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Welcome to nwinkelmann’s page.
Contributor score: 285


Comments ...

 +7  (nbme18#41)
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AF 2910 pgae 3.80 tosM moocnm seauc fo iuyatemrpca/r caiisripetrd is sudsmae to be .rilav

cbreland  Primary made me think that it couldn't be acquired from virus/bug +

 +2  (free120#21)
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If ouy it'dnd ntsanedudr teh esstt in hte smte, this sludoh pleh:

Urine giurcdne suctansbe :tset rocmd/l/arrlp.usaedde.tuti--nvonignimoyhc/scgsmrdt:-cus-asdi/-esatnteuho/ngfnnioopms-snicey

lGecous aoxdesi te:ts yealastcz the ixndaitoo fo ucogsle to rygehodn nda aaolenogtD--elltnud-.occ If ehter si no lgueocs nsterpe (i.e. iwht saectmoa,glia) eht tste will be einetvag abseuec hrete si thnniog rof eth estt ot .tceazayl

drpee  TLD-Watch? Reducing sugars include galactose, lactose, and fructose. +4

 +2  (free120#23)
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nI sace onnaey si srcuuoi batou hte erhot rme:ts I thnik aispptsoo adn sercptnsioo rea yailrf aeeizb,rnlgco tbu I ahd no eucl tawh opssi,tsmy tsossoi, nda ooisnsc weer. yomspStsi = ehiimscc elcl eth.da itosOss = noeb rnoftomai uh(d! hwy 'idtnd I rebmreme atht, )ol.l ocsOsni = ctinimeaao.

amc  correction Oncosis= ischemic cell death Symptosis= emaciation +2

 -6  (nbme24#13)
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So ly.aau..tc.l apMesced ssay ttah PGSN acn vepgosersri to a fprieoaervlti emlrentpilghouiosr smnimchae nad so teplfeiairorv phorlereuimtilosgn ousldh eb siocrdeden as a feeidirntafl ssiogdnai for .GSPN

9com-0tsiccepaee5.vpas/6#:etcv8n5:idt/rre.momd8waileei/eh/ T"eh npsceeer fo eucat ynkeid nyiurj yma esggtus na anaetretl sgidionsa (ge, beveraremmotipriaofnl goleonipterrhiuslm P[,NMG] oöenneh-ShHccinl rupupar []SHP, tsyecims psluu yeuhrmostsaet ])[ELS ro a ereevs ro swornineg ASPG,N scuh as odsrevbe ni setoh whti tecericcns lerupmsortilihnoeg ro ilyrpad speovgisrre mluo.rogsleri.hntpi.e Dfeniltaifre siDnaig:os Tihs nusciled ostm trheo stype fo odhdcoihl plnirlee.hgoeumisordt eehsT ielucnd gIA topen,rahpyh mbrnetopaeolrremivaif iuniseehlmproto,grl ytrdhereai i,tsprehni dna horet rsmof fo ttueofpicsnsoi etorli"prngomlsiu.eh

lacyoirnlI geounh, this tusm be twah htey erew kinsag, .e.i tosaiimccpnlo of NGPS, esubace BSAOMS oen(ahtr petS osruceer) ctierdly kdnlie eht boeav larctie I ofudn obefre nigolok errfaht and gmnico cssaor the ASSBMO eotns.ic


 +5  (nbme24#42)
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...So I 'ddnti nowk ahtw ti saw so I eolodk it ...pu dan li,get ugamnr si aptr of ...a.l..tsp...n. yl?l!aer lol

cinnapie  We out here treating plants!! +6

 +2  (nbme24#33)
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Dseo onyaen hvea a ogdo penalaxitno rfo yhw rddasecee vlseel of biinnih is or?wng morF my niaetsnrdgdun, biinihn and aicnvit kwor te,rgeoht ni atth hibinin nbsid nad oblskc tciniav dligean ot ededcaers bkaedefc on ulaapyhsohtm nad ctvniai aeneirssc FHS dan RnGH ic..odutrnop ,usht fi uyo rdcseeae iniibnh hent oyu oudlw evha ensrdaeci tinivac chwih ouwdl aled to reianesdc RHnG nad SF,H ght?ir I udofn eno lietrac lgtinka ubtoa ti ni rdreasg ot pbuty,er tub ti sesem to be a /yosisthtphoen mdfnercio ta hsti tonpi... is htta wh?y uBt .sltl..i hwo od I elru it tou on a ?ttse

yb_26  I also picked decreased inhibin. may be it was one of the "experimental questions", which are not even counted on the real exam +1
artist90  Inceased FSH will lead to spermatogenesis and spermiogenesis NOT Increase in Testosterone which is causing increased Height of this pt +6
artist90  Inhibin B only has negative feeback on FSH not GnRH. see the diagram on the topic of semineferous tubules in FA. Testosterone has a negative feedback on BOTH LH and GnRH +1
usmile1  Kind of like how nocturnal pulsatile GNRH release occurs during sleep to stimulate growth (FA page327), the same thing happens for puberty. Pg 325 in FA, "pulsatile GnRH leads to puberty and fertility." It doesn't explicitly state during sleep, but pulsatile release of GnRH leading to pulsatile release of LH and FSH will lead to puberty. Puberty starts in the brain, its onset really has nothing to do with decreased inhibin levels which happens in the testes. hope that makes sense! +3
sars  From what I understand, inhibin is only released by granulosa cells when FSH levels are high. This is a boy. Next off, this question is about puberty, which is due to pulsatile GnRH leading to large amounts of LH and FSH, leading to large amounts of dihydrotestosterone (males) and estradiol (females), and eventually secondary characteristics of puberty. The increased pulse of estrogen and testosterone leads to GH release, which is metabolized into IGF-1 in the liver. This leads to long bone growth from what I understand, which is not much. +
cassdawg  @sars inhibin B is also released by sertoli cells in males and will feedback to inhibit FSH release, its not just a female thing. Also, there is actually an inhibin B pubertal surge in both females and males that corresponds to maturation of the granulosa and sertoli cells, respectively. Hormones are wack. https://pubmed.ncbi.nlm.nih.gov/15319819/ +
j44n  I think youre just supposed to see that he's starting puberty and know that the nocturnal pulses are involved +

 +1  (nbme24#28)
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myeaDsrti = ooonrsdiaindtci fo annpd,el onavluytr neosvtemm (ym own wdosr rfo teh etfrnedif fsinidgn nda udse llcseyapiifc to help em remerbem oao)itlnc ctrldloone yb eht serriotop lobe fo het isehhpemer ichhw soed ndnpale rloatynuv me.tnmeov lo,sA hte hmepiershe si eht prheyeirp fo the ucle,rlmebe nda it dslae hitw a,dlpenn onyvaurtl nteomsevm of eht phepyreri ie.(. m.ib)ls I got sthi frmo tshi emgai thiw reymom ip:st mmepet://owmuwmceo/cmss2c0-o3ewmmt/.inrdcih.0/wb.eoeltl4enlh1s.

ehtrO fuplehl :nskli

  1. Pyttre datldiee y:aaotnm _li-mefd3.hw_w.0o.Mt:sa//gpp2aic_iob/rrdenkem/tdwh0/momgt

  2. cIvteitrena seit lal oubat teh uceermlble (npeb3sd/heitclen//t:.r/mh/e0.accsrsua5ttecu.phh/ommtt.nu,) tub het omst eplhluf tceupir rfo me wsa shit noe (ms_/h.aeopejcurWNecypk-/atc_ru..hg/g/:encosiEa3_pdmt/t5mnngdshstiemtr//ibue3gmsi/ea.)


 +2  (nbme24#18)
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hisT is typtre gtear oo:t ioleshmth-yy-s/evet/otivee-taa//rlp/pen:mpistdirc/tesfau.isotmst-dnyceedhetpesmmia


 +11  (nbme24#24)
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I jstu thothug fo a awy ot hllpuy)o(ef iovda titgneg hetse typse of wrnsase ng.owr s,itFr hnwe I aedr etmh I sawyal ookl ofr the tesal ho"ses"al reaws.n heT,n fi ru'eyo tlsil scu,kt yrt ot tpu het etemtnast toni a ueotq htta you dwluo say ot a entpati as a hnca,spyii enmerierbgm htta deep-ed,non ejun-onalnmgtd nqsosuite aer eid.al

heT aesnrw ofr shit oculd be rdeshap sa a sinteneuemtqtoast/ yb eth oto,dcr to the yiaf,ml sa "lelT me meor abtuo owh htis cmipaingt rouy fiylma and aldyi f"l.ei Had it neeb sehpdar ikle hatt, I DIEIFYENTL ntduow'l hvae tognte ti wnorg. I udolw aehv reevn vnee had hte ioyurtntppo ot aekm an imstasunpo btuao eht 'alsifmy hinftggi eigbn due to idet soernncc nad thsu ndigeen a nnitittsuoir efrearl (hihwc is atwh I sceh).o

usmile1  I think the reason dietician was incorrect is because she has had diabetes for 6 years and her diabetes was well controlled that entire time. Then for the past two months her glucose control has been poor. This is pointing towards the issue NOT being that they don't know how to manage the diabetes so referring to a dietician wouldn't be useful. +4
tiredofstudying  99.99/100 times the answer will never include referral. The only reason I do not say 100/100 is because there may be an answer one day that is to refer, but through all of UW, Rx, and NBME it has never been to refer, so do with that info what you will +2

 +0  (nbme24#41)
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oeDs ynaone nokw how ot lure tou E? I've evnre nrelaed uoatb nomgrsamcoisri llscycpfeiai ntvtcagaii a csle'l ,CsAM tub ehnw I ooldke ti up, I dofnu htsi aerticl (3r5wc/i/nw.cgMlomp/9n3l.:tP7ab0cemp//hntwCsist.iv/.h.) The clrtiae doetn's iaeflpycislc ntoenmi maiosludpm sa uigsn ti, tbu laesrev fo eht ecurssoer for the iatecrl do.se


 +1  (nbme24#41)
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nuFdo ihts egrat omntduec thiw slesdi taobu the fnetedrfi speh:tanog niptm1brSo.g1/_s9cSa9s_mrpt-aGnhaiptr0:grs.3e///pd/n0apng2hetcic20frP


 +1  (nbme23#1)
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reHse' a ARTGE iveod pgixnlanie rntousdalu nfiigsnd fo pnae.ycgnr :7@95 is a rtgae reupitc so raf htwi ballse of the kylo ac,s talasgnetoi ,caks etafl ,eplo nda aim.non enO tnghi hte preosn nigpainlxe idas thta I hotught ulwdo be oodg to epke in nmid is ttha teh kyol sac okosl like a iocheer sineid the aangitltoes ca.s l,oAs ihst etsi sha a unhcb of icersutp as wl:le aedrergiaar=?o/g/lpsih-rtfediniaa:rt.mssep/lstuscrtot/ti.

zpatel  what video? +7
usmlecharserssss  porn video how they make this embryo and yolk sac +1
samsam3711  Shorter video that explains this pretty well: https://www.youtube.com/watch?v=01mMBDEthV8 +5
focus  @samsam3711 that video is BOMB. Thank you!!! +

 +1  (nbme23#4)
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..oS. Ie'v bene rgtyni ot urigef tsih out adn I ntkhi I tog .t..i

Oen of hte nmai lneaacrce uscnheiqte yb eht ybod si eavtrxlraascu ssyemiloh by eth ESR. eyoHmsils fo sRCB lesda to daleteve umrse HDL eeausb(c CRsB heav hihg uonmsat fo ctetlaa dosgyeeradhne hiwhc is ersdalee niot reusm treaf eihmlo.)yss ecrdIesna HLD can nthe dale to nicredesa peartuyv ot tceatla rono,ecsnvi iwhch oludw dleeept het obdy of rayteuvp adn laed ot ecaserdni anriaboec il.cysgsloy sA hte resspco ,esoncnitu ipgomyalhyce erssutl due to olizeviuinottra fo rmseu ous.celg

I reaeg wtih bo@otsutay tath hsit si a lihlsubt eusonqit ofr Spte 1 uyof(lelph it was rietred uescbae it asw na teerminaxlep nesoqtui at hte eitm nad on one eknw i,t .ol)l 'mI gdla atht I saw bael ot ytr to fuegir tou siepbols sip,tshaeogne t.gohhu Thta si blaprybo ywh it was dsaek, wehn ti wsa sakd,e to rimnetede if snseudtt coudl YRVE lcirlyicta hkitn obtau lla fo eth lpnoicmiacsto of aialram dan htaw ilsatcmociopn hsteo norlaiig saclocpioimnt uldoc aeld ,to sjtu yb know onlamr o/yhgpglphisysoyotpailhyoo fo het .byod I amce ot eehst cnonoulssic dabes no itntugp heteortg irimotfnoan morf vlseaer fo aodnArm auds'sunHga eidovs :034-(74:@0 _?hdpwcb_srutuc.twozwta=ymx4://vt.wg/whoWef, K1wssTXtumeuLa2c/Epa=yO&uvF;t&d/gasZDxmTtpwlcimme=Kep?bip=Uawsyh.yqtSzCnwveVteDP/6hLobt6.c0oiL;qw:oQ).


 +2  (nbme23#41)
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eTh intshg atth ofcsenud mIe/ o:rotgf lrzaooitnh zeag dan crthaiysrd .chepes

hTe lnorthzoia ezga si a mntiaocoibn fo saisnlg weetenb PFRP enrmipaa(da teiponn lirtarecu rfto)anmio, F,ML nda rohte isovin ralacni ser.vne RPPF si lselocy dlaocet to het ,MFL hichw si in eth odarls spno, os a aaillrbs eyrtar tf,rican ..ei ltaenvr nspo ntri,fca tno'w mpclloeyte iihitbn teh PRPF, dna stuh hyw smeo lhatznoior geza tcinnuof is aa.vaeilbl

yrtrciDash eecshp = cdfeet ni ioacuttalnir fo pecshe myilan deu ot rotom toeemmvsn of ,csephe so ebseauc SCT dna BCT aer iermpadi in bllrsaia erytar o,islne ti eamks snsee ttha teh omrto function of epcshe lduwo lsao be ir.edmaip


 +5  (nbme23#33)
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I odunf a piurcet iowgsnh eht rmstanissoni by tow yzrtuoesoghe hapal isstaaamelh airtt niaas (tidc-isolen)e naetprs, nda diiedmfo it to oals hswo het ritnehecnai yb otw yshroeougezt lahap atseialahsm acnafir doail)rsnent-(te atpsnre. ereH oyu g:o V.vt/1IJsTnn?c:upJOehqdUegi9o./7dpogh/QdHoPwro14etRWElv89=wmwci2Td

makinallkindzofgainz  broken link +1
drdoom  broken link +

 +11  (nbme23#32)
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FA 9210 gpae 4:35 oglnnGia styc = ledidlu-fliF gllwsein egnrvyloi nojti or tenodn ,ateshh mtso lcyoommn ta eht dsarol eisd of het r.wtsi erAssi morf ehnriaotin of nsede eocticnvne ses.uit.

FA deson't iuscdss rmegt-lno ercssuo/oringops.

erP htsi clteiar (McbC/pse/:i/mw4n/hnh/ts7m.ir.il.ca8tg026pvtwP2n/wo.lc,) eht ngoilang ytssc ifuld is edu ot txarcriatel-aru nimuc epodrlt ucacu.nlamito It sola dsaiintec 05% rngedou sntuaeonops nsleorti.uo On nitenomi,aax tiwrs aiglnngo rae ylsaulu 12– cm icstcy ess,cuttrru geliefn chmu eikl a ifmr rrbbue blla atth si ellw eedrhett in acepl yb sti eatahtncmt ot the duninrylge noijt pueaslc ro ndenot ase.thh eehTr si no oasdeascti atmwrh or rhmaeety nda het tsyc radeyil usaeitmnasl.inlrt

oT uelr uto hte oehrt tio:snpo

A. reP eht vaobe ertc,ila teesh 'teanr yaellr ycsst ueasbce ehrte is no iinn:lg t"I hodlus be ipmazheesd that necsi on sloanviy nigiln isesxt ni these csrtetur,su tyhe catonn eb lcfsiseiad sa ruet cst.ys ghhouT eerth rae facol eaasr of imouscun inogreenadte in het tycs wall, htrinee gifanitisnc llaogb reedenitaegv ,hnescag sesiocnr nro rnatlayiommf hcsgean tinhwi eth pecuysotsd or nrsdonruiug esitssu vhea eneb "emedrstntdao = A is grwon sa it lu'downt ahev inagtlmna poatin.lte

.B tneyHlos otn seur how to urle tihs snwrae tou eceuabs if it spmsecerod teh apeliuisfcr raadil eevrn abrcesh,n attocryehelli it cldou eausc psae.stehrsia ahTt gibne idas, het pucoel of tcirlaes Iev' rdea avhe lyon dnidticae iottaelpn itaeaprshes ude ot ggnlnoia tcys ingbe deu ot lasdro yst,cs ONT volra scsy.t .C eadsB on seeht uicspret (ct.c/j/pihthl0tyb3/o:, /3i0t:b4Hpoh.ltCy/t/l, /rpVylhti/ktt.0:BF3b/, adn ah/hbN.03:Zttqpity//l,) olarv annlgogi tscys a(s hits aentpit s)ha od nto ucesa nextsero ucnrautilme ernve mptna,retne nda shtu ear llkeuyin to edcurpo adrila nreve plya.s sl,Ao hte adalir nrvees oscels to a vrola oagilngn sty,c eems to eb seuacnuto sa popdeos to omro,t so if tyhe ddi cseau oco,rmpnssie it wulod eyklli loyn lade to nroyses dietcf,i tno rotmo dtciif.e

.D ,Yse 5%0 sauyonetlnpso gsrer.es

.E yiotsvnSi = on eausecb it si nto na rmilmotfayan oincnodti

apc  One thing to correct, this is a dorsal cyst (not volar). Dorsal normally doesn't have compression sx, but volar can be in contact with neurovascular structures (median nerve or radial artery) & may need ultrasound-guided aspiration +7

 +12  (nbme23#47)
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msrMruu dan r:aesvnmue t1s oghhtut = how sode ti naechg iwht oed.rpla lAl rsumurm xceept MH,OC M,VP and tlriaa oymaxm sveetyir is ecditrly otoirlpopanr to ahngce in orlpdea e(i.. arcesnide rawesldoo=rep urrumm, ct.e). ceuesaB fo th,is xDD nac eb worraned wdno ot O,HCM MV,P nad talair axoymm hgtir aawy ceaeubs het ummurr dernowes ihtw aesdecerd opadler e..(i gndntasi pu) wnhe lal tbu espnocexit hiwt r.emopvi

tlrAai aomyxm = MCC aryimrp cirdcaa umotr due to rirflpoeioatn fo niocnvceet ssueti hcem;mnesey a pleucudtaend smsa ndentccoe avi klsta to amtuir mtspue that is edepsudns ni eth aalitr bdolo luvome dna vosem tihw teh lmueov oem.tevmn

tensenr:iaoPt artdi of )1 lritma vlvae ctorbuinsto .e.(i esmal,ia sysmomtp fo cdiacar l,fareiu sypcnoe, .c)t,e 2) mpostyms of mobilsme i(e.. icafla dan gtrih rma isepsehaimr ni )atpient, dna 3) stutclnoiatnio msmotpys ei(.. ,fevre weitgh slo,s mysmpost nebgrliems inetoecnvc isteus eaedsi,s seeacub rtoum eealrsse -)LI6. sOthre ulneicd ounricoelg stm,mpyso mpitsdau"-olre avlev eia"sdes sltuyuraaoct snfdiign .(ei. tiilacods mm,)rruu and tiarla negtenmaelr h(cwih lucod cssmrope nudnegliry usctserrut adn cesau mpsysmot .oasl)

toN lyno eods adtngsin rescaeed eol,dpra hihcw mensa AL ulvome si lrwoe os sasm sn'ti as sne"updsed" tbu reom ,biomle ntisagnd sola sinecresa teh dowwrdan irigvtanoat eor,fc chwih luwod eortiuctnb ot eth muotr iogvnm tsaowdr the asbe of hte traail hmb,aecr "pin"pplgo on eht tmalri alvve fat,eslle nad tylnpteoial ntegenxdi hhgurot adn sacnigu a nifltoncau tpey fo amtilr stoisens (i..e nwgiensro isadoitcl m)rur.um isTh veido pxisnela ti lyrael wlle: l?wocu:LIm/agvtwscsV=t6&psYe1wn.tiha;b=u.wpt6o1h/4mt/y

dentist  Sorry, you narrowed it down to HOCM, MVP, and LA myoxma, but I only see LA myxoma as an answer choice. Wouldn't you have been able to stop right there? +2
hello  @dentist, I appreciate this full answer b/c nwinkelmann is telling those of us that were wondering "how to ddx one from the other in case we need to"? +4
hello  @dentist btw, HOCM is an answer choice (RVOT is part of HOCM) +3
thotcandy  @hello but since that's pseudo-aortic stenosis, it would present with a systolic murmur, correct? +

 +11  (nbme23#33)
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I illetlyar jtus zaireedl why isth uoineqst nuscdfoe em so mchu (and Ie'v eritd ot rigeuf ti otu a pceolu of stiem, l).lo I tel eth loaquollic ienintfoid fo ailbium .ie(. oi)mtvgni ikstc in ym m,ind htta I fogotr teh tcuaal ailmecd iotdifnein = nramol BMI 8t1(&;)g + eigbn naeitg and gingpur er(ewh urnipgg lcuod be eiddcun ogitnmvi or eidutirc esu ro vxitlaea esu o/drna ceeivexss eei.esrx)c So lreyal, thwa itsh queitson wsa kaigns si iplysm thwa si eth leelcotyetr cenblaa of sixcseeve daar?erih Z!EGE I mdea it os hmuc aerhdr ni ym dhae hwen rytgin to enswra it rnioigya.ll

eriharDa usseca nannio-no apg .ei.( h)hoereliymcprc iometcabl iodaisc.s oltoS ernpmdlotayin tnoansic 3H-OC nad ,K+ os escxvseie areardhi = xcvesiese sslo fo -CO3H adn .K+ doehlrCi lelsve in hte rsuem lilw eb naerscdie edu ot eht lnmaor -H-/OCC3l ,qbuiileruim so as eenvaigt ahgrce psiasetisd edu ot sslo fo -H3OC, l-C wlil reneisac icntrcegro eth n-gi.panao

drdoom  Bulimia comes from Greek "ravenous hunger"; the term is a literal concatenation of the words for ox (bous) + hunger (limos). So, in Greek, bou-limia is literally "ox hunger", which is a nod to how the word is used in medicine = perpetual and insatiable appetite for food (the very "opposite" of vomiting). +4
abhishek021196  I agree with your reasoning but the classic case description of Bulima lists electrolyte disturbance of HypOkalemia, HypOchloremia, and Metabolic Alkalosis, along with other things like parotid hypertrophy and dorsal hand calluses due to the induced vomiting. I tripped up there. :/ FA 20 Pg 567 +
llamastep1  Take home lesson: reasoning > memorizing +2

 -2  (nbme23#2)
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hAntore way ot loko :ta thsi qetnious is telieylsans ginska htwa si the CMC dsie fecetf fo ttaurmpocecihehe ntegas ni arel?gne nArews = onbe raorwm sseupopnsir stuh ftafsec uograyt.sncel


 +5  (nbme23#13)
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Pre losnye.glhocmotpnioa

kaLluopikea = krsi fsatroc ecinuld eaml enged,r -0407 asyre odl, msigo,kn eWtih achtp or qpa,lue 5 mm ro ,erom on orla muuosc aernbmesm taht tnnaco eb drvmeeo by ngp,isarc ont ued ot ehantro dseiesa tyitne usch sa celinh psuanl or nsacsdiaidi adn tno sverdere yb rlaevom fo rtasiinrt dan silnoe utms eb edsonedrci rucasrpneeco iltnu norvep os.ierhwte nmrangPltaie ienlso sfnatmtoorrain uowdl adel ot ninoavsi of the ocusumb.as

cirMo = sVaeir iohytgscoallil ofmr ashatso,icn hierrsk,otspaye saspyaidl or oaciacnrm in tius (cotiaadsse hwit lmocphytyse adn o)cmehpa.gsra shiT ilecrat nsxielpa ti muhc terbte dan sah ic:rtupse ehwpde/te1i#rstae:0/7ad.io6e/4/a-mc4e.vcsivm6lm8cpceirneto. easBd no shti liracte dna het i,srctuep d'I ays hte stioh desil ni eth euisnqto is ta eltas doreatme uouasqms idsp.layas

iHyar kuLoiepakal = t,Wehi uoenlntcf aehctps fo lffuyf )ahry(i as,oumc tairl,leab glnao rltaeal teugon, nda doisctesaa itwh VIH+ snpaiett (DSIA yma earapp twiinh 2 - 3 esray) ubt uayltcal eud to VBE notfcinei

otHis = ryiHttcerpkaoe aorl umaocs due to lignpi fo aketirtco msuouasq ietielhpm,u dyCrwo ypet A auenntarlric ,snosluicin Baloonl cslle iwht gnanartioim fo arminocth (nrauelc gain;)deb EBV trenspe ni elcra ellsc of opiusns e,ylar raevalbi iocoi,oyslkts puesdmosprie nadaCdi iicnnot,fe ihttwuo mtylfmiaonra .ponssere

oFrm uecitpsr nd(a sthi d:oevi yeuhu/qK/8u1vb:6txStpsoI/t.h taesmimtp 2:)2,1 yhiar kaapkeloilu sha a gtyhill iaetdns abdn of lelcs "balnol e"lslc in eht sarumtt spimunso cihhw si eewrh hte BVE .sielv tI kloso mchu fetedifnr ntha hte thois dlsei ohnws ni the ntieu.soq

yb_26  great explanation, thanks for sharing! +
cathartic_medstu  on point +

 +4  (nbme23#4)
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So hist oqsneiut asw onitgemhs I yellar erudltsgg h.twi I tn'idd rgoezcine htat eth etnsepnatrio was fo MERFR as meesono tsdtea ,elbwo dan I kwno uyo tdo'n ende to wokn htta to nrwaes het qit,ensou ubt ti wduol aveh bene lpuehf.l My gsiegbt trsianftrou wsa the gnwordi fo eht psiyob luersts a"blnamor isnccamtuolau of "oiraiom.tcdhn ihTs nyondae me eesbacu hte itnnoiidef fo edggar edr iefsrb ih(cwh 'mI uamngiss wsa rhite ont)tienin is ltiuascmauocn" fo aamlnbro a"itrioncmod.h Tshoe rea wto yrev firnfteed esmnatstet ni ym nid,m lol. ehT ,ftirs ot ,em sujt sanme 'tehres oot hcum hdit,oiamorcn but hte dcosen snmea tehre's oot hcmu NDA hety ntae'r nunonifgtci .yoperlpr ts'I aols ujst eth ftac of rembgeremin all of eht metsr orf TEC at eht eitm of aiedrgn het tuenoiqs (.ie. I 'tdnid knhti taobu the caft htat ETC si lsao elacld acurllle estioarprn ro sujt rpa)rsn.iiteo

I losa tn'ddi learly sdetunndar ufyll thwa mxOV2a si = 2OV" x,am sola woknn as ximamal egoxny pku,tae is the aermetsemnu of the mximmua noumta of oxgeny a enrspo nca ziletui igrdun isntnee sre.xe.i.ec dan is sedab no eth esepmri ahtt eth roem eoxgny smeudocn ngrdiu eerxsie,c eth omer eht yobd will tanergee oisaneend tisepopahhtr P()AT eyegnr in .slc.le. O2V xma is dcahere whne uyro enoxgy nctsonuipmo rsaenmi ta a satedy tseat eipestd na saceinre in eth kdwa.orol tI is ta siht aplaeut thta hte []cslemu seomv from arbocei amblmesoti to anrceibao oam"lmisetb 27sc-0iorxe:yvw-t0alhwwft.to2ew13//-sthvwmmal/-.i9p.

edasB erlyup no ihts ifi,ndetino herwe axV2mO = ytslnsleaie eht teim ta hihcw iabrcoe sescwhit ot abnieorca a,seinpirtor ym rtaoerniitnpte fo oto chmu ntidchaomori vs oto umch adn bda rmtrdcoihnaio dtdi'n mert,at ucseaeb eenv hwne eth hirontdcmoai aer couinnigntf loyrprpe, ehyt acrhe a tpion dan ictshw ot nbc,reoiaa suht fi ereht swa oot mcuh rnmola dciomrh,otani sith wluod ourcc festra ecaebsu eehtr wodul eb moer lloreav lleruacl onitsriprea ncorugc,i eangmni the doby dwlou sicthw to coaarnibe adn eztulii gslyisiolc ot tlcatea fro eeyrng, tpos zlgtiiniu teh rtdhocmo,niia dna huts 2xVamO uldwo dr.esaece

EO..REVWH.. bsaucee hist si a MRERF qeonu,sti eht edror fo evnste si a eittll ifednert,f itedspe teh otuecom bgien teh mase ta( sltea stth'a hwo I sanrdeudnt )i.t oS, I knthi eth yke to nay ocaohilditnmr rdoirdse si emeeigmbrrn ahtt eth uasttoinm rea altmso tiylraenc going ot ftafec an eeodcnd reipont nad hust a eycienifcd of thta eionp.rt One eialctr taht I odufn aisd taht teh tRNA utonamist s(a in R)MRFE eua:cs i"tspudr tiohaonimrdcl einorpt tes,nisyhs ndeicerags eth tciityav of pCloemx I and to a srlees xneett lpCxmoe V...I hcihw dsrecease oseiantripr dna rwoesl tronop gnippum, rdmitcllayaa ndeesgaicr het mnabrmee onelptati and nrptoo ecceloerchiatml netotlaip raitnedg crsosa het inlhtidmoarco ennir mab.rmnee heT oontpr cleelhamoiecctr oepaitltn arniedtg is eht viindrg rfcoe ofr TPA ythsissen dna gisdceenar it aytnsautisllb rweosl eth amamlix etra of TPA tes"snsyh.i .t930b-063sxsi44y/h6i/uf0e1.iol21.1.j/ebrwl.om/2.090y:/feoa.n.6tcdl7r911linlp/

Besda no ym ieudrngandnts fo viiadeoxt npshpolioothr,ay O2 nupocmontis .e(i. atkign hte oetrlnce ofmr mepocxl VI adn igutptn it no /12 2O to eertca HO2 adn H+ rvsdei hte rpoton dngreiat hhcwi vredis PTA otocr.dipnu hT:us netdciefi psrtieayrro xoidntaoi .ie(. ANDmt muiattson fo eth CET ye)enmsz aldes to wreloed 2O nutoopinmsc (so welerdo V2O ax)m cwihh then lsade ot roweeld PAT cinr,dooput dan shut idecvefte ioindtc.amohr eThn, doewrle lhodcrnamtiio nouficnt slade ot eeascdedr rbcoiea otenrisarpi sunigthn TAP oputdciron to rioabecna eisnp,roairt nrdeiv yb lcyysgls,io nad sthu riingecasn taaetlc elevsl.

Hoep iths hlsp!e shiT ootk me WYA OTO LNGO to guferi uo,t oll, but loeflphyu I nvere infaergk grfote it, .oll

,loAs fi oyu tnaw yna meor rdage,in I flynlai fndou na tlaeicr htta yctaalul fyull inpexasl het bcomihiealc nad asiyghlopyptoho of nlohitcrimoad haoit:psemy a754sieh/cpr//m/c3a1.u3c2itotr6b1/tp3emnda:24.2/li//oca

rorSy 'sit os gnl!o

djtallahassee  lol yea. I thought they were trying to say there was an abnormally large amount of mitochondria present which made me get the opposite answer :/ +1
alexxxx30  no I so agree. The grammar was completely wrong (clearly whoever wrote the question needs to work on english). This was very frustrating to me because I recognized that it was ragged red fibers, but then the wording made me doubt my own knowledge (thinking how could the test writer mess that up?). abnormal accumulations either means too much or too little. accumulations of abnormal mito means thee mitochondria is faulty. Correct grammar is putting the adjective right next to the word it is describing. So this was definitely wrong and I share your sentiment. This really frustrated me! +1
azibird  Definitely a mitochondrial myopathy, but I actually don't think it's Myoclonic epilepsy with ragged-red fibers (MERRF). This normally entails Myoclonic jerks, Generalized seizures, Cerebellar ataxia, and Dementia (according to Amboss). Maybe it's CPEO (chronic progressive external ophthalmoplegia): progressive extraocular ophthalmoplegia with bilateral ptosis. Not sure which one would account for her poor exercise tolerance. Either way, recognizing it's mitochondrial is enough. +

 +10  (nbme23#42)
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g8@9h8 ceBas"ue teh orcoiuntbst is voaeb teh eravolla sgorine ereth is a ecesaedr in ari fol,w otn nulg lems,vuo hihwc dwulo akme siht na vbttourcsei phyloota"g is hte omst pluhfle ianaeot.nxpl If you wonk the mtso sicab ipitinsayhodotofnlo/ghpeiy of ttrcouisevb vs srtiieertcv hicwh( I ,od sutj dntid' ni tath tosm ipdlimsife ),ywa nhet oyu anc rfugie gyanhint .tuo fI oithsgmne is tapncimig iaywar fwol = ,uetoscvibtr fi mhgstnioe is mtnagipic wryiaa olmeuv = itr.scertvei TNHAK O!YU

burningmoon  How about emphysema? airway volume changed but it's obstructive. +2
almondbreeze  i think OP meant to say that something DECREASING airway volume = restrictive +3
jgraham3  I think they mean if something is impacting LUNG volume (ie. expansion/compliance) = restrictive Airway disorder --> obs. / Parenchymal disorder --> res. With emphysema the airway collapses (obs.) before they are able to exhale fully thus the air is trapped +
dna_at  Just to be clear, this is not a classical obstructive lung disease affecting the small airways, as it is above the carina (trachea). This is better classified as a fixed upper airway obstruction. See the flow loop here for "fixed obstruction" - it came up in IMED UWorld so maybe familiarize yourself with the image since it is unique! https://www.grepmed.com/images/2948 +3

 +14  (nbme23#32)
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,So fro osme nsor,ae niemastetrousnrrt si egnhitmso vIe' AYLWSA gltdgsure ...iwht yrpablbo ucseeab I t'nswa htagut ti ewll so enver layrel nleaerd t,i tjsu aerlned ohgeun rof revwehat .amxe I jstu nufod isth oob rhhgotu NIBC nda its ATINCTSA!F sIt' rmfo 1200 so timhg eb ,dlo utb ti wsa t.erag Yuo nac hsacer orhgtuh eth boko dna fdni eht esr.pctha I rtetyp hmcu stju twne turohgh all fo eth etennrtraoritsmu pa.etrhc pc/..h:79kg..ooi/n9Nbm/lssw1ovtb0hnn/wi/wtKB

My iamn aeaa:teak-tamGlyuwts = ajmor aeiytcotxr ietnrrttuemar.ons owT setpy of est r)c:o1pre apomc,erbtoit somt fo wchih rae tsypceripna Gi ichwh sdeal ot rsadedece NDAM petrorce itayvict dna sirk of iitytctex,oxioic or inysocpttsap Gq esecprort ttah lead ot saircnee Na,+ +K, nad seraddcee aeuatgtlm essuac aaoenzoiprdtli and icrendsae +M+g scelteipadnm adn DMAN rtpecoer aivticyt and sikr fo oxici,ctetityox nad )2 ocpntriooi hlscnane ncdlniiug DMNA dan in/aaAkPAeMt la,nehnsc wihhc lla lalwo efnicnicspo atcoin xn,ulif utb nloy MNDA lloaws a+C+ lnufxi nda( ylon ni a glatove dtenepedn nrmaen refta sefiifnuct onatozaleirpdi has ipcedldsa the rnithoiib g++M oni ni eht eac.lh)nn

GBAA adn ecygnli = byriohinit traeresruonitsnm.t )1 AGAA-B dna CBAA-G = ciioornotp hnsanecl thta elad ot xufle of -,Cl adn epedtis this gciuasn eotnirizao,plda eth onneru itlls tsyas bowel nristeg paelitn.ot BA-AAG innidgb iest orf atarbtruesbi, osdire,ts ,BGAA dan ixcpotinor = nsdeii oper fo ealc.nhn ABG-AA ndibign etis of zaidnzpnbeesoie = dsuteoi of epor fo hlec.nna 2 ) ilncyeG nealcnh si a vrey mrsliai Cl- lxfeu lhnanec. ) 3 -BAAGB si a ibtpcaoertom cnnelha taht vsttcieaa Gi ldngeia to eescddare PcAM hcihw teaitvsca ufefxl +K lnchneas nda ihtniisb +Ca+ fiuxnl nasclenh gnlaeid to ezoha.tpayiironlrp

ocgiiBen iseanm = leaecschanomti mipnedoa (riionctnooad fo ydbo ommvent,e errad,w n,tmiatioov neeen,trirf)com inpeoeernnhirp (lepes, kfauenwsl,se ntao,neitt efeignd vie,baorh heipnrienep l(seowt neactntoirnoc ni NC,S) ulsp itrsonone elesp,( ss,neweluafk soesidpe,rn ,xanyeit enasu)a dna thieamnis u,(ralosa antti,etno e,arllyg iusset ,maegad nda amy ncilenuef odlbo biran wo.l)f b,ouysviOl lal of ihst si ni naoidtid ot ercagirned ioasmrntioneussnr adn hlgfit, hrif,tg nda gifth n.rseespo

PAT adn orteh reupnis = ycirtaxeto nao,sismtnsir ec-saerelod thwi reoht suelmlll-emaoc esrrtmu.onasrttnie ndeAsione 'inst asaylcslcil ncseiorded a atrrtotneusrinme escebau ti si'nt td/esraeeesrldo ni aC++ eentdepdn ,narenm btu edirdve mrfo TAP oeefrb nhivag an eycotrxati oanieptt.l

ehlloncyAtcie = ojarm oemueratstntirrn ieonvldv ni asnsnsumeoitrrnio via rcunasim dna incnictio ct.eorsepr

tdeePip rremrntaisuoetnst = mlnoomyc deesrlae sa oetrpippde erlagr srpruercso ttah aer lcavede by cepfcsii seeznym ahtt eewr ni het asem trnseratmitornue lvcseie onup eea.lesr vFie ystep = igtub/nar psee,dtip poidio i,eptsedp utiartpiy pest,pdi cpohhmaality engilsear ,ormosehn nda oesth ont dialsf.seic aEmpselx = rocurrpse atth igevs srie ot stuascneb P phom,i(pupsca ,rteooxcen and IGT and deeaselr rofm salml rdeaimte PSN C brifse atht atstnimr apni dna mtaeupeterr ofmi,anotrin rluwofep ipvtsee,hony dteiihinb by oodipi pe,esdpit) enkiinuorn A, pturenpeodei ,K dna eeotrpdupien gm,ama nda oodiip tidppsee glnincidu talnp asollakid (ekil mpirhone), cihnsytet ipodoi eastvdirie,v and r,ndeinopsh po,ninyhsrd dna esphlk.annei nI elagren dopiio eeisppdt aer npeasresdst ei..( aiaganels cne)mhsmia, ieovvdln ni pelomxc svheoiarb uexal(s rtaotacti,n segrise/evsumvgabsisi vi,)sebhroa nda ticpaemlid oh(hugt ont ieivi)tefnd in iahccrytsip .ordsdesir

,lOveral rntrmsuatitsoeenr = type ypset: lellsmucalmeo- rmrtstiatens dan ipeeots,enprdu weerh mum-ellslecsola rrmaeissnttt aer afrset adn medtaie rpdai isnptacy tnisaimnssro .(e.i aogendnr SNS gigtfliti//hhgffthr qikcu speoresn), ehewr as nerespedioutp (golan thiw gcbilioo asiemn nad emso sllam eluceoml )tmetsianrtrs ear oserwl and daimete dgur,ala ogodrnpel iusmso.sinentnaror

mSeo stp:eucri o_hote/ppildtae:etdudktthnv/ifn/itkbh_nw/vmew.ornrcup.ri/usruee_pmaaw.rmtseseo, toPiRiwaGc-3tet6e-5r-eg-4pfge1rt0du7oeifguhrtd96prbw2bebAief/ao64-d3and0ss8p1tmBsc/n14//ho/lArss2p/.2eaaelp-l3/frreauBa38a-Treccw-r0:010ns.ibgi16gh, adn atrdbesiw./lfa1e./tlbofat1id5r2i-.w_afxg4/e6isgb#33td61---gb/x=s;975d-&nr2b--=egpa1eeehltuna-g:/adf0/ehwlecp8na0mhUw

sweetmed  This is amazing. thank you +
sweetmed  This is amazing. thank you +
paulkarr  Woah... +
brotherimodu  Short video someone posted from NBME-21 answers: https://www.youtube.com/watch?v=4-DuvwoH2zQ +2
dorischang  Didn't finish reading this, but it looks awesome +1

 +0  (nbme23#9)
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So, ni crehgasneri siht rruhetf, I udfeigr tou a wya to eurl eht etohr sersenwa uto. rPe siht rl,etcia /:8.twwiwsC8/ghimlhp/tcaM0co6..pPcv/s//ltr3nim3nb.e4n, olhrmua lyeachcaerpmi fo ynaamlcgin is ceadus by 4 aismchsmen hwit cessex PrTPH rtnoceeis enbig M.CC xscEse PTPHr rinceseto crsocu in sus"aomqu cell s,cernac airyrnu tcrta csrnaec la(ren ecranc nda badrdle ae)nc,cr ebarts nc,cear oni'nskdngHo mphoamy,l and irnavoa racnce autcnco ofr teh itmoryaj of cniaagisemnl dieagnl to iecmcylpehara iav rPH.T"P hTe ehotr 3 uescas ueidcnl pychecmeilraa nsoyecrda ot poorvcridouent fo icai,rltoc eoysttilco tem,sesatsa adn HTP mediedta yhaiccrmleape apahrdr(otiy oimnaracc adn ccotpei udoconptr.)i l,Aso FA lyno mostnnie HPTPr in arrsegd to SCC of nlug dna leanr llec .mnarocaic

e,ttraPos o,locn nda aeartccpni nscerca are roem oonlmymc cdoamicaernn,oa dna less ieyllk ot leesrea HTrPP, dna hdytoir naeccr si sloa lsse leik,yl uhgtho I idd dinf oen tlireca atht ndfuo rPHPT slrdeeae yb lal fo stehe rncaces os I n'dot wkn.o I ugess mI' tusj going to og twhi CSC of ngul ebing CCM fo PHrTP haroulm ymelaaerhccpi fo ianlna,ycgm pusl attp'nsei rioegadhpcms ('s60 elm)a.


 +0  (nbme23#7)
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I dfuno itsh butoa aisdre :CPI eatetPirsnn"o fo reiads rcniinrlataa erpuesrs = c,heaadeh eipael,pdlma ntage/,msoniaivu oerws in the rgonmin sa CIP essira ndgiur eth nhigt as a useeonncqec of cnomecybre, a esri ni PO2C rnugdi pslee acdues yb srtyaoerirp pss,ordinee dan rbypolab a recaeeds ni FCS otasripn,bo puayripll liidnota, ostpi,s epadmiri eagz, yrrirtspaoe erairu,lyrgti AMS, nad gchsena in P,B ,HR dna ryoritaspre ertnapt ear uulslay late ssngi fo dresai PIC and adeerlt ot ersmtbina oiirdottns or caiims".eh

_//3/nihm2:et1/ltmnc/jso3ujt.co./b7pptnnpps


 +4  (nbme22#4)
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sTih acitrle slpieaxn eth tyhaoppyihsogol ell:w .bwh/ot.cis/onkngBs44Nlv/m1/tp:b.wn.3wo0hK8/i.

heT girth itrlnecev si imlyairrp lppiduse yb eht CRA hihwc aslo pespsuli teh SA eodn dan AV oden 90(% fo tsrhea uacbees tyhe ear ghrit moant)dni, gnaidel to olss fo initacyltcotr fo het itrhg ed,si dan shut idluf diuuplb sgncaiu tleaeevd nlcetra oevnsu rer.espus teEldvea erpsruses ni teh lirve nad optalr sstemy odulw eald ot oatyhgpeleam nad fere fuild aatuncliumco ni het o.eeumptrni

henoch280  Hellppp. pls why is it not decreased capillary oncotic pressure? +
whoissaad  @ henoch280 Because there is no change in the levels of protein in the blood. +8
drzed  theoretically you could develop liver failure from the increase in central venous pressure (e.g. cardiac cirrhosis) and THEN you would develop a decrease in oncotic pressure. +1

 +1  (nbme22#7)
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S,o I hutghot hits touqsnie asw sreup euagv dna ont taeg...r htat negib siad, ivnagh ogtent it rnowg dna ton lraely naivhg a odgo txeaioanlpn orf teh ewar,sn I did a iettll arhceser dna fnuod siht ertali:c //11.Twhww:o.pog1l.a/..5d4rtf106anh.rR7/3.oS1a/0pui1s0jd/ts

iThs wsa eth nima nccuonil:os hT"e lssuert fo the ternspe tdus,y dieam at nsessigas the eectfsf of srekto on lexsua i,utgcoinfnn lerave a asgcfinniit idclene ni dloi,ib lctoia yque,efrcn uslxae rolasa,u dan atotsifnacsi hiwt elxsau flei in ohbt rtesko eistnatp dna ehtir sepusos. Teh tnpeesr lsteurs aols eaotdnemtrs hatt eodsrsird of leusxa fnsonicut era toms yntslafingici datosescai wthi usaoriv ssapicyooclh rtfcao,s chsu sa penti’ats rnlgaee ttedtiua dwrtao ae,tsliyux fare fo etpm,oneci nad yiibtla to iudscss iestyxlu,a sa llwe as twih eht rdeeeg fo rookptsset cinualnfto ildasbity.i eoMrrevo, lxeasu cousninyfdt swa dleetar ot hte repeecsn and egeedr of dspseoi,nre dasibtee t,uilmels dan disvurcoaraalc idmnoci.tae ehT ytoeligo ro oaonctli of the oesrkt and the eerndg or aramtli stutsa of hte esnatpit erew not aactsdeios twih cagsnhe ni tsopkterso ulxytaies in ptneatis in teh snptere .y"usdt

oongkiL ta the tiqnoesu aaig,n I'm neiugssg eth gtefia"u dan cfulidgifnti epgnleis adn gc"tatonnrcine matsentte asw osppsude to eb a ucel rof psisdonee,r saicpyleel eicsn ti arettsd rfeta sih sort.ke sAo,l on pycahlsi binasetrmailo tesugsg tugncinofin is natcit dan tsuh trnuonlca eseoirtcn ouwld eb epdeverrs aoyl.rlnm sihT si ujst sudti.p

ls3076  appreciate this kind of effort to look up journal articles but honestly this is not really what nbme answers is for... we should be able to get the answer from process of elimination/basic science concepts and not from looking up studies as we obviously can't do this on the test +

 +7  (nbme22#9)
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I've nveer neeb oogd ta cnnvrgoiet tusin :( lol os hda ot sak ym h.trerbo He dlot em th:at

ndiecsta × detiancs = icsaetnd2 = eara

n,ad

ecsdatin × sdtniaec × inesactd = atcnised2 × nacstide = adentsic3 = lvueom

toGta voel ucbilp hsoolc rfo never neeb agttuh htat ... hgsee bvlsouio(y 'evI eodn eth usnetqioa adn tusf,f jtus enver bnee dlot ti ahtt wtthaa/y pmeisl re).bofe nKgoniw htat ameks rngifigu tou the uetqioan uhmc e:raesi

woFl rate = yctvleio × ACS = 02 em/scc × cm22 = c4m03e/sc

oT covntre to /mLni, tjsu tilylp:um

0m4c3/sec × 60 mse/inc × /1100,Lcm03 = 0042 ,100L/0 min = .24 /Linm

Hpoe tihs dlh!epe

impostersyndromel1000  to all my public school peeps out there (and not the nice public schools in rich areas, the real public schools)... we made it! +3
angelaq11  Thankfully I was taught how to convert units, but let me tell you that I was SO lost on this one. It's USELESS to know how to do it if you (I, I mean I) don't know the damn formula xD. Obviously got this one wrong, but it's good to know that if it ever comes up again (and I know it won't) I already know it. +1

 +1  (nbme22#41)
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'reseH eosm peigodoymile iifnnmoator tbuao pnsnsoueato :psnoeum eTehr era two knsid, rmiayrp ntpaosnoseu openmsu SPP() dna ersycdoan (S.SP) sPPS cocur in plpoee aged 00-23 ,ayrse hwti a peka neicdcnei is ni hte elayr s2,0 si rlyare desbeorv ni lopepe edrlo hatn 04 ra,sye whit a ealm to maefel taroi of 26,1:. adn mtos fuyrteneql ccsour in ,ltla nthi enm, ghutho ksgomni ssierance srik neev rehtu.fr PSsS ccuor in ipaestnt iwth nynuregidl gunl dconni,isto hucs sa ODdPC/lreo tapten.si fI het tpai'nste egcaoipmdhr was elrod and dha yoitrsh of lgnu eis,desa ubt atht 'awsnt na ntopio, thne I nkith skogmin lwuod eb the prepiaaotpr iohcec auecsbe nkmiosg si het tgbsige riks crofat rof yilrnugedn lngu sinodc.otni

igeRdnrga hte aua,trm tcaarimtu irjnyu upemsno ostm nolocmmy ccuor eud to rotmo chlevie cdtisean rwehe eerht si yniruj ie(.. arcufe)rt ot tsehc l,law adn wthi latsb rjn.iesiu ghAultho the euqitosn it'ddn eicysfp teh cshte wlla asw dvoi fo sr,tuafrec it olsa 'dtdin yas ctarfsure rewe sentpe,r os I tnikh it duolw be fesa to msuesa that eht sociolnil inrjyu ntid'd avhe noguhe ecfro to ceaus teh nm,oupe eyalseilcp tihw pengkie in idnm hte peeilyigomd of mriaryp onaneuopsst somnu.pe

At esta,l sthi is my ghtuhto resospc ighavn dseecrreha ti mo,er nw.o


 +4  (nbme22#1)
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omFr oT:UaptDe INSSHAEEPGOT

kLei mots tohre esucas fo tyermanoipha, ehart leafuri asiprmi teh tlbyiai to eteecrx tneedisg wtrea yb eicnngisra ctantierdiiu mhnooer evsl.el nheW icaacrd upotut adn mesisytc dbool eussrrep are reddec,u myvo"ol"icpeh sohrmn,eo such as rienn w(thi a tubusensqe nirsaeec in ngesonitnai II raomoti,nf) inaeiidtrctu rmnhoeo D(,H)A nad prnepe,eiinnroh nrpdose -[.3]1 lutgohhA osauedmte atetpins hwti rtahe alfuier vhae ecirnaeds asmpal nda lraalxcteurle lfdiu osev,uml hte obyd cvesepeir movleu niotldpee eu(ddrec fveteeifc irlataer lodob u)mvleo csein hte lwo aracdci potuut sceeersda het ruepesrs pfeurngsi the rboaetecspror in the rtcaido nssui nda het naelr taeernff tr.aeelheri To ergdee fo mralronoeuhu itoancvati si llerengay rtleeda to teh eierystv of caricda c,nyditounfs as deessssa yb tlfe iuevtacrrnl enitecjo riantofc ro tcialuofnn lsasc [2]. eTh ulhunmreaoro schenag imtil ohbt musodi nda rewat cxeiontre ni na eatmttp ot nterur rnfueipso spreuesr ot .alnmor DAH sreaele ricydetl eesnahnc tarwe otonrseribpa in eth otnelclgci eu,ustlb erehwsa sgoiintenna II dan nnhoepnperieir tmlii sltdai wraet ldevirye nda( retyheb treaw tnxi)reoce by rginewlo het rroglealmu rttaifolni etar u(ed to a kreamd toucrenid ni aenlr rpesnfu)io dna yb cnseiiangr oxirlpam dsmiuo dan rwtea oribterspona ]4.[ nI dia,notid thbo eth wol aarcdic tutpuo adn ghih tnninsgoaie II vesell rae tntope ilimsut to hittr,s adelgin ot aechndne raetw n.ktaie

sheattosw.e-ia#na:iuaylntciutmhpsmt2tae/a.ttpi-epfo-thwHcnt-rh-enwwi/o//tneodrpr


 +2  (nbme22#50)
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I nwok taht empceotl slmoe od ont ciatnon ltaef eutiss .(.ie loyn ocrncihoi ,svlilu ay,cstooblphtort nda aossbrycycthpoilstno) adn itlpaar lmeo as tfela sitsu,e hoicncroi ull,isv ylttrashoc,potbo dna aryosoptilnccb.syhot ylsbuOoiv ocohmeetitiap mset lecls ear aelft astpr sa hyet rtun toni blodo ,sllce utb what si the rvllaoe diniftenoi of alfet rtasp?


 -1  (nbme22#46)
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I terpderetin eht patniet to ehva COSP (htsiu,rmsi h,reomreaan ianaorv sms)a tugohh eth uesrp levdaeet toenetossrte is emro necrnignco for enrc erp( tsih :ticelra .iia.p//1evwCnct7/.schw/gP6rp/tln9miw6bt0o0/Mnhcsl:.m.) If teh attiepn has ,OPCS hse si lykeli bsoee nad ta girhhe iksr fro NLFDA ihhwc acn be acdeaitsos iwth dtaeelve ailklane h,easphtapos ldipi oucictanlmua, nad lteeevda eststotrnoe,e utb ton DUE ot dnaegrcnoi sfecfet umer(s" aongrden vesell were otn oidaetscas wiht the prescene of F.ALND iThs is iylridnect indrceomf wthi ruo ulsrte on o.nehppetsy ,amNeyl ether is no ecefnrdeif ni DNLAF evpncraeel wbeetne gyecn,aprrdhieno dna yprncegnn-aodehnroi ro eerirpvtcuod POCS .eenpsthypo FDALN is ndirecsdeo a peaihct nenpcomot fo tboeialcm omreynds thwi a nelacrt tgaceionph elro fo nuisiln cnsetsraie htta olsa efascft teh otrrpaa-ohinohatmyl-iauavypti saix in sbstujec wthi S.OCP.. doyaHnrcgereipn tseta may eb edu to linsiun .tcaiesr"esn t/p2/yibhjGty/.K:ltFW.)

eTn,h sa idas by -,nytblc@ eevletda netossorttee ni a afmlee si tovrenced ot groneest and snetoer dan kebdaecf hniiibst het hstyhoaalmpu ieganld ot aecrdsdee HFS nda HL e,sllev but SHF si tdenibiih moe,r os etrhe is an esidraenc HLS:FH .tiaro

a,ilynlF nreaigdrg APS ihh(wc sode rccuo ni mweo,n ohw e?nwk l,l)o het roetoicnlra ebwteen oeentstsoetr nda PAS in mne si slilt rpteyt wkee ni( shit u,sydt eerht wsa ylno a trolacornei and a ewka eno at ta,ht rfeta auetlrmivtia lsyaisna tjganiuds rfo leavser sintgh ci:Ml04/6liphp3m/n/./wPsroia.ht0/5c.wbs5tng.twnCv/cem) os ehret si iednyteifl ont a eiolroanrtc ni oewm.n vHwr,oee epr sith tsudy (h.npnw1ms8iwl/0ec4:/.b.6m/9int.d2bth/ugv/owp) rhete mya eb na itasnisaooc weneteb etiracn osnagdern (ton noet)tsetrsoe dna PSA ni mwnoe.


 +0  (nbme22#19)
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aCn eneooms lpxeian how ot urel out hte hetor arnews ciho?cres

warbyparker1  you can r/o SMA because as kidneys ascend they get stuck low in the INFERIOR MA (L3 level). So I guess there should be no problem w SMA +3
hello  I think friability of vascular tissue would indicate in inflammatory process (the one I can think of is strawberry cervix) -- so i think that's why you can rule out choice C. +1
avocadotoast  You can rule out multiple ureters with abnormal courses because the ureteral development relies on the ureteric bud. There will multiple ureters if the ureteric bud divides before it comes in contact with the metanephric blastema. Horseshoe kidneys are simply due to fusion of the lower poles and don't involve the embryonic tissues, so those two processes are not likely related. +

 +0  (nbme22#1)
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Tihs is a ogod mniionata eodiv fo btrlminaoeasi of tug oatorint CMS(UI IS IWRDE, ol)l: 5tgh.uu:w=Qw?8ETvtyccaJ//T.ohodewtts2bpTw/m dna rpta 1 fi yuo atwn ot ees a dgoo maaintnio of eth nmarlo gut rttnoaoi laso( wdeir mui,cs ..ei si eht sm,ea o:)ll t9aUvthGw4/a?moYwsehobxtvypwwcu/.cu/Z=.wdt:


 +2  (nbme22#15)
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heT xialnoeatpn yb vnrleirdigteiy uslp the npexiltoana ni het lceiatr peostd lbowe (/Mmie/9/9c.c9ih..Pclpaw4tgs//:Cnm4ns.r8pnb6/wwtlohitv) are the sb,et tsuj nede to eb dnmecibo ):. eTh leiinteadfrf diosangis bteal 1 (c0tot?hmn/P.lnsbet0o.:/-ea-6-9s=/crlbtLn/io/C1TvpMg1ppMaBh8Sc.9et0wc1eii4lj/wr.9/4mly4nbtrwO/o) ayccpelilisf stnideieif teh doncotiin in ihst useoqnit sa putosratpm httsidi.yrio

elayUtlmt,i if you wkon atht opisihhdmyrtoy ahs a irtstnnae ymtedshyrohipir eapsh d(ue to mutnmoiuea dntoritcsue of eht lcsel hhwci adyearl dah peefmordr TH nda os it saw eedlaers nupo dunirotes)ct erfeob syhromiopthydi nnuongini(tocfn cslel os tanc' kate pu ini)ode dan hatt yorthsphoiimdy is a cypchoyilmt aftiignrtnil yttrd,sohiii uyo llwi onkw the rseawn. I had a rahd imte ertnsnaugddni htis ta tisrf eecbuas ew vgeoutldni/aaaees adbse on eht nercpsee of tPn-iTOa ,Ab tbu eth uegdrlynni sgehenaptois of het irydtoh stnotdeciur is deaemdic-llet etp(y VI yeivnsrt)hptyesii not Ab etdmdiea (epyt II sntpethevisiyi)yr like gre.sav ih'Hsmoatos = yocmhliytpc orinanttfiil twhi mirgeanl ctneres whhc(i nac mofntrsar to B ellc oyml)pham iwht ltehhru lclse (preink csolpmtya cl)es.l


 +4  (nbme22#47)
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rypeutHeca = tsmenui to horsu, soth edroremfp Ab staaing fagtr lenedolihat cell Ag = plommnitce ac,aotnitvi hlenoedialt eag,dma ianilmoafmtn iti(hnw het ,stuesi TNO uistrneitmi,t) oilntctg ,eascadc icicesmh scsoiern and .moisbhstro ytpalclsuy:tcdKpim/Rtt.ocihuiebr/hsnmAe/.srij/Hm.tkpp/

uetAc = wseek ot snhtmo = tgraf Ag itstcaeav thso D4C dan C8D T sllce ailegdn to ayecphnmarl lecl eamgd,a aieiirstlttn ytcpimlycho iinrtanfoilt, and elhdieot.itnais p//lrtM/iujopihmctdpbs..yt/mirchleAmyRosnd/stkKea:.pti

nicCroh = mhston to ra,yse rccniho TDH yt(pe IV iseyyvitisper)thn otnierca in selesv allw igneald to mailtni oohmts mlecsu clle ifplearorntoi nad sevlse sloon,ciuc whit sipoby goisnhw norwedra urasvlac lmuen nda nveistexe osmtho cuselm.

GVDH = gftra csell ot(sm caitlylyp nboe rrawmo )ansalntstpr zneorgcie otsh cslel sa grs/ofeinlef dna laed to irstdntoecu of hots tseius gidlnae to ar,sh ,cdajnieu idhe,arra dan GI haregemorh s(hti srucco ceuabes toms bneo rrmwoa sptalnatnr tnaeispt hvae nguedoern ulfl tnioirada hchiw kattsac hte aplyird vdpionirg llces omst (e.i. ,snik GI asuocm, hir,a etohayptsec) so rgatf sndrettoiuc fo osth clels in thsoe reasa sldea ot tposmm.y)s

mop/tct:pi.ustp/.ms/hc


 +3  (nbme22#39)
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I dnouf htis ehnw ynrtgi ot ntreadndus wyh deencarsi NO udaecs s:hadeaehc stnrira/itsiteNet rae a very ocmmno dhaaehec dna mieganir dfoo gsgrrtie MDWbe)( dan eisra rctiin xidoe slevl.e ihgH slleev of itnicr idoex era caidatssoe wtih giaeminr d(uS.)ty saHcedhae nad garmsinie aer sloa very mnomco in cisemtniado that boost iirnct edo,ix hcus a aigrav d)sty,u( ubt ti si leurcan yhw this hnppse.a Teh lagriion shieytspho saw taht rcntii doxei ranecessi dobol lveess zies dan isrtrgge a aiimgen,r ubt teh rvaiag suydt dan ehrots sedvdiopr ths.i eewNr dusetis on cirtni ioxde wsohs ttha ti nrceesisa hte epiedpt CPGR)( atht si oirdsdence opeissblrne rfo errgtiggni srmgienai dSyu)t( eftra enescairs in oiiatml.manfn euBeacs riictn eixod is tcsdaioase ugcnroniee maniailtofnm seisa,des t'is eilkyl atht hedchasea nad nemgisiar rfmo ritnic dixeo era a gnnrwia nsgi fo hits lmfaiantnomi .u)ydS(t

The asercrhe is yiblsacla tgntasi thta natsetir eirsa itnrci xedoi lsvlee dna hgih rnicit xdeoi lesevl cseraeni nlimimtofana dna ahhadscee and gnsiamr.ie ,rwevoHe eht eactx eosnra yhw itsh sanhpep is .knnonuw

s--o/nw//waasuhtredd.p-Wtimat.h-cqehyhwocre:cauatsose

taediggity  Goljan and FA mentioned this as Monday Disease for people who worked in industries that heavily used nitrates, where they would build tolerance during the week and then get a headache when they went back to work on Monday +3
nootnootpenguinn  Just to add to this- one of the side effect of NG when given to patients with MI is "massive headache"! That's how I the question right! +
mumenrider4ever  This is similar in how triptans induce vasoconstriction which is used to treat migraines +

 +1  (nbme22#9)
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shTi nikl has a ldblaee olecnrte rcepcomios gamie fo dacirca ytmyesoc iekl eth eiunosqt etxn to a roncaot ,iegma so tis' rlaley h.pfulle eTreh is osla a godo ocrednispt.i lolrSc all the ayw odwn ot eht tlas ufirg.e

ebecwewrgwgwttstvlu1_178rMu_?/o8u=as/eCnoepr43ey_ai.1/e3:/c/on_eekicOhhonl1itts.rtteafpollifs_vhste


 +4  (nbme22#36)
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FA 2091 aegp 246: A srspcoe otn( jsut a du)ucinegsaremottn/ euri tqsre:hta suioDse:rcl siisscundo of ptnieretn niformtanoi i(usgn lcmadie eietrn,trrep ,di)e eendf annUgirsdnte:d yibilat ot ,ponhmcreed apctyCia: aylbiit ot aeorns a dn emka ,oes'n wno nsiiocesd (idtnics t mrof poete,mcnec a elalg ee)oitnti,danmr sunls:rVonaeit dfroeem omrf eorincco dan minoaipln.atu

Ptiesant stum evha na enlligteint grstdiunnaden of rthei soganiids dan the rini/etksfbses of ropspode eernttmta nad rtenaaitlev itonpso, nuigdcinl no nttetme.ar


 +7  (nbme22#35)
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I TEAHD tshi pe,iucrt stuj ekli eervyeno ,esle ll,o os I did some oemr dnggi.gi evneoEyr olbew is cetroc,r tath eht toratepinsne si tigsuggsen an cunfeitois r.ssopce IsTU acn easuc uecat tireieyosnhp,pl adn fi crconh,i peesrsgros to cricn.oh rpeythiilPneos is a siaiolebtlirttntuu i.adsees I fnduo tshi inormaifotn dagrngier ti, dan ni the satl p,tra ti dsebcseir teh ossgr ogthloapy fo rccohni peynhplie.sroit ormF ym trnanpitee,itro it osnuds eilk ahtw eht utircep is ghswi,no but I 'swtna beal to ifdn a btetsj/uetr sa gdoo neo nileno t,ey so I 'tdon nwko ofr re.su

ucAet uaonellriTtsiutbti rsNhiet:pi tuAec lmnfionataim fo elubsut and nseiittiutmr anc caeus R,FA nda if het iryoaanfmlmt sscepro stpsiser stih nca volvee otin ricocnh ebuttaittnrioslilu pntisreih dan oncrhci ierilttaisnt isbsirfo nda urbulta ptohayr ihtw ksir of siogsoperrn ot t-ngadees keydin asdise.e wTo maroj treisoacge fo cutae tnlesltioiuirabutt ehpriitns are ecuta ntoislpeeiyhrp nda ctaeu syryieesiviptnth lritnitoauetltisub eiis.phrnt

etucA elpo:ntiiyserhp sadCue by taliecbar iicetonfn tmos oyonclmm E. cloi oefitn.cin sivrneiyyHiestpt nttoeslrbaiuitluit trpsei:nih sedCau by na areilcgl seps,oner ofr pme,leax to a grud ro otrhe ensasuscbt atth ear teis,negd usch sa hlareb ese.imdre

yB rfa the smto cmoonm uorte fo iotcfinne ni etuca irpteoneiyhpsl si na eisdcnnga inftcoien in teh ryuinra r,tcta for leeaxp,m vdrdeie romf a atleriabc beadrdl nnofiie.ct tceuA poiylertpihnse = eesnixtev xuinfl of MPNs ithwni teh nritseutt,mii stbulue litui)(,utbs nad mulens of bstuule CW(B a)tcss (/yDBilJ/.yh/2tti:tbpP).

Wiht rpiesnecest ro eucnrrerec fo eatcu spnpeehryli,oti eht ssadeie sreposc evlseov otin nirochc snptohip,yrliee cwhhi ulyasul is mnpoaedcaic by armedk nieroso of hte aailyprpl itp rluginest ni lidoitan of het aaecnjtd lcyxa st.ic(iaelsca)

hTe tosm htetasaiircccr icogplhtao atsefuer of cicrhno yenhlstoppriie ear eth osrgs gacsehn in eht edinyk htiw bd-sboedara rsasc ni hte eyahcrnpam invrolyge saaer fo loairtcc nda raymldelu prthyoa wiht cdtanaej ceiltca.sias ol,sA eht pnsttiaeoern gssegtus yhds,ioorpehnsr nda from my eerch,sar ynihohsd,pseror wnhe o,rvrc/ecsehni nca toncetirbu ot hte redamk lsos of oecxtr and rrscai/sbsfsio of eht lledamu (.md.eNwaRtt//MHlTLpheesEuRh0./Edhu:LAN7pt0At.bmhat/) dan iicltseaasc hih(cw I hknti is eersntp on hits .tiup)erc shTi si the sselcto eruictp wthi idietopsnrc I ocldu dnfi thta ehtamcs eth smte etnnreiopats .i.(e turrerhdoey dan o,sriehhyopsrdn stisggeung ucloveestarrie relfxu dnelagi to cifintoen mfor a" gnol nsgtdian ouctirbnost bbyao(rpl ao)tignlnc"e os elkyli fmro a c)idhl ewdeLbR0uLs.ApMEtRA:N..pTh/lth/h/uha8eNmdmHtEatt0./.

o,Asl ot tnoemin on the oreth mtnmeosc igssprexen rroftnastui htat the ames peruitc asw edsu fro osrmut nad burault ya,rotph form atwh I erd,a ttha ssgro oyghtopal, si hte lngeaer nppcreaaea of ehterrroydu edu to tscotvbrieu uopayhtr (..ie ralbuut hyoa,rtp ,gibasfir/ncrsrsio sacalxie/ayctsicl iidotl,an dan nhti rcicatlo rim due ot y.athopr egooPcoa.yonlhnmtli yssa atht teh aseiicacslt is deaeexgartg ni esls evrees acl/tsiaasrpe uiscornbtot iensc RFG si nto spseueprsd lpltmateodtt.iiwygsh/nicsypwiuone/o:h/octuh.tbowm/rvl.stepkcot.)

Hpeo shit peslh ene!revoy tI ersu ledehp ,em btu otko YAW oot lgno ot tnesanr,dud lo.l

nor16  nice job, but i dont think you need all this for these questions +4
alimd  next step is to do randomized trial) +1

 +0  (nbme22#1)
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ePr Wpe:idkaii The spreitc l,xeref a eepd etonnd efl,erx si a rflexe as it eisictl lonviatunry rtntoncciao of eht rcpesit caiihbr .clesum tI is niiedtati by het creaivCl (of the cekn o)renig psilna verne 7 erevn toro (eht mslla nemsget of hte neevr that sregmee ofrm the pnlias )co.rd eTh lfrexe is tdseet as atrp fo teh aglilocorneu eotnxaamiin to sasess het oysesnr and omtro ytwhasap itihnw teh 7C and 8C aslinp esvn.re

A,ols mfro a idtfrefen :tiesweb Teh etsrpic fexrle is dedeamit by the C6 nad C7 reven os,ort ntpeladriyonm by .7C /sclxrrfymtgte.deth/fssm/yputesuedem/ur/oam:deullnio.ebuer.hnuponr/is..


 +3  (nbme21#2)
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In case nanoey si a nsede sa I am dna jtsu td'dni d/rrebdeeernntumsma hwta ctxaely ptyrreiaxo olwf si = 1EV.F In rtieecvisrt dsiontnco,i F1EV si alronm or irnedecsa deu to esddeacer FC.V nettilriatIs iossbrif = ncrseidea riawya encpaarmhy foadclfs rdnuao hte w,yriasa wchih is what dsioperv dalari ntoc.rtai heT arretge the darial ic,ontrta teh oewlr het lcnlgpaiso fcer,o nad so iterxorayp oflw is c.idsernae

champagnesupernova3  FEV1 is increased due to greater recoil of the lung tissue. FEV1/FVC is increased bc of that and bc of decrease in FVC +
mangotango  But I thought with restrictive diseases, the FEV1 dec a little and FVC decreases a lot, yielding an FEV1/FVC ratio that's normal or increased?? +1

 +0  (nbme21#45)
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So I loodek toin shti thfurer oto caubsee I eryttp cumh ownk iongtnh tobau eth amke up of mse.ne rFom hte csahreer I no,dfu as sa setadt wlbeo yb oy, tfrsocue is teh stom taniotmpr nscioeunttt fo snmee in tsrem ro rmeps ci.tfnonu ewloB si aroiinmtfno I fundo ot srdeasd het etrho nrewsa c.cioehs

nicZ fncdieeiyc i(n e)u,msr epr FA, ash been itadcpemli ni ddeeyla oudnw ehniag,l epsusrpesd ,ntiummyi lmae yogpaiohndsm, ecaedrsed tuald rhia iaxa(ll,yr aacil,f pc,ibu) ,esdsigayu snomiaa, aaimrttcimeorsd eptntheaorcia tcedef( in iltnesniat nizc rptiabosno), nad aym iopsespred to choclaoli cs.oirrihs AF dn'tdi fyipcse hte ellsve in eth sme,en utb erp eht ebowl iar,ltec nismael znci onctten saw nfdou to have rno tenoorirlac to emrn/spemse yele.attci/eivv/tlc I 'dnto oknw if w'eer upepsdos to nkow ,htta utb own I d,o oll. sbd:mnetn//ltipom/.wv0n.7wh.3g3.c7iw5hpub5/.

As nrhobguxy toendienm, uilsmlene is olyn teinendom ceon in FA sa a etentmrat rof t,iean so I eokldo toin it rretfuh. mieSlnue si a nntotce of nm,ese ubt elvesl yrva so hmuc ahtt it erssev no nioprotgsc nccllai aveenrecl ot ntyet,riilif epr shti actrel:i /gcu2nn1wl.p.nms:2bw.ov0.i3pdmhhi5/t/t3/bew.

oT leru uot lla fo hte nrseswa sbc(ueea I indt'd arlley nkow ahnygtin aoutb eht yatqilu fo ),mense I nofdu siht B"y itta,stc-ssti rhtee asw on ftinsangcii eenrecfdfi ni het mnsee aN oirncatnnocte naomg hte etfrnfide opusgr (7 gusrpo ttoal eadsb no repsm ,u)otnc dinincgita the icgnnnfiiista oelr fo aN ni repms lo.myt"iit. 2.1g.lp2w/hdbet1ob.pctnn:u5hn/mimsv/.w/w7i.

,llaFniy I notd' htkni het pa5ahl- ceedtaurs neyemz si altluayc ni s,enem tub I ulocd eb ro.gwn tierEh ya,w it ntldwo'u eb mollybraan vdalteee ro owl fi het oserettnsote vseell ear nml.aro


 +7  (nbme21#45)
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So I elokod ntio tsih rrutfeh oot cuebsea I ptyret cmhu kwno nhgtoin buato het kmea up of .smnee moFr het rcsharee I douf,n sa sa atdtes bowle yb oy, seftcuor is teh smot nmriaoptt tstnuietonc fo snmee ni estmr or ermsp cf.unntio wloeB is intofnioram I odnfu ot asddrse eth theor wneras cico.hes

Zicn niiyfcdeec i(n )us,mre rpe ,AF sah bene teplimaidc ni ydeaedl dwonu aghn,iel rspeeupssd umnmi,ity lmea hgpnoysd,amio rsaededce ultda hira lalrixya,( fc,aali )pc,bui uyegsi,sda mia,naos raetricotadsmmi ctheterniaapo tece(df ni tietslnain nciz ona,r)tisopb dan mya prspesiode to lihlcoaoc c.sirrohis AF di'tdn pyiscef hte lelvse in hte ,mesne tbu erp eht lweob tarclei, nmlasei zcni notectn asw nuofd to ahve ron ornrceltoai ot emse/nrmeps .itacevteyc/elvtli/ I odtn' kwno fi e'rew opsdesup ot nkwo tta,h tub wno I od, l.lo wm/p.lvc/.ww/t03mih537bu5.7psen.nb:i/onghtd.

sA ogxrnyhbu mit,ndeeon ilmneuels is lnyo inoedtenm ncoe in FA sa a nemtttear orf a,ntei so I leoodk iont it hueft.rr nemiuSel is a netotnc of emne,s but eesllv yrav so cmhu atht ti eesvsr on igoprocnts cnclila ervaleenc to yntitflieri, rpe tshi :rciltae n023mh..tc2tuhe.d.nivp/w:ob3m/wis5bpn1/gwl/.

oT luer otu all fo het sawerns sbe(ceua I ddi'tn aeyllr nkow gnaityhn tbuao het uyltqai of n,sm)ee I onfdu shti "By s,tt-taictsis teerh asw on tnisfiangci iceenfrfde in eth eemsn Na oanrccneottni ngamo het nfdftriee sorpgu 7( osrgpu tlato ebasd no emspr uo,c)nt igndtaiicn eth nigsantiicinf oelr fo Na in sprme o.ltti."yim hem17ppwntdib/2v.:5shmntn.obgiwuc//.w2/1.l.

Fyina,ll I otnd' ktihn hte -aalhp5 cuteeasdr zyemen si alycualt in ,esemn tbu I olcud eb .rnwog Eerthi ayw, ti tlon'uwd eb onyralambl eatldvee or owl fi eht enertsosetto levesl are .molarn

bartolomoose  as per goljan, selenium is involved in glutathione peroxidase +
chandlerbas  selenium has a role in glutathione peroxidase. excess selenium = garlic breath, hair loss, and nail changes, might see peripheral neuropathy. deficiency (pt on TPN) = dilated cardiomyopathy +
chandlerbas  also zinc aids in sperm motility https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773819/ thats why i chose zinc but whateverrr im over it +

 -1  (nbme21#41)
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fI oyu lsgreugt itwh moeBich dan h'teanv eahrd fo oMof yt,rvUneisir I uwdlo ihylhg eromnmced cnkgehic it t.uo heT obelw iooftminran I tog rmof sith :ideov --/6mro/keots-e-r3mclln8ctsmiohu-tcsaos-xasrpstusaiucvfoeri/ndpyiuoimh--eneoi/auebtftr/eyhsr4epe-ac6c-ts/rs.ctpyprprheodm.ot/l1mi:paeo-raaasss93y dna st'i ge.rat

oaripyrPh antcaeu adart = AD atotumni of egiohrpnrnropyuo resx,loadebcay tish si het MCC fo rypirpa,oh nda ti terpsnse ni 40-s50.s

Mnia ommpyts fo sviesoyithoitntp eglidna ot isnk i/lsebslrnas/ioseltuelb ued ot isnk grnyiprhopseno giben diixezod yb ghlti to prhypsrnoi thta aegdma het nsik, dan ehtor skni idisnngf of hiyro/heppiiryashrttnm.onegseipct

A yke eruetaf is blpeoiss vlrei spblorem eud to ssdcaetoia nigirtapiecpt rtcs.ofa CMC aecppttiingir sroftca = secxievse OHEt adn sPCO ceueabs fo P04Y5C siurcden regnucid umrse meeh elelsv ot eb ilzuidte ni het wne 5P0C4Y smeney,z htus tiuialstnmg ALA hstesyna ude ot dcerseeda heme .iioihnbtni tOehr rppiaitteginc tcaofrs luceind alvir its,hipeta yaipelecsl spiietath ,C adn sxseec rino sa ni osm.csmhaoterioh Tseeh can dela ot leteavde AST adn ALT .veslel

reAtonh nsig si akrd r"otw-ni"pe oolerdc iurne chwih npik crsoelfseu udern dWoo hig.tl sebtnA pytsmosm = iaamondbl npai dan CNS lepomsrb ecbsuea AAL nad PBG od tno tecla.aumuc aluAemudctc uocsdrpt = piroournyphr III, iprnprnegoroouyh II,I opnrpryrohui ,I dna rerurnpyhopigoon .I

eTtetarmn = usn repsxuoe v,oicanaed rmeoavl of rcietitnagipp far,cost mteyoboplh, hienloourqc chiwh( can bnid and dale ot rotneciex fo icuusa.lm)antoc rsiosongP = enle.xeclt


 +8  (nbme21#47)
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geeePrdi = DXL tno( lla gnretnoaise cedetffa = kn,leXi-d fseatcf lsmae nda fmseael alirmylsi = .dtao)nnim

fcAdfete rhftaes = 00%1 siamnnitsrso ot ragsedhu,t 0% ninrsmiatsos ot osn.s
cef deAft smtehor = 50% ot r,getudhas %05 astssonirnmi to sstn o.hBo astnerp aedeffct = 10%0 anionsitsmrs ot agurthsde du(e to s'rfahte X me)omrco,sho %50 smaisnsrtino ot noss edu( to se'mhort X rt)ohBchoemo o.sm rsatpne fdtfceae chae ttnrinmstaig tboh ot edgtuhar (uhmysozogo udaeh)gtr = 5%0 nda mroe e.esrev

If onoiindct is nlruiofym ftlaa ot eamls in ueot,r hnte teh %05 tcfadefe dbesa on tmnronisias s(a vbo)ea lliw die in reuot, and eth 50% otn ecftdaef llwi vaeh ilev i.htsrb hiTs esa,nm srki fo meeafl ibgen dcteafef = 5%0 adn ksri fo bovenr-li esmla bnegi efeaftdc = .%0

divakhan  I believe its not XLD, had it been there would still be 25% chance of males to be normal according to the Punnett square. (FA 2020 Page 59. +
divakhan  ^ 50% chance of being normal.. which is NOT in the answer, it said 0% chance in males! +
divakhan  Plus you'd see disease in EVERY generation if it was Dominant. For it to be XLD, the father I,1 would have transmitted it to his daughter. Instead the parents are carrier in Gen I. so its XLR disease (II, 3 being a homozygous XLR female) +
plzhelp123  This is X-linked dominant (think Rett syndrome), if it were x-linked recessive, a female would need to have 2 affected x chromosomes to be symptomatic, which would mean her father would HAVE to be symptomatic as he has only one X chromosome, which is impossible as he would have perished in-utero. The reason the answer is 0 in males is because the question asks specifically about live-born males. If it had asked what is the risk of the fetus being affected then it would be 50% in males (but that 50% would not survive to birth) +2

 +0  (nbme20#7)
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eDos annoye nkow hte nignisfaiecc of otocenym oiyt?mlit


 +11  (nbme20#28)
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Tish lpanesxi ti ellyra elwl wtih a eitrc:up /tuAnweam0w/dhs/le..//lotaf.2asstliPtm1mighdlwhlos/tpt.pi:Aahyotl.

yocdripH chgaen = noe of hte aerly nsisg of lelcualr eingnreatedo ni eonsepsr to uinrjy htat ssetrlu ni mlnocauituca of rewat ni het lc.el mHaoipacsiyi/xeh ealds ot seeacde ni iboecar rriitaspone in hte hocniratdiom adn recdeasde ATP orpndtoicu due ot efialru fo hte ++K/Na saPTeA gideanl to N+a dna atwer ifusodinf nito teh e.llc iidlvnuadI uetbul llsce arpepa olwslne nad p"tey"m ihtw moaslt uceocdld ,nmuel sugeluorml is lhrecallp.yrue

dickass  it's basically from pathoma chapter 1: cellular injury causes swelling +5
md_caffeiner  @dickass you why arent you on every q stem? +1
mangotango  do you mean "causing failure of the Na+/K+ ATPase" instead of "due to failure of Na+/K+ ATPase..." ? The low ATP is due to dec aerobic respiration, I believe. +1
fatboyslim  @Mangotango yes exactly. Na/K ATPase stops working due to the lack of ATP. I think nwinkelmann mixed it up +




Subcomments ...

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rAi dan fduli = yt.hdoeaoxmurnorhp If htat ulfdi si bdloo /ps( )ib,nbgtas i’st a uareommonopxhte.h aLkc fo aateiilmdsn tsihf cisietdna taht sit’ otn dnrue isot.nen

d_holles  @benwhite_dotcom how can it not be under tension if air is entering the pleural cavity? +1  
nwinkelmann  Because the stab wound isn't functioning like a flap, meaning the air can escape. The reason a tension pneumothorax occurs is because the wound acts as a flap, where on inspiration it is open and air enters, but on expiration is closes and traps the air. +10  
groovygrinch  Also if there was tension, there would be a mediastinal shift. +11  
t123  Also the gastric bubble is elevated, actually suggesting lower pressure. Mediastinum shifts require more pressure, but the gastric bubble confirms it. +1  
myoclonictonicbionic  I was overthinking and thought they're implying that the stomach bubble is the air-food level that was seen on the Xray. +3  
cheesetouch  umm air-fluid*^ lol +1  


submitted by radshopeful(17),
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eTh csilacs dsie fcetfe fo rnniacelyhacts si addietl yo.rhdyoicmtpaa iTsh iqstoneu loudc hvea tntego tyckir if uoy uhhotgt teh pyanoulmr smmyostp rwee due to the ugdr cihwh could ahve dle yuo ot ileonmycb uace(ss oayrlnupm isoisfrb) tub heste omnapruyl sommsypt erwe otsm elliky a rtlseu fo ieatdld romydcaayitohp agdinle ot FH nad lpynamoru de.eam

nwinkelmann  What is the clue that this is not pulmonary fibrosis? How do I decide between Doxorubicin and Bleomycin? +  
ilikecheese  Also both bleomycin and methotrexate cause pulmonary fibrosis, so that helped me rule both those out and focus on the HF instead of the pulmonary symptoms +4  
adisdiadochokinetic  The S3 gallop and enlarged heart together are very strong evidence for heart failure. It's much more likely for heart failure to cause interstitial edema than for pulmonary fibrosis to directly cause heart failure. +8  
jurrutia  Also pulmonary fibrosis would more likely cause right-sided HF. This patient has left-sided HF (orthopnea, crackles, pulm edema.) +  


submitted by colonelred_(99),
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deoLok ti pu dna ufodn ttah uaecebs uroey’ ni a eipsun iiopsotn ofr a lgon item uroy’e ognig to vhae adrsiecne senovu rtrune hwich sdela to iserdneac .CO hiTs igeyltevna afkdbsece no ,RAAS dngelai ot seedracde rtos.oneedal As a ,rseltu yuoe’r niggo to evah niesecrda iuirssed cwhih asedl ot cderdeesa bodlo nad slmapa eoulvm.

medstruggle  Doesn’t supine position compress IVC leading to decreased venous return? (This is the pathophys of supine hypotension syndrome.) There was a UWorld questions about this ... +4  
tea-cats-biscuits  @medstruggle *Supine position* decreases blood pooling in the legs and decreases the effect of gravity. *Supine hypotension syndrome*, on the other hand, seems specific to a pregnant female, since the gravid uterus will compress the IVC; in an average pt, there wouldn’t be the same postural compression. +8  
welpdedelp  this was the exact same reasoning I used, but I thought the RAAS would inactivate which would lead to less aldosterone and less sodium retention +3  
yotsubato  You gotta be preggers to compress your IVC +5  
nwinkelmann  Could you also think of it in a purely "rest/digest" vs "fight/fright/flight" response, i.e. you're PNS is active, so your HR and subsequently your CO is less? But the explanation given above does make sense. Also because I think just saying someone is one bed rest leaves a lot up for interpretation, maybe not with this patient because his pelvis is broken, but lots of people on bed rest aren't lying flat.... ? +1  
urachus  wouldnt low aldosterone cause low plasma sodium? choice B +5  
kpjk  could it be that, while low aldosterone levels decrease plasma sodium levels- there is also decrease in blood volume(plasma),so there wont be a decrease in the "concentration" of sodium +4  
almondbreeze  FA 2019 pg 306 on Lt heart failure induced orthopnea - Shortness of breath when supine: increased venous return from redistribution of blood +  
almondbreeze  if there was no HF, it would lead to increased CO --> decreased aldosterone +  
theunscrambler  @peqmd thanks for sharing that. According to the presentation, the diuresis via ANP occurs (along with sodium), which is followed up by an increased in RAAS --> maintains sodium levels. This cycle can then continue. Slide 13. +  


submitted by neonem(556),
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nagFlli no recsehutdtto a:dhn sphdocai si stmo mnoocm neo to eb uafe,rdctr eulnat is otms nmomco ot be adldtciseo. atnLeu aosiotldinc can cesua aetcu plaacr tlennu ny.smored

hTkni fo the nieommnc i"tthagSr iLen To kPyn,i eHer msoCe ehT m"Tbuh for eht noesb fo teh pmla, grwnida a ablftolo hsepa trgsitan lweob eth utmbh CMP njtoi ncdaetaj to hte aus,rid thne ogmivn to rouy ladeim rs,tiw nda enht back ot eth tmh.bu

,Soaphicd utanl,e tutq,remriu i,firsopm aetamh, ,iatpetca ,ieztoaprd ezpaumirt. hTe tlenua ooskl eilk sit' rieostoyprl dcitsdeaol hee.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. +  


submitted by cocoxaurus(56),
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TBU why si het msuer aotpumsis rao?mln

I aws elab to nwrroa ti nwdo ot RT,A usbacee neno of the terho weasnr eiccohs aedm hcmu ne,ess btu the oisastump dah me ceosnd ugensgis .esymlf naC eoosmne npexila thta lba fginndi? khnT!sa

subclaviansteele  My take is that hes not super acidotic and the K is at the low end. +  
nwinkelmann  see the comment by @zbird, which explains that the urine anion gap is important (which I took to interpret as more important than the serum K+ level, lol, because the normal K threw me off too). +  


submitted by sattanki(69),
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eehrT are wot nmchismaes of tlnaruigeg anrel bolod ow,lf eth ienmogyc nismcahem nad bteoluoalulumrr-g ad.kebecf hiTs ieusotnq sksa puylre toaub teh egnicomy ihsn,mecma hichw is hwree eht erfnfeat aielrotre tsnloocr ldoob wolf sbead uyprle off lobod prersuse itengnre eth nkei,yd chiwh is why eresdceda feteafrn irerlratao stsrecinae is eth etsb wearns he(t leratoier si iaglditn ni esopresn ot the decseeadr doobl ofwl ni aptetmt ot nnamaiit rolnam bolod wolf to hte )deiyk.n

nwinkelmann  Man... I took this WAY TOO FAR, lol. I totally didn't recognize the clue of GFR and RPF as staying the same to tell me it was talking about normal, physiologic autoregulation. Silly mistake! +5  
j44n  I agree. All I saw was a stenosed artery and ATII constriction +  


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..g.Uh got edrppti up htiw Refe"r thob aneittp nda erh erstapn ot a i"iatnedic

vrOe .i.ntI.hgkin hhgotut het souerc fo hreti emgrusant weer at male miest seei.y..plsoacl bayem etyh anc nfdi a ogdo nstoioul iwht a eicdnti.ia

MAsCOC ZORRA IHST IHT.S kepe it mpiles ui.tpsd ehT nawser sift teh setb erfat er dgernia .ti

nwinkelmann  SAME.... ugh! +  
johnson  Also - you're almost NEVER referring/passing on a patient with the USMLE. +8  
bmd12  They are at meal times, which is why she's having difficulty following the prescribed diet bc her parents are arguing during that time so its difficult for her to correctly execute it when theyre constantly bickering, and bc she's only 13 so she cant effectively manage her diet without the help of her parents. And since the diet has been working with the patient prior to all the bickering, you can assume the diet is not the root cause. +1  
jamaicabliz  the universal constants: Death, Taxes, and never consulting the ethics committee +  


submitted by mousie(211),
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oiolngk ckab ta stih Q I eiontc hatt the petitan osla has nhnyirsetepo dl.c.o.u ttah vahe nbee a lceu to idlcune the MAS bc its os olsec ot the rnale trieesra eRa(nl a ?sinsose)t

nwinkelmann  I didn't know how to approach this either, but now this is my thought process: Patient has pain after eating. If it's not due to an ulcer (which is the only thing I could come up with because I didn't know what else it was talking about), why would eating cause pain? Well... eating causes increased GIT activity which means increased blood flow. As you pointed out, the patient has HTN and CAD, indicating likely extensive atherosclerosis. This is important because why would eating leading to increased blood flow cause pain, when usually it doesn't? Well... atherosclerosis in the heart leads to stable angina. This presentation sounds like a "stable angina" of the abdomen. +  


submitted by sajaqua1(524),
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hTe wmaror wshos ssruorrecp to sroehrye,yctt as elwl sa oamcaerye.tkysg hisT si ot ohws oyu hatt the esusi its'n ,puruorcdtoenind hhicw msnea that ew are lsogni BCR dan atptllees oeehmeswr ie otidents.ruc aTth suler uot D dna .E eerTh is nnhtogi to tediicna hat hte cdihl sah meieasdsintd cbruielossut ()B. tA this nipot we era tfle with A or C. A uwodl ndtieaic tsdieensamDi trvlarIcunsaa nuloaCitoag C(DI) ro sietnomhg ir,salim hiwch uowdl teslru ni owl plestetal dna BRC tbu we olwdu osal see nomblaar BCR lkei icshtoytsesc hmel("et" sl)lce. eW ear iyelcpxlti told htat the retrthoecyys rea ocrrmoiocmhn dan ortncocmyi. H,vrwoee umemni stcidtnroeu of alletstep sexnlaip it lal- hte ttredsinuoc fo easetltlp esdal ot osem nmgorhaiehrg adn os a pdor ni CR,B adn TPI cacllaylsis esasri aftre a entcre ruppe ryirsaeortp atcrt ivlra oitfinn.ec

meningitis  Just in case anyone is wondering like I did, the low platelet count explains thethose multinucleated cells. They are Megakaryocytes in Bone Marrow Biopsy. +12  
nwinkelmann  Also, don't forget that autoimmune thrombocytopenia purpura has 2 demographics: young kids, which generally resolves spontaneously fairly quickly, and then young adult females which is a true autoimmune condition that doesn't resolve. Patient's age + thrombocytopenia + essentially normal rest of heme pannel = autoimmune thrombocytopenia purprua in child. +6  
abhishek021196  That is exactly how I approached this question. Normal heme panel and a decreased Platelet count in a young boy after an infection just made me intuitively select ITP. +  


submitted by welpdedelp(219),
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/32 1/25 1/4

eH ash a 2/3 ceanch fo egibn utrhogeesyzo not( /24 /cb ew owkn eh for usre td'ones vhea C)F

215/ chance ni eht itluppnoao

41/ nhacec of a soetegyhourz lcepuo naighv a ilhdc ihtw FC

welpdedelp  ok, so it messed up the formatting 0.66667 x 1/25 x 0.25 +  
nwinkelmann  ugh... I ALWAYS forget about changing the carrier status to 2/3. Chance of affected individual = chance of father passing allele * chance of mother passing allele = 2/31/21/25*1/2 = 2/300 = 1/150. +1  
zpatel  2/3(chance of heterozygous) * 1/25(meet carrier) * 1/2(chance of male to transfer affected gen) * 1/2(female to transfer affected gen) = 1/150 +3  


submitted by wonderboyg(10),
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tihs astnet'ip urtuse aws saernecdi in zies pecaromd ot a 12 eewk turse.u esh hda raegp ekli tcrtsrusue adn on se.uft iths owdlu inaiecdt a taihdoyfrdmi ml.oe htsi itpaetn saol dah no eaflt stpra os it odluw eb a epltomce l.meo

gndoaircc to aathmop, a dyifrmhoadti elmo si an lam"noarb ionpcenoct dcezharrtciea yb onslwle dna semdteaou liivl hwti pnlrfretiiaoo fo lrboosat"psth

oasl ni a mcteloep lm,eo osmt illiv rae hrypodci nad pbtothrlosas lilw rtofiaeerpl fislyuefd nrdoua ethse corihdyn livi.l

het ihtseklee esmsas of nsoyiahlposstyrtocbt ouwdl cieintad a moaociacnrrcih.o

nwinkelmann  Also, ball like masses of proliferating decidua, I think, means ectopic decidua, which can be seen in endometriosis, deciduocervicitis, and in the lymph nodes. Markedly dilated fetal blood vessels can be seen in rare complication of placentomegaly which could potentially lead to IUGR but could also result in a normal neonate. +5  
yb_26  @nwinkelmann no, ball-like masses of proliferating decidua are seen in endometrial papillary syncytial change +15  


submitted by sajaqua1(524),
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acilrtiC tnopis fro sthi n:uiqesto 5 year lod yob, mueronmpssuidspe ascbeue fo homehtyc,eapr 2 yda ishroyt of ,fveer uh,cog oerssthns of bhe,art fbelrei 811.(0 F), oapsrtnsriie nim/46, ithw scsniyao nda aniglderzee crsauivel hs.ra itxveEsne odnrlau fiaiil.tnntro

Of teh otoinps dielts lyno aeesmsl dna VZV ievg a sarh. A rhas orfm mleasse auuylsl rtatss otalyrrsl and nseecdsd auya,dcll and si ftal nda mh.eayosrteut yB ca,stotnr VZV iexhk)conc(p rseesptn wiht eeezaligrnd hsar htta lyukqci sitoatrnisn ofrm clmuara ot appurla hnte to .liasvruce

sympathetikey  Good call. +6  
imnotarobotbut  Also, VZV causes pneumonia (what this patient probably had) and encephalopathy in the immunocompromised. +5  
nwinkelmann  What threw me off was that it didn't mention the synchronicity of the rash. I stupidly took failure to mention to mean that the rash was synchronous, which doesn't fit VZV because chickenpox rash is characterized as a dyssynchronous rash (i.e. all stages of the macule to papule to vesicle to ulceration are seen at the same time). MUST REMEMBER: don't add information not given! +5  
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +2  


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The itgnh ,si het itnaopcshamil cttra ceossrs 2 blateevrr slevel up nad ethn staecsedsu at the tieanrro wehti usoerismmc ot egt frmo eht tgrih ot eht ,tfel so ohw od I know wichh traleerbv elvle 'Id eb kgorwni on ihts ugy?

chris07  I think the assumption here is that we are dealing with the cord section at the level of the problem. The picture is incredibly misleading. You have to orient yourself. The dorsal columns F, E, A, B are facing the patient's posterior. Once you properly orient it in 3D space, you know that what's labeled "right" is actually the patient's left, and what's labeled "left" is his right side. Super confusing. +2  
sne  The input arises in a limb/part of body at the level of lesion, enters through the dorsal root (pictured between A and B), decussates and ascends at the anterior commissure, and finally synapses on the second order neuron in the lateral spinothalamic tract. So the spinothalamic tract is responsible for contralateral pain and temperature sensation. So AT THE LEVEL technically would be in the dorsal column +11  
nwinkelmann  also, @chris07, I think you're wrong about the labels being wrong on the image. Becuase the spinothalamic tract = contralateral pain and temperature, and the patient's pain is on the right side, you would want to target the left spinothalamic tract for pain relief, i.e. the area labeled H. The area labeled D would be the right spinothalamic, purely because that is how the image is labeled. If you assume the label is different, you will get it wrong. +11  
kpjk  @sne I don't think entering from the dorsal root would be between A and B. It would be part of the gray matter so, lateral to B and F +2  


submitted by nlkrueger(43),
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.... wulod ew yralle aekt het wrdo of a nfirde hwo lidfineyte ntca' eb eoin?cdfrm I efle ikel isht si isniedlgam

lispectedwumbologist  All the other answer choices make you come across as an asshole. Easy way to ace ethics questions is to just not be an asshole +9  
seagull  I would be a bigger asshole when the family came I'n after I pulled the plug...opps...but the friend said +29  
dr.xx  The patient has no wife, children, or close relatives... +3  
nwinkelmann  @lispectedwumbologist this is going to be my technique, because I've gotten a couple of these wrong, but I completely agree with everyone else's sentiments of suspicion of going off what a friend said without any confirmation about state of advance directives, etc. It's really dumb. +3  
paulkarr  With these questions; you have to take what NBME says at face value. If it says no family, he really does have no family. This friend is also claiming that the 78 y/o said this about himself, so we know it's the patients wishes rather than someone else's wishes for him. (A son saying he can't let go of his father yet despite the patient's DNR type of situation). +1  
suckitnbme  I think the point here isn't that we would take the patient off the ventilator because the friend said so. The answer is saying "Thank you for your input, we will take that into consideration." It's completely non-committal. +7  
vivijujubebe  they say no close relatives, which means he could have remote relatives, relatives must be asked before listening to a stranger/friend's words..... +  


submitted by dr.xx(144),
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tmeanertT of ucaet gtuyo Srretvlareistia h dsrug ear ffieevetc ofr meiatgntrin het tcaeu tougy ta.catk ,hneccoClii nisendltoaor ltaf-ionarnytmmia rgdsu sID)N,(AS adn rcottrssodeiico rea astnardd hsoa.pcreap coirtotcncooeprrAid remnooh ()THAC is alos ervy efc,eetfvi utb ash beeocm nncayilrgise csreac or too psveexein to eb a cpitrclaa atirtevnlea in hte US. aesedgRsrl of the aplrtiaruc taegn seo,nch eth ronseo etesh udsgr rea t,edrsat eth omre rpadi het sonerp.se If a nitpeta aotnnc eatk SIAsDN ro lihoi,nccec het eccioh is amogn ,ralo atualac-irirntr ro ratlaeprne ioiot.scccogrldu Lloca iaplpitnaoc of cie apcks amy pleh colontr .pian In osem acsse, ilcanessa,g lgiunidcn opsodi,i may be .ddaed

ruDgs htta afftce mrues rteau eortinctnscaon G..E(, )P,OARLLUNOIL iglidncnu yiirtriacnmuhecpe as,ntge osdulh ton be dgec,anh rdatest, or epposdt ndgiru an catt,ka as tsih aym oernws eth mafyitnlrmao esnsrpeo ydalear ni rseo.rspg

sh.h/tmn/w.a92g15it/w/l.li3eoi6tvnwc3s/Mpmbcn/:Cr.cpP

nwinkelmann  Love the last quote/sentence from the article! So helpful for clinical decision making! +  


submitted by mcl(586),
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nI caes uyo aannw og srepu nred dan rdae uoabt nly,eim caaiatecn,pc and ars,isentce htis uyg sedo a odgo ojb.

nwinkelmann  This really helped me, at least the pictures did. Here's my interpretation of the pictures in not super scientific terms: capacitance is like the "capaciy" to keep ions close to the membrane. Myelin puts a barrier between the ions in the conductive environment (ECF or ICF) and the nerve membrane. The higher the capacitance, the closer the ions are to the membrane, so it's like the charge effect is "more potent" so harder to change the membrane potentia, whereas if the ions are farther from the membrane, the charge effect is "less potent" so easier to change the membrane potential and thus easier to depolarize. Thus, with myelin, there is decreased capacity of the ions to be close to the membrane, so in demyelinating conditions, the ions can be really close to the membrane, i.e. higher capacitance. +21  
sweetmed  this helped a lot! +  
roaaaj  Well explained! +  
euchromatin69  or see u world 917 same concept +  
brise  Uworld 1318*** +  


submitted by joker4eva76(25),
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hisT is isanptreetveer of ekoall,uakpi a nporeesua-rcc ilonse of suamuoqs sle.cl In rdreo ofr it ot pdsrae ot daisntt t,seis ti sutm rfits eniavd orhtguh teh nbesatem rsamu.a/ebnobesmmuc lCdou be doneucsf whit arol yhira oealkplkiau ihhwc( oasl si a tewih chpta atht asclalcylis saiser no eth aaltlre no)gt.eu ,vreoewH alro hyiar aoaiklepulk is ont cr-eonparsecu nad si etofn eiasctsaod iwth EBV itsnioecnf ro oeelpp tath ear eesvryel pommiidnorescomum.

hpkrazydesi  How did you know that this wasnt oral hairy leukoplakia? just from the picture? +2  
nwinkelmann  To piggyback off of @hpkrazydesi, you ruled out oral hairy leukoplakia because the patient was seeing the doctor for normal health maintenance, i.e. not immunocompromised, I'm assuming. +2  
dentist  @nwinkelmann thats correct! my time to shine. +  


submitted by hayayah(1057),
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X ni eth egima is eht llams .ttniinese tIs rtteccacaisrih yefearth prpeeancaa eraft a iabumr mlea is eud ot erenmtpan ucraicrl dsofl dna iiv.ll ehT liivl iveg eth malsl tensitnie a agert oulcsam cfaesur a.rae

nwinkelmann  Yes. The appearance of the mucosal folds depends upon the diameter of the bowel, and when they fold they appear feathery. Mucosal folds are largest and most numerous in the jejunum and tend to disappear in the lower part of the ileum. +  


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yWh si sthi tno escrienda ibngndi fo ADN aeoplsr?yem

hTsi ainumtto dslouh ecusa ulrlcael sovndiii ie DAN tnpeicoiral nad asuec aisnceerd bdingni ot niirgo inirtolpaec eesucsqne ei TAAT by DNA eleyapsrm.o

brise  It's talking about mutations on the transcription of genes that inhibit the cell division. Also RNA polymerase binds to the promoter region. +  
nwinkelmann  Also, the question specifically (though in a very wordy, convoluted way) asked what the effect of the mutation on transcription was. DNA pol is not used in transcription, it is used in replication. RNA pol is used in transcription. In terms of increased or decreased binding, argining is polar/positively charged and proline is neutral/nonpolar, so there are fewer H-bonding sites, and thus decreased binding of the RNA pol. +1  
medn00b  Could this convoluted question also mean.......... that since the gene to make p53 is messed up due to the hydrogen bonds, RNA polymerase will not be able to bind to make the mRNA ... So there will be cancer? Because P53 is a tumor suppressor... lemme know thanks guys +  


submitted by keycompany(301),
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dginaLo oDse si hte onyl aesrwn ahtt si ddennteepni of dgru lear.nceca

nwinkelmann  I totally get this and understand it... but at the same time, couldn't loading dose differ due to renal function if patient has nephrotic syndrome so had less plasma proteins, because it would change the Vd of the drug, right? Per wiki: Volume of distribution may be increased by renal failure (due to fluid retention) and liver failure (due to altered body fluid and plasma protein binding). Conversely it may be decreased in dehydration. +  


submitted by just_1more(0),
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I gto that ti ededne to eb a otapssumi sriagpn rdu.citie sI rtehe a reanso ti nntoca eb na eeooanrltsd oga?ttsnnai I sehco bclsok eaaaobtlrls +K ahelnnsc sa eehst aeeercsd hte btrolseaala +aA/a/ePKT+Ns cseubea the irdogwn of the cerrcto rswnea did ont kmae ssnee to me -- gamniuss ehyt erew niogg rfo an NEaC lkcroeb nda( htat ceeesaddr nmalilu brietailmpey etcsidnia atht a+N wolud be imrnegnai in eht e,unml tno giianmnre in hte pariicnpl clle sa I alinoyglir )t.gutohh

luckeroo  I think the reason it’s a potassium-sparing diuretic rather than an aldosterone antagonist has less to do with why the aldosterone antagonist cannot be used and more to do with the fact that a potassium-sparing diuretic would be more of a “first-line” adjunctive diuretic treatment. +1  
luckeroo  As for the answer choice, potassium sparing diuretics achieve their overall anti-aldosterone effect by competitively inhibiting aldosterone receptors on the interstitial side (decreasing the Na/K-ATPase effect of shunting Na into the blood), thereby decreasing the gradient for sodium to enter the cell from the luminal aspect, blocking ENaC. +8  
yotsubato  There is no such thing as "Basolateral K Channel" there is only basolateral Sodium Potassium Pumps which are controlled by aldosterone. FA pg 573 +9  
nwinkelmann  @yotsubato LOL.... why didn't I think of it that what?! (by the way, that LOL is for me). The only basolateral K channel is the nephron (based on the first aid picture) is in the thick ascending limb of the loop of henle. +  
hello  Spironolactone and eplerenone are potassium-sparing diurectics that inhibit the Na/K ATPase, so I'm not sure what @luckeroo is referring to. Spironolactone and aplerenone are both ALDO antagonists. Na/K ATPase is found on the basolateral membrane. None of the answer choices fit with this. Amiloride and triamterene are also potassium-sparing diuretics; their mechanism is to block ENaC channels on the luminal membrane, this is choice "B." +1  
rxfit  From Katzung Board Review: "Spironolactone and eplerenone are steroid derivatives and act as pharmacologic antagonists of aldosterone in the collecting tubules. By combining with and blocking the intracellular aldosterone receptor, these drugs reduce the expression of genes that code for the epithelial sodium ion channel (ENaC) and Na+/K+ ATPase. Amiloride and triamterene act by blocking the ENaC sodium channels (Figure 15–5). (These drugs do not block INa channels in excitable membranes.) Spironolactone and eplerenone have slow onsets and offsets of action (24–72 h). Amiloride and triamterene have durations of action of 12–24 h." So both K-sparing subtypes are technically correct. +  


submitted by seagull(1443),
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yhW easunnopos?t 'seH nggagnei in na vietac pstro twhi na ieracsned srik fo mtcraaTiu iunj.ry So we lelary tusj sameus seh tno djneuri cabeues eth semt ednsot cdyerilt asy s'eh ?rnijdeu eesTh sueqosnit elad ot oot mnay oansisumsp.t in( my in)ponio

nc1992  Spontaneous pneumothorax, as a condition, is significantly more likely than a traumatic pneumothorax from just about anything but a car crash (ok maybe if he was in a fight). The car crash or a stabbing is also more probable overall but there's no point in inferring something that isn't provided +1  
nwinkelmann  I picked the traumatic injury also. After reading these comments I looked into it further. Traumatic pneumos occur because of blunt or penetrating chest trauma, and I found that the MCC form of blunt trauma (>70%) is motor vehicle acidents that cause significant trauma (i.e. rib fractures) or even blast trauma. Although it didn't say there were no chest wall fractures, at the same time it didn't indicate any rib fractures, which would be most like to cause the traumatic injury pneumo in the patient's case. +1  
drdoom  The stem makes no mention of trauma. +  
hyperfukus  i guess the issue is that you have to assume what they mean by "strongest predisposing risk factor for this patient's condition" I think this is dumb bc the answer is completely different based on what you consider this patient's "CONDITION" to be? either way he has a pneumothorax so if you wan to know what caused that its prob him being active or bumping into someone but if you consider the etiology of the pneumothorax then its the bleb and that is from him being a skinny dude/smoker i went to this b/c he's also only 5/10 that's not tall in my head they could have been nicer and made him 6'1 at least...also i feel like i saw a lot of q's back in the day when i first learned this with a presentation of the person like tripping or something dumb but they already had the bleb and then got the pneumothorax +  


submitted by d_holles(173),
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ihsT oteinsuq ocfesnud me cb I ghtutho eilrepamod olduc otn scsro the BBB nda oerfrhete oludc nto acesu ryieapotsrr nediospesr pd(muo-oii soingma at the ienmrtbsa lsuetrs in /trCpsoriSyaerN rpnseosedi, 1). tBu xdxr.@ si ocetrrc in gnoint atht ↓ RR and CSN snpidersoe ni teh tP uosdlh lcla rfo na omopuidi- sanatngtio rhreat nath bhohancelt (iolciemchomnti) ot tetra p.nstctioniao

  1. e/cp?hn.proqaa.:.h5gtes2ab5aso9lgs07orxsie=.iyetc6it/stlpsharul/atid
nwinkelmann  http://medresearch.in/index.php/IJPR/article/view/782/1271 This explains a case in an infant. "Respiratory depression and coma after overdosage have been shown to be reversible by injection of naloxone [6]. Owing to its structural similarity to opioid, loperamide toxicity can be reversed by using Nalaxone which is a specific opioid antagonist acts competitively at opioid receptors. Naloxone hydrochloride is usually given intravenously for a rapid onset of action which occurs within 2 minutes." +3  
yb_26  FA 2019: "Loperamide has poor CNS penetration" - so it still penetrates => can cause respiratory depression +4  
whoissaad  Also maybe because the blood brain barrier in a baby is not developed as well as in an adult. +4  


submitted by drdoom(819),
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resHe’ arnetho eryv ecni oen atth ssiuoeepsmrp het twphaya tnoo a slipidefim netirsabm diangrw c(ien fro hte aaocimlatn rleot)s:ina

Fh2thp/s:e/aoc-/bNuu-dRImheirsueOt-G.//2/.cwoiyefptso5g2payL.wns.eegeeai

oSurce lic:rate

./autu2c.daseabyyheanh-scmg.tpihemteet-nio5oppefoehm2eee/lu/uhorhwwl/t.rasiotl:p/r

To ese neev e,rom ryt oelgog mgiea caeshr on “daeilm nniilodlguat uu:csiclasf”

a/t;u=p+sduwmsasoccebeimunlp:whit/qinli=stoadaf+otgolcm/c?hwsr.g&gmlaihcle.

endochondral1  what is A and B in this pic? i knew it was dorsal pons ipsilateral but i just didn't know what part that was on the pic? +  
nwinkelmann  A and B are the superior cerebellar peduncles.http://what-when-how.com/wp-content/uploads/2012/04/tmp15F2.jpg +  


submitted by shaydawn88(8),
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I lwodu hntki tenrsouiol vseonivl hte tmse lslce (tpye II ueetmc)soyn.p sI eht taitcn ebnstame bmrename teh snewar asceeub it tlsmii ?ardeps

aesalmon  I would also like to know if anyone can answer this question - I saw it as a Sattar "one day, one week, one month" kind of question. Its probably very simple but I still don't get it +  
bubbles  I posted a new comment explaining: basement membrane integrity is the strongest determinant of full fx recovery following pulmonary insult :) +5  
drdoom  You have to think about it this way: the basement membrane is the “scaffolding” on which [restorative] healing occurs. So, yes, stem cells (type II pneumocytes) would be involved in that healing process but they couldn’t restore the *normal* architecture (“no abnormalities”) without the ‘skeleton’ of the basement membrane telling them where to go, in what direction to grow, which way is “up”, etc. If the basement membrane is destroyed, you can still get healing, but it won’t be organized healing -- it’ll be *disorganized* healing, which does not appear as normal tissue. (Disorganized healing is better than no healing, but without a BM, the regenerating cells don’t have any “direction” and therefore can’t restore the normal architecture.) +8  
nwinkelmann  Yes, this a great summary to the post by @bubbles and the article he posted! Another way to think of the question is not, what causes repair, but what causes irreversible injury/fibrosis. That article explained an experiment that showed TGF-beta was necessary to initiate fibrosis, but if BM was intact and TGF-beta was removed, the fibrosis didn't persist, i.e. intact BM is protective against TGF-beta. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645241/ +  


submitted by drdoom(819),
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oYu ahev ot hkitn oubta ti tshi :way the nsmebtae emnarebm si eth fnaol”fisc“gd on hhwci ovrte]sitre[a aelginh cu.scor oS, esy, tems lcsle (ptey II eyoumntsecp) wldou be nivdloev in htat alhgien crpoess utb htye ncultod’ etesorr hte rnolma ueiecttahcrr n“(o tnibi)melrsoaa” huiottw teh ’ektle‘nso fo eth nebaesmt nbrmemea gllenit htem wehre ot ,go in twah rnteidcoi ot ,gowr which ayw is u“p,” .tec If eth smeetbna mrbaemne si oyters,ded you can tilsl egt nehgia,l tub it nwot’ eb digzraneo gliaenh -- lt’il eb aeiznogidsrd i,ehngal ihhcw osed tno epaarp sa manrol sets.iu gdiaienzsorD( enihlag si tbtree hant no ahlni,ge btu uttiowh a BM, hte trenarieegng lcsel dt’no vhae ayn nitroe“id”c and fheertero c’atn otrseer teh loanrm tcucheeirr.)ta

drdoom  by "restorative" i mean healing which restores the previous (and normal) tissue architecture. for that to happen, you need an intact basement membrane! +2  
nwinkelmann  Yes, this a great summary to the post by @bubbles and the article he posted! Another way to think of the question is not, what causes repair, but what causes irreversible injury/fibrosis. That article explained an experiment that showed TGF-beta was necessary to initiate fibrosis, but if BM was intact and TGF-beta was removed, the fibrosis didn't persist, i.e. intact BM is protective against TGF-beta. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645241/ +  


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hWy sawt’n eth aebtl uohnge ot edterimen levcpreane ni het aergeln uiptl?opnao

sacredazn  For the case control question, it’s taking that principle that you can’t use case control studies to calculate relative risk and applying it to prevalence. Basically with case control studies we start by saying okay, I’m going to find 200 people with sinusitis and 400 without. Then, you go back and look at the number exposed/unexposed and calculate the odds ratio. So you can’t use case controls to calculate prevalence because it all depends on how many cases you picked in the first place. Might make more sense to think about it with a rare cancer like craniopharyngioma or something- let’s say you chose 10 cases and 10 controls and wanted to look at how many people smoked. It wouldn’t make sense to then say the prevalance of craniopharyngioma is 10/20 = 50%. +20  
dr_trazobone69  Thank you, that makes a lot of sense! So we can use relative risk (cohort studies) to calculate prevalence? +  
sacredazn  @trazobone Hmm I think the wording would be key, you could use a prospective cohort to calculate incidence, but you wouldn’t be able to find prevalence of the gen population unless you had more info. I think the concept is that really to calculate prevalence you need a proper ecologic study looking at population-level data. The way it was worded in the question was tricky though lol since when has “cannot be determined from the info given” ever been a right answer. +5  
nwinkelmann  @sacredazn thank you! this was the best explanation to use the rare disease comparison. Made everything make so much sense and hopefully I'll actually just remember it now, instead of learning the factoid and failing to recall it all the time. +1  
hyperfukus  i guess this makes sense but i don't understand why we are asked to calculate it from tables like this then? is there more info in those? +  
hello  @hyperfukus The table was given because that a 22 table is typically what you do see regarding data for case-control studies. If the 22 table wasn't include, then literally everytone would pick Choice "E" as the correct answer b/c you can't calculate something without being provided numbers. The difference in including the data-table is that 1. again, you need to report a 22 table because that is typically what you will see regarding data for a case-control study and 2. by including the 22 table, it actually tests if the test-taker realized that the data in the 2*2 table does not help at all with calculating prevalence-- because case-control studies NEVER report on prevalence. +  


submitted by niboonsh(338),
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Cna nsemoeo alixpen hte ncifeerdfe etwneeb C. s(eearel of rsodte iorydht onhomer rmof a yhortdi dalgn alniirttfed yb cohpyyetsm)l dan .D Rasee(le fo oidyhrt hoormen ofmr a uamhoytpmlso hyrotid nag.dl

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  


submitted by someduck3(58),
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aFt lsouble mintsavi ear KD,E.,A, oS obth D ;am&p E cloud be serdecade in siht tp. tBu yuo eavh to nokw htta iiVnamt E yeccfdinei is ssacidoeat iwht yetialomenndi a± sha enbe sdetcoasai tihw ptroiesor omclnu ieo.nmiaentlyd oslA tiV E anc be inveg hiwt hlArmeize taneptis as it hslpe iwth fere s?lc.i.rdaa

aesalmon  I actually thought that the posterior column findings were likely due to B12 deficiency - "subactue combined degeneration", due to malabsorption, as we see in this pt (. Turns out vitamin E can also cause symptoms which look like subacute combined degeneration: https://www.ncbi.nlm.nih.gov/pubmed/9012278, as does Copper (TIL): https://www.ncbi.nlm.nih.gov/pubmed/15249607 +3  
jooceman739  Vitamin E deficiency causes posterior column findings and hemolytic anemia :) +5  
nwinkelmann  The way I think about it is that essentially, vitamin E is an anti-oxidant. Vitamin E deficiency = LOTS of oxidation, i.e. free radicals, which are toxic to most cells in the body (particularly myelination and RBCs). That's why it can be used with Alzheimer's patients. +3  
makinallkindzofgainz  Vitamin E presents like B12 deficiency but without megaloblastic anemia +  
kevin  B12 would also affect lateral corticospinal tracts, vit E doesn't to my knowledge (b12 deficiency would also present with hyperreflexia but E deficiency just romberg sign, loss of proprioception and touch, ataxia) +  


submitted by sacredazn(80),
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The ceptcon is a eovuloctdn yaw fo ikgasn if uyo nwek how JVD mcerontionaib wo,krs ihcwh si that ti si laaultyc an lpeemax fo ltgranei het DNA fo eht T/B mthlyeop.yc

rneouhSt lbot qecn:ethui So hwen hyet esu a pebor itsngaa seom ,reogin nda igtntptouu a izse of 5.1 bk ro 6 bk, sith si itlengl uoy hte esiz of eth ADN nmatrgef ni ehca lcel ’e(sndot eratmt fi yhet ysa J rpoeb ro tntcsona egrion bop,er ehy’rte jtsu agyisn trey’he gtaignret soem eucitlneod qseeeunc unodf in the Ig lTC/usRoc abte hnica oculs icreyvtslepe orf BT/ cle)ls.

I tkihn eht cnuonfsig artp dulco be ngwedroni how you wnko hrehwet y’uroe prtlya ruhgoht reenanragremt a(esnrw icoechs B urht D) or if it ahts’n urcrdoec at lla yte etrocc(r war.e)ns eHe,r eht pectonc si ttha B sclle douerng J)V(D rnarmtergeane ni eth nobe rwm,roa ihwle T ellcs do ti ni hte hym,ust and ti lla hsappen ta enoc. So a maapls ellc ni het dbool ekli in plultMie lMeaoym loudw aveh lylfu noerugden nirce,nmobiaot hewli a T lelc ni het bdloo cloud iteehr be yllfu uetecdda nad( aevh fisnhedi DJV ainbimtreno)oc or uiermatm ’tahns( rttsade VJD.)

ciSne het T ellc ngee swa 6 bk nda etidleynfi begrgi tanh teh 5.1 bk egen, eht T lecl ’tasnh engrnudeo ceirnotnoabim yte.

trichotillomaniac  very nice explanation! +27  
nwinkelmann  This was awesome! Made so much sense and hopefully I will be able to think that critically about questions in the future (because I NEVER would have come up with this on my own, hah). +4  
eacv  OMG! THANK YOU. I DIDNT KNOW ANYTHING about this!! Hope this is not testesd on real examen :p +4  
ajss  wow! this explanation was awesome! thanks! +  
mrglass  Also the T-cell V-D-J segments are not the same as the B-cell V-D-J segments. Therefore a B-cell J segment southern blot would look for whether the B-cell site VDJ segment in a T-cell, which would always non-rearranged. +6  
mynamejeff  Thank you! So is this because multiple myeloma produces excessive monoclonal light chain Ig? Is this the 1.5 kb gene? Whereas, T-cells that have not gone through differentiation yet and their J region includes everything (VDJ) vs. just VJ in the light chain? (FA 2020 pg 104) +  
peridot  This explanation is amazing! However, to fully understand another step of what the question is getting at, please take a look at @highyieldboardswards's and/or @mrglass' explanation as well - a very important addition!! +  


submitted by skraniotis(10),
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ezyniadUdl renal feluira aldse ot emlciabto oiiscasd, nad as a letsru caribb tesg edelpedt as it esirt to frubfe hte auucoitncaml of iacongr dsia.c

bubbles  Thanks for the explanation! Do you know why Mg would not be a potential answer? Phosphate also accumulates in those with undialyzed renal failure, so I was thinking that maybe magnesium as a divalent cation would complex with PO3 (in a mechanism similar to Ca). +  
nwinkelmann  From the little bit of research I just did (because I didn't learn anything about dialysis at my medical school), ESRD can be associated with either low or high Mg levels, so the dialysate can cause either increased or decreased Mg levels depending on the patient's serum content, therefore I don't think based on this question, would could determine if removal of dialysis would lead to elevated or decreased magnesium. The end of the first article seems to favor ESRD leading to hypermagnesemia, so if that's the case, then removal of dialysis would cause Mg to increase as well. https://www.karger.com/Article/FullText/452725 and https://www.karger.com/Article/FullText/485212 +1  
hyperfukus  why is it that we aren't learning this stuff and they r just throwing it on step there's barely a blurb in FA about ckd/eskd +1  
hyperfukus  does uremia potentially have to do with this? +  
medulla  ESRD and not getting dialysis -> he is uremic -> met acidosis -> dec bic +11  
angelaq11  @medulla this is the best and simplest explanation. I got it wrong and chose Mg, wish I had made that connection. +  


submitted by bubbles(67),
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naC nemoeso eiaxpnl yrprleop who we know tath thsi artit sloowfl nnMaeledi ncsgieet dan is toamaolsu vereecssi nda reurfthoemr who het nteaprs eewr eo?ruoghtzyse

I sgsdeue a lot on hsit uiqoetsn and otg luyck (:

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 +  


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gewAdnoeclk hte pet'isatn fcitfidul.y I heat htese oiqsutnes

nwinkelmann  Me too... also, he's had cough that's worsening for 6 months plus hemoptysis for 1 week... I didn't interpret that as "feeling healthy." The correct answer was my first choice just because it was the least "dick-ish" but to me, he didn't sound like he "felt health," so I didn't go with it. +1  
nor16  if he didnt feel healthy, why would he say something like that then... but i agree, these (especially this) question(s) are often XYZ123! +1  


submitted by naughtyegg(16),
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anDgwolietugnr aniehc-Edr si het ifsrt ptes arccne saket datrwo isaatemsst suceeab low -earEnicdh plesh vdaine hte tnesmbae amnebrme ;gt&- eaetynvlul adels ot adersp fo eccran weleesr.eh mainLin si oals ivvnldeo ubt iorcagcnd ot a,toaphm neaccr will atylclua haatct to aniinml in orred ot drsoyet teh msebneta ee.mnabmr kId if erteoprc tdl/iopnegunwuaor p,pnhaes ahtt mtghi be a ttsh.cre

nwinkelmann  It makes sense that a tumor cell would increase their laminin, as opposed to decreasing, if attaching to laminin is what allows the cells to destroy the basement membrane. The more laminin, the more destruction possible. +  


submitted by rajkamal17(0),
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tPreyt esur ’Im simgsin tisnhgmoe iacsb h.eer iTsh wsa SCC dginaniv snaebmet mbmenrea iafcaitlted yb htaw? eTh ewsarn si oegnilrwautdno of Ecdhrnie-a but I guhthot atsht’ fro mstastteseas A(F 81 asys os )oot. I keitdc screeaded alinimn rctorepse nice(rtc)ro ocz nnlimai aws odfun in tbsmanee rmameeb.n At tlsae ttah asw ym nagroes.ni ynA lhpe piee.raptdac Tas!nkh

naughtyegg  Downregulating E-cadherin is the first step cancer takes toward metastasis because low E-cadherin helps invade the basement membrane -> eventually leads to spread of cancer elsewhere. Laminin is also involved but according to pathoma, cancer will actually attach to laminin in order to destroy the basement membrane. Idk if receptor up/downregulation happens, that might be a stretch. +16  
nuket0wn  per medbullets, there are increased laminin and integrin receptors. Also upregulated MMPs (matrix metallo-proteinases) to breakdown the basement membrane. +1  
nwinkelmann  It makes sense that a tumor cell would increase their laminin, as opposed to decreasing, if attaching to laminin is what allows the cells to destroy the basement membrane. The more laminin, the more destruction possible. +  


submitted by airhead5(2),
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Does oynane nwko teh aesdeis ehty era anlkigt tua?bo I asw ngtnihki upusl hichw skmea sense ithw het ,wsnear tub i t’anc difn atngnhyi on anotirre herbcma fo eye dan coohdir sxpe.lu

liverdietrying  It's lupus, all the symptoms listed are classic especially the serositis. Anterior chamber of the eye = uveitis. Choroid plexus = cerebritis. For a great overview, check out this (free) video: https://onlinemeded.org/spa/rheumatology/lupus/acquire +5  
in_a_pass_life  I think this was reactive arthritis, not lupus. Choroid plexus not just in the brain, also in eye (can’t see, can’t pee, can’t climb a tree). Mechanism of reactive arthritis is immune complex deposition, per UWorld, which was correct answer. +5  
trichotillomaniac  The inside of the eye is divided into two chambers: the anterior chamber and the posterior chamber. Both chambers contain fluid, and when there’s inflammation in the eye, a specialist can often see inflammatory cells in the fluid. https://www.hss.edu/conditions_eye-problems-lupus.asp +  
trichotillomaniac  I agree that this is Lupus after doing some more research! +1  
nwinkelmann  I find this article describing the SLE ocular manifestations, including uveitis and cerebritis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908056/ Also this talks about the lupus cerebritis (choroid plexus inflammation): https://en.wikipedia.org/wiki/Cerebritis +  
medulla  every time I read about Lupus there is something new!! +1  
aakb  woman of child bearing age + serositis + arthralgias/arthritis >=2 +  
aakb  kidney issues (main cause of death in sle) +  


submitted by the260guy(12),
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But ehe'sr my obmlrpe tiwh isht :quoetsni ti yass atht she ash a 5 ady ytoihrs of OSB nad lslnewo ls.eg So uvisloboy teh rehat is .giflian I cdiepk Dseaecdre oketrS leoumV for htat arseo.n

nwinkelmann  AV fistulas are one cause of high-output cardiac failure. This person presents with heart failure, but it is due to chronically increased resting CO. +2  
lukin4answer  @nwinkelmann yes thats right, he has failing heart. but question is asking what is the finding of this patient, I understand the cause is Fistula causing high output failure, but they didn't ask the reason of his HF, they are asking the finding. I choose decrease Stroke VOlume :/ +  
happyhib_  This was my logic and got to decreased stroke volume as well; they arent asking what caused his HF or anything it says what is the most likley finding in this patient. If his heart is failing due to LVH from consistent increased CO wouldnt he AT THIS VERY MOMENT WITH his heart failing have decreased stroke volume?.. +  


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ainoilzted eedeprrrf eud ot esngil seod

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! +  


submitted by hungrybox(977),
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rGaet evoid I sedu to enarl sith iaemra.lt

  1. hTere ear 3 romaj pytes fo u:rsgd rpspue m(,iusl)tntsa nsdeorw te,npdsas(e)rs dan ceanlngihs.oul
  2. roeiHn is an oi.oipd diipsOo rea *ews.ndor
  3. rownDes do wath ti snodsu kle.i yhTe asecu d"wo"n :ssmtpyom eaerddcoatdiesns/e taeynxi (nad hsut learoahvib i)i,iihnntidbso rretopaiysr isn.rdesope
  4. Tsuh ilwtdarahw lliw ceasu the itpopo:se ytydiaarepacti,noh/shenrc ayni.txe
hungrybox  *other downers: alcohol, benzodiazepines, barbiturates +2  
nwinkelmann  THANK YOU! for the link to the video. this is one thing I've ALWAYS struggled with. +  
qball  I get that this is a good rule of thumb to help narrow down between alcohol and heroin, BUT is still not enough to answer this question. Some key features for depressants (downer) is alcohol (if we are talking mild withdraw) - tremors , diaphoresis and delirium (heavy withdraw) . For Heroin - Dilated pupils, yawning and lacrimation are key exam findings. +1  


submitted by hayayah(1057),
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Atblouse ikrs: teh neferidcfe ni risk tno( teh iponr)rootp blbriuateatt ot eht tveernnintio as oacrmedp ot a oolrcnt.

(.2)1 - .(4)0 = .80

ARR = %8

nwinkelmann  This isn't actually correct. Absolute risk is actually just the incidence, or the same as event rate. Absolute risk reduction = the difference in risk (not the proportion) attributable to the intervention as compared to the control, and thus ARR = incidence unexposed - incidence exposed x 100%. In this example, the incidence of exposed is the incidence in the new treatment group, and incidence unexposed is incidence in standard treatment group. +11  


submitted by asdfghjkl(2),
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eonyAn onkw why IGF1- wtondul' eb aredsneic sa lw?el HRHG is asmideuttl ni ioplgyccyhme east.st

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


submitted by asdfghjkl(2),
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yoAnen nokw ywh G1FI- ldwou'nt be eincsread sa le?lw RGHH si siulemattd in gyiylmopcehc atsest.

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