasyland virus +5  
yotsubato  Also Hep B is a ssDNA virus that goes to RNA, then is reverse transcribed to dsDNA +  


submitted by hipster_do(6),
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I tnikh tihs asw rfierreng ot reveres rratsetnc,apis adn hte noyl wot ieruvss I ekwn that ueds emht ewer eHBp dna oterrues.i/IVHrvs Gneiv the ctonetx I pcdeik e/trrssHIriovVeu hwich ear SS + n.eess Tsih swa ndki of reiwd hugoth ensci het vuisr swa new”“ ... but I’ev enrlead ttah “new” sluyula aesnm very iltlet on etshe ttes.s

yotsubato  "New" means made up fantasyland virus +5  
yotsubato  Also Hep B is a ssDNA virus that goes to RNA, then is reverse transcribed to dsDNA +  


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rOu lletti ierfdn hsa a ovrPvarsui ifiencnto, wcihh siecnft ohrtyedir crsrospe,ur uncgisa rtoeuiitrpnn of ythrrecyteo tdroiupcno. ihTs si hte same way it ecsasu ydrposh altfsei in obnnru besbai dna laictpas eanmia ni ikselc l,lce tce.

gainsgutsglory  I get Parvo has tropism for RBC precursors, but wouldn’t it take 120 days to manifest? +  
keycompany  RBCs don’t just spill out of the bone marrow every 4 months on the dot. Erythropoesis is a constant process. If you get a parvo virus on “Day 1” then the RBCs that were synthesized 120 days before “Day 1” will need to be replaced. They can’t be because of parvovirus. This leads to symptomatic anemia within 5 days because the RBCs that were synthesized 125-120 days before the infection are not being replaced. +20  
drdoom  @gainsgutsglory @keycompany It seems unlikely that “1 week” of illness can explain such a large drop in Hb. It seems more likely that parvo begins to destroy erythroid precursors LONG BEFORE it manifests clinically as “red cheeks, rash, fever,” etc. Might be overkill to do the math, but back-of-the-envelope: 7 days of 120 day lifespan -> represents ~6 percent of RBC mass. Seems unlikely that failure to replenish 6 percent of total RBC mass would result in the Hb drop observed. +  
yotsubato  He can drop from 11 to 10 hgb easily +3  
ls3076  Apologies if this is completely left-field, but I didn't think this was Parvovirus. Parvo would affect face. Notably, patient has fever and THEN rash, which is more indicative of Roseola. Thoughts?? +4  
hyperfukus  @is2076 check my comment to @hello I thought the same thing for a sec too :) +  
hyperfukus  also i think you guys are thinking of hb in adults in this q it says hb is 10g/dL(N=11-15) so it's not relatively insanely low +  
angelaq11  @Is3076 I completely agree with @hyperfukus and I think that thinking of Roseola isn't crazy, but remember that usually with Roseola you get from 3-5 days of high fever, THEN fever is completely gone accompanied by a rash. This question says that the patient has a history of 4 days of rash and 7 days of fever, but never mentioned that the fever subsided before the appearance of the rash. And Roseola is not supposed to present with anemia. +3  
suckitnbme  @Is3076 another point is that malar rash refers to the butterfly rash on the cheeks that is commonly seen in lupus, so the face is NOT spared. +  
mdmikek89  Honestly y'all lmao First line...RED CHEEKS AND RASH Malar Erythema --- Hello? Rash - Eventually it may extend to the arms, trunk, thighs and buttocks, where the rash has a pink, lacy, slightly raised appearance Hemoglobin is 1 g/dL below normal. This is Parvo B19 -- SLAPPED CHEEK. I swear man, y'all make this easy nonsence. WAY to hard. +1  


submitted by marbledoc(0),
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yhW duwlo oyu kas hte ptianet to ediniytf teh sorp adn s?onc I o’dtn gte the corhappa !ehre

someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +6  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +5  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +2  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +3  


submitted by seagull(1392),
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otu of soiriytu,c who mya pleoep newk ith?s ont(d be shy ot say you idd or ?dndt)i

yM veyptro ncuaoetid dn'tdi iagnnir ihts ni .me

johnthurtjr  I did not +1  
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. +4  
snoochi95  hell no brother +  
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 +1  
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 +  


submitted by seagull(1392),
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tuo fo ryocistu,i how yma polpee knew h?tsi o(dnt be syh to say uyo did or tid?)nd

yM ortypev acdueiont 'ddtni nriangi tish in e.m

johnthurtjr  I did not +1  
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. +4  
snoochi95  hell no brother +  
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 +1  
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 +  


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faomTnixe sah to be ledtzeaboim iav rifts pssa tebsmiloam to an vctiea elmbtioaet oi.d(n)fexen hTe iaenttp sah aeecdreds cretascnonnoit fo hte edlieobmzat ducrtpo tagindiinc tath eht netsipat’ apir of chteoromcy 54P0 allelse nraet’ gieatbominzl imxanotfe .rycetcorl hTe oeiusqnt is ignask wtha the seccnha ear hte esisrt hsa teh aesm gpeeot,ny hhiwc uowdl be 25% --&;tg 1/2 * 21/ = 41/

medschul  How do we know the parents are not homozygous +2  
yotsubato  Chances are they are not unless they had or are incestuous +  


submitted by joha961(43),
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ecniaeMnnat osed = C(ss * CL * )t / F

... hreew t is esladpe mtei wnetebe essod tn(o nvterlea heer eisnc ’its ucotnosniu )onniifsu dan F si vlybotiilaiiaba whhi(c si 1%00 or 10. reeh bsueaec i’ts geivn IV).

totrs​Cna thwi ongdila od:es

Css( * Vd) / F

... erewh dV si molveu of to.dnsbiirtui

yotsubato  So do we just have to memorize this... +9  
gh889  yep +12  
drschmoctor  @yotsubato Not necessarily. I can't remember a formula to save my life. The Css is the amount you want in the blood. The clearance is the fraction removed per unit time. Since we want to maintain a steady state, we only need to replace what is removed. Thus, maintenance dose = amount present * fraction removed. +8  
mambaforstep  https://www.youtube.com/watch?v=gnqOUmNhmdg good & short explanation +1  
castlblack  I remember CLoCk Time as in check the clock time to give the next dose Cl = clearance, C = concentration and T = half life. I have never had to use F. +21  
baja_blast  This is on p. 233 in FA 2019. +  


submitted by haliburton(208),
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aiksop oa.sacmr H.VH8 ivuoslacoe rlupp)e( sosn.eli ddnacaev IHV CD4 &l;t 002 (W)H.O

yotsubato  Yeah thats the easy part. But the histology is whats hard +  


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I tog it dnwo ot econlbiym pa;m& lrhccoblmuia dna nwte ihtw ohllabucimcr oeusnd(d klei luufas“”bn ... l)ol seecuba I gtotuhh oynlbimce swa ofr teractsilu edkgnornH/casci ypo.mmalh I letra nduof uto thta cumlrchibalo si yalcutal a rpdeefrer rettanmte ofr LL!C Is ti aeecbsu clohbmicaulr usaesc eeevsr ieipo?ssupnmrosmnu So yuo tdu’wlon be nigigv it ot a 72 oy man in the risft plac?e

yotsubato  Bleomycin is the big boy of cancer treatment. I've never heard of chlorambucil and its not in FA. +1  
vulcania  I had never heard of chlorambucil either and after researching it found out that it's also an alkylating agent, specifically a nitrogen mustard - same as busulfan, so you weren't wrong! Based on what FA says re: bleomycin & busulfan (extrapolating this to chlorambucil), they both cause pulmonary fibrosis & skin hyperpigmentation, however, in the Lange Pharmacology flashcards it says that the hyperpigmentation with busulfan is from adrenal insufficiency so I guess you would expect to see symptoms of that as well if the same applies to chlorambucil? +1  
vulcania  jk ignore my previous comment. just checked uptodate and it doesn't list hyperpigmentation as a side effect of chlorambucil. +  


submitted by yotsubato(965),
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Teh itatnpe ash Neieropuntc efev.r SCFG wlli teoesrr sih oslit.hrenup

yotsubato  His RBC and platelets are low, but at acceptable levels for someone undergoing chemotherapy. +16  


submitted by liltr(22),
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I cseoho MPV to,o tbu hist aes’ptint iman ytmmspo is uocgh nylo rdgnui xe.cerise Tihs is reom icantveiid of ceexiesdr sodtaeasci m.astha You dlocu ese nestsorhs fo abehrt in MPV idrung xseeeci,r utb oshnocgi PVM saeevl teh ugohc dutceuoncna rf.o

.ooo.   I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps. +14  
uslme123  I mean... couldn't increased BP during exercise worsen his MVP and give him SOB? +  
uslme123  (by causing slight regurg) +1  
yotsubato  "Lungs are clear to auscultation" +6  
sahusema  But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for? +  
cienfuegos  I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts? +2  
cienfuegos  Just noticed that he has FHx, game changer. +1  
kimcharito  clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise) +1  
pg32  Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP. +  
happyhib_  it took me a little; the FHx really pushed me to exercise induced. I was also looking at malingering but there wasnt a real reason to push me to this (as a doctor it would be sad to be like hes faking it becasue he doesnt want to play sports with out being sure first; led me away because there wasnt enough pointing there). Also MVP could be slightly benign and is very common and usually no Sx and his lungs were clear as was rest of exam. All pushed to Asthma +  
mittelschmerz  I think MVP on its own shouldnt cause SoB with cough (in a question, I'm sure it could in the real world). In the world of NBME questions where you need to follow the physiology perfectly, you would need some degree of MR that lead to LV dysfunction/vol overload, and theres no pulmonary edema nor an S3 that point us towards that. Malingering would have to be faked for gain, and theres no external gain here or evidence that he's faking symptoms. You would also need to r/o physical illness before diagnosing malingering, which hasnt been done. Cold weather is certainly known for exacerbating EIA and are the exam buzzwords, but any exercise can absolutely be a trigger +2  


submitted by lnsetick(90),
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I tujs errememb aSrtat ysaing MPV dtsne to eb tmoytcai.pasm ol,As I htkin hte kid nodlmpieca siiyaflclepc fo inco,hggu dan taht amed me rellya ealn ywaa orfm V.MP

yo  he also has a family history of asthma. that's shit is genetic. +1 for asthma. +5  
yotsubato  Cheif complaint is SOB during exercise with coughing. Mitral valve prolapse is not going to do that so I picked asthma as well. +1  


submitted by hungrybox(963),
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thore sr:wesna

hoinibinit of 2H oepstcerr: r(fo RED)G ntveepr gatircs daci eeotsrnci idtin(ceemi,

itnboiniih fo eioadpossephhetssr (:DE)P

  • loynithheelp a)tsma(h iibsthin cMAP DEP
  • lsf-ina c(dki ls)ipl for DE bhtiiin PMGc EPD

β2 s:ngaotsi (ofr hat)ams cusea chtanbodoinlrio

  • buarolelt so(htr inatgc - A rfo tuAe)c
  • am,slreotle oolrtrofem gn(lo ingatc - ysairlxhppo)

id(k tcleymhyop beeranmm liabzs)tiinato

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +16  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2  


submitted by haliburton(208),
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from FAPA ED fo mixed cagonir nda ohsicygepcn nrigoi is ocno.mm yigPcehcons esucsa ear eorm kleyil enwh hte pinaett has ornalm niecotesr hwti toriubastnam or ehnw urctlaonn peinle cnucmetsee si olna.mr

yotsubato  Couldnt a psychogenic cause reduce libido? +2  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +7  
home_run_ball  whoops meant to comment on the other comment +  


submitted by taway(29),
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Tshi ntqueosi si sehrpad lsnet,aryg tub 'sti selaetnsiyl sigkna "wath ouwdl pehnpa fi this snma'wo rdyioyhhmtisop bmeeac teonuclrdonl eovr eth rousce of rhe anpr?gnyc"e

urnelrtyc reh HST si gdoo t-&-g; llrc-needollwto hdtAsrHiETo phoLTOPyYmCHiyI high SHT t;--g& reh hdoporhmytyiis msut ONT eb weodelltorclnl- d(eu to nodsritpiu fo het T3//TS/HHTTR4 deoeincnr isax)

S,o nwo atht we rddnatesun thta het eoinqtsu is asgnki a"wht oldwu pnahpe if ehr pydsiyoorhhmit aws do"on?lneurclt

rsA:new tremnicis

I knhti htat siht qiouents is eharpds a,oouitcyrls ubt rfa be it rmof me ot iiitcrzec teh MSULE cnlesgnii b..o.rad

yotsubato  I think that this question is phrased atrociously, Just like the rest of the NBME +17  
b1ackcoffee  exactly how does maternal hashimoto can cause cretinism? +  
notyasupreme  @b1ackcoffee, it's not maternal hashimoto, basically you just have to disregard the ENTIRE question stem and the last part of the sentence (if the mom's TSH goes up) means that there's hypothyroidism going on, which causes cretinism. +1  
b1ackcoffee  Thanks you @notyasupreme! +  


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immAeunuot dstoiiyrthi aak( )omhHitsoa + gp;-ntate&nr-g Tknhi batuo bolisiiypts fo telfa pyiidsothrohym edu to bdatoniy edmatdei rtlaenam ositpridhhoy.ym aedsL ot mtCen.isir Fsnnidig ni ftnain are teh 6P' (toP lebly, ,alPe fPfyu fea,c drunitrgPo c,sbuiuilm tebraunPtro uton,eg nad rPoo Bianr enmdotlpve.e

neonem  I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism? +  
poojaym  @neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4. An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland. +31  
arezpr  TSH, T3, T4 and thyroglobulin cannot cross the placental barrier. +  
chamaleo  @arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can +  
yotsubato  The baby has its own TSH though +  
sbryant6  TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work. +  
kimcharito  no goiter then? +  
lola915  I think there is no goiter because the baby's thyroid gland has not fully developed and these immunogloblulins from the mother could attack the thyroid gland leading to issues with it's development. +  


submitted by haliburton(208),
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ilkn ot ctanroo iagdarm

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


submitted by aishu007(3),
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aloEeintsv in ybod teurpmeatre cucor enwh tonsnietccaorn fo sgdrnoaliantp E(2) ()E(P2G) iesencar hniwti irenact rsaae of hte .ebrhiTeasn siltvaeone aetrl het infgri raet of nsnuore ahtt rcootln itroemoltuhnagre in het .amsup.lhyhaot It is won acelr that omst ietnciyparts okrw yb higiintnib eth ynemze nyysgleooxccae and cugrnide eht eslvel of (EG)P2 tiwihn hte lh.thupaamsyo

1w4w56hnt.nl.v.t1p/oscui:mbe/6gn6m//1.pbhwid

yotsubato  Ugh, again a concept NOT in UFAP anywhere. Bites me in the ass every time +9  
epr94  pg213 FA2019 +8  


submitted by notadoctor(151),
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shTi einqostu swa skigna utaob the arevdes ffecets of oronpt pmpu sthiiorbin clsalipyee evngi vurisope yikdne .ussesi PsPI cdreesae sumre Mg and msreu Ca tbasoiprno nad nac eaiernsc eth krsi fo trrucfae iyelp(aselc in hte reel.)ydl

yotsubato  PPI therapy *begins* the day she presents. She has not taken PPI before +15  
notadoctor  You're right, I missed that! +  
naught  MEN 1 is pituitary (monitor cortisol), pancreas, parathyroid (monitor calcium) but is not the ask of this question. +  


submitted by nosancuck(85),
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oY isd B gto NO NILNTREA FEAELM GROANS

yWh a!??td?

We be ooikln ta ensoome hiwt na SRY mfor edre Y m eiohyreDc! be a Y rihmeco iomHe so hety be iankm emso isestT nitenrmeDi rFcato iwchh I be urse kesam eosm ienc lli NTIA EANILURLM OCTFAR so edy tnia got taht eaFeml atnIlrne Trcat u wkno ahwt i be nasiy

Adn scnie iimnwzm si ad DLUTAEF ythe itsl eb titgen dseo sspuy lsip nda teersasb

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


submitted by haliburton(208),
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FA 017:2 hnCcroi pciohyx opmlryuan onsriscvniotocat estursl in upaylonmr ytipnnhsroee nda .HRV

yotsubato  Yeah but in a chronic case this guy would produce more RBC and not be hypoxic anymore. +20  


submitted by hayayah(1056),
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nCicessy-eeietytn cekoneihm rretoecp 5 CC(R5) si a tionepr ufdno on eth uasrcfe of CD4 scll.e

yotsubato  Note, this is NOT in FA +2  
sbryant6  It is in UWorld. +3  
almondbreeze  it's in FA2019 pg.110 +1  
almondbreeze  but missing the full name for CCR5 +4  
demihesmisome  CXCR4 is also a chemokine receptor. +2  


submitted by cantaloupe5(72),
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hTis eon asw kiytcr but I tkhin yuo ueolc’vd node shti oen httuwoi onwelgkde of NDAM rocrepte.s Stme dlot uyo ttha tutageaml satcaetiv obht n-NDMnoA and ADNM ereorpstc utb ti vtaeticda ylno MDA-nnNo sroretpce in hte laery .shape Ttha saemn AMDN preestrco vctiatea aerft -oDnMnNA ceos.eptrr Tath eanms igomshetn aws adyngeli DNAM trerocpe cnaitiavgt dna eth nlyo asnwer atht adme enses sa het Mg bngiithini DANM ta gesnitr tlt.aeipon Oenc eht clel si epierddolza yb -MNnADno eosrcrp,te DMNA ertspoecr cna be taivatc.ed

hungrybox  I forgot/didn't know this factoid and narrowed it to the correct answer and a wrong answer. Guess which one I chose? +11  
yotsubato  >That means something was delaying NMDA receptor activating and the only answer that made sense as the Mg inhibiting NMDA at resting potential. What makes the fasting gating kinetics choice incorrect then? +5  
imgdoc  NMDA receptors are both voltage gated and ligand gated channels. Glutamate and aspartate are endogenous ligands for this receptor. Binding of one of the ligands is required to open the channel thus it exhibits characteristics of a ligand channel. If Em (membrane potential) is more negative than -70 mV, binding of the ligand does NOT open the channel (Mg2+ block on the NMDA receptor). IF Em is less negative than -70 mV binding of the ligand opens the channel (even though no Mg2+ block at this Em, channel will not open without ligand binding. Out of the answer choices only NMDA receptors blocked by Mg2+ makes sense. Hope this helps. +6  
divya  sweet explanation imgdoc +  
lovebug  really~~~ sweet. thankyou :) +  


submitted by tinydoc(223),
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yeTp 1 iFimalla spieiDadilmy pg.( 94 AF 19 )

recadnesi GT ;&-t-g- ptinaescrtia tupEecr i / rtpisiru sXtan ohandam SMH

aCn eb descua yb peiotLirnpo laspie ro ooAritenpp IIC defciycnie

heyt siad ttah LPL si nief os ist OPA CII

peHarin tesespare PLL rfmo raHnerpi tSluafe eotyMi no ascV dimoeluEhtn gownlial us to estt tis oninctfu ni hte .abl

I got it ognwr oto - diSput teRo tonaozrmiime lalecr oe.sQitun

masonkingcobra  I think you need to know that ApoCII activates LPL not necessarily know the disease +10  
yotsubato  Knowing the disease makes it easier to remember the details though +2  
pg32  Mnemonic for these 4 types of dyslipidemias and their causes: 1 = LP meaning LPL is deficient (or anything associated with activating LPL, like C-II) 2 = LD meaning LDLR is deficient (or anything involved in interacting with LDLR, like B-100) 3 = E meaning ApoE is defective and 4 for more (VLDL) ("more" just meaning more letters in the cause (VLDL oversecretion)) +2  
castlblack  One too many chylomicrONs, two much cholesterol, threE apo E gone, 4 put the fork down fatty +1  


submitted by priapism(6),
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Per ritFs iAd: nedostibai atsgian BOA oldob syept tnde ot eb gIM or gI,G wichh si yhw the ansrwe si IGg + cempteomnl nda not AIg + emlpomcnet

yotsubato  IgA also has no role in any hypersensitivity reaction +2  
divya  hi. where is this given in first aid? +  


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oduheryit scki esoynmrd is meissemto lledca ow"l T3 .enm"doyrs lsAo oyu nwok ahtt teh epiantt is uirtdeyho sbeacue erh 4T dan STH are wtiinh the eeferncer gnar.e eSh is ksic.

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  


submitted by aesalmon(81),
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I tewn bcak and atdehwc siht ceonist on amtahop rtfae ntgteig eth siteqoun ngrow - .rD Srttaa ayss ttah namCroosdh dna Conosmrhcdasaor rsaie ni hte LD,UELMA adn not the .trocxe roHevwe het onutsiqe emst etasst atth rteeh si h"kncteniig fo hte iisaydshp nad stnpriudio of eth CXETRO thwi oalfc aaer of rdacnesie i"ioacl,atncfic ???

yotsubato  It arises in the medulla and *passes* through the cortex because its invasive and malignant. +12  


submitted by hungrybox(963),
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Fowllnigo a oset,rk ihst tepaitn dah ksesanwe of her lfet eafc nda obdy, os eth skerot tmsu eavh aefedfct eth trigh desi of ehr r.bani B asw teh yonl coiche no eth thirg dsei of reh .birna

lSilt ce?snfduo deaR no...

The atounyvlr rtoom rebsif iicopocnslr(at ttarc) escdedn morf hte rrpmayi troom re,tcox rcsso (ete)sacdsu ta the duylrlame d,ympsiar adn hetn snsyape at hte eritnaro oortm hron of teh liapsn l.lvee

ucBsaee of osdestucina ta eth uealmrlyd myarsipd, ouy udsloh akme a neto fo wrehe any soertk urc.soc sI ti veabo hte yluermadl iyspm?ard eThn it llwi aftcef hte sied piootpes eht setokr roa)clel(ttnaar. Is it olbew het uadmyrlel pairdms?y henT it ilwl atffce eth ames eids sa the ekostr ai(pralse)tli.

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +7  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +16  


submitted by sympathetikey(1248),
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ehoCci A. dolwu vhea eenb cocretr if hsit apitent saw cu.pniiedomsmommro reP ritFs ,iAd "fI C4D t0&10;l, s.ai..:tFnginlneodlrBa loiNhceiurtp almoatn.fmIni

o,weveHr sa isht itptnea ash a tntmeepco meumin st,yesm buzz rwosd are atellste ienitrgczno guorsanalm.

yotsubato  Everyones choice A is different. +  
sugaplum  they mean- Diffuse neutrophil infiltration +1  
macrohphage95  what does stellate necrotizng granuloma means ? +1  
krisgsxr600  always with the details! losing dumb points :( +1  
futuredoc12345  @sympathetikey Doesn't the biopsy finding vary with the biopsy location: Lymph nodes have stellate granulomas and Bacillary Angiomatosis (skin lesion) has neutrophilic inflammation. What do you think? +  
chextra  @sympathetikey Pathoma chapter 2 says cat scratch disease forms non-caseating granulomas +1  
almondbreeze  @ chextra Same with FA 2019 pg. 218 +2  
almondbreeze  Sketchy micro: Immunocompetent: regional LN in axilla in one arm (like our pt here) Immunocompromised: bacillary angiomatsis is transmitted by cat scratches +  


submitted by laminin(14),
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acn eenosmo lpxnaei yhw it ssay eh sah an tina'ct' TPH oto.ia.cnsnrti.enc it to etl us ownk htat teh THP tatcnnooernic si a letusr fo aatoloyhdng p? was'th his xd? nsh!akt

yotsubato  I swear they make up some of this stuff. Like whats up with the thirst, urination, and peptic ulcer diseases. +6  
redvelvet  hypercalcemia can cause nephrogenic diabetes inspidus; so thirst, urination. hypercalcemia can also cause peptic ulcer disease. His symptoms are all about hypercalcemia due to hyperparathyroidism. +2  
namira  "Hypercalcemia can cause renal dysfunction such as nephrogenic diabetes insipidus (NDI), but the mechanisms underlying hypercalcemia-induced NDI are not well understood." https://www.kidney-international.org/article/S0085-2538(16)30704-9/fulltext +  
dulxy071  Why can't the correct answer be C) which points towards renal failure, which may lead to secondary hyperparathyroidism having the same results I believe +1  
pmofmalasia  The secondary hyperparathyroidism in renal failure is due to loss of calcium in the non-functioning kidney. In this question the calcium was elevated, so you can rule out renal failure. +  
sars  Hyper-calcemia causes stones (calcium stones), groans (constipation), thrones (increased urination), bones (increased osteoclast activation), and psychiatric overtones (depression). +  


submitted by killme(13),
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ehT ncoetpc begin sdteet is hwa"t eods THP od taht edals ot c ece"myliaarhp..gps/c/tKP/a.bjntVoie:3hmdg/bispi

yotsubato  ugh, bullshit. I was trying to figure out an actual disease process here. +3  
rio19111  its primary hyperparathyroidism caused by parathyroid adenoma. addition of the peptic ulcer suggest Zollinger ---> MEN1 but none of that is imp because that's not what they are asking. All they are asking for is the function of PTH. +2  


submitted by xxabi(248),
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cengroBhinco oaarccnmi = gunl caernc

aTth neigb ,aids lung ocedarnaonaimc ilfaceplciys si cdesaiosta twhi piptcorhehry prtaysheotoaroh,t ihchw is a elpiacrtaapsno esmnrdyo erdachteizcra yb iiatldg cbln,igbu trhagi,alar njtio siffuos,ne dna osrspteoisi fo rauutbl nbeso

luke.10  why not systemic scleroderma since i did this question wrong and i chose systemic sclerosis scleroderma , can someone explain that ? +2  
kernicterusthefrog  My best guess answer to that @luke.10 is that: a) there's no mention of any skin involvement (which there would be in order to be scleroderma) b) Scleroderma shows pitting in the nails, not clubbing c) There would be collagen deposition with fibrosis, not hypertrophy of the bone at joints Saying that, I also got this wrong! (but put RA...) so I'm not claiming to "get this" Hope my thought process helps, though! +6  
yotsubato  This is in FA 2019 page 229 +9  
larascon  I agree with @kernicterusthefrog on this one, Bronchogenic carcinoma = lung cancer. Squamous cell carcinoma gives you hypercalcemia (new bone formation; maybe?), commonly found in SMOKERS ... +3  
waterloo  the clubbing is the symptom that takes out alot of the answer choices. It's super tricky. +  
jawnmeechell  Plus the patient has an 84 pack-year smoking history, super high risk for lung cancer +  
veryhungrycaterpillar  FA 2019 pg 229 is all paraneoplastic syndromes. There is no mention of bronchogenic carcinoma in any of them. There is adenocarcinoma, but that is most likely in non smokers, not in someone with 84 pack year of smoking history. Why does he have 5 upvotes for referencing first aid here, what am I missing? +2  
jakeisawake  @veryhungrycaterpillar sounds like bronchogenic carcinoma is a general term for lung cancer. You are right that if a non-smoker gets lung cancer it is most likely adenocarcinoma as non-smokers rarely get small cell. However, smokers can get adenocarcinomas as well. The oncologist that I shadow sees this frequently. Adenocarcinoma of the lung causes hypertrophic osteoarthropathy per 229 in FA2019 +2  
mangotango  @verhungrycaterpillar @jakeisawake Adenocarcinoma is the most common tumor in nonsmokers and in female smokers (like this patient), so adenocarcinoma would still be the most likely cancer for this pt over the others. Pathoma Pg. 96. +3  
fatboyslim  Apparently bronchogenic carcinoma is basically an umbrella term for lung cancer. Source: https://radiopaedia.org/articles/lung-cancer-3 +  
lifeisruff  bronchogenic is another term for adenocarcinoma in situ according to pathoma +  


submitted by celeste(78),
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sThi sdsonu ielk acFonin .doynsmer eTh xrilpoam balruut tieileaphl slelc ehav a darh itme gorbabenris ttriel,fa so y'ullo see a slos fo opp,satheh anmoi dai,sc eiancrb,otba nda lsuego.c

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +4  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +1  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +1  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +  


submitted by beeip(123),
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thuohTg ihst ldowu be eitmsnhgo rngdgirea trci"biaar ",ryegrus utb e,pno just on" schyrta o,ofsd eabscue 'eroyu dpci.i"-etreba

hello  Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +  
yotsubato  such a BS question IMO +5  
yotsubato  such a BS question IMO +  
breis  I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +4  
teetime  This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +1  
dr_jan_itor  Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1  
dhkahat  yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +  


submitted by beeip(123),
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tTohhug shit dluwo eb ghmsiotne rrgdanige cariib"atr sg,ery"ur btu n,epo sutj no" ytcrhsa df,oos eubacse 'ureyo .dcei"ar-iepbt

hello  Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +  
yotsubato  such a BS question IMO +5  
yotsubato  such a BS question IMO +  
breis  I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +4  
teetime  This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +1  
dr_jan_itor  Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1  
dhkahat  yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +  


submitted by neonem(549),
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gahelSli sasceu na iartlmomnafy ih;arerad ti rusecdop a tixon and nac vidnea etussi ied.tyclr nI idnoadit, it si rsnestita ot a,icd os it sah a csreliiacrataylcth wol ieecifntv esdo (~10 amrsoig,)sn cwhih icaatiftsel its oaarcellf- so-ptnoe()se-ronpr dspare yleiescpal in sttengsi ehrew ieyngeh may eb mo,ropcdesim chsu sa ni ycadrae ro tsantiuotlini .ohgusni tI acn eb fearintfitddee romf E. lCoi E(HCE) sueceab E ioCl dntos'e ehva sa chmu oe-oprnteosrn-ps sdprae dna nloy acesus GI daagem by eth aikgleish- otn,xi ont tcirde inavnsio. rferhTo,ee ECHE wol'untd ltiiftaeca sa togsrn fo a iupelcihtrno psres.neo

yotsubato  I assumed all the kids in the daycare had the same lunch, thus got food poisoning, thus all got EHEC. +3  


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nI sccpehyogin i,osdapliyp emsur suidom si ,owl dan ferat tarwe iarndtevipo ttse, erinu looiytsaml is U esnediiner.arc iaoylostml deos ton eesaicrn tihw vprsesinoas oeinnjcit

In ocneepnghri bidtseae dpisisu,ni usemr dmusoi is ihgh nad tehre si on gdhaiml/nce nesareci ni uerni ilyolmaots retaf tarew rinvtdpiaeo

yotsubato  This patient does not undergo a water deprivation test +12  
niboonsh  Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric populations. Effects of increased water intake can lead to hyponatremia causing symptoms of nausea, vomiting, seizures, delirium and can even be life threatening if not recognized and managed early. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579464/ +7  
missi19998  Just wondering why it in not resistance to ADH action of vasopressin +  
amarousis  because he would be hypernatremic with no ADH. can't resorb any water +1  
minhphuongpnt07  low osm/urine, low os/plasma => psychogenic polydipsia +  
benitezmena  In this question the pt had a normal urine osm (80) a low urine osm would be <50mosmol/kg. +  
euchromatin69  u world 212 +  


submitted by strugglebus(163),
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hwoereN aehv I eneb abel ot ndif why eht hlel iths si a ithg.n

yotsubato  Its not in FA, Sketchy, or Pathoma, or U world. I knew it wasnt cancer because its bilateral. And Diabetes made no sense to me. So I just threw down Drug effect and walked away. +6  
breis  same^^^ +  
feliperamirez  The only possible explanation I think is that she was under a K sparing diuretic, such as spironolactone (which would lead to gynecomastia). +  
chandlerbas  you had me at its not in sketchy ;) +1  
j44n  i thought HTN induced empty sella would cause this because they got type II diabeetus. So if you need a pro zebra hunter holler at me. +  


submitted by hayayah(1056),
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luoasvRcenar eeisads si the tosm ncmomo secau fo °2 TNH ni dalu.st aCn eb /td aiheimsc mfor rneal nstoessi ro auorlccsvamir i.easdse Can aerh eanlr utrbsi elatlra to ubiulmics.

niaM useasc of alern yaerrt :tiessosn

  • rectelsArhtcoio o—xplpslriuameaq 3/dr1 an feorl y,trera allusyu ni erold lsmae, emskrso.

  • urcusmrolibaF iysplsa—daialdst 23dr/ nr eolaf earryt or nemegtlsa ase,cbrnh uylsa lunoyug or ed-lmgaedid aesl.fem

Lab seualv sdaeb :ffo

  1. Snisotes sseraecde bdloo fwlo ot loguser.lum
  2. lauerotguJxrmal uatappsra )GJ(A desropsn by secigertn innr,e whhic rneotsvc sgenonanioitnge to ngnesntaoii .I
  3. tninAegnosi I si oecdretvn to ositgnnenai II AI()TI yb nantnigseoi ntgvcreoin ynemez AEC( -n-i u)slng
  4. IATI areiss obdlo usprrees by )(1 tcnotcraign aarrreilot tsmooh elsm,cu erciagnisn atlot ehirrppael eciasesnrt dna 2() ntoprgmoi naledra reelesa fo oenlrosd,tae ihwhc nseiacers iobtnesorrap fo uoisdm (whree Na+ geos 2OH llwi fwlloo) ni eth lsidat toloevucnd lutueb d(agneipxn amspal mle).uvo naC elda to imlokypehaa (nese in hte aslb for this souqt)nei
  5. aLesd to TNH whit neeardsci lamspa rnnei adn ntaulirlae ahrptoy de(u ot wol boold w)olf of eht tcfdfaee ienydk; enhreit atrfuee si sene in aymrrip nyhtpoesnire
uslme123  So both causes would result in increased aldo and MR is the only way to differentiate the two? +2  
hello  @USMLE123 I think both are causes of renal artery stenosis and that could be seen via MR angiography. It is asking what could help DIAGNOSE this patient -- and her most likely cause of the findings is fibromuscular dysplasia. So, yes, MR angiography would look different for the 2 different etiologies and thus could can be used to differentiate the two from one another. However, epidemiologically, we are looking to diagnose her with the suspected most probable cause. +8  
yotsubato  @USLME123 I think measuring Aldosterone is an incorrect answer because you already know its increased due to low K. Knowing she has high Aldosterone wouldnt provide you evidence for a final diagnosis. +4  


submitted by hayayah(1056),
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apiaetCt adn nuaetl aer ni the etrnce fo het pal.m Ctepaiat si otn na ,poitno so utlane is hte rwns.ae

Dcoisnltoia fo neluta yma sucae ueatc prlnacna telu ersymn.od

yotsubato  Lunate is the only carpal bone that is frequently dislocated. Scaphoid is frequently fractured. Hook of hamate is also frequently fractured. +3  
redvelvet  and also point tenderness in the anatomical snuffbox may indicate a scaphoid fracture. +3  
chandlerbas  yes lunate is the most common dislunated carpal bone ;) +4  
almondbreeze  FA 2019 pg. 439 : dislocation of lunate may cause acute carpal tunnel syndrome +  


submitted by strugglebus(163),
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,OK so if I rmrmeeeb rtcyoelrc hsti is hte eno ahtt oshws teh anhtcniieer e.ptantr aocinroihmtdl si osla dpssae by teh o;hremt erv,ohwe it can heav ilraabve txpsieyvsier nda ilecoemtnp ncn,tereeap ihwhc is hwy smeo reesbmm reew ont ffc.etade

hyoscyamine  Also, question said there was a deficiency in NADH dehydrogenase activity which is another fancy way of saying complex I in the mitochondria. +13  
yotsubato  That unaffected male really threw me off... : ( +20  
charcot_bouchard  It was pure MELAS description. the unaffected male threw me off +2  
mbourne  I think the affected male on the right side is actually a helpful hint. Mitochondrial conditions can be inherited by males or females, but are only passed on through the females. +1  


submitted by hayayah(1056),
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aIglnuni nesaihr rea ylaulsu iereb,lduc ealfrom hanseir rea .tno

ihsT si an dteniirc ignlauni rian.he tI reents eiltnnar iinunlag gnir lelarat ot nroifrie rigeticpsa eveslss nad si riosuerp ot eth nalungii tnmel.iga

deuaCs yb feulari of sssopuerc nlisvgiaa ot cesol na(c from y)elrhcdoe. Mya eb noidect ni nsnifta ro vroidesdce in htaloud.do cuMh meor omnomc ni s.male

yotsubato  Heres a good picture to help with the concept. https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwjVkIi0yN7iAhWLjqQKHbeXCTUQjRx6BAgBEAU&url=https%3A%2F%2Fwww.herniaclinic.co.nz%2Finformation%2Ftypes-of-hernias%2F&psig=AOvVaw2BzGtQLvSmUN8ymhdvETG5&ust=1560244112252834 +4  
sbryant6  Note that direct inguinal hernias typically happen in older adults. This question presents a younger baby, so it is more like to be indirect. +7  
jawnmeechell  So a femoral hernia would be inferior to inguinal, but direct/indirect would be superior? +  
azharhu786  The direct and indirect hernia are both superior to the inguinal ligament but the femoral hernia is basically inferior to the inguinal ligament. The direct hernia is medial to the inferior epigastric vessels whereas, the indirect is lateral to the epigastric vessels. An indirect hernia is seen in young people whereas, direct hernia happens in adults. +4  


submitted by hayayah(1056),
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esCa of caolesolrrrots.iesi

Heilsartpcyp oeliolrcrtaesossir volvenis cngihinket fo evsesl wlal yb resilppayha fo hoomst eclmus -ko'in(nnios n)'apeprcaae

  • ueqeonCecns of ainntaglm ynnerhstipeo 811;(20tg0&/ w/ ctaue edr-nanog ad)mgea
  • tRulsse in erucdde esslve raeicbl hitw ennrg-dao eismhaic
  • May elda ot rbiionifd ecrsnosi fo hte elvsse awll whit grhm;oreaeh lsscayiclla asescu uetac rnale ifaerlu )AR(F wthi a cctaetircahris fl'-iba'entte eaanerpapc
masonkingcobra  From Robbin's: Fibromuscular dysplasia is a focal irregular thickening of the walls of medium-sized and large muscular arteries due to a combination of medial and intimal hyperplasia and fibrosis. It can manifest at any age but occurs most frequently in young women. The focal wall thickening results in luminal stenosis or can be associated with abnormal vessel spasm that reduces vascular flow; in the renal arteries, it can lead to renovascular hypertension. Between the focal segments of thickened wall, the artery often also exhibits medial attenuation; vascular outpouchings can develop in these portions of the vessel and sometimes rupture. +  
asapdoc  I thought this was a weirdly worded answer. I immediately ( stupidly) crossed of fibromuscular dysplasia since it wasnt a younger women =/ +16  
uslme123  I was thinking malignant nephrosclerosis ... but I guess you'd get hyperplastic arteries first -_- +  
hello  The answer choice is fibromuscular HYPERplasia - I think this is different from fibromuscular DYSplasia (seen in young women); +23  
yotsubato  hello is right. Fibromuscular hyperplasia is thickening of the muscular layer of the arteriole in response to chronic hypertension (as the question stem implies) +6  
smc213  Fibromuscular Hyperplasia vs Dysplasia...... are supposedly the SAME thing with multiple names. Fibromuscular dysplasia, also known as fibromuscular hyperplasia, medial hyperplasia, or arterial dysplasia, is a relatively uncommon multifocal arterial disease of unknown cause, characterized by nonatherosclerotic abnormalities involving the smooth muscle, fibrous and elastic tissue, of small- to medium-sized arterial walls. http://www.medlink.com/article/fibromuscular_dysplasia +1  
smc213  *sorry I had to post this because it was confusing!!!*Fibromuscular dysplasia is most common in women between the ages of 40 of and 60, but the condition can also occur in children and the elderly. The majority (more than 90%) of patients with FMD are women. However, men can also have FMD, and those who do have a higher risk of complications such as aneurysms (bulging) or dissections (tears) in the arteries. https://my.clevelandclinic.org/health/diseases/17001-fibromuscular-dysplasia-fmd +1  
momina_amjad  These questions are driving me crazy- fibromuscular dysplasia/hyperplasia is the same thing, and it is NOT this presentation and it doesn't refer to arteriolosclerosis seen in malignant HTN! Is the HTN a cause, or a consequence? I read it as being the cause (uncontrolled HTN for many years) If it was the consequence, the presentation is still not classical! -_- +1  
charcot_bouchard  Poor controlled HTN is the cause here +  
charcot_bouchard  Also guys if u take it as Fibromuscular dysplasia resulting in RAS none of the answer choice matches +