NBME Answers : prolific_pygophilic's page

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submitted by peteandplop(42), visit this page

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This patient is presenting with with STEMI (FA2019 p301), thus the entire vessel must be occluded. Coronary vasospasm via a1 stimulation (increased smooth muscle contraction) would lead to these findings.

As far as the nitro aspect, I think this could be referring to pt history of ischemic heart disease, and the scenario of coronary steal, however I don't think you would need that to answer this question (and I could be going down an unnecessary rabbit hole of misery).

Other helpful pages are FA2019 p238, a1 sympathetic stimulation results in increased vascular smooth muscle contraction.

Last, big ups to the brother for setting arguments aside and still taking his hermano to the emergency department. Perhaps they were arguing at who responded to COVID-19 and medical education worse: USMLE or Prometric.

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prolific_pygophilic ^Comment of they year +2

chaosawaits Who else got a little distracted by the tragic story of watching your brother have a heart attack because of an argument you were having with him and then had to refocus to get this question? +

an1 wouldn't coronary vasospasm refer to prinzmetal angina? can someone go over the other options? +

neurotic999 The way I approached it was, since they specifically asked about the role that the argument played in developing the symptoms, it seemed as though they were pointing in the direction of vasospasm rather than an occlusive cause like atheroemboli, ruptured plaque, etc. So I looked at the options with that in mind. Some of the options were blatantly wrong: -vasospasm d/t beta (beta is vasodilatory) -increased afterload d/t beta (beta 2 would cause vasodilation, decreasing afterload. beta 1 would increase hr but I don't think it alone is enough to increase afterload) -negative chronotropy d/t alpha (that would be a beta blocker) -positive inotropy d/t b2 (that would be beta 1, not 2) The one I wasn't sure about was decreased perload d/t alpha1 stimulation. I was thinking decreased preload, hence decreased blood in the coronary circulation. But it didn't seem convincing enough to cause an MI. Plus not sure if alpha stimulation decreases preload to begin with. +

neurotic999 If the ST elevation part of it throws you off, FA2019 301 says prinzmetal angina has transient ST elevation. +1

submitted by youssefa(162), visit this page

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I mean why would a testicle turn around itself when someone's sleeping. This typically occurs after sports/ bicycle riding etc..

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brotherimodu People can move in their sleep? +2

prolific_pygophilic Actually in highschool this happened to a couple of my friends in their sleep, woke up with the sack all twisted +1

submitted by bwdc(697), visit this page

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I’m going to point out that a normal healthy kid with no cardiac history or symptoms and no family history of sudden cardiac death for a pre-sports physical is probably going to have a benign exam no matter what you think you hear.

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the260guy What a weird question. I could definitely hear a fixed split heart sound. And it was loudest over the pulmonic valve too which makes it even more of a dirty question. But I guess what I was actually hearing was an S3 heart sound. +16

wutuwantbruv @the260guy I believe the splitting is being heard only during inspiration, making this normal physiologic splitting. Perhaps that's just my ears. +18

angelaq11 don't have adobe and couldn't download it, so I just chose whatever, but your explanation suddenly makes me feel dumb but grateful! Loving your tips! @benwhite_dotcom +1

blah @the260guy Have to agree with wutuwantbruv. I interpreted this as a physiological splitting, had the opportunity to hear it in a newborn as well. +4

prolific_pygophilic Definitely S3. FA 2020 pg 287 "but can be normal in children, young adults, athletes, and pregnancy" +2

dhkahat I swear to god it wasnt just during inspiration but what the hell do i know +

jbrito718 I thought I heard a "LOUD S2" but thats what happens when you read FA 30,000 times. +2

chaosawaits I swear I had the volume to the max and couldn't hear shit. Then when I came back the second time to get the answers, it was working; but my dumb ass was hearing a skip beat. No dumbass, that's just the loop. +

submitted by paperbackwriter(161), visit this page

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S2,3,4 keeps the 3 P's off the floor (Penis, Poo, and Pee)

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alexxxx30 love it +1

prolific_pygophilic A true scholar +6

submitted by aladar50(41), visit this page

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So there’s 100 residents, and the prevalence after 2 years is =10 at the beginning, +5 in the first year, +10 second year, and -3 that healed, for a total prevalence of 22 residents or 22/100=22 percent. Thus, prevalence = above the standard. For incidence, it’s 15 new cases out of 90 residents over the 2 years (100 total residents – 10 that already had ulcers), or 15 new ulcers per 180 patient⋅years. This would be 83.3 new ulcers per 1000 patient⋅years if you extrapolated it out -- basically (1000/180) * 15 -- thus, incidence = above the standard.

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zelderonmorningstar Okay I feel like an idiot cause I thought: Above the Standard = Doing a good job keeping old people from getting ulcers. Thumbs up. Below the Standard = I wouldn’t let my worst enemy into your ulcer ridden elder abuse shack. +68

aladar50 @zelderon Ohh damn. I could totally see how one could view the answer choices that way. I think it is important to read how they are phrased - they are asking if the center is above THE standard or below THE standard. The “standard” is an arbitrary set point, and the results of the study are either above or below that cut off. Maybe if it was “above/below standards” that would work. Also, being above the standard could either be a good thing or bad thing. If say you were talking about qualifying for a competition and you have to do 50 push ups in a minute, then being above=good and below=bad. In this case, having more ulcers than the standard = bad. +4

saynomore @aladar Thank you!!! but how did you get the 15 new ulcers per 180 patient⋅years? I mean I understand the 15 part, but not the second part ... hence why I messed this up, lol :| +2

aladar50 @saysomore Because the study is looking at 100 residents over a period of 2 years. Since 10 already had the disease at the start, when looking at incidence you only include the subjects that have /the potential/ of developing the disease, so 90 patients over 2 years. This would be 90 patient⋅years per year, or a total of 180 patient⋅years over the course of the study. +7

sympathetikey @zelderonmorningstar I thought the same exact thing. Had the right logic, but then just put the backwards answer. +4

kai I wonder if they chose this wording on purpose just to fuck with us or if this was accidental. My guess is there's some evil doctor twirling his thumbs somewhere thinking you guys are below the standard. +16

symptomatology Got it wrong!messed up in understanding options, Btw, 15/90 is somewhat 16 percent and their standerd is 50/1000 5 percent!.. this is how i knew that incidance is way up! +

donttrustmyanswers Patients with an ulcer are not immune to getting new ulcers --> You should include all patients at risk. But either way, the answer is the same as long as you can read NBME speak. +

doublethinker Damn, guess my reading comprehension is not "up to the standard" of the NBME writers. Smh. +

prolific_pygophilic If you forgot that its patient years (15/180) not (15/90) you still get the right answer because they are both above 5% :). +

submitted by keycompany(351), visit this page

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Type I Diabetes is characterized as the destruction of pancreatic islets (specifically beta cells) by T-cells. The most likely cause for hypoglycemia following insulin administration, therefore, is the destruction of alpha cells that surround the beta cells. This would cause decreased levels of circulating glucagon.

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titanesxvi I think rather that high insulin is going to block the release of glucagon +6

mdmikek89 No, his answer is more correct. Obviously insulin will decrease glucagon release, but it says PROLONGED. So if I give a rapid acting insulin, serum glucose decreases, the insulin degrades...no rise in glucagon. The alpha cells are destroyed as well. This is the how I came to the answer and the best explanation. +3

melanoma https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402257/ +

melanoma the answer is not correct +1

melanoma his answer +1

prolific_pygophilic I actually think this has some merit. I believe there is a U world question that talks about how very long history of T1DM (20 years in this patient) can progress to destruction of alpha cells and hence impaired release of glucagon and episodes of hypoglycemia. Thats how I reasoned it. The first answer is also possible. +1

submitted by seagull(1933), visit this page

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What a terrible picture. They they covered up part of it with lines. WTF

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sympathetikey Agreed. +18

catch-22 Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3

yotsubato I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +15

lolmedlol why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +4

catch-22 You're looking at the ventral aspect of the brainstem. +11

catch-22 ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1

amarousis think of the belly of the pons as a pregnant lady. so you're looking at the front of her +6

hello which letter is CN IX in this diagram? +

miriamp3 there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +

jesusisking Don't G and H lowkey look like VII and VIII? I chose H b/c of that +

ljennetten G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1

prolific_pygophilic Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1

soccerfan23 There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +

submitted by adong(144), visit this page

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neuroendocrine cells doesn't always mean neural crest

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prolific_pygophilic you're god damn right.... kms +3