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Welcome to zevvyt’s page.
Contributor score: 20


Comments ...

 +1  (nbme22#31)

You dont really need to know the murmur to get the question right, but I'm confused about the murmur. It sounds like Mitral Regurgitation. So why is it in the left sternal border and not the apex?


 +0  (nbme21#27)

Of all the things they can test us on, they're testing our fucking Gadar??

peridot  Don't mean to be an eager beaver but I thought it was pretty cool to get tested on our gaydar! I think that's an important thing to pick up on. As for their answer choices, I'm not always the biggest fan of those since I think there's more than one right way to do something... +

 +2  (nbme21#37)

A= Caudate ( flanks Lateral Ventricle) B= Internal Capsule, between Thalamus and Lentiform Nucleus( Putamen, GP) C= Thalamus( Flanks 3rd Ventricle D= Temporal Lobe E= Occipital Lobe


 +0  (nbme21#43)

to me, this is a process of elimination question.

Fasciotomy and bosentan don't make sense.

Clopidogrel and aspirin kinda make sense, Except Treatment of DVT is not part of their clinical use. (Clopidogrel 429 and aspirin 475 of FA 2019).

So we're left w Embolectomy.

PS. Thrombolytics and Direct Factor Xa inhibitors are used for DVT

personalpurposes  Yeah I dont think is going for a DVT though, the patient is presenting with "coolness and paleness" in her LE with absence of pulses". This is basically implying an arterial occlusion and thus an embolus in the ARTERIAL system. In a DVT we can say arterial supply is normal so we would feel a warm extremity with normal presentation. Either way I guess at the end of the day you could embolize the DVT clot too. +
yhm17  And the mention of irregularly irregular rhythms clues you in that a clot was formed in the heart and embolized to the lower extremity arteries. +




Subcomments ...

submitted by notadoctor(140),
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Ulsua stiiatletnri iiteupnnmso is the osotlghlaiic noiefdtnii fo oIcdatpiih urlpyamno sbisifr.o eW onwk ttha sthi ntptaie sah apomrnyul risibsof bucsaee the stqioune sseatt ttah rtehe is isfurbo nkieinthcg of eth erovllaa ta.pse ishT qetosinu asw jstu gnsteit atth we enwk teh eohtr masen orf Pmyuroanl ori.bsisF

aneurysmclip  Nbme back at it again +20  
pg32  Is it still considered idiopathic pulmonary fibrosis is it appears to have been caused by an atypical pneumonia? +  
zevvyt  Why not Sarcoidosis? Wouldn't Sarcodosis also be a chronic inflamation with fibrous thickening? +2  
swagcabana  UIP is a better answer. Sarcoid is a leap in logic, usual interstitial pneumonitis is textbook histological definition of idiopathic pulmonary fibrosis. The biopsy has no mention of noncaseating granulomas and the clinical picture is not consistent with an inflammatory process. You have to focus on the better answers, try not to get caught up in the "why nots?" Calling this sarcoidosis is like someone coming in with prototypical asthma and jumping to eosinophilic granulomatous with polyangiitis. Sure its a possibility but its definitely not likely. +5  
mangotango  I picked “diffuse alveolar damage” with Pulmonary Fibrosis in mind but these are actually key words for ARDS :/ +1  
zevvyt  thank you swagcabana! Very good explanation and strategy! +  


submitted by welpdedelp(198),
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tI saw ,iebssac hhwic si tmnrisaedtt ereornspnop-.o

welpdedelp  **person-person lol +5  
suckitnbme  NBME loves their scabies +11  
dentist  did you get scabies from "burrows" and "night itching" +  
pg32  My question is where do you get scabies originally? I knew it was transmitted person-to-person, but thought it has to originate somewhere (a pet possibly?) so I went with pets. The internet only seems to say that you get scabies from another person with scabies, so the question remains: where do people contract scabies from? +  
leaf_house  @pg32 , long quote: + "Sarcoptes scabiei mites seek the source of stimuli originating from the host when they are off the host but in close proximity to it. This behavior may facilitate their finding a host if they are dislodged from it and contaminate the host environment. Thus, direct contact with an infested host may not be required for humans and other mammals to become infected with S. scabiei. In the case of human scabies, live mites in bedding, furniture, toys, and clothing can be a source of infection. Sarcoptes scabiei var. hominis have been recovered from laundry bins in a nursing home." + from here: https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-017-2234-1 +  
zevvyt  to summarize leafhouse: Fomites +1  


submitted by keycompany(268),
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Neigortn aeablcn si a nemusarteem fo rntpoie maeomltisb ni teh dybo. A eviaetng nntiegor ancable idcitasne elsumc sols, as nerdseaic smtnaou of ainom dcisa rae gnibe mezdlitobea to odrcpeu ygenr.e hTsi nrcaseies the tnmaou of tiornneg ceerdest mfor teh .bydo ueeBsca eth utmnao fo tregoinn you are ikngta in is sels nath hte nmoatu of irgneotn uoy aer teigrnecs, you veha a eaitveng onergnit aecalbn.

Tihs amn is ueonlhdria,sm esmdeutoa, cat,eicch nda sha .lehnumiayabmiop heTse lnciclia fngnisid tipno ot eoprint lrounnttiami (hkraiawsoK ieass)De, hchwi ssueac daeme eud ot eacesrded srume coiontc eurrs.spe woL tnccooi resepsru ni tshi esac is eud ot eirtonp slos, dna ncehe a gvneteai oetnnigr ealcn.ba

drdoom  Nice! +7  
dubywow  I knew your last sentence and suspected Kwashiorkor. It's just everything else I did not know. I have not heard or thought of muscle/protein changes in terms of "nitrogen balance" before... and that's why I got this wrong. Nice explanation! +3  
macrohphage95  I agree with you in first part but i dont think it has any relation to kwashirkor. It is simply due to cachexia which causes muscle destruction through the proteasome pathway .. +3  
zevvyt  also, it says that his albumin is low. +  


I put constipation because I thought the medication being described might be CCB: can someone explain why nitrates over CCB?

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance. +4  
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload. +2  
beto  decrease of cardiac preload is another word of Venodilation, so Nitrates primarly venodilators. CCB dilate arteria more than veins +  
zevvyt  also, verapamil is the one that causes constipation. But Verampamil is non-dyhydropiridine, so it works more on the heart than the vessels +2  


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ehT ettainp ffresude ofmr umInem mbyt.reoahicpoonT tteunoidabaois asgitan the synieoprlotgc 2/3APG.B

On lbsa, uyll’o e:se ecairsne in ecamrgo;yaktsye on eth seonqtui mtse ’teeyrh isdcbdree as rrea“ ubt e”rg.al oacgsMeayrkyte aer not epsussred.p

ergogenic22  isolated thrombocytopenia (low platelets) should be highly suggestive of ITP https://www.aafp.org/afp/2012/0315/p612.html +2  
pg32  I agree that in ITP you will see an increase in megakaryocytes, but where did you see that in the stem? Platelets being, "rare but large" doesn't mean megakaryocytes, does it? Also... can anyone explain why she was anxious but alert and had petechiae distal to the blood pressure cuff? +  
meryen13  @pg32, I'm not too sure about the "anxious but alert" but I think they might wanted to mention she is oriented so in case there was no lab values, you would guess that she is not extremely anemic or something. and about the petechia with the cuff and the tooth brushing bleeds, that is a sign of platelet problems because its a superficial bleed. if you saw deep bleeds like joint bleedings, think about coagulation pathway problems (like hemophilia) +1  
zevvyt  "rare" means thrombocytopenia. "Large" means there are megakaryocytes to make up for the thrombocytopenia +  


submitted by cantaloupe5(69),
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oiostgHyl dswohe tialvaueocg cosensri er(sveeprd cteiearhruct of ralcidoyam srief)b ihtw hleipuornt laoinnittifr hiwch hdenti ttah teh MI wsa iwthni 42 sohru. oMst keilly aceus fo ahedt iihntw frtis 42 osruh of IM si airhytmr.ha idMrayaocl prteuru dulwo slao eb sibilve on sosrg cnarpaapee fo teh her,at cihhw yeth edrcdbeis ni eth te.sm

bighead478  in FA it shows softening of the myocardium to happen at 3-14 days. Do you think this was overly misleading people (like me) into choosing myocardial rupture? I understand the histo features are consistent with < 24 hours, but the stem should also match this in every detail +9  
sbryant6  Myocardial rupture would not happen until 3-14 days. Since this shows signs of <24 hrs, the answer is arrythmia. +2  
hello  @bighead478 You have to look at the whole picture. Histo shows preserved architecture, which indicates coagulative necrosis -- coagulative necrosis is a histo finding only in the first 24h. The most common causes of MI-related sudden death are: arrythmia > cardiogenic shock (heart pump problem) > rupture. +  
jcmed  I chose the rupture as well due to the timeline. Somebody gave me this advice the other day, NBME classically will give you an entire vignette leading you somewhere, and the what it asks will be something completely different; or in this case will give you a photo of something and will ask about the photo. They do what they want. +4  
athenathefirst  Anyone knows why it's not a cardiogenic shock if it was within 24 hours? +1  
zevvyt  It says "Mottling" which happens in the first day. If it was 3-14 days it would be yellow (p 302 2019). He can be having angina for 3 weeks leading up to an MI. +  


submitted by mcl(517),
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oedtliD is vdtnraieen by lrxialya rn,vee ihhwc msceo mrfo sroto 6C/C5. coAtisn fo hte tddeilo uecilnd itaudcnbo fo the eprpu r.xtiyetme

seagull  I hope everyone memorized every single part of the brachial plexus and all the roots of each, No detail let untouched!!! +23  
mcl  In case anyone else has purged the whole brachial plexus from your memory (like me), this is a great resource linked by another user. https://geekymedics.com/nerve-supply-to-the-upper-limb/ +9  
zevvyt  I thought it was radial since he lost sensation in his thumb. If Radial is C5-T1, wouldn't that be included in C5-C6? +1  
alimd  they force us to know brachial plexus like the holy bible +  


Can't histamine also cause swelling or is it just not involved in the pathology of gout?

zevvyt  yes. Histamine causes vasodilation and increased vessel permeability. But it's not involved in Gout. Gout is more about Neutrophils and Macrophages activating eachother and not really about Mast cells. +2  


submitted by notadoctor(140),
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lUasu inteislttair pinsteniumo is het agltihclsooi eoifidinnt of hadoctIipi puylnoarm ofrbisi.s eW wonk tath this aptntei ahs uonlaprmy sbirsofi ucabsee teh nsuqoite staets htat heert is birusfo ehincgkitn fo het lvleoara .seatp sThi eousniqt saw sujt etsitgn thta ew kenw het ertoh emnas orf yanoPrmul obFiri.ss

aneurysmclip  Nbme back at it again +20  
pg32  Is it still considered idiopathic pulmonary fibrosis is it appears to have been caused by an atypical pneumonia? +  
zevvyt  Why not Sarcoidosis? Wouldn't Sarcodosis also be a chronic inflamation with fibrous thickening? +2  
swagcabana  UIP is a better answer. Sarcoid is a leap in logic, usual interstitial pneumonitis is textbook histological definition of idiopathic pulmonary fibrosis. The biopsy has no mention of noncaseating granulomas and the clinical picture is not consistent with an inflammatory process. You have to focus on the better answers, try not to get caught up in the "why nots?" Calling this sarcoidosis is like someone coming in with prototypical asthma and jumping to eosinophilic granulomatous with polyangiitis. Sure its a possibility but its definitely not likely. +5  
mangotango  I picked “diffuse alveolar damage” with Pulmonary Fibrosis in mind but these are actually key words for ARDS :/ +1  
zevvyt  thank you swagcabana! Very good explanation and strategy! +  


submitted by meningitis(412),
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LPS fudon in treuo enrmbaem of agmr acbie⊝ atr th(bo ocicc dan rd.)so msdopCeo fo O tnaigne + rceo yceisoprlcaahd + plidi A t(eh xocti .n)cpenmoto

tteAascvi goprcaahMes dna cdnesiu ThlNpaFa lrseeae -&g;t ieonnspoytH and eefv.r

Pg 133 ntoE.oxnid

zevvyt  and just to note answer b) "induction of histamine release" DOES happen , but it's not the "Initial Event" that the question asks for +  


submitted by cantaloupe5(69),
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Retcurrne ikyend onsste luodhs incdelu yphdemrhirartipoyas no oyru leitrfeadfin, opcleu atth thiw ataogmrsni and oyr’eu koognil at MEN .1 aiLsopm ear slao dtasaicose with NEM .1

sympathetikey  Yeah, I probably should have went with that. Just got thrown off, since I know that usually the serum calcium levels for someone with Calcium kidney stones is normal. +  
snoochi95  i understand the link to MEN 1, but why are we checking the calcium level? +  
cmun777  I feel like it's important to get a baseline of where the calcium is at for two reasons: 1. if the patient does indeed have MEN 1 it would be good to know if she has high calcium levels and possible Parathyroid etiology 2. You're putting the patient on a PPI which are known to decrease calcium levels and increase risk of osteoporosis for both these possible factors/concerns it would be good to see where calcium is currently at +4  
zevvyt  Couldn't a Pituatary tumor secrete ACTH, causing high cortisol? +1  
lola915  Patient has symptoms of a gastrinoma (Zollinger-Ellison Syndrome)- patients present with diarrhea, epigastric pain, duodenal and jejunal ulcers. Associated with MEN1 syndrome. +  


submitted by tinydoc(189),
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icnrstfa louwd eb a remo prlaeierhp eedwg sehpa

csaseb otludnw be nsaevvii ot hte idurungsnro aera i h.nitk

qusoasmu clle si more cnlareylt doaeclt

ts'naw %001 user ubt shtat het tsbe waresn lutshohg spuidt ot gvie 0 oymsmpts dan ujst a er,tiucp innhtog elik na taulac cinlaicl naiecros

tsl19  Squamous cell is centrally located and has cavitation, which you can see in the pic. Similar to this one: https://webpath.med.utah.edu/LUNGHTML/LUNG068.html +4  
drdoom  ^ linkifying: https://webpath.med.utah.edu/LUNGHTML/LUNG068.html +3  
zevvyt  I also didn't choose infarct cuz i think the lung would have a red infarct. +  


submitted by strugglebus(154),
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codtH/oyMoradonneheed nac adle ot epeue-ydeoc-dnn ivado in onlg rmet es.u DAsSNI you osla daoiv due ot arlpita snseeffceeivitn ni uicehotpran pnia sa wlle as eculr irk.s sCTA' rae nkonw to eartt ichpnuoaret inap ryev lwel ..e(i tbdiase,e RAT yerpath)

champagnesupernova3  Drugs for neuropathic pain: TCAs, gabapentin and pregabalin +1  
mangotango  SNRIs +  
mangotango  also SNRIs* +1  
zevvyt  methadone isn't a pain med(even though it's an opiate), it's used for opiate addiction. And hydrocodone is used for "moderate" pain and this person is in "severe" pain. +  


submitted by stepbystep(1),
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odse oems dnim nnixlpigae hyw hist sint' a rate in eth atccsii ?renve

sugaplum  It is a very thick nerve, so I think it is hard to tear without physically cutting it. Also if it tore you would have tibial and common fibular nerve symptoms as well. You would see sensory numbness and tingling along the dermatome also the mechanism of injury is focused on spine so a disc rupture is more likely +1  
zevvyt  I got this question wrong but I really like because it helped me get past a confusion I hadon this subject. If it were a tear, you'd see the loss of motor function that sugaplum was taling about(FA 444 2019). But if it's a herniation, like in this case, you see Radiculopathy/Sciatica symptoms that are on 446. +2  


submitted by hayayah(989),
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In eodrr orf a dgru to be decaerl by the ndyiek, ti msut sfrti eb tflreedi ni the lo.rmgluei ugDsr iwht a ihhg VD ehva orme of eth udrg in eht tssuie atth era otn lailbavea ot ieerldtf yb the .ndiyek sugrD whti high ipotner ninbdig o'tnw be fidtlree e.etrih oS you wtan a rgdu thwi wol Vd adn olw ibginnd if uoy ntwa it lerdcae iva het isneykd and u.enir

zevvyt  But a low VD corresponds to high Plasma Binding Concentration(FA 233, 2019). That's my main confusion with this question. +2  


submitted by hayayah(989),
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etcAu ttaielstiinr enlar in.tmoailfmna yraPiu cyac(aslilsl on)hoipsiles and ztoiaaem gucrronic etfar niiaotrdntmisa fo urgds that cat as se,hpatn dniniguc ystvityrenheispi ge,( cdtiuesir, NASs,ID iellinpicn ,etsiaevivdr trnopo ppmu bsi,niorith pmf,riain sonqoien,ul fsm.usdnoa)iel

hungrybox  But how is a 2-year history acute? +3  
jinzo  there is also " Chronic interstitial disease " +3  
targetmle  i got it wrong because there wasnt rash, also there was proteinuria, doesnt it indicate glomerular involvement? +1  
zevvyt  Got it wrong too cuz of that. But there can be proteinuria in nephritis, just not as much as in nephrotic syndrome. I guess that's confusing cuz this type of nephritis isn't grouped with the other nephritic conditions. +1