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LAP 100-249 do not fall into the answer choice but would still be considered high value and thus +LAP to indicate leukemoid. A LAP- would be in the normal values which is 20-100, not below 250 like the answer choice indicates.
i got 2 leishmania questions 38 and 39 in 3rd block , both got incorrect because i thought no way they can do that (((((((
Glad I wasn't the only one to solve it this way...didn't even think to bother with the calculation.
No hepatosplenomegaly, ascites, or edema through me off. We that being said, I shied away from cirrhosis. I thought that he showed signed of depression, so I went with the thyroid. But who's to say he isn't injection anabolic steroids?!
The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum.
He likely has hepatitis B/C given his history of intravenous drug use. I believe both can have liver dysfunction but may or may not have ascites, whereas the type of damage we would expect from alcohol that would match this presentation would also show ascites.
For Ascities u need to have portal HTN. Thats a must. (unless exudative cause like Malignancy)
For anyone who needs it; the FA photo is kinda burned into my mind for these questions. NBME has some weird infatuation with this clinical presentation.. FA (2019) Pg: 383 "Cirrhosis and Portal HTN".
@paulkarr the problem was that the FA image was burned into my mind so without no ascites or edema threw me off of cirrhosis.
cirrhosis doesn't present hepatomegaly, instead, the liver could be shrunken.
Cirrhosis (most likely due to alcoholism in this patient) leads to an increase in sex hormone binding globulin, causing a relative increase in estrogen compared to androgens. Cirrhosis doesn't always have to present with ascites and adema. I agree with @catch-22 that liver disease is a spectrum. This patient does not have ascites because his liver is still able to produce enough albumin to maintain oncotic pressure in the blood.
I'm not 100% about this so take it with a grain of salt. But i was confused about why there would be a systolic murmur. I think its b/c prolonged ASD would eventually cause pulmonic stenosis which would present as a systolic murmur. But besides that I super agree with @sympathetikey
Low key was hoping for someone to try and argue this one...
She taught me more than my med school professors did...
Just adding that Clopidogrel irreversibly inhibits the P2Y12 receptor. This can be found in FA2019, pg 403. The other drugs in this category are: Prasugrel, ticagrelor, and ticlopidine. Ticlopidine is famous for causing Neutropenia and having an increased risk for TTP.
I personally have not read that, but I wouldn't be surprised by that fact. I think with these NBME problems though, if you can get the answer within one "step" that should be your choice. Here you can just go Squamous Cell Carcinoma with a direct action on serum calcium levels (via PTHrP). Thyroid requires a few more steps, (assuming your statement is true) so in the eyes of NBME, it ain't gonna be the right choice. Always follow the "KISS" logic!
Because you'll see some blast cells in a leukemoid reaction. It won't be 0%.
Also, don't get confused with 0% Basophils. Basophils are seen in CML but not in Leukemoid reactions. I just went with LAP because they pointed it out in the lab values. Had that not been there, I would have chosen "0% basophils"
the "left shift" you see in leukomoid reaction actually is describing the increase in immature leukocytes on CBC. that is why the LAP is important to be able to distinguish them
I was thinking that "Diffuse fibrosis" was trying to point to IgG4 Riedel Thyroiditis rather than Hashimoto's.
It's only been 10 months, per the question stem. This probably isn't long enough for fibrosis to be correct
LOL. Achey Granpa Meynert. I'm gonna steal this from you.
Achey grandpa Meynert = ACh / Basal Nucleus of Meynert
Dope Cousin VT = Dopamine / Ventral tegmentum, SNc
Uncle and aunt Raphe and Sara = Serotonin / Raphe nuclei(medulla, pons)
Cousin Gabby always screaming NA-NA-NA = GABA / Nucleus Accumbens
Norepi = Locus ceruleus.
ACHey GRANDPA MEYNERT TREMBLES in the BASEment; DOPE cousin VT SNaCks DOWNstairs by the kitchen TAP; NANA GABBY ROCKS and ANXIOUSLY cooes...; "NENENENE... NENENENE...NENENE...NENE" to CRYING BLUE-eyed baby ELSIE; aunt SERO and uncle RAPHE DULLY PARK in the DOWNpour. CAPS = relevant info, lowercase = irrelevant. Includes diseases: DOWN, ANXIOUSLY, CRYING, DOWN = anxiety/depression; TREMBLES, TAP, ROCKS, PARK = movement disorder; GRANDPA = Alzheimer's. Note: ELSIE = LC = Locus ceruleus
The extended "NENE" series is just for humor - shorten if you like ;)
Also, ANXIOUSLY applies to both NTs in that sentence: GABA and NE.
I almost didn't even look at this review but then I thought "maybe someone has a cool mnemonic." and would you look at this.
This is amazing. thank you
This is amazing. thank you
Didn't finish reading this, but it looks awesome
Also, the nice little puppet show from sketchy for those visual learners like me.
how could i forget that puppet show?!
FA 2019 does mention it P 149
"Lyme Disease caused by Borrelia Burgdorferi, which is transmitted by the ixodes deer tick (also vector for Anaplasma spp. and protozoa babesia)."
FA 2019, Pg 146
I also chose Gemfibrozil too because its the best TG lowering drug listed but I can see where there might be some red flags for this drug in the way they asked the question... 40 year old obese woman with some upper abdominal pain ..... HELLO GALL STONES which is a common adverse outcome of Fibrates.
Well I didn't wanna give a fat, forty, female, that smokes a fibrate. So a statin, for me, was the best next option.
Used same reasoning to choose statins. Fibrates are the main drug of choice for hypertriglyceridemia but given her symptoms, statins made more sense. Why do they do this to us...
what a tricky question! there are multiple factors should be taken in consideration.. she has triglyceridemia which put her in risk of pancreatitis, and most importantly atherosclerotic disease, and all of that would outweigh the risk of giving her gallstone.
Yeah I had statins selected initially because "statins are always the answer" but when I saw them stating first line "recently diagnosed with hyper TG" I figured this follow-up was purely to address that. So Fibrate is the best move.
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
I would be a bigger asshole when the family came I'n after I pulled the plug...opps...but the friend said
The patient has no wife, children, or close relatives...
@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.
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).
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.
they say no close relatives, which means he could have remote relatives, relatives must be asked before listening to a stranger/friend's words.....
Definitely was the same for me. I was so confused for like 5 mins
dude i almost didn't get the question bc of this ... i thought the age of onset was the actual age of onset (36)
Are you serious. NBME strikes again with shitty formatting.
OMG!! Now I just realized that. Super confused and also thought onset of age was 36. :-/
what is 36 supposed to be?
Think the number of people in that group
Yup...was looking at it for a good 3 min before just doing the "fuck it..it's gotta be 99"
Age of Onset is the Title of the table, which I didn't figure out until after exam was over. What terrible formatting.
Damn, epi at it again...
And even if it was Wilson disease, it would have the exact same consequence leading to Fanconi syndrome.
Fanconi syndrome Generalized
reabsorption defect in
PCT = Increased excretion of
amino acids, glucose,
HCO 3 – , and PO 4 3– ,
and all substances
reabsorbed by the
May lead to
(eg, Wilson disease,
Polyuria, renal tubular acidosis type II, growth failure,
electrolyte imbalances, hypophosphatemic rickets =
Fanconi syndrome (multiple combined dysfunction of the
proximal convoluted tubule).
This is where the timing of everything in the question trips me up. FA say PV mechanism is increase EPO (2019, p299)
Different types of Polycythemia have different effects on EPO levels. "Appropriate Absolute" and "Inappropriate Absolute" will both increase EPO levels (Inappropriate is caused by this EPO increase). Where as Polycythemia Vera has decreased EPO levels due to the negative feedback loop. FA2019 pg 425 hooks it up nicely.
First off, do yourself a favor and check this out - https://www.youtube.com/watch?v=NJYNf-Jcclo
The LDL receptor is found on peripheral tissues. It recognizes B100 on LDL, IDL, and VLDL (secreted from the liver). Therefore, an issue with that would cause an increase in those, but mainly LDL.
Since in this question we see that Triglycerides and Chylomicrons are elevated, that points towards a different problem. That problem is in the Lipoprotein Lipase receptor. This is the receptor that allows tissues to degrade TGs in Chylomicrons. So, if it's not working, you get increased TGs and Chylomicrons. Additionally, you get eruptive xanthomas, which are the yellow white papules the question refers to.
There is much easier way go to page 94 in first aid. This kid has Type 1 Hyper-Chylomicronemia which is I) Increased Chylomicrons, Increase TG and Increased Cholesterol.
It can be either Lipoprotein Lipase or Apolipoprotein CII Deficiency
The video sympathetikey referred to only mentions pancreatitis in type IV but according to page 94 of FA 2019 it is also present in type I Hyper-chylomicronemia which is what the question stem is referring to with the abdominal pain, vomiting and increased amylase activity
thats not the only difference in that video....
Pixorize has a set of videos on all the lipid disorders that made it a breeze to answer.
Pixorize is basically sketchy but for biochem and other basic science subjects.
Pancreatitis was a huge clue for me to think of hyperchylomicronemia