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Welcome to jesusisking’s page.
Contributor score: 16


Comments ...

 +2  (step2ck_form7#36)

"I think there's no intervention necessary here. Newborns should have mom's antibodies. Related. Pay attention to the first bullet point, its a testable concept." reddit.com/r/medicalschool/nbme_7step_2_5_questions/


 +1  (step2ck_form7#8)

Tumbleweed

drdoom  need more cowboys in these here parts .. +2

 +0  (step2ck_form7#24)

I believe the vertebrae toward the bottom are fused corresponding to the boy's low-back pain and the diagnosis

jesusisking  Also sacroiliac joints eroded and sclerosed +1

 +0  (step2ck_form7#16)

I guess people on PCP don't have to be aggressive.


 +0  (step2ck_form7#23)

I question this, most appropriate next step would be to investigate if they're safe at home. Because if he is abusive and learns more about the daughter's behavior and that the mom wasn't telling him (through family therapy), it could get ugly. If only it was an option


 +2  (step2ck_form7#26)

Did anyone else think autonomic insufficiency given the diabetes? I know it was previously well controlled but still a 10 year history

seagull  ya dude. +

 +2  (nbme24#48)

I got this wrong b/c didn't read where it said "[pain localized] to the distal portion of the absent extremity." That's the giveaway :D





Subcomments ...

submitted by jesusisking(16),

I believe the vertebrae toward the bottom are fused corresponding to the boy's low-back pain and the diagnosis

jesusisking  Also sacroiliac joints eroded and sclerosed +1  


submitted by buttercup(14),

Bone marrow examination is generally not required for the initial evaluation in most cases of unexplained isolated thrombocytopenia in children. This child has pancytopenia and therefore requires a bone marrow aspiration.

jesusisking  Why wouldn't it be platelet transfusion 1st? +  
jesusisking  Just found the answer. Patient was stable and not actively bleeding w/ 30K platelet count. For this type of patient, start transfusing at <10K: https://www.aafp.org/afp/2011/0315/hi-res/afp20110315p719-t2.gif +4  
deathbystep1  well the question said "his gums started bleeding when he brushed his teeth". So wouldn't that be considered active bleeding? I was aware about the aafp guidelines as there was a similar question in Uworld as well. The only reason i chose platelet transfusion was because he was "actively" bleeding from the gums. Otherwise it was clear that he had pancytopenia and you need to do a bone marrow biopsy. +  
zalzale96  Isn't bone marrow aspiration considered an invasive procedure and thus we should transfuse since his platelets level is below 50k? +  


submitted by buttercup(14),

Bone marrow examination is generally not required for the initial evaluation in most cases of unexplained isolated thrombocytopenia in children. This child has pancytopenia and therefore requires a bone marrow aspiration.

jesusisking  Why wouldn't it be platelet transfusion 1st? +  
jesusisking  Just found the answer. Patient was stable and not actively bleeding w/ 30K platelet count. For this type of patient, start transfusing at <10K: https://www.aafp.org/afp/2011/0315/hi-res/afp20110315p719-t2.gif +4  
deathbystep1  well the question said "his gums started bleeding when he brushed his teeth". So wouldn't that be considered active bleeding? I was aware about the aafp guidelines as there was a similar question in Uworld as well. The only reason i chose platelet transfusion was because he was "actively" bleeding from the gums. Otherwise it was clear that he had pancytopenia and you need to do a bone marrow biopsy. +  
zalzale96  Isn't bone marrow aspiration considered an invasive procedure and thus we should transfuse since his platelets level is below 50k? +  


submitted by keycompany(301),
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Thsi atnpiet ahs a munah.xtepoor nrHleetoipntalivy is nto eonugh ot apsoetcemn rfo eht rvaello eercdaes in nglu usaecfr eraa.

_yeetmasterflex  Could the pneumothorax also cause less ventilation due to decreased lung surface, retaining more CO2 causing respiratory acidosis? That's how I got to the answer at least. +4  
duat98  I think pneumothorax would increase RR because you're probably hypoxic. Also I'm sure when you have a lung collapse on you you'd be scared and that would trigger your sympathetic so your RR will go up either way. +3  
kateinwonderland  Arterial blood gas studies may show respiratory alkalosis caused by a decrease in CO2 as a result of tachypnea but later hypoxemia, hypercapnia, and acidosis. The patient's SaO2 levels may decrease at first, but typically return to normal within 24 hours. (https://journals.lww.com/nursing/Fulltext/2002/11000/Understanding_pneumothorax.52.aspx) +1  
linwanrun1357  How about choice C, --ARDS? +2  
bullshitusmle  there is no bilateral lung opacities as you would see in ARDS +4  
jesusisking  Was thinking some sort of infection b/c of the atelectasis so picked empyema but this makes sense! +  
djeffs1  does it need to be ARDS to cause "diffuse alveolar damage"? +  


submitted by sympathetikey(1265),
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Better irutecp - snBwto.hlwpee/atraal.1dc//c1p-/pgw0o-/j0:wbtontNv8./cctpauule2es/mhrs

yb_26  @at0xibolic, I think you won this competition on finding better picture lol thanks +5  
drschmoctor  Those may be better, but this is the BEST. http://bitly.com/98K8eH +8  
brotherimodu  god damnit +  
jesusisking  Not again (´∀`) +  


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Elhledntaio tihgt sincto’unj batrlpiiemye is ecedrasni in erspenos to yunjri nda lionatifnmm,a awlgnoli riitganmo fo ihtew olbdo lecls adn niedfsr ot eth siet of jy.inru

jesusisking  Thank you! +  
focus  Ugh I was thrown off by "disruption of vascular basement membranes" since it seemed similar to the correct answer but I can see how "separation" would be a normal, expected response of the body that is needed vs. "disruption" would be traumatic and abnormal... please correct me if I am wrong! +1  
blah  @focus reasoning sounds right. I nearly picked that but the other choice sounded better. Just semantics. +2  


submitted by kentuckyfan(43),
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ctoNie ahtt )A nrtcoinBrchsntco,ooi )B rlanauGld ,eornictes )D estas,sirPil E) intsdooiVaal fo iskn rae lla nured tpaeyciprtsahma oc.rlnot

Teh lony csiyptehatm loocnrt is hater rae,t cwhih doluw isrecena.

drzed  Vasodilation of the skin is under sympathetic control as well -- beta-2 receptors when stimulated cause vasodilation (via increase of cAMP in vascular smooth muscle). The key is recognizing that stimulation of a GANGLION of the pns will lead to release of NOREPINEPHRINE, which preferentially stimulates alpha-1 receptors. Those receptors will cause vasoconstriction. If the question asked what happens when you stimulate the adrenal medulla, the answer would be (potentially) vasodilation. This is because the adrenal medulla releases EPINEPHRINE which preferentially stimulates beta-1/2 receptors. +6  
jesusisking  @drzed Awesome explanation except I think sympathetic response induces vasoconstriction in the skin though vasodilation in the muscles! +1  
usmile1  @jesusisking yes you are correct! α1: vasoconstriction in skin and intestine ; β2: vasodilation in skeletal muscle (transmitter: only epinephrine!) +  


submitted by sajaqua1(524),
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A dnadatrs denaivoit si a aeursem of irobtlypiba in enmeilbgrs het eavaer.g enO addasrnt itanvodei on a llbe ecvru rtisobuiidtn secerta a %67 ncache atht teh sernwa lwli eil ni .hetre woT rstdndaa dtsevniiao wlil taerce a 5%9 nc.ceah Teehr adsnrdta deiniatosv eacestr a %979. acc.ehn

hiTs ntaitpe ash na rveeaga of ,131 nad a 9%5 nnfdoieecc ta 0-61111 ensam that eht DS si 5.1 . So neo idnltdoiaa DS wudol egiv su a rnaeg of 510581,.-17. nueoddr ot 1118.0-8

usmleuser007  How did you get the SD to be 1.5? +  
usmleuser007  NVM Got it +1  
jesusisking  You wouldn't use Standard error with Confidence Interval? (pg. 262 FA 2019) +  


submitted by haozhier(16),

I chose C because I thought it has been four weeks so it must have been acute tubular necrosis. Can anyone explain? Thanks!

miriamp3  @haozhier if you are deciding to think that he had a ATN because of the 4 weeks.. then he should be by now in the recovery phase(polyuria, Bun/cr fall) But he is with HF and his urine output has progressively decrease. So AKI prerenal HF Bun/cr >20. the only one is D. Don't get confused with the rest of the information. +  
jesusisking  I thought the same thing so chose C as well! +  


submitted by link981(157),
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vwereoH wirde, ouy hvea ot crpsete eht ei'patnts ielsebf sa lgon as htye ntre'a ngutpit hte rbwonne at am.hr In hetse pyset of eoqnsstui yuo avhe to iudbl tpaitysnancipeh-i shsaopreniilt abcesue het eptntia gtihm ebecmo effddoen fi uoy geadisrrd erthi be.eflis So hweli eth oerwnbn otms iyklel sah asg adn nto et"h vlei ee,"y cioche E is hte elats gnf"onefdi" asnwre thta suetgsgs mtntar.ete

charcot_bouchard  Exactly. If she was cracking the egg on Baby's head u stop her lol (i am cracking up on my own jokes) +3  
jesusisking  I feel it but dang, she lowkey drizzlin salmonella all over that baby +2  


submitted by seagull(1443),
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Wtha a erelrbti .peciutr They tehy redocve pu part fo it hwti eis.nl WFT

sympathetikey  Agreed. +11  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +  


submitted by lfsuarez(141),
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Frist rteha osund (1S) is eaednergt by wto taerh vla:evs eth tilrma levav dan spiirtucd .veval ealyrN neuuasiltsmo csnogil of ehets slvaev olmanyrl nasgretee a ngsiel 1S ond.su pgtinliSt fo het S1 uodsn si rehda hnwe mlitar nad rcpdiistu vaeslv losec at hysltgli tfrfeinde ,tsiem wthi usllyua the altrim osncgil ferboe rpdusiict

yotsubato  Then why the fuck is it describing a mitral valve sound in the tricuspid area +23  
dr.xx  it's describing a splitting S1 — consisting of mitral and tricuspid valve closure — that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. +31  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +4  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +1  
drzed  It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post) The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound. +10  
alexxxx30  yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation. +10  
jesusisking  Thanks @alexxxx30, you the man! RIP Kobe +  


submitted by bobson150(11),
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heT wgdrnoi fo hsit equnsito fncdusoe e.m siTh si knasgi "wchih of ethes selevss is het high reessurp e"yssmt ?tgirh oS hte ghih eprsrseu uroisrep alctre is gusncia iasdercne esprrseu tino teh irefiron lterca?

welpdedelp  Superior rectal comes from the inferior mesenteric vein which comes from the splenic vein --> portal veins Thus, this dude had cirrhosis so it would "back-up" into the superior rectal vein. FA 2018: p360 +13  
nc1992  Superior rectal not superior mesenteric. Took me a minute +  
hyperfukus  ugh am i ever gonna get these right EVER +5  
titanesxvi  why not the inferior mesenteric, since the superior rectal drains there +2  
thomasburton  @titanesxvi think it is because question says direct which is why superior rectal +2  
lilyo  thomasburton, so are they asking what vessels do internal hemorrhoids directly drain into? The order is Superior rectal vein--> Inferior mesenteric vein--> portal vein. +  
thomasburton  Yes exactly, so they do eventually reach IMV but not 'directly' +  
pg32  Also worded poorly because the varicosities are connections between the superior rectal and the middle/inferior rectal veins of the systemic circulation. So the blood could be in both the superior rectal vein and the middle/inferior rectal vein as that is what a varicosity is. +2  
snripper  You just gotta know indirect vs. direct hemorrhoids. In this case, it's an indirect hemorrhoid (superior rectal vein) because of the rectal bleeding. +  
jesusisking  @titanesxvi DrDoom explained it pretty well below: "Defining tributary: https://i.imgur.com/2zDxPbW.png Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them)" +  


submitted by seagull(1443),
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uot of rityuio,sc hwo yam eolepp kwne ?hits nodt( be syh to sya ouy ddi or )tddi?n

My yrtpveo tdiuaceon ditn'd rgnniia ihst ni 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 +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
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?" +7  
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. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
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 +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
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. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  


submitted by kchakhabar(44),
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What trwhe me ffo ni shit tuqiosne si the spahre eclsl" tiwh tiellt captslmyo tath are tewic eth esiz of lo.mcspe"ytyh I oguhth mlsal" llce imoa"carcn atoncn be ahtt .big

nala_ula  Omg literally the same thought process I had, that phrase through me off! +  
nala_ula  threw* +1  
jesusisking  Super counter-intuitive but apparently SCC cells are 1.5-4x the size of lymphocytes: https://www.ncbi.nlm.nih.gov/pubmed/1313679 +1  


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To tnanmiai aplsam toloylsami -gt;& eeNd ot lxtyeac eeprcal all hte ulsifd tsol in hte day

ehS taoncn trectanoecn rnuei obeva 054 /sgmOkm , so hte umnmimi nomtau fo rweat ieqerrud to be retecdex yb nsdeyki si 1 to( ecxteer het 540 msmO hes caucsealmut epr y.)ad Teh ummmini ceeitnrxo rwtea uedqerri si yirsscaelen ta max ocnri;nteatonc if oyu wree to ysa epdocur idtlreu re,uni sya 2mgs5kOm2,/ tihs odwlu rrqiuee 2 L of tr.aew Teh qnouiset awtsn eth mmmuiin bpoleiss werta mue,ovl os ew muessa ’sesh cnantrcteiong ot eth mxa.

1 L soless rmof kdnyie + 090 mL eseilibnns + 010 Lm in saewt dna efces = 2L ssloes t&;g- edne to nitges 2 L fo reatw ot c.plerea

jesusisking  So helpful, thank you! +