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NBME 21 Answers

nbme21/Block 2/Question#29 (58.7 difficulty score)
A healthy 25-year-old man is participating in ...

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submitted by assoplasty(90),
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sFat ear tnecgeoik epxce(t dod anhic F,)A os etyh erdoucp etksneo ofr rnyege pdirotncou tyolCAe)A-c( ehrrta hatn gocs.eul fI eth snuqotie akdse ahwt eth arpyrmi coresu fo rnygee cuorpndtio was, it uodlw lslti eb cgogeyln d(an ont se,t)knoe abcusee htsi is tnhwii 24 hsuro. owervHe ftera 24 hosru eth awsnre dlcuo be oentek bisod.e ,geRarlsesd the tosiqnue esaiclyclpif adis het tp hda a eusrm gsoleuc fo 10,0 ciinniadtg taht ew rea ongolik rof shmogeint htta soprdvei a eutrssabt orf cgool.snnegsieue

Dungir sodprei of antri,svaot eturtbsass rfo eosecsgnoignuel meco fmor wot eusrcso: 1() donbwkera of ntisegxi ec,sulm ro 2() vai hdcadnio- FA gtruhoh op-oiyn.loprAC *V(inlae osla sdfee oint rooilpnyp CAo, but is not indvevol riungd vrattnioas -t&g;- see le)wbo

)(1 The teaueannvapiryl- ceylc vpdsroei thsi ui(ngelamt in cesulm + yuvretpa -g-;&t enailan g&-;t- eogs to ilrev ;--g&t sniaronintatam to ho-oketleuapatglrat &t;g-- etvraupy si sepaadert rmof mingatuel -g-&t; lunetmgai goes ot urae el,ycc arteuvpy oges no to tceaatL can also be edsu (ihts dlocu hvea eenb a rtgih resanw if it erwe diltes).

(2) Odd ihacn sAF ear laos eil,cgcgonu tbu cserati icad dopr(evdi in hte ewnasr hcoeci) ’nsit odd hnai,c so it is onyl teicngeko nda nca be erdlu ou.t

tuohhAlg nvaile d(an rehot dabhrcen a.a.) fdee noti i,oopPArol-Cyn eyht era otn udse in snrtvatiao sucbeea sorvinatat ylttcirs rseile on etapchi eugeonesolscig.n eTseh ..aa ear ont mobizteelad in eht lveir baecues teh irevl kacsl hrndacibchae-n a.a. aertsnasrfe .yemnez In risFt iAd, hocmieB co,nseti unrde Fitrnatins,/tSvaoag ni boht teh nsa“tigf ”eatts (hwhci si nithiw het ietm mrefa fo tihs qot)eins,u or teh iratonta“vs tt,”esa ohtb uitezli eicphta ncislees.engooug yM inspuotsma si htta laienv si sued diugnr gerular be,tsmomali adn otn uirgdn oresdip fo rntso.viaat

hello  I want to re-emphasize something that @assoplasty has already stated :). The Q-stem states serum glucose = 100, and the Q asks why the patient is able to maintain normoglycemia. Therefore, you can immediately eliminate choices A and C because acetoacetate and beta-hydroxybutyrate are sources of energy during ketogenesis -- ketogenesis does not provide glucose energy sources. +4  
chandlerbas  ^ this checks out: valine and isoleucine are broken down in the muscle into branched chain 2 oxo acid via branched chain aminotransferase (reversible) then the valine and isoleucine leave the muscle and swims to the liver to be acted on by branched chain 2 oxo acid DH (irreversible). So bascially the process from taking BCAA valine and isoleucine requires 2 enzymes. the first enzyme is in the muscle, and the second enzyme is in the liver (for simplification purposes --> both organs contain both enzymes but dont have the same affinity for their substrate). source: so you're right to say that the liver +4  
toxoplasmabartonella  Thank you for such a great explanation. Isn't it glutamate instead of glutamine that combines with pyruvate in muscle to yield alanine for Cahill cycle? +1  
almondbreeze  @ toxoplasmabartonella think you are right +  

submitted by hayayah(1000),
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.P 91 of AF ash a uiqck nenpalxaiot orf is!ht

laiaBycls nceo oyu'er ni a tarsvnig staet eeths'r listl atiehpc oseglieeucngsno ngoig no (sa well sa iunsg A)FF tub eht ononlesscegeigu is gcniom mfor ihparleper sitsue eatclat nad eanalin.

submitted by hello(259),
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I watn ot sheezap-meri steiogmhn htat tay@plssaso ahs eaayrld attdse .):

heT e-tQsm eatsts resmu gouecls = 010, and the Q asks hwy eth teptian si eabl to itmaainn mgo.miyorlaenc

eerefr,Tho yuo cna iidameytlme limianete iohccse A dan C eebucsa oeteaatccaet nda axhebuorrya-ydetttby rea uesorsc of nrgyee irugnd eenestgsiko -- eektsonsgie esod not eirdpvo lgscoeu gyreen u.csoesr

submitted by frimmy_11(0),
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luseMc prnteio earbsk wndo niot hte nmaio adci nailena ihwch rteesn aihCll cCyel ot ofmr sulegoc ...

volcanobuns  @frimmy_11 Why would protein break down after only 20 hours? Shouldn’t fat be the major contributor now? Also, if protein is being used, then why isn’t valine the choice? Valine is also glucogenic. +  

submitted by volcanobuns(2),
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1fiy1_rmm@ hWy dlwou einrpto rebka dnow earft ynol 20 hrs?uo oudtlhn’S atf be het mojar rcotruotinb nwo? oAsl fi ineport si eignb use,d nteh why ’sint nieavl het ?ecoich ts’I loas ouln.ceiggc

submitted by hello(259),
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leePas pleh

yWh si vaniel tcconierr?

An enlnopaaixt eowbl assy atht lnevia dluow eb eodnetvrc ot suloceg irugdn aurgerl set?aomibml

rluRaeg bitlamosme = dfe ,etsta so yhw ldwou eainlv eevn be ecntdvero to oecls?ug