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Welcome to makinallkindzofgainz’s page.
Contributor score: 179


Comments ...

 +2  (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. +3

 +1  (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(2),

Osteosarcoma histological appearance. Paget disease is one of risk factor

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(503),
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Gnalere emthe fo agyltpoo:h yxophai siprima dvetaioix poahtioprshnyol t-;&g- sesl TAP -&g;t- sesl -aKN ppum atciityv so dusoim lubsid up ni hte ellc, ncisuag se.gwnlil ihsT is teh strfi est.p heTn uydo' tge teh cmlaciu liupdub ni eht llce and lvutneea abeoiracn slygcli,oys aginscu calcit idac octonprudi nad drolewe ...pH btu hist papnehs alter adn nit's eht deitrc ceusa of cluralle gin,lslew ihwch is twah the qntieous si erft.a

aneurysmclip  can we have a moment of appreciation for Dr Sattar +9  
makinallkindzofgainz  blessed be His name +5  


submitted by yb_26(191),
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My meipsl dsnidgrutnena is htat 'spt reaht yocirattcnitl si edearecds eud ot MI =&tg; rteha actn' upmp a tol fo ldboo ;g&=t sdrieecna pkbacu oflw oint unplarmoy lartucavesu =t;g& neidscaer CPW.P

oeMr olbod ni alnompryu arlvcustaeu ;t=g& tyhe illw atdiel ni reord ot tjus epke lla ehset olodb ;g=&t saededrce uoamylrpn curlsvaa sceatrnsie

raeescdeD icdrcaa uottpu g&t;= ieprelhpar sotstoivnnoircac t=&g; randeices imstsyce caslvrua senistarce

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. +1  
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(272),
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MHG oCA aRucstede tirhsoinib rptveen eht rlevi mofr nisgztneiyhs its own slo.oleehtrc nI rdeor ot inatmain ist ende orf ,leosrtelcho eth vrlei has no hcoiec by ot canseeri ist LLD rctoeepr eiepxsosrn ni rerod ot ekat ohsrtlocele rfmo the ooldb.

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 +3  
madden875  stop whining. no one asked you to buy the exam^ +3  


submitted by neonem(503),
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iTsh ttainpe s'tin ,vltygnntoeahipi 'rheyte HEYe,agPnRnlvitit nheec teh 2PCO t;&l 40 mm .Hg

Let's alwk it dcrakaw:sb Teyh aer lnnhpariyiettgev ot eceaspmton orf eht boaetlmci acdsoiis cuseda yb wpdrieeads opax.hiy letinaperinHvgty olawsl yuo to wolb ffo eorm 2C.O

Wyh are they yi?cxpho Teh oerspn is piyoxch ued ot malfitniaomn dan tueca rairyeprsto sstdsrie nysmdroe omfr hte ou.nnmpiea lAl teh cnketisoy orfm the mrmafantylio lecls ausec eesnrcida molyarupn ayrciapll eagal,ke iwhch colbks up eht aovlrale namemebr os thta O2 nc'ta get orguhht to the o.bodl

Why od etyh vhae metloicba ssadiico in teh stfir ?cealp oN yxngeo ;g--&t on letecrno tpnarotrs ihanc adn no TAC t-&-g; ccatli .icsoidas

diabetes  no pneumonia it is UTI +2  
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) +7  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by neonem(503),
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hsTi eatnpit 'itns optn,hilyegantiv ee'hrty ,aRiiEenttHnPlgvY hnece eht 2OCP &t;l 04 mm .Hg

'stLe walk ti caa:wdbrsk heTy rea itiaplrtvnngeyeh to teesocnpam ofr teh cablmeiot isaoidsc euadsc by warsiedepd .oapixhy Heiiryltpngvtaen wloasl uyo to wlob fof erom 2OC.

hWy rae ythe ?xoihypc hTe ropsen si ciyoxph edu ot amiatnolmnif nad ecuat yosairperrt sssrtied yndmsero ofrm the imnaeu.npo llA the tkiocnyes fmor teh tmaiyorlmafn cllse ascue daisenrec yaunormlp ayapicllr geeakl,a chhiw osklbc up het lvareloa merneabm os ttah O2 ntca' etg hurhgot to eth l.bood

Wyh do they ahev emilcbtoa diacssoi in teh fistr e?cpal oN goynex tg-&;- on cerlteno tasprotnr icnah adn no TAC &t-;-g accitl csiida.so

diabetes  no pneumonia it is UTI +2  
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) +7  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by nwinkelmann(258),
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I dfnou a pcetrui gnhoisw the inmtnosrsisa yb wot gtseyzerouoh plaha ssiathemlaa triat iansa -c)seodinleit( estr,nap adn oiefmidd ti ot salo wsho hte htnaiiercen by two yeszhgouorte aphla taamslahsei icrfana (in-oslnart)edet rap.etns reeH uoy :og thRHT9mdE9v8d/pineetuvnwOI/lrPVWwTgooJsd2d:14cghoQ1.Jc?eiq/w.op7U=

makinallkindzofgainz  broken link +1  
drdoom  broken link +  


submitted by sajaqua1(462),
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maPasl nsmrebema rea a idpli ybalei,r lyitypcla tihw pahhtsoep dahes on haec saceufr nda gnol banrco atsli on the ei.idsn Teseh arsbonc are trleaun, dan doegunr oobydpcihrh oeciistnatnr orf na netlrcalieeyg elaaovbrf ate.st

aegItlnr mrmeaben esinprto spsa hhougrt isht ilpid bi,rylae adn os ustm eb lbcaaep of gitnncretia tohb iwth eth lraop soveslnt of teaurnrlcaill nda ellcuaxtearrl ,aceps as well as eth idbropcohhy eocr of hte ey.rla heT aemnrestamnrb oriopnt nteof ash aill-hahpleac aoncreyds faoomn,tcoinr hwti rdcohpbhiyo esrsidue eilk ncelygi on eht tueoisd rdtoswa het acbnro tlais ihtw prloa amnio icad eesidurs ektudc .in

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


submitted by sugaplum(235),
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sayalw emerrmeb htme ni derro twhi m,lfoaur =TIISAESE
adn hte two no eth DNE are TNOUIDC-AD

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? +1  
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. +  


submitted by sugaplum(235),
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yslawa rebmreem temh ni erdor ithw f,romaul ISIE=ESTA
dna het owt on the NDE era OIUDNCT-DA

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? +1  
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. +  


submitted by yogi(10),
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PIT - telPalte + Ab sgeo to snepel - esLdy - oLw ptl ottcrnAe.uf mnslceyptoe - ylsaulu ptl nuoct ovpriem and Pripaerehl bodlo maers swoh - HJ bseodi sa a gnsi fo episalna ( nleucra enmartns ni CBR lluuyas omedvre yb l)sn.epe If ehetr was na srcsecoay eplsen hh(icw aws otn inclofunat nhwe the mnia npslee asw r)ionkgw wlil aekt rvoe hte ocnutifn dgayrlaul - JH biosde wlli ipdapaesr nda Ptl srtats to yels - cihwh ahs hedneppa ni htsi aesc oncs.eira

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 +1  


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iodoSeltrsngy rpsateeten the nsik ysll(auu hte f,ete) lavrtes onit hte s,tlborodaem enrset the gl/certsauahn heerw it is lasluyu choudge pu nda hnet dwslolwae ntoi eth IG tctr.a hyeT cna lay eggs ni teh ienes,sitnt adn ehwn the levraa chh,ta yhet anc eeteranpt eth atlnnsitei wlla and enert eth dlbroesmtao iaan.g

makinallkindzofgainz  Strongyloides is fucking metal holy shit +3  


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hTe pehlncohmobrean wudol eb no eth aatucl ufest os tujs etg rid of D).( hTe k"clba "ehlo that eth tsfeu is ongtailf in si eht aestlganiot acs so etg ird of .)(C woN I am on ulatnrsodu perxet tbu I owkn htta hte iinatmoc avityc vteuyaenll axdspen ot eusf wtih the crinhoo erhteby eamgnilitni the inihoocrc tvyaci .)B( In tsrme of werhe the inmtaoci cayivt is nsowh ni hsit migea, I ma otn ,esur so amyeb meooens cna help but shit lsevae the kyol sca hiwch tayypclli esrppaa twinih eth nttogesaali sca aruond 55. .kewes

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) +3  
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. +4  
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(192),
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tdleelmubs hsa a ince uonncmpei orf eth dlielk :invcecsa

etRs In Paeec s:alyAw

ebsiRa
lenafzIu n
loioP a)lkS(
ta Hetiips 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 +  


submitted by monkd(17),
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Am I rzcay ro idd lowrdU otn ahve a ieostqnu htat sadtte tSstnia rae eth tsmo efcfeviet grud eedgrsrasl fo alnbsiee i.dplis shTi gilco etwrh ym f.of

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. +13  
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 +3  
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 +9  
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 +1  
cbreland  "Statins are always the answer", "Fat Female 40 Fertile", "Fibrates can cause gallstones". I feel lied to +  


submitted by wired-in(61),
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itcMnnaeaen dose mfuorla si sCs( × Cl × ua)t ÷ F

ehrwe ssC is tsdtaty-eaes gaertt saplam c.noc fo grd,u lC si alcrecaen, tua is aodseg traelnvi m;pa& F is iat.ayobiliblvia

Nithere sagedo evilratn orn aybiaiioblalitv is engv,i so ngoigrin setoh a∓ puiggngl in eht ubrmesn (aelurcf ot ortcnve nusit ot d)g//:kmayg

(2=1 /mgLu × 1 00/g0m1 )gu × 90(.0 /ghLk/r × 0010 L/m1 L × 42 h1r/ dya)
= 5.922 ay/gd/gmk

c..i.hwh ni'st ayn of the rswaen hcicseo l.sidet eThy tusm aehv dnerduo 900. Lk/rhg/ ot .10 gL/r,h/k adn ognid os ivesg ayxtlce 82.8 /gmykag/d hoe(cic )C

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +53  
hyoid  ^^^^^ +11  
seagull  lol..my math never worked either. I also just chose the closest number. also, screw this question author for doing that. +6  
praderwilli  Big mad +8  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +14  
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 +1  
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 +1  
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 +1  
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 +11  
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😡 +  


submitted by rainlad(20),

my approach to this question was to eliminate all the answer choices that mentioned specificity or sensitivity, since the data here did not provide information about any sort of screening test.

that left me with two possible answer choices: I eliminated the one about consistency of other studies, since no other studies were mentioned in the question stem.

not sure if I oversimplified things, but it led me to the right answer!

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? +2  


submitted by aladar50(37),
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For eth C,GE I iinliytla ohugtth ti saw 2dn edereg epyT 1 eacsebu it edmsee taht eth RP rsalvneti erwe ainecrgins tniul a etba swa ddorpep, tub fi you olko at ti ,loeslyc smoe of eht P esvwa ewer hdined in eht SRQ spmxleco.e If ouy oncite ,tath ehnt ouy can ese ttha heter rwee ruegrla P esawv nad rgrulae QRS sm,eeoclxp btu eerth asw a opecltem aosctonisiid bnteeew hemt wchih msane it asw rd3 eederg heart bockl, so teh snwera was ibanalot raen eht AV n.oed

yotsubato  answer was ablation near the AV node. No it wasnt. It was ablation OF THE AV node itself. Which faked me out. +8  
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  


Seems like I did what most of you did. I read the "symptom" as pain and went for PGE2.

Turns out if I had just read the 2008 paper Undiscovered role of endogenous thromboxane A2 in activation of cardiac sympathetic afferents during ischaemia I would have known that TXA2 MAY be a cause of MI pain. https://www.ncbi.nlm.nih.gov/pubmed?term=18483073

There are also theories that the pain is from adenosine/bradykinin/acid/ROS/5-HT which you can read about here:

https://www.ncbi.nlm.nih.gov/pubmed?term=10099685 https://www.ncbi.nlm.nih.gov/pubmed?term=10222339 https://www.ncbi.nlm.nih.gov/pubmed?term=11458709 https://www.ncbi.nlm.nih.gov/pubmed?term=12411532

I found these via the UpToDate page Angina pectoris: Chest pain caused by coronary artery obstruction which does say the mechanism is "complex and not entirely understood."

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. +8  


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natetiP is tcurern s-eetfar,db os ew can eaimenlit cufsoert rtcse(fou is dunof ni hyoen adn iftrsu nda smeo uof,mlar btu not ni eabtrs m)ikl. teatinP ash cdenugir uetascsnbs tbu on ogseulc ni teh i,reun os eh tmsu msoe eoungn-clso r.ugsa My drfelniatfie rfo eriungcd cselnug-ono rgasus ni eht urien is srsdordie ceotsurf selmioabmt or lgtacosea mtob.elsaim We vhae mteeadinil csufro,et so that svaeel su iwht iscoatgalneka ifdceneiyc or sisaccl tgoc.ealamasi

sympathetikey  & Galactokinase deficiency would be much milder. +6  
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 +  
makinallkindzofgainz  @almondbreeze; Glucose-6-phosphatase deficiency is Von Gierke disease, they are not referring to G6PD deficiency (an entirely seperate disease) +5  


submitted by yotsubato(806),
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alascpPanriee is cbaalylis rata"Pcenic E"ymensz ni nfyac stanp ENMB dolrw

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. +3  


submitted by thirdaid(8),

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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bgoAmsuui tuniqseo btu ni eseacub it is raley ksco,h teehr si tno unoghe ietm to ittaceav het AARS to crnseiea enkyid sirfeupon.

makinallkindzofgainz  This is not an ambiguous question. It makes perfect sense. +3  


submitted by imgdoc(128),
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I tnhik aotl fo leopep timgh hvea vroe ehsemizpda who tamtoprin NPA dan PNB ayrlel rea, yse ti is mtoipnatr ot onwk ehset eptsepid etg srtecede yb eht aiaittrrevrl/naucl amomuidrcy nuigrd herat fuiearl. ewHvero their elloarv evfietssecnfe ni ittrgnae rhaet laeruif is lcz,hi a prtpcreoe dolt em htta if PAN and NPB erwe so uflsue ni initrseraus hetn wyh do we ivge sritdue?ic Ist' aecsebu SAAR resvoepowr sith sysmet ceenh agcsiun teiagvne fesecft dna the ldesnes olop fo arhte ifleua.r AKA yhw we egvi ECA s.rniiithob

ownnKig atth PNA gtse antedirzule by eht RAAS ,msseyt we cna ihstf uor fcous cabk ot ahetr iuaelrf in shit an,etipt erehw dcicaar puutot si cded,raese glaedni to DAH csenroite dan linafyl duinllitoa naapyhe.itorm

almondbreeze  a concept continuously emphasized by uw, but I get always wrong :'( +1  
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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esPale acn yuo dinylk shaer NBME 22 nad 32 unotesisQ ithw me . I yoln see eht eswasrn but I do tno veah eth lluf uhnksT?qoeis atn ni eadnacv

makinallkindzofgainz  I think you may have this website confused with nbmequestions.com +6  
teepot123  why don't u buy the exams like the rest of us? +2  


submitted by rogeliogs(8),
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Tihs Qsniteou sti baotu ryarostipre bustr

ettinsPa hiwt PAHND odf=ccincinheeciyr ugamaonotruls deseias (G)CD

enEv huhgot pisntaet iwth CDG 'ctan kema roduexep,Si teyh nca eus it rofm teh tabaicers dan tcoevrn ti to lbaehc OHCL dan llki eth s.acrietab

TUB iaasectbr ithw tsalceaa syemenz ainzrueelt terhi now opdxeriuse dna thtas ywh the GDC titepna anc't klli ethm.

aetsalCa ivoipste saarcebit: S. usurae - ilAusesplrg

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  


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tNo %001 rseu on tihs eno, btu e’srhe ohw I apocardehp :it hmitsaien asecus tarrelia itladoni edeacrs=d(e earlartoir i)teesnsrc,a tub lal of ahtt ldobo ahs to go rmoeheswe senci uoy onw eahv rmoe bodlo iglowfn hgthuor the searirte dan atth ewermseoh is hte lisaelicrpa ircde(anes yaacllpri taicoryhdst pssru)eer. einmtasiH ssceua acdseiner itlreibapmye fo het pos-crpaytlail sevlenu n(eo of Dr. ttsraSa’ vaioterf tcaf)s so yuo’d avhe eaersdnci yllaarcpi oartitnlfi rae.t

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). +7  


submitted by moloko270(60),
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sols of dfuli geirstgr rtdeoaoesln onpud,tiorc os ntpieat wlli evah neyratpaimehr dna oalekipmyha as a rltseu

makinallkindzofgainz  dat RAAS +2  


submitted by usmleuser007(326),
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oertMh is ghn-Re t-&g-; ehs lliw etanerge Ran-Hoisi1eb) td setfu eafetdcf by A-Rnthi fi ti si eip)vRoisth 2- evne fi vs-ROteoihP-i is i,gven hent llsit m'horste eitR-anhbdiso lliw tatakc usadrsfent lodob due ot its cells noiacgintn R+h3) reehfotre, ge-aeO-hivtnR is bste

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(79),
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I efel dubm fro nkagsi ubt acn eesonom nilpaxe ist?h fI his septnar ear of elcos to ramlon IBM adn rae orenedcnc auobt his ewihgt hwy duwlo hyte eb liwlnaog ihs lraceoi potocsnumin ot deceex shi neergy di?npeeuterx ( AKA intletg hte idk ate oto hmuc nad tno eerxicse ge)ohnu

meningitis  That's a modern day mystery. +14  
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. +2  
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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hWy lwoud you ska eht etatinp to yfdnitei eht rspo dna cons? I dnot’ tge the acrpphao !ehre

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... +4  
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(413),
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I thog:uht orelw elop etnh ncat eb nreaupsarl nor mhaotcs hwcih aer ier"hg"h

unmuoeDd nad odBy fo saenrcpa pt(cexe )ltia rea petroarltnoeier dna lenidim

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 +  


makinallkindzofgainz  upvote for credible source +13  


submitted by welpdedelp(198),
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Tihs is a-bEtaLtm,nreo hwhic mesrpoiv wtih mmetnevo sa admoepcr ot hMteiyensa cigasar hihcwh owsnres wiht oentemmv

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 +9  


submitted by someduck3(50),
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taF uoelbls amntvsii ear AED,,K., oS hbto D ;ma&p E dcolu be aeeeddrcs ni iths p.t Btu oyu heav ot onkw atth amVniit E iececfnidy is dsitesocaa ihtw innyilamteedo &pma; has ebne taceaissod hwti pioerstor olcnmu iei.nmalonyted Asol tiV E acn be gienv hwit lrhiemAez tntepsia as ti ehspl htiw free ?ic.a.srald

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(20),
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tepS yb :tspe

  1. pH = owl = ioisacds
  2. OC3H = lwo = osicsiad
  3. C2O = ihhg = aisciods

o,S hawt e'vI nadelre si ,ttah ni eess,nce citlombea sidscoai wslaay atesk iipyorrt in seeth e.rsoiscan s'tI tndivee htat teh nopers is nto ncioeams,npgt ubt uyo anwt to etclaaclu aynawy by sgniu tenrWi = 5.1 H3(O)C + 8 .
f I uoy alatucecl yuo wlil ese that hte eexetpcd si .03.5

  1. fI OC2 si ghehri naht dcpextee = acintnoocmt traipersoyr cissoadi
  2. fI OC2 si rolew nath detexcpe = ctncntaoiom spiotrraery osikllasa

eerH it si eirhhg tahn eedpxtec (5)6 os toconatmnci riateorpysr caiod.iss

I seugs fi you tdwaen ot rtsta hwti eth sryrrtapieo sdicisoa you elowvud' nteka onti iodraceitnsno thta abateobrnci hues'vldo oneg pu to tpmnec.aose It nidt'd so is't su.nemopetadcn Not ures if e'tsrhe a frumoal to eclalutac the etorh fsuft

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(48),
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Gslcuoe si asttd-ooncprre onit tyreceonste of SI via osmdui

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...? +2  
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 :) +1  
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(48),
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esclGuo si prsat-nocoterd noti yeertconets fo IS iva osuimd

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...? +2  
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 :) +1  
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(48),
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oDnw syndmore 2dn mrteisetr sercen (llusuay drnuoa k1s)8w6-1 hsswo racsddeee FPA, letiosr adn irdaceens GhC nad ihbiinn .A

fO itsmryo 1,/213/18 wDon dynSmroe is hte lnyo ot evha na levteede GCh

makinallkindzofgainz  "Down Syndrome has high HI (hCg and inhibin)" the relationship between the words down/high really stuck for me +1  
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) +2  


DKA is a state of decreased insulin; since we know that insulin causes a shift of K+ into the cells low levels of insulin will prevent this and result in hyperkalemia. In addition, due to hyperglycemia and high ECF osmolality water will shift out of the cells into the ECF and K+ shifts out with the water which will futher increase the hyperkalemia

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(25),
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roF hist oen I ktinh thwa yuo had to wokn si ttha iTrptsancrnoi RAAtN()&D;-g-N is mrepoedrf by ANR oryet ep.Ilmas asw tno NDA osylrmeape ubsecae stih neo rptseclaei D-A-;(NtA&)NgD

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(806),
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nI ygi,lboo hspae vaoiriatn si a dmoeht orf niagled iwht ridpyal gaivynr tnrnseovenmi thtwoiu uinergirq dramno .iutnmato It osvivnel teh aiaovnirt of pretoni rpnxeies,so tequnleyfr ni na ooffn- o,nshfia whntii dfneifetr parst fo a bielaacrt pt.oluanopi sA schu het phteenypo nca citswh at usrcefeqein tath ear uchm hgeihr sotsemime( >)1% tanh saialcscl uaomnitt setar. haePs iaiantovr sntctrobuei ot eluenrciv by tenegraign etyroe.getihen ughhAlto it ash been ostm ooycnmml tudesdi in hte teoxntc fo iuemmn son,viea it is dbevores ni anym rheto araes as llew nda si lmeodeyp by rsoiuva yepts fo itcabr,ae igcnlundi eoaSmlllan eepcis.s

a.:daaineo//w/pcehsrwatoP_twihnwivkwinm/s.t

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. +3  
makinallkindzofgainz  This isn't in Zanki, Lightyear, or First Aid, and I don't remember ever learning about this in class. Thanks NBME! :D +16  


submitted by usmleuser007(326),
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nI scase fo cidhl or tudal abuse

)1 if etreh si eaclr veenceid scuh sa if a clihd ttseas ttah apnetrs sunhip by htgitni, hidlc si gwhison rfea of anetrp ---- lcal lcihd trtooepinc rhtgi waay ( 'dton nede ot iwat adn )aks

2) emsa itnhg egos orf het luadt utb llca hte tadul noicptoetr csservei

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. +6  


submitted by bubbles(63),
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oriChnc eranl icyfc:enfiinus

)1 oopr eshapthpo lccaaeenr gt&;-- ghhi mesru rnnigcoai ushhospproo

)2 hihg urmes ahpespoth t&--g; semelcpxo thiw nledavti ainotc aC t-;-g& Ca lsfla

3) aC lafls -&g-t; etrsigrg HPT xais

4) dneyik aurfile g--&t; reesddace tcavyiit fo heyys-o1ardlx ta teh nykide tg--&; lsse lalticoirc

makinallkindzofgainz  this guy renals +4  
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(517),
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CCD cdemedmeonr tmttenrae of ioathmssocs osamnni is r.nuaztpqaeli

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 +11  
rockodude  ya until step 1 fucks us with some esoteric cdc guideline +  


submitted by emmy2k21(22),
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Jsut a cmmnenio ot epek crtak of csae octronl w/ dsdo troai nad octrho w/ tvelerai .srki -niCokR:hl atOCsnTe ilatyetonlinn eisdlmepsl rof sdod iaotoCrohRRt for teliaerv sirk

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 :) +2  


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It idsa it asw taafl to lames in ro,ute and teh tqnoiuse adesk auotb veil rnbo rffpo.ngsi nSeci eht semla tr’nea engbi rbno in hte ifstr ec,lap I iads %05 almseef adn %0 es.lam

hungrybox  fuck i got baited +26  
jcrll  "live-born offspring" ← baited +11  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  


submitted by uslme123(44),
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reyv updsit .notsiequ heT rsivu was hdlenia -- satb angh iupdse enhw eyth sepel nda doo.rl oS ti aseprds ot eht abrni tyiredlc mrof eth afootlyrc ytssem avi eaerrdogtr rantsprot utogrhh vee.rsn

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! +  


submitted by usmleuser007(326),
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If you du'ntocl eemmrrbe ihhcw wree estil;neas then eiaanltvert ldouw vahe eneb to iezlear taht iwoggrn hnlriedc eend escll to evidid. hTsi srqureei DNA iraltepocni nad t.tlnasraoni fO hchiw eth lcucien cadi iyhetm is ato.pnritm tI euqreirs a yehmtl retanfsr.

hsTi si hewer nmehiionte meosc .in teehMionni mcinsoeb whit PTA ot orfm MSA a( thyeml orno)d

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 :) +1  


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i llef fro elgndbie morf inlsoe at oeshc sisrspaio btu osaiiprss spt xripecenee t.ncgihi l,sAo hte irubdntitois si ton e.cratthrsciaic

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(326),
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stju a hh.u...nc zoraOelpem si ywalas eth higrt anwers

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 +4  
cry2mucheveryday  same doubt..marked miso +1  
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(42),
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rbtlaOi rolof ucrrteaf:

1- iboInaartrfl vrene r:uyjni Nnesubsm dan ssreeaphita fo the rpuep c,hkee upper l,pi reppu gv.iniga

-2 mpaEnnettr fo het irefiron uresct eumcsl: rImpeiad uardwp zaeg

3- amoitoEsnhlps

-4 sogulnCi of lmirlayax s:iusn roperadT insg

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. +3  


submitted by hayayah(990),
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eCrettah mctane:lep

0/oelp6t:jot00ycpd0peia//wp/s/h4g8n0emsaku../eta-ntn8o1g/mc2es

eacRll ttha the ugln paxe dxseetn eoabv eht rsfti .rib

hungrybox  His expression is so blissful. U can tell they're shootin up some full u-opioid agonist codeine type of shit and not some shitty partial u-opioid agonist buprenorphine type of shit or some shit like loperamide that doesn't even act on the CNS +26  
rerdwins  even better, if you recall that the esophagus is RETROperitoneal ( its in like half the answer choices). hence, to get to it you have to go WAAYYYYY deep ( like rick and morty smuggling shit). after that, the lung option makes the most sense. +9  
hello  Also, pulmonary artery is way too far away to be damaged by internal jugular vein catherization. +  
makinallkindzofgainz  @hungrybox my mans just slipped in 3 high yield facts within a joke +2  
makinallkindzofgainz  @hayayah, I have an issue with that picture unless I'm missing something. In every other source I have, the internal jugular vein lies LATERAL to the common carotid artery. The picture you provided shows the internal jugular veins medial to the common carotid artery. +1  
cmun777  Look at the other side... I think it must be the manipulation of turning the head to the opposite side that better exposes the jugular for catheterization purposes +  


submitted by hayayah(990),
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ehtrateC anpcetelm:

ehc2s/4u0jc/l/od1ei0asn:gktpntte.-/p/p/8s0agw.80enop06otmay/em

Rclael ttah hte lung axep xedetsn obvae hte tisfr br.i

hungrybox  His expression is so blissful. U can tell they're shootin up some full u-opioid agonist codeine type of shit and not some shitty partial u-opioid agonist buprenorphine type of shit or some shit like loperamide that doesn't even act on the CNS +26  
rerdwins  even better, if you recall that the esophagus is RETROperitoneal ( its in like half the answer choices). hence, to get to it you have to go WAAYYYYY deep ( like rick and morty smuggling shit). after that, the lung option makes the most sense. +9  
hello  Also, pulmonary artery is way too far away to be damaged by internal jugular vein catherization. +  
makinallkindzofgainz  @hungrybox my mans just slipped in 3 high yield facts within a joke +2  
makinallkindzofgainz  @hayayah, I have an issue with that picture unless I'm missing something. In every other source I have, the internal jugular vein lies LATERAL to the common carotid artery. The picture you provided shows the internal jugular veins medial to the common carotid artery. +1  
cmun777  Look at the other side... I think it must be the manipulation of turning the head to the opposite side that better exposes the jugular for catheterization purposes +  


submitted by hayayah(990),
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aynodScer mitpydehhyrarirsoap ly(luasu t/d ohrccni eanrl if.rle)ua

aLb fdiinsng ucdinel ↑ PHT onpss(ere to wlo icc)a,mlu ↓ sruem cmluica n(elra aiu,l)ref ↑ rsemu hpsheopta ae(rnl rufi),ael nad ↑ aienllka thaapshpoes PT(H tcviitnaga sott)e.sosaBl

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. +1  
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