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 +2  (nbme22#1)

Anyone else figure out how a surgeon gets his hand inside the patient deep enough to avulse the hepatic veins from the IVC during a LAPAROTOMY? Baffles me.

mesoform  I think this one was pretty easy if you just know the regional anatomy. That was the only answer choice that could remotely have that presentation, so I think it was just testing your knowledge of the structures listed relative to the description.
kimcharito  aorta is also behind of liver...

 +0  (nbme24#11)

If anyone wouldn’t mind: How am I supposed to know that T1DM has a similar pedigree to schizophrenia? Teach me how to think, ples.

ankistruggles  I think they were getting at how developing T1DM and schizophrenia are both multifactorial. I don’t remember what the other choices were off the top of my head, but they had clear inheritance patterns.

 +3  (nbme20#27)

When you have a traveler who has intermittent abdominal symptoms and diarrhea, and who has traveled to the likes of northern Africa and such, Schistosomiasis needs to be on your radar. At least, that’s how I’ve incorporated this nugget into my mental space.

 +3  (nbme20#11)

This has to do with intron splicing. Remember GTAG. This mutation induced an AG closer where it was supposed to be, so some of that intron just became an exon.

 +7  (nbme20#32)

This is the only choice that comes close to nicking the thoracic duct, specifically at its inlet, the left subclavian.

kpjk  why not midsternal thoracotomy?
wuagbe  because the thoracic duct ascends the thorax posteriorly, and enters venous circulation from behind. link to image: https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/thoracic-duct

 +1  (nbme20#14)

Encapsulated organisms run rampant in patients who have no spleen, whether physically or functionally. (Recall the wide-array of sequalae sickle cell patients experience thanks to their functional autosplenectomy.)

sympathetikey  Agreed -- went with E. Coli like a dingus, just because I didn't associate DIC with S. Pneumo. Thought it was too easy.
chillqd  Isn't E. Coli also an encapsulated organism? What makes Strep pneumo more likely in this question just because its the more common cause?
studentdo  Pseudomonas aeruginosa is encapsulated as well. I think the right answer has to do with DIC but why?
mgoyo89  The only reason i found was S. pneumo is more common, I went with Pseudomonas because of the "overwhelming sepsis" :(
kard  Everyone is correct about the Encapsulated microbes, but this is one of those of "MOST LIKELY", and by far the most likely is S.Pneumo>>H.infl>N.Mening. (omitting that patients with history of splenectomy must be vaccinated.
djinn  Gram negative are more common in DIC my friends

 +3  (nbme20#28)

Annular pancreas is the only answer that accounts for the bile in the vomit; of the choices, it is the only obstruction distal to where bile enters the GI tract.

ergogenic22  Meckel diverticulum also occurs distal to the CBD but less likely to be associated with bilious vomiting
sympathetikey  Correct. Might cause pain due to ectopic gastic tissue.

 +5  (nbme20#10)

This is indirectly asking about peak bone density. That whole thing about weight-bearing exercises, eating right, yada yada, before and during that down-slope phase of life for bone density. All about reducing that 1% per year age-related bone density loss as best as we can. Level of activity is precisely like weight-bearing exercise. (Consider: no activity, bed-ridden -- say goodbye to your bones; highly active, runs every other day -- good amount of weight-bearing / stress to induce remodeling and maintain integrity of the bones.)

sympathetikey  Yeah, I was thinking about that while taking the exam. Just got thrown off because I don't see how that matters, now that they've fractured the femur. How do prior increases in bone density allow for better chances of bone healing?

 +1  (nbme20#26)

Decreased total, normal free (unbound) = Thyroid hormone-binding globulin deficiency

 +11  (nbme20#32)

This is a conditional called craniocleidodysplasia. The kid on Stranger Things with the lisp has the disorder. No collar bones, too many teeth, frontal bossing => craniocleidodysplasia. CBFA1 is a gene highly implicated in osteoblast function.

 +6  (nbme20#11)

This is a hypoplasia of the pleuroperitoneal membrane. The guts herniate into the thorax, usually on the left side, and result in hypoplasia of the lungs (because they're horribly compressed).

johnthurtjr  Usually on the left because the liver prevents herniation through the right hemidiaphragm
asdfghjkl  aka congenital diaphragmatic hernia
pg32  What's weird to me is that if you usually see air in the intestines on x-ray when they are in the abdomen, why is there no air in the thorax in CDH? The intestines should still have air in them, right? Also, what is filling the abdomen that causes it to appear grayed-out in CDH?

 -1  (nbme20#19)

Is this the one with the poor kidney that was cut in half against its will and has a dilated distal ureter? If so, probably showing us transitional carcinoma with mild invasion into that distal ureter. Pathoma does a pretty awesome job of talking about GU cancers (and most cancers) ((and most medicine)) IMO.

 +0  (nbme20#20)

I have regarded crepitus as the rubbing of bone-on-bone. My study partner and I think this is a purely definitional question. Yes, crepitus could also be trapped air. Context, I guess.

medstudent65  Crepitus is used to describe bone-on-bone grinding. Subcutaneous crepitus is very specific sound referencing air finding its way into the skin which you can hear but also feel by rubbing your hand over the affected area. The addition of subcutaneous lets you know we are specifically talking about air in the skin.

 +5  (nbme20#36)

I think Shigella is the most appropriate, as it is actually regarded as highly inflammatory. Yes, E. coli can be of the EHEC/STEC variety, but E. coli could also be of the ETEC variety or whatever other strains it has. Ergo, E. coli may be plausible, but it is not the 'most likely.' Bleh to these kinds of questions.

 +3  (nbme20#23)

If you want to clear a drug, it is probably best that it not be bound to proteins (so that it gets filtered) and it has a low volume of distribution (so it isn't in the deep, hard to reach tissues).

kingtime9119  But that doesn't make sense. Page 233 of First Aid 2019 edition clearly states that being plasma protein bound creates the lowest volume of distribution, because not being bound to proteins increases the chance it will reach deep into the tissues before it reaches the kidneys. Discrepancy with First Aid?
haliburton  my reasoning was comparing two drugs, both with Vd of 1, the drug with the lower albumin binding would be cleared faster @kingtime. I don't think you're considering that A and B have equal Vd.

 +3  (nbme20#21)

This patient is experiencing hypersensitivity pneumonitis from the parakeets. I was thinking M. Avium when I selected parakeets -- I think my logic was flawed given the specifics of the patient's story.

 +11  (nbme20#17)

As a rule of thumb, if you give someone an ACE inhibitor and they get a problem, they had renal artery stenosis (usually bilaterally, or so we were taught at our med school). Probably has to do with decreased GFR thanks to decreased Angiotensin II–selective vasoconstriction of the efferent arteriole => decreased sodium delivery to macula densa => increased renin release.

lilyo  Vasoconstriction of the EFFERENT arteriole actually leads to increased GFR. It selective VASODILATION of the efferent arteriole effect of ACE inhibitors since they undo Angiotensin II actions. This patient already has rescued renal blood flow due to bilateral renal artery stenosis, the addition of an ACE inhibitor further decrease GFR prompting an increase in renin due to loss of negative feedback.

 +8  (nbme20#30)

Anytime you have a person who bumps their head, gets back up, and then has severe issues or dies like 6 hours later -- you have yourself an epidural hematoma from laceration to the middle MENINGEAL artery. (Goljan really emphasizes that you don't screw up and select middle cerebral.) You know it has to be an arterial laceration since the dura is tightly adhered to the skull's inner surface. Goljan referred to his experience with it as needing pliers to remove the dura from the skull; graphic, but it drives the point home. Tenting seen on CT is because the epidural hematoma gets stuck between the suture lines. When it manages to break past one of the suture lines, it is my understanding that then is when you get severe sequelae, like death or whatever.

usmile1  omg monoloco!! I miss you dude! We used to hang forever ago, hope all is going well in med school!

Subcomments ...

submitted by hayayah(505),

Pregnancy + Hx of thrombosis --> think antiphospholipid syndrome

The PT and PTT are prolonged d/t interference from the antibodies to phospholipids. Thrombin time normal.

Had to find research articles about it so take it from here and don't waste your time...

monoloco  yeah, i’ve never heard of antiphospholipids increasing PT time ... +4  
goldenwakosu  Not sure if that little detail was to throw us off. I think the point of the question was to ID antiphospholipid syndrome based on the clinical criteria (spontaneous abortion + thrombosis) +1  
johnthurtjr  I actually went down a rabbit hole with this one recently - essentially in vitro findings =/= in vivo findings, clot-wise with anti-phospholipid antibodies. +1  
link981  No mention of lupus anticoagulant, anticardiolipin, or anti Beta 2 antibodies. FA mentios prolonged PTT but nothing on PT. What a piece of shit question. But thanks to the dudes above who explained it +4  
yb_26  UWorld mentioned "prolong aPTT (and sometimes PT)" in APS +1  
oslerweberrendu  @yb_26 Can u please tell the QID because the one I have seen it says, "Although patients often have prolonged ptt (because the antiphospholipid interferes with ptt test), pt is normal." QID: 1298 +