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Welcome to alexxxx30’s page.
Contributor score: 50


Comments ...

 +14  (nbme23#17)

did anyone else have to reread this question several times? The jumping back and forth from "this happened before, 1 week after, 6 weeks after" then this happened today, then" this happened 6 weeks postop" gave me whiplash. Tell the story in order! haha

confidenceinterval  RIP anyone with a learning disability. I honestly think someone tried really hard to write something this confusing. +1
faus305  Quentin Tarantino wrote this one +

 +4  (nbme23#1)

also the word annular was supposed to be very helpful (it means ring shaped)...however my dumbo self didn't know this. Would have lead me directly to ring worm tinea





Subcomments ...

submitted by lsmarshall(417),
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yrnoSinvetabp is eth eratgt fo stnpiaseaotnm tanetus( ;xi)not lmuces samssp rea retac.aciitcsrh nyOl ehort rnwase you migth cenrsdoi is Actecrsolatihseeenly scnei he is a emrfar nad sdzzrwobu tnefo carry su ot eht dmipeors n.l.ad. but tsmpomsy of a helirgcinco rtoms rae .atnseb

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +45  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +46  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +37  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +3  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  
flvent2120  I'm not even mad I got this wrong +  


submitted by dbg(152),
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mA I eht lnoy one woh hhtu,otg ym hwoel e,fil thta ti ycltlaua ginsaritoe omfr eht dyihort utb juts cayisplyhl ncedntceo ot eth oegunt

nbmehelp  same +14  
medguru2295  me! I went with submandibular gland bc I thought there was a gland under there. +  
alexxxx30  nope...i definitely thought the same thing...when I clicked thyroid I was like wow that was an easy question. HA +1  


submitted by medstruggle(12),
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hyW is it nto aoarniv llolefic lcesl? I touthhg hte lmfaee gaolna fo eiSltor nad yigeLd si t/ulsaeogancrah ls.cel

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +11  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +4  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +11  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +3  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +38  
mcl  But seriously though, pathology outlines says sertoli-leydig tumor "may be suspected clinically in a young patient presenting with a combination of virilization, elevated testosterone levels and ovarian / pelvic mass on imaging studies." As for follicle cell tumors, granulosa cell tumors usually occur in adults and would cause elevated levels of estrogens. Theca cell tumor would also primarily produce estrogens. Putting the links at the end since idk if they're gonna turn out right lol Link pathology outlines for sertoli leydig granulosa cell tumor theca cell tumor +12  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +5  
medpsychosis  So after doing some intense research, UPtoDate, PubMed, an intense literature review on the topic I have come to the final conclusion that...... ...... ...... ...... Wait for it.... ..... ..... Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +9  
charcot_bouchard  Hello, i just want to add that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
giggidy  Hold up, so I'm confused - I read all the posts above but I still am unsure - are sertoli-leydig cells notorious for producing androgen? +4  
subclaviansteele  Hold the phone.....Females can get sertoli leydig cell tumors which are notorious for producing androgen? TIL TL;DR - Females can get sertoli leydig cell tumors = high androgens +  
cinnapie  I just found a recent study on PubMed saying "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +2  
youssefa  Hahahahaha ya'll just bored +9  
water  Bored? you wouldn't think so if you knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
nbmehelp  I dont get it +  
redvelvet  how don't you get it that females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen? +1  
drmomo  what if this means..... females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen +  
sunshinesweetheart  hahahaha this made my day #futurephysicians #lowkeyidiots +  
sunshinesweetheart  @medstruggle look up placental aromatase deficiency (p. 625 FA 2019), it would have a different presentation +  
deathbystep1  i am sure i would ace STEP 1 if i only knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
noplanb  Wait... I might actually never forget this now lol +3  
drmohandes  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +1  
lilmonkey  Don't forget that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! You're welcome! +  
drpatinoire  Now I get it that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens. Thank you very much.. So why choose Sertoli-Leydig cell tumor again? +  
dr_ligma  The reason is because females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! This is easy to remember, as you can remember it through the simple mnemonic "FCGSLCTWANFPLOA" which stands for "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen!" +18  
minion7  after receiving a f*king score..... this post made me smile and thanks to the statement-- females can get sertoli-leydig cell tumours, which are notorious for producing lots of androgen! +1  
djtallahassee  My worthless self put adrenal zona fasciculate but now I will never forget that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
medguru2295  Wait..... so can females get Sertoli Leydig cells that produce androgens then?????? +  
peqmd  Going to snapshot this to my anki deck card: "females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of {{c1::androgens}}" +1  
paperbackwriter  Watch me f*ck up the fact that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgens on the real deal. +2  
alexxxx30  just made sure to add to my notes "Females can get sertoli leydig cell tumors, which are notorious for producing lots of androgens" +2  
peridot  I also just wanna add that if you look on in FA on p.696969, you'll see that they'll mention "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +  
mbate4  According to the literature [lol] females can get sertoli-leydig cell tumors, which are notorious for producing lots of antigens +  
drdoom  the tradition lives on +1  
jamaicabliz  Wait... so for clarification, is it that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen? Or that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen?? HELP +  
abkapoor  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen sorry for bad Englesh +  
faus305  Sertoli-leydig cells are notorious for producing lots of androgens, females can get these. +  
djeffs1  the fact that a bunch of medstudents can get so weird about how females can get sertoli-leydig cell tumors: notorious for producing lots of androgens- just made my week!! I love you guys +  


submitted by hayayah(1081),
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eH hsa celfa noinectnenic os hsi axlntere ecnristph si megda,ad hcwih si tdarnnivee yb hte adnuplde .n ).S-(S42 The vilpec ncpnacilsh env,rse ihhcw iemteda het erecnito seoc,rps ear osal -2S.4S

thomasburton  Why could this not be dysuria? +3  
lilyo  I think that you are thinking about urinary incontinence. If we damage the pudendal nerve S2-S4, you can exhibit urinary and fecal incontinence since this nerve innervates both the urethral and the external anal sphincters. However since the pelvic splanchnic nerves also have roots that originate in S2-S4 a patient with pudendal nerve damage will also have impotence since these control the erection reflex. He wouldn't have dysuria which is painful urination. Most likely caused by a urethral infection or a blockade of the urinary tract. He would have urinary incontinence. I hope this helps. +16  
alexxxx30  dysuria is painful urination...if it said urinary incontinence then you'd be right. But decreased innervation wouldn't cause pain (that would mores be associated with UTI) +3  
peqmd  Another approach is fecal incontinence => parasympathetic nerve dysfunction => no boner +  
dul071  ahhhhh fucked up with terminology again thinking dysuria was urinary incontinence +  


S2,3,4 keeps the 3 P's off the floor (Penis, Poo, and Pee)

alexxxx30  love it +1  
prolific_pygophilic  A true scholar +3  


submitted by cbrodo(61),
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ehT rportseio unlmcos liF(cacsusu ssaFulnscecuiuut/ca r)iliacgs crrya irfonntioam ot het rinba igradengr oonrpcrieptiop, rvito,anbi entcviimsdiria houtc nda rpesrsue. ilycsPha xmae idgfsnin tsusgge a siloen erhe (eth thmipaolacnis artct rrsieca ippknanrpc/ii adn ea,eutmreprt dan hsete ewer mo)al.nr niSec teh nipeatt sha rboaalmn nfgiinds in teh lwore ttei,eesmrxi nad ralmno fninisgd ni eth euppr r,emxitseiet het eanrsw si ucuacisFsl s.rlaigci hsTi is easucbe iitrafnonom form odby eraas eoblw eth eelvl fo 6T is rreiacd by gscialir dna iinraomtonf mfor oydb seara evabo eht lvele fo 6T is rceradi yb nuascute.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +4  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  


submitted by cbrodo(61),
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eTh otesrpior lnmcuso suac(Fucsil antclsuiuaFusu/csce iglicsar) yarrc fninomoatri to the abnir garniedgr otrceppip,rooin naib,tvrio triidsmiecianv hcuot dna peruress. aPiylshc xmea iinfsdgn geugsst a nolsie eehr teh( nliohmpaitcas rctat erascri niank/ipircpp nad rettaeur,emp adn eesht wree )orln.ma ncSei the ttiaenp sha ralnmboa snnfdgii in eht rlweo mti,ieeetxsr nda oramnl isnfngid ni hte pepru iiet,mteesrx hte aernws si scicuaFuls ric.salig iThs is seaecbu tfniniaroom mrof ydbo aresa oeblw teh elelv fo T6 is crraeid by raiisglc and nirtmfooina ormf body saera bovea teh elvle fo T6 si dcraier by ceaunuts.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +4  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  


submitted by yotsubato(1041),
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oS orf Cadandi we anc sue

elozsA a()fzeonlcluo hbiiti(n 5C0PY4 ioemyhl)tednta

tpohAnircme B rp(eo tonmirfoa ni ngflau llec eaermnm)b

upfngiCsnoa p(vtreen crsilnniogsk fo btae ucsalgn ni llce a)llw

or nyisaNt fro lrao or ahgoplease cessa re(po foorn)tami

Tihs qsuiotne si siynag hatt hes si gkaitn an AROL ugrd to aertt aandicd stainig.iv

pceArothnmi si IV

nsupCiofgna is slao VI

so w'eer letf ihwt lzeaos

zleosA itinhbi sysesnthi fo tslrergeoo yb ginihinbit PCY 054 tath rstovecn eornstlalo ot rsotrol.gee

qball  Nystatin does treat vaginal candidiasis but is TOPICAL. +1  
thotcandy  Nystatin is NOT for esophageal candidiasis, Swish and spit, not swallow. +2  
staghorn  Me - picks Metronidazole -_- +1  
alexxxx30  @thotcandy...actually you can swish and swallow nystatin for esophageal infections (per Sketchy micro candida sketch) +5  
turtlepenlight  I have seen that on the wards so I hope it works! +  
fexx  and my smartass picks amphp B +2  
avocadotoast  Please no one give a poor girl with a yeast infection amphoterrible +2  


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dDi aonnye else go wdon e:ht se'sh tseoiphvney so ebamy elhl's get searuwtheo enidcrhirsef onmeydrs caueebs oninthg lees si kmgani esnes ot em at tish ton??ip? uoret -

sunrT otu, evsree aalmair nca ecaus cdovlisacuraar lopacles nad .hnoointesyp

redvelvet  me too :( +1  
abigail  me three :( +1  
yex  Me four :-/ +1  
link981  Slowly raising my hand as well +1  
tinydoc  Sammmme +1  
bullshitusmle  same here!!!:@ +1  
usmlecharserssss  patient has malaria with obvious picture and clinic, i answered because only thing associated with liver was hypoglycemia +12  
aisel1787  me five( +  
myoclonictonicbionic  I was thinking that she is hypotensive which can cause an infarct of the pituitary (since pituitary is growing during pregnancy) and therefore she'd have secondary adrenal insufficiency. +1  
alexxxx30  sammmeeeee +  
snripper  Dumbasses unite lmao +  
usmleaspirant2020  lol saaaaame! +  
usmleaspirant2020  lol saaaaame! +  
anechakfspb  me also :/ sitting there trying to figure it out during the test I thought I was so smart too - like "wow nbme, way to tie in micro and endocrine, not getting me though!" ... i was wrong. +1  


What is the area labeled 'G' and 'C'? And more characters?

alexxxx30  lateral corticospinal i think +3  


submitted by nwinkelmann(297),
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oS shit iountqes swa iesthgnom I rleyla relgdtusg thw.i I idn'td irzenegco atht teh ratesetpnino wsa of RFRME as eeosnmo etdsat owb,el nad I wkno uyo odnt' nede to nkwo ttha to rsenaw eth ist,ouneq ubt ti dwoul evah eebn feh.lupl My sggbtei irsuatotrfn swa het giornwd fo het ibyspo eltrsus lanm"rabo cntlascauoimu fo ."ontiamdohrci sTih donnaye em ebucase eht eoiiifndtn fo eradgg red rsfbie hwh(ci m'I ngsisuam asw hrtei tetnnoii)n is iacou"mlasntuc fo rlaamnbo ia.t"cinodhorm eohsT era two eryv nierdffet statesmten ni ym m,din l.ol The frtsi, to e,m ustj smean sreteh' too mchu itnhcaidroom, but teh edcons nasem etrs'he oto hucm AND thye etar'n ftnoinignuc l.poyrerp Is't lsoa stuj eth afct of emebrinergm all of the setrm ofr TCE at the mite fo rniagde eth ueinstqo i.(.e I tdn'id hknit obtau eht tfac ttha TEC si losa llcade lcluerla npiarosetr ro jtus tranieproi.s)

I soal ddtin' llryea nneurdstad ylflu wtah Ox2mVa si = OV"2 ,xam soal nwnko as mxlaaim ognexy e,putak si teh emusemtrnae fo eht muixmam ntaomu of ngxyoe a opsenr nca tzeiuil diugnr tnsieen ee.e.isxr.c dan is basde on het persime thta eht orem ygoexn omscenud rniugd ecre,iexs het eorm hte odyb will eeeantgr sennedioa pittaohepshr P)T(A eneryg ni cl.s.el. 2VO mxa si ehdcera ewhn ryou ngxeoy nusnitpocom rasimne ta a tsyaed seatt deitesp an eaeicrns ni eht o.dwraokl It is at shit aptaelu atht teh sum[l]ce vmeso ofmr acboire olbmatimse to ecbraaoni "btmioamsle .-roit2:-07s01ctwmyh3.ewfvmseop/xw-ltatww/i9l-a2v/h.

Bdesa lpreyu on hist nie,doitnfi hrwee Om2xaV = esinyasltel eht etmi ta chwhi boiearc hwiescst ot neaabrcoi otseinri,apr ym proetneiatrtin of oto mhuc mdooritcanih vs too cuhm dna abd ardiohtocirmn id'dnt r,ttema eesubca vene ehnw teh irtocoinmahd rae icunintnfgo lyrrep,po they creah a noitp dan tshwic ot iarn,ocbae tuhs if tehre wsa oot uhcm namorl omctr,nidiaho tsih ouldw rocuc arstfe casbuee hetre ulowd eb mero vrealol raculell rptaiseonri ccrongu,i ainegnm het oydb olwdu ictwsh to neorabcai dna ziueilt oslyiclisg to tatalec rfo ge,nrye ptso iglzuitin hte mrhntiioc,ado nda usht 2mOaVx oduwl .ercaesde

OE.V.HERW.. uaebcse htis is a RFEMR stneuq,oi eht dorre fo ventes si a lteitl n,drfietef tipdsee teh eomcuto bieng het same t(a stael tha'ts owh I tnndsdurea .t)i ,oS I khtni the eyk to ayn lctmrinhdooia ddrseiro is eirrnegmbme that het toaiunmts rae aolmst neylaictr ngogi ot eafctf an oncedde eonritp nad huts a ifidceynce of taht rpe.niot nOe alcrtei tath I ndofu said taht teh ANRt ttisomuan as( in RERMF) cesu:a d"pusitr tiimlhodnroca peoitrn siy,thsnse raegdncsei the aivtiytc of exloCpm I nad to a srlees neextt plmoeCx ..I.V hicwh seeeradsc rnoretpisia nad woelsr rpoont ppngi,um trimcaaldyla edeangicsr the raeembnm tioapnelt and tonrpo metirhelcccleao etlonptai inadrgte scosar eth onomdhiltiacr renin n.maemerb ehT rntpoo cectelcroehlami eptntialo tdaegrin si hte rigvdni efocr orf PTA esitnsshy dna recndgasie it ibtyataslnlus leorws eht immlxaa erat fo TPA te.yns"hssi uc62/by6lt0/s4l.n0.imiirpow2nt.yx0i/1e/3.b-l.7fsh31orof.0199:110ae./d9e/4jl.l6

eBdsa no ym grnninetaddsu fo txdeivoia lyoi,hsroohaptpn 2O npunitsoocm .e.i( taignk eht tcoelenr morf cxlmepo VI nda ttugpin ti on /21 2O ot atrece 2HO adn +H ivdrse the otrnpo agetnrid iwchh diesvr ATP tnp.dciuoor hTsu: cfndteiei yprasitrreo daoxiiotn (e.i. tmADN mstouitna fo eht CET nsemz)ey ldesa ot eewodlr O2 nsnomituopc o(s redwoel OV2 ax)m ciwhh neht edlsa to rdlowee ATP ,toroupdcin dna thus eidctefve iiacmohrtdo.n nTeh, eldrwoe iocdlihrmaont tnicfonu leasd ot eeedrasdc aioerbc troiprsniae nsuhtnig ATP rntocdpoui to roeaciabn o,rrseitipna vrdnie by cyo,lsyilgs adn tsuh aniegiscrn cltaeat sevel.l

Hope siht ls!ehp Thsi ktoo em AWY OOT ONLG to igruef uot, lol, but ulfelhpoy I nerve kirngaef fergto it, ol.l

sA,lo fi uyo awtn yan oemr reiang,d I lyfialn ufond na icrteal ahtt uacltyla lflyu enslaxpi hte ilmiobeachc dna soyglyioppothha of mdrtiioonchla tyapshiem:o i3tc:/2e5.2a.a17o13mo/62rcibclmipunt3d/a/hsc/r4a/et//p4

orrSy its' os o!lgn

djtallahassee  lol yea. I thought they were trying to say there was an abnormally large amount of mitochondria present which made me get the opposite answer :/ +1  
alexxxx30  no I so agree. The grammar was completely wrong (clearly whoever wrote the question needs to work on english). This was very frustrating to me because I recognized that it was ragged red fibers, but then the wording made me doubt my own knowledge (thinking how could the test writer mess that up?). abnormal accumulations either means too much or too little. accumulations of abnormal mito means thee mitochondria is faulty. Correct grammar is putting the adjective right next to the word it is describing. So this was definitely wrong and I share your sentiment. This really frustrated me! +1  
azibird  Definitely a mitochondrial myopathy, but I actually don't think it's Myoclonic epilepsy with ragged-red fibers (MERRF). This normally entails Myoclonic jerks, Generalized seizures, Cerebellar ataxia, and Dementia (according to Amboss). Maybe it's CPEO (chronic progressive external ophthalmoplegia): progressive extraocular ophthalmoplegia with bilateral ptosis. Not sure which one would account for her poor exercise tolerance. Either way, recognizing it's mitochondrial is enough. +  


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veEn fi uyo 'tnidd hwich eon tvoerc swa Apanaa,lsm I eebilev ihccoe A swa the noyl oen ni hchwi thob mgoanrssi dhesra eth mesa rco.vte

stinkysulfaeggs  Agreed, that's how I made my final decision! +  
alexxxx30  yeah I literally had no clue what anaplasma was, but came to the correct answer the same way +  


submitted by hopsalong(25),
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I tge tsih si a luyfff siqoteun nad wdngancoelkig hte piasnett' nsrseao orf iisnsgm nlsinui eitcinnsjo si teh te,lcuddis ubt I flee ielk tihs sewarn tswo teh niel a itb. uoY tdo'n wnta to yas ahtt isgmsin seosd is o,k ubt yuo also d'nto nwta ot be anem ot titanep eehirt. I tthuhog tish wenasr )A( aws noncondgi erh singims eth snen,jciiot os I ekpdci ).(C nI pstetcrreo, I ugsse aewndkogcle msnea lkat oobc/sufatu eht nceonvratosi aronu.d

dentist  I would say: "I understand why you are missing injections, but you're going to have a BAD TIME IF YOU KEEP MISSING INJECTIONS" +3  
alexxxx30  @dentist, I was searching for that answer as well, but it wasn't there so I picked C ahahaha +  
123ojm  you would definitely do C as well. key word is "initial step" +  


submitted by welpdedelp(229),
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The tp adh shamta O,SB( sekwa pu ta htnig otu of erth,ab sha lgeaer)lis. It eksad ofr eht rsuceporr fo tsoreeinlk,eu hhiwc is coiairdhcna idca. hTe porb veag him oasltenkutM or nhileda ccouiroisodc.ltg

ls3076  wtf is up with the phrasing of this question +35  
djtallahassee  Must have been Montelukast right? Since GCs do more of a downregulation thing than a true receptor blocking. Maybe I am not reading that last sentence correct though. +1  
alexxxx30  @Is3076 haha agreed!! +1  
calleocho305  Thought this patient had GERD Induced asthma so I said histamine... Fixing GERD will normally fix the asthma and a h2 blocker would do that.. +5  
yesa  GERD-induced symptoms would be related to meals +  


submitted by lfsuarez(143),
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striF ahert undso (S1) si readentge by tow rahet s:evlva eth lmiart lvvae dan uctiisdrp .aevlv reyalN usmnultaieos noslcig fo shtee vaslve lmaryoln regtnasee a lsigne 1S ou.sdn iltpSnigt of eth S1 dnuos is hreda enwh alitrm nda pirduscit vavlse lsceo ta itlhgysl trfiendef mise,t wthi lylusau het irtaml oligcsn eebfor cdsutprii

yotsubato  Then why the fuck is it describing a mitral valve sound in the tricuspid area +25  
dr.xx  it's describing a splitting S1 — consisting of mitral and tricuspid valve closure — that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. +36  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +4  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +1  
drzed  It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post) The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound. +10  
alexxxx30  yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation. +10  
jesusisking  Thanks @alexxxx30, you the man! RIP Kobe +  
yesa  @drzed unless it's paradoxical splitting Ex] aortic stenosis, then it is aortic valve closing first at S2. +