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Welcome to catch-22’s page.
Contributor score: 67


Comments ...

 +4  (nbme24#1)
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I wduo do a ptcrtsrveeoie otcohr eehr. I otdn' khtin hsit onqiuste si rcoctre dna srvpiode oto litetl mitninaorof to gte hte ecrcrto nwas.er imTe" ctni"feief is het anrtepo dwro heer btu tyeh ilpyms 'dindt nrsdoiec taht rstrepeievcot rcohot luwod be a reettb egndsi rehe sa nogl sa eht srlbeviaa are d.odce

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. +1
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. +




Subcomments ...

submitted by seagull(1112),
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tahW a tlbrreie .ectripu eyhT htye eeodvrc up trpa of ti whti ei.lns TFW

sympathetikey  Agreed. +1  
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 +10  
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. +9  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +2  
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  


submitted by seagull(1112),
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tWah a lrteebir ce.iptur Thye they eecodvr up atpr of ti hwti le.isn TFW

sympathetikey  Agreed. +1  
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 +10  
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. +9  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +2  
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  


submitted by sympathetikey(980),
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Mad ta efmlys for acnhnggi ym e.nsraw

tyFlua ilocg emad me oerndw if iittngh oryu adhe dulow usdcea neiesdcra IPC ,os elki a sichgnu ul,erc uoy luwod egt rndcaseei Vusga eevnr iyattvci dna embya idyacaadrbr + inhpoeson.yt tBu I segus het ASRA esymts uldwo avhe orecncedttua atht nad dasuec nitiacsnstoocovr vreo 24 h,urso so cvHlyimepoo ohsck is ifideeynlt eth stbe e.cchio

wyAasl ludhos go wiht eth svobuoi wseanr ):

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. +7  
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(462),
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mynietao,scaG irepds maingaao,t nda msdyniaoophg as( llwe sa mrplaa )tmheaeyr are lal nissg of eessxc egoten.rs ehT lvrei in pstineat ihtw hpteica desieas si iidmaepr dan os acnton arcle neergost fyucitensf.il Six 21 oz esber yidal 2(7 oz, or fahl a alognl) is oot hm,cu adn si intsoedyrg ihs rv.eil

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?! +4  
catch-22  The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum. +11  
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". +3  
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(1112),
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hWat a rreelbit trpieuc. heTy htey cvredoe pu aprt fo it hwit lesin. WFT

sympathetikey  Agreed. +1  
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 +10  
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. +9  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +2  
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  


submitted by docred123(4),
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yWh is eth rwanes to isth isutoenq nto ihveiedsA s.siitualC..p

hayayah  Adhesive capsulitis causes severe restriction of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation). +19  
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. +2  
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(1112),
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'im stlli niencvocd ihst si rieatirlb beowl ye.mrdson naeCgh ym .idnm

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. +1  
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. +2  
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. +12  
arcanumm  I think you may have confused it with IBD, IBS would not present like this. +2  


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etniPat ash a ucfartre ot teh neiiforr .brtio This cna gdm 2V ro peantr eht IR .smeclu lnyO IR ernpetmtna wdoul raiipm ivoni.s

nlkrueger  if this isn't a globe rupture than idk what is tbh +11  
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. +11  
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(462),
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HMC I ctiufnon si litnager ot erncac sp.seospriun CHM I dailsysp ldesnyouegon nsedhytsezi nitrespo nad etresnsp htem to 8DC+ T lclse. heT rfiaeul to spialyd MHC I, or MCH I ydplais of snefo-ln (and by stonneexi nruoecsca) enrpoits rigrsegt a rluleacl mmuein rsnpse,oe agilnde to tiosecudtrn fo teh el.lc

hTe armeopeots is edus rfo the aonrdgaetdi fo ornw out, ecnss,etne or mrdloemfa onerspi.t sA cncare ,vsdpleeo emor msutatoin dael to ernadices wngro .irentsop Oyln yb pesioxersn of eth s,meepaorot or its nrrve,spoxieo-es anc steeh tuamnt epotrnis be deedagdr astf oenguh ot tno be dyiaspedl yb CHM I adn eald to teh clle gbien dlkle.i Btmioeborz skoblc het posmer,oate so teh numatt spnitero are eadldpyis no hte eursca,f niogwlal eht mniuem esmtsy ot zngoreice dan klil cotgaoaphlil .lselc

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/ +21  
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) +3  
azibird  But CD8+ and NK cells kill via perforin! Why is this answer wrong? Is it because it's not the primary effect? +1  
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/ +