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Contributor score: 240


Comments ...

 +3  (nbme24#21)

This is a case of lingual thyroid, a persistence of thyroid tissue at the base of the tongue due to failure of migration.


 +0  (nbme23#7)

Helpful image to understand that its isomerization:

https://www.viapath.co.uk/sites/default/files/upload/Newsletter/jaundice%20fig2.png

drzed  That made me want to vomit tbh; I forgot about NMRs until just now. I hated those things. +

 +3  (nbme22#37)

Dr. Sattar says that decreased blood flow --> atrophy. Fibromuscular dysplasia of the left renal artery is essentially renal artery stenosis --> atrophy of the left kidney


 -5  (nbme22#47)

Pentad of TTP = FAT RN

  • Fever
  • Anemia (MAHA)
  • Thrombocytopenia
  • Renal failure
  • Neurologic symptoms

This is TTP not ITP

makinallkindzofgainz  I seem to have commented on the wrong question, sorry! I wish I was able to delete my comment, but I can't. +4

 +2  (nbme22#42)

Androgenetic alopecia is a progressive, nonscarring alopecia that affects the regions of the scalp with the most androgen-sensitive hair follicles, resulting in a characteristic pattern of balding (bitemporal scalp in men and vertex and frontal scalp in women).

Follicular miniaturization: Androgen shortens the anagen phase of hair growth → vellus hair formation (thin, short hair)

  • Vellus hair does not cover the scalp adequately. As the anagen phase shortens further, the hair shaft does not grow long enough to reach the scalp.

TL;DR - DHT can lead to baldness


 +0  (nbme22#28)

Isolated gastric fundal varices are seen in splenic vein thrombosis.

Thrombosis increases pressure in the short gastric veins --> gastric varices only in the fundus

  • Seen in pancreatic inflammation (ex. pancreatitis, pancreatic cancer), which can cause a blood clot within the splenic vein, backing up blood into the short gastric veins (gastrocaval shunt - drained by the inferior phrenic vein) when ruptured causes gastric bleeding, hemoptysis (seen in stem), and melena

 +7  (nbme22#7)

It's D because you're being compassionate and every other answer makes no sense:

  • A: You can't promise that things will be okay.
  • B: Being a dick.
  • C: Being a dick.
  • E: Being a dick.




Subcomments ...

submitted by mahesh(5),
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asotcsoaemOr hotcoiglalis .raneeapapc tPaeg idsseae is one of rksi oftacr

spow  Looking back, I know it's osteosarcoma but the lung metastases made me think of Ewing's +  
makinallkindzofgainz  Ewing sarcoma is common in boys <15 years old. This patient is a 70 year old woman. The stem notes elevated periosteum and a sunburst pattern which are characteristic of osteosarcoma. +1  
llamastep1  Also "sunburst pattern" is a classic description of Osteosarcoma. +  


submitted by neonem(572),
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arnlGee mtehe fo lh:tpagooy ahxoiyp iispram ivietoadx hsrnilhotoyoppa -;t-&g sles TPA -g;&-t ssel a-KN mppu vtiiacty os smouid ibslud up ni eht l,lce cgasuni giwsl.nle hisT is eht sfrit .pste enTh u'ydo egt eth liauccm lbiudup in hte lcle adn ntlaeevu eanocbiar lysil,gsoyc sagciun tcical dcia nirdoutcpo adn erlodew H..p. tub hits phnpesa larte nad s'tin eht erictd acues of culrleal snglel,iw whcih si tahw teh iutsqone is tfrea.

aneurysmclip  can we have a moment of appreciation for Dr Sattar +23  
makinallkindzofgainz  blessed be His name +8  


submitted by yb_26(258),
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yM plsmei ransntdugeind si atht ts'p herta aitlytonctcri si aerdesedc ude to IM g&=;t htrea 'atnc uppm a lot of oobdl &tg=; neiasredc upkbca wflo ntoi mnarpyuol vaueacsurtl ;t=g& iceaendsr PPC.W

reoM olodb in malrpuony vclauuastre g;&=t ethy liwl daitle in reord to usjt kpee lla eeths bldoo &;t=g redacdees onprluamy avsuarcl seectnrsia

eDecdsare idrcaac uupott &g;=t lrieheppra snsicvonacoiottr t&;g= eisaencdr mcessity cuavrsla isanetsrce

susyars  The question says “ST elevation in the anterior leads“ so, in some way I was thinking of the most anterior part of the heart which is the right ventricle, and not the left one. +4  
makinallkindzofgainz  Anterior STEMI = ST elevations in V3, V4 which is supplied mostly by the LAD. RV is mostly supplied by the RCA, which would show up on an EKG with ischemic changes in II, III, and avF +4  
qiss  Btw increased PCWP indicates increased blood in the left atrium, not necessarily increased blood in the pulmonary vasculature see here. +  


submitted by m-ice(340),
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GHM oCA utdcaeRse iribtosnhi ptevren het rievl omfr yeinthzsgnsi sit own oeeolh.ctslr In doerr ot ianamnti ist eedn rof lct,rsleoheo teh elrvi ash no icohce by ot seecrina tsi LLD tcrerpoe spnxeoseri in dorer ot ktea eotohelcrls fmor het l.doob

suckitnbme  Not sure why NBME felt like they needed two questions on statin MOA on this form. +5  
makinallkindzofgainz  because they didn't even realize it because they make insanely low effort practice exams with awful formatting and vague vignettes, yet here we are paying 60 bucks a pop for "high quality" exams, gimme a break. ok i'm done venting +4  
madden875  stop whining. no one asked you to buy the exam^ +4  
neoamin  Why does anyone scramble this site? >< +1  
neoamin  and how about lipoprotein lipase? +  


submitted by neonem(572),
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iTsh ttepain ist'n pgti,lnyheanovti r'eethy ngt,YEivtaeRnPlHi ehnec eth 2COP l;t& 04 mm gH.

et'Ls wkal it wrbkadcs:a eyhT rae nvirittalheegynp to mcnpeeatos for teh tbeoaimcl dacosisi eadscu by adirwpsede h.ipxayo penntravtyilgeHi wlaslo oyu to lwob ffo omer OC.2

Why era yeht ochi?pyx hTe pseonr is xyoipch due to omalminitafn adn eacut oireyrptars seisstdr yenmsdor mofr eht uo.mianenp llA teh sieoycnkt ormf teh nomirafymalt elscl aecsu cesadrien olnpamury clyaairpl leke,gaa ihwhc klbsco pu the aolarlev ebnmrmae os atth O2 tc'an teg truhohg ot the bod.lo

Why do yteh aehv lcetbaimo sociidas in teh frtsi e?apcl No geoynx g;-&-t on lecntore pstrontar haicn nad no CAT -;tg-& actcil ssa.icodi

diabetes  no pneumonia it is UTI +3  
makinallkindzofgainz  The infection from the UTI spread to her lungs +  
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1  
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +17  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +3  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by neonem(572),
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siTh ateptni ntsi' ,anvieylnophtigt hyrtee' PRHtvltgYniaeniE, cnhee eht C2PO ;< 04 mm .Hg

s'eLt alwk ti d:rakcsbwa yThe rea egeptyhinnalitvr to tesmnaecop rof het omlbeaict coidissa caedsu yb dswepirade xhopyi.a tegyintiHlrpvaen laolsw uoy ot lbow ffo emor 2C.O

yWh era they co?iyhpx The oerspn is oicxhpy due ot itfmnlmoniaa adn aecut trreipayors rsisteds esrdoynm rmfo eht nn.pouamei All eht ienksocyt rmfo eth anatimmrfoyl cells ucsae edcsianre unrymploa palyriacl ka,eegal hhcwi bslkoc up het rolvleaa beemmnar os hatt 2O a'ntc etg uohrght to teh lood.b

yhW od ehyt ehav aimecbtol daiiscso in het itrfs ae?cpl oN yxoneg --g;&t no neeroltc otrnpsrat ahcni dan no ATC t-&;-g caltci sdsc.oiia

diabetes  no pneumonia it is UTI +3  
makinallkindzofgainz  The infection from the UTI spread to her lungs +  
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1  
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +17  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +3  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by nwinkelmann(297),
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I duonf a turcpie nsohwig the tssiinaosmrn yb two grstehuzeoyo aahpl ahslastaeim atrit asain c-s(dlti)eieno santre,p dan efididom it ot olsa ohws eht enarceintih yb otw urthyzeosoge paalh laaamhiesst aircafn nn-ettearl)(dios pastr.ne Hree you :go gl1/PprnJTvO9wd?E9tw1c=npo.4.dWHiU2gv8mu7shedtQVo/eqTh/oioIR:wecJd

makinallkindzofgainz  broken link +1  
drdoom  broken link +  


submitted by sajaqua1(535),
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Pmslaa rbeaesnmm rea a ilpdi br,aeyli lpyiltacy whit patohesph ehdsa no haec frcseua adn nolg rbcaon satil no het ei.isdn sehTe orabcns ear tnau,lre adn rgednuo hoyhrocbidp nntsaitceior for an retlngcaeleiy oaaelfbvr .tsaet

grlaIent aerbmemn sotniepr assp rhogthu hsti ipild byi,lrea dna os utms be lbceaap of intentaigrc bhto with het praol sntvoesl of lrcelniurlaat adn rxtcuaeraelll c,esap as lelw sa the ochrphoybdi reco fo eth .alery heT marmntsaeernb nporoit ontef sha la-lpceaihlah rosedcany nnromatioc,of hwit ohhobrcpdyi usriesed kile nycgile no eht sieotud oratwsd teh cabrno tasil hwit olpra oanim cadi serusied cedkut ni.

makinallkindzofgainz  "high school biology" lmao we really out here +6  


submitted by sugaplum(382),
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yalswa erebmemr mhet in dorer thwi luafmo,r E=IESSIAT
dan the tow no hte EDN era UN-IDTODAC

makinallkindzofgainz  The supraspinatus AB-ducts. The Subscapularis ADDucts +  
makinallkindzofgainz  disregard my comment, I misread what you meant +  
drzed  How are you supposed to remember which S is which? +2  
drschmoctor  @drzed "Supra" = on top, so the 1st S is for supraspinatus. +1  
usmleaspirant2020  according to Physeo : INFraspinatus--EXternal rotaTION------INF-ECTION +  
destinyschild  wow, sugapulm, that mnemonic is gold. you are gold. +1  


submitted by sugaplum(382),
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aawlys embermer ehmt ni edorr tiwh ,olruafm SISAETIE=
dan eth owt on eth EDN aer CADN-OUDTI

makinallkindzofgainz  The supraspinatus AB-ducts. The Subscapularis ADDucts +  
makinallkindzofgainz  disregard my comment, I misread what you meant +  
drzed  How are you supposed to remember which S is which? +2  
drschmoctor  @drzed "Supra" = on top, so the 1st S is for supraspinatus. +1  
usmleaspirant2020  according to Physeo : INFraspinatus--EXternal rotaTION------INF-ECTION +  
destinyschild  wow, sugapulm, that mnemonic is gold. you are gold. +1  


submitted by yogi(12),
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ITP - teltelaP + bA eogs ot slenep - yseLd - Low ptl rAcntuofte. cemneoslpyt - usluyal ltp oucnt rmpiveo adn aerPephlri bolod erams swoh - HJ bioesd as a nigs fo pnlsaiae ( lrncuae mtnasren ni CBR luuyals oreevdm yb pl.s)een I f trehe swa an orcyasces ensepl ihhc(w wsa ton iannluofct whne teh main eslenp wsa )ognkwri ilwl ktea vreo hte finuotnc lyuaalrgd - HJ desbio iwll asppdiare nda Ptl srtast to syle - chiwh ash hpednepa in ihts seac eioscn.ar

spow  But why are there no bite cells? Question stem states that there is normal morphology? That's why I didn't pick accessory spleen +2  
makinallkindzofgainz  Bite cells are seen when splenic macrophages take "bites" out of hemoglobin precipitates in G6PD deficiency, which doesn't have to do with our question. This patient had a splenectomy 3 months ago, 6 weeks later showed Howell-Jolly bodies (asplenia), and then today now has normal erythrocytes (spleen is working again somehow = accessory spleen) +3  
snripper  @spow Bite cells are associated with G6PD deficiency, not ITP. +1  
srdgreen123  Main takeaway is the HJ bodies. They're seen pretty much whenever you have no spleen. So if they dissapear, that means another spleen-like structure has showed up +2  


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glyeotoSrnids snreetpate the insk uysllau( eht efe),t resvlta toin the dobtomraesl, rsteen het /agecrsauhtln wheer ti is uulylsa odueghc pu adn then llsaowewd ntoi the IG .rtatc heTy can yal gseg in het isi,entestn dna ehnw teh arleva hht,ac eyth anc ptenraete hte eaiinnltts wlal adn teern hte oadesbrmlot a.aing

makinallkindzofgainz  Strongyloides is fucking metal holy shit +4  


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The ebohoecparnlnhm udowl eb on hte autcla esftu os stuj get ird of )D.( eTh c"akbl "hoel ttha eht uesft si gatonifl in is het nasiotatelg sac os teg rdi of C.)( woN I ma no utodusalnr eerptx but I ownk thta hte miactnoi tyciva leylnuetva pasdexn ot sefu whit hte iocnhro yheterb iaminlniget teh hcioicorn ctivya )(.B nI rsetm fo ehwre het taoinmic vtaiyc is hnwos in this mae,gi I ma otn usr,e os bmyea oesemno anc pelh btu ihst vlaees eth yklo asc hicwh tcyplilya sraapep wnitih hte atnotsaelig sca nudroa .55 es.wke

kateinwonderland  At the end of the fourth week, the yolk sac presents the appearance of a small pear-shaped opening (traditionally called the umbilical vesicle), into the digestive tube by a long narrow tube, the vitelline duct. (Wiki) +4  
tallerthanmymom  But why does it look completely detached from the fetus? I eliminated yolk sac first because of this +  
makinallkindzofgainz  If you look reeeeeeeally closely, you'll see some signal between the yolk sac and the baby. Although you can't see the entire connection, they are connected. +5  
thotcandy  Pt is roughly 8 weeks pregnant so and typically by 9th week, Amniotic cavity has expended to fill entire volume of Gestational sac. So the entire black part around the fetus is GS/AC. +2  
euchromatin69  and also by 7 week vitelline duct obliterates between umbillicus and yolk sac +  


incorrect question. PPIs are associated with diarrhea and c diff which would cause acute onset severe diarrhea https://www.mayoclinicproceedings.org/article/S0025-6196(17)30841-8/fulltext

makinallkindzofgainz  PPIs don't usually directly cause diarrhea. The stem mentions nothing about potential C. diff. Misoprostol directly causes diarrhea. I also put PPI, but I can see why I was wrong. +2  
mhmdreyad  https://www.ncbi.nlm.nih.gov/pubmed/10392669 this also say that PPI is the first line in treatment +  


submitted by haliburton(215),
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mtdllesbeu hsa a ncei numipnoec for the keldil eia:cvncs

estR In ceePa yw:Asla

bsiaRe
aeulnz nIf
ooilP k(Sla)
atspieit H A

paulkarr  Also, the nice little puppet show from sketchy for those visual learners like me. +1  
makinallkindzofgainz  just remembered that MMR is a live attenuated vaccine +  
faus305  how could i forget that puppet show?! +  


submitted by monkd(18),
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mA I zrayc or did lordwU nto avhe a esuntoqi ttha tdesta itasntS era hte msto evfieectf drug rsagseedrl fo aeneslib l.sipdi This glico tewhr my of.f

adisdiadochokinetic  You are not crazy. I got this question wrong for the same reason but here's why I think NBME was going with fibrates. You can use the Friedewald equation to calculate LDL cholesterol from the values they give. This equation is LDL= Total Cholesterol-HDL Cholesterol-(Triglycerides/5). The Triglycerides/5 term is an estimate for VLDL. If you calculate it in this case you get an LDL of 120 which is firmly normal and thus the patient would ostensibly not benefit from statin therapy. +14  
hello36654  omg when the hell am I going to remember this equation? Jesuusssssss, this kind of details makes me want to give up on STEP +4  
almondbreeze  Her goal LDL should still be <100, bc she has 3 CHD risk equivalents (https://www.aafp.org/afp/2002/0301/p871.html#afp20020301p871-t3) CHD risk equivalent=the major risk factors that modify LDL goals 1) age(M>45, F>55), 2) smoking status, 3) hypertension(>140/90), 4) ow HDL level (<40), and 5) family history. (https://www.aafp.org/afp/2002/0301/p871.html#sec-4) +  
almondbreeze  *low HDL level (refer to table 3 of the article) +  
makinallkindzofgainz  These guys are hitting up attending-level cardiovascular risk factor calculations, meanwhile I picked statins because I think I remember that they help the heart +12  
jimdooder  So I ended up going with fibrates because of her age (39). I vaguely remember being taught that statins are really only recommended for patients >40 because the big study that came out about them was in the 40-75 age group. I think this might contribute to the question but I'm not totally sure. https://en.wikipedia.org/wiki/Statin#Primary_prevention +  
ytho  This question inspired my screen name +2  
cbreland  "Statins are always the answer", "Fat Female 40 Fertile", "Fibrates can cause gallstones". I feel lied to +  
brise  I'm not sure if this question is correct. I chose statins according to what an attending told me and UWOLRD 2, I just went back to check and on uworld 2, you only consider giving fibrates if their TG levels are above 1,000. So idk what the nbme is smoking. Or if doctors actually write these questions. +  


submitted by wired-in(67),
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acMnneiante sdeo froalmu si sCs( × lC × atu) ÷ F

eewrh ssC si a-sdseayttte ttaegr asmpla cc.no fo ,gurd Cl is rcac,enlea uat is doeags elnivtar &pam; F si aiilaloybt.ibavi

eritNhe saogde tnieavlr rno ibolibiayltavai si ve,ing so inogrgin ehsot ;map& ipnugggl in the enusmbr (arlefcu to rtoncev tnsui ot dm/gy:g)a/k

(2= 1 gumL/ × 1 00m01g/ ug) × 09(.0 h/Lg/rk × 0001 m/L1 L × 24 rh/1 yd)a
= 292.5 k/gmad/yg

wi...hhc ints' nay fo eth ewnsar sehicoc eslt.id Tehy umst hvae edrdnou .090 k/g/rLh to 1.0 gr/h/kL, adn ndgio os segiv tyxleac 2.88 gmy/ka/gd c(heico )C

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +75  
hyoid  ^^^^^ +11  
seagull  lol..my math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +9  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but i´d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +5  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +3  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +17  
qball  Me after plugging in the right numbers and not rounding down : https://i.kym-cdn.com/entries/icons/original/000/028/539/DyqSKoaX4AATc2G.jpg +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😡 +  
yesa  12ug/ml = 12mg/L; 12mg/L x .1L/hr/kg x 24hr/day = 28.8. No need to multiple numerators and denominators by 1000s +  


submitted by rainlad(23),
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ym pophaacr to siht tnuioqes aws to emailneti all eht nreaws isohecc ahtt netediomn ctsiciieyfp ro tiesni,siytv nesci teh daat ereh did ton pvidore tairnooimnf atoub yna tros of sreenignc es.tt

ahtt lfet em ihtw wot eslisbop raeswn e:sihcco I aeinltmide eth one tuabo cieosytsncn of hreto stu,eids sncie no treho eisustd eewr ennotimed in het ntisqoeu st.me

ton ruse if I mesviriiolfedp tsignh, tub it dle em ot eht irthg naes!rw

makinallkindzofgainz  this is exactly how I reasoned through it. Were we correct in our line of thinking? We'll never knooooow +  
qball  But will you ever know on the real thing? +1  
drdoom  but will you ever know in real life? you may do the right thing (given time constraints, & information available), but outcome is bad; maybe you do the wrong thing, but the outcome is good (despite your decision). how to know the difference? +3  


submitted by aladar50(40),
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roF het GCE, I alilnyiti ohhtgtu it saw 2nd redeeg peyT 1 baeceus ti medees that teh RP itnasvelr rewe irsgnicena itlnu a tabe was podde,pr utb if uyo look at ti sellco,y emso fo eht P wasev reew ehidnd in het SRQ mpeeclxos. fI uyo oecnti h,tat neth uyo anc ese that ehetr eerw rulgrae P ewvas dan rrulgea RSQ ,lmoecpsex btu rethe saw a eelcmpot oaontiiicssd weenbte etmh ihchw smena it asw dr3 eedrge ertah olbkc, os eht ersawn aws noblatai near teh VA noe.d

yotsubato  answer was ablation near the AV node. No it wasnt. It was ablation OF THE AV node itself. Which faked me out. +9  
makinallkindzofgainz  The tangent by user "brbwhat" says that there is "pr lengthening progressively" but there is not. This is 3rd degree AV block. The P waves march out consistently at their own rate, and the QRS complexes march out at their own rate. There is complete dissociation between the P waves and QRS complexes. They have no relationship. This is exactly what you would see if you ablated the AV node. The SA node would continue to to create P waves. The bundle of His would continue to generate junctional (normal looking) QRS complexes. +6  


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emseS kile I idd atwh ostm of ouy .idd I drae eht p"mt"myos as pnia dna entw fro 2EP.G

ursTn out if I dha utjs aedr the 8200 eappr rdnviUedcseo elor of dsooneuneg rnhtxomboea A2 in avcnatiito of crdacia pemtcyaihts rasefefnt rdgiun aiichmase I ldouw evha nonkw htat 2TAX YMA be a cuesa of MI ipn.a l.w0i:t83?p/tpnobi3mdvmwe8nn.w/7h/1emb.=hur4tcg.s

rTeeh rae alos rehtioes atht eth npia is mrof idikaab/TRn5oiOesHyc-/ia/dnSndn/er chwhi ouy nca eadr uatbo ee:rh

dn9/h1n?rtmm/bw=g:wpcni.0i.o/e.e5hmt6s0pvtulb89w. gtnom2h.lpi:b?/.eu2r/ttnw92wwe.3cm3vsmb/=nip0.hd1 wmimt/7eb5=np.h01p.dlhnvt4.t.guobercmw9ni:1sw8//? s/u14h/bim/e.rt1mp2n.mn5d3ehgip:bnttl=w..w?w2ocv1

I onfdu eseth via het TUpoeatD page gAnnai sirot:pce Cseht ianp ueascd by orncrayo eryrta tcibuntsroo wchih seod ysa het scmeaihmn is "xlcopme dna nto ntyeielr dnsod"re.uto

makinallkindzofgainz  this is all irrelevant. the dude is having an MI so the answer is Thromboxane A2 +  
drschmoctor  Bruh, you gotta read all the 2008 papers. It was a fire year for obscure shit you need to know in 2020. +13  


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iPtnate is uecnrrt ebdtea,frs- os ew anc eiematinl tfrucoes ors(ectuf is nudfo in noeyh dan surtif nda omes rolaum,f utb ton ni etasrb ikl)m. iettPan ash drgucnie stbcensaus but on uloegcs ni eth urn,ie os eh utsm esmo -genscolonu ur.gsa yM atenirlfidef ofr reniucgd nlo-cegouns sugars in the euinr is oissdderr strcoufe mmaosltebi ro olcgeaats eaom.bmtlsi eW evah itnialdeem tuseoc,rf so that esvael su tiwh etnilaokscgaa ecicdnyife or cacsisl aitacgaoesml.

sympathetikey  & Galactokinase deficiency would be much milder. +7  
smc213  Big was soybean formula not giving any issues. Soy-milk can be used as a substitute formula in patients with Classic Galactosemia since it contains sucrose (->fructose and glucose). +1  
oslerweberenu  Why can't this be glucose 6 phosphatase deficiency Confused me +  
almondbreeze  @oslerweberenu G6PD - increased RBC susceptibility to oxidant stress (eg, sulfa drugs, antimalarials, infections, fava beans) -> hemolysis; has nothing to do with presence of reducing sugar +1  
makinallkindzofgainz  @almondbreeze; Glucose-6-phosphatase deficiency is Von Gierke disease, they are not referring to G6PD deficiency (an entirely seperate disease) +7  


submitted by yotsubato(1041),
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necaPsripeala si salbcyila ae"nPirtacc n"sezEmy ni acfny sntap NBME lwrod

makinallkindzofgainz  "Pancreatic enzymes, also known as pancrelipase and pancreatin, are commercial mixtures of amylase, lipase, and protease. They are used to treat malabsorption syndrome due to certain pancreatic problems. These pancreatic problems may be due to cystic fibrosis, surgical removal of the pancreas, long term pancreatitis, or pancreatic cancer, among others. The preparation is taken by mouth." +  


This question in it's essence is asking that after inserting the catheter in the femoral artery, which landmark should we use beyond which superiorly lies the renal artery, and the answer is the origin of the testicular artery. What a weirdly worded question though. :?

makinallkindzofgainz  I don't think it's worded that weirdly. The guide wire should be advanced superiorly just beyond the testicular artery to approach the right renal artery. +  


Pentad of TTP = FAT RN

  • Fever
  • Anemia (MAHA)
  • Thrombocytopenia
  • Renal failure
  • Neurologic symptoms

This is TTP not ITP

makinallkindzofgainz  I seem to have commented on the wrong question, sorry! I wish I was able to delete my comment, but I can't. +4  


submitted by thirdaid(9),

The initial presentation looks like cancer: weight loss and progressive dyspnea over the course of months in a heavy smoker. Then, the question describes extra-pulmonary symptoms and a paraneoplastic syndrome.

More acutely, there is development of edema of the face and jugular venous distention. Because this is localized to upper body, we should think of a mechanical obstruction to venous flow as opposed to some cardiogenic reason. This is an extra-pulmonary symptom of lung cancer.

[ Superior Vena Cava Syndrome caused by the medial spreading of the tumor. Can be exacerbated in the physical exam by asking patient to raise both arms. ]

Finally, there is a single highlighted lab value -> hyponatremia. Small cell lung cancer can release inappropriate levels of antidiuretic hormone -> SIADH. ADH will retain water and decrease sodium concentration possibly leading to cerebral edema and seizures.

[ Syndrome of Inappropriate ADH (due to small cell carcinoma, a neuroendocrine tumor of the lung) decreases sodium concentration. Paraneoplastic syndrome. ]

In SketchyPath: SVC syndrome is the red balloon near the mediastinum ship and SIADH is the guy trying to carry the water cooler and getting water all over himself.

makinallkindzofgainz  I agree! Superior sulcus tumors is a lung carcinoma that occurs in the apex of the lung and can cause SVC syndrome. +1  


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isbmouugA uetsnioq ubt in abuesce it si yrlae oc,hks htree si otn uehnog mtie ot avctetai teh ARAS ot snrceeia knydei .noripseuf

makinallkindzofgainz  This is not an ambiguous question. It makes perfect sense. +5  
khaleb  In early shock you have increased SVR due to vasoconstriction. This would cause increased flow to the kidney. I could be wrong but I think what makes that answer incorrect is NOT that RAAS hasn't been activated yet. It is what is causing vasoconstriction via Angiotensin II. What is possibly wrong about that answer is that it says via sympathetic stimulation. I do think it is a little vague between those two answers though. Because you can get sympathetic activation of the RAAS system causing vasoconstriction and blood shunted to vital organs such as the kidneys. Bottom line is you can't argue with weak pulse during hypovolemic shock.... so an obvious right answer. You could make a case for the increased blood flow to the kidney though. +2  
zqatan  @makinallkindzofgainz no need to dismiss the question... so pretentious +  


submitted by imgdoc(135),
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I inkth alto of ppeeol hmigt ehav oerv aihepedsmz how patrnoitm ANP dan BPN ylrlae ,ear sye ti is rioptmatn to nokw ethse dpeptsie egt eretesdc yb het aarieltracrvn/itul rycmumodia rdguin tehra e.riluaf ovweerH terhi lroalev vfeefssintcee in itntrgae ahrte fiarlue is ,zilch a pocpterer dlot me ttah if PAN nad PBN rwee so fuleus in siitrurnaes neht ywh do we geiv ?dericutsi 'tIs esaceub AARS ovsrwpeoer hits tmysse neche usaicng tegviean ftefesc and teh sneesdl oplo fo retah eaufrl.i AKA why we ievg CEA t.osirbiihn

Kiwgonn ahtt ANP tesg dultraineez by het RSAA setyms, ew nca sfhti uor csofu cbka ot arhte uefalri ni tish ,tteanpi hrwee raccaid utotup is eeaseddr,c eadnilg to DHA tercnoise and nflialy idutialnol ipnmoar.ethya

almondbreeze  a concept continuously emphasized by uw, but I get always wrong :'( +2  
almondbreeze  good work done! +  
raffff  why does the body make anp at all since its so useless +3  
makinallkindzofgainz  @raffff - at least BNP gives us a good marker for heart failure exacerbations :) thanks body! +  
mannan  Yeah it's important clinically because it has a high sensitivity (if negative, rule out) for Heart failure. +  
alimd  At the same time ANP inhibits renin release? +  


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seeaPl nac you likdny rahse NBEM 22 dan 32 niQustseo ihtw em . I ylon ese hte srwenas ubt I do otn eavh the fllu sta?uhs oinTqenk in neavcad

makinallkindzofgainz  I think you may have this website confused with nbmequestions.com +7  
teepot123  why don't u buy the exams like the rest of us? +2  


submitted by rogeliogs(9),
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Tshi ensoiuQt ist obuta epriarysrot tbusr

saPetnti htwi PNDHA ion=ciidnyeherccfc gatnaulrsmoou esiesda D)C(G

nvEe ghhout ptsntaie ihwt GDC at'nc meka uepSxoider, yhet anc eus ti mfro eht baarstiec adn tocnerv it to baclhe OHLC adn lkil hte siabrte.ac

UBT ibaesrtca hiwt alcetaas nzsemey euznlatrie erthi nwo ieupserxdo adn atsht hyw the GCD netpait 'tnac kill .ethm

leaataCs pvotsiie :iractbaes S. uueasr - isslArlupge

thomasburton  I thought E.coli was catalase positive too? Why can that not be correct? +6  
mb10  (FA 186) Catalase (+) microbes, especially S aureus +4  
makinallkindzofgainz  @thomasburton - because First Aid said so, so suck it +1  
jurrutia  @thomasburton, because S aureus is more common. I guess. +  


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otN 10%0 sreu on htis ,neo but s’rehe woh I caohedappr it: emitsnahi ecsusa aariterl oadltini eadcrsee(d= rrlioaeart ),iseeratscn btu all fo thta doblo sha ot go wmeeroshe esnic oyu wno ahev roem bolod lwifong trguohh hte restriae dan thta emresweho si hte lipascrliae eencardi(s ayprlacli trdacshtoiy rsru.e)sep aiHsmient aescsu rcneiseda miepelytirab fo het clr-iatyosalpp snuevel on(e fo D.r ataS’srt vaetifro fasc)t so y’dou evah dreiecsan llycpaari tionrltfia e.tra

taediggity  Totally agree, arterial dilation--> increases blood flow into capillaries/increases capillary hydrostatic pressure + increasing permeability of the post-capillary venules= Increased Capillary Filtration Rate +1  
makinallkindzofgainz  I love you explanation, but I don't think filtration rate is dependent upon permeability of the post-capillary venules. I think the filtration rate is increased simply due to the increased blood flow; this is similar to how increased renal blood flow will increase Glomerular Filtration Rate (GFR). +10  


submitted by moloko270(66),
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olss of ilfdu tieggsrr dasoelrtneo poc,oturnid os ttepnia wlli veah arphemiyeantr and poaekihlyam as a ltreus

makinallkindzofgainz  dat RAAS +4  


submitted by usmleuser007(397),
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throeM si heRn-g tg--&; she lwil etaenegr aoiid1 )t-nsebRH stfue faeedctf by AhnR-it if it is s pi2thoRiv)-e evne fi vP-iOith-eosR si egin,v then still teo'mhsr Ronbisea-thid lwil attcka suatsrdenf odlob ued to its lcsle anctgionni +) hR3 eroh,efrte veRO-egatn-ih si etsb

makinallkindzofgainz  you're not wrong, but I think it's better to have put O-negative because that's the preferred type of RBC for transfusion unless you've type and crossed your patient +  
mtkilimanjaro  I think fetus is O+ but if you give them that the RBCs will still be destroyed. You want to give O- as it wont get destroyed and wont affect the fetus in any way. Similar mechanism to giving platelets to someone with TTP, HUS, etc. they just get destroyed so its useless +  
tylerwill33  In utero, should give O- to avoid mom attacking again. After birth, O+ probably better. +  


submitted by aesalmon(84),
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I lfee budm rof ganski utb acn nsemeoo palnixe hs?it fI ihs ranespt era of scloe to ornlam MIB dan rae eecodcnnr auotb ihs etihwg hyw olwdu tyeh be wolnilga shi rcleaio tcupnnsooim ot excdee shi eyrneg etr?diueepnx ( KAA tltgnei the dki tae oot cmhu dan ont eeiscrex )enohug

meningitis  That's a modern day mystery. +17  
drdoom  The prompt is only asking "what's the likely cause of obesity?" It's not that they're "allowing" him to eat more than exercise. (Few parents can monitor their kids that closely!) The prompt is only asking what's the most likely explanation for his 95th percentile weight and BMI (given that he otherwise appears normal); in the United States, the most likely explanation is eating way more than you expend. +1  
niboonsh  aka 'merica #firstworldproblems +4  
makinallkindzofgainz  If you are obese, it's because you have consumed calories in excess of your energy expenditure, end of story. (there are factors that affect your energy expenditure, but the simple statement is 100% true, unless you want to argue against the laws of thermodynamics). A is the only correct answer. +1  
tulsigabbard  This answer hit too close to home. +4  
castlblack  I think the reason they point out the average weight of the parents is because leptin disorders are inherited. It helps you eliminate that answer choice. +1  


submitted by marbledoc(0),
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hyW uwdlo uyo ska hte attiepn to dytenfii eht psro dan nsoc? I o’dtn gte eth ropacpah !eerh

someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +6  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +5  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +2  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +3  


submitted by meningitis(546),
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I huogth:t relwo ploe enth tanc be unaasperrl rno scotmah wcihh aer e"ihgr"h

mDunduoe dna Boyd fo arpescan (extepc ali)t are eaortrtineperlo and nelidim

makinallkindzofgainz  I ruled out duodenum because it's towards the right side, and I ruled out body of pancreas because that's basically midline. We are talking about the left lower kidney, which is by the spleen and splenic flexure. Idk if this logic checks out, but I got it right +  


submitted by sbryant6(167),
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yskrasnmt-dwecuahoe.c/allcamafi--renw:s/tmo/mhtptewdd/rs.pca

makinallkindzofgainz  upvote for credible source +21  


submitted by welpdedelp(229),
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Tshi is rtLabo-a,Eetnm hcwih vprioesm itwh nemteovm as cparmedo ot ityaneeMsh argaisc hcwhhi rowness ithw envmmote

sbryant6  Lambert-Eaton is typically associated with Small Cell Lung Cancer. Since there was no mentino of that, I was thrown off. Such is the difference between UWorld and NBME I guess. +1  
makinallkindzofgainz  I'm laughing about Myasthenia "gracias" lmao +16  


submitted by someduck3(60),
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taF ebluslo visnmtai aer ,EDKA.,, So hobt D a&p;m E cdluo be dcdseerae in iths tp. But uoy aevh to wonk htta Vnitima E dcyieenfic si iasscoated iwht itnlmedaioney pm;a& sha enbe sodsietaac thiw eotprrsoi nmuocl aide.neitymnol Alos tiV E can be ngeiv tiwh eAlizmrhe ttsienap sa ti elshp hwti rfee arcdi?..sal

aesalmon  I actually thought that the posterior column findings were likely due to B12 deficiency - "subactue combined degeneration", due to malabsorption, as we see in this pt (. Turns out vitamin E can also cause symptoms which look like subacute combined degeneration: https://www.ncbi.nlm.nih.gov/pubmed/9012278, as does Copper (TIL): https://www.ncbi.nlm.nih.gov/pubmed/15249607 +3  
jooceman739  Vitamin E deficiency causes posterior column findings and hemolytic anemia :) +5  
nwinkelmann  The way I think about it is that essentially, vitamin E is an anti-oxidant. Vitamin E deficiency = LOTS of oxidation, i.e. free radicals, which are toxic to most cells in the body (particularly myelination and RBCs). That's why it can be used with Alzheimer's patients. +3  
makinallkindzofgainz  Vitamin E presents like B12 deficiency but without megaloblastic anemia +  
kevin  B12 would also affect lateral corticospinal tracts, vit E doesn't to my knowledge (b12 deficiency would also present with hyperreflexia but E deficiency just romberg sign, loss of proprioception and touch, ataxia) +  


submitted by privwill(24),
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ptSe yb :spet

  1. Hp = olw = iicsoasd
  2. OHC3 = owl = iodscais
  3. OC2 = hhig = issacido

S,o htwa Ie'v edrneal is atth, ni csen,ees actoilbem sidcsoai lwsaya stkae topyriir ni tseeh isnecraso. 'sIt evntdie htta eth onersp is otn ctepimsoann,g tub oyu nawt to llcacuaet aaywyn by gnuis nirWte = 5.1 H3O()C + 8 .
fI uoy lelutacac ouy ilwl ees atth hte edeexptc si 30..5

  1. fI OC2 is hriehg tahn xceeeptd = aotntconimc irpyoarerts sasodcii
  2. fI O2C is leorw than tedecepx = iactmnontco ryaeritopsr laoslkais

eHer ti is hrgehi hnat dtexecpe 5)6( so tatcimnocon rpryraeosit i.saiscdo

I sugse if oyu ednawt to sartt with eht ytpraeirrso daisiosc you edwuov'l eknat iont nscotriedaion atth ioebcatbrna l'euvdosh goen up to eeoctmpa.ns It 'ddtni os i'st maecston.puned oNt srue fi er'sthe a aofrlum ot ltlcceaau hte eohtr ftfus

makinallkindzofgainz  don't forget to add the +/- 2 to the end of Winter's formula. You have a tiny range in which CO2 can fall within +2  
cbreland  I started with respiratory acidosis and thought that any compensation would have an increased HCO3-. HCO3- is lower than normal levels, so that would mean met. acidosis as well. No math involved like you alluded to +  


submitted by armymed88(47),
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cGoslue si ttadrrnse-ocop iton rysetnecoet of IS avi ouimds

toxoplasmabartonella  That makes that glucose needs to be given with sodium. But, what about bicarb? Isn't the patient losing lots of bicarb from diarrhea? +3  
pg32  Had the same debate. I knew glucose/sodium was the textbook answer for rehydration but also was wondering if we just ignore the bicarb loss in diarrhea...? +4  
makinallkindzofgainz  @pg32 - Sure, they are losing bicarb in the diarrhea, and yes this can effect pH, but it doesn't matter that much. You're not going to replace the bicarb for simple diarrhea in a stable, but hydrated previously healthy 12 year old. You're gonna give him some oral rehydration with a glucose/sodium-containing beverage. Don't overthink the question :) +2  
makinallkindzofgainz  *dehydrated +  
teepot123  salt and sugar, that's all the kid needs when ill simple +1  
mtkilimanjaro  Hm I put bicarb/K+ since thats lost in diarrhea, but I think the key thing in this Q is that its only 6 hours of acute diarrhea and nothing else. You would prob give bicarb and K+ in more "chronic" diarrhea over a few days or longer not just a few hours +1  


submitted by armymed88(47),
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uslGcoe is -ooserdtrptacn iton seyrctneteo fo SI avi suodmi

toxoplasmabartonella  That makes that glucose needs to be given with sodium. But, what about bicarb? Isn't the patient losing lots of bicarb from diarrhea? +3  
pg32  Had the same debate. I knew glucose/sodium was the textbook answer for rehydration but also was wondering if we just ignore the bicarb loss in diarrhea...? +4  
makinallkindzofgainz  @pg32 - Sure, they are losing bicarb in the diarrhea, and yes this can effect pH, but it doesn't matter that much. You're not going to replace the bicarb for simple diarrhea in a stable, but hydrated previously healthy 12 year old. You're gonna give him some oral rehydration with a glucose/sodium-containing beverage. Don't overthink the question :) +2  
makinallkindzofgainz  *dehydrated +  
teepot123  salt and sugar, that's all the kid needs when ill simple +1  
mtkilimanjaro  Hm I put bicarb/K+ since thats lost in diarrhea, but I think the key thing in this Q is that its only 6 hours of acute diarrhea and nothing else. You would prob give bicarb and K+ in more "chronic" diarrhea over a few days or longer not just a few hours +1  


submitted by armymed88(47),
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woDn nyodemsr 2dn eemtritrs rcesne (ayuslul rondua w8)1ks6-1 ssohw rdeaeedsc FA,P otiselr dna eardsncei GCh dna inihbin A.

Of omyrits 3,82/1/11 owDn omerSydn is teh nloy to heav an etlvedee hCG

makinallkindzofgainz  "Down Syndrome has high HI (hCg and inhibin)" the relationship between the words down/high really stuck for me +2  
drzed  An easy way to remember the other aneuploides is that the "lower" ones (e.g. lower than 21 = 13,18) have "lower" values (e.g. LOW hCg and LOW inhibin) +3  


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KDA is a staet fo eadseercd un;ilnsi nices we nkwo atht nnuilis uaecss a sfthi of +K tion the llces wlo ellevs of lusnnii illw pvrenet iths nad rseltu in lhren i.mkaIpaey idatnoid, ude ot realyhimpgcye nad ghhi CEF llsomoiaty rwate lwil sithf out fo eht selcl nito the CEF and K+ hftsis tuo iwth eht wrtae cwhhi liwl tufher eaesrcin het apelyriemahk

dentist  I know Insulin cause shift K+ into cells due to closing of ATP-sensitive K channels (blocking K from leaving)? Does it increase K in the cells by another mechanism? +  
makinallkindzofgainz  @dentist - Insulin stimulates the Na+-K+-ATPase pump, this drives K+ into the cell (Source: Amboss) +  
castlblack  Another mechansim = acidosis causes hyperkalemia due to H+/K+ antiporters. H+ is high in blood so shifts into cells via this antiporter, which shifts K+ out. --potassium section of acid/base chapter in Costanzo physiology +  


submitted by fenestrated(29),
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oFr tihs noe I ihntk htaw oyu hda to onwk is hatt iTrtrcspnioan g(AA;-&NtR-)ND is fodrpeemr yb ANR Iamplysoet er. asw otn NDA lpsmoaeyre bauesce hsti neo ictaprlsee &)g-N;ADNDtA(-

fenestrated  between increased or decreased binding I picked decreased because it was a mutation which affected the hydrogen bonds which is how nucleotides bind to each other +1  
makinallkindzofgainz  this is how I got it right +  


submitted by yotsubato(1041),
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In bgo,olyi seaph naovairti is a omhetd for ngliead ihtw liyarpd yginvra noirveennstm hottiwu uqgirneir mnrado m.nuatiot tI ivnsevol eth riianatvo fo proetin sxori,pense ylfrenqeut ni an ofofn- ino,sahf wthini fetdefrni rtspa fo a acatliebr .aoopuinlpt sA chsu teh noepetphy nac hiswtc at eqcsnueferi htat aer hcum hhigre emt(oimses t1;g%&) ahtn ssaiclacl aotuintm a.rets saPeh ratiovain nobtesturci ot enueivrlc by teaeggnnir gtreyetoinee.h lghhoutA ti sha bene omst mloymcno dtsuied in eht txtceon fo umnmie aivsne,o ti is vrdesboe in mnay heotr seraa sa lwel dna si ylmdpoee yb oivusra sptye of ecabi,atr ndlgniicu aelonllmaS e.csespi

dh./wnawtiisapwwtocsoitenewaP/hr_n/v:ka/im.

whoissaad  is it the same thing as antigenic variation? +8  
dorsomedial_nucleus  No, antigenic variation involves genomic rearrangement Phase variation can be thought of as MORE or LESS of something. An on/off switch. No DNA is being rearranged, just under or overexpressed in response to the environment. +6  
makinallkindzofgainz  This isn't in Zanki, Lightyear, or First Aid, and I don't remember ever learning about this in class. Thanks NBME! :D +18  
jurrutia  You wouldn't expect the difference in phenotype of a given organism in a given patient to change because of mutations. It has to be something other than mutation. Phase variation is the only option that sounded like non-mutation. +  


submitted by usmleuser007(397),
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nI seasc of dcilh ro uladt buaes

1) fi ethre is arcel eeevdicn husc as fi a hlicd aetsts thta pnstear nhipus by inthitg, hildc si hiwonsg reaf of ratnpe ---- acll cihld nctterioop griht ywaa ( t'don ened ot twai nda sak)

2) asme higtn egos rfo eth tdula utb lcla hte taudl itpcrotnoe crevsesi

osler_weber_rendu  Does anyone not remember Dr Daugherty's lessons which said domestic violence on adults is NOT necessary to report? Instead help them find an escape route in case of an emergency and encourage them to report it themselves. +  
makinallkindzofgainz  @osler_weber_rendu: Domestic violence is not the same thing as dependent adult abuse, such as a special needs adult or an elderly adult (basically anyone who depends on others for care). What you said applies IF the adult is living independently and fully capable to make their own decisions. +7  


submitted by bubbles(70),
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rhicoCn rneal iufnciiye:cfns

)1 opor hpoeapsht calcreean g--;t& ghih srmeu innrogica phooshosurp

2) hghi rmeus haepophts &-;-gt mlcospexe tihw evadnlti nciota Ca -g;t&- aC allsf

3) Ca slalf ;gt--& sritggre PHT saix

)4 kinyed lireuaf &--t;g dcaeredes itticyva of hsyoa1lerdxy- ta hte kyendi -t&g-; essl cilcaiortl

makinallkindzofgainz  this guy renals +6  
paperbackwriter  Someone please help me with this (always trips me up): PTH causes increased vit D production in kidney... are we assuming the increased PTH can't catch up with the kidney failure? Is it the level prior to PTH compensation that they want? D: +  
miriamp3  @paperbackwriter what it works for me ;;;; is find the first abnormality so CKD low calcitriol (no D vit) ---> is gonna increase PTH ---> the kidney are not working (chronic, they don't tell u recently- you can;t revert a CKD so the kidney never going to catch up) --> increase inorganic phosphorus.--> always start with the problem. I also use this for celiac and types of shocks. start with the problem, and trust yourself. +2  
paperbackwriter  @miriamp3 thank you! I will try out your strategy next time!! :) +1  
snripper  I thought renal insufficiency -> inability to reabsorb phosphate at PCT -> decreased phosphate? +2  


submitted by mcl(601),
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DCC dmdmeoreecn tarenmtet fo stmoisahosc insnaom is rpailaq.tnezu

makinallkindzofgainz  It's also the pretzel in the Sketchy video, which I think most would agree is more reputable than whoever these "CDC" people are +15  
rockodude  ya until step 1 fucks us with some esoteric cdc guideline +  


submitted by emmy2k21(23),
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tsJu a omemninc to ekpe crkta of saec tronloc w/ sodd oarit nda otohrc /w liteearv ikr.s OnkRhsnteTaCil-oC: neiytnnoaltli spsemliled fro ddso hotRoro tCiRa rof levteira rski

makinallkindzofgainz  I like Dr. Ryan's way to remember it better: Just look at the 2nd to last letter in each word. Case ContrOl --> Odds Ratio and CohoRt --> Relative risk :) +4  


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tI idas ti wsa aftal to mesal ni tre,ou adn het euqsinot deask uoatb ievl brno .sifgnpfro nicSe the sealm nreat’ ebgin rnob in eth stfri plcae, I iasd 5%0 alfseem nad 0% l.smae

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


submitted by uslme123(67),
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yerv iuptds ioqnu.set heT riusv asw eidalnh -- tsba hgan sidpue nhwe hety eslpe nda .dorol oS ti adpsrse ot teh aibrn tcelidyr romf eth ltyfracoo tsemsy iva rergdeorat anrrtpost ohurhgt ensevr.

niboonsh  yea, aeresol transmission via bat poop in caves +  
len49  How do you know the virus was inhaled? Doesn't mention it. Moreover, non-bite/scratch transmission is extremely rare. +  
makinallkindzofgainz  You get rabies by being bitten, not by inhaling it +  
drzed  She was probably bitten by a bat; many times the bite is not recognized ('unapparent bites'), and thus the CDC recommends that even if you think you have been bitten by a bat (or that you COULD have been bitten), you should go and get active/passive immunization immediately. +  
mangotango  Sketchy (and Zanki) says you can get rabies via animal bites OR aerosol transmission. In the U.S. it's most commonly through bats. It could also be through skunks (Western U.S.) or foxes/raccoons (Eastern U.S.). I remember this by thinking about how skunks smell so bad! +  
shieldmaiden  But the question is "how it got to the brain" not how she got it, so the best answer is through the nerves +  


submitted by usmleuser007(397),
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fI you d'cuonlt rebmrmee hwhic rwee ;ansstleei nthe eeaalvritnt dwluo vhea been ot raeeilz tath nigorgw hrliendc eden slelc to dd.ievi This qrieerus ADN irioptlcnae nda nlarotn.stia fO hhwci het cniluec cadi itehym is ntrtmopai. tI usqirere a htlyem .rnsetarf

Tihs is ewerh nnimiheteo mecos n.i nietenoMhi bcseinmo ihtw TAP to omfr MSA (a hyletm ron)od

whossayin  That’s a legendary explanation. Thanks dude! +  
makinallkindzofgainz  This is exactly how I solved it! I remembered that Methionine is essential for methyl transfers, and you would need that in dividing (growing) cells. But now I'll just remember PVT TIM HaLL too :) +2  


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i lfle for degeblni rfom sloien at ohcse srispoasi tbu soiaspris pts epeeienrcx hii.cntg ,slAo eht rtotisnbduii si nto ccatcirsirae.th

makinallkindzofgainz  Yes it is. These areas are all sun-exposed areas, and he is a farmer. Multiple years of sun-exposure can lead to Actinic Keratosis, a precursor of SCC. +3  
mangotango  @makinallkindzofgainz -- I think cry2mucheveryday means "distribution is not characteristic" of psoriasis +1  


submitted by usmleuser007(397),
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stju a nhc.uh... Ozolmeerap is lwsaay eht irthg rwsaen

nala_ula  Famotidine is an H2 blocker which really only stops acid secretion via the stimulation of H+/K+ ATPase by histamine, but it still has vagus and gastrin stimulation. If you use Omeprazole, you get irreversible inhibition of the pump itself which stops the secretion of acid even if there is histamine, gastrin, vagus stimulation. +6  
temmy  what about the healing of her mucosa. Is that not the action of prostaglandin?. That threw me off cos according to FA, misoprostol increases secretion of the gastric mucosa +5  
cry2mucheveryday  same doubt..marked miso +2  
sahusema  I guess because misoprostol is more associated with treatment of NSAID related ulcers and PPIs are 1st line DOC for GERD? +1  
makinallkindzofgainz  @temmy, I think that Omeprazole is a better answer because although Misoprostol would promote healing of her esophageal mucosa, it wouldn't do anything to relieve the symptoms of GERD (due to acidic contents in the esophagus) +  


submitted by burak(56),
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ltaOirb rlofo rreftcu:a

-1 Inifaobalrrt eenrv i:jruny mnsseNub and seiphretsaa of hte uerpp c,ekeh perpu ,ilp urepp na.vggii

-2 repatEnntm of the eirorfin creust cems:ul pimraIde adurwp gaze

3- topsahosEmiln

-4 niusgolC of mlaaiylxr issnu: dTepaorr nigs

minion7  if IR muscle is affected it is impaired downward gaze!!! +  
makinallkindzofgainz  @minion7, If the Inferior Rectus muscle is impaired (e.g. nerve dysfunction), then yes, downward gaze would be affected. However, the question states that there is ENTRAPMENT of muscles. Trapping the inferior rectus muscle essentially locks the eye into a downward gaze, therefore impairing upward gaze, as the inferior rectus muscle is essentially trapped in contraction. +4  


submitted by hayayah(1081),
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atheterC a:ecltpmen

//d204mpscaennepe-tnt//006mtiy/guk:apjpocs0ghw.e8t//0eooa1sl8.

lacRel ttah the lgun paxe sxtdeen baeov eht rifst .rbi

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


submitted by hayayah(1081),
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etrCteah epnmtc:ael

8//.0s46pt0l8mk.nd0/o20cgt1aceuon-yhe/n/weapoimatpp/j:gtese/s0

lacRel that eth lnug xpae etesdxn obave het tirsf b.ri

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


submitted by hayayah(1081),
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aecnSoydr idpryipratyserhamoh usyuall( /dt hicnroc nrale laue)ir.f

baL gisdnfni ildcenu ↑ THP eposnrse( to low ),lcicuma ↓ rsmue acilmcu n(aelr uaierf)l, ↑ sumer hhpoetpas rl(ena leuri),fa dna ↑ aenlikal hhteoappsas PHT( cvtiitanag .ssatooBs)tel

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +2  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +1  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +1  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1