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NBME 20 Answers

Block/Question (55.0 difficulty score)
A 37-year-old nurse is accidentally stuck ...
Inhibits reverse transcriptaseπŸ”

Block/Question (40.4 difficulty score)
A mother who has toxoplasmosis gives birth to ...
Antitoxoplasma IgM antibody concentrationsπŸ”

Block/Question (25.8 difficulty score)
A 48-year-old man comes to the physician for ...
Upregulation of the LDL receptorsπŸ”

Block/Question (41.8 difficulty score)
A 50-year-old man is brought to the emergency ...
Formic acidπŸ”

Block/Question (25.2 difficulty score)
A 24-year-old African American man comes to ...
Pseudofolliculitis barbaeπŸ”

Block/Question (46.7 difficulty score)
A 16-year-old student has uncontrollable ...
Direct transition from wakefulness to REM sleepπŸ”

Block/Question (35.7 difficulty score)
A 5-year-old girl with AIDS develops a ...
Thymidine kinaseπŸ”

Block/Question (29.7 difficulty score)
A 10-year-old girl is brought to the ...
Breast bud developmentπŸ”

Block/Question (28.2 difficulty score)
A 50-year-old man is brought to the physician ...
Pick diseaseπŸ”

Block/Question (42.5 difficulty score)
A 77-year-old woman has been having ...
C7-T1 foraminal stenosisπŸ”

Block/Question (36.5 difficulty score)
The sequence surrounding the first two exons ...
Disruption of normal splicing by creation of a new 3β€² splice siteπŸ”

Block/Question (79.0 difficulty score)
A 72-year-old woman with dysphagia is ...
Right kidneyπŸ”

Block/Question (38.1 difficulty score)
A 6-week-old girl is brought to the physician ...
Immature lower esophageal sphincterπŸ”

Block/Question (41.2 difficulty score)
A 28-year-old man who is a migrant worker ...
Psoas majorπŸ”

Block/Question (46.0 difficulty score)
A 30-year-old man who completed a successful ...
Adjustment disorder with anxietyπŸ”

Block/Question (53.7 difficulty score)
A 30-year-old woman with multiple sclerosis ...
PonsπŸ”

Block/Question (83.2 difficulty score)
A 50-year-old woman comes to the physician ...
Drug effectπŸ”

Block/Question (40.3 difficulty score)
A 36-year-old man comes to the physician ...
Urine output: increased; Urine potassium: increasedπŸ”

Block/Question (38.4 difficulty score)
A 60-year-old man comes to the physician ...
Urine Na+: increased; Serum osmolality: decreasedπŸ”

Block/Question (39.9 difficulty score)
An 8-year-old boy is evaluated for ...
Coarctation of the aortaπŸ”

Block/Question (34.3 difficulty score)
A 75-year-old woman comes to the physician ...
Multinucleated giant cells and neutrophil infiltratesπŸ”

Block/Question (24.5 difficulty score)
A 38-year-old woman comes to the physician ...
VagusπŸ”

Block/Question (43.5 difficulty score)
A 34-year-old man who is HIV positive is ...
CD4+ T lymphocytesπŸ”

Block/Question (53.2 difficulty score)
A 50-year-old man comes to the physician ...
OmeprazoleπŸ”

Block/Question (31.8 difficulty score)
A 25-year-old primigravid woman at 42Β weeks’ ...
Phosphoinositide hydrolysisπŸ”

Block/Question (29.0 difficulty score)
Serum cholesterol concentrations are measured ...
16%πŸ”

Block/Question (23.1 difficulty score)
A 53-year-old woman comes to the physician ...
Schistosoma mansoni πŸ”

Block/Question (14.9 difficulty score)
A previously healthy 16-year-old girl comes ...
Trichomonas vaginalisπŸ”

Block/Question (51.1 difficulty score)
During an experiment, an investigator ...
LysineπŸ”

Block/Question (33.0 difficulty score)
A 33-year-old woman comes to the emergency ...
LunateπŸ”

Block/Question (43.4 difficulty score)
A 66-year-old man has had fatigue, shortness ...
Focal pulmonary fibrosisπŸ”

Block/Question (43.1 difficulty score)
A 56-year-old woman is brought to the ...
Placement of the central line via the left internal jugular veinπŸ”

Block/Question (48.5 difficulty score)
A 17-year-old girl comes to the emergency ...
MitochondrialπŸ”

Block/Question (46.1 difficulty score)
A strain of Escherichia coli produces a ...
MissenseπŸ”

Block/Question (70.2 difficulty score)
A 70-year-old man dies of coronary artery ...
Spastic hemiparesis on the rightπŸ”

Block/Question (22.9 difficulty score)
A 56-year-old man is admitted to the hospital ...
RhabdomyolysisπŸ”

Block/Question (62.4 difficulty score)
A 1-month-old male newborn is brought to the ...
Na+: 132; K+: 3.2; Clβˆ’: 90; HCO3βˆ’: 37πŸ”

Block/Question (27.9 difficulty score)
A 9-year-old girl is brought to the physician ...
Diverticulum of the roof of the embryonic oral cavityπŸ”

Block/Question (32.4 difficulty score)
A 3-month-old boy is brought to the office by ...
Lateral to the inferior epigastric artery and superior to the inguinal ligamentπŸ”

Block/Question (46.4 difficulty score)
Monoclonality of neoplastic cells in ...
X chromosome-linked isoenzymesπŸ”

Block/Question (30.2 difficulty score)
A 45-year-old man has fever, chills, dysuria, ...
Escherichia coliπŸ”

Block/Question (36.0 difficulty score)
A 60-year-old man has two-pillow orthopnea, ...
Jugular venous pressure of 12 mm HgπŸ”

Block/Question (41.7 difficulty score)
A randomized clinical trial is conducted to ...
Neither procedure is superiorπŸ”

Block/Question (31.3 difficulty score)
A 35-year-old woman with newly diagnosed ...
MR angiography of the renal arteriesπŸ”

Block/Question (20.2 difficulty score)
A 2-year-old boy is brought to the physician ...
Amino Acids: decreased; Glucose: decreased; Phosphate: decreased; HCO3–: decreasedπŸ”

Block/Question (38.3 difficulty score)
A 55-year-old woman comes to the physician ...
CholecalciferolπŸ”

Block/Question (26.3 difficulty score)
A 60-year-old woman with type 2 diabetes ...
Rupture of a papillary muscleπŸ”

Block/Question (30.7 difficulty score)
An otherwise healthy 4-month-old girl is ...
Spontaneous involutionπŸ”

Block/Question (61.7 difficulty score)
A 56-year-old man comes to the physician ...
Fibromuscular hyperplasia of arteriolesπŸ”

Block/Question (13.3 difficulty score)
A 26-year-old man undergoes an abdominal ...
SplenicπŸ”

Block/Question (28.2 difficulty score)
A 17-year-old girl comes to the emergency ...
Speak with the patient and her parents about the findingsπŸ”

Block/Question (50.2 difficulty score)
Following a wedding reception that was ...
NorovirusπŸ”

Block/Question (49.2 difficulty score)
An investigator compares the DNA sequences of ...
5β€² CCGGπŸ”

Block/Question (19.2 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 (29.1 difficulty score)
A 32-year-old woman has had fecal ...
Damage to the anal sphincterπŸ”

Block/Question (67.3 difficulty score)
An 18-year-old boy has just been diagnosed ...
50%πŸ”

Block/Question (56.7 difficulty score)
A 30-year-old man comes to the physician ...
Increased osteoclast maturation and activityπŸ”

Block/Question (50.5 difficulty score)
Three elderly residents of an assisted living ...
Legionella pneumophilaπŸ”

Block/Question (26.4 difficulty score)
An otherwise healthy 16-year-old girl comes ...
Cold, dry airπŸ”

Block/Question (34.1 difficulty score)
A 70-year-old woman is transferred to a ...
Activity level before the fractureπŸ”

Block/Question (37.9 difficulty score)
A female newborn delivered at 36 weeks' ...
Incomplete formation of pleuroperitoneal membraneπŸ”

Block/Question (41.4 difficulty score)
An 80-year-old man with type 2 diabetes ...
Pelvic splanchnicπŸ”

Block/Question (38.4 difficulty score)
A 25-year-old woman comes to the physician ...
A phospholipid (cardiolipin) on charcoal particlesπŸ”

Block/Question (37.9 difficulty score)
A 23-year-old woman has had fever, ...
Streptococcus pneumoniaeπŸ”

Block/Question (28.1 difficulty score)
A 55-year-old man comes to the physician ...
DextromethorphanπŸ”

Block/Question (24.6 difficulty score)
A 10-year-old boy with mild mental ...
Tuberous sclerosisπŸ”

Block/Question (54.1 difficulty score)
A 57-year old man has a hemoglobin ...
Chronic obstructive pulmonary diseaseπŸ”

Block/Question (27.5 difficulty score)
A 65-year-old man is brought to the emergency ...
ST-segment elevationπŸ”

Block/Question (54.9 difficulty score)
A 66-year-old man is brought to the emergency ...
Cigarette smokingπŸ”

Block/Question (48.8 difficulty score)
A 19-year-old man who is a college student is ...
Subcutaneous crepitusπŸ”

Block/Question (44.3 difficulty score)
A 25-year-old woman comes to the physician 2 ...
Granulomas containing stellate microabscessesπŸ”

Block/Question (31.5 difficulty score)
A 44-year-old woman comes to the physician ...
Ubiquitin ligaseπŸ”

Block/Question (36.4 difficulty score)
Which of the following changes in the ...
Increased basal systolic blood pressureπŸ”

Block/Question (25.8 difficulty score)
A patient with a 1-week history of diarrhea ...
Decreased arterial Pco2πŸ”

Block/Question (49.2 difficulty score)
A 14-year-old girl is brought to the ...
Mitochondrial tRNALeuπŸ”

Block/Question (48.1 difficulty score)
A male newborn is found to have a decreased ...
Thyroid hormone-binding globulin deficiencyπŸ”


Block/Question (28.0 difficulty score)
At a postnatal checkup, a 6-week-old female ...
Annular pancreasπŸ”

Block/Question (34.2 difficulty score)
A 25-year-old woman has a flu-like illness ...
PicornavirusπŸ”

Block/Question (50.9 difficulty score)
A 78-year-old man is brought to the emergency ...
CortisolπŸ”

Block/Question (36.8 difficulty score)
A 25-year-old man comes to the physician 8 ...
Rupture of an intervertebral discπŸ”

Block/Question (60.0 difficulty score)
A 12-year-old girl is brought to the ...
OsteoblastsπŸ”

Block/Question (13.9 difficulty score)
A study is conducted to assess the effect of ...
Lead-timeπŸ”

Block/Question (22.6 difficulty score)
A 28-year-old man has excessive thirst and ...
HypothalamusπŸ”

Block/Question (59.4 difficulty score)
A 36-year-old woman comes to the office ...
SplenomegalyπŸ”

Block/Question (30.1 difficulty score)
A 31-year-old man has a large, yellow, soft ...
LiposarcomaπŸ”

Block/Question (35.8 difficulty score)
A 28-year-old woman of Eastern European ...
Recombinational double-stranded DNA break repairπŸ”

Block/Question (22.3 difficulty score)
A 50-year-old woman with a restrictive ...
Functional residual capacity: decreased; Residual volume: decreased; Vital capacity: decreasedπŸ”

Block/Question (25.9 difficulty score)
A 29-year-old man comes to the physician ...
Absence of peptidoglycanπŸ”

Block/Question (22.9 difficulty score)
A 70-year-old man has a 3-month history of ...
Squamous cell carcinomaπŸ”

Block/Question (53.1 difficulty score)
Purified serum antibodies elicited by ...
Proteins X and Y express the same epitopesπŸ”

Block/Question (31.8 difficulty score)
A previously healthy 32-year-old woman is ...
PreloadπŸ”

Block/Question (50.1 difficulty score)
An 18-year-old woman comes to the physician ...
OvariesπŸ”


Block/Question (26.5 difficulty score)
A new antiplatelet agent is developed for the ...
8%πŸ”

Block/Question (27.3 difficulty score)
A physician prescribes a newly marketed drug ...
Discontinue the new drug in affected patients and file MedWatch reports on the FDA's Web siteπŸ”

Block/Question (42.5 difficulty score)
A 35-year-old man comes to the physician to ...
1:4πŸ”

Block/Question (46.6 difficulty score)
A sedentary 50-year-old man with hypertension ...
Antidepressant therapyπŸ”

Block/Question (40.1 difficulty score)
An 82-year-old woman is brought to the ...
Decreased slope of diastolic depolarizationπŸ”

Block/Question (33.5 difficulty score)
A 27-year-old woman comes to the physician ...
PheochromocytomaπŸ”

Block/Question (47.9 difficulty score)
The frequency of an autosomal recessive ...
1/25πŸ”

Block/Question (33.3 difficulty score)
A 23-year-old woman is brought to the ...
Xanthine oxidaseπŸ”

Block/Question (18.7 difficulty score)
A 45-year-old woman has a thyroidectomy ...
CalcitoninπŸ”

Block/Question (37.3 difficulty score)
An 18-year-old woman comes to the physician ...
Reactive T lymphocytesπŸ”

Block/Question (29.7 difficulty score)
A 35-year-old man comes to the physician ...
MethotrexateπŸ”

Block/Question (18.3 difficulty score)
A new drug has the following effects on the ...
Pathway labeled 'H' (Conversion of Leukotriene A4 to Leukotriene B4πŸ”

Block/Question (31.8 difficulty score)
A 10-year-old boy has a palpable mass in the ...
Endoderm of foramen caecumπŸ”

Block/Question (29.5 difficulty score)
A 12-year-old girl is brought to the ...
PolyubiquitinationπŸ”

Block/Question (23.6 difficulty score)
A 62-year-old man comes to the physician ...
ProstateπŸ”

Block/Question (25.4 difficulty score)
A 59-year-old man develops fatigue and ...
HemolysisπŸ”

Block/Question (56.3 difficulty score)
A 3-year-old boy is brought to the physician ...
Heterozygous mutation in the ankyrin geneπŸ”

Block/Question (22.7 difficulty score)
A 46-year-old man has dyspnea, orthopnea, and ...
Mitral regurgitationπŸ”

Block/Question (27.0 difficulty score)
A 45-year-old woman develops proteinuria and ...
Tubulointerstitial nephritisπŸ”

Block/Question (17.7 difficulty score)
During a clinical study, an investigator ...
Increase the sample sizeπŸ”

Block/Question (34.0 difficulty score)
A 23-year-old woman, who was diagnosed with ...
Substance PπŸ”

Block/Question (11.2 difficulty score)
A 41-year-old woman with systemic lupus ...
Ask the attending physician to obtain informed consentπŸ”

Block/Question (12.9 difficulty score)
A 45-year-old man comes to the emergency ...
Schizoid personality disorderπŸ”

Block/Question (45.5 difficulty score)
An 18-year-old woman comes to the physician ...
50%πŸ”

Block/Question (36.7 difficulty score)
A 23-year-old man comes to the physician ...
Area labeled β€˜B’ (Mitochondrion)πŸ”

Block/Question (39.7 difficulty score)
A 67-year-old woman comes to the physician ...
Low sensitivityπŸ”

Block/Question (28.2 difficulty score)
A newborn is born with a lethal chromosome ...
Feed by whatever means necessary to maintain comfortπŸ”

Block/Question (24.4 difficulty score)
In patients with breast cancer, metabolically ...
Gonadotropin by the pituitary glandπŸ”

Block/Question (69.9 difficulty score)
A 50-year-old woman is brought to the ...
pKa: 6.0; Protein binding in plasma: 20%; Volume of distribution at steady state: 1 L/kgπŸ”

Block/Question (32.0 difficulty score)
A 2-month-old girl is brought to the ...
Thyroid function testsπŸ”

Block/Question (21.5 difficulty score)
A 4-week-old infant is brought to the ...
Hypertrophic pyloric stenosisπŸ”

Block/Question (29.6 difficulty score)
A 3-month-old boy is brought to the physician ...
Mannose 6-phosphateπŸ”

Block/Question (13.8 difficulty score)
A 55-year-old man with type 2 diabetes ...
PravastatinπŸ”

Block/Question (24.7 difficulty score)
A 23-year-old woman who is 6 months pregnant ...
Antiplatelet antibodiesπŸ”

Block/Question (27.1 difficulty score)
An 83-year-old man is brought to the ...
Early septic shockπŸ”

Block/Question (29.9 difficulty score)
A 22-year-old woman who recently emigrated ...
Obstruction of the right interventricular foramen (foramen of Monro)πŸ”

Block/Question (20.5 difficulty score)
A 62-year-old woman comes to the physician ...
Ξ²-TubulinπŸ”

Block/Question (17.7 difficulty score)
A 54-year-old woman with terminal metastatic ...
NonmaleficenceπŸ”

Block/Question (20.7 difficulty score)
A 31-year-old woman receives a prescription ...
Formation of complexes with mineral ionsπŸ”

Block/Question (18.4 difficulty score)
A 22-year-old woman comes to the emergency ...
Release of bacterial productsπŸ”

Block/Question (41.3 difficulty score)
A 51-year-old man has the acute onset of ...
Cytomegalovirus infectionπŸ”

Block/Question (50.2 difficulty score)
A 4-year-old boy has had fever, abdominal ...
Shigella sonneiπŸ”

Block/Question (34.6 difficulty score)
A 62-year-old man with alcohol-induced liver ...
SpironolactoneπŸ”

Block/Question (44.1 difficulty score)
A 23-year-old man with a 3-year history of ...
Psychogenic polydipsiaπŸ”

Block/Question (42.2 difficulty score)
A 19-year-old woman has severe refractory ...
Teratogenic effects in the embryoπŸ”

Block/Question (17.2 difficulty score)
Two days after admission to the hospital ...
Do not proceed with the transfusionπŸ”

Block/Question (42.9 difficulty score)
A 2-year-old child undergoes resection of the ...
Increase in glomerular sizeπŸ”

Block/Question (41.6 difficulty score)
A 13-year-old girl has an episode of severe ...
Epstein-Barr virus genomeπŸ”

Block/Question (25.9 difficulty score)
A 71-year-old man comes to the physician ...
CilostazolπŸ”

Block/Question (50.1 difficulty score)
A 56-year-old man is brought to the emergency ...
Capillary hydrostatic: increased; Interstitial hydrostatic: increased; Interstitial oncotic: decreasedπŸ”

Block/Question (23.7 difficulty score)
A 39-year-old man reports bright red spots on ...
ConstipationπŸ”

Block/Question (39.9 difficulty score)
Removal of the thymus at birth results in ...
Thymic lymphocytes produced before thymectomy are long-livedπŸ”

Block/Question (36.0 difficulty score)
A 60-year-old woman has prolonged apnea ...
SuccinylcholineπŸ”

Block/Question (20.6 difficulty score)
A 48-year-old woman comes to the physician ...
HypothyroidismπŸ”

Block/Question (47.4 difficulty score)
A 92-year-old woman who was recently admitted ...
Atrophy of dermal collagenπŸ”

Block/Question (37.3 difficulty score)
A 62-year-old man comes to the physician ...
Agonist at Ξ³-aminobutyric acid B (GABAB) receptorsπŸ”

Block/Question (42.0 difficulty score)
A 32-year-old man comes to the physician ...
Tissue: testicle; Effect: estradiol productionπŸ”

Block/Question (18.3 difficulty score)
A study is conducted to identify healthy ...
LiverπŸ”

Block/Question (39.8 difficulty score)
A 23-year-old woman comes to the physician ...
Collagen synthesisπŸ”

Block/Question (31.0 difficulty score)
A 20-year-old man comes to the physician ...
OlfactoryπŸ”

Block/Question (29.8 difficulty score)
Immediately after a cerebral infarction, a ...
Area labeled β€˜A’ (Broca’s area)πŸ”

Block/Question (21.6 difficulty score)
A 51-year-old man develops diaphoresis, ...
Alcohol withdrawalπŸ”

Block/Question (39.2 difficulty score)
A 33-year-old woman with HIV infection is ...
Non-Hodgkin lymphomaπŸ”

Block/Question (38.5 difficulty score)
A 58-year-old man is brought to the emergency ...
HypertensionπŸ”

Block/Question (24.0 difficulty score)
A previously healthy 37-year-old woman comes ...
Tumor of the adrenal zona fasciculataπŸ”

Block/Question (29.1 difficulty score)
A 65-year-old woman who has a 25-year history ...
Hydroxylation of prolineπŸ”

Block/Question (30.3 difficulty score)
A 37-year-old man who is HIV positive comes ...
NortriptylineπŸ”

Block/Question (36.3 difficulty score)
An investigator is conducting a randomized, ...
Analyze all nonadherent participants according to the group of the study to which each was randomizedπŸ”

Block/Question (57.7 difficulty score)
A 62-year-old woman comes to the physician ...
Bronchogenic carcinomaπŸ”

Block/Question (26.9 difficulty score)
A 60-year-old man has a round, ...
Basal cell carcinomaπŸ”

Block/Question (41.3 difficulty score)
A 45-year-old man is undergoing a surgical ...
Decreasing respiratory rateπŸ”

Block/Question (49.8 difficulty score)
An investigator wishes to determine the ...
Ductal ion reabsorption is more efficient at low flow ratesπŸ”

Block/Question (32.0 difficulty score)
A previously healthy 55-year-old man has ...
Renal artery stenosisπŸ”

Block/Question (33.5 difficulty score)
A 35-year-old man comes to the physician ...
GastrinπŸ”

Block/Question (26.4 difficulty score)
A 55-year-old man with severe emphysema comes ...
Percussion: hyperresonant; Tactile fremitus: decreased; Expiratory phase: prolongedπŸ”

Block/Question (41.8 difficulty score)
A 5-year-old boy is brought to the physician ...
HypophosphatemiaπŸ”

Block/Question (67.1 difficulty score)
A 47-year-old woman comes to the physician ...
Contact with parakeetsπŸ”

Block/Question (25.6 difficulty score)
A 35-year-old man is given cyclosporine ...
Decreased synthesis of interleukinsπŸ”

Block/Question (13.5 difficulty score)
A 45-year-old woman who is intubated and ...
Ξ²-Glucan carbohydrates in the cell wallπŸ”

Block/Question (39.4 difficulty score)
A 27-year-old man comes to the physician ...
Deep branch of the ulnar nerve at the hook of the hamate boneπŸ”

Block/Question (43.6 difficulty score)
A 52-year-old man is brought to the emergency ...
Increased total peripheral resistance and decreased cardiac outputπŸ”

Block/Question (34.7 difficulty score)
A 33-year-old man comes to the physician ...
Rectus femorisπŸ”

Block/Question (32.1 difficulty score)
An investigator is studying patients with ...
Case seriesπŸ”

Block/Question (44.2 difficulty score)
A 78-year-old man dies of chronic congestive ...
Failure of the Na+–K+ pumpπŸ”

Block/Question (27.1 difficulty score)
A 15-year-old girl is brought to the ...
DoxycyclineπŸ”

Block/Question (29.6 difficulty score)
A 32-year-old woman is brought to the ...
Arterial lacerationπŸ”

Block/Question (41.3 difficulty score)
A 48-year-old man is brought to the emergency ...
Cl-: 96 mEq/L; HCO3-: 8 mEq/LπŸ”

Block/Question (47.9 difficulty score)
A 55-year-old man comes to the physician ...
Partial oxidation of fatty acidsπŸ”

Block/Question (27.9 difficulty score)
A 65-year-old woman with cardiovascular ...
Increased bile saltπŸ”


Block/Question (14.7 difficulty score)
A 62-year-old man comes to the physician for ...
ContemplationπŸ”

Block/Question (22.0 difficulty score)
A 25-year-old woman is brought to the ...
Factitious disorderπŸ”

Block/Question (28.0 difficulty score)
A 16-year-old girl with cystic fibrosis is ...
Vitamin EπŸ”

Block/Question (21.3 difficulty score)
A 45-year-old man comes to the physician ...
Tumor necrosis factorπŸ”

Block/Question (21.8 difficulty score)
A 30-year-old woman develops serum sickness ...
C3aπŸ”

Block/Question (25.1 difficulty score)
A 6-month-old girl is brought to the ...
Ornithine transcarbamylaseπŸ”

Block/Question (42.1 difficulty score)
A 56-year-old man with a 20-year history of ...
NaloxoneπŸ”

Block/Question (62.4 difficulty score)
A 65-year-old woman dies 6 months after the ...
MeningealπŸ”

Block/Question (41.9 difficulty score)
A physician is assigned to a search and ...
Negative nitrogen balanceπŸ”

Block/Question (52.5 difficulty score)
A 45-year-old man comes to the office for ...
Starchy foodsπŸ”

Block/Question (13.3 difficulty score)
A 12-year-old boy is brought to the physician ...
Terminal components of complementπŸ”

Block/Question (70.7 difficulty score)
A 28-year-old woman at 32 weeks' gestation ...
Obstructive uropathyπŸ”

Block/Question (27.2 difficulty score)
A 61-year-old man has erectile dysfunction ...
Area labeled β€˜D’ (Corpus cavernosum)πŸ”

Block/Question (35.2 difficulty score)
A 24-year-old man comes to the emergency ...
Lipoprotein lipaseπŸ”

Block/Question (43.3 difficulty score)
A 23-year-old woman sustains significant ...
Direct antiglobulin testπŸ”

Block/Question (17.0 difficulty score)
A previously healthy 16-year-old girl is ...
Prescribe antibiotics without notifying her parentsπŸ”

Recent comments ...

... hayayah made a comment on nbme20/block1/q#40 (Monoclonality of neoplastic cells in endometrial...)
 +31 
submitted by hayayah(1056)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

pNlseioaa si ewn eissut wtgorh atth si gaeduulret,n lreerivrbsei, nad ooonna.llmc

yinCtaoll acn eb edeimntder yb al-pugehp6ts-cooseh rseedhoeadyng GD)(6P ymenze isomorsf. PDG6 si -lnikdXe.

*rFo roem miftnoriaon ekchc otu C.h 3 isNepaoal in omPatah

hello  This is great, thank you. +4
breis  Pathoma ch. 3 pg 23 "Basic Principles" +7
charcot_bouchard  Shoutout to Imam Satter! Without him this question wasnt possible for me to answer in 10 sec. +13
fatboyslim  Clonality can also be determined by androgen receptor isoforms, which is also present on the X chromosome (Pathoma Ch. 3 Neoplasia) +1
lovebug  @fatboyslim thanks for reminding! +
... amorah made a comment on nbme20/block3/q#35 (A 51-year-old man has the acute onset of fever and...)
 +31 
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eervF ;tg-& lrue tuo letf rractlvnuie iluafer M ST-XPM rpspaxiyhlo ;-t&g erlu uot inPousctmeys iivy noKrcideej psrtalannt btu on CBRC/WB ni eiunr >- uler out sntlptnaar jctroieen

ivanLeg MCV nad plactayi ciuemmacoyrtb sa eth iangerinm wot tipnos.o MCV is mero ekilly ni a ttpannsrla e.tniapt

... hayayah made a comment on nbme20/block3/q#44 (A 56-year-old man is brought to the emergency...)
 +30 
submitted by hayayah(1056)
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LV tseoppd ong,iwrk rpseersu cedakb pu onit mpul .ccuirti Pmlu uciicrt rhugloy si amed of 3 "rtsp"a - het ,iarpelcisal naiiirttlste ,caesp nad the olveil.a

nI icocdgneria cosk,h het xaert dloob neiasresc lpriyaacl aiydcrsttoh srpusere, gnirivd uidfl tnoi eht lattiiisnter p.ceas mraCodep ot teh oal,lvei eth litetrinasit paecs wno hsa more ldiuf t(hsu ermo tenasiiittlr isyotchtrda usrrseep adn essl iontocc ersruesp deu to raiot fo iudfl to n,eortip) and sa a etslur fo sith baaingnulnc fo r,fsoec uldif sevom tino hte vaoliel &;--tg lmpryuaon daeem.

... masonkingcobra made a comment on nbme20/block4/q#21 (A 47-year-old woman comes to the physician because...)
 +30 
submitted by masonkingcobra(313)
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eaPg 2 has a aretg cturepi

epw/s:1)99-c37p.6rijr(.o//hita12wtn00/1a4n8S6cifteglw-6o0dl/

kamilia20  chlamydophila psittaci?? +1
... strugglebus made a comment on nbme20/block1/q#17 (A 50-year-old woman comes to the physician because...)
 +26 
submitted by strugglebus(163)
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weoeNrh ahve I nbee aelb to fdni why hte lhel sith si a nt.hig

yotsubato  Its not in FA, Sketchy, or Pathoma, or U world. I knew it wasnt cancer because its bilateral. And Diabetes made no sense to me. So I just threw down Drug effect and walked away. +6
breis  same^^^ +
feliperamirez  The only possible explanation I think is that she was under a K sparing diuretic, such as spironolactone (which would lead to gynecomastia). +
chandlerbas  you had me at its not in sketchy ;) +1
j44n  i thought HTN induced empty sella would cause this because they got type II diabeetus. So if you need a pro zebra hunter holler at me. +
... hayayah made a comment on nbme20/block2/q#32 (A 12-year-old girl is brought to the physician by...)
 +25 
submitted by hayayah(1056)
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A gbi nihtg eerh too is gnctnioi ttha eth ALP is cdes.adere tbseatlosO iiaytcvt si damsuere yb obne PLA. I ikhtn atth asw teh nmia sufco erhe dan not htta uoy reessincayl ened to onkw eth BA1FC nege .uomatint

sympathetikey  Exactly. That's the only way I got to the answer. +3
pakimd  isnt increased alk phos consistent with increased osteoblastic activity? +
champagnesupernova3  A defect with chondrocytes would cause an short limbs like in achondroplasia so those are ruled out +
pg32  Exactly. Can also be helpful if you remember that the clavicles are formed by intramembranous ossification rather than endochondral; that allows you to rule out the chondroblast/cyte answer choices. +4
... imgdoc made a comment on nbme20/block4/q#20 (A 5-year-old boy is brought to the physician for a...)
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uYo can sosrc uto the otp ehetr sawrne ehci,sco B,C.A, uYo wnot eb rnbgrosaieb nayhitgn in eth TPC in f'nnacsoi osem.drny kLginoo ta imopk,aelayh moa,hyrnaitep and omtoehpphpiyhasa now. akpolmiHyea a'ctn eb rcotrec ecsbaue eevn guhtoh apumssoti is ltso it will eb orebeabsdr at eht ratel thcki dngsaeicn oolp dan fi hatt ntdose emak sesen, teh obyd wlil sutdja rof olw mresu tmuaispos tbu catgtiainv teh H/K++ pmup no cells. It it'sn erptimhanayo csabuee at the lolcgtncie dctu ncpiralip ,slcel obeoirprnast llwi crcou. iTsh aelves teapsphhohaoymip as eht rroccet dna olny aesrwn coie.hc

imgdoc  by* +2
larascon  Excellent explanation, thank you ! +1
waterloo  It's worth mentioning, that 25% of Na is reabs in the thicc ascending limb. 67% of filtered Na is reabsorbed in the PCT, whereas 85% of phosphate reabsorbed in the PCT. So pt more likely to show Hypophos. +
coconut  UWorld QID:7626 says lab results in people with Fanconi syndrome will show hypokalemia +
j44n  coconut i thought that too but then i remebred fanconi is associated with hypophosphatemic rickets/ VIT D resistant rickets and this little dude is going to be growing because he's 5 and thats gonna increase the demand for phosphate in his body +
... hayayah made a comment on nbme20/block1/q#34 (A strain of Escherichia coli produces a...)
 +24 
submitted by hayayah(1056)
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nsseiMes itntmasou nlvevoi a tencluodie isntstoutibu etginruls ni ndhagec amoin dsa.ci oteimmeSs eth fstcefe of esemissn mtsitnuao amy be oynl prtpanea edrnu arntcei ervmntlneoain tsin;oocndi chus smesnise tsmnitaou are dclela aintodlncio oitmsa.nut ynMa mssnseei saittmnou ulerst in otepsirn hatt are ltsli ncotauf,lni ta atesl ot some .egered

sl,oA all eth oreht esnwsra dluow brlyabpo aevle oyu hwit etrehi a telragy tdaelre ro o-uanolnntnifc npi.treo

thefoggymist  I chose nonsense because I thought it'll make the enzyme shorter (since less bonds = more heat liable = can't work at 42 degrees) but yea, probably won't work even at 30 if it's an early nonsense. +6
joanmadd  A good clinically related example is HbC disease on electrophoresis. HbC disease is due to a missense mutation (glutamic acid (-) for valine (neutral)). The mutated hemoglobin is still fairly functional but when placed on gel electrophoresis the HbC migrates the least far from the negative electrode due to less negative propulsion (lack of wild type glutamic acid). +1
fatboyslim  @Joanmadd Just to clarify, glutamic acid substitution for valine occurs in sickle cell disease not HbC. HbC is glutamic acid substitution for lysine :) +6
rockodude  lyCCCCine for HbC +2
... hello made a comment on nbme20/block3/q#44 (A 56-year-old man is brought to the emergency...)
 +24 
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anistt'eP ymotmpss ngabe 30 nmi raetf nwiogm waln .ei.( ratef gidno pshyclai ai.i)ytvct He sah revsee schet pain dna is o,loc lmc,yam atecorphid.i eH has ceadriens rapomuyln taryre upssrree nad iadencser tlef ilatra sep.urers Tknae aegrthe,olt tihs is diagronicec hoksc.

Ciedicarngo cshok si a athre pmpu reblomp -- the VL ti'sn gorkw.ni

When eth V,L 'nsit ,gikrnwo ti eusacs a bcka up in eht etriinodc speoipto ot how oodbl ymlonlar soflw. ereeh,rfTo lodob illw ackb pu in eth .usnlg

shiT ssecua asrdienec lylpricaa yahoctridst peerrsus ;t-g&- tihs drevis more udifl iotn eht siimrtueintt g;-t-& stih uesasc iesedracn iitlistaenrt tyitorcsahd psrresue &g-;t- herte is onw omre diluf tnha olanmr ni het nutttiemiris -;>- htis fftasce hte ronetip ritoa nthiiw the rmtuentsiit ;&-tg- shti euascs eacerdsde asretiinltti tcoconi seerupsr.

targetusmle  awesomely explained :) +
lilyo  This was amazingly explained Thank you @Hello! +
pseudopseudopth  For edema to occur shouldn't interstitial oncotic pressure be increased?(when proteins are there, they can pull the fluid) +1
pseudopseudopth  And when increased interstitial hydrostatic pressure is pressure, shouldn't it oppose the edema by pushing against it? +1
pseudopseudopth  *when interstitial hydrostatic pressure is increased +2
... celeste made a comment on nbme20/block2/q#6 (An 18-year-old boy has just been diagnosed with...)
 +23 
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heilW the ieeitlmf kisr ni hte gelnrea oltuapinpo si tujs lwoeb %1, ti si %65. in deretfs-gier teresaliv of nittespa dan it irsse ot emro atnh 0%4 in onygtomzoci istnw fo ffedceta oleepp. laAnngziy iclassc etssidu fo eht scngteei fo cpsnhizhreaoi eond as ylera sa in s,1093 iFhsecr udcnleosc ahtt a crncnoacdoe arte orf chsypoiss of uabto 5%0 ni inozmyotcgo itnws eemss ot be a raetlicis i,ettesam hwchi si syaitclnnfgii hrheig ntah ttha in gzdiictyo itnws fo boaut 9–11%0 (o36at#6i.if//smn.PcClp9v3l4ige./c5hnrbnMr/c2me)

imnotarobotbut  How is one supposed to know this before having read this article? +32
imgdoc  This question falls under the either you know it or you dont category. It isnt in FA or Uworld +
jaxx  So why would these A-holes put it on there as if prepping for this exam isn't stressful enough :-| +7
doodimoodi  Lol just why seriously +2
champagnesupernova3  This was mentioned in the Kaplan behavioral videos +
usmlecrasher  and there's so much unnecessarily BS instead of real questions +1
j44n  I'm just glad we're seeing this garbage now instead of having an aneurysm in the prometric center +1
... xxabi made a comment on nbme20/block4/q#46 (A 28-year-old woman at 32 weeks' gestation comes to...)
 +23 
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sAol rfo estoh of uoy hwo era tyotlal ceesslul elki ,me iayurrn ttcra noubtstiroc = rvtuisotecb .uohparyt

... justgettinby made a comment on nbme20/block1/q#24 (A 50-year-old man comes to the physician because of...)
 +22 
submitted by justgettinby(22)
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atzlIcneaoro ruiqsree hte aicdci tmevionnren fo the tosahcm ot eb abbsdr.oe elmazpreOo nihitibs eth H+K+/ mpup of teh ,stohamc ryteebh dincsgerea hte tiaicyd fo eht .athcoms So ewhn eht teaptin ktesa arzemolOpe dna croaoItaelzn gete,htor tcIaooaenzlr t'won eb bdbesrao niot the ob.dy taThs' why ti has on ecef.tf

Ist' nmecedrdmoe to keat oneimicsdta at letas 2 uohsr orrpi to tkngia an cditnaa.

necrotizingfasciitis  Just adding support to the above explanation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671798/ +3
pakimd  do all azoles or just itraconazole only requires an acidic environment to be absorbed? +2
chandlerbas  just itraconazole and posaconazole +5
lilyo  @chandlerbas, where did you find this information? I was looking over this on FA but they do not mention it and I would like a bit more information. Thanks! +5
chandlerbas  haha no stress! the article above submitted by @necrotizingfasciitis does a descent job explaining it, however its not good enough, I looked into a bit more on uptodate but wasn't fruitful in my endeavours. goodluck! +
haozhier  How are we supposed to know this!! It is not in UWORLD or FA right? +7
kevin  Someone said it on here, since there was no CYP inducer of the answer choices, the only way to even think about an answer to this question was to just go with a less acidic environment from the PPI affecting absorption. It was simply the only reasonable answer choice, I don't think there's any way we were expected to know of this exact interaction prior +
aoa05  Golan pharm book states the exact same thing. Cannot be given to patients with acholrhydria. +
... medbitch94 made a comment on nbme20/block3/q#26 (A 3-month-old boy is brought to the physician...)
 +22 
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F1290A epag :74 Icell- sdesaei inlucnios( clel diaudliipesossic/mose ytep β€”)dIeirItihen lslamysoo gtoersa irde;dsro ectfde in f1lspceasrrcany-iams-h-Nglpoeotaehuytlons r;ra&r ilrauef of eht lGoig to ophayloethpsr samonen duressie ni(mrfog )hso-eoeaat6mhpps-nn on tloncyirsogep ;&rrar tesrnpoi rea etcsdeer tealcyrarelllux hretar athn evledired to mse.ylosos Reslstu in scearo ifacal eate,rufs vaniglgi ayhpilsape,r eoducdl ,noecsar itrscderte noitj mmeeotsv,n lcwa anhd ifimortes,de sikohoio,yspcsl and ghhi pmasal vselel of yssloloam zy.semen etOfn fatal ni hdoco.lidh

... yotsubato made a comment on nbme20/block1/q#42 (A 60-year-old man has two-pillow orthopnea, severe...)
 +21 
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fiiBd ordaict eslups are nees in ritocA sseonist or ritounaigetrg

daiCtro irBut is dareh twhi csasotolesirehr of mconmo aotrcdi rareyt

owlS irnigs eesdreacd mlveou oditcra usepl si ccraaesthiritc of atoirc n.stsoies

nnaoCn vswae rae ense ni opmtecle VA ,cobkl sa rthig lireevtnc nda aairt atnrtcoc d.edlinpyeentn

chextra  I mis-remembered normal JVP as 8-12. Therefore, I picked "Slow-rising, decreased-volume carotid pulse". Is there a reason why this is NOT a result of HF, or is it simply not the best (which I agree is JVD)? +1
len49  For those wondering normal JVP is 6-8 mmHg +3
fatboyslim  @chextra I think the reason why it's NOT slow-rising decreased-volume carotid pulse (sign of aortic stenosis) is because the patient had a h/o prolonged substernal chest pain 5 days ago. I think he had an MI and is now presenting w/ heart failure. +
... banieb made a comment on nbme20/block4/q#46 (A 28-year-old woman at 32 weeks' gestation comes to...)
 +20 
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Dgniur the tasl flah of neacrgnyp niodatli of hte rupep uryianr atctr cna crcuo ued ot mpeonorsisc fo teh eeturrs yb the gniogwr /etrssufuetu nda the alein trsinim.lae ehT ssmeoonirpc of htese si nto llainwgo diulf paegass oitn eht blrddae gsncuia unire luiubpd ni eth dyki,en shti deasl ot oiidlatn of het enkdyi that nsde up uisganc atmpsmcoyit yoshohdepnr.ris itsh nac edn up in itinncoef dan msopstym hcus as hte seon psrteen ni siht aittenp ilke abck pain dan CAV sn.nrdetsee hte ryingc is namily deu ot teh napi auecds yb eht citurnbso.ot dn a tjus sa mieshngto trxa:e ubloed giitpla esehtrtac si a asef nda emlpsi wya fo tgraetin ytscmpaomti dnoeshrrhpyosi fo nncreyag.p

banieb  Ureteral obstruction by the pregnant uterus https://www.ncbi.nlm.nih.gov/pubmed/1579937 +1
... onyx made a comment on nbme20/block1/q#12 (72 yo woman with dysphagia)
 +19 
submitted by onyx(41)
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iaochcrT tucd .natesiolr

consuela_salon  This was the picture that I liked the most for this question. If you imagine that the injury is at the level of the left subclavian vein (LSV) and thoracic duct (TD) crossing each other, maybe it will help you realize that the left breast & left upper extremity bypass the injury. The right lung is drained by the right lymphatic duct, not the TD (see one of the links bellow). And the heart is where eventually all the drainage is going to end up to be pumped again (TD -> LSV -> SVC -> heart). +14
mbourne  To keep it simple, the Thoracic Duct drains lymph from the entire body EXCEPT for 3 structures: Right Upper Extremity Right Thoracic Cavity Right Side of Head and Neck These 3 areas are drained by the Right Lymphatic Duct which enters the Right Internal Jugular Vein +8
... hello made a comment on nbme20/block1/q#17 (A 50-year-old woman comes to the physician because...)
 +19 
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nGjoal adh a leuterc thta nteenmiod ahtt fI" a tetpina sha haercoaglart, vriewe eyrve udrg t'eerhy aitnkg iensc amyn rudgs cuaes "tcaoaerrhlga.

hTe noly nihgt fo seopslib nraeeecvl ni isth mtsQ-e is htat hes tksae a e,ainciomtd heroetref teh easrnw of "urgd ctf"efe si teh somt lyliek nraose rfo ehr ecraarlta.goh

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +5
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1
... strugglebus made a comment on nbme20/block2/q#20 (A 19-year-old man who is a college student is...)
 +19 
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noo=chrypnohB nneiyropEtaaomrpui x tsdri=or ertcaranbhihlooc rbottiuscno rnesm(gs/iafo dotrbI ia)oypsryn ridstro = agllraeyn uu sriictScsncotounobs pa=hsls etts rof yoipcrl isetssno

neWh eterh is a edafcrrtu bir ti llwi uecsa a amuart oaerxmnptoh wihch cna scaue iar ot ceapse dna eomceb aedtppr eundr eht kins leadgni to etruip.sc

charcot_bouchard  Actually when a fractured rib puncture lung then it cause sc emphysema. +2
mbourne  "Chest trauma, a major cause of subcutaneous emphysema, can cause air to enter the skin of the chest wall from the neck or lung. When the pleural membranes are punctured, as occurs in penetrating trauma of the chest, air may travel from the lung to the muscles and subcutaneous tissue of the chest wall. When the alveoli of the lung are ruptured, as occurs in pulmonary laceration, air may travel beneath the visceral pleura (the membrane lining the lung), to the hilum of the lung, up to the trachea, to the neck and then to the chest wall. The condition may also occur when a fractured rib punctures a lung; in fact, 27% of patients who have rib fractures also have subcutaneous emphysema. Rib fractures may tear the parietal pleura, the membrane lining the inside of chest wall, allowing air to escape into the subcutaneous tissues." +1
... monoloco made a comment on nbme20/block2/q#32 (A 12-year-old girl is brought to the physician by...)
 +19 
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iThs si a ocanndiloti delcla ilpddenscaylcsioai.oar The kdi on Sgrnerat inhsTg twih eht plsi sha het ddseriro. oN loalcr ,soneb too myan thet,e tlorfan sinbgso =;g&t dlindicolaoasrcpyi.eas B1FAC is a gnee hhilgy iatpcdeiml in atlosstobe nc.tfuino

... hayayah made a comment on nbme20/block1/q#7 (A 5-year-old girl with AIDS develops a progressive...)
 +18 
submitted by hayayah(1056)
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ivyrlAc,co ,irfoavclmic clrciyvaaolv aer unasnoegi asanlg.o Tehy odnureg visnorcneo to acoiyclvr hpmoooetanpsh aiv srivu edecond syaie.kinhtinmde- lel,tUmayti tyeh ibtiihn vairl AND epelmyasro by hacin taoinmnit.re

uattdeM avirl hitienmdy iaskne nac eascu stne.isacre

len49  Foscarnet and Cidofovir on the other hand do not require phosphorylation by viral kinase, therefore should be used in strains that are shown to be resistant. +3
... meningitis made a comment on nbme20/block2/q#50 (A 27-year-old woman comes to the physician because...)
 +18 
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enWh ndsntaig u,p the dboy nallrymo vciaatste itapcheymst steyms ot oavid osircothtat isnoeytno.ph

tBu icnse ereht si nwo na adiedvit tcfefe fo the oopyohomthecracm nerieac,grds it iwll adle to a nhryetoeispn

:e.(i blouDe anoisocsitntrvoc = ehoP cerdgirsnae + mpShcytaeti smtyse)

sympathetikey  Brilliant. +4
medschul  Would pheo have a normal resting BP though? +10
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +7
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1
nala_ula  No problem! Thank you for all your contributions throughout this page! +1
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +
hello_planet  FA 2019 pg. 336 +1
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +
... medbitch94 made a comment on nbme20/block3/q#49 (A 92-year-old woman who was recently admitted to a...)
 +18 
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itccinA prruupa stulesr mofr oenaxttsrvaia of dbool iotn the dsir.em hTis nnnepoeohm si ude to the isnk opatyhr nda het tflgaryii of eht obdol veslses ni eyllred iv,nddisulia chwih si rxtedaebace by icrohnc uns .eporexus icniAtc prpruau ielsnos era caedlot on pesuoesdnx- r,seaa leki eht sa,mr fcae, dan ekcn.

kinS ahorpty ni ssaotpiremorod is eud to an ltaritonea of ,ceonlagl irialms to htta hwihc si seen in otoprosssi.oe hTis deprncunoo ksin apotyrh csadeu by teh -paonigghot skema the madrel usrlvcaa konewtr ervy eetsivisn ot eth tthsisegl raautm or rahengsi r.ecfo

md_caffeiner  Google actinic purpura, look through 5-10 images, and you get the idea. +10
... monoloco made a comment on nbme20/block4/q#30 (A 32-year-old woman is brought to the emergency...)
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submitted by monoloco(132)
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emynAit ouy vhae a nerpso who sumbp ehtir da,he tges kbac ,pu nad nhte ash seever esuiss or edsi ekil 6 hsuro trael -- yuo veha rfelyuos an edaurlip amhteamo rmof rtloecaian ot hte lidmde NAEINMELG trryea. jo(naGl aelrly miphaeszse ahtt yuo ot'nd wsrce pu nda scelet idlmde .errbeca)l oYu onwk ti has ot be an taealirr aretnolcia cnsei the uadr si itlyhgt aehdedr to eth lsl'uks renni srae.fuc ljoanG dreefrer to ihs ecpenxiere ihwt it sa diennge epirsl ot omveer eth urda ofmr the ;lklsu icpah,rg tub ti srveid eht ntopi .eomh nTniget enes no CT si eeaubsc eht rpledaui amaohtem tgse tcsuk nebwtee het seutru lnie.s nWhe it naasmeg ot aerkb psta one of hte uurste l,sien it si my nunsgdndtirae taht hnte is hnwe uoy get seerev qlease,eu elik hatde ro ahwevtr.e

usmile1  omg monoloco!! I miss you dude! We used to hang forever ago, hope all is going well in med school! +9
... sympathetikey made a comment on nbme20/block1/q#35 (A 70-year-old man dies of coronary artery disease....)
 +17 
submitted by sympathetikey(1245)
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sA edatst bl,weo eth eLtf csru iberrce swa magaedd ese( awth ti duhols amlynlro olok liek ob.elw) Tsih ntcoinas het pnoirioatslcc ctatr. icSen hte scinocpaltiro artct eutscadse at the ,lmduela ebowl the nridbmia icsteon were' nolgiko ,ta you doluw see tlloatarernaC )Rihtg( icSptsa pmrassieHei

hello  What identifies that a cross-section is medulla vs midbrain vs pons? +4
kernicterusthefrog  @hello I like to pay attention to the Cerebral Aqueduct (diamond/spade shape seen mostly in Midbrain, and transitioning to 4th ventricle in rostral Pons), and then the shape and size of the 4th ventricle as you move down Pons to rostral&middle Medulla, and eventual closing and absence of fluid space at caudal Medulla. +11
hello  @kernicterusthefrog Thank you. +
mbourne  NGL, I thought the right side had the pathology lmao ty +20
... andrewk1 made a comment on nbme20/block2/q#9 (An otherwise healthy 16-year-old girl comes to the...)
 +17 
submitted by andrewk1(17)
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ishT rilg has xeiecres udncide .msaaht It si ont lwel udndseoort wyh it naspeph tbu the sigegrrt ear noger.zdice raymlNol ewhn bahrngtei cusorc rai si knaet ni by hte neso adn eth nslaa aagsessp and iuasenttbr tac to merove dstu nad /myirmduwihaf hte iar. Lailclgyo itsh kmeas the air rnesde TnP.=Rv oS henw ecrnigesi,x triehabng tgohrhu the soen si aedresdec and lepdrace yb rmeo vogsuiro othum eb.garthni sihT nemsa eht rai si tno mudifiedhi adn armdew u.p eTh rai si essl ensde nad eht athsam snue.se Teh tnesoqui okot htis esma lprepinic xpceet dvreseer it yb gniska tahw nelaxetr otoicnnid uoldc elad to eht smaath nad htta ulwod eb cold yrd ai.r

eacv  oooh thank u !!! I choose wrong, cold air hehhe +4
eacv  moisture air instead! +
... drdoom made a comment on nbme20/block1/q#11 (The sequence surrounding the first two exons of the...)
 +16 
submitted by drdoom(802)
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As bcidseedr ni het eniqusto mset, htsi tnuaoitm curcso nhtiwi an inotrn a( gnee mtnseeg cwihh si rceantirsbd RNDN;A]A-&tg[ but not natle.dtrs)a ANR ngcipisl s)zm(nyee rabg RNA dna oloβ€œp i”t; an trinno is uct uot adn teh nsoex on iehret eisd fo teh rntion are ijdna,oed keil shti:

e2nnnβ€”iooxenrβ€”xt1o &;tg= xenoeβ€”1n2ox

il,yyaplcT iths ipsilngc orcsuc ta het vyer gdsee of the tnnior a(wth I eentddo wiht hte β€œβ€”β€ .rrhaac)cte tBu ni oru ,sace a muontiat thwnii teh rtinno is scaungi RAN gicsilnp eynzem ot reicneozg a enw :tesi the riscelp tusc ihniwt teh tionnr tdesina( fo ta teh yevr d,eeg as it dlho.)us S,o ew etg thsegiomn that oolks ilke st:ih

on1xeβ€”β€”2ierotnxn

’thTas a ttlalyo dffrnetei RNmA ,lmecloeu nad s'ti iogng ot maek rou ilbgon-Ξ² nrtepio loko (and vaeeb)h ylawulf rsne.agt

drdanielr  I remember that in the pre-mRNA, the splicing sites of the intron where the spliceosome attaches are surrounded by "GU---AG" like "guac", so here the homologous DNA to this strand would be transcribed into "gu............ag......" and this would create a 3' slice site too soon +4
vivarin  if this is supposed to be pre-mRNA, why are there T's in the sequence? I'm so confused by this for some reason +7
sars  This is the gene (DNA), not heterogenous mRNA. +
... karljeon made a comment on nbme20/block3/q#2 (A 23-year-old woman is brought to the emergency...)
 +16 
submitted by karljeon(111)
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hsTi eno aws a thsmaewo lmseip nseoiuqt snice rethmeocypha &g--t; trmou yisls t&g;-- eedn ihnaetnx xiadoes ihobintir g(,e xesu.tb)aoft

UTB WHY IS MBNE MMAGRAR SO PC?RA UTP YUOR MSMACO NI THE TGRHI CE!LAP

... hayayah made a comment on nbme20/block3/q#20 (A 67-year-old woman comes to the physician for a...)
 +16 
submitted by hayayah(1056)
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stivityeSni etsst ear sude ofr si.neegcrn Scctifipyei stets ear edus orf nnmaictroiof ftrea toesivpi cseegnn.sir

tveyniiisSt sttes aer duse ofr gsneei who yanm lopepe yrult ehav the deea.ssi tpyieficciS tsset rea ofr osthe who od nto ahev eth s.seiead

A hlhgyi ivteeniss ttse, nweh ,nevtieag resul UOT iedsaes. A hiylhg ipefcsci st,te nhew itpi,sove serlu NI iesdeas. ,oS a estt ihwt ithw wol nstiiytsiev ncoant elur otu a iees.das A tets hitw wlo ceiiyscpift na'tc rule in see.dias

Teh orodtc nda ettainp antw to ensecr ofr lnooc nercac nad uelr ti uo.t The rotcod olwud anwt a tets thwi ghhi ytetinssivi ot eb laeb to do ahtt. He nwkos ahtt teigtsn reh sotlo orf blodo liwl nto uelr tou eht ilyspsiitob fo cnolo C.A

sympathetikey  SeN Out (Snout) --> sensitive test; - test rules out SPec In (Specin) --> specific test; + test rules in +21
usmlecrasher  can anyone pls explain why it is not << potential false- positive results >> ??? +
almondbreeze  correct me if I'm wrong, but 'high FP (choice C)=low specificity (choice B)'. Whereas high specificity is required to rule in dz +2
almondbreeze  picked positive predictive value myself. can anyone explain why not PPV? +
williamfreakingosler  The principle @hayayah is talking about (a negative test being relied upon to reliably rule out) is negative predictive value ("NPV"). I don't see why "uncertain NPV" isn't the correct answer, particularly because NPV is predicated on the disease having the same base rate in the person(s) being tested as in the population that was characterized for the test statistic. Given that the patient has a strong family history of colon cancer, the NPV of FOBT is uncertain. Said another way, the sensitivity of a test does not change with the population, but the NPV does. The whole reason the doctor is denying FOBT is because of bayesian thinking (a priori information related to family history), and from my point of view bayesian logic is more relevant to PPV/NPV than to sensitivity, hence my confusion over why NPV isn't the right answer. +2
ibestalkinyo  I thought negative predictive value for the same reasoning +
... hayayah made a comment on nbme20/block1/q#4 (A 50-year-old man is brought to the emergency...)
 +15 
submitted by hayayah(1056)
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onlaMhte is cioxt yb two amshscim:en

rF,sti aehntlom can be aaflt ude to sit SCN ndsesrtaep sprieetpro in eht asem enramn as nltoaeh iisgopnon.

S,oedcn ni a sposerc of ni,ttxocioa it si zeitombadle ot icrfom acid via oyddehlfrmea in a opscres iaitntied by het ezmeny llooach ydehogerasedn ni teh ilv.er noealhMt is ncervdeto to lferdaeyohmd vai lcolhao renddyeehosga )A(HD dna ldderayhemfo si rnedeovct ot mrfcio dcai )(tfmraoe iva deheyadl dehonseaygdre D)AL(H.

otFeram is xtoci cubsaee it ibitihns dmanohriitlco ehrtcooycm c sexi,ado nsucgai hpyoixa at hte cllleuar ell,ev and eobamitlc dsacio,is omgan a traievy of rohte aolmtebci c.rabudnsiste

sugaplum  Good pictograph comparing methanol, alcohol, and ethylene glycol. https://wikem.org/wiki/File:Toxic_alcohol_ingestion.JPG +9
... hayayah made a comment on nbme20/block1/q#20 (An 8-year-old boy is evaluated for ventricular...)
 +15 
submitted by hayayah(1056)
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taCoonritca of eth oarat alsed to snedeacri VL orovadle ingcusa LV yprhtperoyh nad a L siax viid.otnae

hungrybox  Similarly, RV overload leads to R axis deviation. Could point to PAH. +1
... onyx made a comment on nbme20/block1/q#31 (66 yo man, cavitary lesion in right lower lobe of lung)
 +15 
submitted by onyx(41)
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A aahpdgiyoliclarr ibveils falrid-iu levle gstgessu a erptyt eargl oleisn e,nech( iyaac”)t.rvβ€œ s'htTa ont gngio to eombec oramnl istues nagi.a Sxi tnmhos nolowgilf onosrietlu fo stmpoysm oyu anc extcpe lenhagi ni hte mfor of a sr;ca tath si, ifrssoib btu onyl ni a lnsgie stpo.

masonkingcobra  Robbin's: The basic mechanisms of fibrosis are the same as those of scar formation during tissue repair. However, tissue repair typically occurs after a short-lived injurious stimulus and follows an orderly sequence of steps, whereas fibrosis is induced by persistent injurious stimuli such as infections, immunologic reactions, and other types of tissue injury. The fibrosis seen in chronic diseases such as pulmonary fibrosis is often responsible for organ dysfunction and even organ failure. +4
fatboyslim  @step1234 Yes pulmonary fibrosis occurs after liquefactive necrosis as a means of repair. Think of it as liquefactive necrosis = damage done in response to Klebsiella -> 6 months later you will see focal fibrosis in that area (scar formation) where the damage happened. +3
... hayayah made a comment on nbme20/block1/q#38 (A 9-year-old girl is brought to the physician...)
 +15 
submitted by hayayah(1056)
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iPtneat sha a gmynnaoarioparihc. sotM mmcoon ioclhdhdo rauprinatstleo t.ourm erDeidv mfro mrtnensa of kahetR pochu a(orl e)ot.rdcme tfilaccCiiaon is m.noomc eorlsCethlo lcsastyr ofdun ni tromβ€œo l-”elioki ufldi hiintw mtruo.

A csciyt sallsrpruea ssma ihwt tacsicifnaciol adn nnantcmheee of teh llwa or sdloi rsotnpio in a hicld or dscatoeeln si oltams waaysl a nia.rniaoygmparhco

yaM eb feuosdnc thwi taptiuyri aemanod thb(o acuse elaipbtomr .oeaaini)pmh

dickass  Cholesterol crystals in motor oil +
ally123  "Due to the proximity of the tumor to the hormone-producing cells of the hypothalamus and the pituitary gland, there is significant endocrine dysfunction in most children and adolescents presenting with craniopharyngioma...Among the hormone deficiencies, growth hormone deficiency is the most common and is seen in approximately 75% of children with craniopharyngioma." Source: http://campus.neurochirurgie.fr/Programme_Enseignement/_art1030/endocrinManifest.pdf +
... hayayah made a comment on nbme20/block2/q#17 (A 57-year old man has a hemoglobin concentration of...)
 +15 
submitted by hayayah(1056)
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hTis is atvrciee myaepoylhitc ra,ve cwhih is ued ot high litadeut or gnlu e.isaesd SOa2 is o,wl dan PEO is er.acsiedn

rotenAh ayw ot crpahapo hte iqtensou si linokgo at hte ooldb eras.m s'tI tptyre anrlmo n(o cgm,yaoeeatsrky on ednceiras rbmenu fo e,ttlapesl no d,ros hnniotg e,blu )ct.e A obdlo smaer fmor a CODP itapetn wlil eb anolm.r stuJ an rdiaecnes bnrmeu of BRsC due to eht ensacdrie EPO idglnea ot deiaencrs bgH.

mbourne  You shouldn't call it reactive polycythemia "vera", as polycythemia vera is a seperate disease with entirely different etiology. This is Reactive Polycythemia, or as another poster said, appropriate absolute polycythemia secondary to chronic hypoxia. +15
j44n  i jumped on myelodysplastic thinking it was PV due to the jak w mutation but you technically get elevated everything in that mutation so it would be more than just RBC's +
... sympathetikey made a comment on nbme20/block2/q#25 (A 14-year-old girl is brought to the physician...)
 +15 
submitted by sympathetikey(1245)
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otnaMtsui ni LM1T-T oln(tilMarihydoc coeednd tRAN ceiueln )1

A comomn umantoti si 323A.G4 nCa etruls ni emuilltp iilrtohcanmod efcneiiescdi and isdceotsaa r.dorsside tI is aetsiosdac ht:iw

  • otdhioilnMrac oeypaocahnhlyptme
  • tiLcca cosdsiia
  • lkerie-Sokt sposidee ASM)E(L

AEMSL si a rrea alodtoricimnh eoirrdsd nonwk to tcffae ynam ptrsa fo het ydob, aecpilleys het vsnorue tsymse adn eht iarn.b topSymms fo ASEML nudicle:

  • rRnteruce evsree eshcehada
  • cseMul saneewks pm)y(oathy
  • rngiaeH ossl
  • e-orkliStke oedeissp twhi a sslo fo csu,snonsoscei ur,ezisse dna reoht pbsmolre tgnieacff the reonuvs smeyts.

ecSoru: otidi:whLT.k-kep/s1/gip/rMii/etaTw.n

j44n  i just saw that every tissue that was affected had a high 02/aTP requirement and mixed with the lactic acid that meant she wasnt using her electron transport chain so i picked the only answer that had mitochondria in it +1
... hayayah made a comment on nbme20/block3/q#34 (A 22-year-old woman comes to the emergency...)
 +15 
submitted by hayayah(1056)
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ntioiasAnridtm of nilliPcnie ofr hisylpSi aym leda to hte eriaeehJHscmrhrxi- arnectoi srouh rtfea tntea.ertm sccOur ued to yslsi fo hecsroiepst (os it can corcu ihtw Bareilor dna opieroistpsLs sa .wlle) Teh enictaor si aredehcraictz yb erevf nda slhi.lc

eTh ailscclas oxnpaatnlie of eht heeerrmxiH rtcaenio si ttah ttetnmera lsretus ni hte nudsde thdae dna rditetcsnou fo rglea urbenms of n,epromsete ihtw eth aielrboint of epnrtio cusotprd nad t.xinso

almondbreeze  FA pg.148 +5
... neonem made a comment on nbme20/block3/q#50 (A 62-year-old man comes to the physician because of...)
 +15 
submitted by neonem(549)
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Tihs npiteta likyle ahs emso morf of prupe ootmr ureonn nlieos ro ieaseds - MUN sinelso era chrteizecaard by ,easwknes neesdacir pdee ntndoe r,lesfexe nad sicastp rpais.es ocflaBne si a -BAGBA tnaiogs ccfesiip to the nailps codr, esud ot aertt emsluc cyisist,atp dtnosyia, adn SM. AB-BGA is a rnG-tioep elpcduo ocertper ocludpe ot Gi, os oigsamn fo tish eotercrp seusac pyithaoalrieporzn fo hte nrsenuo dan ceeddaesr eeasler of tyatriecox utlte.aamg

kevin  stimulates K+ efflux (hyperpolarization) and inhibits Ca2+ influx (no vesicle release) +1
lovebug  FA 2019, 538page !! +
... hayayah made a comment on nbme20/block4/q#17 (A previously healthy 55-year-old man has recently...)
 +15 
submitted by hayayah(1056)
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Al,so yuo hdunl'sto eb esnegi egdra-nno gdamea or reeiadcsn nienr / ydenik osprnsee thwi a iyvprsoelu tyhealh tinaetp hatt ujst vepldedeo tessilane NH.T hTe dyob s'dtoen want ot carsiene irnne hewn ti has HTN. w,erHoev if ouy vaeh s,ssiento eth ydnikse afkre otu aesecub r'hetye ton eitnggt guhoen oflw nad inkth the woelh odby 'inst hte,ire os tyhe tecatvia teh RSAA mstys.e henW yuo geiv tehm na ,IE-AC teh inrne is sillt gnibe crudoepd by hte yikn,ed ti utjs ints' ngebi orvecednt to ogI-isanIenn.it

To anmliteie orhet occs:hie

  • He ash erasnecid nrine iictyvat os ouy acn ielenmita irrmyap ssontordilem.a That hsa .cin ,aredetosoln d.ce irn.en
  • No signs ro ssx fo u'ssigChn os sht'ta iltdna.eiem
  • --exsoy1yl1aBhrd iecicdyefn lwuod sxs ithw het elnigaati. udo'Y aehv ec.d nnrie cyaitvit kdeloert-lnisea(o tfcfese tlils .)reenstp
  • lEentaiss :THN dneipxael oabve
sammyj98  I like you sticking up for the kidneys, thinking they're increasing Renin for the benefit of the whole body, but lets face it, the kidneys are a couple selfish dicks who want the high blood pressure all for themselves. LeftVentricularSolidarity +4
... johnthurtjr made a comment on nbme20/block2/q#12 (An 80-year-old man with type 2 diabetes mellitus is...)
 +14 
submitted by johnthurtjr(138)
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0129AF p 375 on ltsirtaGtesnniao lbodo spylpu dna tpyiapcrseamtah initrnnaove:

  • oeFgrtu --;&tg icelca artyer, vasgu ovnantniire
  • iudgtM -;-tg& S,MA vgaus
  • utnigHd -;t&g- IMA, civepl nniarineovt
neovanilla  Don't force it out, you gotta relax and it'll come out naturally ;) +
mysteriousmantyping  Why couldn't the answer be Inferior rectal nerve since that controls the external anal sphincter? +1
draykid  @mysteriousmantyping I think this question is looking at complications of T2DM, more specifically diabetic autonomic neuropathy. Patient more than likely has diabetic gastroparesis which may explain his constipation and abdominal distension. +1
cuthbertallg0od  Pudendal nerve controls external anal sphincter (per FA), and gastroparesis wouldn't have anything to do w pelvic splanchnics but instead vagus nerve... Don't know why pudendal nerve couldn't be right if he was just clogged up from not being able to relax his sphincter anymore ---- is parasympathetic just more likely to be the issue statistically or something? +1
cuthbertallg0od  Or would losing pudendal nerve result in incontinence... Its never been clear to me if activation/inactivation opens/closes sphincters... +1
cuthbertallg0od  Just realized that says perineal... whoops +2
vivijujubebe  External sphincter is innervated by pudendal nerve, more often damaged during labor. DM patients have autonomic neuropathy with parasympathetic/sympathetic nerves more likely damaged +
... strugglebus made a comment on nbme20/block2/q#46 (A physician prescribes a newly marketed drug to 45...)
 +14 
submitted by strugglebus(163)
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I oshec tsih leloys besceau it was so amdn iccsfipe

sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +4
karljeon  I didn't choose it because it was so damn specific. :( +40
lovebug  Could anyone explain for B) for me? because I choose B).:( +2
j44n  B.) is wrong because its never been shown to show adverse effects "any offcial data linking the drug" and the fact that it's "newly marketed" +
j44n  and because its in 5/45 patients roughly 10% of the population, that might not seem like much but most of the diseases we freak out over are in 1-2% of the population, to put that into perspective if we gave this drug to every person in the US (every big pharma wet dream) with a population of 300 million... 30 million people would have this adverse event... hope that helps +
... jotajota94 made a comment on nbme20/block3/q#1 (The frequency of an autosomal recessive disease in a...)
 +14 
submitted by jotajota94(13)
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sUe eht rgeyb-WHdrnaei oeiatnuq

  1. kaTe het asureq troo of 11,00/6 nad that lwil ivge uyo eht ncfyqreue fo het vieessrec lellae = 04/.1
  2. tcCullaae teh nuefeqcyr of eth mdnaoint eellal wiht =,+p1q cwhih si p= .5.079
  3. yThe rae etgllni uoy to lutcelaac het enfcryqeu fo eth eisased raerc,ris chhwi si with eht aoqineut .p2q
  4. Thye awtn ynol teh essidae aisrercr ni hwhic ldeoetin is rt.sepne oT ltclcaaeu hsit, use eth q uaevl 14/0() adn pmlytlui yb %08 ni thsi doslhu igev oyu 2.0.0
  5. na,liFyl caclatule for 2q2 P 5(9(.270.))00= 040. = /25.1
yex  Nice! ...and we are supposed to read the stem and do all this in a minute or so? :-/ +22
charcot_bouchard  Allele frequency 1/40. so carrier freq 1/20. 80% of 1/20 is 1/25 (80/100 x 1/20) +14
dickass  Ah feck, 2pq got me +
hello_planet  A handy shortcut for Hardy-Weinberg is that you generally can assume p ~= 1 if q if fairly low. It also tends to be easier to work in fractions if the answer choices are in fractions so you don't have to bounce back and forth between fractions and decimals. So with that, you send up with 2pq = 2 * 1 * 1/50 = 2/50 = 1/25. +4
... hayayah made a comment on nbme20/block3/q#23 (A 50-year-old woman is brought to the emergency...)
 +14 
submitted by hayayah(1056)
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In rroed for a rgud ot be eraedlc yb eht kd,yien it tmsu trfis be dirfleet in eth .llgeriomu rgDsu thiw a hihg VD vahe emor fo teh gurd ni het suites ttha rea not vaalaebli ot ldrfeeti yb eht nik.dey Drgsu hwit hgih rienotp nniibgd twn'o eb eedifrlt het.eri So ouy tanw a urdg whit wol dV nda wlo nnidibg if uyo nwta it dcaeerl vai eth dyskine adn ui.ren

zevvyt  But a low VD corresponds to high Plasma Binding Concentration(FA 233, 2019). That's my main confusion with this question. +2
kevin  If it's high plasma binding, then it's low Vd. But, low VD doesn't necessarily require high plasma binding. Low Vd can simply be due to it being a large polar molecule +
... louisville made a comment on nbme20/block3/q#36 (A 4-year-old boy has had fever, abdominal cramping,...)
 +14 
submitted by louisville(12)
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ueten-lheelyMb seatdin celfa mares vleedre romeunus lunphtrseoi tb(u ton ayn nirgsoa)sm. igllaShe si lseosoclr wehn tasndei htwi yemehtnle ;lueb E olic stains lbue twih entmhlyee belu eceasub ti setfnmer cslotea.

sympathetikey  E. coli stains green (just fyi) otherwise, perfect. +13
chandlerbas  only E coli stains green, all other lactose fermenters stain purple/black (just fyi) otherwise, perfect. ;) FA144 bottom +4
dmotav  I think this is actually a separate concept – E. coli stains "metallic green" on eosin methylene blue agar, which is in the E. coli sketchy and first aid. However this question is referring to the methylene blue test on a fecal smear. From what I can gather, this test will be positive (indicated by presence of neutrophils) in cases of invasive diarrhea (i.e. shigella, salmonella, enterohemorrhagic E. coli). The test will be negative (no neutrophils) in cases of diarrhea caused by toxins (cholera, enterotoxigenic E. coli, giardia, viral diarrhea). So even though E. coli can present with fecal PMNs (if it's the enterohemorrhagic type), I guess that's less likely than shigella? source: https://www.ncbi.nlm.nih.gov/pubmed/4554412 +3
... thecatguy made a comment on nbme20/block1/q#16 (A 30-year-old woman with multiple sclerosis comes to...)
 +13 
submitted by thecatguy(16)

This is a very nitpicky question. As I see it, the 3 main concepts tested are:

  • This patient has trigeminal neuralgia (sharp, brief, episodic pain in the face), which is caused by a lesion to primary sensory fibers that carry pain sensation from the face.
  • Multiple sclerosis, which the patient has, is a demyelinating disease (i.e., it affects white matter).
  • The myelinated axons carrying pain sensation from the ipsilateral face enter the brainstem at the level of the pons and then descend (become the spinal tract of the trigeminal). These white matter fibers pass through the pons to synapse on the spinal nucleus of the trigeminal, which is in the medulla (nucleus = gray matter). (picture here). Therefore, a lesion in the white matter (i.e., plaque) in the pons could cause trigeminal neuralgia, and this phenomenon has been observed.

Above the level of the brainstem (thalamus & cerebral cortex), you have second order sensory neurons. Lesions in this part of the circuit are not generally in trigeminal neuralgia. I suppose they also want us to assume that once the spinal tract of the trigeminal enters the medulla, it's not myelinated anymore. I don't think this is completely true, but given the logic described above, pons would still be the better answer.

As people have pointed out, the primary sensory fibers carrying light touch sensation from the face synapse on the chief sensory nucleus in the pons immediately after they enter the pons. This question is not asking about those fibers though.

I got the question wrong too..

mightymito  Wow this is the best explanation yet! Thanks so much for very clearly walking us through a tricky question. +3
lovebug  @thecatguy Are.... you a professor? thank you very much :) +
... hayayah made a comment on nbme20/block1/q#46 (A 55-year-old woman comes to the physician for a...)
 +13 
submitted by hayayah(1056)
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tiN,ceo teh mste sysa "rssorepcro ni het nski"

3D lrlaloocie(fecch) ofrm sueoexpr fo kisn rutatms( )aalsbe ot nsu, noseigitn of f,his k,mli nsp.lat

D2 ga)irrl(loceeofc rfmo engsntioi fo ,ntlasp ifung, ey.tssa

ohtB eoretvcnd to -OH52 D3 o(atesrg r)ofm ni evlri and to the veitac rofm 2-51O)2,(H D3 cc)tioaril(l in nkei.dy

sympathetikey  C is the 3rd letter in the alphabet. Hence, D3 = Cholecalciferol +4
karljeon  Thanks for the explanation. The question stem made it sound like "what future step will be decreased?" Actual question: "Decreased production of which... is most LIKELY TO OCCUR in this patient?" Maybe NBME needs a grammar Nazi working for them. +8
bharatpillai  question says "decreased production of which of the following precursors in skin is most likely to occur in this patient? the answer has to be 7-dehydrocholecalciferol! +4
bharatpillai  7 dehydrocholesterol +2
brbwhat  Yeah i did the same, but then realised acc to uw flowchart 7dehydrochole.. is converted to cholecalciferol in presence of uv rays. So the decreased precursor would be cholecalciferol since we already have 7 dehydrocholecalciferol not being converted by uvrays Tho the uw chart sites both ergo and chole as dietary sources. +2
drzed  Wouldn't 7-dehydrocholesterol build up in the skin? Since UV rays convert 7-dehydrocholesterol into cholecalciferol, if you are lacking the conversion, the reactant (7-dehydrocholesterol) should accumulate. +
brbwhat  They’re asking decreased production of which of the following precursor would occur? 7 dehydrocholestrol builds up, but decreased production of cholecalciferol takes place, which is a precursor in the pathway for vitamin d formation +1
... hayayah made a comment on nbme20/block1/q#49 (A 56-year-old man comes to the physician because of...)
 +13 
submitted by hayayah(1056)
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Cesa fo elaloiricroess.rots

eHltrppyscia ssaoelcrolsroetiri esniovvl gnthckniie fo sevsel llwa yb rpplaeyshia of oshtom mucels -'okson(nini ea'pprnace)a

  • Ceecuqneson of nalmtgnia epyhnsoiretn 0t2;(/8&10g1 /w aetuc g-rdoaenn d)aeagm
  • ssletuR ni euedrcd eessvl ecbalri itwh nrngod-ae eicsamih
  • yaM ldea ot oibirdfni orcissne of teh sevesl lwal htwi ;garhmeoreh csilalyalsc sauces cteau laern rlueifa A(FR) ihwt a trcraciitcahse lbiea'e'tn-ft earaeapncp
masonkingcobra  From Robbin's: Fibromuscular dysplasia is a focal irregular thickening of the walls of medium-sized and large muscular arteries due to a combination of medial and intimal hyperplasia and fibrosis. It can manifest at any age but occurs most frequently in young women. The focal wall thickening results in luminal stenosis or can be associated with abnormal vessel spasm that reduces vascular flow; in the renal arteries, it can lead to renovascular hypertension. Between the focal segments of thickened wall, the artery often also exhibits medial attenuation; vascular outpouchings can develop in these portions of the vessel and sometimes rupture. +
asapdoc  I thought this was a weirdly worded answer. I immediately ( stupidly) crossed of fibromuscular dysplasia since it wasnt a younger women =/ +16
uslme123  I was thinking malignant nephrosclerosis ... but I guess you'd get hyperplastic arteries first -_- +
hello  The answer choice is fibromuscular HYPERplasia - I think this is different from fibromuscular DYSplasia (seen in young women); +23
yotsubato  hello is right. Fibromuscular hyperplasia is thickening of the muscular layer of the arteriole in response to chronic hypertension (as the question stem implies) +6
smc213  Fibromuscular Hyperplasia vs Dysplasia...... are supposedly the SAME thing with multiple names. Fibromuscular dysplasia, also known as fibromuscular hyperplasia, medial hyperplasia, or arterial dysplasia, is a relatively uncommon multifocal arterial disease of unknown cause, characterized by nonatherosclerotic abnormalities involving the smooth muscle, fibrous and elastic tissue, of small- to medium-sized arterial walls. http://www.medlink.com/article/fibromuscular_dysplasia +1
smc213  *sorry I had to post this because it was confusing!!!*Fibromuscular dysplasia is most common in women between the ages of 40 of and 60, but the condition can also occur in children and the elderly. The majority (more than 90%) of patients with FMD are women. However, men can also have FMD, and those who do have a higher risk of complications such as aneurysms (bulging) or dissections (tears) in the arteries. https://my.clevelandclinic.org/health/diseases/17001-fibromuscular-dysplasia-fmd +1
momina_amjad  These questions are driving me crazy- fibromuscular dysplasia/hyperplasia is the same thing, and it is NOT this presentation and it doesn't refer to arteriolosclerosis seen in malignant HTN! Is the HTN a cause, or a consequence? I read it as being the cause (uncontrolled HTN for many years) If it was the consequence, the presentation is still not classical! -_- +1
charcot_bouchard  Poor controlled HTN is the cause here +
charcot_bouchard  Also guys if u take it as Fibromuscular dysplasia resulting in RAS none of the answer choice matches +
... neovanilla made a comment on nbme20/block2/q#23 (Which of the following changes in the cardiovascular...)
 +13 
submitted by neovanilla(35)

The way I approached the question was to consider what happens 1. When you grow from a baby to a child, and 2. when you grow from a teenager to an older adult. Whatever remained true between both of them was the right answer.

Right answer: The resting BP of a newborn is 65/40 (google), while that of a 1-month old is 95/60. The average adult is higher, with the American Heart Association citing (absurdly, IMO) that "normal" is <120/<80. Nevertheless, the trend is that BP increases as we age, whether we are newborns or old people.

Wrong answers: Development of coronary atherosclerosis: Perhaps due to the American diet it can be argued that the development of atherosclerosis is almost inevitable as you become an older adult. Certainly not true as a baby --> child.

Development of mitral stenosis: Similar reasoning as coronary atherosclerosis; you MAY develop it as an adult (not nearly as common as a buildup of atherosclerotic plaques), but sure, let's say that it can happen. Not true as a baby --> child.

Increased basal heart rate: The opposite is actually true. The basal heart rate of a newborn can easily exceed 150, and that's considered normal. As we age, this heart rate goes down.

Increased cardiac muscle mass: This one was the hardest to work through. It is true that as we age from a baby --> child our heart grows in size. But if we tweak our assumption from before with the American diet, and instead put our patient on a more moderate diet, realistically his heart shouldn't increase in size too much, at least to the point of cardiomegaly.

Increased compliance of arteries: As we become older adults, the compliance of arteries decreases and stiffness increases (careful not to confuse arteries with lungs, which actually do increase in compliance as we age!)

rockodude  basically the American diet is... SAD;) +1
... usmle11a made a comment on nbme20/block3/q#19 (A 23-year-old man comes to the physician because of...)
 +13 
submitted by usmle11a(73)
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2t6w=thAecp/wmawosu/t0:/qhtYbEycvp?.kAwu-o.

syug tihs ivode spanxiel oatl

... strugglebus made a comment on nbme20/block4/q#11 (A 37-year-old man who is HIV positive comes to the...)
 +13 
submitted by strugglebus(163)
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dotcneohreMydoea/Hnod cna eadl ot -eennycoueeddp- iavdo in gnol trme .use IDAsNS oyu oals vidao eud ot aaltpir sfcnvsiefeteien in cnprituoahe iapn sa lelw sa urelc ksr.i 'sCTA are owknn ot rttea huipnatreoc aipn veyr lwel i..e( eadb,ites TAR pretah)y

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. +
... monoloco made a comment on nbme20/block4/q#17 (A previously healthy 55-year-old man has recently...)
 +13 
submitted by monoloco(132)
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As a elur of uht,bm fi you vige emosneo an CAE tionrhiib adn ehty egt a ,erbpolm htye dha narle yrtrea tssisone (lluyasu albtylaei,rl ro os we rewe ttuhag ta ruo emd s.)olhoc arboyblP sah ot do iwht sdceadeer GRF khanst ot cdeesraed inosntinegA ItIlesciv–ee irasotvooitcnnsc fo hte neeefrtf orrleeait g;&=t dadcreese odimus devrilye to amlauc neasd ;=g&t sadeircen nrein relaese.

lilyo  Vasoconstriction of the EFFERENT arteriole actually leads to increased GFR. It selective VASODILATION of the efferent arteriole effect of ACE inhibitors since they undo Angiotensin II actions. This patient already has rescued renal blood flow due to bilateral renal artery stenosis, the addition of an ACE inhibitor further decrease GFR prompting an increase in renin due to loss of negative feedback. +2
drpee  We should always expect GFR to drop a little after adding an ACE-inhibitor due to efferent arterial vasodilation. For this reason we should also expect Renin levels to rise via tubuloglomerular feedback. So it's not really the reaction to the ACE inhibitor that gives this away as RAS (which is why I got it wrong). I think what we are expected to be looking at it are lab values: Hypokalemia, and secondary hyperaldosteronism. https://www.aafp.org/afp/2017/1001/hi-res/afp20171001p453-t5.gif +
stepwarrior  ACE inhibitors would actually have the opposite effect of AT-II, and result in efferent dilation. But the actual mechanism of increased renin activity per UWorld is lack of systemic vasoconstriction by AT-II leading to blood shunting away from the kidney. +
... sympathetikey made a comment on nbme20/block4/q#26 (A 33-year-old man comes to the physician because of...)
 +13 
submitted by sympathetikey(1245)
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dooG ripucte oigwshn eht tymonaa fo eth ghhit ormf a T2 IRM rtippescvee.

4ki00-7.p0j9.-_9s27109wno7do08o307yr40gp/uhpu31787t/007ont-:5t0e9Bc0/mecy51lp50l/79ao/77//1dg5s36ta

jcmed  Was so close to picking vastus intermedius +1