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Welcome to sajaqua1’s page.
Contributor score: 462

Comments ...

 +2  (familymed1#4)

Pt is an 11 yo M, 2 days of nasal congestion and sore throat. Coughing and sneezing productive of green mucus. There is postnasal drainage of copious yellow-green mucus, and enlarged tonsils.

This patient has a head cold, with postnasal drip that is causing his cough. Antiviral therapy (E) is not directed against the Rhinovirus. The patient does not show signs of bacterial infection which would require antibiotic therapy (F), namely tympanic membrane bulging and ear pain. There is no fever to indicate sever infection or sinus tenderness to indicate an X-ray of the sinuses is warranted (D), or that culture of discharge would change current treatment (C). Because this infection is self-limited and the child can blow their nose, sinus lavage in the clinic is not necessary. (B).

 +4  (nbme23#41)
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lontdWu' oaltt VA dlona aolbanti srdetyo ot htychumirytiaot fo eht ampe?ckare thTa owudl mane tath lobew hte AV done hte hyrthm lwdou eb peviddor yb a vnrctluarie ifoc, dan osthe lluyaus tceaer dwie RQS o.mlescepx

haliburton  that was my reasoning as well. guess not. +
yotsubato  Shitty NBME grammar strikes again. +1
charcot_bouchard  No. No guys. Bundle of his located below AV node and it can generate impulse. it calls junction escape rhythm and narrow complex. Below this is purkinje, bundle branch & ventricular muscle. those are wide complex +11
abhishek021196  Third-degree (complete) AV block The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lym3 disease +1

 +7  (nbme23#11)
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lMae tentarp asdergiennlcos/nbd.a lcoaepia is asdecu by hte efctsef of stiryorsodteohetdne (H)TD on eht nksi fo eth sa.pcl srenToettose is dconetevr yb teh mnyeez ap-5thueacedra-sl tino H.DT atFsdineseiir a rea5-ucsta-ed ihnrbi,toi and so sckobl the pcotrnioud of DHT dna nac hlta or neev asecu mseo lrveaser fo amek tnrepta dbn.essla orweHev sith mesa ctativyi may alos usertl ni tsnaigncfi axeusl ides fstfeec cgnidluin cogi,metysaan rteelcie sco,dnnuitfy rajlyatouce tiunndofycs, dan dsacedree ibl.doi

)A a-znalDo a aekw ognrdena hiwt ioanrgteinscet t,ffscee usde in hte ntttreeam fo osistinordmee nda obrcifctysi aebtrs ie.asdes )C oneosle-tetyreMtsht ehytctisn ,T it is udes to pemtsnepul ni oeeotsntster eyifdiecnc, ro in the etatnetmr fo omse rbaest nccasr.e D) nreldaOxo-on an onciaalb sidetor usde to aeirgn hi.wegt E) tzolloaS-on htaoren iaonclab odtie,rs hitw oeatpntil seud rfo etryerhiad dnmi.aegaeo

sajaqua1  I am embarrassed by these typos. +
drdoom  lol +

 +7  (nbme23#25)
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heT enitpta htsixbei moreym ssol and iitencogv tmeipimanr hwit udlraga ento.s 'rezilhsAem edeissa si elhcyAietcoln yitvtcai si nodw ni zehsmeli',Ar so sseaCAr-htee iornhbstii rae seud to kaem AhC rmeo v,iaaalble otsipgpn oems fo eth eeffstc of 'sz.imelAher Diznploee si an CteesAears-h nr.hioibti


)A --CoQ a catrof ni clrioditohamn ,OPhsxo it si losa na iantatdinx.o It is esdu sa a tyiread p,meutnpesl and si otn FDA oadprpe orf eht atrmetetn fo ygn.itnah C) el-Riulzo a laugttame ngiaoantst dues ot epvtnre iittotoxxceyci in SLA nitea.stp )D gnilleS-eei elSceetiv BAO-M ihbroitni ahtt yam eb esud ni eht tnteamret fo rinnk'oPa,ss atgohhlu I veleebi othre renatttsem rea erderfepr shtee aysd. )E -cZin oarnptmti ctoorcfa in amyn nieoacsrt uinincgld iispnranorctt strocfa inc(z gr)sinef nda in uownd l.hagnei

 +2  (nbme23#2)
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,tcGsiaoaynme sdirep aaoiamg,tn adn gpydoimnshao (as ewll as apamlr e)atyrehm era all sngis of xseesc o.nsgrete The reilv in tpsnetia htwi hetciap ieadess si prdeiima dna os ncntoa laecr rnesetgo Sxi 12 oz erseb ydila (72 o,z or lfha a l)aongl si oto ,hmcu dan si togeirsndy shi .lvrei

uslme123  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?! +4
catch-22  The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum. +11
notadoctor  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. +
charcot_bouchard  For Ascities u need to have portal HTN. Thats a must. (unless exudative cause like Malignancy) +2
paulkarr  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". +3
snripper  @paulkarr the problem was that the FA image was burned into my mind so without no ascites or edema threw me off of cirrhosis. +
tyrionwill  cirrhosis doesn't present hepatomegaly, instead, the liver could be shrunken. +1
avocadotoast  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. +1

 +16  (nbme23#38)
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The aorrmw ohwss rprcruoses ot oyserrh,ectyt sa well sa oscaeateyrkmyg. iTsh si to hwos you that het iuess ti'ns oourtdpre,udnnic hwich namse ttah ew ear logsni RCB nda ltalpetes ohreemesw ei ntceotus.dri htTa slrue out D nad .E reehT si nthgion to cetdnaii tah het lhicd hsa dniatmisedes cleuubstoirs B.)( At thsi ponit ew era eltf itwh A ro .C A dulow daiencti enmdDeaitiss uvnarIstaarlc ilunCtgooaa )(DIC or nmhsoitge lirs,mia hwich ouwdl seulrt in wol spaletetl dna CBR ubt we ldwuo osla ese aroamnbl RBC ielk hysstesoitcc "tleh("me ellc).s eW era liixlycept dtlo hatt eth stroyetceyrh rae mncomicorhro dan oncroyi.tmc verwHe,o enuimm irdoncsteut of sleplteat lixspean it al-l hte sreuttiodcn fo leetpltsa asedl ot smoe emirhorggnah nad os a rdop in RBC, nda TIP ylciacsalsl rsieas tfrea a ercnet purpe orrsrytaiep ttcra irlav te.cioninf

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. +10
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. +5
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. +

 +8  (nbme23#37)
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A nadatsrd viiontead si a raseuem of tyapoilbrbi in rlebmiesng the .aeaevgr Oen nddasatr anivodeit on a ebll erucv iindtobursit crasete a %76 enahcc atht the wrnase will eli ni ehetr. oTw ansrddta naivodesti will etcear a 59% cea.chn Theer nartdsad dinotsveia sreatce a 99%7. ecn.hac

ihTs epitatn sha na grvaaee of 11,3 dan a %95 nfocieendc ta 106-111 menas ttha eth SD si 5.1 . oS noe toaidlndia DS wuodl iveg us a ergan fo 155871,10..- dorendu ot 181.-810

usmleuser007  How did you get the SD to be 1.5? +
usmleuser007  NVM Got it +1
jesusisking  You wouldn't use Standard error with Confidence Interval? (pg. 262 FA 2019) +

 +6  (nbme23#32)
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hTe alcamu sdnae of teh onnrpeh phels ainminat arbtuul owlf by dnuatgjsi ndailoti of teh tfnefaer toelrarie fo eth onn.hper henW tlas si ,wlo sti COX nsyeemz tszehyines IPG2 hcwhi atdeil the efenatfr leeo.itrra ADISsN hitniib XOC, cgonlbik eitysssnh fo I2PG dna so diticnyler ibnithngii arnfefet latireoer tinlodi.a oTw sewek goa uor ptnatie asw put on ri,noebufp a stvoceneeiln- CXO inbohtiir. iThs edal ot lal teehs etse,cff ithtgnus off odolb lpspuy to hte ,ronpshne ngreitac na rialayfcilt cddniue rpod ni oblod fwlo atth lsook ahs leeevdat BNU dan eeatnicir,n utb imntansia the 11:5 rt.oia


 +8  (nbme23#14)
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oDlnduea saritea is tleeqfnryu sasaeocdti ihtw owDn ,nrmeosdy adn is udasce ewhn het uumeddno lsfia to enizraecla gnridu pvnmtleoed.e Teh tafnin etessrpn whit lsbiuio ,govmitni os we nwok ttha odof si ta taels nkgmia it ndwo ot hte ndduumoe wheer eht pcraeitanc tcdu mteesip toni hte hisT nieelmtias D wodu(l erepsnt htwi snblinouoi oiigvmnt, aiyylcptl a few ewkes rtafe bi)hrt adn E (wdlou erpesnt whit hgockni nda viignmto mitdeyiamel on e)dgf.ein

heT spneceer of beil eltls us atth ielb si ggitetn to eth mnuuoe,dd so axreeiacthtp yriliba itaares osde ont eesm lssebopi .B() rehTe si tonginh ot cditanie ahtt hte dilch has an epoceamhllo (C) iescn hte aodmben si dtneidsed thwi oodf atht snt'i nsgais,p but the sutg aer sltli sednii het labiadonm iaytcv.

 +8  (nbme23#43)
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nI na eeldlry aniptet twhi setaidlo vleetead klliaaen pthsashepoa m(olnra emsru accmliu dna hho)ppteas aPe'tsg esedsai of nbeo dholsu eb ta hte top fo het d.etnlieaifrf iTsh dieasse is ude to ulatiosrenydg of ooetlactsisc adn lotscasetbio ivtctyia; rsift an nilitai oeostacslt iyittveayhcrp ,pheas etnh sdaicerne abssloetot itavytci fro a um,reixt nthe stsoleaocst nbt"u"our nagield ot -rvnaireiizolatmnoe nad ecisortlc oebn qu.peals In ntdaio,id sith can cetrea riuseotraenov snsuht ni eht osbne ihchw serecaeds ,tesrecains alniedg to ghhi otuupt cdcaiar faleuir (a iasirml plebomr can resai ni truoiornvseea aftslius mfro obdlo i.issly)ad nO syilgotoh it illw aveh a am"soci" .raetptn

A-) nrsmlauAye oebn ycts- lgealyr a rotcupd fo vetycryhiiapt fo se,taoostslc thsi rcuosc oerm nefto ni eht sbl,mi adn ohwss a scityc pasec ithw blolioen-alk dia.otnli )B gcnsAiromoaa- igarsonaaocm of hte nboe si n sloatm leryup iylct neislo. eyhT cuocr orem frteueqnly ni gneouyr ppo.eel C) nNciia idi-eccnyef I cna indf nhgtoni utabo ibtnamvi B3 dnyfciceie nognvvlii nobe.s B3 iefntccied tlresus in ale,argpl ihwt eth aclissc ehTre D'-s dteairsitm shr(a ecncakel no /CC34 droe)amm,te damneeti, nda dier.hara E) -aOacemorosts dFnuo tmsaol clsvyeleuix ni uoyerng pole,pe hsti bnoe ghowtr curosc at eht thrgow ,tpeal yapruclrialt at teh lroipamx nde of eht abi,ti idatls ned fo eth rue,mf or xamlrpio den fo teh shuuemr i(n the ogln sneob adruon uyor enkse or ta oruy slhus)r.doe It wssho a egar,l lodsi nrgiwgo ssma taht yam arsei het msuteioper ni a untbusrs masdoe'tanptrCn/ lt.garien )F rtPatiosc a-cicanomr earr ofr inbge noe ,of fi nto het olny tstacaeitm oebn cncera thta is eurylp stsltooa.bice

alexb  Great explanation, except that there was a question in NBME 22 in which the prostatic carcinoma was osteolytic. One of the commenters here looked it up and apparently it's like that 30% of the time or something. So I guess you would have to use the high output HF, normal Ca, high ALP, and mosaic pattern to "play odds" as Goljan would say. +1
qball  At least they were nice enough to put Paget disease because I had no idea what osteitis deformans is. +1
drzed  USMLE seems to be moving away from using eponymous names... so it's a good idea to see if there is a descriptive name for diseases. For example, they don't use the word "Wegener" anymore if you have noticed, since it turns out that guy was a nazi. So now they call it by what it is -- granulomatosis with polyangitis. +2

 +3  (nbme23#36)
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meruS scnesski is a eTyp 3 iyptisenhyeivrts rocnaet,i ni iwchh eht ydbo esrsnopd to acniteign ldiemca catsbenuss dna crdouesp iot.iabesnd ehsTe iitasondbe in aiuocltnirc etnh bnid ot the cntgnieia dgrus nad tse ffo het mmnepectol s.cceada iRtmduaeho hsiairttr is laso a epyT 3 tishtyrivsnypeie eo.acrnit

)A oiostsppA fo chaaegps-mro iaoptsops is yeallerng otn a ptey of pvhyyeiettsiisrn oicaetr.n B) sMta lec dnugalentiaor- iths si tarp of a Tpey 1 eyhitiiryspevtsn /l,htsaiyprnanaaoxcie in wihch samt clesl dnib EgI no rthie e,uarscf adn IgE bdignin ot teh eartgt geantni ecnsuid a iomntrfanoclao ngache ni het EIg htat tess fof mtsa lelc .nnglitadreuao C) altruNa illerK ellC -iiklngl asypl a vieryta fo reslo, gdunilinc ccnaer pisssorenup dan eurttsocdni of iavylrl nditecef .eslcl If hyet layp a roel in trehiipiye,sntvsy ti si prat fo Tepy 2 SRH ni wihch eyth ulowd onrsped to Ig no the llce f.screua E) leWeh nad flare raicsen-ot Tshi si saol a eTyp 1 .HSR

meningitis  I didn't pick this one because I thought Serum sickness was too systemic and RA was a more localized Type 3. Again, im overthinking things. +
youssefa  Goljan: RA is a mixed type III and type IV immune reaction +6
dinagohe23  I though NK cell killing was similar to T cell so and RA is also Type IV +3
nephcard  ,blll sdouof +1
usmile1  NK cell killing would be a type of innate immunity, not similar to memory T cells. because they did not give an example of a type 4 HSY, the answer must be serum sickness. +

 +8  (nbme24#11)
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Pirmyar tvoreinpen si an cvteai ptse eknta to head off ro tmgateii a s-eidase ntikh of tc.saiivncaon nI iths ecs,a ti is esltlfeyi ticodnmaioif ere)cxes(i to ehpl 0-034 yrae lod weomn (getiwh ngabire sriexece cna aettimig iosotspr,soeo ebientsf of bacioer )

eacydnSo rpnveentoi si eryla dteceniot fo a ees,sadi roomtgnip eayrl teeintvon.nri hTis dluoc linuce shtgin ilke IHV segttni eryve 6 mh,otsn ro ro nunaal paogmmr.hmya

areyitTr tvietenrinon is hperyta iigman ta cgunider itimpcna,csool ilagnolw ,rpslaee ro igrnimvop noc.tniuf ebincesntA frmo lcoahlo aym eb ereh uecbesa of asbtesncu euabs ,blomepsr ro ecausbe meso daegam orvuyiplse noed yb cholloa tocnna be nedpteevr. lmSaryiil ofr a low hcdtrybaeroa etid we amy eb niiagitgtm the ftescfe no bosemlmait atht eahv elraday been noe.d

sunshinesweetheart  p 269 FA 2019 +

 +6  (nbme24#22)
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Teh skye to itsh saenwr rea htta it is iyrfla ndedsu ni ts,noe nda gi.maesrt nNoe fo eth threo esswnra olcud iepanlx hte mneemovt fo apni mrfo flnka to QLL to rco.tums lWieh eht nikeyd senot oesd ton cltyalau rntee eth motrcs,u eth aipn can be efrerder ot eth l.ceessitt

 +14  (nbme24#20)
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Vibior calehro nda V. sictraamoplheayu rea enuqlyrtfe adiascetos whit innposomtuc fo coeodudrenk ofsdoea liek hshi.flels V. vuilunfics is doasteiacs ihtw bksiahrc earwt or srleatat.w

)A B. -eursce segivtetn tden to itacseoas hist whti edrheeat rice at a ubfte,f nigvtmoi si roem omnocm thna dar.herai B) .C jn-ujie ascdeoitas whti cdnroekoued o,fdo lpslcyaeei cnhc,eik ro nca be catendcort yb ntccoat tihw It eusacs ,mmyoalairtfn doobly e,rdhiaar dan may saol leda ot uBaerliaGnl-r dryones.m )C .C ensrnep-rgif as a ,roulrsotap iths is destaocasi ithw gdoo ttha is htdeaere tehn eltf ot meiganetr ta romo peuererattm rof a nglo emit ereobf pu.onscmtino pmmySost enilduc oimgntvi dan h.rierdaa D) .S au-seru a ahet sbetal nxoit duoedcrp yb .S eruusa is ietasacosd ihtw apdir stneo fo nvtoi,igm mya be ndampieacoc by .rradhiae tosM foetn seaaosicdt itwh driay dscoprtu dan amt.e

armageddon_oh  Perfringens is also usually a delayed response, can help in vignettes! +

 +13  (nbme24#44)
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sihT wasnre ssert on the riceeneffd tenewbe Flatoe adn o.onricevLu ecrtltaIhna txomhrateete is gvein ot cblok ddlaeforoythi ueectsrda R()DHF ofmr agknmi cfiol acdi niot H,DF dna ehtn ginrutn tath HDF iotn .TFH Tsih is nedo to neptrev hte iodcpnruot fo nerndtomswa sucdtrpo nycaserse orf ebslaomimt nuncigdli AND istssyeh.n cLuronovei ola(s dlceal TF)ymof-H-5rl can eb sude ot estspdei stih otrpudc yb bnegi upt iton apyl tw.dosnamer eeS hte idargam rhe:e gofmawialiomlmes/nri:otwo/treid.tnhtr-t.why-.dcf-/mn--g/adoaaou-eihp-ce-cdd eotFla si esitld sa Fciol ,diAc hxoeratmteet rfeeenitrs wiht RF,DH dna rooLicnveu si F-rm.o5Hy-lTf hTere is sloa ferrthu cnsoriptdei r:ehe 8w:0.cDgn1uwk/puarsdt5a/0/bdrhwsg.Bt/

hWy oesd itsh nto sipmly doun het atcoin of ?xteaeettmrho Tsih si asecbeu ynam scncaer do otn vhae teh ecrddue efltao rciear.r oS hte narecsc ckpi up feolta and tretemxhet,ao dan ihert NAD snhtsysei si curddee. Maileewhn oetrh thhyela lescl cna kcpi up teh Loouevrcin and atevs off smeo of the rtows s.ftefce mr,eemebR ocrevuloni ntcona be vieng aht.llcnyreait


 +16  (nbme23#3)
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ceuBsea hte bb'ysa rhtome sah Teyp 1 tbseaieD mleliuts, ti si lseualpbi tath yhte had etvaleed bdloo seulgoc veesll dgirnu ro hrytols ferbeo r.htbi lnIisnu seod nto cross eth atp,aecln tbu gclseuo sdoe, so rgnuid trbhi the ontnaee wldou vahe nbee cgyeper.hmcily hsiT ouwdl dela to eht naoaeltn nsarcpea ngeiersal s,ninuil dginriv csuleog tnio sllce nda nnugitr onwd sceouegsg;lnieno stih si hwy hte byab is oycpgehmylci hrigt no.w

B) aecsrdeDe lgogneyc n-tcrocoinaent I 'dont kwno the yglgneco oinncentctoar draomcpe ot an tulda itetna,p tub a dercesae ni ncyeoggl otacntrncnoie oulwd ietcadin lo/nygeglueocgsc r,esaele wchih wodlu otn eb a pygcmlieyoch etats. C) ceseredDa yegonlcg hyastnes vyiatc-it dresadece onegylgc asetyhsn vtytaiic scdiainte eygrne ta,lsabcmio and dwuol adel ot irhegh meusr suleocg sv.leel )D eecDdeasr remsu sliniun -teorotacnincn cddeseera resum sliunin ouwld elad ot hhiger llesev fo cuoegls in eusr.m )E ecnserIda seumr iinuleksi-ln otgrhw -ctofar IGF esdo nto idbn lenrya sa well ot siiulnn srercopet as liuinsn ed,so dan so lduow avhe ot be ni lteeymexr hghi contriensoanct ot ahve tish .tefcef IGF si tedcaosais hwti tcmasoi throwg nda mlcesu dp.eetonlmve

yotsubato  His glycogen concentration is high, since he's been hyperglycemic with lots of insulin until birth. +3
alexb  Also explains why he's 12 pounds. +3
krewfoo99  Also, think of it like this: Insulin causes hypoglycemia, thus this baby must have increased insulin. It is also an anaobolic hormone which is clear by the babys weight. Insulin increases glycogen synthase activity, and causes an increase in concentrations of glycogen. Decrease in insulin would do exactly the opposite +1
tyrionwill  fetus of a mom with DM will develop pancreatic beta cell hyperplasia, which leads to insulinemia trying to reduce the blood glucose. after birth, the excessive blood glucose will be automatically withdrawn while the insulin at that moment is still high, which leads to hypoglycemia. +1

 +4  (nbme23#7)
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tA keew 8 in atsonlgiaet emvleotdnep hte dvnipgeole gtu srhneetia tuo fo the yreomb adn engedruso ifgnastiinc htwr.go tA keew 10, hsit otaetsr and si rsoeedrabb tnio teh laionbdam icyvat. liaeFur to eclltempoy robsbrae eht ugt nda orteta ryorpple can usletr in a mnberu fo d.esetfc csGitissharso is ferilua to llpyeecotm rabesbrdeo the ,gtu vnaeigl meso iceutso teh bmo,neda whit on ni.vgecro ectet:Rc2%afneepredyl.aho/inonF0t/lm.eemptmeoptovergth//l

)B tMdgiu svuullv-o ucorcs as a suelrt fo notoaaimrtl as eht gtu si eeadbborr.s diiOnlayrr eht mcceu is dleh ot the akbc of hte QRL yb suobifr In het tneve of dtugmi o,vvusllu esthe nbsad (asLdd' s)bnad ear ilstl ahdettac ot het wno edicdpsal ccmue ni eht U;RQ eth mssrecop on eth ,iintnsetse geepvnnrit dofo morf nmvgio thgohru dan fnteo ngaicsu usliiob giotnmvi in wrnsn.beo C) emh-alpOeclo a cdtfee rmsilia ot istso,arsigsch but eedrcvo yb het elhpocoeaml cs.a )D labicilmU ehirn-a the utg si tnrieeyl ordebebsar ni teh mboane,d utb a etedcf in teh ucmlasru wlal rlngoeviy ti awllso enotaml tfa ro tgu ot sipl hgrothu dan gbelu uot aenr het iiuuc,slmb sillt atehbne eht ni.ks hsTi aerihn si luuaysl ecriudebl tiwh rspr.seue E) haclraU t-iafsul ureiafl fo teh hauusrc to oec,sl lenrigsut ni eth ienlakg of enriu ofmr na ngonepi arne het bc.ilmuius

 +7  (nbme23#8)
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loabateLl si a eilcentnvseo la-pah1 dna Btae areeicrdgn oatn.intsga nI het areautlsvuc, a-hal1p cotserpre aer serbepinsol rof lucraasv nttsocoirnci hcwhi secenrias odblo espytrscmreusi/se arsvucla iserst.neac mAiasogntn oudlw edecreas het PB. tA the ames ,ietm 1-teBa sprtreoce in teh aehrt rae nbleeirssop fro a ovpesiti ipnocitor adn ihtoocrpcnor sfeet,cf ercgainnis tobh tehra reat dna rocnatytictl.i mnagotsAin ta teh 1eatB- tpsrceroe ni the htear dwoul acrdeees eatrh e.tar

A) eotruAlb-l rstho gctian Bt2-ae tsaiogn, sedu fro inbocniolahdtor in hte erThe is ytlcpaliy no egrla tmycesis .opsanirobt C) -inlahPtenoem a ensine-covelt 1-hlpaa and hal2ap- ereerlibsv eptvticoeim totgnnas,ia ti nca eb sdeu ni tseivnrehype eeeegcsirmn ro in adyRaun onnoenmhp.e It wdolu ton efceft eahrt .atre D) o-zsrnPai na aphla-1 tanan,tsigo it nca be dsue to etart enpsiyehotrn or ot tetra sgrmhtaein coidatsaes htiw SD.PT tI lwoud ont ftcefe eatrh atre E) lrl-poPnaoo a cancoiter-vln-eseodi Btea singtaa,otn esdu fro nmya aricdac su,ssie for ,yxainte nda in s.orhhomceomptcyeo hsTi owldu ont ceftaf ytsisecm sralaucv nseaecir.ts

 +7  (nbme23#15)
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rtvaasinPat si eht oyln tsatni gurd not leiemodatbz by hte 04P5 sysetm ni the erilv. Becueas fo t,sih ttnasaivrap si laso unuqei ni htat mero fo ti is rceedxet yb hte ydksnie naht nay rheto atitn,s In dadiotin ot ohpysimthrodyi siht tietpan sah mldi rlena u.lrfaei iTsh iwll maripi xnereitoc of ,itnaaatvpsr ngldeai to caieedsrn ansatipvatr nad tis lio,mtaebtes raicngsine sti taeoinlpt rof igcausn oyhypmta.

B) Nrps-hieaoshtili lhwie eht patneit si cehm,alcpiceyr psrinttavaa eosd not aeesnirc the cinceeind fo ekydin o.tnses )C -irscatPtnaei I od ont know fo nay iicasitfnng actortneniis netwebe teh naracpse adn sttrpi.vnaaa D) ocxiT et-hstiiap ehwli stasnit anc eacus limdyl eavdeetl lvier nntofciu sett ors,ecs heyt era rlygaelne otn atdceiosas ihwt iotaxpyt.echito )E yeTp 2 tibaDese smt-iuell I od not wnko of yan ecffte ttah riavttasnpa ahs no isebtade or stebeadi etoimi.sndca

motherfucker2  Lucid. Nice +
qfever  But isn't statin associated with hepatotoxicity too? FA 2019 page 320 +3
srdgreen123  @qfever. I think thats why OP said that statins are not metabolized in the liver. +

 +16  (nbme23#5)
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hisT ptneati hsa weeddrsapi scnuriotted of thob nldaaer sl,ngda hcihw anmse htta seh liwl leso tohb rhe crsniooidraeitolmc dan hre sorccoi.goltcuid hTe slso fo het droocemliisaoircnt dna het feftec on teh esndiky si thaw si genib eedstt nehW oelsdtnreoa is iifgtconnun adn daatn,bnu ti sha svaleer aiilctrc fuosnicnt on teh r.hopnne Fst,ri it uapgseulret +NK/a+ seTAPa erioxspens no eth aebltrasalo ebanermm, igihsnbatsel a gsotnr tmcceolelriheca tgaeidrn thta rbtete sosbarb ,a+N ehilw teh ircdnesea rcaeiltuanrll +K cnonacniretto kamse ti asiree ot elso K+ orfm eth ellc toni eth nume.l eeAoldtnsor oals leptsureagu teh renixsepso of ltlaiiephe suomdi snhnecal aEC()N no het icolnegtcl ctd,u bosgrribane mreo aN+. ayinFl,l tnsoeoeardl ceassnrei irpxseseno fo H+ sPeaATs on l-ahpntcarieetalda llesc fo eth olltgcnice tu,dc hcwih rae esblpsoneri ofr gsirnetce H+ i(ths si tarp of rtaiootcncn llsa.ika)so

tiWh hte osls of rteeano,sldo we lwil ese a sedeercas Ka+/+N igartend dan eeecdasrd +aN ororinbpts;ae itsh esdla ot darsdceee eusmr uisdom dna cereansdi seurm iuamsstop. At eht easm ,mite otn eresxsnigp H+ TAaPsse lwil dlea to +H ton nbige teecsdr,e cgeartin a rmeo idcaic mienvnrtoen (pH iwll ese).eardc

abhishek021196  Very well written explanation. Bravo +1

 +19  (nbme23#28)
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roesortiP crod yredsmno urocsc edu ot ntncrfoiia of teh troesiopr half of eth splani rc,od romf oluiosncc fo hte rtieopros ilspna yr.rate ruO itentap ssenptre iwht adercedse onaisetsn to cpprkini bwelo the elelv fo the eensk as well as lagiknw twih a wdae-sbied ,gait ellyik icintgadni sosl of tcp.pieoopirrno The eptiant is loas cameni htiw endygtperhe-mse r.eontlisuhp

regmeespdteynH iolpnhtersu rea tylcplaiy duesac yb na nyliiibta to eakm ohunge DNA, audsec by a kcla of esrncaeys psecrrorsu nad ivasmint iunnligcd B9 oatlf()e and 12B i)(bcnl.amoa If hte nptetia is taleof eitcnfid,e we ese vteedael ihntsoymeoce nyec.eciidf fI the atpiten si B21 iftc,ednie ew ees vealedet actmohilyemln daci and iteoyshcnemo lvele.s ecnaypreieHyhmtmosoi nca csenaeir mobhrtsois. bsioormsTh ni eht sotoeirpr splani rrtaye acn ceaus oisoptrer crdo eyrmsno.d nI ,dodntiia aclk of mtvanii 1B2 aisripm iyenlm fitrnmaoo dna esdla ot etuuabSc oeCmbnid er,neegoianDt ciwhh fcfesta hte iatmlinacShpo crtat cnng(aictou ofr aesdecedr ikipnprc ,ssnetnioa) ooilprtniCacs tac,rT adn rlDaos ComdulMnlae-i meLissucn aTctr giau(cnnotc fro het ddruece tppnco.ioroeipr

)A rrtoenAi codr reomdsn-y lsos fo mroto aomnm,cd sa llwe as labrteali olss of ehat adn inp,a the itanept sha not ltos torom ionntuf,c os it ctnnoa eb tish. B) arentlC ordc meory-snd pnesetsr as a nocibmtiaon of oormt nda yosnsre ,lsos ausluly itwh ldbrdae in.ftnyosduc hiTs iptaten sdoe tno iyaspld rootm ossl or ardbedl sin.nyctdouf C) imoedHrc rdnsemy-o sAlo elcald eBrrdo-Swquna, hsti is clemtepo inujyr to eietrh eht tlfe ro ghrit sied of eth pansli r.cod It rpenests htiw oomrt inoufcdysnt adn feelrx iutfscnydon ltaepiiasyllr at hte lvlee fo eth loie;ns slos fo upper motro dmacomn elobw eht olisne raiiyslealltp asspcit( is;parse) lsso of oasrld -cecilmurdnaro sitoannse litlaarsylpei ta dan blewo het oeinls; nad lsso fo ipan adn emtupearrte sonnaites yaatlrcnlaeltor 2 to 3 rrbaevte lewbo the nsei.lo )E gaeSeymnrt rsmneo-yd a cnaongeitl iulefra ot eovldpe rpta of het lspina dcor. hTe wne teson fo ysomtsmp at 82 arsye old kemsa sith an ilelnyku nis.g,aidos

yb_26  amazing, thank you! +
aisel1787  great explanation +
rockodude  sensation to pinprick is DCML tract. SCD affects spinocerebellar (not spinothalamic), corticospinal, and DCML. otherwise good explanation. +1
azibird  Sensation to pinprick is not dorsal column-medial lemniscal tract, it's spinothalamic tract. So this patient has a lesion of the dorsal columns, spinothalamic tract hypersegmented neutrophils, and anemia. What the hell is going on? How is this just posterior cord syndrome? Spinothalamic is not posterior cord. +4

 +10  (nbme23#47)
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rBiiCddauh- msroedyn ouccsr ewnh trhee is lcioouscn fo hte ahpicet nvie or eth pacithe inev ilsaf to nradi otni the .CIV hiTs nac be sdceua by isorhbotms fo eth hicpeta ,eivn ro by rhtig sddei aetrh aleufir (agcnuis lbodo to cbak' 'pu ,rwehveeyre btu ist ostfamnnetiai hohtgru eth pechati ievn ear all het gnsis of udiaCdhr-iB ondsermy). iAnntyhg htta acn iercnase het kisr of rsibostomh can tneh aiesecnr teh sirk fo i-idhrCdBau .roeydsnm iThs decilnus yyahimcltpoe ar,ev a rohpaaeyleblcug ts.eta rOu pnatite nda VP utb dsiems shi pmnapettion tow ekews gao. He now ptersesn iwht rslcela ritu,ces na erendlga rle,vi and some ngssi fo oplrta ynpiesrt.oenh hibmossrTo of eht lony aaitamncol iopotn tnrpeesed htta corvse lal fo tshi si het ihtepac eniv ie our tteainp hsa .rdBCa-dihui remmRbee ahtt iddhauBi-Cr wlli aveh a une"mtg v"eril apaepracen on srgso ptaohog.yl

)B ateipHc o-irsircsh s'ti lnyiteer obslipes our tnpaeti edso aveh cptiaeh siorhscri orf lnarudete ,sneraso hreweov the cteau etons mkesa hsti ssle lykeil. C) renaPiccat i-macocnar nptacricea ccriaanmo crtsbtnouio of teh cmonmo blei utcd lcoud acuse a ac'bk up' of ,bile aiymttlule ngcsaui smoe elirv aaemgd dan elrcsla stceiru. wevHero ceno naiag het nmtigi amkes itsh ukeyn.lli )D Potarl vein -brooihstsm arpolt inve sothmorbis udclo uasec seom ilepnsc tegleaenmrn dan olratp er.ehnpotnyis eweH,ovr its stntobcioru ouldw otn uscea a ndr,eet eglednar ierlv abeescu it si rmaup.ste E) mrPraiy eocisos-hartommh deu ot a ecdeft in hdcipine dtroino,cpu isth rion rlvoeado ptnreess tiwh daenrdke ks,ni nuniisl edinagruo,tils teihcpa aegdam hwti( teh taonpeitl ofr herplolcatlaue anaomcirc) nda ahtre isdseea icvtrters(ei or letdiad od,icyopmarthay pddeegnin on ryou re)s.uoc hTe lnyo eno fo esthe issgn htat rou teitpan sha is na eldernga ivrl.e

almondbreeze  FA 2019 pg 386 +

 +35  (nbme23#44)
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A and J speterern het ciregal s,sufaicluc ehilw B nda I preretsen hte ctaenue lu.cfuacsis Tgerthoe yhte kmae pu hte adlosr emluncm-iload menslcail ctr,at beoeslpsirn orf onitippn pcirtne,eop rtcrpinepopio,o tnrovbi,ai dna essurerp. tnpIu si aitalpeslr.i

C dna H kema pu eth aerlatl ioptsoclrncia acrtt sa(ol edlcla the alalter lroesbrepniac )fiulsu,ascc nsirsplbeeo rof trmoo dacmmon of staplaleiir si.blm

D dna G srrtepeen het tlerlaa lhimaopnsacti ttcra. It si orssnipeebl fro pnai and eptmertreua nnd.cuotcoi ehT untpi iesasr ni a lmib (left ewolr ryteitexm ni hsti )c,eas tseren hohgrut teh ardsol root ir(dtpcue ewtbeen J dna H,) eeastdsusc dan anedscs ta eth irontaer emmcusisor j(stu dibnhe E adn ),F nad fllnyai nepssysa no hte ceosnd roerd uonern ni teh araltle oasiniplahtmc rt.atc oS hte ihacpamontsil tatrc si seibpolrnes ofr nerlaaltaotcr ipna nda meteteurpra ntsneas.oi ceBusae uro ttiepna sha lots ennsitaos on eht t,efl hte enslio si in eth hrgt.i

E dan F are eth ierrnota oilcrcsaotpni tI is vvodilne ni toomr ooctnrl fo lpxmoair scmls,ue plcltyyai of het trnku.

nor16  good job +5
jimdooder  Pretty infuriating that this question has the standard R and L label while the other spinal cord question had it flipped. +2
larry  A and J represent the gracile fasciculus, while B and I represent the cuneate fasciculus. Together they make up the dorsal column-medial lemniscal tract, responsible for pinpoint perception, proprioception, vibration, and pressure. Input is ipsilateral. C and H make up the lateral corticospinal tract (also called the lateral cerebrospinal fasciculus), responsible for motor command of ipsilateral limbs. +1
larry  D and G represent the lateral spinothalamic tract. It is responsible for pain and temperature conduction. The input arises in a limb (left lower extremity in this case), enters through the dorsal root (pictured between J and H), decussates and ascends at the anterior commissure (just behind E and F), 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. Because our patient has lost sensation on the left, the lesion is in the right. E and F are the anterior corticospin +1

 +11  (nbme23#39)
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srt,iF ,cartlilciy ti si nto sbrdecdie as ino ntiidaaro ahla(p nad tabe )pciaeltrs but sa aiiadnort atht hsa na aizniioont ecff.te rOu armrfe ash been tou tsadngin in hsi l,dife agksion pu eht l.sguniht UB-V is ewva idoratnai ttah nuceisd the anifootmr of efre .riadclas hseeT free salciadr in utrn od mageda to eht lc,el unglidcni eht anmoirtof fo prenidiimy .smiedr sihT AND aeadmg si teh bssae ofr his susaomuq clle aancim.orc roF eomr no BVU- incudde eerf acdrali damage fo ,DAN s.5mh6wtvmu6ip:/1b//wic4g5/n.wdnehp..7lbn6to . roF mero mfanootniir on UV riaaitnod mrof het mrniAcea ercaCn ecoSi,yt leepsa ivits sxmdvu.cec/i.wai/.i-olvestrie-nhhaarrtecstg/s-rr/octcn-iwarau-/aiutu:odpndee/wi-chptovrnwoca/naursa-tana

)A eacsreeDd niufontc of the sink sa a brrraie ot sogcrien-nca hte ptniate sah no sorytih seugtgs osxeerup ot ecsagninorc seidebs VU hlg,ti dan sa gonl as eht nski si icantt adn reyevtlail etlhayh ti houlsd oincntfu as eoms inkd fo ba.rreir )C deIersacn ercnisvnoo of 32D-5 to 13,-25D - hist nvrnisceoo astke clpea ni het iedknsy iva a1-el-rdhxpyasoyhal, loas rsepdsexe ni rmagosulan a(dn os 231D5,- is netfo leeevatd in rssoic)daois. hsiT uodlw tno eaxilpn rceac.n )D resIencda ictoimt icvyiatt orgthhu snuttomilai of neytseomc-al uor enttpai is anidgedso whti soausqmu cell manrcica,o ton E) cnrIaedes siticyebpisltu to kins aart-mu hiwel eth gamead ofmr UV glhti ot nllagoce odse emka iskn rehtinn dan omre rildaey ddamea,g ihst udwlo nto apixenl osqumusa elcl r.aocmncia

 +10  (nbme23#6)
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Blrnrdoeie roliapsenyt r-dodiers iegslnfe fo "tpi"nsm,see isdctuliyia, u-fillonmest,ait entlaubs nptselhroi,sia and roem mnomoc in onmwe atnh ni A momocn efdesne hmienscma in this soerddri is gltp"sitni" in hiwch epeolp aer nsee as elinrtye doog or tyeernil ad.b nedBoerlir oteypnalisr irdodrse si olas part fo hte Ceulrts B rptlnosayei srd,osider which rea iocsasdaet wtih tsncsbaeu au.seb

imnotarobotbut  Suicide attempts are also commonly seen with Borderline +4

 +21  (nbme23#42)
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heT tnapeti ash a porri itsryoh of rmyoctseyeth itwh ltireaalb -,rnopogosctlpeyihomao dna dcvreiee nrlxteae bmea adtiioran ot het .vspeli hTe teaptin wno sapyisdl hsoedrirpnyosh nad tu,ererorhdy with distla atrleure rgaoinrwn tb.aylalrile Teh eltliisek tnooip si taht ew ear senieg sdnihaeso fomr veisuopr gerusry stoincctr hte esrrue,t uingacs

E) alrleihtUo oaimacrnc ao(ls lcleda iltnnaoirtas clel imcorc)naa is laso a islpbsiio.ty hWat aeksm thsi uniykell is the oaltin:oc bilea.altr hTe rroip ttremoceyysh dna lretiabla -rosoooyoalgcmepnhtip wldou eavel sarc isutse no htob idses fo eht bod,y ubt eth sddo fo arhetoulil ocaamcinr rsaiign trlaalyleib era evry ls.mi

A) The iatptne adh a yreoysctt,emh so het dsdo fo uerretrcn rcvlaice namrccoia aer slao ednylirbci wol. )C dna )D heatUrlr noolcmayd dan rhrtuael tinaroinaslt elcl oamipallp rea in eht nwgor tclioaon ot cutnoac rof aleliatrb uharertl aonwgirrn ihwt eho.rrytuedr

stinkysulfaeggs  Great explanation - just one addition. The retroperitoneal fibrosis could also be a direct consequence of the external beam radiation. It's linked to both causes. Either way, it's a better fit than urothelial carcinoma (in retrospect). +12
spow  Why would the onset be 15 years later though? +3
drzed  I was thinking the same thing @spow. I had put urothelial carcinoma, thinking that a field defect would result in bilateral tumor. +3

 +3  (nbme23#9)
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oFmr isrFt -iAd psiyohtzacl lsenpeistoair tiibehx enictcrec arnap,eeapc dod sefblie ro aimlcag gi,htnikn dna prlrsneeiotan awrwadssk.en heeTs birscede hte lvrasee larsye fo chet,sol ilebef ni ihsccyp aetslibii nad ylrtscas, dan oopr eye ntotcca.

A) ol-dnrirBee ubtalsen oodms ihwt uliismyp,ivt tfimseoat,inlul- tadcyli,isui nda a eessn fo ,psinemtse anogl thiw a gertrae hiikloodel ni mowen )B nDetep-dne eshot tihw na secesx need orf psoptur nad owl ne-efieodfnlccs H)nCic-otiris eveceisyslx te,nomliao seske etoanittn, yuexalls e,voiocvartp dcncnoere wiht ernpacapae sra"'(oct "adies)es )D -isrtsciaiNsc roiig,tsdany t,dlneite csakl pteh,yam admends eh't 'sbet )E dihocSi-z lyaontuvr scaoil ahw,diwalrt eitdiml nliotameo ssoneripex, entntco to eb no itrhe own

abhishek021196  SCHIZOTYPAL = Included on the schizophrenia spectrum. Pronounce schizO-TYPE-al: Odd-TYPE thoughts. +

 +10  (nbme23#22)
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CMH I uctinofn si alrengti to anrcec irossn.upsep CMH I isydspal gnusonoeldye ztensysiedh tsrpeion nda nereptss meht ot D+C8 T sl.elc hTe ureliaf to dilyasp HCM ,I or MHC I adsiply of lse-nfno a(nd by xnotenies raesuconc) nrtipsoe ggrirest a calerlul emunmi srsenop,e enadlig ot douecsirttn of het cll.e

The oseroeapmt is sude rof eth eagoidtdnra of nwro ,tou nt,eesencs or dfmoearml nosritep. sA cnrcae dveleso,p roem ntiousamt dlea ot csaiednre ognrw tons.erpi lOny by eisseopxrn fo teh taepm,osroe or sit is,spee-rxvooenr acn thsee nmttau spternio eb geeddrad afst eunohg ot nto eb dediaslyp yb MCH I dna leda ot eth ellc ginbe kliedl. orbzoimBte bsolkc eht rpa,eootmes os eth umtnta eoirtsnp era siadlepyd on the f,rsucea lwnlioga het mumnie sytsme ot cezoenrgi nad klil gcihaloltaop cl.sel

catch-22  Another way to approach it is to think about MHC class I processing. Basically, if you inhibit the proteasome, peptides will not be generated and nothing is available to be loaded onto MHC I (remember MHC I has to be loaded before it's transported to the cell surface). Cells that don't express MHC I get killed by the natural killers. +21
kai  "In conclusion, we have demonstrated that the proteasome inhibitor bortezomib down-regulates class I and enhances the sensitivity of myeloma to NK cell–mediated lysis" from the conclusion of the NIH paper +5
maddy1994  another mechanism is by blocking proteosome u even decrease degration of proapoptotic it enchances apoptosis(from uworld) +3
azibird  But CD8+ and NK cells kill via perforin! Why is this answer wrong? Is it because it's not the primary effect? +1
testready  "The proteasome is the major source of proteolytic activity involved in the generation of peptides for presentation by major histocompatibility complex class I molecules. We report the new observation that bortezomib down-regulates HLA class I on MM cells, resulting in increased NK cell–mediated lysis." +

 +6  (nbme23#40)
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slamPa nemsbemra era a ipidl yl,rabie iaylcptyl htiw hoaspthpe heasd no ache ucafesr adn olgn norcba laits no teh desin.i eThes oncbsar are ulren,ta dan oerungd ohiphorydbc triitcansone rfo na lyeaneecrglit rfoaalbev etst.a

glIneart aenbrmem tnspreoi asps trhugho this diilp ,ilreaby dan so tmsu be aablpce of iacrtgennit boht whti the orpal tesonsvl fo tulcarrlailne dan aelrretxclual seca,p as wlel as teh hrycpdihobo ceor of eth elry.a eTh ebnmsanmtarer onprtio oeftn has ailepaahcl-lh cadsrynoe ooinoarntmf,c whti pcroobhyhdi drusseie ikel yglcnei on het euiostd wdrtoas hte ronbca itlas whti roalp oaimn icda uriedses dcekut .ni

makinallkindzofgainz  "high school biology" lmao we really out here +6

 +7  (nbme23#14)
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eTh atnipte ertdats ienercigv scui-srtalpog ucetbusasoun aiuaalnooigntct yreathp, so otms ekyill eeihrt fanaidtocerntu penairh ro low rmeolaulc teihwg L)(MW ipaernh. detrnnaatficUo 'seaihrnp ayiprrm tucnooatngliiaa iyitalb esmoc mfor irkwogn htiw ihatotbrminn III ot lkobc gcauniaolsot afrotsc II dna X.

o,eHvwer aernphi nac saol nbid to a ttpllaee ieopnrt cdlela teeaPllt Focart 4 4)P(,F fnodu in enhlulgpras-a.a eWnh it bnsid 4,PF the wen ahFrpePn-i4 ceueomll is igmuneonmc.i eTh emiumn epnseosr ot tihs sreengtea -nnPietaFh4ipr-a Ig. leletatsP yraaeld evah gI eesorcprt no ehtri fcsr,eusa os nwhe sethe 4P-arnh-itenapfi Ig rgigetr hte ecrtropes on eht tspe,ellat htese aleleptst luetedrgan.a The oinaauetnrdlg ksikc fof ehurrft ctignlto, igneald to a ordp tofen( moer ntah %50) in tteeapll co.ntu


 +4  (nbme23#46)
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scieTneltycar rae mulcaic thcgneial aseBuce fo sh,ti in a lvignoepde utfes or idlhc etyh will dinb ot acmcuil ,oisedspt mnylea teeht nda .besno ishT acn acsue lcul-kbabe arioitnosdcol of tth,ee nad si ndnridcaciatteo ni atngenpr hemsotr for ihst senrao or in nliderhc erndu 8 aseyr fo ga.e dyaAdl,ontili tshi aesm elcmahic ytrproep of ndigibn to macclui si wyh ecratni ltvidena scotian ,cua(limC eiua,nmgsm inro +2Fe])[ veretnp antsooibpr of ,cstrlneiytea dan os imdsicnee wiht sehet onis a,ias(dntc niro ulintnpapt)eeosm ldsuoh eb medti tno ot feeirernt iwth bopntris.oa

 +18  (nbme23#18)
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enEmyz A sdsnta ni ofr oilspahpsPhoe A,2 nugrint phoiliposspdh ni eht clel amrmneeb inot dcianhiocar dc.isa orFm rhe,te nmEeyz B tsdnsa ofr segycyCoxoelan ()OXC, wileh nyEmez C dssatn ofr epo-ngasLyiex5 (OL-.5) O5-L sedocpur E,E-TH5P ihhcw is retdun into k.euletisoenr neueoekirLst layp a doulbe leor in nvstee eilk ahs,tam ausebce hety cause rstithrboocnnocoinc (enes ni itsh ta)etpni nad yb agitnc as aclhmeci atasnatttrc orf rlotminaayfm ll,esc wheos vtcytiai lilw eclso eht awyiar utfher.r By kongbicl XOC usrpeamyl(b htwi an ),ADSNI we veeal oemr of eth rbuatsets ahrciadconi dica orf 5-XOL ot amytltluie rvntcoe iotn seeoi.tknerlu Tish is hte asibs for haisastriaimrtetolnnap,-n- chiwh is leyerfqtun ascasodeit ihwt salan .olppsy msS'tr(ae r)d.ait


)D yilsrctanPco hetssyna . )E aobehTornxm tasehyns

 +8  (nbme23#30)
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eTh atnpeti tdnneurwe vremaol of a leract urotm icwhh ahd tvenvmionel hiwt eht .aotrptse ehT iascrtpto lpcause is hric ihwt eevrsn nligcdiun the iclevp cnhnsilpca seev,rn a tes of cpataerpyshitam srnvee eosbelnrisp rfo PNS oonumatci onrag.teuli ncEitrseo aer a phicatasmyertpa .ocntnfiu

A) rGya rmia mfor eht tehciaytmsp ahic-n inceoetsr rea a mphaeysttrpcaai tfncni,uo not ttcmphiyase. mioEnssi of spemr is a acpteymshit ,toncinuf adn is terceidd by teh nroeiifr rchsipaotgy n.reev )C dlP-eaund eht endlupda nreev is a scaotim enrve ttah rvciseee seninoast mrof eht n,spei orposerit ,sortucm rtil,ciso dan i,abla as elwl sa inbge eblisnorpse ofr eoms emevmnot fo teh liecvp o,frol adn juoalctani.e D) operruSi rospiyhcgat en-evr a yiatmcestph rev,ne stih buiterotncs to het yaotchigspr sluxep dan amy aslo tiuoncbrte ot ytesciahptm ocrlnto fo ismeoi.ns E) alVnrte imrea of 2-4SS- heeTs rima toniubtecr ot hte dldeanup reev.n

focus  Diagrams here are pretty good too: "Point, Squeeze, Shoot" Point- erection: pelvic splanchnic nerves (S2-4) Squeeze- emission: superior hypogastric plexus Shoot- ejaculation: pudendal nerve +

 +10  (nbme23#34)
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ehT enlgis tmso rtiomnatp ghtin auobt shti rosgs plooathgy si ttah eth sisaeed si numlluradoit. shiT ntecsiadi eeaamtstss mfor natidts .essti

irevL esbcasess are suauyl ,slurniag filedl tiwh cyamre loyewl s,pu nad yma hwso a fiobusr lpcsaue. oirirChss enfot wssho a lwoyle coorl edu ot tytfa nhagce as wlle as egrvienetear o,sdlenu chwhi ear not erpnste A aofcl aodunlr epsaphrilay si a aungirls umrot of eth ,virel and hsti si ndmtoui.arllu tetiapHis B is a leltit edhrra ot huisidnsigt ceaesbu frmo whta I anc llet ti nca be rudaontlimul in osem s,acse ubt thsi vrlie osla howss onne fo teh rlssecios morf hrnocic mlnnifaiamto htta odwlu eyilkl oymapccan Hpe .B Flyaln,i we ees no kadr ilrasctnoidoo to tiancide o.ctinafinr

monkd  It doesn't explain the sudden death, but I suppose they aren't asking for that! +4
charcot_bouchard  I hate this type of ques. Here it is. Tell me what it is? +2
divya  also, a liver infarct is unlikely due to rich dual blood supply. +1
drzed  @divya Rather, if there was an infarct, it will be hemorrhagic, not pale. +1
llamastep1  Multiple solid lesions on a healthy liver = meta. I assumed breast wouldn't meta to liver (it's usually GI cancers) but it makes sense since all the blood gets filtered by the liver at some point. TIL! +

 +22  (nbme23#25)
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ailciCtr inptos rof isth quentosi: 5 eyra old b,yo pnmdsueesismpour ubeaecs fo rechyat,ohepm 2 ady torhsiy fo erve,f ouc,gh stesshnor of tr,bhea blfeire (0.811 )F, tsasrreioipn /6,nim4 whti icssnyoa adn egedliearzn uvaielrsc s.rah Esintvxee aronlud ilann.fioirtt

Of the osonpti lisetd lony asseelm adn ZVV gevi a ahrs. A asrh rfom measles asuully sartst tsarlyolr dna ceedssdn acu,lyald nda si tlfa nad ahett.suomrye By oatrsntc, VZV (exich)cnopk etrsnpse htiw iadenezlger arhs ahtt iuqykcl tassitrnion ofrm ralcmua to laruppa neht to virclu.eas

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! +4
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +1

Subcomments ...

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atPient has a crueraft ot eht eriforin it.rbo Tihs cna gdm V2 or artnpe eth RI ulemcs. yOnl IR tprtenname loudw marpii i.svnoi

nlkrueger  if this isn't a globe rupture than idk what is tbh +11  
mousie  the air in the center of the globe made me think rupture too ..... +3  
sajaqua1  There may be some global rupture, but impairment of one of the ocular muscles causing diplopia would still be the best explanation for this patient's double vision. +11  
catch-22  Globe rupture leads to entrapment of the IR muscle which causes diplopia. The question is asking what is causing his visual complaints, which is diplopia, not loss of vision. +2  

submitted by sajaqua1(462),
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aeMl attenpr gla/dcodiasnren.snbe laeocipa si edusca by hte ctefesf fo esdreooostrtdethiyn HTD)( on het sikn of het cp.sal rsooTnesttee is ndceorvet by het mnezey l-uted5hacaer-psa toin T.HD aFiserdnetiis a aa5dtr-e-eucs iiohi,rtbn dna os sklocb eth pnruoodcit of TDH dan nac htla or eenv asuce omse resevral of maek enrttpa asslbnde. oerHvew shit asme tytvacii mya osal ruslet ni isacfningt ualxes eisd tcffsee guidilcnn ,yoaimactegns leciteer fosc,tnundiy yjuraletcao yof,ndctsuni adn edceedsra li.bdoi

A) aD-lnazo a waek nengarod wiht nanitcoeirgtse efest,cf usde in eth ttamreent fo msdneioseitro nad iyccftsbrio aerstb diseae.s )C rtytostleheee-ntsoM incsehtyt T, it is sedu ot sunetlpmpe ni soetneeosrtt dien,fceciy or ni hte atetmtren fo smoe esbtra e.csnacr D) daOelonnxo-r an aicnlboa ditsore edus to egainr iwh.get E) noSzot-aoll rnotaeh lnboaaic sdit,ero thiw aotnplite seud for reerahidty neaoa.gdeim

sajaqua1  I am embarrassed by these typos. +  
drdoom  lol +  

submitted by shaydawn88(8),
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sI ti rornaaeia-vtll artntsseaud uecsbea thsi ptnaeti thimg vhae HF dt/ a. bif nad elft itaarl eartte&nnm;lg-ge cni adyohctrits sts;e-eg&rurp ansautdret lraupel ?fueifnso

sajaqua1  Basically. +2  
medschul  Why can it not be arterial hypertension? +2  
meningitis  I think Arterial HTN is referring to Pulmonary Artery HTN which would be present in LT HF in the long run with RT HF and edema. Pulm HTN would cause a backflow, and doesn't really answer the question "explain the patients Dyspnea". At least, that's how I saw it. Hope this helped. +5  
sugaplum  the question has 2 murmurs, so does she have aortic stenosis too? i guess it is not relevant since it asked for what is causing her SOB +2  
nukie404  I guess pulmonary HTN would happen in response to increased pressure after the edema happens, and would cause backflow (to the RV) over pulmonary edema. +  
vulcania  There's a really great diagram in UWorld (QID 234) that explains what happens as a result of mitral stenosis. Very similar sounding to the patient in this question. +  
srdgreen123  @sugaplum, yes rheumatic heart disease can cause mitral and aortic stenosis. Rheumatic aortic stenosis can be distinguished from degenerative aortic stenosis by 1)coexisting mitral stenosis and 2)fusion of the commisures. +1  

submitted by seagull(1112),
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sihT si a napic tatcak. yrteltvoepanniHi sodrp pOC2 gdinale to a yiapoerrsrt ai.loakssl po2 is arletively atfencfeud 'ntd(o ask em h)w?o

sympathetikey  Yeah haha I had the same conundrum. +  
sajaqua1  If she's breathing deep as she breathes fast, then oxygen is still reaching the alveoli , so arterial pO2 would not be effected. +15  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +1  
soph  Maybe Po2 is unaffected bc its perfusion (blood) limited not difusion limited (under normal circumstances). +2  
charcot_bouchard  PErioral tingling- due to transient hypocalcemia induced by resp alkalosis. +1  
rainlad  I believe CO2 diffuses ~20x faster than O2, so increases in her respiratory rate have more effect on her PCO2 than her PO2 +1  
usmile1  adding onto Charcot_bouchards comment, I found this: Respiratory alkalosis secondary to hyperventilation is probably the most common cause of acute ionised hypocalcaemia. Binding between calcium and protein is enhanced when serum pH increases, resulting in decreased ionised calcium. Respiratory alkalosis can induce secondary hypocalcaemia that may cause cardiac arrhythmias, conduction abnormalities and various somatic symptoms such as paraesthesia, PErioral numbness, hyperreflexia, convulsive disorders, muscle spasm and tetany. +1  

submitted by m-ice(272),
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hTe patinte esmse to ahev an cioeftnin eud to eihtr dleateev uteaemrerpt dan lnbomraa tcesh r.a-Xy wvreeoH, threi ctoukelye cnuot is owl. nI o,iaditnd eth eaitpnt sah ithpsiate ,C iwhhc si oefnt atosdescia with iailrsm simtnoarssni oestru to H,VI ikle asovrnnutei urgd

sajaqua1  Not only is their WBC count low, it is not uniform. If we assume a minimum normal WBC count of 5000 cells/mL^3, and a regular range of ~60% neutrophils, then normally a person should have ~3,000 neutrophils/mL^3. This patient has a total of 2000 cells/mL^3, with 1,800 neutrophils/mL^3. Their lymphocytes and macrophages have been whiped out. This is best accounted for by HIV. +25  

submitted by keycompany(268),
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Cna dbomsoye woh nedtadsnru hyw RVP rceaeseds with a tddiS-fLee tnrcaif seleap nntleehgi e.m I odlwu lsoa paectrepai ti if you oldcu rletea ti to grthi sedid rthea raiufle oto i.e(. woh udwlo it )hngec.a

sajaqua1  I believe that keycompany's answer comes the closest. In an MI, consider it as cardiogenic shock. The heart is a pump, and it is failing to move blood out of the heart and into vasculature. This is why PCWP increases. Because of insufficient output, the body has a sympathetic response. The catecholamines then cause vasoconstriction in peripheral vasculature to keep blood pressure up and continue flow, leading to increased SVR. Meanwhile, the sympathetic response causes vasodilation in the lungs; this would be an appropriate autoregulatory response, because the body is trying to keep up the flow of oxygen throughout the system. This decreases PVR. Is a pretty good article on this. Of course the binding of catetcholamines changes depending on saturation and the response is not perfectly understood. +10  
usmleuser007  My understanding is that the pulmonary circulation changes very little in terms of an acute MI. It is b/c pulmonary circulation has a lot more room to fill with blood much like the spleen in terms of blood accumulation. With higher volume of blood in pulmonary circulation, more blood vessels are able to be recruited specially the apex. With more recruited blood vessels = reduced pressure d/t circulation in parallel. +1  

submitted by seagull(1112),
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I heva na sseiu iwht shit eotinsqu hwich asol tocnilsfc hwti dr.oWlU nI redor ot eb adegdedr by omeoporetss teh mdoidfsel noitpre uwold dene to eb petresn ni hte ctoolys for u.ninuibtoa It it aludteaccmu ni the RRE ethn ohw odse ti tge tagdge? eHltnyos, os oed.f.litcc.n

sajaqua1  So ordinarily a misfolded protein does undergo ubiquitination and proteolysis. It is noteable that CFTR misfolding doesn't even allow it escape the ER, so it accumulates in the ER +5  

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anC bynadoy enlixpa sthi e?on I tpu reaepted tsset csebaeu I smsueda na e--ra3dlyo8 noamw si an uanusul rghceapodmi for .hispsyil

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +4  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +3  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +10  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +7  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +10  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see and +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  

submitted by neonem(503),
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heT npetati sah owl cio,rolts hhwci cauess yodb .gnsawti The iatnetp si hdpreitnmgyepe necsi wol clisrtoo sesenraci HCTA ceenrtios morf teh tui,yaprti btu thsi haesrs a ocommn rrsperuoc nepoitr iwht tuetcyltgaiesml-oiamnn ehmorno (H),SM os tath's etonf a igns fo ehteir anledra ufaelri or an nCArieecTt-Hgs ur.omt utP rgtoteh,e het hhgi HATC tbu lwo ositclro phigaepnn reov a rdieop fo 6 mhotns amens atht the ardeanl sutm be engtgit hti by nhioetgms -- nlyo pntooi reeh was eonuaiummt iohe-raernFetdecssruiWh nrdosemy alos suscea daraenl yncfuiiseifcn tbu ihst nhsappe a,tulcey ni het rammietef fo asrh-sy.oud

sajaqua1  The combination of low blood pressure (from lack of mineralocorticoids) and low glucocorticoids (cortisol) indicate adrenal failure. Hyperpigmented skin is a sign of elevated ACTH, indicating that this is a failure of the adrenal gland and not the pituitary. In the industrialized western world, autoimmune destruction of adrenal glands is the leading cause of primary adrenal failure (disseminated tuberculoid destruction of the adrenal glands is significant outside of industrialized nations). It also fits the time line better than Waterhouse-Friederichsen syndrome, which is sudden in onset and associated with hemorraging. Metastases to the adrenal glands *might* be a possibility, but autoimmune destruction is simply likelier. +20  
mamorumyheart  Chronic Addisons disease. Pretty straightforward here. Decreased gland function -> decreased Cortisol, decreased Aldosterone -> hypotension (with hyponatremic volume contraction) Hyperpigmentation from increased ACTH (from POMC) making MSH. (FA) Due to adrenal atrophy or destruction by disease (autoimmune destruction most common in the Western world; TB most common in the developing world). +1  
ac3  I picked autoimmune adrenalitis but was tempted to pick Waterhouse syndrome because of the low BP (hemorrhaging). But I believe Waterhouse-Fried. syndrome is more likely associated with Neisseria infection +  

submitted by hyoid(33),
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Cna snoeemo aneixpl this I–oe–n di'tdn eylarl oknw awht ot eamk fo the bal avleu.s erylCla she swa nkagit oot cuhm uin,inls ubt ohw acn oyu eteirandtiffe sicittaufo oesidrrd mrfo a tepy 1 btdceiai who ekats oto uchm of treih lnniusi ode?s

m-ice  I think the trick here is that they don't mention that the daughter has a history of Type 1 DM, so she has no reason to be taking insulin at all. She's definitely receiving insulin, but we don't have any history implying she's a type 1 diabetic. That, combined with the fact that there have been multiple episodes like this one, favors that the mother is giving the daughter insulin when she doesn't need it. +11  
sajaqua1  C-peptide is produce by endogenous insulin, but is not part of exogenous insulin. She has elevated insulin, with low C-peptide, so she is receiving too much exogenous insulin. A history of recurrent episodes this year implies a behavioral issue; Factitious disorder imposed on another (also called Munchausen syndrome by proxy). +6  

submitted by m-ice(272),
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hisT mna hsa pususl rusoaax,pd a gnsi in cwihh dloob ussrerpe cdsseerea yaraicsdltl udginr itoisnrn.aip usulPs oapudarxs si a clascsi gnis fo ilaceidarrp ndae.pmtao

henW lfidu (tnfeo b)dool sha dopelo ndoaur hte r,thae the ahetr tgseugrls to pedaxn nda illf hwti odobl. sThi omcsebe a erggib mploerb orf het tghir itenvlecr dgniru inrni,soiapt caubese teh higrt desi of teh aerht eecveirs sidaecnre eonusv rnetur rgduni ornsapi.itin seuBeca ereth si fdlui tgpeevnrin eht irtgh enictelrv ofrm pixnegnda rdtw,uoa het olny tehor lapec it acn andpex to tacaomomdce si yb punighs on het pt,smue riikghnns the ezis of eth left lcvtie.ner isTh aceuss dcraseeed PB nwhe teh tlfe lerivncte nratsotcc ndurig tath cacdrai .eclcy

sajaqua1  In addition to causing pulsus paradoxus, we see jugular venous distension, and muffled/distant heart sounds (hard to hear through the cardiac tamponade). +2  
drdoom  ^ linkify +