NBME Answers : monoloco's page

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+1 (nbme22#1)

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ynoeAn slee frgieu out ohw a gsuneor sget hsi dhna insdie eth aetitpn pdee ounheg ot aelusv teh piatehc nsiev mfor eth CVI ndurgi a O?PMARATLOY efBsfla em.

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. +2

kimcharito aorta is also behind of liver... +1

medguru2295 I also didn't realize the surgeon's hands would so deep in he could touch the IVC on a Lappy....kinda eliminates the point of a Lappy.... +

iwannabeadoctor2 "A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity." Exploratory laparOTOMY very different than LaparoSCOPY, which is what I think you may be confused about. One is a gaping hole from which you can observe everything, and the other uses tiny incisions and scopes. Even still, a hand port used during laparoscopy can allow for digital manipulation of organs as needed. +2

bbr I dont think the physician caused the avulsion, I think it was there already and he grazed the area. Causing it to fully avulse and break what ever clotting was going on. +

+0 (nbme24#11)

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If onnaye odwunlt’ mni:d oHw ma I ppsdeuos to know hatt 1TMD has a siimral edgireep to r?copanhiihsze Tceah me hwo to hinkt, selp.

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. +7

pathogen7 Just as a slight tangent, is there a difference between "multifactorial" and "polygenic" inheritance? +

ac3 polygenic = multiple genes affect phenotype while multifactorial = genes, environmental factors, etc that can affect phenotype +1

sars Multifactorial: cleft lip, cleft palate, type 1 diabetes mellitus, sjogren syndrome, pyloric stenosis, congenital heart disease, neural tube defects +

+7 (nbme20#27)

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hneW uyo hvae a vaertelr owh hsa ntetrmetiitn olabmdain spystomm nad arah,rdie dna ohw hsa draevtel ot eht elski fo ernorhtn riafAc nda hcsu, ashiootismiscsS ednes to be on yruo r.arad At s,eatl ’htsta hwo vI’e pdorrnaietoc siht gnutge oitn ym tnalem .spcae

+3 (nbme20#11)

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hTsi has ot od tihw tinorn gcs.ipnli eeRbmrme G.TGA isTh tomtuian ineudcd an GA locrse ehwre ti saw spdupeso to ,be os esmo fo atth oirtnn stju mabece na .xoen

+10 (nbme20#32)

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sTih si the yonl choeci tath ecmos csloe ot giknicn teh ccrthaoi ,duct clicipyeslfa ta its etnl,i teh telf sb.invlacau

kpjk why not midsternal thoracotomy? +1

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 +5

almondbreeze lateral image backing wuagbe : https://www.google.com/search?biw=1440&bih=682&tbm=isch&sxsrf=ACYBGNS9mJgyLM9AyaysvyAn-kkayda9ng%3A1578324433947&sa=1&ei=0VETXuKuOdTemAX7_p2oAQ&q=midsternal+thoracotomy+thoracic+duct&oq=midsternal+thoracotomy+thoracic+duct&gs_l=img.3...7982.22243..22370...5.0..0.421.2545.4j16j4-1......0....1..gws-wiz-img.......35i39.7LA7tZlDuRo&ved=0ahUKEwii2-bZpO_mAhVUL6YKHXt_BxUQ4dUDCAc&uact=5#imgrc=IwcmegTWYZRhPM: +2

+2 (nbme20#14)

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acsndeaEpult srsaomgni rnu traapnm in nptaesit ohw ahve no pneels, threehw lapyhcysli or liyotcfnn.alu clRla(e het iwayrda-er fo selaquae kliecs lcle astipnte nreceexepi anshtk to iethr fonicualtn asytctoumpnloe)e.

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? +16

studentdo Pseudomonas aeruginosa is encapsulated as well. I think the right answer has to do with DIC but why? +1

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. +1

djinn Gram negative are more common in DIC my friends +1

drzed Correct me if I am wrong, but I am pretty sure that E. coli is NOT a common cause of pneumonia because it must be aspirated to enter the lung. Thus, only patients with aspiration risk (e.g. stroke, neurogenic conditions) would be at a chance of getting E. coli pneumonia. +

+7 (nbme20#28)

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nruAanl sencpraa si het oynl swrane htta ucosactn ofr eht ileb in eth tvmoi; fo teh cchseoi, it is teh noly uotostncbir stiadl to whree eibl senret eht IG ar.tct

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. +1

+6 (nbme20#10)

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iTsh si ilcneridyt sankgi uotab akpe onbe dsiten.y Ttha lhoew itghn boatu iegwbnteghar-i rssxe,eiec tiagen hi,tgr adya aad,y eoferb adn nrgdiu that deplowsn-o epsha fo file rof nebo t.sdenyi llA otbua eudcnirg atht %1 per eary ge-deelrtaa ebno nydseit lsso sa tebs as ew n.ac levLe of atiyictv si cepilrsye ikel iwag-iehnbgetr rscix.eee dCno(:iser no i,atvtciy di-rdebdne -- asy bgoodey ot uyor s;bnoe lihghy aetv,ic nsur eyver retho ady -- ogdo tmonua fo brinwgae-ihegt / sstres to dceuni romeliedng adn iamtainn rnygietit fo eht .sonb)e

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? +7

rsp I think that bone density is important here, but think about all of the other things that go in to recovering from a fracture at that age too. How strong are the muscle that will stabilize you while going through the motions of physical therapy? How conditioned are you? +2

+8 (nbme20#26)

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redeDaces toa,tl rlaomn eefr uoun()nbd = drTiyho nonderhgbinomi- lilbunog cdefyeniic

+19 (nbme20#32)

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shTi is a aoltdniinco eldcla oirdp.daollsciacnsiyea heT dik on retgnrSa hngTis thwi teh pisl sha eth .riodsdre oN aclorl ebo,sn too myna et,the aroftln gobniss &tg;= .coayciadioneasrdisllp AB1CF si a geen hyilgh etidalcpim in laoobstets .citfunno

+9 (nbme20#11)

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ishT is a silhyppoaa fo the ianelrpooeturepl aebmr.mne The stgu ihrteane noit het ,xtaohr asyuull no eht left seid, adn tuselr in yapsolphia of hte nguls euab(sce e'ytrhe lrbyhori .r)pesemsdoc

johnthurtjr Usually on the left because the liver prevents herniation through the right hemidiaphragm +7

asdfghjkl aka congenital diaphragmatic hernia +2

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? +

drzed @pg32 You can actually see a gastric bubble if you squint hard enough. Look at where the NG tube is placed; there is a radiolucency to the patient's right of the NG tube which is most likely the stomach. It probably then is radioopaque distally due to the pyloric sphincter, and air having a tendency to rise. +2

bbr Any idea what "absence of bowel gas in the abdomen" is referring to? +

rkdang my interpretation was absence of bowel gas in abdomen --> the bowel is not in the abdomen --> incomplete formation of pleuroperitoneal membrane bowel gas is a normal finding that you often see on x rays of the abdomen in a normal patient +1

seba0039 @rkdang is it also abnormal that you cannot see any air in the lungs? This threw me off when I was trying to read the radiograph. +

-3 (nbme20#19)

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Is htis hte neo whit the poor diyekn taht saw cut in aflh tiasang tsi will nda has a latddei alsidt retu?er fI ,os laopybrb osgwnhi su aoitnralitns caciroanm hitw midl anivsoin iont thta datils ureer.t Pthomaa dseo a tteryp oewsmae jbo of klantgi taobu UG ernscca na(d smto arnsce)c (dn(a most )ice)mnied MO.I

-3 (nbme20#20)

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I evha eedrgdar iectprsu as the buringb fo enebbo-non-o. My udyst ernartp nad I hktni tish si a puyrel fntiioneilda s.eonqtui seY, rutcpeis uocld olas be detarpp ari. o,nettCx I g.euss

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. +1

len49 You may also see the word in regards to gas gangrene (C. perfringens soft tissue infection) FA 2019 pg 138 +1

+7 (nbme20#36)

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I htnik alheSlgi is eth mtso ,oitppearpra sa ti si laylutac redadegr as yhglih oiayalnrm.tmf es,Y E. cilo cna eb fo hte CHSEEC/TE areyvti, btu E. iolc culdo alos eb fo eth ECET ayvirte ro areewvth ohter istsnra it sha. grE,o .E coil yam eb luiea,bpsl ubt ti si not hte sotm' yill.ek' hBle to heest sdink of t.siesqoun

jcmed This is why I picked this one because of the mucoid stools/inflammatory nature :) +

+3 (nbme20#23)

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If ouy tawn ot eaclr a gdu,r ti is laorpbby etbs tath ti not eb ubond ot rtsionpe o(s ttha it stge )reietfld nad it hsa a low vmelou fo oniistbturdi so( ti 'ntsi in het e,dpe arhd ot arceh susiset).

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. +6

+3 (nbme20#21)

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Tihs tenpiat si reiceeinxpgn esvrpteysiiytnhi enimtpsouin omrf the a.seraptek I wsa intinkgh M. mAuvi hewn I deslecte eapketras -- I hitnk my licgo aws adwfle gevin teh csfciispe fo teh etai'tnps otys.r

+13 (nbme20#17)

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As a lreu of thbmu, if uyo vige onmseoe an AEC nhiibotri adn eyth get a bl,pmeor hyte had enral ytrare ssseoint llasu(yu ,ytarabelill ro os we erwe hgutta at oru emd )hocs.ol bborPyla hsa ot do ihwt ecesddear FRG htsnak to rsdaecdee ingAnoesint sect–eIlIvei tioaisonstccornv fo hte eftneefr ietreolar g=;t& adrsecdee domius rlvyieed to lcuama seand t;&g= rsdnceaei nrien seral.ee

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. +2

drpee We should always expect GFR to drop a little after adding an ACE-inhibitor due to efferent arterial vasodilation. For this reason we should also expect Renin levels to rise via tubuloglomerular feedback. So it's not really the reaction to the ACE inhibitor that gives this away as RAS (which is why I got it wrong). I think what we are expected to be looking at it are lab values: Hypokalemia, and secondary hyperaldosteronism. https://www.aafp.org/afp/2017/1001/hi-res/afp20171001p453-t5.gif +

stepwarrior ACE inhibitors would actually have the opposite effect of AT-II, and result in efferent dilation. But the actual mechanism of increased renin activity per UWorld is lack of systemic vasoconstriction by AT-II leading to blood shunting away from the kidney. +

+18 (nbme20#30)

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emyAnti ouy heva a rosnpe how mbspu eirht aedh, gtse ckab p,u dna ehnt hsa revese ssueis ro dsei elik 6 uorhs lrate -- you veha olsfeyur an ripaudle tameamoh rfom cniaoltear ot hte leddim NLIEGAEMN ate.rry oljan(G earlyl mszepasieh thta you tnod' ercws up dan etecsl diemld recl.)bear uYo okwn ti sah ot be an ailrtrae eranltoaci ncsie eht arud si ghiltty dhardee to het lsu'slk ernin ruf.esac njGloa errfedre ot shi ecpnierexe ithw ti as ningede rlipes to vmeoer hte adru morf eht ;lksul rcpaigh, utb ti ervsdi eth ptnoi hme.o igentTn eesn no TC is becseau teh earpildu meaoahtm estg sctku entbwee het ursetu n.isle enWh ti egnmsaa to kraeb psat eon fo the reustu ,nseil it si my nusareidtngnd ttha nteh is when you gte sreeev esql,euea eilk teahd ro vrae.weht

usmile1 omg monoloco!! I miss you dude! We used to hang forever ago, hope all is going well in med school! +7