why can't this be chronic bacterial prostatis?...ughh the gram stain and leukocytes on UA threw me off
Motor + Sensory + rapid progress :: may be R/O Acute inflammatory demyelinating polyradiculopathy
i think this was tested in a similar way in another question in this form. the patients have a right to know or not know their resuts.
MM will be induced a AL(primary amyloidosis).
Draw out your 4/4 box.
Note that prevalence does not change specificity or sensitivity and that's why you can eliminate C and D right off the bat.
so with low prevalence, you decrease the amount of people with the disease and if you write out for formulas for PPV and NPV you can see that PPV has its variable in the numerator and denominator decrease (decrease overall) while the NPV only has its numerator in the denominator decrease. i wish I could draw it out i hate typing out math
Pathoma 2018 pg. 53. Chemotherapy hurts neutrophils the most. Radiation hurts lymphocytes the most.
honestly someone explain this one to me other than the memory loss is her newest thing and needs to be evaluated. pls
Patient does NOT currently have back pain- asking for how to prevent her back pain from occuring.
Being obese is the most important risk factor in back pain and osteoarthritis (step-prep)
Secondary prevention also includes exercise therapy and education, and according to this NBME weight loss as well.
HBsAb = HBs Antibody = negative... so give the vaccine
Why it's not the other choices:
Cystic hygroma: if you see this, associate it with Turners.
Thyroglossal duct cyst: moves up and down with swallowing and doesnt cause the sx presented in this stem.
Tracheomalacia: In tracheomalacia, the cartilage of the windpipe does not develop properly in utero, leaving them weak and flaccid. The weakened walls are likely to collapse and cause an obstruction of the airway. Yes it can cause stridor but has no relation or association with maternal Graves as the cause and also doesnt present as a neck mass.
Vascular ring: occurs when the aorta or its branches form a complete ring around the trachea and the esophagus. This happens when certain parts of the aorta that normally disappear during fetal development persist abnormally. Sx are dysphagia and cough. Most sx are so mild that children who have it often go years without diagnosis. Also doesnt present as a neck mass.
A way to differentiate between a leukemoid reaction vs CML is that CML has a very low leukocyte alkaline phosphatase (LAP) as a result of low activity in malignant neutrophils, vs benign neutrophilia (leukemoid reaction) in which LAP is due to leukocyte count with neutrophilia in response to stressors (eg, infections, medications, severe hemorrhage).
Also some helpful hints is that his temperature is raised as well as his leukocyte count. So an infection from his cut.
I think "leukoclastic response" was just there to trip you up. The closest thing I could find to that term online was: Leukocytoclastic vasculitis (LCV), which refers to small blood vessel inflammation.
Leukopenia is LOW leukocyte count.
Leukoplakia is that "white plaque" you see with Bowens disease (squamous cell CA of penis) and can also be seen in vulvar CA.
Leukotrienes deal with your immune system and are synthesized and released on demand from basophils.
γ-aminobutyric acid =GABA, so not a neurotransmitter dealing with pain. deals with excitability and movement.
dopamine: think of parkinson's (too little of it) and schizophrenia (too much of it), either way doesn't deal with pain reception.
Enkephalin: related to a type of opioid receptor. It closes presynaptic Ca2+ channels, open postsynaptic K+channels and thus decreases synaptic transmission. It actually inhibits the release of ACh, norepinephrine, 5-HT, glutamate, substance P.
Serotonin: think of depression. again, doesnt deal with pain reception.
Substance P: even if you didn't know exactly what it did, you could rule out the others. you could also remember the pathophysiology of migraines: "Due to irritation of CN V, meninges, or blood vessels (release of vasoactive neuropeptides [eg, substance P, calcitonin gene-related peptide]) causing the immense pain of migraines."
For completeness sake: "Muscle nociceptors contain neuropeptides, including substance P (SP) and calcitonin-gene-related peptide (CGRP). These peptides are released when nerve endings are activated and induce local edema by dilating the local blood vessels and increasing their permeability." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696782/
also, good to know aprepitant is an anti-emetic that is Substance P antagonist. Blocks NK1(neurokinin-1) receptors in brain. yes, theres no mention of "pain" in that FA definition but Substance P got its hands in a lot of cookie jars ok
Albinism: Normal melanocyte number with DECREASED melanin production due to decreased tyrosinase activity or defective tyrosine transport. risk of skin cancer.
pressure (decubitus) ulcers
diabetic foot ulcers
venous stasis ulcers
Histamine causes endothelial contraction, this increases vascular permeability and leakage of protein-rich fluid from the postcapillary venules into the interstitial space -> increases interstitial oncotic pressure. (choice C).
Due to this it also increases capillary filtration rate, because the endothelial contracts. (choice A)
Because there is more fluid in the interstitial space, there is more lymph flow. (choice E).
FA19, pg 213
The only variable that changes with diet is the triglycerides (goljan)
The formula for total cholesterol:
We need this patient to be fasting to get an appropriate Total cholesterol level.
This one got me :( i had the right answer but i switched because i kept getting hung up on his PPI treatment (rereading the stem now, it seems he's off treatment)
but can someone explain to me what the answer would be if the guy were on a PPI and had intractible vomiting?
This was identical to the question in NBME8 - physiological splitting with inhalation - really did not even need the media for this.
Lady with mets and increased ca2+ (hypercalcemia of malignancy) at risk for cervical spine compression. She also has neurological impairment which makes her a candidate for surgery - decompress spinal cord and cervical stabilization.
I think this lady needs way more than a soft tissue collar and PT - more conservative therapy.
Mithramycin is evidently an antitumor drug used in testicular cancer
Tamoxifen therapy - treat her immediate neurological issues
I copy/pasted my Anki card. I think it's herpes instead of chancroid because chancroid is usually a single large ulcer.
Haemophilus ducreyi == chancroid
Treponema pallidum == syphilis
Chlamydia trachomatis == lymphogranuloma venereum
I totally thought this guy had Huntington's possibly.
Estrogen increases Thyroid Binding Globulin (TBG). (FA2020 - 331).
TBG binds free T4 --> increased total T4 and decreases free T4.
TSH rises to compensate for decreased free T4 to return to normal states.
Therefore in pregnancy total T4 is increased but free T4 is normal. If T4 were to be increased --> hyperthyroidism.
I got this one through the process of elimination. He has significant blood loss, which can be inferred he might be in hypovolemic shock. This would activate the sympathetic nervous system, which would contract the systemic arteriole and venous smooth muscle to shunt blood back to the heart. Secretion of renin will be increased to increase BP. ANP is the hormone that counteracts the effect of aldosterone so it would be decreased in this case.
Among these answers, only reabsorption of fluid into capillaries make sense as it would help increase the intravascular volume.
Idk but I thought of this like the B cell immunodeficiencies, most of which cause susceptibility to encapsulated organisms like S. pneumoniae.
One of the risk factors associates with any vascular repair is the detachment of the atherosclerosis plaque. It can clog and cause embolism with the histology of needle shape cholesterol cleft.
Since the obturator nerve innervate most of the adductor muscles in the hip, section it would relieve the adduction contracture.
I got this one wrong because I didn't know the difference between the area postrema and the OVLT, since both are not covered by the BBB and exposed to the contents in circulation, so I thought both can cause vomiting.
But apparently the OVLT are osmoreceptor responding to sodium content and the osmotic pressure through regulating the activity of ADH, while the area postrema is the vomiting center, responding to the visceral afferent input from CN IX and CN X.
The description match with UC. Crohn would spare the rectum, tend to affect the terminal ileum, and have non-caseating granuloma in the crypt.
Amebic dysentery caused by E.histolytica would probably present similar with bloody diarrhea, and "flask-shaped" ulcers but the hx should include some risk factors such as traveler, MSM...
Ischemic bowel disease usually associates with atherosclerosis. Commonly see in elderly.
Among these, only amphetamine is a stimulant drug. Stimulants intoxication usually characterize by mydriasis, high BP, high HR, and one way to detox is through activated charcoal. Pt may also experience paranoia which can be mistaken for schizophrenia. Another drug that has the same presentation is cocaine since they are both stimulants.
Barbiturate, benzo, and opioids characterized by respiration depression, miosis (for opioid). Marijuana intoxication with sx of hyperphagia and probably other sx but I forgot.
Nitrogen is a fundamental component of amino acids, which are the molecular building blocks of protein. Therefore, measuring nitrogen inputs and losses can be used to study protein metabolism.
Positive nitrogen balance is associated with periods of growth, hypothyroidism, tissue repair, and pregnancy. This means that the intake of nitrogen into the body is greater than the loss of nitrogen from the body, so there is an increase in the total body pool of protein.
Negative nitrogen balance is associated with burns, serious tissue injuries, fevers, hyperthyroidism, wasting diseases, and during periods of fasting. This means that the amount of nitrogen excreted from the body is greater than the amount of nitrogen ingested.
A negative nitrogen balance can be used as part of a clinical evaluation of malnutrition.
although each answer choice can be used to treat Nausea and vomiting, only ondansetron is specifically used for chemo-induced nausea and vomiting.
Question about cellular injury:
Hydropic change means swelling. Patient has a hypoxic change too.
Reversible cell injury: Decrease ATP --> Decrease activity of Ca2+ and Na+/K+ pump -->cellular swelling (earliest morphologic manifestation), mitochondrial swelling.
FA2020. pag 207
can anyone elaborate why they chose this answer?
The pt has Paget's disease of the bone aka Osteitis deformans. ISOLATED INCREASE IN ALK PHOS = PAGETS!!! always.
With the question stem saying "bruit over right posterior flank" that was the clue I used to pick renal artery stenosis. First Aid defines it as the following:
"Renal Artery Stenosis: Clinically, patients can have refractory HTN with negative family history of HTN, asymmetric renal size, epigastric/flank bruits."
I also looked at it this way: Crohn disease is T-cell mediated (noncaseating granulomas). Major factor in the promotion of granulomatous inflammation are CD4s, which you would want to inhibit.
Missense - Nucleotide substitution results in CHANGED aminoacid..like what happens on Sickle cell disease, substitution of glutamic acid with valine..
the question says requires exogenous tryptophan for growth at 42 but no at 30.. so its still partially functional,so it cant be NONSENSE.
Simple way to think about it: remember a disease that presents in the same way aka Follicular Lymphoma which has constitutively active bcl-2. aka follicular lymphoma promotes it nasty cancerous ways via decreasing cell death.
I think this is another prime example of NBME not expecting you to know every small detail but instead just answer their question straightforwardly. The question said "...involved in reproducible changes in HOX gene expression" and the only answer choice that deals with modifying gene expression is: transcription factors.
The encapsulated formulation of itraconazole has been associated with wide variability in plasma concentrations due to variability in absorption from the gastrointestinal (GI) tract.
Encapsulated itraconazole requires an acidic pH in the stomach for the proper dissolution and absorption in the duodenum (small intestine).
Proton pump inhibitor medications can increase the gastric pH and thereby decrease the dissolution of the capsule and the amount of itraconazole available for absorption from the GI tract for systemic delivery.
by:Anthony J. Busti, MD, PharmD, FNLA, FAHA
this question does not feel complete. I think the correct diagnosis is compartment syndrome. If there is tightness and pain after an operation, compartment syndrome must be considered.
Psoas muscle is located in the lower lumbar region of the spine and extends through the pelvis to the femur. This muscle works by flexing the hip joint and lifting the upper leg towards the body. The patient pain is when he flexes his leg and difficulty/pain when trying to stand in a fully upright posture...also, the question says the infection spread from the lumbar spine ... only flexor in the answer choices is the psoas muscle.
HSV identification FA20. 166 Tzanck smear - Multinucleated giant cel, but PCR is the test of choice. Picture here https://healthjade.net/tzanck-test/
CAUSES OF LEFT AXIS DEVIATION:
Left ventricular hypertrophy, Left BBB, Inferior MI,WPW syndrome (accessory pathway in the left side), Left anterior block..
Question asks about the cause of the enlargement of Lymph nodes .. Lymph node Paracortex enlarges in an extreme cellular immune response (paracortical hyperplasia) against virus infected cells (FA20.Pag 96.) T cells regulate cell- mediate immunity ... CD4 T cells specifically is the DIRECT Cell Immunne response. CD8 T cell is cytotoxic.
this question is asking about mechanism of resistance of Acyclovir, famciclovir, valacyclovir. They are Monophosphorylated by HSV/VZV thymidine kinase. Clinical use: HSV and VZV. Mechanism of resistance: Mutated viral thymidine kinase
Unless there is a contraindication because of the ascites, it would be an exploratory laparoscopy not a laparotomy. I took flak on GYN-Onc for saying the wrong one
This is not correct. While atropine is the correct answer to manage organophosphate poisoning, it is more appropriate to stop the seizure immediately. Benzos should be given initially in the presence of seizure with atropine and 2-pam for management of poisoning
The question stem is describing a pt with Multiple Sclerosis. INO is HIGHLY associated with that. Then if you follow the rule of 4's, you know that the MLF is medial and ipsilateral to the affected side. Thus, it must be the medial right structure.
ok i think i got it hmmhmm credit to old dirtyusmle video that got deleted. his mneumonic only went up to 12 months
people don't put up mneumonics anymore- here's one from the dirtyusmle video before he took it down and never put it back up - ill put it down as a subcomment to this comment
This one got me :[ i was looking for the LH>FSH and the ovarian masses - but other than that i agree this pretty much matches up.
Man I don't know what I was thinkin - i was between glucagon and insulin and then the panic set in. If you have high glucose (in the setting of diabetes) then you're going to suppress the hormone that releases more sugar and increase the hormone that will store more sugar.
Wtf, Wells Criteria for DVT says always do confirmation thru US/D-Dimer before treating...
Can someone explain the correlation between 450 mOsmol/day and needing to excrete 1 L of water? Thanks
could someone please explain why increased static lung compliance is wrong
Kicking myself rn for getting this wrong, but here's how to think of this (for anyone who needs a step-by-step approach instead of a page number):
(1) Heparin inhibits Factor IIa, and factors Xa by potentiating Antithrombin III---more specifically, it binds up Factor IIa (thrombin) and prevents it from activating fibrinogen into fibrin; it also binds up Factor Xa (which indirectly also decreases the formation of IIa)
(2) The fact that they threw in Warfarin in the question stem is a distractor. Warfarin's effects typically take a while for them to be seen, which is evidenced by the fact that the PT & INR are normal in this case--even after 24 hours post-warfarin administration
(3) This means the effects of the Heparin are still going on, which could only mean that factor IIa is still being inhibited by ATIII and thus, hella low = PTT is prolonged
theres a zanki card in the GI deck from costanzo showing luminal side H+/dipeptide and H+/tripeptide co-transporters. Then inside the intestinal mucosa, the di and tripeptides are broken down into amino acids where a basal side transporter puts them into the blood stream
Heres a link showing that:
can someone please explain this answer :D
I understand why K+ is increased. But why isn't chloride also increased? This is a metabolic acidosis, so bicarb will be low and H+ will be high. You need an ion to balance charges --> increased chloride?
I-cell trafficking disease: Failure Golgi to phosphorylate mannose residues so, decrease mannose 6 phosphate: coarse facial features, restricted joint movements, high plasma levels of lysosomal enzymes.
During end-life care, priority is given to improving the patient's comfort. FA20-pg272
Can someone help me out? I chose E.Coli too, and I'm too thick to understand the comments here. The question said fecal smear not special agar culture dishes...why are we talking about stain colors? and why would methylene blue stained fecal smear show no organism? I thought methylene blue stains just about any cells that has DNA/RNA. If the question is trying to tell us that there were NO ORGANISMS seen in the smear, why would Shigella not be seen? Is it because Shigella invades cells and considered more intracellular than E.Coli?
-Few data shows that antibiotics (ABs) are helpful in treating Salmonella gastroenteritis (as it may prolong the illness). It is difficult to treat because of lots of antibiotic resistance. ABs are used in severely ill patients only. ABs are not of benefit in uncomplicated cases. In fact, ABs may prolong the period in which you carry the bacteria and can infect others, and they can increase your risk of relapse. Side note: Anti peristalsis med like loperamide are contraindicated.
-For typhoid fever, some people take ceftriaxone, fluoroquinolones.
-In comparison, Shigella is kinda sweet in this matter that ABs ingestion improves symptoms, reduces shedding in the stool so others won't get sick and hence can limit spread.
[Salmonella and ABs treatment outcome] (https://www.mayoclinic.org/diseases-conditions/salmonella/diagnosis-treatment/drc-20355335)
Vitals and need to be treated first, so atropine and then pralidoxime.
RIP I’m not descrambling this link
Important note that organophosphate becomes irreversible at a certain point so pralidoxime does still need to be given early
Cool and pale extremities rules out distributive causes (neurogenic, anaphylaxis, septic).
Hypovolemia would describe a process of volume loss bleeding (or dehydration) and would not explain the crackles or jugular venous distention.
Don’t be thrown off by the normal heart sounds. I am getting real good at this descrambling thing.
He has a down and out pupil caused by CN III palsy. His gaze is due to opposed action of the lateral rectus and superior oblique; ptosis due to denervation of levator palpebrae superious.
The only injury listed that could cause a CN III palsy is aneurysm of the PCA compressing the occulomotor nucleus.
Diagnosis: strawberry hemangioma
Heme = blood -ang- = vessel -oma = benign mass
A benign tumor of capillaries, therefore the origin is endothelium
Why not Multiple renal artery aneurysms? I was thrown off by the description of hyperplastic arteriolosclerosis and so I went with this choice. I thought hyperplastic arteriolosclerosis may lead to fibrinoid necrosis of the vessel wall with hemorrhage.
DMD->Deleted dystrophin, Dystrophin helps anchor muscle fibers, primarily in skeletal and cardiac muscle. It connects the intracellular cytoskeleton(actin) to transmembrane proteins α and β-dystroglycan, which are connected to the extracellular matrix.
NAPQI is a toxic intermediate is formed by in small amounts by metabolism of acetaminophen. Depletion of hepatic glutathione stores by NAPQI leads to acute APAP(?) toxicity and acute liver injury.
Acute MI and mitral regurg from the murmur leads to LV failure and backflow of blood into the lungs.
This leads to increased pulmonary hydrostatic capillary pressure. This will lead to excess volume leaking from the pulmonary capillaries into the interstitial and this will manifest as pulmonary edema (crackles).
Pulmonary edema will interfere with gas exchange leading to hypoxemia.
Classic myasthenia gravis picture. Worsens with use. Sx include diplopia improvement with AChE
Also side note don’t focus on the pregnancy status but women who are in the postpartum period are at particularly high risk of developing myasthenia gravis
Strep Viridans is oral flora causes subacute endocarditis affecting previously damaged valves, and is often associated with sequelae of dental procedure.
A) Enterococci can also cause subacute endocarditis but they are gamma hemolytic and follow GG/UI procedure B) beta hemolysis causes acute beta hemolysis and i got too lazy to unscramble the rest i dont think it even addresses my question
T-cells are necessary to kill virally-infected cells, especially cytotoxic T-cells.
Kill virus infected, neoplastic and donor graft cells by inducing apoptosis. Cytotoxic T cells have CD8, which binds to MHC I on virus-infected cells FA2019 pg 102
the way I approached this was that the patient has intact vibration sense but has lost sensation to pinprick. if the lesion was in the dorsal root ganglia (a) or dorsal horn (b) or dorsal root afferents (d), the sensory loss would be more widespread than loss of one modality.
There is no thymus = DiGeorge
Think back to Step 1 embryology (thymus forms from third and fourth pharyngeal pouches)
Pheochromocytomas can present with NF1, RET gene (MEN2), and VHL
Give benzo for acute panic attack symptoms
This woman has scurvy (vitamin C deficiency) as evidenced by her bleeding gums and perifollicular hemorrhages
This is common in older people who may not have the proper nutrients
Do not be tricked by using allopurinol during acute gout attack...it should be use as prophylaxis
During acute attack use NSAID (like indomethacin)
This patient has gestational trophoblastic disease as evidenced by the extreme B-hCG concentration below 20 weeks gestation, no fetal heart sounds, large uterus, and the round densities in lung + shortness of breath
This patient has a pheochromocytoma = adrenal gland tumor
I believe that this is an ovarian cyst...recheck at different point in cycle
Using the paralytic agents for a large chunk of patients in the lorazepam group and then basing the effectiveness on movement during anesthesia = confounding variable
Radiation sickness: Potassium iodide is effective in four ways:
(a) by diluting the entering iodide pool (b) by saturating the iodide transport system (c) by blocking organification of iodide and thus inhibiting thyroid hormone synthesis (the Wolff-Chaikoff effect) (d) by promoting excretion and thus lowering the total body dose
ACE/ARB therapy for patients with diabetes to prohibit diabetic nephropathy
Malabsorption of fat soluble vitamins (seem like the patient has celiac disease or perhaps a pancreatic issue) Low calcium = Vitamin D deficiency
Itching, white thin vulva, and absent labia minora should clue you in to lichen sclerosis Plus the patient age
Sickle cell = hemolysis MCV > 100 Needs more folic acid supplementation to correct the anemia
Muddy brown casts = acute tubular necrosis
Pretty straightforward..do thoracentesis to evaluate the effusion
He has CHF so look for the transudative effusion.. low protein, leukocyte count, normal glucose
Immunocompromised (undergoing chemo for Hodgkin disease) + the x-ray presentation (diffuse pattern) = best choice is pneumocystis jiroveci
Patient has symptoms of SIADH = low Na, which presents with small cell carcinoma of the lung
Screen patients who have symptoms of depression ("future appears bleak, too tired to think about it") for suicidal feelings
Pain over the sternum, low BP, and high PCWP... myocardial contusion because heart cannot properly pump blood PCWP increases when LR is added.. further localizes the problem to the heart
Hemolytic disease of the newborn.. happens when a Rh - mother is exposed to Rh + child Hints here include that this is her second child, and that she did not have prenatal care...probably meaning that she did not receive RhoGam Ignore the ABO, look for negative mother with positive child :)
Note: ABO incompatibility can also cause some symptoms of hemolysis but differences include way more mild presentation and also can be seen in first child (O mother with child anything other than O)