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Welcome to d_holles’s page.
Contributor score: 173

Comments ...

 +0  (nbme23#49)
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tP sha SAA ationclreen ,ashmta hciwh anesm NSAID si ccaiai.ttonddner kicP lcciih.ncoe

 +1  (nbme23#23)
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osesnL eealrnd -- teh NEBM o'nsted lapy fI ti oklso itrgh, it si i.trgh

thotcandy  but also when it looks wrong it's right, or when it looks right it's wrong, or when it looks wrong it's wrong. you never know with NBME :) +8

 -2  (nbme23#10)
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nvEe hto AF dna ShkyMreicoct te'ndos meotinn t,i tbho almnaApas nda oslhschiEri are rerdiac yb niRob fo dxsIoe.

bulgaine  FA 2019 does mention it P 149 +
charcot_bouchard  Ehrlichia - Lone star tick +2
paulkarr  "Lyme Disease caused by Borrelia Burgdorferi, which is transmitted by the ixodes deer tick (also vector for Anaplasma spp. and protozoa babesia)." FA 2019, Pg 146 +5

 +1  (nbme23#2)
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yex  There is a Q on UWorld about rotator cuff tendinitis #380186 w/ a similar presentation... I kind of remembered about that, but honestly I do not know how I got it right. +
yex  Correction: Q id is # 1732 +

 +8  (nbme22#24)
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Thsi si a ohPtaam 3Ch Q 28()p.

rmuTo osnvniai and perdsa

  1. ltiehEalip otrum eclsl ear dhtaeatc to noe roehtna by -ihnrEdcae r(lelulac hinoesad ole)m.eulc Dneuangwtrlooi fo ida-ehcrnE → iinoaosctids of dacthtae elsc.l
  2. lCles tthaca to niianml nda odesyrt etmbaens bmrmenae via oacleenlags.
  3. lslCe aathct ot fnntoibicer ni hte EMC dna rdesap lyalcol.
  4. naEtcrne iton auvaslcr or icmtylaph asceps llaosw ofr imatsessat.


 +2  (nbme22#22)
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I aws nevre athutg ahtw tttes- vs Chiu-aserqd .was iognG off of het AF telba 'dntid lhp.e Tish ivode bowel edxplenai eth tcoepcn rlayle lw.le


For hte Q ferer ot 1@'msc .ocmemtn

 +0  (nbme22#31)
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anC paorlt NTH ncoerbtuti to hapctie cpyoh?etlahaenp

djtallahassee  Sorry for the late add. Portal system does contribute to hepatic enceph ESPECIALLY when there is a TIPS or shunt that bypasses the liver. However before, it won't directly contribute to more NH3+ +2

 +13  (nbme22#44)
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mDna I feel lkei BEMN iukfgcn lsoev iasebcs or soem it.hs

 +1  (nbme22#14)
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aGjnlo tneeodnmi isht ton( esru waht lrteceu -- hmtgi evha bene hte endo ).noe

 +6  (nbme22#50)
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This eodvi aneixpsl eth cdaptiier nonerousauteuc rdssdiero ewl.l


Biascayll the yek here is egidyhmonpetp cmeausl. 1FN has cfea au aietl otpss e(nyghdmpperiet s)ucealm ewihl STC sah has alef sotps ey(donimphtgpe uace)lsm. hTsi si a deedco the wozubdrz eylts tnsieq.uo I lfte like I 'ntidd elyral stndneduar sehet sredro iutln I chdawet hte bveoa ioev.d

pg32  I figured this out for a few reasons. The hypopigmented patches are ashleaf spots and the raised, flesh-colored lesion on the back is a Shagreen patch (only seen in TSC). Multiple brain lesions = hamartomas. Additionally, NF1 has 100% penetrance, though it also has variable expressivity, meaning if it were NF1 we would probably see some family history of similar symptoms. +3
castlblack  Agree. CAFESPOTS Cafe-au-lait, Axillary Freckles, Eye (Lisch nodules), Sarcoidosis, Pheo, Optic Tumor (glioma), Seizures +
rockodude  the video is very helpful +

 +3  (nbme22#35)
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This si a dgoo utpicre fo na ipextremne nhgowsi hsti:


nnoceOge lvomeu 6,2 psage 2–2222119 270()0

 +13  (nbme22#11)
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I gto thsi oen via scpoesr of anitim.lineo toN ersu hwo uoy era oupsespd ot emmbrree lla hatt shti.

 +1  (nbme22#5)
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ihsT tnqiuseo unfeocsd me bc I ougthth elrmaoiped lucod tno osscr het BBB nad hoeererft coudl tno ucaes aistrroypre onsisederp dmoi(i-uop inasmgo at teh staebrnmi lsresut ni CarSNrte/yropsi se,oinesdrp .1) Btu xrx@.d si rtocecr in ngnoti htta ↓ RR and SCN nrspodsiee in eth tP lhusod lacl rof na dioi-opmu insataogtn rhrate ntha cealonhhbt eclhiommt)inoci( ot reatt .tnpocntaoiis

  1. 2y5iahsq5/ao70.rh9tniae=/lcttepltrsrh.a:lptgdsexu6.scg.aasiebi?ops/o
nwinkelmann This explains a case in an infant. "Respiratory depression and coma after overdosage have been shown to be reversible by injection of naloxone [6]. Owing to its structural similarity to opioid, loperamide toxicity can be reversed by using Nalaxone which is a specific opioid antagonist acts competitively at opioid receptors. Naloxone hydrochloride is usually given intravenously for a rapid onset of action which occurs within 2 minutes." +3
yb_26  FA 2019: "Loperamide has poor CNS penetration" - so it still penetrates => can cause respiratory depression +4
whoissaad  Also maybe because the blood brain barrier in a baby is not developed as well as in an adult. +4

 +14  (nbme22#15)
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onajlG sressset eth Bsdoar inggiv teh ukaiemle setiosunq aayw bsaed on teh eag eignv ni eth quoestni ts.sme

ALL = 14-0

MLA = 19;5-3 5490-

LCL = +60

LCM = 05-94


impostersyndromel1000  thanks for the reminder, often overlooked are the simple demographic hints. helps you make an educated guess +
hyperfukus  also a key thing to remember in general is a person who undergoes chemo is a big demographic hint to later developing AML regardless of the clues :) and yes the AGE!!! +2

 +6  (nbme21#23)
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02% blnmiua is ciYRPoHtnE dna scuase rgdwain of duilf tou fo teh tntirteiusm and tion eht o.obdl

mbun"lAi )uman(H 2%0 si aniictded ni the ecyeermng tetemnrat fo oiepymvhloa hwti or owiutht Ist ftceifeeevnss ni nsivrreeg vyomlaophie denpdse reyalgl opnu its yabtiil to dwra tetliiniatsr dlfui itno the tnciclriuoa. It si mtos feitecvef ni istpntea hwo aer lelw redh.ydat eWhn lbdoo vmoeul dtifcei is eth rulset of mehrra,ohge cbmepliota rde loobd cesll or heolw oobdl usodlh be edrsiindtame sa kyqculi sa bes"s.lipo


 +5  (nbme21#20)
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tshi si a liscsac irepoitsdcn of tsrntpseei uieMranll uctd nymeosdr


due to calk fo MFI uatoitn(m ni hte gene atth meska I)FM → snertspeeic fo eht liunealrM utcd → uertus adn lnafpliao etub eesprnt ni a XY elam w/ tsstee acityyl(lp r.h)icctrdpoy

 +5  (nbme21#5)
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r'eeHs na leltnxece aimge omfr OBAMSS fi oeeppl ear ivhang duyicifflt svugizanili ths:i ip/WtQ//hma/mgoc:.musVmhtRr

lovebug  very helpful! thanks! +

 +3  (nbme21#2)
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,Alos I thnki hatw si yek is ot iarelze ttha gjnniiru CN X 'op(ettaainreriv NC X iu'njy)r seod not adel to rmiapdahg yaisspra,l ylno iceprnh rneev jruyni oudwl do .taht


,rheeFturrom eth oetrh ointsop r(ntoccsii'aidy rnx to uensr'oelafv and ynirdoan'e trropeec c)tfeed' rae orf maantnilg emhyp,rhteira TNO ueanlb ot rbhtea ayont.ulnsesop

Subcomments ...

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eTh sffecte of excsse irtyhod orm:hnoe tdeptamte ptcrosmaeyno HST rss,nippeous easnceri ni hotb T4 nda eerf ,T4 dan romnal GB.T Neto that teh eiqnotus otnsd’e vnee igehn no GTB and si olsa uyknelil ot no teh aerl tngh.i

d_holles  When do we care about TBG? +  
zpatel  @d_holles in pregnancy. +  

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itSgiplnt si na mtimareu dfsenee niamsmehc fenot ypedemol yb ptasient htwi rlenrboeid etiylonrpsa drr.seoid enhW iistlp,ntg a spneor slafi ot ese otehrs as cbpelaa of avhgni thob psitoevi dna ivegneat i;qlutaise ta yan nevgi eimt, is’t lla or ionnhgt.

d_holles  Got this one wrong -- thought it was acting out. +1  
cheesetouch  FA 2018 p539 the 'nurses are cold, doctors are friendly' example is what first aid uses too haha +  

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ekStro rdcrazeihecta by tefl srheaesiipm nad ighrt 21NC .sapyl sodCrse fndngsii enma a arsibenmt n.sioel thRgi ap)tl(silirae uoegt,n dsdilf-eet cntarlraol)ea(t neaseksw msane eht iegxnit hrigt oyslhsogpal revne sha ebne ftacdefe (iwhtin teh ihrgt delaum)l. C si eth mdrpaiy rwehe eth lcapcrtisnoio ctrta nurs ot nctoolr lumessc (orirp to teh ica.susenodt) hTis si konnw as the amldei adellryum nyedorms or neereDij rom.ynesd

d_holles  It seems to me that the brain stem problems can all be answered using the Rule of 4s rather than memorizing the actual brain stem histology. +13  
llamastep1  Yeah I think so too! With the right CN12 palsy you already know it has to be medial (factor of 12) and that would be enough to answer this question. The hemiparesis just confirms that its a medial lesion (starts with M). I know many of us like to really understand the concepts not just use these "tricks" but hey if it works it works. +4  

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irA nda fidul = o.hryxhtorpanmoued If that dlfiu is obdlo p(/s inbasb)tg, ti’s a n.aextmomphuooerh akLc of mtsineliada fhits eacsiintd ttha its’ ton enrdu isoe.ntn

d_holles  @benwhite_dotcom how can it not be under tension if air is entering the pleural cavity? +1  
nwinkelmann  Because the stab wound isn't functioning like a flap, meaning the air can escape. The reason a tension pneumothorax occurs is because the wound acts as a flap, where on inspiration it is open and air enters, but on expiration is closes and traps the air. +10  
groovygrinch  Also if there was tension, there would be a mediastinal shift. +11  
t123  Also the gastric bubble is elevated, actually suggesting lower pressure. Mediastinum shifts require more pressure, but the gastric bubble confirms it. +1  
myoclonictonicbionic  I was overthinking and thought they're implying that the stomach bubble is the air-food level that was seen on the Xray. +3  
cheesetouch  umm air-fluid*^ lol +1  

submitted by wired-in(67),
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eaMtnenican soed rualmof si Cs(s × lC × t)au ÷ F

wrhee sCs is eyeat-stdats tgrtea pamlas fo gurd, lC is aecac,renl aut is daeosg vnaleitr &m;ap F si oiiltaay.bialibv

eiethrN sdaoeg anivrelt nor vyaltaiiibaobli si niv,eg so nigornig theos pa;&m uglinpgg in hte erunmbs afre(cul ot trnceov unsti ot d/ka:ygg)/m

1= 2( Lmgu/ × 1 0gm00/1 g)u × 9(00. Lk//rgh × 0001 m1/L L × 42 rh1/ day)
= 52.29 dgm/ay/kg 'stin yna fo het resnwa soichce desl.ti yeTh umts vaeh erddoun 009. rg//Lhk to .01 k/g,hr/L and giond so vgies laytxec 882. ggdy/m/ka ccheio( C)

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +72  
hyoid  ^^^^^ +11  
seagull math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but i´d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +3  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +2  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +15  
qball  Me after plugging in the right numbers and not rounding down : +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😡 +  

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I ghthotu of tshi sa qssomauu lcle miaccnrao fo teh nglu giscanu eiaesrncd HTPPr adn ehmey.crpialca

d_holles  I thought this was medullary thyroid cancer but demographically SCC works better. +  
smc213  Medullary thyroid carcinoma increases calcitonin levels leading to decreased serum Ca2+ by increasing Ca2+ renal excretion. So high levels of calcitonin secreted by the tumor may lead to hypOcalcemia. Source: Pathoma +20  
brise  actually according to pathoma, you rarely see hypocalcemia even though calcitonin is high! +  

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owH is siht teh rsewan fi trhee si no iamlyf ithrosy fo errutencr arecrf?uts I ththgou neosogesiest iartpeefmc aws atlsmooua nnamd?oit

seagull  Exactly!! it's an autosomal dominate disease! +10  
emcee  Autosomal dominant diseases are variably expressive. Still, I think this was a badly written question (should have given us some family history). +  
wutuwantbruv  Also, FA says that fractures may occur during the birthing process, which is what I believe they were going for. I don't believe these findings would be seen at birth with any of the other choices. +  
d_holles  Yeah I thought I outsmarted NBME by selecting Rickets bc it said no family history ... guess I got played lol. +9  
jean_young2019  Could it be a sporadic cases? Spontaneous Mutation This is a change in a gene that occurs without an obvious cause, in a family where there is no history of the particular gene mutation. OI is inherited as an autosomal dominant trait. Approximately 35% of cases have no family history and are called "sporadic" cases. In sporadic cases, OI is believed to result from a spontaneous new mutation. +6  
avocadotoast  Amboss says the severe subtypes (types II, III) of OI are usually due to a new (sporadic) mutation in COL1A1 or COL1A2, while patients with the mild forms (types I, IV) typically have a parent with the condition. +  

submitted by yotsubato(979),
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asW ti sjut me, ro idd "aeg ta tneso in "rysea aparpe ITRGH bevao eht unremb of aeptst,in raterh tahn het m.nea hicWh fncseuod em fro a dgoo 3 setnmi.u

fulminant_life  Definitely was the same for me. I was so confused for like 5 mins +13  
d_holles  dude i almost didn't get the question bc of this ... i thought the age of onset was the actual age of onset (36) +7  
mellowpenguins  Are you serious. NBME strikes again with shitty formatting. +7  
yex  OMG!! Now I just realized that. Super confused and also thought onset of age was 36. :-/ +5  
monkey  what is 36 supposed to be? +1  
thomasburton  Think the number of people in that group +5  
paulkarr  Yup...was looking at it for a good 3 min before just doing the "fuck's gotta be 99" +4  
arcanumm  Age of Onset is the Title of the table, which I didn't figure out until after exam was over. What terrible formatting. +3  

submitted by mousie(211),
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Wyh on gtinesaw? I neam I gte tcEysas si lrbpaoyb teh grdu fo ohceci rebeof an lal hgint ncade tprya l(o)l but 'dton tndaesurnd yhw rtehe ouldw be clod sxeetiemirt dna no wenigsat henw si AF ti sysa hyearthipemr adn rd??ho?ba?

sympathetikey  FA says, "euphoria, disinhibition, hyperactivity, distorted sensory and time perception, bruxism. Lifethreatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome." So I think they wanted you to see Sinus Tachy and jump for MDMA. Idk why Ketamine couldn't also potentially be correct though. +11  
amorah  I picked ketamine because it said no diaphoresis. But if you need to find a reason, I guess the half life of ketamine might rule it out. Remember from sketchy, ketamine is used for anaesthesia induction, so probably won't keep the HR and BP high for 8 hrs. In fact, its action is ~10-15 mins-ish iv. +9  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +18  
fulminant_life  you wouldnt see tachycardia with ketamine. It causes cardiovascular depression but honestly i saw " all-night dance party" picked the mdma answer and moved on lol +8  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +4  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +1  
dashou19  Take a look at why the patient has pale and cold extremities. "Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation." +3  
drzed  @sbryant6 you're both saying the same thing. Ketamine has a direct negative inotropic effect on the heart, but it is also a sympathomimetic. You are both correct. +  
paperbackwriter  @drzed Can you please site that? As far as I understand ketamine has a sympathomimetic effect on the CV system --> increased chronotropy and BP. I also don't see how they're saying the same thing. One person said "stimulation" and the other said "depression" +  
nutmeg_liver  People tend to drink a lot of water on MDMA. I just guessed the confusion was a result of hyponatremia (too much free water) but no idea if there's any data saying that people tend to become hyponatremic due to water over-consumption on MDMA lol. +1  
cassdawg  "Despite possessing a direct negative cardiac inotropic effect, ketamine causes dose dependent direct stimulation of the CNS that leads to increased sympathetic nervous system outflow. Consequently, ketamine produces cardiovascular effects that resemble sympathetic nervous system stimulation. Ketamine is associated with increases in systemic and pulmonary blood pressures, heart rate, cardiac output, cardiac work, and myocardial oxygen requirements."( +  
brise  LSD does cause HTN and tachycardia according to uworld! @d_holles +  

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heT yaw I thguoth atuob stih ousteiqn swa atht ni MM htree is a NTO fo eandoistbi nibge d,ame os eht VDJ entgsem is inbeg ekorbn tne/ea/lsaeprddrreucge anmy tsime dan sha been reenhsotd to k..b15 As for teh T lC,els that onrgei s’int enbig eusd ec(nsi ereth is no clalno sainepoxn or oc)itenles os ’tis sillt otg the ulfl k6b tlgehn .hdcnetuuo

d_holles  T cells still undergo VDJ recombination to form their TCRs. +2  

submitted by seagull(1443),
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tou of s,icrityuo hwo yma lpeope kwen i?ths d(tno be syh to asy you ddi ro ?it)ddn

My eptvory natcouied t'dnid ginarni shit ni me.

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  

submitted by armymed88(47),
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dtnoypHgpieem iosnesl errfe ot h-Asleaf sp,sto NSC nsoisle iklely taahsrmoma . TS asol aocatssdie iwht r.sszeeui

fcambridge  How is Tuberous Sclerosis the most likely given that it is an AD disorder and there is no family history of "seizure disorder or major medical illnesses"? +11  
d_holles  @fcambridge variable expressivity of TSC allows for many different phenotypes. +1  

submitted by pppro(23),
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niatPet ahs .HBP evGi aphla eno ngnstaoiat to uredce mohsto lcuems ntcrocanito and leevrie ifyduftcli .igntriuna

d_holles  lol i thought it was some kind of urinary retention problem and put H. +15  
sbryant6  How is H wrong? Oxybutinin or tolterodine treat urinary incontinence by blocking M3 muscarinic acetylcholine receptors --> urinary retention. We're just supposed to assume they are talking about BPH here because he is old? +  
jaxx  I agree. I picked "H" for that same logic. Does anyone know where we should have come to the conclusion that this was BPH? +  
forerofore  they are telling you he's having "difficulty urinating", one of the clinical criteria for BPH is reduced urinary flow rate. this is not incontinence because they are not telling you he leaks at all, just that he pees "a lot" +12  
drzed  Even if he was urinating too much, anticholinergics are contraindicated in the elderly (Beers criteria) +3  
pathogen7  @drzed tI mean techinically alpha-1 blockers are on the Criteria too ... +1  

submitted by niboonsh(338),
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uaHu/=thQww/o.otw.s:c/tubDy2ove?wv4mwpthzc- fi ru zyla elki m,e shti si a ogod erehrsref ieodv

d_holles  Amazing video dude. Somehow never learned this in neuro lol. +6  
aag  Awesome video! Is this why you can give Mg2+ to eclampsia patients, because if so, mind goddamn blown. +1  

submitted by yo(79),
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I jstu kenw hatt psrme dnee fsrceou,t ton esur hwat isedase rscospe siht si ho.tugh He saw rttpye ranmlo os 5a rtedasucae toe'dns rentesp lkei htt.a I ws'nta suer fi ethre wsa any odd ues of eth toher es.rawns erhe is a k.inl Flee eefr ot d.peanx


csrtoeFu kseam pu %99 of the gnudiecr sagur etsnpre in e.mnes iThs augsr si ddecruop ni eht sanilem ev.ssicel hnidseDimi leesvl fo rteucsfo heav been hswno ot aapllrel neodgnar yneccifedi dna eht osetentsoter .vleel wngiooFll estetoostner epht,ayr eht lvele of urcoftse etrhscl aingue.Aohs hte tecfsuor tets is otn aprt fo a eointur nmese ,snisyaal ti si useful in aessc of zraoaepismo e(sbneac of mserp in )n.eesm In proazmsiaeo raecnydso to het scbeena fo clvsisee or fi ereth is an tooncuri,tbs no seufotcr si eepr.snt nI tcleitasur rsmioa,zpeao rcosufet is tsep.nre neWh aooezismrpa and olw mesen eolmvu xsse,it eht fustrceo tets odshlu soal be neo,d on a ctuespeojaatl reniu paelms to kecch rof rrtredaoge eicjoualta.n Tish occrsu when teh eatuljcea geos ntio teh dbleard edisnat of tuo eth Tu.hrhtear e rcderoeup orf mrdgieinten eht tnomau of cufoters ni mense vilensov agihetn enesm in a rtogns dcia in teh pecersne fo er.lnsocior corstueF sigve a rde corol nlfv(eSoiof ein)tcrao nad aym eb drea in a eprmteooht. Teh manorl agaveer is /35m1Lgd ueort.fsc

sam.l  Thank you for the explanation. I'm still confused about this answer. I was in between Zinc and fructose. Zinc deficiency also presents with anosmia (pg 71 First Aid 2019). Fructose is used for the movement. His hormones are normal. +3  
d_holles  Apparently diabetes, occlusion, and inflammation can result in ↓ fructose in sperm. Mauss et al, Fert Stert 25, 1974 +4  
cienfuegos  Thanks all for the info, quick note on the Zinc reply above @Sam.I: anosmia = lost sense of smell. +  
sam1  Great find yo! I believe this question was alluding to cystic fibrosis and the congenital absence of the vas deferens. Here is a link to a NEJM article about it below: +  
burak  zinc deficiency cause hypogonadism. there is no hypogonadism, sperms are damaged? +  
fatboyslim  @Sam1 but cystic fibrosis will show abnormal physical findings (clubbing, pulmonary crackles etc). The question says physical exam shows no abnormalities. +  
pg32  Confused as to how we can rule out zinc... From "Zinc also plays a role in healthy sperm production. According to a 2018 review article in the Journal of Reproduction and Infertility, zinc deficiency may contribute to poor semen quality and infertility." +  
bekindstep1  @pg32 I am not sure of how Zinc contributes to sperm production, but the question was asking about abnormalities in the semen and fructose is present in the semen. Maybe zinc plays a role in sperm development before it is mixed in with semen and so one with zinc deficiency wouldn't have low in zinc in their semen perhaps, but it their blood. This is just a hypothesis though.... +  
brise  ^^ Yeah that's how I ruled it out. You can find fructose in the semen, but you wouldn't be able to find zinc in the semen! It might help the sperm, but it's not going to be chilling with them +  

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eth frtacni ecurdocr 61 hrs goa, morf 2rh1s42- trfae hte tficarn ehetr will be deR os.Nneru

tsl19  FA 2018 - p. 496: ischemia -> pyknosis within 12-24 hours. +  
d_holles  yeah the infarct occurring 16 hr ago is key. i zoomed in only on the died 1 hr later +  
apurva  Me too zoomed on “1 hour later” and marked no change +  

submitted by hayayah(1057),
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kncWaoorrfeifskK-e ym.snoder Don't have to eb na lclioaohc to get hits, stju uuyalls si teeadlr ot oosmilcahl / haetinim decnicfy.ei

d_holles  Yeah the negative EtOH screen threw me off +3  
dr_jan_itor  Why cant it be early alzheimers and hippocampus? She could easily have been a former prominent physician and member of city council. Am i supposed to assume that simply because shes disheveled and poor hygeine that she must be an alcoholic homeless person? It also mentions no symptoms of nystagmus, ataxia, etc. +2  
kimcharito  it said broad based gait and nystagmus +9  
lilmonkey  She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment. +  
fatboyslim  @ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus." +  
suckitnbme  NBME questions also stereotype the shit out of their patients +5  

submitted by lamhtu(113),
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iNedeng gr"hhie ansnicn"otecotr fo teh B6 ofr ezeynm cyitivat si rtaheno yaw of asygni mK si rhheig neics moer is ieqdeurr rof /21 axvm avtt.ycii adceesInr mK suaelv esultr ni /m1K ibneg serllam cel(ors ot 0 on teh )a-six,x cihhw si nedtsrtodmae ni weasnr eiochc B.

A o"rnal"m mzenye tivyatci in eht ercnepes of gerhih B6 aootcetnrcsinn asnem htta Vxam is ont hgcn,gain tub mK i.s

d_holles  In other words, Normal enzyme activity = Vmax Adding more B6 to a mutated enzyme will improve it back to normal (Vmax stays constant, so Km will decreased due to ↑ affinity of the enzyme). +  

submitted by assoplasty(91),
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I ikthn teh ptceonc eryt’eh gitesnt si het daiensrec BTG lsevel ni pg,yeancnr dna not sutj porityimdshreyh ni lae.engr

Wnhe srenngcie orf ,yphspitdery/ihomorhy STH eeslvl era WAAYSL yrairftepellne khedcec eeasbuc ethy aer meor siveienst ot uitmen eerfncdsife ni T.T34/ fnOte tiesm HST levsel can eamrtntdeos a gnceha enev ewhn 4T3T/ veslel aer in het nicclbsiula rnaeg. heT nlyo ceetpxion ot sith uodwl eb ni neycnrgap dan( I esgsu mbyae vlier eiura?lf I uotbd tyhe wdoul aks ihts .gh)outh gihH osrnteeg lsvele pstrenev hte ilver omrf brakinge nowd BG,T anlgdei to srieacnde TGB lvsele in eth surm.e ihTs nidsb to eerf T4, earicgedns eht anumto of lielaabav reef 4.T sA a atyoonsercmp mn,mhiscae HTS slleev era anynlisetrt nearscedi dan het RETA fo 4T pncidortuo si seiacendr to enilhpers anblsiee eref T4 evllse. vwHereo teh TALOT anoumt of T4 is e.rcesinda

Teh unqeisot si iksang hwo to ifmncro mperyhdtryhiiso ni a gtpaennr manwo &g;-t- ouy need to hkecc EREF T4 vllese u(saebec yeth hsduol eb lranom deu ot oeosantrcymp poen.ress) Yuo tnnaoc kecch TSH uaslu(yl eteedavl in pracyneng ot eotmncpsea rfo ndierecsa ),TBG dan oyu aotcnn kecch tltoa 4T elelsv (liwl eb re.edcna)is oYu got hte sarwne igrht ireteh ayw tub I hnkti iths is a dieffenrt niorneasg wrhto oiednsng,cir bcuseea hety anc ksa thsi pecontc in rohet coexnstt fo ,mhprorineegts-esy and fi hyet eitsdl ST”“H sa an rsenaw coiech thta owlud be reoc.ncirt

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +8  
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +2  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +  
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +1  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +1  
lovebug  Amazing answer! THX +  

submitted by niboonsh(338),
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ehT bliqoesu do het pptesioo aiocnt of irhte men.a oifIrnre eoilbqu seomv eth eye PU dna OUT xeont,tro(i eivoan,tle iBun)oAc.dt Sncie hte neqtiosu ayss htta hreet is a uetrafcr lnnigvvio hte rliaotb lrf,oo thta tctuiyalmoaal eulsr tuo D el(dmia setrcu adn irfrioen qol)eiu,b vlaengi eth only claigol ewrans ot be eth oirifenr suertc nad nirrofei o.ulqeib ?=Wc.bWht/kws.wwh/tatEIIpyWoHetvD:wKmlcou/u

aishu007  hi, but inferior oblique moves up and in and not out +  
d_holles In case ppl need a refresher +  

submitted by hayayah(1057),
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ewlro dnaptuniqar:aao ritlaape elsnio

sv prepu iaaaannroudtqp = orlmeapt osienl

mcl  also, to differentiate whether it is the left or right parietal lobe, recall that stimuli from the left visual field hits the nasal side of the left retina and the temporal side of the right retina, then goes to the right side of the brain. [This figure]( is helpful. +6  
d_holles  So you're saying that there's two crosses, making it ipsilateral? @mci +  

submitted by neonem(556),
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hisT is a spamtpruto oodm sbendauir,ct a yetprt conmom sedrdiro ahtt ahs ot avhe na osnte inthiw 4 weeks fo lyeivder to be meterd as .cuhs umaPosprtt usble si teh otsm l,dim htwi a -%5805 nieinedcc erta (erp AF ,1082) usyuall evsoresl inwhti 10 sayd dan amnteettr si oyln itsvpeuopr tub ndee to ullofpow- to seasss rof bpslioes rtostpampu dspreos.nie pttsamPruo sprosnedie = %105-1 ater, arzhideectrac by epdsresde fat,efc axtny,ei proo innoatneotrcc rof rterega atnh 2 skewe and dense to eb earedtt w/ CBT + S.ISR I hintk het qutnoeis is tggient at riegsennc orf shit nad a eltalpntyoi meor maictbloepr oomtlpaiinc,c rmappsoutt yoish.spcs

thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +11  
d_holles  Same @thisisfine. +2  
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +  

submitted by haliburton(209),
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tsih si a lacirvce psailn rcdo teh tacuene lsuaicuscf si cattin E(U) riantbvio nad pitoicprnpeoo,r ubt het hietw nciteso is het iegracl ssiuafcucl L)(E dan is dgdmeaa. I itknh the eaartll prointo atth is nenveu is tusj .na/itarftulacatr

arezpr  thorax section +3  
guillo12  How do you know the gracile fasciculus is damage?!?! +2  
cr  which parte of the image its damage?, the pink? or black? +  
usmile1  the pink park yes +2  
d_holles  If you look at you can see that the closer to the center = legs, while further away = arms. +4  
hyperfukus  i still don't see where the damage is lol! FML +  
hyperfukus  i finally figured it out lol that was a slow moment i hope im not this slow on step yikes! +  
angelaq11  @hyperfukus I had the same problem at first, marked it and then came back. If you remember, in the spinal cord the white matter and gray matter are "reversed" compared to the brain. That said, if the butterfly shaped region (ie, the gray matter) is colored (in this case) lilac and the rest (ie, white matter) is blackish, the only thing that is actually abnormal, is the region where the dorsal columns are, because it stains just like the normal gray matter. After that, you have to think about which fasciculus is damaged, the gracilis or the cuneatus. The gracilis is medial while the cuneatus is lateral (picture someone with glued legs and open arms). Hope this helped +12  
azharhu786  Gracilus Fasciculus = Graceful legs +  
icedcoffeeislyfe  Check out FA2020 pg 508 Put simply--> myelin= black --> color of the normal white matter no myelin= pink --> color of the normal gray matter and the damaged area Dorsal columns= vibration, proprioception, pressure fine touch F. graciLis= Lower body F. cUtaneous= Upper body +2  

submitted by sinforslide(49),
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eaMl nlrtanei ielaitgna ;&g-t taInct RYS , es,sett dna otes.srnettoe

oN mefael letnrian ileganait g&;-t Pneersec of FMI mr(elltiaunnai oernmh)o nad ttncia rtSeoli lcel cnotnf.ui

Feelam aetnerlx gnalaieit &-t;g No dnrnegoa rspne,et iwhch is rriuedeq rfo leam nxeetrla ielgantia fomt.nioar

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +18  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +2  

submitted by sinforslide(49),
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elMa aentnilr iagnaleit &g;-t antctI RSY , sts,tee dna orostetn.eest

oN aeflme larientn eaniitgla -t&g; nPcseere of IFM naeitrumlna(li oorehm)n dan ntatci Sritole llce

elmaeF nletaerx eigtnlaia g-&;t oN ndnerago esernpt, chihw is drieeurq orf lmae rlexneat gleaitnia amroot.fni

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +18  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +2  

submitted by sinforslide(49),
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eMla tlneianr aialitegn t;&g- cttanI RSY , eetst,s dan .teoeretnotss

No lmeaef ilaetnnr niegaital -&t;g rcsneePe fo FMI (rnluineaimlat heoor)nm and taicnt riolteS ellc .utoincfn

lmeeaF teenrlax angliatie t&;-g oN ndonegra e,nesprt iwhch si qerrduei orf lema ertxlena naegliiat roatfoim.n

d_holles  Not sure I understand why T is wrong, but DHT is correct. +1  
d_holles  I thought about this some more -- DHT forms external genitalia while T forms 'male genital ducts'. That's why the correct answer is DHT, not T, since the PT had +ext genitalia, but -internal genitalia. I was thinking that the PT had CAIS, but that would lead to testes only w/o male genital ducts. See FA2019 p608. +18  
d_holles  *I meant -ext genitalia, +int genitalia +  
adong  T is wrong because you still need T to make the internal male organs which he has based off the MRI +2