nbmeanswers.com will be going offline for ~hour for some updates! we’ll be right back! --the webmaster (2:17am) ❤️
NBME 22 Answers

Block 1/Question#1
A 66-year-old man develops worsening shortness of breath and ...
Dilution of serum sodium due to ADH (vasopressin) secretion

Block 1/Question#2
A 28-year-old man has recurrent pancreatitis associated with ...
Decreasing VLDL

Block 1/Question#3
Parenterally administered cholera vaccines consisting of ...
Inability of the vaccine to elicit secretory antibody at the epithelial surface

Block 1/Question#4
A 48-year-old man begins furosemide therapy for pedal edema ...
Decreases the luminal permeability to Na+ in the collecting duct

Block 1/Question#5
A 10-month-old girl is brought to the emergency department ...
Naloxone

Block 1/Question#6
A 2-month-old boy is brought to the physician because of a ...
Human papillomavirus

Block 1/Question#7
Two patients, a 54-year-old man (Patient X) and a 76-year-old ...
Loading dose

Block 1/Question#8
A 16-year-old girl has pain and tingling in her left hand ...
Cervical rib

Block 1/Question#9
A 54-year-old man has an aneurysm in the distal portion of ...
2.4

Block 1/Question#10
A 25-year-old woman is admitted to the hospital because of ...
Streptococcus pneumoniae

Block 1/Question#11
A 6-month-old boy has recently been diagnosed with ...
Sphingomyelin degradation

Block 1/Question#12
During the first week of life, a male newborn has vomiting, ...
21-Hydroxylase

Block 1/Question#13
A 13-year-old girl is brought to the physician by her mother ...
Ask the mother to leave the room before asking the patient any questions

Block 1/Question#14
A 57-year-old woman comes to the physician because of ...
Trigeminal neuralgia

Block 1/Question#15
A 35-year-old woman has weakness and fever. When she was 25 ...
Acute myelocytic leukemia

Block 1/Question#16
An Rh-negative woman, gravida 3, para 2, has had an ...
O, Rh-negative

Block 1/Question#17
A 27-year-old man is brought to the emergency department ...
Eversion

Block 1/Question#18
A 13-year-old boy is brought to the physician for a ...
Reassurance

Block 1/Question#19
An 11-year-old boy has had pain in his right mid-thigh for 2 ...
Ewing sarcoma

Block 1/Question#20
A 49-year-old man comes to the physician because of ...
Avascular necrosis

Block 1/Question#21
A 30-year-old man comes to the physician because of a 2-day ...
Polycystin

Block 1/Question#22
A previously healthy 6-year-old boy is brought to the ...
Does anyone else in the family have an itchy rash like this?

Block 1/Question#23
A patient in the early stages of hemorrhagic shock is most ...
A weak pulse due to decreased stroke volume

Block 1/Question#24
A 48-year-old man with renal artery stenosis undergoes stent ...
Testicular artery

Block 1/Question#25
During an experiment, a 22-year-old man receives an infusion ...
Arteriolar resistance: decreased;
Capillary hydrostatic pressure: increased;
Capillary filtration rate: increased


Block 1/Question#26
A 42-year-old man comes to the physician because of a 1-month ...
Hydrochlorothiazide

Block 1/Question#27
During a clinical study, 15 patients with renal allografts ...
Azathioprine

Block 1/Question#28
A 48-year-old man comes to the physician because of fatigue, ...
Transferrin saturation and serum ferritin measurements

Block 1/Question#29
A 28-year-old man comes to the emergency department because ...
Jejunum

Block 1/Question#30
A 42-year-old woman is brought to the emergency department by ...
Temporal lobe

Block 1/Question#31
A 60-year-old woman comes to the physician because of a ...
Lung cancer

Block 1/Question#32
A 17-year-old boy is brought to the emergency department 45 ...
Hypokalemia

Block 1/Question#33
A 32-year-old woman begins to hyperventilate and then ...
Cerebral blood flow

Block 1/Question#34
A 15-year-old girl is brought to the physician by her mother ...
First-degree burn

Block 1/Question#35
A 35-year-old man is brought to the hospital after a diving ...
Alteration of the thermostatic set point

Block 1/Question#36
A 67-year-old woman comes to the physician because of a ...
Idiopathic pulmonary fibrosis

Block 1/Question#37
A 28-year-old woman is brought to the physician because of a ...
Area labeled ‘C’ (Abducens nucleus, right)

Block 1/Question#38
A newborn born at 26 weeks' gestation has respiratory ...
Dipalmitoyl lecithin

Block 1/Question#39
A 23-year-old woman develops multiple red, papulovesicular ...
Processing of antigen by Langerhans cells, leading to activation of CD4+ T cells

Block 1/Question#40
A 45-year-old man with chronic pancreatitis caused by alcohol ...
Pancrelipase

Block 1/Question#41
A 21-year-old man is brought to the emergency department 1 ...
Gender and body habitus

Block 1/Question#42
An 18-year-old woman develops sepsis after an abortion. ...
Decreased plasma fibrinogen concentration

Block 1/Question#43
A 13-year-old girl is brought to the emergency department 15 ...
C1 inhibitor

Block 1/Question#44
A 52-year-old man with a history of alcoholic cirrhosis is ...
Superior rectal

Block 1/Question#45
A 16-year-old girl is brought to the physician because of ...
Diuretics

Block 1/Question#46
A 12-year-old girl is referred to the emergency department by ...
Conversion disorder

Block 1/Question#47
A 25-year-old woman comes to the physician because of easy ...
Immune thrombocytopenic purpura

Block 1/Question#48
A 1-year-old boy is found to have an impairment of the ...
Staphylococcus aureus

Block 1/Question#49
A 17-year-old primigravid woman at 16 weeks' gestation has a ...
Azithromycin

Block 1/Question#50
A 9-year-old boy is brought to the physician by his mother ...
Protein structure

Block 2/Question#1
A 29-year-old woman is brought to the emergency department 1 ...
Avulsion of hepatic veins from the inferior vena cava

Block 2/Question#2
A 65-year-old man starts using topical fluorouracil for ...
Thymidylate synthase

Block 2/Question#3
A previously healthy 28-year-old man comes to the physician's ...
Nephrolithiasis

Block 2/Question#4
A previously healthy 60-year-old woman is admitted to the ...
Increased central venous pressure

Block 2/Question#5
A 74-year-old man with emphysema and lung cancer is brought ...
Negative nitrogen balance

Block 2/Question#6
A 52-year-old man is brought to the emergency department 1 ...
4 Months

Block 2/Question#7
A 66-year-old man comes to the physician because of a 2-month ...
Libido: decreased;
Nocturnal erections: normal


Block 2/Question#8
A 73-year-old man has difficulty urinating and frequent ...
Area labeled ‘E’

Block 2/Question#9
A 26-year-old woman develops hypotension and hemoglobinuria ...
Antibody, complement C5-9

Block 2/Question#10
A 56-year-old man with a palpable hard nodule on the prostate ...
Pelvic parasympathetic nerves

Block 2/Question#11
A 52-year-old man comes to the physician because a lump in ...
Sensation from the anterior surface of the scrotum

Block 2/Question#12
A 42-year-old woman with frequent heartburn has relief of ...
cAMP

Block 2/Question#13
A 5-year-old boy who lives on a farm has had diarrhea, ...
Yersinia enterocolitica

Block 2/Question#14
A previously healthy 12-year-old boy is brought to the ...
Glucose and sodium

Block 2/Question#15
A 62-year-old woman comes to the physician 3 days after ...
Carcinoma of the breast

Block 2/Question#16
A 60-year-old man is brought to the emergency department ...
Prostate adenocarcinoma

Block 2/Question#17
Ten healthy human subjects are given a new oral drug and ...
Phase 1

Block 2/Question#18
A 32-year-old man comes to the physician because of a 2-week ...
Reverse transcriptase

Block 2/Question#19
A 50-year-old man comes to the physician 3 days after his ...
Calcium

Block 2/Question#20
A 26-year-old nulligravid woman comes to the physician ...
Hypothalamus

Block 2/Question#21
A newborn has cyanosis, tachypnea, and retractions of the ...
Respiratory acidosis and metabolic acidosis

Block 2/Question#22
A 35-year-old man comes to the physician because of a 3-year ...
Adenylyl cyclase

Block 2/Question#23
A 32-year-old woman comes to the physician because of a 1-day ...
Reduviid bug

Block 2/Question#24
A 72-year-old man is given ketorolac for pain control after ...
Acute renal failure

Block 2/Question#25
A 37-year-old woman undergoes excision of a 1-cm, painless, ...
Angiogenesis

Block 2/Question#26
A randomized controlled trial is conducted to assess the ...
(194/2371) – (123/2365)

Block 2/Question#27
A 50-year-old man who has smoked 2 packs of cigarettes a day ...
Increased blood HCO3−

Block 2/Question#28
A 65-year-old man comes to the physician for a follow-up ...
Ulnar and tibial

Block 2/Question#29
A 79-year-old man is brought to the emergency department by ...
Insertion of transvenous pacemaker

Block 2/Question#30
A 40-year-old woman comes to the physician because of a ...
Multifactorial

Block 2/Question#31
An unimmunized 1-year-old boy is admitted to the hospital ...
Phase variation

Block 2/Question#32
A 54-year-old man who works in a delicatessen comes to the ...
Schwann cells

Block 2/Question#33
A 29-year-old woman comes to the physician because of a ...
Thyroid-stimulating hormone: decreased;
Free thyroxine: decreased;
Free triiodothyronine: increased


Block 2/Question#34
A 30-year-old man and a 24-year-old woman (indicated by the ...
1 in 600

Block 2/Question#35
A 45-year-old man with Li-Fraumeni syndrome agrees to ...
Decreased binding of RNA polymerase

Block 2/Question#36
Which of the following drug effects is the most common reason ...
Anticholinergic

Block 2/Question#37
A 63-year-old man has had progressive stiffness over the past ...
Area labeled ‘D’

Block 2/Question#38
Following a stroke, a patient is hoarse and cannot detect ...
Lateral medulla

Block 2/Question#39
A 22-year-old woman comes to the office because of a 3-day ...
Cardiomyopathy

Block 2/Question#40
A previously healthy 7-year-old girl is brought to the ...
Serum potassium concentration

Block 2/Question#41
A 12-year-old boy is swimming in a mountain stream. He is ...
Central blood volume: increased;
Serum ADH (vasopressin): decreased;
Serum atrial natriuretic peptide: increased


Block 2/Question#42
A 75-year-old woman has taken 12 over-the-counter ...
Plasma renin activity

Block 2/Question#43
A 20-year-old man comes to the physician because of tingling ...
Area labeled ‘C’

Block 2/Question#44
A 3-day-old full-term male newborn is brought to the ...
Hepatic UDP-glucuronosyltransferase activity

Block 2/Question#45
An 86-year-old man who lives in a skilled nursing care ...
Dextromethorphan

Block 2/Question#46
A 62-year-old man is being evaluated for rectal bleeding. An ...
Greater mucosal surface area

Block 2/Question#47
A 22-year-old woman who is at 16 weeks' gestation has ...
Down syndrome

Block 2/Question#48
Clostridium perfringens-α toxin affects cells and facilitates ...
Splitting lecithin to phosphorylcholine and diglyceride

Block 2/Question#49
A physician is unable to communicate "bad news" to a patient ...
Countertransference

Block 2/Question#50
An 18-month-old boy is admitted to the hospital because of ...
Tuberous sclerosis complex

Block 3/Question#1
A 35-year-old man comes to the physician because of a 6-week ...
C7 nerve root

Block 3/Question#2
A 30-year-old man is brought to the emergency department 30 ...
Increased serum angiotensin II concentration

Block 3/Question#3
An obese 45-year-old woman with type 2 diabetes mellitus, ...
Diarrhea

Block 3/Question#4
A 29-year-old woman has an inflammatory disease involving her ...
Immune complex-mediated cytotoxicity

Block 3/Question#5
A 72-year-old man with multiple myeloma agrees to participate ...
Unrearranged immunoglobulin gene

Block 3/Question#6
A 50-year-old man is admitted to the hospital because of ...
Intracellular [Na+]: increased;
Intracellular [K+]: decreased;
Intracellular [Ca2+]: increased


Block 3/Question#7
A 50-year-old man who is a college professor has had an ...
It must be difficult for you to accept this diagnosis when you feel healthy.

Block 3/Question#8
A 38-year-old man who lives at sea level flies to a mountain ...
pH: increased;
HCO3-: increased;
Volume: increased


Block 3/Question#9
Microelectrode injection of antibodies to α-actinin results ...
Area labeled ‘C’

Block 3/Question#10
A 50-year-old man comes to the physician for follow-up ...
Yes; the patient may wish to consider the money's influence on the physician's recommendation

Block 3/Question#11
A 38-year-old man with Down syndrome is brought to the ...
Contact adult protective services

Block 3/Question#12
An 82-year-old woman has been bedridden since surgical repair ...
Carboxylation of precursor proteins

Block 3/Question#13
A previously healthy 26-year-old woman comes to the physician ...
Acute retroviral infection

Block 3/Question#14
A 57-year-old woman comes to the physician 2 weeks after ...
Intercostal

Block 3/Question#15
An 18-year-old man comes to the physician 10 days after ...
C8

Block 3/Question#16
A 27-year-old woman comes to the physician because of ...
Antiphospholipid antibodies

Block 3/Question#17
A 50-year-old man with chronic gastritis is diagnosed with a ...
Helicobacter pylori

Block 3/Question#18
An 85-year-old woman is diagnosed with a fracture of the ...
Morphine is metabolized to active metabolites that accumulate

Block 3/Question#19
A 42-year-old man comes to the physician because of numbness ...
Sensory neuropathy

Block 3/Question#20
A 43-year-old man is brought to the emergency department ...
Fibularis (peroneus) brevis

Block 3/Question#21
A screening test for cancer is developed and applied to 500 ...
Data point labeled ‘A’

Block 3/Question#22
A study is conducted to assess the prevalence of hypertension ...
Chi-square test

Block 3/Question#23
A 45-year-old woman comes to the physician for a follow-up ...
25%

Block 3/Question#24
An 84-year-old woman comes to the physician because of a ...
Downregulation of E-cadherin

Block 3/Question#25
A 3-month-old girl is brought to the physician by her mother ...
Motor: normal;
Social: delayed;
Verbal and cognitive: delayed


Block 3/Question#26
A study is conducted to assess the extent of cardiac valvular ...
Type I error: No change;
Type II error: decreased


Block 3/Question#27
A 45-year-old man with poorly controlled type 2 diabetes ...
Enterococcus faecalis

Block 3/Question#28
A 12-year-old girl who recently immigrated to the USA from ...
Praziquantel

Block 3/Question#29
A 45-year-old man with end-stage renal failure is brought to ...
Bicarbonate

Block 3/Question#30
Which of the following is required for the synthesis of ...
Glutamine

Block 3/Question#31
A 35-year-old man is admitted to the hospital because he has ...
Absorption of nitrogenous products from the gastrointestinal tract

Block 3/Question#32
A 25-year-old woman comes to the physician because of a ...
Fasting insulin: increased;
Testosterone: increased;
Luteinizing hormone: increased


Block 3/Question#33
A 22-year-old man comes to the physician because of ...
47,XXY

Block 3/Question#34
The risk for hemorrhagic stroke from drug X is investigated ...
Case-control study

Block 3/Question#35
A 4-year-old boy is brought to the physician by his parents ...
Interstitial inflammation

Block 3/Question#36
A 62-year-old man comes to the physician's office for ...
Alternative treatments

Block 3/Question#37
A 35-year-old man with bronchial asthma starts taking ...
Increase in cAMP

Block 3/Question#38
A 73-year-old man comes to the physician with his wife ...
Blood pressure

Block 3/Question#39
A 52-year-old man with stable angina pectoris begins ...
Headache

Block 3/Question#40
A 49-year-old man has had the gradual onset of numbness and ...
Essential thrombocythemia

Block 3/Question#41
A 56-year-old man develops brief episodes of ventricular ...
CL x Css

Block 3/Question#42
A 62-year-old man comes to the physician for a follow-up ...
Inorganic phosphorus: increased;
Parathyroid hormone: increased;
Calcitriol: decreased


Block 3/Question#43
A 53-year-old woman shows evidence of adrenal failure. On CT ...
Autoimmune adrenalitis

Block 3/Question#44
A 35-year-old man comes to the physician because of an itchy ...
Prescribe permethrin for the patient and his family

Block 3/Question#45
A 28-year-old man who is seropositive for HIV has numerous ...
Slit-like vascular spaces with plump spindle-shaped stromal cells

Block 3/Question#46
A 54-year-old woman with hypertension and bilateral renal ...
Vasodilating prostaglandins at the afferent arteriole

Block 3/Question#47
A 10-year-old boy receives a renal transplant from a living, ...
Lymphocytes infiltrating tubular epithelium

Block 3/Question#48
A 2-year-old boy is brought to the physician because of fever ...
Bruton agammaglobulinemia

Block 3/Question#49
A 42-year-old man is brought to the emergency department ...
Dopaminergic neurons in the substantia nigra

Block 3/Question#50
A 56-year-old woman is brought to the emergency department by ...
Herpes encephalitis

Block 4/Question#1
A 2-day-old full-term female newborn suddenly develops ...
Superior mesenteric

Block 4/Question#2
Thirty minutes after taking 2 aspirin tablets for a tension ...
Acetaminophen

Block 4/Question#3
A 60-year-old man comes to the physician because of ...
Alveolar macrophage

Block 4/Question#4
A 24-year-old man who is comatose is admitted to the hospital ...
25 mL/cm H2O

Block 4/Question#5
A new virus has been isolated that causes encephalitis. The ...
Single-stranded positive-sense

Block 4/Question#6
A population of vegetarians is surveyed to investigate the ...
t-Test

Block 4/Question#7
A 27-year-old man comes to the physician for a routine ...
Ask the patient to identify the pros and cons of smoking cessation

Block 4/Question#8
A 6-year-old boy who recently emigrated from Russia is ...
Vitamin E

Block 4/Question#9
A 5-year-old boy is brought to the physician because of a ...
Interruption of erythrocyte production

Block 4/Question#10
An 81-year-old man comes to the physician for ongoing ...
Atherosclerosis

Block 4/Question#11
A 26-year-old woman comes to the physician 5 weeks after the ...
Sertraline

Block 4/Question#12
A 73-year-old woman dies 7 years after the onset of ...
Hydrocephalus ex vacuo

Block 4/Question#13
A 36-year-old woman comes to the physician because of a ...
Cytosol with translocation into the nucleus

Block 4/Question#14
In patients with adenosine deaminase deficiency, there is a ...
Ribonucleotide reductase

Block 4/Question#15
A 24-year-old woman, gravida 1, para 1, comes to the ...
Release of stored thyroid hormone from a thyroid gland infiltrated by lymphocytes

Block 4/Question#16
A 4-month-old boy is brought to the office by his parents ...
Maxillary and medial nasal prominences

Block 4/Question#17
A 62-year-old man with dyslipidemia is brought to the ...
Gemfibrozil

Block 4/Question#18
A 10-year-old girl has a slightly painful 2-mm subcutaneous ...
Granuloma

Block 4/Question#19
A 76-year-old man with a 1-month history of a pulsatile ...
Anomalous origins of multiple renal arteries to each kidney

Block 4/Question#20
During a study of symptomatic proximal deep venous ...
Open-label clinical trial

Block 4/Question#21
A previously healthy 45-year-old woman has had fever, ...
Thrombotic thrombocytopenic purpura

Block 4/Question#22
A 37-year-old man comes to the physician for a follow-up ...
Hyperplastic arteriolosclerosis

Block 4/Question#23
A 57-year-old woman comes to the office because of a 5-week ...
Autoimmune downregulation of Ca2+ channels of the presynaptic terminal

Block 4/Question#24
A 39-year-old woman with rheumatoid arthritis comes to the ...
Tumor necrosis factor-α

Block 4/Question#25
A healthy 25-year-old man eats a meal consisting of 60% ...
Fusion of an intracellular vesicle with the plasma membrane

Block 4/Question#26
A 60-year-old woman comes to the physician because of a ...
Meningioma

Block 4/Question#27
A 78-year-old man comes to the physician because of a 3-month ...
Metastatic carcinoma

Block 4/Question#28
A 48-year-old man comes to the emergency department because ...
Splenic vein

Block 4/Question#29
A 45-year-old man who is HIV positive comes to the physician ...
Disruption of the pathogen cell membrane

Block 4/Question#30
A 27-year-old man who is a construction worker is brought to ...
Splenic flexure

Block 4/Question#31
A 65-year-old man comes to the emergency department because ...
Crackles

Block 4/Question#32
A case-control study is conducted to assess the relationship ...
Cannot be determined from the data given

Block 4/Question#33
A 38-year-old single woman with a history of chronic ...
Displacement

Block 4/Question#34
A 17-year-old boy comes to the physician because of a 1-week ...
B lymphocyte

Block 4/Question#35
Nicotinic acid acts at which of the following labeled sites ...
Pathway labeled ‘C’

Block 4/Question#36
A 38-year-old man is admitted to the hospital after ...
Acute-phase response

Block 4/Question#37
A 53-year-old woman with a long history of fibromuscular ...
Tubular atrophy

Block 4/Question#38
Patients with mucolipidosis II (I-cell disease) lack the ...
Secreted from the cells

Block 4/Question#39
A 5-year-old boy is brought to the physician because of pain ...
Retinal cells

Block 4/Question#40
A 5-year-old boy with mental retardation is grossly obese and ...
Maternal origin of both chromosomes 15

Block 4/Question#41
A 65-year-old woman with a 20-year history of osteoarthritis ...
L-3 to 4

Block 4/Question#42
A 31-year-old man comes to the physician because of concerns ...
Dihydrotestosterone

Block 4/Question#43
A 44-year-old man comes to the physician because of fever and ...
Tricuspid insufficiency

Block 4/Question#44
A 10-year-old boy has bruised easily since swallowing some of ...
Prolonged prothrombin time

Block 4/Question#45
An 1814-g (4-lb) male newborn is delivered in the hospital at ...
Endodermal cells

Block 4/Question#46
A 39-year-old woman comes to the physician because of ...
Hemoglobin

Block 4/Question#47
A 56-year-old woman comes to the physician for a follow-up ...
Maintenance of basement membrane integrity

Block 4/Question#48
An 8-year-old boy is brought to the physician by his parents ...
Calorie consumption that exceeds energy expenditure

Block 4/Question#49
A 52-year-old man with metastatic oat cell carcinoma begins ...
Ensure that the patient receives enough medication to control his pain

Block 4/Question#50
A 31-year-old woman in the second trimester of pregnancy is ...
Hematopoietic stem cells

Recent comments ...

... meningitis made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +7  upvote downvote
submitted by meningitis(118)

I also thought the same as @bubbles, but now trying to "justify" this tricky NBME question: I think this revolves on the fact that the patient has a HIGH blood pressure meaning we should focus on an answer that explains both increased BP and Hypovolemia (i.e: increased ADH which vasoconstricts and also absorbs free-water, both of which increase BP and cause hypovolemia).

Maybe if this patient were decompensated with LOW BP, one could think more about ANP.

I still think this question is TOO tricky.

meningitis  Sorry, hyponatremia* right?
... bubbles made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +1  upvote downvote
submitted by bubbles(25)

This question confused me a lot because so many questions have drilled me on the importance of the ANP escape mechanism in times of fluid overload (as in CHF).

I thought ANP was a huge player in the loss of Na in circumstances of volume overload as in this patient (which is why you see euvolemic hypOnatremia in patients with SIADH or overactivity of the RAAS as in CHF).

Why is ADH now being named as the responsible agent?

jooceman739  My thinking is that ANP causes natriuresis, so you're losing salt and water at the same time (isoosmotic fluid?). Meanwhile, ADH absorbs only free water, so it would dilute the serum. Correct me if i'm wrong.
bubbles  Ohhh you are right. Thank you for the explanation! I got so fixated on that one mechanism haha.
... imgdoc made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +3  upvote downvote
submitted by imgdoc(18)

I think alot of people might have over emphasized how important ANP and BNP really are, yes it is important to know these peptides get secreted by the atrial/ventricular myocardium during heart failure. However their overall effectiveness in treating heart failure is zilch, a preceptor told me that if ANP and BNP were so useful in natriuresis then why do we give diuretics? It's because RAAS overpowers this system hence causing negative effects and the endless loop of heart failure. AKA why we give ACE inhibitors.

Knowing that ANP gets neutralized by the RAAS system, we can shift our focus back to heart failure in this patient, where cardiac output is decreased, leading to ADH secretion and finally dilutional hyponatremia.

... moloko270 made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +1  upvote downvote
submitted by moloko270(28)

https://www.ncbi.nlm.nih.gov/pubmed/7058822

"syndrome of "dilutional hypo-osmolality" in severe congestive heart failure may be caused by an inappropriately high ADH secretion in which the osmoreceptor system is dominated by nonosmolar stimuli"

hayayah  Apparently, in chronic CHF you see hyponatremia. Because CHF causes a decrease in cardiac output and circulating blood volume, which in turn triggers a compensatory response aimed at preserving blood pressure. This stimulates the body to retain both water and sodium.
seagull  i agree with Hayayah... the RAAS system is activated due to poor perfusion to the kidney due to decomp heart failure.
... dr.xx made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +1  upvote downvote
submitted by dr.xx(34)

CHF patients often display signs and symptoms of increased vasopressin secretion.

hyperfukus  if all else fails i hope i just drill this one statement in my brain and it comes out in the right way on test day thank u!!!
... fuckster made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
... nwinkelmann made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +1  upvote downvote
submitted by nwinkelmann(54)

From UpToDate: PATHOGENESIS

Like most other causes of hyponatremia, heart failure impairs the ability to excrete ingested water by increasing antidiuretic hormone levels. When cardiac output and systemic blood pressure are reduced, "hypovolemic" hormones, such as renin (with a subsequent increase in angiotensin II formation), antidiuretic hormone (ADH), and norepinephrine, respond [1-3]. Although edematous patients with heart failure have increased plasma and extracellular fluid volumes, the body perceives volume depletion (reduced effective arterial blood volume) since the low cardiac output decreases the pressure perfusing the baroreceptors in the carotid sinus and the renal afferent arteriole. The degree of neurohumoral activation is generally related to the severity of cardiac dysfunction, as assessed by left ventricular ejection fraction or functional class [2]. The neurohumoral changes limit both sodium and water excretion in an attempt to return perfusion pressure to normal. ADH release directly enhances water reabsorption in the collecting tubules, whereas angiotensin II and norepinephrine limit distal water delivery (and thereby water excretion) by lowering the glomerular filtration rate (due to a marked reduction in renal perfusion) and by increasing proximal sodium and water reabsorption [4]. In addition, both the low cardiac output and high angiotensin II levels are potent stimuli to thirst, leading to enhanced water intake.

https://www.uptodate.com/contents/hyponatremia-in-patients-with-heart-failure#H2

... fuckster made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
... fuckster made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
... lauri made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +0  upvote downvote
submitted by lauri(0)

I CANNOT VIEW THE ENTIRE QUESTION. IS THIS NORMAL?

trichotillomaniac  Hi Lauri, this is normal. We can't post the whole question due to copy right laws but you can almost always find the question you are looking for and the answer to by going to the form and then Ctrl + find -ing the age of the patient and other key words or the answer!
drdoom  HI LAURI. THANK YOU FOR DEMONSTRATING YOUR PROFICIENCY WITH ALL-CAP COMPOSITION!
... hello made a comment on nbme22/block1/q#1 (A 66-year-old man develops worsening shortness of...)
 +0  upvote downvote
submitted by hello(49)

There has to be a better explanation for why ANP is wrong?

... armymed88 made a comment on nbme22/block1/q#2 (A 28-year-old man has recurrent pancreatitis...)
 +0  upvote downvote
submitted by armymed88(13)

Shouldn't the treatment for hyperTG be a fibrates? Which would indicate the answer to be increasing HDL (FA.2017 p306)

I see decreasing VLDL as a function of niacin, which serves to decrease hepatic VLDL..

keycompany  Fibrates inhibit VLDL secretion (by inhibiting 7-a Hydroxylase) and they increase HDL. However, this patient has chronic pancreatitis, which decreases enzymes that allow for fat absorption. Because a large portion of HDL is synthesized in enterocytes from newly absorbed fat, HDL content is unlikely to increase in patients with chronic pancreatitis from any of the lipid-lowering agents. Hope this helps!
mr_haib  fibrates cause decreased VLDL as well as niacin. They increase the activity of LpL by activating PPARa causing increase catabolism of VLDL and chylomicrons. since VLDL are rich in triglycerides, this is how they decrease triglycerides.
lordxrequiem  but fibrates also decrease bile acid production by inhibiting 7alpha hydroxylase, which is how they cause increased cholesterol gallstones.
... gh889 made a comment on nbme22/block1/q#2 (A 28-year-old man has recurrent pancreatitis...)
 +3  upvote downvote
submitted by gh889(32)

The answer is due to an exception outlined here where niacin is used in pts w/o diabetes who have refractory hypertriglyceridemia at high risk or has a hx of pancreatitis.

I agree that fibrates are first line (and so does that article) but NBME was honing in on a specific exception that niacin can also be used since VLDL and TGs are high in hypertriglyceridemia.

The "clue" they had was "recurrent pancreatitis" which is supposedly a lead towards niacin.

I also put increase HDL....

wutuwantbruv  Correct, you would not want to give fibrates to someone with recurrent pancreatitis since fibrates increase the risk of cholesterol gallstones due to inhibition of cholesterol 7α-hydroxylase.
kernicterusthefrog  FYI @gh889 can't follow your link w/o an NYIT username and password, unless there's a more tech-savvy way around that.. I appreciate the info, though. Niacin rx for familial hypertriglyceridemia w/ recurrent pancreatitis. Now I know..
impostersyndromel1000  Great points, very in depth knowledge taking place here. Also, familial hypertriglyceridemia (per FA 2019 pg 94) has hepatic overproduction of VLDL so picking this would have been the easiest answer (in retrospect)
hyperfukus  @impostersyndrome1000 literally that's the ONE thing i remembered and i went YOLO lol cuz i was staring for a while
... dr.xx made a comment on nbme22/block1/q#2 (A 28-year-old man has recurrent pancreatitis...)
 -1  upvote downvote
submitted by dr.xx(34)

Fibrates decrease triglycerides by reducing the production of VLDL.

... hyperfukus made a comment on nbme22/block1/q#2 (A 28-year-old man has recurrent pancreatitis...)
 +1  upvote downvote
submitted by hyperfukus(4)

so I think if you forget actual drugs on the market that we know of and how they work, the question is purposely not asking you that specifically...If you flip it in your head to think what the problem is that leads to inc TG its because of VLDL therefore they said administering a DRUG with which of the following EFFECTS is MOST appropriate--->DECREASING VLDL b/c that's the culprit

Although drugs we know of have the other characteristics, for this guy, we would be looking for the effect of VLDL everything else is a side thing that doesn't directly address his condition

... upstairs_bumblebee made a comment on nbme22/block1/q#3 (Parenterally administered cholera vaccines...)
 +5  upvote downvote
submitted by upstairs_bumblebee(7)

The question asks about parenteral administration of the vaccine (meaning, not using the oral route). Non-oral vaccines will not strongly elicit IgA response. Non-oral vaccines not super helpful in combating a gut mucosal infection such as V. cholera, where IgA is more salient. Not sure if this is the actual correct reasoning, but it led to the right answer.

aesalmon  I totally skipped over the word "parentally" when taking this - ugh!
... biliarytree220 made a comment on nbme22/block1/q#4 (A 48-year-old man begins furosemide therapy for...)
 +0  upvote downvote
submitted by biliarytree220(5)

Should use a potassium-sparing diuretic (FA 591). Triamterene and amiloride work by blocking ENaC channels.

... just_1more made a comment on nbme22/block1/q#4 (A 48-year-old man begins furosemide therapy for...)
 +1  upvote downvote
submitted by just_1more(1)

I got that it needed to be a potassium sparing diuretic. Is there a reason it cannot be an aldosterone antagonist? I chose blocks basolateral K+ channels as these decrease the basolateral K+/Na+/ATPase because the wording of the correct answer did not make sense to me -- assuming they were going for an ENaC blocker (and that decreased luminal permeability indicates that Na+ would be remaining in the lumen, not remaining in the principal cell as I originally thought).

luckeroo  I think the reason it’s a potassium-sparing diuretic rather than an aldosterone antagonist has less to do with why the aldosterone antagonist cannot be used and more to do with the fact that a potassium-sparing diuretic would be more of a “first-line” adjunctive diuretic treatment.
luckeroo  As for the answer choice, potassium sparing diuretics achieve their overall anti-aldosterone effect by competitively inhibiting aldosterone receptors on the interstitial side (decreasing the Na/K-ATPase effect of shunting Na into the blood), thereby decreasing the gradient for sodium to enter the cell from the luminal aspect, blocking ENaC.
yotsubato  There is no such thing as "Basolateral K Channel" there is only basolateral Sodium Potassium Pumps which are controlled by aldosterone. FA pg 573
nwinkelmann  @yotsubato LOL.... why didn't I think of it that what?! (by the way, that LOL is for me). The only basolateral K channel is the nephron (based on the first aid picture) is in the thick ascending limb of the loop of henle.
hello  Spironolactone and eplerenone are potassium-sparing diurectics that inhibit the Na/K ATPase, so I'm not sure what @luckeroo is referring to. Spironolactone and aplerenone are both ALDO antagonists. Na/K ATPase is found on the basolateral membrane. None of the answer choices fit with this. Amiloride and triamterene are also potassium-sparing diuretics; their mechanism is to block ENaC channels on the luminal membrane, this is choice "B."
... hello made a comment on nbme22/block1/q#4 (A 48-year-old man begins furosemide therapy for...)
 +0  upvote downvote
submitted by hello(49)

Spironolactone and eplerenone are potassium-sparing diurectics that inhibit the Na/K ATPase. Na/K ATPase is on the basolateral membrane. None of the answer choices fit with this.

Amiloride and triamterene are also potassium-sparing diuretics. The mechanism is to block ENaC channels on the luminal membrane, this is choice "B."

... dr.xx made a comment on nbme22/block1/q#5 (A 10-month-old girl is brought to the emergency...)
 -1  upvote downvote
submitted by dr.xx(34)

Normal respiratory rate for a 10 month old > 50 breaths per minute.

Naloxone should be given in the presence of respiratory depression and may require repeated dosing.

https://www.ncbi.nlm.nih.gov/pubmed/28506439

... d_holles made a comment on nbme22/block1/q#5 (A 10-month-old girl is brought to the emergency...)
 +0  upvote downvote
submitted by d_holles(29)

This question confused me bc I thought loperamide could not cross the BBB and therefore could not cause respiratory depression (mu-opioid agonism at the brainstem results in CNS/respiratory depression, 1). But @dr.xx is correct in noting that ↓ RR and CNS depression in the Pt should call for an mu-opioid antagonist rather than bethanchol (cholinomimetic) to treat constipation.

  1. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2675905
nwinkelmann  http://medresearch.in/index.php/IJPR/article/view/782/1271 This explains a case in an infant. "Respiratory depression and coma after overdosage have been shown to be reversible by injection of naloxone [6]. Owing to its structural similarity to opioid, loperamide toxicity can be reversed by using Nalaxone which is a specific opioid antagonist acts competitively at opioid receptors. Naloxone hydrochloride is usually given intravenously for a rapid onset of action which occurs within 2 minutes."
yb_26  FA 2019: "Loperamide has poor CNS penetration" - so it still penetrates => can cause respiratory depression
whoissaad  Also maybe because the blood brain barrier in a baby is not developed as well as in an adult.
... seagull made a comment on nbme22/block1/q#6 (A 2-month-old boy is brought to the physician...)
 +0  upvote downvote
submitted by seagull(349)

True vocal cords are often damaged in singing or yelling. THis allows HPV to enter the underlying nucleated cells. HPV 16 and 18 are common subtypes that may cause SCC.

meningitis  Out of all of the virus', HPV has a predilection for stratified squamous epithelium and there is no indication of vesicles(HSV) or linear ulcers (CMV)in the question stem. But with HPV you usually get a big/small (depending on time) unilateral nodule. You are correct to say singing and yelling can cause nodules but these would be bilateral in the and would appear differently. So if a question stem could easily have included that as an option: maybe irritation or something like that.
... chosened made a comment on nbme22/block1/q#6 (A 2-month-old boy is brought to the physician...)
 +1  upvote downvote
submitted by chosened(1)

Correct me if I m wrong but I think it's laryngeal papillomatosis. Papillomas can develop anywhere along the respiratory tract, but most often affect the larynx and the vocal cords (laryngeal papillomatosis). Not sure how HY this is but heres More info: https://rarediseases.org/rare-diseases/recurrent-respiratory-papillomatosis/

hyperfukus  yes you are definitely correct i think its a common wtf q that pops up bc there's one on uworld that asks if its true or false vocal cords and i had to hunt my prof down to figure it out...
hyperfukus  also i think they love anything that compromises the airway
... keycompany made a comment on nbme22/block1/q#7 (Two patients, a 54-year-old man (Patient X) and a...)
 +1  upvote downvote
submitted by keycompany(103)

Loading Dose is the only answer that is independent of drug clearance.

nwinkelmann  I totally get this and understand it... but at the same time, couldn't loading dose differ due to renal function if patient has nephrotic syndrome so had less plasma proteins, because it would change the Vd of the drug, right? Per wiki: Volume of distribution may be increased by renal failure (due to fluid retention) and liver failure (due to altered body fluid and plasma protein binding). Conversely it may be decreased in dehydration.
... usmleuser007 made a comment on nbme22/block1/q#7 (Two patients, a 54-year-old man (Patient X) and a...)
 +0  upvote downvote
submitted by usmleuser007(84)

Someone care to explain why [time to steady-state concentration] is not the correct answer?

omerta  In pharmacokinetics, steady state refers to the situation where the overall intake of a drug is fairly in dynamic equilibrium with its elimination. In practice, it is generally considered that steady state is reached when a time of 4 to 5 times the half-life for a drug after regular dosing is started. The time to reach steady state is defined by the elimination half-life of the drug. So in a patient with renal dysfunction, the plasma half-life is going to be prolonged and the time to reach steady state will increase proportionally.
belleng  loading dose is independent of the concentration of the drug in the plasma and the dose frequency...this is why you give a patient who is seizing a huge dose of anti-seizure meds in order to reach a theraputic range on the first dose despite the high risk of toxicity and side effects...primary objective when seizing is stoping the seizure so you want to increase the dose response curve with a massive load
belleng  loading dose is independent of DOSE (should have said dose, not concentration in plasma) & FREQUENCY
... amitgrewal990 made a comment on nbme22/block1/q#7 (Two patients, a 54-year-old man (Patient X) and a...)
 +1  upvote downvote
submitted by amitgrewal990(1)

its in first aid 2019. Loading dose is unchanged in liver or renal dx. (FA 2019 pg233)

... mcl made a comment on nbme22/block1/q#8 (A 16-year-old girl has pain and tingling in her left...)
 +0  upvote downvote
submitted by mcl(167)

Homegirl got some cervical outlet syndrome and should probably take some stuff out of her backpack or get one of those lil roller ones.

mcl  Whoops, my bad, THORACIC outlet syndrome
dr.xx  Stretching, occupational and physical therapy are common non-invasive approaches used in the treatment of TOS. The cervical rib can be surgically removed.
... pparalpha made a comment on nbme22/block1/q#8 (A 16-year-old girl has pain and tingling in her left...)
 +0  upvote downvote
submitted by pparalpha(13)

According to BnB:

Cervical rib is an anomalous extra rib from the 7th cervical vertebrae. People with this are at risk for thoracic outlet syndrome (aka compression of nerves and vessels that leave the thorax. This occurs above the first rib and behind the clavicle).

Clinical features include:

1) brachial plexus injury (such as Klumpke palsy, which is a lower plexus injury)

2) Venous compression

3) Arterial compression

*An important anatomical correlate the scalene triangle (anterior scalene, middle scalene, above the first rib)

... keycompany made a comment on nbme22/block1/q#9 (A 54-year-old man has an aneurysm in the distal...)
 +10  upvote downvote
submitted by keycompany(103)

Flow Rate = Velocity x Cross-Sectional Area

2 cm^2 x 20 cm/sec x 60 sec/min x 1 L/1,000 cm^3 = 2.4 L/min

1,000 cm^3 = 1 L

seagull  Well, I missed this one. I don't even feel bad.
link981  @keycompany a small typo, 100 cm^3 = 1 L not 1000cm^3. 1000 mL^3= 1 L
hello  @keycompany how did you edit your original comment to fix your typo?
... kernicterusthefrog made a comment on nbme22/block1/q#9 (A 54-year-old man has an aneurysm in the distal...)
 +0  upvote downvote
submitted by kernicterusthefrog(17)

Just in case that lovely little equation provided by @keycompany wasn't quite enough for you, here's a link to a more complete explanation by Kahn Academy. Helped me, when I looked at the equation and said, whaaaa?

... nwinkelmann made a comment on nbme22/block1/q#9 (A 54-year-old man has an aneurysm in the distal...)
 +2  upvote downvote
submitted by nwinkelmann(54)

I've never been good at converting units :( lol so had to ask my brother. He told me that distance x distance = distance^2 = area, and distance x distance x distance = distance^2 x distance = distance^3 = volume. Gotta love public school for never been taught that... geesh (obviously I've done the equations and stuff, just never been told it that way/that simple before). Knowing that makes figuring out the equation much easier.

Flow rate = velocity x CSA = 20 cm/sec * 2cm^2 = 40cm^3/sec. To convert to L/min, just multiply: 40cm^3/sec X 60 sec/min X 1L/100cm^3 = 240 L/100 min = 2.4 L/min

Hope this helped!

impostersyndromel1000  to all my public school peeps out there (and not the nice public schools in rich areas, the real public schools)... we made it!
... seagull made a comment on nbme22/block1/q#10 (A 25-year-old woman is admitted to the hospital...)
 +0  upvote downvote
submitted by seagull(349)

Splenectomy patients are vulnerable against encapsulated organisms. Which commonly include Strep Pneumo, Niesseria, H. Influenza.

... atstillisafraud made a comment on nbme22/block1/q#11 (A 6-month-old boy has recently been diagnosed with...)
 +2  upvote downvote
submitted by atstillisafraud(39)

Niemann-Pick Disease presents with mental retardation, lipid laden (foam cells) in bone marrow and cherry red spot on macula. No sphingomyelinase results in buildup of sphingomyelin which builds up in macrophages.

meningitis  "Pick your **Big** **Foamie** **Zeibra** nose with your Sphinger" Choose options with the letter I. SpIngomyelin, Sphingomyelinase, bIgorgans (hepatomegaly etc), zeIbra bodies, Foam cells
... meningitis made a comment on nbme22/block1/q#11 (A 6-month-old boy has recently been diagnosed with...)
 +1  upvote downvote
submitted by meningitis(118)

"Pick your Big, Foamie, Zeibra nose with your Sphinger"

Choose options with the letter I.

SpIngomyelin, Sphingomyelinase, bIgorgans (hepatomegaly etc), zeIbra bodies, Foam cells

... dr.xx made a comment on nbme22/block1/q#12 (During the first week of life, a male newborn has...)
 +0  upvote downvote
submitted by dr.xx(34)

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

https://en.wikipedia.org/wiki/Congenital_adrenal_hyperplasia_due_to_21-hydroxylase_deficiency

wutuwantbruv  Can't be 17α-hydroxylase because this would present with hypertension and some sort of ambiguous sexual presentation (males) or lack of secondary sexual development (females). Can't be 11β-hydroxylase because this would present with the opposite of the kid's presentation due to the production of 11-deoxycorticosterone (similar effects to aldosterone but not nearly as potent). The other two would not really make sense since there are increased levels of 17-hydroxyprogesterone.
... wutuwantbruv made a comment on nbme22/block1/q#12 (During the first week of life, a male newborn has...)
 +1  upvote downvote
submitted by wutuwantbruv(2)

Can't be 17α-hydroxylase because this would present with hypertension and some sort of ambiguous sexual presentation (males) or lack of secondary sexual development (females). Can't be 11β-hydroxylase because this would present with the opposite of the kid's presentation due to the production of 11-deoxycorticosterone (similar effects to aldosterone but not nearly as potent). The other two would not really make sense since there are increased levels of 17-hydroxyprogesterone

... organicmechanic made a comment on nbme22/block1/q#13 (A 13-year-old girl is brought to the physician by...)
 -2  upvote downvote
submitted by organicmechanic(1)

Hereditary (or acquired) angioedema = C1 inhibitor deficiency. Patient has a 9-year Hx of soft tissue swelling, especially of the face. It's Autosomal Dominant if inherited, or can be acquired through multiple mechanisms.

https://www.ncbi.nlm.nih.gov/pubmed/11532278

dr.xx  wrong question?
... dr.xx made a comment on nbme22/block1/q#13 (A 13-year-old girl is brought to the physician by...)
 +1  upvote downvote
submitted by dr.xx(34)

During this initial encounter, we establish what the parents' concerns are, obtain a family history, and ask about previous medical problems. This begins the transition from parent to teen as the medical historian. We next ask parents to wait in the waiting room so that we can speak privately with the adolescent. We interview the adolescent alone, perform a physical examination with a chaperone, and then invite the parents back into the room at the conclusion of the visit to discuss our findings.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070800/

... atstillisafraud made a comment on nbme22/block1/q#15 (A 35-year-old woman has weakness and fever. When she...)
 +4  upvote downvote
submitted by atstillisafraud(39)

Alkylating agents (merchlorethamine) (the other drugs listed are microtubule inhibitors) increase the risk of AML.

keycompany  Additionally, AML is the only answer choice that has multiple blast forms (myeloblasts, promyelocytes, etc.). ALL is characterized by a single blast form (lymphoblasts).
seagull  CML has blasts too but they tend to favor mature forms.
kash1f  You see numerous blast forms == AML, which is characterized by >20% blasts
keycompany  The answer choices are all of lymphoid origin except for AML and Hodgkin Disease. We know Hodgkin Disease is a lymphoma (not leukemia) and would present with lymphadenoapthy. So the answer must be AML #testtakingstrategies
impostersyndromel1000  @atstillisafraud thanks for mentioning the merchlorethamine increasing risk for AML, i was trying to make a connection with the drugs but couldnt. Had to lean on the test taking skills just like key company
sweetmed  Procarbazine is alkylating as well.
... d_holles made a comment on nbme22/block1/q#15 (A 35-year-old woman has weakness and fever. When she...)
 +2  upvote downvote
submitted by d_holles(29)

Goljan stresses the Boards giving the leukemia questions away based on the age given in the question stems.

ALL = 0-14

AML = 15-39; 40-59

CLL = 60+

CML = 40-59

https://forums.studentdoctor.net/threads/goljan-on-leukemias.303605/

impostersyndromel1000  thanks for the reminder, often overlooked are the simple demographic hints. helps you make an educated guess
hyperfukus  also a key thing to remember in general is a person who undergoes chemo is a big demographic hint to later developing AML regardless of the clues :) and yes the AGE!!!
... sweetmed made a comment on nbme22/block1/q#15 (A 35-year-old woman has weakness and fever. When she...)
 +1  upvote downvote
submitted by sweetmed(27)

Procarbazine side effect is leukemia. FA 2018 page 428

... keycompany made a comment on nbme22/block1/q#16 (An Rh-negative woman, gravida 3, para 2, has had an...)
 +2  upvote downvote
submitted by keycompany(103)

O, Rh-negative blood is the universal donor for blood plasma.

keycompany  Edit:: Blood RBCs***
... usmleuser007 made a comment on nbme22/block1/q#16 (An Rh-negative woman, gravida 3, para 2, has had an...)
 +2  upvote downvote
submitted by usmleuser007(84)

Mother is Rh-neg --> she will generate RH-antibodies 1) fetus affected by Anti-Rh if it is Rh-positive 2) even if O-Rh-Positive is given, then still mother's Rh-antibodies will attack transfused blood due to its cells containing Rh+ 3) therefore, O-Rh-negative is best

... _pusheen_ made a comment on nbme22/block1/q#17 (A 27-year-old man is brought to the emergency...)
 +0  upvote downvote
submitted by _pusheen_(1)

How can you tell that the ankle fracture is eversion?

lnsetick  Because there is avulsion fracture on medial side from deltoid ligament and fibular fracture on oppostie side, this is classic for an eversion.
... seagull made a comment on nbme22/block1/q#17 (A 27-year-old man is brought to the emergency...)
 +3  upvote downvote
submitted by seagull(349)

https://singaporeosteopathy.com/2015/05/23/ankle-injuries-sprain-strains-and-fractures/

Figure 2. although figure 1 looks shockingly similar

... pitaziki made a comment on nbme22/block1/q#17 (A 27-year-old man is brought to the emergency...)
 +0  upvote downvote
submitted by pitaziki(0)

Why is the answer fibularis brevis and not fibularis tertius? How do you distinguish between the two from this vignette?

gainsgutsglory  tertius is an anterior muscle and overlays the dorsum of foot as it fans out to the toes. Does not relate to the lateral malleolus.
... moloko270 made a comment on nbme22/block1/q#18 (A 13-year-old boy is brought to the physician for a...)
 +1  upvote downvote
submitted by moloko270(28)

increased amount of estrogen compared to androgen activity is physiologic in puberty

... meningitis made a comment on nbme22/block1/q#18 (A 13-year-old boy is brought to the physician for a...)
 +3  upvote downvote
submitted by meningitis(118)

Tanner stages start at TEN years old

Stage I:

  • I is flat, as in flat chest;
  • I is alone, as in no sexual hairs.

Stage II (2): stage II starts at 11 y/o (II look like 11)

  • 2 balls (testicular enlargement)
  • 2 hairs (pubic hairs now appearing)
  • 2 breast buds form

Stage III (3): starts at 13 y/o

  • If you rotate 3, it looks like small breasts (Breast mounds form);
  • If you squiggle the III they look like curly+coarse pubic hair
  • Increased penis length and size can be represented by: II --> III
    (your penis was thin II but now its thicker III)

Stage IV (4): starts at 14 y/o

  • First imagine: The I in IV represents the thigh, and the V in IV looks like the mons pubis between your legs:
    MEANING: you have hair in mons pubis (V) but you have a border detaining the hair from growing into thighs.
  • The V is pointy, as in now the breasts are pointy (raised areola or mound on mound)

Stage V (5): 15 y/o

  • V has no borders detaining hair from growing into thighs (pubic hair + thigh hair)
  • 5 fingers(as in hands) flattening the areolas when grabbing them (areola flatten at this stage and no more "mound on mound")

meningitis  Sorry about the format, it came out wrong but I hope his helps.
drdoom  looks good to me!
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from?
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions.
endochondral1  stage 3 breast mound is for females not males btw
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females
... dr.xx made a comment on nbme22/block1/q#18 (A 13-year-old boy is brought to the physician for a...)
 +1  upvote downvote
submitted by dr.xx(34)

Pubertal gynecomastia is thought to be a physiological phenomenon, and is most commonly seen in midpuberty with Tanner stage 3–4 pubic hair and testicular volumes of 5 to 10 mL bilaterally.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706045/

... impostersyndromel1000 made a comment on nbme22/block1/q#18 (A 13-year-old boy is brought to the physician for a...)
 +0  upvote downvote
submitted by impostersyndromel1000(4)

so its reassurance bc some boys can have mild breast development at 13? I've never heard or seen this before can someone please clarify. Basically reassuring that this is (relatively) normal?

... mcl made a comment on nbme22/block1/q#19 (An 11-year-old boy has had pain in his right...)
 +0  upvote downvote
submitted by mcl(167)

Ewing sarcoma is the second most common bone malignancy in children. Histology is usually described as a small cell tumor with high N:C ratio.

praderwilli  Also the concentric layers of reactive bone sounded like "onion skin" to me!
... meningitis made a comment on nbme22/block1/q#19 (An 11-year-old boy has had pain in his right...)
 +2  upvote downvote
submitted by meningitis(118)

Ewing sarcoma cells look like small blue hypercromatic cells because they are neuroectodermal origin (PNET) and are therefore undifferentiated with high N:C ratio.

Also remember 22+11 translocation (EWS gene on chromosome 22 and the FLI-1 gene on chromosome 11)

Yeah, I thought the same @praderwilli (about the concentric layers)

... link981 made a comment on nbme22/block1/q#19 (An 11-year-old boy has had pain in his right...)
 +0  upvote downvote
submitted by link981(23)

Important to know here is location. Apart from learning the histologic descriptions (which are boring as shit), neoplasia in the diaphysis is consistent with Ewing sarcoma. Osteosarcoma location is at the Metaphysis.

... usmleuser007 made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -1  upvote downvote
submitted by usmleuser007(84)

(A) Risk factors for developing avascular necrosis include:

1) Trauma = Injuries, such as hip dislocation or fracture, can damage nearby blood vessels and reduce blood flow to bones.

2) Steroid use= Use of high-dose corticosteroids, such as prednisone, is a common cause of avascular necrosis. The reason is unknown, but one hypothesis is that corticosteroids can increase lipid levels in your blood, reducing blood flow.

3) Excessive alcohol use = Consuming several alcoholic drinks a day for several years also can cause fatty deposits to form in your blood vessels.

4) Bisphosphonate use = Long-term use of medications to increase bone density might contribute to developing osteonecrosis of the jaw. This rare complication has occurred in some people treated with high doses of these medications for cancers, such as multiple myeloma and metastatic breast cancer.

5) Certain medical treatments = Radiation therapy for cancer can weaken bone. Organ transplantation, especially kidney transplant, also is associated with avascular necrosis.

(B) Medical conditions associated with avascular necrosis include:

Pancreatitis Diabetes Gaucher's disease HIV/AIDS Systemic lupus erythematosus Sickle cell anemia

... usmleuser007 made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -2  upvote downvote
submitted by usmleuser007(84)

Causes

1) Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. Reduced blood supply can be caused by:

2) Joint or bone trauma. An injury, such as a dislocated joint, might damage nearby blood vessels. Cancer treatments involving radiation also can weaken bone and harm blood vessels.

3) Fatty deposits in blood vessels. The fat (lipids) can block small blood vessels, reducing the blood flow that feeds bones.

4) Certain diseases. Medical conditions, such as sickle cell anemia and Gaucher's disease, also can cause diminished blood flow to bone.

For about 25 percent of people with avascular necrosis, the cause of interrupted blood flow is unknown.

... fuckster made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -5  upvote downvote
submitted by fuckster(-43)

[special]

... fuckster made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -3  upvote downvote
submitted by fuckster(-43)

[special]

... meningitis made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -1  upvote downvote
submitted by meningitis(118)

I think the small dark area on the left head of femur and the darkened neck are the avascular sites.

Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg

Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg

... seagull made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -2  upvote downvote
submitted by seagull(349)

maybe someone can explain why this is avascular necrosis and not sepsis. It doesn't mention fever or absence of fever. The MRI has a small amount of hypodensity but to get avascular necrosis seems odd/

someduck3  Pg 455 of F.A. mentions that alcoholism can be a cause of avascular necrosis.
meningitis  I think the small dark area on the left head of femur and the darkened neck are the avascular sites. Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg
yotsubato  He wouldnt be playing golf if he had septic arthritis. Avascular necrosis is a more chronic condition that has a slow onset.
... aerrow3 made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 -1  upvote downvote
submitted by aerrow3(-1)

What are we supposed to be seeing on the MRI? Or do you just base it off the patient being an alcoholic with hip problems? I would’ve assumed avascular necrosis would’ve shown something on the X-ray but the x-ray showed no abnormalities so idk if the MRI is showing something?

skinnynomore  alcoholic in the hx should point you towards avascular necrosis when there is an “atraumatic” complaint
... dr.xx made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 +0  upvote downvote
submitted by dr.xx(34)

MRI is highly sensitive, specific, and accurate in the detection of AVN.

T1-weighted images: AVN most often presents with a crescentic, ring-like or well defined band of low signal within the superior portion of the subchondral femoral head bone marrow. This band is thought to represent the reactive interface between the necrotic and reparative zones, and typically extends to the subchondral plate.

http://radsource.us/avn-of-the-hip/

... warbyparker1 made a comment on nbme22/block1/q#20 (A 49-year-old man comes to the physician because of...)
 +0  upvote downvote
submitted by warbyparker1(0)

I thought it was septic arthritis bc pain with weight bearing + mri, but 2 months with septic arthritis come on, it was an easy question and I missed it.

warbyparker1  Evolution time is key
... usmleuser007 made a comment on nbme22/block1/q#21 (A 30-year-old man comes to the physician because of...)
 -1  upvote downvote
submitted by usmleuser007(84)

1) ADPKD = polycystins (PC2)

2) ARPKD = fibrocystin /polyductin (FPC) -- similar to polycystins

FPC protein is found on the primary cilia of epithelia cells of cortical and medullary collecting ducts and cholangiocytes of bile ducts

FPC interacts with ADPKD protein PC2 and may also participate in this regulation pathway of the mechanosensory function of the primary cilia, calcium signaling, and PCP.

... fuckster made a comment on nbme22/block1/q#21 (A 30-year-old man comes to the physician because of...)
 -2  upvote downvote
submitted by fuckster(-43)

[special]

... dr.xx made a comment on nbme22/block1/q#21 (A 30-year-old man comes to the physician because of...)
 +0  upvote downvote
submitted by dr.xx(34)

The most common and severe form of autosomal dominant polycystic kidney disease (ADPKD) results from mutations in PKD1, encoding polycystin-1 (PC1)..

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4348948/

yotsubato  Here we thank FA for failing us yet again. Giving us PKD1, but not polycystin. I got the question right but I just guessed it because nothing else made sense.
usmleuser007  Autosomal dominant polycystic kidney disease 1) occurs in patients with mutations in the gene (PKD1) encoding polycystin-1 (PC1). 2) PC1 is a complex polytopic membrane protein expressed in cilia that undergoes autoproteolytic cleavage at a G protein–coupled receptor proteolytic site (GPS). 3) A quarter of PKD1 mutations are missense variants, though it is not clear how these mutations promote disease. 4) GPS cleavage is required for PC1 trafficking to cilia. 5) A common feature among a subset of pathogenic missense mutations is a resulting failure of PC1 to traffic to cilia regardless of GPS cleavage. 6) Missense mutation in the gene encoding polycystin-2 (PC2) that prevented this protein from properly trafficking to cilia. 
... welpdedelp made a comment on nbme22/block1/q#22 (A previously healthy 6-year-old boy is brought to...)
 +4  upvote downvote
submitted by welpdedelp(63)

It was scabies, which is transmitted person-operon.

welpdedelp  **person-person lol
... atstillisafraud made a comment on nbme22/block1/q#23 (A patient in the early stages of hemorrhagic shock...)
 -2  upvote downvote
submitted by atstillisafraud(39)

Ambiguous question but in because it is early shock, there is not enough time to activate the RAAS to increase kidney perfusion.

... dr.xx made a comment on nbme22/block1/q#23 (A patient in the early stages of hemorrhagic shock...)
 +2  upvote downvote
submitted by dr.xx(34)

Hypovolemia is a direct loss of effective circulating blood volume leading to:

  • A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia
  • Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction
  • Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis
  • Hypothermia due to decreased perfusion and evaporation of sweat
  • Thirst and dry mouth, due to fluid depletion
  • Cold and mottled skin (Livedo reticularis), especially extremities, due to insufficient perfusion of the skin

https://en.wikipedia.org/wiki/Shock_(circulatory)

... moloko270 made a comment on nbme22/block1/q#24 (A 48-year-old man with renal artery stenosis...)
... endochondral1 made a comment on nbme22/block1/q#24 (A 48-year-old man with renal artery stenosis...)
 +0  upvote downvote
submitted by endochondral1(4)

is this question asking what we physically pass through or by?

impostersyndromel1000  no, basically the question is testing if you know the branches of the abdominal aorta and which is closest to the renal (in this case, inferior to the renal arteries)
impostersyndromel1000  what you are passing by would better answer your question actually
... atstillisafraud made a comment on nbme22/block1/q#25 (During an experiment, a 22-year-old man receives an...)
 +0  upvote downvote
submitted by atstillisafraud(39)

Histamine causes capillary arteriolar dilation (decrease resistance)(increased pressure in the capillary because efferents remain the same size) Histamine also increases capillary permeability.

... moneysacs made a comment on nbme22/block1/q#25 (During an experiment, a 22-year-old man receives an...)
 +0  upvote downvote
submitted by moneysacs(0)

Histamine causes a decrease in hydrostatic pressure (get this, it’s a vasodilator) but then causes an increase in capillary hydrostatic pressure? (Okay, this is how it causes edema, I guess.) Does anyone get how this actually works?

its_raining_jimbos  Not 100% sure on this one, but here’s how I approached it: histamine causes arterial dilation (decreased arteriolar resistance), but all of that blood has to go somewhere since you now have more blood flowing through the arteries and that somewhere is the capillaries (increased capillary hydrostatic pressure). Histamine causes increased permeability of the post-capillary venules (one of Dr. Sattar’s favorite facts) so you’d have increased capillary filtration rate.
... its_raining_jimbos made a comment on nbme22/block1/q#25 (During an experiment, a 22-year-old man receives an...)
 +3  upvote downvote
submitted by its_raining_jimbos(8)

Not 100% sure on this one, but here’s how I approached it: histamine causes arterial dilation (=decreased arteriolar resistance), but all of that blood has to go somewhere since you now have more blood flowing through the arteries and that somewhere is the capillaries (increased capillary hydrostatic pressure). Histamine causes increased permeability of the post-capillary venules (one of Dr. Sattar’s favorite facts) so you’d have increased capillary filtration rate.

... link981 made a comment on nbme22/block1/q#25 (During an experiment, a 22-year-old man receives an...)
 +2  upvote downvote
submitted by link981(23)

Histamine causes arteriole vasodilation, causing a buildup of blood in the capillaries. The increased blood in the capillaries will cause the pressure there to rise. Filtration is dependent on pressure, the higher the pressure, the more the filtration.

Remember blood flow: veins to venules to capillaries to arterioles to arteries

yb_26  agree in all, except the blood flow - it is right the opposite [https://teachmeanatomy.info/the-basics/ultrastructure/blood-vessels/]
link981  I stand corrected @yb_26. Brainfart moment 🙈
... alexb made a comment on nbme22/block1/q#25 (During an experiment, a 22-year-old man receives an...)
 +0  upvote downvote
submitted by alexb(10)

What they mean by filtration...

Fluid comprised of water and electrolytes, with a very small amount of protein and other macromolecules, normally leaves capillaries and small postcapillary venules by a process called filtration. Filtration is primarily driven by the capillary hydrostatic pressure, and the amount filtered per unit time is additionally influenced by the permeability of the vessel wall (endothelium and basement membrane). The fluid that filters into the tissue flows within the intercellular space (the interstitium) and most of it is reabsorbed at the venular end of capillaries where the hydrostatic pressure is lower. Some of the filtered fluid is taken up by lymphatic vessels and returned to the circulation.

... asapdoc made a comment on nbme22/block1/q#26 (A 42-year-old man comes to the physician because of...)
 +1  upvote downvote
submitted by asapdoc(17)

Patient has nephrogenic Diabetes Insipidus. One of the treatments is Hydrochlorthiazide.

meningitis  hydrocholorothiazide is DOC for Nephrogenic Diabetes insipidus because it paradoxically causes an increase in BP by increasing sodium absorption and thus water absorption, Pathoma explains this nicely. Also you shouldn't have chosen Desmopressin because upon fasting (fluid restriction) ADH is increased meaning ADH is being released Centrally but is not working in the kidneys at the V2 receptors of the epithelial renal cells at Collecting duct. On that note, Amiloride is used for Lithium induced nephrogenic DI.
... meningitis made a comment on nbme22/block1/q#26 (A 42-year-old man comes to the physician because of...)
 +3  upvote downvote
submitted by meningitis(118)

hydrocholorothiazide is DOC for Nephrogenic Diabetes insipidus because it paradoxically causes an increase in BP by increasing sodium absorption and thus water absorption, Pathoma explains this nicely.

Desmopressin is incorrect because upon fasting (fluid restriction) ADH is increased meaning ADH is being released Centrally but is not working in the kidneys at the V2 receptors of the epithelial renal cells at Collecting duct.

On that note, Amiloride is used for Lithium induced nephrogenic DI.

hello  Where in Pathoma? I couldn't find it.
... gh889 made a comment on nbme22/block1/q#26 (A 42-year-old man comes to the physician because of...)
 +1  upvote downvote
submitted by gh889(32)

according to uptodate thiazides cause a mild hypovolemic state thus your PCT will see more Na and H2O --> by principle that the PCT always reabsorbs 60% of what it sees, it will reabsorb more water and Na.

... link981 made a comment on nbme22/block1/q#27 (During a clinical study, 15 patients with renal...)
 +0  upvote downvote
submitted by link981(23)

Page 36 of FA 2018. Purine antagonist drugs are:

6-MP(Azathioprine is a prodrug of 6-MP), Mycophenolate, ribavirin.

sbryant6  I forgot what the MP stood for in 6-MP, so I chose methylprednisolone. Silly mistake.
... lamhtu made a comment on nbme22/block1/q#28 (A 48-year-old man comes to the physician because of...)
 +3  upvote downvote
submitted by lamhtu(25)

Hemochromatosis associated with HLA-A3, but the appropriate screening test is serum transferrin saturation and ferritin levels

... keycompany made a comment on nbme22/block1/q#28 (A 48-year-old man comes to the physician because of...)
 +2  upvote downvote
submitted by keycompany(103)

While this question stem is vague, the most likely diagnosis is Hereditary Hemochromatosis.

... usmleuser007 made a comment on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
 +0  upvote downvote
submitted by usmleuser007(84)

Intussusception is generally caused by a blockage in the GI tract caused by a tumor, polyp, diverticulum, or just immobility at part of the tract.

1) My thought was that the patient had a Meckel diverticulum yes it happens in 2 feet from the ileocecal valve; but that is in about %2 of the population

... mcl made a comment on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
 +0  upvote downvote
submitted by mcl(167)

These images are useful in combination.

... iviax94 made a comment on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
 +0  upvote downvote
submitted by iviax94(5)

CT shows mass on the left side of his abdomen and you’re told it’s intussusception. Asks which part of the GI tract is most likely to cause the pain. I immediately looked for ileocecal junction ... not an answer choice. Why is the answer jejunum (vs. duodenum)?

liverdietrying  The picture is key here. You’re right that ileocecal is most common, but ileo-ileal and jejuno-jejunal are the next most common (I think I might just know this from having done clerkships already, not sure). Ileo-ileal isn’t an answer, so that rules that out. Look at where the arrows are pointing in the picture as well. Its on the L, ruling out appendix and cecum. And the slice is not at the level of the duodenum, ruling out that answer. So by process of elimination based on the picture you could get this one too.
dr.xx  Duodeno-duodenal intussusception is a rare because of the retroperitoneal fixation of the duodenum. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529645/
... lnsetick made a comment on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
 +0  upvote downvote
submitted by lnsetick(28)

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

zelderonmorningstar  I think the small intestine narrows as you go along, so jejunum would most likely intuss into the duodenum.
yotsubato  Duodenum is fixed to the retroperitoneal wall, and also has lots of named vessels attached to it, along with the pancreaticobiliary duct and ampulla. It cant really intussuscept.
gh889  You should also know that the duodenum is almost purely on the right side of the body
... wolvarien made a comment on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
 +0  upvote downvote
submitted by wolvarien(0)

I have answered this question with this method the CT is showing a mass on the left appendix is on the right so this choice is wrong Ceacum is on the right so this choice is wrong stomach is on the middle so this choice is wrong duodenum intussusception never heard of it so the only thing left is Jejunum

... hello made a comment on nbme22/block1/q#29 (A 28-year-old man comes to the emergency department...)
 +0  upvote downvote
submitted by hello(49)

Please help - how are you able to tell that the CT image is not at the level of duodenum?

I don't know what I'm looking for to compare and contrast a CT at the level of the duodenum vs the CT given in this Q.

... moloko270 made a comment on nbme22/block1/q#30 (A 42-year-old woman is brought to the emergency...)
 +10  upvote downvote
submitted by moloko270(28)

FA p.547 - burning rubber smell hallucination occurs as an aura for temporal lobe epilepsy

.
.
.


See all comments for NBME 22 Answers (slow load)