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Comments ...

 +5  (nbme17#21)

What you can see is

1.Hyperkeratosis (thickened stratum corneum) 2.Parakeratosis (you can see the nuclei very clearly in the stratum corneum) 3.Dysplasia (notice keratinocytes hyperchromatic and large nuclei go up almost all the way to the top. This isnt so in normal skin)

all this fits actinic keratosis

cassdawg  Actinic keratosis is FA2020 p482 if anyone needs it! +4
baja_blast  FA2019 p. 472 +1
cheesetouch  Sweet name @osler_weber_rendu #represent #cureHHT +

 +2  (free120#15)

Monoclonal Antibodies are always last resort! I just use this as a general rule





Subcomments ...

submitted by rolubui(13),
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1) Alolhco awhltrawdi &g-t;- ezsruei

)2 uezireS t--;&g cieanedrs seaerel of aecolahsimntec (nsmvhw:4eb/w5.bmg6u/ttnh.oipw82./cd0npl/3i.,) laso BP fo 800/110 isentcdai ihhg llvsee fo hilaecmcanetos

)3 rajoM oshmeron that istfh K+ ynaeurcillrllta aer unnisli m;pa& -re2ieb-cangadert sngastoi (.g.e ieenpneriph (hgd2/a/iedosus.m0sliu./f0k.pw6ct1ne1nhc8etpil.gg7iw.cuclt:pi/an/inwi)

)4 solA they are ngkais hwy esrum K+ si low, NTO yhw uerin K+ is high

osler_weber_rendu  Point 4) above helps you RULE OUT MUSCLE BREAKDOWN. It will cause initial hyperkalemia. Hypokalemia, if at all happens weeks later in ATN. +3  
hungrybox  Thanks for explaining why it's not muscle breakdown. Was stuck on that one. +  


submitted by sympathetikey(1349),
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sotienH caiatltenyo wlsoal for ilanetxora fo hte NDA os taht icnotpraistnr cna drepco.e lAl asnrt toienicr idca scaesu eth gunlsyeatcro ni PLMA ot erhfurt e,atmur ihwch seiuqerr NAD tncpniroatsir / .saanrolttni

osler_weber_rendu  The questions asks for response to ATRA. Should that not be decreased transcription to treat the cancer? Which makes methyl transferase (aka methylation) the more likely answer +6  
pg32  @osler, no @sympathetikey is correct. ATRA's mechanism in treating APML is to encourage the cells to mature. Maturation would require gene transcription, meaning histone acetylases would be used. +2  
nnp  but ATRA is letting transcription of an abnormal protein ( that is 15:17 translocation) +2  
lowyield  i believe the mechanism of APML is that the compound protein is ineffective at allowing for maturation of the blasts. giving ATRA allows the blasts to circumnavigate this step, relieving the backup +10  


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heT inetapt sah ATN yrcanosed to lnrae macihsi.e ueD ot urbtalu iosrcnse, hte taitnep wlil ehva an ldetavee N.eFa eTh 'pinsatet riuen liwl sola eb ,edltui tbu hist iwll eb rlfteedce yb hte olw riune olytslamoi, not eth aeNF

mousie  Hypotension can also cause pre renal azotemia with a FENa <1%.... How do you know this is ischemic ATN and not hypotension induced Prerenal Azotemia? +11  
sympathetikey  I had the same thought as you @mousie, but I think "azotemia" and low urine output push it more towards ATN (looking back; I got it wrong too). Plus, the initially MVC / muscle damage probably caused some tubule injury by itself. +2  
ajo  This might help clarify why the pt. has ATN rather than pre renal azotemia. The question did mention, though subtly, that the bleeding was controlled. That most likely indicates that his hypovolemia has been corrected. Developing azotemia 24 hrs after correction of hypovolemia is more suggestive of ATN (since he doesn't have hypovolemia anymore). I hope that helps and feel free to correct me, if I am wrong. +40  
ajo  In addition to my earlier comment, I just noticed the question also explicitly mentioned that he was fully volume restored. Which is consistent with my earlier assumption! +14  
gh889  Although initially, hypotension causes prerenal azotemia, the volume correction pushes you away from prerenal azotemia. but they want you to remember that in hypovolemia, the kidneys are also becoming ischemic, and so development of azotemia 24 hours later is more indicative of intrarenal azotemia due to ATN +  
sugaplum  for anyone who wants to see it: FA 2019 pg591 +1  
divya  i'm confused about one thing. if the tubules aren't working like they should, the bun:cr ratio falls right? doesn't that essentially mean azotemia reduces too? +  
osler_weber_rendu  Lets all take a moment to admire how shit this question is "Bp 90/60.""Repeated episodes of hypotension in the OR" and still the answer is ATN +4  
donttrustmyanswers  @osler_wever_rendu ATN can be caused by ischemia. +2  


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ehT corptree in tesoqinu si a G tnreipo tcoerpre no teh ruiitatpy .sasm sihT wdoul eb het HRHG orc.etrpe Teh GH rcreepot wlil eb espenrt onstdremaw os ttah GH ealedser rfmo het uyttriapi cna ndib ot ti (stehe aer JAKT/TSA s eoc)er.RtHrHpG preoctrse rea s¬G pco.esretr Thees rreeptcos era dnbou ta hte tpbsaila-uunh ot GPD in teh iieatvnc .saett enWh RHGH dbisn thye aietcatvd wnhe TGP thetscaa to eht ilnu-hbpautas deni.sta dnA tyeebrh rotepsmoo ayldne cyclaes aie icavs.TyGtPt si lsbionseerp to avcele shit PGT rmof het lahpa tubisnu ot tshciw of het e.erotcep eehoTrrf a lcka fo aTesGP ytiiacvt llwi rnreed he sG croprtee ni a dneroplgo no sttae  cneaerIsd ittcyiav fo ylenAd .csaCyel

osler_weber_rendu  Brilliant explanation +  


submitted by gh889(125),
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hTe sewran si ude ot an opxeetcni nulteiod ereh rhewe acnini is desu ni pst o/w ebasiedt owh ahev cftyaerrro pitcyarrgdmerelhyeii ta ighh rkis or ahs a xh fo aanittcrpes.i

I arege htat treiafbs rea tfris neil (adn so osed taht el)citra tbu NEMB aws nohgni ni on a fpiicces exepnitco atth anncii cna alos be esdu inecs DLLV adn sGT are high in ryemi.yialrcerhdtpgie

hTe cle""u teyh had swa eerrncr"tu "tnapsectairi hiwhc si sodelpysup a aedl taodrws inn.cia

I lsoa tup erasicen ....HLD

wutuwantbruv  Correct, you would not want to give fibrates to someone with recurrent pancreatitis since fibrates increase the risk of cholesterol gallstones due to inhibition of cholesterol 7α-hydroxylase. +  
kernicterusthefrog  FYI @gh889 can't follow your link w/o an NYIT username and password, unless there's a more tech-savvy way around that.. I appreciate the info, though. Niacin rx for familial hypertriglyceridemia w/ recurrent pancreatitis. Now I know.. +2  
impostersyndromel1000  Great points, very in depth knowledge taking place here. Also, familial hypertriglyceridemia (per FA 2019 pg 94) has hepatic overproduction of VLDL so picking this would have been the easiest answer (in retrospect) +2  
hyperfukus  @impostersyndrome1000 literally that's the ONE thing i remembered and i went YOLO lol cuz i was staring for a while +  
osler_weber_rendu  @gh889 I agree niacin is the answer, but even niacin causes increase in HDL. As if getting to the drug wasnt tough enough, NBME puts two of its actions in the options! What a shit question +1  
mtkilimanjaro  I forget where I saw (maybe UWorld), but I always thought increasing HDL is never really a primary form of lipid control. You want to lower the bad cholesterol etc. since increasing good cholesterol wont change LDL VLDL etc. +  
jaramaiha  @mtkilimanjaro I believe it was in BnB. Dr.Ryan mentioned that there hasn't been enough evidence that raising HDL would be beneficial as far as lipid control goes. Better studies were done on statins hence why they are usually first line Tx. +  


submitted by usmleuser007(395),
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Iuuptessncisotn is yeleglrna aedusc by a kbeaclog ni the IG tctra cedusa yb a m,utro ,pyopl uciterim,vdul or utsj tbyioiimml at tarp fo eht t.trac

)1 My totghhu swa taht teh aptniet adh a cMekel c iteuridmvlu eys ti phensap ni 2 tefe rfom eht llcceioea a;velv btu taht is in outba %2 of het anoptoluip

hpsbwz  Meckel diverticulum itself occurs in 2% of the population. Also it would present much sooner rather than in a 28 year old man. +  
osler_weber_rendu  Meckels is an incidental finding in 98% patients. (only 2% symptomatic) It is a well known lead point for intussusception +1  


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Cna eanyon enpalix yhw brsiouF assrc thwi samapl cllse si otn the crotcer sarew?n

osler_weber_rendu  Exactly. Three months can fall under chronic rejection as well. FA pg 119 states "interstitial fibrosis". Chronic rejection is predominantly Bcell mediated (plasma cells). +  
beto  chornic rejection > 6 month acute < 6 month +2  
beto  also there are no B cells in the site of fibrosis. humoral response due to antibody themself,not by direct B cells response +2  


submitted by usmleuser007(395),
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In sseac fo clhdi or udlat buesa

1) fi teerh is alerc ecenediv chsu as if a dhicl sseatt that pretans nhspui yb ithi,gtn dchil si nihsogw erfa fo neatrp ---- llac lhidc cpnriottoe irtgh yaaw ( dno't need to wtai nda )ksa

2) mesa ignth osge rfo het tdual tub acll het ladut pctotreino resvcies

osler_weber_rendu  Does anyone not remember Dr Daugherty's lessons which said domestic violence on adults is NOT necessary to report? Instead help them find an escape route in case of an emergency and encourage them to report it themselves. +  
makinallkindzofgainz  @osler_weber_rendu: Domestic violence is not the same thing as dependent adult abuse, such as a special needs adult or an elderly adult (basically anyone who depends on others for care). What you said applies IF the adult is living independently and fully capable to make their own decisions. +6  


submitted by meatus(1),
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'Im ryrso btu whta am I nsigmis ree...h I uhtthgo teh welho piton fo ucrtesdii is to rorctce mlovue oladeorv by erdisi?us woH udwol laott emoulv be idcees??ran

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


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NSC aeibmssoia is omts tousloyroin dscuea by eNleagira flwe,roi wcihh I rceeonagu yuo ot moirmeze as het -“naanietbrig .aa”bmeo noFud ni rawf-rthees siobde fo wtaer ikel nosdp adn k,slae ti sha reeht :frsom a s,tyc a eoozirpttho d)baie(o,m adn a fllbalteiage e(i.. has otw a.)llelfga Ioicntfen si aiv oocltfyra ellc onxas rhhutog eth cmrfririob tapel ot hte a.brni

mullerplouis  To add to this it causes Meningoencephalitis. Look out for confusion and brain signs mixed with signs of meningitis. Only a handful of organisms that cause both. +3  
osler_weber_rendu  Am I the only one who thought portal of entry cant be through a nerve and just ignored all the nerves? +37  
luciana  @osler_weber_rendu I thought the same... I knew it was through cribriform plate, but not that was actually through the nerve +10  
paperbackwriter  @osler_weber_rendu yeah same here, otherwise would have been a much simpler question +  
melchior  In line with the thinking above, SketchyMicro teaches it as if it just passes through the cribriform plate, ignoring the nerves. Wikipedia says that it actually enters the nerves, then passes through the plate. +5  
j44n  this is such an AWFUL disease, I worked in a hospital in south carolina where it happens A LOT and there's nothing at all you can do for them. When your cells go to phagocytose it it has an outer layer it sheds off like how a lizzard will sacrifice its tail when attacked by a predator. +1  


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Rlsehoaniipt ihtw rfeomr tnsetaip rae ayrlgelen dofnrew on, but ethr’ye lyesclaeip tmaoprcielb if hte ntpeait swa a istpcryicha etn,ptia as hte pewor lamcbniea fo eth ieetti-iaprctanptnor nhsoalptieir nad tofnonriami hte pveoirrd is yrpiv ot suceabe fo teihr aientpt rcea mlonetvnevi plduceer a ayelhth claneabd rhaisnploeit fo ea.qslu

osler_weber_rendu  But what if she hot? +2  


submitted by gonyyong(106),
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heT dki has aaecnyoitgms due to trpubey ssxc(ee trtoneeessot → hionssget )reT ogse aayw ynlatalru peaypa(ntlr ni 21 to 81 tnhosm)

I tkinh you ndt'o hvae ot do bdloo setst eecbsau eh hsa mralon lxseua metpevodnle rof shi age nad hetre aer no thero sgi?sn

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +29  
howdywhat  my exact thought, telling him that it will last for somewhere around a year and a half doesnt seem so reassuring +1  
suckitnbme  I thought it was reassuring in that the kid is being told this isn't permanent as well as that this isn't something serious. It's important to inform him about the prognosis. +8  
thotcandy  "don't worry your gynecomastia isn't permanent, but the mental scars from the bullying you will receive in HS definitely will be :) good luck!" +4  
therealslimshady  What is the gynecomastia is from a prolactinoma? +  
misterdoctor69  @therealslimshady the gynecomastia is from the sudden surge of testosterone during puberty being converted into estrogen => more breast tissue. +3  
mnunez187  My breasts are not rubbery nodules, thank you very much! +