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 +5  (free120#32)

This is a bad question. Platelet aggregation time being normal, ok fine I can see that. But VWF stabilizes factor 8 and you'd see an increase in PTT (first line next to VWF in First Aid). Why is their PTT normal?

a1_antitrypsin  Totally agree, and they give you a slight increase in PT instead
mambaforstep  yeah but if they gave you an increase in PTT then Hemophilia A could have been a valid answer choice. so they prob showed a nl PTT to differentiate vWF dz from hemophlia A
drpee  VWD only sometimes presents with a slightly increased PTT. Don't let those anki facts steer you wrong... Plus all the other answers make no sense. Afibrinogenemia? That means literally no fibrinogin (PT and PTT would be infinitely increased). Hemophelia? Or vitamin K deficiency? Those are coagulation factor disorders so they would present with deep bleeding and large bruising. (Unlike platelet disorders, including VWD, which present with mucosal bleeding, petechiae, and heavy menses). VWD is actually the ONLY one that makes sense.

 +0  (nbme20#21)

How would you know that it isn't wool sorters disease?

cienfuegos  FA 2018 137: inhalation of spores leads to flu-like symptoms that progress quickly to fever, pulmonary hemorrhage, mediastinitis and shock, with imaging possibly showing widened mediastinum

 +1  (nbme22#7)

Acknowledge the patient's difficulty. I hate these questions

nwinkelmann  Me too... also, he's had cough that's worsening for 6 months plus hemoptysis for 1 week... I didn't interpret that as "feeling healthy." The correct answer was my first choice just because it was the least "dick-ish" but to me, he didn't sound like he "felt health," so I didn't go with it.
nor16  if he didnt feel healthy, why would he say something like that then... but i agree, these (especially this) question(s) are often XYZ123!

 +4  (nbme22#46)

Prostaglandins vasodilate the afferent arteriole and increase GFR. NSAIDs inhibit prostaglandin synthesis (FA 2019 pg 577)

 +1  (nbme22#24)

UWorld Question ID 1084 has a great explanation of this

mcm94  UWORLD: Invasive tumor from carcinoma in situ includes the following: Tumor cells DETACH from surrounding cells in a process commonly determined by DECREASED adhesion molecules E-cadherin Tumor cells ADHERE to the basement membrane; this is facilitated by INCREASED expression of laminin Tumor cells INVADE the basement membrane via enhanced secretion of proteolytic enzymes (e.g, metalloproteinases)

 +5  (nbme22#50)

Although there are no specific herpes indicators, a CSF panel with mostly leukocytes indicates a viral infection (as well as the normal glucose). So you can rule out TB, neurosarcoidosis and bacterial. Brudzinski/kernig sign are related to meningitis, but even if you don't know what those are, the question says that there is an abnormality in the TEMPORAL lobe (meningitis = meninges). Encephalitis would be the best answer, especially because Herpes Encephalitis affects the temporal lobe.

taediggity  Also look for Kluver-Bucy like symptoms in the stem
b1ackcoffee  I agree with everything but normal glucose. Glucose here is NOT normal. to quote wiki "The glucose level in CSF is proportional to the blood glucose level and corresponds to 60-70% of the concentration in blood. Therefore, normal CSF glucose levels lie between 2.5 and 4.4 mmol/L (45–80 mg/dL)."
baja_blast  NBME reference table gives normal CSF glucose to be 40-70 mg/dL. As far as I'm concerned, for the purposes of the exam the reference table is probably a better source than wiki.

 +1  (nbme23#32)

Secondary hyperparathyroidism due to chronic renal failure. Low Ca, high phosphate and high PTH. FA 2019 page 342

imnotarobotbut  Basically PTH keeps telling the kidney that it wants it to reabsorb Calcium and dump phosphate, but the kidney is broken and cant do that.

 +2  (nbme23#36)

A medical student shouldn't be the one giving someone a cancer diagnosis. This is a really sensitive issue and the results should be given by someone with higher authority like a resident or attending. At the same time, you shouldn't lie to the patient and say that the results aren't back yet if they are. Best thing to do is deflect the conversation and follow up with the resident..

drdoom  It isn’t so much “someone with higher authority” as it is someone with a license! Without a license, an individual is not permitted legally to provide clinical interpretations, as that would constitute the (unlawful) practice of medicine!

 +6  (nbme23#15)

The treatment of cholera is mostly supportive - you want to rehydrate the patient by giving them an isotonic saline since they're losing a lot of fluids.

 +4  (nbme23#11)

Strongyloides penetrates the skin (usually the feet), travels into the bloodstream, enters the lungs/trachea where it is usually coughed up and then swallowed into the GI tract. They can lay eggs in the intestines, and when the larvae hatch, they can penetrate the intestinal wall and enter the bloodstream again.

makinallkindzofgainz  Strongyloides is fucking metal holy shit

 +9  (nbme23#50)

From lnsetick on reddit: "This was my reasoning: you're compressing either the blood supply to the baby, or the blood flow away. If you compress the supply to the baby, pressure would tank and regulatory systems would get its heart to work harder. If you compress the blood flow away, then SVR would rise and regulatory systems would reflexively slow the heart down."

 +1  (nbme23#24)

Pathoma says there are 3 things that differentiate leukemoid from CML: + Leukocyte alkaline phosphatase (only in leukemoid) + Basophils (only in CML) + t(9;22) translocation (only in CML)

nor16  yeah but pathoma doesnt help here...
thotcandy  Yeah but LAP is normally 20-100 so a 100-250 U/L is still + which would indicate Leukemoid reaction, no? That's why I didn't pick it, Because I figured 250 u/l was just some random number and it didn't make sense. a -LAP would be in the normal range, 20-100 which would THEN indicate CML.

 +4  (nbme23#37)

Cool, discolored foot with tingling and numbness = blood clot. Cardiac symptoms may indicate that she has some sort of thrombotic disease. The wording of the answer choice isn't great, but none of the other answer choices fit.

 +13  (nbme23#17)

Visceral leishmaniasis causes hepatosplenomegaly and most importantly, pancytopenia. It is often found in people who visit the Middle East and is transmitted by the Sandfly. Why did NBME put 2 Leishmania questions on this form lol

stinkysulfaeggs  tell me about it... I got both in one block and started seriously reconsidering my answer choices!

 +2  (nbme23#50)

Clodipogrel prevents platelet aggregation by blocking the ADP receptor. The ADP receptor is what is responsible for putting GpIIb/IIIa receptors on the surface of platelets. Without GpIIb/IIIa, the platelets cannot aggregate together.

paulkarr  Just adding that Clopidogrel irreversibly inhibits the P2Y12 receptor. This can be found in FA2019, pg 403. The other drugs in this category are: Prasugrel, ticagrelor, and ticlopidine. Ticlopidine is famous for causing Neutropenia and having an increased risk for TTP.

 +2  (nbme23#31)

Spironolactone inhibits 17a-hydroxylase and also directly blocks the androgen receptor (useful for treatment in PCOS). It can cause gynecomastia, impotence and decreased libido. In the K-sparing diuretics video on sketchy, it is symbolized by the man with the lids on his chest (gynecomastia) and the droopy churro (impotence).

 +8  (nbme23#10)

Even if you didn't which one vector was Anaplasma, I believe choice A was the only one in which both organisms shared the same vector.

stinkysulfaeggs  Agreed, that's how I made my final decision!
alexxxx30  yeah I literally had no clue what anaplasma was, but came to the correct answer the same way

 +5  (nbme23#18)

The key is the free air in the abdominal cavity. Ulcers, especially duodenal ulcers, can perforate into the abdominal cavity. This can cause a pneumoperitoneum (free air under the diaphragm). Not a listed symptom in this question, but this can also cause referred pain to the shoulder by irritating the phrenic nerve. FA 2019 pg 374

et-tu-bromocriptine  To add on to this, anterior* duodenal ulcers tend to perforate (makes sense because closest to the abdominal cavity) whereas posterior duodenal ulcers tend to bleed (due to proximity to the gastroduodenal artery).
smc213  Acute pancreatitis can also occur with a posterior duodenal ulcer rupture. Source: Pathoma

Subcomments ...

submitted by hayayah(883),

Of all the options, psoas major is the only one that is really associated with the lumbar vertebrae.

Q. Lumborum involves the transverse process of L1 but Psoas Major originates from L1-L5

imnotarobotbut  QL is connected to L1-L5 vertebrae as well (https://en.wikipedia.org/wiki/Quadratus_lumborum_muscle) +  

submitted by hayayah(883),

Iron overdose is a cause of a high anion gap metabolic acidosis.

meningitis  I found this to add a little bit more explanation as to how it causes the acidosis if anyone needs it. 1. Mitochondrial toxicity - decreases aerobic respiration and shunts to lactic acid production 2. Cardio toxicity (Secondary to Mitochondrial toxicity) leads to cardiogenic shock (hypoperfusion), which causes lactic acidosis 3. Hepatotoxicity - Decreases lactate metabolism, causing lactic acidosis 4. When in trivalent form (Fe+3), it can react with 3 molecules of H2O --> FeOH3 + 3H+ This will then deplete Bicarb buffering system resulting in non-gap acidosis. Source: https://forums.studentdoctor.net/threads/iron-poisoning-anion-gap-or-non-anion-gap-acidosis.958285/ +13  
sympathetikey  None of the other choices were even metabolic acidosis. They threw us a bone with this one. +2  
imnotarobotbut  Don't changes in bicarb take a few days? How did his bicarb drop down to 8 in 12 hours? +  
charcot_bouchard  its met acidsis. not compensation +4  

submitted by celeste(62),

While the lifetime risk in the general population is just below 1%, it is 6.5% in first-degree relatives of patients and it rises to more than 40% in monozygotic twins of affected people. Analyzing classic studies of the genetics of schizophrenia done as early as in 1930s, Fischer concludes that a concordance rate for psychosis of about 50% in monozygotic twins seems to be a realistic estimate, which is significantly higher than that in dizygotic twins of about 10–19% (ncbi.nlm.nih.gov/pmc/articles/PMC4623659/#ref3)

imnotarobotbut  How is one supposed to know this before having read this article? +15  
imgdoc  This question falls under the either you know it or you dont category. It isnt in FA or Uworld +  
jaxx  So why would these A-holes put it on there as if prepping for this exam isn't stressful enough :-| +5  
doodimoodi  Lol just why seriously +2  
champagnesupernova3  This was mentioned in the Kaplan behavioral videos +  
usmlecrasher  and there's so much unnecessarily BS instead of real questions +1  

submitted by usmleuser007(279),

Note: the questions stated "respiratory burst" suggesting an URT infection.

1) this rules out anything but respiratory infection (non rep infection: E. coli, E. faceium)

2) G6PD deficiency more susceptible to catalase positive organisms -- this rules out (all strep organisms)

3) Left with H. influenzae & Straph. aureus (BOTH are catalase positive)

4) Encapsulated organism are most concerning when there is asplenia.

imnotarobotbut  Respiratory burst has nothing to do with a respiratory infection. It describes the process of phagocytosing a bacteria and using NADPH oxidase/ROS to lyse it +3  
belleng  Aspergillus is still in the running, it is catalase positive as well...but not a choice +  

submitted by sup(10),

Why not PGI2 by way of ASA? Especially given other answer choices of proteins C + S: doesn't warfarin also suppress these?

imnotarobotbut  Protein C and S are ANTI-thrombotic, so although Warfarin does decrease them, they wouldn't decrease the patient's risk for thrombosis +1  
epr94  the question ask "suppression" of which one will decrease risk of thrombosis if you suppress C and S which and anti-thrombotic you get thrombotic +1  

submitted by aaaaaaa(5),

orlistat is used for weight loss (its not a statin as some people thought in the comments here). its in FA 2019 pg 294, m/c side effects are GI including diarrhea

imnotarobotbut  Thanks! It's actually page 394 +1  
tiredofstudying  FA 2020: Page 400 +  

submitted by seagull(839),

out of curiosity, how may people knew this? (dont be shy to say you did or didnt?)

My poverty education didn't ingrain this in me.

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +10  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +14  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +  
jaxx  Not a clue. This was so random. +  
wolvarien  I did not +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +5  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +2  
djtallahassee  yea, I mature 30k anki cards to see this bs +3  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +1  
drschmoctor  Is it biochemistry? Then I do not know it. +2  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +  
amy  +1 no idea! +  

submitted by sajaqua1(389),

Borderline personality disorder- feelings of "emptiness," suicidality, self-mutilation, unstable relationships, and more common in women than in men. A common defense mechanism in this disorder is "splitting" in which people are seen as entirely good or entirely bad. Borderline personality disorder is also part of the Cluster B personality disorders, which are associated with substance abuse.

imnotarobotbut  Suicide attempts are also commonly seen with Borderline +2  

Secondary hyperparathyroidism due to chronic renal failure. Low Ca, high phosphate and high PTH. FA 2019 page 342

imnotarobotbut  Basically PTH keeps telling the kidney that it wants it to reabsorb Calcium and dump phosphate, but the kidney is broken and cant do that. +3  

submitted by sajaqua1(389),

Critical points for this question: 5 year old boy, immunosuppressed because of chemotherapy, 2 day history of fever, cough, shortness of breath, febrile (101.8 F), respirations 46/min, with cyanosis and generalized vesicular rash. Extensive nodular infiltration.

Of the options listed only measles and VZV give a rash. A rash from measles usually starts rostrally and descends caudally, and is flat and erythematous. By contrast, VZV (chickenpox) presents with generalized rash that quickly transitions from macular to papular then to vesicular.

sympathetikey  Good call. +3  
imnotarobotbut  Also, VZV causes pneumonia (what this patient probably had) and encephalopathy in the immunocompromised. +5  
nwinkelmann  What threw me off was that it didn't mention the synchronicity of the rash. I stupidly took failure to mention to mean that the rash was synchronous, which doesn't fit VZV because chickenpox rash is characterized as a dyssynchronous rash (i.e. all stages of the macule to papule to vesicle to ulceration are seen at the same time). MUST REMEMBER: don't add information not given! +1  
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +1  

submitted by seagull(839),

This is a panic attack. Hyperventilation drops pCO2 leading to a respiratory alkalosis. po2 is relatively unaffected (don't ask me how?)

sympathetikey  Yeah haha I had the same conundrum. +  
sajaqua1  If she's breathing deep as she breathes fast, then oxygen is still reaching the alveoli , so arterial pO2 would not be effected. +8  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +1  
soph  Maybe Po2 is unaffected bc its perfusion (blood) limited not difusion limited (under normal circumstances). +2  
charcot_bouchard  PErioral tingling- due to transient hypocalcemia induced by resp alkalosis. +1  
rainlad  I believe CO2 diffuses ~20x faster than O2, so increases in her respiratory rate have more effect on her PCO2 than her PO2 +1  

submitted by aladar50(33),

The important thing for most of the ethics questions are to look for the answer where you are being the nicest/most professional while respecting the patient’s autonomy, beneficence, non-maleficence, etc. Most of the choices here were either accusatory or basically being mean to the patient. The correct choice is to help the patient but also motivate them to continue physical therapy and to only use the permit as little as necessary. A similar question (which I think was on NBME 23 -- they are kind of blending together) was the one where the patient had test results that indicated he had cancer but the resident said not to (voluntarily) tell him until the oncologist came in later that day, and the patient asked you about the results. You don’t want to the lie to the patient and say you don’t know or that he doesn’t have cancer, but you also don’t want to be insubordinate to the resident’s (reasonable) request.

drdoom  @aladar Your response is good but it’s actually mistaken: You *never* lie to patients. Period. In medicine, it’s our inclination not to be insubordinate to a “superior” (even if the request sounds reasonable -- “let’s not inform the patient until the oncologist comes”) but *your* relationship with *your* patient takes precedence over your relationship with a colleague or a supervisor. So, when a patient asks you a question directly, (1) you must not lie and (2) for the purposes of Step 1, you mustn’t avoid providing an answer to the question (either by deferring to someone else or by “pulling a politician” [providing a response which does not address the original question]). +1  
drdoom  As an addendum, legally speaking, you have a contractual relationship with your patient, *not with another employee of the hospital* or even another “well-respected” colleague. This is why, from a legal as well as moral standpoint, your relationship with someone for whom you provide medical care takes precedence over “collegial relationships” (i.e., relationships with colleagues, other providers, or employers). +  
imnotarobotbut  @drdoom, it's not about lying to the patient but it would be wrong for an inexperienced medical student to give the patient their cancer diagnosis, or for a doctor to give a cancer diagnosis if they feel that the patient should be seen by oncology. In fact, the correct answer that the question that was referred to by aladar50 says that you do NOT give the patient their cancer diagnosis even if they asked you directly about it. +  
charcot_bouchard  Dont give it to him. DOnt lie to him that yyou dont know. Tell him let me get the resident rn so we can discuss together Best of both world +2  

submitted by usmleuser007(279),

PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium)

imnotarobotbut  That's not the right answer tho, the answer is the binding of PGE to it's receptor +  
tinydoc  Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1  
maxillarythirdmolar  Keep it simple, stupid. +1  
roaaaj  @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +  

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