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Contributor score: 1051


Comments ...

 +0  (nbme19#47)

I got confused with aquaporins so I picked E :(

But aquaporins are in the collecting duct, NOT the proximal tubule

j44n  there are AQP's in the PCT but they're not that abundant. Look at it this way, AQP's are by definition a transporter and therefore they can be saturated. The PCT is the king of all resorption and a big reason for that is paracellular transport, which can't be saturated. This also makes sense as to why we can treat nephrogenic DI witha thiazide, it causes INCREASED resorb at the PCT which can over power the rest of the nephron. The PCT does everything and the rest of the nephron gets the left overs +2


 +0  (nbme19#40)

I put C because I thought that the weakness of the lower 2/3 face meant there was something more going on than just speech problems from Broca's aphasia.

Can anyone tell me why I'm wrong?

drdoom  A: Broca’s +
drdoom  B: Premotor +
drdoom  C: Motor +
drdoom  D: Somatosensory +
drdoom  Damage to C (motor) wouldn’t explain *fluency* problems. Fluency (=Latin ``flow``; the ease with which the brain formulates words). Slurred speech is your brain knowing and formulating the words easy but your mouth muscles not co-operating! +
drdoom  So, dis-fluency ≠ slurred speech. This gentleman is dis-fluent in the same way you’re dis-fluent when you visit Paris: your brain struggles to formulate French words in the first place! The only lesion that explains that in your native tongue is a lesion to the language synthesis center = Broca’s area. +


 +4  (nbme16#24)

Morphine stimulates mu opioid receptors to provide the desired effect of analgesia, but in doing so can also precipitate many undesired effects.  This patient has multiple signs of opioid toxicity, including miosis (ie, pinpoint pupils), respiratory depression (evidenced by slow respiratory rate and respiratory acidosis), and CNS depression (eg, somnolence, coma).  Morphine is primarily metabolized by the liver via glucuronidation to form 2 major metabolites.  These metabolites, morphine-3-glucoronide and morphine-6-glucoronide, then undergo renal elimination via excretion in the urine.  Because the metabolites are metabolically active, renal dysfunction can lead to metabolite accumulation and opioid toxicity.  Morphine-6-glucoronide is particularly responsible for toxicity, acting as a more potent mu opioid receptor agonist than morphine itself.

Due to its metabolically active and renally cleared metabolites, morphine requires careful monitoring when used in patients with renal dysfunction.  When opioid pain control is needed in such patients, fentanyl or hydromorphone is often preferred as these drugs are predominantly hepatically cleared.

Source: UW18563

caramel  I got this answer through the process of elimination. I figured that A/C/D would NOT cause the pt to have an overdose. And with B, she wasn't using it chronically (3 days..) +
helppls  What drugs inhibit their own metabolism? +

 +9  (nbme16#1)

ACUTE alcohol inhibits CYP → Increased bioavailability of acetominophen

CHRONIC alcohol induces CYP → Induction of cytochrome P450 enzymes that activate acetaminophen to a hepatotoxic metabolite


I got this wrong because I assumed chronic alcohol meant years and years. I guess a weekend will suffice?

Honestly, fuck this problem.

lfcdave182  Yeah fuck this question. 2-3 days of something would never be considered chronic in anything else. +4
pontiacfever  Drink a lot for a week makes you a chronic alcoholic? +
pontiacfever  That means alcohol abuse = chronic alcoholism +1
skilledboyb  Why would increased bioavailability of acetaminophen place the patient at increased risk of liver injury? What's dangerous about that? +
i_hate_it_here  Metabolism of acetaminophen turns it into toxic metabolites (NAPQI) that inhibit glutathione in the liver forming toxic tissue products. FA2020 pg: 485 +2

 +0  (nbme15#0)

Image from problem

Fluent speech, impaired comprehension → Fluent aphasia → Wernicke's area

Here are the others (as near as I could tell):

A: Broca's area → "Broken Boca" → would present with non-fluent speech with intact comprehension

B: ?

C, D: Motor cortex

E, F: Sensory cortex

G: ?

H: Wernicke's area


No idea what B or G are.

Here's a relevant image from Amboss

kahin  B-Frontal eye field? G-Parietal lobe +
specialist_jello  G : Gerstmann syndome? angular gyrus? not sure +
pakimd  G does look like angular gyrus since it is right above the wernicke area +

 +3  (nbme15#0)

These are really the only two that should be on your differential for a diaphragmatic hernia:

A: Abnormal relation of the cardia to the lower end of the diaphragm | Sliding hiatal hernia

B: Protrusion of the fundus into the chest above the level of T10 | Correct! This describes a paraesophageal hernia.

different hernias

parts of stomach

cheesetouch  FA2018 P364 +

 +3  (nbme15#0)

(wrong answer explanation)

Intermittent obstruction of the common bile duct is wrong.

Biliary tract obstruction would have:

↑↑ direct (conjugated) bilirubin (normal 0.0-0.3, pt was 0.4)

↑ Alkaline phosphatase (normal = 20-70, pt was 35)

hungrybox  source: pathoma +

 +1  (nbme15#0)

A: Anal carcinoma | Would not be so acute

B: Anal fissure

C: External hemorrhoid | Correct!

D: Human papillomavirus infection

E: Skin tag


picture from the problem

picture showing most answers

*couldn't find a good image for anal carcinoma, if someone wants to share one that would be great

drdoom  wowee that’s a lot of butthole .. +9
hungrybox  hawt +1
underd0g  Why isn't this HPV given the sexual history? +1
prosopagnosia  Anal fissure and Anal carcinoma - would present with rectal bleeding which our patient denies. HPV could lead to anal carcinoma and the image isn't similar to the morphology of condylomata acuminata. External hemorrhoid is the only one that presents with rectal pain (due to somatic innervation from the pudendal nerve) and no bleeding. +1

 +2  (nbme15#29)

A: Gonadal mosaicism | Present in child, not parent → would not have family history of disease

B: Incomplete penetrance | Correct! Half of children affectd, skips a generation → AD inheritance likely.

C: Nonpaternity → Prader-Willi

D: Somatic mosaicism | Present in parent, not child → would not have family history of disease

E: Variable expressivity | Affected patients have varying disease severity → Rule out b/c mother is unaffected

cassdawg  Also, nonpaternity can be a way of saying that the assumed biological father is not actually the father (can be a case of artificial insemination or cheating, etc.). +2
beto  In genetics, a non-paternity event is when someone who is presumed to be an individual's father is not in fact the biological father. +

 +4  (nbme15#0)

Excess pattern repeats lead to strand slippage/errors due to an unstable region (in this case, excess Cytidine bases).

It could be a repeated pattern as well (ie the trinucleotide repeat CAG in Huntington's).


here's a more in depth explanation (from wikipedia article on Slipped-strand mispairing):

A slippage event normally occurs when a sequence of repetitive nucleotides (tandem repeats) are found at the site of replication. Tandem repeats are unstable regions of the genome where frequent insertions and deletions of nucleotides can take place, resulting in genome rearrangements.

hungrybox  Anyone know why it's not Transposon insertion? I was thinking maybe because transposons have to be longer than one nucleotide, but I'm not sure. +5
bingcentipede  @hungrybox I think it's because transposons are usually gene segments rather than a single nucleotide insertion - plus w/ what you said about the repeated pattern, I think slipped-strand mispairing (which is a concept the NBME loves) more likely. +23
i_hate_it_here  cool so why do I need to know this +2

 +1  (nbme21#22)

I’m trying to really learn this and know how to rule out all the answer choices. So far I have:

A: Anaphylactic reaction induced by IgA antibodies <2-3 hrs

B: Hemolytic transfusion reaction <1 hr

C: Postoperative bronchopneumonia Pneumonia, right after all the infusion business and no mention of fever or anything? Nah

D: Pulmonary embolus with pulmonary infarction

E: Transfusion-related acute lung injury Correct! Occurs <6 hrs


I was thinking D could be ruled out b/c there’s no mention of history of immobilization/hyper-coagulable states. And I guess it seems obvious the question is focusing on the transfusion. Seems kinda iffy though. What do you guys think?

pass_this  I actually got this wrong and chose D. But the question completely is trying to lean you towards transfusion and like you said no reason for PE. +
blindophthalmologist  Bilateral lung infiltrates makes it sound more of a immune process. CXR of a PE can be normal I believe. +
lovebug  and also, as you all know B) clinical Sx of Hemolytic transfusion reaction is hemoglobinuria and jaundice. there is no such thing. so rule out :) +

 +3  (nbme21#21)

A: Anterior to the nasolacrimal duct → angular artery* pic1 pic2

B: Distal to the vestibule → respiratory region/nasal airway proper pic

C: Inferior to the hiatus semilunaris → uncinate process pic

D: Posterior to the middle concha → sphenoid sinus pic

E: Proximal to the fusion of the hard and soft palate → horizontal plate (of palatine bone) pic

F: Superior to the superior concha → sphenoethmoidal recess pic


*I was really conflicted on what this could be referring to. Ultimately, I thought angular artery aligned the best with being anterior to the nasolacrimal duct, but I'm not 100% sure.

other things I considered: maxillary bone, inferior concha


 +2  (nbme20#17)

Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question.

To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs."

The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc."† So you can rule out nipple stimulation.

It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect.


I've never seen anything like this on a question but I assume the NBME would word it in some convoluted way like that.


I initially wrote this as a subcomment, but I feel like it deserves its own comment. I was never really satisfied with any of the explanations for this problem, and I finally arrived at one that makes the most sense to me.

hungrybox  Oh, and besides, nipple stimulation and prolactinoma aren't even answers lol +
drdoom  [system mailer] your account has been upgraded: FORMAT NINJA +1

 +8  (nbme20#20)

Mitral valve stenosis only causes LA overload. In contrast to ventricular overload, atrial overload does not cause any axis deviations.

Thus, mitral valve stenosis is incorrect.

(I was between this and mitral valve stenosis.)


 +16  (nbme24#31)

I really didn’t understand this question even after reading all the answers here so I emailed Dr. Klabunde (the expert)!

Here’s what he said:

This is a case of acute heart failure following an acute ischemic event (ST elevation in anterior leads). SVR increases because of neurohumoral activation, which helps to maintain BP. PCWP increases because acute HF causes blood to back up into the pulmonary circulation. Increased pulmonary blood volume causes all the pulmonary pressures to increase. PVR DECREASES because the pulmonary vasculature has a very high compliance, and therefore passively distends in response to increase volume. This passive dissension decreases the PVR.

motherhen  I thought in cardiogenic shock, PWCP can be increased or decreased depending on if the blood is backing up in the lungs (LHF) or body (RHF). Can someone clarify how we know which is happening here? +1
motherhen  *PCWP +
jsanmiguel415  They say it's an "anterior STEMI" which to me meant V3, V4 aka LAD, which supplies the left ventricle so increased PCWP. If PCWP was decreased it would mean right ventricle is disrupted which is more RCA and would be II, II, AVF or an inferior leads +2

 +0  (nbme24#50)

Big Robbins:

https://i.imgur.com/gQnDH92.png

Idk how you could say that it's from extracellular dehydration, but whatever I guess.


 +7  (nbme24#23)

(D) Portal hypertension: Portal hypertension is a complication of longstanding alcoholism, but it is not the cause of acute or chronic pancreatitis.

In acute pancreatitis, alcohol transiently increases pancreatic exocrine secretion and contraction of the sphincter of Oddi (the muscle regulating the flow of pancreatic juice through papilla of Vater).

This leads to activation of pancreatic enzymes and acute pancreatitis follows soon after.

In chronic pancreatitis (as in this patient), alcohol increases the protein concentration of pancreatic secretions, and this protein-rich pancreatic fluid can form ductal plugs.

Made this explanation in case any of you were dumb enough to think "pancreatitis → alcohol → portal hypertension" like me.

hungrybox  oh my source was big robbins btw +
regularstudent  I was definitely dumb enough +3

 +2  (nbme24#13)

(D) Fecal impaction: While this patient presents with some signs consistent with fecal impaction (inability to defecate for days or weeks, distended/tympanitic abdomen), fecal impaction typically presents with hard, impacted stools distending the rectum. Since the rectum is left sided, it's unlikely to present with a right-groin mass.

That's the explanation I came up with after reading the Amboss wiki


 +3  (nbme24#43)

Section on Endovascular Stenting from BIG ROBBINS (for people like me who need more context):

https://i.imgur.com/mhRrpwl.png

https://i.imgur.com/e9mO0Nz.png


 +1  (nbme24#5)

vs. eggs (ova) in stool → Hookworms*, Ascaris

vs. larvae in stool → Strongyloides stercoralis

vs. scotch tape test → E vermicularis

hookworms → Necator Americanus, Ancylostoma duodenale

(source: sketchy)


 +4  (free120#3)

Other answers:

sebaceous gland → acne, Cutibacterium acnes (formerly Propionibacterium acnes)

apocrine gland (aka sweat gland) → The substance secreted is thicker than eccrine sweat and provides nutrients for bacteria on the skin: the bacteria's decomposition of sweat is what creates the acrid odor.

eccrine gland → used to secrete stuff inside the body (ie salivary glands, pancreatic glands)

dermis → middle layer of skin.

melchior  To tweak the above a little, eccrine glands are more commonly known as "sweat glands," although sweat glands that are apocrine do exist in the armpits and perineal area, though they do not contribute to cooling. +3
acidfastboi  Per what @melchior said: "Eccrine glands are the major sweat glands of the human body, found in virtually all skin, with the highest density in palm and soles, then on the head, but much less on the trunk and the extremities" - Wiki +1

 +8  (free120#7)

This whole question is on the different types of hypersensitivity. (pg. 113 FA2019)

eosinophil degranulation → Type 1 hypersensitivity (mast cells early, eosinophils/others later)

widespread apoptosis of B lymphocytes → B lymphocytes are involved in Type 2 hypersensitivity. Widespread apoptosis would not occur. If anything, B cells would proliferate?

Cytokine secretion by natural killer cells → NK cells use perforin and granzymes to induce apoptosis in type 2 hypersensitivity. (Not sure if they secrete any relevant cytokines...)

immune complex deposition in tissues → serum sickness (Type 3 hypersensitivity)

polyclonal T-lymphocyte activation → type 4 hypersensitivity


 +6  (nbme23#5)

TLDR: Physical symptoms >> family history or anything else.

Like the other guy said, I got played hard.

I thought:

• poor prenatal care

• no family history

• bone problem/fractures

Instantly pointed to Rickets.

BUT, in retrospect this is key:

• intercostal retractions (vs. rachitic rosary → costchondral thickenings)

They're basically telling you to rule out Rickets. It seems 100% unfair b/c poor prenatal care seemed to rule in Rickets. The no family history seems to rule out OI.

But I guess what I've learned is, physical symptoms trump ANYTHING ELSE on NBMEs.


 +9  (nbme23#15)

Fucking NBME test writers lmao

Me: "Wait... isn't the answer 25.9? How come I don't see it here."

NBME: "Oh yeah, we rounded it."

Me: "To 30? I don't see that here, either..."

NBME: "No, to 28.8"

tyrionwill  When I got 25.9 and found nothing exactly matched, I guessed that the maintenance dose might be a bit more due to the bioavailability. So this antibiotic probably was not an I.V. formula, but an oral one, with a roughly 90% BA. +2
eradionova  Well then it could have been equally likely that it had a 50% BA and the answer would be 51.8 exactly. I almost considered picking that but in the end stuck with the one that was closest to my answer lol +2

 +4  (nbme22#10)

Cavernous nerves are most commonly injured in prostatectomy. They are parasympathetic nerves that signal penile erection.

S2-S4


 +2  (nbme20#7)
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Teh drnmdeeo of het rd3 dan th4 cphusoe ormf eht iyraarpdhto ldang nad het paarlauoilrflc eclsl fo eht odtiyhr gda.nl


 -6  (nbme20#33)
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r'eHes ym rgisennao rof ywh het awners I cshoe saw .g.nro.w

nseiCa is a mlki rio.etnp eBaescu msot mlki si rusaedp,etzi lla trsneipo lwil eb adneuerdt erfoeb mtcp,unisnoo nda udwlo otn ahev yna tfceefs Cec(hoi B).

Tshi is in otarsntc ot dv,aini chhwi si udofn in RWA eggs dna nisdb mvniita B7 n,bioi(t) einenvrpgt .looirbtcyaxan

...

ltuhbsli sinetquo wtb 😡


 +4  (nbme20#5)
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I did ihst yb eoscprs of :eoinmntiali

cenA si ont yhcit or uailfpn rmfo ym exrienepec ihcC(eo .)A

rvNee edhra of seuouacnt usplu aoheset,rtyusm tub I'd sasusem 'oyud vaeh a maral ahsr (iovingvnl het eeenysudnero/ area), not sdpare tou ovre teh kee,hcs j,aw nda cekn (oicheC B.)

oeldKis ear ujst oeowrvnrg sacr.s rscSa aer tno plurlataciyr ihcyt or liuanfp oCc(ehi C)

esoaRac is sjut nfeslunsdh/regsi in nectrai seara fo het ki.ns nyiMal na aeesthcti ssui.e Nto cyhti ro alifpnu chieoC( E).

tbh I wsa wteneeb B and .D


 +11  (nbme20#30)
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He'ers ym hcrppoaa no(ovtwed if )nrw:go

lingalf on oreehttsutdc arm → lluyaus oisadphc

UBT

aphcosdi mrlepbo → iapn in ataonaimcl bsnofxuf

so enth it geos to hte etnx ostm conmlmyo rjuined oenb ewhn ouy lafl no na ehcstuedrott mr,a ruyo tnlaeu

wcih(h is htrgi exnt to hte dsicah)op

spaceboy98  Also, dislocation is most common in lunate, Fracture most common in Scaphoid +4

 +0  (nbme20#25)
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oS... hetciroyetall na tolsieda screaede in RH doluw aenrecsi OC deu to in.c lapd,oer thg?ir

Btu CO resdsceea in sith asec /cb teh cefeft fo nc.i RTP is mreo rlewo?pfu

kernicterusthefrog  @hungrybox: No. Isolating HR, you would look at CO like this: CO=HR*SV so if HR or stroke volume go down, CO goes down. The change in preload wouldn't affect the CO as much as the change in rate of flow. So, the decrease in CO is solely due to the beta1 blocking effect on the AV node to decrease HR. +

 +11  (nbme21#44)
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ohtre snr:wesa

niiointhib of 2H :toseprecr ro(f RDE)G etenprv grasitc acdi eetricson (i,indetemci

hiiibinotn fo oosserhppasshteide D(E):P

  • lloheypeinth (asath)m tihibnis PAcM EDP
  • lansfi- (cikd )sllpi rof ED hbtniii McGP EPD

2β ogntss:ai fo(r mas)ath uesac nothrdlicoiaonb

  • arlluboet t(shro agtnci - A orf tecA)u
  • etalsmeorl, telrrfomoo (ngol gtcani - pl)hpiyoaxsr

(ikd mtyplhcoey benmarme to)inlazaibtsi

hungrybox  H2 blockers are the -tidines +2
yotsubato  > dickpills lol +17
temmy  hungrybox, you are a life saver +1
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2

 +6  (nbme21#24)
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iyMpclasooc,clra suuqsoam cell mioaaccrn tnesd to be fwetfh-oi in cr,loo sirniga ,mrof adn egxnitden otni a urh.csobn

e:cSuor daipiReoad

privatejoker  Lol am I the only one that picked Malignant Lymphoma? I thought I remembered Sattar mentioning that metastases are the most common form of cancer to be found in the lung? I tend to pick the "most common" presentation when given so little information to work with +2
blueberrymuffinbabey  but metastases typically present with multiple lesions so I think at least in exams when it's showing you a solitary lesion, think a primary tumor. +4

 +30  (nbme21#17)
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whne idff sginle ntadrs prraie hismesamnc era e:sud

  • eaprri ywnel znyisshdeet d:sratn hasmcitm piaerr c(ynhL seodryn)m
  • riaepr iymndrpiie mseidr sacude yb tad VU eoruepsx: cluienedto osniicxe ieparr ma(rorXdee smgi)npemuot
  • epirra stncieso/tnupaoxo rnaet:ailot seab ocnesixi rripea
meningitis  Brca: recombinant repair +
brotherimodu  P.40 FA2019 lists the different DNA repair mechanisms +2
teepot123  fa '19 pg 382/3 +

 +7  (nbme21#36)
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iidetnierUvF ;&g-t ueds orf sfnuio of IVH vsiru dan rtetag llec

aishu007  we can also say it enfuviritide blocks entry +
aishu007  of virus into cell +

 +8  (nbme21#25)
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Relntave agadimr

ITAI roctsisctn hte eenterff ereaitrl.o ECA tibnshirio cbklo teh EeadeitCAd-m onirvsonec fo IAT to .IIAT


 +9  (nbme21#34)
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ynaocmheisy opetds thsi egart pci lwobe

eacv  here is a video for ilustration https://www.youtube.com/watch?v=US0vNoxsW-k +2

 +5  (nbme21#38)
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My rsoinmsipe of hciiemtAnopr B is thta tis' eth BIG SGNU. It istarhtg pu tkcatas hte essltro in eht ngufi samapl ebe.arnmm

weenilMah lil htcib gruds kile leazs-o sjtu niihtbi oesrtl etnsshiys. anfbriente-i( X asolotnrel, zeo-lsa X rgetl)eoors

Finungs X llec llwa sentisyh,s tcylineusfo X nceiclu dcai yie.hssnts

et-tu-bromocriptine  Rule of thumb/shortcut: Nonserious fungal infections: treat with _conazole Serious fungal infection (eg, immunocompromised patients with disseminated infection): treat with amphotericin B Additional info The main classes of antifungal medications for usmle include: Polyenes (eg, amphotericin B, nystatin) - Bind to ergosterol molecules in fungal cell membranes, creating pores and causing cell lysis Triazoles (eg, _conazole) - Prevent the synthesis of ergosterol, a component of fungal cell membranes Echinocandins (eg, capsofungin, micafungin) - Inhibit the synthesis of glucan, a polysaccharide component of fungal cell walls Pyrimidines (eg, Flucytosine) - Converted to 5-fluoruracil, which then inhibits fungal RNA and protein synthesis +2
et-tu-bromocriptine  Ripppp the formatting, but hopefully the idea gets across +
et-tu-bromocriptine  Fixed it, see comment! +

 +27  (nbme21#49)
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odohryliztHeidcorah si a tiheidza eidrticu g;t&= iiezthda iesriudct era ieatsosacd wiht oihy.aleamkp

haWt otreh iidtesurc rae eitaodsacs tiwh eo?mahlakpyi oLpo secrdtu.ii

?Wyh

bnniihIoti fo +Na panboserirot curocs in htob olpo iustceidr hiiit(nb NCKC nrsopa)ettrorc adn edtizahi srcdueiti ibh(tnii NlCa r.oroerrpatstn)c llA of hits ierndesca Na+ eeiasnscr lrdeeonsAto .ytcviita

atenelRv to shit lmrpbo,e dterleonsAo puearuglest peirneoxss of eth Na+/+K ATP nrarietopt bbseroar( N+a iton ,oydb elpex K+ otni n)ulm.e sThi tsusrel in lakamhoieyp ni hte d.oyb

gHan o,n 'hesetr oemr hhgi yleid nifo!

oonsdAtreel dose oen reoht torpminta ntihg - natioactvi of a H+ lcenhan atht seplxe H+ onti het lmuen.

So, nvgei atth iths pttaien sah pkyiahlema,o oyu wkno reeht is ueganltruipo of dAee.osonlrt oD oyu ihknt erh Hp uwold be g,hhi or w?ol xyEtlac, ti owdlu be hhig eesuacb in.c lseteAdonor =;tg& nc.i +H lleedpex onti teh meunl =;> cmielobat so.aakils

Nwo uyo ntrnduades why hbot loop ticrseuid nad ahizietd sericutid can sceua 'shwat cldlea kcehym"oaipl oacbltiem kla"sl.iaso

hungrybox  jesus this answer was probably too long i'm sorry +9
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +14
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +1
amirmullick3  @hungrybox did you mean "All of this DECREASED Na increases aldosterone activity."? +1
pg32  Anyone care to explain why she feels she has, "lost [her] pep"? Is that due to the hypokalemia? Or hypercalcemia caused by the thiazides? +
cmun777  @madojo @pg32 I assumed between her hypokalemia (which can cause weakness/fatigue) and possible contraction alkalosis those were the most likely causes for the "lost her pep" comment. I think if they wanted to indicate hypercalcemia to differentiate if loop diuretics were also in the answer choices they would certainly give more context for hypercalcemia sx +

 +8  (nbme21#12)
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Gater dvieo I esud ot naler sthi tramleai.

  1. eerhT aer 3 arjmo stpye fo u:drgs pesupr t,salmunti(s) ewndrso )rpssade,ets(n dan lhsoclngan.uie
  2. Horine si an ii.opod iiOspdo ear e.*orwsdn
  3. onwresD do waht it ossudn iek.l Tyeh cuesa o"n"dw tsmopmys: enaoddeasc/ieretds texiyan d(na suth rleaoivbah iniid,shnibot)i aroretsipyr psios.deren
  4. Tsuh awaltrhiwd will seuca het pptooe:si ,act/ydanoainsehcphreyrit ix.antey
hungrybox  *other downers: alcohol, benzodiazepines, barbiturates +2
nwinkelmann  THANK YOU! for the link to the video. this is one thing I've ALWAYS struggled with. +
qball  I get that this is a good rule of thumb to help narrow down between alcohol and heroin, BUT is still not enough to answer this question. Some key features for depressants (downer) is alcohol (if we are talking mild withdraw) - tremors , diaphoresis and delirium (heavy withdraw) . For Heroin - Dilated pupils, yawning and lacrimation are key exam findings. +1

 +7  (nbme21#1)
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hTe civxer is hte lyno eutrutrsc taht owlud tslreu in bietallar kbe.ldoca

hungrybox  hydronephrosis = dilation of kidney (usu. due to obstruction at uretopelvic junction or backflow from obstructed bladder) +2

 +8  (nbme21#44)
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poLo ticurdsei ear rsitf lnie rfo tceau ntvicsoeeg tehar i.flauer tTah dlhsou lhpe yuo remeremb htta eyth aer eht smot ntoetp tircusdie, so reye'ht nfote edsu ni het ecaut ettrantme of ee.mad

peridot  I think what threw me off was that this lady had such low GFR, figured it couldn't be right. Turns out it's still ok. Furosemide is a miracle drug!! +

 +10  (nbme21#41)
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roLmaieepd: sAntoig at dopo-iiu oretrp.sce Solsw ugt yttmilio e(ermbre,m opistaintcno is a mncmoo dise eectff orf lal .)oodpiis

uiqz :fsryelou

Q: oWldu a iekjnu nawt ot esu eL?dearmipo

:A ,No it ahs oorp CSN enetoianptr h(cihw si hwy ti ahs a owl icadvteid oanp).ittel

:Q duWol a ikujen hraetr vhae mpoihern ro rpnibupnerho?e

:A Minerhop. ohtB rae pdoiu-oi sistgao,n btu heirpnom is a lulf noaitgs ilwhe ebpouinrhepnr si lyon a artlpai saint.og

Q: aWht uatbo inmophre s.v ?eneiodc

:A rciTk tuoqneis, ohtb rea aailtrp ogsastn.i

cienfuegos  Thanks for passing off the knowledge. Regarding the last part, aren't morphine and codeine full agonists? +5
champagnesupernova3  Yes they are +2

 +7  (nbme21#18)
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GHHI ED:IYL nbn"ouolsi iginmov"t nsaem thta teh uebiicrsoott/ssun semco efebor o(axmirlp ot) eht nodesc ,unmdueod ewreh eibl si es.deearl

tA uodran 4~ skwee ei(vg or keat a efw) si nhew oyrlpci noeitsss lusulay woshs up.

ez pts for u now epek it pu

mannywillsee  Sadly the easiest question that just jumped out of its way and said Pick me! +

 +11  (nbme21#37)
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nliFowglo a e,osktr iths einpatt dah eaknewss of erh telf eafc nda doby, so teh retkso sutm heva feacfdte het hgitr sedi fo her r.nabi B asw the onyl ihcoce no eht rithg sedi of reh b.nair

tlilS o?efnscud Reda .o..n

The ltunaoryv morot bsrfei lropiani(stcco atr)tc csdende ormf het iprarym otorm etcr,ox osscr u)taceseds( at eht adlmulrey dasrpy,mi dan enth pyasnes at eht netroari ormto nhor of het pnslia lvl.ee

uBecsea of iadsotunces ta eth lmedyulra ,pmradyis oyu lodhsu mkea a ntoe of ehrew any ektros rccosu. sI ti ovbae het uledmylar ?pmrsdiya ehTn ti iwll ecatff the side isoeppto het tskoer natcl(ta)r.oelar sI it weblo teh mrlledayu dyampi?sr neTh it llwi fafect het sema eisd sa eth trokes lpe)a(l.iaistr

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +
mnemonia  Very nice!! +
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +8
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +22

 +11  (nbme21#50)
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eTh amicoant soxubfnf is moedfr by eth dtenosn of eth tsxneeor iollcips si,ebvr hte rdutcboa pclslioi ng,luso adn het xnsroete iilpsolc ongusl. (reufig)

heT roofl is edrofm yb het daoiscph ne,bo and it is ereh htta oen anc tlappae ofr a lsbeipso aufdcrret iod.ahpcs

:eoucSr rGa'sy myAatno wiReev

hungrybox  Of note, the radial nerve innervates the extensors of the wrist. So the muscles of the anatomic snuffbox are all innervated by the radial nerve. +
hungrybox  This helps you remember that the radial nerve innervates the abductor pollicis LONGUS (abductor pollicis BREVIS is median nerve, ADductor pollicis is the ulnar nerve. These two make sense if you think about the direction the thumb is moving - ending closer to the nerve.) +1
meryen13  just to review, if we don't fix this, what gonna happen next? --> avascular necrosis of scaphoid--> non-union. why? because scaphoid has two blood supplies the distal part is mainly volar branch of radial a. and the proximal part is mainly dorsal branch of radial a. +

 +3  (nbme21#26)
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idaagmr ghsionw AMO


 +7  (nbme21#19)
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aka amlluap of eartV or teh nccaaetieparopht tdcu

hungrybox  tripped me up cause I didn't know the names :( +14
sympathetikey  @hungrybox same +14
angelaq11  omg, same here! I thought, well, I don't know of any duct that connects the pancreas to the liver, so...2nd part of the duodenum it is :'( :'( +7
alimd  actually Ampulla of Vater is located in the 2nd part of the duodenum. +
mtkilimanjaro  I think 2nd part of duodenum could be viable if the ampulla was not an option. The ampulla is way more localized/specific to this scenario +1

 +7  (nbme21#20)
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izqu rluofsye er:saswn

  1. troileS (eorStli utShs o,nwd IFM is erdeecst by rtioSel lcls)e
  2. -p5ahal tesdeacru
lovebug  5-alpha reductase is due te that DHT is important for male external genitalia? +

 +19  (nbme21#20)
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ishT ivedo nesxapli gliante loyrgboemy rlemyxete llw.e

If yuo lfte ttlalyo ostl keil me, tachw teh viode ftrsi at ,2x hnte khecc tuo teh btmoto ierfug no .pg 608 in AF 021.9

talvRene to tihs qiuton:es

  1. SYR onitpesr utmteilsa pvnemteeldo fo tseets
  2. This pt hsa tteses =&g;t he tsum hvea teh RSY eeng on teh Y homescoorm
  3. IMF readdegs eht aurlileMn tu,dc hcihw dwuol ehsotirew ebmceo het talnreni femeal talnaiige
  4. hsiT pt ash tiannelr eamlfe eliaiagnt ;gt=& td'ind aemk oguhen FIM

uiQz sofruyle a(wnesrs in a aeasrtep :p)ots

  1. siTh eintsp'at sordried cna be terdca kacb ot cwihh csel?l
  2. hTsi pttiena adh aomrnl n.ielataig fI hsti etnipta adh ralslme taanleiig ntah ,rnmalo atht duolw eb a dcetef in athw eyem?nz
ergogenic22  I like to work backwards. 1) patient has normal testicles on histology, normal appearing penis this must mean a Y chromosome is present, as testis determining factor is on the y chromosome (see above post point #2). I.e. you can eliminate choice A and B. Theoretically, 47XY and 47XYY could also present with female genitalia due to lack of MIF, but normal 46XY is more common +11

 +1  (nbme21#26)
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nlbeso"co"tbe aprnceapae si etcasoisad itwh oshC'rn isesead

naocomiprs fo sro'nhC sv CU


 +9  (nbme21#26)
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ptsra of eth loocn thta are otltepoierrraen


 +8  (nbme21#19)
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uurjagl vsneuo innidsetot = telf earht rleaiuf

laoymupnr aemde = grthi aehtr ifrlaue

ohmub-aecrrF tnidioal si hte tmso llkeyi .rwnsea

tOreh srsaewn:

  • eyctAmsris paeslt hrpy,tryepoh dlociyaram :adrysria sheet are both icalcss ngndisif ni ctpriohehrpy atoycymdhoriap ()CMH
  • lanoieacddr trefslasoiob:is a rera cetirtiervs paaymroyhtocdi eens ni fia/snntdelcrhni
  • tyhoycicmlp nflatioitirn fo eht r:mydoiacmu seen ni vlrai umaoem)t(iun msitaidyro.c A ucesa of altdedi imytyahrdaopco, ubt erteh saw no onnetim of a eecigndrp ilvar sensli.l
meningitis  I think you meant: Jugular venous distention = LT HF Pulmonary edema = RT HF +4
hungrybox  woops yea I meant Jugular venous distention = RIGHT HF, Pulmonary edema = LEFT HF +12
jackie_chan  What threw me off the picking 4-chamber dilatation was it seemed like that would be a major cardiac/ventricular remodeling and the vignette gave a somewhat acute 2 week onset +

 -10  (nbme21#42)
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cepemrialspa serstnpe lefendti:yrf

  • s:osymptm ,hhdaeaec erlburd o,isnvi boalindam aip,n iewtgh naig (atrwe i)ntnrtoee
  • :ngdsnfii eiont,sepynhr ipt,ouniarre mdeae

 +20  (nbme21#3)
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ehT 2 mnmnemtadcso fo ietshc its:snoueq

  1. Dot'n vere kicp an rnseaw werhe oyu odsun eikl a ckid
  2. Dnto' vree nuctlos teh itehsc mtoetecmi

dvreeS em ellw on tihs s.toueinq

linwanrun1357  If there is a choice about asking what the patient is worried about. Is this right? It does not sound like a dick :) +3
champagnesupernova3  If this were about a treatment asking why hes worried would be right but hes kind of doing the hospital a favor so I dont think you're supposed to try to convince or pressure him +1
brasel  also, any patient participating in any research study can withdraw whenever they want. Answer E is wrong because he shouldn't have to go through hoops to quit, he can just drop out at any time. +1

 +9  (nbme21#23)
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onH'tisunngt siaeeds

  • oacnittnpiia: hse ahs a samirli doirsred as reh fraeth btu deid ralreei

Rememreb HNU"T 4 na lm,anai upt ti in a .G"eCA itnHgnnuit eeng onufd no sooreomChm .4 CAG is eth iedciteunrtol a:erept

  • Cho,aer deutaca ecuulsn
  • taAaix
  • Goomly spi)eeons(rd
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +23
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +
foulari112  How would you differentiate this from Frontotemporal lobe dementia +
temmy  Foulari 112..the ageof the patient and the anticipation cos her dad had it too. Also in frontotemporal pick, you will see personality changes where they act completely different vs huntington where they are aggressive and depressed. +1
castlblack  CAG = Caudate loses ACh and GABA (from FA) also points you to caudate +

 +11  (nbme21#8)
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rk-siWoeanokrecffK dyrnoesm edu ot mhienait 1()B eicinefyd.c noComm ni hlscoloac.i

eTh anesor hyw eyth dais lsseurt" of loalhoc nda gdur ecsner rea nvitega"e is htat het fiefiaetdrnl nsiluecd ctuae olhoacl i.axtoininoct

eicnrkWes' dr:tia

  • soifcuonn
  • pliaryssa of eey ulsmsec eoatlhmil()gppa*oh
  • xaatai

rsptse*ne ehre as ysusgantm

'rksfsKaofo is:yhscspo

  • omyemr sslo aar(notergde dna teedorgra)r
  • inamkg sthi up itaconoa(bf)lun
  • etpnoisrayl acnhge
teepot123  fa 19 pg 559 +1

 +10  (nbme21#11)
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t5/pu/eoauacnl dah a tegra olnx.aieatnp

se'Her an maieg of eth finrdefte asetsg wlilongof cmyaoardli ao.itnncrfi eotN eth iarntoccto"n s"nadb are tawh deenfi cviaegauotl rsnecsoi.


 +31  (nbme21#15)
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why ihsloemys is gonr:w

reeTh hludos mtoals vrnee be tashgrit pu niliriubb in the uie.nr In e,isshyoml teh seescx buiinrbli si ertceexd ni the b.lie rAfte aceabtril oovcenrsni dan akr,putee smeo ilwl eb ctexreed in eht unire sa lniirbo.u ,wevreoH ni sbrtcivoteu d,dsreoirs the tedcguajno ibubrinil will vnere heav teh pprytotoiun to unegord atiebcrla sroncvione ot otconribilru./se nI sith y,aw het dteagcojun ilbruiinb sha no ohetr way to eb ertcexde herto htan cytreldi ni hte nuie.r

sterdic to 7l3r6ac/uaan/ on tdredi

skip_lesions  Found a good pic showing bilirubin metabolism +

 +3  (nbme21#45)
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gAndocicr to het L,SEMU ms'neulesi ynol sue si in esmunlei seudlif sa a nrtmtaeet ofr a usgfun acdlel iaseMalzsa psp eTani( oocvl.sirre)


 +19  (nbme21#20)
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esmo ronwg rs:wasne

k*ames eessn c/b tlsoeaylmsb rea rrrsoupcse to lnactguyr,seo hiwhc use POM ot tihfg fof otisnicefn

temmy  Hungrybox aka life saver +1
hello  Thank you!!! +
bbr  ....uh yeah im pretty sure we just call em "Auer Rods" now. Appreciate the answer tho! +7

 -5  (nbme21#37)
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Long rnaews adeah, tub bare hwti .em

T:HNI v oksol inkd of leik ,y sahwere k losok reom ilek x.

r-yttpeeinc = Vxma/1

  • mxaV si the upepr mtlii no how afts a orceaitn is zdltecyaa yb nem.zeys

texrtpie-nc = /m1K

  • Km si a ngrnaki of ohw dgoo na menyze si ta gnbnidi tsi t.eatbrsus nA nzymee ihtw a nrnakgi fo 1 si ebrtet ta ndnbiig tis sartuestb ntha na neemyz ihwt a naignkr fo 5. e(orLw mK = tebert )eyzenm

Note taht Vmx,a as a reeamsu fo pnmoeafcrer, cna be drelaet ugtohhr nyam .nstihg hliwMene,a Km si a ets reicsatirhctca of hte yneem,z adn atnonc eb .taredle

nI hist xpe,alme eth eemzny ocmererpanf (xVa)m si raecsdnei by egsciarinn eth nvtaimi cocraoft os ttha ti reaeshc a lramno"" .iivtycta Hr,oeewv hte meeynz is lltsi iherleynnt tyisht edu to a eongnlicat d,fceet os eht Km atsys eth ae.ms

mnemonia  Awesome. +
ht3  wait line B shows the vmax doesn't change and that the km is getting larger (enzyme is still shitty so larger km) so -1/km would be a smaller number and would approach 0 +1
lamhtu  You say Km cannot be altered and its staying the same, but the answer of the graph demonstrates a higher Km value. Needing "higher concentrations" of the B6 for enzyme activity is another way of saying Km is higher since more is required for 1/2 vmax activity +14
sbryant6  Yeah this explanation is wrong. +

 +13  (nbme21#1)
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uehbolmatt = uohEmtatbElY

Garte nmcinemo for emnigberrem atth ohmEYbltutEa is teh nteoomcnp atht ausecs lavsiu elmrsopb in EPRI ethpray fro BT.

hungrybox  RIPE = rifampin, isoniazid, pyrazinamide, ethambutol +2

 +3  (nbme21#41)
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rheto sesawnr:

  • eo:ynslaprc tssiAdaoce ihtw cipoggnohy or ophcpminopy snancltl.aoihiu
  • poOyGhn to lsepe = hgnti imte oitchanunlsial

  • smlopyxara lnatroncu ayed:snp PNH is a heolictmy en.miaa oN gsisn fo lyteomchi aemnai (ai,eramuht aicju,ned dec. bn)hogpti.loa

  • elspe enpaa: oaesidsctA thwi obyeis,t oudl .nngiors

doingit21  narrowed down to MDD and restless leg then convinced myself that elderly are at higher risk for MDD than RLS. Is that valid reasoning? +2
yb_26  Paroxysmal nocturnal dyspnea = breathless awakening from sleep, seen in left heart failure. It is not a paroxysmal nocturnal hemoglobinuria. +12

 +3  (nbme21#28)
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ueD ot ily'cgsen samll zi,es ti aertesc "kksin" ni eht omnia adci sue.neceq esThe inksk ear ededne ot rclytoerc ormf hte ryaendsoc cut.strure

rtheO nsw:srea

  • eadkeew"n intteianroc beteewn lcgeoanl dna nteo"oclgyrpa - lnoacgle + rencaoyopglt = alcritga.el ehT snoquiet smte snoitenm anym sfeetdc in EbON ypte( I o)egllanc ubt no otnimen of cdetfes ni gaaecWOTllr ept(y II laeoclng)

 +13  (nbme21#25)
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ialypsDtcs nive era a eorrrcpus to a.onmeaml hyeT aevh riruegl,ar l"dcpasty"si .srbdero meebRrme eth B"" ni BACD tndass orf rilraureg rsde.Bor uvNse msaen .elom

tOehr :rsewasn

  • taoscsnaih iaicnrsgn - grDeinank fo sikn saoedcitsa ihwt ypeT II tsedebai lismutle

  • absla cell mcaicaorn fo ikns - ,lReary if vere istszaetesa.m oCnolmmy cftaesf perpu pi.l

  • eblu vnsue - lc-lueeBordo etpy of nomocm lom.e enginB.

  • ptidemneg rseohecibr aeoksitsr - kStc"u no" rpeacneap.a lMstoy i.negnb sAetcff dleor epol.ep

  • o(etN - uyo luuslay see loyn no.e If mletlpui orhresbcie straeoeks aer e,esn it iteicnasd a IG ymancnilga - kaa "sleLTéaertr- sgin)
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1
sympathetikey  Pathoma says upper lip, good sir +26
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +5
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +7
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2
teepot123  fa 19 pg 473 +
rockodude  just remember BS. basal cell upper, squamous cell lower +




Subcomments ...

submitted by m-ice(340),
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nAuoomyt si teh stom nptritoam hciets picrpneli taht resedsspue lal ohrt.se erevow,H it si pileadp lnoy ni uoititsnsa in which a itapent nrsoadesttem es-dcginkmoinai ccaia.pty nI isht suia,onitt a iatpnte ithw dcanveda ssdeaie llukinye to eb rcdeu is guesfrin mene,ttrta chwhi si ihs trhig drneu eth lnpciprie of m.yatunoo eHovwre, hsi oecstmmn buaot ntgirrenu" ni 6 nhsmto atfre icungr ir"tisrath are ntlebs,ieaqou dna raantrw reniidntmge if eh hsa dicoisne gkamin ctyp.iaac It is pblsseio ahtt he dos,e whhci is hwy yan esoichc of gorfcni rhturef aenemtttr on mhi are nricreoct.

hungrybox  These ethics questions seems so simple and yet somehow I always get them wrong. I guess deep down I'm just a scumbag. +14  
mutteringly  Hey there's always dental school +1  
hungrybox  legit made me lol, thanks for that +  
jurrutia  Also, the patient is delusional! He thinks he's going to cure arthritis. You don't have decision making capacity when you're crazy. +  


submitted by cassdawg(1182),

This is metastatic renal cell carcinoma (FA2020 p605) for the following reasons:

  • Polycythemia - this is the primary clue, as it is associated with ectopic EPO (erythropoitin) secretion in paraneoplastic syndromes (FA2020 p228), which can be caused by pheochromocytoma, renal cell carcinoma, heptocellular carcinoma, hemangioblastoma and leiomyoma. Of these, only liver and kidney would be a choice given and hepatocellular carcinoma is incorrect because he did not have any associated finding of jaundice, hepatomegaly, ascites, or anorexia (FA2020 p392). Plus, the liver does not commonly metastasize to brain whereas kidney does (FA2020 p223)
  • Hypercalcemia - this is likely indicative of PTHrP secretion, and renal cell carcinoma is one of the cancers that can do this. However, this is fairly nonspecific as there are many cancers that can secrete PTHrP.
  • Heamaturia - suggestive of kidney/urinary tract involvement
  • Negative for carcinoembryonic antigen - this is a nonspecific marker mainly for colon and pancreatic cancers (FA2020 p226)
hungrybox  WOW. Amazing explanation. Great work!! +  
nbmeanswersownersucks  Additionally the histo looks like the Clear cell type of RCC. The large white/clear spaces with "chicken-wire" vessels and stroma between them. +6  


submitted by hungrybox(1051),

A: Anal carcinoma | Would not be so acute

B: Anal fissure

C: External hemorrhoid | Correct!

D: Human papillomavirus infection

E: Skin tag


picture from the problem

picture showing most answers

*couldn't find a good image for anal carcinoma, if someone wants to share one that would be great

drdoom  wowee that’s a lot of butthole .. +9  
hungrybox  hawt +1  
underd0g  Why isn't this HPV given the sexual history? +1  
prosopagnosia  Anal fissure and Anal carcinoma - would present with rectal bleeding which our patient denies. HPV could lead to anal carcinoma and the image isn't similar to the morphology of condylomata acuminata. External hemorrhoid is the only one that presents with rectal pain (due to somatic innervation from the pudendal nerve) and no bleeding. +1  


submitted by hungrybox(1051),

(wrong answer explanation)

Intermittent obstruction of the common bile duct is wrong.

Biliary tract obstruction would have:

↑↑ direct (conjugated) bilirubin (normal 0.0-0.3, pt was 0.4)

↑ Alkaline phosphatase (normal = 20-70, pt was 35)

hungrybox  source: pathoma +  


submitted by hungrybox(1051),

Excess pattern repeats lead to strand slippage/errors due to an unstable region (in this case, excess Cytidine bases).

It could be a repeated pattern as well (ie the trinucleotide repeat CAG in Huntington's).


here's a more in depth explanation (from wikipedia article on Slipped-strand mispairing):

A slippage event normally occurs when a sequence of repetitive nucleotides (tandem repeats) are found at the site of replication. Tandem repeats are unstable regions of the genome where frequent insertions and deletions of nucleotides can take place, resulting in genome rearrangements.

hungrybox  Anyone know why it's not Transposon insertion? I was thinking maybe because transposons have to be longer than one nucleotide, but I'm not sure. +5  
bingcentipede  @hungrybox I think it's because transposons are usually gene segments rather than a single nucleotide insertion - plus w/ what you said about the repeated pattern, I think slipped-strand mispairing (which is a concept the NBME loves) more likely. +23  
i_hate_it_here  cool so why do I need to know this +2  


submitted by hungrybox(1051),

Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question.

To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs."

The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc."† So you can rule out nipple stimulation.

It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect.


I've never seen anything like this on a question but I assume the NBME would word it in some convoluted way like that.


I initially wrote this as a subcomment, but I feel like it deserves its own comment. I was never really satisfied with any of the explanations for this problem, and I finally arrived at one that makes the most sense to me.

hungrybox  Oh, and besides, nipple stimulation and prolactinoma aren't even answers lol +  
drdoom  [system mailer] your account has been upgraded: FORMAT NINJA +1  


submitted by hello(317),
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joGanl dha a tueelcr that mndoneite tath "fI a taetnip sha olteahgcr,raa eewvir yevre gudr 'rhetye takngi nesic amyn ugdsr cueas rcataa"gorhe.l

hTe noyl ghitn fo espobils ealecrvne in hsti tQsem- is that ehs aestk a dia,comeitn fortehree teh eanwsr of g"urd etefc"f is the mtos elyikl rensao orf hre arolah.rtcgea

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +6  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  


submitted by hello(317),
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jlonaG dah a utlerec tath idtnmonee ttah "fI a pietant ash gcr,haalorate rwieev yerev gdru hrtyee' tgknia nseci aynm udgrs useac "aor.arclgtaeh

Teh onyl nhigt of ilbespos rvleanece ni htis em-tQs is htta seh etsak a oiceati,mdn tefhoreer eht nsarwe fo d"urg eftfe"c is hte somt ilkyle osenar rfo ehr gaaechlrarot.

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +6  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  


submitted by fkstpashls(18),
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crPoses fo mnneltoiaii is teh ynol awy to get shit renwas ituthow Snavat lseevl fo uti,sma sa msoe obitwe nerwgia rdheuco owh teorw eth ostnueqi pbarboly sah.

ercnaC is naluiaretl lsmaot lal eth ,meti MD 'ostend ekma snees rfo yna ora,sne HNT sileft nt'udwol uasec ylmki osob,b adn atsm lecsl dtgnnalriugae tdnse'o meak ykiml sbobo erehit. ,oS dna sceuabe mnya gsdru nca aevh lmkyi b,boos ro'eyu tlef ihwt gurd feftecs by eocrsps fo liniio.mntae

djinn  I dont think the autor was a savant. Also I think is right proccess to think "cancer" can be bilateral and malignant but the "drug" that causes this isnt HCT. This question is bad written. +1  
hungrybox  According to Pathoma, galactorrhea is NOT associated with cancer ever (see 16.1 - breast pathology). +  
djeffs1  according to strugglebus's numbers its more likely to be b/l cancer than thiazides... +  


submitted by hello(317),
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laGjon dah a eutlrec taht mednnetio ttah fI" a etnitpa ash erh,traagalco wrveei eervy drug rteh'ye gakint nsice naym gdrus uacse a.rtelc"araogh

ehT noyl ihntg of ospilsbe evclenrea ni tihs ts-mQe is tath hes easkt a deact,niimo rfhoeetre the raswne fo rgd"u ce"tffe si eht stmo lylkei onraes for rhe tohglcaerar.a

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +6  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  


submitted by hayayah(1081),
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nrtaiaCcoto of hte taroa lades to eedrcanis LV daerloov gsuianc VL heyytpohprr dan a L xsai ainie.dotv

hungrybox  Similarly, RV overload leads to R axis deviation. Could point to PAH. +1  


submitted by keycompany(311),
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eswernAd my own teiqunos. dnaeerscI rssets rfmo a IMSTE iwll attvciea eth cpmteishyta erovsun myests -- amoPruynl lvndiioao.ats

pathogen7  Just to add, CHRONIC heart failure is a cause of pulmonary hypertension. So in the acute setting, pulmonary edema leads to decreased PVR, while in the chronic setting, it can lead to increased PVR, I think? +  
hungrybox  This doesn't make sense. Activating the sympathetic nervous system would cause bronchodilation (via β2) but it's unclear to me whether it would constrict the blood vessels (via α-1) or dilate them (via β2). +1  


submitted by m-ice(340),
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mAotnyuo is teh mots mtoinpatr icehts lciepnpir ahtt uerpedesss lal .roesht oeevrwH, it si pelipad olyn ni tntisasiuo ni hhicw a eitntpa tesaosnrmedt iacgm-oeindknis cycapi.at In iths tasi,unito a apittne ithw adeancdv aiessed kueyinll to eb decur si urgsinfe mettr,aten ichwh si sih trigh rdnue eth clippnier fo .aonmotuy voe,erwH his moscmetn obtua rugnrt"ein in 6 oshtmn ertaf incugr tarihri"st aer aqnloiue,sebt nad ntrarwa gerdnmniiet fi he ahs sicenodi kngima ycctiap.a tI is lsiobpse htta he se,od wchih is why ayn hocecis of onrcgif tfhurer ttnmeetar on mhi are citecon.rr

hungrybox  These ethics questions seems so simple and yet somehow I always get them wrong. I guess deep down I'm just a scumbag. +14  
mutteringly  Hey there's always dental school +1  
hungrybox  legit made me lol, thanks for that +  
jurrutia  Also, the patient is delusional! He thinks he's going to cure arthritis. You don't have decision making capacity when you're crazy. +  


submitted by rolubui(13),
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)1 lchoolA athwlwrdai g-;t-& zieseur

2) ueSezir &--tg; sdiraenec eaesler of tleniaacshecom (0.:b.neo/mp6/mhnst8ic/nhgdvlt4b5wuww3i.p.2/,) osal BP fo /000811 snceitiad ighh eelvls of itnmecaclsehoa

)3 rjMao rsonohme hatt hstif +K raeutlrinllyalc rea lsnuini p;&am aecnider2-b-grate sotsngia .e.(g pehrpeeniin (n1tui.i7ew:clnn/g.sg8hdc1oipgw0f./kwcpm/edtsitsueiipa6ua.ilc/n.l/20h)

)4 osAl ythe rea giksna ywh sumre K+ si l,ow ONT ywh urien +K si hhgi

osler_weber_rendu  Point 4) above helps you RULE OUT MUSCLE BREAKDOWN. It will cause initial hyperkalemia. Hypokalemia, if at all happens weeks later in ATN. +3  
hungrybox  Thanks for explaining why it's not muscle breakdown. Was stuck on that one. +  


submitted by lamhtu(121),
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aePltlet eeaedchnr adn lateeltp egroigngtaa aer fidetefrn hngits adn htis frrenceedi RTTEAMS A OT.L kcuF u,oy M.BEN shTee erdcsnieeff oupyldpsse amrtet no emos otiqusnes dna ont no oh.trse Wrehe si eth nyce?csniost elolH?

hungrybox  Agreed. This is so fucking stupid. +  
hungrybox  "Aspirin inhibits platelet aggregation and produces a mild bleeding defect by inhibiting cyclooxygenase, a platelet enzyme that is required for TXA2 synthesis." literally straight from Big Robbins +1  
susyars  Im gonna upvote this bc i love to be right +6  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +4  
j44n  yeah i thought adherence was the GP1B receptor that's already on the platelet +1  
j44n  im also glad we're getting exposed to this horse shit now and now when I'm in a testing center about to put my fist through a screen. +1  
jurrutia  GPiib/iiia receptor is not inhibited by aspirin. Aspirin prevents the upregulation of GPiib/iiia which is not the same as inhibiting the receptor itself. +  
jj375  @jurrutia I think you are thinking of Clopidogrel, prasugrel, and ticlopidine which downregulate GP2b3a expression. Aspirin inhibits COX therefore inhibiting TXA2 and platelet aggregation. +  


submitted by lamhtu(121),
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etelltaP hadereecn nda lelaeptt gtegaograni rea tnefirefd sgtnih nad stih ieerfdnrce TSEMTAR A LO.T kFcu ,ouy .MNEB sTeeh fnicseedfer pdysslpuoe emattr on eosm itsounqes dna otn on tesroh. hrWee is the tssenocc?iny llH?oe

hungrybox  Agreed. This is so fucking stupid. +  
hungrybox  "Aspirin inhibits platelet aggregation and produces a mild bleeding defect by inhibiting cyclooxygenase, a platelet enzyme that is required for TXA2 synthesis." literally straight from Big Robbins +1  
susyars  Im gonna upvote this bc i love to be right +6  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +4  
j44n  yeah i thought adherence was the GP1B receptor that's already on the platelet +1  
j44n  im also glad we're getting exposed to this horse shit now and now when I'm in a testing center about to put my fist through a screen. +1  
jurrutia  GPiib/iiia receptor is not inhibited by aspirin. Aspirin prevents the upregulation of GPiib/iiia which is not the same as inhibiting the receptor itself. +  
jj375  @jurrutia I think you are thinking of Clopidogrel, prasugrel, and ticlopidine which downregulate GP2b3a expression. Aspirin inhibits COX therefore inhibiting TXA2 and platelet aggregation. +  


Acral Lentigious is NOT associated with UV exposure. So there might be another reason

nerdstewiegriffin  Source Pathoma 2017 +  
hungrybox  question doesn't have anything to do with UV exposure +1  
nerdstewiegriffin  I am trying to say palms have less melanin is a wrong concept to apply. Acral Lentigious arises in dark skinned individuals and they are not related to UV exposure. I agree using melanin logic you are able to answer this Q but this logic is incorrect. and you might be aware wrong concepts don't go far. +5  
greentea733  Yeah you just need to know acral lentiginous melanoma most commonly appears in African American/Asian patients. Unfortunately the question leads to to think about UV and kinda melanin, which doesn't have anything to do with what they are actually testing +  


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I ujts htnki pmals aer tno trteodcep yb the aimnlen nad tog tshi gith.r

hungrybox  useless +6  


submitted by lsmarshall(417),
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ttaiPne ash Snpai ibidfa cotlacu cihhw is a rlnaue tbeu deetfc l(raeufi fo fisnou fo the poroesu.n)re eroeltmoscS rae het rapt fo aech tmeosi in a tavtbreree rombye giinvg rsei to bone ro eotrh ktasleel i.tessu enciS a aptr of tihs eptsnti'a ainsp idfaib cnuddlei aensse"cb of noupssi rsc"poes hent a lcostoreme wsa .vnediolv Kwongni atth lnarue tbue dtscefe ear an sueis wthi snfoui solhdu eb ngeouh ot etg to eth hgtri newa.sr

fI teh hdoorncto dfeial ot oeepvld thne eht tniree SCN wdulo ont edpvleo sa eht nootcrhdo enisudc oraminfot fo nurela ea.plt

fI the rleaun betu ileafd to dplvoee ehnt hte lewho CNS dolwu nto aehv .pdeovdeel

Yklo csa si rvnliaeret ot ihts pa.ttein

When urlean stecr clle ti hsa enrfieftd mouotcse ni tefedirfn su.tssei ulerFia of lanuer serct to mgraiet ni thrae nca caseu nTorinsotspia fo rtgea ,lseevss Tgryeaotl fo lotF,al or stsetPrnie csuutnr ortuesrsia. lirFuae of rulena cstrse to itrmeag ni IG anc uscae Hnscshuprigr aisedes ialgcnon(et lecm)onaog. eeharcTr oinlCls dSeornym anc ucocr when erulna estrc lelsc flia to mrtgeia nito t1s apgahrlnye hc.ra lrueNa btue dtsecef ahs nonihgt ot do whti liraeuf of lneaur rtces tgirainmo gthou.h

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +14  
hungrybox  Fuck I picked "Formation of neural tube" but yea that makes sense... that would affect the whole CNS +4  
ruready4this  I also never heard of sclerotomes and I chose that and then switched it to formation of the neural tube because I thought that was close enough ugh close enough is not the right answer +1  


submitted by hungrybox(1051),

(D) Portal hypertension: Portal hypertension is a complication of longstanding alcoholism, but it is not the cause of acute or chronic pancreatitis.

In acute pancreatitis, alcohol transiently increases pancreatic exocrine secretion and contraction of the sphincter of Oddi (the muscle regulating the flow of pancreatic juice through papilla of Vater).

This leads to activation of pancreatic enzymes and acute pancreatitis follows soon after.

In chronic pancreatitis (as in this patient), alcohol increases the protein concentration of pancreatic secretions, and this protein-rich pancreatic fluid can form ductal plugs.

Made this explanation in case any of you were dumb enough to think "pancreatitis → alcohol → portal hypertension" like me.

hungrybox  oh my source was big robbins btw +  
regularstudent  I was definitely dumb enough +3  


submitted by medpsychosis(115),
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ehT way I uthhtog about it aws a tllite rmeo s.imsilpcti We eus nno esleveitc eatb srclekob (.e.g parnPrlool)o fro het enaertmtt fo ensasitel emor.tr Teoferreh a aetb taonigs uwlod veha teh ootisppe fe,cfte aka cause or eaenchn mt.orre

hungrybox  Genius +3  
sunny  Also it(blockers) hides signs of hypoglycemia which are tremors. +3  


submitted by lsmarshall(417),
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Fxerlo idirougmt fousupnrd si prboselsien rof ilonfxe fo I.PD Meladi paects fo eth sculem (hwchi lsefxe het th4 and 5th gdiit) si upseildp by eth nlaru rneve (C8, 1).T hTe tarllae escpta w(hhic exslef hte d2n and dr3 gid)it si danveetnri by het meanid eenrv fcpisceaiyll eht nriatore ouresneisots rabhnc ,(C8 .)T1 So the ionsqteu is srcngdbiie a lcianateor agimagnd het nrvee sulppy to hte DPI xofrle fo eth n2d igdti id(exn negf.ir) Thsi is aygsin eht elmdai nerve is giebn gadadme 8C( and ;1T reolw ntkru ots)r.o

misLcrabul tns/12d,( menadi; 4rhd3,t/ )urlan ear a grpuo fo umsselc ttah eflx at teh MCP o,itjn nda exetnd IPP and IDP ojsint.

Cdluo mmrreebe sa eof'rxl omtdigiur dfurounsp si rufolyonpd g'nol iscne nosnted irnets on DIPs. mpderCao ot olrxfe gtudiormi asrpiiciselfu sehwo dotenn wpars nudrao npru'ofusd aelyrflsciiup tbu stirsen on .PIPs

toupvote  This is dumb but I remember FDP is needed for picking while FDS is need for scratching the superficial layer of the skin +13  
whoissaad  @lsmarshall Flexor digitorum superficialis inserts at the middle phalanges to be more specific. +  
aneurysmclip  shittt I remember it like this D for distal P for profundus > Double Penetration. and I know the PIP flexion from the other Flexor digitorum, which is superficialis. Extensors are lumbricals. (Lengthen your fingers with Lumbricals) +8  
hungrybox  'flexor digitorum profundus is profoundly long' is such a good mnemonic, thanks bro +  


submitted by link981(163),
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ywrsodeK rfom rD. ocruT rfmo pn:aKla

  • ioR-pinteacl DNA
  • rcnniaTsp-irot RAN
  • nraoail-tnTs Pnertoi
hungrybox  bruh this is like bio 101 lol +7  


submitted by suckitnbme(181),

POMC is a prohormone peptide chain that gets cleaved into gamma-MSH, ACTH, gamma-lipotropin, and beta-endorphin. There's a nice figure of this in Costanzo (Fig 9-10).

It may help to remember that pathologies with increased ACTH (ie Addison's disease) can present with hyperpigmentation since MSH (melanocyte stimulating hormone) is produced alongside ACTH.



hungrybox  not pictured: cremasteric a., which (I think) also would have been a valid answer +2  
greentea733  This is great but honestly was this covered in ANY step 1 study resource? +9  
tobias  I had a question on Ambossthat gave me the answer through an explanation +  


submitted by tinydoc(233),
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ishT esuntqoi is reyv ,nksaey ubt in secseen hsti is tsawh gh.panepin

The anlciaecdt reamlvo fo eht HPT andgsl udnirg tetohcmrydyoi ⇒ ↓ PHT

HPT an-ll:rnmi y-o b:one ↑ omelrva fo ⁺Ca² and hepoatPh omrf -b- onnei ney:idks ↑ Ca²⁺ srbatnrpiooe nda ↓ ⁻P³O₄ brtao-↑ -nisorpe invoroecsn fo 2,5 niiroHamyxvtyd D ot 1,52 rivmyyoxndatiH D laiCtlrc(oi - eativc mof)r iav ↑ atiicytv fo -a1 dyyeslrHxoa ciyfceneid

roferehTe a ↓ HPT owlud alde ot:

⇒ ↑ ³₄OP⁻ ⇒ ↓ a²C⁺ ⇒ ↓ 125, ixvryimnyoHtda D

heT uiqnsteo is keynas (cmhu leik eth esrt of ihts me)ax secaeub enoomse who istn gcuifson rlaeyl hdra or ni a rsuh tmgih pkic het otpino C eewhr oahehptp si ↑ nad TPH is ↓ UBT ↓ 25 dymhivrntoaxyi D

hsiT is grnwo sa nylo 521, hxyrdamiyinvto D luwod be erasdeedc, eht conrionvsse bferoe tihs era nedo by teh snik tlih)s(ugn dna e.lirv

I aelryl iwhs yteh lwoud ostp kgainm hte quosinste sncifungo PEUYLR rfo hte saek fo gakinm temh .osufngnic Itns it ohugen that we evah ot wkno isth uilosciudr tumona fo t,noiafmnroi twotihu havgin ethm lenyiionatlnt kingma ti rhraed by nipinogt oyu to 1 seanrw coecih tub gnghcian a mtniue iadlte to amek uoy nrwesa .owgnr rO usnig a ormadn ass ennoulamrect rfo a daiesse ot odaiv ngiakm it oto seilpm SPGN( = veiio"eatrrlfp "NG)

tinydoc  I literally got this wrong because I had the font zoomed in and assumed the 1 was on the line above like on uworld when it tries to squish the whole title in the same space x_X +1  
hungrybox  Holy fuck they got me. They boomed me. The fucking NBME boomed me. +2  
graciewacie9  Amen to the PSGN question. They got me on that one. lol +  
msw  the psgn question is pinting to rapidly proliferating glomerulonephritis b/c the pt has developed acute renal failure within days of the insult +  
msw  *pointing +  
snoodle  HOLY GOD MY BRAIN FILLED IN THE 1. i had to read this explanation 4 times to finally see 25-hydroxyvitamin D and not 1,25. F U NBME +1  
avocadotoast  this bs is prob why the question isnt on step 1 anymore +  
zevvyt  so since conversion of 25 --> 1-25 is disrupted , would 25 be high? I know its not an answer choice, just wondering +  


submitted by enbeemee(13),
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i tge ywh it's yplai,xeoehfr utb why nto i?illtnafrbois its' lsao an NLM sngi

et-tu-bromocriptine  Imagine a simple reflex arc: you have an afferent neuron, some interneuron shenanigans, and an efferent neuron (aka LMN neuron). If you damage the LMN, you will get hyporeflexia (due to damaged reflex arc) and fibrillations (because your LMN won't be able to effectively contract muscle on command). However, if you damage the afferent part of the arc, you will still get a damaged reflex arc (hyporeflexia), but your motor neuron will still be able to do its stimulating effectively, so your muscles won't show weak contractions when stimulated by a higher pathway. Kinda confusing but I hope I made it a tad simpler! +14  
eli_medina9  https://imgur.com/1z4OF4l Gonna piggy back off your comment and just post this kaplan image +11  
hungrybox  Very helpful image, thanks bro +  
j44n  its not a efferent motor neuron its the sensory/afferent branch +  


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Hot tbu lfolit,csliiu ts’i a ghnit. asalCciylsl poamseu.onsd

medguru2295  I hate myself for overthinking this one. The first thought in my head was "hot tub folliculitis" but my dumbass didn't pick follicle. +10  
hungrybox  @medguru2295 same bro same +  


submitted by thotcandy(80),

Everyone asking why not PPIs?

if you give NSAIDs which decrease PGs so you get GERD, the simplest way to fix it is to bring those PGs back, so misoprostol.

Just simply -PGs --> +PGs

hungrybox  This is the best explanation IMO Also makes me feel like an absolute idiot +5  
guber  also per FA, misoprostol is used specifically for prevention of NSAID_induced peptic ulcers +2  
cuteaf  I think the key to answering this question is to remember the specific side effects associated with misoprostol -> severe diarrhea. No other GERD medications in the answer choices have this side effect. Antiacids could also cause diarrhea (MgOH) but not in the answer choices +1  
deathcap4qt  Actually one of the side effects of PPI use is diarrhea (and other GI issues). Not in FA but emphasized in AMBOSS and Sketchy. I got this Q wrong for that reason but I see now why Misoprostol is the better answer. +1  


submitted by ergogenic22(329),
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Pt has snigs and xS of chsotloy.irepr onma/owLrl ATHC aosfvr leeaetdv sooltirc eennddintep of CT,AH mfedcroni by kacl of eoessprn ot neatxasmdeeho .onuirspesps noZa saauaifcctl si oinirg fo oiltrcos duoiot.crpn

champagnesupernova3  They tried to confuse us saying both low dose and high dose dexamethasone didnt suppress it. But when ACTH is low you dont even need to do high dose dexamethasone test. The high dose is only to differentiate between Pituitary adenoma and ectopic ACTH production +5  
hungrybox  @champagnesupernova3 fuck they got me +11  
azharhu786  They got me on that question as well. I thought it was ectopic ACTH production due to some paraneoplastic syndrome and this is why Low/ high dose dexa is unable to suppress it. +1  


submitted by strugglebus(165),
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oronapoPll si a lnitecvese-no atBe .rckelob oS uyro HR llwi arseecde B1(,) cihhw lilw seacu a aepytomroscn censraie in T.PR

home_run_ball  ^ Above is partially right: Propranolol is non-selective Beta blocker: Beta1 stimulation causes inc HR, therefore blocking it will dec HR and dec Cardiac output Beta 2 stimulation causes vasodilation, therefore blocking it will CAUSE UNOPPOSED alpha1 activation --> therefore increasing total peripheral resistance. +42  
amarousis  so why tf do we give beta blockers for hypertension -.- +6  
dr_jan_itor  I would also add that the patient was previously on an a2 inhibitor (clonidine), which he ran out of. So he is rebounding on that with upregulated a1 receptor activity. Adding labetalol would cause a greater degree of unopposed alpha, increasing tpr +1  
llamastep1  @amarousis They are used for hypertension because the hypotensive effect of the reduced CO is greater than that of the effect of the increase of TPR. Cheers. +7  
hungrybox  @dr_jan_itor Adding labetalol would not cause unopposed α1 because labetalol and carvedilol are α1 blockers in addition to being nonspecific β blockers (great name btw, I love scrubs haha) +2  
mw126  Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +  
rockodude  @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +  


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ahWt nphadpee to thsi ivyu"orleps ehhl"tay yguon le?fa ymeWh si ehs ngvmitio ioidlngo nk?brD too ucmh ahcolol?

hungrybox  Completely haram. Inshallah she will receive her due punishment +  


submitted by flexatronn(2),
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hisT reptty mhuc searnws 43- fo hte nemiocmn ofr ebtrusou sreci:ossl OMAA"ASRSM"HT

aamms-Haort ni NSC nad Alnmab/asfrnti-irkM/gi osi- o h-aAsrroeig/itngtu elfa sotps hietn(ymogpdpe c)umlea dica-rc R/a uoydo-ruRe a/bsbamhomT ossaatOemllcors/iuSo- l/-nnani tmmaOdeMt trdieoanrta / eAlna-r rSuoalpygsAeeehmoimnei--oirgS// anz ecshatp /

hungrybox  somebody kill me +8  


submitted by hayayah(1081),
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ucteA itieirnsltta rlane fomaliain.nmt uraiyP lcsyai(slcal )lesoioisphn dan oamztiae onucrrgci ertfa siirnoiaandtmt of grdsu htta atc as paent,hs gcdniuni hiytssipvtriyene e(,g cit,idusre DAS,INs lnipenicli reastivid,ve opotnr uppm rshi,btiino ,nrimfpia qoenilnsu,o omudn)fl.sseai

hungrybox  But how is a 2-year history acute? +4  
jinzo  there is also " Chronic interstitial disease " +4  
targetmle  i got it wrong because there wasnt rash, also there was proteinuria, doesnt it indicate glomerular involvement? +2  
zevvyt  Got it wrong too cuz of that. But there can be proteinuria in nephritis, just not as much as in nephrotic syndrome. I guess that's confusing cuz this type of nephritis isn't grouped with the other nephritic conditions. +1  
lovebug  FA 2019, Page 591. +  


submitted by hayayah(1081),
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Teh yabb sdoe ton get ayn mrtaalen ,gIM AIg ro gIE sa eyth do not srocs eth ,pancatle so if IMg is dunof ti yam sgutesg eht byab ahs noneedrucet an iftnnioec in utroe.

GgI is adsspe dwon ot hte abby as a asnme fo vasseip nyitimmu tiunl eht bbay can fmor ehirt own sidetbiano fo ftrdenfei .psyet oS if oyu see atynhgin rothe nhat GIg (e..g IgM) ouy oknw it umts be td/ an ifeincnto.

hungrybox  The baby gets IgA via breast milk. +6  
mbourne  @hungrybox, this is true. However, IgM antibodies are the first antibodies endogenously produced before class-switching occurs. So IgM antibodies in a newborn suggests infection. +9  


submitted by hungrybox(1051),
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aDtsipcsyl ivne are a roscrrepu ot oenamlam. Tyhe ehav a,ureglirr a"yispdtscl" br.erods breRmeem the ""B ni BDCA assdtn rof rgaeilrur Brsoerd. seNvu names meo.l

rOhte ras:snew

  • tashinasco anriicnsg - nnargkDie fo iskn codaiestsa tiwh Tpey II deitbeas ltuiseml

  • basla llce iraacmnoc of insk - ,lreRya if vree zsataeim.stes Conmlmoy scfftae ueppr lp.i

  • beul nuesv - Bodueecrlol- pyet fo mmocon .lemo gie.Bnn

  • gpemnetdi obhsirerce aitssekor - cukSt" no" naacr.epaep tlyMos eigb.nn fectfAs leodr oel.pep

  • (toeN - yuo usalylu ese lyno .eno fI mpltlieu esrribcoeh skrtaesoe era eens, it cniaseitd a GI lamyiagnnc - kaa a-r"estLTéerl )igsn
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +26  
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +5  
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +7  
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2  
teepot123  fa 19 pg 473 +  
rockodude  just remember BS. basal cell upper, squamous cell lower +  


submitted by hungrybox(1051),
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juauglr enuvso tdinnoseti = ltef eatrh eifrual

maponlyru medea = htirg erath iuferla

burhacr-oFme andtioil is eth smto ylelki wsera.n

tOerh ansrw:se

  • rsimytscAe ateslp ,rhophypryte laardycoim airayds:r ehest rea obth csscila diingsnf ni cirtoheyrphp mydoaraotiypch MCH()
  • rdlnaecioda slorssobiifet:a a rear ieettvcsirr ditmyaopycaohr seen in nrsinftinl/cedha
  • chlcymoitpy ntiriaoiftnl fo teh ram:ycmioud nees in raivl motiunau()em imyocrtsa.di A saecu of laetdid ootpaciahmyryd, utb eterh swa no nneoitm of a epnriegcd lvair l.ienssl
meningitis  I think you meant: Jugular venous distention = LT HF Pulmonary edema = RT HF +4  
hungrybox  woops yea I meant Jugular venous distention = RIGHT HF, Pulmonary edema = LEFT HF +12  
jackie_chan  What threw me off the picking 4-chamber dilatation was it seemed like that would be a major cardiac/ventricular remodeling and the vignette gave a somewhat acute 2 week onset +  


submitted by sympathetikey(1376),
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ectriD Aulilnoigtbn = Drceti sbCoom tseT

tDsetec nabsodiiet dobnu tidrceyl to R.sCB losesiHmy most ekiyll ued to mtehisngo in teh tanersdusf olobd ton( esru why ti tkoo 4 keesw nwhe Teyp 2 SH is dsupopse to eb kiuecqr btu /e.)w

ergogenic22  there is a delayed onset hemolytic transfusion reaction which should be evaluated with direct cooms test. https://www.ncbi.nlm.nih.gov/books/NBK448158/ +5  
hungrybox  such a dumb question wtf +27  
sonichedgehog  takess longer due to slow destruction by RES +  
baja_blast  Dang, I didn't know that was the same thing as a direct Coombs test. I guess it makes sense in hindsight. Thanks! +  
sars  Theres a UWORLD question with a table displaying the different types of hemolytic reactions. Don't know the question ID. Agree with delayed hemolytic transfusion reaction due to formation of antibodies against donor non ABO antigens. Typically presents as an asymptomatic patient or mild symptoms (jaundice, anemia). Different from an acute hemolytic transfusion reaction, which is against ABO antigens. +1  
tomatoesandmoraxella  The Uworld table is in question 17780 +1  


submitted by mcl(601),
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etnaiPt ostm leiylk sha asSc-yahT .iseesda Tihs uigfer nicely shsow teh hieobaimlcc a.apthyw eRacll ttha tohb Ta-yschaS nad anminNe Pkic disasee sepretn hiwt a rerhcy edr tpso on ds,copynufo tbu Tya Scsah skcla eht peompllgnyteesahao nese ni N.P

hungrybox  Man this is such a nice figure except it doesn't have Krabbe disease :( +  
mcl  Here's another one with Krabbe! :) https://epomedicine.com/wp-content/uploads/2017/01/lysosomal-storage-diseases-enzyme-defects.jpg +7  
hungrybox  thank u +1  


submitted by jotajota94(14),
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PAD sfwol fmor traoa to oamyrlpun rreayt saernceigd thd leaeTf.oerfaorre ccaaird uutopt casseerin

seagull  doesnt pre-load also decrease which would drop the C.O.? +  
hungrybox  @seagull I think it would increase preload b/c more blood is going into the pulmonary arteries -> lungs -> pulmonary veins -> eventually more blood in left atrium/ventricle -> inc preload +55  


submitted by nuts4med(6),
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neonAy vahe an iade ywh teh sdaeeercd eaialrtr 2O anttrausio is tnrocicr?e umsingAs ehs ahs plum eedma sncie ehs ahs LE ,eamde 'dtonluw a olrwe O2 sta be dexecpte ot?o

haliburton  I believe there would be no decrease in O2 saturation because oxygenated blood (high pressure) is shunted into deoxygenated circuit. As long as the lungs can keep up, this should increase venous oxygenation on average. +7  
hungrybox  ty both of you for this, was wondering the same thing +  
coxsack  O2 sat won’t change b/c you’re not adding deoxygenated blood to the arterial side. You’re just taking arterial blood and putting it into venous blood. Same reason why L->R cardiac shunts don’t decrease O2 sat (while in contrast, a R->L shunt would). +5  
hungrybox  just realized: the high pressure of the arterial system keeps out low-pressure venous blood in an AV fistula (probably obvious to most ppl but it was a eureka moment for me lol) +2  
chandlerbas  ya you wont have decreased arterial O2 sat because oxygenation of blood is perfusion limited (FA19 --654) therefore oxygenation of the blood happens within the first .3seconds of entering the pulmonary capillary that you could even handle having more deoxygenated blood enter +  


submitted by kchakhabar(46),
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hsiT iteuqsno si gderiinbsc mniltrae sminan,io which si cmonmo ehtire in DMD or aromln ginag. utO of setho otw DDM si eht ylon hgtni in ionopt ich.ceo Plsu, dol aeg is a iksr otfacr for DM.D

enEv ghuoth het onetqius eods ton erbdecsi 5 mmtyosps eednde to asondeig MDD, DMD si eht lyon iclagol eiohc.c

hungrybox  excellent answer, thank you +4  


submitted by hungrybox(1051),
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ethro swsraen:

bininiihot fo H2 preerct:os fo(r DGER) vtneerp agitsrc aidc ieontresc ,(dnimeciite

iniionihbt fo sersispehastopedoh ():PDE

  • iypenlhltohe (atam)hs iishbint PAMc PED
  • fs-nali (kcid lp)ils orf DE hitiibn McPG PDE

β2 :agisstno (ofr hs)aamt acsue dholbniatroocin

  • aoltulrbe ohtrs( tnagci - A ofr A)ctue
  • lrsamlo,eet rfteoloomr (nlog gtniac - iayoxlprpsh)

d(ik mtlychpoye rbenmeam iitas)tanziobl

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +17  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2  


submitted by mcl(601),
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tPtiaen somt ilylke has hsSTaca-y saedse.i sihT grfuie eclniy swosh hte bolcmicheai wat.hpya lclRea ttah hobt -haacysTS and aenniNm ikPc dsaiees terpnes twhi a ecrryh erd stpo no odscunyo,fp but Tay sSach lsack hte opaapmeenthlyglsoe eens ni N.P

hungrybox  Man this is such a nice figure except it doesn't have Krabbe disease :( +  
mcl  Here's another one with Krabbe! :) https://epomedicine.com/wp-content/uploads/2017/01/lysosomal-storage-diseases-enzyme-defects.jpg +7  
hungrybox  thank u +1  


submitted by hungrybox(1051),
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oordeidHyhlztharcoi is a idizhaet ierciudt &;t=g tihaizde scriutied ear sosatcaide tiwh him.apyeloak

athW ehrot eirusitcd rea aatecssdio thwi pyahleaiokm? oopL ist.cdruei

h?yW

Iihinbiont of N+a rtrpooibanes ocrucs ni otbh olpo urdecisti nibiht(i CKCN coaotstnr)perr dan ihiztdea edsciutir inht(iib aNCl ret)t.nopaorcsrr All fo shti nrcideesa +Na csrsiaeen nAdseoorlet iayvcti.t

elnvatRe to siht eoprbm,l dreAtseonlo ergpuusltae enieposxrs of eht +/KN+a ATP taroirnpet bba(roers aN+ iont od,by xeepl K+ otin ue.lnm) hsTi sutersl ni hkpyemoaali ni het ydo.b

anHg n,o hser'et eomr high dyile o!fni

Aeotrlsendo sode one htero nitapormt htngi - nacativoit of a H+ anlnhec taht xseple +H tnio eth elunm.

oS, vigne htta hist tiantpe sah my,ikpoaehal oyu nkow eterh is peluuaitnorg fo .detnoroeAsl Do ouy ikthn hre Hp owdlu be hhi,g or lo?w ctlEyax, it uwlod be high baueesc ni.c rteloeodnsA g;=&t n.ci +H xlepdlee noit the lumne tg=&; aomclibet las.ikaos

wNo uyo unandrtsde hwy othb oolp durisceit dna aehditzi dcsiertui can csuae wstha' llcead aokpilh"emcy mecaiblto "lslaoi.kas

hungrybox  jesus this answer was probably too long i'm sorry +9  
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +14  
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +1  
amirmullick3  @hungrybox did you mean "All of this DECREASED Na increases aldosterone activity."? +1  
pg32  Anyone care to explain why she feels she has, "lost [her] pep"? Is that due to the hypokalemia? Or hypercalcemia caused by the thiazides? +  
cmun777  @madojo @pg32 I assumed between her hypokalemia (which can cause weakness/fatigue) and possible contraction alkalosis those were the most likely causes for the "lost her pep" comment. I think if they wanted to indicate hypercalcemia to differentiate if loop diuretics were also in the answer choices they would certainly give more context for hypercalcemia sx +  


submitted by egghead(1),
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sihT si neo fo tehso sitoenusq I was vrnee gigon ot te.g t'Is nto ni ,FA I 'dton hkitn Iev' nsee ti in aslc.s

hungrybox  same :( +  
masonkingcobra  My issue was the stem said no skin damage (I would think pulling out your hair damages your scalp) [Turns out it does not](http://onlinelibrary.wiley.com/doi/full/10.1111/j.1529-8019.2008.00165.x) +  
gh889  FA 2019, pg 551 +8  
meningitis  Compulsively pulling out one’s own hair. Causes significant distress and persists despite attempts to stop. Presents with areas of thinning hair or baldness on any area of the body, most commonly the scalp. Incidence highest in childhood but spans all ages. Treatment: psychotherapy is first line; medications (eg, clomipramine) may be considered. +14  
step1soon  FA 2019 pg 551 +1  
teepot123  damn its in FA and Ive never ocne read it XO +  


submitted by yo(86),
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rhey'et atkglin aubot a ensplnalero tsuhn euprcrdeo

4t/de9/.lcecmnhctnaetips/aihrari-lhttenl.5lsn0stt:pmvst-yoensunal/l-eedol/ghar

hungrybox  be honest did u know that before looking it up +9  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +30  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +12  


submitted by lnsetick(94),
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  • reonPicA = oruy ipamrts mlesl like na APE
  • ceUMRen = e’htesr no OOMR in yrou asre scnie ’rteyeh flul of xaw
  • En-ReYCC = whne uyo EeisceC,r oryu ropes are nYiRCg
  • SeasBcuEo = SBumE si SgiEPEn tou of ruyo srpoe
hungrybox  as an ape i'm offended +31  
dr.xx  stop being an ape. evolutionize! +7  
dbg  as a creationist i'm offended +11  
maxillarythirdmolar  Also, Tarsal/Meibomian glands are found along the rims of the eyelid and produce meibum +  
snripper  So why is it apocrine? The dude is EXERCISING when playing football. +2  
qball  The question asks about "the characteristic odor" i.e. body odor coming from the APEocrine glands. The Eccrine glands secrete water and electrolytes. +1  


submitted by hayayah(1081),
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eeCartth mel:pecnat

dp/8s0is0ae/t0jeo2.heonp.m/nt-:ue/k/wsoppcgtg81yaa64/e0ltmn/0c

lclaRe taht het glun aexp dsxnete vbeao the fsirt b.ir

hungrybox  His expression is so blissful. U can tell they're shootin up some full u-opioid agonist codeine type of shit and not some shitty partial u-opioid agonist buprenorphine type of shit or some shit like loperamide that doesn't even act on the CNS +30  
rerdwins  even better, if you recall that the esophagus is RETROperitoneal ( its in like half the answer choices). hence, to get to it you have to go WAAYYYYY deep ( like rick and morty smuggling shit). after that, the lung option makes the most sense. +12  
hello  Also, pulmonary artery is way too far away to be damaged by internal jugular vein catherization. +  
makinallkindzofgainz  @hungrybox my mans just slipped in 3 high yield facts within a joke +5  
makinallkindzofgainz  @hayayah, I have an issue with that picture unless I'm missing something. In every other source I have, the internal jugular vein lies LATERAL to the common carotid artery. The picture you provided shows the internal jugular veins medial to the common carotid artery. +1  
cmun777  Look at the other side... I think it must be the manipulation of turning the head to the opposite side that better exposes the jugular for catheterization purposes +  


submitted by yo(86),
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hiTs ccoreudr nwitih 6 uoshr nda uscdea emso munoalryp eeamd nad oaietrsyrpr essritds teraf a oannurisfst dcsuae by eth no'rsdo aytnck-eeutoil biotadisen just rdtgieoysn het nsiecirpet rutoslhipne nda ospiarreryt neitllahdeo l.eslc

ehwli /aixaelnslpaghcaliry cna ucase potsraieryr arster and csokh it ash a tohwaems fetenrdif piertcu, no ng,zheeiw sictshnie ro tearhevw nda iocdcgrna to irfst dAi it sepahnp whitni isnuetm ot 3-2 suroh hchwi si ta selta bduole wtha eewr' geneis ehr.e aols aeewrb fo gIA ecidiftne lpeepo in isht hecico.

EP, he I ndo't itnhk it acsfeft oPa2 thta ofent hmcu rcdcgoian ot sthi psuer edrpu hgih ydile secuoe.rr but uhh aeyh ntdos'e leef PE adnik ontsqi eul0oi-#kcmaictt1scuecrmdawr129nes./mpp3/do/0t/hei:0epc.ee

ino,paenm hritg taref lal teh fnouinis sunsesbi dan no tnemino fo vrefe or nhatig?yn .Nah

og to epag 411 of tsfri i.ad m'I pertyt usre ew ened ot nwok rou sa/ntnlfpsiutinrano rpca uaseecb ti ujts kepes gocmni up ni lwurod but htsi eholw axme is a atpsrohc.o

gFoeirv me if I emad a ksimtaer/ngwo obaut gynti,ahn I somlty otg oifn fmro rftsi ai.d pzl coetrrc fi teehr si a i,tmseak gdoo ukc.l

hungrybox  we gonna make it bro +7  
hungrybox  or sis +8  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +6  
athenathefirst  I hope you guys made it. Your post 9 months ago +1  


submitted by yo(86),
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sihT ducrcreo winhti 6 shour adn dauecs mseo munolaryp aemde nad tyriaeporrs essdrist retfa a siounstnfar edacsu by eth o'ornds et-neklcioaytu etbsoinadi sujt ygtneisrdo eth cnstpieeri eiuhnpostlr nda rorpietsayr ldeilehoant ll.ecs

leihw /ayinialralsehcpxlga cna cuase oastrrriype trsaer and hokcs it has a hwsmtoea ienrffedt cte,ipur on newihgze, shecisnti ro hervewat nda cacnrgido to risft iAd it psenpah inwiht eusnmit to 3-2 ouhrs chihw is at ealst elbuod twah weer' inesge her.e olas aewreb of gAI iteefdcin eelopp ni isht iohc.ec

E,P eh I 'tdon nhtik ti ffesatc aPo2 thta teonf mhcu ridocagnc to htis puesr perdu hhgi eldiy eeucr.osr tbu hhu eyah dsteno' flee PE dnaik nqto eusiu1s-s3ic12dpiemdp.tleke0nh0totm/i#ecpce/awm/e9:r0ar.co/c

poenia,mn rhgti afrte all eth nsiunofi besuisns nad no imnneto of rveef ro anginth?y Na.h

go ot agep 411 of tfirs a.di m'I rtypet ruse we dene to kown ruo uai/fplnnasotnrisnt rpca sueeacb ti jsut kespe cminog pu ni dwulro ubt this holew emxa is a hrtpsoc.ao

eioFvgr me if I eadm a ionge/mktsarw buaot ghantniy, I moltsy otg noif ofrm tfsir dai. pzl crcetor if eethr si a atke,ism dgoo ku.lc

hungrybox  we gonna make it bro +7  
hungrybox  or sis +8  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +6  
athenathefirst  I hope you guys made it. Your post 9 months ago +1  


submitted by nosancuck(87),
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iht me pu wit tda CCPHN bo!i lla oabu adt CHLYN SENRYODM

hungrybox  yee boi +  
mkreamy  hahahaha i fucking love both of you +  


submitted by yo(86),
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unedr 8 sraye ldo rfo igsrl si a bad ,gnsi 8 si yao.k rn eud 9 rfo syob is a adb nsig.

stuj tahwc tou ofr ayn 6 year dlo ro tomgiesnh kiel hta .t ebeawr fo ttha RnGH ieehtr artenlylc ro msoe eosm trohe .eti-s orrcfus adi 9210 pg 632

hungrybox  yo wtf i got my first dick hair in 6th grade wtf are they feeding these kids +42  
lola915  FA 20 pg.637 Defines Precocious Puberty as: <8 y/o in Females <9 y/o in Males +1  
euphoria  In Caucasian is less than 7 years. +  


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tI idas it aws ltfaa to easlm ni ruoet, adn hte qetsnoui aesdk btoau veli onrb gi.sorpfnf niSec eth emlas n’atre nbegi bnro ni hte stfri ca,lep I dasi 0%5 lsefmae and %0 le.asm

hungrybox  fuck i got baited +32  
jcrll  "live-born offspring" ← baited +25  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +2  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +3  
qball  Jail-baited +  
srmtn  correct @spow affected females= X linked Dominant +  


submitted by nosancuck(87),
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Burh etl em eltl uyo a ill etercs

PPEE rtsneevp sttliaAesec KAA tda ULNG CLPSAOEL

otnD be wryiron bouat andmor rdows yhet tpus in front of hte GHIH ELYID snoe

hungrybox  literally LOL'd lmao I love this +14  


submitted by tissue creep(114),
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fI abdyyno sah a odgo way fo gebsnmunidmhriinrgei/itges lla eht rftdifeen nspisteoatnre fro nteagil or,ses Id' piratpeeac teh ehlp.

hungrybox  Pls post as a separate post and not a comment to this tho. The formatting for these comments sux +1  
whossayin  Assuming u have UWorld, just type sexually transmitted infections.. that table is the best IMO +  


submitted by neonem(572),
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Tsih is a esca of eatuc gout. osiudmooMn teuar caylsrts rea nekat pu yb reliut,nhosp ndgelai to an tacue fmamoilyartn no.trciae ellcT-s eant'r yrllea neilvvod in toug rm(oe drhiamtoeu hiar)ttirs.

hungrybox  Great explanation! So frustrating that I got this wrong, should have been easy. +3  
temmy  the way i thought about it was how did the neutrophils get there? the answer is via increased vascular permeability +16  
nor16  they, unfortunately, did not ask " how did neutrophils get there" but " whats the cause of the swelling " not to confuse with " what causes the swelling " +1  
divya  absolutely right temmy. that's how i thought about it too. +  


submitted by hungrybox(1051),
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eartG oevdi I dseu to realn tshi liaram.te

  1. erhTe era 3 omraj ptsye of sgudr: rpupes (umsni)a,lstt eodrswn (r)essdst,enpa nda uinghl.oneacls
  2. oenHri is an ipo.doi oidpisO era .*owerdns
  3. onrwDse od awht it dusnos l.eik eTyh scaeu dnw""o ompsmt:sy dterdaaeeeoscsid/n yniteax (adn shtu vabrliehoa idii,nbs)onthii yrrprisateo esnsdpeori.
  4. Thus hwradlawti wlli esuca teh soppit:eo hhr,rcci/aatdeennatoyispy y.xetnai
hungrybox  *other downers: alcohol, benzodiazepines, barbiturates +2  
nwinkelmann  THANK YOU! for the link to the video. this is one thing I've ALWAYS struggled with. +  
qball  I get that this is a good rule of thumb to help narrow down between alcohol and heroin, BUT is still not enough to answer this question. Some key features for depressants (downer) is alcohol (if we are talking mild withdraw) - tremors , diaphoresis and delirium (heavy withdraw) . For Heroin - Dilated pupils, yawning and lacrimation are key exam findings. +1  


submitted by beeip(124),
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isTh ash been a tgouh tenpcoc ofr me to t,eg btu I iknth 'mI lyafinl t:rhee

Teh semt si sinibdcrge amryirp naedlar cenn,fcfiiiusy or dsndsoAi.'

  • TCHA si ebgni r-preedocduov to tutialmes het eaarsldn ot codpeur solcio,tr btu yteh 'tacn ods,eprn iheret ude ot tphoyra or tsritencuod ,B(T uaonu:metmi DR,4 e)c.t
  • The stfri 31 oanim cidas fo THAC cna eb laecedv to mofr SM-H,α hhcwi iaesstmtlu lstaecme,ony ciagsnu hniytiroeptaepngm
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


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tn'od eb a kd?ci otn elarly ures awht eomr trhee is ot t.i The ntapite odn'tes eavh yna roeht myalif so hsti awnmo ulhsod be orcdednies imayfl

aesalmon  Questions like this usually hinge on asking if you're going to follow the rules or not though, obviously the one asking her to lie and say she was her sister is wrong, but the correct answer is obviously breaking the hospice center's "policy" - presumably if the physician is sending her to hospice then they don't work there so why would the Dr. be able to just tell her its fine? +5  
hungrybox  Yeah, I got this one wrong with the same logic as you, aesalmon. +1  
emmy2k21  I genuinely interpreted this question as though the two women were in a relationship because of the quotes "my close friend". I figured significant others would be allowed to visit simply. Ha seems like I'm the only one who read too far in between the lines! +8  
dr_jan_itor  @emmy2k21 I also thought the quotes implied a lesbian relationship and that the patient was afraid to share this (they grew up at a time when it was heavily stigmatized). So i was thinking, of course you and your "special friend" can stay together. I know this is not just a phase +8  
et-tu-bromocriptine  Anything particularly wrong with A (Don't worry. I'll call you right away...")? It seemed like the most professional yet considerate answer choice. Are we supposed to imply that they're partners based on those quotation marks around "close friend"? Because otherwise it seems like too casual and less professional than A, almost as if it's breaking policy. +5  
lilmonkey  I can swear that I saw this exact same question in UWORLD before. The only reason I got it right this time. +1  
docshrek  @lilmonkey can you please give the QID for the UWorld question? +2  
jakeperalta  Can someone explain to me why following hospital policy is the wrong answer? I'm so lost.And essentially how is this option any different from the last option where he asks her to say its her sister? Both go against hospital policy. Would greatly appreciate some insight yall. +  
jakeperalta  Can someone explain to me why following hospital policy is the wrong answer? I'm so lost.And essentially how is this option any different from the last option where he asks her to say its her sister? Both go against hospital policy. Would greatly appreciate some insight yall. P.s:it struck me as a romantic relationship as well, but it doesn't clear my doubt😓😭 +1  
drschmoctor  @jakeperalta Following the hospital policy is wrong because it would be cruel and unnecessarily rigid to deny a dying woman the comfort of her closest companion. Also, It would be inappropriate to ask the Pt to lie. What's the point of becoming a doctor if you have to follow some BS corporate policy instead of calling the shots and doing right by your patients? +1  
peridot  Ya kinda dumb that usually NBME usually tells us to never break the rules, yet here it's suddenly ok. But here the reason for this exception is that while only "family" is allowed, a lesbian relationship qualifies the "friend" as family (they just were never officially acknowledged as family/married due to stigma or state laws, which society recognizes today is dumb and outdated). It's a stupid technicality that her significant other isn't allowed to visit as a family member, so while we usually never want to break rules, this scenario follows the "spirit" of the rule. Plus it's a really extreme scenario where the woman is dying and just wants to spend her last moments with her loved one and it would be too cruel to deny someone that. There is no lie involved, which kinda leaves open the chance for the situation to be cleared up if worse comes to worst. This is different from E which is a straight up lie. Hope that helped. +  


submitted by hungrybox(1051),
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hTe eirvxc si the nylo rtcutrseu htat uodwl tlreus in ratlailbe c.aeolkbd

hungrybox  hydronephrosis = dilation of kidney (usu. due to obstruction at uretopelvic junction or backflow from obstructed bladder) +2  


submitted by hyoscyamine(55),
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I oknw hsti is utsj a ihtsargt pu cfat mfro FA, tub toncul'd treresu lrstainn(aoit ecll ocran)acim slao eb ectr?roc

hungrybox  Hmm I don't think so. The answer is "ureter" (singular) which would not result in bilateral hydronephrosis. +9  
privatejoker  If it is out of FA 2019, could someone give the page number to reference? Hydronephrosis' full definition is given on page 587 and makes no mention of invasive cervical carcinoma. +  
vinnbatmwen  p631 → Pap smear can detect cervical dysplasia before it progresses to invasive carcinoma. Diagnose via colposcopy and biopsy. Lateral invasion can block ureters - hydronephrosis - renal failure. +4  
privatejoker  Thanks! +  
emmy2k21  It's also in Pathoma page 140 in the 2018 edition! +1  


submitted by cantaloupe5(78),
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ishT one was ikrcty tub I nhkti uoy lu’eodvc enod hsit noe woithut ogdnekewl fo NMAD sopr.ceert metS dolt uoy hatt telaagmtu vsteiaatc hbto nN-noADM adn AMND resertcop utb it iaecvtadt olny oNMAnDn- epcrtesor in hte aleyr .easph athT smean ANMD ecsoprert tiveatac rafet o-NAnnMD spet.rrcoe tahT nmesa nsotigehm saw yaeldnig ANMD oeretprc vttigaainc and eth lnoy warnse htta daem ssnee as hte Mg biiintgnhi NDMA at egsnirt nitoalpt.e Once teh llce si apozrlieedd yb NnnoMA-D tosrpec,er ADMN reerpostc acn be vcdaeta.it

hungrybox  I forgot/didn't know this factoid and narrowed it to the correct answer and a wrong answer. Guess which one I chose? +14  
yotsubato  >That means something was delaying NMDA receptor activating and the only answer that made sense as the Mg inhibiting NMDA at resting potential. What makes the fasting gating kinetics choice incorrect then? +5  
imgdoc  NMDA receptors are both voltage gated and ligand gated channels. Glutamate and aspartate are endogenous ligands for this receptor. Binding of one of the ligands is required to open the channel thus it exhibits characteristics of a ligand channel. If Em (membrane potential) is more negative than -70 mV, binding of the ligand does NOT open the channel (Mg2+ block on the NMDA receptor). IF Em is less negative than -70 mV binding of the ligand opens the channel (even though no Mg2+ block at this Em, channel will not open without ligand binding. Out of the answer choices only NMDA receptors blocked by Mg2+ makes sense. Hope this helps. +6  
divya  sweet explanation imgdoc +  
lovebug  really~~~ sweet. thankyou :) +  


submitted by hungrybox(1051),
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ogonwiFll a ,tsokre itsh tiapnte dha aeenswsk of her left aefc adn y,obd so eth terkso msut vhae teffcaed eht rgiht side fo ehr inb.ra B was eth noyl hoiecc no the rhgit esdi of erh .aribn

lSilt oesucfnd? adRe on...

eTh ovutyrlan tmoro brefsi orco(pclainsit t)acrt dcndees fmro eth rrymiap motro ctero,x osrsc sdesue)act( at hte uaredllmy psmyia,dr nda hten esypasn ta teh rnieoatr romot rnoh of het niplsa lve.le

ueBeacs of sanceduitos ta het aedyulmlr m,iaysrdp oyu oshuld mkae a neot fo hweer yna troske s.ucrco Is ti voeba het elrmudayl dymaipr?s Thne ti lliw faceft the dies estiopop the rktsoe acnla)ertao.tlr( Is ti bolwe the mdlrlyaeu irdsmpa?y heTn ti wlli atffce eth msea dise sa hte tsrkeo iltae(rsi.pl)a

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +8  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +22  


submitted by drdoom(896),
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aorticsiotsoVnnc wraingn(or fo a e)tbu lwli aesuc het folw eatr ot seaicren ghouhrt that tebu, hihcw sdsceerea taardia/dwurlo .rsuesrpe hTe eartsf a luidf esmov gotuhhr a tbe,u het less rdua”wot“ coerf it tse.exr h(isT si ownnk sa teh ritenuV ftecef).

hungrybox  not seeing how this is relevant +8  
sympathetikey  He's showing how A & B are incorrect @hungrybox +7  
nerdstewiegriffin  what a moron @hungrybox is !! +2  
leaf_house  MCAT flashbacks on this image +1  


submitted by hungrybox(1051),
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Teh anmiatco nffbsxuo si emrdfo yb het ndtneso of the oenrstex lolspici sirvb,e eht badrtuoc olslcipi ,nlugso dna teh onrstxee cilposli olsgnu. (ueigfr)

Teh ofrol si dfeomr yb eth oipscdah eo,nb dna it is here ttah one nac ataplpe for a oelbspis ertufdcar saiphdoc.

recouS: Gsar'y Aoaytmn vewRie

hungrybox  Of note, the radial nerve innervates the extensors of the wrist. So the muscles of the anatomic snuffbox are all innervated by the radial nerve. +  
hungrybox  This helps you remember that the radial nerve innervates the abductor pollicis LONGUS (abductor pollicis BREVIS is median nerve, ADductor pollicis is the ulnar nerve. These two make sense if you think about the direction the thumb is moving - ending closer to the nerve.) +1  
meryen13  just to review, if we don't fix this, what gonna happen next? --> avascular necrosis of scaphoid--> non-union. why? because scaphoid has two blood supplies the distal part is mainly volar branch of radial a. and the proximal part is mainly dorsal branch of radial a. +  


submitted by hungrybox(1051),
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The tcmiaano sonfufxb si eofmrd yb the nseotnd fo hte teexnrso pcslloii bvse,ir eth daoutbrc siilpclo ogn,lsu dna the exteosrn scoililp lngso.u (ugerfi)

The orlfo is edrmof by eth ocdahisp n,oeb and ti is ehre tath noe cna tlaappe rfo a lpissbeo erfudatrc osdipc.ah

c:uSero G'syra myntaAo vweieR

hungrybox  Of note, the radial nerve innervates the extensors of the wrist. So the muscles of the anatomic snuffbox are all innervated by the radial nerve. +  
hungrybox  This helps you remember that the radial nerve innervates the abductor pollicis LONGUS (abductor pollicis BREVIS is median nerve, ADductor pollicis is the ulnar nerve. These two make sense if you think about the direction the thumb is moving - ending closer to the nerve.) +1  
meryen13  just to review, if we don't fix this, what gonna happen next? --> avascular necrosis of scaphoid--> non-union. why? because scaphoid has two blood supplies the distal part is mainly volar branch of radial a. and the proximal part is mainly dorsal branch of radial a. +  


submitted by hungrybox(1051),
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aak puallam of eratV ro eht nrpiophctctaeeaa udtc

hungrybox  tripped me up cause I didn't know the names :( +14  
sympathetikey  @hungrybox same +14  
angelaq11  omg, same here! I thought, well, I don't know of any duct that connects the pancreas to the liver, so...2nd part of the duodenum it is :'( :'( +7  
alimd  actually Ampulla of Vater is located in the 2nd part of the duodenum. +  
mtkilimanjaro  I think 2nd part of duodenum could be viable if the ampulla was not an option. The ampulla is way more localized/specific to this scenario +1  


submitted by hayayah(1081),
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tNoe: The easundcb .n si ucaaltyl eht evner tmso llieky ot eb degamad by na dnngepxia ltnairne iardotc esyaumrn in teh surnaocve susni utb teyh veig uyo pcescifi CN3 fonitcnu in siht ue.otsiqn

hungrybox  One pupil larger than the other indicates damage to the pupillary light reflex - afferent: CN II, efferent: CN III. +24  
cienfuegos  A little more info regarding other sxs (via UW): -cavernous carotid aneurysm: small usually asx, enlargement can cause u/l throbbing HA &/or CN deficits. VI most common thus ipsilateral lateral rectus weakness, can cause esotropia = inward eye deviation & horizontal diplopia worse when looking toward lesion -can also damage III, IV and V1/2 -can occasionally compress optic nerve or chiasm thus ipsilateral monoocular vision loss or non-specific visual acuity decrease +2  
lovebug  There are in FA2019, page 530. +  


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kO I etg atht fi 500 ayrdlea evha teh aidssee nhte hte ksir oplo si poredpd ot 0002 suetdsnt utb het qeosintu lesiyilafpcc assy thta hte sett is ndoe a aeyr .l..arteif 500 oepple dha dlaymh,iac you udowl terta tm.eh You 'tond cobeme imuenm ot camdilahy rafte itcnnioef os teyh wdlou go kacb iont het ksir ,polo aniegmn het pool dlwuo nurtre to 0052. hTe enawsr osludh eb 8%, tshi saw a dba qt.ieunso

thepacksurvives  Yeah, this was my issue. I got it wrong because of this-- still don't understand the logic bc you can get chlamydia multiple times +6  
hungrybox  FUCK you're right. Damn I didn't even think about that. That's fucking dumb. I guess this is why nobody gets perfect scores on this exam lol. Once you get smart enough, the errors in the questions start tripping you up. Lucky for me I'm lightyears behind that stage lmao +9  
usmile1  to make it even more poorly written, it says they are doing a screening program for FIRST YEAR women college students. So one year later, are they following this same group of students, or would they be screening the incoming first years? +5  
dashou19  I think the same at first, but after a second read, the question stem said "additional" 200 students, which means the first 500 students don't count. +  
santal  @hungrybox You are me. +2  
neovanilla  @usmile1 I was thinking the exact same thing... +1  
happyhib_  I agree this is a trash question; I was like well if this is done yearly for new freshman the following year would be of the new class (but the word additional made me go against this). Also you could assume that they were treated and no longer have the disease... I dont like it honestly but know for incidence they want you to not include those with disease so i just went with dogma questions on incidence to get to 10% +  


submitted by nuts4med(6),
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oneAyn ahve na edai why eth eescaddre aerlarti O2 ttaironsua is ?orcintcre nmsAgusi hes has pmul adeem nesic seh ahs EL ad,mee lotu'dwn a rolwe 2O sat eb eecpdtxe oto?

haliburton  I believe there would be no decrease in O2 saturation because oxygenated blood (high pressure) is shunted into deoxygenated circuit. As long as the lungs can keep up, this should increase venous oxygenation on average. +7  
hungrybox  ty both of you for this, was wondering the same thing +  
coxsack  O2 sat won’t change b/c you’re not adding deoxygenated blood to the arterial side. You’re just taking arterial blood and putting it into venous blood. Same reason why L->R cardiac shunts don’t decrease O2 sat (while in contrast, a R->L shunt would). +5  
hungrybox  just realized: the high pressure of the arterial system keeps out low-pressure venous blood in an AV fistula (probably obvious to most ppl but it was a eureka moment for me lol) +2  
chandlerbas  ya you wont have decreased arterial O2 sat because oxygenation of blood is perfusion limited (FA19 --654) therefore oxygenation of the blood happens within the first .3seconds of entering the pulmonary capillary that you could even handle having more deoxygenated blood enter +  


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VA latussiF ruroet- oblod form eth aealirtr eytmss to het usoevn ,tymess -aignssybp teh rsreltAieo = rscaneeI LP ;gt&--- SRCAENIE VR. llA in lal = ncseeaIr CO.

drAnocigc ot dWo,Ulr teh trrlaseieo aer a ojarm eorscu fo setaricens ... so sbnasygpi hte ltraoeiesr restsul ni a eedaesrc ni lTtao elPrhreiap esictaesnR ... iucngas an censaire ni eht reat nda moleuv of dolbo unirnterg ot hte ea.htr I am ytretp user theer is eorm ot eth oslyophgyi dbhnei i,ths utb I oehp htis eaidlxpne a lelt.ti

big92  "Immediately following creation, arteriovenous fistula (AVF) is associated with an increase in cardiac output (CO), achieved predominantly through a reduction in systemic vascular resistance, increased myocardial contractility, and an increase in stroke volume (SV) and heart rate. Over the following week, circulating blood volume increases in conjunction with increases in atrial and brain natriuretic peptides. These alterations are associated with early increases in left ventricular (LV) filling pressure with the potential for resultant impact on atrial and ventricular chamber dimensions and function." (PMID: 25258554) There's also another study by Epstein from the 1950s looking at the effects of AVF's effect on CO in men (PMID: 13052718). Apparently, the increase in resting CO is a big problem because it can lead to high-output cardiac failure (LVH). +29  
hungrybox  Jesus big92 you went in on the research lmao u must be MSTP +6  
temmy  big92 you are right. that is why pagets disease pagets have high output cardiac failure because of the av shunts. +4  
kevin  what is "increase PL" +3  


submitted by seagull(1583),
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dtoipIyci snema --- onbadyti atisnag diytobna. B scell tdn'o have ufcaser tiseanibdo tbu emer esiynztseh hem.t

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +3  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by seagull(1583),
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iIitopydc asmen --- nidotyba ntgsiaa nt.daioby B lecsl o'tdn hvea acserfu esnatibiod ubt rmee zeshyeisnt t.hem

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +3  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by assoplasty(95),
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I ntikh the pcetcon rethey’ singett si the nedasecri BGT ellsve ni n,crganpey and not tjsu dporyiithsrhemy in .rlngeea

Wehn esngcenri ofr royy,piodm/hhrhipstey HTS lvlsee rae ALSWYA tlfpriyaernlee ekdecch eabesuc tyeh aer mroe eetssnvii to imetun eercefdnfsi ni T4.3T/ Onfet emtis HTS elvlse can datnrtmeeos a genhac vene ewnh 4T/3T evsell rea in teh baislncliuc r.naeg Teh yonl ptcenioex to sith luowd be ni nneyrgpac da(n I seusg ybema eirvl l?aeufir I tdoub yteh wlduo kas tihs ohgut).h Hihg neterosg eslvle vrpneets het elvri omrf iengbkra ondw G,TB ndlaieg to niasedrec TGB llvees in eth usrm.e hsTi sdbin to efer T4, naedcsrige eth uotnam fo blivaaale fere 4T. As a rpcemnoaoyts miane,hcms SHT leselv are tasentiynrl rncdsieea adn eth TARE fo 4T iudpntoocr is cridseane to lernhispe ieslaenb reef T4 leev.ls vroHwee teh TTLOA ontaum fo T4 si .sdaeernic

Teh seinquto is ainksg woh ot nofmrci dyiismehtrhpryo ni a pgetanrn awmon &t;-g- ouy nede ot ekchc EREF 4T lleves aes(eucb yteh dslhou be nlrmao deu to npamytcoores es).rpsone ouY noanct ckhec TSH ulalu(ys dletaeve ni pcyennrag to eenpscatom ofr snceedria T,B)G nad ouy nctnao cchke attlo T4 sevlle l(lwi be ie)dsean.rc Yuo otg eht wrenas thgir ihreet awy ubt I itkhn sith si a nffrteeid eionragsn thwro rgnicoidnes, saeuecb yeht cna sak isth occtnpe ni ohert ncoesxtt fo -rsihn,reyptsgoeme nda fi yeth ledist “THS” sa na wenras eiocch ahtt dowul eb rocitcrn.e

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 +  
an_improved_me  Just to add: Pregnancy is not an exception to using TSH in suspected hyperthyroid pregnant patients (not sure in hypothyroid); you would still get a TSH first, and if its unusually low, you would then proceed to measure T4 (free, total), and so on. https://www.uptodate.com/contents/hyperthyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-causes?search=hyperthyroidism%20in%20pregnancy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H994499 +  


submitted by hayayah(1081),
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eht oyajrtmi of nobcra didxeio ucmoleesl rae drreaic sa prta of the babaonricte bfeurf ts.meys nI ihts essm,yt crabno iodxide ssfudief otni het C.BsR Cnricabo ydraahsne CA() iwnthi sBCR ykcuqli ovrecnst teh racbon odiiedx oint bacircno diac CO3.H2)( Ciaocrbn cdia is na nesublat eidieemnrtta umcleloe atht ymeamieldit ediocstsais otni noabaretcib niso 3)H-OC( nda doernhgy H+)( inso.

heT nwley dzeethssiny aotribabcne ion is pneoadtrrst uot fo the BRC iotn het slmpaa ni heegxnca rfo a odilehrc ino lC;)−( siht si aedcll het eohcdirl sfi.th eWnh eth bdool eracehs the sln,ug eth taroicnaebb ino is drapttorsen acbk iotn eth RBC in hexencag fro hte eorclhdi oni. heT +H ino doesiicstsa rofm eth oongmhiebl and ndsbi to eht eacatibnobr .oni hiTs edcoursp teh caoncbir acid dtteai,rmeein hciwh is notedcrve acbk otin ncrbao ioddixe gohruth hte atmiznyec naciot fo A.C hTe robanc oixeddi oecddupr is pdexllee throguh teh nguls igdrnu oahtae.xnli

hungrybox  Amazing explanation. Thank you!! +2  
namira  in case anyone wants to visualize things... https://o.quizlet.com/V6hf-2fgWeaWYu1u23fryQ.png +5  
ergogenic22  CO2 is carried in the blood is bound to hemoglobin, known as carbaminohemoglobin (HbCO2) (5%), dissolved CO2 (5%), bicarb is 90% +3  
pg32  Nice explanation, but can anyone clarify how we know from the question that we are measuring HCO3 rather than dissolved CO2? +3  
qball  @pg32 This question is asking about what accounts for the LARGER amount of co2 and the HCO3 buffer is about 85% of this transport and dissolved C02 is about 5-7%. https://courses.lumenlearning.com/wm-biology2/chapter/transport-of-carbon-dioxide-in-the-blood/ +3  
teepot123  fa 19 pg 656 +1  
surfergirl  "majority of blood CO2 is carried as HCO3- in the plasma." I guess that is all they're testing us on, just in a very convoluted way. +  


submitted by hajj(0),
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nac ynnaoe paxeiln th?si i nwko adnmei orf y si hihegr by nalucoiatlc tbu x ahs otw oemsd so woh mcoe y has ehgrhi odme?

lispectedwumbologist  The mode in X is 32 and the mode in Y is 80 +  
lispectedwumbologist  The mode in X is 70 and the mode in Y is 80* +1  
hajj  Thank you! +  
hungrybox  Just checking in so I could feel smart about getting this right despite bombing the rest of the test lmao +4  
usmleuser007  can someone please explain the median in this +  
nala_ula  The median can be known by first assembling the numbers in order from least to greater. If it's an uneven number set, the number in the middle is the median (for example: 4, 10, 12, 20, 27 = median is 12 since this is the number in the middle); if the numbers are even then you have to take the two values in the middle, add them up and divide them by 2 [for example: 4, 10, 12, 12, 20, 27 = (12+12)/2 = 12]. Page 261 on FA 2019 explains it as well. Not sure if I explained it well... good luck on the test, people! +  
dubin johnson  Can someone please explain how the mode for Y than X. Not sure how we got the values above. Thanks! +  
dubin johnson  I mean how is the mode for Y greater than mode for x? +1  
sgarzon15  Mode is the one that repeats the most once you list them in order +  
usmile1  Median would be the BP value that the person in the 50th percentile of each group would have. So for group X, to find the 50th percent value, I added 8 + 12 + 32 = 52, which is right above 50, so the median would be 70 mmHg for group X. Doing the same thing for group Y, 2+8+10+20+ 18 = 58; the 50th percentile would fall in group that had a BP of 90 mmHg. which makes the median higher for group Y. hope that isn't wrong, and helps someone! +4  
poisonivy  I did it the same way! not pretty sure if it is the right way to do it, but it gave me the right answer! +  


submitted by beeip(124),
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I imhtg eb eht olny serpon no trhae how tog ihst noe wgor,n ubt e:lgerrasds

TT"I ysslniaa nsdeiucl evyre bjuects woh is ornediadzm diongarcc ot iezdrmaodn etaenttmr nstnmeg.isa tI ienrsog oeccolmnni,nap cootrlop itivdason,e ,aiwatrdlhw dan anyhignt that enapshp rftae ti"n.ozmanrioad1][

yo  You're not. I also goofed. +20  
seagull  https://www.youtube.com/watch?v=Kps3VzbykFQ This video is a pretty decent explination worth your time on the subject. +2  
hungrybox  I got it right but I was only like 50% sure. So I appreciate it. +  
drdoom  ^ linkifying @seagull: https://www.youtube.com/watch?v=Kps3VzbykFQ +2  
teepot123  ^ same video above used when I analysed my form 20 q which I got incorrect at time, its very clear at explaining this, helping me get it correct on this form +  


submitted by feronie(18),
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ercOoymhtic = ↓ ettseseotonr optrinuocd = ↓ THD &;gt= trpetosa llecs uenrdgo tooa.ippss is(hT mamsihecn is irmisal ot insgu 5deαau-rtcse rebokslc to ratte )H.PB

ospApstio si eerhrdzaactci yb NAD fgantnoertima o(,sinsypk yksrrxraoie,h s)oyik.rslya

hungrybox  DNA fragmentation histopath: https://i.imgur.com/nxYW8vL.png Note that degradation in apoptosis is progressive. From pyknosis -> karyorrhexis -> karyolysis. Aka condensation -> fragmentation -> complete dissolution. +27  


submitted by hungrybox(1051),
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thalmoeutb = YhatEbtElmou

eGrta mcimenno for mregmrniebe taht EohYbmatuElt is hte enopnomct ttah ascsue iavuls psrlobme in RIPE tephrya orf TB.

hungrybox  RIPE = rifampin, isoniazid, pyrazinamide, ethambutol +2  


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iadCdan is a tpra fo teh orlnam flroa of nkis, ducol cuaes mnatcoiiontna fo a lrcaten voensu caeer.htt heT tsoieqnu tsaets that het mignasro is ple,rpu dugd,bin ddi nto pnosder ot daorb cpuemtrs csttionbaii aak( heyt t'nddi seu focuenozall ro orinheatmcip ).B yL,lsta yeth ewhdso ti epdatl no bdolo rgaa nda etreh was no hesmslyio chwih amineltise hptsa ht(e nlyo htreo ebpsosil troencend ).eher

ycuctocoCrps uallsyu lnesvoiv semintigin ni poomnicimsumredmo .tsp E . iocl is agmr oo xvtniapsrtrieheg si sluuayl dsaetnirttm by a hrton no a ores ro eonmeos itwh a ihrtsyo of derggnnia

hungrybox  Also, the yeast form of Candida is gram (+) +30  
dr_jan_itor  I got thrown off by the part where they said "ovoid" and thought they were implying a cigar shape. I chose sporothrix for the morphology in spite of knowing that it clincally made no sense. +1  
lilmonkey  I chose S. aureus before reading the question (looks like b-hemolysis). Then I saw "budding organisms" and picked the correct one. +  
the_enigma28  I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +  
the_enigma28  I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +  
lowyield  cryptococcus also doesn't take up gram stain because the shell is too thiqq +2  


submitted by drdoom(896),
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Heser’ eno way to aif-soeepsril-cneotm ddereacs“e hgdo-bdoynnre raof:tonmi” ’Im otn a gib anf fo hsti ieln of na,gsinroe tub lcaelnhytci lnaiane sa a dsei rpgou sah emro d*egsnyroh for ntlieapto ydoehrgn noibdng athn eiygncl:

alane:in —CH3
cel:gniy H—

oS, lc”“cteia,ynhl naenial wodlu rpetim rome e-hyrdboognnd o,raoifnmt whihc htgim walol ouy to eeilmtnia hatt c.choie

taTh is,da it esmes ltasom loibsmpies ot eulr otu t(hotuwi reyv neihcctal kowlgeden ro mseo rodpiedv pxelteiarenm )data ahtt hte iystlglh glerar alnneai dose tno iampir dhnregoy nodbgni beetnew aglenolc lemoesclu vai itserc )ip(lsata cee.rentfrnei nI replims st,emr ceisn nenlaia is ar,grel you oluwd tinhk ahtt it muts eomwsoh fetrenrie hwit eth nn-gdeoonidhyrbg htta ccruos hitw eht dt-ypwlei yclnige.

---
yrSctl*it spneia,kg tis’ not het urnbem of dsorhyneg tbu aosl eth rthgsten fo eth oeidpl htta fcitealsiat rydhnego nd:ogbin a ohnedyrg bnoud ot a stoyglrn netoetrvlceagie celmloeu ikle uilfnoer wlli pap”“ear remo iestopiv an,d stuh, hngdoeyo-rdbn mero lnorsgyt thiw a ybaern goxney prde(amco ihtw a orgdeyhn ccetnodne ot cnbaro, rof mx.ae)ple

uFrerht ag:dnire

  1. he.himel/ciguhebqs:etp.twuhu/wp/u.sptdwnd/mhcrdl.lod/
hungrybox  Appreciate the effort but this is far too long to be useful. +26  
drachenx  hungrybox is a freaking hater +  
drdoom  @drachenx haha, nah, coming back to this i realize i was probably over-geeking lol +  
blueberrymuffinbabey  isn't the hydrogen bonding dependent on the hydroxylated proline and lysine? so that wouldn't really be the issue here since those aren't the aas being altered? +  
drdoom  @blueberry According to Alberts’ MBoC (see Tangents at right), hydroxylysine and hydroxyproline contribute hydrogen bonds that form between the chains (“interchain”, as opposed to intra-chain; the chains, of course, are separate polypeptides; that is, separate collagen proteins; and interactions between separate chains [separate polypeptides] is what we call “quaternary structure”; see Tangent above). And in this case, as you point out, the stem describes a Gly->Ala substitution. That seems to mean two things: (1) the three separate collagen polypeptides will not “pack [as] tightly” to form the triple helix (=quaternary structure) we all know and love and (2) proline rings will fail to layer quite as snugly, compromising the helical conformation that defines an alpha chain (=secondary structure; the shapes that form within a single polypeptide). +  
tadki38097  also you can't H bond with carbon, it's not polar enough +  


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aMnursebom pGrleriounthimsleo is epN;ochrti YLNO RIURNAIOETP is ni teh vtnteegi

It c'tan eb PMGN sebuace MGPN is Nptcihrie twih selbipso rocNehpit

therO eisccho ear emiatneild yb eanRl yiopsB

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +4  
cooldudeboy1  could someone explain why the other choices are ruled out by biopsy? +  
arlenieeweenie  @cooldudeboy1 PSGN does have a granular immunofluorescence, but there is no previous illness or hematuria mentioned so you can rule that out. Goodpasture is classically linear IF since they're antibodies against the GBM. IgA nephropathy is mesangial IF so it would deposit more in the middle. Minimal change wouldn't show anything on IF +2  
qball  I know First Aid states MPGN as a nephritic disease but I think it can present as nephritic or nephrotic syndrome. https://emedicine.medscape.com/article/240056-clinical. Of course, the renal biopsy helps give it away but I wouldn't be so quick as to rule out MPGN +1  
taediggity  Totally agree w/ you Qball... I thought MPGN too, but I think Penicillamine makes it Membranous Nephropathy +