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NBME 16 Answers

Block/Question (16.7 difficulty score)
A 27-year-old man who is being treated for ...
Donor T lymphocytes reacting against host cellsπŸ”

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Long-chain acyl-CoA dehydrogenaseπŸ”

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Serum calcium concentrationπŸ”

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Ξ±-Adrenergic agonistπŸ”

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Amino acids: decreased; Glucose: decreased; Phosphate: decreased; HCO3: decreasedπŸ”

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DextromethorphanπŸ”

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Lesch-Nyhan syndrome, an X-linked recessive ...
1/50,000πŸ”

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Decreased function of Na+–K+ ATPaseπŸ”

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Intravenous infusion of 0.9% saline for 5 minutesπŸ”

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10%πŸ”

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Go for a long walk outside dailyπŸ”

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Area labeled by the letter 'E'πŸ”

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Cerebral edemaπŸ”

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2.4πŸ”

Block/Question (7.6 difficulty score)
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UreterπŸ”

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An 18-year-old man with acute lymphoblastic ...
Amphotericin BπŸ”

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Parathyroid hormone: decreased; 1,25-Dihydroxycholecalciferol: increasedπŸ”

Block/Question (5.2 difficulty score)
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Pseudofolliculitis barbaeπŸ”

Block/Question (18.3 difficulty score)
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Abnormal myelin sheathsπŸ”

Block/Question (13.0 difficulty score)
During an experiment, the concentration of ...
Glyceraldehyde-3-phosphate dehydrogenaseπŸ”

Block/Question (6.6 difficulty score)
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Increased follicle-stimulating hormoneπŸ”

Block/Question (9.9 difficulty score)
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LysosomesπŸ”


Block/Question (14.1 difficulty score)
An 85-year-old woman is diagnosed with a ...
Morphine is metabolized to active metabolites that accumulateπŸ”

Block/Question (9.5 difficulty score)
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Glycogen phosphorylaseπŸ”

Block/Question (8.1 difficulty score)
During an experimental study of oxygen ...
Proximal tubuleπŸ”

Block/Question (15.1 difficulty score)
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Adenylyl cyclaseπŸ”

Block/Question (15.4 difficulty score)
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Induction of cytochrome P450 enzymes that activate acetaminophen to a hepatotoxic metaboliteπŸ”

Block/Question (6.8 difficulty score)
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Bullous pemphigoid antigenπŸ”

Block/Question (6.3 difficulty score)
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IronπŸ”

Block/Question (7.9 difficulty score)
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Increased absorption of calcium in the gastrointestinal tractπŸ”

Block/Question (8.7 difficulty score)
A 53-year-old homeless man with alcoholism is ...
Normal oral floraπŸ”

Block/Question (6.9 difficulty score)
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Interstitial nephritisπŸ”

Block/Question (7.8 difficulty score)
A Gram stain is performed on a sputum ...
Outer membraneπŸ”

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Natural transformationπŸ”

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β€œYour daughter’s development is normal.β€πŸ”

Block/Question (8.1 difficulty score)
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ClomipheneπŸ”

Block/Question (7.1 difficulty score)
A study is designed to evaluate the ...
Cross-sectionalπŸ”

Block/Question (6.9 difficulty score)
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Interferon gammaπŸ”

Block/Question (8.4 difficulty score)
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Pulmonary small cell carcinoma metastatic to the brainπŸ”

Block/Question (7.3 difficulty score)
A 68-year-old man comes to the physician ...
Right ophthalmicπŸ”

Block/Question (5.4 difficulty score)
A 27-year-old woman comes to the physician ...
ReassuranceπŸ”

Block/Question (10.7 difficulty score)
A female newborn is delivered at term to a ...
Enlarged thyroid glandπŸ”

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A 70-year-old man comes to the physician ...
Schedule regular appointments to monitor the patientπŸ”

Block/Question (7.6 difficulty score)
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Fasting insulin: increased; Testosterone: increased; Luteinizing hormone: increasedπŸ”

Block/Question (8.2 difficulty score)
A 10-year-old girl has fatigue and appears ...
Deficiency of erythrocyte spectrinπŸ”

Block/Question (5.7 difficulty score)
A 24-year-old woman comes to the physician ...
Tuberous sclerosisπŸ”

Block/Question (10.6 difficulty score)
A 78-year-old man comes to the physician ...
Bacterial endocarditisπŸ”

Block/Question (8.6 difficulty score)
A 39-year-old woman with rheumatoid arthritis ...
Tumor necrosis factor-Ξ±πŸ”

Block/Question (15.1 difficulty score)
A 35-year-old man comes to the physician ...
GastrinπŸ”

Block/Question (8.5 difficulty score)
A 42-year-old woman undergoes biopsy of ...
High-grade, low-stage neoplasmπŸ”

Block/Question (5.4 difficulty score)
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Brief psychotic disorderπŸ”

Block/Question (12.8 difficulty score)
A 70-year-old woman is found to have ...
Candida albicansπŸ”

Block/Question (13.7 difficulty score)
A 43-year-old woman comes to the physician ...
Degeneration of motoneurons of the lumbar cordπŸ”

Block/Question (19.7 difficulty score)
A 51-year-old woman comes to the physician ...
Area labeled by the letter 'B'πŸ”

Block/Question (18.2 difficulty score)
A 32-year-old man begins to laugh while ...
While swallowing: closed; Immediately after laryngeal irritation: closed; while coughing: openπŸ”

Block/Question (9.2 difficulty score)
A new antiplatelet agent is developed for the ...
8%πŸ”

Block/Question (8.7 difficulty score)
A 42-year-old woman is brought to the ...
Posterior communicatingπŸ”

Block/Question (16.4 difficulty score)
A 32-year-old woman, gravida 4, para 0, ...
Unbalanced chromosome rearrangementπŸ”

Block/Question (5.2 difficulty score)
A 40-year-old woman comes to the emergency ...
Entamoeba histolyticaπŸ”

Poorly_written_question
Block/Question (10.2 difficulty score)
A 35-year-old woman participates in a study ...
Day 12πŸ”

Block/Question (5.3 difficulty score)
A full-term female newborn develops ...
Congenital diaphragmatic herniaπŸ”

Block/Question (4.9 difficulty score)
A previously healthy 52-year-old man is ...
Binding of antibody to the acetylcholine receptorπŸ”


Block/Question (9.3 difficulty score)
A 40-year-old woman comes to the physician ...
Antagonizes VLDL-cholesterol secretionπŸ”

Block/Question (5.4 difficulty score)
A 55-year-old woman comes to the physician ...
Parathyroid hormone: down; 1,25-Dihydroxycholecalciferol: upπŸ”

Block/Question (9.0 difficulty score)
A 39-year-old woman with type 1 diabetes ...
Stimulation of hepatic glucose productionπŸ”

Block/Question (4.7 difficulty score)
A 15-year-old boy is brought to the physician ...
FibrillinπŸ”

Block/Question (7.6 difficulty score)
A newborn female is diagnosed with ...
Thyroxine (T4)πŸ”

Block/Question (5.1 difficulty score)
A 48-year-old man is referred for evaluation ...
Increase in widthπŸ”

Block/Question (5.4 difficulty score)
A 57-year-old man comes to the physician ...
Inferior mesentericπŸ”

Block/Question (6.8 difficulty score)
A 66-year-old man has a surgical excision of ...
KidneyπŸ”

Block/Question (8.6 difficulty score)
Poliovirus mRNA lacks a 5' m7G cap but is ...
Presence of an internal ribosome entry siteπŸ”

Block/Question (5.9 difficulty score)
A 30-year-old woman with Li-Fraumeni syndrome ...
Impaired regulation of apoptosisπŸ”

Block/Question (4.4 difficulty score)
A 30-year-old man develops hemoptysis, ...
Autoantibodies against host basement cell membraneπŸ”

Block/Question (4.3 difficulty score)
A 53-year-old man is brought to the emergency ...
Microglial cellsπŸ”

Block/Question (4.7 difficulty score)
A 43-year-old man comes to the physician ...
RotundumπŸ”

Block/Question (6.0 difficulty score)
A 50-year-old man comes to the physician ...
CollagenπŸ”

Block/Question (4.2 difficulty score)
A 7-year-old girl is brought to the emergency ...
Right lowerπŸ”

Block/Question (4.6 difficulty score)
A 16-year-old girl with cystic fibrosis is ...
Vitamin EπŸ”

Block/Question (5.3 difficulty score)
A 1-year-old boy is brought to the physician ...
Inability to produce melaninπŸ”

Block/Question (5.7 difficulty score)
A 25-year-old man comes to the physician 8 ...
Rupture of an intervertebral discπŸ”

Block/Question (4.0 difficulty score)
A 62-year-old man with unstable angina ...
Left coronaryπŸ”

Block/Question (4.1 difficulty score)
A 36-year-old man comes to the physician ...
Activation of antithrombin IIIπŸ”

Block/Question (3.9 difficulty score)
A 1400-g (3-lb 2-oz) female newborn is ...
CyclooxygenaseπŸ”

Block/Question (6.7 difficulty score)
A healthy 24-year-old woman participates in a ...
"B" point on the graphπŸ”

Block/Question (3.7 difficulty score)
A 31-year-old woman is diagnosed with ...
T lymphocytesπŸ”

Block/Question (3.2 difficulty score)
A 29-year-old woman comes to the physician ...
Follicular atrophyπŸ”

Block/Question (5.0 difficulty score)
A male newborn delivered at 28 weeks' ...
Decreased numbers of lamellar bodiesπŸ”

Block/Question (3.6 difficulty score)
A 56-year-old woman has frequently burned ...
Syrinx of the central region of the spinal cord from C-4 to T-5πŸ”

Block/Question (4.4 difficulty score)
A 5-year-old boy with mental retardation is ...
Maternal origin of both chromosomes 15πŸ”

Block/Question (4.0 difficulty score)
A 64-year-old man with a 25-year history of ...
Killing of bacteria in the gut that generate ammoniaπŸ”

Block/Question (6.4 difficulty score)
A 2-year-old boy is brought to the physician ...
HeteroplasmyπŸ”

Block/Question (3.1 difficulty score)
A 54-year-old man is scheduled for physical ...
Lateral (external) rotationπŸ”

Block/Question (3.5 difficulty score)
A previously healthy 59-year-old man comes to ...
DNA polymeraseπŸ”

Block/Question (3.7 difficulty score)
A 26-month-old boy is brought to the ...
Nocardia asteroidesπŸ”

Block/Question (4.7 difficulty score)
A 51-year-old man who is a farmer comes to ...
Leukemoid reactionπŸ”

Block/Question (6.2 difficulty score)
A 50-year-old man comes to the emergency ...
NADPH oxidaseπŸ”

Block/Question (2.6 difficulty score)
An 80-year-old woman who develops fever and ...
Pseudomonas aeruginosaπŸ”

Block/Question (2.9 difficulty score)
A 66-year-old man is brought to the emergency ...
Increasing cGMPπŸ”

Block/Question (6.1 difficulty score)
Two sets of patients (Groups X and Y) of ...
Blood:gas partition coefficientπŸ”

Block/Question (2.6 difficulty score)
A 62-year-old man comes to the physician for ...
ContemplationπŸ”

Block/Question (5.3 difficulty score)
A 56-year-old man is scheduled for repair of ...
Ligamentum flavumπŸ”

Block/Question (6.5 difficulty score)
An otherwise healthy 60-year-old man comes to ...
Scattered shrunken cellsπŸ”

Block/Question (4.9 difficulty score)
A 28-year-old woman, gravida 2, para 1, comes ...
Venous hypertensionπŸ”

Block/Question (5.2 difficulty score)
On three separate occasions, a 25-year-old ...
Partial agonist at angiotensin II receptorsπŸ”

Block/Question (3.1 difficulty score)
A 35-year-old man with a longstanding history ...
ParietalπŸ”

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An increase in the amount of iron inside ...
Translation of ferritin mRNAπŸ”

Block/Question (7.8 difficulty score)
A 35-year-old woman is given 500 mg of drug X ...
8 πŸ”

Block/Question (3.6 difficulty score)
A 30-year-old woman comes to the physician ...
OligodendrocytesπŸ”

Block/Question (5.0 difficulty score)
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Volume depletionπŸ”

Block/Question (7.4 difficulty score)
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Feces-contaminated soilπŸ”

erections libido
Block/Question (6.5 difficulty score)
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Pudendal nervesπŸ”

Block/Question (4.8 difficulty score)
Two days after undergoing a right hip ...
Dead spaceπŸ”

Block/Question (6.3 difficulty score)
A 9-month-old boy is brought to the emergency ...
Ectodermal neural crest cellsπŸ”

Block/Question (6.0 difficulty score)
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46,XXYπŸ”

Block/Question (4.3 difficulty score)
A 49-year-old woman with breast cancer ...
Microtubules for axonal transportπŸ”

Block/Question (3.3 difficulty score)
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FacialπŸ”

Block/Question (6.2 difficulty score)
A 64-year-old man is evaluated for cough, ...
HyponatremiaπŸ”

Block/Question (6.7 difficulty score)
A 76-year-old man with a 1-month history of a ...
Anomalous origins of multiple renal arteries to each kidneyπŸ”

Block/Question (4.1 difficulty score)
A healthy 25-year-old man lives at 10,000 ...
HematocritπŸ”

Block/Question (3.9 difficulty score)
A 62-year-old man with chronic renal disease ...
Plasma hemoglobin concentrationπŸ”

Block/Question (5.7 difficulty score)
A 46-year-old man comes to the physician ...
Neuronal degenerationπŸ”

Block/Question (4.1 difficulty score)
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JejunumπŸ”

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Two days after admission to the hospital ...
Renal papillary necrosisπŸ”

Block/Question (7.1 difficulty score)
A 24-year-old woman was stung on her right ...
Influx of macrophages producing interleukin-1 (IL-1), IL-6, and tumor necrosis factor-alphaπŸ”

pharm pharmacology
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TubulinπŸ”

Block/Question (3.6 difficulty score)
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Chronic inflammationπŸ”

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"B" label on the CTπŸ”

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LabetalolπŸ”

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A 9-year-old boy is brought to the physician ...
Protein structureπŸ”

Block/Question (2.8 difficulty score)
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Bartonella henselaeπŸ”

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0%πŸ”

Block/Question (10.6 difficulty score)
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Kallikrein formationπŸ”

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An investigator is conducting a study of ...
EnfuvirtideπŸ”

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TranscriptionπŸ”

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Procollagen synthesisπŸ”

Block/Question (5.8 difficulty score)
The chemotherapy regimen prescribed for a ...
Ventricular cardiac muscle fibersπŸ”

Block/Question (4.4 difficulty score)
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T-lymphocyte deficiencyπŸ”

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An investigator is conducting a study of ...
P. vivax and P. ovaleπŸ”

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A 68-year-old woman comes to the physician ...
Superior mesentericπŸ”

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Substance PπŸ”

Block/Question (3.2 difficulty score)
A 66-year-old man comes to the physician ...
Dilated cardiomyopathyπŸ”

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Pelvic parasympathetic nervesπŸ”

Block/Question (4.0 difficulty score)
A 52-year-old man comes to the physician ...
Fasting serum glucose concentrationπŸ”

Block/Question (4.0 difficulty score)
A 70-year-old African American woman comes to ...
GenderπŸ”

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MigraineπŸ”

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Aortic valve stenosisπŸ”

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PericarditisπŸ”

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Iron deficiency anemiaπŸ”

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Wegener granulomatosisπŸ”

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Cigarette smokingπŸ”

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Drinking home-distilled liquorπŸ”

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A pale 62-year-old man has increasing fatigue ...
Hairy cell leukemiaπŸ”

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Chediak-Higashi syndromeπŸ”

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ProstateπŸ”

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EclampsiaπŸ”

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Normal agingπŸ”

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Segmental ischemic necrosisπŸ”

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MyxomaπŸ”

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DermatomyositisπŸ”

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A 55-year-old woman develops a headache, ...
Streptococcus pneumoniaeπŸ”

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Peutz-JeghersπŸ”

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A previously healthy 27-year-old woman comes ...
CostochondritisπŸ”

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A 26-year-old man undergoes colonoscopy ...
Ulcerative colitisπŸ”

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A 35-year-old man is referred for psychiatric ...
Dysthymic disorderπŸ”

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A 69-year-old African American woman has ...
IrbesartanπŸ”

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SildenafilπŸ”

Block/Question (2.3 difficulty score)
A 27-year-old man with acute myelocytic ...
MesnaπŸ”

Block/Question (3.7 difficulty score)
A 38-year-old woman undergoes laparoscopic ...
OndansetronπŸ”

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A 12-year-old girl who recently immigrated to ...
PraziquantelπŸ”

Block/Question (6.1 difficulty score)
A 6-week-old boy is brought to the physician ...
Streptococcus pneumoniaeπŸ”

Block/Question (2.4 difficulty score)
A 51-year-old woman receives the diagnosis of ...
PhenoxybenzamineπŸ”

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A 70-year-old woman is brought to the ...
CimetidineπŸ”

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A 15-year-old Native American boy is brought ...
PhysostigmineπŸ”

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A 5-year-old girl is brought to the physician ...
EthosuximideπŸ”

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A 19-year-old woman is brought to the physician by
RisperidoneπŸ”

Block/Question (6.2 difficulty score)
A 67-year-old woman comes to the physician ...
Low sensitivityπŸ”

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A case-control study is conducted to explore ...
Biased measurement of the exposureπŸ”

Block/Question (5.8 difficulty score)
A study is conducted to assess 32 patients in ...
31πŸ”

Block/Question (3.1 difficulty score)
To determine whether children of workers in a ...
First-graders whose parents had never worked at the foundryπŸ”

Block/Question (2.6 difficulty score)
A 10-year-old girl is brought to the ...
Leukotriene C4πŸ”

Block/Question (1.5 difficulty score)
A 68-year-old woman is diagnosed with ...
Substitution of d-lactate for d-alanine in peptidoglycan πŸ”

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A 25-year-old man develops a temperature of ...
Evaporation of sweatπŸ”

Block/Question (4.6 difficulty score)
A 4-month-old boy is diagnosed with a rare ...
Dilated rough endoplasmic reticulum πŸ”

Block/Question (2.9 difficulty score)
A 12-year-old girl is brought to the ...
PolyubiquitinationπŸ”

Block/Question (2.1 difficulty score)
An 18-year-old man is brought to the ...
Amphetamines πŸ”

Block/Question (1.4 difficulty score)
A 20-year-old woman comes to the physician ...
Herpes simplex virus πŸ”

Block/Question (2.4 difficulty score)
A 25-year-old man is brought to the emergency ...
Ureteral calculusπŸ”

Block/Question (2.6 difficulty score)
A 20-year-old woman is found to have a blood ...
Chronic pyelonephritisπŸ”

Block/Question (1.7 difficulty score)
A 23-year-old man comes to the emergency ...
Determine which drugs have been prescribed for the patient in the pastπŸ”

Block/Question (1.6 difficulty score)
A 21-year-old woman comes to the physician ...
FluoxetineπŸ”


Block/Question (1.9 difficulty score)
A previously health 67-yeaer-old woman comes ...
Influenza virusπŸ”

Recent comments ...

... cassdawg made a comment on nbme16/block1/q#2 (A 66-year-old man has a surgical excision of a brain...)
 +13 
submitted by cassdawg(924)

This is metastatic renal cell carcinoma (FA2020 p605) for the following reasons:

  • Polycythemia - this is the primary clue, as it is associated with ectopic EPO (erythropoitin) secretion in paraneoplastic syndromes (FA2020 p228), which can be caused by pheochromocytoma, renal cell carcinoma, heptocellular carcinoma, hemangioblastoma and leiomyoma. Of these, only liver and kidney would be a choice given and hepatocellular carcinoma is incorrect because he did not have any associated finding of jaundice, hepatomegaly, ascites, or anorexia (FA2020 p392). Plus, the liver does not commonly metastasize to brain whereas kidney does (FA2020 p223)
  • Hypercalcemia - this is likely indicative of PTHrP secretion, and renal cell carcinoma is one of the cancers that can do this. However, this is fairly nonspecific as there are many cancers that can secrete PTHrP.
  • Heamaturia - suggestive of kidney/urinary tract involvement
  • Negative for carcinoembryonic antigen - this is a nonspecific marker mainly for colon and pancreatic cancers (FA2020 p226)
hungrybox  WOW. Amazing explanation. Great work!! +
nbmeanswersownersucks  Additionally the histo looks like the Clear cell type of RCC. The large white/clear spaces with "chicken-wire" vessels and stroma between them. +3
... bingcentipede made a comment on nbme16/block1/q#30 (5 yo boy, presents to ER after 16 hours of severe vomiting, increased sleepiness)
 +12 
submitted by bingcentipede(209)

Kid had a viral URI then took aspirn -> Reye syndrome, a hepatic encephalopathy. There is increased ammonia production because of the liver damage, leading to hyperammonemia. This gets to the brain, is ocnverted to glutamine (an osmolyte). This causes the brain swelling.

It's not E) viral encephalitis because it implies the virus is directly causing the encephalitis. Instead, the viral infection -> aspirin -> liver damage -> ammonia -> crosses BBB -> converted to glutamine -> draws in water -> cerebral edema

https://step1.medbullets.com/gastrointestinal/107080/hepatic-encephalopathy

... hungrybox made a comment on nbme16/block3/q#1 (20 yo man, 4 hours abdominal pain, nausea, vomiting)
 +9 
submitted by hungrybox(961)

ACUTE alcohol inhibits CYP β†’ Increased bioavailability of acetominophen

CHRONIC alcohol induces CYP β†’ Induction of cytochrome P450 enzymes that activate acetaminophen to a hepatotoxic metabolite


I got this wrong because I assumed chronic alcohol meant years and years. I guess a weekend will suffice?

Honestly, fuck this problem.

lfcdave182  Yeah fuck this question. 2-3 days of something would never be considered chronic in anything else. +3
pontiacfever  Drink a lot for a week makes you a chronic alcoholic? +
pontiacfever  That means alcohol abuse = chronic alcoholism +1
skilledboyb  Why would increased bioavailability of acetaminophen place the patient at increased risk of liver injury? What's dangerous about that? +
i_hate_it_here  Metabolism of acetaminophen turns it into toxic metabolites (NAPQI) that inhibit glutathione in the liver forming toxic tissue products. FA2020 pg: 485 +1
... cassdawg made a comment on nbme16/block2/q#38 (A 3-year-old boy is brought to the physician by his...)
 +9 
submitted by cassdawg(924)

I think this is Strongyloides stercoralis (threadworm) is a roundworm whose larvae live in soil and who can cause pulmonary disease. It has the ability to penetrate skin from the soil but can also be obtained by ingesting feces contaminates soil (FA2020 p159) https://www.cdc.gov/parasites/strongyloides/gen_info/faqs.html

Most intestinal roundworms are fecal-oral route except strongyloides which can also penetrate skin, hookworm (necator americanus) which only penetrates skin, and trichinella which can come from undercooked meats (especially pork) but whose symptoms do not match that of the patient. Trichinella larvae enter the blood stream and infect muscle and can also cause trichinosis with fever, nausea, vomiting, periorbital edema, and myalgia.

shervinbd  I think it is Ascaris, not Stringlyloides. The symptoms could be explained by Loeffler syndrome, caused by Ascaris larva migration. Ascaris is transmitted through fecal oral route, so ingestion of feces contaminated soil could cause the problem. Per FA, Strongylides is transmitted by larva penetrating skin. +4
drmifta  Its Ascaris. Fecal oral transmission -> Larvae penitrate GIT -> Blood Stream -> Lung {Maturation, Respiratory Symptom} -> Coughed up and swallowing -> Adult Warm in GIT -> Egg release -> Egg in stool. +1
i_hate_it_here  Didn't the stem mention that roundwarm larvae were found? I thought Ascaris is diagnosed by bile coated eggs in feces? +1
... medninja made a comment on nbme16/block2/q#13 (5 yo boy, 8 months of recurrent middle ear and upper respiratory tract infection)
 +8 
submitted by medninja(15)

I cell disease β€”inherited lysosomal storage disorder (autosomal recessive); defect in N-acetylglucosaminyl-1-phosphotransferase --> failure of the Golgi to phosphorylate mannose residues (decrease mannose-6-phosphate) on glycoproteins --> Β proteins are secreted extracellularly rather than delivered to lysosomes

iury_r1beiro  FA 2020 p 47 +
... bingcentipede made a comment on nbme16/block4/q#26 (42 yo woman, biopsy of suspicious calcifications on mammogram)
 +8 
submitted by bingcentipede(209)

Grade refers to the differentiation, whereas stage refers to the TNM decriptions

This is high-grade because of the "poorly demarcated... cells growing in sheets" wit a high N:C ratio. Means it's got low differentiation.

This is low-stage because there is NO METASTASIS. Even though there is invasion (and thus, a cancer), M for the TNM is most important.

the_enigma28  Excellent explanation. For additional info, look up at Page 220, FA 2020. +
... zincy7 made a comment on nbme16/block4/q#39 (32 yo man, begins to laugh while eating dinner with friends)
 +8 
submitted by zincy7(13)
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CESENRFER:E

WLHIE WLONSGWLAI es(e laragyLen ecrulos orfm laolwwniS)g

.ur.e.t calov fldo sceourl hatt si eth mipryar hoaplngyraeargynl rvetcpiteo eahicnmms to rnvetep rstoanipai nidugr lnliwagswo

  • ioLgc = lrNmoa ;fntoicnu neptevsr ofod rmof niggo nito aahtecr andstei of oshus.apge Yuo tdon tawn ot aitaspre ofdo wnhe you ,alowlws so oyu oclse yuor tgltios dan sCV

MEAEIMIDLTY AFRTE NITIATRORI see( oCgginuh - arparhgpa batuo hte emmhiscna of the ,gohcu setp 3)

.T.h.e ogittls oelssc s(ceslmu edrivnenat by rtnrrceue lyageranl v)enre dan the alocv csord tctarnco to htus eth a.xlrny

  • igLco = EFXLER ot tneverp raotniaspi of ifrgone byod mfro iongg hfrtrue onti at.rhace

WHEIL ONGIGUCH s(ee hggiCnuo - arprgapha uboat eht heinscmma of ,ohcug pets )5

h...Te calvo crsod exlra dan eht gitlsot ne,sop rislneage ira ta rveo 010 hp.m

  • ogiLc = To pehl eepxl the ngfreoi odyb ut.o

NUF FATC

oFm(r Swwolginal kiW)i

Seinc eth reut lcaov osdlf dduact rdgniu eth owal,swl a eniitf orpied of aapen wasoilgwn(l aa)npe tums eeranlscisy akte eapcl hiwt hcae wolwa.sl ehWn reanitlg sialwwolgn to ,osernrpitai ti ash eneb rtmneodsdate thta aigwwolsln cosruc smot oftne duinrg aix,inptroe nvee at lulf oeixitpnar a feni rai ejt is riedepx brpybloa to clera eht euppr aynlxr mfro dofo nmaetnrs ro uqdl.ii ehT lciiancl iciginaefcsn of htsi nnidfig si tath petstian thiw a sinlabee of mriesdomcpo ngul tinnfuco lilw, rove a riodpe of eim,t deploev rstopairyer tisssred sa a emal rposegsrse

... eTh easrtoyirrp tnecre of the lmadule si tcyleird eitbiihnd yb teh wolgislanw ecetnr orf het rvey ebrif eitm atth ti ksaet ot allos.ww sThi nsema hatt it is lbiyfre ilsebimpos ot teherba udrnig htsi aehps of igawonlwls nda eht emntmo ehrwe bagtneihr si entedevpr si noknw as toidelntuig pna.ea

alimd  Well he was eating and laughing at the same time, so it makes sense that his vocal cords were opened during swallowing, right?! +
meryen13  @alimd well i thought the same but remember its asking while swallowing not while chewing and laughing. I have to remind myself to don't overthink and answer what exactly they're looking for. sometimes they give you all these random info and they ask about something else... same as this q. +
... cassdawg made a comment on nbme16/block3/q#1 (A 22-year-old man comes to the physician because of...)
 +8 
submitted by cassdawg(924)

This question can be answered by a process of elimination approach in my opinion: (FA2020 p638)

  • Because he has testes that formed, he has to have the SRY gene and thus the Y chromosome which eliminates 46,XX and 47,XXX.
  • This is not a normal-looking biopsy and the question asks about a chromosomal abnormality so you can eliminate 46,XY.
  • Mosaic karyotype 45,X/46,XY is associated with Turner's syndrome. These individuals present with female external genetalia and testes undescended or rarely descended into the labia majora. They would not have scrotal testes, and thus this eliminates this answer.

This leaves only 47,XXY which is Kleinfelter's syndrome and is associated with testicular atrophy and extensive fibrosis and hyalinization leading to infertility.

i_hate_it_here  Kleinfelter's = fibrosed testis = decreased leydig and sertoli cells Turner's = fibrosed ovaries = decreased theca and granulosa cells +1
... andro made a comment on nbme16/block1/q#37 (54 yo man, aneurysm of distal abdominal aorta)
 +7 
submitted by andro(169)

Flow rate ( Q) = V * A
V- velocity A - cross sectional area

Our velocity is given as 20cm/sec Convert this to cm/min 20cm/sec * 60seconds = 1200cm/min

Plugging in this value into our equation for flow rate we get 1200cm/min * 2 square cm = 2400 cubic cm /min

Note : 1000 cubic cm = 1 L and therefore we can convert our answer to L/min which are the required units by dividing by 1000

= 2.4 L/min

... bingcentipede made a comment on nbme16/block1/q#25 (A 54-year-old woman is admitted to the hospital with...)
 +7 
submitted by bingcentipede(209)

FA 2019, P. 304:

2-7 days following an MI, there can be a papillary muscle rupture, leading to mitral regurgitation. Thus the murmur in the answer, specifically the description of holosystolic and cardiac apex

baja_blast  A) describes Aortic Regurgitation. B) describes Mitral stenosis. C) describes Aortic stenosis. D) describes a PDA. +1
... andro made a comment on nbme16/block1/q#26 (A 40-year-old woman comes to the physician for an...)
 +7 
submitted by andro(169)

Niacin( Vit B3)
- inhibits lipolysis ( hormone sensitive lipase ) and hepatic VLDL synthesis /secretion .

Side effects : Facial flushing , secondary to prostaglandin release . Pre treat with NSAIDS
- Also causes Hypergl;ycemia and Hyperuircemia , as such avoid in Gouty patients and Diabetics

... bingcentipede made a comment on nbme16/block1/q#16 (40 yo woman, gunshot wound to abdomen)
 +6 
submitted by bingcentipede(209)

Dudes and dudettes, let me tell you how high yield Pathoma Ch. 1-3 are. Dr. Sattar is the freaking man.

Anyway, this is reversible cell injury because of swelling. If the Na/K ATPase is not working, Na is not leaving. Na follows water, so water is getting stuck in the cell, leading to swelling.

Most important is recognizing that it's reversible cell injury - everything else (except PFK lol) is talking about cell death

cassdawg  Love this explanation lol Dr. Sattar for president. FA2020 p207 for anyone who wants more details. +3
the_enigma28  Ribosomal disaggregation (detachment) does occur in reversible cellular injury, but that is not the mechanism of cellular swelling! +1
topgunber  this last comment is extremely important to recognize when asking about reversible injury +
... bingcentipede made a comment on nbme16/block1/q#24 (79 yo woman, right hip fracture after falling)
 +6 
submitted by bingcentipede(209)

You want something that improves her osteoporosis, which is usually weight-bearing exercise. So avoid the swimming one, because that's just decreased gravity. The best answer is walking outside every day that could strengthen her over time.

ezzo  I overthought this and figured that the long walk would just make her fall and break her other hip UGH +9
jsanmiguel415  I only got it because I did the opposite - assumed that going to a wet pool could cause her to slip and fall +3
... bingcentipede made a comment on nbme16/block1/q#49 (In an experiment, glycolytic intermediates are measured in human endothelial cells)
 +6 
submitted by bingcentipede(209)

First, notice that there's a drop in concentration after glyceraldehdye 3-phosphate to 1,3-bisphosphoglycerate. Thus, the conversion is impaired here.

Next, it's somehow remembering which freaking enzyme is involved. Which is glyceraldehyde-3-phosphate dehydrogenase in the glycolytic pathway. This is one where if you know the substrate name you know the enzyme name.

... feliperamirez made a comment on nbme16/block4/q#32 (70 yo woman, persistent fever despite intravenous broad-spectrum antibiotic therapy)
 +6 
submitted by feliperamirez(31)
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gdIilenwln VI achserett si a oncomm cesau fo aidndmitsese nadiasicdis dan it is edu ot neraechde of het atyse to teh ec.strteha

eRbmreem atth mienaetiddss oifnnceit aym laos trlseu in itspaent iwth ruaeitennpo

IMC fstnouniydc (ADI,S SDCI) psdpssereoi ot mnutcausoceuo TON amedesidtnis fcsieinnto

... cassdawg made a comment on nbme16/block1/q#5 (Poliovirus mRNA lacks a 5' m7G cap but is translated...)
 +6 
submitted by cassdawg(924)

In eukaryotes, the 5' methylguanosine (m7G) cap is important in the initiation of translation because eukaryotic initiation factors (eIFs) identify the cap and help assemble the ribosome at that site (FA2020 p45).

The absence of a 5' m7G cap would thus require a different sequence to allow translation initiation and ribosomal entry (i.e. an internal ribosomal entry site).

The 5' and 3' untranslated regions are more important in regulation of translation and termination of translation, respectively, and their absence would not aid translation of the viral mRNA. The 3' poly-A tail is important for protection of eukaryotic mRNA from degradation and aiding in exportation from the nucleus; its absence would not aid translation. A very short open reading frame would not make a significant difference in ability to be translated (the open reading frame is the part of the mRNA able to be translated).

... daddyyikes made a comment on nbme16/block1/q#48 (12 yo boy, 6 months difficulty walking and leg pain)
 +5 
submitted by daddyyikes(1)
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it is htccaro ameir ohtot eadeiss as it si ihrteined nda tiwh oalnambr yneilm hthe,sa ootf p,rdo hremam toe .cte

... ace9yak made a comment on nbme16/block2/q#18 (Animal study conducted to assess the effects of smoking on pulmonary defense)
 +5 
submitted by ace9yak(6)

fa 2019 pg 662, Inhalation injury and sequelae. in the inhalation injury and sequelae part they say signed nasal hairs or soot in the oropharynx -> decreased activity of airway cilia as there is soot overlying them and cant function properly tobacco has silica (fa 2019 pg 663) - silica can disrupt phagolysosomes and impair macrophages -> decreased alveolar macrophage function as for the increased mucus production and secretion - idk i figured there is an irritant and your body will be trying to clear it some how, i guess think about COPD

meryen13  i was so confused by the "1 week" i was thinking is one week enough to decrease the macrophages? or are they gonna be hyper active to clean the smoke particles. smh +1
... bingcentipede made a comment on nbme16/block3/q#7 (15 yo girl, brought to ER 12 hours after ingesting 100 capsule vitamin D in suicide attempt)
 +5 
submitted by bingcentipede(209)

Her calcium is only a little higher than normal (upper limit 10.2) due to the excess vitamin D supplements she took. According to FA '19 (p. 70), activated vitamin D:

-Increases intestinal absorption of calcium and phosphorus --This is what increase her calcium concentration in the serum -Increases bone mineralization (lower levels) -Increases bone resorption (higher levels)

... bingcentipede made a comment on nbme16/block3/q#17 (Gram stain performed on sputum specimen)
 +5 
submitted by bingcentipede(209)

Pink rods is describing a Gram negative bacteria, which has two membranes an outer membrane and an inner membrane (whereas Gram positives have just one thicc membrane).

Both Gram + and - bacteria have an ER, can be inhibited fluoroquinolones (though negatives > positives), both have the peptidoglycan wall (positives thicker than negatives), and either can have polysaccharide capsules.

deathcap4qt  FA2019 pg 124 +1
... bingcentipede made a comment on nbme16/block3/q#25 (27 yo nulligravid woman, 2 years inability to conceive)
 +5 
submitted by bingcentipede(209)

Clomiphene is a SERM that antagonizes estrogen receptors in the hypothalamus.

If estrogen is antagonized there, there is decreased negative feedback to improve FSH and LH release to stimulate ovulation. This is very important in PCOS and other disorders with decreased fertility.

notyasupreme  I guess I wasn't sure because it said FSH and LH levels were normal, so I assumed the problem was with progesterone. But I thought too deep into it and should've just went with my gut. +1
feochromocytoma  Clopmiphene is usually the answer for infertility with NORMAL anatomy and NORMAL appearing labs +
drdoom  very nice +
... zincy7 made a comment on nbme16/block4/q#24 (35 yo man, 6 months burning abdominal pain one to two hours after eating)
 +5 
submitted by zincy7(13)
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  • inurngB Ainmladob iPan usroh efrta naiteg = csraGit lecru
  • klcBa sltsoo for 2 adsy = ???
  • rocaRtrefy ot CTO ndasAcit adn 2H klocresB
  • giStwane nda oLw PB
  • iatacencrP Msas = omts lkyeli OASGINTRMA
IOCL G

oatumIncmishmceohil aielnlgb suse idaetbiosn sa skmrera rof hwat etyh awnt to fdi.n In sith se,ca reew' gupintcess ansgtir vigne teh msopmyst

:eotN Yuo lhsodu rvsiee eht itocu,fnn itouam,itsnl dna tesi fo eaeerls ofr heac fo eht emshoorn mnetnodie sa ewll

ERCEF:EEN REn-lenslliorioZgl yrdnemSo

bingcentipede  Black stool because blood in the GI tract? +1
passplease  I was tempted to pick insulin, because of the orthostatics and sweating that could resemble hypoglycemic episodes. Why are those present in a gastrinoma? +3
deberawr  @passplease it's possible that increased gastrin -> peptic ulcers -> perforation -> shock -> sympathetic nervous system overload -> sweating and hypotension +
jsanmiguel415  Black stool = melena = bleeding above the ligament of trietz from ulcers +
rina  @passplease according to amboss gastrinomas can cause steatorrhea and malabsorption, in addition to anemia from GI bleeding. that might explain the light headedness and low-ish bp. +
jj375  Zollinger Ellison Syndrome --> causes duodenal ulcers that are bleeding causing melena and the low blood volume (symptoms of light headed and low BP). I would guess that sweating is from what @deberawr said of the increased sympathetics from the low blood volume +
... bingcentipede made a comment on nbme16/block4/q#32 (70 yo woman, persistent fever despite intravenous broad-spectrum antibiotic therapy)
 +5 
submitted by bingcentipede(209)

Ugh this question. The Gram stain and purple made me thing Staph aureus, but it also mentions "budding" and "elliptical" (SA is a coccus). Additionally, SA is not a common UTI infection while Candida is.

Annoying because of the Gram stain and purple descriptor.

From quora: "when decolourizer is added, the crystal violet taken up by yeast cells is retained." https://www.quora.com/Why-does-a-yeast-cell-give-Gram-positive-reaction

melanoma  Also we can recognize Staph aureus for the beta hemolysis in a blood agar +1
... andro made a comment on nbme16/block1/q#7 (2 yo boy, increased thirst, urinary frequency, failure to thrive)
 +4 
submitted by andro(169)

Fanconi Syndrome
Impaired reabsorption of Bicarbonate and other compounds in the Proximal convoluted Tubules ( eg amino acids , glucose phosphate )

Clinical Features : Vitamin D resistant Hypophosphatemic Rickets/osteomalacia

Fanconi syndrome presents with proximal Renal Tubular Acidosis ( normal anion gap metabolic acidosis )

... privatejoker made a comment on nbme16/block2/q#18 (Animal study conducted to assess the effects of smoking on pulmonary defense)
 +4 
submitted by privatejoker(42)
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Cna eonnay xneapli wyh omgraceahp ttyiviac lduow be dceredeas ni shit? I ewatnd to ckip neo taht hda tbho cusum crigetsne ivycaitt as nibeg inceeadrs nlgoa wthi rieesancd aregaphmoc tyativic whit otncnimoatc eecrdaes ni ciilray yvtcatii ubt isth wan'ts na ptoino os I wtne htwi lla ncsdri.eea cieSn t'is sblete-lehiawdls hatt gpoaaehrcsm sueca dgamea in meyhmaspe ipcslyela(e in okrssme deu to ncnoatst tntraiioir mofr eth eosm),k ohw si ti pslbosei thta grhaepaomc vitytaci olwud go ?NDWO

kard  Mucus hypersecretion --> Induce airflow limitation in COPD "potential risk factor for accelerated decline in lung function" Cigarette smoke impairs both the phagocytic and respiratory burst function of neutrophils! Macrophages-->activated by cigarette smoke extract to release inflammatory mediators COPD--> alveolar macrophages and neutrophils are defective in their antimicrobial functions. Macrophages from COPD patients--> show reduced phagocytic uptake of bacteria. "Streptococcus pneumoniae and nontypeable Haemophilus influenzae" I Hope This Helps... +22
... hungrybox made a comment on nbme16/block2/q#24 (85 yo woman, fracture of the right femur, begins treatment with morphine)
 +4 
submitted by hungrybox(961)

Morphine stimulates mu opioid receptors to provide the desired effect of analgesia, but in doing so can also precipitate many undesired effects.Β  This patient has multiple signs of opioid toxicity, including miosis (ie, pinpoint pupils), respiratory depression (evidenced by slow respiratory rate and respiratory acidosis), and CNS depression (eg, somnolence, coma).Β  Morphine is primarily metabolized by the liver via glucuronidation to form 2 major metabolites.Β  These metabolites, morphine-3-glucoronide and morphine-6-glucoronide, then undergo renal elimination via excretion in the urine.Β  Because the metabolites are metabolically active, renal dysfunction can lead to metabolite accumulation and opioid toxicity.Β  Morphine-6-glucoronide is particularly responsible for toxicity, acting as a more potent mu opioid receptor agonist than morphine itself.

Due to its metabolically active and renally cleared metabolites, morphine requires careful monitoring when used in patients with renal dysfunction.Β  When opioid pain control is needed in such patients, fentanyl or hydromorphone is often preferred as these drugs are predominantly hepatically cleared.

Source: UW18563

... itsalwayslupus made a comment on nbme16/block3/q#20 (Investigator studying strains of Streptococcus pneumoniae)
 +4 
submitted by itsalwayslupus(27)

Natural transformation is when bacteria take up naked bacterial chromosomal DNA in their environment (usually from cell lysis). A cell "lysate" is what remains of bacterial genes when the bacteria is dead (can be extracted from bacteria, as shown here). The SHiN bugs all can undergo transformation. You know it is transformation even without knowing which bugs can do so because it doesn't take up the DNA when DNase is added (it kills any free environmental DNA in the lysate)

topgunber  just wondering why is plasmid transfer not a good option??? +
m0niagui  Transduction requires the presence of a bacteriophage virus. Plasmid transfer requires two different live bacteria, point mutations will not occur across colonies so uniformly and neither will strand mispairing. +1
... medstudent made a comment on nbme16/block4/q#8 (24 yo woman, follow-up examination; 8 years of seizure disorder refractory to treatment)
 +4 
submitted by medstudent(11)

FA 2020 p. 525.

Ash-leaf spots are pretty pathognomonic for TSC. The subependymal nodules add further support for TSC

bingcentipede  Other symptoms of TSC: "Hamartomas in CNS and skin, Angiofibromas C , Mitral regurgitation, Ash-leaf spots D , cardiac Rhabdomyoma, (Tuberous sclerosis), autosomal dOminant; Mental retardation (intellectual disability), renal Angiomyolipoma E , Seizures, Shagreen patches." Most important is the seizure disorder and the ash-leaf spots, like you said +
bingcentipede  Other symptoms of TSC: "Hamartomas in CNS and skin, Angiofibromas C , Mitral regurgitation, Ash-leaf spots D , cardiac Rhabdomyoma, (Tuberous sclerosis), autosomal dOminant; Mental retardation (intellectual disability), renal Angiomyolipoma E , Seizures, Shagreen patches." Most important is the seizure disorder and the ash-leaf spots, like you said +
... maxillarythirdmolar made a comment on nbme16/block4/q#11 (78 yo man, 1 month fever, chills, fatigue, 5.4 kg weight loss)
 +4 
submitted by maxillarythirdmolar(35)
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uoY losduh eb thngikin fo emotisghn lkie ceccrnou.Esto heTy hda a UG errducpeo dna uetbunsqse ccarida susies.

eWhn I rahe ostf 1,S i kihnt atth the epiattn muts have ahd a eisus twih eth lsocgin fo irtehe eth trlaim or sdirtpiuc vsv.ael Pinlgay d,sdo ihst hldous be het tlraim avle.v oYu salo eher an lyrae distlaico m,murur so uoy ghmit be inkginht elovmu dravooel 3)(S.

baja_blast  You're almost certainly right that it's mitral valve endocarditis. The murmur is accentuated by Expiration, consistent with lEft-sided murmurs. On the other hand, rIght-sided murmurs are accentuated by Inspiration. Note the capital letters for a handy trick. God Bless Dr. Jason Ryan. +2
... bingcentipede made a comment on nbme16/block4/q#35 (51 yo woman, 6 months burning abdominal pain one to two hours after eating)
 +4 
submitted by bingcentipede(209)

Good explanation on reddit: https://www.reddit.com/r/step1/comments/d8aqj5/spoiler_nbme_16_hey_can_anybody_advice_how_to_get/

Essentially, A = mucinous glands (foamy cytoplasm) B = parietal cells (stain eosinophilc, P ar I etal cells stain PInk w/ a fried egg appearance. Additionally, they're above chief cells C = chief cells (stain basophilic, super dark, and below parietal cells)

md_caffeiner  reddit: Its not about histology knowledge, you just need to know two things about parietal cells - they are eosinophilic on histo and they are located more superficially compared to chief cells (super basophilic, labeled as C). If you know chief cells are C, mucinous glands are A due to the foamy cytoplasm, the answer has to be B. +
md_caffeiner  reddit2#You're exactly right (although I would say it is histology knowledge). Gastrin stimulates both parietal and chief cells but only parietal cells release hydrogen ions (and chloride ions - to make HCl). ArtiomK is right about the staining and location of parietal cells being highly acidophilic (pink) and predominantly at the apical part of the gastric gland - they're often described as having a fried egg type of appearance (big, round cytoplasm [egg white] with a central, round [yolk] nucleus). Chief cells produce pepsinogen (enzyme) so display the basal basophilic (purple) staining and they're found predominantly at the base of the gastric gland. So, it's a mix of theory and practical understanding - knowing the structure and function of the gastric gland and then the practical histology of the gland (and its cellular composition). +1
md_caffeiner  dont go to reddit and get distracted for 15 minutes lol +6
deberawr  it's better than redownloading tiktok and getting distracted for 3 hours lol (don't do what i did its embarrassing) +
... cassdawg made a comment on nbme16/block1/q#14 (A 30-year-old man develops hemoptysis, dyspnea,...)
 +4 
submitted by cassdawg(924)

This is goodpasture syndrome which has antibodies directed against alveolar and glomerular basement membranes (FA2020 p596)

The key hints are:

  • Lung involvement
  • Crescent formation (indicating rapidly progressive "crescentic" glomerulonephritis)
  • "Linear" deposits of IgG and C3 - this is characteristic of Goodpasture because the antibodies are to the glomerular basement membrane so they deposit all along the glomerulus basement membrane leading to linear immunofluorescence.
  • Remember that the other main lung/kidney combination, granulomatosis with polyangiitis, is Pauci immune with no immunofluorescence and they will usually mention ANCA
... barbados made a comment on nbme16/block1/q#31 (A healthy 24-year-old woman participates in a study...)
 +4 
submitted by barbados(4)

Did anyone else feel like the question should have been more specific as in saying "just before the consumption of a meal"? As in saying she has high ghrelin = high hunger just before she eats so point B?

lee280  I agree, at the start, I got a bit confused because I felt like the question was probably less specific than it would have been, but NBME being NBME this is really expected. When you think about it more closely, once you consume the meal then ghrelin will peak and start dropping. +9
notyasupreme  I agree, I had B at first but then thought too deep into it. I thought if she ATE a meal, she'd be full and low ghrelin. Annoying to get a question wrong on something so simple. +1
radzio1  Also got this question wrong. A really bad explanation what they want from the curve... +1
... cassdawg made a comment on nbme16/block2/q#12 (Two sets of patients (Groups X and Y) of similar...)
 +4 
submitted by cassdawg(924)

The blood:gas partition coefficient is the ratio of concentration of anesthetic in the blood vs. in the lungs when a steady state is reached. Blood/gas partition coefficient is an expression of solubility of the drug in plasma, and less soluble agents have a faster onset/offset.

MAC (minimum alveolar concentration) is the concentration of anesthetic in the lungs where 50% of the population does not move in response to a surgical srtandard stimulus. It is analogous to ED50 in other areas of pharmacology. MAC is increased with decreasing solubility (decreaseing blood/gas partition coefficients) and decreased potency. If you think about it this would make sense because if a drug is less soluble or not as potent, you have to administer more of the drug and thus would have to have a higher minimal alveolar concentration to see an effect. [FA2020 p549]

NOTE: MAC is additive so if you mix two gases at 0.75% of their MACs, you get a total 1.5% MAC. Thus for the question, you are essentially administering the same TOTAL MAC to each group, so it is not the difference in MAC that is causing the difference observed.

The brain:gas partition coefficient, more commonly called the oil:gas partition coefficient, is used as a surrogate for the amount of anesthetic in the brain and corresponds to lipid solubility. CNS drugs must be lipid soluble or actively transported. As these are inhlaed anesthetics, the lipid solubility actually does not greatly contribute to time of onset/offset; instead the plasma solubility is the limiting factor. Oil/gas partition coefficient would be associated with the drug potency.

... cassdawg made a comment on nbme16/block2/q#32 (A 35-year-old woman is given 500 mg of drug X...)
 +4 
submitted by cassdawg(924)

First order elimination: a constant FRACTION of drug is metabolized per unit time (i.e. elimination rate is proportional to the drug concentration)

This differs from zero order elimination where a constant amount of drug is metabolized per unit time (i.e. rate stays constant)

In this question:

  • In two hours, 2.5 mg of 12.5 mg is metabolized, which is a fraction of 2.5/12.5 = 0.2 or 20%
  • Thus, in another two hours, another 20% will be metabolized since this is first-order elimination
  • 20% of 10 is 2 and 10-2 = 8

FA2020 p232

m0niagui  how will it work if this followed a zero order elimination? +
drdoom  @m0niagui Zero-order would like like this: 12.5mgβ€”10mgβ€”7.5mgβ€”5mgβ€”2.5mgβ€”0mg (this assumes 2.5mg is eliminated per unit time) +1
... cassdawg made a comment on nbme16/block3/q#27 (Two days after admission to the hospital because of...)
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submitted by cassdawg(924)

Renal papillary necrosis is a common complication of sickle cell disease which would cause gross hematuria (FA2020 p602, p422).

Glomerulonephritis would be associated with RBC casts rather than gross hematuria (casts are present if they are released from the glomerulus or tubules). Nephrolithiasis (kidney stones) are not associated with sickle cell and would likely be associated with crystals of some sort on urinalysis. Prostatitis would likely present with more WBCs and does not commonly present with hematuria but rather urgency and dysuria. Transitional cell carcinoma is rare in the kidney and transitional cell carcinoma of the bladder is associated painless hematuria.

... cassdawg made a comment on nbme16/block4/q#5 (A 60-year-old man with no history of bleeding...)
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submitted by cassdawg(924)

The key here is this man has no history of bleeding problems yet he has an extremely prolonged PTT (associated with the intrinsic coagulation cascade pathway). This is suggestive that he is deficient in the "unnecessary" factor of the intrinsic pathway, factor XII. (FA2020 p412)

Factor XIIa (Hageman's factor) of the intrinsic pathway activates prekallikrein to kallikrein.

Histamine release, phagocytosis, and C5a generation are not associated with the intrinsic coagulation cascade. Platelet aggregation impairment could be associated with increased PTT (i.e. vWF deficiency, p428), but not that extreme of prolongation without symptoms of bleeding issues.

the_enigma28  Adding to this, XII activates prekallikrein β†’ kallikrein. And, kallikrein converts plasminogen β†’ plasmin. Plasmin causes fibrin degradation. https://upload.wikimedia.org/wikipedia/commons/thumb/2/28/Kinin-Kallikrein_System_Simplified_.jpg/200px-Kinin-Kallikrein_System_Simplified_.jpg +1
... cassdawg made a comment on nbme16/block1/q#38 (A 58-year-old African American man with congestive...)
 +4 
submitted by cassdawg(924)

Sildenafil is a PDE5 inhibitor that runs the risk of causing hypotension in patients on nitrates due to the synergy of the mechanisms of action. [FA2020 p246]

Nitrates, like nitroglycerin, work by increasing NO production which in turn acts to increase cGMP in smooth muscle causing vasodilation. PDE5 inhibitors act by decreasing the breakdown of cGMP in smooth muscle, enhancing the action of NO to cause vasodilation. Thus, when combined there can be systemic vasodilation that leads to dangerous hypotension.

lee280  For some reason, I had two answers that I felt like both made absolute sense to me. As explained above, that totally came to my mind and I knew this was the case. When I thought about Metoprolol blocking B1 receptors in a patient with an ejection fraction of only 30%, I was thinking this could as well be a contraindication, not sure if it's an absolute one or relative. Now, am I right if I said that Beta-blockers are only contraindicated in acute decompensated HF? and can be used unless otherwise? Someone, please help me clarify this, so then this distinction can come clean in my thoughts. Thanks +2
notyasupreme  I thought the same thing as you, I think we're just overthinking the most important thing - never give antihypertensive with Viagra lmfao. I totally thought too deep into it. +1
topgunber  sildenafil does make sense, especially since hes on 2 vasodilators. I picked diltiazem because the pt has systolic heart failure. thought it was contra indicated to give CCB to systolic heart failure because you could further decrease contractility. Either way never give NTG and viagra +
... medninja made a comment on nbme16/block1/q#3 (38 yo woman, 10 weeks epigastric pain, frequent stools)
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submitted by medninja(15)

MEN 1--> Pituitary tumors, pancreatic endocrine tumors (zollinger ellison or gastrinoma) and parathyroid adenomas.

nbmeanswersownersucks  the question hints at a possible parathyroid adenoma with her history of 2 episodes of renal calculi. +3
feochromocytoma  Yup, also as a tip for next time, if you see that a patient has some sort of pancreatic cell tumor, such as Zollinger in this case, look for other MEN 1 associated findings. +
... bingcentipede made a comment on nbme16/block1/q#17 (Investigator studying pulmonary lymphatic flow using animal model)
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submitted by bingcentipede(209)

IV normal saline will increase hydrostatic pressure in the vasculature. This isotonic solution is freely filtered across the capillaries, which is collected by lymphatics and can be picked up in this experiment.

motherhen  Why does albumin solution not have this effect? +3
notyasupreme  I think it's because albumin in saline is hypertonic, which would cause the opposite effect of what the experiment was going for. Fluid would go across the capillaries into the vasculature, rather than vice versa. +2
... bingcentipede made a comment on nbme16/block2/q#49 (An experimental study of oxygen consumption in kidney)
 +3 
submitted by bingcentipede(209)

The two sections of the nephron most susceptible to hypoxic conditions are the 1) proximal convoluted tubule and the 2) mTAL (medullary section of the thick ascending loop of Henle)

cassdawg  FA2020 p210 has the regions of specific organs most susceptible to hypoxic injury +2
biochemgirl22  Im thinking this is because the PCT does the most work as far as reabsorbing stuff, so probably needs the most ATP for those pumps. +2
... bingcentipede made a comment on nbme16/block3/q#3 (83 yo man, 3 days painful blisters on torso)
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submitted by bingcentipede(209)

The stem is describing bullous pemphigoid, which produces IgG antibodies hemidesmosomes. (PV is IgG antibodies aginst desmoglein-1 and desmoglein-3, in the oral mucosa).

BP produces the tense blisters that have a negative Nikolsky sign (don't rupture with rubbing). This is because they're supepidermal. Surprised they didn't ask about hemidesmosomes, but I think that that the BP antigen is part of the hemidesmosomes and recruits the autoantibodies.

i_hate_it_here  New stem was describing Bullous pemphigoid, just never heard of BP antigen lol +
... bingcentipede made a comment on nbme16/block3/q#38 (68 yo man, 2 hours loss of vision)
 +3 
submitted by bingcentipede(209)

2 things:

1) if there was an embolus in any of the other arteries, there would be more severe symptoms outside of the vision loss

2) Ophthalmic artery (a branch of the internal carotid artery) also supplies the retinal artery and blood to the eye most directly

... bingcentipede made a comment on nbme16/block3/q#40 (Female newborn delivered at term to 35 yo primigravid woman)
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submitted by bingcentipede(209)

IgG antibodies can cross the placenta, leading to thyroid enlargement. This can also explain the stridor and issues with respiration in the newborn. Essentially, this is causing neonatal Graves disease.

From UpToDate: "Neonatal Graves disease refers to the hyperthyroidism that is seen in a small percentage of infants born to mothers with Graves disease. Although neonatal Graves disease is usually self-limited, it can be severe, even life-threatening, and have deleterious effects on neural development"

nbmeanswersownersucks  Was anyone else thrown off because the neck mass was asymmetric and graves usually causes diffuse enlargement of the thyroid? +4
... bingcentipede made a comment on nbme16/block4/q#12 (39 yo woman, rheumatoid arthritis, follow-up examination)
 +3 
submitted by bingcentipede(209)

This is a patient with RA not responding to steroids or MTX. Next line of therapy is a TNF-a inhibitor like adalimumab, an anti-TNF alpha antibody.

... aoa05 made a comment on nbme16/block4/q#34 (43 yo woman, 3 months progressive difficulty walking)
 +3 
submitted by aoa05(21)

Weakness with decreased muscle bulk implies problems that include the lower motor neuron system. Decreased DTRs implies a disrupted reflex loop but the absence of sensory loss implies that it is on the motor side of the reflex loop. Of the available choices, B is the best fit. "A" is arguably true because a strictly motor polyneuropathy (such as in lead poisoning) could account for the findings, but a 3-month course could hardly be called "acute."

itsalwayslupus  I was able to deduce the right answer, but what is the specific reason against "demyelination of the corticospinal pathways"? just out of curiousity +1
lsp1992  I believe it's because damage to the corticospinal tract would be considered UMN damage, while degeneration of motorneurons is LMN damage. LMN damage causes decreased reflexes. UMN disease would cause hyperreflexia....I think. That's how I reasoned through it at least +11
nbmeanswersownersucks  I also think you can rule out peripheral neuropathy because typically that includes both motor and sensory +2
saqeer  yes but is not Achilles an S1 reflex (sacral cord) ? how does the degeneration in lumbar cord affects it ? i rule it out first thing because of this :S +
meryen13  i think she just had a dics herniation. there can be problem with temperature and sensation in some case but those are usually very severe herniations. not sure tho... but it can on your differentials. +
djeffs1  I assumed that "motoneurons of the lumbar chord" means upper and not peripheral +
... feliperamirez made a comment on nbme16/block4/q#48 (32 yo woman, gravida 4, para 0, aborta 3, delivers female newborn at term with dysmorphic features, organ anomalies)
 +3 
submitted by feliperamirez(31)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Sstucpe nnceldauba rtotonaislnac hwen hetre aer ietupmll thrbi oessls adn esom tbihrs lstuer ni iesiortsm.

rbmmReee ti ssauce 4 % of woDn eynsrdmo

bingcentipede  "Unbalanced chromosome rearrangement" is also a description of trisomy in and of itself +
bingcentipede  "Unbalanced chromosome rearrangement" is also a description of trisomy in and of itself +
... cassdawg made a comment on nbme16/block1/q#13 (A 30-year-old woman with Li-Fraumeni syndrome is...)
 +3 
submitted by cassdawg(924)

Li Fraumeni syndrome is associated with a loss of function mutation in p53 (FA2020 p224, p46)

p53 is a modulator at the G1/S restriction point. p53 activation in the presence of DNA damage, misfolded protein, and hypoxia leads to activation of BAK/BAX and subsequent activation of the apoptotic pathway (p208). Thus, loss of function of p53 will lead to impaired regulation of apoptosis and uninhibited cell division in cancer cells.

Li Fraumeni syndrome is associated with multiple tumors at a young age (SBLA - sarcoma, breast, leukemia, adrenal)

cassdawg  ALSO REMEMBER: since it is a loss of function mutation that leads to cancer, p53 is a tumor suppressor gene NOT an oncogene. +2
... notyasupreme made a comment on nbme16/block1/q#21 (A 50-year-old man comes to the physician because of...)
 +3 
submitted by notyasupreme(18)

Just wondering if someone could explain the difference between collagen and elastin for this one? I thought either or could be used for tensile strength. Anyone have clarification, don't know why collagen is the best answer!

notyasupreme  Lol, never mind I realize, it's a scar and that's type III collagen! +2
meryen13  type III is whats usually present but then it gets replaced by collagen I in the scar tissue to add more strength. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4352699/ +
i_hate_it_here  It is also the disulfide bonds that add to tensile strength of collagen, while the inter-chain fibril cross-linking that leads to elastins elasticity FA2020 pg: 51&52 +
xw1984  I think the Q emphasized postoperatiive. Maybe the production of elastin does not increase much comparing to collagen. +
topgunber  i think they would refer to elastin in cases of arteriolar compliance +
... cassdawg made a comment on nbme16/block1/q#30 (A 1400-g (3-lb 2-oz) female newborn is delivered to...)
 +3 
submitted by cassdawg(924)

A continuous, machine-like murmur is characteristic of a patent ductus arteriosus (FA2020 p291, p298)

The patency of the ductus arteriosus is maintained by prostaglandins (hence why newborns who need to keep a patent ductus arteriosus due to other heart defects are put on prostaglandin drips).

In this newborn's case, the patent ductus arteriosus is not necessary (there are no signs of additional heart defect that would necessiate it) and thus we want to close it.

To close a PDA, we would want to inhibit prostaglandins somehow, and cyclooxygenase inhibitors (NSAIDs) inhibit the production of prostaglandins and thus would speed up closure of the ductus arteriosus. IV indomethacin or ibuprofen are most commonly used to close the PDA.

Though inhibition of phospholipase A2 by corticosteroids would also serve to inhibit production of prostaglandins, this is more nonspecific and could be associated with more unwanted side effects. Coritcosteroids in a newborn are more often used for neonatal respiratory distress syndrome to elicit production of surfactant.