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Welcome to hungrybox’s page.
Contributor score: 791


Comments ...

 +0  (nbme19#47)

I got confused with aquaporins so I picked E :(

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



 +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. +


 +2  (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


 +6  (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. +2
pontiacfever  Drink a lot for a week makes you a chronic alcoholic? +
pontiacfever  That means alcohol abuse = chronic alcoholism +

 +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 +

 +1  (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 +

 +1  (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 +

 +0  (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 .. +4
hungrybox  hawt +
underd0g  Why isn't this HPV given the sexual history? +

 +0  (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. +

 +3  (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. +1
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. +12

 +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

 +5  (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.)


 +6  (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.


 +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.


 +3  (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 +

 +1  (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


 +2  (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)


 +1  (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. +

 +4  (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.


 +5  (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)

The endoderm of the 3rd and 4th pouches form the parathyroid gland and the parafollicular cells of the thyroid gland.


 -5  (nbme20#33)

Here's my reasoning for why the answer I chose was wrong...

Casein is a milk protein. Because most milk is pasteurized, all proteins will be denatured before consumption, and would not have any effects (Choice B).

This is in contrast to avidin, which is found in RAW eggs and binds vitamin B7 (biotin), preventing carboxylation.

...

bullshit question btw 😡


 +3  (nbme20#5)

I did this by process of elimination:

Acne is not itchy or painful from my experience (Choice A).

Never heard of cutaneous lupus eryhtematosus, but I'd asssume you'd have a malar rash (involving the nose/undereye area), not spread out over the cheeks, jaw, and neck (Choice B).

Keloids are just overgrown scars. Scars are not particularly itchy or painful (Choice C)

Rosacea is just redness/flushing in certain areas of the skin. Mainly an aesthetic issue. Not itchy or painful (Choice E).

tbh I was between B and D.


 +8  (nbme20#30)

Here's my approach (downvote if wrong):

falling on outstretched arm → usually scaphoid

BUT

scaphoid problem → pain in anatomical snuffbox

so then it goes to the next most commonly injured bone when you fall on an outstretched arm, your lunate

(which is right next to the scaphoid)

spaceboy98  Also, dislocation is most common in lunate, Fracture most common in Scaphoid +1

 +0  (nbme20#25)
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.S.o. oyltaetrleich na saeitdol adreesec ni RH owdul inasecer CO ued to .cin drpal,eo ?htgri

tBu OC esasecrde in ihst sace cb/ eht eeftcf of cin. RPT is rmeo pwer?fluo

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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otehr anesw:rs

niobiihint fo 2H tpree:cosr o(rf G)EDR vneeprt tigsarc dcia eieonrsct mteci(en,iid

bninihioit fo heeisasorsspeohpdt :(D)PE

  • yhoeepthllin satm(h)a nitsbihi cMAP EPD
  • lf-iasn idkc( )silpl fro DE ibhtini cMPG PED

β2 siaost:gn fro( )smhata aseuc nialrboihcontod

  • aorlubelt hostr( cagitn - A rof )ectAu
  • ,letomrlsea mootrrloef ln(og gitnca - pispxoa)lryh

k(di cpyyehlotm mremnbea ialittanibs)zo

hungrybox  H2 blockers are the -tidines +2
yotsubato  > dickpills lol +15
temmy  hungrybox, you are a life saver +1
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +1

 +6  (nbme21#24)
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rooalcMlia,pyccs qmossuau lcel amccinora nstde to eb ffohwiet- in orlc,o giirasn orm,f dna gntxeedni tion a sr.ubhonc

cSruo:e edidRpaioa

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. +1

 +28  (nbme21#17)
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wneh ifdf ielsng ardtsn iearpr insmamhsce are ued:s

  • airrep leywn nseyetdhizs :dsatnr atsichmm pirera c(ynhL eosmynd)r
  • arpeir enpiyiidmr msdier saduce yb tda UV pu:soxeer nieoducelt xosincei rrieap adoXe(mrre emtousgpnim)
  • pierar inesoousnptaotxc/ toiaetlran: abse cesixnio reirap
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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iedvireFitnU &tg;- dsue rfo fsuoin of HIV sviru nda tragte lcel

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

 +8  (nbme21#25)
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Rtanelev gmdiaar

IAIT tircsnsotc het rfnfeeet ao.rteilre EAC inbihsirot okbcl eth tECi-deeAadm ronensiocv of AIT ot AIIT.


 +8  (nbme21#34)
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ysacmnhyioe estpdo htsi rateg cpi boewl

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

 +5  (nbme21#38)
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My esniisompr fo ithiorcnmepA B si ttah 'tsi het IBG GNUS. tI gitsthra up asacttk het rslesto ni the ginfu lapsma n.emeabmr

neealwMhi ill cbiht ugsdr ekli olz-esa jstu tniihbi rselto .ssstyhnei earitbennif-( X loreao,sntl lozase- X retegoolr)s

gnuinsF X lcle awll s,setyinhs nfcsliueyto X celucni ciad ss.niyseth

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! +

 +26  (nbme21#49)
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oaHzrddticeolyrhoih is a zihtaied uciidrte &;=tg zditaehi tsiciuerd are esaoscdtia ithw yipoheamkal.

What eohtr icsuiedrt are doiastscea hwti ykopelahmai? pooL csi.uitdre

?Why

iIibnnotih of N+a stapornrobie oruccs ni btho lpoo ucriitesd (iiibtnh NCCK rctnaotserp)ro nda iitehdza csuitdrie (btihnii laCN acrtstror).nepor lAl of sthi rdciaesen +Na rneesscia teoeAsonlrd tacvyiit.

Rtenealv to tshi bm,oerlp lsteonAdreo utesuepgrla srsoeenipx of eht /+N+Ka APT onartpreti r(obrsaeb +Na otin bod,y peexl +K tnio m.lu)en Tish leussrt in kaaoyimelhp ni eht oy.db

Hgna no, r'esteh moer gihh lydei n!iof

enrsdAletoo dseo one htreo itrptmano hintg - ctaaiintov fo a H+ nenchal ttah plesex +H tion het uenlm.

o,S gvein tath shit eatitnp hsa kpiohaaylm,e yuo owkn eethr is laoitpnuguer fo elosedtonA.r Do uoy itnhk her Hp udlwo be hg,ih ro ?wol Elt,xyac it wdulo eb gihh auebsec nc.i Aoeltodnrse &t=g; nc.i +H peldleex toni teh nlume g;=&t omeblaict .okssaial

Nwo uoy ddtanrsuen wyh hotb lpoo riuecdtsi dna izaeidth ctursidei anc aucse 'sawth eldcal amioekyh"plc itoaembcl kal.as"ilso

hungrybox  jesus this answer was probably too long i'm sorry +2
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +10
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +
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 +

 +7  (nbme21#12)
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eGatr dievo I uesd to naerl this marelati.

  1. heerT rae 3 romaj espty fo sg:rdu prpues nitsas(ltm),u rnesdwo s,ee(radp)tssn nda clnuali.sehong
  2. nioerH is an ipoi.do piisdoO are so.r*ednw
  3. ewsnorD od hwta ti odsnus e.kil Tyeh uesac n"w"do smyt:mspo eneidaserdo/detcas enxyiat nd(a hust vliaebaorh n,itiiihionsdb) tryrrapoies pne.rsdsoie
  4. Tsuh adiwarhlwt ilwl cuase eth otops:eip pa,n/eacrtnciharsyiedtyoh nyax.iet
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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heT vrxcie is hte lnyo eustrctru htat odluw ultesr ni ltlabirae aek.obcld

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

 +7  (nbme21#44)
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oopL iedcursti era ifstr nlie fro cuate evsotcgein ehtra ureifl.a hatT lshodu elhp yuo rbeemrme taht hety era eth ostm pnteto cturi,sedi os ryeeh't onfet udes ni eht etcau ternatetm of .aemde

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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derpeaiLmo: gnsAoti ta iido-oup reeo.psrct wsSol tug iytitmol ememr,ebr( nitpcasotino si a mnoocm eisd tefcfe orf lla i)so.iodp

uzqi oulreysf:

:Q doluW a kjunei nawt ot ues eimoa?peLrd

A: o,N ti ash proo NCS teaietnponr hc(whi is yhw ti ash a wol dvtecdaii t.liopte)na

:Q dlouW a einukj arhert eahv hominerp or ruieorheppbn?n

A: .roephinM tBoh rae updoi-io ssgain,ot but ieromhpn si a lflu ansogti ewhil puniorhpeebrn is noly a rapilta .agtsion

:Q ahWt ouatb mpihnroe .vs ei?oendc

A: ikTrc nostqiu,e thbo aer ripalat s.niosgta

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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HIHG EDYIL: noounsi"lb vtgioni"m amens ttah eth utos/inoisbscuter oscme feoreb moprlxi(a ot) hte ednsoc dumduo,en ewehr ilbe is .edaeselr

tA dnruoa ~4 eeswk (vegi ro kate a w)fe si wehn lpyroic nsisetso yuluals hwsso .pu

ze tsp rfo u now eepk it up

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

 +10  (nbme21#37)
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owollFign a sretko, tshi paiettn dah ssewnaek fo her ftel ceaf dna oyb,d so eth ktrsoe mtsu ehav dtfeaecf het grhit seid of rhe nba.ir B wsa eht lnoy hceoci no eth higrt sdie of rhe nabir.

liltS u?ocdefsn aRed ..on.

hTe utyolnvar omotr ifesbr anrolpstioic(c rt)tca ededncs omrf the prmiary omtro eor,cxt rscos )sce(utsdea ta eht alrmyulde sa,dymipr and hnte naesyps ta teh riaenotr tromo orhn fo het pilasn ee.vll

aseBuec of istnuadceos at eht dlrmyaule ydip,mrsa uyo uslhod kmae a oent fo eehwr any teksro orccu.s sI ti boeva het leaymulrd rym?padis nheT ti illw eaffct hte ieds eotopspi hte reksto ca.r)ate(tlraoln Is it loewb the delumryal sdmpyr?ai henT ti wlli fcftea het esam edsi as eth rtskeo pels).rati(ail

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 +7
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 +15

 +8  (nbme21#50)
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heT amnatcio ofnsfbux si foerdm yb teh tnoends of hte exnrtoes opiillsc bsver,i eth cbauotdr iplolcsi ,gnolus dna eth xrnoetes plliicso nsul.go (egirfu)

eTh olrof is moferd by teh aohdcsip bo,ne nda it is erhe htat eon acn aepaltp rfo a epibsosl fuatecrdr o.ahspcid

urocSe: G'rsay onytamA wieeRv

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.) +
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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riagmad hnwosig MAO


 +6  (nbme21#19)
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aak plmuaal fo earVt or eth entichtaraopaepc utdc

hungrybox  tripped me up cause I didn't know the names :( +11
sympathetikey  @hungrybox same +7
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 :'( :'( +6
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 +

 +7  (nbme21#20)
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zqui oylsferu en:wrsas

  1. ltoiSer Slto(ier uhtSs ,nwod MIF si cedreets by oreltSi l)ecsl
  2. -hp5aal esrdaecut
lovebug  5-alpha reductase is due te that DHT is important for male external genitalia? +

 +19  (nbme21#20)
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isTh vdeoi neilaspx leinatg rmyyeoglbo leryemtex wlle.

fI you eftl tolatly oslt eilk ,me wcaht eht ediov itsrf ta x,2 tneh ekhcc uto the mobott eugrif no .gp 608 in AF 210.9

tlneReav to isht :toneiqsu

  1. YSR rptonesi itmtuelas empdeneltov of ssttee
  2. sThi tp sah tssete =&t;g eh smut vahe eht YSR ngee on the Y mosmrocheo
  3. MFI sgeaedrd eht nMiulerla tdc,u hwich dlwuo whrtiesoe cmeobe hte eltrnnia lemaef galaniiet
  4. Tihs pt ash ireantln meleaf nitaliaeg g=t;& dn'tid maek nuoehg FIM

Qiuz oeysflru snsw(rea ni a eparsaet o:pt)s

  1. iTsh ntpetisa' irroesdd anc be decart bkca ot chwhi s?ellc
  2. hsTi eattipn had anrlmo gaiei.lant If hsti ttnpeai hda easlrml getlainai ahtn nm,laro ttah lwoud eb a dfeetc in htwa nym?eze
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 +8

 +1  (nbme21#26)
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sltbobone"c"e naaaecpper is atoassdiec thwi hon'Csr esdasei

psomnraoic fo hnsro'C vs CU


 +8  (nbme21#26)
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aprts fo the ncloo atht ear ptrinaroerotele


 +6  (nbme21#19)
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lurgaju sueonv sntntdieoi = eftl eahtr erifula

npyruoalm ademe = thrig ehtra raeiflu

omFehrbc-aru itilodan is eth sotm ylkile nr.sawe

ehrOt sw:esnra

  • ritmcAssye taelps ytperhrypoh, cdmoylaair ri:srdyaa hetse rea hobt lcascis dgiisnfn in iyphprchotre ootamadrhpyicy C(MH)
  • ddacrenaloi rtofsa:iobssiel a rera rirtceestiv pdchtaomyoyria esen ni rinntchdfiea/sln
  • lmcipytycoh tarfotnilnii fo teh ram:oumyidc sene in alrvi et)omni(uuma iyora.tmcsdi A uscea of atelddi omioadthayr,cyp ubt hrtee was no mtnonie fo a gernepcid ivrla .nlelsis
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 +10
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 +

 -8  (nbme21#42)
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iarcelepapsm prssneet d:fetilyernf

  • sytpmsmo: ea,hacedh uedlrrb ivn,soi naoliabdm a,ipn hiwtge ngia wate(r )ttnnreieo
  • i:idgnnsf oisn,htepryen tper,anouiri meead

 +18  (nbme21#3)
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The 2 mnmtdnamocse fo techsi nqoessuti:

  1. oD'nt veer ikcp an resnwa rwehe uoy nduos klie a dkci
  2. Dotn' vree nousltc teh hseitc meitecomt

edverS me llew on iths eun.ioqts

linwanrun1357  If there is a choice about asking what the patient is worried about. Is this right? It does not sound like a dick :) +1
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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u'ngstHotnin disaees

  • actiatopinin: esh has a smliari osrirded sa hre trafeh but ddie arereil

eeermmbR HTUN" 4 na ,milaan ptu it ni a .eC"AG gntinHuint egen ofnud no omesorhmCo .4 CGA is eth dttecriolnuei ae:rtep

  • aoC,erh audcaet ulcsenu
  • aaiAtx
  • ylooGm p)iredse(nos
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. +11
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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ffeoakcrsr-kniKoeW msdeynor eud to hinaiemt 1(B) ndecyicie.f ommnoC ni laiool.chcs

Teh nroesa hyw ehyt iasd "urstels of oaohlcl nad grud csneer are inee"avtg si htat teh ldtfiafrneie idnlcuse ecatu ooclhla nncxatioiot.i

cenreWsi'k driat:

  • sinoocfun
  • aslisypar fo eye scmuels a*impelaoop)hht(gl
  • iataax

terespn*s heer sa msygnsuta

sorak'ffosK op:cyssish

  • mmoyer sslo oanra(retedg adn ro)targreed
  • nikgma tsih pu nioaoctul(an)bf
  • rseontiplya agnhce
teepot123  fa 19 pg 559 +1

 +9  (nbme21#11)
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5ouc//aeplatun adh a traeg npel.taixoan

reHs'e na igema of eht ffetdienr etsgas nioolfwlg rdcaoyimal an.ioitfcnr Ntoe eht cono"tnitrac sa"nbd rae thwa edefni itguacevlao nesr.soci


 +29  (nbme21#15)
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ywh oslmshyie is w:orgn

rTeeh dsolhu ltsoma nvree eb trhatgsi pu iiiblunrb ni the uri.ne nI ysliemo,sh hte cesexs iiibnrubl si eecertxd in hte lbie. tefAr laetabrci ooennsrvci adn eaekut,rp mseo lilw be eeexcdtr ni hte inuer as b.iloiunr H,eoerwv ni ritobectvus dedrs,rsio het encdjoatug biurlibni iwll ernev avhe eht uinotoytprp ot ndreuog rabicaetl vncerisoon ot sriobtneiucrl/o. In tish a,wy eht ectndgaouj nbiuiblri has on rteoh wya to be cdreetxe treoh hatn ectyidrl ni het .ienru

tsdcrei to /7l/r6aua3nca no eitdrd

skip_lesions  Found a good pic showing bilirubin metabolism +

 +2  (nbme21#45)
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congiArcd to hte ,EMSUL lsuem'ensi lyon ues si in esenilum esulfdi as a emttnatre fro a fuusng alcdel saaMlzesia psp aeTn(i cevsolo.ir)r


 +16  (nbme21#20)
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emos rgonw srne:saw

sm*kea sseen c/b mlsbslyoeat ear oerscpurrs ot usn,crloaetyg hwchi use MOP ot fgthi off istnenfoic

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! +4

 -5  (nbme21#37)
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ongL nesarw hda,ea tub aebr hiwt .em

INH:T v oslko dnki of ilke y, erahsew k oolks orme ikel x.

npttere-yic = /Vam1x

  • mxVa si het erpup iltmi on ohw afts a ecoatirn si tdyaezcal yb en.emsyz

etcexp-irtn = /K1m

  • Km is a rinagkn of who dgoo na menyze si at inigbdn tis .bautetrss An myezen itwh a knrgian of 1 is eerttb at nnbgdii ist sabtruets naht an eyznme thwi a nkngira fo .5 (Lreow mK = trbtee nm)eyez

oetN taht a,Vmx sa a ruseame fo efrco,pnarme can eb earltde guthroh nyma .hisntg i,hleMenaw Km is a est aicrehcactsitr of teh y,zemne dna cannto be etrae.ld

In hist ,pemleax eht yzeemn fcrropaneme (V)mxa is snriadeec by aincsirgne teh mvatini ccfootar so that ti escehar a ""nomrla tyvtai.ic er,evoHw the yzenme is itsll ennerlytih tsyiht eud ot a ngoatcline dtefe,c os hte Km sysat the .emas

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 +4
sbryant6  Yeah this explanation is wrong. +

 +13  (nbme21#1)
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lbouhettam = uthoElYEmtba

retaG nmecnoim rfo bemnigererm hatt ubtlmhYEtaEo is the ocopetnnm ahtt ucasse vuiasl rebosmlp in RIEP tehrypa orf .TB

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

 +3  (nbme21#41)
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ohtre resasnw:

  • acnp:rsoyle stAosdeiac ihwt oinypghgoc ro pomnopyphci clntuialhosni.a
  • OnyphGo to slpee = tginh iemt clsaunthlnoiai

  • ypmsaolxra auntclonr nedsyp:a NPH si a htmeioylc ieamn.a No isnsg fo imhceltyo anemia ra(ehai,tum ijuac,edn edc. abhogt)nlpo.i

  • epsel aea:pn tssaciAeod hwti t,obyesi ould sro.nnig

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. +11

 +3  (nbme21#28)
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euD to geicl'syn slaml eszi, it ercesat "kksni" in eht aniom diac seuecen.q Teshe kskni ear ndedee to octcrlrye omfr het ondceaysr crtr.euuts

erOht n:wssare

  • eeaendwk" ierncatotin wtneeeb lgeoclan dna otcaloer"gpny - gclnloea + trayglcpoeno = altegraci.l heT qountsei mtse imsneton naym cdfseet ni bEON yt(ep I g)enlocal tbu on niemnto fo sfdecte in aWgTrlOealc epty( II ae)lgclon

 +13  (nbme21#25)
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sptyaclDis ienv rea a rurersopc to nlaaomme. eTyh eavh eliurr,rga sa"tl"picsdy bedr.rso mmReerbe het B"" ni DCAB dsasnt ofr rlrarueig er.dBrso suvNe esman l.meo

erOth reasnw:s

  • icatsahson srcagnini - nagrkDien of nisk dasoiactse itwh yTpe II deabiset mellsiut

  • saabl clel aacrncoim of nski - a,erRly if erve aeesam.ttsisz omnmClyo ceaftsf pprue .ilp

  • uble uvens - udeeolB-ocrl etpy of ommnoc leom. ig.ennB

  • eeiptnmdg roeihcbser ieaokrtss - uktS"c on" aaanpp.cree oyMtsl gin.ben ftfeAsc odrel olee.pp

  • teoN( - uoy slalyuu ees lony n.eo fI ilmptuel roehscrebi ekrsetsao era e,sen it dceiaistn a IG lngniacmay - kaa e"lr-eéLTrast in)sg
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1
sympathetikey  Pathoma says upper lip, good sir +24
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 +4
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. +1
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 cassdawg(580),

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. +1  


submitted by hungrybox(791),

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 .. +4  
hungrybox  hawt +  
underd0g  Why isn't this HPV given the sexual history? +  


submitted by hungrybox(791),

(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(791),

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. +1  
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. +12  


submitted by hungrybox(791),

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(251),
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nGojal dha a etlcrue htat tmoenedni that f"I a npetait hsa ehorrgltaac,a evreiw verye udgr h'ytree ngtaik enisc nyma dgurs ceaus h"rcragaltoae.

heT lyon nihtg of olbpseis clnveeear in iths t-sQem si htat hes akste a citd,oainme reortheef the eawsrn of ug"rd eef"fct si het somt keilyl arseon for ehr a.oahaeltcrgr

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. +3  
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(251),
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Gnaojl had a tuceler atth ntmoeeidn taht "fI a ettnipa sah oa,htrarcegla rwviee eryev rudg yrhee't nitagk icnes myan gsudr ecsua rorgcaae"hlta.

heT nloy nhitg of epslsbio renleveac ni tsih Qm-ste si atth hes ketsa a andcoet,imi erfehtroe hte wernas of dgur" cftf"ee si the tmso ikylle roanes ofr hre otc.hrgrlaaae

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. +3  
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(13),

Process of elimination is the only way to get this answer without Savant levels of autism, as some bowtie wearing doucher who wrote the question probably has.

Cancer is unilateral almost all the time, DM doesn't make sense for any reason, HTN itself wouldn't cause milky boobs, and mast cells degranulating doesn't make milky boobs either. So, and because many drugs can have milky boobs, you're left with drug effects by process of elimination.

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). +  


submitted by hello(251),
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onlGja adh a etcrleu taht mitnedneo tath fI" a nipeatt sah lraghat,aeorc vreeiw yevre rugd eyth'er itkagn encsi nmya ugrds eaucs crr."aoalageth

hTe noly nitgh of bpsoelis recaelnev ni sthi -tseQm si htat seh ktsea a ,odmteiican heefeorrt teh aerwns fo dgu"r tfe"cfe is teh msto kelily sareon fro hre .aaorhtelacrg

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. +3  
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(990),
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oataocintrC of eht tarao aelds to ceandrise LV adleoorv singcua LV eopphytyrrh and a L xasi vdt.onaiei

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


submitted by keycompany(268),
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nAreedsw my onw .seoqntui Idarecsen tserss rfmo a EISTM lliw eticavta teh hictseamtyp ursonve tmsyse -- roPmnulya tavdniio.lsoa

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(272),
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noAumtyo si teh tsmo iarotmnpt hsceit eniipcplr ahtt rssseedeup lal rsheot. eHervo,w ti is eidplap oyln in stautsinoi ni whchi a netpait nsedaormtste dicnagoeiksmi-n accya.pit In tshi nti,aosiut a tnaepti wiht cdevnada iedssae lnilkyeu to eb cuerd is rsfeugin ttrnmtea,e hwchi is ish ithrg dreun eht prnpilcei of .ntymaoou evHoe,wr shi nmtsceom oubta urnrtgin"e ni 6 hnosmt ertaf ucignr ra"irtisth are tqbalineue,so nda trarnaw demgitnnrie fi he sha cioisnde agnimk pcaciy.ta It is ilspoesb htat eh d,seo iwhch is yhw yan cehciso of ngcifor uehtrrf traneettm no hmi aer rncectroi.

hungrybox  These ethics questions seems so simple and yet somehow I always get them wrong. I guess deep down I'm just a scumbag. +7  


submitted by rolubui(10),

1) Alcohol withdrawal --> seizure

2) Seizure --> increased release of catecholamines (https://www.ncbi.nlm.nih.gov/pubmed/6538024), also BP of 180/100 indicates high levels of catecholamines

3) Major hormones that shift K+ intracellularly are insulin & beta-2-adrenergic agonists (e.g. epinephrine (http://www.clinicalguidelines.scot.nhs.uk/media/1286/fig1picu007.png)

4) Also they are asking why serum K+ is low, NOT why urine K+ is high

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. +2  
hungrybox  Thanks for explaining why it's not muscle breakdown. Was stuck on that one. +  


submitted by lamhtu(87),
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laPlttee eaehrdnec nad ltetpale gatgreogain aer ienfrftde thgins nda siht neerecfird SRTTAME A .LTO uFck ,uyo E.BNM hesTe csfdeiefrne dseupoypls matetr no oesm ssionquet dan otn on r.theso Wrhee is the n?nsiyetocsc Helol?

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 +2  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +1  


submitted by lamhtu(87),
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Pallteet cndaehere nda pealltte ogriggeaant rea efnfrdiet htgsin and tish redenefirc EAMSTRT A LOT. cuFk uyo, .NBEM hesTe firescfeend lyspsouped ettarm on meos ntiqsseou nad nto no srh.ote reWeh si teh scseciyonn?t H?oell

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 +2  
regularstudent  It's always a horrible, horrible feeling to pick the wrong answer that you know they think is right. Amazing job NBME... +1  


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 +  


I just think plams are not protected by the melanin and got this right.

hungrybox  useless +4  


submitted by lsmarshall(348),
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nPteiat hsa niaSp diaibf ucatloc whhic si a runael ebut dctfee (relafiu of fnusoi of eth ue.eoorsp)rn mscloeroteS rea teh tpra of ceha ieosmt in a tvaebrrete emoyrb gniigv esri to oenb or ertoh sektleal .eutsis Scein a part of tish 'tsanitep asinp iaidbf icnueldd sa"cnbees fo spniuos op"ercss neth a osclmeoter aws vivl.dneo gKnoinw htta nulaer tube detcsfe aer na sisue tihw fosuni oldshu eb ngeuoh ot tge ot the itgrh na.eswr

fI the tohncodor fdaiel ot ledepov ehtn hte eriten SCN wodul tno vdpleoe sa het tchornodo nsceiud fmtaoniro fo rneual e.palt

If eht nlareu ubte iaefdl ot vopedel hnet eth ohewl NSC udlow tno aehv pedeoev.dl

lYko csa is tvarreniel to hsit ttenp.ai

When rnalue restc elcl ti sha rtfenfdie stcuomoe in ertdfnfie s.usetsi leuraFi fo aunler ctrse ot itrameg ni herta anc uesca priisonosnTta fo tegar vlees,ss grlyateTo fo oal,ltF or esiertnsPt uuscrnt orua.srtesi aieruFl fo lnurea srtsec to metirga ni GI nac caues rsghrnsHpuic assdeei acoetnign(l ol.mgano)ce Trehcrae Cilonls Syomdner nca rccuo when nearlu ectsr secll ailf to atgimer toni 1ts hyalerpnag rac.h ualreN ebtu dftcsee sha tghionn to do wthi raeflui of luaner ertsc anoitmrgi t.hohgu

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +7  
hungrybox  Fuck I picked "Formation of neural tube" but yea that makes sense... that would affect the whole CNS +1  
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 +  


submitted by hungrybox(791),

(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 +  


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Teh awy I utoghht utabo it was a itltle oemr is.iitpcsml We esu onn ceeietlvs tabe csrbloke .(.ge ro)lronaplPo ofr hte nemtrteta of aeitselsn tmorer. hTorfreee a teab goastin ldwuo have teh sooietpp ffcete, aka saceu or hecanen mrt.oer

hungrybox  Genius +2  
sunny  Also it(blockers) hides signs of hypoglycemia which are tremors. +1  


submitted by lsmarshall(348),
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Feolxr iditgumor nuufprsod si penrlisbose fro xonelfi fo DI.P iMadel psecta fo eht clmeus wich(h felxse eht th4 adn th5 ii)gdt si upedipls by teh aruln verne C(,8 1T). heT laetral tsceap cw(hih lsxfee eth 2dn nda 3dr gt)dii si vneeadntri yb the mdenia rneve fcilayceipsl hte ratieorn eneotroissus anbhcr (8C, )1T. So het ueiostnq si icdegsribn a itarlcaneo gginadam het evren yppuls to the DIP orxelf fo teh 2dn igdti ndi(xe )fre.ing hiTs si gyinas teh ldieam eenrv is ienbg daamged C8( and T;1 owelr nrukt o)rot.s

smabcurlLi tns(21/,d id;anem 4,3/thrd )rulan aer a gopru of smcluse taht exlf at teh MPC ijo,tn adn entxde IPP nda IDP nostij.

dColu brememre sa lf'roex timdrogui npudousrf is lnrpuyofod lon'g ensic odennst irsnet on sI.DP mrpdaeoC to flreox mtoiugdri fuspsiacirlei owhes teodnn aprsw nuraod nudfuprs'o eiaucilpyfsrl ubt rtinses no .PIsP

toupvote  This is dumb but I remember FDP is needed for picking while FDS is need for scratching the superficial layer of the skin +10  
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) +3  
hungrybox  'flexor digitorum profundus is profoundly long' is such a good mnemonic, thanks bro +  


submitted by link981(134),
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drewKosy mrof D.r cToru from Ka:panl

  • intlpRcioa-e NDA
  • ri-cosiantnrTp NRA
  • ornanilsa-tT roPteni
hungrybox  bruh this is like bio 101 lol +3  


submitted by suckitnbme(116),

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 +  
greentea733  This is great but honestly was this covered in ANY step 1 study resource? +2  


submitted by tinydoc(190),
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Tsih iotneuqs is yrev ,aeskyn tub ni cseeens stih si ahstw pagph.inne

eTh ciadnctale melovar fo teh HPT agdnls dgrniu tmtoyyirehcdo ⇒ ↓ HPT

PHT nyn -a:-mrilol e:nob ↑ ovamelr fo C²⁺a dna atoephPh omrf -en-bn oi sdkiyen: ↑ a⁺C² eaobrpitnsro adn ↓ ⁻₄OP³ nestr-oo ↑rp-aib onveiorcsn fo ,25 vointmrxidyyaH D to 215, tyyvmoixndHari D ollCraiic(t - ativec )rmof via ↑ tivactiy of -a1 yeyaxlsroHd eecdfincyi

Theefeorr a ↓ PHT wluod dlae :to

⇒ ↑ O⁻³₄P ⇒ ↓ a⁺²C ⇒ ↓ ,152 omyirtyxvdniaH D

heT tnesuoqi is aeyskn uhcm( lkei het trse fo hits xm)ea ecsubae moeones who istn ugcosfin ylrale drah or ni a hrus mtigh ipkc teh ntpooi C herew hopptaeh is ↑ dna HPT is ↓ UTB ↓ 52 mronidhiyavxyt D

ihTs is rgown as lyon 251, xyaoiyhvitrdnm D duwol be es,eaddrce teh nvrocnsisoe refboe shit aer deno yb teh knsi isln)(hgtu nda i.elvr

I yrlale wish hety ulowd spto akgimn eth qutoensis nnsgofuic ELYPUR rfo teh ksae of ngamki htme cifusogn.n tnsI ti uogehn taht ew have ot wnok stih idsouuilrc tounma of ooaif,irmtnn ottwhiu gavnhi temh ylantoinilent gmnkai it herard yb noinigtp yuo ot 1 eanwrs ehocci ubt cnagihgn a utienm lidtea to akem you nwsaer go.wrn rO sungi a ndramo sas onueceralnmt rfo a deeisas to doiav kngaim it too eipmsl SGPN( = oarefvi"prteli G)N"

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 +  


submitted by enbeemee(13),
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i etg ywh tis' y,rioxpfaeehl tbu wyh tno lio?alsrfntbii si't oasl an NLM insg

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! +11  
eli_medina9  https://imgur.com/1z4OF4l Gonna piggy back off your comment and just post this kaplan image +7  
hungrybox  Very helpful image, thanks bro +  


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toH utb uif,itllsiolc t’si a ihng.t llyalsscCia unsoapds.oem

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. +5  
hungrybox  @medguru2295 same bro same +  


submitted by thotcandy(48),

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 +1  
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 +  
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. +  


submitted by ergogenic22(243),
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tP ahs issng and xS fo chorsolr.iepty nL/wlmooar TCHA rvsfoa eaeevtld lorcoist ennntdepeid of CTAH, mcdonrief yb aclk fo ensspeor ot oeanhmadetsxe oispsseup.nr Zona acauicflsta is griino fo irslotco nuctoirdo.p

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 +10  
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. +  


submitted by strugglebus(154),
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loPropalno si a nseevoclnit-e taeB .clekbro oS uoyr RH lilw cdereesa )B1(, wcihh liwl suaec a ayorscmtpnoe cneaersi in .RTP

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. +35  
amarousis  so why tf do we give beta blockers for hypertension -.- +5  
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. +4  
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 +  


What happened to this "previously healthy" young female? Why is she vomiting blood? Drinking too much alcohol?

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


submitted by flexatronn(-1),

This pretty much answers 3-4 of the mnemonic for tuberous sclerosis: "HAMARTOMASS"

H-amartomas in CNS and skin/ A-ngiofibromas/ M-itral regurgitation/ A-sh leaf spots (hypopigmented macule) / R-cardiac Rhabdomyoma/ T-uberous Sclerosis/ O-autosomal dOminant/ M-mental retardation / A-renal Angiomyolipoma/ S-eizures/ S-hagreen patches /

hungrybox  somebody kill me +7  


submitted by hayayah(990),
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cuetA iltitrtaseni nrela oaman.fimitnl yPraui lli(caclssay ish)plnieoos nda zaoatiem inugrrcoc raetf dsiirttnaoianm fo rudsg taht cta sa enpsah,t cigdinun vpeiisrttysyneih eg(, iudistcr,e D,sNSAI cenipillni veirv,asedti porton uppm htb,snrioii i,rfnaipm n,inoelousq fndi.ueosalms)

hungrybox  But how is a 2-year history acute? +3  
jinzo  there is also " Chronic interstitial disease " +3  
targetmle  i got it wrong because there wasnt rash, also there was proteinuria, doesnt it indicate glomerular involvement? +1  
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  


submitted by hayayah(990),
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hTe ybba osed tno gte ayn rntelaam ,IgM gIA or EIg as tyhe do ton corss the cptaa,lne os fi gMI is fondu it may gsstegu the yabb hsa dneeoecurtn na nnfceotii ni rtoue.

GgI si spesda ondw to teh byab as a nsaem fo pssaevi uymmniit lntui the yabb nca fmro hietr nwo seatbdinoi of tdefirfen .etsyp oS fi uoy ees ahygntni toehr anht GgI e(g.. )IMg ouy wnok ti tums eb /td an .eiocntifn

hungrybox  The baby gets IgA via breast milk. +1  
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. +4  


submitted by hungrybox(791),
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tDyslscaip vein aer a reorsrupc ot aan.oelmm hyTe evha gre,uirlra lpsti"cd"say .breosrd bemmreRe hte ""B in ABDC sntasd for urrgeiral r.seBdor sNeuv enams emlo.

Otehr s:ensraw

  • ihtncassao iicrsgnna - gknDniera of isnk dcoeistsaa wiht peyT II etsadieb eltuimsl

  • slbaa cell occirmana fo ikns - re,Rlya fi rvee atits.aesszem yommnolC afcstfe perpu .ilp

  • lbeu eusvn - orluldeeBco- peyt of ncmmoo oeml. enin.Bg

  • mntgidepe iceesrrbho asksrotie - Suctk" "on e.nraeaappc Mtlosy b.negin Actesff derlo .poeelp

  • te(oN - uoy ullysau ees noly n.oe If pueimltl ebserihcor tkessaero ear ne,es ti aieicnstd a GI aliyngncma - aak "éteasrTerLl- sn)ig
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +24  
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 +4  
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. +1  
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(791),
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ruujlag senvou teosinndit = fetl raeht riauelf

onylamrpu mdeae = htgir trhea elruaif

-hFmuceorrba nidoatli is eht otsm eiykll .rwasen

eOrth rsw:aesn

  • iycsArsmet aetpsl hyoyerr,hppt cairyalodm rriyaa:sd etshe rea obht asisclc nifngids ni rpioherthypc ohamcpaitydyro (HM)C
  • lcenoaddira a:ibioelfsrtsos a earr eirctsteirv pctamrhoyaodyi enes in rlndnn/itfeahics
  • mychiptlcoy ilotnniirfta of het ycimd:ruamo eesn in vlira nm)(tumiaeou rsacdtm.yiio A ceasu of tiedadl hiyrpaycomoa,td ubt teerh wsa on tnnemoi fo a greniedpc lrvia eil.nlss
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 +10  
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(980),
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treiDc nliulgiobtnA = Dciert smoCob tTse

tecesDt ediianbsto onubd icdtlery to .BRsC eysiomHsl tmso lelkiy deu to hnmtgisoe in het eudrasfstn obodl (tno rseu hyw it toko 4 ewesk newh pTye 2 HS si uoppsesd to eb ucqkrie ubt /ew).

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 +21  
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 +  


submitted by mcl(517),
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ietanPt omts ieykll hsa hSyc-Taas .edasise Thsi uerifg ecnily shwso hte cbihemlaoci hyaatp.w lRlace that tbho y-saachTS dan enNanim ciPk seidsea ntrpsee hwti a rchyer red stop no oousfycdp,n btu yTa hsSca slkca eht eotmpgeolynlephaas nees ni PN.

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 +5  
hungrybox  thank u +  


submitted by jotajota94(14),
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DPA wolfs orfm artao to rpyoalumn ratyer ascenredgi tf.Tfoeoaeraedrher l aacdcir uouptt inscraees

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 +32  


submitted by nuts4med(6),
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neynoA ahev na idea hwy eht cesdareed talrreia O2 ottrasiuan is i?rccnerto ingAussm she ash mupl daeme seicn hse ash LE ,emdae lnu'dotw a welro 2O ast be eexptdec 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. +6  
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). +4  
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(34),
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Tihs ueoistnq is bncgsrdiei ntimelar namoi,sni ichwh is ocomnm theire ni MDD ro omrnal ggin.a tuO of tesoh otw MDD si teh lyon itgnh ni oipotn o.hicec ul,sP dol aeg is a riks oafcrt rof .DDM

Evne htough eht tnuoqsei sedo nto isdecrbe 5 pmsymsto eeendd to aigsoend MDD, DMD si hte nylo ialgloc occh.ei

hungrybox  excellent answer, thank you +4  


submitted by hungrybox(791),
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rhtoe awsre:sn

iitibhonin of H2 opetersc:r rf(o EGDR) trepnev rsgcati icad crseetnoi cinidtei(e,m

niiihontib of sissatehreodposeph E)(D:P

  • lhoyhpteeinl t)aahs(m biisitnh AMcP PDE
  • failns- icd(k si)llp for ED tbihiin McPG DPE

2β nosi:sgta fro( ath)ams csuae roaidcobotnhnli

  • ulrtloaeb rhts(o igctan - A fro Auec)t
  • ero,msltael orrtfmoole onlg( tgcnai - ih)prosypalx

kid( mhetypycol mraeenbm ibaztiatli)ons

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +15  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +1  


submitted by mcl(517),
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atniePt stom llkyie sha TcySah-as .adieess sihT rgeuif nleiyc hswos het coemiichbla ht.ayawp Ralcel hatt obht -aSaycThs nda emnianN cPik edsaies seeptrn hitw a cyrrhe red otps no u,pyodocnfs tub yTa csSah klcsa hte oeythgomaeenspallp ense in .NP

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 +5  
hungrybox  thank u +  


submitted by hungrybox(791),
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zdiihradolyHtorceho si a idtahize curideti ;=tg& tiidhaez icrsutedi are eidsactosa htwi iyakap.elmoh

hWat retho iicstduer rae stedoiacsa wtih kel?payohaim Lpoo c.esiitdur

W?yh

hbinoitiIn fo aN+ ositnraebrpo sroccu ni ohtb ploo ucreidtis iihtbni( KCNC psntoerorcrat) dna eitzhiad sutceirid iiihtn(b laNC seacr.rntorp)tro All of hsit ncrediase +Na aeinsresc Aroesdenotl y.acvtiti

levntRea to shit mep,lrob eAtledonrso usgaleuretp iesxrsnope of the +KaN+/ PTA nerirotpat bsr(reoab N+a oint o,dyb eplex +K ntio )len.mu isTh tersslu ni ehaoayipmkl in eht oy.bd

aHgn n,o e'hesrt roem high iydel i!nfo

trolenesdoA eods oen ohtre tparmtoni higtn - iintotavca of a H+ anclneh hatt expesl H+ inot eht mneu.l

S,o gvien taht shti nteptai hsa mph,eayloika you wkno erthe is nuraegtlpiou fo eotnr.esoAdl Do uyo tkhin her pH uwldo eb ihgh, ro ?olw ylxcEa,t it dlouw eb high csueabe icn. eAsteoroldn =;> .icn H+ xpelelde tion eht lmune tg=;& icmaotble si.kasalo

owN oyu andstnured why tohb olpo iuecisrdt and itdiahez tisdcriue anc easuc stwah' ecdall kolhcy"iamep bciamleto l"ksisaal.o

hungrybox  jesus this answer was probably too long i'm sorry +2  
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +10  
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +  
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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Tshi is eno of heots nsisutoeq I wsa reevn ongig to eg.t 'stI tno in ,FA I dotn' nhitk eIv' enes it ni c.slas

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 +7  
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. +5  
step1soon  FA 2019 pg 551 +1  
teepot123  damn its in FA and Ive never ocne read it XO +  


submitted by yo(53),
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eeyr'th taiglnk toabu a elnpraseonl nsthu eurrdpeoc

gaame94dstprt:tl/is/tnlnilonlu-rhic/y5rpleoceh/d/alh0-ee-tm.ascnestnevhstn.lta

hungrybox  be honest did u know that before looking it up +8  
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. +13  
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 +7  


submitted by lnsetick(84),
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  • riePcoAn = uory mspatri slmel ikle an PAE
  • eceURnM = e’esthr no OOMR ni ryou easr niesc te’ryeh lluf fo awx
  • EnRYeC-C = newh uoy criCs,eeE uyro oserp ear iRngCY
  • uBcasoESe = muEBS si nEgPEiS out of yrou rpoes
hungrybox  as an ape i'm offended +18  
dr.xx  stop being an ape. evolutionize! +6  
dbg  as a creationist i'm offended +9  
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. +1  
qball  The question asks about "the characteristic odor" i.e. body odor coming from the APEocrine glands. The Eccrine glands secrete water and electrolytes. +  


submitted by hayayah(990),
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teCeatrh mca:etnepl

p/:4t.a.yge/dca0noe0gtp08/c2/o/0s8mpel/m6sa-hk1pu0teewnjniot/s

Rcalel ahtt het lugn axep entsxed ebova eht risft .rbi

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 +26  
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. +9  
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 +2  
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(53),
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hTsi urrdcceo witnih 6 uhors dan asduec seom rmynoulap edmae dan oeprrairsty eidstssr aertf a ruafoistnsn dceasu by het oo'rdns n-lotkecaeuyti itodbensia tsju getosidyrn eth spreceniti rpneitsolhu adn rporraiseyt hoeiltendla cllse.

wheil /yrgnxaplicasielaahl cna seuca riyarposrte etrars adn ocshk ti ahs a twsoeamh rffietnde tcrpeu,i no wzg,ienhe tsicneihs ro eavehtrw nad gcdroianc ot trsif dAi it ahepnsp ihntiw tmnisue ot 3-2 ohrsu whhci si at telsa lbuoed wtah rwe'e nsiege .heer olsa erbwea of gAI cfeeitnid oelepp in siht c.ieohc

,PE eh I o'tnd ntikh ti safcetf oP2a atht tneof mchu cnicgdroa ot isth eusrp urepd ghih deily reesucor. tbu huh ahey dnoste' leef EP niadk nsoqit uece.ph0ms//c#pa31seoe/1m:io9.krin2cc-u0tiwatepcemddr/t0el

,mapnoine grhit eartf lla teh snuifoin esussbni nad no nenmiot of rfeve or ?naiyhngt Nha.

og to paeg 114 of ritfs ia.d 'mI tytepr rseu ew dene to konw ruo isi/asnrtnatfunplon pcra sbaceeu ti sutj pseek cginmo up ni olwdru tbu sthi lweho exam is a r.shtpcaoo

erFvigo me if I maed a aognewrisk/tm tboua taghinn,y I oystml gto foin romf frsti ida. plz rrtocec if eehrt si a tsakm,ie gdoo ulkc.

hungrybox  we gonna make it bro +5  
hungrybox  or sis +6  
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 +5  
athenathefirst  I hope you guys made it. Your post 9 months ago +  


submitted by yo(53),
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hsTi eccrudro itwhni 6 hrsuo dan escdua soem lmaopnury edeam adn ayptirsrreo tssidser after a nfrsuotisan ucsdea yb the snor'od centkioluet-ay iitesanodb utjs dryisntgoe het pneeisrcti nhleioputsr nad praesyrrtoi ndoltiaelhe .secll

ewhli xaglaiiynsaplelra/hc cna escua trrpayersio rsaert nad hcoks it ash a maoshtwe nfrdeeift u,pecitr no ,zgiehwne htiescisn or eathevrw dna ingdcroac to frits Adi ti pepashn hnwiti esiumtn ot 2-3 ruhso chwih is ta ltesa delobu wtah 'weer seiegn h.eer olas baweer fo IgA fdeienict olpeep ni tsih cohec.i

E,P he I 'otnd thikn ti secaftf oa2P ahtt oefnt hucm dcgricano ot sith eupsr drpeu high edliy esrr.eouc ubt uhh heya d'sonte elef PE nidka qnsu iteo.:oes1p/decmpica00r3/tt#amh/oe-eee/d0t.cclnpswrk9c2imu1i

,apenniom ihtrg rfate lla eth niiunfos sesisunb nda no iteonmn fo fever or naghnt?iy haN.

go ot eapg 141 of rtisf dia. m'I ytpret rseu we edne ot nokw uor nsatlatponunriin/sf pcar bcaseue ti sutj speke miognc pu ni ruolwd utb hsti lehwo meax si a ocsoh.rpta

rveoFig me fi I dmae a aekwos/imtrng touba gtanyni,h I olsymt gto info from irtsf a.id lpz etorrcc fi trhee si a semtiak, ogod kl.uc

hungrybox  we gonna make it bro +5  
hungrybox  or sis +6  
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 +5  
athenathefirst  I hope you guys made it. Your post 9 months ago +  


submitted by nosancuck(74),
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thi em pu tiw tad HCCPN !obi all ouba adt HCLNY DESONRMY

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


submitted by yo(53),
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druen 8 ayers dol rfo risgl si a bda ,ngsi 8 is ya.ko nredu 9 ofr sbyo is a bda gs.in

just awhtc uot rfo yna 6 yare odl or gosnheimt elki ahtt. ewrabe of taht GRHn reihte lctlayner ro osem moes oehtr tfcs.u reio-sr ida 9012 pg 623

hungrybox  yo wtf i got my first dick hair in 6th grade wtf are they feeding these kids +29  
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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It dias it aws taalf ot lseam ni etu,or adn eht uqisneto dskea aotub viel onbr .gofpfnris cnSie hte amles rn’tae genbi bnor ni eht frsti e,pcla I disa 5%0 sfaeeml adn %0 slaem.

hungrybox  fuck i got baited +26  
jcrll  "live-born offspring" ← baited +11  
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. +1  
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 +2  
qball  Jail-baited +  


submitted by nosancuck(74),
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urhB tel em tell yuo a lli tsreec

EEPP venpstre aselestticA AAK dta LNGU AESOLCLP

tDon be ioyrnrw obuat rmaodn wrsod hyet supt ni tnfro of hte IHGH IDLYE enso

hungrybox  literally LOL'd lmao I love this +8  


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fI ynoybad hsa a ogod ayw of inehugigtbmisesmd/nngierri lla the entreffid sntpoteranesi orf algient sroes, 'Id ecpatireap het lp.eh

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(503),
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ihsT is a sace fo tauec gou.t ndoiousoMm taeru acrslyts rea tenka up by ,upierolnsht nadielg ot an etacu lfaramtiynom teaicnro. llcs-Te ent'ra arlyel nievdovl in guot e(orm rmeiahtdou raih.it)rst

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 +12  
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(791),
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tGare vdioe I sued ot eraln htis etali.mra

  1. hTree rea 3 omraj tyspe fo :urgsd purpse nta)ulss,im(t ewordns d)(sassetnper, nda sl.iuhnaoglenc
  2. rnHeoi si an d.oiiop diOospi rea w.oe*nsrd
  3. esnDorw od tawh it ossudn e.ilk hTye aesuc d"no"w ty:mpmsos eddn/ecearsateodsi nyiexta (adn tsuh oibvrleaha osinbdiiihn),ti roertpsariy issdonrp.ee
  4. husT hrldawtawi wlli seacu eht s:oopitep echrpisr,ahycatitaoy/dnen iyexa.tn
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(116),
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ihTs sah nebe a hguot nepccto rfo em to teg, btu I hnitk 'Im lyanfli :eerth

hTe smet si csdbngerii mayiprr alrdnea ncf,fsiyncueii or Ao.isdd'sn

  • TCHA si iegnb oudrdvep-oerc ot astietulm teh aarelnds to porcdue oscl,rtio utb hety anct' rone,spd riheet ued to tohyarp or dsnurecttoi ,B(T no:iuamutme DR4, )ect.
  • ehT isftr 13 amnio csaid fo CTAH anc be adelevc ot ofrm ,H-αMS ihcwh stteumalis eoyamtcseln, sginauc aotgipehnernmpyit
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 :( +2  
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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ondt' be a kic?d ton alyrel erus wath rmeo eerht si to t.i Teh tinapet stno'ed vhae any hteor lmafyi os tihs mnawo hsuold be dconseierd limyfa

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. +4  
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(791),
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eTh civxre si teh oynl ecrruutts ahtt odluw utlers ni iablaetrl dckab.ole

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 nowk sith is stju a stragtih up afct morf F,A tub tcou'dln sterreu tirotaai(nsnl lcel micnao)rac osal eb crt?reco

hungrybox  Hmm I don't think so. The answer is "ureter" (singular) which would not result in bilateral hydronephrosis. +6  
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(69),
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Tshi one aws tkrciy utb I nkhit uyo ocle’duv ndoe shit neo otwituh knlweodeg fo DMAN stc.eporre Semt lotd ouy htta gtlameuat tvseaicta hbot no-nDMNA dan AMDN sepreoctr btu it ietdtavac nloy N-oMDAnn cprreetso in teh eyarl a.seph Ttah mnase DNAM oeercsprt tatvicea fatre oADnM-Nn se.etrorpc hatT saenm itehnsmgo aws yaldgeni NMAD ocreterp anivictatg dan het lyno raensw atht made snees sa teh Mg ingnhitbii AMDN ta stiergn t.lipatone Ocen the ecll is rpodleiadez by n-AMonND ,ecorsrtpe ADNM sepcrrtoe cna eb .taiacvtde

hungrybox  I forgot/didn't know this factoid and narrowed it to the correct answer and a wrong answer. Guess which one I chose? +11  
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. +5  
divya  sweet explanation imgdoc +  


submitted by hungrybox(791),
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lioglownF a stke,ro iths tinetap dah nasekwes fo hre tfel ceaf nad yobd, os eth sroekt mstu evah teadcffe eth htirg desi of erh .airbn B swa hte nlyo cocehi on het ihgtr sied of hre rbn.ai

tSlli uecofs?dn aRde ...no

heT ylvuntora torom srbief pnoitcacos(lri r)ttac dendesc ofrm het ymirrpa oormt rocetx, scors sasecdet)(u ta eht yeldlmuar pday,msri adn nteh ensspay at the ierrtona omrot hnor fo eth lpnisa lleev.

aseBcue fo dnestiouacs ta the delarmylu mrpsdiy,a you hdluos kmae a note fo hrwee nay sroket ru.ccso Is it evbao het yllmurdae mpiads?yr eTnh it will tfcefa eth dsei poopties the okerts (l.aacrn)lertaot Is it oelwb hte rmdyelaul dir?sypam nheT it illw teffca hte esma seid sa eth eokrts (s.r)taaleilip

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 +7  
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 +15  


submitted by drdoom(647),
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catistnosocrinoV (iwganrnro fo a te)ub lilw cesua the olwf eart ot resnieac ughhrto atth eut,b hchiw sesercdae drladuoria/wat es.reupsr hTe featsr a iufld emovs thgoruh a ,eutb hte elss ua”otdr“w rfeco it t.eerxs hiTs( si nkown as het Vinetur efftec).

hungrybox  not seeing how this is relevant +5  
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(791),
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eTh tonaimac unofsxbf si emfrod by eth senodtn fo het teronxes icilolsp ,bevsri het obucardt osicipll ols,nug dan the xsetreno icslploi nguslo. (frguei)

heT ofolr si oemdfr by hte dchsaipo e,nbo and it is rhee atht neo nac eaalptp rof a beliposs ctfarrdue p.cadiohs

uSoe:cr 'saGry nAatoym ivReew

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.) +  
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(791),
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ehT tanamcio xnsbffuo is eordfm yb eht nnsoted fo eth eonxtsre pclilsoi esrv,bi teh curtoadb pclliois os,lgun adn hte rosxntee lsopcili luno.sg (fiurge)

eTh oflro si eormdf by the adpchois ,noeb nad it si rhee ahtt one nca tpapela for a sobpesil fetarurcd si.acpdho

:Soeucr 'yaGsr Amtoyna ewviRe

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.) +  
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(791),
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aka ullamap of arVte or eht aperneticaptahco cdut

hungrybox  tripped me up cause I didn't know the names :( +11  
sympathetikey  @hungrybox same +7  
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 :'( :'( +6  
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 +  


submitted by hayayah(990),
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oe:Nt hTe saunebcd .n is lutlaayc eth rnvee tmso leiykl ot eb dmdegaa by na neaixgndp nnirtela cdaoitr ermunyas in teh ncesarovu nissu utb hyte vegi you cpifiecs CN3 foucnnit ni thsi uqnotsie.

hungrybox  One pupil larger than the other indicates damage to the pupillary light reflex - afferent: CN II, efferent: CN III. +13  
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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Ok I tge htta if 005 dylarea haev hte dseeisa nthe het srki loop si rpedodp ot 0020 tenutsds tub hte neqostui ilpcyiaselcf ssay ttha hte tste si dnoe a reya ia.erl.t.f 500 oppeel adh clmdy,aiah oyu would ratte t.emh Yuo tndo' ecboem muimen ot lahdimyca tefra nfiotcien os htey luwdo go ckba itno teh sikr pool, amngine teh loop ldwuo rruten to 05.20 Teh wsrnae lhsodu be 8%, itsh swa a dba sunqe.oti

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 +5  
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 +6  
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. +1  
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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onenyA have an deai hwy eht scrddeeae aaltrier 2O raoatuntsi si rocinrce?t insgmusA she sha uplm amdee csein ehs sha EL ma,eed d'tlonwu a lower O2 ats be eeetdxcp 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. +6  
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). +4  
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 tisFalsu -truero dobol rmof het arialret tssemy to hte enouvs ystsme, pgnia-ssby teh riAerotles = ercesanI LP -&-t-;g CENAREIS .RV llA ni lal = eaercIns C.O

dcnorAgic ot ,WoldrU het teoelsarri rea a oamjr osrecu fo sisnaectre ... so sgnaiybsp eht ieotsrealr rstsule ni a dsceeare ni Tltao iaelPrpehr cinaetesRs ... ucgnasi an srcniaee ni the rate nad vemoul fo odobl nrurgnite to teh th.aer I ma tepytr ersu eetrh is moer to teh gsiyhopoly nedbhi t,ihs tub I oeph sith eainxelpd a l.eitlt

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). +14  
hungrybox  Jesus big92 you went in on the research lmao u must be MSTP +5  
temmy  big92 you are right. that is why pagets disease pagets have high output cardiac failure because of the av shunts. +3  
kevin  what is "increase PL" +  


submitted by seagull(1112),
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cpItiydio mneas --- tidnyoba igtnaas ybati.dno B scell dno't vaeh eacrufs dinteobsai tub reme iestenyhsz tmeh.

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 +2  
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(1112),
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ctiIdiypo smane --- ndiyatbo stangai anydbti.o B llcse nd'ot vaeh auecsfr eiobstadin btu eemr yesizhnest met.h

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 +2  
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(87),
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I thnik the tcpocen rehty’e ettnsgi is eht aenisrecd TBG seevll ni cnea,gypnr dan otn jtsu deyyrpiomsithrh ni l.naeegr

hnWe srgeecnin fro ,timeyhrypy/oidsrohph HTS leslve ear SAWYAL npfelirrayetle kccheed auesbec eyth aer ermo eesitvsni to tenmui endeeciffrs in TT/4.3 ftneO estmi HST lselve nac odetemrtnsa a cgahen veen hnew 3TT4/ elevls ear in eht lncbiulsaic nagre. eTh olyn cpeteinxo to htis uldow eb in nearcpnyg (dna I egssu meyab ielvr rf?ualei I boutd yhte wdluo ksa tshi hhut.)og ihHg nreeotsg elvels rpsevnet hte ervil rofm agnkrbei nowd T,GB gdlnaei ot aesnriedc TBG lvesle in eth .seumr hsTi ndibs to erfe T,4 enegsdciar teh aontum of laeblavai eerf .T4 sA a coaseyptmnor ,ehimmncsa THS evlles era ttnaryiensl ensaeicdr nad eht AERT fo 4T irdocnptuo si erscedina to peelshrin liebsean reef 4T lesvle. wHeveor the OALTT aonumt fo 4T is .raedscein

ehT stuoeqni si ikgasn hwo to rcnmfoi pstrohydhiiryme ni a nnregtap namow &t-g-; oyu edne ot chkce REFE T4 elslve bc(eusae tehy shulod be ornlam eud to eaoopmctrysn s)ornse.ep ouY oannct kcehc SHT usu(lyal dveteela in npcgaynre to amecospnte ofr iendacser GBT), nad ouy caotnn eckch tlato 4T ellevs l(lwi be .ircdnea)se oYu tog het wsrean thgir hirtee wya but I itnhk stih is a fndfreite inrsoeagn rhtwo ngorcdnesi,i bceesau hety cna aks isht tocnepc ni teorh cseoxttn of rmenreiyo,hessgtp- nad if ehyt dselit S”HT“ sa na senraw heicoc htta wdlou eb rn.ccioter

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +5  
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +2  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +  
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +1  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +1  
lovebug  Amazing answer! THX +  


submitted by hayayah(990),
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eht trymojai fo roacbn oiidedx llesuemco aer rdcirae sa rapt of het tabracienob bfferu mtess.y In tish y,etsms raoncb exiiddo fsisfued toni hte B.RCs baConcri ydarensah C)(A winhit BCsR luqcyki tevroncs hte crnboa iedxdoi into aibcronc daci HO2(C3). boincCra adic si na atselbnu ntidmreaeeit lolmueec hatt mityiameeld scaiiodtses into oratcebanib isno O-H)C3( and gdohyrne H+)( nosi.

hTe nwely yzstdehenis ibaenortcab ion is etrtopsdnra tuo of eht BCR toni hte asmapl ni exgachne rof a hrlceodi nio −(;)Cl tish si lcelad eth olihrced stih.f Wenh hte doolb caesher eht lg,sun het naecroabbti oni si noetrtaspdr kbac itno hte CRB ni xehgecan rfo hte olcdhire on.i The +H noi esotcidsias from teh honoimeglb nda bsndi ot het rciabotbane no.i ihTs ocurspde het bcarncio dcai ideiatremn,et cwhhi si reonetcvd kcba toni cbnora iedidxo othuhrg eth ytanzeimc natoci fo C.A The craobn ioddexi odcpedur is xeldpele rghuhot eht gusln gnriud x.alehoitna

hungrybox  Amazing explanation. Thank you!! +1  
namira  in case anyone wants to visualize things... https://o.quizlet.com/V6hf-2fgWeaWYu1u23fryQ.png +4  
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? +1  
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/ +1  
teepot123  fa 19 pg 656 +1  


submitted by hajj(0),
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can nnayoe alxnpie htis? i wkno neamid rof y si egrhhi by aunlaloctci ubt x ahs wto esmod os who omec y sha heihgr moe?d

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(116),
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I himgt eb hte noyl eponsr no hrtea how otg stih eon n,gwro btu lsaer:sregd

T"TI asislayn cenlusid eyevr teucsjb woh si oirezmdadn dganroicc to amndiroedz ertttamen .masigtsenn It oenrisg eoinponamn,clc pltocoro ,sovidaneti wwalrhiadt, and iygnhnta ahtt senhapp eatfr ind"zaanmio.otr[]1

yo  You're not. I also goofed. +11  
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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cirOotmhecy = ↓ oeettnsotres tnirdupoco = ↓ HDT gt&;= opettsra slelc euodnrg aostpp.osi sh(iT ecsmnmahi si aisimlr to iugsn sueca5deαtr- lokercbs ot taert B)P.H

ssAoppito si eedzcrchtiraa yb NAD ogaenitmtafrn ipk,(synso shiryexorkr,a lrsais.kyoy)

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. +14  


submitted by hungrybox(791),
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utaobeltmh = mltaYbEhotEu

rGtae mnoinecm ofr mmeeribgnre htta oaltmhtEbEYu si het potmnecon thta csseua vslaiu bolpesmr ni EPIR rypahte orf BT.

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


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Cdiaadn si a rtpa fo the ranolm lofar fo ,isnk dluoc ascue nttcoanaimoni fo a rantecl noveus t.rceetha ehT iutensoq stsate that hte anomsrgi is pru,ple n,ddugbi idd nto eoprnsd ot dobra utmcspre aiicisobntt (aka ehty id'tnd seu uzocenafoll ro ietcinhrpamo .)B sya,lLt ehyt hdeosw it taelpd no dbloo arag nad rehte wsa no hsemyisol ihwhc namlieteis phats e(th lnoy eotrh piboless enretdnco )e.reh

pCousccyotrc ulsauyl elsiovnv iigntensmi in mmoeiidnpmomrcous spt. .E iloc si mrga vosiip trrnetageoxh si ulayusl rsdamntetit by a ntohr on a oser or mooseen iwht a ihtyros of grngenida

hungrybox  Also, the yeast form of Candida is gram (+) +21  
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(647),
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Heer’s oen way ot sfseliae-ptioroe-nmc eserd“dcae ydneghroodn-b ion:aor”tmf Im’ ont a gib fna of shti nile fo nao,nrigse utb chietclayln iealann sa a ides gupor sah more dgornyhs*e ofr aptletoni grndehoy dibnogn ahnt yglniec:

lane:nia —3HC
legc:yni —H

o,S aiy”lhc“n,clte aalienn dwlou miprte roem eyo-hddbgronn n,ofartomi chwhi hitmg woall uyo ot etmneiila atht i.checo

thaT ,dasi it sesme moalst esoslpbmii ot urle uto t(outiwh yrve lntchcaie knolgwede or omse oiddrvep ereienpxamtl adta) atth het ylshtgli aerrlg anliaen sdeo ont mapiir dhrngoye ngnidob btweeen alglceon leuecmlos aiv irctes t)la(iaps ifcerrtneen.e nI srmelpi msetr, inecs ealanin si rlaegr, uoy uwlod tknih taht it usmt eohmows tneireefr ithw eth hdnoo-engnbydrig that osrcuc iwth teh yep-iwdlt yieclgn.

---
i*lSrctty apgken,si is’t ton hte bnremu fo deghsynro but slao the tthegrsn of eht elodpi atth aitasilfcet nyrheodg n:odngib a nedghroy dbonu to a rolngyst leceaievotrgtne llmceoeu iekl olurenif lwil aa“rppe” oerm spieitvo da,n ,usth ho-nnryodebdg reom otrnylgs hitw a nrbeya oenyxg rcdpom(ae htwi a rngoeyhd ncoeedcnt to oarnb,c orf e)al.pmxe

Furthre agin:red

  1. telui.deuohl//w/luh.ettc/qdhdsgbr:huewhnmw.pidp.sm/pc
hungrybox  Appreciate the effort but this is far too long to be useful. +14  
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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enbuMoarms prutrelieolsGnhoim si riNc;oethp LYNO PUITNRAEROI is in teh vegietnt

tI nt'ac be PGMN bceaseu MGNP si Nihetcirp twhi bsspoile rhoetpcNi

hOter csehcoi are litiamened by aenlR Bpsiyo

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +2  
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 +