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 +3  (nbme23#10)
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hyW is ti %99 and ton %?59 It kades for osnte of eesiads at sels hatn 9 yaser of ea.g mI' arlylec nsgismi ensgmihot rehe

cbrodo  @fulminant_life because the mean age is 3.8 with a standard deviation of 1.8. An age of onset of 9 years is nearly 3 standard deviations above the mean. Therefore, since we know +/- 2 SD covers 95% of the bell curve, it must be higher than that. The only option higher than 95% is 99%. +10
charcot_bouchard  Yes 9.2 was the upper limit for 99% CI. I picked 95 first because i thought 2.5% would be out of this range. But changed ans because it should be less than 2.5% because 9.2 is so close to 9. Also they are asking CLOSEST to which of the following? +4
aakb  I see what you are saying but you have to remember to add the things on the right side to include all the values under 9. So even if you go with the 2 standard deviations for 95%, youd have to add 2.5% that's on the left. which would be 97.5 and you know you would still add more on the left to get to 9 years of age so it would have to be closer to 99% than to 95%. hope that helps +

Subcomments ...

submitted by brethren_md(90),
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eriReqsu nowking ohw to ltacaecul an aionn pag - kolo it up. In tsih ec,sa ti is a rmaonl innoa agp aolicbmte a.iosscdi Know the msinumcneo DEMLISPU dna .HADSASR elnaR rlabuuT idcssoai is eth lnyo wrnsea hicoec that is an elepxam fo a nmlaro onnai mobiatcle

mousie  Anion Gap: Na - (Cl + HCO3) = normally around 10-12 +3  
seagull  good to know. I keep looking up the urine values but all it said was "varies", then I threw my computer and yelled "does that vary Mother F****ers. I do feel better now. +69  
_yeetmasterflex  glad I wasn't the only one who got very pissed off at the urine values +4  
fulminant_life  Usually the first thing I look at is whether or not the Cl- is high. Generally if the Cl- is high its going to be a normal gap +7  
henoch schonlein  i think they gave you the urine values bc you can calculate the URINE anion gap which is (Na + K - Cl). In this case the Urine Anion Gap is positive (5). Boards and Beyond mentions that a positive UAG is due to Renal Tubular Acidosis Type 1 (inability of alpha intercalated cells to secrete hydrogen ions). just another approach to answer this q +19  
270onstep1  Actually diarrhea is the "D" in "HARDASS"(reason why I was stuck between Chron's and RTA). Ended up getting it right with RTA.. +1  
talha_s  So the reason this is not Crohn's disease is actually what BnB explains in Renal Tubular acidosis video. Anytime there is a Metabolic Acidosis with intact kidney secretion of H+, the URINARY Anion gap (Na+K-Cl) is NEGATIVE. This is because the excess NH4 that is secreted into urine is combined with Cl-. Therefore, in Crohn's disease and Type 2 Renal Tubular Acidosis, the urinary anion gap is NEGATIVE. In this question, the urinary anion gap is POSITIVE so this would be an example of Type 1 RTA because the kidney can not excrete H+. I got it right by chance, definitely did not understand it in this much detail when I was answering it lol +8  

submitted by m-ice(340),
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hsiT onmaw sha a olt fo ginss htta iotnp wdorat an lteininats rictiaasp :tfonciien rnecte avrlte ot paPau eNw iueGna, ugcoh and lvlroaea tlretfai,nis gihh lnhsiopoie ,untco adn a ostlo plseam ttah has a womr in i.t Msto lykiel het patetni hsa a oylidgSestnro ,enitnofci sa hsti is het ntisetnila easiatpr taht swhos avlar on otosl aclaylsiB all lasinnttei atsrspiae can be eedtrat twih azBldeone rg,uds hcus sa .doelinTzabahe rzutaeniqPal udlow be oemr rtapiepparo for a rwom ro evlri lfkeu

fulminant_life  just to add to the explanation above," cutaneous larva currens" is a specific finding for strongyloides. Also the picture they used is the exact same one on wikipedia lol +9  
yb_26  they really should add Wikipedia in the list of top-rated review resources with A+ level of recommendation in FA2020))) +10  
usmile1  also a side note: cutaneous larva CURRENS is pathognomonic for strongyloides whereas Cutaneous larva MIGRANS is for ancylostoma braziliense or nectar Americanus +5  
solgabrielamoreno  FA 2019 pg 159 . Bendazoles because worms are bendy. (Treatment for roundworms) Praziquantel is for Cysticercosis (Taenia Solium) and Diphyllobothrium Latum Mefloquine : treats malaria Hydroxycloroquine: treats Malaraia, also RA & Lupus (immunisuppresive & anti-parasite) Dexamethasone: Steroid for inflammation +2  
abhishek021196  FA20 says Ivermectin OR Bendazoles for Strogyloides, so in a future question, if Ivermectin is listed, that could be the right answer for this as well. +2  
jurrutia  When in doubt, pick a bendazole +  
jurrutia  When in doubt, pick a bendazole +  

submitted by medstruggle(12),
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aCn eemoons apnxile why seod ihts tpetnia aevh mikypeh?aola

colonelred_  Catecholamines activate the Na/K pump, which will drive K inside. +11  
trazabone  Read online that catachelamines are released following tonic clonic seizures. Besides that, BP of 180/100 could indicate that catecholamines are circulating. +1  
fulminant_life  This mechanism is why giving albuterol for hyperkalemia works +9  
nbmehelp  Why does this guy have increased catecholamines tho +  
johnson  His SNS activity is seriously increased --> increased catecholamines. +  
nbmehelp  Why is his SNS activity increased? Is the BP literally the only hint? +  
youssefa  Alcohol withdrawal creates a hyper- catecholaminergic state + Seizures do that as well. +5  
water  My best guess is that withdrawal puts the body in a state of stress (same for seizures) and with stress you have release of catecholamine which we'll see in the BP and the hypokalemia. +3  

submitted by vshummy(163),
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So hte sbte i lcduo fdni was in Fsrit dAi 1902 pg 346 uednr eDabciti tsioseico.dKa Teh maileyeygphcr adn kyrepaeialmh ceaus an ocmisto duresisi os the eentir doyb steg eltpeedd of udsfil. ceeHn hyw ratp fo teh rnettamte rfo AKD si VI ldi.sfu Yuo ithgm even yler on atth icpee fo tminrifonoa aloen ot nesawr iths ,ntisoequ that ADK si tetaerd thiw VI fsuli.d

fulminant_life  I just dont understand how that is the cause of his altered state of consciousness. Why wouldnt altered affinity of oxygen from HbA1c be correct? A1C has a higher affinity for oxygen so wouldnt that be a better reason for him being unconscious? +6  
toupvote  HbA1c is more of a chronic process. It is a snapshot of three months. Also, people can have elevated A1c without much impact on their mental status. Other organs are affected sooner and to a greater degree than the brain. DKA is an acute issue. +6  
snafull  Can somebody please explain why 'Inability of neurons to perform glycolysis' is wrong? +3  
johnson  Probably because they're sustained on ketones. +3  
doodimoodi  @snafull glucose is very high in the blood, why would neurons not be able to use it? +2  
soph  @snafull maybe u are confusing bc DK tissues are unable to use the high glucose as it is unable to enter cells but I dont think thats the case in the neurons? +1  
drmomo states its primarily due to acidosis along wth hyperosmolarity. so most relevant answer here would be dehydration +1  
drmohandes  I thought the high amount of glucose in the blood (osmotic pressure), sucks out the water from the cells. But you also pee out all that glucose and water goes with it. That's why you have to drink and pee a lot.. +7  
titanesxvi  Neurons are not dependent on insulin, so they are not affected by utilization of glucose (only GLUT4 receptors in the muscle and adipose tissue are insulin dependent) +25  
drpatinoire  @titanesxvi You really enlightened me! +  
mutteringly  I don't make the connection of what titanesxvi said to the question - can someone explain? +  
motherhen  @mutteringly it explains why the answer choice "inability of neurons to perform glycolysis" is wrong +1  

submitted by m-ice(340),
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sihT tioueqsn ynlo soncncer enmwo in het 54-50 age .rpguo eTh pugro sha a anem of 264 dna dsrtdaan oiienvtad of 0.5 e,fTreerho lal tesho thiw aulsve rtaereg hnta 962 rea lla sohte vaobe oen dtandsar eitnda.iov /32 of lla slveua no a lrmnoa iiutodinbsrt era tiwihn neo drantsad vodiaeitn ni ehteri onit.drcei ere,fToehr 31/ rea soeuidt of iths ni eehtir trii,econd enimagn /31 fo mnwoe aevh a euavl essl atnh 961 or arrgtee than 926. fI we slitp ttha in aflh to lony ohceso estoh aeetgrr tahn ,629 ew teg 1/6 nm,ewo chiwh si uabto 61%.

guillo12  Sorry, but there is not other way that I can understand this? +1  
fulminant_life  @guillo12 basically 67% fall within 1 sd. That means that 33% are +/- >1sd. So taking only those with above 296, you only look at those >1sd above the mean which is 16.5% . The other 16.5% are those >1sd below the mean. +12  
guillo12  Thank you!!! @fulminant_life +  

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uYo nwok tis’ na elpdeevon rsivu sceni ti dsoen’t lhod up ot cadi or enigb d.edri uoY know ti scsuea a reevf dna a ,cuhog lehwi afcngefit eht yr.nlxa Olny vsrui acgrtoye thta sitf lla atth noif is hte uoarirsvcon (escusa )ASRS mfor atht .ilts

zelderonmorningstar  EBV doesn’t cause fever and cough? +1  
zelderonmorningstar  Wow, just checked First Aid and it doesn’t list “cough” as a symptom of EBV. +4  
drdoom  EBV is not a “respiratory virus”; it’s a *B cell virus*. Even though you might associate it with the “upper respiratory tract” (=kissing disease), it doesn’t cause respiratory inflammation since that’s not its trope. B cells are its trope! That’s why EBV is implicated in Burkitt Lymphoma, hairy leukoplakia and other blood cancers. (EBV is also known as “lymphocryptovirus” -- it was originally discovered “hiding” in *lymphocytes* of monkeys.) So, EBV = think B cells. +27  
fulminant_life  EBV does cause pharyngeal and laryngeal inflammation along with fever, malaise, and cough and LAD. The only thing that pointed me away from mono and towards coronavirus was the patients age. +7  
nbmehelp  Can someone explain what not holding up to acid or being dried has to do with being enveloped? +  
yb_26  @nbmehelp, the envelope consists of phospholipids and glycoproteins => heat, acid, detergents, drying - all of that can dissolve the lipid bilayer membranes => viruses will loss their infectivity (because they need an envelope for two reasons - to protect them against host immune system, and to attach to host cells surface in order to infect them) +10  
lowyield  @yb_26 does that mean that non-enveloped viruses hold up better to acid/dryness? +2  
rina  yes enveloped viruses are easier to kill (see post from drsquarepants: also i think the "when dried" might refer to the fact that coronavirus is spread by respiratory droplets (don't even need to read first aid can just read the news at this point!) +3  

submitted by m-ice(340),
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The tenipat dense damleci aotnttein die,mtmyalie hwcih taileiesnm oaiitnbng a corut ordre, or afrnrgtsinre hr.e A runes sdoe ton aevh hte esma nriniatg dan islfaiuaqciotn sa a yipcn,iahs so it olwdu eb enraitppoarpi to ask mhte ot xaimnee eht anptiet. nkAigs eht plaisoth pncailha angai docul eb ,opiipaneprrat dan dluwo teak roem t.eim froeTre,he the esbt ootnpi ngmoa steho gevin is ot ksa the tteanip if hes iwll waoll whit rhe bahdsun .spnerte

sympathetikey  Garbage question. +60  
masonkingcobra  So two men is better than one apparently +29  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gárbágé +4  
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +12  
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. +9  
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +16  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +26  
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +  
niboonsh  This question is a3othobillah +5  
sunshinesweetheart  this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +5  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +12  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +11  
korahelqadam  All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +  
sars  This is a very fair question. I agree with sunshinesweetheart above. That is all. +  
wrongcareer69  Garbage question +  
alimd  well we should wait for the question "if a man shouts I CANT BREATHE with a police knee on his neck, what is your next step? Ans- wait 8 minutes." +1  

submitted by mousie(220),
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Wyh no etgwns?ai I eanm I teg ycEasst si pylbrabo the dugr of eohicc foerbe na lal hintg denca ypart l(o)l tbu o'tnd ntsdnedaur hyw terhe woldu be ldoc tetemirixes nda on stwinega nhew si FA it ssya hrphymerieat dan rdb??ho??a

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. +12  
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. +12  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +20  
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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rTyeexpdilhihn nda oBnenirpzte aer autmaiirscsncin atth can raett the rsetign terrom dna giyirdti fo niosmink.aprs

mousie  haloperidol induced Parkinson's... ? adding a anticholinergic can counter these adverse effects of the antipsychotic .. ? +3  
fulminant_life  @mousie yeah it balances the dopamine-cholinergic imbalance caused by the antipsychotics +  
kai  +So antipsychotics induce Extrapyramidal side effects which is drug induced Parkinson = low Dopamine High Ach, and you would treat this with anticholinergic (Benztropine).This is neurologic. +Antipsychotics also produce non-neurologic, systemic anti-cholinergic effects like dry mouth, sedation, hypotension etc +  

submitted by yotsubato(1041),
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Wsa it utsj ,me or ddi "eag ta sonet in sy"rea aparpe GRHTI oeavb the nrmbeu fo sinp,etta htarre naht eth an.em hihcW suncfoed em orf a odog 3 ntseium.

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" +5  
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