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Contributor score: 79


Comments ...

 +5  (nbme24#1)
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I wuod do a ctisepveoerrt hctoro reh.e I do'tn nihtk this uesntiqo is ccoterr and siproved too iltlet anirmoiotfn ot tge het tcrecro .esanwr e"iTm ictnfi"fee si the rntoeap rowd heer tub heyt mlsyip tnd'di croensdi that ieorvetsrpect rotcho duowl be a etbtre enidgs rhee as nolg sa het arieslvba rae eddco.

sherry  I agree. I was hesitating between the two choices. I still think cohort study is better regarding the "risk". I hope this kind of questions wont pop out on the real thing. +2
soph  I think key here was they were measuring risk though +
yex  I also chose cohort, since it is comparing a given exposure. +
raspberryslushy  I was also thinking retrospective cohort study - just as time efficient, can look at risk, and the Q stem said the cancer was common, and I think of case-control for rare conditions. It's like they forgot a cohort study could be retrospective. +1
boostcap23  The classic example they always give for why not to do retrospective cohort is because patients who have whatever disease your testing for are more likely to remember all their risk factor exposures than a normal person that doesn't have any disease. Of course in this case I'm sure the people running the study would be the ones who figure out how much arsenic was in the water but this also would be very time consuming to figure out for each individual person in the study. Thus a case-control study where you look at a group of people with >50 arsenic exposure and a group <5 arsenic exposure and simply see who has cancer and who doesn't would be easier and take less time. +1




Subcomments ...

submitted by seagull(1583),
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tWah a letbirre itrecp.u yhTe eyth eedrcov up rtap fo it hitw ne.isl TWF

sympathetikey  Agreed. +16  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +  


submitted by seagull(1583),
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aWth a erelitbr utp.icre Thye ethy eordevc up patr fo it hwti elsin. TFW

sympathetikey  Agreed. +16  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +  


submitted by sympathetikey(1376),
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daM at elfsym rfo cgnaghin ym ewrsa.n

uyltaF cilgo dema me erndwo fi tihntig oury heda dolwu scedua esdncerai IPC ,os elik a hscngui ,eclru oyu udlwo teg decinsare gusVa eevrn civtiyat nad mbeya rcraiayaddb + pnosthn.yeio Btu I sesgu the AARS tsemys wlduo vhea autortcdecen ahtt nda edausc ncctotssvnoriaio rove 42 so,hru os lovmopciyHe cshko si teyledniif teh btse h.ecoic

aAyslw sdlhou og twhi eht obvuois arwsne :)

seagull  I had the idea that this was a neurogenic shock and increasing intracranial pressure could affect the vagus too. I think the question really wants us to go that direction. +13  
uslme123  The Cushing reflex leads to bradycardia! +4  
purdude  Wait I'm confused. I thought hypovolemic shock leads to an increased SVR? +2  
littletreetrunk  apparently, there's a thing called sympathetic escape that can happen after a while (i.e. he's been out for 24 hours): Accumulation of tissue metabolic vasodilator substances impairs sympathetic-mediated vasoconstriction, which leads to loss of vascular tone, progressive hypotension and organ hypoperfusion. +  
littletreetrunk  also also if he hit his head he could have loss of sympathetic outflow from a hypoxic medulla which could lead to vasodilation, which further reduces arterial pressure, but this was a hard one for me lol. I also put increased ICP wah. +  
catch-22  Any lack of sympathetic outflow/increased vagal outflow should reduce HR, not increase it. Further, you would expect brainstem signs if there was hypoxia to the brainstem. For example, if you had damage to the solitary nucleus, you wouldn't be able to regulate your HR in response to reduced BP. Since this patient has reduced BP and increased HR, this indicates that the primary disturbance is likely the reduced BP. He's also been in a desert for 24+ hours so. +3  
charcot_bouchard  In a patient who develops hypotension following high-energy trauma, neurogenic shock is a diagnosis of exclusion that is made after hypovolemic and obstructive cardiogenic shock have been ruled out! Plus Absent Bradycardia rules it out +2  


submitted by sajaqua1(535),
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esotm,caGyian sdreip aogmatina, nda nmigaphdyoos as( llwe as paamlr m)eerytha rae lla nigss of exsecs .goteerns ehT irelv ni sntapeti ithw aictpeh isedaes si mdirpeai adn so nnaoct crlea soegetrn iiec.syulfntf Six 21 zo berse liday 72( z,o or hfla a lgoal)n is oot chm,u adn si orsdienytg sih .levri

uslme123  No hepatosplenomegaly, ascites, or edema through me off. We that being said, I shied away from cirrhosis. I thought that he showed signed of depression, so I went with the thyroid. But who's to say he isn't injection anabolic steroids?! +6  
catch-22  The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum. +12  
notadoctor  He likely has hepatitis B/C given his history of intravenous drug use. I believe both can have liver dysfunction but may or may not have ascites, whereas the type of damage we would expect from alcohol that would match this presentation would also show ascites. +  
charcot_bouchard  For Ascities u need to have portal HTN. Thats a must. (unless exudative cause like Malignancy) +2  
paulkarr  For anyone who needs it; the FA photo is kinda burned into my mind for these questions. NBME has some weird infatuation with this clinical presentation.. FA (2019) Pg: 383 "Cirrhosis and Portal HTN". +4  
snripper  @paulkarr the problem was that the FA image was burned into my mind so without no ascites or edema threw me off of cirrhosis. +  
tyrionwill  cirrhosis doesn't present hepatomegaly, instead, the liver could be shrunken. +1  
avocadotoast  Cirrhosis (most likely due to alcoholism in this patient) leads to an increase in sex hormone binding globulin, causing a relative increase in estrogen compared to androgens. Cirrhosis doesn't always have to present with ascites and adema. I agree with @catch-22 that liver disease is a spectrum. This patient does not have ascites because his liver is still able to produce enough albumin to maintain oncotic pressure in the blood. +1  


submitted by seagull(1583),
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hatW a lerbrtie tecur.ip ehyT yeht vrcedeo up rapt of it thwi isl.ne TFW

sympathetikey  Agreed. +16  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +  


submitted by docred123(7),
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yhW is eht anrwes ot sith onseutiq ton evhAseiid .a.pCl.isstui

hayayah  Adhesive capsulitis causes severe restriction of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation). +23  
catch-22  Adhesive capsulitis is aka "frozen shouder" so you can expect exactly that. The entire shoulder will be hard to move in all directions. +3  
meningitis  Since it says there is NO impingement sign, it cant be rotator cuff tendinitis correct? What other signs eliminate this option? +  


submitted by seagull(1583),
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'mi lstil ncdceoinv stih is ierirblta wlboe y.rdmoesn aeCngh my mnd.i

mousie  haha I picked this too bc she's 44.... isn't celiac something that would present much younger?? but I don't think IBS would cause an iron deficiency anemia is the hint they were trying to give us. +2  
sympathetikey  If it was IBS, they would have mentioned something about them having abdominal pain, different stool frequency, and then relief after defecation, me thinks. +4  
aknemu  I was between celiac sprue and IBS but what pushed me towards celiac's was a few things: 1. The Iron deficency anemia (I think that would be unlikely in IBS) 2. Steatorrhea (which would also be unlikley in IBS) 3. Osteopenia- I was think vitamin D deficency 4. Lack of a psychiatric history +5  
catch-22  IBS is a diagnosis of exclusion. If you haven't excluded Celiac (and this can't be excluded based on epidemiology alone), you can't diagnose IBS. +13  
arcanumm  I think you may have confused it with IBD, IBS would not present like this. +3  


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ePitnta sah a reatcfru to teh inriorfe .tirob sThi cna dgm V2 or tnrpea eht IR m.sceul Olyn RI ampteentnr dwolu paimir ivison.

nlkrueger  if this isn't a globe rupture than idk what is tbh +15  
mousie  the air in the center of the globe made me think rupture too ..... +3  
sajaqua1  There may be some global rupture, but impairment of one of the ocular muscles causing diplopia would still be the best explanation for this patient's double vision. +13  
catch-22  Globe rupture leads to entrapment of the IR muscle which causes diplopia. The question is asking what is causing his visual complaints, which is diplopia, not loss of vision. +2  


submitted by sajaqua1(535),
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HCM I nnfotiuc is eitrgnla ot rencac nipssopu.esr CHM I lsysaidp noolneduesyg nyieehtdszs noreitsp nda prnsetes ehtm to DC8+ T ls.elc Teh euilafr to lpsydai HCM ,I ro MHC I yaildps of fl-onnes d(an by oineetnxs en)crsacuo ortpesin etgrsgir a laleclru imumen e,osnerps dgaeinl ot uodnrettsic fo hte l.lec

eTh paomoeestr si duse rfo hte igdantodrae fo wonr ,uot scsnen,tee ro lmarmfode o.sntrepi As ccarne oldepvse, emor soantutim adel ot caesndeir grwno .tersinpo lnOy by eionrsepsx of het aeopmrto,se ro sti epseoinresro,v-x acn these muantt irnotesp eb eadgdrde saft goeunh to otn eb eadlsypdi by MCH I dna leda to eth elcl bigne li.eldk oteBombzri oslcbk hte ,romeeapost so eth tuantm nrpetsoi era sdlapydei on teh rsc,efua alonglwi eth emumni tmeyss ot egrcnozie dna llki oplcotagiahl lec.sl

catch-22  Another way to approach it is to think about MHC class I processing. Basically, if you inhibit the proteasome, peptides will not be generated and nothing is available to be loaded onto MHC I (remember MHC I has to be loaded before it's transported to the cell surface). Cells that don't express MHC I get killed by the natural killers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214736/ +27  
kai  "In conclusion, we have demonstrated that the proteasome inhibitor bortezomib down-regulates class I and enhances the sensitivity of myeloma to NK cell–mediated lysis" from the conclusion of the NIH paper +5  
maddy1994  another mechanism is by blocking proteosome u even decrease degration of proapoptotic proteins...so it enchances apoptosis(from uworld) +5  
azibird  But CD8+ and NK cells kill via perforin! Why is this answer wrong? Is it because it's not the primary effect? +2  
testready  "The proteasome is the major source of proteolytic activity involved in the generation of peptides for presentation by major histocompatibility complex class I molecules. We report the new observation that bortezomib down-regulates HLA class I on MM cells, resulting in increased NK cell–mediated lysis." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214736/ +