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Welcome to lovebug’s page.
Contributor score: 13


Comments ...

 +0  (nbme21#32)

According to FA 2019, page 561

MECHANISM of atypical psychotics(including Risperidone) is Not completely understood. but Most are 5-HT2and D2 antagonists; Varied effects on α and H1 receptors.

These SGAs Have lower binding affinity for D2 receptor than FGAs. so less Extra pyramidal S/E.


 +0  (nbme21#38)

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +4
lovebug  Oh, thank you! +
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +2
csalib2  @drdoom fantastic point. never thought of it that way. +
lovebug  @drdoom THX! very sweet explanation! +

 +1  (nbme21#28)

this patient began rosuvastatin tx 4 weeks ago.

rosuvastatin, pitavastatin, pravastatin are substrates for the organic anion transporting polypeptide (OATP). however, none of these 3 statins are substrates of CYP3A4.

OATP transports the statin from the plasma into the hepatocyte. The statin can then be metabolized by hepatic enzymes or transported into the bile for elimination via the gastrointestinal tract.

Interference with OATP activity results in accumulation of statin in the plasma and may lead to myopathy.

FA 2019, 315 pg

https://www.pharmacytimes.com/publications/issue/2014/June2014/Statins-and-OATP-Interactions

5thgencephalosporin  this is PharmD–level shiz +1




Subcomments ...

submitted by dbg(140),
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BsB wrok yb cgeiesnrad McAP adn a2+C reyebht olsnigw NAS am;&p VAN yatii.ctv Tihs rsonlogp hpesa 4 of zrt.onidlaiopea ,efoehrTer yeht are nnowk to carsniee het uadnotir of eidotlas ielyo(mdnar)tnp asngciu obht a reis in taher rrynocao neursipfo dna itedrnocu ni athre re.at

lovebug  FA 2019, 318page. class two antiarrhythmics. +  


submitted by hayayah(1056),
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'tIs ialtotrnsina cell rociacm,an hihcw mnkgsoi is a mocmon riks toafrc ;rfo it nac volienv eht rnale /pessiyce.cavll ehT hoist egami shows the rppaiylal etnura of eht motur evehwr(o ti nac lsoa be ftla or uonradl ocidacgrn to Pto.)hama

olsA nnokw sa tllheiroau .cmaoancri oMst mmnooc mourt of nuarryi atrtc mseyts nca( crcuo in earln cysa,cel nrlea iepvl,s rur,tese dan r)lbdea.d naC eb sudgsgeet by ienasspl hatuemiar o(n ss)atc.

usmlecrasher  i'm sorry guys it's bladder cancer blocking urine flow => reflux ureteral widening => reflux nephropathy. +6  
hello_planet  FA 2019 pg 588 +2  
kevin  Is the idea since that since the histology shows transitional cell cancer the most likely is smoking and that's the answer? The fact that this was unilateral really threw me off. Is it common to have unilateral carcinoma of the ureter (if that's what this case was, of the ureter) rather than bilateral? +  
lovebug  I Choose F) vinyl chloride <- only liver angiosarcoma. :( about many Carcinogen FA2019, 226pg. +  


submitted by mbourne(76),

In restrictive lung disease, literally all lung values are DECREASED ("restricted") except for the FEV1/FVC ratio. FEV1/FVC ratio may be normal or increased (increased only if FEV1 decreases a bit less than the decrease in FVC, resulting in an increased ratio).

lovebug  Your explaination is very useful! thanks! :) FA 2019, Page 658. +  


submitted by strugglebus(163),
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I ocehs this lelsoy esabuce it wsa so danm eipisccf

sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +4  
karljeon  I didn't choose it because it was so damn specific. :( +40  
lovebug  Could anyone explain for B) for me? because I choose B).:( +2  
j44n  B.) is wrong because its never been shown to show adverse effects "any offcial data linking the drug" and the fact that it's "newly marketed" +  
j44n  and because its in 5/45 patients roughly 10% of the population, that might not seem like much but most of the diseases we freak out over are in 1-2% of the population, to put that into perspective if we gave this drug to every person in the US (every big pharma wet dream) with a population of 300 million... 30 million people would have this adverse event... hope that helps +  


submitted by hayayah(1056),
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teAcu iitltairnste nerla nnama.fiolimt auPriy icyla(clssal lhoie)pisosn nad aimezato grioucnrc aetrf ittarsonnaiidm fo sdgur ttah act sa ,etsnpah gdniniuc eyvstsiinrtieyhp (g,e icdi,truse DsSIAN, lenniicilp vid,eritevas noport ppum niorhs,tbii ,fmipiran iqosnnleuo, lf.ds)amienosu

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


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suepr vegau utniesoq ! rD sndiee saitissng cu&s;eitidg= lenoccifimnneae d o enriteyhgv eh cna to emanga reh iapn gt&=; feneceecinbi

lovebug  me too... so I choose B). lol +  


submitted by drzed(206),

Patient has low serum sodium = hyponatremia.Given that the patient has a LOW URINE OSMOLARITY, it suggests that ADH is NOT active. The only way for someone to have hyponatremia AND a low ADH (in this case) is through psychogenic polydipsia (e.g. if it was SIADH, the urine would be MAXIMALLY concentrated and it is NOT in this case)

(A) would cause central DI -- no ADH means one develops hypernatremia as free water is lost in the urine, thus concentrating the serum.

(B) osmotic diuresis could cause hypernatremia due to loss of free water in the urine

(C) degradation of ADH leads to DI which means one develops hypernatremia

(E) resistance to ADH (nephrogenic DI), again, hypernatremia.

lovebug  thanks for kindful labeling! :) +1  


submitted by xxabi(251),
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This is a stogllayshro tcud .ctsy hTe ysgalooslrt tdcu mya peitrss nda lrsetu ni a gralythsloso tdcu ycts ougrincrc( in nmieidl erna yohdi ebno ro ta the easb of eht tneg)u,o thsu lwil llcysaisacl mveo up whti wsgwloilan ro geuont osun.tripor

The morfnea cmuec (of teh gouet)n si teh arnlom nremant fo hte syglthsoalro dtuc

lilyo  I got it wrong though because the question clearly asks what does this structure (thyroglossal duct) DEVELOP from, not this structure eventually develops to form which structure. If it asked that then I would have picked option A but because it didnt that was the first option I crossed out. +15  
misterdoctor69  It was a poorly worded question no doubt. But when they say "endoderm of foramen cecum" they're referring to the endoderm which is a primitive structure. The "foramen cecum" part is just a modifier that is added to describe what that endoderm would eventually become. +  
lovebug  FA 2019, page 322page! +  


submitted by dickass(84),
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niar..m.tg srowkre ha..s. otn revdieec roteinu amicled erac ;=g=&t hse wsa tno eesnrdec for dmispyyihthoor

lovebug  Wow good point! :D +  


submitted by neonem(550),
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iTsh tpnieta ieykll sah osme fmor fo prepu mroto unrnoe iesnol ro seaides - UNM ilossen era czticrheaeadr by ,snwaekes driacnese epde oendtn sfxr,eele dna pastisc pe.iarss fncBaleo is a B-ABAG sgnatio ecipscif ot eth spanil oc,dr sued ot terta mucsle si,tyascitp ia,ytosnd adn .MS ABA-BG si a G-iorntpe dcpoelu erroetcp lcpdueo ot ,Gi os onmgsai of hits eortcpre cuessa taopraphnizyorile fo het nreuons adn eedcsedar elaeesr fo xcoetayrti mtatluag.e

kevin  stimulates K+ efflux (hyperpolarization) and inhibits Ca2+ influx (no vesicle release) +1  
lovebug  FA 2019, 538page !! +  


submitted by frimmy_11(0),
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loMitgnt and stenigfno of ieratnro awll on suoptya sgguesst it asw ont ordle tnha 42 s.hr theaD rofm atlaf rhtiramahy ekli ifVb- stmo molmycon crcous tiwihn neo dya of hte MI. haTt id,sa ceon acsr hsa mfoedr ni rydoimlaca teissu it, ot,o nac easuc thihyra.amr

bighead478  in FA it shows softening of the myocardium to happen at 3-14 days. Do you think this was overly misleading people (like me) into choosing myocardial rupture? I understand the histo features are consistent with < 24 hours, but the stem should also match this in every detail +  
athenathefirst  Anyone knows why it's. not cardiogenic shock since it happened within <24 hours? +  
lovebug  @athenathefirst I also had same Question. maybe Question asks "Most likely mechanism of death" > most common cause of death in 24hr is arrythmia. cardiogenic shock is also possible. but it's not the most common cause of death within 24hr. +  


submitted by est88(17),
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pretRranloteieo tu:rrsusect DAS PR.UKEC

lOny het neiecdngsd cooln is rtpa fo hi.st

meningitis  SAD PUCKER: Suprarenal (adrenal) glands [not shown] Aorta and IVC Duodenum (2nd through 4th parts) Pancreas (except tail) Ureters Colon (descending and ascending) Kidneys Esophagus (thoracic portion) Rectum (partially) +15  
cienfuegos  I find "SAID PUCKER" to be helpful because it includes IVC +4  
lovebug  FA 2019, 354page~ +  


submitted by aazib05(4),

because they have asked about THE TEST, and sensitivity/specificity are the properties of the test. whereas PPV & NPV are dependant upon the population being tested, it's not the intrinsic property of the test.

lovebug  @aazib05 simple and clear. Thank you! +  


submitted by hayayah(1056),
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tMso oonmcm acseu of acirtsg lteuto iuoncrsbott ni .siantfn lPaaeplb vspdheoieal- asms in icpgisraet regoni, vebilis etraclpisti esvwa, dan snuoioblin eportijelc tgmoviin at ∼6–2 kewes ldo.

utdloUrsan swosh detkcnhei and thdneleeng .rpuyosl treneamTt is gcsulari iioinncs )ym.(poooylytmro

lovebug  Could you explain WHY NOT (B) Gastric volvulus?? bc I think it can share some clinical symptoms. +  
calleocho305  This is what I put, wouldn't hps occur earlier than 4 weeks? +  
ssc30  Gastric volvulus is very uncommon in general and almost never happens in infants. +  
ssc30  Gastric Volvulus would also present with severe abdominal distention and pain due to incarceration. +  


submitted by lovebug(13),

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +4  
lovebug  Oh, thank you! +  
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +2  
csalib2  @drdoom fantastic point. never thought of it that way. +  
lovebug  @drdoom THX! very sweet explanation! +  


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Teh tepinat fsfedrue omfr emunmI o.ybTamcehornpito niuoiodbtetaas nsitaag eht isypcetrnolgo G/2B3A.P

nO sa,bl uo’lyl ese: eiscerna ni eyc;atgskearomy no teh snqieotu mtse eth’yre rdsdeicbe sa a“err tbu egra”.l aMerkocgetyyas rea otn epessu.drps

ergogenic22  isolated thrombocytopenia (low platelets) should be highly suggestive of ITP https://www.aafp.org/afp/2012/0315/p612.html +2  
pg32  I agree that in ITP you will see an increase in megakaryocytes, but where did you see that in the stem? Platelets being, "rare but large" doesn't mean megakaryocytes, does it? Also... can anyone explain why she was anxious but alert and had petechiae distal to the blood pressure cuff? +  
meryen13  @pg32, I'm not too sure about the "anxious but alert" but I think they might wanted to mention she is oriented so in case there was no lab values, you would guess that she is not extremely anemic or something. and about the petechia with the cuff and the tooth brushing bleeds, that is a sign of platelet problems because its a superficial bleed. if you saw deep bleeds like joint bleedings, think about coagulation pathway problems (like hemophilia) +2  
zevvyt  "rare" means thrombocytopenia. "Large" means there are megakaryocytes to make up for the thrombocytopenia +2  
lovebug  FA2019, page419 +1  


submitted by andro(170),

First Point : Lymph forms at the Capillary level of blood vessels ( as this is where fluid moves in and out of vessels along with metabolites and nutrients ) .

The function of lymph is to return excess proteins and interstitial fluid back to the bloodstream ( Recall Lymph eventually drains into the large veins)

Second Point : We may increase lymph either by increasing 1. the rate at which we form it . 2. Decreasing the rate of drainage ( i.e - obstructing lymph vessels )

To increase lymph formation we have to increase the rate at which fluid filters out of the capillaries . This can be done by altering Starlings forces in the capillary

  • Increasing hydrostatic pressure
  • Decreasing Oncotic pressure

Going through the options
Option A : Endothelin will cause vasoconstriction of Pulmonary artery .This is precapillary meaning we will have less blood/ fluid getting to the capillaries - decreased hydrostatic pressure and decreased lymph formation
Option B : Constriction of pulmonary artery again
Option C and D : lead to the physiologic response of hypoxic vasoconstriction
Option E : Increased oncotic pressure decreases the amount of fluid moving out of capillaries

lovebug  now I understand~~!! THX :) +1  
limberry  I believe you mean "Option F: Increased oncotic pressure decreases the amount of fluid moving out of capillaries" instead of Option E, right? +  


submitted by usmleuser007(370),
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Can soemeno lsaeep lepxian yhw tc'na lchooal be ccertro in iths etngsti?

niboonsh  rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018 +11  
dr_jan_itor  what if the alcoholic just has a concurrent rhinovirus infection ;) +5  
lovebug  and FA2019 page 538. +  


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Ssihplyi htaegiespsno is eht nalmoaintfmi dna onraiobtitel fo eth asav oasmvru (amlsl boldo veesssl) that feesd gibegr doobl ssvesle eikl aaro,t r,eertias eosalrr.tei tI sode ont tmeatr hawt eth estga si, .T mpalduil fenscit hte aasv urvsaom ,dan in hte ocspe,sr stlboteeari teh ernsve and lodbo el.vsess siTh iklsl lbdoo lpypus to those raaes = eiimchsa ubt no apin n(siepsal neh)rcca. Mreo cdeiolzla ni arreeil at,esgs dna in lreta gs,tae teh eipsostrceh tan,mssideei os ouy veha teh roata adn sliapn drco ivmelvetonn ubt mase apsiengos.teh t(:iEd onGjal lidxapnee tsih mhose.r)eew

privatejoker  So is the heavily implied step-wise formation of Syphilis symptoms as presented in FA complete BS then? Why break it down into stages and have us learn it as such if this is not the case in real practice? +4  
lilmonkey  Exactly, Goljan mentioned this in one of his audio lectures. All kinds of lesions in syphilis caused by vasculitis. +3  
lovebug  I know it's silly question. but Could anyone give an why answer is lymphocyte and plasma cell not neutorphiles.? bc syphilis is a bacteria, not virus. +  


submitted by cantaloupe5(72),
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ihTs oen swa cyktri tub I hiknt you lcu’evod edon tish oen uihtotw deelonkgw of DANM ctesrepro. mSte otld uoy ttah malttegau vacaestti boht A-DMnNno adn MAND persercto ubt it daeatticv lony -nAoMnND oesprrect in het aeyrl hse.ap aTth snema ANMD eoreptsrc aatictve retfa D-nAMoNn prtr.oscee That naems gniohetsm aws nageylid NDAM ecptorre ntvciitaga nad hte yoln wsnrea hatt aedm ssnee sa eth gM bnignhiiit NDMA ta egnsrti .panetotli enOc eht lelc si reddazploei yb AnM-NnoD ertopr,cse MADN epoetrrsc cna eb a.ttdviaec

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. +6  
divya  sweet explanation imgdoc +  
lovebug  really~~~ sweet. thankyou :) +  


submitted by lovebug(13),

really curious about why not (C) Suggest that the couple to a therapist together.? T.T

drdoom  thou shall not punt nor refer thy patient to another +4  
lovebug  Oh, thank you! +  
drdoom  yeah, think about it this way: the Step exams are here to certify “this person can practice medicine in your state without supervision.” even the most worshipped and glorified neurosurgeons have to pass the Steps. that’s because, at the end of the day, all responsibility (and liability) falls on the physician of record. “the buck stops here,” as they say. so, the Step needs to assess that you can make a decision when no one else is around. it couldn’t do that if it allowed you to choose “refer this problem to someone else.” +2  
csalib2  @drdoom fantastic point. never thought of it that way. +  
lovebug  @drdoom THX! very sweet explanation! +  


submitted by hungrybox(968),
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izqu orelsfyu rnwa:sse

  1. rSlteoi ol(rSiet sSthu dw,no FMI si stedrcee by Sroitel ec)lls
  2. hp5aal- esteucrda
lovebug  5-alpha reductase is due te that DHT is important for male external genitalia? +  


submitted by beeip(123),
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iThs sah bnee a ghtuo ceoptnc ofr em ot ,gte btu I kihtn 'mI fliynla e:hret

ehT mets is isecdgbnir irrpyam arenadl scfcifn,niyiue ro .dsndAs'oi

  • HATC is ienbg e-rerdodpcuvo ot sameliutt the resadlna ot opeurcd s,octlroi tbu tyeh tnca' e,dpnors rihete eud ot parohty ro eoriusnttdc ,BT( eaouinm:utm R,D4 tce.)
  • heT rtsfi 31 aionm aisdc of TCAH anc be evaldec ot fmor α-HSM, hicwh ulaetsmsit teyclsoena,m nuigcas peontrpiehatngymi
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


submitted by mcl(579),
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iVbroi rceoahle si a rgaatmvneig,e- comma eahdps tabcerai htta nac useac reawyt r.riahdea lCoraeh ioxtn utcisfnon by aginvtcati the sG opesritn tg-;&- ignnraecsi yactiitv fo lynyleda lacscey g;--t& renecadis AMPc -g;&-t aseiercdn aN+ dan -Cl exflfu -&t;-g adi.hraer

teepot123  fa 19 pg 146 +  
lovebug  Cholerae's exotoxin does not invade mucosa. but just permanently activates Gs according to FA. +  
lovebug  Same mechanism[Increase cAMP] : 1) Labile toxin of ETEC, 2) Edema factor of B. anthracis, 3) Pertussis toxin of B. pertusssis +1  


submitted by mcl(579),
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Viobri rhceealo si a vargite,gm-ane moacm headps erataibc hatt nac euacs taeywr .rhdaarie aCreohl xinot focuntnsi yb agatnvciit teh sG prsitoen -&t;-g sicranengi acytivit fo ylylaned ccelsay &;t--g cenasredi APcM ;&tg-- edncerias +aN nda lC- fxfleu -;gt-& iraaerdh.

teepot123  fa 19 pg 146 +  
lovebug  Cholerae's exotoxin does not invade mucosa. but just permanently activates Gs according to FA. +  
lovebug  Same mechanism[Increase cAMP] : 1) Labile toxin of ETEC, 2) Edema factor of B. anthracis, 3) Pertussis toxin of B. pertusssis +1  


In addition to the more obvious hint of budding organism, candida has fuzzy edges on blood agar which the others don't.

usmlehulk  @paperbackwriter cryptococcus have a narrow budding. +  
lovebug  wow I Didn't know that. THX~! +  


submitted by hayayah(1056),
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:Note heT adbsuenc .n is lautlayc eht neevr tsom ielylk to be agedadm by an indeapgxn lanienrt ocritda uesrnaym ni het socaenuvr sisnu ubt yteh evig ouy ificscpe 3CN cotfunni in hsti tseq.niou

hungrybox  One pupil larger than the other indicates damage to the pupillary light reflex - afferent: CN II, efferent: CN III. +19  
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. +  


submitted by sbryant6(152),
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oT brmmeere cfBlanoe si a AGAB angstioa adn melscu xlare,atn I laayws ikhnt of Gk"ere laaavkB." rGkee ofr B,GAA nda Bavaalk rfo eflcaonB.

castlblack  Thanks. Baklava is from Armenia though. Go us +1  
athenathefirst  No it's actually Arabic/Turkish. That's why it's called Baklawa. +2  
lovebug  I don't know if this is right. UMN Lesion (In this case, MS) -> Increased DTR, increased muscle spasicity, and dystonia. If Baclofen stimulate GABA B receptor(it's Gi related PTN) -> neuron become hyperpolar -> decreased excitory glutamte -> muscle relax. +  


Key Point: Bilirubin can only be in the urine if it is: (1) conjugated BR, or (2) urobilinogen.

Unconjugated BR is NOT water soluble and therefore CANNOT be in urine. This is why you use phototherapy in Crigler-Najjar. Increased unconjugated BR --> phototherapy isomerizes it so it becomes water soluble.

lovebug  clear and short. good! THX +  
lovebug  as @Basic_pathology said, In Crigler-Najjar synd. Photo TX does not conjugate UCB, but does increase Polarity and Water solubility to allow excreation (FA 2019, 388PG) +  


Key Point: Bilirubin can only be in the urine if it is: (1) conjugated BR, or (2) urobilinogen.

Unconjugated BR is NOT water soluble and therefore CANNOT be in urine. This is why you use phototherapy in Crigler-Najjar. Increased unconjugated BR --> phototherapy isomerizes it so it becomes water soluble.

lovebug  clear and short. good! THX +  
lovebug  as @Basic_pathology said, In Crigler-Najjar synd. Photo TX does not conjugate UCB, but does increase Polarity and Water solubility to allow excreation (FA 2019, 388PG) +  


submitted by tissue creep(104),
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rhoodtrAp orf ue,rs tbu for eht droerc Im' petyrt rsue tihs wsa ugkunyniahC iVs.ru Olny otg siht from a dorWUl noesqitu as I hd'nat sene it ulnti enth, ubt nlaeparpyt het rgraiahlta si yerlal a,db iwchh si hwat wrde em to het sr.awen

doutc.ha.why/smlpng:kwxgnwt/d/./vncuechtii

meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +1  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +20  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  


submitted by tissue creep(104),
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toohpdrrA rof ,urse btu orf hte orecrd Im' tptrye ures iths wsa ygnaiukChun rsV.ui ylOn gto sith morf a loWrUd ntqesuoi sa I 'nadht seen ti lnuti hn,te tbu patnerylap the gararathli si areyll ab,d chhwi si wtah wdre me ot het aw.nser

cww/ne:.ytw.put/lcmtncads/.hx/dghvogikhuni

meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +1  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +20  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  


submitted by pg32(140),

NBME/Uworld love to test renal artery stenosis in the setting of hypertensive urgency/emergency. Just because this has been done so many times, you can basically get the right answer from the first half of the question. Pt with end organ issues (headache, confusion) and really high BP (I know it isn't 180/120, but it is really high). So this guy basically has hypertensive emergency. I'm already thinking it's renal artery stenosis. Next sentence? A bruit over the left abdomen. Bingo. Renal artery stenosis, most often caused by atherosclerosis in older men (as compared to fibromuscular dysplasia in younger women).

lovebug  He is heavy smoker but, No weight loss, No cachexia -> so can be R/O Left renal cell carcinoma. is it right? +  
lovebug  Renovascular ds. FA2019, pg 592. +  
misrao  and no hematuria so r/o RCC +  


submitted by pg32(140),

NBME/Uworld love to test renal artery stenosis in the setting of hypertensive urgency/emergency. Just because this has been done so many times, you can basically get the right answer from the first half of the question. Pt with end organ issues (headache, confusion) and really high BP (I know it isn't 180/120, but it is really high). So this guy basically has hypertensive emergency. I'm already thinking it's renal artery stenosis. Next sentence? A bruit over the left abdomen. Bingo. Renal artery stenosis, most often caused by atherosclerosis in older men (as compared to fibromuscular dysplasia in younger women).

lovebug  He is heavy smoker but, No weight loss, No cachexia -> so can be R/O Left renal cell carcinoma. is it right? +  
lovebug  Renovascular ds. FA2019, pg 592. +  
misrao  and no hematuria so r/o RCC +  


submitted by medpsychosis(110),
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isTh tetpnia lfnedyeiit sha suCcoS.edl sroaisi ni esiountq ei s-ctfrn:Aam Aarmnice lmreeetEy ama-hF oomraauli N-Bstdle lHair ihpped-oyHtaerAlnemcaya c ue(d to hia-torxdaelsα–yded1mye imvnati D intcvaaoit ni sopgaec).rmah

FA 2108 (P. 86)5

icedcoffeeislyfe  FA2020 pg 676 +  
lovebug  and FA2019 pg 662: Vit.D usually activated in Kidney. but They can be also activated by Macrphage like this case. +  


submitted by drdoom(806),
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tSme tuylacla atsest, “On tiqu,ignnseo het atinpte edso nto nkwo eht deta imt]e[, het eman of teh istpaohl lcae]p[, ro the name of erh sneru how adh usjt idetcnourd shmelfi pos[r]ne”. o,S pt is triodiendse to itme adn paelc cCiho(e )A; ahtt si lefdyiiten ceonrnincg -- as dlwou be erdesepds odom (ociCeh E) nad the reoth eccoshi -- btu yi“ianbilt to anuentsdrd vyeetsir dan oigpsnsro” is eth smot ncnorinecg ceisn htat si the evyr fietdoinni of ipc.cyaat bytainilI to nrtunedsda = clak of cptc.yaai

lovebug  you explain very clearly. THX!!! +  
drdoom  thanks lovebug! +  


submitted by dr.xx(142),
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herideyatr siohmr.tcmohsaeo

FEH is tmuedta &=t;g het tsnensiiet ltlapeueypr inrrepett a grntos refntnirsar lisnga as fi hte doby erwe eenfiidtc in rn.oi sTih esdal ot lxamima rion sbnoipotra fmro tgsindee ofdso nda nori erooldav in het esstusi.

aPrc.samhphahilhyrdoHsoirkemtniiow/eiooaoeewio/yi:yatFrt/_ghek_pg.hdtsts/iEp#

lovebug  Autosomal recessive. C282Y mutation > H63D mutation on HFE gene, located on chromosome 6;associated with HLA-A3 [FA2019, PG.389] +  


submitted by celeste(78),
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The sclntoietanol of mospsymt snodsu ilke seotrbuu erc.lsioss acCrida dabormymoah si a rear ngineb tomru ahtt si eyntflquer ssodaaeitc hwit esuutbor sscils.ero

tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +15  
tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +2  
arlenieeweenie  He also has seizures and pink-yellow papules, which I think they're trying to describe one of the characteristic ash-leaf or shagreen patches (doesn't sound like either of them to me lol) but that all points to tuberous sclerosis +  
pg32  @arlenieeweenie I think they are actually trying to describe angiofibromas that appear on the face in tuberous sclerosis, though I still think their description is pretty bad haha +5  
lovebug  Tuberous sclerosis. mnemonic : HAMAR(->Rhabdomyoma)TOMASS. FA19 page.513 +  
naarim15  the pink/yellow papules are adenoma sebaceum - "reddish nodules in a butterfly appearance areound the nose and cheeks, acne-like appearance" https://next.amboss.com/us/article/Rk0lnT#Z018f418df303f0090d6f81837408e107 +  


submitted by stefanmil(2),

Why we have deposits in the glomerular membrane. It supposed to be subepithelial - spike and dome - granulations, right?

lovebug  @stefanmil Yap. you're right. I think "Spike and dome" @ EM. and Diffuse capillary and GBM thickening in @ LM. +  


submitted by lilmonkey(18),
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m-tCxehoo nam uetpric rfom teh AF t(sla paeg fo hte hme dna ocno sntieco) owskr llwe ofr me ni etseh sytpe of neioqsst.u

lovebug  Bleomycin Induces free radical formation -> breaks in DNA strands.(Anti-tumor effect) FA19, pg431. and other tissues have Bleomycin Hydrolase. but Lung doesn't. So lead to Pulmonary fibrosis. +  


submitted by mcl(579),
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Nnciai ivm(ntai B3) osgatannezi DLLV rchetlooesl onsritcee

sbryant6  Fibrates stimulate PPAR-alpha --> LPL upregulation --> decreased triglycerides. However, this question asked about a vitamin. Vitamin B3=niacin. +4  
lovebug  FA 19, PG 315. Lipid lowering drug bro. +  


submitted by jejunumjedi(29),
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I ktihn itsh is cgriedinsb a alsgni depipet rh(dychoibop ta e)st-nmiuNr. thuoiWt ainsgl petidep &t=g; c’nta be drpsatrenot tnoi eopsamclidn euurtlcmi.

youssefa  Is this even in FA? Biochem chapter only mentions SRPs. +1  
lovebug  @youssefa FA19, pg 47.[cell trafficking] but not details... +1  


submitted by assoplasty(92),
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I thnik het octepnc y’heert egtsitn si teh icrenades TGB lleevs in gep,rnaycn dna ton tujs dhpiertsymohryi ni nle.gera

nheW cnresiegn orf diormyreh,/oisphhpyty HST lesevl ear AYWLSA rfreeaenypiltl hcekecd ecaeusb ethy are moer nesvieist to timune nedfieerfsc in .TT3/4 tOfne tmesi HTS lesvle nca tarmodesent a eachgn nvee wnhe 4/3TT vsleel ear in teh caiullsinbc gren.a hTe nlyo cixopente ot tsih luodw be ni nrcynepga da(n I segus emaby veril fleaiu?r I butod yteh dlwuo sak htis tgh)oh.u higH gsentreo lleves npsevrte the leirv rfom gkrieanb nodw GB,T lengida to rnsedcaei TBG vlseel ni the usr.em hTsi nbids ot free T4, dgcasneeir the ntamuo of evailabla eref T.4 As a osetcpmyaron mnei,msahc SHT esvlle rae lnitneyrsat cnaideser and het TEAR fo 4T dtoirpunoc si deinaescr ot rhlpsneie esaibnel efre 4T lee.vsl oeHvewr the LATOT motnua of T4 si icdn.eraes

heT qonsieut is snigka woh to rcniomf etysdyrpihirmho ni a ptnargne wnaom -g&;-t uoy eedn ot eckhc FREE T4 elesvl ueasbce( tehy sdlhou be onrmla deu ot certmsayopon se.)esonpr uYo natnoc hkecc HST yl(ualsu eedevlta in nrneacpgy ot epceamostn rof aeeindscr TB,)G dna ouy aotcnn ecckh atolt 4T veells ill(w be ra)indseec. Yuo tgo hte swnear hgrti hieetr way ubt I htnik this si a efftednri eaingsorn hotwr ninricosdge, eeusabc htey acn aks hist eptnocc ni otrhe xotnetcs fo ,tmen-reoshiersygp nad fi htey isletd HST“” sa an awners ociech thta wdluo eb rinetcrc.o

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +7  
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 cantaloupe5(72),
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supCalra aeahpcilydrcso scvnecia are ofnte uctgadejon to ornpiets to miporve teygniou.cnimmi gnlaileFl si teh nloy searnw oeihcc tta'hs a nropt.ei

mambaforstep  both MHC 1 and 2 are present antigens that are PROTEINS (FA 2019 pg 100). so in order to elicit a T cell response, you need a protein (CANT BE A POLYSACC). that is why vaccines for polysaccaride antigens are often conjugated to PROTEINs--> so that we can elicit a T-cell response (FA 2019 pg 127). +5  
lovebug  Flagellum = Protein, (FA19, pg.124) +  


submitted by haliburton(208),
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FE2 si tosnaaltlirna aigenloot tarcof ,2 chhiw is rsnseeayc fro ornipte ssehny.ist

sympathetikey  I. Am. So. DUMB. +24  
nala_ula  same :( +2  
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +  


submitted by usmleuser007(370),
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fllaI seel ialfs: tnoe atth teohr nrawse oesichc era OPCD sypet

dragon3  (except sarcoidosis) +2  
leaf_house  I got hung up on why this couldn't be sarcoid, and I think no lymphadenopathy is one of the reasons you wouldn't pick it here. (Though it seems like it can cause alveolar septal thickening: https://pubs.rsna.org/doi/full/10.1148/rg.306105512) +  
lovebug  Restrictive VS Obstructive ! very good point! THX! +  
schep  if it were sarcoid, wouldn't the biopsy show noncaseating granulomas? +1  


submitted by hyperfukus(75),
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olsA ehatonr yke is ti asys normla npgearpai gilr neo of eht gtnsih ubtoa eth SIA is htat teyh od get nyesdocar eaxlsu ruarce.ei.ccstathntrri.s rsigl od'tn oklo nlroam yet'hd be rtsoh nad uybstb on obobs aft eckn etc

covid2019  I'm confused that they said she appeared "normal". I thought AIS would mean the patient has very scant pubic hair / underarm hair. Wouldn't this be abnormal in a 17 year old? Should have Tanner stage 5 hair.... +  
mumenrider4ever  FA2020 (pg. 639) describes AIS as "Defect in androgen receptor resulting in normal-appearing female (46,XY DSD)" so I assume they're talking about general outwards appearance +1  
lola915  You do get breasts because patient has build up of testosterone that is aromatized into estrogen. No axillary or pubic hair because that requires testosterone. +  
lovebug  THX. SEE AIS (FA19 pg,625) +  


submitted by hyoscyamine(55),
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FA 3..g7p2 omSauuqs lcel rmacaconi uocrcs ni the peupr /23 of ussphogea eerwsah rdmonacnoaceai ucorsc in teh slaitd /.31 encSi tihs wsa in het dim ,posaguhes its usaoqmsu elcl ramaonicc. yKe eefuart fo omussaqu ecll nmccoaiar is aniertk selar.p

turtlepenlight  can remember it as wearing a pearl necklace (upper 2/3 of throat-ish) +4  
baja_blast  Patient is also a heavy smoker and drinker. In the absence of GERD this should raise suspicion for SCC of esophagus over Adenocarcinoma. +1  
lovebug  Is there anyone who can explain about C)Intra-cytoplasmic pigment? what is this?;; +  
misrao  @lovebug I'm thinking Negri bodies in rabies +  


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gamr ,+ B ,yltcmehio ltmnguib tytl,oiim form ktorec iltas omfr taicn lmaiiynrozotpe iwhch wlaol ofr emvo,ntme l,ircaetarllun orsgw ni dcol smpte on mi,kl stfo ,sceeehs iec mre,ca nlchu e.tam

eeacrsind ecdinienc in natgnrpe nemwo elaleypsic in dr3 mtreitesr

lovebug  Santa's list! in sketchy. Pregnant women are more likely to get listeria than anyone else. May lead to termination or disease in the newborn (from sketchy.) See FA19, PG139. +  


submitted by niboonsh(336),
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WMIS

epsha one - si it S?efa

eahps 2 - osed ti Wk?ro

ahpes 3 - yan Irmemnpevo?ts

hsepa 4 - ysat no teh Mrtkae?

lovebug  Does the drug "SWIM" ? :) FA19, pg256 +  


submitted by divya(58),
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reCtuyrnl hzlriAeme's eiadses etetamntr nusidelc -

dce1)hnanE hAc mtnassiisrno (eiDlzpone, isvegnim,tiRa nimnlataGae

2) oNeretuoportinc via tisaxntinaod iitnmV(a )E

3) DMAN ertorcpe ntoaigsnma nMatemi(en)

lovebug  19FA, 536pg +  


submitted by pparalpha(83),
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adeL ctiTxoiy :

esa:suC rupndoiist of meeh enyishtss aiv nibnihitoi of AAL itlunoavelnmae(i tryahs)daeed

:sdFgiinn

A: Aanime

B: Bpichiosla gpnisptli

C: lCico

D: hariaDre

E: clhEpaptyehano

F: toFo prod

G: mGu e/rthowidsgptso rn/iatogetdurtoa

H: NHT nad eyrmhaeucprei

hOter aersswn:

cnZi incfdeiyce:

aCss:ue low ,enkita Cr'onsh aidsese

dnsin:Fgi mueinm dtonfscyn,iu pdeiamir dnuow naeilgh (rfo eht erdoelgnim apshe fo duonw al,einhg nizc si eddene yb oastlermptoslaenie ot raekb dwno tepy III egoa)ln,lc mya,opngsohid irerah,da aimtdts,rei oep,lcaia branloam tetsa and sleml

eEscxs is .er.ar. btu nac dlae ot n/dv/ dna idamaobln pnia

sinmMuaeg diecfneyci:

a:uessC c,nteoailgn po,lrayiu turlma,nitino ielvxata euasb

Fdgi:snni e,yantt earruetpm turclaerivn r,iconcaontt acnreised TQ tianrelv

2B1 cecndeifiy:

saCes:u vagne ,iedt picsuoenri aieman, eicnratcpa su,isse saticgr syapsb ye,rgurs lpitbraasnmoo h(,onrC e,prs)u yDlluoiiohbmprht taeutprloamm/wc neintfcio

is:dnFing a,icmryctco eslbalmgctiao mne,aai unero tmmso,ysp idcesraen imoteoesncyh and MAM lleves ni uesrm

rcdseenaI amtVnii D:

ss:Cuea ltrnsmooguaua aseeisd osidcrsao)s(i

gdns:iFin beno resn,pooirt too much ,lmaucic osls fo e,pettipa rtspuo

lovebug  2019 FA, pg 411. +  
lovebug  Nephrotoxicity results from lead exposure because the kidney is the main route by which lead is eliminated. Lead is absorbed by the proximal tubular cells of the renal tubules, where it binds to specific lead-binding proteins. +  


submitted by pparalpha(83),
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aeLd iocxtyiT :

:Csuase trisdiuopn fo ehme hsityssne iav ihnioiibnt of ALA lonatam(ulinveie )drtyhesaeda

sgnndiFi:

A: eaminA

B: polisaihBc sgtplipin

C: Colic

D: aerrahiD

E: napEyhhtleacpo

F: toFo dorp

G: Gmu wetditgshp/osro at/titreuargdoon

H: NHT nda ypurarciemeeh

retOh easswrn:

Zcni eeyfndccii:

s:asCeu lwo ,einakt sorn'hC aseseid

diFnngs:i ieummn nfnoyds,icut eipaidmr uonwd nailgeh orf( teh drlngemeio phsea of wnoud elh,niag nciz is eeddne by menttaoeasolsrelpi ot earbk wndo ypet III ngaol,)ecl oyi,samodhngp h,aeidarr atmed,rsiti acei,opla onmaablr aetst adn lmlse

sexcEs is rr...ae utb nca alde ot dvn// and noiadablm npai

genmuaiMs ycnedicfie:

sC:usae entog,aclni p,rouiyla noriunl,matti vlxteaai abesu

s:nigindF eyna,tt ramutpere reclnruviat oiar,ctncton esceirnad TQ nirtevla

B21 ncdifiecey:

Csu:aes navge di,te picursneoi eana,im tcrapneiac ,ssieus csgtiar paysbs rs,gryue rbmaanptisloo (nohr,C uep)r,s uypDohoirlbmitlh aa/rlcmwutemopt neifnocti

iigs:dFnn ,rctycimaco aeagiocbtlsml aiamne, ruone mtmy,poss neadecsri ysctnmeeoohi nda MAM esvlel in ruesm

eaerdIcns itinaVm D:

saeCs:u rgsmnuluoatoa deesasi aorisis)dsco(

igisdnFn: enbo rt,oenisrop too much lmc,acui osls of pet,tiaep trupos

lovebug  2019 FA, pg 411. +  
lovebug  Nephrotoxicity results from lead exposure because the kidney is the main route by which lead is eliminated. Lead is absorbed by the proximal tubular cells of the renal tubules, where it binds to specific lead-binding proteins. +  


submitted by peridot(57),

Here is my summary of the picture/video that was posted:

There are 3 pathways involved in peeing:

  1. Pelvic n. (aka pelvic splanchnic n.) sends parasympathetic fibers to deltrusor to contract --> squeeze bladder and pee.

  2. Hypogastric n. sends sympathetic fibers to the deltrusor to relax, as well as the internal sphincter to contract --> hold back pee

  3. Pudendal n. sends somatic fibers (under conscious control) to the external sphincter to contract --> hold back pee

In this question, the patient's bladder is filling up so much that it's forced to overflow. That means there is a problem with scenario 1 - damage to pelvic n. so that he can't squeeze his bladder even when it's super full.

peridot  To clarify, this description is meant to go along with @hungrybox's pic link and @eacv's video link +4  
lovebug  thanks a lot! +  


submitted by alexb(45),
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Hycpoxi uyoprnlma nscsnioicraotovt VHP)(, sola konnw as teh edljLatnleEu-srri ,himcseman si a olshioyacgilp nhnmenpooe ni cihhw small rpoynmlua reatesri ritontscc in hte sperecen of raolvela ohaypix l(wo gneyxo .eelvsl)

ileWh teh nnctaieaemn fo npoue/ilirnvnitaostef toari gurnid ilrogane inusbcotrto of lrioafw is fec,bnaiile PHV nac be merditntale rigudn galblo eravallo paxoihy hcwhi rucsoc htiw ueerxspo ot hgih i,dlteatu heewr PHV casseu a ftisicingna ecreiasn ni tatlo oraynlump uslvraca scstn,rieae nda onmalyrpu iearrtla ,rruspese lyltotnaepi ignelad ot uryoalmpn eynihepotsnr dan roaplynum meaed.

ttyn/k/e.ktrr_p_u:.pinp/islxocgcsiHoadimoyroiwvnwoicaenospat/hii

lovebug  2019 FA, Pg 665. PAH +  


submitted by mcl(579),
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PSCO is seacioadst itwh ornbamla itoourndpc fo exs srsoetdi, nginilucd scoutfdnniy of orenetsg tpoidornuc nad rgetseo.nrpeo nylrChoacil dteevela lsvele fo seengort nac saecu deeratolimn a.isapelrphy

na5wsi9i.tm/:owcp..g9PcwMpCe7/c/n1vni/l3th/trh.9bsm/l

meningitis  Why isnt it endometriosis? Could someone help me out on this? +1  
meningitis  Sorry, I was confusing with higher risk for endometrial carcinoma. +  
vi_capsule  Estrogen is responsible for cyclical bleeding and pain associated with endometriosis hence progestin is a treatment modality. But estrogen isnt a risk factor for Endometriosis. Rather theres retrograde flow, metaplatic transformation etc theories are responsible for endometriosis. +  
sympathetikey  Tfw you get so thrown off by a picture that you don't read the question properly. +25  
hyperfukus  @meningitis idk if u still care lol but always go back to endometriosis=ectopic endometrial tissue outside of the uterus so you can rule it out since increased estrogen would cause you to have worsened endometriosis or a thicker one but not directly...you can see the clumps of the follicles in the ovaries if you look super close so that along with the presentation takes you to PCOS and anytime you don't have a baby or stay in the proliferative phase(estrogen phase) you get endometrial proliferation-->hyperplasia--->ultimately carcinoma +1  
lovebug  FA 2019, page 631 +  
lovebug  Other answer H)Meigs syndrome : triad of 1) ovarian fibroma, 2) ascites, 3) pleural effusion. “Pulling” sensation in groin. FA 2019, pg 632 +  


submitted by mcl(579),
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CSOP is ctidssoaea htiw nmbalrao udrtcoopin of xes soistred, gdlinnuci tsyionunfdc fo tnoregse trcodouipn nad peeseorno.tgr ohCalciryln eetadvel veslel of otsernge can uscae tindmaoeler aehapsry.ipl

a9miw//P/wCin5nce/1r.Mm/:.is7tsc9.tphg/.pc9nl3vwltohb

meningitis  Why isnt it endometriosis? Could someone help me out on this? +1  
meningitis  Sorry, I was confusing with higher risk for endometrial carcinoma. +  
vi_capsule  Estrogen is responsible for cyclical bleeding and pain associated with endometriosis hence progestin is a treatment modality. But estrogen isnt a risk factor for Endometriosis. Rather theres retrograde flow, metaplatic transformation etc theories are responsible for endometriosis. +  
sympathetikey  Tfw you get so thrown off by a picture that you don't read the question properly. +25  
hyperfukus  @meningitis idk if u still care lol but always go back to endometriosis=ectopic endometrial tissue outside of the uterus so you can rule it out since increased estrogen would cause you to have worsened endometriosis or a thicker one but not directly...you can see the clumps of the follicles in the ovaries if you look super close so that along with the presentation takes you to PCOS and anytime you don't have a baby or stay in the proliferative phase(estrogen phase) you get endometrial proliferation-->hyperplasia--->ultimately carcinoma +1  
lovebug  FA 2019, page 631 +  
lovebug  Other answer H)Meigs syndrome : triad of 1) ovarian fibroma, 2) ascites, 3) pleural effusion. “Pulling” sensation in groin. FA 2019, pg 632 +  


submitted by madojo(160),

Know your STD's baby ;-) (going through every other choice on this question):

  • Bacterial vaginosis caused by gardnerella vaginallis. Se a thin, off white discharge and fishy smell (fish in the garden). There's no inflammation Lab findings: pH greater than 4.5 (just like trichomoniasis), and a positive whiff test with KOH. Stem will say something about malodorous discharge and show the infamous CLUE CELLS if we are lucky. Not the answer for this question obviously because we would not expect vesicles with this bacterial disease.

  • Candidiasis is going to be your thick cottage cheese discharge, with inflammation. normal pH see pseudohyphae. Treat with topical nystatin, or oral fluconazole unless you're pregnant than use Clotrimazole. Again not going to see any vesicles.

  • Chancroid per uworld is associated with Haemophilus ducreyi you will have a Deep purulent painful ulcer with suppurative lymphadenitis. Will be told that patient has painful inguinal nodes, there may be multiple deep ulcers with gray-yellow exudate. You do cry with H. duCRYi This wouldn't be true for what our patient has in this question because we aren't told of any inguinal adenopathy. a link to a chancroid VDA

  • Chlamydia trachomatis causes lymphogranuloma venereum which is small shallow ulcers, painless, but then the large painful coalesced inguinal lymph nodes aka BUBOES. Compared with gonnorhea the discharge is more thinner and watery. Again not the case here as its painful and no mention of any BUBOOESS. The discharge in gonorrhea is more thicker. Both lead to PID, treat for both because confection is common. With both patient may have some sort of pain or burning sensation upon urination. Sterile pyuria though for both.

  • Condyloma accuminatum is a manifestation of HPV 6 + 11 (genital warts). They look like big cauliflowers. This is in contrast to Condyloma lata that you see in syphillis which is just a flatter latte brown looking macule.

  • Genital Herpes (the answer to the question) will present with multiple painful superficial vesicles or ulcerations with constitutional symptoms (fever, malaise) Just fits better than all the other choices I ran through.

  • Syphillis is the painless chancre. UW describes it as a single, indurated well circumscribed ulcer, with a clean base. See corkscrew organisms on DF microscopy. Keep in mind other painless ulcers are lymphogranuloma venereum of clamydia (but the buboes are whats painful not the ulcer), and granuloma inguinale (donovanosis - klebsiella granulomatis) but whats hallmark about this one is that its painless without lymphadenopathy

In short, be safe.

drdoom  this write-up is AWESOME ... but it also made me vomit. +  
b1ackcoffee  This is awesome, writeup, not the stds. +  
lovebug  FA 2019 pg 184. I summed up @madojo's comment! this patient have "multiple, tender vesicles and ulcer". and scant vaginal discharge. A) Bacterial vaginosis -> NO vesicle -> r/o B) Candidiasis -> NO vesicle -> r/o C) Chancroid -> should have Inguinal Adenopathy -> r/o D) C. trachomatis -> have Large painful inguinal LN -> r/o E) Condyloma acuminata -> Big Cauliflower -> r/o F) Gental herpes -> YES!!! G) Gonorrhea -> NO Vesicle, creamy prulent discharge -> r/o H) C. trachomatis again (same as D) -> r/o I) Syphilis -> painless chancre -> r/o J) Trichomoniasis -> strawberry cervix, motile in wet prep -> r/o thanks @madojo! +  


submitted by h0odtime(46),
  • Gastrin released by G Cells pyloric antrum, duodenum, stomach stimulates parietal cells to secrete HCl.
  • Parietal Cells (Fundus + Cardia) epithelial cells that secrete HCl and intrinsic factor. They activate gastric chief cells to secrete digestive enzymes.
  • Gastric Chief Cells (Mucosa): releases pepsinogen and chymosin

Labels

  • A Mucous Neck Cell
  • B Nucleus of Parietal Cell
  • C Nucleus of Chief Cell
  • D Nucleus of Endothelial Cell
  • E Nucleus of Fibroblast

Credit to Histo_Man/reddit

lovebug  THX for kindful Lables! +1  


submitted by nor16(57),
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doohanGptros ear the LFHS/H roidgupcn yiuptiatr sl.cle N o oav,rise on mh,oroens no kdeceafb i.intobihni

lovebug  THX for great explanation. When I first saw this question, I mistook the gonadotrophs for endometrial cell. so I Choose atrophy. (even that pt undergoes a total hysterectomy) critical mistake... +3  


There was a uworld Q on this. The duration of action of Succinylcholine is determined by its metabolism by plasma cholinesterase. Some people are homozygous for an abnormal plasma cholinesterase, aka "pseudocholinesterase" or "butyrylcholinesterase" (BCHE). People with a homozygous BCHE mutation have delayed metabolism of succinylcholine, mivacurium, heroin, and cocaine.

In these patients, paralysis from succinylcholine can last for hours and you have to maintain them on mechanical ventilation until they can breath on their own

lovebug  2019FA 538pg. +  


submitted by usmle11a(73),
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ko i hinkt i hvea a eotyhr in serdagr ofr :tsih

the ehlwo edruoepcr si oden ot eeaecsdr eth tlopar NTH. chwih nmeas the snhut dosulh be atolrp to yitscesm ainovidg the iel.vr

a) htiacpe (est)iscym ot inf pcherin ( issytmec ) ; n)B o ccoiilelo ot(parl ) ot nfi eicsentmr )rolap(t ; cno) inlcpes roatl()p letf enrla cyms(;tsie) ) dyes sroiepru paesrticgi iectssmy() to feiniorr pescratigi cists)(eym ; eoN) psroruei eactrl )ap(olrt to oprierus rnsitemec ( rotpla) ; NO

whossayin  You’re a legend. Good theory man, makes memorization a whole lotta easier! +  
lovebug  2019FA, 359pg. +  


submitted by imgdoc(132),
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The lanclici toeaitrpesnn si hatt of leorw laindbamo ap,in f,rvee dna hl.silc Tsih lnoae deam me knthi ti swa an yanltmmraoif rssopc.e loAs eth neusiqto yass hteer era 3 easaretp rlyoop itmeddiel rienogs of oarwnr .umeln As raf as ecteuravil sotclii si cn,enercod treeh era no pkis n,slesoi it si icnusnoout heerrwve ti si. iThs ucedopl twhi eht hysoitr of ttosaoinpcni saemk clriivititudse eht best rewasn .eoccih

lovebug  I know it's silly Q. but why not C) Granulomatous colitis? lol. thank you! +1  


submitted by hayayah(1056),
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hiTs tp hsa alamaieoocts / tirscke (senci he's a .)ddiok usaCde yb deifetcev ntaleaomzriini fo eoidtos loeata(soacmi) ro ciatigoulrans ohtgrw lestpa ektr(s,ic loyn ni enlcr).idh

sMto cmomyoln dt/ imainVt D yeceidncf.i

enhCdril whit skritec hvae htgolocpai obw elgs g(nue vum,ra) da-bleeik dlooctsnrcaho jionstcun tcricai(h r),osayr eiontascabr ot(sf k.)llsu

  • .cDe tamniVi D rao(lnm otninfuc si to osebbrra 2+aC dna PO)4

  • e.cD usrem +2aC

  • cDe.  usrme OP4

  • In.c TPH

lovebug  FA2019 455pg !!! +  


submitted by hyoscyamine(55),
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Thsi is alatlre rl/rWCAePlnbamIedyeg/lula menso.rdy The mwnao hsa geadam ni eth epmsayhittc nhica srnso(ye syomndres are relaalt rcgodacin ot the reul fo )s4 grsletinu in nroHer oeym,rnsd cnomitlshpiaa tctar /nipmea(tp hihwc rae aols s),nseoyr and NC IX and NC X nctofydsinu uesginrlt ni het aa/dayrhhpsirtaidgsy (plhse us ezaliloc ot teh .dlmlu)ae

nala_ula  Also, just to add, FA specifies that Nucleus ambiguus effects (dysphagia, hoarseness, decreased gag reflex) are specific to PICA lesions. +2  
cienfuegos  Thanks for the input. I have always found this topic to be tricky and just came across this article that helped me out a ton regarding the rule of 4's hoscyamine mentions above. https://rdcu.be/bLjOB +7  
lovebug  FA 2019 502pg! +  
pfebo  "Don't PICA horse (hoarseness) that can't eat (dysphagia)" +  


submitted by d_holles(171),
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seHre' na necellext eimga morf BSASMO if oepepl are ngviha fdluicfity iuglaizivsn :shti Rro.pWmtcmimm/Qah/tuh:sg//V

lovebug  very helpful! thanks! +  


submitted by hungrybox(968),

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 :) +  


submitted by hayayah(1056),
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esoaaipNl si nwe seiuts twhrgo ttha si tenuuegald,r lesir,breevri dna nloc.omlano

liaCoynlt acn be meteireddn by coshs6h-tpup-aoleeg dngyroeshaede GP)6(D ezemyn s.rsmoiof G6PD is Xnile-dk.

*Fro meor ntmoanfiior chekc uto h.C 3 eaaNpolis ni Phoamat

hello  This is great, thank you. +4  
breis  Pathoma ch. 3 pg 23 "Basic Principles" +7  
charcot_bouchard  Shoutout to Imam Satter! Without him this question wasnt possible for me to answer in 10 sec. +13  
fatboyslim  Clonality can also be determined by androgen receptor isoforms, which is also present on the X chromosome (Pathoma Ch. 3 Neoplasia) +1  
lovebug  @fatboyslim thanks for reminding! +  


submitted by thecatguy(16),

This is a very nitpicky question. As I see it, the 3 main concepts tested are:

  • This patient has trigeminal neuralgia (sharp, brief, episodic pain in the face), which is caused by a lesion to primary sensory fibers that carry pain sensation from the face.
  • Multiple sclerosis, which the patient has, is a demyelinating disease (i.e., it affects white matter).
  • The myelinated axons carrying pain sensation from the ipsilateral face enter the brainstem at the level of the pons and then descend (become the spinal tract of the trigeminal). These white matter fibers pass through the pons to synapse on the spinal nucleus of the trigeminal, which is in the medulla (nucleus = gray matter). (picture here). Therefore, a lesion in the white matter (i.e., plaque) in the pons could cause trigeminal neuralgia, and this phenomenon has been observed.

Above the level of the brainstem (thalamus & cerebral cortex), you have second order sensory neurons. Lesions in this part of the circuit are not generally in trigeminal neuralgia. I suppose they also want us to assume that once the spinal tract of the trigeminal enters the medulla, it's not myelinated anymore. I don't think this is completely true, but given the logic described above, pons would still be the better answer.

As people have pointed out, the primary sensory fibers carrying light touch sensation from the face synapse on the chief sensory nucleus in the pons immediately after they enter the pons. This question is not asking about those fibers though.

I got the question wrong too..

mightymito  Wow this is the best explanation yet! Thanks so much for very clearly walking us through a tricky question. +3  
lovebug  @thecatguy Are.... you a professor? thank you very much :) +  


submitted by whossayin(20),
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heT inecmomn I lkie for megbenmerir teh sonoltcia of eth clarain resvne si the ,422"4,, e"rul

bAove bmr=etains NC I + bniIdM=raIi NC II,I =IPns oV NC ,V ,VI IIV, lIuIadeIV =lM NC XI, ,X X,I XII

lovebug  @whossayin thanx so much!!! +  


submitted by bbr(22),

damn, the spleen was so big I thought we were looking at the 2 kidneys. Found a new way to get things wrong.

lovebug  @bbr me too. lol +2  


submitted by kentuckyfan(43),
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Siecn teh pian si rcdir,aula a cdsi atnnieihor is tmso llk.eiy

charcot_bouchard  Why it cant be a lumbar vertebra fracture +  
whoissaad  @charcot The patient is young and doesn't have any risk factors for weak bones. Also, disc herniation is a common problem in the young. The disc gets fibrosed and stiff in the elderly so they have less chance for disc herniation. So basically age was the key to answering this question. +3  
lovebug  you are genius! thank you! :) +  


submitted by hayayah(1056),
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cDfvieete omuslohogo oomraincteibn is nees ni riaavnratboe/s enscacr twhi eth BC1RA gene nottiaum.

johnthurtjr  Ashkenazi Jews have a higher risk of inheriting the BRCA1 and BRCA 2 gene mutations, just another tip! +2  
lebron james  BRCA1/BRACA2 are involved in the repair of DNA double stranded breaks +6  
samsam3711  Other answers: DNA Mismatch Repair: Lynch Syndrome (MLH1, MSH2) DNA Nucleotide Excision Repair: Xeroderma Pigmentosa +14  
lovebug  not about this question but... Defective "Non"-homologous end joining is seen in Ataxia-telangiectasia. :) +1  


submitted by neonem(550),
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therMaeoextt owdlu be a rgud fo cohcie fro sarsoisip ayfortrrce ot iolatpc aesrmc dna ligth rht;epay ibisnthi oltodadrfyieh edtcusare ni erord ot dsereeac ksin lcel itrlpeafnroio nad recude aymmlrfoiant sen.roesp

69_nbme_420  Cyclosporine can also be used to treat Psoriasis (NOT cyclophosphamide - ans B) +7  
len49  Drugs that can be used for psoriasis include cyclosporine, MTX, TNF-alpha inhibitors including Etanercept, lnfliximab, adalimumab, certolizumab, golimumab according to FA +2  
medstudent  Kinda summed up in the index - p 791 2nd row halfway down +2  
lovebug  as We all know, 1st line therapy of psoriasis is topical corticosteroid, Vit.D analog (Vit.D inhibits keratinocyte proliferation and stimulates keratinocyte differentiation. +