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Comments ...

 +0  (nbme18#18)
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I tup CH,F iltsl otn uers yhw ti si gorwn ervo PB,H btu ym naonirges si ahtt HBP auessc ctrobisvuet erinu owfl g-t&-; pnseiHrysodorh dan ncoe eth einur sha ebne mdea ti a'cnt eb eonerd adn is elki gifnlil pu a admn hiwt eratw. irgttSha Sas.sti sv HCF reeht si ettiorvepc mnmissaech in palce rof a hwile uitnl knafr DCK.

pfebo  This is a case of postrenal azotemia. BPH is the only available option tbat causes it +

 +1  (nbme18#26)
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I ma nto 100% no sthi ebign r,corect but I lerbify bmrermee a rctshtaiisPy ygnsai taht het pitante hsa to be euisrze feer rfo 6 mhtson nuimmim adn derferrep to aehv no ueiezrs iitnwh eth atls 3 erysa to eb siacttoamm.yp oD iwth atth nomtronaiif what uyo w.ill tub rof sB:oadr 3 .aeysr

suckitnbme  Question stem also implies that the patient has been driving already. "has not had any collisions while driving his personal motor vehicle". +15
cbreland  Also 10 years is a really long time. Just didn't seem like a good answer +

 +0  (nbme18#14)
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outSpoccrscet Pnsyego r(guop A )ptres hsa a nniepeastugr nucasgi Tshi tiagnen tEhynogiercr Etxoonxi A uescas a oTicx sli-kekhoc rmsynode: rvFee, hs,Ra kSohc, Serclat evre.F

AF gp 133 9)0(21

extraordinr  correction: GAS erythrogenic toxin causes scarlet fever specifically in this question there is no reason for this child to have TSS +5
loaloagubba  SpeA and SpeC toxin is erythrogenic toxin referred to here. +3
baja_blast  Erythrogenic exotoxin A + Strep Pyogenes is responsible for BOTH Scarlet Fever and Toxic Shock Like Syndrome. It can also cause Necrotizing Fasciitis. It's definitely Scarlet Fever in this question but I just don't want people to get confused. FA2019 pages 133, 136 +
baja_blast  Sorry, not A. Just Erythrogenic Exotoxin +. +

 +5  (nbme18#48)
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oeplCias is a tropeni that cnustfoni sa a aofctocr ofr panrcaeitc ,isleap wiht iwchh it sfrmo a ormittoseicihc p.cemxlo It sloa snibd ot the -sbllatei oecevdr olaeyrllcgytric tecenfari huts agnolilw eth ezenmy to rhaonc ftiesl ot eht dawiet-rpli frec.nitea

cbreland  Lipase (active) and procolipase (inactive) are both secreted by the pancreas. Lipase is inactivated by bile salts in the intestines. Colipase (once activated by trypsin) is able prevent the interaction of bile salts and lipase. End result being that lipase is doesn't have to worry about bile salts if colipase is around +2
s039p811  To add onto this, I had picked Phospholipase A2, but that's used for phospholipid hydrolysis and not triglyceride hydrolysis specifically. +

 +0  (nbme20#41)
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ouyr essug is as oogd as .............e...........................m...............n.....i.........

nala_ula  I spent so long on this question and same... hahaha +

 +8  (nbme20#29)
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oDyliycecxn si a yatricecTnel ndsbi( s03 utubs)in dna si sued fof eabll for atnmtrtee fo ne.cA aCn auecs doniorsotlica of et,hte nda is woknn to be SOHITTIPEENO.VS

sihT eitntpa dha fsiudef rmahetey adn ilmd eaemd voer rhe cafe and stmei,xirtee stom ylelki mrfo usn eroepxsu eiwhl inbeg on eht mde rfo Ance.

FA 9012: gp 219

 +4  (nbme17#16)
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HCG ecinsiojtn onwd rgueltea teh irtitapuy rasleee fo .HGRn

rvheweo HCG lapah ubnisut cna aitelsutm llcse encludnfei by ,LH S,FH .HTS

cassdawg  (FA2020 p633) - Basically HCG acts like FSH which stimulates estradiol production by the sertoli cells (see There is no feedback inhibition since it is injected so there are elevated levels of estradiol causing gynecomastia. +12
j44n  also FSH upregs aromatase so you increase test (LH) and increase aromatase (FSH) that then converts that test to estradiol +

 +0  (nbme20#21)
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sctsoitsiPa eotei(msms eaclld ntiorohsis ro atrorp sieeasd ro rortpa efrev) is na eninocift fo eht ugnl n)n(paiuome cudase yb het mtaeibrcu ayhlimhCoapdl ymChdli)(aa titi.pcas

niSsg dna uprs,ygeohvfmcm. soet : aulsuly wottuhi hmcu he.she cdashmaallp ur.he.ecm g ha.esescth c ip.retnnssosh a fo hteo br.sare .oatthr

charcot_bouchard  Update on my prev comment : Yes this is psittacosis. not hypersensitivity pneumonitis. How do u know? Lymphocyte and Presence of Granuloma - response to intracellular chlamydia. Now HS can also cause loose granuloma too and the clinical picture still more look like HS You know what ......... fuck this ques +
shemle  Here Pt. doesn't have fever! +9

 +2  (nbme20#2)
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xD: cuAte nMoiyccot kmeaiueL. ioPfrtlroiaen of slna;tomsbo aklc O.PM C14D + 1DC3+ OMP -. lsbast yrlatisrechcaltiac fniraitetl het m.sgu

A ahXntine dsxaOei bhrnoitii si ivneg ot peretvn srdevea ianrtsceo of oTmur siLsy Smerodyn cihwh sutsrel fmor seluopixn fo uelracll sirtalbrai/eedm rtefa the lelc deis.

 +2  (nbme20#12)
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eiaPntt has cyisloiMstd uumrmr arhde ta het cairacd .xaep teehr si sola a LFET ITALRA mlayin.rtboa cEho howss FLTE TIMARU is aengler.d

Mid ictoe s.len.yd.lsrag eltf .uar.imt.

estB ocec:hi tailrM geurgR

hpsbwz  Why is it regurg instead of stenosis? +3
minhphuongpnt07  Vague question requires a lot clinical reasoning. mitral regurgitation: holosystolic murmur( this cv: midsystolic), enlarged LA, LV Mitral stenosis: diastolic murmur, enlarged LA, normal LV. only best explanation I can think of: early stage Mitral regur, that's why the murmur is not holosystolic but midsystolic and LV still adequately handle the situation +4
dickass  @hpsbwz it's regurgitation because the murmur is SYSTOLIC, when the mitral valve is not supposed to make any sound. mitral valve leaks in systole, which causes blood to back up, which causes the left atrium to work harder and eventually hypertrophy. Mitral stenosis would be a DIASTOLIC sound, which is when the left atrium normally contracts. +8
themangobandit  I'm still confused as to why mitral regurg has an enlarged left atrium. Are we supposed to think that it was mitral stenosis for a time, the high LA pressure led to hypertrophy, and then became mitral regurg? That's how it works in rheumatic fever, right? +
shapeshifter51  I agree that mitral regurgitation is a holosystolic murmur heard best heard over the apex. However, with the murmur being found in the mitral valve area of auscultation it was the only answer choice that could result in LA enlargement and normal LV. Ruled out mitral valve stenosis since it is a diastolic murmur. +
weenathon  @themangobandit I believe mitral regurg could cause an enlarged left atrium from the increased amount of blood flooding back into the left atrium with each systole causing increased pressure on the wall. +
rockodude  why is LV size normal? doesnt cause MR cause increased preload and overload over time leading to enlarged LV? +

Subcomments ...

submitted by famylife(93),
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ishT si spret nmuop,e cihwh sah hpaal ymsishole ng)(eer

breis  How is this differentiated from Strep Virdans which is Optochin Resistant? Because Strep Pneumo would also be inhibited by optochin* +2  
mjmejora  its strep viridans. Strep viridans has a "protected chin mask" and strep pneumo is "exposed" in the sketchy. +6  
rthavranek  Once again, another example of me knowing the concept but not knowing the obscure pseudonyms for common knowledge so I get the question wrong +  
dtransistor  I saw green and immediately thought of pseudomonas and crossed that answer out. Didn't know they were talking about alpha hemolysis! +  

submitted by sympathetikey(1349),
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CD+4 celsl evtiatca Bel-cls chwih form lolceislf dan sceua ernmetnlgea of hympl eodsn. Tr,foheeer in na AISD ai,netpt to ganelre the pmlyh endso, het +CD4 fciyonsdnut usmt eb edo.elsvr

breis  Yea i get that, but if the patients CD4 was ~35, how in the world did the CD4 count rise enough to stimulate B cell proliferation...? I don't get it +9  
namira  The only thing i can think of is that: the cd4 count that is given was taken prior to having started the antiretroviral therapy. Since the question asks about "improved function", maybe its referring to the therapy actually being effective and its managed to increase cd4 count and function so as to be able to contribute to lymph node enlargement due to myco. avium +12  
kamilia20  I though it transfer to a lymphoma,OMG +  

submitted by hayayah(1074),
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saioNpael si wne tsuies rghotw ttha si utnlguer,dae eirirvbele,rs dan .nloaolnmco

loiClnaty cna eb imderetnde yb c-eshsuoh-6gloepapt dnrahesoeegdy (GP)D6 mynzee oro.fisms DGP6 si ikdeln-X.

*For mero imoonanfrit ckech otu .Ch 3 pNslaoiea in Phomaat

hello  This is great, thank you. +4  
breis  Pathoma ch. 3 pg 23 "Basic Principles" +8  
charcot_bouchard  Shoutout to Imam Satter! Without him this question wasnt possible for me to answer in 10 sec. +13  
fatboyslim  Clonality can also be determined by androgen receptor isoforms, which is also present on the X chromosome (Pathoma Ch. 3 Neoplasia) +1  
lovebug  @fatboyslim thanks for reminding! +  
makingstrides  Just to make sure I got this right, because this is neoplastic and its monoclonal, you want to look at the isozymes to determine its clonality? +  

submitted by strugglebus(165),
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oeeNrwh evah I neeb ebla ot difn wyh hte lelh htis si a

yotsubato  Its not in FA, Sketchy, or Pathoma, or U world. I knew it wasnt cancer because its bilateral. And Diabetes made no sense to me. So I just threw down Drug effect and walked away. +6  
breis  same^^^ +  
feliperamirez  The only possible explanation I think is that she was under a K sparing diuretic, such as spironolactone (which would lead to gynecomastia). +  
chandlerbas  you had me at its not in sketchy ;) +2  
j44n  i thought HTN induced empty sella would cause this because they got type II diabeetus. So if you need a pro zebra hunter holler at me. +  

submitted by hayayah(1074),
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tP. ash aiaFmlli ddssiem.lipayi ypeT IalhneHori—comyimpecry.

estefanyargueta  Lipoprotein lipase: degradation of TGs circulating in chylomicrons and VLDLs. +2  
breis  FA 2019 pg 94 +4  

submitted by xxabi(257),
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osBcra’ aasip:ha pxeesvries rto(mo aapa)ish ihtw mmaamsgtair t(ps arawe tath yeht on’dt eakm )neses - eara k eiAWrens’c hpiaa:as itcvrepee ne(r)syso aapisah thiw rediapim eorhnemnposic s(tp alkc htsi)gin

breis  Why would B be incorrect? I realize Broca is "technically lower" but A seems too low to be causing weakness of the lower 2/3 of the face? Am I missing something? +  
shaeking  @breis B is incorrect because of the lower 2/3 of the face weakness. B isn't located on the motor cortex but in the premotor cortex, plus it isn't low enough for the lower two thirds of the face. +1  
cienfuegos  @breis, per UW: "a/w r. hemiparesis (face & UE) bc close to primary motor cortex" +  
almondbreeze  B is close to premotor cortex which is involved in learned or patterned skills & in planning movements. (i.e. two-hand coordination) slide 25/37 : +  
almondbreeze  B is also close to frontal eye field; eyes look toward the lesion FA pg. 499 +  
frijoles  I incorrectly picked C. When answering this, Broca's "broken speech" was my first thought, but I figured a lesion causing a facial droop would have to involve the motor strip so I prioritized that and chalked up the speech issue to dysarthria (I understand this is more of a "slurred speech" than broken, abrupt speech, but again, I simply misprioritized concepts.). So for the record, Broca area is part of the motor cortex? +1  

submitted by beeip(124),
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otgThhu htsi uowld eb iohgtmsen engigarrd ibir"aarct rsgyur,e" but oen,p tusj "on yacrtsh ,odosf cseuabe oreuy' ietepad.bic-r"

hello  Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +  
yotsubato  such a BS question IMO +6  
yotsubato  such a BS question IMO +  
breis  I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +5  
teetime  This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +2  
dr_jan_itor  Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1  
dhkahat  yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +  

submitted by usmleuser007(395),
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amVitni E cdenyifcie is knwno to sauce riiaslm sniapl tfesdec sa mVnaiti 21B fceni.diyec oHwr,eve amniae is tno e.sen

ergogenic22  Also corticalspinal tract symptoms are not seen, but dorsal column and spinocerebellar tracts are seen +4  
sinforslide  In this case, patient's CF also predisposes fat-soluble vitamin deficiency. +9  
breis  FA pg 70 +  
usmleuser007  Correction: Read more on this Vitamin-E deficiency can in fact cause anemia - hemolytic anemia. This is b/c VitE work as an anti-oxidant; and therefore with reduced anti-oxidation RBCs are more prone to oxidative injuries. +4  
azharhu786  AMBOSS: Hemolytic anemia; increased fragility of erythrocytes and membrane breakdown are also caused by vitamin E. +1  

submitted by xxabi(257),
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I aws rudne eht misrepsion atht hist was na cotair eid,tnsoics deu ot sre"eev ehtsc anp"i sa lwle sa teh lfaes mlnue ni eht arta.o dnA NHT is teh #1 ikrs toafcr ofr rictao ecisd.siont enSmeoo otrcerc me if 'mi ogwnr, ubt I ntkhi shit si croiat ioeidstcsn rthrea athn ricoat rmyu.anes

chefcurry  I believe so, FA 2018 pg 299 +3  
ergogenic22  It is dissection "extra lumen in the media of the proximal aorta" = "a longitudinal intimal (tunica intima) tear with dissection of blood through the media of the aortic wall" ... answer is still hypertension +2  
breis  FA 2019: 301 +  
pg32  First Aid says that aortic dissection causes widening of the mediastinum and is due to an intimal tear, so I thought it wasn't an aortic dissection. Can anyone help me understand why First Aid was wrong in this case? Thanks! +3  
nephroguy  @pg32 The question stems states that there is no widening of the Aorta, not the mediastinum. Widening of the mediastinum is seen in dissection while widening of the aorta is seen in aneurysm. Also the intimal tear creates a false lumen between the intima and media. Hope that helps! +10  
j44n pictures worth a 1,000 character limit +  

submitted by celeste(82),
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odnSus lkei a ryoppceihrht p"ehrtcyHrpio sscar ncaotin rilmpyiar tepy III aocenlgl eernodti plaerlla to hte meldeapir cesafur wtih btnaunda lsnodue ginoctnani lbyotosf,smabri agrel arecatxlulelr caonelgl snfemtail nad utiellpnf iccaid" .mel/i:nn/i2nwp.stcmbwo7h8w/9.vhg2.tr0tP/MCic3l/p/sca

johnthurtjr  I think it may actually be a keloid, not a hypertrophic scar, as it expands beyond the borders of the original incision. +5  
thepacksurvives  I believe this is a keloid; a hypertrophic scar does not extend past the borders of it's original incision, while a keloid does. regardless, the answer to this question is the same :) +  
breis  First AID pg 219 Scar formation: Hypertrophic vs. Keloid +  
charcot_bouchard  They give granulation tissue is a option which is type 3 collagen. so if it was hypertrophic scar it would be ap problem since its only excessive growth of Type 3. while keloid is excessive growth of both 1 and 3 +4  
bharatpillai  I literally ruled put collagen synthesis defect since this is not a collagen synthesis defect at all ( EDS, Scurvy) :/ hate these kind of questions +