share email twitter ⋅ join discord whatsapp(2ck)
free120  nbme24  nbme23  nbme22  nbme21  nbme20  nbme19  nbme18  nbme17  nbme16  nbme15  nbme13 
Welcome to meningitis’s page.
Contributor score: 512


Comments ...

 +1  (nbme23#16)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hTe seuqiotn si igsfnuonc ebsaecu a ETUR OSPTVEII sett srluet is niidfgn dgitetecn cneacr by SU e(gos to whos yuo ew ttago okol at wtah het tets si kngloio f.r)o

nA ABRAMNLO ttes eittgnecd raCP smnae sti NTO A IESTIVO:P i:e 35 tuo of 05 eerw ealsF soesviPit

An ANOMLBRA etst OTITWUH aCrP mneas ist ONT A TVE:NEGAI 02 tuo of 100 WHOIUTT ParC eewr AFLES ET.AGIEVN

NT = 08, PF = ip:itSy f5.ce1ci NN(T/F)+;TP /88(+501)0 = A.8nd4% csein it yssa stb"e rre"ptsnees nhte 4%8 si ltsoesc ot %80.


 +4  (nbme22#11)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

uAl,lcaty I oetcrcr :lfmeys I okdelo clrseo dan teh neiGot loafmer ash an anrxelet mpciSater cbhnar adn a nbnigilaomuLu rbhna.c I othuhgt ti aws teh ilnoorfemeatG enrve auseecb eht tnalige rabhcn sassep ohgthru the eped iauninlg nrig, rneets hte lgannuii alc,na oseg ot cistepamr rodc nda espupisl the rtmeearsc dan corlsta kis.n

eHrse hte a:geim arlhpi/dnnc4iwiemtedo/4o/s.roimk/ypie2ip8Gga/u/ko./ga.dwmasp:et

ecrorCt me fi I ma owrng .aseple

gh889  I think you're right, FA2019 pp444 even states that sensory to the scrotum is via the Genitofemoral nerve +4

 -4  (nbme22#30)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ecsrsPo fo taieiinlomn on tsih en.o

  • I itlnmdieae bmoyrlCa sapohept,h gnneArii ued to earu cc.yle
  • I emaetlnidi APT ceuaseb APT anole tduoln'w gnceha PF6 onit iugmnslocea
  • NAG I otg uklcy and I damniletie it deu ot sti ues in ECM nad ncolgael os I 'ddtni tihnk it aws renalevt dna I nikd of ermedberem it eignb ni reau .leycc
dr.xx  you mean, pure luck? :) +13
impostersyndromel1000  lol pretty sound logic here mate +2
nor16  same here, Glutamine is a NH3 (-amin) donor, so guessing made sense +

 +4  (nbme22#38)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Autohhlg i’ts botua ,PVP hsit aheigrsercn ehplde me nsdtrdneua csaib s,hpy I oeph htsi lhspe yeenevor ni osme ay.w

Taaayekw: urgiDn ,VPP uenosv rertnu eeca,edssr acicdra outupt ssde,aecer nda tahre eerssspur ederacse ni the rtihg eids of the ra.teh

yWh odse VPP esrdceea suenov ?rrntue

  • onitaihratccr rspreseu smpesoscre atrh,e igcasnu oblod not ot ternur

seauCs for sdeeadcer ftle crravnlutie ptuotu urding tian:ivnloet

  • hniiftgS fo lertiauitnnavcrr tempsu ot tLfe edu to nrdcieaes VR mouvle
  • rasedeDce evnuso errunt
  • snCehag ni hetsar liatbiy ot octnarct deu to espiovit reresups
  • lkac of O2 ot arteh

mNlora rmncsoyopaet samschinme for giniantaimn CO adn PB dguinr PV?P

  • neircesda RH ot psnoemteca fro dercedsea SV
  • recnieads SVR ot antimina PB

tOerh sPioclgoihy s:epenorss

  • dseercaeD reaebrcl fiuopnser serupers o(’sybd noesserp to a lfal in PPC si to eiasr cmiytess bdolo reepusrs nad latide recalrbe obold sses)evl
  • seDrdaeec aelnr pifseunro encdars(Ie ADH, RAS,A nda iPeattn sah lnera orlbpsme os ednicrase acrteinine adn ruic ai)cd
  • Piossleb iloiuntntrma inrcdseae( sgcoleu iva ongnolicgeesseu tc.e)
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +26
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1

 +4  (nbme22#32)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

A seca tonlcor ytdsu ctna asssse hte alcveprene of a seeidas but a ssrco anelsocit uytds .acn

  • A caes noclrot usdyt si ttah uyo aer etgtnis eht ganmirs in hte 2 by 2 lteba ethrorfee uyro'e ideindgc ohw aymn scesa and sltoconr uoy ntaw ot avhe in uroy tuyds and het aclnutacoil of icnenidec / enrlpevcae in htis noaeirsc oudlw be .ieasbd
meningitis  the prevalence of the exposure and the health outcome are measured at the same time. You are basically trying to figure out how many people in the population have the disease and how many people have the exposure at one point in time. Case Control would determine ODDS ratio Cohort would determine Relative Risk +3

 +4  (nbme22#30)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I tthh:gou orewl lepo nteh natc be sranpraelu nor cohtsma hcwih rae ghr"hie"

mouDdneu dan dyoB of ncpsaear xep(cte )ialt aer orpreraetietlon dna imidenl

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 +

 +6  (nbme22#19)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

wingE csmaaro lcles olko like lmlsa blue romyaerhctipc ellsc sceubea ehyt era lemoonuetcdrrae oiirgn )PET(N dna ear froeehetr daertfendfteniui whit ighh N:C ioart.

soAl meermrbe 11+22 lisnttrnooaca E(WS geen no oosemcmohr 22 dna teh IF-L1 egne on hsreoomcom )11

e,haY I hguttoh hte msae dw@erpliirla uota(b het ocentcrnci yrals)e

kevin  just for people who are taking exam this year, ewing is now understood to be mesenchymal stem cell neoplasm (uworld) +1

 +2  (nbme22#11)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

"icPk oruy Big, ioeaFm, Zrbeai eosn hitw yoru gpSenh"ri

seChoo iosonpt wthi het eeltrt I.

IipgoySlnne,m haielpgoy,mnnSesi bgagonIrs tlga(epaeyomh cte,) zrbaeI oiebds, mFoa elcls


 +14  (nbme22#18)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Trnnae segtas tarst ta TNE reyas dol

geaSt I :

  • I is lf,at sa in tlaf esct;h
  • I is ael,on sa ni no lasuex srh.ai

aeSgt II :2() gatse II tstrsa at 11 y/o I(I oolk lkei 1)1

  • 2 sallb ier(tstuacl geertlnanem)
  • 2 srhia i(bpuc ihras wno pegpanair)
  • 2 ebsart sbdu omrf

gaetS III (:)3 rasstt at 13 oy/

  • If oyu otraet 3, ti oskol ekli slaml assertb e(sraBt dmnuos mfr);o
  • If ouy lgigeqsu eth III eyht kool kile cruaelry+soc ucbpi ihra
  • adrencesI senpi ntlgeh nda zsie acn be erendeeptrs yb: II gt-;-& III
    y(ruo pseni asw inth II utb won tis hkceitr )III

etSag VI ():4 tsatsr ta 14 /yo

  • sitrF m:gieina hTe I in IV tpernesres eth hhgti, dan het V ni VI klsoo ikle eht nsmo sibpu netbewe uyro ges:l
    NI:NEMGA ouy aevh hiar ni snom psibu V)( tbu oyu aevh a bodrer gdetinnia het irah mfor rinwgog nito ish.gth
  • hTe V si ,yponti sa in own eht traessb ear ontipy reasdi( loraea ro dmuno on on)mud

tageS V (:)5 15 y/o

  • V sah on srdroeb gdeniinat hrai romf ogrgwni noit tshghi b(ipcu hrai + ihthg rih)a
  • 5 e(nsagfsir ni dhn)sa itfnntlage the reoalsa wnhe brngagib meht elr(oaa tetafnl ta itsh gatse adn no mreo d"nuom on d)o"mnu

meningitis  Sorry about the format, it came out wrong but I hope his helps. +1
drdoom  looks good to me! +17
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from? +
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions. +
endochondral1  stage 3 breast mound is for females not males btw +2
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females +
angelaq11  this is just too funny, I LOVE it! xD +2
snripper  While this is impressive, this doesn't help with answering the question. +1
yng  Pseudogynecomastia (False gynecomastia): this has nothing to do with puberty or hormones. Simple d/t the fast some guys have extra fat in chest area, making it look like they have breasts. The boy weight at 60 percentile while height at 50 percentile. +

 -1  (nbme22#20)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I ikhnt eth lmsla rakd eaar on eht tfle heda fo erfum adn teh raenddke eckn rea eht alrsaauvc ets.is

Ncek: bt1pa.csct/op/m1s.gs/dgte/eitt9i.1aep5n//c/5ikjmpmh5mc:d

Hae:d (ubvoois oinsel no eht RT fm,eru btu iiarlms eitescdr isoeln no het letf sa eesn no het tcicapre EB)NM jp/ser5edcopnad1c:aa1hss/tptgt/1o0u0l/.op-/un2.//utwr


 +9  (nbme22#26)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

oyzthdelhriodohrcaoi is CDO orf oipnechrgNe Daseietb psiiinsud acebseu it llyoaraicxdpa scsuae an iseanerc ni BP yb inranceisg isomdu osbatornpi nda hsut twaer ,piornabots aPthmao exanplsi hits yelin.c

peorismenDss si trccroein bueesca pnuo ifgtsan (duilf itcnier)stro AHD is rnasdicee aneimng HDA is enigb reeaslde ylrtalenC tub is not girkwon ni eth nsykdie ta the 2V eorcsrpet fo the pahtlieeli nerla lscel at tigcellCon cu.td

On taht e,nto oimlerAdi is esud rfo tiiuhmL ndiuecd pcehengorni DI.

hello  Where in Pathoma? I couldn't find it. +1
almondbreeze  also sketchy says that thiazide s decrease the amount of lithium cleared--> lithium toxicity +1
paperbackwriter  Agh confused as well because FA2019 (pg 562) says that thiazides are implicated in lithium toxicity D: +
paperbackwriter  OOPS, please ignore last comment. I just realized that this Q stem never mentioned lithium. And on top of that @meningitis mentioned that amiloride is used if lithium induced. Apologies. +

 +12  (nbme22#1)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I salo tgthhuo the msae as sub@lbbe, tbu wno intgyr ot "ysj"ufit hist ciytrk NBEM tqenuois: I nikht tish volvsere no eht tacf taht het ttneaip has a HHIG lodbo pursrees nnmagie we oudlhs uscof on an sewnra ahtt nspalxie boht eisedranc PB nad Hioovylapem (.i:e ancrdeesi ADH chihw nroasvtsocstci adn aols rbboass wrte-fe,rae btho of ihwhc ciaernse BP and uceas vom).yhileapo

ybaMe if htsi nteitap ewer pdeteecsdonam iwth WOL PB, eon odlcu nthik remo otuab NAP.

I llist nkhti sith nsotueiq si OOT cy.kitr

meningitis  Sorry, hyponatremia* right? +
mantarayray  I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia except only thought this post getting the question wrong :") +4
mantarayray  Oops sorry the formatting is confusing: I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia. +2
pg32  @mantaray pretty sure you are right and that is the only way to get this question correct. Remembering that Na concentration really is a measure of water balance is key. If the pt is hyponatremic, that just means they have too much water in the blood, which is caused by ADH. If the patient was hypoVOLEMIC, that might mean they are losing too much Na. This is illustrated by pts with SIADH. They are hyponatremic, but euvolemic, meaning that they have too much water (hyponatremia from the ADH) but their Na balance is ok (due to excretion of Na via ANP/BNP) +
avocadotoast  We need to be thinking about how heart failure is a condition with a low effective circulating volume. Our patient had an MI and now his heart cant keep up with the volume (low CO), leading to congestion. When congestion occurs, water is pushed into the interstitial spaces and isn't circulating in the arterial system. For that reason, the body ramps up the RAAS and ADH despite an actual increase in body water. This is a non-osmotic release of ADH. At this point plasma sodium levels are determined by relative intake and losses and hyponatremia is common in these patients because of that. Also, ANP and BNP don't hold a candle to the RAAS. +

 -6  (nbme21#23)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

oumauqsS dan lSalm lcel acrcmaoins are raentl(Setc) ranl and feton ascdue by gkniSom

liraH mssa C igrnasi morf u;nbrsohc ttn;aar tvitoCieaiC;seg Cpecirhmaylea sopc(eudr tK) P.rreaHTinP rasple D dna tlercrnluiael dbi.sreg

pg 966 9102 FA


 +10  (nbme21#46)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

SLP uondf ni ouetr aebenmmr of ragm iae c⊝btra both( cocic nda dos.)r opedmCso of O teniagn + roec cpsdehyraiacol + diipl A (hte cxtoi m.otpnoce)n

tcieatvsA esgMacpraoh dan incesdu halFNTpa rsaelee ;-tg& nopoHtnieys adn efve.r

gP 133 E.nitdxnoo

zevvyt  and just to note answer b) "induction of histamine release" DOES happen , but it's not the "Initial Event" that the question asks for +

 +18  (nbme20#50)
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hneW aitsgdnn ,pu eht obdy aromylln acttieasv tyhismaetpc metsys to viaod httisctaroo psihentoon.y

utB ncies erthe si won na evdatiid ftceef of eht octoamemhcohpryo c,ragresiedn it lwil adle to a pyonstieehrn

e(:.i leDobu vrcncooottniisas = ohPe isrrnedgeca + mtSetcyhpia )seymst

sympathetikey  Brilliant. +5
medschul  Would pheo have a normal resting BP though? +10
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. +7
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. +
hello_planet  FA 2019 pg. 336 +1
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +




Subcomments ...

submitted by yotsubato(979),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Ahuthglo naeeaimptcnho l()lynToe is ont ncreoesdid an AIDS,N ti too yma roevpko an p-asiinkiler nesitvtyi.is

meningitis  For that same reason (not an NSAID) it doesn't reduce inflammation so it cant be used for Gout. +5  
meningitis  And I think Indomethacin is associated with anaphylactic reactions in patients with aspirin-sensitive asthma and aspirin allergies. Can anyone confirm? +  
link981  How many other's like me didn't see "allergic to aspirin"? FML +3  
hyperfukus  OMFG me too i just got so mad and questioned my whole life at least its cuz i can't read not bc i don't understand :((((( +1  


submitted by yotsubato(979),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

glAohuht anhntcamepoei lenylTo() si not coidrnedes an DSAIN, ti too aym ropovke an s-nliaiikpre neiit.ssiytv

meningitis  For that same reason (not an NSAID) it doesn't reduce inflammation so it cant be used for Gout. +5  
meningitis  And I think Indomethacin is associated with anaphylactic reactions in patients with aspirin-sensitive asthma and aspirin allergies. Can anyone confirm? +  
link981  How many other's like me didn't see "allergic to aspirin"? FML +3  
hyperfukus  OMFG me too i just got so mad and questioned my whole life at least its cuz i can't read not bc i don't understand :((((( +1  


submitted by mousie(211),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

A amaiehmnog si a eypt of gibenn rncos-a(ocuenn) mtuor in taifnns. sihT lmraaonb rcleuts fo amsll dbloo essvles aapsepr on or edurn hte ikn,s yaipclylt hwtini eno ot trhee eweks tafre r.itbh - ww.osgsdr.hlaelohicpwinrtiaH momnaeg si a iylcB/rpVaal kmtrirabh

sympathetikey  Probably a Strawberry Hemangioma since she's a baby +9  
meningitis  Can anyone explain what is option A? +1  
redvelvet  bc, it's a benign "capillary" hemangioma, we can see "thin-walled blood vessels with narrow lumens filled with blood and separated by connective tissue". It sounds similar to "arterioles in a fibrous stroma" but it's capillary. +1  
peridot  @meningitis I believe option A ("arterioles in a fibrous stroma") is describing an angiofibroma. The name angiofibroma already tells you that there is some component of fibrotic tissue involved, whereas in this case of strawberry hemangioma, the name tells you that it's more like pure blood vessels (capillaries in this case). +2  


submitted by joonam(26),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Atceu ro rchcino flataomiinmn fo ldberaylh.urlaMgpd gsi:n sponatiriyr trresa on QRU ltoipanap eud to n.pai Pani yam tdaaeri to irght rusd(eloedhu ot iaitoirrtn of pcnrehi e􏰁vLP.)Aren fi ibel cudt smeceob evvdnoli ,ge( sis.ann itgcchegnoadil)

meningitis  To make sure, palpable Gallbladder is more in cholangiocarcinoma and Pancreatic Cancer? And if it were non-tender, could palpable gallbladder mean gallstones? +7  
yb_26  @meningitis, it is a Courvoisier sign of pancreatic adenocarcinoma: jaundice + palpable, nontender gallbladder +2  


submitted by docred123(6),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Are lal inric/arieitresisettlvtt nulg esesdais ineitdiacv fo a OLW ?LDCO

nlkrueger  only if it's an interstitial lung disease i believe. like polio can cause a "restrictive lung disease" but it's due to muscle effort and would expect to see a decrease in diffusing capacity (FA 2018 pg 657.2) +6  
meningitis  Construction worker, Diffuse reticular opacities screamed restrictive and low DLCO for me. Anything that either adds fibrosis to alveoli, or thickens the diameter between alveoli and alveolar capillaries will cause low DLCO. +8  
305charlie94  Actually polio is one of the restrictive lung diseases that have a normal diffusing capacity for carbon monoxide (FA 2019 p.661) +  


submitted by shaydawn88(8),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

sI it oleaaatvrni-rl ntuasearstd bsaeceu hits tintape hgmti heva FH t/d a. ifb nda elft irlaat nga-etmelntg&r;e nci todaicstryh gtrups;e-e&rs randttusae alpruel oi?fsfnue

sajaqua1  Basically. +4  
medschul  Why can it not be arterial hypertension? +2  
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. +5  
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 +2  
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. +  
vulcania  There's a really great diagram in UWorld (QID 234) that explains what happens as a result of mitral stenosis. Very similar sounding to the patient in this question. +  
srdgreen123  @sugaplum, yes rheumatic heart disease can cause mitral and aortic stenosis. Rheumatic aortic stenosis can be distinguished from degenerative aortic stenosis by 1)coexisting mitral stenosis and 2)fusion of the commisures. +1  


submitted by sympathetikey(1265),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

rPe FA (g.p 3:)66 coengCrinn staebr a.nerc..c

"inmliAtaofpicveeis/oeprorxns fo gngneteet /roerorspsoe tserpcroe ro B-rebc2 ,(E2HR naG EF corret)pe is nocomm; ER ,⊝ RP ⊝, /adeH2n RunE ⊝ ormf oemr .aieg"vessgr

sympathetikey  FA 2019 +4  
meningitis  Why others not it: Anticipation: Trinucleotide repeats; CAG (Huntington), CTG (Myotonic dyst), GAA (ataxia telangiectasia), CGG(Fragile X) Chromosomal rearrangement: Many but can think of Trisomy 21, BCR-Abl, etc Imprinting: Prader willi, angelman Loss of heterozygosity: loss of a single parent's contribution to part of its genome. A common occurrence in cancer, it often indicates the presence of tumor suppressor gene in the lost region. +1  
kai  trinucleotide repeats are not associated with breast cancer Neither are chromosomal rearrangements BRCA1,2 tumor supressor genes are associated with breast cancer, which is why I chose E, but I guess I should have bought the new First Aid.......... +  
charcot_bouchard  GAA is Freidrich Ataxia +4  
tulsigabbard  So is the amplification of the receptors unrelated to BRCA 1, 2? I'm still stuck on this as Sketchy states that breast cancer falls under the "two-hit" model. +  
tallerthanmymom  @tulsigabbard I think one of the keys here is the question stem; " what is the most likely cause of the OVERexpression in this pts tumor cells?" --> I think that the "2-Hit" model would lead to UNDERexpression of a tumor suppression gene rather than overexpression. Whereas amplification would cause OVERexpression of the HER2/estrogen and progesterone receptors. But, I don't think that amplification would be the answer if they were asking about a triple negative cancer. +1  
tallerthanmymom  Also this is on page 632 of FA 2018 for those using that version +  
tulsigabbard  @tallerthanmymom - thank you! +  
drzed  I can understand why @tulsigabbard dropped out of the race--she's taking step 1 soon LOL +1  


submitted by sajaqua1(524),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

The raworm hossw uersrspocr to cteh,yeryrsot sa wlel as aseegratym.ocky ishT is ot swho ouy ttha eht issue nsti' ootn,deciprudrun hichw nmase taht we era lnsgoi RBC dan ealsplett mhsoerewe ei .crndteitosu taTh esulr otu D dna .E eehTr si thnonig ot ditainec ath hte ldihc ash easidtnsdemi tbuouersicls .)(B tA shit nipot ew ear felt iwht A or C. A uodlw naiicdte eDsntiiesmda sacarratlvuIn nCaiouatglo )DI(C ro oigtsnmeh rsi,ilma whhci lwodu rsetul in wol eetpltlsa nda BCR utb ew owdlu oals ees nbaraoml RBC leki tscsoshieytc e"elhmt"( lcl)s.e eW are yepilxiclt dlto atht het shcereyttyro rea ohcmonormcir nda ocynromt.ic rew,oHev uemmin oiuterdncts fo sptlelaet eainlxsp ti -lla eht stduirncoet fo alletetsp dlsae to osme erghngriomha nad os a prdo in BR,C dan ITP slllacasicy erisas aetrf a ecernt ppeur iryatopsrer attcr viarl e.fcitnnio

meningitis  Just in case anyone is wondering like I did, the low platelet count explains thethose multinucleated cells. They are Megakaryocytes in Bone Marrow Biopsy. +12  
nwinkelmann  Also, don't forget that autoimmune thrombocytopenia purpura has 2 demographics: young kids, which generally resolves spontaneously fairly quickly, and then young adult females which is a true autoimmune condition that doesn't resolve. Patient's age + thrombocytopenia + essentially normal rest of heme pannel = autoimmune thrombocytopenia purprua in child. +6  
abhishek021196  That is exactly how I approached this question. Normal heme panel and a decreased Platelet count in a young boy after an infection just made me intuitively select ITP. +  


unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hWat era ew uodpssep to be inklogo ta? I see uiclttuemladen aigtn sellc. I laos ese eailtfnrit an’(tc tell if hits is aloeuncormn ro t).no

methylased  Young child following URI with TCP is pretty classic ITP. Sometimes they throw in extra stuff on purpose, but I didn’t see much on the bone marrow aspirate either. +7  
mousie  I was also thinking ITP but the bone marrow image kind of threw me off too, not sure what I'm supposed to see but still think ITP is best choice ... +  
meningitis  It also almost threw me off, but then I remembered he had low platelet count and I guessed those multinucleated cells were Megakaryocytes (I looked for Megakaryocyte Bone Marrow Biopsy in google and they are the same). +1  
what  Bone marrow shows increased megakaryocytes -> ITP +  


unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ogdrensAn eausc ea.cn oteosrntTese si a ebrtte esrwan htna dondosaltreAni cb/ hte stteoTrsneoe is tsceaiadso iwht ueb,rtyp eraostidndAnlo is eorm seasictdoa hiwt teh ledrnaa lds.nag

meningitis  I chose Testosterone but I almost chose GnRH because it is surged when starting puberty and therefore increases everything downstream. +10  
temmy  When answering the question, i thought to myself that if GnRH is correct, LH will be too cos GnRH stimulates the Leydig cells via LH to release testosterone. That left testosterone as the best answer because it had the most direct effect. +10  
goaiable  GnRH and LH are increased in a pulsatile fashion at the onset of puberty, so idk if that constitutes as the "rapid increase" that this question is asking for. Tripped me up also. +  
tallerthanmymom  I originally eliminated testosterone and chose androstanediol because women can have Acne Vulgaris too, and Testosterone should not be rising to the same degree. Do I not understand how puberty works? +1  
drzed  Women can still make testosterone though; and androstAnediOL is not the same as androstEnediONE +3  


submitted by sympathetikey(1265),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I ees what reeyt'h ganiys si(ht asw my oesdnc ioe)chc utb at the emsa iemt I leef kiel a puakbc fo loodb ulowd atecitva het reoecrabrstop dna aseuc ecraddsee tahcimeytsp ivyttica to the SA p&m;a VA o.den

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


submitted by sympathetikey(1265),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I ese hatw 'teehry isnyga (isht saw ym necdso )cceohi tbu at het easm etim I elfe liek a kcaubp fo lobod wodlu caevitta eht orbetsorapecr and esacu edcaseerd tyasceimhpt iytiavct ot the SA &;amp VA o.nde

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


submitted by sajaqua1(524),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

rSuem kesscins si a yTpe 3 tprynitesivseiyh taoicn,er in cihhw teh dboy peosnsdr to enignacti daliemc sucassbent adn scdoperu tabineodi.s eeshT beiaitosnd in ortcniaucli enth idbn to hte iticngane gdurs dan tes fof the meolmtcnpe scd.acae eouthaidmR rtsirahti si aosl a Tpye 3 hpntiiieetsyysrv caio.tnre

)A tppiAsoos of macorhspa-eg pitaososp is lgnlereay ton a yept of ettiysipvehinrys ote.nacir B) tMsa lce urnnat-gdaoile hits si rpat of a Tyep 1 eypetssthyivriin ahsxclrnyiia,aaep/not ni whhic smat llsec inbd EgI on eirht ucrfes,a nda EIg dinnibg ot eht ttgare teinang ciensdu a acoafroonnmlti gchaen in the IEg that sets ffo mtas lcle luanare.ngtdoi C) luartNa Kirlel Clel nligli-k yslap a iraveyt fo seor,l uigincldn nccaer erssipounps nad uoedtcsnrit fo yvirlla ecedtifn ecls.l If htey play a erol in h,tynvsieiyipestr it si prat fo Tepy 2 HRS ni icwhh yteh uowld rdosnep ot Ig no hte llec fc.uasre E) heleW dna felra stircoane- ishT is lsoa a peTy 1 HS.R

meningitis  I didn't pick this one because I thought Serum sickness was too systemic and RA was a more localized Type 3. Again, im overthinking things. +  
youssefa  Goljan: RA is a mixed type III and type IV immune reaction +6  
dinagohe23  I though NK cell killing was similar to T cell so and RA is also Type IV +4  
nephcard  ,blll sdouof +3  
usmile1  NK cell killing would be a type of innate immunity, not similar to memory T cells. because they did not give an example of a type 4 HSY, the answer must be serum sickness. +  


submitted by dr.xx(144),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hr.gti eh leabouytls tsum amienr ni eht niwgati raae os atht he is ta nhad to taackt his wief ewheervn hre xmae edns. go EMN!B

meningitis  I guess it was all about not offering battering information in order to not make matters worse since he will figure out that the wife told on him.. Also, its a HUGE STRETCH but the only reason I thought he should stay in the waiting room was just in case the wife died they could detain him and call the police for questioning. +10  
temmy  Also, he should stay there because his wife did not grant him the permission to see him. Patients requests trumps. +  
nephcard  Doctor should not believe what wife told her. There may be some other reason for injury so batttering information should not be provided. But her wish of not letting her husband in should be fulfilled +2  
charcot_bouchard  No. In real life patient lies. In Board ques they always tell the truth. Unless they make it very obvious. in fact its a board ques rule. So u believe her untill proven otherwise. +3  
drdoom  The prevailing rule of American medicine and law is individual autonomy. No other person is granted “default access” or privilege to another person’s body—that includes the physician! The physician must receive consent from a (conscious) “person” before they become “a patient”. In the same way, the person (the patient) must give consent before anyone else is permitted to be involved in her care, spouses included! +  


unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

raMlaia nac mraiip ethaicp iennlgeoesscugo nda acn olsa ncsemou usocgle rfo sti nwo cteloaimb eddsma.n

yotsubato  Truly a bull shit question... Its not in FA, Sketchy or Pathoma +54  
meningitis  I will try to remember this by associating it with P. vivax, that stay in the liver (liver=gluconeogenesis). Thank you @thomasalterman. +8  
focus  ADDITIONAL INFO: If we were asked to identify the stage of the lifecycle, it would be (intra-erythrocytic) schizont stage: https://labmedicineblog.files.wordpress.com/2018/06/mal3.jpg?w=840 Life-cycle: https://www.cddep.org/wp-content/uploads/2017/06/malaria-life-cycle_4-1440x1080.jpg +1  
dul071  i solved this question by seeing that there are hemolytic inclusions resembling parasites and that they require glucose being a living organism, hence hypoglycemia. +  
curlycheesefriesguy  I knew that malaria causes hypoglycemia but i saw the word drowsy and like an idiot thought it was african sleeping sickness +  


submitted by sympathetikey(1265),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ooeDxsmaehetn pssrpusese CAHT = ruatiiPty aAsexnmadenm tDeoohoe lasif ot rsuppsse TCAH = cpcotiE HACT (xe - laSlm eCll nugL ce)Carn

sympathetikey  *ACTH +  
meningitis  If im not mistaken, Dexamethosone also fails to suppress ACTH = Adrenal Gland Adenoma +1  
therealloureed  I think an adrenal gland tumor would have low/undetectable ACTH? aka no dex suppression +13  
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +12  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Tnrena gaetss tarst ta TEN syera lod

eSagt :I

  • I si a,tfl as ni alft he;tcs
  • I si la,neo sa in on xlseua hris.a

gStae II 2)(: tesga II stsart at 11 /oy I(I oklo eilk 1)1

  • 2 bllas tceliautsr( e)tnenemragl
  • 2 hisar iub(pc ahsri now )rpangpeai
  • 2 etarbs sbud mfor

gateS III ):3( tssart at 13 /o y

  • If you tearto ,3 ti okosl keli allms sestarb (staeBr omdsun mr)o;f
  • If uyo slgeiguq teh III eyth lkoo ekil yelcrrsc+aou ipcbu hiar
  • ceIeardns pnsei glhetn dna szei nca eb eetrndeespr :by II -gt-&; III
    u(yor esnip saw itnh II tbu wno tis htrceki III)

tgeaS IV 4:() stsatr ta 14 o/y

  • strFi ngiim:ea Teh I in IV nsprsteere the ighth, dna het V in IV ksloo lkie het nsmo pubsi newteeb royu sg:le
    :GNNI AEM ouy hvea hrai in omsn sbpui V() btu you haev a rreobd tinngdaie het rhai fmor ignwogr nito ihghts.
  • Teh V si ,npotiy as in own eth abtrsse era nypito (iaedrs erlaoa ro noudm on donm)u

teagS V )(5: 15 yo/

  • V sah no dbsoerr ndgnetaii raih morf rniogwg ntio htgsih pu(bci airh + tihgh h)air
  • 5 fgseisa(nr ni s)ahdn nfetgitlan eth oaerasl wnhe aggibnbr etmh eorl(aa flttaen ta hist aetsg adn no more "odnmu on "u)mond

meningitis  Sorry about the format, it came out wrong but I hope his helps. +1  
drdoom  looks good to me! +17  
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from? +  
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions. +  
endochondral1  stage 3 breast mound is for females not males btw +2  
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females +  
angelaq11  this is just too funny, I LOVE it! xD +2  
snripper  While this is impressive, this doesn't help with answering the question. +1  
yng  Pseudogynecomastia (False gynecomastia): this has nothing to do with puberty or hormones. Simple d/t the fast some guys have extra fat in chest area, making it look like they have breasts. The boy weight at 60 percentile while height at 50 percentile. +  


unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

HTP si cadnsieer ecesbau erusm cilcmua si .wol ucaeeBs PTH is en,sairedc oohpohusprs is ae.sdrcede hTe wnaom ni beanul to abrbso mnaivti D a( taf uolesbl ,iv)aitmn so lciatcroil si adeceesdr o(n ivntaim D fro eth dikeyn to vcatitae noit trolca.lici)

gabeb71  What does this have to do with the Celiac Sprue? +1  
medpsychosis  I believe they were explaining the reason for the mentioned "mild osteopenia" in the pt presentation. +  
meningitis  No, I think this person got confused with another question about celiac sprue, PTH, Calcitriol, and Vit D (it was an arrow type question). +  
diabetes  explanation for decreased bone density . +  


submitted by docred123(6),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Wyh si hte enwsra ot hist oseqtnui tno iiheesAdv pausi.iC.slt.

hayayah  Adhesive capsulitis causes severe restriction of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation). +22  
catch-22  Adhesive capsulitis is aka "frozen shouder" so you can expect exactly that. The entire shoulder will be hard to move in all directions. +3  
meningitis  Since it says there is NO impingement sign, it cant be rotator cuff tendinitis correct? What other signs eliminate this option? +  


unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

She utjs cmdpltoee the soecur of rixtaum,bi ichhw gtsrate DC02 rctpr.eseo Bc-ell dceyincife nca sipdoepsre to ctreablia insefntoi.c

b) BM rieaful si otn oidtscseaa with marixti)c ub w)orgd n neo)r wg tihs rcoscu inw/ 170- ydas of girsttna etnr,ettma and dowlu not crcou tarfe negclimtop a 4tmnoh- ecosur of .aitumrxbi

meningitis  Forgot the time frame for Serum sickness and got it wrong.. thanks @thomasalterman +20  
stinkysulfaeggs  Same. Crap. +2  
medstudent22  Taking it one step further - B-cell depletion = decreased Ab secretion = decreased opsonization. Opsonization with subsequent phagocytosis by spleen = #1 mechanism by which encapsulated bacteria (ie Strep Pneumo) are degraded. +1  


submitted by beeip(123),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

The tesb I anc ena,ndrtdus y'ehert genicsridb orealdmtnie aeapsilprhy, a rsulte of esesxc eeotrgns, a oidsert eoronmh htta oattrcssaeln to teh eculusn nda insdb sit soctnnrtriaip .coraft

mousie  My exact thinking also! +7  
sympathetikey  Ditto. +  
meningitis  My thought as well but the answer says: "Binding of ligand to Nuclear transcription factor" and I thought to myself: "Estrogen Receptors aren't transcription factors.. they are receptors with Transcription Factor function that bind to the ER Element and recruit more Transcription Factors". Can anyone explain what I am missing? Am overthinking things? +  
criovoly  You are overthinking it, Steroid hormones receptor is found intracellular in the cytoplasm then they are translocated to the nucleus where they regulate gene transcription. HOPE THIS HELPS +4  
eve1000  Could this be due to the PTEN gene being linked to endometrial hyperplasia? +  
feochromocytoma  The question stem says it's glandular hyperplasia "without" atypia It's just due to increased levels of estrogen causing the hyperplasia +4  
faus305  This is a bunch of scientific mumbo jumbo +  


submitted by mcl(586),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

icSne yr'oeu sginol lal oury abrcbi otin oruy ,pee oyu woudl etcxep the pH to be mreo a.kleainl ls,oA neisc hreet si desredcea a+HN+/ tionpta,r ehrte si ssle osdmiu esedoabrrb nda reeteohfr aceesidnr ossl of efre iudlf to hte ni.ure

joker4eva76  Why wouldn't this be similar to a Type 2 RTA where urinary pH <5.5? +1  
mcl  I can't remember exactly what the question was asking off the top of my head, I think it was asking about relative to normal? But I think you're right in that the alpha intercalated cells (AIC) can still dump H+ into the urine and acidify it to an extent. And, like in RTA2, I don't know that the action of the AIC would be able to overcome the bicarb and acidify the urine enough for it to be the usual pH, so the urine should still be more alkaline compared to baseline. Kinda sucks, pH less than 5.5 should technically be acidic but it's alkaline for pee. +  
mcl  JK, normal urine pH is around 4-8, but I guess they consider closer to 5.5 on the more alkaline side...? I guess I would go more off that the alpha intercalated cells can't completely compensate for the amount of bicarb in the pee due to the CA inhibitor, not so much the actual pH. +  
meningitis  Anhydrase inhibitors also affect the anhydrase inhibitors that are used in the AIC in order to excrete the H+. Here is a link: http://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/distal_0.png +4  
mcl  ohhhhhhhhhhhhhhhhhhhhhhh my god duh yes thank you <3 +1  
meningitis  Lol yw!! +  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

nWeh gdasnint pu, het yobd lnarlmyo casetvati pctmathyeis smytes to oaivd tttcsiohrao iteynpnoo.sh

tuB nsiec trhee si won na idativde ctefef of eht oharhooympometcc isgcr,raedne ti lwli edal ot a yternohenspi

.:(ei oelbuD ovsoaictirosnntc = Phoe ernicsaredg + ymteSpacthi mtyes)s

sympathetikey  Brilliant. +5  
medschul  Would pheo have a normal resting BP though? +10  
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. +7  
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. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I saol ohhttgu the seam sa sb@lube,b tub own inytgr to f"jituys" siht iktcry MNEB s:noiutqe I inhtk htis vereslov no hte caft ttha eht entipat ahs a HGHI dlobo erpusser imegnna ew lsdhou scouf no an wrnaes thta nilxaeps othb cenadersi BP dan aHlmpiyveoo .:(ie eredcnias DHA ciwhh cnssrotovctasi nda also soabsrb -erreew,fat thob of chwih rcsaneei BP nad saeuc maoilv.yh)epo

aeyMb fi tsih iattpen erwe easdemcoetndp itwh LWO B,P oen olcud kihnt eomr uotba P.AN

I tills tihnk htsi sitnoequ is TOO tykic.r

meningitis  Sorry, hyponatremia* right? +  
mantarayray  I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia except only thought this post getting the question wrong :") +4  
mantarayray  Oops sorry the formatting is confusing: I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia. +2  
pg32  @mantaray pretty sure you are right and that is the only way to get this question correct. Remembering that Na concentration really is a measure of water balance is key. If the pt is hyponatremic, that just means they have too much water in the blood, which is caused by ADH. If the patient was hypoVOLEMIC, that might mean they are losing too much Na. This is illustrated by pts with SIADH. They are hyponatremic, but euvolemic, meaning that they have too much water (hyponatremia from the ADH) but their Na balance is ok (due to excretion of Na via ANP/BNP) +  
avocadotoast  We need to be thinking about how heart failure is a condition with a low effective circulating volume. Our patient had an MI and now his heart cant keep up with the volume (low CO), leading to congestion. When congestion occurs, water is pushed into the interstitial spaces and isn't circulating in the arterial system. For that reason, the body ramps up the RAAS and ADH despite an actual increase in body water. This is a non-osmotic release of ADH. At this point plasma sodium levels are determined by relative intake and losses and hyponatremia is common in these patients because of that. Also, ANP and BNP don't hold a candle to the RAAS. +  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

uhgAlhto st’i otuab PPV, hits haigrecensr heedpl em rndudnetsa cisba ,psyh I phoe htsi sleph nervyoee in semo a.wy

w:yeaakaT Dugnri VP,P snouve ernutr asres,edce rcdaaci toutup eserase,dc dna ehrta peursress serceaed in hte hirgt edsi of hte rh.tae

yhW oesd PPV derasece nsoeuv rnrt?eu

  • iaahrtrocntic ursereps sompsceesr ta,rhe cnsagiu dbloo ont ot reurtn

aCsesu rof ddcreasee ltfe vuncrleiatr upottu ndurig vln:tioiaten

  • Snghifti of rivarrtctaliunne tseump ot Lfet eud to iensadcre VR muevlo
  • eaesrdDce seovun urrnet
  • nhaeCgs ni ershat abtiliy ot tcrocant ued ot pteviois serupres
  • akcl of O2 to thaer

olrNma ncpsmtyrooea csnmhseami for tniminigaan OC nda BP nrgiud ?PPV

  • raedsneci HR ot etenospcam rof eacedrdes SV
  • nrceseiad VRS to aintinma BP

erhOt ioygsPocilh e:epssnsro

  • seecdreDa crarbeel iofsnuerp surrespe byod’s( ponseser ot a fall in PPC si ot ieasr cmetsysi ooldb repssure nad aieldt reecblra bdool selsesv)
  • areDcdsee arlne esroupinf ere(sdncIa HAD, SA,RA dan iPtatne ahs nelra pmbsrloe so rdeainsec ntieicaenr nda ciur iac)d
  • ePbssoil utorntlnaiim cdniera(es csoleug iav oecgnsngoeulies ce)t.
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +26  
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1  
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1  


submitted by bubbles(67),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ustJ ot eb alcryst reacl beuse(ca 'vIe tetnog remo thiydor xisa utsoqensi gwrno ahtn I shd)lo:u

4T ;-&g-t T3 si pilsobes but T3 &;--tg 4T ?it'ns

meningitis  Exactly. I know there are papers saying there is some conversion of T3 to T4 but I try to keep it simple and think of it as once you break it apart (T4->T3), you cant put it back together. Only thyroglobin etc can put another I on it, so any T3 cant become T4 because you need it to be done in thyroid. +8  
angelaq11  I honestly don't know about this, but the way I reasoned this was: she is taking a whole lot of T3, so on top of already having hypothyroidism, she is just making things worse, so TSH is going to be decreased because of feedback inhibition, and hence T4 (Which is the main one produced by the thyroid) is also going to be decreased. I think the high T3 is the exogenous T3. +  


submitted by mattnatomy(41),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I lvbeeie eyehtr' frenirerg to eomoprcisns of enhsacbr of eth gIilnliinauo erNve bo(yspils het teArrnio raSoctl rseveN.

:ruSoce r__rnkco//nktsora.ritstetwvoAs/ri/d:weaepegpiheiii.nl

armymed88  Ilioingual covers part of the medial thigh, base of penis and anterior scrotum Posterior scrotal nerves are a branch of pudendal and cover said area Doral nerves cover the dorsum of the penis which are also from the pudendal +1  
meningitis  I thought it was the Genitofemoral nerve because the genital branch supplies the cremaster and scrotal skin, but I looked it up and: The genital branch passes through the *deep inguinal ring* and enters the inguinal canal; also, Ilioinguinal wraps around the spermatic cord just like the question stem says. +1  
jean_young2019  "The structures which pass through the canals differ between males and females: in males: the spermatic cord[6] and its coverings + the ilioinguinal nerve." from wiki "Inguinal canal", which means the ilioinguinal nerve lies on the external surface of spermatic cord. https://en.wikipedia.org/wiki/Inguinal_canal The contents of spermatic cord includes, "nerve to cremaster (genital branch of the genitofemoral nerve) and testicular nerves (sympathetic nerves). It is worth noting that the ilio-inguinal nerve is not actually located inside the spermatic cord, but runs along the outside of it, in the inguinal canal." from wiki spermatic cord. https://en.wikipedia.org/wiki/Spermatic_cord +1  


submitted by bubbles(67),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

saH dnyabyo fuodn a doog apatenlnxio fro ihts ightos?loy I lynugenie ahev no edai awth m'I ilkgnoo .at

meningitis  This is common in Klinefelter.. think of the equivalent of Streaked ovaries seen in Turners. White streaks, red/pink material of hyaline, and hyperplasia of Leydig cells. Just remember: It doesn't look like normal structured testicle histology (No organized seminiferous tubules with Sertoli cells around) +10  
niboonsh  https://www.pathologyoutlines.com/topic/testisklinefelter.html these pictures are kinda similar +2  


submitted by aesalmon(81),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Lyideg ecll lihayeap,prs lhuosd aslo see rsbisoif nda antnlhyiiaoz fo eth usbetul btu im' ont nseieg .i..t ¯_ツ¯)/(_

meningitis  I think its there.. I thought it was the lighter red/pink material (hyaline material) And I thought the white streaks were the fibrosis like "streaked ovaries"in Turners. +  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hulgAoht ’sit tuaob ,PVP ihts rhacrsiegen eldpeh me stdndearnu csaib sphy, I ehop shit plehs neeroeyv ni omes .awy

:aakyeawT gDniru VP,P osuenv neurtr d,seceesar ciadarc ttupou ecesrsade, nad rheat resepsrus eeadserc ni hte hrgti edis fo eht hera.t

yWh dose VPP saeredce uenvso r?nteru

  • rtacctaiironh psseurer opessscrem ,ahtre icsgnau olbdo otn to nuetrr

eCuass for ersdedcea ltef enurtclrvai topuut rudgin vtinta:oilne

  • hitnfSig fo lriatteiranvcurn teuspm to feLt edu ot iedrascen VR uemvol
  • rcdsaDeee nsveuo etnurr
  • gaCeshn in satrhe alytbii to cncortat ude to esioivpt euspsrre
  • lakc fo O2 to aerth

maorlN naemsyprtoco imcaseshnm ofr tgiinnamnai OC dna PB dnrugi ?PVP

  • sicaderne HR ot neatpmosce rof sedarecde SV
  • csreainde SRV ot anitniam PB

ehOrt cPoyiosglhi rsessn:epo

  • eedrsceDa balcerre rfsoupnei rurepsse ’obsyd( sopesrne ot a allf in CPP is ot iarse yesmstic bldoo rsrupsee nad dielat rrleecba ldobo leses)vs
  • ereasceDd lerna fospuirne aIcdeen(rs ,ADH AR,AS nda aPteint ahs reanl mlrsoebp so ecesdianr ntineiacre and criu id)ac
  • ssolbPie ltioarmniunt acrid(snee gouslec vai suieogcneeglons e).tc
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +26  
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1  
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1  


submitted by welpdedelp(219),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

dreansIec tnrcairaalin sueerpsr atht eutrsls ni u'ngisshC tdari fo dcrisnaee boold ,usrpesre grilaeurr ghabe,tnir dan rrdby.idaaca Tu,hs ighh 2OC cisuend snuicgh iardt nad if ouy igve PP hnte it lwil redudce ,O2C nda hten wndo uaetgrel eth semhapcytit avsntscc.rionioot gOyniairll hte airbn dah so chum CO2 tath ti zspedaz uto nda rtedi to aceniers eht PB in rrdeo to usph oemr dnyogaxeet olodb to the a.rnbi

t/KmZem/pC.5Ada/:pSUps:tacgk3rjibAgsmgih./lsewoqtf.-J

lispectedwumbologist  "Bradycardia" 84 bpm lol +  
lispectedwumbologist  The hypertension in obstructive sleep apnea is due to increased sympathetic tone not increased intracranial pressure lmao +1  
meningitis  @lispectedwumbologist : Be mature enough to correct him/her and move on, not laugh at him/her. +14  


submitted by mattnatomy(41),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

erevSe htpenrnoseyi etonf edsal to itlerycpshap osolrlsaiieretscor inik-(oonns .)nepaaprace solA see anlfoiirprteo fo omotsh clsmeu csll.e

meningitis  and explains the flame hemorrhages (Goljan) caused by malignant HTN +5  
taediggity  FA 2020 pg. 537 +  
dentist  FA 2020 pg 301* +  
ally123  The flame hemmorhages are also a good buzz word for recognizing he has hypertensive retinopathy 2e chronic, uncontrolled HTN. Pt's with hypertensive retinopathy can also present with "cotton wool spots" and "macular star". Pics on FA 2019, p. 299 +2  
surfacegomd  Pathoma (2018) p. 69 +  


submitted by k_tron_3000(31),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

tsJu a nroadm dtfoica s(a far as I nw,k)o ni snipttea tihw neiractitspa the msot klyeli esvles rfo ibsmorohst is eth celspni nvei eud ot scole ina“comta ste”i wiht eht a.ncaserp hTsi doluw aslo aescu a-prieosglcnst r,vsecia xnpgaineli eth ogvntiim of bdo.lo

meningitis  Also explains the splenomegaly. If you have thrombosed splenic vein, the blood will pool in the spleen, can also cause expansion of red pulp of spleen. +10  
pg32  I picked splenic vein because of this ^^ association. However, why is the patient vomiting blood if there isn't a backup of blood into the left gastric/esophageal veinous system? +1  
savethewhales  The splenic vein drains the fundus of the stomach. So, splenic vein thrombosis can cause gastric fundal varices, which explains his bloody vomit. +3  
medschooler1  how do you rule out arteries? +  
ac3  @medschooler1 Just my guess, but when answering this I assumed that splenomegaly meant splenic congestion with blood which can only happen if its outflow tract (splenic vein) is blocked. +4  


submitted by aesalmon(81),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

FA .gp 670 - lrfeaiu fo noisfu fo the xmlrlyaai nda redegm lmiade alasn eropecsss oot(franmi fo aipyrmr laat)ep

meningitis  I think Cleft palate could also be due to failure of fusion of lateral and medial nasal prominences.. but since the baby had lip involvement and the lateral nasals can be seen, I went with failure of Maxillary and medial nasal fusion. Someone correct me if im wrong. +4  
redvelvet  a helpful photo +3  
snripper  @meningitis this is cleft lip, not cleft palate +2  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

A csae onclrto styud tnca ssssae hte rcnpeaelve of a aesiesd but a ocrss stlaceion yustd nc.a

  • A csea tlnrcoo uystd si thta yuo rae gesnitt eth rgmnasi in eth 2 by 2 bltae trohefeer u'eroy idgdnice owh ynam escsa dan conrltso uyo wnat ot have ni your ysudt nda the nlutclcoaai of incdineec / arlcvpenee in itsh senrcoai luodw eb dei.asb
meningitis  the prevalence of the exposure and the health outcome are measured at the same time. You are basically trying to figure out how many people in the population have the disease and how many people have the exposure at one point in time. Case Control would determine ODDS ratio Cohort would determine Relative Risk +3  


submitted by aesalmon(81),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I eefl umdb ofr ksgnai utb anc eoseomn leaixpn hti?s If ihs apnters ear fo scoel to aornml MIB and rae drneocnec btauo sih eghtwi why owdul they be lolgnawi ish oieclar osmcnpuotni to decexe hsi neeryg pdtree?xiune ( KAA entlgti het kid eat oot uhcm adn ton xrseecei ho)guen

meningitis  That's a modern day mystery. +16  
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 mattnatomy(41),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I veieleb shit is rrreefgin to ugdmit atomnrtolai. euD ot ppoermri ooitnipsngi fo wlebo o(n hte hrtgi de.si) adLsd snbad tneocnc teh lreag tnstieine to the e.rvli

Cna deal ot:

  1. sovluluV

  2. duDaenlo sintbrctoou

3. MSA iOsnuolcc -- I'm gessginu dsbea on eht sanewr to het etuosinq

meningitis  Yes, the question clicked for me when I realized the ligament was on the RT side instead of LT so I thought of Volvulus. Image of ligament of treitz: https://media.springernature.com/original/springer-static/image/chp:10.1007/978-3-642-13327-5_17/MediaObjects/978-3-642-13327-5_17_Fig3_HTML.gif +3  
hyperfukus  So Volvulus regardless in baby or adult is gonna cause SMA prob + Duodenal Obstruction: d/t Ladd bands im gonna go back and remember those associations :) +1  
pg32  Yeah, recall that the midgut rotates AROUND THE SMA in development. If you can recognize that the ligament of Treitz is on the wrong side (right) then you know you have a malrotation issue. Then you recall the midgut rotates around the SMA and you pick that answer out of pure association recall and get it right. Nice. +1  


unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

cimekNan-iPn ssieaeD tsseenrp ihtw etlman atnrroaedti, ipdli andel (omfa escll) in beno rrwmoa nda hrreyc der tosp on uac.mal No yoeslmeipngshina surstel ni dlpbuui fo nplysiegmhnio ihhcw lbiusd up ni heg.msrpaoca

meningitis  "Pick your **Big** **Foamie** **Zeibra** nose with your Sphinger" Choose options with the letter I. SpIngomyelin, Sphingomyelinase, bIgorgans (hepatomegaly etc), zeIbra bodies, Foam cells +1  


submitted by seagull(1443),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Teru ocvla drsoc rea tfneo mdagdea ni siningg or l.gneiyl sTiH slwoal PHV ot nerte the lgneiduryn tdcnaeelu l.slce PVH 16 nad 18 aer momonc eybssput ttha yam ausce SCC.

meningitis  Out of all of the virus', HPV has a predilection for stratified squamous epithelium and there is no indication of vesicles(HSV) or linear ulcers (CMV)in the question stem. But with HPV you usually get a big/small (depending on time) unilateral nodule. You are correct to say singing and yelling can cause nodules but these would be bilateral in the and would appear differently. So if a question stem could easily have included that as an option: maybe irritation or something like that. +11  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Trnean aesstg atsrt at TNE ayesr dol

teSga I:

  • I is at,lf sa in ftal cesht;
  • I is le,aon sa ni no sxuela r.iash

geaSt II :)2( esatg II ssttar at 11 o/y (II okol elki 1 1)

  • 2 sabll ar(eutcltsi m)enerelntag
  • 2 arihs pcib(u hasri onw pragenai)p
  • 2 stabre ubsd mrof

gaeSt III )(3: sarstt ta 13 / oy

  • fI oyu toreta 3, it klsoo iekl lmlas besatsr erBst(a udosnm )m;fro
  • fI you eqguslgi hte III tehy kloo ekil resclycr+oau icubp hair
  • Icaenersd speni gletnh adn zsie cna eb redeteperns yb: II -gt;-& III
    uory( inpes asw tinh II utb now tis tekrhci )III

tSgae IV (4): rsttsa at 14 yo/

  • Ftsri neiim:ga ehT I in VI seeerspntr teh th,igh and the V ni IV loosk ilek het sonm sbpiu weneebt yoru l:esg
    A NIMGE:N you hvae rahi in snmo bspiu )V( tbu ouy ahve a rdeorb adnitgine hte iahr morf oiwggnr otin hgt.shi
  • ehT V is yopnt,i as ni onw eth ssaerbt ear tpioyn risd(ae roaale ro ndoum no dnuom)

geatS V :(5) 15 /oy

  • V ash on oersdrb ndgiitnae hiar fomr rgwogni nito sigthh pibcu( aihr + ghhti ari)h
  • 5 ssrifgn(ae in nhsad) nltantegif teh rsaaleo nweh gnbrbiga emth aleoa(r tleaftn at shit estga dna no roem nmod"u on n)"dmou

meningitis  Sorry about the format, it came out wrong but I hope his helps. +1  
drdoom  looks good to me! +17  
gh889  According to FA2019, stage 2 ends at 11, stage 3 starts 11.5-13, and stage 4 starts at 13-15, where did you get your info from? +  
meningitis  You can change it to ENDS at 11, ENDS at 13, ENDS at 14... I simply have it as a range just like you stated in a couple of them. The importance is in how the kid presents because he/she will have some things mature but others not, the age will vary in questions. +  
endochondral1  stage 3 breast mound is for females not males btw +2  
endochondral1  see pg. 635 in FA it just pubertal. Idk if that correlates to the same stage as females +  
angelaq11  this is just too funny, I LOVE it! xD +2  
snripper  While this is impressive, this doesn't help with answering the question. +1  
yng  Pseudogynecomastia (False gynecomastia): this has nothing to do with puberty or hormones. Simple d/t the fast some guys have extra fat in chest area, making it look like they have breasts. The boy weight at 60 percentile while height at 50 percentile. +  


submitted by armymed88(47),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

samyeemhp delas to 2CO itnaprgp niadgle ot enacrsei CpOa2 ni teh loobd, hcwhi egsvi oyu a psyiearortr oiidcssa re Porp ernla ootmpniceasn lliw nceirsea adrbci bersa dna easedcre iet-onxcer gginiv uyo idnresaec arbbci ni hte dlboo

meningitis  Increased blood HCO3 could have easily been interpreted as increased blood pH aswell. FOllowing your explanation, since the pt had acidosis, the increased HCO3 will just make it a normal pH. Another way to think of the question is: if there is decreased exhalation due to COPD --> increased CO2 --> increased CO2 transported in blood by entering the RBC's with Carbonic Anhydrase and HCO3 is released into blood stream. So increased CO2 -> increased HCO3 seeing as this type of CO2 transport is 70% of total CO2 content in blood. +21  
drmohandes  I thought you could never fully compensate, so your pH will never normalize. Primary problem = respiratory acidosis → pH low. Compensatory metabolic alkalosis will increase blood HCO3-, but not enough to normalize pH, it will just be 'less' low, but still an acidosis. +3  
mtkilimanjaro  I also think decreased blood PCO2 and increased blood pH are very similar (less CO2 in the blood means less acidic, pH could go up) therefore I ruled both of them out just from that +  
brise  Aka this is the Bohr effect! +  


submitted by hayayah(1057),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

wtorhG nmrohoe grinlesea mhrooen cast aiv dcoeG-pul eeprco.rts G pueldoc oretrsecp edne TPG ot emcebo aatdtviec and eGsaPT to ocebem natdeaiti.vc

No aPTGs-e &--;tg nohrlaccyil atcvie ohtrgw emoonhr lsreainge hnoomer ctreepor ;t&-g- csotannt niaatiovtc of nlaydyle aclscye / cPAM paahtyw nad eraslee of trhowg hnoom.er

mcl  This figure is useful https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png +  
mcl  [link](https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png) +  
meningitis  How did you knkow it was GHRH and not GH perse? +4  
meningitis  nevermind; I just read down below. Thank you +13  


submitted by hayayah(1057),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hGtwro ehoornm irgalnese mnoeorh acts avi eGcl-dpuo oterpse.cr G louecdp tpeorscer ened GPT to emocbe atectavdi dan PGsTae to ebmeoc cta.idaetnvi

No aeGsPT- &-t-;g hcilnyolcra ceativ rogthw omenroh liseergan neoohmr cptreoer -;g-t& tncntaos ivoacnttai of edlyalny acylsec / MPcA pthaway nda elaesre fo ghwtor omhrne.o

mcl  This figure is useful https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png +  
mcl  [link](https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/a025a0e224d366e987bc15edd0f7764ef5611e0d/4-Figure3-1.png) +  
meningitis  How did you knkow it was GHRH and not GH perse? +4  
meningitis  nevermind; I just read down below. Thank you +13  


submitted by welpdedelp(219),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

oS I thnik htta usesi fo tiswr xnoetnise /arndo rfngei opdr ldwuo be mreo iardla eern.v H,revwoe tehre asw reom mxoirlap es,sewkan so ti duowl eb C.7

7"-8 ayl htme rtitg"sah, eth pt uctldn'o a"yl ethm h"ritatsg os ti lodwu be 7C root

welpdedelp  *As an addition, median nerve involvement would have leaned more toward C8 than C7. +4  
meningitis  Do you have anymore useful mnemonics for brachial plexus? +  
henoch280  FA pg 494 for mnemonics +  
winelover777  Doesn't look like there are many in FA 2019. S1/S2 - Buckle my shoe. L3/L4 - Shut the door. C5/C6 - Pick up sticks. +  
drzed  S2-S4 keeps the penis off the floor :) (cremaster reflex) +  
peridot  What's crazy @drzed is that in FA 2019 it says L1-L2 ("testicles move") on p.498 so I wonder if that changed +  


submitted by mcl(586),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Secni ruoy'e gsniol lal uory bcibar tion uyor ee,p uoy uwodl ctxeep teh Hp ot eb emro alinleka. s,oAl iscne htree is edcaesder +aN+H/ onipt,rta rhtee is slse ouisdm roasebrbed adn efrehrote iasnecdre sosl of erfe fidul to the niue.r

joker4eva76  Why wouldn't this be similar to a Type 2 RTA where urinary pH <5.5? +1  
mcl  I can't remember exactly what the question was asking off the top of my head, I think it was asking about relative to normal? But I think you're right in that the alpha intercalated cells (AIC) can still dump H+ into the urine and acidify it to an extent. And, like in RTA2, I don't know that the action of the AIC would be able to overcome the bicarb and acidify the urine enough for it to be the usual pH, so the urine should still be more alkaline compared to baseline. Kinda sucks, pH less than 5.5 should technically be acidic but it's alkaline for pee. +  
mcl  JK, normal urine pH is around 4-8, but I guess they consider closer to 5.5 on the more alkaline side...? I guess I would go more off that the alpha intercalated cells can't completely compensate for the amount of bicarb in the pee due to the CA inhibitor, not so much the actual pH. +  
meningitis  Anhydrase inhibitors also affect the anhydrase inhibitors that are used in the AIC in order to excrete the H+. Here is a link: http://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/distal_0.png +4  
mcl  ohhhhhhhhhhhhhhhhhhhhhhh my god duh yes thank you <3 +1  
meningitis  Lol yw!! +  


submitted by meningitis(512),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

nWhe nidsnatg ,pu hte obdy lmolrany cvaetista tmpatsycihe eyssmt to vodia htosoiarttc neyoosnitp.h

tuB sicen rhete is won na aidevtid feceft fo teh hoooccpyammtohre ,icegrnsdear it lliw deal to a ohsteenprnyi

(.:ie loDebu saicootvtsrinocn = oPhe iercsneradg + pScthteymai ss)yemt

sympathetikey  Brilliant. +5  
medschul  Would pheo have a normal resting BP though? +10  
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. +7  
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. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by moloko270(65),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ioMrsfbliy rae omsepcdo of aelsmrl strrtcsueu alelcd ln.mefatyisom eehrT rae otw inam tpyse fo nale:fmist kctih nlamtiesf nda ihnt iamsfnlet; ceha hsa ferdeinft nsomostocipi dan losioa.nct hTcik nsefilatm ucocr nloy ni the A nbda fo a iyi.flbomr hTni fnmtseali chtata to a toipren in eth Z sdci delacl c-inlhpaatnai dan occru asocsr teh nterie gehlnt of eht I ndba nad warpaty tion het A nb.da

ipe-ctp/cnoa-emo1tot/rnio:/cdb/nclxn/eaoosc-am-4tg/rtlicesctlnaoyobhop.t9u-ht

meningitis  isn't letter C the intercalated disc where the gap junctions are? +11  
chediakhigashi  The actin is bound to structural proteins at the Z-line, this was on u-world #1734 if i understood correctly +  


submitted by johnthurtjr(139),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

'seerh a goelgo

johnthurtjr  FTR I had no idea this was a thing, and was pretty disappointed in myself when the google search had it in big bold letters right in my face. +3  
drdoom  via @johnthurtjr link: "Testosterone and other androgens have an erythropoietic stimulating effect that can cause polycythemia, which manifests as an increase in hemoglobin, hematocrit, or red blood cell count." https://www.medscape.com/viewarticle/773465 +3  
meningitis  I guess that's another reason for steroids and doping up. +7  
drschmoctor  For once I feel like I've been led astray by Pathoma. My instinct was to go with hemoglobin, but I talked myself out of it after remembering Dr. Sattar saying that the reason why women have lower hemoglobin is due to menstruation. +2  
fexx  F U testosterone! and F U NBME 22 question +1  
schep  I only knew this because there are three (at least three, maybe more that I don't know) contraindications to giving testosterone replacement therapy: +OSA +prostate cancer +hematocrit >50% +2  
drdoom  ^ linkify @drdoom https://www.medscape.com/viewarticle/773465 +  


submitted by oznefu(21),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ohw od yuo anorrw owdn that ereesoostntt nasidecer lgomeiohbn noacnnetrc?oit tjsu a ndmaro fact to ?wkno i ptu illkanea ahhpoptases eebusca i rfeugid eisandcer tstrteseoneo lwil erasenic boen rhtgow dna dlure uot seccfe-tatsporipi tneigna bc ’ist a w.omna

hysitron  I guessed this one cause men have a higher hemoglobin than women. +10  
notadoctor  High levels of testosterone will result in amenorrhea. I guessed that since she's not menstruating she will not be losing blood and therefore hemoglobin. Therefore her hemoglobin levels will be higher than expected. +5  
meningitis  It kinda makes sense knowing testosterone causes catabolism so I was in between Alkaline phosphatase and hemoglobin... +1  
enbeemee  isn't testosterone anabolic? +4  
syoung07  ALK phosph is indicative of osteoclast activity. Testosterone keeps male bones strong just like estrogen does for women. Testosterone builds bone (osteoblast activity) therefore we would not see a rise in ALK phos +  


submitted by seagull(1443),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

eamby oeonmse anc xianlep hyw iths si aasavulcr resiocns dna otn ssiesp. It ensot'd ionemtn rfeve ro abenesc fo re.fev The MRI sah a lsaml mnatou fo dhyiptnesyo utb to get urcsaaalv snseirco eesms o/dd

someduck3  Pg 455 of F.A. mentions that alcoholism can be a cause of avascular necrosis. +5  
meningitis  I think the small dark area on the left head of femur and the darkened neck are the avascular sites. Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg +3  
yotsubato  He wouldnt be playing golf if he had septic arthritis. Avascular necrosis is a more chronic condition that has a slow onset. +3  


submitted by asapdoc(61),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

aePntit has ocnigreehnp ebetiDas sIisd.pnui Oen of teh rmtettsane si hdirr.loHeyocadzthi

meningitis  hydrocholorothiazide is DOC for Nephrogenic Diabetes insipidus because it paradoxically causes an increase in BP by increasing sodium absorption and thus water absorption, Pathoma explains this nicely. Also you shouldn't have chosen Desmopressin because upon fasting (fluid restriction) ADH is increased meaning ADH is being released Centrally but is not working in the kidneys at the V2 receptors of the epithelial renal cells at Collecting duct. On that note, Amiloride is used for Lithium induced nephrogenic DI. +1  


submitted by hungrybox(977),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

nehw fdif neglis dntsar arrpie hmmenasisc are ed:su

  • eiprra nwley nhesieszdyt sandrt: cmatihms riprea nych(L rosde)nym
  • arrpie impirneidy midesr cuesad yb adt VU oxseprue: dtcunleoei ciexinos pirrae eraredm(Xo spuoet)gnmmi
  • prirae ctseuati/nnoxopso ntoe:alriat abes oiecxins erraip
meningitis  Brca: recombinant repair +  
brotherimodu  P.40 FA2019 lists the different DNA repair mechanisms +2  
teepot123  fa '19 pg 382/3 +  


submitted by tissue creep(106),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

rortophAd for s,eur btu fro het ocdrer 'Im pyertt usre tsih was hiygCanunku irsuV. lynO ogt hsti mrfo a orUlWd qoutesni sa I dnath' nees it ltuni e,tnh btu erapplynta hte railtgahra is laryle da,b wcihh is thaw redw em ot hte wesn.ra

wm/no.thhccw.vpikd/yhu:.tg/unxgdnict/wesal

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


submitted by nosancuck(85),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

aDm nso hits lli b gto meso BLTDAICMEUI uslcMomlu lla pu ni reh znbesis

drdoom  tru. +  
meningitis  Pg 164 FA 2019 +1  
dr.xx  likely not "lil b" as 2-4 times as many cases are found in whites than in persons of other races +7  
drdoom  lil b not a referent of race; cf. lil boo, lil baybay, lil bowow, &c. +  
dr.xx  I disagree. Google "lil b" for images. See what you may discover. +  


submitted by egghead(1),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hTsi si eno fo ohtes ineoqstsu I saw rneve gniog ot .etg tIs' not ni AF, I do'nt hitnk Iv'e sene ti in lasc.s

hungrybox  same :( +  
masonkingcobra  My issue was the stem said no skin damage (I would think pulling out your hair damages your scalp) [Turns out it does not](http://onlinelibrary.wiley.com/doi/full/10.1111/j.1529-8019.2008.00165.x) +  
gh889  FA 2019, pg 551 +8  
meningitis  Compulsively pulling out one’s own hair. Causes significant distress and persists despite attempts to stop. Presents with areas of thinning hair or baldness on any area of the body, most commonly the scalp. Incidence highest in childhood but spans all ages. Treatment: psychotherapy is first line; medications (eg, clomipramine) may be considered. +13  
step1soon  FA 2019 pg 551 +1  
teepot123  damn its in FA and Ive never ocne read it XO +  


submitted by yo(79),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

eyhre't kgiltna batou a oerelnplsan nsuth ercuerodp

tlmnuhlnr:nt9a.s5tlapmhlysa-/iletp/dg.en/-tdairlnav4s-esecnoectcttie//rhhles0o

hungrybox  be honest did u know that before looking it up +9  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +24  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +11  


submitted by est88(17),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

pRonttelarrieoe sscuteru:tr DSA EURCKP.

Oyln hte sneencdgid locon is artp fo tshi.

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


submitted by hungrybox(977),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

lgujaur uvseno eiosttidnn = lfte eahtr iluafer

ruamnopyl eadme = rihgt heatr airluef

r-cmuorebhFa dlinaoti is het toms llieyk .wnaesr

reOth ass:rwen

  • scmytAries stealp tpyo,eryphrh alodrymaic irya:sard etshe rea tbho sicalsc dfnsingi in trppceihhoyr aohdryymcaiopt M)CH(
  • andcredolai s:siolbftesoari a rrea rrvscieetti dampiyooatyrch eesn in nn/adltnecifrhsi
  • iylcyothcmp iifltaontnir fo teh icm:rduoaym nsee in ilvar ou)(mtumneia omia.tydicrs A auesc of tadeldi yoir,oythadacmp tub terhe swa no noitnem fo a cerpngeid ivrla sil.lsen
meningitis  I think you meant: Jugular venous distention = LT HF Pulmonary edema = RT HF +4  
hungrybox  woops yea I meant Jugular venous distention = RIGHT HF, Pulmonary edema = LEFT HF +12  
jackie_chan  What threw me off the picking 4-chamber dilatation was it seemed like that would be a major cardiac/ventricular remodeling and the vignette gave a somewhat acute 2 week onset +  


submitted by mcl(586),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

OCSP si aotceidsas hiwt alnrbamo onoudtricp of xes ,iedsosrt gncuindli ytnosfuindc of geteonsr ipndurcoot adn teorsegn.oerp nircChyolla evetleda sevlle fo tgnesreo anc asuec delomrtiane hryiesplpaa.

tm9otm7inbP/h9e5i/pwc//.9w/1sn..atMlwcgsC:plc/.ri3hvn

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


submitted by mcl(586),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

POSC si cesoditaas hiwt blarnoma ndotorcpui fo exs sdoite,sr ilgdcinun nytdisuonfc fo eosetngr uoirocpntd dan epegno.estror linlahoCcry tdlevaee lvesle fo gesoenrt acn ausec dtaeoinrelm hlyeip.rpaas

7c9:c./9rnom/Mlwt1sPmi5Cbc.w/pig.th9aeti3wlpn/h/v.ns/

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


submitted by nosancuck(85),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Yo agwd ew lla uatob PTV IMT LLHa

iana,nnPeyehll lnaeiV, DKtrToy,pNA rehoni,eTn oicuIsen,el tnMinieeoh, isidHt,ine euencLi sieLny

meningitis  I don't understand what the question is asking... can someone please explain it to me? Patient doesnt eat protein, shes chubby. What does methionine have to do with this? +2  
charcot_bouchard  Just basically asking which is essential amino acids. +3  
usmleuser007  Essential amino acids (something i came up with) 1. "Three HAL fans will try meth" a. Threonine = Three b. Histidine; Arginine; Lysine = HAL c. Phenylalanine = fans d. Valine; Isoleucine; Leucine = will e. Tryptophan = try f. Methionine = meth +3  
nala_ula  They're saying there is a lack of good quality protein -> slight nutritional deficiency. She may have acquired weight but it's not because of protein. So they're specifically asking what amino acid she might be missing due to her subpar diet. Since essential amino acids are those that the body cannot make itself, out off those listed, methionine is the essential amino acid. It's on page 81 of FA 2019. +9  
nala_ula  correct me if I'm wrong please :) +  
hello  For anyone confused trying to follow @usmleuser007's comment -- slightly modified Essential amino acids mnemonic "Ah, Three fans will try meth" Ah = arginine, histidine Three = Threonine Fans (phans)= Phenylalanine Vil (Will -- German accent pronouncing English word 'will') = valine, isoleucine, leucine, lysine Try = tryptophan Meth = Methionine +1  
pg32  Why does @hello and @usmleuser007 mnemonic contain arginine? That isn't in the PVT TIM HaLL mnemonic for essential amino acids... +  
paperbackwriter  @pg32 arginine is semi-essential. It is essential in preterm infants who cannot synthesize it https://www.sciencedirect.com/science/article/pii/S0955286304000701?via%3Dihub +  


submitted by neonem(556),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

hiTs is a aesc fo yparrhpoi anactue tadra. heT wya I eeremmrb shti is that i'ts eth noyl hhdygie-li iyarphpro htta ahs ksni insiatenasfomt ude ot .UV I emberrem htis yb efArt" U )u,iypr(rnprooh tis' ."UV ylrpAteanp s'it soal oseaascidt ihtw Haitsitep ,C hhwic udolc be teh aensro hwy 'terhes nsecaierd TSA m&a;p ,ATL ro it dcoul be eud to citox udulipb of stemradintiee ni hmee sihs.etsny

meningitis  Why cant it be protoporphyrinogen oxidase? It was because of that reason (Increased AST and ALT) I thought it wasnt uroporphyrinogen decarb. My train of thought was: "wow, mitochondria are messed up.. there must be a lot of intermediates in there,therefore the Uroporph decarb must OK." +  
arlenieeweenie  FA 2019 pg. 417, the later on the defect in the heme synthesis pathway is the one more associated with skin findings! Also according to this year's edition uroporphyrinogen synthase is now known as prophobilinogen deaminase +5  
nobody  AMBOSS has estrogen therapy listed as a susceptibility factor for PCT. I could not find a link between elevated AST/ALT and estrogen therapy that would occur 15 years into treatment. +  


submitted by taway(30),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Dose ybydano snudneradt wyh ew rae loldewa ot tefenirer tihw eht iccnlail kegciandminios fo wot ehrot iealpsisstc delyritc? dWlnto'u atth uymdd hte ratsew veen roem by dinagd oru pioi?onn I 'otdn ese hte nlrgeudnyi npiecrpli hatt elxsiapn the nriatleao in tshi .sarenw

jcrll  I think it's about adding our opinion and more about seeing what the situation is because a patient contacted you in distress. The others are about contacting management off hearsay; that could also "muddy the waters," I Is this question also addressing quaternary prevention? +1  
meningitis  I agree with jcrll. My same thought process but then I changed it to psychiatric consultation in order to first attend the patient's distress and anxiety since it was hindering her decision making. Besides, the whole ordeal about her treatments and ineffectiveness was emotionally and physically exhausting her. +2  
vi_capsule  Referral is NEVER a answer +10  
tsl19  Going straight to the chair of the ethics committee without having spoken to the other physicians would be inappropriate because it would be jumping a bunch of steps in communication first - like jcrll said, you want to get the picture of what's going on from the other physicians first. Maybe the gynecologic oncologist isn't actually as opposed to palliative measures as the patient perceives him to be and thinks he's doing what the patient wants, etc. It could just be miscommunication, which you could help clear up without getting ethics involved ... better to start there. +10  


submitted by nosancuck(85),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

oY sid B otg NO TERLANNI EFAEML ASROGN

yhW ?!?da?t

We eb konloi ta esonmeo iwht an RYS fmro edre Y mo!ecyiehrD eb a Y meoirhc meHio so ythe eb mkina smeo setiTs neirmnDiet tocaFr hchiw I be ruse kmesa osme cnei lli ANTI IRLUANEML RAOFCT os dye tnai ogt hatt Femael naneIltr rTcat u nkow hwta i be naisy

Adn cinse mnizwmi si ad UDTEAFL they stli be tgteni seod pusys slip dan bresaest

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by hungrybox(977),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

dzrithldoeaioorHhyc si a hitedzai riuicted &;t=g idtaiehz itdruiecs rae adsciotsae wthi amyoekpailh.

tahW ohret idreuicts era sdstaeaioc wtih leapok?yaihm oopL citirdse.u

yWh?

iohinIntbi of aN+ ntorisbreapo rouccs in obht oolp uieisctrd ib(hitni NCKC r)pntrarosecot adn ziaehitd escdtriui i(btihin ClNa snorrrroctpat).e All fo shit esrnaiecd +Na siresenac elosnteAord ttayciv.i

eteaRnvl to hits e,ormlbp Aotdernsloe sgtpeleuaru nxpseoisre fo teh a+K/N+ PAT tiprratnoe (orbaebrs +Na iont yo,bd lpeex K+ oint )nue.ml ishT ruslste ni ehpiaaoymlk in eth .oybd

angH n,o rsth'ee remo ghhi eilyd f!noi

teonrAsloed seod one tohre ntrotmpia githn - iactvtonia of a +H lcaehnn ttah lxpsee +H iotn hte l.uenm

,oS gievn htat tish ttieapn has yaohake,pmil ouy nwok rhtee is patouneriulg of droseolnte.A oD uoy thnki ehr Hp lwdou be gh,ih ro owl? tlaxE,yc ti ldwuo be high cebesua ci.n nedseArolto t&=;g nic. H+ lelepxed noti het neuml g&;t= mibloetac sisloak.a

wNo you sndeutdnar ywh hbot lopo citerusdi nad zdtiehai reiudsict nac casue ws'hta caeldl ohlmcpaiky"e ctmeliaob "ai.lsosalk

hungrybox  jesus this answer was probably too long i'm sorry +7  
meningitis  I disagree. It's the complete thought process needed for many Thiazide/Loop question that can be thrown. Thanks. +12  
amirmullick3  This is what NBME should be providing with each question's correct answer! Thanks hungrybox! +  
amirmullick3  @hungrybox did you mean "All of this DECREASED Na increases aldosterone activity."? +1  
pg32  Anyone care to explain why she feels she has, "lost [her] pep"? Is that due to the hypokalemia? Or hypercalcemia caused by the thiazides? +  
cmun777  @madojo @pg32 I assumed between her hypokalemia (which can cause weakness/fatigue) and possible contraction alkalosis those were the most likely causes for the "lost her pep" comment. I think if they wanted to indicate hypercalcemia to differentiate if loop diuretics were also in the answer choices they would certainly give more context for hypercalcemia sx +  


submitted by calcium196(11),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

-iiaetuiqdbUiedtmn ryossetoilp is otn ybesirrvel dcaeetff by nunii.sl ehT nuqeisto asks orf veselebrri swya atth sniilun asffcet it, nad iubutiqniiaton oldwu edal to ntioaeddarg vai sao,sepetr whcih si ton reesliv.erb ceripmatNs/lcyuocal tginhsun emsak snese ceuabse OXFO si a iosanrttinprc ,cfaort os ti nat’c od ist ojb if it is ni hte ys!tmaclop

meningitis  Thank you for your explanation! One question: How about the serine phosphorylation? Is it answered by pure memorization that the FOXO TF is serine phosphorylated, or is it a general fact that all TF's are serine-threonine phosphorylated? +  
tsl19  I'm not sure, but it may be as simple as this: ubiquitin-mediated proteolysis is irreversible, but both N/C shuttling and phosphorylation are generally reversible processes. +  
didelphus  I also guessed that FOXO must be a part of the PI3K pathway, since insulin regulates metabolism through PI3K and the question stem specifically mentions that. Phosphorylation is a major part of that pathway, so even indirectly phosphorylation would regulate FOXO. Frustrating question. +17  
niboonsh  yes, FOXO is affected downstream of the activation of PI3K. This is a really good video that explains the whole cascade https://www.youtube.com/watch?v=ewgLd9N3s-4 +2  
alexb  According to wikipedia (https://en.wikipedia.org/wiki/FOXO1) phosphorylation of FOXO1 is irreversible. This is referring to phosphorylation of serine residues on FOXO by Akt, which occurs in response to insulin. But the NBME answer suggests it's reversible. What's up? +1  
almondbreeze  could wiki be wrong on phosphorylation being irreversible? according to this article, it is a reversible process: regulation of FoxO transcription factors by reversible phosphorylation and acetylation (https://www.sciencedirect.com/science/article/pii/S0167488911000735#s0010) some wiki info, however, is helpful : In its un-phosphorylated state, FOXO1 is localized to the nucleus, where it binds to the insulin response sequence located in the promoter for glucose 6-phosphatase and increases its rate of transcription. FOXO1, through increasing transcription of glucose-6-phosphatase, indirectly increases the rate of hepatic glucose production.[19] However, when FOXO1 is phosphorylated by Akt on Thr-24, Ser-256, and Ser-319, it is excluded from the nucleus, where it is then ubiquitinated and degraded. The phosphorylation of FOXO1 by Akt subsequently decreases the hepatic glucose production through a decrease in transcription of glucose 6-phosphatase. +  
leaf_house  It seems like the phosphorylation from Akt leads to destruction, but maybe the assumption is that that phosphorylation step (excluding every other step of ubiquitin-proteosome pathway) is reversible, where proteolysis is final. @niboonsh video is good but doesn't split this one. +  


submitted by neonem(556),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

urbcevtOsit taurypoh scuaes a naoprlest eomtaiza t-&-;g hnwe dgonepl,or ubarlut egaadm .ssneeu Tihs saedl to na cateu ruaublt cssnerio, izrtrhccedaae yb coctrnei sgplu in the bultuar mstsye sa nees ni hte geima

meningitis  Does anyone know the relevance of the stem saying: "during this time she also has been crying frequently"? +37  
usmleuser007  Think the postrenal azotemia is d/t her pregnancy. With the increasing in size fetus, the pelvic cavity is being compressed and thus there is pressure on the ureters. This leading to the presentation. As per above --- the crying maybe just d/t her pain and emotional stress caused by worrying about possible complications regarding her fetus. +4  
maxillarythirdmolar  My gut tells me it must be some sort of transient change in placental size with hormonal changes. It's reminiscent of what you might expect for breast changes during the menstrual cycle, imo +  
j44n  or maybe the fetus is literally crushing her ureters into the wall of her pelvis and shes got an infected kidney +1  


submitted by johnthurtjr(139),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

Im' ton a fan fo ssogr ahtp megsai adn nsqistuoe ttha asy o,lok" hatw si isht ?htn"gi - htat siad snngiiemmoa are eht msot ocmnmo naibr mruot nda sith urectpi is is a dgoo xleepma fo e.on I adh no idae hwat tehse tgshin dleoko kiel adn otg it rngo,w .oot kTae a ookl ta tish noe

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +1  
meningitis  I got it wrong because I didn't see any apparent Dura mater nor other meninges (The veins aren't being covered by any "shiny layer"), so I thought the tumor was coming from inside the brain and not compressing it like meningiomas usually do. +3  
meningitis  But it did follow the common aspect where they are found in between divisions of brain and are circular growths like a ball. +7  
nala_ula  Since it was basically implied that the patient died and "here look at what this is" I thought it was a malignant tumor (glioblastoma)... but I guess it's all about placement. +11  
thelupuswolf  GBM would be in the perenchyma. Devine podcast said if they show you a gross picture of the bottom of the brain then it's a hemangioblastoma bc it's most often cerebellar. But this one wasn't cerebellar so I went ahead with meningioma (FA says external to brain parenchyma as well) +2  
vivijujubebe  GBM would have necrosis and bleeding whereas the ball-shaped tumor in the picture looks smooth and very benign...even tho I have no idea how someone can die so suddenly from meningioma +  
seba0039  Minor correction, but I do not think that Meningiomas are the most common brain tumor; they are the most common benign brain tumor of adults (Pathoma), but I'm not sure if they're the most common overall. +  


submitted by johnthurtjr(139),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

I'm otn a afn fo gsros phat geamis adn nistuoqse ttha yas ol,o"k ahtw si hsti t?hign" - thta asid esommininag rae eht tsmo mcmoon inbra otmru nad shti iuctpre is is a oogd xleapme of on.e I adh on diae wtah teehs tnhsgi oekldo ilke adn got ti owgnr, o.to aTek a okol at shti eno

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +1  
meningitis  I got it wrong because I didn't see any apparent Dura mater nor other meninges (The veins aren't being covered by any "shiny layer"), so I thought the tumor was coming from inside the brain and not compressing it like meningiomas usually do. +3  
meningitis  But it did follow the common aspect where they are found in between divisions of brain and are circular growths like a ball. +7  
nala_ula  Since it was basically implied that the patient died and "here look at what this is" I thought it was a malignant tumor (glioblastoma)... but I guess it's all about placement. +11  
thelupuswolf  GBM would be in the perenchyma. Devine podcast said if they show you a gross picture of the bottom of the brain then it's a hemangioblastoma bc it's most often cerebellar. But this one wasn't cerebellar so I went ahead with meningioma (FA says external to brain parenchyma as well) +2  
vivijujubebe  GBM would have necrosis and bleeding whereas the ball-shaped tumor in the picture looks smooth and very benign...even tho I have no idea how someone can die so suddenly from meningioma +  
seba0039  Minor correction, but I do not think that Meningiomas are the most common brain tumor; they are the most common benign brain tumor of adults (Pathoma), but I'm not sure if they're the most common overall. +  


submitted by hayayah(1057),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

ronI vsdoroee si a csaue fo a hgih nnoai agp tilaemobc .iossadic

meningitis  I found this to add a little bit more explanation as to how it causes the acidosis if anyone needs it. 1. Mitochondrial toxicity - decreases aerobic respiration and shunts to lactic acid production 2. Cardio toxicity (Secondary to Mitochondrial toxicity) leads to cardiogenic shock (hypoperfusion), which causes lactic acidosis 3. Hepatotoxicity - Decreases lactate metabolism, causing lactic acidosis 4. When in trivalent form (Fe+3), it can react with 3 molecules of H2O --> FeOH3 + 3H+ This will then deplete Bicarb buffering system resulting in non-gap acidosis. Source: https://forums.studentdoctor.net/threads/iron-poisoning-anion-gap-or-non-anion-gap-acidosis.958285/ +17  
sympathetikey  None of the other choices were even metabolic acidosis. They threw us a bone with this one. +21  
imnotarobotbut  Don't changes in bicarb take a few days? How did his bicarb drop down to 8 in 12 hours? +2  
charcot_bouchard  its met acidsis. not compensation +7  
j44n  they did throw us a bone however I didnt catch it +1  


submitted by hayayah(1057),
unscramble the site ⋅ remove ads ⋅ become a member ($39/month)

sotM crtorsietni nesmyez nbid sdmlriope.an

So hbot 5CCGG' or C3'GGC owudl hvea neeb ccatbpeael in tshi orceisna.

meningitis  Yes, correct. The 5'GGCC option could cause some confusion. +  
guillo12  I really don't understand the question nor the answer. Can someone explain it for dummies like me? +8  
whossayin  yes please.. I'm with guillo12 on this +  
sugaplum  @guillo12 @whossayin questions says you've created a new cut site, 1. look at the region on the sick vs healthy. The C to G is the change 2. Write out the sick "CCGG" from 5'3'- you could write out the whole thing, but the answer only has 4 letters, so being lazy here 3. write under it, its complement, the dna base pair. So "GGCC" 4. remember both strands are going in opposite directions when you write them out on top of each other. 5. So the bottom strand actually reads 5' CCGG 3' so that is the answer I hope that clears it up +48  
shirafune  To add to the palindrome part, many restriction endonucleases actually function as dimers. Each individual subunit usually has a nickase, so to create a double-stranded break in DNA, they must bind a palindrome so that each enzymatic domain creates a single-stranded break (thus a double-stranded break). +1  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +2  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +1  
ssbhatti  I think its due to the palindrome requirement? +  
bbr  Maybe I'm missing a part here, but the substrate that the enzyme will bind to will be the DNA. I went with the line that was from the questions stem, as it is the mtuated DNA will be recognized by the restriction enzyme. I didnt see the need to convert it into base pairing. Let me know what you guys think. +1  
uloveboobs  @bbr I agree. I'm definitely not an expert in these lab tests, but the question asks "substrate specificity." I was thinking that it would recognize the abnormal DNA; nothing to do with RNA. I didn't know about the palindromic preference of restriction enzymes, but I don't think there's any need to figure out base-pairing and whatnot here. (At least for this question it didn't work out that way!) +  
spaceboy98  sugaplum, I'd give you an award if this was Reddit +5