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Comments ...

 +2  (nbme20#35)

I can get behind splenomegaly, but what is the disorder?

sup  Felty syndrome, an extraarticular manifestation of RA. Symptoms include a triad of RA, splenomegaly and neutropenia. It's in FA, you just have to squint (look at the fine print under the RA vs OA table in the MSK section).

Subcomments ...

submitted by yotsubato(364),

Why is the patient not in pain. I wouldnt expect Incarcerated hernia to present with zero pain, but 1 week of constipation and swelling.

yotsubato  Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Like really? Why is he not in pain? +1  
medschul  I thought that inguinal hernias were reducible? +  
fahmed14  could be a femoral hernia as they are more likely to cause incarceration. They do, however, present more often in females. (FA 2019- 364) +  
wowo  incarcerated, not strangulated, thus no pain as there's no serious tissue damage/ischemia. Incarcerated hernias may progress to strangulated in which case he would have pain Under section, "complications" https://www.amboss.com/us/knowledge/Inguinal_hernia +  

Why is alternative splicing or post-transcriptional modification incorrect?

tea-cats-biscuits  You just have to know that POMC is a pro-protein that must be cleaved; not sure if there’s anything in the stem that would really have given it away. +  
mcl  Dunno if this helps, but it says "this protein" (singular) is the precursor of two different protein products. This must mean that the modification occurs after the protein is made, which means after transcription and splicing has already happened. +9  
ngman  Also I believe mRNA refers to after the splicing already occurs. If the protein products are from the same mRNA then it can't be alternate splicing. +  
medschul  They're cleaved by tissue-specific proteases +  
duat98  I think: Alternative splicing occurs with hnRNA not mRNA. You get mRNA from alternatively splicing the hnRNA. an mRNA can only make 1 type of protein. Since the question says the 2 proteins comes from the same mRNA it cannot be alternative splice or post transcriptional mod. FA 2018 page 43 has a good illustration. +4  

submitted by shaydawn88(6),

Is it intra-alveolar transudates because this patient might have HF d/t a. fib and left atrial enlargement-> inc hydrostatic pressure-> transudate pleural effusion?

sajaqua1  Basically. +1  
medschul  Why can it not be arterial hypertension? +  
meningitis  I think Arterial HTN is referring to Pulmonary Artery HTN which would be present in LT HF in the long run with RT HF and edema. Pulm HTN would cause a backflow, and doesn't really answer the question "explain the patients Dyspnea". At least, that's how I saw it. Hope this helped. +2  
sugaplum  the question has 2 murmurs, so does she have aortic stenosis too? i guess it is not relevant since it asked for what is causing her SOB +  
nukie404  I guess pulmonary HTN would happen in response to increased pressure after the edema happens, and would cause backflow (to the RV) over pulmonary edema. +  

submitted by welpdedelp(101),

No diet deficiency, the patient had excess carotene due to his diet

sympathetikey  Would never have thought of that. Thanks +4  
medschul  that's messed up dog +5  
hpkrazydesi  Excess carotene in what way? sorry if thats a stupid question +  
davidw  this is directly from Goljan "Dietary β-carotenes and retinol esters are sources of retinol. β-carotenes are converted into retinol. (a) Increased β-carotenes in the diet cause the skin to turn yellow (hypercarotenemia). Sclera remains white, whereas in jaundice the sclera is yellow, which can be used to distinguish the two conditions. (c) Vitamin toxicity does not occur with an increase in serum carotene" +3  
davidw  β-Carotenes are present in dark-green and yellow vegetables. +  
hyperfukus  ohhhh hellllll no +1  
dashou19  When I was a little kid, I like to eat oranges, like I could eat 10 oranges at once, and after a few days, I could tell that I turned yellow... +2  

Patient has a ganglion cyst, which can spontaneously regress.

medschul  Mine would beg to differ >:O +3  
usmleuser007  Where would I have come across something like this (FA, Pathoma, or out of my S)? +1  
motherfucker2  I thought this bitch was a lipoma. Mother fucker +1  
divya  mf2 lipomas is fat. although fat may exist in liquid form, its still opaque, therefore negative transillumination. unlike ganglion cyst. +  

Tamoxifen has to be metabolized via first pass metabolism to an active metabolite (endoxifen). The patient has decreased concentrations of the metabolized product indicating that the patient’s pair of cytochrome P450 alleles aren’t metabolizing tamoxifen correctly. The question is asking what the chances are the sister has the same genotype, which would be 25% --> 1/2 * 1/2 = 1/4

medschul  How do we know the parents are not homozygous +1  
yotsubato  Chances are they are not unless they had or are incestuous +  

submitted by seagull(529),

Couple ways to get the answer. 1. sensation of the anterior thigh and medial leg are by branches of the femoral nerve (L3, L4, L5). 2. Since the anterior thigh is affected the platellar reflex is likely affected which is a branch of L4.

medschul  Isn't the femoral nerve innervated by L2-4? +1  

submitted by meningitis(199),

When standing up, the body normally activates sympathetic system to avoid orthostatic hypotension.

But since there is now an additive effect of the pheochromocytoma adrenergics, it will lead to a hypertension

(i.e: Double vasoconstriction = Pheo adrenergics + Sympathetic system)

sympathetikey  Brilliant. +2  
medschul  Would pheo have a normal resting BP though? +1  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +5  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  

submitted by strugglebus(84),

The strawberry hemangiomas tend to grow and then randomly involute.

medschul  My problem with this question is that a strawberry hemangioma should continue to grow until 5-8 yrs old so I did not see the answer choice "Continued enlargement as the child grows" would not be an acceptable answer as well. +3  
eliassam1  It says what will happen over the next 5 years......so you literally answered your question. It will grow, and what will happen in 5 years is that it will go away +  

submitted by strugglebus(84),

As an edit: 108,001 people reported to have side effects when taking Hydrochlorothiazide. Among them, 25 people (0.02%) have Breast discharge

neonem  I think the best way to answer this question was by process of elimination. +  
sympathetikey  That's some bullshit lol +2  
karljeon  Haha I eliminated the answer by process of elimination. +10  
medschul  I eliminated thiazides by process of elimination :( +  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +1  

submitted by celeste(43),

This sounds like Fanconi syndrome. The proximal tubular epithelial cells have a hard time reabsorbing filtrate, so you'll see a loss of phosphate, amino acids, bicarbonate, and glucose.

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +2  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +