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Comments ...

 +0  (nbme24#36)

Can someone explain why the answer couldn’t be phenylalanine?

donutsnduodenums  The kid has albinism, which is due to decreased tyrosinase activity. If he has a problem metabolizing Phenylalanine, he would be presenting with the PKU sx like intellectual disability, musty body odor, etc., in addition to his fair complexion.
zelderonmorningstar  I see, so if it was PKU he wouldn’t just be presenting for a routine examination. It would be one of those “oh crap what’s wrong with my baby” ones.
wowo  FA2019 p83
nbme4unme  Just a note that UWorld says phenylketonuria patients ALSO have albinism, it's just that the neuro sx and musty order are giveaways.

 +0  (nbme24#34)

Why is the answer decreased blood volume as opposed to decreased plasma sodium concentration?

tea-cats-biscuits  I think it might just be what NBME feels “decreased plasma sodium concentration” means, since through the mechanism that BV is lowered in bedrest, you would definitely have a decreased plasma sodium concentration compared to not-bedrest. However you won’t be presenting with any pathologic signs of hyponatremia because the Na+ would still be maintained in normal limits. Low blood volume is the cause of one of the main pathologic states associated w/bedrest -- cardiac deconditioning and postural hypotension once out of bedrest. Seems like poor wording though.
mnemonia  Remember that changes in sodium concentration over a long period time need to be due to a water dysregulation problem (like SIADH, polydipsia, HF, etc.). Here we just have physiologically increased effective circulating volume, and the body will compensate by diuresing, and since Na+ (and K+) are regulated ions, their plasma levels will not fluctuate.




Subcomments ...

Why is acetaminophen the correct answer other than process of elimination. NSAIDs can be used for tension HA and she’s too old for Reye Syndrome (i mean technically shes a child since shes <17, but not a classic picture at all). I’m confused.

zelderonmorningstar  My reasoning was that aspirin and the other 3 are all NSAIDs, and she had an adverse reaction. Acetaminophen is not an NSAID, so she probably won’t have the reaction. +  
gainsgutsglory  @zelderon But what’s the pathophys here? +  
generic_login  This is aspirin-intolerant asthma. Acetaminophen only inhibits COX within the CNS, so doesn't cause the leukotriene shunting that characterizes that disease. +2  


submitted by lnsetick(28),

How are you able to tell that the CT slice is not at the level of duodenum?

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 +3  


submitted by oznefu(7),

I’m having trouble understanding why this is a better choice than Paget disease, especially with the increased ALP?

zelderonmorningstar  Paget’s would also show some sclerosis. +1  
seagull  ALK is increased in bone breakdown too. Prostate loves spreading to the lumbar Spine. It's like crack-cocaine for cancer. +1  
aesalmon  I think the "Worse at night" lends itself more towards mets, and the pt demographics lean towards prostate cancer, which loves to go to the lumbar spine via the Batson plexus. I picked Paget but i think they would have given something more telling if they wanted pagets, histology or another clue +  
fcambridge  @seagull and aesalmon, I think you're a bit off here. Prostate mets would be osteoblastic, not osteolytic as is described in the vignette. +5  
sup  Yeah I chose Paget's too bcz I figured if it wasn't prostate cancer (which as @fcambridge said would present w/ osteoblastic lesions) they would give us another presenting sx of the metastatic cancer (lung, renal, skin) that might point us in that direction. I got distracted by the increased ALP too and fell for Paget :( +  
kernicterusthefrog  @fcambridge, not exactly. Yes, prostate mets tends to be osteoblastic, but about 30% are found to be lytic, per this study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768452/ Additionally, the night bone pains point to mets, and Paget's is much more commonly found in the cranial bones and appendicular skeleton, than axial. This could also be RCC mets! +  
sweetmed  I mainly ruled out pagets because they said the physical examination was normal. He would def have other symptoms. +1  


submitted by aladar50(15),

So there’s 100 residents, and the prevalence after 2 years is =10 at the beginning, +5 in the first year, +10 second year, and -3 that healed, for a total prevalence of 22 residents or 22/100=22 percent. Thus, prevalence = above the standard. For incidence, it’s 15 new cases out of 90 residents over the 2 years (100 total residents – 10 that already had ulcers), or 15 new ulcers per 180 patient⋅years. This would be 83.3 new ulcers per 1000 patient⋅years if you extrapolated it out -- basically (1000/180) * 15 -- thus, incidence = above the standard.

zelderonmorningstar  Okay I feel like an idiot cause I thought: Above the Standard = Doing a good job keeping old people from getting ulcers. Thumbs up. Below the Standard = I wouldn’t let my worst enemy into your ulcer ridden elder abuse shack. +6  
aladar50  @zelderon Ohh damn. I could totally see how one could view the answer choices that way. I think it is important to read how they are phrased - they are asking if the center is above THE standard or below THE standard. The “standard” is an arbitrary set point, and the results of the study are either above or below that cut off. Maybe if it was “above/below standards” that would work. Also, being above the standard could either be a good thing or bad thing. If say you were talking about qualifying for a competition and you have to do 50 push ups in a minute, then being above=good and below=bad. In this case, having more ulcers than the standard = bad. +1  
saynomore  @aladar Thank you!!! but how did you get the 15 new ulcers per 180 patient⋅years? I mean I understand the 15 part, but not the second part ... hence why I messed this up, lol :| +  
aladar50  @saysomore Because the study is looking at 100 residents over a period of 2 years. Since 10 already had the disease at the start, when looking at incidence you only include the subjects that have /the potential/ of developing the disease, so 90 patients over 2 years. This would be 90 patient⋅years per year, or a total of 180 patient⋅years over the course of the study. +2  
sympathetikey  @zelderonmorningstar I thought the same exact thing. Had the right logic, but then just put the backwards answer. +1  
kai  I wonder if they chose this wording on purpose just to fuck with us or if this was accidental. My guess is there's some evil doctor twirling his thumbs somewhere thinking you guys are below the standard. +4  


Can someone explain why the answer couldn’t be phenylalanine?

donutsnduodenums  The kid has albinism, which is due to decreased tyrosinase activity. If he has a problem metabolizing Phenylalanine, he would be presenting with the PKU sx like intellectual disability, musty body odor, etc., in addition to his fair complexion. +3  
zelderonmorningstar  I see, so if it was PKU he wouldn’t just be presenting for a routine examination. It would be one of those “oh crap what’s wrong with my baby” ones. +2  
wowo  FA2019 p83 +  
nbme4unme  Just a note that UWorld says phenylketonuria patients ALSO have albinism, it's just that the neuro sx and musty order are giveaways. +1  


You know it’s an enveloped virus since it doesn’t hold up to acid or being dried. You know it causes a fever and a cough, while affecting the larynx. Only virus category that fits all that info is the coronavirus (causes SARS) from that list.

zelderonmorningstar  EBV doesn’t cause fever and cough? +  
zelderonmorningstar  Wow, just checked First Aid and it doesn’t list “cough” as a symptom of EBV. +  
drdoom  EBV is not a “respiratory virus”; it’s a *B cell virus*. Even though you might associate it with the “upper respiratory tract” (=kissing disease), it doesn’t cause respiratory inflammation since that’s not its trope. B cells are its trope! That’s why EBV is implicated in Burkitt Lymphoma, hairy leukoplakia and other blood cancers. (EBV is also known as “lymphocryptovirus” -- it was originally discovered “hiding” in *lymphocytes* of monkeys.) So, EBV = think B cells. +6  
fulminant_life  EBV does cause pharyngeal and laryngeal inflammation along with fever, malaise, and cough and LAD. The only thing that pointed me away from mono and towards coronavirus was the patients age. +1  
nbmehelp  Can someone explain what not holding up to acid or being dried has to do with being enveloped? +  
yb_26  @nbmehelp, the envelope consists of phospholipids and glycoproteins => heat, acid, detergents, drying - all of that can dissolve the lipid bilayer membranes => viruses will loss their infectivity (because they need an envelope for two reasons - to protect them against host immune system, and to attach to host cells surface in order to infect them) +  


You know it’s an enveloped virus since it doesn’t hold up to acid or being dried. You know it causes a fever and a cough, while affecting the larynx. Only virus category that fits all that info is the coronavirus (causes SARS) from that list.

zelderonmorningstar  EBV doesn’t cause fever and cough? +  
zelderonmorningstar  Wow, just checked First Aid and it doesn’t list “cough” as a symptom of EBV. +  
drdoom  EBV is not a “respiratory virus”; it’s a *B cell virus*. Even though you might associate it with the “upper respiratory tract” (=kissing disease), it doesn’t cause respiratory inflammation since that’s not its trope. B cells are its trope! That’s why EBV is implicated in Burkitt Lymphoma, hairy leukoplakia and other blood cancers. (EBV is also known as “lymphocryptovirus” -- it was originally discovered “hiding” in *lymphocytes* of monkeys.) So, EBV = think B cells. +6  
fulminant_life  EBV does cause pharyngeal and laryngeal inflammation along with fever, malaise, and cough and LAD. The only thing that pointed me away from mono and towards coronavirus was the patients age. +1  
nbmehelp  Can someone explain what not holding up to acid or being dried has to do with being enveloped? +  
yb_26  @nbmehelp, the envelope consists of phospholipids and glycoproteins => heat, acid, detergents, drying - all of that can dissolve the lipid bilayer membranes => viruses will loss their infectivity (because they need an envelope for two reasons - to protect them against host immune system, and to attach to host cells surface in order to infect them) +