NBME Answers : dickass's page

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+0 (nbme20#42)

Patient has acutely decompensated heart failure, most likely due to an MI 5 days ago. Orthopnea-dyspnea-edema would mean he likely also has jugular venous distention and hepatic congestion.

+3 (nbme20#33)

Got this one wrong because of those 2 unaffected children. Here's the explanation from FA pg 59:

Mitochondrial inheritance - Transmitted only through the mother. All offspring of affected females may show signs of disease.

Variable expression in a population or even within a family due to heteroplasmy.

Heteroplasmy basically means that multiple mitochondria are transmitted to each offspring. Their ratio may change at each generation, and cause more severe or less severe disease, even within the same family.

Those unaffected dudes lucked out.

dickass That'll teach me not to skim FA, you really gotta look up the words you don't know. +

chandlerbas heteroplasmy is a fancy way of saying variable expressivity just specific to mitochondrial diseases i do declare +

+2 (nbme20#19)

SIADH: + Excessive free water retention + Euvolemic hyponatremia with continued urinary Na excretion + Urine osmolality > serum osmolality

Body responds to water retention with DECREASED aldosterone and INCREASED ANP and BNP

Water retention => Less aldosterone => Less ENAC channels => Less sodium reuptake => Loss of sodium in urine

+4 (nbme20#24)

...migrant workers ...has not received routine medical care ==> she was not screened for hypothyroidism

+1 (nbme20#38)

Yeah, so, turns out this is not Nephrogenic DI due to lithium use, you don't give lithium to treat schizophrenia.

mbourne If it was Nephrogenic DI, you would have essentially have the effects of too LITTLE ADH. This patient shows severe hyponatremia, essentially the effects of too much water in the serum. This could be from SIADH or polydipsia, and the question stem and answer choices leave us with Psychogenic Polydipsia as the correct response. +1

rockodude I was thinking about carbamazepine causing SIADH but that is an anti-epileptic not antipsychotic and also as someone said above, the urine would have high osmolarity due to water reuptake at the collecting duct. just fyi +

+2 (nbme20#32)

Nonmaleficence: “Do no harm.”

Even if the patient wants to die, I guess.

champagnesupernova3 FA says you cant assist suicide but you can prescribe pain medication which they can conveniently overdose on +1

dickass "Physicians may, however, prescribe medically appropriate analgesics even if they shorten the patient's life." (wink, wink) It's vague, but I guess the main point is to let the patient have relief, side effects no longer important. I still don't think you can just give the patient a bottle of benzos though. +1

raga7 FA 2018 PG 260 +

misterdoctor69 FA 2020 p. 268 +

+5 (nbme20#31)

Paclitaxel hyperstabilizes polymerized microtubules (made up of alpha- and beta- tubulin)

md_caffeiner And clinical use is in breast and ovarian CA (FA19 433) +2

len49 TAXes stabilize society. +

alimd Tarzan: taxanes (e.g. paclitaxel, docetaxel, cabazitaxel. SKETCHY +

+5 (nbme20#41)

FA pg 567:

Congenital solitary functioning kidney: Condition of being born with only one functioning kidney. Majority asymptomatic with compensatory hypertrophy of contralateral kidney, ...

dermgirl FA 2020 Pg 579 +

+5 (nbme20#9)

Remember kids, GFR corresponds with Salt (mineralocorticoids), Sugar (glucocorticoids), and Sex (androgens).

misterdoctor69 Thanks @dickass, not sure why you got downvoted :( +

+6 (nbme20#37)

FA pg 70:

Vit E deficiency:

Neurologic presentation may appear similar to vitamin B12 deficiency, but without megaloblastic anemia, hypersegmented neutrophils, or serum methylmalonic acid levels.

dickass and VitB12 neurologic symptoms are described on pg 518 +

+1 (nbme20#1)

Testicles have significant aromatase activity. This enzymatic activity is regulated by LH (and of course bHCG)

https://www.ncbi.nlm.nih.gov/pubmed/9267128

+2 (nbme20#4)

It can't be the Facial nerve, physical examination was normal. Someone would probably notice the face symptoms.

I went with Glossopharyngeal, but that wasn't it.

garima I thought the same for olfactory, he would have realize he can't smell... :O +2

+1 (nbme20#35)

I spent like 5 minutes trying to figure out what kind of trick question this was. They're just trying to get you to figure out 'oh look the spleen is YUGE!'

Subcomments ...

submitted by dickass(78),

Nonmaleficence: “Do no harm.”

Even if the patient wants to die, I guess.

champagnesupernova3 FA says you cant assist suicide but you can prescribe pain medication which they can conveniently overdose on +1

raga7 FA 2018 PG 260 +

misterdoctor69 FA 2020 p. 268 +

submitted by hayayah(990),

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Froatmropeotln iamdente (lrrfmyoe nknow sa Pcki :)sadeise aElry gshcnea ni aptsrynlioe adn baiverho ieaboh(avlr riavan),t ro aiashpa (pyimarr provsgeeirs i.ha)asap yaM ehav otcisedasa neveomtm sirdoedsr e(,g iispkrm.)noans

ehiWl sthi etrsnesp evyr iylsmiilar to stogtngi,nu'nH you can reidfeanftiet ti asbeeuc in thsi etsm it yass thp"rayo fo eth aftorln eolsb "etrllaaibly resaweh nuto'tnHnigs has rtyahop fo acauted and nemaptu with ex vauoc l.ncgteamlvryioeu

dickass and the patient has no chorea +1

submitted by hayayah(990),

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nietPat ahs a racmaniaohrnyopig. soMt ncommo ildohhdoc otplareinasurt tmu.ro iDedevr ofrm nsrnamet of hetkaR cuhop ol(ar tr.)cemdoe nfCiaotcilcai is mnc.omo rsCohotelle rsatlsyc dfoun ni “omort ilkio-el” udifl tiiwnh .tmoru

A cctisy aurplaeslsr sams with iitaanicolcsfc adn emhenenntac of the llwa ro osdil nstporio ni a lcihd or lacdstoene si olatms awyals a aionporcihaymrng.a

yMa be unfoecds iwht irptiyaut daoaemn ho(bt asuec emaoibtlrp ohai)i.maenp

dickass Cholesterol crystals in motor oil +

passfail I also just thoughtL: failure to secrete GH = tumor affecting anterior pituitary hormone --> anterior pituitary is derived from Rathke's pouch +

ally123 "Due to the proximity of the tumor to the hormone-producing cells of the hypothalamus and the pituitary gland, there is significant endocrine dysfunction in most children and adolescents presenting with craniopharyngioma...Among the hormone deficiencies, growth hormone deficiency is the most common and is seen in approximately 75% of children with craniopharyngioma." Source: http://campus.neurochirurgie.fr/Programme_Enseignement/_art1030/endocrinManifest.pdf +

submitted by dickass(78),

Got this one wrong because of those 2 unaffected children. Here's the explanation from FA pg 59:

Mitochondrial inheritance - Transmitted only through the mother. All offspring of affected females may show signs of disease.

Variable expression in a population or even within a family due to heteroplasmy.

Those unaffected dudes lucked out.

dickass That'll teach me not to skim FA, you really gotta look up the words you don't know. +

chandlerbas heteroplasmy is a fancy way of saying variable expressivity just specific to mitochondrial diseases i do declare +

submitted by hayayah(990),

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AF emn:mnico OA"TG "HGA

dickass I figured "if Oxytocin can cause milk secretion and enough uterine contractions to expel a full baby, it's probably activating smooth muscle contraction through Gq coupled second messengers" +3

submitted by hayayah(990),

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ihTs ipenatt ash lsmla lcle rcamai.nco shTi eypt of encrca si asacstoide ihtw sceinaoatplrap nosdsmeyr cush s:a hnsuiCg neor,mySd DHISA, ro onsdeiiatb tgaasni a+C2 cseahlnn mnLo-tbeEa(t)ra or usn.eorn Anmoipaiclfit fo cmy ogneeocsn is saol oommn.c

IHADS (eSyrdonm of rniaeparptoip ctuaeirdinti hoernom eencotsi)r is hczdrtaaciree :by

csxesievE refe erwta tnentoier
Eiuveoclm ayrimahtnepo htiw innitudenyru aroc Na+ iocerxtne
riUne moioltslay &tg; msreu mliolayots

yodB nssedrop ot tearw tnrotneie hitw dnoereolsta adn NPA and P.BN Thta is htaw saeucs teh rcsdaneei yinrrua +aN otnecsrei hihcw lased ot moinaarnzloti of ucalreltlrxae fidlu lvemou nad eht lecuoivme ayoenhptimr.a

hello Why would body respond to water retention with ALDO? ALDO would increase water retention... +3

nala_ula @hello, the body's response is to decrease Aldosterone since there is increased volume retention and subsequently increased blood pressure. This concept confused me a lot, but I ended up just viewing it as separate responses. First, the increased volume retention leads to increase ANP and BNP secretion that lead to decreased Na+ reabsorption in the tubules (page 294 in FA 2019) and second, this increased volume basically leads to increased pressure so lets also decrease aldosterone so there is no Na+ retention (since water comes with it)... I thought it was counterintuitive to secrete so much Na+ since you're already having decreased serum osmolality (decreased Na+ concentration) because of the water retention, but I'm guessing that this is just another way our body's well intentions end up making us worse XD +22

compasses see page 344 FA2019 for SIADH. +

dickass author pasted text straight from FA but the arrows didn't copy over, inverting the original meaning +3

medninja The idea of increasing urine Na is getting rid of water, thats why this mechanism end increasing urine Na secretion even when there are very low serum Na levels. +

submitted by dr_jan_itor(64),

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Can aeyonn anresw why tsih neo nct'a be F. etaB mhatslieaa o?majr I aws hktnngii ecsabue of sih neaaim dna eht aoeu"epnr dsn"ecet whcih uelcsind hte riaeatndnmie nreauope.s sleUsn EMBN rserwit thkin tath opuenaer oyln asnme the neso hitw exatr htwie popeel llo

dickass European implies northern european (they even specified the patient was a person of pallor), mediterranean descent is usually implied by country of origin or by straight-out writing 'mediterranean'. +

poisonivy The MCV is normal, thalassemias are microcytic anemias, that hint helps to rule out the thalassemias. However, I got it wrong, not sure why it cannot be a homozygous mutation in the ankyrin gene +2

adong @poisonivy, other commenter pointed out it's autosomal dominant so best answer would be heterozygous +

submitted by jotajota94(14),

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eUs het nHber-Wadeigry oqeaiunt

Take hte aersqu roto of 16/,100 dan hatt wlil eigv uyo eth yeucfenqr of hte rscveeeis elalel = .401/
lceaulatC eth erynufqec fo teh oimntnda ellale itwh p=+,1q ihhwc is =p 90.5.7
Tyeh ear inleltg oyu ot aelatcluc the euqyrcfen fo hte eisdsae ,rrascrie hihcw si ihwt het oieqtuan pq.2
yThe tanw only teh eedasis iacrerrs in whihc nidolete si rt.enpes oT cceaaltul hits, esu teh q laeuv 041(/) nad plmuiylt by 80% in htis dohlus evgi oyu 0.0.2
a,lnlyiF etluaclca rof 2P 2q 0.79205.()=)(0 .400 = 1/.52

yex Nice! ...and we are supposed to read the stem and do all this in a minute or so? :-/ +14

charcot_bouchard Allele frequency 1/40. so carrier freq 1/20. 80% of 1/20 is 1/25 (80/100 x 1/20) +13

dickass Ah feck, 2pq got me +

hello_planet A handy shortcut for Hardy-Weinberg is that you generally can assume p ~= 1 if q if fairly low. It also tends to be easier to work in fractions if the answer choices are in fractions so you don't have to bounce back and forth between fractions and decimals. So with that, you send up with 2pq = 2 * 1 * 1/50 = 2/50 = 1/25. +1

submitted by breis(35),

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Bset cocie:h laMirt Rgreug

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 +3

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? +

submitted by hayayah(990),

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ailaFmli dtmaaeunsoo opssliopy is na ulootmasa ninatmdo it.toumna ssToahund fo slppoy eaisr agitstnr farte pt;erbuy lian;pcocno slwaay livvseon .emtcru tPlhiccopayr meotlocyc or esle %010 sgsprroe to CCR.

lotAmsaou doamintn seesasid ehv,a on rav,eeag %50 cheanc fo gebni despas nwdo to ofspif.rgn

sympathetikey I would say this is Lynch Syndrome (APC is usually thousands of polyps) but lynch syndrome would generally have a family history of other cancers as well, so you might be right. Either way, both autosomal dominant so win win. +1

smc213 uptodate states: Classic FAP is characterized by the presence of 100 or more adenomatous colorectal polyps +

dickass @sympathetikey Lynch Syndrome is literally called "Hereditary NON-POLYPOSIS colorectal cancer" +9

fatboyslim I think this actually is Lynch syndrome. Lynch syndrome can also develop colonic polyps but not nearly as bad as FAP. FAP has so many polyps you can't even see the normal mucosa. If you Google Lynch colonoscopy you can see that they develop a few polyps. +

cbay0509 some links for clarification FAP - https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-familial-adenomatous-polyposis?sectionName=Turcot%20syndrome&topicRef=2605&anchor=H625428197&source=see_link#H625428197 Lynch (HNPCC) - https://www.uptodate.com/contents/lynch-syndrome-hereditary-nonpolyposis-colorectal-cancer-clinical-manifestations-and-diagnosis?sectionName=Extracolonic%20manifestations&topicRef=2593&anchor=H4&source=see_link#H4 +

rockodude I forgot it was AD inheritance but regardless at the time I was confused because APC is a tumor suppressor so it needs two hits. I guess AD inheritance and then you need another hit to develop CRC kind of like familial retinoblastoma or li fraumeni syndrome +

submitted by dickass(78),

FA pg 70:

Vit E deficiency:

Neurologic presentation may appear similar to vitamin B12 deficiency, but without megaloblastic anemia, hypersegmented neutrophils, or serum methylmalonic acid levels.

dickass and VitB12 neurologic symptoms are described on pg 518 +

submitted by nwinkelmann(258),

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isTh enplaxsi ti erllya well whit a cri:etup mows/ly.tsdpuhptAti/aoasniattgwd.A/fli0/lt/.hotw.e:1mesah/ll2Phlm.

rHdcpoyi nhgcea = noe of eht rlaey snsgi fo elullarc ideeognetnra ni rpsseeon to iynurj ahtt ltserus in uactliacmoun fo ewatr ni the .ecll iiaH/opyxmcshaei eslda ot secdaee in recaiob risorineapt ni the nhamdoiocrti dna cdedeares PTA irdnpocuto eud ot uriefal of hte aKN++/ TaeAPs dnaiegl ot a+N dan eawtr snfuoiidf toni het .clle uddIalvnii tluueb ellcs aarpep slwleon and tp"m"ye ithw loasmt cdluedco m,elnu usurgomell si epuhlcrlylrea.

dickass it's basically from pathoma chapter 1: cellular injury causes swelling +4

md_caffeiner @dickass you why arent you on every q stem? +1

mangotango do you mean "causing failure of the Na+/K+ ATPase" instead of "due to failure of Na+/K+ ATPase..." ? The low ATP is due to dec aerobic respiration, I believe. +1

fatboyslim @Mangotango yes exactly. Na/K ATPase stops working due to the lack of ATP. I think nwinkelmann mixed it up +

submitted by step420(33),

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-CGBH adn S,HFHLS,HT rsahe emsa aphla bu,intus os HGC anc tciteaav othse croetrpes fi its in ihhg euohng qyniuta.t inActagitv LH rtoreecp wlil dale to mero ttenseosoreT fomr the gdieLy s.clel oerM estenetootrs cna ldea to emro rsteneog roaionfmt aiv o.asateamr

dickass bHCG directly increases testicular aromatase activity, it's not because of the increased amount of testosterone. +4

vulcania And for those who were wondering (cause I was), Sertoli cells have aromatase (FA 2019 p. 614) +2

submitted by medbitch94(29),

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WYH hes sha a euhg ass veril oto? I d'ton dstnrdaenu woh uyo can ocsohe ibg psnele oerv gib lveri or isav avesr

dickass I like big spleens and I can not lie~ +4

submitted by step420(33),

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Tish is inllmraue .iasgseen omrlaN seviaor tub natseb u.trsue

endochondral why not androgen insensitivity? +

shaeking I was wondering the same thing because doesn't androgen insensitivity also have normal female secondary characteristics. Was it the levels of hormones because she doesn't have abnormally high testosterone? +1

swb Androgen insensitivity has the same presentation and symptoms. What's the clue that it is mullerian agenesis instead ? +11

sugaplum Testosterone would be high if it was androgen insensitivity FA 2019 Pg 625 +12

charcot_bouchard Testo would be high in AIS. in AIS pubic hair, axillary hair doesnt devlop because of androgen insensitivity. both have normal breast dev and primary amenorrhea +1

dickass This is not androgen insensitivity because she has perfectly normal Estradiol, which means she has perfectly normal ovaries. She also has regular female levels of testosterone. +4

rockodude thank you @dickass +