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Welcome to niboonsh’s page.
Contributor score: 338


Comments ...

 +1  (free120#24)
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xnlaerte otracdi ahrcnb speusipl eth oreupirs athiopyrrda sdnalg sa ..?...le.lw..

yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch. +
llamastep1  No they do not, parathyroids are supplied by the inferior thyroid arteries. https://teachmeanatomy.info/neck/viscera/parathyroid-glands/ +11
suckitnbme  Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery. +

 +2  (nbme18#23)
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cnOcetiNCr - rssNtctCiO cnvreilet

eEntrCCci - CEpnaCds revinectl )npe(dsax

jmangels  Also, he's an endurance athlete. It would most likely be a physiological adaptation. "Volume overload-induced cardiac hypertrophy is known as eccentric hypertrophy. In endurance training, the volume load is a predominant factor; therefore, the endurance-trained heart develops eccentric hypertrophy" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2300466/ +2
cbreland  Also, the patient has nothing wrong with him, no symptoms, so the other options are a no go +

 +3  (nbme23#35)
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eOn fo eth tsnesoqui ni het ordwul ecaipctr etts 2 autallcy uocetdh on t.shi

amatitoo viln ntv iiinntcnwde aigoier:i
  • tsaecnbus esu dssdoirer
  • throe rovisabhe ni pesittna how ear otn yrdea ot hengac
rcips n lpei
  • eealdowgknc tnsciserae to chnage
  • sdsdrea csidprsnceaie bewenet ohrabevi nda long term aolgs
  • eacnneh naomiitvot to ncahge
  • eunjomgnnadtl
iThnueqc e ()RSO A
  • Aks deOedn-nep nusitosqe e(cognuear ftehurr )siiocndsus
  • eviG mAarifoftisn
  • eRlfetc nad muamerSzi amin tsnoip

 +1  (nbme23#34)
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:.sTmtde/dMuuILL0EVLHh5a/a/hphtt./l9t.EVwteRhepI.mb


 -4  (nbme23#33)
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vwst30//P:9l/rl6/t..bwimcniMctwge/pp/9Cinmhs..10aochn


 +3  (nbme20#13)
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duofn thsi nni:eol c/cu/2t0r5/tid0lrp8i1po4k9../uepreca4ta//:0/cma0m5haseo/hmy

iHhpptyrcore lournmapy hhotapooryastetr AP(HO) si a ydrsemno aderaczcireth yb hte idatr of serstio,itpi tgiaild bclgbuni and fapnliu aprhtaytrho fo hte glera t,njsoi elecilaysp nolgiinvv eht lrwoe .islbm buiCnlbg is arceadirzchet by sboubul neenlmgaetr fo enliramt teesgnsm fo the ifgsner nda oets eud ot reropaiitfnlo of uaubusgln cieevonntc eu.ists

.ray..mirp is a aerr hedaityrer no.tcdnoii

A yrtamoji of scsae 0);g&(9%t of noceydars HAOP era aositaceds thiw uropamnly lacsgminanie 6][ ro onihccr pitruepsauv oalprmuyn sisdea.es

nPuylroma iclnsgnamei,a uciindgln prariym [],7 iattacmtes guln ccenar dan otahrnaictirc hymal,mop ncutaco rfo 80% of esasc of syrocaned .PAOH ncmoaeinAradoc fo eth gnul si hte stmo eetnfurq nda small llce aomarincc is teh aeslt ertqefun ohsthotgcaipilo ytpe fo lung nacrec dstaioasce whit PAHO ]7[.

ehrot esoicadtas cithacrraxeot lsnnieiaacgm nlecdui healpnysrgonaa ,anmraocic relna lcle armaocnci, gloaspeeoha cecarn, iscrgta tmrouu ,[]8 aicrnetapc a,nrcec tbrsea loyldhpes romtuu 9][, aomelmn,a drtiohy arecn,c saemtocrosoa and sltinneait ymhapolm.

Viuoasr iteacgoomlrhu no,siintcod lndgicuni AR ],[01 SA ],11[ lteiaosyitrpr dnoaso, LES 12[,] yuksaTaa sseiead 1],3[ ocss,ioirasd SAP dan aenndteMrarei rvfee ear nkwno ot be ssdecaatoi twhi shti ioncndoit as l.elw

omPurnlya ncoodsitni shcu as tsiycc f,siibors srcei,uosbtul hcdpoiaiit pamlonryu sirfibso 14[] and ngul iapnrnaltottsan avhe olsa bene oadstiscea iwht .HOAP


 +0  (nbme24#8)
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is on one esel cnednerco aotub the fatc hatt ryhete igvgni a btae 2 sitngao ot a awnmo sowh 28 ekews an.r.np.tg?....e

yobo13  Beta 2 agonists relax the uterus so this would be okay, right? +2
med4fun  inhaled drugs do not have as much of systemic affect and B-agonists are used often in pregnancy for asthma control. SABAS are deemed safe but there are increased birth defects with long acting B-agonists. +

 +1  (nbme24#45)
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orme ifon touba eBar oymyctepLh moynrdeS yonib-/nonie#tntgdgtoom/hcmncnsyvhesecepr/l.nl.iired:ytimhhapir-tt-ah/yp-roe.


 +1  (nbme24#24)
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ineroPecdb ekmas uoy Pee

iichleconC cneehcls uyor bcleiutrsmou


 +49  (nbme24#30)
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tshi qsenituo emkas me twna ot eta na e lcio ikooec dan epoh i ldebe otu

caitlyncloy  pick C and move on was my strategy :P help lol +1
thegooddoctor2  lol good one +1

 +4  (nbme22#36)
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tir-CyCilC detspesnteiarn - tnia C heocrii,gnl C tna sdtan up 1(a kb)l,co C itodiarxoc rpoln(og qt by gmsnsei w na h)selncan

waterloo  that's cool and all but there are so many side affects when it comes to TCAs. H1 antagonism, reduced libido, convulsions. +

 +1  (nbme22#15)
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Cna oemneso pinxeal eht edieffrnce wnebeet .C rae(lees of deotsr rthyido moerohn mrof a iytrodh adlgn defnliritta yb )smopyehcytl dan D. (leeseaR of odiyrht ohoenmr mrfo a omamshyuplto dihrtyo gandl.

drdoom  @niboonsh, ending a comment with a question mark will make it appear on the "comments seeking answers" lists +4
nwinkelmann  A lymphomatous thyroid gland can either be due to primary thyroid lymphoma (which is almost always NHL, but is very rare) or due to Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. These, I believe, would still present with hypothyroidism, and thus would have low T4 and high TSH (opposite of this patient). +1

 +0  (nbme22#20)
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I ma osinoucnf. ywh woluntd isht be a ssrco evor ts?ydu

shokay  there is no washout period and the order of drugs given isn't switched +7

 +0  (nbme22#5)
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My gesus si ahtt they rea rriefregn to Rtivrrueos /T)HH-LIV(V a inlesg sradednt tpsievoi essen nieral NRA. veRsreoiutrs rae nknow to rayrc evsreer attsasenprcri nANRe(e-ndtpde mNeDyl-.)Aaoesrp The iaicpsnehtel is awth ehrtw em ffo cuz I aluiotmatclay ghuttho fo eht aymn nateeigv ensse RAN uvesirs ahtt uaecs eitphlicensa ilek( rausrnieva or .nyrbu)suiva yartpnelAp heert aevh nbee a efw easucs of LHTV cgiunsa .h..nicepliaets meayb this si hwta ethy eerw tgynir to gte t?a dkI tbu i tujs tnpes wya oot mhuc meti on sith dnam uoestiqn b8w8ccc/nvCatnti/tg./.smlilshhpeo.n1m/w7/wMPp5/8.ir:7


 +0  (nbme22#19)
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/11dnhhw/9i9vwmgp.t5einn:lu5b/6smcpw..o3t/b. Teh hrosoeesh nidkey asw eddttcee oefrbe srruegy in 12 titnpase %08() by goaopuyhtrr,asnl ir,aoyphgagn ectuodmp hmgaotoryp C(T) or ytreocrex yru.gahopr pgrgoiaAnhy vldaeree emlptuli or moolaasnu lnare terraies in 8 fo 21 neatpist dsdteiu eiprrvoypeltea


 +3  (nbme22#20)
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Tshi nlik ahs godo tpuscier as frerceene a-oolioer.bhr/tsprilgeispu-/fsviagetvneiwcrlohe-rot/-i-ng/gnso/ileb.unt-sswubru-toipdtspsetrglraeewym:-bh


 +2  (nbme22#47)
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Tish si a seca of tuaec tlrsaatnpn neetjirco. keews to hsmnot erfta eth ,sltnnrpata rpeieictn cd8 darn/o 4cd t llsec are itectdaav stanagi het rodno (a ptye 4 R)HS adn the drono atsrst nmgkia sioiebndat inatasg hte tlartnanps. hsTi peenrsst sa a siuviasctl hitw sedne rtltteisaiin oycylmthcip s.teanilfrti 18F0A(2 pg )911

ls3076  Actually was confused about this due to a UW explanation. UW said acute txp rejection has two types - humoral and humoral and cellular. Humoral has Neutrophilic infiltrate + necrotizing vasculitis while cellular has lymphocytosis. Can anyone simplify/explain this please? +3
apurva  We usually look for c4d complement for humoral response in acute graft rejection. Because c4d makes covalent bond with the endothelium can can be found on staining because it is long lasting. +

 -1  (nbme21#34)
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Teh eoquibls od eht itpsepoo cniato fo hrtei anm.e nfIoerri qibuleo smveo teh eey PU dan OTU et,(iotxonr vel,einoat Btu.nco)Aid Scein het uostqine ayss hatt hrtee is a tureacrf nolivigvn teh tlorabi lfo,or hatt yclauomaitatl urles out D lm(ieda setruc nda frinioer ,ueoil)qb iaegnvl het nloy oaigcll rwnesa to be eht rirofein usrtce nad ofrnieri qbeuil.o utvcasWIch=eyh/w.DWtwo.:kwouttw?HIpEK/mWl/b

aishu007  hi, but inferior oblique moves up and in and not out +
d_holles  https://www.youtube.com/watch?v=3J2UZiLVZKA In case ppl need a refresher +

 +5  (nbme21#26)
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i iktnh of ihst sa elo rrmeaf oej on ish tiancic fmar inpkicg rstaka r(scora)t (iictcna )rseitkosa

bbr  haha good point +

 +0  (nbme21#32)
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ym dnudesrganitn of itsh is omrf aampoth - laetritstIin tp)(cyilaa euanmniop - sucead by ufdifse rtliantietsi fins.areltti Can be caedsu yb saMapmoylc mope,un RS,V admychali enmpu,o nlfnzae,iu xcielalo ebirnuti

athenathefirst  Yeah but how does that help you choose Usual interstital pneumonia? +

 +15  (nbme21#40)
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MWIS

eahps eon - si it Sf?ea

hpsae 2 - sode it W?rko

paehs 3 - nya Ismepemotn?vr

saeph 4 - tysa no hte Markte?

lovebug  Does the drug "SWIM" ? :) FA19, pg256 +

 +3  (nbme21#38)
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i tog sthi oinetuqs hrtig btu wyh uloctdn ti be igkon bi?alob

nor16  and why no therapy, i.e. cognitive training` +
jessica_kaushal  first step is to make the patient's environment accomodating for the patient. +2
jessica_kaushal  first step is to make the patient's environment accomodating for the patient. +
tryntofigritout  Because this is a western medicine test. Even though it has shown great protection against AD and memory protection, this test won't allow that. I initially clicked on ginko but thought to myself... na this test doesn't accept an eastern idea. so clicked on the one I know they wanted me to say, and I got it right. ha +6
mumenrider4ever  Wikipedia says "Gingko extract has also been studied in Alzheimer's disease, but there is no good evidence that it has any effect." https://en.wikipedia.org/wiki/Ginkgo_biloba#Traditional_medicine +3

 +10  (nbme21#35)
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hist swa a mbdu .ntiouesq teh nmuconime "IDDeoniasn assuec nraapceDIDs"i si uulefs ehre


 +45  (nbme21#45)
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/wvtouoc?4tw=ubwhspH.uz/t:Dmwchya2vQ-eowt/. if ru ylaz elki e,m htsi si a gdoo hrreerfes voeid

d_holles  Amazing video dude. Somehow never learned this in neuro lol. +6
aag  Awesome video! Is this why you can give Mg2+ to eclampsia patients, because if so, mind goddamn blown. +1

 +2  (nbme20#17)
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" etOhr slcssae of idatcomnsie atht uscae cypaapoetrhrnliemi lcdneui stas,iprndastene spnheyaietivetnr sn,etag adn dgrsu tath aerseinc below ioy.mttil porimriytcealpeaHn deacus yb coetmisaidn is myonclmo ctoympsai,mt ncsiuga tlhoa,argrace stuernaml ctisnuadebr, adn mepnoe.tic tI si tranpItmo to surnee ttha ynrocetreplpmhaiia ni an Iviadudnil teiapnt is edu ot oadcenmiit dan ont ot a urcltuastr senlio ni eth ayc/riattiahihopmypult ea;ra htis nac eb lsichpdacoem yb ()1 sitnogpp the diinctameo lieomrpayrt ot mrdinetee teehwhr iplocantr eesllv rrunet to r,noaml )2( wciitshng to a ieatndicom thta soed otn eucsa irarecohyapmipetln "

w.bp2pt/6/bvs/nmm:ed14wwc.iigt.h8lnh.n0/5o9u

ne-t"oeeNdpd-nsdeno deis efcstef — guAlhoht oew-dsol yhapert eemss to niemzmii teh labometci aimnptccloiso cdieudn by a hziiated or ikeiadehiztl- ,rcituied it aym ont sieryscenal emiitalne rehto iesd efftes.c As an ,elmxape sa amyn as 25 trneepc of emn dttaere itwh 52 a/ydgm of tehlnchoarodil pvolede a icdenel ni xauels cofnnuti [].43 eSlpe ectsinbuarsd anc sloa ,courc clarilpatryu fi the tpateni is no a ildwoo-sum tied ]3.[4 woH tsehe slebporm cruoc si tno w."knno

nt2soitpiim/spwcitteshnuae-rtioawf-a:-d/ttsrte8095uin.rd-ot-rieespewsnon-3yp/i/n-.p02mt9taHahoheswltnysztde5h-cic#ui-ee


 +4  (nbme20#47)
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w=1ytFtGtu0v.wAW/wkbhhFq/W.?pawc:N/osmtecuo iluoyicnslhncce luasluy hsa v asft oatunird of oicatn cuzb itdoelmaebz yb msapla niuopseoshertc.ldseae ithW aliytpca ls,poisdotrhseuncaeee dcedaeesr smamletbio fo cucncolylhniise dan tsuh uessca a goprnedol ritdnuoa of cntaoi fo yceilnscoiulhnc -tg--&;- AEPAN

chandlerbas  i love that mosquito and then SLAP +




Subcomments ...

submitted by lsmarshall(396),
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astPrrea"lna eehav )tifl( crcosu gndiru htirg lueritancrv eoyyprrhpht .e.i( ategenre)lnm or very laeyrr ersvee ftle aatrli mlagen.nret"e RV prpoehytyrh can eb eesn os easyli sbeuace teh VR si ta hte errotnia rcsufae of teh tc.esh

In tihs ienattp ldoob rmof LA ot VL arceedses in sntau,otiar so it is oigng eseehwo.rm From teh O2 ast. ew nca cuddee erteh si rbbaolyp a SDV dsein(raec RV eeursrsp duwol auesc HRV and lnpteraaras v)aehe. ,rmertoFhru teh tgetiven si lyiekl irindbegcs ogltytrae fo tallof cau(sde yb uenietpraorsro iepmnceldast fo hte nirliubnuafd m)eus.pt In Tte ssl,epl RV flootuw si oot tscdoubetr nda itnptea tesg onacsisy nda RL;&tg gunnhtis aSsqtu rasceine VR,S eacsnredgi ;gLtR& isnnh,ugt pnitugt emro dolbo huhortg nupalrmoy tiicurc dan viilnrege nscsyaoi.

seagull  i'm pretty sure your a prof and not a student. +15  
nor16  nevertheless, we are greatful for explanation! +  
niboonsh  I remember seeing a question describe parasternal lift in the context of pulm htn. still got this wrong tho fml +  
anotherstudent  Did my question have a typo? It says O2 saturation in the right ventricle is 70, which is equal to the Right atrium and vena cava. It says the O2 saturation in the left ventricle is 82%, which is a decrease from the LA (95) but not equal to the RV, which is why I thought there wasn't a VSD, I assumed there was a weird shunt from the LV to some other part. Will O2 saturation not always equalize? +1  
pseudomonalisa  This is a right to left VSD due to the pulmonic stenosis present in Tetralogy of Fallot. O2 sat will be low (70) in the right ventricle, and from there it'll enter the left ventricle and mix with freshly oxygenated blood coming from the left atrium (95). Because of the mixing, the O2 sat of blood in the left ventricle will be somewhere in the middle of 70 and 95 (82 in this case). You're correct, though, that most other VSDs are left to right and you'd see greater O2 sat in the right ventricle in that case (not sure if it equalizes with the left ventricle though). +  


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Cna moeseon elepsa ficyalr het nweas.r Is aedsdeecr dchereena meas sa ddseaceer aiea?tggrgon ;tWnodul tbiniinohi of eth aIIIIbI/ copterer eentrvp toanigrg?gae

xxabi  I'm not completely sure...but I think its because its aspirin, and aspirin doesn't work on IIb/IIIa receptors. That's why i picked decreased adherence of platelets, figured that was the closest thing to decreased aggregation that still made sense with aspirin's mechanism of action. Hope that helps! +2  
ihavenolife  Aspirin irreversibly inhibits COX which leads to decreased TXA2. TXA2 normally is a vasoconstrictor and induces platelet aggregation, so aspirin inhibits platelet aggregation by downplaying TXA2 not by interacting with IIb/IIIa receptor. (Source FA and UWorld) +21  
fallenistand  In this case, inhibition of COX-1 by aspirin will also reduce the amount of precursors for vascular prostacyclin synthesis, provided, for example, from adhering platelets https://www.ncbi.nlm.nih.gov/pubmed/9263351 +1  
niboonsh  inhibition of IIb/IIIa receptor is the moa of a completely separate class of drugs - Glycoprotein IIb/IIIa (abciximab, eptifabide, tirofiban) +1  
t123  Bad question - TXA2 upregulates GpIIb/IIIa on platelets. So aspirin inhibits their expression. +1  


submitted by neonem(556),
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TRNsI rea eht nmai HVI aypthre drgu htta can uesca bneo orwamr ensppusrsoi no(t sa omnomc wiht .NRsT)NI siTh sascl ludcsine ienovizdud, isoian,dden aieitibrmcnte, lvu,mnidaie audinsvte, ic.avabra nduiivZoed si omst onnkw rof itsh dise tcff.ee

inilevNarf = eseaoptr h tcrmbzotoinnihraiiyi = oyciednsigoalm t(on ealrly edsu ofr miHeendV Ii)natp = raenhto nor,macltibiai symtol edsu orf ssuocntymeip I mnkevh inauLii?td = rnaheto RNTI but sesl wnkno fro bneo marrow nsrsuesoppi

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  


submitted by neonem(556),
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TIsRN are eht amin VIH reptahy rgud thta can aeucs nbeo rmarow srsneusiopp nto( sa moomnc wtih )TI.NsNR Tshi alscs iesldcnu idniozedvu, ,idniaoesnd eii,recmnabtti inlim,aveud esdv,iuatn abcariva. duiioZdenv si msot wonnk fro tshi side tefc.fe

lrevfiaNni = tpearoes botnazryhtiomrii hcini = ieolyigamoncds no(t ylelra uesd for apeIidmnentHiV) = hroeant ramnco,itlbaii tysolm sdeu fro symneipstcuo I i?dvnnmtuie iLhka = aoehtrn NTIR tbu essl nwkno fro nbeo rmwroa osrsepuspni

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  


submitted by m-ice(326),
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The teinapt nedse lcidame naotintet d,aiyielmetm hwhci maleisntei bgannoiit a utorc ,droer ro rnrirnetgfas her. A urnes esdo tno have hte mesa ntaignri nad ituafaisliqocn as a cia,nyhsip so it woudl eb rpriepaiotapn ot aks htem ot mneiaxe eht aintpe.t skngiA hte ohtpials pcanailh niaag ulocd eb opnarre,ipipta adn udwol atek reom tmei. rh,refToee hte bset nioopt omgan osteh iegnv is ot ksa het eintapt if ehs lwli loawl hwit erh uabnshd t.pserne

sympathetikey  Garbage question. +56  
masonkingcobra  So two men is better than one apparently +28  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gárbágé +4  
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +12  
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39 +9  
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +15  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +25  
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +  
niboonsh  This question is a3othobillah +5  
sunshinesweetheart  this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +5  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +11  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +10  
korahelqadam  All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +  
sars  This is a very fair question. I agree with sunshinesweetheart above. That is all. +  
wrongcareer69  Garbage question +  
alimd  well we should wait for the question "if a man shouts I CANT BREATHE with a police knee on his neck, what is your next step? Ans- wait 8 minutes." +1  


submitted by neonem(556),
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agliFln no udectostrhet ahdn: poadichs si sotm oommcn oen to be rafctdr,ue ntelau si tsom cmmoon ot eb dtosadlcei. naeuLt lcisoontiad nca aescu aucte apalrc ltuenn orenmys.d

ikTnh of eth micnoenm iagrtSht" iLen To ynPi,k Heer Cmeos hTe "hTumb rfo eth nobes of eth l,map drwagin a latolofb sehap nirsattg olewb het mutbh MCP iotnj adncejta to het ir,saud tnhe ivnmgo to royu edalim ,rwsit adn enth ckba ot teh m.thbu

a,Sdchipo ateuln, rtetqimruu, i,isrmopf e,mtaah t,iecatap pt,doaeizr eipa.zurtm Teh ntaeul oskol ilke s'ti eosltryiorp elddtioasc hree.

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. +  


submitted by cinnapie(19),
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Wyh sdeo yeerv NMEB vhea eno ro owt enrcitoe trladee ??ieonsqust

youssefa  Cause we all know what bout to happen to us in this exam :D +35  
niboonsh  lmfaooooooo +  
corgilobacter  erections are a very hard subject +9  


submitted by usmleuser007(377),
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eomS eohrt nnorieedc kiel lcesl adn odrrsisde rof free:creen

  1. tarean-dplSepp- icomntahr n(efi rragnaul mplo)csaty ni cnEoednri otus:rm

  2. Muadlyrle dytiroh omcrnicaa

  3. eunrorneoncedi ds coroeahoyhtpurmnm ctoaom
  4. icdronCia roumT eonto(s)rin --- (osla has eshest fo nufmior )ellsc
  5. mlSla ellC iCoranamc fo slgun = l,mlSa eubl t heswclli csnta pmoalcyst nda rglnruaa aoim c)n=hrt ,ftla dshae-alovp cwi slelth nacts lasyotpcm dna oihtmcyeaprrhc iuelcn

  6. lSlam uBle Clles

  7. wiEng armcsao aalsnapt(ic alnmnagti r)tmou
  8. SCC fo uglns
  9. flt,a ohdalav-pse ieclshw tl atsnc osatlcpmy dna hcrtpiyhacemro eciuln
happysingh  i've never heard of " 6. Small Blue Cells" cancer / tumor / carcinoma .... +1  
niboonsh  might want to look at fa pg 665 +  


submitted by roygbiv(20),
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Wyh oclud hsti otn eb xrlusaaacterv soyeml?sih In AF ti asys aeuct elthoicym urtssoifnna ecntorai cna be eud to BAO ianitmciltpoybi ro vsraaraulcxte hi.lomyses

niboonsh  because extravascular hemolysis is associated w jaundice. Intravascular hemolysis would have hemoglobinuria but that's not an answer +1  
niboonsh  i mean that is the answer lol +  
krewfoo99  According to pathoma: Intrvascular haemolysis will lead to haemoglobin binding to haptoglobin. This complex will travel to the kidneys and be excreted. This will lead to red colored urine and haemosiduria (Note: This can also lead to acute tubular necrosis) Extravascular haemolysis is when macrophages break down the RBC. Then the Haeme is converted to biliverdin then bilirubin and conjugated in liver, and then excreted. +4  
paperbackwriter  If you look under the "clinical presentation" column of the blood transfusion reactions chart (pg114), it says that hemoglobinuria is with intravascular hemolysis and jaundice is with extravascular. Makes sense because with extravascular hemolysis your splenic macrophages are are chewing up the RBCs and sequestering it in the spleen so you don't get "spillover" -- i.e. clean urine. +1  


submitted by roygbiv(20),
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hWy ldocu tshi ton be rvraatxasulec hmoe?sslyi nI FA it says aecut ltohcyime runnaossitf racentio cna be due to BOA tciiiptaylbimon or vrrxeltuasaac lmyi.hseos

niboonsh  because extravascular hemolysis is associated w jaundice. Intravascular hemolysis would have hemoglobinuria but that's not an answer +1  
niboonsh  i mean that is the answer lol +  
krewfoo99  According to pathoma: Intrvascular haemolysis will lead to haemoglobin binding to haptoglobin. This complex will travel to the kidneys and be excreted. This will lead to red colored urine and haemosiduria (Note: This can also lead to acute tubular necrosis) Extravascular haemolysis is when macrophages break down the RBC. Then the Haeme is converted to biliverdin then bilirubin and conjugated in liver, and then excreted. +4  
paperbackwriter  If you look under the "clinical presentation" column of the blood transfusion reactions chart (pg114), it says that hemoglobinuria is with intravascular hemolysis and jaundice is with extravascular. Makes sense because with extravascular hemolysis your splenic macrophages are are chewing up the RBCs and sequestering it in the spleen so you don't get "spillover" -- i.e. clean urine. +1  


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tI sida it was ftala ot lesma in toue,r dan eth tsoueniq dseka tboau ivel rbon irpf.ngsfo Scein the lmase tnrae’ ibneg obnr in the rstif alp,ce I aids 05% easelfm adn %0 smeal.

hungrybox  fuck i got baited +30  
jcrll  "live-born offspring" ← baited +21  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  


submitted by drdoom(819),
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cinCotusllaa rof dad. ehT iyblbioaptr fo hte fetrha giebn a arricer si 32/ senic it si oknwn atth eh ’entdso heav eht asi.seed henT eth tyiolrbpabi fo mhi aisspgn ti on to ihs kdi is ,12/ huts:

  • lboiyrPtiab fo dda inebg eriacrr = 2/3
  • bobiPiltary fo add pignssa no ieseasd lelela = 21/

lCisnoatucal for omm. Wtih het reHdbireWng-ay irpcP,leni oyu can ufigre tuo teh iabrlobytip of the morhte bneig a ri:raecr

q = 1/0s0q0r)(0t,4 = 2/100

o,S pq2 = 2 * 01/02 * 029/910, hchwi si rpaoxp .0110/

roF teh cdhli to etg eth eallel romf omm, wto tignhs eend to :henppa 1() mom usmt eb a rirerca eo]gr[theyo”ezt“ adn ()2 omm mtsu saps het alelel to ic:ldh

  • aytliibPorb of mom nigeb rcrreia = 01/01
  • atiPlybboir of mom gpsaisn no deasies elaell = 1/2

ugtiPn it lal hoeegttr. No,w cmnobei all ho:ttereg

= ry(bpbtoiial fo add igenb )eicrrar * libtprob(aiy of dad spsangi no dieeass )elalel * atribbilypo( of omm bgnie raercri) * ibibportay(l of mmo iapssgn no eiesdas le)lela

= 3/2 * 12/ * 10/10 * /21
= 1 ni 060

kernicterusthefrog  To quote Thorgy Thor, drag queen: "ew, Jesus, gross" +37  
niboonsh  This question makes me want to vomit +11  
drdoom  lol +  
5thgencephalosporin  okay wow +  


submitted by aesalmon(81),
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I flee bdmu fro skaign btu nac monesoe pixlnae ?sith If his tapsner aer of lcoes to ronmal BMI adn aer ncodcreen tbuoa ihs hwetgi hyw uowdl etyh eb oignalwl ish rolecai otsiuncopmn ot ceeexd his eyrnge ndpeeextur?i ( KAA nitelgt eht ikd aet oot cmuh adn ont ecesrexi )nouheg

meningitis  That's a modern day mystery. +16  
drdoom  The prompt is only asking "what's the likely cause of obesity?" It's not that they're "allowing" him to eat more than exercise. (Few parents can monitor their kids that closely!) The prompt is only asking what's the most likely explanation for his 95th percentile weight and BMI (given that he otherwise appears normal); in the United States, the most likely explanation is eating way more than you expend. +1  
niboonsh  aka 'merica #firstworldproblems +4  
makinallkindzofgainz  If you are obese, it's because you have consumed calories in excess of your energy expenditure, end of story. (there are factors that affect your energy expenditure, but the simple statement is 100% true, unless you want to argue against the laws of thermodynamics). A is the only correct answer. +1  
tulsigabbard  This answer hit too close to home. +4  
castlblack  I think the reason they point out the average weight of the parents is because leptin disorders are inherited. It helps you eliminate that answer choice. +1  


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nmaesonigmi ucont as nhanicgen ens?osli ths(i etcnomm esend to eb orme htan 50 actcrrhesa ayar)netppl.

goldenwakosu  I think it’s because meningiomas are able to calcify (aka sometimes they have psamomma bodies). I got this question wrong too but I totally did not completely register that the tumor was in the dura (interhemispheric fissure + central sulcus). Hope that helps! +2  
pipter  the only reason I got this right was because they described the tumour as being near the falx cerebri. +2  
fcambridge  Other hints include being described as round and seen in a female. Both indicative of Meningioma +15  
niboonsh  also meningiomas typically present with seizures or focal neurological signs +  
suckitnbme  I thought enhancing meant it uptakes contrast. Meningiomas are commonly enhancing lesions per Radiopaedia. +  


submitted by johnthurtjr(139),
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I tknhi hist is as dgoo na oiaatlnexpn sa I acn idnf



submitted by seagull(1443),
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tuo fo tiyrocius, hwo amy peeolp kwen h?sit (todn eb syh to asy you idd or itnd?)d

yM ytpvroe nidtuoeac tn'ddi aniirng ihts ni e.m

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  


submitted by bubbles(67),
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asH yandoby fodun a ogod neaxpanoilt for tshi ygsloo?thi I ieyunnlge eahv on eaid twha m'I loigokn .at

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


submitted by bubbles(67),
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yrSor fi 'mI bigne .s.d.whyeen deos htsi wmona haev rardaihe eud to ittssna, t,die adn ex?siecer I dtn'di yerall sduanndter hwat tyhe eewr ksaign rfo heer to be eotnhs.

.ooo.   I believe they were asking what the most common effect of statins, which is GI upset (including diarrhea). Rarely you can have hepatotoxicity and myopathy but neither of these are a side effect in the answer choices. Hopefully this helps! +1  
niboonsh  Theyre asking about the most common side effect of Orlistat - which is really fatty diarrhea +3  
asharm10  Orlistat is not a statin drug, it basically inhibits pancreatic lipase so that you absorb less fatm drug is used for weight loss. So when you are not absorbing fat you are inviting diarrhea. +2  


submitted by bubbles(67),
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Cna omnoese nleapix pyrreolp how ew wkon ttha hist irtta wofolls Miednlaen stegicne nad si ooatsmlua vsreiscee and foerrtemrhu ohw teh stenrpa erwe s?ogehryuozet

I uesegds a tlo on ihts onsiequt dan tgo kculy (:

niboonsh  Autosomal Dominant disorders usually present as defects in structural genes, where as Autosomal Recessive disorders usually present as enzyme deficiencies. P450 is an enzyme, so we are probably dealing with an autosomal recessive disorder. furthermore, the question states there was a "homozygous presence of p450.....". In autosomal recessive problemos, parents are usually heterozygous, meaning that 1/4 of their kiddos will be affected (aka homozygous), 1/2 of the kids will be carriers, and 1/4 of their kids will be unaffected. +36  
nwinkelmann  Is this how we should attack this probelm?: First clue stating endoxifen is active metabolite of Tamoxifen should make us recognize this undering first pass hepatic CYP450 metabolism? Once we know that, the fact that the metabolite is decrease suggests an enzyme defect, which is supported by patient's homozygous enzyme alleles. Then use the general rule that enzyme defects are AR whereas structural protein defects are AD inheritance patters. Once we know the pattern, think that most common transmission of AR comes from two carrier parents. So offspring alleles = 25% homozygous normal, 50% heterozygous carrier, and 25% homozygous affected, thus sister has a 25% of having the same alleles as patient (i.e. homozygous CYP450 2D6*4)? +6  
impostersyndromel1000  we had the exact same thought process, so i too am hoping this is the correct way to approach it get reasoning friend +  
ajss  thanks for this explanation, I totally forgot about AR patterns are most likely enzymes deficiencies, this kind of make the question easier if you approach it that way, thanks +  


submitted by meatus(1),
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I'm rrsoy but htwa ma I ismnsgi .h.r.ee I tutgohh teh hwoel tpnio of cideturis si to tcrocre lvmuoe ovroelad yb eu?srdiis wHo ldwuo alott umelov eb an?icdsr?ee

niboonsh  the question is asking what would happen to the URINARY ph, bicarb, and volume. dont worry, i misread the question too -_- +12  
link981  Also misread the question, thought about the lab volumes of the BLOOD smh +5  
hyperfukus  yooooo me too!!! this is the second NBME i did this on they purposely don't write urine on the arrow categories to mess u up i swear!!! AHHHHHH +2  
medulla  missed this question for the same reason .. still pissed +2  
osler_weber_rendu  I DID NOT READ "URINARY" OH NOOOOOO. Im so dumb. +2  


submitted by k_tron_3000(31),
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The cosepnrdiit fo ealtirlba erlwo ibml slso fo tniraivbo pisemil LDCM deam,ag nda eth sneatb sDTR + omgeRrb emes to me to eb yplngimi hatt he olssbpyi sah atbes rsoldais fomr hilpissy ro( insgeomth ryve iamlsri in a.rst)pntoneei

sA for teh treoh w,sasner A is ogrnw aebseuc hsi rtmoo iuctnfon si atitnc, B si nrgow ausceeb apin dan murepetaert eiiftcsd are not tnnmdi,eeo C is ognwr usecabe it ielpsmi a cefiscip erenv si ntep,raepd utb eh has slto irbtaella nsetiosan in sih ritene lrowe isiteeemtrx

D is teh riektistc, nad ’mI nto 0%10 ruse, utb I ulwod ihntk adyacprliuoth of the aitorrne ltne(vr)a soort doulw cusea ortmo idstecfi necis tehy acyrr morto ene.ersftf uYo mhtig saol txeecp htta mroto tfuoncsidny ot be ,aliltenura csine it udwol be lukienyl ot evha a rpboeml ihtw hte eervn rotos on tboh s.iesd sola the CLDM si not deoltac aenr eth otinaerr otors of teh pnasil rc,od so if het raietnro trsoo rewe efaecfdt you erllya no’ldtuw etpecx to ees yobvrrtia .sslo

So casliyabl scsoepr fo iloeni,tnami I do efle liek rsoyens puanrtohye is an eetylmxre eauvg rnwesa hgtouh nda I ’wtsan a nfa of teh uteqsno.i

keycompany  This is a great rationale. I would like to add on that D is wrong because Radicular Neuropathy of the anterior lumbar roots would (1) be painful [radicular neuropathy is characterized by radiating pain (hence the word “Radicular”); this patient has numbness and tingling, not pain] and (2) because the anterior lumbar roots are the motor roots and do not carry sensory innervation. This patient is having a problem with his dorsal spinal cord (not anterior/ventral). +30  
hello  Want to clarify that "radiculopathy" is not synonymous with pain. Radiculopathy can cause pain, weakness, or numbness. I think the only reason Choice D. was incorrect because it discussed the "anterior lumbar roots", which would affect motor function. +15  
niboonsh  Radiculopathy is damage to the actual nerve itself, wouldnt that make it a LMN lesion and babinski would be negative? +1  
link981  Great explanation guys +  
usmel2020  UW QID: 12035 explains what you are testing with Romberg sign +7  
jurrutia  "Radiculo-pathy" comes from latin terms meaning "root-disease". +  


submitted by sirminalot(-81),
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[cspaie]l

niboonsh  this is disgusting. +11  


submitted by haliburton(209),
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likn to tranooc maigdra

yotsubato  How is that NOT posterior to middle concha? bad question +11  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +3  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +3  


submitted by whossayin(22),
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het itqusoen saw evyr porylo rdoewd ni my ,onioinp abnyody lese agee?r

niboonsh  yea it was a dumbass question, whoever is writing these questions is undoubtedly a crazy genius but homeboy (or homegirl...homeperson?) needs a few grammar lessons. +4  
yex  I agree. We know that it is a teratogen, but how does that question directs you to think about teratogenic effects instead of something physiologic? +5  
dr_jan_itor  The questions in the NBMEs by default are reject questions. So highly selective to be awful questsions. I am recieving regular heads up that the stems on the real thing lately are like 10-12 lines long. So these questions are not anywhere near like the test. NBME has f'd us good for this particular round of practice forms. +  


submitted by tissue creep(106),
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Atrdorohp ofr r,use tbu for eht drreoc 'mI ttepyr sure tish swa yuikgnhanCu .srVui lynO ogt stih ormf a UlrWod qinotues sa I 'hadtn nese ti iunlt ,hetn tub atyplpearn the aagrtlriah is lleary a,bd ihhcw is waht rdew me ot the rw.anes

uitanwccygdh:x/d/n/tchkesnl.wmthiw/go.u.pv

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


submitted by drdoom(819),
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,0250 detsstun ... utb uyo difn uto drgiun uoyr atiiiln rcenes that 050 yedrlaa aehv eth iasdes.e So, ktursitoe esoht eoelp.p ahTt lvaese ,0002 tsusentd hwo do’nt vhae the easi.sed

reOv het oecusr fo 1 ra,ye uyo sirdeovc 200 tsensudt vpdeloeed teh enniitcf.o u:Tsh

200 wne casse / 0,002 elopep woh nddit’ veah het eiaedss hewn uoy etrsdta ryuo sduty = 01 etnrecp

yiT,krc crkyit NEBM ...

sympathetikey  Ah, I see. Thank you! +  
niboonsh  Im mad at how simple this question actually is +7  
sahusema  Incidence is measured from those AT RISK. People with the disease are not considered to be at risk. So 2500 - 500 = 2000 people at-risk. Of those 2000, within one year 200 develop the disease. So 200/2000 of the at-risk population develop the disease. 20/2000 = 10% = incidence +3  
daddyusmle  fuck im retarded +2  


submitted by nosancuck(85),
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oY ids B ogt ON INRENLTA AEFEML ANGSRO

hWy t!ad???

We eb koilno at semoeon whit an YRS form erde Y cmrDho!ei ye eb a Y remhoic emoHi so eyth eb knaim omse sisTte iemiDtnren rctaoF ihchw I eb sure mksae emos ecin lli NATI LIMURLEAN RCFATO os yde nita got hatt emalFe tanenIlr rTact u onkw hwat i eb anisy

nAd eincs zmnwmii is ad TAUDEFL htey stli be ettgni esdo spusy ipsl adn tsesbrea

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


submitted by mcl(586),
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erP 8p06 in FA 01,92 SRY no Y oomehcomrs trsleus in eeteldpmovn of sttse.e HTD ssrtuel ni mpeleedotnv fo lmea atexlnre alieintag nad( eth pt)are.ots

mrsmac  No sertoli cells or lack of mullerian inhibitory factor makes more sense. bc there is both male and female internal genitalia but only male external genatalia. and karyotype would show 46XY. First Aid 2018 pg. 604 - the "Sexual Differentiation" charge delineates exactly this. If it were 5areductase deficiency the child would have testicles and scrotum, which in this case is absence. Hope this makes sense. Please let me know if you disagree and why. Thanks. +  
mixmasta  I believe the tricky part is that they don't mention the status of the Male external genitalia. Pg. 605 from FA ( bottom portion) shows the external development of the Male/Female genitalia; you see DHT is need for male. Furthermore, pg. 604 (SEXUAL DIFFERENTIATION) DHT is also needed for Male external development. +  
niboonsh  My understanding of this is that the diagnosis is 5alpha reductase deficiency because the newborn has female external (aka ambiguous) with male internal (aka "male genital ducts"). According to FA, leydig cells produce testosterone, which can either stimulate the mesonephric duct to form the INTERNAL male genitals (as see in the pt). Testosterone can also be acted on by 5alpha reductase to become Dihydrotestosterone, which forms the male EXTERNAL genitalia. Since this kid has "female" genitals, but has male insides and is 46XY, id say this is a simple case of 5alpha reductase deficiency. No sertoli cells or no MIF would present as both female and male internal (because MIF typically inhibits differentiation of female internal) and male external genitalia (bcuz leydig cells are unaffected) +15  


submitted by uslme123(57),
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ervy ptudis seoqnuit. eTh isurv asw hneilad -- tsab nhga sdiupe hewn hyet eeslp nda .lordo oS ti adersps to teh biran eildtrcy rmfo hte oafryoclt yemtss iav drtaeroger ostatnrpr hguroth rev.ens

niboonsh  yea, aeresol transmission via bat poop in caves +  
len49  How do you know the virus was inhaled? Doesn't mention it. Moreover, non-bite/scratch transmission is extremely rare. +  
makinallkindzofgainz  You get rabies by being bitten, not by inhaling it +  
drzed  She was probably bitten by a bat; many times the bite is not recognized ('unapparent bites'), and thus the CDC recommends that even if you think you have been bitten by a bat (or that you COULD have been bitten), you should go and get active/passive immunization immediately. +  
mangotango  Sketchy (and Zanki) says you can get rabies via animal bites OR aerosol transmission. In the U.S. it's most commonly through bats. It could also be through skunks (Western U.S.) or foxes/raccoons (Eastern U.S.). I remember this by thinking about how skunks smell so bad! +  


submitted by mcl(586),
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iineMenoth si an tsealeisn amoin adc.i lAl otersh tidles rae n.to

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 calcium196(11),
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ddibuiamttneiqUie- potelriossy si ton bevsryilre aetcedff by .nsuniil ehT eqtsunoi assk orf rleribvsee ways tath nsuilni acsfeft ti, nad qitiitauunbino owlud alde to trgoidaaned iav speeot,rsa iwhch si tno rievelers.b roycesptcm/laluNcia ignntuhs kames senes bcsaeue FXOO is a icnonptiastrr fortac, os ti an’tc do its ojb if it is ni eth pslaomyct!

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


submitted by usmleuser007(377),
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Can omonese lpasee iexlanp hwy cn'ta llcaoho eb croterc ni isht sitge?nt

niboonsh  rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018 +11  
dr_jan_itor  what if the alcoholic just has a concurrent rhinovirus infection ;) +5  
lovebug  and FA2019 page 538. +  


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litaieonzd frerrdpee edu ot isnlge sode

sweetmed  or metronidazole +  
niboonsh  what would his diagnosis be tho? +  
lostweightthxnorovirus  @niboonsh Giardia I believe. the trophozoite is pictured in the problem and has a classic "shield-like" appearance. FA 2019 pg. 155 has more information and the sketchy for it was really good! +1  
nwinkelmann  Per FA, DOC for giardia = metronidazole. MOA of metronidazole = formation of toxic free radical metabolites in the bacterial cell wall that damage DNA making it bactericidal and antiprotozoal. Metro treats = GET GAP = giardia, entamoeba, trichomonas, Gardnerella, anaerobes (below diaphragm), and H. pylori (as an alternative to amoxicillin in PCN allergy). Adverse effects = disulfiram-like reaction, HA, and metallic taste. I didn't know what Tinidazole is, and found out it is of the same drug class as Metronidazole, so makes sense why it would also be used for Giardia. For the purpose of the UMSLE 1, though, I think metronidazole would be DOC (especially because tinidazole isn't in FA). +8  
mannywillsee  This little bug has has a face, and now you can't unsee it either! +  


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dirtueyho cksi ymonsred si eeisotmms ldecla lo"w 3T srdmye"n.o loAs oyu nokw htat het aenittp si rytieoudh buecesa hre T4 dan TSH aer tiinhw het fceeerern nreag. hSe si ksic.

yotsubato  This is not in FA btw. +9  
niboonsh  https://www.ncbi.nlm.nih.gov/books/NBK482219/ probably caused by her recurrent pneumonia +3  
eacv  I though in this one as a sick sinus syndrome hahaha in UW. +  
pg32  Pretty sure boards and beyond teaches this wrong. Dr. Ryan says that in euthyroid sick syndrome T3, T4 and TSH will be low, but rT3 will be elevated. +  
pathogen7  In reality, TSH and T4 levels can be highly variable based on the stage of Euthyroid sick syndrome. One thing that happens for sure, I believe, is that T3 is down and rT3 is up. +1  


submitted by taway(30),
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utJs sa a etno ofr dnaoyby lees hwo aws WFT ta hwo 2)(033(/)30/092 = ./a1..15 tol of qtinsuoe kbsna rduon /0293 (or nya lsiaymirl ragle rtoi)facn tou ot 1

gh889  I think you meant 2(29/30)(1/30) just to clarify! +7  
niboonsh  i am confusion +2  
arkmoses  You have to use the hardy weinberg formula (1=p^2+2qp+q^2)and p + q = 1 they basically tell you that q^2=1/900 which makes q=1/30 now you can figure out (p=1-q) so p=1-(1/30), p=29/30 then to figure out carrier you solve for 2qp, 2(29/30)(1/30)=1/15 I got it wrong cuz I forgot how to figure out p but hopefully wont happen on the real deal. +5  
garibay92  2pq= 2(29/30)(1/30).... Transform this to 2 1 1 2 1 x x = _ = ____ 1 1 30 30 15 +  
garibay92  Nevermind :/ It didn't come out as planned :( +  
garibay92  /Users/carlosgutierrez/Desktop/IMG_2423.jpg +  
pg32  How do we know this disease is autosomal recessive? I assumed it was just because they love these carrier frequency questions with AR diseases, but how do we know it's AR? +  
turtlepenlight  Sounds like Gaucher (ish?) if i'm remembering correctly +5  


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nI ygheccpnsoi i,sopypaidl remsu usimdo si ,wlo and atefr rtawe idatnopevir s,tet niure oaostymlil si .ceUiedsa erirnn msoiltlyoa eods not airseenc thwi oerisapvnss nitojeicn

nI reniohegncp stbeaedi isp,isiund resmu mosudi is gihh dan reeht si on algmhecdi/n resancei ni rinue italmsoyol tfaer arewt dtvaiopnier

yotsubato  This patient does not undergo a water deprivation test +12  
niboonsh  Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric populations. Effects of increased water intake can lead to hyponatremia causing symptoms of nausea, vomiting, seizures, delirium and can even be life threatening if not recognized and managed early. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579464/ +7  
missi19998  Just wondering why it in not resistance to ADH action of vasopressin +  
amarousis  because he would be hypernatremic with no ADH. can't resorb any water +1  
minhphuongpnt07  low osm/urine, low os/plasma => psychogenic polydipsia +  
benitezmena  In this question the pt had a normal urine osm (80) a low urine osm would be <50mosmol/kg. +  
euchromatin69  u world 212 +