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Welcome to nala_ula’s page.
Contributor score: 86


Comments ...

 +3  (nbme21#46)
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olTl lkie eopstrcre are tpntaer onrgicnoeti osctprree (no einatn imiuytmn slelc iekl hcao)gpermas ttah rniegozec topheagn doicatesas uelclomar nsrattpe MAsP)(P dna elad ot oniavtitac of k-.BNF eOn mlapexe fo a PPMA is PLS a(rmg nvgteeia rcabet)i.a Tihs eadsl to snteioerc fo -L1I, -6LI ae(usc ee,f)vr -FNaT caeuss( rveef nad no)pe,nsotiyh itricN dixeO esa(cus yspi.hoe)nont

pmteelComn icnavatoit fietls esdla ot oseohnpinyt iav C3a, as l.lew

llA hist acn be donuf on gaep 331 no A,F sa emniig@isnt pntoied ,otu dna geap 99 of FA .0291


 +3  (nbme21#37)
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nI tcedabii iesoasdoit,ck rheet is ecrednsai dcai in het xlureracalelt a.secp Acigndcor to AF reteh si a rtlralceaulns ihstf ued to ddereeasc innsiul that dsale to omer +H ietrnnge the cell in gxchneea ofr .+K iTsh ldsea to aahmpyleirke itwh dldeepet aenrtlullciar oterss fo K.+ eTrhe is saol tcomosi idussrei atth salde ot sciandree +K lsso in het eruni nad tolat dbyo K+ odneip.elt eTh qntoeisu sask atth si tosm ylkile ot deceesra whti nliinsu htayrpe: urmse pumtsosai ceotoaircnnnt lliw screeade sa +K is wno cenadhgxe for +H sneidi the clle.

cienfuegos  Additional UW fun facts regarding Potassium and DKA: use caution giving insulin and IV fluids to dehydrated hyperglycemic because i forces K in cells causing fast decrease of extracellular Potassium, thus give K supplementation even when serum K elevated +3
linwanrun1357  Why urine K+ does not decrease? +1

 +5  (nbme21#43)
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M. lsuotrbucies lteapeirsc ni na cekendhcu nfosaih whniti teh aielvlo dan ollareva oaahcsmrgep ued ot rlneeuvic acfrost crd(o ofca)rt atht veptner dmgpcor-edahiaeemat oohsmlasegpoy tr.tdiseucon eftAr a fwe eske,w casheoarmgp tedcnfie dplsaiy etanngi on HMC II ot suamltite T D+4C slcle icwhh aesdl ot an iscrenea in nfir-eotynre (h1T k)ycoitne htat vactei racom.ahepgs vtietAdac msgcaraepho cna also tanifereifted iotn iphitleioed oytstscheii and osecaecl niot etctaunedlumil gnsanhaL aignt elslc tath lawl ffo rueclrlxaltea iatoaerbcmyc nhtwii o.uraganslm


 +10  (nbme20#11)
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hTe stoyighol is fo rhespsoctey mall(s pihcsaler llesc o/w tanlrec l.)loapr ertadeirHy opiycsesostrh is edu ot dtefec in sntorpie tnegticniar whti BCR amneermb etnkosel nad slamap emenambr n,aik(ryn ndab ,3 pneorit 2.4, rn)e.sictp Moslyt tulooasam mdnnatio aciternehin (os gehsuoeyzort ttinamuo cinse ouy noly deen noe antmtu alleel ot gte eht )si.eeasd

wuagbe  To add to this: homozygous HS presents with hemolysis even in absence of stressors. this patient is only presenting with pale skin, and there are no schistocytes on the peripheral smear, so it's a heterozygous ankyrin mutation. +7
pg32  I wanted to pick hereditary spherocytosis but the mean corpuscular concentration was normal and I thought it was supposed to be elevated? Also, why are there so many RBCs that are way bigger than the spherocytes? +4
nephroguy  I'm assuming that the MCC is normal because the patient is heterozygous for HS. Not sure if this is correct, but that was my thought process +1
draykid  Are there any papers that explain the difference in expression of homozygous vs heterozygous HS? +4
waterloo  I don't know if that matters as much, like the phenotype difference of homozygous or heterozygous for this question. Since you only need one allele to show this, play odds. Is he more likely to have AA or Aa. That was my thought process. Also if you see spherocytes you'd be going for ankyrin right, not B-globin bc that should be target cells - regardless of MCHC. +1
alimd  as I remember AD are always heterzygous. Because homozygous are always lethal. +1




Subcomments ...

submitted by colonelred_(86),
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eTh oinssiagd si etabsrwyrr hammaignoe, moclmyon phnsaep ni sik,d fteon ssrelveo no ist own as yeth teg .oelrd

shaeking  A strawberry hemangioma is normally pink or red (which is why it is named strawberry). The description has a flat purplish lesion which makes me think of a port wine stain on the face. How do you know to think of strawberry hemangioma over port wine based on this question stem? +1  
sheesher  This sounds more like a nevus simplex, which is very similar to a port wine stain, though it regresses over time. +2  
seagull  the age is key here. Newborns have strawberry hemangiomas typically on their face. Sturge-Weber could also be the case but none of the answer choices matched to that description. +1  
vshummy  I would agree with Sturg Webber nevus flammeus but I also noticed First Aid says it's a non-neoplastic birth mark so I should have known not to pick malignant degeneration or local invasion. Also because capillary hemangiomas don't have to be flat but the nevus flammeus is consistently flat. But I'm also reading on Wiki that the nevus flammeus doesn't regress so they must be trying to describe strawberry hemangioma even though I don't agree with their color choice... +  
nala_ula  Maybe (and I can only hope I'm right and the test makers are not -that much of- sadists) they would have made sure to write "in a cranial nerve 5 (either ophthalmic or maxillary) distribution" if it were Sturge-Weber. +1  


submitted by haliburton(192),
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2EF si tnlntolsiaara eooltngai fotcra ,2 hhcwi is erysscnae rof oritnpe sishn.tesy

sympathetikey  I. Am. So. DUMB. +18  
nala_ula  same :( +2  
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +  


submitted by nosancuck(74),
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Yo adwg ew all uoabt VTP TMI LLaH

hnlelP,nnyaiae n,Vliea pNo,KrDtyTA erTon,inhe nle,oeIsicu in,tneoheMi iestdiHni, ceeLniu yiLsen

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 nosancuck(74),
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Yo dagw ew lal ubato VPT MTI HLaL

lnelPni,anhyae ne,ilaV ,tToKpANrDy r,nohneeiT n,cueoseIil ieh,toMinne siHtiin,ed eLceuin nLysie

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 halux(4),
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cna eosm eno paesel enplixa wyh si eth piasphryale?

beeip  Loss of negative feedback from resected ovaries leads to gonadotroph hyperplasia. +2  
halux  so, the explanation is that in the absence of Estrogen negative feedback inhibition to LH and FSH, this leads to Gonadotrophs Hyperplasia at the Pituitary resulting in elevated LH and FSH secretion levels? I get busted by this one :/ Thanks in advance! +4  
nala_ula  @halux exactly, there's no negative feedback telling them there is an increase in the hormones (since there are no ovaries) so gonadotrophs work in overdrive to keep stimulating the gonads via FSH and LH. +  


submitted by asdfghjkl(2),
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ennoyA konw hyw 1FI-G nl'udotw be deceasnir sa llw?e HHGR is iuetdtalms in cceghoilymyp .astste

nala_ula  Honestly, it's something that has confused me for a while. Why is it that GH secretion is stimulated by hypoglycemia? I mean, it's literally called growth hormone (for growth!), and hypoglycemia, which is basically a "starvation" state, will stimulate this hormone? +  
shaeking  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529368/ This might help answer your question. I basically didn't pick IGF-1 because it would increase the uptake of glucose leading to a worsen hypoglycemic state. Didn't have a true reason otherwise. +  
temmy  IGF-1 is regulated by insulin. so it will be decreased because insulin levels are also low. +2  
nala_ula  thank you @shaeking! +  
nwinkelmann  I found this and it also explains to a more genetic/cellular level. Essentially, it says that starvation induces some factors that cause GH resistance and IGF1 suppression. +1  
nwinkelmann  Sorry forgot the link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575072/ +  


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dtrhoprAo rfo ur,es but ofr eth dcoerr 'Im teytpr esur hsit swa aighnnkCuuy rsuVi. nlyO ogt isth fmor a rUlWdo uneqsiot sa I tn'had eesn it nluit h,tne btu npaatplyer eht aatrihlrga is llerya adb, hhwic si atwh wred em ot eth awn.ser

vni:dn/huilthpc.ugnc//eksamdowxhw/tyt.g.wc

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. +10  
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. +1  
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. ) +  


submitted by hajj(0),
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acn nynaeo lanxpie si?th i nokw ndeaim for y is hhegri yb iacunltcalo tub x ash wto semdo so how omec y ahs hirhge ed?mo

lispectedwumbologist  The mode in X is 32 and the mode in Y is 80 +  
lispectedwumbologist  The mode in X is 70 and the mode in Y is 80* +1  
hajj  Thank you! +  
hungrybox  Just checking in so I could feel smart about getting this right despite bombing the rest of the test lmao +4  
usmleuser007  can someone please explain the median in this +  
nala_ula  The median can be known by first assembling the numbers in order from least to greater. If it's an uneven number set, the number in the middle is the median (for example: 4, 10, 12, 20, 27 = median is 12 since this is the number in the middle); if the numbers are even then you have to take the two values in the middle, add them up and divide them by 2 [for example: 4, 10, 12, 12, 20, 27 = (12+12)/2 = 12]. Page 261 on FA 2019 explains it as well. Not sure if I explained it well... good luck on the test, people! +  
dubin johnson  Can someone please explain how the mode for Y than X. Not sure how we got the values above. Thanks! +  
dubin johnson  I mean how is the mode for Y greater than mode for x? +1  
sgarzon15  Mode is the one that repeats the most once you list them in order +  
usmile1  Median would be the BP value that the person in the 50th percentile of each group would have. So for group X, to find the 50th percent value, I added 8 + 12 + 32 = 52, which is right above 50, so the median would be 70 mmHg for group X. Doing the same thing for group Y, 2+8+10+20+ 18 = 58; the 50th percentile would fall in group that had a BP of 90 mmHg. which makes the median higher for group Y. hope that isn't wrong, and helps someone! +4  
poisonivy  I did it the same way! not pretty sure if it is the right way to do it, but it gave me the right answer! +  


submitted by aishu007(3),
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nac oenayn npixlae ywh ictcuonfseasrccaeloe si het wrsane ree?h

priapism  Best I can guess is that both S. aureus and E. faecalis can cause UTI, but S. aureus is described as having clusters where as the other Gm+ cocci are in chains +5  
nala_ula  My doubt here in this question is the fact that Enterococcus faecalis is a normal gut microorganism that causes these different symptoms of sickness after genitoruinary or gastrointestinal procedures... but in this question there is no mention of any procedures. +  
fez_karim  its says chains, so not staph. only other is entero +  
temmy  according to first aid, staph aureus is not one of the high yield bugs for UTIs +1  
temmy  uti bugs are E.Coli Staph saprophyticus Klebsiella pneumonia Serratia Marcescens Enterococcus Proteus mirabilis Pseudomonad aeruginosa +  
privatejoker  Where in FA 2019 does it list that C.coccus is specifically in chains? +  
privatejoker  E.Coccus* i mean +  
divya  @privatejoker FA 2018 Pg 134 table +  
jennybones  @privatejoker Enterococcus is Group-D STREP. Streps are arranged in chains. +1  
santal  FA 2019 Page 639, too. +  
backwardsprogress  Enteroccocus is also a pretty common cause of chronic prostatitis, which was the give away in the prompt if you didnt know the characteristics of entero: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715713/ +  


submitted by hyoscyamine(55),
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Tshi si aeatllr lem/aeruCbaIePglW/Anrlldy neymrosd. heT wanom sha gdeama in teh cmyhieptast cahni nsyroes( rnsodyems era laatlre ccrdaiong to eth urle fo )s4 unlsegitr ni renoHr nsd,rmyeo plsiintamocah cratt tmpneipa(/ ihchw are aosl oye)r,ssn nad NC XI nda CN X cnioyntfdsu trunislge in the a/pdhtrysdayaihriags ehp(ls us iaelozcl ot het .umlea)dl

nala_ula  Also, just to add, FA specifies that Nucleus ambiguus effects (dysphagia, hoarseness, decreased gag reflex) are specific to PICA lesions. +2  
cienfuegos  Thanks for the input. I have always found this topic to be tricky and just came across this article that helped me out a ton regarding the rule of 4's hoscyamine mentions above. https://rdcu.be/bLjOB +5  
lovebug  FA 2019 502pg! +  


submitted by hayayah(990),
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eoySancrd adyyhsmhropprraiite au(lusly td/ ochnicr ealnr ief)ual.r

Lba gnndifis iceundl ↑ PTH snepreo(s to olw u,a)mclic ↓ eursm umaiclc lerna( ,ifaler)u ↑ mruse ptpaehhso alren( )ruai,efl adn ↑ aanlklie staespphaoh P(HT ttivnaaigc tltassosoBe.)

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +1  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +1  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +1  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1  


submitted by yotsubato(806),
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Why si ish obdiLi rola?mn I'ts ltaoylt ptexeedc ttha he aym vhea ddeucre diolbi afret sih ewfi ddei 2 ysaer ago mrof esom brieorlh eponrolgd senills.

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by yotsubato(806),
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Wyh si ihs Lboiid al?mrno st'I olaltty edxecpet thta eh aym ehav ruedecd oibdil rteaf ish iwef deid 2 esrya ago mfor mseo rbihelro lgonoderp slin.lse

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by yo(53),
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iThs corcrude iwnith 6 hours nad asecud esmo oayrlnupm aedme adn ypsrtroiare sstirdes freat a ifnrnutosas duacse yb the 'rnsood ae-uneocttyikl etidsonbia tsuj rniegsodyt the necirsetpi lstnheuipor dan risaoytprre iholenealtd llecs.

ehiwl l/xliasacneprygihaal anc ausce rsityaporer retrsa nad hscko it sah a smoweath ernfetifd ,iuectpr no hgizn,wee tsniseich or ewahetvr dna cnaocdirg ot fitsr Aid ti heppsan niwtih uistnme to -23 ruohs chwih is at tlase oeudlb whta eerw' ieseng .erhe laos reebaw of AIg tiicfndee eplpeo in sith chcoei.

E,P eh I 'ntod ktinh it atfecsf P2ao ahtt fenot hmuc craongicd to thsi sruep eudrp hhig yiedl rceeosu.r utb uhh yaeh ed'otsn efel EP anidk ionseq utciitw.tue0rp.-/0s9a1apsrne#mhpdi1/lcdc/eomc:cee30teo2/km

neaimnop, ghtri eaftr lal the nsoiifun esuinssb and on timeonn fo vreef or hgn?niyta Nh.a

go to agep 141 fo srift i.da 'mI prytet erus we eedn ot owkn rou nsinipnntur/sfloaat acrp ebcuaes ti tusj kpsee mognic up in wldoru utb iths eohwl axme is a spr.oahtoc

oFivegr em if I emda a /wisgrtkaomen tobua ni,anghyt I stlymo tgo fnoi mfor sritf a.id zlp eccrrto if reeth is a ei,matsk ogdo lc.ku

hungrybox  we gonna make it bro +5  
hungrybox  or sis +6  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +5  
athenathefirst  I hope you guys made it. Your post 9 months ago +  


submitted by meningitis(413),
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heWn adigtsnn ,up eth dybo yollramn aescatvit ctsehiyamtp tsmyes ot odvai ttotsoiarch eshinoynto.p

tBu cenis rhete si onw an idvdeiat feceft fo eht ctyomrepcaomhhoo snd,riecaegr ti llwi eadl to a ontnrpyseeih

:i.e( blueDo tnciviotroocsans = Peoh rsncgaedire + tptyheicmaS sm)yset

sympathetikey  Brilliant. +4  
medschul  Would pheo have a normal resting BP though? +4  
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 +  
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 usmleuser007(326),
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usjt a ...nuhc.h emzOlapeor si alwyas het griht arwesn

nala_ula  Famotidine is an H2 blocker which really only stops acid secretion via the stimulation of H+/K+ ATPase by histamine, but it still has vagus and gastrin stimulation. If you use Omeprazole, you get irreversible inhibition of the pump itself which stops the secretion of acid even if there is histamine, gastrin, vagus stimulation. +6  
temmy  what about the healing of her mucosa. Is that not the action of prostaglandin?. That threw me off cos according to FA, misoprostol increases secretion of the gastric mucosa +4  
cry2mucheveryday  same doubt..marked miso +1  
sahusema  I guess because misoprostol is more associated with treatment of NSAID related ulcers and PPIs are 1st line DOC for GERD? +1  
makinallkindzofgainz  @temmy, I think that Omeprazole is a better answer because although Misoprostol would promote healing of her esophageal mucosa, it wouldn't do anything to relieve the symptoms of GERD (due to acidic contents in the esophagus) +  


submitted by hungrybox(791),
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oFlngwiol a rokset, tish tpiaten dha wsseaenk of reh tfel fcae and ,oybd so het oskter tsum ehav tefecdfa teh hirgt esid fo rhe iba.nr B swa hte lnoy ohccie on hte hirtg sdei of hre .rinba

Stlli efd?uocns eadR ..o.n

The aynolurvt ootrm fisebr aocsno(plrciti atr)tc cddseen omfr teh mapyirr torom ,eotxrc ssocr causet)e(ds at eht mrldlyeua prasmd,iy dna hten pasneys at the neioratr oormt rnho of hte plnais vlee.l

cuBseea of tnadcuoisse ta the lmluaerdy miad,ypsr yuo hudlos aemk a toen fo wereh nay soretk u.orscc Is ti obvae teh myallrued rm?aysdip enTh it lilw cefatf het desi poiepost eht etoksr c(l)a.rntaraelot Is ti elowb the mlrluyeda prd?iamys eThn it wlil atfefc het easm eids as the kroste isltra)ip.lae(

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +7  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +15  


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I get htat htsi serawn ocehic is eht otsm lmbecaai ernswa.

tuB lenshoty het ayw yteh kesad eht nsoiuetq ti" si msot eprppaaitor rof eth hicpnsyai to arssedd het sisue of a enigfed ebtu in wcihh fo the lloogfiwn nn"resam

yM aersnongi saw: lwer.blef..oe hte yimlfa acn neev nebgi to uareg whta do od dont' uoy have to pesorpo a ildacem aeteatn/mmenrangttem rtgyt?aes hhwci si hwy I ewnt hwti cdo"mernem a tue"..b.

home_run_ball  Like what is the learning objective of this question? On first aid if you go by the Surrogate decision maker priority: you do spouse first...so like wtf nbme? +12  
uslme123  I think it's because there isn't a legally appointed health care surrogate in this case. The family hierarchy is only an "ethical suggestion." +1  
nala_ula  According to first aid, there is an order to who makes decisions when the patient is not able to and hasn't left any directives. My issue was the same as home_run_ball, since they specifically asked about the feeding tube and not "who is supposed to make decisions now" even though that is also warped since the spouse has precedence. +1  
badstudent  If you look at the wording for the rest of the recommend a tube option ("because feeding will be more efficient and prevent starvation") it seems like you would be persuading the family to move forward with a feeding tube for their ease and convenience rather than proceeding with a feeding tube to avoid the possible dangers of an aspiration pneumonia. A family that is visiting daily likely doesn't mind any challenges associated with feeding. Instead it would be more important to recommend a feeding tube to avoid risk. Dumb questions for sure, just wanted to explain why i ruled that answer out. +  


submitted by kchakhabar(34),
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Wtah rweth me fof ni tish sneioqtu is teh sprhea lesc"l twhi lttile asmpctylo thta are wctei eth eszi of otmp.eys"lyhc I hthogu s"mlal clle omncric"aa onncat eb taht gbi.

nala_ula  Omg literally the same thought process I had, that phrase through me off! +  
nala_ula  threw* +1  
jesusisking  Super counter-intuitive but apparently SCC cells are 1.5-4x the size of lymphocytes: https://www.ncbi.nlm.nih.gov/pubmed/1313679 +1  


submitted by kchakhabar(34),
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haWt rhetw em ffo ni itsh ioetsqun si teh aesprh lls"ec hwti tteill mytcpslao ahtt era wicet the ezis fo s."tmepocyhyl I ughtho sa"llm clle ac"caonrmi aontnc be ttha ig.b

nala_ula  Omg literally the same thought process I had, that phrase through me off! +  
nala_ula  threw* +1  
jesusisking  Super counter-intuitive but apparently SCC cells are 1.5-4x the size of lymphocytes: https://www.ncbi.nlm.nih.gov/pubmed/1313679 +1  


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eeLaionlgl is omncom ssecau fo ompnaiune usmpeoiesrdp no rohccni utvbrocties onlarupym sa.edise

asapdoc  Im pretty sure so is strept pneumoniae +4  
usmleuser007  COPD is also exacerbated by Viral infection: Rhinovirus, influenza, parainfluenza; and Bacterial infection: Haemophilus influenzae, Moraxella catarrhalis, Streptococcus. however, the questions gives a hint that it may be legionella = "weekend retreat" which may be associated with this infection +4  
loopers  From FA 2017 pg 139: Legionnaires’ disease—severe pneumonia (often unilateral and lobar A ), fever, GI and CNS symptoms. Common in smokers and in **chronic lung disease.** +1  
kentuckyfan  I also believe that the other attendees showed signs of pontiac fever, which is another hint they tried to get at. +2  
luke.10  i did it wrong and chose influenza virus since it is most common infection in COPD but the clue in the Question is that the other attendee didnt get sick since in legionella there is no person to person transmission +  
endochondral   but in Uworld s. pneumo is one of the most common bacterial exacerbation of COPD legionella wasn't even mentioned. How do we rule out s. pneumo ? +3  
nala_ula  maybe because in children s.pneumo causes otitis media? +  
smc213  Another hint made in the Q stem is the location being rural Pennsylvania.... Legionnaires disease was first discovered by the outbreak in 1976 at a convention held in Philadelphia, Pennsylvania. Not sure why I know this fact... +5  
hpsbwz  Biggest hint towards legionella to me was that they all were at a residence hall... i.e. where there'd be air conditioners and such. +4  


submitted by meningitis(413),
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ehWn ntsgiadn ,up hte ybdo orynlmla tvcetaais shmtacteiyp msyest to divao othsrattcio te.hopsoinny

utB ceisn hetre si won na tdaivide etfcef of the rycoooehotmhpcam sinrgcered,a ti iwll dale ot a onnphyitrsee

i(e:. buloDe ontciacsrvoonsit = Peoh gnreaiserdc + hcmiaptteSy yts)mse

sympathetikey  Brilliant. +4  
medschul  Would pheo have a normal resting BP though? +4  
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 +  
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 breis(35),
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ouyr sugse si sa godo sa ........................................n.............im............e....

nala_ula  I spent so long on this question and same... hahaha +  


submitted by asdfghjkl(2),
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nnAoye wnok why 1-IFG 'ltowudn eb iecdrsane sa lle?w GRHH si tsitaudlme in cyohmcplgyei aets.ts

nala_ula  Honestly, it's something that has confused me for a while. Why is it that GH secretion is stimulated by hypoglycemia? I mean, it's literally called growth hormone (for growth!), and hypoglycemia, which is basically a "starvation" state, will stimulate this hormone? +  
shaeking  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529368/ This might help answer your question. I basically didn't pick IGF-1 because it would increase the uptake of glucose leading to a worsen hypoglycemic state. Didn't have a true reason otherwise. +  
temmy  IGF-1 is regulated by insulin. so it will be decreased because insulin levels are also low. +2  
nala_ula  thank you @shaeking! +  
nwinkelmann  I found this and it also explains to a more genetic/cellular level. Essentially, it says that starvation induces some factors that cause GH resistance and IGF1 suppression. +1  
nwinkelmann  Sorry forgot the link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575072/ +  


submitted by thomas(-1),
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wnersA si ortAtye.sc taitnPe sha msalootlgbai .truofemilm lohugtAh nemnigoaism aym ucroc at ontxe,visiec ognmniieasm era bngein dna nfoet matapotcmiy.s Tyeh yam eascu a/h ze,uersis tbu luowd be illekuny to sucae thdea iw/n m6 fo esnot of /ah. eTh eszi fo ourtm and ecrsuo fo ellsisn is sscteiotnn whit het rouecs of GMB

masonkingcobra  Above is obviously incorrect because the answer is Meningeal lol. Here is a link to a good picture: http://neuropathology-web.org/chapter7/chapter7fMiscellaneous.html +16  
kernicterusthefrog  Obviously thomas is disagreeing with the presentation of the question, and I agreed with him! This absolutely sounds like GBM, with rapid onset leading to death, and the symptoms. The question stem leads you to GBM, and the gross image to meningioma (I guess). +2  
kernicterusthefrog  Furthermore, where are the meninges on the gross image form which this (meningioma) grew?! It should at least show the tissue from whence it came! +1  
nala_ula  Had the same problem, got confused since it appeared that the growth was malignant :( +  
sugaplum  FA 2019 pg 514, also agree with everyone. weird presentation. Glios are malignant death within 1 year, meningioma are often asymptomatic or have focal signs. just a gross pathology question at this point +  
garima  ı think she died bc of pressure or something guys, its obviously round shaped benign lesion, its also extra axial not like GBM. she had this maybe years before death +2  


submitted by johnthurtjr(127),
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I'm otn a afn fo sgosr tahp iaemsg dna ieunsqtso ttah ays ",loko whta is hsit h?itg"n - thta iads neniaiomgsm rea het sotm mmonoc irnab motur and isth euctrip si si a oodg lpexmea fo .eon I adh on diea what teehs isghnt odkoel keli nda tgo it gnr,wo t.oo kaeT a olko at siht oen

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +  
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. +2  
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. +10  
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 celeste(68),
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Tihs dssonu kiel aFcinno mey.nords eTh morlaxpi trbualu tlaipihele lcsle have a adrh emit rsbngbaeoir ite,talrf so oluly' ees a olss fo epshthao,p inoam csa,id acni,oarebtb adn oeg.lucs

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +3  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +1  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +1  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +  


submitted by haliburton(192),
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AF 17:02 Istecnf B leslc ughhotr 1.CD2 pAliayct ohsycleytpm no lpapoblrh doeier raems G —not ieeftndc sclleB tbu cervtaei coyoitcxt T lcels. ⊕ otoMpnos ieitetdshn iol—eohsatteerpb edeetcdt yb ailgg intonafuot heeps or sohre C UesBRs. fo almiinlxcio in ncsiouenomslanoc uesac crtcataicsrieh polarpaalmucu .sarh

zup  misread the "accounts for" question as what's the reason for the atypical lymphocytes. So I answered "virus infected B lymphocytes." Anyone else misread it like that? +10  
nala_ula  Shit, I misread that too and I noticed it now. Nerves get the best of us! +  
stevenorange  If the question is ask what is the atypical lymphocyte in the brain , than it should be the infected B cell, RIGHT? +  


submitted by hayayah(990),
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sThi npttiae hsa smlal ecll cnaamrico. ihTs etyp fo ecracn si casdsaiteo ihwt appotcaarilnse roedysmns husc as: gnuiCsh roemnSd,y DSIAH, or noaisbtied aaitsng +C2a snehcnal t-raE)bm(eantLo ro nse.uron ifimoAacntipl fo ycm eonecosng is asol om.nmoc

SIAHD Snro(meyd fo errappnioptai edntutiiirca ornmeho itcorn)ees si tzrareceidcha :yb

  • Esexvcise erfe tearw reontteni
  • milvcoEue aypotinemrah wiht oricrnityuna endu aN+ cornixeet
  • rneUi atosmlilyo gt;& ermus oslloayimt

yodB sopderns ot terwa noeenttir thwi oodnelsraet dan ANP nad PB.N Taht si thwa cusase teh ndiaresce rrunyia a+N otiseercn ihcŽhw aelsd ot talaomrnioizn fo lrlalctxeraeu duilf eomuvl dnŽa eth ucovleiem reyohimntaap.

hello  Why would body respond to water retention with ALDO? ALDO would increase water retention... +3  
nala_ula  @hello, the body's response is to decrease Aldosterone since there is increased volume retention and subsequently increased blood pressure. This concept confused me a lot, but I ended up just viewing it as separate responses. First, the increased volume retention leads to increase ANP and BNP secretion that lead to decreased Na+ reabsorption in the tubules (page 294 in FA 2019) and second, this increased volume basically leads to increased pressure so lets also decrease aldosterone so there is no Na+ retention (since water comes with it)... I thought it was counterintuitive to secrete so much Na+ since you're already having decreased serum osmolality (decreased Na+ concentration) because of the water retention, but I'm guessing that this is just another way our body's well intentions end up making us worse XD +22  
compasses  see page 344 FA2019 for SIADH. +  
dickass  author pasted text straight from FA but the arrows didn't copy over, inverting the original meaning +3  
medninja  The idea of increasing urine Na is getting rid of water, thats why this mechanism end increasing urine Na secretion even when there are very low serum Na levels. +