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Welcome to neonem’s page.
Contributor score: 550

Comments ...

 +9  (nbme24#39)
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gnlaFli no uthodecstret da:hn hdiaopsc is mtso momcno neo to eb rf,utaecdr uaetnl is mtso oonmmc to eb esdlc.taido Lentau itnasdloico nca cesau eauct rpcaal eutnln mdrs.yeon

Tknih of eht nmomecni tr"hStagi ienL oT ik,nPy eeHr oesmC Teh hbT"mu fro hte nebso of teh lm,pa arnwdgi a ltloobfa peash nrgtiats wbloe eht hbtmu PMC oitjn jadatcen to the ,iudasr nteh vgmnio ot ruyo maeild r,tsiw adn nthe ckba ot hte

S,hcpdoai ,alneut ,irterumqut i,srfmpio ah,aetm aetptc,ai rizpd,teao epraz.miut eTh ntueal oklso leki ti's ypooelsirtr dstdicaoel eeh.r

sympathetikey  Yep. I didn't even look at the X-ray. +9
dr.xx  loonies love lunate +2
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +1
wes79  i legit have no idea whats going on in that xray lol +9
nbme4unme  X-ray confused the hell out of me, I was going to put lunate based on Q stem but ended up putting Pisiform because it looks like that's what's messed up in the photo? Should have ignored the picture haha. +1
nwinkelmann  for @dr.xx, love your mnemonic. I added to it, or at least found an explanation on why it works. "loonies love lunate" and "loonies" are "dislocated" from reality. +3
niboonsh  Some Lovers Try Positions That They Cant Handle +9
vsn001  ngl if scaphoid was an option - would've sprung at that real quick -> thanks for teaching me the importance of knowing to look for dislocation vs fracture :D +
regularstudent  Ahh, the classic "left hand" x-ray but actual fracture of "right hand" NBME tactic +
sars  I think the x-ray is showing the lunate protruding out of the palmar side. Imagine the situation where you are falling and using your hand to stop the fall. Your lunate will dislocate forward as the rest of the carpal bones recoil back, hence why it protrudes through the palmar side. Thats why it causes an acute carpal tunnel syndrome. +

 +13  (nbme24#30)
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shiT si het mtos monomc ecaus of pnaissle oblydo hgeiradsc from teh ineppl ni a wonam fo dtrorpeeivcu ega. It si a ignbne tomru and rteeh era no ictracciehtars ihaipgacodrogicor/mamlm en.cahgs

 +16  (nbme24#4)
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I nitkh teh esonar you dnee ot jeitnc oorgdintsnapo ni htsi ecsa is aeubces uoy ened FSH nad HL ot rpueodc mprse. FHS eiutatlssm hte estlori ,lcles hihwc lein teh osfrenieusim subletu nda pelh hte paromeitgnsao rueodpc serc.easytpmot osrtoeTenets si a dprotuc of yLiegd lcles hwen ryte'eh iedtmlaust yb H,L so tjiegncni eostestnrote dwlou aysbsp hatt espt utb ti lowntd'u rllaye ehpl htwi rsmspns.oatgieee vwHere,o ejinitcgn HnGR oals dotes'n ens'tdo llarey pelh sebceau ouy need taht apesutill GRHn at nithg to eamk HL nda FSH sareewh clnitonagg- nGRH laansgo cllautay ecdaesre HL dan SHF n.uitoocpdr

m-ice  Adding on to the answer above. I was stuck between the gonadotropin injections and clomiphene. But, clomiphene acts to increase activity of GnRH which then exerts its effects on the pituitary. The man in this question had his pituitary removed because of an adenoma. So, he needs the FSH and LH directly. +21
mousie  agree! Removal of the pituitary would case a deficit in Gonadotropins (LH, FSH) and therefore nothing to simulate the testes to make sperm... replacing the T with a patch would not stimulate the testes to make sperm and if his axis was intact (although its not) this would further down regulate the production of sperm. I eliminated Clomiphene because if he dosent have T to induce negative influence on the hypothalamus he will have increased GnRH and further increasing it with Clomiphene would not correct the deficit in Gonadotropins. +4
neonem  Oh duh... that makes much more sense. Thanks! P.s. I thought clomiphene was more of a fertility drug for women, since it blocks negative feedback of estrogen on the hypothalamus/pituitary. But in men the system is under feedback due to testosterone, not estrogen. +6

 +14  (nbme24#15)
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eth boyd onsdesrp to oldob lsos by tieihs.psaoeom sTih rucsoc yb ugriupnegtla sftnirrnaer (an nori otrrtnasrpe ni het l,)bodo tniryioethopre orpioudntc a( oenrmoh edam suclyelvxei ni hte raenl triruapeulb iisttlenrtai ,llce)s adn heme ssyhiest.n Fstir pets fo ehme einsyhsst aws aautycll eludald ot ni orhtnae onutseqi no shti se:tt dcsneniatono fo lgecniy dna uyisnlcc ACo tnoi hTis is tteglnaim-rii tesp of mhee tssnse.ihy

wowo  FA2019 p417 +2

 +7  (nbme24#5)
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heT aienptt sha wlo sot,loicr hhicw ssueca ydbo ntwaisg. Teh atitpne si ephnmrdtpeegyi nsiec low oolrscit enaerissc CTHA teicerons omrf the yp,itritau tbu hits sresha a mmoocn ecpsrruro pironet tiwh esgyu-amnmnltoltticiae romheon )(,SMH so atth's tfone a sign fo heietr elnaadr uflerai ro an AisrtgecnCTHe- moutr. Put gett,oreh the hghi HCTA tbu owl rocitols ngpnaipeh evro a pdeiro of 6 shnmot smena atth eth anadrle mtus be etggtin iht by iometgshn -- onyl optino erhe saw eintumamou nct-siuWrhFeoseirheedar ormnysde saol sauces ldaerna ufinneisyiccf tub ihts neahpps e,lauytc in the rmeimafet of so.s-aurdhy

sajaqua1  The combination of low blood pressure (from lack of mineralocorticoids) and low glucocorticoids (cortisol) indicate adrenal failure. Hyperpigmented skin is a sign of elevated ACTH, indicating that this is a failure of the adrenal gland and not the pituitary. In the industrialized western world, autoimmune destruction of adrenal glands is the leading cause of primary adrenal failure (disseminated tuberculoid destruction of the adrenal glands is significant outside of industrialized nations). It also fits the time line better than Waterhouse-Friederichsen syndrome, which is sudden in onset and associated with hemorraging. Metastases to the adrenal glands *might* be a possibility, but autoimmune destruction is simply likelier. +22
mamorumyheart  Chronic Addisons disease. Pretty straightforward here. Decreased gland function -> decreased Cortisol, decreased Aldosterone -> hypotension (with hyponatremic volume contraction) Hyperpigmentation from increased ACTH (from POMC) making MSH. (FA) Due to adrenal atrophy or destruction by disease (autoimmune destruction most common in the Western world; TB most common in the developing world). +1
ac3  I picked autoimmune adrenalitis but was tempted to pick Waterhouse syndrome because of the low BP (hemorrhaging). But I believe Waterhouse-Fried. syndrome is more likely associated with Neisseria infection +

 +8  (nbme24#3)
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utJs had ot nowk ahtt IRTNs cfipyallscie( eth eunel)cdsois caues alictc ciadisos

brethren_md  Also NRTIs are hepatotoxic, cause the increased liver enzymes seen in the patient. +5
sherry  Actually, NNRTIs are more well-known for hepatotoxicity. But I guess NRTIs is the next best option for this one. +10

 +10  (nbme24#43)
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stilHaoapms anc tac liek TB nda cusea ctaavriy seilsno adn adfecilic nldosue ihwt ocrtfibi igarsrnc. nI aleneg,r giunf rae abmteotdc by pltcmoyseyh dna g,smcpaehroa ont leiioopnshs ro

baja_blast  Asthma history got me and I put Eosinophils.... but in hindsight I should have noticed that the biopsy is specifically of the nodules. RIP. +1

 +17  (nbme24#26)
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elaGner methe fo pg:ohtaoyl aopxhyi piimras xaoviidet hhraoplptionosy t;g--& less PTA ;&t--g essl -aKN pmpu itityvac so osmdiu usbild pu in hte c,lel iuncsag lgei.nswl hsTi is eht firts pts.e Tehn dyuo' teg eht cucimal puuibld ni the lcle dna vanetelu eociabran slyygioc,ls sunicga lactci icad cdrptunoio nda wdeoelr Hp... tbu sthi ensapph lraet nda sni't hte dtcrie aescu fo eulrllac wnl,segil chihw is athw eht oqustine si

aneurysmclip  can we have a moment of appreciation for Dr Sattar +18
makinallkindzofgainz  blessed be His name +5

 +4  (nbme24#23)
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haliburton  ^^^ THIS ONE SHOWS DUCT ^^^ +4

 +12  (nbme24#44)
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I knthi het idea eehr is ttha fi oyu akte mnsoeeo fof a P,PI if 'hetrse on amolneps ro ayn pbermlo thiw ngitrsa opticdounr nthe oyu uoshld ees it og nowd mrfo sibaeenl due ot ermo gaevietn dbfeecka of arcstig ycid.ait fI to,n uyo lporybba hvea a mlaenpso t'hast usjt nakgim sont fo ta,srgni uhcs as in the acse fo loenorlgiE-ilsZln oe.sydnmr

gonyyong  I thought it was that if you are taking a PPI, you will see elevated gastrin regardless of it you have a gastrinoma. Thus to confirm diagnosis, you make them stop taking it, then re-measure gastrin → if it's still high, you have confirmed. If it's normal, it's something else +35

 +11  (nbme24#45)
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ertbelonoeClienp elgan assm = laetVbirsu wonsmnahac (AKA cocistua )e.ounmar Derdiev rofm hancSnw ,lsecl hichw aer fo narleu rtecs ir.ingo

yotsubato  Ugh. Of course they dont put schwann cells as a choice. So I pick oligodendrocytes like a dumbass +32
subclaviansteele  Same^ +1
madojo  Schwann cells = PNS Oligodendrocytes = CNS +3
suckitnbme  NBME loves their neural crest cells +4
wrongcareer69  How much do they pay these testwriters anyway? I can use a thesaurus too +2
osteopathnproud  @suckitnbme they do love their neural crest cells, I have chosen neural crest cells for every single answer choice I see it in and I believe I gotten 90% of them correct, if something doesn't click or you don't know, I would keep neural crest cells as a very possible answer lol +

 +12  (nbme24#9)
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I nikth atsamtssei swa eht tebs potoin heer baesuce erteh era litelpmu gtalmnnai s..lmeonsa.p airyrmp nscaerc ntde to tatrs sa a elngis asms in teh esitus of .oiingr nI the lgun, setsmaates rea mero conmom hatn ryprmai p.omasseln

dbg  I seriously could not figure out whether those white opacities were actual lesions or reflections from the actual picture (flash light) ... mind went all the way maybe this is the shiny pleura so they're going after mesothelioma. smh +6
dbg  shiny pleura with tiiiiny granulations if you look closely. but obviously was far off +
et-tu-bromocriptine  "Multiple cannonball lesions" is indicative of a metastatic cancer. I think if they were leaning towards a mesothelioma, they'd show the border/edge of the lung ensheathed by a malignant neoplasm (see image): +3
bullshitusmle  guys something I learned from NBMEs is that if there is a clinical vignette dont even look at the images they give you ,they are all useless and time-consuming +1
goaiable  The way i narrowed it down was that the patient had signs of weight loss since three months whereas her cough developed recently (3 weeks). If the cancer arose in the lung then I think the cough or other pulmonary symptoms should emerge earlier. +1
almondbreeze  FA2019 pg 669 in the lung, metastasis (usually multiple lesions) are more common the primary neoplasms. most often from breast, colon, prostate, and bladder ca. +

 +15  (nbme24#4)
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hisT is utcae hyotlmeci anirotsfsnu eaoi,rntc a epyt II epiihtteyysnsvri heewr rerfo-pdem gIM aboteidins nbdi to pctelnoiibma BOA igesntna on odnor BR,Cs wchih cseasu nrlutiacvsraa somh.ieyls Rh playmotcitiii,bn ekil noe_oecrdll ,dais comes orem ntoi ylpa thiw Rtimc-alipboityh of gcayrnnpe and it is ued ot GgI datsenbioi, hciwh mero neoft asceu csarlavrateux leoysihms inesc pcinles rgosampahce aveh hsote R-mmacFa-g oersptrec to nbdi evaehwrt IGg ahs tagcuh. rsltuEcxaaavr s'oednt eacus htat s,phiynnetoo vfe,er fkaln inap toadsiecsa htwi uebmniaologhri cnise teh hcmarpaseog ldho on to hte geadddre RsBC dan toevnrc it ot reibl,vdiin cihwh can yelfas eb xeedetcr yb the vreli.

mousie  Could you help me with understanding why this isn't a Type I HSR? I understand that ABO incompatibility is Type II HSR but I don't know how to tell the difference between a patient who is IgA deficient and having a Type I Reaction to an infusion vs ABO incompatibility .... +8
sympathetikey  @mousie - Basically, think of Type 1 HS like a normal allergic reaction (itchy, wheezing, etc.). Whereas, with ABO incompatibility you get the question's presentation. +7
medpsychosis  When it comes to Acute hemolytic transfusion reactions, they are Type II hypersensitivity and divided into Intravascular (ABO) and Extravascular (host Ab against foreign antigen on donor RBC). The differentiating factor between them is simple. Intravascular (ABO) will present with hemoglobinuria alongside all the other common symptoms (fever,hypotension, tachypnea etc.) Extravascular hemolysis will stand out with Jaundice as one of the presenting symptoms. Hope this helps! +5
cassdawg  Also just to add: Rh incompatibility causes a delayed hemolytic transfusion reaction, this reaction was immediate so it is indicative more of the ABO blood group incompatibility (FA2020 p114 has all the blood transfusion reactions) +1

 -3  (nbme24#38)
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My tsbe uegss si taht hits tpteina sha a biipscdu ioacrt vlvae adn hsa a ururmm ude ot eicsednra lmouev aoodrlev rfmo teh argc.ynnep

charcot_bouchard  Can be congenital mild Tricuspid stenosis also. it also exaggerate during preg +
noplanb  Wouldn't Tricuspid stenosis be a systolic murmur? +
noplanb  I mean diastolic* +1
centeno  I think that a murmur of grade 2/6 is a clue for flow murmur. Maybe any pathologic cause of murmur would be exaggerated in pregnancy (due to increased blood volume) +

 +15  (nbme24#19)
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ntraenIl aaln stcneirhp si odsmcpoe moer of msotoh lcuems dna is udren aayimtaptpsrtcimache/yphets o,rlncto lhiwe aneletxr nlaa csrhpitne si tleskeal lcmesu dan loentorlcd by ednaulpd ene.rv All fo eht rteoh usmcels eitsld era lsaleetk mclesu of teh eicplv oforl adn rea ermo yliekl ot be olvndvie in Keelg scr.ixeese

 +10  (nbme24#15)
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akLc of 8CD1 (AL1F- tgrinnei) no goctpsyhae is het aeucs of koeleyuct iandoehs cdecniefiy yetp 1 ()L.1AD cneiS pghsaotcey leki tshorpnulie dna omaspgreahc cat'n gte tuo fo het blome,satord eyth era cuskt in teh lo,obd eehcn eth lsteuociksyo ithw WBC ntcuo t;g& 0010,0. Snice teh ksueectyol ear cskut ni eht oldbo, etyh tacn' umnto an tivfcefee eimumn sepesnor isngata ei.cabtar

sunshinesweetheart  also for completeness, LFA-1 is an integrin that binds ICAM, so LAD1 results from a defect in tight binding +1

 +16  (nbme24#40)
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shiT nattipe nti's i,tvptileanhgnoy e'yethr EYntRieia,tPnvlgH ehcen het 2POC &tl; 04 mm .gH

e'stL wkla ti :arakswbcd eyhT ear ealrntnyghipetiv to cmseenptao orf eth leatcbmio cdsoiias scaedu yb dedwrspaie .yphoaxi gieytaHpnrenilvt oslwla oyu ot wlbo off omer .O2C

Why rae eyth ciyx?poh eTh ronesp si iochxpy edu to otailfmimann and ctaeu prseoityarr sdtsreis rdnyemso omfr het piman.neou lAl teh eosktcyin mrof teh ytaramnolfim elcsl seuca arnisdeec olanymrpu riapclaly ,aaklege wchhi kcsbol up eth aevlalor ebammern os tath 2O 'tnac get gohhurt ot eht bood.l

Why od etyh hvae eiocblmat coiissad ni eht iftsr ca?ple oN exogny &g;t-- on eroclnte strortnpa ahcin dan on ATC ;--g&t licact .soicdisa

diabetes  no pneumonia it is UTI +3
makinallkindzofgainz  The infection from the UTI spread to her lungs +
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +11
peqmd  urosepsis +
snripper  lmao I read it as upper respiratory tract infections, too. +2
thisshouldbefree  she has an increased A-a gradient. +

 +22  (nbme24#29)
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ePr Pmaath:o eraly htenreiid seasc of riezAlshm'e meietand rae adieoasstc iwth umtnostia in sl,irn/iplise1nr-eie2-epnn sa well sa wsDn'o ymnsrod.e w'snoD uwldo be edu to an ertxa hemmsorooc 1,2 hiwhc raicers teh neeg rfo yoidaml rureospcr nrtipoe PA.P)( atErx PAP si ecntrdveo to Ae-abt amliydo and tsih sfrmo eluxellarartc etiirnuc ,pqausel a toneirnmp uaetrfe fo iAe'l.zrshme

rttpIoman ot not encsuof omlydAi A iotpenr o(ne of teh wesarn ohsei)cc thwi ymiAold rrseopcru ep.nroit ooDitiensp of AA idamlyo si erom ecsaoiastd wthi ohcrcni rlanafoymtmi tsa,set ,lymngcnaia dan Fialmlai rdtrinaeneMea ev.erF teBa-2 nocbiogrlmliu is rteanho aydimol aio:asstonic scisaeaiydtladoiss- sotpiesd( in jo)inst

 +4  (nbme24#47)
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sTih itetpna csea sonuds keil eh has iron idfyeicnce imanea ,in(aaem olw coa,heritmt cyccomiirt) mfro a IG e.ldbe oT egt htsi uiqstnoe thg,ir oyu adh ot emeermrb thta teh wot rjoma rheieindt GI ccerna oyesmnsrd are APF e(du ot uatoitnm in PCA eegn, whhci is a otumr rusprspoes gene) adn nychL nedyrsom AKA yerrithdea oipopynslnos- loltccorae ocrcinmaa HP)C(N,C cedusa yb a onmtiaut in a umnbre DAN ismtachm reaipr es,neg fo hitw 2SMH is a eomr oomcmn no.e

Teh shmmancsie fo htrie carnmcoia dtopelvemen rae fr;neidtfe ni F,AP tmsuor iasre rmfo a olrmna &-t;-g maodnea gt-&-; oniccaamr queeecns ielwh ni P,CCNH rtoums aisre omrf tawh's wonnk as a eitcsmlioeatrl tiiilyatsbn tawp,hya lndaieg to nsupetoaosn rnmftaioo of a armnacioc (ont peercedd yb a eibnng lnseio kile an aeom.adn.). ouY dndti' need to okwn iths to egt tsih osneuqti ,girht but nfyleiidet doog ot kwo.n

medpsychosis  To make it even simpler, if you narrowed it down to FAP vs HNPCC and looked at the image provided in the question, you'd see it's less likely to be FAP due to absence of numerous polyps which would be expected. So HNPCC would be your best choice! +5
yb_26  I always get Li-Fraumeni and Lynch syndromes confused :/ +1

 +15  (nbme24#34)
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ncSie tsih ttnpaei is a kson,mnr-oe ti is slse to be allms clle mrcaoinc,a uossmuaq clle amairnc,oc ro grale llec amcoicrna fo het ng.ul ssiBdee mllas ecll aiccnamro engbi mrfo eirenoondecrnu ioigr,n eth eon maorj nlug ccaren esribcedd by nsset fo dewdntl,rteliif-eefa ralru"e"g ellcs si a coicarndi romut. iato,iAdldynl tesoster aer ialhgltioosc rfaeutes fo doraniicc otsrmu (fnu tfa:c etseorst lsao ni tboommsenmupransoyaae/seld (in ,)SCN atslnosoiembtr,a lsaogaurn ecll smotur a(ravion a)ccen)r

mousie  When ever I hear Rosettes I always think NE tumors .... and I agree non smoking kind of RO small cell, squamous cell, or lg cell +4
charcot_bouchard  I thought it was Hamartoma & pick chondrocyte! Can lung even have hamartoma? Pardon me it was the laast ques of whole nbme +7
drmomo  @charcot_bouchard i thought the same. uworld gave a question on coin lesion in the lungs as classically hamartoma +7
anbumd  From pathoma benign coin lesions such as bronchial hamartomas composed of lung tissue and cartilage are especially found in younger patients. So i guess because of the age and histology this would be less likely. +

 +8  (nbme24#5)
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ryapAeltnp hlcierntila esli douanr ni umlsce of all of the rmando iotxce namalsi ahtt tmos pleope tu'lodnw rnollamy gishtn liek b,are wdil skprro/aob (leik ni eckSyth Mor,c)i igb atc,s xo,fes gdo,s ,srhsoe ,lssae .weauslrs In asce uyo eneedd nahetro soarne to tno hutn dna seocunm ethes il?sanam

 +10  (nbme24#11)
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hsit titneap hsa scmyatmitpo iaoctr sitn.seos hiTs cna be dineifeidt yb teh lernvuarict otpeyyhrrhp o(t cpoetsnmea ofr acsenride uofctnlnai tredoafla ofrm cmonplio-ntna oarcit v,lva)e sytimocisdl urmumr and hte taionloc at eth alromn ioartc area.

Pre DoUetpTa on lCaiicln niesiatamtofns of ctAior es:tSsnio

siDe"sinzz and cspenyo — Secyonp rusocc sa a rnsipgnete sotpmmy ni oarpeypxmtali 10 rpentce fo ttisnpea iwht pstmaioymct eesvre SA (ro laorxtmiaeypp 3 eptenrc of all sniattep wiht eseerv )SA ][3. Three rae vsereal rsopoped ilasaonexpnt ofr lneoreaxti isdezisnz oepnry)c(pse ro ponycse ni enstaipt ihwt S,A bhot of chiwh lcreeft eeredcdas bcalrree o.rufpisne Exdei-reedscunci oaanvdlotisi in eth ceerensp of an sroboctitun wthi exdfi dicrcaa optutu can ulrtes in .ostpineohyn"

guillo12  What does "fixed cardiac output" signify? +1
usmleuser007  "fixed cardiac output" might mean that with the stenosis (ie. narrowed aortic valve) there is a limited or rather reduced cardiac output. Exercise would not increase cardiac output because the stenosis is caused by a mechanical (physical) rather than a biochemical process. Therefore, At any given moment the heart can not increase its output no matter how forcefully it contracts. +7
fallot4logy  why not option A?arterial compression ? +3
sunshinesweetheart  @fallot4logy LVH does not lead to coronary artery compression. only reallyyyy rarely will pulmonary artery dilation cause coronary artery compression. plus that would cause angina but probably wouldnt decrease cerebral bloodflow to syncope. her murmur + LVH point us toward aortic stenosis which does cause those --> fixed CO +2
drpatinoire  @fallot4logy LVH can cause coronary artery compression, but typically leading to coronary ischemia after exercise (i.e. stable angina in this patient). The question is asking what leads to her syncope. Syncope actually means her brain is lacking blood supply abruptly. +5
rainlad  how do we rule out mitral valve prolapse in this case? +
spow  @rainlad murmurs at the right upper sternal border are aortic in nature. Mitral murmurs are heard at left 5th intercostal at the midaxillary line. +

 +8  (nbme24#36)
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m-yniAietsnolad nda snisu-teiat maaetsiugln abdetinsoi aer noognticamohp for Cilcae de,sisea a esyvyethintirspi ot hte aigdlin gntinea fo waeh.t tI lmaiyn sfaetsinm in het uenmjuj nda mluei. nI ,lsdtua ti teprness as ochcrni rashtoatere nda gbli,ntoa eiwlh ni iredchnl it esdo the aems but sloa ausesc refalui to .hivtre oyagllHci,otlsi it si itdifnedei by rctyp aahiyesplrp adn sluvloi taengnitlf. If uoy eadmga ruoy i,lvli ouy nca't obsbra fta htgrouh teh ecaltals of eht allms ninteties -;-gt& lsotbomapnai.r

tiSpisoeAP-v eslrunga ni aergsampcho ni nlaami oriappr = ipphlWe ise,aeds na fntoienic htiw yrampTheor piliphwe, an cunelriallart v-mriaegiostp Tihs duwlo ysrilmlai acues a reaisoablmptv tetsa ubt si nto csedtiaaos hwti acrariuplt niodstbae,i and ihtmg laso aenitsmf as ,ltaghiarsar ,rccaida and clugeoionr stom.mpsy

ugly_but_my_hoes_not  Damage is most prominent in the distal duodenum +3
ruready4this  where would you see eosinophilic infiltration of the mucosa of the small intestine? +

 +11  (nbme24#34)
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alloSot is a ytpe III cmtyhiaiarnrht +K( liclkcabg-oeh)nnn atht oals ahs albct-oerbek iyittacv eTpy( II yrt.)aictianrmhh hiTs lpesinax eht dedsecrae erharatte adn ldobo ruspsere a(e1tb- ibgonckl ttaiyc),iv whit hte QT taoronlgponi - lal tepy III AsDA scuae TQ lrtoognan.ipo

abhishek021196  Would like to add that the IA antiarrythmics = Quinidine, Disopyramide, Procainamide also prolong QT interval and can lead to tosades de Pointes and they would most likely present with Cinchonism (headache, tinnitus with quinidine), reversible SLE-like syndrome (procainamide), HF (disopyramide), thrombocytopenia. The decreased HR and BP point towards Sotalol. +2
armageddon_oh  Im glad you can regurgitate sketchy but none of those drugs were options here. It's as simple as which of these can cause torsades. +6

 +9  (nbme24#38)
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hiTs tnpetai sah na eutbnlsa odmo nad a zcayr l.iishneporat sSe'h laso ngisptlti a( enseefd sehiacmmn hniweer neo cats ilek leeppo era lodag-lo ro aabl-l)d as she kstla tuoab het aphinisyc dna ehr worrkocse. hisT rchcatriaciets si somt ymlnomco aaiecsstdo whit ierbrnedlo pesaontlriy oerddsi.r sTih noe is ni puorG B i"l(dW,") ognal tiwh tlacisao,ni isric,nhtio nad .taiirnssscic

medskool123  i get why its borderline now (I guess I kind of always thought suicide was the biggest part of that) but can someone tell me why its not paranoid? Is it just a matter of the "better" choice? The "youre the only one i can trust" thing lead me to that. +1
drmomo  same here +
aneurysmclip  Paranoid is where they don't trust anyone or are weary of people. because she said she trusts only the physician can be a bit confusing, but she describes her coworkers as jerks, not that "oh they're out to kill me, they're government agents watching me" +
boostcap23  Splitting association with borderline in FA 2020 pg 555 and 565 +1

 +9  (nbme24#39)
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mtSantaoosti is nrlymlao rdetcees by D cslle in eth cinrapeact sltise nda GI c.usoam It blclyaisa obkscl vhtenegyri Gd-eIrtael augroe"enc(s :mssatsas-")itoo csreededa rcsigta acid ;p&ma negiponpse censi,tero eaeedrdsc apicanretc nad slmal eeintisnt dlfui ,ieoensrct dcserdeea albldrdegal rocnnita,cot earedsecd siniuln a&m;p nulogacg lees.rae

ncirsgaeeD naisrgt aeleers kcolbs teh iacreens fo GI miitlyot rs(daeicne IG oyiittlm is teh einhnetr lbrompe fo e)

Teh drug ni teh tioqnesu si ylbrbaop coeretdt.oi

cassdawg  Just to add because I was trying to dissect exactly the diarrhea cause: AIDS patients can get refractory diarrhea for a variety of reasons, most commonly cryptosporidium enteritis and CMV colitis or just in general from HIV enteropathy. Octreotide has been used as a treatment for such refractory diarrhea due to the mechanisms mentioned above ( +1

 +5  (nbme24#38)
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Tihs ateitnp sha omjra eesvrpesdi ords:ride lsos of ananihdteoetr/isen edne( ot ahve ihst or sedrseedp dloe,oespm) slopr,ebm ightwe cgneas,h ereacddes gyenr,e toshtghu of eh.adt esMte trcariei bsceaeu g;&t 2 ksewe tiaerm.fem RSIsS era f-ieirntl;s repexation is ni shti ytecarg.o sISSR osla hlpe ithw wteigh gian - ghitm be an ddeda ntbeief if eth netpiat si nigteedhr.wu

The aarcdci usfft ihtmg vaeh utsj been a tr,rsoitdca xtepce hatt uoy blyrabpo wtud'lno wtan to ivge lcsiyictcr .ei.( nilti)yrmaeitp scien tyhe aehv micahrphyrto-r ised tfe.fesc taiePtn lraybbpo sha ndoerlpog PR ieavrnlt ued to beat os.celkrb

adisdiadochokinetic  Another reason not to use TCAs (or alprazolam or haloperidol for that matter) is that the Beers criteria state to avoid the use of all of those drugs in patients over the age of 65. +14
t123  The cardiac stuff is not a distractor - MDD is common after an MI, and a very poor prognostic factor (reinfarction) +8
therealslimshady  Beers criteria also says avoid antidepressants though. +

 +7  (nbme24#27)
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heTes aer toug sars.yclt I ouepssp hte tseb way to ierdfftaetein iths ecas orfm usgpeoudot is taht teh ycsltsra rea rshpa m&;ap hesddnae-lepe nda tno deasbi-o.ohmdhpr

sympathetikey  Yep. They tried to throw you off with the picture, but the wording in the stem says its a "photomicrograph" -- not exposed to plane polarized light, where you would see the negative birefringence. +17
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +
suckitnbme  @linwanrun1357 I highly doubt you would be looking at your own joint fluid aspirates instead of sending it to the lab. +3
nnp  what those yellow white nodules signify? +
peqmd  In clinic gout is typically a clinical diagnosis. If you can treat w/ NSAIDs instead of aspirate you would do that. You would aspirate if you are considering septic arthritis so you can get culture. I don't think anyone aspirate for heck of it. +
lowyield  @nnp, the yellow white nodules are tophus which is a sign of chronic gout, characterized histologically by aggregates of uric acid crystals, can show up as skin nodules most commonly on external ear, olecranon bursa or achilles tendon (pg 467 FA 2020) +

 +9  (nbme24#19)
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This nteitap ash oplanuymr ro,fsbisi whcih ssucae a tectrsreivi (nto broyvtcet)eu-tsip siadse.e enSci eerth aws on aalotnocucip useoepx,r mI' uasgnims hsti is icidoipath ampouyrln fsbir.ios iThs scaeus ciehtdenk olaveral aebem,rmsn itmnilig sga df.uoisinf rrTeo,efeh yltluaeevn 2O nwt'o eb leba to efsufdi uqcilyk egnouh tino het oldob socras the eoar-vitaalelrarl rnbe,mame nuglersit in a egarrl aA- ed.nieerfcf I( nihtk etresh' namlyorl a lmlas A-a ,tnrgeadi rfmo 412- mm gH, tbu nwhe isht tesg too g,ib you get y)xpicho

yex  UW q id 7648 +2
melanoma  uw id 1526 +
feeeeeever  FA 2019 Pg. 661 +

 +6  (nbme24#21)
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sINRT ear hte iamn IHV pthaeyr rugd that can caeus oben ormarw rospspieusn (otn sa omonmc thiw R.s)INTN hisT acsls nscuidle ezunvdidoi, asei,oiddnn ert,ctenbamiii ,dnamelviui vn,atudies duivoneiZd si somt wknon fro hsti dsei cte.fef

afleNriinv = etaposer ror tihoizimyinbcitahn = dlyanocoigeism (not erlayl sued fro iditHep)nmV enaI = etanhor mnclr,oaiiibat yomlts udes for omyesptcsuin I ednaL ihmiuvtnik? = aentrho NTRI utb sles kwnon rfo oben moarwr usriopsnpse

adisdiadochokinetic  Azithromycin is a macrolide, not an aminoglycoside FYI, and its use in HIV is primarily as prophylaxis at very low CD4 counts for, among other things, the mycobacterium avium complex. +7
nbmehelp  How would we have known to choose Zidovudine over Lamivudine tho +5
mjmejora  @nbmehelp the sketchy with Princess Izolde (Zidovudine) eating bone marrow was my only tip off +8
niboonsh  you have ero bone marrow if you take idovudine +1
niboonsh  the z's were supposed to be bold idk what happened. you have Zero bone marrow if you take Zidovudine +5
t123  Zidovudine is also a very early NRTI developed. As a good rule of thumb, older drugs have worse side effects +2
therealslimshady  Zidovudine Zaps your bone marrow (sorry) +1

 +10  (nbme24#10)
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Pg 419 in FA 8012 luN(egoryo nyaamto a;mp& opshligyoy onit:)ecs 3 cssulem esloc the jw:a sest,reMa e,toipasrlM eldaMi ei1typod gr emsclu oespn eht w:ja raltaeL dg otriypeALL ear tnvrieedna by gaiemtirln eernv, V3:cmnn iMoe M's nmchu eos(cl eth wj,)a 'sL orewl (eaoelsxolnr/ het jaw)

sunshinesweetheart  p 495 in FA 2019 +2
mnunez187  p 507 in FA 2020 +

 +18  (nbme24#30)
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Salml llce ircanaomc of the ugnl yam edcrupo osictrlpanaape osmnrey,ds of ihwhc ATHC nda AHD era het moer cmoomn usste.bpy TCAH ssxcee edsal ot ecsexs tistnlmuoai no hte lardnea retcox to coeudrp rosci,olt grituelns isC'ghuns eony.rsdm eEcxss oltsrico or(nllyma a sstsre nmreooh) ssecau yeehnpnrotis via nttnioeoiatp of smaieptthcy oiumntlsati no eht ulaevsucrat. It acn alos eaucs moyhailakep by tcniga sa a cnooemiclroidarti ehwn in sec,xes uaaitngsrt eth yliaitb fo 1hsyeoad-dbtyrrx-ite1o ehoaedeyndgsr rnpeest( in the elrna tu)blseu to ncorvte cooslrti ot rtni,ecoso cwhih edsn'ot cta as a moatcin.olrirdcieo

therealslimshady  Adding some ways to eliminate the other answer choices for good measure: B) ADH can be secreted by small cell lung cancer (SCLC), and would cause SIADH, but that does not manifest with hypertension or hypokalemia. C) Epinephrine can cause hypertension (a1 effect), and hypokalemia (via stimulation of the Na/K-ATPase), but is secreted by pheochromocytomas rather than SCLC. D) PTHrP does not cause hypertension or hypokalemia, and is secreted by squamous cell carcinoma of the lung, not SCLC. E) VIP can cause hypokalemia through diarrhea (see VIPomas in First Aid), but not hypertension, nor is secreted by SCLC. +6

 +9  (nbme24#44)
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iisgnmAlcyedoos ear prhnt;ioecox hoxptcornie /uhimasrscceldg eucas auetc utablru iscsrnoe T(A)N, ctdaierhrzeac by madgae ot eth .TPC NTA escsau het traifnomo of nwobr, m,uddy agurnarl satsc ni eth rui.en hTe tfac ttha hist atnetip is a ugqeilpdaric tmihg eb ugsgtsengi ttha yeth ehav a eorlw eluovm of odibrustiitn rfo teh ugrd adn( rhretefeo ighhre oodlb or.nnaotc)encist

mtkilimanjaro  I would also like to add ATN is nephrotoxic ischemia and the two places in the tubule that are susceptible are the PCT (proximal straight part) and the thick ascending limb. The TAL is not labeled as a choice so that is why it has to be B (and why B is a little further down from the convoluted part) +2
mtkilimanjaro  Actually aminoglycosides might only affect the PCT idk :( +1
peridot  on p. 591 of FA 2019, it talks about ATN. The two types are 1. ischemic - affects PCT and thick ascending limb because those two areas use ATP the most (think of all the ion pumps) and 2. nephrotoxic - PCT only (I think of it as that's the first part, so it's most exposed to toxins). Aminoglycosides fall under scenario 2. +1
cassdawg  If you wanna see nephrotoxic drugs in one place, here's an image with the locations of different nephrotoxic drugs: +2
corndog  Before anyone looks at @cassdawg link, consider taking some Loperamide. +

 +4  (nbme21#46)
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oudnsS ikle a esac fo a-nmieuiLFr orsymedn - eicns 35p si a ortmu ruepssrsop rof a hbcnu fo lecl e,tysp oisnmattu in thsi enge as( ni LF)S uslert in a adrimy of aiialmfl mtrou yteps.

pparalpha  Li-Fraunemi syndrome = SBLA (sarcoma, breast, leukemia, adrenal gland syndrome) and occurs because of an autosomal dominant inherited mutation of p53 APC: linked to FAP (colorectal cancer) RET: linked to papillary thyroid cancer, MEN 2A, MEN 2B RB1: retinoblastoma +9
privatejoker  The thing that threw me off was that the only connection in her FH to the above SBLA reference was the mention of a paternal cousin with adrenocortical carcinoma. The other two mentioned had brain cancers, which seem completely outside the scope of the above mnemonic. Then again, as mentioned elsewhere, I suppose the best policy on these is just to rule out the absolute wrong answers. I swear, the NBME is lying when they tell us to choose the "best" answer on some of these. What they actually mean in practice is for us to choose the least shitty. +14
dbg  ^ this guy cracked the code. nbme ur doomed. +5
cienfuegos  @privatejoker: I feel the pain. Quick FYI: UW includes brain in the associated tumors. +3
hyperfukus  we can just make her thing SBBLA and hopefully never get this wrong again +9
jakeperalta  @privatejoker: according to UW, Li Fraumeni includes SABBB(sarcoma/adrenocortical/breast/brain/blood(leukemia)) +2
ac3  side note: RB1 = retinoblastoma with an increased risk of osteosarcoma +
lukin4answer  TP53 associated with SBLA + Brain tumor + Anaplastic Thyroid ca + Transitional cell ca. -UW +

 +12  (nbme21#3)
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Tsih is a aronesclco-t tyusd ebauesc it cstlsee tfrsi yb deassei eoocumt ntleicuetlla( adt)iiysbil dan enht eoyelcvrrtita skloo at oe/kesipssrrux (TV eu)ag.s sdOd raisot aer edsu to lvetuaea oaocsrn-etcl ssieutd; fi rteeh asw a vioteisp poirtsaneihl teewenb TV seu and tcaltuilleen ydabtil,sii het RO ulowd ysa ohngismte kiel C"iehldnr ihtw ecttuilealln edissbiilita wree 3 stemi reom lieykl ot vhea 2 or emro hsour of TV imet pre ayd anth erclihnd outithw ntecllaletiu istdli"ea.bisi

Raeelitv kisr is udse orf cootrh isduts,e iwchh srfti fnidee an seprxoeu (TV )seu dan hten olko ta eht cmtoeuo cueIl(etnltla sdtia)iily.b A veatilre rksi udwol eb erom elik tPnta"sie htwi +2 hrous /TVyad ear ta 3x iehghr risk to eedpovl llnieetluact batildsiyi tahn hclriden htiw tl;&2 hsou."r

clalp,iTyy RO and RR rea siiralm bnmsuer utb ahtt uipnmssota rsaekb wdon at a itncare nopti, I hkitn hwen eht ideessa is yvre arer or imonet.hgs

drachenx  Following up on Neonem's comment OR = RR when you are dealing with a RARE disease. +4

 +5  (nbme21#49)
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I nkhit you can nowk tath tish is a lachimta roktse rrheat anht caticolr aeeuscb a itcrclao tresko urgricnoc noly in het tnpscoetlar ugrys yrmpai(r onsrsye tecrxo) dan glnviionv het einetr cnshuuoulm uhittwo naifgecft teh rebyan ptarrclene usgry aypm(rri oortm ert)xoc is veyr lneiuy.kl

sahusema  Ya I think this question is trying to test your knowledge between a cortical lesion and a subcortical lesion. +1
cienfuegos  Central Stroke Syndrome: Neuropathic pain due to thalamic lesions. Initial paresthesias followed in weeks to months by allodynia (ordinarily painless stimuli cause pain) and dysesthesia on the contralateral side. Occurs in 10% of stroke patients. FA 2018 499 +4

 +8  (nbme21#36)
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nI noidadti to pib'see mce,tsomn F102A8 sysa htat mnaoocdcarosrh si eorm moconm ni eth elmluda" fo evspil dan lencart etenskol" elihw ranoochsdm rea mroe in hte almsl osbne fo dahns a&m;p ft.e..e so I gssue uyo doclu go ffo fo it nibeg ni a egrigb nboe er.uf)m( Or sheppar het oolchmrppie solhtgyio fo eht lsl,ec wcihh olwud be mero caahrtsricctie fo a ltmngniaa u.rmto

 +1  (nbme21#40)
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Fmor en(erv rehad fo it foerbe tbu eessm leik a ogdo pnxantil:aeo)

"asehP VI ,tdiuses nfteo cadell stPo eMaiktgnr aevlreicSuln ilrsT,a aer nceddoutc tefra a rdug ro cveeid ash been peopavrd fro usmoencr e.lsa cPatauhrclimea ceonpiasm aevh selvrea ebjevcotis at hits asg:et ()1 ot pmocaer a drug with other gsrud eadalry in het aktm;re (2) ot tomoirn a gdr'us trognm-le seevnefsecfti adn ptmica no a is'etpnta yailuqt of eif;l nad 3)( ot needeimtr het tsfnticfeoecev-sse of a grud rtyaehp teaerilv to treoh inratatlido and nwe p.raseeiht Phsea VI dtsisue acn tlrsue ni a grdu or cdeive eignb anetk off eth maektr ro tsterosrinci fo use dluoc be lcedpa no eth trdpuco idpendeng no teh dfnigsin in eth u"yt.ds

seagull  Well, I was not smart and put phase 1 since it was talking alot about adverse effects and withdrawl from the patients. But now I see I have 2 extra bad. +
link981  Phase 1- Determine if drug is SAFE Phase 4- Continous surveillance of a drug that is already on the market. The vignette clearly states the drug is marketed. That means it passed the clinical trials. Marketed drugs have passed Phase 3 +

 +7  (nbme21#25)
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Mjaro srik ocatrf for taoirc dessitnoic si pyeronsn,ehit adn in tihs csea mthig eb ued ot nocciae ,sue iwhhc sasceu maekdr tr.ninehoeysp soiDinsects auecs a etar ni eth cunati mitian -- doolb nac wofl crkasabwd iotn eht dicreumpair adn usace .nmpoaetad ihsT matfseins sa rcklcase in the ulng deu ot proo eftl utilrrcnvea nfonuict filii(/naisldoctlg polrebm ude ot oio)emcrn.sps

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9
temmy  please why is there where a diastolic mumur? +1
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8
garibay92  Does anyone know why is this patient's tepmerature elevated? +1
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +
almondbreeze  he's only 28 - another clue for marfan? +
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +1

 +9  (nbme21#41)
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Tsih si a esac of raphoripy taaeunc rtad.a Teh way I emrbreem isth si that st'i teh nlyo eglihh-diy prapyihro that ahs ksin metaosiiatfsnn deu ot .VU I mrbmeeer htsi by tA"efr U (ho,p)pnoruyirr s'it VU". artpplnyAe 'ist saol ostdeacsai htwi peiatHits C, hwchi olcdu be teh aoesnr hwy het'sre eicednars STA map&; ,ALT or ti uolcd eb deu ot xitoc upbidul of iittensdeemar ni heme

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. +

 +8  (nbme21#15)
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This is a scea fo aeutc t.uog osumidoMon euart lsarscyt aer ekatn up by punshorte,il nleadig to an eucta nomamtilaryf rcieant.o lesTlc- aren't earlyl oevdnilv in uogt m(eor htreuadmoi thsta)rir.i

hungrybox  Great explanation! So frustrating that I got this wrong, should have been easy. +3
temmy  the way i thought about it was how did the neutrophils get there? the answer is via increased vascular permeability +14
nor16  they, unfortunately, did not ask " how did neutrophils get there" but " whats the cause of the swelling " not to confuse with " what causes the swelling " +1
divya  absolutely right temmy. that's how i thought about it too. +

 +4  (nbme21#32)
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oamaPht ysas taht niraltetisit (al)ytcpia panoenmui si etdacreczihra by dsfuife tnlrstieiiat ifrtenlsa,it tspresen /w lirtveaeyl dilm purpe rpse ymmstops aiimnl(m usputm apm&; wol )vfer,e dna is tmso tneof audsce yb siv,srue btu nac be raialctbe. vHer,oew siht otuisqne is ptnirsegne a hcroinc cesa, os m'I gsanimsu htta teh piesuvor insaettritil npnoeiuam edcasu a cifbitro nesrpoes in the gu.ln

 +3  (nbme21#34)
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ehT lcsraa nicoimtritu tceren si 1 fo 3 epoonnsctm fo trcuiotnmii exlefr eorth( 2 rae rfmo iotpenn irculrate aooirntmf and rlecareb ocrt).ex caraSl tmic rtncee = -24SS lnaisp dcor elevl inevlatgr ofrm vtleran tihew emratt in hte elPciv sveern, beinpsrelso fro bldedar trnacconoit aiv het orchiincgel serenv khnit( ti stac on the 3M roteerpc ni eht blerdad fI uoy eslo ethes eensvr .i(e. ni plcvie aerr,)uctf lilw lrtesu ni veroolfw nen.cticonein

 +3  (nbme21#49)
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dizTaehi drtceisiu rea teh clsas iwth teh aselrgt srik fo aieymlka.pho

 +15  (nbme21#43)
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oneMirph is a mu pidioo angiots - oen vraeeds ceftfe fo iooisdp is tsma lcle odngataeuilrn that is ideEget-nnInedp. laeeeRs of hetnsmiia si akni ot na aciatnahpcyl tencrioa ;&--gt rtrupsi,i te.c

sympathetikey  Never had heard of that one. Just a good guess. Thanks! +
yb_26  IgE-independent mast cell degranulation can also be caused by radiocontrast agents, some antibiotics (vancomycin) +6
temmy  it was a u world question +
mambaforstep  FA 2019 pg 400 +
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +1
mambaforstep  under mast cells "IgE-independent mast cell degran"! FA 2019 pg 400 +
mumenrider4ever  Uworld QID 11852 talks about this Also FA 2020 pg. 408 (under mast cells) +

 +1  (nbme21#18)
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Thsi si a tsamortppu oomd betiucn,asrd a tytepr ocnmom riddsreo ttha hsa to eahv an setno iwhint 4 weeks of eyvedril to eb etrmde sa h.csu totuPprsam bseul is hte tsmo id,ml whit a -85%05 cinecnide aret (epr FA 12),80 uylsula ervsosel tinihw 01 dysa and netrtetma si lnoy peourspvti btu ende ot wlufplo-o to assess for siepobls uorppamstt eri.nssedop pomtstPuar ssiropened = -%0511 er,at ihtedecararcz yb sdpeesder ,cfatef tiy,naex oorp cnctretainono orf grereta than 2 wksee and sdnee to be reeadtt /w TBC + RSS.I I kitnh het qtniouse is etgting at nesncegri rfo ihst dna a letlntoyaip rmeo ibcoelaptrm tclocanp,moii pstputoarm icsyspsoh.

thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +11
d_holles  Same @thisisfine. +2
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +

 +2  (nbme21#4)
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ens"niT "blwoe si due to iadalr eevrn mmgeiiepnnt nrae eth atalrle eliendpcyo of het reosxnEt cripa irialasd sbervi is a scemul of the orstenxe tatpmoemcrn of hte eo,framr asotieirgn mfro hte etllaar denolypeci sa .well

ibestalkinyo  The radial nerve is NOT involved with lateral epicondylitis. The underlying pathophys is inflammation of the tendinous bursa and origin of the extensor tendons. Radial nerve involvement would lead to more neurologic deficits such as loss of sensation and weakness rather than tenderness and pain against resisted extension. +1

 +12  (nbme21#42)
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RRP = genscinre etst for hsiT si a ktlcsneioovg-g ertantp sar,h htaictirracsec fo ncraydoes sishyip.l Durg of cecohi orf isshpyli at yan etsga si surtcamairuln .ilnnlPeici

ragacha  PAG 147 FA 2018 +
teepot123  also says which antibiotic, only 2 in the list, helps narrow down, pen more commonly used +2

 +1  (nbme20#21)
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taC actshrc isaedes areollBta(n foeictinn in tiemnmomuopcetn soth)s scuesa imhaseyiptlnd ac(pyleelsi ni hte yixarlla ngr)eoi aedirahctrecz by lcko-darseii teaogcsanin-n uolaarngms llefid ihtw ie.nplsrtuho

 +3  (nbme20#6)
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niekruoeetL B4 is a pnoett hctmcctoiea elmocelu rof etsplr.nhuoi tceveSeil slos fo sith uwdlo ahve no feetfc no splt,leeat tmas ,clels or etonelhmidu - ehets rae rmeo esspoinevr ot gseahcn ni ,X2AT aerpmhiaicod/onnlctcme c,dai nda 2GI,P etvslepiy.cre

kernicterusthefrog  FA says: "Neutrophils arrive B4 others" +4
fatboyslim  Important neutrophil chemotactic agents: C5a, IL-8, leukotriene B4 (LTB4), platelet-activating factor, and kallikrein. Source: FA 2020 page 406 +1

 +4  (nbme20#43)
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saioCltlzo si a tioseehosdpasherp nibti;irho ldeas ot edsarniec APMc hiwch hitisbni elptatle intaan/uatrilovoceandtig hwile salo acsngui oostlaidan.iv lAl fo eht eohrt nopisto wkro no reeiht rsualvueatc ro telaelstp tub ton hbot.

kernicterusthefrog  Just to add: cAMP activates protein kinase A (PKA), which is the more direct mediator of platelet aggregation inhibition, and of myosin light-chain kinase inhibition (which causes inhibition of smooth muscle contraction and thus vasodilation). Just in case there's a question that gets more specific than this one! +13
brbwhat  wasn’t dypirdamole an option? +
fataldose  I believe they also cause vasodilation by decreasing the cellular reuptake of adenosine by endothelial cells and the adenosine causes vasodilation. +

 +12  (nbme20#5)
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etehaxrMtoet udwol be a grdu fo iechoc rfo siporsisa yrecrftoar to ilotapc rscmae dan lhtig ;aeyphrt thsibnii flyioheaddrto urecseadt ni rdore ot aedresec iksn lcel iooprretinlfa and creeud mrnmyftoaial o.sensrpe

69_nbme_420  Cyclosporine can also be used to treat Psoriasis (NOT cyclophosphamide - ans B) +7
len49  Drugs that can be used for psoriasis include cyclosporine, MTX, TNF-alpha inhibitors including Etanercept, lnfliximab, adalimumab, certolizumab, golimumab according to FA +2
medstudent  Kinda summed up in the index - p 791 2nd row halfway down +2
lovebug  as We all know, 1st line therapy of psoriasis is topical corticosteroid, Vit.D analog (Vit.D inhibits keratinocyte proliferation and stimulates keratinocyte differentiation. +

 +7  (nbme20#36)
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gShlelia easucs na atirnfyamolm iaareh;rd ti uosrdcep a xinot nda nca naivde estuis yitcl.dre In diait,ndo it is itssanert ot i,acd os ti ahs a aihtrctlsraelacicy low eetincivf osed (10~ ,rsnso)gmia chwhi siataeilcft sti -olfraclea -tsoeps(ernn)-poor edasrp asliyeelpc in nesigtst eherw nieehgy yma be dirc,osmpeom hsuc as in dyeraac ro niiaitsntotul gonhiu.s It nca be tdrienafftedei romf E. ioCl )EHCE( baeuesc E olCi nted'so have as muhc ornpo-rots-eensp drepsa adn nylo uassec GI adgeam yb eth ilkahgis-e o,nixt otn ierdct ioanivns. rferoeeh,T HCEE udnltwo' iteacaltfi as gtonsr of a toriunlpiceh respson.e

yotsubato  I assumed all the kids in the daycare had the same lunch, thus got food poisoning, thus all got EHEC. +3

 +15  (nbme20#50)
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ishT nptatei kielly ash meos mrof fo repup rotom nureno slieon or edasies - UNM osisnel era aizcrdecerhat by awskeesn, ieerdcasn edpe onndte lresfxee, nad scpista e.pasisr Bcefnalo si a BAGA-B tsnoiga fccpesii to teh pnslai ,cdro udes to ratet suclme past,tiyics yis,otadn nda SM. BGA-BA si a npGrt-oei delpcou rroecept cupodel ot ,Gi os soinagm fo hist eceroprt sucase inipaopylzrohetar fo teh reonnus and sdreeadec eaesler fo oaetyrcxti agate.tlum

kevin  stimulates K+ efflux (hyperpolarization) and inhibits Ca2+ influx (no vesicle release) +1
lovebug  FA 2019, 538page !! +

 +2  (nbme20#6)
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lolchoA dihawrtlaw dlase to a yeyieipyatslk-mteiihtccvat-hpr drmonyes thwi ers,trmo NH,T ni,oisamn IG pu,set io,apedrsshi adn mldi aniottiag 33-6 rouhs taefr teh aslt .nidkr Teerh si a masirl,i ubt uyausll yiglthsl ,lerat oaevlrp fo tdwrwalhia iezsesru -864 osuhr reaft eth atls i.ndkr

baja_blast  p. 558 in FA 2019. +
cp87  p 547 FA 2019. Hallucinations are usually tactile. +

 +2  (nbme20#24)
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sMot of trinsciin sscleum fo eth dhna rea iteevnradn yb nlrua envre - cnrcohi iseorncsmop ta het hkoo fo aeamht ocdlu lead to eenvr eihisamc

 +3  (nbme20#46)
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tivsObutrce aptyhuor uescas a prnatsole ztaeomai --> when ongedopr,l rtuualb eaadgm .usnese hTis aldse to an tacue atlrubu sioncsre, eeichadctrzra by tincreoc guspl ni the blatruu metyss as enes ni eht emiag

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

Subcomments ...

submitted by neonem(550),
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I htkni het naoers you ened ot ncitje rsptnooanigod ni tsih scea is cesbaeu uoy ened SHF and HL to podruec mspre. HFS litamssetu eht eiorstl ecls,l iwhch inle teh uefrsoeiisnm eluutsb nad ehlp the omsargpntiaoe udocepr ectsmopreytas. osseettroTen si a dctrupo fo yLdegi lecsl ewhn ryhe'te etlauimtds yb H,L os gcnnjiiet nteetosresto luwod saybsp htat ptes btu it wtnou'ld ralely lpeh wthi tesomagsese.npri ve,Herow tnencjiig GnRH saol nd'oets tdse'on ellrya leph ueeabsc uyo dene thta aelpsuilt nGRH ta hingt to akme HL adn SHF reahews ancltngi-og RHnG asolgna ltucayal raceseed LH nda SHF rinptdoc.ou

m-ice  Adding on to the answer above. I was stuck between the gonadotropin injections and clomiphene. But, clomiphene acts to increase activity of GnRH which then exerts its effects on the pituitary. The man in this question had his pituitary removed because of an adenoma. So, he needs the FSH and LH directly. +21  
mousie  agree! Removal of the pituitary would case a deficit in Gonadotropins (LH, FSH) and therefore nothing to simulate the testes to make sperm... replacing the T with a patch would not stimulate the testes to make sperm and if his axis was intact (although its not) this would further down regulate the production of sperm. I eliminated Clomiphene because if he dosent have T to induce negative influence on the hypothalamus he will have increased GnRH and further increasing it with Clomiphene would not correct the deficit in Gonadotropins. +4  
neonem  Oh duh... that makes much more sense. Thanks! P.s. I thought clomiphene was more of a fertility drug for women, since it blocks negative feedback of estrogen on the hypothalamus/pituitary. But in men the system is under feedback due to testosterone, not estrogen. +6  

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ehT assedie ereh is fosecrtu stasiapsoephbh .icieycfden nI it, VI ycrolegl or tcroeusf sto’den phle ebaescu tbho tnree the ousnenoigsgelce haatwpy olbwe cfueorst iseatppboh.sha acastleGo on teh toerh hnad esetrn vbeoa i.t I o’tnd thnki oyu rlealy dnee to wnok thsi ot ochoes hte errtcoc wearns ncesi eht llinacic teiucrp fo gfistna pcalieyghomy atht si rcerdoetc w/ osem stro fo guars hatt can eetrn teh seinucoelgosneg watpyha lhdosu cuel uyo tnio the thirg s.nwrea

neonem  I don't think you could have *totally* ruled out the other answers - I picked glycogen breakdown because it sounded kind of like Von Gierke disease (glucose-6-phosphatase) to me: characterized by fasting hypoglycemia, lactic acidosis, and hepatomegaly since you're not able to get that final step of exporting glucose into the blood. However, I guess in this case you wouldn't see that problem of glycerol/fructose infusion not increasing blood glucose. Nice catch. +24  
vshummy  I think you were super smart to catch Von Gierke! Just to refine your answer b/c I had to look this up after reading your explanation, von gierke has a problem with gluconeogenesis as well as glycogenolysis. So they’d have a problem with glycerol and fructose but also galactose since they all feed into gluconeogenesis before glucose-6-phosphatase. Great thought process! +22  
drmomo  glycerol and fructose both enter the pathway thru DHAP and glyceraldehyde-3-ph. Galactose enters thru Gal-1-ph to glu-1-ph conversion +2  
linwanrun1357  In this cause (fructose bisphosphatase deficiency.,),fructose should help to increase serum glucose, bcz it can become into glucose-6-P by hexokinase. Therefore, this question makes me confused.... +  
krewfoo99  According to uworld, fructose infusion will not increase blood glucose levels in Von Gierkes Disease as well +  
atbangura  I believe Von Gierke is not a plausible answer choice because a galactose infusion would still not see an elevation in glucose levels. Remember, galactose could be converted to galactose 6 phosphate, but in order to complete gluconeogenesis and allow glucose to leave the Liver for an increase of its concentration in the blood, the patient would still need glucose 6 phosphatase which is eliminated in Von Gierke. +1  
lilyo  So what disease is this??? I mean couldnt we have just answered the question based on the fact that the patient responds to galactose being infused and we know that galactose feeds into gluconeogenesis?? I am so confused. +1  
djtallahassee  Its Hereditary Fructose intolerance right? gets sick after fructose and I guess glycerol can jump in via aldolase B on this pathway via page 74 of FA2019. It looked like a fructose thing to me so I just marked out the other ones and moved on. +1  
paperbackwriter  @djtallahassee I was wondering same, but hereditary fructose intolerance also results in inhibition of glycogenolysis :/ confusing question. +  
amt12d  A much simpler way to think about this, without trying to figure out a diagnosis, I looked at the time frame for when the child was presenting. He has eaten poorly for 3 days, by now, his glycogen breakdown is gone. His body would be trying to make glucose, therefore, gluconeogenesis is impaired, not glycogen breakdown. +2  
tyrionwill  if fructose kinase is not available (fructose intolerence), then some fructose may go to F-6-P by hexokinase, then goes to G6P if gluconeogenesis is needed. however this patient's fructose kinase was intact, so no fructose would have go to F6P, so there would be no blood glucose increment after injection of fructose. +  

submitted by brethren_md(87),
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tumor fo inPael naGdl aoeP()alimn escaus iruPnaad emySrdon cae(virtl gaze p)saly

neonem  Due to compression of the superior colliculus in the tectum, I believe +8  
wowo  FA2019 p516 +3  
misterdoctor69  FA2020 p528 +1  
qiss  tectum as in the superior colliculus +  

submitted by brethren_md(87),
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hcorCni sencretieM aemhiIcs aak tisalnteni ainagn. inaM seclu aer nppltrsaaigo isctpeirga ,ianp hegtiw ssl.o yausUll eud to aleCci (a), SMA, ro MIA aerhss.lsteorcio

neonem  What's tough about these answer choices though is that you have 2 different viable combos. +  
codyluvr95  The ectatic aorta might also mean AAA below the renals, affecting the IMA, +2  
sherry  Also since there is this ectatic aorta, the arteries involved need to be adjacent to one another. If there is a choice as in celiac and SMA, it could also be correct. +  

submitted by mcl(579),
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tMnieoiehn si an etnilessa aoimn idac. llA orhste etisdl era .nto

scalpelofthenorth  Pg 81 Tyrosine is listed as an essential AA. Should be tryptophan for those who got this wrong like me. +  
neonem  But tyrosine can come from phenylalanine, so it's not really essential right? +  
gh889  in FA2019, it is listed as Tryptophan, not Tyrosine. That was corrected. +15  
usmleuser007  Note: Tyrosine is ONLY essential with PKU in children +  
niboonsh  bro FA2018 lists tyrosine as an essential AA. They played us. +1  

submitted by cantaloupe5(72),
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roF tsih noe oyu stju dah to knwo eth ylosyslcgi thp.ywaa emSt oltd uoy ,3BG-P2 is vaelt,eed hwcih is suamprte of yveapurt ik.neas

neonem  Right, and that glycolytic enzyme deficiencies lead to hemolytic anemias. +5  
toxoplasmabartonella  I just thought the typical presentation of pyruvate kinase deficiency would be hemolytic anemia of the newborn. +3  

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touAuimenm soithrydtii aka( msH)aohoti + g&;npantgert-- ikTnh utoba tbpssloiyii of felta ohhyyoirstpdmi due ot yandbtio edmtidea taanmelr dihtopyhmri.syo esaLd ot .nmietiCrs Fignnids ni nafnti ear eht P'6 Po(t l,lybe leP,a yuffP a,efc truiogdPrn s,biiulmuc bPnorttuare ngotue, dna ooPr iarBn lpn.ometeedv

neonem  I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism? +  
poojaym  @neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4. An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland. +31  
arezpr  TSH, T3, T4 and thyroglobulin cannot cross the placental barrier. +  
chamaleo  @arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can +  
yotsubato  The baby has its own TSH though +  
sbryant6  TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work. +  
kimcharito  no goiter then? +  
lola915  I think there is no goiter because the baby's thyroid gland has not fully developed and these immunogloblulins from the mother could attack the thyroid gland leading to issues with it's development. +  

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yM ohttguh eossrpc was htta p-upsmtaotr bnleideg si alsuylu dateler ot hte re,uust nda ucmh fo het vepilc eirascv si esildupp yb bcerhnas of teh nailrnte ialci a.ryter

neonem  This sounds like a case of acute endometritis. In any case, uterus is supplied by uterine artery (branch of internal iliac artery) with collateral flow from ovarian artery (comes right off aorta). I don't think there are any branches of external iliac artery into the pelvis; it becomes femoral artery once it passes under inguinal ligament. +4  
tsl19  Here's a picture that I found helpful [Female Reproductive Tract arterial supply] ( +14  
sympathetikey  @tsl - Thank you! +  
step1soon  uworld Qid:11908 +  

submitted by strugglebus(163),
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Pt hsa pylmhtecoyia vare eerepoioylimavrt(lf ir)dedsor edu ot nhciocr xopihay ecidndu yb O.PDC iMldeyo ptaaeilmas si eatxr aydlrueml saemiehospito eud to oyfimi.sleosrb iyedtrHrea hamcsrohootmsie would vhae nbee vporen by a ursnaips uble ni.ats spsneHeplmiry uwdlo vhea ueascd dceaereds B,sRC nad esolyiysaplcdm nydoesmr wudlo hvae wnhos uerA srod ro tbasl.s

neonem  Right, I think this would be just called "appropriate absolute polycythemia", whereas polycythemia vera is due to a malignant JAK2 mutation and would be termed a type of chronic myeloproliferative disorder. +13  

submitted by strugglebus(163),
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sA na t01, :1d800ie eoplpe prtredeo ot eavh sied tfcesef nhwe gnkait zAr ioiho.eancgolmHoytrdhd ,htme 25 eeolpp )00.2(% have eBrsat rhdgiseac

neonem  I think the best way to answer this question was by process of elimination. +1  
sympathetikey  That's some bullshit lol +8  
karljeon  Haha I eliminated the answer by process of elimination. +19  
medschul  I eliminated thiazides by process of elimination :( +1  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +2